Plan Details. Get the most out of your plan. See inside to find resources and details about your new plan and benefits.

Transcription

1 2016 Plan Details Get the most out of your plan. See inside to find resources and details about your new plan and benefits. Toll-Free <TOLL_FREE_NUMBER>, , TTY 711TTY <OPERATING_HOURS> a.m. - 8 p.m. local time, 7 days a week <CORRESPONDENCE_URL> UHEX16MP _000 UH <MA_kc>

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3 Hello Hlddn G Jigds, Welcome and thank you for being a member. Here are the Sharp SecureHorizons Plan by UnitedHealthcare (HMO) plan details so you can learn about your plan and get started using your benefits. Table of Contents Benefit Highlights Check here for a quick list of the costs for commonly used benefits. Formulary (Drug List) See if a specific drug is covered by your plan. Pharmacy Directory Learn about our pharmacy network and find pharmacies near you. Provider Directory Find network doctors and specialists in your area. Evidence of Coverage Read details about your plan, including coverage, costs and more. page 7 page 9 page 57 page 67 page 117 Do we have the right address for you? If not, please let us know so we can keep you informed about your plan. Y0066_150624_ Accepted UHEX16MP _000 Page 5

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5 Benefit highlights Sharp SecureHorizons Plan by UnitedHealthcare (HMO) This is a short description of 2016 plan benefits. For complete information, please refer to your Summary of Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply. Plan Costs If you have full Medicaid benefits or are a Qualified Medicare Beneficiary, you will pay $0 for your Medicarecovered services. You may have small copays for your Part D prescription drugs. Monthly plan premium $0 Annual out-of-pocket maximum* $3,500 *The most you may pay in a year for medical care covered by the plan. Benefit Highlights Medical Benefits Doctor s office visit Preventive services Inpatient hospital care Skilled nursing facility (SNF) Outpatient surgery Diabetes monitoring supplies Home health care Diagnostic radiology services (such as MRIs, CT scans) Diagnostic tests and procedures (nonradiological) Lab services Outpatient x-rays Ambulance Emergency care Urgently needed services Primary Care Provider: $10 copay Specialist: $35 copay (referral needed) $0 copay $260 copay per day: days 1-7 $0 copay per day after that $0 copay per day: days 1-20 $155 copay per day: days $0 copay per day: days $250 copay $0 copay $0 copay 20% of the cost 20% of the cost $19 copay $10 copay $275 copay $65 copay (worldwide) $30 - $50 copay ($65 copay for worldwide coverage) Page 7

6 Benefits and Services beyond Original Medicare Routine physical Vision - routine eye exams Hearing - routine exam Hearing aids Fitness program through SilverSneakers Fitness program NurseLine SM Prescription Drugs $0 copay; 1 per year $35 copay; 1 every year $10 copay; 1 per year $390 - $450 copay for each hi HealthInnovations hearing aid, up to 2 per year (Additional fees with Power Max model) Basic membership in a fitness program at a network location Speak with a registered nurse (RN) 24 hours a day, 7 days a week Your Cost Annual prescription deductible $0 Initial coverage stage Standard Retail (30-day) Preferred Mail Order (90-day) Tier 1: Preferred Generic Drugs $4 copay $0 copay Tier 2: Generic Drugs $8 copay $0 copay Tier 3: Preferred Brand Drugs $47 copay $131 copay Tier 4: Non-Preferred Brand Drugs $100 copay $290 copay Tier 5: Specialty Tier Drugs 33% of the cost 33% of the cost Coverage gap stage After your total drug costs reach $3,310, you will pay no more than 58% of the total cost for generic drugs or 45% of the total cost for brand name drugs, for any drug tier during the coverage gap Catastrophic coverage stage After your total out-of-pocket costs reach $4,850, you will pay the greater of $2.95 copay for generic (including brand drugs treated as generic), $7.40 copay for all other drugs, or 5% of the cost Optional riders available See the Summary of Benefits or Evidence of Coverage for information Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan s contract renewal with Medicare. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. This information is not a complete description of benefits. Contact the plan for more information. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. Limitations, copayments, and restrictions may apply. Y0066_MABH_16_FINAL_H ACCEPTED UHCA16HM _000 Page 8

7 Abridged FORMULARY (Partial list of covered drugs) Sharp SecureHorizons Plan by UnitedHealthcare (HMO) Please read: This document contains information about some of the drugs we cover in this plan. This Abridged Formulary (drug list) is not a complete list of drugs covered by our plan. For a complete list of covered drugs or if you have other questions, please contact Sharp SecureHorizons Plan by UnitedHealthcare Customer Service at: Toll-Free , TTY a.m. to 8 p.m. local time, 7 days a week Medicare Approved Formulary File ID , Version 9 Y0066_150605_220832A_FINAL_M19 Approved Last updated August 1, 2015 Page 9

8 2 2 This document includes a partial list of the drugs (formulary) for our plan and is current as of August 1, For a complete, updated formulary (drug list), please contact us. Our contact information, along with the date we last updated the formulary, appears on the cover. When this drug list (formulary) refers to we, us, or our, it means UnitedHealthcare. When it refers to plan or our plan, it means Sharp SecureHorizons Plan by UnitedHealthcare. Note to existing members: Our list of covered drugs is called a Formulary. We call it the "Drug List" for short. This partial drug list has changed since last year. Please review this document to make sure the plan still covers the drugs you take. You must generally use network pharmacies to use your prescription drug benefit. Page 10

