2015 Prescription Drug List. UnitedHealthcare & Affiliated Companies

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1 2015 Prescription Drug List UnitedHealthcare & Affiliated Companies

2 Table of Contents 2015 Prescription Drug List Introduction...3 Prescription Drug List Medication Overview....3 Tier Designations....3 Over-the-Counter and Therapeutically Equivalent Medications....4 Keys to Symbols...4 Generic Medication Policy....4 Specialty Medications....4 Medications Requiring Notification and Other Pharmacy Programs...5 How to Obtain Authorization...5 Chapters Anti-Infectives...7 Antineoplastic & Immunosuppressant Drugs Autonomic & CNS Drugs, Neurology & Psych Cardiovascular, Hypertension & Lipids Dermatologicals/Topical Therapy Ear, Nose & Throat Medications Endocrine/Diabetes Gastroenterology Immunology, Vaccines & Biotechnology Musculoskeletal & Inflammatory Obstetrics & Gynecology Ophthalmology Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes Diagnostics & Miscellaneous Agents Brand Only Exclusions...48 Index November 2014

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4 2015 Prescription Drug List Introduction The UnitedHealthcare Prescription Drug List (PDL) 1 provides a list of medications in various therapeutic classes for use in meeting the prescription medication needs of your patients who are our members. This list is intended for use with UnitedHealthcare health plans and affiliated companies pharmacy benefit plan designs. The PDL applies only to prescription medications dispensed to outpatients and does not include inpatient medications or medications obtained or administered in a physician s office. The PDL does not define benefit coverage. Benefit coverage is determined by the member s pharmacy benefit plan. 2 This means that there may be medications listed on the PDL that are not covered under a particular member s pharmacy benefit plan. You may also access PDL information by visiting our website at UnitedHealthcareOnline.com. Prescription Drug List Medication Overview Tier decisions are made by our PDL Management Committee based on clinical, economic, and other factors. The PDL Management Committee is comprised of senior UnitedHealth Group physician and business leaders. The UnitedHealth Group National Pharmacy & Therapeutics (P&T) Committee, comprised of physicians and pharmacists, reviews new and existing medications and provides clinical guidance to the PDL Management Committee. Guidance is based on similarities and differences compared with other medications that treat the same disease or condition. The Tier placement of a medication on the PDL may change. While medications change Tiers infrequently, such changes generally occur two times per calendar year. Additionally, when a brand-name medication becomes available as a generic, the Tier status of the brand-name medication and its corresponding generic will be evaluated. When a medication changes Tiers, your patient may be required to pay more or less for that medication. These changes may occur without prior notice to you or your patient. However, you may visit our website at UnitedHealthcareOnline.com for the most up-to-date information for a particular medication. And your patient can find the most up-to-date Tier status and cost* information for a particular medication by visiting our member website at myuhc.com and/or calling the toll-free member phone number located on his or her health care ID card. Tier Designations Prescription medications are categorized within three Tiers on the PDL. 3 Each Tier is assigned a cost,* which is determined by the member s pharmacy benefit plan. You may refer to the PDL as a guide to select the most appropriate medication with the lowest member cost for your patients. Your patient s Your patient s Your patient s lowest-cost midrange-cost highest-cost medications medications medications medications are your patient s lowest-cost option. Members can maximize their cost savings when you prescribe medications, if you decide they are appropriate for your patient s treatment. medications are your patient s midrange-cost option. Consider medications if no medication is appropriate to treat your patient s condition. medications are your patient s highest-cost option. If your patient is currently taking a medication in, you may want to determine if there is an appropriate alternative in or. You and your patient make decisions about health care and medication treatments. Note: If the member has a closed pharmacy benefit (a two-tier pharmacy benefit plan that does not cover medications classified in of this PDL), medications in Tier 3 are generally not covered, except under certain processes consistent with applicable law. Compounded medications, those medications containing one or more ingredients that are prepared onsite by a pharmacist, are classified at the level, provided that the individual ingredients used in compounding are covered under the pharmacy benefit. Note: Some members have a four-tier prescription plan and these are noted as T4 throughout the document. Members with a four-tier prescription plan should refer to their enrollment materials, check the Medication Pricing / Coverage information on our member website or call the toll-free member phone number provided on their health care ID card for more information about their benefit plan. Note: Not all medications are represented in this PDL. Only the most commonly prescribed medications are included. * UnitedHealthcare operates a wide number of benefit programs and products, and some benefit programs may have alternative benefit designs. Physicians should always check the member s specific benefit prior to prescribing medications. 3

