Your 2015 Prescription Drug List
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- Cori Curtis
- 7 years ago
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1 Your 205 Prescription List Effective January, 205 Please read: This document contains information about the drugs covered under your pharmacy benefit plan. For a complete list of covered drugs or if you have questions: Call the toll-free member phone number on the back of your ID card. Visit optumrx.com Locate a participating retail pharmacy by zip code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx optumrx.com
2 Your Prescription List This Prescription List (PDL) outlines the most commonly prescribed medications from your plan s complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to optumrx.com for complete and up-to-date drug information Since the PDL may change, we encourage you to visit our website, optumrx.com. 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. John Smith John Smith John Smith 2
3 Table of Contents tiers and cost and limits... 6 s by category... 9 Anti-Infectives Antibiotics... 9 Antifungals... 9 Antivirals Cancer... 9 Cardiovascular/Heart Disease Anticoagulants High Blood Pressure... 0 High Cholesterol... 0 Other.... Pulmonary Arterial Hypertension... Central Nervous System Attention Deficit Disorder... Depression.... Migraine... Multiple Sclerosis... 2 Other Sedatives/Hypnotics... 2 Seizure Disorders... 2 Dermatology... 3 Diabetes/Endocrine Blood Glucose Monitoring... 3 Insulin... 4 Non-Insulin... 4 Endocrine Growth Hormone... 5 Other Thyroid Hormone Replacement... 5 Eye Conditions Allergies Antibiotics... 5 Glaucoma... 5 Other Gastrointestinal Acid Suppression... 5 Nausea/Vomiting... 5 Other HIV/AIDS... 6 Infertility... 6 Inflammatory Conditions... 6 Men s Health Prostate... 6 Testosterone Therapy... 7 Miscellaneous... 7 Musculoskeletal Osteoporosis... 7 Other Pain Relief... 8 Overactive Bladder... 8 Respiratory Asthma/COPD... 8 Nasal Allergies... 9 Oral Allergies... 9 Transplant... 9 Vitamins/Electrolytes... 9 Women s Health Birth Control... 9 Hormone Replacement Vaginal Anti-Infectives Index
4 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 Prescription List. What is a Prescription List (PDL)? This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. s 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 Administration (FDA). Please note: Where differences are noted between this PDL 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 optumrx.com or call the toll-free member phone number on the back of your ID card for more information. How do I use my Prescription List? When choosing a medication, you and your doctor should consult the PDL. 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 optumrx.com or call the toll-free member phone number on the back of your ID card. 4
5 What are tiers? s 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. medications are your lowest-cost options. If your medication is placed in 2 or 3, look to see if there is a option available. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs. $ Includes $ $$ $$ $$$ $$$ $$$$ $$$$ $$$$$ Preferrred Generics 2 Non-preferred generics 3 Preferred Brands 4 Non-Preferred Brands 5 Specialty Lower-cost generic drugs. Higher-cost generic drugs. Lower-cost brand drugs. Higher-cost brand drugs. Specialty drugs. 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 optumrx.com, or call the toll-free member phone number of the back of your ID card for more information about your benefit plan. 5
