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State Health Plan PPO Medicare Prescription Drug Plan (PDP)Your 2021 Comprehensive FormularyAdministered by OptumRx Effective January 1, 2021Please read: this document contains information about the drugs we cover in this plan.This comprehensive formulary was updated on August 6, 2020, and is a complete list of drugscovered by our plan. For more recent information or if you have questions, please contact:OptumRx Member ServicesPhone (toll-free):TTY users:Hours of operation:Website:1-866-635-594171124 hours a day, 7 days a weekoptumrx.comNote to existing members: This formulary has changed since last year. Please review thisdocument to make sure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us,” or “our,” it means OptumRx. When it refers to“plan” or “our plan,” it means State Health Plan PPO Medicare Prescription Drug Plan.You must generally use network pharmacies to use your prescription drug benefit. Benefits,formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January1, 2022.Last Updated Date: August 2020Formulary ID 21106Version 7S8841 21 MC-DS11 C MCC
What is the Comprehensive Formulary?A formulary is a list of covered drugs selected by State Health Plan PPO in consultation withOptumRx and a team of healthcare providers, which represents the prescription therapies believedto be a necessary part of a quality treatment program. This plan will generally cover the drugs listedin our formulary as long as the drug is medically necessary, the prescription is filled at an OptumRxnetwork pharmacy, and other plan rules are followed.Can the formulary (drug list) change?Yes. If you are taking a drug on our 2021 formulary that is covered at the beginning of the year, wewill not discontinue or reduce coverage of the drug during the 2021 coverage year except when anew, less-expensive generic drug becomes available, or when new adverse information about thesafety or effectiveness of a drug is released.If we make a negative change to our formulary (i.e. add prior authorization, quantity limits, and/orstep therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, when applicable), wemust notify affected members. Members will receive a notice regarding the change at least 60 daysbefore the change becomes effective, or at the time the member requests a refill of the drug, at whichtime the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA)deems a drug on our formulary to be unsafe, or the drug’s manufacturer removes the drug from themarket, we will immediately remove the drug from our formulary and provide notice to members whotake the drug.The enclosed formulary is current as of January 1, 2021. To get updated information about covereddrugs, please contact OptumRx. You may also visit our website at optumrx.com where you will findthe most up-to-date information about our list of covered drugs (formulary) by using the “DrugInformation” tool (found under the “Member Tools” tab). Our contact information is shown on the frontand back cover pages.How do I use the formulary?There are two ways to find your drug within the formulary: Medical ConditionThe formulary begins on page 7. The drugs in this formulary are grouped into categoriesdepending on the type of medical conditions that they are used to treat. For example, drugs usedto treat a heart condition are listed under the category “Cardiovascular Agents.” If you know whatyour drug is used for, look for the category name in the list that begins on page 7. Then, lookunder the category name for your drug. Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 118. The Index provides an alphabetical list of all drugs included in thisdocument. Both brand-name drugs and generic drugs are listed in the Index.Last Updated Date: August 2020Page 2
