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Arkansas State and Public School Employees Preferred Drug List (PDL) - Effective 01/01/2014
This PDL is a list of the most commonly prescribed drugs. It is not all-inclusive and is not a guarantee of coverage. Plan Benefit Design is the final determinate of coverage. For drugs not listed, please call the pharmacy program number listed on the back of your ARBenefits ID card for benefit coverage information. PLEASE NOTE: Use of generic drugs can save both you and your health plan money. Generics that are new to the market will
require a copyment equal to its branded product. These are indicated in the PDL with *(NG) and are shown in bold type. These new
generics will not have the standard Tier 1 copayment that older generic products have. In addition, brand-name medications that are
available in the generic form will require a generic drug copayment PLUS the difference in the plan's cost between the generic and
equivalent brand-name drug.
Specialty drugs may require prior authorization (PA) by EBRx (1-866-564-8258) to ensure appropriate usage. These medications are
indicated in the PDL located under Tier 4.
Compounded medications will require prior authorization (PA). Your physician may request a PA by contacting EBRx at (1-866-564-
8258).
Key: Certain drugs (*) may be subject to Day Supply (DS), Quantity Limits (QL), Prior Authorization (PA), Step Therapy (ST),
Contingent Therapy (CT), New Generics (NG) or Reference Pricing (RP) requirements according to Benefit Design. Items indicated
as *(RP) require special copayment pricing and do not apply to the standard tier copayments. This PDL is subject to change
at any time.
ANTI-INFECTIVES
cefaclor, cefadroxil, cephalexin, Cedax, Spectracef, Kaletra, Lexiva, Sustiva, Combivir, Epivir Aptivus, Atripla,
Crixivan, Emtriva,
Epzicom, Invirase,
Isentress*(PA),
Prezista, Prezista
soln*(PA),
Rescriptor, Reyataz,
Trizivir,
Truvada*(PA),
Selzentry, Stribild
tablet*(QL)*(PA)
Baraclude,
Pegasys*(PA), Peg-
Intron*(PA),
Victrelis*(PA)
CARDIOVASCULAR
*(RP) Reference Priced
Altoprev, Crestor 5mg, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Antihyperlipidemic-HMG
(Statins): Plan pays $0.30 per
unit. Member is responsible
for remaining cost.
Other Antihyperlipidemic cholestyramine resin, colestipol, Niaspan, niacin
extended release
tablet*(NG), Welchol
tablet
ACE Inhibitors and ACE amlodipine/benazepril, captopril, Antagonist (ARB)/Direct irbesartan/HCTZ, irbesartan, Renin Inhibitors (DRI) *(RP) Reference Priced
Amturnide, Atacand, candesartan*(NG), Atacand HCT, candesartan
Antagonist (ARB)/Direct Angiotensin Receptor
cilexetil/HCTZ, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Blockers (ARB): Plan pays
Diovan, Diovan HCT, valsartan/HCTZ, Edarbi, Edarbyclor, Exforge, Exforge $0.81 per unit. Member is
HCT, Hyzaar, Micardis, telmisartan*(NG), Micardis HCT, Tekturna,
responsible for remaining
Tekturna HCT, Teveten, Teveten HCT, Twynsta, telmisartan/amlodipine*(NG)
*(RP) Reference Priced
Caduet---all other strengths (brand and generic). No prior authorization
Antihypertensive--Other:
(PA) required.
Plan pays $0.30 per unit.
Member is responsible for
remaining cost.
Lopressor, Lopressor HCT, Tenoretic, Tenormin, Toprol XL Cardizem, LA, SR, CD, Norvasc, Sular, Tiazac, Verelan PM CENTRAL NERVOUS SYSTEM
CD*(QL), ER*(QL), Provigil* (PA), Ritalin Tablet, LA*(QL), SR, Vyvanse*(QL) *(RP) Long Acting
Long Acting Amphetamines are reference priced for members 26 years of
Amphetamines: Plan pays
age or older; *Quantity Limits will still apply to reference priced long
$2.50 per unit. Member is
responsible for remaining
cost.
Adderall XR*(QL), amphetamine salts*(QL) extended release, Dexedrine*(QL), dextroamphetamine*(QL) extended release, Vyvanse*(QL) Aricept, donepezil*(NG),
Aricept ODT, Exelon,
Namenda*(PA),
Namenda XR*(PA),
Razadyne, Razadyne ER
Percocet*(QL), Percodan, Tylenol w Codeine*(QL) Lamictal CD, Neurontin, Potiga*(PA), Phenytek, Tegretol, Topamax, Trileptal, Zonegran *(RP) Reference Priced
Lyrica (Note: The generic drug gabapentin will remain at a Tier 1 copay.)