6 When does the Prescription List 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 or July 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 the back of your ID card. 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. PA ST QL Prior Authorization Your doctor is required to provide additional information to determine coverage. Step Therapy Trial of lower cost medication(s) is required before a higher-cost medication is covered. Quantity Limits Amount of medication covered per copayment or in a specific time period. AR Age Restrictions Some restrictions may apply based on patient age. SP GR Specialty Medication Medication is designated as a specialty pharmacy drug. Gender Restrictions Some restrictions may apply based on patient gender. To learn more about a pharmacy program or to find out if it applies to you, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 6
7 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, Coumadin) and generic drugs in plain type (for example, Warfarin). 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 optumrx.com to make sure. 7
8 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 PDL. OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx Specialty Pharmacy at and have your prescriptions delivered right to your home or office. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit optumrx.com or call the toll-free member phone number on the back of your ID card for more current information. When you register at optumrx.com 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 mail service prescriptions View your order status and claims history Sign up for text reminders to take and refill your medicine View your benefits in real time Order medical supplies Shop for health and wellness products More information If you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com. 8
9 Name Name Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Clavulanate Azithromycin Bethkis 5 SP Cefdinir Cefuroxime Tab Cephalexin Ciprodex Otic Suspension 4 Ciprofloxacin Tab Clarithromycin Clindamycin Cap Dificid 4 PA Doxycycline Hyclate Cap Doxycycline Hyclate Tab (immediate Release) Doxycycline QL Monohydrate Cap Levofloxacin Tab Metronidazole Tab Minocycline Cap Neomycin/Polymyxin/ HC Otic Suspension, Solution Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Ofloxacin Otic Solution Oracea 4 QL Penicillin VK Solodyn 4 QL Sulfamethoxazole- Trimethoprim Sulfamethoxazole- Trimethoprim DS Anti-Infectives: Antifungals Fluconazole Nystatin Suspension Terbinafine Tab Anti-Infectives: Antivirals Acyclovir Tab, Cap, Suspension Baraclude 5 QL, SP Famciclovir Tab Olysio 5 PA, QL, SP Pegasys 5 PA, SP Sovaldi 5 PA, QL, SP Tamiflu 4 QL Valacyclovir Cancer Anastrozole Tab Gleevec 5 PA, QL, SP Letrozole PA Revlimid 5 PA, QL, SP Tamoxifen Tab Tasigna 5 PA, QL, SP Zytiga 5 PA, SP Cardiovascular/Heart Disease: Anticoagulants Aggrenox 3 QL Brilinta 3 QL Clopidogrel QL Coumadin 4 Effient 3 QL Eliquis 4 QL Enoxaparin Pradaxa 3 QL Warfarin Xarelto 3 QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9
10 Name Cardiovascular/Heart Disease: High Blood Pressure Amlodipine QL Amlodipine/Benazepril QL Atenolol Atenolol/Chlorthalidone Azor 3 QL, ST Benazepril Benazepril/HCTZ Benicar 3 QL, ST Benicar HCT 3 QL, ST Bisoprolol Bisoprolol/HCTZ Bumetanide Bystolic 3 QL Cartia XT QL Carvedilol Chlorthalidone Clonidine Tab Coreg CR 4 QL, ST Diovan 4 QL, ST Doxazosin Dutoprol 3 QL Edarbi 4 QL, ST Edarbyclor 4 QL, ST Enalapril Exforge 3 QL, ST Exforge HCT 3 QL, ST Felodipine QL Fosinopril Furosemide Guanfacine Tab Hydralazine Hydrochlorothiazide Irbesartan QL Irbesartan/HCTZ QL Labetalol Lisinopril Lisinopril/HCTZ Losartan QL Losartan/HCTZ QL Metoprolol Succinate Metoprolol Tartrate Nadolol Name Nifedipine ER Propranolol Propranolol ER Quinapril Ramipril QL Spironolactone Tarka 3 Tekturna 3 QL, ST Tekturna HCT 3 QL, ST Telmisartan QL Terazosin Torsemide Tab Triamterene/HCTZ Tribenzor 3 QL, ST Valsartan QL Valsartan/HCTZ QL Verapamil ER Cardiovascular/Heart Disease: High Cholesterol Atorvastatin QL Crestor 3 QL Fenofibrate QL Gemfibrozil QL Lipitor 4 QL, ST Lipofen 4 QL Livalo 4 QL, ST Lovastatin Lovaza 4 QL Niacin ER Tab QL Omega-3 Acid Cap gm QL Pravastatin Simcor 3 QL Simvastatin QL Simvastatin 80 mg PA, QL Vascepa 3 QL Vytorin 3 QL Vytorin Tab 0-80 mg 3 PA, QL Welchol 3 QL Zetia 4 QL Bold type = Brand-name name drug [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 0