5 Over-the-Counter and Therapeutically Equivalent Medications For some conditions, you and your patient may decide that an over-the-counter (OTC) medication is the most appropriate treatment. According to UnitedHealthcare benefit design, OTC medications are defined as medications that do not require a prescription by federal or state law to be dispensed. In some instances, OTC medications are listed on the PDL for reference purposes only. OTC medications may cost less than the member s out-of-pocket expense for prescription medications. Therapeutically equivalent means that medications can be expected to produce essentially the same therapeutic outcome and toxicity or adverse event. If the patient or physician requests a therapeutically equivalent product or an OTC product, the patient may be required to pay the entire cost of the product as they may not be covered under the member s pharmacy benefit. Please refer to the member s pharmacy benefit plan. Keys To Symbols Symbols Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ** Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. Generic Medication Policy While there are exceptions, generic medications are generally included on the PDL in. If a generic medication does not offer significant financial savings over the brand, it may be placed in the same Tier as the brand or in a higher Tier. Generic medications are noted in italics font. Note that when a brand-name medication becomes available as a generic, that brand-name product may move to a higher Tier. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. The member s payment is determined by the pharmacy benefit plan. When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approval from the prescribing physician or other health care professional to substitute the generic equivalent. Specialty Medications Some members may have coverage for self-administered injectable and oral specialty medications through their pharmacy benefit plan. You will find these medications included in the body of this document within the appropriate therapeutic categories. UnitedHealthcare has developed a Specialty Pharmacy Program including requiring the majority of specialty medications be obtained through a designated specialty pharmacy. These medications are noted by throughout the document. The specialty pharmacy program includes specialty pharmacies, each selected based on their clinical expertise for the targeted therapeutic classes, quality of services and cost. Their pharmacists are trained to help educate members and create personalized plans, if needed, for these specialty medications, which may help improve treatment adherence. Participating members should be instructed to call the toll-free member number on the back of their ID card where a representative will answer questions about our program and then transfer them to a specialty pharmacy based on their particular specialty medication prescription. * UnitedHealthcare operates a wide number of benefit programs and products, and some benefit programs may have alternative benefit designs. Physicians should always check the member s specific benefit prior to prescribing medications. 4

6 Medications Requiring Notification and Other Pharmacy Programs Selected medications may require prior authorization and review to be eligible for coverage under the member s pharmacy benefit plan. Such medications have a notation N in this booklet. Depending on your patients benefit and/ or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. The pharmacy benefit may exclude coverage of medications for certain uses. The medications requiring prior authorization are noted throughout the document with an N notation and the clinical criteria are available on our website at UnitedHealthcareOnline.com. The criteria reflect UnitedHealth Group National Pharmacy and Therapeutics Committee decisions. For a member to receive benefit coverage for a medication requiring notification, the physician or the physician s designee must provide information to the prior authorization department. Some benefit plans may include our Step Therapy program. Step Therapy offers a stepwise approach to therapy for certain high-cost medications and requires that a member first try a more cost-effective medication before another high-cost medication. Such medications have a notation ST (for Step Therapy). Supply limits define the maximum supply of medication per copayment or period of time. Supply limits are based on several factors that may include FDA-approved dosing guidelines as defined in the product package insert, medical literature, guidelines or supportive data. Such medications have a notation (for supply limit). The Refill and Save Program (also known as Adherence Incentive) encourages members to adhere to their treatment regimen by rewarding them with a discount on their copayment/coinsurance for refilling their prescription within the defined time period. Eligible medications have an RS notation (RS for Refill and Save). To receive pharmacy benefit coverage on some medications, a member is required to fill their prescription through a designated Mail Order Pharmacy or stay at retail with a lower- Tier alternative. Such medications have an SDP notation in this booklet. How to Obtain Authorization? The Online Prior Authorization tool (available through UnitedHealthCareOnline.com) is easy to use. The majority of online prior authorizations are approved in real time, and an auto-population feature provides 95 percent of a member s information. The OptumRx Prior Authorization team is also available by phone at Prior authorizations can also be submitted online by logging into > Healthcare Professionals > Prior Authorizations. 1 In certain documents the Prescription Drug List (PDL) was referred to as the Preferred Drug List (PDL). This change in descriptive terms does not affect your patient s benefit coverage. 2 Where differences are noted, the benefit plan documents will govern. 3 In certain documents was referred to as generics; was referred to as preferred brands or brand-name on the PDL; and was referred to as non-preferred brands, not on the PDL, or brand-name not on the PDL. These changes in descriptive terms do not affect your patient s benefit coverage. 5

