Prescription Drug Program

Transcription

1 Prescription Drug Program Southern Health knows how important it is to provide you with dependable health care benefits that cover the prescription medications you and your family need. That is why Coventry Health Care has built a national network that features more than 58,000 pharmacies thoughout the country, including national chains and independent drug stores. You can view a directory of participating pharmacies using the Pharmacy Locator tool on our website, A list of pharmacies also is included in our Directory of Health Care Providers. Coventry Health Care has contracted with Caremark as our pharmacy vendor to offer the prescription drug program. This program offers: Coverage for certain over-the-counter (OTC) drugs. Southern Health members can obtain Prilosec OTC and loratadine (generic Claritin) for a generic copay when a prescription from a physician is submitted. Copayments that give you a choice of covered drugs The convenience and cost savings of mail order The ability to view prescription history, locate a retail pharmacy, and view mail order prescription status online A single sign-on link to the Caremark website for password-protected personal services. When you login to Southern Health s My Online Services and have previously registered on the Caremark site, you will be able to access your Caremark information without logging in again. Our Prescription Drug List Members enrolled in a plan with a prescription drug benefit have access to medications that are on Southern Health s Prescription Drug List. A Prescription Drug List is a list of approved medications covered by Southern Health. The Prescription Drug List includes a list of both brand name and generic medications. You also have access at a higher copayment to medically-necessary prescription drugs not listed on the Prescription Drug List. The 2006 Prescription Drug List, self-administered injectable drugs, preauthorization drugs, a list of drugs with quantity limits, and drugs with mail order exclusions are on the following pages. Preauthorization If PA is listed next to a drug on the Prescription Drug List, preauthorization is required. Your physician must receive preauthorization from Southern Health before you fill the prescription. If preauthorization is not received, your medication may not be covered. Southern Health is a registered trade name of Southern Health Services, Inc. and Coventry Health and Life Insurance Company. HMO and POS products are underwritten by Southern Health Services, Inc. PPO products are underwritten by Coventry Health and Life Insurance Company and administered by Southern Health Services, Inc. Members includes members of Coventry Health and Life Insurance Company administered by Southern Health.

2 Quantity Limits Some medications on the Prescription Drug List have restrictions on the quantity that Southern Health will cover. Preauthorization may be required if the dosage of the medication being prescribed varies from the FDA and manufacturer s recommended dose. Generic Drugs Southern Health s program requires mandatory generic substitution if the FDA has determined the generic to be equivalent to the brand product. We believe generic medications are as safe and effective as their brand name equivalents as determined by the FDA. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. Online Drug List Our online Prescription Drug List will provide you with important information such as generic and preferred drug alternatives, quantity limits, or preauthorization requirements. You also can access the mail order program. To use the online formulary, visit the Members section of and click on the link for Prescription Formulary on the right side of the page. Important points to remember when accessing your pharmacy benefits You must use your ID card or have your membership information available to fill a prescription. You may only file a claim for reimbursement for a prescription after it was purchased if it is a true emergency. Exceptions may be made if you have not yet received your ID card but need to fill a prescription. If PA is listed next to a drug, preauthorization is required. Retail prescriptions must be filled at a participating pharmacy or a nonparticipating pharmacy that has agreed to accept Southern Health s reimbursement rate as payment in full. You pay the appropriate copayment or the cost of the medication if it is less than the copayment. You also may have a retail maintenance benefit. Contact the Pharmacy Help Desk at for information regarding the retail maintenance benefit. If you take specific maintenance medications on a regular basis, you may be eligible to get your prescriptions filled through the mail order program. The mail order benefit allows up to a 90-day supply to be delivered directly to your home. Southern Health does not cover certain controlled substances through the mail order program. To find out about mail order coverage, please call Caremark at

3 Prescription Drug List With our prescription drug plan, you have three options when a doctor gives you a prescription: Preferred Generic (Tier One): includes most generic and a few selected OTC drugs. Preferred Brand (Tier Two): includes preferred brand name drugs with no generic equivalents and preferred brand with generic equivalents. Non-Preferred Drug (Tier Three): includes non-preferred brand name, and a few non-preferred generic drugs. These drugs may have a lower cost alternative on Tier One or Tier Two. Tier One: Preferred Generic A Acebutolol Acetazolamide Acetic acid ear drops Acetic acid-aluminum acetate Acetohexamide Acetylcysteine Acyclovir (not ointment) Albuterol AIlopurinol AIprazolam (not XR) AltoPrev Aluminum chloride Amantadine Amiloride Amiloride/HCTZ Amino acid - urea Aminocaproic acid Amiodarone Amitriptyline Amoxapine AmoxiciIIin Amoxicillin-pot clavulanate Amphetamine Ampicillin Amylase-lipase-protease Anagrelide Anthralin Apri Aranelle Aspirin/butalbital/caffeine Aspirin/caff/butalbital/codeine Atenolol Atenolol/chlorthalidone Atropine Aviane B Baclofen Benazepril Benazepril HCTZ Benzonatate Benztropine C Calcitriol Camila Captopril Captopril/HCTZ Carbamazepine Carbidopa/levodopa Carboptic Carisoprodol Carisoprodol/aspirin Cefaclor Cefadroxil Cefuroxime Cephalexin Cesia Chloral hydrate Chlordiazepoxide Chlordiazepoxide/clidinium Chloroquine Chlorothiazide Chlorphen/phenyleph/methscop Chlorpromazine (Spansule Tier Three) Chlorpropamide Chlorthalidone Cholestyramine Choline & magnesium Citalopram Citrate/citric acid Clarithromycin (not XL) Clemastine 2.68mg Clindamycin Clobetasol Clomipramine Clonazepam Clonidine Clorazepate (not SD) Clozapine Codeine Colchicine Cromolyn sodium Cryselle Cyclobenzaprine (not 5mg) Cyclopentolate Cyclophosphamide Cyclosporine Cyproheptadine D Danocrine Dantrolene Desipramine Desmopressin acetate Desonide Desoximetasone Dexamethasone Dexchlorpheniramine Dextroamphetamine Diazepam Diclofenac sodium (XR Tier Three) Dicloxacillin Dicyclomine Diethylstilbestrol Diflorasone diacetate Diflunisal Digoxin Diltiazem Diphenoxylate-atropine Dipivefrin Dipyridamole Disopyramide DisuIfiram Doxazosin mesylate Doxepin Doxycycline (Doryx, Monodox, Adoxa-Tier- Three) EnaIapriI Enalapril HCTZ Enpresse Epinephrine HCI ErgocaIciferol Errin Est estrogen/methyltest Estradiol Estropipate Ethosuximide Etodolac (XL Tier Three) Famotidine Felodipine Fenofibrate Fenoprofen Fentanyl patch Fexofenadine Flecainide Fluconazole Fludrocortisone acetate Fluocinolone (topical) Fluocinonide (topical) (PA) Preauthorization Required. limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information. E F Fluoride/polyvitamins for children Fluoride vitamins A,D,C for children Fluorometholone FIuorouraciI Fluoxetine (20mg tablet Tier Three) Fluphenazine Flurazepam Flurbiprofen Flurbiprofen sodium (ophth) Flutamide Fluvoxamine maleate Folic acid 1 mg Furosemide G Gabapentin Ganciclovir GemfibroziI Gentamicin Glimepiride Glipizide, XL Glyburide Guaifenesin/codeine Guanabenz acetate Guanfacine H Haloperidol HydraIazine Hydralazine/HCTZ Hydrochlorothiazide Hydrocodone/APAP Hydrocortisone enema Hydrocortisone tablets Hydromorphone HCI Hydroxychloroquine Hydroxyzine pamoate Hyoscyamine I Ibuprofen Imipramine Indapamide Indomethacin, SR (not suppos.) Ipratropium (not inhaler) Isoniazid Isosorbide dinitrate Isosorbide mononitrate

