First Choice Pharmacy Benefit Guide. Effective January 1,

Transcription

1 First Choice Pharmacy Benefit Guide Effective January, 205

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3 TABLE OF CONTENTS First Choice Overview... First Choice Contact Numbers... Understanding Coverage and Cost-sharing... 2 About Drugs... 2 Formulary Overview... 2 For Prospective Members... 3 Understanding Our Symbols... 3 Prior Authorization... 3 Step Therapy... 3 Quantity Limits... 3 Filling Your Prescription... 3 Retail... 3 Mail Order...4 Provider...4 Filling Your Prescription When Traveling...4 Medication Supplies Not Covered by UPMC Health Plan...4 First Choice Formulary... 5 Medications Not Covered by First Choice...29 Non-Covered Medications with Covered Alternatives First Choice Brand/ Reference Guide...35

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5 FIRST CHOICE OVERVIEW The First Choice pharmacy program provides both value and freedom of choice. It does so by offering a variety of high-quality, effective generic and certain brand-name prescription drugs. This guide provides information that is applicable to most members. For information specific to your plan, refer to your plan s prescription drug rider. This guide provides an overview of your pharmacy benefit with UPMC Health Plan. It explains the copayment structure, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. FIRST CHOICE CONTACT NUMBERS Current Members: UPMC Health Plan Health Care Concierge Team: UPMC Health Plan Pharmacy Services (for doctors and pharmacies): TTY Services: Prospective Members: Prospective members should direct their questions to their company s benefits administrator or to the UPMC Health Plan Health Care Concierge team at Online information is available at

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

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

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

9 Effective January, MOP PA 2 medication abacavir abacavir/lamivudine/ zidovudine Abilify PA, QL (ST <2 years of age) Abilify Maintena PA, QL (ST <2 years of age) Abstral PA, QL 2 acamprosate acarbose acebutolol acetaminophen/ caffeine/ dihydrocodone QL acetaminophen/ codeine QL acetazolamide ER capsule acetic acid acetic acid/ hydrocortisone 2 2 medication acitretin 2 medication Actemra PA, QL 2 medication Acthar gel PA, QL 2 medication Actimmune PA 2 medication Actonel ST, QL NFC alendronate, ibandronate, risedronate Actonel Weekly ST, QL NFC alendronate, ibandronate, risedronate Acuvail QL NFC ketorolac, diclofenac, bromfenac acyclovir acyclovir ointment Aczone NFC tretinoin, benzoyl peroxide, clindamycin, adapalene (PA) Adagen PA 2 medication adapalene (PA >35 years of age) Adcirca PA, QL 2 medication Adderall XR QL (PA < 4 and >8 years of age) adefovir PA 2 medication Adempas PA, QL 2 medication Adrenaclick NFC EpiPen, Auvi-Q Advair 2 Advicor NFC atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Niaspan Aerospan ST NFC Flovent HFA, QVAR, Asmanex Afinitor PA, QL 2 medication Aggrenox NFC dipyridamole, ticlopidine, Effient, clopidogrel alagesic albuterol solution QL alclometasone dipropionate ointment Aldurazyme PA 2 medication alendronate Alferon N PA 2 medication alfuzosin ER Alkeran 2 allopurinol Alocril NFC azelastine, epinastine, Pataday, Patanol Alomide NFC azelastine, epinastine, Pataday, Patanol Alora QL NFC estradiol patch, Premarin Aloxi ST, QL NFC ondansetron Alphagan P 0.% 2 alprazolam alprazolam ODT ST = Medications 2 = Brand Medications & Medications NFC = 5

10 Effective January, 205 Alrex NFC fluorometholone, prednisolone Altavera Alvesco ST NFC Asmanex, Flovent HFA, QVAR amantadine amcinonide Amethia Amethia Lo Amethyst Amevive PA, QL 2 medication amiodarone Amitiza QL 2 amitriptyline amlodipine/ atorvastatin amlodipine besylate amlodipine besylate/ benazepril ammonium lactate Amnesteem amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ER amphetamine salts QL (PA <4 and >8 years of age) Ampyra PA, QL 2 medication Amturnide ST 2 Analpram HC cream NFC hydrocortisone/ pramoxine Analpram HC lotion NFC hydrocortisone/ pramoxine anastrozole Androderm PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Androgel % PA, ST 2 Androgel.62% (PA) Androgel.62% PA 2 Android PA, ST NFC testosterone injection (PA), Androgel.62% (PA) androxy PA, ST testosterone injection (PA), Androgel.62% (PA) Angeliq NFC Premarin, estradiol, estropipate Anoro Ellipta 2 Anzemet ST, QL NFC ondansetron Apidra ST, QL NFC Humalog, Novolog Apokyn PA, QL 2 medication apraclonidine Apri Apriso ER 2 Aptiom PA, QL NFC carbamazepine, oxcarbazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide Aptivus 2 Aquoral NFC Caphosol Aralast NP PA 2 medication Aranelle Aranesp PA 2 medication arbinoxa Arcalyst PA, QL 2 medication Arcapta ST NFC Serevent, Foradil Armour Thyroid NFC levothyroxine, liothyronine Asacol HD 2 Ascensia Blood Glucose Meters Asmanex 2 Atelvia ST, QL NFC alendronate, ibandronate, risedronate atenolol atenolol/chlorthalidone 2 = Medications 2 = Brand Medications & Medications NFC = 6