Formulary designThe formulary structure features generic drugs, preferred brand-name drugs, and non-preferred brandname drugs.Drug TierHelpful TipsTier 1Most generic drugs are listed under Tier 1 and have the lowest copayments.Tier 2Drugs listed under Tier 2 generally include preferred brand-name drugs that havelower copayments than non-preferred brand-name drugs.Tier 3Drugs listed under Tier 3 generally have higher copayments than preferred brandname drugs and may include some specialty or high-cost drugs*.* High-cost (or some Specialty) drugs are those that cost 670 or more for up to a 30-day maximumsupply. These types of drugs are labeled in the formulary as “NDS” under the Requirements/Limitscolumn, and will not be dispensed in more than a 30-day supply.Please refer to your Evidence of Coverage for more information.What are generic drugs?Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA ashaving the same active ingredient as the brand-name drug. Generally, generic drugs cost less thanbrand-name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:Prior Authorization (PA)You or your physician may need to get prior authorization for certaindrugs. This means you will need to get approval from OptumRx beforeyou fill your prescriptions. If you do not get approval, the drug may not becovered.Quantity Limits (QL)For certain drugs, there is a limit on the amount of the drug we willcover.Step Therapy (ST)In some cases, it is required that you first try certain drugs to treat yourmedical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, we maynot cover Drug B unless you try Drug A first. If Drug A does not work foryou, we will then cover Drug B.To find out if your drug has any additional requirements or limits, look in the formulary that begins on page 7.You can also get more information about restrictions applied to specific covered drugs by visiting our websiteor by calling OptumRx. Our contact information, along with the date we last updated the formulary, is shownon the front and back cover pages.Last Updated Date: August 2020Page 3
You can ask OptumRx to make an exception to these restrictions or limits, or for a list of other similardrugs that may treat your health condition. See the section “How do I request an exception to theformulary?” on page 4 for additional information.What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact OptumRx andask if your drug is covered. Our contact information, along with the date we last updated the formulary, isshown on the front and back cover pages.If your drug is not covered, you have 2 options: You can ask OptumRx for a list of similar drugs that are covered. When you receive the list, show it toyour doctor and ask him or her to prescribe a similar drug that is covered. You can ask OptumRx to make an exception and cover your drug. See below for information abouthow to request an exception.State Health Plan PPO offers supplemental coverage (also called WRAP coverage) on someprescription drugs not normally covered under Medicare Part D. Please contact OptumRx for anyquestions regarding your supplemental coverage.How do I request an exception to the formulary?You can ask OptumRx to make an exception to our coverage rules. There are several types ofexceptions that you can