HEALTH INSURANCE MARKETPLACE INDIVIDUAL FORMULARY

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1 HEALTH INSURANCE MARKETPLACE INDIVIDUAL FORMULARY Effective September 2014 Provided by Catamaran Introduction The Total Health Care (THC) Health Insurance Marketplace Individual Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of costeffective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC & Catamaran, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. How to Read the Formulary All drugs are listed first by their generic names (in lowercase) in each category. The preferred brand name drugs are listed next, and non-preferred brand drugs are listed last. Brand name drugs (preferred and nonpreferred) are displayed in proper name form (first letter of the name capitalized). Specific drug listings may be accessed by using the index, by using the generic name or brand name and by therapeutic drug category (in uppercase white letters). Any drug not found in this Formulary listing, or any Formulary updates published by Total Health Care, shall be considered a non-formulary drug. i

2 Tier Guidelines Generic Tier 1 Preferred Tier 2 Brand Non-Preferred Tier 3 Brand and Non- Preferred Generic Specialty Tier 4 Preventive $0 co-pay at in-network pharmacies Medical Benefit Benefit may be available under medical coverage. The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, coinsurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization (PA) Quantity Limit (QL) Step Therapy (ST) Age Limitation (AL) Gender Edit (GE) Over the Counter (OTC) Specialty Requires prior authorization through a specific physician request process. Coverage may be limited to specific quantities per prescription &/or time period. Coverage requires that an alternative or trial of another drug be used before the medication is covered. Coverage may depend on patient age. Coverage may depend on patient gender. Coverage is available for drugs that are available OTC with an authorized prescription from your provider. Requires that the drug be processed using THC s contracted specialty pharmacy CVS/Caremark. Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand-name drugs and their generic alternatives, which are preferred by the plan. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the Total Health Care Health Insurance Marketplace Individual Formulary. Members should contact Total Health Care at if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. ii

3 Preventive Medications Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network providers. These drugs are indicated on the THC Health Insurance Marketplace Individual Formulary under the Preventive Tier. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. Medical Benefit Drugs indicated on the THC Health Insurance Marketplace Individual Formulary under the Medical Benefit Tier are not available for coverage as a pharmacy benefit. Please refer to the Certificate of Coverage to determine if drugs listed as a Medical Benefit on the formulary are covered through the Medical Benefit. Prior Authorization (PA) Drugs indicated with a PA require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care and Catamaran websites at or https://www.catalystrx.com/www/public/physicianlogin.jsp. You may also request a form by calling Catamaran Member Services Department at or Total Health Care at Completed prior authorization forms should be faxed to Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC s website has a contact link where members can contact THC s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not located on the Total Health Care Health Insurance Marketplace Individual Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to: OTC medications or their equivalents unless otherwise specified in the Formulary listing. Drug products used for cosmetic purposes Drug products for infertility treatment Experimental drug products, or any drug product used in an experimental manner Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA) iii

4 Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as generic wherever an FDA-approved generic drug product is available. If a member or physician requests a brandname product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic drug, plus the brand copay. Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care s Pharmacy & Therapeutic Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC s drug criteria by calling the Pharmacy Department at Diabetic Testing Supplies Total Health Care works exclusively with Healthy Living Pharmacy to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Advocate Redi-Code glucometer, Advocate test strips, Advocate lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through Healthy Living Pharmacy. If you have any questions about our diabetic supply program, please contact Healthy Living Pharmacy at Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with CVS/Caremark Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through CVS/Caremark Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to Catamaran at with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care and Catamaran websites at or https://www.catalystrx.com/www/public/physicianlogin.jsp. Once the order is received, Catamaran obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies CVS/Caremark. Then the CVS/Caremark staff ships the medication directly to the physician's office or the patient s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty iv

