Formulary Comprehensive. (Complete list of covered drugs) AARP MedicareRx Saver Plus (PDP) Inside

Transcription

1 01 Comprehensive Formulary (Complete list of covered drugs) AARP MedicareRx Saver Plus (PDP) Inside tiers and drug payment stages and limits Complete list of drugs by category Index of covered drugs Please read: This document contains information about the drugs covered by this plan. Note to existing members: This complete formulary has changed since last year. Please review this document to make sure it still contains the drugs you take , 8 Y0066_9818_000_Final_P0 CMS Approved

2 About this complete drug list This is a complete list of prescription drugs that are covered by the AARP MedicareRx Saver Plus (PDP) plan, insured through UnitedHealthcare, for the 01 plan year. It is called the Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan. For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your drug is covered: 1. See if your drug is included in this complete drug list.. Visit the plan website at You can use online tools to look up your drugs. The information is updated on a regular basis.. Call UnitedHealthcare Customer Service at , TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. UnitedHealthcare Customer Service can look up your drugs and let you know if they are covered. For more information Please take the time to review your Evidence of Coverage and any other 01 plan materials you have received. These materials give more detailed information about your drug coverage in the plan. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day, 7 days a week. TTY/TDD users should call Or visit Questions? If you have questions, we re here to help. Call UnitedHealthcare Customer Service at , TTY a.m. to 8 p.m. local time, 7 days a week Or visit Online tools Visit to Look up your drugs and see what you could save with lower-cost drugs View your cost and benefits summary Track your payment status and claims history Find network pharmacies Print plan forms and materials If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the UnitedHealthcare Customer Service number on the back of your member ID card.

3 01 Complete drug list The AARP MedicareRx Saver Plus plan is designed to help you manage your prescription drug costs. An important part of this is giving you choices so you and your doctor can choose the best course of treatment for you. A formulary is a list of the drugs covered by a Part D plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The plan will generally cover the drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. With your doctor s help, you can use this drug list as a tool to choose the drugs that work best for you and to find lower-cost drugs, if needed. Using the drug list There are two ways to find your prescription drugs in this complete drug list: 1. Alphabetical list (index): Turn to the Index of covered drugs section, which begins on page 6, to see the list of drug names in alphabetical order.. Medical condition: Turn to the Covered drugs by category section, which begins on page 8, to look for drug names based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular s category and look under Cholesterol Control s. Is it a generic or brand name drug? The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin). More information about your drug Some drugs have requirements or limits. Please see the and limits section on page for more information on drugs you may use. This document is a complete list of covered drugs. If your drug is not included in this drug list, you should contact UnitedHealthcare Customer Service to ask if it s covered, or go to to look it up online. If you learn that the plan does not cover your drug, you have two options: 1. You can ask UnitedHealthcare Customer Service for a list of similar drugs that are covered by the plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.. You can ask the plan to make an exception and cover your drug. See the Coverage decisions section on page 5 for information about how to request an exception. 1

4 tiers and drug payment stages The amount you pay for a covered drug will depend on: Your drug payment stage. The plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage you re in. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a different copay or coinsurance amount. The chart below shows the differences between the tiers. For more information about drug payment stages and copay or coinsurance amounts for each tier, please refer to the plan s Evidence of Coverage (EOC). If you qualify for extra help If you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for extra help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to find out what your costs are. You can also contact UnitedHealthcare Customer Service. Copay or Coinsurance 1: Preferred generic Lowest copay : Non-preferred generic Low copay : Preferred brand Medium copay : Non-preferred brand Highest copay 5: Specialty tier Coinsurance Includes Lower-cost, commonly used generic drugs. Most generic drugs. Many common brand name drugs, called preferred brands, and some higher cost generic drugs. Non preferred generic and non-preferred brand name drugs. Unique and/or very high cost drugs. Helpful Tips Use 1 drugs for the lowest out of-pocket costs. Use drugs, instead of or, to help reduce your out-of-pocket costs. Many drugs have lower cost options in 1 or. Ask your doctor if they could work for you. Many drugs have lower-cost options in 1, or. Ask your doctor if you can switch to one of these drugs to help reduce your out of-pocket costs. You pay a percentage of the total drug cost, called coinsurance.

5 Generic drugs The plan covers both brand name and generic drugs. The Food and Administration (FDA) requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs, whether preferred or non-preferred, may save you money on your copays or coinsurance and may help you stay out of the coverage gap if you have one. To pay less out of pocket, talk with your doctor to see if any of the brand name drugs you take have generic versions. While most generics are in of the drug list, some generics can be found in 1. While generic drugs usually cost less than brand name drugs, newly available generic drugs can be expensive so they may be in, or of the drug list. Vaccines The plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine medication and the administration of the vaccine shot. Some vaccines, like those for the flu and pneumonia, may be covered by Medicare Part B (doctor and outpatient health care). For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state allows it. The administration fee likely will be lower at a network pharmacy than at your doctor s office. You also won t have to fill out a form to get paid back (reimbursed). If the administration fee is less than $0, you will pay only your copay or coinsurance amount. If it is more than $0, you will pay the extra amount. If you get your vaccines at your doctor s office, you will pay the entire cost of the vaccine and administration fee to your doctor. You will have to submit a form to the plan to get reimbursed. You will pay your copay or coinsurance amount, plus the difference between $0 and the administration fee charged by your doctor. Please see your Evidence of Coverage for more information about vaccines and their costs. To make sure a recommended vaccine is covered or to request a reimbursement form, call UnitedHealthcare Customer Service at , TTY 711. Or visit to download a reimbursement form.

6 and limits Some of the plan s drugs have requirements or limits to help ensure safe, effective and affordable use. If your drug has any requirements or limits, there will be a code(s) in the & Limits column of the drug list starting on page 8. The codes and what they mean are shown below. Visit for more information. You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug. See the Coverage decisions section on the next page or see your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement or limit, you may be responsible for paying the full cost of the drug. B/D LA PA ST Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. Limited access s are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don t get approval, the plan may not cover the drug. Step therapy There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. For more information about requirements and limits, call UnitedHealthcare Customer Service at , TTY 711.

7 Coverage decisions At times you may need to ask for drug coverage that s not normally provided by the plan. When you do, the plan will consider your request and respond with a coverage decision (coverage determination). Examples of coverage decisions you may ask for include: Asking the plan to pay you back for the cost of a drug you bought at an out of network pharmacy. Asking for an exception to the plan s coverage rules. How to request an exception You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make. You can ask the plan to cover your drug even if it is not on the formulary (formulary exception). You can ask the plan to waive coverage restrictions or limits on your drug (utilization exception). For example, for certain drugs, the plan limits the amount of the drug that it will cover. You can ask the plan to provide a higher level of coverage for your drug (tier exception). If your drug is in the non-preferred tier, you can ask the plan to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in the plan s formulary, you may not ask us to provide a higher level of coverage for the drug. exceptions are not available for drugs in the specialty tier. Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Asking for a coverage decision You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling UnitedHealthcare Customer Service at , TTY 711. When you are requesting a formulary, tiering or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. See your Evidence of Coverage for more information. Receiving a coverage decision Generally, the plan will make a coverage decision within 7 hours after receiving your prescribing physician s statement. You can request an expedited, or fast, decision if you or your doctor believe your health requires it. If the plan agrees to a fast decision, you will receive a decision within hours after the plan receives your prescriber s or prescribing physician s supporting statement. 5

8 list changes The plan recognizes that drug list stability is very important to you. That is why the plan tries to make as few changes to the drug list as possible during the plan year. From time to time, drug list changes may be necessary for safety or other reasons. The drug list may change throughout the year when the plan: Adds a new drug. Removes a drug. Changes the requirements or limits for a drug. Moves a drug to a lower-cost tier. Moves a drug to a higher-cost tier. If the FDA declares a drug to be unsafe or the drug s manufacturer removes the drug from the market, the plan will immediately remove the drug from the drug list and inform affected members. If a drug moves to a higher cost tier or undergoes some other change, the plan will inform affected members at least 60 days before the change or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. Generally, if you are taking a drug on the 01 drug list that was covered at the beginning of the year, the plan will not remove the drug from the drug list or move a drug to a higher tier during the 01 coverage year except when a new, less expensive generic equivalent drug becomes available (for example, the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), or when new information about the safety or effectiveness of a drug is released. Other types of changes, such as removing a drug from the drug list, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. It is important that you have continued access for the remainder of the coverage year to the list of drugs that were available when you chose the plan, except for cases in which you can save additional money or your safety is a concern. If there are changes to the drug list such as regular or necessary updates, members may see information in the Explanation of Benefits statement, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The plan website also has updated information. 6

9 Transition supply process New or continuing members As a new or continuing member in the plan, you may be taking drugs that are not on the formulary. Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception so that the plan will cover the drug you take. While you talk to your doctor to determine the right course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a member of the plan. For each of your drugs that is not on the formulary, or if your ability to get your drugs is limited, the plan will cover a temporary 1-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 1-day supply, the plan will not pay for these drugs, even if you have been a member of the plan less than 90 days. Long-term care facility residents If you re a resident of a long-term care facility, the plan will allow you to refill your prescription until we have provided you with a 91- and up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is for fewer days). The plan will also cover one or more refills for the first 90 days of your membership. If you need a drug that s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of your plan membership, the plan will cover a 1-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that s not on the drug list, or if it s difficult for you to get your drugs, you are required to use the plan s exception process. You may ask for a one-time emergency supply of up to 1 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. For more information For more detailed information about AARP MedicareRx Saver Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call UnitedHealthcare Customer Service at , TTY a.m. to 8 p.m. local time, 7 days a week Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day, 7 days a week. TTY/TDD users should call Or visit 7

10 Covered drugs by category The comprehensive formulary (drug list) below provides coverage information about all of the drugs covered by the plan. It is current as of January 1, 01. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the column tells you if the plan has any special requirements for coverage of your drug. If you have trouble finding your drug in the list, turn to the Index of covered drugs section that begins on page 6. If your prescription is not in this complete formulary, please visit or call UnitedHealthcare Customer Service at , TTY 711, for additional help. Name Name Analgesics s to Treat Pain, Inflammation, and Muscle and Joint Conditions Nonsteroidal Anti-Inflammatory s Pain/Anti-Inflammatory s Diclofenac Potassium Diclofenac Sodium DR Diclofenac Sodium ER Diflunisal Etodolac (00mg Capsule, Tablet) Flurbiprofen Ibuprofen (Suspension, 00mg Tablet, 600mg Tablet, 800mg Tablet) Indomethacin (Capsule) Ketoprofen Ketorolac Tromethamine (Tablet) Ketorolac Tromethamine (15mg/ml Injection, PA 0mg/ml Injection) Mefenamic Acid Meloxicam (Tablet) 1 Meloxicam (Suspension) Naproxen Naproxen DR Naproxen Sodium (75mg Tablet, 550mg Tablet) Oxycodone/Ibuprofen Sulindac Opioid Analgesics, Long-Acting Opioid Pain Relievers Astramorph Duramorph Exalgo Fentanyl (Patch) Levorphanol Tartrate Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 8

11 Name Name Methadone HCl (Concentrate, Oral Solution, Tablet) Methadone HCl (Injection) Methadose (Tablet) Morphine Sulfate (Oral Solution, Tablet) Morphine Sulfate ER Nucynta ER Opioid Analgesics, Short-Acting Opioid Pain Relievers Acetaminophen/Codeine Butorphanol Tartrate Co-Gesic Codeine Sulfate (Tablet) Fentanyl Citrate Oral Transmucosal 5 PA Hydrocodone/ Acetaminophen (Oral Solution, 00mg; 10mg Tablet, 00mg; 5mg Tablet, 00mg; 7.5mg Tablet, 5mg; 10mg Tablet, 5mg; 5mg Tablet, 5mg; 7.5mg Tablet, 500mg; 10mg Tablet, 500mg;.5mg Tablet, 500mg; 5mg Tablet, 500mg; 7.5mg Tablet, 650mg; 10mg Tablet, 650mg; 7.5mg Tablet, 660mg; 10mg Tablet, 750mg; 10mg Tablet, 750mg; 7.5mg Tablet) Hydrocodone/Ibuprofen Hydromorphone HCl (Tablet) Nalbuphine HCl Onsolis 5 PA Oxycodone HCl (Capsule, Concentrate, 15mg Tablet, 0mg Tablet, 5mg Tablet) Oxycodone/ Acetaminophen Oxycodone/Aspirin Roxicet (500mg; 5mg Tablet) Stagesic Tramadol HCl Tramadol HCl/ Acetaminophen Anesthetics s for Numbing Local Anesthetics Lidocaine (Ointment) B/D Lidocaine HCl (External Solution) Lidocaine HCl (0.5% Injection, 1% Injection) B/D Lidocaine HCl (Gel) Lidocaine Viscous Lidocaine/Prilocaine (Cream) B/D Lidoderm Antibacterials s to Treat Bacterial Infections Aminoglycosides Antibiotics Amikacin Sulfate (500mg/ml Injection, 50mg/ml Injection) Gentak (Ointment) Gentamicin Sulfate (Cream, Injection, 0.1% Ointment, Ophthalmic Solution) Gentamicin Sulfate/NaCl (1.mg/ml; 0.9% Injection, 1.6mg/ml; 0.9% Injection, 1mg/ml; 0.9% Injection) 9

