Use of generic drugs can save both you and your health plan money

University of Arkansas
April 2016
Use of generic drugs can save both you and your health plan money. This list is not all-inclusive and is not a guarantee of coverage. Plan Benefit design is the final determinate of coverage. Certain drugs (*) may be subject to Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Reference Based Pricing (RBP) requirements according to Benefit Design. Unless noted, multisource brand drugs (brand drugs with generic equivalent) are covered at 100% copay. If you have any questions about these requirements or other formulary questions, please contact a MedImpact Healthcare customer service representative at 800-788-2949. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Drug Type
Antibiotics – Cephalosporins cefaclor, cefadroxil, cefdinir, CEFTIN susp, SUPRAX 400mg only* (QL) (Quantity Limit) cefpodoxime, cefprozil, Note: all other Suprax strengths are 100% cefditoren,cefuroxime, cephalexin Antibiotics - Macrolides azithromycin, clarithromycin, clarithromycin ext-rel, erythromycin delayed-rel, erythromycin ethylsuccinate, erythromycin stearate Antibiotics - Fluoroquinolones ciprofloxacin, ciprofloxacin ext-rel, levofloxacin ,moxifloxacin Antibiotics - Penicillins clavulanate, dicloxacillin, penicillin VK Antibiotics – Other* (Prior clindamycin HCl, doxycycline hyclate, linezolid* (PA), minocycline, tetracycline Antifungals* (Prior Authorization) fluconazole, itraconazole* (QL), (Quantity Limit) ketoconazole, terbinafine tabs , voriconazole Antivirals - Influenza* (Quantity amantadine, rimantadine Antivirals - Herpes acyclovir, famciclovir, valacyclovir, valganciclovir tab Antivirals - Other - ribasphere, ribavirin HARVONI*(PA), PEGASYS* (PA), DAKLINZA* (PA), TECHINIVIE* (PA) Interferons/Interferon Combinations PEGINTRON* (PA), REBETOL (Prior Authorization) susp, SOVALDI*(PA) Anti-Adrenergic Blockers Peripherally doxazosin, prazosin, terazosin Anticoagulants/Antiplatelet Agents cilostazol, clopidogrel, AGGRENOX, ELIQUIS (QL), ( Quantity Limits) dipyridamole, ticlopidine, PRADAXA (QL), XARELTO (QL) Antihyperlipidemics - HMG (Statins) RBP: PLAN WILL PAY $0.50/PILL; REMAINING COST WILL BE APPLIED TO pravastatin, simvastatin REFERENCE BASED PRICING ADVICOR, ALTOPREV, CRESTOR, LIVALO, SIMCOR, VYTORIN Other Antihyperlipidemic Agents cholestyramine, colestipol, gemfibrozil

University of Arkansas
April 2016
Drug Type
ACE Inhibitors and ACE Inhibitor captopril, captopril-HCTZ, enalapril, fosinopril, fosinopril- hydrochlorothiazide, lisinopril, lisinopril-HCTZ, quinapril, quinapril HCTZ, ramipril, trandolapril Angiotensin II Receptor Antagonists* candesartan/-HCTZ (ST), BENICAR* (ST), BENICAR HCT* (ST), (ST), TEVETEN HCT* (ST) (ST)/-HCTZ (ST),losartan, HCTZ, valsartan/-HCTZ Antihypertensive Combinations (Step AZOR*(ST), TRIBENZOR*(ST), Antihypertensive - Others eplerenone Beta-blockers* (Quantity Limit) atenolol, carvedilol, carvedilol BYSTOLIC, COREG CR* (QL), ext-rel, metoprolol, metoprolol ext-rel, propranolol, propranolol Calcium Channel Blockers amlodipine, diltiazem ext-rel, isradipine, nimodipine, nisoldipine, verapamil ext-rel Chronic Angina* (Prior Authorization) Direct Renin Inhibitors/Combo* (Step AMTURNIDE*(ST),TEKTURNA* (ST), TEKTURNA HCT* (ST) furosemide, HCTZ, triamterene-HCTZ, torsemide Paroxysmal Nocturnal Hemoglobinuria Agents* (Prior Pulmonary Arterial Hypertension sildenafil (PA) ADCIRCA* (PA), ADEMPAS* (PA), (Prior Authorization) LETAIRIS, TRACLEER Central Nervous System
ADHD Medications* (Prior DAYTRANA* (ST), VYVANSE* (QL) Authorization) (Quantity Limit) (Step dexmethylphenidate ext-rel, methylphenidate, EFFECTIVE 1/1/13 - Extended-
methylphenidate ext-rel, Release ADHD medications will not modafinil (PA), ADDERALL XR be covered for members who are 26 years and older. Regular release ADHD drugs will continued to be covered at existing tiers. Alzheimer's Disease* galantamine,memantine* (age), rivastigmine Analgesics - Narcotic* (Quantity KADIAN (200mg), OXYCONTIN* ABSTRAL, FENTORA* (QL), KADIAN Limit)(Prior Authorization) codeine-APAP, fentanyl (40mg,70mg, 130mg, 150mg), transdermal/- buccal*(QL), hydromorphone, morphine/-ER, morphine supp, oxycodone- /APAP ER, oxycodone ibuprofen, propoxyphene, propoxyphene napsylate-APAP, tramadol/-ER

