UMP (WSRxS) Preferred Drug List (PDL) 2024



2024UMPPreferredDrugListfor

PublicEmployeesBenefitsBoard(PEBB)and

SchoolEmployeesBenefitsBoard(SEBB)members



WhatistheUMPPreferredDrugList?

TheUniformMedicalPlan(UMP)PreferredDrugList(PDL)offersachoiceofcoveredprescriptiondrugsthat

aresafe,effective,andevidence‐based.

HowdoesthePDLwork?

ThisPDLclassifiesprescriptiondrugsintotiers.Theamountyoupayforyourprescriptiondrugdependsonits

tier,thepharmacyyouuse,andyourplanbenefits.Forallplans,youpay$0forcoveredpreventivedrugs.

Also,forallplansyoudonothavetomeetyourdeductiblebeforetheplanpaysforcoveredinsulins.

Coinsuranceforcoveredinsuliniscappedat$35per30‐daysupply.

Appliestothefollowingplans:

UMPClassic,UMPSelect,UMPAchieve1,UMPAchieve2,UMPPlus(PEBBandSEBB),

UMPCDHP,andUMPHighDeductible*

Tier Howmuchyoupayatnetworkpharmaciesper30daysupply

PreventiveTier $0

ValueTier 5%coinsuranceor$10whicheverisless

Tier1 10%coinsuranceor$25whicheverisless

Tier2 30%coinsuranceor$75whicheverisless

Coveredinsulins:30%coinsuranceor$35whicheverisless

*ForUMPCDHPandUMPHighDeductible,tiersonlyapplytocoveredinsulins



HowisprescriptiondrugcoveragedifferentforUMPConsumer‐DirectedHealthPlan

(CDHP)andUMPHighDeductible?

Tiersdonotapplytomostprescriptiondrugs.Afteryoumeetyourdeductible,youpay15

percentcoinsuranceforprescriptiondrugsonthePDL,exceptforthefollowing:

 Coveredpreventivedrugs:Youpay$0.

 Coveredinsulins:Thedeductibleiswaived,andyourcost‐sharewillbetheamount

showninthetableabovewhenyoufillyourinsulinprescriptionatanetworkpharmacy.

Ifyouhavenotmetyourdeductible,yourcoinsurancewillbeappliedtoyour

deductible.



ThePDLmaychangethroughouttheyear.Forapreviousversion,pleasecontactWSRxSat1‐888‐361‐1611(TRS:711).

Additionally,forcertainprescriptiondrugs,thedeductibleiswaivedandyoupay15percent

coinsurancewhenyouuseanetworkpharmacy.Thetablebelowshowswhatdrugsthisappliesto.

Drugclass Drugs

AngiotensinConvertingEnzyme

(ACE)inhibitors

enalapril

enalapril/hydrochlorothiazide



lisinopril

lisinopril/hydrochlorothiazide

Anti‐resorptivetherapy alendronate

Beta‐blockers atenolol

bisoprolol/hydrochlorothiazide

carvedilol



metoprololsuccinate

metoprololtartrate

Inhaledcorticosteroids budesonidesuspension

fluticasoneHFA

Non‐insulinglucoseloweringagents glimepiride

glipizide

glyburide



glyburide/metformin

metformin

Continuousglucosemonitors FreestyleLibre Dexcom

Glucosemeters TolearnhowtoreceiveafreeglucosemetermanufacturedbyAscensia

orAbbott,contactWSRxScustomerserviceat1‐888‐361‐1611(TRS:711).

SelectiveSerotoninReuptake

Inhibitors(SSRIs)

citalopram

escitalopram



fluoxetine

sertraline

Statins

Age40&over:Deductiblewaived,

coveredasPreventive($0)

Ageunder40:Deductiblewaived,

15%coinsurance

rosuvastatin

atorvastatin

lovastatin

pravastatin

simvastatin

WhodecideswhichprescriptiondrugsareonthePDL?

TwoorganizationsdeterminewhichprescriptiondrugsareonthePDL.TheWashingtonStatePharmacyand

TherapeuticsCommittee(anindependentgroupofdoctorsandpharmacists)andWashingtonState

PrescriptionServices(WSRxS)recommendsafeandeffectiveprescriptiondrugsforthePDL.WSRxS

determineswhattiertheprescriptiondrugsareplacedonandwhichdrugsarecost‐effective.

DoesthePDLcontainpricinginformation?

ThePDLcontainsinformationaboutwhatpercentageormaximumcost‐shareyoumaypay.Todetermine

yourestimatedcostbasedonthespecificsofyourplanandcoverage,useUMP’sPrescriptionPriceCheck

Toolatthewebsitelistedunder“ForMoreInformation.”



ThePDLmaychangethroughouttheyear.Forapreviousversion,pleasecontactWSRxSat1‐888‐361‐1611(TRS:711).

HowdoIreadthePDL?

ThetablesbelowdefinesometermsyouwillfindinthePDL.ThePDLchangesthroughouttheyearasnew

prescriptiondrugsareapprovedforuse.Newprescriptiondrugsmaynotbecoveredduringthefirst180

daystheyareavailable.



Drugtierkey Drugtierdescription

CAPITAL

LETTERS

Brandnameprescriptiondrugs

Smallletters

Genericprescriptiondrugs

Preventive

PreventivedrugsrequiredunderthePatientProtectionandAffordableCareActorrecommended

bytheU.S.PreventiveServicesTaskForceandtheAdvisoryCommitteeonImmunizationPractices

oftheCentersforDiseaseControlandPrevention

Value

Specifichigh‐valueprescriptiondrugsusedtotreatcertainchronicconditions

Tier1

Primarilylow‐costgenericprescriptiondrugs

Tier2

Preferredbrand‐namedrugsandhigh‐costgenericprescriptiondrugs

Tier1

Specialty

Specialtyprescriptiondrugsthataresafe,effective,andrepresentthemostcost‐effectiveoption

withintheirtherapeuticcategory

Tier2

Specialty

SpecialtyprescriptiondrugsthathavebeenreviewedbyUMPandfoundtobeclinicallyeffective

atafavorablecostwhencomparedwithotherprescriptiondrugsinthesamecategory



ThePDLmaychangethroughouttheyear.Forapreviousversion,pleasecontactWSRxSat1‐888‐361‐1611(TRS:711).



Formoreinformation:

• Refertoyourplan’scurrentcertificateofcoveragebyvisitingFormsandpublicationsat

 hca.wa.gov/ump‐coc



• CallWashingtonStateRxServicesat1‐888‐361‐1611(TRS:711)



• VisitUMP’sPrescriptionsdrugswebpagestoaccessUMP’sPriceCheckToolorfindmore

 information:

 PEBBProgrammembers:ump.regence.com/pebb/benefits/prescriptions

 SEBBProgrammembers:ump.regence.com/sebb/benefits/prescriptions

SpecialCode SpecialCodedescription

AMSP

ArdonMandatorySpecialtyPharmacyProgram:Specialtydrugsareusedtotreatcomplexchronic

healthconditions.Theyoftenrequirespecialhandlingtechniques,carefuladministration,anda

uniqueorderingprocess.Mostspecialtydrugsrequirepreauthorization.Theplanonlycovers

specialtydrugswhenyoupurchasethemthroughArdonHealth,UMP’sspecialtypharmacy.Toset

upanaccountwithArdonHealth,call1‐855‐425‐4085.

IfArdonHealthdoesnothaveaccesstoaspecialtydrug,wewillnotifyyouabouthowtofillyour

prescriptionatanothernetworkspecialtypharmacy.Theplanwillonlycoveritthroughthat

specialtypharmacy.IfArdongainsaccesstothespecialtydrug,wewillsendyouanotification

askingyoutotransferyourprescriptiontoArdonHealth.

LD

LimitedDistribution:Youmustaccessthesespecialtyprescriptiondrugsthroughtheexclusive

specialtypharmacyindicated.Alllimiteddistributiondrugsrequireapreauthorizationbeforethey

canbedispensed.

LMSP

LumiceraMandatorySpecialtyPharmacyProgram:Youmustaccessthesespecialtydrugsthrough

theexclusiveLumiceraSpecialtypharmacy.LumiceraMandatorySpecialtyPharmacyProgram

prescriptiondrugsrequireapreauthorizationbeforetheycanbedispensed.Toenrollwith

LumiceraSpecialtyPharmacy,calltoll‐freeat855‐847‐3553.

OTC

Over‐the‐Counter:Whilesomedrugsmaybepurchasedwithoutaprofessionalprovider’s

prescription,tobecoveredunderUMPyoumusthaveaprescriptionandbuyitatthepharmacy

counter.WSRxSfollowsthefederaldesignationofoverthecounter(OTC)prescriptiondrugsto

decideifanOTCprescriptiondrugis

covered.

PA

Preauthorization:Thesedrugsrequirepreauthorizationtodetermineiftheyaremedically

necessary.Youmustreceiveapprovalbeforetheplanwillcoverthedrug.You,yourprescribing

provider,oryourpharmacistmaycontactWSRxStoinitiatethepreauthorizationprocess.

QL

Quantitylimits:Someprescriptiondrugshavelimitstohowmuchyoucangetperprescriptionor

refill.

RDX

RestrictedtoDiagnosis:Theplanwillcoverthesedrugsiftheyareprescribedforanapproved

diagnosis.Thepharmacymustsubmitthediagnosiscodeontheclaim.

SF

SplitFill:Theseprescriptiondrugsarelimitedtotwo15dayfillspermonthforthefirst3months

oftherapy.

SMKG

SmokingCessation:Smokingcessationprescriptiondrugsareinthepreventivetierandcoveredat

nocosttoyou.Certainrestrictionsmayapply.

ST

StepTherapy:Youmusttrycertainprescriptiondrugsforyourconditionbeforetheplanwill

coverthesedrugs.

VAC

VaccineProgram:Certainimmunizationsandrelatedadministrationfeesarecoveredatnocost

toyouifreceivedatnetworkretailpharmacies.



Search Tip:

This is a large document, but you can search quickly and easily by clicking on the binocular icon on your toolbar or using the CTRL+F search function from

your keyboard. It will then display a search box for you to type in the name of the drug you want to locate. If you do not know the correct spelling, you

can start your search by entering just the first few letters of the name.

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List

ANTIVIRALSTier 1QLabacavir soln (ZIAGEN equiv) (QL= 960ml/30 days)

ANTIVIRALSTier 1QLabacavir tab (ZIAGEN equiv) (QL= 2 tabs/day)

ANTIVIRALSTier 1QLabacavir/lamivudine tab (EPZICOM equiv) (QL= 1 tab/day)

ANTIVIRALSTier 1QLabacavir/lamivudine/zidovudine tab (TRIZIVIR equiv) (QL= 2 tabs/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPABILIFY ASIMTUFII INJ 720MG/2.4ML

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPABILIFY ASIMTUFII INJ 960MG/3.2ML

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPABILIFY MAINTENA INJ

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFabiraterone acetate tab 500mg (ZYTIGA equiv) (QL= 2 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFabiraterone tab 250mg (ZYTIGA equiv) (QL= 4 tabs/day)

VACCINES

Preventi

QL-VACABRYSVO INJ (QL= 1 inj/fill, 1 fill/lifetime)

VACCINES

Preventi

-ACAM2000 INJ

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-acamprosate calcium DR tab (CAMPRAL equiv)

ANTIDIABETICSTier 1-acarbose tab (PRECOSE equiv)

BETA BLOCKERSTier 1-acebutolol cap (SECTRAL equiv)

ANALGESICS - OPIOIDTier 2QL

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE TAB (QL= 18 tabs/fill for

members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

acetaminophen/codeine soln (QL= 90ml/fill for members age 20 or younger;

QL= 210ml/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 1QL

acetaminophen/codeine tab (TYLENOL/CODEINE equiv) (QL= 18 tabs/fill for

members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

MIGRAINE PRODUCTSTier 1-acetaminophen/isometheptene/dichloral cap (MIDRIN equiv)

MIGRAINE PRODUCTSTier 2-ACETAMINOPHEN/ISOMETHEPTENE/DICHLORAL CAP

DIURETICSTier 1-acetazolamide ER cap (DIAMOX SEQUEL equiv)

DIURETICSTier 1-acetazolamide tab

OTIC AGENTSTier 1-acetic acid otic soln (VOSOL equiv)

OTIC AGENTSTier 1-ACETIC ACID/ALUMINUM ACETATE OTIC SOLN

COUGH/COLD/ALLERGYTier 1-acetylcysteine soln (MUCOMYST equiv)

DERMATOLOGICALSTier 2ST

acitretin cap (SORIATANE equiv) (Step Therapy requires trial of adapalene,

adapalene/benzoyl peroxide, or tretinoin)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA

ACTHAR HP GEL INJ (Only available through Accredo 800-803-2523 or

Walgreens 888-347-3416)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA

ACTHAR INJ 80UNIT (Only available through Accredo 800-803-2523 or

Walgreens 888-347-3416)

COUGH/COLD/ALLERGYTier 2QLACTINEL LIQUID (QL= 1200ml/30 days)

OPHTHALMIC AGENTSTier 2-ACULAR (LS) OPHTH SOLN

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 1 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

OPHTHALMIC AGENTSTier 2-ACUVAIL OPHTH SOLN

ANTIVIRALSTier 1-acyclovir cap (ZOVIRAX equiv)

DERMATOLOGICALSTier 2-acyclovir cream (ZOVIRAX equiv)

DERMATOLOGICALSTier 2-acyclovir oint (ZOVIRAX OINT equiv)

ANTIVIRALSTier 1-acyclovir susp (ZOVIRAX equiv)

ANTIVIRALSTier 1-acyclovir tab (ZOVIRAX equiv)

TOXOIDS

Preventi

VACADACEL/BOOSTRIX INJ

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLADALIMUMAB-ADAZ INJ 40MG/0.4ML (QL= 2 inj/28 days)

DERMATOLOGICALSTier 1QLadapalene cream (DIFFERIN equiv) (QL= 360g/30 days)

DERMATOLOGICALSTier 1QLadapalene gel 0.3% (DIFFERIN equiv) (QL= 360g/30 days)

ANTIVIRALS

Tier 1

Specialty

AMSP-QLadefovir dipivoxil tab (HEPSERA equiv) (QL= 1 tab/day)

ANTIDIABETICSTier 2QL-ST

ADMELOG INJ, HUMALOG INJ (QL= 60 units/30 days; Step Therapy requires

trial of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

ADMELOG SOLOSTAR INJ, INSULIN LISPRO KWIKPEN INJ (JUNIOR) (QL= 60

units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP)

COUGH/COLD/ALLERGYTier 1QLADVIL COLD/ TAB SINUS (QL= 240 tabs/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLAEROCHAMBER (QL= 1 device/365 days)

VACCINES

Preventi

QL-VACAFLURIA INJ (QL= 0.5ml/fill)

VACCINES

Preventi

VACAFLURIA INJ, FLUZONE INJ

ANTIDIABETICSTier 2QL-ST

AFREZZA INH POWDER (QL= 180 inhalations/28 days; Step Therapy requires

trial of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

AFREZZA INH POWDER (QL= 360 inhalations/28 days; Step Therapy requires

trial of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

AFREZZA INH POWDER (QL= 630 inhalations/30 days; Step Therapy requires

trial of NOVOLOG, INSULIN ASPART, or FIASP)

MIGRAINE PRODUCTSTier 2PA-QLAIMOVIG INJ (QL= 1 pack/28 days)

MIGRAINE PRODUCTSTier 2PA-QLAJOVY INJ (QL= 1 inj/28 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1QLALBUTEROL HFA INHALER (QL= 2 inhalers/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1QLalbuterol HFA inhaler (PROAIR equiv) (QL= 2 inhalers/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1QLalbuterol HFA inhaler (PROVENTIL equiv) (QL= 2 inhalers/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-albuterol neb soln

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-ALBUTEROL NEBULIZER SOLN

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-albuterol sulfate syrup

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-albuterol sulfate tab

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-albuterol/ipratropium neb soln (DUONEB equiv)

DERMATOLOGICALSTier 1-alclometasone cream (ACLOVATE equiv)

DERMATOLOGICALSTier 1-alclometasone oint (ACLOVATE OINT equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 2 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLALECENSA CAP (QL= 8 caps/day)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLalendronate sodium oral soln (FOSAMAX equiv) (QL= 300ml/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Value-alendronate tab (FOSAMAX equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Value-ALENDRONATE TAB 40MG

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-alfuzosin SR tab (UROXATRAL equiv)

ANTIHYPERTENSIVESTier 2ST

aliskiren tab (TEKTURNA equiv) (Step Therapy requires trial of one

angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor

blockers (ARB))

GOUT AGENTSTier 1-allopurinol tab (ZYLOPRIM equiv)

MIGRAINE PRODUCTSTier 2QL-ST

almotriptan tab (AXERT equiv) (QL= 12 tabs/30 days; Step Therapy requires

30 day trial of 2: naratriptan tab, rizatriptan tab or sumatriptan tab)

MIGRAINE PRODUCTSTier 2QL-ST

almotriptan tab (AXERT equiv) (QL= 9 tabs/30 days; Step Therapy requires 30

day trial of 2: naratriptan tab, rizatriptan tab, or sumatriptan tab)

OPHTHALMIC AGENTSTier 2-ALOCRIL OPHTH SOLN

GASTROINTESTINAL AGENTS - MISC.Tier 1-alosetron tab (LOTRONEX equiv)

ANTIANXIETY AGENTSTier 1-alprazolam ER tab (XANAX XR equiv)

ANTIANXIETY AGENTSTier 2-alprazolam ODT (NIRAVAM equiv)

ANTIANXIETY AGENTSTier 1-alprazolam tab (XANAX equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

ALUNBRIG TAB 30MG (QL= 4 tabs/day; Only available through Biologics

800-850-4306 or Onco360 877-662-6633)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

ALUNBRIG TAB 90MG, 180MG (QL= 1 tab/day; Only available through

Biologics 800-850-4306 or Onco360 877-662-6633)

ANTIPARKINSON AGENTSTier 1-amantadine cap (SYMMETREL equiv)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1-amantadine soln

ANTIPARKINSON AGENTSTier 1-amantadine syrup (SYMMETREL equiv)

ANTIPARKINSON AGENTSTier 1-amantadine tab

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QLambrisentan tab (LETAIRIS equiv) (QL= 1 tab/day)

DERMATOLOGICALSTier 1-AMCINONIDE CREAM 0.1%

DERMATOLOGICALSTier 2-AMCINONIDE LOTION

DERMATOLOGICALSTier 2ST

amcinonide oint (Step therapy requires trial of 2 high potency steroids (eg.

betamethasone, clobetasol, halobetasol))

CONTRACEPTIVES

Preventi

-amethyst tab (LYBREL equiv)

DIURETICSTier 1-amiloride tab (MIDAMOR equiv)

DIURETICSTier 1-AMILORIDE/HCTZ TAB

DIURETICSTier 1-amiloride/hydrochlorothiazide tab (MODURETIC equiv)

HEMOSTATICS

Tier 1

Specialty

AMSPaminocaproic acid soln (AMICAR equiv)

HEMOSTATICSTier 2-aminocaproic acid tab (AMICAR equiv)

ANTIARRHYTHMICSTier 1-amiodarone tab (CORDARONE equiv)

ANTIDEPRESSANTSValue-amitriptyline tab (ELAVIL equiv)

CALCIUM CHANNEL BLOCKERSValue-amlodipine tab (NORVASC equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 3 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CARDIOVASCULAR AGENTS - MISC.Tier 2QL-ST

amlodipine/atorvastatin tab (CADUET equiv) (QL= 1 tab/day; Trial of a CCB

(eg. amlodipine, nifedipine, diltiazem) AND a statin (eg. atorvastatin,

simvastatin))

ANTIHYPERTENSIVESTier 1-amlodipine/benazepril cap (LOTREL equiv)

ANTIHYPERTENSIVESTier 1-amlodipine/olmesartan tab (AZOR TAB equiv)

ANTIHYPERTENSIVESTier 1-amlodipine/valsartan tab (EXFORGE equiv)

ANTIHYPERTENSIVESTier 2QL-ST

amlodipine/valsartan/hydrochlorothiazide tab (EXFORGE HCT equiv) (QL= 30

tabs/30 days; Step therapy requires trial of olmesartan-amlodipine-HCTZ)

DERMATOLOGICALSTier 1-ammonium lactate cream (LAC-HYDRIN equiv)

DERMATOLOGICALSTier 1-ammonium lactate lotion (LAC-HYDRIN equiv)

DERMATOLOGICALSTier 2-

amnesteem cap, claravis cap, isotretinoin cap, myorisan cap, zenatane cap

(ACCUTANE equiv)

ANTIDEPRESSANTSTier 1QLamoxapine tab (QL= 4 tabs/day)

PENICILLINSTier 1-amoxicillin cap (TRIMOX equiv)

PENICILLINSTier 1-amoxicillin chew tab (AMOXIL equiv)

PENICILLINSTier 1-AMOXICILLIN CHEW TAB 250MG

PENICILLINSTier 1-amoxicillin susp (TRIMOX equiv)

PENICILLINSTier 1-amoxicillin tab (AMOXIL equiv)

PENICILLINSTier 1-amoxicillin/clavulanate susp (AUGMENTIN ES equiv)

PENICILLINSTier 1-amoxicillin/clavulanate tab (AUGMENTIN equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

amphetamine tab (EVEKEO equiv) (QL= 60 tabs/30 days; Step therapy

requires trial dexmethylphenidate, methylphenidate, dextroamphetamine, or

dextroamphetamine/amphetamine)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1-amphetamine/dextroamphetamine ER cap (ADDERALL XR equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 10mg (ADDERALL equiv) (QL= 180

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 12.5mg (ADDERALL equiv) (QL= 150

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 15mg (ADDERALL equiv) (QL= 120

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 20mg (ADDERALL equiv) (QL= 90

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 30mg (ADDERALL equiv) (QL= 60

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 5mg (ADDERALL equiv) (QL= 360

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QL

amphetamine/dextroamphetamine tab 7.5mg (ADDERALL equiv) (QL= 240

tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

amphetamine-dextroamphetamine 3-bead cap er 24hr 12.5mg (MYDAYIS

equiv) (QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen

ER (nonOSM), dexmethylphen ER, or dextroamph ER)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

amphetamine-dextroamphetamine 3-bead cap er 24hr 25mg (MYDAYIS equiv)

(QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER

(nonOSM), dexmethylphen ER, or dextroamph ER)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

amphetamine-dextroamphetamine 3-bead cap er 24hr 37.5mg (MYDAYIS

equiv) (QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen

ER (nonOSM), dexmethylphen ER, or dextroamph ER)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

amphetamine-dextroamphetamine 3-bead cap er 24hr 50mg (MYDAYIS equiv)

(QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER

(nonOSM), dexmethylphen ER, or dextroamph ER)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 4 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PENICILLINSTier 1-ampicillin cap (AMPICILLIN equiv)

HEMATOLOGICAL AGENTS - MISC.Tier 1-anagrelide cap (AGRYLIN equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Preventi

-anastrozole tab (ARIMIDEX equiv)

CONTRACEPTIVES

Preventi

-ANNOVERA RING

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLANORO ELLIPTA INHALER (QL= 60gm/30 days)

OTIC AGENTSTier 1-antipyrine/benzocaine otic soln (AURALGAN equiv)

ANALGESICS - OPIOIDTier 1QL

APAP/CODEINE SOLN (QL= 90ml/fill for members age 20 or younger; QL=

210ml/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

ANTIDIABETICSTier 2QL-ST

APIDRA INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG,

INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

APIDRA SOLOSTAR INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1

Specialty

LD-QL

apomorphine inj (APOKYN equiv) (QL= 54ml/30 days; Only available through

CVS Specialty 800-237-2767)

OPHTHALMIC AGENTSTier 2-apraclonidine ophth soln 0.5% (IOPIDINE equiv)

ANTIEMETICSTier 1QL-ST

aprepitant cap 125mg (EMEND equiv) (QL= 1 cap/21 days; Step Therapy

requires trial of ondansetron)

ANTIEMETICSTier 1QL-ST

aprepitant cap 40mg (EMEND equiv) (QL= 1 cap/28 days; Step Therapy

requires trial of ondansetron)

ANTIEMETICSTier 1QL-ST

aprepitant cap 80mg (EMEND equiv) (QL= 2 caps/21 days; Step Therapy

requires trial of ondansetron)

ANTIEMETICSTier 1QL-ST

aprepitant pak (EMEND equiv) (QL= 3 caps/fill, 2 fills/month; Step Therapy

requires trial of ondansetron)

ANTICONVULSANTSTier 2QLAPTIOM TAB (QL= 1 tab/day)

ANTIVIRALSTier 2QLAPTIVUS CAP (QL= 4 caps/day)

ANTIVIRALSTier 2QLAPTIVUS SOLN (QL= 380ml/30 days)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLARANESP INJ (QL= 4 syringes/30 days)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLARANESP INJ (QL= 4 vials/30 days)

VACCINES

Preventi

QL-VAC

AREXVY INJ (QL= 1 inj/day, 1 fill/lifetime; Covered for members 60 years of

age and older)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QL-ST

arformoterol tartrate neb soln (BROVANA equiv) (QL= 120ml/30 days; Step

Therapy requires trial of albuterol neb soln OR levalbuterol neb soln)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLaripiprazole ODT (ABILIFY equiv) (QL= 2 tabs/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLaripiprazole soln (ABILIFY equiv) (QL= 30 ml/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-aripiprazole tab (ABILIFY equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPARISTADA 675MG/2.4ML INJ

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPARISTADA INJ

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLarmodafinil tab 150mg (NUVIGIL equiv) (QL= 1 tab/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLarmodafinil tab 200mg (NUVIGIL equiv) (QL= 1 tab/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLarmodafinil tab 250mg (NUVIGIL equiv) (QL= 1 tab/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLarmodafinil tab 50mg (NUVIGIL equiv) (QL= 3 tabs/day)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 5 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 2QL-ST

asenapine maleate SL tab (SAPHRIS equiv) (QL= 2 tabs/day; Step Therapy

requires trial of olanzapine, olanzapine ODT, quetiapine, quetiapine XR,

risperidone, or risperidone ODT)

CONTRACEPTIVES

Preventi

-ashlyna tab, daysee tab (SEASONALE, SEASONIQUE equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

ValueQLASMANEX HFA INHALER (QL= 1 inhaler/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

ValueQLASMANEX INHALER (QL= 1 inhaler/30 days)

ANALGESICS - NONNARCOTIC

Preventi

-aspirin chew tab 81mg (Covered for females only)

ANALGESICS - NONNARCOTIC

Preventi

OTCaspirin ec tab 325mg (Covered for females only)

ANALGESICS - NONNARCOTIC

Preventi

OTCaspirin ec tab 81mg (Covered for females only)

ANALGESICS - NONNARCOTIC

Preventi

OTCaspirin tab (Covered for females only)

ANALGESICS - OPIOIDTier 1QL

aspirin/codeine tab (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

HEMATOLOGICAL AGENTS - MISC.Tier 2-aspirin/dipyridamole cap (AGGRENOX equiv)

ANTIANGINAL AGENTSTier 2QL-ST

ASPRUZYO SPRINKLE GRANULES (QL= 2 packets/day; Step therapy

requires trial of ranolazine ER tab)

ANTIVIRALSTier 1QLatazanavir cap 150mg (REYATAZ equiv) (QL= 2 caps/day)

ANTIVIRALSTier 1QLatazanavir cap 200mg (REYATAZ equiv) (QL= 2 caps/day)

ANTIVIRALSTier 1QLatazanavir cap 300mg (REYATAZ equiv) (QL= 1 cap/day)

BETA BLOCKERSValue-atenolol tab (TENORMIN equiv)

ANTIHYPERTENSIVESTier 1-atenolol/chlorthalidone tab (TENORETIC equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 100mg (STRATTERA equiv) (QL= 1 cap/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 10mg (STRATTERA equiv) (QL= 2 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 18mg (STRATTERA equiv) (QL= 2 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 25mg (STRATTERA equiv) (QL= 2 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 40mg (STRATTERA equiv) (QL= 2 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 60mg (STRATTERA equiv) (QL= 1 cap/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLatomoxetine cap 80mg (STRATTERA equiv) (QL= 1 cap/day)

ANTIHYPERLIPIDEMICS

Preventi

atorvastatin tab (LIPITOR equiv) (QL= 1 tab/day; Covered at $0 for members

40 years or older; All other members covered at generic copay)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-atovaquone susp (MEPRON equiv)

ANTIMALARIALSTier 1-atovaquone/proguanil tab (MALARONE equiv)

ANTIVIRALSTier 2QLATRIPLA TAB (QL= 1 tab/day)

OPHTHALMIC AGENTSTier 1-atropine ophth oint

OPHTHALMIC AGENTSTier 1QLatropine ophth soln (ISOPTO ATROPINE equiv) (QL= 1 bottle/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLATROVENT HFA INHALER (QL= 25.8gm/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO TAB 12MG (QL= 120 tabs/30 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 6 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO TAB 6MG (QL= 30 tabs/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO TAB 9MG (QL= 30 tabs/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 12MG (QL= 90 tabs/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 18MG (QL= 2 tabs/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 24MG (QL= 60 tabs/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 30MG (QL= 1 tab/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 36MG (QL= 1 tab/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 42MG (QL= 1 tab/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 48MG (QL= 1 tab/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB 6MG (QL= 210 tabs/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

LMSP-PA-QLAUSTEDO XR TAB TITRATION KIT (QL= 42 tabs/28 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLAUSTEDO XR TAB TITRATION PACK (QL= 28 tabs/28 days)

VAGINAL PRODUCTSTier 2-AVC VAGINAL CREAM

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-QL-ST

AVONEX INJ (QL= 1 kit/28 days; Step therapy requires trial of dimethyl

fumarate, fingolimod, teriflunomide, or glatiramer)

ASSORTED CLASSESTier 1-azathioprine tab (IMURAN equiv)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2QL-ST

azathioprine tab 100mg (QL= 30 tabs/30 days; Step therapy requires trial of

azathioprine tab 50mg)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2QL-ST

azathioprine tab 75mg (QL= 30 tabs/30 days; Step therapy requires trial of

azathioprine tab 50mg)

DERMATOLOGICALSTier 1QLazelaic acid gel (FINACEA equiv) (QL= 300g/30 days)

OPHTHALMIC AGENTSTier 1-azelastine ophth soln (OPTIVAR equiv)

MACROLIDESTier 1-azithromycin susp (ZITHROMAX equiv)

MACROLIDESTier 1-azithromycin tab (ZITHROMAX equiv)

OPHTHALMIC AGENTSTier 2-BACITRACIN OPHTH OINT

OPHTHALMIC AGENTSTier 1-bacitracin/neomycin/polymyxin b ophth oint (NEOSPORIN equiv)

OPHTHALMIC AGENTSTier 1-bacitracin/polymyxin b ophth oint (POLYSPORIN equiv)

OPHTHALMIC AGENTSTier 1-

bacitracin/polymyxin/neomycin/hydrocortisone ophth oint (CORTISPORIN

equiv)

MUSCULOSKELETAL THERAPY AGENTSTier 2QL-ST

baclofen susp (BACLOFEN equiv) (QL= 16 ml/day; ST req trial of baclofen

tabs and tizanidine caps/tabs (can be open or crushed))

MUSCULOSKELETAL THERAPY AGENTSTier 1-baclofen tab (BACLOFEN equiv)

MUSCULOSKELETAL THERAPY AGENTSTier 2-BACLOFEN TAB 5MG

CONTRACEPTIVES

Preventi

-BALCOLTRA TAB

GASTROINTESTINAL AGENTS - MISC.Tier 1-balsalazide cap (COLAZAL equiv)

ANTIDIABETICSTier 2QLBAQSIMI NASAL POWDER (QL= 2 inhalations/fill, 2 fills/month)

ANTIVIRALS

Tier 2

Specialty

AMSP-PA-QLBARACLUDE SOLN (QL= 630ml/30 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 7 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIDIABETICSValueQLBASAGLAR KWIKPEN INJ (QL= 60 units/30 days)

MEDICAL DEVICES AND SUPPLIESTier 1--OTCB-D INSULIN SYRINGE

MEDICAL DEVICES AND SUPPLIESTier 1OTCBD NEEDLES

MEDICAL DEVICES AND SUPPLIESTier 1OTCB-D PEN NEEDLE

ULCER DRUGSTier 2QLb-donna tab (DONNATAL equiv) (QL= 8 tabs/day)

ULCER DRUGSTier 2-BELLADONNA ALKALOID/OPIUM SUPP

ANTIHYPERTENSIVESTier 1-benazepril tab (LOTENSIN equiv)

ANTIHYPERTENSIVESTier 1-benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv)

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PABENEFIX INJ

ANTHELMINTICSTier 2-BENZNIDAZOLE TAB

COUGH/COLD/ALLERGYTier 1-benzonatate cap (TESSALON equiv)

ANTIPARKINSON AGENTSTier 1-benztropine tab

OPHTHALMIC AGENTSTier 2QL-ST

bepotastine besilate ophth soln (BEPREVE equiv) (QL= 5mL/25 days; Step

Therapy requires trial of azelastine 0.05% ophth soln)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

LD-PA-QL

betaine powder for oral solution (CYSTADANE equiv) (QL= 540 grams/30

days; Only available through Walgreens 888-347-3416)

DERMATOLOGICALSTier 1-betamethasone augmented cream (DIPROLENE AF CREAM equiv)

DERMATOLOGICALSTier 1-BETAMETHASONE AUGMENTED GEL

DERMATOLOGICALSTier 1-betamethasone augmented lotion (DIPROLENE LOTION equiv)

DERMATOLOGICALSTier 1-betamethasone augmented oint (DIPROLENE OINT equiv)

DERMATOLOGICALSTier 1-betamethasone diproprionate cream (DIPROSONE CREAM equiv)

DERMATOLOGICALSTier 1-betamethasone diproprionate lotion

DERMATOLOGICALSTier 1-betamethasone diproprionate oint (DIPROSONE OINT equiv)

DERMATOLOGICALSTier 1-betamethasone valerate cream

DERMATOLOGICALSTier 2-betamethasone valerate foam (LUXIQ FOAM equiv)

DERMATOLOGICALSTier 1-betamethasone valerate lotion

DERMATOLOGICALSTier 1-betamethasone valerate oint

OPHTHALMIC AGENTSTier 1-betaxolol ophth soln (BETOPTIC-S equiv)

BETA BLOCKERSTier 1-betaxolol tab (KERLONE equiv)

URINARY ANTISPASMODICSTier 1-bethanechol tab (URECHOLINE equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-SFbexarotene cap (TARGRETIN equiv)

DERMATOLOGICALS

Tier 1

Specialty

AMSP-PA-QLbexarotene gel (TARGRETIN equiv) (QL= 60g/30 days)

VACCINES

Preventi

VACBEXSERO INJ

CONTRACEPTIVES

Preventi

-BEYAZ TAB

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1-bicalutamide tab (CASODEX equiv)

ANTIVIRALSTier 2QLBIKTARVY TAB (QL= 1 tab/day)

OPHTHALMIC AGENTSTier 2QL-ST

bimatoprost ophth soln (QL= 2.5ml/25 days; Step Therapy requires trial of

latanoprost ophth soln)

ULCER

DRUGS/ANTISPASMODICS/ANTICHOLINERGI

Tier 2ST

bismuth/metro/tetra cap (PYLERA equiv) (Step therapy requires trial of oral

metronidazole and tetracycline)

BETA BLOCKERSTier 1-bisoprolol tab (ZEBETA equiv)

ANTIHYPERTENSIVESValue-bisoprolol/hydrochlorothiazide tab (ZIAC equiv)

OPHTHALMIC AGENTSTier 2-BLEPHAMIDE OPHTH SOLN

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 8 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

LD-PA-QL

bosentan tab (TRACLEER equiv) (QL= 2 tabs/day; Only available through

Lumicera 855-847-3553)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

BOSULIF CAP (QL= 5 caps/day; Only available through Walgreens

888-347-3416)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-SFBOSULIF TAB (Only available through Walgreens 888-347-3416)

HEMATOLOGICAL AGENTS - MISC.Tier 2QLBRILINTA TAB (QL= 2 tabs/day)

OPHTHALMIC AGENTSTier 2ST

brimonidine ophth soln 0.15% (ALPHAGAN P 0.15% equiv) (Step Therapy

requires trial of brimonidine ophth soln 0.2%)

OPHTHALMIC AGENTSTier 1-brimonidine ophth soln 0.2% (ALPHAGAN equiv)

DERMATOLOGICALSTier 2QL-ST

brimonidine tartrate gel (MIRVASO equiv) (QL= 60 grams/30 days; ST req trial

of azelaic acid gel and metronidazole topical)

OPHTHALMIC AGENTSTier 2ST

brimonidine tartrate ophth soln 0.1% (ALPHAGAN P equiv) (Step Therapy

requires trial of brimonidine ophth soln 0.2%)

OPHTHALMIC AGENTSTier 2QL-ST

brimonidine tartrate-timolol maleate ophth soln (COMBIGAN equiv) (QL= 5ml/25

days; Step Therapy requires trial of 2: brimonidine 0.2%, dorzolamide/timolol,

carteolol, levobunolol, timolol maleate)

OPHTHALMIC AGENTSTier 2ST

brinzolamide ophth susp (AZOPT equiv) (Step Therapy requires trial of

dorzolamide 2% ophth soln)

OPHTHALMIC AGENTSTier 2ST

bromfenac ophth soln (BROMDAY equiv) (Step Therapy requires trial of

diclofenac sodium ophth soln or ketorolac ophth soln)

OPHTHALMIC AGENTSTier 2QL-ST

bromfenac sodium ophth soln 0.07% (PROLENSA equiv) (QL= 3ml./30 days;

Step Therapy requires trial of diclofenac sodium ophth soln or ketorolac ophth

soln)

ANTIPARKINSON AGENTSTier 1-bromocriptine cap (PARLODEL equiv)

ANTIPARKINSON AGENTSTier 1-bromocriptine tab (PARLODEL equiv)

CORTICOSTEROIDSTier 2-budesonide ER tab (UCERIS equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

ValueQL

budesonide inh susp 0.25mg/2ml, 0.5mg/2ml (PULMICORT equiv) (QL= 120

units/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

ValueQLbudesonide inh susp 1mg/2ml (QL= 60 units/30 days)

ANORECTAL AND RELATED PRODUCTSTier 2QL-ST

budesonide rectal foam (UCERIS equiv) (QL= 100.2g/30 days; Step therapy

requires trial of hydrocortisone enema)

CORTICOSTEROIDSTier 1-budesonide SR cap (ENTOCORT EC equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QL-ST

budesonide/formoterol inhaler (BREYNA equiv) (QL= 10.3g/30 days; Step

therapy requires trial of two: fluticasone/salmeterol, WIXELA, DULERA)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QL-ST

budesonide/formoterol inhaler (SYMBICORT equiv) (QL= 10.2g/30 days; Step

therapy requires trial of two: fluticasone/salmeterol, WIXELA, DULERA)

DIURETICSTier 1-bumetanide tab (BUMEX equiv)

ANALGESICS - OPIOIDTier 2ST

buprenorphine hcl buccal film (BELBUCA equiv) (Step therapy requires trial of

buprenorphine patch)

ANALGESICS - OPIOIDTier 1-buprenorphine patch (BUTRANS equiv)

ANALGESICS - OPIOIDTier 1-buprenorphine SL tab (SUBUTEX equiv)

ANALGESICS - OPIOIDTier 1-buprenorphine/naloxone sl film (SUBOXONE equiv)

ANALGESICS - OPIOIDTier 1-buprenorphine/naloxone SL tab (SUBOXONE equiv)

ANTIDEPRESSANTSTier 1-bupropion ER tab (WELLBUTRIN equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGbupropion SR tab (ZYBAN equiv) (Limited to 180 days/plan year)

ANTIDEPRESSANTSTier 1-bupropion tab (WELLBUTRIN equiv)

ANTIDEPRESSANTSTier 1-bupropion XL tab (WELLBUTRIN XL equiv)

ANTIANXIETY AGENTSTier 1-buspirone tab (BUSPAR equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 9 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANALGESICS - NONNARCOTICTier 2-butalbital/acetaminophen cap

ANALGESICS - NONNARCOTICTier 1QLbutalbital/acetaminophen tab (PHRENILIN equiv) (QL= 6 tabs/day)

ANALGESICS - NONNARCOTICTier 1-butalbital/acetaminophen/caffeine soln

ANALGESICS - OPIOIDTier 1QL

butalbital/acetaminophen/caffeine/codeine cap (FIORICET/CODEINE equiv)

(QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

butalbital/aspirin/caffeine/codeine cap (FIORINAL/CODEINE equiv) (QL= 18

caps/fill for members age 20 or younger; QL= 42 caps/fill for members age 21

or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QLbutorphanol nasal spray (QL= 5ml/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-cabergoline tab (DOSTINEX equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

CABOMETYX TAB (QL= 1 tab/day; Only available through Walgreens

888-347-3416)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1-caffeine citrate soln (CAFCIT equiv)

DERMATOLOGICALSTier 1-calcipotriene cream (DOVONEX CREAM equiv)

DERMATOLOGICALSTier 1-calcipotriene oint

DERMATOLOGICALSTier 1-CALCIPOTRIENE SOLN

DERMATOLOGICALSTier 1-calcipotriene soln (DOVONEX SOLN equiv)

DERMATOLOGICALSTier 2-calcipotriene/betamethasone oint (TACLONEX equiv)

DERMATOLOGICALSTier 2QL-ST

calcipotriene-betamethasone dipropionate susp (CALCIPOTRIENE/

BETAMETHASONE SUSP equiv) (QL= 400gm/30 days; Step Therapy requires

trial of 2: high potency corticosteroids, topical calcipotriene)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2-calcitonin inj (MIACALCIN equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-calcitonin nasal spray (MIACALCIN equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-calcitriol cap (ROCALTROL equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-calcitriol soln (CALCITRIOL equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-calcium acetate cap (PHOSLO equiv)

MEDICAL DEVICES AND SUPPLIESTier 2OTCCALIBRATION LIQUID

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFCALQUENCE CAP (QL= 2 caps/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFCALQUENCE TAB (QL= 2 tabs/day)

ANTIHYPERTENSIVESTier 1ST

candesartan tab (ATACAND equiv) (Step Therapy requires trial of: losartan or

losartan/hctz and irbesartan or irbesartan/hctz)

ANTIHYPERTENSIVESTier 1-candesartan/hydrochlorothiazide tab (ATACAND HCT equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSPcapecitabine tab (XELODA equiv)

COUGH/COLD/ALLERGYTier 2QLCAPMIST DM TAB (QL= 4 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

CAPRELSA TAB 100MG (QL= 2 tabs/day; Only available through Biologics

800-850-4306)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

CAPRELSA TAB 300MG (QL= 1 tab/day; Only available through Biologics

800-850-4306)

DERMATOLOGICALSTier 2-capsaicin/menthol topical patch (SINELEE equiv)

ANTIHYPERTENSIVESTier 2ST

captopril tab (CAPOTEN equiv) (Step Therapy requires trial of 2

angiotensin-converting enzyme (ACE) inhibitors)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 10 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIHYPERTENSIVESTier 1-captopril/hydrochlorothiazide tab (CAPOZIDE equiv)

ANTIHYPERTENSIVESTier 2--ST

CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB (Step Therapy requires trial of

one angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor

blocker (ARB) combination drug)

ANTICONVULSANTSTier 1-carbamazepine chew tab (TEGRETOL equiv)

ANTICONVULSANTSTier 1-carbamazepine ER cap (CARBATROL equiv)

ANTICONVULSANTSTier 1-carbamazepine ER tab (TEGRETOL XR equiv)

ANTICONVULSANTSTier 1-carbamazepine susp (TEGRETOL equiv)

ANTICONVULSANTSTier 1-carbamazepine tab (TEGRETOL equiv)

ANTIPARKINSON AGENTSTier 1-carbidopa tab (LODOSYN equiv)

ANTIPARKINSON AGENTSTier 1-carbidopa/levodopa ER tab (SINEMET CR equiv)

ANTIPARKINSON AGENTSTier 1-carbidopa/levodopa ODT (PARCOPA equiv)

ANTIPARKINSON AGENTSTier 1-carbidopa/levodopa tab (SINEMET equiv)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QL

carbidopa-levodopa-entacapone tab 12.5-50-200mg (STALEVO equiv) (QL= 8

tabs/day)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QL

carbidopa-levodopa-entacapone tab 18.75-75-200mg (STALEVO equiv) (QL=

8 tabs/day)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QL

carbidopa-levodopa-entacapone tab 25-100-200mg (STALEVO equiv) (QL= 8

tabs/day)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QL

carbidopa-levodopa-entacapone tab 31.25-125-200mg (STALEVO equiv)

(QL= 8 tabs/day)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QL

carbidopa-levodopa-entacapone tab 37.5-150-200mg (STALEVO equiv) (QL=

8 tabs/day)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QL

carbidopa-levodopa-entacapone tab 50-200-200mg (STALEVO equiv) (QL= 6

tabs/day)

ANTIHISTAMINESTier 1QLCARBINOXAMINE SOLN (QL= 40ml/day)

ANTIHISTAMINESTier 1QLcarbinoxamine tab (PALGIC equiv) (QL= 240 tabs/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

LD-PA

carglumic acid tab (CARBAGLU equiv) (Only available through Accredo

888-773-7376)

MUSCULOSKELETAL THERAPY AGENTSTier 1QL-ST

carisoprodol tab (SOMA equiv) (QL= 4 tabs/day; Step Therapy requires trial of

2: baclofen, cyclobenzaprine, tizanidine, tizanidine, methocarbamol, or

orphenadrine ER)

MUSCULOSKELETAL THERAPY AGENTSTier 1-CARISOPRODOL/ASPIRIN TAB

MUSCULOSKELETAL THERAPY AGENTSTier 1-carisoprodol/aspirin tab (SOMA COMPOUND equiv)

MUSCULOSKELETAL THERAPY AGENTSTier 1-CARISOPRODOL/ASPIRIN/CODEINE TAB

MUSCULOSKELETAL THERAPY AGENTSTier 1-carisoprodol/aspirin/codeine tab (SOMA COMPOUND/CODEINE equiv)

OPHTHALMIC AGENTSTier 1-CARTEOLOL OPHTH SOLN

OPHTHALMIC AGENTSTier 1-carteolol ophth soln (OCUPRESS equiv)

BETA BLOCKERSTier 2-carvedilol phosphate ER cap (COREG CR equiv)

BETA BLOCKERSValue-carvedilol tab (COREG equiv)

ANTI-INFECTIVE AGENTS - MISC.

Tier 2

Specialty

LDCAYSTON INH SOLN (Only available through Walgreens 888-347-3416)

CEPHALOSPORINSTier 1-cefadroxil cap (DURICEF equiv)

CEPHALOSPORINSTier 1-cefadroxil susp (DURICEF equiv)

CEPHALOSPORINSTier 1-cefadroxil tab (DURICEF equiv)

CEPHALOSPORINSTier 1-cefdinir cap (OMNICEF equiv)

CEPHALOSPORINSTier 1-cefdinir susp (OMNICEF equiv)

CEPHALOSPORINSTier 1-cefixime cap (SUPRAX equiv)

CEPHALOSPORINSTier 1-cefixime susp (SUPRAX equiv)

CEPHALOSPORINSTier 1-cefpodoxime proxetil susp (VANTIN equiv)

CEPHALOSPORINSTier 1-cefpodoxime proxetil tab (VANTIN equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 11 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CEPHALOSPORINSTier 1-cefprozil susp (CEFZIL equiv)

CEPHALOSPORINSTier 1-cefprozil tab (CEFZIL equiv)

CEPHALOSPORINSTier 1-cefuroxime tab (CEFTIN equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-celecoxib cap (CELEBREX equiv)

CEPHALOSPORINSTier 1-cephalexin cap (KEFLEX equiv)

CEPHALOSPORINSTier 2QL-ST

cephalexin cap 750mg (QL= 5 caps/day; Step therapy requires trial of

cephalexin 250mg tab/cap or cephalexin 500mg tab/cap)

CEPHALOSPORINSTier 1-cephalexin susp (KEFLEX equiv)

CEPHALOSPORINSTier 1-CEPHALEXIN TAB

MEDICAL DEVICES AND SUPPLIESTier 2QLCEQUR SIMPLICITY 2U (QL= 10 patches/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLCEQUR SIMPLICITY INSERTER (QL= 1 device/lifetime)

MEDICAL DEVICES AND SUPPLIESTier 2QLCEQUR SIMPLICITY INSERTER (QL= 1 inserter/lifetime)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

LD-PA

CERDELGA CAP (Only available through Accredo 800-803-2523 or

Walgreens 888-347-3416)

VACCINES

Preventi

VACCERVARIX INJ

MEDICAL DEVICES AND SUPPLIES

Preventi

-CERVICAL CAP

MOUTH/THROAT/DENTAL AGENTSTier 1-cevimeline cap (EVOXAC equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGCHANTIX PAK (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGCHANTIX TAB (Limited to 180 days/plan year)

GASTROINTESTINAL AGENTS - MISC.

Tier 2

Specialty

-CHENODAL TAB

ANTIANXIETY AGENTSTier 1-chlordiazepoxide cap (LIBRIUM equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2-CHLORDIAZEPOXIDE/AMITRIPTYLINE TAB

ULCER DRUGSTier 1-chlordiazepoxide/clidinium cap (LIBRAX equiv)

MOUTH/THROAT/DENTAL AGENTSTier 1-chlorhexidine gluconate soln (PERIDEX equiv)

ANTIMALARIALSTier 1-chloroquine tab (ARALEN equiv)

DIURETICSTier 1-CHLOROTHIAZIDE TAB

DIURETICSTier 1-chlorothiazide tab (DIURIL equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-chlorpromazine tab (THORAZINE equiv)

DIURETICSValue-chlorthalidone tab

MUSCULOSKELETAL THERAPY AGENTSTier 1QLchlorzoxazone tab (QL= 4 tabs/day)

MUSCULOSKELETAL THERAPY AGENTSTier 2QL-ST

chlorzoxazone tab (QL= 4 tabs/day; Step Therapy requires trial of 2:

baclofen, cyclobenzaprine, tizanidine, tizanidine, methocarbamol, or

orphenadrine ER)

MUSCULOSKELETAL THERAPY AGENTSTier 2QL-ST

chlorzoxazone tab 375mg (QL= 4 tabs/day; Step Therapy requires trial of 2:

baclofen, cyclobenzaprine, tizanidine, tizanidine, methocarbamol, or

orphenadrine ER)

MUSCULOSKELETAL THERAPY AGENTSTier 1-chlorzoxazone tab 500mg

ANTIHYPERLIPIDEMICSTier 1-cholestyramine lite powder (QUESTRAN LITE equiv)

ANTIHYPERLIPIDEMICSTier 1-cholestyramine lite powder pack (QUESTRAN LITE equiv)

ANTIHYPERLIPIDEMICSTier 1-cholestyramine powder (QUESTRAN equiv)

ANTIHYPERLIPIDEMICSTier 1-cholestyramine powder pack (QUESTRAN equiv)

DERMATOLOGICALSTier 2-cicatrace kit (REXASIL equiv)

DERMATOLOGICALSTier 1-ciclopirox cream (LOPROX CREAM equiv)

DERMATOLOGICALSTier 1-ciclopirox gel (LOPROX GEL equiv)

DERMATOLOGICALSTier 1-ciclopirox nail soln (PENLAC SOLN equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 12 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

DERMATOLOGICALSTier 1-ciclopirox shampoo (LOPROX SHAMPOO equiv)

DERMATOLOGICALSTier 1-ciclopirox topical susp (LOPROX SUSP equiv)

HEMATOLOGICAL AGENTS - MISC.Tier 1-cilostazol tab (PLETAL equiv)

ANTIVIRALSTier 2-CIMDUO TAB

ULCER DRUGSTier 1-cimetidine soln (CIMETIDINE equiv)

ULCER DRUGSTier 1-cimetidine tab (TAGAMET equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLcinacalcet tab 30mg (SENSIPAR equiv) (QL= 2 tabs/day)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLcinacalcet tab 60mg (SENSIPAR equiv) (QL= 2 tabs/day)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLcinacalcet tab 90mg (SENSIPAR equiv) (QL= 4 tabs/day)

OTIC AGENTSTier 1-ciporofloxacin/dexamethasone otic susp (CIPRODEX equiv)

FLUOROQUINOLONESTier 1-CIPRO SUSP

OPHTHALMIC AGENTSTier 1-ciprofloxacin ophth soln (CILOXAN equiv)

OTIC AGENTSTier 2-CIPROFLOXACIN OTIC SOLN

FLUOROQUINOLONESTier 1-ciprofloxacin susp (CIPRO equiv)

FLUOROQUINOLONESTier 1-ciprofloxacin tab 250mg, 500mg, 750mg (CIPRO equiv)

ANTIDEPRESSANTSTier 1-citalopram soln (CELEXA equiv)

ANTIDEPRESSANTSValue-citalopram tab (CELEXA equiv)

MACROLIDESTier 2-CLARITHROMYC SUSP

MACROLIDESTier 1-clarithromycin ER tab (BIAXIN XL equiv)

MACROLIDESTier 1-clarithromycin tab (BIAXIN equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-clindamycin cap (CLEOCIN equiv)

DERMATOLOGICALSTier 2QL-ST

clindamycin foam (EVOCLIN equiv) (QL= 300g/30 days; Step Therapy

requires clindamycin gel/solution/lotion/swab OR erythromycin gel/soln)

DERMATOLOGICALSTier 1-clindamycin gel (CLEOCIN GEL equiv)

DERMATOLOGICALSTier 1-clindamycin lotion (CLEOCIN- T equiv)

DERMATOLOGICALSTier 1-clindamycin pad (CLEOCIN-T equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-clindamycin soln (CLEOCIN equiv)

DERMATOLOGICALSTier 1-clindamycin topical soln (CLEOCIN-T equiv)

VAGINAL PRODUCTSTier 1QLclindamycin vaginal cream (CLEOCIN equiv) (QL= 1 tube/fill)

DERMATOLOGICALSTier 2QL-ST

clindamycin/tretinoin gel (ZIANA equiv) (QL= 360g/30 days; Step Therapy

requires trial of 1: adapalene or tretinoin, AND trial of 1: clindamycin or

erythromycin)

ANTICONVULSANTSTier 1QLclobazam susp (ONFI equiv) (QL= 480ml/30 days)

ANTICONVULSANTSTier 1-clobazam tab (ONFI equiv)

DERMATOLOGICALSTier 2-clobetasol E foam (OLUX E equiv)

DERMATOLOGICALSTier 1-clobetasol foam (OLUX equiv)

DERMATOLOGICALSTier 1-clobetasol lotion (CLOBEX equiv)

DERMATOLOGICALSTier 1-clobetasol propionate cream (TEMOVATE equiv)

DERMATOLOGICALSTier 1-clobetasol propionate emollient cream (TEMOVATE E equiv)

DERMATOLOGICALSTier 1-clobetasol propionate gel (TEMOVATE GEL equiv)

DERMATOLOGICALSTier 1-clobetasol propionate oint (TEMOVATE equiv)

DERMATOLOGICALSTier 1-clobetasol propionate soln (TEMOVATE equiv)

DERMATOLOGICALSTier 1-clobetasol shampoo (CLOBEX equiv)

DERMATOLOGICALSTier 1-clobetasol spray (CLOBEX equiv)

DERMATOLOGICALSTier 2QL-ST

clocortolone pivalate cream (CLOCORTOLONE equiv) (QL= 1 tube/30 days;

Step therapy requires trial of one preferred topical steroid)

ANTIDEPRESSANTSTier 1-clomipramine cap (ANAFRANIL equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 13 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTICONVULSANTSTier 1-clonazepam ODT (KLONOPIN equiv)

ANTICONVULSANTSTier 1-clonazepam tab (KLONOPIN equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLclonidine ER tab (KAPVAY equiv) (QL= 4 tabs/day)

ANTIHYPERTENSIVESTier 2-clonidine patch (CATAPRES-TTS equiv)

ANTIHYPERTENSIVESTier 1-clonidine tab (CATAPRES equiv)

HEMATOLOGICAL AGENTS - MISC.Tier 1QLclopidogrel tab 300mg (PLAVIX equiv) (QL= 4 tabs/30 days)

HEMATOLOGICAL AGENTS - MISC.Tier 1-clopidogrel tab 75mg (PLAVIX equiv)

ANTIANXIETY AGENTSTier 1-clorazepate tab (TRANXENE-T equiv)

DERMATOLOGICALSTier 1-clotrimazole cream (LOTRIMIN AF CREAM equiv)

MOUTH/THROAT/DENTAL AGENTSTier 1-clotrimazole troches (MYCELEX TROCHES equiv)

DERMATOLOGICALSTier 1-clotrimazole/betamethasone cream (LORTRISONE CREAM equiv)

DERMATOLOGICALSTier 1-CLOTRIMAZOLE/BETAMETHASONE LOTION

DERMATOLOGICALSTier 1-clotrimazole/betamethasone lotion (LOTRISONE LOTION equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLCLOZAPINE ODT (QL= 3 tabs/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLclozapine ODT 25mg, 100mg (CLOZAPINE, FAZACLO equiv) (QL= 3 tabs/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLclozapine tab (CLOZARIL equiv) (QL= 3 tabs/day)

ANALGESICS - OPIOIDTier 1QL

codeine sulfate tab (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2QL

CODEINE SULFATE TAB (QL= 18 tabs/fill for members age 20 or younger;

QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

COUGH/COLD/ALLERGYTier 2QLCODITUSSIN LIQUID DAC (QL= 1200ml/30 days)

GOUT AGENTSTier 2QLcolchicine cap (MITIGARE equiv) (QL= 4 caps/day)

GOUT AGENTSTier 1QLcolchicine tab (COLCRYS equiv) (QL= 4 tabs/day)

GOUT AGENTSTier 1-colchicine/probenecid tab (COL-BENEMID equiv)

COUGH/COLD/ALLERGYTier 1QLcold/allergy elx children (QL= 2400ml/30 days)

ANTIHYPERLIPIDEMICSTier 2ST

colesevelam pack (WELCHOL equiv) (Step Therapy requires trial of 2:

cholestyramine, colesevelam, or colestipol)

ANTIHYPERLIPIDEMICSTier 1-colesevelam tab (WELCHOL equiv)

ANTIHYPERLIPIDEMICSTier 1-colestipol granule (COLESTID equiv)

ANTIHYPERLIPIDEMICSTier 1-colestipol powder packet (COLESTID equiv)

ANTIHYPERLIPIDEMICSTier 1-colestipol tab (COLESTID equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLCOMBIVENT RESPIMAT INHALER (QL= 2 inhalers/30days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PACOMETRIQ KIT (Only available through Optum 877-445-6874)

VACCINES

Preventi

VACCOMIRNATY INJ

VACCINES

Preventi

VACCOMIRNATY INJ 30MCG/0.3ML

ANTIVIRALSTier 2QLCOMPLERA TAB (QL= 1 tab/day)

MULTIVITAMINSTier 2-CONCEPT DHA CAP

DIAGNOSTIC PRODUCTSTier 1QLCONTOUR BLOOD GLUCOSE TEST STRIP (QL= 300 strips/30 days)

DIAGNOSTIC PRODUCTSTier 1OTC-QLCONTOUR TEST STRIP (QL= 300 test strips/30 days)

VAGINAL PRODUCTS

Preventi

OTCCONTRACEPTIVE FILM

VAGINAL PRODUCTS

Preventi

OTCCONTRACEPTIVE FOAM

VAGINAL PRODUCTS

Preventi

OTCCONTRACEPTIVE GEL

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 14 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

VAGINAL PRODUCTS

Preventi

OTCCONTRACEPTIVE SUPP

CORTICOSTEROIDSTier 2-CORTISONE ACETATE TAB

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLCOSENTYX INJ (1-PACK) (QL= 1 inj/28 days)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLCOSENTYX INJ (2-PACK) (QL= 2 inj/56 days)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLCOSENTYX INJ 300MG/2ML (QL= 1 inj/28 days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LMSP-PA-QLCOTELLIC TAB (QL= 3 tabs/day)

DIAGNOSTIC PRODUCTS

Preventi

QLCOVID-19 TEST (QL= 2 tests/30 days)

VACCINES

Preventi

QLCOVID-19 VACCINE BIVALENT BOOSTER INJ (MODERNA) (QL=1 inj/fill)

VACCINES

Preventi

QLCOVID-19 VACCINE BIVALENT BOOSTER INJ (PFIZER) (QL= 1 inj/fill)

VACCINES

Preventi

QLCOVID-19 VACCINE BIVALENT BOOSTER INJ 5-11Y (PFIZER) (QL= 1 inj/fill)

VACCINES

Preventi

COVID-19 VACCINE BIVALENT BOOSTER INJ 6M-4Y (PFIZER) (QL= 1 inj/fill)

VACCINES

Preventi

COVID-19 VACCINE BIVALENT BOOSTER INJ 6M-5Y (MODERNA) (QL= 1

inj/fill)

VACCINES

Preventi

QLCOVID-19 VACCINE INJ (JANSSEN) (QL= 1 dose/45 days)

VACCINES

Preventi

QLCOVID-19 VACCINE INJ (NOVAVAX) (QL= 1 dose/17 days)

VACCINES

Preventi

VACCOVID-19 VACCINE INJ 5-11Y (PFIZER)

VACCINES

Preventi

VACCOVID-19 VACCINE INJ 6M-11Y (MODERNA)

VACCINES

Preventi

VACCOVID-19 VACCINE INJ 6M-4Y (PFIZER)

DIGESTIVE AIDSTier 2-CREON CAP

ANTIVIRALSTier 2-CRIXIVAN CAP

GASTROINTESTINAL AGENTS - MISC.Tier 1-cromolyn conc (GASTROCROM equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-cromolyn neb soln (INTAL equiv)

OPHTHALMIC AGENTSTier 1-cromolyn ophth soln (CROLOM equiv)

OPHTHALMIC AGENTSTier 1-CROMOLYN SODIUM OPHTH SOLN

CONTRACEPTIVES

Preventi

-cryselle tab

DIAGNOSTIC PRODUCTS

Preventi

QLCUE HEALTH MIS MONITOR (QL= 1 kit/year)

HEMATOPOIETIC AGENTSTier 1-cyanocobalamin inj

HEMATOPOIETIC AGENTSTier 2ST

cyanocobalamin nasal spray 500mcg/0.1ml (NASCOBAL equiv) (ST req trial

of cyanocobalamin injection)

MUSCULOSKELETAL THERAPY AGENTSTier 2QL-ST

cyclobenzaprine ER cap (AMRIX equiv) (QL= 4 tabs/day; Step Therapy

requires trial of 2: baclofen, cyclobenzaprine, tizanidine, methocarbamol, or

orphenadrine ER)

MUSCULOSKELETAL THERAPY AGENTSTier 1-cyclobenzaprine tab (FLEXERIL equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 15 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

MUSCULOSKELETAL THERAPY AGENTSTier 2ST

cyclobenzaprine tab 7.5mg (Trial of 2: cyclobenzaprine 5mg,

cyclobenzaprine 10mg, tizanidine, methocarbamol, baclofen, chlorzoxazone,

orphenadrine)

OPHTHALMIC AGENTSTier 1-cyclopentolate ophth soln (CYCLOGYL equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

-cyclophosphamide cap

ANTIMYCOBACTERIAL AGENTSTier 1-cycloserine cap (CYCLOSERINE equiv)

ASSORTED CLASSESTier 2-cyclosporine cap (SANDIMMUNE equiv)

ASSORTED CLASSESTier 1-cyclosporine modified cap (NEORAL equiv)

ASSORTED CLASSESTier 1-cyclosporine modified soln (NEORAL equiv)

OPHTHALMIC AGENTSTier 1QLcyclosporine ophth emulsion (RESTASIS equiv) (QL= 60 vials/30 days)

ANTIHISTAMINESTier 1-cyproheptadine syrup

ANTIHISTAMINESTier 1-cyproheptadine tab

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-QL

CYSTADANE POWDER (QL= 540 grams/30 days; Only available through

AnovoRx 844-288-5007)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2

Specialty

LD-RDX

CYSTAGON CAP 150MG (Only available through CVS Specialty

800-237-2767; Diagnosis Restricted – Nephrophatic cystinosis (E72.04))

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2

Specialty

LD-QL-RDX

CYSTAGON CAP 50MG (QL= 2 caps/day; Only available through CVS

Specialty 800-237-2767; Diagnosis Restricted – Nephrophatic cystinosis

(E72.04))

OPHTHALMIC AGENTS

Tier 2

Specialty

LD-QL-RDX

CYSTARAN OPHTH SOLN (QL= 4 bottles/28 days; Diagnosis Restricted –

Cystinosis (E72.04); Only available through Walgreens 888-347-3416)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-CYTRA K CRYSTALS

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-CYTRA-3 SYRUP

ANTICOAGULANTSTier 1QLdabigatran etexilate mesylate cap (PRADAXA equiv) (QL= 2 caps/day)

ANTIVIRALS

Tier 2

Specialty

LMSP-PADAKLINZA TAB (Only available through Lumicera 855-847-3553)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-PAdalfampridine ER tab (AMPYRA equiv)

ANDROGENS-ANABOLICTier 1QLdanazol cap (DANOCRINE equiv) (QL= 4 caps/day)

MUSCULOSKELETAL THERAPY AGENTSTier 2QL-ST

dantrolene cap (DANTRIUM equiv) (QL= 4 tabs/day; Step Therapy requires

trial of 2: baclofen, cyclobenzaprine, tizanidine, tizanidine, methocarbamol, or

orphenadrine ER)

DERMATOLOGICALSTier 2QL-ST

dapsone gel (ACZONE equiv) (QL= 360g/30 days; Step Therapy requires

clindamycin gel/solution/lotion/swab OR erythromycin gel/soln)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-dapsone tab

URINARY ANTISPASMODICSTier 2ST

darifenacin SR tab (ENABLEX equiv) (Step Therapy requires trial of 2:

oxybutynin, oxybutynin ER, tolterodine, tolterodine ER, trospium, or trospium

ER)

ANTIVIRALSTier 1QLdarunavir tab 600mg (PREZISTA equiv) (QL= 2 tabs/day)

ANTIVIRALSTier 1QLdarunavir tab 800mg (PREZISTA equiv) (QL= 1 tab/day)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1

Specialty

AMSP-PAdeferasirox granules packet (JADENU equiv)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1

Specialty

AMSP-PAdeferasirox tab (EXJADE equiv)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1

Specialty

AMSP-PAdeferasirox tab 90mg, 360mg (JADENU equiv)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1

Specialty

LD-PA

deferiprone tab (FERRIPROX equiv) (Only available through Lumicera

855-847-3553)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 16 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1

Specialty

LD-PA

deferiprone tab 1000mg (FERRIPROX equiv) (Only available through Lumicera

855-847-3553)

CORTICOSTEROIDS

Tier 2

Specialty

LD-PA

deflazacort susp (EMFLAZA equiv) (Only available through Accredo

888-773-7376)

CORTICOSTEROIDS

Tier 2

Specialty

AMSP-PAdeflazacort tab (EMFLAZA equiv)

ANTIVIRALSTier 2-DELSTRIGO TAB

TETRACYCLINESTier 1-demeclocycline tab (DECLOMYCIN equiv)

CONTRACEPTIVES

Preventi

QLDEPO-PROVERA INJ (QL= 1 inj/84 days)

CONTRACEPTIVES

Preventi

QLDEPO-PROVERA SC INJ 104MG (QL= 1 inj/84 days)

DERMATOLOGICALSTier 1QLdermawerx pak (DERMACINRX KIT equiv) (QL= 1 kit/30 days)

ANTIVIRALSTier 2PA-QLDESCOVY TAB (QL= 1 tab/day)

ANTIDEPRESSANTSTier 1-desipramine tab (NORPRAMIN equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-desmopressin acetate nasal spray (DDAVP equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-desmopressin acetate tab (DDAVP equiv)

DERMATOLOGICALSTier 2-desonate gel

DERMATOLOGICALSTier 1-desonide cream

DERMATOLOGICALSTier 2-DESONIDE GEL

DERMATOLOGICALSTier 1-desonide lotion

DERMATOLOGICALSTier 1-desonide oint

DERMATOLOGICALSTier 1-desoximetasone cream (TOPICORT CREAM equiv)

DERMATOLOGICALSTier 1-desoximetasone gel (TOPICORT equiv)

DERMATOLOGICALSTier 1-desoximetasone oint (TOPICORT equiv)

DERMATOLOGICALSTier 2-desoximetasone spray 0.25% (TOPICORT equiv)

ANTIDEPRESSANTSTier 1QLdesvenlafaxine ER tab (PRISTIQ equiv) (QL= 1 tab/day)

CORTICOSTEROIDSTier 2-DEXAMETHASONE CONC

CORTICOSTEROIDSTier 1-dexamethasone elixir

CORTICOSTEROIDSTier 1-dexamethasone pak (DEXPAK equiv)

CORTICOSTEROIDSTier 2-DEXAMETHASONE SOLN

CORTICOSTEROIDSTier 1-dexamethasone tab (DEXAMETHASONE equiv)

CORTICOSTEROIDSTier 2QLDEXAMETHASONE TAB 20MG (QL= 8 tabs/30 days)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLDEXCOM G6 RECEIVER (QL= 1 receiver/year)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLDEXCOM G6 SENSOR (QL= 3 sensors/30 days)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLDEXCOM G6 TRANSMITTER (QL= 1 transmitter/90 days)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLDEXCOM G7 RECEIVER (QL= 1 receiver/year)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLDEXCOM G7 SENSOR (QL= 3 sensors/30 days)

ULCER

DRUGS/ANTISPASMODICS/ANTICHOLINERGI

Tier 2QL-ST

dexlansoprazole DR cap (DEXILANT equiv) (Covered for members age 17 or

younger; QL=1 cap/day; Step therapy requires trial of all: omeprazole,

esomeprazole, lansoprazole cap, rabeprazole, and pantoprazole tab)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdexmethylphenidate ER cap (FOCALIN XR equiv) (QL= 1 cap/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdexmethylphenidate tab 10mg (FOCALIN equiv) (QL= 60 tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdexmethylphenidate tab 2.5mg (FOCALIN equiv) (QL= 240 tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdexmethylphenidate tab 5mg (FOCALIN equiv) (QL= 120 tabs/30 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 17 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CORTICOSTEROIDSTier 2STDEXPAK TAB (Step Therapy requires trial of dexamethasone)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdextroamphetamine 5mg tab (QL= 180 tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLdextroamphetamine ER cap 10mg (DEXEDRINE equiv) (QL= 2 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLdextroamphetamine ER cap 15mg (QL= 4 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLdextroamphetamine ER cap 5mg (DEXEDRINE equiv) (QL= 2 caps/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdextroamphetamine soln (PROCENTRA equiv) (QL= 1800ml/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

dextroamphetamine sulfate tab 15mg (ZENZEDI equiv) (QL= 3 tabs/day; Step

Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

dextroamphetamine sulfate tab 2.5mg (ZENZEDI equiv) (QL= 3 tabs/day; Step

Therapy requires trial of dexmethylphenidate, dextroamphetamine,

amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

dextroamphetamine sulfate tab 20mg (ZENZEDI equiv) (QL= 3 tabs/day; Step

Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

dextroamphetamine sulfate tab 30mg (ZENZEDI equiv) (QL= 3 tabs/day; Step

Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

dextroamphetamine sulfate tab 7.5mg (ZENZEDI equiv) (QL= 3 tabs/day; Step

Therapy requires trial of dexmethylphenidate, dextroamphetamine,

amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLdextroamphetamine tab 10mg (QL= 6 tabs/day)

MULTIVITAMINSTier 1-DIALYVITE TAB

MULTIVITAMINSTier 1-DIALYVITE/ZINC TAB

MEDICAL DEVICES AND SUPPLIES

Preventi

-DIAPHRAGM

ANTIANXIETY AGENTSTier 1-diazepam conc (VALIUM equiv)

ANTICONVULSANTSTier 2QLDIAZEPAM GEL (QL= 1 kit/30 days)

ANTIANXIETY AGENTSTier 1QLdiazepam oral soln (QL= 360ml/30 days)

ANTICONVULSANTSTier 1QLdiazepam rectal gel (QL= 1 pack/30 days)

ANTIANXIETY AGENTSTier 1-diazepam tab (VALIUM equiv)

ANTIDIABETICSTier 1-diazoxide susp (PROGLYCEM equiv)

DIURETICS

Tier 1

Specialty

AMSP-PA-QLdichlorphenamide tab (KEVEYIS equiv) (QL= 4 tabs/day)

DERMATOLOGICALSTier 1QLdiclofenac gel (SOLARAZE equiv) (QL= 100gm/fill, 2 fills/month)

MIGRAINE PRODUCTSTier 2QL-ST

diclofenac potassium (migraine) packet (CAMBIA equiv) (QL= 9 packets/30

days; ST req trial of 2 preferred oral NSAIDs (eg. diclofenac) or triptans (eg.

sumatriptan))

ANALGESICS - ANTI-INFLAMMATORYTier 2QL-ST

diclofenac potassium cap (ZIPSOR equiv) (QL= 4 caps/day; Step therapy

requires trial of diclofenac sodium EC or diclofenac sodium ER tablets)