4 Tier One: Preferred Generic Isotretinion (PA) Itraconazole capsules (PA) J Jolivette Junel FE K Kariva Ketoconazole Ketoprofen (ER Tier Three) Ketorolac L Labetalol Lactulose Leena Lessina Levobunolol Levodopa/carbidopa Levora Levothyroxine Lidocaine viscous Lidocaine-prilocaine Lindane Liothyronine LisinopriI LisinopriI/HCTZ Lithium Loratadine OTC Lorazepam Lovastatin Loxapine Lutera M Maprotiline Mebendazole Meclofenamate Medroxyprogesterone (tab, inj.) Megestrol acetate Meperidine Mercaptopurine Mesalamine enema Metaproterenol Metformin, XR Methadone Methazolamide Methenamine Methimazole Methocarbamol Methotrexate (oral) Methyldopa Methyldopa/HCTZ Methylphenidate Methylprednisolone Metipranolol (ophth) Metoclopramide Metolazone Metoprolol Metronidazole Mexiletine Microgestin Fe Minoxidil (not soln) Mirtazapine Misoprostol MonaNessa Morphine MPH-A Muciprocin oint N Nabumetone Nadolol Naltrexone Naproxen Naproxen sodium Necon Nelova Neomycin Neomycin, bacitracin Nephazoline ophth Nifedipine XL Nitrofurantoin Nitroglycerin, all forms Nor-BE Norethindrone acetate Norgestrel-ethinyl estradiol Nortrel Nortriptyline Nystatin O Ofloxacin Omeprazole (see Prilosec OTC) Oxaprozin Oxazepam Ogestrel Oxybutynin (not XL) Oxycodone HCI (SR - PA) P Pancrelipase Papain-urea Penicillin VK Pentoxifylline Pergolide Permethrin Perphenazine Phenazopyridine Phenobarbital Phenytoin Physostigmine sulfate Pilocarpine (not Ocusert) Pindolol Piroxicam Podofilox solution Polyethylene glycol 3350 Portia Potassium chloride Pramoxine/HC Prazosin Prednisolone Prednisone Prenatal vitamins (prescription forms only) Prilosec OTC 20mg Requires Doctor s Prescription (Prilosec 10 mg Tier- Three (Prilosec 20 & 40mg Not Covered) Primidone Probenecid Prochlorperazine Promethazine Propafenone HCI Propantheline Propoxyphene Propoxyphene HCl/APAP Propoxyphene napsylate/apap Propranolol Propylthiouracil ProtriptylineT Q QuinapriI QuinapriI/HCTZ Quinidine Quinine sulfate R Ranitidine(Gel & efferdose Tier Three) Ribasphere (PA) Ribavirin (PA) Rifampin S Salsalate Selegiline Selenium sulfide 2.5% Silver sulfadiazine Sodium fluoride (drops, tablets) Sodium polystyrene sulfonate Sotolol Spironolactone Spironolactone/HCTZ Sprintec SucraIfate Sulfacetamide Sulfacetamide/phenylephrine Sulfacetamide prednisolone Sulfacetamide/sulfur Sulfamethoxazole/trimethoprim Sulfasalazine SuIfinpyrazone SuIfisoxazole Sulindac T Tamoxifen citrate Temazepam Terazosin Terbutaline sulfate Tetracycline Theophylline Thioridazine Thiothixene Ticlopidine Timolol Timolol maleate Tizanidine Tobramycin Tolazamide Tolbutamide Tolmetin Tramadol Trazodone Tretinoin Triamcinolone topical (cream, lot., oint.) Triamterene/HCTZ Triazolam Trifluoperazine Trifluridine Trihexyphenidyl Trimethobenzamide Trimethoprim Trimethoprim-polymyxinB Trinessa Triple sulfa TriPrevifem Tri-Sprintec Trivora U Ursodiol V Valproic acid Vancomycin (susp) Velivet Verapamil, SR (long acting) W Warfarin Z Zovia Tier Two: Preferred Brand with no generic equivalent A Accolate Aceon Actinex Actiq (PA) Actos (PA) Adrenalin Advair Advicor Agenerase (PA) Preauthorization Required. limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information.

5 Tier Two: Preferred Brand with no generic equivalent Aggrenox Aldara Alkeran Allegra D Alocril Alomide Amaryl Anakit Aricept Arimidex Aromasin Asacol Asmanex Astelin Atrovent Inhaler, HFA Avandamet (PA) Avandia (PA) Avelox Azelex Azopt B Bactroban Cream Benicar Benicar HCT Betimol Betoptic-S Biaxin XL Biltricide Blephamide Bromfed, PD, DM C CaIderol Capex Shampoo Capitrol Carbatrol Casodex Catapres TTS CeeNu CellCept Celontin Ciloxan Ciprodex Colestid Combivent Combivir Comtan Concerta Coreg Cortifoam Cotazym Cotazym-S Coumadin* Crixivan Cuprimine Cytadren D Dapsone Daranide Daraprim Depakote (ER Tier Three) Depen Derma-Smoothe/FS Diastat Dibenzyline Dilantin* Dostinex Dovonex Dritho-Scalp Dynacirc CR E Effexor, XR (PA) Elmiron Emcyt Emtriva Epifrin Epipen, Jr Epivir HBV (PA) Esclim Estrostep Eurax Evista Evoxac Exelderm F Famvir Fareston Femara Flonase Flovent, Rotadisk, HFA Fluoroplex Fortovase Fosamax Furoxone G Gleevec (PA) Grifulvin V Grisactin Ultra Gris-Peg H Hepsera (PA) Hexalen Hivid HMS Humalog (pens/cartridges - PA) Humulin (pens/cartridges - PA) Hytakerol I Imitrex InnoPran XL Insulin, only Lilly Brands Humulin, Humalog [Pens/ Cartridges (PA)] Invirase Iopidine K Kaletra KIaron Kytril L Lamisil (tabs only) PA Lanoxin* Lantus Leukeran Levothroid Lexapro Lexiva Lipitor Livostin Lofibra Lorabid (suspension only) Lotronex Lumigan Lysodren M Matulane Mavik Maxair Maxalt, MLT Mephyton Mepron Methergine MetroGel MetroLotion Miacalcin Nasal Spray Micardis Micardis HCT MigranaI Mirapex Mycelex Troche Mycobutin Myleran N Namenda Nardil Nasonex Nebupent Neo-Decadron Niaspan Nilandron Nimotop Nitrolingual Translingual Spray Nitrostat SL Norvir NuvaRing O Omnicef Ortho Evra Ortho-Tri-Cyclen LO Ovcon Oxsoralen, Ultra P Parnate PCE PhosLo Phospholine Iodide Pima Plavix Poly-Pred Precose Premarin Premphase Prempro Preven Prevpac Procanbid Prograf Prometrium Proscar Prostigmin Protonix Pulmicort Respules (only patients < 5 yrs) (PA) Pulmozyme Q Quixin QVAR R Rapamune Requip Rescriptor Retin A Micro Retrovir Reyataz Ridaura Rifamate RisperdaI Rowasa S Seasonale Sebizon Sensipar (PA) Serevent Seroquel Singulair (PA) Soriatane Spiriva Sporanox soln. (PA) SSKI Sular Sustiva Synarel (PA) Preauthorization Required. limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information.

