2016 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary)

Transcription

1 2016 Cigna-HealthSpring COMPREHENSIVE LIST (Formulary) Please read: This document contains information about all of the drugs we cover in this plan. Plans covered Cigna-HealthSpring Preferred (HMO) Cigna-HealthSpring Preferred (PPO) Cigna-HealthSpring Preferred AR (HMO) Cigna-HealthSpring Preferred KNX (HMO) Cigna-HealthSpring Preferred NGA (HMO) Cigna-HealthSpring Preferred SMS (HMO) Cigna-HealthSpring Preferred Plus (HMO) Cigna-HealthSpring Premier (HMO-POS) Cigna-HealthSpring Premier Plus (HMO-POS) Cigna-HealthSpring PreventiveCare (HMO) This drug list was updated on June 1, The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. HPMS Approved Formulary File Submission ID 16152, Version Number 15 Y0036_16_32224c_Final_1e Approved

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3 Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Cigna-HealthSpring. When it refers to plan or our plan, it means Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred (PPO), Cigna-HealthSpring Preferred AR (HMO), Cigna-HealthSpring Preferred KNX (HMO), Cigna-HealthSpring Preferred NGA (HMO), Cigna- HealthSpring Preferred SMS (HMO), Cigna-HealthSpring Preferred Plus (HMO), Cigna-HealthSpring Premier (HMO- POS), Cigna-HealthSpring Premier Plus (HMO-POS) and Cigna-HealthSpring PreventiveCare (HMO). This document includes a list of the drugs (formulary) for our plans, which is current as of June For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. What is the Cigna-HealthSpring Comprehensive Drug List? A drug list is a list of covered drugs selected by Cigna- HealthSpring 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. Cigna- HealthSpring will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Drug List (formulary) change? Generally, if you are taking a drug on our 2016 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our drug list to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of June To get updated information about the drugs covered by Cigna-HealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis. How do I use the Drug List? There are two ways to find your drug within the drug list: Medical Condition The drug list begins on page 15. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 15. Then look under the category name for your drug. 1

4 Covered Drug Index If you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 54. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. What are generic drugs? Cigna-HealthSpringcovers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Cigna-HealthSpring requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna- HealthSpring before you fill your prescriptions. If you don t get approval, Cigna-HealthSpring may not cover the drug. Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover. For example, Cigna-HealthSpring allows for 1 tablet per day for CRESTOR. This applies to standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days). Step Therapy: In some cases, Cigna-HealthSpring requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna-HealthSpring may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna- HealthSpring will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 15. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Cigna-HealthSpring drug list? on page 3 for information about how to request an exception. Options for Maintenance Medications Taking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal: Talk with your doctor about whether a 90 day supply of your ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90 day prescriptions of these medications can ensure that you don t miss a dose. You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies. Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications. How can I use my prescription drug coverage to save money on my medications? There may be opportunities for you to save money on your medications using your Cigna-HealthSpring coverage. Ask your doctor (or other prescriber) if there are any lowercost generic alternatives available for any of your current medications. Explore whether the CMS extra help program may offer additional financial support for your medications. If your medication is not covered on the Cigna-HealthSpring drug list, talk with your doctor about alternative medications which are covered in the drug list. What if my drug is not in the Drug List? If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Cigna-HealthSpring. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring. You can ask Cigna-HealthSpring to make an exception and cover your drug. See below for information about how to request an exception. 2

5 How do I request an exception to the Cigna-HealthSpring Drug List? You can ask Cigna-HealthSpring to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not in our drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Brand tier or the Generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the respective Preferred Brand or Preferred Generic tier instead. This would lower the amount you must pay for your drug. If your drug is contained in our Brand tier you can ask to cover it at the cost-sharing amount that applies to drugs in the respective Generic tier if all generic alternatives in the lower cost tier used to treat the same condition/disease are determined to be not as effective as the Brand. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier. Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan. For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30- day supply, we will not pay for these drugs, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring s Drug List The comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 54. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of your drug. 3

6 Some Cigna-HealthSpring plans offer additional prescription drug coverage in the coverage gap. Please refer to your Evidence of Coverage to see if your plan has this coverage and for more information. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 15 along with the amount dispensed per the days supplied. (For example: CRESTOR 30/30; this means the drug CRESTOR is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days). For more information For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or, visit Key: B/D This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances. Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home. PA This drug requires prior authorization QL This drug has quantity limits ST This drug has step therapy requirements Drug Tier and Cost-Share Table The following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the costshare amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier number 3 is for Preferred Brand drugs. Tier number 4 is for Non-Preferred Brand drugs. Tier 5 is for Specialty tier drugs. You may also refer to your Evidence of Coverage document for additional details. Note for customers receiving Extra Help: Your LIS copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug. 4

7 To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll. Service Area: Alabama H , H Cigna-HealthSpring Preferred (HMO) Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, Alabama Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $1/$2/$2 $1/$2 Tier 2: Generic Drugs $15/$30/$30 $15/$30 Tier 3: Preferred Brand Drugs $47/$94/$94 $47/$94 Tier 4: Non-Preferred Brand Drugs $95/$190/$190 $95/$190 Tier 5: Specialty Tier 29% 29% Service Area: Alabama H Cigna-HealthSpring Premier (HMO-POS) Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, Alabama Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $0/$0/$0 $0/$0 Tier 2: Generic Drugs $12/$24/$30 $12/$30 Tier 3: Preferred Brand Drugs $45/$90/$ $45/ Tier 4: Non-Preferred Brand Drugs $85/$170/$ $85/$ Tier 5: Specialty Tier 33% 33% 5

8 Service Area: Arkansas H Cigna-HealthSpring Preferred AR (HMO) Craighead, Crittenden, Greene, Lawrence, Mississippi and Poinsett, Arkansas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $3/$6/$9 $3/$9 Tier 2: Generic Drugs $20/$40/$60 $20/$60 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $100/$200/$300 $100/$300 Tier 5: Specialty Tier 33% 33% Service Area: Arkansas H Cigna-HealthSpring Preferred (HMO) Conway, Crawford, Franklin, Johnson, Logan, Pope, Scott, Sebastian and Yell, Arkansas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $2/$4/$5 $2/$5 Tier 2: Generic Drugs $11/$22/$27.50 $11/$27.50 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 33% 33% Service Area: Florida H Cigna-HealthSpring Premier (HMO-POS) Bay, Escambia, Okaloosa, Santa Rosa and Walton, Florida Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $1/$2/$2 $1/$2 Tier 2: Generic Drugs $15/$30/$30 $15/$30 Tier 3: Preferred Brand Drugs $47/$94/$94 $47/$94 Tier 4: Non-Preferred Brand Drugs $95/$190/$190 $95/$190 Tier 5: Specialty Tier 30% 30% 6

9 Service Area: Georgia H Cigna-HealthSpring Preferred (HMO) Baldwin, Banks, Barrow, Bartow, Butts, Chattooga, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Elbert, Fayette, Floyd, Forsyth, Franklin, Fulton, Gordon, Greene, Gwinnett, Habersham, Hall, Hart, Henry, Jackson, Jasper, Lamar, Lumpkin, Madison, Morgan, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Putnam, Rabun, Rockdale, Spalding, Stephens, Walton, White and Wilkes, Georgia Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $3/$6/$9 $3/$9 Tier 2: Generic Drugs $12/$24/$36 $12/$36 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs $85/$170/$255 $85/$255 Tier 5: Specialty Tier 30% 30% Service Area: Illinois H Cigna-HealthSpring Premier (HMO-POS) Cook, DuPage, Kane, Will and Illinois Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $7/$14/$21 $7/$21 Tier 2: Generic Drugs $15/$30/$45 $15/$45 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs 37% 37% Tier 5: Specialty Tier 33% 33% Service Area: Indiana H Cigna-HealthSpring Premier (HMO-POS) Lake, Indiana Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $5/$10/$15 $5/$15 Tier 2: Generic Drugs $15/$30/$45 $15/$45 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs 38% 38% Tier 5: Specialty Tier 33% 33% 7

10 Service Area: Kansas City H Cigna-HealthSpring Preferred (HMO) Clay, Jackson, Platte and Ray, Missouri; Johnson and Wyandotte, Kansas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $1/$2/$3 $1/$3 Tier 2: Generic Drugs $3/$6/$9 $3/$9 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 30% 30% Service Area: Maryland H Cigna-HealthSpring Preferred (HMO) Anne Arundel, Baltimore, Baltimore City, Caroline, Dorchester, Harford, Howard, Kent, Queen Anne s and Talbot, Maryland Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $7/$14/$17.50 $7/$17.50 Tier 2: Generic Drugs $15/$30/$37.50 $15/$37.50 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 26% 26% Service Area: Mid-Atlantic H Cigna-HealthSpring Preferred (HMO) District of Columbia; Kent, New Castle and Sussex, Delaware; Montgomery and Prince George s, Maryland Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $7/$14/$17.50 $7/$17.50 Tier 2: Generic Drugs $12/$24/$30 $12/$30 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 26% 26% 8

11 Service Area: Mid-Atlantic H Cigna-HealthSpring PreventiveCare (HMO) District of Columbia; Kent, New Castle and Sussex, Delaware; Montgomery and Prince George s, Maryland H Cigna-HealthSpring PreventiveCare (HMO) Anne Arundel, Baltimore, Baltimore City, Caroline, Dorchester, Harford, Howard, Kent, Queen Anne s and Talbot, Maryland Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $7/$14/$17.50 $7/$17.50 Tier 2: Generic Drugs $15/$30/$37.50 $15/$37.50 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 26% 26% Service Area: Mississippi H , H Cigna-HealthSpring Preferred SMS (HMO) Attala, Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Leake, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $1/$2/$2 $1/$2 Tier 2: Generic Drugs $15/$30/$37 $15/$37 Tier 3: Preferred Brand Drugs $47/$94/$117 $47/$117 Tier 4: Non-Preferred Brand Drugs $95/$190/$237 $95/$237 Tier 5: Specialty Tier 26% 26% Service Area: North Carolina, South Carolina H , H Cigna-HealthSpring Preferred (HMO) Alexander, Cabarrus, Catawba, Cleveland, Davidson, Davie, Forsyth, Gaston, Guilford, Iredell, Lincoln, Polk, Rowan, Stokes, Union and Yadkin, North Carolina; Cherokee, Chester, Greenville, Lancaster, Spartanburg, Union and York, South Carolina Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $3/$6/$9 $3/$9 Tier 2: Generic Drugs $15/$30/$45 $15/$45 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 28% 28% 9

12 Service Area: North Georgia H Cigna-HealthSpring Preferred NGA (HMO) Catoosa, Dade and Walker, Georgia Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $3/$6/$9 $3/$9 Tier 2: Generic Drugs $20/$40/$60 $20/$60 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $100/$200/$300 $100/$300 Tier 5: Specialty Tier 28% 28% Service Area: Pennsylvania H Cigna-HealthSpring Preferred (HMO) Berks, Bucks, Chester, Cumberland, Delaware, Lancaster, Lehigh, Montgomery, Northampton, Philadelphia and York, Pennsylvania Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $4/$8/$10 $4/$10 Tier 2: Generic Drugs $12/$24/$30 $12/$30 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 26% 26% Service Area: Pennsylvania H Cigna-HealthSpring PreventiveCare (HMO) Berks, Bucks, Chester, Cumberland, Delaware, Lancaster, Lehigh, Montgomery, Northampton, Philadelphia and York, Pennsylvania Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $4/$8/$10 $4/$10 Tier 2: Generic Drugs $10/$20/$25 $10/$25 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 26% 26% 10

13 Service Area: Pennsylvania H Cigna-HealthSpring Preferred Plus (HMO) Bucks, Chester, Delaware, Montgomery and Philadelphia, Pennsylvania Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $4/$8/$10 $4/$10 Tier 2: Generic Drugs $8/$16/$20 $8/$20 Tier 3: Preferred Brand Drugs $40/$80/$120 $40/$120 Tier 4: Non-Preferred Brand Drugs $80/$160/$240 $80/$240 Tier 5: Specialty Tier 28% 28% Service Area: Pennsylvania H Cigna-HealthSpring Premier (HMO-POS) Berks, Bucks, Lehigh, Montgomery, Northampton and Philadelphia, Pennsylvania Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $7/$14/$17.50 $7/$17.50 Tier 2: Generic Drugs $10/$20/$25 $10/$25 Tier 3: Preferred Brand Drugs $40/$80/$120 $40/$120 Tier 4: Non-Preferred Brand Drugs $80/$160/$240 $80/$240 Tier 5: Specialty Tier 26% 26% Service Area: Tennessee H Cigna-HealthSpring Preferred KNX (HMO) Anderson, Blount, Campbell, Cocke, Grainger, Hamblen, Hancock, Jefferson, Knox, Loudon, Morgan, Roane, Scott, Sevier and Union, Tennessee Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $5/$10/$15 $5/$15 Tier 2: Generic Drugs $20/$40/$60 $20/$60 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $100/$200/$300 $100/$300 Tier 5: Specialty Tier 28% 28% 11

14 Service Area: Tennessee H Cigna-HealthSpring Premier Plus (HMO-POS) Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Rhea, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $0/$0/$0 $0/$0 Tier 2: Generic Drugs $12/$24/$36 $12/$36 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs $100/$200/$300 $100/$300 Tier 5: Specialty Tier 33% 33% Service Area: Tennessee H , H Cigna-HealthSpring Preferred (HMO) H Cigna-HealthSpring Premier (HMO-POS) Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Rhea, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $3/$6/$9 $3/$9 Tier 2: Generic Drugs $17/$34/$51 $17/$51 Tier 3: Preferred Brand Drugs $47/$94/$141 $47/$141 Tier 4: Non-Preferred Brand Drugs $100/$200/$300 $100/$300 Tier 5: Specialty Tier 33% 33% 12

15 Service Area: Texarkana H Cigna-HealthSpring Preferred (PPO) Miller, Arkansas; Bowie, Cass and Titus, Texas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $7/$14/$17.50 $7/$17.50 Tier 2: Generic Drugs $11/$22/$27.50 $11/$27.50 Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135 Tier 4: Non-Preferred Brand Drugs $95/$190/$285 $95/$285 Tier 5: Specialty Tier 33% 33% Service Area: Texas H Cigna-HealthSpring Preferred (HMO) Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston (77510, 77511, 77517, 77518, 77539, 77546, 77549, , 77568, 77573, 77574, 77590, 77591, and 77592), Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb and Willacy, Texas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $0/$0/$0 $0/$0 Tier 2: Generic Drugs $4/$8/$10 $4/$10 Tier 3: Preferred Brand Drugs $40/$80/$120 $40/$120 Tier 4: Non-Preferred Brand Drugs $80/$160/$240 $80/$240 Tier 5: Specialty Tier 33% 33% Service Area: Texas H , H Cigna-HealthSpring Preferred (HMO) Bexar, Collin, Dallas, Denton, El Paso, Henderson, Hood, Johnson, Lubbock, Parker, Rusk, Smith, Tarrant, Upshur, Van Zandt and Wise, Texas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $3/$6/$7.50 $3/$7.50 Tier 2: Generic Drugs $8/$16/$20 $8/$20 Tier 3: Preferred Brand Drugs $35/$70/$105 $35/$105 Tier 4: Non-Preferred Brand Drugs $70/$140/$210 $70/$210 Tier 5: Specialty Tier 33% 33% 13

16 Service Area: Texas H Cigna-HealthSpring Preferred (PPO) Cherokee, Collin, Dallas, Denton, Henderson, Johnson, Lubbock, Rusk, Tarrant, Upshur, Van Zandt and Wood, Texas Standard Retail Standard Mail Order 30/60/90 Days 30/90 Days Tier 1: Preferred Generic Drugs $0/$0/$0 $0/$0 Tier 2: Generic Drugs $4/$8/$10 $4/$10 Tier 3: Preferred Brand Drugs $40/$80/$120 $40/$120 Tier 4: Non-Preferred Brand Drugs $80/$160/$240 $80/$240 Tier 5: Specialty Tier 33% 33% My Medications In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at , 7 days a week, 8 a.m. - 8 p.m. TTY users can call 711. My Medications Page Number in the Drug List Cost-Share through Cigna-HealthSpring Generic Available? Generic Cost-Share 14

17 Covered Drugs By Category NAME Analgesics Analgesics butalbital/acetaminophen/ 3 PA QL(180/30) caffeine caps butalbital/acetaminophen/ 3 PA QL(180/30) caffeine tabs 325mg; 50mg; 40mg butalbital/aspirin/caffeine 3 PA QL(180/30) esgic caps 3 PA QL(180/30) margesic 3 PA QL(180/30) zebutal caps 325mg; 50mg; 3 PA QL(180/30) 40mg Nonsteroidal Anti-inflammatory Drugs celecoxib 2 QL(60/30) diclofenac potassium 2 diclofenac sodium dr tbec 2 25mg, 50mg diclofenac sodium dr tbec 75mg 1 diclofenac sodium er 2 diflunisal 2 etodolac 2 etodolac er 2 fenoprofen calcium 2 flurbiprofen 2 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 1 800mg ketoprofen 2 ketoprofen er 2 meclofenamate sodium 2 meloxicam tabs 1 nabumetone 2 naproxen dr 2 naproxen sodium tabs 275mg, 550mg 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. NAME naproxen susp 2 naproxen tabs 250mg 2 naproxen tabs 375mg, 500mg 1 oxaprozin 2 piroxicam 2 salsalate 2 sulindac 2 tolmetin sodium 2 Opioid Analgesics, Long-acting DURAMORPH 4 fentanyl 2 QL(15/30) INFUMORPH INFUMORPH levorphanol tartrate 2 QL(180/30) methadone hcl conc 2 QL(500/30) methadone hcl inj 4 methadone hcl intensol 2 QL(500/30) methadone hcl oral soln 2 QL(2000/30) 10mg/5ml methadone hcl oral soln 2 QL(4000/30) 5mg/5ml methadone hcl tabs 2 QL(360/30) morphine sulfate er tbcr 2 QL(90/30) morphine sulfate inj 0.5mg/ml, 4 1mg/ml oxymorphone hydrochloride er 2 QL(60/30) tramadol hcl er tb24 2 QL(30/30) XARTEMIS XR 4 QL(120/30) Opioid Analgesics, Short-acting acetaminophen/caffeine/ 2 QL(360/30) dihydrocodeine acetaminophen/codeine #2 2 QL(360/30) acetaminophen/codeine #3 2 QL(360/30) acetaminophen/codeine #4 2 QL(240/30) acetaminophen/codeine oral soln 2 QL(5000/30) Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 15

18 Covered Drugs By Category NAME NAME acetaminophen/codeine 2 QL(240/30) phosphate tabs 300mg; 60mg acetaminophen/codeine tabs 2 QL(240/30) 300mg; 60mg acetaminophen/codeine tabs 2 QL(360/30) 300mg; 15mg ascomp/codeine 3 PA QL(180/30) butalbital/acetaminophen/ 3 PA QL(180/30) caffeine/codeine butalbital/aspirin/caffeine/ 3 PA QL(180/30) codeine butorphanol tartrate inj 4 butorphanol tartrate nasal soln 2 QL(6/30) endocet 2 QL(360/30) fentanyl citrate inj 100mcg/2ml 4 B/D PA fentanyl citrate oral 5 PA QL(120/30) transmucosal hydrocodone bitartrate/ 3 QL(5400/30) acetaminophen oral soln 325mg/15ml; 7.5mg/15ml hydrocodone bitartrate/ 3 QL(360/30) acetaminophen tabs 325mg; 2.5mg hydrocodone bitartrate/ 3 QL(390/30) acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg hydrocodone/acetaminophen 3 QL(360/30) tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg hydrocodone/ibuprofen 3 QL(150/30) hydromorphone hcl dosette 4 hydromorphone hcl inj 1mg/ml, 4 2mg/ml, 4mg/ml, 500mg/50ml hydromorphone hcl liqd 2 QL(1200/30) hydromorphone hcl tabs 2 QL(240/30) ibudone tabs 5mg; 200mg 3 QL(150/30) LAZANDA 5 PA QL(44/28) lorcet 3 QL(360/30) lorcet hd 3 QL(360/30) lorcet plus tabs 325mg; 7.5mg 3 QL(360/30) lortab tabs 3 QL(360/30) MORPHINE SULFATE ADD- 4 VANTAGE MORPHINE SULFATE INJ 4 10MG/ML, 150MG/30ML, 15MG/ML, 1MG/ML, 25MG/ML, 2MG/ML, 4MG/ML, 50MG/ML, 8MG/ML morphine sulfate inj 4mg/ml 4 morphine sulfate oral soln 2 QL(540/30) 100mg/5ml morphine sulfate oral soln 2 QL(2700/30) 20mg/5ml morphine sulfate oral soln 2 QL(5400/30) 10mg/5ml MORPHINE SULFATE TABS 3 QL(360/30) nalbuphine hcl 4 oxycodone hcl caps 2 QL(240/30) oxycodone hcl conc 2 QL(360/30) oxycodone hcl oral soln 2 QL(1200/30) oxycodone hcl tabs 2 QL(240/30) oxycodone/acetaminophen tabs 2 QL(360/30) 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg oxycodone/aspirin 2 QL(360/30) oxycodone/ibuprofen 2 QL(150/30) reprexain tabs 10mg; 200mg 3 QL(150/30) roxicet tabs 2 QL(360/30) TALWIN 4 tramadol hcl 2 QL(240/30) tramadol hydrochloride/ 2 QL(240/30) acetaminophen trezix caps 320.5mg; 30mg; 2 QL(360/30) 16mg vicodin es tabs 300mg; 7.5mg 3 QL(390/30) vicodin hp tabs 300mg; 10mg 3 QL(390/30) vicodin tabs 300mg; 5mg 3 QL(390/30) xylon 3 QL(150/30) Anesthetics Local Anesthetics glydo 2 lidocaine hcl external soln 2 16

19 Covered Drugs By Category NAME lidocaine hcl gel 2 lidocaine hcl inj 4 lidocaine hcl jelly 2 lidocaine hcl mouth/throat soln 1 lidocaine hcl viscous 1 lidocaine oint 2 lidocaine ptch 2 PA QL(90/30) lidocaine viscous 1 lidocaine/prilocaine crea 2 premium lidocaine 2 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 2 PA disulfiram 2 Opioid Dependence Treatments buprenorphine hcl inj 4 buprenorphine hcl subl 2 PA QL(24/30) buprenorphine hcl/naloxone hcl 2 PA QL(90/30) naltrexone hcl 2 PA SUBOXONE 3 PA QL(90/30) Opioid Reversal Agents naloxone hcl 2 Smoking Cessation Agents buproban 2 QL(60/30) bupropion hcl sr tb12 150mg 2 QL(60/30) CHANTIX 3 PA QL(336/365) CHANTIX CONTINUING 3 PA QL(336/365) MONTH PAK CHANTIX STARTING MONTH 3 PA QL(106/365) PAK NICOTROL INHALER 3 PA QL(504/30) NICOTROL NS 3 QL(40/30) NAME Antibacterials Aminoglycosides amikacin sulfate 4 gentak 2 gentamicin sulfate crea 2 gentamicin sulfate inj 4 gentamicin sulfate oint 2 gentamicin sulfate ophthalmic 4 soln gentamicin sulfate pediatric 4 gentamicin sulfate/0.9% sodium 4 chloride isotonic gentamicin 4 neomycin sulfate 2 neomycin/polymyxin b sulfates 4 paromomycin sulfate 2 streptomycin sulfate 4 tobramycin sulfate inj 1.2gm, 4 10mg/ml, 40mg/ml, 80mg/2ml tobramycin sulfate ophthalmic 2 soln TOBREX OINT 3 ZYLET 3 Antibacterials, Other alcohol prep pads 1 baciim 4 bacitracin inj 4 bacitracin ophthalmic oint 2 bacitracin/polymyxin b 2 BACTROBAN NASAL 3 chloramphenicol sodium 1 succinate clindacin etz pledgets 2 clindacin-p 2 clindamax 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 17

