Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk

Transcription

1 Quantity Limit List Category Medication * Stadol Nasal Spray Analgesics Ultram tablets Anzemet 50mg & 100mg tabs Emend 40mg (non-preferred) Anti-Emetic Products Emend 80mg Emend 125mg Antineoplastic Agents Zolinza Antipsychotic Agents Beta agonist inhalant and nebulizing agents Central Nervous System (CNS) Stimulants (effective ) CO-2 Sparing Agents Erectile Dysfunction Agents Estrogen patches Granulocyte Colony-Stimulating Factor HMG-CoA Reductase Inhibitors Insulin Narcotic Analgesics (added per P& T action ) Nasal steroid inhalers Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Zydis / Zyprexa All products (e.g. albuterol, metaproterenol) Duoneb Levalbuterol Adderall R 5mg, 10mg, 15mg (preferred) Adderall R 20mg, 25mg, 30mg (preferred) Concerta all strengths except 36mg (preferred) Concerta 36mg strength ONLY (preferred) Metadate CD all strengths (non-preferred) Provigil all strengths (non-preferred) Ritalin LA 20mg & 40mg (non-preferred) Ritalin LA 30 mg (non-peferred) Strattera 10mg, 18mg, 25mg, 40mg (Preferred) Strattera 60mg, 80mg, 100mg (Preferred) Vyvanse (all strengths) (non-preferred) Celebrex 50mg, 100mg & 200mg tabs (non-preferred) Mobic 7.5mg & 15mg tabs (non-preferred) Cialis (all strengths) Levitra (all strengths) Stendra (all strengths) Viagra (all strengths) Generic products Granix Neupogen Neulasta Caduet (all strengths) (non-preferred) Crestor (all strengths) (non-preferred) All products Actiq (all strengths) Avinza (all strengths) Duragesic patches (all strengths) Fentora Kadian (all strengths) MS Contin (all strengths) Oramorph (all strengths) Oxycontin (ECEPT 10MG and 20MG) Oxycontin 10mg and 20mg strengths All products (e.g. beclomethasone, flunisolide) Quantity Limit 5mL (2 bottles) / month 240 tablets / month 12 tablets / copay - 2 fills per month 5 capsules month 2 caps per month 1 cap per month 120 capsules per month 34 tablets per month 2 inhalers or bottles of solution / month 360 ml / month (120 vials) 288 ml / month (96 vials) 34 capsules per month 68 capsules per month 34 tablets per month 68 tablets per month 34 tablets per month 68 capsules per month (prior notification required) 34 capsules per month 68 capsules / month 68 capsules / month 68 capsules / month 68 tablets / month 5 tablets / month 5 tablets / month 5 tablets / month 5 tablets / month 90 day supply for 1 copay 5 doses per chemo cycle 5 doses per chemo cycle 5 doses per chemo cycle 34 tablets / month 34 tablets / month 3 vials or 2 boxes of pens / copay 90 Oralets / month 68 capsules / month 11 patches per strength per month 84 tablets 136 capsules / month 204 tablets / month 204 tablets / month 136 tablets / month 180 tablets / month 1 inhaler / month NSAIDS Clarinex 5mg & Clarinex D 24 hr (non-preferred) Clarinex D 12 hour yzal 5mg (non-preferred) Toradol 10mg tablets 34 tablets per month 68 tablets per month 34 tablets per month 20 tablets / month

