ADVANTAGE CHOICE PHARMACY BENEFIT GUIDE. Effective January 1,

Transcription

1 ADVANTAGE CHOICE PHARMACY BENEFIT GUIDE Effective January, 20

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3 TABLE OF CONTENTS Advantage Choice Overview... Advantage Choice Contact Numbers... Understanding Coverage and Cost-sharing... 2 About Drugs... 2 Formulary Overview... 2 For Prospective Members... 2 Understanding Our Symbols... 3 Prior Authorization... 3 Step Therapy... 3 Quantity Limits... 3 Filling Your Prescription... 3 Retail... 3 Mail Order... 3 Provider...4 Filling Your Prescription When Traveling...4 Medication Supplies Not Covered by UPMC Health Plan...4 Advantage Choice Formulary... Medications Not Covered by Advantage Choice...26 Advantage Choice Brand/ Reference Guide... 27

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

6 UNDERSTANDING COVERAGE AND COST-SHARING Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. UPMC Health Plan s Pharmacy and Therapeutics (P&T) Committee researches and evaluates medications it may cover. Committee members include local doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug s safety, effectiveness, and cost. Advantage Choice prescription drugs are organized into five copayment tiers on the formulary: Tier is for generic medications. drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. Advantage Choice requires you to use a generic version of the drug if one is available. Tier 2 is for preferred-brand medications. UPMC Health Plan classifies these drugs as preferred because of their value and effectiveness. Tier 3 is for non-preferred brand medications. Tier 4 is for specialty medications, for which you will have the highest level of cost-sharing. medications usually treat complex and rare conditions and are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Tier is for select preventive medications. About Drugs drugs have the same active ingredients as their brand-name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. drugs have the same active ingredients as brandname drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brandname drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brandname drug. FORMULARY OVERVIEW The most commonly prescribed Advantage Choice drugs are listed in the formulary section of this booklet. For the latest information on the complete Advantage Choice formulary and other pharmacy benefits, visit our website at Select Advantage Choice to access the drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card or on page of this booklet. If you are a current UPMC Health Plan member, refer to your Schedule of Benefits for your copayment amounts. If you did not receive a Schedule of Benefits in your Welcome Kit, contact our Health Care Concierge team at the number on the back of your member ID card. Your member ID card should also list your copayment amounts. For Prospective Members If you are thinking about joining UPMC Health Plan and would like information about copayment amounts, review the Schedule of Benefits. If you did not receive a Schedule of Benefits, contact the UPMC Health Plan Health Care Concierge team at the number listed on page of this booklet. 2

7 UNDERSTANDING OUR SYMBOLS Prior Authorization You will see the symbol PA next to certain drugs on our formulary tables in this booklet. PA stands for prior authorization. If a drug requires prior authorization, the UPMC Health Plan Pharmacy Services Department must authorize the use of this drug before it will be covered. Drugs that require prior authorization are often: Newer drugs for which UPMC Health Plan wants to track usage. Drugs not used as a standard first option in treating a medical condition. Drugs with potential side effects that UPMC Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications. All compounded medications require prior authorization. Compounded Hormone Replacement Therapy and Compounded Narcotic Analgesics will not be covered by the Advantage Choice benefit. Step Therapy You will see the symbol ST next to certain drugs on the formulary tables in this booklet. ST stands for step therapy. Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. The preferred first course of treatment may be generic medications or drugs that are considered as the standard first-line treatment. Step therapy is built into the electronic system that checks your medication history. A drug with step therapy will be automatically approved if there is a record that you have already tried the preferred drug(s). If there is no record that you tried the preferred drug(s) in your medication history, your physician must submit relevant clinical information to the UPMC Health Plan Pharmacy Services Department before it will be covered. Quantity Limits You will see the symbol QL next to certain drugs on the formulary tables in this booklet. QL stands for quantity limits. Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed during a specified period of time. These limits are based on FDA guidelines, clinical literature, and manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. 3 For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Your physician can request an exception to the quantity limit through the UPMC Health Plan Pharmacy Services Department. Prescriptions for controlled substances and specialty medications are limited to a 30-day supply. FILLING YOUR PRESCRIPTION Retail UPMC Health Plan s network of retail pharmacies includes hundreds of locations independent pharmacies as well as multistore chains throughout the region. You can take your prescription to any pharmacy in the network. You must use 7 percent of your medication before you can get a refill. For specific pharmacy names, locations, and telephone numbers, visit or call our Health Care Concierge team. The phone number is listed on the back of your member ID card and on page of this booklet. Mail Order If you take maintenance medications for a chronic condition, you can get them through a mail order pharmacy. Maintenance medications are drugs that are taken on a regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma, high cholesterol, and more. With convenient mail-order service: You receive a 90-day supply of most drugs, plus refills, as prescribed by your doctor. You usually pay a lower out-of-pocket cost for a 90-day supply at a mail-order pharmacy than you would pay at a retail pharmacy. You get these drugs delivered right to your door. Most mail order prescriptions are written for a 90-day supply. If your doctor writes for a 30-day supply with two refills, the mail order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should indicate this on the mail-order form. For a first-time prescription or a new medication, UPMC Health Plan recommends that you try a 30-day supply of the drug from a retail pharmacy. That way your doctor has a

