Welcome to Scrip World - Protect Plans · Check your benefit plan documents to find out your specific pharmacy plan costs. $ Drug Tier Includes Helpful Tips Tier 1 Lowest Cost Lower-cost,

Welcome to Scrip World

Member Welcome Packet for

www.meritain.com | © 2017–2018 Meritain Health, Inc. All rights reserved.

Scrip World Pharmacy Benefits ManagementFlexible. Integrated. Effective.

Scrip World partners with OptumRx to administer pharmacy benefits to employer groups. Scrip World’s role is to work with you to ensure your benefit performs to your satisfaction. The team includes experienced, clinically trained account managers who will analyze your plan data, core clinical programs, drug spend and utilization, and any changes in the marketplace. OptumRx’s role is to work on the back end to process the claims on behalf of Scrip World.

Important Contact Information

Call Customer Service

1-855-312-6103

Visit the Member Website

www.optumrx.com (24/7 access to pharmacy assistance)

Visit the Mobile App

Get the free app by searching OptumRx in your app store

*Please note: if you’re having difficulty filling a prescription, or any other sort of issue, simply call the number listed on your ID Card.

Formulary &SpecialtyDrug Lists

5

What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

Use Tier 1 drugs for the lowest out-of- pocket costs.

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs.

Tier 3 Highest Cost

Mostly higher-cost brand drugs, also known as non-preferred brands.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on your plan’s member website, or call the toll-free member phone number on your ID card for more information about your benefit plan.

When does the Formulary change?

• Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available.• Medications may move to a higher tier or be excluded from coverage

on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, call customer service at the toll-free member phone number on your ID card.

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6

Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

AR Age Restrictions – Some restrictions may apply based on patient age.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

ST Step Therapy – Trial of lower cost medication(s) is required before a higher-cost medication is covered.

QL Quantity Limits – Amount of medication covered per copayment or in a specific time period.

SPSpecialty Medication – Medication is designated as a specialty pharmacy drug.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on your ID card.

9

Bold type = Brand-name drug [Plain type = Generic drug]

PA Prior Authorization ST Step Therapy

QL Quantity LimitsSP Specialty Program

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefadroxil Cap 1Cefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Moxifloxacin 1Neomycin/Polymyxin/

HC Otic Suspension, Solution

1

Nitrofurantoin Macrocrystalline

1

Drug NameDrug Tier

Programs and Limits

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 3Penicillin VK 1Solodyn 3Sulfamethoxazole-

Trimethoprim1

Sulfamethoxazole-Trimethoprim DS

1

Anti-Infectives: Antifungals

Fluconazole 1Jublia Solution 3 PAKerydin Solution 3 PANystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Daklinza 3 PA, QL, SPEntecavir 1 QL, SPEpclusa 2 PA, QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPSovaldi 2 PA, QL, ST, SPTamiflu 3 QLValacyclovir 1 QLZepatier 2 PA, QL, SP

CancerAkynzeo 3 QLAnastrozole Tab 1Capecitabine 1 PA, SPLetrozole 1Revlimid 3 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Tasigna 3 PA, SPTemozolomide 1 PA, SPZytiga 3 PA, SP

10


AR Age Restrictions PA Prior Authorization ST Step Therapy


Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 2Eliquis 3 QLEnoxaparin 1 QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLCardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Amlodipine/Valsartan/

HCTZ1

Atenolol 1Atenolol/Chlorthalidone 1Azor 3 STBenazepril 1Benazepril/HCTZ 1Benicar 3 STBenicar HCT 3 STBisoprolol 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Patch 1Clonidine Tab 1Diltiazem Tab 1Doxazosin 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Enalapril/HCTZ 1Felodipine 1Fosinopril 1Furosemide 1

Drug NameDrug Tier

Programs and Limits

Guanfacine Tab (Immediate Release)

1

Hydralazine 1Hydrochlorothiazide 1Irbesartan 1Irbesartan/HCTZ 1Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Tribenzor 3 STValsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Cholestyramine 1Crestor 3Fenofibrate 40 mg,

43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1

Gemfibrozil 1Lipitor 3 ST

11




Drug NameDrug Tier

Programs and Limits

Lovastatin 1Lovaza 3Niacin ER Tab 1Omega-3 Acid Cap

1 gm1

Praluent 2 PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1 PAVascepa 2Vytorin 10-10 mg,