ANALGESICS - ANTI-INFLAMMATORYTier 1-diclofenac potassium tab (CATAFLAM equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 2QL-ST

diclofenac potassium tab 25mg (QL= 4 tabs/day; Step therapy requires trial

of diclofenac sodium EC or diclofenac sodium ER tablets)

ANALGESICS - ANTI-INFLAMMATORYTier 1-diclofenac sodium EC tab (VOLTAREN equiv)

OPHTHALMIC AGENTSTier 1-diclofenac sodium ophth soln (VOLTAREN equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 18 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

DERMATOLOGICALSTier 2ST

diclofenac sodium soln 2% (Step therapy requires trial of of diclofenac 1.5%

soln)

ANALGESICS - ANTI-INFLAMMATORYTier 1-diclofenac sodium XR tab (VOLTAREN XR equiv)

DERMATOLOGICALSTier 2-diclofenac soln 1.5% (PENNSAID equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-diclofenac/misoprostol DR tab (ARTHROTEC equiv)

PENICILLINSTier 1-dicloxacillin cap (DYNAPEN equiv)

ULCER DRUGSTier 1-dicyclomine cap (BENTYL equiv)

ULCER DRUGSTier 1-dicyclomine soln (BENTYL equiv)

ULCER DRUGSTier 1-dicyclomine tab (BENTYL equiv)

ANTIVIRALSTier 1QLdidanosine DR cap (VIDEX EC equiv) (QL= 1 cap/day)

ANTIVIRALSTier 2QLDIDANOSINE DR CAP (QL= 2 caps/day)

MACROLIDESTier 2QLDIFICID SUSP (QL= 126 mL/10 days)

MACROLIDESTier 2QLDIFICID TAB (QL= 20 tabs/10 days)

DERMATOLOGICALSTier 2-diflorasone oint

ANALGESICS - NONNARCOTICTier 1-diflunisal tab (DOLOBID equiv)

OPHTHALMIC AGENTSTier 2QL-ST

difluprednate ophth emulsion (DUREZOL equiv) (QL= 10ml/28 days; Step

Therapy requires trial of prednisolone acetate 1% ophth susp)

CARDIOTONICSTier 2-digoxin soln (LANOXIN equiv)

CARDIOTONICSTier 1-digoxin tab (LANOXIN equiv)

CARDIOTONICSTier 1QLdigoxin tab 62.5mcg (LANOXIN equiv) (QL= 1 tab/day)

MIGRAINE PRODUCTSTier 2QLdihydroergotamine mesylate inj (D.H.E. equiv) (QL= 24ml/28 days)

MIGRAINE PRODUCTSTier 2QL-ST

dihydroergotamine mesylate nasal spray (MIGRANAL equiv) (QL= 8ml/28

days; Step Therapy requires trial of 2: naratriptan, rizatriptan, rizatriptan ODT,

or sumatriptan)

ANTICONVULSANTSTier 2-DILANTIN CAP 30MG

CALCIUM CHANNEL BLOCKERSTier 1-diltiazem ER cap (CARDIZEM CD equiv)

CALCIUM CHANNEL BLOCKERSTier 1-diltiazem ER cap (CARDIZEM SR equiv)

CALCIUM CHANNEL BLOCKERSTier 1-diltiazem ER cap (DILACOR XR equiv)

CALCIUM CHANNEL BLOCKERSTier 1-diltiazem ER cap (TIAZAC equiv)

CALCIUM CHANNEL BLOCKERSTier 1-diltiazem ER tab (CARDIZEM LA equiv)

CALCIUM CHANNEL BLOCKERSTier 1-diltiazem tab (CARDIZEM equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-QLdimethyl fumarate DR cap (TECFIDERA equiv) (QL= 60 caps/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-QL

dimethyl fumarate DR starter pack (TECFIDERA STARTER PACK equiv) (QL=

60 caps/30 days)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-diphenhydramine cap 50mg (BENADRYL equiv) (Only 50mg covered)

ANTIHISTAMINESTier 1-diphenhydramine inj

ANTIDIARRHEAL/PROBIOTIC AGENTSTier 2-DIPHENOXYLATE/ATROPINE LIQUID

ANTIDIARRHEALSTier 1-diphenoxylate/atropine tab (LOMOTIL equiv)

HEMATOLOGICAL AGENTS - MISC.Tier 1-dipyridamole tab (PERSANTINE equiv)

ANTIARRHYTHMICSTier 1-disopyramide cap (NORPACE equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-disulfiram tab (ANTABUSE equiv)

DIURETICSTier 2-DIURIL SUSP

ANTICONVULSANTSTier 1-divalproex ER tab (DEPAKOTE ER equiv)

ANTICONVULSANTSTier 1-divalproex sodium DR tab (DEPAKOTE equiv)

ANTICONVULSANTSTier 1-divalproex sprinkle cap (DEPAKOTE equiv)

ANTIARRHYTHMICSTier 2-dofetilide cap (TIKOSYN equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 19 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-donepezil ODT (ARICEPT equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QLdonepezil tab 10mg (ARICEPT equiv) (QL= 1 tab/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QLdonepezil tab 23mg (ARICEPT equiv) (QL= 1 tab/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QLdonepezil tab 5mg (ARICEPT equiv) (QL= 1 tab/day)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

LD-PA-QL

DOPTELET TAB (QL= 2 tabs/day; Only available through Accredo

800-803-2523)

OPHTHALMIC AGENTSTier 1-dorzolamide ophth soln (TRUSOPT equiv)

OPHTHALMIC AGENTSTier 1ST

dorzolamide/timolol (pf) ophth soln (Step Therapy requires trial of

dorzolamide/timolol ophth soln)

OPHTHALMIC AGENTSTier 1-dorzolamide/timolol ophth soln (COSOPT equiv)

OPHTHALMIC AGENTSTier 2-DORZOLAMIDE/TIMOLOL OPHTH SOLN

ANTIHYPERTENSIVESTier 1-doxazosin tab (CARDURA equiv)

ANTIDEPRESSANTSTier 1QLdoxepin cap (SINEQUAN equiv) (QL= 2 tabs/day)

ANTIDEPRESSANTSTier 1-doxepin conc (SINEQUAN equiv)

DERMATOLOGICALSTier 2ST

doxepin hcl cream (ST req trial of a topical corticosteroid AND topical

tacrolimus)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 2QL-ST

doxepin tab (SILENOR equiv) (QL= 30 tabs/30 days; Step Therapy requires

trial of 2: eszopiclone, zaleplon, zolpidem, zolpidem ER tab, or zolpidem SL)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2-doxercalciferol cap (HECTOROL equiv)

DERMATOLOGICALSTier 2QL-ST

doxycycline (rosacea) cap delayed release (ORACEA equiv) (QL= 1 cap/day;

Step Therapy requires trial of doxycycline monohydrate)

TETRACYCLINESTier 1QLdoxycycline hyclate cap (QL= 2 caps/day)

TETRACYCLINESTier 1QLdoxycycline hyclate cap 50mg (VIBRAMYCIN equiv) (QL= 2 caps/day)

TETRACYCLINESTier 2QL-ST

doxycycline hyclate DR tab (DORYX equiv) (QL= 2 tabs/day; Step Therapy

requires trial of doxycycline monohydrate)

TETRACYCLINESTier 1QL-ST

doxycycline hyclate DR tab 100mg (DORYX equiv) (QL= 2 tabs/day; Step

Therapy requires trial of doxycycline monohydrate)

TETRACYCLINESTier 2QL-ST

doxycycline hyclate DR tab 200mg (DORYX equiv) (QL= 1 tab/day; Step

Therapy requires trial of doxycycline monohydrate)

TETRACYCLINESTier 2QL-ST

doxycycline hyclate DR tab 50mg (DORYX equiv) (QL= 2 tabs/day; Step

Therapy requires trial of doxycycline monohydrate)

TETRACYCLINESTier 2QL-ST

doxycycline hyclate DR tab 75mg (QL= 2 tabs/day; Step Therapy requires

trial of doxycycline monohydrate)

TETRACYCLINESTier 1QLdoxycycline hyclate tab (VIBRATAB equiv) (QL= 2 tabs/day)

TETRACYCLINESTier 2QL-ST

doxycycline hyclate tab 150mg (TARGADOX equiv) (QL= 2 tabs/day; Step

therapy requires trial of doxycycline monohydrate tablets)

TETRACYCLINESTier 2ST

doxycycline hyclate tab 50mg (TARGADOX equiv) (Step Therapy requires trial

of doxycycline monohydrate)

TETRACYCLINESTier 2QL-ST

doxycycline hyclate tab 75mg (TARGADOX equiv) (QL= 2 tabs/day; Step

therapy requires trial of doxycycline monohydrate tablets)

TETRACYCLINESTier 2QLdoxycycline monohydrate cap (MONODOX equiv) (QL= 2 caps/day)

TETRACYCLINESTier 2QLdoxycycline monohydrate cap 100mg (MONODOX equiv) (QL= 2 caps/day)

TETRACYCLINESTier 1QLdoxycycline monohydrate cap 50mg (MONODOX equiv) (QL= 2 caps/day)

TETRACYCLINESTier 1QLdoxycycline monohydrate tab (ADOXA equiv) (QL= 2 tabs/day)

TETRACYCLINESTier 2QL-ST

doxycycline monohydrate tab 150mg (ADOXA PAK equiv) (QL= 2 tabs/day;

Step therapy requires trial of doxycycline monohydrate 50mg or 100mg

tablets)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 20 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

TETRACYCLINESTier 1-doxycycline susp (VIBRAMYCIN equiv)

ANTIEMETICSTier 1QLdoxylamine/pyridoxine dr tab (DICLEGIS equiv) (QL= 120 tabs/30 days)

ASSORTED CLASSESTier 2-D-PENAMINE TAB

ANTIEMETICSTier 2QLdronabinol cap (MARINOL equiv) (QL= 2 caps/day)

CONTRACEPTIVES

Preventi

-drospirenone/ethinyl estradiol/levomefolate tab (BEYAZ equiv)

HEMATOPOIETIC AGENTSTier 2-DROXIA CAP

VASOPRESSORS

Tier 1

Specialty

AMSPdroxidopa cap (NORTHERA equiv)

DERMATOLOGICALSTier 2-DRYSOL SOLN

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLDULERA INHALER (QL= 1 inhaler/30 days)

ANTIDEPRESSANTSTier 2QLduloxetine cap 40mg (IRENKA equiv) (QL= 2 caps/day)

ANTIDEPRESSANTSTier 1QLduloxetine EC cap 20mg (QL= 6 caps/day)

ANTIDEPRESSANTSTier 1QLduloxetine EC cap 30mg (QL= 4 caps/day)

ANTIDEPRESSANTSTier 1QLduloxetine EC cap 60mg (CYMBALTA equiv) (QL= 2 caps/day)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLDUPIXENT INJ (QL= 2 inj/28 days)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLDUPIXENT PEN INJ (QL= 2 inj/28 days)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLDUPIXENT PEN INJ (QL= 2 syringes/28 days)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-dutasteride cap (AVODART equiv)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2ST

dutasteride/tamsulosin cap (JALYN equiv) (Step Therapy requires trial of

finasteride tab or dutasteride AND tamsulosin cap)

DERMATOLOGICALSTier 1-econazole cream (SPECTAZOLE equiv)

ANTIVIRALSTier 2QLEDURANT TAB (QL= 1 tab/day)

ANTIVIRALSTier 1-EFAVIRENZ CAP

ANTIVIRALSTier 1-efavirenz tab (SUSTIVA equiv)

ANTIVIRALSTier 1QLefavirenz/emtricitabine/tenofovir df tab (ATRIPLA equiv) (QL= 1 tab/day)

ANTIVIRALSTier 1-efavirenz/lamivudine/tenofovir df (lo) tab (SYMFI (LO) equiv)

MIGRAINE PRODUCTSTier 2QL-ST

eletriptan tab (RELPAX equiv) (QL= 9 tabs/30 days; Step Therapy requires

trial of 2: naratriptan, rizatriptan, rizatriptan ODT, or sumatriptan)

ANTICOAGULANTSTier 2QLELIQUIS STARTER PACK 5MG (QL= 1 pack/30 days)

ANTICOAGULANTSTier 2QLELIQUIS TAB 2.5MG (QL= 60 tabs/30 days)

ANTICOAGULANTSTier 2QLELIQUIS TAB 5MG (QL= 74 tabs/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2-ELIXOPHYLLIN ELIXIR

CONTRACEPTIVES

Preventi

-ELLA TAB

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2-ELMIRON CAP

CONTRACEPTIVES

Preventi

-eluryng vaginal ring (NUVARING equiv)

MIGRAINE PRODUCTSTier 2PA-QLEMGALITY INJ (QL= 1 inj/28 days)

ANTIVIRALSTier 1QLemtricitabine cap (EMTRIVA equiv) (QL= 1 cap/day)

ANTIVIRALSTier 1QL

emtricitabine/tenofovir disoproxil fumarate tab (TRUVADA equiv) (QL= 30

tabs/30 days)

ANTIVIRALS

Preventi

emtricitabine/tenofovir disoproxil fumarate tab 200-300mg (TRUVADA equiv)

(QL= 30 tabs/30 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 21 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIVIRALSTier 2QLEMTRIVA SOLN (QL= 850ml/30 days)

ANTIHYPERTENSIVESTier 2QL-ST

enalapril maleate oral soln (EPANED equiv) (QL= 40ml/day; Step therapy

requires trial of two: enalapril tab, lisinopril tab, ramipril tab, benazepril tab)

ANTIHYPERTENSIVESValue-enalapril tab (VASOTEC equiv)

ANTIHYPERTENSIVESValue-enalapril/hydrochlorothiazide tab (VASERETIC equiv)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLENBREL INJ (QL= 8 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLENBREL INJ 25MG (QL= 8 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLENBREL INJ 50MG (QL= 4 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLENBREL MINI INJ (QL= 4 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLENBREL SURECLICK INJ 50MG (QL= 4 inj/28 days)

VAGINAL PRODUCTSTier 2PAENDOMETRIN INSERT

VACCINES

Preventi

VACENGERIX-B INJ, RECOMBIVAX-HB INJ

ANTICOAGULANTSTier 1-enoxaparin inj (LOVENOX equiv)

ANTICOAGULANTSTier 1-enoxaparin inj 300mg (LOVENOX equiv)

CONTRACEPTIVES

Preventi

-enpresse tab (TRI-LEVELEN equiv)

ANTIPARKINSON AGENTSTier 1-entacapone tab (COMTAN equiv)

ANTIVIRALS

Tier 1

Specialty

QLentecavir tab (BARACLUDE equiv) (QL= 1 tab/day)

CARDIOVASCULAR AGENTS - MISC.Tier 2QLENTRESTO CAP (QL= 8 caps/day)

CARDIOVASCULAR AGENTS - MISC.Tier 2QLENTRESTO TAB (QL= 2 tabs/day)

CORTICOSTEROIDSTier 2RDX-ST

EOHILIA SUS 2MG/10ML (Step therapy requires trial of fluticasone MDI AND

budesonide vials; Diagnosis Restricted – Eosinophilic esophagitis (K20.0))

ANTICONVULSANTS

Tier 2

Specialty

LD-PAEPIDIOLEX SOLN (Only available through Lumicera 855-847-3553)

OPHTHALMIC AGENTSTier 2QL-ST

epinastine ophth soln (ELESTAT equiv) (QL= 5mL/25 days; Step Therapy

requires trial of azelastine 0.05% ophth soln)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 2-epinephrine hcl nasal soln (ADRENALIN equiv)

VASOPRESSORSTier 1-epinephrine inj (ADRENALIN equiv)

VASOPRESSORSTier 2-EPINEPHRINE INJ

VASOPRESSORSValueQLEPINEPHRINE INJ 0.15MG (QL= 2 inj/fill)

VASOPRESSORSValueQLEPINEPHRINE INJ 0.3MG (QL= 2 inj/fill)

VASOPRESSORSValueQLepinephrine pen inj 0.15mg, 0.3mg (EPIPEN (JR) equiv) (QL= 2 inj/fill)

ANTIVIRALS

Tier 2

Specialty

AMSP-QLEPIVIR HBV SOLN (QL= 720ml/30 days)

ANTIHYPERTENSIVESTier 1-eplerenone tab (INSPRA equiv)

MIGRAINE PRODUCTSTier 2QLERGOTAMINE/CAFFEINE TAB (QL= 40 tabs/28 days)

MIGRAINE PRODUCTSTier 2QLergotamine/caffeine tab (CAFERGOT equiv) (QL= 40 tabs/28 days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFERIVEDGE CAP (QL= 1 cap/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLERLEADA TAB (QL= 4 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLERLEADA TAB 240MG (QL= 1 tab/day)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 22 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFerlotinib tab 100mg (TARCEVA equiv) (QL= 3 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFerlotinib tab 150mg (TARCEVA equiv) (QL= 3 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFerlotinib tab 25mg (TARCEVA equiv) (QL= 3 tabs/day)

DERMATOLOGICALSTier 1-ERY PAD

MACROLIDESTier 1-erythromycin DR cap (ERYC equiv)

MACROLIDESTier 2-ERYTHROMYCIN EC CAP

MACROLIDESTier 1-erythromycin ethylsuccinate susp (ERYPED equiv)

DERMATOLOGICALSTier 1-erythromycin gel

OPHTHALMIC AGENTSTier 1-erythromycin ophth oint

DERMATOLOGICALSTier 1-erythromycin pad

DERMATOLOGICALSTier 1-erythromycin soln

MACROLIDESTier 1-erythromycin tab (ERY-TAB equiv)

MACROLIDESTier 1-erythromycin tab (ERYTHROMYCIN equiv) (all forms except PCE)

ANTIDEPRESSANTSTier 1-escitalopram soln (LEXAPRO equiv)

ANTIDEPRESSANTSValue-escitalopram tab (LEXAPRO equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-estazolam tab (PROSOM equiv)

ESTROGENSTier 1-esterified estrogens/methyltestosterone tab (ESTRATEST equiv)

VAGINAL PRODUCTSTier 2-estradiol cream (ESTRACE equiv)

ESTROGENSTier 2QL-ST

estradiol gel 0.06% (ESTRADIOL equiv) (QL= 50 gm/30 days; Step therapy

requires trial of 2: estradiol tab/patch/vaginal tab, Jinteli/Fyavolv,

Lopreeza/Mimvey/Amabelz)

ESTROGENSTier 2QLestradiol patch (CLIMARA equiv) (QL= 4 patches/28 days)

ESTROGENSTier 2QLestradiol patch (VIVELLE-DOT equiv) (QL= 8 patches/28 days)

ESTROGENSTier 1-estradiol tab (ESTRACE equiv)

ESTROGENSTier 2QL-ST

estradiol td gel (DIVIGEL equiv) (QL= 1 packet/day; Step therapy requires trial

of 2: estradiol tab/patch/vaginal tab, Jinteli/Fyavolv,

Lopreeza/Mimvey/Amabelz)

ESTROGENSTier 2QL-ST

estradiol td gel 1.25mg/1.25gm (DIVIGEL equiv) (QL= 37.5gm/30 days; Step

therapy requires trial of 2: estradiol tab/patch/vaginal tab, Jinteli/Fyavolv,

Lopreeza/Mimvey/Amabelz)

VAGINAL PRODUCTSTier 1-estradiol vaginal tab, yuvafem vaginal tab (VAGIFEM equiv)

ESTROGENSTier 2ST

estradiol valerate inj (ST req trial of 2: estradiol tab, estradiol patch, estradiol

vaginal tab, Estring)

ESTROGENSTier 1-estradiol/norethindrone tab (ACTIVELLA equiv)

VAGINAL PRODUCTSTier 2QLESTRING (QL= 1 ring/90 days; 3 copays per Rx)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1QLeszopiclone tab (LUNESTA equiv) (QL= 1 tab/day)

DIURETICSTier 2-ethacrynic tab (EDECRIN equiv)

ANTIMYCOBACTERIAL AGENTSTier 1-ethambutol tab (MYAMBUTOL equiv)

ANTICONVULSANTSTier 1-ethosuximide cap (ZARONTIN equiv)

ANTICONVULSANTSTier 1-ethosuximide soln (ZARONTIN equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-etodolac cap (LODINE equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-etodolac ER tab (LODINE XL equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-etodolac tab

ANTINEOPLASTICSTier 1-etoposide cap (VEPESID equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

-ETOPOSIDE CAP

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 23 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIVIRALSTier 1QLetravirine tab 100mg (INTELENCE equiv) (QL= 4 tabs/day)

ANTIVIRALSTier 1QLetravirine tab 200mg (INTELENCE equiv) (QL= 2 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFeverolimus tab (AFINITOR equiv) (QL= 1 tab/day)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2AMSP-PA-QL-SFeverolimus tab (ZORTRESS equiv) (QL= 2 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFeverolimus tab for oral susp (AFINITOR equiv) (QL= 1 tab/day)

ANTIVIRALSTier 2QLEVOTAZ TAB (QL= 1 tab/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Preventi

-exemestane tab (AROMASIN equiv)

NEUROMUSCULAR AGENTS

Tier 2

Specialty

LD-PA-QL

EXSERVAN FILM (QL= 60 films/30 days; Only available through PantherRx

Pharmacy 855-726-8479)

ANTIHYPERLIPIDEMICSTier 1QLezetimibe tab (ZETIA equiv) (QL= 1 tab/day)

ANTIHYPERLIPIDEMICSTier 1QLezetimibe/simvastatin tab (VYTORIN equiv) (QL= 1 tab/day)

CONTRACEPTIVES

Preventi

-FALESSA KIT

ANTIVIRALSTier 1QLfamciclovir tab 125mg (FAMVIR equiv) (QL= 2 tabs/day)

ANTIVIRALSTier 1QLfamciclovir tab 250mg (FAMVIR equiv) (QL= 2 tabs/day)

ANTIVIRALSTier 1QLfamciclovir tab 500mg (FAMVIR equiv) (QL= 21 tabs/fill, 2 fills/month)

ANTIDIABETICSTier 2QLFARXIGA TAB (QL= 1 tab/day)

GOUT AGENTSTier 2QLfebuxostat tab (ULORIC equiv) (QL= 1 tab/day)

ANTICONVULSANTSTier 1QLfelbamate susp (FELBATOL equiv) (QL= 30ml/day)

ANTICONVULSANTSTier 1QLfelbamate tab 400mg (FELBATOL equiv) (QL= 9 tabs/day)

ANTICONVULSANTSTier 1QLfelbamate tab 600mg (FELBATOL equiv) (QL= 6 tabs/day)

CALCIUM CHANNEL BLOCKERSTier 1-felodipine ER tab (PLENDIL equiv)

MEDICAL DEVICES AND SUPPLIES

Preventi

OTCFEMALE CONDOMS

ANTIHYPERLIPIDEMICSTier 1-fenofibrate cap 43mg, 130mg (ANTARA equiv)

ANTIHYPERLIPIDEMICSTier 1-fenofibrate cap 67mg, 134mg, 200mg (LOFIBRA equiv)

ANTIHYPERLIPIDEMICSTier 2-FENOFIBRATE CAP, LIPOFEN CAP 50MG, 150MG

ANTIHYPERLIPIDEMICSTier 2-fenofibrate tab 40mg, 120mg (FENOGLIDE equiv)

ANTIHYPERLIPIDEMICSTier 1-fenofibrate tab 48mg, 54mg, 145mg, 160mg (TRICOR equiv)

ANTIHYPERLIPIDEMICSTier 1-fenofibric acid DR cap (TRILIPIX equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 2QL-ST

fenoprofen calcium cap (NALFON equiv) (QL= 8 tabs/day; Step therapy

requires trial of 2: diclofenac, diclofenac XR, etodolac, etodolac ER, or

ibuprofen)

ANALGESICS - ANTI-INFLAMMATORYTier 2ST

fenoprofen calcium tab (Step Therapy requires trial of 2: diclofenac,

diclofenac XR, etodolac, etodolac ER, or ibuprofen)

ANALGESICS - OPIOIDTier 2PA-QL

fentanyl citrate lollipop (ACTIQ equiv) (QL= 18 lozenges/fill for members age

20 or younger; QL= 42 lozenges/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2PA-QLfentanyl patch (DURAGESIC equiv) (QL=15 patches/30 days)

URINARY ANTISPASMODICSTier 2QL-ST

fesoterodine fumarate er tab (TOVIAZ equiv) (QL= 1 tab/day; Step therapy

requires trial of 2: oxybutynin tab/syrup/ER tab, tolterodine tab/SR cap,

trospium tab/SR cap)

ANTIDIABETICSValueQLFIASP FLEXTOUCH INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLFIASP INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLFIASP PENFILL INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLFIASP PUMP CARTRIDGE (QL= 60 units/30 days)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-finasteride tab (PROSCAR equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 24 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-QLfingolimod hcl cap (GILENYA equiv) (QL= 30 caps/30 days)

OPHTHALMIC AGENTSTier 2-FLAREX OPHTH SUSP

URINARY ANTISPASMODICSTier 2QL-ST

flavoxate tab (URISPAS equiv) (QL= 8 tabs/day; Step therapy requires trial of

oxybutynin chloride or solifenacin succinate)

ANTIARRHYTHMICSTier 1-flecainide tab (TAMBOCOR equiv)

MINERALS & ELECTROLYTESTier 2-FLORIVA DROPS

MULTIVITAMINS

Preventi

-FLORIVA PLUS DROPS

VACCINES

Preventi

VACFLUAD INJ

VACCINES

Preventi

VACFLUAD QUAD INJ

VACCINES

Preventi

VACFLUBLOK INJ

VACCINES

Preventi

VAC-QLFLUBLOK INJ (QL= 0.5ml/fill)

VACCINES

Preventi

VACFLUBLOK QUAD PF INJ

VACCINES

Preventi

QL-VACFLUCELVAX INJ (QL= 0.5ml/fill)

VACCINES

Preventi

VACFLUCELVAX QUAD INJ

ANTIFUNGALSTier 1-fluconazole susp (DIFLUCAN equiv)

ANTIFUNGALSTier 1-fluconazole tab (DIFLUCAN equiv)

ANTIFUNGALSTier 1-flucytosine cap (ANCOBON equiv)

CORTICOSTEROIDSTier 1-fludrocortisone tab (FLORINEF equiv)

VACCINES

Preventi

VACFLULAVAL QUAD INJ, FLUZONE QUAD INJ

VACCINES

Preventi

VACFLUMIST QUADRIVALENT NASAL SUSP

DERMATOLOGICALSTier 1-fluocinolone acetonide cream

DERMATOLOGICALSTier 1-fluocinolone acetonide oil

DERMATOLOGICALSTier 1-fluocinolone acetonide oint

DERMATOLOGICALSTier 1-fluocinolone acetonide soln

OTIC AGENTSTier 1-fluocinolone otic oil (DERMOTIC equiv)

DERMATOLOGICALSTier 1-fluocinonide cream 0.05% (LIDEX equiv)

DERMATOLOGICALSTier 2-fluocinonide cream 0.1%

DERMATOLOGICALSTier 1-fluocinonide emollient cream

DERMATOLOGICALSTier 1-FLUOCINONIDE GEL

DERMATOLOGICALSTier 1-fluocinonide oint

DERMATOLOGICALSTier 1-fluocinonide soln

MINERALS & ELECTROLYTES

Preventi

FLUORABON SOLN (Covered at $0 for members 5 years or younger; All

other members covered at preferred brand copay)

MOUTH/THROAT/DENTAL AGENTSTier 1-FLUORIDEX SENSITIVITY PASTE

OPHTHALMIC AGENTSTier 1-fluorometholone ophth soln (FML LIQUIFILM equiv)

DERMATOLOGICALSTier 1-fluorouracil cream (EFUDEX CREAM equiv)

DERMATOLOGICALSTier 1-fluorouracil soln (FLUOROURACIL equiv)

DERMATOLOGICALSTier 2-FLUOROURACIL SOLN

ANTIDEPRESSANTSValue-fluoxetine cap (PROZAC equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 25 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Value-FLUOXETINE CAP (PMDD)

ANTIDEPRESSANTSTier 1-fluoxetine cap 90mg (PROZAC equiv)

ANTIDEPRESSANTSValue-fluoxetine soln (PROZAC equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2-FLUOXETINE TAB

ANTIDEPRESSANTSValue-fluoxetine tab 10mg, 20mg (PROZAC equiv)

ANTIDEPRESSANTSTier 2-FLUOXETINE TAB 60MG

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-fluphenazine tab (PROLIXIN equiv)

DERMATOLOGICALSTier 2-flurandrenolide cream (CORDRAN equiv)

DERMATOLOGICALSTier 2-flurandrenolide lotion (CORDRAN equiv)

DERMATOLOGICALSTier 2-flurandrenolide oint (CORDRAN equiv)

OPHTHALMIC AGENTSTier 2ST

FLURBIPROFEN OPHTH SOLN (Step Therapy requires trial of diclofenac

sodium ophth soln or ketorolac ophth soln)

ANALGESICS - ANTI-INFLAMMATORYTier 1-FLURBIPROFEN TAB

ANALGESICS - ANTI-INFLAMMATORYTier 1-flurbiprofen tab (ANSAID equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1-flutamide cap (EULEXIN equiv)

DERMATOLOGICALSTier 2ST

FLUTICASONE LOTION (ST req tri of 2 lower-mid potency topical

corticosteroid (eg. Betamet lot 0.05%, Fluocin crm 0.025%))

DERMATOLOGICALSTier 1-fluticasone propionate cream (CUTIVATE equiv)

DERMATOLOGICALSTier 2-fluticasone propionate lotion (CUTIVATE equiv)

DERMATOLOGICALSTier 1-fluticasone propionate oint (CUTIVATE equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1QL

fluticasone/salmeterol inhaler, wixela inhaler (ADVAIR equiv) (QL= 1

inhaler/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLFLUTICASONE-SALMETEROL INHALER (QL= 1 inhaler/30 days)

ANTIHYPERLIPIDEMICS

Preventi

QL-ST

fluvastatin cap (LESCOL equiv) (QL= 2 caps/day; Step Therapy requires trial

of 2: atorvastatin, lovastatin, rosuvastatin, pravastatin, or simvastatin;

Covered at $0 for members 40 years or older; All other members covered at

generic copay)

ANTIHYPERLIPIDEMICS

Preventi

QL-ST

fluvastatin ER tab (LESCOL XL equiv) (QL= 1 tab/day; Step Therapy requires

trial of 2: atorvastatin, lovastatin, rosuvastatin, pravastatin, or simvastatin;

Covered at $0 for members 40 years or older; All other members covered at

generic copay)

VACCINES

Preventi

VACFLUVIRIN INJ

ANTIDEPRESSANTSTier 2QLfluvoxamine ER cap (LUVOX CR equiv) (QL= 2 caps/day)

ANTIDEPRESSANTSTier 1-fluvoxamine tab (LUVOX equiv)

VACCINES

Preventi

VACFLUZONE HD PF INJ

VACCINES

Preventi

VACFLUZONE HIGH DOSE PF INJ

VACCINES

Preventi

VACFLUZONE QUAD INJ

VACCINES

Preventi

VACFLUZONE/FLUARIX QUAD INJ

MULTIVITAMINSTier 1-FOLBEE PLUS CZ TAB

HEMATOPOIETIC AGENTS

Preventi

folic acid cap (Covered at $0 for females only; All other members covered at

generic copay)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 26 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

HEMATOPOIETIC AGENTS

Preventi

folic acid tab 1mg (Covered at $0 for females only; All other members

covered at generic copay)

HEMATOPOIETIC AGENTS

Preventi

OTCfolic acid tab 400mcg (Covered for females only)

HEMATOPOIETIC AGENTS

Preventi

OTCfolic acid tab 800mcg (Covered for females only)

ANTICOAGULANTSTier 1-fondaparinux inj 10mg/0.8ml (ARIXTRA equiv)

ANTICOAGULANTSTier 1-fondaparinux inj 2.5mg/0.5ml (ARIXTRA equiv)

ANTICOAGULANTSTier 1-fondaparinux inj 5mg/0.4ml (ARIXTRA equiv)

ANTICOAGULANTSTier 1-fondaparinux inj 7.5mg/0.6ml (ARIXTRA equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QL-ST

formoterol fumarate neb soln (PERFOROMIST equiv) (QL= 120ml/30 days;

Step Therapy requires trial of albuterol neb soln OR levalbuterol neb soln)

ANTIVIRALSTier 1QLfosamprenavir tab (LEXIVA equiv) (QL= 4 tabs/day)

ANTI-INFECTIVE AGENTS - MISC.Tier 2-fosfomycin tromethamine powder pack (MONUROL equiv)

ANTIHYPERTENSIVESTier 1-fosinopril tab (MONOPRIL equiv)

ANTIHYPERTENSIVESTier 1-fosinopril/hydrochlorothiazide tab (MONOPRIL HCT equiv)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREE LIBRE 3-PLUS SENSOR (QL= 2 sensors/30 days)

DIAGNOSTIC PRODUCTSTier 1OTC-QLFREESTYLE INSULINX TEST STRIP (QL= 300 test strips/30 days)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREESTYLE LIBRE 2 RECEIVER (QL= 1 receiver/year)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREESTYLE LIBRE 2 SENSOR (QL= 2 sensors/28 days)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREESTYLE LIBRE 3 READER (QL= 1 receiver/1 year)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREESTYLE LIBRE 3 SENSOR (QL= 2 sensors/28 days)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREESTYLE LIBRE RECEIVER (QL= 1 receiver/year)

MEDICAL DEVICES AND SUPPLIESTier 1PA-QLFREESTYLE LIBRE SENSOR (14-DAY) (QL= 2 sensors/28 days)

DIAGNOSTIC PRODUCTSTier 1OTC-QLFREESTYLE LITE TEST STRIP (QL= 300 test strips/30 days)

DIAGNOSTIC PRODUCTSTier 1OTC-QLFREESTYLE PRECISION NEO TEST STRIP (QL= 300 test strips/30 days)

DIAGNOSTIC PRODUCTSTier 1OTC-QLFREESTYLE TEST STRIP (QL= 300 test strips/30 days)

DIAGNOSTIC PRODUCTSTier 1QLFREESTYLE TEST STRIPS (QL= 300 strips/30 days)

MIGRAINE PRODUCTSTier 2QLfrovatriptan tab (FROVA equiv) (QL= 10 tabs/30 days)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLFULPHILA INJ (QL= 2 syringes/28 days)

DIURETICSValue-FUROSEMIDE SOLN

DIURETICSValue-furosemide soln (LASIX equiv)

DIURETICSValue-furosemide tab (LASIX equiv)

ANTIVIRALS

Tier 2

Specialty

AMSPFUZEON INJ

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2PA-QLgabapentin (once-daily) tab (GRALISE equiv) (QL= 2 tabs/day)

ANTICONVULSANTSTier 1-gabapentin cap (NEURONTIN equiv)

ANTICONVULSANTSTier 1-gabapentin tab (NEURONTIN equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QLgalantamine ER cap (RAZADYNE ER equiv) (QL= 1 cap/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-GALANTAMINE SOLN

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QLgalantamine tab (RAZADYNE equiv) (QL= 60 tabs/30 days)

VACCINES

Preventi

VACGARDASIL 9 INJ

VACCINES

Preventi

VACGARDASIL INJ

OPHTHALMIC AGENTSTier 2-gatifloxacin ophth soln (ZYMAXID equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 27 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

LAXATIVES

Preventi

GAVILYTE-C SOLN (Covered at $0 for members 45-75 years-Limited to 2

fills/calendar year; All other members covered at generic copay)

LAXATIVESTier 2-gavilyte-h kit

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QLgefitinib tab (QL= 1 tab/day)

ANTIHYPERLIPIDEMICSTier 1-gemfibrozil tab (LOPID equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 0.2MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 0.4MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 0.6MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 0.8MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 1.2MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 1.4MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 1.6MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 1.8MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 12MG (QL= 4 cartridges/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 1MG (QL= 35 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 2MG (QL= 21 syringes/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLGENOTROPIN INJ 5MG (QL= 9 cartridges/28 days)

OPHTHALMIC AGENTSTier 1-GENTAK OPHTH OINT

OPHTHALMIC AGENTSTier 1-gentamicin ophth soln (GARAMYCIN equiv)

DERMATOLOGICALSTier 1-gentamicin sulfate cream

DERMATOLOGICALSTier 1-gentamicin sulfate oint

ANTIVIRALSTier 2QLGENVOYA TAB (QL= 1 tab/day)

CONTRACEPTIVES

Preventi

-gianvi tab, ocella tab (YASMIN, YAZ equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

GILOTRIF TAB (QL= 1 tab/day; Only available through Accredo

800-803-2523)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-QLglatiramer inj 20mg/ml (COPAXONE equiv) (QL= 30 syringes/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-QLglatiramer inj 40mg/ml (COPAXONE equiv) (QL= 12 syringes/28 days)

ANTIDIABETICSValue-glimepiride tab (AMARYL equiv)

ANTIDIABETICSValue-glipizide ER tab (GLUCOTROL XL equiv)

ANTIDIABETICSValue-glipizide tab (GLUCOTROL equiv)

ANTIDIABETICSTier 1-glipizide/metformin tab (METAGLIP equiv)

ANTIDIABETICSTier 2QLGLUCAGEN HYPOKIT INJ (QL= 2 inj/fill, 2 fills/month)

DIAGNOSTIC PRODUCTSTier 2-GLUCAGEN INJ

ANTIDIABETICSTier 2QLGLUCAGON EMR INJ (QL= 2 inj/fill)

ANTIDIABETICSTier 2QLGLUCAGON INJ KIT (QL= 2 inj/fill)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 28 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIDIABETICSTier 1-GLYBURID MCR TAB

ANTIDIABETICSValue-glyburide tab (MICRONASE equiv)

ANTIDIABETICSValue-glyburide/metformin tab (GLUCOVANCE equiv)

ULCER DRUGSTier 1QLglycopyrrolate oral soln (CUVPOSA equiv) (QL= 9ml/day)

ULCER DRUGSTier 1-glycopyrrolate tab (ROBINUL equiv)

ANTIDIABETICSTier 2QL-ST

GLYXAMBI TAB (QL= 1 tab/day; Step Therapy requires trial of metformin tab

or metformin er tab)

ANTIEMETICSTier 1QLgranisetron tab (KYTRIL equiv) (QL= 8 tabs/30 days)

BIOLOGICALS MISCTier 2QLGRASTEK SL TAB (QL= 30 tabs/30 days)

ANTIFUNGALSTier 2-griseofulvin micro tab (GRIFULVIN V equiv)

ANTIFUNGALSTier 1-griseofulvin susp (GRIFULVIN equiv)

ANTIFUNGALSTier 2-griseofulvin tab (GRIS-PEG equiv)

COUGH/COLD/ALLERGYTier 1OTC-QL

guaifenesin/codeine syrup (TUSSI-ORGANIDIN-S equiv) (QL= 240ml/fill, 2

fills/month)

COUGH/COLD/ALLERGYTier 2OTC-QLGUAIFENESIN/CODEINE SYRUP (QL= 240ml/fill, 2 fills/month)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLguanfacine ER tab (INTUNIV equiv) (QL= 1 tab/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLguanfacine ER tab 1mg (INTUNIV equiv) (QL= 2 tabs/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLguanfacine ER tab 2mg (INTUNIV equiv) (QL= 2 tabs/day)

ANTIHYPERTENSIVESTier 1-guanfacine IR tab (TENEX equiv)

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Tier 1-GUANIDINE TAB

ANTIDIABETICSTier 2QLGVOKE INJ (QL= 2 inj/fill, 2 fills/month)

ANTIDIABETICSTier 2QLGVOKE INJ KIT (QL= 2 vials/fill, 2 fills/30 days)

ANTIDIABETICSTier 2QLGVOKE PFS INJ (QL= 2 inj/fill, 2 fills/month)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLHADLIMA INJ 40MG/0.4ML (QL= 2 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLHADLIMA INJ 40MG/0.8ML (QL= 2 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLHADLIMA PUSH INJ 40MG/0.4ML (QL= 2 inj/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLHADLIMA PUSH INJ 40MG/0.8ML (QL= 2 inj/28 days)

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

HAEGARDA INJ 2000U (QL= 30 vials/30 days; Only available through

Accredo 800-803-2523)

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

HAEGARDA INJ 3000U (QL= 20 vials/30 days; Only available through

Accredo 800-803-2523)

DERMATOLOGICALSTier 2ST

halcinonide cream (HALOG equiv) (Step Therapy requires trial of 2 High

potency corticosteroids)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

-HALDOL DECANOATE INJ

DERMATOLOGICALSTier 1-halobetasol propionate cream (ULTRAVATE equiv)

DERMATOLOGICALSTier 2ST

halobetasol propionate foam (HALOBETASOL AER equiv) (ST req trial of 2

high potency steroids (eg. betamethasone, clobetasol, halobetasol))

DERMATOLOGICALSTier 1-halobetasol propionate oint (ULTRAVATE equiv)

DERMATOLOGICALSTier 1-halonate pac kit (ULTRAVATE KIT equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 1

Specialty

AMSPhaloperidol decanoate inj

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-haloperidol lactate conc (HALDOL equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-haloperidol tab (HALDOL equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 29 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

VACCINES

Preventi

VACHAVRIX INJ, VAQTA INJ

DERMATOLOGICALSTier 1-HC BUTYRATE CREAM

DERMATOLOGICALSTier 2-HC BUTYRATE SOLN

ANTICOAGULANTSTier 1-heparin porcine inj

VACCINES

Preventi

VACHEPLISAV-B INJ

ANTINEOPLASTICS

Tier 2

Specialty

LDHEXALEN CAP (Only available through Walgreens 888-347-3416)

OPHTHALMIC AGENTSTier 2-HOMATROPINE OPHTH SOLN

ANTIDIABETICSTier 2QL-ST

HUMALOG INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

HUMALOG KWIKPEN INJ (QL= 12 units/30 days; Step Therapy requires trial

of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

HUMALOG KWIKPEN INJ (QL= 60 units/30 days; Step Therapy requires trial

of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

HUMALOG MIX INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

HUMALOG MIX KWIKPEN, INSULIN LISPRO MIX KWIKPEN (QL= 60 units/30

days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

HUMALOG PEN INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

HUMALOG TEMPO PEN INJ 100UNIT/ML (QL= 60ml/30 days; Step Therapy

requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2OTC-QL-ST

HUMULIN MIX INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLIN)

ANTIDIABETICSTier 2OTC-QL-ST

HUMULIN MIX PEN INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLIN)

ANTIDIABETICSTier 2OTC-QL-ST

HUMULIN N INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLIN)

ANTIDIABETICSTier 2OTC-QL-ST

HUMULIN N PEN INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLIN)

ANTIDIABETICSTier 2OTC-QL-ST

HUMULIN R INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLIN)

ANTIDIABETICSTier 1QLHUMULIN R INJ U-500 (QL= 40 units/30 days)

ANTIDIABETICSTier 1QLHUMULIN R U-500 KWIKPEN INJ (QL= 24 units/30 days)

ANTINEOPLASTICS

Tier 2

Specialty

LMSP-PAHYCAMTIN CAP

COUGH/COLD/ALLERGYTier 1QLHYD POL/CPM SUSP (QL= 10ml/day)

ANTIHYPERTENSIVESTier 1-hydralazine tab (APRESOLINE equiv)

DIURETICSValue-hydrochlorothiazide cap (MICROZIDE equiv)

DIURETICSValue-hydrochlorothiazide tab (HYDRODIURIL equiv)

ANALGESICS - OPIOIDTier 2PA-QL-ST

HYDROCODONE BITARTRATE ER CAP (QL= 2 caps/day; Step Therapy

requires trial of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

hydrocodone bitartrate ER cap (ZOHYDRO equiv) (QL= 2 caps/day; Step

Therapy requires trial of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QLhydrocodone bitartrate er tab (HYSINGLA equiv) (QL= 1 tab/day)

ANALGESICS - OPIOIDTier 1QL

hydrocodone/acetaminophen cap (LORCET equiv) (QL= 18 caps/fill for

members age 20 or younger; QL= 42 caps/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 30 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANALGESICS - OPIOIDTier 1QL

hydrocodone/acetaminophen soln (HYCET, LORTAB equiv) (QL= 90ml/fill for

members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2QL

hydrocodone/acetaminophen soln 10-325 mg/15ml (HYCET equiv) (QL=

90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

hydrocodone/acetaminophen tab 10-325mg (QL= 18 tabs/fill for members age

20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit

of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2QL

hydrocodone/acetaminophen tab 10mg-300mg (XODOL equiv) (QL= 18

tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21

or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

hydrocodone/acetaminophen tab 2.5-325mg (NORCO equiv) (QL= 18 tabs/fill

for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

hydrocodone/acetaminophen tab 5-325mg (QL= 18 tabs/fill for members age

20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit

of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2QL

hydrocodone/acetaminophen tab 5mg-300mg (XODOL equiv) (QL= 18 tabs/fill

for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2QL

hydrocodone/acetaminophen tab 7.5mg-300mg (XODOL equiv) (QL= 18

tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21

or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

hydrocodone/acetaminophen tab 7.5mg-325mg (QL= 18 tabs/fill for members

age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

COUGH/COLD/ALLERGYTier 1-hydrocodone/chlorpheniramine CR susp (TUSSIONEX equiv)

COUGH/COLD/ALLERGYTier 1-hydrocodone/homatropine syrup (HYCODAN equiv)

ANALGESICS - OPIOIDTier 1QL

HYDROCODONE/IBUPROFEN TAB (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 1QL

hydrocodone/ibuprofen tab (VICOPROFEN equiv) (QL= 18 tabs/fill for

members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

DERMATOLOGICALSTier 1-hydrocortisone butyrate cream (LOCOID equiv)

DERMATOLOGICALSTier 1-hydrocortisone butyrate lipocream (LOCOID equiv)

DERMATOLOGICALSTier 1-hydrocortisone butyrate oint (LOCOID equiv)

DERMATOLOGICALSTier 1-hydrocortisone butyrate soln (LOCOID equiv)

DERMATOLOGICALSTier 1-hydrocortisone cream (PROCTOCORT equiv)

ANORECTAL AGENTSTier 1-hydrocortisone enema (CORTENEMA equiv)

DERMATOLOGICALSTier 1-hydrocortisone lotion (HYTONE equiv)

DERMATOLOGICALSTier 2-hydrocortisone lotion (LOCOID equiv)

DERMATOLOGICALSTier 1-hydrocortisone oint

CORTICOSTEROIDSTier 1-hydrocortisone tab (CORTEF equiv)

DERMATOLOGICALSTier 1-hydrocortisone valerate cream

DERMATOLOGICALSTier 1-hydrocortisone valerate oint (WESTCORT equiv)

ANALGESICS - OPIOIDTier 2PA-QLhydromorphone ER tab 12mg (EXALGO equiv) (QL= 1 tab/day)

ANALGESICS - OPIOIDTier 2PA-QLhydromorphone ER tab 16mg (EXALGO equiv) (QL= 1 tab/day)

ANALGESICS - OPIOIDTier 2PA-QLhydromorphone ER tab 32mg (EXALGO equiv) (QL= 2 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLhydromorphone ER tab 8mg (EXALGO equiv) (QL= 1 tab/day)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 31 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANALGESICS - OPIOIDTier 1QL

hydromorphone liquid (DILAUDID equiv) (QL= 90ml/fill for members age 20 or

younger; QL= 210ml/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 1QL

HYDROMORPHONE SUPP (QL= 90ml/fill for members age 20 or younger; QL=

210ml/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

hydromorphone tab (DILAUDID equiv) (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANTIMALARIALSTier 1-hydroxychloroquine tab (PLAQUENIL equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLHYDROXYPROGESTERONE CAPROATE INJ (QL= 1 vial/35 days)

PROGESTINS

Tier 2

Specialty

AMSP-PA-QLhydroxyprogesterone caproate inj (MAKENA equiv) (QL= 4 vials/28 days)

ANTINEOPLASTICSTier 1-hydroxyurea cap (HYDREA equiv)

ANTIANXIETY AGENTSTier 1-hydroxyzine pamoate cap (VISTARIL equiv)

ANTIANXIETY AGENTSTier 1-hydroxyzine syrup (ATARAX equiv)

ANTIANXIETY AGENTSTier 1-hydroxyzine tab (ATARAX equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2-HYOPHEN TAB

PASSIVE IMMUNIZING AND TREATMENT

AGENTS

Tier 2-HYPERRAB INJ, IMOGAM INJ

MEDICAL DEVICESTier 2OTCHYPODERMIC NEEDLES

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-ibandronate tab 150mg (BONIVA equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-ibuprofen susp (Rx ONLY) (ADVIL, MOTRIN equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-ibuprofen tab

COUGH/COLD/ALLERGYTier 1QLibuprofen tab cold/sinus (QL= 240 tabs/30 days)

HEMATOLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QLicatibant inj (SAJAZIR equiv) (QL= 36ml/30 days)

HEMATOLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QL-LD

icatibant inj (SAJAZIR equiv) (QL= 36ml/30 days; Only available through

Accredo 888-773-7376)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-SFICLUSIG TAB (Only available through AcariaHealth 800-511-5144)

ANTIHYPERLIPIDEMICSTier 1QLicosapent ethyl cap 0.5gm (VASCEPA equiv) (QL= 2 caps/day)

ANTIHYPERLIPIDEMICSTier 1QLicosapent ethyl cap 1gm (VASCEPA equiv) (QL= 4 caps/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QLimatinib tab 100mg (GLEEVEC equiv) (QL= 3 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QLimatinib tab 400mg (GLEEVEC equiv) (QL= 2 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

IMBRUVICA CAP 140MG (QL= 3 caps/day; Only available through Optum

877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

IMBRUVICA CAP 70MG (QL= 1 cap/day; Only available through Optum

877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

IMBRUVICA SUSP (QL= 2 bottles/30 days; Only available through Optum

877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

IMBRUVICA TAB (QL= 1 tab/day; Only available through Optum

877-445-6874)

ANTIDEPRESSANTSTier 2-imipramine pamoate cap (TOFRANIL PM equiv)

ANTIDEPRESSANTSTier 1-imipramine tab (TOFRANIL equiv)

DERMATOLOGICALSTier 2QL-ST

imiquimod cream 3.75% (IMIQUIMOD equiv) (QL= 7.5gm/28 days; Step

Therapy requires trial of 2: imiquimod 5% cream, podophyllum resin,

fluorouracil cream or topical solution)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 32 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

DERMATOLOGICALSTier 1QLimiquimod cream 5% (ALDARA equiv) (QL= 24gm/30 days)

VACCINESTier 2-IMOVAX INJ

ANTI-INFECTIVE AGENTS - MISC.

Tier 2

Specialty

AMSP-QLIMPAVIDO CAP (QL= 3 caps/day)

CONTRACEPTIVES

Preventi

-IMPLANON IMPLANT, NEXPLANON IMPLANT

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

INCRELEX INJ (Only available through Accredo 800-803-2523 or Walgreens

888-347-3416)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLINCRUSE ELLIPTA INHALER (QL= 30 units/30 days)

DIURETICSTier 1-indapamide tab (LOZOL equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-indomethacin cap (INDOCIN equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-indomethacin CR cap (INDOCIN SR equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 2QL-ST

indomethacin suppository (INDOCIN equiv) (QL= 4 supp/day; ST req trial of

two NSAIDS (e.g. indomethacin, celecoxib, naproxen, diclofenac, meloxicam,

etc))

ANALGESICS - ANTI-INFLAMMATORYTier 2QL-ST

indomethacin susp (INDOCIN equiv) (QL= 1200ml/30 days; ST req trial of 2:

Naproxen susp, Ibuprofen susp)

TOXOIDS

Preventi

VACINFANRIX INJ

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

INGREZZA CAP (QL= 1 cap/day; Only available through PantherRx Pharmacy

855-726-8479)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

INGREZZA PACK 40-80MG (QL= 1 pack/28 days; Only available through

PantherRx Pharmacy 855-726-8479)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

INLYTA TAB (QL= 8 tabs/day; Only available through Walgreens

888-347-3416)

ANTIDIABETICSValueQLINSULIN ASPART FLEXPEN INJ (NOVOLOG equiv) (QL= 60 units/30 days)

ANTIDIABETICSValueQLINSULIN ASPART INJ (NOVOLOG equiv) (QL= 60 units/30 days)

ANTIDIABETICSValueQL

INSULIN ASPART MIX FLEXPEN INJ (NOVOLOG equiv) (QL= 60 units/30 days)

ANTIDIABETICSValueQLINSULIN ASPART MIX INJ (NOVOLOG equiv) (QL= 60 units/30 days)

ANTIDIABETICSValueQLINSULIN ASPART PENFILL INJ (NOVOLOG equiv) (QL= 60 units/30 days)

ANTIDIABETICSValueQL

INSULIN GLARGINE SOLN PEN-INJ 300 UNIT/ML (1 UNIT DIAL) (QL= 18ml/30

days)

ANTIDIABETICSValueQL

INSULIN GLARGINE SOLN PEN-INJ 300 UNIT/ML (2 UNIT DIAL) (QL= 18ml/30

days)

ANTIDIABETICSValueQLINSULIN LISP INJ 100/ML (QL= 60 units/30 days)

ANTIVIRALSTier 2QLINTELENCE TAB (QL= 4 tabs/day)

ANTIVIRALSTier 2QLINTELENCE TAB 25MG (QL= 4 tabs/day)

ANTINEOPLASTICS

Tier 2

Specialty

AMSPINTRON-A INJ

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPINVEGA HAFYERA INJ

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPINVEGA SUSTENNA INJ

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPINVEGA TRINZA INJ

ANTIVIRALSTier 2QLINVIRASE CAP (QL= 10 caps/day)

ANTIVIRALSTier 2QLINVIRASE TAB (QL= 4 tabs/day)

DERMATOLOGICALSTier 1-iodoquinol/hydrocortisone cream 1% (VYTONE equiv)

DERMATOLOGICALSTier 2-iodoquinol/hydrocortisone cream 1.9-1% (VYTONE equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 33 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

VACCINES

Preventi

-IPOL INJ

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 1-ipratropium nasal spray (ATROVENT equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-ipratropium neb soln (ATROVENT equiv)

ANTIHYPERTENSIVESTier 1-irbesartan tab (AVAPRO equiv)

ANTIHYPERTENSIVESTier 1-irbesartan/hydrochlorothiazide tab (AVALIDE equiv)

ANTIVIRALSTier 2QLISENTRESS (HD) TAB (QL= 2 tabs/day)

ANTIVIRALSTier 2QLISENTRESS CHEW TAB (QL= 6 tabs/day)

ANTIVIRALSTier 2QLISENTRESS POWDER PACK (QL= 2 packets/day)

CONTRACEPTIVES

Preventi

-isibloom tab, enskyce tab, apri tab (DESOGEN equiv)

MIGRAINE PRODUCTSTier 1-isometheptene/caffeine/acetaminophen tab (PRODRIN equiv)

MIGRAINE PRODUCTSTier 2-ISOMETHEPTENE/CAFFEINE/ACETAMINOPHEN TAB

ANTIMYCOBACTERIAL AGENTSTier 1-ISONIAZID TAB

ANTIANGINAL AGENTSTier 2ST

isosorbide dinitrate tab 40mg (ISORDIL equiv) (Step Therapy requires trial of

isosorbide dinitrate, isosorbide dinitrate ER, isosorbide dinitrate SL, isosorbide

mononitrate, or isosorbide mononitrate ER)

ANTIANGINAL AGENTSTier 1-isosorbide dinitrate tab 5mg (ISORDIL equiv)

CARDIOVASCULAR AGENTS - MISC.Tier 1QLisosorbide dinitrate-hydralazine hcl tab (BIDIL equiv) (QL= 6 tabs/day)

ANTIANGINAL AGENTSTier 1-isosorbide mononitrate ER tab (IMDUR equiv)

ANTIANGINAL AGENTSTier 1-ISOSORBIDE MONONITRATE TAB

ANTIANGINAL AGENTSTier 1-isosorbide mononitrate tab (MONOKET equiv)

CARDIOVASCULAR AGENTS - MISC.Tier 2QLISOXSUPRINE TAB (QL= 120 tabs/30 days)

CALCIUM CHANNEL BLOCKERSTier 1-isradipine cap (DYNACIRC equiv)

ANTIFUNGALSTier 1-itraconazole cap (SPORANOX equiv)

ANTIFUNGALSTier 2-itraconazole soln (SPORANOX equiv)

CARDIOVASCULAR AGENTS - MISC.Tier 1PA-QLivabradine hcl tab (CORLANOR equiv) (QL= 60 tabs/30 days)

DERMATOLOGICALSTier 2QL-ST

ivermectin cream (SOOLANTRA equiv) (QL= 45gm/30 days; Step Therapy

requires trial of oral doxycycline and topical metronidazole)

ANTHELMINTICSTier 1-ivermectin tab (STROMECTOL equiv)

OPHTHALMIC AGENTSTier 2QL-ST

IYUZEH OPHTH DROPS (QL= 30 single use containers/30 days; Step therapy

requires trial of latanoprost ophth soln)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

JAKAFI TAB (QL= 2 tabs/day; Only available through Walgreens

888-347-3416)

ANTIDIABETICSTier 2QLJARDIANCE TAB (QL= 1 tab/day)

ANTIDIABETICSTier 2QLJENTADUETO TAB (QL= 2 tabs/day)

ANTIDIABETICSTier 2QLJENTADUETO XR TAB (QL= 2 tabs/day)

ESTROGENSTier 1-jinteli tab (FEMHRT equiv)

ANTIVIRALSTier 2QLJULUCA TAB (QL= 1 tab/day)

CONTRACEPTIVES

Preventi

-junel FE tab (LOESTRIN FE equiv)

CONTRACEPTIVES

Preventi

-junel tab (LOESTRIN equiv)

ANTIHYPERLIPIDEMICS

Tier 2

Specialty

LD-PAJUXTAPID CAP (Only available through Accredo 888-773-7376)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA-QL

JYNARQUE PAK (QL= 2 tabs/day; Only available through Walgreens

888-347-3416)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA-QL

JYNARQUE TAB 15MG (QL= 2 tabs/day; Only available through Walgreens

888-347-3416)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 34 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA-QL

JYNARQUE TAB 30MG (QL= 1 tab/day; Only available through Walgreens

888-347-3416)

VACCINES

Preventi

-JYNNEOS INJ

ANTIVIRALSTier 2QLKALETRA TAB 100-25MG (QL= 2 tabs/day)

ANTIVIRALSTier 2QLKALETRA TAB 200-50MG (QL= 4 tabs/day)

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

KALYDECO PAK (QL= 2 packets/day; Only available through Walgreens

888-347-3416)

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

KALYDECO TAB (QL= 2 tabs/day; Only available through Walgreens

888-347-3416)

CONTRACEPTIVES

Preventi

-kelnor tab (DEMULEN equiv)

DERMATOLOGICALSTier 1-ketoconazole cream (NIZORAL CREAM equiv)

DERMATOLOGICALSTier 2-ketoconazole foam 2% (EXTINA equiv)

DERMATOLOGICALSTier 1-ketoconazole shampoo

ANTIFUNGALSTier 1-ketoconazole tab (NIZORAL equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-ketorolac inj

ANALGESICS - ANTI-INFLAMMATORYTier 2-KETOROLAC INJ

OPHTHALMIC AGENTSTier 1-ketorolac ophth soln .05% (ACULAR (LS) equiv)

OPHTHALMIC AGENTSTier 2-ketorolac ophth soln .4% (ACULAR (LS) equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-ketorolac tab (TORADOL equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLKISQALI PAK (QL= 91 tabs/28 days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLKISQALI TAB (QL= 63 tabs/28 days)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 2-KLOXXADO NASAL SPRAY

ANTIMALARIALSTier 2QLKRINTAFEL TAB (QL= 2 tabs/365 days)

MINERALS & ELECTROLYTESTier 1-K-TAB

CONTRACEPTIVES

Preventi

-KYLEENA IUD

BETA BLOCKERSTier 1-labetalol tab (NORMODYNE equiv)

ANTICONVULSANTSTier 1QLlacosamide oral solution (VIMPAT equiv) (QL= 1200ml/30 days)

ANTICONVULSANTSTier 1QLlacosamide tab (VIMPAT equiv) (QL= 2 tabs/day)

LAXATIVESTier 1-lactulose soln

ANTIVIRALSTier 2QL

LAGEVRIO CAP 200MG (QL= 40 caps/5 days, 40 caps/fill; Covered for

members age 18 years or older)

ANTIVIRALSTier 1QLlamivudine soln (EPIVIR equiv) (QL= 960ml/30 days)

ANTIVIRALS

Tier 1

Specialty

AMSP-QLlamivudine tab 100mg (EPIVIR HBV equiv) (QL= 1 tab/day)

ANTIVIRALSTier 1QLlamivudine tab 150mg (EPIVIR equiv) (QL= 2 tabs/day)

ANTIVIRALSTier 1QLlamivudine tab 300mg (EPIVIR equiv) (QL= 1 tab/day)

ANTIVIRALSTier 1QLlamivudine/zidovudine tab (COMBIVIR equiv) (QL= 2 tabs/day)

ANTICONVULSANTSTier 1-lamotrigine chew tab (LAMICTAL equiv)

ANTICONVULSANTSTier 1QLlamotrigine ER tab 100mg (LAMICTAL XR equiv) (QL= 3 tabs/day)

ANTICONVULSANTSTier 1QLlamotrigine ER tab 200mg (LAMICTAL XR equiv) (QL= 2 tabs/day)

ANTICONVULSANTSTier 1QLlamotrigine ER tab 250mg (LAMICTAL XR equiv) (QL= 2 tabs/day)

ANTICONVULSANTSTier 1QLlamotrigine ER tab 25mg (LAMICTAL XR equiv) (QL= 6 tabs/day)

ANTICONVULSANTSTier 1QLlamotrigine ER tab 300mg (LAMICTAL XR equiv) (QL= 2 tabs/day)

ANTICONVULSANTSTier 1QLlamotrigine ER tab 50mg (LAMICTAL XR equiv) (QL= 6 tabs/day)

ANTICONVULSANTSTier 2QL-ST

lamotrigine odt (LAMICTAL equiv) (QL= 2 tabs/day; Step Therapy requires trial

of lamotrigine chew)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 35 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTICONVULSANTSTier 2-lamotrigine ODT kit (LAMICTAL ODT KIT equiv)

ANTICONVULSANTSTier 1-lamotrigine tab (LAMICTAL equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLLAMPIT TAB 120MG (QL= 225 tabs/30 days)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLLAMPIT TAB 30MG (QL= 360 tabs/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2OTCLANCET KIT

MEDICAL DEVICES AND SUPPLIESTier 2OTCLANCETS

GASTROINTESTINAL AGENTS - MISC.Tier 1QL-ST

lanthanum carbonate chew tab (FOSRENOL equiv) (QL= 3 tabs/day; ST req

trial of sevelamer carbonate tab or sevelamer HCL tab)

GASTROINTESTINAL AGENTS - MISC.Tier 1QL-ST

lanthanum carbonate chew tab 500mg (FOSRENOL equiv) (QL= 5 tabs/day;

ST req trial of sevelamer carbonate tab or sevelamer HCL tab)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QLlapatinib ditosylate tab (TYKERB equiv) (QL= 5 tabs/day)

OPHTHALMIC AGENTSValue-latanoprost ophth soln (XALATAN equiv)

CONTRACEPTIVES

Preventi

-layolis FE tab, wymzya FE tab (FEMCON FE equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-leflunomide tab (ARAVA equiv)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 1

Specialty

LD-PA-QL

lenalidomide cap (REVLIMID equiv) (QL= 1 cap/day; Only available through

Onco360 877-662-6633)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

LENVIMA CAP (QL= 3 caps/day; Only available through Optum

877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Preventi

-letrozole tab (FEMARA equiv)

ANTINEOPLASTICSTier 1-leucovorin tab

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLLEUPROLIDE INJ (QL= 1 kit/90 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-levalbuterol neb soln (XOPENEX equiv)

ANTICONVULSANTSTier 1-levetiracetam ER tab (KEPPRA XR equiv)

ANTICONVULSANTSTier 1-levetiracetam soln (KEPPRA equiv)

ANTICONVULSANTSTier 1-levetiracetam tab (KEPPRA equiv)

OPHTHALMIC AGENTSTier 1-LEVOBUNOLOL OPHTH SOLN

OPHTHALMIC AGENTSTier 1-levobunolol ophth soln (BETAGAN equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-levocarnitine soln (CARNITOR equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-levocarnitine tab (CARNITOR equiv)

OPHTHALMIC AGENTSTier 1-levofloxacin ophth soln (QUIXIN equiv)

FLUOROQUINOLONESTier 1-levofloxacin oral soln 25mg/ml (LEVOFLOXACIN equiv)

FLUOROQUINOLONESTier 1-levofloxacin tab (LEVAQUIN equiv)

CONTRACEPTIVES

Preventi

OTClevonorgestrel tab (PLAN B equiv)

CONTRACEPTIVES

Preventi

-levonorgestrel-ethinyl estradiol-fe tab (BALCOLTRA equiv)

THYROID AGENTSTier 1-levothyroxine tab (SYNTHROID equiv)

HEMATOPOIETIC AGENTS

Tier 1

Specialty

AMSP-QL-ST

l-glutamine powder packet (ENDARI equiv) (QL= 6 packets/day; Step therapy

requires trial of hydroxyurea caps)

DERMATOLOGICALSTier 2-lidocaine cream 3% (LIDAMANTLE equiv)

DERMATOLOGICALSTier 2-lidocaine cream 3.88% (LIDOTRAL CREAM equiv)

DERMATOLOGICALSTier 1-LIDOCAINE GEL

DERMATOLOGICALSTier 1-lidocaine gel (GLYDO equiv)

DERMATOLOGICALSTier 2-lidocaine gel (XYLOCAINE equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 36 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

DERMATOLOGICALSTier 2-lidocaine lotion

DERMATOLOGICALSTier 1QLlidocaine oint (QL= 8gm/day)

MOUTH/THROAT/DENTAL AGENTSTier 2-LIDOCAINE ORAL SOLN 4%

DERMATOLOGICALSTier 1-lidocaine soln (XYLOCAINE equiv)

MOUTH/THROAT/DENTAL AGENTSTier 1-lidocaine viscous soln 2% (LIDOCAINE HCL VISCOUS SOLN 2% equiv)

ANORECTAL AGENTSTier 1-lidocaine/hydrocortisone cream (ANAMANTLE equiv)

ANORECTAL AGENTSTier 1-lidocaine/hydrocortisone kit (ANALPRAM equiv)

ANORECTAL AGENTSTier 1-LIDOCAINE/HYDROCORTISONE RECTAL CREAM KIT

DERMATOLOGICALSTier 1-lidocaine/prilocaine cream (EMLA equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLLIKMEZ SUSP (QL= 210ml/14 days)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-linezolid susp

ANTI-INFECTIVE AGENTS - MISC.Tier 1-linezolid tab (ZYVOX equiv)

THYROID AGENTSTier 1-liothyronine tab (CYTOMEL equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLlisdexamfetamine dimesylate cap (VYVANSE equiv) (QL= 1 cap/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLlisdexamfetamine dimesylate chew tab (VYVANSE equiv) (QL= 1 tab/day)

ANTIHYPERTENSIVESValue-lisinopril tab (PRINIVIL/ZESTRIL equiv)

ANTIHYPERTENSIVESValue-lisinopril/hydrochlorothiazide tab (ZESTORETIC equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-lithium carbonate cap (ESKALITH ER equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-lithium carbonate ER tab (LITHOBID equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-lithium carbonate tab

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-lithium oral solution (LITHIUM equiv)

CONTRACEPTIVES

Preventi

-LO LOESTRIN TAB

DERMATOLOGICALSTier 1-LOCOID LIPOCREAM

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2QL-ST

LOKELMA PAK (QL= 1 pak/day; Step therapy requires trial of 1 diuretic:

furosemide, bumetanide, torsemide, HCTZ, metolazone, chlorthalidone)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA

LONSURF TAB (Only available through Optum 877-445-6874 or Walgreens

888-347-3416)

ANTIDIARRHEALSTier 1-loperamide cap (IMODIUM equiv)

ANTIVIRALSTier 1QLlopinavir/ritonavir soln (KALETRA equiv) (QL= 480ml/30 days)

ANTIVIRALSTier 1QLlopinavir-ritonavir tab 100-25mg (QL= 2 tabs/day)

ANTIVIRALSTier 1QLlopinavir-ritonavir tab 200-50mg (QL= 4 tabs/day)

ANTIANXIETY AGENTSTier 1-lorazepam conc (ATIVAN equiv)

ANTIANXIETY AGENTSTier 1-lorazepam tab (ATIVAN equiv)

COUGH/COLD/ALLERGYTier 1QLLORTUSS EX LIQUID (QL= 1200ml/30 days)

COUGH/COLD/ALLERGYTier 2QLLORTUSS LIQUID (QL= 1200ml/30 days)

ANTIHYPERTENSIVESValue-losartan tab (COZAAR equiv)

ANTIHYPERTENSIVESValue-losartan/hydrochlorothiazide tab (HYZAAR equiv)

OPHTHALMIC AGENTSTier 2ST

LOTEMAX OPHTH OINT 0.5% (Step therapy requires trial of two:

prednisolone susp/soln 1%, dexameth soln 0.1%, or fluorometh susp 0.1%)

OPHTHALMIC AGENTSTier 2-LOTEMAX SM GEL

OPHTHALMIC AGENTSTier 2QL-ST

loteprednol etabonate ophth gel (LOTEMAX equiv) (QL= 5g/28 days; Step

therapy requires trial of two: prednisolone 1%, dexameth soln 0.1%, or

fluorometh susp 0.1%)

OPHTHALMIC AGENTSTier 2QL-ST

loteprednol etabonate ophth susp 0.2% (ALREX equiv) (QL= 5ml/30 days;

Step therapy requires trial of two: prednisolone 1%, dexameth soln 0.1%, or

fluorometh susp 0.1%)

OPHTHALMIC AGENTSTier 1-loteprednol ophth susp (LOTEMAX equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 37 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIHYPERLIPIDEMICS

Preventi

lovastatin tab (MEVACOR equiv) (QL= 2 tabs/day; Covered at $0 for members

40 years or older; All other members covered at generic copay)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-loxapine cap (LOXITANE equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1QLlubiprostone cap (AMITIZA equiv) (QL= 60 caps/30 days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PALUPRON DEPOT INJ

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QLLUPRON DEPOT INJ PED (QL= 1 syringe kit/180 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QLLUPRON DEPOT-PED INJ (1-MONTH) (QL= 1 syringe kit/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QLLUPRON DEPOT-PED INJ (3-MONTH) (QL= 1 syringe kit/90 days)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLlurasidone hcl tab (LATUDA equiv) (QL= 1 tab/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

LYNPARZA CAP (QL= 16 caps/day; Only available through Biologics

800-850-4306)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

LYNPARZA TAB (QL= 4 tabs/day; Only available through Biologics

800-850-4306)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LDLYSODREN TAB (Only available through Walgreens 888-347-3416)

ANTIDIABETICSTier 2QL-ST

LYUMJEV INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

LYUMJEV KWIKPEN (QL= 12 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

LYUMJEV KWIKPEN INJ (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

ANTIDIABETICSTier 2QL-ST

LYUMJEV TEMPO PEN INJ 100UNIT/ML (QL= 60ml/30 days; Step Therapy

requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

DERMATOLOGICALSTier 1-malathion lotion (OVIDE equiv)

ANTIDEPRESSANTSTier 1-MAPROTILINE TAB

ANTIVIRALSTier 1QLmaraviroc tab 150mg (SELZENTRY equiv) (QL= 2 tabs/day)

ANTIVIRALSTier 1QLmaraviroc tab 300mg (SELZENTRY equiv) (QL= 4 tabs/day)

COUGH/COLD/ALLERGYTier 2QLMAR-COF CG LIQUID (QL= 473ml/month)

ANTINEOPLASTICS

Tier 2

Specialty

LDMATULANE CAP (Only available through Walgreens 888-347-3416)

ANTIVIRALS

Tier 1

Specialty

AMSP-QLMAVYRET PAK (QL= 5 packets/day)

ANTIVIRALS

Tier 1

Specialty

AMSP-QLMAVYRET TAB (QL= 3 tabs/day)

OPHTHALMIC AGENTSTier 2-MAXIDEX OPHTH SOLN

ANALGESICS - ANTI-INFLAMMATORYTier 2-MECLOFENAMATE CAP

CONTRACEPTIVES

Preventi

QLmedroxyprogesterone inj (DEPO-PROVERA equiv) (QL= 1 inj/84 days)

PROGESTINSTier 1-medroxyprogesterone tab (PROVERA equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 2-mefenamic acid cap (PONSTEL equiv)

ANTIMALARIALSTier 2-mefloquine tab (LARIAM equiv)

PROGESTINSTier 1-megestrol ES susp (MEGACE ES equiv)

PROGESTINSTier 1-MEGESTROL SUSP

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1-megestrol susp (MEGACE equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1-megestrol tab (MEGACE equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 38 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LMSP-PA-QLMEKINIST SOLN (QL= 40ml/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLMEKINIST TAB 0.5MG (QL= 3 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLMEKINIST TAB 2MG (QL= 1 tab/day)

ANALGESICS - ANTI-INFLAMMATORYTier 2QL-ST

meloxicam (VIVLODEX equiv) (QL= 1 cap/day; Step Therapy requires trial of

meloxicam, ketoprofen, oxaprozin, sulindac, or tolmetin)