11 atorvastatin atovaquone suspension Atripla 2 atropine drops Atrovent HFA 2 Aubagio PA, QL 2 medication Aubra aurodex auroguard Auvi-Q 2 Aveed PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Aviane Avodart 2 Avonex QL 2 medication Axert ST, QL NFC naratriptan, rizatriptan, sumatriptan, zolmitriptan Axiron PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Azasite NFC erythromycin azathioprine azelastine Azelex ST NFC topical acne agents Azilect 2 azithromycin QL Azopt 2 baclofen Bactroban nasal ointment balsalazide disodium 2 Banzel PA NFC felbamate, lamotrigine, topiramate, valproate Bayer Blood Glucose Meters 2 Bayer Blood Glucose Test Strips (QL > 8 years of age) Bayer Lancets (QL > 8 years of age) 2 2 Beconase AQ ST NFC fluticasone, flunisolide, Veramyst beflex benazepril benazepril/hctz Benlysta PA 2 medication benprox benzoyl peroxide benztropine Bepreve NFC azelastine, epinastine, Pataday, Patanol Berinert PA 2 medication Besivance NFC ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox betamethasone Betaseron ST, QL 2 medication betaxolol Bethkis QL 2 medication Betimol NFC timolol, Betoptic S Betoptic S 2 Beyaz 2 Biafine NFC ammonium lactate, Zenieva bicalutamide bisoprolol bisoprolol/hctz Bivigam PA 2 medication Blephamide 2 Bosulif PA, QL 2 medication Botox PA, QL 2 medication bp 0- wash = Medications 2 = Brand Medications & Medications NFC = 7

12 Effective January, 205 BPO gel Breeze Blood Glucose Meters Breo Ellipta 2 Briellyn 2 Brilinta QL NFC clopidogrel, Effient brimonidine tartrate Brintellix PA, QL NFC paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) bromfenac ophthalmic solution Brovana NFC Serevent, Foradil budeprion XL budesonide EC budesonide nasal spray ST budesonide respules fluticasone, flunisolide Buphenyl tablet PA 2 medication buprenorphine PA, QL buprenorphine/ naloxone tablet PA, QL bupropion bupropion SA buspirone butorphanol nasal spray QL Bydureon QL 2 NFC Suboxone film (PA), Zubsolv (PA) Byetta ST, QL NFC Bydureon, Victoza Bystolic ST NFC atenolol, metoprolol, propranolol calcipotriene calcitriol calcium acetate Camila Camrese Camrese Lo Canasa NFC mesalamine, balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol candesartan candesartan/hctz capecitabine PA 2 medication Caphosol 2 Caprelsa PA, QL 2 medication captopril captopril/hctz Carac 2 medication Carbaglu PA 2 medication carbamazepine ER carbidopa carbidopa/levodopa carbidopa/levodopa/ entacapone Cardene SR NFC amlodipine besylate, cartia XT, diltiazem, Nifediac CC, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR Cardura XL ST, QL NFC alfuzosin ER, doxazosin, prazosin, tamsulosin, terazosin Carimune NF PA 2 medication carisoprodol carteolol cartia XT carvedilol Cayston QL 2 medication cefaclor cefadroxil cefdinir cefpodoxime cefprozil = Medications 2 = Brand Medications & Medications NFC = 8

13 ceftazidime ceftibuten cefuroxime celecoxib ST, QL NSAIDs (diclofenac, etodolac, ibuprofen, meloxicam, naproxen) Cenestin NFC estradiol, estropipate, Premarin cephalexin Cerezyme PA 2 medication cevimeline Chantix ST, QL 2 Chateal Chemet PA 2 chlordiazepoxide chlorpromazine (ST <2 years of age) chlorpropamide chlorthalidone chlorzoxazone cholestyramine ciclopirox cilostazol Ciloxan NFC ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox cimetidine Cimzia PA, QL 2 medication Cinryze PA, QL 2 medication Cipro HC 2 Ciprodex 2 ciprofloxacin ciprofloxacin 0.2% ear drops ciprofloxacin ER QL citalopram QL Claravis clarithromycin clarithromycin ER Climara-PRO QL NFC estradiol Clinac BPO NFC benzoyl peroxide clindamycin clobetasol clonazepam clonazepam ODT ST clonidine clonidine ER ST, QL clonidine clopidogrel clorazepate clotrimazole clozapine (ST <2 years of age) clozapine ODT QL (ST <2 years of age) Coartem 2 codeine sulfate Colcrys 2 Colestid granules NFC colestipol colestipol Combigan 2 Combipatch QL NFC estradiolnorethindrone, Jinteli, Prempro, Premphase Combivent Respimat 2 Cometriq PA, QL 2 medication Complera 2 Contour Blood Glucose Meters 2 Copaxone QL 2 medication Copegus QL 2 medication Coreg CR NFC carvedilol cortamox Cortef NFC hydrocortisone tablets = Medications 2 = Brand Medications & Medications NFC = 9

