Health Alliance Plan. Commercial Formulary. July 1, 2015

Transcription

1 Health Alliance Plan Commercial Formulary July 1, 2015 This document includes a list of the covered drugs (formulary) for our plan which is current as of July 1, When this drug list (formulary) refers to we, us, or our, it means Health Alliance Plan or Personal Alliance. When it refers to plan or our plan, it means Commercial HMO and AHL Plans For more information If you have questions about your plan please contact our Client Services Representative. You may contact us by phone or visit us at Our business hours are Monday through Friday from 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 12 noon. For HMO Plans please call (800) For PPO Plans please call (888) Disclaimer: A drug's formulary status may change prior to being updated in this document. The listing of a drug does not imply coverage for all benefits. Some dosage forms or strengths of an existing formulary drug may not be covered. Please contact plan for details 1

2 What is the Prescription Drug Formulary (Drug List)? A formulary is a list of covered prescription drugs. Prescription drugs are self-administered drugs that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered prescription drugs is selected in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will cover the drug listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. Formulary list can change over time. We may add new drugs as they are approved by the FDA and likewise we may remove drugs as new information about safety and effectiveness is available. We may also change the tier which reflects your cost-share for the drug. We may update our rules for coverage meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage (see page XX for recent formulary changes). This list included medical drugs that are required to be obtained from HAP contracted Specialty Pharmacy. Medical drugs are drugs that are administered in the physician office or healthcare facility. These are generally supplied by your doctor or other healthcare provider. Drugs provided for home infusion therapy are also considered medical. Please refer to your Summary of Benefits and Coverage (SBC) for information about your cost-sharing for Medical drugs. We will post an updated Drug Formulary to our website at hap.org/formulary How do I use the Formulary? The formulary has a list of covered generic and brand name drugs and is organized by categories depending on the type of medical conditions that they are used to treat. For example drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list. Then look under the category name for your drug. If you are not sure what category to look under, you should look for your drug in the Index that is at the end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document. You can also find your drug by searching the document, just type in the generic drug name in the search box. What is Generic Substitution? When an FDA approved generic drug is available, your prescription will be filled with the generic form of the medication. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a brand name drug. What are Specialty drugs? Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy. For this reason HAP has contracted with Pharmacy Advantage, a specialty pharmacy from whom you can obtain specialty drugs. Specialty drugs require prior authorization and 2

3 Pharmacy Advantage can help you and your doctor submit a request for prior authorization for specialty drugs. You or your doctor can contact Pharmacy Advantage at (800) Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. The coverage requirements are listed on the Formulary. These requirements and limits may include: Prior Authorization: Some medications on our formulary have criteria you must meet before we cover them. This means that you will need to get approval from HAP before you fill your prescriptions for these drugs. Step Therapy: In some cases, HAP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, HAP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Quantity : Certain drugs have quantity limits. Quantity limit is the maximum quantity that can be dispensed per each fill of medication or the maximum number of fills allowed for treatment of certain conditions. Specialty drugs injectable drugs (except insulin) and select oral drugs (e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugs require a15-day first fill. Benefit Limitations Our drug formulary applies to drugs used in an outpatient setting. It does not affect medication given in the doctor s office or while in the hospital. These are known as medical drugs. Note that some medical drugs are listed on this formulary because they are part of our Specialty Program. Please refer to what are specialty drug? section for information about these medications. The following are general drug coverage exclusions that apply to all members: Over-the-Counter (OTC) medications and their equivalents are not covered unless specified in the formulary or on the rider. Drug products used for cosmetic purposes are not covered. Experimental drugs and/or any drug products used in an experimental manner are not covered. Replacement of lost or stolen medication is not covered. Since the selected drug packages and coverage vary for each Plan, check your benefit package to verify your co-pays and exclusions What if my drug is not on the Formulary? When your drug is not listed on the Formulary it is considered non-formulary. You or your doctor can ask us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist if one of the formulary alternatives will work for you. Exception approvals for standard non formulary medications will process at the highest non specialty ( three) copayment. Exception approvals for non-formulary Specialty medication will 3