ask us to make: You can ask us to cover a drug even if it is not on our formulary. If approved, the drug will be coveredat a predetermined cost-sharing level, and you will not be able to ask us to provide the drug at a lowercost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level. If approved, this would lowerthe amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,we may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask usto waive the limit and cover a greater amount.Note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to providea higher level of coverage for the drug.Generally, we will only approve your request for an exception if the drug is included on the plan’s formulary,or if additional utilization restrictions would not be as effective in treating your condition and/or would causeyou to have adverse medical effects.You should contact OptumRx for an initial coverage decision for a formulary, tier, or utilization restrictionexception. When you request a formulary, tier, or utilization restriction exception, you mustsubmit a statement from your doctor (or other prescriber) supporting your request.Generally, we must make our decision within 72 hours of getting your doctor’s (or other prescriber’s)supporting statement. You can request an expedited (fast) exception if you or your doctor believe thatyour health could be seriously harmed by waiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no later than 24 hours after we get a supportingstatement from your doctor (or other prescriber).Last Updated Date: August 2020Page 4
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary, oryou may be taking a drug that is on our formulary but your ability to get it is limited. For example, youmay need a prior authorization from us before you can fill your prescription. You should talk to yourdoctor (or other prescriber) to decide if you should switch to an appropriate drug that we cover or requesta formulary exception. While you talk to your doctor (or other prescriber) to determine the right course ofaction for you, we may cover your drug in certain cases during the first 90 days you are a member of ourplan.For each of your drugs not on our formulary, or if your ability to get your drugs is limited, we will cover atemporary 30-day supply (unless you have a prescription written for fewer days) when you go to a networkpharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a memberof the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill your prescription until we haveprovided you with 31-day transition supply, written for as many pills as necessary, unless you have aprescription written for fewer days. We will cover more than one refill of these drugs for the first 90 daysyou are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get yourdrugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-dayemergency supply of that drug (unless you have a prescription for fewer days) while you get a formularyexception.If you are a current enrollee with a level-of-care change and you need a drug that is not on our formulary,or if your ability to get your drugs is limited, we will cover a temporary 31-day transition supply (unlessyou have a prescription written for fewer days) while you seek a formulary exception. If you are in theprocess of seeking an exception, we will consider allowing continued coverage until a decision is made.For more informationFor more detailed information about your prescription drug coverage, please review your other planmaterials. If you have questions about the plan, please call OptumRx. Our contact information, alongwith the date we last updated the formulary, is shown on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day, 7 days a week. Youmay also visit medicare.gov.Last Updated Date: August 2020Page 5