ANALGESICS - ANTI-INFLAMMATORYTier 1-meloxicam tab (MOBIC equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSPMELPHALAN TAB

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QL-ST

memantine ER cap (NAMENDA XR equiv) (QL= 1 cap/day; Step Therapy

requires trial of memantine tab)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QLmemantine soln (NAMENDA equiv) (QL= 300 ml/30 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-memantine tab (NAMENDA equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1QLmemantine titrapak (NAMENDA equiv) (QL= 49 tabs/28 days)

VACCINES

Preventi

VACMENACTRA INJ

COUGH/COLD/ALLERGYTier 2QLM-END DMX LIQUID (QL= 1800ml/30 days)

VACCINES

Preventi

VACMENHIBRIX INJ

VACCINES

Preventi

VACMENOMUNE INJ

VACCINES

Preventi

VACMENQUADFI INJ

VACCINES

Preventi

VACMENVEO INJ

VACCINES

Preventi

VACMENVEO SOLN

ANALGESICS - OPIOIDTier 2QL

MEPERIDINE SOLN (QL= 90ml/fill for members age 20 or younger; QL=

210ml/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

meperidine tab (DEMEROL equiv) (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANTIANXIETY AGENTSTier 2-meprobamate tab (MILTOWN equiv)

ANTINEOPLASTICSTier 1-mercaptopurine tab (PURINETHOL equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1QLmesalamine DR cap (DELZICOL equiv) (QL= 6 caps/day)

GASTROINTESTINAL AGENTS - MISC.Tier 1QLmesalamine DR tab (LIALDA equiv) (QL= 4 tabs/day)

GASTROINTESTINAL AGENTS - MISC.Tier 1-mesalamine enema (ROWASA equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1QLmesalamine ER cap (APRISO equiv) (QL= 4 caps/day)

GASTROINTESTINAL AGENTS - MISC.Tier 2QL-ST

mesalamine ER cap (PENTASA equiv) (QL= 8 caps/day; Step therapy requires

trial of 1: generic APRISO or LIALDA)

GASTROINTESTINAL AGENTS - MISC.Tier 1QLmesalamine supp (CANASA equiv) (QL= 1 supp/day)

GASTROINTESTINAL AGENTS - MISC.Tier 2-mesalamine tab (ASACOL equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 2-MESALAMINE TAB DR 800MG

ANTINEOPLASTICS

Tier 2

Specialty

AMSPMESNEX TAB

MUSCULOSKELETAL THERAPY AGENTSTier 2-metaxalone tab (SKELAXIN equiv)

ANTIDIABETICSTier 2-metformin ER osmotic tab (FORTAMET equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 39 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIDIABETICSTier 2--ST

metformin ER osmotic tab (GLUMETZA equiv) (Step Therapy requires trial of

metformin or metformin ER)

ANTIDIABETICSValue-metformin ER tab (GLUCOPHAGE XR equiv)

ANTIDIABETICSTier 2-metformin soln (RIOMET equiv)

ANTIDIABETICSValue-metformin tab (GLUCOPHAGE equiv)

ANALGESICS - OPIOIDTier 1QLmethadone soln (QL= 4 ml/day)

ANALGESICS - OPIOIDTier 1QLmethadone soln 10mg/5ml (QL= 20ml/day)

ANALGESICS - OPIOIDTier 1QLmethadone soln 5mg/5ml (QL= 40ml/day)

ANALGESICS - OPIOIDTier 1QLmethadone tab 10mg (DOLOPHINE equiv) (QL= 4 tabs/day)

ANALGESICS - OPIOIDTier 1QLmethadone tab 5mg (DOLOPHINE equiv) (QL= 8 tabs/day)

ANALGESICS - OPIOIDTier 1PA-QLmethadose tab (QL= 1 tab/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLmethamphetamine tab (DESOXYN equiv) (QL= 5 tabs/day)

DIURETICSTier 2ST

methazolamide tab (NEPTAZANE equiv) (Step Therapy requires trial of

acetazolamide)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-methenamine hippurate tab (HIPREX equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-methenamine mandelate tab

THYROID AGENTSTier 1-methimazole tab (TAPAZOLE equiv)

MUSCULOSKELETAL THERAPY AGENTSTier 1-methocarbamol tab (ROBAXIN equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1-methotrexate inj

ANTINEOPLASTICSTier 1-methotrexate tab (TREXALL equiv)

DERMATOLOGICALSTier 1-methoxsalen cap (OXSORALEN ULTRA equiv)

ULCER DRUGSTier 1-methscopolamine tab (PAMINE equiv)

ANTICONVULSANTSTier 2QL-ST

methsuximide cap (CELONTIN equiv) (QL= 4 caps/day; ST requires trial of

ethosuximide tab/soln)

DIURETICSTier 1-METHYCLOTHIAZIDE TAB

ANTIHYPERTENSIVESTier 1-methyldopa tab (ALDOMET equiv)

ANTIHYPERTENSIVESTier 2-METHYLDOPA TAB

ANTIHYPERTENSIVESTier 1-methyldopa/hydrochlorothiazide tab (ALDORIL equiv)

OXYTOCICSTier 1-methylergonovine tab (METHERGINE equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLmethylphenidate CD cap (METADATE CD equiv) (QL= 1 cap/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QLmethylphenidate chew tab (METHYLIN equiv) (QL= 3 tabs/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate ER cap (RITALIN LA equiv) (QL= 60 caps/30 days; Step

therapy requires trial of 2: dextro/amphet ER, dexmethylph ER, methylphen ER

27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 10mg (APTENSIO XR equiv) (QL= 60 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 15mg (APTENSIO XR equiv) (QL= 60 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 20mg (APTENSIO XR equiv) (QL= 60 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 30mg (APTENSIO XR equiv) (QL= 60 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 40 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 40mg (APTENSIO XR equiv) (QL= 30 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 50mg (APTENSIO XR equiv) (QL= 30 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate er cap 60mg (APTENSIO XR equiv) (QL= 30 caps/30 days;

Step Therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM))

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLmethylphenidate ER tab (QL= 1 tab/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLmethylphenidate ER tab 10mg (QL= 3 tabs/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLmethylphenidate ER tab 20mg (QL= 3 tabs/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1-methylphenidate soln (METHYLIN equiv)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLmethylphenidate tab 10mg (RITALIN equiv) (QL= 180 tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLmethylphenidate tab 20mg (RITALIN equiv) (QL= 90 tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 1QLmethylphenidate tab 5mg (RITALIN equiv) (QL= 360 tabs/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

methylphenidate td patch (DAYTRANA equiv) (QL= 1 patch/day; Step therapy

requires trial of 2: dextro/amphet ER, dexmethylph ER, methylphen ER

27/36/54 (non-OSM))

CORTICOSTEROIDSTier 1-methylprednisolone dose pack (MEDROL equiv)

CORTICOSTEROIDSTier 1-methylprednisolone tab (MEDROL equiv)

ANDROGENS-ANABOLICTier 2PA-QLmethyltestosterone cap (QL= 150 tablets/30 days)

OPHTHALMIC AGENTSTier 2-METIPRANOLOL OPHTH SOLN

GASTROINTESTINAL AGENTS - MISC.Tier 1-metoclopramide soln (REGLAN equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-metoclopramide tab (REGLAN equiv)

DIURETICSTier 1-metolazone tab (ZAROXOLYN equiv)

BETA BLOCKERSValue-metoprolol ER tab (TOPROL XL equiv)

BETA BLOCKERSValue-metoprolol tab (LOPRESSOR equiv)

ANTIHYPERTENSIVESTier 1-metoprolol/hydrochlorothiazide tab (LOPRESSOR HCT equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2-metronidazole cap (FLAGYL equiv)

DERMATOLOGICALSTier 1-metronidazole cream (METROCREAM equiv)

DERMATOLOGICALSTier 2-metronidazole gel (METROGEL equiv)

DERMATOLOGICALSTier 1-metronidazole lotion (METROLOTION equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-metronidazole tab (FLAGYL equiv)

VAGINAL PRODUCTSTier 2-metronidazole vaginal gel (METROGEL equiv)

ANTIHYPERTENSIVESTier 2PA-QLmetyrosine cap (DEMSER equiv) (QL= 448 caps/28 days)

ANTIARRHYTHMICSTier 1-mexiletine hcl cap

CONTRACEPTIVES

Preventi

-mibelas chew tab (MINASTRIN equiv)

DERMATOLOGICALSTier 2-MICORT-HC CREAM

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-midazolam hcl syrup

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-midazolam inj (MIDAZOLAM equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 41 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

VASOPRESSORSTier 1-midodrine tab (PROAMATINE equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Preventi

-mifepristone tab (MIFEPREX equiv)

ANTIDIABETICS

Tier 1

Specialty

--AMSP-PA-QLmifepristone tab (KORLYM equiv) (QL= 4 tabs/day)

MIGRAINE PRODUCTSTier 2QLMIGERGOT SUPP (QL= 20 supp/28 days)

ANTIDIABETICSTier 2-MIGLITOL TAB

ANTIDIABETICSTier 2-miglitol tab (MIGLITOL equiv)

HEMATOPOIETIC AGENTS

Tier 1

Specialty

LD-PA

miglustat cap (ZAVESCA equiv) (Only available through Accredo

800-803-2523)

TETRACYCLINESTier 1-minocycline cap (MINOCIN equiv)

TETRACYCLINESTier 2QL-ST

minocycline ER tab (SOLODYN equiv) (QL= 1 tab/day; Step Therapy requires

trial of minocycline cap or minocycline tab)

TETRACYCLINESTier 2-minocycline tab (DYNACIN equiv)

ANTIHYPERTENSIVESTier 1-minoxidil tab (LONITEN equiv)

URINARY ANTISPASMODICSTier 2ST

mirabegron tab er (MYRBETRIQ equiv) (ST req trial 2: oxybutynin tab/syrup,

oxybutynin ER tab, tolterodine tab/SR cap, trospium tab/SR cap)

CONTRACEPTIVES

Preventi

-MIRENA IUD

ANTIDEPRESSANTSTier 1-mirtazapine ODT (REMERON equiv)

ANTIDEPRESSANTSTier 1-mirtazapine tab (REMERON equiv)

ULCER DRUGS

Preventi

-misoprostol tab (CYTOTEC equiv)

VACCINES

Preventi

VACM-M-R II INJ

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

ValueQLmodafinil tab (PROVIGIL equiv) (QL= 2 tabs/day)

ANTIHYPERTENSIVESTier 1-moexipril tab (UNIVASC equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 2-MOLINDONE TAB

ANTIVIRALS

Preventi

QLMOLNUPIRAVIR CAP (QL= 40 caps/fill)

DERMATOLOGICALSTier 1-mometasone cream (ELOCON equiv)

DERMATOLOGICALSTier 1-mometasone oint (ELOCON equiv)

DERMATOLOGICALSTier 1-mometasone soln (ELOCON equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-montelukast chew tab (SINGULAIR equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-montelukast granule pack (SINGULAIR equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-montelukast tab (SINGULAIR equiv)

ANALGESICS - OPIOIDTier 2QL-ST

MORPHINE SULFATE ER CAP (QL= 2 caps/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 1PA-QL-ST

morphine sulfate ER cap 100mg (QL= 2 caps/day; Step Therapy requires trial

of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

morphine sulfate ER cap 10mg (KADIAN equiv) (QL= 2 caps/day; Step

Therapy requires trial of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

morphine sulfate ER cap 20mg (QL= 2 caps/day; Step Therapy requires trial

of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 1PA-QL-ST

morphine sulfate ER cap 30mg (QL= 2 caps/day; Step Therapy requires trial

of morphine sulfate ER tab)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 42 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANALGESICS - OPIOIDTier 2PA-QL-ST

morphine sulfate ER cap 50mg (QL= 2 caps/day; Step Therapy requires trial

of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

morphine sulfate ER cap 60mg (QL= 2 caps/day; Step Therapy requires trial

of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

morphine sulfate ER cap 80mg (QL= 2 caps/day; Step Therapy requires trial

of morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 1PA-QLmorphine sulfate ER tab (MS CONTIN equiv) (QL= 3 tabs/day)

ANALGESICS - OPIOIDTier 1QL

MORPHINE SULFATE ORAL SOLN 100MG/5ML (QL= 90ml/fill for members age

20 or younger; QL= 210ml/fill for members age 21 or older; Day supply limit of

42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

morphine sulfate oral soln 10mg/5ml (MORPHINE equiv) (QL= 90ml/fill for

members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

MORPHINE SULFATE SOLN (QL= 90ml/fill for members age 20 or younger;

QL= 210ml/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 1QL

morphine sulfate soln (MORPHINE equiv) (QL= 90ml/fill for members age 20 or

younger; QL= 210ml/fill for members age 21 or older; Day supply limit of 42

days in 90 days

)

ANALGESICS - OPIOIDTier 2QL

MORPHINE SULFATE SOLN (QL= 90ml/fill for members age 20 or younger;

QL= 210ml/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 2QL

MORPHINE SULFATE SUPP (QL= 90ml/fill for members age 20 or younger;

QL= 210ml/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 1QL

morphine sulfate tab (QL= 18 tabs/fill for members age 20 or younger; QL=

42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 2QL

MORPHINE SULFATE TAB (QL= 18 tabs/fill for members age 20 or younger;

QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

GASTROINTESTINAL AGENTS - MISC.Tier 2PA-QLMOVANTIK TAB (QL= 30 tabs/30 days)

OPHTHALMIC AGENTSTier 1-moxifloxacin ophth soln (VIGAMOX OPHTH SOLN equiv)

FLUOROQUINOLONESTier 1-moxifloxacin tab (AVELOX equiv)

HEMATOPOIETIC AGENTSTier 1-multigen plus tab (CHROMAGEN FORTE equiv)

HEMATOPOIETIC AGENTSTier 1-multigen tab (CHROMAGEN equiv)

DERMATOLOGICALSTier 1-mupirocin cream (BACTROBAN CREAM equiv)

DERMATOLOGICALSTier 1-mupirocin oint (BACTROBAN OINT equiv)

ASSORTED CLASSESTier 1-mycophenolate DR tab (MYFORTIC equiv)

ASSORTED CLASSESTier 1-mycophenolate mofetil cap (CELLCEPT equiv)

ASSORTED CLASSESTier 1-mycophenolate mofetil susp (CELLCEPT SUSP equiv)

ASSORTED CLASSESTier 1-mycophenolate mofetil tab (CELLCEPT equiv)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2-MYHIBBIN SUSP

ANTINEOPLASTICS

Tier 2

Specialty

AMSPMYLERAN TAB

ANALGESICS - ANTI-INFLAMMATORYTier 1-nabumetone tab (RELAFEN equiv)

BETA BLOCKERSTier 1-nadolol tab (CORGARD equiv)

DERMATOLOGICALSTier 2QL-ST

naftifine cream (NAFTIN equiv) (QL= 1 tube/30 days; Step therapy requires

trial of 2 preferred topical antifungal products)

DERMATOLOGICALSTier 2-NAFTIFINE CREAM 1%

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 43 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

DERMATOLOGICALSTier 2-naftifine gel (NAFTIN equiv)

DERMATOLOGICALSTier 2QL-ST

naftifine hcl gel 2% (QL= 60 grams/30 days; ST Trial of 2: ciclopirox

gel/cream, clotrimazole cream, econazole nitrate cream, ketoconazole cream)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Value-naloxone hcl nasal spray (NARCAN equiv)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1-naloxone inj

ANTIDOTES AND SPECIFIC ANTAGONISTS

Value-NALOXONE NASAL SPRAY

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1-naloxone prefilled inj

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 1--QLNALOXONE PREFILLED INJ (QL= 2 inj/fill, 2 fills/month)

ANTIDOTESTier 1-naltrexone tab (REVIA equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QL-ST

NAMENDA XR TITRATION PACK (QL= 28 caps/28 days; Step Therapy

requires trial of memantine tab)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QL-ST

NAMZARIC CAP (QL= 1 cap/day; Step Therapy requires trial of 2: donepezil,

donepezil ODT, memantine, or memantin er)

ANALGESICS - ANTI-INFLAMMATORYTier 1-naproxen EC tab (NAPROSYN EC equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 2-naproxen sodium CR tab (NAPRELAN CR equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-naproxen sodium tab (ANAPROX equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-naproxen susp (NAPROSYN equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 2-NAPROXEN SUSP

ANALGESICS - ANTI-INFLAMMATORYTier 1-naproxen tab (NAPROSYN equiv)

MIGRAINE PRODUCTSTier 1QLnaratriptan tab (AMERGE equiv) (QL= 9 tabs/30 days)

ANTIDOTES AND SPECIFIC ANTAGONISTS

ValueOTCNARCAN HCL SPRAY (OTC)

OPHTHALMIC AGENTSTier 2QLNATACYN OPHTH SUSP (QL= 45ml/30 days)

CONTRACEPTIVES

Preventi

-NATAZIA TAB

ANTIDIABETICSTier 1-nateglinide tab (STARLIX equiv)

BETA BLOCKERSTier 1QLnebivolol hcl tab (BYSTOLIC equiv) (QL= 1 tab/day)

ANTIDEPRESSANTSTier 1-NEFAZODONE TAB

ANTIDEPRESSANTSTier 1-nefazodone tab 50mg, 250mg

AMINOGLYCOSIDESTier 1-neomycin tab

OPHTHALMIC AGENTSTier 1-NEOMYCIN/POLYMIXIN/GRAMICIDIN OPHTH SOLN

OTIC AGENTSTier 1-neomycin/polymixin/hydrocoritisone otic soln (CORTISPORIN equiv)

OTIC AGENTSTier 1-neomycin/polymixin/hydrocoritisone otic susp (CORTISPORIN equiv)

OPHTHALMIC AGENTSTier 1-neomycin/polymyxin/dexamethasone ophth oint (MAXITROL equiv)

OPHTHALMIC AGENTSTier 1-neomycin/polymyxin/dexamethasone ophth soln (MAXITROL equiv)

OPHTHALMIC AGENTSTier 2-NEOMYCIN/POLYMYXIN/HYDROCORTISONE OPHTH SOLN

HEMATOPOIETIC AGENTSTier 2-NEPHRON FA TAB

ANTIVIRALSTier 1QLnevirapine ER tab (VIRAMUNE XR equiv) (QL= 1 tab/day)

ANTIVIRALSTier 2QLNEVIRAPINE ER TAB (QL= 3 tabs/day)

ANTIVIRALSTier 2QLNEVIRAPINE SUSP (QL= 1200ml/30 days)

ANTIVIRALSTier 1QLnevirapine tab (VIRAMUNE equiv) (QL= 2 tabs/day)

COUGH/COLD/ALLERGYTier 2QLNEXAFED SINUS TAB + PAIN (QL= 240 tabs/30 days)

CONTRACEPTIVES

Preventi

-NEXPLANON IMPLANT

CONTRACEPTIVES

Preventi

QLNEXTSTELLIS TAB (QL= 28 tabs/24 days)

ANTIHYPERLIPIDEMICSTier 1QLniacin ER tab (NIASPAN equiv) (QL= 2 tabs/day)

CALCIUM CHANNEL BLOCKERSTier 1-nicardipine cap (CARDENE equiv)

TETRACYCLINESTier 2-NICAZELDOXY KIT

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGNICODERM PATCH (Limited to 180 days/plan year)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 44 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGNICORETTE GUM (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGNICORETTE LOZENGE (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGnicotine gum (NICORETTE equiv) (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGNICOTINE KIT (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGnicotine lozenge (COMMIT equiv) (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

OTC-QL-SMKGnicotine patch (NICODERM equiv) (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGNICOTROL INHALER (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGNICOTROL NASAL SPRAY (Limited to 180 days/plan year)

CALCIUM CHANNEL BLOCKERSTier 1-nifedipine cap (PROCARDIA equiv)

CALCIUM CHANNEL BLOCKERSTier 1-nifedipine ER tab (ADALAT CC equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QLnilutamide tab (NILANDRON equiv) (QL= 150mg/day after the first 30 days)

CALCIUM CHANNEL BLOCKERSTier 2-nimodipine cap (NIMOTOP equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PANINLARO CAP

CALCIUM CHANNEL BLOCKERSTier 2-nisoldipine ER tab (SULAR equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLnitazoxanide tab (ALINIA equiv) (QL= 6 tabs/fill, 2 fills/month)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

LMSP-PAnitisinone cap (ORFADIN equiv)

ANTIANGINAL AGENTSTier 2-NITRO-BID OINT

ANTI-INFECTIVE AGENTS - MISC.Tier 1-nitrofurantoin macrocrystals cap (MACRODANTIN equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-nitrofurantoin monohydrate cap (MACROBID equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-nitrofurantoin susp (FURADANTIN equiv)

ANTIANGINAL AGENTSTier 1-NITROGLYCERIN ER CAP

ANTIANGINAL AGENTSTier 2-nitroglycerin lingual spray (NITROLINGUAL equiv)

ANORECTAL AND RELATED PRODUCTSTier 1RDX

nitroglycerin oint (RECTIV equiv) (Diagnosis Restricted – Anal Fissure

(K60.2))

ANTIANGINAL AGENTSTier 1-nitroglycerin patch (NITRO-DUR equiv)

ANTIANGINAL AGENTSTier 1-nitroglycerin SL tab (NITROSTAT equiv)

ULCER DRUGSTier 1-nizatidine cap (AXID equiv)

ULCER

DRUGS/ANTISPASMODICS/ANTICHOLINERGI

Tier 2-NIZATIDINE CAP

DERMATOLOGICALSTier 1OTCnizoral a-d shampoo (NIZORAL equiv)

CONTRACEPTIVES

Preventi

norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24) (TAYTULLA

equiv)

CONTRACEPTIVES

Preventi

-norethindrone tab (NORA-QD equiv)

PROGESTINSTier 1-norethindrone tab (AYGESTIN equiv)

CONTRACEPTIVES

Preventi

-norethindrone/ethinyl estradiol 21 tab (LOESTRIN 21 equiv)

CONTRACEPTIVES

Preventi

-norethindrone/ethinyl estradiol FE tab (LOESTRIN FE equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 45 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CONTRACEPTIVES

Preventi

-norethindrone/ethinyl estradiol tab (LOESTRIN equiv)

ANTIARRHYTHMICSTier 2-NORPACE CR CAP

CONTRACEPTIVES

Preventi

-nortrel 7/7/7 tab, pirmella 7/7/7 tab (TRI-NORINYL equiv)

CONTRACEPTIVES

Preventi

-nortrel tab (OVCON 35 equiv)

ANTIDEPRESSANTSTier 1-nortriptyline cap (PAMELOR equiv)

ANTIDEPRESSANTSTier 1-nortriptyline oral soln (NORTRIPTYLINE equiv)

ANTIVIRALSTier 2QLNORVIR CAP (QL= 12 caps/day)

ANTIVIRALSTier 2QLNORVIR POWDER PACK (QL= 12 packets/day)

ANTIVIRALSTier 2QLNORVIR SOLN (QL= 480ml/30 days)

MEDICAL DEVICES AND SUPPLIESTier 1OTCNOVOFINE PEN NEEDLE

ANTIDIABETICSValueOTC-QLNOVOLIN 70/30 FLEXPEN INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN 70/30 INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN N FLEXPEN INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN N INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN N RELION INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN R FLEXPEN INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN R INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN RELION INJ 70/30 (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLIN VIAL (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLOG FLEXPEN INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLOG INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLOG MIX FLEXPEN INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLOG MIX INJ (QL= 60 units/30 days)

ANTIDIABETICSValueQLNOVOLOG PENFILL INJ (QL= 60 units/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLNOVOPEN ECHO (QL= 1 pen device/365 days)

MEDICAL DEVICES AND SUPPLIESTier 1OTCNOVOTWIST PEN NEEDLE

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

NUBEQA TAB (QL= 4 tabs/day; Only available through Walgreens

888-347-3416)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2

Specialty

AMSP-PA-QLNUCALA INJ (QL= 1 inj/28 days)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QL-ST

NUEDEXTA CAP (QL= 2 caps/day; Step therapy requires trial of 1 SSRI AND 1

TCA)

CONTRACEPTIVES

Preventi

-NUVARING

VAGINAL PRODUCTSTier 2QL-ST

NUVESSA VAGINAL GEL, VANDAZOLE GEL (QL= 1 package/30 days; Step

therapy requires trial of metronidazole tab or clindamycin cap/oral soln)

DERMATOLOGICALSTier 1-nystatin cream (MYCOSTATIN CREAM equiv)

DERMATOLOGICALSTier 1-nystatin oint

ANTIFUNGALSTier 1-nystatin powder

MOUTH/THROAT/DENTAL AGENTSTier 1-nystatin susp

ANTIFUNGALSTier 1-nystatin tab

DERMATOLOGICALSTier 1-nystatin topical powder

DERMATOLOGICALSTier 1-nystatin/triamcinolone cream

DERMATOLOGICALSTier 1-nystatin/triamcinolone oint

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLNYVEPRIA INJ (QL= 2 inj/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

AMSP-PAoctreotide inj (SANDOSTATIN equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 46 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

AMSP-PAOCTREOTIDE INJ 100MCG

ALLERGENIC EXTRACTS/BIOLOGICALS

MISC

Tier 2QLODACTRA SL TAB (QL= 30 tabs/30 days)

ANTIVIRALSTier 2QLODEFSEY TAB (QL= 1 tab/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-SFODOMZO CAP

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL-SF

OFEV CAP (QL= 2 caps/day; Only available through Accredo 800-803-2523

or Walgreens 888-347-3416)

OPHTHALMIC AGENTSTier 1-ofloxacin ophth soln (OCUFLOX equiv)

OTIC AGENTSTier 1-ofloxacin otic soln (FLOXIN equiv)

FLUOROQUINOLONESTier 1-ofloxacin tab (FLOXIN equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPolanzapine inj (ZYPREXA equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLolanzapine ODT (ZYPREXA equiv) (QL= 1 tab/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-olanzapine tab (ZYPREXA equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QLolanzapine/fluoxetine cap (SYMBYAX equiv) (QL= 1 cap/day)

ANTIHYPERTENSIVESTier 1-olmesartan tab (BENICAR equiv)

ANTIHYPERTENSIVESTier 1QL

olmesartan/amlodipine/hydrochlorothiazide tab (TRIBENZOR TAB equiv) (QL=

30 tabs/30 days)

ANTIHYPERTENSIVESTier 1-olmesartan/hydrochlorothiazide tab (BENICAR HCT equiv)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 2QLolopatadine nasal spray (PATANASE equiv) (QL= 30.5ml/30 days)

ANTIVIRALS

Tier 2

Specialty

LD-PAOLYSIO CAP (Only available through Walgreens 888-347-3416)

ANTIHYPERLIPIDEMICSTier 1QLomega-3-acid ethyl esters cap (LOVAZA equiv) (QL= 4 caps/day)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD 5 G6 KIT (QL= 1 kit/year)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD 5 G6 MIS PODS (QL= 15 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD 5 G7 KIT INTRO (QL= 1 kit/year)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD 5 G7 MIS PODS (QL= 15 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD 5 PACK PODS (QL= 15 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD DASH KIT (QL= 1 kit/year)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD DASH PODS (QL= 15 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 10 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 15 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 20 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 25 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 30 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 35 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD GO KIT 40 UNITS/DAY (QL= 10 pods/30 days)

MEDICAL DEVICES AND SUPPLIESTier 2QLOMNIPOD STARTER KIT (QL= 1 kit/year)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLOMNITROPE INJ (QL= 9 cartridges/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-QLOMNITROPE INJ 5.8MG (QL= 8 vials/28 days)

ANTIEMETICSTier 1-ondansetron ODT (ZOFRAN equiv)

ANTIEMETICSTier 1QLondansetron soln (ZOFRAN equiv) (QL= 50ml/fill, 1 fill/15 days)

ANTIEMETICSTier 1-ONDANSETRON TAB

ANTIEMETICSTier 1-ondansetron tab (ZOFRAN equiv)

CONTRACEPTIVES

Preventi

-OPILL TAB

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 47 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

OPSUMIT TAB (QL= 1 tab/day; Only available through Accredo

800-803-2523)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Tier 2-OPVEE NASAL SPRAY

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2-ORACIT SOLN

BIOLOGICALS MISCTier 2QLORALAIR SL TAB (QL= 30 tabs/30 days)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PAORENITRAM TAB (Only available through Accredo 888-773-7376)

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

ORKAMBI GRANULES PACKET (QL= 2 packets/day; Only available through

Walgreens 888-347-3416)

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

ORKAMBI TAB (QL= 4 tabs/day; Only available through Walgreens

888-347-3416)

MUSCULOSKELETAL THERAPY AGENTSTier 1-orphenadrine citrate ER tab (NORFLEX equiv)

MUSCULOSKELETAL THERAPY AGENTSTier 2QL-ST

orphenadrine/aspirin/caffeine tab (NORGESIC FORTE equiv) (QL= 4 tabs/day;

Step therapy requires trial of 2: baclofen tab, tizanidine tab/cap,

cyclobenzaprine tab, methocarbamol tab, carisoprodol tab, orphenadrine tab)

ANTIVIRALSTier 1QLoseltamivir cap 30mg (TAMIFLU equiv) (QL= 40 caps/183 days)

ANTIVIRALSTier 1QLoseltamivir cap 45mg (TAMIFLU equiv) (QL= 40 caps/183 days)

ANTIVIRALSTier 1QLoseltamivir cap 75mg (TAMIFLU equiv) (QL= 20 caps/183 days)

ANTIVIRALSTier 1QLoseltamivir susp (TAMIFLU equiv) (QL= 360ml/183 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLOTEZLA STARTER PACK (QL= 1 pack/28 days)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLOTEZLA TAB (QL= 2 tabs/day)

OTIC AGENTSTier 1-otomax-HC otic soln (CORTANE-B equiv)

ANDROGENS-ANABOLICTier 1PAOXANDROLONE TAB

ANALGESICS - ANTI-INFLAMMATORYTier 1-oxaprozin tab (DAYPRO equiv)

ANTIANXIETY AGENTSTier 2ST

oxazepam cap (SERAX equiv) (Step Therapy requires trial of 2: alprazolam,

chlordiazepoxide, diazepam, or lorazepam tab)

ANTICONVULSANTSTier 1-oxcarbazepine susp (TRILEPTAL equiv)

ANTICONVULSANTSTier 1-oxcarbazepine tab (TRILEPTAL equiv)

DERMATOLOGICALSTier 2-oxiconazole nitrate cream (OXISTAT equiv)

URINARY ANTISPASMODICSTier 1-oxybutynin ER tab (DITROPAN XL equiv)

URINARY ANTISPASMODICSTier 1-oxybutynin syrup

URINARY ANTISPASMODICSTier 1-oxybutynin tab (DITROPAN equiv)

ANALGESICS - OPIOIDTier 1QL

oxycodone cap (OXYIR equiv) (QL= 18 caps/fill for members age 20 or

younger; QL= 42 caps/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 2QL

oxycodone conc (ROXICODONE equiv) (QL= 90ml/fill for members age 20 or

younger; QL= 210ml/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 10MG (QL= 2 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 15MG (QL= 2 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 20MG (QL= 2 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 30MG (QL= 2 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 40MG (QL= 2 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 48 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 60MG (QL= 2 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 2PA-QL-ST

OXYCODONE ER TAB 80MG (QL= 4 tabs/day; Step Therapy requires trial of

morphine sulfate ER tab)

ANALGESICS - OPIOIDTier 1QL

oxycodone soln (ROXICODONE equiv) (QL= 90ml/fill for members age 20 or

younger; QL= 210ml/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone tab (ROXICODONE equiv) (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone/acetaminophen cap (TYLOX equiv) (QL= 18 caps/fill for members

age 20 or younger; QL= 42 caps/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone/acetaminophen tab 10-325mg (PERCOCET equiv) (QL= 18 tabs/fill

for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone/acetaminophen tab 2.5-325mg (PERCOCET equiv) (QL= 18 tabs/fill

for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone/acetaminophen tab 5-325mg (PERCOCET equiv) (QL= 18 tabs/fill

for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone/acetaminophen tab 7.5-325mg (PERCOCET equiv) (QL= 18 tabs/fill

for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

OXYCODONE/ASPIRIN TAB (QL= 18 tabs/fill for members age 20 or younger;

QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 1QL

OXYCODONE/IBUPROFEN TAB (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 1QL

oxycodone/ibuprofen tab (COMBUNOX equiv) (QL= 18 tabs/fill for members

age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 10MG (QL= 2 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 15MG (QL= 2 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 20MG (QL= 2 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 30MG (QL= 4 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLoxymorphone ER tab 30mg (OPANA ER equiv) (QL= 4 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 40MG (QL= 4 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLoxymorphone ER tab 40mg (OPANA ER equiv) (QL= 4 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 5MG (QL= 2 tabs/day)

ANALGESICS - OPIOIDTier 2PA-QLOXYMORPHONE ER TAB 7.5MG (QL= 2 tabs/day)

ANALGESICS - OPIOIDTier 1QL

oxymorphone tab (OPANA equiv) (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANTIDIABETICSTier 2QL-RDX

OZEMPIC INJ (QL= 3ml/28 days; Diagnosis Restricted – Type 2 Diabetes

(E11))

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLpaliperidone ER tab (INVEGA equiv) (QL= 1 tab/day)

CONTRACEPTIVES

Preventi

-PARAGARD IUD

DERMATOLOGICALSTier 1-paramox hc gel (NOVACORT GEL equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 49 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1-paricalcitol cap (ZEMPLAR equiv)

AMINOGLYCOSIDESTier 1-paromomycin cap (HUMATIN equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QLparoxetine cap (BRISDELLE equiv) (QL= 1 cap/day)

ANTIDEPRESSANTSTier 2-paroxetine ER tab (PAXIL CR equiv)

ANTIDEPRESSANTSTier 2QL-ST

paroxetine oral susp (PAXIL equiv) (QL= 900ml/30 days; Step therapy

requires trial and failure of 2 generic SSRI/SNRIs)

ANTIDEPRESSANTSTier 1-paroxetine tab (PAXIL equiv)

ANTIVIRALSTier 2QLPAXLOVID TAB 150-100

ANTIVIRALSTier 2QLPAXLOVID TAB 300-100

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFpazopanib hcl tab (VOTRIENT equiv) (QL= 120 tabs/30 days)

ULCER DRUGSTier 2QLpb-belladonna elixir (DONNATAL equiv) (QL= 1200ml/30 days)

MACROLIDESTier 2-PCE TAB

MULTIVITAMINS

Preventi

-pediatric multiple vitamins/fluoride soln

LAXATIVESTier 2-peg 3350 soln (100 gram Moviprep equiv) (MOVIPREP equiv)

LAXATIVES

Preventi

peg 3350/electrolytes soln (COLYTE equiv) (Covered at $0 for members

45-75 years-Limited to 2 fills/calendar year; All other members covered at

generic copay)

ANTIVIRALS

Tier 2

Specialty

AMSP-PAPEGASYS INJ

ANTIVIRALS

Tier 2

Specialty

LMSP-PAPEG-INTRON INJ (Only available through Lumicera 855-847-3553)

VACCINES

Preventi

-PENBRAYA INJ (Covered for members age 10 through 25 years)

DERMATOLOGICALSTier 2QL-ST

penciclovir cream (DENAVIR equiv) (QL= 5 grams/30 days; Step therapy

requires trial of 2: VALACYCLOVIR HCL TAB, FAMCICLOVIR TAB,

ACYCLOVIR TAB)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2-penicillamine cap (CUPRIMINE equiv)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 1QLpenicillamine tab (DEPEN TITRATAB equiv) (QL= 480 tabs/30 days)

PENICILLINSTier 1-penicillin vk tab (VEETIDS equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2-pentamidine neb soln (NEBUPENT equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 2STPENTASA CAP 500MG (Step Therapy requires trial of APRISO or LIALDA)

ANALGESICS - OPIOIDTier 1QL

pentazocine/acetaminophen tab (TALACEN equiv) (QL= 18 tabs/fill for

members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

ANALGESICS - OPIOIDTier 1QL

pentazocine/naloxone tab (TALWIN NX equiv) (QL= 18 tabs/fill for members

age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

HEMATOLOGICAL AGENTS - MISC.Tier 1-pentoxifylline ER tab (TRENTAL equiv)

ANTIHYPERTENSIVESTier 1-perindopril tab (ACEON equiv)

DERMATOLOGICALSTier 1-permethrin cream (ELIMITE CREAM equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-perphenazine tab (TRILAFON equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-PERPHENAZINE/ AMITRIPTYLINE TAB

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPPERSERIS INJ

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-phenazopyridine tab (PYRIDIUM equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 50 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIDEPRESSANTSTier 1QLPHENELZINE SULFATE TAB (QL= 4 tabs/day)

ANTIDEPRESSANTSTier 1-phenelzine tab (NARDIL equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-phenobarbital elixir

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-phenobarbital tab

ANTIHYPERTENSIVESTier 2-phenoxybenzamine cap (DIBENZYLINE equiv)

OPHTHALMIC AGENTSTier 1-phenylephrine ophth soln (MYDFRIN equiv)

ANTICONVULSANTSTier 1-phenytoin cap (DILANTIN equiv)

ANTICONVULSANTSTier 1-phenytoin chew tab (DILANTIN equiv)

ANTICONVULSANTSTier 1-phenytoin susp (DILANTIN equiv)

VAGINAL AND RELATED PRODUCTS

Preventi

QLPHEXXI GEL (QL= 180gm/30 days)

GASTROINTESTINAL AGENTS - MISC.Tier 2-PHOSLYRA SOLN

VITAMINSTier 1-phytonadione tab (MEPHYTON equiv)

ANTIVIRALSTier 2-PIFELTRO TAB

OPHTHALMIC AGENTSTier 1-pilocarpine ophth soln (ISOPTO CARPINE equiv)

MOUTH/THROAT/DENTAL AGENTSTier 1-pilocarpine tab (SALAGEN equiv)

DERMATOLOGICALSTier 2ST

pimecrolimus cream (ELIDEL equiv) (Step Therapy requires trial of tacrolimus

oint)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2-PIMOZIDE TAB

BETA BLOCKERSTier 1-pindolol tab (VISKEN equiv)

ANTIDIABETICSTier 1QLpioglitazone tab (ACTOS equiv) (QL= 1 tab/day)

ANTIDIABETICSTier 2ST

pioglitazone/glimepiride tab (DUETACT equiv) (Step Therapy requires trial of

metformin or metformin ER)

ANTIDIABETICSTier 1-pioglitazone/metformin tab (ACTOPLUS MET equiv)

RESPIRATORY AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QL-SFpirfenidone cap (ESBRIET equiv) (QL= 3 caps/day)

RESPIRATORY AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QL-SFpirfenidone tab 267mg (ESBRIET equiv) (QL= 9 tabs/day)

RESPIRATORY AGENTS - MISC.

Tier 1

Specialty

LD-PA-QL-SF

PIRFENIDONE TAB 534MG (QL= 4 tabs/day; Only available through Lumicera

855-847-3553)

RESPIRATORY AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QL-SFpirfenidone tab 801mg (ESBRIET equiv) (QL= 3 tabs/day)

ANALGESICS - ANTI-INFLAMMATORYTier 1-piroxicam cap (FELDENE equiv)

ANTIHYPERLIPIDEMICSTier 2QL-ST

pitavastatin calcium tab (LIVALO equiv) (QL= 1 tab/day; ST req trial of 2:

Altoprev tab, FLOLIPID SUSP, Ator, Lova, Rosu, Prava OR Simvastatin tabs)

CONTRACEPTIVES

Preventi

OTCPLAN B TAB

VACCINES

Preventi

VACPNEUMOVAX INJ

DERMATOLOGICALSTier 2-PODOCON SOLN

DERMATOLOGICALSTier 2QL-ST

podofilox gel (CONDYLOX equiv) (QL= 15g/30 days; ST req trial of podofilox

soln AND imiquimod 5% cream)

DERMATOLOGICALSTier 1-podofilox soln (CONDYLOX equiv)

PHARMACEUTICAL ADJUVANTSTier 2-POLYETHYLENE GLYCOL 8000 GRANULES

OPHTHALMIC AGENTSTier 1-polymyxin b/trimethoprim ophth soln (POLYTRIM equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

POMALYST CAP (QL= 21 caps/28 days; Only available through Walgreens

888-347-3416)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 51 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIFUNGALSTier 2QL-ST

posaconazole DR tab (NOXAFIL equiv) (QL= 8 tabs/day; Step Therapy

requires trial of fluconazole, itraconazole or VFEND)

ANTIFUNGALSTier 2ST

posaconazole susp (NOXAFIL equiv) (Step therapy requires trial of

fluconazole, itraconazole or voriconazole)

MINERALS & ELECTROLYTESTier 1-POT/CHLORIDE EFFER TAB

VITAMINSTier 2-POTABA POWDER PACKET

MINERALS & ELECTROLYTESTier 2-potassium bicarbonate effer tab (K-LYTE equiv)

MINERALS & ELECTROLYTESTier 1-potassium chloride effer tab (K-LYTE/CL equiv)

MINERALS & ELECTROLYTESTier 1-potassium chloride ER cap (MICRO-K equiv)

MINERALS & ELECTROLYTESTier 1-potassium chloride ER tab (K-TAB equiv)

MINERALS & ELECTROLYTESTier 1-potassium chloride micro tab (K-DUR equiv)

MINERALS & ELECTROLYTESTier 2-potassium chloride powder packet (KLOR-CON equiv)

MINERALS & ELECTROLYTESTier 2-potassium chloride soln

MINERALS & ELECTROLYTESTier 1-POTASSIUM CHLORIDE TAB ER

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-potassium citrate CR tab (UROCIT-K TAB equiv)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-potassium citrate/citric acid powder pack (POLYCITRA equiv)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-potassium citrate/citric acid soln (POLYCITRA-K equiv)

COUGH/COLD/ALLERGYTier 1QLpotassium iodide oral soln (SSKI equiv) (QL= 90ml/30 days)

MINERALS & ELECTROLYTESTier 1QLpotassium phosphate monobasic tab (K-PHOS equiv) (QL= 8 tabs/day)

ANTIPARKINSON AGENTSTier 2QLpramipexole ER tab (MIRAPEX ER equiv) (QL= 1 tab/day)

ANTIPARKINSON AGENTSTier 1-pramipexole tab (MIRAPEX equiv)

DERMATOLOGICALSTier 2-PRAMOSONE CREAM 1-1%

DERMATOLOGICALSTier 2-PRAMOSONE E CREAM

HEMATOLOGICAL AGENTS - MISC.Tier 1QLprasugrel tab (EFFIENT equiv) (QL= 1 tab/day)

ANTIHYPERLIPIDEMICS

Preventi

pravastatin tab (PRAVACHOL equiv) (QL= 1 tab/day; Covered at $0 for

members 40 years or older; All other members covered at generic copay)

ANTHELMINTICSTier 1-praziquantel tab (BILTRICIDE equiv)

ANTIHYPERTENSIVESTier 1-prazosin cap (MINIPRESS equiv)

DIAGNOSTIC PRODUCTSTier 1OTC-QLPRECISION XTRA TEST STRIP (QL= 300 test strips/30 days)

OPHTHALMIC AGENTSTier 2-PRED MILD OPHTH SOLN

OPHTHALMIC AGENTSTier 2-PRED-G OPHTH SOLN

DERMATOLOGICALSTier 2-PREDNICARBATE CREAM

DERMATOLOGICALSTier 2-PREDNICARBATE OIN

CORTICOSTEROIDSTier 2ST

prednisolone ODT (ORAPRED equiv) (Step therapy requires trial of two of the

following: prednisolone oral soln, methylprednisolone, prednisone tab/soln)

OPHTHALMIC AGENTSTier 1-PREDNISOLONE OPHTH SUSP

OPHTHALMIC AGENTSTier 1-PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN

CORTICOSTEROIDSTier 1-prednisolone soln

CORTICOSTEROIDSTier 1-prednisolone soln (PEDIAPRED equiv)

CORTICOSTEROIDSTier 2-PREDNISOLONE SOLN

CORTICOSTEROIDSTier 2ST

prednisolone tab (MILLIPRED equiv) (Step therapy requires trial of 2:

prednisolone oral soln, methylprednisolone, prednisone tab/soln)

CORTICOSTEROIDSTier 1-prednisone pack

CORTICOSTEROIDSTier 1-PREDNISONE SOLN

CORTICOSTEROIDSTier 1-prednisone tab (DELTASONE equiv)

ANTICONVULSANTSTier 1-pregabalin cap (LYRICA equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 52 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QL-ST

pregabalin ER tab (LYRICA equiv) (QL= 30 tabs/30 days; Step Therapy

requires trial of gabapentin and pregabalin cap or pregabalin soln)

ANTICONVULSANTSTier 1QLpregabalin soln (LYRICA equiv) (QL= 30ml/day)

MULTIVITAMINSTier 2-PRENATABS RX TAB

MULTIVITAMINSTier 2-PRENATAL 19 CHEW TAB

MULTIVITAMINSTier 2-PRENATAL 19 TAB

MULTIVITAMINSTier 2-PRENATAL VITAMINS (PRENATAL PLUS, PREPLUS, PRENAPLUS)

MOUTH/THROAT/DENTAL AGENTS

Preventi

PREVIDENT 5000 PLUS CREAM (Covered at $0 for members 5 years or

younger; All other members covered at preferred brand copay)

VACCINES

Preventi

VACPREVNAR 13 INJ

VACCINES

Preventi

VACPREVNAR 20 INJ

ANTIVIRALSTier 2QLPREZCOBIX TAB (QL= 1 tab/day)

ANTIVIRALSTier 2QLPREZISTA SUSP (QL= 400ml/30 days)

ANTIVIRALSTier 2QLPREZISTA TAB (QL= 1 tab/day)

ANTIVIRALSTier 2QLPREZISTA TAB 150MG (QL= 8 tabs/day)

ANTIVIRALSTier 2QLPREZISTA TAB 600MG (QL= 2 tabs/day)

ANTIVIRALSTier 2QLPREZISTA TAB 75MG (QL= 16 tabs/day)

ANTIMALARIALSTier 2-primaquine tab (PRIMAQUINE equiv)

ANTICONVULSANTSTier 1QLPRIMIDONE TAB (QL= 4 tabs/day)

ANTICONVULSANTSTier 1QL--primidone tab (MYSOLINE equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2-PRIMSOL SOLN

VACCINES

Preventi

VACPRIORIX INJ

GOUT AGENTSTier 1-probenecid tab (BENEMID equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-prochlorperazine supp (COMPAZINE equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-prochlorperazine tab (COMPAZINE equiv)

ANORECTAL AGENTSTier 2-PROCTOFOAM HC FOAM

ANORECTAL AGENTSTier 1-proctosol HC cream (ANUSOL HC equiv)

MIGRAINE PRODUCTSTier 1-PRODRIN TAB

PROGESTINSTier 1-progesterone cap (PROMETRIUM equiv)

PROGESTINSTier 1-progesterone oil inj

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-PA-QLPROMACTA POWDER (QL= 6 packets/day)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-PA-QLPROMACTA TAB (QL= 2 tabs/day)

COUGH/COLD/ALLERGYTier 1-promethazine DM syrup

ANTIHISTAMINESTier 1-promethazine inj (PHENERGAN equiv)

ANTIHISTAMINESTier 1-promethazine supp (PHENERGAN equiv)

ANTIHISTAMINESTier 1-promethazine syrup

ANTIHISTAMINESTier 1-promethazine tab (PHENERGAN equiv)

COUGH/COLD/ALLERGYTier 1-PROMETHAZINE VC SYRUP

COUGH/COLD/ALLERGYTier 1-promethazine VC syrup (PHENERGAN VC equiv)

COUGH/COLD/ALLERGYTier 1-PROMETHAZINE VC/CODEINE SYRUP

COUGH/COLD/ALLERGYTier 1-promethazine VC/codeine syrup (PHENERGAN VC/CODEINE equiv)

COUGH/COLD/ALLERGYTier 1-promethazine/codeine syrup (PHENERGAN/CODEINE equiv)

ANTIHISTAMINESTier 1-PROMETHEGAN SUPP

ANTIARRHYTHMICSTier 2-propafenone ER cap (RYTHMOL SR equiv)

ANTIARRHYTHMICSTier 1-propafenone tab (RYTHMOL equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 53 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ULCER DRUGSTier 2-PROPANTHELINE TAB

OPHTHALMIC AGENTSTier 1-proparacaine ophth soln (ALCAINE equiv)

BETA BLOCKERSTier 1-propranolol ER cap (INDERAL LA equiv)

BETA BLOCKERSTier 1-propranolol oral soln

BETA BLOCKERSTier 1-PROPRANOLOL SOLN

BETA BLOCKERSTier 1-propranolol tab (INDERAL equiv)

ANTIHYPERTENSIVESTier 1-propranolol/hydrochlorothiazide tab (INDERIDE equiv)

THYROID AGENTSTier 1-propylthiouracil tab

VACCINES

Preventi

-PROQUAD INJ

ANTIDEPRESSANTSTier 1-protriptyline tab (VIVACTIL equiv)

ANTIDEPRESSANTSTier 2QL-ST

PROZAC WEEKLY CAP (QL= 4 caps/28 days; Step Therapy requires trial of

fluoxetine IR)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 1QLpseudoephedrine ER tab 120mg (QL= 2 tabs/day)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 1QLpseudoephedrine liquid 15mg/5ml (QL= 2400ml/30 days)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 1QLpseudoephedrine tab 30mg (QL= 8 tabs/day)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 1QLpseudoephedrine tab 60mg (QL= 4 tabs/day)

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

AMSP-QL-RDXPULMOZYME INH SOLN (QL= 30 ampules/30 days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-STPURIXAN SUSP (Step Therapy requires trial of mercaptopurine tab)

ANTIMYCOBACTERIAL AGENTSTier 1-pyrazinamide tab

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Tier 1-pyridostigmine CR tab (MESTINON equiv)

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Tier 1-pyridostigmine tab (MESTINON equiv)

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Tier 2-pyridstigmine soln (MESTINON equiv)

ANTIMALARIALS

Tier 1

Specialty

LD-PA-QL

pyrimethamine tab (DARAPRIM equiv) (QL= 3 tabs/day; Only available through

Walgreens 888-347-3416)

ANTIDIABETICSTier 2QL-ST

QTERN TAB (QL= 30 tabs/30 days; Step Therapy requires trial of metformin

or metformin ER)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLquetiapine tab (SEROQUEL equiv) (QL= 3 tabs/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLquetiapine XR tab (SEROQUEL XR equiv) (QL= 1 tab/day)

ANTIHYPERTENSIVESTier 1-quinapril tab (ACCUPRIL equiv)

ANTIHYPERTENSIVESTier 1-QUINAPRIL/HCTZ TAB

ANTIHYPERTENSIVESTier 1-quinapril/hydrochlorothiazide tab (ACCURETIC equiv)

ANTIARRHYTHMICSTier 2-quinidine gluconate CR tab

ANTIARRHYTHMICSTier 1QLquinidine sulfate tab (QL= 8 tabs/day)

ANTIARRHYTHMICSTier 2QLQUINIDINE SULFATE TAB 200MG (QL= 8 tabs/day)

ANTIARRHYTHMICSTier 2QLQUINIDINE SULFATE TAB 300MG (QL= 5 tabs/day)

ANTIMALARIALSTier 1-quinine sulfate cap (QUALAQUIN equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

ValueQLQVAR REDIHALER (QL= 21.2gm/30 days)

VACCINESTier 2VACRABAVERT INJ

NEUROMUSCULAR AGENTS

Tier 2

Specialty

LD-PA-QL

RADICAVA ORS SUSP (QL= 70ml/28 days; Only available through Accredo

800-803-2523)

BIOLOGICALS MISCTier 2QLRAGWITEK SL TAB (QL= 30 tabs/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Preventi

QLraloxifene tab (EVISTA equiv) (QL= 1 tab/day)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 2QL-ST

ramelteon tab (ROZEREM equiv) (QL= 1 tab/day; Step Therapy requires trial of

2: eszopiclone, zaleplon, zolpidem, zolpidem ER tab, or zolpidem SL)

ANTIHYPERTENSIVESTier 1-ramipril cap (ALTACE equiv)

ULCER DRUGSTier 1-ranitidine cap (ZANTAC equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 54 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ULCER DRUGSTier 1-ranitidine syrup (ZANTAC equiv)

ULCER DRUGSTier 1-ranitidine tab (Rx Only) (ZANTAC equiv)

ANTIANGINAL AGENTSTier 1QLranolazine tab (RANEXA equiv) (QL= 120 tabs/30 days)

ANTIPARKINSON AGENTSTier 1QLrasagiline tab (AZILECT equiv) (QL= 1 tab/day)

ANTIVIRALS

Tier 2

Specialty

AMSP-PAREBETOL SOLN

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

LDREBINYN INJ (Only available through Walgreens 888-347-3416)

ANTIVIRALSTier 2QLRELENZA DISKHALER (QL= 1 inhaler/fill, 1 fill/month)

GASTROINTESTINAL AGENTS - MISC.Tier 1-RELTONE CAP

ANTIDIABETICSTier 1-repaglinide tab (PRANDIN equiv)

ANTIDIABETICSTier 2-REPAGLINIDE TAB

ANTIHYPERLIPIDEMICSTier 2PA-QLREPATHA INJ (QL= 2 inj/28 days)

ANTIHYPERLIPIDEMICSTier 2PA-QLREPATHA PUSHTRONEX INJ (QL= 1 inj/28 days)

ANTIVIRALSTier 2-RESCRIPTOR TAB

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLRETACRIT INJ (QL= 12 vials/30 days)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLRETACRIT INJ (QL= 4 vials/30 days)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 2QL-ST

REXULTI TAB (QL= 2 packs/plan year; Step Therapy requires trial of 2:

aripiprazole, quetiapine, ziprasidone, olanzapine, risperidone, or lurasidone)

ANTIVIRALSTier 2QLREYATAZ POWDER PACK (QL= 5 packets/day)

ANTIDIARRHEALSTier 1-REZYST CHEW TAB

ANTIVIRALS

Tier 2

Specialty

AMSP-STRIBAPAK TAB (Step Therapy requires trial of ribavirin)

ANTIVIRALS

Tier 1

Specialty

AMSPRIBAVIRIN CAP

ANTIVIRALS

Tier 1

Specialty

AMSPribavirin cap (REBETOL equiv)

ANTIVIRALS

Tier 1

Specialty

AMSPRIBAVIRIN TAB

ANTIMYCOBACTERIAL AGENTSTier 1-rifabutin cap (MYCOBUTIN equiv)

ANTIMYCOBACTERIAL AGENTSTier 1-rifampin cap (RIFADIN equiv)

NEUROMUSCULAR AGENTS

Tier 1

Specialty

AMSPriluzole tab (RILUTEK equiv)

ANTIVIRALSTier 1-RIMANTADINE TAB

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLRINVOQ ER TAB (QL= 1 tab/day)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLRINVOQ ER TAB 45MG (QL= 1 tab/day, 3 fills/year)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLRINVOQ ORAL SOLN (QL= 360ml/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2QL-ST

risedronate DR tab (ATELVIA equiv) (QL= 4 tabs/28 days; Step Therapy

requires trial of alendronate)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2QL-ST

risedronate tab 150mg (ACTONEL equiv) (QL= 1 tab/30 days; Step Therapy

requires trial of alendronate)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLrisedronate tab 30mg (ACTONEL equiv) (QL= 1 tab/day)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLrisedronate tab 35mg (ACTONEL equiv) (QL= 4 tabs/28 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 55 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1QLrisedronate tab 5mg (ACTONEL equiv) (QL= 1 tab/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 1

Specialty

AMSPrisperidone microspheres inj (RISPERDAL equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-risperidone ODT (RISPERDAL M equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 2-RISPERIDONE ODT

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-risperidone soln (RISPERDAL equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-risperidone tab (RISPERDAL equiv)

ANTIVIRALSTier 1QLritonavir tab (NORVIR equiv) (QL= 12 tabs/day)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1-rivastigmine cap (EXELON equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2QLrivastigmine patch (EXELON equiv) (QL= 1 patch/day)

MIGRAINE PRODUCTSTier 1QLrizatriptan ODT (MAXALT equiv) (QL= 12 tabs/30 days)

MIGRAINE PRODUCTSTier 1QLrizatriptan tab (MAXALT equiv) (QL= 12 tabs/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1PA-QLroflumilast tab (DALIRESP equiv) (QL= 1 tab/day)

ANTIPARKINSON AGENTSTier 2QL-ST

ropinirole ER tab (REQUIP XL equiv) (QL= 1 tab/day; Step Therapy requires

trial of ropinirole)

ANTIPARKINSON AGENTSTier 1-ropinirole tab (REQUIP equiv)

ANTIHYPERLIPIDEMICS

Preventi

rosuvastatin tab (CRESTOR equiv) (QL= 1 tab/day; Covered at $0 for

members 40 years or older; All other members covered at generic copay)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

RUBRACA TAB (QL= 4 tabs/day; Only available through Optum

877-445-6874)

ANTICONVULSANTSTier 2QL-ST

rufinamide susp (BANZEL equiv) (QL= 80ml/day; Step Therapy requires trial

of two: valproate, lamotrigine, topiramate, pregabalin, levetiracetam)

ANTICONVULSANTSTier 2QL-ST

rufinamide tab (BANZEL equiv) (QL= 8 tabs/day; Step Therapy requires trial

of two: valproate, lamotrigine, topiramate, pregabalin, levetiracetam)

ANTIDIABETICSTier 2QL-RDX

RYBELSUS TAB (QL= 1 tab/day; Diagnosis Restricted – Type 2 Diabetes

(E11))

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPRYKINDO INJ

MEDICAL DEVICES AND SUPPLIESTier 2-SAFETY SYRINGE

DERMATOLOGICALSTier 2-salicylic acid aerosol

DERMATOLOGICALSTier 1-salicylic acid shampoo (SALEX equiv)

ANALGESICS - NONNARCOTICTier 1-salsalate tab (DISALCID equiv)

DERMATOLOGICALSTier 2QLSANTYL OINT (QL= 90gm/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

AMSP-PAsapropterin dihydrochloride powder packet (KUVAN equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

AMSP-PAsapropterin dihydrochloride soluble tab (KUVAN equiv)

ANTIDIABETICSTier 2QL-ST

saxagliptin hcl tab (ONGLYZA equiv) (QL= 1 tab/day; ST req trial of metformin

AND Tradjenta OR Jentadueto)

ANTIDIABETICSTier 2QL-ST

saxagliptin-metformin hcl tab er 24hr (KOMBIGLYZE equiv) (QL= 2 tabs/day;

Step Therapy requires trial of metformin AND Tradjenta, OR Jentadueto)

ANTIEMETICSTier 1QLscopolamine patch (TRANSDERM-SCOP equiv) (QL= 10 patches/30 days)

CONTRACEPTIVES

Preventi

-SEASONIQUE TAB

ANTIPARKINSON AGENTSTier 1-selegiline cap (ELDEPRYL equiv)

ANTIPARKINSON AGENTSTier 1QLselegiline tab (ELDEPRYL equiv) (QL= 2 tabs/day)

DERMATOLOGICALSTier 1-selenium sulfide lotion

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 56 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

DERMATOLOGICALSTier 1-selenium sulfide shampoo (SELSEB equiv)

ANTIVIRALSTier 2QLSELZENTRY SOLN (QL= 31ml/day)

ANTIVIRALSTier 2QLSELZENTRY TAB 150MG (QL= 2 tabs/day)

ANTIVIRALSTier 2QLSELZENTRY TAB 25MG (QL= 4 tabs/day)

ANTIVIRALSTier 2QLSELZENTRY TAB 300MG (QL= 4 tabs/day)

ANTIVIRALSTier 2QLSELZENTRY TAB 75MG (QL= 2 tabs/day)

ANTIDEPRESSANTSValue-sertraline conc (ZOLOFT equiv)

ANTIDEPRESSANTSValue-sertraline tab (ZOLOFT equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-sevelamer hydrochloride tab (RENAGEL equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-sevelamer powder pak (RENVELA equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-sevelamer tab (RENVELA TAB equiv)

VACCINES

Preventi

VACSHINGRIX INJ (Covered for members age 18 or older)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA-QL

SIGNIFOR INJ (QL= 2 vials/day; Only available through Anovo Specialty

Pharmacy 844-288-5007)

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

AMSP-PA-QLsildenafil susp (REVATIO equiv) (QL= 224ml/30 days)

CARDIOVASCULAR AGENTS - MISC.Tier 1QLsildenafil tab 20mg (REVATIO equiv) (QL= 3 tabs/day)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2-silodosin cap (RAPAFLO equiv)

DERMATOLOGICALSTier 2-SILVER NITRATE SOLN

DERMATOLOGICALSTier 1-silver sulfadiazine cream (SILVADENE CREAM equiv)

ANTIHYPERLIPIDEMICSTier 2QL-ST

SIMVASTATIN SUSP (QL= 300ml/30 days; Step Therapy requires trial of 2:

atorvastatin, rosuvastatin or simvastatin)

ANTIHYPERLIPIDEMICS

Preventi

simvastatin tab 5mg, 10mg, 20mg, 40mg (ZOCOR equiv) (QL= 1 tab/day;

Covered at $0 for members 40 years or older; All other members covered at

generic copay)

ANTIHYPERLIPIDEMICS

Preventi

PA-QL

simvastatin tab 80mg (ZOCOR equiv) (QL= 1 tab/day; Covered at $0 for

members 40 years or older; All other members covered at generic copay)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2-sirolimus soln (RAPAMUNE equiv)

ASSORTED CLASSESTier 2-sirolimus tab (RAPAMUNE equiv)

ANTIMYCOBACTERIAL AGENTS

Tier 2

Specialty

LDSIRTURO TAB (Only available through MMS Solutions 855-691-0963)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLSIVEXTRO TAB (QL= 6 tabs/fill)

CONTRACEPTIVES

Preventi

-SKYLA IUD

GASTROINTESTINAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLSKYRIZI 180MG/1.2ML CARTRIDGE (QL= 1 cartridge/56 days)

GASTROINTESTINAL AGENTS - MISC.

Tier 2

Specialty

AMSP-PA-QLSKYRIZI INJ (QL= 1 cartridge/56 days)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLSKYRIZI INJ 150MG/ML (QL= 1 inj/84 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QLSKYTROFA INJ (QL= 4 inj/28 days)

CONTRACEPTIVES

Preventi

-SLYND TAB

ANTI-INFECTIVE AGENTS - MISC.Tier 1-smz/tmp (DS) tab (BACTRIM DS equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-smz/tmp susp (BACTRIM, SEPTRA equiv)

MINERALS & ELECTROLYTESTier 1-sodium chloride inj

COUGH/COLD/ALLERGYTier 1-sodium chloride neb soln (HYPER-SAL equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 57 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-sodium citrate/citric acid soln (BICITRA equiv)

MINERALS & ELECTROLYTES

Preventi

sodium fluoride chew tab (LURIDE equiv) (Covered at $0 for members 5 years

or younger; All other members covered at generic copay)

MOUTH/THROAT/DENTAL AGENTS

Preventi

sodium fluoride cream (PREVIDENT equiv) (Covered at $0 for members 5

years or younger; All other members covered at generic copay)

MOUTH/THROAT/DENTAL AGENTSTier 1-sodium fluoride gel (PREVIDENT equiv)

MOUTH/THROAT/DENTAL AGENTSTier 1-sodium fluoride paste (PREVIDENT equiv)

MINERALS & ELECTROLYTES

Preventi

sodium fluoride soln (LURIDE equiv) (Covered at $0 for members 5 years or

younger; All other members covered at generic copay)

MINERALS & ELECTROLYTES

Preventi

SODIUM FLUORIDE TAB (Covered at $0 for members 5 years or younger; All

other members covered at generic copay)

MOUTH/THROAT/DENTAL AGENTSTier 1-sodium fluoride/potassium nitrate paste (PREVIDENT equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

AMSP-PAsodium phenylbutyrate powder (BUPHENYL equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

AMSP-PAsodium phenylbutyrate tab (BUPHENYL equiv)

ASSORTED CLASSESTier 2-sodium polystyrene powder (KAYEXALATE equiv)

ASSORTED CLASSESTier 2-sodium polystyrene susp (SPS equiv)

DERMATOLOGICALSTier 1-sodium sulfacetamide lotion (KLARON equiv)

LAXATIVESTier 1QLsodium/potassium/magnesium soln (SUPREP equiv) (QL= 2 fills/year)

ANTIVIRALS

Tier 1

Specialty

AMSP-PA-QLSOFOSBUVIR/VELPATASVIR TAB (QL= 1 tab/day)

URINARY ANTISPASMODICSTier 1QLsolifenacin tab (VESICARE equiv) (QL= 1 tab/day)

CORTICOSTEROIDSTier 2-SOLU-CORTEF INJ

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PA

SOMAVERT INJ (Only available through Accredo 800-803-2523 or Walgreens

888-347-3416)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFsorafenib tosylate tab (NEXAVAR equiv) (QL= 4 tabs/day)

BETA BLOCKERSTier 1-sotalol AF tab (BETAPACE AF equiv)

BETA BLOCKERSTier 1-sotalol tab (BETAPACE equiv)

VACCINES

Preventi

QLSPIKEVAX INJ (QL= 1 dose/24 days)

VACCINES

Preventi

VACSPIKEVAX INJ 50/0.5ML

VACCINES

Preventi

VACSPIKEVAX INJ 50MCG/0.5ML

DERMATOLOGICALSTier 2QLSPINOSAD SUSP (QL= 1 bottle/fill, 1 fill/month)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLSPIRIVA RESPIMAT INHALER 1.25MCG/ACT (QL= 1 inhaler/30 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLSPIRIVA RESPIMAT INHALER 2.5MCG/ACT (QL= 1 inhaler/30 days)

DIURETICSTier 2QL-ST

spironolactone susp (CAROSPIR equiv) (QL= 600ml/30 days; ST req trial of

furosemide oral soln)

DIURETICSValue-spironolactone tab (ALDACTONE equiv)

DIURETICSTier 1-spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv)

CONTRACEPTIVES

Preventi

-sprintec 28 tab (ORTHO-CYCLEN equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-SFSPRYCEL TAB

COUGH/COLD/ALLERGYTier 2QLSTAHIST AD TAB 25-60MG (QL= 4 tabs/day)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 58 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIVIRALSTier 1QLstavudine cap (ZERIT equiv) (QL= 2 caps/day)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLSTELARA INJ (QL= 1 inj/84 days )

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLSTELARA INJ (QL= 1 inj/84 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2-STIMATE NASAL SOLN

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLSTIOLTO INHALER (QL= 1 inhaler/30 days)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL

STIVARGA TAB (QL= 84 tabs/28 days; Only available through Walgreens

888-347-3416)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

LD-PASTRENSIQ INJ (Only available through PantherRx Pharmacy 855-726-8479)

ANTIVIRALSTier 2QLSTRIBILD TAB (QL= 1 tab/day)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLSTRIVERDI RESPIMAT INHALER (QL= 1 inhaler/30 days)

ANALGESICS - OPIOIDTier 2QLSUBOXONE SL FILM 12-3MG (QL= 2 films/day)

ANALGESICS - OPIOIDTier 2QLSUBOXONE SL FILM 8-2MG (QL= 3 films/day)

ULCER

DRUGS/ANTISPASMODICS/ANTICHOLINERGI

Tier 1-sucralfate susp (CARAFATE equiv)

ULCER DRUGSTier 1-sucralfate tab (CARAFATE equiv)

LAXATIVESTier 2QLSUFLAVE SOLN (QL= 2 fills/year)

OPHTHALMIC AGENTSTier 2-SULFACETAMIDE SODIUM OPHTH OINT

OPHTHALMIC AGENTSTier 1-sulfacetamide sodium ophth soln (BLEPH-10 equiv)

OPHTHALMIC AGENTSTier 1-sulfacetamide sodium/prednisolone ophth soln (VASOCIDIN equiv)

SULFONAMIDESTier 1QLsulfadiazine tab (SULFADIAZINE equiv) (QL= 8 tabs/day)

SULFONAMIDESTier 2QLSULFADIAZINE TAB (QL= 8 tabs/day)

DERMATOLOGICALSTier 2-SULFAMYLON CREAM

GASTROINTESTINAL AGENTS - MISC.Tier 1-sulfasalazine EC tab (AZULFIDINE equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-sulfasalazine tab (AZULFIDINE equiv)

ANALGESICS - ANTI-INFLAMMATORYTier 1-sulindac tab (CLINORIL equiv)

MIGRAINE PRODUCTSTier 2QLsumatriptan inj (IMITREX equiv) (QL= 8 inj/30 days)

MIGRAINE PRODUCTSTier 2QLSUMATRIPTAN INJ 6MG/0.5ML (QL= 8 inj/30 days)

MIGRAINE PRODUCTSTier 1QL-ST

sumatriptan nasal spray (IMITREX, SUMATRIPTAN equiv) (QL= 6 sprays/30

days; Step therapy requires trial of two: naratriptan tab, rizatriptan tab,

rizatriptan ODT, or sumatriptan tab)

MIGRAINE PRODUCTSTier 1QLsumatriptan tab (IMITREX equiv) (QL= 9 tabs/30 days)

MIGRAINE PRODUCTSTier 2QLsumatriptan vial inj (IMITREX equiv) (QL= 1 inj/7 days)

MIGRAINE PRODUCTSTier 2QL-ST

sumatriptan/naproxen tab (TREXIMET equiv) (QL= 9 tabs/30 days; Step

Therapy requires trial of 2: naratriptan, rizatriptan, rizatriptan ODT, or

sumatriptan)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSP-PA-QL-SFsunitinib malate cap (SUTENT equiv) (QL= 1 cap/day)

RESPIRATORY AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

SYMDEKO TAB (QL= 2 tabs/day; Only available through Walgreens

888-347-3416)

VASOPRESSORSValueQLSYMJEPI INJ (QL= 2 inj/fill)

GASTROINTESTINAL AGENTS - MISC.Tier 2PA-QLSYMPROIC TAB (QL= 30 tabs/30 days)

ANTIVIRALSTier 2-SYMTUZA TAB

PASSIVE IMMUNIZING AND TREATMENT

AGENTS

Tier 2

Specialty

LMSP-PA-QLSYNAGIS INJ (QL= 2 inj/28 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 59 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2-SYNAREL NASAL SOLN

ANTIDIABETICSTier 2QLSYNJARDY TAB (QL= 2 tabs/day)

ANTIDIABETICSTier 2QLSYNJARDY XR TAB 10-1000MG, 25-1000MG (QL= 1 tab/day)

ANTIDIABETICSTier 2QLSYNJARDY XR TAB 5-1000MG, 12.5-1000MG (QL= 2 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PASYNRIBO INJ (Only available through US Bioservices 888-518-7246)

MEDICAL DEVICES AND SUPPLIESTier 2OTCSYRINGE LUER-LOK

ANTINEOPLASTICS

Tier 2

Specialty

AMSP-QLTABLOID TAB (QL= 4 tabs/day)

ASSORTED CLASSESTier 1-tacrolimus cap (PROGRAF equiv)

DERMATOLOGICALSTier 1-tacrolimus oint (PROTOPIC OINT equiv)

CARDIOVASCULAR AGENTS - MISC.Tier 1QLtadalafil tab (CIALIS equiv) (QL= 1 tab/day)

CARDIOVASCULAR AGENTS - MISC.Tier 1QLtadalafil tab (PAH) (ADCIRCA equiv) (QL= 2 tabs/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLTAFINLAR CAP (QL= 4 caps/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LMSP-PA-QLTAFINLAR TAB (QL= 12 tabs/day)

OPHTHALMIC AGENTSTier 1QL-ST

tafluprost preservative free (pf) ophth soln (ZIOPTAN equiv) (QL= 30

pouches/30 days; Step Therapy requires trial of latanoprost ophth soln)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QLTAGRISSO TAB (QL= 1 tab/day)

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TAKHZYRO INJ (QL= 2 inj/28 days; Only available through Accredo

800-803-2523)

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TAKHZYRO INJ (QL= 2 prefilled syringes/28 days; Only available through

Accredo 800-803-2523)

HEMATOLOGICAL AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TAKHZYRO INJ 150MG/ML (QL= 2 prefilled syringes/28 days; Only available

through Accredo 800-803-2523)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Preventi

tamoxifen tab (NOLVADEX equiv) (Covered at $0 for women 35 years or

older; All other members covered at generic copay)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-tamsulosin cap (FLOMAX equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-SFTASIGNA CAP

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1

Specialty

AMSP-PAtasimelteon capsule (HETLIOZ equiv)

DERMATOLOGICALSTier 2ST

tavaborole soln (KERYDIN SOLN equiv) (Step Therapy requires trial of 2:

ciclopirox nail soln, itraconazole cap or terbinafine tab)

DERMATOLOGICALSTier 1QLtazarotene cream 0.1% (TAZORAC equiv) (QL= 360g/30 days)

DERMATOLOGICALSTier 1QLtazarotene gel (TAZORAC equiv) (QL= 360g/30 days)

DERMATOLOGICALSTier 2QL-ST

tazarotene gel 0.1% (TAZORAC equiv) (QL= 360g/30 days; Step Therapy

requires trial of 2: adapalene, tretinoin, tazarotene 0.1% cream, 0.05% gel)