5 Bio-Pharmaceutical Pharmacy program, please contact Catamaran at or CVS/Caremark at Medication Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction; quantity/day supply limitation, and/or a limitation on the duration of therapy. In most instances topical steroids are limited to the two largest commercially available tubes per month, with some products limited to one package size per month. Quantity Limitations Drug Label Name Quantity Limit ABACAVIR TAB 300MG Max Daily Dose of 2 ADVAIR DISKUS 1 inhaler per month ADVAIR HFA Max Daily Dose of 2; 1 inhaler per month ADVOCATE LANCETS 100 per month ADVOCATE STRIPS 100 per month ALCOHOL SWABS 100 per month ALENDRONATE TAB 70MG 4 tabs per 28 days ALTAVERA TAB Max Daily Dose of 1 ALVESCO AER Max of 2 inhalers per month ALYACEN TAB 1/35 Max Daily Dose of 1 ALYACEN TAB 7/7/7 Max Daily Dose of 1 AMLODIPINE TAB Max Daily Dose of 1 AMOX/K CLAV TAB Limit to 28 tablets per 14 days AMPHETAMINE CAP ER Max Daily Dose of 1 ANORO ELIPTA Limited to 1 inhaler per month APEXICON E CRE 0.05% 120gm per month APRI TAB Max Daily Dose of 1 APTIVUS CAP 250MG Max Daily Dose of 4 APTIVUS SOL Max Daily Dose of 10ml per day ARCAPTA CAP 75MCG Max Daily Dose of 1 ASMANEX 2 inhalers per month ASPIRIN 81MG Max Daily Dose of 2; Covered for ages ASPIRIN TAB 325MG Max Daily Dose of 1; Covered for ages ASPIRIN TAB 325MG EC Max Daily Dose of 1; Covered for ages v

6 ATORVASTATIN TAB Max Daily Dose of 1 ATOVAQ/PROGU TAB Max Daily Dose of 1 ATRIPLA TAB Max Daily Dose of 1 ATROVENT HFA AER 17MCG AUG BETAMET CRE 0.05% AUG BETAMET GEL 0.05% AUG BETAMET LOT 0.05% 26gm per month (2 inhalers per month) 100gm per month 100gm per month 120ml per month AUG BETAMET OIN 0.05% AVIANE TAB; FALMINA; LESSINA; LUTERA; ORSYTHIA; SRONYX 100gm per month Max Daily Dose of 1; female only AZITHROMYCIN POW 1GM PAK Max Daily Dose of 1 AZITHROMYCIN TAB 250MG Max Daily Dose of 4 AZITHROMYCIN TAB 500MG & 600 Max Daily Dose of 2 BETAMETH DIP CRE 0.05% BETAMETH DIP LOT 0.05% BETAMETH DIP OIN 0.05% BETAMETH VAL CRE 0.1% BETAMETH VAL LOT 0.1% BETAMETH VAL OIN 0.1% 90gm per month 120ml per month 90gm per month 90gm per month 120ml per month 90gm per month BEYAZ TAB Max Daily Dose of 1 BREO ELIPTA BRONCHO SAL AER 0.9% Limited to 1 inhaler per month 180ml per month BUDEPRION TAB SR Max Daily Dose of 2; 90 days per 365 days 60 vials/120ml per month; Covered for members up to age BUDESONIDE SUS 8 BYDUREON INJ 4 injections per month CAMILA TAB 0.35MG Max Daily Dose of 1 CAPEX SHA 0.01% 120ml per month CAZIANT PAK Max Daily Dose of 1 CESIA PAK Max Daily Dose of 1 CHANTIX PAK 0.5& 1MG Max Daily Dose of 2; limit to a 90 day supply per year CHANTIX TAB Max Daily Dose of 2; limit to a 90 day supply per year CHATEAL TAB 0.15/30 Max Daily Dose of 1 CITALOPRAM TAB Max Daily Dose of 1.7; Limited to 51 tablets per month vi