University of Arkansas
April 2016
Drug Type
Analgesics - Anti-Inflammatory/ choline magnesium trisalicylate, diclofenac, etodolac, ibuprofen, indomethacin ext-rel, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, sulindac carbamazepine, clonazepam, CELONTIN, GABITRIL BANZEL* (PA), DEPAKENE, DEPAKOTE, (Prior Authorization) clonazepam ODT, diazepam (12mg,16mg), STAVZOR DEPAKOTE ER, DILANTIN, FYCOMPA, (rectal), divalproex LYRICA (PA), ONFI (PA), OXTELLAR XR gabapentin, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, valproic acid, zonisamide alprazolam/- ext-rel, buspirone, diazepam, lorazepam, Antidepressants - Other* amitriptyline, bupropion/-ext-rel, (Quantity Limit) clomipramine, desipramine, doxepin, mirtazapine, nortriptyline, trazodone Antidepressants - SSRIs citalopram, escitalopram ,fluoxetine, paroxetine/-ER, sertraline Antidepressants - SNRIs duloxetine, venlafaxine/-ER Antiparkinsonian Agents amantadine, benztropine, AZILECT, MIRAPEX ER, ZELAPAR bromocriptine, cabergoline, levodopa ext-rel, entacapone, pramipexole, ropinirole/-XL, selegiline, tolcapone, trihexyphenidyl Antimanic Agents lithium carbonate Antipsychotic Agents* aripiprazole* (PA), MOBAN, NAVANE 20mg only, (Prior Authorization) chlorpromazine, clozapine, fluphenazine, haloperidol, olanzapine, perphenazine, paliperidone tabs, quetiapine (IR), risperidone, thioridazine, Migraine Products* (Quantity Limit) almotriptan* (QL), CAFERGOT, RELPAX* (ST,QL), ZOMIG dihydroergotamine inj, ergotamine-caffeine tabs, naratriptan (QL), rizatriptan (QL), sumatriptan (QL), zolmitriptan (QL) Multiple Sclerosis Drugs (Prior AVONEX, AUBAGIO (PA), BETASERON, Authorizatiion)(Quantity Limit) GILENYA*(PA)(QL), TECFIDERA (PA) Sedative Hypnotics – flurazepam, temazepam Benzodiazepines (BZD) (except 7.5mg and 22.5mg), triazolam Sedative Hypnotics* - Non- zaleplon* (QL), zolpidem* (QL) RBP: PLAN WILL PAY $0.19/PILL; REMAINING COST WILL BE APPLIED TO Benzodiazepine (Quantity Limit) REFERENCE BASED PRICING zolpidem tartrate ER* (QL,RBP), EDLUAR*(QL,RBP),eszopiclone (QL,RBP)INTERMEZZO*(RBP),ROZEREM* (QL,RBP), SILENOR*(QL,RBP),