20 Covered Drugs By Category NAME NAME clindamycin hcl 2 clindamycin phosphate addvantage 4 clindamycin phosphate crea 2 clindamycin phosphate external 2 soln clindamycin phosphate gel 2 clindamycin phosphate in d5w 4 clindamycin phosphate inj 4 300mg/2ml, 600mg/4ml, 900mg/6ml clindamycin phosphate lotn 2 clindamycin phosphate 4 pharmacy bulk package clindamycin phosphate swab 2 colistimethate sodium 4 CUBICIN 5 B/D PA lansoprazole/amoxicillin/ 2 clarithromycin LINCOCIN 4 lincomycin hcl 4 linezolid inj 600mg/300ml 4 PA linezolid susr 5 PA linezolid tabs 5 PA methenamine hippurate 2 metronidazole crea 2 metronidazole gel 2 metronidazole in nacl 0.79% 4 metronidazole inj 4 metronidazole lotn 2 metronidazole tabs 1 metronidazole vaginal 2 mupirocin 2 neomycin/bacitracin/polymyxin 2 neomycin/polymyxin/bacitracin/ 2 hydrocortisone neomycin/polymyxin/gramicidin 2 neomycin/polymyxin/ 2 hydrocortisone nitrofurantoin 2 nitrofurantoin macrocrystals 2 QL(90/365) caps 100mg, 50mg nitrofurantoin monohydrate 2 QL(90/365) nitrofurantoin monohydrate/ 2 QL(90/365) macrocrystals NORITATE 3 polymyxin b sulfate 4 polymyxin b sulfate/ 2 trimethoprim sulfate PRIMSOL 3 rosadan 2 silver sulfadiazine 3 SSD 3 SYNERCID 4 trimethoprim 2 trimethoprim sulfate/polymyxin 2 b sulfate TYGACIL 5 vancomycin hcl caps 125mg 5 QL(40/10) vancomycin hcl caps 250mg 5 QL(80/10) vancomycin hcl in dextrose 4 vancomycin hcl inj 1000mg, 4 10gm, 5000mg, 500mg, 750mg vandazole 2 XIFAXAN TABS 200MG 4 PA QL(9/30) XIFAXAN TABS 550MG 5 PA QL(60/30) ZYVOX SUSR 5 PA Beta-lactam, Cephalosporins cefaclor 2 cefaclor er 2 cefadroxil 2 CEFAZOLIN 4 cefazolin sodium inj 10gm, 4 1gm, 1gm; 5%, 500mg cefazolin sodium/dextrose inj 4 2gm; 3% cefdinir 2 cefepime 4 cefixime 2 cefotaxime sodium inj 1gm, 2gm, 500mg 4 18

21 Covered Drugs By Category NAME cefoxitin sodium inj 10gm, 1gm, 4 2gm cefpodoxime proxetil 2 cefprozil 2 ceftazidime 4 ceftazidime/dextrose 4 ceftriaxone in iso-osmotic 4 dextrose ceftriaxone sodium inj 10gm, 4 1gm, 250mg, 2gm, 500mg cefuroxime axetil 2 cefuroxime sodium inj 1.5gm, 4 7.5gm, 750mg, 75gm cephalexin caps 250mg, 500mg 1 cephalexin susr 2 cephalexin tabs 2 SUPRAX SUSR 500MG/5ML 3 tazicef inj 1gm, 2gm, 6gm 4 TEFLARO 4 Beta-lactam, Other AZACTAM IN ISO-OSMOTIC 4 DEXTROSE aztreonam 4 cefotetan 4 imipenem/cilastatin 2 INVANZ 4 meropenem 2 Beta-lactam, Penicillins amoxicillin caps 1 amoxicillin chew 2 amoxicillin susr 1 amoxicillin tabs 2 amoxicillin/clavulanate 2 potassium amoxicillin/clavulanate 2 potassium er NAME ampicillin 2 ampicillin sodium 4 ampicillin-sulbactam 4 AUGMENTIN SUSR 3 125MG/5ML; 31.25MG/5ML BICILLIN L-A 4 dicloxacillin sodium 2 nafcillin sodium 4 oxacillin sodium 4 penicillin g potassium inj unit, unit penicillin v potassium oral soln 1 penicillin v potassium tabs 1 250mg penicillin v potassium tabs 2 500mg pfizerpen-g 4 piperacillin sodium/ tazobactam 4 sodium piperacillin sodium/tazobactam 4 sodium piperacillin/tazobactam 4 ZOSYN INJ 5%; 2GM/50ML; GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML Macrolides AZASITE 3 azithromycin inj 4 azithromycin pack 3 QL(3/30) azithromycin susr 200mg/5ml 2 QL(75/30) azithromycin susr 100mg/5ml 2 QL(150/30) azithromycin tabs 2 QL(12/28) clarithromycin 2 clarithromycin er 2 QL(60/30) e.e.s CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 19

22 Covered Drugs By Category NAME NAME E.E.S. GRANULES 3 ery 2 ERY-TAB 3 ERYPED ERYPED ERYTHROCIN 4 LACTOBIONATE erythrocin stearate 2 erythromycin base 2 erythromycin ethylsuccinate 2 erythromycin external soln 2 erythromycin gel 2 erythromycin oint 2 erythromycin pads 2 ilotycin 2 KETEK 3 QL(20/30) ZMAX 3 QL(60/30) Quinolones AVELOX INJ 4 BESIVANCE 4 CILOXAN OINT 3 CIPRO HC 3 CIPRODEX 3 ciprofloxacin er 2 ciprofloxacin hcl ophthalmic 2 soln ciprofloxacin hcl tabs 100mg, 2 750mg ciprofloxacin hcl tabs 250mg, 1 500mg ciprofloxacin i.v.-in d5w 4 ciprofloxacin inj 400mg/40ml 4 ciprofloxacin susr 2 levofloxacin in d5w 4 levofloxacin inj 4 levofloxacin oral soln 2 levofloxacin tabs 2 MOXEZA 3 moxifloxacin hcl inj 4 moxifloxacin hcl tabs 2 ofloxacin 2 VIGAMOX 3 Sulfonamides BLEPHAMIDE 3 BLEPHAMIDE S.O.P. 3 sodium sulfacetamide 2 ophthalmic soln sulfacetamide sodium 2 ophthalmic soln sulfacetamide sodium susp 2 sulfacetamide sodium/ 2 prednisolone sodium phosphate sulfadiazine 2 sulfamethoxazole/trimethoprim 1 ds sulfamethoxazole/trimethoprim 4 inj sulfamethoxazole/trimethoprim 1 susp sulfamethoxazole/trimethoprim 1 tabs sulfatrim pediatric 1 Tetracyclines demeclocycline hcl 2 doxy doxycycline caps 75mg 2 doxycycline hyclate caps 1 doxycycline hyclate inj 4 doxycycline hyclate tabs 100mg 1 doxycycline hyclate tabs 20mg 2 doxycycline monohydrate 2 doxycycline susr 2 minocycline hcl 2 mondoxyne nl 2 morgidox 1x100mg caps 1 morgidox 2x100mg caps 1 tetracycline hcl 1 20

23 Covered Drugs By Category NAME Anticonvulsants Anticonvulsants, Other APTIOM TABS 200MG, 4 QL(30/30) 400MG, 800MG APTIOM TABS 600MG 4 QL(60/30) FYCOMPA 4 levetiracetam er 2 levetiracetam inj 4 levetiracetam oral soln 2 levetiracetam tabs 2 POTIGA 3 PA QL(90/30) SPRITAM TB3D 1000MG, 4 QL(60/30) 250MG, 500MG SPRITAM TB3D 750MG 4 QL(120/30) Calcium Channel Modifying Agents CELONTIN 3 ethosuximide 2 LYRICA CAPS 225MG, 300MG 3 QL(60/30) LYRICA CAPS 100MG, 3 QL(90/30) 150MG, 200MG, 25MG, 50MG, 75MG LYRICA ORAL SOLN 3 QL(900/30) zonisamide 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 0.125mg, 2 QL(150/30) 0.25mg, 0.5mg, 1mg clonazepam odt tbdp 2mg 2 QL(300/30) clonazepam tabs 0.5mg, 1mg 2 QL(150/30) clonazepam tabs 2mg 2 QL(300/30) diazepam gel 3 divalproex sodium 2 divalproex sodium dr 2 divalproex sodium er 2 gabapentin 2 GABITRIL TABS 16MG 3 QL(90/30) NAME GABITRIL TABS 12MG 3 QL(120/30) ONFI SUSP 3 QL(480/30) ONFI TABS 10MG 3 QL(60/30) ONFI TABS 20MG 3 QL(120/30) phenobarbital 2 primidone 2 SABRIL PACK 5 PA QL(200/30) SABRIL TABS 5 PA QL(180/30) tiagabine hydrochloride tabs 2 4mg tiagabine hydrochloride tabs 2 QL(240/30) 2mg valproate sodium 4 valproic acid 2 Glutamate Reducing Agents felbamate 2 lamotrigine 2 lamotrigine er 2 lamotrigine odt 2 topiramate 2 TROKENDI XR CP24 100MG, 4 QL(30/30) 25MG, 50MG TROKENDI XR CP24 200MG 4 QL(60/30) Sodium Channel Agents BANZEL SUSP 5 PA BANZEL TABS 400MG 5 PA BANZEL TABS 200MG 4 PA carbamazepine 2 carbamazepine er 2 DILANTIN CAPS 30MG 3 epitol 2 fosphenytoin sodium 4 oxcarbazepine 2 PEGANONE 3 phenytoin 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 21

24 Covered Drugs By Category NAME NAME phenytoin infatabs 2 phenytoin sodium 4 phenytoin sodium extended 2 TEGRETOL-XR TB12 100MG 3 VIMPAT INJ 4 QL(1200/30) VIMPAT ORAL SOLN 3 QL(1200/30) VIMPAT TABS 3 QL(60/30) Antidementia Agents Antidementia Agents, Other ergoloid mesylates 2 PA NAMZARIC 3 QL(30/30) Cholinesterase Inhibitors donepezil hcl tabs 23mg, 5mg 2 QL(30/30) donepezil hcl tabs 10mg 2 QL(60/30) donepezil hcl tbdp 5mg 2 QL(30/30) donepezil hcl tbdp 10mg 2 QL(60/30) EXELON PT24 3 QL(30/30) galantamine hydrobromide 2 QL(30/30) cp24 galantamine hydrobromide oral 2 QL(200/30) soln galantamine hydrobromide tabs 2 QL(60/30) rivastigmine tartrate 2 QL(60/30) rivastigmine transdermal 2 QL(30/30) system N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl tabs 10mg 2 QL(60/30) memantine hcl tabs 5mg 2 QL(90/30) memantine hcl titration pak 2 QL(49/28) memantine hydrochloride 2 QL(300/30) NAMENDA ORAL SOLN 3 QL(300/30) NAMENDA TABS 10MG 3 QL(60/30) NAMENDA TABS 5MG 3 QL(90/30) NAMENDA TITRATION PAK 3 QL(49/28) NAMENDA XR 3 QL(30/30) NAMENDA XR TITRATION PACK 3 QL(28/28) Antidepressants Antidepressants, Other BRINTELLIX 4 QL(30/30) ST bupropion hcl 2 bupropion hcl er tb12 100mg, 2 QL(60/30) 200mg bupropion hcl er tb12 150mg 2 QL(90/30) bupropion hcl sr tb12 100mg, 2 QL(60/30) 200mg bupropion hcl sr tb12 150mg 2 QL(90/30) bupropion hcl xl tb24 300mg 2 QL(30/30) bupropion hcl xl tb24 150mg 2 QL(90/30) maprotiline hcl 2 mirtazapine 2 QL(30/30) mirtazapine odt 2 QL(30/30) nefazodone hcl 2 QL(60/30) trazodone hcl tabs 300mg 2 trazodone hcl tabs 100mg, 1 150mg, 50mg Monoamine Oxidase Inhibitors EMSAM PT24 6MG/24HR, 3 9MG/24HR EMSAM PT24 12MG/24HR 5 MARPLAN 4 phenelzine sulfate 2 tranylcypromine sulfate 2 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide oral 1 QL(600/30) soln citalopram hydrobromide tabs 1 QL(30/30) 40mg citalopram hydrobromide tabs 1 QL(60/30) 10mg, 20mg duloxetine hcl cpep 20mg, 2 QL(60/30) 60mg duloxetine hcl cpep 30mg 2 QL(90/30) escitalopram oxalate 2 FETZIMA 4 QL(30/30) ST FETZIMA TITRATION PACK 4 QL(28/28) ST 22

25 Covered Drugs By Category NAME fluoxetine 2 fluoxetine dr 2 fluoxetine hcl caps 2 fluoxetine hcl oral soln 2 fluoxetine hcl tabs 10mg, 20mg 2 fluvoxamine maleate 2 fluvoxamine maleate er cp24 2 QL(60/30) 150mg fluvoxamine maleate er cp24 2 QL(90/30) 100mg olanzapine/fluoxetine 2 QL(30/30) paroxetine hcl er tb mg 2 QL(30/30) paroxetine hcl er tb mg 2 QL(60/30) paroxetine hcl er tb24 25mg 2 QL(90/30) paroxetine hcl tabs 30mg, 2 QL(60/30) 40mg paroxetine hcl tabs 10mg 1 QL(30/30) paroxetine hcl tabs 20mg 1 QL(60/30) PAXIL SUSP 3 QL(900/30) ST PRISTIQ 4 QL(30/30) sertraline hcl conc 2 QL(300/30) sertraline hcl tabs 25mg 2 QL(30/30) sertraline hcl tabs 100mg 2 QL(60/30) sertraline hcl tabs 50mg 2 QL(90/30) venlafaxine hcl 2 venlafaxine hcl er cp24 2 venlafaxine hcl er tb24 150mg, mg, 75mg VIIBRYD 4 QL(30/30) ST VIIBRYD STARTER PACK 4 QL(30/30) ST Tricyclics amitriptyline hcl 3 PA amoxapine 2 clomipramine hcl 2 PA desipramine hcl 2 NAME doxepin hcl 3 PA imipramine hcl 3 PA imipramine pamoate 3 PA nortriptyline hcl caps 1 nortriptyline hcl oral soln 2 perphenazine/amitriptyline 2 PA protriptyline hcl 2 SURMONTIL 4 PA trimipramine maleate 2 PA Antiemetics Antiemetics granisetron hcl inj 1mg/ml 4 B/D PA Antiemetics, Other meclizine hcl tabs 2 promethazine hcl plain 2 PA promethazine hcl syrp 2 PA promethazine hcl tabs 2 PA TRANSDERM-SCOP 3 QL(12/36) Emetogenic Therapy Adjuncts ALOXI 4 B/D PA dronabinol 2 PA QL(90/30) EMEND CAPS 40MG 3 B/D PA QL(2/30) EMEND CAPS 125MG 3 B/D PA QL(4/30) EMEND CAPS 80MG 3 B/D PA QL(8/30) EMEND CAPS 3 B/D PA QL(12/30) granisetron hcl inj 0.1mg/ml, 4 B/D PA 1mg/ml granisetron hcl tabs 2 B/D PA QL(60/30) ondansetron hcl inj 40mg/20ml, 4 4mg/2ml ondansetron hcl oral soln 2 B/D PA ondansetron hcl tabs 24mg 1 B/D PA ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(90/30) ondansetron odt 1 B/D PA QL(90/30) CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 23

26 Covered Drugs By Category NAME NAME Antifungals Antifungals ABELCET 5 PA AMBISOME 4 PA amphotericin b 4 PA CANCIDAS 5 PA ciclodan 2 ciclopirox nail lacquer 2 ciclopirox olamine 2 ciclopirox sham 2 ciclopirox susp 2 clotrimazole external crea 2 clotrimazole external soln 2 clotrimazole troc 2 clotrimazole/betamethasone 2 dipropionate econazole nitrate 2 fluconazole in dextrose 4 fluconazole in nacl 4 fluconazole susr 2 fluconazole tabs 100mg, 2 200mg, 50mg fluconazole tabs 150mg 1 QL(8/30) flucytosine 5 griseofulvin microsize 2 griseofulvin ultramicrosize 2 itraconazole 2 PA QL(120/30) ketoconazole crea 2 ketoconazole sham 2 ketoconazole tabs 2 naftifine hcl 2 naftifine hydrochloride 2 NAFTIN 3 NATACYN 3 NOXAFIL SUSP 5 PA QL(600/30) NOXAFIL TBEC 5 PA QL(93/30) nyamyc 2 nystatin crea 2 nystatin oint 2 nystatin powd unit/gm 2 nystatin susp 2 nystatin tabs 2 nystatin/triamcinolone 2 nystop 2 SPORANOX ORAL SOLN 3 PA terbinafine hcl tabs 1 QL(180/365) terconazole 2 voriconazole inj 4 PA voriconazole susr 5 PA voriconazole tabs 5 PA Antigout Agents Antigout Agents allopurinol 1 ALOPRIM 4 colchicine 2 COLCRYS 3 probenecid 2 probenecid/colchicine 2 ULORIC 3 ST Antimigraine Agents Ergot Alkaloids cafergot 2 dihydroergotamine mesylate inj 2 migergot 2 Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl 2 QL(9/30) rizatriptan benzoate 2 QL(12/30) rizatriptan benzoate odt 2 QL(12/30) sumatriptan 3 QL(12/30) sumatriptan succinate inj 2 QL(8/30) sumatriptan succinate refill 2 QL(8/30) sumatriptan succinate tabs 2 QL(9/30) Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL 3 MESTINON TIMESPAN 3 24

27 Covered Drugs By Category NAME pyridostigmine bromide 2 REGONOL 4 Antimycobacterials Antimycobacterials, Other dapsone 2 rifabutin 2 Antituberculars CAPASTAT SULFATE 4 cycloserine 2 ethambutol hcl 2 isoniazid inj 4 isoniazid syrp 2 isoniazid tabs 100mg 2 isoniazid tabs 300mg 1 PASER 3 pyrazinamide 2 rifampin caps 2 rifampin inj 4 RIFATER 3 SIRTURO 4 PA TRECATOR 3 Antineoplastics Alkylating Agents BENDEKA 5 B/D PA BICNU 4 B/D PA BUSULFEX 5 B/D PA cyclophosphamide caps 3 B/D PA cyclophosphamide inj 4 B/D PA dacarbazine 4 B/D PA EVOMELA 5 PA GLEOSTINE 3 HEXALEN 5 ifosfamide 4 B/D PA NAME LEUKERAN 3 MATULANE 5 melphalan hydrochloride 5 B/D PA MUSTARGEN 4 B/D PA thiotepa 4 PA TREANDA 5 B/D PA VALCHLOR 5 PA YONDELIS 5 PA ZANOSAR 4 B/D PA Antiandrogens bicalutamide 2 flutamide 2 NILANDRON 5 XTANDI 5 PA QL(120/30) ZYTIGA 5 PA QL(120/30) Antiangiogenic Agents POMALYST 5 PA QL(21/28) REVLIMID 5 PA QL(28/28) THALOMID CAPS 150MG, 5 PA QL(60/30) 200MG, 50MG THALOMID CAPS 100MG 5 PA QL(90/30) Antiestrogens/Modifiers EMCYT 3 FARESTON 5 FASLODEX 5 B/D PA SOLTAMOX 3 tamoxifen citrate 2 Antimetabolites adrucil 4 B/D PA ALIMTA INJ 500MG 5 B/D PA ARRANON 4 cladribine 4 B/D PA CLOLAR 4 B/D PA cytarabine 4 B/D PA CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 25

28 Covered Drugs By Category NAME NAME cytarabine aqueous 4 B/D PA DROXIA 3 ELITEK 5 B/D PA fluorouracil inj 4 B/D PA FOLOTYN 5 B/D PA gemcitabine 4 B/D PA gemcitabine hcl inj 1gm, 4 B/D PA 200mg, 2gm hydroxyurea 2 LONSURF TABS 8.19MG; 5 PA QL(80/28) 20MG LONSURF TABS 6.14MG; 5 PA QL(100/28) 15MG mercaptopurine 2 NIPENT 5 B/D PA PURIXAN 4 PA TABLOID 3 Antineoplastics, Other ABRAXANE 5 B/D PA amifostine 5 B/D PA azacitidine 5 B/D PA BELEODAQ 5 PA bleomycin sulfate 4 B/D PA carboplatin 4 B/D PA cisplatin 4 B/D PA COSMEGEN 5 B/D PA daunorubicin hcl 4 B/D PA DAUNOXOME 5 B/D PA decitabine 5 dexrazoxane 4 B/D PA DOCEFREZ INJ 20MG 5 B/D PA docetaxel 5 B/D PA doxorubicin hcl 2 B/D PA epirubicin hcl inj 200mg/100ml 5 B/D PA epirubicin hcl inj 50mg/25ml 4 B/D PA ERWINAZE 5 B/D PA fludarabine phosphate 4 B/D PA FUSILEV 5 HALAVEN 5 PA IBRANCE 5 PA QL(21/28) idarubicin hcl inj 10mg/10ml 5 B/D PA irinotecan 4 B/D PA ISTODAX 5 PA IXEMPRA KIT 5 B/D PA JEVTANA 5 B/D PA leucovorin calcium inj 100mg, 4 350mg, 500mg, 50mg leucovorin calcium tabs 2 levoleucovorin calcium 5 levoleucovorin inj 250mg/25ml 5 LYNPARZA 5 PA QL(480/30) mesna 2 B/D PA MESNEX TABS 5 mitomycin 4 B/D PA mitoxantrone hcl 2 B/D PA NINLARO 5 PA QL(3/28) ODOMZO 5 PA QL(30/30) ONCASPAR 5 B/D PA oxaliplatin 5 B/D PA paclitaxel 4 B/D PA PORTRAZZA 5 PA QL(100/21) PROLEUKIN 5 B/D PA SYLATRON 5 PA SYNRIBO 5 PA TRISENOX 4 B/D PA VELCADE 5 B/D PA VENCLEXTA STARTING PACK 5 PA QL(84/365) VENCLEXTA TABS 100MG 5 PA QL(120/30) VENCLEXTA TABS 50MG 4 PA QL(30/30) VENCLEXTA TABS 10MG 4 PA QL(60/30) vinblastine sulfate 4 B/D PA vincasar pfs 4 B/D PA vincristine sulfate 4 B/D PA vinorelbine tartrate 4 B/D PA ZOLINZA 5 QL(120/30) Aromatase Inhibitors, 3rd Generation anastrozole 2 QL(30/30) exemestane 2 letrozole 2 QL(30/30) 26

