UMP Classic 2015 High Cost Generic Tier 2 Drug Program
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1 UMP Classic 2015 High Cost Generic Tier 2 Program The listing below identifies select generic medications that are covered under Tier 2 coinsurance level and possible cost effective alternatives. For additional cost effective alternatives not listed below, please contact Washington State Rx customer service at Consult with your prescriber to identify which alternative medications are right for you. NOTE: This list is subject to change. acetazolamide ER s Diamox extended release acetic acid/ hydrocortisone, Acetasol HC acetazolamide Vosol HC drops acetic acid/aluminum acetate drops acitretin Soriatane triamcinolone betamethasone acyclovir Zovirax ointment acyclovir s adapalene Differin lotion generic topical tretinoin almotriptan malate Axert generic sumatriptan rizatriptan alprazolam Niravam rapid dissolve alprazolam naratriptan amlodipine atorvastatin Caduet amlodipine + simvastatin amlodipine + atorvastatin amlodipine besylate/valsartan amlodipine valsartan hctz amphet asp/amphet/ d amphet Exforge losartan Exforge HCT losartan Adderall XR sustained release 24 hr methylin IR methylphenidate HCL ER apraclonidine hcl Lopidine drops latanoprost drops levobunolol drops aripiprazole odt Abilify Discmelt rapids olanzapine ODT aripiprazole aspirin dipyridamole ER Aggrenox clopidogrel azelastine hcl Optivar drops ketotifen drops (OTC not covered by UMP) risperidone (Revised 10/29/2015) Page 1
2 UMP Classic 2015 High Cost Generic Tier 2 Program azelastine hcl Astepro spray/pump fluticasone nasal spray oral antihistamines (OTC not covered by UMP) betamethasone dipropionate flunisolide nasal spray gel betamethasone cream fluocinolone cream betamethasone valerate Luxiq foam betamethasone valerate ointment, cream or lotion bimatoprost Lumigan drops generic latanoprost bromfenac sodium Bromday drops prednisolone sodium phosphate drops flurbiprofen sodium drops budesonide Entocort EC delayed & extended release dexamethasone prednisone ketorolac drops methylprednisolone Budesonide Rhinocort Aqua spray/pump fluticasone nasal spray flunisolide nasal spray buprenorphine naloxone Suboxone sublingual buprenorphine sublingual naltrexone butalbital acetaminophencaffeine butalbital acetaminophencaffeine codeine calcipotrienebethamethasone DP Fioricet butalbital acetaminophen caffeine Fioricet with Codeine butalbital acetaminophen caffeine codeine Taclonex ointment betamethasone triamcinolone candesartan cilexetil Atacand losartan candesartan cilexetil/hctz Atacand HCT losartan carbidopa levodopaentacapone Stalevo carbidopa levodopa cevimeline Evoxac pilocarpine s clindamycin phos benzoyl peroxide Duac gel clindamycin lotion erythromycin/benzoyl peroxide gel (Revised 10/29/2015) Page 2
3 UMP Classic 2015 High Cost Generic Tier 2 Program clindamycin phosphate Evoclin foam clindamycin lotion tretinoin cream clocortolone pivalate Cloderm cream triamcinolone betamethasone clonidine Catapres TTS 1 Catapres TTS 2 Catapres TTS 3 transdermal weekly patch clonidine HCL ER Kapvay extended release 12 hr table clonidine clonidine (immediate release) clozapine Fazaclo rapid dissolve clozapine s (immediate release) risperidone s clozapine ODT Fazaclo tab rapids generic clozapine oral colchicine Mitigare Colcrys & cyclobenzaprine hcl Amrix sustained release 24 hr allopurinol probenecid colchicine baclofen desloratadine Clarinex cetirizine (OTC) dexmethylphenidate HCL ER dexmethylphenidate HCL XR dextroamphetamine sulfate probenecid methocarbamol Focalin XR methylphenidate ER methylphenidate IR Focalin XR methylin IR methylphenidate ER Dexedrine sustained action methylin IR methylphenidate HCL ER diclofenac sodium Solaraze gel imiquimod cream fluorouracil cream diclofenac sodium Pennsaid drops oral NSAID diflorasone diacetate Apexicon E cream, ointment betamethasone cream hydrocortisone cream dihydroergotamine mesylate diltiazem hcl, Matzim LA D.H.E. 45 Migranal Cardizem LA ampule spray/pump sustained release 24hr isomethept/acetaminop/dichlphn amlodipine doxercalciferol Hectorol calcitriol sumatriptan nicardipine (Revised 10/29/2015) Page 3