9 3 The Sharp SecureHorizons Plan by UnitedHealthcare ABRIDGED FORMULARY (drug list) 3 A formulary is a list of covered drugs selected by your plan 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 call it the "Drug List" for short. Your plan will generally cover the drugs listed in our formulary (drug list) as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial drug list and includes only some of the drugs covered by your plan. For a complete listing of all prescription drugs covered by your plan, please visit our website or call us. Our contact information, along with the date we last updated the drug list, appears on the cover. Your plan s complete (comprehensive) drug list includes all of the drugs covered by your plan. For your drug to be covered by your plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our network pharmacies. To find out if your drug is covered: Formulary 1. See if your drug is included in this partial drug list. 2. If you cannot find your drug in this partial list, you can check the complete drug list by visiting your plan website. Use the online tools to look up your drugs. The information is updated on a regular basis. The Web address appears on the cover. 3. Call Customer Service. Our contact information appears on the cover. Page 11

10 4 When the drug list may change We try to make as few changes to the drug list as possible during the plan year. If there are changes to the drug list, such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The drug list may change throughout the year when your plan: Adds a new drug as they become available, including new generic drugs. Removes a drug from the list because it has been found to be ineffective or unsafe. Changes the requirements or limits for a drug. Moves a drug into a different tier. Generally, if you are taking a drug on the 2016 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from the drug list, will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the coverage year. We feel it is important for you to have access for the entire coverage year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, during the coverage year we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) declares a drug on our drug list to be unsafe, or if the drug s manufacturer removes the drug from the market, your plan will immediately remove the drug from the drug list and notify members who take the drug. The enclosed drug list is current as of the date printed on the cover. To get updated information about the drugs covered by your plan, please call Customer Service or visit our website using the information provided on the cover of this drug list. Page 12 4

11 Drug tiers and drug payment stages The amount you pay for a covered drug will depend on: Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you re in. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a copay and/or co-insurance amount. The chart below shows the differences between the tiers. For more information about drug coverage and co-pay or co-insurance amounts for each tier, please review your Evidence of Coverage. 5 Drug Tier Includes Tier 1: Preferred generic Tier 2: Generic Lower-cost, commonly used generic drugs. Many generic drugs. Formulary Tier 3: Preferred brand Tier 4: Non-preferred brand Tier 5: Specialty tier Many common brand name drugs, called preferred brands, and some higher-cost generic drugs. Non-preferred generic and non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in Tier 4. Unique and/or very high-cost drugs. If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider). Please read it to learn about your costs. You can also contact Customer Service. Our contact information appears on the cover. 5 Page 13

12 6 How to use the drug list There are two ways to find your prescription drugs in this partial drug list: 1. Medical condition: Turn to the Covered drugs by medical condition section, which begins on page 12, to look for drugs based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular Agents category and look under Dyslipidemics, HMG CoA Reductase Inhibitors. 2. Alphabetical list (index): If you are not sure what category to look under, turn to the Index of covered drugs section, which begins on page 41. Find the name of your drug. The page number where you can find the drug will be next to it. Generic drugs Your plan covers both brand name drugs and generic drugs. Generic drugs are approved by the Food and Drug Administration (FDA) as having the same active ingredients as brand name drugs. Generic drugs usually cost less than brand name drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money. The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin). Page 14 6

13 Dummy Required actions, restrictions or limits Some covered drugs may have additional requirements or limits on coverage. If your drug has any requirements or limits, there will be a code(s) in the Required actions, restrictions or limits column of the drug list. The codes and what they mean are shown below. 7 Utilization Management Restrictions PA - Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don t get approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug for one co-pay/co-insurance or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. Formulary HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. Note: If you are 65 or older, you will need to get a prior authorization (PA) or formulary exception from the health plan before the plan will cover a high risk medication (HRM). If you are under 65, the prior authorization (PA) will not apply to you until the first time you get your prescription filled after turning 65. LA - Limited access Drugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. 7 Page 15

14 8 You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the Covered drugs by medical condition section that begins on page 12. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the cover. You and your doctor may ask the plan for an exception to these requirements, restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the, How to request an exception to the Sharp SecureHorizons Plan by UnitedHealthcare drug list section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug. If your drug is not on the drug list If your drug is not included in this partial formulary (list of covered drugs), you should contact Customer Service and ask if your drug is covered. Because this is only a partial list of covered drugs, your plan may cover the drug even if it s not in this list. Our contact information, along with the date we last updated the drug list, appears on the cover. If you learn that your plan does not cover your drug, you have two options: 1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the appropriate drugs from the list. 2. Ask your plan to make an exception and cover your drug. See next page for information about how to request an exception. Page 16 8

15 How to request an exception to the Sharp SecureHorizons Plan by UnitedHealthcare drug list At times you may need to ask for drug coverage that s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination). You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask your plan to make. 9 Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. Tiering exception: You can ask your plan to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. Utilization exception: You can ask your plan to waive coverage restrictions or limits on your drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a quantity limit, you can ask your plan to waive the limit and cover more. Formulary Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects. Who can ask for a coverage decision You, your authorized representative or your doctor can ask for an initial coverage decision for a formulary exception, tiering exception or utilization restriction exception. When you are requesting a formulary exception, tiering exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. Receiving a coverage decision Generally, your plan will make a coverage decision within 72 hours after receiving your prescribing physician s statement. You can request an expedited, or fast, decision if you or your doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a decision within 24 hours after your plan receives your doctor s or prescribing physician s supporting statement. 9 Page 17

16 10 What to do while you talk to your doctor about changing your drugs or requesting an exception New or continuing members As a new or continuing member in your plan, you may be taking drugs that are not on the drug list. Or you may be taking a drug that is on the drug list, but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that your plan covers, or request a formulary exception so your plan will cover the drug you are currently taking. While you talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days you are a member of your plan. For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited, your plan may cover a temporary 30-day supply (unless you have a prescription written for fewer days) from a network pharmacy. After your first 30-day supply, your plan will not pay for these drugs, even if you have been a member of your plan less than 90 days. Long-term care facility residents If you re a resident of a long-term care facility, your plan may allow you to refill your prescription until we have provided you with a maximum of a 91- and may be up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is written for fewer days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a member of your plan. If you need a drug that s not on the drug list or if you have limited ability to get your drugs, but you are past the first 90 days of membership in the plan, your plan will cover a 31-day emergency supply of the drug (unless your prescription is written for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that s not on the drug list, or if it s difficult for you to get your drugs, you are required to use your plan s exception process. You may ask for a one-time emergency supply of up to 30 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. 10 Page 18

