How To Get Your Medicine From A Pharmacy For Free

Transcription

1 Your Choice Pharmacy Benefit Guide Effective January, 205

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3 TABLE OF CONTENTS Your Choice Overview... Your Choice Contact Numbers... Understanding Coverage and Cost-Sharing... 2 About Drugs... 2 Formulary Overview... 2 For Prospective Members... 3 Understanding Our Symbols... 3 Prior Authorization... 3 Step Therapy... 3 Quantity Limits... 3 Filling Your Prescription... 3 Retail... 3 Mail Order... 3 Provider...4 Filling Your Prescription When Traveling...4 Medication Supplies Not Covered by UPMC Health Plan...4 Your Choice Formulary... 5 Medications Not Covered by Your Choice...25 Non-Covered Medications with Covered Alternatives...26 Your Choice Brand/ Reference Guide...3

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5 YOUR CHOICE OVERVIEW The Your Choice pharmacy program provides both value and freedom of choice. It does so by offering a variety of high-quality, effective generic and brand-name prescription drugs. This guide provides information that is applicable to most members. For information specific to your plan, refer to your plan s prescription drug rider. When you need a prescription medication, you and your doctor can choose from four different levels, or tiers. Each tier has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. This guide provides an overview of your pharmacy benefit with UPMC Health Plan. It explains the copayment structure, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. YOUR CHOICE CONTACT NUMBERS Current Members: UPMC Health Plan Health Care Concierge Team: UPMC Health Plan Pharmacy Services (for doctors and pharmacies): TTY Services: Prospective Members: Prospective members should direct their questions to their company s benefits administrator or to the UPMC Health Plan Health Care Concierge team at Online information is available at

6 UNDERSTANDING COVERAGE AND COST-SHARING Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. UPMC Health Plan s Pharmacy and Therapeutics (P&T) Committee researches and evaluates medications it may cover. Committee members include local doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug s safety, effectiveness, and cost. Your Choice prescription drugs are organized into four copayment tiers on the formulary: Tier is for generic medications, which have the lowest copayment. drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. Your Choice requires you to use a generic version of the drug if one is available. This means that if you receive a brand-name drug when a generic is available, you must pay the brand copayment in addition to the retail cost difference between the brand-name and generic forms of the drug. Tier 2 is for preferred-brand medications. UPMC Health Plan classifies these drugs as preferred because of their value and effectiveness. Tier 3 is for non-preferred brand medications. Tier 4 is for specialty medications. medications usually treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). drugs require close management by a physician. Physicians need to monitor these drugs due to potential side effects and the need for frequent dosage adjustments. About Drugs drugs have the same active ingredients as their brand-name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. drugs have the same active ingredients as brandname drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brandname drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brandname drug. FORMULARY OVERVIEW The most commonly prescribed Your Choice drugs are listed in the formulary section of this booklet. Please note that there are other drugs that Your Choice covers in addition to the ones listed in this booklet. For the latest information on the complete Your Choice formulary and other pharmacy benefits, visit our website at Select Your Choice to access the searchable drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card or on page of this booklet. Some medications not covered on our formulary are listed in the sections of the booklet titled Medications Not Covered by Your Choice and Non-Covered Medications with Covered Alternatives. 2

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

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

9 Effective January, MOP PA 3 medication abacavir abacavir/lamivudine/ zidovudine Abilify Maintena PA, QL 3 medication (ST <2 years of age) Abilify PA, QL 2 (ST <2 years of age) Abstral PA, QL 3 fentanyl citrate (PA) acamprosate acarbose acebutolol acetaminophen/caffeine/ dihydrocodone QL acetaminophen/codeine QL acetazolamide ER capsule acetic acid acetic acid/ hydrocortisone acitretin 3 medication Actemra PA, QL 3 medication Acthar gel PA, QL 3 medication Actimmune PA 3 medication Actonel ST, QL 3 alendronate, ibandronate, risedronate Actonel Weekly ST, QL 3 alendronate, ibandronate, risedronate Acuvail QL 3 ketorolac, diclofenac, bromfenac acyclovir acyclovir ointment Aczone 3 tretinoin, benzoyl peroxide, clindamycin, adapalene (PA) Adagen PA 3 medication adapalene (PA >35 years of age) Adcirca PA, QL 3 medication Adderall XR QL (PA <4 and >8) adefovir PA 3 medication Adempas PA, QL 3 medication Adrenaclick 3 EpiPen, Auvi-Q Advair 2 Advicor 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, niacin ER Aerospan ST 3 Flovent HFA, QVAR, Asmanex Afinitor PA, QL 3 medication Aggrenox 3 clopidogrel, ticlopidine, dipyridamole, Effient alagesic albuterol QL alclometasone dipropionate Aldurazyme PA 3 medication alendronate Alferon N PA 3 medication alfuzosin er Alkeran 2 allopurinol Alocril 3 azelastine, epinastine, Pataday, Patanol Alomide 3 azelastine, epinastine, Pataday, Patanol Alora QL 3 estradiol patch, Premarin Aloxi ST, QL 3 ondansetron Alphagan P 0.% 2 alprazolam alprazolam ODT ST alprazolam Alrex 3 fluorometholone, prednisolone Altavera Alvesco ST 3 Flovent HFA, QVAR, Asmanex amantadine amcinonide Amethia Amethia Lo Amethyst Amevive PA, QL 3 medication amiodarone Amitiza QL 2 KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 5

10 Effective January, 205 amitriptyline amlodipine/atorvastatin amlodipine besylate amlodipine besylate/ benazepril ammonium lactate Amnesteem amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ER amphetamine salts QL (PA < 4 and >8 years of age) Ampyra PA, QL 3 medication Amturnide ST 2 Analpram HC cream 3 hydrocortisone/ pramoxine Analpram HC lotion 3 hydrocortisone/ pramoxine anastrozole Androderm PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Androgel % PA, ST 2 Androgel.62% (PA) Androgel.62% PA 2 Android PA, ST 3 testosterone injection (PA), Androgel.62% (PA) androxy PA, ST testosterone injection (PA), Androgel.62% (PA) Angeliq 3 Premarin, estradiol, estropipate Anoro Ellipta 2 Anzemet ST, QL 3 ondansetron Apidra ST, QL 3 Humalog, Novolog Apokyn PA, QL 3 medication apraclonidine Apri Apriso ER 2 Aptiom PA, QL 3 carbamazepine, oxcarbazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide Aptivus 2 Aquoral 3 Caphosol Aralast NP PA 3 medication Aranelle Aranesp PA 3 medication arbinoxa Arcalyst PA, QL 3 medication Arcapta ST 3 Serevent, Foradil Armour Thyroid 3 levothyroxine, liothyronine Asacol HD 2 Ascensia Blood Glucose 2 Meters Asmanex 2 Atelvia ST, QL 3 alendronate, ibandronate, risedronate atenolol atenolol/chlorthalidone atorvastatin atovaquone suspension Atripla 2 atropine drops Atrovent HFA 2 Aubagio PA, QL 3 medication Aubra aurodex auroguard Auvi-Q 2 Aveed PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Aviane Avodart 2 Avonex QL 3 medication Axert ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Axiron PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Azasite 3 erythromycin azathioprine azelastine Azelex ST 3 topical acne agents KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 6

11 Azilect 2 azithromycin QL Azopt 2 baclofen Bactroban nasal ointment 2 balsalazide disodium Banzel PA 3 felbamate, lamotrigine, topiramate, valproate Baraclude PA 3 medication Bayer Blood Glucose 2 Meters Bayer Blood Glucose Test 2 Strips (QL > 8 years of age) Bayer Lancets 2 (QL > 8 years of age) Beconase AQ ST 3 fluticasone, flunisolide, Veramyst beflex benazepril benazepril/hctz Benlysta PA 3 medication benprox benzoyl peroxide benztropine Bepreve 3 azelastine, epinastine, Pataday, Patanol Berinert PA 3 medication Besivance 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox betamethasone Betaseron ST, QL 3 medication betaxolol Bethkis QL 3 medication Betimol 3 timolol, Betoptic S Betoptic S 2 Beyaz 2 Biafine 3 ammonium lactate, zenieva bicalutamide bisoprolol bisoprolol/hctz Bivigam PA 3 medication Blephamide 2 Bosulif PA, QL 3 medication Botox PA, QL 3 medication bp 0- wash BPO gel Breeze Blood Glucose 2 Meters Breo Ellipta 2 Briellyn Brilinta QL 3 clopidogrel, Effient brimonidine tartrate Brintellix PA, QL 3 paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) bromfenac ophthalmic solution Brovana 3 Serevent, Foradil budeprion XL budesonide EC budesonide nasal spray ST budesonide respules Buphenyl tablet PA 3 medication buprenorphine PA, QL buprenorphine/naloxone tablet PA, QL bupropion bupropion SA buspirone butorphanol nasal spray QL Bydureon QL 2 3 Suboxone film (PA), Zubsolv (PA) Byetta ST, QL 3 Bydureon, Victoza Bystolic ST 3 atenolol, metoprolol, propranolol calcipotriene calcitriol calcium acetate Camila Camrese Camrese Lo KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 7