University of Arkansas
April 2016
Drug Type
Skeletal Muscle Relaxants baclofen, carisoprodol, RBP: PLAN WILL PAY $0.09/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING chlorzoxazone, cyclobenzaprine, methocarbamol, tizanidine orphenadrine (RBP), orphenadrine compound (RBP), metaxalone (RBP), Other Dermatologicals*(Prior fluorouracil, spinosad*(PA) Rectal Preparations lidocaine HC ANAMANTLE HC (0.5 %-3 %) Endocrine
Diabetes - Insulin HUMALOG, HUMALOG MIX, HUMULIN, LANTUS/-SOLOSTAR, NOVOLIN, NOVOLOG Diabetes - Insulin Sensitizing metformin/-XR, pioglitazone Agents*(Prior Authorization) Diabetes - Insulin Secreting Agents chlorpropamide, glimepiride, glipizide, glipizide ext-rel, glyburide, tolazamide Diabetes - Combinations AVANDIA* (PA), AVANDAMET* (PA), metformin, metformin ext-rel, AVANDARYL* (PA), JANUVIA, Diabetes - Other Medications GLYSET, GLUCAGON BYETTA*(ST), SYMLIN EMERGENCY KIT* (QL) Diabetic - Supplies $0 copay for ABBOTT and BAYER Test Strips, Lancets, Alcohol Swabs, Insulin Needles, and Syringes. GLUCOMETER**, HUMAPEN MEMOIR, LIFESCAN TEST STRIPS, ROCHE TEST STRIP and all other NON-ABBOTT/NON- BAYER Test strips levothyroxine Antispasmodic/GI Motility phenobarbital, atropine, glycopyrrolate, hyoscyamine/-ext rel, lactulose, peg 3350- GOLYTELY, MOVIEPREP, SUPREP electrolytes, polyethylene pancrelipase CREON, PANCREAZE, ULTRESA, ZENPEP (EXCEPT ZENPEP 5K-17K-27K Gallstone Solubilizing Agents cimetidine, famotidine, nizatidine, ranitidine

University of Arkansas
April 2016
Drug Type
Genitourinary Medications bethanechol, oxybutynin RBP: PLAN WILL PAY $0.30/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING chloride, phenazopyridine, potassium citrate oxybutynin ext-rel (2nd Tier
tolterodine/-XL (RBP), trospium (RBP), GELNIQUE (RBP), MYRBETRIQ (RBP), OXYTROL (RPB), TOVIAZ (RBP), VESICARE (RBP) Inflammatory Bowel* (Quantity Limit) balsalazide, budesonide, APRISO*(QL), DELZICOL*(QL), CANASA, DIPENTUM, ENTOCORT EC, mesalamine, sulfasalazine, GIAZO, UCERIS* (ST) sulfasalazine delayed-rel Immunosuppressive Agents
Immunosuppressive* (Prior azathioprine, cyclosporine, AZASAN, RAPAMUNE, ZORTRESS*(PA) cyclosporine modified, (caps/tabs), tacrolimus caps Men's Health
Erectile Dysfunction* (Prior MUSE* (PA) (QL), VIAGRA* (PA) CIALIS* (PA) (QL), LEVITRA* (PA) (QL), Authorization) (Quantity Limit) STENDRA*(PA), STAXYN* (PA) Hormone Replacement * testosterone cyprionate, (Prior Authorization) testosterone enanthate EFFECTIVE ON 1/1/15 – TOPICAL TESTOSTERONES ARE COVERED AT alfluzosin, dutasteride, finasteride, tamsulosin Ophthalmics
Anti-Allergic Agents azelastine,cromolyn, epinastine ALAMAST, ALOCRIL, ALOMIDE, EMADINE, LASTACAFT, PATADAY Anti-Infective/Antiviral Agents bacitracin, ciprofloxacin, AZASITE, VIGAMOX erythromycin, gentamicin, gramicidin, ofloxacin, levofloxacin, polymyxin B- bacitracin, polymyxin B- trimethoprim, sulfacetamide, tobramycin, trifluridine Anti-Glaucoma Agents/ Beta- betaxolol, brimonidine, ALPHAGAN P (0.10%), BETIMOL, blockers (Quantity Limit) dipivefrin, latanoprost, BETOPTIC S, COMBIGAN, COSOPT levobunolol, metipranolol, PF,LUMIGAN (0.01%), RESCULA pilocarpine, timolol, Carboptic Anti-Inflammatory Agents bromfenac, dexamethasone, FLAREX, FML FORTE, FML ACUVAIL, ALREX, LOTEMAX diclofenac sodium, S.O.P., MAXIDEX, NEVANAC, fluorometholone, prednisolone acetate, prednisolone phosphate Respiratory
Nasal Products* (Quantity Limit) azelastine*(QL), flunisolide, RBP: PLAN WILL PAY $22.42/inhaler; REMAINING COST WILL BE APPLIED REFERENCE BASED PRICING fluticasone* (QL) budesonide spray/pump (QL,RBP), triamcinolone* (QL,RBP), BECONASE AQ* (QL,RBP), DYMISTA (RBP), NASONEX* (QL,RBP), OMNARIS* (QL,RBP), QNASL* (RBP), VERAMYST* (QL,RBP), ZETONNA (RBP)

