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The Medication Therapy Management approach is a progressive model of prescription utilization and consumer centered purchase options. The program offers the consumer a variety of options for prescription access and out of pocket cost management. Over the Counter, generic, best brand, non-best brand, and cost share prescriptions are available. Step therapy, prior authorization management tools are incorporated into the program to assist in managing prescription costs; evidence based prescription approaches with clinical excellence as an outcome objective. Enclosed are the prescription resources to assist in effective prescription purchasing.  Prescription Flowsheet  OptumRx Mobile Friendly Website  Step Therapy/RxResults  Covered and Non-Covered Drugs  Prior Authorization/RxResults  High Deductible Health Savings Account Benefit Plans Wellness Drug List  OptumRx Specialty/Biotech Prescriptions  IEBP Political Subdivision Preferred Formulary  Cost Share Prescriptions/Sample Cost Share Letter  OptumRx - Accessing the Pharmacy Locator - Internet Direct Access (IDA) Dedicated to Services Measuring the Patient Healthcare Experience by
Managing the Integrity of the Healthcare Dollar Optimized by Efficient Performance Based Outcome
Resource
Contact Information
Accessible Hours
TML MultiState Intergovernmental Employee Benefits Pool (IEBP) 1821 Rutherford Lane, Suite 300 Austin, Texas 78754
PO Box 149190 Austin, Texas 78714-9190
Customer Care Helpline: 8:30 AM - 5:00 PM Central Secured Customer Care E-mail: Visi click on the "Login" button click on "Online
8:30 AM - 5:00 PM Central Customer Care" under the "My Tools" menu TML MultiState IEBP Internet Website: Twenty-four (24) hours Medical Authorizations: 8:30 AM - 5:00 PM Central Prescription Authorizations: RxResults Toll Free: (855) 892-0936 Local: (501) 686-7463
Professional Health Coaches: Professional Health Coaches will answer basic health 8:30 AM - 6:00 PM Central or and medication questions and assist Covered Individuals with the Healthy Initiatives Scheduled Appointment Incentive Program. Covered Individuals may enroll in professional health coaching. Spanish Line: Where to Mail Paper Medical Claims: TML MultiState IEBP PO Box 149190 Austin, Texas 78714-9190
Where to Mail Paper OptumRx Prescription Claims: OptumRx PO Box 29044 Hot Springs, AR 71903
OptumRx Prescription Pharmacist Service Center: (800) 788-7871
OptumRx Prescription Member Customer Service: OptumRx Prescription Mail Service Customer Service: Register at optumrx.com to receive e-mail reminders when it is time to refill your (800) 797-9791 (TTY 711)
prescription. OptumRx Specialty/Biotech Pharmacy: (866) 218-5445 Fax: (800) 491-7997
1-800-Teladoc
After Hours and/or Weekend Medical and Mental Healthcare Emergencies: Call 911 or immediately go to the emergency department. Page 1 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide
TABLE OF CONTENTS
Page 2 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide PRESCRIPTION FLOWSHEET
How to get the most out of your IEBP Medication Therapy Management Program
Medication Therapy Management Alliance Partners
 Pharmacy Benefit Manager Network: OptumRx Membership: (888) 543-1369 24 hours a day/7 days a
OptumRx Online Pharmacy Locator Tool: Members can locate a Value Network pharmacy near them by using the OptumRx Online Pharmacy Locator Tool a  OptumRx Pharmacy Help Desk: (800) 788-7871
 OptumRx Mail Service Program: (800) 797-9791 (TTY 711)  OptumRx Specialty Pharmacy: (866) 218-5445 Fax: (800) 491-7997
 Submit OptumRx Paper Prescription Claims to: OptumRx PO Box 29044 Hot Springs, AR 71903
 Evidence-Based Medication Review: RxResults Toll Free: (855) 892-0936 Local: (501) 686-7463 Fax: (877) 540-9036
EBRx provides both clinical and economical evaluations of drugs through its Pharmacy and Therapeutics (P&T) Committee. Retail and Mail Order Covered Individual Copayments
MAC A Plan: If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference
between the brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference
between the brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The MAC
differential applies to all prescriptions purchased through this program when a generic alternate is available.
MAC C Plan: If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the appropriate
brand copay.
Covered Individual Out of Pocket (OOP)
Prescribed (Doctor Ordered)
(up to 34 day supply max Over the Counter Alternates and Prescription Networks
unless noted otherwise) (up to 34 day dispensement)  Smoking Cessation (Nicorette Gum), Quantity Limit - 3 months per plan year  Aspirin, Folic Acid, Fluoride Chemoprevention Supplements, Iron Deficiency Supplements, and Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at an increased risk for falls; per prescription Network Retail: 34 day Non-Cost Share most Generic Dispensement $0.00 (up to 34 day supply) Network Retail: 90 day Non-Cost Share most Generic Dispensement $9.00 (35 up to 90 day supply) OptumRx Network Non-Cost Share Best Brand/Formulary List OptumRx Network Non-Cost Share Non-Best Brand/Non-Formulary List OptumRx Network Cost Share OptumRx Specialty/Biotech Prescriptions $100.00 (up to 34 day supply) OptumRx Biosimilar Generic Prescriptions $75.00 (up to 34 day supply) Prescription Refill Control Standards Women's Preventive Health Services Covered Individual Out of Pocket (OOP)
Retail Rx
Medical Plan Prescription Plan
Plan Ineligible
Oral Contraceptives Generic (no cost share) IUD Device (no cost share) Implant Device (no cost share) Permanent Implantable Contraceptive Coil (subject to the appropriate deductible and benefit percentages) Insertion and/or Removal of Devices (no cost share) Sonogram to Detect Placement of Device (no cost share) Injectable Contraceptives (no cost share) Injectable Administration Fee (no cost share) Diaphragm (cervical), Hormone Vaginal Ring, Hormone Patch, Cervical Cap, Spermicides, Sponges (no cost share) Diaphragm Instruction and Fitting Fee (no cost share) Emergency Birth Control Over-The-Counter (OTC) Birth Control Contraceptive Management (no cost share) Female Condoms (no cost share) Medications for risk reduction of breast cancer in women who are at increased risk for breast cancer and at low risk for adverse medication effects: Tamoxifen or Raloxifene Page 3 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Step 1: Check the Cost
Save on Generics at OptumRx Pharmacies!
Most generics are $0 at OptumRx Network Pharmacies. Find a Network Pharmacy near you by going to: www.optumrx.com Go to OptumRx.com and Log In to check the cost of your prescription. Save on Over the Counter Equivalents!
The following over the counter (OTC) equivalents are $0 with a prescription: Please keep in mind that drug prices may change Doctor Ordered: frequently, and can vary by pharmacy.  Smoking Cessation (Nicorette Gum), Quantity Limit - 3 months per plan year  Aspirin, Folic Acid, Fluoride Chemoprevention Supplements, Iron Deficiency Supplements, and Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at an increased risk for falls; per prescription Step 2: Step Therapy, Prior Authorization & Cost Share
You should check the attached Step Therapy, Prior Authorization and Cost Share prescription sheets to find out if your prescription must be pre-authorized. Important Information
» IEBP Billing & Eligibility: (800) 282-5385 » IEBP Website If your prescription is on a step therapy or prior authorization list, please have your doctor/prescription prescribing provider contact
RxResults toll free: (855) 892-0936 or local: (501) 686-7463.