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

9 Effective January, 20 Select Select 8-MOP PA 4 medication abacavir abacavir/lamivudine/ zidovudine Abilify Maintena 4 medication PA, QL (ST < 2 years of age) Abilify PA, QL 2 (ST < 2 years of age) Abstral PA, QL 4 medication acarbose acebutolol acetaminophen/ caffeine/ dihydrocodeine QL acetaminophen/ codeine QL acetazolamide acetazolamide ER acetic acid acetylcysteine acitretin ST 4 medication Actemra PA, QL 4 medication Acthar gel PA, QL 4 medication Actimmune PA 4 medication Actonel ST, QL 3 alendronate, ibandronate, risedronate Acuvail QL 3 bromfenac, diclofenac, ketorolac acyclovir acyclovir ointment Adagen PA 4 medication adapalene (PA > 3 years of age) Adcirca PA, QL 4 medication Adderall XR QL (PA < 4 and 8 years of age) adefovir PA 4 medication Adempas PA, QL 4 medication Advair 2 Aerospan ST 3 Flovent, QVAR, Asmanex Afinitor PA, QL 4 medication Aggrenox 3 clopidogrel, dipyridamole, ticlopidine, Effient Alamast ST 3 azelastine, cromolyn, epinastine Albenza 2 albuterol QL alclometasone dipropionate Aldurazyme PA 4 medication alendronate Alferon N PA 4 medication alfuzosin er Alimta 4 medication Alinia 2 Alkeran 2 allopurinol Alocril ST 3 azelastine, cromolyn, epinastine Alomide ST 3 azelastine, cromolyn, epinastine Aloxi ST, QL 3 ondansetron Alphagan P 0.% 2 alprazolam alprazolam ODT ST alprazolam Alrex 3 fluorometholone, prednisolone Altabax 3 Altavera Alvesco ST 3 Asmanex, Flovent, QVAR Alyacen amantadine amcinonide ST betamethasone, fluocinonide Amethia Amethia Lo Amethyst Amevive PA, QL 4 medication amiodarone Amitiza QL 2 amitriptyline = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications

10 Effective January, 20 Select Select amlodipine/ atorvastatin amlodipine/ benazepril amlodipine besylate ammonium lactate Amnesteem amoxicillin amoxicillin/ clavulanate amoxicillin/ clavulanate ER amoxicillin capsule amphetamine salts QL (PA < 4 and 8 years of age) ampicillin capsule Ampyra PA, QL 4 medication Amturnide ST 2 Anadrol PA 3 anagrelide anastrozole Androderm PA 3 testosterone injection (PA), Androgel.62% (PA) Androgel % PA 3 testosterone injection (PA), Androgel.62% (PA) Androgel.62% PA 2 androxy PA testosterone injection (PA), Androgel.62% (PA) Anoro Ellipta 2 antipyrine/ benzocaine Anucort-HC Apidra ST, QL 3 Humalog, Novolog Apokyn PA, QL 4 medication apraclonidine Apri Apriso ER 2 Aptiom PA, QL 3 carbamazepine, oxcarazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide Aptivus 4 medication = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 6 Aralast NP PA 4 medication Aranelle Aranesp PA 4 medication arbinoxa Arcalyst PA, QL 4 medication Arcapta ST 3 Foradil, Serevent Armour Thyroid 3 levothyroxine, liothyronine Asacol HD 2 Asmanex 2 Atelvia ST, QL 3 alendronate, ibandronate, risedronate atenolol atenolol/ chlorthalidone atorvastatin atovaquone/proguanil PA atovaquone suspension Atripla 4 medication atropine drops Atrovent HFA 2 Aubagio PA, QL 4 medication Aubra aurodex auroguard Auvi-Q 2 Aveed PA 3 testosterone injection (PA), Androgel.62% (PA) Aviane Avodart 2 Avonex QL 4 medication Axert ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Axiron PA 3 testosterone injection (PA), Androgel.62% (PA) Azasite 3 erythromycin azathioprine azelastine Azilect 2 azithromycin QL

11 Effective January, 20 Select Select Azopt ST 3 dorzolamide Azurette baclofen balsalazide disodium Balziva Banzel PA 3 felbamate, lamotrigine, topiramate, valproate Baraclude PA 4 medication benazepril benazepril/ Benicar PA 3 candesartan, eprosartan, irbesartan, losartan, Edarbi (ST), telmisartan Benlysta PA 4 medication benzoyl peroxide benztropine Bepreve ST 3 azelastine, cromolyn, epinastine Berinert PA 4 medication Besivance 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin betamethasone Betaseron ST, QL 4 medication betaxolol bethanechol Bethkis QL 4 medication Betoptic S 3 betaxolol, carteolol, timolol Beyaz 2 bicalutamide bisoprolol bisoprolol/ Bivigam PA 4 medication Blephamide 3 sulfacetamide sodium/prednisolone sodium phosphate Bosulif PA, QL 4 medication Botox PA, QL 4 medication Breo Ellipta 2 Briellyn Brilinta QL 3 clopidogrel, Effient brimonidine tartrate Brintellix PA, QL 3 citalopram, paroxetine, sertraline, venlafaxine ER capsules, duloxetine (ST) bromfenac ophthalmic solution Brovana 3 Serevent, Foradil budeprion XL budesonide EC budesonide respules bumetanide bumetanide 0. mg tablet bumetanide mg tablet Buphenyl tablet PA 4 medication buprenorphine PA, QL buprenorphine/ naloxone tablet PA, QL 3 Suboxone film (PA), Zubsolv (PA) buproban bupropion bupropion XL buspirone butalbital/ acetaminophen/ caffeine butorphanol nasal spray QL Butrans PA, QL 3 Bydureon QL 2 Byetta ST, QL 3 Bydureon, Victoza Bystolic ST 3 atenolol, metoprolol, propranolol calcipotriene calcitriol calcium acetate Camila Campral 3 Camrese = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 7