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8 Anti-Infectives Penicillins Amoxicillin Trihydrate Capsule, Chewable Tablet, Suspension, Tablet (Amoxil) Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin Chewable Tablet, Tablet, Suspension) Dicloxacillin Sodium Capsule (Dynapen) Penicillin V Potassium (Pen-V K) Amoxicillin Clavulanate ER Tablet, Sustained-Release 12 Hour (Augmentin XR)*** Tetracyclines Doxycycline Hyclate Tablet 20 mg (Periostat) Doxycycline Monohydrate 50, 100 mg Capsule (Monodox) Minocycline HCl Capsule (Minocin) Doxycycline Hyclate 50, 75, 100, 150 mg (Morgidox, Vibra-Tabs, Vibramycin)** Adoxa Doxycycline Hyclate Tablet, Enteric-Coated (Doryx)*** Doxycycline Monohydrate 75 mg Capsule (Monodox)*** Doxycycline Monohydrate Capsule (Adoxa 150 mg)*** Oracea Minocycline HCl Tablet (Dynacin)*** Minocycline HCl Tablet, Extended-Release 24 Hour (Solodyn 45, 90, 135 mg)*** Solodyn Tetracycline HCl (Achromycin V)*** Vibramycin Suspension T4 T4 Cephalosporins FIRST GENERATION CEPHALOSPORINS Cefadroxil Hydrate (Duricef) Cephalexin Monohydrate (Keflex) SECOND GENERATION CEPHALOSPORINS Cefaclor (Ceclor, Ceclor CD) Cefpodoxime Tablet (Vantin) Cefprozil (Cefzil) Cefuroxime Axetil Suspension, Tablet (Ceftin) Ceftin Suspension THIRD GENERATION CEPHALOSPORINS Cefditoren Pivoxil (Spectracef) Cefdinir (Omnicef)** Cedax Suprax Tablet, Capsule, Suspension Erythromycins & Other Macrolides Azithromycin (Zithromax) Clarithromycin Tablet (Biaxin) Erythromycin Base Capsule, Delayed-Release (Eryc) Erythromycin Base Tablet, Enteric-Coated 250, 333 mg (E-Mycin, Ery-Tab) Erythromycin Ethylsuccinate (E.E.S.) Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) Clarithromycin Suspension (Biaxin)** Clarithromycin Sustained-Release Tablet (Biaxin XL)** PCE Zmax T4 Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 7

9 Anti-Infectives Quinolones Ciprofloxacin Tablet (Cipro) Levofloxacin (Levaquin Tablet, Solution) Ofloxacin (Floxin) Ciprofloxacin Oral Suspension (Cipro Suspension)** Ciprofloxacin Tablet, Sustained-Release 24 Hour (Cipro XR)*** Factive Moxifloxacin Tablet (Avelox)*** Noroxin Sulfas & Related Agents Sulfadiazine (Sulfadiazine) Sulfamethoxazole/Trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS) Urinary Tract Agents Methenamine Mandelate (Methenamine Mandelate) Nitrofurantoin Macrocrystal (Macrodantin 50, 100 mg) Nitrofurantoin Suspension, Oral (Furadantin) Nitrofurantoin/Nitrofurantoin Macrocrystal (Macrobid) Trimethoprim (Proloprim) Macrodantin 25 mg Monurol Primsol Antivirals MISCELLANEOUS ANTIVIRALS Acyclovir (Zovirax) Adefovir (Hepsera) Amantadine HCl (Symmetrel) Ganciclovir (Cytovene) Lamivudine (Epivir HBV) Ribavirin (Copegus) Ribavirin (Rebetol Capsules) Rimantadine HCl Tablet (Flumadine) Entecavir (Baraclude)** Famciclovir (Famvir)** Olysio Rebetol Solution Valacyclovir HCl (Valtrex)** Valcyte Relenza Ribapak*** Tamiflu Tyzeka N Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required**** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ****Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. 8

