Providerbasics 23 FE9B73F9

Provider Basics
A Reference Guide for Treating PEHP Patients
From PEHP Managing Director. . . . . . . .Page 1 Services That Need Preauthorization...Page 7

General Provider Tips. . . . . . . . . . . . . . . . . Page 2 Covered Drug List . . . . . . . . . . . . . . . . . . . . Page 8
Tips By Specialty . . . . . . . . . . . . . . . . . . . . . .Page 4 Exclusions From Coverage. . . . . . . . . . . . Page 28
PROUDLY SERVING UTAH PUBLIC EMPLOYEES
10/27/20
FROM THE PEHP MANAGING DIRECTOR
Let Us Help You Help Our Members
O
n behalf of PEHP, our members. Our members work
members, and employer in the public sector as teachers,
groups, I want to sincerely firefighters, social service workers,
thank you for partnering with us in and the like. We know how
so ably serving our members. important health benefits are to
them as well as the significant
The purpose of this publication is financial burden of such things as
to be as transparent as possible in unnecessarily paying for a brand
helping you understand the health name drug or facing a denied
plan policies of PEHP to: genetic testing bill of $5,000 that
» reduce payment denials for you, was never preauthorized.
and If you have suggestions on how
» minimize uncovered and/or we can improve this publication,
unnecessary healthcare costs for our relationship, or our efforts
our members to minimize uncovered and/or
unnecessary costs for our members,
At PEHP, we do everything at cost. please feel free to email me at
We have no financial interest in [email protected] or call me
improperly denying claims. We at 801-366-7399.
have been entrusted by our groups
to administer their health benefits Thanks again for partnering with us
under the terms of the plan. and so ably serving our members.
Every dollar paid for a claim comes

directly from the reserves of the
participating employer group.
Similarly, every dollar that remains
is theirs as well. We do our very
best to be fair and prudent in our
R. Chet Loftis
duties. PEHP Managing
Director
It is our sincere hope that you
use this publication to help our
PEHP Provider Basics » Page 1

PROVIDER TIPS
IMPORTANT: This is a brief list of common medications, exclusions, preauthorizations
and may not be complete. It was current at the time of printing and is subject to change.
Additions and subtractions can be made to the list at any time. For the latest list, go to
www.pehp.org or call PEHP at 801-366-7555 or 800-765-7347.
Preauthorization
» See the list on Page 7 for services that require preauthorization.

» To obtain preauthorization, fill out the appropriate form at PEHP for Providers at
www.pehp.org and fax or mail it to us.
» These services generally require preauthorization:
› Inpatient hospital medical admissions at Primary Children’s Medical Center.
› These types of inpatient admissions: hospital rehabilitation, skilled nursing
facilities, mental health, LTAC, and substance abuse.
› All out-of-network inpatient admissions.
› Facility-based sleep studies.
» For more information about preauthorization, contact your Provider Relations
Representative or visit our website at pehp.org
Referrals/Networks
PEHP offers five different Networks. Please help us protect PEHP members from
unnecessary large bills by referring them to providers in the PEHP network
selected by the patient. This includes making sure that every person, lab, and facility
involved in the patient’s care is not just contracted with PEHP but is specifically part
of the member’s network. Otherwise, the patient can be balanced billed for out-of-
network services. Find in-network providers at www.pehp.org/ProviderLookup.
Networks
Networks
PEHP Advantage » Includes Intermountain Healthcare. Includes certain others based
on geographic need.
PEHP Summit » Includes University of Utah, Steward, and MountainStar. Includes
Primary Children’s Hospital and rural IHC facilities except Logan Regional Hospital.
PEHP Summit Exclusive » Includes University of Utah, Steward, and MountainStar
facilities. Includes Primary Children’s Hospital and rural IHC facilities.
PEHP Preferred » Includes both Advantage and Summit providers.
PEHP Capital » Primarily IASIS and University of Utah Healthcare. Includes Primary
Children’s Hospital and all rural facilities.

Prescription Drugs
Get preauthorization by calling 801-366-7551. Forms are available at PEHP for
Providers at www pehp.org. See the Preferred Drug List on Page 8.
Affordable Care Act (ACA)
We cover preventive services at no cost to members. To help your office understand

which CPT and diagnosis code combinations qualify for the ACA preventive visits,
see our ACA Coding Table. It’s available at www.pehp.org/providers (click “Preventive
Services“ under the “Claims and Billing” menu at left).
Labs and Imaging

Find in-network laboratories at www.pehp.org/ProviderLookup. In-network, free-
standing labs, such as LabCorp and Quest Diagnostics, are less-expensive alternatives
to sending the tests through a hospital. In general, the cost for labs are three to
six times more expensive in a hospital outpatient setting. For example, in 2018, a
comprehensive metabolic panel costs a patient around $13-14 when done in office
or by an independent laboratory, compared to $86 at a hospital. Another example:
Urinalysis done in office or by an independent laboratory costs a patient around $3-4,
compared to $41 when done by a hospital. This same comparison is true for all labs.
Free-standing imaging centers are also less expensive and are available in-network for
patients on the PEHP Summit, Preferred, and Capital networks. All genetic tests require
preauthorization.
Exclusions
See complete list of exclusions on Page 26.

Tips by Specialty
This is a partial list only.
All genetic tests require preauthorization. Complete medical necessity policies (such as celiac disease,
colon cancer, IBD, and hereditary pancreatitis ) are available at PEHP for Providers. Tests performed at
Prometheus Laboratory will not be reimbursed by PEHP.
Cardiology
» Life Vests (only provided by Zoll) are paid at the in-network benefit, but member may be balance
billed. This provider will not contract with PEHP.
» All genetic/molecular diagnostic tests require preauthorization.
» PEHP pays non-contracted Holter monitoring as a out-of-network provider; the member may be
balance billed.
» Genetic testing for predisposition to hypertrophic cardiomyopathy (HCM) is considered medically
necessary for individuals who are at risk for development of HCM, defined as having a first-degree
relative (e.g., siblings, parents, and offspring) with established HCM, only when there is a known
pathogenic gene mutation present in that affected relative.
» PEHP does not cover genetic testing for Brugada syndrome.
» PCSK9 inhibitors (Repatha, Praluent) are not covered.
Gastroenterology
» Crohn’s Disease: PEHP requires a trial and failure to 1 conventional therapy (if the disease is severe
or fistulizing and TNF therapy is recommended first line, please send appropriate documentation).
PEHP preferred agents (Remicade, Cimzia, Enyvio)at Tier A $150 max copayment.
» Humira is covered after failure of the above agents at a tier C (20%) benefit after any applicable
deductible.
» Cimzia and Entyvio are available through Accredo. They are only covered through the pharmacy
benefit.
» Ulcerative Colitis » PEHP requires a trial and failure to 1 conventional therapy. PEHP preferred agents
are Remicade and Entyvio.
» Humira and Simponi are not covered.
» PEHP covers moderate conscious sedation for colonoscopies and endoscopies. Monitored
Anesthesia Care (MAC) requires preauthorization.
» Capsule endoscopy tests require preauthorization.

Ophthalmology
» Intravitreal Avastin (bevacizumab) does not require preauthorization.
» Amniotic membranes and intra-corneal rings require preauthorization.
» In all instances, extended ophthalmologic tests or screening (92283, 92284) must be medically
necessary. To establish medical necessity, a serious ophthalmologic condition must exist, or be
suspected, based on routine ophthalmological tests and require further detailed study.
» Vision therapy ( 92065) is covered for convergence insufficiency. There is a lifetime limit of 12 visits.
Orthopedic
» Bone grafts and skin grafts require preauthorization. Total ankle replacement requires PA. PEHP
does not cover subtalar implants.
» Post-op pain management: Because of safety and efficacy concerns, PEHP limits high-dose opioids
(≥ 150 MED) to pain management physicians. PEHP requires preauthorization on all long-acting
opioids, with the exception of morphine sulfate ER (MS Contin) and Nucynta ER. However, after
surgery patients can fill up to three months of Oxycontin without a preauthorization. If a patient
has a need for long-term, high-dose opioids following surgery, PEHP can help to arrange a pain
management consultation with our preferred pain providers. Please contact us at 888-366-7551 for
additional questions.
» Bone growth stimulators require preauthorization.
Physical Medicine
» Neurolysis (64640) requires preauthorization.
» PEHP allows up to 20 PT/OT visits without preauthorization. The physical and occupational therapy
benefit is capped at 20 visits per plan year for most groups.
» Spinal cord stimulators require preauthorization.
» PEHP does not cover trigger point injections, greater or lesser occipital nerve blocks, or
radiofrequency for headaches.
» Cervical and lumber radiofrequency requires preauthorization.
Neurology
» Video and ambulatory EEG requires preauthorization.
» Vagus nerve stimulators require preauthorization.
» Ear lobe cutaneous peripheral nerve stimulator for pain control are not covered.

Podiatry
» Skin substitutes require preauthorization.
» PEHP considers platelet-rich plasma and/or stem cells, alone or in conjunction with treatment of
plantar fasciitis, experimental.
» Metatarsal or tarsometatarsal arthodesis requires preauthorization.
» Hammer toe surgery (28285) requires preauthorization.
» Implants for hammer toe surgery are considered investigational and not covered
» Chemical neurolysis for Morton’s neuroma and plantar fasciitis are considered investigational.
Rheumatology
Rheumatoid Arthritis
PEHP requires trial and failure of at least one DMARD. PEHP preferred agents (Enbrel, Cimzia,
Remicade, Xeljanz, Actemra) at Tier A $150 max copayment.
Humira and Simponi are covered after failure of preferred agents at a tier C (20%) benefit.
Enbrel, Cimzia, Remicade, Actemra, and Xeljanz available through Accredo.
Juvenile Idiopathic Arthritis

PEHP requires 30-day trial and failure of at least one NSAID and eight-week trial and failure of at least
one DMARD
PEHP preferred agents — Enbrel, Actemra, Orencia
Humira is covered following at least an 8 week trial and failure of Enbrel
Psoriatic Arthritis
PEHP requires 30-day trial and failure of at least one DMARD.
PEHP preferred agents – Enbrel, Cimzia, Remicade, Otezla, and Stelara (dose will not exceed 45mg)
Humira and Simponi are covered after failure of preferred agents

Services That Need Preauthorization
SURGERY
» All out-of-state surgery » Intrastromal corneal ring segments » Skin grafts
» Blepharoplasty — select plans only implantation » Spinal cord stimulator placement/removal
» Breast reconstruction surgery » Jaw surgery » Stereotactic radiosurgery procedures
» Breast reduction — select plans only » Male urinary incontinence procedures » Strayer Procedure (Gastroc recession)
» Cochlear implant and related devices » Neuroelectrode implantation/removal » Surgery performed in conjunction with
» Collagen knee implant » Neurostimulator placement/removal obesity surgery
» Destruction of cutaneous vascular » Obstructive sleep apnea surgery, including » TMJ Surgery
proliferative lesions uvulopalatoplasty/uvuloplasty, or any other » Total ankle replacement
surgery for snoring
» Facial reconstruction surgery » Total disc arthroplasty
» Organ or tissue transplants (except cornea)
» Foot surgeries with implants » Transanal endoscopic microsurgery
» Palatoplasty
» Gastric neurostimulator placement/removal » Vein surgery — endovenous ablation —
» Panniculectomy radiofrequency or laser
» Implantable infusion pumps
» Pectus excavatum or carinatum » Vestibuloplasty
» Implantable medications (excluding
contraception) » Penile revascularization » Video EEG monitoring (VEEG)
» Implantation of artificial devices » Rhinoplasty
IMAGING / RADIOLOGY / NUCLEAR MEDICINE

» Coronary CT angiography (CCTA) » Intensity modulated radiotherapy (IMRT) » Neutron beam treatment
» Gastrointestinal tract imaging, intraluminal » Magnetocephalography (MEG)/magnetic » Proton beam treatment
(Pillcam) source imaging » Stereotactic radiation treatment delivery
» Virtual (CT or MRI) colonoscopy
INJECTIONS/INFUSIONS
» Botox » IV Iron » Remicade
» Growth hormone » IVIG (intravenous immunoglobulin) » Synagis
» Hemophilia medications » Lupron » Vivitrol
MEDICAL EQUIPMENT (DME) LABORATORY

See list at www.pehp.org Genetic testing (molecular diagnostics)
OTHER
» Anesthesia during standard colonoscopy or » Extracorporeal shock wave therapy » Outpatient Mental Health (certain plans only)
EGD surgery, other than moderate sedation » Home Health » Psoriasis treatment (laser)
(conscious sedation) » Human pasteurized milk » Radiofrequency (RF) neurolysis for lower back
» Attended Sleep Studies and Sleep Studies » Hyperbaric oxygen treatment (lumbosacral) or neck (cervical) pain.
performed in a facility.» Chelation therapy » Inpatient stays with an expected length of » Transcranial Magnetic Stimulation
» Dental procedures performed in an outpatient greater than 6 days requires authorization» » Voice therapy
facility for patients 6 years of age or older Intrathecal pumps » Wound care, except for diagnosis of burns
» Dialysis when using non-contracted providers » New and unproven technologies » Wound vac
To get preauthorization, your doctor must call PEHP.