29 Covered Drugs By Category NAME Enzyme Inhibitors ETOPOPHOS 4 B/D PA etoposide inj 3 B/D PA toposar 3 B/D PA topotecan hcl inj 4mg 5 ZYDELIG 5 PA QL(60/30) Molecular Target Inhibitors AFINITOR DISPERZ TBSO 5 PA QL(60/30) 2MG, 3MG AFINITOR DISPERZ TBSO 5 PA QL(120/30) 5MG AFINITOR TABS 2.5MG, 5MG, 5 PA QL(30/30) 7.5MG AFINITOR TABS 10MG 5 PA QL(60/30) ALECENSA 5 PA QL(240/30) BOSULIF 5 PA CAPRELSA 5 PA COMETRIQ 5 PA COTELLIC 5 PA QL(63/28) ERIVEDGE 5 PA QL(30/30) FARYDAK 5 PA QL(9/28) GILOTRIF 5 PA QL(30/30) GLEEVEC 5 PA QL(60/30) ICLUSIG 5 PA imatinib mesylate 5 PA QL(60/30) IMBRUVICA 5 PA QL(120/30) INLYTA TABS 5MG 5 PA QL(120/30) INLYTA TABS 1MG 5 PA QL(240/30) IRESSA 5 PA QL(30/30) JAKAFI 5 PA QL(60/30) LENVIMA 10MG DAILY DOSE 5 PA LENVIMA 14MG DAILY DOSE 5 PA LENVIMA 20MG DAILY DOSE 5 PA LENVIMA 24MG DAILY DOSE 5 PA MEKINIST 5 PA CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. NAME NEXAVAR 5 PA SPRYCEL 5 PA STIVARGA 5 PA QL(84/21) SUTENT 5 PA TAFINLAR 5 PA TAGRISSO 5 PA QL(30/30) TARCEVA 5 PA TASIGNA 5 PA TYKERB 5 PA VOTRIENT 5 PA QL(120/30) XALKORI 5 PA QL(60/30) ZELBORAF 5 PA QL(240/30) ZYKADIA 5 PA Monoclonal Antibodies AVASTIN 5 B/D PA CYRAMZA 5 PA DARZALEX 5 PA EMPLICITI 5 PA ERBITUX 5 B/D PA GAZYVA 5 PA HERCEPTIN 5 B/D PA KADCYLA 5 PA KEYTRUDA 5 PA OPDIVO 5 PA PERJETA 5 PA RITUXAN INJ 500MG/50ML 5 PA UNITUXIN 5 PA VECTIBIX INJ 100MG/5ML 3 B/D PA YERVOY 5 B/D PA ZALTRAP 5 PA Retinoids bexarotene 5 PANRETIN 5 TARGRETIN 5 tretinoin caps 5 Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 27

30 Covered Drugs By Category NAME NAME Antiparasitics Anthelmintics ALBENZA 3 ivermectin 2 Antiprotozoals ALINIA 3 atovaquone 5 atovaquone/proguanil hcl 2 chloroquine phosphate 2 COARTEM 3 DARAPRIM 3 hydroxychloroquine sulfate 2 mefloquine hcl 2 NEBUPENT 3 B/D PA PENTAM PRIMAQUINE PHOSPHATE 3 quinine sulfate 1 Pediculicides/Scabicides lindane 2 malathion 2 permethrin 2 Antiparkinson Agents Anticholinergics benztropine mesylate inj 4 benztropine mesylate tabs 2 PA trihexyphenidyl hcl 2 PA Antiparkinson Agents, Other entacapone 2 tolcapone 5 Dopamine Agonists APOKYN 5 PA QL(60/30) bromocriptine mesylate 2 NEUPRO 4 QL(30/30) pramipexole dihydrochloride 2 QL(90/30) pramipexole dihydrochloride er 2 QL(30/30) tb mg, 3mg, 4.5mg pramipexole dihydrochloride er 2 QL(90/30) tb mg, 0.75mg, 1.5mg ropinirole hcl 2 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa 2 carbidopa/levodopa 2 carbidopa/levodopa er 2 carbidopa/levodopa odt 2 carbidopa/levodopa/ 3 entacapone Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 3 selegiline hcl 2 Antipsychotics 1st Generation/Typical chlorpromazine hcl inj 4 50mg/2ml chlorpromazine hcl tabs 2 compazine supp 2 compro 2 fluphenazine decanoate 4 fluphenazine hcl conc 2 fluphenazine hcl elix 2 fluphenazine hcl inj 4 fluphenazine hcl tabs 1mg 1 fluphenazine hcl tabs 10mg, 2 2.5mg, 5mg haloperidol conc 2 haloperidol decanoate 4 haloperidol lactate 4 haloperidol tabs 0.5mg, 1mg, 1 2mg, 5mg haloperidol tabs 10mg, 20mg 2 loxapine 2 loxapine succinate 2 ORAP 3 perphenazine 2 pimozide 2 prochlorperazine 2 prochlorperazine edisylate 4 prochlorperazine maleate tabs 1 10mg 28

31 Covered Drugs By Category NAME prochlorperazine maleate tabs 2 5mg thioridazine hcl 2 PA thiothixene caps 10mg, 1mg, 2 5mg thiothixene caps 2mg 1 trifluoperazine hcl 2 2nd Generation/Atypical ABILIFY MAINTENA INJ 5 QL(1.5/30) 300MG ABILIFY MAINTENA INJ 5 QL(2/30) 400MG aripiprazole odt 5 QL(60/30) ST aripiprazole oral soln 2 QL(900/30) ST aripiprazole tabs 2 QL(30/30) ST ARISTADA INJ 441MG/1.6ML 5 QL(1.6/30) ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30) ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30) FANAPT TABS 10MG, 12MG, 5 QL(60/30) ST 6MG, 8MG FANAPT TABS 1MG, 2MG, 4 QL(60/30) ST 4MG FANAPT TITRATION PACK 4 QL(16/30) ST GEODON INJ 4 QL(60/30) INVEGA SUSTENNA INJ 5 QL(0.75/28) 117MG/0.75ML INVEGA SUSTENNA INJ 5 QL(1/28) 156MG/ML INVEGA SUSTENNA INJ 5 QL(1.5/28) 234MG/1.5ML INVEGA SUSTENNA INJ 4 QL(0.25/28) 39MG/0.25ML INVEGA SUSTENNA INJ 4 QL(0.5/28) 78MG/0.5ML INVEGA TB24 9MG 5 QL(30/30) ST INVEGA TB24 1.5MG, 3MG 4 QL(30/30) ST INVEGA TB24 6MG 4 QL(60/30) ST NAME INVEGA TRINZA INJ 5 QL(0.88/90) 273MG/0.875ML INVEGA TRINZA INJ 5 QL(1.32/90) 410MG/1.315ML INVEGA TRINZA INJ 5 QL(1.75/90) 546MG/1.75ML INVEGA TRINZA INJ 5 QL(2.63/90) 819MG/2.625ML LATUDA TABS 120MG, 20MG, 4 QL(30/30) ST 40MG, 60MG LATUDA TABS 80MG 4 QL(60/30) ST olanzapine inj 4 olanzapine odt 2 QL(30/30) olanzapine tabs 2 QL(30/30) paliperidone er tb24 1.5mg, 2 QL(30/30) ST 3mg paliperidone er tb24 6mg 2 QL(60/30) ST paliperidone er tb24 9mg 5 QL(30/30) ST quetiapine fumarate 2 QL(90/30) REXULTI 5 QL(30/30) ST RISPERDAL CONSTA INJ MG, 50MG RISPERDAL CONSTA INJ MG, 25MG risperidone m-tab tbdp 0.5mg, 2 QL(90/30) 1mg, 2mg, 3mg risperidone m-tab tbdp 4mg 2 QL(120/30) risperidone odt tbdp 0.25mg, 2 QL(90/30) 0.5mg, 1mg, 2mg, 3mg risperidone odt tbdp 4mg 2 QL(120/30) risperidone oral soln 2 QL(360/30) risperidone tabs 0.25mg, 2 QL(90/30) 0.5mg, 1mg, 2mg, 3mg risperidone tabs 4mg 2 QL(120/30) SAPHRIS 3 QL(60/30) ST SEROQUEL XR TB24 150MG, 200MG 3 QL(30/30) CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 29

32 Covered Drugs By Category NAME NAME SEROQUEL XR TB24 300MG, 3 QL(60/30) 400MG, 50MG VRAYLAR CAPS 5 QL(30/30) ST VRAYLAR CPPK 4 QL(14/365) ST ziprasidone hcl 2 QL(60/30) ZYPREXA RELPREVV 5 Antipsychotics molindone hydrochloride 2 Treatment-Resistant clozapine 2 clozapine odt 3 FAZACLO TBDP 100MG, 4 ST 12.5MG, 25MG VERSACLOZ 5 Antispasticity Agents Antispasticity Agents baclofen tabs 10mg 1 baclofen tabs 20mg 2 dantrolene sodium 2 tizanidine hcl tabs 2 Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir 5 ganciclovir inj 4 B/D PA VALCYTE ORAL SOLN 5 valganciclovir 5 ZIRGAN 3 ST Anti-hepatitis B (HBV) Agents adefovir dipivoxil 5 QL(30/30) BARACLUDE ORAL SOLN 3 entecavir 2 EPIVIR HBV ORAL SOLN 3 INTRON A INJ 50MU, UNIT/ML INTRON A INJ 10MU, 10MU/ 5 ML, 18MU INTRON A W/DILUENT INJ 10MU, 18MU 5 INTRON A W/DILUENT INJ 4 50MU lamivudine 2 TYZEKA 5 PA Anti-hepatitis C (HCV) Agents HARVONI 5 PA QL(28/28) moderiba 1200 dose pack 5 PA moderiba 800 dose pack 5 PA moderiba misc 5 PA moderiba tabs 2 PA OLYSIO 5 PA QL(28/28) PEG-INTRON REDIPEN 5 PA PEG-INTRON REDIPEN PAK 4 5 PA PEGINTRON 5 PA REBETOL ORAL SOLN 4 PA ribasphere caps 2 PA RIBASPHERE RIBAPAK 5 PA RIBASPHERE TABS 600MG 5 PA ribasphere tabs 200mg 2 PA RIBASPHERE TABS 400MG 4 PA ribavirin 2 PA SOVALDI 5 PA QL(28/28) Anti-HIV Agents, Integrase Inhibitors (INSTI) GENVOYA 5 ISENTRESS CHEW 100MG 3 QL(180/30) ISENTRESS CHEW 25MG 3 QL(360/30) ISENTRESS PACK 3 ISENTRESS TABS 5 QL(60/30) TIVICAY 5 QL(60/30) VITEKTA 5 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA 5 EDURANT 5 INTELENCE TABS 200MG 5 QL(60/30) INTELENCE TABS 100MG 5 QL(120/30) INTELENCE TABS 25MG 4 QL(180/30) nevirapine er 2 nevirapine susp 3 30

33 Covered Drugs By Category NAME nevirapine tabs 2 ODEFSEY 5 QL(30/30) RESCRIPTOR 3 STRIBILD 5 SUSTIVA 3 VIRAMUNE XR TB24 100MG 3 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir 2 abacavir sulfate/lamivudine/ 5 zidovudine DESCOVY 5 QL(30/30) didanosine 2 EMTRIVA 3 EPZICOM 5 lamivudine 2 lamivudine/zidovudine 4 RETROVIR IV INFUSION 4 stavudine 2 TRUVADA 5 VIDEX PEDIATRIC 3 VIREAD 5 ZIAGEN ORAL SOLN 3 zidovudine 2 Anti-HIV Agents, Other ATRIPLA 5 FUZEON 5 QL(60/30) SELZENTRY TABS 150MG 5 QL(60/30) SELZENTRY TABS 300MG 5 QL(120/30) TRIUMEQ 5 QL(30/30) TYBOST 3 Anti-HIV Agents, Protease Inhibitors APTIVUS 5 CRIXIVAN 3 NAME EVOTAZ 5 INVIRASE 5 KALETRA ORAL SOLN 5 KALETRA TABS 200MG; 5 50MG KALETRA TABS 100MG; 4 25MG LEXIVA SUSP 4 LEXIVA TABS 5 NORVIR 3 PREZCOBIX 5 PREZISTA SUSP 5 QL(400/30) PREZISTA TABS 800MG 5 QL(30/30) PREZISTA TABS 600MG 5 QL(60/30) PREZISTA TABS 150MG 4 QL(180/30) PREZISTA TABS 75MG 4 QL(360/30) REYATAZ 5 VIRACEPT 5 Anti-influenza Agents amantadine hcl 2 rimantadine hcl 2 TAMIFLU CAPS 75MG 3 QL(56/365) TAMIFLU CAPS 45MG 3 QL(60/365) TAMIFLU CAPS 30MG 3 QL(120/365) TAMIFLU SUSR 3 QL(700/365) Antiherpetic Agents acyclovir 2 acyclovir sodium inj 50mg/ml 4 DENAVIR 3 famciclovir 2 QL(21/7) trifluridine 2 valacyclovir hcl tabs 1000mg 2 QL(30/30) valacyclovir hcl tabs 500mg 2 QL(60/30) ZOVIRAX CREA 3 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 31

34 Covered Drugs By Category NAME NAME Anxiolytics Anxiolytics, Other buspirone hcl tabs 10mg, 5mg 1 buspirone hcl tabs 15mg, 2 30mg, 7.5mg Benzodiazepines alprazolam odt tbdp 0.25mg, 2 QL(90/30) 0.5mg alprazolam odt tbdp 1mg 2 QL(120/30) alprazolam odt tbdp 2mg 2 QL(150/30) alprazolam tabs 0.25mg, 0.5mg 2 QL(90/30) alprazolam tabs 1mg 2 QL(120/30) alprazolam tabs 2mg 2 QL(150/30) clorazepate dipotassium tabs 2 QL(90/30) 3.75mg, 7.5mg clorazepate dipotassium tabs 2 QL(120/30) 15mg diazepam inj 5mg/ml 2 diazepam oral soln 2 QL(1200/30) diazepam tabs 2 QL(120/30) lorazepam conc 2 QL(150/30) lorazepam inj 2mg/ml, 4mg/ml 4 lorazepam intensol 2 QL(150/30) lorazepam tabs 2 QL(120/30) oxazepam 2 QL(120/30) Bipolar Agents Mood Stabilizers lithium carbonate caps 300mg 1 lithium carbonate caps 150mg, 2 600mg lithium carbonate er 2 lithium carbonate tabs 2 Blood Glucose Regulators Antidiabetic Agents acarbose 2 QL(90/30) BYDUREON 3 QL(4/28) BYETTA 3 QL(2.4/30) CYCLOSET 4 glimepiride tabs 1mg, 2mg 1 QL(30/30) glimepiride tabs 4mg 1 QL(60/30) glipizide 1 glipizide er 1 glipizide xl 1 glipizide/metformin hcl 1 GLYSET 3 INVOKAMET 3 QL(60/30) INVOKANA 3 QL(30/30) JANUMET 3 QL(60/30) JANUMET XR TB MG; 3 QL(30/30) 100MG JANUMET XR TB MG; 3 QL(60/30) 50MG, 500MG; 50MG JANUVIA 3 QL(30/30) JENTADUETO 3 QL(60/30) metformin hcl 1 metformin hcl er tb24 500mg, 1 750mg nateglinide 2 QL(90/30) pioglitazone hcl 2 QL(30/30) pioglitazone hcl-glimepiride 2 QL(30/30) pioglitazone hcl/metformin hcl 2 QL(90/30) repaglinide 2 RIOMET 3 SYMLINPEN PA QL(11/28) SYMLINPEN 60 3 PA QL(6/30) TRADJENTA 3 QL(30/30) TRULICITY 3 QL(2/28) VICTOZA 3 QL(9/30) Glycemic Agents GLUCAGEN HYPOKIT 4 PROGLYCEM 3 Insulins HUMALOG 3 HUMALOG KWIKPEN 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 3 KWIKPEN HUMALOG MIX 75/

35 Covered Drugs By Category NAME HUMALOG MIX 75/25 3 KWIKPEN HUMULIN 70/30 3 HUMULIN 70/30 KWIKPEN 3 HUMULIN N 3 HUMULIN N KWIKPEN 3 HUMULIN R 3 HUMULIN R U (CONCENTRATED) HUMULIN R U-500 KWIKPEN 3 LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 TOUJEO SOLOSTAR 3 TRESIBA FLEXTOUCH 3 Blood Products/Modifiers/Volume Expanders Anticoagulants ELIQUIS TABS 2.5MG 3 QL(60/30) ELIQUIS TABS 5MG 3 QL(74/30) enoxaparin sodium inj 5 QL(24/30) 120mg/0.8ml enoxaparin sodium inj 100mg/ 5 QL(30/30) ml, 150mg/ml enoxaparin sodium inj 4 QL(9/30) 30mg/0.3ml enoxaparin sodium inj 4 QL(12/30) 40mg/0.4ml enoxaparin sodium inj 4 QL(18/30) 60mg/0.6ml enoxaparin sodium inj 4 QL(24/30) 80mg/0.8ml enoxaparin sodium inj 4 QL(90/30) 300mg/3ml fondaparinux sodium inj 2.5mg/0.5ml 4 QL(15/30) NAME fondaparinux sodium inj 5 QL(12/30) 5mg/0.4ml fondaparinux sodium inj 5 QL(18/30) 7.5mg/0.6ml fondaparinux sodium inj 5 QL(24/30) 10mg/0.8ml heparin sodium inj 10000unit/ 4 ml, 1000unit/ml, 20000unit/ ml, 2000unit/ml, 2500unit/ml, 5000unit/ml heparin sodium/d5w 4 heparin sodium/nacl 0.45% inj 4 50unit/ml; 0.45% heparin sodium/nacl 0.9% 4 heparin sodium/sodium chloride 4 0.9% heparin sodium/sodium chloride 4 0.9% premix jantoven 1 PRADAXA 3 QL(60/30) warfarin sodium 1 XARELTO STARTER PACK 3 QL(102/365) XARELTO TABS 10MG, 20MG 3 QL(30/30) XARELTO TABS 15MG 3 QL(60/30) Blood Formation Modifiers anagrelide hydrochloride 2 ARANESP ALBUMIN 4 PA FREE INJ 10MCG/0.4ML, 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML ARANESP ALBUMIN 5 PA FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML LEUKINE INJ 250MCG 5 PA CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 33

36 Covered Drugs By Category NAME NAME NEULASTA 5 PA NEUPOGEN 5 PA PROCRIT INJ 20000UNIT/ML, 5 PA 40000UNIT/ML PROCRIT INJ 10000UNIT/ML, 4 PA 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML PROMACTA 5 PA QL(30/30) ZARXIO 5 PA Coagulants tranexamic acid inj 2 PA tranexamic acid tabs 2 Platelet Modifying Agents AGGRENOX 3 QL(60/30) aspirin/dipyridamole 2 QL(60/30) BRILINTA 3 QL(60/30) cilostazol 2 clopidogrel tabs 300mg 2 QL(1/30) clopidogrel tabs 75mg 2 QL(30/30) EFFIENT TABS 10MG 4 QL(36/30) EFFIENT TABS 5MG 4 QL(42/30) Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl ptwk 0.1mg/24hr, 2 QL(4/28) 0.2mg/24hr clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28) clonidine hcl tabs 0.3mg 2 clonidine hcl tabs 0.1mg, 0.2mg 1 midodrine hcl 2 Alpha-adrenergic Blocking Agents DIBENZYLINE 3 phenoxybenzamine 2 hydrochloride prazosin hcl 1 Angiotensin II Receptor Antagonists BENICAR 3 QL(30/30) BENICAR HCT 3 QL(30/30) candesartan cilexetil 2 candesartan cilexetil/ hydrochlorothiazide 2 ENTRESTO 3 PA QL(60/30) irbesartan 1 irbesartan/hydrochlorothiazide 1 losartan potassium tabs 100mg 1 QL(30/30) losartan potassium tabs 50mg 1 QL(60/30) losartan potassium tabs 25mg 1 QL(90/30) losartan potassium/ 1 QL(30/30) hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg losartan potassium/ 1 QL(60/30) hydrochlorothiazide tabs 12.5mg; 50mg telmisartan 2 QL(30/30) telmisartan/amlodipine 2 QL(30/30) telmisartan/hydrochlorothiazide 2 QL(30/30) valsartan 2 valsartan/hydrochlorothiazide 2 Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl 1 benazepril hcl/ 2 hydrochlorothiazide captopril 1 captopril/hydrochlorothiazide 2 enalapril maleate 1 enalapril maleate/ 1 hydrochlorothiazide fosinopril sodium 2 fosinopril sodium/ 2 hydrochlorothiazide lisinopril 1 lisinopril/hydrochlorothiazide 1 moexipril hcl 2 moexipril/hydrochlorothiazide 2 perindopril erbumine 1 quinapril hcl 1 quinapril/hydrochlorothiazide 2 ramipril 1 trandolapril 2 Antiarrhythmics amiodarone hcl inj 4 amiodarone hcl tabs 2 34

37 Covered Drugs By Category NAME flecainide acetate 2 lidocaine hcl inj 4 mexiletine hcl 2 MULTAQ 3 QL(60/30) pacerone 2 propafenone hcl 2 propafenone hcl er 2 quinidine sulfate 2 sorine 2 sotalol hcl 2 sotalol hcl (af) 2 TIKOSYN 3 Beta-adrenergic Blocking Agents acebutolol hcl 2 atenolol 1 atenolol/chlorthalidone 1 betaxolol hcl 2 bisoprolol fumarate 2 bisoprolol fumarate/ 1 hydrochlorothiazide BYSTOLIC TABS 20MG 3 QL(60/30) BYSTOLIC TABS 2.5MG, 5MG 3 QL(90/30) BYSTOLIC TABS 10MG 3 QL(120/30) carvedilol 1 COREG CR 3 labetalol hcl inj 4 labetalol hcl tabs 2 metoprolol succinate er 2 metoprolol tartrate inj 4 metoprolol tartrate tabs 1 metoprolol/hydrochlorothiazide 2 nadolol tabs 80mg 2 nadolol tabs 20mg, 40mg 1 nadolol/bendroflumethiazide 2 NAME pindolol 1 propranolol hcl er 2 propranolol hcl inj 4 propranolol hcl oral soln 2 propranolol hcl tabs 60mg 2 propranolol hcl tabs 10mg, 1 20mg, 40mg, 80mg propranolol/hydrochlorothiazide 2 timolol maleate tabs 2 Calcium Channel Blocking Agents afeditab cr 2 amlodipine besylate 1 amlodipine besylate/benazepril 2 hydrochloride amlodipine besylate/valsartan 2 amlodipine/valsartan/hctz 2 cartia xt 2 dilt-xr 2 diltiazem cd 2 diltiazem hcl er 2 diltiazem hcl inj 100mg, 4 125mg/25ml, 25mg/5ml, 50mg/10ml diltiazem hcl tabs 1 felodipine er 2 isradipine 2 matzim la 2 nicardipine hcl caps 2 nicardipine hcl inj 4 nifedical xl 2 nifedipine er 2 nimodipine 2 nisoldipine 2 nisoldipine er 2 taztia xt 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 35