10 Anti-Infectives HIV/AIDS THERAPY Abacavir Sulfate Tablet (Ziagen) Abacavir/Lamivudine/Zidovudine (Trizivir) Didanosine Capsule, Enteric-Coated (Videx EC) Lamivudine Tablet (Epivir) Nevirapine (Viramune) Stavudine (Zerit) Zidovudine (Retrovir) Zidovudine/Lamivudine (Combivir) Aptivus Atripla Complera Crixivan Emtriva Edurant Epivir Epzicom Fuzeon Intelence Invirase Isentress Kaletra Lexiva Nevirapine Extended-Release (Viramune XR) Norvir Prezista Rescriptor Reyataz Selzentry N Sustiva Truvada N Viracept Viread Ziagen Stribild N Antifungal Agents Clotrimazole Troche (Mycelex) Fluconazole (Diflucan) Flucytosine (Ancobon) Griseofulvin Microsize (Grifulvin V) Griseofulvin Ultramicrosize (Gris-Peg) Itraconazole Capsule (Sporanox Capsule) Ketoconazole (Nizoral) Nystatin (Mycostatin) Terbinafine HCl Tablet (Lamisil) Voriconazole (Vfend) Noxafil Suspension Sporanox Solution, Oral Lamisil Granules Onmel Vancomycin Vancomycin HCl (Vancocin HCl) Miscellaneous Anti-infectives Clindamycin HCl (Cleocin HCl 150, 300 mg) Neomycin Sulfate (Neomycin Sulfate) Bethkis** Cayston Cleocin HCl 75 mg Clindamycin Palmitate HCl (Cleocin Palmitate)** Dapsone Zyvox Dificid Ketek Tobi Podhaler Tobramycin Nebulized Solution (Tobi)*** Xifaxan E T4 N N N E N T4 N Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 9

11 Anti-Infectives ANTIPARASITICS Atovaquone (Mepron) Metronidazole (Flagyl) Paromomycin Sulfate (Humatin) Albenza Alinia Biltricide NebuPent Stromectol Flagyl ER Tablet Tinidazole (Tindamax)*** ANTIMALARIALS Chloroquine Phosphate (Aralen Phosphate) Hydroxychloroquine Sulfate (Plaquenil) Mefloquine HCl (Lariam) Quinine Sulfate (Qualaquin) Atovaquone/Proguanil HCl (Malarone)** Coartem Daraprim Primaquine ANTIMYCOBACTERIALS Ethambutol HCl (Myambutol) Isoniazid (Isoniazid) Pyrazinamide (Pyrazinamide) Rifampin (Rifadin) Rifampin/Isoniazid (Rifamate) Priftin Rifater Situro N Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required**** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ****Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. 10