12 Effective January, 205 Canasa 3 mesalamine, balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol candesartan candesartan/hctz capecitabine PA 3 medication Caphosol 2 Caprelsa PA, QL 3 medication captopril captopril/hctz Carac 3 medication Carbaglu PA 3 medication carbamazepine ER carbidopa carbidopa/levodopa carbidopa/levodopa/ entacapone Cardene SR 3 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate Cardura XL ST, QL 3 doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er Carimune NF PA 3 medication carisoprodol carteolol cartia XT carvedilol Cayston QL 3 medication cefaclor cefadroxil cefdinir cefpodoxime cefprozil ceftazidime ceftibuten cefuroxime Celebrex ST, QL 3 NSAIDS (diclofenac, etodolac, ibuprofen, meloxicam, naproxen) Cenestin 3 Premarin, estradiol, estropipate cephalexin Cerezyme PA 3 medication cevimeline Chantix ST, QL 2 Chateal Chemet PA 3 chlordiazepoxide chlorpromazine (ST <2 years of age) chlorpropamide chlorthalidone chlorzoxazone cholestyramine ciclopirox cilostazol Ciloxan 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox cimetidine Cimzia PA, QL 3 medication Cinryze PA, QL 3 medication Cipro HC 2 Ciprodex 2 ciprofloxacin ciprofloxacin 0.2% ear drops ciprofloxacin ER QL citalopram QL Claravis clarithromycin clarithromycin ER Climara-PRO QL 3 estradiol Clinac BPO 3 benzoyl peroxide clindamycin clobetasol clonazepam clonazepam ODT ST clonazepam clonidine clonidine ER ST, QL clonidine clopidogrel clorazepate KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 8

13 clotrimazole clozapine (ST <2 years of age) clozapine ODT QL (ST <2 years of age) Coartem 2 codeine sulfate Colcrys 2 Colestid granules 3 colestipol colestipol Combigan 2 Combipatch QL 3 estradiol-norethindrone, Jinteli, Prempro, Premphase Combivent Respimat 2 Cometriq PA, QL 3 medication Complera 2 Contour Blood Glucose 2 Meters Copaxone QL 3 medication Copegus QL 3 medication Coreg CR 3 carvedilol cortamox Cortef 3 hydrocortisone tablet Cortifoam 3 hydrocortisone suppositories, proctozone Cosopt PF 3 Azopt, betaxolol, Betoptic S, carteolol, dorzolamide, dorzolamide-timolol, timolol maleate Covera- HS 3 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate Creon 2 Crinone 4% gel 2 Crixivan 2 cromolyn Cryselle Cuprimine PA 3 medication Cuvposa (PA > 6 years of age) Cyclafem cyclobenzaprine 3 glycopyrrolate tablet cyclopentolate drops Cycloset 3 bromocriptine cyclosporine cyclosporine modified Cystadane powder PA 3 medication Cystagon PA 2 Cystaran PA, QL 3 medication Daliresp PA 3 Advair, Breo Ellipta, Foradil, Serevent, Spiriva, Symbicort, Tudorza danazol PA dantrolene Dapsone 2 Dasetta Daysee Delatestryl PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Delyla Delzicol 2 Demser PA 3 medication Denavir 3 For cold sore treatment use over-the-counter agents Depen PA 3 medication Dermatop 3 topical steroids desogestrel/ethinyl estradiol desonide desoximetasone Desvenlafaxine ER ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) dexamethasone dexmethylphenidate ER QL (PA < 4 and > 8 years of age) dexmethylphenidate QL (PA < 4 and > 8 years of age) dextroamphetamine QL (PA < 4 and > 8 years of age) KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications * Age restrictions apply to some medications. 9

14 Effective January, 205 Diastat 2 Diastat Acudial 3 diazepam diazepam Dibenzyline PA 3 medication diclofenac diclofenac ophthalmic solution diclofenac-misoprostol dicloxacillin didanosine Dificid ST, QL 3 medication diflorasone digoxin dihydroergotamine diltiazem diltiazem ER Dipentum ST 3 balsalazide disodium, Apriso, Asacol HD, Delzicol dipyridamole disulfuram divalproex sodium divalproex sodium ER Divigel 3 estradiol donepezil PA dorzolamide dorzolamide/timolol doxazosin doxercalciferol doxycycline drithocreme Dritho-Scalp 2 dronabinol Duavee 3 estradiol-norethindrone, Jinteli, Prempro, Premphase Dulera 2 duloxetine ST, QL Durasal 3 salicyclic acid Durezol 3 fluorometholone, prednisolone Dymista ST 3 fluticasone, flunisolide, Veramyst Dynacirc CR 3 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate dyphylline gg Dyrenium 3 triamterene-hctz Dysport PA, QL 3 medication Edarbi ST 3 losartan, eprosartan, irbesartan, candesartan, telmisartan, valsartan Edarbyclor ST 3 candesartan-hctz, irbesartan-hctz, losartan-hctz, telmisartan- HCTZ, valsartan-hctz Edurant 2 Effient QL 2 Elaprase PA 3 medication Elelyso PA 3 medication Elidel PA 3 topical steroids Eligard PA, QL 3 medication Elinest eliphos Eliquis QL 2 Ella 3 levonorgestrel, Next Choice Elmiron 2 Emadine 3 azelastine, epinastine, Pataday, Patanol Emcyt PA 3 medication Emend capsule QL 2 Emend vial QL 3 Emoquette Emtriva 2 enalapril Enbrel PA, QL 3 medication Endocet QL Enjuvia 3 estradiol, estropipate, Premarin enoxaparin QL Enpresse Enskyce entacapone Entyvio PA, QL 3 medication epinastine ophthalmic solution KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 0

15 epinephrine EpiPen 2 eplerenone Epogen PA 3 medication epoprostenol PA 3 medication eprosartan Epzicom 2 ergotamine/caffeine Erivedge PA, QL 3 medication Errin EryPed 3 erythromycin Ery-tab EC Ery-tab EC 500mg 2 erythromycin erythromycin/benzoyl peroxide gel escitalopram QL Estarylla Estrace cream 3 estradiol, estropipate, Premarin Estraderm QL 3 estradiol estradiol estradiol/norethindrone estradiol patch QL Estring 3 estradiol, estropipate, Premarin Estrogel 3 Premarin estropipate eszopiclone ST, QL etidronate etodolac etoposide PA 3 medication Euflexxa PA, QL 3 medication Evamist 3 estradiol Evzio PA, QL 3 medication Exelon patch PA 3 rivastigmine tartrate capsules (PA), donepezil (PA), Namenda (PA), Namenda XR (PA) exemestane Exjade PA 3 medication Eylea PA 3 medication Fabior (PA >35 years of age) 3 topical acne agents Fabrazyme PA 3 medication Factive QL 3 ciprofloxacin, levofloxacin Falmina famciclovir QL famotidine Fanapt PA, QL (ST <2 years of age) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Fareston PA 3 medication felbamate felodipine FemHRT 3 estradiol-norethindrone, Jinteli, Prempro, Premphase Femring 3 estradiol, estropipate, Premarin Femtrace 3 estradiol, estropipate, Premarin fenofibrate fenofibric acid ST fenoprofen fentanyl citrate PA, QL fentanyl transdermal QL Fentora PA, ST, QL 3 fentanyl citrate (PA), Abstral (PA) Ferriprox PA 3 medication Fetzima PA, QL 3 venlafaxine ER, duloxetine (ST) Finacea 3 topical acne agents finasteride Firazyr PA, QL 3 medication Firmagon PA, QL 3 medication First Testosterone 2% cream PA, ST First Testosterone 2% ointment PA, ST 3 testosterone injection (PA), Androgel.62% (PA) 3 testosterone injection (PA), Androgel.62% (PA) First-BXN Mouthwash 3 diphenhydramine, lidocaine, nystatin KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications

16 Effective January, 205 Flarex 3 fluorometholone, prednisolone Flebogamma PA 3 medication flecainide Flovent HFA 2 fluconazole QL flunisolide fluocinolone fluocinonide Fluor-A-Day chew Fluor-A-Day drops 2 fluorometholone fluoxetine fluoxetine (28 unit pack) ST fluoxetine DR QL fluphenazine (ST <2 years of age) flurbiprofen fluticasone fluvastatin fluvoxamine FML Forte 3 fluorometholone, prednisolone FML S.O.P. 2 fondaparinux QL Foradil 2 Forteo ST, QL 3 medication Fortesta PA, ST 3 testosterone injection (PA), Androgel.62% (PA) fosinopril fosinopril/hctz Fosrenol 3 calcium acetate, sevelamer carbonate, Renvela powder packet Fragmin QL 3 medication Frova ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Fulyzaq PA, QL 3 medication furosemide Fuzeon 3 medication Fycompa PA, QL 3 felbamate, lamotrigine, topiramate, valproate gabapentin Gablofen 3 galantamine ER PA galantamine PA Galzin PA 2 Gammagard PA 3 medication Gammaked PA 3 medication Gammaplex PA 3 medication Gamunex PA 3 medication Gamunex-C PA 3 medication ganciclovir gatifloxacin Gattex PA, QL 3 medication gavilyte-g gemfibrozil Generess FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Gianvi Gildagia Gildess Gilenya PA, QL 3 medication Gilotrif PA, QL 3 medication Glassia PA 3 medication Gleevec PA, QL 3 medication glimepiride glipizide glipizide/metformin glipizide ER Glucagon 2 glyburide glyburide/metformin Glyset 3 acarbose Gralise PA, QL 3 gabapentin granisetron ST, QL ondansetron granisol ST, QL ondansetron Granix PA 3 medication griseofulvin guanfacine Halflytely 3 peg-3350, Suprep, Moviprep KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 2

17 halobetasol Halog 3 topical steroids haloperidol (ST <2 years of age) HCTZ Heather Helidac 3 bismuth subsalicylate (OTC), metronidazole, tetracycline Hetlioz PA, QL 3 medication Hexalen 3 medication Hizentra PA 3 medication homatropine drops Horizant PA, QL 3 gabapentin, pramipexole, ropinirole Humalog 50/50 QL 2 Humalog 75/25 QL 2 Humalog QL 2 Humira PA, QL 3 medication Humulin 50/50 QL 2 Humulin 70/30 QL 2 Humulin N QL 2 Humulin R QL 2 Hycamtin PA 3 medication hydralazine hydrocodone/ibuprofen hydrocodone/ acetaminophen QL hydrocort/pramoxine cream hydrocortisone hydromorphone hydroxychloroquine hydroxyurea hydroxyzine hyoscyamine ibandronate IV ST, QL 3 alendronate, ibandronate, risedronate ibandronate tablet QL ibuprofen Iclusig PA, QL 3 medication Ilaris PA, QL 3 medication Ilevro 3 ketorolac, diclofenac, bromfenac Imbruvica PA, QL 3 medication imiquimod Increlex PA 3 medication Incruse Ellipta 3 Spiriva, Tudorza indomethacin Infergen PA, QL 3 medication Inlyta PA, QL 3 medication Innopran XL ST 3 atenolol, metoprolol, propranolol Intelence PA 2 Intron A PA 3 medication Introvale Intuniv ST, QL 3 guanfacine Invega PA, QL (ST <2 years of age) Invega Sustenna PA, QL (ST <2 years of age) Invirase 2 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) 3 medication Invokana QL 3 metformin, glyburide, glipizide, Januvia, Tradjenta ipratropium ipratropium/albuterol solution irbesartan irbesartan/hctz Iressa PA, QL 3 medication Isentress 2 Isopto Carbachol 3 betaxolol, brimonidine, carteolol, dorzolamide, latanoprost, levobunolol, timolol, Combigan, Azopt, Betoptic S Isopto Homatropine 3 homatropine, atropine, cyclopentolate, tropicamide isosorbide isradipine Istalol 3 timolol itraconazole capsule PA, QL Jakafi PA, QL 3 medication KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 3

18 Effective January, 205 Jalyn 2 Janumet 2 Janumet XR 2 Januvia 2 Jencycla Jentadueto 2 Jetrea PA, QL 3 medication Jinteli Jolessa Jolivette Junel Junel FE Juxtapid PA, QL 3 medication Kalbitor PA 3 medication Kaletra 2 Kalydeco PA, QL 3 medication Kariva Kazano ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Ketek QL 3 azithromycin, clarithromycin ER, erythromycin ketoconazole ketoprofen ketorolac ophthalmic solution ketorolac QL Khedezla ER ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Kineret PA, QL 3 medication Kombiglyze XR ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Korlym PA, QL 3 medication Krystexxa PA, QL 3 medication Kurvelo Kuvan PA 3 medication Kynamro PA, QL 3 medication labetalol lactulose lamivudine lamivudine/zidovudine lamivudine HBV PA lamotrigine lansoprazole/amoxicillin/ clarithromycin pack lansoprazole QL Lantus QL 2 Larin Larin Fe Lastacaft 3 azelastine, epinastine, Pataday, Patanol latanoprost Latuda ST, QL (ST <2 years of age) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Lazanda PA, ST, QL 3 fentanyl citrate (PA), Abstral (PA) Leena leflunomide Lessina Letairis PA, QL 3 medication letrozole Leukeran 2 Leukine PA 3 medication leuprolide PA 3 medication levalbuterol ST Levatol ST 3 atenolol, metoprolol, propranolol Levemir QL 2 levetiracetam levetiracetam ER QL levobunolol levocetirizine levofloxacin levofloxacin ophthalmic Levonest levonorgestrel Levora levothyroxine Lexiva 2 Lialda ST 3 balsalazide disodium, Apriso, Asacol HD, Delzicol lidocaine patch ST, QL KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 4

19 lidocaine-hc gel LidoVir ointment compounding kit 3 For cold sore treatment use over-the-counter agents Lifescan Blood Glucose 2 Meters Lifescan Blood Glucose 2 Test Strips (QL > 8 years of age) Lifescan Lancets 2 (QL > 8 years of age) Linzess QL 3 Amitiza liothyronine Lipofen 3 fenofibrate Liptruzet ST 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia lisinopril lisinopril/hctz Lo Loestrin FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Loestrin 24 FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lomedia 24 FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lo Minastrin FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lomustine 2 loratadine OTC lorazepam Lorcet HD QL Lorcet plus QL Lortab QL Loryna losartan losartan/hctz Lotemax 3 fluorometholone, prednisolone Lotronex PA 3 medication lovastatin Low-ogestrel loxapine (ST <2 years of age) Lucentis PA 3 medication Lumigan 2 Lumizyme PA 3 medication Lupaneta PA, QL 3 medication Lupron PA, QL 3 medication Lyrica PA, QL 3 gabapentin, Savella (PA) Lysodren PA 3 medication Lyza Makena PA 3 medication malathion Matulane 3 medication matzim LA Maxair ST, QL 3 Ventolin HFA Maxaquin 3 ciprofloxacin, levofloxacin Maxidex 3 fluorometholone, prednisolone meclizine medroxyprogesterone acetate injection QL mefenamic acid Mekinist PA, QL 3 medication meloxicam Menest 3 Premarin, estradiol, estropipate Menostar QL 3 estradiol meperidine tablet mercaptopurine mesalamine metaxalone metformin metformin ER Methadose methamphetamine QL (PA < 4 and > 8 years of age) KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 5

20 Effective January, 205 methazolamide Methitest PA 3 testosterone injection (PA), Androgel.62% (PA) methocarbamol methotrexate methoxsalen PA 3 Medication methylin ER QL (PA < 4 and > 8 years of age) methylin QL (PA < 4 and > 8 years of age) methylphenidate ER QL (PA < 4 and > 8 years of age) methylphenidate QL (PA < 4 and > 8 years of age) methylprednisolone metipranolol metoclopramide metoprolol metoprolol/hctz metoprolol ER metronidazole Miacalcin 3 alendronate, ibandronate, risedronate Microgestin Microgestin FE midazolam syrup Migergot migragesic IDA Mimvey Mimvey Lo Minastrin 24 Fe 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Minivelle QL 3 estradiol patch, Premarin minocycline Mirapex ER ST 3 pramipexole, ropinirole mirtazapine Mirvaso PA 3 metronidazole, sodium sulfacetamide/sulfur, tretinoin, adapalene modafinil PA, QL Moderiba QL 3 medication moexipril moexipril/hctz mometasone Mono-linyah MonoNessa montelukast QL Monurol 2 morphine sulfate ER tablet QL morphine sulfate IR Moviprep 2 Moxeza 2 moxifloxacin Mozobil PA, QL 3 medication Multaq 2 mupirocin Myalept PA, QL 3 medication mycophenolate mofetil mycophenolate sodium Myobloc PA, QL 3 medication Myorisan Myozyme PA 3 medication Myrbetriq ER QL 3 oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare Myzilra nabumetone nadolol nadolol/ bendroflumethiazide Naglazyme PA 3 medication Namenda PA 2 Namenda XR PA, QL 2 naproxen naratriptan QL Nasonex ST 3 flunisolide, fluticasone, Veramyst Natazia 2 nateglinide Nebupent 2 Necon KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 6