6 Tier Two: Preferred Brand with No Generic T Tarceva (PA) Tazorac Tegretol Tegretol XR Temodar (PA) Teslac Testim (PA) Thalomid (PA) Theo-24 Theolair Thioguanine Tikosyn Tilade Tobi TobraDex Tonocard Toprol XL Torecan Tracleer (PA) Travatan Trisoralen Trizivir U Uniphyl Univasc Urispas Urocit K UroXatral V Valcyte VaItrex Ventolin Rotacaps Vesanoid Vexol Vfend (PA) Videx Videx EC Viokase Vira-A Viracept Viramune Vivelle Voltaren ophthalmic Vytorin X Xeloda (PA) Y Yasmin Yodoxin Z Zaditor Zerit Zelnorm (PA) Ziagen Zithromax (Zmax Tier Three) Zocor Zofran Zoloft Zyvox (PA) Tier 2: Preferred Tier 2: Preferred The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor. *Generic equivalent available at Tier One copay. A A/T/S* AccuNeb* Accupril* Accuretic* Accutane* (PA) Accuzyme* Actifed-C* Actigall* Adalat CC* Adderall* (XR Tier Three) Agrylin* Aldactazide* Aldactone * Aldomet* Aldoril* Alesse* Allegra* Alphagan* Alupent* Amicar* Amino-Cerv* Amoxil * Anafranil * Analpram HC* Anaprox, DS* Anaspaz* Android * Erythromycin albuterol Quinapril HCl Quinapril-HCTZ Isotretinoin Papain-Urea Pseudoeph-Triprolidine-Cod Ursodiol Nifedipine ER Amphetamine- Dextroamphetamine Anagrelide HCl Spironolactone-HCTZ Spironolactone Methyldopa Methyldopa-HCTZ Levonorgestrel-Ethinyl Estrad Fexofenadine Brimonidine Tartrate Metaproterenol Sulfate Aminocaproic Acid Amino Acid-Urea Amoxicillin Clomipramine HCl Hydrocortisone-pramoxine Naproxen Sodium Hyoscyamine Sulfate Methyltestosterone Ansaid* Antabuse* Anturane* Anusol-HC* Apresazide* Apresoline* Aralen* Arava* Artane* Atarax* Ativan* Atrovent Soln* Augmentin ES* Augmentin* Auralgan* Aventyl* Aygestin* B Bactrim, DS* Bactroban Oint.* Bentyl* Betagan* Betapace AF* Betoptic* Biaxin* Bicitra * BIeph10* Blocadren * Brethine* Bumex * Buspar* Flurbiprofen Disulfiram Sulfinpyrazone Hydrocortisone Hydralazine-HCTZ Hydralazine HCl Chloroquine Phosphate leflunovide Trihexyphenidyl HCl Hydroxyzine HCl Lorazepam Ipratropium Bromide Amoxicillin-Pot Clavulanate Amoxicillin-Pot Clavulanate Benzocaine-Antipyrine Nortriptyline HCl Norethindrone Acetate Sulfamethoxazole-Trimethoprim Mupirocin Dicyclomine HCl Levobunolol HCl Sotalol HCl AF Betaxolol HCl Clarithromycin Sod Citrate-Citric Acid Sulfacetamide Sodium Timolol Maleate Terbutaline Sulfate Bumetanide Buspirone HCl * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information.

7 Tier 2: Preferred Tier 2: Preferred C Cafergot* Calan*, SR* CaIciferol * Capoten * Capozide* Carafate* Cardizem*, SR*, CD* Cardura* Cartia XT* Catapres* Ceclor*, CD* Ceftin* Celexa* Cetamide* Cheracol* Cipro* (XR Tier Three) Cleocin, Vag, T* Climara * Clinoril* Clozaril* Cogentin* Colyte* Compazine* Condylox Gel, Soln* Cordarone* Corgard * Cortef* Cortenema* Cortisporin* Creon* Crolom * Cyclogyl* Cycrin* Cylert* Cystospaz* Cytomel* Cytotec* Cytovene* Cytoxan* D Dalmane* Danazol* Dantrium* Darvocet N100* Darvocet N50* Darvon * DDAVP* Decadron* Deconamine SR* Deltasone* Demerol* Ergotamine-Caffeine Verapamil HCl Ergocalciferol Captopril Captopril-HCTZ Sucralfate Diltiazem HCl, SR Doxazosin Mesylate Diltiazem HCl Coated Beads Clonidine HCl Cefaclor Cefuroxime Axetil Citalopram Hydrobromide Sulfacetamide sodium Codeine-Guaifenesin Ciprofloxacin HCl Clindamycin Estradiol Sulindac Clozapine Benztropine mesylate PEG 3350-KCl-NaBcb-NaCl- NaSulf Prochlorperazine Podofilox Amiodarone Nadolol Hydrocortisone Hydrocortisone Neomycin-Polymyxin-HC Pancrelipase Cromolyn Sodium Cyclopentolate HCl Medroxyprogesterone Acetate Pemoline Hyoscyamine Liothironine sodium Misoprostol Ganciclovir Cyclophosphamide Flurazepam HCl Danocrine Dantrolene Propoxyphene N-APAP Propoxyphene N-APAP Propoxyphene HCl Desmopressin Acetate Dexamethasone Chlorpheniramine-Pseudoeph Prednisone Meperidine HCl Demulen* Depakene* Desowen* Desyrel* Dexedrine* Diabeta* Diabinese* Diamox* Diflucan* Dilacor XR* Dilaudid* Diprolene*, AF Diprosone* Disalcid* Ditropan* (XL Tier Three) Diuril* Dolobid* Dolophine* Domeboro Otic* Donnatal (caps Tier Three)* Drysol* Duragesic* Duratap/PD* Duravent DA* Duricef* Dyazide* Dymelor* E EC-Naprosyn* Econopred, Plus* EES* Efudex* EIaviI* Eldepryl* Elimite* Elocon* Emla* Empirin 2, 3, 4* E-Mycin* Entex PSE* Eppy-N* Eryc* Ery-Derm* Erymax* Ery-Tab* Erythrocin* Eserine* Eskalith*, CR Estrace* Estraderm* Estratest, HS* Ethynodiol Diac-Eth Estradiol valproic acid Desonide Trazodone HCl Dextroamphetamine Sulfate Glyburide Chlorpropamide Acetazolamide Fluconazole Diltiazem HCl Hydromorphone HCl Aug Betamethasone Dipropionate Betamethasone Dipropionate Salsalate Oxybutynin Chloride Chlorothiazide Diflunisal Methadone HCl Acetic Acid-Aluminum Acetate Scopolamine/atropine/ phenobarb/hyoscyamine Aluminum Chloride Fentanyl Chlorpheniramine-Pseudoeph Chlorphen-Phenyleph-Methscop Cefadroxil Triamterene-HCTZ Acetohexamine Naproxen Prednisolone Acetate Erythromycin Ethylsuccinate Fluorouracil Amitriptyline HCl Selegiline HCl Permethrin Mometasone Furoate Lidocaine-Prilocaine Aspirin-codeine Erythromycin Pseudoephedrine-Guaifenesin Epinephryl Borate Erythromycin Base Erythromycin Erythromycin Erythromycin Erythromycin stearate Physostigmine Sulfate Lithium Carbonate Estradiol Estradiol Esterified estrogen/methyltest osterone * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. Please Note: This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. Brand names are listed for informational reference. Under some circumstances, preferred drugs may be excluded from your plan (for example, oral contraceptives). We periodically review our Prescription Drug List. This is the most current list at the time of printing and is subject to change. Some medications may require preauthorization or have quantity limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information.