2 Quantity Limit List Category Oral Contraceptives Oral Steroid Inhalers Proton Pump Inhibitors All products All products Medication Dexilant all strengths (non-preferred PA required) Ambien all strengths (preferred Ambien CR all strengths (non-preferred) Sedative / Hypnotic Agents Lunesta all strengths (preferred) (effective ) Rozerem all strengths (non-preferred) Sonata all strengths (preferred) Amerge 1mg & 2.5mg tabs Axert 6.26mg & 12.5mg tabs Frova tabs (all strengths) Imitrex Syringe Imitrex 25mg, 50mg, and 100mg tabs Imitrex Nasal Spray 5mg & 20mg Selective Serotonin Receptor Agonist Imitrex Vials Maxalt 5mg & 10mg tablets & disintegrating tabs Relpax 20mg & 40mg tablets Zomig 2.5mg tablets Zomig Nasal Spray Zomig 5mg tablets & Zomig ZMT 5mg Citalopram 40mg tablets (preferred) fluoxetine 10mg (preferred) fluoxetine 20mg (preferred) fluoxetine 40mg (non-preferred) Luvox and fluvoxamine 25mg tab (non-preferred) Luvox and fluvoxamine 50mg tab (nonpreferred) Luvox and fluvoxamine 100mg tab (non-preferred) Luvox CR 100mg & 150mg Selective Serotonin Reuptake Inhibitor Paxil 10mg tablets (non-preferred) Medicaion Class / Antipsychotics Paxil 20mg, 30mg, & 40mg tablets (nonpreferred) Paroxetine 20mg, 30mg, & 40mg tablets (preferred) Paxil CR 12.5mg, 25mg, & 37.5mg (non-preferred) Prozac 10mg tab/cap (non-preferred) Prozac 20mg caps (non-preferred) Prozac 40mg caps (non-preferred) Prozac 90mg caps (non-preferred) Symbyax all strengths (non-preferred) Smoking Cessation Products Chantix (preferred) * Generic products are subject to quantity limits Quantity Limit 3 month supply / 3 copays 2 inhalers / month 9 tablets / Rx; 18 tablets / month 6 tablets / Rx; 12 tablets / month 9 tablets / Rx; 18 tablets / month 1 Kit (2 syringes) / Rx; 2 fills per month 9 tablets (each strength) / Rx; 18 tablets month 6 spray bottles (1 box) / month 5 vials (1 pack) per Rx; 10 vials/ per month 12 tablets / Rx; 24 tablets / month 6 tablets per fill / 12 tablets per month 6 tablets / 12 month 1 box of 6 UD sprays per month 3 tablets / month 45 tablets / month 34 tablets / month 90 capsules / month 68 tablets / month 34 tablets / month 68 tablets / month 102 tablets / month 34 tablets / month 34 tablets / month 68 tablets / month 68 tablets / month 68 tablets / month 34 tablets / month 90 capsules / month 4 capsules / month up to 6 months per calendar year

3 Preferred Drug List Category Preferred (Tier 1 or 2) SSRI's fluoxetine 10mg & 20mg citalopram sertraline paroxetine Celexa Lexapro Luvox Paxil Paxil CR Prozac Sarafem Symbyax Viibryd (PA REQUIRED) Central Nervous System (CNS) methylphenidate methylphenidate SR Stimulants amphetamine salts and Adderall R Strattera Concerta (effective ) Daytrana Focalin Metadate CD Nuvigil (not covered) Provigil (requires prior notification) Ritalin LA Vyvanse Congestive Heart Failure Agents Agents except BiDil BiDil Diabetic Agents glimepiride Avandia Avandaryl Exubera (Prior notification approval required) Glumetza Kombiglyze R Prandimet (ind. Products are preferred) Insulin Non Preferred (Tier 3) HMG-CoA Reductase Agents (Including combination products) and the fenofibrate Agents Symlin Bydureon (Prior notification & step edit) Byetta (Prior Notification Required) Victoza (not a covered benefit) fenofibrate generic products Pravachol lovastatin Lipitor 40mg & 80mg Vytorin Zetia Zocor(simvastatin) (effective ) Advicor Antara (step edit required generic fenofibrate) Caduet Crestor Lescol Lipitor 10mg & 20mg (step edit - simvastatin) Livalo (not a covered benefit) Mevacor Pravigard PAC Simcor Tricor (step edit requires generic fenofibrate) Trilipix (step edit requires generic fenofibrate)

