Overview Effective 07/0/206 Introduction to the Drug Formulary The Community Health Options Drug Formulary serves as a guide for embers, Providers and other healthcare professionals in the selection of cost effective drug therapy. To ensure that the medications prescribed are covered, and to minimize ember out of pocket expenses, we recommend that embers and prescribers consult the Community Health Options Drug Formulary before writing or filling prescriptions. The Community Health Options Drug Formulary is a list of preferred generic and brand name medications that are approved by the Food and Drug Administration (FDA) and are eligible for coverage under the Community Health Options outpatient prescription drug benefit. How to Read the Formulary The formulary includes the following four columns: Special Code Tier Category The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NEXIU) and generic drugs are listed in lower case (e.g., amoxicillin). Special Code The second column titled Special Code identifies coverage limits or notes for drugs when applicable. Following are the definitions for Special Codes: Special Code Definition Description CI Chronic Illness Support Program The Chronic Illness Support Program provides expanded coverage for specific medication used to treat the following chronic illnesses: Diabetes, Asthma, Chronic Obstructive Lung Disease (COPD)/ Emphysema and Hypertension. Expanded coverage is limited to $0 cost share for Tier medications and 50% reduction in cost share for Tier 2 medications. Deductibles are waived. NC Not Covered There is no coverage for this drug. PA* Prior approval required for reduced copay Drug is covered without a prior approval (PA), but if the patient meets certain PA criteria, they receive the drug for a lower patient pay amount. SKG Smoking Cessation This drug is specifically used in the treatment of Smoking Cessation. VAC Vaccine Program This drug is included in the Vaccine Program. These drugs are covered at zero cost share for embers who are 8 years of age and older. embers who are 7 years of age and younger can receive vaccines for free through their provider under State coverage. INF Infertility This drug is an Infertility product. OTC Over the Counter This drug is an over the counter product that is covered with a prescription from the prescriber. Quantity Limit There is a limit to how much of this drug the ember may receive each fill and/or a limit of fills per month. Available through Specialty Pharmacy Program This drug is available through a specialty pharmacy.
andatory Specialty Pharmacy Program This drug must be obtained directly through one of the mandatory specialty pharmacies: Apothecary By Design or Diplomat. PA Prior Approval Prior Approval, also known as Prior Authorization, is required to determine coverage. RS edication is covered only when prescribed by a specialist. ST Step Therapy Coverage is determined based on use of other first line therapies or drugs (trial and failure of preferred drug). Tier The third column of the chart lists the drug tier. Out of Pocket costs are determined based on the drug tier. Generally, Tier medicines are generics and are less expensive than Tier 2 or medicines, which are Brand name. Specialty drugs are also typically more expensive. The Summary of Benefits and Coverage provides the out ofpocket cost for each drug tier. Tier Definition Generics and certain low cost brand name