14 Effective January, 205 Cortifoam NFC hydrocortisone suppository, proctozone Cosopt PF NFC Azopt, betaxolol, Betoptic S, carteolol, dorzolamide, dorzolamide-timolol, timolol maleate Covera-HS NFC amlodipine besylate, cartia XT, diltiazem, Nifediac CC, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR Delatestryl PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Delyla Delzicol 2 Demser PA 2 medication Denavir NFC For cold sore treatment use overthe-counter agents Depen PA 2 medication Dermatop NFC topical steroids Creon 2 Crinone 4% gel 2 Crixivan 2 cromolyn Cryselle Cuprimine PA 2 medication Cuvposa (PA > 6 years of age) NFC glycopyrrolate tablet desogestrel/ethinyl estradiol desonide desoximetasone Desvenlafaxine ER ST, QL NFC citalopram, fluoxetine, paroxetine, sertaline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Cyclafem dexamethasone cyclobenzaprine cyclopentolate drops dexmethylphenidate QL (PA <4 and >8 years of age) Cycloset NFC bromocriptine cyclosporine cyclosporine modified Cystadane powder PA 2 medication Cystagon PA 2 Cystaran PA, QL 2 medication Daliresp PA NFC Advair, Breo Ellipta, Foradil, Serevent, Spiriva, Symbicort, Tudorza danazol PA dantrolene Dapsone 2 Dasetta Daysee dexmethylphenidate ER QL (PA < 4 and >8 years of age) dextroamphetamine QL (PA <4 and >8 years of age) Diastat 2 Diastat Acudial NFC diazepam diazepam Dibenzyline PA 2 medication diclofenac diclofenac ophthalmic solution diclofenac-misoprostol dicloxacillin didanosine = Medications 2 = Brand Medications & Medications NFC = 0

15 Dificid ST, QL 2 medication diflorasone digoxin dihydroergotamine diltiazem diltiazem ER Dipentum ST NFC balsalazide disodium, Apriso, Asacol HD, Delzicol dipyridamole disulfuram divalproex sodium divalproex sodium ER Divigel NFC estradiol donepezil PA dorzolamide dorzolamide-timolol doxazosin doxercalciferol doxycycline drithocreme Dritho-Scalp 2 dronabinol Duavee NFC estradiolnorethindrone, Jinteli, Prempro, Premphase Dulera 2 duloxetine ST, QL Durasal NFC salicyclic acid Durezol NFC fluorometholone, prednisolone Dymista ST NFC fluticasone, flunisolide, Veramyst Dynacirc CR NFC amlodipine besylate, cartia XT, diltiazem, Nifediac CC, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR dyphylline gg Dyrenium NFC triamterene-hctz Dysport PA, QL 2 medication Edarbi ST NFC losartan, eprosartan, irbesartan, candesartan, telmisartan, valsartan Edarbyclor ST NFC candesartan-hctz, irbesartan-hctz, losartan-hctz, telmisartan-hctz, valsartan-hctz Edurant 2 Effient QL 2 Elaprase PA 2 medication Elelyso PA 2 medication Elidel PA 2 topical steroids Eligard PA, QL 2 medication Elinest eliphos Eliquis QL 2 Ella 2 levonorgestrel, Next Choice Elmiron 2 Emadine NFC azelastine, epinastine, Pataday, Patanol Emcyt PA 2 medication Emend capsule QL 2 Emend vial QL Emoquette Emtriva 2 enalapril NFC Enbrel PA, QL 2 medication Endocet QL Enjuvia NFC estradiol, estropipate, Premarin enoxaparin QL Enpresse Enskyce = Medications 2 = Brand Medications & Medications NFC =

16 Effective January, 205 entacapone entecavir PA 2 medication Entyvio PA, QL NFC medication epinastine ophthalmic solution epinephrine EpiPen 2 eplerenone Epogen PA 2 medication epoprostenol PA 2 medication eprosartan Epzicom 2 ergotamine/caffeine Erivedge PA, QL 2 medication Errin EryPed NFC erythromycin Ery-tab EC Ery-tab EC 500 mg 2 erythromycin erythromycin/benzoyl peroxide gel escitalopram QL Estarylla Estrace Cream NFC estradiol, estropipate, Premarin Estraderm QL NFC estradiol estradiol estradiolnorethindrone estradiol patch QL Estring NFC estradiol, estropipate, Premarin Estrogel NFC Premarin estropipate eszopiclone ST, QL etidronate etodolac etoposide PA 2 medication Euflexxa PA, QL 2 medication Evamist NFC estradiol Evzio PA, QL 2 medication Exelon patch PA NFC rivastigmine tartrate capsules (PA), donepezil (PA), Namenda (PA), Namenda XR (PA) exemestane Exjade PA 2 medication Eylea PA 2 medication Fabior (PA >35 years of age) NFC topical acne agents Fabrazyme PA 2 medication Factive QL NFC ciprofloxacin, levofloxacin Falmina famciclovir QL famotidine Fanapt PA, QL (ST <2 years of age) NFC risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Fareston PA 2 medication felbamate felodipine FemHRT NFC estradiolnorethindrone, Jinteli, Premphase, Prempro Femring NFC estradiol, estropipate, Premarin Femtrace NFC estradiol, estropipate, Premarin fenofibrate fenofibric acid ST fenofibrate fenoprofen fentanyl citrate PA, QL = Medications 2 = Brand Medications & Medications NFC = 2

17 fentanyl transdermal QL Fentora PA, ST, QL NFC fentanyl citrate (PA), Abstral (PA) Ferriprox PA 2 medication Fetzima PA, QL NFC venlafaxine ER, duloxetine (ST) Finacea NFC topical acne agents finasteride Firazyr PA, QL 2 medication Firmagon PA, QL 2 medication First-BXN Mouthwash NFC diphenhydramine, lidocaine, nystatin First Testosterone 2% cream PA, ST First Testosterone 2% ointment PA, ST NFC NFC testosterone injection (PA), Androgel.62% (PA) testosterone injection (PA), Androgel.62% (PA) Flarex NFC fluorometholone, prednisolone Flebogamma PA 2 medication flecainide Flovent HFA 2 fluconazole QL flunisolide fluocinolone fluocinonide Fluor-A-Day chew Fluor-A-Day drops 2 fluorometholone fluoxetine fluoxetine (28 unit pack) ST fluoxetine DR QL fluphenazine (ST <2 years of age) flurbiprofen fluticasone fluvastatin fluvoxamine FML Forte NFC fluorometholone, prednisolone FML S.O.P. 2 fondaparinux QL Foradil 2 Forteo ST, QL 2 medication Fortesta PA, ST NFC testosterone injection (PA), Androgel.62% (PA) fosinopril fosinopril/hctz Fosrenol NFC calcium acetate, sevelamer carbonate, Renvela powder packet Fragmin QL 2 medication Frova ST, QL NFC naratriptan, rizatriptan, sumatriptan, zolmitriptan Fulyzaq PA, QL 2 medication furosemide Fuzeon 2 medication Fycompa PA, QL NFC felbamate, lamotrigine, topiramate, valproate gabapentin Gablofen NFC galantamine PA galantamine ER PA Galzin PA 2 Gammagard PA 2 medication Gammaked PA 2 medication Gammaplex PA 2 medication Gamunex PA 2 medication Gamunex-C PA 2 medication = Medications 2 = Brand Medications & Medications NFC = 3