INPATIENT ADMISSIONS Most doctors know how and when to do this, but it’s
» Inpatient hospital medical admissions at Primary Children’s Medical
your responsibility to verify. Otherwise, your benefits
Center or any inpatient hospital admission of more than six days could be reduced or denied.
» These types of inpatient admissions: hospital rehabilitation, skilled » Phone: 801-366-7555 » Fax: 801-366-7449
nursing facilities, mental health and substance abuse, long-term
acute care (LTAC) stays
» Mental health and substance abuse (including Day Treatment and
This is a list of the most common services requiring written Preauthorization. It is
Intensive Outpatient) not all inclusive. Call PEHP if you have any questions regarding Preauthorization.
» All out-of-network inpatient admissions
10/27/2020
CURRENT AS OF OCTOBER 2020
Covered Drug List
IMPORTANT: This is a list of common medications and may

not be complete. It was current at the time of printing and is
subject to change. Additions and subtractions can be made to
the list at any time. For the latest list, go to www.pehp.org or
call PEHP at 801-366-7555 or 800-765-7347.
About the Categories of Medications Table of Contents

Covered Drug List Your pharmacy and specialty benefit Preferred medications
The Covered Drug List is a listing is categorized by the following tiers: (Tier 1, Tier 2)
of prescription medications » Tier 1: Preferred generic ...............................Pages 3-6
chosen by PEHP to be available drugs available at the lowest
Non-preferred medications
at a lower copayment. The copayment.
(Tier 3)
medications on the Covered » Tier 2: Preferred brand name
.............................Pages 7-12
Drug List provide the best overall drugs available at the middle
value based on quality, safety, copayment. ACA medications list
effectiveness, and cost. The » Tier 3: Non-preferred ..................................Page 13
Covered Drug List is modified medications available at the
Examples of medications
periodically with changes highest copayment. that aren’t covered
based on recommendations » Tier A: Specialty medications
..................................Page 14
from PEHP’s Pharmacy and available at the lowest specialty
Therapeutics Committee. Copayment listed in your Benefit Specialty medications
Summary. (Tier A, B and C)
PEHP pharmacy benefits do not » Tier B: Specialty medications ...........................Pages 15-18
apply to the following groups: available at the intermediate Expanded preventive
Jordan School District, Salt Lake specialty Copayment listed in medications list
City School District, USBA your Benefit Summary. ..................................Page 19
» Tier C: Specialty medications
available at the highest specialty Contact information
Always consult ..................................Page 20
with your doctor before making Copayment listed in your Benefit
medication changes. Summary.
8-21-20
WWW.PEHP.ORG 2
Preferred Medications
Lowercase = Tier 1 | ALL CAPS = Tier 2 | QL = Quantity limit applies | PA = Requires preauthorization
^ = Must use specialty pharmacy Accredo | * = Not available for home delivery
A atenolol/chlorthalidone calcitriol clopidogrel (QL)

atomoxetine camila clorazepate
a-b otic*
ATROVENT HFA CANASA SUPPOSITORY clotrimazole troche
abacavir/lamivudine/
AXID SOLUTION CAPEX SHAMPOO clotrimazole w/
zidovudine
azathioprine captopril betamethasone
aripiprazole (QL)
azithromycin* captopril/hctz clozapine
ACANYA GEL PUMP (QL)
AZOPT carbamazepine codeine sulfate (QL)*
acetaminophen with codeine
(QL)* CARBATROL COLAZAL
acetazolamide B carbidopa/levodopa colestipol
acetylcysteine bacitracin* carisoprodol* colesevelam (QL)
ACTIVELLA 0.5/0.1 baclofen cartia xt COMBIPATCH
acyclovir BAQSIMI carvedilol COMBIVENT
adapalene (QL) benazepril cefaclor* COMTAN
adefovir dipivoxi (QL) benazepril/hctz cefadroxil* CONDYLOX
AGGRENOX (QL) benzonatate cefdinir* CORTIFOAM
ALAMAST benzoyl peroxide cefprozil* CREON
albuterol benzoyl peroxide/ ceftriaxone* CRINONE (PA)
alendronate (QL) clindamycin cefuroxime* cromolyn
alfuzosin benztropine CENESTIN cyclobenzaprine*
ALKERAN BESIVANCE (QL)* cephalexin* cyclopentolate
allopurinol betamethasone chloral hydrate* cyclophosphamide
allres g suspension* betaxolol chlordiazepoxide* cyclosporine
ALPHAGAN P 0.1% BETIMOL chloroquine CYTOMEL
alprazolam, xr* BETOPTIC-S chlorothiazide
ALTOPREV (QL) bisoprolol chlorpromazine D
ALVESCO (QL) bisoprolol/hctz chlorpropamide dantrolene*
amantadine BRILINTA (QL) chlorthalidone DAYTRANA (QL)*
amiloride brimonidine chlorzoxazone* DESCOVY (QL)
amiloride/hctz bromocriptine cholestyramine desipramine
aminocaproic acid budeprion sr, xl (QL) choline & magnesium desmopressin (PA)
amiodarone budesonide nasal (QL) salicylates desmopressin nasal (PA) (QL)
amitriptyline budesonide respules (QL) cimetidine desonide
amlodipine bumetanide CIPRODEX dexamethasone
amlodipine/benazepril buprenorphine (QL)* ciprofloxacin* dexmethylphenidate*
amoxicillin* bupropion, sr, xl (QL) citalopram (QL) dextroamphetamine*
amoxicillin-pot clavulanate* buspirone clarithromycin* DIASTAT (QL)*
amphetamine salt* butalbital-apap-caffeine* clemastine, syrup* diazepam*
ampicillin* butalbital-aspirin-caffeine* clindamycin* dibenzyline
anagrelide butalbital-caff-apap-codeine* clindinium/chlordiazepoxide diclofenac
anastrozole (QL) butorphanol (QL)* clobetasol dicloxacillin*
ANDRODERM (QL) BUTRANS TRANSDERMAL (QL)* clomipramine dicyclomine
antipyrine/benzocaine (QL)* clonazepam* didanosine
ASMANEX (QL) C clonidine diethylstilbestrol
aspirin-codeine* calcipotriene solution clonidine ER (QL) DIFFERIN GEL 0.3%,
atenolol calcitonin clonidine patches (QL) LOTION (QL)
Always consult with your doctor before making medication changes.
3
WWW.PEHP.ORG
diflorasone erythromycin/benzoyl FREESTYLE LIBRE (PA) (QL) indomethacin

diflunisal peroxide FREESTYLE TEST STRIPS (QL) introvale (QL)
digoxin esterified estrogens furosemide ipratropium
dihydroergotamine (PA) (QL)* ESTRACE VAGINAL ipratropium-albuterol
DILANTIN 30MG, 50 MG CREAM G isometheptene/
DILAUDID LIQUID* ESTRADERM PATCH (QL) acetaminophen/
gabapentin
estradiol, inj (QL) dichloralphenazone*
diltiazem, er ganciclovir
estradiol transderm patch (QL) isoniazid
diphenoxylate/atropine gemfibrozil
estropipate isosorbide
dipyridamole gentamicin*
eszopiclone (QL) itraconazole (PA) (QL)
disopyramide glimepiride
disulfiram ethosuximide
glipizide, er, xl J
divalproex etodolac, xl
glipizide-metformin
divalproex er EURAX JARDIANCE
glyburide
donepezil EVOXAC JENTADUETO (QL)
glyburide/metformin
DOVONEX CREAM EXALL-D LIQUID*
griseofulvin
doxazosin (QL) guaifenesin/codeine*
K
doxepin F guanfacine KALETRA
doxycycline hycolate famciclovir GYNAZOLE-1 ketoconazole
dronabinol (PA) (QL) famotidine ketoprofen
DULERA (QL) FARXIGA H ketorolac (QL)*
duloxetine (QL) felodipine er halobetasol klor-con (except 25 meq)
dutasteride fenofibrate (QL) haloperidol klor-con ef
dutasteride/tamsulosin fentanyl lozenge (PA) (QL)* hydralazine klor-con m (except 15 meq)
finasteride (QL) hydralazine/hctz KOMBIGLYZE XR
E flecainide hydrochlorothiazide k-phos neutral
EASIVENT (QL)* fluconazole hydrocodone/apap (QL)*
econazole fludrocortisone hydrocodone/ L
EDURANT (QL) flunisolide nasal spray (QL) chlorpheniramine (QL)* labetalol
EFFIENT (QL) fluocinolone hydrocodone/homatropine* lactulose
eletriptan (QL)* fluocinonide hydrocodone/ibuprofen (QL)* LAMISIL GRANULE (PA) (QL)*
ELIDEL (QL) fluorouracil hydrocortisone lamivudine
ELIQUIS (QL) fluoxetine, solution (QL) hydrocortisone/lidocaine lamotrigine
ELMIRON (QL) fluphenazine hydromet LANOXIN
EMCYT flurazepam (QL) hydromorphone (QL)* lansoprazole capsules(QL)
EMEND (QL)* flurbiprofen hydromorphone ER (PA)(QL)* LANTUS, SOLOSTAR
EMTRIVA, SOL flutamide hydroxychloroquine latanoprost
ENABLEX fluticasone hydroxyurea leflunomide (QL)
enalapril fluticasone nasal spray (QL) hydroxyzine LEUKERAN
enalapril/hctz fluticasone-salmeterol inhaler hyomax sl, sr
levalbuterol solution (QL)
endacof dc (QL)* (QL) hyoscyamine
levetiracetam
endocet (QL)* fluvoxamine HYPER-SAL 7%
levobunolol
ENJUVIA folic acid 1 mg (QL) levofloxacin 0.5% Opthalmic
ENTRESTO (QL) FORADIL I Solution
entecavir fortical ibuprofen levothyroxine
EPIPEN, EPIPEN JR (QL)* FOSAMAX SOLUTION (QL) imipramine hcl levoxyl
epitol fosinopril imiquimod (QL) lidocaine patches(QL)
erythromycin capsules* fosinopril/hctz indapamide lindane
WWW.PEHP.ORG 4
LINZESS (QL) methylin er (QL)* nifedipine, er, xl penicillin*

liothyronine methylphenidate er (QL)* nimodipine perindopril (QL)
LIPOFEN (QL) methylphenidate sr (QL)* NITRO-BID OINTMENT permethrin
lipram methylphenidate, solution* nitrofurantoin,macrocrystal perphenazine
lisinopril methylprednisolone nitroglycerin phenazopyridine
lisinopril/hctz metoclopramide NITROLINGUAL SPRAY* phenobarbital
lithium, er metolazone NITROSTAT phenytoin
lorazepam* metoprolol, xl nizatidine pilocarpine
losartan, hctz metoprolol/hctz nogestimate, ethinyl estradiol pindolol
LOTRONEX (PA) (QL) metronidazole nortriptyline pioglitazone (QL)
lovastatin (QL) mexiletine NORVIR pioglitazone/metformin (QL)
low-ogestrel metaxalone* NOVOLIN R, N, L, U, or 70/30 piroxicam
loxapine MINITRAN NOVOLOG, 70/30 portia
LUMIGAN minocycline capsule NOXAFIL (PA) (QL) potassium chloride
mirtazapine (QL) NUCYNTA ER (QL)* potassium citrate
M misoprostol nystatin* pramipexole
MATULANE (PA) modafinil 100mg (PA) (QL)
pramoxine/hc
mebendazole modafinil 200mg (QL) O pravastatin (QL)
meclizine molindone ofloxacin* prazosin
meclofenamate mometasone topical olanzapine prednisolone
medroxyprogesterone (QL) mometasone nasal spray olmesartan (QL)
(QL) prednisone
megestrol olmesartan/hctz (QL) pregabalin (QL)
MONOJECT INS SYR
meloxicam olopatadine PREMPHASE (QL)
montelukast (QL)
meperidine* omega-3-acid ethyl esters PREMPRO (QL)
morphine tablet, IR (QL)*
MEPHYTON (PA) omeprazole (QL) prevalite
MOXEZA
MEPRON ondansetron (QL)* primidone
moxifloxacin (QL)*
mercaptopurine ondansetron ODT (PA) (QL)*
MULTAQ (QL) PROAIR HFA (QL)
mesalamine enema ONGLYZA (QL)
mupirocin PROAIR RESPICLICK (QL)
mesalamine tablet OPTIVAR (QL)
MYCOBUTIN probenecid
MESTINON SYRUP, 180 MG orphenadrine, compound forte*
mycophenolate prochlorperazine
METADATE CD (QL)* OTIC CARE OTIC*
MYLERAN PROCTOFOAM-HC
metadate er (QL)* oxaprozin
MYRBETRIQ proctosol-hc
metaproterenol oxazepam*
proctozone-hc
metformin, er (QL) oxcarbazepine tablets,
N suspension progesterone
metformin-glyburide
nabumetone oxybutynin, er (QL) progesterone in oil (QL)
methadone 5mg, 10mg
nadolol oxycodone (QL)* PROGRAF
tablet* (PA)(QL)
naloxone injection oxycodone/apap (QL)* promethazine
methadone 40mg tablet* (PA)
(QL) naltrexone tablet (QL) oxymorphone er (PA) (QL)* promethazine/codeine*
methazolamide NAMENDA XR (QL) oxymorphone (PA) (QL)* propafenone
methenamine naproxen OZEMPIC (QL) propranolol
METHERGINE TABLET naratriptan (QL)* pancrelipase propranolol/hctz
methimazole NEBUPENT pantoprazole (QL) propylthiouracil
methocarbamol* nefazodone paricalcitol PROSTIGMIN
methotrexate, inj neomycin* paromomycin protriptyline
methyldopa nevirapine, ER paroxetine (QL) PULMICORT FLEXHALER (QL)
methyldopa/hctz niacin extended release PATADAY pyrazinamide
5
WWW.PEHP.ORG
Q SPIRIVA (QL) timolol TUDORZA PRESSAIR