MEDICAL DEVICES AND SUPPLIESTier 2-TB SYRINGE

ANTIVIRALS

Tier 2

Specialty

LD-PA-QL

TECHNIVIE TAB (QL= 1 pack/28 days; Only available through Walgreens

888-347-3416)

ANTIHYPERTENSIVESTier 1-telmisartan tab (MICARDIS equiv)

ANTIHYPERTENSIVESTier 2ST

telmisartan/amlodipine tab (TWYNSTA equiv) (Step Therapy requires trial of:

losartan or losartan/hctz and irbesartan or irbesartan/hctz)

ANTIHYPERTENSIVESTier 2ST

telmisartan/hydrochlorothiazide tab (MICARDIS HCT equiv) (Step Therapy

requires trial of: losartan or losartan/hctz and irbesartan or irbesartan/hctz)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 60 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIHYPERTENSIVESTier 2ST

telmisartan/hydrochlorothiazide tab 40-12.5MG (MICARDIS HCT equiv) (Step

Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz)

ANTIHYPERTENSIVESTier 2ST

telmisartan/hydrochlorothiazide tab 80-25MG (MICARDIS HCT equiv) (Step

Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-temazepam cap 15mg (RESTORIL equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 2-temazepam cap 22.5mg (RESTORIL equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-temazepam cap 30mg (RESTORIL equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 2-temazepam cap 7.5mg (RESTORIL equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1

Specialty

AMSPtemozolomide cap (TEMODAR equiv)

ANTIVIRALSTier 1QLtenofovir disoproxil fumarate tab (VIREAD equiv) (QL= 1 tab/day)

ANTIHYPERTENSIVESTier 1-terazosin cap (HYTRIN equiv)

ANTIFUNGALSTier 1-terbinafine tab (LAMISIL equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-terbutaline sulfate tab (BRETHINE equiv)

VAGINAL PRODUCTSTier 1-terconazole cream (TERAZOL equiv)

VAGINAL PRODUCTSTier 1-TERCONAZOLE CREAM 0.8%

VAGINAL PRODUCTSTier 1-terconazole supp (TERAZOL equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-QLteriflunomide tab (AUBAGIO equiv) (QL= 30 tabs/30 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QL

teriparatide (recombinant) soln pen-inj 600mcg/2.4ml (FORTEO equiv) (QL=

2.4 units/28 days)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QLTERIPARATIDE INJ 620MCG/2.48ML (QL= 2.48 units/28 days)

ANDROGENS-ANABOLICTier 1-testosterone cypionate inj (DEPO-TESTOSTERONE equiv)

ANDROGENS-ANABOLICTier 1--QL

testosterone cypionate inj (DEPO-TESTOSTERONE equiv) (QL= 1 vial/28 days)

ANDROGENS-ANABOLICTier 1--QL

testosterone cypionate inj (DEPO-TESTOSTERONE equiv) (QL= 4 vials/28

days)

ANDROGENS-ANABOLICTier 1QL

testosterone cypionate inj 200mg/ml (DEPO-TESTOSTERONE equiv) (QL= 4

vials/28 days)

ANDROGENS-ANABOLICTier 2QLTESTOSTERONE ENANTHATE INJ (QL= 4 vials/28 days)

ANDROGENS-ANABOLICTier 1QLtestosterone gel 1% 25mg (ANDROGEL equiv) (QL= 150gm/30 days)

ANDROGENS-ANABOLICTier 2QL-PATESTOSTERONE GEL 1% 25MG (QL= 1 packet/day)

ANDROGENS-ANABOLICTier 1QLtestosterone gel 1% 50mg (QL= 300gm/30 days)

ANDROGENS-ANABOLICTier 1QL

testosterone gel 1% pump (VOGELXO GEL, ANDROGEL equiv) (QL=

300gm/30 days)

ANDROGENS-ANABOLICTier 2PA-QLtestosterone gel 1.62% 1.25gm (ANDROGEL equiv) (QL= 1 packet/day)

ANDROGENS-ANABOLICTier 2PA-QLtestosterone gel 1.62% 2.5gm (ANDROGEL equiv) (QL= 2 packets/day)

ANDROGENS-ANABOLICTier 2PA-QLTESTOSTERONE GEL 10MG/ACT (QL= 2 bottles/30 days)

ANDROGENS-ANABOLICTier 2PA-QLtestosterone gel 2% (FORTESTA equiv) (QL= 2 bottles/30 days)

ANDROGENS-ANABOLICTier 2PA-QLTESTOSTERONE GEL PUMP (QL= 4 bottles/30 days)

ANDROGENS-ANABOLICTier 1QLtestosterone gel pump 1.62% (ANDROGEL equiv) (QL= 150gm/30 days)

ANDROGENS-ANABOLICTier 1QLTESTOSTERONE GEL PUMP, VOGELXO GEL PUMP (QL= 300g/30 days)

ANDROGENS-ANABOLICTier 2QLTESTOSTERONE INJ (QL= 1 vial/28 days)

ANDROGENS-ANABOLICTier 2QLTESTOSTERONE INJ (QL= 4 vials/28 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 61 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANDROGENS-ANABOLICTier 2QLTESTOSTERONE PROP IM OR SUBCUTANEOUS INJ (QL= 1 vial/28 days)

ANDROGENS-ANABOLICTier 2PA-QLtestosterone soln (AXIRON equiv) (QL= 2 bottles/30 days)

TOXOIDS

Preventi

VACTETANUS/DIPHTHERIA TOXOID INJ

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 1

Specialty

AMSP-PAtetrabenazine tab (XENAZINE equiv)

OPHTHALMIC AGENTSTier 1-tetracaine ophth soln

TETRACYCLINESTier 1-tetracycline cap

ASSORTED CLASSES

Tier 2

Specialty

LD-QL

THALOMID CAP (QL= 2 caps/day; Only available through Walgreens

888-347-3416)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-theophylline CR tab (QUIBRON-T equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-theophylline ER tab (UNIPHYL equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-theophylline soln

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLTHEOPHYLLINE TAB ER (QL= 1 tab/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-thioridazine tab (MELLARIL equiv)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-thiothixene cap (NAVANE equiv)

ANTICONVULSANTSTier 1QLtiagabine tab 12mg (GABITRIL equiv) (QL= 4 tabs/day)

ANTICONVULSANTSTier 1QLtiagabine tab 16mg (GABITRIL equiv) (QL= 3 tabs/day)

ANTICONVULSANTSTier 1QLtiagabine tab 2mg (GABITRIL equiv) (QL= 4 tabs/day)

ANTICONVULSANTSTier 1QLtiagabine tab 4mg (GABITRIL equiv) (QL= 4 tabs/day)

NEUROMUSCULAR AGENTS

Tier 2

Specialty

LD-PATIGLUTIK SUSP (Only available through AnovoRx 844-288-5007)

OPHTHALMIC AGENTSTier 2QLtimolol maleate (pf) ophth soln 0.5% (TIMOPTIC equiv) (QL= 2ml/day)

OPHTHALMIC AGENTSTier 2ST

timolol maleate ophth gel (TIMOPTIC-XE equiv) (Step Therapy requires trial of

timolol maleate ophth soln)

OPHTHALMIC AGENTSValue-timolol maleate ophth soln 0.25% (TIMOPTIC equiv)

OPHTHALMIC AGENTSTier 2ST

timolol maleate ophth soln 0.5% (ISTALOL equiv) (Step Therapy requires trial

of timolol maleate ophth soln)

OPHTHALMIC AGENTSValueST--timolol maleate ophth soln 0.5% (TIMOPTIC equiv)

OPHTHALMIC AGENTSTier 2QLtimolol maleate preservative free ophth soln (TIMOPTIC equiv) (QL= 2ml/day)

BETA BLOCKERSTier 1-timolol maleate tab (BLOCADREN equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-tinidazole tab (TINDAMAX equiv)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1

Specialty

LD-PA-QL

tiopronin tab (THIOLA equiv) (QL= 8 tabs/day; Only available through

Eversana 636-519-2400)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 2

Specialty

LD-PA-QL

tiopronin tab delayed release (THIOLA EC equiv) (QL= 8 tabs/day; Only

available through Eversana 636-519-2400)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1QL

tiotropium bromide cap inhaler (SPIRIVA equiv) (QL= 1 cap/day; For use with

Handihaler device)

ANTIVIRALSTier 2QLTIVICAY PD TAB (QL= 180 tabs/30 days)

ANTIVIRALSTier 2QLTIVICAY TAB (QL= 180 tabs/30 days)

MUSCULOSKELETAL THERAPY AGENTSTier 2-tizanidine cap (ZANAFLEX equiv)

MUSCULOSKELETAL THERAPY AGENTSTier 1-tizanidine tab (ZANAFLEX equiv)

OPHTHALMIC AGENTSTier 2-TOBRADEX OPHTH OINT

AMINOGLYCOSIDES

Tier 1

Specialty

AMSP-PAtobramycin neb soln (BETHKIS equiv)

AMINOGLYCOSIDES

Tier 1

Specialty

AMSP-PAtobramycin neb soln (TOBI equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 62 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

OPHTHALMIC AGENTSTier 1-tobramycin ophth soln (TOBREX equiv)

OPHTHALMIC AGENTSTier 1-tobramycin/dexamethasone ophth soln (TOBRADEX equiv)

VAGINAL PRODUCTS

Preventi

OTCTODAY SPONGE

ANTIDIABETICSTier 1-tolazamide tab (TOLINASE equiv)

ANTIDIABETICSTier 2-TOLBUTAMIDE TAB

ANTIPARKINSON AGENTSTier 2QLtolcapone tab (TASMAR equiv) (QL= 3 caps/day)

ANALGESICS - ANTI-INFLAMMATORYTier 1-tolmetin cap (TOLECTIN DS equiv)

URINARY ANTISPASMODICSTier 2-tolterodine SR cap (DETROL LA equiv)

URINARY ANTISPASMODICSTier 2-tolterodine tab (DETROL equiv)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

LD-PA-QL

tolvaptan tab (SAMSCA equiv) (QL= 2 tabs/day; Only available through

Walgreens 888-347-3416)

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 1

Specialty

LD-PA-QL

tolvaptan tab 15mg (SAMSCA equiv) (QL= 1 tab/day; Only available through

Walgreens 888-347-3416)

ANTICONVULSANTSTier 2QL-ST

topiramate cap er 200mg (TROKENDI equiv) (QL= 2 caps/day; Step therapy

requires trial of topiramate followed by topiramate ER sprinkle)

ANTICONVULSANTSTier 2QL-ST

topiramate er cap (TROKENDI XR equiv) (QL= 1 cap/day; ST req trial of

topirmate followed by topiramate ER sprinkle)

ANTICONVULSANTSTier 2QL-ST

topiramate ER cap 100mg (QUDEXY equiv) (QL= 1 cap/day; Step Therapy

requires trial of generic topiramate IR)

ANTICONVULSANTSTier 2QL-ST

topiramate ER cap 150mg (QUDEXY equiv) (QL= 2 caps/day; Step Therapy

requires trial of generic topiramate IR)

ANTICONVULSANTSTier 2QL-ST

topiramate ER cap 200mg (QUDEXY equiv) (QL= 2 caps/day; Step Therapy

requires trial of generic topiramate IR)

ANTICONVULSANTSTier 2QL-ST

topiramate ER cap 25mg (QUDEXY equiv) (QL= 1 cap/day; Step Therapy

requires trial of generic topiramate IR)

ANTICONVULSANTSTier 2QL-ST

topiramate ER cap 50mg (QUDEXY equiv) (QL= 1 cap/day; Step Therapy

requires trial of generic topiramate IR)

ANTICONVULSANTSTier 1-topiramate sprinkle cap (TOPAMAX equiv)

ANTICONVULSANTSTier 1-topiramate tab (TOPAMAX equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 1STtoremifene tab (FARESTON equiv) (Step Therapy requires trial of tamoxifen)

DIURETICSTier 1-torsemide tab (DEMADEX equiv)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TRACLEER TAB 32MG (QL= 4 tabs/day; Only available through Accredo

800-803-2523)

ANTIDIABETICSTier 2QLTRADJENTA TAB (QL= 1 tab/day)

ANALGESICS - OPIOIDTier 2PAtramadol ER tab (RYZOLT equiv)

ANALGESICS - OPIOIDTier 1PAtramadol ER tab 100mg (ULTRAM ER equiv)

ANALGESICS - OPIOIDTier 1PAtramadol ER tab 200mg (ULTRAM ER equiv)

ANALGESICS - OPIOIDTier 1PAtramadol ER tab 300mg (ULTRAM ER equiv)

ANALGESICS - OPIOIDTier 1QL

tramadol hcl tab 100mg (QL= 18 tabs/fill for members age 20 or younger; QL=

42 tabs/fill for members age 21 or older; Day supply limit of 42 days in 90

days)

ANALGESICS - OPIOIDTier 1QL

tramadol tab (ULTRAM equiv) (QL= 18 tabs/fill for members age 20 or

younger; QL= 42 tabs/fill for members age 21 or older; Day supply limit of 42

days in 90 days)

ANALGESICS - OPIOIDTier 1QL

tramadol/acetaminophen tab (ULTRACET equiv) (QL= 18 tabs/fill for members

age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

ANTIHYPERTENSIVESTier 1-trandolapril tab (MAVIK equiv)

ANTIHYPERTENSIVESTier 1-trandolapril/verapamil ER tab (TARKA equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 63 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

HEMOSTATICSTier 1QLtranexamic acid tab (LYSTEDA equiv) (QL= 180 tabs/30 days)

ANTIDEPRESSANTSTier 1-tranylcypromine tab (PARNATE equiv)

OPHTHALMIC AGENTSTier 1QL-ST

travoprost ophth soln (TRAVATAN Z equiv) (QL= 1 bottle/fill, 1 fill/month; Step

Therapy requires trial of latanoprost ophth soln)

ANTIDEPRESSANTSTier 1-trazodone tab 50mg, 100mg, 150mg (DESYREL equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLTRELEGY ELLIPTA INHALER (QL= 1 inhaler/30 days)

DERMATOLOGICALS

Tier 2

Specialty

AMSP-PA-QLTREMFYA INJ (QL= 1 inj/56 days)

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

LD-PA

treprostinil inj 10mg/ml (REMODULIN equiv) (Only available through Walgreens

888-347-3416)

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

LD-PA

treprostinil inj 1mg/ml (REMODULIN equiv) (Only available through Walgreens

888-347-3416)

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

LD-PA

treprostinil inj 2.5mg/ml (REMODULIN equiv) (Only available through Walgreens

888-347-3416)

CARDIOVASCULAR AGENTS - MISC.

Tier 1

Specialty

LD-PA

treprostinil inj 5mg/ml (REMODULIN equiv) (Only available through Walgreens

888-347-3416)

ANTINEOPLASTICS

Tier 1

Specialty

AMSPtretinoin cap (VESANOID equiv)

DERMATOLOGICALSTier 1-tretinoin cream (RETIN-A CREAM equiv)

DERMATOLOGICALSTier 1-tretinoin gel (RETIN-A GEL equiv)

DERMATOLOGICALSTier 2--QL-ST

tretinoin gel (QL= 300g/30 days; Step Therapy requires trial of 2: adapalene,

tretinoin, tazarotene 0.1% cream, 0.05% gel)

DERMATOLOGICALSTier 2ST

triamcinolone acetonide oint (TRIANEX equiv) (Step Therapy requires trial of

triamcinolone acetonide oint 0.025% or 0.1%)

DERMATOLOGICALSTier 1-triamcinolone acetonide oint 0.025% (TRIANEX equiv)

DERMATOLOGICALSTier 1-triamcinolone acetonide oint 0.1% (TRIANEX equiv)

DERMATOLOGICALSTier 1-triamcinolone acetonide oint 0.5% (TRIANEX equiv)

DERMATOLOGICALSTier 1-triamcinolone cream

MOUTH/THROAT/DENTAL AGENTSTier 1-triamcinolone in orabase paste (KENALOG/ORABASE equiv)

DERMATOLOGICALSTier 1-triamcinolone lotion

DERMATOLOGICALSTier 2-triamcinolone spray (KENALOG equiv)

DIURETICSTier 2ST

triamterene cap (DYRENIUM equiv) (Step Therapy requires trial of amiloride or

spironolactone)

DIURETICSTier 1-triamterene/hydrochlorothiazide cap (DYAZIDE equiv)

DIURETICSTier 1-triamterene/hydrochlorothiazide tab (MAXZIDE equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1-triazolam tab (HALCION equiv)

GENITOURINARY AGENTS -

MISCELLANEOUS

Tier 1-tricitrates soln (POLYCITRA-LC equiv)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 1STtrientine cap 250mg (SYPRINE equiv) (ST req trial of generic penicillamine tab)

MISCELLANEOUS THERAPEUTIC CLASSES

Tier 2ST

TRIENTINE CAP 500MG (ST req trial of generic penicillamine tab and then trial

of gen trientine 250mg cap)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1-trifluoperazine tab (STELAZINE equiv)

OPHTHALMIC AGENTSTier 1-TRIFLURIDINE OPHTH SOLN

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1-trihexyphenidyl elixir (ARTANE equiv)

ANTIPARKINSON AND RELATED THERAPY

AGENTS

Tier 1QLTRIHEXYPHENIDYL SOLN (QL= 946ml/28 days)

ANTIPARKINSON AGENTSTier 1-trihexyphenidyl tab (ARTANE equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 64 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

CONTRACEPTIVES

Preventi

-tri-legest tab (ESTROSTEP FE equiv)

LAXATIVES

Preventi

trilyte soln (NULYTELY equiv) (Covered at $0 for members 45-75

years-Limited to 2 fills/calendar year; All other members covered at generic

copay)

ANTIEMETICSTier 1-trimethobenzamide cap (TIGAN equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-trimethoprim tab (PROLOPRIM equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2-TRIMETHOPRIM TAB

ANTIDEPRESSANTSTier 1ST

trimipramine cap (SURMONTIL equiv) (Step Therapy requires trial and failure

of 2 generic SSRI/SNRIs)

COUGH/COLD/ALLERGYTier 1QLtriprolidine/pseudoephedrine tab 2.5-60 mg (QL= 4 tabs/day)

COUGH/COLD/ALLERGYTier 1OTC-QLtrispec pse liquid (QL= 1200ml/30 days)

CONTRACEPTIVES

Preventi

-tri-sprintec tab (ORTHO TRI-CYCLEN (LO) equiv)

ANTIVIRALSTier 2QLTRIUMEQ PD TAB (QL= 6 tabs/day)

ANTIVIRALSTier 2QLTRIUMEQ TAB (QL= 1 tab/day)

MULTIVITAMINS

Preventi

-TRI-VITAMIN FLUORIDE DROPS

OPHTHALMIC AGENTSTier 1-tropicamide ophth soln (MYDRIACYL equiv)

URINARY ANTISPASMODICSTier 2-trospium chloride SR cap (SANCTURA XR equiv)

URINARY ANTISPASMODICSTier 2-trospium tab (SANCTURA equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 2QLTRULANCE TAB (QL= 30 tabs/30 days)

ANTIDIABETICSTier 2QL-RDX

TRULICITY INJ (QL= 2ml/28 days; Diagnosis Restricted – Type 2 Diabetes

(E11))

VACCINES

Preventi

VACTRUMENBA INJ

COUGH/COLD/ALLERGYTier 1-tussigon tab (HYCODAN equiv)

COUGH/COLD/ALLERGYTier 1QLtussin cf liquid (QL= 1200ml/30 days)

VACCINES

Preventi

VACTWINRIX INJ

CONTRACEPTIVES

Preventi

-TWIRLA PATCH

CONTRACEPTIVES

Preventi

-TYBLUME TAB

ANTIVIRALSTier 2-TYBOST TAB

ENDOCRINE AND METABOLIC AGENTS -

MISC.

Tier 2

Specialty

AMSP-PA-QLTYMLOS INJ (QL= 1.56 units/30 days)

OPHTHALMIC AGENTSTier 2QL-ST

TYRVAYA SOLN (QL= 8.4ml/30 days; Step therapy requires trial of

cyclosporine 0.05% ophth emulsion (generic Restasis))

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TYVASO DPI POWDER 16-32-48MCG (QL= 4 cartridges/day; Only available

through Accredo 800-803-2523)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TYVASO DPI POWDER 16-32MCG (QL= 4 cartridges/day; Only available

through Accredo 800-803-2523)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TYVASO DPI POWDER 32-48MCG (QL= 4 cartridges/day; Only available

through Accredo 800-803-2523)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TYVASO DPI POWDER (QL= 4 cartridges/day; Only available through

Accredo 800-803-2523)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

TYVASO INH SOLN (QL= 1 ampule/day; Only available through Accredo

800-803-2523)

ANTIVIRALS

Tier 2

Specialty

LD-PATYZEKA TAB (Only available through Walgreens 888-347-3416)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 65 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

MIGRAINE PRODUCTSTier 2QL-ST

UBRELVY TAB (QL= 10 tabs/30 days; ST requires trial of 2: naratriptan tab,

rizatriptan tab, rizatriptan ODT, sumatriptan tab)

DERMATOLOGICALSTier 2-umecta mouss aer (HYDRO 40 equiv)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

UPTRAVI TAB (QL= 2 tabs/day; Only available through Accredo

800-803-2523)

GASTROINTESTINAL AGENTS - MISC.Tier 1-ursodiol cap (ACTIGALL equiv)

GASTROINTESTINAL AGENTS - MISC.Tier 1-ursodiol tab (URSO (FORTE) equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-UTA cap

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPUZEDY INJ

ANTIVIRALSTier 1-valacyclovir tab (VALTREX equiv)

DERMATOLOGICALS

Tier 2

Specialty

LD-PA-QL

VALCHLOR GEL (QL= 4 tubes/30 days; Only available through Optum

877-445-6874)

ANTIVIRALSTier 1-valganciclovir soln (VALCYTE equiv)

ANTIVIRALSTier 1-valganciclovir tab (VALCYTE equiv)

ANTICONVULSANTSTier 1-valproic acid cap (DEPAKENE equiv)

ANTICONVULSANTSTier 1-valproic acid syrup (DEPAKENE equiv)

ANTIHYPERTENSIVESTier 2QLVALSARTAN SOLN (QL= 2400ml/30 days)

ANTIHYPERTENSIVESTier 1-valsartan tab (DIOVAN equiv)

ANTIHYPERTENSIVESTier 1-valsartan/hydrochlorothiazide tab (DIOVAN HCT equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 1QLvancomycin cap 125mg (VANCOCIN equiv) (QL= 56 caps/30 days)

ANTI-INFECTIVE AGENTS - MISC.Tier 1QLvancomycin cap 250mg (VANCOCIN equiv) (QL= 112 caps/30 days)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-vancomycin hcl for iv soln (VANCOMYCIN equiv)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLvancomycin hcl for oral soln 25mg/ml (FIRVANQ equiv) (QL= 300ml/30 days)

ANTI-INFECTIVE AGENTS - MISC.Tier 2QLvancomycin hcl for oral soln 50mg/ml (FIRVANQ equiv) (QL= 300ml/30 days)

ANTI-INFECTIVE AGENTS - MISC.Tier 1-VANCOMYCIN INJ

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGvarenicline tartrate tab (CHANTIX equiv) (Limited to 180 days/plan year)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKG

varenicline tartrate tab start pack (VARENICLINE equiv) (Limited to 180

days/plan year)

VACCINES

Preventi

VACVARIVAX INJ

ANTIEMETICSTier 2QL-STVARUBI TAB (QL= 2 tabs/day; Step Therapy requires trial of ondansetron)

VACCINES

Preventi

VACVAXCHORA SUSP

TOXOIDS

Preventi

VACVAXELIS INJ

VACCINES

Preventi

VACVAXNEUVANCE INJ

CONTRACEPTIVES

Preventi

-VELIVET PAK

CONTRACEPTIVES

Preventi

-velivet tab (CYCLESSA equiv)

ANTIVIRALS

Tier 2

Specialty

AMSP-QLVEMLIDY TAB (QL= 1 tab/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PAVENCLEXTA STARTER PACK (Only available through Optum 877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PAVENCLEXTA TAB (Only available through Optum 877-445-6874)

ANTIDEPRESSANTSTier 1-venlafaxine ER cap (EFFEXOR XR equiv)

ANTIDEPRESSANTSTier 2-VENLAFAXINE ER TAB

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 66 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTIDEPRESSANTSTier 1-venlafaxine tab (EFFEXOR equiv)

CARDIOVASCULAR AGENTS - MISC.

Tier 2

Specialty

LD-PA-QL

VENTAVIS INH SOLN (QL= 9 ampules/day; Only available through Accredo

800-803-2523)

CALCIUM CHANNEL BLOCKERSTier 2ST

verapamil SR cap (VERELAN equiv) (Step Therapy requires trial of verapamil

ER tab (generic Calan))

CALCIUM CHANNEL BLOCKERSTier 1-verapamil SR tab (CALAN SR, ISOPTIN SR equiv)

CALCIUM CHANNEL BLOCKERSTier 1-verapamil tab (CALAN equiv)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFVERZENIO TAB (QL= 2 tabs/day)

ANTIDIABETICSTier 2QL-RDX

VICTOZA INJ (QL= 9ml/30 days; Diagnosis Restricted – Type 2 Diabetes

(E11))

ANTIVIRALSTier 2QLVIDEX SOLN (QL= 600ml/30 days)

ANTIVIRALS

Tier 2

Specialty

LMSP-PA-QL

VIEKIRA PAK TAB (QL= 4 tabs/day; Only available through Lumicera

855-847-3553)

ANTIVIRALS

Tier 2

Specialty

LMSP-PA-QL

VIEKIRA XR TAB (QL= 3 tabs/day; Only available through Lumicera

855-847-3553)

CONTRACEPTIVES

Preventi

-vienva tab, lessina tab, kurvelo tab (ALESSE equiv)

ANTICONVULSANTS

Tier 1

Specialty

LD-PA-QL

vigabatrin powder pack (SABRIL POWDER equiv) (QL= 6 packs/day; Only

available through Lumicera 855-847-3553)

ANTICONVULSANTS

Tier 1

Specialty

LD-PA-QL

vigabatrin powder pack (SABRIL POWDER equiv) (QL= 6 packs/day; Only

available through PantheRx 855-726-8479)

ANTICONVULSANTS

Tier 1

Specialty

LD-PA-QL

vigabatrin tab (SABRIL equiv) (QL= 6 tabs/day; Only available through

Lumicera 855-847-3553)

ANTIDEPRESSANTSTier 2QL-ST

vilazodone hcl tab (VIIBRYD equiv) (QL= 1 tab/day; Step therapy requires trial

of 2: cital, escital, fluox, parox IR/ER, sertr, desven ER, venlfx IR/ER, dulox)

CONTRACEPTIVES

Preventi

-viorele tab, kariva tab (MIRCETTE equiv)

ANTIVIRALSTier 2-VIRACEPT TAB

ANTIVIRALSTier 2-VIREAD POWDER

ANTIVIRALSTier 2QLVIREAD TAB (QL= 1 tab/day)

ANTIDOTES

Tier 2

Specialty

LDVISTOGARD PAK (Only available through Biologics 800-850-4306)

VITAMINSTier 1-vitamin D cap (RX strength only)

ANTIDOTES

Tier 2

Specialty

AMSPVIVITROL INJ

ANTIFUNGALSTier 1-voriconazole susp (VFEND equiv)

ANTIFUNGALSTier 1-voriconazole tab (VFEND equiv)

ANTIVIRALS

Tier 2

Specialty

AMSP-PA-QLVOSEVI TAB (QL= 1 tab/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFVOTRIENT TAB (QL= 120 tabs/30 days)

MULTIVITAMINSTier 1-VP-PNV-DHA CAP

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 2QL-ST

VRAYLAR CAP (QL= 2 packs/plan year; Step Therapy requires trial of 2:

aripiprazole, quetiapine, ziprasidone, olanzapine, risperidone, or lurasidone)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 2QL-ST

VRAYLAR PACK (QL= 2 packs/plan year; Step Therapy requires trial of 2:

aripiprazole, quetiapine, ziprasidone, olanzapine, risperidone, or lurasidone)

ANALGESICS - NONNARCOTICTier 1-VTOL SOLN

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Tier 2

Specialty

AMSP-QL-ST

VUMERITY CAP (QL= 120 caps/30 days; Step therapy requires trial of

dimethyl fumarate, fingolimod, teriflunomide, or glatiramer)

ANTICOAGULANTSTier 1-warfarin tab (COUMADIN equiv)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 67 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

XALKORI CAP (QL= 2 caps/day; Only available through Walgreens

888-347-3416)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

XALKORI SPRINKLE CAP (QL= 6 caps/day; Only available through Walgreens

888-347-3416)

ANTICOAGULANTSTier 2QLXARELTO STARTER PACK 15MG/20MG (QL= 1 pack/30 days)

ANTICOAGULANTSTier 2QLXARELTO SUSP (QL= 10ml/day)

ANTICOAGULANTSTier 2QLXARELTO TAB 10MG (QL= 30 tabs/30 days)

ANTICOAGULANTSTier 2QLXARELTO TAB 15MG (QL= 60 tabs/30 days)

ANTICOAGULANTSTier 2QLXARELTO TAB 2.5MG (QL= 60 tabs/30 days)

ANTICOAGULANTSTier 2QLXARELTO TAB 20MG (QL= 30 tabs/30 days)

OPHTHALMIC AGENTS

Tier 2

Specialty

LD-QL-RDX

XDEMVY DROP (QL= 10 units/42 days; Only available through CVS Specialty

800-238-7828 or Walgreens 888-347-3416; Claim requires DX of Demodex

blepharitis (acariasis or unspecified blepharitis))

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLXELJANZ SOLN (QL= 10ml/day)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLXELJANZ TAB (QL= 2 tabs/day)

ANALGESICS - ANTI-INFLAMMATORY

Tier 2

Specialty

AMSP-PA-QLXELJANZ XR TAB (QL= 1 tab/day)

ANTIDIABETICSTier 2QLXIGDUO XR TAB (QL= 1 tab/day)

ANTIDIABETICSTier 2QLXIGDUO XR TAB 2.5-1000MG (QL= 2 tabs/day)

ANTIDIABETICSTier 2QLXIGDUO XR TAB 5-1000MG (QL= 2 tabs/day)

ANTIDIABETICSTier 2QLXIGDUO XR TAB 5-500MG, 10-500MG, 10-1000MG (QL= 1 tab/day)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2

Specialty

AMSP-PA-QLXOLAIR INJ (QL= 1 syringe/28 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2

Specialty

AMSP-PA-QLXOLAIR INJ (QL= 1 vial/28 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2

Specialty

AMSP-PA-QLXOLAIR INJ 150MG/ML (QL= 1ml/28 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2

Specialty

AMSP-PA-QLXOLAIR INJ 300MG/2ML (QL= 2ml/28 days)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2

Specialty

AMSP-PA-QLXOLAIR INJ 75MG/0.5ML (QL= 0.5ml/28 days)

CONTRACEPTIVES

Preventi

-YASMIN TAB

CONTRACEPTIVES

Preventi

-YAZ TAB

VACCINES

Preventi

-YF-VAX INJ

CONTRACEPTIVES

Preventi

-zafemy patch (XULANE equiv)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 1-zafirlukast tab (ACCOLATE equiv)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1QLzaleplon cap (SONATA equiv) (QL= 1 cap/day)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1QLzaleplon cap 10mg (SONATA equiv) (QL= 2 caps/day)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLZARXIO INJ (QL= 15 syringes/30 days)

HEMATOPOIETIC AGENTS

Tier 2

Specialty

AMSP-QLZARXIO INJ 480/0.8 (QL= 15 syringes/30 days)

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 68 of 197

Special Code

Tier

Category

Drug Name

Alphabetical Index

Last Updated 8/1/2024

UMP Preferred Drug List Cont.

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SF

ZEJULA CAP (QL= 30 caps/30 days; Only available through Optum

877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PA-QL-SFZEJULA TAB (QL= 1 tab/day; Only available through Optum 877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LMSP-PA-QL-SFZELBORAF TAB (QL= 8 tabs/day)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

zenzedi tab 10mg (DEXEDRINE equiv) (QL= 3 tabs/day; Step Therapy requires

trial of 2: dexmethylphenidate, dextroamphetamine,

amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A

NOREXIANTS

Tier 2QL-ST

zenzedi tab 5mg (DEXEDRINE equiv) (QL= 3 tabs/day; Step Therapy requires

trial of dexmethylphenidate, dextroamphetamine,

amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

ANTIVIRALS

Tier 2

Specialty

AMSP-PA-QLZEPATIER TAB (QL= 1 tab/day)

NASAL AGENTS - SYSTEMIC AND TOPICAL

Tier 2QLzephrex-d tab 30mg (QL= 240 tabs/30 days)

OPHTHALMIC AGENTSTier 2QLZERVIATE OPHTH SOLN (QL= 30 single use containers/30 days)

ANTIVIRALSTier 1QLzidovudine cap (RETROVIR equiv) (QL= 6 caps/day)

ANTIVIRALSTier 1QLzidovudine syrup (RETROVIR equiv) (QL= 1920ml/30 days)

ANTIVIRALSTier 1QLzidovudine tab (RETROVIR equiv) (QL= 2 tabs/day)

ANTIASTHMATIC AND BRONCHODILATOR

AGENTS

Tier 2QLzileuton ER tab (ZYFLO CR equiv) (QL= 2 tabs/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTSTier 1QLziprasidone cap (GEODON equiv) (QL= 2 caps/day)

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 1

Specialty

AMSPziprasidone mesylate inj (GEODON equiv)

OPHTHALMIC AGENTSTier 2-ZIRGAN OPHTH GEL

MACROLIDESTier 2-ZITHROMAX POWDER PACK

ANTINEOPLASTICS

Tier 2

Specialty

LMSP-PA-SFZOLINZA CAP

MIGRAINE PRODUCTSTier 2QL-ST

zolmitriptan nasal spray (ZOMIG equiv) (QL= 6 sprays/fill, 2 fills/30 days; Step

Therapy requires trial of 2: sumatriptan tab, naratriptan tab, rizatriptan tab or

ODT)

MIGRAINE PRODUCTSTier 2QLzolmitriptan ODT (ZOMIG equiv) (QL= 9 tabs/30 days)

MIGRAINE PRODUCTSTier 1QLzolmitriptan tab (ZOMIG equiv) (QL= 9 tabs/30 days)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 1QLzolpidem ER tab (AMBIEN CR equiv) (QL= 1 tab/day)

HYPNOTICSTier 1QLzolpidem tab (AMBIEN equiv) (QL= 1 tab/day)

HYPNOTICS/SEDATIVES/SLEEP DISORDER

AGENTS

Tier 2QLzolpidem tartrate SL tab (INTERMEZZO equiv) (QL= 1 tab/day)

ANTICONVULSANTSTier 1-zonisamide cap (ZONEGRAN equiv)

PSYCHOTHERAPEUTIC AND

NEUROLOGICAL AGENTS - MISC.

Preventi

QL-SMKGZYBAN TAB (Limited to 180 days/plan year)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

LD-PAZYDELIG TAB (Only available through Optum 877-445-6874)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFZYKADIA CAP (QL= 3 caps/day)

ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES

Tier 2

Specialty

AMSP-PA-QL-SFZYKADIA TAB (QL= 3 tabs/day)

OPHTHALMIC AGENTSTier 2-ZYLET OPHTH SUSP

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Tier 2

Specialty

AMSPZYPREXA RELPREVV INJ

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 69 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

AMPHETAMINES

amphetamine/dextroamphetamine ER cap (ADDERALL XR equiv)

- Tier 1

amphetamine/dextroamphetamine tab 10mg (ADDERALL equiv) (QL= 180 tabs/30 days)

QL Tier 1

amphetamine/dextroamphetamine tab 12.5mg (ADDERALL equiv) (QL= 150 tabs/30 days)

QL Tier 1

amphetamine/dextroamphetamine tab 15mg (ADDERALL equiv) (QL= 120 tabs/30 days)

QL Tier 1

amphetamine/dextroamphetamine tab 20mg (ADDERALL equiv) (QL= 90 tabs/30 days)

QL Tier 1

amphetamine/dextroamphetamine tab 30mg (ADDERALL equiv) (QL= 60 tabs/30 days)

QL Tier 1

amphetamine/dextroamphetamine tab 5mg (ADDERALL equiv) (QL= 360 tabs/30 days)

QL Tier 1

amphetamine/dextroamphetamine tab 7.5mg (ADDERALL equiv) (QL= 240 tabs/30 days)

QL Tier 1

dextroamphetamine 5mg tab (QL= 180 tabs/30 days)

QL Tier 1

dextroamphetamine soln (PROCENTRA equiv) (QL= 1800ml/30 days)

QL Tier 1

dextroamphetamine tab 10mg (QL= 6 tabs/day)

QL Tier 1

amphetamine tab (EVEKEO equiv) (QL= 60 tabs/30 days; Step therapy requires trial dexmethylphenidate, methylphenidate,

dextroamphetamine, or dextroamphetamine/amphetamine)

QL-ST Tier 2

amphetamine-dextroamphetamine 3-bead cap er 24hr 12.5mg (MYDAYIS equiv) (QL= 30 caps/30 days; ST req trial of 2:

amphet/dextro ER, methylphen ER (nonOSM), dexmethylphen ER, or dextroamph ER)

QL-ST Tier 2

amphetamine-dextroamphetamine 3-bead cap er 24hr 25mg (MYDAYIS equiv) (QL= 30 caps/30 days; ST req trial of 2:

amphet/dextro ER, methylphen ER (nonOSM), dexmethylphen ER, or dextroamph ER)

QL-ST Tier 2

amphetamine-dextroamphetamine 3-bead cap er 24hr 37.5mg (MYDAYIS equiv) (QL= 30 caps/30 days; ST req trial of 2:

amphet/dextro ER, methylphen ER (nonOSM), dexmethylphen ER, or dextroamph ER)

QL-ST Tier 2

amphetamine-dextroamphetamine 3-bead cap er 24hr 50mg (MYDAYIS equiv) (QL= 30 caps/30 days; ST req trial of 2:

amphet/dextro ER, methylphen ER (nonOSM), dexmethylphen ER, or dextroamph ER)

QL-ST Tier 2

dextroamphetamine ER cap 10mg (DEXEDRINE equiv) (QL= 2 caps/day)

QL Tier 2

dextroamphetamine ER cap 15mg (QL= 4 caps/day)

QL Tier 2

dextroamphetamine ER cap 5mg (DEXEDRINE equiv) (QL= 2 caps/day)

QL Tier 2

dextroamphetamine sulfate tab 15mg (ZENZEDI equiv) (QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate

tab, amphetamine/dextroamphetamine tab, dexmethylphenidate tab)

QL-ST Tier 2

dextroamphetamine sulfate tab 2.5mg (ZENZEDI equiv) (QL= 3 tabs/day; Step Therapy requires trial of

dexmethylphenidate, dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

QL-ST Tier 2

dextroamphetamine sulfate tab 20mg (ZENZEDI equiv) (QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate

tab, amphetamine/dextroamphetamine tab, dexmethylphenidate tab)

QL-ST Tier 2

dextroamphetamine sulfate tab 30mg (ZENZEDI equiv) (QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate

tab, amphetamine/dextroamphetamine tab, dexmethylphenidate tab)

QL-ST Tier 2

dextroamphetamine sulfate tab 7.5mg (ZENZEDI equiv) (QL= 3 tabs/day; Step Therapy requires trial of

dexmethylphenidate, dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

QL-ST Tier 2

lisdexamfetamine dimesylate cap (VYVANSE equiv) (QL= 1 cap/day)

QL Tier 2

lisdexamfetamine dimesylate chew tab (VYVANSE equiv) (QL= 1 tab/day)

QL Tier 2

methamphetamine tab (DESOXYN equiv) (QL= 5 tabs/day)

QL Tier 2

zenzedi tab 10mg (DEXEDRINE equiv) (QL= 3 tabs/day; Step Therapy requires trial of 2: dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

QL-ST Tier 2

zenzedi tab 5mg (DEXEDRINE equiv) (QL= 3 tabs/day; Step Therapy requires trial of dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or methylphenidate)

QL-ST Tier 2

ANALEPTICS

caffeine citrate soln (CAFCIT equiv)

- Tier 1

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS

atomoxetine cap 100mg (STRATTERA equiv) (QL= 1 cap/day)

QL Tier 1

atomoxetine cap 10mg (STRATTERA equiv) (QL= 2 caps/day)

QL Tier 1

atomoxetine cap 18mg (STRATTERA equiv) (QL= 2 caps/day)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 70 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Cont.

atomoxetine cap 25mg (STRATTERA equiv) (QL= 2 caps/day)

QL Tier 1

atomoxetine cap 40mg (STRATTERA equiv) (QL= 2 caps/day)

QL Tier 1

atomoxetine cap 60mg (STRATTERA equiv) (QL= 1 cap/day)

QL Tier 1

atomoxetine cap 80mg (STRATTERA equiv) (QL= 1 cap/day)

QL Tier 1

clonidine ER tab (KAPVAY equiv) (QL= 4 tabs/day)

QL Tier 1

guanfacine ER tab (INTUNIV equiv) (QL= 1 tab/day)

QL Tier 1

guanfacine ER tab 1mg (INTUNIV equiv) (QL= 2 tabs/day)

QL Tier 1

guanfacine ER tab 2mg (INTUNIV equiv) (QL= 2 tabs/day)

QL Tier 1

STIMULANTS - MISC.

armodafinil tab 150mg (NUVIGIL equiv) (QL= 1 tab/day)

QL Tier 1

armodafinil tab 200mg (NUVIGIL equiv) (QL= 1 tab/day)

QL Tier 1

armodafinil tab 250mg (NUVIGIL equiv) (QL= 1 tab/day)

QL Tier 1

armodafinil tab 50mg (NUVIGIL equiv) (QL= 3 tabs/day)

QL Tier 1

dexmethylphenidate ER cap (FOCALIN XR equiv) (QL= 1 cap/day)

QL Tier 1

dexmethylphenidate tab 10mg (FOCALIN equiv) (QL= 60 tabs/30 days)

QL Tier 1

dexmethylphenidate tab 2.5mg (FOCALIN equiv) (QL= 240 tabs/30 days)

QL Tier 1

dexmethylphenidate tab 5mg (FOCALIN equiv) (QL= 120 tabs/30 days)

QL Tier 1

METHYLPHENIDATE ER TAB (QL= 1 tab/day)

QL Tier 1

methylphenidate ER tab 10mg (QL= 3 tabs/day)

QL Tier 1

methylphenidate ER tab 20mg (QL= 3 tabs/day)

QL Tier 1

methylphenidate soln (METHYLIN equiv)

- Tier 1

methylphenidate tab 10mg (RITALIN equiv) (QL= 180 tabs/30 days)

QL Tier 1

methylphenidate tab 20mg (RITALIN equiv) (QL= 90 tabs/30 days)

QL Tier 1

methylphenidate tab 5mg (RITALIN equiv) (QL= 360 tabs/30 days)

QL Tier 1

methylphenidate CD cap (METADATE CD equiv) (QL= 1 cap/day)

QL Tier 2

methylphenidate chew tab (METHYLIN equiv) (QL= 3 tabs/day)

QL Tier 2

methylphenidate ER cap (RITALIN LA equiv) (QL= 60 caps/30 days; Step therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 10mg (APTENSIO XR equiv) (QL= 60 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 15mg (APTENSIO XR equiv) (QL= 60 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 20mg (APTENSIO XR equiv) (QL= 60 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 30mg (APTENSIO XR equiv) (QL= 60 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 40mg (APTENSIO XR equiv) (QL= 30 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 50mg (APTENSIO XR equiv) (QL= 30 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate er cap 60mg (APTENSIO XR equiv) (QL= 30 caps/30 days; Step Therapy requires trial of 2:

dextro/amphet ER, dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

methylphenidate td patch (DAYTRANA equiv) (QL= 1 patch/day; Step therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM))

QL-ST Tier 2

modafinil tab (PROVIGIL equiv) (QL= 2 tabs/day)

QL Value

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

ALLERGENIC EXTRACTS

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 71 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ALLERGENIC EXTRACTS/BIOLOGICALS MISC Cont.

ODACTRA SL TAB (QL= 30 tabs/30 days)

QL Tier 2

AMINOGLYCOSIDES

neomycin tab

- Tier 1

paromomycin cap (HUMATIN equiv)

- Tier 1

tobramycin neb soln (BETHKIS equiv)

AMSP-PA

Tier 1

Specialty

tobramycin neb soln (TOBI equiv)

AMSP-PA

Tier 1

Specialty

ANALGESICS - ANTI-INFLAMMATORY

ANTIRHEUMATIC - ENZYME INHIBITORS

RINVOQ ER TAB (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

RINVOQ ER TAB 45MG (QL= 1 tab/day, 3 fills/year)

AMSP-PA-QL

Tier 2

Specialty

RINVOQ ORAL SOLN (QL= 360ml/30 days)

AMSP-PA-QL

Tier 2

Specialty

XELJANZ SOLN (QL= 10ml/day)

AMSP-PA-QL

Tier 2

Specialty

XELJANZ TAB (QL= 2 tabs/day)

AMSP-PA-QL

Tier 2

Specialty

XELJANZ XR TAB (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

ADALIMUMAB-ADAZ INJ 40MG/0.4ML (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

HADLIMA INJ 40MG/0.4ML (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

HADLIMA INJ 40MG/0.8ML (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

HADLIMA PUSH INJ 40MG/0.4ML (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

HADLIMA PUSH INJ 40MG/0.8ML (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)

celecoxib cap (CELEBREX equiv)

- Tier 1

diclofenac potassium tab (CATAFLAM equiv)

- Tier 1

diclofenac sodium EC tab (VOLTAREN equiv)

- Tier 1

diclofenac sodium XR tab (VOLTAREN XR equiv)

- Tier 1

diclofenac/misoprostol DR tab (ARTHROTEC equiv)

- Tier 1

etodolac cap (LODINE equiv)

- Tier 1

etodolac ER tab (LODINE XL equiv)

- Tier 1

etodolac tab

- Tier 1

FLURBIPROFEN TAB

- Tier 1

flurbiprofen tab (ANSAID equiv)

- Tier 1

ibuprofen susp (Rx ONLY) (ADVIL, MOTRIN equiv)

- Tier 1

ibuprofen tab

- Tier 1

indomethacin cap (INDOCIN equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 72 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANALGESICS - ANTI-INFLAMMATORY Cont.

indomethacin CR cap (INDOCIN SR equiv)

- Tier 1

ketorolac inj

- Tier 1

ketorolac tab (TORADOL equiv)

- Tier 1

meloxicam tab (MOBIC equiv)

- Tier 1

nabumetone tab (RELAFEN equiv)

- Tier 1

naproxen EC tab (NAPROSYN EC equiv)

- Tier 1

naproxen sodium tab (ANAPROX equiv)

- Tier 1

naproxen susp (NAPROSYN equiv)

- Tier 1

naproxen tab (NAPROSYN equiv)

- Tier 1

oxaprozin tab (DAYPRO equiv)

- Tier 1

piroxicam cap (FELDENE equiv)

- Tier 1

sulindac tab (CLINORIL equiv)

- Tier 1

tolmetin cap (TOLECTIN DS equiv)

- Tier 1

diclofenac potassium cap (ZIPSOR equiv) (QL= 4 caps/day; Step therapy requires trial of diclofenac sodium EC or

diclofenac sodium ER tablets)

QL-ST Tier 2

diclofenac potassium tab 25mg (QL= 4 tabs/day; Step therapy requires trial of diclofenac sodium EC or diclofenac sodium

ER tablets)

QL-ST Tier 2

fenoprofen calcium cap (NALFON equiv) (QL= 8 tabs/day; Step therapy requires trial of 2: diclofenac, diclofenac XR,

etodolac, etodolac ER, or ibuprofen)

QL-ST Tier 2

fenoprofen calcium tab (Step Therapy requires trial of 2: diclofenac, diclofenac XR, etodolac, etodolac ER, or ibuprofen)

ST Tier 2

indomethacin suppository (INDOCIN equiv) (QL= 4 supp/day; ST req trial of two NSAIDS (e.g. indomethacin, celecoxib,

naproxen, diclofenac, meloxicam, etc))

QL-ST Tier 2

indomethacin susp (INDOCIN equiv) (QL= 1200ml/30 days; ST req trial of 2: Naproxen susp, Ibuprofen susp)

QL-ST Tier 2

KETOROLAC INJ

- Tier 2

MECLOFENAMATE CAP

- Tier 2

mefenamic acid cap (PONSTEL equiv)

- Tier 2

meloxicam (VIVLODEX equiv) (QL= 1 cap/day; Step Therapy requires trial of meloxicam, ketoprofen, oxaprozin, sulindac,

or tolmetin)

QL-ST Tier 2

naproxen sodium CR tab (NAPRELAN CR equiv)

- Tier 2

NAPROXEN SUSP

- Tier 2

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

OTEZLA STARTER PACK (QL= 1 pack/28 days)

AMSP-PA-QL

Tier 2

Specialty

OTEZLA TAB (QL= 2 tabs/day)

AMSP-PA-QL

Tier 2

Specialty

PYRIMIDINE SYNTHESIS INHIBITORS

leflunomide tab (ARAVA equiv)

- Tier 1

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS

ENBREL INJ (QL= 8 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

ENBREL INJ 25MG (QL= 8 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

ENBREL INJ 50MG (QL= 4 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

ENBREL MINI INJ (QL= 4 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

ENBREL SURECLICK INJ 50MG (QL= 4 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 73 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANALGESICS - NONNARCOTIC

ANALGESIC COMBINATIONS

butalbital/acetaminophen tab (PHRENILIN equiv) (QL= 6 tabs/day)

QL Tier 1

butalbital/acetaminophen/caffeine soln

- Tier 1

VTOL SOLN

- Tier 1

butalbital/acetaminophen cap

- Tier 2

SALICYLATES

aspirin chew tab 81mg (Covered for females only)

Preventiv

aspirin ec tab 325mg (Covered for females only)

OTC

Preventiv

aspirin ec tab 81mg (Covered for females only)

OTC

Preventiv

aspirin tab (Covered for females only)

OTC

Preventiv

diflunisal tab (DOLOBID equiv)

- Tier 1

salsalate tab (DISALCID equiv)

- Tier 1

ANALGESICS - OPIOID

OPIOID AGONISTS

codeine sulfate tab (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 1

hydromorphone liquid (DILAUDID equiv) (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21

or older; Day supply limit of 42 days in 90 days)

QL Tier 1

HYDROMORPHONE SUPP (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 1

hydromorphone tab (DILAUDID equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age

21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

meperidine tab (DEMEROL equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

methadone soln (QL= 4 ml/day)

QL Tier 1

methadone soln 10mg/5ml (QL= 20ml/day)

QL Tier 1

methadone soln 5mg/5ml (QL= 40ml/day)

QL Tier 1

methadone tab 10mg (DOLOPHINE equiv) (QL= 4 tabs/day)

QL Tier 1

methadone tab 5mg (DOLOPHINE equiv) (QL= 8 tabs/day)

QL Tier 1

methadose tab (QL= 1 tab/day)

PA-QL Tier 1

morphine sulfate ER cap 100mg (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 1

morphine sulfate ER cap 30mg (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 1

morphine sulfate ER tab (MS CONTIN equiv) (QL= 3 tabs/day)

PA-QL Tier 1

MORPHINE SULFATE ORAL SOLN 100MG/5ML (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members

age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

morphine sulfate oral soln 10mg/5ml (MORPHINE equiv) (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

MORPHINE SULFATE SOLN (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 1

morphine sulfate soln (MORPHINE equiv) (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21

or older; Day supply limit of 42 days in 90 days

)

QL Tier 1

morphine sulfate tab (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 74 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANALGESICS - OPIOID Cont.

oxycodone cap (OXYIR equiv) (QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone soln (ROXICODONE equiv) (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone tab (ROXICODONE equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age

21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxymorphone tab (OPANA equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

tramadol ER tab 100mg (ULTRAM ER equiv)

PA Tier 1

tramadol ER tab 200mg (ULTRAM ER equiv)

PA Tier 1

tramadol ER tab 300mg (ULTRAM ER equiv)

PA Tier 1

tramadol hcl tab 100mg (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

QL Tier 1

tramadol tab (ULTRAM equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

CODEINE SULFATE TAB (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

QL Tier 2

fentanyl citrate lollipop (ACTIQ equiv) (QL= 18 lozenges/fill for members age 20 or younger; QL= 42 lozenges/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

PA-QL Tier 2

fentanyl patch (DURAGESIC equiv) (QL=15 patches/30 days)

PA-QL Tier 2

HYDROCODONE BITARTRATE ER CAP (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

hydrocodone bitartrate ER cap (ZOHYDRO equiv) (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER

tab)

PA-QL-ST Tier 2

hydrocodone bitartrate er tab (HYSINGLA equiv) (QL= 1 tab/day)

PA-QL Tier 2

hydromorphone ER tab 12mg (EXALGO equiv) (QL= 1 tab/day)

PA-QL Tier 2

hydromorphone ER tab 16mg (EXALGO equiv) (QL= 1 tab/day)

PA-QL Tier 2

hydromorphone ER tab 32mg (EXALGO equiv) (QL= 2 tabs/day)

PA-QL Tier 2

hydromorphone ER tab 8mg (EXALGO equiv) (QL= 1 tab/day)

PA-QL Tier 2

MEPERIDINE SOLN (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day supply

limit of 42 days in 90 days)

QL Tier 2

MORPHINE SULFATE ER CAP (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

QL-ST Tier 2

morphine sulfate ER cap 10mg (KADIAN equiv) (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

morphine sulfate ER cap 20mg (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

morphine sulfate ER cap 50mg (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

morphine sulfate ER cap 60mg (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

morphine sulfate ER cap 80mg (QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

MORPHINE SULFATE SOLN (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 2

MORPHINE SULFATE SUPP (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 2

MORPHINE SULFATE TAB (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

QL Tier 2

oxycodone conc (ROXICODONE equiv) (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21

or older; Day supply limit of 42 days in 90 days)

QL Tier 2

OXYCODONE ER TAB 10MG (QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

OXYCODONE ER TAB 15MG (QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

OXYCODONE ER TAB 20MG (QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

OXYCODONE ER TAB 30MG (QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

OXYCODONE ER TAB 40MG (QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 75 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANALGESICS - OPIOID Cont.

OXYCODONE ER TAB 60MG (QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

OXYCODONE ER TAB 80MG (QL= 4 tabs/day; Step Therapy requires trial of morphine sulfate ER tab)

PA-QL-ST Tier 2

OXYMORPHONE ER TAB 10MG (QL= 2 tabs/day)

PA-QL Tier 2

OXYMORPHONE ER TAB 15MG (QL= 2 tabs/day)

PA-QL Tier 2

OXYMORPHONE ER TAB 20MG (QL= 2 tabs/day)

PA-QL Tier 2

OXYMORPHONE ER TAB 30MG (QL= 4 tabs/day)

PA-QL Tier 2

oxymorphone ER tab 30mg (OPANA ER equiv) (QL= 4 tabs/day)

PA-QL Tier 2

OXYMORPHONE ER TAB 40MG (QL= 4 tabs/day)

PA-QL Tier 2

oxymorphone ER tab 40mg (OPANA ER equiv) (QL= 4 tabs/day)

PA-QL Tier 2

OXYMORPHONE ER TAB 5MG (QL= 2 tabs/day)

PA-QL Tier 2

OXYMORPHONE ER TAB 7.5MG (QL= 2 tabs/day)

PA-QL Tier 2

tramadol ER tab (RYZOLT equiv)

PA Tier 2

OPIOID COMBINATIONS

acetaminophen/codeine soln (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older;

Day supply limit of 42 days in 90 days)

QL Tier 1

acetaminophen/codeine tab (TYLENOL/CODEINE equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill

for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

APAP/CODEINE SOLN (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 1

aspirin/codeine tab (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or older; Day

supply limit of 42 days in 90 days)

QL Tier 1

butalbital/acetaminophen/caffeine/codeine cap (FIORICET/CODEINE equiv) (QL= 18 caps/fill for members age 20 or

younger; QL= 42 caps/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

butalbital/aspirin/caffeine/codeine cap (FIORINAL/CODEINE equiv) (QL= 18 caps/fill for members age 20 or younger; QL=

42 caps/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/acetaminophen cap (LORCET equiv) (QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/acetaminophen soln (HYCET, LORTAB equiv) (QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill

for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/acetaminophen tab 10-325mg (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/acetaminophen tab 2.5-325mg (NORCO equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/acetaminophen tab 5-325mg (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members

age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/acetaminophen tab 7.5mg-325mg (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

HYDROCODONE/IBUPROFEN TAB (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21

or older; Day supply limit of 42 days in 90 days)

QL Tier 1

hydrocodone/ibuprofen tab (VICOPROFEN equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone/acetaminophen cap (TYLOX equiv) (QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone/acetaminophen tab 10-325mg (PERCOCET equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone/acetaminophen tab 2.5-325mg (PERCOCET equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone/acetaminophen tab 5-325mg (PERCOCET equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 76 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANALGESICS - OPIOID Cont.

oxycodone/acetaminophen tab 7.5-325mg (PERCOCET equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

OXYCODONE/ASPIRIN TAB (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

OXYCODONE/IBUPROFEN TAB (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days)

QL Tier 1

oxycodone/ibuprofen tab (COMBUNOX equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

pentazocine/acetaminophen tab (TALACEN equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

tramadol/acetaminophen tab (ULTRACET equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE TAB (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 2

hydrocodone/acetaminophen soln 10-325 mg/15ml (HYCET equiv) (QL= 90ml/fill for members age 20 or younger; QL=

210ml/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 2

hydrocodone/acetaminophen tab 10mg-300mg (XODOL equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 2

hydrocodone/acetaminophen tab 5mg-300mg (XODOL equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 2

hydrocodone/acetaminophen tab 7.5mg-300mg (XODOL equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42

tabs/fill for members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 2

OPIOID PARTIAL AGONISTS

buprenorphine patch (BUTRANS equiv)

- Tier 1

buprenorphine SL tab (SUBUTEX equiv)

- Tier 1

buprenorphine/naloxone sl film (SUBOXONE equiv)

- Tier 1

buprenorphine/naloxone SL tab (SUBOXONE equiv)

- Tier 1

butorphanol nasal spray (QL= 5ml/30 days)

QL Tier 1

pentazocine/naloxone tab (TALWIN NX equiv) (QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for

members age 21 or older; Day supply limit of 42 days in 90 days)

QL Tier 1

buprenorphine hcl buccal film (BELBUCA equiv) (Step therapy requires trial of buprenorphine patch)

ST Tier 2

SUBOXONE SL FILM 12-3MG (QL= 2 films/day)

QL Tier 2

SUBOXONE SL FILM 8-2MG (QL= 3 films/day)

QL Tier 2

ANDROGENS-ANABOLIC

ANABOLIC STEROIDS

OXANDROLONE TAB

PA Tier 1

ANDROGENS

danazol cap (DANOCRINE equiv) (QL= 4 caps/day)

QL Tier 1

testosterone cypionate inj (DEPO-TESTOSTERONE equiv)

- Tier 1

testosterone cypionate inj (DEPO-TESTOSTERONE equiv) (QL= 1 vial/28 days)

--QL Tier 1

testosterone cypionate inj (DEPO-TESTOSTERONE equiv) (QL= 4 vials/28 days)

--QL Tier 1

testosterone cypionate inj 200mg/ml (DEPO-TESTOSTERONE equiv) (QL= 4 vials/28 days)

QL Tier 1

testosterone gel 1% 25mg (ANDROGEL equiv) (QL= 150gm/30 days)

QL Tier 1

testosterone gel 1% 50mg (QL= 300gm/30 days)

QL Tier 1

testosterone gel 1% pump (VOGELXO GEL, ANDROGEL equiv) (QL= 300gm/30 days)

QL Tier 1

testosterone gel pump 1.62% (ANDROGEL equiv) (QL= 150gm/30 days)

QL Tier 1

TESTOSTERONE GEL PUMP, VOGELXO GEL PUMP (QL= 300g/30 days)

QL Tier 1

methyltestosterone cap (QL= 150 tablets/30 days)

PA-QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 77 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANDROGENS-ANABOLIC Cont.

TESTOSTERONE ENANTHATE INJ (QL= 4 vials/28 days)

QL Tier 2

TESTOSTERONE GEL 1% 25MG (QL= 1 packet/day)

PA-QL Tier 2

testosterone gel 1.62% 1.25gm (ANDROGEL equiv) (QL= 1 packet/day)

PA-QL Tier 2

testosterone gel 1.62% 2.5gm (ANDROGEL equiv) (QL= 2 packets/day)

PA-QL Tier 2

TESTOSTERONE GEL 10MG/ACT (QL= 2 bottles/30 days)

PA-QL Tier 2

testosterone gel 2% (FORTESTA equiv) (QL= 2 bottles/30 days)

PA-QL Tier 2

TESTOSTERONE GEL PUMP (QL= 4 bottles/30 days)

PA-QL Tier 2

TESTOSTERONE INJ (QL= 1 vial/28 days)

QL Tier 2

TESTOSTERONE INJ (QL= 4 vials/28 days)

QL Tier 2

TESTOSTERONE PROP IM OR SUBCUTANEOUS INJ (QL= 1 vial/28 days)

QL Tier 2

testosterone soln (AXIRON equiv) (QL= 2 bottles/30 days)

PA-QL Tier 2

ANORECTAL AGENTS

INTRARECTAL STEROIDS

hydrocortisone enema (CORTENEMA equiv)

- Tier 1

RECTAL COMBINATIONS

lidocaine/hydrocortisone cream (ANAMANTLE equiv)

- Tier 1

lidocaine/hydrocortisone kit (ANALPRAM equiv)

- Tier 1

LIDOCAINE/HYDROCORTISONE RECTAL CREAM KIT

- Tier 1

PROCTOFOAM HC FOAM

- Tier 2

RECTAL STEROIDS

proctosol HC cream (ANUSOL HC equiv)

- Tier 1

ANORECTAL AND RELATED PRODUCTS

INTRARECTAL STEROIDS

budesonide rectal foam (UCERIS equiv) (QL= 100.2g/30 days; Step therapy requires trial of hydrocortisone enema)

QL-ST Tier 2

VASODILATING AGENTS

nitroglycerin oint (RECTIV equiv) (Diagnosis Restricted – Anal Fissure (K60.2))

RDX Tier 1

ANTHELMINTICS

ivermectin tab (STROMECTOL equiv)

- Tier 1

praziquantel tab (BILTRICIDE equiv)

- Tier 1

BENZNIDAZOLE TAB

- Tier 2

ANTIANGINAL AGENTS

ANTIANGINALS-OTHER

ranolazine tab (RANEXA equiv) (QL= 120 tabs/30 days)

QL Tier 1

ASPRUZYO SPRINKLE GRANULES (QL= 2 packets/day; Step therapy requires trial of ranolazine ER tab)

QL-ST Tier 2

NITRATES

isosorbide dinitrate tab 5mg (ISORDIL equiv)

- Tier 1

isosorbide mononitrate ER tab (IMDUR equiv)

- Tier 1

ISOSORBIDE MONONITRATE TAB

- Tier 1

isosorbide mononitrate tab (MONOKET equiv)

- Tier 1

NITROGLYCERIN ER CAP

- Tier 1

nitroglycerin patch (NITRO-DUR equiv)

- Tier 1

nitroglycerin SL tab (NITROSTAT equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 78 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIANGINAL AGENTS Cont.

isosorbide dinitrate tab 40mg (ISORDIL equiv) (Step Therapy requires trial of isosorbide dinitrate, isosorbide dinitrate ER,

isosorbide dinitrate SL, isosorbide mononitrate, or isosorbide mononitrate ER)

ST Tier 2

NITRO-BID OINT

- Tier 2

nitroglycerin lingual spray (NITROLINGUAL equiv)

- Tier 2

ANTIANXIETY AGENTS

ANTIANXIETY AGENTS - MISC.

buspirone tab (BUSPAR equiv)

- Tier 1

hydroxyzine pamoate cap (VISTARIL equiv)

- Tier 1

hydroxyzine syrup (ATARAX equiv)

- Tier 1

hydroxyzine tab (ATARAX equiv)

- Tier 1

meprobamate tab (MILTOWN equiv)

- Tier 2

BENZODIAZEPINES

alprazolam ER tab (XANAX XR equiv)

- Tier 1

alprazolam tab (XANAX equiv)

- Tier 1

chlordiazepoxide cap (LIBRIUM equiv)

- Tier 1

clorazepate tab (TRANXENE-T equiv)

- Tier 1

diazepam conc (VALIUM equiv)

- Tier 1

diazepam oral soln (QL= 360ml/30 days)

QL Tier 1

diazepam tab (VALIUM equiv)

- Tier 1

lorazepam conc (ATIVAN equiv)

- Tier 1

lorazepam tab (ATIVAN equiv)

- Tier 1

alprazolam ODT (NIRAVAM equiv)

- Tier 2

oxazepam cap (SERAX equiv) (Step Therapy requires trial of 2: alprazolam, chlordiazepoxide, diazepam, or lorazepam

tab)

ST Tier 2

ANTIARRHYTHMICS

ANTIARRHYTHMICS TYPE I-A

disopyramide cap (NORPACE equiv)

- Tier 1

quinidine sulfate tab (QL= 8 tabs/day)

QL Tier 1

NORPACE CR CAP

- Tier 2

quinidine gluconate CR tab

- Tier 2

QUINIDINE SULFATE TAB 200MG (QL= 8 tabs/day)

QL Tier 2

QUINIDINE SULFATE TAB 300MG (QL= 5 tabs/day)

QL Tier 2

ANTIARRHYTHMICS TYPE I-B

mexiletine hcl cap

- Tier 1

ANTIARRHYTHMICS TYPE I-C

flecainide tab (TAMBOCOR equiv)

- Tier 1

propafenone tab (RYTHMOL equiv)

- Tier 1

propafenone ER cap (RYTHMOL SR equiv)

- Tier 2

ANTIARRHYTHMICS TYPE III

amiodarone tab (CORDARONE equiv)

- Tier 1

dofetilide cap (TIKOSYN equiv)

- Tier 2

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ANTIASTHMATIC - MONOCLONAL ANTIBODIES

NUCALA INJ (QL= 1 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 79 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIASTHMATIC AND BRONCHODILATOR AGENTS Cont.

