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Prescirption forumulary

University of Arkansas
January 2012
Use of generic drugs can save both you and your health plan money. This list is not all-inclusive and is not a guarantee of coverage. Plan Benefit design is the final determinate of coverage. Certain drugs (*) may be subject to Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Reference Based Pricing (RBP) requirements according to Benefit Design. Branded products with an available generic equivalent may be subject to the highest copayment1 according to Benefit Design. If you have any questions about these requirements or other formulary questions, please contact a MedImpact Healthcare customer service representative at 800-788-2949. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Drug Type
Anti-Infectives
cefditoren,cefuroxime, cephalexin ciprofloxacin, ciprofloxacin ext-rel, hyclate, minocycline, tetracycline acyclovir, famciclovir, valacyclovir Cardiovascular
enalapril, fosinopril, fosinopril- University of Arkansas
January 2012
Drug Type
atenolol, carvedilol, carvedilol ext- rel, propranolol, propranolol ext- Central Nervous System
donepezil,galantamine, rivastigmine University of Arkansas
January 2012
Drug Type
amitriptyline, bupropion/-ext-rel, RBP: PLAN WILL PAY $0.19/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING
zolpidem tartrate ER* (QL,RBP),AMBIEN* (QL,RBP), AMBIEN CR* (QL,RBP), PROGRAM (RBP)
EDLUAR*(QL,RBP),LUNESTA* (QL,RBP), ROZEREM* (QL,RBP), SILENOR*(QL,RBP),SONATA* (QL,RBP), ZOLPIMIST*(RBP) RBP: PLAN WILL PAY $0.09/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING
orphenadrine (RBP), orphenadrine compound (RBP), metaxalone (RBP), PROGRAM (RBP)
AMRIX (RBP), FEXMID (RBP),FLEXERIL(RBP), NORFLEX(RBP), NORGESIC(RBP), NORGESIC FORTE (RBP), ROBAXIN (RBP), SKELAXIN Dermatologicals
Endocrine
University of Arkansas
January 2012
Drug Type
$0 copay for Glucose Test Strips, Lancets, Alcohol Swabs, Insulin Gastrointestinal/Urinary
cimetidine, famotidine, nizatidine, RBP: PLAN WILL PAY $0.64/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING
ACIPHEX* (QL,RBP), DEXILANT* (QL,RBP), lansoprazole*(QL,RBP), NEXIUM* PROGRAM (RBP)
(QL,RBP), omeprazole-sodium bicarbonate* (QL,RBP), pantoprazole* (QL,RBP), PREVACID* (QL,RBP), PRILOSEC* (QL,RBP), PROTONIX* (QL,RBP), bethanechol, oxybutynin chloride, RBP: PLAN WILL PAY $0.30/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING
trospium (RPB), DETROL (RPB), DETROL LA (RPB), DITROPAN (RPB), PROGRAM (RBP)
oxybutynin ext-rel (2nd Tier
DITROPAN XL (RPB), GELNIQUE (RPB), OXYTROL (RPB), SANCTURA (RPB), Copay)
SANCTURA XR (RPB), TOVIAZ (RPB), VESICARE (RPB) Immunosuppressive Agents
Men’s Health
Ophthalmics
University of Arkansas
January 2012
Drug Type
betaxolol, brimonidine, dipivefrin, metipranolol, pilocarpine, timolol, Respiratory
RBP: PLAN WILL PAY $22.42/inhaler; REMAINING COST WILL BE APPLIED REFERENCE BASED PRICING
triamcinolone* (QL,RBP), ASTELIN* (QL), ASTEPRO* (QL), BECONASE AQ* PROGRAM (RBP)
(QL,RBP), FLONASE* (QL,RBP), NASACORT AQ* (QL,RBP), NASAREL* (QL,RBP), NASONEX* (QL,RBP), OMNARIS* (QL,RBP), RHINOCORT AQUA* acetic acid, acetic acid-aluminum Women's Health
Sprintec, Tri-Previfem, Trinessa, University of Arkansas
January 2012
NOTE: If a product may be used to treat infertility prior authorization RBP: PLAN WILL PAY $0.26/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING
PROGRAM (RBP)
ACTONEL (RBP), ATELVIA (RBP), BONIVA (RBP), FOSAMAX (RBP) Miscellaneous

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of
prescription coverage. It is not inclusive and does not guarantee coverage. Specific prescription benefit plan design may not cover
certain categories, regardless of their appearance in this document. The plan participant’s prescription benefit plan may have a different
copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents
brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in
therapeutic categories are for representational purposes only. This is not an all-inclusive list. Listed products may be available
generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log
in to www.medimpact.com to check coverage and copay information for a specific medicine.
1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a
Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid
by a Plan.
2 Atacand should be reserved for plan participants who meet CHARM (Candesartan in Heart Failure – Assessment of Reduction in
Mortality and Morbidity) trial criteria.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical
manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the
prescriber.

Source: http://www.uasys.edu/choosewell/prevent/pharmacy_corner/formulary.pdf

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