Step Therapy
Prior Authorization
Cost Share

Note:
RxResults is the IEBP contracted Evidence-Based Prescription Pharmacy Review Organization. RxResults should be contacted for the Prior Authorization Services identified below. The RxResults (Doctor/Prescription Prescribers Only) number is toll free: (855) 892-0936 or local: (501) 686-
7463. All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate
new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines.
Page 4 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Step Therapy
For Clinical Authorization, doctor/prescription prescribers should call RxResults toll free: (855) 892-0936 or local: (501) 686-7463.
Your doctor/prescription prescriber will be asked a series of questions and RxResults will then approve or deny the authorization
request.
Sample of what will occur at pharmacy:
Claim is processing for Advair® & the following message will alert the pharmacist: Step Therapy after inhaled steroid 1st or Prior
Authorization call toll free: (855) 892-0936 or local: (501) 686-7463.
Required for members <40 years of age who have not demonstrated adherence to an inhaled corticosteroid (ICS) (90 days of therapy in the past 120 days). Category A

Inhaled corticosteroid (ICS) - Member must demonstrate adherence to an inhaled steroid and/or satisfy specific clinical criteria as determined by RxResults prior to obtaining a Category B medication. Category B (Only after failure with a Category A medication)
 Advair®
 Perforomist® Treatment Plan Adherence is required for authorization to be approved.
Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice
to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines. Important Information
»
IEBP Billing & Eligibility: (800) 282-5385 RxResults (Doctor/Prescription Prescribers Only): Toll Free: (855) 892-0936 Local: (501) 686-7463
Page 5 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Clinical Prior Authorization
The list of conditions below may change as appropriate for the plan. For prior authorization requests, please have your
doctor/prescription prescriber call RxResults toll free: (855) 892-0936 or local: (501) 686-7463. Your doctor/prescription prescriber
will be asked a series of questions and RxResults will then approve or deny the authorization request. A Prior Authorization is active
for one year. If the covered individual has consistently taken the medication, (no lapse in medication greater than 100 days) the
prescribing provider will be required to resubmit clinical information to maintain the ongoing Prior Authorization Approval.
Antibiotics
 Zyvox®
General
These medications may be reimbursed following satisfaction of clinical criteria as determined by prior authorization review.
 Attention Deficit Disorder ADHD (For individuals 17 years of age or older)
 Narcolepsy Medications including Xyrem® (For individuals 17 years of age or older)
 Acne Medications: only required for Tretinoin all dosage forms (e.g. Retin-A, Differin, Tazorac) (For individuals 26 years of age or

Major Biotech Prescription Categories
 Blood Cell Deficiency  Crohn's Disease
 Cystic Fibrosis  Osteoarthritis  Pulmonary Arterial Hypertension  Rheumatoid Arthritis  HIV/Immune Deficiency Medications  Multiple Sclerosis  Oncology Oral  Renal Disease
Testosterone - All Products
Two separate morning lab results defining the testosterone level will be required. The lab report will indicate whether the level is low or within normal ranges.  Injectable Only (topical and buccal testosterone products are not covered)
Diabetes
These medications may be reimbursed following satisfaction of clinical criteria as determined by prior authorization review.
 Bydureon®  Byetta®
 Januvia®/Janumet®, Janumet XR® (covered for diabetes only)  Jentadueto®  Juvisync®  Kazano®  Kombiglyze®  Victoza®
Lipid-Lowering Agents (Statins)
 Crestor® (Prior authorization required for 40mg strength only. Other strengths considered Cost Share Copay drugs.)
Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice
to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines. Page 6 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide OptumRx Specialty/Biotech Pharmacy
OptumRx Specialty Pharmacy is the IEBP Specialty/Biotech prescription alliance partner for the IEBP membership. Steps Necessary for Specialty/Biotech Medication
For prior authorization requests, your provider will be required to call RxResults toll free: (855) 892-0936 or local: (501) 686-7463
for a prior authorization form.

RxResults Phone: Toll Free: (855) 892-0936 Local: (501) 686-7463
RxResults Fax: (877) 540-9036 OptumRx Specialty Pharmacy Phone: (866) 218-5445 OptumRx Specialty Pharmacy Fax: (800) 491-7997 Ordering Specialty/Biotech Prescriptions
 You can order directly from OptumRx Specialty Pharmacy by calling (866) 218-5445.
 Please note: Biotech-$100.00 copay, Biosimilar-$75.00 copay
* Prescriptions require Prior Authorization Bold Underlined are Ineligible Prescriptions
(Toll Free: (855) 892-0936 Local: (501) 686-7463)
*Mitoxantron (Onc Inj) Detoxicants
Androgens
*Perjeta (Onc Inj) Anti Convulsants
Hycamtin (oral) (Onc Inj) *Proleukin (Onc Inj) Anti Gout Agents
Anti Hypertensive
Birth Control
Antiemedic
*Sylatron (Onc Inj) Blood Disorders
Antilipemic Agents
Anti Neoplastic
*Adcetris (Onc Inj) *Leuprolide (Onc Inj) Temodar (Onc Inj) Temozolomide (Onc Inj) Antiviral
*Marqibo (Onc Inj) Erwinaze (Onc Inj) *Torisel (Onc Inj) *Treanda (Onc Inj) Azacitidine (Onc Inj) Trelstar Dep (Onc Inj) Trelstar LA (Onc Inj) Page 7 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Enzyme Therapy
*Neupogen (Blood Mod) Hormonal Agents
Repronex
Conditions
Vidaza (Onc Inj) Hormones and
Hormone Modifiers
Immune Globulin
Chorionic
Hemophilia
Growth Hormone
HIV/AIDS
Iron Overload
Zoladex (Onc Inj) Metabolic Agents
Central Nervous
System Agents
Multiple Sclerosis
*Aranesp (Blood Mod) Coagulation Therapy
*Gilenya (Tier 3) Modifiers
Infertility
Bravelle
Cetrotide
Chor Gonadot
Follistim AQ
Ganirelix AC
Gonal-f RFF
Zoledronic (Onc Inj) Page 8 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Narcolepsy
Oncology
Respiratory Tract
Ophthalmic Agents
Pain Management
Parkinson's Disease
Therapeutic
Nutrients
Pregnancy
Recombinant Human
Leptin Analog
Transplant
Pulmonary Fibrosis
Respiratory Agents
Pulmonary
Disclaimer: Not all Biotech/Biosimilar medications are eligible under the IEBP Medication Therapy Management Plan.