XOLAIR INJ (QL= 1 syringe/28 days)

AMSP-PA-QL

Tier 2

Specialty

XOLAIR INJ (QL= 1 vial/28 days)

AMSP-PA-QL

Tier 2

Specialty

XOLAIR INJ 150MG/ML (QL= 1ml/28 days)

AMSP-PA-QL

Tier 2

Specialty

XOLAIR INJ 300MG/2ML (QL= 2ml/28 days)

AMSP-PA-QL

Tier 2

Specialty

XOLAIR INJ 75MG/0.5ML (QL= 0.5ml/28 days)

AMSP-PA-QL

Tier 2

Specialty

ANTI-INFLAMMATORY AGENTS

cromolyn neb soln (INTAL equiv)

- Tier 1

BRONCHODILATORS - ANTICHOLINERGICS

ipratropium neb soln (ATROVENT equiv)

- Tier 1

tiotropium bromide cap inhaler (SPIRIVA equiv) (QL= 1 cap/day; For use with Handihaler device)

QL Tier 1

ATROVENT HFA INHALER (QL= 25.8gm/30 days)

QL Tier 2

INCRUSE ELLIPTA INHALER (QL= 30 units/30 days)

QL Tier 2

SPIRIVA RESPIMAT INHALER 1.25MCG/ACT (QL= 1 inhaler/30 days)

QL Tier 2

SPIRIVA RESPIMAT INHALER 2.5MCG/ACT (QL= 1 inhaler/30 days)

QL Tier 2

LEUKOTRIENE MODULATORS

montelukast chew tab (SINGULAIR equiv)

- Tier 1

montelukast granule pack (SINGULAIR equiv)

- Tier 1

montelukast tab (SINGULAIR equiv)

- Tier 1

zafirlukast tab (ACCOLATE equiv)

- Tier 1

zileuton ER tab (ZYFLO CR equiv) (QL= 2 tabs/day)

QL Tier 2

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

roflumilast tab (DALIRESP equiv) (QL= 1 tab/day)

PA-QL Tier 1

STEROID INHALANTS

ASMANEX HFA INHALER (QL= 1 inhaler/30 days)

QL Value

ASMANEX INHALER (QL= 1 inhaler/30 days)

QL Value

budesonide inh susp 0.25mg/2ml, 0.5mg/2ml (PULMICORT equiv) (QL= 120 units/30 days)

QL Value

budesonide inh susp 1mg/2ml (QL= 60 units/30 days)

QL Value

QVAR REDIHALER (QL= 21.2gm/30 days)

QL Value

SYMPATHOMIMETICS

ALBUTEROL HFA INHALER (QL= 2 inhalers/30 days)

QL Tier 1

albuterol HFA inhaler (PROAIR equiv) (QL= 2 inhalers/30 days)

QL Tier 1

albuterol HFA inhaler (PROVENTIL equiv) (QL= 2 inhalers/30 days)

QL Tier 1

albuterol neb soln

- Tier 1

ALBUTEROL NEBULIZER SOLN

- Tier 1

albuterol sulfate syrup

- Tier 1

albuterol sulfate tab

- Tier 1

albuterol/ipratropium neb soln (DUONEB equiv)

- Tier 1

fluticasone/salmeterol inhaler, wixela inhaler (ADVAIR equiv) (QL= 1 inhaler/30 days)

QL Tier 1

levalbuterol neb soln (XOPENEX equiv)

- Tier 1

terbutaline sulfate tab (BRETHINE equiv)

- Tier 1

ANORO ELLIPTA INHALER (QL= 60gm/30 days)

QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 80 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIASTHMATIC AND BRONCHODILATOR AGENTS Cont.

arformoterol tartrate neb soln (BROVANA equiv) (QL= 120ml/30 days; Step Therapy requires trial of albuterol neb soln OR

levalbuterol neb soln)

QL-ST Tier 2

budesonide/formoterol inhaler (BREYNA equiv) (QL= 10.3g/30 days; Step therapy requires trial of two:

fluticasone/salmeterol, WIXELA, DULERA)

QL-ST Tier 2

budesonide/formoterol inhaler (SYMBICORT equiv) (QL= 10.2g/30 days; Step therapy requires trial of two:

fluticasone/salmeterol, WIXELA, DULERA)

QL-ST Tier 2

COMBIVENT RESPIMAT INHALER (QL= 2 inhalers/30days)

QL Tier 2

DULERA INHALER (QL= 1 inhaler/30 days)

QL Tier 2

FLUTICASONE-SALMETEROL INHALER (QL= 1 inhaler/30 days)

QL Tier 2

formoterol fumarate neb soln (PERFOROMIST equiv) (QL= 120ml/30 days; Step Therapy requires trial of albuterol neb soln

OR levalbuterol neb soln)

QL-ST Tier 2

STIOLTO INHALER (QL= 1 inhaler/30 days)

QL Tier 2

STRIVERDI RESPIMAT INHALER (QL= 1 inhaler/30 days)

QL Tier 2

TRELEGY ELLIPTA INHALER (QL= 1 inhaler/30 days)

QL Tier 2

XANTHINES

theophylline CR tab (QUIBRON-T equiv)

- Tier 1

theophylline ER tab (UNIPHYL equiv)

- Tier 1

theophylline soln

- Tier 1

ELIXOPHYLLIN ELIXIR

- Tier 2

THEOPHYLLINE TAB ER (QL= 1 tab/day)

QL Tier 2

ANTICOAGULANTS

COUMARIN ANTICOAGULANTS

warfarin tab (COUMADIN equiv)

- Tier 1

DIRECT FACTOR XA INHIBITORS

ELIQUIS STARTER PACK 5MG (QL= 1 pack/30 days)

QL Tier 2

ELIQUIS TAB 2.5MG (QL= 60 tabs/30 days)

QL Tier 2

ELIQUIS TAB 5MG (QL= 74 tabs/30 days)

QL Tier 2

XARELTO STARTER PACK 15MG/20MG (QL= 1 pack/30 days)

QL Tier 2

XARELTO SUSP (QL= 10ml/day)

QL Tier 2

XARELTO TAB 10MG (QL= 30 tabs/30 days)

QL Tier 2

XARELTO TAB 15MG (QL= 60 tabs/30 days)

QL Tier 2

XARELTO TAB 2.5MG (QL= 60 tabs/30 days)

QL Tier 2

XARELTO TAB 20MG (QL= 30 tabs/30 days)

QL Tier 2

HEPARINS AND HEPARINOID-LIKE AGENTS

enoxaparin inj (LOVENOX equiv)

- Tier 1

enoxaparin inj 300mg (LOVENOX equiv)

- Tier 1

fondaparinux inj 10mg/0.8ml (ARIXTRA equiv)

- Tier 1

fondaparinux inj 2.5mg/0.5ml (ARIXTRA equiv)

- Tier 1

fondaparinux inj 5mg/0.4ml (ARIXTRA equiv)

- Tier 1

fondaparinux inj 7.5mg/0.6ml (ARIXTRA equiv)

- Tier 1

heparin porcine inj

- Tier 1

THROMBIN INHIBITORS

dabigatran etexilate mesylate cap (PRADAXA equiv) (QL= 2 caps/day)

QL Tier 1

ANTICONVULSANTS

ANTICONVULSANTS - BENZODIAZEPINES

clobazam susp (ONFI equiv) (QL= 480ml/30 days)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 81 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTICONVULSANTS Cont.

clobazam tab (ONFI equiv)

- Tier 1

clonazepam ODT (KLONOPIN equiv)

- Tier 1

clonazepam tab (KLONOPIN equiv)

- Tier 1

diazepam rectal gel (QL= 1 pack/30 days)

QL Tier 1

DIAZEPAM GEL (QL= 1 kit/30 days)

QL Tier 2

ANTICONVULSANTS - MISC.

carbamazepine chew tab (TEGRETOL equiv)

- Tier 1

carbamazepine ER cap (CARBATROL equiv)

- Tier 1

carbamazepine ER tab (TEGRETOL XR equiv)

- Tier 1

carbamazepine susp (TEGRETOL equiv)

- Tier 1

carbamazepine tab (TEGRETOL equiv)

- Tier 1

gabapentin cap (NEURONTIN equiv)

- Tier 1

gabapentin tab (NEURONTIN equiv)

- Tier 1

lacosamide oral solution (VIMPAT equiv) (QL= 1200ml/30 days)

QL Tier 1

lacosamide tab (VIMPAT equiv) (QL= 2 tabs/day)

QL Tier 1

lamotrigine chew tab (LAMICTAL equiv)

- Tier 1

lamotrigine ER tab 100mg (LAMICTAL XR equiv) (QL= 3 tabs/day)

QL Tier 1

lamotrigine ER tab 200mg (LAMICTAL XR equiv) (QL= 2 tabs/day)

QL Tier 1

lamotrigine ER tab 250mg (LAMICTAL XR equiv) (QL= 2 tabs/day)

QL Tier 1

lamotrigine ER tab 25mg (LAMICTAL XR equiv) (QL= 6 tabs/day)

QL Tier 1

lamotrigine ER tab 300mg (LAMICTAL XR equiv) (QL= 2 tabs/day)

QL Tier 1

lamotrigine ER tab 50mg (LAMICTAL XR equiv) (QL= 6 tabs/day)

QL Tier 1

lamotrigine tab (LAMICTAL equiv)

- Tier 1

levetiracetam ER tab (KEPPRA XR equiv)

- Tier 1

levetiracetam soln (KEPPRA equiv)

- Tier 1

levetiracetam tab (KEPPRA equiv)

- Tier 1

oxcarbazepine susp (TRILEPTAL equiv)

- Tier 1

oxcarbazepine tab (TRILEPTAL equiv)

- Tier 1

pregabalin cap (LYRICA equiv)

- Tier 1

pregabalin soln (LYRICA equiv) (QL= 30ml/day)

QL Tier 1

PRIMIDONE TAB (QL= 4 tabs/day)

QL Tier 1

primidone tab (MYSOLINE equiv)

QL-- Tier 1

topiramate sprinkle cap (TOPAMAX equiv)

- Tier 1

topiramate tab (TOPAMAX equiv)

- Tier 1

zonisamide cap (ZONEGRAN equiv)

- Tier 1

APTIOM TAB (QL= 1 tab/day)

QL Tier 2

lamotrigine odt (LAMICTAL equiv) (QL= 2 tabs/day; Step Therapy requires trial of lamotrigine chew)

QL-ST Tier 2

lamotrigine ODT kit (LAMICTAL ODT KIT equiv)

- Tier 2

rufinamide susp (BANZEL equiv) (QL= 80ml/day; Step Therapy requires trial of two: valproate, lamotrigine, topiramate,

pregabalin, levetiracetam)

QL-ST Tier 2

rufinamide tab (BANZEL equiv) (QL= 8 tabs/day; Step Therapy requires trial of two: valproate, lamotrigine, topiramate,

pregabalin, levetiracetam)

QL-ST Tier 2

topiramate cap er 200mg (TROKENDI equiv) (QL= 2 caps/day; Step therapy requires trial of topiramate followed by

topiramate ER sprinkle)

QL-ST Tier 2

topiramate er cap (TROKENDI XR equiv) (QL= 1 cap/day; ST req trial of topirmate followed by topiramate ER sprinkle)

QL-ST Tier 2

topiramate ER cap 100mg (QUDEXY equiv) (QL= 1 cap/day; Step Therapy requires trial of generic topiramate IR)

QL-ST Tier 2

topiramate ER cap 150mg (QUDEXY equiv) (QL= 2 caps/day; Step Therapy requires trial of generic topiramate IR)

QL-ST Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 82 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTICONVULSANTS Cont.

topiramate ER cap 200mg (QUDEXY equiv) (QL= 2 caps/day; Step Therapy requires trial of generic topiramate IR)

QL-ST Tier 2

topiramate ER cap 25mg (QUDEXY equiv) (QL= 1 cap/day; Step Therapy requires trial of generic topiramate IR)

QL-ST Tier 2

topiramate ER cap 50mg (QUDEXY equiv) (QL= 1 cap/day; Step Therapy requires trial of generic topiramate IR)

QL-ST Tier 2

EPIDIOLEX SOLN (Only available through Lumicera 855-847-3553)

LD-PA

Tier 2

Specialty

CARBAMATES

felbamate susp (FELBATOL equiv) (QL= 30ml/day)

QL Tier 1

felbamate tab 400mg (FELBATOL equiv) (QL= 9 tabs/day)

QL Tier 1

felbamate tab 600mg (FELBATOL equiv) (QL= 6 tabs/day)

QL Tier 1

GABA MODULATORS

tiagabine tab 12mg (GABITRIL equiv) (QL= 4 tabs/day)

QL Tier 1

tiagabine tab 16mg (GABITRIL equiv) (QL= 3 tabs/day)

QL Tier 1

tiagabine tab 2mg (GABITRIL equiv) (QL= 4 tabs/day)

QL Tier 1

tiagabine tab 4mg (GABITRIL equiv) (QL= 4 tabs/day)

QL Tier 1

vigabatrin powder pack (SABRIL POWDER equiv) (QL= 6 packs/day; Only available through Lumicera 855-847-3553)

LD-PA-QL

Tier 1

Specialty

vigabatrin powder pack (SABRIL POWDER equiv) (QL= 6 packs/day; Only available through PantheRx 855-726-8479)

LD-PA-QL

Tier 1

Specialty

vigabatrin tab (SABRIL equiv) (QL= 6 tabs/day; Only available through Lumicera 855-847-3553)

LD-PA-QL

Tier 1

Specialty

HYDANTOINS

phenytoin cap (DILANTIN equiv)

- Tier 1

phenytoin chew tab (DILANTIN equiv)

- Tier 1

phenytoin susp (DILANTIN equiv)

- Tier 1

DILANTIN CAP 30MG

- Tier 2

SUCCINIMIDES

ethosuximide cap (ZARONTIN equiv)

- Tier 1

ethosuximide soln (ZARONTIN equiv)

- Tier 1

methsuximide cap (CELONTIN equiv) (QL= 4 caps/day; ST requires trial of ethosuximide tab/soln)

QL-ST Tier 2

VALPROIC ACID

divalproex ER tab (DEPAKOTE ER equiv)

- Tier 1

divalproex sodium DR tab (DEPAKOTE equiv)

- Tier 1

divalproex sprinkle cap (DEPAKOTE equiv)

- Tier 1

valproic acid cap (DEPAKENE equiv)

- Tier 1

valproic acid syrup (DEPAKENE equiv)

- Tier 1

ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine ODT (REMERON equiv)

- Tier 1

mirtazapine tab (REMERON equiv)

- Tier 1

ANTIDEPRESSANTS - MISC.

bupropion ER tab (WELLBUTRIN equiv)

- Tier 1

bupropion tab (WELLBUTRIN equiv)

- Tier 1

bupropion XL tab (WELLBUTRIN XL equiv)

- Tier 1

MAPROTILINE TAB

- Tier 1

MONOAMINE OXIDASE INHIBITORS (MAOIS)

PHENELZINE SULFATE TAB (QL= 4 tabs/day)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 83 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIDEPRESSANTS Cont.

phenelzine tab (NARDIL equiv)

- Tier 1

tranylcypromine tab (PARNATE equiv)

- Tier 1

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

citalopram soln (CELEXA equiv)

- Tier 1

escitalopram soln (LEXAPRO equiv)

- Tier 1

fluoxetine cap 90mg (PROZAC equiv)

- Tier 1

fluvoxamine tab (LUVOX equiv)

- Tier 1

paroxetine tab (PAXIL equiv)

- Tier 1

FLUOXETINE TAB 60MG

- Tier 2

fluvoxamine ER cap (LUVOX CR equiv) (QL= 2 caps/day)

QL Tier 2

paroxetine ER tab (PAXIL CR equiv)

- Tier 2

paroxetine oral susp (PAXIL equiv) (QL= 900ml/30 days; Step therapy requires trial and failure of 2 generic SSRI/SNRIs)

QL-ST Tier 2

PROZAC WEEKLY CAP (QL= 4 caps/28 days; Step Therapy requires trial of fluoxetine IR)

QL-ST Tier 2

citalopram tab (CELEXA equiv)

- Value

escitalopram tab (LEXAPRO equiv)

- Value

fluoxetine cap (PROZAC equiv)

- Value

fluoxetine soln (PROZAC equiv)

- Value

fluoxetine tab 10mg, 20mg (PROZAC equiv)

- Value

sertraline conc (ZOLOFT equiv)

- Value

sertraline tab (ZOLOFT equiv)

- Value

SEROTONIN MODULATORS

NEFAZODONE TAB

- Tier 1

nefazodone tab 50mg, 250mg

- Tier 1

trazodone tab 50mg, 100mg, 150mg (DESYREL equiv)

- Tier 1

vilazodone hcl tab (VIIBRYD equiv) (QL= 1 tab/day; Step therapy requires trial of 2: cital, escital, fluox, parox IR/ER, sertr,

desven ER, venlfx IR/ER, dulox)

QL-ST Tier 2

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

desvenlafaxine ER tab (PRISTIQ equiv) (QL= 1 tab/day)

QL Tier 1

duloxetine EC cap 20mg (QL= 6 caps/day)

QL Tier 1

duloxetine EC cap 30mg (QL= 4 caps/day)

QL Tier 1

duloxetine EC cap 60mg (CYMBALTA equiv) (QL= 2 caps/day)

QL Tier 1

venlafaxine ER cap (EFFEXOR XR equiv)

- Tier 1

venlafaxine tab (EFFEXOR equiv)

- Tier 1

duloxetine cap 40mg (IRENKA equiv) (QL= 2 caps/day)

QL Tier 2

venlafaxine ER tab

- Tier 2

TRICYCLIC AGENTS

amoxapine tab (QL= 4 tabs/day)

QL Tier 1

clomipramine cap (ANAFRANIL equiv)

- Tier 1

desipramine tab (NORPRAMIN equiv)

- Tier 1

doxepin cap (SINEQUAN equiv) (QL= 2 tabs/day)

QL Tier 1

doxepin conc (SINEQUAN equiv)

- Tier 1

imipramine tab (TOFRANIL equiv)

- Tier 1

nortriptyline cap (PAMELOR equiv)

- Tier 1

nortriptyline oral soln (NORTRIPTYLINE equiv)

- Tier 1

protriptyline tab (VIVACTIL equiv)

- Tier 1

trimipramine cap (SURMONTIL equiv) (Step Therapy requires trial and failure of 2 generic SSRI/SNRIs)

ST Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 84 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIDEPRESSANTS Cont.

imipramine pamoate cap (TOFRANIL PM equiv)

- Tier 2

amitriptyline tab (ELAVIL equiv)

- Value

ANTIDIABETICS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose tab (PRECOSE equiv)

- Tier 1

MIGLITOL TAB

- Tier 2

miglitol tab (MIGLITOL equiv)

- Tier 2

ANTIDIABETIC COMBINATIONS

glipizide/metformin tab (METAGLIP equiv)

- Tier 1

pioglitazone/metformin tab (ACTOPLUS MET equiv)

- Tier 1

GLYXAMBI TAB (QL= 1 tab/day; Step Therapy requires trial of metformin tab or metformin er tab)

QL-ST Tier 2

JENTADUETO TAB (QL= 2 tabs/day)

QL Tier 2

JENTADUETO XR TAB (QL= 2 tabs/day)

QL Tier 2

pioglitazone/glimepiride tab (DUETACT equiv) (Step Therapy requires trial of metformin or metformin ER)

ST Tier 2

QTERN TAB (QL= 30 tabs/30 days; Step Therapy requires trial of metformin or metformin ER)

QL-ST Tier 2

REPAGLINIDE TAB

- Tier 2

saxagliptin-metformin hcl tab er 24hr (KOMBIGLYZE equiv) (QL= 2 tabs/day; Step Therapy requires trial of metformin AND

Tradjenta, OR Jentadueto)

QL-ST Tier 2

SYNJARDY TAB (QL= 2 tabs/day)

QL Tier 2

SYNJARDY XR TAB 10-1000MG, 25-1000MG (QL= 1 tab/day)

QL Tier 2

SYNJARDY XR TAB 5-1000MG, 12.5-1000MG (QL= 2 tabs/day)

QL Tier 2

XIGDUO XR TAB (QL= 1 tab/day)

QL Tier 2

XIGDUO XR TAB 2.5-1000MG (QL= 2 tabs/day)

QL Tier 2

XIGDUO XR TAB 5-1000MG (QL= 2 tabs/day)

QL Tier 2

XIGDUO XR TAB 5-500MG, 10-500MG, 10-1000MG (QL= 1 tab/day)

QL Tier 2

glyburide/metformin tab (GLUCOVANCE equiv)

- Value

BIGUANIDES

metformin ER osmotic tab (FORTAMET equiv)

- Tier 2

metformin ER osmotic tab (GLUMETZA equiv) (Step Therapy requires trial of metformin or metformin ER)

--ST Tier 2

metformin soln (RIOMET equiv)

- Tier 2

metformin ER tab (GLUCOPHAGE XR equiv)

- Value

metformin tab (GLUCOPHAGE equiv)

- Value

DIABETIC OTHER

diazoxide susp (PROGLYCEM equiv)

- Tier 1

mifepristone tab (KORLYM equiv) (QL= 4 tabs/day)

AMSP-PA-QL

Tier 1

Specialty

BAQSIMI NASAL POWDER (QL= 2 inhalations/fill, 2 fills/month)

QL Tier 2

GLUCAGEN HYPOKIT INJ (QL= 2 inj/fill, 2 fills/month)

QL Tier 2

GLUCAGON EMR INJ (QL= 2 inj/fill)

QL Tier 2

GLUCAGON INJ KIT (QL= 2 inj/fill)

QL Tier 2

GVOKE INJ (QL= 2 inj/fill, 2 fills/month)

QL Tier 2

GVOKE INJ KIT (QL= 2 vials/fill, 2 fills/30 days)

QL Tier 2

GVOKE PFS INJ (QL= 2 inj/fill, 2 fills/month)

QL Tier 2

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

saxagliptin hcl tab (ONGLYZA equiv) (QL= 1 tab/day; ST req trial of metformin AND Tradjenta OR Jentadueto)

QL-ST Tier 2

TRADJENTA TAB (QL= 1 tab/day)

QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 85 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIDIABETICS Cont.

INCRETIN MIMETIC AGENTS

OZEMPIC INJ (QL= 3ml/28 days; Diagnosis Restricted – Type 2 Diabetes (E11))

QL-RDX Tier 2

VICTOZA INJ (QL= 9ml/30 days; Diagnosis Restricted – Type 2 Diabetes (E11))

QL-RDX Tier 2

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

OZEMPIC INJ (QL= 3ml/28 days; Diagnosis Restricted – Type 2 Diabetes (E11))

QL-RDX Tier 2

RYBELSUS TAB (QL= 1 tab/day; Diagnosis Restricted – Type 2 Diabetes (E11))

QL-RDX Tier 2

TRULICITY INJ (QL= 2ml/28 days; Diagnosis Restricted – Type 2 Diabetes (E11))

QL-RDX Tier 2

INSULIN

HUMULIN R INJ U-500 (QL= 40 units/30 days)

QL Tier 1

HUMULIN R U-500 KWIKPEN INJ (QL= 24 units/30 days)

QL Tier 1

ADMELOG INJ, HUMALOG INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP)

QL-ST Tier 2

ADMELOG SOLOSTAR INJ, INSULIN LISPRO KWIKPEN INJ (JUNIOR) (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

AFREZZA INH POWDER (QL= 180 inhalations/28 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP)

QL-ST Tier 2

AFREZZA INH POWDER (QL= 360 inhalations/28 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP)

QL-ST Tier 2

AFREZZA INH POWDER (QL= 630 inhalations/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP)

QL-ST Tier 2

APIDRA INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

APIDRA SOLOSTAR INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG KWIKPEN INJ (QL= 12 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG KWIKPEN INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG MIX INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG MIX KWIKPEN, INSULIN LISPRO MIX KWIKPEN (QL= 60 units/30 days; Step Therapy requires trial of

NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG PEN INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

HUMALOG TEMPO PEN INJ 100UNIT/ML (QL= 60ml/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP)

QL-ST Tier 2

HUMULIN MIX INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN)

OTC-QL-ST Tier 2

HUMULIN MIX PEN INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN)

OTC-QL-ST Tier 2

HUMULIN N INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN)

OTC-QL-ST Tier 2

HUMULIN N PEN INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN)

OTC-QL-ST Tier 2

HUMULIN R INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN)

OTC-QL-ST Tier 2

LYUMJEV INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

LYUMJEV KWIKPEN (QL= 12 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

LYUMJEV KWIKPEN INJ (QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or FIASP)

QL-ST Tier 2

LYUMJEV TEMPO PEN INJ 100UNIT/ML (QL= 60ml/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP)

QL-ST Tier 2

BASAGLAR KWIKPEN INJ (QL= 60 units/30 days)

QL Value

FIASP FLEXTOUCH INJ (QL= 60 units/30 days)

QL Value

FIASP INJ (QL= 60 units/30 days)

QL Value

FIASP PENFILL INJ (QL= 60 units/30 days)

QL Value

FIASP PUMP CARTRIDGE (QL= 60 units/30 days)

QL Value

INSULIN ASPART FLEXPEN INJ (NOVOLOG equiv) (QL= 60 units/30 days)

QL Value

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 86 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIDIABETICS Cont.

INSULIN ASPART INJ (NOVOLOG equiv) (QL= 60 units/30 days)

QL Value

INSULIN ASPART MIX FLEXPEN INJ (NOVOLOG equiv) (QL= 60 units/30 days)

QL Value

INSULIN ASPART MIX INJ (NOVOLOG equiv) (QL= 60 units/30 days)

QL Value

INSULIN ASPART PENFILL INJ (NOVOLOG equiv) (QL= 60 units/30 days)

QL Value

INSULIN GLARGINE SOLN PEN-INJ 300 UNIT/ML (1 UNIT DIAL) (QL= 18ml/30 days)

QL Value

INSULIN GLARGINE SOLN PEN-INJ 300 UNIT/ML (2 UNIT DIAL) (QL= 18ml/30 days)

QL Value

INSULIN LISP INJ 100/ML (QL= 60 units/30 days)

QL Value

NOVOLIN 70/30 FLEXPEN INJ (QL= 60 units/30 days)

OTC-QL Value

NOVOLIN 70/30 INJ (QL= 60 units/30 days)

QL Value

NOVOLIN N FLEXPEN INJ (QL= 60 units/30 days)

QL Value

NOVOLIN N INJ (QL= 60 units/30 days)

QL Value

NOVOLIN N RELION INJ (QL= 60 units/30 days)

QL Value

NOVOLIN R FLEXPEN INJ (QL= 60 units/30 days)

QL Value

NOVOLIN R INJ (QL= 60 units/30 days)

QL Value

NOVOLIN RELION INJ 70/30 (QL= 60 units/30 days)

QL Value

NOVOLIN VIAL (QL= 60 units/30 days)

QL Value

NOVOLOG FLEXPEN INJ (QL= 60 units/30 days)

QL Value

NOVOLOG INJ (QL= 60 units/30 days)

QL Value

NOVOLOG MIX FLEXPEN INJ (QL= 60 units/30 days)

QL Value

NOVOLOG MIX INJ (QL= 60 units/30 days)

QL Value

NOVOLOG PENFILL INJ (QL= 60 units/30 days)

QL Value

INSULIN SENSITIZING AGENTS

pioglitazone tab (ACTOS equiv) (QL= 1 tab/day)

QL Tier 1

MEGLITINIDE ANALOGUES

nateglinide tab (STARLIX equiv)

- Tier 1

repaglinide tab (PRANDIN equiv)

- Tier 1

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA TAB (QL= 1 tab/day)

QL Tier 2

JARDIANCE TAB (QL= 1 tab/day)

QL Tier 2

SULFONYLUREAS

GLYBURID MCR TAB

- Tier 1

tolazamide tab (TOLINASE equiv)

- Tier 1

TOLBUTAMIDE TAB

- Tier 2

glimepiride tab (AMARYL equiv)

- Value

glipizide ER tab (GLUCOTROL XL equiv)

- Value

glipizide tab (GLUCOTROL equiv)

- Value

glyburide tab (MICRONASE equiv)

- Value

ANTIDIARRHEAL/PROBIOTIC AGENTS

ANTIPERISTALTIC AGENTS

DIPHENOXYLATE/ATROPINE LIQUID

- Tier 2

ANTIDIARRHEALS

ANTIDIARRHEAL AGENTS - MISC.

REZYST CHEW TAB

- Tier 1

ANTIPERISTALTIC AGENTS

diphenoxylate/atropine tab (LOMOTIL equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 87 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIDIARRHEALS Cont.

loperamide cap (IMODIUM equiv)

- Tier 1

ANTIDOTES

VISTOGARD PAK (Only available through Biologics 800-850-4306)

Tier 2

Specialty

OPIOID ANTAGONISTS

naltrexone tab (REVIA equiv)

- Tier 1

VIVITROL INJ

AMSP

Tier 2

Specialty

ANTIDOTES AND SPECIFIC ANTAGONISTS

ANTIDOTES - CHELATING AGENTS

deferasirox granules packet (JADENU equiv)

AMSP-PA

Tier 1

Specialty

deferasirox tab (EXJADE equiv)

AMSP-PA

Tier 1

Specialty

deferasirox tab 90mg, 360mg (JADENU equiv)

AMSP-PA

Tier 1

Specialty

deferiprone tab (FERRIPROX equiv) (Only available through Lumicera 855-847-3553)

LD-PA

Tier 1

Specialty

deferiprone tab 1000mg (FERRIPROX equiv) (Only available through Lumicera 855-847-3553)

LD-PA

Tier 1

Specialty

OPIOID ANTAGONISTS

naloxone inj

- Tier 1

naloxone prefilled inj

- Tier 1

NALOXONE PREFILLED INJ (QL= 2 inj/fill, 2 fills/month)

--QL Tier 1

KLOXXADO NASAL SPRAY

- Tier 2

OPVEE NASAL SPRAY

- Tier 2

naloxone hcl nasal spray (NARCAN equiv)

- Value

NALOXONE NASAL SPRAY

- Value

NARCAN HCL SPRAY (OTC)

OTC Value

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

granisetron tab (KYTRIL equiv) (QL= 8 tabs/30 days)

QL Tier 1

ondansetron ODT (ZOFRAN equiv)

- Tier 1

ondansetron soln (ZOFRAN equiv) (QL= 50ml/fill, 1 fill/15 days)

QL Tier 1

ONDANSETRON TAB

- Tier 1

ondansetron tab (ZOFRAN equiv)

- Tier 1

ANTIEMETICS - ANTICHOLINERGIC

scopolamine patch (TRANSDERM-SCOP equiv) (QL= 10 patches/30 days)

QL Tier 1

trimethobenzamide cap (TIGAN equiv)

- Tier 1

ANTIEMETICS - MISCELLANEOUS

doxylamine/pyridoxine dr tab (DICLEGIS equiv) (QL= 120 tabs/30 days)

QL Tier 1

dronabinol cap (MARINOL equiv) (QL= 2 caps/day)

QL Tier 2

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant cap 125mg (EMEND equiv) (QL= 1 cap/21 days; Step Therapy requires trial of ondansetron)

QL-ST Tier 1

aprepitant cap 40mg (EMEND equiv) (QL= 1 cap/28 days; Step Therapy requires trial of ondansetron)

QL-ST Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 88 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIEMETICS Cont.

aprepitant cap 80mg (EMEND equiv) (QL= 2 caps/21 days; Step Therapy requires trial of ondansetron)

QL-ST Tier 1

aprepitant pak (EMEND equiv) (QL= 3 caps/fill, 2 fills/month; Step Therapy requires trial of ondansetron)

QL-ST Tier 1

VARUBI TAB (QL= 2 tabs/day; Step Therapy requires trial of ondansetron)

QL-ST Tier 2

ANTIFUNGALS

flucytosine cap (ANCOBON equiv)

- Tier 1

griseofulvin susp (GRIFULVIN equiv)

- Tier 1

nystatin powder

- Tier 1

nystatin tab

- Tier 1

terbinafine tab (LAMISIL equiv)

- Tier 1

griseofulvin micro tab (GRIFULVIN V equiv)

- Tier 2

griseofulvin tab (GRIS-PEG equiv)

- Tier 2

IMIDAZOLE-RELATED ANTIFUNGALS

fluconazole susp (DIFLUCAN equiv)

- Tier 1

fluconazole tab (DIFLUCAN equiv)

- Tier 1

itraconazole cap (SPORANOX equiv)

- Tier 1

ketoconazole tab (NIZORAL equiv)

- Tier 1

voriconazole susp (VFEND equiv)

- Tier 1

voriconazole tab (VFEND equiv)

- Tier 1

itraconazole soln (SPORANOX equiv)

- Tier 2

posaconazole DR tab (NOXAFIL equiv) (QL= 8 tabs/day; Step Therapy requires trial of fluconazole, itraconazole or

VFEND)

QL-ST Tier 2

posaconazole susp (NOXAFIL equiv) (Step therapy requires trial of fluconazole, itraconazole or voriconazole)

ST Tier 2

ANTIHISTAMINES

ANTIHISTAMINES - ETHANOLAMINES

CARBINOXAMINE SOLN (QL= 40ml/day)

QL Tier 1

carbinoxamine tab (PALGIC equiv) (QL= 240 tabs/30 days)

QL Tier 1

diphenhydramine cap 50mg (BENADRYL equiv) (Only 50mg covered)

- Tier 1

diphenhydramine inj

- Tier 1

ANTIHISTAMINES - PHENOTHIAZINES

promethazine inj (PHENERGAN equiv)

- Tier 1

promethazine supp (PHENERGAN equiv)

- Tier 1

promethazine syrup

- Tier 1

promethazine tab (PHENERGAN equiv)

- Tier 1

PROMETHEGAN SUPP

- Tier 1

ANTIHISTAMINES - PIPERIDINES

cyproheptadine syrup

- Tier 1

cyproheptadine tab

- Tier 1

ANTIHYPERLIPIDEMICS

ANTIHYPERLIPIDEMICS - COMBINATIONS

ezetimibe/simvastatin tab (VYTORIN equiv) (QL= 1 tab/day)

QL Tier 1

ANTIHYPERLIPIDEMICS - MISC.

icosapent ethyl cap 0.5gm (VASCEPA equiv) (QL= 2 caps/day)

QL Tier 1

icosapent ethyl cap 1gm (VASCEPA equiv) (QL= 4 caps/day)

QL Tier 1

omega-3-acid ethyl esters cap (LOVAZA equiv) (QL= 4 caps/day)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 89 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIHYPERLIPIDEMICS Cont.

BILE ACID SEQUESTRANTS

cholestyramine lite powder (QUESTRAN LITE equiv)

- Tier 1

cholestyramine lite powder pack (QUESTRAN LITE equiv)

- Tier 1

cholestyramine powder (QUESTRAN equiv)

- Tier 1

cholestyramine powder pack (QUESTRAN equiv)

- Tier 1

colesevelam tab (WELCHOL equiv)

- Tier 1

colestipol granule (COLESTID equiv)

- Tier 1

colestipol powder packet (COLESTID equiv)

- Tier 1

colestipol tab (COLESTID equiv)

- Tier 1

colesevelam pack (WELCHOL equiv) (Step Therapy requires trial of 2: cholestyramine, colesevelam, or colestipol)

ST Tier 2

FIBRIC ACID DERIVATIVES

fenofibrate cap 43mg, 130mg (ANTARA equiv)

- Tier 1

fenofibrate cap 67mg, 134mg, 200mg (LOFIBRA equiv)

- Tier 1

fenofibrate tab 48mg, 54mg, 145mg, 160mg (TRICOR equiv)

- Tier 1

fenofibric acid DR cap (TRILIPIX equiv)

- Tier 1

gemfibrozil tab (LOPID equiv)

- Tier 1

FENOFIBRATE CAP, LIPOFEN CAP 50MG, 150MG

- Tier 2

fenofibrate tab 40mg, 120mg (FENOGLIDE equiv)

- Tier 2

HMG COA REDUCTASE INHIBITORS

atorvastatin tab (LIPITOR equiv) (QL= 1 tab/day; Covered at $0 for members 40 years or older; All other members covered

at generic copay)

Preventiv

fluvastatin cap (LESCOL equiv) (QL= 2 caps/day; Step Therapy requires trial of 2: atorvastatin, lovastatin, rosuvastatin,

pravastatin, or simvastatin; Covered at $0 for members 40 years or older; All other members covered at generic copay)

QL-ST

Preventiv

fluvastatin ER tab (LESCOL XL equiv) (QL= 1 tab/day; Step Therapy requires trial of 2: atorvastatin, lovastatin,

rosuvastatin, pravastatin, or simvastatin; Covered at $0 for members 40 years or older; All other members covered at

generic copay)

QL-ST

Preventiv

lovastatin tab (MEVACOR equiv) (QL= 2 tabs/day; Covered at $0 for members 40 years or older; All other members

covered at generic copay)

Preventiv

pravastatin tab (PRAVACHOL equiv) (QL= 1 tab/day; Covered at $0 for members 40 years or older; All other members

covered at generic copay)

Preventiv

rosuvastatin tab (CRESTOR equiv) (QL= 1 tab/day; Covered at $0 for members 40 years or older; All other members

covered at generic copay)

Preventiv

simvastatin tab 5mg, 10mg, 20mg, 40mg (ZOCOR equiv) (QL= 1 tab/day; Covered at $0 for members 40 years or older; All

other members covered at generic copay)

Preventiv

simvastatin tab 80mg (ZOCOR equiv) (QL= 1 tab/day; Covered at $0 for members 40 years or older; All other members

covered at generic copay)

PA-QL

Preventiv

pitavastatin calcium tab (LIVALO equiv) (QL= 1 tab/day; ST req trial of 2: Altoprev tab, FLOLIPID SUSP, Ator, Lova, Rosu,

Prava OR Simvastatin tabs)

QL-ST Tier 2

SIMVASTATIN SUSP (QL= 300ml/30 days; Step Therapy requires trial of 2: atorvastatin, rosuvastatin or simvastatin)

QL-ST Tier 2

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe tab (ZETIA equiv) (QL= 1 tab/day)

QL Tier 1

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS

JUXTAPID CAP (Only available through Accredo 888-773-7376)

LD-PA

Tier 2

Specialty

NICOTINIC ACID DERIVATIVES

niacin ER tab (NIASPAN equiv) (QL= 2 tabs/day)

QL Tier 1

PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 90 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIHYPERLIPIDEMICS Cont.

REPATHA INJ (QL= 2 inj/28 days)

PA-QL Tier 2

REPATHA PUSHTRONEX INJ (QL= 1 inj/28 days)

PA-QL Tier 2

ANTIHYPERTENSIVES

ACE INHIBITORS

benazepril tab (LOTENSIN equiv)

- Tier 1

fosinopril tab (MONOPRIL equiv)

- Tier 1

moexipril tab (UNIVASC equiv)

- Tier 1

perindopril tab (ACEON equiv)

- Tier 1

quinapril tab (ACCUPRIL equiv)

- Tier 1

ramipril cap (ALTACE equiv)

- Tier 1

trandolapril tab (MAVIK equiv)

- Tier 1

captopril tab (CAPOTEN equiv) (Step Therapy requires trial of 2 angiotensin-converting enzyme (ACE) inhibitors)

ST Tier 2

enalapril maleate oral soln (EPANED equiv) (QL= 40ml/day; Step therapy requires trial of two: enalapril tab, lisinopril tab,

ramipril tab, benazepril tab)

QL-ST Tier 2

enalapril tab (VASOTEC equiv)

- Value

lisinopril tab (PRINIVIL/ZESTRIL equiv)

- Value

AGENTS FOR PHEOCHROMOCYTOMA

metyrosine cap (DEMSER equiv) (QL= 448 caps/28 days)

PA-QL Tier 2

phenoxybenzamine cap (DIBENZYLINE equiv)

- Tier 2

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan tab (ATACAND equiv) (Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz)

ST Tier 1

irbesartan tab (AVAPRO equiv)

- Tier 1

olmesartan tab (BENICAR equiv)

- Tier 1

telmisartan tab (MICARDIS equiv)

- Tier 1

valsartan tab (DIOVAN equiv)

- Tier 1

VALSARTAN SOLN (QL= 2400ml/30 days)

QL Tier 2

losartan tab (COZAAR equiv)

- Value

ANTIADRENERGIC ANTIHYPERTENSIVES

clonidine tab (CATAPRES equiv)

- Tier 1

doxazosin tab (CARDURA equiv)

- Tier 1

guanfacine IR tab (TENEX equiv)

- Tier 1

methyldopa tab (ALDOMET equiv)

- Tier 1

prazosin cap (MINIPRESS equiv)

- Tier 1

terazosin cap (HYTRIN equiv)

- Tier 1

clonidine patch (CATAPRES-TTS equiv)

- Tier 2

METHYLDOPA TAB

- Tier 2

ANTIHYPERTENSIVE COMBINATIONS

amlodipine/benazepril cap (LOTREL equiv)

- Tier 1

amlodipine/olmesartan tab (AZOR TAB equiv)

- Tier 1

amlodipine/valsartan tab (EXFORGE equiv)

- Tier 1

atenolol/chlorthalidone tab (TENORETIC equiv)

- Tier 1

benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv)

- Tier 1

candesartan/hydrochlorothiazide tab (ATACAND HCT equiv)

- Tier 1

captopril/hydrochlorothiazide tab (CAPOZIDE equiv)

- Tier 1

fosinopril/hydrochlorothiazide tab (MONOPRIL HCT equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 91 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIHYPERTENSIVES Cont.

irbesartan/hydrochlorothiazide tab (AVALIDE equiv)

- Tier 1

methyldopa/hydrochlorothiazide tab (ALDORIL equiv)

- Tier 1

metoprolol/hydrochlorothiazide tab (LOPRESSOR HCT equiv)

- Tier 1

olmesartan/amlodipine/hydrochlorothiazide tab (TRIBENZOR TAB equiv) (QL= 30 tabs/30 days)

QL Tier 1

olmesartan/hydrochlorothiazide tab (BENICAR HCT equiv)

- Tier 1

propranolol/hydrochlorothiazide tab (INDERIDE equiv)

- Tier 1

QUINAPRIL/HCTZ TAB

- Tier 1

quinapril/hydrochlorothiazide tab (ACCURETIC equiv)

- Tier 1

trandolapril/verapamil ER tab (TARKA equiv)

- Tier 1

valsartan/hydrochlorothiazide tab (DIOVAN HCT equiv)

- Tier 1

amlodipine/valsartan/hydrochlorothiazide tab (EXFORGE HCT equiv) (QL= 30 tabs/30 days; Step therapy requires trial of

olmesartan-amlodipine-HCTZ)

QL-ST Tier 2

CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB (Step Therapy requires trial of one angiotensin-converting enzyme (ACE)

inhibitor or angiotensin receptor blocker (ARB) combination drug)

ST Tier 2

telmisartan/amlodipine tab (TWYNSTA equiv) (Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz)

ST Tier 2

telmisartan/hydrochlorothiazide tab (MICARDIS HCT equiv) (Step Therapy requires trial of: losartan or losartan/hctz and

irbesartan or irbesartan/hctz)

ST Tier 2

telmisartan/hydrochlorothiazide tab 40-12.5MG (MICARDIS HCT equiv) (Step Therapy requires trial of: losartan or

losartan/hctz and irbesartan or irbesartan/hctz)

ST Tier 2

telmisartan/hydrochlorothiazide tab 80-25MG (MICARDIS HCT equiv) (Step Therapy requires trial of: losartan or

losartan/hctz and irbesartan or irbesartan/hctz)

ST Tier 2

bisoprolol/hydrochlorothiazide tab (ZIAC equiv)

- Value

enalapril/hydrochlorothiazide tab (VASERETIC equiv)

- Value

lisinopril/hydrochlorothiazide tab (ZESTORETIC equiv)

- Value

losartan/hydrochlorothiazide tab (HYZAAR equiv)

- Value

DIRECT RENIN INHIBITORS

aliskiren tab (TEKTURNA equiv) (Step Therapy requires trial of one angiotensin-converting enzyme (ACE) inhibitor or

angiotensin receptor blockers (ARB))

ST Tier 2

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

eplerenone tab (INSPRA equiv)

- Tier 1

VASODILATORS

hydralazine tab (APRESOLINE equiv)

- Tier 1

minoxidil tab (LONITEN equiv)

- Tier 1

ANTI-INFECTIVE AGENTS - MISC.

metronidazole tab (FLAGYL equiv)

- Tier 1

tinidazole tab (TINDAMAX equiv)

- Tier 1

trimethoprim tab (PROLOPRIM equiv)

- Tier 1

LIKMEZ SUSP (QL= 210ml/14 days)

QL Tier 2

metronidazole cap (FLAGYL equiv)

- Tier 2

pentamidine neb soln (NEBUPENT equiv)

- Tier 2

PRIMSOL SOLN

- Tier 2

TRIMETHOPRIM TAB

- Tier 2

IMPAVIDO CAP (QL= 3 caps/day)

AMSP-QL

Tier 2

Specialty

ANTI-INFECTIVE MISC. - COMBINATIONS

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 92 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTI-INFECTIVE AGENTS - MISC. Cont.

smz/tmp (DS) tab (BACTRIM DS equiv)

- Tier 1

smz/tmp susp (BACTRIM, SEPTRA equiv)

- Tier 1

UTA cap

- Tier 1

HYOPHEN TAB

- Tier 2

ANTIPROTOZOAL AGENTS

atovaquone susp (MEPRON equiv)

- Tier 1

LAMPIT TAB 120MG (QL= 225 tabs/30 days)

QL Tier 2

LAMPIT TAB 30MG (QL= 360 tabs/30 days)

QL Tier 2

nitazoxanide tab (ALINIA equiv) (QL= 6 tabs/fill, 2 fills/month)

QL Tier 2

GLYCOPEPTIDES

vancomycin cap 125mg (VANCOCIN equiv) (QL= 56 caps/30 days)

QL Tier 1

vancomycin cap 250mg (VANCOCIN equiv) (QL= 112 caps/30 days)

QL Tier 1

vancomycin hcl for iv soln (VANCOMYCIN equiv)

- Tier 1

VANCOMYCIN INJ

- Tier 1

vancomycin hcl for oral soln 25mg/ml (FIRVANQ equiv) (QL= 300ml/30 days)

QL Tier 2

vancomycin hcl for oral soln 50mg/ml (FIRVANQ equiv) (QL= 300ml/30 days)

QL Tier 2

LEPROSTATICS

dapsone tab

- Tier 1

LINCOSAMIDES

clindamycin cap (CLEOCIN equiv)

- Tier 1

clindamycin soln (CLEOCIN equiv)

- Tier 1

MONOBACTAMS

CAYSTON INH SOLN (Only available through Walgreens 888-347-3416)

Tier 2

Specialty

OXAZOLIDINONES

linezolid susp

- Tier 1

linezolid tab (ZYVOX equiv)

- Tier 1

SIVEXTRO TAB (QL= 6 tabs/fill)

QL Tier 2

URINARY ANTI-INFECTIVES

methenamine hippurate tab (HIPREX equiv)

- Tier 1

methenamine mandelate tab

- Tier 1

nitrofurantoin macrocrystals cap (MACRODANTIN equiv)

- Tier 1

nitrofurantoin monohydrate cap (MACROBID equiv)

- Tier 1

nitrofurantoin susp (FURADANTIN equiv)

- Tier 1

fosfomycin tromethamine powder pack (MONUROL equiv)

- Tier 2

ANTIMALARIALS

ANTIMALARIAL COMBINATIONS

atovaquone/proguanil tab (MALARONE equiv)

- Tier 1

ANTIMALARIALS

chloroquine tab (ARALEN equiv)

- Tier 1

hydroxychloroquine tab (PLAQUENIL equiv)

- Tier 1

quinine sulfate cap (QUALAQUIN equiv)

- Tier 1

pyrimethamine tab (DARAPRIM equiv) (QL= 3 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 1

Specialty

KRINTAFEL TAB (QL= 2 tabs/365 days)

QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 93 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIMALARIALS Cont.

mefloquine tab (LARIAM equiv)

- Tier 2

primaquine tab (PRIMAQUINE equiv)

- Tier 2

ANTIMYASTHENIC/CHOLINERGIC AGENTS

GUANIDINE TAB

- Tier 1

pyridostigmine CR tab (MESTINON equiv)

- Tier 1

pyridostigmine tab (MESTINON equiv)

- Tier 1

pyridstigmine soln (MESTINON equiv)

- Tier 2

ANTIMYCOBACTERIAL AGENTS

cycloserine cap (CYCLOSERINE equiv)

- Tier 1

ethambutol tab (MYAMBUTOL equiv)

- Tier 1

isoniazid tab

- Tier 1

pyrazinamide tab

- Tier 1

rifabutin cap (MYCOBUTIN equiv)

- Tier 1

rifampin cap (RIFADIN equiv)

- Tier 1

SIRTURO TAB (Only available through MMS Solutions 855-691-0963)

Tier 2

Specialty

ANTINEOPLASTICS

ALKYLATING AGENTS

HEXALEN CAP (Only available through Walgreens 888-347-3416)

Tier 2

Specialty

MYLERAN TAB

AMSP

Tier 2

Specialty

ANTIMETABOLITES

mercaptopurine tab (PURINETHOL equiv)

- Tier 1

methotrexate tab (TREXALL equiv)

- Tier 1

TABLOID TAB (QL= 4 tabs/day)

AMSP-QL

Tier 2

Specialty

ANTINEOPLASTIC ENZYME INHIBITORS

ZOLINZA CAP

LMSP-PA-SF

Tier 2

Specialty

ANTINEOPLASTICS MISC.

hydroxyurea cap (HYDREA equiv)

- Tier 1

tretinoin cap (VESANOID equiv)

AMSP

Tier 1

Specialty

INTRON-A INJ

AMSP

Tier 2

Specialty

MATULANE CAP (Only available through Walgreens 888-347-3416)

Tier 2

Specialty

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS

leucovorin tab

- Tier 1

MESNEX TAB

AMSP

Tier 2

Specialty

MITOTIC INHIBITORS

etoposide cap (VEPESID equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 94 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTINEOPLASTICS Cont.

TOPOISOMERASE I INHIBITORS

HYCAMTIN CAP

LMSP-PA

Tier 2

Specialty

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

ALKYLATING AGENTS

cyclophosphamide cap

Tier 1

Specialty

temozolomide cap (TEMODAR equiv)

AMSP

Tier 1

Specialty

MELPHALAN TAB

AMSP

Tier 2

Specialty

ANTIMETABOLITES

METHOTREXATE INJ

- Tier 1

capecitabine tab (XELODA equiv)

AMSP

Tier 1

Specialty

PURIXAN SUSP (Step Therapy requires trial of mercaptopurine tab)

AMSP-ST

Tier 2

Specialty

ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS

INLYTA TAB (QL= 8 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL-SF

Tier 2

Specialty

LENVIMA CAP (QL= 3 caps/day; Only available through Optum 877-445-6874)

LD-PA-QL-SF

Tier 2

Specialty

ANTINEOPLASTIC - BCL-2 INHIBITORS

VENCLEXTA STARTER PACK (Only available through Optum 877-445-6874)

LD-PA

Tier 2

Specialty

VENCLEXTA TAB (Only available through Optum 877-445-6874)

LD-PA

Tier 2

Specialty

ANTINEOPLASTIC - EGFR INHIBITORS

erlotinib tab 100mg (TARCEVA equiv) (QL= 3 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

erlotinib tab 150mg (TARCEVA equiv) (QL= 3 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

erlotinib tab 25mg (TARCEVA equiv) (QL= 3 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

gefitinib tab (QL= 1 tab/day)

AMSP-PA-QL

Tier 1

Specialty

GILOTRIF TAB (QL= 1 tab/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TAGRISSO TAB (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS

ERIVEDGE CAP (QL= 1 cap/day)

AMSP-PA-QL-SF

Tier 2

Specialty

ODOMZO CAP

AMSP-PA-SF

Tier 2

Specialty

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS

anastrozole tab (ARIMIDEX equiv)

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 95 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cont.

exemestane tab (AROMASIN equiv)

Preventiv

letrozole tab (FEMARA equiv)

Preventiv

tamoxifen tab (NOLVADEX equiv) (Covered at $0 for women 35 years or older; All other members covered at generic

copay)

Preventiv

bicalutamide tab (CASODEX equiv)

- Tier 1

flutamide cap (EULEXIN equiv)

- Tier 1

megestrol susp (MEGACE equiv)

- Tier 1

megestrol tab (MEGACE equiv)

- Tier 1

toremifene tab (FARESTON equiv) (Step Therapy requires trial of tamoxifen)

ST Tier 1

abiraterone acetate tab 500mg (ZYTIGA equiv) (QL= 2 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

abiraterone tab 250mg (ZYTIGA equiv) (QL= 4 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

nilutamide tab (NILANDRON equiv) (QL= 150mg/day after the first 30 days)

AMSP-PA-QL

Tier 1

Specialty

ERLEADA TAB (QL= 4 tabs/day)

AMSP-PA-QL

Tier 2

Specialty

ERLEADA TAB 240MG (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

HYDROXYPROGESTERONE CAPROATE INJ (QL= 1 vial/35 days)

AMSP-PA-QL

Tier 2

Specialty

LEUPROLIDE INJ (QL= 1 kit/90 days)

AMSP-PA-QL

Tier 2

Specialty

LUPRON DEPOT INJ

AMSP-PA

Tier 2

Specialty

LYSODREN TAB (Only available through Walgreens 888-347-3416)

Tier 2

Specialty

NUBEQA TAB (QL= 4 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

ANTINEOPLASTIC - IMMUNOMODULATORS

POMALYST CAP (QL= 21 caps/28 days; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

ANTINEOPLASTIC COMBINATIONS

KISQALI PAK (QL= 91 tabs/28 days)

AMSP-PA-QL

Tier 2

Specialty

LONSURF TAB (Only available through Optum 877-445-6874 or Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

ANTINEOPLASTIC ENZYME INHIBITORS

everolimus tab (AFINITOR equiv) (QL= 1 tab/day)

AMSP-PA-QL-SF

Tier 1

Specialty

everolimus tab for oral susp (AFINITOR equiv) (QL= 1 tab/day)

AMSP-PA-QL-SF

Tier 1

Specialty

imatinib tab 100mg (GLEEVEC equiv) (QL= 3 tabs/day)

AMSP-PA-QL

Tier 1

Specialty

imatinib tab 400mg (GLEEVEC equiv) (QL= 2 tabs/day)

AMSP-PA-QL

Tier 1

Specialty

lapatinib ditosylate tab (TYKERB equiv) (QL= 5 tabs/day)

AMSP-PA-QL

Tier 1

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 96 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cont.

pazopanib hcl tab (VOTRIENT equiv) (QL= 120 tabs/30 days)

AMSP-PA-QL-SF

Tier 1

Specialty

sunitinib malate cap (SUTENT equiv) (QL= 1 cap/day)

AMSP-PA-QL-SF

Tier 1

Specialty

ALECENSA CAP (QL= 8 caps/day)

AMSP-PA-QL

Tier 2

Specialty

ALUNBRIG TAB 30MG (QL= 4 tabs/day; Only available through Biologics 800-850-4306 or Onco360 877-662-6633)

LD-PA-QL-SF

Tier 2

Specialty

ALUNBRIG TAB 90MG, 180MG (QL= 1 tab/day; Only available through Biologics 800-850-4306 or Onco360

877-662-6633)

LD-PA-QL-SF

Tier 2

Specialty

BOSULIF CAP (QL= 5 caps/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

BOSULIF TAB (Only available through Walgreens 888-347-3416)

LD-PA-SF

Tier 2

Specialty

CABOMETYX TAB (QL= 1 tab/day; Only available through Walgreens 888-347-3416)

LD-PA-QL-SF

Tier 2

Specialty

CALQUENCE CAP (QL= 2 caps/day)

AMSP-PA-QL-SF

Tier 2

Specialty

CALQUENCE TAB (QL= 2 tabs/day)

AMSP-PA-QL-SF

Tier 2

Specialty

CAPRELSA TAB 100MG (QL= 2 tabs/day; Only available through Biologics 800-850-4306)

LD-PA-QL

Tier 2

Specialty

CAPRELSA TAB 300MG (QL= 1 tab/day; Only available through Biologics 800-850-4306)

LD-PA-QL

Tier 2

Specialty

COMETRIQ KIT (Only available through Optum 877-445-6874)

LD-PA

Tier 2

Specialty

COTELLIC TAB (QL= 3 tabs/day)

LMSP-PA-QL

Tier 2

Specialty

ICLUSIG TAB (Only available through AcariaHealth 800-511-5144)

LD-PA-SF

Tier 2

Specialty

IMBRUVICA CAP 140MG (QL= 3 caps/day; Only available through Optum 877-445-6874)

LD-PA-QL-SF

Tier 2

Specialty

IMBRUVICA CAP 70MG (QL= 1 cap/day; Only available through Optum 877-445-6874)

LD-PA-QL-SF

Tier 2

Specialty

IMBRUVICA SUSP (QL= 2 bottles/30 days; Only available through Optum 877-445-6874)

LD-PA-QL

Tier 2

Specialty

IMBRUVICA TAB (QL= 1 tab/day; Only available through Optum 877-445-6874)

LD-PA-QL

Tier 2

Specialty

JAKAFI TAB (QL= 2 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL-SF

Tier 2

Specialty

KISQALI TAB (QL= 63 tabs/28 days)

AMSP-PA-QL

Tier 2

Specialty

LYNPARZA CAP (QL= 16 caps/day; Only available through Biologics 800-850-4306)

LD-PA-QL-SF

Tier 2

Specialty

LYNPARZA TAB (QL= 4 tabs/day; Only available through Biologics 800-850-4306)

LD-PA-QL-SF

Tier 2

Specialty

MEKINIST SOLN (QL= 40ml/day)

LMSP-PA-QL

Tier 2

Specialty

MEKINIST TAB 0.5MG (QL= 3 tabs/day)

AMSP-PA-QL

Tier 2

Specialty

MEKINIST TAB 2MG (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 97 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Cont.

NINLARO CAP

AMSP-PA

Tier 2

Specialty

RUBRACA TAB (QL= 4 tabs/day; Only available through Optum 877-445-6874)

LD-PA-QL-SF

Tier 2

Specialty

sorafenib tosylate tab (NEXAVAR equiv) (QL= 4 tabs/day)

AMSP-PA-QL-SF

Tier 2

Specialty

SPRYCEL TAB

AMSP-PA-SF

Tier 2

Specialty

STIVARGA TAB (QL= 84 tabs/28 days; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

TAFINLAR CAP (QL= 4 caps/day)

AMSP-PA-QL

Tier 2

Specialty

TAFINLAR TAB (QL= 12 tabs/day)

LMSP-PA-QL

Tier 2

Specialty

TASIGNA CAP

AMSP-PA-SF

Tier 2

Specialty

VERZENIO TAB (QL= 2 tabs/day)

AMSP-PA-QL-SF

Tier 2

Specialty

VOTRIENT TAB (QL= 120 tabs/30 days)

AMSP-PA-QL-SF

Tier 2

Specialty

XALKORI CAP (QL= 2 caps/day; Only available through Walgreens 888-347-3416)

LD-PA-QL-SF

Tier 2

Specialty

XALKORI SPRINKLE CAP (QL= 6 caps/day; Only available through Walgreens 888-347-3416)

LD-PA-QL-SF

Tier 2

Specialty

ZEJULA CAP (QL= 30 caps/30 days; Only available through Optum 877-445-6874)

LD-PA-QL-SF

Tier 2

Specialty

ZEJULA TAB (QL= 1 tab/day; Only available through Optum 877-445-6874)

LD-PA-QL-SF

Tier 2

Specialty

ZELBORAF TAB (QL= 8 tabs/day)

LMSP-PA-QL-SF

Tier 2

Specialty

ZYDELIG TAB (Only available through Optum 877-445-6874)

LD-PA

Tier 2

Specialty

ZYKADIA CAP (QL= 3 caps/day)

AMSP-PA-QL-SF

Tier 2

Specialty

ZYKADIA TAB (QL= 3 tabs/day)

AMSP-PA-QL-SF

Tier 2

Specialty

ANTINEOPLASTICS MISC.

bexarotene cap (TARGRETIN equiv)

AMSP-PA-SF

Tier 1

Specialty

SYNRIBO INJ (Only available through US Bioservices 888-518-7246)

LD-PA

Tier 2

Specialty

MITOTIC INHIBITORS

ETOPOSIDE CAP

Tier 1

Specialty

ANTIPARKINSON AGENTS

ANTIPARKINSON ADJUVANTS

carbidopa tab (LODOSYN equiv)

- Tier 1

ANTIPARKINSON ANTICHOLINERGICS

benztropine tab

- Tier 1

trihexyphenidyl tab (ARTANE equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 98 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIPARKINSON AGENTS Cont.

ANTIPARKINSON COMT INHIBITORS

entacapone tab (COMTAN equiv)

- Tier 1

tolcapone tab (TASMAR equiv) (QL= 3 caps/day)

QL Tier 2

ANTIPARKINSON DOPAMINERGICS

amantadine cap (SYMMETREL equiv)

- Tier 1

amantadine syrup (SYMMETREL equiv)

- Tier 1

amantadine tab

- Tier 1

bromocriptine cap (PARLODEL equiv)

- Tier 1

bromocriptine tab (PARLODEL equiv)

- Tier 1

carbidopa/levodopa ER tab (SINEMET CR equiv)

- Tier 1

carbidopa/levodopa ODT (PARCOPA equiv)

- Tier 1

carbidopa/levodopa tab (SINEMET equiv)

- Tier 1

pramipexole tab (MIRAPEX equiv)

- Tier 1

ropinirole tab (REQUIP equiv)

- Tier 1

pramipexole ER tab (MIRAPEX ER equiv) (QL= 1 tab/day)

QL Tier 2

ropinirole ER tab (REQUIP XL equiv) (QL= 1 tab/day; Step Therapy requires trial of ropinirole)

QL-ST Tier 2

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

rasagiline tab (AZILECT equiv) (QL= 1 tab/day)

QL Tier 1

selegiline cap (ELDEPRYL equiv)

- Tier 1

selegiline tab (ELDEPRYL equiv) (QL= 2 tabs/day)

QL Tier 1

ANTIPARKINSON AND RELATED THERAPY AGENTS

ANTIPARKINSON ANTICHOLINERGICS

trihexyphenidyl elixir (ARTANE equiv)

- Tier 1

TRIHEXYPHENIDYL SOLN (QL= 946ml/28 days)

QL Tier 1

ANTIPARKINSON DOPAMINERGICS

amantadine soln

- Tier 1

carbidopa-levodopa-entacapone tab 12.5-50-200mg (STALEVO equiv) (QL= 8 tabs/day)

QL Tier 1

carbidopa-levodopa-entacapone tab 18.75-75-200mg (STALEVO equiv) (QL= 8 tabs/day)

QL Tier 1

carbidopa-levodopa-entacapone tab 25-100-200mg (STALEVO equiv) (QL= 8 tabs/day)

QL Tier 1

carbidopa-levodopa-entacapone tab 31.25-125-200mg (STALEVO equiv) (QL= 8 tabs/day)

QL Tier 1

carbidopa-levodopa-entacapone tab 37.5-150-200mg (STALEVO equiv) (QL= 8 tabs/day)

QL Tier 1

carbidopa-levodopa-entacapone tab 50-200-200mg (STALEVO equiv) (QL= 6 tabs/day)

QL Tier 1

apomorphine inj (APOKYN equiv) (QL= 54ml/30 days; Only available through CVS Specialty 800-237-2767)

LD-QL

Tier 1

Specialty

ANTIPSYCHOTICS/ANTIMANIC AGENTS

ANTIMANIC AGENTS

lithium carbonate cap (ESKALITH ER equiv)

- Tier 1

lithium carbonate ER tab (LITHOBID equiv)

- Tier 1

lithium carbonate tab

- Tier 1

lithium oral solution (LITHIUM equiv)

- Tier 1

ANTIPSYCHOTICS - MISC.

lurasidone hcl tab (LATUDA equiv) (QL= 1 tab/day)

QL Tier 1

ziprasidone cap (GEODON equiv) (QL= 2 caps/day)

QL Tier 1

ziprasidone mesylate inj (GEODON equiv)

AMSP

Tier 1

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 99 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIPSYCHOTICS/ANTIMANIC AGENTS Cont.

VRAYLAR CAP (QL= 2 packs/plan year; Step Therapy requires trial of 2: aripiprazole, quetiapine, ziprasidone,

olanzapine, risperidone, or lurasidone)

QL-ST Tier 2

VRAYLAR PACK (QL= 2 packs/plan year; Step Therapy requires trial of 2: aripiprazole, quetiapine, ziprasidone,

olanzapine, risperidone, or lurasidone)

QL-ST Tier 2

BENZISOXAZOLES

paliperidone ER tab (INVEGA equiv) (QL= 1 tab/day)

QL Tier 1

risperidone ODT (RISPERDAL M equiv)

- Tier 1

risperidone soln (RISPERDAL equiv)

- Tier 1

risperidone tab (RISPERDAL equiv)

- Tier 1

risperidone microspheres inj (RISPERDAL equiv)

AMSP

Tier 1

Specialty

RISPERIDONE ODT

- Tier 2

INVEGA HAFYERA INJ

AMSP

Tier 2

Specialty

INVEGA SUSTENNA INJ

AMSP

Tier 2

Specialty

INVEGA TRINZA INJ

AMSP

Tier 2

Specialty

PERSERIS INJ

AMSP

Tier 2

Specialty

RYKINDO INJ

AMSP

Tier 2

Specialty

UZEDY INJ

AMSP

Tier 2

Specialty

BUTYROPHENONES

haloperidol lactate conc (HALDOL equiv)

- Tier 1

haloperidol tab (HALDOL equiv)

- Tier 1

haloperidol decanoate inj

AMSP

Tier 1

Specialty

HALDOL DECANOATE INJ

Tier 2

Specialty

DIBENZAPINES

CLOZAPINE ODT (QL= 3 tabs/day)

QL Tier 1

clozapine ODT 25mg, 100mg (CLOZAPINE, FAZACLO equiv) (QL= 3 tabs/day)

QL Tier 1

clozapine tab (CLOZARIL equiv) (QL= 3 tabs/day)

QL Tier 1

loxapine cap (LOXITANE equiv)

- Tier 1

olanzapine ODT (ZYPREXA equiv) (QL= 1 tab/day)

QL Tier 1

olanzapine tab (ZYPREXA equiv)

- Tier 1

quetiapine tab (SEROQUEL equiv) (QL= 3 tabs/day)

QL Tier 1

quetiapine XR tab (SEROQUEL XR equiv) (QL= 1 tab/day)

QL Tier 1

asenapine maleate SL tab (SAPHRIS equiv) (QL= 2 tabs/day; Step Therapy requires trial of olanzapine, olanzapine ODT,

quetiapine, quetiapine XR, risperidone, or risperidone ODT)

QL-ST Tier 2

olanzapine inj (ZYPREXA equiv)

AMSP

Tier 2

Specialty

ZYPREXA RELPREVV INJ

AMSP

Tier 2

Specialty

DIHYDROINDOLONES

MOLINDONE TAB

- Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 100 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIPSYCHOTICS/ANTIMANIC AGENTS Cont.

PHENOTHIAZINES

chlorpromazine tab (THORAZINE equiv)

- Tier 1

fluphenazine tab (PROLIXIN equiv)

- Tier 1

perphenazine tab (TRILAFON equiv)

- Tier 1

prochlorperazine supp (COMPAZINE equiv)

- Tier 1

prochlorperazine tab (COMPAZINE equiv)

- Tier 1

thioridazine tab (MELLARIL equiv)

- Tier 1

trifluoperazine tab (STELAZINE equiv)

- Tier 1

QUINOLINONE DERIVATIVES

aripiprazole ODT (ABILIFY equiv) (QL= 2 tabs/day)

QL Tier 1

aripiprazole soln (ABILIFY equiv) (QL= 30 ml/day)

QL Tier 1

aripiprazole tab (ABILIFY equiv)

- Tier 1

REXULTI TAB (QL= 2 packs/plan year; Step Therapy requires trial of 2: aripiprazole, quetiapine, ziprasidone, olanzapine,

risperidone, or lurasidone)

QL-ST Tier 2

ABILIFY ASIMTUFII INJ 720MG/2.4ML

AMSP

Tier 2

Specialty

ABILIFY ASIMTUFII INJ 960MG/3.2ML

AMSP

Tier 2

Specialty

ABILIFY MAINTENA INJ

AMSP

Tier 2

Specialty

ARISTADA 675MG/2.4ML INJ

AMSP

Tier 2

Specialty

ARISTADA INJ

AMSP

Tier 2

Specialty

THIOXANTHENES

thiothixene cap (NAVANE equiv)

- Tier 1

ANTIVIRALS

ANTIRETROVIRALS

emtricitabine/tenofovir disoproxil fumarate tab 200-300mg (TRUVADA equiv) (QL= 30 tabs/30 days)

Preventiv

abacavir soln (ZIAGEN equiv) (QL= 960ml/30 days)

QL Tier 1

abacavir tab (ZIAGEN equiv) (QL= 2 tabs/day)

QL Tier 1

abacavir/lamivudine tab (EPZICOM equiv) (QL= 1 tab/day)

QL Tier 1

abacavir/lamivudine/zidovudine tab (TRIZIVIR equiv) (QL= 2 tabs/day)

QL Tier 1

atazanavir cap 150mg (REYATAZ equiv) (QL= 2 caps/day)

QL Tier 1

atazanavir cap 200mg (REYATAZ equiv) (QL= 2 caps/day)

QL Tier 1

atazanavir cap 300mg (REYATAZ equiv) (QL= 1 cap/day)

QL Tier 1

darunavir tab 600mg (PREZISTA equiv) (QL= 2 tabs/day)

QL Tier 1

darunavir tab 800mg (PREZISTA equiv) (QL= 1 tab/day)

QL Tier 1

didanosine DR cap (VIDEX EC equiv) (QL= 1 cap/day)

QL Tier 1

EFAVIRENZ CAP

- Tier 1

efavirenz tab (SUSTIVA equiv)

- Tier 1

efavirenz/emtricitabine/tenofovir df tab (ATRIPLA equiv) (QL= 1 tab/day)

QL Tier 1

efavirenz/lamivudine/tenofovir df (lo) tab (SYMFI (LO) equiv)

- Tier 1

emtricitabine cap (EMTRIVA equiv) (QL= 1 cap/day)

QL Tier 1

emtricitabine/tenofovir disoproxil fumarate tab (TRUVADA equiv) (QL= 30 tabs/30 days)

QL Tier 1

etravirine tab 100mg (INTELENCE equiv) (QL= 4 tabs/day)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 101 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIVIRALS Cont.

etravirine tab 200mg (INTELENCE equiv) (QL= 2 tabs/day)

QL Tier 1

fosamprenavir tab (LEXIVA equiv) (QL= 4 tabs/day)

QL Tier 1

lamivudine soln (EPIVIR equiv) (QL= 960ml/30 days)

QL Tier 1

lamivudine tab 150mg (EPIVIR equiv) (QL= 2 tabs/day)

QL Tier 1

lamivudine tab 300mg (EPIVIR equiv) (QL= 1 tab/day)

QL Tier 1

lamivudine/zidovudine tab (COMBIVIR equiv) (QL= 2 tabs/day)

QL Tier 1

lopinavir/ritonavir soln (KALETRA equiv) (QL= 480ml/30 days)

QL Tier 1

lopinavir-ritonavir tab 100-25mg (QL= 2 tabs/day)

QL Tier 1

lopinavir-ritonavir tab 200-50mg (QL= 4 tabs/day)

QL Tier 1

maraviroc tab 150mg (SELZENTRY equiv) (QL= 2 tabs/day)

QL Tier 1

maraviroc tab 300mg (SELZENTRY equiv) (QL= 4 tabs/day)

QL Tier 1

nevirapine ER tab (VIRAMUNE XR equiv) (QL= 1 tab/day)

QL Tier 1

nevirapine tab (VIRAMUNE equiv) (QL= 2 tabs/day)

QL Tier 1

ritonavir tab (NORVIR equiv) (QL= 12 tabs/day)

QL Tier 1

stavudine cap (ZERIT equiv) (QL= 2 caps/day)

QL Tier 1

tenofovir disoproxil fumarate tab (VIREAD equiv) (QL= 1 tab/day)

QL Tier 1

zidovudine cap (RETROVIR equiv) (QL= 6 caps/day)

QL Tier 1

zidovudine syrup (RETROVIR equiv) (QL= 1920ml/30 days)

QL Tier 1

zidovudine tab (RETROVIR equiv) (QL= 2 tabs/day)

QL Tier 1

APTIVUS CAP (QL= 4 caps/day)

QL Tier 2

APTIVUS SOLN (QL= 380ml/30 days)

QL Tier 2

ATRIPLA TAB (QL= 1 tab/day)

QL Tier 2

BIKTARVY TAB (QL= 1 tab/day)

QL Tier 2

CIMDUO TAB

- Tier 2

COMPLERA TAB (QL= 1 tab/day)

QL Tier 2

CRIXIVAN CAP

- Tier 2

DELSTRIGO TAB

- Tier 2

DESCOVY TAB (QL= 1 tab/day)

PA-QL Tier 2

DIDANOSINE DR CAP (QL= 2 caps/day)

QL Tier 2

EDURANT TAB (QL= 1 tab/day)

QL Tier 2

EMTRIVA SOLN (QL= 850ml/30 days)

QL Tier 2

EVOTAZ TAB (QL= 1 tab/day)

QL Tier 2

GENVOYA TAB (QL= 1 tab/day)

QL Tier 2

INTELENCE TAB (QL= 4 tabs/day)

QL Tier 2

INTELENCE TAB 25MG (QL= 4 tabs/day)

QL Tier 2

INVIRASE CAP (QL= 10 caps/day)

QL Tier 2

INVIRASE TAB (QL= 4 tabs/day)

QL Tier 2

ISENTRESS (HD) TAB (QL= 2 tabs/day)

QL Tier 2

ISENTRESS CHEW TAB (QL= 6 tabs/day)

QL Tier 2

ISENTRESS POWDER PACK (QL= 2 packets/day)

QL Tier 2

JULUCA TAB (QL= 1 tab/day)

QL Tier 2

KALETRA TAB 100-25MG (QL= 2 tabs/day)

QL Tier 2

KALETRA TAB 200-50MG (QL= 4 tabs/day)

QL Tier 2

NEVIRAPINE ER TAB (QL= 3 tabs/day)

QL Tier 2

NEVIRAPINE SUSP (QL= 1200ml/30 days)

QL Tier 2

NORVIR CAP (QL= 12 caps/day)

QL Tier 2

NORVIR POWDER PACK (QL= 12 packets/day)

QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 102 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIVIRALS Cont.

NORVIR SOLN (QL= 480ml/30 days)

QL Tier 2

ODEFSEY TAB (QL= 1 tab/day)

QL Tier 2

PIFELTRO TAB

- Tier 2

PREZCOBIX TAB (QL= 1 tab/day)

QL Tier 2

PREZISTA SUSP (QL= 400ml/30 days)

QL Tier 2

PREZISTA TAB (QL= 1 tab/day)

QL Tier 2

PREZISTA TAB 150MG (QL= 8 tabs/day)

QL Tier 2

PREZISTA TAB 600MG (QL= 2 tabs/day)

QL Tier 2

PREZISTA TAB 75MG (QL= 16 tabs/day)

QL Tier 2

RESCRIPTOR TAB

- Tier 2

REYATAZ POWDER PACK (QL= 5 packets/day)

QL Tier 2

SELZENTRY SOLN (QL= 31ml/day)

QL Tier 2

SELZENTRY TAB 150MG (QL= 2 tabs/day)

QL Tier 2

SELZENTRY TAB 25MG (QL= 4 tabs/day)

QL Tier 2

SELZENTRY TAB 300MG (QL= 4 tabs/day)

QL Tier 2

SELZENTRY TAB 75MG (QL= 2 tabs/day)

QL Tier 2

STRIBILD TAB (QL= 1 tab/day)

QL Tier 2

SYMTUZA TAB

- Tier 2

TIVICAY PD TAB (QL= 180 tabs/30 days)

QL Tier 2

TIVICAY TAB (QL= 180 tabs/30 days)

QL Tier 2

TRIUMEQ PD TAB (QL= 6 tabs/day)

QL Tier 2

TRIUMEQ TAB (QL= 1 tab/day)

QL Tier 2

TYBOST TAB

- Tier 2

VIDEX SOLN (QL= 600ml/30 days)

QL Tier 2

VIRACEPT TAB

- Tier 2

VIREAD POWDER

- Tier 2

VIREAD TAB (QL= 1 tab/day)

QL Tier 2

FUZEON INJ

AMSP

Tier 2

Specialty

ANTIVIRAL COMBINATIONS

PAXLOVID TAB 150-100

QL Tier 2

PAXLOVID TAB 300-100

QL Tier 2

CMV AGENTS

valganciclovir soln (VALCYTE equiv)

- Tier 1

valganciclovir tab (VALCYTE equiv)

- Tier 1

HEPATITIS AGENTS

adefovir dipivoxil tab (HEPSERA equiv) (QL= 1 tab/day)

AMSP-QL

Tier 1

Specialty

entecavir tab (BARACLUDE equiv) (QL= 1 tab/day)

Tier 1

Specialty

lamivudine tab 100mg (EPIVIR HBV equiv) (QL= 1 tab/day)

AMSP-QL

Tier 1

Specialty

MAVYRET PAK (QL= 5 packets/day)

AMSP-QL

Tier 1

Specialty

MAVYRET TAB (QL= 3 tabs/day)

AMSP-QL

Tier 1

Specialty

RIBAVIRIN CAP

AMSP

Tier 1

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 103 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIVIRALS Cont.

ribavirin cap (REBETOL equiv)

AMSP

Tier 1

Specialty

RIBAVIRIN TAB

AMSP

Tier 1

Specialty

SOFOSBUVIR/VELPATASVIR TAB (QL= 1 tab/day)

AMSP-PA-QL

Tier 1

Specialty

BARACLUDE SOLN (QL= 630ml/30 days)

AMSP-PA-QL

Tier 2

Specialty

DAKLINZA TAB (Only available through Lumicera 855-847-3553)

LMSP-PA

Tier 2

Specialty

EPIVIR HBV SOLN (QL= 720ml/30 days)

AMSP-QL

Tier 2

Specialty

OLYSIO CAP (Only available through Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

PEGASYS INJ

AMSP-PA

Tier 2

Specialty

PEG-INTRON INJ (Only available through Lumicera 855-847-3553)

LMSP-PA

Tier 2

Specialty

REBETOL SOLN

AMSP-PA

Tier 2

Specialty

RIBAPAK TAB (Step Therapy requires trial of ribavirin)

AMSP-ST

Tier 2

Specialty

TECHNIVIE TAB (QL= 1 pack/28 days; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

TYZEKA TAB (Only available through Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

VEMLIDY TAB (QL= 1 tab/day)

AMSP-QL

Tier 2

Specialty

VIEKIRA PAK TAB (QL= 4 tabs/day; Only available through Lumicera 855-847-3553)

LMSP-PA-QL

Tier 2

Specialty

VIEKIRA XR TAB (QL= 3 tabs/day; Only available through Lumicera 855-847-3553)

LMSP-PA-QL

Tier 2

Specialty

VOSEVI TAB (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

ZEPATIER TAB (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

HERPES AGENTS

acyclovir cap (ZOVIRAX equiv)

- Tier 1

acyclovir susp (ZOVIRAX equiv)

- Tier 1

acyclovir tab (ZOVIRAX equiv)

- Tier 1

famciclovir tab 125mg (FAMVIR equiv) (QL= 2 tabs/day)

QL Tier 1

famciclovir tab 250mg (FAMVIR equiv) (QL= 2 tabs/day)

QL Tier 1

famciclovir tab 500mg (FAMVIR equiv) (QL= 21 tabs/fill, 2 fills/month)

QL Tier 1

valacyclovir tab (VALTREX equiv)

- Tier 1

INFLUENZA AGENTS

oseltamivir cap 30mg (TAMIFLU equiv) (QL= 40 caps/183 days)

QL Tier 1

oseltamivir cap 45mg (TAMIFLU equiv) (QL= 40 caps/183 days)

QL Tier 1

oseltamivir cap 75mg (TAMIFLU equiv) (QL= 20 caps/183 days)

QL Tier 1

oseltamivir susp (TAMIFLU equiv) (QL= 360ml/183 days)

QL Tier 1

RIMANTADINE TAB

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 104 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ANTIVIRALS Cont.