11 Name Name Cardiovascular/Heart Disease: Other Amiodarone Amlodipine/Atorvastatin 2 QL, ST Digoxin Flecainide Isosorbide Mononitrate Nitrostat 3 Ranexa 3 ST Sotalol Cardiovascular/Heart Disease: Pulmonary Arterial Hypertension Adcirca 5 PA, QL, SP Letairis 5 PA, QL, SP Opsumit 5 PA, QL, SP Sildenafil Tab 20 mg 5 PA, QL, SP Tracleer 5 PA, QL, SP Central Nervous System: Attention Deficit Disorder Amphetamine- Dextroamphetamine QL, AR Amphetamine- Dextroamphetamine 2 QL, ST, AR SR 24Hr Cap Dexmethylphenidate ER 2 QL, ST, AR Focalin XR 4 QL, ST, AR Intuniv 3 QL, AR Methylphenidate ER Cap 2 QL, ST, AR Methylphenidate ER Tab QL, AR Methylphenidate Sa Osm ER Tab 2 QL, ST, AR Methylphenidate Tab QL, AR Strattera 3 QL, AR Vyvanse 3 QL, AR Central Nervous System: Depression Amitriptyline Budeprion XL QL Bupropion Bupropion SR Citalopram QL Cymbalta 4 QL Doxepin Duloxetine Cap QL Escitalopram Tab QL Fluoxetine Cap (not PMDD) Forfivo XL 3 QL Mirtazapine Nortriptyline Paroxetine Pristiq 3 QL Sertraline Trazodone Venlafaxine Venlafaxine ER Cap QL Viibryd 4 QL, ST Central Nervous System: Migraine Butalbital- Acetaminophen- Caffeine Cap QL mg Migranal 4 QL Phrenilin 4 QL Relpax 4 QL Rizatriptan Tab, ODT QL Sumatriptan Tab and Spray QL Sumavel Dose 4 QL Zomig Nasal Spray 3 QL Bold type = Brand-name name drug [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions
12 Name Central Nervous System: Multiple Sclerosis Ampyra 5 PA, QL, SP Avonex Kit 5 PA, QL, SP Avonex Pen Kit 5 PA, QL, SP Avonex Prefill Kit 5 PA, QL, SP Betaseron 5 PA, QL, SP Copaxone 5 PA, QL, SP Gilenya 5 PA, QL, ST, SP Rebif 5 PA, QL, ST, SP Rebif Titrtn 5 PA, QL, ST, SP Tecfidera 5 PA, QL, SP Central Nervous System: Other Abilify Tab 3 QL Abilify Disc 3 QL Abilify Solution 3 QL Alprazolam Tab QL Benztropine Buspirone Carbidopa/Levodopa Tab Diazepam Tab Donepezil Tab QL Hydroxyzine HCL Hydroxyzine Pamoate Lithium Carbonate Lorazepam Tab QL Modafinil 2 PA, QL Namenda Tab 3 QL Namenda XR 3 QL Olanzapine Tab QL Pramipexole Prochlorperazine Quetiapine QL Risperidone Tab QL Ropinirole Saphris 3 QL Seroquel XR 3 QL Zelapar 4 Ziprasidone Cap 2 QL, ST Name Central Nervous System: Sedatives/Hypnotics Eszopiclone Tab QL Lunesta 4 QL Silenor 4 QL Temazepam QL Triazolam Tab QL Zolpidem QL Zolpidem ER QL Central Nervous System: Seizure Disorders Carbamazepine Tab Clonazepam QL Divalproex DR Divalproex ER Gabapentin Lamictal 3 Lamictal ODT 3 Lamictal XR 4 QL Lamotrigine Lamotrigine ER QL Levetiracetam Levetiracetam ER QL Lyrica Cap 3 QL Onfi 5 PA, SP Oxcarbazepine Phenytoin Topiramate Tab [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 2
13 Name Dermatology Acanya Gel 4 QL Acyclovir Ointment 5% Aczone Gel 3 Atralin 3 QL, AR Benzaclin 4 QL Carac 3 Clindamycin Gel, Lotion, Solution Clindamycin/ Benzoyl Peroxide QL Gel -5% Clobetasol Cream, Gel, Ointment Clobex 4 Cloderm 4 Clotrimazole/ Betamethasone Cream, Lotion Condylox 4 Desonide Cream Differin 4 QL Econazole Cream Elidel 3 QL, ST, AR Epiduo 4 QL Finacea 3 Fluocinonide Cream, Gel, Ointment 0.05% Hydrocortisone Cream 2.5% Ketoconazole Cream/ Shampoo Metrogel 4 Metronidazole Gel 0.75% Mometasone Mupirocin QL Nystatin Cream, Ointment, Powder Nystatin/Triamcinolone Cream, Ointment Name Oxsoralen-Ul 3 PA Permethrin Cream 5% Protopic Ointment 3 QL, ST, AR Retin-A Micro 4 QL, AR Silver Sulfadiazine Cream % Taclonex 4 QL Tretinoin Microsphere Gel QL, AR Triamcinolone Vectical 4 Zovirax Cream 3 Zovirax Ointment 4 Zyclara 4 QL Diabetes/Endocrine Blood: Glucose Monitoring Accu-Chek Act/Gluc Calibration Liquid 4 Accu-Chek Aviva Plus Test Strips 3 QL Accu-Chek Aviva Test Strips 3 QL Accu-Chek Comfort Test Strips 3 QL Accu-Chek Cpt/Gluc Calibration Liquid 4 Accu-Chek Drum Test Strips 3 QL Accu-Chek Kit Aviva Plus 3 Accu-Chek Kit Compact 3 Accu-Chek Kit Fastclix 3 Accu-Chek Kit Mlticlix 3 Accu-Chek Kit Nano 3 Accu-Chek Kit Softclix 3 Accu-Chek Mlticlix Lancets 3 Accu-Chek Smart Calibration Liquid 4 Accu-Chek Smart Test Strips 3 QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 3