12 Antineoplastic & Immunosuppressant Drugs Antineoplastic & Immunosuppressant Drugs ALKYLATING AGENTS Cyclophosphamide (Cytoxan) Temozolamide (Temodar) Alkeran Leukeran Myleran ANTIMETABOLITES Capecitabine (Xeloda) Mercaptopurine (Purinethol) Methotrexate Sodium (Methotrexate) Rheumatrex, Trexall ANDROGENS, ESTROGENS, HORMONES & RELATED DRUGS ANDROGENS Oxandrolone (Oxandrin)** HORMONES Megestrol Acetate (Megace) Megestrol Acetate Suspension (Megace ES)*** ANTIESTROGENS Anastrozole (Arimidex) Letrozole (Femara) Tamoxifen (Nolvadex) Exemestane (Aromasin)** Fareston ANTIANDROGENS Bicalutamide (Casodex) Flutamide (Eulexin) Nilandron N IMMUNOSUPPRESSANT DRUGS Azathioprine (Imuran) Cyclosporine, Modified (Gengraf) Mycophenolate Mofetil Capsule, Tablet (CellCept) Sirolimus (Rapamune) Tacrolimus Anhydrous (Prograf) CellCept Mycophenolic Acid (Myfortic)** Astagraf XL Azasan Neoral T4 Sandimmune T4 MISCELLANEOUS ANTINEOPLASTIC DRUGS Etoposide (VePesid) Hydroxyurea (Hydrea) Leuprolide Acetate (Lupron 1 mg/0.2 ml) N Octreotide Acetate (Sandostatin) N Afinitor N Bosulif N ST Caprelsa N Cometriq N Droxia Emcyt Erivedge N Gleevec N Hexalen Hycamtin N Jakafi N Lysodren Matulane Mekinist N Nexavar N Revlimid N Stivarga N Sutent N Sylatron N Tafinlar N Tarceva N Tasigna N Thalomid N Tretinoin (Vesanoid)** Tykerb N Votrient N Xalkori N Zelboraf N Zolinza Zytiga N Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 11

13 Antineoplastic & Immunosuppressant Drugs Pomalyst Somatuline Depot Sprycel Xtandi Zykadia N N T4 N ST N ST N Adjunctive Agents Leucovorin Calcium (Leucovorin Calcium 5, 25 mg) Leucovorin Calcium 10, 15 mg (Leucovorin Calcium) Leukine Neupogen Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required**** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ****Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. 12

14 Autonomic & CNS Drugs, Neurology & Psych Narcotic Analgesics NARCOTICS Codeine Sulfate (Codeine Sulfate) Hydromorphone HCl (Dilaudid) Levorphanol Tartrate (Levo-Dromoran) Methadone HCl (Dolophine HCl) Meperidine HCl (Demerol) Morphine Sulfate Solution, Oral (MSIR 20 mg/ml, Roxanol) Morphine Sulfate Tablet, Sustained-Action (MS Contin) Oxycodone HCl (Roxicodone, OxyIR) Oxycodone HCl Concentrate, Oral (OxyFAST) Fentanyl Citrate Lollipop (Actiq)** Fentanyl Transdermal (Duragesic)** Opana ER OxyContin Oxymorphone Tablet (Opana)** Abstral Butrans Exalgo Fentora Hydromorphone Extended-Release Tablet (Exalgo)*** Lazanda Morphine Sulfate Capsule, Extended-Release (Avinza)*** Morphine Sulfate Capsule, Extended-Release Pellets (Kadian)*** Oxymorphone HCl Tablet, Sustained-Release 12 Hour (Opana ER)*** Subsys Zohydro ER N N N E N T4 ST T4 N T4 E N T4 N N N T4 E N T4 N N N T4 COMBINATION NARCOTIC /ANALGESICS Acetaminophen/Caffeine/Butalbital mg (Fioricet) Acetaminophen/Caffeine/Butalbital/Codeine mg Aspirin/Caffeine/Butalbital (Fiorinal) Aspirin/Caffeine/Dihydrocodone (Synalgos-DC) Codeine Phosphate/Acetaminophen (Tylenol w/codeine) Codeine Phosphate/Aspirin/Caffeine/ Butalbital (Fiorinal w/codeine 30 mg) Hydrocodone Bit/Acetaminophen (Norco) Ibuprofen/Hydrocodone (Vicoprofen) Oxycodone HCl/Acetaminophen Tablet (Percocet) Oxycodone HCl/Ibuprofen (Combunox) Oxycodone/Aspirin (Percodan) Hydrocodone Bit/Acetaminophen Solution, Oral (Hycet)** Codeine Phosphate/Acetaminophen/ Caffeine/Butalbital mg (Fioricet w/codeine)*** Hydrocodone/Acetaminophen (Xodol, Vicodin, Vicodin ES, Vicodin HP)*** E T4 Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 13