8 Tier 2: Preferred Tier 2: Preferred Eulexin* Extendryl* F Feldene* Fenesin DM* Fioricet * Fiorinal w/codeine* Fiorinal* Flagyl* (ER Tier Three) Flexeril* (5mg Tier Three) Florinef* Floxin* FML, FML Forte, FML S* G Gantrisin* Garamycin* Genoptic* Glucophage*, XR* Glucotrol*, XL* Glynase* Golytely* Guiatuss AC* H Halcion* Haldol * Histussin D* Histussin HC* Humatin* Hycodan* Hycomine* Hycotuss* Hydrea* Hydrodiuril* Hygroton* Hytrin* I Flutamide Chlorphen-Phenyleph-Methscop Piroxicam Dextromethorphan-Guaifenesin Butalbital-APAP-Caffeine Butalbital-ASA-Caff-Codeine Butalbital-Aspirin-Caffeine Metronidazole Cyclobenzaprine HCl Fludrocortisone Acetate Ofloxacin Fluoromethalone Sulfisoxazole Gentamicin Sulfate Gentamicin Sulfate Metformin HCl Glipizide Glyburide Micronized Polyethylene Glycol Codeine-Guaifenesin Triazolam Haloperidol Pseudoeph-Hydrocodone Phenyleph-Chlorphen- Hydrocod Paromomycin Sulfate Hydrocodone-Homatropine Hydrocodone-pa Hydrocodone-Guaifenesin Hydroxyurea Hydrochlorothiazide Chlorthalidone Terazosin HCl Ilotycin* Erythromycin Imdur* Isosorbide Mononitrate Imuran* Azathioprine Inderal* (LA Tier Three) Propranolol HCl Indocin, SR* (suppositories Tier Three) Indomethacin Inflamase, Forte* Prednisolone Sodium Phosphate Intal * Cromolyn Sodium ISMO* Isosorbide Mononitrate Isoptin* Verapamil HCl Isopto Atropine* Atropine Sulfate Isopto Carbachol* Carbachol Isopto Carpine* Pilocarpine HCl Isordil* Isosorbide Dinitrate K Karidium * Kayexalate* K-Dur* Keflex* Kenalog* Klonopin* K-Lor* K-Lyte* K-Phos Neutral* KweIl* L Lasix* Lessina-28* Levoxyl * Levsin* Levsinex* Librax* Librium* Lidex* Lioresal* Lo/Ovral* Locoid* Lodine* (XL Tier Three) Loestrin* Lomotil* Loniten* Lopid * Lopressor* Lopressor HCT* Lotensin HCT* Lotensin* Lotrisone Cream* Loxitane* Lozol * Ludiomil* Luride* M Macrobid * Macrodantin * Mandelamine* Maxitrol * Maxzide* Meclomen* Medrol * Megace* MelIariI * Menest* Mestinon* Metadate ER* MetroCream Sodium Fluoride Sodium Polystyrene Sulfonate Potassium Chloride Crys CR Cephalexin Triamcinolone Acetonide Clonazepam Potassium Chloride Potassium Bicarbonate K Phos Di & Mono-Sod Phos Mono Lindane Furosemide Levonorgestrel-Ethinyl Estrad Levothyroxine Sodium Hyoscyamine Sulfate Hyoscyamine Sulfate Clidinium-Chlordiazepoxide Chlordiazepoxide HCl Fluocinonide Baclofen Norgestrel-Ethinyl Estradiol HC butyrate Etodolac Norethindrone Acet-Ethinyl Est Diphenoxylate-Atropine Minoxidil Gemfibrozil Metoprolol Tartrate Metoprolol/HCTZ Benazepril-HCTZ Benazepril HCl Clotrimazole-Betamethasone Loxapine Succinate Indapamide Maprotiline HCl Sodium Fluoride Nitrofurantoin Monohyd Macro Nitrofurantoin Macrocrystal Methenamine Mandelate Neomycin-Polymyxin-Dexameth Triamterene-HCTZ Meclofenamate Sodium Methylprednisolone Megestrol Acetate Thioridazine HCl Esterified Estrogens Pyridostigmine Bromide Methylphenidate HCl Metronidazole cream * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. limits. Please consult teh Pharmacy Help Desk for any questions about your coverage or for more information.