FormularyThe formulary below provides information about your covered drugs. If you have trouble finding yourdrug in the list, turn to the Index that begins on page 118.The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., COZAAR),and generic drugs are listed in lower-case italics (e.g., atenolol). The abbreviations in the“Requirements/Limits” column tell you if there are any special requirements for coverage of your drugRequirements/LimitsHelpful TipsB/DThis prescription drug has a Part B versus D administrative priorauthorization requirement. This drug may be covered underMedicare Part B or D depending upon the circumstances.Information may need to be submitted describing the use andsetting of the drug to make the determination.NDSNon-Extended Days' Supply. This prescription drug is not availablefor an extended days' supply.PAPrior Authorization. Our plan requires you or your physician to getprior authorization for certain drugs. This means you will need to getapproval from OptumRx before you fill your prescriptions. If you donot get approval, your drug may not be covered.QLQuantity Limit. For certain drugs, our plan limits the amount of thedrug that will be covered.STStep Therapy. In some cases, our plan requires you to first trycertain drugs to treat your medical condition before we will coveranother drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover drug B unlessyou try Drug A first. If Drug A does not work for you, we will thencover Drug B.Last Updated Date: August 2020Page 6
Drug NameDrug Tier Requirements/LimitsAnalgesicsNonsteroidal Antiinflammatory DrugsDrug NameDrug Tier Requirements/Limitsibuprofen oral tablet 400mg, 600 mg, 800 mg1indomethacin er oralcapsule extendedrelease1CELEBREX ORALCAPSULE3QL (60 EA per30 days)celecoxib oral capsule1QL (60 EA per30 days)indomethacin oralcapsule 25 mg, 50 mg1diclofenac epolaminetransdermal patch1PA; QL (60 EAper 30 days)1diclofenac potassiumoral tabletindomethacin sodiumintravenous solutionreconstituted3diclofenac sodium eroral tablet extendedrelease 24 hour13ketoprofen er oralcapsule extendedrelease 24 hourketoprofen oral capsule1diclofenac sodium oraltablet delayed release3ketorolac tromethamineinjection solution1diclofenac sodiumtransdermal gel 1 %1QL (1000 GMper 30 days)ketorolac tromethamineintramuscular solution1diclofenac sodiumtransdermal solution1PAketorolac tromethaminenasal solution1QL (5 EA per30 days); NDSketorolac tromethamineoral tablet1QL (20 EA per30 days)klofensaid ii transdermalsolution 1.5 %1PAlodine oral tablet3NDSmeclofenamate sodiumoral capsule1diclofenac-misoprostoloral tablet delayedrelease3diflunisal oral tablet1DUEXIS ORAL TABLET3etodolac er oral tabletextended release 24hour1mefenamic acid oralcapsule1etodolac oral capsule1meloxicam oral tablet1etodolac oral tablet1nabumetone oral tablet1fenoprofen calcium oralcapsule 400 mg13fenoprofen calcium oraltablet1NAPRELAN ORALTABLET EXTENDEDRELEASE 24 HOUR375 MG, 500 MGnaproxen dr oral tabletdelayed release1naproxen oral tablet1naproxen sodium er oraltablet extended release24 hour1naproxen sodium oraltablet 275 mg, 550 mg1FLECTORTRANSDERMALPATCH3flurbiprofen oral tablet1ibu oral tablet1ibuprofen lysineintravenous solution1ibuprofen oralsuspension1Last Updated Date: August 2020QL (90 EA per30 days); NDSPA; QL (60 EAper 30 days)NDSnaproxen-esomeprazoleoral tablet delayedrelease1NDSPA; QL (60 EAper 30 days);NDSPage 7