4 process at the highest Specialty ( four) copayment. Non-formulary specialty medications when approved for use by the plan can be required to be dispensed by Pharmacy Advantage How do I request Prior Authorization or Formulary Exception? You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us to cover a medication not included on our formulary or ask us to exempt you from a formulary requirement through the exception process. Your doctor must submit a request to us indicating why formulary requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us information when requesting either prior authorization or exception to the formulary. What is included in the Formulary List? The name of the covered drug is listed in the First column. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., gabapentin). When a generic drug is listed on the formulary only the generic is covered and the brand version of the generic is not covered. The second column represents the drug s cost-sharing level, or tier. Every drug on the Drug List is in one of 4 prescription cost-sharing tiers. The table below will translate how the 4 tiers shown in the Drug List are applicable to your plan s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your cost-sharing information. Description of Copay * Preventive generic prescription preventive drugs that are mandated by the Affordable Care Act. These are covered at zero copay when Health Care Reform rules are met. Generic These are generic drugs and they have the lowest Copay Preferred Brand- These are formulary Brand drugs and have the lowest Brand Copay Non-Preferred Brand These are Brand name formulary drugs that are not in the Preferred Brand. Specialty Drugs These are drugs that are biologics or drugs that require close monitoring for safety and efficacy. Medical Drugs - These are drugs that are infused or administered in doctor s office or facility and are covered under the medical benefit of your plan. 0 copay 1 copay 2 copay 3 copay 4 copay Medical Coinsurance 4

5 The third column lists the Requirements/ that must be met for coverage of your drug. Please refer to the abbreviations used in this column and their explanation. The fourth column is the Comment section and may include specific information about strengths or dosage forms that are covered The fifth column is the list of covered lower cost alternatives that you may be able to use. Abbreviations for Requirements/ are as follows: You or your physician are required to get prior authorization from HAP before you fill your prescription for this drug. Without prior approval, we may not cover this drug. We limit the amount of this drug that is covered per prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. ST Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) What are the changes to the formulary in the past 6 months? DATE (2015) DRUG NAME CHANGE FEBRUARY HARVONI Added as Specialty drug with, 4 SOVALDI Added as Specialty drug with, 4 VIEKRIA Added as Specialty drug with, 4 OLYSIO colchicine MARCH 2015 celecoxib FORTEO Removed from formulary generic now available and added to formulary Generic now available and added to formulary Changed requirement to step therapy Updated Step therapy to include trial with PROLIA OVIDREL Added with,, 3 FORMULARY ALTERNATIVE HARVONI, SOVALDI, VIKERIA meloxicam Alendronate Ibandronate 5

6 DATE DRUG NAME CHANGE APRIL 2015 PROAIR REICLICK Added with, 2 MAY 2015 IBRANCE Added as Specialty drug with, 4 MEFLOQUINE Atovaquone/Progu anil BUPRENORPHINE/ NALOXONE Added Added Added FORMULARY ALTERNATIVE 6

7 ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES ETHANOLAMINE DERIVATIVES carbinoxamine clemastine fumarate diphenhydramine phenyltoloxamine-acetaminophen FIRST GEN. ANTIHIST. DERIVATIVES, MISC. cyproheptadine hcl PHENOTHIAZINE DERIVATIVES promethazine & phenylephrine promethazine hcl brompheniramine PROPYLAMINE DERIVATIVES brompheniramine & phenyleph brompheniramine & pseudoeph chlorpheniramine & phenylephrine chlorpheniramine & pseudoeph chlorpheniramine tannate-phenylephrine tannate chlorpheniramine tan-pyrilamine tanphenylephrine tan chlorpheniramine-methscopolamine chlorpheniramine-phenylephrine-methscopolamine chlorpheniramine-pseudoephedrine & methscopolamine chlorpheniramine-pyrilamine & phenylephrine chlorphen-phenyltolox-pe dexchlorpheniramine maleate ED-CHLOR-TAN (chlorpheniramine) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

8 ANTIHISTAMINE DRUGS SECOND GENERATION ANTIHISTAMINES loratadine ( 30 tabs/ 30 days) loratadine Syrup loratadine & pseudoephedrine SEMPREX-D (acrivastine & pseudoephedrine) ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA (albendazole) BILTRICIDE (praziquantel) mebendazole STROMECTOL (ivermectin) ANTIBACTERIALS AMINOGLYCOSIDES neomycin sulfate (60 tabs/ 30 days) tobramycin bacitracin clindamycin clindamycin ANTIBACTERIALS, MISCELLANEOUS Nebs for inhalation Capsule Solution vancomycin hcl XIFAXAN (rifaximin) ZYVOX (linezolid) ZYVOX (linezolid) CEPHALOORINS CEDAX (ceftibuten) cefaclor cefadroxil cefdinir (60 ml/day) suspension (28/14 days) tabs For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