12 Name Name Gentamicin Sulfate/ NaCl (0.9mg/ml; 0.9% Injection, 1.mg/ml; 0.9% Injection) Isotonic Gentamicin (0.8mg/ml; 0.9% Injection) Kanamycin Sulfate Neomycin Sulfate Neomycin/Polymyxin B Sulfates Paromomycin Sulfate Streptomycin Sulfate Tobi 5 B/D Tobramycin Sulfate (Ophthalmic Solution) Tobramycin Sulfate (10mg/ml Injection, 80mg/ml Injection) Tobramycin Sulfate/ Sodium Chloride Tobrex (Ointment) Antibacterials, Other Antibiotics Baciim Bacitracin (Injection, Ophthalmic Ointment) Bacitracin/Polymyxin B Chloramphenicol Sodium Succinate Cleocin (75mg Capsule) Cleocin Galaxy Cleocin in D5W Cleocin Phosphate (900mg/6ml Injection) Clindamycin HCl (150mg Capsule, 00mg Capsule) Clindamycin Phosphate (Cream) Clindamycin Phosphate Add-Vantage Colistimethate Sodium Cubicin 5 B/D Flagyl ER Lincocin Methenamine Hippurate Metronidazole Metronidazole in NaCl 0.79% Metronidazole Vaginal Mupirocin Neomycin/Bacitracin/ Polymyxin Neomycin/Polymyxin/ Gramicidin Nitrofurantoin Nitrofurantoin Macrocrystalline (50mg Capsule) Nitrofurantoin Monohydrate Polymyxin B Sulfate Primsol Silver Sulfadiazine SSD Synercid 5 Thermazene Trimethoprim Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 10

13 Name Name Trimethoprim Sulfate/ Polymyxin B Sulfate Tygacil Vancocin HCl 5 PA Vancomycin HCl (1000mg Injection, 10gm Injection, B/D 500mg Injection) Vancomycin HCl (Capsule) 5 PA Vandazole Vibativ (50mg Injection) Xifaxan (00mg Tablet) Xifaxan (550mg Tablet) 5 Zyvox 5 PA Beta-Lactam, Cephalosporins Antibiotics Cedax (Capsule) Cefaclor Cefaclor ER Cefadroxil Cefazolin Sodium (10gm Injection, 1gm Injection, 1gm; 5% Injection, 500mg Injection) Cefdinir Cefepime (1gm Injection, gm Injection) Cefotaxime Sodium (10gm Injection, 1gm Injection, gm Injection) Cefoxitin Sodium Cefoxitin Sodium/ Dextrose Cefpodoxime Proxetil Cefprozil Ceftazidime (1gm Injection, gm Injection, 6gm Injection) Ceftazidime/Dextrose Ceftriaxone Sodium Cefuroxime Axetil (Tablet) Cefuroxime Sodium (1.5gm Injection, 7.5gm Injection, 750mg Injection) Cephalexin Claforan (1gm Injection) Fortaz (1gm/50ml; 5% Injection, gm Injection, gm/50ml; 5% Injection, 6gm Injection) Suprax Zinacef (750mg Injection) Zinacef in Iso-Osmotic Dextrose Zinacef in Iso-Osmotic Diluent Beta-Lactam, Other Antibiotics Azactam in Iso-Osmotic Dextrose Aztreonam (1gm Injection) Cayston 5 PA Cefotetan Doribax (500mg Injection) Imipenem/Cilastatin Invanz Meropenem (500mg Injection) Primaxin Beta-Lactam, Penicillins Antibiotics Amoxicillin Amoxicillin/Potassium Clavulanate Amoxicillin/Potassium Clavulanate ER Ampicillin Ampicillin Sodium (10gm Injection, 15mg Injection, 1gm Injection) 11

14 Name Name Ampicillin-Sulbactam (10gm; 5gm Injection, gm; 1gm Injection) Bactocill in Dextrose (1gm/50ml Injection) Bactocill in Dextrose (gm/50ml Injection) 5 Bicillin C-R Bicillin L-A Dicloxacillin Sodium Nafcillin Sodium (10gm Injection, 1gm Injection) Nallpen/Dextrose (1gm/50ml Injection) Oxacillin Sodium (10gm Injection, 1gm Injection) Penicillin G Potassium (5mu Injection) Penicillin G Potassium in Iso-Osmotic Dextrose Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium Pfizerpen-G (0mu Injection) Piperacillin Sodium/ Tazobactam Sodium (gm; 0.75gm Injection, gm; 0.5gm Injection) Timentin (0.1gm; gm Injection) Zosyn (gm; 0.75gm Injection, 5%; gm/50ml; 0.5gm/50ml Injection, 5%; gm/50ml; 0.75gm/50ml Injection) Macrolides Antibiotics Azithromycin (500mg Injection, Suspension Reconstituted, Tablet) Clarithromycin Clarithromycin ER Dificid 5 PA E.E.S. 00 E.E.S. Granules Ery Ery-Tab Eryped Erythrocin Lactobionate (500mg Injection) Erythrocin Stearate Erythromycin (External Solution, Gel, Ointment) Erythromycin Base Erythromycin Ethylsuccinate Ketek PA PCE Zmax Quinolones Antibiotics Avelox (Tablet) Avelox (Injection) Avelox ABC Pack Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 1

15 Name Name Cipro (Suspension Reconstituted) Cipro IV (00mg/100ml; 5% Injection) Ciprofloxacin (00mg/0ml Injection) Ciprofloxacin ER Ciprofloxacin HCl Factive Levofloxacin Levofloxacin in D5W (5%; 500mg/100ml Injection) Moxeza Noroxin Ofloxacin Sulfonamides Antibiotics Sodium Sulfacetamide (Ophthalmic Solution) Sulfacetamide Sodium (Ointment) Sulfadiazine Sulfamethoxazole/ Trimethoprim Sulfamethoxazole/ Trimethoprim DS Tetracyclines Antibiotics Demeclocycline HCl Doxycycline (75mg Capsule) Doxycycline Hyclate (Capsule, Injection, Tablet, 100mg Tablet Delayed Release, 75mg Tablet Delayed Release) Doxycycline Hyclate (150mg Tablet Delayed Release) Doxycycline Monohydrate (150mg Tablet, 50mg Tablet, 75mg Tablet) Minocycline HCl (Capsule) Minocycline HCl ER Tetracycline HCl Vibramycin (Syrup) Anticonvulsants s to Treat Seizures Anticonvulsants, Other Seizure Control s Levetiracetam (500mg/5ml Injection, Oral Solution, Tablet) Levetiracetam ER Phenobarbital (Elixir, 16.mg Tablet, 0mg Tablet,.mg Tablet, PA 6.8mg Tablet, 97.mg Tablet) Potiga Calcium Channel Modifying Agents Seizure Control s Celontin Ethosuximide Lyrica Zonisamide Gamma-Aminobutyric Acid (GABA) Augmenting Agents Seizure Control s Clonazepam PA Clonazepam ODT Clorazepate Dipotassium PA Diazepam (Gel) PA Divalproex Sodium Divalproex Sodium DR Divalproex Sodium ER Gabapentin Gabitril Onfi PA Primidone 1

16 Name Name Sabril 5 PA Valproate Sodium (100mg/ml injection) Valproic Acid Glutamate Reducing Agents Seizure Control s Felbamate (Tablet) Felbamate (Suspension) 5 Felbatol (Tablet) Felbatol (Suspension) 5 Lamictal ODT (Tablet Dispersible) Lamictal Starter Kit Lamotrigine (Tablet) Lamotrigine (Tablet Chewable) Topiramate Sodium Channel Agents Seizure Control s Banzel Carbamazepine Carbamazepine ER (Capsule Extended Release 1 Hour) Dilantin Dilantin Infatabs Epitol Equetro Fosphenytoin Sodium (100mg pe/ml Injection) Oxcarbazepine Peganone Phenytek Phenytoin Phenytoin Sodium Phenytoin Sodium Extended Tegretol Tegretol-XR Trileptal (Suspension) Vimpat (Oral Solution, Tablet) Vimpat (Injection) PA Antidementia Agents s to Treat Alzheimer s Disease and Dementia Cholinesterase Inhibitors Alzheimer s Disease and Dementia s Donepezil HCl Exelon (Oral Solution) Exelon (Patch Hour) ST Rivastigmine Tartrate N-methyl-D-aspartate (NMDA) Receptor Antagonists Alzheimer s Disease and Dementia s Namenda Namenda Titration Pak Antidepressants s to Treat Depression Antidepressants, Other Antidepressants Budeprion SR Bupropion HCl Bupropion HCl SR Bupropion XL Maprotiline HCl Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 1

17 Name Name Mirtazapine Mirtazapine ODT (0mg Tablet Dispersible, 5mg Tablet Dispersible) Nefazodone HCl Trazodone HCl Monoamine Oxidase Inhibitors Antidepressants Emsam ST Marplan Nardil Phenelzine Sulfate Selegiline HCl Tranylcypromine Sulfate Serotonin/Norepinephrine Reuptake Inhibitors Antidepressants Citalopram Hydrobromide (Tablet) 1 Citalopram Hydrobromide (Oral Solution) Cymbalta PA Escitalopram Oxalate Fluoxetine DR Fluoxetine HCl (Capsule, Oral Solution, 10mg Tablet, 0mg Tablet) Fluvoxamine Maleate Paroxetine HCl Paroxetine HCl ER Paxil (Suspension) Pristiq PA Sertraline HCl (Tablet) 1 Sertraline HCl (Concentrate) Venlafaxine HCl ST Venlafaxine HCl ER (Capsule Extended Release Hour) Viibryd ST Tricyclics Antidepressants Amitriptyline HCl Amoxapine Clomipramine HCl Desipramine HCl Doxepin HCl Imipramine HCl Imipramine Pamoate Nortriptyline HCl Perphenazine/Amitriptyline Protriptyline HCl Trimipramine Maleate Antidotes, Deterrents and Toxicologic Agents s for Overdose or Deterrents Alcohol Deterrents/Anti-Craving Antidotes/Deterrents/Protectants Antabuse Disulfiram Naltrexone HCl Vivitrol 5 Opioid Antagonists Antidotes/ Deterrents/Protectants Buprenorphine HCl Naloxone HCl (1mg/ml Injection) Suboxone Smoking Cessation Agents Deterrents Buproban Chantix Chantix Pak Nicotrol Inhaler Nicotrol NS 15

18 Name Name Antiemetics s to Treat Nausea and Vomiting Antiemetics, Other Nausea and Vomiting s Meclizine HCl Emetogenic Therapy Adjuncts Nausea and Vomiting s Aloxi Anzemet (50mg Tablet) B/D Anzemet (100mg Tablet) 5 B/D Cesamet 5 B/D, PA Dronabinol (.5mg Capsule, 5mg Capsule) B/D, PA Dronabinol (10mg Capsule) 5 B/D, PA Emend (Capsule) B/D, PA Granisetron HCl (0.1mg/ml Injection, 1mg/ml Injection) Granisetron HCl (Tablet) B/D Granisol B/D Ondansetron HCl (Tablet) B/D Ondansetron HCl (mg/ml Injection) Ondansetron HCl (Oral Solution) B/D Ondansetron ODT B/D Sancuso 5 Antifungals s to Treat Fungal Infections Antifungals Fungal Infection s Abelcet 5 B/D AmBisome 5 B/D Amphotec (50mg Injection) B/D Amphotericin B B/D Ancobon 5 Cancidas 5 Ciclopirox Ciclopirox Nail Lacquer Ciclopirox Olamine Clotrimazole (External Cream, External Solution, Troche) Clotrimazole/ Betamethasone Dipropionate Econazole Nitrate Eraxis (100mg Injection) 5 Fluconazole Fluconazole in Dextrose (56mg/ml; 00mg/00ml Injection) Flucytosine 5 Gris-Peg Griseofulvin Microsize Itraconazole PA Ketoconazole (Cream, Shampoo, Tablet) Ketoconazole (Foam) Lamisil (Packet) Miconazole Mycamine 5 Natacyn Noxafil 5 Nyamyc Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 16

19 Name Name Nystatin (Cream, Ointment, unit/gm Powder, Suspension, Tablet) Nystatin/Triamcinolone Nystop Pedi-Dri Sporanox (Oral Solution) PA Terbinafine HCl (Tablet) Terconazole (0.% Cream, Suppository) Vfend (Suspension Reconstituted) 5 Vfend (Tablet) 5 ST Vfend IV Voriconazole (Tablet) 5 Zazole (Cream) Antigout Agents s to Treat Gout Antigout Agents Gout s Allopurinol (Tablet) Allopurinol Sodium (Injection) Colcrys Probenecid Probenecid/Colchicine Uloric ST Antimigraine Agents s to Treat Migraines Ergot Alkaloids Migraine s Dihydroergotamine Mesylate Ergotamine Tartrate/ Caffeine Migergot Serotonin (5-HT) 1b/1d Receptor Agonists Migraine s Maxalt Maxalt-MLT Naratriptan HCl Sumatriptan Succinate (Tablet) Sumatriptan Succinate (6mg/0.5ml Injection) Antimyasthenic Agents s to Treat Myasthenia Gravis Parasympathomimetics Myasthenia Gravis s Mestinon (Syrup) Mestinon Timespan Mytelase Pyridostigmine Bromide Regonol Antimycobacterials s to Treat Infections Antimycobacterials, Other Miscellaneous Anti-Infectives Dapsone Mycobutin Antituberculars Tuberculosis s Capastat Sulfate Ethambutol HCl Isoniazid Paser Priftin Rifampin (Capsule) Rifampin (Injection) Rifater Seromycin Trecator Antineoplastics s to Treat Cancer Alkylating Agents Chemotherapy Agents BiCNU Busulfex 5 17

