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Your 2019 Prescription Drug ListAdvantage Three-TierEffectiveJan. 1,1,2019EffectiveJanuary2019This Prescription Drug List (PDL) is accurate as of Jan. 1 2019 and is subject to change afterthis date. The next anticipated update will be July 1, 2019. This PDL applies to members of ourUnitedHealthcare, Neighborhood Health Plan, River Valley, All Savers and Oxford medical planswith a pharmacy benefit subject to the Advantage Three-Tier PDL. Your estimated coverage andcopayment/coinsurance may vary based on the benefit plan you choose and the effective dateof the plan.
Table of ContentsGastrointestinalAcid Suppression. . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . 16Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Understanding your PrescriptionDrug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Medication tips . . . . . . . . . . . . . . . . . . . . . . 5Reading your PDL. . . . . . . . . . . . . . . . . . . . 6Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . 8Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . 17Drugs by category . . . . . . . . . . . . . . . . . . . 9HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . 17Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals. . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . 18Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis,Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . 18Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Cardiovascular/Heart DiseaseCoagulation Therapy. . . . . . . . . . . . . . . . . .High Blood Pressure. . . . . . . . . . . . . . . . . .High Cholesterol . . . . . . . . . . . . . . . . . . . . .Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Central Nervous SystemAttention Deficit Disorder. . . . . . . . . . . . . . .Depression . . . . . . . . . . . . . . . . . . . . . . . . .Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . .Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . .Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sedatives/Hypnotics . . . . . . . . . . . . . . . . . .Seizure Disorders . . . . . . . . . . . . . . . . . . . .Medications for Sexual Dysfunction. . . . 18Men’s HealthProstate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Testosterone Therapy. . . . . . . . . . . . . . . . . 1910101111Miscellaneous. . . . . . . . . . . . . . . . . . . . . . 19MusculoskeletalMuscle Spasms. . . . . . . . . . . . . . . . . . . . . . 19Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . 20Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . 2011121212121313Overactive Bladder. . . . . . . . . . . . . . . . . . 20RespiratoryAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . 20Pulmonary Arterial Hypertension. . . . . . . . 21Dermatology . . . . . . . . . . . . . . . . . . . . . . . 13DiabetesBlood Glucose Monitoring. . . . . . . . . . . . . . 14Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 15Smoking Cessation. . . . . . . . . . . . . . . . . . 21Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 21Vitamins/Electrolytes. . . . . . . . . . . . . . . . 22EndocrineGrowth Hormone. . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Thyroid Hormone Replacement. . . . . . . . . . 16Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . .Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . .Dry Eye Disease. . . . . . . . . . . . . . . . . . . . .Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . .Women’s HealthContraceptives. . . . . . . . . . . . . . . . . . . . . . .Hormone Replacement. . . . . . . . . . . . . . . .Miscellaneous. . . . . . . . . . . . . . . . . . . . . . .Prenatal Vitamins . . . . . . . . . . . . . . . . . . . .1616161622242424Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Understanding your Prescription Drug List (PDL)What is a PDL?This document is a list of the most commonlyprescribed medications. It includes both brand-nameand generic prescription medications approved by theFood and Drug Administration (FDA). Medications arelisted by common categories or classes and placedin tiers that represent the cost you pay out-of-pocket.They are then listed in alphabetical order.How do I use my PDL?You and your doctor can consult the PDL to help youselect the most cost-effective prescription medications.This guide tells you if a medication is generic or abrand-name, and if there are coverage requirements orlimits. Bring this list with you when you see your doctor.If your medication is not listed here, please visit yourplan’s member website or call the toll-free memberphone number on your health plan ID card.About this PDLWhere differences exist betweenthis PDL and your benefit plandocuments, the benefit plandocuments rule. This PDL is nota complete list of medications,and not all medications listedmay be covered by your plan.Please look at the benefit plandocuments provided by youremployer or health plan to seewhich medications are coveredunder your plan.What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,determined by your employer or benefit plan. This is how much you will pay whenyou fill a prescription. See page 6 for additional information.When does the PDL change?PDL changes typically occur twice per year. However, changes that have a positive impact foryou — such as coverage for new medications or cost savings — may occur at any time. Youcan log in to the member website listed on your health plan ID card at any time to check yourmedication coverage and lower-cost options.3
Understanding your Prescription Drug List (continued)Why are some medications excluded from coverage?We review medications based on their total value, including effectiveness and safety, how muchthey cost, and the availability of alternative medications to treat the same or similar medicalconditions. Certain medications may be excluded from coverage or subject to prior authorization(sometimes referred to as precertification)1 if similar alternatives are available at a lower cost.Examples include medications that work the same way, but one is much more expensive thanthe other, or options that are available without a prescription (also referred to as over-the-countermedications2). There are also some instances where the same product can be made by two ormore manufacturers, but greatly vary in cost. In these instances, only the lower-cost product maybe covered.You should review your benefit plan documents to confirm if any medications are excluded fromyour plan. You can log in to the member website listed on your health plan ID card at any time tocheck your medication coverage. Talk to your doctor to see if there are lower-cost options or overthe-counter medications available.Who decides which medications are covered?Thousands of medications are already available and more come to the market regularly.Often, several medications are available to treat the same condition. The UnitedHealthcare Pharmacy and Therapeutics Committee, which includes both internal and external physicians andpharmacists, meets regularly to provide clinical reviews of all medications. Using this information,the PDL Management Committee, which includes senior UnitedHealth Group physicians andbusiness leaders, meets to evaluate overall health care value. They also determine coverage andtier status for all medications.1. Depending on your benefit, you may have notification or medical necessity requirements forselect medications.2. For New York and New Jersey plans, a prescription drug product that is therapeuticallyequivalent to an over-the-counter drug may be covered if it is determined to be medicallynecessary.4
