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UPREHS Prime Medicare Part DPrescription Drug Plan (PDP),administered by OptumRx2018 Abridged Formulary(Partial List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANThis abridged formulary was updated on July, 2017 and is not a complete list of drugs covered by ourplan.For a complete listing or if you have questions please contact:OptumRx Member ServicesPhone: 1-866-443-1095TTY users call: 711Hour of operation: 24 hours a day, 7 days a weekWebsite: optumrx.comNote to existing members: This formulary has changed since last year. Please review this documentto 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 UPREHS Prime Medicare Part D Prescription Drug Plan.This document includes a partial list of the drugs (formulary) for our plan which is current as ofJanuary 1, 2018. For a complete, updated formulary, please contact us. Our contact information, alongwith the date we last updated the formulary, appears on the front and back cover pages.You must generally use network pharmacies to use your prescription drug benefit. Benefits,formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1,2019.Formulary ID 18090Version 5Optum Insurance of Ohio, Inc. is a Medicare approved Part D sponsor and administers this planthrough its pharmacy benefit manager, OptumRx, on behalf of your employer, union or trustees of afund. If you need this information in another language or other format (Braille, large print, audio),please contact OptumRx Member Services at the number located on the back of your ID card.S8841 18 MC-DS10 UNP
What is the Abridged Formulary?A formulary is a list of covered drugs selected by UPREHS Prime Medicare Part D Prescription DrugPlan in consultation with OptumRx and a team of health care providers, which represents theprescription therapies believed to be a necessary part of a quality treatment program. UPREHS PrimeMedicare Part D Prescription Drug Plan will generally cover the drugs listed in our formulary as longas the drug is medically necessary, the prescription is filled at an OptumRx network pharmacy, andother plan rules are followed.This document is a partial formulary and includes only some of the drugs covered by this plan. For acomplete listing of all prescription drugs covered, please visit our website or call us. Our contactinformation, along with the date we last updated the formulary, appears on the front and back coverpages.Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of theyear, we will not discontinue or reduce coverage of the drug during the 2018 coverage year exceptwhen a new, less expensive generic drug becomes available, or when new adverse information aboutthe safety or effectiveness of a drug is released.If we remove drugs from our formulary; add prior authorization, quantity limits, and/or step therapyrestrictions on a drug; or move a drug to a higher cost-sharing tier (as applicable), we must notifyaffected members of the change at least 60 days before the change becomes effective, or at the timethe member requests a refill of the drug, at which time the member will receive a 60-day supply of thedrug. If the Food and Drug Administration deems a drug on our formulary to be unsafe, or the drug’smanufacturer removes the drug from the market, we will immediately remove the drug from ourformulary and provide notice to members who take the drug. The enclosed formulary is current as ofJanuary 1, 2018. To get updated information about the drugs covered, please contact OptumRxMember Services. Our contact information appears on the front and back cover pages.If there is a mid-year non-maintenance formulary change (i.e., remove drugs from our formulary; addprior authorization, quantity limits; and/or step therapy restrictions on a drug; or move a drug to ahigher cost-sharing tier), we will update our formulary and post it on our website. The updatedformulary may be obtained from our website at optumrx.com or by calling OptumRx MemberServices. Our contact information, along with the date we last updated the formulary, appears on thefront and back cover pages. We will notify beneficiaries in writing prior to making this type ofchange.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 9. The drugs in this formulary are grouped into categories depending onthe type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, “Cardiovascular Agents.” If you know what your drug is usedfor, look for the category name in the list that begins on page 9. Then look under the category namefor your drug.2
Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that beginson page 42. The Index provides an alphabetical list of all of the drugs included in this document. Bothbrand name drugs and generic drugs are listed in the Index.Formulary DesignThe formulary structure features preferred generic drugs, generic drugs, preferred brand name drugs,non-preferred brand name drugs, and high-cost drugs. Tier 1 drugs: Drugs listed under “Tier 1” generally will have the lowest copayments.Tier 2 drugs: Drugs listed under “Tier 2” generally include generic drugs that may have aslightly higher copayment than preferred generic drugs.Tier 3 drugs: Drugs listed under “Tier 3” generally will have lower copayments than regularbrand name drugs, but higher copayments than generic drugs.Tier 4 drugs: Drugs listed under “Tier 4” generally have higher copayments than preferredbrand name drugs.Tier 5 drugs: High-cost drugs listed under “Tier 5” include drugs that cost 670 or more forup to a 30-day supply. These drugs can only be supplied for 31 days at a time.CoveredPrescriptionDrugsTier 1(Preferred GenericDrugs)Tier 2(Non-Preferred GenericDrugs)Tier 3(Preferred BrandDrugs)Tier 4(Non-Preferred BrandDrugs)Tier 5(High-Cost Drugs)RetailPharmacy(up to a 31day supply)RetailPharmacy(up to a 90day supply)Depot DrugPreferredMail-OrderPharmacy(up to a 90-daysupply)Non-PreferredMail-OrderPharmacy(up to a 90-daysupply) 15 45 9 45 20 60 30 60 30 90 45 90Greater of: 90 or 33%Greater of: 270 or 33%Greater of: 225 or 33%Greater of: 270 or 33%33%33%33%33%You must obtain a 90-day supply of Tier 1 Generics when using Depot Drug mail. If you needless than a 90-day supply of Tier 1 Generics, you must use a retail network pharmacy. Youmay obtain a 30, 60 or 90-day supply of Tier 2, 3 or 4 prescription drugs from Depot Drugmail. If you use a mail-order pharmacy outside of the plan’s network, your prescription willnot be covered.Please refer to your Evidence of Coverage for more information.3
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: A prior authorization requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from OptumRxbefore you fill your prescriptions. If you do not get approval, the drug may not be covered.Quantity Limits: For certain drugs, there is a limit on the amount of the drug that will becovered.Step Therapy: In some cases, it will be required that you first try certain drugs to treat yourmedical condition before we will cover another drug for that condition. For example, if DrugA and Drug B both treat your medical condition, we may not cover Drug B unless you tryDrug A first. If Drug A does not work for you, we will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formularythat begins on page 9. You can also get more information about the restrictions applied to specificcovered drugs by visiting our website. For more information, please call OptumRx Member Services.Our contact information, along with the date we last updated the formulary, appears on the front andback cover pages.You can call OptumRx at 1-866-443-1095 to make an exception to these restrictions or limits, or for alist of other similar drugs that may treat your health condition. See the section, “How do I request anexception to the formulary?” on page 4 for information about how to request an exception.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 MemberServices and ask if your drug is covered. This document includes only a partial list of covered drugs,so we may cover your drug. For more information, please call OptumRx Member Services. Ourcontact information appears on the front and back cover pages.If your drug is not covered, you have two options: You can ask Member Services for a list of similar drugs that are covered. When you receivethe list, show it to your 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 informationabout how to request an exception.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 willbe covered at a predetermined cost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level.4