12 Effective January, 20 Select Select Camrese Lo Canasa 3 balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol, mesalamine candesartan candesartan/ capecitabine PA 4 medication Caphosol 2 Caprelsa PA, QL 4 medication captopril/ captopril tablet Carbaglu PA 4 medication carbamazepine carbamazepine ER carbidopa/levodopa carbidopa/levodopa/ entacapone carbidopa ST Carimune NF PA 4 medication carisoprodol carteolol cartia XT carvedilol tablet Cayston QL 4 medication Caziant cefaclor cefadroxil cefdinir cefditoren ceftibuten cefpodoxime cefprozil Ceftin 3 cefaclor, cefprozil cefuroxime Celebrex ST, QL 3 NSAIDS (such as diclofenac, etodolac, ibuprofen, meloxicam, naproxen) Cellcept suspension 4 medication Cenestin ST 3 estradiol, estropipate, Premarin cephalexin cephalexin capsule Cerezyme PA 4 medication Cesamet ST 3 ondansetron Cesia cevimeline Chantix ST, QL Chateal chlordiazepoxide chlorhexidine rinse chloroquine PA chlorpromazine (PA < 2 years of age) chlorpropamide chlorthalidone chlorzoxazone cholestyramine chorionic gonadotropin 4 medication PA ciclopirox cilostazol Ciloxan 3 ciprofloxacin, gatifloxin, levofloxacin, ofloxacin cimetidine Cimzia PA, QL 4 medication Cinryze PA, QL 4 medication Cipro HC 3 ciprofloxacin Ciprodex 3 ciprofloxacin, dexamethasone ciprofloxacin ciprofloxacin 0.2% ear drops ciprofloxacin 20 mg tablet ciprofloxacin 00 mg tablet ciprofloxacin ER QL citalopram QL Claravis clarithromycin = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 8

13 Effective January, 20 Select Select clarithromycin ER clindamycin clindamycin/benzoyl peroxide gel PA clobetasol Cloderm ST 3 generic topical steroids clonazepam clonazepam ODT ST clonazepam clonidine clonidine ER ST, QL clonidine clopidogrel clorazepate clotrimazole clozapine (PA < 2 years of age) clozapine ODT ST, QL (PA < 2 years of age) Coartem 2 codeine sulfate Colcrys 2 colestipol Combigan 2 Combipatch QL 3 norethindroneestradiol, Jinteli, Prempro, Premphase Combivent Respimat 2 Cometriq PA, QL 4 medication Complera 4 medication constulose Copaxone QL 4 medication Cortisporin topical 3 Cosopt PF ST 3 dorzolamide-timolol Creon 2 Crestor PA 3 atorvastatin, lovastatin, pravastatin, simvastatin Crinone 4% gel 3 Crixivan 2 cromolyn Cryselle Cuprimine PA 4 medication Cuvposa (PA > 6 years of age) 4 medication Cyclafem cyclobenzaprine cyclopentolate cyclophosphamide Cycloset 3 bromocriptine cyclosporine cyclosporine modified cyproheptadine Cystadane powder PA 4 medication Cystagon 4 medication Daliresp PA 3 Advair, Breo Ellipta, Foradil, Serevent, Spiriva, Tudorza danazol PA dantrolene Dapsone 2 Daraprim PA 3 Dasetta Delyla Delzicol 2 Demser PA 4 medication Depen PA 4 medication desipramine desloratadine ST levocetirizine desogestrel/ethinyl estradiol desonide desoximetasone ST betamethasone, fluocinonide Desvenlafaxine ER, ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) dexamethasone Dexilant PA, QL 3 lansoprazole, omeprazole, pantoprazole dexmethylphenidate ER QL (PA < 4 and 8 years of age) = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 9

14 Effective January, 20 Select Select dexmethylphenidate QL (PA < 4 and 8 years of age) dextroamphetamine QL (PA < 4 and 8 years of age) diazepam diazepam rectal gel Dibenzyline PA 4 medication diclofenac diclofenac/ misoprostol diclofenac ophthalmic solution dicloxacillin dicyclomine didanosine Dificid ST, QL 4 medication diflorasone digoxin diltiazem diltiazem ER Dipentum ST 3 balsalazide disodium, Apriso, Asacol HD, Delzicol diphenoxylate/ atropine dipyridamole disulfuram divalproex sodium divalproex sodium ER donepezil PA dorzolamide dorzolamide/timolol doxazosin doxercalciferol doxycycline drithocreme Dritho-Scalp 2 dronabinol Duavee 3 estradiolnorethindrone, Jinteli, Prempro, Premphase Dulera 2 duloxetine ST, QL Durezol 3 fluorometholone, prednisolone Dyrenium ST 3 triamterene/, spironolactone, spironolactone/ Dysport PA, QL 4 medication Edarbi ST 3 candesartan, eprosartan, irbesartan, losartan, valsartan, telmisartan Edarbyclor ST 3 candesartan/, irbesartan/, losartan/, valsartan/, telmisartan/ Edurant 4 medication Effient QL 2 Elaprase PA 4 medication Elelyso PA 4 medication Elidel PA 3 generic topical steroids Eligard PA, QL 4 medication Elinest eliphos Eliquis QL 2 Ella 3 levonorgestrel, Next Choice Elmiron 3 Emadine ST 3 azelastine, cromolyn, epinastine Embeda PA, QL 3 morphine sulfate ER, fentanyl patches, oxymorphone ER, Opana ER Emcyt PA 4 medication Emend capsule QL 2 Emend vial QL 3 Emoquette = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 0

15 Effective January, 20 Select Select Emsam PA, QL 3 phenelzine, tranylcypromine Emtriva 2 Enablex ST 3 oxybutynin, oxybutynin ER, tolterodine, trospium, trospium ER, tolterodine ER, Toviaz, Vesicare enalapril enalapril/ Enbrel PA, QL 4 medication Endocet QL Enjuvia ST 3 estradiol, estropipate, Premarin enoxaparin QL 4 medication Enpresse entacapone Entyvio PA, QL 4 medication epiklor epinastine ophthalmic solution epinephrine EpiPen 2 eplerenone Epogen PA 4 medication epoprostenol PA 4 medication eprosartan Epzicom 4 medication Ergomar PA, QL 3 ergotamine/caffeine, isometheptine/ acetaminophen/ dichloralphenazone ergotamine/caffeine Erivedge PA, QL 4 medication Errin EryPed 3 erythromycin Ery-tab EC 20 mg tablet Ery-tab EC 333 mg tablet erythromycin erythromycin/benzoyl peroxide gel PA escitalopram QL Estarylla estazolam Estrace cream 3 estradiol, estropipate, Premarin estradiol estradiol/ norethindrone estradiol patch QL Estrogel 3 Premarin estropipate eszopiclone ST, QL ethambutol ethosuximide etidronate etodolac etoposide PA 4 medication Euflexxa PA, QL 4 medication Eurax 3 permethrin Evzio PA, QL 4 medication Exalgo PA, QL 3 morphine sulfate ER, fentanyl patches, oxymorphone ER, Opana ER Exelderm 3 ketoconazole, metronidazole Exelon patch PA 3 rivastigmine capsules (PA), donepezil (PA), Namenda (PA), Namenda XR (PA) exemestane Exjade PA 4 medication Eylea PA 4 medication Fabior PA (PA > 3 years of age) 3 generic topical acne agents Fabrazyme PA 4 medication Factive QL 3 ciprofloxacin, levofloxacin Falmina famciclovir QL famotidine = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications

16 Effective January, 20 Select Select Fanapt PA, QL (PA < 2 years of age) 3 risperidone, olanzapine, quetiapine, Abilify, ziprasidone Fareston PA 4 medication felbamate felodipine Femring 3 estradiol, estropipate, Premarin fenofibrate fenoprofen fentanyl citrate PA, QL 4 medication fentanyl transdermal QL Fentora PA, ST, QL 4 medication Ferriprox PA 4 medication Fetzima PA, QL 3 venlafaxine ER capsules, duloxetine (ST) Finacea PA, ST 3 adapalene (PA), tretinoin finasteride Firazyr PA, QL 4 medication Firmagon PA, QL 4 medication First-BXN Mouthwash 3 diphenhydramine, lidocaine, nystatin Flarex 3 fluorometholone, prednisolone Flebogamma PA 4 medication flecainide Flovent 2 fluconazole QL flucytosine 4 medication fludrocortisone flunisolide fluocinolone fluocinonide Fluor-A-Day chew fluorometholone fluoxetine fluphenazine (PA < 2 years of age) flurazepam flurbiprofen fluticasone fluvastatin fluvoxamine FML Forte 3 fluorometholone, prednisolone FML S.O.P. 3 fluorometholone fondaparinux QL 4 medication Foradil 2 Forteo ST, QL 4 medication Fortesta PA 3 testosterone injection (PA), Androgel.62% (PA) fortical fosinopril fosinopril/ Fosrenol ST 3 calcium acetate, sevelamer carbonate, Renvela powder packet Fragmin QL 4 medication Frova ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Fulyzaq PA, QL 4 medication furosemide solution furosemide tablets Fuzeon 4 medication Fycompa PA, QL 3 felbamate, lamotrigine, topiramate, valproate gabapentin galantamine ER PA galantamine PA Galzin PA 3 Gammagard PA 4 medication Gammaked PA 4 medication Gammaplex PA 4 medication Gamunex PA 4 medication Gamunex-C PA 4 medication ganciclovir gatifloxacin Gattex PA, QL 4 medication gavilyte gemfibrozil = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 2

17 Effective January, 20 Select Select Generess FE 3 generic oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo generlac gentamicin Geodon vial PA 3 Gianvi Gildagia Gildess Gilenya PA, QL 4 medication Gilotrif PA, QL 4 medication Glassia PA 4 medication Gleevec PA, QL 4 medication glimepiride glipizide glipizide/metformin glipizide ER Glucagon 2 glyburide glyburide/metformin glycopyrrolate Glyset 3 acarbose Gralise PA, QL 3 gabapentin granisetron ST, QL ondansetron granisol ST, QL ondansetron Granix PA 4 medication griseofulvin guanfacine Halflytely 3 peg-330, Suprep, Moviprep halobetasol Halog ST 3 betamethasone dipropionate, fluocinonide haloperidol (PA < 2 years of age) Heather Hetlioz PA, QL 4 medication Hexalen 3 Hizentra PA 4 medication homatropine drops Horizant PA, QL 3 gabapentin, pramipexole, ropinirole = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 3 Humalog 0/0 QL 2 Humalog 7/2 QL 2 Humalog QL 2 Humira PA, QL 4 medication Humulin 0/0 QL 2 Humulin 70/30 QL 2 Humulin N QL 2 Humulin R QL 2 Hycamtin PA 4 medication hydralazine 2. mg capsule 2 mg tablet 0 mg tablet hydrocodone/ acetaminophen QL hydrocodone/ chlorpheniramine hydrocodone/ homatropine hydrocodone/ ibuprofen hydrocortisone hydrocortisone/ pramoxine cream hydromorphone hydroxychloroquine hydroxyurea hydroxyzine hyoscyamine Hypercare solution ibandronate syringe ST, QL ibandronate vial ST, QL 3 alendronate, ibandronate, risedronate ibandronate tablet QL ibuprofen Iclusig PA, QL 4 medication Ilaris PA, QL 4 medication Ilevro 3 bromfenac, diclofenac, ketorolac Imbruvica PA, QL 4 medication imiquimod