20 Name Name CeeNU Cyclophosphamide (Tablet) B/D Dacarbazine (00mg Injection) Hexalen 5 PA Ifosfamide (1gm Injection) Leukeran Matulane 5 Melphalan HCl 5 Mustargen 5 Thiotepa Treanda (100mg Injection) 5 PA Zanosar 5 Antiangiogenic Agents Chemotherapy Agents Caprelsa 5 PA Revlimid (10mg Capsule, 15mg Capsule, 5mg 5 PA, LA Capsule, 5mg Capsule) Thalomid 5 PA Antiestrogens/Modifiers Chemotherapy Agents Emcyt PA Fareston Faslodex 5 Tamoxifen Citrate Antimetabolites Chemotherapy Agents Cladribine 5 B/D Clolar 5 Cytarabine (500mg Injection) B/D Cytarabine Aqueous (0mg/ml Injection) B/D Cytarabine Aqueous (100mg/ml Injection) B/D Droxia Elitek (1.5mg Injection) 5 Fluorouracil (500mg/10ml Injection) B/D Folotyn (0mg/ml Injection) 5 PA Gemcitabine HCl (1gm Injection) 5 Gemzar (1gm Injection) 5 Hydroxyurea Mercaptopurine Pentostatin 5 Tabloid PA Antineoplastics, Other Chemotherapy Agents Abraxane 5 PA Adriamycin (mg/ml Injection) B/D Alimta (500mg Injection) 5 PA Amifostine 5 Arranon 5 Bleomycin Sulfate (0unit Injection) B/D Carboplatin (150mg/15ml Injection) Cerubidine Cisplatin (100mg/100ml Injection) Cosmegen Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 18

21 Name Name Dacogen 5 Daunorubicin HCl (5mg/ml Injection) Dexrazoxane (500mg Injection) 5 PA Docefrez 5 Docetaxel (80mg/ml Injection, 5 80mg/8ml Injection) Doxil 5 B/D Doxorubicin HCl (mg/ml Injection) B/D Elspar Epirubicin HCl (50mg/5ml Injection) Erivedge 5 PA Fludarabine Phosphate (50mg Injection) 5 Fusilev 5 Halaven 5 PA Idarubicin HCl (10mg/10ml Injection) 5 Irinotecan (100mg/5ml Injection) Istodax 5 PA Ixempra Kit (5mg Injection) 5 Jakafi 5 PA Jevtana 5 PA Leucovorin Calcium (100mg Injection, 50mg Injection, Tablet) Menest Mesna Mesnex (Tablet) Mitomycin (0mg Injection) Mitoxantrone HCl PA Ontak 5 PA Oxaliplatin (100mg/0ml Injection) 5 Paclitaxel (00mg/50ml Injection) Picato Proleukin 5 PA Sylatron 5 PA Taxotere (80mg/ml Injection) 5 Trisenox PA Velcade 5 PA Vidaza 5 PA Vinblastine Sulfate (10mg Injection) B/D Vincasar PFS B/D Vincristine Sulfate B/D Vinorelbine Tartrate (50mg/5ml Injection) Zolinza 5 PA Zytiga 5 PA Aromatase Inhibitors, rd Generation Chemotherapy Agents Anastrozole Aromasin Exemestane Letrozole Enzyme Inhibitors Chemotherapy Agents Etopophos 5 Etoposide (Injection) Hycamtin (Injection) 5 Toposar Topotecan HCl (mg Injection) 5 Molecular Target Inhibitors Chemotherapy Agents Afinitor 5 PA Gleevec 5 PA Inlyta 5 PA Nexavar 5 PA Sprycel 5 PA 19

22 Name Name Sutent 5 PA Tarceva 5 PA Tasigna 5 PA Tykerb 5 PA Votrient 5 PA Xalkori 5 PA Zelboraf 5 PA Monoclonal Antibodies Chemotherapy Agents Arzerra 5 PA Avastin (100mg/ml Injection) 5 PA Campath 5 PA Erbitux (100mg/50ml Injection) 5 PA Herceptin 5 PA Rituxan 5 PA Vectibix (100mg/5ml Injection) 5 PA Yervoy (50mg/10ml Injection) 5 PA Retinoids Chemotherapy Agents Panretin 5 PA Targretin 5 PA Tretinoin (Capsule) 5 Antiparasitics s to Treat Parasitic Infections Anthelmintics Worm Infection s Albenza Biltricide Stromectol Antiprotozoals Protozoal Infection s Alinia Atovaquone/Proguanil HCl (50mg; 100mg Tablet) Chloroquine Phosphate Daraprim Hydroxychloroquine Sulfate Malarone Mefloquine HCl Mepron 5 Nebupent B/D Pentam 00 Primaquine Phosphate Qualaquin PA Pediculicides/Scabicides Scabies and Lice s Lindane Malathion Permethrin (Cream) Antiparkinson Agents s to Treat Parkinson s Disease Anticholinergics Parkinson s Disease s Benztropine Mesylate Cogentin Trihexyphenidyl HCl Antiparkinson Agents Parkinson s Disease s Comtan Tasmar 5 Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 0

23 Name Name Dopamine Agonists Parkinson s Disease s Apokyn 5 Bromocriptine Mesylate Pramipexole Dihydrochloride Ropinirole HCl Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors Parkinson s Disease s Carbidopa/Levodopa Carbidopa/Levodopa ER Carbidopa/Levodopa ODT Stalevo Antipsychotics s to Treat Mood Disorders 1st Generation/Typical Mood Disorder s Chlorpromazine HCl Compro Fluphenazine Decanoate Fluphenazine HCl Haloperidol Haloperidol Decanoate Haloperidol Lactate Loxapine Succinate Orap Perphenazine Prochlorperazine Prochlorperazine Edisylate Prochlorperazine Maleate Thioridazine HCl Thiothixene Trifluoperazine HCl nd Generation/Atypical Mood Disorder s Abilify ST Abilify Discmelt ST Fanapt ST Fanapt Titration Pack ST Geodon (Injection) Invega ST Invega Sustenna (9mg/0.5ml Injection, 78mg/0.5ml Injection) Invega Sustenna (117mg/0.75ml Injection, 156mg/ml Injection, 5 mg/1.5ml Injection) Latuda PA Olanzapine Olanzapine ODT Quetiapine Fumarate Risperdal Consta (1.5mg Injection, 5mg Injection) Risperdal Consta (7.5mg Injection, 5 50mg Injection) Risperidone (Tablet) Risperidone (Oral Solution) Risperidone ODT Saphris Seroquel XR Ziprasidone HCl (Capsule) Zyprexa (Injection) Treatment-Resistant Mood Disorder s Clozapine Fazaclo 1

24 Name Name Antispasticity Agents s to Treat Spasms Antispasticity Agents Muscle Spasm s Baclofen Dantrolene Sodium (Capsule) Gablofen (10000mcg/0ml Injection, 50mcg/ml B/D, PA Injection) Gablofen (0000mcg/0ml 5 B/D, PA Injection) Lioresal Intrathecal (0.05mg/ml Injection, B/D, PA 10mg/0ml Injection) Lioresal Intrathecal (10mg/5ml Injection) 5 B/D, PA Tizanidine HCl (Tablet) Antivirals s to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral s Cytovene B/D Foscarnet Sodium B/D Ganciclovir (Capsule) Ganciclovir (Injection) B/D Valcyte 5 Vistide 5 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors HIV s Atripla 5 Complera 5 Edurant 5 Intelence (100mg Tablet, 00mg Tablet) 5 Nevirapine (Tablet) Rescriptor Sustiva Viramune (Tablet) Viramune (Suspension) Viramune XR Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors HIV s Combivir 5 Didanosine Emtriva Epivir (Oral Solution) Epivir (Tablet) Epivir HBV Epzicom 5 Lamivudine Lamivudine/Zidovudine 5 Retrovir IV Infusion Stavudine (Capsule) Trizivir 5 Truvada 5 Videx Pediatric (gm Oral Solution) Viread 5 Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug

25 Name Name Zerit (Oral Solution) Ziagen Zidovudine Anti-HIV Agents, Other HIV s Fuzeon 5 Isentress 5 Selzentry 5 Anti-HIV Agents, Protease Inhibitors HIV s Aptivus 5 Crixivan Invirase (Capsule) Invirase (Tablet) 5 Kaletra (100mg; 5mg Tablet) Kaletra (Oral Solution, 00mg; 50mg Tablet) 5 Lexiva (Suspension) Lexiva (Tablet) 5 Norvir Prezista (150mg Tablet, 75mg Tablet) Prezista (00mg Tablet, 600mg Tablet) 5 Reyataz (100mg Capsule) Reyataz (150mg Capsule, 00mg Capsule, 5 00mg Capsule) Viracept 5 Anti-Influenza Agents Flu s Amantadine HCl Relenza Diskhaler Rimantadine HCl Tamiflu Antihepatitis Agents Hepatitis s Baraclude (Oral Solution) Baraclude (Tablet) 5 Hepsera 5 Incivek 5 PA Infergen (15mcg/0.5ml Injection) 5 PA Intron-A (10mu/0.ml Injection, mu/0.ml Injection, unit/ PA ml Injection) Intron-A (5mu/0.ml Injection) 5 PA Intron-A W/Diluent (10mu Injection) 5 PA Peg-Intron (50mcg/0.5ml Injection) 5 PA Peg-Intron Redipen 5 PA Pegasys 5 PA Pegasys Proclick (15mcg/0.5ml Injection) 5 PA Rebetol (Oral Solution) PA Ribapak (Tablet) 5 PA Ribasphere (Capsule, 00mg Tablet) PA Ribasphere (00mg Tablet, 600mg Tablet) 5 PA Ribavirin PA Tyzeka 5 Victrelis 5 PA Antiherpetic Agents Herpes s Acyclovir Acyclovir Sodium (500mg Injection) B/D Famciclovir Trifluridine Valacyclovir HCl

26 Name Name Anxiolytics s to Treat Anxiety Anxiolytics, Other Anxiety s Alprazolam (0.5mg Tablet, 0.5mg Tablet, 1mg Tablet, PA mg Tablet) Buspirone HCl Chlordiazepoxide HCl PA Chlordiazepoxide/ Amitriptyline Diazepam (Oral Solution, Tablet) PA Diazepam Intensol PA Lorazepam (Tablet) PA Lorazepam Intensol PA Bipolar Agents s to Treat Mood Disorders Mood Stabilizers Mood Disorder s Lithium Carbonate Lithium Carbonate ER Lithium Citrate Lithobid Blood Glucose Regulators s to Regulate Blood Sugar Antidiabetic Agents Diabetic s Acarbose Actoplus Met (15-500mg Tablet, mg Tablet) Actos Avandamet PA Avandaryl PA Avandia PA Byetta Duetact Glimepiride Glipizide 1 Glipizide ER Glipizide/Metformin HCl Glyburide 1 Glyburide Micronized 1 Glyburide/Metformin HCl Kombiglyze XR Metformin HCl 1 Metformin HCl ER (500mg Tablet Extended Release Hour, 750mg Tablet Extended Release Hour) Nateglinide Onglyza Prandimet Prandin Riomet Symlinpen 10 PA Symlinpen 60 PA Tolbutamide Tradjenta Victoza Glycemic Agents Diabetic s Clinimix.5%/ Dextrose 0% B/D Clinimix 5%/ Dextrose 15% B/D Clinimix 5%/ Dextrose 0% B/D Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug

27 Name Name Clinimix E.75%/ Dextrose 10% B/D Clinimix E.75%/ Dextrose 5% B/D Clinimix E.5%/ Dextrose 5% B/D Clinimix E.5%/ Dextrose 5% B/D Clinimix E 5%/ Dextrose 15% B/D Clinimix E 5%/ Dextrose 5% B/D Dextrose 10%/ NaCl 0.5% Dextrose 10% Flex Container Dextrose 10%/NaCl 0.% Dextrose.5%/ Sodium Chloride 0.5% Dextrose 5% Dextrose 5%/NaCl 0.% Dextrose 5%/ NaCl 0.5% Dextrose 5%/NaCl 0.% Dextrose 5%/NaCl 0.5% Dextrose 5%/NaCl 0.9% Glucagen Hypokit Glucagon Emergency Kit Ionosol-B/Dextrose 5% Ionosol-MB/ Dextrose 5% KCl 0.075%/D5W/ NaCl 0.5% KCl 0.15%/D5W/LR KCl 0.15%/D5W/ NaCl 0.% KCl 0.15%/D5W/ NaCl 0.5% KCl 0.15%/D5W/ NaCl 0.9% KCl 0.%/D5W/ NaCl 0.5% KCl 0.%/D5W/ NaCl 0.9% Normosol-R in D5W Potassium Chloride 0.15%/D5W/ NaCl 0.5% Viaflex Potassium Chloride 0.15%/D5W/NaCl 0.% Potassium Chloride 0.%/D5W/NaCl 0.5% Proglycem Insulins Diabetic s Levemir (Vial) Novolin (Vial) Novolog (Vial) Blood Products/Modifiers/Volume Expanders s to Treat Blood Disorders Anticoagulants Blood Thinners Argatroban 5 (100mg/ml Injection) Argatroban (15mg/15ml; 5 0.9% Injection) Arixtra (.5mg/0.5ml Injection) Arixtra (10mg/0.8ml Injection, 5 5mg/0.ml Injection, 7.5mg/0.6ml Injection) Coumadin (Tablet) Enoxaparin Sodium (0mg/0.ml Injection, 0mg/0.ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection) 5