You can ask us to cover a formulary drug at a lower cost-sharing level if the drug is not inthe high-cost drug tier. If approved, this would lower the amount you must pay for yourdrug.You can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, we may limit the amount of the drug that we will cover. If your drug has aquantity limit, you can ask us to waive the limit and cover a greater amount.Generally, we will only approve your request for an exception if the drug is included on the plan’sformulary, or additional utilization restrictions would not be as effective in treating your conditionand/or would cause you to have adverse medical effects.You should contact OptumRx for an initial coverage decision for a formulary, tiering, or utilizationrestriction exception. When you request a formulary, tiering, or utilization restriction exception,you should submit a statement from your prescriber or physician supporting your request.Generally, we must make our decision within 72 hours of getting your prescriber’s supportingstatement. You can request an expedited (fast) exception if you or your doctor believe that your healthcould be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite isgranted, we must give you a decision no later than 24 hours after we get a supporting statement fromyour doctor or other prescriber.What do I do before I can talk to my doctor about changing my drugs orrequesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary.Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example,you may need a prior authorization from us before you can fill your prescription. You should talk toyour doctor to decide if you should switch to an appropriate drug that we cover or request a formularyexception. While you talk to your doctor to determine the right course of action for you, we may coveryour drug in certain cases during the first 90 days you are a member of our plan.For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, wewill cover a temporary 30-day supply (unless you have a prescription written for fewer days) whenyou go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even ifyou have been a member of 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 wehave provided you with 31-day transition supply, consistent with dispensing increment, (unless youhave a prescription written for fewer days). We will cover more than one refill of these drugs for thefirst 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, wewill cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days)while you pursue a formulary exception.5
If you are a current enrollee with a level-of-care change and you need a drug that is not on ourformulary, or if your ability to get your drugs is limited, we will cover a temporary 31-day transitionsupply (unless you have a prescription written for fewer days) while you seek to obtain a formularyexception. If you are in the process of seeking an exception, we will consider allowing continuedcoverage 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 Member Services. Our contactinformation, along with the date we last updated the formulary, appears on the front and back coverpages. If you have general questions about Medicare prescription drug coverage, please call Medicareat 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877486-2048. Or, visit www.medicare.gov.FormularyThe abridged formulary below provides coverage information about some of the drugs covered. If youhave trouble finding your drug in the list, turn to the Index that begins on page 42.Remember: This is only a partial list of drugs covered. If your prescription is not in this partialformulary, please contact us. Our contact information, along with the date we last updated theformulary, appears on the front and back cover pages.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 theRequirements/Limits column tell you if there are any special requirements for coverage of your drug.B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. Thisdrug may be covered under Medicare Part B or D depending upon the circumstances. Informationmay need to be submitted describing the use and setting of the drug to make the determination.HI: Home Infusion. This prescription drug may be covered under our medical benefit.LA: Limited Availability. This prescription may be available only at certain pharmacies.MO: Mail Order Drug. This prescription drug is available through a mail order service.PA: Prior Authorization. Our plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from OptumRx before you fill yourprescriptions. If you do not get approval, your drug may not be covered.QL: Quantity Limit. For certain drugs, our plan limits the amount of the drug that will be covered.ST: Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.6
OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race,color, national origin, age, disability, or sex in its health programs or activities.We provide assistance free of charge to people with disabilities or whose primary language is notEnglish. To request a document in another format, such as large print, or to get language assistancesuch as a qualified interpreter, please call the number located on the back of your prescription ID card,TTY 711.Representatives are available 24 hours a day, seven days a week.If you believe that we have failed to provide these services or discriminated in another way on thebasis of race, color, national origin, age, disability, or sex, you can send a complaint to:OptumRx Civil Rights Coordinator11000 Optum CircleEden Prairie, MN 55344Phone: 1-800-562-6223, TTY 711Fax:1-855-351-5495Email: Optum Civil Rights@Optum.comIf you need help filing a complaint, please call the number located on the back of your prescription IDcard, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file acomplaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:Online: laint forms are available at : Toll-free 1-800-368-1019, 800-537-7697 (TDD)Mail: U.S. Dept. of Health and Human Services200 Independence Avenue, SW Room 509F, HHH BuildingWashington, D.C. 20201This information is available in other formats like large print.To ask for another format, please call the telephone numberlisted on your prescription plan ID card.Multi-language interpreter servicesATTENTION: If you speak English, language assistance services, free of charge, areavailable to you. Please call the toll-free phone number listed on your identificationcard.ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas,sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece ensu tarjeta de identificación.7
請注意：如果您說中文 ��話 號碼。XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợgiúp về ngôn ngữmiễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mgalibreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng teleponona nasa iyong identification card.ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей роднойязык является русском (Russian). Позвоните по бесплатному номерутелефона, указанному на вашей идентификационной карте. الرجءا ال ص تالا ى لع رمق ف تا ھال ي نا جمال دوجومال ى لع . فًإ خت اهذ اجد اع سول ا و غلليج المججي ٌا ام تحج لك ،(Arabic) العربية إار كت ي تث ذ حت : يه ث ٌت . رعمف ال وضعية ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratispou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.ATTENTION : Si vous parlez français (French), des services d’aide linguistique voussont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurantsur votre carte d’identification.UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza.Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej.ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência deidiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão deidentificação.ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibiliservizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefonoverde indicato sulla vostra tessera identificativa.ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachlicheHilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf derRückseite Ihres Mitgliedsausweises 利用いただけます。健康保険 �お電話ください。 لا افط ب شمارٍ لتفى ي ٌا گ يا ر هکر ي و کارت . ت اهذخ دادها ي ٌات س هة روط ً اگ يا رد ر ي تخاار شام ي ن دشا ب ، ( اشت Farsi) ی سرا ف 8
اگرز بً ا ش ام :ٍ و تج . ا ساً شيی اهش د يق هذ ش تم سا د ير ي گة आप:पपप(Hindi)-, आप,:पपपपCEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb raukoj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuajcim qhia tus � �សាខ្មរម ��យឥតគិតថ្លៃ ��តគិតថ្លៃ ��។PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe ngaawanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero titelepono nga nakalista ayan iti identification card mo.DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí,t'áá jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí ninaaltsoos nitł'izí bee nééhozinígíí bine'dęę' t'áájíík'ehgo béésh bee hane'í biká'ígíí bee hodíilnih.OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oobilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee kuyaalla kaarkaaga aqoonsiga.9
