Your Choice Pharmacy Benefit Guide. Effective January 1,

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1 Your Choice Pharmacy Benefit Guide Effective January, 205

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3 TABLE OF CONTENTS Your Choice Overview... Your Choice Contact Numbers... Understanding Coverage and Cost-Sharing... 2 About Drugs... 2 Formulary Overview... 2 For Prospective Members... 3 Understanding Our Symbols... 3 Prior Authorization... 3 Step Therapy... 3 Quantity Limits... 3 Filling Your Prescription... 3 Retail... 3 Mail Order... 3 Provider...4 Filling Your Prescription When Traveling...4 Medication Supplies Not Covered by UPMC Health Plan...4 Your Choice Formulary... 5 Medications Not Covered by Your Choice...25 Non-Covered Medications with Covered Alternatives...26 Your Choice Brand/ Reference Guide...3

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5 YOUR CHOICE OVERVIEW The Your Choice pharmacy program provides both value and freedom of choice. It does so by offering a variety of high-quality, effective generic and brand-name prescription drugs. This guide provides information that is applicable to most members. For information specific to your plan, refer to your plan s prescription drug rider. When you need a prescription medication, you and your doctor can choose from four different levels, or tiers. Each tier has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. This guide provides an overview of your pharmacy benefit with UPMC Health Plan. It explains the copayment structure, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. YOUR CHOICE CONTACT NUMBERS Current Members: UPMC Health Plan Health Care Concierge Team: UPMC Health Plan Pharmacy Services (for doctors and pharmacies): TTY Services: Prospective Members: Prospective members should direct their questions to their company s benefits administrator or to the UPMC Health Plan Health Care Concierge team at Online information is available at

6 UNDERSTANDING COVERAGE AND COST-SHARING Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. UPMC Health Plan s Pharmacy and Therapeutics (P&T) Committee researches and evaluates medications it may cover. Committee members include local doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug s safety, effectiveness, and cost. Your Choice prescription drugs are organized into four copayment tiers on the formulary: Tier is for generic medications, which have the lowest copayment. drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. Your Choice requires you to use a generic version of the drug if one is available. This means that if you receive a brand-name drug when a generic is available, you must pay the brand copayment in addition to the retail cost difference between the brand-name and generic forms of the drug. Tier 2 is for preferred-brand medications. UPMC Health Plan classifies these drugs as preferred because of their value and effectiveness. Tier 3 is for non-preferred brand medications. Tier 4 is for specialty medications. medications usually treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). drugs require close management by a physician. Physicians need to monitor these drugs due to potential side effects and the need for frequent dosage adjustments. About Drugs drugs have the same active ingredients as their brand-name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. drugs have the same active ingredients as brandname drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brandname drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brandname drug. FORMULARY OVERVIEW The most commonly prescribed Your Choice drugs are listed in the formulary section of this booklet. Please note that there are other drugs that Your Choice covers in addition to the ones listed in this booklet. For the latest information on the complete Your Choice formulary and other pharmacy benefits, visit our website at Select Your Choice to access the searchable drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card or on page of this booklet. Some medications not covered on our formulary are listed in the sections of the booklet titled Medications Not Covered by Your Choice and Non-Covered Medications with Covered Alternatives. 2