15 Autonomic & CNS Drugs, Neurology & Psych Non-Narcotic Analgesics MISCELLANEOUS ANALGESICS Pentazocine HCl/Naloxone HCl (Talwin NX) Tramadol HCl (Ultram) Tramadol HCl/Acetaminophen (Ultracet) Butorphanol Tartrate Aerosol, Spray (Stadol)** Tramadol HCl Tablet, Sustained-Release 24 Hour (Ultram ER)** Conzip E T4 Nucynta T4 Nucynta ER N T4 Tramadol HCl Tablet, Extended-Release Multiphase 24 Hour (Ryzolt)*** E T4 NARCOTIC ANTAGONISTS/OPIOID DEPENDENCE Buphrenorphine Hydrochloride (Subutex) N Naltrexone HCl (ReVia) Zubsolv** N Buphrenorphine HCl/Naloxone HCl Tablet, Sublingual (Suboxone)** E N T4 Suboxone Film E N T4 Migraine & Cluster Headache Therapy Dihydroergotamine Mesylate (D.H.E.45) Dihydroergotamine Mesylate Aerosol, Spray with Pump (Migranal) Isometheptene Mucate/Acetaminophen/ Dichloralphenazone (Midrin) Naratriptan HCl (Amerge) Sumatriptan Succinate Injection (Imitrex Injection) Sumatriptan Succinate Tablet (Imitrex Tablet) Ergomar Relpax Rizatriptan Benzoate Tablet (Maxalt)** Sumatriptan Succinate Nasal Spray (Imitrex Nasal Spray)** Alsuma Axert Cafergot Frova Rizatriptan Benzoate Tablet, Disintegrating (Maxalt MLT)*** Sumavel Dosepro Treximet Zolmitriptan (Zomig)*** Zolmitriptan Orally Disintegrating Tablet (Zomig-ZMT)*** Zomig Nasal Spray E T4 SDP SDP E T4 Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required**** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ****Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. 14

16 Autonomic & CNS Drugs, Neurology & Psych Antiparkinsonism Agents Amantadine HCl (Symmetrel) Benztropine Mesylate (Cogentin) Bromocriptine Mesylate (Parlodel) Carbidopa/Levodopa (Sinemet) Carbidopa/Levodopa/Entacapone (Stalevo) Carbidopa/Levodopa Tablet, Rapid Dissolve (Parcopa) Carbidopa/Levodopa Tablet, Sustained-Action (Sinemet CR) Entacapone (Comtan) Pramipexole Di-HCl (Mirapex) Ropinirole HCl (Requip) Selegiline HCl (Eldepryl) Trihexyphenidyl HCl (Artane) Apokyn Tasmar Azilect Mirapex ER Ropinirole HCl Tablet, Extended-Release 24 Hour (Requip XL)*** Zelapar Anticonvulsants Carbamazepine (Tegretol) Clonazepam (Klonopin) Diazepam, Rectal (Diastat Acudial) Divalproex Sodium Tablet (Depakote) Divalproex Sodium Tablet, Sustained-Release (Depakote ER) Ethosuximide (Zarontin) Felbamate (Felbatol) Gabapentin (Neurontin) Lamotrigine 5, 25 mg Chewable Tablet (Lamictal Chewable) Lamotrigine Tablet (Lamictal) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Phenobarbital (Phenobarbital) Phenytoin (Dilantin) Phenytoin Sodium Extended-Release (Dilantin, Phenytek) Primidone (Mysoline) Tiagabine HCl (Gabitril) Topiramate Capsule, Sprinkle (Topamax) Topiramate Tablet (Topamax) Valproic Acid (Depakene) Zonisamide (Zonegran) Carbamazepine Tablet, Sustained-Release 12 Hour (Tegretol XR)** Celontin Dilantin Divalproex Sodium (Depakote Sprinkle)** Levetiracetam Tablet, Extended-Release 24 Hour (Keppra XR)** Mysoline Peganone Sabril Tegretol Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 15