drugs 2 Preferred brand name drugs and certain high cost generic drugs Non preferred brand drugs $0 Preventative drugs Specialty drugs NC Non covered drugs. Not all non covered drugs are listed within the formulary. Category The fourth column of the chart lists the Category of the drug, which is the therapeutic class of the drug. Additional Important Information generic (BRAND equiv) When a generic product is listed on the formulary with the (BRAND equiv) in parenthesis behind it and the brand is not listed elsewhere on the formulary, then the brand is covered at Tier but is considered a non preferred drug. If the brand equivalent drug is prescribed, the member must pay the Tier copay plus the difference between the cost of the generic drug and the cost of the brand drug (the cost share ). In the following example the ember s cost share is $90.00, which is the ember s coinsurance amount for the Tier drug ($20.00) plus the difference between the cost of the Tier generic drug and the Tier brand drug ($70.00): Cost of the acetaminophen/codeine tab, a generic Tier drug, is $0.00. Cost of the Tylenol/Codeine, a non preferred brand Tier drug, is $00.00. The difference between cost of the Tier generic drug and the Tier brand drug is $70.00. The member s 20% coinsurance amount for the Tier drug is $20.00 (20% of $00.00). The member s cost share is $90.00 ($20.00 coinsurance + $70.00 cost difference between the generic and brand drugs). Note The drug costs and copay amounts shown are only an example. How to Search the Formulary To search the electronic Adobe PDF version: Hold down the Ctrl and F keys at the same time, or click on the Binoculars icon, to open the search pane. Type in the first few letters of the drug name, and click Enter. Continue to click on the Arrow in the search pane to scroll through the matches within the document.
The general order of search results is:. Alphabetical index listing of all the drugs listed on the formulary. 2. Category listing where drugs are grouped by drug class.. Therapeutic Interchange List Alternatives for non preferred or not covered drugs. Note that the suggested interchange is product appropriate for OST indications. embers should discuss alternatives with their prescriber. What if a Drug is Not Listed on the Formulary? If a drug is not listed in the formulary, contact ember Services at 855 624 646 (onday through Friday, 8am 6pm) and ask if the drug is covered. ember Services can also provide names of alternative drugs that are covered. What if a Drug is Not Covered? If the drug is not covered, there are two options:. Ask ember Services for a list of alternative drugs that are covered. Contact your Provider and request a prescription for a similar drug that is covered. 2. Ask ember Services how to submit an Exception to Coverage form. What is needed for drugs that require Prior Approval (PA)? Drugs that include the special code PA on the formulary require prior approval. If the drug requires prior approval, your Provider must complete the appropriate Prior Authorization form and submit it to Express Scripts for review and approval.. The PA forms are available to members on the www.healthoptions.org website via the member account, or members can contact ember Services at 855624646 (onday through Friday, 8am6pm) to request a copy of a form.
