Preferred Drug List (PDL) - Ohio f ective Date: 11/1/19 - UHCprovider.com
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Preferred Drug List (PDL) Ohio Ef f ective Date: 11/1/19 © 2019 United HealthCare Services, Inc. All rights reserved.
Preferred Drug List
This PDL is not intended to be a substitute for the
INTRODUCTION knowledge, expertise, skill and judgment of the medical
UnitedHealthcare Community Plan is pleased to provide provider in their choice of prescription drugs.
this Preferred Drug List (PDL) to be used when prescribing
for patients covered by the pharmacy benefit plan offered UnitedHealthcare Community Plan assumes no
by UnitedHealthcare Community Plan. The drugs listed in responsibility for the actions or omissions of any medical
this PDL are intended to provide sufficient options to treat provider based upon reliance, in whole or in part, on the
patients who require treatment with a drug from that information contained herein. The medical provider should
pharmacologic or therapeutic class. The drugs listed in the consult the drug manufacturer’s product literature or
UnitedHealthcare Community Plan PDL have been standard references for more detailed information.
reviewed and approved by the UnitedHealthcare
Community Plan Pharmacy and Therapeutics Committee. National guidelines can be found on the Web sites listed in
The drugs have been selected to provide the most clinically the Web site section or go to the National Guideline
appropriate and cost-effective medications for patients who Clearinghouse site at http://www.guideline.gov.
have their drug benefit administered through
UnitedHealthcare Community Plan. It is also recognized The PDL and quarterly updates are also available on our
there may be occasions where an unlisted drug is desired web site at www.uhccommunityplan.com.
for proper medical management of a specific patient. In
those infrequent instances, the unlisted medication may be
requested through the Medical prior authorization process. PREFACE
The UnitedHealthcare Community Plan PDL is organized
The drugs represented have been reviewed by the by sections. Each section includes therapeutic groups
UnitedHealthcare Community Plan Pharmacy and identified by either a drug class or disease state.
Therapeutics (P&T) Committee and are approved for
inclusion. The PDL is reflective of current medical practice Products are listed by generic name. Brand names are
as of the date of review. included as a reference to assist in product recognition.
Unless exceptions are noted, generally all applicable
This edition incorporates drugs added to the PDL since the dosage forms and strengths of the drug cited are included in
last edition as well as numerous revisions to the prescribing the PDL. Generics should be considered the first line of
information based on changes in pharmacotherapy. prescribing.
Comments and suggestions from practicing physicians have
also been incorporated to ensure that the UnitedHealthcare The UnitedHealthcare Community Plan PDL covers
Community Plan PDL is reflective of current medical selected over-the-counter (OTC) products. Many are noted
practice. in the drug lists; a complete list is included on page 44.
You are encouraged to prescribe OTC medications when
clinically appropriate.
NOTICE
The information contained in this PDL and its appendices is
provided by UnitedHealthcare Community Plan, solely for
the convenience of medical providers. UnitedHealthcare
Community Plan does not warrant or assure accuracy of
such information nor is it intended to be comprehensive in
nature.
iPHARMACY AND THERAPEUTICS (P&T) PDL, examples are noted below. The general principles
COMMITTEE shown in the examples can then usually be extended to
The UnitedHealthcare Community Plan P&T Committee other entries in the book. Any exceptions are noted in the
includes physicians and pharmacists who are not employees drug list. There may also be a statement associated with a
or agents of UnitedHealthcare Community Plan or its drug list that gives additional information about which
affiliates. They must adhere to the Ethics Policy standards specific products or dosage forms are covered.
of the P&T Committee. UnitedHealthcare Community Plan
medical directors and pharmacists also participate in the Products covered include all strengths associated
P&T Committee. UnitedHealthcare Community Plan’s with the dosage form of the cited brand name
P&T Committee meets quarterly to discuss a variety of product.
issues. Those issues pertaining to pharmaceutical selection carvedilol Coreg
and pharmacy program management are communicated
quarterly. This newsletter is distributed to all participating All strengths of Coreg would be covered by this listing.
physicians who have received UnitedHealthcare
Community Plan’s PDL. PDL decisions are also Extended-release and delayed-release products
communicated quarterly on the UnitedHealthcare
require their own entry.
Community Plan internet site. diltiazem sustained release CARDIZEM SR
OUTPATIENT PRESCRIPTION DRUG Dosage forms covered will be consistent with the
BENEFIT-COVERED MEDICATIONS category and use where listed.
Medically necessary outpatient prescription drugs are
covered when prescribed by a provider licensed to
Neomycin/polymyxin B/ Cortisporin
prescribe federal legend drugs or medicines. Some items
Hydrocortisone
are covered only with prior authorization. Eligibility for
Outpatient Prescription Drug Benefits is based on the
As listed in the OTIC section, this is limited to the otic
individual member’s benefit plan.
solution and suspension. From this entry the ophthalmic
solution and ointment, and the topical cream cannot be
PRODUCT SELECTION CRITERIA assumed to be on the list unless there are entries for these
The UnitedHealthcare Community Plan P&T Committee products in the OPHTHALMIC and DERMATOLOGY
considers clinical information on new-to-market drugs that sections of the PDL.
are typically included in an outpatient pharmacy benefit.
The evaluation includes all or part of the following: When a strength or dosage form is specified, only the
• Safety specified strength and dosage form is on the PDL.
• Efficacy Other strengths/dosage forms of the reference product
• Comparison studies are not
• Approved indications
• Adverse effects citalopram 40 mg tabs Celexa tabs
• Contraindications/Warnings/Precautions
• Pharmacokinetics DRUG TIERS
• Patient administration/compliance considerations
• Medical outcome and pharmacoeconomic
The drugs listed in the PDL have different tiers. The tiers
studies
are listed in the grid below.
When a new drug is considered for PDL inclusion, it will
be reviewed relative to similar drugs currently included in
Tier Name Drug Tier
the UnitedHealthcare Community Plan PDL. This review
process may result in deletion of drug(s) in a particular Tier 1 Generic
therapeutic class in an effort to continually promote the Tier 2 Brand
most clinically useful and cost-effective agents.
GENERIC SUBSTITUTION
All the information in the PDL is provided as a reference The UnitedHealthcare Community Plan PDL requires
for drug therapy selection. Specific drug selection for an generic substitution on the majority of products when a
individual patient rests solely with the prescriber. generic equivalent is available.