14 Name Accu-Chek Sol Calibration Liquid 4 Accu-Chek Sol Comfort 4 Calibration Liquid Fastclix Lancets 3 Glucocard Test Strips Insulin Pen Needle 3 Insulin Syringe/ Needle 3 Novofine 4 Novofine Auto 4 Novotwist 4 Onetouch Kit Ultra Smart 3 Onetouch Kit Ultra 3 Onetouch Kit Ultra 2 3 Onetouch Kit Ultra Mini 3 Onetouch Kit Verio IQ 3 Onetouch Test Strips 3 QL Onetouch Ultra Blue Test Strips 3 QL Onetouch Verio IQ Test Strips 3 QL Onetouch Verio Test Strips 3 QL Soft Touch Lancets 3 Softclix Lan Mis Device 4 Softclix Lancets 3 Surestep Test Strips 3 QL Truetrack Test Strips 4 QL Diabetes/Endocrine: Insulin Humalog Vials 3 Humalog Kwik Pen 3 Humalog Mix 50/50 Kwik Pen 3 Humalog Mix 50/50 Vials 3 Humalog Mix 75/25 Kwik Pen 3 Name Humalog Mix 75/25 Vials 3 Humulin 70/30 Vials 3 Humulin N Vials 3 Humulin N Pen 3 Humulin Pen 70/30 3 Humulin R U Humulin R Vials 3 Lantus Solostar 3 Lantus Vials 3 Levemir Flexpen 3 Levemir Vials 3 Novolin 70/30 Vials 3 Novolin N Vials 3 Novolin R Vials 3 Novolog Flexpen 3 Novolog Mix Flexpen 3 Novolog Mix 70/30 Vials 3 Novolog Penfill 3 Novolog Vials 3 Diabetes/Endocrine: Non-Insulin Byetta 3 QL, ST Glimepiride Glipizide Glipizide ER Glipizide XL Glyburide Glyburide/Metformin Invokamet 3 QL, ST Invokana 3 QL, ST Janumet 3 QL, ST Janumet XR 3 QL, ST Januvia 3 QL, ST Jentadueto 3 QL, ST Kombiglyze 3 QL, ST Metformin Metformin ER Onglyza 3 QL, ST Pioglitazone QL Tradjenta 3 QL, ST Victoza 4 QL, ST [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 4
15 Name Endocrine: Growth Hormone Nutropin 5 PA, SP Nutropin AQ 5 PA, SP Saizen 5 PA, SP Tev-Tropin 5 PA, SP Endocrine: Other Calcitriol Cap Dexamethasone Tab Lupron Depot 3.75 mg,.25 mg 5 PA, SP Lupron Depot 7.5 mg, 22.5 mg, 5 PA, SP 30 mg, 45 mg Methylprednisolone Tab Prednisolone Solution (5 mg/5 ml and 5 mg/5 ml) Prednisone Sensipar 5 SP Endocrine: Thyroid Hormone Replacement Armour Thyroid 4 Levothyroxine Liothyronine Methimazole Synthroid 4 Eye Conditions: Allergies Azelastine Solution Pataday 3 Patanol 3 QL Eye Conditions: Antibiotics Ciprofloxacin QL Erythromycin Ointment Gentamicin Moxeza 3 QL Ofloxacin QL Polymyxin B/ Trimethoprim Solution Name Tobramycin Tobramycin/ Dexamethasone Vigamox 3 QL Eye Conditions: Glaucoma Alphagan P 3 QL Azopt 3 QL Brimonidine QL Combigan 3 QL Dorzolamide-Timolol Maleate Latanoprost QL Lumigan 3 QL Timolol Timoptic Ocudose 3 Travatan Z 3 QL Eye Conditions: Other Ketorolac Opthalmic Solution QL Prednisolone Opth Restasis 4 PA Gastrointestinal: Acid Suppression Carafate Suspension 3 Dexilant 3 QL Famotidine Tab 20 mg and 40 mg (Rx only) Lansoprazole (Rx only) QL Nexium (Rx only) 3 QL Omeprazole (Rx only) QL Pantoprazole QL Rabeprazole 2 QL, ST Ranitidine Tab, Cap, Syrup (Rx only) Sucralfate Tab Gastrointestinal: Nausea/Vomiting Meclizine 2 Metoclopramide QL Ondansetron Tab QL Transderm-Scop 4 [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 5