Medication tipsWhat is the difference between brand-name andgeneric medications?Generic medications contain the same activeingredients (what makes the medication work) asbrand-name medications, but they often cost less.Once the patent for a brand-name medication ends,the FDA can approve a generic version with the sameactive ingredients. These types of medications areknown as generic medications. Sometimes, the samecompany that makes a brand-name medication alsomakes the generic version.What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-namemedication, ask if a generic equivalent or lower-costoption is available and could be right for you. Genericmedications are usually your lowest-cost option, butnot always. For some benefit plans, if a brand-namedrug is prescribed and a generic equivalent is available,your cost-share may be the copayment PLUS the costdifference between the brand-name drug and thegeneric equivalent.Over-the-counter(OTC) medicationsAn OTC medication may bethe right treatment option forsome conditions. Talk to yourdoctor about available OTCoptions. Even though thesemedications may not becovered by your pharmacybenefit, they may cost lessthan a prescription medication.What if I am taking a specialty medication?Specialty medications are high-cost and are used to treat rare or complex conditions that requireadditional care and support. For most plans, these medications are managed through the specialtypharmacy program. Take advantage of personalized support designed to help you get the most outof your treatment plan. Visit the member website listed on your health plan ID card or call the toll-freephone number on your ID card to learn more.Please note, not all specialty medications are listed here. If you’re taking a specialty medication thatis on a higher tier, call the toll-free phone number on your ID card to talk with a pharmacist aboutfinding lower-cost options or a financial assistance program.5
Reading your PDLThe PDL gives you choices so you and your doctor can determine your best course of treatment.In this PDL, brand-name medications are shown in bold type and generic medications in plain type.Tier information.Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may havemultiple or no tiers. Please note: If you have a high deductible plan, the tier cost levels may applyonce you hit your deductible.Drug TierIncludesHelpful TipsTier 1 Lower-costMedications that provide the highestoverall value. Mostly generic drugs. Somebrand-name drugs may also be included.Use Tier 1 drugs for thelowest out-of-pocket costs.Tier 2 Mid-range costMedications that provide good overall value.A mix of brand-name and generic drugs.Use Tier 2 drugs, instead ofTier 3, to help reduce yourout-of-pocket costs.Tier 3 Highest-costMedications that provide the lowestoverall value. Mostly brand-name drugs,as well as some generics.Ask your doctor if a Tier 1 or Tier 2option could work for you.6
Reading your PDL (continued)Drug list information.In this drug list, some medications are noted with letters next to them to help you see which onesmay have coverage requirements or limits. Your benefit plan determines how these medicationsmay be covered for you.EMay be excluded from coverage or subject to Prior Authorization inConnecticut, New Jersey and New York. (Referred to as First Start inNew Jersey)Lower-cost options are available and covered.H ealth Care Reform PreventiveHThis medication is part of a health care reform preventive benefit and may beavailable at no additional cost to you.H-PA ealth Care Reform Preventive with Prior AuthorizationHMay be part of health care reform preventive and available at no additionalcost to you if prior authorization criteria is met.PA Prior Authorization (sometimes referred to as Precertification)3Requires your doctor to provide information about why you are takinga medication to determine how it may be covered by your plan.RS Refill and Save Program4Save money on your copayment when you refill your prescription on timeas prescribed. Program eligibility may vary.SP Specialty MedicationSpecialty medications treat complex or rare conditions and may require specialstorage and handling. You may be required to obtain these medications from aspecialty pharmacy.ST Step Therapy (referred to as First Start in New Jersey)Requires prior authorization and may require you to try one or more othermedications before the medication you are requesting may be covered.SL Supply LimitsSpecifies the largest quantity of medication covered per copaymentor in a defined period of time.3. Depending on your benefit, you may have notification or medical necessity requirements forselect medications.4. Not applicable to Neighborhood Health Plan and Oxford plans.7