17 Autonomic & CNS Drugs, Neurology & Psych Banzel Carbamazepine Capsule, Extended-Release Multiphase 12 Hour (Carbatrol)*** Depakote Depakote ER Equetro Fycompa Keppra Keppra XR Lamictal Lamictal Dose Pack Lamictal ODT Lamictal XR Lamotrigine Orally Disintegrating Tablet (Lamictal ODT)*** Lamotrigine Tablet, Extended-Release 24 Hour (Lamictal XR)*** Lyrica Neurontin Onfi Oxtellar XR Potiga Stavzor Topamax Trileptal Trokendi XR Vimpat Zonegran N N ST T4 N ST T4 N N ST T4 N ST T4 N ST T4 N ST N ST T4 N ST T4 ST ST SDP T4 N ST T4 N E N ST T4 N N ST N ST T4 N ST T4 E N ST T4 N N ST T4 Miscellaneous Neurological Therapy Donepezil HCl Tablet (Aricept) Galantamine Capsule 24 Hour Sustained-Release Pellets (Razadyne ER) Galantamine Tablet, Solution (Razadyne) Nimodipine (Nimotop) Rivastigmine Tartrate Capsule (Exelon) Donepezil HCl Tablet, Rapid Dissolve (Aricept ODT)** Mytelase Nuedexta Donepezil 23 mg (Aricept 23 mg)*** Exelon Solution Gralise Horizant Namenda XR Savella E T4 E T4 T4 T4 Muscle Relaxants & Antispasmodic Therapy MYASTHENIA GRAVIS Pyridostigmine Bromide Tablet (Mestinon 60 mg) Mestinon Prostigmin Multiple Sclerosis Ampyra Avonex Betaseron Copaxone Tecfidera Aubagio Extavia Gilenya Rebif N N N N N N ST T4 E N ST T4 N ST N ST T4 Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required**** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ****Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. 16

18 Autonomic & CNS Drugs, Neurology & Psych Psychotherapeutic Drugs HYPNOTIC AGENTS Chloral Hydrate (Chloral Hydrate) Flurazepam HCl (Dalmane) Temazepam (Restoril) Triazolam (Halcion) Zaleplon (Sonata) Zolpidem Tartrate (Ambien) Edluar Eszopiclone (Lunesta)*** Intermezzo Rozerem Sonata Silenor Zolpidem Tartrate Tablet, Multiphasic-Release (Ambien CR)*** Zolpimist ANTIDEPRESSANT AGENTS TRICYCLICS Amitriptyline HCl (Elavil) Amoxapine (Asendin 50, 100 mg) Clomipramine HCl (Anafranil) Desipramine HCl (Norpramin) Doxepin HCl (Sinequan) Imipramine Pamoate (Tofranil-PM) Nortriptyline HCl (Pamelor) Protriptyline HCl (Vivactil) E ST T4 ST E ST T4 ST ST E T4 E ST T4 ST T4 MISCELLANEOUS ANTIDEPRESSANTS Bupropion HCl (Wellbutrin) Bupropion HCl Tablet, Sustained-Action (Wellbutrin SR) Bupropion HCl Tablet, Sustained-Release 24 Hour (Wellbutrin XL) Maprotiline HCl (Ludiomil) Mirtazapine (Remeron) Mirtazapine Dispersible Tablet (Remeron SolTab) Nefazodone HCl (Serzone) Trazodone HCl (Desyrel) Venlafaxine HCl Capsule, Sustained-Release 24 Hour (Effexor XR) Aplenzin E T4 Desvenlafaxine E T4 Duloxetine (Cymbalta)*** Forfivo XL E T4 Khedezla E T4 Oleptro ER E T4 Pristiq RS Venlafaxine HCl Tablet, Extended-Release 24 Hour (Venlafaxine HCl ER)*** E T4 Viibryd T4 MAO INHIBITORS Phenelzine Sulfate (Nardil) Tranylcypromine Sulfate (Parnate) Emsam Marplan Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 17