This Specialty Pharmacy Drug List may not be a complete representation of all available specialty drugs; this list is subject to change at any time without prior notice. Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please consult your physician. Page 9 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Cost Share Copay Drugs
IEBP has implemented a clinical evidence-based approach to its prescription plan for groups adopting 2014-2015 Plan Year benefits. As such, IEBP will impose a higher patient copayment for drugs for which there is no clinical evidence to show that non-preferred "Cost Share Drugs" perform any better than therapeutic doses of less costly preferred "Alternative Drugs". ADHD/CNS Stimulants
 Impacts utilization on: Immediate Release Amphetamine Products: Adderall®, Dexedrine®; Immediate Release Methylphenidate
Products: Ritalin® (brand only), Focalin®; Extended Release Amphetamine Products: Adderall XR®, Amphetamine ER, Dexedrine
CR®, dextroamphetamine ER; Extended Release Methylphenidate Products: Concerta®, Daytrana®, Focalin XR®, Metadate CD®,
methylphenidate ER, Ritalin LA®, Intuniv®, Kapvay®, Nuvigil®, Provigil® (brand only); Alternate Drugs: Generic: methylphenidate®,
amphetamine, guanfacine immediate release (for Intuniv®), clonidine (for Kapvay®), modafinil (for Provigil®, Nuvigil®); Brand:
Strattera®, Vyvanse®
Analgesics/Anti-Inflammatory/Pain Agents
 Impacts utilization on: Lazanda®, Subsys®; Alternative Drugs: Generic: fentanyl patch, fentanyl lozenge
 Impacts utilization on: Celebrex®, Naprelan®, Flector patch®, Solaraze®, Pennsaid®, Zipsor®; Alternative Drugs: Generic:
naproxen, diclofenac  Impacts utilization on: Conzip®, Rybix®, Ryzolt®, tramadol ER, Ultracet®, Ultram®, Ultram ER®; Alternative Drug: Generic:
Antibiotics: Anti-Infective Agents
 Impacts utilization on: Adoxa®, Doryx®, Dynacin®, minocycline ER, Monodox®, Moxatag®, Periostat®, Solodyn®, Oraxyl®, Oracea®;
Alternative Drugs: Generic: amoxicillin (for Moxatag), capsule minocycline (for Dynacin®, Solodyn®), doxycycline (for Adoxa®,
Doryx®, Monodox®, Periostat®, Oracea®, Oraxyl®)
Anticonvulsants
 Impacts utilization on: Gralise®, Lamictal XR®, lamotrigine ER, Lyrica®, Neurontin®; Alternative Drugs: Generic: gabapentin (for
Gralise®, Lyrica®, Neurontin®), lamotrigine (for Lamictal XR®, lamotrigine ER) Antidepressants/Fibromyalgia
 Impacts utilization on: Cymbalta®, duloxetine, Effexor XR, Pristiq, Savella®, Viibryd®; Alternate Drugs: Generic: bupropion,
citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER (capsules only) Antihypertensive Agents
 Impacts utilization on: Amturnide®, Atacand®/Atacand HCT®, Avapro®/Avalide®, Azor®, Benicar®/Benicar HCT®, Cozaar®/Hyzaar®
(brand only), Diovan®/Diovan HCT® (brand only), Edarbi®/Edarbyclor®, Exforge®/Exforge HCT® (brand only), Micardis®/Micardis
HCT®, Tekamlo®, Tekturna®/Tekturna HCT®, Teveten®/Teveten HCT®, Tribenzor®, Twynsta®, Valturna®; Alternate Drugs: Generic:
metroprolol-hydrochlorothiazide (for Dutoprol®), any generic ACE Inhibitor, losartan/losartan HCTZ (for Cozaar®/Hyzaar®),
irbesartan/irbesartan HCTZ (for Avapro®/Avalide®), eprosartan/eprosartan HCTZ (for Teveten®/Teveten HCT®),
valsartan/valsartan HCTZ (for Diovan®/Diovan HCT®)
Central Nervous System: Sedative Hypnotics
 Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, zolpidem ER®, Intermezzo®, Silenor®,
Zolpimist®; Alternate Drugs: Generic: zolpidem immediate release (generic for Ambien®), zaleplon (generic for Sonata®),
doxepin (for Silenor®), zolpidem (for Intermezzo®, Zolpimist®)
Lipid-Lowering Agents (Statins)
 Impacts utilization on: Advicor®, Altoprev®, amlodipine/atorvastatin combination, Caduet®, Crestor® (except 40mg strength),
Lescol®, Lescol XL®, Lipitor®, Livalo®, Mevacor®, Pravachol®, Simcor®, Vytorin®, Zocor®, Zetia®; Alternate Drugs: atorvastatin
(generic for Lipitor®), lovastatin (generic for Mevacor®), pravastatin (generic for Pravachol®), simvastatin (generic for Zocor®)
Lipid-Lowering Agents (Fibric Acid Derivatives)
 Impacts utilization on: Antara®, fenofibric acid, Fenoglide®, Fibricor®, Lipofen®, Lofibra®, Lopid®, Tricor®, Triglide®, Trilipix®,
fenofibrate 43, 130 and 145mg; Alternate Drugs: fenofibrate (generic for Tricor® and various other brands), gemfibrozil
(generic for Lopid®)
Page 10 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Migraine Headaches
 Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Maxalt®, Relpax®, Treximet®, zolmitriptan, Zomig®, Zomig ZMT®;
Alternate Drugs: Generic: sumatriptan (for Imitrex®), naratriptan (for Amerge®), rizatriptan (for Maxalt®)
Nasal Steroids
 Impacts utilization on: Beconase AQ®, Dymista®, Flonase® (brand), Nasacort AQ®, Nasonex®, Omnaris®, Rhinocort AQ®, Veramyst®,
QNASL®, triamcinolone, Zetonna®; Alternate Drugs: Generic: fluticasone (for Flonase®) and flunisolide
Osteoporosis Drugs
 Impacts utilization on: Actonel®, Actonel® w/Calcium, Alendronate® (brand), Atelvia®, Binosto®, Boniva®, Fosamax®, Fosamax-D®,
ibandronate (generic for Boniva®); Alternate Drug: Generic: alendronate
Otic Products
 Impacts utilization on: Auralgan®; Alternate Drug: Generic: benzocaine-antipyrine
Overactive Bladder Drugs
 Impacts utilization on: Detrol®, Detrol LA®, Ditropan XL®, Gelnique®, Myrbetriq®, Enablex®, oxybutynin ER®, Oxytrol® patches,
Sanctura®, Sanctura XR®, tolterodine, Toviaz®, trospium CL, trospium CL ER, Vesicare®; Alternate Drugs: Generic: oxybutynin
immediate release
Respiratory/Allergy/Asthma: Antihistamines
 Impacts utilization on: Clarinex®, levocetirizine, Xyzal®; Alternate Drugs: Over-the-Counter (OTC) versions of Allegra
(fexofenadine), Claritin (loratadine), and Zyrtec (cetirizine) are available at member's out of pocket cost. Respiratory/Allergy/Asthma: Antihistamines – Decongestant
 Impacts utilization on: Clarinex-D®; Alternate Drugs: Over-the-Counter (OTC) versions of Allegra-D (fexofenadine-D), Claritin-D
(loratadine-D), and Zyrtec-D (cetirizine-D) are available at member's out of pocket cost. Skeletal Muscle Relaxants
 Impacts utilization on: Amrix®, Carisoprodol® 250mg (brand), cyclobenzaprine ER, Fexmid®, Flexeril®, Lorzone®, metaxalone
(generic for Skelaxin®), Norflex® (including its generic orphenadrine injection), Parafon Forte®, Robaxin®, Skelaxin®, Soma®, Soma®
Compound, Soma® Compound w/Codeine, Zanaflex®; Alternate Drug: Generic: carisoprodol, chlorzoxazone, cyclobenzaprine,
methocarbamol, tizanidine
Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton Pump Inhibitors
 Impacts utilization on: Aciphex®, Dexilant®, Duexis®, lansoprazole, Nexium® (prescription strength), Prevacid® (prescription
strength), Prilosec® (prescription strength), Protonix®, Vimovo®, Zegerid capsules (prescription strength – including generic
omeprazole/bicarbonate); Alternate Drugs: Generic: omeprazole, pantoprazole, ibuprofen, and famotidine separately (for
Duexis®); Over-the Counter (OTC) versions of Nexium 24 HR (esomeprazole), Priolosec® (omeprazole), Prevacid® (lansoprazole),
and Zegerid® (omeprazole/sodium bicarbonate) are available at member's out of pocket cost.
