May 2015 P&T Updates. Prior Authorization. Traditional. Formulary. Yes No. Formulary. Non Formulary. Non Formulary. Non Formulary

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1 Commercial Triple Tier 4th Tier Applicable Traditional s EVOTAZ 2 2 Alternatives Flovent Diskus/HFA, Pulmicort Flexhaler, Qvar, Asmanex HFA eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine, trazodone, estazolam, flurazepam, quazepam, temazepam, triazolam, zolpidem ER FARYDAK 3 2 per 21 Thalomid, Pomalyst*, Revlimid* fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta ER*, LENVIMA 3 2 per, 30 supply Caprelsa*, Cometriq*, Nexavar* Aranesp*, Epogen*, Procrit* PREFILLED SYRINGES 1 1 PREZCOBIX 2 2 fentanyl, morphine sulfate ER, oxycodone ER*, tramadol ER, Avinza, Butrans*, Nucynta ER*,

2 CHIP Tier - - EVOTAZ 2 FARYDAK 2 - LENVIMA 2 PREFILLED SYRINGES s per 21 per, 30 s supply Alternatives Flexhaler, Qvar, Asmanex HFA eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine, trazodone, estazolam, flurazepam, quazepam, temazepam, triazolam, zolpidem ER Thalomid, Pomalyst*, Revlimid* - Aranesp*, Epogen*, Procrit* 2 PREZCOBIX 2 - -

3 GHP Family AMNESTEEM, CLARAVIS, MYORISAN, ZENATANE GHP Family Tier Generic EVOTAZ Brand FARYDAK Brand LENVIMA Brand PREFILLED SYRINGE NATROBA Generic PREZCOBIX Brand s per 21 s per, 30 supply Alternative(s) tretinoin, adapalene 0.1%, benzoyl peroxide, clindamycin, erythromycin, sulfacetamide, benzoyl peroide/clindamycin, benzoyl peroxide/erythromycin, teteracycline, doxycycline, minocycline, erythromycin, trimethoprim/sulfamethoxazole, azithromycin Advair Diskus/HFA*, Asmanex HFA, Asmanex, Dulera, Flovent Diskus/HFA zaleplon, zolpidem, flurazepam, temazepam, triazolam Aptivus (capsule/solution), Crixivan, Invirase, tablet Pomalyst*, Revlimid* tramadol ER^, morphine sulfate ER^, fentanyl^ Aranesp*, Epogen*, Procrit* Lindane Shampoo, Malathion, Permetherin 1%, Piperonyl butoxide/pyrethrin shampoo Aptivus (capsule/solution), Crixivan, Invirase, tablet warfarin, Eliquis, Pradaxa*, Xarelto tramadol ER^, morphine sulfate ER^, fentanyl^, methadone^

4 Geisinger Gold $0 Deductible EVOTAZ Specialty FARYDAK Specialty Standard ILUVIEN Medical LENVIMA Specialty PREZCOBIX Specialty RAPIVAB ZERBAXA Specialty s per 21 ed to 3 capsules per Alternative(s) Flexhaler, QVAR, Asmanex HFA, Symbicort trazodone, mirtazapine, estazolam, temazepam, Rozerem, Silenor, zolpidem*, zolpidem ER*, zaleplon* (*prior authorization/quantity limits apply) Crixivan, Aptivus, Kaletra, Lexiva, Reyataz, Invirase, Prezista, Viracept Pomalyst*, Revlimid*, Thalomid* (* authorization required) Tramadol ER, morphine sulfate ER, fentanyl, Butrans*, (*PA required) (* authorization required) Procrit*, Aranesp*, Epogen* (* authorization required) Crixivan, Aptivus, Kaletra, Lexiva, Reyataz, Invirase, Prezista, Viracept Relenza, Tamiflu, amantadine, rimantadine, Pradaxa Ampicillin/sulbactam, aztreonam, cefadroxil, cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin, imipenem/cilastatin, levofloxacin, meropenem, piperacillin/tazobactam, Timentin, Invanz, Primaxin IM, Tygacil Tramadol ER, morphine sulfate ER, fentanyl, Butrans*, (*PA required)

5 Marketplace Tier s EVOTAZ 3 FARYDAK Specialty LENVIMA Specialty PREFILLED SYRINGES per 21 per, 30 supply Alternatives Flexhaler, Qvar, Asmanex HFA eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine, trazodone, estazolam, flurazepam, quazepam, temazepam, triazolam, zolpidem ER Thalomid, Pomalyst*, Revlimid* Aranesp*, Epogen*, Procrit* 2 PREZCOBIX 3

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