17 Drugs with dosages other than 30 days Drugs packaged in an extended day supply Some drugs are packaged from the manufacturer to provide greater than a 30-day supply. When you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single prescription. For more information, please contact Customer Service using the information on the cover. Daily cost share for oral medications filled for less than a 30-day supply Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than 30 days under applicable law. The daily cost share requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions. For more information For more information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please call us tollfree at , TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. Or visit us online at If you have general questions about Medicare prescription drug coverage, visit or call Medicare at , TTY , 24 hours a day, 7 days a week. 11 Formulary 11 Page 19

18 1tRACK 1 12 Covered drugs by medical condition The Abridged Formulary (drug list) below provides coverage information about some of the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the Index of covered drugs, which begins on page 41. Remember: This is only a partial list of drugs covered by your plan. If your drug is not in this partial drug list, please contact us. Our contact information, along with the date we last updated the drug list, appears on the cover. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The second column of the chart lists which coverage level (Tier) your drug is in. The Required actions, restrictions or limits column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages track Drug Name Drug Tier Required Actions, Restrictions or Limits Analgesics Nonsteroidal Anti-inflammatory Drugs Celecoxib (Capsule) 4 QL Potassium Diclofenac Potassium (Tablet) Sodium DR Diclofenac Sodium DR (25mg Tablet Delayed- Release, 50mg Tablet Delayed-Release, 75mg Tablet Delayed-Release), Diclofenac Sodium ER (100mg Tablet Extended- Release 24 Hour) Ibuprofen (100mg/5ml Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet) Meloxicam (Tablet) 1 Naproxen (Tablet Immediate-Release) Voltaren (Gel) 4 PA Opioid Analgesics, Long-acting Drug Name Drug Tier Required Actions, Restrictions or Limits Fentanyl (100mcg/hr Patch 72 Hour, 12mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Hour, 50mcg/hr 4 QL Patch 72 Hour, 75mcg/hr Patch 72 Hour) HCl Methadone HCl (10mg/ 5ml Oral Solution, 5mg/ 5ml Oral Solution, 10mg 3 QL Tablet, 5mg Tablet) Sulfate ER Morphine Sulfate ER (Tablet Extended-Release) 3 QL (Generic MS Contin) ER Opana ER (Crush Resistant) (Tablet Extended-Release 12 Hour Abuse-Deterrent) 3 QL Opioid Analgesics, Short-acting Acetaminophen/Codeine (Tablet) 2 QL Bold type = Brand name drug Plain type = Generic drug 12 Page 20

19 Chantix 2tRACK 2 Last updated August 1, Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Hydrocodone/Acetaminophen Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 3 QL 5mg-325mg Tablet, 7.5mg-325mg Tablet) HCl Hydromorphone HCl (Tablet Immediate- 2 QL Release) HCl Oxycodone HCl (Tablet Immediate-Release) 2 QL Oxycodone/Acetaminophen Acetaminophen (10mg-325mg Tablet, 2.5mg-325mg Tablet, 3 QL 5mg-325mg Tablet, 7.5mg-325mg Tablet) HCl Tramadol HCl (Tablet Immediate-Release) 2 QL HCl/Acetaminophen Tramadol HCl/ Acetaminophen (Tablet) 2 QL Anesthetics Local Anesthetics Lidocaine (Gel, Ointment, 2% Viscous Solution) 3 Lidocaine/Prilocaine (Cream) 3 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving Calcium DR Acamprosate Calcium DR (Tablet Delayed-Release) 4 Disulfiram (Tablet) 3 HCl Naltrexone HCl (Tablet) 3 Opioid Dependence Treatments HCl Buprenorphine HCl (Tablet Sublingual) 4 QL Suboxone (Film) 4 PA, QL Smoking Cessation Agents Chantix (Tablet) 4 Inhaler Nicotrol Inhaler 4 Antibacterials Aminoglycosides Sulfate Gentamicin Sulfate (0.1% Cream, 0.1% Ointment, 0.3% Ophthalmic Ointment, 0.3% Ophthalmic Solution) Sulfate Tobramycin Sulfate (Ophthalmic Solution) Antibacterials, Other HCl Clindamycin HCl (Capsule Immediate- Release, Oral Solution) Metronidazole (Tablet Immediate-Release) Mupirocin (Ointment) 2 Macrocrystals Nitrofurantoin Macrocrystals (50mg Capsule) (Generic 3 QL, HRM Macrodantin) Monohydrate Nitrofurantoin Monohydrate (100mg Capsule) (Generic Macrobid) 3 QL, HRM Beta-lactam, Cephalosporins Cefdinir (300mg Capsule, 125mg/5ml Suspension, 3 250mg/5ml Suspension) Axetil Cefuroxime Axetil (Tablet) 2 Cephalexin (Capsule, Suspension) Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 21