7 CLOBETASOL CRE 0.05% CLOBETASOL GEL 0.05% CLOBETASOL OIN 0.05% CLOBETASOL SOL 0.05% 120gm per month 120gm per month 120gm per month 100ml per month CLOPIDOGREL TAB Max Daily Dose of 1 CLOTRIM/BETA CRE DIPROP CLOTRIM/BETA LOT DIPROP COLCHICINE TAB 0.6MG 90gm per month 60ml per month 20 tablets per month COMBIVENT AER 30gm per month (2 inhalers per month) COMBIVENT AER RESPIMAT 4gm per month (1 inhalers per month) COMPLERA TAB Max Daily Dose of 1 CORDRAN 24X3 TAP 4MCG/CM 1 per month CRESTOR TAB Max Daily Dose of 1 CRIXIVAN CAP 200MG Max Daily Dose of 12 CRIXIVAN CAP 400MG Max Daily Dose of 6 CRYSELLE-28 TAB 28 TABS Max Daily Dose of 1 CVS NASAL SPR MIST 254ml per month CYCLAFEM TAB 1/35 Max Daily Dose of 1 CYCLAFEM TAB 7/7/7 Max Daily Dose of 1 DASETTA TAB 1/35 Max Daily Dose of 1 DASETTA TAB 7/7/7 Max Daily Dose of 1 DAYTRANA DIS Max Daily Dose of 1 DESIPRAMINE TAB Max Daily Dose of 2 DESONATE GEL 0.05% 120gm per month DESONIDE CRE 0.05% 120gm per month DESONIDE LOT 0.05% 120ml per month DESONIDE OIN 0.05% 120gm per month DESOXIMETAS CRE DESOXIMETAS GEL 0.05% DESOXIMETAS OIN 0.05% DESOXIMETAS OIN 0.25% 200gm per month 120gm per month 120gm per month 200gm per month DIDANOSINE CAP 125MG Max Daily Dose of 2 DIDANOSINE CAP 200MG Max Daily Dose of 2 DIDANOSINE CAP 250MG Max Daily Dose of 1 DIDANOSINE CAP 400MG Max Daily Dose of 1 DIFLORASONE CRE 0.05% DIFLORASONE OIN 0.05% 120gm per month 120gm per month DILTIA XT CAP 120MG/24 Max Daily Dose of 1 DILTIAZEM CAP ER Max Daily Dose of 2 DILTIAZEM HCL 24HR CAP (Cartia XT, Dilt-CD) Max Daily Dose of 1 vii

8 DILTIAZEM HCL 24HR CAP (Taztia XT, Diltzac) Max Daily Dose of 1 DILTIAZEM HCL ER TAB (Matzim LA, Cardizem LA) Max Daily Dose of 1 DULERA AER 13gm per month (1 inhaler per month) EASIVENT Mask 2 per 365 days ECONAZOLE CRE 1% 85gm per month EDURANT TAB 25MG Max Daily Dose of 1 ELINEST TAB Max Daily Dose of 1 EMOQUETTE TAB Max Daily Dose of 1 EMTRIVA CAP 200MG Max Daily Dose of 1 EMTRIVA SOL 10MG/ML Max Daily Dose of 20ml per day ENPRESSE-28 TAB Max Daily Dose of 1 EPINEPHRINE INJ Limit to 2 syringes every 3 months EPIPEN-JR INJ 2-PAK Limit to 2 syringes every 3 months EPIVIR SOL 10MG/ML Max Daily Dose of 30ml per day EPIVIR HBV SOL 5MG/ML Max Daily Dose of 60ml per day EPIVIR HBV TAB 100MG Max Daily Dose of 3 EPZICOM TAB Max Daily Dose of 1 ERRIN TAB 0.35MG Max Daily Dose of 1 ESTARYLLA TAB Max Daily Dose of 1 ESTRADIOL DIS 4 patches per 28 days FELODIPINE TAB ER Max Daily Dose of 1 FER-IRON DRO 15MG/ML 50ml per month FLOVENT DISK AER 100MCG FLUCONAZOLE SUS 1 inhaler per month 3.5 ml per day FLUCONAZOLE TAB Max Daily Dose of 1 FLUNISOLIDE SPR 0.025% FLUOCIN ACET CRE FLUOCIN ACET OIL SCALP FLUOCIN ACET OIN 0.025% FLUOCIN ACET SOL 0.01% FLUOCINONIDE CRE 0.05% FLUOCINONIDE GEL 0.05% FLUOCINONIDE OIN 0.05% FLUOCINONIDE SOL 0.05% FLUTICASONE CRE 0.05% FLUTICASONE OIN 0.05% FLUTICASONE SPR 50MCG 50ml per month (limited to 2 inhalers per month) 120gm per month 120ml per month 120gm per month 120ml per month 120gm per month 120gm per month 120gm per month 120ml per month 120gm per month 120gm per month 16ml per month (1 inhaler per month) FOCALIN XR CAP Max Daily Dose of 1 FOLIC ACID TAB Max Daily Dose of 1 FORADIL CAP AEROLIZE 1 package (60 doses) per month viii