38 Covered Drugs By Category NAME NAME verapamil hcl er 2 verapamil hcl inj 4 verapamil hcl sr cp24 360mg 2 verapamil hcl tabs 120mg, 1 80mg verapamil hcl tabs 40mg 2 Cardiovascular Agents, Other DEMSER 5 digitek tabs 0.125mg 1 QL(30/30) digitek tabs 0.25mg 1 PA digox tabs 125mcg 1 QL(30/30) digox tabs 250mcg 1 PA digoxin inj 4 PA digoxin tabs 125mcg 1 QL(30/30) digoxin tabs 250mcg 1 PA LANOXIN PEDIATRIC 4 PA NORTHERA 5 PA QL(180/30) pentoxifylline er 2 RANEXA TB MG 3 QL(60/30) ST RANEXA TB12 500MG 3 QL(120/30) ST TEKTURNA 3 ST TEKTURNA HCT 3 ST Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 2 acetazolamide sodium 4 Diuretics, Loop bumetanide inj 4 bumetanide tabs 0.5mg, 1mg 1 bumetanide tabs 2mg 2 EDECRIN 3 ethacrynate sodium 4 furosemide inj 2 furosemide oral soln 2 furosemide tabs 1 SODIUM EDECRIN 4 torsemide 2 Diuretics, Potassium-sparing amiloride hcl 2 amiloride/hydrochlorothiazide 1 spironolactone tabs 25mg 1 spironolactone tabs 100mg, 2 50mg spironolactone/ 2 hydrochlorothiazide triamterene/hydrochlorothiazide 2 caps 25mg; 50mg triamterene/hydrochlorothiazide 1 caps 25mg; 37.5mg triamterene/hydrochlorothiazide 1 tabs Diuretics, Thiazide chlorothiazide 2 chlorothiazide sodium 4 chlorthalidone tabs 25mg, 1 50mg hydrochlorothiazide caps 1 hydrochlorothiazide tabs 25mg, 1 50mg hydrochlorothiazide tabs mg indapamide 1 metolazone 2 Dyslipidemics, Fibric Acid Derivatives fenofibrate caps 2 fenofibrate micronized 2 fenofibrate tabs 145mg, 160mg, 2 48mg, 54mg fenofibric acid dr 2 gemfibrozil 2 LIPOFEN 3 Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium 2 QL(30/30) CRESTOR 3 QL(30/30) fluvastatin caps 20mg 2 QL(30/30) fluvastatin caps 40mg 2 QL(60/30) lovastatin tabs 40mg 2 QL(60/30) lovastatin tabs 10mg, 20mg 1 QL(90/30) pravastatin sodium tabs 80mg 1 QL(30/30) pravastatin sodium tabs 40mg 1 QL(60/30) pravastatin sodium tabs 10mg, 20mg 1 QL(90/30) 36

39 Covered Drugs By Category NAME rosuvastatin calcium 4 PA QL(30/30) simvastatin tabs 20mg, 40mg, 1 QL(30/30) 80mg simvastatin tabs 10mg, 5mg 1 QL(90/30) Dyslipidemics, Other cholestyramine 2 cholestyramine light 2 colestipol hcl gran 2 colestipol hcl tabs 2 KYNAMRO 5 PA niacin er tbcr 500mg 2 QL(30/30) niacin er tbcr 1000mg, 750mg 2 QL(60/30) niacor 2 omega-3-acid ethyl esters 2 QL(120/30) prevalite 2 REPATHA 5 PA QL(3/30) REPATHA SURECLICK 5 PA QL(3/30) VASCEPA 4 QL(120/30) WELCHOL 3 ZETIA 3 QL(30/30) Vasodilators, Direct-acting Arterial hydralazine hcl inj 4 hydralazine hcl tabs 2 minoxidil 2 Vasodilators, Direct-acting Arterial/Venous BIDIL 3 QL(180/30) isosorbide dinitrate er 2 isosorbide dinitrate tabs 2 isosorbide mononitrate 2 isosorbide mononitrate er 2 minitran 2 nitroglycerin 4 nitroglycerin lingual translingual soln 2 NAME nitroglycerin transdermal 2 NITROSTAT 3 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/ 2 QL(60/30) dextroamphetamine cp24 amphetamine/ 2 QL(90/30) dextroamphetamine tabs dextroamphetamine sulfate er 2 QL(90/30) cp24 10mg, 5mg dextroamphetamine sulfate er 2 QL(120/30) cp24 15mg dextroamphetamine sulfate oral 2 QL(1800/30) soln dextroamphetamine sulfate 2 QL(90/30) tabs 5mg dextroamphetamine sulfate 2 QL(180/30) tabs 10mg Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl er 2 dexmethylphenidate hcl 2 QL(60/30) metadate er 2 QL(90/30) methylphenidate hcl er tbcr 2 QL(90/30) 20mg methylphenidate hcl er tbcr 2 QL(180/30) 10mg methylphenidate hcl sr 2 QL(90/30) methylphenidate hcl tabs 2 QL(90/30) STRATTERA 3 Central Nervous System, Other HETLIOZ 5 PA QL(30/30) NUEDEXTA 3 riluzole 4 tetrabenazine tabs 12.5mg 5 PA QL(90/30) CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 37

40 Covered Drugs By Category NAME NAME tetrabenazine tabs 25mg 5 PA QL(120/30) XENAZINE TABS 12.5MG 5 PA QL(90/30) XENAZINE TABS 25MG 5 PA QL(120/30) Multiple Sclerosis Agents AMPYRA 5 PA QL(60/30) AVONEX 5 QL(4/28) AVONEX PEN 5 QL(4/28) COPAXONE INJ 40MG/ML 5 glatopa 5 QL(30/30) REBIF 5 QL(6/28) REBIF REBIDOSE 5 QL(6/28) REBIF REBIDOSE TITRATION 5 QL(4.2/28) PACK REBIF TITRATION PACK 5 QL(4.2/28) TYSABRI 5 PA Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate oral 1 rinse oralone 2 paroex 1 periogard 1 pilocarpine hcl tabs 2 pilocarpine hydrochloride 2 triamcinolone acetonide pste 2 triamcinolone in orabase 2 Dermatological Agents Dermatological Agents acitretin 5 PA ammonium lactate 2 calcipotriene 2 QL(120/30) calcitrene 2 QL(120/30) calcitriol oint 3 CARAC 3 claravis 2 curity gauze pads 2 x2 2 diclofenac sodium gel 1% 4 PA QL(1000/30) diclofenac sodium transdermal 2 soln doxepin hydrochloride 2 ELIDEL 3 erythromycin/benzoyl peroxide 2 fluorouracil crea 5% 2 fluorouracil crea 0.5% 3 fluorouracil external soln 2 imiquimod 2 methoxsalen 5 myorisan 2 PICATO 4 ST podofilox 2 PRUDOXIN 3 REGRANEX 5 PA SANTYL 3 selenium sulfide lotn 1 tacrolimus oint 2 TAZORAC CREA 3 QL(120/30) TAZORAC GEL 3 QL(100/30) tretinoin crea 2 PA QL(45/30) tretinoin gel 0.01%, 0.025% 2 PA QL(45/30) tretinoin microsphere 2 PA tretinoin microsphere pump 2 PA UVADEX 4 B/D PA VECTICAL 3 VOLTAREN GEL 3 QL(1000/30) ST zenatane 2 ZONALON 3 ZYCLARA 5 ZYCLARA PUMP CREA 2.5% 5 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN 5 PA ALDURAZYME 5 PA BUPHENYL TABS 5 CEREZYME 5 B/D PA CREON 3 CYSTADANE 5 38

41 Covered Drugs By Category NAME CYSTAGON 3 ELAPRASE 5 PA FABRAZYME 5 B/D PA KUVAN 5 PA LUMIZYME 5 PA NAGLAZYME 5 PA ORFADIN 5 sodium phenylbutyrate 5 VPRIV 5 PA ZAVESCA 5 ZENPEP 3 Gastrointestinal Agents Antispasmodics, Gastrointestinal anaspaz 2 atropine sulfate inj 0.05mg/ml, 4 0.1mg/ml, 0.4mg/ml, 1mg/ml dicyclomine hcl caps 1 dicyclomine hcl oral soln 2 dicyclomine hcl tabs 1 ed-spaz 2 glycopyrrolate inj 4 glycopyrrolate tabs 2 hyoscyamine sulfate elix 2 hyoscyamine sulfate odt 2 hyoscyamine sulfate subl 2 hyoscyamine sulfate tabs 2 hyoscyamine sulfate tbdp 2 hyosyne elix 2 methscopolamine bromide 2 nulev 2 oscimin 2 propantheline bromide 2 symax fastabs 2 symax-sl 2 NAME Gastrointestinal Agents, Other cromolyn sodium conc 2 diphenoxylate/atropine 2 GATTEX 5 PA loperamide hcl caps 2 metoclopramide hcl inj 4 metoclopramide hcl oral soln 1 metoclopramide hcl tabs 10mg 1 metoclopramide hcl tabs 5mg 2 OSMOPREP 3 RELISTOR INJ 8MG/0.4ML 4 PA QL(12/30) RELISTOR INJ 12MG/0.6ML 4 PA QL(18/30) ursodiol 2 Histamine2 (H2) Receptor Antagonists cimetidine 2 cimetidine hcl 2 famotidine inj 4 famotidine premixed 4 famotidine tabs 20mg 1 famotidine tabs 40mg 2 nizatidine caps 2 ranitidine hcl caps 2 ranitidine hcl inj 150mg/6ml 4 ranitidine hcl syrp 2 ranitidine hcl tabs 1 Irritable Bowel Syndrome Agents alosetron hydrochloride 5 PA QL(60/30) AMITIZA 3 QL(60/30) LINZESS 4 QL(30/30) Laxatives constulose 1 enulose 1 gavilyte-c 2 gavilyte-g 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 39

42 Covered Drugs By Category NAME NAME gavilyte-n/flavor pack 2 generlac 1 lactulose 1 MOVIPREP 3 peg 3350/electrolytes 2 peg-3350/electrolytes 2 peg-3350/nacl/na bicarbonate/ 2 kcl polyethylene glycol 3350 powd 2 SUPREP BOWEL PREP 3 trilyte 2 Protectants CARAFATE SUSP 3 misoprostol 2 sucralfate 2 Proton Pump Inhibitors DEXILANT 4 QL(60/30) ST esomeprazole magnesium 2 QL(60/30) esomeprazole sodium 4 lansoprazole 2 omeprazole cpdr 2 pantoprazole sodium tbec 2 Genitourinary Agents Antispasmodics, Urinary flavoxate hcl 2 oxybutynin chloride 1 oxybutynin chloride er tb24 2 QL(30/30) 5mg oxybutynin chloride er tb24 2 QL(60/30) 10mg, 15mg tolterodine tartrate 1 VESICARE 3 QL(30/30) Benign Prostatic Hypertrophy Agents alfuzosin hcl er 2 QL(30/30) AVODART 3 doxazosin mesylate tabs 1mg, 1 QL(30/30) 2mg, 4mg doxazosin mesylate tabs 8mg 1 QL(60/30) dutasteride 2 dutasteride/tamsulosin 2 hydrochloride finasteride tabs 5mg 2 QL(30/30) JALYN 3 tamsulosin hcl 2 terazosin hcl caps 1mg, 5mg 1 QL(30/30) terazosin hcl caps 10mg, 2mg 1 QL(60/30) Genitourinary Agents, Other bethanechol chloride 2 ELMIRON 3 phenazopyridine hcl 2 Phosphate Binders AURYXIA 4 calcium acetate caps 2 calcium acetate tabs 667mg 2 PHOSLYRA 4 RENVELA PACK 3 QL(180/30) RENVELA TABS 3 QL(540/30) VELPHORO 4 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) a-hydrocort 4 ala cort 1 ALA SCALP 3 alclometasone dipropionate 2 amcinonide 2 augmented betamethasone 2 dipropionate betamethasone dipropionate 2 betamethasone valerate 2 clobetasol propionate crea 2 clobetasol propionate e 2 clobetasol propionate emollient 2 clobetasol propionate external 2 soln clobetasol propionate foam 2 clobetasol propionate gel 2 40

43 Covered Drugs By Category NAME NAME clobetasol propionate oint 2 clobetasol propionate sham 2 clodan 2 cormax scalp application 2 cortisone acetate 2 DEPO-MEDROL INJ 20MG/ML 4 desonide lotn 2 desonide oint 2 desoximetasone crea 2 desoximetasone gel 2 desoximetasone oint 0.25% 2 dexamethasone elix 2 dexamethasone intensol 2 dexamethasone oral soln 2 dexamethasone sodium 2 phosphate inj 20mg/5ml, 4mg/ ml dexamethasone sodium 4 phosphate inj 10mg/ml, 120mg/30ml dexamethasone tabs 1.5mg, 2 1mg, 2mg, 6mg dexamethasone tabs 0.5mg, mg, 4mg diflorasone diacetate 2 fludrocortisone acetate 2 fluocinolone acetonide body 2 fluocinolone acetonide crea 2 fluocinolone acetonide ear 2 drops fluocinolone acetonide external 1 soln fluocinolone acetonide oint 2 fluocinolone acetonide scalp 2 fluocinonide 2 fluocinonide-e 2 fluticasone propionate crea 2 fluticasone propionate oint 2 halobetasol propionate 2 hydrocortisone butyrate 2 hydrocortisone butyrate 2 (lipophilic) hydrocortisone external crea 1 hydrocortisone in absorbase 2 hydrocortisone lotn 2.5% 2 hydrocortisone oint 1%, 2.5% 2 hydrocortisone tabs 2 hydrocortisone valerate 2 MEDROL TABS 2MG 3 methylprednisolone 2 methylprednisolone acetate 4 methylprednisolone dose pack 2 methylprednisolone 4 sodiumsuccinate inj 125mg, 40mg mometasone furoate crea 2 mometasone furoate external 2 soln mometasone furoate oint 2 prednicarbate oint 2 prednisolone oral soln 2 prednisolone sodium 2 phosphate oral soln prednisone intensol 2 prednisone oral soln 2 prednisone tabs 50mg 2 prednisone tabs 10mg, 1mg, 1 2.5mg, 20mg, 5mg prednisone tbpk 1 procto-pak 2 proctosol hc 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 41

44 Covered Drugs By Category NAME NAME proctozone-hc 2 SOLU-CORTEF 4 TEXACORT 3 triamcinolone acetonide crea %, 0.5% triamcinolone acetonide crea 1 0.1% triamcinolone acetonide lotn 2 triamcinolone acetonide oint 2 trianex 2 triderm 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) chorionic gonadotropin 4 PA desmopressin acetate inj 4 desmopressin acetate nasal 2 soln desmopressin acetate tabs 2 INCRELEX 4 PA NOVAREL 4 PA PREGNYL W/DILUENT 4 PA BENZYL ALCOHOL/NACL SAIZEN 5 PA SAIZEN CLICK.EASY 5 PA STIMATE 3 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM 5 PA QL(120/30) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 5 PA oxandrolone tabs 10mg 2 PA QL(60/30) oxandrolone tabs 2.5mg 2 PA QL(120/30) Androgens ANDROGEL 3 PA ANDROGEL PUMP GEL 1.62% 3 PA ANDROXY 3 PA danazol 2 TESTIM 3 PA testosterone cypionate 4 PA testosterone enanthate 4 PA testosterone gel 25mg/2.5gm 2 PA testosterone pump 2 PA Estrogens ALORA 3 PA QL(8/28) altavera 2 alyacen 1/35 2 alyacen 7/7/7 2 amethia 2 amethia lo 2 apri 2 aranelle 2 aubra 2 aviane 2 azurette 2 balziva 2 bekyree 2 blisovi fe 1.5/30 2 blisovi fe 1/20 2 briellyn 2 caziant 2 chateal 2 cryselle-28 2 cyclafem 1/35 2 cyclafem 7/7/7 2 cyred 2 dasetta 1/35 2 dasetta 7/7/7 2 DELESTROGEN 4 delyla 2 DEPO-ESTRADIOL 4 desogestrel/ethinyl estradiol 2 42

45 Covered Drugs By Category NAME elinest 2 emoquette 2 enpresse-28 2 enskyce 2 estarylla 2 estradiol pttw 2 PA QL(8/28) estradiol ptwk 2 PA QL(4/28) estradiol tabs 2 PA estradiol valerate 4 estradiol/norethindrone acetate 2 PA ESTRING 3 QL(1/90) falmina 2 FEMRING 3 gildagia 2 gildess 1.5/30 2 gildess 1/20 2 gildess fe 1.5/30 2 gildess fe 1/20 2 introvale 2 juleber 2 junel 1.5/30 2 junel 1/20 2 junel fe 1.5/30 2 junel fe 1/20 2 kariva 2 kelnor 1/35 2 kimidess 2 kurvelo 2 larin 1.5/30 2 larin 1/20 2 larin fe 1.5/30 2 larin fe 1/20 2 lessina 2 levonest 2 NAME levonorgestrel and ethinyl 2 estradiol tabs 0; 0 levonorgestrel/ethinyl estradiol 2 levora 0.15/ lopreeza 2 PA low-ogestrel 2 lutera 2 marlissa 2 MENEST 3 PA MENOSTAR 3 PA QL(4/28) microgestin 1.5/30 2 microgestin 1/20 2 microgestin fe 2 microgestin fe 1.5/30 2 mimvey 2 PA mimvey lo 2 PA MINIVELLE 3 PA QL(8/28) mono-linyah 2 myzilra 2 necon 0.5/ necon 1/35 2 necon 1/ necon 10/ necon 7/7/7 2 norethindrone acetate/ethinyl 2 estradiol tabs 20mcg; 1mg norethindrone acetate/ethinyl 2 estradiol/ferrous fumarate norgestimate/ethinyl estradiol 2 nortrel 0.5/35 (28) 2 nortrel 1/35 2 nortrel 7/7/7 2 ogestrel 2 orsythia 2 philith 2 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 43

46 Covered Drugs By Category NAME NAME pimtrea 2 pirmella 1/35 2 pirmella 7/7/7 2 portia-28 2 PREMARIN CREA 3 PREMARIN INJ 4 PREMARIN TABS 3 PA QL(30/30) previfem 2 quasense 2 reclipsen 2 setlakin 2 sprintec 28 2 sronyx 2 tarina fe 1/20 2 tri-estarylla 2 tri-legest fe 2 tri-linyah 2 tri-previfem 2 tri-sprintec 2 trivora-28 2 VAGIFEM 3 velivet 2 vienva 2 viorele 2 vyfemla 2 wera 2 zenchent 2 zovia 1/35e 2 zovia 1/50e 2 Progesterone Agonists/Antagonists ELLA 3 Progestins camila 2 deblitane 2 DEPO-PROVERA 4 errin 2 heather 2 jencycla 2 lyza 2 MAKENA 5 medroxyprogesterone acetate 4 QL(1/90) inj medroxyprogesterone acetate 1 tabs megestrol acetate susp 40mg/ 2 PA ml megestrol acetate tabs 2 PA norethindrone 2 norethindrone acetate 2 norlyroc 2 progesterone caps 2 sharobel 2 Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride 2 QL(30/30) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tabs 1 LEVOXYL 3 liothyronine sodium inj 4 liothyronine sodium tabs 2 SYNTHROID 3 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3 UNITHROID 3 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN 3 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABS 30MG 3 QL(60/30) SENSIPAR TABS 60MG 5 QL(60/30) SENSIPAR TABS 90MG 5 QL(120/30) 44

47 Covered Drugs By Category NAME Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline 2 ELIGARD INJ 30MG 4 PA QL(1/120) ELIGARD INJ 45MG 4 PA QL(1/180) ELIGARD INJ 7.5MG 4 PA QL(1/30) ELIGARD INJ 22.5MG 4 PA QL(1/90) FIRMAGON INJ 80MG 4 B/D PA QL(4/28) FIRMAGON INJ 120MG 5 B/D PA QL(6/365) leuprolide acetate 4 PA QL(5.6/28) LUPRON DEPOT INJ 30MG 5 PA QL(1/112) LUPRON DEPOT INJ 45MG 5 PA QL(1/168) LUPRON DEPOT INJ 3.75MG, 5 PA QL(1/30) 7.5MG LUPRON DEPOT INJ 22.5MG 5 PA QL(1/84) LUPRON DEPOT INJ 11.25MG 5 PA QL(1/90) LUPRON DEPOT-PED 5 PA QL(1/30) octreotide acetate inj 1000mcg/ 5 PA ml, 500mcg/ml octreotide acetate inj 100mcg/ 4 PA ml, 200mcg/ml, 50mcg/ml SANDOSTATIN LAR DEPOT 5 PA SIGNIFOR 5 PA SOMATULINE DEPOT 5 PA SOMAVERT INJ 25MG, 30MG 5 PA QL(30/30) SOMAVERT INJ 15MG, 20MG 5 PA QL(60/30) SOMAVERT INJ 10MG 5 PA QL(90/30) SYNAREL 5 PA TRELSTAR INJ 3.75MG 5 PA QL(2/28) TRELSTAR INJ 11.25MG 5 PA QL(2/84) TRELSTAR MIXJECT INJ 5 PA QL(2/168) 22.5MG TRELSTAR MIXJECT INJ 3.75MG 5 PA QL(2/28) NAME TRELSTAR MIXJECT INJ 11.25MG Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole 2 propylthiouracil 2 Immunological Agents 5 PA QL(2/84) Angioedema (HAE) Agents CINRYZE 5 PA FIRAZYR 5 PA Immune Suppressants ASTAGRAF XL 4 PA AZASAN 3 PA azathioprine tabs 2 PA BENLYSTA 5 PA CELLCEPT INTRAVENOUS 4 PA cyclosporine caps 2 PA cyclosporine inj 4 PA cyclosporine modified 2 PA ENBREL 5 PA QL(8/28) ENBREL SURECLICK 5 PA QL(8/28) ENVARSUS XR 4 PA gengraf 2 PA HUMIRA INJ 10MG/0.2ML, 5 PA QL(2/28) 20MG/0.4ML HUMIRA INJ 40MG/0.8ML 5 PA QL(6/28) HUMIRA PEDIATRIC CROHNS 5 PA QL(6/28) DISEASE STARTER PACK HUMIRA PEN 5 PA QL(6/28) HUMIRA PEN-CROHNS 5 PA QL(6/28) DISEASESTARTER HUMIRA PEN-PSORIASIS 5 PA QL(6/28) STARTER KINERET 5 PA QL(20.1/30) CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 45