QuestionsFor the most current list of covered medications or if you have questions: all the toll-free member phone numberCon your health plan ID card. isit your plan’s member website listedVon your health plan ID card to: View your pharmacy benefit and coverageinformation, including prescription historyAnd, if home delivery servicesare included in your pharmacybenefit, you can also: Refill prescriptions View medication interactions and side effects Check the status of your order Locate a participating retail pharmacyby ZIP code Set up reminders for refills Look up possible lower-cost medicationalternatives Compare medication pricing and options8 Manage your account
Drug NameDrug RequirementsTier & LimitsDrug NameAnti-Infectives: AntibioticsAmoxicillin Capsule, ChewableTabletAmoxicillin/Potassium ClavulanateChewable Tablet, TabletDrug RequirementsTier & LimitsAnti-Infectives: Antifungals11Cresemba3Econazole Cream3Fluconazole Tablet1SLAzithromycin Tablet1Itraconazole Capsule1SLCefadroxil Capsule, Tablet1Ketoconazole Cream1SLCefdinir Capsule1Noxafil Tablet, Suspension2Cefixime Suspension3Nystatin Cream, Ointment1Cefprozil Tablet1Terbinafine Tablet1SLCefuroxime Tablet1Anti-Infectives: AntiviralsCephalexin Capsule1Acyclovir Ointment3PA, SL, STCiprodex3Acyclovir Tablet1Ciprofloxacin Tablet1Famciclovir Tablet2Clarithromycin Tablet1Oseltamivir Capsule, Suspension2SLClindamycin Capsule1Valacyclovir Tablet1SLDificid3Valganciclovir1SLAlunbrig2PA, SL, SPBexarotene Capsule3E, SPDoxycycline Hyclate 50, 100 mgCapsule, TabletDoxycycline Monohydrate50, 100 mg CapsuleSLCancer21Levofloxacin Tablet1Bicalutamide1Metronidazole Tablet1Bosulif2PA, SL, SP, STMinocycline Capsule1Braftovi3PA, SL, SPMoxifloxacin Tablet3Calquence2PA, SL, SPNitrofurantoin Capsule1Cyclophosphamide Capsule2Nitrofurantoin MacrocrystalCapsule1Erleada3Ofloxacin Otic Solution2Hydroxyurea Capsule1Ofloxacin Tablet1Ibrance2PA, SL, SPPenicillin V Potassium Tablet1Idhifa2PA, SL, SPImatinib Tablet1PA, SL, SPImbruvica2PA, SL, SPLeucovorin Calcium Tablet1Sulfamethoxazole-TrimethoprimTabletSuprax Capsule, ChewableTablet, Tablet13Bold type Brand-name drug[Plain type Generic drug]PA, SL, SPPA Prior authorization requiredRS May be eligible for the refill and save programSL Supply limitSP Specialty medicationST Step therapyE May be excluded from coverageH May be part of health care reform preventiveH-PA May be part of health care reform preventive withprior authorizationDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.9
Drug NameDrug RequirementsTier & LimitsMektovi3Mercaptopurine Tablet1Nerlynx2RevlimidDrug NamePA, SL, SPDrug RequirementsTier & LimitsBisoprolol-Hydrochlorothiazide1Bystolic2PA, SL, SPByvalson22PA, SL, SPCartia XT2Rydapt2PA, SL, SP1Sutent2PA, SL, SPCarvedilol Immediate-ReleaseTabletTargretin Capsule2SPChlorthalidone1Targretin Gel3SLClonidine Tablet1Tasigna2PA, SL, SP, STDiltiazem 24 Hour CD2Verzenio2PA, SL, SPXeloda1SL, SPZykadia2PA, SL, SPZytiga2PA, SL, SPDiltiazem Sustained-ReleaseCapsuleDiltiazem Sustained-ReleaseTabletCardiovascular/Heart Disease: Coagulation Enoxaparin Sodium2SLPradaxa2SLPrasugrel3SLSavaysa3SLWarfarin Sodium1Xarelto2SLCardiovascular/Heart Disease: High Blood de1Metoprolol Succinate ExtendedRelease 50, 100, 200 mgMetoprolol Tartrate 25, 50,100 mg21Nadolol1Nifedipine rothiazide2SLPropranolol Extended-ReleaseCapsule2Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.10SL