9 GILDESS 1/20 TAB Max Daily Dose of 1 GILDESS FE TAB 1.5/30 Max Daily Dose of 1 GILDESS FE TAB 1/20 Max Daily Dose of 1 GLIPIZIDE ER TAB Max Daily Dose of 2 GLUCAGON KIT 1MG 2 kits per month GRANISETRON TAB 1MG 10 tablets per month GRANISOL SOL 2MG/10ML 60ml per month HALOBETASOL CRE 0.05% HALOBETASOL OIN 0.05% 100gm per month 100gm per month HALOG CRE 0.1% 100gm per month HALOG OIN 0.1% 100gm per month HC PRAMOXINE CRE 1-2.5% HC VALERATE CRE 0.2% HC VALERATE OIN 0.2% 60gm per month 120gm per month 120gm per month HEATHER TAB 0.35MG Max Daily Dose of 1 HYDROCORT CRE 1% 120gm per month HYDROCORT CRE 2.5% 90gm per month HYDROCORT LOT 1% 240ml per month HYDROCORT LOT 2.5% 120ml per month HYDROCORT OIN 1% 90gm per month HYDROCORT OIN 2.5% 90gm per month INTELENCE TAB 100MG Max Daily Dose of 4 INTELENCE TAB 200MG Max Daily Dose of 2 INTELENCE TAB 25MG Max Daily Dose of 16 INTERMEZZO SUB 3.5MG Max Daily Dose of 1 INVIRASE CAP 200MG Max Daily Dose of 10 INVIRASE TAB 500MG Max Daily Dose of 4 IPRATROPIUM SPR 0.03% IPRATROPIUM SPR 0.06% ISENTRESS 30ml per month (1 inhaler per month) 15ml per month (1 inhaler per month) Max Daily Dose of 2 per day JANUMET TAB Max Daily Dose of 2 JANUMET XR TAB Max Daily Dose of 1 JANUVIA TAB Max Daily Dose of 1 JENTADUETO TAB Max Daily Dose of 2 JEVANTIQUE TAB 1MG-5MCG; JINTELI TAB 1MG-5MCG Max Daily Dose of 1; female only JOLIVETTE TAB 0.35MG Max Daily Dose of 1 JUNEL 1.5/30 TAB Max Daily Dose of 1 JUNEL 1/20 TAB Max Daily Dose of 1 JUNEL FE TAB 1.5/30 Max Daily Dose of 1 ix

10 JUNEL FE TAB 1/20 Max Daily Dose of 1 KALETRA SOL Max Daily Dose of 15ml per day KALETRA TAB MG Max Daily Dose of 12 KALETRA TAB MG Max Daily Dose of 6 KELNOR TAB 1/35; ZOVIA 1/35E TAB Max Daily Dose of 1; female only KETOPROFEN CAP 200MG ER Max Daily Dose of 1 KETOPROFEN CAP 50MG Max Daily Dose of 6 KETOPROFEN CAP 75MG Max Daily Dose of 4 KETOROLAC TAB 10MG Max Daily Dose of 4; Limited to 5 day supply (20 tablets per month) KETOSTIX 50 per month KOMBIGLYZE TAB Max Daily Dose of 1 KURVELO TAB 0.15/30 Max Daily Dose of 1 LAMIVUD/ZIDO TAB Max Daily Dose of 2 LAMIVUDINE TAB 150MG Max Daily Dose of 2 LAMIVUDINE TAB 300MG Max Daily Dose of 1 LANSOPRAZOLE CAP LANSOPRAZOLE SUS 3MG/ML LANSOPRAZOLE TAB LATANOPROST SOL 0.005% Max Daily Dose of 1 per day Max Daily Dose of 5ml per day Max Daily Dose of 2 per day 5ml per month LETROZOLE TAB 2.5MG 1 tablet daily LEVETIRACETA TAB 1000MG Max Daily Dose of 3 LEVETIRACETA TAB 250MG Max Daily Dose of 12 LEVETIRACETA TAB 500MG Max Daily Dose of 6 LEVETIRACETA TAB 750MG Max Daily Dose of 4 LEVOFLOXACIN TAB LEVONEST TAB Max Daily Dose of 1 Max Daily Dose of 1; limit to 14 tabs per month LEVONOR/ETHI TAB ESTRADIO Max Daily Dose of 1 LEVONORGESTR TAB 0.75MG; NEXT CHOICE TAB 0.75MG 2 tablets per month; female only LEVORA-28 TAB 0.15/30 Max Daily Dose of 1 LEXIVA SUS 50MG/ML Max Daily Dose of 60ml per day LEXIVA TAB 700MG Max Daily Dose of 4 LIDOCAINE CRE 3% 85gm per month LIDOCAINE GEL 2% 90ml per month LIDOCAINE LOT 3% 100ml per month LIDOCAINE OIN 5% 70.8gm per month LIDOCAINE SOL VISC 100ml per month LO LOESTRIN TAB Max Daily Dose of 1 x