4 Preferred Drug List Preferred Category (Tier 1 or 2) Inhaled Nasal Steroids Fluticasone propionate Step edit requires use of generic product prior to using a brand name agent. NSAID Agents Non-Sedating Antihistamine (note the step edit for nasal steroid inhalers {fluticasone or flunisolide} is use of one generic nasal steroid inhaler before using a brand name product) Leukotriene Receptor Antagonist (step edit for class =use of nasal steroid inhaler OR other asthma medication within previous 12 months) Antiviral Agents Hepatitis B Agents Flunisolide Beconase AQ (Step edit - use of generic product) Flonase (Step edit - use of generic product) Nasacort AQ (Step edit - use of generic product) Nasonex (Step edit - use of generic product) Rhinocoft Aqua (Step edit - use of generic product) Omnaris (Step edit - use of generic product) Veramyst (Step edit - use of generic product) Acetic Acid Agents (indomethacin capsule, sulindac, diclofenac delayed release tablet, tolmetin) Fenemates (meclofenamate) Oxicams (piroxicam) Proprionic Acid Agents (flurbiprofen, ibuprofen, naprosyn sodium tablet, fenoprofen, ketoprofen) Pyranocarboxylic Acid (etodolac tablet) Misc (nabumetone) Celebrex Clarinex Clarinex D 12 hour and 24 hour yzal Advair (available at tier 1 copay) Zyflo Zyflo CR Acyclovir Famvir- Step Edit - acyclovir first line therapy Valtrex - Step Edit - acyclovir first line therapy Epivir Baraclude Non Preferred (Tier 3) (Tier 2 if patient had a 60 trial of Epivir within the previous 90 days)

5 Preferred Drug List Category Sedative Hypnotics - Non Barbiturate Combination Products Antispasmodic Agents Flurazepam Temazepam Triazolam Sonata Ambien Ambien CR Lunesta Rozerem ibuprofen and oxycodone individually metformin and glipizide pravastatin and aspirin Combunox (ibuprofen/oxycodone) Exforge (amlodipine / valsartan) Metaglip (metformin and glipizide) Pravigard PAC (pravastatin and aspirin) Ditropan & Ditropan L Detrol & Detrol LA Enablex Preferred (Tier 1 or 2) Non Preferred (Tier 3) Bisphosphonates - (Bone resorption suppression agents) Neuropathic Pain Agents (effective ) Sanctura & Sanctura R Toviaz alendronate risedronate Forteo (PA required) Atelvia Boniva Neurontin Lyrica not a covered benefit (Tier 2 if patient has had a 60 day trial of Neurontin (gabapentin) in the last 90 days)

6 Preferred Drug List Category Misc Agents Actoplus Met R Altabax Alvesco HFA Inhaler / Alvesco Inhaler (step edit - trial of all formulary inhaled steroid asthma products) Amturnide Antara Apriso Astragraf L (step edit = immediate release tacrilimus Azilect Azor B-Nexa Breo Ellipta Bepreve Brovana Calafol R Centany Citranatal Products Clarifoam EF Cleeravue -M Clobeta + Plus Coartem Combigan Coreg CR Cosopt PF Dificid (Step edit - course of oral Vancomycin) Dulera Dutoprol Edarbi Epidou Equetro Exalgo Fexmid Gelnique Horizant Jentadueto Keppra R Kombiglyze R Lamictal R Lavoclen-4 and Lavoclen-8 Lovaza Maxaron Forte Metrogel Combo Package Metvixia Moviprep Multaq Nesina Nicomide Omnaris Omontys Onglyza Onsolis Otosporin Ostiva Otosporin Oxandrin Patanase Nasal Spray Prepopik Pristiq Profera OB Pyrlex and Pyrlex PD Rapaflo Remesense Renvela Requip L Rosac Saphris Preferred (Tier 1 or 2) Non Preferred (Tier 3)