28 Name Name Enoxaparin Sodium (100mg/ml Injection, 10mg/0.8ml Injection, 150mg/ml Injection) Fondaparinux Sodium (.5mg/0.5ml Injection) Fondaparinux Sodium (10mg/0.8ml Injection, 5mg/0.ml Injection, 7.5mg/0.6ml Injection) Fragmin (5000unit/ml Injection, 500unit/0.ml Injection, 5000unit/0.ml Injection) Fragmin (10000unit/ml Injection, 1500unit/0.5ml Injection, 15000unit/0.6ml Injection, 18000unit/0.7ml Injection, 7500unit/0.ml Injection) Heparin Sodium (10000unit/ml Injection, 1000unit/ml Injection, 0000unit/ml Injection, 5000unit/ml Injection) Heparin Sodium/D5W (5%; 0unit/ml Injection) Heparin Sodium/NaCl (100unit/ml; 0.5% Injection, 50unit/ml; 0.5% Injection) Heparin Sodium/ NaCl 0.9% Premix Jantoven Lovenox (00mg/ml Injection) Pradaxa PA Warfarin Sodium Xarelto PA Blood Formation Modifiers Blood Formation s Anagrelide HCl Aranesp Albumin Free (100mcg/0.5ml Injection, 100mcg/ml Injection, 5mcg/0.ml Injection, 5mcg/ml Injection, B/D, PA 0mcg/0.ml Injection, 0mcg/ml Injection, 60mcg/0.ml Injection, 60mcg/ml Injection) Aranesp Albumin Free (150mcg/0.ml Injection, 00mcg/0.ml Injection, 00mcg/ml Injection, 5 B/D, PA 00mcg/0.6ml Injection, 00mcg/ml Injection, 500mcg/ml Injection) Epogen B/D, PA Leukine 5 PA Mozobil 5 PA Neulasta 5 PA Neumega PA Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 6

29 Name Name Neupogen (00mcg/0.5ml Injection, 80mcg/0.8ml 5 PA Injection, 80mcg/1.6ml Injection) Procrit (10000unit/ml Injection, 000unit/ml Injection, B/D, PA 000unit/ml Injection, 000unit/ml Injection) Procrit (0000unit/ml Injection, 5 B/D, PA 0000unit/ml Injection) Promacta 5 PA Blood Products/Modifiers/Volume Expanders Cinryze 5 PA Coagulants Blood Clotting s Cyklokapron Tranexamic Acid Platelet Modifying Agents Platelet Modifying s Aggrenox Brilinta PA Cilostazol Clopidogrel Dipyridamole (Tablet) PA Effient PA Ticlopidine HCl Cardiovascular Agents s to Treat Heart and Circulation Conditions Alpha-Adrenergic Agonists Blood Pressure s Clonidine HCl (Tablet) Clonidine HCl (Patch Weekly) Guanfacine HCl Methyldopa Methyldopa/ Hydrochlorothiazide Methyldopate HCl Midodrine HCl Alpha-Adrenergic Blocking Agents Blood Pressure s Dibenzyline Prazosin HCl Reserpine Angiotensin II Receptor Antagonists Blood Pressure s Benicar Benicar HCT Edarbi Edarbyclor Losartan Potassium 1 Losartan Potassium/ Hydrochlorothiazide 1 Micardis Micardis HCT Angiotensin-Converting Enzyme (ACE) Inhibitors Blood Pressure s Benazepril HCl 1 Benazepril HCl/ Hydrochlorothiazide 1 Captopril Captopril/ Hydrochlorothiazide Enalapril Maleate Enalapril Maleate/ Hydrochlorothiazide Lisinopril 1 Lisinopril/ Hydrochlorothiazide 1 Antiarrhythmics Heart Regulation s Amiodarone HCl (50mg/ml Injection, Tablet) Disopyramide Phosphate 7

30 Name Name Flecainide Acetate Mexiletine HCl Multaq Pacerone (00mg Tablet) Pacerone (100mg Tablet) Procainamide HCl Propafenone HCl Propafenone HCl ER Quinidine Gluconate Quinidine Gluconate ER Quinidine Sulfate Quinidine Sulfate ER Sorine Sotalol HCl (Tablet) Sotalol HCl (Injection) Tikosyn Beta-Adrenergic Blocking Agents Blood Pressure s Atenolol 1 Atenolol/Chlorthalidone 1 Bisoprolol Fumarate/ Hydrochlorothiazide Bystolic Carvedilol 1 Labetalol HCl Metoprolol Succinate ER Metoprolol Tartrate (Tablet) 1 Metoprolol Tartrate (Injection) Metoprolol/ Hydrochlorothiazide Nadolol Pindolol Propranolol HCl Propranolol HCl ER Propranolol/ Hydrochlorothiazide Timolol Maleate (Tablet) Calcium Channel Blocking Agents Blood Pressure s Amlodipine Besylate 1 Cartia XT Dilt-CD (10mg Capsule Extended Release Hour, 00mg Capsule Extended Release Hour) Dilt-XR (180mg Capsule Extended Release Hour, 0mg Capsule Extended Release Hour) Diltiazem CD (10mg Capsule Extended Release Hour, 0mg Capsule Extended Release Hour, 00mg Capsule Extended Release Hour) Diltiazem HCl (100mg Injection, 50mg/10ml Injection, Tablet) Nicardipine HCl Nimodipine Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 8

31 Name Name Nisoldipine (17mg Tablet Extended Release Hour, mg Tablet Extended Release Hour, 8.5mg Tablet Extended Release Hour) Nisoldipine ER Verapamil HCl (Tablet) Verapamil HCl (Injection) Verapamil HCl ER (Tablet Extended Release) Cardiovascular Agents, Other Miscellaneous Cardiac s Demser 5 Digoxin Lanoxin (Tablet) Pentoxifylline ER Ranexa ST Tekturna ST Tekturna HCT ST Diuretics, Carbonic Anhydrase Inhibitors Cardiac s Acetazolamide Sodium Diuretics, Loop Cardiac s Bumetanide Furosemide Torsemide (0mg/ml Injection, Tablet) Diuretics, Potassium-Sparing Cardiac s Amiloride HCl Amiloride/ Hydrochlorothiazide Eplerenone Spironolactone Spironolactone/ Hydrochlorothiazide Triamterene/ Hydrochlorothiazide Diuretics, Thiazide Cardiac s Chlorothiazide Chlorothiazide Sodium Chlorthalidone (5mg Tablet, 50mg Tablet) Diuril Hydrochlorothiazide Indapamide Methyclothiazide Metolazone Dyslipidemics, Fibric Acid Derivatives Cholesterol Control s Antara Fenofibrate Fenofibrate Micronized Gemfibrozil Dyslipidemics, HMG CoA Reductase Inhibitors Cholesterol Control s Atorvastatin Calcium Crestor Lovastatin Pravastatin Sodium 1 Simvastatin 1 Dyslipidemics, Other Miscellaneous Cholesterol Control s Cholestyramine Light (Packet) Colestipol HCl (Tablet) Colestipol HCl (Granules) Lovaza Niaspan Prevalite (Powder) Welchol Zetia 9

32 Name Name Vasodilators, Direct-Acting Arterial Chest Pain s Hydralazine HCl Minoxidil (Tablet) Vasodilators, Direct-Acting Arterial/ Venous Chest Pain s Isosorbide Dinitrate Isosorbide Dinitrate ER Isosorbide Mononitrate (0mg Tablet) Isosorbide Mononitrate ER Minitran Nitro-Bid Nitroglycerin (Injection, Patch) Nitrolingual Pumpspray Nitromist Nitrostat Central Nervous System Agents s to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents, Amphetamines ADHD s Amphetamine/ Dextroamphetamine (Tablet) Dextroamphetamine Sulfate Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines ADHD s Dexmethylphenidate HCl Intuniv Methylphenidate HCl Methylphenidate HCl ER (0mg Tablet Extended Release) Methylphenidate HCl ER (Capsule Extended Release Hour) Strattera ST Central Nervous System, Other Miscellaneous Central Nervous System s Butalbital/Acetaminophen/ Caffeine/Codeine Rilutek Xenazine 5 PA Multiple Sclerosis Agents Multiple Sclerosis s Ampyra 5 PA Copaxone 5 PA Gilenya 5 PA Dental and Oral Agents s to Treat Mouth and Throat Conditions Dental and Oral Agents Chlorhexidine Gluconate Oral Rinse Kepivance 5 Periogard Pilocarpine HCl (Tablet) Triamcinolone in Orabase Dermatological Agents s to Treat Skin Conditions Dermatological Agents Skin Agents 8-MOP 5 Adapalene Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 0

33 Name Name Amevive 5 PA Ammonium Lactate Amnesteem Avita PA Calcipotriene Carac Claravis Clindamycin Phosphate (External Solution, Foam, Gel, Lotion, Swab) Clindamycin/Benzoyl Peroxide (5%; 1% Gel) Dovonex Elidel ST Erythromycin/Benzoyl Peroxide Finacea Fluorouracil (Cream) Imiquimod Laclotion Oxsoralen PA Oxsoralen Ultra 5 PA Podofilox Protopic ST Regranex 5 PA Santyl Selenium Sulfide (Lotion) Solaraze PA Soriatane 5 Stelara 5 PA Sulfacetamide Sodium (Suspension) Tazorac PA Tretin-X (Kit) PA Tretinoin (Cream, Gel) PA Uvadex Vectical Zyclara Enzyme Replacements/Modifiers s to Treat Enzyme Deficiency Enzyme Replacements/Modifiers Enzyme Replacement/Modifying s Adagen 5 Aldurazyme 5 Buphenyl 5 Carbaglu 5 Cerezyme (00unit Injection) 5 PA Creon Cystadane 5 Cystagon Elaprase 5 Fabrazyme (5mg Injection) 5 Kuvan 5 Lumizyme 5 Myozyme 5 Naglazyme 5 Orfadin 5 Sucraid 5 Vpriv 5 PA Zavesca 5 Zenpep Gastrointestinal Agents s to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal Bowel Treatment s Atropine Sulfate (0.05mg/ml Injection, PA 0.1mg/ml Injection) Cuvposa Dicyclomine HCl (Capsule, Oral Solution, Tablet) PA Glycopyrrolate 1

34 Name Name Methscopolamine Bromide Propantheline Bromide Gastrointestinal Agents, Other Miscellaneous Gastrointestinal s Cromolyn Sodium (Concentrate) Diphenoxylate/Atropine PA Halflytely Bowel Prep/ Flavor Packs Loperamide HCl (Capsule) Metoclopramide HCl Relistor (1mg/0.6ml Injection) PA Ursodiol Histamine (H) Blocking Agents Ulcer and Stomach Acid s Cimetidine Cimetidine HCl Famotidine (Injection, 0mg Tablet, 0mg Tablet) Famotidine Premixed Nizatidine Ranitidine HCl (Capsule, 150mg/6ml Injection, Tablet) Irritable Bowel Syndrome Agents Bowel Treatment s Amitiza ST Lotronex 5 PA Laxatives Bowel Treatment s Enulose Gavilyte-C Gavilyte-G Gavilyte-N/Flavor Pack Lactulose Nulytely/Flavor Packs Polyethylene Glycol 50 (Powder) Suprep Bowel Prep Trilyte Protectants Ulcer and Stomach Acid s Carafate (Suspension) Misoprostol (00mcg Tablet) Sucralfate Proton Pump Inhibitors Ulcer and Stomach Acid s Dexilant Lansoprazole Nexium Nexium I.V. Omeprazole (Capsule Delayed Release) Pantoprazole Sodium Vimovo Genitourinary Agents s to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary Bladder Control s Flavoxate HCl Oxybutynin Chloride Oxybutynin Chloride ER Toviaz Vesicare Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug

35 Name Name Benign Prostatic Hypertrophy Agents Prostate Enlargement s Alfuzosin HCl ER Doxazosin Mesylate Finasteride (Tablet) Rapaflo Tamsulosin HCl Terazosin HCl Genitourinary Agents, Other Miscellaneous Bladder, Genital and Kidney Conditions s Bethanechol Chloride Elmiron Phosphate Binders Phosphate-Removing Agents Fosrenol 5 Renagel ST Renvela Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) s to Regulate Hormones Glucocorticoids/Mineralocorticoids Anti-Inflammatory s A-Hydrocort Ala-Cort Alclometasone Dipropionate Amcinonide Augmented Betamethasone Dipropionate (Lotion) Betamethasone Dipropionate Betamethasone Valerate Clobetasol Propionate (External Solution, Gel, Lotion, Ointment, Shampoo) Clobetasol Propionate (Foam) Clobetasol Propionate E Cortisone Acetate Depo-Medrol (0mg/ml Injection) Desonide Desowen (Cream, Lotion) Desoximetasone (Cream, Gel, 0.5% Ointment) Dexamethasone (Elixir, Tablet) Dexamethasone Intensol Dexamethasone Sodium Phosphate (mg/ml Injection) Diflorasone Diacetate Fludrocortisone Acetate Fluocinolone Acetonide (Cream, External Solution, Ointment) Fluocinonide (External Solution, Gel, Ointment) Fluocinonide-E Fluticasone Propionate (Cream, Lotion, Ointment) Halobetasol Propionate Hydrocortisone (1% Cream,.5% Cream,.5% Lotion, 1% Ointment,.5% Ointment, Tablet) Hydrocortisone Valerate Lokara Methylprednisolone (Tablet) Methylprednisolone Acetate (Injection) Methylprednisolone Dose Pack

36 Name Name Methylprednisolone Sodium Succinate (Injection) Mometasone Furoate Prednicarbate Prednisolone Sodium Phosphate (Oral Solution) Prednisone Prednisone Intensol Proctocream HC Solu-Cortef (100mg Injection, 50mg Injection) Solu-Medrol (gm Injection) Triamcinolone Acetonide (Cream, Lotion, Ointment) Triderm U-Cort Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) s to Regulate Hormones Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) Hormone Replacement/Modifying s Chorionic Gonadotropin PA Desmopressin Acetate Egrifta 5 PA Genotropin 5 PA Genotropin Miniquick (0.mg Injection) PA Genotropin Miniquick (0.mg Injection, 0.6mg Injection, 0.8mg Injection, 1.mg Injection, 1.mg Injection, 5 PA 1.6mg Injection, 1.8mg Injection, 1mg Injection, mg Injection) Humatrope 5 PA Increlex 5 PA Norditropin Flexpro 5 PA Norditropin Nordiflex Pen 5 PA Nutropin 5 PA Nutropin AQ 5 PA Omnitrope (10mg/1.5ml Injection) PA Omnitrope (5.8mg Injection, 5 PA 5mg/1.5ml Injection) Pregnyl W/Diluent Benzyl Alcohol/NaCl PA Saizen 5 PA Serostim 5 PA Stimate Tev-Tropin PA Zorbtive 5 PA Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug

37 Name Name Hormonal Agents, Stimulant/ Replacement/Modifying (Sex Hormones/Modifiers) s to Regulate Hormones Anabolic Steroids Hormone Replacement/Modifying s Oxandrolone (.5mg Tablet) PA Oxandrolone (10mg Tablet) 5 PA Androgens Hormone Replacement/ Modifying s Androgel (50mg/5gm Gel) Androgel Pump (1.6% Gel) Androxy Danazol Testosterone Cypionate Testosterone Enanthate Estrogens Hormone Replacement/ Modifying s Amethia Amethyst Apri Aranelle Aviane Balziva Briellyn Cryselle Cyclafem 1/5 Cyclafem 7/7/7 Divigel (1mg/gm Gel) Emoquette Enjuvia Enpresse Estradiol Estradiol Valerate Estradiol/Norethindrone Acetate (1mg; 0.5mg Tablet) Estropipate Gianvi Introvale Jinteli Junel Junel Fe Kariva Kelnor Leena Lessina Levora Low-Ogestrel Lutera Marlissa Microgestin Microgestin Fe Mononessa Necon Nortrel Nuvaring Ocella Ogestrel Orsythia Portia Premarin (Cream, Tablet) Premphase Prempro Previfem Quasense Reclipsen Sprintec Sronyx Tri-Legest Fe Tri-Previfem 5

38 Name Name Tri-Sprintec Trinessa Trivora Velivet Vestura Zeosa Zovia Progesterone Hormone Replacement/ Modifying s Ella Progestins Hormone Replacement/ Modifying s Camila Crinone Depo-Provera (00mg/ml Injection) Errin Jolivette Medroxyprogesterone Acetate Megace ES Megestrol Acetate Next Choice Nora-BE Norethindrone Acetate Selective Estrogen Receptor Modifying Agents Hormone Replacement/ Modifying s Evista Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) s to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) Thyroid Replacement s Levothroid Levothyroxine Sodium (Tablet) Levoxyl Liothyronine Sodium Synthroid Unithroid (100mcg Tablet, 11mcg Tablet, 15mcg Tablet, 150mcg Tablet, 175mcg Tablet, 00mcg Tablet, 5mcg Tablet, 00mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet) Hormonal Agents, Suppressant (Adrenal) s to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) Hormone Suppressants Lysodren Hormonal Agents, Suppressant (Parathyroid) s to Regulate Hormones Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants Sensipar (0mg Tablet) Sensipar (60mg Tablet, 5 90mg Tablet) Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 6

39 Name Name Hormonal Agents, Suppressant (Pituitary) s to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Cabergoline Firmagon (80mg Injection) PA Firmagon (10mg Injection) 5 PA Leuprolide Acetate Lupron Depot (.75mg Injection) Lupron Depot (.5mg Injection, 0mg Injection, 5 5mg Injection, 7.5mg Injection) Lupron Depot-PED (11.5mg Injection Month) Lupron Depot-PED (11.5mg Injection 1 Month, 15mg Injection 5 1 Month) Octreotide Acetate (100mcg/ml Injection, PA 50mcg/ml Injection) Octreotide Acetate (1000mcg/ml Injection, 00mcg/ml Injection, 5 PA 500mcg/ml Injection) Sandostatin LAR Depot 5 PA Somatuline Depot 5 PA Somavert 5 PA Synarel 5 PA Trelstar Depot 5 Trelstar LA 5 Trelstar Mixject 5 Hormonal Agents, Suppressant (Sex Hormones/Modifiers) s to Regulate Hormones Antiandrogens Hormone Suppressants Bicalutamide Flutamide Nilandron Hormonal Agents, Suppressant (Thyroid) s to Suppress Thyroid Hormones Antithyroid Agents Thyroid Suppressing s Methimazole Propylthiouracil Immunological Agents s that Stimulate or Suppress the Immune System Immune Suppressants Immune System s Azasan Azathioprine Azathioprine Sodium Benlysta (10mg Injection) 5 PA Cellcept (Suspension Reconstituted) 5 B/D, PA Cellcept Intravenous B/D, PA Cimzia 5 PA Cyclosporine B/D Cyclosporine Modified (100mg Capsule, 50mg B/D Capsule, Oral Solution) Enbrel 5 PA Gengraf B/D Humira 5 PA Humira Starter Kit 5 PA Kineret 5 PA 7

40 Name Name Methotrexate (Tablet) Methotrexate Sodium (5mg/ml Injection) Methotrexate Sodium (1gm Injection) Mycophenolate Mofetil B/D, PA Myfortic (180mg Tablet Delayed Release) B/D Myfortic (60mg Tablet Delayed Release) 5 B/D Nulojix 5 B/D, PA Orencia 5 PA Prograf (Injection) B/D, PA Rapamune (0.5mg Tablet) B/D Rapamune (Oral Solution, 5 B/D 1mg Tablet, mg Tablet) Remicade 5 PA Sandimmune (Capsule) B/D Simponi 5 PA Tacrolimus (0.5mg Capsule, 1mg Capsule) B/D, PA Tacrolimus (5mg Capsule) 5 B/D, PA Torisel 5 Zortress (0.5mg Tablet) B/D, PA Zortress (0.5mg Tablet, 0.75mg Tablet) 5 B/D, PA Immunizing Agents, Passive Immune System s Atgam 5 B/D Carimune Nanofiltered (gm Injection) 5 B/D, PA Gammagard Liquid 5 B/D, PA Gammaplex (10gm/00ml Injection) 5 B/D, PA Gamunex-C (1gm/10ml Injection) 5 B/D, PA Hizentra (1gm/5ml Injection) 5 B/D, PA Privigen (0gm/00ml Injection) 5 B/D, PA Thymoglobulin 5 B/D Immunomodulators Immune System s Actemra (00mg/10ml Injection) 5 PA Actimmune 5 Arcalyst 5 PA Avonex 5 PA Extavia 5 PA Ilaris 5 PA Leflunomide Simulect (0mg Injection) 5 B/D Synagis (50mg/0.5ml Injection) 5 Tysabri 5 PA, LA Vaccines ActHIB Adacel Boostrix Cervarix Comvax Daptacel Decavac Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 8

41 Name Name Engerix-B B/D Gardasil Havrix Infanrix IPOL Ixiaro M-M-R II Menactra Menomune- A/C/Y/W-15 Menveo Pedvax HIB ProQuad Rabavert Recombivax HB (10mcg/ml Injection, B/D 0mcg/ml Injection) RotaTeq Tetanus/Diphtheria Toxoids-Adsorbed Adult Twinrix Typhim Vi Vaqta (5unit/0.5ml Injection) Varivax YF-Vax Zostavax Inflammatory Bowel Disease Agents s to Treat Inflammatory Bowel Disease Aminosalicylates Inflammatory Bowel Disease s Apriso Asacol Balsalazide Disodium Mesalamine (Kit) Glucocorticoids Inflammatory Bowel Disease s Budesonide (Capsule Extended Release Hour) Colocort Hydrocortisone (Enema) Millipred (Tablet) Sulfonamides Inflammatory Bowel Disease s Sulfasalazine (Tablet) Sulfazine EC Metabolic Bone Disease Agents s to Treat Bone Conditions Metabolic Bone Disease Agents Osteoporosis (Bone Loss) s Alendronate Sodium Calcitonin-Salmon Calcitriol (Capsule, Injection, Oral Solution) B/D Etidronate Disodium Forteo B/D, PA Fortical Hectorol B/D Miacalcin (Injection) B/D, PA Pamidronate Disodium (0mg/10ml Injection, B/D 90mg/10ml Injection) Pamidronate Disodium (6mg/ml Injection) B/D Prolia PA Reclast PA Xgeva 5 PA Zemplar B/D Zometa 5 9

42 Name Name Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Alcohol Preps (Pad) Botox (100unit Injection) PA Ferriprox 5 PA Firazyr 5 PA Fomepizole 5 Gauze Pads Insulin Syringes, Needles Intralipid (1.7%; 0% Injection) B/D Intralipid (.5%; 0% Injection) B/D Lactated Ringers Irrigation Levocarnitine B/D Liposyn III (1.%;.5%; 10% Injection, 1.%; B/D.5%; 0% Injection) Methergine Methylergonovine Maleate (Tablet) Physiolyte Physiosol Irrigation Ringers Irrigation Sodium Chloride 0.9% (Irrigation Solution) Sterile Water Irrigation Ophthalmic Agents s to Treat Eye Conditions Ophthalmic Agents, Other Miscellaneous Eye s AK-Con Proparacaine HCl Restasis Tropicamide Ophthalmic Anti-Allergy Agents Allergy, Infection and Inflammation s Azelastine HCl (Ophthalmic Solution) Bepreve Cromolyn Sodium (Ophthalmic Solution) Epinastine HCl Lastacaft Ophthalmic Anti-Inflammatories Allergy, Infection and Inflammation s Alrex Blephamide Blephamide S.O.P. Bromday Bromfenac Dexamethasone Sodium Phosphate (Ophthalmic Solution) Diclofenac Sodium (Ophthalmic Solution) Durezol Flurbiprofen Sodium Ketorolac Tromethamine (Ophthalmic Solution) Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 0

43 Name Name Lotemax Neomycin/Polymyxin/ Bacitracin/Hydrocortisone Neomycin/Polymyxin/ Dexamethasone Neomycin/Polymyxin/ Hydrocortisone (Ophthalmic Suspension) Nevanac Prednisolone Acetate Prednisolone Sodium Phosphate (Ophthalmic Solution) Sulfacetamide Sodium/ Prednisolone Sodium Phosphate Tobradex (Ointment) Tobramycin/ Dexamethasone Zylet Ophthalmic Antiglaucoma Agents Glaucoma s Acetazolamide Acetazolamide ER Alphagan P (0.1% Ophthalmic Solution) Apraclonidine Betaxolol HCl (Ophthalmic Solution) Brimonidine Tartrate Carteolol HCl Combigan Dorzolamide HCl Dorzolamide HCl/ Timolol Maleate Iopidine (1% Ophthalmic Solution) Levobunolol HCl (0.5% Ophthalmic Solution) Methazolamide Metipranolol Phospholine Iodide Pilopine HS Timolol Maleate (Gel Forming Solution, Ophthalmic Solution) Ophthalmic Prostaglandin and Prostamide Analogs Glaucoma s Latanoprost Lumigan Travatan Z Otic Agents s to Treat Ear Conditions Otic Agents Ear s Acetasol HC Acetic Acid Dermotic Fluocinolone Acetonide (Otic Oil) Hydrocortisone/Acetic Acid Neomycin/Polymyxin/ Hydrocortisone (Solution, Suspension) Respiratory Tract Agents s to Treat Allergies, Cough, Cold and Lung Conditions Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung s Asmanex Budesonide (Suspension) B/D Dulera Flunisolide (0.05% Nasal Solution) Fluticasone Propionate (Nasal Suspension) Nasonex 1

44 Name Name Pulmicort B/D Pulmicort Flexhaler QVAR Symbicort Triamcinolone Acetonide (Inhaler) Antihistamines Allergy s Astepro Azelastine HCl (Nasal Spray) Carbinoxamine Maleate Cetirizine HCl (Syrup) Clemastine Fumarate (Syrup,.68mg Tablet) Hydroxyzine HCl Hydroxyzine Pamoate Levocetirizine Dihydrochloride (Tablet) Phenadoz Promethazine HCl Promethazine VC Promethegan (5mg Suppository, 50mg Suppository) Antileukotrienes Asthma/Lung s Singulair Zafirlukast Bronchodilators, Anticholinergic Asthma/Lung s Atrovent HFA Combivent Ipratropium Bromide (Nasal Solution) Ipratropium Bromide (Inhalation Solution) B/D Ipratropium Bromide/ Albuterol Sulfate B/D Spiriva Handihaler Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) Asthma/Lung s Aminophylline Elixophyllin Theophylline ER (100mg Tablet Extended Release 1 Hour, 00mg Tablet Extended Release 1 Hour, 00mg Tablet Extended Release 1 Hour, 50mg Tablet Extended Release 1 Hour, Tablet Extended Release Hour) Bronchodilators, Sympathomimetic Asthma/Lung s Albuterol Sulfate (Syrup, Tablet) Albuterol Sulfate (Nebulization Solution) B/D Albuterol Sulfate ER Brovana B/D Epinephrine HCl (0.1mg/ml Injection) Epipen Foradil Aerolizer Levalbuterol B/D, ST Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug

45 Name Name Metaproterenol Sulfate Perforomist B/D Proair HFA Serevent Diskus ST Terbutaline Sulfate (Tablet) Terbutaline Sulfate (Injection) Twinject Mast Cell Stabilizers Asthma/Lung s Cromolyn Sodium (Nebulization Solution) B/D Pulmonary Antihypertensives Asthma/Lung s Adcirca 5 PA Letairis 5 Remodulin 5 B/D, PA Revatio 5 PA Tracleer 5 LA Ventavis (10mcg/ml Inhalation Solution) 5 B/D, PA Respiratory Tract Agents, Other Asthma/Lung s Acetylcysteine B/D Aralast NP (00mg Injection) 5 PA Glassia 5 PA Kalydeco 5 PA Prolastin-C 5 PA Pulmozyme 5 B/D Tyzine Xolair 5 PA Zemaira 5 PA Sedatives/Hypnotics s for Sedation and Sleep GABA Receptor Modulators Sedation and Sleep s Temazepam (15mg Capsule, 0mg Capsule) PA Zaleplon Zolpidem Tartrate (5mg Tablet, 10mg Tablet) Sleep Disorders, Other Miscellaneous Sedation and Sleep s Provigil PA Xyrem PA, LA Skeletal Muscle Relaxants s to Treat Pain, Inflammation, and Muscle and Joint Conditions Skeletal Muscle Relaxants Pain/Swelling Management s Carisoprodol (50mg Tablet) Chlorzoxazone Cyclobenzaprine HCl (10mg Tablet, 5mg Tablet) Methocarbamol Orphenadrine Citrate ER Orphenadrine Compound DS Orphenadrine/Aspirin/ Caffeine Therapeutic Nutrients/Minerals/ Electrolytes s to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Modifiers Vitamin, Mineral and Body Fluid Deficiency s Chemet Exjade (15mg Tablet Soluble)