21 Nesina ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Neulasta PA 3 medication Neumega 3 medication Neupogen PA 3 medication Neupro 3 pramipexole, ropinirole Nevanac 3 ketorolac, diclofenac, bromfenac nevirapine nevirapine ER Nexavar PA, QL 3 medication Nexium ST, QL 3 omeprazole, lansoprazole, pantoprazole Next Choice Next Choice One Dose niacin ER nicotine gum QL nicotine lozenges QL nicotine patches QL Nicotrol Inhaler ST, QL 2 Nicotrol Nasal Spray ST, 2 QL nifediac CC nifedipine nifedipine ER Nikki Nilandron PA 3 medication nimodipine nisoldipine nisoldipine ER nitrofurantoin nitroglycerin Nitrostat 3 nitroglycerin nizatidine nodolor Nora-BE Norditropin PA 3 medication Norlyroc Noroxin 3 ciprofloxacin, levofloxacin Nortrel nortriptyline Norvir 2 Novolin 70/30 QL 2 Novolin N QL 2 Novolin QL 2 Novolin R QL 2 Novolog Mix 70/30 QL 2 Novolog QL 2 Noxafil PA 3 medication Nplate PA 3 medication Nuedexta PA, QL 3 medication Nulojix PA 3 medication Numoisyn 3 Caphosol Nuvaring QL 2 Nuvigil PA, QL 3 amphetamine salts, Adderall XR, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, methylphenidate ER, modafinil (PA) NuZon 3 hydrocortisone Ocella octreotide 3 medication ofloxacin Oforta PA 3 medication Ogestrel olanzapine/fluoxetine PA, QL (ST <2 years of age) olanzapine QL (ST <2 years of age) olanzapine vial Olysio PA, QL 3 medication Omeclamox-Pak 3 omeprazole, clarithromycin, amoxicillin omega-3 acid ethyl esters omeprazole QL Omnaris ST 3 fluticasone, flunisolide, Veramyst Omontys PA 3 medication ondansetron QL KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 7

22 Effective January, 205 One Touch Blood Glucose Meters 2 One Touch Blood Glucose 2 Test Strips (QL > 8 years of age) Onfi PA, QL 3 felbamate, lamotrigine, topiramate, valproate Onglyza ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Onmel PA, QL 3 itraconazole (PA) Onsolis PA, ST, QL 3 fentanyl citrate (PA), Abstral (PA) Opana ER QL 2 Opsumit PA, QL 3 medication OramagicRx 3 lidocaine, First-Mouthwash Orap 2 (ST <2 years of age) Orencia PA, QL 3 medication Orenitram PA 3 medication Orfadin PA 3 medication Orsythia Ortho Tri-Cyclen LO 2 Oseni 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Osmoprep 3 peg-3350, Suprep, Moviprep Otezla PA, QL 3 medication Otosporin ear drops 3 Acetic acid/ hydrocortisone Otrexup PA, QL 3 medication oxaprozin oxazepam oxcarbazepine Oxsoralen PA 3 medication oxybutynin oxybutynin ER oxycodone/ acetaminophen QL oxycodone/aspirin QL oxycodone/ibuprofen QL oxycodone IR Oxycontin PA, QL 3 morphine sulfate ER, fentanyl patches, oxymorphone ER oxymorphone oxymorphone ER QL Pancreaze ST 3 Creon Pancrelipase ST 3 Creon Pandel 3 topical steroids Panretin PA 3 medication pantoprazole QL paricalcitol paroxetine paroxetine CR QL Pataday 2 Patanase 3 azelastine Patanol 2 peg-3350 Peganone PA 3 carbamazepine, lamotrigine, oxcarbazepine, phenytoin, topiramate, valproic acid Pegasys PA, QL 3 medication Peg-Intron PA, QL 3 medication pemoline penicillin Pentasa 3 balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol pentazocine/ acetaminophen QL pentazocine/naloxone Perforomist 3 Serevent, Foradil perindopril permethrin cream perphenazine (ST <2 years of age) Pertzye ST 3 Creon phenelzine phenobarbital phenytoin Philith Phospholine Iodide 3 pilocarpine KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 8

23 Picato PA 3 5-fluorouracil, imiquimod pilocarpine Pilopine HS 3 pilocarpine Pimtrea pindolol pioglitazone pioglitazone/glimepiride pioglitazone/metformin Pirmella piroxicam podofilox Pomalyst PA, QL 3 medication Portia potassium chloride Potiga PA, QL 3 carbamazepine, phenytoin, oxcarbazepine, valproic acid, levetiracetam, topiramate, tiagabine, zonisamide Pradaxa QL 2 pramipexole Pramosone 3 hydrocortisone/ pramoxine Prandimet 3 metformin, repaglinide pravastatin prazosin Pred Mild 3 fluorometholone, prednisolone prednicarbate prednisolone prednisone Prefest 3 estradiolnorethindrone, Jinteli, Prempro, Premphase Premarin 2 Premarin Vaginal Cream 2 Premphase 2 Prempro 2 Prenate 3 generic prenatal vitamins Prepopik 3 peg-3350, Suprep, Moviprep Prevident 3 sodium fluoride gel Prezista 2 primidone Pristiq ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Privigen PA 3 medication ProAir HFA ST, QL 3 Ventolin HFA Procrit PA 3 medication Proctofoam-HC 2 Procysbi PA, QL 3 medication progesterone capsule Prolastin PA 3 medication Prolastin-C PA 3 medication Prolensa 3 ketorolac, diclofenac, bromfenac Proleukin 3 medication Prolia PA, QL 3 medication Promacta PA, QL 3 medication propafenone ER propranolol propranolol/hctz propranolol SA Protopic PA 3 topical steroids protriptyline Proventil HFA ST, QL 3 Ventolin HFA pruvate 2-7 Pulmicort Flexhaler ST 3 QVAR, Flovent HFA, Asmanex Pulmozyme PA, QL 3 medication QNASL ST 3 flunisolide, fluticasone, Veramyst Quartette 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Quasense quetiapine PA, QL (ST <2 years of age) quinapril quinapril/hctz Qutenza PA, QL 3 medication QVAR 2 raloxifene KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 9

24 Effective January, 205 ramipril Ranexa 2 ranitidine Rapaflo ST 3 doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er Ravicti PA, QL 3 medication Rebif ST, QL 3 medication Rectiv PA 3 topical diltiazem compound, topical nifedipine compound Regranex QL 3 medication Relenza QL 3 amantadine Relistor PA 3 medication Relpax ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Remicade PA 3 medication Remodulin PA 3 medication renalpren Renvela 2 Renvela powder packet 2 repaglinide reprexain Rescriptor 2 Rescula ST 3 latanoprost, Lumigan Restasis QL 2 Revlimid PA, QL 3 medication Reyataz 2 Ribasphere QL 3 medication Ribatab QL 3 medication ribavirin QL 3 medication rifabutin rifampin riluzole PA, QL 3 medication Riomet 3 metformin risedronate QL Risperdal Consta PA, QL 3 medication (ST <2 years of age) risperidone ODT QL (ST <2 years of age) risperidone QL (ST <2 years of age) Rituxan PA, QL 3 medication rivastigmine tartrate capsules PA rizatriptan QL ropinirole ropinirole ER Roxicet solution 2 Sabril PA, QL 3 medication Safyral 2 salicylic acid Samsca PA, QL 3 medication Sancuso ST, QL 3 ondansetron Sandostatin LAR PA, QL 3 medication Santyl 2 Saphris ST, QL (ST <2 years of age) Savella PA, QL 2 selegiline selenium sulfide shampoo Selzentry PA 2 Sensipar 2 Serevent 2 Seroquel XR PA, ST, QL (ST <2 years of age) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Serostim PA 3 medication sertraline sevelamer carbonate Signifor PA, QL 3 medication sildenafil 20mg PA, QL 3 medication Simbrinza 3 brimonidine, dorzolamide, Azopt, Combigan Simcor ST 3 simvastatin, niacin ER Simponi Aria PA, QL 3 medication Simponi PA, QL 3 medication simvastatin sirolimus PA Sirturo PA 3 Sivextro QL 3 medication sodium fluoride gel KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 20