20 3tRACK 3 14 Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Suprax (100mg/5ml Suspension, 200mg/5ml Suspension, 100mg Tablet Chewable, 200mg Tablet Chewable) Suprax (400mg Capsule, 500mg/5ml Suspension) Beta-lactam, Other Invanz (Injection) 4 Meropenem (Injection) 4 Beta-lactam, Penicillins Amoxicillin (250mg Capsule, 500mg Capsule, 1 500mg Tablet, 875mg Tablet) Potassium Amoxicillin/Clavulanate Potassium (Tablet 2 Immediate-Release) (Generic Augmentin) V Potassium Penicillin V Potassium 2 (Tablet) Macrolides Azithromycin 1 (Suspension, Tablet) Erythromycin (Ophthalmic 2 Ointment) Base Erythromycin Base 4 (Tablet) Quinolones HCl Ciprofloxacin HCl (Tablet 2 Immediate-Release) Levofloxacin (Tablet) 1 Sulfonamides Sulfadiazine Silver Sulfadiazine (Cream) Sulfamethoxazole/Trimethoprim Trimethoprim (Tablet), Sulfamethoxazole/ Trimethoprim DS (Tablet) Tetracyclines Hyclate Doxycycline Hyclate (Capsule Immediate- Release) HCl Minocycline HCl (Capsule Immediate-Release) Anticonvulsants Anticonvulsants, Other Levetiracetam (Tablet Immediate-Release) Potiga (Tablet) 5 QL Calcium Channel Modifying Agents Ethosuximide (250mg Capsule, 250mg/5ml Oral 3 Solution) Zonisamide (Capsule) 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents Sodium Divalproex Sodium (Capsule Sprinkle), Divalproex Sodium DR (Tablet Delayed-Release), 2 Divalproex Sodium ER (Tablet Extended-Release 24 Hour) Gabapentin (100mg Capsule, 300mg Capsule, 2 400mg Capsule, 600mg Tablet, 800mg Tablet) Glutamate Reducing Agents Lamotrigine (Tablet 2 Immediate-Release) Bold type = Brand name drug Plain type = Generic drug 14 Page 22

21 4tRACK 4 Last updated August 1, Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Topiramate (Tablet Immediate-Release) Sodium Channel Agents Carbamazepine (100mg/ 5ml Suspension, 200mg Tablet, 100mg Tablet Chewable), Carbamazepine ER (100mg Capsule Extended-Release 12 Hour, 200mg Capsule Extended-Release 12 Hour, 300mg Capsule Extended-Release 12 Hour, 200mg Tablet Extended-Release 12 Hour, 400mg Tablet Extended-Release 12 Hour) Oxcarbazepine (Tablet) 3 Sodium Extended Phenytoin Sodium Extended (Capsule) 2 Antidementia Agents Cholinesterase Inhibitors HCl Donepezil HCl (Tablet Immediate-Release) 1 QL HCl ODT Donepezil HCl ODT (Tablet Dispersible) 2 QL Tartrate Rivastigmine Tartrate (Capsule Immediate- Release) 3 QL N-methyl-D-aspartate (NMDA) Receptor Antagonist Namenda (Tablet Immediate-Release) 4 PA, QL 2 3 Namenda (Oral Solution), Namenda XR (Capsule Extended- 3 PA, QL Release 24 Hour) Antidepressants Antidepressants, Other HCl Bupropion HCl (Tablet Immediate-Release), Bupropion HCl SR (Tablet Extended-Release 12 2 Hour), Bupropion HCl XL (Tablet Extended-Release 24 Hour) Mirtazapine (Tablet Immediate-Release), Mirtazapine ODT (Tablet Dispersible) 2 SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Brintellix (Tablet) 4 QL Hydrobromide Citalopram Hydrobromide (Tablet) Oxalate Escitalopram Oxalate (Tablet) Pristiq (Tablet Extended-Release 24 Hour) HCl Sertraline HCl (Tablet) 1 HCl Trazodone HCl (Tablet) 1 Tricyclics QL HCl Amitriptyline HCl (Tablet) 4 PA, HRM Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 23

22 Dapsone 5tRACK 5 16 Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits HCl Doxepin HCl (100mg Capsule, 10mg Capsule, 150mg Capsule, 25mg Capsule, 50mg Capsule, 4 PA, HRM 75mg Capsule, 10mg/ml Concentrate) HCl Nortriptyline HCl (10mg Capsule, 25mg Capsule, 50mg Capsule, 75mg 2 PA, HRM Capsule, 10mg/5ml Oral Solution) Antiemetics Antiemetics, Other HCl Metoclopramide HCl (Tablet) 1 Transderm-Scop (Patch 72 Hour) 4 Emetogenic Therapy Adjuncts Dronabinol (10mg Capsule) 5 PA, QL Dronabinol (2.5mg Capsule, 5mg Capsule) 4 PA, QL Ondansetron (Tablet Immediate-Release), Ondansetron ODT (Tablet 2 B/D, PA Dispersible) Antifungals Antifungals Fluconazole (Tablet) 2 Ketoconazole (2% Cream, 2% Shampoo, 200mg Tablet) Nystatin (Cream, Ointment, Oral Suspension, Topical Powder) Nystop (Powder) HCl Terbinafine HCl (Tablet) 2 Antigout Agents Antigout Agents Allopurinol (Tablet) 1 Colchicine (0.6mg Tablet) (Generic Colcrys) 3 QL Uloric (Tablet) 3 ST Antimigraine Agents Ergot Alkaloids Mesylate Dihydroergotamine Mesylate (Injection) Migergot (Suppository) 3 Serotonin (5-HT) 1b/1d Receptor Agonists Benzoate Rizatriptan Benzoate (Tablet Immediate- 3 QL Release) Benzoate ODT Rizatriptan Benzoate ODT (Tablet Dispersible) 4 QL Succinate Sumatriptan Succinate (Tablet) 3 QL Antimyasthenic Agents Parasympathomimetics Bromide Pyridostigmine Bromide (Tablet) 2 Antimycobacterials Antimycobacterials, Other Dapsone (Tablet) 3 Rifabutin (Capsule) 4 Antituberculars HCl Ethambutol HCl (Tablet) 3 Isoniazid (Tablet) 3 Rifampin (Capsule) 3 Antineoplastics 4 Bold type = Brand name drug Plain type = Generic drug 16 Page 24