48 Covered Drugs By Category NAME NAME methotrexate 2 methotrexate sodium inj 1gm, 4 1gm/40ml, 250mg/10ml, 50mg/2ml mycophenolate mofetil 2 PA mycophenolic acid dr 2 PA NULOJIX 5 PA PROGRAF INJ 4 PA RAPAMUNE ORAL SOLN 3 PA REMICADE 5 PA SANDIMMUNE ORAL SOLN 4 PA sirolimus 2 PA tacrolimus caps 2 PA TORISEL 5 B/D PA ZORTRESS TABS 0.5MG, 5 PA 0.75MG ZORTRESS TABS 0.25MG 4 PA Immunizing Agents, Passive ATGAM 4 PA BIVIGAM 5 B/D PA FLEBOGAMMA DIF 5 B/D PA GAMASTAN S/D 4 B/D PA GAMMAGARD LIQUID INJ 5 B/D PA 2.5GM/25ML, 30GM/300ML GAMMAKED 5 B/D PA GAMMAPLEX INJ 5 B/D PA 10GM/200ML, 5GM/100ML GAMUNEX-C 5 B/D PA OCTAGAM INJ 10GM/100ML, 5 B/D PA 1GM/20ML, 20GM/200ML, 5GM/50ML OCTAGAM INJ 2GM/20ML 4 B/D PA PRIVIGEN INJ 10GM/100ML, 5 B/D PA 20GM/200ML, 5GM/50ML THYMOGLOBULIN 3 B/D PA Immunomodulators ACTIMMUNE 5 PA ARCALYST 5 PA ILARIS 5 PA leflunomide 2 QL(30/30) RIDAURA 5 SIMULECT 5 B/D PA SYNAGIS INJ 50MG/0.5ML 5 PA Vaccines ACTHIB 4 ADACEL 4 BEXSERO 4 BOOSTRIX 4 CERVARIX 4 DAPTACEL 4 DIPHTHERIA/TETANUS 4 TOXOIDS ADSORBED PEDIATRIC ENGERIX-B 4 B/D PA GARDASIL 4 GARDASIL 9 4 HAVRIX 4 IMOVAX RABIES (H.D.C.V.) 4 INFANRIX 4 IPOL INACTIVATED IPV 4 IXIARO 4 KINRIX 4 M-M-R II 4 MENACTRA 4 MENOMUNE-A/C/Y/W MENVEO 4 PEDVAX HIB 4 PROQUAD 4 QUADRACEL 4 RABAVERT 4 RECOMBIVAX HB 4 B/D PA ROTARIX 3 ROTATEQ 3 TENIVAC 4 TETANUS/DIPHTHERIA 4 TOXOIDS-ADSORBED TETANUS/DIPHTHERIA 4 TOXOIDS-ADSORBED ADULT TRUMENBA 4 TWINRIX 4 TYPHIM VI 4 46

49 Covered Drugs By Category NAME VAQTA 4 VARIVAX 4 VARIZIG INJ 125UNIT/1.2ML 4 YF-VAX 4 ZOSTAVAX 4 Inflammatory Bowel Disease Agents Aminosalicylates APRISO 3 balsalazide disodium 2 DELZICOL 3 mesalamine 2 Glucocorticoids budesonide cpep 2 colocort 2 hydrocortisone enem 2 Sulfonamides sulfasalazine 2 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium tabs 35mg, 1 QL(4/28) 70mg alendronate sodium tabs 10mg, 2 QL(30/30) 40mg, 5mg calcitonin-salmon 2 QL(3.7/30) calcitriol caps 2 calcitriol inj 4 calcitriol oral soln 2 doxercalciferol caps 2 doxercalciferol inj 4 etidronate disodium 2 FORTEO 5 PA QL(2.4/28) ibandronate sodium tabs 2 QL(1/28) NAME MIACALCIN INJ 4 pamidronate disodium 4 B/D PA paricalcitol caps 2 PROLIA 4 QL(1/180) ST risedronate sodium tabs 150mg 2 QL(1/28) risedronate sodium tabs 35mg 2 QL(4/28) risedronate sodium tabs 30mg, 2 QL(30/30) 5mg XGEVA 5 PA zoledronic acid 4 B/D PA Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents bd safetyglide 27g x 5/8 2 QL(200/30) FERRIPROX 5 PA fomepizole 5 INTRALIPID 4 B/D PA LACTATED RINGERS 4 IRRIGATION levocarnitine inj 4 levocarnitine oral soln 2 levocarnitine tabs 2 NATPARA 5 PA novofine 30gx8mm 2 QL(200/30) novofine 31 2 QL(200/30) novofine 32gx6mm 2 QL(200/30) novofine autocover 30gx8mm 2 QL(200/30) novotwist 30gx8mm 2 QL(200/30) novotwist 32gx5mm 2 QL(200/30) PHYSIOLYTE 4 PHYSIOSOL IRRIGATION 4 RINGERS IRRIGATION 4 sodium chloride 0.9% 4 sterile water irrigation 4 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 47

50 Covered Drugs By Category NAME NAME Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost 2 QL(5/30) COMBIGAN 3 latanoprost 2 QL(5/30) LUMIGAN 3 QL(5/30) TRAVATAN Z 3 QL(5/30) ZIOPTAN 4 QL(5/30) Ophthalmic Agents, Other atropine sulfate ophthalmic soln 2 LACRISERT 3 naphazoline hcl 2 polycin 2 proparacaine hcl 2 RESTASIS 3 QL(64/30) tropicamide 2 Ophthalmic Anti-allergy Agents ALOCRIL 3 azelastine hcl ophthalmic soln 2 cromolyn sodium ophthalmic 2 soln epinastine hcl 2 olopatadine hcl ophthalmic soln 2 PATADAY 3 PAZEO 3 Ophthalmic Anti-inflammatories bromfenac 2 dexamethasone sodium 2 phosphate ophthalmic soln diclofenac sodium ophthalmic 2 soln DUREZOL 3 fluorometholone 3 flurbiprofen sodium 2 ILEVRO 3 ketorolac tromethamine 2 ophthalmic soln LOTEMAX 4 neomycin/polymyxin/ 2 dexamethasone PRED MILD 3 PRED-G 3 PRED-G S.O.P. 3 prednisolone acetate 3 prednisolone sodium 1 phosphate ophthalmic soln TOBRADEX OINT 3 tobramycin/dexamethasone 2 Ophthalmic Antiglaucoma Agents acetazolamide er 2 apraclonidine 2 AZOPT 3 betaxolol hcl 2 brimonidine tartrate ophthalmic 2 soln 0.2% brimonidine tartrate ophthalmic 3 soln 0.15% carteolol hcl 2 dorzolamide hcl 2 dorzolamide hcl/timolol maleate 2 levobunolol hcl ophthalmic soln 1 0.5% methazolamide 2 metipranolol 2 PHOSPHOLINE IODIDE 4 pilocarpine hcl ophthalmic soln 3 SIMBRINZA 4 timolol maleate ophthalmic soln 1 Otic Agents Otic Agents acetasol hc 2 acetic acid 2 acetic acid/aluminum acetate 2 CORTISPORIN-TC 3 fluocinolone acetonide oil 2 hydrocortisone/acetic acid 2 neomycin/polymyxin/hc 2 48

51 Covered Drugs By Category NAME neomycin/polymyxin/ hydrocortisone Respiratory Tract/Pulmonary Agents 2 Anti-inflammatories, Inhaled Corticosteroids budesonide susp 32mcg/act 2 QL(17.2/30) budesonide susp 0.25mg/2ml, 2 B/D PA QL(120/30) 0.5mg/2ml, 1mg/2ml DULERA 3 QL(18/30) FLOVENT DISKUS AEPB 3 QL(120/30) 250MCG/BLIST, 50MCG/BLIST FLOVENT DISKUS AEPB 3 QL(180/30) 100MCG/BLIST FLOVENT HFA AERO 44MCG/ 3 QL(22/30) ACT FLOVENT HFA AERO 3 QL(24/30) 110MCG/ACT, 220MCG/ACT flunisolide 1 fluticasone propionate susp 2 QL(16/30) QVAR 3 QL(18/30) SYMBICORT AERO 160MCG/ 3 QL(12/30) ACT; 4.5MCG/ACT SYMBICORT AERO 80MCG/ 3 QL(14/30) ACT; 4.5MCG/ACT Antihistamines azelastine hcl nasal soln 2 QL(60/30) desloratadine 2 QL(30/30) desloratadine odt 2 QL(30/30) diphenhydramine hcl inj 4 levocetirizine dihydrochloride 2 QL(300/30) oral soln levocetirizine dihydrochloride 2 QL(30/30) tabs Antileukotrienes montelukast sodium 2 QL(30/30) zafirlukast 2 Bronchodilators, Anticholinergic NAME ATROVENT HFA 3 QL(26/30) COMBIVENT RESPIMAT 3 QL(8/30) ipratropium bromide inhalation 2 B/D PA QL(300/30) soln ipratropium bromide nasal soln 2 QL(30/30) 0.06% ipratropium bromide nasal soln 2 QL(60/30) 0.03% ipratropium bromide/albuterol 2 B/D PA QL(540/30) sulfate SPIRIVA HANDIHALER 3 QL(30/30) SPIRIVA RESPIMAT 3 QL(4/30) Bronchodilators, Sympathomimetic albuterol 1 albuterol sulfate er 2 albuterol sulfate nebu 0.5% 1 B/D PA QL(360/30) albuterol sulfate nebu 0.083% 1 B/D PA QL(375/30) albuterol sulfate nebu 2 B/D PA QL(375/30) 0.63mg/3ml, 1.25mg/3ml albuterol sulfate syrp 1 albuterol sulfate tabs 1 epinephrine hcl 4 EPIPEN 2-PAK 3 QL(2/30) EPIPEN-JR 2-PAK 3 QL(2/30) FORADIL AEROLIZER 3 QL(60/30) metaproterenol sulfate 2 PERFOROMIST 3 B/D PA QL(120/30) PROAIR HFA 3 QL(17/30) PROAIR RESPICLICK 3 QL(1.3/30) SEREVENT DISKUS 3 QL(60/30) STRIVERDI RESPIMAT 3 QL(4/30) terbutaline sulfate inj 4 terbutaline sulfate tabs 2 Cystic Fibrosis Agents CAYSTON 5 PA CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 49

52 Covered Drugs By Category NAME NAME KALYDECO 5 PA QL(60/30) PULMOZYME 5 B/D PA TOBI PODHALER 5 QL(1568/365) tobramycin 4 B/D PA Mast Cell Stabilizers cromolyn sodium nebu 2 B/D PA Phosphodiesterase Inhibitors, Airways Disease aminophylline 4 DALIRESP 3 PA QL(30/30) THEO-24 3 theochron 2 theophylline cr 2 theophylline er 2 Pulmonary Antihypertensives ADEMPAS 5 PA QL(90/30) LETAIRIS 5 PA QL(30/30) OPSUMIT 5 PA QL(30/30) REMODULIN 5 B/D PA sildenafil tabs 2 PA QL(90/30) TRACLEER 5 PA QL(60/30) Respiratory Tract Agents, Other acetylcysteine inhalation soln 2 B/D PA ARALAST NP INJ 500MG 5 B/D PA ESBRIET 5 PA PROLASTIN-C 5 B/D PA STIOLTO RESPIMAT 3 TYZINE PEDIATRIC NASAL 3 DROPS VIRAZOLE 5 B/D PA XOLAIR 5 PA ZEMAIRA 5 B/D PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants cyclobenzaprine hcl tabs 10mg, 3 PA 5mg orphenadrine citrate er 2 PA Sleep Disorder Agents GABA Receptor Modulators temazepam 2 QL(90/365) zaleplon 2 QL(90/365) zolpidem tartrate tabs 3 PA QL(90/365) Sleep Disorders, Other modafinil tabs 100mg 4 PA QL(30/30) modafinil tabs 200mg 4 PA QL(60/30) NUVIGIL 4 PA QL(30/30) ROZEREM 3 QL(30/30) SILENOR 3 QL(30/30) XYREM 5 PA QL(540/30) Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers CHEMET 3 CUPRIMINE 5 DEPEN TITRATABS 3 EXJADE 5 JADENU 5 kionex 2 SAMSCA TABS 30MG 5 PA QL(60/30) SAMSCA TABS 15MG 5 PA QL(90/30) sodium bicarbonate inj 4 sodium bicarbonate partial fill 4 SODIUM LACTATE INJ 5MEQ/ 4 B/D PA ML sodium polystyrene sulfonate 2 powd sodium polystyrene sulfonate 2 susp 15gm/60ml, 30gm/120ml sps 2 SYPRINE 5 Electrolyte/Mineral Replacement AMINOSYN 7%/ 4 B/D PA ELECTROLYTES AMINOSYN 8.5%/ 4 B/D PA ELECTROLYTES AMINOSYN II 4 B/D PA 50

53 Covered Drugs By Category NAME AMINOSYN II 8.5%/ 4 B/D PA ELECTROLYTES AMINOSYN INJ 90MEQ/L; 4 B/D PA 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML AMINOSYN M 4 B/D PA AMINOSYN-HBC 4 B/D PA AMINOSYN-PF 4 B/D PA AMINOSYN-PF 7% 4 B/D PA AMINOSYN-RF 4 B/D PA CARBAGLU 5 CLINIMIX 2.75%/DEXTROSE 4 B/D PA 5% CLINIMIX 4.25%/DEXTROSE 4 B/D PA 10% CLINIMIX 4.25%/DEXTROSE 4 B/D PA 20% CLINIMIX 4.25%/DEXTROSE 4 B/D PA 25% CLINIMIX 4.25%/DEXTROSE 4 B/D PA 5% CLINIMIX 5%/DEXTROSE 15% 4 B/D PA CLINIMIX 5%/DEXTROSE 20% 4 B/D PA CLINIMIX 5%/DEXTROSE 25% 4 B/D PA CLINIMIX E 2.75%/ 4 B/D PA DEXTROSE 10% CLINIMIX E 4.25%/ 4 B/D PA DEXTROSE 10% CLINIMIX E 4.25%/ DEXTROSE 25% 4 B/D PA NAME CLINIMIX E 5%/DEXTROSE 4 B/D PA 25% CLINISOL SF 15% 4 B/D PA dextrose 10%/nacl 0.45% 4 B/D PA dextrose 5% /electrolyte #48 4 B/D PA viaflex DEXTROSE 10% FLEX 4 B/D PA CONTAINER dextrose 10%/nacl 0.2% 4 B/D PA dextrose 2.5%/nacl 0.45% 4 B/D PA dextrose 2.5%/sodium chloride 4 B/D PA 0.45% DEXTROSE 20% 4 B/D PA DEXTROSE 25% 4 B/D PA DEXTROSE 30% 4 B/D PA DEXTROSE 40% 4 B/D PA DEXTROSE 5% 4 B/D PA DEXTROSE 5%/LACTATED 4 RINGERS dextrose 5%/nacl 0.2% 4 B/D PA dextrose 5%/nacl 0.225% 4 B/D PA DEXTROSE 5%/NACL 0.3% 4 B/D PA dextrose 5%/nacl 0.33% 4 B/D PA dextrose 5%/nacl 0.45% 4 B/D PA dextrose 5%/nacl 0.9% 4 B/D PA dextrose 5%/potassium 4 B/D PA chloride 0.15% dextrose 5%/sodium chloride 4 B/D PA 0.2% dextrose 5%/sodium chloride 4 B/D PA 0.45% DEXTROSE 50% 4 B/D PA DEXTROSE 70% 4 B/D PA fluoride chew 0.25mg, 1.1mg, 1 2.2mg fluoritab chew 0.5mg, 1mg 1 CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 51

54 Covered Drugs By Category NAME NAME FREAMINE HBC 6.9% 4 B/D PA FREAMINE III INJ 4 B/D PA 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML HEPATAMINE 4 B/D PA k-sol 2 kcl 0.075%/d5w/nacl 0.45% 4 B/D PA kcl 0.15%/d5w/ nacl 0.3% 4 B/D PA kcl 0.15%/d5w/lr 4 B/D PA kcl 0.15%/d5w/nacl 0.2% 4 B/D PA kcl 0.15%/d5w/nacl 0.225% 4 B/D PA kcl 0.15%/d5w/nacl 0.45% 4 B/D PA kcl 0.15%/d5w/nacl 0.9% 4 B/D PA KCL 0.3%/D5W/LR IV LAC 4 B/D PA RING kcl 0.3%/d5w/nacl 0.45% 4 B/D PA kcl 0.3%/d5w/nacl 0.9% 4 B/D PA klor-con 2 klor-con 10 1 klor-con 8 1 klor-con m10 1 klor-con m20 1 klor-con sprinkle 2 LACTATED RINGERS 4 DEXTROSE 5% VIAFLEX LACTATED RINGERS INJ 4 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L LACTATED RINGERS 4 VIAFLEX ludent 1 MAGNESIUM SULFATE INJ 4 B/D PA 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML magnesium sulfate inj 50% 4 B/D PA MOZOBIL 5 QL(9.6/30) NEPHRAMINE 4 B/D PA NORMOSOL -R 4 B/D PA NORMOSOL-M IN D5W 4 B/D PA NORMOSOL-R 4 B/D PA NORMOSOL-R IN D5W 4 B/D PA NUTRILYTE INJ 2.03MEQ/ 4 B/D PA ML; 0.25MEQ/ML; 1.68MEQ/ ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ PERIKABIVEN 4 B/D PA phospha 250 neutral 2 PLENAMINE 4 B/D PA potassium chloride 0.15% /nacl 4 B/D PA 0.45% viaflex potassium chloride 0.15% d5w/ 4 B/D PA nacl 0.33% potassium chloride 0.15% d5w/ 4 B/D PA nacl 0.45% potassium chloride 0.15% d5w/ 4 B/D PA nacl 0.45% viaflex potassium chloride 0.15% w/ 4 B/D PA nacl 0.9% viaflex potassium chloride 0.15%/d5w 4 B/D PA potassium chloride 0.15%/nacl 4 B/D PA 0.9% potassium chloride 0.22% d5w/ 4 B/D PA nacl 0.45% potassium chloride 0.224%/ 4 B/D PA d5w/nacl 0.45% potassium chloride 0.3%/ nacl 4 B/D PA 0.9% potassium chloride 0.3%/d5w 4 B/D PA potassium chloride 0.3%/nacl 4 B/D PA 0.9%/viaflex potassium chloride cr 1 potassium chloride er cpcr 2 potassium chloride er tbcr 1 52

55 Covered Drugs By Category NAME potassium chloride inj 4 B/D PA 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml potassium chloride oral soln 2 potassium chloride pack 2 potassium chloride sr 1 potassium citrate er 2 PREMASOL INJ 52MEQ/L; 4 B/D PA 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol inj 56meq/l; 4 B/D PA 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml PROCALAMINE 4 B/D PA PROSOL 4 B/D PA RINGERS INJECTION 4 sodium chloride 0.45% viaflex 4 sodium chloride inj 0.9%, 4 2.5meq/ml, 3%, 5% sodium fluoride chew 0.5mg, 1 1mg sodium fluoride tabs 1 TPN ELECTROLYTES 4 B/D PA TRAVASOL 4 B/D PA CAPITALIZED = BRAND NAME QL = Quantity Limits listed as (qty/days) PA = Prior Authorization may be required You can find more information on the symbols by going to page 4. NAME TROPHAMINE 4 B/D PA virt-phos 250 neutral 2 Therapeutic Nutrients/Minerals/Electrolytes INTRALIPID 4 B/D PA KABIVEN 4 B/D PA NUTRILIPID 4 B/D PA Vitamins VP-PNV-DHA 3 Needles And Syringes Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents bd eclipse syringe/1ml/30gx1/2 2 QL(200/30) bd insulin syringe 2 QL(200/30) safetyglide/1ml/29g x 1/2 bd insulin syringe 2 QL(200/30) ultrafine/0.3ml/31g x 5/16 bd insulin syringe 2 QL(200/30) ultrafine/0.5ml/30g x 1/2 bd insulin syringe 2 QL(200/30) ultrafine/1ml/31g x 5/16 bd pen needle/mini/ 2 QL(200/30) ultrafine/31g x 3/16 bd pen needle/nano/ultra 2 QL(200/30) fine/32g x 4mm bd pen needle/ultrafine/29g x 12.7mm 2 QL(200/30) Lower case italic = Generic drug ST = Step Therapy rules apply B/D = Drugs covered under Medicare Part B or Part D 53

56 Covered Drugs Index PAGE PAGE PAGE A abacavir...31 abacavir sulfate/lamivudine/ zidovudine...31 ABELCET...24 ABILIFY MAINTENA INJ 300MG...29 ABILIFY MAINTENA INJ 400MG...29 ABRAXANE...26 acamprosate calcium dr...17 acarbose...32 acebutolol hcl...35 acetaminophen/caffeine/ dihydrocodeine...15 acetaminophen/codeine # acetaminophen/codeine # acetaminophen/codeine # acetaminophen/codeine oral soln..15 acetaminophen/codeine phosphate tabs 300mg; 60mg...16 acetaminophen/codeine tabs 300mg; 15mg...16 acetaminophen/codeine tabs 300mg; 60mg...16 acetasol hc...48 acetazolamide...36 acetazolamide er...48 acetazolamide sodium...36 acetic acid...48 acetic acid/aluminum acetate...48 acetylcysteine inhalation soln...50 acitretin...38 ACTHIB...46 ACTIMMUNE...46 acyclovir...31 acyclovir sodium inj 50mg/ml...31 ADACEL...46 ADAGEN...38 adefovir dipivoxil...30 ADEMPAS...50 adrucil...25 afeditab cr...35 AFINITOR DISPERZ TBSO 2MG, 3MG...27 AFINITOR DISPERZ TBSO 5MG...27 AFINITOR TABS 2.5MG, 5MG, 7.5MG...27 AFINITOR TABS 10MG...27 AGGRENOX...34 a-hydrocort...40 ala cort...40 ALA SCALP...40 ALBENZA...28 albuterol...49 albuterol sulfate er...49 albuterol sulfate nebu 0.5%...49 albuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml...49 albuterol sulfate nebu 0.083%...49 albuterol sulfate syrp...49 albuterol sulfate tabs...49 alclometasone dipropionate...40 alcohol prep pads...17 ALDURAZYME...38 ALECENSA...27 alendronate sodium tabs 10mg, 40mg, 5mg...47 alendronate sodium tabs 35mg, 70mg...47 alfuzosin hcl er...40 ALIMTA INJ 500MG...25 ALINIA...28 allopurinol...24 ALOCRIL...48 ALOPRIM...24 ALORA...42 alosetron hydrochloride...39 ALOXI...23 alprazolam odt tbdp 0.25mg, 0.5mg...32 alprazolam odt tbdp 1mg...32 alprazolam odt tbdp 2mg alprazolam tabs 0.25mg, 0.5mg...32 alprazolam tabs 1mg...32 alprazolam tabs 2mg...32 altavera...42 alyacen 1/ alyacen 7/7/ amantadine hcl...31 AMBISOME...24 amcinonide...40 amethia...42 amethia lo...42 amifostine...26 amikacin sulfate...17 amiloride hcl...36 amiloride/hydrochlorothiazide...36 aminophylline...50 AMINOSYN 7%/ELECTROLYTES..50 AMINOSYN 8.5%/ ELECTROLYTES...50 AMINOSYN-HBC...51 AMINOSYN II...50 AMINOSYN II 8.5%/ ELECTROLYTES...51 AMINOSYN INJ 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML...51 AMINOSYN M...51 AMINOSYN-PF...51 AMINOSYN-PF 7%...51 AMINOSYN-RF...51 amiodarone hcl inj...34 amiodarone hcl tabs...34 AMITIZA...39 amitriptyline hcl...23 amlodipine besylate...35