19 Autonomic & CNS Drugs, Neurology & Psych SELECTIVE SEROTONIN REUPTAKE INHIBITORS Citalopram Hydrobromide (Celexa) Escitalopram Tablet (Lexapro) Fluoxetine Capsule, Delayed-Release (Prozac Weekly) Fluoxetine HCl Capsule (Prozac) Fluoxetine HCl Tablet (Sarafem) Fluvoxamine Maleate (Luvox) Paroxetine HCl Tablet (Paxil) Sertraline HCl (Zoloft) Escitalopram Solution, Oral (Lexapro)*** Fluvoxamine Maleate Capsule, Extended-Release 24 Hour (Luvox CR)*** Paroxetine HCl Sustained-Release, 24 Hour (Paxil CR)*** Pexeva E T4 ANTIPSYCHOTICS PHENOTHIAZINES Chlorpromazine HCl Tablet (Thorazine 200 mg) Fluphenazine HCl (Prolixin) Perphenazine (Trilafon) Thioridazine HCl (Mellaril) Trifluoperazine HCl (Stelazine) BUTYROPHENONES Haloperidol (Haldol) Haloperidol Lactate Concentrate, Oral (Haldol) MISCELLANEOUS ANTIPSYCHOTICS Clozapine (Clozaril) Clozapine Orally Disintegrating Tablet (FazaClo) Olanzapine Tablet (Zyprexa) Risperidone Tablet, Rapid Dissolve (Risperdal M-Tab) Risperidone Solution (Risperdal) Risperidone Tablet (Risperdal) Thiothixene (Navane) Olanzapine/Fluoxetine (Symbyax)** Quetiapine Fumarate (Seroquel)** Ziprasidone (Geodon)** Abilify Fanapt Invega Latuda Olanzapine Tablet, Rapid Dissolve (Zyprexa Zydis)*** Saphris Seroquel XR T4 T4 T4 T4 T4 T4 Designated Specialty Program E May be excluded from coverage MC Multiple copay N Notification or Prior Authorization required**** RS May be eligible for the Refill and Save Program SDP Select Designated Pharmacy Supply limit ST Step Therapy T4 May be covered on Tier 4 in selected benefits ****Depending on your patients benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit. 18

20 Autonomic & CNS Drugs, Neurology & Psych MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine (Adderall) N Lithium Carbonate (Eskalith) Lithium Carbonate, Sustained-Action (Eskalith CR) Lithium Carbonate Tablet, Sustained-Action (Lithobid) Methamphetamine HCl (Desoxyn) N Methylphenidate HCl (Methylin Solution, Oral) N Methylphenidate HCl (Ritalin, Ritalin SR) N Methylphenidate HCl Tablet, Sustained-Action (Metadate ER) N Adderall XR** N Concerta** N Metadate CD** N Vyvanse N Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Capsule, Sustained-Release 24 Hour (Adderall XR) E N T4 Clonidine Extended-Release (Kapvay)*** D-Amphetamine Capsule, Extended-Release (Dexedrine)*** N D-Amphetamine Sulfate Tablet, Capsule, (Dexedrine)*** N Daytrana E N T4 Dexmethylphenidate Extended-Release (Focalin XR)*** E N T4 Intuniv E T4 Methylin Tablet, Chewable N Methylphenidate HCl Capsule, Extended-Release Multiphase (Ritalin LA)*** E N T4 Methylphenidate HCl Capsule, Extended-Release Multiphase (Metadate CD) E N T4 Methylphenidate HCl Tablet, Extended-Release 24 Hour (Concerta) E N T4 Modafinil (Provigil)*** E N T4 Nuvigil N T4 Quillivant XR E N T4 Strattera T4 Xyrem N T4 Zenzedi E N T4 ANXIOLYTICS Alprazolam (Xanax) Alprazolam Tablet, Rapid Dissolve (Niravam) Alprazolam Tablet, Sustained-Release 24 Hour (Xanax XR) Buspirone HCl (Buspar) Chlordiazepoxide HCl (Librium) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax) Please refer to page 4 for a definition of notations/symbols. * Products listed in may be covered in in a non-standard Prescription Drug List *** Products listed in may be covered in in a non-standard Prescription Drug List ** Products listed in may be covered in in a non-standard Prescription Drug List ^^ Products listed in may be covered in in a non-standard Prescription Drug List 19

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