Drug NameDrug Tier aprozin oral tablet1PENNSAIDTRANSDERMALSOLUTION3piroxicam oral capsule1profeno oral tablet 600mg1relafen ds oral tablet3NDSSPRIX NASALSOLUTION3QL (5 EA per30 days); NDSsulindac oral tablet1tolmetin sodium oralcapsule1tolmetin sodium oraltablet1VIMOVO ORALTABLET DELAYEDRELEASE3VOLTARENTRANSDERMAL GELZIPSOR ORALCAPSULEDrug NameDrug Tier Requirements/LimitsDURAGESIC-12TRANSDERMALPATCH 72 HOUR3NDSDURAGESIC-25TRANSDERMALPATCH 72 HOUR3NDSDURAGESIC-50TRANSDERMALPATCH 72 HOUR3NDSDURAGESIC-75TRANSDERMALPATCH 72 HOUR3NDSEMBEDA ORALCAPSULE EXTENDEDRELEASE 100-4 MG,20-0.8 MG, 30-1.2 MG,50-2 MG, 60-2.4 MG,80-3.2 MG3NDSPA; QL (60 EAper 30 days);NDSEXALGO ORALTABLET ER 24 HOURABUSE-DETERRENT12 MG, 16 MG, 32 MG,8 MG3NDS3QL (1000 GMper 30 days)fentanyl transdermalpatch 72 hour1NDS3NDShydrocodone bitartrateer oral capsule er 12hour abuse-deterrent1NDShydromorphone hcl eroral tablet er 24 hourabuse-deterrent1NDSHYSINGLA ER ORALTABLET ER 24 HOURABUSE-DETERRENT3ST; NDSINFUMORPH 200INJECTION SOLUTION3NDSINFUMORPH 500INJECTION SOLUTION3NDSKADIAN ORALCAPSULE EXTENDEDRELEASE 24 HOUR3NDSlevorphanol tartrate oraltablet1NDSmethadone hcl injectionsolution3NDSmethadone hcl intensoloral concentrate1NDSNDSPA; NDSOpioid Analgesics,Long-actingARYMO ER ORALTABLET EXTENDEDRELEASE ABUSEDETERRENT3BELBUCA BUCCALFILM3QL (60 EA per30 days); NDSbuprenorphinetransdermal patchweekly1QL (4 EA per28 days); NDSBUTRANSTRANSDERMALPATCH WEEKLY3QL (4 EA per28 days); NDSCONZIP ORALCAPSULE EXTENDEDRELEASE 24 HOUR3PA; NDSDOLOPHINE ORALTABLET3DURAGESIC-100TRANSDERMALPATCH 72 HOUR3Last Updated Date: August 2020ST; NDSNDSNDSPage 8
Drug NameDrug Tier Requirements/Limitsmethadone hcl oralconcentrate1NDSmethadone hcl oralsolution1NDSmethadone hcl oraltablet1NDSmethadose oralconcentrate 10 mg/ml1NDSmethadose sugar-freeoral concentrate1NDSmitigo injection solution1MORPHABOND ERORAL TABLET ER 12HOUR ABUSEDETERRENT 100 MG,15 MG, 30 MG, 60 MG3morphine sulfate erbeads oral capsuleextended release 24hour1Drug Tier Requirements/Limitsoxycodone hcl er oraltablet er 12 hour abusedeterrent 60 mg, 80 mg3NDSOXYCONTIN ORALTABLET ER 12 HOURABUSE-DETERRENT3ST; NDSoxymorphone hcl er oraltablet extended release12 hour1NDSNDStramadol hcl er(biphasic) oral tabletextended release 24hour1NDSST; NDStramadol hcl er oralcapsule extendedrelease 24 hour3PA; NDStramadol hcl er oraltablet extended release24 hour1NDSXTAMPZA ER ORALCAPSULE ER 12HOUR ABUSEDETERRENT2NDSZOHYDRO ER ORALCAPSULE ER 12HOUR ABUSEDETERRENT3ST; NDSABSTRALSUBLINGUAL TABLETSUBLINGUAL 100MCG, 200 MCG, 300MCG, 400 MCG, 600MCG, 800 MCG3PA; NDSacetaminophen-codeine#3 oral tablet1NDSacetaminophen-codeineoral solution1NDSacetaminophen-codeineoral tablet 300-15 mg,300-60 mg1NDSACTIQ BUCCALLOZENGE ON AHANDLE3PA; NDSAPADAZ ORALTABLET3NDSNDSmorphine sulfate er oralcapsule extendedrelease 24 hour1morphine sulfate er oraltablet extended release1NDSMS CONTIN ORALTABLET EXTENDEDRELEASE3NDSNDSNUCYNTA ER ORALTABLET EXTENDEDRELEASE 12 HOUR100 MG, 150 MG, 50MG2NDSNUCYNTA ER ORALTABLET EXTENDEDRELEASE 12 HOUR200 MG, 250 MG3NDSOPANA ER ORALTABLET ER 12 HOURABUSE-DETERRENT10 MG, 15 MG, 20 MG,30 MG, 40 MG, 5 MG,7.5 MG3oxycodone hcl er oraltablet er 12 hour abusedeterrent 10 mg, 15 mg,20 mg, 30 mg, 40 mg2Last Updated Date: August 2020Drug NameNDSNDSOpioid Analgesics,Short-actingPage 9