46 Name Name Exjade (50mg Tablet Soluble, 5 500mg Tablet Soluble) Kionex (Powder) Samsca 5 PA Sodium Lactate Sodium Polystyrene Sulfonate (Suspension) Syprine Electrolyte/Mineral Replacement Vitamin, Mineral and Body Fluid Deficiency s Aminosyn 8.5%/ Electrolytes B/D Aminosyn II B/D Aminosyn II 8.5%/ Electrolytes B/D Aminosyn M B/D Aminosyn-HBC B/D Aminosyn-PF B/D Calcium Acetate (Capsule) Clinimix.75%/ Dextrose 5% B/D Clinimix.5%/ Dextrose 10% B/D Clinimix.5%/ Dextrose 5% B/D Clinimix.5%/ Dextrose 5% B/D Clinimix 5%/ Dextrose 5% B/D Clinimix E 5%/ Dextrose 0% B/D Clinisol SF 15% B/D Dextrose 5%/ Lactated Ringers Dextrose 5%/Potassium Chloride 0.15% Freamine III (8.5% Injection) B/D Freamine III % B/D Hepatamine B/D Hepatasol B/D Isolyte-H/Dextrose 5% Isolyte-M/Dextrose 5% Isolyte-P/Dextrose 5% Isolyte-S Isolyte-S/Dextrose 5% Klor-Con 10 Klor-Con 8 Klor-Con M15 Klor-Con M0 Lactated Ringers Magnesium Sulfate (50% Injection) Nephramine B/D Normosol-M in D5W Normosol-R Phoslo Phoslyra ST Plasma-Lyte Plasma-Lyte/D5W (16meq/L; 0meq/L; 5%; meq/l; 1meq/L; 0meq/L Injection) Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug

47 Name Name Potassium Chloride (0.meq/ml Injection, 10meq/100ml Injection, meq/ml Injection, 0meq/100ml Injection) Potassium Chloride (10meq/50ml Injection) Potassium Chloride 0.15%/NaCl 0.5% Viaflex Potassium Chloride 0.15%/NaCl 0.9% Potassium Chloride 0.%/Dextrose 5% Viaflex Potassium Chloride 0.%/ D5W/Viaflex Potassium Chloride 0.%/NaCl 0.9% Potassium Chloride ER (Capsule Extended Release, 10meq Tablet Extended Release, 0meq Tablet Extended Release) Premasol (10% Injection) B/D Premasol (6% Injection) B/D Procalamine B/D Prosol B/D Ringers Injection Sodium Chloride (0.9% Injection,.5meq/ml Injection, % Injection, 5% Injection) Sodium Chloride 0.5% Viaflex (Injection) Sodium Fluoride (Tablet) TPN Electrolytes Travasol B/D Trophamine B/D Vitamins Vitamin, Mineral and Body Fluid Deficiency s Niacor Prenatal Vitamins 5

48 Index of covered drugs 8-MOP... 0 A Abelcet Abilify... 1 Abilify Discmelt... 1 Abraxane Acarbose... Acetaminophen/Codeine... 9 Acetasol HC... 1 Acetazolamide... 1 Acetazolamide ER... 1 Acetazolamide Sodium... 9 Acetic Acid... 1 Acetylcysteine... Actemra... 8 ActHIB... 8 Actimmune... 8 Actoplus Met... Actos... Acyclovir... Acyclovir Sodium... Adacel... 8 Adagen... 1 Adapalene... 0 Adcirca... Adriamycin Afinitor Aggrenox... 7 A-Hydrocort... AK-Con...0 Ala-Cort... Albenza... 0 Albuterol Sulfate... Albuterol Sulfate ER... Alclometasone Dipropionate... Alcohol Preps...0 Aldurazyme... 1 Alendronate Sodium... 9 Alfuzosin HCl ER... Alimta Alinia... 0 Allopurinol Allopurinol Sodium Aloxi Alphagan P... 1 Alprazolam... Alrex...0 Amantadine HCl... AmBisome Amcinonide... Amethia... 5 Amethyst... 5 Amevive... 1 Amifostine Amikacin Sulfate... 9 Amiloride HCl... 9 Amiloride/ Hydrochlorothiazide... 9 Aminophylline... Aminosyn 8.5%/Electrolytes... Aminosyn-HBC... Aminosyn II... Aminosyn II 8.5%/ Electrolytes... Aminosyn M... Aminosyn-PF... Amiodarone HCl... 7 Amitiza... Amitriptyline HCl Amlodipine Besylate... 8 Ammonium Lactate... 1 Amnesteem... 1 Amoxapine Amoxicillin Amoxicillin/Potassium Clavulanate Amoxicillin/Potassium Clavulanate ER Amphetamine/ Dextroamphetamine... 0 Amphotec Amphotericin B Ampicillin Ampicillin Sodium Ampicillin-Sulbactam... 1 Ampyra... 0 Anagrelide HCl... 6 Anastrozole Ancobon Androgel... 5 Androgel Pump... 5 Androxy... 5 Antabuse Antara... 9 Anzemet Apokyn... 1 Apraclonidine... 1 Apri

49 Apriso... 9 Aptivus... Aralast NP... Aranelle... 5 Aranesp Albumin Free... 6 Arcalyst... 8 Argatroban... 5 Arixtra... 5 Aromasin Arranon Arzerra... 0 Asacol... 9 Asmanex... 1 Astepro... Astramorph... 8 Atenolol... 8 Atenolol/Chlorthalidone... 8 Atgam... 8 Atorvastatin Calcium... 9 Atovaquone/Proguanil HCl... 0 Atripla... Atropine Sulfate... 1 Atrovent HFA... Augmented Betamethasone Dipropionate... Avandamet... Avandaryl... Avandia... Avastin... 0 Avelox... 1 Avelox ABC Pack... 1 Aviane... 5 Avita... 1 Avonex... 8 Azactam in Iso-Osmotic Dextrose Azasan... 7 Azathioprine... 7 Azathioprine Sodium... 7 Azelastine HCl... 0, Azithromycin... 1 Aztreonam B Baciim Bacitracin Bacitracin/Polymyxin B Baclofen... Bactocill in Dextrose... 1 Balsalazide Disodium... 9 Balziva... 5 Banzel... 1 Baraclude... Benazepril HCl... 7 Benazepril HCl/ Hydrochlorothiazide... 7 Benicar... 7 Benicar HCT... 7 Benlysta... 7 Benztropine Mesylate... 0 Bepreve...0 Betamethasone Dipropionate... Betamethasone Valerate... Betaxolol HCl... 1 Bethanechol Chloride... Bicalutamide... 7 Bicillin C-R... 1 Bicillin L-A... 1 BiCNU Biltricide... 0 Bisoprolol Fumarate/ Hydrochlorothiazide... 8 Bleomycin Sulfate Blephamide...0 Blephamide S.O.P...0 Boostrix... 8 Botox...0 Briellyn... 5 Brilinta... 7 Brimonidine Tartrate... 1 Bromday...0 Bromfenac...0 Bromocriptine Mesylate... 1 Brovana... Budeprion SR... 1 Budesonide...9, 1 Bumetanide... 9 Buphenyl... 1 Buprenorphine HCl Buproban Bupropion HCl... 1 Bupropion HCl SR... 1 Bupropion XL... 1 Buspirone HCl... Busulfex Butalbital/Acetaminophen/ Caffeine/Codeine... 0 Butorphanol Tartrate... 9 Byetta... Bystolic... 8 C Cabergoline... 7 Calcipotriene... 1 Calcitonin-Salmon... 9 Calcitriol

50 Calcium Acetate... Camila... 6 Campath... 0 Cancidas Capastat Sulfate Caprelsa Captopril... 7 Captopril/ Hydrochlorothiazide... 7 Carac... 1 Carafate... Carbaglu... 1 Carbamazepine... 1 Carbamazepine ER... 1 Carbidopa/Levodopa... 1 Carbidopa/Levodopa ER... 1 Carbidopa/Levodopa ODT... 1 Carbinoxamine Maleate... Carboplatin Carimune Nanofiltered... 8 Carisoprodol... Carteolol HCl... 1 Cartia XT... 8 Carvedilol... 8 Cayston Cedax CeeNU Cefaclor Cefaclor ER Cefadroxil Cefazolin Sodium Cefdinir Cefepime Cefotaxime Sodium Cefotetan Cefoxitin Sodium Cefoxitin Sodium/Dextrose Cefpodoxime Proxetil Cefprozil Ceftazidime Ceftazidime/Dextrose Ceftriaxone Sodium Cefuroxime Axetil Cefuroxime Sodium Cellcept... 7 Cellcept Intravenous... 7 Celontin... 1 Cephalexin Cerezyme... 1 Cerubidine Cervarix... 8 Cesamet Cetirizine HCl... Chantix Chantix Pak Chemet... Chloramphenicol Sodium Succinate Chlordiazepoxide/ Amitriptyline... Chlordiazepoxide HCl... Chlorhexidine Gluconate Oral Rinse... 0 Chloroquine Phosphate... 0 Chlorothiazide... 9 Chlorothiazide Sodium... 9 Chlorpromazine HCl... 1 Chlorthalidone... 9 Chlorzoxazone... Cholestyramine Light... 9 Chorionic Gonadotropin... Ciclopirox Ciclopirox Nail Lacquer Ciclopirox Olamine Cilostazol... 7 Cimetidine... Cimetidine HCl... Cimzia... 7 Cinryze... 7 Cipro... 1 Ciprofloxacin... 1 Ciprofloxacin ER... 1 Ciprofloxacin HCl... 1 Cipro IV... 1 Cisplatin Citalopram Hydrobromide Cladribine Claforan Claravis... 1 Clarithromycin... 1 Clarithromycin ER... 1 Clemastine Fumarate... Cleocin Cleocin Galaxy Cleocin in D5W Cleocin Phosphate Clindamycin/ Benzoyl Peroxide... 1 Clindamycin HCl Clindamycin Phosphate... 10, 1 Clindamycin Phosphate Add-Vantage Clinimix.75%/ Dextrose 5%... Clinimix.5%/ Dextrose 5%... 8

51 Clinimix.5%/ Dextrose 10%... Clinimix.5%/ Dextrose 0%... Clinimix.5%/ Dextrose 5%... Clinimix 5%/Dextrose 15%... Clinimix 5%/Dextrose 0%... Clinimix 5%/Dextrose 5%... Clinimix E.75%/ Dextrose 5%... 5 Clinimix E.75%/ Dextrose 10%... 5 Clinimix E.5%/ Dextrose 5%... 5 Clinimix E.5%/ Dextrose 5%... 5 Clinimix E 5%/ Dextrose 15%... 5 Clinimix E 5%/ Dextrose 0%... Clinimix E 5%/ Dextrose 5%... 5 Clinisol SF 15%... Clobetasol Propionate... Clobetasol Propionate E... Clolar Clomipramine HCl Clonazepam... 1 Clonazepam ODT... 1 Clonidine HCl... 7 Clopidogrel... 7 Clorazepate Dipotassium... 1 Clotrimazole Clotrimazole/Betamethasone Dipropionate Clozapine... 1 Codeine Sulfate... 9 Cogentin... 0 Co-Gesic... 9 Colcrys Colestipol HCl... 9 Colistimethate Sodium Colocort... 9 Combigan... 1 Combivent... Combivir... Complera... Compro... 1 Comtan... 0 Comvax... 8 Copaxone... 0 Cortisone Acetate... Cosmegen Coumadin... 5 Creon... 1 Crestor... 9 Crinone... 6 Crixivan... Cromolyn Sodium..., 0, Cryselle... 5 Cubicin Cuvposa... 1 Cyclafem 1/ Cyclafem 7/7/ Cyclobenzaprine HCl... Cyclophosphamide Cyclosporine... 7 Cyclosporine Modified... 7 Cyklokapron... 7 Cymbalta Cystadane... 1 Cystagon... 1 Cytarabine Cytarabine Aqueous Cytovene... D Dacarbazine Dacogen Danazol... 5 Dantrolene Sodium... Dapsone Daptacel... 8 Daraprim... 0 Daunorubicin HCl Decavac... 8 Demeclocycline HCl... 1 Demser... 9 Depo-Medrol... Depo-Provera... 6 Dermotic... 1 Desipramine HCl Desmopressin Acetate... Desonide... Desowen... Desoximetasone... Dexamethasone... Dexamethasone Intensol... Dexamethasone Sodium Phosphate..., 0 Dexilant... Dexmethylphenidate HCl... 0 Dexrazoxane Dextroamphetamine Sulfate... 0 Dextrose.5%/ Sodium Chloride 0.5%... 5 Dextrose 5%