Search Tip: This is a large document, but you can search quickly and easily by clicking on the binocular icon on your toolbar. It will then display a search box for you to type in the name of drug you want to locate. If you do not know the correct spelling, you can start your search by entering just the first few letters of the name. Community Health Options Formulary Alphabetical Index 8OP CAP abacavir tab (ZIAGEN equiv) abacavir/ lamivudine/ zidovudine tab (TRIZIVIR equiv) ABILIFY DISCELT (= 2 tabs/day) ABILIFY AINTENA INJ ABILIFY SOLN ABILIFY TAB ABSORICA CAP ABSTRAL SL TAB (= 20 tabs/0 days) acamprosate calcium DR tab (CAPRAL equiv) ACANYA/ONEXTON GEL acarbose tab (PRECOSE equiv) ACCOLATE TAB ACCUCHEK AVIVA PLUS ETER ACCUCHEK AVIVA PLUS TEST STRIP ACCUCHEK NANO ETER ACCUCHEK NANO SARTVIEW ETER ACCUCHEK SARTVIEW TEST STRIP ACCUCHEK TEST STRIP ACCUNEB NEB SOLN ACCUPRIL TAB ACCURETIC TAB acebutolol cap (SECTRAL equiv) ACEON TAB acetaminophen/caffeine/dihydrocodeine cap (TREZIX equiv) ACETAINOPHEN/CAFFEINE/DIHYDROCODEINE TAB acetaminophen/codeine soln acetaminophen/codeine tab (TYLENOL/CODEINE equiv) acetaminophen/isometheptene/dichloral cap (IDRIN equiv) ACETASOL HC OTIC SOLN acetazolamide ER cap (DIAOX SEQUEL equiv) acetazolamide tab ACETAZOLAIDE TAB 25G acetic acid otic soln (VOSOL equiv) ACETIC ACID/ALUINU ACETATE OTIC SOLN acetic acid/hydrocoritisone otic soln (VOSOL HC equiv) acetylcysteine soln (UCOYST equiv) ACIDIC VAGINAL JELLY ACIPHEX RINKLE CAP acitretin cap (SORIATANE equiv) ACLOVATE CREA ACLOVATE OINT ACTERA IV INJ ACTERA SC INJ (= 2 inj/28 days) Special Code Tier Category 2 DERATOLOGICALS ANTIVIRALS ANTIVIRALS PA ANTIPSYCHOTICS/ANTIANIC AGENTS PA ANTIPSYCHOTICS/ANTIANIC AGENTS PA ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS NC DERATOLOGICALS PA ANALGESICS OPIOID PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. DERATOLOGICALS CI ANTIDIABETICS ANTIASTHATIC AND BRONCHODILATOR AGENTS CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 DIAGNOSTIC PRODUCTS CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 DIAGNOSTIC PRODUCTS CIOTC $0 DIAGNOSTIC PRODUCTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES CI BETA BLOCKERS ANTIHYPERTENSIVES ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID NC IGRAINE PRODUCTS OTIC AGENTS CI DIURETICS CI DIURETICS CI DIURETICS OTIC AGENTS OTIC AGENTS OTIC AGENTS COUGH/COLD/ALLERGY 2 VAGINAL PRODUCTS NC ULCER DRUGS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANALGESICS ANTIINFLAATORY PA ANALGESICS ANTIINFLAATORY CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Cont. Alphabetical Index ACTICLATE TAB ACTIGALL CAP ACTIUNE INJ ACTIQ LOZENGE (= 20 lozenges/0 days) ACTIVELLA TAB ACTONEL TAB ACTOPLUS ET TAB ACTOPLUS ET XR TAB ACTOS TAB ACULAR (LS) OPHTH SOLN ACUVAIL OPHTH SOLN acyclovir cap (ZOVIRAX equiv) acyclovir oint (ZOVIRAX OINT equiv) acyclovir susp (ZOVIRAX equiv) acyclovir tab (ZOVIRAX equiv) ACZONE GEL ADACEL/BOOSTRIX INJ (Vaccines are covered for members 9 years or older) ADAGEN INJ ADALAT CC TAB adapalene cream (DIFFERIN equiv) (Acne Only members age 25 or older require Prior Authorization) adapalene gel 0.