7 Savella (step edit) Seradex Seroquel R Servira Signafor x Sklice (step edit - use of Lindane or permethrin) Somatuline Depot Sprycel Stavzor Supervite EC Symbicort Taclonex Tasigna Tribenzor Trilpix Tudorza Pressair Twynsta Udamin Ultram ER Vascepa Veramyst Voltaren Gel erese eljanz (step edit - MT) Ziana Zioptan Zymine R and DR Zyclara Brand Name Products available at the Generic Tier 1 ($7.00) Copay Rate Excluded Products Accolate Advair Diskus Alphagan P 5mL botlle ONLY (Quantity limit of 2 bottles / copay) Aricept Atacand Auvi-Q Auto-Injector Copaxone 20mg (Copaxone 40mg is not a covered benefit) EpiPen and EpiPen Jr (Quantity limit of 2 pens / copay) Flovent Nexium (caps tier 1, susp tier 2) Novolin R, N and 70/30 Vials ONLY Accuhist products Ala-Hist products Alcortin A Aldex products Allfen products Allerx products Aldex products Alodox Aloquin Ambifed Products Amrix Analpram P and Advanced Aplenzin Aquoral Asmalpred Plus Atelvia Avidoxy DK Bifillin G Biomed Brisdelle Brovex Products Bystolic Capcof Carbaphen Cardiotek Products Centratex Cleanse and Treat products Clindareach

8 CNL 8 topical Codiclear DH Comfort PAC - Meloxicam Copaxone 40mg (Copaxone 20mg is covered on the tier 1) Cotab products Coraz Corvite FE Corzall Dallergy products Desonil + Plus Desowen Dexall Dexodryl Dailyvite 5000 Neudexta Dexilant Diclegis Differin products for members > 29 yrs of age. Tier 3 for all others Digex NF Doryx Duac CS Duet DHA Stuartnatal Duexis Duovit DHA Dytan CD Egrifta Embeda Endal CD Endometrin Entereg Entex Epiceram Evamist Extendryl products Fanapt Ferralet 90 Flector Patch Folbee Plus Fosteum Fovex Fulyzaq Gattex Gralise Hemangeol Hetlioz HC Guai Hyaltopic Hydrocortisone /Lidocaine in Coleus Kit Ibudone IC400; IC 800 Intermezzo Iprivask J-Coff DHC J-Max Products J-Tan D HC Jalyn Juvisync Juxtapid Kapidex / Dexilant Kerol Products Lazanda LidoCort KIT Limbrel Livalo Lycelle M-End Max Manuvit SP

9 Maxichlor PSE DM Maxifed products / Maxiflu products / Maxiphen products Medent-DMI Mi-Omega NF Minocin Kits Momexin Momexin Moxatag Myalept Nalfrx Nasofed / Nasotuss Nasohist products Natelle Plus Neo HC Neutrahist Products Niravam Notuss product line Nucynta / Nucynta ER Nuvigil Nutridox Nutrestore Obagi - C Omeclamox-Pak Optinate Oraxyl Orenitram Ortho-Nesic Papfyll Pediatex TDM Pedipirox-4 Pennsaid Topical Peranex HC PhenFlu products Physician Therapeutics products Polytussin DHC Pramine FQ Prefera-OB Prenate products Prenatal vitamins with DHA supplements Probarimin QT Prolinia Protect Cardio / Protect CMB2/Ceramide/Protect Iron/ Protect Bone Pryflex Pylera Quinzyme Radigel Rayos Re Dualvit products Relcof DN PE Renatabs with Iron Reocyte Plus Respi-tann products Rezyst IM Rhinahist Rinnovi Rosadan Rosula products Rowasa KITS Rybix ODT Ryzolt (tramadol preferred; Ultram ER tier 3) Salex Salvax Duo products Samsca Scalacort DK Solaraze Gel Solotuss Strovite Advance + D

10 Subsys Sudates-G Sumadan / Sumaxin CP Sympak products Tachosil Tandem DHA Tear Again Terbinex Tersi Foam Tirosint Tozal Treximet Trital SR Tussicaps Tizanidine (Comfort Pac) Ultravate PAC Uloric Umecta Vanacof products Vanoxide HC Kit V-Hist / V-Cof Velphoro Vimizim Vimovo Viravan products Vitamax Vitaphil Viva DHA olegel DUO and Corepak yralid products Zamicet Zenieva Z-Care Zinotic Zinx Zotex-D Z Tuss 2 Zypram Zytaze Zytopic