23 Fareston Anastrozole 6tRACK 6 Last updated August 1, 2015 Drug Name Alkylating Agents Cyclophosphamide (Capsule) Drug Tier Leukeran (Tablet) 3 Antiandrogens Bicalutamide (Tablet) 2 Required Actions, Restrictions or Limits 4 B/D, PA Zytiga (Tablet) 5 PA, QL Antiangiogenic Agents Pomalyst (Capsule) 5 PA Revlimid (Capsule) 5 PA, LA Antiestrogens/Modifiers Fareston (Tablet) 5 Citrate Tamoxifen Citrate (Tablet) 2 Antimetabolites Hydroxyurea (Capsule) 2 Mercaptopurine (Tablet) 3 Antineoplastics, Other Carboplatin (Injection) 4 Calcium Leucovorin Calcium 3 (Tablet) Aromatase Inhibitors, 3rd Generation Anastrozole (Tablet) 1 Letrozole (Tablet) 2 Enzyme Inhibitors Etoposide (Injection) 3 HCl Topotecan HCl (Injection) 5 Molecular Target Inhibitors Gleevec (Tablet) 5 PA Tarceva (Tablet) 5 PA Tasigna (Capsule) 5 PA Monoclonal Antibodies Avastin (Injection) 5 PA Drug Name Drug Tier 17 Required Actions, Restrictions or Limits Rituxan (Injection) 5 PA Retinoids Targretin (75mg Capsule, 1% Gel) Tretinoin (Capsule) 5 Antiparasitics Anthelmintics Albenza (Tablet) 5 Ivermectin (Tablet) 3 Antiprotozoals HCl Atovaquone/Proguanil HCl (Tablet) (Generic 3 Malarone) Sulfate Hydroxychloroquine 2 Sulfate (Tablet) Pediculicides/Scabicides Lindane (1% Lotion, 1% 4 Shampoo) 5 PA Permethrin (Cream) 3 Antiparkinson Agents Anticholinergics Mesylate Benztropine Mesylate (Tablet) 2 PA, HRM HCl Trihexyphenidyl HCl (Elixir) 4 PA, HRM Antiparkinson Agents, Other HCl Amantadine HCl (100mg Capsule, 50mg/5ml 3 Syrup, 100mg Tablet) Entacapone (Tablet) 4 Dopamine Agonists Dihydrochloride Pramipexole Dihydrochloride (Tablet Immediate-Release) 3 Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 25

24 Carbidopa Azilect Valganciclovir Entecavir 7tRACK 7 18 Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits HCl Ropinirole HCl (Tablet 2 Immediate-Release) Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors Carbidopa (25mg Tablet) 5 Carbidopa/Levodopa (Tablet Immediate- Release), Carbidopa/ 1 Levodopa ER (Tablet Extended-Release) ODT Carbidopa/Levodopa 2 ODT (Tablet Dispersible) Monoamine Oxidase B (MAO-B) Inhibitors Azilect (Tablet) 3 HCl Selegiline HCl (5mg Capsule, 5mg Tablet) Antipsychotics 1st Generation/Typical HCl Fluphenazine HCl (Tablet) 2 Haloperidol (Tablet) 2 2nd Generation/Atypical Latuda (Tablet) 5 QL Olanzapine (Tablet Immediate-Release) Fumarate Quetiapine Fumarate (Tablet Immediate- Release) Risperidone (Tablet) 2 Saphris (Tablet Sublingual) XR Seroquel XR (Tablet Extended-Release 24 Hour) Treatment-Resistant Clozapine (Tablet Immediate-Release) 3 2 QL 2 QL 4 PA, QL 3 QL 3 ODT Clozapine ODT (Tablet Dispersible) 3 QL Versacloz (Suspension) 5 Antivirals Anti-cytomegalovirus (CMV) Agents Valganciclovir (Tablet) 5 Zirgan (Gel) 4 Anti-hepatitis B (HBV) Agents Entecavir (Tablet) 5 Lamivudine (Tablet) 3 Anti-hepatitis C (HCV) Agents Harvoni (Tablet) 5 PA, QL Pegasys (Injection) 5 PA Ribavirin (200mg Capsule) Ribavirin (200mg Tablet) 4 Sovaldi (Tablet) 5 PA, QL Antiherpetic Agents Acyclovir (Tablet) 1 HCl Valacyclovir HCl (Tablet) 3 QL Anti-HIV Agents, Integrase Inhibitors (INSTI) Isentress (Tablet) 5 QL Tivicay (Tablet) 5 QL Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) Atripla (Tablet) 5 QL Intelence (100mg Tablet, 200mg Tablet) 5 QL Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Epzicom (Tablet) 5 QL 3 Bold type = Brand name drug Plain type = Generic drug 18 Page 26

25 8tRACK 8 Last updated August 1, Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Truvada (Tablet) 5 QL Viread (Powder, Tablet) 5 QL Anti-HIV Agents, Other Fuzeon (Injection) 5 QL Selzentry (Tablet) 5 QL Anti-HIV Agents, Protease Inhibitors Norvir (100mg Capsule, 80mg/ml Oral Solution, 4 QL 100mg Tablet) Prezista (100mg/ml Suspension, 150mg Tablet, 600mg Tablet, 5 QL 800mg Tablet) Reyataz (150mg Capsule, 200mg Capsule, 300mg 5 QL Capsule, 50mg Packet) Anti-influenza Agents HCl Rimantadine HCl (Tablet) 3 Tamiflu (30mg Capsule, 45mg Capsule, 75mg Capsule, 6mg/ml Suspension) Antivirals Virazole (Inhalation Solution) Anxiolytics Anxiolytics, Other HCl Buspirone HCl (Tablet) 2 HCl Hydroxyzine HCl (10mg/ 5ml Oral Solution) Benzodiazepines Alprazolam (Tablet Immediate-Release) Clonazepam (Tablet Immediate-Release) 4 QL 5 4 PA, HRM 1 QL 2 QL ODT Clonazepam ODT (Tablet Dispersible) Diazepam (Tablet Immediate-Release), Diazepam Intensol (5mg/ ml Concentrate) Diazepam (1mg/ml Oral Solution) Lorazepam (Tablet Immediate-Release) Intensol Lorazepam Intensol (2mg/ml Concentrate) Bipolar Agents Mood Stabilizers Equetro (Capsule Extended-Release 12 Hour) Carbonate Lithium Carbonate (Capsule Immediate- Release, Tablet Immediate-Release), Lithium Carbonate ER (Tablet Extended-Release) Blood Glucose Regulators Antidiabetic Agents 4 QL 2 QL 2 1 QL 2 QL Bydureon (Injection) 3 QL Byetta (Injection) 4 QL Glimepiride (Tablet) 1 QL Glipizide (Tablet Immediate-Release), Glipizide ER (Tablet Extended-Release 24 Hour) HCl Glipizide/Metformin HCl (Tablet) QL 1 QL Invokamet (Tablet) 3 QL Invokana (Tablet) 3 QL Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 27