RELENZA DISKHALER (QL= 1 inhaler/fill, 1 fill/month)

QL Tier 2

MISC. ANTIVIRALS

MOLNUPIRAVIR CAP (QL= 40 caps/fill)

Preventiv

LAGEVRIO CAP 200MG (QL= 40 caps/5 days, 40 caps/fill; Covered for members age 18 years or older)

QL Tier 2

ASSORTED CLASSES

CHELATING AGENTS

D-PENAMINE TAB

- Tier 2

IMMUNOMODULATORS

THALOMID CAP (QL= 2 caps/day; Only available through Walgreens 888-347-3416)

LD-QL

Tier 2

Specialty

IMMUNOSUPPRESSIVE AGENTS

azathioprine tab (IMURAN equiv)

- Tier 1

cyclosporine modified cap (NEORAL equiv)

- Tier 1

cyclosporine modified soln (NEORAL equiv)

- Tier 1

mycophenolate DR tab (MYFORTIC equiv)

- Tier 1

mycophenolate mofetil cap (CELLCEPT equiv)

- Tier 1

mycophenolate mofetil susp (CELLCEPT SUSP equiv)

- Tier 1

mycophenolate mofetil tab (CELLCEPT equiv)

- Tier 1

tacrolimus cap (PROGRAF equiv)

- Tier 1

cyclosporine cap (SANDIMMUNE equiv)

- Tier 2

sirolimus tab (RAPAMUNE equiv)

- Tier 2

POTASSIUM REMOVING RESINS

sodium polystyrene powder (KAYEXALATE equiv)

- Tier 2

sodium polystyrene susp (SPS equiv)

- Tier 2

BETA BLOCKERS

ALPHA-BETA BLOCKERS

labetalol tab (NORMODYNE equiv)

- Tier 1

carvedilol phosphate ER cap (COREG CR equiv)

- Tier 2

carvedilol tab (COREG equiv)

- Value

BETA BLOCKERS CARDIO-SELECTIVE

acebutolol cap (SECTRAL equiv)

- Tier 1

betaxolol tab (KERLONE equiv)

- Tier 1

bisoprolol tab (ZEBETA equiv)

- Tier 1

nebivolol hcl tab (BYSTOLIC equiv) (QL= 1 tab/day)

QL Tier 1

atenolol tab (TENORMIN equiv)

- Value

metoprolol ER tab (TOPROL XL equiv)

- Value

metoprolol tab (LOPRESSOR equiv)

- Value

BETA BLOCKERS NON-SELECTIVE

nadolol tab (CORGARD equiv)

- Tier 1

pindolol tab (VISKEN equiv)

- Tier 1

propranolol ER cap (INDERAL LA equiv)

- Tier 1

propranolol oral soln

- Tier 1

PROPRANOLOL SOLN

- Tier 1

propranolol tab (INDERAL equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 105 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

BETA BLOCKERS Cont.

sotalol AF tab (BETAPACE AF equiv)

- Tier 1

sotalol tab (BETAPACE equiv)

- Tier 1

timolol maleate tab (BLOCADREN equiv)

- Tier 1

BIOLOGICALS MISC

ALLERGENIC EXTRACTS

GRASTEK SL TAB (QL= 30 tabs/30 days)

QL Tier 2

ORALAIR SL TAB (QL= 30 tabs/30 days)

QL Tier 2

RAGWITEK SL TAB (QL= 30 tabs/30 days)

QL Tier 2

CALCIUM CHANNEL BLOCKERS

diltiazem ER cap (CARDIZEM CD equiv)

- Tier 1

diltiazem ER cap (CARDIZEM SR equiv)

- Tier 1

diltiazem ER cap (DILACOR XR equiv)

- Tier 1

diltiazem ER cap (TIAZAC equiv)

- Tier 1

diltiazem ER tab (CARDIZEM LA equiv)

- Tier 1

diltiazem tab (CARDIZEM equiv)

- Tier 1

felodipine ER tab (PLENDIL equiv)

- Tier 1

isradipine cap (DYNACIRC equiv)

- Tier 1

nicardipine cap (CARDENE equiv)

- Tier 1

nifedipine cap (PROCARDIA equiv)

- Tier 1

nifedipine ER tab (ADALAT CC equiv)

- Tier 1

verapamil SR tab (CALAN SR, ISOPTIN SR equiv)

- Tier 1

verapamil tab (CALAN equiv)

- Tier 1

nimodipine cap (NIMOTOP equiv)

- Tier 2

nisoldipine ER tab (SULAR equiv)

- Tier 2

verapamil SR cap (VERELAN equiv) (Step Therapy requires trial of verapamil ER tab (generic Calan))

ST Tier 2

amlodipine tab (NORVASC equiv)

- Value

CARDIOTONICS

CARDIAC GLYCOSIDES

digoxin tab (LANOXIN equiv)

- Tier 1

digoxin tab 62.5mcg (LANOXIN equiv) (QL= 1 tab/day)

QL Tier 1

digoxin soln (LANOXIN equiv)

- Tier 2

CARDIOVASCULAR AGENTS - MISC.

CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

isosorbide dinitrate-hydralazine hcl tab (BIDIL equiv) (QL= 6 tabs/day)

QL Tier 1

amlodipine/atorvastatin tab (CADUET equiv) (QL= 1 tab/day; Trial of a CCB (eg. amlodipine, nifedipine, diltiazem) AND a

statin (eg. atorvastatin, simvastatin))

QL-ST Tier 2

ENTRESTO CAP (QL= 8 caps/day)

QL Tier 2

ENTRESTO TAB (QL= 2 tabs/day)

QL Tier 2

IMPOTENCE AGENTS

tadalafil tab (CIALIS equiv) (QL= 1 tab/day)

QL Tier 1

PERIPHERAL VASODILATORS

ISOXSUPRINE TAB (QL= 120 tabs/30 days)

QL Tier 2

PROSTAGLANDIN VASODILATORS

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 106 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

CARDIOVASCULAR AGENTS - MISC. Cont.

treprostinil inj 10mg/ml (REMODULIN equiv) (Only available through Walgreens 888-347-3416)

LD-PA

Tier 1

Specialty

treprostinil inj 1mg/ml (REMODULIN equiv) (Only available through Walgreens 888-347-3416)

LD-PA

Tier 1

Specialty

treprostinil inj 2.5mg/ml (REMODULIN equiv) (Only available through Walgreens 888-347-3416)

LD-PA

Tier 1

Specialty

treprostinil inj 5mg/ml (REMODULIN equiv) (Only available through Walgreens 888-347-3416)

LD-PA

Tier 1

Specialty

ORENITRAM TAB (Only available through Accredo 888-773-7376)

LD-PA

Tier 2

Specialty

TYVASO DPI POWDER 16-32-48MCG (QL= 4 cartridges/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TYVASO DPI POWDER 16-32MCG (QL= 4 cartridges/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TYVASO DPI POWDER 32-48MCG (QL= 4 cartridges/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TYVASO DPI POWDER (QL= 4 cartridges/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TYVASO INH SOLN (QL= 1 ampule/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

VENTAVIS INH SOLN (QL= 9 ampules/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

ambrisentan tab (LETAIRIS equiv) (QL= 1 tab/day)

AMSP-PA-QL

Tier 1

Specialty

bosentan tab (TRACLEER equiv) (QL= 2 tabs/day; Only available through Lumicera 855-847-3553)

LD-PA-QL

Tier 1

Specialty

OPSUMIT TAB (QL= 1 tab/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TRACLEER TAB 32MG (QL= 4 tabs/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

sildenafil tab 20mg (REVATIO equiv) (QL= 3 tabs/day)

QL Tier 1

tadalafil tab (PAH) (ADCIRCA equiv) (QL= 2 tabs/day)

QL Tier 1

sildenafil susp (REVATIO equiv) (QL= 224ml/30 days)

AMSP-PA-QL

Tier 1

Specialty

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

UPTRAVI TAB (QL= 2 tabs/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

SINUS NODE INHIBITORS

ivabradine hcl tab (CORLANOR equiv) (QL= 60 tabs/30 days)

PA-QL Tier 1

CEPHALOSPORINS

CEPHALOSPORINS - 1ST GENERATION

cefadroxil cap (DURICEF equiv)

- Tier 1

cefadroxil susp (DURICEF equiv)

- Tier 1

cefadroxil tab (DURICEF equiv)

- Tier 1

cephalexin cap (KEFLEX equiv)

- Tier 1

cephalexin susp (KEFLEX equiv)

- Tier 1

CEPHALEXIN TAB

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 107 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

CEPHALOSPORINS Cont.

cephalexin cap 750mg (QL= 5 caps/day; Step therapy requires trial of cephalexin 250mg tab/cap or cephalexin 500mg

tab/cap)

QL-ST Tier 2

CEPHALOSPORINS - 2ND GENERATION

cefprozil susp (CEFZIL equiv)

- Tier 1

cefprozil tab (CEFZIL equiv)

- Tier 1

cefuroxime tab (CEFTIN equiv)

- Tier 1

CEPHALOSPORINS - 3RD GENERATION

cefdinir cap (OMNICEF equiv)

- Tier 1

cefdinir susp (OMNICEF equiv)

- Tier 1

cefixime cap (SUPRAX equiv)

- Tier 1

cefixime susp (SUPRAX equiv)

- Tier 1

cefpodoxime proxetil susp (VANTIN equiv)

- Tier 1

cefpodoxime proxetil tab (VANTIN equiv)

- Tier 1

CONTRACEPTIVES

COMBINATION CONTRACEPTIVES - ORAL

amethyst tab (LYBREL equiv)

Preventiv

ashlyna tab, daysee tab (SEASONALE, SEASONIQUE equiv)

Preventiv

BALCOLTRA TAB

Preventiv

BEYAZ TAB

Preventiv

cryselle tab

Preventiv

drospirenone/ethinyl estradiol/levomefolate tab (BEYAZ equiv)

Preventiv

enpresse tab (TRI-LEVELEN equiv)

Preventiv

FALESSA KIT

Preventiv

gianvi tab, ocella tab (YASMIN, YAZ equiv)

Preventiv

isibloom tab, enskyce tab, apri tab (DESOGEN equiv)

Preventiv

junel FE tab (LOESTRIN FE equiv)

Preventiv

junel tab (LOESTRIN equiv)

Preventiv

kelnor tab (DEMULEN equiv)

Preventiv

layolis FE tab, wymzya FE tab (FEMCON FE equiv)

Preventiv

levonorgestrel-ethinyl estradiol-fe tab (BALCOLTRA equiv)

Preventiv

LO LOESTRIN TAB

Preventiv

mibelas chew tab (MINASTRIN equiv)

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 108 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

CONTRACEPTIVES Cont.

NATAZIA TAB

Preventiv

NEXTSTELLIS TAB (QL= 28 tabs/24 days)

Preventiv

norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24) (TAYTULLA equiv)

Preventiv

norethindrone/ethinyl estradiol 21 tab (LOESTRIN 21 equiv)

Preventiv

norethindrone/ethinyl estradiol FE tab (LOESTRIN FE equiv)

Preventiv

norethindrone/ethinyl estradiol tab (LOESTRIN equiv)

Preventiv

nortrel 7/7/7 tab, pirmella 7/7/7 tab (TRI-NORINYL equiv)

Preventiv

nortrel tab (OVCON 35 equiv)

Preventiv

SEASONIQUE TAB

Preventiv

sprintec 28 tab (ORTHO-CYCLEN equiv)

Preventiv

tri-legest tab (ESTROSTEP FE equiv)

Preventiv

tri-sprintec tab (ORTHO TRI-CYCLEN (LO) equiv)

Preventiv

TYBLUME TAB

Preventiv

VELIVET PAK

Preventiv

velivet tab (CYCLESSA equiv)

Preventiv

vienva tab, lessina tab, kurvelo tab (ALESSE equiv)

Preventiv

viorele tab, kariva tab (MIRCETTE equiv)

Preventiv

YASMIN TAB

Preventiv

YAZ TAB

Preventiv

COMBINATION CONTRACEPTIVES - TRANSDERMAL

TWIRLA PATCH

Preventiv

zafemy patch (XULANE equiv)

Preventiv

COMBINATION CONTRACEPTIVES - VAGINAL

ANNOVERA RING

Preventiv

eluryng vaginal ring (NUVARING equiv)

Preventiv

NUVARING

Preventiv

COPPER CONTRACEPTIVES - IUD

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 109 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

CONTRACEPTIVES Cont.

PARAGARD IUD

Preventiv

EMERGENCY CONTRACEPTIVES

ELLA TAB

Preventiv

levonorgestrel tab (PLAN B equiv)

OTC

Preventiv

PLAN B TAB

OTC

Preventiv

PROGESTIN CONTRACEPTIVES - IMPLANTS

IMPLANON IMPLANT, NEXPLANON IMPLANT

Preventiv

NEXPLANON IMPLANT

Preventiv

PROGESTIN CONTRACEPTIVES - INJECTABLE

DEPO-PROVERA INJ (QL= 1 inj/84 days)

Preventiv

DEPO-PROVERA SC INJ 104MG (QL= 1 inj/84 days)

Preventiv

medroxyprogesterone inj (DEPO-PROVERA equiv) (QL= 1 inj/84 days)

Preventiv

PROGESTIN CONTRACEPTIVES - IUD

KYLEENA IUD

Preventiv

MIRENA IUD

Preventiv

SKYLA IUD

Preventiv

PROGESTIN CONTRACEPTIVES - ORAL

norethindrone tab (NORA-QD equiv)

Preventiv

OPILL TAB

Preventiv

SLYND TAB

Preventiv

CORTICOSTEROIDS

GLUCOCORTICOSTEROIDS

budesonide SR cap (ENTOCORT EC equiv)

- Tier 1

dexamethasone elixir

- Tier 1

dexamethasone pak (DEXPAK equiv)

- Tier 1

dexamethasone tab (DEXAMETHASONE equiv)

- Tier 1

hydrocortisone tab (CORTEF equiv)

- Tier 1

methylprednisolone dose pack (MEDROL equiv)

- Tier 1

methylprednisolone tab (MEDROL equiv)

- Tier 1

prednisolone soln

- Tier 1

prednisolone soln (PEDIAPRED equiv)

- Tier 1

prednisone pack

- Tier 1

PREDNISONE SOLN

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 110 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

CORTICOSTEROIDS Cont.

prednisone tab (DELTASONE equiv)

- Tier 1

budesonide ER tab (UCERIS equiv)

- Tier 2

CORTISONE ACETATE TAB

- Tier 2

DEXAMETHASONE CONC

- Tier 2

DEXAMETHASONE SOLN

- Tier 2

DEXAMETHASONE TAB 20MG (QL= 8 tabs/30 days)

QL Tier 2

DEXPAK TAB (Step Therapy requires trial of dexamethasone)

ST Tier 2

EOHILIA SUS 2MG/10ML (Step therapy requires trial of fluticasone MDI AND budesonide vials; Diagnosis Restricted –

Eosinophilic esophagitis (K20.0))

RDX-ST Tier 2

prednisolone ODT (ORAPRED equiv) (Step therapy requires trial of two of the following: prednisolone oral soln,

methylprednisolone, prednisone tab/soln)

ST Tier 2

PREDNISOLONE SOLN

- Tier 2

prednisolone tab (MILLIPRED equiv) (Step therapy requires trial of 2: prednisolone oral soln, methylprednisolone,

prednisone tab/soln)

ST Tier 2

SOLU-CORTEF INJ

- Tier 2

deflazacort susp (EMFLAZA equiv) (Only available through Accredo 888-773-7376)

LD-PA

Tier 2

Specialty

deflazacort tab (EMFLAZA equiv)

AMSP-PA

Tier 2

Specialty

MINERALOCORTICOIDS

fludrocortisone tab (FLORINEF equiv)

- Tier 1

COUGH/COLD/ALLERGY

ANTITUSSIVES

benzonatate cap (TESSALON equiv)

- Tier 1

hydrocodone/homatropine syrup (HYCODAN equiv)

- Tier 1

tussigon tab (HYCODAN equiv)

- Tier 1

COUGH/COLD/ALLERGY COMBINATIONS

ADVIL COLD/ TAB SINUS (QL= 240 tabs/30 days)

QL Tier 1

cold/allergy elx children (QL= 2400ml/30 days)

QL Tier 1

guaifenesin/codeine syrup (TUSSI-ORGANIDIN-S equiv) (QL= 240ml/fill, 2 fills/month)

OTC-QL Tier 1

HYD POL/CPM SUSP (QL= 10ml/day)

QL Tier 1

hydrocodone/chlorpheniramine CR susp (TUSSIONEX equiv)

- Tier 1

ibuprofen tab cold/sinus (QL= 240 tabs/30 days)

QL Tier 1

LORTUSS EX LIQUID (QL= 1200ml/30 days)

QL Tier 1

promethazine DM syrup

- Tier 1

PROMETHAZINE VC SYRUP

- Tier 1

promethazine VC syrup (PHENERGAN VC equiv)

- Tier 1

PROMETHAZINE VC/CODEINE SYRUP

- Tier 1

promethazine VC/codeine syrup (PHENERGAN VC/CODEINE equiv)

- Tier 1

promethazine/codeine syrup (PHENERGAN/CODEINE equiv)

- Tier 1

triprolidine/pseudoephedrine tab 2.5-60 mg (QL= 4 tabs/day)

QL Tier 1

trispec pse liquid (QL= 1200ml/30 days)

OTC-QL Tier 1

tussin cf liquid (QL= 1200ml/30 days)

QL Tier 1

ACTINEL LIQUID (QL= 1200ml/30 days)

QL Tier 2

CAPMIST DM TAB (QL= 4 tabs/day)

QL Tier 2

CODITUSSIN LIQUID DAC (QL= 1200ml/30 days)

QL Tier 2

GUAIFENESIN/CODEINE SYRUP (QL= 240ml/fill, 2 fills/month)

OTC-QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 111 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

COUGH/COLD/ALLERGY Cont.

LORTUSS LIQUID (QL= 1200ml/30 days)

QL Tier 2

MAR-COF CG LIQUID (QL= 473ml/month)

QL Tier 2

M-END DMX LIQUID (QL= 1800ml/30 days)

QL Tier 2

NEXAFED SINUS TAB + PAIN (QL= 240 tabs/30 days)

QL Tier 2

STAHIST AD TAB 25-60MG (QL= 4 tabs/day)

QL Tier 2

EXPECTORANTS

potassium iodide oral soln (SSKI equiv) (QL= 90ml/30 days)

QL Tier 1

MISC. RESPIRATORY INHALANTS

sodium chloride neb soln (HYPER-SAL equiv)

- Tier 1

MUCOLYTICS

acetylcysteine soln (MUCOMYST equiv)

- Tier 1

DERMATOLOGICALS

ACNE PRODUCTS

adapalene cream (DIFFERIN equiv) (QL= 360g/30 days)

QL Tier 1

adapalene gel 0.3% (DIFFERIN equiv) (QL= 360g/30 days)

QL Tier 1

clindamycin gel (CLEOCIN GEL equiv)

- Tier 1

clindamycin lotion (CLEOCIN- T equiv)

- Tier 1

clindamycin pad (CLEOCIN-T equiv)

- Tier 1

clindamycin topical soln (CLEOCIN-T equiv)

- Tier 1

ERY PAD

- Tier 1

erythromycin gel

- Tier 1

erythromycin pad

- Tier 1

erythromycin soln

- Tier 1

sodium sulfacetamide lotion (KLARON equiv)

- Tier 1

tretinoin cream (RETIN-A CREAM equiv)

- Tier 1

tretinoin gel (RETIN-A GEL equiv)

- Tier 1

amnesteem cap, claravis cap, isotretinoin cap, myorisan cap, zenatane cap (ACCUTANE equiv)

- Tier 2

clindamycin foam (EVOCLIN equiv) (QL= 300g/30 days; Step Therapy requires clindamycin gel/solution/lotion/swab OR

erythromycin gel/soln)

QL-ST Tier 2

clindamycin/tretinoin gel (ZIANA equiv) (QL= 360g/30 days; Step Therapy requires trial of 1: adapalene or tretinoin, AND

trial of 1: clindamycin or erythromycin)

QL-ST Tier 2

dapsone gel (ACZONE equiv) (QL= 360g/30 days; Step Therapy requires clindamycin gel/solution/lotion/swab OR

erythromycin gel/soln)

QL-ST Tier 2

tretinoin gel (QL= 300g/30 days; Step Therapy requires trial of 2: adapalene, tretinoin, tazarotene 0.1% cream, 0.05% gel)

QL-ST Tier 2

ANTIBIOTICS - TOPICAL

gentamicin sulfate cream

- Tier 1

gentamicin sulfate oint

- Tier 1

mupirocin cream (BACTROBAN CREAM equiv)

- Tier 1

mupirocin oint (BACTROBAN OINT equiv)

- Tier 1

ANTIFUNGALS - TOPICAL

ciclopirox cream (LOPROX CREAM equiv)

- Tier 1

ciclopirox gel (LOPROX GEL equiv)

- Tier 1

ciclopirox nail soln (PENLAC SOLN equiv)

- Tier 1

ciclopirox shampoo (LOPROX SHAMPOO equiv)

- Tier 1

ciclopirox topical susp (LOPROX SUSP equiv)

- Tier 1

clotrimazole cream (LOTRIMIN AF CREAM equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 112 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DERMATOLOGICALS Cont.

clotrimazole/betamethasone cream (LORTRISONE CREAM equiv)

- Tier 1

CLOTRIMAZOLE/BETAMETHASONE LOTION

- Tier 1

clotrimazole/betamethasone lotion (LOTRISONE LOTION equiv)

- Tier 1

econazole cream (SPECTAZOLE equiv)

- Tier 1

iodoquinol/hydrocortisone cream 1% (VYTONE equiv)

- Tier 1

ketoconazole cream (NIZORAL CREAM equiv)

- Tier 1

ketoconazole shampoo

- Tier 1

nizoral a-d shampoo (NIZORAL equiv)

OTC Tier 1

nystatin cream (MYCOSTATIN CREAM equiv)

- Tier 1

nystatin oint

- Tier 1

nystatin topical powder

- Tier 1

nystatin/triamcinolone cream

- Tier 1

nystatin/triamcinolone oint

- Tier 1

iodoquinol/hydrocortisone cream 1.9-1% (VYTONE equiv)

- Tier 2

ketoconazole foam 2% (EXTINA equiv)

- Tier 2

naftifine cream (NAFTIN equiv) (QL= 1 tube/30 days; Step therapy requires trial of 2 preferred topical antifungal products)

QL-ST Tier 2

NAFTIFINE CREAM 1%

- Tier 2

naftifine gel (NAFTIN equiv)

- Tier 2

naftifine hcl gel 2% (QL= 60 grams/30 days; ST Trial of 2: ciclopirox gel/cream, clotrimazole cream, econazole nitrate

cream, ketoconazole cream)

QL-ST Tier 2

oxiconazole nitrate cream (OXISTAT equiv)

- Tier 2

tavaborole soln (KERYDIN SOLN equiv) (Step Therapy requires trial of 2: ciclopirox nail soln, itraconazole cap or

terbinafine tab)

ST Tier 2

ANTI-INFLAMMATORY AGENTS - TOPICAL

diclofenac sodium soln 2% (Step therapy requires trial of of diclofenac 1.5% soln)

ST Tier 2

diclofenac soln 1.5% (PENNSAID equiv)

- Tier 2

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL

diclofenac gel (SOLARAZE equiv) (QL= 100gm/fill, 2 fills/month)

QL Tier 1

fluorouracil cream (EFUDEX CREAM equiv)

- Tier 1

fluorouracil soln (FLUOROURACIL equiv)

- Tier 1

bexarotene gel (TARGRETIN equiv) (QL= 60g/30 days)

AMSP-PA-QL

Tier 1

Specialty

FLUOROURACIL SOLN

- Tier 2

VALCHLOR GEL (QL= 4 tubes/30 days; Only available through Optum 877-445-6874)

LD-PA-QL

Tier 2

Specialty

ANTIPRURITICS - TOPICAL

doxepin hcl cream (ST req trial of a topical corticosteroid AND topical tacrolimus)

ST Tier 2

ANTIPSORIATICS

calcipotriene cream (DOVONEX CREAM equiv)

- Tier 1

calcipotriene oint

- Tier 1

CALCIPOTRIENE SOLN

- Tier 1

calcipotriene soln (DOVONEX SOLN equiv)

- Tier 1

methoxsalen cap (OXSORALEN ULTRA equiv)

- Tier 1

tazarotene cream 0.1% (TAZORAC equiv) (QL= 360g/30 days)

QL Tier 1

tazarotene gel (TAZORAC equiv) (QL= 360g/30 days)

QL Tier 1

acitretin cap (SORIATANE equiv) (Step Therapy requires trial of adapalene, adapalene/benzoyl peroxide, or tretinoin)

ST Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 113 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DERMATOLOGICALS Cont.

tazarotene gel 0.1% (TAZORAC equiv) (QL= 360g/30 days; Step Therapy requires trial of 2: adapalene, tretinoin,

tazarotene 0.1% cream, 0.05% gel)

QL-ST Tier 2

COSENTYX INJ (1-PACK) (QL= 1 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

COSENTYX INJ (2-PACK) (QL= 2 inj/56 days)

AMSP-PA-QL

Tier 2

Specialty

COSENTYX INJ 300MG/2ML (QL= 1 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

SKYRIZI INJ 150MG/ML (QL= 1 inj/84 days)

AMSP-PA-QL

Tier 2

Specialty

STELARA INJ (QL= 1 inj/84 days )

AMSP-PA-QL

Tier 2

Specialty

STELARA INJ (QL= 1 inj/84 days)

AMSP-PA-QL

Tier 2

Specialty

TREMFYA INJ (QL= 1 inj/56 days)

AMSP-PA-QL

Tier 2

Specialty

ANTISEBORRHEIC PRODUCTS

selenium sulfide lotion

- Tier 1

selenium sulfide shampoo (SELSEB equiv)

- Tier 1

ANTIVIRALS - TOPICAL

acyclovir cream (ZOVIRAX equiv)

- Tier 2

acyclovir oint (ZOVIRAX OINT equiv)

- Tier 2

penciclovir cream (DENAVIR equiv) (QL= 5 grams/30 days; Step therapy requires trial of 2: VALACYCLOVIR HCL TAB,

FAMCICLOVIR TAB, ACYCLOVIR TAB)

QL-ST Tier 2

BURN PRODUCTS

silver sulfadiazine cream (SILVADENE CREAM equiv)

- Tier 1

SULFAMYLON CREAM

- Tier 2

CAUTERIZING AGENTS

SILVER NITRATE SOLN

- Tier 2

CORTICOSTEROIDS - TOPICAL

alclometasone cream (ACLOVATE equiv)

- Tier 1

alclometasone oint (ACLOVATE OINT equiv)

- Tier 1

AMCINONIDE CREAM 0.1%

- Tier 1

betamethasone augmented cream (DIPROLENE AF CREAM equiv)

- Tier 1

betamethasone augmented gel

- Tier 1

betamethasone augmented lotion (DIPROLENE LOTION equiv)

- Tier 1

betamethasone augmented oint (DIPROLENE OINT equiv)

- Tier 1

betamethasone diproprionate cream (DIPROSONE CREAM equiv)

- Tier 1

betamethasone diproprionate lotion

- Tier 1

betamethasone diproprionate oint (DIPROSONE OINT equiv)

- Tier 1

betamethasone valerate cream

- Tier 1

betamethasone valerate lotion

- Tier 1

betamethasone valerate oint

- Tier 1

clobetasol foam (OLUX equiv)

- Tier 1

clobetasol lotion (CLOBEX equiv)

- Tier 1

clobetasol propionate cream (TEMOVATE equiv)

- Tier 1

clobetasol propionate emollient cream (TEMOVATE E equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 114 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DERMATOLOGICALS Cont.

clobetasol propionate gel (TEMOVATE GEL equiv)

- Tier 1

clobetasol propionate oint (TEMOVATE equiv)

- Tier 1

clobetasol propionate soln (TEMOVATE equiv)

- Tier 1

clobetasol shampoo (CLOBEX equiv)

- Tier 1

clobetasol spray (CLOBEX equiv)

- Tier 1

dermawerx pak (DERMACINRX KIT equiv) (QL= 1 kit/30 days)

QL Tier 1

desonide cream

- Tier 1

desonide lotion

- Tier 1

desonide oint

- Tier 1

desoximetasone cream (TOPICORT CREAM equiv)

- Tier 1

desoximetasone gel (TOPICORT equiv)

- Tier 1

desoximetasone oint (TOPICORT equiv)

- Tier 1

fluocinolone acetonide cream

- Tier 1

fluocinolone acetonide oil

- Tier 1

fluocinolone acetonide oint

- Tier 1

fluocinolone acetonide soln

- Tier 1

fluocinonide cream 0.05% (LIDEX equiv)

- Tier 1

fluocinonide emollient cream

- Tier 1

fluocinonide gel

- Tier 1

fluocinonide oint

- Tier 1

fluocinonide soln

- Tier 1

fluticasone propionate cream (CUTIVATE equiv)

- Tier 1

fluticasone propionate oint (CUTIVATE equiv)

- Tier 1

halobetasol propionate cream (ULTRAVATE equiv)

- Tier 1

halobetasol propionate oint (ULTRAVATE equiv)

- Tier 1

halonate pac kit (ULTRAVATE KIT equiv)

- Tier 1

HC BUTYRATE CREAM

- Tier 1

hydrocortisone butyrate cream (LOCOID equiv)

- Tier 1

hydrocortisone butyrate lipocream (LOCOID equiv)

- Tier 1

hydrocortisone butyrate oint (LOCOID equiv)

- Tier 1

hydrocortisone butyrate soln (LOCOID equiv)

- Tier 1

hydrocortisone cream (PROCTOCORT equiv)

- Tier 1

hydrocortisone lotion (HYTONE equiv)

- Tier 1

hydrocortisone oint

- Tier 1

hydrocortisone valerate cream

- Tier 1

hydrocortisone valerate oint (WESTCORT equiv)

- Tier 1

LOCOID LIPOCREAM

- Tier 1

mometasone cream (ELOCON equiv)

- Tier 1

mometasone oint (ELOCON equiv)

- Tier 1

mometasone soln (ELOCON equiv)

- Tier 1

paramox hc gel (NOVACORT GEL equiv)

- Tier 1

triamcinolone acetonide oint 0.025% (TRIANEX equiv)

- Tier 1

triamcinolone acetonide oint 0.1% (TRIANEX equiv)

- Tier 1

triamcinolone acetonide oint 0.5% (TRIANEX equiv)

- Tier 1

triamcinolone cream

- Tier 1

triamcinolone lotion

- Tier 1

AMCINONIDE LOTION

- Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 115 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DERMATOLOGICALS Cont.

amcinonide oint (Step therapy requires trial of 2 high potency steroids (eg. betamethasone, clobetasol, halobetasol))

ST Tier 2

betamethasone valerate foam (LUXIQ FOAM equiv)

- Tier 2

calcipotriene/betamethasone oint (TACLONEX equiv)

- Tier 2

calcipotriene-betamethasone dipropionate susp (CALCIPOTRIENE/ BETAMETHASONE SUSP equiv) (QL= 400gm/30 days;

Step Therapy requires trial of 2: high potency corticosteroids, topical calcipotriene)

QL-ST Tier 2

clobetasol E foam (OLUX E equiv)

- Tier 2

clocortolone pivalate cream (CLOCORTOLONE equiv) (QL= 1 tube/30 days; Step therapy requires trial of one preferred

topical steroid)

QL-ST Tier 2

desonate gel

- Tier 2

DESONIDE GEL

- Tier 2

desoximetasone spray 0.25% (TOPICORT equiv)

- Tier 2

diflorasone oint

- Tier 2

fluocinonide cream 0.1%

- Tier 2

flurandrenolide cream (CORDRAN equiv)

- Tier 2

flurandrenolide lotion (CORDRAN equiv)

- Tier 2

flurandrenolide oint (CORDRAN equiv)

- Tier 2

FLUTICASONE LOTION (ST req tri of 2 lower-mid potency topical corticosteroid (eg. Betamet lot 0.05%, Fluocin crm

0.025%))

ST Tier 2

fluticasone propionate lotion (CUTIVATE equiv)

- Tier 2

halcinonide cream (HALOG equiv) (Step Therapy requires trial of 2 High potency corticosteroids)

ST Tier 2

halobetasol propionate foam (HALOBETASOL AER equiv) (ST req trial of 2 high potency steroids (eg. betamethasone,

clobetasol, halobetasol))

ST Tier 2

HC BUTYRATE SOLN

- Tier 2

hydrocortisone lotion (LOCOID equiv)

- Tier 2

MICORT-HC CREAM

- Tier 2

PRAMOSONE CREAM 1-1%

- Tier 2

PRAMOSONE E CREAM

- Tier 2

PREDNICARBATE CREAM

- Tier 2

PREDNICARBATE OIN

- Tier 2

triamcinolone acetonide oint (TRIANEX equiv) (Step Therapy requires trial of triamcinolone acetonide oint 0.025% or 0.1%)

ST Tier 2

triamcinolone spray (KENALOG equiv)

- Tier 2

ECZEMA AGENTS

DUPIXENT INJ (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

DUPIXENT PEN INJ (QL= 2 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

DUPIXENT PEN INJ (QL= 2 syringes/28 days)

AMSP-PA-QL

Tier 2

Specialty

EMOLLIENT/KERATOLYTIC AGENTS

umecta mouss aer (HYDRO 40 equiv)

- Tier 2

EMOLLIENTS

ammonium lactate cream (LAC-HYDRIN equiv)

- Tier 1

ammonium lactate lotion (LAC-HYDRIN equiv)

- Tier 1

ENZYMES - TOPICAL

SANTYL OINT (QL= 90gm/30 days)

QL Tier 2

IMMUNOMODULATING AGENTS - TOPICAL

imiquimod cream 5% (ALDARA equiv) (QL= 24gm/30 days)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 116 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DERMATOLOGICALS Cont.

imiquimod cream 3.75% (IMIQUIMOD equiv) (QL= 7.5gm/28 days; Step Therapy requires trial of 2: imiquimod 5% cream,

podophyllum resin, fluorouracil cream or topical solution)

QL-ST Tier 2

IMMUNOSUPPRESSIVE AGENTS - TOPICAL

tacrolimus oint (PROTOPIC OINT equiv)

- Tier 1

pimecrolimus cream (ELIDEL equiv) (Step Therapy requires trial of tacrolimus oint)

ST Tier 2

KERATOLYTIC/ANTIMITOTIC AGENTS

podofilox soln (CONDYLOX equiv)

- Tier 1

salicylic acid shampoo (SALEX equiv)

- Tier 1

PODOCON SOLN

- Tier 2

podofilox gel (CONDYLOX equiv) (QL= 15g/30 days; ST req trial of podofilox soln AND imiquimod 5% cream)

QL-ST Tier 2

salicylic acid aerosol

- Tier 2

LOCAL ANESTHETICS - TOPICAL

LIDOCAINE GEL

- Tier 1

lidocaine gel (GLYDO equiv)

- Tier 1

lidocaine oint (QL= 8gm/day)

QL Tier 1

lidocaine soln (XYLOCAINE equiv)

- Tier 1

lidocaine/prilocaine cream (EMLA equiv)

- Tier 1

capsaicin/menthol topical patch (SINELEE equiv)

- Tier 2

lidocaine cream 3% (LIDAMANTLE equiv)

- Tier 2

lidocaine cream 3.88% (LIDOTRAL CREAM equiv)

- Tier 2

lidocaine gel (XYLOCAINE equiv)

- Tier 2

lidocaine lotion

- Tier 2

MISC. TOPICAL

DRYSOL SOLN

- Tier 2

ROSACEA AGENTS

azelaic acid gel (FINACEA equiv) (QL= 300g/30 days)

QL Tier 1

metronidazole cream (METROCREAM equiv)

- Tier 1

metronidazole lotion (METROLOTION equiv)

- Tier 1

brimonidine tartrate gel (MIRVASO equiv) (QL= 60 grams/30 days; ST req trial of azelaic acid gel and metronidazole

topical)

QL-ST Tier 2

doxycycline (rosacea) cap delayed release (ORACEA equiv) (QL= 1 cap/day; Step Therapy requires trial of doxycycline

monohydrate)

QL-ST Tier 2

ivermectin cream (SOOLANTRA equiv) (QL= 45gm/30 days; Step Therapy requires trial of oral doxycycline and topical

metronidazole)

QL-ST Tier 2

metronidazole gel (METROGEL equiv)

- Tier 2

SCABICIDES & PEDICULICIDES

malathion lotion (OVIDE equiv)

- Tier 1

permethrin cream (ELIMITE CREAM equiv)

- Tier 1

SPINOSAD SUSP (QL= 1 bottle/fill, 1 fill/month)

QL Tier 2

WOUND CARE PRODUCTS

cicatrace kit (REXASIL equiv)

- Tier 2

DIAGNOSTIC PRODUCTS

DIAGNOSTIC DRUGS

GLUCAGEN INJ

- Tier 2

DIAGNOSTIC PRODUCTS, MISC.

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 117 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DIAGNOSTIC PRODUCTS Cont.

FREESTYLE LITE TEST STRIP (QL= 300 test strips/30 days)

OTC-QL Tier 1

DIAGNOSTIC TESTS

COVID-19 TEST (QL= 2 tests/30 days)

Preventiv

CUE HEALTH MIS MONITOR (QL= 1 kit/year)

Preventiv

CONTOUR BLOOD GLUCOSE TEST STRIP (QL= 300 strips/30 days)

QL Tier 1

CONTOUR TEST STRIP (QL= 300 test strips/30 days)

OTC-QL Tier 1

FREESTYLE INSULINX TEST STRIP (QL= 300 test strips/30 days)

OTC-QL Tier 1

FREESTYLE PRECISION NEO TEST STRIP (QL= 300 test strips/30 days)

OTC-QL Tier 1

FREESTYLE TEST STRIP (QL= 300 test strips/30 days)

OTC-QL Tier 1

FREESTYLE TEST STRIPS (QL= 300 strips/30 days)

QL Tier 1

PRECISION XTRA TEST STRIP (QL= 300 test strips/30 days)

OTC-QL Tier 1

DIGESTIVE AIDS

DIGESTIVE ENZYMES

CREON CAP

- Tier 2

DIURETICS

CARBONIC ANHYDRASE INHIBITORS

acetazolamide ER cap (DIAMOX SEQUEL equiv)

- Tier 1

acetazolamide tab

- Tier 1

dichlorphenamide tab (KEVEYIS equiv) (QL= 4 tabs/day)

AMSP-PA-QL

Tier 1

Specialty

methazolamide tab (NEPTAZANE equiv) (Step Therapy requires trial of acetazolamide)

ST Tier 2

DIURETIC COMBINATIONS

AMILORIDE/HCTZ TAB

- Tier 1

amiloride/hydrochlorothiazide tab (MODURETIC equiv)

- Tier 1

spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv)

- Tier 1

triamterene/hydrochlorothiazide cap (DYAZIDE equiv)

- Tier 1

triamterene/hydrochlorothiazide tab (MAXZIDE equiv)

- Tier 1

LOOP DIURETICS

bumetanide tab (BUMEX equiv)

- Tier 1

torsemide tab (DEMADEX equiv)

- Tier 1

ethacrynic tab (EDECRIN equiv)

- Tier 2

FUROSEMIDE SOLN

- Value

furosemide soln (LASIX equiv)

- Value

furosemide tab (LASIX equiv)

- Value

POTASSIUM SPARING DIURETICS

amiloride tab (MIDAMOR equiv)

- Tier 1

spironolactone susp (CAROSPIR equiv) (QL= 600ml/30 days; ST req trial of furosemide oral soln)

QL-ST Tier 2

triamterene cap (DYRENIUM equiv) (Step Therapy requires trial of amiloride or spironolactone)

ST Tier 2

spironolactone tab (ALDACTONE equiv)

- Value

THIAZIDES AND THIAZIDE-LIKE DIURETICS

CHLOROTHIAZIDE TAB

- Tier 1

chlorothiazide tab (DIURIL equiv)

- Tier 1

indapamide tab (LOZOL equiv)

- Tier 1

METHYCLOTHIAZIDE TAB

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 118 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

DIURETICS Cont.

metolazone tab (ZAROXOLYN equiv)

- Tier 1

DIURIL SUSP

- Tier 2

chlorthalidone tab

- Value

hydrochlorothiazide cap (MICROZIDE equiv)

- Value

hydrochlorothiazide tab (HYDRODIURIL equiv)

- Value

ENDOCRINE AND METABOLIC AGENTS - MISC.

BONE DENSITY REGULATORS

alendronate sodium oral soln (FOSAMAX equiv) (QL= 300ml/28 days)

QL Tier 1

calcitonin nasal spray (MIACALCIN equiv)

- Tier 1

ibandronate tab 150mg (BONIVA equiv)

- Tier 1

risedronate tab 30mg (ACTONEL equiv) (QL= 1 tab/day)

QL Tier 1

risedronate tab 35mg (ACTONEL equiv) (QL= 4 tabs/28 days)

QL Tier 1

risedronate tab 5mg (ACTONEL equiv) (QL= 1 tab/day)

QL Tier 1

calcitonin inj (MIACALCIN equiv)

- Tier 2

risedronate DR tab (ATELVIA equiv) (QL= 4 tabs/28 days; Step Therapy requires trial of alendronate)

QL-ST Tier 2

risedronate tab 150mg (ACTONEL equiv) (QL= 1 tab/30 days; Step Therapy requires trial of alendronate)

QL-ST Tier 2

teriparatide (recombinant) soln pen-inj 600mcg/2.4ml (FORTEO equiv) (QL= 2.4 units/28 days)

AMSP-PA-QL

Tier 2

Specialty

TERIPARATIDE INJ 620MCG/2.48ML (QL= 2.48 units/28 days)

AMSP-PA-QL

Tier 2

Specialty

TYMLOS INJ (QL= 1.56 units/30 days)

AMSP-PA-QL

Tier 2

Specialty

alendronate tab (FOSAMAX equiv)

- Value

ALENDRONATE TAB 40MG

- Value

CORTICOTROPIN

ACTHAR HP GEL INJ (Only available through Accredo 800-803-2523 or Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

ACTHAR INJ 80UNIT (Only available through Accredo 800-803-2523 or Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

GROWTH HORMONE RECEPTOR ANTAGONISTS

SOMAVERT INJ (Only available through Accredo 800-803-2523 or Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

GROWTH HORMONES

GENOTROPIN INJ 0.2MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 0.4MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 0.6MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 0.8MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 1.2MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 1.4MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 1.6MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 119 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ENDOCRINE AND METABOLIC AGENTS - MISC. Cont.

GENOTROPIN INJ 1.8MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 12MG (QL= 4 cartridges/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 1MG (QL= 35 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 2MG (QL= 21 syringes/28 days)

AMSP-QL

Tier 2

Specialty

GENOTROPIN INJ 5MG (QL= 9 cartridges/28 days)

AMSP-QL

Tier 2

Specialty

OMNITROPE INJ (QL= 9 cartridges/28 days)

AMSP-QL

Tier 2

Specialty

OMNITROPE INJ 5.8MG (QL= 8 vials/28 days)

AMSP-QL

Tier 2

Specialty

SKYTROFA INJ (QL= 4 inj/28 days)

AMSP-PA-QL

Tier 2

Specialty

HORMONE RECEPTOR MODULATORS

raloxifene tab (EVISTA equiv) (QL= 1 tab/day)

Preventiv

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

INCRELEX INJ (Only available through Accredo 800-803-2523 or Walgreens 888-347-3416)

Tier 2

Specialty

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

SYNAREL NASAL SOLN

- Tier 2

LUPRON DEPOT INJ PED (QL= 1 syringe kit/180 days)

AMSP-PA-QL

Tier 2

Specialty

LUPRON DEPOT-PED INJ (1-MONTH) (QL= 1 syringe kit/30 days)

AMSP-PA-QL

Tier 2

Specialty

LUPRON DEPOT-PED INJ (3-MONTH) (QL= 1 syringe kit/90 days)

AMSP-PA-QL

Tier 2

Specialty

METABOLIC MODIFIERS

calcitriol cap (ROCALTROL equiv)

- Tier 1

calcitriol soln (CALCITRIOL equiv)

- Tier 1

cinacalcet tab 30mg (SENSIPAR equiv) (QL= 2 tabs/day)

QL Tier 1

cinacalcet tab 60mg (SENSIPAR equiv) (QL= 2 tabs/day)

QL Tier 1

cinacalcet tab 90mg (SENSIPAR equiv) (QL= 4 tabs/day)

QL Tier 1

levocarnitine soln (CARNITOR equiv)

- Tier 1

levocarnitine tab (CARNITOR equiv)

- Tier 1

paricalcitol cap (ZEMPLAR equiv)

- Tier 1

betaine powder for oral solution (CYSTADANE equiv) (QL= 540 grams/30 days; Only available through Walgreens

888-347-3416)

LD-PA-QL

Tier 1

Specialty

carglumic acid tab (CARBAGLU equiv) (Only available through Accredo 888-773-7376)

LD-PA

Tier 1

Specialty

nitisinone cap (ORFADIN equiv)

LMSP-PA

Tier 1

Specialty

sapropterin dihydrochloride powder packet (KUVAN equiv)

AMSP-PA

Tier 1

Specialty

sapropterin dihydrochloride soluble tab (KUVAN equiv)

AMSP-PA

Tier 1

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 120 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ENDOCRINE AND METABOLIC AGENTS - MISC. Cont.

sodium phenylbutyrate powder (BUPHENYL equiv)

AMSP-PA

Tier 1

Specialty

sodium phenylbutyrate tab (BUPHENYL equiv)

AMSP-PA

Tier 1

Specialty

doxercalciferol cap (HECTOROL equiv)

- Tier 2

CYSTADANE POWDER (QL= 540 grams/30 days; Only available through AnovoRx 844-288-5007)

LD-QL

Tier 2

Specialty

STRENSIQ INJ (Only available through PantherRx Pharmacy 855-726-8479)

LD-PA

Tier 2

Specialty

POSTERIOR PITUITARY HORMONES

desmopressin acetate nasal spray (DDAVP equiv)

- Tier 1

desmopressin acetate tab (DDAVP equiv)

- Tier 1

STIMATE NASAL SOLN

- Tier 2

PROGESTERONE RECEPTOR ANTAGONISTS

mifepristone tab (MIFEPREX equiv)

Preventiv

PROLACTIN INHIBITORS

cabergoline tab (DOSTINEX equiv)

- Tier 1

SOMATOSTATIC AGENTS

octreotide inj (SANDOSTATIN equiv)

AMSP-PA

Tier 1

Specialty

OCTREOTIDE INJ 100MCG

AMSP-PA

Tier 1

Specialty

SIGNIFOR INJ (QL= 2 vials/day; Only available through Anovo Specialty Pharmacy 844-288-5007)

LD-PA-QL

Tier 2

Specialty

VASOPRESSIN RECEPTOR ANTAGONISTS

tolvaptan tab (SAMSCA equiv) (QL= 2 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 1

Specialty

tolvaptan tab 15mg (SAMSCA equiv) (QL= 1 tab/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 1

Specialty

JYNARQUE PAK (QL= 2 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

JYNARQUE TAB 15MG (QL= 2 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

JYNARQUE TAB 30MG (QL= 1 tab/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

ESTROGENS

ESTROGEN COMBINATIONS

esterified estrogens/methyltestosterone tab (ESTRATEST equiv)

- Tier 1

estradiol/norethindrone tab (ACTIVELLA equiv)

- Tier 1

jinteli tab (FEMHRT equiv)

- Tier 1

ESTROGENS

estradiol tab (ESTRACE equiv)

- Tier 1

estradiol gel 0.06% (ESTRADIOL equiv) (QL= 50 gm/30 days; Step therapy requires trial of 2: estradiol tab/patch/vaginal

tab, Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz)

QL-ST Tier 2

estradiol patch (CLIMARA equiv) (QL= 4 patches/28 days)

QL Tier 2

estradiol patch (VIVELLE-DOT equiv) (QL= 8 patches/28 days)

QL Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 121 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ESTROGENS Cont.

estradiol td gel (DIVIGEL equiv) (QL= 1 packet/day; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz)

QL-ST Tier 2

estradiol td gel 1.25mg/1.25gm (DIVIGEL equiv) (QL= 37.5gm/30 days; Step therapy requires trial of 2: estradiol

tab/patch/vaginal tab, Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz)

QL-ST Tier 2

estradiol valerate inj (ST req trial of 2: estradiol tab, estradiol patch, estradiol vaginal tab, Estring)

ST Tier 2

FLUOROQUINOLONES

CIPRO SUSP

- Tier 1

ciprofloxacin susp (CIPRO equiv)

- Tier 1

ciprofloxacin tab 250mg, 500mg, 750mg (CIPRO equiv)

- Tier 1

levofloxacin oral soln 25mg/ml (LEVOFLOXACIN equiv)

- Tier 1

levofloxacin tab (LEVAQUIN equiv)

- Tier 1

moxifloxacin tab (AVELOX equiv)

- Tier 1

ofloxacin tab (FLOXIN equiv)

- Tier 1

GASTROINTESTINAL AGENTS - MISC.

AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC)

TRULANCE TAB (QL= 30 tabs/30 days)

QL Tier 2

GALLSTONE SOLUBILIZING AGENTS

RELTONE CAP

- Tier 1

ursodiol cap (ACTIGALL equiv)

- Tier 1

ursodiol tab (URSO (FORTE) equiv)

- Tier 1

CHENODAL TAB

Tier 2

Specialty

GASTROINTESTINAL ANTIALLERGY AGENTS

cromolyn conc (GASTROCROM equiv)

- Tier 1

GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS

lubiprostone cap (AMITIZA equiv) (QL= 60 caps/30 days)

QL Tier 1

GASTROINTESTINAL STIMULANTS

metoclopramide soln (REGLAN equiv)

- Tier 1

metoclopramide tab (REGLAN equiv)

- Tier 1

INFLAMMATORY BOWEL AGENTS

balsalazide cap (COLAZAL equiv)

- Tier 1

mesalamine DR cap (DELZICOL equiv) (QL= 6 caps/day)

QL Tier 1

mesalamine DR tab (LIALDA equiv) (QL= 4 tabs/day)

QL Tier 1

mesalamine enema (ROWASA equiv)

- Tier 1

mesalamine ER cap (APRISO equiv) (QL= 4 caps/day)

QL Tier 1

mesalamine supp (CANASA equiv) (QL= 1 supp/day)

QL Tier 1

sulfasalazine EC tab (AZULFIDINE equiv)

- Tier 1

sulfasalazine tab (AZULFIDINE equiv)

- Tier 1

mesalamine ER cap (PENTASA equiv) (QL= 8 caps/day; Step therapy requires trial of 1: generic APRISO or LIALDA)

QL-ST Tier 2

mesalamine tab (ASACOL equiv)

- Tier 2

MESALAMINE TAB DR 800MG

- Tier 2

PENTASA CAP 500MG (Step Therapy requires trial of APRISO or LIALDA)

ST Tier 2

SKYRIZI 180MG/1.2ML CARTRIDGE (QL= 1 cartridge/56 days)

AMSP-PA-QL

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 122 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

GASTROINTESTINAL AGENTS - MISC. Cont.

SKYRIZI INJ (QL= 1 cartridge/56 days)

AMSP-PA-QL

Tier 2

Specialty

INTESTINAL ACIDIFIERS

lactulose soln

- Tier 1

IRRITABLE BOWEL SYNDROME (IBS) AGENTS

alosetron tab (LOTRONEX equiv)

- Tier 1

PERIPHERAL OPIOID RECEPTOR ANTAGONISTS

MOVANTIK TAB (QL= 30 tabs/30 days)

PA-QL Tier 2

SYMPROIC TAB (QL= 30 tabs/30 days)

PA-QL Tier 2

PHOSPHATE BINDER AGENTS

calcium acetate cap (PHOSLO equiv)

- Tier 1

lanthanum carbonate chew tab (FOSRENOL equiv) (QL= 3 tabs/day; ST req trial of sevelamer carbonate tab or sevelamer

HCL tab)

QL-ST Tier 1

lanthanum carbonate chew tab 500mg (FOSRENOL equiv) (QL= 5 tabs/day; ST req trial of sevelamer carbonate tab or

sevelamer HCL tab)

QL-ST Tier 1

sevelamer hydrochloride tab (RENAGEL equiv)

- Tier 1

sevelamer powder pak (RENVELA equiv)

- Tier 1

sevelamer tab (RENVELA TAB equiv)

- Tier 1

PHOSLYRA SOLN

- Tier 2

GENITOURINARY AGENTS - MISCELLANEOUS

ALKALINIZERS

CYTRA K CRYSTALS

- Tier 1

CYTRA-3 SYRUP

- Tier 1

potassium citrate CR tab (UROCIT-K TAB equiv)

- Tier 1

potassium citrate/citric acid powder pack (POLYCITRA equiv)

- Tier 1

potassium citrate/citric acid soln (POLYCITRA-K equiv)

- Tier 1

sodium citrate/citric acid soln (BICITRA equiv)

- Tier 1

tricitrates soln (POLYCITRA-LC equiv)

- Tier 1

ORACIT SOLN

- Tier 2

CYSTINOSIS AGENTS

CYSTAGON CAP 150MG (Only available through CVS Specialty 800-237-2767; Diagnosis Restricted – Nephrophatic

cystinosis (E72.04))

LD-RDX

Tier 2

Specialty

CYSTAGON CAP 50MG (QL= 2 caps/day; Only available through CVS Specialty 800-237-2767; Diagnosis Restricted –

Nephrophatic cystinosis (E72.04))

LD-QL-RDX

Tier 2

Specialty

INTERSTITIAL CYSTITIS AGENTS

ELMIRON CAP

- Tier 2

PROSTATIC HYPERTROPHY AGENTS

alfuzosin SR tab (UROXATRAL equiv)

- Tier 1

dutasteride cap (AVODART equiv)

- Tier 1

finasteride tab (PROSCAR equiv)

- Tier 1

tamsulosin cap (FLOMAX equiv)

- Tier 1

dutasteride/tamsulosin cap (JALYN equiv) (Step Therapy requires trial of finasteride tab or dutasteride AND tamsulosin

cap)

ST Tier 2

silodosin cap (RAPAFLO equiv)

- Tier 2

URINARY ANALGESICS

phenazopyridine tab (PYRIDIUM equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 123 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

GENITOURINARY AGENTS - MISCELLANEOUS Cont.

URINARY STONE AGENTS

tiopronin tab (THIOLA equiv) (QL= 8 tabs/day; Only available through Eversana 636-519-2400)

LD-PA-QL

Tier 1

Specialty

tiopronin tab delayed release (THIOLA EC equiv) (QL= 8 tabs/day; Only available through Eversana 636-519-2400)

LD-PA-QL

Tier 2

Specialty

GOUT AGENTS

GOUT AGENT COMBINATIONS

colchicine/probenecid tab (COL-BENEMID equiv)

- Tier 1

GOUT AGENTS

allopurinol tab (ZYLOPRIM equiv)

- Tier 1

colchicine tab (COLCRYS equiv) (QL= 4 tabs/day)

QL Tier 1

colchicine cap (MITIGARE equiv) (QL= 4 caps/day)

QL Tier 2

febuxostat tab (ULORIC equiv) (QL= 1 tab/day)

QL Tier 2

URICOSURICS

probenecid tab (BENEMID equiv)

- Tier 1

HEMATOLOGICAL AGENTS - MISC.

ANTIHEMOPHILIC PRODUCTS

BENEFIX INJ

AMSP-PA

Tier 2

Specialty

REBINYN INJ (Only available through Walgreens 888-347-3416)

Tier 2

Specialty

BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant inj (SAJAZIR equiv) (QL= 36ml/30 days)

AMSP-PA-QL

Tier 1

Specialty

icatibant inj (SAJAZIR equiv) (QL= 36ml/30 days; Only available through Accredo 888-773-7376)

AMSP-PA-QL-LD

Tier 1

Specialty

COMPLEMENT INHIBITORS

HAEGARDA INJ 2000U (QL= 30 vials/30 days; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

HAEGARDA INJ 3000U (QL= 20 vials/30 days; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

HEMATORHEOLOGIC AGENTS

pentoxifylline ER tab (TRENTAL equiv)

- Tier 1

PLASMA KALLIKREIN INHIBITORS

TAKHZYRO INJ (QL= 2 inj/28 days; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TAKHZYRO INJ (QL= 2 prefilled syringes/28 days; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TAKHZYRO INJ 150MG/ML (QL= 2 prefilled syringes/28 days; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

PLATELET AGGREGATION INHIBITORS

anagrelide cap (AGRYLIN equiv)

- Tier 1

cilostazol tab (PLETAL equiv)

- Tier 1

clopidogrel tab 300mg (PLAVIX equiv) (QL= 4 tabs/30 days)

QL Tier 1

clopidogrel tab 75mg (PLAVIX equiv)

- Tier 1

dipyridamole tab (PERSANTINE equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 124 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

HEMATOLOGICAL AGENTS - MISC. Cont.

prasugrel tab (EFFIENT equiv) (QL= 1 tab/day)

QL Tier 1

aspirin/dipyridamole cap (AGGRENOX equiv)

- Tier 2

BRILINTA TAB (QL= 2 tabs/day)

QL Tier 2

HEMATOPOIETIC AGENTS

AGENTS FOR GAUCHER DISEASE

miglustat cap (ZAVESCA equiv) (Only available through Accredo 800-803-2523)

LD-PA

Tier 1

Specialty

CERDELGA CAP (Only available through Accredo 800-803-2523 or Walgreens 888-347-3416)

LD-PA

Tier 2

Specialty

AGENTS FOR SICKLE CELL ANEMIA

DROXIA CAP

- Tier 2

AGENTS FOR SICKLE CELL DISEASE

l-glutamine powder packet (ENDARI equiv) (QL= 6 packets/day; Step therapy requires trial of hydroxyurea caps)

AMSP-QL-ST

Tier 1

Specialty

COBALAMINS

cyanocobalamin inj

- Tier 1

cyanocobalamin nasal spray 500mcg/0.1ml (NASCOBAL equiv) (ST req trial of cyanocobalamin injection)

ST Tier 2

FOLIC ACID/FOLATES

folic acid cap (Covered at $0 for females only; All other members covered at generic copay)

Preventiv

folic acid tab 1mg (Covered at $0 for females only; All other members covered at generic copay)

Preventiv

folic acid tab 400mcg (Covered for females only)

OTC

Preventiv

folic acid tab 800mcg (Covered for females only)

OTC

Preventiv

HEMATOPOIETIC GROWTH FACTORS

ARANESP INJ (QL= 4 syringes/30 days)

AMSP-QL

Tier 2

Specialty

ARANESP INJ (QL= 4 vials/30 days)

AMSP-QL

Tier 2

Specialty

DOPTELET TAB (QL= 2 tabs/day; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

FULPHILA INJ (QL= 2 syringes/28 days)

AMSP-QL

Tier 2

Specialty

NYVEPRIA INJ (QL= 2 inj/28 days)

AMSP-QL

Tier 2

Specialty

PROMACTA POWDER (QL= 6 packets/day)

AMSP-PA-QL

Tier 2

Specialty

PROMACTA TAB (QL= 2 tabs/day)

AMSP-PA-QL

Tier 2

Specialty

RETACRIT INJ (QL= 12 vials/30 days)

AMSP-QL

Tier 2

Specialty

RETACRIT INJ (QL= 4 vials/30 days)

AMSP-QL

Tier 2

Specialty

ZARXIO INJ (QL= 15 syringes/30 days)

AMSP-QL

Tier 2

Specialty

ZARXIO INJ 480/0.8 (QL= 15 syringes/30 days)

AMSP-QL

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 125 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

HEMATOPOIETIC AGENTS Cont.

HEMATOPOIETIC MIXTURES

multigen plus tab (CHROMAGEN FORTE equiv)

- Tier 1

multigen tab (CHROMAGEN equiv)

- Tier 1

NEPHRON FA TAB

- Tier 2

HEMOSTATICS

HEMOSTATICS - SYSTEMIC

tranexamic acid tab (LYSTEDA equiv) (QL= 180 tabs/30 days)

QL Tier 1

aminocaproic acid soln (AMICAR equiv)

AMSP

Tier 1

Specialty

aminocaproic acid tab (AMICAR equiv)

- Tier 2

HYPNOTICS

NON-BARBITURATE HYPNOTICS

zolpidem tab (AMBIEN equiv) (QL= 1 tab/day)

QL Tier 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

ANTIHISTAMINE HYPNOTICS

diphenhydramine cap 50mg (BENADRYL equiv) (Only 50mg covered)

- Tier 1

BARBITURATE HYPNOTICS

phenobarbital elixir

- Tier 1

phenobarbital tab

- Tier 1

HYPNOTICS - TRICYCLIC AGENTS

doxepin tab (SILENOR equiv) (QL= 30 tabs/30 days; Step Therapy requires trial of 2: eszopiclone, zaleplon, zolpidem,

zolpidem ER tab, or zolpidem SL)

QL-ST Tier 2

NON-BARBITURATE HYPNOTICS

estazolam tab (PROSOM equiv)

- Tier 1

eszopiclone tab (LUNESTA equiv) (QL= 1 tab/day)

QL Tier 1

midazolam hcl syrup

- Tier 1

midazolam inj (MIDAZOLAM equiv)

- Tier 1

temazepam cap 15mg (RESTORIL equiv)

- Tier 1

temazepam cap 30mg (RESTORIL equiv)

- Tier 1

triazolam tab (HALCION equiv)

- Tier 1

zaleplon cap (SONATA equiv) (QL= 1 cap/day)

QL Tier 1

zaleplon cap 10mg (SONATA equiv) (QL= 2 caps/day)

QL Tier 1

zolpidem ER tab (AMBIEN CR equiv) (QL= 1 tab/day)

QL Tier 1

temazepam cap 22.5mg (RESTORIL equiv)

- Tier 2

temazepam cap 7.5mg (RESTORIL equiv)

- Tier 2

zolpidem tartrate SL tab (INTERMEZZO equiv) (QL= 1 tab/day)

QL Tier 2

SELECTIVE MELATONIN RECEPTOR AGONISTS

tasimelteon capsule (HETLIOZ equiv)

AMSP-PA

Tier 1

Specialty

ramelteon tab (ROZEREM equiv) (QL= 1 tab/day; Step Therapy requires trial of 2: eszopiclone, zaleplon, zolpidem,

zolpidem ER tab, or zolpidem SL)

QL-ST Tier 2

LAXATIVES

LAXATIVE COMBINATIONS

GAVILYTE-C SOLN (Covered at $0 for members 45-75 years-Limited to 2 fills/calendar year; All other members covered

at generic copay)

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 126 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

LAXATIVES Cont.

peg 3350/electrolytes soln (COLYTE equiv) (Covered at $0 for members 45-75 years-Limited to 2 fills/calendar year; All

other members covered at generic copay)

Preventiv

trilyte soln (NULYTELY equiv) (Covered at $0 for members 45-75 years-Limited to 2 fills/calendar year; All other members

covered at generic copay)

Preventiv

sodium/potassium/magnesium soln (SUPREP equiv) (QL= 2 fills/year)

QL Tier 1

gavilyte-h kit

- Tier 2

peg 3350 soln (100 gram Moviprep equiv) (MOVIPREP equiv)

- Tier 2

SUFLAVE SOLN (QL= 2 fills/year)

QL Tier 2

LAXATIVES - MISCELLANEOUS

lactulose soln

- Tier 1

MACROLIDES

AZITHROMYCIN

azithromycin susp (ZITHROMAX equiv)

- Tier 1

azithromycin tab (ZITHROMAX equiv)

- Tier 1

ZITHROMAX POWDER PACK

- Tier 2

CLARITHROMYCIN

clarithromycin ER tab (BIAXIN XL equiv)

- Tier 1

clarithromycin tab (BIAXIN equiv)

- Tier 1

CLARITHROMYC SUSP

- Tier 2

ERYTHROMYCINS

erythromycin DR cap (ERYC equiv)

- Tier 1

erythromycin ethylsuccinate susp (ERYPED equiv)

- Tier 1

erythromycin tab (ERY-TAB equiv)

- Tier 1

erythromycin tab (ERYTHROMYCIN equiv) (all forms except PCE)

- Tier 1

ERYTHROMYCIN EC CAP

- Tier 2

PCE TAB

- Tier 2

FIDAXOMICIN

DIFICID SUSP (QL= 126 mL/10 days)

QL Tier 2

DIFICID TAB (QL= 20 tabs/10 days)

QL Tier 2

MEDICAL DEVICES

PARENTERAL THERAPY SUPPLIES

HYPODERMIC NEEDLES

OTC Tier 2

MEDICAL DEVICES AND SUPPLIES

CONTRACEPTIVES

CERVICAL CAP

Preventiv

DIAPHRAGM

Preventiv

FEMALE CONDOMS

OTC

Preventiv

DIABETIC SUPPLIES

DEXCOM G6 RECEIVER (QL= 1 receiver/year)

PA-QL Tier 1

DEXCOM G6 SENSOR (QL= 3 sensors/30 days)

PA-QL Tier 1

DEXCOM G6 TRANSMITTER (QL= 1 transmitter/90 days)

PA-QL Tier 1

DEXCOM G7 RECEIVER (QL= 1 receiver/year)

PA-QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 127 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

MEDICAL DEVICES AND SUPPLIES Cont.

DEXCOM G7 SENSOR (QL= 3 sensors/30 days)

PA-QL Tier 1

FREE LIBRE 3-PLUS SENSOR (QL= 2 sensors/30 days)

PA-QL Tier 1

FREESTYLE LIBRE 2 RECEIVER (QL= 1 receiver/year)

PA-QL Tier 1

FREESTYLE LIBRE 2 SENSOR (QL= 2 sensors/28 days)

PA-QL Tier 1

FREESTYLE LIBRE 3 READER (QL= 1 receiver/1 year)

PA-QL Tier 1

FREESTYLE LIBRE 3 SENSOR (QL= 2 sensors/28 days)

PA-QL Tier 1

FREESTYLE LIBRE RECEIVER (QL= 1 receiver/year)

PA-QL Tier 1

FREESTYLE LIBRE SENSOR (14-DAY) (QL= 2 sensors/28 days)

PA-QL Tier 1

CALIBRATION LIQUID

OTC Tier 2

LANCET KIT

OTC Tier 2

LANCETS

OTC Tier 2

OMNIPOD 5 G6 KIT (QL= 1 kit/year)

QL Tier 2

OMNIPOD 5 G6 MIS PODS (QL= 15 pods/30 days)

QL Tier 2

OMNIPOD 5 G7 KIT INTRO (QL= 1 kit/year)

QL Tier 2

OMNIPOD 5 G7 MIS PODS (QL= 15 pods/30 days)

QL Tier 2

OMNIPOD 5 PACK PODS (QL= 15 pods/30 days)

QL Tier 2

OMNIPOD DASH KIT (QL= 1 kit/year)

QL Tier 2

OMNIPOD DASH PODS (QL= 15 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 10 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 15 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 20 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 25 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 30 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 35 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD GO KIT 40 UNITS/DAY (QL= 10 pods/30 days)

QL Tier 2

OMNIPOD STARTER KIT (QL= 1 kit/year)

QL Tier 2

PARENTERAL THERAPY SUPPLIES

B-D INSULIN SYRINGE

--OTC Tier 1

BD NEEDLES

OTC Tier 1

B-D PEN NEEDLE

OTC Tier 1

NOVOFINE PEN NEEDLE

OTC Tier 1

NOVOTWIST PEN NEEDLE

OTC Tier 1

CEQUR SIMPLICITY 2U (QL= 10 patches/30 days)

QL Tier 2

CEQUR SIMPLICITY INSERTER (QL= 1 device/lifetime)

QL Tier 2

CEQUR SIMPLICITY INSERTER (QL= 1 inserter/lifetime)

QL Tier 2

HYPODERMIC NEEDLES

OTC Tier 2

NOVOPEN ECHO (QL= 1 pen device/365 days)

QL Tier 2

SAFETY SYRINGE

- Tier 2

SYRINGE LUER-LOK

OTC Tier 2

TB SYRINGE

- Tier 2

RESPIRATORY THERAPY SUPPLIES

AEROCHAMBER (QL= 1 device/365 days)

QL Tier 2

MIGRAINE PRODUCTS

CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG

UBRELVY TAB (QL= 10 tabs/30 days; ST requires trial of 2: naratriptan tab, rizatriptan tab, rizatriptan ODT, sumatriptan

tab)

QL-ST Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 128 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

MIGRAINE PRODUCTS Cont.