11 Benefit Exclusions Compounded Products Cosmetic Agents - Medications used for cosmetic purposes are not covered. (e.g. Propecia) Vitamins - OTC Vitamins are not covered - Prescription vitamins may be covered SPHN covers the following Over-the-Counter Medications ($5.00 Copay for a days supply, depending on package size) Nicotine Patches, Lozenges, and Gum (quantity limit of 2 boxes per fill) OTC Prilosec and OTC omeprazole loratadine tablets and liquid Prior Notification Medications (all Specialty Pharmacy Medications require prior notification) Medication Information Abstral Submit request to MedImpact. If approved, covered on Tier 3 Actemra Submit request to MedImpact. If approved, covered on Tier 2 Adempas Submit request to MedImpact. If approved, covered on Tier 3 Adcirca Submit request to MedImpact. If approved, covered on Tier 2 Afinitor Submit request to MedImpact. If approved, covered on Tier 3 Ampyra Submit request to MedImpact. If approved, covered on Tier 3 Arcalyst Submit request to MedImpact. If approved, covered on Tier 3 Aplenzin Submit request to MedImpact. If approved, covered on Tier 3 Astagraf L (step edit - generic tacrolimus) Submit request to MedImpact. If approved, covered on Tier 3 Aubagio Submit request to MedImpact. If approved, covered on Tier 3 Benlysta Bosulif Submit request to MedImpact. If approved, covered on Tier 3 Brilinta Brintellix Brovana Submit request to MedImpact. If approved, covered on Tier 3 Bydureon Submit request to MedImpact. If approved, covered on Tier 3 Butrans Submit request to MedImpact. If approved, covered on Tier 3 Byetta Submit request to MedImpact. If approved, covered on Tier 3 Carbaglu Submit request to MedImpact. If approved, covered on Tier 3 Castagon Submit request to MedImpact. If approved, covered on Tier 3 Chemotherapy oral brand name agents Submit request to PHP - Health Helps Cimzia Submit request to MedImpact. If approved, covered on Tier 2 Compounded Prescriptions Not a covered beneft with the exception of oral liquids, which may be covered. Cometriq Submit request to MedImpact. If approved, covered on Tier 3 Daliresp Submit request to MedImpact. If approved, covered on Tier 3 Dificid Submit request to MedImpact. If approved, covered on Tier 3 (requires tx with oral vanco first) Duavee Submit request to MedImpact. If approved, covered on Tier 3 Egrifta Submit request to MedImpact. If approved, covered on Tier 2 Emend 40mg Submit request to MedImpact. If approved, covered on Tier 3 Emsam Submit request to MedImpact. If approved, covered under Tier 3. Oral seligiline is preferred Enbrel Submit request to MedImpact. If approved, covered on Tier 2 Erivedge Submit request to MedImpact. If approved, covered on Tier 3 ESA Agents Submit request to PHP Submit request to Plan. If approved, covered on Tier 3 Submit request to Plan. If approved, covered on Tier 3 Prior Authorization Required. Submit request to Plan Exalago Submit request to MedImpact. If approved, covered on Tier 3 Famvir Submit request to MedImpact. If approved, covered on Tier 3. Fentora Submit request to MedImpact. If approved, covered under Tier 3. Fetzima Submit request to MedImpact. If approved, covered under Tier 3. Firazyr Submit request to MedImpact. If approved, covered under Tier 3. Flolan Submit request to MedImpact. If approved, covered on Tier 2 Forteo Submit request to MedImpact. If approved, covered on Tier 2 Fortesta Submit request to MedImpact. If approved, covered under Tier 3. Fycompa Submit request to MedImpact. If approved, covered under Tier 3. Gilenya Submit request to MedImpact. If approved, covered under Tier 3. Gilotrig Submit request to MedImpact. If approved, covered under Tier 3.