PDL PRODUCT DESCRIPTIONS Generic substitution is a pharmacy action whereby a
To assist in understanding which specific strengths and generic equivalent is dispensed rather than the brand name
dosage forms are covered on the product. The PDL indicates generic availability in the
“Covered Drug” column.
iiIf a brand name drug is medically necessary, please submit indications, and a determination of “fully effective” was
a prior authorization request. made for most of these products and they remain in the
marketplace. A few DESI products remain classified as
The UnitedHealthcare Community Plan MAC list sets a “less than fully effective” while awaiting final
ceiling price for the reimbursement of certain multisource administrative disposition. Also, classified as DESI are
prescription drugs. This price will typically cover the many products listed as identical, similar, or related to
acquisition of most generics but not branded versions of the actual DESI products. UnitedHealthcare Community
same drug. The products selected for inclusion on the Plan’s PDL does not cover DESI “less than fully effective”
MAC list are commonly prescribed and dispensed and have drug products.
usually gone through the FDA’s review and approval
process. An important consideration for generic PLAN EXCLUSIONS
substitution is the knowledge that all approvals of generic The following drug categories are excluded from coverage
drugs by the FDA since 1984, and many generic approvals under the outpatient pharmacy benefit and are not part of
prior to 1984, have a showing of bioequivalence between the UnitedHealthcare Community Plan PDL.
the generic versions and the reference brand product. To
gain FDA approval: • DESI drugs
• Anti-obesity agents
1. The generic drug must contain the same active • Experimental / research drugs
ingredient(s), be the same strength and the same dosage • Cosmetic drugs
form as the brand name product. • Nutritional / diet supplements
• Blood and blood plasma products
2. The FDA has given the generic an “A” rating compared • Agents used to promote fertility
to the branded product indicating bioequivalence, and • Agents used for erectile dysfunction
has determined the generic is therapeutically equivalent • Agents used for cosmetic hair growth
to the reference brand. The ratings of generic drugs are • Drugs from manufacturers that do not participate
available by referring to the FDA reference, Approved in the FFS Medicaid Drug Rebate Program
Drug Products with Therapeutic Equivalence • Diagnostic products
Evaluations (Orange Book). • Medical supplies and DME except as listed:
insulin syringes, insulin needles, lancets, alcohol
When the above two criteria are met, a generic can be swabs, spacers, preferred diabetes test strips, peak
substituted with the full expectation that the substituted flow meters (Astech, Assess, Peak Air brands,
product will produce the same clinical effect and safety max two per year), vaporizer (limit of 1 per 3
profile as the prescribed product. Drug products that have a years), humidifier (limit of 1 per 3 years)
narrow therapeutic index (NTI) can also be guided by these
principles. It is not necessary for the health care provider to DAYS SUPPLY DISPENSING LIMITATIONS
approach any one therapeutic class of drug products (e.g., UnitedHealthcare Community Plan members may receive
NTI drugs) differently from any other class, when there has up to a one month supply of a specific medication per
been a determination of therapeutic equivalence by the prescription order or prescription refill. A medication may
FDA for the drug products under consideration. Also, be reordered or refilled when eighty-five percent (85%) of
additional clinical tests or examinations by the physician the medication has been utilized. If a claim is submitted
are not needed when a therapeutically equivalent generic before 85% of the medication has been used, based on the
drug product is substituted for the brand name product. original day supply submitted on the claim, the claim will
reject with a "refill too soon" message. Please call the
There are now many brand name products that are UnitedHealthcare Community Plan Pharmacy Department
repackaged or distributed under a generic label. The generic at 800-310-6826 with questions or for help with dosage
label version should always be considered therapeutically change authorization.
equivalent and substitutable for the source branded product.
MANDATORY GENERIC SUBSTITUTION
DRUG EFFICACY STUDY IMPLEMENTATION The UnitedHealthcare Community Plan PDL requires
(DESI) DRUGS mandatory generic substitution on the vast majority of
Drugs first marketed between 1938 and 1962 were products when a generic equivalent is available; however,
approved as safe but required no showing of effectiveness brand name drugs may be covered in certain situations by
for FDA approval. Beginning in 1962, all new drugs were requesting a prior authorization.
required to be both safe and effective before they could be The UnitedHealthcare Community Plan PDL prior
marketed. This legislation also applied retroactively to all authorization (PA) list does not include branded items
drugs approved as safe from 1938-1962. The DESI where a generic equivalent is covered.
program was established by the FDA to review the
effectiveness of these pre-1962 drugs for their labeled
iiiPRIOR AUTHORIZATION OF NON-PDL
MEDICATIONS Pharmacies may dispense a one-time, 15-day supply to
The drugs in the UnitedHealthcare Community Plan PDL members requiring an immediate supply of an ongoing
have been selected to provide the most clinically medication. The pharmacist must contact the plan to
appropriate and cost-effective medications for patients who obtain a manual 15-day override. Before the next
have their drug benefit administered through dispensing, the pharmacy must contact the physician to
UnitedHealthcare Community Plan. It is also recognized discuss a PDL drug or if a prior authorization request is
that there may be occasions where an unlisted drug is warranted. If the prescribing physician feels a drug is
desired for the proper medical management of a specific medically necessary, the physician may fax a request for
patient. In those infrequent instances, the prior prior authorization to UnitedHealthcare Community Plan at
authorization process reviews requests for unlisted 866-940-7328, Attn: Pharmacy Department.
medications the physician may consider medically
necessary for patient management. QUANTITY LIMITATIONS (QL)
Prescriptions for monthly quantities greater than the
Requests for these exceptions should be made in writing by indicated limit require a prior authorization request.
the physician and faxed or mailed to:
Quantity limits based on Efficient Medication Dosing
UnitedHealthcare Community Plan The Efficient Medication Dosing Program is designed to
Pharmacy Services Department consolidate medication dosage to the most efficient daily
Fax 866-940-7328 quantity to increase adherence to therapy and also promote
Phone 800-310-6826 the efficient use of health care dollars.
The limits for the program are established based on FDA
A prior authorization request form is available in the approval for dosing and the availability of the total daily
UnitedHealthcare Community Plan provider manual and dose in the least amount of tablets or capsules daily.
should be used for all prior authorization requests if Quantity Limits in the prescription claims processing
possible. Appropriate documentation must be provided to system will limit the dispensing to consolidate dosing. The
support the medical necessity of the non-PDL request. The pharmacy claims processing system will prompt the
UnitedHealthcare Community Plan Pharmacy Department pharmacist to request a new prescription order from the
will respond to all requests in accordance with state physician.
requirements.
Controlled Substances
Physicians are requested to adhere to this PDL when You may fill any FOUR medications from the following
prescribing for patients covered by their pharmacy benefit classes in a 30-day period:
plan offered by UnitedHealthcare Community Plan. If a • benzodiazepines
pharmacist receives a prescription for a non-PDL drug, the • sedative hypnotic agents
pharmacist should contact the prescribing physician and • barbiturates
request that the prescription be changed to a medication • select muscle relaxants
included in this PDL. If a PDL alternative is not Additional fills will require prior authorization.
appropriate the physician should then be instructed to Medications in these classes may also be subject to
contact the Plan for a prior authorization. individual quantity limits.
