WIXLIB

Your 2021 Select Standard FormularyEffective July 1, 2021For the most current list of covered medications or if you have questions:Call the number on your member ID cardVisit your plan’s website on your member ID card or log on to the OptumRx app to: Find a participating retail pharmacy by ZIP code Look up possible lower-cost medication alternatives Compare medication pricing and options

Understanding your formularyWhat is a formulary?About this formularyA formulary is a list of prescribed medications or otherpharmacy care products, services or supplies chosen fortheir safety, cost, and effectiveness. Medications arelisted by categories or classes and are placed into costlevels known as tiers. It includes both brand and genericprescription medications.When differences between this formulary and yourbenefit plan exist, the benefit plan documents rule. Thisformulary may not be a complete list of medications thatare covered by your plan. Please review your benefit planfor full details.To create the list, OptumRx is guided by the Pharmacy andTherapeutics Committee. This group of doctors, nurses, andpharmacists reviews which medications will be covered, howwell the drugs work, and overall value. They also make surethere are safe and covered options.When does the formulary change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a genericequal becomes available. Medications may move to a higher tier or be excluded fromHow do I use my formulary?coverage on January 1 or July 1 of each year.You and your doctor can use the formulary to help youchoose the most cost-effective prescription medications.This guide tells you if a medication is generic or brand, andif special rules apply. If your medication is not listed here,please visit your plan’s website or call the number on yourmember ID card.If a medication changes tiers, you may have to pay a differentamount for that medication.Why are some medications excludedfrom coverage?What are tiers?A medication may be excluded from coverage under yourpharmacy benefit when it works the same as or is similar toanother prescription or over-the-counter (OTC) medication.Tiers are the different cost levels you pay for a medication.Each tier is assigned a cost, set by your employer orplan sponsor.What if I don’t agree with a decision about anexcluded medication?You, your authorized representative, or your doctor canask for a coverage request by calling the number on yourmember ID card.Medication tipsWhat is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but theyoften cost less. In some situations, brand-name medications could be lower in cost.What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if alower-cost option could be right for you.Over-the-countermedications (OTC)What if I am taking a specialty medication?Talk to your doctor about OTCoptions. Even though OTCmedications may not be coveredby your pharmacy benefit,they may cost less than aprescription medication.Specialty medications are used to treat complex conditions and are generally higherin cost. Please note, not all specialty medications are listed in the formulary. Ourspecialty pharmacy can provide most of your specialty medications along withhelpful programs and services. Call 1-855-427-4682 and ask how you can haveyour prescriptions delivered right to your home or doctor’s office.2

Reading your formularyThe formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary,brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase(for example, clobetasol).Tier informationUsing lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers.Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.Drug TierIncludesHelpful TipsTier 1 Lower-costgenerics andsome brand nameUse Tier 1 drugs for the lowest out-of-pocket costs.Tier 2 Mid-range costpreferred brandnameUse Tier 2 drugs instead of Tier 3 to help reduce yourout-of-pocket costs.Tier 3 Higher-costbrand name andsome genericsMany Tier 3 drugs have lower-cost options in Tier 1 or 2.Ask your doctor if they could work for you.Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coveragerequirements or limits. Your benefit plan decides how these medications may be covered.PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.QLQuantity Limit – Medication may be limited to a certain quantity.SPSpecialty Medication – Medication is designated as specialty.STStep Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.3PTier 3 preferred3

Table of ContentsAnalgesics - Drugs for Pain.6Analgesics - Drugs for Pain and Inflammation. 6Anesthetics.6Anti-Addiction / Substance Abuse Treatment Agents. 7Antibacterials.7Anticoagulants.8Anticonvulsants - Drugs for Seizures. 8Antidementia Agents - Drugs for Alzheimer's Disease and Dementia. 8Antidepressants.8Antiemetics - Drugs for Nausea and Vomiting. 9Antifungals.9Antigout Agents. 9Antimigraine Agents. 9Antineoplastics - Drugs for Cancer.9Antiparasitics. 10Antiparkinson Agents. 10Antiplatelets.10Antipsychotics - Drugs for Mood Disorders. 10Antivirals.11Anxiolytics - Drugs for Anxiety.11Bipolar Agents - Drugs for Mood Disorders.11Blood Products and Modifiers - Drugs for Blood Disorders.11Cardiovascular Agents - Drugs for Heart and Circulation Conditions. 12Central Nervous System Agents - Drugs for Attention Deficit Disorder. 13Central Nervous System Agents - Drugs for Multiple Sclerosis. 14Central Nervous System Agents - Miscellaneous. 14Dental and Oral Agents - Drugs for Mouth and Throat Conditions.14Dermatological Agents - Drugs for Skin Conditions. 15Diabetes - Antidiabetic Agents. 16Diabetes - Glucose Monitoring. 16Diabetes - Glycemic Agents. 17Diabetes - Insulins.17Electrolytes / Minerals / Metals / Vitamins.18Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer.18Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.19Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment. 19Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.19Genitourinary Agents - Drugs for Prostate Conditions. 20Hormonal Agents - Adrenal. 20Hormonal Agents - Men's Health.20Hormonal Agents - Osteoporosis. 20Hormonal Agents - Pituitary. 20Hormonal Agents - Sex Hormones and Birth Control.21Hormonal Agents - Thyroid. 22Immunological Agents - Drugs for Immune System Stimulation or Suppression. 22Inflammatory Bowel Disease Agents.23Metabolic Bone Disease Agents - Drugs for Osteoporosis. 24Metabolic Bone Disease Agents - Other. 24Miscellaneous Therapeutic Agents. 24Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation.24Ophthalmic Agents - Drugs for Glaucoma.244