spironolactone timolol-dorzolamide
quinapril
spironolactone/hctz TIVICAY U
quinapril/hctz
sprintec tizanidine ULORIC (QL)
QVAR (QL)
STRIBILD TOBRADEX* estradiol vaginal tablet
SUBOXONE (PA) (QL)* tobramycin*
R sucralfate TOBREX OINTMENT* V
rabeprazole (QL) sulfacetamide prednisolone tolazamide
valacyclovir (QL)
raloxifene (QL) sulfacetamide topical sol tolbutamide
(QL) VALCYTE
ramipril (QL) tolmetin
sulfamethoxazole/ valproic acid
RANEXA (QL) tolterodine tartrate
trimethoprim* valsartan/hctz (QL)
ranitidine tolterodine tartrate er
sulfasalazine, EC VASCEPA (QL)
RENAGEL topiramate
sumatriptan (QL)* venlafaxine, er
REYATAZ torsemide
SUSTIVA VENTOLIN HFA (QL)
rifampin* TOUJEO
SYMBICORT (QL) verapamil, er
risperidone, odt (QL) TRADJENTA (QL)
VIGAMOX*
rivastigmine (QL) tramadol (QL)*
ropinirole
T tramadol/apap (QL)*
VIMPAT (QL)
VIRACEPT
rosuvastatin (QL) TAMIFLU (QL)* trandolapril
VOLTAREN GEL (QL)
RYTARY tamoxifen trandolapril/verapamil
tamsulosin (QL) tranylcypromine
S TAZORAC (PA) (QL)
W
trazodone
telmisartan (QL) TRELEGY (QL) warfarin
SANCTURA XR (QL)
SANDIMMUNE temazepam (QL) tretinoin (PA) (QL)
SAVELLA (QL) terazosin triamcinolone
X
SELZENTRY (QL) terbinafine (QL) triamterene/hctz XARELTO (QL)
SEREVENT DISKUS terbutaline triazolam (QL) XIFAXAN 550MG (PA) (QL)
sertraline (QL) testosterone cypionate (QL)* TRIBENZENOR (QL)
sevelamer carbonate testosterone enanthate (QL)* trifluoperazine Z
simvastatin (QL) tetracycline trifluridine zafirlukast
sirolimus theophylline trihexyphenidyl zaleplon (QL)
sodium fluoride (age 1-11) THIOLA trimethobenzamide ZIANA (QL)
sodium polystyrene thioridazine trimethoprim zolpidem, er (QL)
sulfonate thiothixene trimethoprim-polymyxin B zonisamide
solifenacin ticlopidine TRULICITY ZYLET*
sotalol TIKOSYN (QL) TRUVADA (QL)
WWW.PEHP.ORG 6
Common Tier 3 Medications
With Preferred Alternatives
QL = Quantity limit applies | PA = Requires preauthorization | * = Not available for hme delivery | PREFERRED ALTERNATIVES: Lowercase = Tier 1 | ALL CAPS = Tier 2
Did you know that you may lower your copayment by asking your doctor if your prescription can be
changed to a similar Tier 1 or Tier 2 medication? Tier 1 medications are available at the lowest copayment and
Tier 2 medications can save you up to 25% compared to Tier 3 medications. PEHP recommends speaking with
your doctor about Tier 1 and Tier 2 alternatives when he/she has chosen a Tier 3 drug
NON PREFERRED BRAND PREFERRED ALTERNATIVE NON PREFERRED BRAND PREFERRED ALTERNATIVE
ABILIFY (QL) aripiprazole (QL) ANZEMET TABLETS (QL)* ondansetron (QL)*
ACCUPRIL quinapril ANORO ELLIPTA (QL) SPIRIVA (QL)
ACCURETIC quinapril/hctz APTIOM (QL)
ACEON (QL) perindopril (QL), lisinopril, ARAVA (QL) leflunomide
benazepril
ARCAPTA (PA) (QL) FORADIL
ACIPHEX (QL) omeprazole (QL), pantoprazole
(QL), lansoprazole capsules (QL) ARICEPT (QL) donepezil (QL)
ACTIQ (PA) (QL)* fentanyl citrate (QL)* ARIMIDEX (QL) anastrozole (QL)
ACTONEL (QL) alendronate (QL) armodafinil (QL) modafinil (PA) (QL)
ACTOPLUS MET XR (QL) pioglitazone/metformin (QL) ARMOUR THYROID levothyroxine
ACTOPLUS MET (QL) pioglitazone/metformin (QL) AROMASIN exemestane
ACTOS (QL) pioglitazone (QL) ARTHROTEC diclofenac/misoprostol
ACZONE GEL (QL) benzoyl peroxide/clindamycin ATACAND (QL) olmesartan (QL), losartan
ADDERALL* amphetamine/dextroamphetamine ATACAND HCT (QL) olmesartan/hctz (QL), losartan/hctz

mixed salt tablets* ATRALIN (PA) (QL) tretinoin (PA) (QL)
ADDERALL XR * methylphenidate ER tablets (QL)*, ATROVENT ipratropium
methylphenidate ER capsules (QL)*
ASACOL HD DELZICOL
amphet./dextroamphet. methylphenidate ER tablets (QL)*,
mixed ER caps* methylphenidate ER capsules (QL)* AURALGAN (QL)* antipyrine/benzocaine*
ADVAIR HFA DISKUS fluticasone/salmeterol diskus (QL), AVALIDE (QL) olmesartan/hctz tabs (QL), losartan/
(PA) (QL) SYMBICORT (QL), DULERA (QL) hctz, irbesartan/hctz (QL)
ADVICOR (QL) AVANDAMET (QL) pioglitazone/metformin (QL)
AEROCHAMBER (QL)* EASIVENT (QL)* AVANDARYL (QL) DUETACT (QL)
ALDARA (QL) imiquimod (QL) AVANDIA (QL) pioglitazone (QL)
ALPHAGAN P 0.15% brimonidine AVAPRO (QL) olmesartan (QL), irbesartan (QL)

(QL), 0.2% AVELOX (QL)* moxifloxacin (QL)*
ALTACE (QL) ramipril (QL) AVINZA (PA) (QL)*
AMARYL glimepiride AVODART dutasteride
AMBIEN (QL) zolpidem (QL) AXERT (QL)* sumatriptan (QL)*, rizatriptan (QL)*,
AMBIEN CR (QL) zolpidem ER (QL) eletriptan (QL)*
AMERGE (QL)* naratriptan (QL)* AXID nizatidine
AMITIZA (QL) (PA) LINZESS (QL) AXIRON testosterone topical solution
ANALPRAM E CREAM hydrocortisone/pramoxine AZELEX benzoyl peroxide/clindamycin

hydrochloride AZMACORT ASMANEX (QL), QVAR (QL)
ANALPRAM HC hydrocortisone/pramoxine AZOR (QL)
hydrochloride
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AZULFIDINE sulfasalazine COREG CR (QL) carvedilol
BACTRIM DS sulfamethoxazole/trimethoprim CORGARD nadolol
BACTROBAN mupirocin* COSOPT timolol/dorzolamide
BANZEL (PA) (QL) divalproex, carbamazepine, phenytoin COUMADIN warfarin
BARACLUDE entecavir COZAAR (QL) losartan
BENICAR, HCT (QL) olmesartan (QL), olmesartan/hctz (QL) CRESTOR (QL) rosuvastatin (QL)
BENSAL HP OINTMENT CYMBALTA (QL) duloxetine (QL)
BENZACLIN benzoyl peroxide/clindamycin phosphate DALMANE (QL) flurazepam (QL)
BEPREVE (QL) PATANOL DDAVP TABLETS, desmopressin (PA) (QL)
NASAL SPRAY (PA) (QL)
BETAPACE, AF sotalol
DELATESTRYL (PA) (QL)*
BIAXIN, XL* clarithromycin*
DELZICOL mesalamine tablet
BONIVA TABLETS (QL) alendronate (QL)
DEMEROL TABLETS* meperidine*
BREO ELLIPTA (QL) SYMBICORT (QL)
DENAVIR acyclovir
BROMDAY (QL)* bromfenac*
DEPAKENE valproic acid
BUSPAR buspirone
DEPAKOTE, ER divalproex
BYDUREON (QL) (PA) TRULICITY (QL)
DEPO-TESTOSTERONE
BYETTA (QL) (PA) TRULICITY (QL) (QL)*
BYSTOLIC (QL) metoprolol DESOXYN* methamphetamine hcl*
CADUET (QL) amlodipine/atorvastatin (QL) DETROL tolterodine tartrate
CALAN, SR verapamil DETROL LA tolterodine tartrate er
CAMPRAL DEXCOM G4/G5/G6 (PA) FREESTYLE LIBRE (PA)(QL)
CARAFATE sucralfate (QL)
CARDIZEM, CD, LA diltiazem, verapamil DEXEDRINE* methylphenidate ER tablets (QL)*,
methylphenidate ER capsules (QL)*
CARDURA, XL doxazosin
DEXILANT (QL) omeprazole (QL), pantoprazole
CASODEX bicalutamide (QL), lansoprazole capsules (QL)
CATAPRES TTS (QL) clonidine patches (QL) dexmethyphendidate ER methylphenidate ER tablets (QL)*
CELEBREX (QL) ibuprofen, meloxicam, naproxen tabs (QL)*
CELEXA (QL) citalopram (QL) dextroamphetamine SR methylphenidate ER tablets (QL)*,
capsules (QL)* methylphenidate ER capsules (QL)*
CELLCEPT mycophenolate
DICLEGIS
CESAMET (PA) (QL) ondansetron (QL)*
DIFFERIN (QL) adapalene (QL)
CHENODAL (PA)
DILANTIN 100 MG phenytoin
CLIMARA (QL) estradiol patch (QL)
DILAUDID (QL)* hydromorphone (QL)*
CLIMARA PRO (QL) COMBIPATCH (QL)
DIOVAN/HCT (QL) valsartan/hctz (QL)
colchicine (QL)
DIPENTUM DELZICOL
COLCRYS
DIPROLENE, AF betamethasone
COMBIVIR lamivudine/zidovudine
DIPROSONE betamethasone
CONCERTA (QL)* methlyphenidate ER (QL)*
DITROPAN, XL (QL) oxybutynin, ER (QL)
COREG carvedilol
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DUAC benzoyl peroxide/clindamycin FYCOMPA (QL)
DUETACT (QL) glimepiride/pioglitazone GARAMYCIN* gentamycin*
DUONEB ipratropium-albuterol GLUCOPHAGE, XR (QL) metformin, XR (QL)

DURAGESIC PATCH (PA) GLUCOVANCE glyburide/metformin
(QL)*
GLYNASE glyburide micronized
EFFEXOR XR venlafaxine ER
GEODON ziprasidone
EFUDEX fluorouracil
GOLYTELY trilyte
ELAVIL amitriptyline
HALCION (QL) triazolam (QL)
ENTOCORT EC (QL) budesonide EC
HALDOL* haloperidol
EPIVIR lamivudine
HEPSERA (QL) adefovir dipivoxi (QL)
EPIVIR HPV lamivudine
HYCODAN* hydrocodone bit-homatropine*
ESTRACE estradiol
HYTRIN terazosin
EVISTA (QL) alendronate (QL), raloxifene (QL)
HYZAAR (QL) losartan/hctz
EXALGO (PA) (QL)* hydromorphone ER (PA)(QL)*
IMDUR isosorbide
EXELON (QL) rivastigmine (QL)
IMITREX (QL)* sumatriptan (QL)*
EXELON PATCH (QL) rivastigmine (QL)
IMURAN azathioprine
EXFORGE (QL) amlodipine/valsartan (QL) tabs,
olmesartan (QL) plus amlodipine INDERAL, LA metoprolol, LA, propranolol, LA
FAMVIR famciclovir INDOCIN, SR indomethacin, SR
FANAPT (QL) risperidone (QL), quetiapine INNOPRAN XL metoprolol LA, propranolol LA

fumarate, olanzapine, ziprasidone INTUNIV ER (QL) (PA) guanfacine, ER (QL)
FELDENE piroxicam INVEGA (QL) risperidone (QL), quetiapine
FEMARA letrozole fumarate, olanzapine
FENTANYL PATCHES JALYN (QL) dutasteride/tamsulosin (QL)

