Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Medications are grouped by the conditions they treat. Each medication is placed in a tier that shows the amount you will pay for that prescription. This is decided by your employer or health plan. Please use this chart as you review these updates. Tier 1 Lowest-cost Tier 2 Midrange-cost Tier 3 Highest-cost Medications moving to a lower tier The following are moving to a lower tier, making them more affordable. Therapeutic use Medication name Tier Anticoagulants Blood Thinners Antidiabetic Agents Insulin Topical Acne Anti-inflammatory Agents ELIQUIS TABLET 2.5MG, 5MG 3 2 OZEMPIC INJECTION 2MG/1.5ML EXC 2 REBIF REBIDOSE INJECTION 22MCG/0.5ML, 44MCG/0.5ML EXC 3 REBIF REBIDOSE INJECTION TITRATION PAK EXC 3 REBIF SOLUTION PREFILLED SYRINGE 22MCG/0.5ML, 44MCG/0.5ML EXC 3 REBIF SOLUTION TITRATION PACK EXC 3 ACZONE GEL 7.5% 3 2 SYMPROIC TABLET 0.2 MG 3 2 PROLENSA SOLUTION 0.07% 3 2
Medications moving to a higher tier These are moving to a higher tier and will cost more because there are other lower-cost options. If your medication is listed below, you may still take it, but you may pay a higher cost. Please talk to your doctor about lower-cost option(s) to see if they will work for you. Therapeutic use Medication name Tier Drugs for HIV DESCOVY TABLET 200/25 2 3 Drugs for HIV Drugs for HIV ntral Drugs for HIV ntral GENVOYA TABLET 2 3 ODEFSY TABLET 2 3 STRIBILD TABLET 2 3 Genitourinary Agents Phosphate Binders RENVELA TABLET 800MG 2 3 sevelamer Drugs for Glaucoma BETOPTIC-S SUSPENSION 0.25% 2 3 betaxolol, carteolol, levobunolol, metipranolol, timolol Drugs for Glaucoma TIMOPTIC OCUMETER SOLUTION 0.25%, 0.5% 2 3 betaxolol, carteolol, levobunolol, metipranolol, timolol
Medications that are Excluded The following are excluded. Therapeutic use Medication name Tier Analgesics Drugs for Pain/ Inflammatory Conditions SPRIX SPRAY 15.75MG diclofenac, ibuprofen, meloxicam Antibacterial Agents Drugs to treat Bacterial Infections DORYX MPC TAB 120MG doxycycline hyclate Antibacterial Agents Drugs to treat bacterial infections NORITATE CREAM 1% metronidazole cream/ gel/lotion, SOOLANTRA CREAM Anticonvulsant Agents Drugs for Seizure Disorders SABRIL POWDER PAK 500MG vigabatrin Anticonvulsant Agents Drugs for Seizure Disorders OXTELLAR XR TAB 150MG, 300MG, 600MG topiramate IR Antidiabetic Agents Drugs to Regulate Blood Sugar FORTAMET TABLET 500MG, 1000MG metformin er (generic GLUCOPHAGE XR) Antidiabetic Agents Drugs to Regulate Blood Sugar METFORMIN HCL TAB ER 24HR MODIFIED RELEASE 500 MG, 1000MG metformin er (generic GLUCOPHAGE XR) Antidiabetic Agents Drugs to Regulate Blood Sugar METFORMIN HCL TAB ER 24HR OSMOTIC 500 MG, 1000MG metformin er (generic GLUCOPHAGE XR) Antidiabetic Agents Drugs to Regulate Blood Sugar QTERN TABLET 10MG/5MG GLYXAMBI Antiemetics Drugs to Treat Nausea and Vomiting SANCUSO PATCH 3.1MG granisetron tablet, ondansetron ODT