Drug NameDrug RequirementsTier & LimitsDrug NameDrug RequirementsTier & LimitsPropranolol Tablet1Vascepa3Quinapril12Ramipril1Welchol Packet for hiazide1Verapamil1Verapamil Sustained-Release3PACardiovascular/Heart Disease: OtherCardiovascular/Heart Disease: High ecainide1Isosorbide Mononitrate ER1Multaq3Nitroglycerin Sublingual Tablet1Ranexa2Sotalol1Atorvastatin1H-PA, SLColesevelam Packet forSuspension, Tablet (genericWelchol)3EEzetimibe Tablet3SLEzetimibe/Simvastatin3SLFenofibrate 54, 160 mg Tablet2Fluvastatin in Extended-Release Tablet3Dexmethylphenidate ImmediateRelease TabletDextroamphetamineAmphetamine Immediate-ReleaseTabletDextroamphetamine SulfateImmediate-Release TabletNiaspan2Omega-3-Acid Ethyl EstersCapsule3PAPraluent2PA, SL, SP, STPravastatin1Repatha3PA, SL, SP, STRosuvastatin2SLSimvastatin1H-PAPA, SLPA, SLPACentral Nervous System: Attention Deficit DisorderSL, STHAdderall XR2PA, SLAmphetamine Salt Combo1PAAtomoxetine3SLConcerta2PA, SL1PA1PA3PAGuanfacine Extended-Release2SLMethylphenidate Chewable Tablet3PA2PA, SL3E, PA, SLMethylphenidate ExtendedRelease Capsule (genericMetadate CD, Ritalin LA)Methylphenidate ExtendedRelease Tablet (genericConcerta)Bold type Brand-name drug[Plain type Generic drug]PA Prior authorization requiredRS May be eligible for the refill and save programSL Supply limitSP Specialty medicationST Step therapyE May be excluded from coverageH May be part of health care reform preventiveH-PA May be part of health care reform preventive withprior authorizationDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.11
Drug NameDrug RequirementsTier & LimitsMethylphenidate ExtendedRelease Tablet (Metadate ER,generic Ritalin SR)Methylphenidate ImmediateRelease TabletVyvanse3PA, SL1PA2PA, SLDrug NameDrug RequirementsTier & LimitsRizatriptan ODT, Tablet1SLSumatriptan Nasal Spray2SLSumatriptan Succinate Tablet,Injection1SLCentral Nervous System: Multiple SclerosisCentral Nervous System: DepressionAmpyra2PA, SL, SPAmitriptyline TabletAubagio3PA, SL, SPAvonex2PA, SL, SPBetaseron2PA, SL, SP1Gilenya3PA, SL, SPBupropion Tablet12PA, SL, SPCitalopram Tablet1Glatiramer (generic Copaxone)[Mylan version only]Desvenlafaxine ExtendedRelease Tablet (generic Pristiq)Plegridy3PA, SL, SP2Rebif3PA, SL, SP, STDoxepin1Tecfidera2PA, SL, SPDuloxetine Capsule3Escitalopram Tablet1Fetzima3Fluoxetine Capsule (genericProzac)Bupropion Extended-ReleaseTabletBupropion Sustained-ReleaseTablet11SLCentral Nervous System: OtherSLAlprazolam Extended-ReleaseTablet1Alprazolam Tablet11Aripiprazole Tablet2SLFluvoxamine Tablet1Armodafinil3PA, SLMirtazapine Tablet1Austedo2PA, SL, SPNortriptyline Capsule1Buprenorphine Sublingual Tablet1Paroxetine Tablet1Buspirone Tablet1Sertraline Tablet1Carbidopa-Levodopa1Trazodone Tablet1Diazepam Tablet1Trintellix3Donepezil 5, 10 mg ODT, Tablet1Venlafaxine Extended-ReleaseCapsule1Latuda3Venlafaxine Tablet1Lithium Capsule1Viibryd3SLLorazepam Tablet1Memantine affeine 325 mg/50 mg/40 mg1SLModafinil3Eletriptan2SLNaloxone Vials1Frovatriptan3SLNarcan Nasal Spray2Naratriptan1SLSL, STSL, STCentral Nervous System: MigraineDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.12SLPA, SLSL
Drug NameDrug RequirementsTier & LimitsOlanzapine Tablet1Pramipexole Tablet1Quetiapine Extended-ReleaseTabletQuetiapine Immediate-ReleaseTabletDrug NameLamotrigine Immediate-ReleaseTabletLevetiracetam Extended-ReleaseTabletLevetiracetam Immediate-ReleaseTabletSL3SL1213SL, STLyrica CR3E, SL, STOxcarbazepine Tablet1Phenytoin Capsule, Suspension1Topiramate Immediate-ReleaseTablet1Zonisamide Capsule11Ropinirole Tablet1Suboxone Film3Tolcapone2Xyrem3Zelapar3Ziprasidone Capsule2SLDermatologyZubsolv2SLAczonePA, SL, SP1LyricaRisperidone TabletE, PA, SLDrug RequirementsTier & Limits3SLEszopiclone Tablet2Temazepam Capsule1Triazolam Tablet1Zaleplon Capsule1SLBetamethasone Dipropionate0.05% Augmented Lotion,OintmentBetamethasone Dipropionate0.05% Cream, m Immediate-ReleaseTablet1SLCarac2Ciclopirox Cream, Gel, Lotion,Solution1Claravis2PAClindamycin 