Please contact the UnitedHealthcare Community Plan
Pharmacy Department at 800-310-6826 with questions Additions to the QL program drug list will be made from
concerning the prior authorization process. time to time and providers notified accordingly. As always,
we recognize that a number of patient-specific variables
NON-PDL DRUGS 7-DAY AND 15-DAY OVERRIDES must be taken into consideration when drug therapy is
To ensure the use of PDL drugs, all non- PDL drugs should prescribed and therefore overrides will be available through
be discussed with the prescribing physician. If you cannot the medical exception (prior authorization) process. Please
speak to the physician immediately, and there is an contact the UnitedHealthcare Community Plan Pharmacy
immediate need for the medication, the claim processing Department at 800-310-6826 with questions.
system will accept an override to permit a one-time
dispensing of a 7-day supply of the newly prescribed Specialty Pharmaceutical Management Program
non-PDL drug. The pharmacy should submit a claim for a UnitedHealthcare Community Plan is continuously looking
7 day supply, with a PA Type of 8 and Prior Authorization for ways to provide high quality cost effective care for Plan
number of “00000000120”. members. The Specialty Pharmaceutical Management
Program helps UnitedHealthcare Community Plan to
Please note that non-preferred drugs are available for a 7- achieve these goals.
day supply, however availability is subject to the benefit Injectable medications that are part of this program require
design. For assistance, pharmacies may call 800-310- plan authorization and are not available through the retail
6826. pharmacy network.
ivTo obtain authorization, the provider must submit the
appropriate Prior Authorization form to the calcipotriene Trial of two medium to high
UnitedHealthcare Community Plan Pharmacy Department cream & oint potency corticosteroid topical
via fax at 866-940-7328. 0.005% treatments
The UnitedHealthcare Community Plan Pharmacy
Department will review and respond to all requests in calcitriol Trial of two medium to high potency
accordance with state requirements, and if authorized for 3mcg/gm corticosteroid topical treatments
payment, UnitedHealthcare Community Plan will
coordinate the delivery of the product to the member or DPP4 Inhibitors At least a 90 day trial of 1500mg/day of
provider. (Nesina, metformin.
Drugs that are part of this program and are on the PDL are Kazano, Oseni)
identified in this booklet by the designation "SP".
Prior Authorization request forms can be requested by Elidel Minimum age of 2. Trial of one topical
calling the UnitedHealthcare Community Plan Pharmacy corticosteroid.
Department 800-310-6826.
Eucrisa Trial of a topical corticosteroid AND one
MEDICATIONS REQUIRING DIAGNOSIS of the following: Elidel or tacrolimus
UnitedHealthcare Community Plan requires that the ointment.
diagnosis for prescriptions in certain classes match the
FDA-approved use or a use supported by current published fenofibrate Fill of a statin or 90 days of gemfibrozil
evidence. Drugs in scope will list “Diagnosis required” in within the previous 180 days.
the Requirements and Limits section on the PDL.
GLP-1 Agonists At least a 90 day trial of 1500mg/day of
The diagnosis will be verified at the point-of-sale by the (Adlyxin, metformin.
pharmacy claims processing system. If a matching , Trulicity)
diagnosis is not found in the medical claim file or on the
pharmacy drug claim, the prescription will be rejected at
the pharmacy. The pharmacist may then contact the GLP-1/Insulin Trial of one drug from the following
prescriber to verify the diagnosis and submit it on the Combinations classes: GLP-1 or Basal Insulin
claim. (Soliqua)
If the diagnosis provided still does not match the approved Optivar 14 day trial of ketotifen within previous
use, prior authorization may be requested through the 90 days required first.
standard process by faxing a request to 866-940-7328.
Ranexa Trial of one drug from the following
STEP THERAPY (ST) classes: beta blockers, calcium channel
The following PDL drugs are routinely covered only after a blockers, long acting nitrates
sufficient trial of an indicated first-line agent has been
adequately tried and failed. These medications may also be Renvela 8 week trial of calcium acetate.
requested through the Prior authorization process.
While lower cost PDL alternatives may be appropriate in SGLT-2 At least a 90 day trial of 1500mg/day of
many instances, other non- PDL alternatives are available Inhibitors metformin
with prior authorization (PA). (Jardiance, Invokana,
Invokamet, Invokamet XR,
STEP Drug First-Line Agent(s) Synjardy, Synjardy XR)
Amerge Trial at a minimum dose of 50mg of tacrolimus 0.03% Minimum age of 2. Trial of
sumatriptan tablets. one topical corticosteroid.
Aricept 23mg 90 day trial of Aricept 10mg daily
tacrolimus 0.1% Minimum age of 16. Trial of one
topical corticosteroid.
tolterodine 30 day trial of oxybutynin immediate
release. Step Therapy only applies to
members less than 65 years of age.
tretinoin cream Trial of Differin OTC Gel 0.1%.
(tretinoin cream
v0.025%, 0.05%, 0.1%, LEGEND
and Avita cream 0.025%) # Only the dosage forms/strengths of the brand
name products noted are on the PDL
OTC over-the-counter
trospium 30 day trial of oxybutynin immediate delayed-rel delayed-release (also known as enteric coated)
or extended release. Step Therapy only
applies to members less than 65 years EC
enteric-coated
of age. ext-rel
extended-release (also known as sustained-
release)
8 week trial of up to 600mg of PA Prior Authorization required
Uloric
allopurinol required first. QL Quantity Limits apply
ST Step Therapy, see pages V-VI for details
Specialty Pharmaceuticals, see page V for
Xopenex SP
30 day trial of Albuterol .083% or .5% details
Respules respules.
NOTICE
PDL SUGGESTIONS The information contained in this document is proprietary
Providers who wish to propose PDL suggestions should information. The information may not be copied in whole
forward the information to the UnitedHealthcare or in part without the written permission of
Community Plan Director of Pharmacy Services by either UnitedHealthcare Community Plan. All rights reserved.
mail or fax.
Attn: Director of Pharmacy Services The drug names listed here are the registered and/or
UnitedHealthcare Community Plan unregistered trademarks of third-party pharmaceutical
2 Allegheny Center companies unrelated to and unaffiliated with
Suite 600 UnitedHealthcare Community Plan. These trademarked
Pittsburgh, PA 15212 brand names are included here for informational purposes
Fax: 866-940-7328 only and are not intended to imply or suggest any
affiliation between UnitedHealthcare Community Plan and
Providers should furnish adequate documentation, such as such third-party pharmaceutical companies.
clinical studies from the medical literature, in order for the
request to be considered for PDL addition. This literature
If viewing this PDL via the Internet, please be advised that
should include information documenting clinical necessity
the PDL is updated periodically and changes may appear
as well as therapeutic advantages over current PDL
prior to their effective date to allow for notification.
products. Suggestions received by UnitedHealthcare
Community Plan will be reviewed by the Pharmacy and
Therapeutics Committee at the subsequent P&T Committee
meeting.
EDITOR
Your comments and suggestions regarding the
UnitedHealthcare Community Plan PDL are encouraged.
