2022 Premium Value Formulary Effective January 1 ... - …

1 2022 Premium Value Formulary Effective July 1, 2022 Understanding your formularyWhat is a Formulary ?A Formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. The Formulary gives you choices so you and your doctor can decide your best course of treatment. In this Formulary , brand-name medications are shown in UPPERCASE (for example, BRAND DRUG).

2 Generic medications are shown in lowercase (for example, generic drug).Reading your formularyAbout this formularyWhere differences exist between this list and your benefit plan, the benefit plan documents rule. This is not a complete list of your covered medications. Please review your benefit plan documents for full details. Not all Formulary alternatives listed in this document may be appropriate for your specific condition. Please talk to your informationDrug tierIncludesHelpful tipsTier 1 $ Lower-cost medicationsBrand name and generic medications can be found in any of the 4 tiers. The lower the tier, the less your medications will 2$$ Low-cost medicationsTier 3$$$ Mid-range cost medicationsTier 4$$$$ Higher-cost medicationsDrug list informationPAPrior authorization Your doctor is required to give Optum Rx more information to determine limit Medication may be limited to a certain medication Medication is designated as therapy Must try lower-cost medication(s)

3 Before a higher-cost medication can be Value FormularyTable of ContentsAnalgesics - Drugs for - Drugs for Pain and / Substance Abuse Treatment - Drugs for Agents - Drugs for Alzheimer's Disease and - Drugs for Nausea and - Drugs for - Drugs for Mood - Drugs for Agents - Drugs for Mood Products and Modifiers - Drugs for Blood Agents - Drugs for Heart and Circulation Nervous System Agents - Drugs for Attention Deficit Nervous System Agents - Drugs for Multiple Nervous System Agents - and oral Agents - Drugs for Mouth and Throat Agents - Drugs for Skin - Antidiabetic - Glucose - Glycemic - / Minerals / Metals / Agents - Drugs for Acid Reflux and Agents - Drugs for Bowel, Intestine and Stomach or Enzyme Disorder - Drugs for Replacement, Modification, Agents - Drugs for Bladder, Genital and Kidney Agents - Drugs for Prostate Agents - Agents - Men's Agents - Agents - Agents - Selective Estrogen Receptor Modifying Agents - Sex Hormones and Birth Agents - Agents - Drugs for Immune System Stimulation or Agents - Drugs for Bowel Disease Bone Disease Agents - Drugs for Bone Disease Agents - Therapeutic Agents - Drugs for Eye Allergy, Infection and Agents - Drugs for Agents - Drugs for Miscellaneous Eye Agents - Drugs for Ear Tract / Pulmonary Agents - Drugs for Allergies, Cough.

4 Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Tract / Pulmonary Agents - Drugs for Cystic Tract / Pulmonary Agents - Drugs for Pulmonary Muscle Relaxants - Drugs for Muscle Pain and Disorder NameDrug TierNotesAnalgesics - Drugs for Pain and Inflammationadult aspirin regimen1aspirin adult low dose1aspirin adult low strength1aspirin childrens1aspirin ec low dose1aspirin ec low strength1aspirin ec oral tablet delayed release 325 mg1aspirin low dose1aspirin oral tablet1aspirin oral tablet delayed release1celecoxib oral1 QLdiclofenac potassium oral tablet 50 mg1diclofenac sodium er1diclofenac sodium external gel 1 %1 QLdiclofenac sodium oral1diclofenac-misoprostol2diflunisal oral1etodolac1etodolac er1flurbiprofen oral1goodsense aspirin adults1goodsense aspirin low dose1ibuprofen lysine1ibuprofen oral suspension 100 mg/5ml1ibuprofen oral tablet 400 mg, 600 mg, 800 mg1indomethacin er1 Drug NameDrug TierNotesindomethacin oral capsule 25 mg, 50 mg1indomethacin sodium1ketoprofen oral capsule 75 mg3ketorolac tromethamine injection1ketorolac tromethamine intramuscular1ketorolac tromethamine oral1 QLmeloxicam oral tablet1nabumetone oral1naproxen oral tablet1naproxen oral tablet delayed release1naproxen sodium oral tablet 275 mg.