18 Effective January, 20 Select Select Incivek PA, QL 4 medication Increlex PA 4 medication Incruse Ellipta 3 Spiriva, Tudorza indapamide indomethacin Infergen PA, QL 4 medication Inlyta PA, QL 4 medication Intelence PA 4 medication Intron A PA 4 medication Introvale Intuniv ST, QL 3 guanfacine Invega PA, QL (PA < 2 years of age) Invega Sustenna PA, QL (ST < 2 years of age) 3 risperidone, olanzapine, quetiapine, Abilify, ziprasidone 4 medication Invirase 4 medication Invokana QL 3 metformin, glyburide, glipizide, Januvia, Tradjenta ipratropium ipratropium/albuterol solution Iquix 3 ciprofloxacin, levofloxacin, ofloxacin irbesartan irbesartan/ Isentress 4 medication isoniazid Isopto Carbachol 3 betaxolol, brimonidine, caretolol, dorzolamide, latanoprost, levobunolol, timolol Isopto Homatropine 3 homatropine, atropine, cyclopentolate, tropicamide isosorbide isradipine itraconazole capsule PA, QL Jakafi PA, QL 4 medication Jalyn 2 Jantoven Janumet 2 Janumet XR 2 Januvia 2 Jentadueto 2 Jetrea PA, QL 4 medication Jevantique Jinteli Jolessa Jolivette Junel Junel FE Juxtapid PA, QL 4 medication Kalbitor PA 4 medication Kaletra 4 medication Kalydeco PA, QL 4 medication Kariva Kazano ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Kelnor Ketek QL 3 azithromycin, clarithromycin ER, erythromycin ketoconazole ketoprofen ketorolac ophthalmic solution ketorolac QL Khedezla ER ST, QL 3 citalopram, paroxetine, sertraline, venlafaxine ER capsules, duloxetine (ST) Kineret PA, QL 4 medication Klor-Con Kombiglyze XR ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Korlym PA, QL 4 medication Krystexxa PA, QL 4 medication Kurvelo Kuvan PA 4 medication Kynamro PA, QL 4 medication = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 4

19 Effective January, 20 Select Select labetalol Lacrisert PA 3 generic artificial tears, Restasis lactic acid lactulose lamivudine lamivudine/zidovudine lamivudine HBV PA lamotrigine lansoprazole QL lansoprazole/ amoxicillin/ clarithromycin pack Lantus QL 2 Lantus Solostar QL 2 Larin Larin FE Lastacaft ST 3 azelastine, cromolyn, epinastine latanoprost Latuda ST, QL (PA < 2 years of age) 3 risperidone, olanzapine, quetiapine, Abilify, ziprasidone Lazanda PA, ST, QL 4 medication Leena leflunomide Lessina Letairis PA, QL 4 medication letrozole leucovorin calcium tablet Leukeran 2 Leukine PA 4 medication leuprolide PA 4 medication levalbuterol Levatol ST 3 atenolol, metoprolol, propranolol Levemir QL 2 levetiracetam levetiracetam ER QL levobunolol levocetirizine levofloxacin levofloxacin ophthalmic Levonest levonorgestrel levonorgestrel/ estradiol Levora Levothroid Levothroid 300 mg tablet levothyroxine levothyroxine 300 mg tablet Levoxyl Lexiva 4 medication Lialda ST 3 balsalazide disodium, Apriso, Asacol HD, Delzicol lidocaine lidocaine patch ST, QL Lifescan Blood Glucose 2 Meters Lifescan Blood Glucose 2 Test Strips (QL > 8 years of age) Lifescan Lancets 2 (QL > 8 years of age) liothyronine lisinopril lisinopril/ lisinopril 0 mg tablet lisinopril 2. mg tablet lisinopril 20 mg tablet lisinopril mg tablet lithium Livalo PA 3 atorvastatin, lovastatin, pravastatin, simvastatin Lo Loestrin FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo Lo Minastrin FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications

20 Effective January, 20 Select Select Loestrin 24 FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo Lomedia 24 FE 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo Lomustine 2 lorazepam Lorcet HD QL Lorcet plus QL Lortab QL Loryna losartan losartan/ Lotemax 3 fluorometholone, prednisolone Lotronex PA 3 lovastatin Low-ogestrel loxapine (PA < 2 years of age) Lucentis PA 4 medication Lufyllin ST 3 aminophylline, theophylline Lumigan 2 Lumizyme PA 4 medication Lupaneta PA, QL 4 medication Lupron PA, QL 4 medication Lutera Lyrica PA, QL 3 gabapentin Lysodren PA 4 medication Macugen PA 4 medication mafenide powder Makena PA 4 medication malathion Marlissa Marplan ST 3 phenelzine, tranylcypromine Matulane 4 medication Maxair ST, QL 3 Ventolin HFA mebendazole meclizine medroxyprogesterone acetate injection QL mefenamic acid PA mefloquine PA megestrol meloxicam Menest 3 estradiol, estropipate, Premarin Menostar QL 3 estradiol meperidine Mephyton 3 meprobamate Mepron suspension 2 mercaptopurine mesalamine enema Mesnex 4 medication metaxalone metformin metformin ER methadone Methadose methamphetamine QL (PA < 4 and 8 years of age) methazolamide methimazole Methitest PA 3 testosterone injection(pa), Androgel.62% (PA) methocarbamol methotrexate tablet methotrexate vial 4 medication methoxsalen PA 4 medication methscopolamine methylin ER QL (PA < 4 and 8 years of age) methylin QL (PA < 4 and 8 years of age) methylphenidate CD QL (PA < 4 and 8 years of age) methylphenidate ER QL (PA < 4 and 8 years of age) = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 6

21 Effective January, 20 Select Select methylphenidate QL (PA < 4 and 8 years of age) methylphenidate SR QL (PA < 4 and 8 years of age) methylprednisolone metipranolol metoclopramide metolazone metoprolol/ metoprolol succinate ER metoprolol tartrate tablet metronidazole mexiletine Microgestin Microgestin FE midazolam midodrine Mimvey Mimvey Lo minocycline minoxidil mirtazapine Mirvaso PA 3 metronidazole, sodium sulfacetamine/sulfur, tretinoin, adapalene misoprostol modafinil PA, QL Moderiba QL 4 medication moexipril moexipril/ mometasone Mono-linyah MonoNessa montelukast QL morphine sulfate ER tablet QL morphine sulfate IR Moviprep 2 Moxeza 3 ciprofloxacin, levofloxacin, ofloxacin moxifloxacin Mozobil PA, QL 4 medication Multaq 2 mupirocin Myalept PA, QL 4 medication mycophenolate mofetil mycophenolate sodium Myleran 2 Myobloc PA, QL 4 medication myorisan Myozyme PA 4 medication Myrbetriq ER ST, QL 3 oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare Mytelase 2 Myzilra nabumetone nadolol nadolol/ bendroflumethiazide Naglazyme PA 4 medication Namenda PA 2 Namenda XR PA, QL 2 naproxen naratriptan QL Natazia 2 nateglinide Nature-throid Nebupent 2 Necon nefazodone neomycin Nesina ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Neulasta PA 4 medication Neumega 4 medication = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 7