Drug NameDrug Tier Requirements/Limitsapap-caffdihydrocodeine oralcapsule1apap-caffdihydrocodeine oraltablet1NDSascomp-codeine oralcapsule1PA; NDSbutalbital-apap-caff-codoral capsule1PA; NDSbutalbital-asa-caffcodeine oral capsule1butorphanol tartrateinjection solutionDrug NameDrug Tier Requirements/Limitsfioricet/codeine oralcapsule3PA; NDSFIORINAL/CODEINE#3 ORAL CAPSULE3PA; NDShydrocodoneacetaminophen oralsolution 10-325mg/15ml, 7.5-325mg/15ml1NDSPA; NDShydrocodoneacetaminophen oraltablet1NDS1NDShydrocodone-ibuprofenoral tablet1NDSbutorphanol tartratenasal solution1NDShydromorphone hclinjection solution1NDSCODEINE SULFATEORAL TABLET 15 MG1NDShydromorphone hcl oralliquid1NDScodeine sulfate oraltablet 30 mg, 60 mg1NDShydromorphone hcl oraltablet1NDSDEMEROL INJECTIONSOLUTION3PA; NDSDEMEROL ORALTABLET 100 MG1NDS3NDSDILAUDID INJECTIONSOLUTIONhydromorphone hcl pfinjection solution 1mg/ml, 10 mg/ml, 2mg/ml, 4 mg/ml, 50mg/5ml3NDS1NDSDILAUDID ORALLIQUIDhydromorphone hclrectal suppository3NDS3NDSDILAUDID ORALTABLETIBUDONE ORALTABLET 10-200 MG3NDS1NDSDURAMORPHINJECTION SOLUTIONibudone oral tablet 5200 mg1NDS3PA; NDSdvorah oral tablet3NDSLAZANDA NASALSOLUTION1NDSlorcet hd oral tablet1NDSendocet oral tabletlorcet oral tablet1NDSfentanyl citrate (pf)injection solution1B/D; NDSlorcet plus oral tablet7.5-325 mg1NDSfentanyl citrate (pf)injection solutioncartridge1B/D; NDSLORTAB ORAL ELIXIR3NDS1PA; NDSfentanyl citrate buccallozenge on a handlemeperidine hcl injectionsolution1PA; NDS1NDSfentanyl citrate buccaltabletmeperidine hcl oralsolution3PA; NDS1NDSFENTORA BUCCALTABLETmeperidine hcl oraltablet3PA; NDSmorphine sulfate(concentrate) oralsolution 100 mg/5ml1NDSLast Updated Date: August 2020QL (300 EA per30 days); NDSPage 10
Drug NameDrug Tier Requirements/Limitsmorphine sulfate (pf)injection solution 0.5mg/ml, 1 mg/ml, 2mg/ml1morphine sulfate (pf)injection solution 10mg/ml, 4 mg/ml, 5mg/ml, 8 mg/ml1morphine sulfate (pf)intravenous solution1morphine sulfateinjection solution 10mg/ml, 2 mg/ml, 4mg/ml, 5 mg/ml, 8mg/ml1morphine sulfateintramuscular device1Drug NameDrug Tier Requirements/Limitsoxycodone hcl oraltablet1NDSoxycodoneacetaminophen oralsolution 5-325 mg/5ml1NDSB/D; NDSoxycodoneacetaminophen oraltablet1NDSNDSoxycodone-aspirin oraltablet1NDSoxycodone-ibuprofenoral tablet 5-400 mg1NDSoxymorphone hcl oraltablet1NDSNDSpanlor oral tablet 32530-16 mg1NDSB/D; NDSpentazocine-naloxonehcl oral tablet1NDSpercocet oral tablet3NDSprimlev oral tablet3NDSprolate oral tablet3NDSROXICODONE ORALTABLET3NDSROXYBOND ORALTABLET ABUSEDETERRENT 15 MG,30 MG, 5 MG3NDSSUBSYS SUBLINGUALLIQUID3PA; NDStramadol hcl oral tablet1NDS1NDSNDSNDSmorphine sulfateintravenous solution 1mg/ml, 150 mg/30ml1morphine sulfateintravenous solution 25mg/ml, 50 mg/ml1morphine sulfate oralsolution1NDSmorphine sulfate oraltablet1NDSmorphine sulfate rectalsuppository1NDSnalbuphine hcl injectionsolution1NDSNALOCET ORALTABLET3NDSnorco oral tablet3NDStramadolacetaminophen oraltabletNUCYNTA ORALTABLET3NDStrezix oral capsule3QL (300 EA per30 days); NDSOPANA ORAL TABLET3NDSOXAYDO ORALTABLET ABUSEDETERRENT3NDS3NDSTYLENOL WITHCODEINE #3 ORALTABLET 300-30 MGoxycodone hcl oralcapsule1NDSTYLENOL WITHCODEINE #4 ORALTABLET 300-60 MG3NDSoxycodone hcl oralconcentrate 100 mg/5ml1NDSULTRACET ORALTABLET3NDSoxycodone hcl oralsolution1NDSULTRAM ORALTABLET3NDSvicodin es oral tablet7.5-300 mg1NDSLast Updated Date: August 2020NDSPage 11