26 9tRACK 9 20 Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Janumet (Tablet Immediate-Release), Janumet XR (Tablet Extended-Release 24 Hour) 3 QL Januvia (Tablet) 3 QL Jardiance (Tablet) 3 QL Jentadueto (Tablet) 4 QL Kazano (Tablet) 4 QL XR Kombiglyze XR (Tablet Extended-Release 24 Hour) HCl Metformin HCl (Tablet Immediate-Release), Metformin HCl ER (500mg Tablet Extended- Release 24 Hour, 750mg Tablet Extended-Release 24 Hour) (Generic Glucophage XR), Metformin HCl ER (1000mg Tablet Extended-Release 24 Hour) (Generic Fortamet) 3 QL 1 QL Nesina (Tablet) 4 QL Onglyza (Tablet) 3 QL Oseni (Tablet) 4 QL HCl Pioglitazone HCl (Tablet) 1 QL HCl/Glimepiride Pioglitazone HCl/ Glimepiride (Tablet) HCl/Metformin HCl Pioglitazone HCl/ Metformin HCl (Tablet) 120 Symlinpen 120 (Injection) 60 Symlinpen 60 (Injection) 1 QL 1 QL 5 PA 4 PA Tradjenta (Tablet) 4 QL Trulicity (Injection) 3 QL Victoza (Injection) 3 QL Glycemic Agents Hypokit Glucagen Hypokit 4 (Injection) Emergency Kit Glucagon Emergency 3 Kit (Injection) Insulins Kwikpen Humalog Kwikpen (100unit/ml Injection), Humalog Mix 50/50 Kwikpen, Humalog Mix 75/25 Kwikpen, 3 Humalog Mix 50/50 Vial, Humalog Mix 75/25 Vial, Humalog Vial (Injection) 70/30 Kwikpen, N Kwikpen, 70/30 Vial, N Vial, R Vial Humulin 70/30 Kwikpen, Humulin N Kwikpen, Humulin 70/30 Vial, Humulin N Vial, Humulin R Vial 3 (Injection), Humulin R U-500 Vial (Concentrated Injection) Solostar Lantus Solostar (Injection), Lantus Vial 3 (Injection) FlexTouch Levemir FlexTouch (Injection), Levemir Vial 3 (Injection) Blood Products/Modifiers/Volume Expanders Anticoagulants Eliquis (Tablet) 3 PA, QL Pradaxa (Capsule) 3 PA, QL Sodium Warfarin Sodium (Tablet) 1 Bold type = Brand name drug Plain type = Generic drug 20 Page 28

27 Anagrelide HCl Atenolol 10 track 10 Last updated August 1, Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Xarelto (Tablet) 3 PA, QL Blood Formation Modifiers Anagrelide HCl (Capsule) 2 Procrit (10000unit/ml Injection, 2000unit/ml Injection, 3000unit/ml 4 PA Injection, 4000unit/ml Injection) Procrit (20000unit/ml Injection, 40000unit/ml Injection) 5 PA Blood Products/Modifiers/Volume Expanders Argatroban (Injection) 5 B/D, PA Coagulants Acid Tranexamic Acid (100mg/ml Injection, 3 650mg Tablet) Platelet Modifying Agents Aggrenox (Capsule Extended-Release 12 3 QL Hour) Cilostazol (Tablet) 2 Clopidogrel (75mg Tablet) 2 QL Cardiovascular Agents Alpha-adrenergic Agonists HCl Clonidine HCl (Tablet 1 Immediate-Release) Methyldopa (Tablet) 3 PA, HRM HCl Midodrine HCl (Tablet) 3 Alpha-adrenergic Blocking Agents Mesylate Doxazosin Mesylate 2 (Tablet) HCl Prazosin HCl (Capsule) 2 Angiotensin II Receptor Antagonists Benicar (Tablet) 3 QL Edarbi (Tablet) 4 QL Irbesartan (Tablet) 1 QL Potassium Losartan Potassium (Tablet) 1 QL Telmisartan (Tablet) 1 QL Valsartan (Tablet) 1 QL Angiotensin-converting Enzyme (ACE) Inhibitors HCl Benazepril HCl (Tablet) 1 QL Captopril (Tablet) 1 QL Maleate Enalapril Maleate (Tablet) 1 QL Lisinopril (Tablet) 1 QL HCl Quinapril HCl (Tablet) 1 QL Ramipril (Capsule) 1 QL Antiarrhythmics HCl Amiodarone HCl (200mg Tablet) Acetate Flecainide Acetate (Tablet) Multaq (Tablet) 3 QL HCl Sotalol HCl (Tablet), 2 Sotalol HCl AF (Tablet) Beta-adrenergic Blocking Agents Atenolol (Tablet) 1 Fumarate Bisoprolol Fumarate (Tablet) Bystolic (Tablet) 3 QL Carvedilol (Tablet) 1 HCl Labetalol HCl (Tablet) 2 Succinate ER Metoprolol Succinate ER (Tablet Extended-Release 24 Hour) Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 29