4 UMP Classic 2015 High Cost Generic Tier 2 Program doxycycline hyclate Doryx, delayed release minocycline HCL doxycycline hyclate doxycycline IR DR (doxycycline monohydrate) doxycycline monohydrate (75 mg & 150 mg) Oracea topical metronidazole Adoxa Monodox minocycline HCL doxycycline hyclate dronabinol Marinol ondansetron prochlorperazine duloxetine HCL Irenka generic Cymbalta (duloxetine) dutasteride Avodart finasteride entacapone Comtan carbidopa levodopa ropinirole eplerenone Inspra spironolactone eprosartan Teveten losartan famotidine Pepcid oral suspension cimetidine solution oral ranitidine syrup fentanyl citrate Actiq lozenge morphine solution oral (solution) oxycodone morphine fluocinonide Vanos cream 0.05% flucinonide cream/ointment/gel triamcinolone fluorouracil Carac cream imiquimod fluoxetine HCL (90 mg), delayed release fluoxetine (immediate release) sertraline fluticasone propionate Cutivate lotion betamethasone cream betamethasone lotion hydrocortisone lotion fluvastatin er Lescol XL ER 24 hour atorvastatin lovastatin fluvastatin sodium Lescol simvastatin atorvastatin fluvoxamine maleate Luvox CR ER 24 hour fluvoxamine immediate release sertraline gavilyte H and bisacodyl Halflytely Bisacodyl KIT gavilyte C gavilyte G gavilyte N fluoxetine immediate release (Revised 10/29/2015) Page 4
5 UMP Classic 2015 High Cost Generic Tier 2 Program guanfacine hcl er Intuniv Tablet ER 24 hour dextroamphetamine/amphetamine methylin IR hydrocodone bitartrate/acetaminophen Vicodin 5MG 300MG Vicodin ES 7.5MG 300MG Vicodin HP 10MG 300MG hydrocodone acetaminophen 5MG 325MG hydrocodone acetaminophen 10MG 325MG hydromorphone ER Exalgo ER 24 hour morphine sulfate sustained action (generic for brand MS Contin ) ibandronate sodium Boniva alendronate sodium methylphenidate IR/ER hydrocodone acetaminophen 7.5MG 325MG methadone oxymorphone ER imipramine pamoate Tofranil PM amitriptyline imipramine Sotret, Claravis, Amnesteem (active ingredient: isotretinoin) adapalene gel adapalene cream tretinoin gel tretinoin cream ketoconazole foam ketoconazole cream econazole cream l methylfolate calcium Deplin folic acid lidocaine Lidoderm patch lidocaine cream/ointment meloxicam lindane lotion permethrin cream malathion Ovide lotion permethrin cream meclofenamate sodium etodolac meloxicam naproxen mefenamic acid Ponstel etodolac meloxicam naproxen meprobamate alprazolam diazepam mesalamine w/cleansing wipes Rowasa kit mesalamine enema (not kit) (Revised 10/29/2015) Page 5
6 UMP Classic 2015 High Cost Generic Tier 2 Program metaxalone Skelaxin baclofen methocarbamol metformin ER metformin hcl ER Fortamet metformin (immediate release) metformin sustained release methamphetamine hcl Desoxyn amphet asp/amphet/d amphet amphetamine salt combo) methazolamide Neptazane acetazolamide methylphenidate hcl Concerta, Ritalin LA extended release 24 hr, extended release methylin IR dextroamphetamine methylphenidate sustained action (generic for brand Ritalin SR s and brand Metadate ER s) methylphenidate hcl Methylin chew generic methylphenidate oral solution methylphenidate methylphenidate hcl CD Metadate CD methylin IR methylphenidate sustained action (generic for brand Ritalin SR s and brand Metadate ER s) methyltestosterone Testred generic injectable testosterone metoclopramide hcl odt Metozolv ODT rapids metoclopramide metronidazole Metrogel 1% gel metronidazole topical gel 0.75% sulfacetamide 10% sulfur 5% minocycline hcl Solodyn sustained release 24hr minocycline (immediate release) minocycline hcl Dynacin minocycline (immediate release) doxycycline modafinil Provigil methylin IR methylphenidate sustained action morphine sulfate Kadian, sustained release pellets morphine sulfate sustained action (generic for brand MS Contin ) morphine sulfate ER Avinza sustained release 24hr morphine sulfate sustained action (generic for brand MS Contin ) naftifine hcl Naftin cream ketoconazole ciclopriox (Revised 10/29/2015) Page 6