16 Name Name Gastrointestinal: Other Amitiza 3 QL, ST, AR Apriso 3 QL Asacol HD 4 QL Canasa 3 QL Creon 3 Delzicol 4 QL Dicyclomine Diphenoxylate/Atropine Halflytely Kit 4 QL Moviprep 4 QL Omeclamox Pak 3 QL Pentasa 4 QL Polyethylene 2 Glycol 3350 Pylera 3 QL Suclear Bowel Prep 4 QL Suprep Bowel Prep 4 QL Uceris 4 Zenpep (Not 5,000 units) HIV/AIDS Atripla 5 SP Complera 5 SP Epzicom 5 SP Intelence 5 SP Isentress 5 SP Kaletra 5 SP Norvir 5 SP Prezista 5 SP Reyataz 5 SP Stribild 5 SP Truvada 5 PA, SP Viread 5 SP 3 Infertility Follistim AQ 5 PA, SP Gonal-f 5 PA, SP Gonal-f RFF 5 PA, SP Ovidrel 5 SP Inflammatory Conditions Cimzia 5 PA, QL, SP Enbrel 5 PA, QL, ST, SP Enbrel SureClick 5 PA, QL, ST, SP Humira Kit 5 PA, QL, SP Humira Pen Kit 5 PA, QL, SP Humira Pen Kit Crohns 5 PA, QL, SP Humira Pen Kit Psoriasis 5 PA, QL, SP Hydroxychloroquine Methotrexate Tab Orencia SC 5 PA, QL, ST, SP Simponi 5 PA, QL, SP Stelara 5 PA, QL, SP Men s Health: Prostate Alfuzosin QL Avodart 3 QL Doxazosin Finasteride 5 mg QL Jalyn 3 QL Rapaflo 3 QL Tamsulosin QL Terazosin [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 6
17 Name Men s Health: Testosterone Therapy Androderm 3 PA, QL, GR Androgel 3 PA, QL, GR Fortesta 4 PA, QL, GR Testim 3 PA, QL, GR Testosterone Cypionate IM Injection 2 PA Miscellaneous Allopurinol Antipyrine/Benzocaine Otic Solution % Aranesp 5 PA, SP Benzonatate Botox 00, 200 unit Injection 5 PA, SP Chantix 4 QL Cheratussin Chlorhexidine Colcrys 3 QL Epipen 2-Pak 3 QL Euflexxa 5 PA, SP Fosrenol 4 Hydrocortisone AC Suppository 25 mg Hydromet Lidocaine Viscous Solution 2% Makena 5 PA, SP Phenazopyridine (Rx only) Phentermine Tab 2 Procrit 5 PA, SP Name Promethazine DM Syrup AR Promethazine/Codeine Syrup AR Pulmozyme 5 SP Rectiv 4 Renvela 3 Rezira 4 Suboxone Film 3 PA, QL Synagis 5 PA, SP Synvisc 5 PA, SP Uloric 3 QL, ST Zubsolv 3 PA, QL Zutripro 4 Musculoskeletal: Osteoporosis Actonel 4 QL Alendronate Tab Evista 4 QL Forteo 5 PA, SP Ibandronate Tab QL Raloxifene QL Musculoskeletal: Other Baclofen Tab Carisoprodol 350 mg Cyclobenzaprine Tab 5, 0 mg Metaxalone 2 Methocarbamol Tizanidine Tab [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 7
18 Name Name Musculoskeletal: Pain Relief Acetaminophen w/ Codeine QL Cambia 4 QL Celebrex 4 QL Diclofenac Tab QL Endocet Tab QL Etodolac QL Fentanyl Patch QL Gralise 4 QL, ST Hydrocodone w/ Ibuprofen QL Tab mg Hydrocodone/APAP 5, 7.5, 0/325 mg QL Hydromorphone Tab Ibuprofen Tab 400, 600, 800 mg (Rx only) QL Indomethacin Cap QL Lazanda 4 PA, QL Lidocaine Patch 5% QL Meloxicam QL Methadone Tab Morphine Sulfate ER Tab QL Nabumetone QL Naproxen (Rx only) QL Nucynta 4 QL Nucynta ER 3 QL Oxycodone Tab 5, 5, 30 mg Oxycodone w/ Acetaminophen QL Oxycontin 3 QL Sprix 4 QL Subsys 4 PA, QL Tramadol Tab 50 mg QL Tramadol w/ Acetaminophen QL Vicodin 4 QL Vicodin ES 4 QL Voltaren Gel 3 QL Overactive Bladder Enablex 4 QL Gelnique 3 QL Oxybutynin Oxybutynin ER QL Tolterodine ER 2 QL, ST Toviaz 4 QL Vesicare 3 QL Respiratory: Asthma/COPD Advair Diskus 3 QL Advair HFA 3 QL Aerospan 4 Albuterol Nebulizer Solution Asmanex 3 QL Breo Ellipta 3 QL Budesonide 2 Combivent Respimat 3 QL Dulera 4 QL, ST Flovent Diskus 3 QL Flovent HFA 3 QL Foradil 3 QL, ST Ipratropium/Albuterol 2 Levalbuterol Nebulizer Solution 2 Montelukast QL Perforomist 4 QL Proair HFA 3 QL Proventil 4 QL Pulmicort Flexhaler 3 QL Qvar 3 QL Serevent Diskus 3 QL, ST Spiriva 3 QL Symbicort 3 QL Tudorza Pressair 3 QL Ventolin HFA 3 QL Xolair 5 PA, SP Xopenex HFA 4 QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 8
19 Name Name Respiratory: Nasal Allergies Azelastine Spray QL Dymista Spray 4 QL Fluticasone Spray Ipratropium Spray Nasonex 3 QL Omnaris 4 QL Triamcinolone Spray 2 QL Veramyst 3 QL Zetonna 4 QL Respiratory: Oral Allergies Cetirizine 2 Promethazine Tab AR Desloratadine 2 QL Levocetirizine QL Loratadine 2 Transplant Azathioprine Tab Cellcept Tab/ Suspension 5 SP Cyclosporine Cap 5 SP Mycophenolate 250 mg Cap/500 mg Tab 5 SP Prograf Cap 5 SP Rapamune 5 SP Tacrolimus Cap 5 SP Vitamins/Electrolytes Cyanocobalamine Injection 2 Folic Acid mg (Rx only) Klor-Con M0 and M20 Multi-Vit/Fl Chew Potassium Chloride ER Tab, Cap Potassium Chloride Micro ER Vitamin D 50,000 units (Rx only) Women s Health: Birth Control Apri GR Aviane GR Beyaz 3 GR Cryselle-28 GR Generess Fe Chewable 4 GR Gianvi GR Gildess Fe GR Jolivette GR Junel Fe GR Kariva GR Levora 28 GR Lo Loestrin 4 GR Loryna GR Low-Ogestrel GR Lutera GR Medroxyprogesterone Acetate Injection 2 QL Microgestin GR Microgestin Fe GR Minastrin 24 Fe Chewable 4 GR Mononessa GR Natazia 3 GR Necon GR Norgest/Ethi Estradio GR Nortrel GR Nuvaring 3 Ocella GR Orsythia GR Ortho Tri-Cyclen Lo 4 GR Previfem GR Reclipsen GR Safyral 3 GR Sprintec 28 GR Trinessa GR Tri-Sprintec GR Vestura GR Viorele GR [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 9