% (DIFFERIN equiv) (Acne Only members age 25 or older require Prior Authorization) ADAPALENE LOTION (Acne Only members age 25 or older require Prior Authorization) ADASUVE INHALER ADAZIN CREA ADCIRCA TAB ADDERALL TAB ADDERALL XR CAP ADDYI TAB adefovir dipivoxil tab (HEPSERA equiv) ADEPAS TAB (= tabs/day; Only available through Accredo 88877776) ADOXA TAB ADRENACLICK INJ (= 2 inj/fill; Step Therapy requires trial of EPIPEN) ADVAIR DISKUS INHALER ADVAIR HFA INHALER ADVICOR TAB ADZENYS XR TAB AEROCHABER (= spacer/year) AEROCHABER SUPPLIES AEROAN HFA INHALER AFINITOR DIERZ (= tab/day) Special Code Tier Category PA VAC PA PA PA PA LDPA ST CI CI CIOTC CI PASF NC NC NC $0 2 NC NC NC 2 2 NC NC 2 2 NC TETRACYCLINES GASTROINTESTINAL AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS OPIOID ESTROGENS ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS OPHTHALIC AGENTS OPHTHALIC AGENTS ANTIVIRALS DERATOLOGICALS ANTIVIRALS ANTIVIRALS DERATOLOGICALS TOXOIDS BIOLOGICALS ISC CALCIU CHANNEL BLOCKERS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIPSYCHOTICS/ANTIANIC AGENTS DERATOLOGICALS CARDIOVASCULAR AGENTS ISC. ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIVIRALS CARDIOVASCULAR AGENTS ISC. TETRACYCLINES VASOPRESSORS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIHYPERLIPIDEICS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS EDICAL DEVICES AND SUPPLIES EDICAL DEVICES AND SUPPLIES ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTINEOPLASTICS AND ADJUNCTIVE CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Cont. Alphabetical Index AFINITOR TAB (= tab/day) AFLURIA INJ (Vaccines are covered for members 9 years or older) AFLURIA/FLUZONE INJ (Vaccines are covered for members 9 years or older) AGGRENOX/AIRINDIPYRIDAOLE CAP AGRYLIN CAP AKNEYCIN OINT AKYNZEO CAP (= cap/fill; Restricted to Oncology or Hematology Specialist) ALAAST OPHTH SOLN ALBATUSSIN LIQUID ALBENZA TAB albuterol neb soln 0.08% (PROVENTIL equiv) albuterol neb soln 0.5% (VENTOLIN equiv) albuterol neb soln 0.6mg (ACCUNEB equiv) albuterol neb soln.25mg (ACCUNEB equiv) albuterol sulfate ER tab (VOIRE ER equiv) albuterol sulfate syrup albuterol sulfate tab albuterol/ipratropium neb soln (DUONEB equiv) ALCAINE OPHTH SOLN alclometasone cream (ACLOVATE equiv) alclometasone oint (ACLOVATE OINT equiv) ALCOHOL SWABS ALDACTAZIDE TAB ALDACTAZIDE TAB 5050G ALDACTONE TAB ALDARA CREA ALDURAZYE INJ ALECENSA CAP ALENDRONATE SOLN alendronate tab (FOSAAX equiv) ALENDRONATE TAB 40G ALFERONN INJ alfuzosin SR tab (UROXATRAL equiv) ALINIA SU ALINIA TAB ALKERAN TAB allopurinol tab (ZYLOPRI equiv) almotriptan tab (AXERT equiv) (= 9 tabs/fill, 2 fills/0 days) Special Code Tier Category PASF VAC $0 VAC $0 2 RS 2 2 PA CI CI CI CI CI CI CI CI CIOTC $0 NC 2 2 2 2 ANTINEOPLASTICS AND ADJUNCTIVE VACCINES VACCINES HEATOLOGICAL AGENTS ISC. HEATOLOGICAL AGENTS ISC. DERATOLOGICALS ANTIEETICS OPHTHALIC AGENTS COUGH/COLD/ALLERGY ANTHELINTICS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS OPHTHALIC AGENTS DERATOLOGICALS DERATOLOGICALS EDICAL DEVICES AND SUPPLIES DIURETICS DIURETICS DIURETICS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE GENITOURINARY AGENTS ISCELLANEOUS ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE GOUT AGENTS IGRAINE PRODUCTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Cont. Alphabetical Index ALOCRIL OPHTH SOLN ALOIDE OPHTH SOLN ALORA PATCH alosetron tab (LOTRONEX equiv) ALOXI INJ ALPHAGAN P OPHTH SOLN ALPHAGAN P OPHTH SOLN 0.% alprazolam ER tab (XANAX XR equiv) alprazolam ODT (NIRAVA equiv) alprazolam tab (XANAX equiv) ALREX OPHTH SU/ LOTEAX OPHTH SU ALSUA INJ (= 4 inj/fill, 2 fills/0 days) ALTABAX OINT ALTACE CAP ALTACE TAB ALTOPREV TAB aluminum chloride soln (DRYSOL equiv) ALVESCO INHALER amantadine cap (SYETREL equiv) amantadine syrup (SYETREL equiv) AANTADINE TAB AARYL TAB ABIEN TAB 0G (ale = tab/day; Female = 0.5 tab/day) ABIEN TAB 5G (= tab/day) ABISOE INJ ACINONIDE CREA 0.