Topical Antifungal Agents
 Impacts utilization on: Pedipirox-4®; Alternate Drug: Generic: ciclopirox
Cost Share Copays
 Network Retail Copay – up to 34 day supply - $120 or cost of drug (whichever is less)
 Mail Order Copay – 35 up to 90 days supply - $300 or cost of drug (whichever is less)
Page 11 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Sample Cost Share Letter

Date:

«MemberFN» «MemberLN»
«MemberAdd1» «MemberAdd2»
«MemberCity» «MemberSt» «MemberZip»
Dear TML MultiState IEBP (IEBP) Member:
The purpose of this letter is to notify you that your prescription cost share medications have been updated for the benefit plan anniversary year.
Please read this letter closely due to the prescription benefit updates.
The IEBP records indicate you have taken one of the "Cost Share Drugs" that has a therapeutic alternative drug available for a lower co-payment.
Based on a review of current medical literature, there is no clinical evidence to show that the "Cost Share Drugs" (left column below) perform any
better than the therapeutic "Alternative Drugs". If you choose to continue taking one of the Cost Share Drugs, you will have a larger out of pocket
expense effective on your benefit plan anniversary date. The cost share benefit changes for Plan Year 2014-2015 include:
2014-2015 NEW Cost Share Prescriptions
ADHD/CNS Stimulants
 Impacts utilization on: Immediate Release Amphetamine Products: Adderall®, Dexedrine®; Immediate Release Methylphenidate Products:
Ritalin® (brand only), Focalin®; Extended Release Amphetamine Products: Adderall XR®, Amphetamine ER, Dexedrine CR®, dextroamphetamine
ER; Extended Release Methylphenidate Products: Concerta®, Daytrana®, Focalin XR®, Metadate CD®, methylphenidate ER, Ritalin LA®, Intuniv®,
Kapvay®, Nuvigil®, Provigil® (brand only); Alternate Drugs: Generic: methylphenidate®, amphetamine, guanfacine immediate release (for
Intuniv®), clonidine (for Kapvay®), modafinil (for Provigil®, Nuvigil®); Brand: Strattera®, Vyvanse®
Analgesics/Anti-Inflammatory/Pain Agents
 Impacts utilization on: Lazanda®, Subsys®; Alternative Drugs: Generic: fentanyl patch, fentanyl lozenge
 Impacts utilization on: Celebrex®, Naprelan®, Flector patch®, Solaraze®, Pennsaid®, Zipsor®; Alternative Drugs: Generic: naproxen, diclofenac
 Impacts utilization on: Conzip®, Rybix®, Ryzolt®, tramadol ER, Ultracet®, Ultram®, Ultram ER®; Alternative Drug: Generic: tramadol
Antibiotics: Anti-Infective Agents
 Impacts utilization on: Adoxa®, Doryx®, Dynacin®, minocycline ER, Monodox®, Moxatag®, Periostat®, Solodyn®, Oraxyl®, Oracea®; Alternative
Drugs: Generic: amoxicillin (for Moxatag), capsule minocycline (for Dynacin®, Solodyn®), doxycycline (for Adoxa®, Doryx®, Monodox®, Periostat®,
Oracea®, Oraxyl®)
Anticonvulsants
 Impacts utilization on: Gralise®, Lamictal XR®, lamotrigine ER, Lyrica®, Neurontin®; Alternative Drugs: Generic: gabapentin (for Gralise®,
Lyrica®, Neurontin®), lamotrigine (for Lamictal XR®, lamotrigine ER) Antidepressants/Fibromyalgia
 Impacts utilization on: Cymbalta®, duloxetine, Effexor XR, Pristiq, Savella®, Viibryd®; Alternate Drugs: Generic: bupropion, citalopram,
escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER (capsules only) Antihypertensive Agents
 Impacts utilization on: Amturnide®, Atacand®/Atacand HCT®, Avapro®/Avalide®, Azor®, Benicar®/Benicar HCT®, Cozaar®/Hyzaar® (brand only),
Diovan®/Diovan HCT® (brand only), Edarbi®/Edarbyclor®, Exforge®/Exforge HCT® (brand only), Micardis®/Micardis HCT®, Tekamlo®,
Tekturna®/Tekturna HCT®, Teveten®/Teveten HCT®, Tribenzor®, Twynsta®, Valturna®; Alternate Drugs: Generic: metroprolol-
hydrochlorothiazide (for Dutoprol®), any generic ACE Inhibitor, losartan/losartan HCTZ (for Cozaar®/Hyzaar®), irbesartan/irbesartan HCTZ (for
Avapro®/Avalide®), eprosartan/eprosartan HCTZ (for Teveten®/Teveten HCT®), valsartan/valsartan HCTZ (for Diovan®/Diovan HCT®)
Central Nervous System: Sedative Hypnotics
 Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, zolpidem ER®, Intermezzo®, Silenor®, Zolpimist®; Alternate
Drugs: Generic: zolpidem immediate release (generic for Ambien®), zaleplon (generic for Sonata®), doxepin (for Silenor®), zolpidem (for
Intermezzo®, Zolpimist®)
Page 12 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Lipid-Lowering Agents (Statins)
 Impacts utilization on: Advicor®, Altoprev®, amlodipine/atorvastatin combination, Caduet®, Crestor® (except 40mg strength), Lescol®, Lescol
XL®, Lipitor®, Livalo®, Mevacor®, Pravachol®, Simcor®, Vytorin®, Zocor®, Zetia®; Alternate Drugs: atorvastatin (generic for Lipitor®), lovastatin
(generic for Mevacor®), pravastatin (generic for Pravachol®), simvastatin (generic for Zocor®)
Lipid-Lowering Agents (Fibric Acid Derivatives)
 Impacts utilization on: Antara®, fenofibric acid, Fenoglide®, Fibricor®, Lipofen®, Lofibra®, Lopid®, Tricor®, Triglide®, Trilipix®, fenofibrate 43, 130
and 145mg; Alternate Drugs: fenofibrate (generic for Tricor® and various other brands), gemfibrozil (generic for Lopid®)
Migraine Headaches
 Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Maxalt®, Relpax®, Treximet®, zolmitriptan, Zomig®, Zomig ZMT®; Alternate
Drugs: Generic: sumatriptan (for Imitrex®), naratriptan (for Amerge®), rizatriptan (for Maxalt®)
Nasal Steroids
 Impacts utilization on: Beconase AQ®, Dymista®, Flonase® (brand), Nasacort AQ®, Nasonex®, Omnaris®, Rhinocort AQ®, Veramyst®, QNASL®,
triamcinolone, Zetonna®; Alternate Drugs: Generic: fluticasone (for Flonase®) and flunisolide
Osteoporosis Drugs
 Impacts utilization on: Actonel®, Actonel® w/Calcium, Alendronate® (brand), Atelvia®, Binosto®, Boniva®, Fosamax®, Fosamax-D®, ibandronate
(generic for Boniva®); Alternate Drug: Generic: alendronate
Otic Products
 Impacts utilization on: Auralgan®; Alternate Drug: Generic: benzocaine-antipyrine
Overactive Bladder Drugs
 Impacts utilization on: Detrol®, Detrol LA®, Ditropan XL®, Gelnique®, Myrbetriq®, Enablex®, oxybutynin ER®, Oxytrol® patches, Sanctura®,
Sanctura XR®, tolterodine, Toviaz®, trospium CL, trospium CL ER, Vesicare®; Alternate Drugs: Generic: oxybutynin immediate release
Respiratory/Allergy/Asthma: Antihistamines
 Impacts utilization on: Clarinex®, levocetirizine, Xyzal®; Alternate Drugs: Over-the-Counter (OTC) versions of Allegra (fexofenadine), Claritin
(loratadine), and Zyrtec (cetirizine) are available at member's out of pocket cost. Respiratory/Allergy/Asthma: Antihistamines – Decongestant
 Impacts utilization on: Clarinex-D®; Alternate Drugs: Over-the-Counter (OTC) versions of Allegra-D (fexofenadine-D), Claritin-D (loratadine-D),
and Zyrtec-D (cetirizine-D) are available at member's out of pocket cost. Skeletal Muscle Relaxants
 Impacts utilization on: Amrix®, Carisoprodol® 250mg (brand), cyclobenzaprine ER, Fexmid®, Flexeril®, Lorzone®, metaxalone (generic for
Skelaxin®), Norflex® (including its generic orphenadrine injection), Parafon Forte®, Robaxin®, Skelaxin®, Soma®, Soma® Compound, Soma®
Compound w/Codeine, Zanaflex®; Alternate Drug: Generic: carisoprodol, chlorzoxazone, cyclobenzaprine, methocarbamol, tizanidine
Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton Pump Inhibitors
 Impacts utilization on: Aciphex®, Dexilant®, Duexis®, lansoprazole, Nexium® (prescription strength), Prevacid® (prescription strength), Prilosec®
(prescription strength), Protonix®, Vimovo®, Zegerid capsules (prescription strength – including generic omeprazole/bicarbonate); Alternate
Drugs: Generic: omeprazole, pantoprazole, ibuprofen, and famotidine separately (for Duexis®); Over-the Counter (OTC) versions of Nexium 24
HR (esomeprazole), Priolosec® (omeprazole), Prevacid® (lansoprazole), and Zegerid® (omeprazole/sodium bicarbonate) are available at
member's out of pocket cost.