25 sodium phenylbutyrate 3 medication powder PA sodium sulfacetamide/ sulfur/urea Soliris PA 3 medication Somatuline PA, QL 3 medication Somavert PA, QL 3 medication sotalol Sovaldi PA, QL 3 medication Spectracef 3 cefpodoxime, cefdinir Spiriva 2 spironolactone spironolactone/hctz Sporanox solution PA 3 itraconazole capsule (PA) Sprintec Sprycel PA, QL 3 medication stavudine Stelara PA, QL 3 medication Stivarga PA, QL 3 medication Strattera QL 2 Striant PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Stribild 2 Suboxone film PA, QL 2 Subsys PA, ST, QL 3 fentanyl citrate (PA), Abstral (PA) Suclear 3 peg-3350, Suprep, Moviprep Sucraid PA 3 medication sulfacetamide sodium sulfamethoxazole/ trimethoprim sulfasalazine sulfasalazine EC sulfisoxazole sulindac sumatriptan QL Sumavel DosePro QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Supprelin LA PA, QL 3 medication Suprax 3 cefpodoxime, cefdinir Suprep 2 Sustiva 2 Sutent PA, QL 3 medication Syeda Sylatron PA 3 medication Sylvant PA 3 medication Symbicort 2 Symlin ST, QL 2 Synagis PA, QL 3 medication Synarel PA, QL 3 medication Synvisc One PA, QL 3 medication Synvisc PA, QL 3 medication Syprine PA 3 medication Tabloid PA 2 tacrolimus Tafinlar PA, QL 3 medication Tamiflu QL 3 amantadine tamoxifen tamsulosin Tanzeum ST, QL 3 Bydureon, Victoza Tarceva PA, QL 3 medication Targretin PA 3 medication Tasigna PA, QL 3 medication Tasmar 3 entacapone Tazorac (PA >35 years of age) taztia XT 3 topical acne agents Tecfidera PA, QL 3 medication Tekamlo ST 2 Tekturna HCT ST 2 Tekturna ST 2 telmisartan telmisartan/amlodipine telmisartan/hctz temazepam temozolomide PA 3 medication Tencon terazosin terbinafine QL Testim PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Testopel PA 3 testosterone injection (PA), Androgel.62% (PA) KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 2

26 Effective January, 205 Testosterone gel PA, ST 3 testosterone injection (PA), Androgel.62% (PA) testosterone injection PA Testred PA, ST 3 testosterone injection (PA), Androgel.62% (PA) tetracaine ophthalmic tetracycline Thalomid PA, QL 3 medication Theo-24 ER 3 theophylline ER theophylline ER thioridazine (ST <2 years of age) thiothixene (ST <2 years of age) Thyrogen 3 medication tiagabine ticlopidine Tikosyn 2 Tilia FE timolol tinidazole Tirosint 3 levothyroxine Tivicay 2 tizanidine tablet TOBI Podhaler QL 3 medication Tobradex ST 3 tobramycin/ dexamethasone tobramycin tobramycin/ dexamethasone tobramycin solution for 3 medication nebulization QL Tobrex 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Moxeza, Vigamox tolazamide tolbutamide tolmetin tolterodine tolterodine ER topiragen QL topiramate topiramate sprinkle QL Toviaz 2 Tracleer PA, ST, QL 3 medication Tradjenta 2 tramadol/acetaminophen QL tramadol ER tablet QL tramadol QL trandolapril trandolapril/verapamil tranexamic acid PA, QL Transderm-Scop 3 meclizine tranylcypromine Travatan Z ST 3 latanoprost, Lumigan, travoprost (ST) travoprost ST trazodone Trelstar PA, QL 3 medication tretinoin oral 3 medication tretinoin topical Trezix triamcinolone triamterene/hctz Tri-estarylla trifluoperazine (ST <2 years of age) Tri-legest FE Tri-linyah Trilyte Trinessa Tri-previfem Tri-sprintec Trivora tropicamide drops trospium trospium ER Truvada 2 Tudorza Pressair 2 Tykerb PA, QL 3 medication Tysabri PA, QL 3 medication Tyvaso PA 3 medication Tyzeka PA 3 medication Uceris PA 3 budesonide KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 22

27 Ulesfia 3 Uloric ST, QL 2 allopurinol Ultresa ST 3 Creon unithroid urea Urocit-K 3 potassium citrate ursodiol Vagifem 3 Premarin, estradiol, estropipate valacyclovir QL Valchlor PA 3 medication Valcyte 3 ganciclovir valproate valsartan valsartan/hctz vancomycin capsules Vanoxide-HC 3 benzoyl peroxide Vantas PA, QL 3 medication Vascepa 3 fenofibrate, atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Vasolex 3 Santyl Vectical QL 3 calcipotriene Veletri PA 3 medication Velivet Velphoro 3 calcium acetate, sevelamer carbonate venlafaxine venlafaxine ER capsule QL Ventavis PA 3 medication Ventolin HFA QL 2 Veramyst 2 verapamil verapamil ER PM verapamil extended release verapamil SR Veregen 3 podofilox, imiquimod Vesicare 2 Vestura Vexol 3 fluorometholone, prednisolone Victoza ST 2 Videx solution 2 Vigamox 2 Viibryd PA, QL 3 paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) Vimizim PA 3 medication Vimpat PA 3 carbamazepine, lamotrigine, oxcarbazepine, phenytoin, zonisamide Viokace ST 3 Creon Viracept 2 Viread 2 visqid a/a vistra vitamins (generic pediatric) vitamins (generic prenatal) Vivelle-DOT QL 3 estradiol patch, Premarin Vivitrol PA 3 medication Vogelxo PA, ST 3 testosterone injection (PA), Androgel.62% (PA) Voltaren Gel QL 3 diclofenac, ibuprofen, naproxen voriconazole QL Votrient PA, QL 3 medication VPRIV PA 3 medication Vyfemla Vytorin ST 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia Vyvanse QL (PA < 4 and >8 years of age) 3 amphetamine salts, dexmethylphenidate, methylphenidate, Adderall XR, methylin, methylin ER, methylphenidate ER, Strattera warfarin Welchol 2 Wera WP Thyroid 3 levothyroxine Wymzya Fe KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 23

28 Effective January, 205 Xalkori PA, QL 3 medication Xarelto QL 2 Xeljanz PA, QL 3 medication Xenazine PA, QL 3 medication Xeomin PA, QL 3 medication Xerac AC 2 Xgeva PA, QL 3 medication Xifaxan 200mg QL 3 ciprofloxacin, loperamide Xifaxan 550mg PA, QL 3 lactulose Xolair PA, QL 3 medication Xopenex HFA ST, QL 3 Ventolin HFA Xtandi PA, ST, QL 3 medication Xulane QL Xyrem PA, QL 3 medication zafirlukast zaleplon Zarah Zavesca PA 3 medication Zelapar 3 carbidopa/levodopa, entacapone, ropinirole, pramipexole, carbidopa/levodopa/ entacapone, Azilect Zelboraf PA, QL 3 medication Zemaira PA 3 medication Zenatane Zenchent Fe zenieva Zenpep ST 3 Creon Zeosa Zetia 2 Zetonna ST 3 fluticasone, flunisolide, Veramyst Zinotic ES 3 acetic acid/ hydrocortisone, Ciprodex Zioptan ST 3 latanoprost, Lumigan ziprasidone QL (ST <2 years of age) Zirgan gel 2 Zithranol-RR cream 3 Drithocreme Zmax QL 3 azithromycin, clarithromycin, erythromycin Zoladex PA, QL 3 medication zoledronic acid 4mg 3 medication zoledronic acid 5mg ST, QL Zolinza PA, QL 3 medication zolmitriptan QL zolpidem tartrate Zomig nasal spray QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan zonisamide Zontivity PA, QL 3 clopidogrel, Effient Zorbtive PA 3 medication Zortress PA 2 Zovia Zubsolv PA, QL 2 Zyflo 3 montelukast Zyflo CR 3 montelukast Zykadia PA, QL 3 medication Zylet 3 tobramycin/ dexamethasone Zyprexa Relprevv PA, QL 3 medication (ST <2 years of age) Zytiga PA, QL 3 medication Zyvox QL 2 KEY QL = Quantity Limits PA = Prior Authorization required ST = Step Therapy required * Age restrictions apply to some medications. COPAYMENT TIER = Medications 2 = -Brand Medications 3 = Non- Brand Medications & Medications 24