57 Covered Drugs Index PAGE PAGE PAGE amlodipine besylate/ benazepril hydrochloride...35 amlodipine besylate/valsartan...35 amlodipine/valsartan/hctz...35 ammonium lactate...38 amoxapine...23 amoxicillin caps...19 amoxicillin chew...19 amoxicillin/clavulanate potassium. 19 amoxicillin/clavulanate potassium er...19 amoxicillin susr...19 amoxicillin tabs...19 amphetamine/ dextroamphetamine cp amphetamine/ dextroamphetamine tabs...37 amphotericin b...24 ampicillin...19 ampicillin sodium...19 ampicillin-sulbactam...19 AMPYRA...38 ANADROL anagrelide hydrochloride...33 anaspaz...39 anastrozole...26 ANDROGEL...42 ANDROGEL PUMP GEL 1.62%...42 ANDROXY...42 APOKYN...28 apraclonidine...48 apri...42 APRISO...47 APTIOM TABS 200MG, 400MG, 800MG...21 APTIOM TABS 600MG...21 APTIVUS...31 ARALAST NP INJ 500MG...50 aranelle...42 ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML...33 ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML...33 ARCALYST...46 aripiprazole odt...29 aripiprazole oral soln...29 aripiprazole tabs...29 ARISTADA INJ 441MG/1.6ML...29 ARISTADA INJ 662MG/2.4ML...29 ARISTADA INJ 882MG/3.2ML...29 ARRANON...25 ascomp/codeine...16 aspirin/dipyridamole...34 ASTAGRAF XL...45 atenolol...35 atenolol/chlorthalidone...35 ATGAM...46 atorvastatin calcium...36 atovaquone...28 atovaquone/proguanil hcl...28 ATRIPLA...31 atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 0.4mg/ml, 1mg/ml...39 atropine sulfate ophthalmic soln ATROVENT HFA...49 aubra...42 augmented betamethasone dipropionate...40 AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML...19 AURYXIA...40 AVASTIN...27 AVELOX INJ aviane...42 AVODART AVONEX...38 AVONEX PEN...38 azacitidine...26 AZACTAM IN ISO-OSMOTIC DEXTROSE...19 AZASAN...45 AZASITE...19 azathioprine tabs...45 azelastine hcl nasal soln azelastine hcl ophthalmic soln...48 AZILECT...28 azithromycin inj...19 azithromycin pack azithromycin susr 100mg/5ml...19 azithromycin susr 200mg/5ml...19 azithromycin tabs...19 AZOPT...48 aztreonam...19 azurette...42 B baciim...17 bacitracin inj...17 bacitracin ophthalmic oint bacitracin/polymyxin b...17 baclofen tabs 10mg...30 baclofen tabs 20mg...30 BACTROBAN NASAL...17 balsalazide disodium...47 balziva...42 BANZEL SUSP...21 BANZEL TABS 200MG...21 BANZEL TABS 400MG...21 BARACLUDE ORAL SOLN...30 bd safetyglide 27g x 5/ bekyree...42 BELEODAQ...26 benazepril hcl...34 benazepril hcl/ hydrochlorothiazide...34

58 Covered Drugs Index PAGE PAGE PAGE BENDEKA...25 BENICAR...34 BENICAR HCT...34 BENLYSTA...45 benztropine mesylate inj benztropine mesylate tabs...28 BESIVANCE...20 betamethasone dipropionate...40 betamethasone valerate...40 betaxolol hcl...35 betaxolol hcl...48 bethanechol chloride...40 bexarotene...27 BEXSERO...46 bicalutamide...25 BICILLIN L-A...19 BICNU...25 BIDIL...37 bimatoprost...48 bisoprolol fumarate...35 bisoprolol fumarate/ hydrochlorothiazide...35 BIVIGAM...46 bleomycin sulfate...26 BLEPHAMIDE...20 BLEPHAMIDE S.O.P blisovi fe 1.5/ blisovi fe 1/ BOOSTRIX...46 BOSULIF...27 briellyn...42 BRILINTA...34 brimonidine tartrate ophthalmic soln 0.2%...48 brimonidine tartrate ophthalmic soln 0.15%...48 BRINTELLIX...22 bromfenac...48 bromocriptine mesylate...28 budesonide cpep...47 budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml...49 budesonide susp 32mcg/act...49 bumetanide inj...36 bumetanide tabs 0.5mg, 1mg...36 bumetanide tabs 2mg...36 BUPHENYL TABS...38 buprenorphine hcl inj...17 buprenorphine hcl/naloxone hcl...17 buprenorphine hcl subl...17 buproban...17 bupropion hcl...22 bupropion hcl er tb12 100mg, 200mg...22 bupropion hcl er tb12 150mg...22 bupropion hcl sr tb12 100mg, 200mg...22 bupropion hcl sr tb12 150mg...17 bupropion hcl sr tb12 150mg...22 bupropion hcl xl tb24 150mg...22 bupropion hcl xl tb24 300mg...22 buspirone hcl tabs 10mg, 5mg...32 buspirone hcl tabs 15mg, 30mg, 7.5mg...32 BUSULFEX...25 butalbital/acetaminophen/ caffeine caps...15 butalbital/acetaminophen/ caffeine/codeine...16 butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg...15 butalbital/aspirin/caffeine...15 butalbital/aspirin/caffeine/codeine..16 butorphanol tartrate inj...16 butorphanol tartrate nasal soln...16 BYDUREON...32 BYETTA...32 BYSTOLIC TABS 2.5MG, 5MG...35 BYSTOLIC TABS 10MG...35 BYSTOLIC TABS 20MG C cabergoline...45 cafergot...24 calcipotriene...38 calcitonin-salmon...47 calcitrene...38 calcitriol caps...47 calcitriol inj...47 calcitriol oint...38 calcitriol oral soln...47 calcium acetate caps...40 calcium acetate tabs 667mg...40 camila...44 CANCIDAS...24 candesartan cilexetil...34 candesartan cilexetil/ hydrochlorothiazide...34 CAPASTAT SULFATE...25 CAPRELSA...27 captopril...34 captopril/hydrochlorothiazide...34 CARAC...38 CARAFATE SUSP...40 CARBAGLU...51 carbamazepine...21 carbamazepine er...21 carbidopa...28 carbidopa/levodopa...28 carbidopa/levodopa/entacapone...28 carbidopa/levodopa er...28 carbidopa/levodopa odt...28 carboplatin...26 carteolol hcl...48 cartia xt...35 carvedilol...35 CAYSTON...49 caziant...42 cefaclor...18 cefaclor er...18

59 Covered Drugs Index PAGE PAGE PAGE cefadroxil...18 CEFAZOLIN...18 cefazolin sodium/dextrose inj 2gm; 3%...18 cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg...18 cefdinir...18 cefepime...18 cefixime...18 cefotaxime sodium inj 1gm, 2gm, 500mg...18 cefotetan...19 cefoxitin sodium inj 10gm, 1gm, 2gm...19 cefpodoxime proxetil...19 cefprozil...19 ceftazidime...19 ceftazidime/dextrose...19 ceftriaxone in iso-osmotic dextrose..19 ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg...19 cefuroxime axetil...19 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm...19 celecoxib...15 CELLCEPT INTRAVENOUS...45 CELONTIN...21 cephalexin caps 250mg, 500mg...19 cephalexin susr...19 cephalexin tabs...19 CEREZYME...38 CERVARIX...46 CHANTIX...17 CHANTIX CONTINUING MONTH PAK...17 CHANTIX STARTING MONTH PAK. 17 chateal...42 CHEMET...50 chloramphenicol sodium succinate..17 chlorhexidine gluconate oral rinse..38 chloroquine phosphate...28 chlorothiazide...36 chlorothiazide sodium...36 chlorpromazine hcl inj 50mg/2ml...28 chlorpromazine hcl tabs...28 chlorthalidone tabs 25mg, 50mg...36 cholestyramine...37 cholestyramine light...37 chorionic gonadotropin...42 ciclodan...24 ciclopirox nail lacquer...24 ciclopirox olamine...24 ciclopirox sham...24 ciclopirox susp...24 cidofovir...30 cilostazol...34 CILOXAN OINT...20 cimetidine...39 cimetidine hcl...39 CINRYZE...45 CIPRODEX...20 ciprofloxacin er...20 ciprofloxacin hcl ophthalmic soln...20 ciprofloxacin hcl tabs 100mg, 750mg...20 ciprofloxacin hcl tabs 250mg, 500mg...20 ciprofloxacin inj 400mg/40ml...20 ciprofloxacin i.v.-in d5w...20 ciprofloxacin susr...20 CIPRO HC...20 cisplatin...26 citalopram hydrobromide oral soln...22 citalopram hydrobromide tabs 10mg, 20mg...22 citalopram hydrobromide tabs 40mg...22 cladribine...25 claravis...38 clarithromycin...19 clarithromycin er clindacin etz pledgets...17 clindacin-p...17 clindamax...17 clindamycin hcl...18 clindamycin phosphate add-vantage...18 clindamycin phosphate crea...18 clindamycin phosphate external soln clindamycin phosphate gel...18 clindamycin phosphate in d5w...18 clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml...18 clindamycin phosphate lotn...18 clindamycin phosphate pharmacy bulk package...18 clindamycin phosphate swab...18 CLINIMIX 2.75%/DEXTROSE 5%..51 CLINIMIX 4.25%/DEXTROSE 5%..51 CLINIMIX 4.25%/DEXTROSE 10%. 51 CLINIMIX 4.25%/DEXTROSE 20%. 51 CLINIMIX 4.25%/DEXTROSE 25%. 51 CLINIMIX 5%/DEXTROSE 15%...51 CLINIMIX 5%/DEXTROSE 20%...51 CLINIMIX 5%/DEXTROSE 25%...51 CLINIMIX E 2.75%/ DEXTROSE 10%...51 CLINIMIX E 4.25%/ DEXTROSE 10%...51 CLINIMIX E 4.25%/ DEXTROSE 25%...51 CLINIMIX E 5%/DEXTROSE 25%..51 CLINISOL SF 15%...51 clobetasol propionate crea clobetasol propionate e...40 clobetasol propionate emollient...40 clobetasol propionate external soln clobetasol propionate foam...40 clobetasol propionate gel...40 clobetasol propionate oint...41

60 Covered Drugs Index PAGE PAGE PAGE clobetasol propionate sham clodan...41 CLOLAR...25 clomipramine hcl...23 clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg...21 clonazepam odt tbdp 2mg...21 clonazepam tabs 0.5mg, 1mg...21 clonazepam tabs 2mg...21 clonidine hcl er...37 clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr...34 clonidine hcl ptwk 0.3mg/24hr...34 clonidine hcl tabs 0.1mg, 0.2mg...34 clonidine hcl tabs 0.3mg...34 clopidogrel tabs 75mg...34 clopidogrel tabs 300mg...34 clorazepate dipotassium tabs 3.75mg, 7.5mg...32 clorazepate dipotassium tabs 15mg...32 clotrimazole/betamethasone dipropionate...24 clotrimazole external crea...24 clotrimazole external soln clotrimazole troc...24 clozapine...30 clozapine odt...30 COARTEM...28 colchicine...24 COLCRYS...24 colestipol hcl gran colestipol hcl tabs...37 colistimethate sodium...18 colocort...47 COMBIGAN...48 COMBIVENT RESPIMAT...49 COMETRIQ...27 compazine supp...28 COMPLERA...30 compro...28 constulose...39 COPAXONE INJ 40MG/ML...38 COREG CR...35 cormax scalp application...41 cortisone acetate...41 CORTISPORIN-TC...48 COSMEGEN...26 COTELLIC...27 CREON...38 CRESTOR...36 CRIXIVAN...31 cromolyn sodium conc...39 cromolyn sodium nebu...50 cromolyn sodium ophthalmic soln...48 cryselle CUBICIN...18 CUPRIMINE...50 curity gauze pads 2 x cyclafem 1/ cyclafem 7/7/ cyclobenzaprine hcl tabs 10mg, 5mg...50 cyclophosphamide caps...25 cyclophosphamide inj...25 cycloserine...25 CYCLOSET...32 cyclosporine caps...45 cyclosporine inj...45 cyclosporine modified...45 CYRAMZA...27 cyred...42 CYSTADANE...38 CYSTAGON...39 cytarabine...25 cytarabine aqueous...26 D dacarbazine...25 DALIRESP danazol...42 dantrolene sodium...30 dapsone...25 DAPTACEL...46 DARAPRIM...28 DARZALEX...27 dasetta 1/ dasetta 7/7/ daunorubicin hcl...26 DAUNOXOME...26 deblitane...44 decitabine...26 DELESTROGEN...42 delyla...42 DELZICOL...47 demeclocycline hcl...20 DEMSER...36 DENAVIR...31 DEPEN TITRATABS...50 DEPO-ESTRADIOL...42 DEPO-MEDROL INJ 20MG/ML...41 DEPO-PROVERA...44 DESCOVY...31 desipramine hcl...23 desloratadine...49 desloratadine odt...49 desmopressin acetate inj...42 desmopressin acetate nasal soln..42 desmopressin acetate tabs...42 desogestrel/ethinyl estradiol...42 desonide lotn...41 desonide oint...41 desoximetasone crea...41 desoximetasone gel...41 desoximetasone oint 0.25%...41 dexamethasone elix...41 dexamethasone intensol...41 dexamethasone oral soln...41 dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml...41

61 Covered Drugs Index PAGE PAGE PAGE dexamethasone sodium phosphate inj 20mg/5ml, 4mg/ml...41 dexamethasone sodium phosphate ophthalmic soln...48 dexamethasone tabs 0.5mg, 0.75mg, 4mg...41 dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg...41 DEXILANT...40 dexmethylphenidate hcl...37 dexrazoxane...26 dextroamphetamine sulfate er cp24 10mg, 5mg...37 dextroamphetamine sulfate er cp24 15mg...37 dextroamphetamine sulfate oral soln...37 dextroamphetamine sulfate tabs 5mg...37 dextroamphetamine sulfate tabs 10mg...37 dextrose 2.5%/nacl 0.45%...51 dextrose 2.5%/ sodium chloride 0.45%...51 DEXTROSE 5%...51 dextrose 5% / electrolyte #48 viaflex...51 DEXTROSE 5%/ LACTATED RINGERS...51 dextrose 5%/nacl 0.2%...51 DEXTROSE 5%/NACL 0.3%...51 dextrose 5%/nacl 0.9%...51 dextrose 5%/nacl 0.33%...51 dextrose 5%/nacl 0.45%...51 dextrose 5%/nacl 0.225%...51 dextrose 5%/ potassium chloride 0.15%...51 dextrose 5%/ sodium chloride 0.2%...51 dextrose 5%/ sodium chloride 0.45%...51 DEXTROSE 10% FLEX CONTAINER...51 dextrose 10%/nacl 0.2%...51 dextrose 10%/nacl 0.45%...51 DEXTROSE 20%...51 DEXTROSE 25%...51 DEXTROSE 30%...51 DEXTROSE 40%...51 DEXTROSE 50%...51 DEXTROSE 70%...51 diazepam gel...21 diazepam inj 5mg/ml...32 diazepam oral soln...32 diazepam tabs...32 DIBENZYLINE...34 diclofenac potassium...15 diclofenac sodium dr tbec 25mg, 50mg...15 diclofenac sodium dr tbec 75mg...15 diclofenac sodium er...15 diclofenac sodium gel 1%...38 diclofenac sodium ophthalmic soln..48 diclofenac sodium transdermal soln...38 dicloxacillin sodium...19 dicyclomine hcl caps...39 dicyclomine hcl oral soln dicyclomine hcl tabs didanosine...31 diflorasone diacetate...41 diflunisal...15 digitek tabs 0.25mg...36 digitek tabs 0.125mg...36 digoxin inj...36 digoxin tabs 125mcg...36 digoxin tabs 250mcg...36 digox tabs 125mcg...36 digox tabs 250mcg...36 dihydroergotamine mesylate inj...24 DILANTIN CAPS 30MG...21 diltiazem cd...35 diltiazem hcl er diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml...35 diltiazem hcl tabs...35 dilt-xr...35 diphenhydramine hcl inj...49 diphenoxylate/atropine...39 DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC...46 disulfiram...17 divalproex sodium...21 divalproex sodium dr...21 divalproex sodium er...21 DOCEFREZ INJ 20MG...26 docetaxel...26 donepezil hcl tabs 10mg...22 donepezil hcl tabs 23mg, 5mg...22 donepezil hcl tbdp 5mg...22 donepezil hcl tbdp 10mg...22 dorzolamide hcl...48 dorzolamide hcl/timolol maleate...48 doxazosin mesylate tabs 1mg, 2mg, 4mg...40 doxazosin mesylate tabs 8mg...40 doxepin hcl...23 doxepin hydrochloride...38 doxercalciferol caps...47 doxercalciferol inj...47 doxorubicin hcl...26 doxy doxycycline caps 75mg...20 doxycycline hyclate caps...20 doxycycline hyclate inj doxycycline hyclate tabs 20mg...20 doxycycline hyclate tabs 100mg...20 doxycycline monohydrate...20 doxycycline susr...20 dronabinol...23 DROXIA...26 DULERA...49

62 Covered Drugs Index PAGE PAGE PAGE duloxetine hcl cpep 20mg, 60mg...22 duloxetine hcl cpep 30mg...22 DURAMORPH...15 DUREZOL...48 dutasteride...40 dutasteride/tamsulosin hydrochloride...40 E econazole nitrate...24 EDECRIN...36 ed-spaz...39 EDURANT...30 e.e.s E.E.S. GRANULES...20 EFFIENT TABS 5MG...34 EFFIENT TABS 10MG...34 ELAPRASE...39 ELIDEL...38 ELIGARD INJ 7.5MG...45 ELIGARD INJ 22.5MG...45 ELIGARD INJ 30MG...45 ELIGARD INJ 45MG...45 elinest...43 ELIQUIS TABS 2.5MG...33 ELIQUIS TABS 5MG...33 ELITEK...26 ELLA...44 ELMIRON...40 EMCYT...25 EMEND CAPS EMEND CAPS 40MG...23 EMEND CAPS 80MG...23 EMEND CAPS 125MG...23 emoquette...43 EMPLICITI...27 EMSAM PT24 6MG/24HR, 9MG/24HR...22 EMSAM PT24 12MG/24HR...22 EMTRIVA...31 enalapril maleate...34 enalapril maleate/ hydrochlorothiazide...34 ENBREL...45 ENBREL SURECLICK...45 endocet...16 ENGERIX-B...46 enoxaparin sodium inj 30mg/0.3ml...33 enoxaparin sodium inj 40mg/0.4ml...33 enoxaparin sodium inj 60mg/0.6ml...33 enoxaparin sodium inj 80mg/0.8ml...33 enoxaparin sodium inj 100mg/ml, 150mg/ml...33 enoxaparin sodium inj 120mg/0.8ml...33 enoxaparin sodium inj 300mg/3ml...33 enpresse enskyce...43 entacapone...28 entecavir...30 ENTRESTO...34 enulose...39 ENVARSUS XR...45 epinastine hcl...48 epinephrine hcl...49 EPIPEN 2-PAK...49 EPIPEN-JR 2-PAK...49 epirubicin hcl inj 50mg/25ml...26 epirubicin hcl inj 200mg/100ml...26 epitol...21 EPIVIR HBV ORAL SOLN...30 EPZICOM...31 ERBITUX...27 ergoloid mesylates...22 ERIVEDGE...27 errin...44 ERWINAZE...26 ery...20 ERYPED ERYPED ERY-TAB...20 ERYTHROCIN LACTOBIONATE..20 erythrocin stearate...20 erythromycin base...20 erythromycin/benzoyl peroxide...38 erythromycin ethylsuccinate...20 erythromycin external soln...20 erythromycin gel...20 erythromycin oint...20 erythromycin pads...20 ESBRIET...50 escitalopram oxalate...22 esgic caps...15 esomeprazole magnesium...40 esomeprazole sodium...40 estarylla...43 estradiol/norethindrone acetate...43 estradiol pttw...43 estradiol ptwk...43 estradiol tabs...43 estradiol valerate...43 ESTRING...43 ethacrynate sodium...36 ethambutol hcl...25 ethosuximide...21 etidronate disodium...47 etodolac...15 etodolac er...15 ETOPOPHOS...27 etoposide inj...27 EVOMELA...25 EVOTAZ...31 EXELON PT exemestane...26 EXJADE...50 F FABRAZYME...39 falmina...43

63 Covered Drugs Index PAGE PAGE PAGE famciclovir...31 famotidine inj...39 famotidine premixed...39 famotidine tabs 20mg...39 famotidine tabs 40mg...39 FANAPT TABS 1MG, 2MG, 4MG...29 FANAPT TABS 10MG, 12MG, 6MG, 8MG...29 FANAPT TITRATION PACK...29 FARESTON...25 FARYDAK...27 FASLODEX...25 FAZACLO TBDP 100MG, 12.5MG, 25MG...30 felbamate...21 felodipine er...35 FEMRING...43 fenofibrate caps fenofibrate micronized...36 fenofibrate tabs 145mg, 160mg, 48mg, 54mg...36 fenofibric acid dr...36 fenoprofen calcium...15 fentanyl...15 fentanyl citrate inj 100mcg/2ml...16 fentanyl citrate oral transmucosal...16 FERRIPROX...47 FETZIMA...22 FETZIMA TITRATION PACK...22 finasteride tabs 5mg...40 FIRAZYR...45 FIRMAGON INJ 80MG...45 FIRMAGON INJ 120MG...45 flavoxate hcl...40 FLEBOGAMMA DIF...46 flecainide acetate...35 FLOVENT DISKUS AEPB 100MCG/BLIST...49 FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/BLIST...49 FLOVENT HFA AERO 44MCG/ACT...49 FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT...49 fluconazole in dextrose...24 fluconazole in nacl...24 fluconazole susr...24 fluconazole tabs 100mg, 200mg, 50mg...24 fluconazole tabs 150mg...24 flucytosine...24 fludarabine phosphate...26 fludrocortisone acetate...41 flunisolide...49 fluocinolone acetonide body...41 fluocinolone acetonide crea fluocinolone acetonide ear drops..41 fluocinolone acetonide external soln fluocinolone acetonide oil fluocinolone acetonide oint...41 fluocinolone acetonide scalp...41 fluocinonide...41 fluocinonide-e...41 fluoride chew 0.25mg, 1.1mg, 2.2mg...51 fluoritab chew 0.5mg, 1mg...51 fluorometholone...48 fluorouracil crea 0.5%...38 fluorouracil crea 5%...38 fluorouracil external soln fluorouracil inj fluoxetine...23 fluoxetine dr...23 fluoxetine hcl caps...23 fluoxetine hcl oral soln fluoxetine hcl tabs 10mg, 20mg...23 fluphenazine decanoate...28 fluphenazine hcl conc...28 fluphenazine hcl elix...28 fluphenazine hcl inj fluphenazine hcl tabs 1mg...28 fluphenazine hcl tabs 10mg, 2.5mg, 5mg...28 flurbiprofen...15 flurbiprofen sodium...48 flutamide...25 fluticasone propionate crea...41 fluticasone propionate oint...41 fluticasone propionate susp fluvastatin caps 20mg...36 fluvastatin caps 40mg...36 fluvoxamine maleate...23 fluvoxamine maleate er cp24 100mg...23 fluvoxamine maleate er cp24 150mg...23 FOLOTYN...26 fomepizole...47 fondaparinux sodium inj 2.5mg/0.5ml...33 fondaparinux sodium inj 5mg/0.4ml...33 fondaparinux sodium inj 7.5mg/0.6ml...33 fondaparinux sodium inj 10mg/0.8ml...33 FORADIL AEROLIZER...49 FORTEO...47 fosinopril sodium...34 fosinopril sodium/ hydrochlorothiazide...34 fosphenytoin sodium...21 FREAMINE HBC 6.9% FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML...52