5 550 mg1oxaprozin1piroxicam oral1sulindac oral1tri-buffered aspirin1 Analgesics - Drugs for Painacetaminophen-codeine1 QLacetaminophen-codeine #21 QLacetaminophen-codeine #31 QLacetaminophen-codeine #41 QLascomp-codeine2bac1buprenorphine hcl injection4buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr2PA; QLFor more information regarding the tiers and designations in this drug list, please see the Reading your Formulary section of this NameDrug TierNotesbuprenorphine transdermal patch weekly mcg/hr3PA; QLbutalbital-acetaminophen oral tablet 50-325 mg2butalbital-apap-caff-cod1butalbital-a pap-caffeine1butalbital-asa-caff-codeine 2butalbital-aspirin-caffeine1butorphanol tartrate injection1butorphanol tartrate nasal1 QLcarisoprodol-aspirin-codeine1codeine sulfate1 QLendocet1 QLfentanyl2PA; QLfentanyl citrate buccal lozenge on a handle3PA; QLhydrocodone bitartrate er oral capsule extended release 12 hour3PA; QLhydrocodone-acetaminophen1 QLhydrocodone-ibuprofen1 QLhydromorphone hcl er3PA.

6 QLhydromorphone hcl injection solution 2 mg/ml, 4 mg/ml2 HYDROMORPHONE HCL INTRAVENOUS SOLUTION MG/ML2hydromorphone hcl oral1 QLhydromorphone hcl pf2 HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION2 Drug NameDrug TierNoteshydromorphone hcl solution 1 mg/ml injection2meperidine hcl injection1meperidine hcl oral solution1 QLmethadone hcl injection1methadone hcl intensol1methadone hcl oral concentrate1methadone hcl oral solution1methadone hcl oral tablet1 PAmethadone hcl oral tablet soluble2methadose oral tablet soluble2methadose sugar -free1morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml1 QLmorphine sulfate (pf) injection1morphine sulfate (pf) intravenous solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml1morphine sulfate er beads3PA; QLmorphine sulfate er oral capsule extended release 24 hour2PA; QLmorphine sulfate er oral tablet extended release1PA; QLmorphine sulfate injection solution 2 mg/ml, 4 mg/ml1 MORPHINE SULFATE INTRAVENOUS SOLUTION 1 MG/ML2 For more information regarding the tiers and designations in this drug list, please see the Reading your Formulary section of this NameDrug TierNotesmorphine sulfate intravenous solution 4 mg/ml, 8 mg/ml1morphine sulfate oral1 QLnalbuphine hcl injection3 OXYCODONE HCL ER3PA.

7 QLoxycodone hcl oral capsule1 QLoxycodone hcl oral concentrate 100 mg/5ml3 QLoxycodone hcl oral solution1 QLoxycodone hcl oral tablet1 QLoxycodone-acetaminophen oral tablet 10-325 mg, mg, 5-325 mg, mg1 QLoxymorphone hcl1 QLoxymorphone hcl er3PA; QLpentazocine-naloxone hcl2 QLtramadol hcl er (biphasic)1PA; QLtramadol hcl er oral tablet extended release 24 hour1PA; QLtramadol hcl oral tablet1 QLtramadol-acetaminophen1 QLAnestheticsbupivacaine fisiopharma1bupivacaine hcl (pf)1bupivacaine hcl injection solution %, %1bupivacaine-epinephrine1 Drug NameDrug TierNotesbupivacaine-epinephrine (pf)1glydo1lidocaine external patch 5 %2lidocaine hcl (cardiac) intravenous solution prefilled syringe 100 mg/5ml, 50 mg/5ml1lidocaine hcl (cardiac) pf1lidocaine hcl (pf)