29 MEDICATIONS NOT COVERED BY YOUR CHOICE The following medications are benefit exclusions and will not be covered under the pharmacy benefit: Anabolic steroids Antimalarial agents Antiobesity medications, including, but not limited to, appetite suppressants and lipase inhibitors Blood or blood plasma products* Drugs labeled for investigational use Drugs used for cosmetic purposes or hair growth Drugs used to treat sexual dysfunction (examples are Viagra, Levitra, Cialis, Muse, Caverject, Osphena, Stendra) Fertility agents Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over-the-counter medications Needles/syringes (other than insulin)* Nutrition and dietary supplements* Ostomy supplies* Therapeutic devices/appliances* Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.) *Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Health Care Concierge team at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Health Care Concierge team number listed on page of this booklet. 25

30 NON-COVERED MEDICATIONS WITH COVERED ALTERNATIVES Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs Absorica Acanya gel Aciphex Sprinkle Actoplus Met XR Aerochamber Akten Ala-Scalp Amnesteem, Claravis, Myorisan, Zenatane benzoyl peroxide, clindamycin omeprazole, lansoprazole, pantoprazole, Nexium pioglitazone/metformin, pioglitazone and metformin ER Easivent, Inspirease, Optichamber, Optihaler lidocaine hydrocortisone, fluocinonide, clobetasol, betamethasone Azor Benicar candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor Allfen Aloquin gel Alsuma Altoprev Aluvea Amrix Analpram Advanced Kit Analpram E Kit Apexicon E Cream Aplenzin ER Astagraf XL Atopiclair Atralin Auralgan Aurax HC Solution codeine clotrimazole, miconazole, nystatin sumatriptan lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin urea cyclobenzaprine pramoxine/hydrocortisone pramoxine/hydrocortisone diflorasone, betamethasone, desoximetasone, fluocinonide bupropion SR, bupropion XL tacrolimus ammonium lactate, zenieva tretinoin, adapalene aurodex, auroguard antipyrine/benzocaine drops Benicar HCT Benzamycin Pak BenzEFoam BenzePrO topical foam Benziq betamethasone/calcipotriene ointment Bidil Binosto Blood Glucose Meters Blood Glucose Test Strips Brisdelle candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor benzoyl peroxide/erythromycin benzoyl peroxide benzoyl peroxide benzoyl peroxide betamethasone, calcipotriene hydralazine, isosorbide dinitrate alendronate, ibandronate, risedronate, Actonel, Atelvia Bayer meters (such as Contour, Ascensia, or Breeze), Lifescan meters (such as One Touch) Bayer and Lifescan test strips paroxetine, venlafaxine, fluoxetine Avandamet Avandaryl Avandia Avar Avidoxy DK Kit Azasan pioglitazone, metformin, Januvia, Tradjenta, Janumet, Janumet XR, Jentadueto pioglitazone-glimepiride, metformin, glimepiride, Januvia, Tradjenta pioglitazone, metformin, Januvia, Tradjenta sodium sulfacetamide/sulfur doxycycline, topical salicylic acid products OTC azathioprine Brontex Butrans Cambia Carmol Centany Ointment Chenodal Claritin-D Cleanse & Treat clindamycin/benzoyl peroxide codeine morphine sulfate ER, oxycodone, oxymorphone ER, fentanyl patch diclofenac urea mupirocin ursodiol loratadine OTC, levocetirizine benzoyl peroxide clindamycin and benzoyl peroxide Clindareach clindamycin 26

31 Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs Clobex clobetasol Epaned solution enalapril tablet Cloderm Compounded Hormone Replacement Therapy Compounded Narcotic Analgesics Conzip Cordran cream, lotion, ointment, tape Crestor Cyclobenzaprine ER Daytrana desloratadine Desonate betamethasone, fluocinonide, desoximetasone, triamcinolone, mometasone, hydrocortisone Prempro, Premphase, estradiol, estradiol-norethindrone, Jinteli hydrocodone/acetaminophen, commercially available pain products tramadol, tramadol ER tablet betamethasone, fluticasone, fluocinonide, triamcinolone lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin cyclobenzaprine amphetamine salts, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, Adderall XR, methylin, methylin ER, methylphenidate ER, Strattera loratadine OTC, levocetirizine desonide Epiduo gel Equagesic Ergomar Exforge Exforge HCT Extavia Farxiga benzoyl peroxide, adapalene, tretinoin acetaminophen/butalbital/ caffeine, dihydroergotamine acetaminophen/butalbital/ caffeine, dihydroergotamine candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor Avonex, Rebif, Copaxone, Betaseron Invokana, metformin, glyburide, glipizide, Januvia, Tradjenta Desonil Plus desonide Fenoglide fenofibrate Dexilant Diclegis Diclofenac 3% gel Differin lotion omeprazole, lansoprazole, pantoprazole, Nexium diphenhydramine, meclizine, ondansetron Voltaren gel, diclofenac tablet tretinoin, adapalene Fexmid Fibricor First Lansoprazole First Omeprazole cyclobenzaprine fenofibrate omeprazole, lansoprazole, pantoprazole, Nexium omeprazole, lansoprazole, pantoprazole, Nexium Dilatrate SR isosorbide dinitrate ER Flagyl ER metronidazole Dilaudid liquid hydromorphone Flector patch Voltaren Gel, diclofenac Dolgic Plus doxycycline hyclate delayed release Droxia Duac Duexis Dutoprol Edluar Embeda acetaminophen/butalbital/ caffeine, dihydroergotamine doxycycline hyclate hydroxyurea benzoyl peroxide, clindamycin Celebrex, cimetidine, famotidine, ibuprofen, meloxicam, ranitidine atenolol/chlorthalidone, bisoprolol/hctz, metoprolol/ HCTZ, propranolol/hctz zolpidem, zaleplon, eszopiclone morphine sulfate ER fluvoxamine ER Fosamax Plus D Gelnique Gel-One Genotropin Giazo Glumetza Glycate fluvoxamine alendronate, ibandronate, risedronate, Actonel, Atelvia oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare Euflexxa, Synvisc, Synvisc One Norditropin balsalazide metformin, metformin ER glycopyrrolate tablets, Cuvposa oral solution Emsam Enablex tranylcypromine sulfate, fluoxetine, paroxetine, citalopram, sertraline oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare Halonate Humatrope Hyalgan Hycet triamcinolone, betamethasone, clobetasol Norditropin Euflexxa, Synvisc, Synvisc One hydrocodone 27

32 Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs hydromorphone ER Hylatopic Plus-Aurstat hydromorphone, oxymorphone generic topical corticosteroids, Protopic, Elidel Midamor Millipred spironolactone, triamterene, eplerenone, amiloride prednisolone Ibudone hydrocodone, ibuprofen Mimyx ammonium lactate, zenieva IC400 Kit ibuprofen, naproxen Momexin Combo Pack mometasone, ammonium lactate IC800 Kit ibuprofen, naproxen Monodox doxycycline Incivek Olysio Monovisc Euflexxa, Synvisc, Synvisc One Inderal XL propranolol Morphine sulfate ER capsules morphine sulfate ER tablets Indocin suppository Innohep Inova oral indomethacin, ibuprofen, naproxen enoxaparin, fondaparinux, Fragmin salicylic acid cream, shampoo, gel, 26% topical liquid Moxatag MuGard Myoxin Otic suspension Naprelan CR amoxicillin, penicillin Caphosol, Aquoral, Numoisyn polymyxin/hydrocortisone, Cipro HC naproxen Intermezzo J-Max DHC Jublia zolpidem, zaleplon, eszopiclone hydrocodone terbinafine, itraconazole, ciclopirox Natesto Neobenz Neotic testosterone injection, Androgel.62% benzoyl peroxide aurodex, auroguard Kerafoam urea Neutrasal Caphosol, Aquoral, Numoisyn Keralac urea Nexiclon XR clonidine Keralyt salicylic acid cream, shampoo, gel, 26% topical liquid NitroMist nitroglycerin, Nitrostat, Nitroquick, Nitrolingual spray Kerol Lamisil Granules lamotrigine ER urea, lactic acid terbinafine lamotrigine Novacort Nucort betamethasone, fluticasone, fluocinonide, triamcinolone hydrocortisone, fluocinonide, clobetasol, betamethasone Lescol XL lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin Nucynta hydrocodone, morphine sulfate, oxycodone, oxymorphone, tramadol Levorphanol Liquicet Livalo Locoid Loratadine-D oxycodone, hydromorphone, hydrocodone, oxymorphone hydrocodone/acetaminophen lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin hydrocortisone butyrate loratadine OTC, levocetirizine Nucynta ER Nutropin Oleptro Olux, Olux E Omeprazole/Sodium Bicarbonate hydrocodone, morphine sulfate, oxycodone, oxymorphone, tramadol Norditropin trazodone, nefazodone clobetasol omeprazole, lansoprazole, pantoprazole, Nexium Lorzone Luzu Lycelle Lynox Magnacet Meperidine solution Methadone Intensol Metozolv ODT Metronidazole % gel chlorzoxazone, carisoprodol, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine clotrimazole, econazole, ketoconazole lindane, malathion, permethrin, Ulesfia oxycodone/acetaminophen oxycodone/acetaminophen meperidine tablet methadone tablet metoclopramide metronidazole 0.75% gel Omnitrope Oracea Oravig Orbivan Orthovisc Otic Care Otic Edge Otozin Ovace Plus Shampoo Oxecta Norditropin doxycycline fluconazole, clotrimazole, nystatin, itraconazole acetaminophen/butalbital/ caffeine, dihydroergotamine Euflexxa, Synvisc, Synvisc One aurodex, auroguard aurodex, auroguard aurodex, auroguard sodium sulfacetamide oxycodone 28