1.2%/BenzoylPeroxide 5% Gel3SLClindamycin Gel3SLClindamycin Lotion3Central Nervous System: Sedatives/HypnoticsSLCentral Nervous System: Seizure DisordersCarbamazepine ExtendedRelease CapsuleCarbamazepine ExtendedRelease TabletCarbamazepine ImmediateRelease Tablet231323SLClonazepam Tablet1Clindamycin Solution1Diazepam Tablet1Clindamycin Swabs11Clobetasol Propionate Cream,Ointment2SL2Clobetasol Propionate lproex Delayed-ReleaseTabletDivalproex Extended-ReleaseTabletGabapentin Capsule, TabletBold type Brand-name drug[Plain type Generic drug]SLPA Prior authorization requiredRS May be eligible for the refill and save programSL Supply limitSP Specialty medicationST Step therapyE May be excluded from coverageH May be part of health care reform preventiveH-PA May be part of health care reform preventive withprior authorizationDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.13
Drug NameDrug RequirementsTier & LimitsClotrimazole-BetamethasoneLotion1Dapsone 5% Gel3E, SLDesonide 0.05% Cream, Lotion,Ointment3SLDesoximetasone Gel, Ointment3SLDiflorasone Diacetate 0.05%Cream, Ointment3SLDupixent3PA, SL, SP, STElidel3Enstilar FoamDrug NameDrug RequirementsTier & LimitsTretinoin Cream3Triamcinolone Acetonide Cream,Lotion, Ointment1Vectical3Diabetes: Blood Glucose MonitoringPA, SLSL5Accu-Chek Test Strips3Contour Next EZ Meter2Contour Next Meter2SL, STContour Next One Meter23SLContour Next Test Strips2SLEucrisa3SL, STContour Test Strips3E, SLFinacea3FreeStyle Test Strips3E, SLFluocinolone Cream, Oil, Solution3SLOneTouch Ultra 2 Meter1Fluocinolone Ointment2SLOneTouch Ultra Test Strips1Fluocinonide 0.05% Cream1OneTouch UltraMini Meter1Fluorouracil 0.5% Cream3SLOneTouch Verio Flex Meter1Halobetasol Ointment2SLOneTouch Verio IQ Meter1Hydrocortisone 2.5% Cream,Ointment1OneTouch Verio Meter1Imiquimod 5% Cream1OneTouch Verio Sync Meter1Metronidazole 0.75% Topical Gel1OneTouch Verio Test Strips1Minocycline Extended-Release(generic Solodyn)3E, PAMirvaso3SLMometasone Furoate Cream,Lotion, Ointment1Mupirocin PA, SLRhofade3PA, SLTaclonex Suspension3SLTacrolimus Ointment2SL, STTazarotene 0.1% Cream (genericTazorac)3E, PA, SLTazorac3PA, SLSL5SLE, SLSLSLDiabetic supplies and prescription medications maybe subject to different cost-share arrangements forOxford plans. Please see your Summary of Benefits andCoverage (SBC) for specifics. Medications that requirestep therapy may require prior authorization (sometimesreferred to as precertification) if covered under anotherbenefit.Diabetes: Insulin5Admelog SoloStar, Vials3E, SLApidra SoloStar, Vials3E, SLBasaglar1SLFiasp FlexTouch, Vials3E, SLHumalog KwikPens(all formulations)2SLHumalog Vials (all formulations)1SLHumulin KwikPens(all formulations)2SLHumulin Vials (all formulations)1SLDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.14
Drug NameDrug RequirementsTier & LimitsDrug NameDrug RequirementsTier & LimitsLantus SoloStar3E, SLMetformin1Lantus Vials3E, SL1Levemir FlexTouch, Vials3SLMetformin Extended-ReleaseTablet (generic Glucophage XR)Novolin Vials (all formulations)3E, SLNesina2SLNovolog FlexPen, Vials(all formulations)SLE, SLOnglyza23Oseni2SLTresiba FlexTouch2SLOzempic3SLPioglitazone1SLQtern3E, SL, STSegluromet3E, SL, STSoliqua2PA, SLSteglatro3E, SL, STSteglujan3E, SL, STSynjardy, Synjardy XR2SLTradjenta2SLTrulicity3SLVictoza 2-Pak2SLVictoza 3-Pak3SLXigduo XR3E, SL, ST5Diabetic supplies and prescription medications maybe subject to different cost-share arrangements forOxford plans. Please see your Summary of Benefits andCoverage (SBC) for specifics. Medications that requirestep therapy may require prior authorization (sometimesreferred to as precertification) if covered under anotherbenefit.Diabetes: Non-Insulin5Adlyxin3SLBydureon, Bydureon Bcise2SLByetta2SLFarxiga3E, SL, STGlimepiride1Glipizide1Glipizide Extended-Release1Glyburide1Glyxambi2SL, STInvokamet, Invokamet XR2SLInvokana2SL, STJanumet3SL, STEndocrine: Growth Hormone6Januvia3SL, STNutropin, Nutropin