8 1lidocaine hcl external solution1lidocaine hcl injection solution %1 LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML, 60 MG/3ML1 LIDOCAINE HCL SOLUTION 1 % INJECTION1lidocaine hcl solution 1 % injection1 LIDOCAINE HCL SOLUTION 2 % INJECTION1lidocaine hcl solution 2 % injection1lidocaine hcl urethral/mucosal1lidocaine-epinephrine injection solution %-1:200000, 1 %-1:100000, %-1:200000, 2 %-1:2000001lidocaine-prilocaine external cream1polocaine-mpf injection solution 2 %1 For more information regarding the tiers and designations in this drug list, please see the Reading your Formulary section of this NameDrug TierNotesropivacaine hcl injection solution1 ROPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE %4 SENSORCAINE1 SENSORCAINE-MPF INJECTION SOLUTION %, %1 SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION -1.

9 2000001 XYLOCAINE INJECTION SOLUTION 1 %1 XYLOCAINE-MPF INJECTION SOLUTION 1 %1 Anti-Addiction / Substance Abuse Treatment Agentsacamprosate calcium2 APO-VARENICLINE3 QLbuprenorphine hcl sublingual1 QLbuprenorphine hcl-naloxone hcl2 QLbupropion hcl er (smoking det)1 QLdisulfiram oral1 KLOXXADO2naloxone hcl injection1naltrexone hcl oral1 NARCAN2 SUBLOCADE3 SPvarenicline tartrate3 QLVIVITROL3 SPDrug NameDrug TierNotesAntibacterialsamikacin sulfate injection2amoxicillin1amoxicillin-potass ium clavulanate1amoxicillin-potassium clavulanate er2ampicillin1ampicillin sodium1ampicillin-sulbactam sodium1 ARIKAYCE4PA; SPavidoxy1azithromycin intravenous1azithromycin oral1aztreonam3 BICILLIN L-A3cefaclor er2cefaclor oral capsule1cefaclor oral suspension reconstituted3cefadroxil1cefazolin sodium injection1 CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE2cefazolin sodium intravenous solution reconstituted1cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-%1cefdinir1cefepime hcl injection1 For more information regarding the tiers and designations in this drug list.

10 Please see the Reading your Formulary section of this NameDrug TierNotescefepime hcl intravenous solution2cefepime-dextrose3cefixime oral capsule1cefixime oral suspension reconstituted2cefotaxime sodium1cefoxitin sodium1cefpodoxime proxetil oral suspension reconstituted2cefpodoxime proxetil oral tablet1cefprozil1ceftazidime and dextrose2ceftazidime injection1ceftazidime intravenous1ceftriaxone sodium in dextrose1ceftriaxone sodium injection1ceftriaxone sodium intravenous1ceftriaxone sodium-dextrose1cefuroxime axetil1cefuroxime sodium1cephalexin1 CIPRO oral SUSPENSION RECONSTITUTED2ciprofloxacin hcl oral1ciprofloxacin in d5w1clarithromycin er2clarithromycin oral suspension reconstituted2clarithromycin oral tablet1 Drug NameDrug TierNotesclindamycin hcl oral1clindamycin palmitate hcl2clindamycin phosphate in d5w2 CLINDAMYCIN PHOSPHATE IN NACL2clindamycin phosphate injection1clindamycin phosphate vaginal1colistimethate sodium (cba)3daptomycin3demeclocycline hcl2dicloxacillin sodium1 DIFICID oral TABLET4doxy 1002doxycycline hyclate intravenous2doxycycline hyclate oral capsule1doxycycline hyclate oral tablet 100 mg, 20 mg1doxycycline monohydrate oral capsule 100 mg, 50 mg1doxycycline monohydrate oral suspension reconstituted1doxycycline monohydrate oral tablet1ertapenem sodium3erythromycin base oral capsule delayed release particles2erythromycin base oral tabl