Your input is vital to this PDL’s continued success. All
responses will be reviewed and considered. Please send
your comments to:
UnitedHealthcare Community Plan
Director of Pharmacy Services
2 Allegheny Center
Suite 600
Pittsburgh, PA 15212
Phone: 800-310-6826
Email: pdl_management@uhc.com
Internet: http://www.uhccommunityplan.com
viUnitedHealthcare Community Plan of Ohio, Inc. no discrimina por motivos de sexo, edad, raza,
color, discapacidad o nacionalidad.
Si considera que no hemos proporcionado estos servicios o hemos discriminado de otro modo
en función del sexo, la edad, la raza, el color, la discapacidad o la nacionalidad, puede enviar una
reclamación al Coordinador de derechos civiles.
o En línea: UHC_Civil_Rights@uhc.com
o Por correo postal: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance.
P.O. Box 30608, Salt Lake City, UT 84130
Debe enviar la reclamación dentro de un plazo de 60 días desde que se enteró de la situación.
Se le enviará una decisión dentro de un plazo de 30 días. Si no está de acuerdo con la decisión,
tiene 15 días para pedirnos que analicemos la situación nuevamente. Si necesita ayuda con su
reclamación, llame al 1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes (correo de
voz disponible las 24 horas del día, los 7 días de la semana).
También puede presentar una reclamación ante el Departamento de Salud y Servicios Humanos
de los EE. UU. (U.S. Department of Health and Human Services).
o En línea: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Los formularios de reclamación están disponibles en http://www.hhs.gov/ocr/office/file/index.html.
o Por teléfono: línea gratuita 1-800-368-1019, 800-537-7697 (TDD)
o Por correo postal: U.S. Dept. of Health and Human Services. 200 Independence Avenue,
SW Room 509F, HHH Building Washington, D.C. 20201
Ofrecemos servicios gratuitos para ayudarle a comunicarse con
nosotros, como cartas en otros idiomas o en letra grande. O bien,
puede solicitar un intérprete. Para solicitar ayuda, llame a
1-800-895-2017 (TTY 711), de 7 a. m. a 7 p. m., de lunes a viernes
(correo de voz disponible las 24 horas del día, los 7 días de la
semana).
ATTENTION: If you speak English, language assistance services, free of charge, are available to
you. Please call 1-800-895-2017, TTY 711.
ATENCIÓN: si habla español (Spanish), tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-800-895-2017, TTY 711.
注意：如果您說中文 (Chinese)，您可獲得免費語言協助服務。請致電 1-800-895-2017，或聽障
專線 (TTY) 711。
LƯU Ý: Nếu quý vị nói Tiếng Việt (Vietnamese), chúng tôi có các dịch vụ hỗ trợ ngôn ngữ miễn phí cho
quý vị. Vui lòng gọi số 1-800-895-2017, TTY 711.
CSOH18MC4385074_000참고: 한국어(Korean)를 하시는 경우, 통역 서비스를 무료로 이용하실 수 있습니다.
1-800-895-2017, TTY 711 로 전화하십시오.
ATENSYON: Kung nagsasalita ka ng Tagalog (Tagalog), may magagamit kang mga serbisyo ng
pantulong sa wika, nang walang bayad. Tumawag sa 1-800-895-2017, TTY 711.
ВНИМАНИЕ: Если вы говори е по-русском (Russian), вы може е воспользова ься беспла ными
услугами переводчика. Звони е по ел 1-800-895-2017, TTY 711.
ً
الهاتف،1-800-895-2017 اتصل على الرقم.مجانا تتوفر لك خدمات المساعدة اللغوية،(Arabic) إذا كنت تتحدث العربية:تنبيه
.711 النصي
ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede
w nan lang pa w. Tanpri rele nan 1-800-895-2017, TTY 711.
ATTENTION : Si vous parlez français (French), vous pouvez obtenir une assistance linguistique
gratuite. Appelez le 1-800-895-2017, TTY 711.
UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy
zadzwonić pod numer 1-800-895-2017, TTY 711.
ATENÇÃO: Se fala português (Portuguese), encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-895-2017, TTY 711.
ATTENZIONE: se parla italiano (Italian), Le vengono messi gratuitamente a disposizione servizi di
assistenza linguistica. Chiami il numero 1-800-895-2017, TTY 711.
HINWEIS: Wenn Sie Deutsch (German) sprechen, stehen Ihnen kostenlose Sprachendienste zur
Verfügung. Wählen Sie: 1-800-895-2017, TTY 711.
ご注意：日本語 (Japanese) をお話しになる場合は、言語支援サービスを無料でご利用いただけま
す。電話番号1-800-895-2017、
またはTTY 711（聴覚障害者・難聴者の方用）
までご連絡ください。
. خدمات امداد زبانی به طور رایگان در اختیار شما می باشد،( استFarsi) اگر زبان شما فارسی:توجه
.TTY 711 ، تماس بگیرید1-800-895-2017
CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov
hu rau 1-800-895-2017, TTY 711.
ចំណាប់អារម្ម ណ៍៖ បបើសិនអ្ន កនិយាយភាសាខ្មែ រ (Khmer) បសវាជំនួយភាសាបោយឥតគិតថ្លៃ
គឺមានសំរាប់អ្នក។ សូ មទូ រស័ព្ទបៅបេខ 1-800-895-2017។ TTY 711។
PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan
bayadna, ket sidadaan para kaniam. Maidawat nga awagan iti 1-800-895-2017, TTY 711.OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah,
ayaad heli kartaa. Fadlan wac 1-800-895-2017, TTY 711.
ध्यान ददनुहोस:् ्दद तपयाईं नपालदी
े (Nepali) भयाषया बोलनहन्छ
ु ु भने तपयाईंको लयागि नन:शलकु भयाषया
सहया्तया सेवयाहरू उपलब्ध ्छन।् कृ प्या 1-800-895-2017, TTY 711, मया फोन िनहोस ुनु ।्
XIYYEEFFANNOO: Afaan Kushaitii (Cushite) dubbattu yoo ta’e, tajaajilli gargaarsa afaanii, kanfaltii
malee isiniif ni argama. Maaloo lak. 1-800-895-2017 n TTY 711 n bilbila’a.
LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel
1-800-895-2017, TTY 711.
WICHTIG: Wann du Deitsch schwetzscht (Pennsylvania Dutch) un Hilf witt mit Englisch, kenne
mer dich helfe, unni as es dich ennich ebbes koschte zellt. Ruf 1-800-895-2017, TTY 711 aa.
ATENȚIE: Dacă vorbiți limba română (Romanian), aveți la dispoziție servicii de asistență lingvistică
gratuite. Sunați la 1-800-895-2017, TTY 711.
УВАГА: Якщо ви не говори е українською (Ukrainian) мовою, ви може е скорис а ися
безкош овними послугами перекладача. Телефонуй е за номером 1-800-895-2017, TTY 711.UnitedHealthcare Community Plan of Ohio, Inc. does not discriminate because of sex, age,
race, color, disability or national origin.