University of Arkansas
April 2016
Drug Type
Tier 1
Asthma -Leukotriene Modulators* montelukast, zafirlukast* (ST) Asthma - Steroid Inhalants budesonide neb soln FLOVENT DISKUS/-HFA QVAR AEROBID, AEROBID-M, ALVESCO, ASMANEX, AZMACORT, DULERA Asthma - Beta Agonists Short Acting Albuterol/-ER albuterol PROAIR HFA, PROVENTIL HFA inhalation soln, metaproterenol, terbutaline Asthma - Beta Agonists - Long Acting FORADIL, SEREVENT BROVANA, PERFOROMIST Asthma - Other* (Prior Autorization) ipratropium soln, theophylline ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, DALIRESP* (PA), anhydrous ANORO ELLIPTA, ATROVENT STRIVERDI RESPIMAT, HFA, COMBIVENT, SPIRIVA/- SYMBICORT,TUDORZA, XOLAIR* (PA) acetic acid, acetic acid- COLY-MYCIN S, CORTISPORIN- aluminum acetate, acetic acid- hydrocortisone, ciprofloxacin, polymyxin B-hydrocortisone, ofloxacin otic ciclopirox soln betamethasone dipropionate ELIDEL, CORTISPORIN CORDRAN, FINACEA (15%) gel , 0.05% gel/oint/cream/lotion, fluocinolone scalp oil, triamcinolone spray, betamethasone valerate 0.1% lot/cream/oint, calcipotriene soln, clobetasol 0.05% betamethasone, fluocinolone, lidocaine, mometasone furoate, triamcinolone 0.1%, 0.25% cream/oint/lotion or 0.5% cream/oint Skin – Acne* (Prior Authorization) adapalene, benzoyl peroxide, ALA-QUIN, AZELEX clindamycin, metronidazole, sulfacetamide-sulfur, isotretinoin*(PA), tretinoin Women's Health
Antineoplastic - Hormonal Agents tamoxifen Contraceptives* (All Contraceptives $0 copay for contraceptives subject to Quantity Limit) nclude: generic oral contraceptives such as ethinyl medroxyprogesterone acetate, Apri, Kariva, Levora, Low- Ogestrel, Necon Sprintec, Trinessa, ORTHO-EVRA patch, CLIMARA PRO, COMBIPATCH, PREFEST, PREMPHASE, PREMPRO, PREMPRO LOW Hormone Replacement Therapy estradiol,estradiol patches ALORA, CENESTIN, MENEST, CLIMARA PRO, DIVIGEL, ELESTRIN, MENOSTAR, MINIVELLE, ENJUVIA, ESTRACE vaginal cream, micronized*(PA) ESTRING, FEMRING, FEMTRACE NOTE: If a product may be used to treat infertility prior authorization will be required.