20 Name Women s Health: Hormone Replacement Climara Pro 3 QL, GR Divigel 3 GR Enjuvia 3 QL, GR Estrace Vaginal Cream 4 Estradiol Tab QL, GR Estradiol/Norethindrone Tab 2 QL, GR Medroxyprogesterone Acetate Tab Premarin Tab 3 QL, GR Premarin Vaginal Cream 3 Name Premphase 3 QL, GR Prempro 3 QL, GR Progesterone Cap 2 Vagifem 4 GR Vivelle-Dot 3 QL, GR Women s Health: Vaginal Anti-Infectives Metronidazole Vaginal Gel Terconazole Vaginal Cream QL [Plain type = Generic drug] PA Prior Authorization ST Step Therapy QL Quantity Limits AR Age Restrictions SP Specialty Program GR Gender Restrictions 20
21 Index of Covered s A Abilify Disc Abilify Solution Abilify Tab Acanya Gel Accu-Chek Act/Gluc Calibration Liquid... 3 Accu-Chek Aviva Plus Test Strips Accu-Chek Aviva Test Strips 3 Accu-Chek Comfort Test Strips Accu-Chek Cpt/Gluc Calibration Liquid... 3 Accu-Chek Drum Test Strips 3 Accu-Chek Kit Aviva Plus. 3 Accu-Chek Kit Compact.. 3 Accu-Chek Kit Fastclix... 3 Accu-Chek Kit Mlticlix... 3 Accu-Chek Kit Nano Accu-Chek Kit Softclix... 3 Accu-Chek Mlticlix Lancets 3 Accu-Chek Smart Calibration Liquid Accu-Chek Smart Test Strips3 Accu-Chek Sol Calibration Liquid Accu-Chek Sol Comfort Calibration Liquid... 4 Acetaminophen w/ Codeine 8 Actonel Acyclovir Ointment 5%... 3 Acyclovir Tab, Cap, Suspension 9 Aczone Gel Adcirca Advair Diskus Advair HFA Aerospan Aggrenox Albuterol Nebulizer Solution 8 Alendronate Tab Alfuzosin Allopurinol Alphagan P Alprazolam Tab Amiodarone Amitiza Amitriptyline Amlodipine Amlodipine/Atorvastatin.. Amlodipine/Benazepril... 0 Amoxicillin Amoxicillin/Clavulanate Amphetamine- Dextroamphetamine.. Amphetamine-Dextroamphetamine SR 24Hr. Ampyra Anastrozole Tab Androderm Androgel Antipyrine/Benzocaine Otic Solution Apri Apriso Aranesp Armour Thyroid Asacol HD Asmanex Atenolol Atenolol/Chlorthalidone... 0 Atorvastatin Atralin Atripla Aviane Avodart Avonex Kit Avonex Pen Kit Avonex Prefill Kit Azathioprine Tab Azelastine Solution Azelastine Spray Azithromycin Azopt Azor B Baclofen Tab Baraclude Benazepril Benazepril/HCTZ Benicar Benicar HCT Benzaclin Benzonatate Benztropine Betaseron Bethkis Beyaz Bisoprolol Bisoprolol/HCTZ Botox 00, 200 unit Injection Breo Ellipta Brilinta Brimonidine Budeprion XL Budesonide Bumetanide Bupropion Bupropion SR Buspirone Butalbital-Acetaminophen- Caffeine Cap Byetta Bystolic C Calcitriol Cap Cambia Canasa Carac Carafate Suspension... 5 Carbamazepine Tab Carbidopa/Levodopa Tab.. 2 [Plain type = Generic drug] 2
22 Index of Covered s Carisoprodol Cartia XT Carvedilol Cefdinir Cefuroxime Tab Celebrex Cellcept Tab/Suspension. 9 Cephalexin Cetirizine Chantix Cheratussin Chlorhexidine Chlorthalidone Cimzia Ciprodex Otic Suspension. 9 Ciprofloxacin , 5 Citalopram Clarithromycin Climara Pro Clindamycin/Benzoyl Peroxide Gel Clindamycin Cap Clindamycin Gel, Lotion, Solution Clobetasol Cream, Gel, Ointment Clobex Cloderm Clonazepam Clonidine Tab Clopidogrel Clotrimazole/Betamethasone Cream, Lotion Colcrys Combigan Combivent Respimat... 8 Complera Condylox Copaxone Coreg CR Coumadin Creon Crestor Cryselle Cyanocobalamine Injection. 9 Cyclobenzaprine Tab Cyclosporine Cap Cymbalta D Delzicol Desloratadine Desonide Cream Dexamethasone Tab Dexilant Dexmethylphenidate ER... Diazepam Tab Diclofenac Tab Dicyclomine Differin Dificid Digoxin Diovan Diphenoxylate/Atropine... 