Drug Formulary - Unity Health Insurance

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierRESPIRATORY AGENTS (Asthma, Allergies, etc.)Other Inhaled Medicationscromolyn nebulizer solution ipratropium HFA inhaler (Atrovent HFA) aclidinium bromide (Tudorza Pressair)ipratropium tiotropium inhaler (Spiriva) umeclidinum/vilanterol (Anoro Ellipta)ferrous sulfate dropsferrous sulfate oral suspensionaspirin 81 mg, 162 mg, 325 mgaspirin 81 mg, 162 mg, 325 mgfolic acid tablets 400 mcg, 800 mcgfluoride drops and chewable tabletsInhaler assistance devices/spacers are included in the value tier of RX Outcomes benefits*Oral Respiratory Medicationsalbuterol tabs dyphylline (Lufyllin) roflumilast (Daliresp)metaproterenol tabs theophylline (Theo-24, Theocap) NTI zafirlukastmontelukast*zileuton (Zyflo)terbutaline tabstheophyllineNTIOther Respiratory Medicationssodium chloride 3% for inh aztreonam lysine (Cayston) PA Q acetylcysteinesodium chloride 7% for inh colistimethate for inhalation (Coly-mycin) epinephrine injection (Auvi-Q)tobramycin inj for inh dornase alfa (Pulmozyme) Qtobramycin inhalation (TOBI equiv.)epinephrine injection (Epipen, Epipen Jr)sodium chloride 6% for inh (Nebusal)tobramycin inhalation (TOBI Podhaler, PABethkis)PREVENTIVE MEDICATIONS (Prescription required for OTC versions)age 6 to 12 monthsage 6 to 12 monthsfemales age 55 to 79 years, 1 tablet per day dosing, 100 days supplymales age 45 to 79 years, 1 tablet per day dosing, 100 days supplyfemales age 15 to 50 years, 1 tablet per day dosing, 100 days supplyage 6 months to 6 years$0 copay, generics only when availableBuying OTC bottles in larger quantities without a prescription may be more convenientPA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1430