MIGRAINE COMBINATIONS

acetaminophen/isometheptene/dichloral cap (MIDRIN equiv)

- Tier 1

isometheptene/caffeine/acetaminophen tab (PRODRIN equiv)

- Tier 1

PRODRIN TAB

- Tier 1

ACETAMINOPHEN/ISOMETHEPTENE/DICHLORAL CAP

- Tier 2

ERGOTAMINE/CAFFEINE TAB (QL= 40 tabs/28 days)

QL Tier 2

ergotamine/caffeine tab (CAFERGOT equiv) (QL= 40 tabs/28 days)

QL Tier 2

ISOMETHEPTENE/CAFFEINE/ACETAMINOPHEN TAB

- Tier 2

MIGERGOT SUPP (QL= 20 supp/28 days)

QL Tier 2

sumatriptan/naproxen tab (TREXIMET equiv) (QL= 9 tabs/30 days; Step Therapy requires trial of 2: naratriptan, rizatriptan,

rizatriptan ODT, or sumatriptan)

QL-ST Tier 2

MIGRAINE PRODUCTS

dihydroergotamine mesylate inj (D.H.E. equiv) (QL= 24ml/28 days)

QL Tier 2

dihydroergotamine mesylate nasal spray (MIGRANAL equiv) (QL= 8ml/28 days; Step Therapy requires trial of 2:

naratriptan, rizatriptan, rizatriptan ODT, or sumatriptan)

QL-ST Tier 2

MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES

AIMOVIG INJ (QL= 1 pack/28 days)

PA-QL Tier 2

AJOVY INJ (QL= 1 inj/28 days)

PA-QL Tier 2

EMGALITY INJ (QL= 1 inj/28 days)

PA-QL Tier 2

MIGRAINE PRODUCTS - NSAIDS

diclofenac potassium (migraine) packet (CAMBIA equiv) (QL= 9 packets/30 days; ST req trial of 2 preferred oral NSAIDs

(eg. diclofenac) or triptans (eg. sumatriptan))

QL-ST Tier 2

SEROTONIN AGONISTS

naratriptan tab (AMERGE equiv) (QL= 9 tabs/30 days)

QL Tier 1

rizatriptan ODT (MAXALT equiv) (QL= 12 tabs/30 days)

QL Tier 1

rizatriptan tab (MAXALT equiv) (QL= 12 tabs/30 days)

QL Tier 1

sumatriptan nasal spray (IMITREX, SUMATRIPTAN equiv) (QL= 6 sprays/30 days; Step therapy requires trial of two:

naratriptan tab, rizatriptan tab, rizatriptan ODT, or sumatriptan tab)

QL-ST Tier 1

sumatriptan tab (IMITREX equiv) (QL= 9 tabs/30 days)

QL Tier 1

zolmitriptan tab (ZOMIG equiv) (QL= 9 tabs/30 days)

QL Tier 1

almotriptan tab (AXERT equiv) (QL= 12 tabs/30 days; Step Therapy requires 30 day trial of 2: naratriptan tab, rizatriptan

tab or sumatriptan tab)

QL-ST Tier 2

almotriptan tab (AXERT equiv) (QL= 9 tabs/30 days; Step Therapy requires 30 day trial of 2: naratriptan tab, rizatriptan

tab, or sumatriptan tab)

QL-ST Tier 2

eletriptan tab (RELPAX equiv) (QL= 9 tabs/30 days; Step Therapy requires trial of 2: naratriptan, rizatriptan, rizatriptan

ODT, or sumatriptan)

QL-ST Tier 2

frovatriptan tab (FROVA equiv) (QL= 10 tabs/30 days)

QL Tier 2

sumatriptan inj (IMITREX equiv) (QL= 8 inj/30 days)

QL Tier 2

SUMATRIPTAN INJ 6MG/0.5ML (QL= 8 inj/30 days)

QL Tier 2

sumatriptan vial inj (IMITREX equiv) (QL= 1 inj/7 days)

QL Tier 2

zolmitriptan nasal spray (ZOMIG equiv) (QL= 6 sprays/fill, 2 fills/30 days; Step Therapy requires trial of 2: sumatriptan tab,

naratriptan tab, rizatriptan tab or ODT)

QL-ST Tier 2

zolmitriptan ODT (ZOMIG equiv) (QL= 9 tabs/30 days)

QL Tier 2

MINERALS & ELECTROLYTES

FLUORIDE

FLUORABON SOLN (Covered at $0 for members 5 years or younger; All other members covered at preferred brand

copay)

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 129 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

MINERALS & ELECTROLYTES Cont.

sodium fluoride chew tab (LURIDE equiv) (Covered at $0 for members 5 years or younger; All other members covered at

generic copay)

Preventiv

sodium fluoride soln (LURIDE equiv) (Covered at $0 for members 5 years or younger; All other members covered at

generic copay)

Preventiv

SODIUM FLUORIDE TAB (Covered at $0 for members 5 years or younger; All other members covered at generic copay)

Preventiv

FLORIVA DROPS

- Tier 2

PHOSPHATE

potassium phosphate monobasic tab (K-PHOS equiv) (QL= 8 tabs/day)

QL Tier 1

POTASSIUM

K-TAB

- Tier 1

POT/CHLORIDE EFFER TAB

- Tier 1

potassium chloride effer tab (K-LYTE/CL equiv)

- Tier 1

potassium chloride ER cap (MICRO-K equiv)

- Tier 1

potassium chloride ER tab (K-TAB equiv)

- Tier 1

potassium chloride micro tab (K-DUR equiv)

- Tier 1

POTASSIUM CHLORIDE TAB ER

- Tier 1

potassium bicarbonate effer tab (K-LYTE equiv)

- Tier 2

potassium chloride powder packet (KLOR-CON equiv)

- Tier 2

potassium chloride soln

- Tier 2

SODIUM

sodium chloride inj

- Tier 1

MISCELLANEOUS THERAPEUTIC CLASSES

CHELATING AGENTS

penicillamine tab (DEPEN TITRATAB equiv) (QL= 480 tabs/30 days)

QL Tier 1

trientine cap 250mg (SYPRINE equiv) (ST req trial of generic penicillamine tab)

ST Tier 1

penicillamine cap (CUPRIMINE equiv)

- Tier 2

TRIENTINE CAP 500MG (ST req trial of generic penicillamine tab and then trial of gen trientine 250mg cap)

ST Tier 2

IMMUNOMODULATORS

lenalidomide cap (REVLIMID equiv) (QL= 1 cap/day; Only available through Onco360 877-662-6633)

LD-PA-QL

Tier 1

Specialty

IMMUNOSUPPRESSIVE AGENTS

azathioprine tab 100mg (QL= 30 tabs/30 days; Step therapy requires trial of azathioprine tab 50mg)

QL-ST Tier 2

azathioprine tab 75mg (QL= 30 tabs/30 days; Step therapy requires trial of azathioprine tab 50mg)

QL-ST Tier 2

everolimus tab (ZORTRESS equiv) (QL= 2 tabs/day)

QL Tier 2

MYHIBBIN SUSP

- Tier 2

sirolimus soln (RAPAMUNE equiv)

- Tier 2

POTASSIUM REMOVING AGENTS

LOKELMA PAK (QL= 1 pak/day; Step therapy requires trial of 1 diuretic: furosemide, bumetanide, torsemide, HCTZ,

metolazone, chlorthalidone)

QL-ST Tier 2

MOUTH/THROAT/DENTAL AGENTS

ANESTHETICS TOPICAL ORAL

lidocaine viscous soln 2% (LIDOCAINE HCL VISCOUS SOLN 2% equiv)

- Tier 1

LIDOCAINE ORAL SOLN 4%

- Tier 2

ANTI-INFECTIVES - THROAT

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 130 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

MOUTH/THROAT/DENTAL AGENTS Cont.

clotrimazole troches (MYCELEX TROCHES equiv)

- Tier 1

nystatin susp

- Tier 1

ANTISEPTICS - MOUTH/THROAT

chlorhexidine gluconate soln (PERIDEX equiv)

- Tier 1

DENTAL PRODUCTS

PREVIDENT 5000 PLUS CREAM (Covered at $0 for members 5 years or younger; All other members covered at preferred

brand copay)

Preventiv

sodium fluoride cream (PREVIDENT equiv) (Covered at $0 for members 5 years or younger; All other members covered at

generic copay)

Preventiv

FLUORIDEX SENSITIVITY PASTE

- Tier 1

sodium fluoride gel (PREVIDENT equiv)

- Tier 1

sodium fluoride paste (PREVIDENT equiv)

- Tier 1

sodium fluoride/potassium nitrate paste (PREVIDENT equiv)

- Tier 1

STEROIDS - MOUTH/THROAT

triamcinolone in orabase paste (KENALOG/ORABASE equiv)

- Tier 1

THROAT PRODUCTS - MISC.

cevimeline cap (EVOXAC equiv)

- Tier 1

pilocarpine tab (SALAGEN equiv)

- Tier 1

MULTIVITAMINS

B-COMPLEX W/ FOLIC ACID

DIALYVITE TAB

- Tier 1

DIALYVITE/ZINC TAB

- Tier 1

FOLBEE PLUS CZ TAB

- Tier 1

PED MV W/ FLUORIDE

FLORIVA PLUS DROPS

Preventiv

pediatric multiple vitamins/fluoride soln

Preventiv

TRI-VITAMIN FLUORIDE DROPS

Preventiv

PRENATAL VITAMINS

VP-PNV-DHA CAP

- Tier 1

CONCEPT DHA CAP

- Tier 2

PRENATABS RX TAB

- Tier 2

PRENATAL 19 CHEW TAB

- Tier 2

PRENATAL 19 TAB

- Tier 2

PRENATAL VITAMINS (PRENATAL PLUS, PREPLUS, PRENAPLUS)

- Tier 2

MUSCULOSKELETAL THERAPY AGENTS

CENTRAL MUSCLE RELAXANTS

baclofen tab (BACLOFEN equiv)

- Tier 1

carisoprodol tab (SOMA equiv) (QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine,

tizanidine, methocarbamol, or orphenadrine ER)

QL-ST Tier 1

chlorzoxazone tab (QL= 4 tabs/day)

QL Tier 1

chlorzoxazone tab 500mg

- Tier 1

cyclobenzaprine tab (FLEXERIL equiv)

- Tier 1

methocarbamol tab (ROBAXIN equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 131 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

MUSCULOSKELETAL THERAPY AGENTS Cont.

orphenadrine citrate ER tab (NORFLEX equiv)

- Tier 1

tizanidine tab (ZANAFLEX equiv)

- Tier 1

baclofen susp (BACLOFEN equiv) (QL= 16 ml/day; ST req trial of baclofen tabs and tizanidine caps/tabs (can be open or

crushed))

QL-ST Tier 2

BACLOFEN TAB 5MG

- Tier 2

chlorzoxazone tab (QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine, tizanidine,

methocarbamol, or orphenadrine ER)

QL-ST Tier 2

chlorzoxazone tab 375mg (QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine,

tizanidine, methocarbamol, or orphenadrine ER)

QL-ST Tier 2

cyclobenzaprine ER cap (AMRIX equiv) (QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, methocarbamol, or orphenadrine ER)

QL-ST Tier 2

cyclobenzaprine tab 7.5mg (Trial of 2: cyclobenzaprine 5mg, cyclobenzaprine 10mg, tizanidine, methocarbamol, baclofen,

chlorzoxazone, orphenadrine)

ST Tier 2

metaxalone tab (SKELAXIN equiv)

- Tier 2

tizanidine cap (ZANAFLEX equiv)

- Tier 2

DIRECT MUSCLE RELAXANTS

dantrolene cap (DANTRIUM equiv) (QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, tizanidine, methocarbamol, or orphenadrine ER)

QL-ST Tier 2

MUSCLE RELAXANT COMBINATIONS

CARISOPRODOL/ASPIRIN TAB

- Tier 1

carisoprodol/aspirin tab (SOMA COMPOUND equiv)

- Tier 1

CARISOPRODOL/ASPIRIN/CODEINE TAB

- Tier 1

carisoprodol/aspirin/codeine tab (SOMA COMPOUND/CODEINE equiv)

- Tier 1

orphenadrine/aspirin/caffeine tab (NORGESIC FORTE equiv) (QL= 4 tabs/day; Step therapy requires trial of 2: baclofen

tab, tizanidine tab/cap, cyclobenzaprine tab, methocarbamol tab, carisoprodol tab, orphenadrine tab)

QL-ST Tier 2

NASAL AGENTS - SYSTEMIC AND TOPICAL

NASAL ANTIALLERGY

olopatadine nasal spray (PATANASE equiv) (QL= 30.5ml/30 days)

QL Tier 2

NASAL ANTICHOLINERGICS

ipratropium nasal spray (ATROVENT equiv)

- Tier 1

SYMPATHOMIMETIC DECONGESTANTS

pseudoephedrine ER tab 120mg (QL= 2 tabs/day)

QL Tier 1

pseudoephedrine liquid 15mg/5ml (QL= 2400ml/30 days)

QL Tier 1

pseudoephedrine tab 30mg (QL= 8 tabs/day)

QL Tier 1

pseudoephedrine tab 60mg (QL= 4 tabs/day)

QL Tier 1

epinephrine hcl nasal soln (ADRENALIN equiv)

- Tier 2

zephrex-d tab 30mg (QL= 240 tabs/30 days)

QL Tier 2

NEUROMUSCULAR AGENTS

ALS AGENTS

riluzole tab (RILUTEK equiv)

AMSP

Tier 1

Specialty

EXSERVAN FILM (QL= 60 films/30 days; Only available through PantherRx Pharmacy 855-726-8479)

LD-PA-QL

Tier 2

Specialty

RADICAVA ORS SUSP (QL= 70ml/28 days; Only available through Accredo 800-803-2523)

LD-PA-QL

Tier 2

Specialty

TIGLUTIK SUSP (Only available through AnovoRx 844-288-5007)

LD-PA

Tier 2

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 132 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

OPHTHALMIC AGENTS

BETA-BLOCKERS - OPHTHALMIC

betaxolol ophth soln (BETOPTIC-S equiv)

- Tier 1

CARTEOLOL OPHTH SOLN

- Tier 1

carteolol ophth soln (OCUPRESS equiv)

- Tier 1

dorzolamide/timolol (pf) ophth soln (Step Therapy requires trial of dorzolamide/timolol ophth soln)

ST Tier 1

dorzolamide/timolol ophth soln (COSOPT equiv)

- Tier 1

LEVOBUNOLOL OPHTH SOLN

- Tier 1

levobunolol ophth soln (BETAGAN equiv)

- Tier 1

brimonidine tartrate-timolol maleate ophth soln (COMBIGAN equiv) (QL= 5ml/25 days; Step Therapy requires trial of 2:

brimonidine 0.2%, dorzolamide/timolol, carteolol, levobunolol, timolol maleate)

QL-ST Tier 2

DORZOLAMIDE/TIMOLOL OPHTH SOLN

- Tier 2

METIPRANOLOL OPHTH SOLN

- Tier 2

timolol maleate (pf) ophth soln 0.5% (TIMOPTIC equiv) (QL= 2ml/day)

QL Tier 2

timolol maleate ophth gel (TIMOPTIC-XE equiv) (Step Therapy requires trial of timolol maleate ophth soln)

ST Tier 2

timolol maleate ophth soln 0.5% (ISTALOL equiv) (Step Therapy requires trial of timolol maleate ophth soln)

ST Tier 2

timolol maleate preservative free ophth soln (TIMOPTIC equiv) (QL= 2ml/day)

QL Tier 2

timolol maleate ophth soln 0.25% (TIMOPTIC equiv)

- Value

timolol maleate ophth soln 0.5% (TIMOPTIC equiv)

- Value

CHOLINERGIC AGONISTS

TYRVAYA SOLN (QL= 8.4ml/30 days; Step therapy requires trial of cyclosporine 0.05% ophth emulsion (generic

Restasis))

QL-ST Tier 2

CYCLOPLEGIC MYDRIATICS

atropine ophth oint

- Tier 1

atropine ophth soln (ISOPTO ATROPINE equiv) (QL= 1 bottle/30 days)

QL Tier 1

cyclopentolate ophth soln (CYCLOGYL equiv)

- Tier 1

phenylephrine ophth soln (MYDFRIN equiv)

- Tier 1

tropicamide ophth soln (MYDRIACYL equiv)

- Tier 1

HOMATROPINE OPHTH SOLN

- Tier 2

MIOTICS

pilocarpine ophth soln (ISOPTO CARPINE equiv)

- Tier 1

OPHTHALMIC ADRENERGIC AGENTS

brimonidine ophth soln 0.2% (ALPHAGAN equiv)

- Tier 1

apraclonidine ophth soln 0.5% (IOPIDINE equiv)

- Tier 2

brimonidine ophth soln 0.15% (ALPHAGAN P 0.15% equiv) (Step Therapy requires trial of brimonidine ophth soln 0.2%)

ST Tier 2

brimonidine tartrate ophth soln 0.1% (ALPHAGAN P equiv) (Step Therapy requires trial of brimonidine ophth soln 0.2%)

ST Tier 2

OPHTHALMIC ANTI-INFECTIVES

bacitracin/neomycin/polymyxin b ophth oint (NEOSPORIN equiv)

- Tier 1

bacitracin/polymyxin b ophth oint (POLYSPORIN equiv)

- Tier 1

ciprofloxacin ophth soln (CILOXAN equiv)

- Tier 1

erythromycin ophth oint

- Tier 1

GENTAK OPHTH OINT

- Tier 1

gentamicin ophth soln (GARAMYCIN equiv)

- Tier 1

levofloxacin ophth soln (QUIXIN equiv)

- Tier 1

moxifloxacin ophth soln (VIGAMOX OPHTH SOLN equiv)

- Tier 1

NEOMYCIN/POLYMIXIN/GRAMICIDIN OPHTH SOLN

- Tier 1

ofloxacin ophth soln (OCUFLOX equiv)

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 133 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

OPHTHALMIC AGENTS Cont.

polymyxin b/trimethoprim ophth soln (POLYTRIM equiv)

- Tier 1

sulfacetamide sodium ophth soln (BLEPH-10 equiv)

- Tier 1

tobramycin ophth soln (TOBREX equiv)

- Tier 1

TRIFLURIDINE OPHTH SOLN

- Tier 1

BACITRACIN OPHTH OINT

- Tier 2

gatifloxacin ophth soln (ZYMAXID equiv)

- Tier 2

NATACYN OPHTH SUSP (QL= 45ml/30 days)

QL Tier 2

SULFACETAMIDE SODIUM OPHTH OINT

- Tier 2

ZIRGAN OPHTH GEL

- Tier 2

XDEMVY DROP (QL= 10 units/42 days; Only available through CVS Specialty 800-238-7828 or Walgreens 888-347-3416;

Claim requires DX of Demodex blepharitis (acariasis or unspecified blepharitis))

LD-QL-RDX

Tier 2

Specialty

OPHTHALMIC IMMUNOMODULATORS

cyclosporine ophth emulsion (RESTASIS equiv) (QL= 60 vials/30 days)

QL Tier 1

OPHTHALMIC LOCAL ANESTHETICS

proparacaine ophth soln (ALCAINE equiv)

- Tier 1

tetracaine ophth soln

- Tier 1

OPHTHALMIC STEROIDS

bacitracin/polymyxin/neomycin/hydrocortisone ophth oint (CORTISPORIN equiv)

- Tier 1

fluorometholone ophth soln (FML LIQUIFILM equiv)

- Tier 1

loteprednol ophth susp (LOTEMAX equiv)

- Tier 1

neomycin/polymyxin/dexamethasone ophth oint (MAXITROL equiv)

- Tier 1

neomycin/polymyxin/dexamethasone ophth soln (MAXITROL equiv)

- Tier 1

PREDNISOLONE OPHTH SUSP

- Tier 1

PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN

- Tier 1

sulfacetamide sodium/prednisolone ophth soln (VASOCIDIN equiv)

- Tier 1

tobramycin/dexamethasone ophth soln (TOBRADEX equiv)

- Tier 1

BLEPHAMIDE OPHTH SOLN

- Tier 2

difluprednate ophth emulsion (DUREZOL equiv) (QL= 10ml/28 days; Step Therapy requires trial of prednisolone acetate

1% ophth susp)

QL-ST Tier 2

FLAREX OPHTH SUSP

- Tier 2

LOTEMAX OPHTH OINT 0.5% (Step therapy requires trial of two: prednisolone susp/soln 1%, dexameth soln 0.1%, or

fluorometh susp 0.1%)

ST Tier 2

LOTEMAX SM GEL

- Tier 2

loteprednol etabonate ophth gel (LOTEMAX equiv) (QL= 5g/28 days; Step therapy requires trial of two: prednisolone 1%,

dexameth soln 0.1%, or fluorometh susp 0.1%)

QL-ST Tier 2

loteprednol etabonate ophth susp 0.2% (ALREX equiv) (QL= 5ml/30 days; Step therapy requires trial of two: prednisolone

1%, dexameth soln 0.1%, or fluorometh susp 0.1%)

QL-ST Tier 2

MAXIDEX OPHTH SOLN

- Tier 2

NEOMYCIN/POLYMYXIN/HYDROCORTISONE OPHTH SOLN

- Tier 2

PRED MILD OPHTH SOLN

- Tier 2

PRED-G OPHTH SOLN

- Tier 2

TOBRADEX OPHTH OINT

- Tier 2

ZYLET OPHTH SUSP

- Tier 2

OPHTHALMICS - MISC.

azelastine ophth soln (OPTIVAR equiv)

- Tier 1

cromolyn ophth soln (CROLOM equiv)

- Tier 1

CROMOLYN SODIUM OPHTH SOLN

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 134 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

OPHTHALMIC AGENTS Cont.

diclofenac sodium ophth soln (VOLTAREN equiv)

- Tier 1

dorzolamide ophth soln (TRUSOPT equiv)

- Tier 1

ketorolac ophth soln .05% (ACULAR (LS) equiv)

- Tier 1

ACULAR (LS) OPHTH SOLN

- Tier 2

ACUVAIL OPHTH SOLN

- Tier 2

ALOCRIL OPHTH SOLN

- Tier 2

bepotastine besilate ophth soln (BEPREVE equiv) (QL= 5mL/25 days; Step Therapy requires trial of azelastine 0.05%

ophth soln)

QL-ST Tier 2

brinzolamide ophth susp (AZOPT equiv) (Step Therapy requires trial of dorzolamide 2% ophth soln)

ST Tier 2

bromfenac ophth soln (BROMDAY equiv) (Step Therapy requires trial of diclofenac sodium ophth soln or ketorolac ophth

soln)

ST Tier 2

bromfenac sodium ophth soln 0.07% (PROLENSA equiv) (QL= 3ml./30 days; Step Therapy requires trial of diclofenac

sodium ophth soln or ketorolac ophth soln)

QL-ST Tier 2

epinastine ophth soln (ELESTAT equiv) (QL= 5mL/25 days; Step Therapy requires trial of azelastine 0.05% ophth soln)

QL-ST Tier 2

FLURBIPROFEN OPHTH SOLN (Step Therapy requires trial of diclofenac sodium ophth soln or ketorolac ophth soln)

ST Tier 2

ketorolac ophth soln .4% (ACULAR (LS) equiv)

- Tier 2

ZERVIATE OPHTH SOLN (QL= 30 single use containers/30 days)

QL Tier 2

CYSTARAN OPHTH SOLN (QL= 4 bottles/28 days; Diagnosis Restricted – Cystinosis (E72.04); Only available through

Walgreens 888-347-3416)

LD-QL-RDX

Tier 2

Specialty

PROSTAGLANDINS - OPHTHALMIC

tafluprost preservative free (pf) ophth soln (ZIOPTAN equiv) (QL= 30 pouches/30 days; Step Therapy requires trial of

latanoprost ophth soln)

QL-ST Tier 1

travoprost ophth soln (TRAVATAN Z equiv) (QL= 1 bottle/fill, 1 fill/month; Step Therapy requires trial of latanoprost ophth

soln)

QL-ST Tier 1

bimatoprost ophth soln (QL= 2.5ml/25 days; Step Therapy requires trial of latanoprost ophth soln)

QL-ST Tier 2

IYUZEH OPHTH DROPS (QL= 30 single use containers/30 days; Step therapy requires trial of latanoprost ophth soln)

QL-ST Tier 2

latanoprost ophth soln (XALATAN equiv)

- Value

OTIC AGENTS

OTIC AGENTS - MISCELLANEOUS

acetic acid otic soln (VOSOL equiv)

- Tier 1

ACETIC ACID/ALUMINUM ACETATE OTIC SOLN

- Tier 1

OTIC ANTI-INFECTIVES

ofloxacin otic soln (FLOXIN equiv)

- Tier 1

CIPROFLOXACIN OTIC SOLN

- Tier 2

OTIC COMBINATIONS

antipyrine/benzocaine otic soln (AURALGAN equiv)

- Tier 1

ciporofloxacin/dexamethasone otic susp (CIPRODEX equiv)

- Tier 1

neomycin/polymixin/hydrocoritisone otic soln (CORTISPORIN equiv)

- Tier 1

neomycin/polymixin/hydrocoritisone otic susp (CORTISPORIN equiv)

- Tier 1

otomax-HC otic soln (CORTANE-B equiv)

- Tier 1

OTIC STEROIDS

fluocinolone otic oil (DERMOTIC equiv)

- Tier 1

OXYTOCICS

methylergonovine tab (METHERGINE equiv)

- Tier 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 135 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

PASSIVE IMMUNIZING AND TREATMENT AGENTS Cont.

IMMUNE SERUMS

HYPERRAB INJ, IMOGAM INJ

- Tier 2

MONOCLONAL ANTIBODIES

SYNAGIS INJ (QL= 2 inj/28 days)

LMSP-PA-QL

Tier 2

Specialty

PENICILLINS

AMINOPENICILLINS

amoxicillin cap (TRIMOX equiv)

- Tier 1

amoxicillin chew tab (AMOXIL equiv)

- Tier 1

AMOXICILLIN CHEW TAB 250MG

- Tier 1

amoxicillin susp (TRIMOX equiv)

- Tier 1

amoxicillin tab (AMOXIL equiv)

- Tier 1

ampicillin cap (AMPICILLIN equiv)

- Tier 1

NATURAL PENICILLINS

penicillin vk tab (VEETIDS equiv)

- Tier 1

PENICILLIN COMBINATIONS

amoxicillin/clavulanate susp (AUGMENTIN ES equiv)

- Tier 1

amoxicillin/clavulanate tab (AUGMENTIN equiv)

- Tier 1

PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin cap (DYNAPEN equiv)

- Tier 1

PHARMACEUTICAL ADJUVANTS

SEMI SOLID VEHICLES

POLYETHYLENE GLYCOL 8000 GRANULES

- Tier 2

PROGESTINS

medroxyprogesterone tab (PROVERA equiv)

- Tier 1

megestrol ES susp (MEGACE ES equiv)

- Tier 1

MEGESTROL SUSP

- Tier 1

norethindrone tab (AYGESTIN equiv)

- Tier 1

progesterone cap (PROMETRIUM equiv)

- Tier 1

progesterone oil inj

- Tier 1

hydroxyprogesterone caproate inj (MAKENA equiv) (QL= 4 vials/28 days)

AMSP-PA-QL

Tier 2

Specialty

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

AGENTS FOR CHEMICAL DEPENDENCY

acamprosate calcium DR tab (CAMPRAL equiv)

- Tier 1

disulfiram tab (ANTABUSE equiv)

- Tier 1

ANTIDEMENTIA AGENTS

donepezil ODT (ARICEPT equiv)

- Tier 1

donepezil tab 10mg (ARICEPT equiv) (QL= 1 tab/day)

QL Tier 1

donepezil tab 23mg (ARICEPT equiv) (QL= 1 tab/day)

QL Tier 1

donepezil tab 5mg (ARICEPT equiv) (QL= 1 tab/day)

QL Tier 1

galantamine ER cap (RAZADYNE ER equiv) (QL= 1 cap/day)

QL Tier 1

GALANTAMINE SOLN

- Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 136 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Cont.

galantamine tab (RAZADYNE equiv) (QL= 60 tabs/30 days)

QL Tier 1

memantine ER cap (NAMENDA XR equiv) (QL= 1 cap/day; Step Therapy requires trial of memantine tab)

QL-ST Tier 1

memantine tab (NAMENDA equiv)

- Tier 1

memantine titrapak (NAMENDA equiv) (QL= 49 tabs/28 days)

QL Tier 1

rivastigmine cap (EXELON equiv)

- Tier 1

memantine soln (NAMENDA equiv) (QL= 300 ml/30 days)

QL Tier 2

NAMENDA XR TITRATION PACK (QL= 28 caps/28 days; Step Therapy requires trial of memantine tab)

QL-ST Tier 2

NAMZARIC CAP (QL= 1 cap/day; Step Therapy requires trial of 2: donepezil, donepezil ODT, memantine, or memantin er)

QL-ST Tier 2

rivastigmine patch (EXELON equiv) (QL= 1 patch/day)

QL Tier 2

COMBINATION PSYCHOTHERAPEUTICS

PERPHENAZINE/ AMITRIPTYLINE TAB

- Tier 1

CHLORDIAZEPOXIDE/AMITRIPTYLINE TAB

- Tier 2

olanzapine/fluoxetine cap (SYMBYAX equiv) (QL= 1 cap/day)

QL Tier 2

MOVEMENT DISORDER DRUG THERAPY

tetrabenazine tab (XENAZINE equiv)

AMSP-PA

Tier 1

Specialty

AUSTEDO TAB 12MG (QL= 120 tabs/30 days)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO TAB 6MG (QL= 30 tabs/30 days)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO TAB 9MG (QL= 30 tabs/30 days)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 12MG (QL= 90 tabs/30 days)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 18MG (QL= 2 tabs/day)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 24MG (QL= 60 tabs/30 days)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 30MG (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 36MG (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 42MG (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 48MG (QL= 1 tab/day)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB 6MG (QL= 210 tabs/30 days)

AMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB TITRATION KIT (QL= 42 tabs/28 days)

LMSP-PA-QL

Tier 2

Specialty

AUSTEDO XR TAB TITRATION PACK (QL= 28 tabs/28 days)

AMSP-PA-QL

Tier 2

Specialty

INGREZZA CAP (QL= 1 cap/day; Only available through PantherRx Pharmacy 855-726-8479)

LD-PA-QL

Tier 2

Specialty

INGREZZA PACK 40-80MG (QL= 1 pack/28 days; Only available through PantherRx Pharmacy 855-726-8479)

LD-PA-QL

Tier 2

Specialty

MULTIPLE SCLEROSIS AGENTS

dalfampridine ER tab (AMPYRA equiv)

AMSP-PA

Tier 1

Specialty

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 137 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Cont.

dimethyl fumarate DR cap (TECFIDERA equiv) (QL= 60 caps/30 days)

AMSP-QL

Tier 1

Specialty

dimethyl fumarate DR starter pack (TECFIDERA STARTER PACK equiv) (QL= 60 caps/30 days)

AMSP-QL

Tier 1

Specialty

fingolimod hcl cap (GILENYA equiv) (QL= 30 caps/30 days)

AMSP-QL

Tier 1

Specialty

glatiramer inj 20mg/ml (COPAXONE equiv) (QL= 30 syringes/30 days)

AMSP-QL

Tier 1

Specialty

glatiramer inj 40mg/ml (COPAXONE equiv) (QL= 12 syringes/28 days)

AMSP-QL

Tier 1

Specialty

teriflunomide tab (AUBAGIO equiv) (QL= 30 tabs/30 days)

AMSP-QL

Tier 1

Specialty

AVONEX INJ (QL= 1 kit/28 days; Step therapy requires trial of dimethyl fumarate, fingolimod, teriflunomide, or glatiramer)

AMSP-QL-ST

Tier 2

Specialty

VUMERITY CAP (QL= 120 caps/30 days; Step therapy requires trial of dimethyl fumarate, fingolimod, teriflunomide, or

glatiramer)

AMSP-QL-ST

Tier 2

Specialty

POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS

gabapentin (once-daily) tab (GRALISE equiv) (QL= 2 tabs/day)

PA-QL Tier 2

pregabalin ER tab (LYRICA equiv) (QL= 30 tabs/30 days; Step Therapy requires trial of gabapentin and pregabalin cap or

pregabalin soln)

QL-ST Tier 2

PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS

FLUOXETINE TAB

- Tier 2

FLUOXETINE CAP (PMDD)

- Value

PSEUDOBULBAR AFFECT (PBA) AGENTS

NUEDEXTA CAP (QL= 2 caps/day; Step therapy requires trial of 1 SSRI AND 1 TCA)

QL-ST Tier 2

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

PIMOZIDE TAB

- Tier 2

SMOKING DETERRENTS

bupropion SR tab (ZYBAN equiv) (Limited to 180 days/plan year)

QL-SMKG

Preventiv

CHANTIX PAK (Limited to 180 days/plan year)

QL-SMKG

Preventiv

CHANTIX TAB (Limited to 180 days/plan year)

QL-SMKG

Preventiv

NICODERM PATCH (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

NICORETTE GUM (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

NICORETTE LOZENGE (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

nicotine gum (NICORETTE equiv) (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

NICOTINE KIT (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

nicotine lozenge (COMMIT equiv) (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

nicotine patch (NICODERM equiv) (Limited to 180 days/plan year)

OTC-QL-SMKG

Preventiv

NICOTROL INHALER (Limited to 180 days/plan year)

QL-SMKG

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 138 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Cont.

NICOTROL NASAL SPRAY (Limited to 180 days/plan year)

QL-SMKG

Preventiv

varenicline tartrate tab (CHANTIX equiv) (Limited to 180 days/plan year)

QL-SMKG

Preventiv

varenicline tartrate tab start pack (VARENICLINE equiv) (Limited to 180 days/plan year)

QL-SMKG

Preventiv

ZYBAN TAB (Limited to 180 days/plan year)

QL-SMKG

Preventiv

VASOMOTOR SYMPTOM AGENTS

paroxetine cap (BRISDELLE equiv) (QL= 1 cap/day)

QL Tier 2

RESPIRATORY AGENTS - MISC.

CYSTIC FIBROSIS AGENTS

KALYDECO PAK (QL= 2 packets/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

KALYDECO TAB (QL= 2 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

ORKAMBI GRANULES PACKET (QL= 2 packets/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

ORKAMBI TAB (QL= 4 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

PULMOZYME INH SOLN (QL= 30 ampules/30 days)

AMSP-QL-RDX

Tier 2

Specialty

SYMDEKO TAB (QL= 2 tabs/day; Only available through Walgreens 888-347-3416)

LD-PA-QL

Tier 2

Specialty

PULMONARY FIBROSIS AGENTS

pirfenidone cap (ESBRIET equiv) (QL= 3 caps/day)

AMSP-PA-QL-SF

Tier 1

Specialty

pirfenidone tab 267mg (ESBRIET equiv) (QL= 9 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

PIRFENIDONE TAB 534MG (QL= 4 tabs/day; Only available through Lumicera 855-847-3553)

LD-PA-QL-SF

Tier 1

Specialty

pirfenidone tab 801mg (ESBRIET equiv) (QL= 3 tabs/day)

AMSP-PA-QL-SF

Tier 1

Specialty

OFEV CAP (QL= 2 caps/day; Only available through Accredo 800-803-2523 or Walgreens 888-347-3416)

LD-PA-QL-SF

Tier 2

Specialty

SULFONAMIDES

sulfadiazine tab (SULFADIAZINE equiv) (QL= 8 tabs/day)

QL Tier 1

SULFADIAZINE TAB (QL= 8 tabs/day)

QL Tier 2

TETRACYCLINES

TETRACYCLINE COMBINATIONS

NICAZELDOXY KIT

- Tier 2

TETRACYCLINES

demeclocycline tab (DECLOMYCIN equiv)

- Tier 1

doxycycline hyclate cap (QL= 2 caps/day)

QL Tier 1

doxycycline hyclate cap 50mg (VIBRAMYCIN equiv) (QL= 2 caps/day)

QL Tier 1

doxycycline hyclate DR tab 100mg (DORYX equiv) (QL= 2 tabs/day; Step Therapy requires trial of doxycycline

monohydrate)

QL-ST Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 139 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

TETRACYCLINES Cont.

doxycycline hyclate tab (VIBRATAB equiv) (QL= 2 tabs/day)

QL Tier 1

doxycycline monohydrate cap 50mg (MONODOX equiv) (QL= 2 caps/day)

QL Tier 1

doxycycline monohydrate tab (ADOXA equiv) (QL= 2 tabs/day)

QL Tier 1

doxycycline susp (VIBRAMYCIN equiv)

- Tier 1

minocycline cap (MINOCIN equiv)

- Tier 1

tetracycline cap

- Tier 1

doxycycline hyclate DR tab (DORYX equiv) (QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate)

QL-ST Tier 2

doxycycline hyclate DR tab 200mg (DORYX equiv) (QL= 1 tab/day; Step Therapy requires trial of doxycycline

monohydrate)

QL-ST Tier 2

doxycycline hyclate DR tab 50mg (DORYX equiv) (QL= 2 tabs/day; Step Therapy requires trial of doxycycline

monohydrate)

QL-ST Tier 2

doxycycline hyclate DR tab 75mg (QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate)

QL-ST Tier 2

doxycycline hyclate tab 150mg (TARGADOX equiv) (QL= 2 tabs/day; Step therapy requires trial of doxycycline

monohydrate tablets)

QL-ST Tier 2

doxycycline hyclate tab 50mg (TARGADOX equiv) (Step Therapy requires trial of doxycycline monohydrate)

ST Tier 2

doxycycline hyclate tab 75mg (TARGADOX equiv) (QL= 2 tabs/day; Step therapy requires trial of doxycycline

monohydrate tablets)

QL-ST Tier 2

doxycycline monohydrate cap (MONODOX equiv) (QL= 2 caps/day)

QL Tier 2

doxycycline monohydrate cap 100mg (MONODOX equiv) (QL= 2 caps/day)

QL Tier 2

doxycycline monohydrate tab 150mg (ADOXA PAK equiv) (QL= 2 tabs/day; Step therapy requires trial of doxycycline

monohydrate 50mg or 100mg tablets)

QL-ST Tier 2

minocycline ER tab (SOLODYN equiv) (QL= 1 tab/day; Step Therapy requires trial of minocycline cap or minocycline tab)

QL-ST Tier 2

minocycline tab (DYNACIN equiv)

- Tier 2

THYROID AGENTS

ANTITHYROID AGENTS

methimazole tab (TAPAZOLE equiv)

- Tier 1

propylthiouracil tab

- Tier 1

THYROID HORMONES

levothyroxine tab (SYNTHROID equiv)

- Tier 1

liothyronine tab (CYTOMEL equiv)

- Tier 1

TOXOIDS

TOXOID COMBINATIONS

ADACEL/BOOSTRIX INJ

VAC

Preventiv

INFANRIX INJ

VAC

Preventiv

TETANUS/DIPHTHERIA TOXOID INJ

VAC

Preventiv

VAXELIS INJ

VAC

Preventiv

ULCER DRUGS

ANTISPASMODICS

chlordiazepoxide/clidinium cap (LIBRAX equiv)

- Tier 1

dicyclomine cap (BENTYL equiv)

- Tier 1

dicyclomine soln (BENTYL equiv)

- Tier 1

dicyclomine tab (BENTYL equiv)

- Tier 1

glycopyrrolate oral soln (CUVPOSA equiv) (QL= 9ml/day)

QL Tier 1

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 140 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

ULCER DRUGS Cont.

glycopyrrolate tab (ROBINUL equiv)

- Tier 1

methscopolamine tab (PAMINE equiv)

- Tier 1

b-donna tab (DONNATAL equiv) (QL= 8 tabs/day)

QL Tier 2

BELLADONNA ALKALOID/OPIUM SUPP

- Tier 2

pb-belladonna elixir (DONNATAL equiv) (QL= 1200ml/30 days)

QL Tier 2

PROPANTHELINE TAB

- Tier 2

H-2 ANTAGONISTS

cimetidine soln (CIMETIDINE equiv)

- Tier 1

cimetidine tab (TAGAMET equiv)

- Tier 1

nizatidine cap (AXID equiv)

- Tier 1

ranitidine cap (ZANTAC equiv)

- Tier 1

ranitidine syrup (ZANTAC equiv)

- Tier 1

ranitidine tab (Rx Only) (ZANTAC equiv)

- Tier 1

MISC. ANTI-ULCER

sucralfate tab (CARAFATE equiv)

- Tier 1

ULCER DRUGS - PROSTAGLANDINS

misoprostol tab (CYTOTEC equiv)

Preventiv

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

H-2 ANTAGONISTS

NIZATIDINE CAP

- Tier 2

MISC. ANTI-ULCER

sucralfate susp (CARAFATE equiv)

- Tier 1

PROTON PUMP INHIBITORS

dexlansoprazole DR cap (DEXILANT equiv) (Covered for members age 17 or younger; QL=1 cap/day; Step therapy

requires trial of all: omeprazole, esomeprazole, lansoprazole cap, rabeprazole, and pantoprazole tab)

QL-ST Tier 2

ULCER THERAPY COMBINATIONS

bismuth/metro/tetra cap (PYLERA equiv) (Step therapy requires trial of oral metronidazole and tetracycline)

ST Tier 2

URINARY ANTISPASMODICS

URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLIN) (NEW)

trospium chloride SR cap (SANCTURA XR equiv)

- Tier 2

URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)

oxybutynin ER tab (DITROPAN XL equiv)

- Tier 1

oxybutynin syrup

- Tier 1

oxybutynin tab (DITROPAN equiv)

- Tier 1

solifenacin tab (VESICARE equiv) (QL= 1 tab/day)

QL Tier 1

darifenacin SR tab (ENABLEX equiv) (Step Therapy requires trial of 2: oxybutynin, oxybutynin ER, tolterodine, tolterodine

ER, trospium, or trospium ER)

ST Tier 2

fesoterodine fumarate er tab (TOVIAZ equiv) (QL= 1 tab/day; Step therapy requires trial of 2: oxybutynin tab/syrup/ER

tab, tolterodine tab/SR cap, trospium tab/SR cap)

QL-ST Tier 2

tolterodine SR cap (DETROL LA equiv)

- Tier 2

tolterodine tab (DETROL equiv)

- Tier 2

trospium tab (SANCTURA equiv)

- Tier 2

URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 141 of 197

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Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

URINARY ANTISPASMODICS Cont.

mirabegron tab er (MYRBETRIQ equiv) (ST req trial 2: oxybutynin tab/syrup, oxybutynin ER tab, tolterodine tab/SR cap,

trospium tab/SR cap)

ST Tier 2

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS

bethanechol tab (URECHOLINE equiv)

- Tier 1

URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS (NEW)

flavoxate tab (URISPAS equiv) (QL= 8 tabs/day; Step therapy requires trial of oxybutynin chloride or solifenacin

succinate)

QL-ST Tier 2

VACCINES

BACTERIAL VACCINES

BEXSERO INJ

VAC

Preventiv

MENACTRA INJ

VAC

Preventiv

MENHIBRIX INJ

VAC

Preventiv

MENOMUNE INJ

VAC

Preventiv

MENQUADFI INJ

VAC

Preventiv

MENVEO INJ

VAC

Preventiv

MENVEO SOLN

VAC

Preventiv

PENBRAYA INJ (Covered for members age 10 through 25 years)

Preventiv

PNEUMOVAX INJ

VAC

Preventiv

PREVNAR 13 INJ

VAC

Preventiv

PREVNAR 20 INJ

VAC

Preventiv

TRUMENBA INJ

VAC

Preventiv

VAXCHORA SUSP

VAC

Preventiv

VAXNEUVANCE INJ

VAC

Preventiv

VIRAL VACCINES

ABRYSVO INJ (QL= 1 inj/fill, 1 fill/lifetime)

QL-VAC

Preventiv

ACAM2000 INJ

Preventiv

AFLURIA INJ (QL= 0.5ml/fill)

QL-VAC

Preventiv

AFLURIA INJ, FLUZONE INJ

VAC

Preventiv

AREXVY INJ (QL= 1 inj/day, 1 fill/lifetime; Covered for members 60 years of age and older)

QL-VAC

Preventiv

CERVARIX INJ

VAC

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 142 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

VACCINES Cont.

COMIRNATY INJ

VAC

Preventiv

COMIRNATY INJ 30MCG/0.3ML

VAC

Preventiv

COVID-19 VACCINE BIVALENT BOOSTER INJ (MODERNA) (QL=1 inj/fill)

Preventiv

COVID-19 VACCINE BIVALENT BOOSTER INJ (PFIZER) (QL= 1 inj/fill)

Preventiv

COVID-19 VACCINE BIVALENT BOOSTER INJ 5-11Y (PFIZER) (QL= 1 inj/fill)

Preventiv

COVID-19 VACCINE BIVALENT BOOSTER INJ 6M-4Y (PFIZER) (QL= 1 inj/fill)

Preventiv

COVID-19 VACCINE BIVALENT BOOSTER INJ 6M-5Y (MODERNA) (QL= 1 inj/fill)

Preventiv

COVID-19 VACCINE INJ (JANSSEN) (QL= 1 dose/45 days)

Preventiv

COVID-19 VACCINE INJ (NOVAVAX) (QL= 1 dose/17 days)

Preventiv

COVID-19 VACCINE INJ 5-11Y (PFIZER)

VAC

Preventiv

COVID-19 VACCINE INJ 6M-11Y (MODERNA)

VAC

Preventiv

COVID-19 VACCINE INJ 6M-4Y (PFIZER)

VAC

Preventiv

ENGERIX-B INJ, RECOMBIVAX-HB INJ

VAC

Preventiv

FLUAD INJ

VAC

Preventiv

FLUAD QUAD INJ

VAC

Preventiv

FLUBLOK INJ

VAC

Preventiv

FLUBLOK INJ (QL= 0.5ml/fill)

VAC-QL

Preventiv

FLUBLOK QUAD PF INJ

VAC

Preventiv

FLUCELVAX INJ (QL= 0.5ml/fill)

QL-VAC

Preventiv

FLUCELVAX QUAD INJ

VAC

Preventiv

FLULAVAL QUAD INJ, FLUZONE QUAD INJ

VAC

Preventiv

FLUMIST QUADRIVALENT NASAL SUSP

VAC

Preventiv

FLUVIRIN INJ

VAC

Preventiv

FLUZONE HD PF INJ

VAC

Preventiv

FLUZONE HIGH DOSE PF INJ

VAC

Preventiv

FLUZONE QUAD INJ

VAC

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 143 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

VACCINES Cont.

FLUZONE/FLUARIX QUAD INJ

VAC

Preventiv

GARDASIL 9 INJ

VAC

Preventiv

GARDASIL INJ

VAC

Preventiv

HAVRIX INJ, VAQTA INJ

VAC

Preventiv

HEPLISAV-B INJ

VAC

Preventiv

IPOL INJ

Preventiv

JYNNEOS INJ

Preventiv

M-M-R II INJ

VAC

Preventiv

PRIORIX INJ

VAC

Preventiv

PROQUAD INJ

Preventiv

SHINGRIX INJ (Covered for members age 18 or older)

VAC

Preventiv

SPIKEVAX INJ (QL= 1 dose/24 days)

Preventiv

SPIKEVAX INJ 50/0.5ML

VAC

Preventiv

SPIKEVAX INJ 50MCG/0.5ML

VAC

Preventiv

TWINRIX INJ

VAC

Preventiv

VARIVAX INJ

VAC

Preventiv

YF-VAX INJ

Preventiv

IMOVAX INJ

- Tier 2

RABAVERT INJ

VAC Tier 2

VAGINAL AND RELATED PRODUCTS

VAGINAL CONTRACEPTIVE - PH MODULATORS

PHEXXI GEL (QL= 180gm/30 days)

Preventiv

VAGINAL PRODUCTS

SPERMICIDES

CONTRACEPTIVE FILM

OTC

Preventiv

CONTRACEPTIVE FOAM

OTC

Preventiv

CONTRACEPTIVE GEL

OTC

Preventiv

CONTRACEPTIVE SUPP

OTC

Preventiv

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 144 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Category/Class

DrugName

Special Code Tier

VAGINAL PRODUCTS Cont.

TODAY SPONGE

OTC

Preventiv

VAGINAL ANTI-INFECTIVES

clindamycin vaginal cream (CLEOCIN equiv) (QL= 1 tube/fill)

QL Tier 1

terconazole cream (TERAZOL equiv)

- Tier 1

TERCONAZOLE CREAM 0.8%

- Tier 1

terconazole supp (TERAZOL equiv)

- Tier 1

AVC VAGINAL CREAM

- Tier 2

metronidazole vaginal gel (METROGEL equiv)

- Tier 2

NUVESSA VAGINAL GEL, VANDAZOLE GEL (QL= 1 package/30 days; Step therapy requires trial of metronidazole tab or

clindamycin cap/oral soln)

QL-ST Tier 2

VAGINAL ESTROGENS

estradiol vaginal tab, yuvafem vaginal tab (VAGIFEM equiv)

- Tier 1

estradiol cream (ESTRACE equiv)

- Tier 2

ESTRING (QL= 1 ring/90 days; 3 copays per Rx)

QL Tier 2

VAGINAL PROGESTINS

ENDOMETRIN INSERT

PA Tier 2

VASOPRESSORS

ANAPHYLAXIS THERAPY AGENTS

epinephrine inj (ADRENALIN equiv)

- Tier 1

EPINEPHRINE INJ 0.15MG (QL= 2 inj/fill)

QL Value

EPINEPHRINE INJ 0.3MG (QL= 2 inj/fill)

QL Value

epinephrine pen inj 0.15mg, 0.3mg (EPIPEN (JR) equiv) (QL= 2 inj/fill)

QL Value

SYMJEPI INJ (QL= 2 inj/fill)

QL Value

NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS

droxidopa cap (NORTHERA equiv)

AMSP

Tier 1

Specialty

VASOPRESSORS

midodrine tab (PROAMATINE equiv)

- Tier 1

epinephrine inj

- Tier 2

VITAMINS

OIL SOLUBLE VITAMINS

phytonadione tab (MEPHYTON equiv)

- Tier 1

vitamin D cap (RX strength only)

- Tier 1

WATER SOLUBLE VITAMINS

POTABA POWDER PACKET

- Tier 2

Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered.

NC =Not Covered generic =small letters BRANDS =CAPITAL LETTERS

AMSP Ardon Mandatory Specialty Pharmacy Program EXC Plan Exclusion LD Limited Distribution

LMSP Lumicera Mandatory Specialty Pharmacy Program M Medical Benefit OTC Over-the-Counter

PA Prior Authorization QL Quantity Limit RDX Restricted to Diagnosis

SF Limited to two 15 day fills per month for first 3 months SMKG Smoking Cessation ST Step Therapy

VAC Vaccine Program

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 145 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

abiraterone acetate tab 500mg Tier 1 Specialty

abiraterone tab 250mg Tier 1 Specialty

ACTHAR HP GEL INJ Tier 2 Specialty

ACTHAR INJ 80UNIT Tier 2 Specialty

ADALIMUMAB-ADAZ INJ 40MG/0.4ML Tier 2 Specialty

AIMOVIG INJ Tier 2

AJOVY INJ Tier 2

ALECENSA CAP Tier 2 Specialty

ALUNBRIG TAB 30MG Tier 2 Specialty

ALUNBRIG TAB 90MG, 180MG Tier 2 Specialty

ambrisentan tab Tier 1 Specialty

AUSTEDO TAB 12MG Tier 2 Specialty

AUSTEDO TAB 6MG Tier 2 Specialty

AUSTEDO TAB 9MG Tier 2 Specialty

AUSTEDO XR TAB 12MG Tier 2 Specialty

AUSTEDO XR TAB 18MG Tier 2 Specialty

AUSTEDO XR TAB 24MG Tier 2 Specialty

AUSTEDO XR TAB 30MG Tier 2 Specialty

AUSTEDO XR TAB 36MG Tier 2 Specialty

AUSTEDO XR TAB 42MG Tier 2 Specialty

AUSTEDO XR TAB 48MG Tier 2 Specialty

AUSTEDO XR TAB 6MG Tier 2 Specialty

AUSTEDO XR TAB TITRATION KIT Tier 2 Specialty

AUSTEDO XR TAB TITRATION PACK Tier 2 Specialty

BARACLUDE SOLN Tier 2 Specialty

BENEFIX INJ Tier 2 Specialty

betaine powder for oral solution Tier 1 Specialty

bexarotene cap Tier 1 Specialty

bexarotene gel Tier 1 Specialty

bosentan tab Tier 1 Specialty

BOSULIF CAP Tier 2 Specialty

BOSULIF TAB Tier 2 Specialty

CABOMETYX TAB Tier 2 Specialty

CALQUENCE CAP Tier 2 Specialty

CALQUENCE TAB Tier 2 Specialty

CAPRELSA TAB 100MG Tier 2 Specialty

CAPRELSA TAB 300MG Tier 2 Specialty

carglumic acid tab Tier 1 Specialty

CERDELGA CAP Tier 2 Specialty

COMETRIQ KIT Tier 2 Specialty

COSENTYX INJ (1-PACK) Tier 2 Specialty

COSENTYX INJ (2-PACK) Tier 2 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 146 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

COSENTYX INJ 300MG/2ML Tier 2 Specialty

COTELLIC TAB Tier 2 Specialty

DAKLINZA TAB Tier 2 Specialty

dalfampridine ER tab Tier 1 Specialty

deferasirox granules packet Tier 1 Specialty

deferasirox tab Tier 1 Specialty

deferasirox tab 90mg, 360mg Tier 1 Specialty

deferiprone tab Tier 1 Specialty

deferiprone tab 1000mg Tier 1 Specialty

deflazacort susp Tier 2 Specialty

deflazacort tab Tier 2 Specialty

DESCOVY TAB Tier 2

DEXCOM G6 RECEIVER Tier 1

DEXCOM G6 SENSOR Tier 1

DEXCOM G6 TRANSMITTER Tier 1

DEXCOM G7 RECEIVER Tier 1

DEXCOM G7 SENSOR Tier 1

dichlorphenamide tab Tier 1 Specialty

DOPTELET TAB Tier 2 Specialty

DUPIXENT INJ Tier 2 Specialty

DUPIXENT PEN INJ Tier 2 Specialty

EMGALITY INJ Tier 2

ENBREL INJ Tier 2 Specialty

ENBREL INJ 25MG Tier 2 Specialty

ENBREL INJ 50MG Tier 2 Specialty

ENBREL MINI INJ Tier 2 Specialty

ENBREL SURECLICK INJ 50MG Tier 2 Specialty

ENDOMETRIN INSERT Tier 2

EPIDIOLEX SOLN Tier 2 Specialty

ERIVEDGE CAP Tier 2 Specialty

ERLEADA TAB Tier 2 Specialty

ERLEADA TAB 240MG Tier 2 Specialty

erlotinib tab 100mg Tier 1 Specialty

erlotinib tab 150mg Tier 1 Specialty

erlotinib tab 25mg Tier 1 Specialty

everolimus tab Tier 1 Specialty

everolimus tab for oral susp Tier 1 Specialty

EXSERVAN FILM Tier 2 Specialty

fentanyl citrate lollipop Tier 2

fentanyl patch Tier 2

FREE LIBRE 3-PLUS SENSOR Tier 1

FREESTYLE LIBRE 2 RECEIVER Tier 1

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 147 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

FREESTYLE LIBRE 2 SENSOR Tier 1

FREESTYLE LIBRE 3 READER Tier 1

FREESTYLE LIBRE 3 SENSOR Tier 1

FREESTYLE LIBRE RECEIVER Tier 1

FREESTYLE LIBRE SENSOR (14-DAY) Tier 1

gabapentin (once-daily) tab Tier 2

gefitinib tab Tier 1 Specialty

GILOTRIF TAB Tier 2 Specialty

HADLIMA INJ 40MG/0.4ML Tier 2 Specialty

HADLIMA INJ 40MG/0.8ML Tier 2 Specialty

HADLIMA PUSH INJ 40MG/0.4ML Tier 2 Specialty

HADLIMA PUSH INJ 40MG/0.8ML Tier 2 Specialty

HAEGARDA INJ 2000U Tier 2 Specialty

HAEGARDA INJ 3000U Tier 2 Specialty

HYCAMTIN CAP Tier 2 Specialty

hydrocodone bitartrate ER cap Tier 2

hydrocodone bitartrate er tab Tier 2

hydromorphone ER tab 12mg Tier 2

hydromorphone ER tab 16mg Tier 2

hydromorphone ER tab 32mg Tier 2

hydromorphone ER tab 8mg Tier 2

HYDROXYPROGESTERONE CAPROATE INJ Tier 2 Specialty

icatibant inj Tier 1 Specialty

ICLUSIG TAB Tier 2 Specialty

imatinib tab 100mg Tier 1 Specialty

imatinib tab 400mg Tier 1 Specialty

IMBRUVICA CAP 140MG Tier 2 Specialty

IMBRUVICA CAP 70MG Tier 2 Specialty

IMBRUVICA SUSP Tier 2 Specialty

IMBRUVICA TAB Tier 2 Specialty

INGREZZA CAP Tier 2 Specialty

INGREZZA PACK 40-80MG Tier 2 Specialty

INLYTA TAB Tier 2 Specialty

ivabradine hcl tab Tier 1

JAKAFI TAB Tier 2 Specialty

JUXTAPID CAP Tier 2 Specialty

JYNARQUE PAK Tier 2 Specialty

JYNARQUE TAB 15MG Tier 2 Specialty

JYNARQUE TAB 30MG Tier 2 Specialty

KALYDECO PAK Tier 2 Specialty

KALYDECO TAB Tier 2 Specialty

KISQALI PAK Tier 2 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 148 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

KISQALI TAB Tier 2 Specialty

lapatinib ditosylate tab Tier 1 Specialty

lenalidomide cap Tier 1 Specialty

LENVIMA CAP Tier 2 Specialty

LEUPROLIDE INJ Tier 2 Specialty

LONSURF TAB Tier 2 Specialty

LUPRON DEPOT INJ Tier 2 Specialty

LUPRON DEPOT INJ PED Tier 2 Specialty

LUPRON DEPOT-PED INJ (1-MONTH) Tier 2 Specialty

LUPRON DEPOT-PED INJ (3-MONTH) Tier 2 Specialty

LYNPARZA CAP Tier 2 Specialty

LYNPARZA TAB Tier 2 Specialty

MEKINIST SOLN Tier 2 Specialty

MEKINIST TAB 0.5MG Tier 2 Specialty

MEKINIST TAB 2MG Tier 2 Specialty

methadose tab Tier 1

methyltestosterone cap Tier 2

metyrosine cap Tier 2

mifepristone tab Tier 1 Specialty

miglustat cap Tier 1 Specialty

morphine sulfate ER cap 100mg Tier 1

morphine sulfate ER cap 10mg Tier 2

morphine sulfate ER cap 20mg Tier 2

morphine sulfate ER cap 30mg Tier 1

morphine sulfate ER cap 50mg Tier 2

morphine sulfate ER cap 60mg Tier 2

morphine sulfate ER cap 80mg Tier 2

morphine sulfate ER tab Tier 1

MOVANTIK TAB Tier 2

nilutamide tab Tier 1 Specialty

NINLARO CAP Tier 2 Specialty

nitisinone cap Tier 1 Specialty

NUBEQA TAB Tier 2 Specialty

NUCALA INJ Tier 2 Specialty

octreotide inj Tier 1 Specialty

OCTREOTIDE INJ 100MCG Tier 1 Specialty

ODOMZO CAP Tier 2 Specialty

OFEV CAP Tier 2 Specialty

OLYSIO CAP Tier 2 Specialty

OPSUMIT TAB Tier 2 Specialty

ORENITRAM TAB Tier 2 Specialty

ORKAMBI GRANULES PACKET Tier 2 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 149 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

ORKAMBI TAB Tier 2 Specialty

OTEZLA STARTER PACK Tier 2 Specialty

OTEZLA TAB Tier 2 Specialty

OXANDROLONE TAB Tier 1

OXYCODONE ER TAB 10MG Tier 2

OXYCODONE ER TAB 15MG Tier 2

OXYCODONE ER TAB 20MG Tier 2

OXYCODONE ER TAB 30MG Tier 2

OXYCODONE ER TAB 40MG Tier 2

OXYCODONE ER TAB 60MG Tier 2

OXYCODONE ER TAB 80MG Tier 2

OXYMORPHONE ER TAB 10MG Tier 2

OXYMORPHONE ER TAB 15MG Tier 2

OXYMORPHONE ER TAB 20MG Tier 2

oxymorphone ER tab 30mg Tier 2

OXYMORPHONE ER TAB 40MG Tier 2

OXYMORPHONE ER TAB 5MG Tier 2

OXYMORPHONE ER TAB 7.5MG Tier 2

pazopanib hcl tab Tier 1 Specialty

PEGASYS INJ Tier 2 Specialty

PEG-INTRON INJ Tier 2 Specialty

pirfenidone cap Tier 1 Specialty

pirfenidone tab 267mg Tier 1 Specialty

PIRFENIDONE TAB 534MG Tier 1 Specialty

pirfenidone tab 801mg Tier 1 Specialty

POMALYST CAP Tier 2 Specialty

PROMACTA POWDER Tier 2 Specialty

PROMACTA TAB Tier 2 Specialty

pyrimethamine tab Tier 1 Specialty

RADICAVA ORS SUSP Tier 2 Specialty

REBETOL SOLN Tier 2 Specialty

REPATHA INJ Tier 2

REPATHA PUSHTRONEX INJ Tier 2

RINVOQ ER TAB Tier 2 Specialty

RINVOQ ER TAB 45MG Tier 2 Specialty

RINVOQ ORAL SOLN Tier 2 Specialty

roflumilast tab Tier 1

RUBRACA TAB Tier 2 Specialty

sapropterin dihydrochloride powder packet Tier 1 Specialty

sapropterin dihydrochloride soluble tab Tier 1 Specialty

SIGNIFOR INJ Tier 2 Specialty

sildenafil susp Tier 1 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 150 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

simvastatin tab 80mg Preventive

SKYRIZI 180MG/1.2ML CARTRIDGE Tier 2 Specialty

SKYRIZI INJ Tier 2 Specialty

SKYRIZI INJ 150MG/ML Tier 2 Specialty

SKYTROFA INJ Tier 2 Specialty

sodium phenylbutyrate powder Tier 1 Specialty

sodium phenylbutyrate tab Tier 1 Specialty

SOFOSBUVIR/VELPATASVIR TAB Tier 1 Specialty

SOMAVERT INJ Tier 2 Specialty

sorafenib tosylate tab Tier 2 Specialty

SPRYCEL TAB Tier 2 Specialty

STELARA INJ Tier 2 Specialty

STIVARGA TAB Tier 2 Specialty

STRENSIQ INJ Tier 2 Specialty

sunitinib malate cap Tier 1 Specialty

SYMDEKO TAB Tier 2 Specialty

SYMPROIC TAB Tier 2

SYNAGIS INJ Tier 2 Specialty

SYNRIBO INJ Tier 2 Specialty

TAFINLAR CAP Tier 2 Specialty

TAFINLAR TAB Tier 2 Specialty

TAGRISSO TAB Tier 2 Specialty

TAKHZYRO INJ Tier 2 Specialty

TAKHZYRO INJ 150MG/ML Tier 2 Specialty

TASIGNA CAP Tier 2 Specialty

tasimelteon capsule Tier 1 Specialty

TECHNIVIE TAB Tier 2 Specialty

teriparatide (recombinant) soln pen-inj 600mcg/2.4ml Tier 2 Specialty

TERIPARATIDE INJ 620MCG/2.48ML Tier 2 Specialty

TESTOSTERONE GEL 1% 25MG Tier 2

testosterone gel 1.62% 1.25gm Tier 2

testosterone gel 1.62% 2.5gm Tier 2

TESTOSTERONE GEL 10MG/ACT Tier 2

testosterone gel 2% Tier 2

TESTOSTERONE GEL PUMP Tier 2

testosterone soln Tier 2

tetrabenazine tab Tier 1 Specialty

TIGLUTIK SUSP Tier 2 Specialty

tiopronin tab Tier 1 Specialty

tiopronin tab delayed release Tier 2 Specialty

tobramycin neb soln Tier 1 Specialty

tolvaptan tab Tier 1 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 151 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

tolvaptan tab 15mg Tier 1 Specialty

TRACLEER TAB 32MG Tier 2 Specialty

tramadol ER tab Tier 2

tramadol ER tab 100mg Tier 1

tramadol ER tab 200mg Tier 1

tramadol ER tab 300mg Tier 1

TREMFYA INJ Tier 2 Specialty

treprostinil inj 10mg/ml Tier 1 Specialty

treprostinil inj 1mg/ml Tier 1 Specialty

treprostinil inj 2.5mg/ml Tier 1 Specialty

treprostinil inj 5mg/ml Tier 1 Specialty

TYMLOS INJ Tier 2 Specialty

TYVASO DPI POWDER 16-32-48MCG Tier 2 Specialty

TYVASO DPI POWDER 16-32MCG Tier 2 Specialty

TYVASO DPI POWDER 32-48MCG Tier 2 Specialty

TYVASO DPI POWDER Tier 2 Specialty

TYVASO INH SOLN Tier 2 Specialty

TYZEKA TAB Tier 2 Specialty

UPTRAVI TAB Tier 2 Specialty

VALCHLOR GEL Tier 2 Specialty

VENCLEXTA STARTER PACK Tier 2 Specialty

VENCLEXTA TAB Tier 2 Specialty

VENTAVIS INH SOLN Tier 2 Specialty

VERZENIO TAB Tier 2 Specialty

VIEKIRA PAK TAB Tier 2 Specialty

VIEKIRA XR TAB Tier 2 Specialty

vigabatrin powder pack Tier 1 Specialty

vigabatrin tab Tier 1 Specialty

VOSEVI TAB Tier 2 Specialty

VOTRIENT TAB Tier 2 Specialty

XALKORI CAP Tier 2 Specialty

XALKORI SPRINKLE CAP Tier 2 Specialty

XELJANZ SOLN Tier 2 Specialty

XELJANZ TAB Tier 2 Specialty

XELJANZ XR TAB Tier 2 Specialty

XOLAIR INJ Tier 2 Specialty

XOLAIR INJ 150MG/ML Tier 2 Specialty

XOLAIR INJ 300MG/2ML Tier 2 Specialty

XOLAIR INJ 75MG/0.5ML Tier 2 Specialty

ZEJULA CAP Tier 2 Specialty

ZEJULA TAB Tier 2 Specialty

ZELBORAF TAB Tier 2 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 152 of 197

Prior Authorization Drug List

Last Updated* 8/1/2024

UMP Preferred Drug List cont.

Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The

pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions

regarding prior authorizations.

Drug Name

Tier # for Drug Copay (if prior auth is approved)

ZEPATIER TAB Tier 2 Specialty

ZOLINZA CAP Tier 2 Specialty

ZYDELIG TAB Tier 2 Specialty

ZYKADIA CAP Tier 2 Specialty

ZYKADIA TAB Tier 2 Specialty

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 153 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Over-the-Counter (OTC)

• The following OTC drugs are a covered benefit with a prescription

Over-the-Counter (OTC) Medications

aspirin ec tab 325mg aspirin ec tab 81mg aspirin tab B-D INSULIN SYRINGE

BD NEEDLES B-D PEN NEEDLE CALIBRATION LIQUID CONTOUR TEST STRIP

CONTRACEPTIVE FILM CONTRACEPTIVE FOAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP

FEMALE CONDOMS folic acid tab 400mcg folic acid tab 800mcg

FREESTYLE INSULINX

TEST STRIP

FREESTYLE LITE TEST

STRIP

FREESTYLE PRECISION

NEO TEST STRIP

FREESTYLE TEST STRIP

GUAIFENESIN/CODEINE

SYRUP

HUMULIN MIX INJ HUMULIN MIX PEN INJ HUMULIN N INJ HUMULIN N PEN INJ

HUMULIN R INJ HYPODERMIC NEEDLES LANCET KIT LANCETS

levonorgestrel tab

NARCAN HCL SPRAY (OTC)

NICODERM PATCH NICORETTE GUM

NICORETTE LOZENGE nicotine gum NICOTINE KIT nicotine lozenge

nicotine patch nizoral a-d shampoo NOVOFINE PEN NEEDLE

NOVOLIN 70/30 FLEXPEN

INJ

NOVOTWIST PEN NEEDLE PLAN B TAB

PRECISION XTRA TEST

STRIP

SYRINGE LUER-LOK

TODAY SPONGE trispec pse liquid

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 154 of 197

Last Updated* 8/1/2024

Mandatory Specialty Pharmacy (MSP)

• Navitus utilizes a specialty pharmacy, experienced in handling specialty drugs, to coordinate personalized support for members

impacted by chronic illnesses and complex diseases.

• Specialty drugs are only available for a one month supply due to their high cost and use.

• The following drugs are required to be filled through a Specialty Pharmacy provider.