18 Effective January, 205 ganciclovir gatifloxacin Gattex PA, QL 2 medication gavilyte-g gemfibrozil Generess FE NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Gianvi Gildagia Gildess Gilenya PA, QL 2 medication Gilotrif PA, QL 2 medication Glassia PA 2 medication Gleevec PA, QL 2 medication glimepiride glipizide glipizide ER glipizide/metformin Glucagon 2 glyburide glyburide/metformin Glyset NFC acarbose Gralise PA, QL NFC gabapentin granisetron ST, QL ondansetron granisol ST, QL ondansetron Granix PA 2 medication griseofulvin guanfacine guanfacine ER ST guanfacine Halflytely NFC peg-3350, Suprep, Moviprep halobetasol Halog NFC topical steroids haloperidol (ST <2 years of age) Harvoni PA, QL 2 medication HCTZ Heather Helidac NFC bismuth subsalicylate (OTC), metronidazole, tetracycline Hetlioz PA, QL 2 medication Hexalen 2 medication Hizentra PA 2 medication homatropine drops Horizant PA, QL NFC gabapentin, pramipexole, ropinirole Humalog QL 2 Humalog 50/50 QL 2 Humalog 75/25 QL 2 Humira PA, QL 2 medication Humulin 50/50 QL 2 Humulin 70/30 QL 2 Humulin N QL 2 Humulin R QL 2 Hycamtin PA 2 medication hydralazine hydrocodone/ acetaminophen QL hydrocodone/ ibuprofen hydrocort/pramoxine cream hydrocortisone hydromorphone hydroxychloroquinone hydroxyurea hydroxyzine hyoscyamine = Medications 2 = Brand Medications & Medications NFC = 4

19 ibandronate IV ST, QL alendronate, ibandronate, risedronate ibandronate tablet QL ibuprofen Iclusig PA, QL 2 medication Ilaris PA, QL 2 medication Ilevro NFC ketorolac, diclofenac, bromfenac Imbruvica PA, QL 2 medication imiquimod Increlex PA 2 medication Incruse Ellipta NFC Spiriva, Tudorza indomethacin Infergen PA, QL 2 medication Inlyta PA, QL 2 medication Innopran XL ST NFC atenolol, metoprolol, propranolol Intelence PA 2 Intron A PA 2 medication Introvale Invega PA, QL (ST <2 years of age) Invega Sustenna PA, QL (ST <2 years of age) Invirase 2 NFC risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) 2 medication Invokana QL NFC Jardiance, metformin, glyburide, glipizide, Januvia, Tradjenta ipratropium ipratropium/albuterol solution irbesartan irbesartan/hctz Iressa PA, QL 2 medication Isentress 2 Isopto Carbachol NFC betaxolol, brimonidine, carteolol, dorzolamide, latanoprost, levobunolol, timolol, Combigan, Azopt, Betoptic S Isopto Homatropine NFC homatropine, atropine, cyclopentolate, tropicamide isosorbide isradipine Istalol NFC timolol itraconazole capsule PA, QL Jakafi PA, QL 2 medication Jalyn 2 Janumet 2 Janumet XR 2 Januvia 2 Jardiance 2 Jencycla Jentadueto 2 Jetrea PA, QL 2 medication Jinteli Jolessa Jolivette Junel Junel FE Juxtapid PA, QL 2 medication Kalbitor PA 2 medication Kaletra 2 Kalydeco PA, QL 2 medication Kariva Kazano ST NFC Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta = Medications 2 = Brand Medications & Medications NFC = 5

20 Effective January, 205 Ketek QL NFC azithromycin, clarithromycin ER, erythromycin ketoconazole ketoprofen ketorolac QL ketorolac ophthalmic solution Khedezla ER ST, QL NFC citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Kineret PA, QL 2 medication Kombiglyze XR ST NFC Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Korlym PA, QL 2 medication Krystexxa PA, QL 2 medication Kurvelo Kuvan PA 2 medication Kynamro PA, QL 2 medication labetalol lactulose lamivudine lamivudine HBV PA lamivudine-zidovudine lamotrigine lansoprazole/ amoxicillin/ clarithromycin pack lansoprazole QL Lantus QL 2 Larin Latuda ST, QL (ST <2 years of age) NFC Lazanda PA, ST, QL NFC fentanyl citrate (PA), Abstral (PA) Leena leflunomide Lessina Letairis PA, QL 2 medication letrozole Leukeran 2 Leukine PA 2 medication leuprolide PA 2 medication levalbuterol ST albuterol Levatol ST NFC atenolol, metoprolol, propranolol Levemir QL 2 levetiracetam levetiracetam ER QL levobunolol levocetirizine levofloxacin levofloxacin ophthalmic Levonest levonorgestrel Levora levothyroxine Lexiva 2 Lialda ST NFC balsalazide disodium, Apriso, Asacol HD, Delzicol lidocaine patch ST, QL lidocaine/hc gel Larin Fe Lastacaft NFC azelastine, epinastine, Pataday, Patanol latanoprost LidoVir ointment compounding kit Lifescan Blood Glucose Meters 2 NFC For cold sore treatment use overthe-counter agents = Medications 2 = Brand Medications & Medications NFC = 6

