Leander Independent School District RxResults Initiative List Effective: 1/1/2018

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1 Leander Independent School District RxResults Initiative List Effective: 1/1/2018 For questions, please call RxResults at am-7pm central time Definitions: Reference Pricing This initiative is used when there are one or more lower cost drugs (preferred) in a drug category that are as effective as other high cost drugs (nonpreferred). By switching to the preferred alternative, the member may save money and their out-of-pocket cost may decrease. If the member chooses to fill the nonpreferred drug, their out-of-pocket cost will increase considerably. The plan will only pay the amount it would pay for the lower cost drug(s). The member will pay the difference in cost between the non-preferred drug and the preferred alternative(s). NOTE: the cost difference paid by the member may not apply towards their deductible or maximum out-of-pocket. Exclusion This initiative is used when there are other lower cost drugs that are considered equally effective. OTC - Over-the-counter Notes: -All doses and forms of a medication are impacted unless otherwise noted -Generic medications are italicized and in lower case; all new to market high cost generics may not be listed individually but are generally excluded. -Additional covered alternatives may be available. Costs for the covered alternatives may vary. Other prescription benefit considerations may apply. -Covered specialty medications may require a Prior Authorization through RxResults. Medications may be targeted by RxResults that are listed as Tier 1 on the OptumRx formulary. Please check this document first for your medication. If you are taking any of these drugs: ANALGESIC/ANESTHETICS (pain medications) Narcotic Analgesics APAP/Caff/Dihydrocodone, Exalgo, Nucynta ConZip, Tramadol ER, tramadol ER, Ultracet, Ultram/ER APAP/codeine, fentanyl transdermal patch, immediate release hydrocodone (for Nucynta), hydrocodone/apap, tramadol, morphine sulfate (for Arymo ER), morphine ER tab (for Exalgo, Morphabond ER), tramadol/acetaminophen (for Ultracet) Page 1 of 7

2 Non-Narcotic Allzital, Bupap, butalbital/acetaminophen tablet, butalbital/acetaminophen/caffeine capsule, Esgic tablet, Fioricet, Fiorinal, Tencon, Vanatol LQ Solution anolor, butalbital/acetaminophen mg tablet (for Bupap and Allzital), butalbital/acetaminophen/caffeine tablet, butalbital/aspirin/caffeine tablet ( for Fiorinal), capacet, esgic capsule, marten tablet, zebutal Non-Steroidal Antiinflammatory Drugs (NSAIDs) Sprix nasal spray Anaprox DS, Arthotec, Daypro, diclofenac/misoprostol, Feldene, indomethacin cap ER/SR, Ketoprofen ER, mefenamic acid, Mobic, Naprelan CR, naproxen DS 550mg, naproxen CR, Ponstel, Tivorbex, Vivlodex, Zipsor Oral generic NSAIDs such as ibuprofen, celecoxib, meloxicam, etc. unless otherwise listed as an exclusion or reference price Topical non-narcotic analgesic/anesthetics All topical non-narcotic analgesic/anesthetic medications are excluded (except lidocaine patch 5%) Oral generic NSAIDs such as ibuprofen, celecoxib, meloxicam, etc. unless otherwise listed as an exclusion or reference price; over-the-counter topical medications at 100% member out of pocket ANTIBIOTICS Doxycycline Adoxa, Doryx, Doryx MPC, branded Doxycycline, doxycycline hyclate, doxycycline hyclate DR, doxycycline monohydrate capsules (75mg and 150mg), doxycycline monohydrate tablets (150mg only), Monodox, monodoxyne NL, morgidox, Oracea, Targadox, Vibramycin Generic immediate release doxycycline monohydrate tablets (except 150mg), doxycycline monohydrate capsules (except 75mg and 150mg), or doxycycline 20mg tablets Minocycline Minocin, minocycline tablets, minocycline ER, Solodyn Generic immediate release minocycline capsules Amoxicillin Moxatag Generic immediate release amoxicillin Page 2 of 7

3 ANTICONVULSANTS Anticonvulsants Fanatrex suspension, Lamictal, Lamictal chew, Lamictal ODT, Lamictal Starter Kits, Lamictal XR, Lamictal XR Starter Kits, lamotrigine ER, lamotrigine ODT Gralise, Horizant, Lyrica, Neurontin, Spritam gabapentin, immediate release lamotrigine, lamotrigine chew, levetiracetam ANTIDIABETICS Amylin Analogues All Amylin Analogues such as, but not limited to: SymlinPen Other diabetic drug treatments such as metformin, sulfonylureas, pioglitazone, and/or insulin Biguanides Glumetza, Fortamet and their generics metformin or metformin ER (generic Glyburide XR ONLY) ANTIFUNGALS Antifungals ANTIHISTAMINES Non-sedating Cresemba, Extina AER 2%, Onmel, Jublia, Kerydin SOL 5%, ketoconazole AER 2% All non-sedating antihistamines such as, but not limited to: Clarinex, Xyzal, etc. ciclodan, ciclopirox, fluconazole, ketoconazole, itraconazole Over-the-counter products at 100% member out of pocket Page 3 of 7