9 ANTI-INFECTIVE AGENTS ANTIBACTERIALS CEPHALOORINS cefditoren pivoxil cefpodoxime proxetil cefprozil CEFTIN (cefuroxime) cefuroxime cephalexin SUPRAX (cefixime) MACROLIDES azithromycin azithromycin azithromycin clarithromycin (8 Pack/ fill) Pack (120 ml/fill) Suspension (8 tab /fill) Tablets clarithromycin E.E.S. GRANULES (erythromycin ethylsuccinate) ERYPED 200 (erythromycin ethylsuccinate) ERYPED 400 (erythromycin ethylsuccinate) erythromycin ethylsuccinate erythromycin-sulfisoxazole Extended-release Tablets Granules for suspension Granules for Suspension Granules for Suspension KETEK (telithromycin) PCE (erythromycin base (coated)) ZMAX (azithromycin) PENICILLINS amoxicillin amoxicillin & pot clavulanate For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

10 ANTI-INFECTIVE AGENTS ANTIBACTERIALS PENICILLINS ampicillin dicloxacillin sodium penicillin v QUINOLONES AVELOX (moxifloxacin hcl) ciprofloxacin Extended-release Tablets ciprofloxacin FACTIVE (gemifloxacin mesylate) Tablets levofloxacin Solution levofloxacin NOROXIN (norfloxacin) Tablets ofloxacin sulfadiazine SULFONAMIDES (SYSTEMIC) sulfamethoxazole-trimethoprim sulfasalazine demeclocycline hcl doxycycline minocycline hcl tetracycline hcl TETRACYCLINES ANTIFUNGAL (SYSTEMIC) ALLYLAMINES LAMISIL (terbinafine hcl) terbinafine hcl (90 caps/ 30 days) 50 MG AND 100 MG (14 Pack/ fill) Granules For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

11 ANTI-INFECTIVE AGENTS ANTIFUNGAL (SYSTEMIC) ANTIFUNGALS, MISCELLANEOUS griseofulvin fluconazole AZOLES itraconazole ketoconazole NOXAFIL (posaconazole) ORANOX (itraconazole) voriconazole POLYENES FIRST-BXN MOUTHWASH (diphenhydraminelidocaine-nystatin) nystatin ( 240ML/ FILL) nystatin (mouth-throat) flucytosine dapsone PYRIMIDINES ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, MISCELLANEOUS cycloserine ANTITUBERCULOSIS AGENTS ethambutol hcl isoniazid isoniazid & rifampin MYCOBUTIN (rifabutin) SER (aminosalicylic acid) PRIFTIN (rifapentine) pyrazinamide For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

12 ANTI-INFECTIVE AGENTS ANTIMYCOBACTERIALS ANTITUBERCULOSIS AGENTS rifampin RIFATER (isoniazid-rifampin w/ pyrazinamide) SIRTURO (bedaquiline fumarate) TRECATOR (ethionamide) ANTIPROTOZOALS AMEBICIDES paromomycin sulfate ANTIMALARIALS atovaquone-proguanil hcl chloroquine COARTEM (artemether-lumefantrine) hydroxychloroquine sulfate mefloquine hcl primaquine phosphate Only covered for treatment Only Covered for treatment Tablet (5 tabs / 30 days) Only covered for treatment QUALAQUIN (quinine sulfate) ANTIPROTOZOALS, MISCELLANEOUS ALINIA (nitazoxanide) (60 ml/ fill) Suspension ALINIA (nitazoxanide) FLAGYL ER (metronidazole) MEPRON (atovaquone) metronidazole tinidazole ANTIVIRALS (SYSTEMIC) ADAMANTANES rimantadine hydrochloride (6 tab/ fill) Tablet For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