21 Lifescan Blood Glucose Test Strips (QL >8 years of age) Lifescan Lancets (QL >8 years of age) Linzess QL NFC Amitiza liothyronine Lipofen NFC fenofibrate 2 2 Liptruzet ST NFC atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia lisinopril lisinopril/hctz Loestrin 24 FE NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Lo Loestrin FE NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Lomedia 24 FE NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Lo Minastrin FE NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Lomustine 2 loratadine OTC lorazepam Lorcet HD QL Lorcet plus QL Lortab QL Loryna losartan losartan/hctz Lotemax NFC fluorometholone, prednisolone Lotronex PA 2 medication lovastatin Low-ogestrel loxapine (ST <2 years of age) Lucentis PA 2 medication Lumigan 2 Lumizyme PA 2 medication Lupaneta PA, QL 2 medication Lupron PA, QL 2 medication Lyrica PA, QL 2 Lysodren PA 2 medication Lyza Makena PA 2 medication malathion Matulane 2 medication matzim LA Maxair ST, QL NFC Ventolin HFA Maxaquin NFC ciprofloxacin, levofloxacin Maxidex NFC fluorometholone, prednisolone meclizine medroxyprogesterone acetate injection QL mefenamic acid Mekinist PA, QL 2 medication meloxicam Menest NFC estradiol, estropipate, Premarin Menostar QL NFC estradiol meperidine tablet mercaptopurine mesalamine metaxalone = Medications 2 = Brand Medications & Medications NFC = 7

22 Effective January, 205 metformin metformin ER Methadose methamphetamine QL (PA <4 and >8 years of age) methazolamide Methitest PA NFC testosterone injection (PA), Androgel.62% (PA) methocarbamol methotrexate methoxsalen PA 2 medication methylin QL (PA <4 and >8 years of age) methylin ER QL (PA <4 and >8 years of age) methylphenidate QL (PA <4 and >8 years of age) methylphenidate ER QL (PA <4 and >8 years of age) methylprednisolone metipranolol metoclopramide metoprolol metoprolol/hctz metoprolol ER metronidazole Miacalcin NFC alendronate, ibandronate, risedronate Microgestin Microgestin FE midazolam syrup Migergot migragesic IDA Mimvey Mimvey Lo Minastrin 24 Fe NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Minivelle QL NFC estradiol patch, Premarin minocycline Mirapex ER ST NFC pramipexole, ropinirole mirtazapine Mirvaso PA NFC metronidazole, sodium sulfacetamide/sulfur, tretinoin, adapalene modafinil PA, QL Moderiba QL 2 medication moexipril moexipril/hctz mometasone Mono-linyah MonoNessa montelukast QL Monurol 2 morphine sulfate ER tablets QL morphine sulfate IR Moviprep 2 Moxeza 2 moxifloxacin Mozobil PA, QL 2 medication Multaq 2 mupirocin Myalept PA, QL 2 medication mycophenolate mofetil mycophenolate sodium Myobloc PA, QL 2 medication Myorisan Myozyme PA 2 medication = Medications 2 = Brand Medications & Medications NFC = 8

23 Myrbetriq ER QL NFC oxybutynin, oxybutynin ER, trospium, trospium ER tolterodine, tolterodine ER, Toviaz, Vesicare Myzilra nabumetone nadolol nadolol/ bendroflumethiazide Naglazyme PA 2 medication Namenda PA 2 Namenda XR PA, QL 2 naproxen naratriptan QL Nasonex ST NFC flunisolide, fluticasone, Veramyst Natazia 2 nateglinide Nebupent 2 Necon Nesina ST NFC Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Neulasta PA 2 medication Neumega 2 medication Neupogen PA 2 medication Neupro NFC pramipexole, ropinirole Nevanac NFC ketorolac, diclofenac, bromfenac nevirapine nevirapine ER Nexavar PA, QL 2 medication Nexium ST, QL NFC omeprazole, lansoprazole, pantoprazole Next Choice Next Choice One Dose niacin ER nicotine gum QL nicotine lozenges QL nicotine patches QL Nicotrol Inhaler ST, QL 2 Nicotrol Nasal Spray ST, QL nifediac CC nifedipine nifedipine ER Nikki 2 Nilandron PA 2 medication nimodipine nisoldipine nisoldipine ER nitrofurantoin nitroglycerin Nitrostat NFC nitroglycerin nizatidine nodolor Nora-BE Norditropin PA 2 medication Norlyroc Noroxin NFC ciprofloxacin, levofloxacin Northera PA, QL 2 medication Nortrel nortriptyline Norvir 2 Novolin QL 2 Novolin 70/30 QL 2 Novolin N QL 2 Novolin R QL 2 Novolog QL 2 Novolog Mix 70/30 QL 2 = Medications 2 = Brand Medications & Medications NFC = 9