9 Tier 2: Preferred Tier 2: Preferred Mevacor* lovastatin Ortho-Tri-Cyclen* Norgestimate/ethinyl estradiol Mexitil* Mexiletine HCl Orudis* Ketoprofen Micronase* Glyburide Ovral* Norgestrel-Ethinyl Estradiol Microzide* Hydrochlorothiazide Oxycontin* (PA) Oxycodone HCl Midamor* Amiloride HCl OxyIR* Oxycodone HCl Midrin * APAP-Isometheptene-Dichloral Minipress* Prazosin HCl P MiraIax* Polyethylene Glycol 3350 Pamelor* Nortriptyline HCl Mircette* Desogestrel-Ethinyl Estradiol Pancrease* Pancrelipase Modicon* Norethindrone-Eth Estradiol Pancrease MT* Pancrelipase MT Moduretic* Amiloride-Hydrochlorothiazide Parlodel * Bromocriptine mesylate Motrin* Ibuprofen Paxil* (CR Tier Three, PA) paroxetine HCl MS Contin* Morphine Sulfate Pediazole* Erythromycin-Sulfisoxazole MSIR* Morphine Sulfate PENVK* Penicillin V Potassium Mucomyst* Acetylcysteine Pepcid* (RPD Tier Three) Famotidine Myambutol * Ethambutol HCl Percocet * Oxycodone-Acetaminophen Mycolog II* Nystatin-Triamcinolone Percodan* Oxycodone-Aspirin Mycostatin* Nystatin Periactin * Cyproheptadine HCl Mysoline* Primidone Permax* Pergolide Mesylate N Permitil* Fluphenazine HCl Persantine* Dipyridamole NaIfon* Fenoprofen Calcium Phenergan Codeine, DM, VC, & VC/ Promethazine-Codeine Naprosyn* (Naprelan Tier Three) Naproxen Phenergan * Promethazine HCl Natalins* Prenatal vitamin Pilocar* Pilocarpine HCl Navane* Thiothixene Plaquenil* Hydroxychloroquine Sulfate Neoral* (PA) Cyclosporine Modified Plendil* Felodipine Neosporin ophthalmic* Neomycin-Bacitracin Zn- PIetaI* Cilostazol Polymyx Polaramine* Dexchlorpheniramine Maleate Neptazane* Methazolamide Polyhistine CS, D, DM* Brompheniramine-codeine, pa, Neurontin* Gabapentin detromethorphan Nilstat* Nystatin Polysporin Ophth.* Bacitracin-Polymyxin B Nitrobid * Nitroglycerin Polytrim * Polymyxin B-Trimethoprim NitroDur* Nitroglycerin PoIy-Vi-FIor* Pediatric Multivitamins-Fl Nitrol* Nitroglycerin Pred G, Forte, & Mild* Prednisolone Acetate NizoraI * Ketoconazole Prelone* Prednisolone Nolvadex* Tamoxifen Citrate Prevalite* Cholestyramine Light Nordette* Levonorgestrel-Ethinyl Estrad Primaquine* Primaquine Phosphate Normodyne* Labetalol HCl Principen* Ampicillin Norpace*, CR* Disopyramide Phosphate Prinivil* Lisinopril Norpramin * Desipramine HCl Prinzide* Lisinopril-HCTZ NovahistineDH* Pseudoeph-Chlorphen-Codeine Pro Amatine* Midodrine HCl Nulytely* Polyethylene glycol Probanthine* Propantheline Bromide O Procardia XL* Nifedipine Proctocort* Hydrocortisone Ocufen* Flurbiprofen Sodium Proctocream-HC* Pramoxine-HC Ocuflox* Ofloxacin Proctofoam-HC* Pramoxine-HC Ogen* Estropipate Prolixin* Fluphenazine HCl Optipranolol* Metipranolol Pronestyl*, SR Procainamide HCl Orasone* Prednisone Propine* Dipivefrin HCl Orinase* Tolbutamide Proventil* Albuterol Sulfate Ortho Cept* Desogestrel/ethinyl estradiol Provera* Medroxyprogesterone Acetate Ortho Cyclen* Norgestimate/ethinyl estradiol Prozac* (20mg tablet & weekly Tier Fluoxetine HCl Ortho Est* Estropipate Psorcon* Diflorasone Diacetate Ortho Micronor* Norethindrone Psoriatec* Anthralin Ortho Novum* Norethindrone/ethinyl estradiol (PA) Preauthorization Required. * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information.

10 Tier 2: Preferred Tier 2: Preferred Q Questran, Light* Quinaglute* Quinidex* R Rebetol* (PA) RegIan* Remeron* (sol Tab Tier Three) RestoriI* Retin A* Revia* Rifadin* Rilutek* Ritalin, SR* RMS suppositories* Robaxin* Robitussin AC, DAC* Rocaltrol* Rondec, DM* Rynatan* Rythmol* (SR Tier Three) S Sandimmune* (PA) Sectral* Selsun* Septra & Septra DS* Serax* Silvadene* Sinemet, CR* Sinequan* SIow-K* Soma Compound* Soma* Sporanox capsules* (PA) Stelazine* Sulamyd* SuIfacet-R* Symmetrel* Synalar* Synthroid* T Tagamet* Tambocor* Tapazole* Tavist 2.68mg* Temovate* Tenex* Tenoretic* Tenormin* TessaIon Perles* Theodur* Cholestyramine Quinidine Gluconate Quinidine Sulfate Ribavirin Metoclopramide HCl Mirtazapine Temazepam Tretinoin Naltrexone HCl Rifampin Riluzole Methylphenidate HCl Morphine Sulfate Methocarbamol Guaifenesin-codeine, Pseu doephedrine-codeine-gg Calcitriol Pseudoeph-Carbinox-DM Chlorphen-Pyril-Phenyleph Propafenone HCl Cyclosporine Acebutolol HCl Selenium Sulfide Sulfamethoxazole-Trimethoprim Oxazepam Silver Sulfadiazine Carbidopa-Levodopa Doxepin HCl Potassium Chloride Carisoprodol-Aspirin Carisoprodol Itraconazole Trifluoperazine HCl Sulfacetamide Sulfacetamide Sodium-Sulfur Amantadine HCl Fluocinolone Acetonide Levothyroxine Sodium Cimetidine Flecainide Acetate Methimazole Clemastine Fumarate Clobetasol Propionate Guanfacine HCl Atenolol-Chlorthalidone Atenolol Benzonatate Theophylline Thorazine* Tiazac* Ticlid* Tigan* Timoptic*, XE* Tobrex* Tofranil* (PM Tier Three) Tolectin, DS* Tolinase* Topicort* Toradol * Trandate* Tranxene* (SD, T Tier Three) Trental* Triavil* Trilafon* Trilisate* Trimox* Trimpex* Tri-NorinyI* Tri-Vi-Flor* T-Stat* Tylenol 2, 3, 4* Tylox* Ultram* Univasc* Urecholine* Urised* Valisone* Valium* Vancocin* Vaseretic* Vasocidin* Vasosulf* Vasotec* VePesid* Vermox* Vibramycin* Vicodin, ES* Viroptic* Visken* Vistaril* Vivactil* Volmax* Voltaren* (XR Tier Three) Vosol, HC* Wellbutrin, SR* (XL Tier Three,PA) Chlorpromazine HCl Diltiazem HCl ER Ticlopidine HCl Trimethobenzamide HCl Timolol Maleate Tobramycin Sulfate Imipramine HCl Tolmetin Sodium Tolazamide Desoximetasone Ketorolac Labetalol HCl Clorazepate Dipotassium Pentoxifylline Perphenazine-Amitriptyline Perphenazine Choline & Mag Salicylates Amoxicillin Trimethoprim Norethin-Eth Estrad Triphasic Pediatric Vitamin ACD-Fl Erythromycin Acetaminophen-Codeine Oxycodone-Acetaminophen Tramadol HCl Moexipril HCl Bethanechol Chloride Methen-Bella-Meth Bl-Phen Sal Betamethasone Diazepam Vancomycin HCl Enalapril-Hydrochlorothiazide Sulfacetamide-Prednisolone Phenylephrine-sulfacetamide Enalapril Maleate Etoposide Mebendazole Doxycycline Hyclate Hydrocodone-Acetaminophen Trifluridine Pindolol Hydroxyzine Pamoate Protriptyline HCl Albuterol Diclofenac Sodium Acetic Acid, Hydrocortisone- Acetic Acid Bupropion HCl * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. limits. Please consult the Pharmacy Help Desk for any questions about your coverage or for more information. U V W (PA) Preauthorization Required.