% ACINONIDE LOTION ACINONIDE OINT AERGE TAB (= 9 tabs/fill, 2 fills/0 days) amethyst tab (LYBREL equiv) AEVIVE INJ AICAR SOLN AICAR SYRUP AICAR TAB amifostine inj amikacin inj amiloride tab (IDAOR equiv) amiloride/hydrochlorothiazide tab (ODURETIC equiv) aminocaproic acid syrup (AICAR equiv) aminocaproic acid tab (AICAR equiv) AINOCAPROIC ACID TAB aminophylline tab amiodarone tab (CORDARONE equiv) AITIZA CAP amitriptyline tab (ELAVIL equiv) amlodipine tab (NORVASC equiv) amlodipine/ valsartan tab (EXFORGE equiv) amlodipine/atorvastatin tab (CADUET equiv) amlodipine/benazepril cap (LOTREL equiv) Special Code Tier Category 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS ESTROGENS GASTROINTESTINAL AGENTS ISC. ANTIEETICS 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS 2 OPHTHALIC AGENTS IGRAINE PRODUCTS DERATOLOGICALS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIHYPERLIPIDEICS DERATOLOGICALS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIDIABETICS HYPNOTICS HYPNOTICS ANTIFUNGALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS IGRAINE PRODUCTS $0 CONTRACEPTIVES DERATOLOGICALS NC HEOSTATICS HEOSTATICS HEOSTATICS ANTINEOPLASTICS AND ADJUNCTIVE AINOGLYCOSIDES CI DIURETICS CI DIURETICS HEOSTATICS HEOSTATICS HEOSTATICS CI ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIARRHYTHICS PA GASTROINTESTINAL AGENTS ISC. ANTIDEPRESSANTS CI CALCIU CHANNEL BLOCKERS CI ANTIHYPERTENSIVES CI CARDIOVASCULAR AGENTS ISC. CI ANTIHYPERTENSIVES CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Cont. Alphabetical Index amlodipine/valsartan/hydrochlorothiazide tab (EXFORGE HCT equiv) AONIU CHLORIDE INJ ammonium lactate cream (LACHYDRIN equiv) ammonium lactate lotion (LACHYDRIN equiv) AOXAPINE TAB amoxicillin cap (TRIOX equiv) amoxicillin chew tab (AOXIL equiv) AOXICILLIN CHEW TAB 250G amoxicillin susp (TRIOX equiv) amoxicillin tab (AOXIL equiv) amoxicillin/clavulanate chew tab (AUGENTIN equiv) amoxicillin/clavulanate ER tab (AUGENTIN XR equiv) amoxicillin/clavulanate susp (AUGENTIN ES equiv) amoxicillin/clavulanate tab (AUGENTIN equiv) amphetamine ER cap (ADDERALL XR equiv) amphetamine/dextroamphetamine tab (ADDERALL equiv) APHOTERICIN B INJ ampicillin cap (PRINCIPEN equiv) ampicillin susp (PRINCIPEN equiv) ampicillin/sulbactam inj APYRA TAB (= 2 tabs/day) ATURNIDE TAB ANADROL TAB ANAFRANIL CAP anagrelide cap (AGRYLIN equiv) ANALPRAE KIT ANALPRAHC CREA ANAPROX TAB ANAAZ ODT anastrozole tab (ARIIDEX equiv) ANCOBON CAP ANDRODER PATCH (= patch/day) ANDROGEL % 25G (= packet/day) ANDROGEL % 50G (= 2 packets/day) ANDROGEL.62%.25G (= packet/day) ANDROGEL.62% 2.5G (= 2 packets/day) ANDROGEL PUP % (= 4 bottles/0 days) ANDROGEL PUP.62% (= 2 bottles/0 days) ANDROID/TESTRED CAP ANDROXY TAB ANGELIQ TAB ANORO ELLIPTA INHALER ANTABUSE TAB ANTARA CAP antipyrine/benzocaine otic soln (AURALGAN equiv) ANTIVERT TAB ANUSOLHC CREA Special Code Tier Category CI ANTIHYPERTENSIVES INERALS & ELECTROLYTES DERATOLOGICALS DERATOLOGICALS ANTIDEPRESSANTS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS NC ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIFUNGALS PENICILLINS PENICILLINS PENICILLINS PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIHYPERTENSIVES ANDROGENSANABOLIC ANTIDEPRESSANTS HEATOLOGICAL AGENTS ISC. ANORECTAL AGENTS NC ANORECTAL AGENTS ANALGESICS