52 Dextrose 5%/ Lactated Ringers... Dextrose 5%/NaCl 0.%... 5 Dextrose 5%/NaCl 0.9%... 5 Dextrose 5%/NaCl 0.%... 5 Dextrose 5%/NaCl 0.5%... 5 Dextrose 5%/NaCl 0.5%... 5 Dextrose 5%/Potassium Chloride 0.15%... Dextrose 10% Flex Container... 5 Dextrose 10%/NaCl 0.%... 5 Dextrose 10%/NaCl 0.5%... 5 Diazepam... 1, Diazepam Intensol... Dibenzyline... 7 Diclofenac Potassium... 8 Diclofenac Sodium...0 Diclofenac Sodium DR... 8 Diclofenac Sodium ER... 8 Dicloxacillin Sodium... 1 Dicyclomine HCl... 1 Didanosine... Dificid... 1 Diflorasone Diacetate... Diflunisal... 8 Digoxin... 9 Dihydroergotamine Mesylate...17 Dilantin... 1 Dilantin Infatabs... 1 Dilt-CD... 8 Diltiazem CD... 8 Diltiazem HCl... 8 Dilt-XR... 8 Diphenoxylate/Atropine... Dipyridamole... 7 Disopyramide Phosphate... 7 Disulfiram Diuril... 9 Divalproex Sodium... 1 Divalproex Sodium DR... 1 Divalproex Sodium ER... 1 Divigel... 5 Docefrez Docetaxel Donepezil HCl... 1 Doribax Dorzolamide HCl... 1 Dorzolamide HCl/ Timolol Maleate... 1 Dovonex... 1 Doxazosin Mesylate... Doxepin HCl Doxil Doxorubicin HCl Doxycycline... 1 Doxycycline Hyclate... 1 Doxycycline Monohydrate... 1 Dronabinol Droxia Duetact... Dulera... 1 Duramorph... 8 Durezol...0 E Econazole Nitrate Edarbi... 7 Edarbyclor... 7 Edurant... E.E.S E.E.S. Granules... 1 Effient... 7 Egrifta... Elaprase... 1 Elidel... 1 Elitek Elixophyllin... Ella... 6 Elmiron... Elspar Emcyt Emend Emoquette... 5 Emsam Emtriva... Enalapril Maleate... 7 Enalapril Maleate/ Hydrochlorothiazide... 7 Enbrel... 7 Engerix-B... 9 Enjuvia... 5 Enoxaparin Sodium... 5, 6 Enpresse... 5 Enulose... Epinastine HCl...0 Epinephrine HCl... Epipen... Epirubicin HCl Epitol... 1 Epivir... Epivir HBV... Eplerenone... 9 Epogen... 6 Epzicom... 50

53 Equetro... 1 Eraxis Erbitux... 0 Ergotamine Tartrate/ Caffeine Erivedge Errin... 6 Ery... 1 Eryped... 1 Ery-Tab... 1 Erythrocin Lactobionate... 1 Erythrocin Stearate... 1 Erythromycin... 1 Erythromycin Base... 1 Erythromycin/ Benzoyl Peroxide... 1 Erythromycin Ethylsuccinate...1 Escitalopram Oxalate Estradiol... 5 Estradiol/Norethindrone Acetate... 5 Estradiol Valerate... 5 Estropipate... 5 Ethambutol HCl Ethosuximide... 1 Etidronate Disodium... 9 Etodolac... 8 Etopophos Etoposide Evista... 6 Exalgo... 8 Exelon... 1 Exemestane Exjade..., Extavia... 8 F Fabrazyme... 1 Factive... 1 Famciclovir... Famotidine... Famotidine Premixed... Fanapt... 1 Fanapt Titration Pack... 1 Fareston Faslodex Fazaclo... 1 Felbamate... 1 Felbatol... 1 Fenofibrate... 9 Fenofibrate Micronized... 9 Fentanyl... 8 Fentanyl Citrate Oral Transmucosal... 9 Ferriprox...0 Finacea... 1 Finasteride... Firazyr...0 Firmagon... 7 Flagyl ER Flavoxate HCl... Flecainide Acetate... 8 Fluconazole Fluconazole in Dextrose Flucytosine Fludarabine Phosphate Fludrocortisone Acetate... Flunisolide... 1 Fluocinolone Acetonide..., 1 Fluocinonide... Fluocinonide-E... Fluorouracil... 18, 1 Fluoxetine DR Fluoxetine HCl Fluphenazine Decanoate... 1 Fluphenazine HCl... 1 Flurbiprofen... 8 Flurbiprofen Sodium...0 Flutamide... 7 Fluticasone Propionate..., 1 Fluvoxamine Maleate Folotyn Fomepizole...0 Fondaparinux Sodium... 6 Foradil Aerolizer... Fortaz Forteo... 9 Fortical... 9 Foscarnet Sodium... Fosphenytoin Sodium... 1 Fosrenol... Fragmin... 6 Freamine III... Freamine III %... Furosemide... 9 Fusilev Fuzeon... G Gabapentin... 1 Gabitril... 1 Gablofen... Gammagard Liquid... 8 Gammaplex... 8 Gamunex-C

54 Ganciclovir... Gardasil... 9 Gauze Pads...0 Gavilyte-C... Gavilyte-G... Gavilyte-N/Flavor Pack... Gemcitabine HCl Gemfibrozil... 9 Gemzar Gengraf... 7 Genotropin... Genotropin Miniquick... Gentak... 9 Gentamicin Sulfate... 9 Gentamicin Sulfate/NaCl...9, 10 Geodon... 1 Gianvi... 5 Gilenya... 0 Glassia... Gleevec Glimepiride... Glipizide... Glipizide ER... Glipizide/Metformin HCl... Glucagen Hypokit... 5 Glucagon Emergency Kit... 5 Glyburide... Glyburide/Metformin HCl... Glyburide Micronized... Glycopyrrolate... 1 Granisetron HCl Granisol Griseofulvin Microsize Gris-Peg Guanfacine HCl... 7 H Halaven Halflytely Bowel Prep/ Flavor Packs... Halobetasol Propionate... Haloperidol... 1 Haloperidol Decanoate... 1 Haloperidol Lactate... 1 Havrix... 9 Hectorol... 9 Heparin Sodium... 6 Heparin Sodium/D5W... 6 Heparin Sodium/NaCl... 6 Heparin Sodium/ NaCl 0.9% Premix... 6 Hepatamine... Hepatasol... Hepsera... Herceptin... 0 Hexalen Hizentra... 8 Humatrope... Humira... 7 Humira Starter Kit... 7 Hycamtin Hydralazine HCl... 0 Hydrochlorothiazide... 9 Hydrocodone/Acetaminophen...9 Hydrocodone/Ibuprofen... 9 Hydrocortisone..., 9 Hydrocortisone/Acetic Acid... 1 Hydrocortisone Valerate... Hydromorphone HCl... 9 Hydroxychloroquine Sulfate... 0 Hydroxyurea Hydroxyzine HCl... Hydroxyzine Pamoate... I Ibuprofen... 8 Idarubicin HCl Ifosfamide Ilaris... 8 Imipenem/Cilastatin Imipramine HCl Imipramine Pamoate Imiquimod... 1 Incivek... Increlex... Indapamide... 9 Indomethacin... 8 Infanrix... 9 Infergen... Inlyta Insulin Syringes, Needles...0 Intelence... Intralipid...0 Intron-A... Intron-A W/Diluent... Introvale... 5 Intuniv... 0 Invanz Invega... 1 Invega Sustenna... 1 Invirase... Ionosol-B/Dextrose 5%... 5 Ionosol-MB/Dextrose 5%... 5 Iopidine... 1 IPOL... 9 Ipratropium Bromide...

55 Ipratropium Bromide/ Albuterol Sulfate... Irinotecan Isentress... Isolyte-H/Dextrose 5%... Isolyte-M/Dextrose 5%... Isolyte-P/Dextrose 5%... Isolyte-S... Isolyte-S/Dextrose 5%... Isoniazid Isosorbide Dinitrate... 0 Isosorbide Dinitrate ER... 0 Isosorbide Mononitrate... 0 Isosorbide Mononitrate ER... 0 Isotonic Gentamicin Istodax Itraconazole Ixempra Kit Ixiaro... 9 J Jakafi Jantoven... 6 Jevtana Jinteli... 5 Jolivette... 6 Junel... 5 Junel Fe... 5 K Kaletra... Kalydeco... Kanamycin Sulfate Kariva... 5 KCl 0.%/D5W/NaCl 0.9%... 5 KCl 0.%/D5W/NaCl 0.5%...5 KCl 0.15%/D5W/LR... 5 KCl 0.15%/D5W/ NaCl 0.%... 5 KCl 0.15%/D5W/ NaCl 0.9%... 5 KCl 0.15%/D5W/ NaCl 0.5%... 5 KCl 0.075%/D5W/ NaCl 0.5%... 5 Kelnor... 5 Kepivance... 0 Ketek... 1 Ketoconazole Ketoprofen... 8 Ketorolac Tromethamine...8, 0 Kineret... 7 Kionex... Klor-Con 8... Klor-Con Klor-Con M15... Klor-Con M0... Kombiglyze XR... Kuvan... 1 L Labetalol HCl... 8 Laclotion... 1 Lactated Ringers... Lactated Ringers Irrigation...0 Lactulose... Lamictal ODT... 1 Lamictal Starter Kit... 1 Lamisil Lamivudine... Lamivudine/Zidovudine... Lamotrigine... 1 Lanoxin... 9 Lansoprazole... Lastacaft...0 Latanoprost... 1 Latuda... 1 Leena... 5 Leflunomide... 8 Lessina... 5 Letairis... Letrozole Leucovorin Calcium Leukeran Leukine... 6 Leuprolide Acetate... 7 Levalbuterol... Levemir... 5 Levetiracetam... 1 Levetiracetam ER... 1 Levobunolol HCl... 1 Levocarnitine...0 Levocetirizine Dihydrochloride... Levofloxacin... 1 Levofloxacin in D5W... 1 Levora... 5 Levorphanol Tartrate... 8 Levothroid... 6 Levothyroxine Sodium... 6 Levoxyl... 6 Lexiva... Lidocaine... 9 Lidocaine HCl... 9 Lidocaine/Prilocaine... 9 Lidocaine Viscous... 9 Lidoderm

56 Lincocin Lindane... 0 Lioresal Intrathecal... Liothyronine Sodium... 6 Liposyn III...0 Lisinopril... 7 Lisinopril/ Hydrochlorothiazide... 7 Lithium Carbonate... Lithium Carbonate ER... Lithium Citrate... Lithobid... Lokara... Loperamide HCl... Lorazepam... Lorazepam Intensol... Losartan Potassium... 7 Losartan Potassium/ Hydrochlorothiazide... 7 Lotemax... 1 Lotronex... Lovastatin... 9 Lovaza... 9 Lovenox... 6 Low-Ogestrel... 5 Loxapine Succinate... 1 Lumigan... 1 Lumizyme... 1 Lupron Depot... 7 Lupron Depot-PED... 7 Lutera... 5 Lyrica... 1 Lysodren... 6 M Magnesium Sulfate... Malarone... 0 Malathion... 0 Maprotiline HCl... 1 Marlissa... 5 Marplan Matulane Maxalt Maxalt-MLT Meclizine HCl Medroxyprogesterone Acetate... 6 Mefenamic Acid... 8 Mefloquine HCl... 0 Megace ES... 6 Megestrol Acetate... 6 Meloxicam... 8 Melphalan HCl Menactra... 9 Menest Menomune-A/C/Y/W Menveo... 9 Mepron... 0 Mercaptopurine Meropenem Mesalamine... 9 Mesna Mesnex Mestinon Mestinon Timespan Metaproterenol Sulfate... Metformin HCl... Metformin HCl ER... Methadone HCl... 9 Methadose... 9 Methazolamide... 1 Methenamine Hippurate Methergine...0 Methimazole... 7 Methocarbamol... Methotrexate... 8 Methotrexate Sodium... 8 Methscopolamine Bromide... Methyclothiazide... 9 Methyldopa... 7 Methyldopa/ Hydrochlorothiazide... 7 Methyldopate HCl... 7 Methylergonovine Maleate...0 Methylphenidate HCl... 0 Methylphenidate HCl ER... 0 Methylprednisolone... Methylprednisolone Acetate... Methylprednisolone Dose Pack... Methylprednisolone Sodium Succinate... Metipranolol... 1 Metoclopramide HCl... Metolazone... 9 Metoprolol/ Hydrochlorothiazide... 8 Metoprolol Succinate ER... 8 Metoprolol Tartrate... 8 Metronidazole Metronidazole in NaCl 0.79% Metronidazole Vaginal Mexiletine HCl

57 Miacalcin... 9 Micardis... 7 Micardis HCT... 7 Miconazole Microgestin... 5 Microgestin Fe... 5 Midodrine HCl... 7 Migergot Millipred... 9 Minitran... 0 Minocycline HCl... 1 Minocycline HCl ER... 1 Minoxidil... 0 Mirtazapine Mirtazapine ODT Misoprostol... Mitomycin Mitoxantrone HCl M-M-R II... 9 Mometasone Furoate... Mononessa... 5 Morphine Sulfate... 9 Morphine Sulfate ER... 9 Moxeza... 1 Mozobil... 6 Multaq... 8 Mupirocin Mustargen Mycamine Mycobutin Mycophenolate Mofetil... 8 Myfortic... 8 Myozyme... 1 Mytelase N Nadolol... 8 Nafcillin Sodium... 1 Naglazyme... 1 Nalbuphine HCl... 9 Nallpen/Dextrose... 1 Naloxone HCl Naltrexone HCl Namenda... 1 Namenda Titration Pak... 1 Naproxen... 8 Naproxen DR... 8 Naproxen Sodium... 8 Naratriptan HCl Nardil Nasonex... 1 Natacyn Nateglinide... Nebupent... 0 Necon... 5 Nefazodone HCl Neomycin/Bacitracin/ Polymyxin Neomycin/Polymyxin/ Bacitracin/Hydrocortisone...1 Neomycin/Polymyxin B Sulfates Neomycin/Polymyxin/ Dexamethasone... 1 Neomycin/Polymyxin/ Gramicidin Neomycin/Polymyxin/ Hydrocortisone... 1 Neomycin Sulfate Nephramine... Neulasta... 6 Neumega... 6 Neupogen... 7 Nevanac... 1 Nevirapine... Nexavar Nexium... Nexium I.V... Next Choice... 6 Niacor... 5 Niaspan... 9 Nicardipine HCl... 8 Nicotrol Inhaler Nicotrol NS Nilandron... 7 Nimodipine... 8 Nisoldipine... 9 Nisoldipine ER... 9 Nitro-Bid... 0 Nitrofurantoin Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate...10 Nitroglycerin... 0 Nitrolingual Pumpspray... 0 Nitromist... 0 Nitrostat... 0 Nizatidine... Nora-BE... 6 Norditropin Flexpro... Norditropin Nordiflex Pen... Norethindrone Acetate... 6 Normosol-M in D5W... Normosol-R... Normosol-R in D5W... 5 Noroxin