11 Tier 2: Preferred Tier 2: Preferred Westcort* Wigraine* Wygesic* Wytensin* X Xanax* (XR Tier Three, PA) Xerac AC* Xylocaine* Hydrocortisone Ergotamine-Caffeine Propoxyphene-APAP Guanabenz Alprazolam Aluminum Chloride Lidocaine HCl Z Zanaflex* Zantac* (Gel caps & efferdose Tier Three) Zarontin* Zaroxolyn* Ziac* Zovirax* (oint. Tier Three) Zyloprim * Tizanidine HCl Ranitidine HCl Ethosuximide Metolazone Bisoprolol-HCTZ Acyclovir Allopurinol Tier Three: Non-Preferred Drugs One or Tier Two Drugs Tier Three: Non-Preferred Drugs One or Tier Two Drugs The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor. A Abilify Aciphex Aclovate* Activella Actonel ACTOplus met (PA) Acular Adderall XR Aerobid Altace Ambien Amerge Androderm (PA) Androgel (PA) Anzemet Arthrotec Atacand Atacand HCT Augmentin XR Avalide Avapro Avita Gel Axert Axid Azmacort B Baraclude (PA) Beclovent Beconase Benzaclin Benzamycin Byetta (PA) Clozaril* Risperdal, Seroquel Prilosec OTC TM *, Protonix Hydrocortisone*, Synalar*, Desowen* Prempro, Premphase Fosamax Actos (PA) plus Glucophage* Ocufen*, Voltaren Ophthalmic* Adderall*, Ritalin*, Concerta Flovent, QVAR, Asmanex Aceon, Univasc, Prinivil*, Lotensin*, Mavik, Vasotec*, Accupril* Ativan*, Halcion*, Serax*, Restoril* Maxalt or Imitrex Testim (PA) Testim (PA) Compazine*, Phenergan*, Tigan*, Zofran, Kytril Voltaren* plus Cytotec* Benicar, Micardis Benicar HCT, Micardis HCT Augmentin*, Augmentin ES* Benicar HCT, Micardis HCT Benicar, Micardis Retin A*, Retin A Micro Imitrex, Maxalt Pepcid*, Tagamet*, Zantac* QVAR, Asmanex, Flovent Hepsera (PA), Epivir HBV Flovent, QVAR, Asmanex Flonase, Nasonex, Nasalide* OTC Benzoyl Peroxide plus Topical Clindamycin* OTC Benzoyl Peroxide plus Topical Erythromycin Amaryl*, Diabeta*, Glucophage*, Glucotrol*, Micronase*, Tolinase* C Cardizem LA Cataflam* Cefzil Celebrex Cenestin Cialis Clarinex Colazal Copegus (PA) Cosopt Cozaar Crestor Cutivate Cymbalta (PA) D Demadex* Depakote ER Detrol/Detrol LA Differin Diovan Diovan HCT Dipentum Ditropan XL Doryx* E Elidel Exelon Cardizem CD* Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* Ceftin*, Ceclor* Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* Premarin, Ogen* Erectile dysfunction medications on Tier Three Generic over-the-counter Loratadine is covered with a physician s prescription. Azulfidine*, Asacol Ribasphere (PA) Timoptic* plus Azopt Benicar, Micardis Mevacor*, Zocor, Lipitor, Advicor, Vytorin, Altoprev* Valsione*, Kenalog*, Diprosone*, Topicort*, Synalar*, Locoid*, Westcort*, Elocon* Prozac*, Paxil*, Lexapro, Celexa*, Zoloft Lasix*, Bumex* Depakote Ditropan* Retin-A* Benicar, Micardis Benicar HCT, Micardis HCT Azulfidine*, Asacol Ditropan* Doxycycline* Valsione*, Kenalog*, Diprosone*, Topicort*, Synalar*, Locoid*, Wescort*, Elocon* Aricept, Namenda * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. (PA) Preauthorization Required. limits. Please consult with Pharmacy Help Desk for any questions about your coverage or for more information.

12 Tier Three: Non-Preferred Drugs One or Tier Two Drugs Tier Three: Non-Preferred Drugs One or Tier Two Drugs F FemHRT FemPatch Flomax Focalin Foradil Frova G Geodon Glucovance* H Helidac Hyzaar I Inderal LA Iressa (PA) L Lescol XL Levaquin Levitra Lodine XL* Loprox Lorabid Capsule Lotrel Lunesta (PA) M Metaglip Minocycline* Mobic Monodox* Monopril * N Naprelan* Nasacort Nexium Niravam (PA) Noroxin Norvasc Norgesic/ Norflex Novo Brand Insulins Prempro, Premphase Estraderm*, Vivelle* Cardura*, Hytrin*, Uroxatral Adderall*, Ritalin*, Concerta Serevent Maxalt, Imitrex Risperdal, Seroquel Glucophage* plus Glyburide* Prevpac Benicar HCT, Micardis HCT Innopran XL Tarceva (PA) Lipitor, Zocor, Mevacor *, Advicor, Vytorin, Altoprev* Cipro*, Avelox Erectile dysfunction medications on Tier Three Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* Nizoral* or Nystatin* Ceclor* Lotensin* plus Sular Restoril*, Serax*, Halcion* Glucophage* plus Glucotrol* Vibramycin*, Vibra-Tabs, Sumycin capsules Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* Doxycycline* Prinivil*, Lotensin*, Mavik, Vasotec*, Accupril*, Aceon, Univasc Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* Flonase, Nasonex, Nasalide* Prilosec OTC*, Protonix Xanax* Cipro*, Floxin*, Avelox Calan SR*, Cardizen CD*, Adalat CC, Procardia XL*, Sular, Dynacirc CR Flexeril*, Lioresal*, Robaxin*, Soma* Lilly Brand Insulins O Oruvail* Oxistat Oxytrol P Parafon Forte DSC* Patanol Paxil CR (PA) Prandin Pravachol Prefest Prevacid ODT Procardia* Capsules Protopic (PA) Provigil (PA) Prozac Weekly (PA) Pulmicort Turbuhaler R Ralivia ER (PA) Relpax Remeron Soltab* Reminyl Rescula Rhinocort Ritalin LA Rogaine S Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* Nizoral* or Nystatin* Ditropan* Flexeril*, Lioresal*, Robaxin*, Soma* Zaditor, Alocril, Alomide, Livostin Paxil*, Prozac*, Lexapro, Zoloft Diabeta*, Glucotrol*, Amaryl* Lipitor, Zocor, Mevacor*, Advicor, Vytorin, Altoprev* Prempro, Premphase Prilosec OTC*, Protonix Calan SR*, Cardizem CD*, Adalat CC*, Procardia XL* Hydorcortisone*, Betamethasone*, Triamcinolone*, Elocon*, Temovate*, Sinalar*, Topicort* Ritalin*, Dexedrine*, Adderall* Prozac Capsules* Flovent, QVAR, Asmanex Ultram* Maxalt, Imitrex Desyrel*, Prozac*, Ludiomil*, Lexapro, Remeron* Aricept, Namenda Lumigan, Travatan Flonase, Nasonex, Nasalide* Adderall*, Ritalin*, Concerta Benefit exclusion Salagen* Evoxac Sarafem Prozac Capsules* Serzone* Desyrel*, Prozac*, Lexapro, Paxil* Skelaxin Flexeril*, Lioresal*, Robaxin*, Soma* Sonata Halcion*, Serax*, Restoril* Spectazole* Nizoral* or Nystatin* Stadol NS* Tylenol with Codeine*, Darvocet-N 100*, Ultram* Starlix Diabeta*, Glucotrol*, Amaryl Striant (PA) Testim (PA) Strattera Ritalin*, Adderall*, Concerta Symbyax (PA) Prozac* plus Zyprexa (PA) Symlin (PA) Humulin, Humalog, Lantus T Tamiflu Tarka Tasmar Tequin Terazol* Amantadine* Mavik plus Verapamil* Comtan Cipro*, Avelox, Floxin* Diflucan* 150mg (one tablet) * Generic equivalent available at Tier One copay. If there is a generic equivalent available but you choose to use the brand drug, you will pay the applicable copayment plus the difference in cost between the generic and the brand. (PA) Preauthorization Required. limits. Please consult with Pharmacy Help Desk for any questions about your coverage or for more information.