Antimigraine Agents Drugs to Treat Migraines ONZETRA XSAIL NASAL EXHALER 11MG rizatriptan ODT, sumatriptan succinate injection, sumatriptan nasal spray, zolmitriptan ODT Antimigraine Agents Drugs to Treat Migraines SUMAVEL INJECTION 4MG/0.5ML, 6MG/0.5ML rizatriptan ODT, sumatriptan succinate injection, sumatriptan nasal spray, zolmitriptan ODT Antimigraine Agents Drugs to Treat Migraines ZEMBRACE SYMTOUCH INJECTION 3MG/0.5ML rizatriptan ODT, sumatriptan succinate injection, sumatriptan nasal spray, zolmitriptan ODT Drugs for HIV ATRIPLA TABLET 2 EXC Patients should talk to their doctor about clinically appropriate alternative(s). Anxiolytics Drugs to Treat Anxiety Topical Acne ATIVAN TABLET 0.5MG, 1MG, 2MG lorazepam ACZONE GEL 5% dapsone 5% gel Topical Acne CLINDAGEL GEL 1% adapalene, adapalene/ benzoyl peroxide, clindamycin gel/lotion/ solution, clindamycin/ benzoyl peroxide, erythromycin/benzoyl peroxide, tretinoin cream, EPIDUO, EPIDUO FORTE, ONEXTON Topical Antifungals JUBLIA SOLUTION 10% terbinafine, KERYDIN
Drugs to treat Stomach Conditions ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20MG, 40MG (BASE EQ) lansoprazole, omeprazole, pantoprazole Drugs to treat stomach conditions OMEPRAZOLE- SODIUM BICARBONATE CAP 20-1100MG, 40-1100MG lansoprazole, omeprazole, pantoprazole Drugs to treat stomach conditions OMEPRAZOLE- SODIUM BICARBONATE POWD PACK FOR SUSP 20-1680MG, 40-1680MG lansoprazole, omeprazole, pantoprazole Drugs to treat Inflammatory Bowel Disease DIPENTUM CAPSULE 250MG balsalazide, APRISO AMITIZA CAPSULE 8MCG, 24MCG 2 EXC LINZESS ( for IBS-C/CIC ); SYMPROIC ( for OIC ) TRULANCE TABLET 3MG LINZESS ( for IBS-C/ CIC ) RELISTOR INJECTION 8/0.4ML, 12/0.6ML SYMPROIC ( for OIC ) RELISTOR TABLET 150MG SYMPROIC ( for OIC ) IBS-C/CIC= Irritable Bowel Syndrome with Constipation/ Chronic Idiopathic Constipation OIC= Opioid-Induced Constipation
Genitourinary Agents Drugs for Erectile Dysfunction Hormonal Agents Suppressant (Pituitary) VIAGRA TABLET 25MG, 50MG, 100MG SANDOSTATIN INJECTION 50MCG/ ML, 100MCG/ ML, 200MCG/ ML, 500MCG/ML, 1000MCG/ML sildenafil octereotide injection Hormonal Agents Stimulant/Re/ Modifying (Adrenal) RAYOS TABLET 1MG, 2MG, 5MG prednisone Anti-inflammatory Agents ILEVRO DROP 0.3% PROLENSA Antiinflammatory Agents BROMSITE DROP 0.075% PROLENSA Antiinflammatory Agents NEVANAC SUSP 0.1% PROLENSA Pulmonary Agents Drugs for COPD BEVESPI AEROSOL 9-4.8MCG ANORO ELLIPTA, STIOLTO RESPIMAT Pulmonary Agents Drugs for COPD UTIBRON NEOHALER CAPSULE 27.5-15.6 MCG ANORO ELLIPTA, STIOLTO RESPIMAT Pulmonary Agents Drugs for COPD SEEBRI NEOHALER CAPSULE 15.6MCG INCRUSE ELLIPTA, SPIRIVA Pulmonary Agents ARMONAIR AEROSOL 55/ACT, 113/ACT, 232/ACT ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER
Topical Hormonal Agents Topical Hormonal Agents Topical Hormonal Agents TOPICORT SPRAY 0.25% HALOG CREAM 0.1% HALOG OINTMENT 0.1% desoximetasone cream/ gel/ointment/spray, fluocinonide solution 0.05% fluticasone ointment, halobetasol cream/ointment, triamcinolone cream/ ointment fluticasone ointment, halobetasol cream/ointment, triamcinolone cream/ ointment Need more information? Call or visit us online to learn more about your pharmacy benefits. Call the member phone number on the back of your ID card. Visit optumrx.com. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 2018 Optum, Inc. All rights reserved. ORX7236B-L-CTRX_190101_67871B-082018 Applies to the Premium Formulary