7 If you are a current UPMC Health Plan member, refer to your Schedule of Benefits for your copayment amounts. If you did not receive a Schedule of Benefits in your Welcome Kit, contact our Health Care Concierge team at the number on the back of your member ID card. Your member ID card should also list your copayment amounts. automatically approved if there is a record that you have already tried the preferred drug(s). If there is no record that you tried the preferred drug(s) in your medication history, your physician must submit relevant clinical information to the UPMC Health Plan Pharmacy Services Department before it will be covered. For Prospective Members If you are thinking about joining UPMC Health Plan and would like information about copayment amounts, review the Schedule of Benefits. You may have received one from your company s Benefits Administrator or Human Resources Department. If you did not receive a Schedule of Benefits, contact your Benefits Administrator or the UPMC Health Plan Health Care Concierge team at the number listed on page of this booklet. UNDERSTANDING OUR SYMBOLS Prior Authorization You will see the symbol PA next to certain drugs on our formulary tables in this booklet. PA stands for Prior Authorization. If a drug requires prior authorization, the UPMC Health Plan Pharmacy Services Department must authorize the use of this drug before it will be covered. Drugs that require prior authorization are often: Newer drugs for which UPMC Health Plan wants to track usage. Drugs not used as a standard first option in treating a medical condition. Drugs with potential side effects that UPMC Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications. All compounded medications require prior authorization. Step Therapy You will see the symbol ST next to certain drugs on the formulary tables in this booklet. ST stands for Step Therapy. Quantity Limits You will see the symbol QL next to certain drugs on the formulary tables in this booklet. QL stands for Quantity Limits. Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed during a specified period of time. These limits are based on FDA guidelines, clinical literature, and manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Your physician can request an exception to the quantity limit through the UPMC Health Plan Pharmacy Services Department. Prescriptions for controlled substances and specialty medications are limited to a 30-day supply. FILLING YOUR PRESCRIPTION Retail UPMC Health Plan s network of retail pharmacies includes hundreds of locations independent pharmacies as well as multistore chains throughout the region. You can take your prescription to any pharmacy in the network. You must use 75 percent of your medication before you can get a refill. For specific pharmacy names, locations, and telephone numbers, visit or call our Health Care Concierge team. The phone number is listed on the back of your member ID card and on page of this booklet. Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. The preferred first course of treatment may be generic medications or drugs that are considered as the standard first-line treatment. Step therapy is built into the electronic system that checks your medication history. A drug with step therapy will be 3 Mail Order If you take maintenance medications for a chronic condition, you can get them through a mail-order pharmacy. Maintenance medications are drugs that are taken on a

8 regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma, high cholesterol, and more. With convenient mail-order service: You receive a 90-day supply of most drugs, plus refills, as prescribed by your doctor. You usually pay a lower out-of-pocket cost for a 90-day supply at a mail-order pharmacy than you would pay at a retail pharmacy. You get these drugs delivered right to your door. Most mail order prescriptions are written for a 90-day supply. If your doctor writes for a 30-day supply with two refills, the mail-order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should indicate this on the mail-order form. For a first-time prescription or a new medication, UPMC Health Plan recommends that you try a 30-day supply of the drug from a retail pharmacy. That way your doctor has a chance to make sure that it is the right dose for you and that it does not cause any side effects. Once you re confident that the medication is appropriate, ask your doctor to write a prescription for a 90-day supply of each maintenance drug that you need (plus refills if appropriate). Then order the supply through the mail-order pharmacy. To avoid running out of your mail-order prescription, reorder your medication while you still have an adequate supply remaining, allowing a few weeks for processing and delivery. To request refills, you may order online or over the telephone. You can request a mail-order form by calling our Health Care Concierge team or requesting the form on the UPMC Health Plan website at Provider Most specialty medications must be obtained through our designated specialty provider. When you are prescribed a specialty medication and use a specialty provider, you get mail-order delivery and improved access to drugs, as many retail pharmacies do not carry these types of medications. Filling Your Prescription When Traveling When you travel outside of the western Pennsylvania area, thousands of pharmacies across the country will honor your UPMC Health Plan member ID card. To locate a participating pharmacy, contact our Health Care Concierge team at the phone number listed on the back of your member ID card or on page of this booklet. To fill a prescription at a participating out-of-area pharmacy, present your UPMC Health Plan member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens: If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment. You can request a Pharmacy Program Direct Reimbursement Claim Form by calling our Health Care Concierge team or requesting the form on the UPMC Health Plan website at pharmacy. If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail-order service so that you receive a 90-day supply before you leave home. Medication Supplies Not Covered by UPMC Health Plan No authorizations will be provided for medications that are reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged. Medications received at no charge to the member (workers compensation, medications purchased with a manufacturer s coupon, etc.) will not be covered. Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription. providers also improve care by providing education for our members and expanded access to health care professionals trained in the proper use of these specialty medications. A specialty provider offers cost-effective health care and medication management and compliance programs. 4