12 Grastek Submit request to MedImpact. If approved, covered under Tier 3. Growth Hormones Submit request to MedImpact. If approved, covered under Tier 3. Hizentra Submit request to MedImpact. If approved, covered on Tier 2 Humira Submit request to MedImpact. If approved, covered on Tier 2 Iclusig Submit request to MedImpact. If approved, covered under Tier 3. Imbruvica Submit request to MedImpact. If approved, covered under Tier 3. Incivek Submit request to Plan. If approved, covered on Tier 2 Inlyta Submit request to MedImpact. If approved, covered under Tier 3. Isentress Submit request to MedImpact. If approved, covered under Tier 3. Jakafi Submit request to MedImpact. If approved, covered under Tier 3. Jublia Submit request to MedImpact. If approved, covered under Tier 3. Kalbitor Submit request to the Plan. If approved it is covered under the medical side. Kalydeco Submit request to MedImpact. If approved, covered under Tier 3. Kuvan Submit request to MedImpact. If approved covered on Tier 3. Need diagnosis verification Latuda Submit request to MedImpact. If approved, covered under Tier 3. Letairis Submit request to MedImpact. Lipichol Submit request to MedImpact. If approved, covered under Tier 3. Mervasco Submit request to MedImpact. If approved, covered under Tier 3. Myrbetriq Submit request to MedImpact. If approved, covered under Tier 3. Neupogen Submit request to MedImpact. If approved, covered on Tier 2 Neulasta Submit request to MedImpact. If approved, covered on Tier 2 NPlate Submit request to PHP Olysio Submit request to MedImpact. If approved, covered under Tier 3. Onfi Submit request to MedImpact. If approved, covered under Tier 3. Onsolis Submit request to MedImpact. If approved, covered on Tier 3 Opana Submit request to MedImpact, include documentation showing superiority over other opioids. If approved, covered under Tier 3. Opsumit Submit request to MedImpact, include documentation showing superiority over other opioids. If approved, covered under Tier 3. Oralair Submit request to MedImpact. If approved, covered on Tier 3 Orencia SUBQ Submit request to MedImpact. If approved, covered on Tier 3 Otezla Submit request to MedImpact. If approved, covered on Tier 3 Otrexup Submit request to MedImpact. If approved, covered on Tier 3 Pertzye Submit request to MedImpact. If approved, covered on Tier 3 Picato Submit request to MedImpact. If approved, covered on Tier 3 Potiga Submit request to MedImpact. If approved, covered on Tier 3 Prilosec Submit request to MedImpact. If approved, covered on Tier 3 Procysbi Submit request to MedImpact. If approved, covered on Tier 3 Promacta Submit request to PHP Promalyst Submit request to MedImpact. If approved, covered on Tier 3 Provigil Submit request to MedImpact. If approved, covered on Tier 3 Ragwitek Submit request to MedImpact. If approved, covered on Tier 3 Ranexa Submit request to MedImpact. If approved, covered on Tier 3 Ravicti Submit request to MedImpact. If approved, covered on Tier 3 Relistor Submit request to MedImpact. If approved, covered on Tier 3 Remodulin Submit request to MedImpact. If approved, covered on Tier 2 Revatio Submit request to MedImpact. If approved, covered on Tier 2 Samsca Submit request to MedImpact. If approved, covered on Tier 3 Sancuso Submit request to MedImpact. If approved, covered on Tier 3 Simponi Submit request to MedImpact. If approved, covered on Tier 2 Signifor Submit request to MedImpact. If approved, covered on Tier 3 Sirturo Submit request to MedImpact. If approved, covered on Tier 3 Sovaldi Submit request to MedImpact. If approved, covered on Tier 3 Stelara Submit request to MedImpact. If approved, covered on Tier 3 Stivarga Submit request to MedImpact. If approved, covered on Tier 3