7 UMP Classic 2015 High Cost Generic Tier 2 Program naproxen sodium Naprelan 24hr TBMP generic naproxen IR naproxen sodium CR Naprelan 375 mg TBMP 24hr naproxen DR nateglinide Starlix glimepiride metformin niacin ER Niaspan extended release 24 hr fenofibrate simvastatin gemfibrozil atorvastatin nimodipine Nimotop amlodipine nicardipine nisoldipine Sular sustained release 24hr amlodipine nicardipine nitrofurantoin Furadantin oral suspension nitrofurantoin macrocrystal nitrofurantoin monohyd/m cryst nitroglycerin Nitrolingual Pumpspray non aerosol spray isosorbide dinitrate sublingual olanzapine/fluoxetine Symbyax olanzapine fluoxetine olopatadine HCL Patanase spray/pump fluticasone flunisolide opium tincture paregoric solution orphenadrine/aspirin/ caffeine baclofen methocarbamol oxycodone hcl oral concentrate morphine solution oral oxymorphone hcl morphine sulfate IR (immediate release) hydromorphone hcl oxymorphone hcl ER (7.5 mg & 15 mg) Opana ER sustained release 12 hr paroxetine hcl Paxil CR sustained release 24hr morphine ER fluoxetine (immediate release) fluoxetine sertraline pioglitazone HCL Actos metformin glipizide, glimepiride pioglitazone HCL/metformin HCL Actoplus Met metformin glipizide, glimepiride pramipexole DI HCL Pramipexole ER pramipexole IR (Revised 10/29/2015) Page 7
8 UMP Classic 2015 High Cost Generic Tier 2 Program pramipexole ER Mirapex ER pramipexole IR propafenone HCL Rythmol sustained release 12 hr propafenone HCL flecainide acetate protriptyline hcl Vivactil amitriptyline imipramine nortriptyline quazepam Doral zolpidem estazolam repaglinide Prandin metformin sulfonylurea risedronate sodium Actonel 35mg alendronate sodium risedronate sodium Actonel 5mg, 30mg alendronate ibandronate risedronate sodium DR Atelvia ER generic alendronate rivastigmine Exelon 4.6mg/24H 9.5mg patch TD24 ropinirole HCL Requip XL Sustained release 24 hour salicylic acid/ceramide CMB #1 rivastigmine oral pramipexole cleanser and cream kit salicylic acid shampoo salicylic acid gel ropinirole (immediate release) salicylic acid foam salicylic acid shampoo salicylic acid liquid sevelamer carbonate Renvela calcium acetate 667mg sucralfate Carafate oral suspension misoprostol sucralfate sulfacetamide sodium cleanser selenium suspension topical sulfacetamide sodium/sulfur Prascion FC medicated pads sulfacetamide sodium/sulfur cream sulfacetamide sodium/sulfur lotion sumatriptan succinate Imitrex cartridge naratriptan sumatriptan sumatriptan succinate Alsuma, Imitrex pen injector naratriptan sumatriptan sumatriptan succinate Imitrex vial naratriptan sumatriptan tacrolimus Protopic ointment topical anti inflammatory steroids (Revised 10/29/2015) Page 8
9 UMP Classic 2015 High Cost Generic Tier 2 Program telmisartan Micardis losartan telmisartan amlodipine Twynsta losartan telmisartanhydrochlorothiazid temazepam (7.5 mg & 22.5 mg) Micardis HCT losartan (Revised 10/29/2015) Page 9 Restoril temazepam 15 mg temazepam 30 mg testosterone (1.25 mg) Androgel gel (gram) testosterone cypionate testosterone enanthate testosterone (25 mg & 50mg) Androgel gel packet testosterone cypionate testosterone enanthate testosterone Fortesta gel injectable testosterone cypionate testosterone enanthate testosterone Testim Vogelxo gel testosterone cypionate testosterone enanthate tinidazole Tindamax metronidazole s tizanidine HCL Zanaflex tizanidine baclofen tolterodine tartrate Detrol/LA oxybutynin chloride tramadol HCL ER Conzip 100mg, 200mg, 300mg CPBP 25 75/CPBP tramadol ER Ryzolt extended release 24 hr tramadol HCL tramadol tretinoin Atralin 0.05% gel (gram) tretinoin cream generic Ultram ER triamcinolone acetonide Kenalog topical aerosol triamcinolone cream triamcinolone ointment and lotion triamcinolone acetonide Nasacort AQ aerosol spray flunisolide aerosol spray fluticasone spray suspension triamcinolone acetonide Oralone paste Orabase (OTC not covered by UMP) Oragel (OTC not covered by UMP) trospium chloride (XR) Sanctura (Sanctura XR ) oxybutynin urea (39%) cream urea 40% cream urea 50% cream
10 UMP Classic 2015 High Cost Generic Tier 2 Program venlafaxine HCL extended release 24 hr venlafaxine HCL venlafaxine HCL sustainted release 24 hr voriconazole Vfend ketoconazole fluconazole zolmitriptan (ODT) Zomig (Zomig ZMT ) rapid release zolpidem ER tartrate Ambien CR multiphasic release sumatriptan zolpidem naratriptan zaleplon (Revised 10/29/2015) Page 10
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