9 Effective January, MOP PA 3 medication abacavir abacavir/lamivudine/ zidovudine Abilify Maintena PA, QL 3 medication (ST <2 years of age) Abilify PA, QL 2 (ST <2 years of age) Abstral PA, QL 3 fentanyl citrate (PA) acamprosate acarbose acebutolol acetaminophen/caffeine/ dihydrocodone QL acetaminophen/codeine QL acetazolamide ER capsule acetic acid acetic acid/ hydrocortisone acitretin 3 medication Actemra PA, QL 3 medication Acthar gel PA, QL 3 medication Actimmune PA 3 medication Actonel ST, QL 3 alendronate, ibandronate, risedronate Actonel Weekly ST, QL 3 alendronate, ibandronate, risedronate Acuvail QL 3 ketorolac, diclofenac, bromfenac acyclovir acyclovir ointment Aczone 3 tretinoin, benzoyl peroxide, clindamycin, adapalene (PA) Adagen PA 3 medication adapalene (PA >35 years of age) Adcirca PA, QL 3 medication Adderall XR QL (PA <4 and >8) adefovir PA 3 medication Adempas PA, QL 3 medication Adrenaclick 3 EpiPen, Auvi-Q Advair 2 Advicor 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, niacin ER Aerospan ST 3 Flovent HFA, QVAR, Asmanex Afinitor PA, QL 3 medication Aggrenox 3 clopidogrel, ticlopidine, dipyridamole, Effient alagesic albuterol QL alclometasone dipropionate Aldurazyme PA 3 medication alendronate Alferon N PA 3 medication alfuzosin er Alkeran 2 allopurinol Alocril 3 azelastine, epinastine, Pataday, Patanol Alomide 3 azelastine, epinastine, Pataday, Patanol Alora QL 3 estradiol patch, Premarin Aloxi ST, QL 3 ondansetron Alphagan P 0.% 2 alprazolam alprazolam ODT ST alprazolam Alrex 3 fluorometholone, prednisolone Altavera Alvesco ST 3 Flovent HFA, QVAR, Asmanex amantadine amcinonide Amethia Amethia Lo Amethyst Amevive PA, QL 3 medication amiodarone Amitiza QL 2 KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 5

10 Effective January, 205 amitriptyline amlodipine/atorvastatin amlodipine besylate amlodipine besylate/ benazepril ammonium lactate Amnesteem amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ER amphetamine salts QL (PA < 4 and >8 years of age) Ampyra PA, QL 3 medication Amturnide ST 2 Analpram HC cream 3 hydrocortisone/ pramoxine Analpram HC lotion 3 hydrocortisone/ pramoxine anastrozole Androderm PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Androgel % PA, ST 2 Androgel.62% (PA) Androgel.62% PA 2 Android PA, ST 3 testosterone injection (PA), Androgel.62% (PA) androxy PA, ST testosterone injection (PA), Androgel.62% (PA) Angeliq 3 Premarin, estradiol, estropipate Anoro Ellipta 2 Anzemet ST, QL 3 ondansetron Apidra ST, QL 3 Humalog, Novolog Apokyn PA, QL 3 medication apraclonidine Apri Apriso ER 2 Aptiom PA, QL 3 carbamazepine, oxcarbazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide Aptivus 2 Aquoral 3 Caphosol Aralast NP PA 3 medication Aranelle Aranesp PA 3 medication arbinoxa Arcalyst PA, QL 3 medication Arcapta ST 3 Serevent, Foradil Armour Thyroid 3 levothyroxine, liothyronine Asacol HD 2 Ascensia Blood Glucose 2 Meters Asmanex 2 Atelvia ST, QL 3 alendronate, ibandronate, risedronate atenolol atenolol/chlorthalidone atorvastatin atovaquone suspension Atripla 2 atropine drops Atrovent HFA 2 Aubagio PA, QL 3 medication Aubra aurodex auroguard Auvi-Q 2 Aveed PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Aviane Avodart 2 Avonex QL 3 medication Axert ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Axiron PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Azasite 3 erythromycin azathioprine azelastine Azelex ST 3 topical acne agents KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 6