13 Tier Three: Non-Preferred Drugs One or Tier Two Drugs Tier Three: Non-Preferred Drugs One or Tier Two Drugs Testoderm (PA) Teveten Teveten HCT Tofranil PM Trileptal Trusopt U Ultracet* (PA) Ultravate Uniretic V Vagifem Verelan* Viagra Vicoprofen* Voltaren XR* Testim (PA) Benicar, Micardis Benicar HCT, Micardis HCT Tofranil* Tegretol* Azopt Ultram plus Tylenol* Temovate*, Psorcon, Diprolene* Prinzide*, Vaseretic*, Accuretic*, Univasc+HCTZ, Lotensin HCT* Premarin Cream, Estrace Cream, Ogen Cream Calan SR*, Cardizem CD*, Adalat CC*, Procardia XL* Erectile dysfunction medications on Tier Three Vicodin* plus Ibuprofen* Clinoril*, Disalcid*, Motrin*, Naprosyn*, Orudis*, Voltaren* W Welchol Wellbutrin XL (PA) X Xalatan Xanax XR (PA) Xopenex Xyrem (PA) Z Zantac Gelcap and Efferdose Zelnorm (PA) ZMax Zetia Zomig Zovirax Ointment Zyban* Zyprexa (PA) Zyrtec Zyrtec D Questran*, Colestid Wellbutrin*, Wellbutrin SR* Lumigan, Travatan Xanax* Albuterol Inhaler*, Maxair Inhaler, Albuterol Nebulizer Solution* Adderall*, Ritalin* Zantac Tablet*, Pepcid*, Tagamet* MiraLax*, Chronulac*, Colyte* Zithromax Vytorin, Questran*, Niaspan, Colestid Maxalt, Imitrex Oral Zovirax* Benefit exclusion Risperdal, Seroquel Generic over-the-counter Loratadine is covered with a physician s prescription. Generic over-the-counter Loratadine is covered with a physician s prescription. Self-administered Injectable Drugs Self-administered injectable drugs require preauthorization and must be obtained through Southern Health s contracted specialty pharmacy. Orders are limited to one 31-day supply (or appropriate prescribing unit) per prescription filled and are subject to the applicable copayments, coinsurance, and/or deductibles described in your Schedule of Benefits or Pharmacy Rider. Tier One Heparin* Methotrexate* Tier Two Actimmune Apokyn Avonex Copaxone Enbrel Forteo Fragmin 1 Fuzeon Intron-A Leukine Lovenox 2 Neupogen Norditropin 3 Pegasys Procrit Sandostatin (LAR under medical) Tier Three with Tier Two Alternatives Arixtra 1 Fragmin 1, Lovenox 2 Betaseron Avonex, Copaxone Caverject Erectile Dysfunction Medications on 3rd tier D.H.E 45 Migranal, Imitrex, Maxalt Edex Erectile Dysfunction Medications on 3rd tier Epogen Procrit Humira Enbrel Infergen Pegasys Innohep 1 Fragmin 1, Lovenox 2 Kineret Enbrel Miacalcin Injection Miacalcin Nasal Spray Peg-Intron Pegasys Raptiva Enbrel Rebif Avonex, Copaxone Roferon A Intron-A Serostim No alternative available Somavert Sandostatin Zorbtive No alternative available * Generic available 1 Initial therapy of 5 doses will be covered to assure that therapy is not delayed while the preauthorization request is being reviewed. 2 Initial therapy of 10 doses will be covered to assure that therapy is not delayed while the preauthorization request is being reviewed. 3 Norditropin is the exclusive growth hormone. Genotropin, Humatrope, Nutropin AQ, Saizen, and Tev-tropin are not covered.

14 Preauthorization Drugs The following drugs require preauthorization in Preauthorization Agents ACTOplus met Rebetol (ribavirin)* Actiq (transmucosal fentanyl) Revatio (sildenafil) Accutane (isotretinoin)* Sproranox tablets and oral solution Actos (itraconazole)* Avandamet (rosiglitazone/metformin) Suboxone (Buprenorphine & Naloxone) Avandia (rosiglitazone) Symbyax (olanzapine/fluoxetine) Baraclude (entecavir) Symlin (pramlintide) Blood Glucose Monitors (Lifescan Preferred) Tarceva (erlotinib) Byetta (exenatide) Temodar (temozolomide) Copegus (Ribavirin is covered as a generic capsule) Testosterone Products (Testim, Androgel, Gleevec (imatinib) Striant, Androderm, Testoderm) Hepsera (adefovir) Thalomid (thalidomide) Insulin Pens (Novopen, Humulin Pen, etc.) Tracleer (bosentan) Iressa (gefitinib) Vfend (voriconazole) Lamisil Oral (terbinafine) Xeloda (capecitabine) Lunesta (eszopiclone) Xyrem (Sodium Oxybate) OxyContin (oxycodone sustained release) Zavesca (Miglustat) Provigil (Modafinil) Zelnorm (alosetron) Zyvox (linezolid) Stepped Therapy Drugs Stepped therapy is a form of preauthorization in which a therapeutic trial of specific drugs is required before authorization will be granted for other medications. If you have previously filled a prescription for a first-line drug required in the stepped therapy process (listed under Condition) and we have a record of that prescription, then the stepped therapy drug should process for the appropriate copayment. If we do not have a record of a required trial, then the stepped therapy drug will require preauthorization before you can receive coverage for that drug. Drug Cymbalta Effexor XR Niravam ODT (alprazolam IR) Paxil CR Protopic Ointment Prozac Weekly Pulmicort Respules Relivia Sensipar Singulair Symbyax Ultracet Wellbutrin XL Xanax XR Zyprexa *indicates generic form available Condition Trial & failure of an SSRI and a SNRI Trial & failure of a preferred SSRI Trial & failure of Xanax* Trial & failure of Paxil* Prior prescription for a medium to high potency topical steroid Trial & failure of Prozac* PA required between ages 5 & 8; not covered over the age of 8 Trial & failure of Ultram* Trial & failure Vitamin D analogs & Phoslo PA required for diagnosis other than asthma Combination of Zyprexa and Fluoxetine Trial & failure of Ultram* Trial & failure of Wellbutrin* or Wellbutrin SR* Trial & failure of Xanax* Prior prescription for a preferred atypical antipsychotic. Examples include Risperdal or Seroquel. Italics indicate non-preferred drug