Topical Antifungal Agents
 Impacts utilization on: Pedipirox-4®; Alternate Drug: Generic: ciclopirox
Cost Share Copays
Network Retail Copay – up to 34 day supply - $120 or cost of drug (whichever is less)
Mail Order Copay – 35 up to 90 days supply - $300 or cost of drug (whichever is less)
Members taking one of the above cost share drugs may wish to speak with their physician about less expensive alternatives. Your doctor/prescription
prescriber may also call RxResults' Evidence-Based Prescription Drug Program (EBRx) provider call center toll free: (855) 892-0936 or local: (501) 686-
7463 if they have questions about this plan and the cost share drugs. Your doctor is most qualified to balance quality and safety considerations in
choosing the most appropriate medications for your treatment program. The final prescribing decision rests with you and your doctor – changing
medications is voluntary.
Page 13 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide New OptumRx ID Card
Back
Contact IEBP's customer care at (800) 348-7879 with any questions. Sincerely, Susan L. Smith Executive Director Page 14 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Prescription Benefits
Coverage for eligible biotech and biosimilar prescriptions that are available through the Pharmacy Benefit Manager or from Network Providers will be paid per the Medication Therapy Management Guide. For eligible prescriptions purchased outside of the Pharmacy Benefit Manager or the Network Providers, the plan will pay at the out of network benefit percentage and will not, at any time, pay at 100%. MAC A Rx Plan
If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference between the
brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference between the
brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The MAC differential applies
to all prescriptions purchased through this program when a generic alternate is available.
MAC C Rx Plan
Covered individual will pay the appropriate copayment amount of the prescription. High Deductible Health Savings Account Benefit Plans
The wellness/preventive medication list may be accessed at the copay out of pocket cost. The high deductible will have to be met prior to non-wellness/preventive medications being accessed at the copay out of pocket cost. Authorized Generics
The use of authorized generics undermines the Hatch-Waxman Act by devaluing the 180 day exclusive patent period incentive. Ultimately, consumers pay the prices as brand companies keep drug prices high and access to affordable alternative medicine is delayed. Once a generic (single or multi source) medication alternative is allowed on the market the generic copay will be applied. The generic company that is first to successfully challenge a questionable brand patent, file an abbreviated new drug application with the FDA and receive approval to market that drug is awarded 180 days exclusivity. During the 180 day period, that generic company alone is permitted to compete with the brand company, allowing the generic company to bring affordable medicines to consumers faster. Patents are generally good for 20 years from the date of filing. The abbreviated new drug application approval allows manufacturers
to bring generic competitors to market which allows the generic to challenge the current patent on the brand medication.
Authorized generics are generally coded as brand drugs by Medispan and First Databank due to single source classification and
manufactured by the brand name manufacturer. This brand coding is what causes the higher dollar out of pocket cost.
OptumRx Mail Order Service
OptumRx Mail Service Pharmacy is the mail order alliance partner for IEBP membership. OptumRx state-of-the-art Mail Service Pharmacy sends refrigerated injectable medications via express delivery to patients at the location of their choice, or to providers to administer to patients in their offices. Our goal is to meet and exceed members' needs when it comes to how, when, and where they receive their medications. How do I use OptumRx Mail Service Pharmacy for new prescriptions?
Ordering a new medication is easy with our website. Just log on toFrom there go to My Account then click on
Manage My Mail Service to fill a new prescription through our easy-to-use online tools.
Or, if you prefer to speak to someone on the phone, call (800) 797-9791 (TTY 711) to order through home delivery anytime. How will I order refills from OptumRx Mail Service Pharmacy?
Once you place your first order with OptumRx, you can choose from three different ways to order refills:
 Online: Order refills by logging into selecting Manage my Prescriptions and viewing your Refills.
 Mail: Complete the reorder form included with each medication shipment and then mail it to us for processing.
 Phone: Call customer service at (800) 797-9791 (TTY 711). You can choose to use our automated system or speak with a
Also, if you register a you will receive e-mail reminders when it is time to refill your prescription. Page 15 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide How long will it take to receive my mail service prescription orders?
New prescription orders should arrive in about 10 business days after we receive complete order information, while refills should arrive in about 7 business days. OptumRx Mail Order Form
Page 16 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide OptumRx Mobile Friendly Website

Access your account anytime, anywhere
Manage your prescription drug benefits on your smartphone, iPad or other handheld device.
OptumRx Mobile makes it easy to:
 Refill mail service pharmacy prescriptions  Check the status of and track orders  Locate a pharmacy by ZIP code  View your prescription history  Set up text message medication reminders  Search your formulary by generic or brand-name drug, status, or class How do I find the Mobile Site?
Open your smart phone browser and type in m.optumrx.com. You also can type in our full address,
www.optumrx.com, and you will automatically be directed to the mobile version of our site. Once
the site is loaded on your phone, you can bookmark it.
Can I use the Mobile Site on any Smart Phone?
Yes. Just enter m.optumrx.com into the web browser of your smartphone.
Can I use both the Full Site and the Mobile Site?
Yes. If you make a change to your account or manage your prescriptions on one site, that information will be updated on the other
site as well.
How to Refill Prescriptions
1.
On the home page, click MY PRESCRIPTIONS. Click REFILL PRESCRIPTIONS. (If you are not logged in, you will be prompted to log in first.) Select the prescription(s) you would like refilled by checking the box(es). Click ADD TO CART to proceed to the Shopping Cart page. Review your selections. You can remove items from your cart, keep shopping or check out. When you are finished, click CHECK OUT. Review your shipping information and your order summary. You may change your shipping address or add a new one. Review your order summary. To make changes to your order, click BACK. If your order is complete, click SUBMIT. How to Set Up Text Message Medication Reminders
1.