Anticonvulsants: Plan pays
$0.35 per unit. Member is
responsible for the remaining
cost.
*(RP) Serotonin
Cymbalta, duloxetine, Effexor XR, venlafaxine extended release tablets
norepinephrine reuptake
inhibitors (SNRIs): Plan pays
Antidepressants (SNRIs) $0.75 per unit. Member is
responsible for remaining
cost.
sertraline, fluoxetine, paroxetine, citalopram, fluvoxamine *(RP) Selective serotonin
Lexapro, escitalopram, Luvox CR, fluvoxamine ER, Paxil ER, paroxetine Antidepressants (SSRIs) reuptake inhibitors (SSRIs): ER, Pexeva
Plan pays $0.30 per unit.
Member is responsible for
remaining cost.
Requip, Requip XL, Sinemet, Sinemet CR, Stalevo Symbyax, Risperdal-M, Zyprexa, Zyprexa-Zydis ODT Imitrex*(QL),
Maxalt*(QL), Maxalt
MLT*(QL),
Zolmitriptan*(NG)*(QL),
Zomig*(QL), Zomig -
ZMT*(QL)
Multiple Sclerosis Drugs no generics available at this Aubagio
tablet*(PA)*(QL),
Avonex, Betaseron,
Copaxone, Extavia,
Gilenya, Rebif,
Tecfidera*(PA)*(QL)
*(RP) Reference Priced
Ambiem, Ambien CR, Lunesta, Rozerem, Sonata, zaleplon Sedatives/Hypnotics: Plan
pays $0.15 per unit. Member
is responsible for remaining
cost.
Lioresal, Parafon Forte, Skelaxin, Zanaflex, Zanaflex Caps ENDOCRINE
glipizide, glyburide, nateglinide, repaglinide*(NG)
Janumet*(PA), Kazano*(PA), Kombiglyze XR*(PA), Nesina*(PA), Onglyza*(PA), Oseni*(PA), Precose, Tradjenta*(PA) Diabetic testing strips will now require a copay. Several Tier 1 options are available. Covered test strips
are listed below. Other diabetic testing supplies (lancets and needles) will be provided at a $0 copay to
members actively enrolled in the Diabetes Management Program .
Contour, Bayer Breeze, Accu-Chek Aviva, Accu-Chek Compact, Accu-Chek Smartview, Accu-Chek Comfort Curve, Freestyle, Freestyle Lite GASTROINTESTINAL/URINARY
strengths), Pertyze, Ultrase, Viokace, Zenpep 20mg, omeprazole 40mg, pantoprazole 20 & 40 mg *(RP) Reference Priced
Aciphex, Dexilant, lansoprazole, Nexium, omeprazole/sodium bicarb Proton Pump Inhibitors: Plan capsule,Prevacid, Prevacid 24hr OTC, Prilosec, Prilosec OTC, omeprazole
pays $0.30 per unit. Member OTC, Protonix, Zegerid capsule
is responsible for remaining
cost.
Bowel Preparation Drugs Gavilyte-C/G, PEG oxybutynin (extended release and immediate release) *(RP) Reference Priced
Detrol, tolterodine, Detrol LA, tolterodine (extended release), Ditropan, Overactive Bladder Agents:
Ditropan XL, Enablex, Oxytrol Patch, Sanctura, trospium, Sanctura XR, Plan pays $2.12 per unit.
Member is responsible for
remaining cost.
MEN'S HEALTH
RESPIRATORY
*(RP) Reference Priced Nasal Beconase, Beconase AQ, Flonase, Nasonex, mometasone, Nasacort AQ,
Steroids: Plan pays up to
$26.00 for a one month
supply. Member is
responsible for remaining
cost.
Advair*(ST), Combivent, Atrovent Inhaler, Xolair*(PA)
ipratropium, theophylline 200mg Prelone, Spiriva, Azopt, Betimol, Lumigan Timoptic, Trusopt, Bepreve, Crolom, Elestat, Emadine, Lastacaft, Optivar, Patanol, Zaditor lidocaine*(NG), Locoid Gel, Halonate Kit,
Lipocream, Pramosone, Lotrisone lotion, Synalar,
Protopic
Duac Gel, Noritate, Retin-Benzaclin, Benzamycin, A 0.05% topical solution, Cleocin T, Klaron, Retin- phosphate-benzoyl peroxide gel, Amnesteem, Claravis, Sotret, sulfacetamide sodium 10% topical solution, tretinoin WOMEN'S HEALTH
FemHRT 0.5mg/2.5mg, Activella, Climara Pro, Contraceptives: Plan will pay 100% for all COVERED GENERICS . COVERED BRANDS with no generic
available will be covered by the plan under Tier 3 (limited to oral forms).