If you believe that we have failed to provide these services or discriminated in another way on the
basis of sex, age, race, color, disability or national origin, you can send a complaint to the Civil
Rights Coordinator.
o Online: UHC_Civil_Rights@uhc.com
o Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608,
Salt Lake City, UT 84130
You must send the complaint within 60 days of when you found out about it. A decision will be
sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at
it again. If you need help with your complaint, please call 1-800-895-2017 (TTY 711) from 7 a.m. to
7 p.m. Monday through Friday (voicemail available 24 hours a day/7 days a week).
You can also file a complaint with the U.S. Dept. of Health and Human Services.
o Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
o Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
o Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F,
HHH Building Washington, D.C. 20201
We provide free services to help you communicate with us. Such
as, letters in other languages or large print. Or, you can ask for an
interpreter. To ask for help, please call 1-800-895-2017 (TTY 711)
from 7 a.m. to 7 p.m. Monday through Friday (voicemail available
24 hours a day/7 days a week).
ATTENTION: If you speak English, language assistance services, free of charge, are available to
you. Please call 1-800-895-2017, TTY 711.
ATENCIÓN: si habla español (Spanish), tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-800-895-2017, TTY 711.
注意：如果您說中文 (Chinese)，您可獲得免費語言協助服務。請致電 1-800-895-2017，或聽障
專線 (TTY) 711。
LƯU Ý: Nếu quý vị nói Tiếng Việt (Vietnamese), chúng tôi có các dịch vụ hỗ trợ ngôn ngữ miễn phí cho
quý vị. Vui lòng gọi số 1-800-895-2017, TTY 711.
참고: 한국어(Korean)를 하시는 경우, 통역 서비스를 무료로 이용하실 수 있습니다.
1-800-895-2017, TTY 711 로 전화하십시오.
ATENSYON: Kung nagsasalita ka ng Tagalog (Tagalog), may magagamit kang mga serbisyo ng
pantulong sa wika, nang walang bayad. Tumawag sa 1-800-895-2017, TTY 711.
CSOH18MC4385073_000ВНИМАНИЕ: Если вы говори е по-русском (Russian), вы може е воспользова ься беспла ными
услугами переводчика. Звони е по ел 1-800-895-2017, TTY 711.
ً
الهاتف،1-800-895-2017 اتصل على الرقم.مجانا تتوفر لك خدمات المساعدة اللغوية،(Arabic) إذا كنت تتحدث العربية:تنبيه
.711 النصي
ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede
w nan lang pa w. Tanpri rele nan 1-800-895-2017, TTY 711.
ATTENTION : Si vous parlez français (French), vous pouvez obtenir une assistance linguistique
gratuite. Appelez le 1-800-895-2017, TTY 711.
UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy
zadzwonić pod numer 1-800-895-2017, TTY 711.
ATENÇÃO: Se fala português (Portuguese), encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-895-2017, TTY 711.
ATTENZIONE: se parla italiano (Italian), Le vengono messi gratuitamente a disposizione servizi di
assistenza linguistica. Chiami il numero 1-800-895-2017, TTY 711.
HINWEIS: Wenn Sie Deutsch (German) sprechen, stehen Ihnen kostenlose Sprachendienste zur
Verfügung. Wählen Sie: 1-800-895-2017, TTY 711.
ご注意：日本語 (Japanese) をお話しになる場合は、言語支援サービスを無料でご利用いただけま
す。電話番号1-800-895-2017、
またはTTY 711（聴覚障害者・難聴者の方用）
までご連絡ください。
. خدمات امداد زبانی به طور رایگان در اختیار شما می باشد،( استFarsi) اگر زبان شما فارسی:توجه
.TTY 711 ، تماس بگیرید1-800-895-2017
ध्यान द:ें ्दद आप हिन्दी (Hindi) भयाषया बोलते हैं तो भयाषया सहया्तया सवयाए
े ं आपके ललए ननःशलक
ु
उपलब्ध ह।ैं कॉल करें 1-800-895-2017, TTY 711.
CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov
hu rau 1-800-895-2017, TTY 711.
ចំណាប់អារមណ៍
្ម ៖ បបើសិនអកនិ
្ន យាយភាសាខ្រមែ (Khmer) បសវាជំនួ យភាសាបោយឥតគិតថ្លៃ
ូ ព្ទ បៅបេខ 1-800-895-2017។ TTY 711។
គឺមានសំរាប់អ្ន ក។ សមទរស័
ូ
PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan
bayadna, ket sidadaan para kaniam. Maidawat nga awagan iti 1-800-895-2017, TTY 711.
D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné ЁNavajoЂ Bizaad, saad bee
1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-895-2017, TTY 711.
OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah,
ayaad heli kartaa. Fadlan wac 1-800-895-2017, TTY 711.ध्यान ददनहोस:
ु ् ्दद तपयाईं नपालदी
े (Nepali) भयाषया बोलनहन्छ
ु ु भने तपयाईंको लयागि नन:शलक
ु भयाषया
सहया्तया सवयाहरू
े उपलब्ध ्छन।् कृ प्या 1-800-895-2017, TTY 711, मया फोन िनहोस।ुनु ्
XIYYEEFFANNOO: Afaan Kushaitii (Cushite) dubbattu yoo ta’e, tajaajilli gargaarsa afaanii, kanfaltii
malee isiniif ni argama. Maaloo lak. 1-800-895-2017 n TTY 711 n bilbila’a.
LET OP: Als u Nederlands (Dutch) spreekt, kunt u gratis gebruikmaken van taalhulpdiensten. Bel
1-800-895-2017, TTY 711.
WICHTIG: Wann du Deitsch schwetzscht (Pennsylvania Dutch) un Hilf witt mit Englisch, kenne
mer dich helfe, unni as es dich ennich ebbes koschte zellt. Ruf 1-800-895-2017, TTY 711 aa.
ATENȚIE: Dacă vorbiți limba română (Romanian), aveți la dispoziție servicii de asistență lingvistică
gratuite. Sunați la 1-800-895-2017, TTY 711.
УВАГА: Якщо ви не говори е українською (Ukrainian) мовою, ви може е скорис а ися
безкош овними послугами перекладача. Телефонуй е за номером 1-800-895-2017, TTY 711.