4 ANTIHYPERTENSIVES (High Blood Pressure) Antihypertensive agents BISPHOSPHONATES (Osteoporosis) Bisphosphonates CNS STIMULANTS amlodipine/olmesartan, amlodipine/olmesartan/hct, amlodipine/valsartan, amlodipine/valsartan/hct, Atacand, Atacand HCT, Avalide, Avapro, candesartan, candesartan HCT, Coreg CR, Cozaar, Edarbi, Edarbyclor, Eprosartan, Exforge, Exforge HCT, Hyzaar, Inderal LA, Inderal XL, InnoPran XL, Micardis, Micardis HCT, olmesartan, olmesartan/hct, Tekturna, Tekturna HCT, telmisartan, telmisartan/amlodipine, telmisartan HCT, Twynsta Actonel, Alendronate, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D, ibandronate, risedronate, risedronate DR Generic ACE Inhibitors: benazepril/hct, captopril/hct, enalapril/hct, fosinopril/hct, lisinopril/hct, moexepril/hct, perindopril, ramipril, quinapril/hct, trandolapril Generic ARB Agents: candesartan/hct, losartan/hct, irbesartan, eprosartan; Generic Beta Blocker Agents: carvedilol for Coreg CR; propranolol IR/ER for Inderal LA/XL and InnoPran XL alendronate CNS Stimulants Intuniv, guanfacine ER Children under the age of 26 are exempt All long acting amphetamines and methylphenidates (brand and generic), such as but not limited to: Adzenys XR, Aptensio XR, Concerta, Daytrana, Focalin XR, Kapvay, Metadate CD, Quillichew, Ritalin LA, Vyvanse, Vyvanse chew Immediate release amphetamine, amphetaminedextroamphetamine, dextroamphetamine, guanfacine (for Intuniv), methylphenidate, dexmethylphenidate or clonidine (for Kapvay) Children under the age of 26 are exempt Page 4 of 7

5 DERMATOLOGICALS Steroids Enstilar calcipotriene solution and betamethasone ointment GASTROINTESTINAL AGENTS Chronic Constipation Agents Relistor Movantik HEMATOLOGIC AGENTS Platelet Inhibitors Durlaza OTC aspirin at 100% member out of pocket HYPNOTICS/SEDATIVES (Sleep Aids) Hypnotics/Sedatives Belsomra, Edluar, Intermezzo, Rozerem, Silenor, Sonata, zolpidem ER, zolpidem sublingual, Zolpimist zaleplon, zolpidem KITS - CONVENIENCE Convenience Kits All Convenience Kits such as but not limited to: Atorvastatin/CoQ10, DermacinRx, Dermawerx, Flanax Pain Kit relief, Genadur Kit, Morgidox Kit, Naproxen Kit, SmartRx Pak GABA, etc. Individual ingredients; If the individual ingredient is an OTC item, the member may be responsible for 100% of the cost of the item. LIPID REDUCERS (Cholesterol lowering agents) Fibric Acid Derivatives All Fenofibric acid derivatives such as but not limited to: Fenofibric acid, Fenofibrate, fenofibrate, Fenoglide, Fibricor, Lipofen, Lofibra, Lopid, Tricor, Triglide, Trilipix gemfibrozil, atorvastatin, lovastatin, pravastatin or other lipid lower agents such as statins Page 5 of 7

6 Statins Altoprev, amlodipine/atorvastatin, Caduet, ezetimibe/simvastatin, fluvastatin, fluvastatin ER, Lescol, Lescol XL, Livalo, Mevacor, Pravachol, Zocor atorvastatin, lovastatin, pravastatin, simvastatin Other Cholesterol Reducers MISCELLANEOUS Miscellaneous medications MUSCLE RELAXANTS Lovaza, Niaspan, niacin ER, omega-3 acid, Vascepa Alzair Nasal Spray, Evzio, Rexulti OTC Omega-3 fish oil at 100% member out of pocket; OTC niacin at 100% member out of pocket other naloxone products for Evzio; other antipsychotic/antimanic agents for Rexulti Carisoprodol Soma, carisoprodol 250mg carisoprodol Chlorzoxazone Lorzone, Parafon Forte chlorzoxazone cyclobenzaprine Fexmid, metaxall, metaxalone, Skelaxin, Tabradol cyclobenzaprine Methocarbamol Robaxin methocarbamol Tizanidine tizanidine capsules, Zanaflex tizanidine tablets NASAL STEROIDS Nasal Steroids All Nasal Steroids such as but not limited to: Beconase, Dymista, Flonase, Omnaris Over-the-counter products at 100% member out of pocket Page 6 of 7

7 OVERACTIVE BLADDER Urinary Antispasmodics PROTON PUMP INHIBITORS (Acid Reducers) darifenacin ER, Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique, Myrbetriq, oxybutynin ER, Oxytrol, tolterodine, tolterodine ER, Toviaz, trospium CL, trospium CL ER, Vesicare oxybutynin Proton Pump Inhibitors All PPIs including combination medications and kits with PPIs, such as but not limited to: Prevacid, Prilosec, Dexilant, PrevPac, Duexis, Vimovo, Yosprala Individual products or OTC products at 100% member out of pocket TESTOSTERONE Topical Testosterone Products TRIPTANS (Migraine Agents) All forms of testosterone (unless listed as preferred on the OptumRx Premium formulary), except generic injectables, such as but not limited to: Androderm, Androgel, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo Generic injectable testosterone Triptans almotriptan, Amerge, Axert, Frova, frovatriptan, Imitrex, Imitrex spray, Maxalt, naratriptan, Onzetra, Relpax, sumatriptan spray, Sumavel, Treximet, Zembrace, zolmitriptan, Zomig spray sumatriptan, rizatriptan Page 7 of 7