64 Covered Drugs Index PAGE PAGE PAGE furosemide inj...36 furosemide oral soln...36 furosemide tabs FUSILEV...26 FUZEON...31 FYCOMPA...21 G gabapentin...21 GABITRIL TABS 12MG...21 GABITRIL TABS 16MG...21 galantamine hydrobromide cp galantamine hydrobromide oral soln...22 galantamine hydrobromide tabs GAMASTAN S/D...46 GAMMAGARD LIQUID INJ 2.5GM/25ML, 30GM/300ML...46 GAMMAKED...46 GAMMAPLEX INJ 10GM/200ML, 5GM/100ML...46 GAMUNEX-C...46 ganciclovir inj...30 GARDASIL...46 GARDASIL GATTEX...39 gavilyte-c...39 gavilyte-g...39 gavilyte-n/flavor pack...40 GAZYVA...27 gemcitabine...26 gemcitabine hcl inj 1gm, 200mg, 2gm...26 gemfibrozil...36 generlac...40 gengraf...45 gentak...17 gentamicin sulfate/ 0.9% sodium chloride...17 gentamicin sulfate crea...17 gentamicin sulfate inj...17 gentamicin sulfate oint...17 gentamicin sulfate ophthalmic soln...17 gentamicin sulfate pediatric...17 GENVOYA...30 GEODON INJ...29 gildagia...43 gildess 1.5/ gildess 1/ gildess fe 1.5/ gildess fe 1/ GILOTRIF...27 glatopa...38 GLEEVEC...27 GLEOSTINE...25 glimepiride tabs 1mg, 2mg...32 glimepiride tabs 4mg...32 glipizide...32 glipizide er...32 glipizide/metformin hcl...32 glipizide xl...32 GLUCAGEN HYPOKIT...32 glycopyrrolate inj...39 glycopyrrolate tabs...39 glydo...16 GLYSET...32 granisetron hcl inj 0.1mg/ml, 1mg/ml...23 granisetron hcl inj 1mg/ml...23 granisetron hcl tabs...23 griseofulvin microsize...24 griseofulvin ultramicrosize...24 GUANIDINE HCL H HALAVEN...26 halobetasol propionate...41 haloperidol conc...28 haloperidol decanoate haloperidol lactate...28 haloperidol tabs 0.5mg, 1mg, 2mg, 5mg...28 haloperidol tabs 10mg, 20mg...28 HARVONI...30 HAVRIX...46 heather...44 heparin sodium/d5w...33 heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 2000unit/ml, 2500unit/ml, 5000unit/ml...33 heparin sodium/nacl 0.9%...33 heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%...33 heparin sodium/ sodium chloride 0.9%...33 heparin sodium/ sodium chloride 0.9% premix...33 HEPATAMINE...52 HERCEPTIN...27 HETLIOZ...37 HEXALEN...25 HUMALOG...32 HUMALOG KWIKPEN...32 HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN..32 HUMALOG MIX 75/ HUMALOG MIX 75/25 KWIKPEN. 33 HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML...45 HUMIRA INJ 40MG/0.8ML...45 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK...45 HUMIRA PEN...45 HUMIRA PEN-CROHNS DISEASESTARTER...45 HUMIRA PEN-PSORIASIS STARTER...45 HUMULIN 70/ HUMULIN 70/30 KWIKPEN...33 HUMULIN N...33

65 Covered Drugs Index PAGE PAGE PAGE HUMULIN N KWIKPEN...33 HUMULIN R...33 HUMULIN R U-500 (CONCENTRATED)...33 HUMULIN R U-500 KWIKPEN...33 hydralazine hcl inj...37 hydralazine hcl tabs...37 hydrochlorothiazide caps...36 hydrochlorothiazide tabs 12.5mg...36 hydrochlorothiazide tabs 25mg, 50mg...36 hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg...16 hydrocodone bitartrate/ acetaminophen oral soln 325mg/15ml; 7.5mg/15ml...16 hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg...16 hydrocodone bitartrate/ acetaminophen tabs 325mg; 2.5mg...16 hydrocodone/ibuprofen...16 hydrocortisone/acetic acid...48 hydrocortisone butyrate...41 hydrocortisone butyrate (lipophilic)..41 hydrocortisone enem...47 hydrocortisone external crea hydrocortisone in absorbase...41 hydrocortisone lotn 2.5%...41 hydrocortisone oint 1%, 2.5%...41 hydrocortisone tabs...41 hydrocortisone valerate...41 hydromorphone hcl dosette...16 hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml...16 hydromorphone hcl liqd...16 hydromorphone hcl tabs...16 hydroxychloroquine sulfate...28 hydroxyurea...26 hyoscyamine sulfate elix hyoscyamine sulfate odt...39 hyoscyamine sulfate subl...39 hyoscyamine sulfate tabs hyoscyamine sulfate tbdp hyosyne elix...39 I ibandronate sodium tabs...47 IBRANCE...26 ibudone tabs 5mg; 200mg...16 ibuprofen susp...15 ibuprofen tabs 400mg, 600mg, 800mg...15 ICLUSIG...27 idarubicin hcl inj 10mg/10ml...26 ifosfamide...25 ILARIS...46 ILEVRO...48 ilotycin...20 imatinib mesylate...27 IMBRUVICA...27 imipenem/cilastatin...19 imipramine hcl...23 imipramine pamoate...23 imiquimod...38 IMOVAX RABIES (H.D.C.V.)...46 INCRELEX...42 indapamide...36 INFANRIX...46 INFUMORPH INFUMORPH INLYTA TABS 1MG...27 INLYTA TABS 5MG...27 INTELENCE TABS 25MG...30 INTELENCE TABS 100MG...30 INTELENCE TABS 200MG...30 INTRALIPID...47 INTRALIPID...53 INTRON A INJ 10MU, 10MU/ML, 18MU INTRON A INJ 50MU, UNIT/ML...30 INTRON A W/DILUENT INJ 10MU, 18MU...30 INTRON A W/DILUENT INJ 50MU...30 introvale...43 INVANZ...19 INVEGA SUSTENNA INJ 39MG/0.25ML...29 INVEGA SUSTENNA INJ 78MG/0.5ML...29 INVEGA SUSTENNA INJ 117MG/0.75ML...29 INVEGA SUSTENNA INJ 156MG/ML...29 INVEGA SUSTENNA INJ 234MG/1.5ML...29 INVEGA TB24 1.5MG, 3MG...29 INVEGA TB24 6MG...29 INVEGA TB24 9MG...29 INVEGA TRINZA INJ 273MG/0.875ML...29 INVEGA TRINZA INJ 410MG/1.315ML...29 INVEGA TRINZA INJ 546MG/1.75ML...29 INVEGA TRINZA INJ 819MG/2.625ML...29 INVIRASE...31 INVOKAMET...32 INVOKANA...32 IPOL INACTIVATED IPV...46 ipratropium bromide/ albuterol sulfate...49 ipratropium bromide inhalation soln...49 ipratropium bromide nasal soln 0.03%...49 ipratropium bromide nasal soln 0.06%...49 irbesartan...34 irbesartan/hydrochlorothiazide...34 IRESSA...27

66 Covered Drugs Index PAGE PAGE PAGE irinotecan...26 ISENTRESS CHEW 25MG...30 ISENTRESS CHEW 100MG...30 ISENTRESS PACK...30 ISENTRESS TABS isoniazid inj...25 isoniazid syrp...25 isoniazid tabs 100mg...25 isoniazid tabs 300mg...25 isosorbide dinitrate er...37 isosorbide dinitrate tabs...37 isosorbide mononitrate...37 isosorbide mononitrate er...37 isotonic gentamicin...17 isradipine...35 ISTODAX...26 itraconazole...24 ivermectin...28 IXEMPRA KIT...26 IXIARO...46 J JADENU...50 JAKAFI...27 JALYN...40 jantoven...33 JANUMET...32 JANUMET XR TB MG; 50MG, 500MG; 50MG...32 JANUMET XR TB MG; 100MG...32 JANUVIA...32 jencycla...44 JENTADUETO...32 JEVTANA...26 juleber...43 junel 1.5/ junel 1/ junel fe 1.5/ junel fe 1/ K KABIVEN...53 KADCYLA...27 KALETRA ORAL SOLN...31 KALETRA TABS 100MG; 25MG...31 KALETRA TABS 200MG; 50MG...31 KALYDECO...50 kariva...43 KCL 0.3%/D5W/LR IV LAC RING..52 kcl 0.3%/d5w/nacl 0.9%...52 kcl 0.3%/d5w/nacl 0.45%...52 kcl 0.15%/d5w/lr...52 kcl 0.15%/d5w/nacl 0.2%...52 kcl 0.15%/d5w/ nacl 0.3%...52 kcl 0.15%/d5w/nacl 0.9%...52 kcl 0.15%/d5w/nacl 0.45%...52 kcl 0.15%/d5w/nacl 0.225%...52 kcl 0.075%/d5w/nacl 0.45%...52 kelnor 1/ KETEK...20 ketoconazole crea...24 ketoconazole sham...24 ketoconazole tabs ketoprofen...15 ketoprofen er...15 ketorolac tromethamine ophthalmic soln...48 KEYTRUDA...27 kimidess...43 KINERET...45 KINRIX...46 kionex...50 klor-con...52 klor-con klor-con klor-con m klor-con m klor-con sprinkle...52 KORLYM k-sol...52 kurvelo...43 KUVAN...39 KYNAMRO...37 L labetalol hcl inj...35 labetalol hcl tabs...35 LACRISERT...48 LACTATED RINGERS DEXTROSE 5% VIAFLEX...52 LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L...52 LACTATED RINGERS IRRIGATION...47 LACTATED RINGERS VIAFLEX..52 lactulose...40 lamivudine...30 lamivudine...31 lamivudine/zidovudine...31 lamotrigine...21 lamotrigine er...21 lamotrigine odt...21 LANOXIN PEDIATRIC...36 lansoprazole...40 lansoprazole/amoxicillin/ clarithromycin...18 LANTUS...33 LANTUS SOLOSTAR...33 larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ latanoprost...48 LATUDA TABS 80MG...29 LATUDA TABS 120MG, 20MG, 40MG, 60MG...29 LAZANDA...16 leflunomide...46 LENVIMA 10MG DAILY DOSE...27

67 Covered Drugs Index PAGE PAGE PAGE LENVIMA 14MG DAILY DOSE...27 LENVIMA 20MG DAILY DOSE...27 LENVIMA 24MG DAILY DOSE...27 lessina...43 LETAIRIS...50 letrozole...26 leucovorin calcium inj 100mg, 350mg, 500mg, 50mg...26 leucovorin calcium tabs...26 LEUKERAN...25 LEUKINE INJ 250MCG...33 leuprolide acetate...45 LEVEMIR...33 LEVEMIR FLEXTOUCH...33 levetiracetam er...21 levetiracetam inj...21 levetiracetam oral soln...21 levetiracetam tabs...21 levobunolol hcl ophthalmic soln 0.5%...48 levocarnitine inj...47 levocarnitine oral soln...47 levocarnitine tabs...47 levocetirizine dihydrochloride oral soln...49 levocetirizine dihydrochloride tabs...49 levofloxacin in d5w...20 levofloxacin inj...20 levofloxacin oral soln...20 levofloxacin tabs...20 levoleucovorin calcium...26 levoleucovorin inj 250mg/25ml...26 levonest...43 levonorgestrel and ethinyl estradiol tabs 0; levonorgestrel/ethinyl estradiol...43 levora 0.15/ levorphanol tartrate...15 levothyroxine sodium tabs...44 LEVOXYL...44 LEXIVA SUSP...31 LEXIVA TABS lidocaine hcl external soln...16 lidocaine hcl gel lidocaine hcl inj...17 lidocaine hcl inj...35 lidocaine hcl jelly...17 lidocaine hcl mouth/throat soln...17 lidocaine hcl viscous...17 lidocaine oint...17 lidocaine/prilocaine crea...17 lidocaine ptch...17 lidocaine viscous...17 LINCOCIN...18 lincomycin hcl...18 lindane...28 linezolid inj 600mg/300ml...18 linezolid susr...18 linezolid tabs...18 LINZESS...39 liothyronine sodium inj liothyronine sodium tabs LIPOFEN...36 lisinopril...34 lisinopril/hydrochlorothiazide...34 lithium carbonate caps 150mg, 600mg...32 lithium carbonate caps 300mg...32 lithium carbonate er...32 lithium carbonate tabs...32 LONSURF TABS 6.14MG; 15MG...26 LONSURF TABS 8.19MG; 20MG...26 loperamide hcl caps...39 lopreeza...43 lorazepam conc lorazepam inj 2mg/ml, 4mg/ml...32 lorazepam intensol...32 lorazepam tabs...32 lorcet...16 lorcet hd lorcet plus tabs 325mg; 7.5mg...16 lortab tabs...16 losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg...34 losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg...34 losartan potassium tabs 25mg...34 losartan potassium tabs 50mg...34 losartan potassium tabs 100mg...34 LOTEMAX...48 lovastatin tabs 10mg, 20mg...36 lovastatin tabs 40mg...36 low-ogestrel...43 loxapine...28 loxapine succinate...28 ludent...52 LUMIGAN...48 LUMIZYME...39 LUPRON DEPOT INJ 3.75MG, 7.5MG...45 LUPRON DEPOT INJ 11.25MG...45 LUPRON DEPOT INJ 22.5MG...45 LUPRON DEPOT INJ 30MG...45 LUPRON DEPOT INJ 45MG...45 LUPRON DEPOT-PED...45 lutera...43 LYNPARZA...26 LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG...21 LYRICA CAPS 225MG, 300MG...21 LYRICA ORAL SOLN LYSODREN...44 lyza...44 M MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML...52

68 Covered Drugs Index PAGE PAGE PAGE magnesium sulfate inj 50%...52 MAKENA...44 malathion...28 maprotiline hcl...22 margesic...15 marlissa...43 MARPLAN...22 MATULANE...25 matzim la...35 meclizine hcl tabs...23 meclofenamate sodium...15 MEDROL TABS 2MG...41 medroxyprogesterone acetate inj...44 medroxyprogesterone acetate tabs..44 mefloquine hcl...28 megestrol acetate susp 40mg/ml...44 megestrol acetate tabs...44 MEKINIST...27 meloxicam tabs...15 melphalan hydrochloride...25 memantine hcl tabs 5mg...22 memantine hcl tabs 10mg...22 memantine hcl titration pak...22 memantine hydrochloride...22 MENACTRA...46 MENEST...43 MENOMUNE-A/C/Y/W MENOSTAR...43 MENVEO...46 mercaptopurine...26 meropenem...19 mesalamine...47 mesna...26 MESNEX TABS...26 MESTINON TIMESPAN metadate er...37 metaproterenol sulfate...49 metformin hcl...32 metformin hcl er tb24 500mg, 750mg...32 methadone hcl conc methadone hcl inj...15 methadone hcl intensol...15 methadone hcl oral soln 5mg/5ml...15 methadone hcl oral soln 10mg/5ml..15 methadone hcl tabs...15 methazolamide...48 methenamine hippurate...18 methimazole...45 methotrexate...46 methotrexate sodium inj 1gm, 1gm/40ml, 250mg/10ml, 50mg/2ml...46 methoxsalen...38 methscopolamine bromide...39 methylphenidate hcl er tbcr 10mg...37 methylphenidate hcl er tbcr 20mg...37 methylphenidate hcl sr...37 methylphenidate hcl tabs...37 methylprednisolone...41 methylprednisolone acetate...41 methylprednisolone dose pack...41 methylprednisolone sodiumsuccinate inj 125mg, 40mg...41 metipranolol...48 metoclopramide hcl inj...39 metoclopramide hcl oral soln...39 metoclopramide hcl tabs 5mg...39 metoclopramide hcl tabs 10mg...39 metolazone...36 metoprolol/hydrochlorothiazide...35 metoprolol succinate er...35 metoprolol tartrate inj metoprolol tartrate tabs...35 metronidazole crea metronidazole gel...18 metronidazole inj metronidazole in nacl 0.79%...18 metronidazole lotn...18 metronidazole tabs metronidazole vaginal mexiletine hcl...35 MIACALCIN INJ...47 microgestin 1.5/ microgestin 1/ microgestin fe...43 microgestin fe 1.5/ midodrine hcl...34 migergot...24 mimvey...43 mimvey lo...43 minitran...37 MINIVELLE...43 minocycline hcl...20 minoxidil...37 mirtazapine...22 mirtazapine odt...22 misoprostol...40 mitomycin...26 mitoxantrone hcl...26 M-M-R II...46 modafinil tabs 100mg...50 modafinil tabs 200mg...50 moderiba 800 dose pack...30 moderiba 1200 dose pack...30 moderiba misc...30 moderiba tabs...30 moexipril hcl...34 moexipril/hydrochlorothiazide...34 molindone hydrochloride...30 mometasone furoate crea...41 mometasone furoate external soln..41 mometasone furoate oint...41 mondoxyne nl...20 mono-linyah...43 montelukast sodium...49 morgidox 1x100mg caps...20 morgidox 2x100mg caps...20 MORPHINE SULFATE ADD-VANTAGE...16 morphine sulfate er tbcr...15

69 Covered Drugs Index PAGE PAGE PAGE morphine sulfate inj 0.5mg/ml, 1mg/ml...15 morphine sulfate inj 4mg/ml...16 MORPHINE SULFATE INJ 10MG/ML, 150MG/30ML, 15MG/ML, 1MG/ML, 25MG/ML, 2MG/ML, 4MG/ML, 50MG/ML, 8MG/ML...16 morphine sulfate oral soln 10mg/5ml...16 morphine sulfate oral soln 20mg/5ml...16 morphine sulfate oral soln 100mg/5ml...16 MORPHINE SULFATE TABS...16 MOVIPREP...40 MOXEZA...20 moxifloxacin hcl inj...20 moxifloxacin hcl tabs...20 MOZOBIL...52 MULTAQ...35 mupirocin...18 MUSTARGEN...25 mycophenolate mofetil...46 mycophenolic acid dr...46 myorisan...38 myzilra...43 N nabumetone...15 nadolol/bendroflumethiazide...35 nadolol tabs 20mg, 40mg...35 nadolol tabs 80mg...35 nafcillin sodium...19 naftifine hcl...24 naftifine hydrochloride...24 NAFTIN...24 NAGLAZYME...39 nalbuphine hcl...16 naloxone hcl...17 naltrexone hcl...17 NAMENDA ORAL SOLN...22 NAMENDA TABS 5MG...22 NAMENDA TABS 10MG...22 NAMENDA TITRATION PAK...22 NAMENDA XR...22 NAMENDA XR TITRATION PACK. 22 NAMZARIC...22 naphazoline hcl...48 naproxen dr...15 naproxen sodium tabs 275mg, 550mg...15 naproxen susp...15 naproxen tabs 250mg...15 naproxen tabs 375mg, 500mg...15 naratriptan hcl...24 NATACYN...24 nateglinide...32 NATPARA...47 NEBUPENT...28 necon 0.5/ necon 1/ necon 1/ necon 7/7/ necon 10/ nefazodone hcl...22 neomycin/bacitracin/polymyxin...18 neomycin/polymyxin/ bacitracin/hydrocortisone...18 neomycin/polymyxin b sulfates...17 neomycin/polymyxin/ dexamethasone...48 neomycin/polymyxin/gramicidin...18 neomycin/polymyxin/hc...48 neomycin/polymyxin/ hydrocortisone...18 neomycin/polymyxin/ hydrocortisone...49 neomycin sulfate...17 NEPHRAMINE...52 NEULASTA...34 NEUPOGEN...34 NEUPRO nevirapine er...30 nevirapine susp...30 nevirapine tabs...31 NEXAVAR...27 niacin er tbcr 500mg...37 niacin er tbcr 1000mg, 750mg...37 niacor...37 nicardipine hcl caps...35 nicardipine hcl inj...35 NICOTROL INHALER...17 NICOTROL NS...17 nifedical xl...35 nifedipine er...35 NILANDRON...25 nimodipine...35 NINLARO...26 NIPENT...26 nisoldipine...35 nisoldipine er...35 nitrofurantoin...18 nitrofurantoin macrocrystals caps 100mg, 50mg...18 nitrofurantoin monohydrate...18 nitrofurantoin monohydrate/ macrocrystals...18 nitroglycerin...37 nitroglycerin lingual translingual soln...37 nitroglycerin transdermal...37 NITROSTAT...37 nizatidine caps norethindrone...44 norethindrone acetate...44 norethindrone acetate/ethinyl estradiol/ferrous fumarate...43 norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg...43 norgestimate/ethinyl estradiol...43 NORITATE...18 norlyroc...44 NORMOSOL-M IN D5W...52

70 Covered Drugs Index PAGE PAGE PAGE NORMOSOL -R...52 NORMOSOL-R...52 NORMOSOL-R IN D5W...52 NORTHERA...36 nortrel 0.5/35 (28)...43 nortrel 1/ nortrel 7/7/ nortriptyline hcl caps...23 nortriptyline hcl oral soln NORVIR...31 NOVAREL...42 novofine 30gx8mm...47 novofine novofine 32gx6mm...47 novofine autocover 30gx8mm...47 novotwist 30gx8mm...47 novotwist 32gx5mm...47 NOXAFIL SUSP...24 NOXAFIL TBEC...24 NUEDEXTA...37 nulev...39 NULOJIX...46 NUTRILIPID...53 NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ...52 NUVIGIL...50 nyamyc...24 nystatin crea nystatin oint...24 nystatin powd unit/gm...24 nystatin susp...24 nystatin tabs...24 nystatin/triamcinolone...24 nystop...24 Needles and Syringes bd eclipse syringe/1ml/30gx1/ bd insulin syringe safetyglide/ 1ml/29g x 1/ bd insulin syringe ultrafine/ 0.3ml/31g x 5/ bd insulin syringe ultrafine/ 0.5ml/30g x 1/ bd insulin syringe ultrafine/ 1ml/31g x 5/ bd pen needle/mini/ultrafine/ 31g x 3/ bd pen needle/nano/ultra fine/ 32g x 4mm...53 bd pen needle/ultrafine/ 29g x 12.7mm...53 O OCTAGAM INJ 2GM/20ML...46 OCTAGAM INJ 10GM/100ML, 1GM/20ML, 20GM/200ML, 5GM/50ML...46 octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml...45 octreotide acetate inj 1000mcg/ml, 500mcg/ml...45 ODEFSEY...31 ODOMZO...26 ofloxacin...20 ogestrel...43 olanzapine/fluoxetine...23 olanzapine inj...29 olanzapine odt...29 olanzapine tabs...29 olopatadine hcl ophthalmic soln...48 OLYSIO...30 omega-3-acid ethyl esters...37 omeprazole cpdr...40 ONCASPAR...26 ondansetron hcl inj 40mg/20ml, 4mg/2ml...23 ondansetron hcl oral soln...23 ondansetron hcl tabs 4mg, 8mg...23 ondansetron hcl tabs 24mg...23 ondansetron odt...23 ONFI SUSP ONFI TABS 10MG...21 ONFI TABS 20MG...21 OPDIVO...27 OPSUMIT...50 oralone...38 ORAP...28 ORFADIN...39 orphenadrine citrate er...50 orsythia...43 oscimin...39 OSMOPREP...39 oxacillin sodium...19 oxaliplatin...26 oxandrolone tabs 2.5mg...42 oxandrolone tabs 10mg...42 oxaprozin...15 oxazepam...32 oxcarbazepine...21 oxybutynin chloride...40 oxybutynin chloride er tb24 5mg...40 oxybutynin chloride er tb24 10mg, 15mg...40 oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg...16 oxycodone/aspirin...16 oxycodone hcl caps...16 oxycodone hcl conc...16 oxycodone hcl oral soln...16 oxycodone hcl tabs...16 oxycodone/ibuprofen...16 oxymorphone hydrochloride er...15 P pacerone...35 paclitaxel...26 paliperidone er tb24 1.5mg, 3mg...29 paliperidone er tb24 6mg...29 paliperidone er tb24 9mg...29 pamidronate disodium...47