(PA) (QL)* KADIAN (QL) (PA)* morphine sulfate ER caps (QL) (PA)*
FENTORA (PA) (QL)* fentanyl citrate (QL)* KEPPRA, XR (QL) levetiracetam, ER (QL)
FIORICET* butalbital-apap-caffeine* KLONOPIN* clonazepam*
FIORINAL W/CODEINE* butalbital-aspirin-caffeine-codeine* LAMICTAL lamotrigine
FLAGYL metronidazole LAMISIL TABLET (QL)* terbinafine tabs (QL)*
FLEXERIL* cyclobenzaprine* LATUDA (QL) risperidone (QL), quetiapine
FLOMAX (QL) tamsulosin (QL) fumarate, olanzapine
FLOVENT HFA (QL) ALVESCO (QL), QVAR (QL), LEVAQUIN (QL)* levofloxacin (QL)*
PULMICORT FLEXHALER (QL), LEVSIN hyoscamine
ASMANEX (QL)
FLOXIN* ofloxacin* LEXAPRO (QL) escitalopram oxalate (QL)
FOCALIN, XR (QL)* dexmethylphenidate* LIALDA (QL) DELZICOL
FOSAMAX (QL) alendronate (QL) LIDEX fluocinonide
FOSAMAX PLUS D (QL) alendronate (QL) LIDODERM (QL) lidocaine patches (QL)
FOSRENOL sevelamer carbonate LIPITOR (QL) atorvastatin (QL)
FROVA sumatriptan (QL)* LOCOID, LOTION hydrocortisone butyrate
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LOFIBRA fenofibrate NIMOTOP nimodipine
LOMOTIL diphenoxylate/atropine NITRO-DUR PATCH nitroglycerin td patch
LOPROX ciclopirox NITROMIST SPRAY (QL) nitrostat
LORCET (QL)* hydrocodone/apap (QL)* NIZORAL ketoconazole
LORTAB (QL)* hydrocodone/apap (QL)* NOLVADEX tamoxifen
LOTENSIN/HCT benazepril/hctz NORCO (QL)* hydrocodone/apap (QL)*
LOTREL amlodipine/benazepril (QL) NORPACE, CR disopyramide
LOTRISONE clotrimazole/betamethasone NORVASC (QL) amlodipine
LOVAZA (QL) omega-3-acid ethyl esters (QL) OCUFEN flurbiprofen
LUNESTA (QL) eszopiclone (QL) OCUFLOX* ofloxacin*
LYRICA (QL) pregabalin (QL) ONFI (PA) (QL)
LYSTEDA (QL)* tranexamic acid (QL)* ONSOLIS (PA) (QL)* fentanyl lozenge (QL)*
MACROBID nitrofurantoin macrocrystal OPANA, ER (PA) (QL)* oxycodone (QL)*, oxymorphone

(PA) (QL)*
MACRODANTIN nitrofurantoin
OPTICHAMBER (QL)* EASIVENT (QL)*
MARINOL (PA) (QL) dronabinol (PA) (QL)
ORTHO-TRI-CYCLEN LO nogestimate, ethinyl estradiol
MAXALT, MLT (QL)* rizatriptan (QL)*
OXISTAT* econazole, nystatin
MAXZIDE triamterene/hctz
XTAMPZA (PA) (QL)* "NUCYNTA ER (QL)*, BUTRANS
MEDROL methylprednisolone (QL), morphine sulfate ER (QL)*"
MEGACE megestrol OXYIR* oxycodone IR*
METROGEL metronidazole PAMELOR nortriptyline
MEVACOR (QL) lovastatin PANCREASE MT lipram, CREON, ULTRASE
MICARDIS (QL) telmisartan (QL) PANCREAZE DR lipram, CREON, ULTRASE
MICARDIS HCT (QL) valsartan/hctz (QL), losartan/hctz, PARLODEL bromocriptine
irbesartan/hctz (QL), olmesartan/
hctz (QL) PATANOL olopatadine
MIDRIN* isometheptene/acetaminophen/ PAXIL (QL) paroxetine (QL)
dichloralphenazone* PENTASA sulfasalazine, DELZICOL,
MINOCIN minocycline COLAZAL, balsalazide
MIRAPEX ER (QL) pramipexole PERCOCET (QL)* oxycodone/apap (QL)*
MOBAN molindone PERCODAN (QL)* oxycodone/aspirin (QL)*
MOBIC meloxicam PERSANTINE dipyridamole
MONOPRIL HCT fosinopril/hctz PHENERGAN* promethazine
MOVANTIK LINZESS PHENERGAN WITH promethazine with codeine*
CODEINE*
MS CONTIN (QL)* morphine sulfate ER tabs (QL)*
PHOSLO calcium acetate
MYFORTIC mycophenolate
PLAVIX (QL) clopidogrel (QL)
NEURONTIN gabapentin
POTIGA (QL) lamotrigine, levetiracetam,
NEXIUM (QL) omeprazole (QL), pantoprazole valproate
(QL), lansoprazole capsules (QL)
PRADAXA (QL) (PA) warfarin, ELIQUIS, XARELTO
NIASPAN niacin ER
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PRAMOSON E hydrocortisone/pramoxine REPREXAIN (QL)* hydrocodone/ibuprofen (QL)*
PRANDIN repaglinide REQUIP, XL (QL) ropinirole, XL (QL)
PRAVACHOL (QL) pravastatin (QL) RESTASIS (QL) hydroxymethylcellulose (OTC)
PRECOSE (QL) acarbose (QL) RESTORIL (QL) temazepam (QL)
PRED FORTE prednisolone RETIN-A (PA) (QL) tretinoin (PA) (QL)
PREFEST estradiol/noreth tabs (QL), RISPERDAL M risperidone odt
PREMPHASE (QL), PREMPRO (QL)
RITALIN, SR, LA (QL)* methylphenidate ER tablets (QL)*
PRELONE prednisolone
ROBAXIN* methocarbamol*
PREMARIN estradiol
ROSULA FOAM sulfacetamide topical solution
PREMARIN VAGINAL ESTRACE VAGINAL CREAM
CREAM ROXICODONE* oxycodone (QL)*
PREVACID, SOLUTAB omeprazole (QL), pantoprazole ROZEREM (QL) zolpidem (QL)

(QL) (QL), lansoprazole capsules(QL) RYBELSUS (PA) (QL) TRULICITY (QL), OZEMPIC (QL)
PREVPAC (QL)* omeprazole (QL), clarithromycin*, RYTHMOL, SR propafenone
amoxicillin*
SALVAX DUO KIT salicylic acid
PRILOSEC (QL) omeprazole (QL)
SANCTURA (QL) trospium (QL), tolterodine tartrate,
PRINIVIL lisinopril tolterodine tartrate er, ENABLEX
(QL), VESICARE (QL)
PRINZIDE lisinopril/hctz
SANCUSO (QL)* granisetron (QL)*, ondansetron (QL)*
PRISTIQ (QL) desvenlafaxine (QL), duloxetine (QL)
SEROQUEL quetiapine fumarate
PROCARDIA XL nifedipine ER
SEROQUEL XR (QL) quetiapine fumarate ER (QL)
PROCHEIVE (PA) CRINONE (PA)
SILENOR (PA) (QL) zolpidem (QL), amitriptyline,
PROCTOCORT hydrocortisone imipramine
PROMETRIUM progesterone SINEMET carbidopa/levodopa, ER
PROSCAR (QL) finasteride (QL) SINGULAIR (QL) montelukast (QL)
PROTONIX (PA) (QL) pantoprazole (QL) SIMCOR (QL)
PROTOPIC (QL) ELIDEL (QL) SIVEXTRO (QL)*
PROVENTIL HFA (QL) PROAIR HFA (QL) SKELAXIN* metaxalone*
PROVERA medroxyprogesterone SOMA* carisoprodol*
PROVIGIL (PA) (QL) modafinil (PA) (QL) SONATA (QL) zaleplon (QL), zolpidem (QL)
PROZAC (QL) fluoxetine (QL) SORIATANE (QL) acitretin (QL)
PROZAC WEEKLY (QL) fluoxetine (QL) SPORANOX (PA) (QL)* itraconazole (PA) (QL)*
PULMICORT RESPULES ASMANEX (QL), QVAR (QL), STRATTERA atomoxetine
(QL) budesonide respules (QL)
SYMBYAX olanzapine/fluoxetine
QUTENZA (QL)
SYNTHROID levothyroxine
RAPAMUNE sirolimus
TAGAMET cimetidine
REGLAN metoclopramide
TEGRETOL carbamazepine
RELPAX (QL)* eletriptan (QL)*
TEGRETOL XR carbamazepine ER
REMERON (QL) mirtazapine (QL)
TEKTURNA (QL) losartan, olmesartan (QL)
RENVELA sevelamer carbonate
TENORETIC atenolol/chlorthalidone
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TENORMIN atenolol VYVANSE (QL)* "methylphenidate ER tablets (QL)*,
methylphenidate ER capsules
TERAZOL* terconazole* (QL)*"
TIAZAC diltiazem WELCHOL (QL) colesevelam (QL)
TICLID ticlopidine WELLBUTRIN, SR, XL (PA) bupropion, SR, XL (QL)
TIGAN trimethobenzamide (QL)
TOBREX DROPS* tobramycin drops* XALATAN latanoprost
TOFRANIL imipramine XANAX, XR* alprazolam, XL*
TOLECTIN tolmetin XOPENEX HFA (QL) PROAIR HFA (QL)
TOPAMAX topiramate XOPENEX NEBULIZER (QL) albuterol, levalbuterol (QL)
TOPICORT, LP desoximetasone ZANAFLEX tizanidine
TOPROL XL metoprolol ER ZANTAC ranitidine
TRAVATAN Z (PA) lantanoprost, LUMIGAN ZARONTIN ethosuximide
TRETIN-X (PA) (QL) tretinoin (PA) (QL) ZAROXOLYN metolazone
TRICOR (QL) fenofibrate ZEMPLAR paroicalcitol
TRIGLIDE fenofibrate ZESTRIL lisinopril
TRILEPTAL oxcarbazepine ZETIA (QL) simvastatin (QL), fenofibrate (QL),
WELCHOL (QL), atorvastatin (QL),
TRIZIVIR abacavir/lamivudine/zidovudine niacin ER
TRUSOPT dorzolamide ZIAC bisoprolol
TUSSIONEX (QL)* hydrocodone/chlopheniramine (QL)* ZIAGEN abacavir
UBRELVY (PA) (QL) sumatriptan (QL), rizatriptan(QL) ZITHROMAX (QL)* azithromycin (QL)*
ULTRACET (QL)* tramadol/apap (QL)* ZMAX (QL)* azithromycin (QL)*
ULTRAM, ER (QL)* tramadol, ER (QL)* ZOCOR (QL) simvastatin (QL)
ULTRAVATE, PAC KIT (QL) halobetasol ZOFRAN, ODT (QL)* ondansetron (QL)*, ondasetron ODT
(PA) (QL)*
URELLE methenamine-hyoscamine-salicylate
ZOLOFT (QL) sertraline (QL)
UROXATRAL (QL) alfuzosin
ZOMIG (QL)* sumatriptan (QL)*, rizatriptan
URSO FORTE ursodiol (QL)*, RELPAX (QL)*
VAGIFEM estradiol vaginal tablet ZONTIVITY (QL)
VALIUM* diazepam* ZORTRESS (QL) mycophenolate, PROGRAF,
cyclosporine
VALTREX (QL) valacyclovir (QL)
ZOVIRAX TABS, CAPS acyclovir tabs, caps
VALTURNA (QL) olmesartan (QL), losartan
ZUPLENZ (QL)* ondansetron (QL)*
VASERETIC enalapril/hctz
ZYCLARA (QL)* imiquimod (QL)
VESICARE solifenacin
ZYLOPRIM allopurinol
VFEND voriconazole
ZYMAR* VIGAMOX*, BESIVANCE*
VICODIN (QL)* hydrocodone/apap (QL)*
ZYMAXID (QL)* VIGAMOX*, BESIVANCE*
VIRAMUNE nevirapine
ZYPREXA olanzapine
VISTARIL hydroxyzine pamoate
ZYPREXA ZYDIS olanzapine
VIVELLE DOT (QL) estradiol transderm patches (QL)
ZYVOX (QL)* linezolid (QL)*
VYTORIN (QL)
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ACA Medication List
Under the Affordable Care Act, PEHP Pharmacy offers the following preventive services covered at no cost to you,
payable through the Pharmacy Plan when received at a participating pharmacy with a prescription from your doctor.
Over-the-counter purchases are not covered.
DRUG NAME RESTRICTIONS DRUG NAME RESTRICTIONS