13 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) ANTIRETROVIRALS abacavir sulfate (60 tabs/ 30 day) APTIVUS (tipranavir) ATRIPLA (efavirenz-emtricitabine-tenofovir disoproxil fumarate) COMPLERA (emtricitabine-rilpivirine-tenofovir disoproxil fumarate) (30 tab / 30 days) (30 tab/ 30 days) CRIXIVAN (indinavir sulfate) CRIXIVAN (indinavir sulfate) (180 tabs/ 30 day) 100 MG (180 tabs/ 30 day) 200 and 400 MG didanosine EDURANT (rilpivirine hcl) (60 caps/ 30 day) ( 30 tab / 30 day) EMTRIVA (emtricitabine) EMTRIVA (emtricitabine) (60 caps/ 30 day) Capsule (680ml / 30 day) Solution EPIVIR (lamivudine) EPIVIR HBV (lamivudine) EPZICOM (abacavir sulfate-lamivudine) FUZEON (enfuvirtide) INTELENCE (etravirine) (60 caps/ 30 day) (60 tab / 30 day) (1 kit /30 day) (60 tab / 30 day) INVIRASE (saquinavir) INVIRASE (saquinavir) (120 caps/ 30 day) Capsules (120 tabs/ 30 day) Tablets ISENTRESS (raltegravir potassium) (60 tabs/ 30 day) KALETRA (lopinavir-ritonavir) KALETRA (lopinavir-ritonavir) (640ml / 30 day) Solution (60 tab / 30 day) Tablet lamivudine lamivudine-zidovudine (60 tabs/ 30 day) (60 tab / 30 day) LEXIVA (fosamprenavir calcium) (1500ml / 30 day) Suspension For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

14 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) ANTIRETROVIRALS LEXIVA (fosamprenavir calcium) (120 tabs/ 30 day) Tablet nevirapine NORVIR (ritonavir) NORVIR (ritonavir) (60 tab / 30 day) (60 tabs/ 30 day) Capsule (240 ml/ 30 day) Solution PREZISTA (darunavir) RESCRIPTOR (delavirdine mesylate) REYATAZ (atazanavir sulfate) SELZENTRY (maraviroc) stavudine STRIBILD (elvitegravir-cobicistat-emtricitabinetenofovir) (60 tabs/ 30 day) (180 tab/ 30 day) (60 caps/ 30 day) ( 60 tabs/ 30 day) (60 caps/ 30 day) (30 tab/ 30 day) SUSTIVA (efavirenz) SUSTIVA (efavirenz) (30 caps/ 30 day) Capsule (30 tab/ 30 day) Tablet TRUVADA (emtricitabine-tenofovir disoproxil fumarate) (30 tab / 30 day) required for HIV prophylaxis VIDEX PEDIATRIC (didanosine) (800 ml/ 30 day) VIRACEPT (nelfinavir mesylate) VIRAMUNE (nevirapine) VIREAD (tenofovir disoproxil fumarate) ZIAGEN (abacavir sulfate) zidovudine (120 tabs/ 30 day) (480 ml / 30 day) (30 tab/ 30 day) (480ml / 30 day) (60 tab/ 30 day) zidovudine zidovudine HCV ANTIVIRALS HARVONI (ledipasvir-sofosbuvir) (60 caps/ 30 day) Capsule (480ml / 30 day) Syrup INCIVEK (telaprevir) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

15 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) HCV ANTIVIRALS SOVALDI (sofosbuvir) VICTRELIS (boceprevir) VIEKIRA K (ombitasvir-paritaprevir-ritonavir & dasabuvir) INTERFERONS PEGASYS (peginterferon alfa-2a) Kit PEGASYS (peginterferon alfa-2a) Solution PEG-INTRON (peginterferon alfa-2a) PEG-INTRON REDIPEN (peginterferon alfa-2a) MONOCLONAL ANTIBODIES SYNAGIS (palivizumab) MED Medical Coinsurance NEURAMINIDASE INHIBITORS RELENZA DISKHALER (zanamivir) (20 Blister /365 days) TAMIFLU (oseltamivir phosphate) (10 caps /fill, 2 fill /365 days) TAMIFLU (oseltamivir phosphate) (10 caps /fill, 2 fill /365 days) Gel Caps TAMIFLU (oseltamivir phosphate) acyclovir NUCLEOSIDES AND NUCLEOTIDES (75 ml / fill, 2 fill /365 days) Suspension BARACLUDE (entecavir) entecavir famciclovir For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

16 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) NUCLEOSIDES AND NUCLEOTIDES ganciclovir HEPSERA (adefovir dipivoxil) ribavirin (hepatitis c) TYZEKA (telbivudine) valacyclovir hcl VALCYTE (valganciclovir hcl) URINARY ANTI-INFECTIVES methenamine-hyosc-methylene blue-benzoic acidphenyl sal methenamine-hyosc-methylene blue-sod phosphenyl sal methenamine-hyosc-methylene blue-sod phosphenyl sal (120 CAPS /30 DAYS) MONUROL (fosfomycin tromethamine) nitrofurantoin PRIMSOL (trimethoprim) trimethoprim ANTINEOPLASTIC AGENTS AFINITOR (everolimus) AFINITOR (everolimus) Dispersable tab is non formulary anastrozole bicalutamide capecitabine For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