33 Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs Oxtellar XR oxcarbazepine Rozerem zolpidem, zaleplon, eszopiclone Oxytrol Pacnex Wash Pediaderm AF kit Pediaderm TA complete kit Pennsaid, diclofenac topical drops Perloxx Pexeva Phoslyra Phrenilin Forte Pinnacaine Pramosone E Prevacid Prilosec Primlev Protonix Prumyx Pylera Qudexy XR Quillivant XR Rabeprazole Rayos Refissa Retin-A micro, Tretinoin micro Rheumatrex Riax Ribapak Rosadan Rosula Rowasa Roxicet caplet oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare benzoyl peroxide nystatin triamcinolone Voltaren gel, diclofenac tablets oxycodone/acetaminophen paroxetine, sertraline, citalopram calcium acetate, eliphos acetaminophen/butalbital/ caffeine, dihydroergotamine aurodex, auroguard hydrocortisone/pramoxine omeprazole, lansoprazole, pantoprazole, Nexium omeprazole, lansoprazole, pantoprazole, Nexium oxycodone/acetaminophen omeprazole, lansoprazole, pantoprazole, Nexium ammonium lactate, zenieva metronidazole, tetracycline topiramate amphetamine salts, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, Adderall XR, methylin, methylin ER, methylphenidate ER, Strattera omeprazole, lansoprazole, pantoprazole, Nexium prednisone tretinoin, adapalene tretinoin methotrexate benzoyl peroxide ribavirin metronidazole, tretinoin, clindamycin, erythromycin benzoyl peroxide Asacol HD, balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, mesalamine, Delzicol oxycodone/acetaminophen Rybix ODT Ryneze Saizen Salex salicylic acid 27.5% topical liquid Salkera Salvax Sarafem tablets Scalacort Silenor Sklice Solodyn ER Soltamox Sorilux Spinosad Sprix Sumaxin Supartz Synalgos Synera Patch Terbinex Tetravisc Forte Teveten HCT Tev-Tropin Theophylline solution tizanidine capsule tramadol ER capsule Treagan Otic Trexall Treximet Triaz tramadol, tramadol ER tablet loratadine OTC, levocetirizine Norditropin salicylic acid salicylic acid cream, shampoo, gel, 26% topical liquid salicylic acid products OTC salicylic acid products OTC fluoxetine hydrocortisone, fluocinonide, clobetasol, betamethasone doxepin, zolpidem, zaleplon, eszopiclone lindane, malathion, permethrin, Ulesfia minocycline tamoxifen calcipotriene lindane, malathion, permethrin, Ulesfia ketorolac sodium sulfacetamide/sulfur Euflexxa, Synvisc, Synvisc One hydrocodone lidocaine terbinafine tetracaine, Tetravisc candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor Norditropin oral theophylline tizanidine tablet tramadol ER tablet aurodex, auroguard methotrexate sumatriptan, sumatriptan and naproxen, naratriptan, rizatriptan, zolmitriptan, Axert, Frova, Relpax benzoyl peroxide 29

34 Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs Tribenzor Triglide TriOxin otic Trokendi XR Ultravate X Umecta Uramaxin Venlafaxine ER tablet Veripred Versacloz Victrelis Vimovo Virasal Vituz Xartemis XR candesartan, candesartan/ hctz, eprosartan, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/amlodipine, telmisartan/hctz, valsartan, valsartan/hctz, Edarbi, Edarbyclor fenofibrate polymyxin/hydrocortisone, Cipro HC topiramate halobetasol, triamcinolone, betamethasone, clobetasol urea urea venlafaxine ER capsule, paroxetine, sertraline, citalopram prednisolone clozapine, clozapine ODT Olysio naproxen, lansoprazole salicylic acid products OTC hydrocodone/chlorpheniramine oxycodone/acetaminophen Zencia Zenzedi Ziana gel Zipsor Zithranol shampoo Zoderm Zohydro ER (PA) zolpidem ER Zolpimist Zonatuss Zorvolex Zovirax cream Z-Pram Zuplenz Zyclara Zypram sodium sulfacetamide/sulfur amphetamine salts, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, Adderall XR, methylin, methylin ER, methylphenidate ER, Strattera clindamycin and tretinoin diclofenac, ibuprofen, naproxen drithocreme, Dritho-Scalp benzoyl peroxide fentanyl patch, morphine sulfate ER, oxymorphone ER, methadone zolpidem, zaleplon, eszopiclone zolpidem, zaleplon, eszopiclone benzonatate diclofenac acyclovir ointment hydrocortisone/pramoxine ondansetron imiquimod, tretinoin, adapalene, fluorouracil hydrocortisone/pramoxine Xclair ammonium lactate, zenieva Xodol hydrocodone/acetaminophen Xolox oxycodone/acetaminophen Zamicet hydrocodone/acetaminophen Zantac EFFERdose famotidine, ranitidine 30

35 YOUR CHOICE BRAND/GENERIC REFERENCE GUIDE Brand Accolate Zafirlukast Calan Brand Verapamil Accupril Quinapril Campral Acamprosate Aceon Perindopril Cardizem CD Diltiazem ER Aciphex Rabeprazole Cardizem LA Diltiazem ER Actiq Fentanyl Citrate Casodex Bicalutamide Activella Estradiol-Norethindrone, Mimvey Catapres Clonidine Actonel Risedronate Ceclor Cefaclor ActoPlus Met Pioglitazone/Metformin Cedax Ceftibuten Actos Pioglitazone Ceftin Cefuroxime Acular Ketorolac Cefzil Cefprozil Adderall XR Amphetamine-dextroamphetamine ER Celexa Citalopram Aldactazide Spironolactone/HCTZ Cellcept Mycophenolate Mofetil Aldactone Spironolactone Cetraxal Ciprofloxacin 0.2% ear drops Aldara Imiquimod Cipro Ciprofloxacin Alphagan Brimonidine Claritin OTC Loratadine OTC Altace Ramipril Cleocin Clindamycin Amaryl Glimepiride Climara Estradiol Patch Ambien Zolpidem Tartrate Clobex Clobetasol Amerge Naratriptan Cogentin Benztropine Amoxil Amoxicillin Colazal Balsalazide Disodium Analpram HC cream Hydrocort-Pramoxine cream Combivir Lamivudine/Zidovudine Antabuse Disulfuram Comtan Entacapone Antara Fenofibrate Concerta Methylphenidate ER Antivert Meclizine Coreg Carvedilol Arava Leflunomide Cosopt Dorzolamide/Timolol Aricept Donepezil Coumadin Warfarin Arimidex Anastrozole Cozaar Losartan Arixtra Fondaparinux Cutivate (topical) Fluticasone Aromasin Exemestane Cyclocort Amcinonide Arthrotec Diclofenac/misoprostol Cyclogyl Cyclopentolate Astelin Azelastine Cymbalta Duloxetine Atacand Candesartan Cytomel Liothyronine Atacand HCT Ativan Augmentin Avalide Avapro Avelox Azulfidine, Sulfazine Bactrim Bactroban Biaxin Boniva Buphenyl powder Buspar Caduet Candesartan/HCTZ Lorazepam Amoxicillin/Clavulanate Irbesartan/HCTZ Irbesartan Moxifloxacin Sulfasalazine Sulfamethoxazole/Trimethoprim Mupirocin Clarithromycin Ibandronate Sodium phenylbutyrate powder Buspirone Amlodipine/Atorvastatin Depakote, Depakote ER Derma-Smoothe/FS Desoxyn Desyrel Detrol Detrol LA Dexedrine Diabeta, Micronase Diamox sequels Differin Diflucan Diovan Diovan HCT Ditropan Divalproex sodium, Divalproex sodium ER Fluocinolone Methamphetamine Trazodone Tolterodine Tolterodine ER Dextroamphetamine Glyburide Acetazolamide ER Adapalene Fluconazole Valsartan Valsartan/HCTZ Oxybutynin 3