Drug NameDrug Tier Requirements/Limitsvicodin hp oral tablet10-300 mg1NDSvicodin oral tablet 5-300mg1NDSxylon oral tablet 10-200mg1NDSAnestheticsLocal AnestheticsDrug NameDrug Tier Requirements/LimitsQUTENZA (2 PATCH)EXTERNAL KIT3PA; QL (4 EAper 90 days);NDSQUTENZA EXTERNALKIT3PA; QL (4 EAper 90 days);NDSropivacaine hcl injectionsolution 10 mg/ml, 2mg/ml, 5 mg/ml, 7.5mg/ml1sensorcaine injectionsolution 0.5 %1sensorcaine-mpfinjection solution 0.5 %,0.75 %1bupivacaine fisiopharmainjection solution1bupivacaine hcl (pf)injection solution1bupivacaine hclinjection solution 0.5 %1glydo external prefilledsyringe1PA; QL (30 MLper 30 days)SYNERA EXTERNALPATCH31PA; QL (150GM per 30days)xylocaine dentalinjection solution1ZTLIDO EXTERNALPATCH3lidocaine externalointmentlidocaine external patch5%1PAlidocaine hcl externalsolution1PA; QL (250ML per 30days)AntiAddiction/SubstanceAbuse TreatmentAgents1PA; QL (30 MLper 30 days)AlcoholDeterrents/AnticravingPA; QL (30 MLper 30 days)acamprosate calciumoral tablet delayedrelease1disulfiram oral tablet1lidocaine hclurethral/mucosalexternal gelNDSPA; QL (90 EAper 30 days)lidocaine hclurethral/mucosalexternal prefilledsyringe1lidocaine in dextrosesolution1naltrexone hcl oraltablet1lidocaine-epinephrineinjection solution1lidocaine-prilocaineexternal cream1PA; QL (30 GMper 30 NDSLIDOCAINETETRACAINEEXTERNAL CREAM 77%Opioid Dependence3PA; QL (30 GMper 30 days);NDSBUNAVAIL BUCCALFILM 2.1-0.3 MG3LIDODERMEXTERNAL PATCHST; QL (180EA per 30days)3PA3PLIAGLIS EXTERNALCREAMST; QL (90 EAper 30 days)3PA; QL (30 GMper 30 days)BUNAVAIL BUCCALFILM 4.2-0.7 MGBUNAVAIL BUCCALFILM 6.3-1 MG3ST; QL (60 EAper 30 days)BUPRENEXINJECTION SOLUTION3NDSLast Updated Date: August 2020Page 12
Drug NameDrug Tier Requirements/Limitsbuprenorphine hclinjection solution1buprenorphine hclsublingual tabletsublingual1buprenorphine hclnaloxone hcl sublingualfilm 12-3 mg, 4-1 mg1buprenorphine hclnaloxone hcl sublingualfilm 2-0.5 mg, 8-2 mgbuprenorphine hclnaloxone hcl sublingualtablet sublingual 2-0.5mgNDSQL (60 EA per30 days)1QL (90 EA per30 days)1QL (360 EA per30 days)Drug NameDrug Tier Requirements/LimitsEVZIO INJECTIONSOLUTION AUTOINJECTOR3naloxone hcl injectionsolution1naloxone hcl injectionsolution auto-injector1naloxone hcl injectionsolution prefilled syringe1NARCAN NASALLIQUID3ST; NDSSmoking CessationAgents1QL (90 EA per30 days)bupropion hcl er(smoking det) oral tabletextended release 12hour1QL (60 EA per30 days)LUCEMYRA ORALTABLET3QL (224 EA per14 days); NDS2QL (504 EA per365 days)SUBLOCADESUBCUTANEOUSSOLUTIONPREFILLED SYRINGECHANTIXCONTINUING MONTHPAK ORAL TABLET3NDSCHANTIX ORALTABLET2QL (504 EA per365 days)SUBOXONESUBLINGUAL FILM 123 MG, 4-1 MG23CHANTIX STARTINGMONTH PAK ORALTABLETQL (504 EA per365 days)SUBOXONESUBLINGUAL FILM 20.5 MG, 8-2 MGNICOTROLINHALATION INHALER3QL (2688 EAper 365 days)3NICOTROL NS NASALSOLUTION2QL (360 MLper 365 days)ZYBAN ORAL TABLETEXTENDED RELEASE12 HOUR 150 MG3QL (60 EA per30 days)buprenorphine hclnaloxone hcl sublingualtablet sublingual 8-2 mgQL (60 EA per30 days)QL (90 EA per30 days)ZUBSOLVSUBLINGUAL TABLET0.7-0.18 MG, 5.7-1.4MG3ZUBSOLVSUBLINGUAL TABLET1.4-0.36 MG3ST; QL (360EA per 30days)ZUBSOLVSUBLINGUAL TABLET11.4-2.9 MG3ST; QL (30 EAper 30 days)ZUBSOLVSUBLINGUAL TABLET2.9-0.71 MG3ST; QL (180EA per 30days)3ST; QL (60 EAper 30 days)ZUBSOLVSUBLINGUAL TABLET8.6-2.1 MGST; QL (90 EAper 30 days)AntibacterialsOpioid ReversalAgentsLast Updated Date: August 2020Aminoglycosidesamikacin sulfateinjection solution1ARIKAYCEINHALATIONSUSPENSION3gentamicin sulfateexternal cream1gentamicin sulfateexternal ointment1gentamicin sulfateinjection solution1neomycin sulfate oraltablet1NDSPage 13