17 ANTINEOPLASTIC AGENTS CEENU (lomustine) COMETRIQ (cabozantinib s-malate) cyclophosphamide DROXIA (hydroxyurea (sickle cell anemia)) EMCYT (estramustine phosphate sodium) ERIVEDGE (vismodegib) etoposide exemestane FARESTON (toremifene citrate) floxuridine flutamide GILOTRIF (afatinib dimaleate) GLEEVEC (imatinib mesylate) HEXALEN (altretamine) HYCAMTIN (topotecan hcl) hydroxyurea IBRANCE (palbociclib) IMBRUVICA (ibrutinib) INLYTA (axitinib) INTRON-A (interferon) INTRON-A W/DILUENT (interferon) IRESSA (gefitinib) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

18 ANTINEOPLASTIC AGENTS JAKAFI (ruxolitinib phosphate) letrozole LEUKERAN (chlorambucil) LYSODREN (mitotane) MATULANE (procarbazine hcl) megestrol acetate MEKINIST (trametinib dimethyl sulfoxide) mercaptopurine methotrexate MYLERAN (busulfan) NEXAVAR (sorafenib tosylate) NILANDRON (nilutamide) POMALYST (pomalidomide) REVLIMID (lenalidomide) RHEUMATREX (methotrexate sodium (antirheumatic)) RITUXAN (rituximab) MED Medical Coinsurance RYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib malate) SYLATRON (peginterferon alfa-2b (antineoplastic)) TABLOID (thioguanine) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

19 ANTINEOPLASTIC AGENTS TAFINLAR (dabrafenib mesylate) tamoxifen citrate TARCEVA (erlotinib) TARGRETIN (bexarotene) Capsule TASIGNA (nilotinib) temozolomide tretinoin (chemotherapy) TREXALL (methotrexate) Capsule TYKERB (lapatinib ditosylate) vandetanib VOTRIENT (pazopanib hcl) XALKORI (crizotinib) XTANDI (enzalutamide) ZELBORAF (vemurafenib) ZOLINZA (vorinostat) ZYTIGA (abiraterone acetate) AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANTIMUSCARINICS/ANTISSMODICS atropine sulfate ATROVENT HFA (ipratropium bromide) (15 inhalers /364 days) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

20 AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANTIMUSCARINICS/ANTISSMODICS CANTIL (mepenzolate bromide) clidinium & chlordiazepoxide dicyclomine hcl glycopyrrolate hyoscyamine sulfate ipratropium bromide ipratropium bromide (nasal) methscopolamine bromide propantheline bromide IRIVA HANDIHALER (tiotropium bromide monohydrate) TUDORZA PRESSAIR (aclidinium bromide) AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX (varenicline tartrate) CHANTIX (varenicline tartrate) T0 (56 tabs/28 days, 6 fills/365 days) T0 (56 tabs/28 days, 1 fills/365 days) HCR Rules apply HCR Rules apply nicotine T0 (14 Patches /14 days, 12 fills/365 days) Patch; HCR Rules apply nicotine polacrilex NICOTROL INHALER (nicotine) T0 (360 units /30 days, 6 fills/365 days) T0 (340 units/30 days, 6 fill /365 day) Gum, lozenge; HCR Rules apply NICOTROL NS (nicotine) T0 (340 units/30 days, 6 fill /365 day) RASYMTHOMIMETIC (CHOLINERGIC AGENTS) bethanechol chloride cevimeline hcl donepezil hydrochloride For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

21 AUTONOMIC DRUGS RASYMTHOMIMETIC (CHOLINERGIC AGENTS) EXELON (rivastigmine) (30 Patches/ 30 day) EXELON (rivastigmine) galantamine hydrobromide guanidine hcl MESTINON (pyridostigmine bromide) MESTINON TIMESN (pyridostigmine bromide) MYTELASE (ambenonium chloride) neostigmine physostigmine salicylate pilocarpine hcl (oral) pyridostigmine bromide (30 Patches/ 30 day) Patches rivastigmine SKELETAL MUSCLE RELAXANTS CENTRALLY ACTING SKELETAL MUSCLE RELAXNT carisoprodol carisoprodol w/ aspirin cyclobenzaprine hcl metaxalone methocarbamol tizanidine hcl DIRECT-ACTING SKELETAL MUSCLE RELAXANTS dantrolene sodium GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT baclofen NEUROMUSCULAR BLOCKING AGENTS pancuronium bromide Tabs vecuronium bromide For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