11 Azilect 2 azithromycin QL Azopt 2 baclofen Bactroban nasal ointment 2 balsalazide disodium Banzel PA 3 felbamate, lamotrigine, topiramate, valproate Baraclude PA 3 medication Bayer Blood Glucose 2 Meters Bayer Blood Glucose Test 2 Strips (QL > 8 years of age) Bayer Lancets 2 (QL > 8 years of age) Beconase AQ ST 3 fluticasone, flunisolide, Veramyst beflex benazepril benazepril/hctz Benlysta PA 3 medication benprox benzoyl peroxide benztropine Bepreve 3 azelastine, epinastine, Pataday, Patanol Berinert PA 3 medication Besivance 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox betamethasone Betaseron ST, QL 3 medication betaxolol Bethkis QL 3 medication Betimol 3 timolol, Betoptic S Betoptic S 2 Beyaz 2 Biafine 3 ammonium lactate, zenieva bicalutamide bisoprolol bisoprolol/hctz Bivigam PA 3 medication Blephamide 2 Bosulif PA, QL 3 medication Botox PA, QL 3 medication bp 0- wash BPO gel Breeze Blood Glucose 2 Meters Breo Ellipta 2 Briellyn Brilinta QL 3 clopidogrel, Effient brimonidine tartrate Brintellix PA, QL 3 paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) bromfenac ophthalmic solution Brovana 3 Serevent, Foradil budeprion XL budesonide EC budesonide nasal spray ST budesonide respules Buphenyl tablet PA 3 medication buprenorphine PA, QL buprenorphine/naloxone tablet PA, QL bupropion bupropion SA buspirone butorphanol nasal spray QL Bydureon QL 2 3 Suboxone film (PA), Zubsolv (PA) Byetta ST, QL 3 Bydureon, Victoza Bystolic ST 3 atenolol, metoprolol, propranolol calcipotriene calcitriol calcium acetate Camila Camrese Camrese Lo KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 7

12 Effective January, 205 Canasa 3 mesalamine, balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol candesartan candesartan/hctz capecitabine PA 3 medication Caphosol 2 Caprelsa PA, QL 3 medication captopril captopril/hctz Carac 3 medication Carbaglu PA 3 medication carbamazepine ER carbidopa carbidopa/levodopa carbidopa/levodopa/ entacapone Cardene SR 3 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate Cardura XL ST, QL 3 doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er Carimune NF PA 3 medication carisoprodol carteolol cartia XT carvedilol Cayston QL 3 medication cefaclor cefadroxil cefdinir cefpodoxime cefprozil ceftazidime ceftibuten cefuroxime Celebrex ST, QL 3 NSAIDS (diclofenac, etodolac, ibuprofen, meloxicam, naproxen) Cenestin 3 Premarin, estradiol, estropipate cephalexin Cerezyme PA 3 medication cevimeline Chantix ST, QL 2 Chateal Chemet PA 3 chlordiazepoxide chlorpromazine (ST <2 years of age) chlorpropamide chlorthalidone chlorzoxazone cholestyramine ciclopirox cilostazol Ciloxan 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox cimetidine Cimzia PA, QL 3 medication Cinryze PA, QL 3 medication Cipro HC 2 Ciprodex 2 ciprofloxacin ciprofloxacin 0.2% ear drops ciprofloxacin ER QL citalopram QL Claravis clarithromycin clarithromycin ER Climara-PRO QL 3 estradiol Clinac BPO 3 benzoyl peroxide clindamycin clobetasol clonazepam clonazepam ODT ST clonazepam clonidine clonidine ER ST, QL clonidine clopidogrel clorazepate KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 8