11 LOESTRIN 24 TAB FE Max Daily Dose of 1; female only LOSARTAN POT TAB Max Daily Dose of 1 LOSARTAN/HCT TAB Max Daily Dose of 1 LOW-OGESTREL TAB Max Daily Dose of 1 LUNESTA TAB Max Daily Dose of 1 MARLISSA TAB 0.15/30 Max Daily Dose of 1 MAXAIR AUTOH AER 200MCG 1 inhaler (14 gm) per month MEDROXYPR AC INJ 150MG/ML 1 injection every 3 months MEPRON SUS 210ml per 18 days METADATE CD CAP 20MG Max Daily Dose of 1 METHYLPHENID TAB ER Max Daily Dose of 1 METOPROLOL ER TAB Max Daily Dose of 1 MICROGESTIN TAB 1.5/30 Max Daily Dose of 1 MICROGESTIN TAB 1/20 Max Daily Dose of 1 MICROGESTIN TAB FE 1/20 Max Daily Dose of 1 MICROGESTIN TAB FE1.5/30 Max Daily Dose of 1 MONO-LINYAH TAB Max Daily Dose of 1 MONONESSA TAB Max Daily Dose of 1 MYZILRA TAB Max Daily Dose of 1 NABUMETONE TAB 500MG Max Daily Dose of 4 NABUMETONE TAB 750MG Max Daily Dose of 2 NECON TAB 0.5/35 Max Daily Dose of 1 NECON TAB 1/35 Max Daily Dose of 1 NECON TAB 7/7/7 Max Daily Dose of 1 NEVIRAPINE SUS 50MG/5ML Max Daily Dose of 40ml per day NEVIRAPINE TAB 200MG Max Daily Dose of 2 NICOTINE DIS Max Daily Dose of 1; limited to 90 day supply per year NICOTINE GUM Max Daily Dose of 9; limited to 90 day supply per year NIFEDIAC CC TAB ER Max Daily Dose of 1 NORA-BE TAB 0.35MG Max Daily Dose of 1 NORETHINDRON TAB 0.35MG Max Daily Dose of 1 NORGEST/ETH TAB ESTRAD Max Daily Dose of 1 NORGEST/ETHI TAB 0.25/35 Max Daily Dose of 1 NORGEST/ETHI TAB ESTRADIO Max Daily Dose of 1 NORTREL TAB 0.5/35 Max Daily Dose of 1 NORTREL TAB 1/35 Max Daily Dose of 1 NORTREL TAB 7/7/7 Max Daily Dose of 1 NORVIR CAP 100MG Max Daily Dose of 12 NORVIR SOL 80MG/ML Max Daily Dose of 15ml per day NORVIR TAB 100MG Max Daily Dose of 12 OMEPRA/BICAR CAP Max Daily Dose of 1 xi

