MedPerform Medium Preferred Drug List (PDL)
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1 What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote clinically appropriate utilization of medications in a cost-effective manner. Who decides what medications make up the PDL? The list is developed and maintained by a committee comprised of physicians and pharmacists (the Pharmacy and Therapeutics Committee). Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. Are the medications listed on the PDL the only drugs my physician can prescribe for me? No. The PDL is a select list of commonly prescribed drugs and does not represent all preferred formulary medications available under your plan. The PDL does not limit your prescription coverage, but is provided to encourage the use of preferred generic and brand name drugs within major therapeutic drug classes (e.g., Cardiovascular, Diabetes, etc.). For complete formulary information, visit your Plan website or refer to the phone number listed on your benefit card. How do I get the greatest benefit from my PDL? Print out the Preferred Drug List and take it with you when visiting your physician. Ask your physician to prescribe generic medications whenever possible. All FDA approved generic drugs are considered preferred medications and should reduce your copays. When there is more than one brand name drug available for your medical condition, ask your physician to prescribe a preferred drug listed on your PDL. This should also reduce your copays. Please note: The MedImpact PDL is subject to change due to updates and availability of generic alternatives. Please refer to the MedImpact web site at for the most up-to-date PDL. The PDL is not a complete list of formulary drugs; therefore, you should refer to your plan for a complete drug list and details of any additional coverage or quantity limit restrictions that may apply to certain medications. ALLERGY NASAL CORTICOSTEROIDS Dymista (QL, ST) OPHTHALMIC ANTIHISTAMINES BEHAVIORAL HEALTH ADHD AGENTS ANTIPSYCHOTICS budesonide (QL, ST) flunisolide (QL) fluticasone (QL) triamcinolone (QL) azelastine (QL) olopatadine (QL) dextroamphetamine/ amphetamine methylphenidate aripiprazole (QL) aripiprazole ODT/ oral solution (QL) clozapine (QL) clozapine ODT (QL) olanzapine (QL) quetiapine IR/ER (QL) risperidone (QL) ziprasidone (QL) Nasonex (QL) Qnasl (QL) Adderall XR (QL) Concerta (QL) Quillichew (QL) Quillivant (QL) Vyvanse (QL) Latuda (QL) Rexulti (QL) Saphris (QL) Vraylar (QL) Daytrana (QL, ST) Dynavel XR (QL, ST) Zenzedi (QL, ST) Fanapt (QL) Fazaclo (QL) Invega (QL) Versacloz (QL) Beconase AQ Omnaris Ticanase Xhance Zetonna Bepreve Emadine Lastacaft Pazeo Adzenys ER Adzenys XR-ODT Aptensio XR Cotempla XR-ODT Mydayis Page 1 Copyright 2018 All rights reserved.
2 CARDIOVASCULAR LIPID-LOWERING AGENTS ANTICOAGULANTS atorvastatin (QL) ezetimibe (QL) fluvastatin IR/ER (QL) lovastatin IR/ER (QL) pravastatin (QL) rosuvastatin (QL) simvastatin (QL) (ST on 80mg) simvastatin/ezetimibe (QL) (ST on 80mg) Livalo (QL) Eliquis (QL) Xarelto (QL) Altoprev (QL, ST) Flolipid (PA) Zypitamag (QL, ST) Bevyxxa (QL) Pradaxa (QL, ST) Savaysa (QL, ST) DERMATOLOGY TOPICAL ACNE AGENTS clindamycin/tretinoin Ziana Veltin DIABETES DPP-4 INHIBITORS SGLT-2 INHIBITORS DPP-4 INHIBITOR AND SGLT-2 INHIBITOR GLP-1 AGONISTS Januvia (QL) Janumet (QL) Janumet XR (QL) Jentadueto (QL) Jentadueto XR (QL) Tradjenta (QL) Invokana (QL, ST) Invokamet (QL, ST) Invokamet XR (QL, ST) Jardiance (QL, ST) Synjardy (QL, ST) Synjardy XR (QL, ST) Glyxambi (QL, ST) Trulicity (QL, ST) Victoza (QL, ST) INSULINS, RAPID-ACTING Humalog (QL) Afrezza (PA, QL) Fiasp (QL, ST) Kazano Kombiglyze XR Nesina Onglyza Oseni Farxiga Segluromet Steglatro Xigduo XR Qtern Steglujan Adlyxin Bydureon Bydureon BCise Byetta Ozempic Admelog Apidra Novolog INSULINS, SHORT-ACTING Humulin (QL) Novolin INSULINS, LONG-ACTING Lantus (QL) Toujeo (QL) Basaglar Levemir Tresiba INSULIN (LONG-ACTING) AND GLP-1 AGONIST DIABETIC SUPPLIES ENDOCRINE ANDROGENS me-testosterone testosterone solution (PA) testosterone cypionate (PA) testosterone enanthate Soliqua (QL, ST) Xultophy (QL, ST) Preferred Abbott diabetic supplies (Precision, FreeStyle, FreeStyle Neo) (QL) Abbott FreestyleLibre CGM Androgel (PA) Androderm patch (PA) Fortesta Natesto Testim Vogelxo All non-abbott manufacturers of diabetic test strips and meters Page 2 Copyright 2018 All rights reserved.