22 AUTONOMIC DRUGS SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS orphenadrine citrate SYMTHOLYTIC ADRENERGIC BLOCKING AGENTS ALPHA-ADRENERGIC BLOCKING AGENT(SYMTH) alfuzosin hcl dihydroergotamine mesylate ergoloid mesylates (8 units /30 days) tamsulosin hcl SYMTHOMIMETIC (ADRENERGIC) AGENTS ALPHA- AND BETA-ADRENERGIC AGONISTS AUVI-Q (epinephrine) (30 caps /30 days) ephedrine sulfate (pressors) epinephrine Auto Injector epinephrine Solution EPIPEN (epinephrine) EPIPEN 2-K (epinephrine) EPIPEN-JR 2-K (epinephrine) norepinephrine bitartrate ALPHA-ADRENERGIC AGONISTS LUSONAL (phenylephrine) midodrine hcl phenylephrine hcl (pressors) BETA-ADRENERGIC AGONISTS ADVAIR DISKUS (fluticasone-salmeterol) ADVAIR HFA (fluticasone-salmeterol) (1 inhaler/30 days) (1 inhaler/30 days) albuterol Tablets, syrup, solution for inhalation ARCAPTA NEOHALER (indacaterol maleate) (30 caps/30 days) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

23 AUTONOMIC DRUGS SYMTHOMIMETIC (ADRENERGIC) AGENTS BETA-ADRENERGIC AGONISTS BROVANA (arformoterol tartrate) COMBIVENT (ipratropium-albuterol) COMBIVENT REIMAT (ipratropium-albuterol) FORADIL AEROLIZER (formoterol fumarate) ipratropium-albuterol levalbuterol Nebs MAXAIR AUTOHALER (pirbuterol acetate) metaproterenol sulfate PROAIR HFA, VENTOLIN HFA PERFOROMIST (formoterol fumarate) PROAIR HFA (albuterol) PROAIR REICLICK (albuterol) (120 / 3o days) (15 canister/365 days) (15 canister/365 days) PROVENTIL HFA (albuterol) SEREVENT DISKUS (salmeterol xinafoate) terbutaline sulfate PROAIR HFA, VENTOLIN HFA VENTOLIN HFA (albuterol) (15 canister/365 days) XOPENEX HFA (levalbuterol) BLOOD DERIVATIVES PROAIR HFA, VENTOLIN HFA albumin, human BLOOD FORMATION,COAGULATION & THROMBOSIS ANTIANEMIA DRUGS IRON PRERATIONS b-complex w/ c-min-fe & folic acid fe asparto gly-fe fum-b12-folic acid-vit c-succinic acid fe fumarate-vitamin c-vitamin b12-folic acid For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

24 BLOOD FORMATION,COAGULATION & THROMBOSIS ANTIANEMIA DRUGS IRON PRERATIONS FERREX 150 FORTE (iron polysaccharide complexvit b12-folic acid) FERRO-PLEX HEMATINIC (ferrous fumaratedocusate na-c-e-b12-if-folic acid) ferrous fumarate w/ b12-vit c-fa-ifc ferrous fumarate-folic acid ferrous fumarate-folic acid Tablets ferrous sulfate-vitamin c-folic acid iron combinations iron polysaccharide complex-vit b12-folic acid iron-folic acid-vitamin b12-vitamin c-docusate sodium iron-vitamin c-vitamin b12-folic acid NEPHRON FA (ferrous fumarate w/ fa-dss-b complex-vit c) polysaccharide iron complex ANTIHEMORRHAGIC AGENTS HEMOSTATICS ADVATE (antihemophilic factor) MED Medical Coinsurance ALPHANATE/VON WILLEBRAND FACTOR COMPLEX/HUMAN (antihemophilic factor/von willebrand factor complex (human)) MED Medical Coinsurance ALPHANINE SD (coagulation factor ix) MED Medical Coinsurance aminocaproic acid Syrup aminocaproic acid (300 tab / fill) Tablets antihemophilic factor MED Medical Coinsurance BEBULIN (factor ix complex) MED Medical Coinsurance For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)