Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. April 2017 USAble Administrators Standard with Step Therapy Drug List The USAble Administrators Standard with Step Therapy Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by USAble Administrators. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: • Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. • You may be responsible for the full cost of non-formulary products that are removed from coverage. • For specific information regarding your prescription benefit coverage and copay 1 information, please visit usableadmin.com or contact a USAble Administrators Customer Care representative toll free at 1-888-293-3748. • USAble Administrators may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non- preferred option upon release of the generic product onto the market. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by USAble Administrators. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: • Generics should be considered the first line of prescribing. • This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. • The member's prescription benefit plan may have a different copay for specific products on the list. • Unless specifically indicated, drug list products will include all dosage forms. • Log in to usableadmin.com to check coverage and copay information for a specific medicine. ANALGESICS § NSAIDs diclofenac sodium meloxicam naproxen § NSAIDs, COMBINATIONS diclofenac sodium- misoprostol § NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL PA § COX-2 INHIBITORS celecoxib § GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC ST § OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge PA hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel QL morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel BUTRANS FENTORA PA HYSINGLA ER QL NUCYNTA QL NUCYNTA ER QL OPANA ER QL OXYCONTIN QL SUBSYS PA ANTI-INFECTIVES ANTIBACTERIALS § CEPHALOSPORINS cefdinir
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USAble Administrators Standard with Step Therapy Drug List...Nebulized Passive Inhalation PERFOROMIST § ANTIQL § CYSTIC FIBROSIS tobramycin inhalation solution SGM BETHKIS SGM §
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Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
April 2017
USAble Administrators Standard with Step Therapy Drug List
The USAble Administrators Standard with Step Therapy Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there
may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
PLAN MEMBER
Your benefit plan provides you with a prescription benefit program administered by USAble Administrators. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor.
Please note:
• Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.
• You may be responsible for the full cost of non-formulary products that are removed from coverage.
• For specific information regarding your prescription benefit coverage and copay
1 information, please visit
usableadmin.com or contact a
USAble Administrators Customer Care representative toll free at 1-888-293-3748.
• USAble Administrators may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.
• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product onto the market.
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan administered by USAble Administrators. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list.
Please note:
• Generics should be considered the first line of prescribing.
• This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage.
• The member's prescription benefit plan may have a different copay for specific products on the list.
• Unless specifically indicated, drug list products will include all dosage forms.
• Log in to usableadmin.com to check coverage and copay
information for a specific medicine.
ANALGESICS
§ NSAIDs
diclofenac sodium
meloxicam
naproxen
§ NSAIDs, COMBINATIONS
diclofenac sodium-misoprostol
§ NSAIDs, TOPICAL
diclofenac sodium solution
VOLTAREN GEL PA
§ COX-2 INHIBITORS
celecoxib
§ GOUT
allopurinol colchicine tablet probenecid
COLCRYS
ULORIC ST
§ OPIOID ANALGESICS
codeine-acetaminophen
fentanyl transdermal fentanyl transmucosal
lozenge PA
hydrocodone-acetaminophen
hydromorphone
hydromorphone ext-rel
methadone
morphine
morphine ext-rel QL
morphine suppository
oxycodone
oxycodone-acetaminophen
tramadol tramadol ext-rel BUTRANS
FENTORA PA
HYSINGLA ER QL
NUCYNTA QL
NUCYNTA ER QL
OPANA ER QL
OXYCONTIN QL
SUBSYS PA
ANTI-INFECTIVES
ANTIBACTERIALS
§ CEPHALOSPORINS
cefdinir
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
cefprozil cefuroxime axetil cephalexin
SUPRAX
§ ERYTHROMYCINS / MACROLIDES
azithromycin
clarithromycin
clarithromycin ext-rel erythromycins
DIFICID
§ FLUOROQUINOLONES
ciprofloxacin
ciprofloxacin ext-rel levofloxacin
moxifloxacin
§ PENICILLINS
amoxicillin
amoxicillin-clavulanate
dicloxacillin
penicillin VK
§ TETRACYCLINES
doxycycline hyclate
minocycline
tetracycline
§ ANTIFUNGALS
fluconazole
itraconazole PA
terbinafine tablet
ANTIRETROVIRAL AGENTS
§ ANTIRETROVIRAL COMBINATIONS
ATRIPLA
COMPLERA
DESCOVY
EPZICOM
EVOTAZ
GENVOYA
ODEFSEY
PREZCOBIX
STRIBILD
TRIUMEQ
TRUVADA
INTEGRASE INHIBITORS
ISENTRESS
TIVICAY
§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
abacavir tablet lamivudine
PROTEASE INHIBITORS
NORVIR
PREZISTA
REYATAZ
ANTIVIRALS
§ CYTOMEGALOVIRUS AGENTS
valganciclovir
§ HEPATITIS C AGENTS
ribavirin SGM
EPCLUSA (genotypes 2, 3) SGM
HARVONI
(genotypes 1, 4, 5, 6) SGM
§ HERPES AGENTS
acyclovir valacyclovir
INFLUENZA AGENTS
RELENZA QL
TAMIFLU QL
§ MISCELLANEOUS
clindamycin
ivermectin
metronidazole
nitrofurantoin
sulfamethoxazole-trimethoprim
ALBENZA
SIVEXTRO
XIFAXAN 550 MG
ANTINEOPLASTIC
AGENTS
HORMONAL ANTINEOPLASTIC AGENTS
§ ANTIANDROGENS
bicalutamide
ZYTIGA SGM
§ KINASE INHIBITORS
imatinib mesylate SGM
BOSULIF SGM
SPRYCEL SGM
CARDIOVASCULAR
§ ACE INHIBITORS
fosinopril lisinopril quinapril ramipril
§ ACE INHIBITOR / DIURETIC COMBINATIONS
fosinopril-hydrochlorothiazide
lisinopril-hydrochlorothiazide
quinapril-hydrochlorothiazide
§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS
ZUBSOLV buprenorphine-naloxone sublingual tablet PA, SUBOXONE FILM PA
ZYFLO, ZYFLO CR montelukast, zafirlukast
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.
FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by an independent National Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay 1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.
* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.
§ Generics are available in this class and should be considered the first line of prescribing. † Coverage determined under the Medical Benefit
OTC Over the Counter
PA Prior Authorization
QL Quantity Limit
SGM Specialty Guideline Management
ST Step Therapy 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the
prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include generic CARDIZEM LA. 3 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on
how to obtain a blood glucose meter, call: 1-800-588-4456. 4 Coverage may be altered or copay 1 amounts may vary based on the condition being treated (e.g. psoriasis). 5 ONETOUCH brand test strips are the only preferred options. 6 BD ULTRAFINE syringes and needles are the only preferred options. 7 Listing reflects the authorized generics for TESTIM and VOGELXO.
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We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in various formats (large print, audio, accessible electronic formats, other formats), and language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator.
If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Civil Rights Coordinator 601 Gaines Street, Little Rock, AR 72201 Phone: 1-844-662-2276; TDD: 1-844-662-2275
You can file a grievance in person, by mail, or by email. If you need help filing a grievance our Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201 Phone: 1-800-368-1019; TDD: 1-800-537-7697
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
ATTENTION: Language assistance services, free of charge, are available to you. Call 1- 844-662-2276.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-662-2276 .
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-844-662-2276.
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