*** Brand/Generic difference/penalty pricing will apply if member chooses a COVERED BRAND where a
generic is available.***
Examples of COVERED
GENERICS paid at 100%:
Amethia, Aviane, Azurette, Camrese, Camrese Lo, Cryselle, Daysee, Elinest, Emoquette, Enpresse, Gianvi, Gildess, Introvale, Jolessa, Kariva, Lessina, Levora, LoSeasonique, Loryna, Low-Ogestrel, Lovonest, Lutera, Marlissa, Microgestin, Mircette, Mono-Linyah, MonoNessa, Myzilra, Necon, Nortrel, Ocella, Ogestrel, Orsythia, Ortho-Cyclen,Ortho-Novum, Portia, Previfem, Quasense, Reclipsen, Seasonique, Sprintec, Sronyx, Syeda, Tilia, Trinessa, Tri-Linyah, Tri-Sprintec, Trivora, Wymzya, Vestura, Viorele,Yasmin,Yaz Zarah, Zenchent Examples of COVERED
BRANDS paid at 100%:
Alora, Cenestin, Estrace Climara, Enjuvia, Estrace Menest, Premarin, Prometrium, Vagifem, Vivelle-Dot Atelvia, Boniva, Didronel, Forteo*(PA)
Prolia*(PA)
Concept DHA, Concept Complete-RF Prenatal, OB, Folcal DHA, Folcaps Folivane-OB, HemeNatal PNV, L-Methylfolate PNV O-Cal Prenatal, Venatal- DHA, Tamdem DHA, Virt-FA, Venate, Vol-Nate, RX 1, Ultimatecare One, Vinate PN, Zatean-PN MISCELLANEOUS
Anzemet*(QL),
acitretin*(NG),
Amevive*(PA),
Enbrel*(PA),
Stelara*(PA)
Humatrope*(PA),
Genotropin*(PA),
Norditropin*(PA),
Nutropin/AQ*(PA),
Saizen*(PA),
Serostim*(PA), Tev-
Tropin*(PA)
Myfortic, Prograf capsule, Nulojix*(PA),
Rapamune, Simulect
methotrexate*(PA), leflunomide Trexall*(PA) Actemra*(PA),
Enbrel*(PA),
Humira*(PA),
Kineret*(PA),
Orencia*(PA),
Remicade *(PA),
Simponi*(PA),
Xeljanz*(PA)
Specialty Drug List
This Specialty Drug List includes medications that are classified as Tier 4 drugs (by plan
coverage) and most will require pre-authorization by EBRx (1-866-564-8258) when obtained
from the pharmacy or administered in the physician's office. The coverage requirements for
prescribing or administering these medications can be found on the ARBenefits website at
www.ARBenefits.org
ACROMEGALY
GROWTH HORMONE &
RELATED DISORDERS
ALPHA-1 ANTITRYPSIN DEFICIENCY
Aralast
IGF-1 Deficiency
BOTULINUM TOXINS
HEMATOPOIETICS
CROHN’S DISEASE
HEMOPHILIA & RELATED BLEEDING
DISORDERS
CRYOPYRIN-ASSOCIATED
PERIODIC SYNDROMES
CYSTIC FIBROSIS
ENZYME DEFICIENCY OR
LYSOSOMAL STORAGE DISEASE
Aldurazyme
HEPATITIS B
MACULAR DEGENERATION
HEPATITIS C
MULTIPLE SCLEROSIS
ONCOLOGY – ORAL
ONCOLOGY - SUPPORTIVE CARE
OSTEOARTHRITIS
Euflexxa
HORMONAL THERAPIES
OSTEOPOROSIS
IMMUNE DEFICIENCY
PLAQUE PSORIASIS
IMMUNE THROMBOCYTO-PENIC PURPURA
IRON OVERLOAD
PSORIATIC ARTHRITIS
PULMONARY ARTERIAL HYPERTENSION
TRANSPLANT
RESPIRATORY SYNCYTIAL VIRUS
OTHER THERAPIES
RHEUMATOID ARTHRITIS

Source: http://portal.arbenefits.org/Benefits/2014PDLPreferredDrugList.pdf