28 11 track Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Tartrate Metoprolol Tartrate (Tablet Immediate- 1 Release) HCl Propranolol HCl (Tablet Immediate-Release), Propranolol HCl ER 2 (Capsule Extended- Release 24 Hour) Calcium Channel Blocking Agents Besylate Amlodipine Besylate (Tablet) 1 HCl Diltiazem HCl (Tablet Immediate-Release) 2 HCl ER Diltiazem HCl ER (240mg Capsule Extended- Release, 300mg Capsule Extended-Release) (Generic Cardizem CD), 3 (360mg Capsule Extended-Release) (Generic Tiazac) HCl Verapamil HCl (Tablet Immediate-Release), Verapamil HCl ER (Tablet 2 Extended-Release) Cardiovascular Agents, Other Besylate/Benazepril HCl Amlodipine Besylate/ Benazepril HCl (Capsule) 1 QL Atenolol/Chlorthalidone (Tablet) 1 HCl/Hydrochlorothiazide Benazepril HCl/ Hydrochlorothiazide (Tablet) 1 QL HCT Benicar HCT (Tablet) 3 QL Fumarate/Hydrochlorothiazide Bisoprolol Fumarate/ Hydrochlorothiazide (Tablet) 3 QL Captopril/Hydrochlorothiazide Hydrochlorothiazide (Tablet) 1 QL Digoxin (125mcg Tablet) 2 QL, HRM Digoxin (250mcg Tablet) 2 PA, HRM Edarbyclor (Tablet) 4 QL Maleate/Hydrochlorothiazide Enalapril Maleate/ Hydrochlorothiazide (Tablet) Irbesartan/Hydrochlorothiazide Hydrochlorothiazide (Tablet) Lisinopril/Hydrochlorothiazide Hydrochlorothiazide (Tablet) Potassium/Hydrochlorothiazide Losartan Potassium/ Hydrochlorothiazide (Tablet) Quinapril/Hydrochlorothiazide Hydrochlorothiazide (Tablet) Ranexa (Tablet Extended-Release 12 Hour) Telmisartan/Hydrochlorothiazide Hydrochlorothiazide (Tablet) Triamterene/Hydrochlorothiazide Hydrochlorothiazide (37.5mg-25mg Capsule, 50mg-25mg Capsule, 37.5mg-25mg Tablet, 75mg-50mg Tablet) 1 QL 1 QL 1 QL 1 QL 1 QL 3 QL 1 QL Tribenzor (Tablet) 3 QL Valsartan/Hydrochlorothiazide Hydrochlorothiazide (Tablet) 1 QL Diuretics, Carbonic Anhydrase Inhibitors 2 Bold type = Brand name drug Plain type = Generic drug 22 Page 30

29 Eplerenone Hydralazine HCl 12 track 12 Last updated August 1, Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Acetazolamide (Tablet) 3 ER Acetazolamide ER (Capsule Extended- Release 12 Hour) Diuretics, Loop Bumetanide (Tablet) 1 Furosemide (Tablet) 1 Torsemide (Tablet) 2 Diuretics, Potassium-sparing Eplerenone (Tablet) 3 Spironolactone (Tablet) 2 Diuretics, Thiazide Chlorthalidone (Tablet) 2 Hydrochlorothiazide (12.5mg Capsule, 12.5mg Tablet, 25mg Tablet, 50mg Tablet) Metolazone (Tablet) 3 Dyslipidemics, Fibric Acid Derivatives Fenofibrate (145mg Tablet, 48mg Tablet) (Generic Tricor), (160mg 1 Tablet, 54mg Tablet) (Generic Lofibra) Gemfibrozil (Tablet) 2 Dyslipidemics, HMG CoA Reductase Inhibitors Calcium Atorvastatin Calcium (Tablet) 1 QL Crestor (Tablet) 3 QL Lovastatin (Tablet) 1 QL Sodium Pravastatin Sodium (Tablet) QL Simvastatin (Tablet) 1 QL Dyslipidemics, Other ER Niacin ER (Tablet Extended-Release) Ethyl Esters Omega-3-Acid Ethyl Esters (Capsule) (Generic Lovaza) 3 4 QL Vytorin (Tablet) 4 QL Welchol (3.75gm Packet, 625mg Tablet) Zetia (Tablet) 3 QL Vasodilators, Direct-acting Arterial Hydralazine HCl (Tablet) 2 Minoxidil (Tablet) 2 Vasodilators, Direct-acting Arterial/Venous Dinitrate Isosorbide Dinitrate (Tablet Immediate- Release), Isosorbide 2 Dinitrate ER (Tablet Extended-Release) Mononitrate Isosorbide Mononitrate (Tablet Immediate- Release), Isosorbide Mononitrate ER (Tablet 2 Extended-Release 24 Hour) Nitrostat (Tablet Sublingual) 3 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines Amphetamine/Dextroamphetamine Dextroamphetamine (Tablet Immediate- 3 QL Release) Amphetamine/Dextroamphetamine ER Dextroamphetamine ER (Capsule Extended- Release 24 Hour) 4 QL 3 Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 31