6 Divalproex DR Divalproex ER Divigel Donepezil Tab Dorzolamide-Timolol Maleate 5 Doxazosin , 6 Doxepin Doxycycline Hyclate Doxycycline Monohydrate Cap 9 Dulera Duloxetine Cap Dutoprol Dymista Spray E Econazole Cream Edarbi Edarbyclor Effient Elidel Eliquis Enablex Enalapril Enbrel Enbrel SureClick Endocet Tab Enjuvia Enoxaparin Epiduo Epipen 2-Pak Epzicom Erythromycin Ointment... 5 Escitalopram Tab Estrace Vaginal Cream.. 20 Estradiol/Norethindrone Tab. 20 Estradiol Tab Eszopiclone Tab Etodolac Euflexxa Evista Exforge Exforge HCT F Famciclovir Tab , 5 Fastclix Lancets Felodipine Fenofibrate Fentanyl Patch Finacea Finasteride Flecainide Flovent Diskus Flovent HFA Fluconazole Fluocinonide Cream, Gel, Ointment 0.05% Fluoxetine Cap Fluticasone Spray Focalin XR Folic Acid mg [Plain type = Generic drug] 22
23 Index of Covered s Follistim AQ Foradil Forfivo XL Forteo Fortesta Fosinopril Fosrenol Furosemide G Gabapentin Gelnique Gemfibrozil Generess Fe Chewable.. 9 Gentamicin Gianvi Gildess Fe Gilenya Gleevec Glimepiride Glipizide Glipizide ER Glipizide XL Glucocard Test Strips... 4 Glyburide Glyburide/Metformin Gonal-f Gonal-f RFF Gralise Guanfacine Tab H Halflytely Kit Humalog Kwik Pen Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials. 4 Humalog Mix 75/25 Kwik Pen Humalog Mix 75/25 Vials. 4 Humalog Vials Humira Kit Humira Pen Kit Humira Pen Kit Crohns.. 6 Humira Pen Kit Psoriasis. 6 Humulin 70/30 Vials Humulin N Pen Humulin N Vials Humulin Pen 70/ Humulin R U Humulin R Vials Hydralazine Hydrochlorothiazide Hydrocodone/APAP Hydrocodone w/ Ibuprofen Tab Hydrocortisone AC Suppository Hydrocortisone Cream 2.5% 3 Hydromet Hydromorphone Tab Hydroxychloroquine Hydroxyzine HCL Hydroxyzine Pamoate I Ibandronate Tab Ibuprofen Tab Indomethacin Cap Insulin Pen Needle Insulin Syringe/Needle.. 4 Intelence Intuniv Invokamet Invokana Ipratropium/Albuterol Ipratropium Spray Irbesartan Irbesartan/HCTZ Isentress Isosorbide Mononitrate... J Jalyn Janumet Janumet XR Januvia Jentadueto Jolivette Junel Fe K Kaletra Kariva Ketoconazole Cream/ Shampoo Ketorolac Opthalmic Solution 5 Klor-Con M0 and M Kombiglyze L Labetalol Lamictal Lamictal ODT Lamictal XR Lamotrigine Lamotrigine ER Lansoprazole Lantus Solostar Lantus Vials Latanoprost Lazanda Letairis Letrozole Levalbuterol Nebulizer Solution Levemir Flexpen Levemir Vials Levetiracetam Levetiracetam ER Levocetirizine Levofloxacin Tab Levora [Plain type = Generic drug] 23
24 Index of Covered s Levothyroxine Lidocaine Patch 5% Lidocaine Viscous Solution 2% Liothyronine Lipitor Lipofen Lisinopril Lisinopril/HCTZ Lithium Carbonate Livalo Lo Loestrin Loratadine Lorazepam Tab Loryna Losartan Losartan/HCTZ Lovastatin Lovaza Low-Ogestrel Lumigan Lunesta Lupron Depot Lutera Lyrica Cap M Makena Meclizine Medroxyprogesterone Acetate Injection Medroxyprogesterone Acetate20 Meloxicam Metaxalone Metformin Metformin ER Methadone Tab Methimazole Methocarbamol Methotrexate Tab Methylphenidate ER..... Methylphenidate Sa Osm ER Tab Methylphenidate Tab.... Methylprednisolone Tab... 5 Metoclopramide Metoprolol Succinate Metoprolol Tartrate Metrogel Metronidazole Gel 0.75%.. 3 Metronidazole Tab Metronidazole Vaginal Gel. 20 Microgestin Microgestin Fe Migranal Minastrin 24 Fe Chewable 9 Minocycline Cap Mirtazapine Modafinil Mometasone Mononessa Montelukast Morphine Sulfate ER Tab.. 8 Moviprep Moxeza Multi-Vit/Fl Chew Mupirocin Mycophenolate N Nabumetone Nadolol Namenda Tab Namenda XR Naproxen Nasonex Natazia Necon Neomycin/Polymyxin/HC Otic Suspension, Solution... 9 Nexium Niacin ER Tab Nifedipine ER Nitrofurantoin Macrocrystalline 9 Nitrofurantoin Monohydrate Macrocrystalline Nitrostat Norgest/Ethi Estradio Nortrel Nortriptyline Norvir Novofine Novofine Auto Novolin 70/30 Vials Novolin N Vials Novolin R Vials Novolog Flexpen Novolog Mix 70/30 Vials. 4 Novolog Mix Flexpen... 4 Novolog Penfill Novolog Vials Novotwist Nucynta Nucynta ER Nutropin Nutropin AQ Nuvaring Nystatin Cream, Ointment, Powder Nystatin Suspension Nystatin/Triamcinolone Cream, Ointment O Ocella Ofloxacin Ofloxacin Otic Solution Olanzapine Tab Olysio Omeclamox Pak Omega-3 Acid Cap Omeprazole Omnaris Ondansetron Tab Onetouch Kit Ultra [Plain type = Generic drug] 24