Drug NameAnalgesicsNonsteroidal Anti-inflammatory Drugscelecoxib caps 100mgcelecoxib caps 200mgcelecoxib caps 400mgcelecoxib caps 50mgdiclofenac sodium dr tbec 25mgdiclofenac sodium dr tbec 50mgdiclofenac sodium dr tbec 75mgdiclofenac sodium er tb24 100mgibuprofen tabs 400mgibuprofen tabs 600mgibuprofen tabs 800mgmeloxicam tabs 15mgmeloxicam tabs 7.5mgnaproxen sodium er tb24 375mgnaproxen sodium tabs 275mgnaproxen sodium tabs 550mgnaproxen tabs 250mgnaproxen tabs 375mgnaproxen tabs 500mgOpioid Analgesics, Long-actingBUTRANS PTWK 10MCG/HRBUTRANS PTWK 15MCG/HRBUTRANS PTWK 20MCG/HRBUTRANS PTWK 5MCG/HRBUTRANS PTWK 7.5MCG/HREMBEDA CPCR 100MG; 4MGEMBEDA CPCR 20MG; 0.8MGEMBEDA CPCR 30MG; 1.2MGEMBEDA CPCR 50MG; 2MGEMBEDA CPCR 60MG; 2.4MGEMBEDA CPCR 80MG; 3.2MGmorphine sulfate er tbcr 100mgmorphine sulfate er tbcr 15mgmorphine sulfate er tbcr 200mgmorphine sulfate er tbcr 30mgmorphine sulfate er tbcr 60mgOpioid Analgesics, Short-actingacetaminophen/codeine tabs 300mg; 15mgacetaminophen/codeine tabs 300mg; 30mgacetaminophen/codeine tabs 300mg; 60mghydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mghydrocodone/acetaminophen tabs 325mg; 10mghydrocodone/acetaminophen tabs 325mg; 5mghydrocodone/acetaminophen tabs 325mg; 7.5mgmorphine sulfate tabs 15mgmorphine sulfate tabs 11QL (60 EA per 30 days)QL (60 EA per 30 days)QL (60 EA per 30 days)QL (60 EA per 30 days)3333353333522222QL (4 EA per 28 days)QL (4 EA per 28 days)QL (4 EA per 28 days)QL (4 EA per 28 days)QL (4 EA per 28 days)222222222
Drug Nameoxycodone hcl caps 5mgoxycodone hcl tabs 10mgoxycodone hcl tabs 15mgoxycodone hcl tabs 20mgoxycodone hcl tabs 30mgoxycodone hcl tabs 5mgoxycodone/acetaminophen tabs 325mg; 10mgoxycodone/acetaminophen tabs 325mg; 2.5mgoxycodone/acetaminophen tabs 325mg; 5mgoxycodone/acetaminophen tabs 325mg; 7.5mgtramadol hcl tabs 50mgAnestheticsLocal Anestheticslidocaine hcl gel 2%lidocaine viscous soln 2%lidocaine oint 5%Anti-Addiction/Substance Abuse Treatment AgentsAlcohol Deterrents/Anti-cravingacamprosate calcium dr tbec 333mgdisulfiram tabs 250mgdisulfiram tabs 500mgOpioid Dependence Treatmentsbuprenorphine hcl/naloxone hcl subl 2mg; 0.5mgbuprenorphine hcl/naloxone hcl subl 8mg; 2mgbuprenorphine hcl subl 2mgbuprenorphine hcl subl 8mgnaltrexone hcl tabs 50mgSUBOXONE FILM 12MG; 3MGSUBOXONE FILM 2MG; 0.5MGSUBOXONE FILM 4MG; 1MGSUBOXONE FILM 8MG; 2MGOpioid Reversal Agentsnaloxone hcl inj 0.4mg/mlNARCAN LIQD 4MG/0.1MLSmoking Cessation Agentsbuproban tb12 150mgbupropion hcl sr tb12 150mgCHANTIX CONTINUING MONTH PAK TABS 1MGCHANTIX STARTING MONTH PAK TABS 0CHANTIX TABS 0.5MGCHANTIX TABS 1MGAntibacterialsAminoglycosidesgentamicin sulfate crea 0.1%gentamicin sulfate oint 0.1%Antibacterials, Otherclindamycin hcl caps 150mgclindamycin hcl caps 2442224444QL (360 EA per 30 days)QL (90 EA per 30 days)QL (60 EA per 30 days)QL (360 EA per 30 days)QL (180 EA per 30 days)QL (90 EA per 30 days)232233332222QL (60 EA per 30 days)QL (60 EA per 30 days)QL (504 EA per 365 days)QL (504 EA per 365 days)QL (504 EA per 365 days)QL (504 EA per 365 days)
Drug Nameclindamycin hcl caps 75mgmetronidazole tabs 250mgmetronidazole tabs 500mgmupirocin crea 2%mupirocin oint 2%Beta-lactam, Cephalosporinscefuroxime axetil tabs 250mgcefuroxime axetil tabs 500mgcephalexin caps 250mgcephalexin caps 500mgSUPRAX CAPS 400MGSUPRAX CHEW 100MGSUPRAX CHEW 200MGSUPRAX SUSR 500MG/5MLBeta-lactam, Otheraztreonam inj 1gmaztreonam inj 2gmimipenem/cilastatin inj 250mg; 250mgimipenem/cilastatin inj 500mg; 500mgBeta-lactam, Penicillinsamoxicillin/clavulanate potassium tabs 250mg; 125mgamoxicillin/clavulanate potassium tabs 500mg; 125mgamoxicillin/clavulanate potassium tabs 875mg; 125mgamoxicillin caps 250mgamoxicillin caps 500mgamoxicillin tabs 875mgMacrolidesAZASITE SOLN 1%azithromycin tabs 250mgDIFICID TABS 200MGERY-TAB TBEC 250MGERY-TAB TBEC 333MGERY-TAB TBEC 500MGQuinolonesBESIVANCE SUSP 0.6%ciprofloxacin hcl tabs 250mgciprofloxacin hcl tabs 500mglevofloxacin tabs 250mglevofloxacin tabs 500mglevofloxacin tabs 750mgMOXEZA SOLN 0.5%VIGAMOX SOLN 0.5%Sulfonamidessulfamethoxazole/trimethoprim ds tabs 800mg; 160mgsulfamethoxazole/trimethoprim susp 200mg/5ml; 40mg/5mlsulfamethoxazole/trimethoprim tabs 400mg; 80mgTetracyclinesdoxycycline hyclate caps 331212Requirements/Limits