13 clotrimazole clozapine (ST <2 years of age) clozapine ODT QL (ST <2 years of age) Coartem 2 codeine sulfate Colcrys 2 Colestid granules 3 colestipol colestipol Combigan 2 Combipatch QL 3 estradiol-norethindrone, Jinteli, Prempro, Premphase Combivent Respimat 2 Cometriq PA, QL 3 medication Complera 2 Contour Blood Glucose 2 Meters Copaxone QL 3 medication Copegus QL 3 medication Coreg CR 3 carvedilol cortamox Cortef 3 hydrocortisone tablet Cortifoam 3 hydrocortisone suppositories, proctozone Cosopt PF 3 Azopt, betaxolol, Betoptic S, carteolol, dorzolamide, dorzolamide-timolol, timolol maleate Covera- HS 3 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate Creon 2 Crinone 4% gel 2 Crixivan 2 cromolyn Cryselle Cuprimine PA 3 medication Cuvposa (PA > 6 years of age) Cyclafem cyclobenzaprine 3 glycopyrrolate tablet cyclopentolate drops Cycloset 3 bromocriptine cyclosporine cyclosporine modified Cystadane powder PA 3 medication Cystagon PA 2 Cystaran PA, QL 3 medication Daliresp PA 3 Advair, Breo Ellipta, Foradil, Serevent, Spiriva, Symbicort, Tudorza danazol PA dantrolene Dapsone 2 Dasetta Daysee Delatestryl PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Delyla Delzicol 2 Demser PA 3 medication Denavir 3 For cold sore treatment use over-the-counter agents Depen PA 3 medication Dermatop 3 topical steroids desogestrel/ethinyl estradiol desonide desoximetasone Desvenlafaxine ER ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) dexamethasone dexmethylphenidate ER QL (PA < 4 and > 8 years of age) dexmethylphenidate QL (PA < 4 and > 8 years of age) dextroamphetamine QL (PA < 4 and > 8 years of age) KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications * Age restrictions apply to some medications. 9

14 Effective January, 205 Diastat 2 Diastat Acudial 3 diazepam diazepam Dibenzyline PA 3 medication diclofenac diclofenac ophthalmic solution diclofenac-misoprostol dicloxacillin didanosine Dificid ST, QL 3 medication diflorasone digoxin dihydroergotamine diltiazem diltiazem ER Dipentum ST 3 balsalazide disodium, Apriso, Asacol HD, Delzicol dipyridamole disulfuram divalproex sodium divalproex sodium ER Divigel 3 estradiol donepezil PA dorzolamide dorzolamide/timolol doxazosin doxercalciferol doxycycline drithocreme Dritho-Scalp 2 dronabinol Duavee 3 estradiol-norethindrone, Jinteli, Prempro, Premphase Dulera 2 duloxetine ST, QL Durasal 3 salicyclic acid Durezol 3 fluorometholone, prednisolone Dymista ST 3 fluticasone, flunisolide, Veramyst Dynacirc CR 3 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate dyphylline gg Dyrenium 3 triamterene-hctz Dysport PA, QL 3 medication Edarbi ST 3 losartan, eprosartan, irbesartan, candesartan, telmisartan, valsartan Edarbyclor ST 3 candesartan-hctz, irbesartan-hctz, losartan-hctz, telmisartan- HCTZ, valsartan-hctz Edurant 2 Effient QL 2 Elaprase PA 3 medication Elelyso PA 3 medication Elidel PA 3 topical steroids Eligard PA, QL 3 medication Elinest eliphos Eliquis QL 2 Ella 3 levonorgestrel, Next Choice Elmiron 2 Emadine 3 azelastine, epinastine, Pataday, Patanol Emcyt PA 3 medication Emend capsule QL 2 Emend vial QL 3 Emoquette Emtriva 2 enalapril Enbrel PA, QL 3 medication Endocet QL Enjuvia 3 estradiol, estropipate, Premarin enoxaparin QL Enpresse Enskyce entacapone Entyvio PA, QL 3 medication epinastine ophthalmic solution KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 0