25 Index of Covered s Onetouch Kit Ultra Onetouch Kit Ultra Mini. 4 Onetouch Kit Ultra Smart. 4 Onetouch Kit Verio IQ... 4 Onetouch Test Strips... 4 Onetouch Ultra Blue Test Strips Onetouch Verio IQ Test Strips Onetouch Verio Test Strips 4 Onfi Onglyza Opsumit Oracea Orencia SC Orsythia Ortho Tri-Cyclen Lo Ovidrel Oxcarbazepine Oxsoralen-Ul Oxybutynin Oxybutynin ER Oxycodone Tab Oxycodone w/ Acetaminophen... 8 Oxycontin P Pantoprazole Paroxetine Pataday Patanol Pegasys Penicillin VK Pentasa Perforomist Permethrin Cream 5%... 3 Phenazopyridine Phentermine Tab Phenytoin Phrenilin Pioglitazone Polyethylene Glycol Polymyxin B/Trimethoprim Solution Potassium Chloride ER Tab, Cap Potassium Chloride Micro ER 9 Pradaxa Pramipexole Pravastatin Prednisolone Opth Prednisolone Solution Prednisone Premarin Tab Premarin Vaginal Cream. 20 Premphase Prempro Previfem Prezista Pristiq Proair HFA Prochlorperazine Procrit Progesterone Cap Prograf Cap Promethazine/Codeine Syrup 7 Promethazine DM Syrup.. 7 Promethazine Tab Propranolol Propranolol ER Protopic Ointment Proventil Pulmicort Flexhaler Pulmozyme Pylera Q Quetiapine Quinapril Qvar R Rabeprazole Raloxifene Ramipril Ranexa Ranitidine Tab, Cap, Syrup. 5 Rapaflo Rapamune Rebif Rebif Titrtn Reclipsen Rectiv Relpax Renvela Restasis Retin-A Micro Revlimid Reyataz Rezira Risperidone Tab Rizatriptan Tab, ODT.... Ropinirole S Safyral Saizen Saphris Sensipar Serevent Diskus Seroquel XR Sertraline Sildenafil Tab Silenor Silver Sulfadiazine Cream % 3 Simcor Simponi Simvastatin Softclix Lancets Softclix Lan Mis Device.. 4 Soft Touch Lancets Solodyn [Plain type = Generic drug] 25
26 Index of Covered s Sotalol Sovaldi Spiriva Spironolactone Sprintec Sprix Stelara Strattera Stribild Suboxone Film Subsys Suclear Bowel Prep Sucralfate Tab Sulfamethoxazole-Trimethoprim9 Sulfamethoxazole- Trimethoprim DS Sumatriptan Tab and Spray. Sumavel Dose Suprep Bowel Prep Surestep Test Strips Symbicort Synagis Synthroid Synvisc T Taclonex Tacrolimus Cap Tamiflu Tamoxifen Tab Tamsulosin Tarka Tasigna Tecfidera Tekturna Tekturna HCT Telmisartan Temazepam Terazosin , 6 Terbinafine Tab Terconazole Vaginal Cream. 20 Testim Testosterone Cypionate IM Injection Tev-Tropin Timolol Timoptic Ocudose Tizanidine Tab Tobramycin Tobramycin/Dexamethasone. 5 Tolterodine ER Topiramate Tab Torsemide Tab Toviaz Tracleer Tradjenta Tramadol Tab Tramadol w/ Acetaminophen 8 Transderm-Scop Travatan Z Trazodone Tretinoin Microsphere Gel.. 3 Triamcinolone Triamcinolone Spray Triamterene/HCTZ Triazolam Tab Tribenzor Trinessa Tri-Sprintec Truetrack Test Strips Truvada Tudorza Pressair U Uceris Uloric V Vagifem Valacyclovir Valsartan Valsartan/HCTZ Vascepa Vectical Venlafaxine Venlafaxine ER Cap..... Ventolin HFA Veramyst Verapamil ER Vesicare Vestura Vicodin Vicodin ES Victoza Vigamox Viibryd Viorele Viread Vitamin D Vivelle-Dot Voltaren Gel Vytorin Vytorin Tab 0-80 mg... 0 Vyvanse [Plain type = Generic drug] 26 W Warfarin Welchol Xarelto Xolair Xopenex HFA Z Zelapar Zenpep Zetia Zetonna Ziprasidone Cap Zolpidem Zolpidem ER Zomig Nasal Spray.... Zovirax Cream Zovirax Ointment Zubsolv Zutripro Zyclara Zytiga
27 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 I Take This Medicine For Directions Doctor Example: Lisinopril, 20 mg High blood pressure One tablet daily Dr. Johnson 27
28 optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum TM company a leading provider of integrated health services. Learn more at optum.com. All Optum TM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 205 OptumRx, Inc. ORX725 ORX6700A-COK_500 Core Standard
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