3 (PA) ESTROGENS estradiol estradiol patch estradiol/norethindrone estropipate medroxyprogesterone norethindrone ac-eth Combipatch (QL) Crinone Duavee Menest Premarin Premphase Cenestin Climara Pro (QL) Enjuvia Estring (QL) Femtrace Prefest estradiol Prempro Striant (PA) progesterone, micronized OSTEOPOROSIS AGENTS WEIGHT REDUCTION GASTROINTESTINAL IRRITABLE BOWEL & CONSTIPATION INFLAMMATORY BOWEL DISEASE AGENTS PANCREATIC ENZYMES GENITOURINARY DRUGS TO TREAT IMPOTENCY PAIN MANAGEMENT BUPRENORPHINE- CONTAINING PRODUCTS alendronate (QL on solution) calcitonin ibandronate raloxifene (QL) risedronate risedronate DR phentermine phendimetrazine diethylpropion topiramate balsalazide disodium sulfasalazine Forteo (PA, QL) Tymlos (PA) Linzess (QL) Movantik (QL) Apriso Lialda Pentasa Creon Zenpep Belviq (PA) Belviq XR (PA) Contrave (PA) Saxenda (PA) Amitiza (QL, ST) sildenafil Viagra Cialis 2.5, 5 mg (PA, QL) Cialis 10, 20 mg (QL, ST) buprenorphine/naloxone (CU, QL) buprenorphine sublingual (QL) buprenorphine transdermal (QL) Suboxone (CU, QL) Zubsolv (CU, QL) Bunavail (CU, QL) Binosto Qsymia Symproic Trulance Delzicol Dipentum Pancreaze Pertzye Levitra Staxyn Stendra Belbuca FENTANYL fentanyl citrate Abstral Fentora Lazanda Onsolis Subsys MORPHINE morphine sulfate ER Kadian RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS BETA-AGONISTS, SHORT- ACTING (SABA) INHALED CORTICOSTEROIDS (ICS) epinephrine autoinjector EpiPen Adrenaclick Auvi-Q ProAir HFA ProAir RespiClick Ventolin HFA Arnuity Ellipta (QL) Flovent Diskus/HFA (QL) Qvar (QL) Qvar Redihaler (QL) Advair Diskus/HFA (QL) Breo Ellipta (QL) Dulera (QL) Symbicort (QL) Asmanex (QL, ST) Pulmicort (QL, ST) INHALED CORTICOSTEROID/LONG- ACTING BETA AGONIST (ICS/LABA) INHALED LONG-ACTING Perforomist (QL) Arcapta (QL, ST) levalbuterol tartrate Proventil HFA Xopenex HFA Aerospan Alvesco Armonair RespiClick Airduo RespiClick (brand and authorized generic) Page 3 Copyright 2018 All rights reserved.
4 BETA AGONIST (LABA) Serevent Diskus (QL) Brovana (QL) Striverdi Respimat (QL) INHALED LONG-ACTING MUSCARINIC ANTAGONISTS (LAMA) Spiriva Handihaler (QL) Spiriva Respimat (QL) Incruse Ellipta (QL) Lonhala Magnair (QL) Seebri Neohaler Tudorza Pressair INHALED LONG-ACTING MUSCARINIC ANTAGONISTS AND LONG-ACTING BETA AGONIST (LAMA/LABA) Anoro Ellipta (QL) Stiolto Respimat (QL) INHALED CORTICOSTEROID, Trelegy Ellipta (QL) LONG-ACTING MUSCARINIC ANTAGONIST, AND LONG- ACTING BETA AGONIST (ICS/LAMA/LABA) ANTI-LEUKOTRIENES montelukast zafirlukast SPECIALTY ANEMIA AGENTS Procrit (PA) Aranesp (PA) Epogen (PA) Mircera (PA) AUTOIMMUNE AGENTS GROWTH HORMONES HEPATITIS C AGENTS MULTIPLE SCLEROSIS AGENTS PCSK9 INHIBITORS Glatopa (PA) Cosentyx (PA) Enbrel (PA) Humira (PA) Otezla (PA, ST) Stelara (PA) Norditropin (PA) Omnitrope (PA) Epclusa (PA) Harvoni (PA) Mavyret (PA) Vosevi (PA) Aubagio (PA) Avonex (PA) Copaxone (PA) Gilenya (PA) Plegridy (PA) Rebif (PA) Rebif Rebidose (PA) Tecfidera (PA) Praluent (PA) Repatha (PA) Actemra (PA) Inflectra (PA) Kineret (PA) Orencia (PA) Remicade (PA) Renflexis (PA) Siliq (PA) Simponi 100 mg (PA) Tremfya (PA) Xeljanz (PA) Xeljanz XR (PA) Serostim (PA) Zorbtive (PA) Sovaldi (PA) Ampyra (PA) Betaseron (PA) Bevespi Aerosphere Utibron Neohaler Zyflo Zyflo CR Cimzia Kevzara Olumiant Simponi 50 mg Taltz Genotropin Humatrope Nutropin Nutropin AQ Saizen Zomacton Daklinza Technivie Viekira Pak Viekira XR Zepatier Extavia Page 4 Copyright 2018 All rights reserved.
5 A recommended prescribing guideline may apply (denoted throughout the document using the following symbols): AGE Age Edit Coverage may depend on patient age. CU Concurrent Use Edit Coverage or lack thereof may depend upon concurrent use of another drug PA Prior Authorization Requires specific physician request process. QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period. ST Step Therapy Coverage depends on previous use of another drug Page 5 Copyright 2018 All rights reserved.
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DIABETES (1 of 5) Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10. Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10 $0 $0 $0
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