12 OMEPRAZOLE CAP Max Daily Dose of 2 per day ONDANSETRON SOL 50ml per month ONDANSETRON TAB 24MG 5 tablets per month ONDANSETRON TAB 4MG 15 tablets per month ONDANSETRON TAB 8MG 15 tablets per month ONDANSETRON TAB ODT 10 films per month ONGLYZA TAB Max Daily Dose of 1 ORTHO FLAT DIAPHRAGM 1 per year ORTHO FLEX DIAPHRAGM 1 per year PANTOPRAZOLE TAB 20MG Max Daily Dose of 2 per day PANTOPRAZOLE TAB 40MG Max Daily Dose of 2 per day PENTOXIFYLLI TAB 400MG ER Max Daily Dose of 3 PIOGLITAZONE TAB 1 tablet daily PORTIA-28 TAB Max Daily Dose of 1 PRECISN XTRA TES KETONE 10 per month PREDNICARBAT CRE 0.1% 120gm per month PREDNICARBAT OIN 0.1% 120gm per month PREVIFEM TAB Max Daily Dose of 1 PREZISTA SUS 100MG/ML Max Daily Dose of 16ml per day PREZISTA TAB 150MG Max Daily Dose of 8 per day PREZISTA TAB 400MG, 600MG & 800MG Max Daily Dose of 2 per day PREZISTA TAB 75MG Max Daily Dose of 16 per day PROAIR HFA AER 2 inhalers (8.5 gm each) per month PROVENTIL AER HFA 2 inhalers (6.7 gm each) per month PULMICORT INH 1 inhaler per month (qty 1) PULMOZYME SOL 1MG/ML 60 vials per month QVAR AER 8.7g per month (1 inhaler per month) RECLIPSEN TAB Max Daily Dose of 1 RELENZA MIS DISKHALE Max Daily Dose of 4 per day; limit to 5 day supply RESCRIPTOR TAB 100 MG Max Daily Dose of 12 RESCRIPTOR TAB 200MG Max Daily Dose of 6 REYATAZ CAP 100MG Max Daily Dose of 4 REYATAZ CAP 150MG & 200MG Max Daily Dose of 2 REYATAZ CAP 300MG Max Daily Dose of 1 ROZEREM TAB 8MG Max Daily Dose of 1 SAFYRAL TAB Max Daily Dose of 1 SANCUSO DIS 3.1MG 1 patch per month SCALACORT LOT 2% 120ml per month SELZENTRY TAB Max Daily Dose of 4 SEREVENT DIS AER 1 per month xii

13 SILENOR TAB Max Daily Dose of 1 SIMPLY SALIN AER BABY 88ml per month SOLIA TAB Max Daily Dose of 1 SPIRIVA CAP HANDIHLR Max Daily Dose of 1 SPRINTEC 28 TAB 28 DAY Max Daily Dose of 1 STAVUDINE CAP Max Daily Dose of 2 STAVUDINE SOL 1MG/ML Max Daily Dose of 40ml per day STRIBILD TAB Max Daily Dose of 1 SUMATRIPTAN INJ SUMATRIPTAN SPR SUMATRIPTAN TAB SUMAVEL DOSE INJ 6MG/0.5 5 kits (10 syringes) per month 18 spray unit devices per month 9 tabs per month QL of 6 syringes per month SUSTIVA CAP 200MG Max Daily Dose of 3 SUSTIVA CAP 50MG Max Daily Dose of 12 SUSTIVA TAB 600MG Max Daily Dose of 1 SYMBICORT AER 10.2gm per month (1 inhaler per month) TAMIFLU CAP Max Daily Dose of 2 per day; limit to 5 day supply Max Daily Dose of 15ml; limit to 5 day supply; allow for TAMIFLU SUS 12MG/ML members < 13 years of age TAMIFLU SUS 6MG/ML Max of 120 ml per 10 days; limit of 2 bottles per fill TAMSULOSIN CAP 0.4MG Max Daily Dose of 2 TESTOST CYP INJ 2 injections per month TIZANIDINE Max Daily Dose of 3 TOBRADEX OIN % 1 vial per 10 days TOBRADEX ST SUS 1 bottle per 10 days TRADJENTA TAB 5MG Max Daily Dose of 1 TRAMADOL HCL TAB 50MG Max Daily Dose of 8 TRANDOLAPRIL TAB Max Daily Dose of 1 TRIAMCINOLON CRE 0.025% 160gm per month TRIAMCINOLON CRE 0.1% 160gm per month TRIAMCINOLON CRE 0.5% 60gm per month TRIAMCINOLON LOT 120ml per month TRIAMCINOLON OIN 0.025% 160gm per month TRIAMCINOLON OIN 0.05% 60gm per month TRIAMCINOLON OIN 0.1% 160gm per month TRIAMCINOLON OIN 0.5% 60gm per month TRI-ESTARYLL TAB Max Daily Dose of 1 TRI-LINYAH TAB Max Daily Dose of 1 TRINESSA TAB Max Daily Dose of 1 TRI-PREVIFEM TAB Max Daily Dose of 1 xiii