10-20 mg, 10-40 mg

2

Vytorin 10-80 mg 2 PAWelchol 2Zetia 3

Cardiovascular/Heart Disease: Other

Amiodarone 1Amlodipine/Atorvastatin 1Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Multaq 3Nitrostat 3Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SPCentral Nervous System: Attention Deficit DisorderAdderall XR Cap 3 PA, QL, ST

Drug NameDrug Tier

Programs and Limits

Amphetamine-Dextroamphetamine Tab

1 PA, QL

Amphetamine-Dextroamphetamine SR 24Hr Cap

1 PA, QL

Dexmethylphenidate ER Cap

1 PA, QL

Evekeo 3 PA, QL, STGuanfacine ER Tab 1 QLMethylphenidate

ER Cap1 PA, QL

Methylphenidate ER Tab 1 PA, QLMethylphenidate SA

Osmotic ER Tab1 PA, QL

Methylphenidate Tab 1 PA, QLStrattera 2 QLVyvanse 2 PA, QL

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1Bupropion SR 1Bupropion XL 1 QLDoxepin 1Duloxetine Cap 20 mg,

30 mg, 60 mg1 QL

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Fluvoxamine Tab 1Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 3 QLRisperidone Tab 1 QLSertraline 1Trazodone 1Venlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL, ST

12




Drug NameDrug Tier

Programs and Limits

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 3 QLZolmitriptan Tab 1 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit 2 PA, QL, SPAvonex Pen Kit 2 PA, QL, SPAvonex Prefill Kit 2 PA, QL, SPBetaseron 2 PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL2 PA, QL, SP

Gilenya* 3 PA, QL, ST, SPRebif 3 PA, QL, ST, SPRebif Titrtn 3 PA, QL, ST, SPTecfidera 2 PA, QL, SP

Central Nervous System: Other

Alprazolam Tab 1 QLAripiprazole 1 QLBenztropine 1Buspirone 1Carbidopa/Levodopa

Tab (Immediate Release)

1

Diazepam Tab 1Donepezil Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Invega Sustenna 3Invega Trinza 3

Drug NameDrug Tier

Programs and Limits

Latuda 3 QL, STLithium Carbonate 1Lorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLOlanzapine Tab 1 QLProchlorperazine 1Quetiapine 1 QLRexulti 3 QLRisperidone Tab 1 QLRopinirole


Saphris 2 QLSeroquel XR 3 QLZiprasidone Cap 1 QLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersCarbamazepine Tab 1Clonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine


Lamotrigine ER 1Levetiracetam 1Levetiracetam ER 1Lyrica Cap 2 QLOnfi 3 PAOxcarbazepine 1Phenytoin 1Primidone 1Topiramate Tab 1Vimpat 3Zonisamide 1

* Tier 3 Preferred

13




Drug NameDrug Tier

Programs and Limits

Dermatology

Absorica 3 PAAcanya Gel 3 STAcyclovir Ointment 5% 1Aczone Gel 3Atralin 3 PABenzaclin 3 STBetamethasone

Dipropionate Cream1

Ciclopirox Cream 1Clindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Cortifoam 3Desonide Cream,

Ointment1

Desoximetasone Cream, Gel, Ointment

1

Differin 3 AREconazole Cream 1Elidel 2 STEpiduo & Epiduo

Forte3

Finacea 3 STFluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Drug NameDrug Tier

Programs and Limits

Lidocaine Topical Ointment, Solution

1

Lidocaine/Prilocaine Cream

1

Ketoconazole Cream/Shampoo

1

Metrogel 3Metronidazole Gel

0.75%1

Mirvaso Gel 2Mupirocin Ointment 1Nystatin Cream,

Ointment, Powder1

Nystatin/Triamcinolone Cream, Ointment

1

Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro gel

0.1%, 0.04%3 PA

Soolantra 2Sulfacetamide/Sulfur

Emulsion1

Taclonex 3 QLTazorac 3Tretinoin Cream 1 PATretinoin Microsphere

Gel1 PA

Triamcinolone 1Vectical 3Zovirax Cream 2Zovirax Ointment 3Zyclara 3Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active