On the home page, click MY PRESCRIPTIONS. Click MEDICATION REMINDERS. (If you are not logged in, you will be prompted to log in first.) Enter the mobile phone number where you want the text message reminder(s) to be sent. Select your time zone. Select your mobile carrier. Choose the type of reminder you would like to receive. You can get reminders when mail order prescriptions are ready for refill and renewal, when prescriptions are eligible for transfer to mail service and when orders have been shipped. You can also set reminders for specific times of day and for specific medications. When you are done, click SAVE. Page 17 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide COVERED AND NON-COVERED DRUGS
Drugs Covered under this Benefit
Drugs Not Covered under this Benefit
Dietary supplements, vitamins or formulas, vitamins Insulin or oral diabetic prescription; individually or in combination; Disposable insulin needles/syringes and physician Growth hormones after age 15; prescribed needles/syringes/supplies; Immunization agents, biological sera blood or blood Disposable blood/urine/glucose/acetone testing agents (e.g. Acetest Tablets, Clinitest Tablets, Male pattern baldness medications; hair growth Glucometer (one per calendar year), Lancets, Diastix Strips, Tes-Tape and Chemstrips; Therapeutic devices or appliances, including support Diabetic supplies will be purchased with order for garments and other non-medicinal substances, oral diabetic prescription. The plan will allow regardless of intended use; needles, syringes, lancets and testing strips at no Charges for the administration or injection of any drug; charge if ordered within 30 days of a prescription at Drugs labeled "Caution - limited by Federal Law to the same pharmacy; investigational use" or experimental drugs even Tretinoin all dosage forms (e.g. Retin-A, Differin, though a charge is made to the individual; Medications which are to be taken by or administered Compound medication of which at least one to an individual, in whole or in part, while he or she is a ingredient is a legend drug to maximum $200.00 per patient in a licensed hospital, rest home, sanitarium, prescription payment; extended care facility, convalescent hospital, nursing Any other drug which under the applicable State Law home or similar premises which operates on its may only be dispensed upon the written prescription premises or allows to be operated on its premises, a of a physician or other lawful prescriber; facility for dispensing pharmaceuticals; Contraceptives: Oral, Brand Extended cycle (mail Emergency contraceptives; order only), Generic Extended cycle (Network at 90 Fertility medications; days copay), Transdermal patches, Contraceptive Any prescription refilled in excess of the number devices, Levonorgestrel (Norplant), Prescription specified by the physician or any refill dispensed after one year from the physician's original order; Prescription which an eligible individual is entitled to Central Nervous System Stimulants (e.g. Adderall, receive without charges from any Workers' Adderall XR, Focalin, Focalin XR, Ritalin, Dexedrine, Compensation Laws or which is prescribed for an injury etc) will be covered for individuals through age 16 or illness which is excluded from any medical coverage (Individuals 17 years and older will require prior which is provided in conjunction with this prescription authorization through RxResults.); Prescribed smoking deterrent medications containing Anti-obesity medications; nicotine or any other smoking cessation aids, all Prescribed prenatal vitamins are not covered under the prescription card. Claims for prescribed prenatal Growth hormones through age 15; vitamins with a pregnancy diagnosis may be submitted Extended Release anti-depressive agents: Wellbutrin to IEBP for payment consideration; Cholesterol/Triglyceride-Lowering Agents: Lovaza, Extended Release migraine prophylactic agents: Niaspan and niacin ER; Non-legend drugs other than those listed above; Lifestyle convenience prescriptions (ie: erectile dysfunction prescriptions and topical and buccal testosterone products); Nutritional Supplements (i.e. Deplin, Metanx); SGLT2 Antidiabetics: Invokana, Farxiga, and Jardiance. Page 18 of 31 TML MultiState IEBP
(Rev 5.7.15)

Medication Therapy Management Guide HIGH DEDUCTIBLE HEALTH SAVINGS ACCOUNT BENEFIT PLANS WELLNESS
DRUG LIST
In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions. Preventive medications are defined as those prescribed to prevent the occurrence of a chronic disease or condition for those individuals with risk factors, or to prevent the recurrence of a disease or condition. Some examples of the medications listed are for high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, and heart disease. This list provides examples of your preventive medications by drug category/therapeutic classification. Medications may be added to or removed from the list, depending on different factors, including the intended purpose of the medication and new medications. (Blood Pressure) Adrenergic Antagonists
minoxidil tablet Diuretics
Angiotensin Converting Enzyme
Inhibitors
hydrochlorothiazide methyclothiazide Spironolactone/HCTZ Beta Blockers
triamterene/hctz Renin Inhibitor
Calcium Channel Blockers
Angiotensin II Receptor Blockers
Page 19 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide nadolol / bendroflumethiazide propranolol / hctz Combivent Respimat quinapril / hctz cromolyn nebulizer solution telmisartan / hctz ipratropium / albuterol Tudorza Pressair valsartan / hctz Oral Beta-Agonists
Misc. Antihypertensives Agents
Xanthines
ASTHMA AND COPD
(Chronic Obstructive Pulmonary Disease) Inhaled Beta-Agonists
Combination Antihypertensives
LIPID/CHOLESTEROL LOWERING
amiloride / hctz (Heart Attack and Heart Disease amlodipine / atorvastatin B Prevention) amlodipine / benazepril Bile Acid Sequestrants
atenolol/chlorthalidone ipratropium inhalation solution cholestyramine lite levalbuterol neb benazepril / hctz bisoprolol / hctz candesartan / hctz Striverdi Respimat Niacin Products
captopril / hctz terbutaline sulfate Combination Products
enalapril / hctz Xopenex Solution fosinopril / hctz Hyzaar Inhaled Corticosteriods
Fibric Acid Derivatives
irbesartan / hctz lisinopril / hctz budesonide suspension Flovent Diskus & HFA fenofibric acid DR Misc. Pulmonary Agents
methyldopa / hctz metoprolol / hctz Advair Diskus & HFA Moexipril / hctz Page 20 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide olanzapine-fluoxetine prochlorperazine pioglitazone / glimepiride pioglitazone /metformin omega-3-acid (Rx) OSTEOPOROSIS THERAPY
(Healthy Bones) DIABETES THERAPY
Non-Insulin Hypoglycemic Agents
Combination Products
Testing Supplies
Control Solution — for Diabetic Meters Diabetic Test Strips Diabetic Testing — Lancets Insulin Pen Needles and Needles / Insulins
calcitonin spray (Breast Cancer Prevention) glipizide/metformin Antipsychotic Drugs
glyburide micronized glyburide/metformin Page 21 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide mycophenolic DR SP (Heart Attack, Blood Clot and Stroke Prevention) lamivudine / zidovudine SP nevirapine ER SP tacrolimus cap SP MULTIPLE SCLEROSIS SP*
HIV/AIDS SP*
(Antietroviral Therapy)
abacavir / lamivudine / zidovudine SP (Prevention of Organ Rejection) VITAMINS & HEMATINICS
Pediatric Vitamins with Fluoride
(for example; Poly-Vi-Flor, Tri-Vi-Flor) Generic Products Brand Name Products cyclosporine modified SP Prenatal Multivitamins with Iron and
Folic Acid
(for example; OB Complete, prenatabs FA) Imuran mycophenolate SP Generic Products mycophenolate SP Brand Name Products To help you tell generic and brand drugs apart, all generics start with a lowercase letter. Oral and self-injectable Specialty medications are denoted by "SP" superscript and may be subject to limitations based on plan benefit design. This list is intended as a reference and may not be all-inclusive. Brand or generic availability may not be current due to changes in the market. Use of generics may be required depending upon plan design. Page 22 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide OPTUMRX POLITICAL SUBDIVISION FORMULARY
The most up to date formulary is located under "Benefits & Services > Prescription Benefits" at
OptumRx administers your prescription benefit plan. Our goal is to provide the highest quality pharmaceutical care, at lower costs. The most effective way to control costs is through the use of generic drugs and a drug formulary.