71 Covered Drugs Index PAGE PAGE PAGE PANRETIN...27 pantoprazole sodium tbec...40 paricalcitol caps paroex...38 paromomycin sulfate...17 paroxetine hcl er tb mg...23 paroxetine hcl er tb24 25mg...23 paroxetine hcl er tb mg...23 paroxetine hcl tabs 10mg...23 paroxetine hcl tabs 20mg...23 paroxetine hcl tabs 30mg, 40mg...23 PASER...25 PATADAY...48 PAXIL SUSP PAZEO...48 PEDVAX HIB...46 peg 3350/electrolytes...40 peg-3350/electrolytes...40 peg-3350/nacl/na bicarbonate/kcl..40 PEGANONE...21 PEGINTRON...30 PEG-INTRON REDIPEN...30 PEG-INTRON REDIPEN PAK penicillin g potassium inj unit, unit...19 penicillin v potassium oral soln...19 penicillin v potassium tabs 250mg...19 penicillin v potassium tabs 500mg...19 PENTAM pentoxifylline er...36 PERFOROMIST...49 PERIKABIVEN...52 perindopril erbumine...34 periogard...38 PERJETA...27 permethrin...28 perphenazine...28 perphenazine/amitriptyline...23 pfizerpen-g...19 phenazopyridine hcl...40 phenelzine sulfate...22 phenobarbital...21 phenoxybenzamine hydrochloride..34 phenytoin...21 phenytoin infatabs...22 phenytoin sodium...22 phenytoin sodium extended...22 philith...43 PHOSLYRA...40 phospha 250 neutral...52 PHOSPHOLINE IODIDE...48 PHYSIOLYTE...47 PHYSIOSOL IRRIGATION...47 PICATO...38 pilocarpine hcl ophthalmic soln pilocarpine hcl tabs...38 pilocarpine hydrochloride...38 pimozide...28 pimtrea...44 pindolol...35 pioglitazone hcl...32 pioglitazone hcl-glimepiride...32 pioglitazone hcl/metformin hcl...32 piperacillin sodium/ tazobactam sodium...19 piperacillin sodium/ tazobactam sodium...19 piperacillin/tazobactam...19 pirmella 1/ pirmella 7/7/ piroxicam...15 PLENAMINE...52 podofilox...38 polycin...48 polyethylene glycol 3350 powd polymyxin b sulfate...18 polymyxin b sulfate/ trimethoprim sulfate...18 POMALYST...25 portia PORTRAZZA...26 potassium chloride 0.3%/d5w...52 potassium chloride 0.3%/ nacl 0.9%...52 potassium chloride 0.3%/ nacl 0.9%/viaflex...52 potassium chloride 0.15%/d5w...52 potassium chloride 0.15% d5w/ nacl 0.33%...52 potassium chloride 0.15% d5w/ nacl 0.45%...52 potassium chloride 0.15% d5w/ nacl 0.45% viaflex...52 potassium chloride 0.15%/ nacl 0.9%...52 potassium chloride 0.15% / nacl 0.45% viaflex...52 potassium chloride 0.15% w/ nacl 0.9% viaflex...52 potassium chloride 0.22% d5w/ nacl 0.45%...52 potassium chloride 0.224%/d5w/ nacl 0.45%...52 potassium chloride cr...52 potassium chloride er cpcr...52 potassium chloride er tbcr...52 potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml...53 potassium chloride oral soln...53 potassium chloride pack...53 potassium chloride sr...53 potassium citrate er...53 POTIGA...21 PRADAXA...33 pramipexole dihydrochloride...28 pramipexole dihydrochloride er tb mg, 0.75mg, 1.5mg...28 pramipexole dihydrochloride er tb mg, 3mg, 4.5mg...28 pravastatin sodium tabs 10mg, 20mg...36 pravastatin sodium tabs 40mg...36

72 Covered Drugs Index PAGE PAGE PAGE pravastatin sodium tabs 80mg...36 prazosin hcl...34 PRED-G...48 PRED-G S.O.P PRED MILD...48 prednicarbate oint prednisolone acetate...48 prednisolone oral soln...41 prednisolone sodium phosphate ophthalmic soln...48 prednisolone sodium phosphate oral soln...41 prednisone intensol...41 prednisone oral soln...41 prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg...41 prednisone tabs 50mg...41 prednisone tbpk PREGNYL W/DILUENT BENZYL ALCOHOL/NACL...42 PREMARIN CREA...44 PREMARIN INJ PREMARIN TABS...44 PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML...53 premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml...53 premium lidocaine...17 prevalite...37 previfem...44 PREZCOBIX...31 PREZISTA SUSP...31 PREZISTA TABS 75MG...31 PREZISTA TABS 150MG...31 PREZISTA TABS 600MG...31 PREZISTA TABS 800MG...31 PRIMAQUINE PHOSPHATE...28 primidone...21 PRIMSOL...18 PRISTIQ...23 PRIVIGEN INJ 10GM/100ML, 20GM/200ML, 5GM/50ML...46 PROAIR HFA...49 PROAIR RESPICLICK...49 probenecid...24 probenecid/colchicine...24 PROCALAMINE...53 prochlorperazine...28 prochlorperazine edisylate...28 prochlorperazine maleate tabs 5mg...29 prochlorperazine maleate tabs 10mg...28 PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML...34 PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML...34 procto-pak...41 proctosol hc...41 proctozone-hc...42 progesterone caps...44 PROGLYCEM...32 PROGRAF INJ...46 PROLASTIN-C...50 PROLEUKIN...26 PROLIA...47 PROMACTA...34 promethazine hcl plain...23 promethazine hcl syrp promethazine hcl tabs...23 propafenone hcl...35 propafenone hcl er...35 propantheline bromide...39 proparacaine hcl...48 propranolol hcl er...35 propranolol hcl inj...35 propranolol hcl oral soln...35 propranolol hcl tabs 10mg, 20mg, 40mg, 80mg...35 propranolol hcl tabs 60mg...35 propranolol/hydrochlorothiazide...35 propylthiouracil...45 PROQUAD...46 PROSOL...53 protriptyline hcl...23 PRUDOXIN...38 PULMOZYME...50 PURIXAN...26 pyrazinamide...25 pyridostigmine bromide...25 Q QUADRACEL...46 quasense...44 quetiapine fumarate...29 quinapril hcl...34 quinapril/hydrochlorothiazide...34 quinidine sulfate...35 quinine sulfate...28 QVAR...49 R RABAVERT...46 raloxifene hydrochloride...44 ramipril...34 RANEXA TB12 500MG...36 RANEXA TB MG...36 ranitidine hcl caps....39

73 Covered Drugs Index PAGE PAGE PAGE ranitidine hcl inj 150mg/6ml...39 ranitidine hcl syrp...39 ranitidine hcl tabs...39 RAPAMUNE ORAL SOLN...46 REBETOL ORAL SOLN...30 REBIF...38 REBIF REBIDOSE...38 REBIF REBIDOSE TITRATION PACK...38 REBIF TITRATION PACK...38 reclipsen...44 RECOMBIVAX HB...46 REGONOL...25 REGRANEX...38 RELISTOR INJ 8MG/0.4ML...39 RELISTOR INJ 12MG/0.6ML...39 REMICADE...46 REMODULIN...50 RENVELA PACK RENVELA TABS...40 repaglinide...32 REPATHA...37 REPATHA SURECLICK...37 reprexain tabs 10mg; 200mg...16 RESCRIPTOR...31 RESTASIS...48 RETROVIR IV INFUSION...31 REVLIMID...25 REXULTI...29 REYATAZ...31 ribasphere caps RIBASPHERE RIBAPAK...30 ribasphere tabs 200mg...30 RIBASPHERE TABS 400MG...30 RIBASPHERE TABS 600MG...30 ribavirin...30 RIDAURA...46 rifabutin...25 rifampin caps...25 rifampin inj...25 RIFATER...25 riluzole...37 rimantadine hcl...31 RINGERS INJECTION RINGERS IRRIGATION...47 RIOMET...32 risedronate sodium tabs 30mg, 5mg...47 risedronate sodium tabs 35mg...47 risedronate sodium tabs 150mg...47 RISPERDAL CONSTA INJ 12.5MG, 25MG...29 RISPERDAL CONSTA INJ 37.5MG, 50MG...29 risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg...29 risperidone m-tab tbdp 4mg...29 risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg...29 risperidone odt tbdp 4mg...29 risperidone oral soln...29 risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg...29 risperidone tabs 4mg...29 RITUXAN INJ 500MG/50ML...27 rivastigmine tartrate...22 rivastigmine transdermal system..22 rizatriptan benzoate...24 rizatriptan benzoate odt...24 ropinirole hcl...28 rosadan...18 rosuvastatin calcium...37 ROTARIX...46 ROTATEQ...46 roxicet tabs...16 ROZEREM...50 S SABRIL PACK...21 SABRIL TABS...21 SAIZEN SAIZEN CLICK.EASY...42 salsalate...15 SAMSCA TABS 15MG...50 SAMSCA TABS 30MG...50 SANDIMMUNE ORAL SOLN...46 SANDOSTATIN LAR DEPOT SANTYL...38 SAPHRIS...29 selegiline hcl...28 selenium sulfide lotn...38 SELZENTRY TABS 150MG...31 SELZENTRY TABS 300MG...31 SENSIPAR TABS 30MG...44 SENSIPAR TABS 60MG...44 SENSIPAR TABS 90MG...44 SEREVENT DISKUS...49 SEROQUEL XR TB24 150MG, 200MG...29 SEROQUEL XR TB24 300MG, 400MG, 50MG...30 sertraline hcl conc sertraline hcl tabs 25mg...23 sertraline hcl tabs 50mg...23 sertraline hcl tabs 100mg...23 setlakin...44 sharobel...44 SIGNIFOR...45 sildenafil tabs...50 SILENOR...50 silver sulfadiazine...18 SIMBRINZA...48 SIMULECT...46 simvastatin tabs 10mg, 5mg...37 simvastatin tabs 20mg, 40mg, 80mg...37 sirolimus...46 SIRTURO...25 sodium bicarbonate inj...50 sodium bicarbonate partial fill...50 sodium chloride 0.9%...47

74 Covered Drugs Index PAGE PAGE PAGE sodium chloride 0.45% viaflex...53 sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%...53 SODIUM EDECRIN...36 sodium fluoride chew 0.5mg, 1mg...53 sodium fluoride tabs SODIUM LACTATE INJ 5MEQ/ML..50 sodium phenylbutyrate...39 sodium polystyrene sulfonate powd...50 sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml...50 sodium sulfacetamide ophthalmic soln...20 SOLTAMOX...25 SOLU-CORTEF...42 SOMATULINE DEPOT...45 SOMAVERT INJ 10MG...45 SOMAVERT INJ 15MG, 20MG...45 SOMAVERT INJ 25MG, 30MG...45 sorine...35 sotalol hcl...35 sotalol hcl (af)...35 SOVALDI...30 SPIRIVA HANDIHALER...49 SPIRIVA RESPIMAT...49 spironolactone/ hydrochlorothiazide...36 spironolactone tabs 25mg...36 spironolactone tabs 100mg, 50mg...36 SPORANOX ORAL SOLN...24 sprintec SPRITAM TB3D 750MG...21 SPRITAM TB3D 1000MG, 250MG, 500MG...21 SPRYCEL...27 sps...50 sronyx...44 SSD...18 stavudine...31 sterile water irrigation...47 STIMATE...42 STIOLTO RESPIMAT...50 STIVARGA...27 STRATTERA...37 streptomycin sulfate...17 STRIBILD...31 STRIVERDI RESPIMAT...49 SUBOXONE...17 sucralfate...40 sulfacetamide sodium ophthalmic soln...20 sulfacetamide sodium/ prednisolone sodium phosphate...20 sulfacetamide sodium susp...20 sulfadiazine...20 sulfamethoxazole/ trimethoprim ds...20 sulfamethoxazole/ trimethoprim inj...20 sulfamethoxazole/ trimethoprim susp...20 sulfamethoxazole/ trimethoprim tabs...20 sulfasalazine...47 sulfatrim pediatric...20 sulindac...15 sumatriptan...24 sumatriptan succinate inj...24 sumatriptan succinate refill...24 sumatriptan succinate tabs...24 SUPRAX SUSR 500MG/5ML...19 SUPREP BOWEL PREP...40 SURMONTIL...23 SUSTIVA...31 SUTENT...27 SYLATRON...26 symax fastabs...39 symax-sl...39 SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT...49 SYMLINPEN SYMLINPEN SYNAGIS INJ 50MG/0.5ML...46 SYNAREL...45 SYNERCID...18 SYNRIBO...26 SYNTHROID...44 SYPRINE...50 T TABLOID...26 tacrolimus caps...46 tacrolimus oint...38 TAFINLAR...27 TAGRISSO...27 TALWIN...16 TAMIFLU CAPS 30MG...31 TAMIFLU CAPS 45MG...31 TAMIFLU CAPS 75MG...31 TAMIFLU SUSR...31 tamoxifen citrate...25 tamsulosin hcl...40 TARCEVA...27 TARGRETIN...27 tarina fe 1/ TASIGNA...27 tazicef inj 1gm, 2gm, 6gm...19 TAZORAC CREA...38 TAZORAC GEL...38 taztia xt...35 TEFLARO...19 TEGRETOL-XR TB12 100MG...22 TEKTURNA...36 TEKTURNA HCT...36 telmisartan...34 telmisartan/amlodipine...34 telmisartan/hydrochlorothiazide...34

75 Covered Drugs Index PAGE PAGE PAGE temazepam...50 TENIVAC...46 terazosin hcl caps 1mg, 5mg...40 terazosin hcl caps 10mg, 2mg...40 terbinafine hcl tabs...24 terbutaline sulfate inj...49 terbutaline sulfate tabs...49 terconazole...24 TESTIM...42 testosterone cypionate...42 testosterone enanthate...42 testosterone gel 25mg/2.5gm...42 testosterone pump...42 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED...46 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT...46 tetrabenazine tabs 12.5mg...37 tetrabenazine tabs 25mg...38 tetracycline hcl...20 TEXACORT...42 THALOMID CAPS 100MG...25 THALOMID CAPS 150MG, 200MG, 50MG...25 THEO theochron...50 theophylline cr...50 theophylline er...50 thioridazine hcl...29 thiotepa...25 thiothixene caps 2mg...29 thiothixene caps 10mg, 1mg, 5mg...29 THYMOGLOBULIN...46 THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine hydrochloride tabs 2mg...21 tiagabine hydrochloride tabs 4mg...21 TIKOSYN...35 timolol maleate ophthalmic soln...48 timolol maleate tabs...35 TIVICAY...30 tizanidine hcl tabs...30 TOBI PODHALER...50 TOBRADEX OINT...48 tobramycin...50 tobramycin/dexamethasone...48 tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml, 80mg/2ml...17 tobramycin sulfate ophthalmic soln...17 TOBREX OINT...17 tolcapone...28 tolmetin sodium...15 tolterodine tartrate...40 topiramate...21 toposar...27 topotecan hcl inj 4mg...27 TORISEL...46 torsemide...36 TOUJEO SOLOSTAR...33 TPN ELECTROLYTES...53 TRACLEER...50 TRADJENTA...32 tramadol hcl...16 tramadol hcl er tb tramadol hydrochloride/ acetaminophen...16 trandolapril...34 tranexamic acid inj...34 tranexamic acid tabs...34 TRANSDERM-SCOP...23 tranylcypromine sulfate...22 TRAVASOL...53 TRAVATAN Z...48 trazodone hcl tabs 100mg, 150mg, 50mg...22 trazodone hcl tabs 300mg...22 TREANDA...25 TRECATOR...25 TRELSTAR INJ 3.75MG...45 TRELSTAR INJ 11.25MG...45 TRELSTAR MIXJECT INJ 3.75MG...45 TRELSTAR MIXJECT INJ 11.25MG...45 TRELSTAR MIXJECT INJ 22.5MG...45 TRESIBA FLEXTOUCH...33 tretinoin caps...27 tretinoin crea...38 tretinoin gel 0.01%, 0.025%...38 tretinoin microsphere...38 tretinoin microsphere pump...38 trezix caps 320.5mg; 30mg; 16mg...16 triamcinolone acetonide crea 0.1%...42 triamcinolone acetonide crea 0.025%, 0.5%...42 triamcinolone acetonide lotn...42 triamcinolone acetonide oint...42 triamcinolone acetonide pste...38 triamcinolone in orabase...38 triamterene/hydrochlorothiazide caps 25mg; 37.5mg...36 triamterene/hydrochlorothiazide caps 25mg; 50mg...36 triamterene/hydrochlorothiazide tabs...36 trianex...42 triderm...42 tri-estarylla...44 trifluoperazine hcl...29 trifluridine...31 trihexyphenidyl hcl...28 tri-legest fe...44 tri-linyah...44 trilyte...40 trimethoprim...18 trimethoprim sulfate/ polymyxin b sulfate

76 Covered Drugs Index PAGE PAGE PAGE trimipramine maleate...23 tri-previfem...44 TRISENOX...26 tri-sprintec...44 TRIUMEQ...31 trivora TROKENDI XR CP24 100MG, 25MG, 50MG...21 TROKENDI XR CP24 200MG...21 TROPHAMINE...53 tropicamide...48 TRULICITY...32 TRUMENBA...46 TRUVADA...31 TWINRIX...46 TYBOST...31 TYGACIL...18 TYKERB...27 TYPHIM VI...46 TYSABRI...38 TYZEKA...30 TYZINE PEDIATRIC NASAL DROPS...50 U ULORIC...24 UNITHROID...44 UNITUXIN...27 ursodiol...39 UVADEX...38 V VAGIFEM...44 valacyclovir hcl tabs 500mg...31 valacyclovir hcl tabs 1000mg...31 VALCHLOR...25 VALCYTE ORAL SOLN...30 valganciclovir...30 valproate sodium...21 valproic acid...21 valsartan...34 valsartan/hydrochlorothiazide...34 vancomycin hcl caps 125mg...18 vancomycin hcl caps 250mg...18 vancomycin hcl in dextrose...18 vancomycin hcl inj 1000mg, 10gm, 5000mg, 500mg, 750mg...18 vandazole...18 VAQTA...47 VARIVAX...47 VARIZIG INJ 125UNIT/1.2ML...47 VASCEPA...37 VECTIBIX INJ 100MG/5ML...27 VECTICAL...38 VELCADE...26 velivet...44 VELPHORO...40 VENCLEXTA STARTING PACK...26 VENCLEXTA TABS 10MG...26 VENCLEXTA TABS 50MG...26 VENCLEXTA TABS 100MG...26 venlafaxine hcl...23 venlafaxine hcl er cp venlafaxine hcl er tb24 150mg, 37.5mg, 75mg...23 verapamil hcl er...36 verapamil hcl inj...36 verapamil hcl sr cp24 360mg...36 verapamil hcl tabs 40mg...36 verapamil hcl tabs 120mg, 80mg...36 VERSACLOZ...30 VESICARE...40 vicodin es tabs 300mg; 7.5mg...16 vicodin hp tabs 300mg; 10mg...16 vicodin tabs 300mg; 5mg...16 VICTOZA...32 VIDEX PEDIATRIC...31 vienva...44 VIGAMOX VIIBRYD...23 VIIBRYD STARTER PACK...23 VIMPAT INJ...22 VIMPAT ORAL SOLN...22 VIMPAT TABS...22 vinblastine sulfate...26 vincasar pfs...26 vincristine sulfate...26 vinorelbine tartrate...26 viorele...44 VIRACEPT...31 VIRAMUNE XR TB24 100MG...31 VIRAZOLE...50 VIREAD...31 virt-phos 250 neutral...53 VITEKTA...30 VOLTAREN GEL...38 voriconazole inj...24 voriconazole susr...24 voriconazole tabs...24 VOTRIENT...27 VP-PNV-DHA...53 VPRIV...39 VRAYLAR CAPS VRAYLAR CPPK vyfemla...44 W warfarin sodium...33 WELCHOL...37 wera...44 X XALKORI...27 XARELTO STARTER PACK...33 XARELTO TABS 10MG, 20MG...33 XARELTO TABS 15MG...33 XARTEMIS XR...15 XENAZINE TABS 12.5MG...38

77 Covered Drugs Index PAGE PAGE PAGE XENAZINE TABS 25MG...38 XGEVA...47 XIFAXAN TABS 200MG...18 XIFAXAN TABS 550MG...18 XOLAIR...50 XTANDI...25 xylon...16 XYREM...50 Y YERVOY...27 YF-VAX...47 YONDELIS...25 Z zafirlukast...49 zaleplon...50 ZALTRAP...27 ZANOSAR...25 ZARXIO...34 ZAVESCA...39 zebutal caps 325mg; 50mg; 40mg...15 ZELBORAF...27 ZEMAIRA...50 zenatane...38 zenchent...44 ZENPEP...39 ZETIA...37 ZIAGEN ORAL SOLN...31 zidovudine...31 ZIOPTAN...48 ziprasidone hcl...30 ZIRGAN...30 ZMAX...20 zoledronic acid...47 ZOLINZA...26 zolpidem tartrate tabs...50 ZONALON...38 zonisamide...21 ZORTRESS TABS 0.5MG, 0.75MG...46 ZORTRESS TABS 0.25MG...46 ZOSTAVAX...47 ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML...19 zovia 1/35e...44 zovia 1/50e...44 ZOVIRAX CREA...31 ZYCLARA...38 ZYCLARA PUMP CREA 2.5%...38 ZYDELIG...27 ZYKADIA...27 ZYLET...17 ZYPREXA RELPREVV...30 ZYTIGA...25 ZYVOX SUSR

78 Notes 76

79

80 (TTY 711) October 1 February 14, 8 a.m. 8 p.m. local time, 7 days a week. From February 15 September 30, Monday Friday, 8 a.m. 8 p.m. local time, Saturday, 8 a.m. 6 p.m. local time. Messaging service used weekends, after hours, and on federal holidays. CignaHealthSpring.com This drug list was updated on June 1, For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit This information is available for free in other languages. Please call our customer service number at (TTY 711), 7 days a week, 8 a.m. - 8 p.m.. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al (TTY 711), 7 dias de la semana, 8 a.m. - 8 p.m. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc Cigna