Glucose Control Liquid

3

Accu-Chek Active Test Strips

2 QL

Accu-Chek Aviva Connect Kit

2

14




Drug NameDrug Tier

Programs and Limits

Accu-Chek Aviva Plus Control Liquid

3

Accu-Chek Aviva Plus Kit

2

Accu-Chek Aviva Plus Test Strips

2 QL

Accu-Chek Compact Plus Control Liquid

3

Accu-Chek Compact Plus Test Strips

2 QL

Accu-Chek Compact Plus Kit

2

Accu-Chek FastClix Kit

2

Accu-Chek FastClix Lancets

2

Accu-Chek Guide Control Liquid

3

Accu-Chek Guide Kit 2Accu-Chek Guide Test

Strips2 QL

Accu-Chek Multiclix Kit

2

Accu-Chek Multiclix Lancets

2

Accu-Chek Nano SmartView Kit

2

Accu-Chek SmartView Control Liquid

3

Accu-Chek SmartView Test Strips

2 QL

Accu-Chek Soft Touch Lancets

2

Accu-Chek Softclix Kit 2Accu-Chek Softclix

Lancets2

Bayer Contour Test Strips

3 QL, ST

Dexcom G4 Platinum Kit

3

Dexcom G4 Platinum Sensor Kit

3

Drug NameDrug Tier

Programs and Limits

Dexcom G4 Platinum Transmitter Kit

3

Freestyle Test Strips 3 QL, STDexcom G5 Kit 3Dexcom G5 Sensor

Kit3

Dexcom G5 Transmitter Kit

3

Insulin Pen Needle 2Insulin Syringe/

Needle 2

Novofine Pen Needle 3Novofine Autocover

Pen Needle3

Novotwist Pen Needle

3

Onetouch Kit Ultra Smart

2

Onetouch Kit Ultra 2Onetouch Kit Ultra 2 2Onetouch Kit Ultra

Mini2

Onetouch Kit Verio IQ 2Onetouch Test Strips 2 QLOnetouch Ultra Blue

Test Strips2 QL

Onetouch Verio Test Strips

2 QL

Precision Test Strips 3 QL, ST

Diabetes/Endocrine: Insulin

Basaglar 3 STHumalog Mix 50/50

Vial and KwikPen2

Humalog Mix 75-25 Vial and KwikPen

2

Humalog U-100 Vial and KwikPen

2

Humalog U-200 KwikPen

2

Humulin 70-30 Vial and KwikPen

2

15




Drug NameDrug Tier

Programs and Limits

Humulin N Vial and KwikPen

2

Humulin R U-500 Vial and KwikPen

2

Humulin R Vial 2Lantus SoloStar 2Lantus Vial 2Levemir FlexTouch 2Levemir Vial 2Novolin 70/30 Vial 2Novolin N Vial 2Novolin R Vial 2Novolog Flexpen 2Novolog Mix 70/30

Vial and Flexpen2

Novolog Penfill 2Novolog Vial 2Toujeo SoloStar 2Tresiba 3

Diabetes/Endocrine: Non-Insulin

Bydureon 2 QL, STByetta 2 QL, STFarxiga 3 STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1Glumetza 3 PAGlyburide 1Glyburide/Metformin 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 STKombiglyze 3 STMetformin 1Metformin ER 1Onglyza 3 ST

Drug NameDrug Tier

Programs and Limits

Pioglitazone 1Synjardy 2 STTradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, ST

Endocrine: Growth Hormone

Norditropin 2 PA, SPNutropin AQ 2 PA, SP

Endocrine: Other

Calcitriol Cap 1Dexamethasone Tab 1H.P. Acthar 2 PA, SPHydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg3 PA, SP

Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg

2 PA, SP

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

Sensipar 3 PAEndocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Bepreve 3 STLastacaft 3 STPataday 2Pazeo 2

16




Drug NameDrug Tier

Programs and Limits

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution1

Erythromycin Ointment 1Gentamicin 1Moxeza 2 Neomycin/Polymyxin

B/Dexamethasone Ointment, Suspension

1

Ofloxacin Ophthalmic Solution

1

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 2

Eye Conditions: Glaucoma

Alphagan P 2Azopt 2Betimol 3Brimonidine 1Combigan 2Cosopt PF 3Dorzolamide-Timolol