15 epinephrine EpiPen 2 eplerenone Epogen PA 3 medication epoprostenol PA 3 medication eprosartan Epzicom 2 ergotamine/caffeine Erivedge PA, QL 3 medication Errin EryPed 3 erythromycin Ery-tab EC Ery-tab EC 500mg 2 erythromycin erythromycin/benzoyl peroxide gel escitalopram QL Estarylla Estrace cream 3 estradiol, estropipate, Premarin Estraderm QL 3 estradiol estradiol estradiol/norethindrone estradiol patch QL Estring 3 estradiol, estropipate, Premarin Estrogel 3 Premarin estropipate eszopiclone ST, QL etidronate etodolac etoposide PA 3 medication Euflexxa PA, QL 3 medication Evamist 3 estradiol Evzio PA, QL 3 medication Exelon patch PA 3 rivastigmine tartrate capsules (PA), donepezil (PA), Namenda (PA), Namenda XR (PA) exemestane Exjade PA 3 medication Eylea PA 3 medication Fabior (PA >35 years of age) 3 topical acne agents Fabrazyme PA 3 medication Factive QL 3 ciprofloxacin, levofloxacin Falmina famciclovir QL famotidine Fanapt PA, QL (ST <2 years of age) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Fareston PA 3 medication felbamate felodipine FemHRT 3 estradiol-norethindrone, Jinteli, Prempro, Premphase Femring 3 estradiol, estropipate, Premarin Femtrace 3 estradiol, estropipate, Premarin fenofibrate fenofibric acid ST fenoprofen fentanyl citrate PA, QL fentanyl transdermal QL Fentora PA, ST, QL 3 fentanyl citrate (PA), Abstral (PA) Ferriprox PA 3 medication Fetzima PA, QL 3 venlafaxine ER, duloxetine (ST) Finacea 3 topical acne agents finasteride Firazyr PA, QL 3 medication Firmagon PA, QL 3 medication First Testosterone 2% cream PA, ST First Testosterone 2% ointment PA, ST 3 testosterone injection (PA), Androgel.62% (PA) 3 testosterone injection (PA), Androgel.62% (PA) First-BXN Mouthwash 3 diphenhydramine, lidocaine, nystatin KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications

16 Effective January, 205 Flarex 3 fluorometholone, prednisolone Flebogamma PA 3 medication flecainide Flovent HFA 2 fluconazole QL flunisolide fluocinolone fluocinonide Fluor-A-Day chew Fluor-A-Day drops 2 fluorometholone fluoxetine fluoxetine (28 unit pack) ST fluoxetine DR QL fluphenazine (ST <2 years of age) flurbiprofen fluticasone fluvastatin fluvoxamine FML Forte 3 fluorometholone, prednisolone FML S.O.P. 2 fondaparinux QL Foradil 2 Forteo ST, QL 3 medication Fortesta PA, ST 3 testosterone injection (PA), Androgel.62% (PA) fosinopril fosinopril/hctz Fosrenol 3 calcium acetate, sevelamer carbonate, Renvela powder packet Fragmin QL 3 medication Frova ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Fulyzaq PA, QL 3 medication furosemide Fuzeon 3 medication Fycompa PA, QL 3 felbamate, lamotrigine, topiramate, valproate gabapentin Gablofen 3 galantamine ER PA galantamine PA Galzin PA 2 Gammagard PA 3 medication Gammaked PA 3 medication Gammaplex PA 3 medication Gamunex PA 3 medication Gamunex-C PA 3 medication ganciclovir gatifloxacin Gattex PA, QL 3 medication gavilyte-g gemfibrozil Generess FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Gianvi Gildagia Gildess Gilenya PA, QL 3 medication Gilotrif PA, QL 3 medication Glassia PA 3 medication Gleevec PA, QL 3 medication glimepiride glipizide glipizide/metformin glipizide ER Glucagon 2 glyburide glyburide/metformin Glyset 3 acarbose Gralise PA, QL 3 gabapentin granisetron ST, QL ondansetron granisol ST, QL ondansetron Granix PA 3 medication griseofulvin guanfacine Halflytely 3 peg-3350, Suprep, Moviprep KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 2