ANTIINFLAATORY ULCER DRUGS ANTINEOPLASTICS AND ADJUNCTIVE ANTIFUNGALS PA 2 ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA 2 ANDROGENSANABOLIC PA 2 ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA 2 ANDROGENSANABOLIC PA ANDROGENSANABOLIC 2 ANDROGENSANABOLIC ESTROGENS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIHYPERLIPIDEICS NC OTIC AGENTS ANTIEETICS ANORECTAL AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Cont. Alphabetical Index ANUSOLHC SUPP ANZEET TAB (= 9 tabs/fill) APEXICON E CREA (PSORCON E equiv) APHTHASOL PASTE APIDRA INJ (Step Therapy requires trial of NOVOLOG) APIDRA SOLOSTAR INJ (Step Therapy requires trial of NOVOLOG) APLENZIN TAB APOKYN INJ (Only available through Walgreens 8884746) apraclonidine ophth soln (IOPIDINE equiv) apri tab (DESOGEN equiv) APRISO CAP APTIO TAB APTIVUS CAP APTIVUS SOLN ARALAST/PROLASTIN/ZEAIRA INJ ARALEN TAB aranelle tab (TRINORINYL equiv) ARANE INJ (Step Therapy requires trial of PROCRIT) ARAVA TAB ARCAPTA NEOHALER ARICEPT ODT (= tab/day) ARICEPT TAB (= 2 tabs/day) ARICEPT TAB 2G (= tab/day; Step Therapy requires trial of donepezil 0mg) ARIIDEX TAB aripiprazole tab (ABILIFY equiv) ARIXTRA INJ ARNUITY ELLIPTA INHALER AROASIN TAB ARTHROTEC TAB ARZERRA INJ ASACOL (HD)/LIALDA TAB ASANEX HFA INHALER ASANEX INHALER AIRIN CHEW TAB 75G (Covered for males age 4579 and females age 5579) aspirin chew tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin ec tab 25mg (Covered for males age 4579 and females age 5579) aspirin ec tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin tab 25mg (Covered for males age 4579 and females age 5579) aspirin tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin/codeine tab ASTELIN/ASTEPRO NASAL RAY Special Code Tier Category ST ST LD ST ST PA CI CI CI OTC OTC OTC OTC OTC OTC NC NC 2 NC $0 2 NC $0 2 $0 $0 $0 $0 $0 $0 ANORECTAL AGENTS ANTIEETICS DERATOLOGICALS OUTH/THROAT/DENTAL AGENTS ANTIDIABETICS ANTIDIABETICS ANTIDEPRESSANTS ANTIPARKINSON AGENTS OPHTHALIC AGENTS CONTRACEPTIVES GASTROINTESTINAL AGENTS ISC. ANTICONVULSANTS ANTIVIRALS ANTIVIRALS REIRATORY AGENTS ISC. ANTIALARIALS CONTRACEPTIVES HEATOPOIETIC AGENTS ANALGESICS ANTIINFLAATORY ANTIASTHATIC AND BRONCHODILATOR AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE ANTIPSYCHOTICS/ANTIANIC AGENTS ANTICOAGULANTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS ANTIINFLAATORY ANTINEOPLASTICS AND ADJUNCTIVE GASTROINTESTINAL AGENTS ISC. ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS OPIOID NASAL AGENTS SYSTEIC AND TOPICAL CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Cont. Alphabetical Index ATACAND HCT TAB ATELVIA TAB (Step Therapy requires trial of alendronate) atenolol tab (TENORIN equiv) atenolol/chlorthalidone tab (TENORETIC equiv) ATGA INJ ATIVAN TAB atorvastatin tab (LIPITOR equiv) atovaquone susp (EPRON equiv) atovaquone/proguanil tab (ALARONE equiv) ATRIPLA TAB atropine inj atropine ophth oint atropine ophth soln (ISOPTO ATROPINE equiv) ATROVENT HFA INHALER ATROVENT NASAL RAY AUBAGIO TAB (= tab/day) AUGENTIN ES600 SU AUGENTIN SU AUGENTIN TAB AUGENTIN XR TAB AURYXIA TAB AUVIQ INJ (= 2 inj/fill; Step Therapy requires trial of EPIPEN) AVALIDE TAB AVANDAET TAB AVANDARYL TAB AVANDIA TAB AVAPRO TAB AVAR AEROSOL FOA AVAR GEL AVAR PAD AVC VAGINAL CREA AVELOX TAB aviane tab (ALESSE equiv) AVINZA CAP (= 2 caps/day) AVODART CAP AVONEX INJ AXERT TAB (= 9 tabs/fill, 2 fills/0 days) AXID CAP AXID SOLN