Maleate1

Latanoprost 1 QLLumigan 2 QLSimbrinza 2Timolol 1Timoptic Ocudose 2Travatan Z 2 QL

Eye Conditions: Other

Durezol Ophthalmic Emulsion

3

Lotemax Ophthalmic Gel

3 QL

Drug NameDrug Tier

Programs and Limits

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 2 PAXiidra 2 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLEsomeprazole

Magnesium (Rx only)

1 QL

Famotidine Tab 20 mg and 40 mg (Rx only)

1

Lansoprazole (Rx only) 1 QLOmeprazole (Rx only) 1 QLPantoprazole 1 QLRanitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1

Gastrointestinal: Nausea/Vomiting

Meclizine 1Metoclopramide 1Ondansetron Tab, ODT 1Transderm-Scop 3Varubi 3 QL

Gastrointestinal: OtherAmitiza 2 QL, STApriso 2Canasa 2Creon 2Delzicol 3 STDipentum 3Gavilyte Solution 1Hyoscyamine Sublingual

Tab1

Lactulose 1Lialda 2Linzess 2 QL, STMoviprep 3Omeclamox Pak 2

17




Drug NameDrug Tier

Programs and Limits

Pentasa 3Polyethylene

Glycol 3350 Powder1

Prepopik 3Protosol HC 1Pylera 2Sulfasalazine 1Suprep Bowel Prep 3Uceris Foam 3Zenpep 2HIV/AIDSAtripla 2 SP Complera 2 SPEpzicom 3 SPGenvoya 2 SPIntelence 2 SPIsentress 2 SPKaletra Solution 2 SPKaletra Tablet 3 SPNevirapine 1 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPSustiva 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

Infertility

Cetrotide 2 SPGonal-f 2 PA, SPGonal-f RFF 2 PA, SPOvidrel 3 SP

Inflammatory Conditions

Cimzia Kit 2 PA, SPDepen 2 SPEnbrel 3 PA, SPHumira Kit 2 PA, SPHumira Pen Kit 2 PA, SP

Drug NameDrug Tier

Programs and Limits

Humira Pen Kit Crohns

2 PA, SP

Humira Pen Kit Psoriasis

2 PA, SP

Hydroxychloroquine 1Methotrexate Tab 1Orencia SC 3 PA, ST, SPOtezla 3 PA, ST, SPOtrexup 3 PA, QLRasuvo 2 PA, QLRemicade 2 PA, SPSimponi 2 PA, SPSimponi Aria 2 PA, SPStelara 2 PA, SPTaltz* 3 PA, ST, SPXeljanz 3 PA, ST, SP

Men’s Health: Erectile Dysfunction

Cialis 2 QLLevitra 3 QLStendra 3 QLViagra 2 QL

Men’s Health: Prostate

Alfuzosin 1Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAndrogel 1% 3 PA, STTestosterone Cypionate

IM Injection1 PA

* Tier 3 Preferred

18




Drug NameDrug Tier

Programs and Limits

Miscellaneous

Allopurinol 1Antipyrine/Benzocaine

Otic Solution 5.4 - 1.4%

1

Aranesp 2 PA, SPAuryxia 3Benzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

2 PA, SP

Bunavail 3 PA, QLCerdelga 3 PA, SPChantix 3 QLCheratussin 1Chlorhexidine 1Colcrys 2Cyproheptadine 1Desmopressin 1Epinephrine

Auto-Injector (Authorized Generic of EpiPen made by Mylan)

2

EpiPen & EpiPen Jr 3 STEuflexxa 2 PA, SPFosrenol 3Granix 2 PA, SPGuaifenesin/Codeine

Syrup1

Homatropine/Hydrocodone Syrup

1

Hydrocodone/Chlorpheniramine Liquid

1

Hydrocortisone AC Suppository 25 mg

1

Hydromet 1Lidocaine Viscous

Solution 2%1

Makena 2 PA, SPNarcan 2Neupogen 2 PA, SP

Drug NameDrug Tier

Programs and Limits

Phenazopyridine (Rx only)