15 Commercially Packaged Products The following list of products are commercially packaged and require one applicable copay per unit: Inhaled Products: Advair, Albuterol, Beconase, Combivent, Flovent, Intal, Maxair, Metaprel, Pulmicort, Serevent, Vancenase, Xopenex, etc. Tubes: Retin-A, Zovirax ointment, Hydrocortisone, Protopic 60g, Avita 20g, etc. Oral Contraceptives: Ortho-Cyclen, Ortho-Novum, Ortho-Cept, Modicon, Estrostep, Alesse, Zovia, etc. Patches: Ortho-Evra, Duragesic, Catapres, Estrogen, Oxytrol, Androderm, etc. Misc: Miralax Nasal Sprays: Rhinocort, Flonase, Nasonex, Imitrex spray, Stadol NS, Zomig, etc. Vials: Imitrex vials, Zofran solution, Kytril solution, etc. Note: Insulin vials are excluded from this limitation. Quantity Limitations per Fill Drug Name Actonel 35mg Aerochamber Ambien Amerge 1mg/2.5mg Ana-Kit Axert Anzemet Biaxin XL Blood Glucose Monitor Celexa 10mg Celebrex 200gm/400mg Cialis Cipro XR, 500mg/1000mg Diastat Elidel Cream Epi-pen Emend/Emend Tripack Estrogel Famvir Fosamax 35mg/70mg Fosamax solution Frova 2.5mg Glucagon Emergency Kit Imitrex tabs Imitrex pre-filled syr. Ketorolac Kytril 1mg Levitra Lexapro 10mg Lovenox Prescription Quantity Limits Quantity Limit 4 tabs/month 1 per year 30 tabs/fill 9 tabs/fill 2 injections/fill 6 tabs/fill 10 tabs/fill 28 tabs/fill 1 per year 45 tabs/month 60 caps/month 4 tabs/month 3/14 tabs/fill 1 pack (2 supp)/fill 30 gms/fill 2 injections/fill 3 tabs/1 pack/fill 93 grams/60 days 21 tabs/fill 4 tabs/month 300ml/month 9 tabs/fill 1kit/fill 9 tabs/fill 2 boxes/fill 20 tabs/fill 10 tabs/fill 4 tabs/month 45 tabs/month 10 vials/10 days Drug Name Maxalt/ MLT Metadate CD 20mg Metadate ER Monopril 20mg MUSE Namenda Titration Pack Namenda 5mg, 10mg Peak Flow Meter Prevacid Naprapac 84 units Provigil 200mg Prozac 90mg Pulmicort Respules Pulmozyme Rebetol solution Relpax Reyataz Rythmol SR 225mg Sonata Striant Suboxone 2mg Suboxone 8mg Sular 30mg Tobi Toradol Valtrex 500mg/1gm Viagra Xopenex Zithromax 250mg/500mg /600mg/Susp Zofran 4mg, 8mg, 24mg Zomig 2.5mg/5mg Quantity Limit 6 tabs/fill 60 tabs/month 90 tabs/month 60 tabs/month 6 pellets/month 1 pack/fill 60 tabs/month 1 per year 1 pack/month 60 tabs/month 4 caps/month 60 units/month 30 units/month 500ml/month 6 tabs/fill 60 caps/month 60 caps/month 30 caps/fill 60 tabs/month 90 tabs/month 60 tabs/month 60 tabs/month 60 units/month 20 tabs/fill 42/21 tabs/fill 4 tabs/month 24 units/month 6/3/8/1 bottle/fill 15/1 tabs/fill 6/3 tabs/fill Note: Each fill requires an applicable copay or coinsurance Italics indicate non-preferred Viagra, Levitra, and Cialis are limited to 4 pills per 30 days PLEASE NOTE: This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed above are covered. This is the most current list at the time of printing and is subject to change.

16 Mail Order Program Exclusions Maintenance medications are available through mail order. Maintenance medications are those drugs that are needed for long-term or chronic conditions such as high blood pressure or diabetes. Some of the drugs that are excluded from mail order are listed below and include non-maintenance medications, all controlled substances, and self-administered injectables. This list is not complete and includes examples only. Please contact the Pharmacy Help Desk at for specific questions on medications not included in the list. Migraine Relief Drugs Examples include Amerge, Axert, Cafergot, D.H.E 45, Ergotamine, Frova, Imitrex, Maxalt, Maxalt MLT, Midrin, Migral, Migranal, Relpax, Sansert, Zomig, and Zomig ZMT Antibiotics Examples include Keflex, Duricef, Ceclor, Lorabid, Ceftin, Omnicef, Erythromycin, Pediazole, Zithromax, Biaxin, Amoxil, Trimox, Principen, Dynapen, Pen Vee K, Veetids, Augmentin, and Zyvox Antifungals Examples include Diflucan, Griseofulvin, Lamisil, Nizoral, Nystatin, Sporanox, and Vfend Antiemetics Examples include Anzemet, Emend, Kytril, and Zofran Controlled Substances All controlled substances are excluded from mail order. Examples include drugs in the following classes: Opioids - Oxycontin, MsContin, Percocet, Vicodin, Darvocet CNS depressants - Valium, Ativan, Xanax, Ambien CNS stimulants - Concerta, Adderall, Ritalin, Provigil Cannabinoids - Marinol Anabolic steroids - Androgel, Testim, Androderm Miscellaneous Agents Drugs prohibited from being dispensed in large quantities (Xyrem, Clozaril, and Accutane) Ana-Kit, Epipen, Epipen-JR Copegus and Rebetol Gleevec MUSE Temodar Thalomid Toradol (and generic) Tracleer Valcyte Valtrex (all strengths) Viagra, Cialis, Levitra Spacers for inhalers Zelnorm Glucagon Emergency Kit Diaphragms Lotronex This brochure refers to form numbers SHS.3TRx.1-06, CHL.3TRXPPO.HDHP.1-06 and CHL.3TRxPPO This document provides a general overview of the types of products and services offered by Southern Health. This is not a coverage document. Members or prospective members are encouraged to refer to the plan documents for details on benefits and any corresponding limitations and exclusions. SH.PharmPrg.06 (10-05)