Mandatory Specialty Pharmacy (MSP) Medications

UMP Preferred Drug List

ABILIFY ASIMTUFII INJ

720MG/2.4ML

ABILIFY ASIMTUFII INJ

960MG/3.2ML

ABILIFY MAINTENA INJ

abiraterone acetate tab

500mg

abiraterone tab 250mg ACTHAR HP GEL INJ ACTHAR INJ 80UNIT

ADALIMUMAB-ADAZ INJ

40MG/0.4ML

adefovir dipivoxil tab ALECENSA CAP ALUNBRIG TAB 30MG

ALUNBRIG TAB 90MG,

180MG

ambrisentan tab aminocaproic acid soln apomorphine inj ARANESP INJ

ARISTADA 675MG/2.4ML INJ

ARISTADA INJ AUSTEDO TAB 12MG AUSTEDO TAB 6MG

AUSTEDO TAB 9MG AUSTEDO XR TAB 12MG AUSTEDO XR TAB 18MG AUSTEDO XR TAB 24MG

AUSTEDO XR TAB 30MG AUSTEDO XR TAB 36MG AUSTEDO XR TAB 42MG AUSTEDO XR TAB 48MG

AUSTEDO XR TAB 6MG

AUSTEDO XR TAB

TITRATION KIT

AUSTEDO XR TAB

TITRATION PACK

AVONEX INJ

BARACLUDE SOLN BENEFIX INJ

betaine powder for oral

solution

bexarotene cap

bexarotene gel bosentan tab BOSULIF CAP BOSULIF TAB

CABOMETYX TAB CALQUENCE CAP CALQUENCE TAB capecitabine tab

CAPRELSA TAB 100MG CAPRELSA TAB 300MG carglumic acid tab CAYSTON INH SOLN

CERDELGA CAP COMETRIQ KIT COSENTYX INJ (1-PACK) COSENTYX INJ (2-PACK)

COSENTYX INJ 300MG/2ML

COTELLIC TAB CYSTADANE POWDER CYSTAGON CAP 150MG

CYSTAGON CAP 50MG CYSTARAN OPHTH SOLN DAKLINZA TAB dalfampridine ER tab

deferasirox granules packet deferasirox tab

deferasirox tab 90mg, 360mg

deferiprone tab

deferiprone tab 1000mg deflazacort susp deflazacort tab dichlorphenamide tab

dimethyl fumarate DR cap

dimethyl fumarate DR starter

pack

DOPTELET TAB droxidopa cap

DUPIXENT INJ DUPIXENT PEN INJ ENBREL INJ ENBREL INJ 25MG

ENBREL INJ 50MG ENBREL MINI INJ

ENBREL SURECLICK INJ

50MG

EPIDIOLEX SOLN

EPIVIR HBV SOLN ERIVEDGE CAP ERLEADA TAB ERLEADA TAB 240MG

erlotinib tab 100mg erlotinib tab 150mg erlotinib tab 25mg everolimus tab

everolimus tab for oral susp EXSERVAN FILM fingolimod hcl cap FULPHILA INJ

FUZEON INJ gefitinib tab GENOTROPIN INJ 0.2MG GENOTROPIN INJ 0.4MG

GENOTROPIN INJ 0.6MG GENOTROPIN INJ 0.8MG GENOTROPIN INJ 1.2MG GENOTROPIN INJ 1.4MG

GENOTROPIN INJ 1.6MG GENOTROPIN INJ 1.8MG GENOTROPIN INJ 12MG GENOTROPIN INJ 1MG

GENOTROPIN INJ 2MG GENOTROPIN INJ 5MG GILOTRIF TAB glatiramer inj 20mg/ml

glatiramer inj 40mg/ml HADLIMA INJ 40MG/0.4ML HADLIMA INJ 40MG/0.8ML

HADLIMA PUSH INJ

40MG/0.4ML

HADLIMA PUSH INJ

40MG/0.8ML

HAEGARDA INJ 2000U HAEGARDA INJ 3000U haloperidol decanoate inj

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 155 of 197

HEXALEN CAP HYCAMTIN CAP

HYDROXYPROGESTERON

E CAPROATE INJ

icatibant inj

ICLUSIG TAB imatinib tab 100mg imatinib tab 400mg IMBRUVICA CAP 140MG

IMBRUVICA CAP 70MG IMBRUVICA SUSP IMBRUVICA TAB IMPAVIDO CAP

INCRELEX INJ INGREZZA CAP INGREZZA PACK 40-80MG INLYTA TAB

INTRON-A INJ INVEGA HAFYERA INJ INVEGA SUSTENNA INJ INVEGA TRINZA INJ

JAKAFI TAB JUXTAPID CAP JYNARQUE PAK JYNARQUE TAB 15MG

JYNARQUE TAB 30MG KALYDECO PAK KALYDECO TAB KISQALI PAK

KISQALI TAB lamivudine tab 100mg lapatinib ditosylate tab lenalidomide cap

LENVIMA CAP LEUPROLIDE INJ l-glutamine powder packet LONSURF TAB

LUPRON DEPOT INJ LUPRON DEPOT INJ PED

LUPRON DEPOT-PED INJ

(1-MONTH)

LUPRON DEPOT-PED INJ

(3-MONTH)

LYNPARZA CAP LYNPARZA TAB LYSODREN TAB MATULANE CAP

MAVYRET PAK MAVYRET TAB MEKINIST SOLN MEKINIST TAB 0.5MG

MEKINIST TAB 2MG MELPHALAN TAB MESNEX TAB mifepristone tab

miglustat cap MYLERAN TAB nilutamide tab NINLARO CAP

nitisinone cap NUBEQA TAB NUCALA INJ NYVEPRIA INJ

octreotide inj OCTREOTIDE INJ 100MCG ODOMZO CAP OFEV CAP

olanzapine inj OLYSIO CAP OMNITROPE INJ OMNITROPE INJ 5.8MG

OPSUMIT TAB ORENITRAM TAB

ORKAMBI GRANULES

PACKET

ORKAMBI TAB

OTEZLA STARTER PACK OTEZLA TAB pazopanib hcl tab PEGASYS INJ

PEG-INTRON INJ PERSERIS INJ pirfenidone cap pirfenidone tab 267mg

PIRFENIDONE TAB 534MG pirfenidone tab 801mg POMALYST CAP PROMACTA POWDER

PROMACTA TAB PULMOZYME INH SOLN PURIXAN SUSP pyrimethamine tab

RADICAVA ORS SUSP REBETOL SOLN REBINYN INJ RETACRIT INJ

RIBAPAK TAB RIBAVIRIN CAP RIBAVIRIN TAB riluzole tab

RINVOQ ER TAB RINVOQ ER TAB 45MG RINVOQ ORAL SOLN risperidone microspheres inj

RUBRACA TAB RYKINDO INJ

sapropterin dihydrochloride

powder packet

sapropterin dihydrochloride

soluble tab

SIGNIFOR INJ sildenafil susp SIRTURO TAB

SKYRIZI 180MG/1.2ML

CARTRIDGE

SKYRIZI INJ SKYRIZI INJ 150MG/ML SKYTROFA INJ

sodium phenylbutyrate

powder

sodium phenylbutyrate tab

SOFOSBUVIR/VELPATASVI

R TAB

SOMAVERT INJ sorafenib tosylate tab

SPRYCEL TAB STELARA INJ STIVARGA TAB STRENSIQ INJ

sunitinib malate cap SYMDEKO TAB SYNAGIS INJ SYNRIBO INJ

TABLOID TAB TAFINLAR CAP TAFINLAR TAB TAGRISSO TAB

TAKHZYRO INJ TAKHZYRO INJ 150MG/ML TASIGNA CAP tasimelteon capsule

TECHNIVIE TAB temozolomide cap teriflunomide tab

teriparatide (recombinant)

soln pen-inj 600mcg/2.4ml

TERIPARATIDE INJ

620MCG/2.48ML

tetrabenazine tab THALOMID CAP TIGLUTIK SUSP

tiopronin tab

tiopronin tab delayed release

tobramycin neb soln tolvaptan tab

tolvaptan tab 15mg TRACLEER TAB 32MG TREMFYA INJ treprostinil inj 10mg/ml

treprostinil inj 1mg/ml treprostinil inj 2.5mg/ml treprostinil inj 5mg/ml tretinoin cap

TYMLOS INJ

TYVASO DPI POWDER

16-32-48MCG

TYVASO DPI POWDER

16-32MCG

TYVASO DPI POWDER

32-48MCG

TYVASO DPI POWDER TYVASO INH SOLN TYZEKA TAB UPTRAVI TAB

UZEDY INJ VALCHLOR GEL VEMLIDY TAB

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 156 of 197

VENCLEXTA STARTER

PACK

VENCLEXTA TAB VENTAVIS INH SOLN VERZENIO TAB

VIEKIRA PAK TAB VIEKIRA XR TAB vigabatrin powder pack vigabatrin tab

VISTOGARD PAK VIVITROL INJ VOSEVI TAB VOTRIENT TAB

VUMERITY CAP XALKORI CAP XALKORI SPRINKLE CAP XDEMVY DROP

XELJANZ SOLN XELJANZ TAB XELJANZ XR TAB XOLAIR INJ

XOLAIR INJ 150MG/ML XOLAIR INJ 300MG/2ML XOLAIR INJ 75MG/0.5ML ZARXIO INJ

ZARXIO INJ 480/0.8 ZEJULA CAP ZEJULA TAB ZELBORAF TAB

ZEPATIER TAB ziprasidone mesylate inj ZOLINZA CAP ZYDELIG TAB

ZYKADIA CAP ZYKADIA TAB ZYPREXA RELPREVV INJ

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 157 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

acitretin cap Step Therapy requires trial of adapalene, adapalene/benzoyl peroxide, or tretinoin

ADMELOG INJ, HUMALOG INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

ADMELOG SOLOSTAR INJ, INSULIN

LISPRO KWIKPEN INJ (JUNIOR)

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

AFREZZA INH POWDER

QL= 180 inhalations/28 days; Step Therapy requires trial of NOVOLOG, INSULIN

ASPART, or FIASP

aliskiren tab

Step Therapy requires trial of one angiotensin-converting enzyme (ACE) inhibitor or

angiotensin receptor blockers (ARB)

almotriptan tab

QL= 9 tabs/30 days; Step Therapy requires 30 day trial of 2: naratriptan tab,

rizatriptan tab, or sumatriptan tab

amcinonide oint

Step therapy requires trial of 2 high potency steroids (eg. betamethasone, clobetasol,

halobetasol)

amlodipine/atorvastatin tab

QL= 1 tab/day; Trial of a CCB (eg. amlodipine, nifedipine, diltiazem) AND a statin (eg.

atorvastatin, simvastatin)

amlodipine/valsartan/hydrochlorothiazide tab

QL= 30 tabs/30 days; Step therapy requires trial of olmesartan-amlodipine-HCTZ

amphetamine tab

QL= 60 tabs/30 days; Step therapy requires trial dexmethylphenidate,

methylphenidate, dextroamphetamine, or dextroamphetamine/amphetamine

amphetamine-dextroamphetamine 3-bead

cap er 24hr 12.5mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER

(nonOSM), dexmethylphen ER, or dextroamph ER

amphetamine-dextroamphetamine 3-bead

cap er 24hr 25mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER

(nonOSM), dexmethylphen ER, or dextroamph ER

amphetamine-dextroamphetamine 3-bead

cap er 24hr 37.5mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER

(nonOSM), dexmethylphen ER, or dextroamph ER

amphetamine-dextroamphetamine 3-bead

cap er 24hr 50mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER

(nonOSM), dexmethylphen ER, or dextroamph ER

APIDRA INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

APIDRA SOLOSTAR INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

aprepitant cap 125mg QL= 1 cap/21 days; Step Therapy requires trial of ondansetron

aprepitant cap 40mg QL= 1 cap/28 days; Step Therapy requires trial of ondansetron

aprepitant cap 80mg QL= 2 caps/21 days; Step Therapy requires trial of ondansetron

aprepitant pak QL= 3 caps/fill, 2 fills/month; Step Therapy requires trial of ondansetron

arformoterol tartrate neb soln

QL= 120ml/30 days; Step Therapy requires trial of albuterol neb soln OR levalbuterol

neb soln

asenapine maleate SL tab

QL= 2 tabs/day; Step Therapy requires trial of olanzapine, olanzapine ODT,

quetiapine, quetiapine XR, risperidone, or risperidone ODT

ASPRUZYO SPRINKLE GRANULES QL= 2 packets/day; Step therapy requires trial of ranolazine ER tab

AVONEX INJ

QL= 1 kit/28 days; Step therapy requires trial of dimethyl fumarate, fingolimod,

teriflunomide, or glatiramer

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 158 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

azathioprine tab 100mg QL= 30 tabs/30 days; Step therapy requires trial of azathioprine tab 50mg

azathioprine tab 75mg QL= 30 tabs/30 days; Step therapy requires trial of azathioprine tab 50mg

baclofen susp

QL= 16 ml/day; ST req trial of baclofen tabs and tizanidine caps/tabs (can be open or

crushed)

bepotastine besilate ophth soln QL= 5mL/25 days; Step Therapy requires trial of azelastine 0.05% ophth soln

bimatoprost ophth soln QL= 2.5ml/25 days; Step Therapy requires trial of latanoprost ophth soln

bismuth/metro/tetra cap Step therapy requires trial of oral metronidazole and tetracycline

brimonidine ophth soln 0.15% Step Therapy requires trial of brimonidine ophth soln 0.2%

brimonidine tartrate gel QL= 60 grams/30 days; ST req trial of azelaic acid gel and metronidazole topical

brimonidine tartrate ophth soln 0.1% Step Therapy requires trial of brimonidine ophth soln 0.2%

brimonidine tartrate-timolol maleate ophth

soln

QL= 5ml/25 days; Step Therapy requires trial of 2: brimonidine 0.2%,

dorzolamide/timolol, carteolol, levobunolol, timolol maleate

brinzolamide ophth susp Step Therapy requires trial of dorzolamide 2% ophth soln

bromfenac ophth soln Step Therapy requires trial of diclofenac sodium ophth soln or ketorolac ophth soln

bromfenac sodium ophth soln 0.07%

QL= 3ml./30 days; Step Therapy requires trial of diclofenac sodium ophth soln or

ketorolac ophth soln

budesonide rectal foam QL= 100.2g/30 days; Step therapy requires trial of hydrocortisone enema

budesonide/formoterol inhaler

QL= 10.3g/30 days; Step therapy requires trial of two: fluticasone/salmeterol,

WIXELA, DULERA

buprenorphine hcl buccal film Step therapy requires trial of buprenorphine patch

calcipotriene-betamethasone dipropionate

susp

QL= 400gm/30 days; Step Therapy requires trial of 2: high potency corticosteroids,

topical calcipotriene

candesartan tab

Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz

captopril tab Step Therapy requires trial of 2 angiotensin-converting enzyme (ACE) inhibitors

CAPTOPRIL/HYDROCHLOROTHIAZIDE

TAB

Step Therapy requires trial of one angiotensin-converting enzyme (ACE) inhibitor or

angiotensin receptor blocker (ARB) combination drug

carisoprodol tab

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, tizanidine, methocarbamol, or orphenadrine ER

cephalexin cap 750mg

QL= 5 caps/day; Step therapy requires trial of cephalexin 250mg tab/cap or

cephalexin 500mg tab/cap

chlorzoxazone tab

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, tizanidine, methocarbamol, or orphenadrine ER

chlorzoxazone tab 375mg

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, tizanidine, methocarbamol, or orphenadrine ER

clindamycin foam

QL= 300g/30 days; Step Therapy requires clindamycin gel/solution/lotion/swab OR

erythromycin gel/soln

clindamycin/tretinoin gel

QL= 360g/30 days; Step Therapy requires trial of 1: adapalene or tretinoin, AND trial

of 1: clindamycin or erythromycin

clocortolone pivalate cream QL= 1 tube/30 days; Step therapy requires trial of one preferred topical steroid

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 159 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

colesevelam pack Step Therapy requires trial of 2: cholestyramine, colesevelam, or colestipol

cyanocobalamin nasal spray 500mcg/0.1ml ST req trial of cyanocobalamin injection

cyclobenzaprine ER cap

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, methocarbamol, or orphenadrine ER

cyclobenzaprine tab 7.5mg

Trial of 2: cyclobenzaprine 5mg, cyclobenzaprine 10mg, tizanidine, methocarbamol,

baclofen, chlorzoxazone, orphenadrine

dantrolene cap

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine,

tizanidine, tizanidine, methocarbamol, or orphenadrine ER

dapsone gel

QL= 360g/30 days; Step Therapy requires clindamycin gel/solution/lotion/swab OR

erythromycin gel/soln

darifenacin SR tab

Step Therapy requires trial of 2: oxybutynin, oxybutynin ER, tolterodine, tolterodine

ER, trospium, or trospium ER

dexlansoprazole DR cap

Covered for members age 17 or younger; QL=1 cap/day; Step therapy requires trial of

all: omeprazole, esomeprazole, lansoprazole cap, rabeprazole, and pantoprazole tab

DEXPAK TAB Step Therapy requires trial of dexamethasone

dextroamphetamine sulfate tab 15mg

QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab

dextroamphetamine sulfate tab 2.5mg

QL= 3 tabs/day; Step Therapy requires trial of dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or

methylphenidate

dextroamphetamine sulfate tab 20mg

QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab

dextroamphetamine sulfate tab 30mg

QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab

dextroamphetamine sulfate tab 7.5mg

QL= 3 tabs/day; Step Therapy requires trial of dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or

methylphenidate

diclofenac potassium (migraine) packet

QL= 9 packets/30 days; ST req trial of 2 preferred oral NSAIDs (eg. diclofenac) or

triptans (eg. sumatriptan)

diclofenac potassium cap

QL= 4 caps/day; Step therapy requires trial of diclofenac sodium EC or diclofenac

sodium ER tablets

diclofenac potassium tab 25mg

QL= 4 tabs/day; Step therapy requires trial of diclofenac sodium EC or diclofenac

sodium ER tablets

diclofenac sodium soln 2% Step therapy requires trial of of diclofenac 1.5% soln

difluprednate ophth emulsion

QL= 10ml/28 days; Step Therapy requires trial of prednisolone acetate 1% ophth susp

dihydroergotamine mesylate nasal spray

QL= 8ml/28 days; Step Therapy requires trial of 2: naratriptan, rizatriptan, rizatriptan

ODT, or sumatriptan

dorzolamide/timolol (pf) ophth soln Step Therapy requires trial of dorzolamide/timolol ophth soln

doxepin hcl cream ST req trial of a topical corticosteroid AND topical tacrolimus

doxepin tab

QL= 30 tabs/30 days; Step Therapy requires trial of 2: eszopiclone, zaleplon,

zolpidem, zolpidem ER tab, or zolpidem SL

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 160 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

doxycycline (rosacea) cap delayed release QL= 1 cap/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 100mg QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 200mg QL= 1 tab/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 50mg QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 75mg QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate tab 150mg QL= 2 tabs/day; Step therapy requires trial of doxycycline monohydrate tablets

doxycycline hyclate tab 50mg Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate tab 75mg QL= 2 tabs/day; Step therapy requires trial of doxycycline monohydrate tablets

doxycycline monohydrate tab 150mg

QL= 2 tabs/day; Step therapy requires trial of doxycycline monohydrate 50mg or

100mg tablets

dutasteride/tamsulosin cap Step Therapy requires trial of finasteride tab or dutasteride AND tamsulosin cap

eletriptan tab

QL= 9 tabs/30 days; Step Therapy requires trial of 2: naratriptan, rizatriptan,

rizatriptan ODT, or sumatriptan

enalapril maleate oral soln

QL= 40ml/day; Step therapy requires trial of two: enalapril tab, lisinopril tab, ramipril

tab, benazepril tab

EOHILIA SUS 2MG/10ML

Step therapy requires trial of fluticasone MDI AND budesonide vials; Diagnosis

Restricted – Eosinophilic esophagitis (K20.0)

epinastine ophth soln QL= 5mL/25 days; Step Therapy requires trial of azelastine 0.05% ophth soln

estradiol gel 0.06%

QL= 50 gm/30 days; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz

estradiol td gel

QL= 1 packet/day; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz

estradiol td gel 1.25mg/1.25gm

QL= 37.5gm/30 days; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz

estradiol valerate inj ST req trial of 2: estradiol tab, estradiol patch, estradiol vaginal tab, Estring

fenoprofen calcium cap

QL= 8 tabs/day; Step therapy requires trial of 2: diclofenac, diclofenac XR, etodolac,

etodolac ER, or ibuprofen

fenoprofen calcium tab

Step Therapy requires trial of 2: diclofenac, diclofenac XR, etodolac, etodolac ER, or

ibuprofen

fesoterodine fumarate er tab

QL= 1 tab/day; Step therapy requires trial of 2: oxybutynin tab/syrup/ER tab,

tolterodine tab/SR cap, trospium tab/SR cap

flavoxate tab

QL= 8 tabs/day; Step therapy requires trial of oxybutynin chloride or solifenacin

succinate

FLURBIPROFEN OPHTH SOLN Step Therapy requires trial of diclofenac sodium ophth soln or ketorolac ophth soln

FLUTICASONE LOTION

ST req tri of 2 lower-mid potency topical corticosteroid (eg. Betamet lot 0.05%,

Fluocin crm 0.025%)

fluvastatin cap

QL= 2 caps/day; Step Therapy requires trial of 2: atorvastatin, lovastatin, rosuvastatin,

pravastatin, or simvastatin; Covered at $0 for members 40 years or older; All other

members covered at generic copay

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 161 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

fluvastatin ER tab

QL= 1 tab/day; Step Therapy requires trial of 2: atorvastatin, lovastatin, rosuvastatin,

pravastatin, or simvastatin; Covered at $0 for members 40 years or older; All other

members covered at generic copay

formoterol fumarate neb soln

QL= 120ml/30 days; Step Therapy requires trial of albuterol neb soln OR levalbuterol

neb soln

GLYXAMBI TAB QL= 1 tab/day; Step Therapy requires trial of metformin tab or metformin er tab

halcinonide cream Step Therapy requires trial of 2 High potency corticosteroids

halobetasol propionate foam ST req trial of 2 high potency steroids (eg. betamethasone, clobetasol, halobetasol)

HUMALOG INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

HUMALOG KWIKPEN INJ

QL= 12 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

HUMALOG MIX INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

HUMALOG MIX KWIKPEN, INSULIN

LISPRO MIX KWIKPEN

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

HUMALOG PEN INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

HUMALOG TEMPO PEN INJ 100UNIT/ML

QL= 60ml/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMULIN MIX INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN MIX PEN INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN N INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN N PEN INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN R INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

hydrocodone bitartrate ER cap QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

imiquimod cream 3.75%

QL= 7.5gm/28 days; Step Therapy requires trial of 2: imiquimod 5% cream,

podophyllum resin, fluorouracil cream or topical solution

indomethacin suppository

QL= 4 supp/day; ST req trial of two NSAIDS (e.g. indomethacin, celecoxib, naproxen,

diclofenac, meloxicam, etc)

indomethacin susp QL= 1200ml/30 days; ST req trial of 2: Naproxen susp, Ibuprofen susp

isosorbide dinitrate tab 40mg

Step Therapy requires trial of isosorbide dinitrate, isosorbide dinitrate ER, isosorbide

dinitrate SL, isosorbide mononitrate, or isosorbide mononitrate ER

ivermectin cream

QL= 45gm/30 days; Step Therapy requires trial of oral doxycycline and topical

metronidazole

IYUZEH OPHTH DROPS

QL= 30 single use containers/30 days; Step therapy requires trial of latanoprost ophth

soln

lamotrigine odt QL= 2 tabs/day; Step Therapy requires trial of lamotrigine chew

lanthanum carbonate chew tab QL= 3 tabs/day; ST req trial of sevelamer carbonate tab or sevelamer HCL tab

lanthanum carbonate chew tab 500mg QL= 5 tabs/day; ST req trial of sevelamer carbonate tab or sevelamer HCL tab

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 162 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

l-glutamine powder packet QL= 6 packets/day; Step therapy requires trial of hydroxyurea caps

LOKELMA PAK

QL= 1 pak/day; Step therapy requires trial of 1 diuretic: furosemide, bumetanide,

torsemide, HCTZ, metolazone, chlorthalidone

LOTEMAX OPHTH OINT 0.5%

Step therapy requires trial of two: prednisolone susp/soln 1%, dexameth soln 0.1%,

or fluorometh susp 0.1%

loteprednol etabonate ophth gel

QL= 5g/28 days; Step therapy requires trial of two: prednisolone 1%, dexameth soln

0.1%, or fluorometh susp 0.1%

loteprednol etabonate ophth susp 0.2%

QL= 5ml/30 days; Step therapy requires trial of two: prednisolone 1%, dexameth soln

0.1%, or fluorometh susp 0.1%

LYUMJEV INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

LYUMJEV KWIKPEN

QL= 12 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

LYUMJEV KWIKPEN INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART,

or FIASP

LYUMJEV TEMPO PEN INJ 100UNIT/ML

QL= 60ml/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

meloxicam

QL= 1 cap/day; Step Therapy requires trial of meloxicam, ketoprofen, oxaprozin,

sulindac, or tolmetin

memantine ER cap QL= 1 cap/day; Step Therapy requires trial of memantine tab

mesalamine ER cap QL= 8 caps/day; Step therapy requires trial of 1: generic APRISO or LIALDA

metformin ER osmotic tab Step Therapy requires trial of metformin or metformin ER

methazolamide tab Step Therapy requires trial of acetazolamide

methsuximide cap QL= 4 caps/day; ST requires trial of ethosuximide tab/soln

methylphenidate ER cap

QL= 60 caps/30 days; Step therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 10mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 15mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 20mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 30mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 40mg

QL= 30 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 50mg

QL= 30 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 60mg

QL= 30 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate td patch

QL= 1 patch/day; Step therapy requires trial of 2: dextro/amphet ER, dexmethylph

ER, methylphen ER 27/36/54 (non-OSM)

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 163 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

minocycline ER tab QL= 1 tab/day; Step Therapy requires trial of minocycline cap or minocycline tab

mirabegron tab er

ST req trial 2: oxybutynin tab/syrup, oxybutynin ER tab, tolterodine tab/SR cap,

trospium tab/SR cap

MORPHINE SULFATE ER CAP QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 100mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 10mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 20mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 30mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 50mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 60mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

morphine sulfate ER cap 80mg QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

naftifine cream

QL= 1 tube/30 days; Step therapy requires trial of 2 preferred topical antifungal

products

naftifine hcl gel 2%

QL= 60 grams/30 days; ST Trial of 2: ciclopirox gel/cream, clotrimazole cream,

econazole nitrate cream, ketoconazole cream

NAMENDA XR TITRATION PACK QL= 28 caps/28 days; Step Therapy requires trial of memantine tab

NAMZARIC CAP

QL= 1 cap/day; Step Therapy requires trial of 2: donepezil, donepezil ODT,

memantine, or memantin er

NUEDEXTA CAP QL= 2 caps/day; Step therapy requires trial of 1 SSRI AND 1 TCA

NUVESSA VAGINAL GEL, VANDAZOLE

GEL

QL= 1 package/30 days; Step therapy requires trial of metronidazole tab or

clindamycin cap/oral soln

orphenadrine/aspirin/caffeine tab

QL= 4 tabs/day; Step therapy requires trial of 2: baclofen tab, tizanidine tab/cap,

cyclobenzaprine tab, methocarbamol tab, carisoprodol tab, orphenadrine tab

oxazepam cap

Step Therapy requires trial of 2: alprazolam, chlordiazepoxide, diazepam, or

lorazepam tab

OXYCODONE ER TAB 10MG QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

OXYCODONE ER TAB 15MG QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

OXYCODONE ER TAB 20MG QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

OXYCODONE ER TAB 30MG QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

OXYCODONE ER TAB 40MG QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

OXYCODONE ER TAB 60MG QL= 2 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

OXYCODONE ER TAB 80MG QL= 4 tabs/day; Step Therapy requires trial of morphine sulfate ER tab

paroxetine oral susp QL= 900ml/30 days; Step therapy requires trial and failure of 2 generic SSRI/SNRIs

penciclovir cream

QL= 5 grams/30 days; Step therapy requires trial of 2: VALACYCLOVIR HCL TAB,

FAMCICLOVIR TAB, ACYCLOVIR TAB

PENTASA CAP 500MG Step Therapy requires trial of APRISO or LIALDA

pimecrolimus cream Step Therapy requires trial of tacrolimus oint

pioglitazone/glimepiride tab Step Therapy requires trial of metformin or metformin ER

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 164 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

pitavastatin calcium tab

QL= 1 tab/day; ST req trial of 2: Altoprev tab, FLOLIPID SUSP, Ator, Lova, Rosu,

Prava OR Simvastatin tabs

podofilox gel QL= 15g/30 days; ST req trial of podofilox soln AND imiquimod 5% cream

posaconazole DR tab QL= 8 tabs/day; Step Therapy requires trial of fluconazole, itraconazole or VFEND

posaconazole susp Step therapy requires trial of fluconazole, itraconazole or voriconazole

prednisolone ODT

Step therapy requires trial of two of the following: prednisolone oral soln,

methylprednisolone, prednisone tab/soln

prednisolone tab

Step therapy requires trial of 2: prednisolone oral soln, methylprednisolone,

prednisone tab/soln

pregabalin ER tab

QL= 30 tabs/30 days; Step Therapy requires trial of gabapentin and pregabalin cap or

pregabalin soln

PROZAC WEEKLY CAP QL= 4 caps/28 days; Step Therapy requires trial of fluoxetine IR

PURIXAN SUSP Step Therapy requires trial of mercaptopurine tab

QTERN TAB QL= 30 tabs/30 days; Step Therapy requires trial of metformin or metformin ER

ramelteon tab

QL= 1 tab/day; Step Therapy requires trial of 2: eszopiclone, zaleplon, zolpidem,

zolpidem ER tab, or zolpidem SL

REXULTI TAB

QL= 2 packs/plan year; Step Therapy requires trial of 2: aripiprazole, quetiapine,

ziprasidone, olanzapine, risperidone, or lurasidone

RIBAPAK TAB Step Therapy requires trial of ribavirin

risedronate DR tab QL= 4 tabs/28 days; Step Therapy requires trial of alendronate

risedronate tab 150mg QL= 1 tab/30 days; Step Therapy requires trial of alendronate

ropinirole ER tab QL= 1 tab/day; Step Therapy requires trial of ropinirole

rufinamide susp

QL= 80ml/day; Step Therapy requires trial of two: valproate, lamotrigine, topiramate,

pregabalin, levetiracetam

rufinamide tab

QL= 8 tabs/day; Step Therapy requires trial of two: valproate, lamotrigine, topiramate,

pregabalin, levetiracetam

saxagliptin hcl tab QL= 1 tab/day; ST req trial of metformin AND Tradjenta OR Jentadueto

saxagliptin-metformin hcl tab er 24hr

QL= 2 tabs/day; Step Therapy requires trial of metformin AND Tradjenta, OR

Jentadueto

SIMVASTATIN SUSP

QL= 300ml/30 days; Step Therapy requires trial of 2: atorvastatin, rosuvastatin or

simvastatin

spironolactone susp QL= 600ml/30 days; ST req trial of furosemide oral soln

sumatriptan nasal spray

QL= 6 sprays/30 days; Step therapy requires trial of two: naratriptan tab, rizatriptan

tab, rizatriptan ODT, or sumatriptan tab

sumatriptan/naproxen tab

QL= 9 tabs/30 days; Step Therapy requires trial of 2: naratriptan, rizatriptan,

rizatriptan ODT, or sumatriptan

tafluprost preservative free (pf) ophth soln QL= 30 pouches/30 days; Step Therapy requires trial of latanoprost ophth soln

tavaborole soln

Step Therapy requires trial of 2: ciclopirox nail soln, itraconazole cap or terbinafine tab

tazarotene gel 0.1%

QL= 360g/30 days; Step Therapy requires trial of 2: adapalene, tretinoin, tazarotene

0.1% cream, 0.05% gel

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 165 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

telmisartan/amlodipine tab

Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz

telmisartan/hydrochlorothiazide tab

Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz

telmisartan/hydrochlorothiazide tab

40-12.5MG

Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz

telmisartan/hydrochlorothiazide tab

80-25MG

Step Therapy requires trial of: losartan or losartan/hctz and irbesartan or

irbesartan/hctz

timolol maleate ophth gel Step Therapy requires trial of timolol maleate ophth soln

timolol maleate ophth soln 0.5% Step Therapy requires trial of timolol maleate ophth soln

topiramate cap er 200mg

QL= 2 caps/day; Step therapy requires trial of topiramate followed by topiramate ER

sprinkle

topiramate er cap QL= 1 cap/day; ST req trial of topirmate followed by topiramate ER sprinkle

topiramate ER cap 100mg QL= 1 cap/day; Step Therapy requires trial of generic topiramate IR

topiramate ER cap 150mg QL= 2 caps/day; Step Therapy requires trial of generic topiramate IR

topiramate ER cap 200mg QL= 2 caps/day; Step Therapy requires trial of generic topiramate IR

topiramate ER cap 25mg QL= 1 cap/day; Step Therapy requires trial of generic topiramate IR

topiramate ER cap 50mg QL= 1 cap/day; Step Therapy requires trial of generic topiramate IR

toremifene tab Step Therapy requires trial of tamoxifen

travoprost ophth soln QL= 1 bottle/fill, 1 fill/month; Step Therapy requires trial of latanoprost ophth soln

tretinoin gel

QL= 300g/30 days; Step Therapy requires trial of 2: adapalene, tretinoin, tazarotene

0.1% cream, 0.05% gel

triamcinolone acetonide oint Step Therapy requires trial of triamcinolone acetonide oint 0.025% or 0.1%

triamterene cap Step Therapy requires trial of amiloride or spironolactone

trientine cap 250mg ST req trial of generic penicillamine tab

TRIENTINE CAP 500MG ST req trial of generic penicillamine tab and then trial of gen trientine 250mg cap

trimipramine cap Step Therapy requires trial and failure of 2 generic SSRI/SNRIs

TYRVAYA SOLN

QL= 8.4ml/30 days; Step therapy requires trial of cyclosporine 0.05% ophth emulsion

(generic Restasis)

UBRELVY TAB

QL= 10 tabs/30 days; ST requires trial of 2: naratriptan tab, rizatriptan tab, rizatriptan

ODT, sumatriptan tab

VARUBI TAB QL= 2 tabs/day; Step Therapy requires trial of ondansetron

verapamil SR cap Step Therapy requires trial of verapamil ER tab (generic Calan)

vilazodone hcl tab

QL= 1 tab/day; Step therapy requires trial of 2: cital, escital, fluox, parox IR/ER, sertr,

desven ER, venlfx IR/ER, dulox

VRAYLAR CAP

QL= 2 packs/plan year; Step Therapy requires trial of 2: aripiprazole, quetiapine,

ziprasidone, olanzapine, risperidone, or lurasidone

VRAYLAR PACK

QL= 2 packs/plan year; Step Therapy requires trial of 2: aripiprazole, quetiapine,

ziprasidone, olanzapine, risperidone, or lurasidone

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 166 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Step Therapy (ST)

• The following drugs are covered on the formulary with a Step Therapy.

Step Therapy (ST) Medications

Step Therapy RequirementsDrug Name

VUMERITY CAP

QL= 120 caps/30 days; Step therapy requires trial of dimethyl fumarate, fingolimod,

teriflunomide, or glatiramer

zenzedi tab 10mg

QL= 3 tabs/day; Step Therapy requires trial of 2: dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or

methylphenidate

zenzedi tab 5mg

QL= 3 tabs/day; Step Therapy requires trial of dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or

methylphenidate

zolmitriptan nasal spray

QL= 6 sprays/fill, 2 fills/30 days; Step Therapy requires trial of 2: sumatriptan tab,

naratriptan tab, rizatriptan tab or ODT

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 167 of 197

Smoking Cessation Agents

Last Updated* 8/1/2024

UMP Preferred Drug List

Drug Name

Tier # for Drug Copay

Preventivebupropion SR tab( Limited to 180 days/plan year)

PreventiveCHANTIX PAK( Limited to 180 days/plan year)

PreventiveCHANTIX TAB( Limited to 180 days/plan year)

PreventiveNICODERM PATCH( Limited to 180 days/plan year)

PreventiveNICORETTE GUM( Limited to 180 days/plan year)

PreventiveNICORETTE LOZENGE( Limited to 180 days/plan year)

Preventivenicotine gum( Limited to 180 days/plan year)

PreventiveNICOTINE KIT( Limited to 180 days/plan year)

Preventivenicotine lozenge( Limited to 180 days/plan year)

Preventivenicotine patch( Limited to 180 days/plan year)

PreventiveNICOTROL INHALER( Limited to 180 days/plan year)

PreventiveNICOTROL NASAL SPRAY( Limited to 180 days/plan year)

Preventivevarenicline tartrate tab( Limited to 180 days/plan year)

Preventivevarenicline tartrate tab start pack( Limited to 180 days/plan year)

PreventiveZYBAN TAB( Limited to 180 days/plan year)

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 168 of 197

UMP Preferred Drug List

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

abacavir soln QL= 960ml/30 days

abacavir tab QL= 2 tabs/day

abacavir/lamivudine tab QL= 1 tab/day

abacavir/lamivudine/zidovudine tab QL= 2 tabs/day

abiraterone acetate tab 500mg QL= 2 tabs/day

abiraterone tab 250mg QL= 4 tabs/day

ABRYSVO INJ QL= 1 inj/fill, 1 fill/lifetime

ACETAMINOPHEN/CAFFEINE/DIHYDROC

ODEINE TAB

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

acetaminophen/codeine soln

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

acetaminophen/codeine tab

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

ACTINEL LIQUID QL= 1200ml/30 days

ADALIMUMAB-ADAZ INJ 40MG/0.4ML QL= 2 inj/28 days

adapalene cream QL= 360g/30 days

adapalene gel 0.3% QL= 360g/30 days

adefovir dipivoxil tab QL= 1 tab/day

ADMELOG INJ, HUMALOG INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

ADMELOG SOLOSTAR INJ, INSULIN

LISPRO KWIKPEN INJ (JUNIOR)

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

ADVIL COLD/ TAB SINUS QL= 240 tabs/30 days

AEROCHAMBER QL= 1 device/365 days

AFLURIA INJ QL= 0.5ml/fill

AFREZZA INH POWDER

QL= 630 inhalations/30 days; Step Therapy requires trial of NOVOLOG, INSULIN

ASPART, or FIASP

AIMOVIG INJ QL= 1 pack/28 days

AJOVY INJ QL= 1 inj/28 days

albuterol HFA inhaler QL= 2 inhalers/30 days

ALECENSA CAP QL= 8 caps/day

alendronate sodium oral soln QL= 300ml/28 days

almotriptan tab

QL= 9 tabs/30 days; Step Therapy requires 30 day trial of 2: naratriptan tab, rizatriptan

tab, or sumatriptan tab

ALUNBRIG TAB 30MG

QL= 4 tabs/day; Only available through Biologics 800-850-4306 or Onco360

877-662-6633

ALUNBRIG TAB 90MG, 180MG

QL= 1 tab/day; Only available through Biologics 800-850-4306 or Onco360

877-662-6633

ambrisentan tab QL= 1 tab/day

amlodipine/atorvastatin tab

QL= 1 tab/day; Trial of a CCB (eg. amlodipine, nifedipine, diltiazem) AND a statin (eg.

atorvastatin, simvastatin)

amlodipine/valsartan/hydrochlorothiazide tab

QL= 30 tabs/30 days; Step therapy requires trial of olmesartan-amlodipine-HCTZ

amoxapine tab QL= 4 tabs/day

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 169 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

amphetamine tab

QL= 60 tabs/30 days; Step therapy requires trial dexmethylphenidate,

methylphenidate, dextroamphetamine, or dextroamphetamine/amphetamine

amphetamine/dextroamphetamine tab 10mg

QL= 180 tabs/30 days

amphetamine/dextroamphetamine tab

12.5mg

QL= 150 tabs/30 days

amphetamine/dextroamphetamine tab 15mg

QL= 120 tabs/30 days

amphetamine/dextroamphetamine tab 20mg

QL= 90 tabs/30 days

amphetamine/dextroamphetamine tab 30mg

QL= 60 tabs/30 days

amphetamine/dextroamphetamine tab 5mg QL= 360 tabs/30 days

amphetamine/dextroamphetamine tab

7.5mg

QL= 240 tabs/30 days

amphetamine-dextroamphetamine 3-bead

cap er 24hr 12.5mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER (nonOSM),

dexmethylphen ER, or dextroamph ER

amphetamine-dextroamphetamine 3-bead

cap er 24hr 25mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER (nonOSM),

dexmethylphen ER, or dextroamph ER

amphetamine-dextroamphetamine 3-bead

cap er 24hr 37.5mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER (nonOSM),

dexmethylphen ER, or dextroamph ER

amphetamine-dextroamphetamine 3-bead

cap er 24hr 50mg

QL= 30 caps/30 days; ST req trial of 2: amphet/dextro ER, methylphen ER (nonOSM),

dexmethylphen ER, or dextroamph ER

ANORO ELLIPTA INHALER QL= 60gm/30 days

APAP/CODEINE SOLN

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

APIDRA INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

APIDRA SOLOSTAR INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

apomorphine inj QL= 54ml/30 days; Only available through CVS Specialty 800-237-2767

aprepitant cap 125mg QL= 1 cap/21 days; Step Therapy requires trial of ondansetron

aprepitant cap 40mg QL= 1 cap/28 days; Step Therapy requires trial of ondansetron

aprepitant cap 80mg QL= 2 caps/21 days; Step Therapy requires trial of ondansetron

aprepitant pak QL= 3 caps/fill, 2 fills/month; Step Therapy requires trial of ondansetron

APTIOM TAB QL= 1 tab/day

APTIVUS CAP QL= 4 caps/day

APTIVUS SOLN QL= 380ml/30 days

ARANESP INJ QL= 4 vials/30 days

AREXVY INJ QL= 1 inj/day, 1 fill/lifetime; Covered for members 60 years of age and older

arformoterol tartrate neb soln

QL= 120ml/30 days; Step Therapy requires trial of albuterol neb soln OR levalbuterol

neb soln

aripiprazole ODT QL= 2 tabs/day

aripiprazole soln QL= 30 ml/day

armodafinil tab 150mg QL= 1 tab/day

armodafinil tab 200mg QL= 1 tab/day

armodafinil tab 250mg QL= 1 tab/day

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 170 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

armodafinil tab 50mg QL= 3 tabs/day

asenapine maleate SL tab

QL= 2 tabs/day; Step Therapy requires trial of olanzapine, olanzapine ODT, quetiapine,

quetiapine XR, risperidone, or risperidone ODT

ASMANEX HFA INHALER QL= 1 inhaler/30 days

ASMANEX INHALER QL= 1 inhaler/30 days

aspirin/codeine tab

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

ASPRUZYO SPRINKLE GRANULES QL= 2 packets/day; Step therapy requires trial of ranolazine ER tab

atazanavir cap 150mg QL= 2 caps/day

atazanavir cap 200mg QL= 2 caps/day

atazanavir cap 300mg QL= 1 cap/day

atomoxetine cap 100mg QL= 1 cap/day

atomoxetine cap 10mg QL= 2 caps/day

atomoxetine cap 18mg QL= 2 caps/day

atomoxetine cap 25mg QL= 2 caps/day

atomoxetine cap 40mg QL= 2 caps/day

atomoxetine cap 60mg QL= 1 cap/day

atomoxetine cap 80mg QL= 1 cap/day

atorvastatin tab

QL= 1 tab/day; Covered at $0 for members 40 years or older; All other members

covered at generic copay

ATRIPLA TAB QL= 1 tab/day

atropine ophth soln QL= 1 bottle/30 days

ATROVENT HFA INHALER QL= 25.8gm/30 days

AUSTEDO TAB 12MG QL= 120 tabs/30 days

AUSTEDO TAB 6MG QL= 30 tabs/30 days

AUSTEDO TAB 9MG QL= 30 tabs/30 days

AUSTEDO XR TAB 12MG QL= 90 tabs/30 days

AUSTEDO XR TAB 18MG QL= 2 tabs/day

AUSTEDO XR TAB 24MG QL= 60 tabs/30 days

AUSTEDO XR TAB 30MG QL= 1 tab/day

AUSTEDO XR TAB 36MG QL= 1 tab/day

AUSTEDO XR TAB 42MG QL= 1 tab/day

AUSTEDO XR TAB 48MG QL= 1 tab/day

AUSTEDO XR TAB 6MG QL= 210 tabs/30 days

AUSTEDO XR TAB TITRATION KIT QL= 42 tabs/28 days

AUSTEDO XR TAB TITRATION PACK QL= 28 tabs/28 days

AVONEX INJ

QL= 1 kit/28 days; Step therapy requires trial of dimethyl fumarate, fingolimod,

teriflunomide, or glatiramer

azathioprine tab 100mg QL= 30 tabs/30 days; Step therapy requires trial of azathioprine tab 50mg

azathioprine tab 75mg QL= 30 tabs/30 days; Step therapy requires trial of azathioprine tab 50mg

azelaic acid gel QL= 300g/30 days

baclofen susp

QL= 16 ml/day; ST req trial of baclofen tabs and tizanidine caps/tabs (can be open or

crushed)

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 171 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

BAQSIMI NASAL POWDER QL= 2 inhalations/fill, 2 fills/month

BARACLUDE SOLN QL= 630ml/30 days

BASAGLAR KWIKPEN INJ QL= 60 units/30 days

b-donna tab QL= 8 tabs/day

bepotastine besilate ophth soln QL= 5mL/25 days; Step Therapy requires trial of azelastine 0.05% ophth soln

betaine powder for oral solution QL= 540 grams/30 days; Only available through Walgreens 888-347-3416

bexarotene gel QL= 60g/30 days

BIKTARVY TAB QL= 1 tab/day

bimatoprost ophth soln QL= 2.5ml/25 days; Step Therapy requires trial of latanoprost ophth soln

bosentan tab QL= 2 tabs/day; Only available through Lumicera 855-847-3553

BOSULIF CAP QL= 5 caps/day; Only available through Walgreens 888-347-3416

BRILINTA TAB QL= 2 tabs/day

brimonidine tartrate gel QL= 60 grams/30 days; ST req trial of azelaic acid gel and metronidazole topical

brimonidine tartrate-timolol maleate ophth

soln

QL= 5ml/25 days; Step Therapy requires trial of 2: brimonidine 0.2%,

dorzolamide/timolol, carteolol, levobunolol, timolol maleate

bromfenac sodium ophth soln 0.07%

QL= 3ml./30 days; Step Therapy requires trial of diclofenac sodium ophth soln or

ketorolac ophth soln

budesonide inh susp 0.25mg/2ml,

0.5mg/2ml

QL= 120 units/30 days

budesonide inh susp 1mg/2ml QL= 60 units/30 days

budesonide rectal foam QL= 100.2g/30 days; Step therapy requires trial of hydrocortisone enema

budesonide/formoterol inhaler

QL= 10.2g/30 days; Step therapy requires trial of two: fluticasone/salmeterol, WIXELA,

DULERA

bupropion SR tab Limited to 180 days/plan year

butalbital/acetaminophen tab QL= 6 tabs/day

butalbital/acetaminophen/caffeine/codeine

cap

QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for members age 21

or older; Day supply limit of 42 days in 90 days

butalbital/aspirin/caffeine/codeine cap

QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for members age 21

or older; Day supply limit of 42 days in 90 days

butorphanol nasal spray QL= 5ml/30 days

CABOMETYX TAB QL= 1 tab/day; Only available through Walgreens 888-347-3416

calcipotriene-betamethasone dipropionate

susp

QL= 400gm/30 days; Step Therapy requires trial of 2: high potency corticosteroids,

topical calcipotriene

CALQUENCE CAP QL= 2 caps/day

CALQUENCE TAB QL= 2 tabs/day

CAPMIST DM TAB QL= 4 tabs/day

CAPRELSA TAB 100MG QL= 2 tabs/day; Only available through Biologics 800-850-4306

CAPRELSA TAB 300MG QL= 1 tab/day; Only available through Biologics 800-850-4306

carbidopa-levodopa-entacapone tab

12.5-50-200mg

QL= 8 tabs/day

carbidopa-levodopa-entacapone tab

18.75-75-200mg

QL= 8 tabs/day

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 172 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

carbidopa-levodopa-entacapone tab

25-100-200mg

QL= 8 tabs/day

carbidopa-levodopa-entacapone tab

31.25-125-200mg

QL= 8 tabs/day

carbidopa-levodopa-entacapone tab

37.5-150-200mg

QL= 8 tabs/day

carbidopa-levodopa-entacapone tab

50-200-200mg

QL= 6 tabs/day

CARBINOXAMINE SOLN QL= 40ml/day

carbinoxamine tab QL= 240 tabs/30 days

carisoprodol tab

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine,

tizanidine, methocarbamol, or orphenadrine ER

cephalexin cap 750mg

QL= 5 caps/day; Step therapy requires trial of cephalexin 250mg tab/cap or cephalexin

500mg tab/cap

CEQUR SIMPLICITY 2U QL= 10 patches/30 days

CEQUR SIMPLICITY INSERTER QL= 1 inserter/lifetime

CHANTIX PAK Limited to 180 days/plan year

CHANTIX TAB Limited to 180 days/plan year

chlorzoxazone tab QL= 4 tabs/day

chlorzoxazone tab 375mg

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine,

tizanidine, methocarbamol, or orphenadrine ER

cinacalcet tab 30mg QL= 2 tabs/day

cinacalcet tab 60mg QL= 2 tabs/day

cinacalcet tab 90mg QL= 4 tabs/day

clindamycin foam

QL= 300g/30 days; Step Therapy requires clindamycin gel/solution/lotion/swab OR

erythromycin gel/soln

clindamycin vaginal cream QL= 1 tube/fill

clindamycin/tretinoin gel

QL= 360g/30 days; Step Therapy requires trial of 1: adapalene or tretinoin, AND trial of

1: clindamycin or erythromycin

clobazam susp QL= 480ml/30 days

clocortolone pivalate cream QL= 1 tube/30 days; Step therapy requires trial of one preferred topical steroid

clonidine ER tab QL= 4 tabs/day

clopidogrel tab 300mg QL= 4 tabs/30 days

CLOZAPINE ODT QL= 3 tabs/day

clozapine ODT 25mg, 100mg QL= 3 tabs/day

clozapine tab QL= 3 tabs/day

codeine sulfate tab

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

CODITUSSIN LIQUID DAC QL= 1200ml/30 days

colchicine cap QL= 4 caps/day

colchicine tab QL= 4 tabs/day

cold/allergy elx children QL= 2400ml/30 days

COMBIVENT RESPIMAT INHALER QL= 2 inhalers/30days

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 173 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

COMPLERA TAB QL= 1 tab/day

CONTOUR BLOOD GLUCOSE TEST STRIP

QL= 300 strips/30 days

CONTOUR TEST STRIP QL= 300 test strips/30 days

COSENTYX INJ (1-PACK) QL= 1 inj/28 days

COSENTYX INJ (2-PACK) QL= 2 inj/56 days

COSENTYX INJ 300MG/2ML QL= 1 inj/28 days

COTELLIC TAB QL= 3 tabs/day

COVID-19 TEST QL= 2 tests/30 days

COVID-19 VACCINE BIVALENT BOOSTER

INJ (MODERNA)

QL=1 inj/fill

COVID-19 VACCINE BIVALENT BOOSTER

INJ (PFIZER)

QL= 1 inj/fill

COVID-19 VACCINE BIVALENT BOOSTER

INJ 5-11Y (PFIZER)

QL= 1 inj/fill

COVID-19 VACCINE BIVALENT BOOSTER

INJ 6M-4Y (PFIZER)

QL= 1 inj/fill

COVID-19 VACCINE BIVALENT BOOSTER

INJ 6M-5Y (MODERNA)

QL= 1 inj/fill

COVID-19 VACCINE INJ (JANSSEN) QL= 1 dose/45 days

COVID-19 VACCINE INJ (NOVAVAX) QL= 1 dose/17 days

CUE HEALTH MIS MONITOR QL= 1 kit/year

cyclobenzaprine ER cap

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine,

methocarbamol, or orphenadrine ER

cyclosporine ophth emulsion QL= 60 vials/30 days

CYSTADANE POWDER QL= 540 grams/30 days; Only available through AnovoRx 844-288-5007

CYSTAGON CAP 50MG

QL= 2 caps/day; Only available through CVS Specialty 800-237-2767; Diagnosis

Restricted – Nephrophatic cystinosis (E72.04)

CYSTARAN OPHTH SOLN

QL= 4 bottles/28 days; Diagnosis Restricted – Cystinosis (E72.04); Only available

through Walgreens 888-347-3416

dabigatran etexilate mesylate cap QL= 2 caps/day

danazol cap QL= 4 caps/day

dantrolene cap

QL= 4 tabs/day; Step Therapy requires trial of 2: baclofen, cyclobenzaprine, tizanidine,

tizanidine, methocarbamol, or orphenadrine ER

dapsone gel

QL= 360g/30 days; Step Therapy requires clindamycin gel/solution/lotion/swab OR

erythromycin gel/soln

darunavir tab 600mg QL= 2 tabs/day

darunavir tab 800mg QL= 1 tab/day

DEPO-PROVERA INJ QL= 1 inj/84 days

DEPO-PROVERA SC INJ 104MG QL= 1 inj/84 days

dermawerx pak QL= 1 kit/30 days

DESCOVY TAB QL= 1 tab/day

desvenlafaxine ER tab QL= 1 tab/day

DEXAMETHASONE TAB 20MG QL= 8 tabs/30 days

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 174 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

DEXCOM G6 RECEIVER QL= 1 receiver/year

DEXCOM G6 SENSOR QL= 3 sensors/30 days

DEXCOM G6 TRANSMITTER QL= 1 transmitter/90 days

DEXCOM G7 RECEIVER QL= 1 receiver/year

DEXCOM G7 SENSOR QL= 3 sensors/30 days

dexlansoprazole DR cap

Covered for members age 17 or younger; QL=1 cap/day; Step therapy requires trial of

all: omeprazole, esomeprazole, lansoprazole cap, rabeprazole, and pantoprazole tab

dexmethylphenidate ER cap QL= 1 cap/day

dexmethylphenidate tab 10mg QL= 60 tabs/30 days

dexmethylphenidate tab 2.5mg QL= 240 tabs/30 days

dexmethylphenidate tab 5mg QL= 120 tabs/30 days

dextroamphetamine 5mg tab QL= 180 tabs/30 days

dextroamphetamine ER cap 10mg QL= 2 caps/day

dextroamphetamine ER cap 15mg QL= 4 caps/day

dextroamphetamine ER cap 5mg QL= 2 caps/day

dextroamphetamine soln QL= 1800ml/30 days

dextroamphetamine sulfate tab 15mg

QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab

dextroamphetamine sulfate tab 2.5mg

QL= 3 tabs/day; Step Therapy requires trial of dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or

methylphenidate

dextroamphetamine sulfate tab 20mg

QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab

dextroamphetamine sulfate tab 30mg

QL= 3 tabs/day; Step Therapy requires trial of 2: methylphenidate tab,

amphetamine/dextroamphetamine tab, dexmethylphenidate tab

dextroamphetamine sulfate tab 7.5mg

QL= 3 tabs/day; Step Therapy requires trial of dexmethylphenidate,

dextroamphetamine, amphetamine/dextroamphetamine, methamphetamine, or

methylphenidate

dextroamphetamine tab 10mg QL= 6 tabs/day

DIAZEPAM GEL QL= 1 kit/30 days

diazepam oral soln QL= 360ml/30 days

diazepam rectal gel QL= 1 pack/30 days

dichlorphenamide tab QL= 4 tabs/day

diclofenac gel QL= 100gm/fill, 2 fills/month

diclofenac potassium (migraine) packet

QL= 9 packets/30 days; ST req trial of 2 preferred oral NSAIDs (eg. diclofenac) or

triptans (eg. sumatriptan)

diclofenac potassium cap

QL= 4 caps/day; Step therapy requires trial of diclofenac sodium EC or diclofenac

sodium ER tablets

diclofenac potassium tab 25mg

QL= 4 tabs/day; Step therapy requires trial of diclofenac sodium EC or diclofenac

sodium ER tablets

didanosine DR cap QL= 1 cap/day

DIFICID SUSP QL= 126 mL/10 days

DIFICID TAB QL= 20 tabs/10 days

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 175 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

difluprednate ophth emulsion

QL= 10ml/28 days; Step Therapy requires trial of prednisolone acetate 1% ophth susp

digoxin tab 62.5mcg QL= 1 tab/day

dihydroergotamine mesylate inj QL= 24ml/28 days

dihydroergotamine mesylate nasal spray

QL= 8ml/28 days; Step Therapy requires trial of 2: naratriptan, rizatriptan, rizatriptan

ODT, or sumatriptan

dimethyl fumarate DR cap QL= 60 caps/30 days

dimethyl fumarate DR starter pack QL= 60 caps/30 days

donepezil tab 10mg QL= 1 tab/day

donepezil tab 23mg QL= 1 tab/day

donepezil tab 5mg QL= 1 tab/day

DOPTELET TAB QL= 2 tabs/day; Only available through Accredo 800-803-2523

doxepin cap QL= 2 tabs/day

doxepin tab

QL= 30 tabs/30 days; Step Therapy requires trial of 2: eszopiclone, zaleplon, zolpidem,

zolpidem ER tab, or zolpidem SL

doxycycline (rosacea) cap delayed release QL= 1 cap/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate cap QL= 2 caps/day

doxycycline hyclate cap 50mg QL= 2 caps/day

doxycycline hyclate DR tab QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 100mg QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 200mg QL= 1 tab/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 50mg QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate DR tab 75mg QL= 2 tabs/day; Step Therapy requires trial of doxycycline monohydrate

doxycycline hyclate tab QL= 2 tabs/day

doxycycline hyclate tab 150mg QL= 2 tabs/day; Step therapy requires trial of doxycycline monohydrate tablets

doxycycline hyclate tab 75mg QL= 2 tabs/day; Step therapy requires trial of doxycycline monohydrate tablets

doxycycline monohydrate cap QL= 2 caps/day

doxycycline monohydrate cap 100mg QL= 2 caps/day

doxycycline monohydrate cap 50mg QL= 2 caps/day

doxycycline monohydrate tab QL= 2 tabs/day

doxycycline monohydrate tab 150mg

QL= 2 tabs/day; Step therapy requires trial of doxycycline monohydrate 50mg or

100mg tablets

doxylamine/pyridoxine dr tab QL= 120 tabs/30 days

dronabinol cap QL= 2 caps/day

DULERA INHALER QL= 1 inhaler/30 days

duloxetine cap 40mg QL= 2 caps/day

duloxetine EC cap 20mg QL= 6 caps/day

duloxetine EC cap 30mg QL= 4 caps/day

duloxetine EC cap 60mg QL= 2 caps/day

DUPIXENT INJ QL= 2 inj/28 days

DUPIXENT PEN INJ QL= 2 inj/28 days

EDURANT TAB QL= 1 tab/day

efavirenz/emtricitabine/tenofovir df tab QL= 1 tab/day

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 176 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

eletriptan tab

QL= 9 tabs/30 days; Step Therapy requires trial of 2: naratriptan, rizatriptan, rizatriptan

ODT, or sumatriptan

ELIQUIS STARTER PACK 5MG QL= 1 pack/30 days

ELIQUIS TAB 2.5MG QL= 60 tabs/30 days

ELIQUIS TAB 5MG QL= 74 tabs/30 days

EMGALITY INJ QL= 1 inj/28 days

emtricitabine cap QL= 1 cap/day

emtricitabine/tenofovir disoproxil fumarate

tab

QL= 30 tabs/30 days

emtricitabine/tenofovir disoproxil fumarate

tab 200-300mg

QL= 30 tabs/30 days

EMTRIVA SOLN QL= 850ml/30 days

enalapril maleate oral soln

QL= 40ml/day; Step therapy requires trial of two: enalapril tab, lisinopril tab, ramipril

tab, benazepril tab

ENBREL INJ QL= 8 inj/28 days

ENBREL INJ 25MG QL= 8 inj/28 days

ENBREL INJ 50MG QL= 4 inj/28 days

ENBREL MINI INJ QL= 4 inj/28 days

ENBREL SURECLICK INJ 50MG QL= 4 inj/28 days

entecavir tab QL= 1 tab/day

ENTRESTO CAP QL= 8 caps/day

ENTRESTO TAB QL= 2 tabs/day

epinastine ophth soln QL= 5mL/25 days; Step Therapy requires trial of azelastine 0.05% ophth soln

EPINEPHRINE INJ 0.15MG QL= 2 inj/fill

EPINEPHRINE INJ 0.3MG QL= 2 inj/fill

epinephrine pen inj 0.15mg, 0.3mg QL= 2 inj/fill

EPIVIR HBV SOLN QL= 720ml/30 days

ERGOTAMINE/CAFFEINE TAB QL= 40 tabs/28 days

ERIVEDGE CAP QL= 1 cap/day

ERLEADA TAB QL= 4 tabs/day

ERLEADA TAB 240MG QL= 1 tab/day

erlotinib tab 100mg QL= 3 tabs/day

erlotinib tab 150mg QL= 3 tabs/day

erlotinib tab 25mg QL= 3 tabs/day

estradiol gel 0.06%

QL= 50 gm/30 days; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz

estradiol patch QL= 8 patches/28 days

estradiol td gel

QL= 1 packet/day; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz

estradiol td gel 1.25mg/1.25gm

QL= 37.5gm/30 days; Step therapy requires trial of 2: estradiol tab/patch/vaginal tab,

Jinteli/Fyavolv, Lopreeza/Mimvey/Amabelz

ESTRING QL= 1 ring/90 days; 3 copays per Rx

eszopiclone tab QL= 1 tab/day

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 177 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

etravirine tab 100mg QL= 4 tabs/day

etravirine tab 200mg QL= 2 tabs/day

everolimus tab QL= 1 tab/day

everolimus tab for oral susp QL= 1 tab/day

EVOTAZ TAB QL= 1 tab/day

EXSERVAN FILM QL= 60 films/30 days; Only available through PantherRx Pharmacy 855-726-8479

ezetimibe tab QL= 1 tab/day

ezetimibe/simvastatin tab QL= 1 tab/day

famciclovir tab 125mg QL= 2 tabs/day

famciclovir tab 250mg QL= 2 tabs/day

famciclovir tab 500mg QL= 21 tabs/fill, 2 fills/month

FARXIGA TAB QL= 1 tab/day

febuxostat tab QL= 1 tab/day

felbamate susp QL= 30ml/day

felbamate tab 400mg QL= 9 tabs/day

felbamate tab 600mg QL= 6 tabs/day

fenoprofen calcium cap

QL= 8 tabs/day; Step therapy requires trial of 2: diclofenac, diclofenac XR, etodolac,

etodolac ER, or ibuprofen

fentanyl citrate lollipop

QL= 18 lozenges/fill for members age 20 or younger; QL= 42 lozenges/fill for members

age 21 or older; Day supply limit of 42 days in 90 days

fentanyl patch QL=15 patches/30 days

fesoterodine fumarate er tab

QL= 1 tab/day; Step therapy requires trial of 2: oxybutynin tab/syrup/ER tab,

tolterodine tab/SR cap, trospium tab/SR cap

FIASP FLEXTOUCH INJ QL= 60 units/30 days

FIASP INJ QL= 60 units/30 days

FIASP PENFILL INJ QL= 60 units/30 days

FIASP PUMP CARTRIDGE QL= 60 units/30 days

fingolimod hcl cap QL= 30 caps/30 days

flavoxate tab

QL= 8 tabs/day; Step therapy requires trial of oxybutynin chloride or solifenacin

succinate

FLUBLOK INJ QL= 0.5ml/fill

FLUCELVAX INJ QL= 0.5ml/fill

fluticasone/salmeterol inhaler, wixela inhaler

QL= 1 inhaler/30 days

FLUTICASONE-SALMETEROL INHALER QL= 1 inhaler/30 days

fluvastatin cap

QL= 2 caps/day; Step Therapy requires trial of 2: atorvastatin, lovastatin, rosuvastatin,

pravastatin, or simvastatin; Covered at $0 for members 40 years or older; All other

members covered at generic copay

fluvastatin ER tab

QL= 1 tab/day; Step Therapy requires trial of 2: atorvastatin, lovastatin, rosuvastatin,

pravastatin, or simvastatin; Covered at $0 for members 40 years or older; All other

members covered at generic copay

fluvoxamine ER cap QL= 2 caps/day

formoterol fumarate neb soln

QL= 120ml/30 days; Step Therapy requires trial of albuterol neb soln OR levalbuterol

neb soln

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 178 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

fosamprenavir tab QL= 4 tabs/day

FREE LIBRE 3-PLUS SENSOR QL= 2 sensors/30 days

FREESTYLE INSULINX TEST STRIP QL= 300 test strips/30 days

FREESTYLE LIBRE 2 RECEIVER QL= 1 receiver/year

FREESTYLE LIBRE 2 SENSOR QL= 2 sensors/28 days

FREESTYLE LIBRE 3 READER QL= 1 receiver/1 year

FREESTYLE LIBRE 3 SENSOR QL= 2 sensors/28 days

FREESTYLE LIBRE RECEIVER QL= 1 receiver/year

FREESTYLE LIBRE SENSOR (14-DAY) QL= 2 sensors/28 days

FREESTYLE LITE TEST STRIP QL= 300 test strips/30 days

FREESTYLE PRECISION NEO TEST

STRIP

QL= 300 test strips/30 days

FREESTYLE TEST STRIP QL= 300 test strips/30 days

FREESTYLE TEST STRIPS QL= 300 strips/30 days

frovatriptan tab QL= 10 tabs/30 days

FULPHILA INJ QL= 2 syringes/28 days

gabapentin (once-daily) tab QL= 2 tabs/day

galantamine ER cap QL= 1 cap/day

galantamine tab QL= 60 tabs/30 days

GAVILYTE-C SOLN

Covered at $0 for members 45-75 years-Limited to 2 fills/calendar year; All other

members covered at generic copay

gefitinib tab QL= 1 tab/day

GENOTROPIN INJ 0.2MG QL= 35 syringes/28 days

GENOTROPIN INJ 0.4MG QL= 35 syringes/28 days

GENOTROPIN INJ 0.6MG QL= 35 syringes/28 days

GENOTROPIN INJ 0.8MG QL= 35 syringes/28 days

GENOTROPIN INJ 1.2MG QL= 35 syringes/28 days

GENOTROPIN INJ 1.4MG QL= 35 syringes/28 days

GENOTROPIN INJ 1.6MG QL= 35 syringes/28 days

GENOTROPIN INJ 1.8MG QL= 35 syringes/28 days

GENOTROPIN INJ 12MG QL= 4 cartridges/28 days

GENOTROPIN INJ 1MG QL= 35 syringes/28 days

GENOTROPIN INJ 2MG QL= 21 syringes/28 days

GENOTROPIN INJ 5MG QL= 9 cartridges/28 days

GENVOYA TAB QL= 1 tab/day

GILOTRIF TAB QL= 1 tab/day; Only available through Accredo 800-803-2523

glatiramer inj 20mg/ml QL= 30 syringes/30 days

glatiramer inj 40mg/ml QL= 12 syringes/28 days

GLUCAGEN HYPOKIT INJ QL= 2 inj/fill, 2 fills/month

GLUCAGON EMR INJ QL= 2 inj/fill

GLUCAGON INJ KIT QL= 2 inj/fill

glycopyrrolate oral soln QL= 9ml/day

GLYXAMBI TAB QL= 1 tab/day; Step Therapy requires trial of metformin tab or metformin er tab

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 179 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

granisetron tab QL= 8 tabs/30 days

GRASTEK SL TAB QL= 30 tabs/30 days

GUAIFENESIN/CODEINE SYRUP QL= 240ml/fill, 2 fills/month

guanfacine ER tab QL= 1 tab/day

guanfacine ER tab 1mg QL= 2 tabs/day

guanfacine ER tab 2mg QL= 2 tabs/day

GVOKE INJ QL= 2 inj/fill, 2 fills/month

GVOKE INJ KIT QL= 2 vials/fill, 2 fills/30 days

GVOKE PFS INJ QL= 2 inj/fill, 2 fills/month

HADLIMA INJ 40MG/0.4ML QL= 2 inj/28 days

HADLIMA INJ 40MG/0.8ML QL= 2 inj/28 days

HADLIMA PUSH INJ 40MG/0.4ML QL= 2 inj/28 days

HADLIMA PUSH INJ 40MG/0.8ML QL= 2 inj/28 days

HAEGARDA INJ 2000U QL= 30 vials/30 days; Only available through Accredo 800-803-2523

HAEGARDA INJ 3000U QL= 20 vials/30 days; Only available through Accredo 800-803-2523

HUMALOG INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMALOG KWIKPEN INJ

QL= 12 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMALOG MIX INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMALOG MIX KWIKPEN, INSULIN

LISPRO MIX KWIKPEN

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMALOG PEN INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMALOG TEMPO PEN INJ 100UNIT/ML

QL= 60ml/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

HUMULIN MIX INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN MIX PEN INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN N INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN N PEN INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN R INJ QL= 60 units/30 days; Step Therapy requires trial of NOVOLIN

HUMULIN R INJ U-500 QL= 40 units/30 days

HUMULIN R U-500 KWIKPEN INJ QL= 24 units/30 days

HYD POL/CPM SUSP QL= 10ml/day

HYDROCODONE BITARTRATE ER CAP QL= 2 caps/day; Step Therapy requires trial of morphine sulfate ER tab

hydrocodone bitartrate er tab QL= 1 tab/day

hydrocodone/acetaminophen cap

QL= 18 caps/fill for members age 20 or younger; QL= 42 caps/fill for members age 21

or older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen soln

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen soln 10-325

mg/15ml

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 180 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

hydrocodone/acetaminophen tab 10-325mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen tab

10mg-300mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen tab 2.5-325mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen tab 5-325mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen tab

5mg-300mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen tab

7.5mg-300mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydrocodone/acetaminophen tab

7.5mg-325mg

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

HYDROCODONE/IBUPROFEN TAB

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydromorphone ER tab 12mg QL= 1 tab/day

hydromorphone ER tab 16mg QL= 1 tab/day

hydromorphone ER tab 32mg QL= 2 tabs/day

hydromorphone ER tab 8mg QL= 1 tab/day

hydromorphone liquid

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

HYDROMORPHONE SUPP

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydromorphone tab

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

hydroxyprogesterone caproate inj QL= 4 vials/28 days

ibuprofen tab cold/sinus QL= 240 tabs/30 days

icatibant inj QL= 36ml/30 days; Only available through Accredo 888-773-7376

icosapent ethyl cap 0.5gm QL= 2 caps/day

icosapent ethyl cap 1gm QL= 4 caps/day

imatinib tab 100mg QL= 3 tabs/day

imatinib tab 400mg QL= 2 tabs/day

IMBRUVICA CAP 140MG QL= 3 caps/day; Only available through Optum 877-445-6874

IMBRUVICA CAP 70MG QL= 1 cap/day; Only available through Optum 877-445-6874

IMBRUVICA SUSP QL= 2 bottles/30 days; Only available through Optum 877-445-6874

IMBRUVICA TAB QL= 1 tab/day; Only available through Optum 877-445-6874

imiquimod cream 3.75%

QL= 7.5gm/28 days; Step Therapy requires trial of 2: imiquimod 5% cream,

podophyllum resin, fluorouracil cream or topical solution

imiquimod cream 5% QL= 24gm/30 days

IMPAVIDO CAP QL= 3 caps/day

INCRUSE ELLIPTA INHALER QL= 30 units/30 days

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 181 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

indomethacin suppository

QL= 4 supp/day; ST req trial of two NSAIDS (e.g. indomethacin, celecoxib, naproxen,

diclofenac, meloxicam, etc)

indomethacin susp QL= 1200ml/30 days; ST req trial of 2: Naproxen susp, Ibuprofen susp

INGREZZA CAP QL= 1 cap/day; Only available through PantherRx Pharmacy 855-726-8479

INGREZZA PACK 40-80MG QL= 1 pack/28 days; Only available through PantherRx Pharmacy 855-726-8479

INLYTA TAB QL= 8 tabs/day; Only available through Walgreens 888-347-3416

INSULIN ASPART FLEXPEN INJ QL= 60 units/30 days

INSULIN ASPART INJ QL= 60 units/30 days

INSULIN ASPART MIX FLEXPEN INJ QL= 60 units/30 days

INSULIN ASPART MIX INJ QL= 60 units/30 days

INSULIN ASPART PENFILL INJ QL= 60 units/30 days

INSULIN GLARGINE SOLN PEN-INJ 300

UNIT/ML (1 UNIT DIAL)

QL= 18ml/30 days

INSULIN GLARGINE SOLN PEN-INJ 300

UNIT/ML (2 UNIT DIAL)

QL= 18ml/30 days

INSULIN LISP INJ 100/ML QL= 60 units/30 days

INTELENCE TAB QL= 4 tabs/day

INTELENCE TAB 25MG QL= 4 tabs/day

INVIRASE CAP QL= 10 caps/day

INVIRASE TAB QL= 4 tabs/day

ISENTRESS (HD) TAB QL= 2 tabs/day

ISENTRESS CHEW TAB QL= 6 tabs/day

ISENTRESS POWDER PACK QL= 2 packets/day

isosorbide dinitrate-hydralazine hcl tab QL= 6 tabs/day

ISOXSUPRINE TAB QL= 120 tabs/30 days

ivabradine hcl tab QL= 60 tabs/30 days

ivermectin cream

QL= 45gm/30 days; Step Therapy requires trial of oral doxycycline and topical

metronidazole

IYUZEH OPHTH DROPS

QL= 30 single use containers/30 days; Step therapy requires trial of latanoprost ophth

soln

JAKAFI TAB QL= 2 tabs/day; Only available through Walgreens 888-347-3416

JARDIANCE TAB QL= 1 tab/day

JENTADUETO TAB QL= 2 tabs/day

JENTADUETO XR TAB QL= 2 tabs/day

JULUCA TAB QL= 1 tab/day

JYNARQUE PAK QL= 2 tabs/day; Only available through Walgreens 888-347-3416

JYNARQUE TAB 15MG QL= 2 tabs/day; Only available through Walgreens 888-347-3416

JYNARQUE TAB 30MG QL= 1 tab/day; Only available through Walgreens 888-347-3416

KALETRA TAB 100-25MG QL= 2 tabs/day

KALETRA TAB 200-50MG QL= 4 tabs/day

KALYDECO PAK QL= 2 packets/day; Only available through Walgreens 888-347-3416

KALYDECO TAB QL= 2 tabs/day; Only available through Walgreens 888-347-3416

KISQALI PAK QL= 91 tabs/28 days

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 182 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

KISQALI TAB QL= 63 tabs/28 days

KRINTAFEL TAB QL= 2 tabs/365 days

lacosamide oral solution QL= 1200ml/30 days

lacosamide tab QL= 2 tabs/day

LAGEVRIO CAP 200MG QL= 40 caps/5 days, 40 caps/fill; Covered for members age 18 years or older

lamivudine soln QL= 960ml/30 days

lamivudine tab 100mg QL= 1 tab/day

lamivudine tab 150mg QL= 2 tabs/day

lamivudine tab 300mg QL= 1 tab/day

lamivudine/zidovudine tab QL= 2 tabs/day

lamotrigine ER tab 100mg QL= 3 tabs/day

lamotrigine ER tab 200mg QL= 2 tabs/day

lamotrigine ER tab 250mg QL= 2 tabs/day

lamotrigine ER tab 25mg QL= 6 tabs/day

lamotrigine ER tab 300mg QL= 2 tabs/day

lamotrigine ER tab 50mg QL= 6 tabs/day

lamotrigine odt QL= 2 tabs/day; Step Therapy requires trial of lamotrigine chew

LAMPIT TAB 120MG QL= 225 tabs/30 days

LAMPIT TAB 30MG QL= 360 tabs/30 days

lanthanum carbonate chew tab QL= 3 tabs/day; ST req trial of sevelamer carbonate tab or sevelamer HCL tab

lanthanum carbonate chew tab 500mg QL= 5 tabs/day; ST req trial of sevelamer carbonate tab or sevelamer HCL tab

lapatinib ditosylate tab QL= 5 tabs/day

lenalidomide cap QL= 1 cap/day; Only available through Onco360 877-662-6633

LENVIMA CAP QL= 3 caps/day; Only available through Optum 877-445-6874

LEUPROLIDE INJ QL= 1 kit/90 days

l-glutamine powder packet QL= 6 packets/day; Step therapy requires trial of hydroxyurea caps

lidocaine oint QL= 8gm/day

LIKMEZ SUSP QL= 210ml/14 days

lisdexamfetamine dimesylate cap QL= 1 cap/day

lisdexamfetamine dimesylate chew tab QL= 1 tab/day

LOKELMA PAK

QL= 1 pak/day; Step therapy requires trial of 1 diuretic: furosemide, bumetanide,

torsemide, HCTZ, metolazone, chlorthalidone

lopinavir/ritonavir soln QL= 480ml/30 days

lopinavir-ritonavir tab 100-25mg QL= 2 tabs/day

lopinavir-ritonavir tab 200-50mg QL= 4 tabs/day

LORTUSS EX LIQUID QL= 1200ml/30 days

LORTUSS LIQUID QL= 1200ml/30 days

loteprednol etabonate ophth gel

QL= 5g/28 days; Step therapy requires trial of two: prednisolone 1%, dexameth soln

0.1%, or fluorometh susp 0.1%

loteprednol etabonate ophth susp 0.2%

QL= 5ml/30 days; Step therapy requires trial of two: prednisolone 1%, dexameth soln

0.1%, or fluorometh susp 0.1%

lovastatin tab

QL= 2 tabs/day; Covered at $0 for members 40 years or older; All other members

covered at generic copay

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 183 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

lubiprostone cap QL= 60 caps/30 days

LUPRON DEPOT INJ PED QL= 1 syringe kit/180 days

LUPRON DEPOT-PED INJ (1-MONTH) QL= 1 syringe kit/30 days

LUPRON DEPOT-PED INJ (3-MONTH) QL= 1 syringe kit/90 days

lurasidone hcl tab QL= 1 tab/day

LYNPARZA CAP QL= 16 caps/day; Only available through Biologics 800-850-4306

LYNPARZA TAB QL= 4 tabs/day; Only available through Biologics 800-850-4306

LYUMJEV INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

LYUMJEV KWIKPEN

QL= 12 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

LYUMJEV KWIKPEN INJ

QL= 60 units/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

LYUMJEV TEMPO PEN INJ 100UNIT/ML

QL= 60ml/30 days; Step Therapy requires trial of NOVOLOG, INSULIN ASPART, or

FIASP

maraviroc tab 150mg QL= 2 tabs/day

maraviroc tab 300mg QL= 4 tabs/day

MAR-COF CG LIQUID QL= 473ml/month

MAVYRET PAK QL= 5 packets/day

MAVYRET TAB QL= 3 tabs/day

medroxyprogesterone inj QL= 1 inj/84 days

MEKINIST SOLN QL= 40ml/day

MEKINIST TAB 0.5MG QL= 3 tabs/day

MEKINIST TAB 2MG QL= 1 tab/day

meloxicam

QL= 1 cap/day; Step Therapy requires trial of meloxicam, ketoprofen, oxaprozin,

sulindac, or tolmetin

memantine ER cap QL= 1 cap/day; Step Therapy requires trial of memantine tab

memantine soln QL= 300 ml/30 days

memantine titrapak QL= 49 tabs/28 days

M-END DMX LIQUID QL= 1800ml/30 days

MEPERIDINE SOLN

QL= 90ml/fill for members age 20 or younger; QL= 210ml/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

meperidine tab

QL= 18 tabs/fill for members age 20 or younger; QL= 42 tabs/fill for members age 21 or

older; Day supply limit of 42 days in 90 days

mesalamine DR cap QL= 6 caps/day

mesalamine DR tab QL= 4 tabs/day

mesalamine ER cap QL= 8 caps/day; Step therapy requires trial of 1: generic APRISO or LIALDA

mesalamine supp QL= 1 supp/day

methadone soln QL= 4 ml/day

methadone soln 10mg/5ml QL= 20ml/day

methadone soln 5mg/5ml QL= 40ml/day

methadone tab 10mg QL= 4 tabs/day

methadone tab 5mg QL= 8 tabs/day

Coverage of medications, including those not otherwise identified by qualifiers such as QL, may be subject to safety screenings and other clinical edits in the course of claims

transaction processing.** Products listed may not be all inclusive and are subject to change.

Page 184 of 197

UMP Preferred Drug List Cont.

Last Updated* 8/1/2024

Quantity Limit (QL)

• The following drugs are covered on the formulary with a Quantity Limit.

Quantity Limit (QL) Medications

Quantity LimitDrug Name

methadose tab QL= 1 tab/day

methamphetamine tab QL= 5 tabs/day

methsuximide cap QL= 4 caps/day; ST requires trial of ethosuximide tab/soln

methylphenidate CD cap QL= 1 cap/day

methylphenidate chew tab QL= 3 tabs/day

methylphenidate ER cap

QL= 60 caps/30 days; Step therapy requires trial of 2: dextro/amphet ER, dexmethylph

ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 10mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 15mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 20mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 30mg

QL= 60 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 40mg

QL= 30 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 50mg

QL= 30 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate er cap 60mg

QL= 30 caps/30 days; Step Therapy requires trial of 2: dextro/amphet ER,

dexmethylph ER, methylphen ER 27/36/54 (non-OSM)

methylphenidate ER tab QL= 1 tab/day

methylphenidate ER tab 10mg QL= 3 tabs/day

methylphenidate ER tab 20mg QL= 3 tabs/day

methylphenidate tab 10mg QL= 180 tabs/30 days

methylphenidate tab 20mg QL= 90 tabs/30 days

methylphenidate tab 5mg QL= 360 tabs/30 days

methylphenidate td patch

QL= 1 patch/day; Step therapy requires trial of 2: dextro/amphet ER, dexmethylph ER,

methylphen ER 27/36/54 (non-OSM)

methyltestosterone cap QL= 150 tablets/30 days

metyrosine cap QL= 448 caps/28 days

mifepristone tab QL= 4 tabs/day

MIGERGOT SUPP QL= 20 supp/28 days

minocycline ER tab QL= 1 tab/day; Step Therapy requires trial of minocycline cap or minocycline tab

modafinil tab QL= 2 tabs/day

MOLNUPIRAVIR CAP QL= 40 caps/fill