1

Phentermine Tab 1 PAProcrit 2 PA, SPPromethazine DM Syrup 1Promethazine/Codeine

Syrup1

Pulmozyme 2 PA, QL, SPRenvela Tab, Pack 2Rezira 3Suboxone Film 2 PA, QLSynagis 2 PA, SPSynvisc 2 PA, SPSynvisc One 2 PA, SPUloric 2 STUrsodiol 1Velphoro 3Zarxio 2 PA, SPZostavax Injection 3Zubsolv 2 PA, QLZutripro 3

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLEvista 3Forteo 2 PA, SPIbandronate Tab 1 QLRaloxifene 1

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

19




Drug NameDrug Tier

Programs and Limits

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine

1 PA, QL

Celebrex 3 QLCelecoxib 1 QLDiclofenac Tab 1Embeda 2 QLEndocet Tab 1 PA, QLEtodolac 1Flector patch 3 QLFentanyl Patch

25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr

1 QL

Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

1 QL

Gralise 3 QL, STHydrocodone/APAP

5, 7.5, 10/325 mg 1 PA, QL

Hydromorphone Tab 1 PA, QLIbuprofen Tab 400, 600,

800 mg (Rx only)1

Indomethacin Cap 1Ketorolac Tab 1 QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1Morphine Sulfate Tab 1 PA, QLNabumetone 1Naproxen (Rx only) 1Opana ER 2 QLOxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1 PA, QL

Oxycodone w/ Acetaminophen

1 PA, QL

Oxycontin 2 QLTivorbex 3 STTramadol Tab 50 mg 1

Drug NameDrug Tier

Programs and Limits

Tramadol w/ Acetaminophen

1

Vicodin 1 PA, QLVicodin ES 1 PA, QLVoltaren Gel 3 QL Zohydro ER 3 QL, STZorvolex 3

Overactive Bladder

Myrbetriq 3 STOxybutynin 1Oxybutynin ER 1Tolterodine 1Toviaz 3Vesicare 2

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol

Nebulizer Solution1 QL

Anoro Ellipta 2 QLArnuity Ellipta 2 QLBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera 3 QL, STFlovent Diskus 2 QLFlovent HFA 2 QLForadil 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol

Nebulizer Solution1 QL

Levalbuterol Nebulizer Solution

1 QL

Montelukast 1Perforomist 3 QLProair HFA, RespiClick 2 QLProventil HFA 3 QL, STPulmicort Flexhaler 2 QLQvar 2 QL

20




Drug NameDrug Tier

Programs and Limits

Seebri 3 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLVentolin HFA 2 QLXolair 2 PA, SPXopenex HFA 3 QL, ST

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLFluticasone Spray 1Ipratropium Spray 1 QLMometasone 1 QLNasonex 2 QLOmnaris 3 QLQNasl 3 QLTriamcinolone Spray 1 QLZetonna 3 QL

Respiratory: Oral Allergies

Cetirizine 1Promethazine Tab 1Desloratadine 1Levocetirizine 1

Drug NameDrug Tier

Programs and Limits

Transplant

Azathioprine Tab 1Cellcept Tab/

Suspension3 SP

Cyclosporine Cap 1 SPMycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPRapamune 3 SPTacrolimus Cap 1 SP

Vitamins/Electrolytes

Cyanocobalamine Injection

1

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1Multi-Vit/Fl Chew 1Potassium Chloride ER

Tab, Cap1

Potassium Chloride Micro ER Tab

1

Potassium Citrate 540 mg, 1080 mg Tab

1

Vitamin D 50,000 units (Rx only)

1

21




Drug NameDrug Tier

Programs and Limits

Women’s Health: Birth Control

Apri 1Aviane 1Azurette 1Cryselle-28 1Falmina 1Generess Fe

Chewable3

Gianvi 1Gildess 1Jolivette 1Junel 1Kariva 1Levora 28 1Lo Loestrin 3Lomedia Fe 1Loryna 1Low-Ogestrel 1Lutera 1Medroxyprogesterone

Acetate Injection1 QL

Microgestin 1Microgestin Fe 1Minastrin 24 Fe

Chewable3

Mono-Linyah 1Mononessa 1Natazia 2Necon 1Nora-Be 1Norgest/Ethi Estradio 1Nortrel 1Nuvaring 2Ocella 1Orsythia 1

Drug NameDrug Tier

Programs and Limits

Ortho Tri-Cyclen Lo 3Previfem 1Reclipsen 1Sprintec 28 1Tri-Linyah 1Tri-Previfem 1Trinessa 1Tri-Sprintec 1Vestura 1Viorele 1Xulane 1Zarah 1

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Tab 1Estradiol/Norethindrone

Tab1

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Vagifem 3

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1

Prior Authorizations

What Is Prior Authorization?