Drug Tier
Includes
Helpful Tips
Lower cost, commonly used generic drugs. Use Tier 1 drugs for the lowest out-of-pocket Lowest Cost
Some low cost brands may be included. Many common brand-name drugs, called Use Tier 2 drugs, instead of Tier 3, to help reduce Mid-range Cost
preferred brands. your out-of-pocket costs. Mostly higher cost brand drugs, also known as Many Tier 3 drugs have lower cost options in Tier Highest Cost
non-preferred brands. 1 or 2. Ask your doctor if they could work for you. Bold type = Brand-name drug
Plain type = Generic drug Underlined = Cost Share drug  = Call member customer service * = Tier 3 Preferred
Drug Name
Drug Tier
Drug Name
Drug Tier
Anti-Infectives: Antibiotics
Anti-Infectives: Antivirals
Acyclovir Tab, Cap, Suspension Amoxicillin/Clavulanate Baraclude
Ciprodex Otic Suspension
Ciprofloxacin Tab Doxycycline Hyclate Cap Revlimid
Doxycycline Hyclate Tab (immediate release) Doxycycline Monohydrate Cap Levofloxacin Tab Metronidazole Tab Cardiovascular/Heart Disease: Anticoagulants
Aggrenox
Neomycin/Polymyxin HC Otic Suspension, Solution Brilinta
Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Coumadin
Ofloxacin Otic Solution Sulfamethoxazole-Trimethoprim DS Anti-Infectives: Antifungals
Cardiovascular/Heart Disease: High Blood
Pressure
Nystatin Suspension Amlodipine/Benazepril Page 23 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Atenolol/Chlorthalidone Triamterene/HCTZ Tribenzor
Benicar HCT
Cardiovascular/Heart Disease: High Cholesterol
Bystolic
Fenofibrate 43, 130, 145mg Fenofibrate (other strengths) Dutoprol
Omega-3 Acid Cap 1 gm Edarbyclor
Simvastatin 80 mg Exforge HCT
Vytorin Tab 10-80 mg
Cardiovascular/Heart Disease: Other
Hydrochlorothiazide Amlodipine/Atorvastatin combination Isosorbide Mononitrate Nitrostat
Metoprolol Succinate Cardiovascular/Heart Disease: Pulmonary Arterial
Metoprolol Tartrate Letairis
Sildenafil Tab 20 mg Tracleer
Central Nervous System: Attention Deficit
Disorder
Amphetamine-Dextroamphetamine SR Cap 24Hr Tekturna
Dexmethylphenidate ER Tekturna HCT
Focalin XR
Page 24 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Methylphenidate Cap ER Abilify Disc
Methylphenidate Tab ER Abilify Solution
Methylphenidate HCL Sa Osm ER Tab Methylphenidate Tab Strattera
Carbidopa/Levodopa Tab Central Nervous System: Depression
Hydroxyzine Pamoate Lithium Carbonate Cymbalta
Namenda Tab
Namenda XR
Escitalopram Tab Forfivo XL
Fluoxetine Cap (not PMDD) Prochlorperazine Seroquel XR
Venlafaxine ER Cap Central Nervous System: Sedatives/Hypnotics
Central Nervous System: Migraine
Butalbital-Acetaminophen-Caffeine Tab Migranal
Phrenilin
Rizatriptan Tab, ODT Sumatriptan Tab and Spray Central Nervous System: Seizure Disorders
Sumavel Dose
Carbamazepine Tab Zomig Nasal Spray
Central Nervous System: Multiple Sclerosis
Avonex Kit
Avonex Pen Kit
Lamictal
Avonex Prefill Kit
Lamictal ODT
Betaseron
Lamictal XR
Copaxone
Gilenya*
Rebif Titrtn
Levetiracetam ER Tecfidera
Lyrica Cap
Central Nervous System: Other
Page 25 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Accu-Chek Drum Test Strips
Accu-Chek Kit Aviva Plus
Dermatology
Accu-Chek Kit Compact
Acanya Gel
Accu-Chek Kit Fastclix
Acyclovir Ointment 5% Accu-Chek Kit Multiclix
Aczone Gel
Accu-Chek Kit Nano
Accu-Chek Kit Softclix
Benzaclin
Accu-Chek Multiclix Lancets
Accu-Chek Smart Calibration Liquid
Clindamycin Gel, Lotion, Solution Accu-Chek Smart Test Strips
Clindamycin/Benzoyl Peroxide Gel 1-5% Accu-Chek Sol Calibration Liquid
Clobetasol Cream, Gel, Ointment Accu-Chek Sol Comfort Calibration Liquid
Fastclix Lancets
Glucocard Test Strips
Clotrimazole/Betamethasone Cream, Lotion Insulin Pen Needle
Condylox
Insulin Syringe/Needle
Novofine
Differin
Novofine Auto
Novotwist
Onetouch Kit Ultra Smart
Onetouch Kit Ultra
Onetouch Kit Ultra 2
Fluocinonide Cream, Gel, Ointment 0.05% Onetouch Kit Ultra Mini
Hydrocortisone Cream 2.5% Onetouch Kit Verio IQ
Ketoconazole Cream/Shampoo Onetouch Test Strips
Metrogel
Onetouch Ultra Blue Test Strips
Metronidazole Gel 0.75% Onetouch Verio IQ Test Strips
Onetouch Verio Test Strips
Soft Touch Lancets
Nystatin Cream, Ointment, Powder Softclix Lan Mis Device
Nystatin/Triamcinolone Cream, Ointment Softclix Lancets
Oxsoralen-Ul
Surestep Test Strips
Permethrin Cream 5% Truetrack Test Strips
Protopic Ointment
Diabetes/Endocrine: Insulin
Retin-A Micro
Humalog Vials
Silver Sulfadiazine Cream 1% Humalog Kwik Pen
Taclonex
Humalog Mix 50/50 Kwik Pen
Tretinoin Microsphere Gel Humalog Mix 50/50 Vials
Humalog Mix 75/25 Kwik Pen
Vectical
Humalog Mix 75/25 Vials
Zovirax Cream
Humulin 70/30 Vials
Zovirax Ointment
Humulin N Vials
Humulin N Pen
Diabetes/Endocrine Blood: Glucose Monitoring
Humulin Pen 70/30
Accu-Chek Act/Gluc Calibration Liquid
Humulin R U-500
Accu-Chek Aviva Plus Test Strips
Humulin R Vials
Accu-Chek Aviva Test Strips
Lantus Solostar
Accu-Chek Comfort Test Strips
Lantus Vials
Accu-Chek Cpt/Gluc Calibration Liquid
Levemir Flexpen
Page 26 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Levemir Vials
Eye Conditions: Allergies
Novolin 70/30 Vials
Azelastine Solution Novolin N Vials
Novolin R Vials
Novolog Flexpen
Eye Conditions: Antibiotics
Novolog Mix Flexpen
Novolog Mix 70/30 Vials
Erythromycin Ointment Novolog Penfill
Novolog Vials
Diabetes/Endocrine: Non-Insulin
Polymyxin B/Trimethoprim Solution Eye Conditions: Glaucoma
Alphagan P
Glyburide/Metformin Invokamet
Combigan
Janumet XR
Dorzolamide-Timolol Maleate Jentadueto
Kombiglyze
Timoptic Ocudose
Travatan Z
Eye Conditions: Other
Ketorolac Opthalmic Solution Tradjenta
Prednisolone Opth Restasis
Endocrine: Growth Hormone
Gastrointestinal: Acid Suppression
Nutropin
Carafate Suspension Nutropin AQ
Dexilant
Famotidine Tab 20 mg and 40 mg (Rx only) Tev-Tropin
Lansoprazole (Rx only) Endocrine: Other
Nexium (Rx only)