aspirin 325mg Female age 55-79 Influenza vaccine 6 months and older
Male age 45-79 LO LOESTRIN 24 FE Female under age 50
aspirin 81mg Female age 55-79 LOESTRIN 24 FE Female under age 50
Male age 45-79
Meningitis vaccine Age 2-56
buproban Over age 18
MMR vaccine No Restriction
buproprion HCL SR (generic Over age 18
Zyban) MMR-Varicella vaccine Under age 13
calcium 500+vitamin D Over age 65 MY WAY Female under age 50
CHANTIX Over age 18 NEXT CHOICE ONE DOSE Female under age 50
Chicken Pox vaccine No Restriction NICOTROL Over age 18
children's iron Age 6 months - 1 year NICOTROL NS Over age 18
FC CONDOM, FEMALE Female under age 50 NUVARING Female under age 50
fer-iron Age 6 months - 1 year OTC SMOKING CESSATION Available through
the PEHP Quitline
FLUORABON Age 6 months - 5 years 1-855-366-7500
FLUOR-A-DAY Age 6 months - 5 years peg 3350-electrolyte Age 50-75
fluoride Age 6 months - 5 years PLAN B ONE-STEP Female under age 50
fluoritab Age 6 months - 5 years Pnemonia vaccine 2 years and older
FLURA-DROPS Age 6 months - 5 years raloxifene Female over age 35
folic acid 0.4mg Female age 10-50 Shingles Zoster vaccine 50 years and older
folic acid 0.8mg Female age 10-50 tamoxifen Female over age 35
generic bowel preparations Age 50-75 Tetanus vaccine 7 years and older
generic oral contraceptives Female under age 50 Tetanus-Diptheria vaccine Age 7-65
generic prenatal vitamins during pregnancy VCF Female under age 50
Hepatitis A vaccine No Restriction Whooping cough, Tetanus, No Restriction
Hepatitis B vaccine No Restriction Diptheria vaccine
HPV vaccine Female age 11-27
Male age 11-22
Individual pharmacies may have their own restrictions on age and immunizations offered.
PEHP covers Smoking Cessation for up to 180 days per rolling 365 days.
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Examples of Non-Covered Medications
Note: Not a complete list
Abilify SDV Doryx Intermezzo Oracea Sumavel DosePro
Absorica Doxycycline-MonoTabs Invokamet, XR Oravig Sumaxin
Abstral SL Duexis Invokana Orenitram Sustol
Accu-Chek test strips Dymista Janumet, XR Orkambi Tegsedi
Acyclovir Ointment, Dynacin Januvia Orthovisc Temazepam 22.5 mg
Cream Edarbi Jornay Oxycontin Testim
Adoxa Edarbyclor Kapvay Oxytrol Testosterone Gel
Aimovig Edex Karbinal ER Paroxetine ER Tevtropin
Alevicyn Egrifta Karigel Patanase Tirosint
Align Embeda Keto-Diastix Paxil CR Tofranil PM
Allegra, D Enfolast, N Ketoralac Isecure Penlac Transderm-Scop
Ammonium lactate Erleda Lac-Hydrin Pennsaid Tresiba
Amrix Esbriet Lamictal Dose Pack Pentacel Treximet
Androgel Evekeo Latisse Phentermine Trinaz
Antara Extavia Lazanda Picato Trintellix
Apidra Fenofibrate 40mg, 120mg Lemtrada Polyethylene glycol powder Tri-Vi-Flor
Ascensia test strips Fenoglide 40mg, 120mg Levemir Pregenna Tri-Vite
Astelin Fenoprofen Levitra Prevident Trokendi XR
Astepro Fentanyl 37.5mg, Levocetirizine Proctocream-HC Vaniqa
Atrapro 62.5mg, 87.5mg Lidocaine/Prilocaine Propecia Vantas
Auvi-Q Fetzima Topical Kit Protropin Veltin
Avita cream, gel Fexofenadine Lorzone Qnasl Veramyst
Azelastine Firazyr Lustra Qsymia Viagra
Basaglar Flonase Menopur Qudexy XR Viberzi
Baygam Fluorigard Minocin combo pack Quillivant XR Victoza
Beleodaq Fluoxetine tablets Miralax Rayos Viekira
Belviq 20mg, 60mg Monodox Refissa Viibryd
Belsomra Follistim AQ Mouthkote Renflexis Vitamins (except
Benzefoam Forfivo XL Muse Renova prescription prenatal
Beyaz Fortesta Myferon 150 Repronex vitamins)
Bifera Ganirelix Myrac Restoril 22.5mg Viteka
Bravelle Gelnique Gel Nasalide Reyvow Vimovo
Brisdelle Genotropin Nasarel Riax VSL
Calomist Nasal Spray Glatopa Nasonex Rituxan Hycela Xenical
Cambia Glumetza Neurpath-b Rosula Xiidra
Cartivisc Glyxambi Nuedexta Saizen Xultophy
Caverject Gonal F Nuquin Sarafem Xyzal
Cerefolin Gralise Nurtec Semprex D Zegerid
Cetirizine, D Harvoni Nutropin AQ Serostim Zelapar
Cialis Hetlioz Nuvessa Siliq Zenzedi
Clarinex, D Horizant Nymalize Sitavig Zetonna
Claripel Humalog Ofev Sklice Zinbryta
Corlanor Humatrope Olumiant Skyrizi Zohydro
Contour Test Strips Humulin Omeprazole/sodium Solaquin Zolpimist
Copaxone 20mg Hydroquinone bicarbonate Solodyn Zovirax Ointment,
Cyanocobalamin injection Ilumya Omnaris Sovaldi Cream
Daklinza Imipramine Pamoate Omnitrope Sprix Zyban
Deplin Inflectra One Touch test strips Striant Zyoptin
Dificid Innohep Onpattro Subsys Zyrtec, D
Always consult with your doctor before making medication changes.
WWW.PEHP.ORG 14
Specialty Medications – Tier A
Tier A: Specialty medications available at the lowest specialty Copayment listed in your Benefit Summary.
ALL CAPS = Brand name | ^ = Must use specialty pharmacy Accredo | PA = Requires Preauthorization
QL = Quantity limit applies | HH = PEHP approved Home Health agency
ABRAXANE GRANIX (PA)(HH)

ACTHAR HP (PA)
What are specialty HALAVEN (PA)
ACTEMRA (PA) (HH)
ACTEMRA SUB Q^ (PA)
medications? HELIXATE FS (PA)
HEMOFIL M (PA)
They are costly drugs that require
ACTIMMUNE (PA) (HH) HERCEPTIN
special handling and shipping or are
ADAGEN (PA) HUMATE P (PA) (HH)
required by the manufacturer to be
ADCETRIS (PA) HYALGAN
dispensed by a specific pharmacy,
ADCIRCA^ (PA) (QL) HYCAMTIN^ (PA)
such as PEHP’s specialty pharmacy,
ADVATE (PA) ibandronate IV (PA) (HH)
Accredo. PEHP may require you to buy
AFINITOR^ (PA) (QL) ICLUSIG^ (PA)
your specialty medications through
ALDURAZYME (PA) (HH) ILARIS (PA) (HH)
Accredo for coverage. You can find out
ALFERON-N^ (PA) IMBRUVICA^ (PA)
where to buy your specialty medication
ALPHANATE (PA) INCRELEX^ (PA)
for coverage at www.pehp.org.
ALPHANINE SD (PA) INFERGEN (PA) (HH)
AMNESTEEM (QL) INLYTA^ (PA)
ANZEMET INJ (QL) CYTOVENE INTRON A (PA) (HH)
APOKYN^ (QL) D.H.E. (QL) ISOTRETINOIN (QL)
ARALAST (PA) (HH) decitabine (PA) ISTODAX (PA)
ARANESP (HH) IXEMPRA^ (PA)
DEMEROL PCA
ARCALYST (PA) JEVTANA^ (PA)
ELAPRASE (PA) (HH)
ARRANON (PA) KADCYLA^ (PA)
ELELYSO^ (PA)
ARZERRA^ (PA) (QL) KALYDECO^ (PA)
ELIGARD (PA) (HH)
AVASTIN KEYTRUDA (PA)
enoxaparin
AZACITIDINE (PA) KOATE DVI (PA)
ENTYVIO^ (PA) (QL)
BEBULIN VH (PA) KOGENATE FS (PA)
epoprostenol, RTS (PA) (HH)
BENEFIX (PA) KRYSTEXXA (PA) (HH)
ERBITUX (PA)
BENLYSTA (PA) (HH) KUVAN^ (PA)
ERIVEDGE^ (PA)
BETASERON^ KYPROLIS^ (PA)
EUFLEXXA (QL)
BOTOX (PA)(QL) LENVIMA^(PA)
EXJADE^
BROVANA (PA) LEUKINE (PA)
FABRAZYME (PA) (HH) LEUPROLIDE (PA)
capecitabine^ (PA)
CAPRELSA^ (PA) FEIBA VH (PA) LUCENTIS (PA) (QL)
CARBAGLU^ FERRIPROX (PA) LUMIZYME (PA) (HH)
CARIMUNE (PA) (HH) FIRMAGON (PA) (HH) LUPRON^ (PA) (QL) (HH)
CAYSTON (PA) FLEBOGAMMA (PA) (HH) LYNPARZA^(PA)
CHORIONIC GONADOTROPIN^ (PA) FLOLAN (PA) (HH) MACUGEN (PA)
CIMZIA^ (PA) FOLOTYN (PA) MAKENA VIALS^
CLARAVIS (QL) fondaparinux (QL) MATULANE^ (PA)
COMETRIQ^ (PA) FUZEON (PA) (HH) MEKINIST^ (PA)
COPAXONE 40mg^(QL) GAMASTAN S/D (PA) METOPIRONE
COPEGUS^ (PA) (QL) (NO MAX) GAMUNEX^ (PA) (HH) MITOXANTRONE (PA)
COSENTYX^ (PA) GAMUNEX-C^ (PA) MONOCLATE-P (PA)
CYRAMZA^ (PA) (HH) GAZYVA^ (PA) MONONINE (PA)
CYTOGAM (PA) (HH) GRANISITRON INJ (QL) MORPHINE PCA
15
WWW.PEHP.ORG
Specialty Medications – Tier A
Tier A: Specialty medications available at the lowest specialty Copayment listed in your Benefit Summary.
MOZOBIL (PA) (HH) RAVICTI^ (PA) (QL) TREANDA (PA)