A Prior Authorization (PA) is a safety and cost-saving feature of your prescription benefit plan designed to prevent improper prescribing or use of certain drugs that may not be the best choice for a health condition. PAs may be provided in conjunction with quantity limits or step therapy protocols, all of which are designed for the health and safety of members and the good of the plan.

How it works

The pharmacist enters the prescription information into the Optum Rx system at the point of sale. If the client-approved plan design requires a PA for the drug, the pharmacist will receive an alert and may ask the member to contact the prescriber or may have the prescriber contact the Optum Rx Prior Authorization Department for a consultation. Once the incoming information has been assessed, a decision is made. The decision can be an approval, a denial or may be auto-closed due to lack of information.

If authorization is granted, the prescription will be filled. If authorization is not granted at the retail pharmacy, there are two choices:

1. The member may still have the prescription filled by paying the entire retail cost of the drug.

2. The member may ask the prescriber for an alternate drug covered by your benefit, if available.

Please remember to allow more time for the PA process: in most circumstances, approximately two business days for standard prior authorization and approximately one business day for an urgent prior authorization request.

PAs for Medical Necessity

The P&T Committee has approved exception criteria that allow the member to make a request for access to a non-formulary drug when it is determined to be the only safe and effective treatment. The member must submit the following supporting documentation for consideration:

l A physician statement with the name and strength of the alternatives tried or considered

l Evidence the formulary alternatives were unsafe and ineffective, or have known interactions with other drugs the member is taking

Once the information is reviewed, a decision is made to approve for a period of one year, or to deny. This type of request may incur an additional charge per request. For specific drug coverage information, visit www.optumrx.com or contact an Optum Rx representative at 1.855.312.6103.

90-day grace period for exclusions

New client groups with members currently taking excluded medications are given a 90-day period to transition to a formulary product, during which they can continue to obtain the excluded medication. Members will receive a formulary mailing informing them of the new process.

Diabetic MeterProgram

Free Meter Program

Diabetes can harm your eyes, kidneys, nerves, heart and blood vessels. The impact can be long-term. Regular blood sugar testing can help you manage your diabetes and may lead to better glucose control.

Take advantage of this great offer

To help you monitor blood sugar levels, your pharmacy benefit plan offers a Free Meter Program. With this program, you may be able to get a blood sugar meter at no charge to you. You and your doctor can choose from 10 different meters. For more details, call OptumRx customer service using the toll-free member phone number on the back of your ID card. Or call the meter manufacturers. Their numbers are inside.

How to get your free meter

The first step in every diabetes care plan is talking with your health care team. If you would like a new blood sugar meter, tell your doctor or diabetes educator. They will help you select the no-charge meter that’s right for you. Once you decide, it’s easy to place your order. Just call the manufacturer’s Service Center any time.

Your free meter choices are inside

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.

All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

© 2015 Optum, Inc. All rights reserved. ORX0580-PRE_150917 50782-092015

optumrx.com

Don’t delay. Talk with your doctor about choosing the best brand-name meter for you. Then order your meter by calling the manufacturer’s Service Center.

1 Using U.S. and imported materials 2 Specifications based on current ISO 15197: 2003

Monitor Test Strips

OneTouch Ultra 2 OneTouch® Ultra® Test Strips

OneTouch UltraMini OneTouch® Ultra® Test Strips

OneTouch Verio® OneTouch Verio Test Strips

OneTouch Verio IQ OneTouch Verio Test Strips

OneTouch Verio® Sync OneTouch Verio Test Strips

To order one of these OneTouch® meters call their Service Center at 1-866-355-9962 Order Code: 594PRX100 www.OneTouch.orderpoints.com

Documents

Welcome to Scrip World - Protect Plans · Check your benefit plan documents to find out your specific pharmacy plan costs. $ Drug Tier Includes Helpful Tips Tier 1 Lowest Cost Lower-cost,