AQ65Jardiance2SL, STJentadueto2SLJentadueto XR2SLKazano2SLKombiglyze XR2SLBold type Brand-name drug[Plain type Generic drug]Diabetic supplies and prescription medications maybe subject to different cost-share arrangements forOxford plans. Please see your Summary of Benefits andCoverage (SBC) for specifics. Medications that requirestep therapy may require prior authorization (sometimesreferred to as precertification) if covered under anotherbenefit.2PA, SL, SPCoverage is determined by the consumer’s prescriptiondrug benefit plan. Please consult plan documentsregarding benefit coverage and cost-share. Priorauthorization (sometimes referred to as precertification)may be required for Oxford plans.PA Prior authorization requiredRS May be eligible for the refill and save programSL Supply limitSP Specialty medicationST Step therapyE May be excluded from coverageH May be part of health care reform preventiveH-PA May be part of health care reform preventive withprior authorizationDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.15
Drug NameDrug RequirementsTier & LimitsDrug NameEndocrine: OtherDrug RequirementsTier & LimitsEye Conditions: Dry Eye DiseaseCalcitriol Capsule1Restasis Single Use Vials3PA, SLDesmopressin Tablet1Xiidra3PA, SLDexamethasone Tablet1Eye Conditions: GlaucomaMethylprednisolone Tablet1Alphagan P 0.1%2SLPrenisolone Oral Solution1Azopt2SLPrednisone Tablet1Combigan2SLLatanoprost 0.005% OphthalmicSolution1Lumigan2Endocrine: Thyroid Hormone ReplacementArmour Thyroid3Levothyroxine Sodium Tablet1Liothyronine Sodium Tablet2Timolol 0.25%, 0.5% OphthalmicSolution (generic Timoptic)1Methimazole Tablet1Travatan Z2SLNP Thyroid Tablet1Gastrointestinal: Acid eprazole Capsule1Pantoprazole Tablet1Pylera3Ranitadine Syrup1Rabeprazole Tablet3Sucralfate Tablet1Eye Conditions: AllergiesAzelastine 0.05% OphthalmicSolution1Lastacaft3SLOlopatadine 0.1% OphthalmicSolution3SLEye Conditions: AntibioticsErythromycin 0.5% OphthalmicOintmentGentamicin Ophthalmic Ointment,Solution1SLSLSLGastrointestinal: Nausea/Vomiting1Akynzeo3SLMoxeza3Aprepitant Capsule2SLMoxifloxacin Ophthalmic Solution3Emend Suspension2SL1Ondansetron1Scopolamine Transdermal Patch3Varubi2Ofloxacin 0.3% % OphthalmicSuspensionTobramycin Ophthalmic Solution21Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.16SL
Drug NameDrug RequirementsTier & LimitsDrug NameGastrointestinal: OtherDrug RequirementsTier & LimitsGoutAmitiza3Apriso2Budesonide Extended-ReleaseTablet (generic te-Atropine Tablet1Golytely2Hyoscyamine Tablet1Lialda2Linzess2PA, SLMesalmine Delayed-ReleaseTablet (generic Lialda)3EMetoclopramide Tablet1Movantik3MoviprepPA, SL, STAllopurinol Tablet1Duzallo3Mitigare2Uloric3SL, STZurampic3PA, SLDaklinza3PA, SL, SP, STEpclusa2PA, SL, SPHarvoni2PA, SL, SPMavyret2PA, SL, SPRibavirin Tablet1SPSovaldi3PA, SL, SP, STTechnivie3PA, SL, SP, STViekira Pak3PA, SL, SP, STViekira XR3PA, SL, SP, STVosevi2PA, SL, SP3Zepatier3PA, SL, SP, STPolyethylene Glycol alazine Tablet1Atazanavir Capsule2SPSuprep3Atripla3E, SPSymproic2Cimduo2SPUceris Foam2Complera3SPUceris 2SPGenvoya3SPIntelence2SPEPA, SLHepatitis CE, PA, SLPA, SLPA, SLBold type Brand-name drug[Plain type Generic drug]PA Prior authorization requiredRS May be eligible for the refill and save programSL Supply limitSP Specialty medicationST Step therapyE May be excluded from coverageH May be part of health care reform preventiveH-PA May be part of health care reform preventive withprior authorizationDrugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.17
Drug NameDrug RequirementsTier & LimitsIsentress2SPJuluca2SPKaletra ir Oral Solution2SPNevirapine1SPNevirapine Extended-Release3E, SPOdefsey3SPPrezcobix2SPPrezista2SPRitonavir Tablet2SPSelzentry2PA, SPStribild3SPSymfi2SPSymfi Lo2SPTenofovir tekta2SPCetrotide2PA, SPClomiphene1PAEndometrin2PAGonal-F2PA, SPGonal-F RFF2PA, SPOv
Your 2019 Prescription Drug List Advantage Three-Tier This Prescription Drug List (PDL) is