17 halobetasol Halog 3 topical steroids haloperidol (ST <2 years of age) HCTZ Heather Helidac 3 bismuth subsalicylate (OTC), metronidazole, tetracycline Hetlioz PA, QL 3 medication Hexalen 3 medication Hizentra PA 3 medication homatropine drops Horizant PA, QL 3 gabapentin, pramipexole, ropinirole Humalog 50/50 QL 2 Humalog 75/25 QL 2 Humalog QL 2 Humira PA, QL 3 medication Humulin 50/50 QL 2 Humulin 70/30 QL 2 Humulin N QL 2 Humulin R QL 2 Hycamtin PA 3 medication hydralazine hydrocodone/ibuprofen hydrocodone/ acetaminophen QL hydrocort/pramoxine cream hydrocortisone hydromorphone hydroxychloroquine hydroxyurea hydroxyzine hyoscyamine ibandronate IV ST, QL 3 alendronate, ibandronate, risedronate ibandronate tablet QL ibuprofen Iclusig PA, QL 3 medication Ilaris PA, QL 3 medication Ilevro 3 ketorolac, diclofenac, bromfenac Imbruvica PA, QL 3 medication imiquimod Increlex PA 3 medication Incruse Ellipta 3 Spiriva, Tudorza indomethacin Infergen PA, QL 3 medication Inlyta PA, QL 3 medication Innopran XL ST 3 atenolol, metoprolol, propranolol Intelence PA 2 Intron A PA 3 medication Introvale Intuniv ST, QL 3 guanfacine Invega PA, QL (ST <2 years of age) Invega Sustenna PA, QL (ST <2 years of age) Invirase 2 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) 3 medication Invokana QL 3 metformin, glyburide, glipizide, Januvia, Tradjenta ipratropium ipratropium/albuterol solution irbesartan irbesartan/hctz Iressa PA, QL 3 medication Isentress 2 Isopto Carbachol 3 betaxolol, brimonidine, carteolol, dorzolamide, latanoprost, levobunolol, timolol, Combigan, Azopt, Betoptic S Isopto Homatropine 3 homatropine, atropine, cyclopentolate, tropicamide isosorbide isradipine Istalol 3 timolol itraconazole capsule PA, QL Jakafi PA, QL 3 medication KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 3

18 Effective January, 205 Jalyn 2 Janumet 2 Janumet XR 2 Januvia 2 Jencycla Jentadueto 2 Jetrea PA, QL 3 medication Jinteli Jolessa Jolivette Junel Junel FE Juxtapid PA, QL 3 medication Kalbitor PA 3 medication Kaletra 2 Kalydeco PA, QL 3 medication Kariva Kazano ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Ketek QL 3 azithromycin, clarithromycin ER, erythromycin ketoconazole ketoprofen ketorolac ophthalmic solution ketorolac QL Khedezla ER ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Kineret PA, QL 3 medication Kombiglyze XR ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Korlym PA, QL 3 medication Krystexxa PA, QL 3 medication Kurvelo Kuvan PA 3 medication Kynamro PA, QL 3 medication labetalol lactulose lamivudine lamivudine/zidovudine lamivudine HBV PA lamotrigine lansoprazole/amoxicillin/ clarithromycin pack lansoprazole QL Lantus QL 2 Larin Larin Fe Lastacaft 3 azelastine, epinastine, Pataday, Patanol latanoprost Latuda ST, QL (ST <2 years of age) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Lazanda PA, ST, QL 3 fentanyl citrate (PA), Abstral (PA) Leena leflunomide Lessina Letairis PA, QL 3 medication letrozole Leukeran 2 Leukine PA 3 medication leuprolide PA 3 medication levalbuterol ST Levatol ST 3 atenolol, metoprolol, propranolol Levemir QL 2 levetiracetam levetiracetam ER QL levobunolol levocetirizine levofloxacin levofloxacin ophthalmic Levonest levonorgestrel Levora levothyroxine Lexiva 2 Lialda ST 3 balsalazide disodium, Apriso, Asacol HD, Delzicol lidocaine patch ST, QL KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 4