24 Effective January, 205 Noxafil PA, QL 2 medication Nplate PA 2 medication Nuedexta PA, QL 2 medication Nulojix PA 2 medication Numoisyn NFC Caphosol Nuvaring QL 2 Nuvigil PA, QL NFC amphetamine salts, Adderall XR, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, methylphenidate ER, modafinil (PA) NuZon NFC hydrocortisone Ocella octreotide 2 medication ofloxacin Oforta PA 2 medication Ogestrel olanzapine QL (ST <2 years of age) olanzapine vial olanzapine/fluoxetine PA, QL (ST <2 years of age) Olysio PA, QL 2 medication Omeclamox-Pak NFC omeprazole, clarithromycin, amoxicillin omega-3 acid ethyl esters omeprazole QL Omnaris ST NFC fluticasone, flunisolide, Veramyst Omontys PA 2 medication ondansetron QL One Touch Blood Glucose Meters One Touch Blood Glucose Test Strips (QL > 8 years of age) 2 2 Onfi PA, QL NFC felbamate, lamotrigine, topiramate, valproate Onglyza ST NFC Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Onmel PA, QL NFC itraconazole (PA) Onsolis PA, ST, QL NFC fentanyl citrate (PA), Abstral (PA) Opana ER QL 2 Opsumit PA, QL 2 medication OramagicRx NFC lidocaine Orap (ST <2 years of age) 2 Orencia PA, QL 2 medication Orenitram PA 2 medication Orfadin PA 2 medication Orsythia Ortho Tri-Cyclen LO 2 Oseni NFC Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Osmoprep NFC peg-3350, Suprep, Moviprep Otezla PA, QL 2 medication Otosporin ear drops NFC acetic acid/ hydrocortisone Otrexup PA, QL 2 medication oxaprozin oxazepam oxcarbazepine Oxsoralen PA 2 medication oxybutynin oxybutynin ER oxycodone IR oxycodone/ acetaminophen QL oxycodone/aspirin QL oxycodone/ibuprofen QL = Medications 2 = Brand Medications & Medications NFC = 20

25 Oxycontin PA, QL NFC fentanyl patches, morphine sulfate ER, oxymorphone ER oxymorphone oxymorphone ER QL Pancreaze ST NFC Creon Pancrelipase ST NFC Creon Pandel NFC topical steroids Panretin PA 2 medication pantoprazole QL paricalcitol paroxetine paroxetine CR QL Pertzye ST NFC Creon phenelzine phenobarbital phenytoin Philith Phospholine Iodide NFC pilocarpine Picato PA NFC 5-fluorouracil, imiquimod pilocarpine Pilopine HS NFC pilocarpine Pimtrea pindolol pioglitazone Pataday 2 Patanase NFC azelastine Patanol 2 pioglitazone/ glimepiride pioglitazone/ metformin peg-3350 Peganone PA NFC carbamazepine, lamotrigine, oxcarbazepine, phenytoin, topiramate, valproic acid Pegasys PA, QL 2 medication Peg-Intron PA, QL 2 medication pemoline penicillin Pentasa NFC balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol pentazocine/ acetaminophen QL pentazocine/naloxone Perforomist NFC Serevent, Foradil perindopril permethrin cream perphenazine (ST <2 years of age) Pirmella piroxicam podofilox Pomalyst PA, QL 2 medication Portia potassium chloride Potiga PA, QL 2 carbamazepine, phenytoin, oxcarbazepine, valproic acid, levetiracetam, topiramate, tiagabine, zonisamide Pradaxa QL 2 pramipexole Pramosone NFC hydrocortisone/ pramoxine Prandimet NFC metformin, repaglinide pravastatin prazosin Pred Mild NFC fluorometholone, prednisolone = Medications 2 = Brand Medications & Medications NFC = 2

26 Effective January, 205 prednicarbate prednisolone prednisone Prefest NFC estradiolnorethindrone, Jinteli, Premphase, Prempro Premarin 2 Premarin Vaginal cream 2 Premphase 2 Prempro 2 Prenate NFC generic prenatal vitamins Prepopik NFC peg-3350, Suprep, Moviprep Prevident NFC sodium fluoride gel Prezista 2 primidone Pristiq ST, QL NFC citalopram, fluoxetine, paroxetine, sertaline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Privigen PA 2 medication ProAir HFA ST, QL NFC Ventolin HFA Procrit PA 2 medication Proctofoam-HC 2 Procysbi PA, QL 2 medication progesterone capsule Prolastin PA 2 medication Prolastin-C PA 2 medication Prolensa NFC ketorolac, diclofenac, bromfenac Proleukin 2 medication Prolia PA, QL 2 medication Promacta PA, QL 2 medication propafenone ER propranolol propranolol/hctz propranolol SA protriptyline Proventil HFA ST, QL NFC Ventolin HFA pruvate 2-7 Pulmicort Flexhaler ST NFC Asmanex, Flovent HFA, QVAR Pulmozyme PA, QL 2 medication QNASL ST NFC flunisolide, fluticasone, Veramyst Quartette NFC oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri- Cyclen LO, Safyral Quasense quetiapine PA, QL (ST <2 years of age) quinapril quinapril/hctz Qutenza PA, QL 2 medication QVAR 2 raloxifene ramipril Ranexa 2 ranitidine Rapaflo ST NFC alfuzosin ER, doxazosin, prazosin, tamsulosin, terazosin Ravicti PA, QL 2 medication Rebif ST, QL 2 medication Rectiv PA NFC topical diltiazem compound, topical nifedipine compound Regranex QL 2 medication Relenza QL 2 amantadine Relistor PA 2 medication Relpax ST, QL NFC naratriptan, rizatriptan, sumatriptan, zolmitriptan Remicade PA 2 medication = Medications 2 = Brand Medications & Medications NFC = 22