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions. 25Otic Agents - Drugs for Ear Conditions. 25Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold.25Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions. 26Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis. 27Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension. 27Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm. 27Sleep Disorder Agents. 275

Drug NameDrug Tier NotesDrug NameAnalgesics - Drugsfor PainDrug Tier Notesoxycodoneacetaminophen oraltablet 10-325 mg, 2.5325 mg, 5-325 mg, 7.5325 mg1QLacetaminophencodeine #21QLacetaminophencodeine #31QLOXYCONTIN2PA; QLacetaminophencodeine #41QLtramadol hcl oral tablet50 mg1QLTREZIX3QLXTAMPZA ERAnalgesics - Drugsfor Pain andInflammation2PA; QLacetaminophencodeine oral tablet 30015 mg, 300-60 mg1QLapap-caffdihydrocodeine oralcapsule1QLcelecoxib oral1QLBELBUCA2PA; QLbutalbital-apap-caffeine1diclofenac sodiumexternal gel 1 %1QLfentanyl1PA; QLdiclofenac sodium oral1etodolac oral tablet1QLibuprofen oral tablet1INDOMETHACINORAL CAPSULE 20MG3hydrocodoneacetaminophen oraltablet1hydromorphone hcl oraltablet1QLHYSINGLA ER2PA; QLmorphine sulfate(concentrate) oralsolution 100 mg/5ml,20 mg/mlindomethacin oralcapsule 25 mg, 50 mg11QLketorolac tromethamineoral1morphine sulfate er oraltablet extended releasemeloxicam oral tablet11PA; QLnabumetone oral1morphine sulfate oralsolution1QLNAPRELAN3naproxen oral tablet1NUCYNTA3QLoxycodone hcl oraltablet1QLOXYCODONEACETAMINOPHENORAL TABLET 10-300MG, 2.5-300 MG, 5-300MG3naproxen sodium oraltabletAnestheticsQLSTQL1lidocaine external patch1lidocaine-prilocaineexternal cream1For more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.6

Drug NameDrug Tier NotesDrug NameAnti-Addiction /Substance AbuseTreatment AgentsDrug Tier Notesclarithromycin oraltablet1clindamycin hcl oral1BUNAVAIL3QLCLINDESSE3buprenorphine hclsublingual1QLDIFICID ORALTABLET3buprenorphine hclnaloxone hcl1QLdoxycycline hyclate oralcapsule1CHANTIX STARTINGMONTH PAK3QLdoxycycline hyclate oraltablet1naltrexone hcl hydrate oralcapsule1amoxicillin oral capsule1doxycyclinemonohydrate oral tabletamoxicillin oralsuspensionreconstitutedlevofloxacin oral tablet11metronidazole oraltablet1amoxicillin oral tablet1metronidazole vaginal1minocycline hcl oralcapsule1mupirocin monohydratemacrocrystals1NUZYRA ORAL31QLamoxicillin-potassiumclavulanate lavulanate oral tablet1azithromycin oralsuspensionreconstituted1azithromycin oral tablet1cefdinir1penicillin v potassiumoral tabletcefuroxime axetil1SEYSARA3cephalexin oral capsule1SOLOSEC3cephalexin hoprim oral tablet1XENLETA3ciprofloxacin hcl oraltablet 250 mg, 500 mg1XEPI3XIMINO3STFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.7

Drug NameDrug Tier NotesDrug NameAnticoagulantsDrug Tier NotesVIMPAT3XCOPRI3zonisamide oralAntidementia Agents- Drugs forAlzheimer's Diseaseand Dementia1ELIQUIS2QLELIQUIS DVT/PESTARTER PACK2QLenoxaparin sodium1SP; QLPRADAXA2QLwarfarin sodium oral1XARELTO2QLdonepezil hcl oral tablet10 mg, 23 mg12QLmemantine hcl oraltablet 10 mg, 5 mg1XARELTO STARTERPACKAnticonvulsants Drugs for SeizuresSTNAMZARICAntidepressants2amitriptyline hcl oral1bupropion hcl er (sr)1QLbupropion hcl er (xl)oral tablet extendedrelease 24 hour 150mg, 300 mg1QLBUPROPION HCL ER(XL) ORAL TABLETEXTENDED RELEASE24 HOUR 450 MG3ST; QLbupropion hcl oral1citalopramhydrobromide oraltablet1desvenlafaxinesuccinate er1doxepin hcl oralcapsule 10 mg, 100mg, 25 mg, 50 mg, 75mg1duloxetine hcl oral1PAescitalopram oxalateoral tablet1fluoxetine hcl oralcapsule1fluoxetine hcl oral tablet1BRIVIACTINTRAVENOUS3BRIVIACT ORAL3carbamazepine oraltablet1divalproex sodium er1divalproex sodium oraltablet delayed release1EPIDIOLEX3FYCOMPA3gabapentin oralcapsule1gabapentin oral tablet1lamotrigine er1lamotrigine oral tablet1levetiracetam oraltablet1NAYZILAM3oxcarbazepine oraltablet1SYMPAZAN3topiramate oral tablet1TROKENDI XR3STVALTOCO3QLSTPA; SPQLQLQLQLFor more information regarding the tiers and designations in this drug list, please see the Reading yourformulary section of this booklet.8