Drug Namedoxycycline hyclate caps 50mgdoxycycline monohydrate caps 100mgdoxycycline monohydrate caps 50mgdoxycycline monohydrate tabs 100mgdoxycycline monohydrate tabs 50mgdoxycycline monohydrate tabs 75mgminocycline hcl tabs 100mgminocycline hcl tabs 50mgminocycline hcl tabs 75mgAnticonvulsantsAnticonvulsants, OtherBRIVIACT INJ 50MG/5MLBRIVIACT SOLN 10MG/MLBRIVIACT TABS 100MGBRIVIACT TABS 10MGBRIVIACT TABS 25MGBRIVIACT TABS 50MGBRIVIACT TABS 75MGFYCOMPA SUSP 0.5MG/MLFYCOMPA TABS 10MGFYCOMPA TABS 12MGFYCOMPA TABS 2MGFYCOMPA TABS 4MGFYCOMPA TABS 6MGFYCOMPA TABS 8MGlevetiracetam er tb24 500mglevetiracetam er tb24 750mglevetiracetam tabs 1000mglevetiracetam tabs 250mglevetiracetam tabs 500mglevetiracetam tabs 750mgCalcium Channel Modifying AgentsLYRICA CAPS 100MGLYRICA CAPS 150MGLYRICA CAPS 200MGLYRICA CAPS 225MGLYRICA CAPS 25MGLYRICA CAPS 300MGLYRICA CAPS 50MGLYRICA CAPS 75MGLYRICA SOLN 20MG/MLzonisamide caps 100mgzonisamide caps 25mgzonisamide caps 50mgGamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam tabs 0.5mgclonazepam tabs 1mgclonazepam tabs 54554221111333333333222111QL (90 EA per 30 days)QL (90 EA per 30 days)QL (90 EA per 30 days)QL (90 EA per 30 days)QL (90 EA per 30 days)QL (60 EA per 30 days)QL (90 EA per 30 days)QL (90 EA per 30 days)QL (900 ML per 30 days)
Drug Namedivalproex sodium dr tbec 125mgdivalproex sodium dr tbec 250mgdivalproex sodium dr tbec 500mgdivalproex sodium er tb24 250mgdivalproex sodium er tb24 500mgdivalproex sodium csdr 125mggabapentin caps 100mggabapentin caps 300mggabapentin caps 400mggabapentin tabs 600mggabapentin tabs 800mgGlutamate Reducing Agentslamotrigine tabs 100mglamotrigine tabs 150mglamotrigine tabs 200mglamotrigine tabs 25mgtopiramate tabs 100mgtopiramate tabs 200mgtopiramate tabs 25mgtopiramate tabs 50mgSodium Channel Agentscarbamazepine chew 100mgphenytoin sodium extended caps 100mgphenytoin sodium extended caps 200mgphenytoin sodium extended caps 300mgVIMPAT INJ 200MG/20MLVIMPAT SOLN 10MG/MLVIMPAT TABS 100MGVIMPAT TABS 150MGVIMPAT TABS 200MGVIMPAT TABS 50MGAntidementia AgentsAntidementia Agents, OtherERGOLOID MESYLATES TABS 1MGNAMZARIC CP24 10MG; 14MGNAMZARIC CP24 10MG; 21MGNAMZARIC CP24 10MG; 28MGNAMZARIC CP24 10MG; 7MGCholinesterase Inhibitorsdonepezil hcl tabs 10mgdonepezil hcl tabs 23mgdonepezil hcl tabs 5mggalantamine hydrobromide tabs 12mggalantamine hydrobromide tabs 4mggalantamine hydrobromide tabs 8mgN-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mgmemantine hcl tabs 122224444443333314122222PAQL (30 EA per 30 days)QL (30 EA per 30 days)QL (30 EA per 30 days)QL (30 EA per 30 days)
DrugDrug NameTierNAMENDA XR TITRATION PACK CP24 03NAMENDA XR CP24 14MG3NAMENDA XR CP24 21MG3NAMENDA XR CP24 28MG3NAMENDA XR CP24 7MG3AntidepressantsAntidepressants, Otherbupropion hcl er tb12 100mg1bupropion hcl er tb12 150mg1bupropion hcl er tb12 200mg1bupropion hcl sr tb12 100mg1bupropion hcl sr tb12 150mg1bupropion hcl sr tb12 200mg1bupropion hcl xl tb24 150mg2bupropion hcl xl tb24 300mg2bupropion hcl tabs 100mg2bupropion hcl tabs 75mg2mirtazapine tabs 15mg2mirtazapine tabs 30mg2mirtazapine tabs 45mg2mirtazapine tabs 7.5mg2Monoamine Oxidase Inhibitorsphenelzine sulfate tabs 15mg2tranylcypromine sulfate tabs 10mg4SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotoninand Norepinephrine Reuptake Inhibitorcitalopram hydrobromide tabs 10mg1citalopram hydrobromide tabs 20mg1citalopram hydrobromide tabs 40mg1duloxetine hcl cpep 20mg2duloxetine hcl cpep 30mg2duloxetine hcl cpep 60mg2escitalopram oxalate tabs 10mg1escitalopram oxalate tabs 20mg1escitalopram oxalate tabs 5mg1fluoxetine hcl caps 10mg1fluoxetine hcl caps 20mg1fluoxetine hcl caps 40mg1fluoxetine caps 10mg2fluoxetine caps 20mg2paroxetine hcl tabs 10mg1paroxetine hcl tabs 20mg1paroxetine hcl tabs 30mg1paroxetine hcl tabs 40mg1sertraline hcl tabs 100mg1sertraline hcl tabs 25mg1sertraline hcl tabs 50mg1trazodone hcl tabs 100mg215Requirements/LimitsQL (56 EA per 365 days)QL (30 EA per 30 days)QL (30 EA per 30 days)QL (30 EA per 30 days)QL (30 EA per 3
through its pharmacy benefit manager, OptumRx, on behalf of your employer, union or trustees of a fund. If you need this information in another language or other format (Braille, large print, audio), please contact OptumRx Member Services at the number located on the back of your ID card. S8841_18_MC-DS10_UNP UPREHS Prime Medicare Part D