Drug NameDrug Tier Requirements/LimitsDrug NameDrug Tier Requirements/Limitsparomomycin sulfateoral capsule1clindamycin phosphatevaginal cream1streptomycin sulfateintramuscular solutionreconstituted1colistimethate sodium(cba) injection ECONSTITUTED3NDSCUBICIN AVENOUSSOLUTIONRECONSTITUTED3NDSdaptomycin intravenoussolution reconstituted1NDSIMPAVIDO ORALCAPSULE3NDSlincomycin hcl injectionsolution1linezolid in sodiumchloride intravenoussolution1NDSlinezolid intravenoussolution1NDSlinezolid oralsuspensionreconstituted1QL (1800 MLper 28 days);NDSQL (56 EA per28 days)tobramycin sulfateinjection solution 1.2gm/30ml, 10 mg/ml, 80mg/2mltobramycin sulfateinjection SAntibacterials, OtherAEMCOLO ORALTABLET DELAYEDRELEASE3ALTABAX EXTERNALOINTMENT3AZACTAM INJECTIONSOLUTIONRECONSTITUTED 2GM3aztreonam injectionsolution reconstituted 1gm1PANDSaztreonam injectionsolution reconstituted 2gm1CLEOCIN VAGINALSUPPOSITORY3linezolid oral tablet1clindacin etz externalswab1methenamine hippurateoral tablet1clindacin-p externalswab11clindamycin hcl oralcapsule1metronidazole in naclintravenous solution 50.79 mg/ml-%1clindamycin palmitatehcl oral solutionreconstitutedmetronidazole oraltablet1metronidazole vaginalgel1clindamycin phosphateexternal swab1MONUROL ORALPACKET31nitrofurantoinmacrocrystal oralcapsule1clindamycin phosphateinjection solution 300mg/2ml, 600 mg/4ml,900 mg/6mlLast Updated Date: August 2020NDSPage 14
Drug NameDrug Tier Requirements/LimitsDrug NameDrug Tier Requirements/Limitsvancomycin hcl oralcapsule 125 mg1QL (120 EA per30 days)vancomycin hcl oralcapsule 250 mg1QL (240 EA per30 days); NDSvancomycin hcl oralsolution reconstituted1VANDAZOLE VAGINALGEL1XENLETAINTRAVENOUSSOLUTION3NDSXENLETA ORALTABLET3NDSQL (6 EA per30 days); NDSZYVOXINTRAVENOUSSOLUTION3NDS3QL (6 EA per30 days); NDS3SYNERCIDINTRAVENOUSSOLUTIONRECONSTITUTEDZYVOX ORALSUSPENSIONRECONSTITUTEDQL (1800 MLper 28 days);NDS3NDSZYVOX ORAL TABLET3QL (56 EA per28 days); NDStigecycline intravenoussolution reconstituted1tinidazole oral tablet13NDStrimethoprim oral lor oral capsule3nitrofurantoinmonohydratemacrocrystals ED3polymyxin b sulfateinjection solutionreconstituted1PRIMSOL TED3SIVEXTRO NTRAVENOUSSOLUTIONRECONSTITUTED3NDScefaclor oral suspensionreconstituted3VANCOCIN HCL ORALCAPSULE3QL (120 EA per30 days); NDScefadroxil oral capsule1VANCOCIN ORALCAPSULE3QL (240 EA per30 days); NDScefadroxil oralsuspensionreconstituted1cefadroxil oral tablet1cefazolin sodiuminjection solutionreconstituted 1 gm1cefdinir oral capsule1cefdinir oral suspensionreconstituted1cefepime hcl injectionsolution reconstituted1cefepime hclintravenous solution1vancomycin hcl indextrose intravenoussolution 750-5mg/150ml-%vancomycin hclintravenous solutionreconstituted 1 gm, 500mg, 750 mgVANCOMYCIN HCLINTRAVENOUSSOLUTIONRECONSTITUTED 250MG111Last Updated Date: August 2020Page 15
Drug NameDrug Tier Requirements/LimitsDrug NameDrug Tier Requirements/Limitscefepime-dextroseintravenous solutionreconstituted1cephalexin oral capsule250 mg, 500 mg1cefixime oral capsule11cefixime oralsuspensionreconstitutedcephalexin oralsuspensionreconstituted1cephalexin oral tablet250 mg1FETROJAINTRAVENOUSSOLUTIONRECONSTITUTED3SUPRAX ORALSUSPENSIONRECONSTITUTED 500MG/5ML3suprax oral tabletchewable2tazicef injection solutionreconstituted1tazicef intravenoussolution cefotaxime sodiuminjection solutionreconstituted1cefotetan disodiuminjection solutionreconstituted1cefoxitin sodiuminjection solut
A formulary is a list of covered drugs selected by State Health Plan PPO in consultation with OptumRx and a team of healthcare providers, which represents the prescription therapies