သတိမူရန္ - အကယ္၍ သင္သည္ ျမန္မာ (Burmese) စကားေျပာလွ်င္၊ ဘာသာစကားဆိုင္ရာ ပံ့ပိုးေထာက္ပံ့မႈ
ိ မည္ျဖစ္သည္။ ေက်းဇူးျပဳၿပီး 1-800-895-2017, TTY 711 သို႔ ေခၚဆိုပါ။
ဝန္ေဆာင္မႈမ်ားကို သင္ အခမဲ့ ရ႐ွႏိ ုင္Table of Contents
Antineoplastics & Immunosuppressants . . . 4 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . 4
Hormonal Antineoplastic Agents . . . . . . . . . . . . . 5 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . 18
Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . 6 Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . 6 Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . 18
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . 20
Blood Modifiers - Anticoagulants . . . . . . . . . 7 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Hematopoietic Agents . . . . . . . . . . . . . . . . . . . . . . 7
Scabies and Pediculosis . . . . . . . . . . . . . . . . . . 20
Platelet Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Cardiovascular Agents . . . . . . . . . . . . . . . . . 8
Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Ear, Nose & Throat . . . . . . . . . . . . . . . . . . . . 22
Ace Inhibitor/Diuretic Combinations . . . . . . . . . . 8 Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Adrenolytics, Central . . . . . . . . . . . . . . . . . . . . . . . 9 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Throat and Mouth . . . . . . . . . . . . . . . . . . . . . . . . 23
Angiotensin II Receptor Blockers
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . 24
(Antagonists) . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Adrenal Corticosteroids . . . . . . . . . . . . . . . . . . . 24
Angiotensin II Receptor Blocker
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antiarrhythmics and Cardiac Glycosides . . . . . . 9 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 24
Beta Blockers and Beta Blocker/Diuretic Growth Stimulating Agents . . . . . . . . . . . . . . . . 26
Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Lipodystropy Agents . . . . . . . . . . . . . . . . . . . . . . 26
Calcium Channel Blockers . . . . . . . . . . . . . . . . 10 Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Calcium Channel Blockers/ACE Inhibitor Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . 26
Combination . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . 27
Lipid Lowering Agents . . . . . . . . . . . . . . . . . . . . 11
Constipation/Laxatives . . . . . . . . . . . . . . . . . . . 27
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Potassium-Removing Agents . . . . . . . . . . . . . . 12
Pulmonary Arterial Hypertension . . . . . . . . . . . 12 Emesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Gastroesophageal Reflux Disease (Gerd)/
Peptic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Central Nervous System . . . . . . . . . . . . . . . 13 Gastrointestinal Spasm . . . . . . . . . . . . . . . . . . . 28
Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . 13 Inflammatory Bowel Disease . . . . . . . . . . . . . . . 29
Amyotrophic Lateral Sclerosis (ALS) . . . . . . . . 13 Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . 29
Analeptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Probiotic Supplementation . . . . . . . . . . . . . . . . 29
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Migraine Acute Therapy . . . . . . . . . . . . . . . . . . . 15
Migraine Prophylactic Therapy . . . . . . . . . . . . . 15 Infectious Diseases . . . . . . . . . . . . . . . . . . . 30
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 15 Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . 16 Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . 16 Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Antiprotozoals . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Symptomatic Benign Prostatic Hypertrophy . . 53
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Musculoskeletal . . . . . . . . . . . . . . . . . . . . . . 35
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Vitamins and Minerals . . . . . . . . . . . . . . . . . 54
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . 37
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 57
OB-GYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Hormone Therapy/Menopause . . . . . . . . . . . . 38 Hereditary Angioedema . . . . . . . . . . . . . . . . . . . 57
Ovulation Stimulants . . . . . . . . . . . . . . . . . . . . . 39 Hyperphosphatemia . . . . . . . . . . . . . . . . . . . . . . 57
Vaginal Infections . . . . . . . . . . . . . . . . . . . . . . . . 39 Idiopathic Pulmonary Fibrosis (IPF) . . . . . . . . . 57
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Medical Devices . . . . . . . . . . . . . . . . . . . . . . . . . 57
Metabolic Modifiers . . . . . . . . . . . . . . . . . . . . . . 58
Ophthalmic . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Anti-Inflammatories . . . . . . . . . . . . . . . . . . . . . . . 40
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 OTC MEDICATIONS . . . . . . . . . . . . . . . . . . . 60
Immunologic Agents . . . . . . . . . . . . . . . . . . . . . 42 Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . 60
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Cough/Cold Allergy . . . . . . . . . . . . . . . . . . . . . . 60
Alcohol Deterrents . . . . . . . . . . . . . . . . . . . . . . . 42 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Earwax Removal Products . . . . . . . . . . . . . . . . . 61
Attention Deficit Hyperactivity Disorder Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
(ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 43 Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Lice Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Medications Coverable for Participating Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . 62
Behavioral Health Prescribers . . . . . . . . . . . 45 Ophthalmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . 47 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Smoking Cessation Products . . . . . . . . . . . . . . 63
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 48 Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Vitamins/Minerals . . . . . . . . . . . . . . . . . . . . . . . . 63
Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Respiratory Drugs . . . . . . . . . . . . . . . . . . . . 48 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Antitussives, Decongestants, Expectorants
and Combinations . . . . . . . . . . . . . . . . . . . . . 48 Index of Covered Drugs . . . . . . . . . . . . . . . . 64
Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
Antineoplastics & Immunosuppressants
Antineoplastic Agents
Alkylating Agents
altretamine HEXALEN brand 2
busulfan MYLERAN brand 2
chlorambucil LEUKERAN brand 2
cyclophosphamide CYCLOPHOSPH generic 1 inj 500 mg, PA
cyclophosphamide CYTOXAN generic 1
estramustine
EMCYT brand 2
phosphate sodium
lomustine GLEOSTINE brand 2
melphalan ALKERAN brand 2
temozolomide TEMODAR generic 1 PA, SP
Antimetabolites
capecitabine XELODA generic 1 SP
mercaptopurine PURINETHOL generic 1
thioguanine TABLOID brand 2 QL
trifluridine/tipiracil LONSURF brand 2 PA, SP
Histone Deacetylase Inhibitors
panobinostat FARYDAK brand 2 PA, SP
vorinostat ZOLINZA brand 2 PA, SP
Isocitrate Dehydrogenase (IDH) Inhibitors
enasidenib IDHIFA brand 2 PA, QL, SP
ivosidenib TIBSOVO brand 2 PA, QL, SP
Kinase Inhibitors
abemaciclib VERZENIO brand 2 PA, SP
acalabrutinib CALQUENCE brand 2 PA, QL, SP
afatinib GILOTRIF brand 2 PA, SP
alectinib ALECENSA brand 2 PA, SP
axitinib INLYTA brand 2 PA, SP
bosutinib BOSULIF brand 2 PA, SP
brigatinib ALUNBRIG brand 2 PA, SP
CABOMETYX
cabozantinib brand 2 PA, SP
COMETRIQ
ceritinib ZYKADIA brand 2 PA, SP
cobimetinib COTELLIC brand 2 PA, SP
crizotinib XALKORI brand 2 PA, SP
dabrafenib TAFINLAR brand 2 PA, SP
dasatinib SPRYCEL brand 2 PA, SP
erlotinib TARCEVA brand 2 PA, SP
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
4Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
AFINITOR
everolimus brand 2 PA, SP
AFINITOR DISPERZ
gefitinib IRESSA brand 2 PA, SP
ibrutinib IMBRUVICA brand 2 PA, SP
idelalisib ZYDELIG brand 2 PA, SP
imatinib mesylate GLEEVEC generic 1 PA, QL, SP
lapatinib ditosylate TYKERB brand 2 PA, SP
larotrectinib VITRAKVI brand 2 PA, QL, SP
lenvatinib LENVIMA brand 2 PA, SP
midostaurin RYDAPT brand 2 PA, SP
nilotinib TASIGNA brand 2 PA, SP
palbociclib IBRANCE brand 2 PA, SP
pazopanib VOTRIENT brand 2 PA, SP
ponatinib ICLUSIG brand 2 PA, SP
regorafenib STIVARGA brand 2 PA, SP
ruxolitinib JAKAFI brand 2 PA, SP
sorafenib NEXAVAR brand 2 PA, SP
sunitinib SUTENT brand 2 PA, SP
trametinib MEKINIST brand 2 PA, SP
vandetanib CAPRELSA brand 2 PA, SP
vemurafenib ZELBORAF brand 2 PA, SP
Miscellaneous
leucovorin LEUCOVORIN generic 1 QL, tabs
mesna MESNEX brand 2 SP, tablets
venetoclax VENCLEXTA brand 2 PA, SP
Proteasome Inhibitors
ixazomib NINLARO brand 2 PA, SP
Hormonal Antineoplastic Agents
Androgen Biosynthesis Inhibitors
PA, SP, 250 mg
abiraterone ZYTIGA generic 1
tablets only
Antiandrogens
apalutamide ERLEADA brand 2 PA, QL, SP
bicalutamide CASODEX generic 1
flutamide EULEXIN generic 1
Antiestrogens
tamoxifen NOLVADEX generic 1
toremifene FARESTON brand 2
Aromatase Inhibitors
anastrozole ARIMIDEX generic 1
exemestane AROMASIN generic 1
letrozole FEMARA generic 1
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
5Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
Gonadotropin Releasing Hormone Analog
leuprolide LUPRON generic 1 PA, SP
LUPRON DEPOT
leuprolide LUPRON DEPOT 6-MONTH brand 2 PA, SP
LUPRON DEPOT-PED
Progestin
megestrol acetate MEGACE generic 1
Immunomodulators
Interferons
interferon gamma-1b ACTIMMUNE brand 2 PA, SP
3,000,000 unit/0.2 ML
interferon alfa-2b INTRON A brand 2
only, PA, SP
peginterferon alfa-2b SYLATRON brand 2 PA, SP
Miscellaneous
lenalidomide REVLIMID brand 2 PA, SP
pomalidomide POMALYST brand 2 PA, SP
Immunosuppressants
Antimetabolites
azathioprine IMURAN generic 1
mycophenolate mofetil CELLCEPT generic 1
mycophenolate sodium MYFORTIC generic 1
Calcineurin Inhibitors
cyclosporine SANDIMMUNE generic 1
GENGRAF
cyclosporine, modified generic 1 caps, QL
NEORAL
HECORIA
tacrolimus generic 1
PROGRAF
Other
everolimus ZORTRESS brand 2
Rapamycin Derivative
sirolimus RAPAMUNE generic 1 tabs
sirolimus RAPAMUNE generic 1 soln
Miscellaneous
alitretinoin 1% gel PANRETIN brand 2 PA
bexarotene caps and
TARGRETIN brand 2 PA, SP
topical gel
cysteamine bitartrate CYSTAGON brand 2 SP
etoposide VEPESID generic 1
glasdegib DAURISMO brand 2 PA, QL, SP
hydroxyurea DROXIA brand 2
hydroxyurea HYDREA generic 1
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
6Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
leucovorin calcium WELLCOVORIN generic 1
mitotane LYSODREN brand 2 PA
niraparib ZEJULA brand 2 PA, SP
octreotide SANDOSTATIN generic 1 PA, SP
olaparib LYNPARZA brand 2 PA, SP
pasireotide SIGNIFOR brand 2 PA, SP
procarbazine MATULANE brand 2 SP
rucaparib RUBRACA brand 2 PA, SP
sonidegib ODOMZO brand 2 PA, SP
thalidomide THALOMID brand 2 PA, SP
topotecan HYCAMTIN brand 2 PA, SP
tretinoin VESANOID generic 1 caps, SP
vismodegib ERIVEDGE brand 2 PA, SP
Blood Modifiers - Anticoagulants
Anticoagulants
apixaban ELIQUIS brand 2 QL
betrixaban BEVYXXA brand 2 QL
edoxaban SAVAYSA brand 2 QL
enoxaparin LOVENOX generic 1 QL
INJ 5000 UNIT/ML, PF
heparin HEPARIN generic 1 INJ 5000 UNIT/0.5ML,
INJ 10000 UNIT/ML
warfarin generic 1
Hematopoietic Agents
darbepoetin alfa ARANESP brand 2 PA, SP
eltrombopag PROMACTA brand 2 PA, SP
epoetin alfa-epbx RETACRIT brand 2 PA, SP
filgrastim ZARXIO brand 2 PA, SP
lusutrombopag MULPLETA brand 2 PA, QL, SP
oprelvekin NEUMEGA brand 2 PA, SP
pegfilgrastim NEULASTA brand 2 PA, SP
plerixafor MOZOBIL brand 2 PA, SP
sargramostim LEUKINE brand 2 PA, SP
Platelet Inhibitors
anagrelide AGRYLIN generic 1
BAYER
aspirin generic 1 OTC
ECOTRIN
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
7Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
cilostazol PLETAL generic 1
clopidogrel PLAVIX generic 1 QL
dipyridamole PERSANTINE generic 1
prasugrel EFFIENT generic 1 Diagnosis Required
ticagrelor BRILINTA generic 1 Diagnosis Required, QL
Miscellaneous
aminocaproic acid AMICAR generic 1 tabs, QL
aminocaproic acid AMICAR SOLUTION brand 2 oral solution, QL
caplacizumab-yhdp CABLIVI brand 2 PA, SP
EXJADE
deferasirox brand 2 PA, SP
JADENU
emicizumab-kxwh HEMLIBRA brand 2 PA, QL, SP
pentoxifylline
TRENTAL generic 1
extended-release
Cardiovascular Agents
Ace Inhibitors
benazepril LOTENSIN generic 1
captopril CAPOTEN generic 1
enalapril VASOTEC generic 1
Members ≥ 8 years of
enalapril oral soln EPANED brand 2 age will require prior
authorization.