University of Arkansas
April 2016
Drug Type
Tier 1
alendronate RBP: PLAN WILL PAY $0.26/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING ACTONEL (RBP), ATELVIA (RBP), ibandronate 150mg (RBP) etidronate, Prenatal Vitamins Vaginal Products* (Quantity Limit) clindamycin, clotrimazole, fluconazole* (QL on 150mg), metronidazole, terconazole Antiemetics* (Quantity Limit) granisetron* (QL), ondansetron* EMEND caps* (QL) ANZEMET* (QL), CESAMET* (PA), (QL), trimethobenzamide caps Antineoplastic Enzyme Inhibitors* NEXAVAR* (PA), SPRYCEL* (PA), (Prior Authorization) Antineoplastic Immunomodulator Agents* (Prior Authorization) Growth Hormone (Prior GENOTROPIN* (PA), HUMATROPE* (PA), OMNITROPE* (PA), NORDITROPIN* (PA), SAIZEN* (PA), SEROSTIM* (PA), TEV- NUTROPIN* (PA), NUTROPIN Hematopoietic Growth Factors ARANESP * (PA), EPOGEN* (PA), Insulin-Like Growth Factors* (Prior cevimeline CUVPOSA,NASCOBAL, NARCAN Neurological Disease, misc (Prior Rheumatoid Arthritis (Prior methotrexate HUMIRA* (PA), TREXALL ACTEMRA SC* (PA), ENBREL* (PA), ORENCIA* (PA), REMICADE* (PA), Smoking Cessation bupropion ext-rel, nicotine CHANTIX, NICOTROL INHALER transdermal
FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a
summary of prescription coverage. It is not inclusive and does not guarantee coverage. Specific prescription benefit plan
design may not cover certain categories, regardless of their appearance in this document. The plan participant's
prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list
products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and
lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for
representational purposes only. This is not an all-inclusive list. Listed products may be available generically in certain
strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to
www.medimpact.com to check coverage and copay information for a specific medicine.
1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in
accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other
charge, with the balance, if any, paid by a Plan.
2 Atacand should be reserved for plan participants who meet CHARM (Candesartan in Heart Failure – Assessment of
Reduction in Mortality and Morbidity) trial criteria.

University of Arkansas
April 2016
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Prescription Drug Benefits Under the University of
Arkansas Prescription Drug Program
Summary of Benefits
Effective January 2016
MedImpact Healthcare Systems, Inc. is the prescription benefit manager of this plan.