27 Remodulin PA 2 medication renalpren Renvela 2 Renvela powder packet 2 repaglinide reprexain Rescriptor 2 Rescula ST NFC latanoprost, Lumigan Restasis QL 2 Revlimid PA, QL 2 medication Reyataz 2 Ribasphere QL 2 medication Ribatab QL 2 medication ribavirin QL 2 medication rifabutin rifampin riluzole PA, QL 2 medication Riomet NFC metformin risedronate QL Risperdal Consta PA, QL (ST <2 years of age) 2 medication Sancuso ST, QL NFC ondansetron Sandostatin LAR PA, QL 2 medication Santyl 2 Saphris ST, QL (ST <2 years of age) Savella PA, QL 2 selegiline selenium sulfide shampoo Selzentry PA 2 Sensipar 2 Serevent 2 Seroquel XR PA, ST, QL (ST <2 years of age) NFC NFC risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Serostim PA 2 medication sertraline sevelamer carbonate Signifor PA, QL 2 medication sildenafil 20 mg PA, QL 2 medication risperidone QL (ST <2 years of age) risperidone ODT QL (ST <2 years of age) Simbrinza NFC brimonidine, dorzolamide, Azopt, Combigan Simcor ST NFC simvastatin, niacin ER Rituxan PA, QL 2 medication rivastigmine tartrate capsules PA rizatriptan QL ropinirole ropinirole ER Roxicet solution 2 Sabril PA, QL 2 medication Safyral 2 salicylic acid Samsca PA, QL 2 medication Simponi Aria PA, QL 2 medication Simponi PA, QL 2 medication simvastatin sirolimus PA Sirturo PA 2 Sivextro QL NFC medication sodium fluoride gel sodium phenylbutyrate powder PA sodium sulfacetamide/ sulfur/urea 2 medication Soliris PA 2 medication = Medications 2 = Brand Medications & Medications NFC = 23

28 Effective January, 205 Somatuline PA, QL 2 medication Somavert PA, QL 2 medication sotalol Sovaldi PA, QL 2 medication Spectracef NFC cefpodoxime, cefdinir Spiriva 2 spironolactone spironolactone/hctz Sporanox solution PA NFC itraconazole capsule (PA) Sprintec Sprycel PA, QL 2 medication stavudine Stelara PA, QL 2 medication Stivarga PA, QL 2 medication Strattera QL 2 Striant PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Stribild 2 Suboxone film PA, QL 2 Subsys PA, ST, QL NFC fentanyl citrate (PA), Abstral (PA) Suclear NFC peg-3350, Suprep, Moviprep Sucraid PA 2 medication sulfacetamide sodium sulfamethoxazole/ trimethoprim sulfasalazine sulfasalazine EC sulfisoxazole sulindac sumatriptan QL Sumavel DosePro QL NFC naratriptan, rizatriptan, sumatriptan, zolmitriptan Supprelin LA PA, QL 2 medication Suprax NFC cefpodoxime, cefdinir Suprep 2 Sustiva 2 Sutent PA, QL 2 medication Syeda Sylatron PA 2 medication Sylvant PA 2 medication Symbicort 2 Symlin ST, QL 2 Synagis PA, QL 2 medication Synarel PA, QL 2 medication Synvisc PA, QL 2 medication Synvisc One PA, QL 2 medication Syprine PA 2 medication Tabloid PA 2 tacrolimus tacrolimus ointment PA Tafinlar PA, QL 2 medication Tamiflu QL 2 amantadine tamoxifen tamsulosin Tanzeum ST, QL NFC Bydureon, Victoza Tarceva PA, QL 2 medication Targretin PA 2 medication Tasigna PA, QL 2 medication Tasmar NFC entacapone Tazorac (PA >35 years of age) taztia XT NFC topical acne agents Tecfidera PA, QL 2 medication Tekamlo ST 2 Tekturna ST 2 Tekturna HCT ST 2 telmisartan telmisartan/ amlodipine = Medications 2 = Brand Medications & Medications NFC = 24

29 telmisartan/hctz temazepam temozolomide PA 2 medication Tencon terazosin terbinafine QL Testim PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Testopel PA NFC testosterone injection (PA), Androgel.62% (PA) Testosterone gel PA, ST NFC testosterone injection (PA), Androgel.62% (PA) testosterone injection PA testosterone injection (PA), Androgel.62% (PA) Testred PA, ST NFC testosterone injection (PA), Androgel.62% (PA) tetracaine ophthalmic tetracycline Thalomid PA, QL 2 medication Theo-24 ER NFC theophylline ER theophylline ER thioridazine (ST <2 years of age) thiothixene (ST <2 years of age) Thyrogen 2 medication tiagabine ticlopidine Tikosyn 2 Tilia FE timolol tinidazole Tirosint NFC levothyroxine Tivicay 2 tizanidine tablets TOBI Podhaler QL 2 medication tobramycin Tobradex ST NFC tobramycindexamethasone tobramycindexamethasone tobramycin solution for nebulization QL 2 medication Tobrex NFC ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox tolazamide tolbutamide tolmetin tolterodine tolterodine ER topiragen topiramate topiramate sprinkle QL Toviaz 2 Tracleer PA, ST, QL 2 medication Tradjenta 2 tramadol QL tramadol/ acetaminophen QL tramadol ER tablet QL trandolapril trandolapril/verapamil tranexamic acid PA, QL Transderm-Scop NFC meclizine tranylcypromine Travatan Z ST NFC latanoprost, Lumigan, travoprost (ST) trazodone Trelstar PA, QL 2 medication tretinoin oral 2 medication = Medications 2 = Brand Medications & Medications NFC = 25