MYORISAN (QL) REBETOL^ (PA) (NO MAX) TRELSTAR LA, DEPOT (PA)
MYOZYME (PA) (HH) RECOMBINATE (PA) TYKERB^ (PA) (QL)
NAGLAZYME (PA) (HH) REMODULIN (PA) (HH) TYSABRI^ (PA)(QL)(HH)
NEUMEGA (PA) (QL) (HH) RENFLEXIS^ (PA) (HH) TYVASO^ (PA)
NEUPOGEN^ (HH) REVATIO INJECTION (PA) VANTAS (PA) (HH)
NEXAVAR^ (PA) (QL) REVLIMID^ (PA) VECTIBIX (PA) (QL)
NORDITROPIN^(PA) RIBAPAK^ (PA) VELCADE^ (PA)
NOVAREL^ (PA) RIBASPHERE^ (PA) VELETRI^ (PA)
NOVOSEVEN (PA) RIBAVIRIN^ (PA) VENTAVIS (PA) (HH)
NPLATE (PA) (HH) RITUXAN^ (HH) VIMIZIM^ (PA)
NUCALA^ (PA) SABRIL^ (PA) (QL) VIVITROL^ (PA) (QL) (HH)
NULOJIX^ (PA) SAMSCA^ (PA) VOTRIENT^ (PA) (QL)
octreotide acetate^ (PA) (HH) SANDOSTATIN^ (PA) (HH) VPRIV (PA) (HH)
OFORTA ^ (PA) SENSIPAR WILATE (PA)
OLYSIO^ (PA) (QL) sildenafil 20mg^ (PA) (QL) XALKORI ^ (PA)
OPDIVO (PA) SOMATULINE^ (PA) (HH) XELJANZ^ (PA) (QL)
OPSUMIT^ (PA) (QL) SOMAVERT^ (PA) (QL) XENAZINE^ (PA)
ORFADIN^ SOTRET (QL) XGEVA^ (PA) (HH)
OTEZLA^ (PA) (QL) STELARA^(PA)(QL) XOFIGO (PA)
OVIDREL^ (PA) SUPARTZ XOLAIR^ (PA) (QL) (HH)
PEGASYS^ (PA) SUPRELIN LA (PA)(QL)^ XYNTHA (PA)
PEG-INTRON^ (PA) SYNAGIS (PA) (QL) (HH) YERVOY (PA)
PERFOROMIST TAFINLAR^ (PA) ZAVESCA (PA) (QL)
PERJETA^ TASIGNA^ (PA) (QL) ZEMAIRA (PA) (HH)
PREGNYL^ (PA) temozolomide^ (QL) ZENATANE (QL)
PRIALT (PA) THALOMID^ (PA) (QL) ZOLADEX (PA) (QL) (HH)
PROFASI HP^ (PA) TOBI PODHALER^ (PA) (QL) ZOLINZA^ (PA) (QL)
PROFILNINE SD (PA) tobramycin inh solution ^ (PA) (QL) (HH) ZORBTIVE^ (PA) (QL)
PROLEUKIN (PA) TOBRAMYCIN INJ ZYDELIG^ (PA) (QL)
PROMACTA^ (PA) (QL) TORISEL (PA) (QL) ZYKADIA^ (PA) (QL)
PULMOZYME^ (PA) (QL) (HH) TRACLEER^ (PA) (QL) ZYTIGA^ (PA)
WWW.PEHP.ORG 16
Specialty Medications – Tier B
Tier B: Specialty mediations available at the intermediate specialty Copayment listed in your Benefit Summary.
TIER B ALTERNATIVES
ADEMPAS^ (PA) (QL) TRACLEER^ (PA), OPSUMIT^(PA)9QL), sildenafil 20mg^(PA)(QL), ADCIRCA^ (PA)(QL)
ARIXTRA (HH) fondaparinux (QL) (HH)
BIVIGAM^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE^ (PA) (HH), FLEBOGAMMA^ (PA) (HH)
BONIVA Infused (PA) (HH) ibandronate IV (PA) (HH)
BOSULIF^ (PA) TASIGNA^ (PA) (QL)
CEREZYME (PA) (HH) VPRIV (PA)
CHENODAL (PA)
DACOGEN (PA) decitabine (PA)
EPOGEN (HH) ARANESP
ERWINAZE (PA)
EYLEA^ (PA) AVASTIN, LUCENTIS (PA)
FORTEO^ (PA) (QL) RECLAST
FRAGMIN (QL) (HH) enoxaparin (HH), fondaparinux (QL) (HH)
GAMMAGARD^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
GAMMAGARD SD^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
GAMMAKED^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
GAMMAPLEX^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
HIZENTRA^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
JETREA (PA)
KINERET^ (PA) (QL) RENFLEXIS (PA) (HH)
LETAIRIS^ (PA) TRACLEER^ (PA)
LOVENOX (HH) enoxaparin (HH)
NEULASTA (HH) NEUPOGEN (PA) (HH)
OCTAGAM^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
ORENCIA (PA) (QL) (HH) RENFLEXIS (PA) (HH)
POMALYST^ (PA)
PRIVIGEN^ (PA) GAMUNEX^ (PA) (HH), GAMUNEX-C^ (PA) (HH), CARIMUNE (PA) (HH), FLEBOGAMMA (PA) (HH)
PROCRIT (HH)
REVATIO^ (PA) (QL) sildenafil 20mg^ (PA) (QL)
RIBATAB^ (PA) (QL) RIBAVIRIN^ (PA) (QL)
STIVARGA^ (PA)
TEMODAR^ (QL) temozolomide^ (QL)
TOBI (PA) (QL) (HH) tobramycin inh solution^ (PA)(QL)(HH)
YONDELIS (PA)
XELODA^ (PA) capecitabine^ (PA)
XTANDI^ (PA) ZYTIGA^ (PA)
VIDAZA (PA) AZACITIDINE (PA)
ZALTRAP^ (PA) AVASTIN
ZELBORAF^ (PA) TAFINLAR^ (PA)
17
WWW.PEHP.ORG
Specialty Medications – Tier C
Tier C: Specialty medications available at the highest specialty Copayment listed in your Benefit Summary.
TIER C ALTERNATIVES
AJOVY (PA) (QL)* "topirimate, propanolol, metoprolol, venlafaxine, BOTOX (PA)(QL)"
AMPYRA^ (QL)
AVONEX^(PA) BETASERON^, COPAXONE 40mg^(QL), TYSABRI (PA)(QL)(HH), RITUXAN (HH)
EMGALITY (PA) (QL)* "topirimate, propanolol, metoprolol, venlafaxine, BOTOX^ (PA)(QL)"
ENBREL^ (PA) (QL) CIMZIA^ (PA)
GLEEVEC^ (PA)
GILENYA^(PA) BETASERON^, COPAXONE 40mg^(QL), TYSABRI (PA)(QL)(HH), RITUXAN (HH)
HUMIRA^(PA) CIMZIA^(PA), ACTEMRA^(PA), XELJANZ^(PA), RITUXAN (HH), STELARA^ (PA), OTEZLA^(PA),
COSENTYX^(PA) ENTYVIO^(PA), RENFLEXIS (PA)
IBRANCE^(PA)
ORKAMBI (PA) (QL)
PROLIA^ (QL) (PA) RECLAST

REBIF^(PA) BETASERON^, COPAXONE 40mg^(QL), TYSABRI (PA)(QL)(HH), RITUXAN (HH)
REPATHA^(PA)(QL) atorvastatin, rosuvastatin, fenofibrate, ezetimibe
SIMPONI^(PA) CIMZIA^(PA), ACTEMRA^(PA), XELJANZ^(PA), RITUXAN (HH), STELARA^ (PA), OTEZLA^(PA),
COSENTYX^(PA) ENTYVIO^(PA), RENFLEXIS (PA)
SPRYCEL^ (PA) (QL)
SUTENT^ (PA)
SYMDEKO (PA) (QL)
TARCEVA^ (PA) (QL)

TAGRISSO^ (PA)
TECFIDERA^ (QL) BETASERON^, COPAXONE 40mg^(QL), TYSABRI (PA)(QL)(HH), RITUXAN (HH)
XYREM (PA) (QL)
WWW.PEHP.ORG 18
Expanded Preventive Medications –
STAR HSA Plan
Expanded preventive drug coverage means that PEHP will pay a portion of the drug cost for some STAR
plans even before you meet your deductible. Check your benefit summary for plan coverage details as
not all STAR plans include this benefit. Make sure to visit an in-network pharmacy to receive this benefit.
Diabetes Cardiovascular Respiratory

GLUCOSE RESCUE ANTICOAGULANTS/ RENIN/ANGIOTENSIN ANTICHOLENERGICS
PRODUCTS ANTIPLATELETS SYSTEM ANTAGONIST
(ACEI/ARB) ipratropium bromide
GlucaGen HypoKit clopidogrel
solution
dipyridamole enalapril
Glucagon
warfarin fosinopril INHALED
INSULINS CORTICOSTEROIDS
BETA BLOCKERS irbesartan
Novolog vials
acebutolol lisinopril QVAR inhaler
Novolin vials
bisoprolol losartan
SABA/
Lantus vials quinapril ANTICHOLENERGICS
carvedilol
METFORMIN ramipril
labetalol ipratropium-albuterol
PRODUCTS
metoprolol succinate trandolapril inhaler
glipizide-metformin DIURETICS
metoprolol tartrate ipratropium-albuterol
glyburide-metformin amiloride
propranolol solution nebulized
metformin propranolol tablets bumetanide
SHORT ACTING BETA
metformin ER (non sotalol chlorothiazide AGONISTS
OSM, non MOD) chlorthalidone
timolol maleate tablets
albuterol ER tablets
MISCELLANEOUS furosemide solution
CALCIUM CHANNEL
pioglitazone BLOCKERS furosemide tablets albuterol nebulized
TESTING SUPPLIES amlodipine hydrochlorothiazide albuterol syrup
diltiazem capsules
Freestyle test strips albuterol tablets
felodipine ER hydrochlorothiazide
SULFONYLUREAS tablets
isradipine ProAir HFA inhaler
glimepiride indapamide
nifedipine tablets ER ProAir RespiClick
glipizide methazolamide
verapamil
glipizide ER methyclothiazide Ventolin inhaler
COMBINATION
glyburide PRODUCTS spironolactone
glyburide micronized amiloride & HCTZ torsemide Osteoporosis

atenolol & chlorthalidone MISCELLANEOUS
tolazamide alendronate
bisoprolol & HCTZ prazosin
enalapril & HCTZ clonidine
Depression irbesartan & HCTZ digoxin
lisinopril & HCTZ VASODILATORS
citalopram
losartan & HCTZ hydralazine
escitalopram
metoprolol & HCTZ isosorbide
fluoxetine
nadolol &
sertraline PROUDLY SE
bendroflumethiazide
propranolol & HCTZ
triamterene & HCTZ
19
WWW.PEHP.ORG
Specialty Medications – Agencies
The following are the ONLY PEHP approved Home Health Agencies through which the specified Specialty
Medications are allowed:
» Central Valley Home Health » Intermountain Healthcare » Uintah Basin Home Health
Homecare
» Community Nursing Services/ » University of Utah Home
Love » NuFactor for factor drugs Infusion
» Infusion Innovations » Rock Springs IV Center
Contact Information
PEHP Customer Service Express Scripts Accredo Specialty Pharmacy
801-366-7555 Customer Service Physician Customer Service Line:
or 800-765-7347 800-903-4725 800-987-4904, option 5
www.express-scripts.com PEHP Customer Service Line:
PEHP Appeal Address 877-766-3572
Benefits Review Committee Express Scripts
PEHP COB/Direct Claims Home Delivery Address
560 East 200 South Express Scripts Express Scripts
Salt Lake City, UT 84102-2004 PO Box 2904 PO Box 747000
Clinton, IA 52733-2904 Cincinnati, OH 45274-7000
WWW.PEHP.ORG 20
IMPORTANT: This is a brief list of common exclusions and may not be complete. It was current at the time of printing and
is subject to change. Additions and subtractions can be made to the list at any time. For the latest list, go to
www.pehp.org or call PEHP at 801-366-7555 or 800-765-7347.
Exclusions From Coverage

GENERAL EXCLUSIONS or generally considered Experimental or
Investigational by the medical profession as
1. Charges in excess of contract Limitations or In-
determined solely by PEHP.
Network Rate.
14. Charges for services without adequate
2. All charges for services received as a result of
diagnosis or dates of service.
an Industrial Claim (on-the job) injury or illness,
any portion of which is payable under Worker’s 15. Charges for services, supplies or medications
Compensation or Employer’s liability laws. to the extent they are provided by any
governmental plan or law under which the
3. PEHP will only be liable for Eligible Benefits for
individual is, or could be covered.
which the Member is liable. Payment will not
be made, nor credit given toward Deductibles 16. Charges for services as a result of an auto related
or out-of-pocket expenses for any expense for injury and covered under No-fault insurance. If
which the Member is not legally bound. a Member fails to maintain No-fault insurance
on his/ her own vehicle as required by law in the
4. Charges for educational material or literature.
state they reside in, the minimum dollar amount
5. Charges for nutritional counseling except for they are required to maintain ($3,000 in Utah) for
the benefits provided for diabetes education, claims related to the auto injury are also excluded
anorexia, bulimia, or as allowed under the from Coverage.
Affordable Care Act (Preventive Services under
17. Services, treatments, or supplies furnished by
Section 6.14).
a Hospital or facility owned or operated by
6. Charges for scholastic education, vocational the United States Government or any agency
training, learning disabilities, or behavior thereof while a Member is on active duty.
modification.
18. Services, drugs, or supplies received which
7. Charges for medical care rendered by an were caused by a Member’s active participation
Immediate Family Member. as a result of an insurrection, terrorism, war or
8. Charges prior to Coverage or after termination an act of war, whether declared or undeclared,
of Coverage even if illness or injury occurred or due to injur or illness incurred in the armed
while a Member. services of any country.
9. Provider’s telephone calls or travel time, unless 19. Any service or supply not specifically identified
specifically covered by Employer group as as a benefit.
indicated in the Benefits Summary. 20. Charges for commercial or private aviation
10. Charges for services primarily for convenience, services, meals, accommodations and car
contentment, or other non-therapeutic rental.
purpose. 21. Charges for mileage reimbursement except for
11. Overutilization of medical benefits as eligible ambulance service.
determined by PEHP. 22. Charges by a Provider for case management.
12. Charges that are not medically necessary to 23. Charges for independent medical evaluations
treat the condition, as determined by PEHP, or and/or testing for the purpose of legal defenses
charges for any service, supply or medication or disputes.
not reasonable or necessary for the medical
care of the patient’s illness or injury. 24. Charges for submission of Medical Records
necessary for claims review.
13. Charges for Unproven medical practices or
care, treatment, Devices or medications that 25. Delivery, shipping, handling, sales tax, or
are Experimental or Investigational in nature finance charges.
02/21/18