Retail Day's Supply Limitations:
Up to 90-day supply (one retail copay applies for each 30-day supply purchased). Mail Service Days' Supply Limitations:
Up to 90-day supply on maintenance medicines (members must fill a 60-day supply within a one year period in order to use mail service, one retail copay applies for each 30-day supply purchased). Standard Copay Amounts:
Retail (up to 30-day supply)
Mail Service (up to 90-day supply)
Note: High cost generics may have non-tier 1 copays. Out of Pocket Maximum
Individual
Pharmacy Benefit Manager
MedImpact Healthcare Systems, Inc. Customer Service: 800-788-2949 Mail Service Pharmacy:
MedVantx Pharmacy Services Tel: 866-744-0621 Fax: 605-978-3999 Formulary Type:
3-Tier Primary/Preferred Drug List Dependent Age Limitations:
Children may be covered until the end of the month in which they turn age 26. Prescription Benefit Drug Card Produced
To order a new a new ID card, call UMR at 1-888-438-6105. Refill Restrictions:
Plan participant must use 50 percent of medicine before refill permitted at retail (60 percent if refilled through mail service or Choice90). Paper Claim Reimbursement for Plan
If plan participant fails to use prescription drug card at a retail pharmacy and submits a paper claim to MedImpact Healthcare Systems for reimbursement, the claim will be paid at the same rate the pharmacy would have been paid, less the applicable copay. There is also a $3.00 processing fee withheld from plan participant reimbursement. Paper claim forms available online Pharmacy Network:
Full pharmacy network; most pharmacies in Arkansas are included. For a complete list of participating pharmacies, please log in as a membe Compounded Drug Reimbursement
It is the policy of the University of Arkansas to place all compounded drugs at third tier ($80 copay) under the prescription drug program. A compounded drug is considered to be any drug that is combined with another drug outside of the manufacturer's setting. This policy includes the compounding of one or more generic drugs. Brand Drug Status When Generic is
If the brand drug has a generic equivalent, the member will be responsible for 100% of the Available:
brand drug cost. Brand Drugs with Generic Copay
Due to manufacture pricing, Adderall XR brand name will be available for a generic copay. The generic version will not be covered by the University of Arkansas (subject to change). Generic Drugs with Brand Copay
Some high cost generics may have non-tier 1 copays. Please consult your PDL for more information or call MedImpact Healthcare Systems, Inc. at 800-788-2949. Blood Glucose Monitors
One per calendar year. Bayer and Abbott brands preferred. All other manufacturers will return a non-formulary copay. Compounded Medications
Covered up to $200 per fill. All compound medications are third tier. Dose Optimization
For drugs where FDA approval is once-daily dosing and different strengths are available at similar costs, quantity limits are set at 1 pill per day for the lower strengths in order to decrease costs and increase compliance. For example, if a member is taking two 20mg strength per day and the drug is available in a 40mg strength, a switch to the higher unit dose may be required. The dose optimization program includes but is not limited to, the following drugs (brand and generics): Coreg CR, Cymbalta, Effexor XR, Mirapex ER, Toprol XL, Ultram ER and Vyvanse. The University of Arkansas Pharmacy Advisory Committee, comprised of physicians, pharmacists and benefit specialists, makes all formulary, quantity and days' supply limitations decisions after careful consideration based upon published evidence-based medical data. Please note that the University of Arkansas Preferred Drug List (PDL), administered by MedImpact Healthcare Systems, is
not intended to be inclusive or exclusive of all drugs on the market, but reflects the more commonly used drugs. Be sure to
verify coverage per plan programs and limitations. You may call MedImpact Customer Service toll-free at 1-800-788-2949 or
log in as a member at

(QL) = Quantity or Age Limits (ST) = Step Therapy
*NOTE: Only Bayer and Abbott testing supplies (test strips, lancets) are $0 when purchased with a doctor's prescription. All other brands
are considered tier 3, $80 copay.
** Receive a No Cost Blood Glucose Monitoring System
Blood glucose monitoring systems from Abbott and/or Bayer Healthcare are available by calling Abbot at (866) 224-8892 or Bayer at
(888) 832-1039 (code BDC-MI). These are the preferred manufacturers for diabetic testing supplies for the University of Arkansas
and are available at zero copayment. All other brands are considered tier 3, $80 copay.
PRIOR AUTHORIZATION REQUIRED (PA):

A process that evaluates the drug's prescribed use against a predetermined set of criteria to determine whether your employer will cover
the medication. In most cases, if the physician does not submit a prior authorization prior to you presenting your prescription at the
pharmacy, the claim will be denied at point of service. Contact MedImpact Customer Service toll-free at 1-800-788-2949 with questions and
to begin the prior authorization process.
To obtain a list of drugs that requires a Prior Authorization please consult your PDL or Medimpact's member website.

IMPORTANT INFORMATION ON THE PRIOR AUTHORIZATION PROCESS:
MedImpact Healthcare Systems will provide the necessary paperwork to the prescriber for medications that require prior authorization.
Plan participant or prescriber must contact MedImpact Customer Service toll-free at 1-800-788-2949 to begin the prior authorization
process. In the event a request for prior authorization is denied, plan participants are to contact MedImpact Healthcare Systems toll-
free at 1-800-788-2949 if they wish to make an appeal. All appeals information can be sent to MedImpact Healthcare Systems, P.O. Box
509098, San Diego, CA 92150-9098 or fax to: 858-790-6060.
QUANTITY LIMITS (QL):
A quantity limitation refers to the maximum days' supply or quantity of a medication that you can obtain at one time under your
prescription benefits (example up to a 30 day supply or 100 unit dose). Sometimes general therapeutic categories, specific drug classes or
individual medications may have additional quantity limitation restrictions. Please consult your PDL or MedImpact's member website to
see if your drug has a quantity limit associated with it.