58 Nortrel... 5 Nortriptyline HCl Norvir... Novolin... 5 Novolog... 5 Noxafil Nucynta ER... 9 Nulojix... 8 Nulytely/Flavor Packs... Nutropin... Nutropin AQ... Nuvaring... 5 Nyamyc Nystatin Nystatin/Triamcinolone Nystop O Ocella... 5 Octreotide Acetate... 7 Ofloxacin... 1 Ogestrel... 5 Olanzapine... 1 Olanzapine ODT... 1 Omeprazole... Omnitrope... Ondansetron HCl Ondansetron ODT Onfi... 1 Onglyza... Onsolis... 9 Ontak Orap... 1 Orencia... 8 Orfadin... 1 Orphenadrine/Aspirin/ Caffeine... Orphenadrine Citrate ER... Orphenadrine Compound DS... Orsythia... 5 Oxacillin Sodium... 1 Oxaliplatin Oxandrolone... 5 Oxcarbazepine... 1 Oxsoralen... 1 Oxsoralen Ultra... 1 Oxybutynin Chloride... Oxybutynin Chloride ER... Oxycodone/Acetaminophen... 9 Oxycodone/Aspirin... 9 Oxycodone HCl... 9 Oxycodone/Ibuprofen... 8 P Pacerone... 8 Paclitaxel Pamidronate Disodium... 9 Panretin... 0 Pantoprazole Sodium... Paromomycin Sulfate Paroxetine HCl Paroxetine HCl ER Paser Paxil PCE... 1 Pedi-Dri Pedvax HIB... 9 Peganone... 1 Pegasys... Pegasys Proclick... Peg-Intron... Peg-Intron Redipen... Penicillin G Potassium... 1 Penicillin G Potassium in Iso-Osmotic Dextrose... 1 Penicillin G Procaine... 1 Penicillin G Sodium... 1 Penicillin V Potassium... 1 Pentam Pentostatin Pentoxifylline ER... 9 Perforomist... Periogard... 0 Permethrin... 0 Perphenazine... 1 Perphenazine/Amitriptyline Pfizerpen-G... 1 Phenadoz... Phenelzine Sulfate Phenobarbital... 1 Phenytek... 1 Phenytoin... 1 Phenytoin Sodium... 1 Phenytoin Sodium Extended...1 Phoslo... Phoslyra... Phospholine Iodide... 1 Physiolyte...0 Physiosol Irrigation...0 Picato Pilocarpine HCl... 0 Pilopine HS... 1 Pindolol... 8 Piperacillin Sodium/ Tazobactam Sodium

59 Plasma-Lyte... Plasma-Lyte/D5W... Podofilox... 1 Polyethylene Glycol Polymyxin B Sulfate Portia... 5 Potassium Chloride... 5 Potassium Chloride 0.%/ D5W/Viaflex... 5 Potassium Chloride 0.%/ NaCl 0.9%... 5 Potassium Chloride 0.15%/ D5W/NaCl 0.%... 5 Potassium Chloride 0.15%/ D5W/NaCl 0.5% Viaflex...5 Potassium Chloride 0.15%/ NaCl 0.9%... 5 Potassium Chloride 0.15%/ NaCl 0.5% Viaflex... 5 Potassium Chloride 0.%/ D5W/NaCl 0.5%... 5 Potassium Chloride 0.%/ Dextrose 5% Viaflex... 5 Potassium Chloride ER... 5 Potiga... 1 Pradaxa... 6 Pramipexole Dihydrochloride...1 Prandimet... Prandin... Pravastatin Sodium... 9 Prazosin HCl... 7 Prednicarbate... Prednisolone Acetate... 1 Prednisolone Sodium Phosphate..., 1 Prednisone... Prednisone Intensol... Pregnyl W/Diluent Benzyl Alcohol/NaCl... Premarin... 5 Premasol... 5 Premphase... 5 Prempro... 5 Prenatal Vitamins... 5 Prevalite... 9 Previfem... 5 Prezista... Priftin Primaquine Phosphate... 0 Primaxin Primidone... 1 Primsol Pristiq Privigen... 8 Proair HFA... Probenecid Probenecid/Colchicine Procainamide HCl... 8 Procalamine... 5 Prochlorperazine... 1 Prochlorperazine Edisylate... 1 Prochlorperazine Maleate... 1 Procrit... 7 Proctocream HC... Proglycem... 5 Prograf... 8 Prolastin-C... Proleukin Prolia... 9 Promacta... 7 Promethazine HCl... Promethazine VC... Promethegan... Propafenone HCl... 8 Propafenone HCl ER... 8 Propantheline Bromide... Proparacaine HCl...0 Propranolol HCl... 8 Propranolol HCl ER... 8 Propranolol/ Hydrochlorothiazide... 8 Propylthiouracil... 7 ProQuad... 9 Prosol... 5 Protopic... 1 Protriptyline HCl Provigil... Pulmicort... Pulmicort Flexhaler... Pulmozyme... Pyridostigmine Bromide Q Qualaquin... 0 Quasense... 5 Quetiapine Fumarate... 1 Quinidine Gluconate... 8 Quinidine Gluconate ER... 8 Quinidine Sulfate... 8 Quinidine Sulfate ER... 8 QVAR... R Rabavert... 9 Ranexa... 9 Ranitidine HCl... Rapaflo... Rapamune

60 Rebetol... Reclast... 9 Reclipsen... 5 Recombivax HB... 9 Regonol Regranex... 1 Relenza Diskhaler... Relistor... Remicade... 8 Remodulin... Renagel... Renvela... Rescriptor... Reserpine... 7 Restasis...0 Retrovir IV Infusion... Revatio... Revlimid Reyataz... Ribapak... Ribasphere... Ribavirin... Rifampin Rifater Rilutek... 0 Rimantadine HCl... Ringers Injection... 5 Ringers Irrigation...0 Riomet... Risperdal Consta... 1 Risperidone... 1 Risperidone ODT... 1 Rituxan... 0 Rivastigmine Tartrate... 1 Ropinirole HCl... 1 RotaTeq... 9 Roxicet... 9 S Sabril... 1 Saizen... Samsca... Sancuso Sandimmune... 8 Sandostatin LAR Depot... 7 Santyl... 1 Saphris... 1 Selegiline HCl Selenium Sulfide... 1 Selzentry... Sensipar... 6 Serevent Diskus... Seromycin Seroquel XR... 1 Serostim... Sertraline HCl Silver Sulfadiazine Simponi... 8 Simulect... 8 Simvastatin... 9 Singulair... Sodium Chloride... 5 Sodium Chloride 0.9%...0 Sodium Chloride 0.5% Viaflex... 5 Sodium Fluoride... 5 Sodium Lactate... Sodium Polystyrene Sulfonate... Sodium Sulfacetamide... 1 Solaraze... 1 Solu-Cortef... Solu-Medrol... Somatuline Depot... 7 Somavert... 7 Soriatane... 1 Sorine... 8 Sotalol HCl... 8 Spiriva Handihaler... Spironolactone... 9 Spironolactone/ Hydrochlorothiazide... 9 Sporanox Sprintec... 5 Sprycel Sronyx... 5 SSD Stagesic... 9 Stalevo... 1 Stavudine... Stelara... 1 Sterile Water Irrigation...0 Stimate... Strattera... 0 Streptomycin Sulfate Stromectol... 0 Suboxone Sucraid... 1 Sucralfate... Sulfacetamide Sodium... 1, 1 Sulfacetamide Sodium/ Prednisolone Sodium Phosphate... 1 Sulfadiazine

61 Sulfamethoxazole/ Trimethoprim... 1 Sulfamethoxazole/ Trimethoprim DS... 1 Sulfasalazine... 9 Sulfazine EC... 9 Sulindac... 8 Sumatriptan Succinate Suprax Suprep Bowel Prep... Sustiva... Sutent... 0 Sylatron Symbicort... Symlinpen Symlinpen Synagis... 8 Synarel... 7 Synercid Synthroid... 6 Syprine... T Tabloid Tacrolimus... 8 Tamiflu... Tamoxifen Citrate Tamsulosin HCl... Tarceva... 0 Targretin... 0 Tasigna... 0 Tasmar... 0 Taxotere Tazorac... 1 Tegretol... 1 Tegretol-XR... 1 Tekturna... 9 Tekturna HCT... 9 Temazepam... Terazosin HCl... Terbinafine HCl Terbutaline Sulfate... Terconazole Testosterone Cypionate... 5 Testosterone Enanthate... 5 Tetanus/Diphtheria Toxoids-Adsorbed Adult... 9 Tetracycline HCl... 1 Tev-Tropin... Thalomid Theophylline ER... Thermazene Thioridazine HCl... 1 Thiotepa Thiothixene... 1 Thymoglobulin... 8 Ticlopidine HCl... 7 Tikosyn... 8 Timentin... 1 Timolol Maleate... 8, 1 Tizanidine HCl... Tobi Tobradex... 1 Tobramycin/Dexamethasone...1 Tobramycin Sulfate Tobramycin Sulfate/ Sodium Chloride Tobrex Tolbutamide... Topiramate... 1 Toposar Topotecan HCl Torisel... 8 Torsemide... 9 Toviaz... TPN Electrolytes... 5 Tracleer... Tradjenta... Tramadol HCl... 9 Tramadol HCl/ Acetaminophen... 9 Tranexamic Acid... 7 Tranylcypromine Sulfate Travasol... 5 Travatan Z... 1 Trazodone HCl Treanda Trecator Trelstar Depot... 7 Trelstar LA... 7 Trelstar Mixject... 7 Tretinoin... 0, 1 Tretin-X... 1 Triamcinolone Acetonide..., Triamcinolone in Orabase... 0 Triamterene/ Hydrochlorothiazide... 9 Triderm... Trifluoperazine HCl... 1 Trifluridine... Trihexyphenidyl HCl... 0 Tri-Legest Fe... 5 Trileptal... 1 Trilyte... Trimethoprim

62 Trimethoprim Sulfate/ Polymyxin B Sulfate Trimipramine Maleate Trinessa... 6 Tri-Previfem... 5 Trisenox Tri-Sprintec... 6 Trivora... 6 Trizivir... Trophamine... 5 Tropicamide...0 Truvada... Twinject... Twinrix... 9 Tygacil Tykerb... 0 Typhim Vi... 9 Tysabri... 8 Tyzeka... Tyzine... U U-Cort... Uloric Unithroid... 6 Ursodiol... Uvadex... 1 V Valacyclovir HCl... Valcyte... Valproate Sodium... 1 Valproic Acid... 1 Vancocin HCl Vancomycin HCl Vandazole Vaqta... 9 Varivax... 9 Vectibix... 0 Vectical... 1 Velcade Velivet... 6 Venlafaxine HCl Venlafaxine HCl ER Ventavis... Verapamil HCl... 9 Verapamil HCl ER... 9 Vesicare... Vestura... 6 Vfend Vfend IV Vibativ Vibramycin... 1 Victoza... Victrelis... Vidaza Videx Pediatric... Viibryd Vimovo... Vimpat... 1 Vinblastine Sulfate Vincasar PFS Vincristine Sulfate Vinorelbine Tartrate Viracept... Viramune... Viramune XR... Viread... Vistide... Vivitrol Voriconazole Votrient... 0 Vpriv... 1 W Warfarin Sodium... 6 Welchol... 9 X Xalkori... 0 Xarelto... 6 Xenazine... 0 Xgeva... 9 Xifaxan Xolair... Xyrem... Y Yervoy... 0 YF-Vax... 9 Z Zafirlukast... Zaleplon... Zanosar Zavesca... 1 Zazole Zelboraf... 0 Zemaira... Zemplar... 9 Zenpep... 1 Zeosa... 6 Zerit... Zetia... 9 Ziagen... Zidovudine... Zinacef

63 Zinacef in Iso-Osmotic Dextrose Zinacef in Iso-Osmotic Diluent Ziprasidone HCl... 1 Zmax... 1 Zolinza Zolpidem Tartrate... Zometa... 9 Zonisamide... 1 Zorbtive... Zortress... 8 Zostavax... 9 Zosyn... 1 Zovia... 6 Zyclara... 1 Zylet... 1 Zyprexa... 1 Zytiga Zyvox

64 This complete formulary (drug list) is effective January 1, 01. It was updated August 01. Changes may have been made to this list after it was printed. Call UnitedHealthcare Customer Service for complete, updated information , TTY a.m. to 8 p.m. local time, 7 days a week Or visit If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the UnitedHealthcare Customer Service number on the back of your member ID card. This information is available for free in other languages. Please contact our UnitedHealthcare Customer Service number at , TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. Esta información está disponible sin costo en otros idiomas. Comuníquese con el nuestro Servicio al Cliente de UnitedHealthcare al número , TTY 711, de 8 a.m. a 8 p.m. hora local, los 7 días de la semana. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 01. Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare-approved Part D sponsor. AARP MedicareRx Plans carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. FLXAKEN000_PD0667