26. PEHP is not responsible to pay any benefits or medications used to treat secondary
given verbally or assumed except as written in conditions or Complications due to any
a Preauthorization, documented by Customer non-covered medical services, procedures,
Service or Medical Case Management, or as supplies or medications are not covered. Such
described in this policy. Complications include, but are not limited to:
27. Prescriptive services provided by the Internet or a. Complications relating to services and
catalog. supplies for or in connection with gastric
28. Charges for remote medical evaluation and bypass or intestinal bypass, gastric stapling,
management, including prescriptive services or other similar Surgical Procedure
provided by telephone, unless specifically to facilitate weight loss, or for or in
covered by Employer group as indicated in the connection with reversal or revision of such
Benefits Summary. procedures, or any direct Complications or
consequences thereof;
29. Autopsy procedures.
b. Complications as a result of a Cosmetic
30. Complications as a result of any non-covered Surgery or procedure, except in cases of
service, procedure, Devices, or medication, Reconstructive Surgery:
regardless of when the Surgery was performed
or whether the original Surgery was covered by 1. When the service is incidental to or
a health plan. follows a Surgery resulting from trauma,
infection or other diseases of the
31. Treatment of obesity by means of Surgery, involved party; or
medical services, or prescription medications,
regardless of associated medical, emotional, or 2. Related to a congenital disease or
psychological condition. anomaly of a covered Dependent child
that has resulted in functional defect;
32. Services incurred in connection with injury or
illness arising from the commission of c. Complications relating to services, supplies
or medications which have not yet been
a. a felony; approved by the FDA or which are used
b. an assault, riot or breach of peace; for purposes other than its FDA-Approved
purpose;
c. a Class A misdemeanor;
39. Pelvic or spinal manipulation under anesthesia.
d. any criminal conduct involving the illegal
use of firearm or other deadly weapon; 40. Services, procedures, medications, or Devices
received at or from a birthing center.
e. other illegal acts of violence.
41. All vitamins, oral or injected, and/or the
33. Charges incurred while a Member is
associated administration, not listed as eligible
incarcerated or in police custody.
elsewhere in this Master Policy.
34. Claims submitted past the timely filing limit
42. Minerals, food supplements, homeopathic
allowed per Section 8.1 of this Master Policy.
medicines, and nutritional supplements
35. Charges for expenses in connection with (Prenatal vitamins and folic acid will be covered
appointments scheduled and not kept. for pregnancy).
36. Charges for the treatment of sexual 43. Powders, and non-covered medications used in
dysfunction. compounded preparations.
37. Charges for services received as a result 44. Functional neuromuscular electrical
of medical tourism, or for traveling out of stimulation Devices.
the United States to seek medical services,
45. Whole exome and whole genome sequencing
medications, or Devices, including any
for the diagnosis of genetic disorders.
complications thereof, unless specifically
covered by Employer group as indicated in the 46. Out-of-Network chiropractic services.
Benefits Summary. 47. Trigger point injections done by an Out-of-
38. Medical services, procedures, supplies, Devices, Network Provider.
2
48. Court-ordered drug screening or confirmatory 3. After-hours charges.
drug testing. 4. Charges for ambulance waiting time.
49. Court-ordered treatment that would otherwise
be paid for by a third party, such as the court.
ANESTHESIA
50. Surrogate pregnancy.
The following are Exclusions of the policy:
51. Microprocessor-controlled prosthetic limbs,
except for those plans which offer coverage, 1. Anesthesia in conjunction with ineligible
requires Preauthorization. Please refer to your Surgery.
Employer to inquire if Coverage is offered. 2. Anesthesia administered by the primary
52. Charges related to obtaining or caring for a surgeon.
service animal. 3. Monitored anesthesia care or on-call time for
53. Radiofrequency for the Sacroilial (SI) joint. consultant.
54. Charges in conjunction with or related to 4. Additional charges for supplies, medications,
ineligible procedures, medications, or devices. equipment, etc.
55. Surgical or medical treatment of Peyronie’s 5. Manipulation under anesthesia for any body
Disease. part other than knees, elbows, or shoulders.
56. Micro-processor controlled braces. 6. For Providers who bill for these services
separately, General Anesthesia or Monitored
57. Occipital nerve block for cervicogenic Anesthesia Care for standard colonoscopy or
headache, occipital neuralgia, cluster standard EGD, if a Member does not have an
headaches, chronic daily headache, and ASA score of P3 or higher, or a Mallampati score
migraines. of III or higher.
58. Replacement of equipment, supplies, devices,
Durable Medical Equipment, medications, or
DIAGNOSTIC TESTING,
accessories that are lost, stolen or damaged.
LAB AND X-RAY
ADOPTION BENEFITS 1. Charges in conjunction with ineligible
The following are Exclusions of the policy: procedures, including pre- or post- operative
evaluations.
1. Expenses incurred for the adoption of nieces,
nephews, brothers, sisters, grandchildren, 2. Routine drug screening, except when ordered
cousins, stepchildren, children of adult by a treating physician and done for a medical
designees or in-laws of any of the above. purpose, as determined by PEHP, or unless
otherwise allowed by the Master Policy.
2. Transportation, travel expenses or
accommodations, passport fees, translation 3. Sublingual or colorimetric allergy testing.
fees, photos, postage etc. 4. Charges in conjunction with weight loss
3. Living expenses, food, and/or counseling for programs regardless of Medical Necessity.
the birth mother. 5. Epidemiological counseling and testing.
6. Unbundling of lab charges or panels.
AMBULANCE BENEFITS 7. Medical or psychological evaluations or
The following are Exclusions of the policy: testing for legal purposes such as paternity
suits, custodial rights, etc., or for insurance or
1. Charges for common or private aviation
employment examinations.
services.
8. Hair analysis, trace elements, or dental filling
2. Services for the convenience of the patient or
toxicity.
family.
3
9. Assisted reproductive technologies, including 12. Only conventional, body powered, cable-
but not limited to: invitro fertilization; gamete operated prosthetics or non-electrical
intra fallopian tube transfer; embryo transfer; conventional braces will be eligible for loss of a
zygote intra fallopian transfer; pre-embryo limb or congenitally missing limb(s). Additional
cryopreservation techniques; and/or any charges for more elaborate or precision
conception that occurs outside the woman’s equipment will be the Member’s responsibility.
body. Any related services performed in 13. Functional neuromuscular electrical
conjunction with these procedures are also stimulation Devices.
excluded.
14. Replacement of lost, stolen, or damaged
10. Drug screening or drug confirmatory equipment or supplies.
laboratory tests in conjunction with PEHP
authorized treatment are considered inclusive
to the treatment and are not payable HOME HEALTH
separately. AND HOSPICE CARE
11. Whole exome and whole genome sequencing The following are Exclusions of the policy:
for the diagnosis of genetic disorders.
1. Nursing or aide services which are requested by
12. Chromosomal Microarray Analysis (CMA) for or for the convenience of the Member or family,
Autism Spectrum Disorder. which do not require the training, judgment,
and technical skills of a nurse, whether or not
another person is available to perform such
DURABLE MEDICAL
services. This Exclusion applies even when
EQUIPMENT/SUPPLY BENEFIT services are recommended by a Provider.
The following are some, but not necessarily all, 2. Private duty nursing.
items not covered as a benefit, regardless of the
relief they may provide for a medical condition. 3. Home health aide.
Refer to Durable Medical Equipment, Appendix A, 4. Custodial Care.
for a more detailed list of Non-covered items.
5. Respite Care.
1. Training and testing in conjunction with
6. Travel or transportation expenses, escort
Durable Medical Equipment or prosthetics.
services to Provider’s offices or elsewhere, or
2. More than one lens for each affected eye food services.
following Surgery for corneal transplant.
7. Total Parenteral Nutrition through Hospice.
3. More than two pair of support hose for a
8. Enteral Nutrition, unless obtained through the
medical diagnosis per plan year.
pharmacy card.
4. Durable Medical Equipment that is
9. Skilled Nursing visits for administration of
inappropriate for the patient’s medical
non-covered medications or related to other
condition.
non-covered services under the plan.
5. Diabetic supplies, i.e. insulin, syringes, needles,
etc., are a pharmacy benefit.
HOSPITAL/FACILITY AND
6. Equipment purchased from non-licensed
Providers, and any supplies related to the
EMERGENCY ROOM SERVICES
equipment. (INPATIENT AND OUTPATIENT)
7. Used Durable Medical Equipment. The following are Exclusions of the policy:
8. TENS Unit. 1. Ineligible Surgical Procedures or related