EXCLUSIONS:
Most drugs that are excluded under the University of Arkansas will be allowed to process but the member will be responsible for 100% of
the drug cost.
Drugs may be added to the exclusion list at any time. Please be sure to verify coverage per plan programs and limitations. You may call
MedImpact Customer Service toll-free at 1-800-788-2949 or log in as a member at https://mp.medimpact.com/uas. The majority of
exclusions will be allowed to process, however the member will be responsible for 100% of the cost of the medication. The University of
Arkansas System will not share in the cost.
Note: FDA approval of a drug does not guarantee inclusion as a covered item under the Prescription Drug program. Newly approved drugs
are subject to review by the Pharmacy Advisory Committee before being covered or may be excluded altogether. In addition, the level of
coverage for some Prescriptions may vary depending on the medication's therapeutic classification. As a result, some medications
(including, but not limited to, newly approved Prescriptions) may be subject to quantity limits or may require prior authorization before
being dispensed.
REFERENCE BASED PRICING (RBP):

Drugs to Treat Insomnia
Generic and Branded insomnia drugs will be covered up to $0.19 per pill. Any additional cost will be applied to the copay. (Examples include: Ambien, Ambien CR, Edluar, Lunesta, Rozerem, Sonata). Zolpidem (generic Ambien) will continue to be available at the standard copay rates. Overactive Bladder Drugs
Generic and Branded overactive bladder drugs will be covered up to $0.30 per pill. Any additional cost will be applied to the copay. (Examples include: Detrol, Detrol LA, Ditropan XL, Enablex, Sanctura, Vesicare, and Oxytrol Patches). Oxybutynin Immediat release (generic Ditropan) will continue to be available at the standard copay rates, and Oxybutynin Extended Release (generic Ditropan XL) will be available at a tier 2 copay. Skeletal Muscle Relaxants
Generic and Branded skeletal muscle relaxants (oral formulations) will be covered up to $0.09 per pill. Any additional cost will be applied to the copay. (Examples include: Amrix, Fexmid, Norflex, Skelaxin, Soma, and Zanaflex). Baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizandine,and chlorzoxazone will continue to be available at the standard copay rates. Nasal Steroids
Generic and Branded nasal steroids will be covered up to $22.42 per device. Any additional cost will be applied to the copay. (Examples include: Beconase AQ, Flonase, Nasacort AQ, Nasalide, Nasarel, Nasonex, Omnaris, Rhinocort AQ, and Veramyst). Fluticasone (generic Flonase) and flunisolide (generic Nasalide) will continue to be available at the standard copay rates. Osteoporosis Drugs
Generic and Branded osteoporosis drugs will be covered up to $0.26 per pill. Any additional cost will be applied to the copay. (Examples include: Actonel, Actone w/ Calcium, Atelvia, Boniva, Fosamax, and Fosamax-D). Alendronate (generic Fosamax) will continue to be available at the standard copay rates. ‘Statin' Drugs to Treat Cholesterol
Branded statin drugs and statin combos will be covered up to $0.50 per pill. Any additional costs will be applied to the copay. (Examples include: Advicor, Alotprev, Crestor, Lescol/-XL, Lipitor, Livalo, Simcor, Vytorin). Generic atorvastatin, lovastatin, pravastatin and simvastatin will continue to be available at the standard copay rates.
DRUGS TO TREAT ADHD:
Extended Release (ER) ADHD Drugs
Extended release formulations (Examples include: Adderall XR, Concerta, Vyvanse) of drugs used to treat ADHD are covered for individuals 25 years of age and younger. Non-ER ADHD medications are available at the applicable benefit with no age restrictions.

Source: https://hr.uark.edu/documents/prescription-formulary.pdf