30 Effective January, 205 tretinoin topical Trezix triamcinolone triamterene/hctz Tri-estarylla trifluoperazine (ST <2 years of age) Tri-legest FE Tri-linyah Trilyte Trinessa Tri-previfem Tri-sprintec Trivora tropicamide drops trospium trospium ER Truvada 2 Tudorza Pressair 2 Tykerb PA, QL 2 medication Tysabri PA, QL 2 medication Tyvaso PA 2 medication Tyzeka PA 2 medication Uceris PA NFC budesonide Ulesfia NFC Uloric ST, QL 2 allopurinol Ultresa ST NFC Creon unithroid urea Urocit-K NFC potassium citrate ursodiol Vagifem NFC estradiol, estropipate, Premarin valacyclovir QL Valchlor PA 2 medication Valcyte NFC ganciclovir valproate valsartan valsartan/hctz vancomycin capsules Vanoxide-HC NFC benzoyl peroxide Vantas PA, QL 2 medication Vascepa NFC fenofibrate, atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Vasolex NFC Santyl Vectical QL NFC calcipotriene Veletri PA 2 medication Velivet Velphoro NFC calcium acetate, sevelamer carbonate venlafaxine venlafaxine ER capsule QL Ventavis PA 2 medication Ventolin HFA QL 2 Veramyst 2 verapamil verapamil ER PM verapamil extended release verapamil SR Veregen NFC podofilox, imiquimod Vesicare 2 Vestura Vexol NFC fluorometholone, prednisolone Victoza ST 2 Videx solution 2 Vigamox 2 = Medications 2 = Brand Medications & Medications NFC = 26

31 Viibryd PA, QL NFC paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) Vimizim PA 2 medication Vimpat PA NFC carbamazepine, lamotrigine, oxcarbazepine, phenytoin, zonisamide Viokace ST NFC Creon Viracept 2 Viread 2 visqid a/a vistra vitamins (generic pediatric) vitamins (generic prenatal) Vivelle-DOT QL NFC estradiol patch, Premarin Vivitrol PA 2 medication Vogelxo PA, ST NFC testosterone injection (PA), Androgel.62% (PA) Voltaren gel QL NFC diclofenac, ibuprofen, naproxen voriconazole QL Votrient PA, QL 2 medication VPRIV PA 2 medication Vyfemla Vytorin ST NFC atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia Vyvanse QL (PA <4 and >8 years of age) warfarin NFC amphetamine salts, dexmethylphenidate, methylphenidate, Adderall XR, methylin, methylin ER, methylphenidate ER, Strattera Welchol 2 Wera WP Thyroid NFC levothyroxine Wymzya Fe Xalkori PA, QL 2 medication Xarelto QL 2 Xeljanz PA, QL 2 medication Xenazine PA, QL 2 medication Xeomin PA, QL 2 medication Xerac AC 2 Xgeva PA, QL 2 medication Xifaxan 200 mg QL 2 ciprofloxacin, loperamide Xifaxan 550 mg PA, QL NFC lactulose Xolair PA, QL 2 medication Xopenex HFA ST, QL NFC Ventolin HFA Xtandi PA, ST, QL 2 medication Xulane QL Xyrem PA, QL 2 medication zafirlukast zaleplon Zarah Zavesca PA 2 medication Zelapar NFC carbidopa/levodopa, entacapone, ropinirole, pramipexole, carbidopa/levodopa/ entacapone, Azilect Zelboraf PA, QL 2 medication Zemaira PA 2 medication Zenatane Zenchent Fe zenieva Zenpep ST NFC Creon Zeosa Zetia 2 = Medications 2 = Brand Medications & Medications NFC = 27

32 Effective January, 205 Zetonna ST NFC fluticasone, flunisolide, Veramyst Zinotic ES NFC acetic acid/ hydrocortisone, Ciprodex Zioptan ST NFC latanoprost, Lumigan ziprasidone QL (ST <2 years of age) Zirgan gel 2 Zithranol-RR cream NFC Drithocreme Zmax QL NFC azithromycin, clarithromycin, erythromycin Zoladex PA, QL 2 medication zoledronic acid 4 mg 2 medication zoledronic acid 5 mg ST, QL Zolinza PA, QL 2 medication zolmitriptan QL zolpidem tartrate QL Zomig nasal spray QL NFC naratriptan, rizatriptan, sumatriptan, zolmitriptan zonisamide Zontivity PA, QL NFC clopidogrel, Effient Zorbtive PA 2 medication Zortress PA 2 Zovia Zubsolv PA, QL 2 Zyflo NFC montelukast Zyflo CR NFC montelukast Zykadia PA, QL 2 Zylet NFC tobramycindexamethasone Zyprexa Relprevv PA, QL (ST <2 years of age) 2 medication Zytiga PA, QL 2 medication Zyvox QL 2 = Medications 2 = Brand Medications & Medications NFC = 28

33 MEDICATIONS NOT COVERED BY FIRST CHOICE The following medications are benefit exclusions and will not be covered under the pharmacy benefit: Anabolic steroids Antimalarial agents Antiobesity medications, including, but not limited to, appetite suppressants and lipase inhibitors Blood or blood plasma products* Drugs labeled for investigational use Drugs used for cosmetic purposes or hair growth Drugs used to treat sexual dysfunction (examples are Viagra, Levitra, Cialis, Muse, Caverject, Osphena, Stendra) Fertility agents Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over-the-counter medications Needles/syringes (other than insulin)* Nutrition and dietary supplements* Ostomy supplies* Therapeutic devices/appliances* Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.) *Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Health Care Concierge team at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Health Care Concierge team number listed on page of this booklet. 29