Complications.
9. Neuromuscular Stimulator.
2. Treatment programs for enuresis or encopresis
10. H-wave Electronic Device. for Members age 18 and over.
11. Sympathetic Therapy Stimulator (STS). 3. Services or items primarily for convenience,
4
contentment, or other non-therapeutic purpose, 5. Charges in excess of the In-Network Rate or
such as: guest trays, cots, telephone calls, contract Limitations;
shampoo, toothbrush, or other personal items. 6. All subsequent facility claims related to a
4. Occupational therapy or other therapies for Hospital stay when the Member is discharged
activities of daily living, academic learning, against medical advice;
vocational or life skills, developmental delay, 7. Temporomandibular Joint (TMJ/TMD/Myofacial
unless authorized by PEHP for the treatment of Pain) treatment**;
Autism.
8. Sleep apnea equipment**.
5. Care, confinement or services in a nursing
home, rest home or a transitional living facility, *Except for services billed by Intermountain Health Care
community reintegration program, vocational Facilities
rehabilitation, services to re-train self care, or **Except for HSA-compatible STAR Plans
activities of daily living.
6. Recreational therapy. MEDICAL VISITS
7. Autologous (self) blood storage for future use. The following are Exclusions of the policy:
8. Organ or tissue donor charges, except when 1. Hospital visits the same day as Surgery or
the recipient is an eligible Member covered following a Surgical Procedure except for
under a PEHP plan, and the transplant is treatment of a diagnosis unrelated to the
eligible. Surgery.
9. Nutritional analysis or counseling, except in 2. Examinations made in connection with a
conjunction with diabetes education, anorexia, hearing aid unless specifically covered as
bulimia, or as covered under the Affordable Care indicated in your Benefits Summary.
Act (Preventive Services under Section 6.14).
3. Services for weight loss or in conjunction with
10. Custodial Care and/or maintenance therapy. weight loss programs regardless of the medical
11. Take-home medications., unless legally indications except as allowed under the
required and approved by PEHP. Affordable Care Act (Preventive Services under
Section 6.14).
12. Mastectomy for gynecomastia.
4. Sublingual antigens.
MAXIMUM OUT-OF-POCKET 5. Dental services except those listed in previous
section.
BENEFITS
6. Charges in conjunction with ineligible
Amounts paid by the Member for the following
procedures, including pre- or post-operative
services will not apply to the Member’s out-of-
evaluations.
pocket maximum:
7. Acupuncture treatment unless specifically
1. Attended sleep studies, regardless of place
covered as indicated in your Benefits Summary.
of service*, and unattended sleep studies
performed in a facility whose payment is based 8. Chiropractic, physical, or occupational therapy
on a percentage of the billed amount.** primarily for maintenance care unless allowed
as stated in your Benefits Summary.
2. Infertility testing, Surgery**;
9. Occupational therapy or other therapies for
3. The following surgeries or procedures payable
activities of daily living, academic learning,
at 50%: Blepharoplasty, Breast Reduction;
vocational or life skills, driver’s evaluation or
Sclerotherapy of varicose veins except for
training, developmental delay and Recreational
spider and reticular veins; Microphlebectomy
Therapy, unless authorized by PEHP for the
(stab phlebectomy)**;
treament of Autism.
4. Any service or amount established as ineligible
10. Speech therapy for educational purposes
under this policy or considered inappropriate
or delayed development, or speech therapy
medical care;
5
that does not qualify within the criteria as 27. Any services performed by or referred by a
determined solely by PEHP. non-covered Provider.
11. Functional or work capacity evaluations, 28. Administration fees for non-eligible injections
impairment ratings, work hardening programs or infusions.
or back school.
12. Hypnotherapy or biofeedback. MENTAL HEALTH
13. Hair transplants or other treatment for hair loss AND SUBSTANCE ABUSE
or restoration.
14. Study models, panorex, eruption buttons,
1. Inpatient or outpatient treatment for Mental
orthodontics, occlusal adjustments or
Health and/or substance abuse without
equilibration, crowns, photos, and mandibular
Preauthorization, if required by the Member’s
kinesiograph are some, but not necessarily all,
plan.
ineligible services for the treatment of TMJ/
TMD or myofacial pain. 2. Milieu therapy, marriage counseling, encounter
groups, hypnosis, biofeedback, parental
15. Testing and treatment therapies for
counseling, stress management or relaxation
developmental delay or child developmental
therapy, conduct disorders, oppositional
programs.
disorders, learning disabilities, and situational
16. Rolfing or massage therapy. disturbances.
17. Training and testing in conjunction with 3. Mental or emotional conditions without
Durable Medical Equipment or prosthetics. manifest psychiatric disorder or non-specific
18. Nutritional analysis or counseling, except in conditions.
conjunction with diabetes education, anorexia, 4. Wilderness programs.
bulimia, or as allowed under the Affordable
5. Inpatient treatment for behavior modification,
Care Act (Preventive Services under Section
enuresis, or encopresis.
6.14).
6. Psychological evaluations or testing for legal
19. Reports, evaluations, examinations not
purposes such as custodial rights, etc., or for
required for health reasons, such as
insurance or employment examinations.
employment or insurance examinations, or
for legal purposes such as custodial rights, 7. Occupational or Recreational Therapy.
paternity suits, sports physicals, etc. 8. Hospital leave of absence charges.
20. Visits in conjunction with palliative care of 9. Sodium amobarbital interviews.
metatarsalgia or bunions; corns, calluses or
10. Unless Provider meets PEHP’s defined
toenails, except removing nail roots and care
network needs and meets the PEHP specific
prescribed by a licensed physician treating
credentialing and quality standards, services,
a metabolic or peripheral vascular disease.
procedures, medications, or Devices received
See applicable Benefits Summary for Eligible
at or from a residential treatment center which
Benefits.
is not providing in-patient services, including
21. Cardiac Rehabilitation, Phases 3 and 4. but not limited to, services for residential
22. Pulmonary Rehabilitation, Phase 3. treatment, day treatment and/or intensive
outpatient treatment.
23. Fitness programs.
11. Tobacco abuse.
24. Charges for special medical equipment,
machines, or Devices in the Provider’s office 12. Routine drug screening, except when ordered
used to enhance diagnostic or therapeutic by a treating physician and done for a medical
services in a Provider’s practice. purpose, as determined by PEHP, or unless
otherwise allowed by the Master Policy.
25. Childbirth education classes.
13. Drug screening or drug confirmatory laboratory
26. Topical hyperbaric oxygen treatment.
tests in conjunction with PEHP authorized
6
treatment are considered inclusive to the 17. Biological serum, blood, or blood plasma.
treatment and are not payable separately. 18. Medications and injectables prescribed for
Industrial Claims and Worker’s Compensation.
PRESCRIPTION 19. Medications dispensed from an institution
MEDICATION BENEFITS or substance abuse clinic when the Member
does not use their pharmacy card at a PEHP
Contracted pharmacy are not payable as a
1. A prescription that is not purchased from a pharmacy claim.
designated pharmacy (if required) and/or
20. Medications used for Cosmetic indications.
exceeds any quantity levels or step therapy
disclosed on PEHP’s Preferred Medication List 21. Replacement of lost, stolen or damaged
or website. medications.
2. Vitamin B-12 for fatigue, low energy, or similar 22. Nasal immunizations unless listed in the PEHP
indications. Preferred Medication List.
3. Dental rinses and fluoride preparations. 23. Medications for abortions except if the
(Fluoride tablets will be covered for children up pregnancy is the result of rape or incest, or if
to the age of 12 years old). necessary to save the life of the mother.
4. Hair growth and hair loss products. 24. Medications for the treatment of nail fungus.
5. Medications or nutritional supplements for 25. Medications needed to treat Complications
weight loss or weight gain. associated with Elective bariatric Surgery or other
non-covered services.
6. Investigational and non-FDA Approved
medications. 26. Hypodermic needles.
7. Medications needed to participate in any 27. Oral and nasal antihistamines for allergies,
medication research or medication study. including but not limited to: Azelastine,
Dymista, and Astepro.
8. FDA-approved medication for Experimental or
Investigational indications. 28. Medications obtained outside the United States
that are not for Urgent or emergency use.
9. Non-approved indications determined by PEHP.
29. Medications used for sexual dysfunction or
10. Medications for athletic and mental
enhancement, including but not limited to:
performance.
Cialis, Sildenafil, and Viagra.
11. New medications released by the FDA until
30. Medications for assisted reproductive
they are reviewed for efficacy, safety and cost-
technology.
effectiveness by PEHP. Upon such review, PEHP
may designate the new medication as non- 31. An additional medication that may be
covered. considered duplicate therapy defined by the
FDA or PEHP.
12. Oral infant and medical formulas.
32. Specific medications not listed on the
13. Therapeutic Devices or appliances unless listed
PEHP website, including but not limited to:
in PEHP’s Preferred Medication List.
Adoxa, ammonium lactate, Amrix, Avidoxy
14. Diagnostic agents. DK, Avita, Belsomra, Brintellix, Cialis, DMSO
15. Over-the-counter medications and products (Dimethylsulfoxide), Doryx, Doxal, Dynacin,
unless listed in PEHP’s Preferred Medication Doxycycline monohydrate, Emflaza, Eucrisa,
List or covered under the Affordable Care Act Exondys 51, Farxiga, Fetzima, Fortamet,
(Preventive Services under Section 6.14) and Glumetza, Invokana, Keveyis, Northera,
processed by the pharmacy at the time of Oracea, Oraxyl, Orkambi, Relizorb, Riomet,
service with a valid prescription. Solodyn, Symbyax, Sarafem, Tresiba, Viibryd,
Vraylar, Xiaflex (if prescribed to treat Peyronie’s
16. Take-home prescriptions from a Hospital or
Disease), Xiidra, Xultophy, Zegerid (and its
Skilled Nursing Facility, unless legally required
generic), Zinbryta. For a complete list of covered
and apporved by PEHP.
7
medications, refer to the PEHP website. organ or tissue donor, where the recipient is
33. Medications purchased from non-participating not an eligible Member, covered by PEHP, or
Providers online. when the transplant for the PEHP Member is
not eligible.
34. Minerals, food supplements, homeopathic
medicines, and nutritional supplements 9. Reversal of sterilization.
(Prenatal vitamins and folic acid will be covered 10. Gender reassignment Surgery.
for pregnancy). 11. Rhytidectomy.
12. Dental services, except those listed in previous
SURGERY sections.
The following are Exclusions of the policy: 13. Complications as a result of non-covered or
1. Breast Reconstructive Surgery, augmentation ineligible Surgery, regardless of when the
or implants solely for Cosmetic purposes. Surgery was performed or whether the original
Surgery was covered by a health plan.
2. Capsulotomy, replacement, removal or repair
of breast implant originally placed for Cosmetic 14. Injection of collagen, except as approved for
purposes or any other Complication(s) of urological procedures.
Cosmetic or non-covered breast Surgery. 15. Lipectomy, abdominoplasty, panniculectomy,
3. Obesity Surgery such as Lap Band, gastric repair of diastasis recti, unless any of these
bypass, stomach stapling, gastric balloons, etc., procedures are medically necessary to treat an
including any present or future Complications. unintended adverse event of an eligible surgery.
4. Any service or Surgery that is solely for 16. Sperm banking system, storage, treatment, or
Cosmetic purposes to improve or change other such services.
appearance or to correct a deformity without 17. Non-FDA Approved or Experimental or
restoring a physical bodily function, with the Investigational procedures, medications and
following exceptions: Devices.
a. Breast Reconstructive Surgery as allowed 18. Hair transplants or other treatment for hair loss
under WHCRA for Cosmetic purposes: and or restoration.
b. Reconstructive Surgery made necessary by 19. Chemical peels.
an Accidental injury in the preceding five
20. Treatment for spider or reticular veins.
years.
21. Liposuction.
5. Rhinoplasty for Cosmetic reasons is excluded
except when related to an Accidental injury 22. Orthodontic treatment or expansion appliance
occurring in the preceding five years and in conjunction with jaw Surgery.
requires Preauthorization. 23. Chin implant, genioplasty or horizontal
6. Assisted reproductive technologies: invitro symphyseal osteotomy.
fertilization; gamete intra fallopian tube 24. Unbundling or fragmentation of surgical codes.
transfer; embryo transfer; zygote intra fallopian
25. Any Surgery solely for snoring.
transfer; pre-embryo cryopreservation
techniques; and/or any conception that 26. Otoplasty.
occurs outside the woman’s body. Any related 27. Abortions, except if the pregnancy is the result
services performed in conjunction with these of rape or incest, or if necessary to save the life
procedures are also excluded. of the mother.
7. Surgical
This treatment
information for correction
is provided of refractive
in summary form and may
28.change
Surgicalwithout
treatmentfurther notice.
for sexual For complete
dysfunction.
errors.
details and updated information, please visit www.pehp.org/providers or call us at at 801-366-7557
29. Subtalar implants.
or
8. 800-677-0457.
Expenses incurred for Surgery, pre-operative
30. Mastectomy for gynecomastia.
testing, treatment, or Complications by an
31. Elective home delivery for childbirth.
8
Provider Relations Representatives
To provide optimal service to PEHP providers, each Provider Relations Representative is assigned a specific area to manage.
This assignment is based on the physical locations of the providers. If you are unsure who your representative is, please call PEHP
at 800-365-8772 or 801-366-7700.
SERVICE AREA #1 SERVICE AREA #2

Chantel Lomax Carrie Leeman
Provider Relations Specialist Provider Relations Specialist
Phone: 801-366-7507 or 800-753-7407 Phone: 801-366-7753 or 800-753-7753
Fax: 801-245-7507 Fax: 801-245-7753
In-State Cities In-State Counties In-State Cities

Holladay (84117, 84121 & 84124), Midvale (84047), Salt Lake Box Elder, Cache, Davis, Murray (84107, 84123 &
City (All other zip codes not mentioned in other service Morgan, Rich, Weber 84157)
areas), All University of Utah Out-of-State
Out-of-State Idaho
Colorado
SERVICE AREA #4
SERVICE AREA #3 Jenna Murphy
Henry Cruz Provider Relations Specialist
Provider Relations Specialist Phone: 801-366-7419 or 800-753-7419
Phone: 801-366-7721 or 800-753-7721 Fax: 801-328-7419
Fax: 801-245-7721
In-State Counties In-State Cities
In-State Counties In-State Cities Beaver, Carbon, Daggett, Draper, Herriman (84065
Tooele, Utah Kearns (84118), Magna Duchesne, Emery, Garfield, & 84096), Riverton (84065,
Out-of-State (84044), Taylorsville (84084, Grand, Iron, Juab, Kane, 84095 & 84096), Sandy
Wyoming 84118 & 84119), West Jordan Millard, Piute, San Juan, (84070, 84090, 84091, 84092,
(84084 & 84088), West Valley Sanpete, Sevier, Summit, 84093 & 84094), South
(84119, 84120 & 84128) Uintah, Wasatch, Washington, Jordan (84065 & 84095)
Wayne Out-of-State Cities
Out-of-State Las Vegas, Nevada
Arizona Mesquite, Nevada
MAILING ADDRESSES
All Service Ares & Representatives
PEHP
560 East 200 South
St. George, UT 84102

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Provider Basics

A Reference Guide for Treating PEHP Patients

From PEHP Managing Director. . . . . . . .Page 1 Services That Need Preauthorization...Page 7

PROUDLY SERVING UTAH PUBLIC EMPLOYEES

Let Us Help You Help Our Members

Every dollar paid for a claim comes

PEHP Provider Basics » Page 1

» See the list on Page 7 for services that require preauthorization.

PEHP Provider Basics » Page 2

Affordable Care Act (ACA)

We cover preventive services at no cost to members. To help your office understand

Labs and Imaging

PEHP Provider Basics » Page 3

PEHP Provider Basics » Page 4

PEHP Provider Basics » Page 5

Juvenile Idiopathic Arthritis

PEHP Provider Basics » Page 6

IMAGING / RADIOLOGY / NUCLEAR MEDICINE

MEDICAL EQUIPMENT (DME) LABORATORY

To get preauthorization, your doctor must call PEHP.

Covered Drug List

IMPORTANT: This is a list of common medications and may

About the Categories of Medications Table of Contents

A atenolol/chlorthalidone calcitriol clopidogrel (QL)

Always consult with your doctor before making medication changes.

diflorasone erythromycin/benzoyl FREESTYLE LIBRE (PA) (QL) indomethacin

LINZESS (QL) methylin er (QL)* nifedipine, er, xl penicillin*

Q SPIRIVA (QL) timolol TUDORZA PRESSAIR

ACTONEL (QL) alendronate (QL) armodafinil (QL) modafinil (PA) (QL)

ACTOPLUS MET XR (QL) pioglitazone/metformin (QL) ARMOUR THYROID levothyroxine

ACTOPLUS MET (QL) pioglitazone/metformin (QL) AROMASIN exemestane

ACTOS (QL) pioglitazone (QL) ARTHROTEC diclofenac/misoprostol

ADDERALL* amphetamine/dextroamphetamine ATACAND HCT (QL) olmesartan/hctz (QL), losartan/hctz

ADVICOR (QL) AVANDAMET (QL) pioglitazone/metformin (QL)

AEROCHAMBER (QL)* EASIVENT (QL)* AVANDARYL (QL) DUETACT (QL)

ALDARA (QL) imiquimod (QL) AVANDIA (QL) pioglitazone (QL)

ALPHAGAN P 0.15% brimonidine AVAPRO (QL) olmesartan (QL), irbesartan (QL)

AMERGE (QL)* naratriptan (QL)* AXID nizatidine

AMITIZA (QL) (PA) LINZESS (QL) AXIRON testosterone topical solution

ANALPRAM E CREAM hydrocortisone/pramoxine AZELEX benzoyl peroxide/clindamycin

DUONEB ipratropium-albuterol GLUCOPHAGE, XR (QL) metformin, XR (QL)

FAMVIR famciclovir INDOCIN, SR indomethacin, SR

FANAPT (QL) risperidone (QL), quetiapine INNOPRAN XL metoprolol LA, propranolol LA

FENTANYL PATCHES JALYN (QL) dutasteride/tamsulosin (QL)

FOCALIN, XR (QL)* dexmethylphenidate* LIALDA (QL) DELZICOL

FOSAMAX (QL) alendronate (QL) LIDEX fluocinonide

FOSRENOL sevelamer carbonate LIPITOR (QL) atorvastatin (QL)

FROVA sumatriptan (QL)* LOCOID, LOTION hydrocortisone butyrate

MACROBID nitrofurantoin macrocrystal OPANA, ER (PA) (QL)* oxycodone (QL)*, oxymorphone

PREVACID, SOLUTAB omeprazole (QL), pantoprazole ROZEREM (QL) zolpidem (QL)

DRUG NAME RESTRICTIONS DRUG NAME RESTRICTIONS

Always consult with your doctor before making medication changes.

ABRAXANE GRANIX (PA)(HH)

MOZOBIL (PA) (HH) RAVICTI^ (PA) (QL) TREANDA (PA)

ORKAMBI (PA) (QL)

PROLIA^ (QL) (PA) RECLAST

TARCEVA^ (PA) (QL)

Diabetes Cardiovascular Respiratory

glyburide micronized amiloride & HCTZ torsemide Osteoporosis