19 lidocaine-hc gel LidoVir ointment compounding kit 3 For cold sore treatment use over-the-counter agents Lifescan Blood Glucose 2 Meters Lifescan Blood Glucose 2 Test Strips (QL > 8 years of age) Lifescan Lancets 2 (QL > 8 years of age) Linzess QL 3 Amitiza liothyronine Lipofen 3 fenofibrate Liptruzet ST 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia lisinopril lisinopril/hctz Lo Loestrin FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Loestrin 24 FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lomedia 24 FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lo Minastrin FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lomustine 2 loratadine OTC lorazepam Lorcet HD QL Lorcet plus QL Lortab QL Loryna losartan losartan/hctz Lotemax 3 fluorometholone, prednisolone Lotronex PA 3 medication lovastatin Low-ogestrel loxapine (ST <2 years of age) Lucentis PA 3 medication Lumigan 2 Lumizyme PA 3 medication Lupaneta PA, QL 3 medication Lupron PA, QL 3 medication Lyrica PA, QL 3 gabapentin, Savella (PA) Lysodren PA 3 medication Lyza Makena PA 3 medication malathion Matulane 3 medication matzim LA Maxair ST, QL 3 Ventolin HFA Maxaquin 3 ciprofloxacin, levofloxacin Maxidex 3 fluorometholone, prednisolone meclizine medroxyprogesterone acetate injection QL mefenamic acid Mekinist PA, QL 3 medication meloxicam Menest 3 Premarin, estradiol, estropipate Menostar QL 3 estradiol meperidine tablet mercaptopurine mesalamine metaxalone metformin metformin ER Methadose methamphetamine QL (PA < 4 and > 8 years of age) KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 5

20 Effective January, 205 methazolamide Methitest PA 3 testosterone injection (PA), Androgel.62% (PA) methocarbamol methotrexate methoxsalen PA 3 Medication methylin ER QL (PA < 4 and > 8 years of age) methylin QL (PA < 4 and > 8 years of age) methylphenidate ER QL (PA < 4 and > 8 years of age) methylphenidate QL (PA < 4 and > 8 years of age) methylprednisolone metipranolol metoclopramide metoprolol metoprolol/hctz metoprolol ER metronidazole Miacalcin 3 alendronate, ibandronate, risedronate Microgestin Microgestin FE midazolam syrup Migergot migragesic IDA Mimvey Mimvey Lo Minastrin 24 Fe 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Minivelle QL 3 estradiol patch, Premarin minocycline Mirapex ER ST 3 pramipexole, ropinirole mirtazapine Mirvaso PA 3 metronidazole, sodium sulfacetamide/sulfur, tretinoin, adapalene modafinil PA, QL Moderiba QL 3 medication moexipril moexipril/hctz mometasone Mono-linyah MonoNessa montelukast QL Monurol 2 morphine sulfate ER tablet QL morphine sulfate IR Moviprep 2 Moxeza 2 moxifloxacin Mozobil PA, QL 3 medication Multaq 2 mupirocin Myalept PA, QL 3 medication mycophenolate mofetil mycophenolate sodium Myobloc PA, QL 3 medication Myorisan Myozyme PA 3 medication Myrbetriq ER QL 3 oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare Myzilra nabumetone nadolol nadolol/ bendroflumethiazide Naglazyme PA 3 medication Namenda PA 2 Namenda XR PA, QL 2 naproxen naratriptan QL Nasonex ST 3 flunisolide, fluticasone, Veramyst Natazia 2 nateglinide Nebupent 2 Necon KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 6

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