14 TRI-SPRINTEC TAB Max Daily Dose of 1 TRIVORA-28 TAB Max Daily Dose of 1 TRIZIVIR TAB Max Daily Dose of 2 TRUVADA TAB Max Daily Dose of 1 TUDORZA PRES AER 400/ACT VALACYCLOVIR TAB 1GM VALACYCLOVIR TAB 500MG 1 pouch (60 doses) per month VANOS CRE 0.1% 120gm per month VELIVET PAK Max Daily Dose of 1 VENTOLIN HFA AER Allow #21 tablets for first fill, additional fills require PA Allow #10 tablets for first fill, additional fills require PA Limited to 2 inhalers (8gm each)/month VERAPAMIL TAB ER Max Daily Dose of 1 VIDEX SOL 2GM Max Daily Dose of 20.1ml per day VIRACEPT TAB 250MG Max Daily Dose of 10 VIRACEPT TAB 625MG Max Daily Dose of 4 VIRAMUNE XR TAB 400MG Max Daily Dose of 1 VIREAD TAB Max Daily Dose of 1 VITAMIN D CAP 400UNIT Max Daily Dose of 2 VIVELLE-DOT DIS; ALORA; MINIVELLE 8 patches per 28 days WERA TAB 0.5/35 Max Daily Dose of 1 Max Daily Dose of 1 for up to 35 days, after 35 days PA XARELTO TAB required XOPENEX HFA AER 2 inhalers (15 gm each) per month ZEGERID POW Max Daily Dose of 1 ZIAGEN SOL 20MG/ML Max Daily Dose of 30ml per day ZIDOVUDINE CAP 100MG Max Daily Dose of 6 ZIDOVUDINE SYP 50MG/5ML Max Daily Dose of 60ml per day ZIDOVUDINE TAB 300MG Max Daily Dose of 2 ZOLPIDEM TAB Max Daily Dose of 1 ZOLPIDEM ER TAB Max Daily Dose of 1 ZONISAMIDE CAP 100MG Max Daily Dose of 6 ZONISAMIDE 25MG CAP Max Daily Dose of 12 ZONISAMIDE 50MG CAP Max Daily Dose of 12 ZUPLENZ MIS 10 films per month Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. xiv

15 Age Limitations Generic Name Brand Name Limitation Description Other limitations acyclovir 200mg/5ml suspension Zovirax Susp Covered for members up to age 12 amitriptyline Elavil PA for members over age 65 amoxipine Asendin PA for members over age 65 amphetamine/dextroamphetamine mix salt Adderall Covered for members age 6-17 aspirin 81mg and 325mg Aspirin Covered for members age $0, QL, OTC budesonide inhaled susp cefdinir suspension cefuroxime suspension Pulmicort Respules OmniCef Ceftin Covered for Members Up to Age 8 QL Covered up to age 11 Covered up to age 11 chlordiazepoxide Librium PA for members over age 65 dexmethlyphenidate Focalin Covered for members age 6-17 dextroamphetamine Dexedrine Covered for members age 6-17 xv

16 dextroamphetamine SR Dexedrine Spans Covered for members age 6-17 diazepam Valium PA for members over age 65 diphenhydramine (all forms) Benadryl (OTC) Covered up to age 65, then PA required OTC doxepin Sinequin PA for members over age 65 enoxaparin Lovenox Females ages will require PA ferrous sulfate drops 15mg/ml Iron drops Covered for members up to age 1 QL, AL, PA $0, QL, OTC fluticasone inhaler Flovent Diskus (50, 100) Flovent HFA (44mcg) Covered for members ages 4-11 QL flurazepam Dalmane PA for members over age 65 folic acid Folic Acid Covered for members age $0, QL, OTC imipramine Tofranil PA required for members over age 65 letrozole Femara Covered for members 18 or older lidocaine/prilocaine Emla Covered up to age 15 xvi