22 Effective January, 20 Select Select Neupogen PA 4 medication Nevanac 3 bromfenac, diclofenac, ketorolac nevirapine nevirapine ER Nexavar PA, QL 4 medication Nexium ST, QL 3 lansoprazole, omeprazole, pantoprazole Next Choice Next Choice One Dose niacin ER nicardipine nicotine gum QL nicotine lozenges QL nicotine patches QL Nicotrol inhaler ST, QL Nicotrol nasal spray ST, QL nifediac CC nifedipine nifedipine ER Nikki Nilandron PA 4 medication nimodipine nisoldipine ER ST Nitro-dur 3 nitroglycerin nitrofurantoin nitroglycerin Nitrostat 3 nitroglycerin nizatidine Nora-BE Norditropin PA 4 medication Norditropin Nordiflex 4 medication Pen PA norgestimate/ estradiol Norlyroc Noroxin 3 ciprofloxacin, levofloxacin Nortrel nortriptyline Novofine 2 Novotwist 2 Norvir 2 Novolin 70/30 QL 2 Novolin N QL 2 Novolin QL 2 Novolin R QL 2 Novolog Mix 70/30 QL 2 Novolog QL 2 Noxafil PA 4 medication Nplate PA 4 medication Nuedexta PA, QL 4 medication Nulojix PA 4 medication Numoisyn 3 Caphosol Nuvaring 2 Nuvigil PA, QL 3 amphetamine salts, Adderall XR, dexmethylphenidate, methylphenidate, methylphenidate ER, modafinil (PA) nystatin Ocella octreotide 4 medication ofloxacin Oforta PA 4 medication Ogestrel olanzapine/fluoxetine PA, QL (PA < 2 years of age) olanzapine QL (PA < 2 years of age) olanzapine vial Olysio PA, QL 4 medication omega-3 acid ethyl esters omeprazole QL ondansetron QL One Touch Blood 2 Glucose Meters One Touch Blood 2 Glucose Test Strips (QL > 8 years of age) Onfi PA 3 felbamate, lamotrigine, topiramate, valproate = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 8

23 Effective January, 20 Select Select Onglyza ST 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Onsolis PA, ST, QL 4 medication Opana ER QL 2 Opsumit PA, QL 4 medication OramagicRx 3 lidocaine, First-Mouthwash Orap 3 (PA < 2 years of age) Oravig PA, QL 3 fluconazole Orencia PA, QL 4 medication Orenitram PA 4 medication Orfadin PA 4 medication orphenadrine Orsythia Ortho Tri-Cyclen LO 2 Oseni 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Osmoprep 3 peg-330, Suprep, Moviprep Otezla PA, QL 4 medication Otrexup PA, QL 4 medication Ovcon-0 3 oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo oxandrolone PA oxaprozin oxazepam oxcarbazepine Oxsoralen PA 4 medication oxybutynin oxybutynin ER oxycodone/ acetaminophen QL oxycodone/aspirin QL oxycodone/ibuprofen QL oxycodone IR Oxycontin PA, QL 3 morphine sulfate ER, fentanyl patches, oxymorphone ER, Opana ER oxymorphone oxymorphone ER QL pamidronate vial Pandel ST 3 generic topical steroids Panretin PA 4 medication pantoprazole QL paricalcitol paroxetine Pataday ST 3 azelastine, cromolyn, epinastine Patanase ST 3 azelastine, fluticasone, flunisolide Patanol ST 3 azelastine, cromolyn, epinastine peg-330 Pegasys PA, QL 4 medication Peg-Intron PA, QL 4 medication penicillin penicillin VK 20 mg tablet Pentasa 3 balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol pentazocine/ acetaminophen QL pentazocine/naloxone Perforomist 3 Foradil, Serevent perindopril permethrin cream perphenazine (PA < 2 years of age) phenelzine phenobarbital phenytoin Philith Phospholine Iodide 3 pilocarpine Picato PA 3 -fluorouracil, imiquimod pilocarpine = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 9

24 Effective January, 20 Select Select Pilopine HS 3 pilocarpine Pimtrea pindolol pioglitazone pioglitazone/ glimepiride pioglitazone/ metformin Pirmella piroxicam podofilox Pomalyst PA, QL 4 medication Portia potassium chloride Potiga PA, QL 3 carbamazepine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide Pradaxa QL 2 pramipexole Prandimet 3 metformin, repaglinide pravastatin prazosin Pred Mild 3 fluorometholone, prednisolone prednicarbate prednisolone prednisone Premarin 2 Premarin Vaginal 2 Cream Premphase 2 Prempro 2 Prepopik 3 peg-330, Suprep, Moviprep Prezista 4 medication Primaquine PA 3 primidone Pristiq ST, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Privigen PA 4 medication ProAir HFA ST, QL 3 Ventolin HFA probenecid prochlorperazine Procrit PA 4 medication proctosol-hc proctozone-hc progesterone Prolastin PA 4 medication Prolastin-C PA 4 medication Proleukin 4 medication Prolia PA, QL 4 medication Promacta PA, QL 4 medication promethazine promethazine/codeine propafenone propafenone ER propranolol propranolol/ propranolol 0 mg tablet propranolol 20 mg tablet propranolol 40 mg tablet propranolol 80 mg tablet propranolol ER Protopic PA 3 generic topical steroids protriptyline Proventil HFA ST, QL 3 Ventolin HFA prudoxin ST Pulmicort Flexhaler ST 3 Asmanex, Flovent, QVAR Pulmozyme PA, QL 4 medication pyridostigmine bromide = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 20