Omeprazole (Rx only) Dexamethasone Tab Lupron Depot 3.75 mg, 11.25 mg
Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg
Ranitidine Tab, Cap, Syrup (Rx only) Methylprednisolone Tab Prednisolone Solution (5 mg/5 mL and 15 mg/5 mL) Gastrointestinal: Nausea/Vomiting
Sensipar
Endocrine: Thyroid Hormone Replacement
Armour Thyroid
Transderm-Scop
Gastrointestinal: Other
Synthroid
Asacol HD
Page 27 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Men's Health: Prostate
Delzicol
Diphenoxylate/Atropine Halflytely Kit
Finasteride 5 mg Moviprep
Omeclamox Pak
Polyethylene Glycol 3350 Men's Health: Testosterone Therapy
Suclear Bowel Prep
Testosterone Cypionate IM Injection Suprep Bowel Prep
Miscellaneous
Zenpep (Not 5,000 units)
Antipyrine/Benzocaine Otic Solution 5.4-1.4% HIV/AIDS
Complera
Botox 100, 200 unit Injection
Intelence
Isentress
Epipen 2-Pak
Prezista
Euflexxa
Fosrenol
Stribild
Hydrocortisone AC Suppository 25 mg Lidocaine Viscous Solution 2% Infertility
Follistim AQ
Phenazopyridine Tab Gonal-f RFF
Promethazine DM Syrup Inflammatory Conditions
Promethazine/Codeine Syrup Pulmozyme
Enbrel SureClick
Humira Kit
Humira Pen Kit
Suboxone Film
Humira Pen Kit Crohns
Humira Pen Kit Psoriasis
Hydroxychloroquine Methotrexate Tab Orencia SC
Zutripro
Musculoskeletal: Osteoporosis
Men's Health: Erectile Dysfunction
Alendronate Tab (generic) Alendronate (brand)
Page 28 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Vesicare
Musculoskeletal: Other
Respiratory: Asthma/COPD
Advair Diskus
Advair HFA
Carisoprodol 250mg Aerospan
Cyclobenzaprine Tab 5, 10 mg Albuterol Nebulizer Solution Breo Ellipta
Musculoskeletal: Pain Relief
Combivent Respimat
Acetaminophen w/Codeine Flovent Diskus
Celebrex
Flovent HFA
Ipratropium/Albuterol Levalbuterol Nebulizer Solution Perforomist
Hydrocodone w/Ibuprofen Tab 7.5-200 mg Proair HFA
Hydrocodone/APAP 5, 7.5, 10/325 mg Proventil
Pulmicort
Ibuprofen Tab 400, 600, 800 mg (Rx only) Indomethacin Cap Serevent Diskus
Lidocaine Patch 5% Symbicort
Tudorza Pressair
Ventolin HFA
Morphine Sulfate ER Tab Xopenex HFA
Naproxen (Rx only) Respiratory: Nasal Allergies
Azelastine Spray Nucynta ER
Dymista Spray
Oxycodone Tab 5, 15, 30 mg Fluticasone Spray Oxycodone w/Acetaminophen Ipratropium Spray Oxycontin
Triamcinolone Spray Tramadol Tab 50 mg Veramyst
Tramadol w/Acetaminophen Respiratory: Oral Allergies
Vicodin ES
Voltaren Gel
Promethazine Tab Overactive Bladder
Gelnique
Transplant
Page 29 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Drug Name
Drug Tier
Drug Name
Drug Tier
Cellcept Tab/Suspension
Nuvaring
Cyclosporine Cap Mycophenolate 250 mg Cap/500 mg Tab Ortho Tri-Cyclen
Rapamune
Ortho Tri-Cyclen Lo
Vitamins/Electrolytes
Cyanocobalamine Injection Folic Acid 1 mg (Rx only) Klor-Con M10 and M20 Multi-Vit/Fl Chew Potassium Chloride ER Potassium Chloride Micro ER Tab, Cap Vitamin D 50,000 units (Rx only) Women's Health: Hormone Replacement
Women's Health: Birth Control
Climara Pro
Estrace Vaginal Cream
Generess Fe Chewable
Estradiol/Norethindrone Tab Medroxyprogesterone Acetate Tab Premarin Tab
Premarin Vaginal Cream
Premphase
Progesterone Cap Lo Loestrin
Vivelle-Dot
Women's Health: Vaginal Anti-Infectives
Metronidazole Vaginal Gel Medroxyprogesterone Acetate Injection Terconazole Vaginal Cream Minastrin 24 Fe Chewable
Norgest/Ethi Estradio Some of the medications on this list may NOT be covered by your plan. Their presence on this list does NOT guarantee Page 30 of 31 TML MultiState IEBP
(Rev 5.7.15) Medication Therapy Management Guide Biosimilar FDA Approval Standards
The FDA typically approves small molecule generics on the basis of pharmaceutical equivalence. Pharmaceutical equivalence suggests that the generic contains the same active ingredient at the same strength as the brand (including the particular salt if relevant). We do not believe that the FDA will insist that a biosimilar be exactly the same as the innovator product (brand); rather it will employ a more flexible standard of sameness. Such a standard would partly depend on some structure-function understanding of the innovator product. For relatively small proteins, we expect that these will be required to exhibit an identical amino acid sequence. This standard may be more flexible for larger molecules, such as antibodies. The agency will also likely consider the impact of posttranslational protein modifications, such as glycosylation. Given that structural identity is unlikely for biosimilars, the FDA is also likely to require demonstration that the biological activity of the biosimilar is very close to the reference (innovator) molecule. In the case of Lovenox, this could be demonstrated with a straight forward predictive in vitro bioassay. While such a standard could be employed in a few instances, for example in agents used to treat clotting disorders, such as hemophilia, we believe that some clinical data will be necessary for most applications. Although clinical data will be needed for most applications, the data requirements are likely to be different from the registrational studies for the reference product. A key element, in our view, is the ability to demonstrate that the biosimilar is reliably producing a biological effect that is the same as the reference product. We believe that a combination of data utilizing reliable clinical measures, and data showing clear biological response would be sufficient. For example, extensive characterization of in vitro biological activity of an oncology drug, such as receptor activity, combined with demonstration of equivalent response rates in patients, could be viewed as sufficient, without the need to undergo a lengthy clinical trial with "hard" endpoints, such as survival. Page 31 of 31 TML MultiState IEBP
(Rev 5.7.15)

Source: http://portlandtx.com/DocumentCenter/View/906