36 Brand Dovonex Calcipotriene Brand Iopidine Apraclonidine Duac gel Clindamycin/Benzoyl Peroxide %-5% gel Kapvay Clonidine ER Duetact Pioglitazone/Glimepiride Keflex Cephalexin Duoneb Ipratropium/Albuterol Solution Kenalog (topical) Triamcinolone Duragesic Fentanyl Keppra Levetiracetam Duricef Cefadroxil Hydrate Keppra XR Levetiracetam ER Effexor Venlafaxine Klonopin Clonazepam Effexor XR Venlafaxine ER Capsules Kytril Granisetron Elavil Amitriptyline Lamictal Lamotrigine Elestat Epinastine Lasix Furosemide Elocon Mometasone Lescol Fluvastatin Entocort EC Budesonide EC Levaquin Levofloxacin Epivir Lamivudine Lexapro Escitalopram Epivir HBV Lamivudine HBV Lidoderm Lidocaine Patch Evista Raloxifene Lipitor Atorvastatin Evoxac Cevimeline Lodine Etodolac Exelon Rivastigmine Lodosyn Carbidopa Famvir Fazaclo Feldene Femara Femcon Fe Femhrt /5 Flagyl Flexeril Flolan Flomax Flonase Focalin Focalin XR Fortamet Fortaz Fosamax Gabitril Gengraf Geodon Glucophage Glucotrol Golytely Hectorol Hepsera Hyzaar Ilotycin Imitrex Inderal Indocin Inspra Famciclovir Clozapine ODT Piroxicam Letrozole Zeosa, Wymzia Fe, Zenchent Fe Jinteli Metronidazole Cyclobenzaprine Epoprostenol Tamsulosin Fluticasone Dexmethylphenidate Dexmethylphenidate ER Metformin ER Ceftazidime Alendronate Tiagabine Cyclosporine modified Ziprasidone Metformin Glipizide Gavilyte-G Doxercalciferol Adefovir Losartan/HCTZ Erythromycin Sumatriptan Propranolol Indomethacin Eplerenone Loestrin Fe Lofibra Lopid Lopressor LoSeasonique Lotrel Lovaza Lovenox Lunesta Lybrel Lysteda Macrodantin Marinol Maxalt Metadate CD Metadate ER Mevacor Micardis Micardis HCT Micronor Migranal Minocin Mirapex Mobic Motrin MS Contin Myfortic Naprosyn Nasacort AQ Gildess Fe, Junel Fe, Larin Fe, Microgestin Fe Fenofibrate Gemfibrozil Metoprolol Amethia Lo, Camrese Lo Amlodipine Besylate/Benazepril Omega-3 acid ethyl esters Enoxaparin Eszopiclone Amethyst Tranexamic acid Nitrofurantoin Dronabinol Rizatriptan Methylphenidate ER Methylphenidate ER Lovastatin Telmisartan Telmisartan/HCTZ Camila, Heather, Jencycla, Lyza, Norlyroc Dihydroergotamine Minocycline Pramipexole Meloxicam Ibuprofen Morphine Sulfate ER Mycophenolate Sodium Naproxen Triamcinolone Acetonide 32

37 Brand Neoral Neurontin Niaspan Nizoral Nordette Norvasc Nulytely Omnicef Omnipred % drops Opana Opana ER Optivar Ortho-Cept Ortho-Cyclen Ortho Evra Ortho Tri-Cyclen Ovcon Ovide Oxsoralen Ultra Palgic Parcopa Paxil Pepcid Percocet PhosLo Plan B Plan B One-Step Plavix Plendil Ponstel Prandin Pravachol Precose Prevacid Prevpac Prilosec Prinivil, Zestril Prinzide, Zestoretic Procardia Prograf Prometrium Protonix Provigil Prozac Prozac Weekly Pulmicort respules Quixin Cyclosporine modified Gabapentin Niacin ER Ketoconazole Portia, Chateal, Kurvelo Amlodipine Besylate Peg-3350 Cefdinir Prednisolone Acetate % drops Oxymorphone Oxymorphone ER Azelastine Apri, Enskyce, desogestrel-ethinyl estradiol Mono-linyah, Estarylla, Sprintec Xulane Tri-linyah, Tri-estarylla, Tri-sprintec Briellyn, Gildagia, Philith, Pirmella, Vyfemla Malathion Methoxsalen Arbinoxa Carbidopa/Levodopa Paroxetine Famotidine Oxycodone/Acetaminophen Calcium Acetate Levonorgestrel, Next Choice Next Choice One Dose Clopidogrel Felodipine Mefenamic acid Repaglinide Pravastatin Acarbose Lansoprazole Lansoprazole/amoxicillin/clarithromycin pack Omeprazole Lisinopril Lisinopril/HCTZ Nifedipine Tacrolimus Progesterone capsule Pantoprazole Modafinil Fluoxetine Fluoxetine DR Budesonide respules Levofloxacin Brand Rapamune Sirolimus Razadyne Galantamine Reclast Zoledronic acid 5mg Reglan Metoclopramide Remeron Mirtazapine Renvela Sevelamer carbonate Repliva 2-7 Pruvate 2-7 Requip Ropinirole Requip XL Ropinirole XL Restoril Temazepam Retin A Tretinoin Revatio Sildenafil Rhinocort Aqua Budesonide nasal spray Rilutek Riluzole Risperdal Risperidone Ritalin Methylphenidate Ritalin LA Methylphenidate ER Rosula Sodium Sulfacetamide/Sulfur/Urea Rowasa Mesalamine Rythmol SR Propafenone ER Sanctura Trospium Sanctura XR Trospium ER Sandimmune Cyclosporine Seasonale Jolessa, Quasense Seasonique Amethia, Camrese Seroquel Quetiapine Singulair Montelukast Sodium Skelaxin Metaxalone Soma Carisoprodol Sonata Zaleplon Soriatane Acitretin Sporanox Itraconazole Stalevo Carbidopa/Levodopa/Entacapone Starlix Nateglinide Suboxone Buprenorphine/Naloxone Subutex Buprenorphine Sular Nisoldipine ER Symbyax Olanzapine/Fluoxetine Tarka Trandolapril/Verapamil Tegretol XR Carbamazepine ER Temodar Temozolomide Temovate Clobetasol Tenex Guanfacine Tenormin Atenolol Teveten Eprosartan Tindamax Tinidazole TOBI Tobramycin solution for nebulization 33

38 Brand Tobradex Tobramycin-Dexamethasone Brand Wellbutrin Bupropion Topamax Topiramate, Topiragen Wellbutrin XL Budeprion XL Topicort Desoximetasone Xalatan Latanoprost Toprol XL Metoprolol ER Xanax Alprazolam Travatan Travoprost Xeloda Capecitabine Trexall Methotrexate Xibrom Bromfenac Tricor Fenofibrate Xopenex Levalbuterol Tridesilon Desonide Xyzal Levocetirizine Trileptal Oxcarbazepine Yasmin Ocella, Syeda, Zarah Trilipix Fenofibric acid Yaz Gianvi, Loryna, Vestura, Nikki Trizivir Abacavir/lamivudine/zidovudine Zantac Ranitidine Trusopt Dorzolamide Zemplar Paricalcitol Twynsta Telmisartan/amlodipine Zerit Stavudine Tylenol # 3 Acetaminophen/Codeine Ziagen Abacavir Ultram Tramadol Zithromax Azithromycin Uroxatral Alfuzosin ER Zocor Simvastatin Urso Ursodiol Zofran Ondansetron Valium Diazepam Zoloft Sertraline Valtrex Valacyclovir Zometa Zoledronic acid 4mg Vancocin Vancomycin Zomig Zolmitriptan Vasotec Enalapril Zonegran Zonisamide Veetids Penicillin Zovirax Acyclovir Vfend Voriconazole Zyloprim Allopurinol Vibramycin Doxycycline Zymaxid Gatifloxacin Vicodin, Vicodin ES Hydrocodone/Acetaminophen Zyprexa Olanzapine Videx EC Didanosine Viramune Nevirapine Vivactil Protriptyline Voltaren Diclofenac In this document, the term UPMC Health Plan refers to benefit plans offered by UPMC Health Network, Inc., as well as plans offered by UPMC Health Plan, Inc. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. This Pharmacy Benefit Guide is current as of January, 205. For the latest information on the Your Choice drug formulary and other pharmacy benefits, visit com/pharmacy. Select Your Choice to access the searchable drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card and on page of this booklet. 34

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