25 Effective January, 20 Select Select Quasense quetiapine PA, QL (PA < 2 years of age) quinapril quinapril/ quinidine Qutenza PA, QL 4 medication QVAR 2 rabeprazole PA, QL raloxifene ramipril Ranexa 2 ranitidine ranitidine 0 mg tablet Rapaflo ST 3 alfuzosin er, doxazosin, prazosin, tamsulosin, terazosin Ravicti PA, QL 4 medication Rebif ST, QL 4 medication Reclipsen Rectiv PA 3 compounded topical diltiazem, compounded nifedipine Regranex QL 3 Relenza QL 3 amantadine Relistor syringe PA 4 medication Relpax ST, QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan Remicade PA 4 medication Remodulin PA 4 medication Renvela 2 Renvela powder packet 2 repaglinide Rescriptor 2 Rescula ST 3 latanoprost, Lumigan reserpine Restasis QL 2 Revlimid PA, QL 4 medication Reyataz 4 medication Ribasphere QL 4 medication ribavirin QL 4 medication rifabutin rifampin Rilutek PA, QL 4 medication risedronate QL Risperdal Consta 4 medication PA, QL (ST < 2 years of age) risperidone ODT QL (PA < 2 years of age) risperidone QL (PA < 2 years of age) Rituxan PA, QL 4 medication rivastigmine PA rizatriptan QL ropinirole ropinirole ER ST Roxicet solution 3 oxycodone/ acetaminophen tablet Rozerem PA 3 zolpidem, zaleplon Sabril PA, QL 4 medication Safyral 2 salicylic acid salsalate Samsca PA, QL 4 medication Sancuso ST, QL 3 ondansetron Sandostatin LAR PA, 4 medication QL Santyl 3 Saphris ST, QL (PA < 2 years of age) 3 risperidone, olanzapine, quetiapine, Abilify, ziprasidone Savella PA, QL 3 gabapentin, generic tricylic antidepressant, generic muscle relaxants selegiline selenium sulfide Selzentry PA 4 medication Sensipar 2 Serevent 2 = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 2

26 Effective January, 20 Select Select Seroquel XR PA, ST, QL (PA < 2 years of age) 3 risperidone, olanzapine, quetiapine, Abilify, ziprasidone Serostim PA 4 medication sertraline sevelamer carbonate Signifor PA 4 medication sildenafil 20mg PA, QL 4 medication silver nitrate Simbrinza 3 brimonidine, dorzolamide Simcor ST 3 simvastatin, niacin ER Simponi Aria PA, QL 4 medication Simponi PA, QL 4 medication simvastatin sirolimus PA Sivextro QL 4 medication Sklice PA 3 spinosad sodium fluoride gel sodium phenylbutyrate 4 medication powder PA sodium sulfacetamide sodium sulfacetamide/ sulfur sodium sulfacetamide/ sulfur/urea Solia Soliris PA 4 medication Somatuline PA, QL 4 medication Somavert PA, QL 4 medication sotalol Sotret Sovaldi PA, QL 4 medication Spectracef 3 cefpodoxime, cefdinir spinosad Spiriva 2 spironolactone spironolactone/ spironolactone 2 mg tablet Sporanox solution PA 3 itraconazole capsule (PA) Sprintec Sprycel PA, QL 4 medication Sronyx stavudine Stelara PA, QL 4 medication Stivarga PA, QL 4 medication Strattera QL 2 Striant PA 3 testosterone injection (PA), Androgel.62% (PA) Stribild 4 medication Suboxone film PA, QL 2 Subsys PA, ST, QL 4 medication Suclear 3 peg-330, Suprep, Moviprep Sucraid PA 4 medication sucralfate sulfacetamide sodium sulfadiazine sulfamethoxazole/ trimethoprim sulfasalazine sulfasalazine EC sulfisoxazole sulindac sumatriptan QL Supprelin LA PA, QL 4 medication Suprax 3 cefpodoxime, cefdinir Suprep 2 Sustiva 4 medication Sutent PA, QL 4 medication Syeda Sylatron PA 4 medication Sylvant PA 4 medication Symlin ST, QL 2 Synagis PA, QL 4 medication Synarel PA, QL 4 medication Synera PA 3 lidocaine/prilocaine cream Synthroid 3 levothyroxine, liothyronine Synvisc One PA, QL 4 medication Synvisc PA, QL 4 medication = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 22

27 Effective January, 20 Select Select Syprine PA 4 medication Tabloid PA 2 Taclonex suspension PA 3 generic topical steroids tacrolimus Tamiflu QL 3 amantadine tamoxifen tamsulosin Tanzeum ST, QL 3 Victoza, Bydureon Tarceva PA, QL 4 medication Targretin PA 4 medication Tasigna PA, QL 4 medication Tasmar ST 3 entacapone Tazorac ST (PA > 3 years of age) 3 generic topical acne agents taztia XT Tecfidera PA, QL 4 medication Tecfidera Starter Pack 4 medication PA, QL Tekamlo ST 2 Tekturna HCT ST 2 Tekturna ST 2 telmisartan telmisartan/amlodipine telmisartan/hctz temazepam Temodar PA 4 medication Tencon terazosin terbinafine QL terconazole Testim PA 3 testosterone injection (PA), Androgel.62% (PA) testosterone injection PA tetracaine ophthalmic tetracycline Thalomid PA, QL 4 medication theophylline ER thioridazine (PA < 2 years of age) thiothixene (PA < 2 years of age) Thyrogen 4 medication tiagabine ticlopidine Tikosyn 3 Tilia FE timolol tinidazole Tirosint 3 levothyroxine, liothyronine Tivicay 2 tizanidine tablet TOBI Podhaler QL 4 medication Tobradex ST 3 tobramycin/ dexamethasone tobramycin tobramycin/ dexamethasone Tobrex 3 ciprofloxacin, levofloxacin, ofloxacin, ofloxacin tolazamide tolbutamide tolmetin tolterodine tolterodine ER topiragen QL topiramate topiramate sprinkle QL torsemide Toviaz 2 Tracleer PA, ST, QL 4 medication Tradjenta 2 tramadol/ acetaminophen QL tramadol ER tablet QL tramadol QL trandolapril tranexamic acid PA, QL Transderm-Scop 3 meclizine tranylcypromine Travatan Z ST 3 latanoprost, Lumigan trazodone Trelstar PA, QL 4 medication = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 23