30 13 track Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits Sulfate Dextroamphetamine Sulfate (Tablet Immediate- Release), Dextroamphetamine Sulfate ER (Capsule Extended-Release) 4 QL Vyvanse (Capsule) 4 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines HCl Methylphenidate HCl (Tablet Immediate- Release) (Generic Ritalin) 3 QL Strattera (Capsule) 4 QL, ST Central Nervous System, Other Nuedexta (Capsule) 4 PA Riluzole (Tablet) 3 Fibromyalgia Agents HCl Duloxetine HCl (Capsule Delayed-Release) 3 QL Lyrica (Capsule) 3 QL Savella (Tablet) 3 Multiple Sclerosis Agents Aubagio (Tablet) 5 PA, QL Avonex (Injection) 5 PA Betaseron (Injection) 5 PA Copaxone (Injection) 5 PA Gilenya (Capsule) 5 PA, QL Rebif (Injection) 5 PA Tecfidera (Capsule Delayed-Release) Dental and Oral Agents Dental and Oral Agents Gluconate Oral Rinse Chlorhexidine Gluconate Oral Rinse (Solution) 5 PA, QL 2 Periogard (Solution) 2 HCl Pilocarpine HCl (Tablet) 3 in Orabase Triamcinolone in Orabase (Paste) Dermatological Agents Dermatological Agents Lactate Ammonium Lactate (12% Cream, 12% Lotion) Imiquimod (Cream) 4 Santyl (Ointment) 4 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers Creon (Capsule 3 Delayed-Release) Zenpep (Capsule 3 Delayed-Release) Gastrointestinal Agents Antispasmodics, Gastrointestinal HCl Dicyclomine HCl (10mg 2 Capsule, 20mg Tablet) Bromide Methscopolamine 4 Bromide (Tablet) Gastrointestinal Agents, Other Diphenoxylate/Atropine 4 (Tablet) HCl Loperamide HCl 2 (Capsule) Ursodiol (300mg Capsule, 250mg Tablet, 500mg 4 Tablet) Histamine2 (H2) Receptor Antagonists Cimetidine (Oral Solution, 2 Tablet) Famotidine (Tablet) 2 HCl Ranitidine HCl (Tablet) Bold type = Brand name drug Plain type = Generic drug 24 Page 32

31 14 track 14 Last updated August 1, 2015 Drug Name Drug Tier Irritable Bowel Syndrome Agents Required Actions, Restrictions or Limits Amitiza (Capsule) 3 QL Linzess (Capsule) 3 QL Laxatives Lactulose (Oral Solution) 2 Glycol 3350 Polyethylene Glycol 3350 (Powder) (Generic Miralax) Protectants Carafate (Suspension) 4 Sucralfate (Tablet) 2 Proton Pump Inhibitors Omeprazole (10mg Capsule Delayed-Release, 40mg Capsule Delayed- 2 QL Release) Omeprazole (20mg Capsule Delayed-Release) 2 Sodium Pantoprazole Sodium (Tablet Delayed-Release) 1 QL Genitourinary Agents Antispasmodics, Urinary Myrbetriq (Tablet Extended-Release 24 3 Hour) Chloride Oxybutynin Chloride (5mg/5ml Syrup, 5mg 2 Tablet) Chloride ER Oxybutynin Chloride ER (Tablet Extended-Release 24 Hour) 3 QL Vesicare (Tablet) 3 QL Benign Prostatic Hypertrophy Agents HCl ER Alfuzosin HCl ER (Tablet Extended-Release 24 2 Hour) 2 Drug Name Finasteride (5mg Tablet) (Generic Proscar) Drug Tier 1 25 Required Actions, Restrictions or Limits Rapaflo (Capsule) 3 QL HCl Tamsulosin HCl (Capsule) 1 HCl Terazosin HCl (Capsule) 2 Genitourinary Agents, Other Chloride Bethanechol Chloride 2 (Tablet) Elmiron (Capsule) 4 Phosphate Binders Acetate Calcium Acetate (Capsule) Renagel (Tablet) 3 ST Renvela (800mg Tablet) 3 Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) Dose Pack Methylprednisolone Dose 2 Pack (Tablet) Prednisone (Tablet) 1 Prednisone (5mg/5ml Oral Solution), Prednisone 2 Intensol (5mg/ml Concentrate) Acetonide Triamcinolone Acetonide (0.025% Cream, 0.1% Cream, 0.5% Cream, % Ointment, 0.1% Ointment, 0.5% Ointment) Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Acetate Desmopressin Acetate 3 (Tablet) 3 Formulary You can find information on what the symbols and abbreviations in this table mean by going to page Page 33

32 Lysodren Cabergoline 15 track Last updated August 1, 2015 Drug Name Drug Tier Required Actions, Restrictions or Limits Drug Name Drug Tier Required Actions, Restrictions or Limits AQ Nutropin AQ (Injection) 5 PA Hormonal Agents, Stimulant/Replacement/ Modifying (Prostaglandins) Hormonal Agents, Stimulant/ Replacement/Modifying (Prostaglandins) Korlym (Tablet) 5 PA, QL Hormonal Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers) Androgens Androderm (Patch 24 Hour) 3 PA, QL Androgel (1.62% Packet), Androgel 3 PA Pump (1.62% Gel) Cypionate Testosterone Cypionate (Injection) 4 Estrogens Estradiol (Tablet) (Generic Estrace) 3 PA, HRM Premarin (Vaginal Cream) 3 Progestins Acetate Medroxyprogesterone Acetate (Tablet) 2 Acetate Norethindrone Acetate (Tablet) 2 Progesterone (Capsule) 2 Selective Estrogen Receptor Modifying Agents HCl Raloxifene HCl (Tablet) 3 QL Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) Sodium Levothyroxine Sodium 1 (Tablet) Sodium Liothyronine Sodium (Tablet) Synthroid (Tablet) 3 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) Lysodren (Tablet) 5 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) Sensipar (30mg Tablet) 3 QL Sensipar (60mg Tablet, 90mg Tablet) 5 QL Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) Cabergoline (Tablet) 3 Depot Lupron Depot (Injection), Lupron Depot-PED (Injection) 5 PA Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents Methimazole (Tablet) 2 Propylthiouracil (Tablet) 2 Immunological Agents Angioedema (HAE) Agents Cinryze (Injection) 5 PA, LA Firazyr (Injection) 5 PA Immune Suppressants Azathioprine (Tablet) 2 B/D, PA Enbrel (Injection) 5 PA Humira (Injection) 5 PA Methotrexate (Tablet) 2 Immunizing Agents, Passive 2 Bold type = Brand name drug Plain type = Generic drug 26 Page 34