fosinopril MONOPRIL generic 1 QL
lisinopril ZESTRIL generic 1 QL
moexipril hcl UNIVASC generic 1
perindopril erbumine ACEON generic 1
quinapril ACCUPRIL generic 1 QL
ramipril ALTACE generic 1
trandolapril MAVIK generic 1
Ace Inhibitor/Diuretic Combinations
benazepril/
LOTENSIN HCT generic 1
hydrochlorothiazide
captopril/
CAPOZIDE generic 1
hydrochlorothiazide
enalapril/
VASERETIC generic 1
hydrochlorothiazide
fosinopril/
MONOPRIL-HCT generic 1 QL
hydrochlorothiazide
lisinopril/
ZESTORETIC generic 1 QL
hydrochlorothiazide
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
8Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
moexipril-
UNIRETIC generic 1
hydrochlorothiazide
quinapril/
ACCURETIC generic 1 QL
hydrochlorothiazide
Adrenolytics, Central
clonidine CATAPRES generic 1
clonidine transdermal CATAPRES- TTS generic 1
guanfacine TENEX generic 1
Alpha Blockers
doxazosin CARDURA generic 1
prazosin MINIPRESS generic 1
terazosin HYTRIN generic 1
Angiotensin II Receptor Blockers (Antagonists)
losartan COZAAR generic 1 QL
Angiotensin II Receptor Blocker Combinations
losartan/HCTZ HYZAAR generic 1 QL
sacubitril/valsartan ENTRESTO brand 2 PA, QL
Antiarrhythmics and Cardiac Glycosides
amiodarone tabs CORDARONE generic 1 200 mg and 400 mg
digoxin LANOXIN generic 1
disopyramide NORPACE generic 1
disopyramide
NORPACE CR brand 2
extended-release
dofetilide TIKOSYN generic 1
flecainide TAMBOCOR generic 1
mexiletine MEXITIL generic 1
propafenone RYTHMOL generic 1 IR only
quinidine gluconate QUINIDINE GLUCONATE
generic 1
extended-release EXT-REL
quinidine sulfate QUINIDINE SULFATE generic 1
quinidine sulfate QUINIDINE SULFATE
generic 1
extended-release EXT-REL
Beta Blockers and Beta Blocker/Diuretic Combinations
acebutolol SECTRAL generic 1
atenolol TENORMIN generic 1
atenolol/chlorthalidone TENORETIC generic 1
betaxolol KERLONE generic 1
bisoprolol ZEBETA generic 1
bisoprolol/
ZIAC generic 1
hydrochlorothiazide
carvedilol COREG generic 1 QL
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
9Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
labetalol TRANDATE generic 1
metoprolol LOPRESSOR generic 1 25, 50, 100mg tablets
metoprolol succinate TOPROL XL generic 1
nadolol CORGARD generic 1
propranolol INDERAL generic 1
propranolol ER 24hr INDERAL LA generic 1 Diagnosis Required, QL
propranolol/HCTZ INDERIDE generic 1
sotalol BETAPACE generic 1
sotalol AF BETAPACE AF generic 1
Calcium Channel Blockers
Dihydropyridines
amlodipine NORVASC generic 1 QL
felodipine
PLENDIL generic 1 QL
extended-release
nicardipine CARDENE generic 1
nifedipine PROCARDIA generic 1
nifedipine ADALAT CC
generic 1 QL
extended-release PROCARDIA XL
nimodipine NIMOTOP generic 1 QL
nimodipine oral soln NYMALIZE brand 2
Nondihydropyridines
diltiazem CARDIZEM generic 1
diltiazem
CARDIZEM CD generic 1 QL
extended-release
diltiazem DILACOR XR
generic 1 QL
extended-release TIAZAC
diltiazem
CARDIZEM SR generic 1 QL
sustained-release
verapamil CALAN generic 1
verapamil
CALAN SR generic 1 QL
extended-release
Calcium Channel Blockers/ACE Inhibitor Combination
amlodipine-benazepril LOTREL generic 1
Diuretics
amiloride MIDAMOR generic 1
amiloride/
MODURETIC generic 1
hydrochlorothiazide
bumetanide BUMEX generic 1
chlorothiazide DIURIL generic 1
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
10Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
DIURIL ORAL
chlorothiazide brand 2 QL
SUSPENSION
chlorthalidone CHLORTHALIDONE generic 1
furosemide LASIX generic 1
hydrochlorothiazide HYDROCHLOROTHIAZIDE generic 1 soln, tabs
hydrochlorothiazide MICROZIDE generic 1 12.5 mg caps
indapamide LOZOL generic 1
metolazone ZAROXOLYN generic 1
spironolactone ALDACTONE generic 1
spironolactone/
ALDACTAZIDE generic 1
hydrochlorothiazide
torsemide DEMADEX generic 1
triamterene/ DYAZIDE
generic 1
hydrochlorothiazide MAXZIDE
Lipid Lowering Agents
Bile Acid Resin
Only the bulk products
QUESTRAN are covered (cans).
cholestyramine generic 1
QUESTRAN-LIGHT Individual packets are not
covered.
Fibrates
fenofibrate LIPOFEN brand 2 cap
fenofibrate LOFIBRA generic 1 ST
gemfibrozil LOPID generic 1
HMG-CoA Reductase Inhibitors and Combinations
atorvastatin LIPITOR generic 1 QL
lovastatin MEVACOR generic 1 QL
simvastatin ZOCOR generic 1 QL
Others
fish oil caps FISH OIL generic 1 OTC
inositol niacinate NIACINOL generic 1 500 mg caps only, OTC
Niacins
niacin NIACOR generic 1
niacin extended-release NIASPAN generic 1
Miscellaneous
PA, QL, SP, NDC starting
alirocumab PRALUENT brand 2
w/72733 pref w/PA
PA, QL, SP, NDC starting
evolocumab REPATHA brand 2
w/72511 pref w/PA
ezetimibe ZETIA generic 1 PA
omega 3 acid
LOVAZA generic 1 PA
ethyl esters
OTC = Over the Counter ST = Step Therapy *Available without PA for
PA = Prior Authorization required SP = Specialty Pharmacy participating Behavioral Health
QL = Quantity Limit Prescribers
11Covered
Generic Drug Name Brand Drug Name Tier Requirements & Limits
Drug
Nitrates
Oral
isosorbide dinitrate ISORDIL generic 1
isosorbide dinitrate ISOSORBIDE
generic 1
extended-release DINITRATE ER
isosorbide mononitrate ISMO generic 1
isosorbide mononitrate
IMDUR generic 1
extended-release
Sublingual
isosorbide dinitrate ISORDIL S.L. generic 1
nitroglycerin NITROLINGUAL generic 1
nitroglycerin NITROSTAT generic 1
Transdermal
NITREK transdermal, not 0.3 mg
nitroglycerin generic 1
NITRO-DUR or 0.8 mg, QL
nitroglycerin NITRO-BID generic 1 oint
Potassium-Removing Agents
patiromer VELTASSA brand 2 PA, QL
sodium polystyrene
KALEXATE generic 1 powder
sulfonate
sodium polystyrene
KAYEXALATE generic 1 susp only
sulfonate
sodium zirconium
LOKELMA brand 2 PA, QL
cyclosilicate
Pulmonary Arterial Hypertension
ambrisentan LETAIRIS generic 1 Diagnosis Required, SP
MembersYou can also read