13 Suboxone Submit request to MedImpact. If approved, covered on Tier 2 Synalar TS Submit request to MedImpact. If approved, covered on Tier 3 Tafinlar Submit request to MedImpact. If approved, covered on Tier 3 Tanzeum Submit request to MedImpact. If approved, covered on Tier 3 Tecfidera Submit request to MedImpact. If approved, covered on Tier 3 Thalomid Submit request to MedImpact. If approved, covered on Tier 3 Thelin Submit request to MedImpact. If approved, covered on Tier 2 Tivicay Submit request to MedImpact. If approved, covered on Tier 3 Tracleer Submit request to MedImpact. If approved, covered on Tier 2 Tykerb Submit request to MedImpact. If approved, covered on Tier 3 Valchlor Submit request to MedImpact. If approved, covered on Tier 2 Valtrex (step edit - acyclovir) Submit request to MedImpact. If approved, covered on Tier 3 Vandetanib Submit request to MedImpact. If approved, covered on Tier 2 Ventavis Submit request to MedImpact. If approved, covered on Tier 3 Victrelis Submit request to Plan. If approved, covered on Tier 2 Victoza (step edit - Byetta/Bydureon) Submit request to MedImpact. If approved, covered on Tier 3 Viibryd Submit request to MedImpact. If approved, covered on Tier 2 Vimpat Submit request to MedImpact. If approved, covered on Tier 3 Votrient Submit request to MedImpact. If approved, covered on Tier 2 Weight Loss Medications (Legend only) Submit request to MedImpact alkori Submit request to MedImpact. If approved, covered on Tier 3 enazine Submit request to MedImpact. If approved, covered on Tier 2 Zegerid Submit request to MedImpact. If approved, covered on Tier 3 Zelboraf Submit request to MedImpact. If approved, covered on Tier 3 Zithranol Submit request to MedImpact. If approved, covered on Tier 2 Zontivity Submit request to MedImpact. If approved, covered on Tier 3 Zykadia Submit request to MedImpact. If approved, covered on Tier 3 Zytiga Submit request to MedImpact. If approved, covered on Tier 3

14 Medication Extended Supply List Please Note: Generic dispensed when available. Brand name in most cases only listed for name recognition. *Asterisked agents do not currently have a generic available. I. 100 Units or 34 days supply, whichever is greater Antidiabetic Agents Chlorpropamide (eg. Diabinese) Glipizide (Glucotrol) Glyburide (Micronase/Diabeta) Metformin (Glucophage) Antihypertensives Atenolol (eg. Tenormin) Diltiazem (Dilacor R only) Hydrochlorothiazide / Triamterene (eg.dyazide/maxzide) Nifedipine (Adalate CC only) Nitroglycerine (eg. Nitrobid/Nitrostat) Propranolol (eg. Inderal) Verapamil (Verapamil SR only) Cardiac Agents Digoxin Procainamide HCl (Procan/Pronestyl) Quinidine Diuretics Bumetanide (Bumex) Chlorthalidone (eg. Hygroton) Chlorothiazide (eg. Diuril) Furosemide (eg. Lasix) Hydrochlorothiazide (eg. Hydrodiuril) Conjugated Estrogens Maximum 3 packs Anti-inflamatory agents (eg. Premarin*, Premaphase*, Prempro*) Ibuprofen (eg. Motrin) Medroxyprogesterone (Provera) Naproxen (eg. Naprosyn) Naproxen Sodium (eg. Anaprox) Anti-Lipid Agents Atorvastatin (Lipitor) Fluvastatine (Lescol)* Gemfibrozil (Lopid) Lovastatin (Mevacor) Pravastatin (Pravachol) Simvastatin (Zocor) Bronchodilators Theophylline (eg. Theodur/Slo-bid) H 2 Blockers Cimetidine Ranitidine Hyperuricemia/Gout agents Allopurinol (eg. Zyloprim) Potassium Chloride (eg. Kay Ciel/Slow K/K Dur/ Micro K/Klotrix) Estrogen and Hormone Therapy Esterified Estrogens (eg. Estratab, Estrace, Ortho-est) II. 200 Units or 34 day supply, whichever is greater Phenytoin (eg. Dilantin) Isoniazid (eg. INH) Primidone (eg. Mysoline) Levothyroxine (eg. Levothroid/Synthroid) Propylthiouricil (eg. PTU) Para-Aminosalicylic acid (eg. PAS) Thyroid (eg. Armour Thyroid)