Drug Formulary - Unity Health Insurance

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierINFECTIOUS DISEASEAntiviral – Hepatitisadefovir boceprevir (Victrelis) PA SP interferon alfacon (Infergen) PA SPlamivudine entecavir (Baraclude) ribavirin (Ribapak, Moderiba, PARibasphere 400 mg & 600 mg)ribavirin interferon alfa (Intron A) PA SP simeprevir (Olysio) PA SP Q1st line: pegylated interferon PA SP Q telbivudine (Tyzeka)(PegIntron)2nd line: pegylated interferon PA SP Q(Pegasys)ribavirin solution (Rebetol)sofosbuvir (Sovaldi)PA SP Qtelaprevir (Incivek)PA SPAntiviral – HIVabacavir tablets* SP abacavir suspension (Ziagen suspension)* SP maraviroc (Selzentry) SPabacavir/lamivudine/zidovudine* SP abacavir/lamivudine (Epzicom)* SP tipranavir (Aptivus) SPdidanosine* SP atazanavir (Reyataz)* SPlamivudine* SP darunavir (Prezista)* SPlamivudine/zidovudine SP delavirdine (Rescriptor)* SPnevirapine* SP dolutegravir (Tivicay)* SPnevirapine XR* SP efavirenz (Sustiva)* SPstavudine SP efavirenz/emtricitabine/tenofovir (Atripla)* SPzidovudine* SP elvitegravir/cobicistat/emtricitabine/ SPtenofovir (Stribild)*emtricitabine (Emtriva)*emtricitabine/rilpivirine/tenofovir(Complera)*emtricitabine/tenofovir (Truvada)*enfuvirtide (Fuzeon)*etravirine (Intelence)*fosamprenavir (Lexiva)*indinavir (Crixivan)*lopinavir/ritonavir (Kaletra)*nelfinavir (Viracept)*raltegravir (Isentress)*rilpivirine (Edurant)*ritonavir (Norvir)*saquinivir (Invirase)*tenofovir (Viread)*Other Antiviralacyclovir oral oseltamivir (Tamiflu) Q acyclovir topicalamantadine valganciclovir (Valcyte) famciclovirrimantadine zanamivir (Relenza) QvalacyclovirSPSPSPSPSPSPSPSPSPSPSPSPSPSPPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1418