17 lisdexamfetamine Vyvanse Covered for members age 6-17 methylphenidate Ritalin Covered for members age 6-17 methylphenidate SR Concerta, Ritalin SR Covered for members age 6-17 QL- Concerta oseltamivir Tamiflu 6mg/ml suspension Covered up to age 13 QL temazepam Restoril PA for members over age 65 tretinoin topical Retin-A, Avita Covered for members under age 29 (QL applies) QL triazolam Halcion PA for members over age 65 Zostavax Herpes Zoster Vaccine Covered for age 60 and over 15mg and 30mg only Gender edits are indicated with a GE on the formulary and require the member to be a specific gender for coverage. Gender Edits Generic Name Brand Name Gender requirement Enoxaparin Lovenox PA is required for females ages Estradiol transdermal patches Alora Female Oral estrogen Premarin Female letrozole Femara Female Levonorgesterol Plan B, Next Choice Female Medroxyprogesterone injection Depo-Provera Female Anastrozole Arimidex Female xvii

18 Oral Contraceptives Various generic oral contraceptives Female Androgens Depo-Testosterone Male Step Therapy medications are indicated with a ST on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria Antimigraine Sumatriptan (Imitrex) Axert, Relpax, Frova, Naratriptan, Zomig Prior use of sumatriptan or rizatriptan in the last 90 days Nasal Corticosteriods Flunisolide, Fluticasone, Nasonex Beconase AQ, QNASL, Rhinocort, Veramyst, Zetonna Prior use of flunisolide, fluticasone or Nasonex in last 180 days Osteoporosis Alendronate (Fosamax) Actonel, Altelvia Prior use of alendronate within the last 90 days. Urinary Antispasmodics Oxybutynin Oxybutynin-ER Detrol/Detrol LA, Enablex, Sanctura, Trospium, Vesicare Prior use of Oxybutynin/oxybutynin-ER within past 90 days. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of catamaran. The presence of a medication on this formulary list does not guarantee coverage. xviii

19 Table of Contents ANTI-INFECTIVES PENICILLINS CEPHALOSPORIN FIRST GENERATION SECOND GENERATION THIRD GENERATION MACROLIDES TETRACYCLINES QUINOLONES AMINOGLYCOSIDES SULFONAMIDES ANTIMYCOBACTERIAL AGENTS ANTIFUNGALS ANTIVIRALS ANTIMALARIALS AMEBICIDES ANTHELMINTICS MISC. ANTI-INFECTIVES ANTINEOPLASTICS, ETC ALKYLATING AGENTS ANTIBIOTICS ANTINEOPLASTIC ENZYMES ANTIMETABOLITES ANGIOGENESIS INHIBITORS ANTIBODIES HORMONAL AGENTS IMMUNOMODULATORS MITOTIC INHIBITORS ENZYME INHIBITORS TOPOISOMERASE I INHIBITOR ANTINEOPLASTICS MISC CHEMOTHERAPY RESCUE CHEMOTHERAPY ADJUNCTS CARDIOVASCULAR DRUGS CARDIAC GLYCOSIDES ANTIANGINAL AGENTS BETA BLOCKERS

20 CALCIUM CHANNEL BLOCKERS ANTIARRHYTHMICS ACE INHIBITORS ANGIOTENSIN RCPTR BLOCKER DIRECT RENIN INHIBITORS ANTIHYPERTENSIVES MISC ANTIHYPERTENSIVE COMBO DIURETICS VASOPRESSORS ANTIHYPERLIPIDEMICS CARDIOVASCULAR - MISC DERMATOLOGICALS ACNE PRODUCTS ROSACEA AGENTS ANTIBIOTICS - TOPICAL ANTIFUNGALS - TOPICAL ANTIVIRALS - TOPICAL ANTI-INFLAMMATORY AGENTS ANTIPRURITICS ANTIPSORIATICS ANTISEBORRHEIC AGENTS CORTICOSTEROIDS - TOPICAL IMMUNOMODULATING AGENTS DERMATOLOGICALS - MISC ENDOCRINE AND METABOLIC CORTICOSTEROIDS ANDROGENS-ANABOLIC ESTROGENS CONTRACEPTIVES PROGESTINS ANTIDIABETIC AGENTS INSULIN AMYLIN ANALOGS INCRETIN MIMETIC AGENTS SULFONYLUREAS BIGUANIDES MEGLITINIDE ANALOGUES DIABETIC OTHER ALPHA-GLUCOSIDASE INHIBIT

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