28 Effective January, 20 Select Select tretinoin oral 4 medication tretinoin topical triamcinolone triamterene/ triazolam Tri-estarylla trifluoperazine (PA < 2 years of age) trihexyphenidyl Tri-legest FE Tri-linyah Trilyte with flavor packets trimethobenzamide trimipramine Trinessa Tri-previfem Tri-sprintec Trivora tropicamide drops trospium trospium ER Truvada 4 medication Tudorza Pressair 2 Tykerb PA, QL 4 medication Tysabri PA, QL 4 medication Tyvaso PA 4 medication Tyzeka PA 4 medication Uceris PA 3 budesonide Ulesfia 3 spinosad Uloric ST, QL 2 allopurinol unithroid urea ursodiol Vagifem 3 estradiol, estropipate, Premarin valacyclovir QL Valchlor PA 4 medication Valcyte 3 ganciclovir valproic acid valsartan valsartan/ vancomycin capsules = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 24 Vantas PA, QL 4 medication Vasolex Veletri PA 4 medication Velivet Velphoro ST 3 calcium acetate, sevelamer carbonate, Renvela powder packet venlafaxine venlafaxine ER capsule QL Ventavis PA 4 medication Ventolin HFA QL 2 Veramyst 2 verapamil verapamil ER Veregen 3 imiquimod, podofilox Vesicare 2 Vestura Vexol 3 fluorometholone, prednisolone Victoza ST 2 Victrelis PA, QL 4 medication Videx solution 2 Vigamox 3 ciprofloxacin, levofloxacin, ofloxacin Viibryd PA, QL 3 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Vimizim PA 4 medication Vimpat PA 3 divalproex sodium, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate, zonisamide Viorele Viracept 4 medication Viread 4 medication Visicol 3 peg-330, Suprep, Moviprep vitamins, generic pediatric

29 Effective January, 20 Select Select vitamins, generic prenatal Vivitrol PA 4 medication Vogelxo PA 3 testosterone injection (PA), Androgel.62% (PA) Voltaren Gel QL 3 oral NSAIDS (such as diclofenac, etodolac, ibuprofen, meloxicam, naproxen) voriconazole QL Votrient PA, QL 4 medication VPRIV PA 4 medication Vyfemla Vyvanse PA, QL (PA < 4 and 8 years of age) 3 amphetamine salts, Adderall XR, dexmethylphenidate, methylphenidate, methylphenidate ER, Strattera warfarin Welchol 2 Wera WP Thyroid 3 levothyroxine Wymzya Fe Xalkori PA, QL 4 medication Xarelto QL 2 Xeljanz PA, QL 4 medication Xenazine PA, QL 4 medication Xeomin PA, QL 4 medication Xerac AC 3 Hypercare solution Xgeva PA, QL 4 medication Xifaxan 200mg QL 3 ciprofloxacin, loperamide Xifaxan 0mg PA, QL 3 lactulose Xolair PA, QL 4 medication Xopenex HFA ST, QL 3 Ventolin HFA Xtandi PA, ST, QL 4 medication Xulane QL Xyrem PA, QL 4 medication Yervoy PA 4 medication Yodoxin 2 zafirlukast zaleplon Zarah Zavesca PA 4 medication = Medications 2 = -Brand Medications 3 = Non- Brand Medications 4 = Medications * Age restrictions apply to some medications. = Select Medications 2 Zelboraf PA, QL 4 medication Zemaira PA 4 medication Zenchent Zenchent Fe zenieva Zenpep ST 3 Creon Zeosa Zetia 2 Ziagen 2 Ziana gel ST (PA > 3 years of age) 3 adapalene (PA), benzoyl peroxide, clindamycin, erythromycin, tretinoin zidovudine Zioptan ST 3 latanoprost, Lumigan ziprasidone QL (PA < 2 years of age) Zirgan gel 2 Zoladex PA, QL 4 medication zoledronic acid 4mg 4 medication zoledronic acid mg 4 medication ST, QL Zolinza PA, QL 4 medication zolmitriptan QL zolpidem tartrate Zomig nasal spray QL 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan zonisamide Zontivity PA, QL 3 clopidogrel, Effient Zorbtive PA 4 medication Zortress PA 4 medication Zovia Zubsolv PA, QL 2 Zyflo CR ST 3 montelukast Zyflo ST 3 montelukast Zykadia PA, QL 4 medication Zylet 3 tobramycin/ dexamethasone Zyprexa Relprevv 4 medication PA, QL (ST < 2 years of age) Zytiga PA, QL 4 medication Zyvox QL 2

30 MEDICATIONS NOT COVERED BY ADVANTAGE CHOICE The following medications are benefit exclusions and will not be covered under the pharmacy benefit: Antimalarial agents when used for prevention Antiobesity medications, including, but not limited to, appetite suppressants and lipase inhibitors Blood or blood plasma products* Drugs labeled for investigational use Drugs used for cosmetic purposes or hair growth Drugs used to treat sexual dysfunction (examples are Viagra, Levitra, Cialis, Muse, Caverject, Stendra) Fertility agents Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over-the-counter medications Needles/syringes (other than insulin)* Nutrition and dietary supplements* Ostomy supplies* Therapeutic devices/appliances* Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.) *Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Health Care Concierge team at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Health Care Concierge team number listed on page of this booklet. 26