AXIRON SOLN (= 2 bottles/0 days) AYGESTIN TAB AZASAN TAB AZASITE SOLN azathioprine tab (IURAN equiv) azelastine nasal spray (ASTELIN/ASTEPRO equiv) azelastine ophth soln (OPTIVAR equiv) Special Code Tier Category ANTIHYPERTENSIVES ST ENDOCRINE AND ETABOLIC AGENTS ISC. CI BETA BLOCKERS CI ANTIHYPERTENSIVES ASSORTED CLASSES ANTIANXIETY AGENTS CI ANTIHYPERLIPIDEICS ANTIINFECTIVE AGENTS ISC. ANTIALARIALS ANTIVIRALS ULCER DRUGS OPHTHALIC AGENTS OPHTHALIC AGENTS CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS NASAL AGENTS SYSTEIC AND TOPICAL PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PENICILLINS PENICILLINS PENICILLINS PENICILLINS GASTROINTESTINAL AGENTS ISC. ST VASOPRESSORS ANTIHYPERTENSIVES CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS ANTIHYPERTENSIVES DERATOLOGICALS 2 DERATOLOGICALS NC DERATOLOGICALS 2 VAGINAL PRODUCTS FLUOROQUINOLONES $0 CONTRACEPTIVES ANALGESICS OPIOID GENITOURINARY AGENTS ISCELLANEOUS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. IGRAINE PRODUCTS ULCER DRUGS ULCER DRUGS PA ANDROGENSANABOLIC PROGESTINS ASSORTED CLASSES 2 OPHTHALIC AGENTS ASSORTED CLASSES NASAL AGENTS SYSTEIC AND TOPICAL OPHTHALIC AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Cont. Alphabetical Index AZELEX CREA AZENASE PAK AZILECT TAB azithromycin susp (ZITHROAX equiv) azithromycin tab (ZITHROAX equiv) AZOPT OPHTH SU AZOR TAB AZULFIDINE ENTABS AZULFIDINE TAB BACITRACIN OPHTH OINT bacitracin/ neomycin/ polymyxin b ophth oint (NEOORIN equiv) bacitracin/ polymyxin b ophth oint (POLYORIN equiv) bacitracin/ polymyxin/ neomycin/ hydrocortisone ophth oint (CORTIORIN equiv) BACLOFEN CREA COPOUND KIT baclofen tab BACTRI DS TAB BACTROBAN CREA BACTROBAN NASAL OINT BACTROBAN OINT balsalazide cap (COLAZAL equiv) BANZEL SU BANZEL TAB BARACLUDE TAB (= tab/day) BD INSULIN SYRINGE BD PEN NEEDLE bdonna tab (DONNATAL equiv) BECONASE AQ NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) BELBUCA FIL BELLADONNA ALKALOID/OPIU SUPP BELSORA TAB benazepril tab (LOTENSIN equiv) benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv) BENICAR HCT TAB BENICAR TAB BENTYL CAP BENTYL SYRUP BENTYL TAB BENZACLIN GEL BENZAYCIN GEL BENZAYCIN GEL PACK benzonatate cap (TESSALON equiv) benztropine tab BEPREVE OPHTH SOLN BESIVANCE OPHTH SU (Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA) BETAGAN OPHTH SOLN betamethasone augmented cream (DIPROLENE AF CREA equiv) betamethasone augmented gel (DIPROLENE GEL equiv) Special Code Tier Category PA DERATOLOGICALS NC NASAL AGENTS SYSTEIC AND TOPICAL 2 ANTIPARKINSON AGENTS ACROLIDES ACROLIDES 2 OPHTHALIC AGENTS ANTIHYPERTENSIVES GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. 2 OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS NC DERATOLOGICALS USCULOSKELETAL THERAPY AGENTS ANTIINFECTIVE AGENTS ISC. DERATOLOGICALS NASAL AGENTS SYSTEIC AND TOPICAL DERATOLOGICALS GASTROINTESTINAL AGENTS ISC. 2 ANTICONVULSANTS 2 ANTICONVULSANTS ANTIVIRALS CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 EDICAL DEVICES AND SUPPLIES NC ULCER DRUGS ST NASAL AGENTS SYSTEIC AND TOPICAL NC ANALGESICS OPIOID 2 ULCER DRUGS NC HYPNOTICS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES NC ANTIHYPERTENSIVES CI 2 ANTIHYPERTENSIVES ULCER DRUGS ULCER DRUGS ULCER DRUGS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS COUGH/COLD/ALLERGY ANTIPARKINSON AGENTS OPHTHALIC AGENTS ST OPHTHALIC AGENTS OPHTHALIC AGENTS DERATOLOGICALS DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Cont. Alphabetical Index betamethasone augmented lotion (DIPROLENE LOTION equiv) betamethasone augmented oint (DIPROLENE OINT equiv) betamethasone diproprionate cream (DIPROSONE CREA equiv) betamethasone diproprionate lotion betamethasone diproprionate oint (DIPROSONE OINT equiv) betamethasone valerate cream betamethasone valerate foam (LUXIQ FOA equiv) betamethasone valerate lotion betamethasone valerate oint BETAPACE AF TAB BETAPACE TAB BETASERON INJ betaxolol ophth soln (BETOPTICS equiv) betaxolol tab (KERLONE equiv) bethanechol tab (URECHOLINE equiv) BETHKIS NEB SOLN BETIOL OPHTH SOLN BETOPTICS OPHTH SOLN bexarotene cap (TARGRETIN equiv) BEXSERO INJ (Vaccines are covered for members 9 years or older) BEYAZ TAB BIAFINE EULSION BIAXIN SU BIAXIN TAB BIAXIN XL TAB bicalutamide tab (CASODEX equiv) BIFERARX TAB BILTRICIDE TAB bisoprolol tab (ZEBETA equiv) bisoprolol/hydrochlorothiazide tab (ZIAC equiv) BLEPH0 OPHTH SOLN BLEPHAIDE OPHTH SOLN BLEPHAIDE S.O.P. OPHTH OINT BONIVA TAB 50G (= tab/0 days; Step Therapy requires trial of alendronate) BOSULIF TAB BOTOX INJ BREO ELLIPTA INHALER BRETHINE TAB BRILINTA TAB (Restricted to Cardiology Specialist) brimonidine ophth soln (ALPHAGAN P equiv) BRISDELLE CAP BRIVIACT INJ 50G/5L BRIVIACT SOLN 0G/L BRIVIACT TAB bromfenac ophth soln (BRODAY equiv) Special Code Tier Category DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS BETA BLOCKERS BETA BLOCKERS NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OPHTHALIC AGENTS CI BETA BLOCKERS URINARY ANTIASODICS NC AINOGLYCOSIDES 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE VAC $0 VACCINES $0 CONTRACEPTIVES NC DERATOLOGICALS ACROLIDES ACROLIDES ACROLIDES ANTINEOPLASTICS AND ADJUNCTIVE NC HEATOPOIETIC AGENTS 2 ANTHELINTICS CI BETA BLOCKERS CI ANTIHYPERTENSIVES OPHTHALIC AGENTS 2 OPHTHALIC AGENTS OPHTHALIC AGENTS ST ENDOCRINE AND ETABOLIC AGENTS ISC. PASF ANTINEOPLASTICS AND ADJUNCTIVE NEUROUSCULAR AGENTS CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS RS HEATOLOGICAL AGENTS ISC. OPHTHALIC AGENTS NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. NC ANTICONVULSANTS NC ANTICONVULSANTS NC ANTICONVULSANTS OPHTHALIC AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Cont. Alphabetical Index BROFENAC OPHTH SOLN 0.09% (TWICE DAILY) bromocriptine cap (PARLODEL equiv) bromocriptine tab (PARLODEL equiv) BRONCOPECTOL SYRUP BROVANA NEB SOLN BSERENE PAD budesonide inh susp (PULICORT equiv) budesonide nasal spray (RHINOCORT AQUA equiv) (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) budesonide SR cap (ENTOCORT EC equiv) bumetanide tab (BUEX equiv) BUNAVAIL SL FIL BUPHENYL POWDER BUPHENYL TAB buprenorphine SL tab (SUBUTEX equiv) buprenorphine/naloxone SL tab (SUBOXONE equiv) bupropion ER tab (WELLBUTRIN equiv) bupropion SR tab (ZYBAN equiv) (Limited to 80 days/plan year) bupropion tab (WELLBUTRIN equiv) bupropion XL tab (WELLBUTRIN XL equiv) BUAR TAB buspirone tab (BUAR equiv) buspirone tab 0mg (BUAR equiv) BUSULFEX INJ butalbital/acetaminophen/caffeine tab (FIORICET equiv) BUTALBITAL/AIRIN/CAFFEINE TAB BUTISOL ELIXIR BUTISOL TAB butorphanol nasal spray (STADOL equiv) (= bottle/fill, 2 fills/0 days) BUTRANS PATCH (= 4 patches/28 days) BYDUREON INJ (= 4 inj/28 days) BYDUREON PEN INJ (= 4 inj/28 days) BYETTA INJ BYSTOLIC TAB cabergoline tab (DOSTINEX equiv) CABOETYX TAB CADUET TAB CAFCIT SOLN CAFERGOT TAB caffeine citrate soln (CAFCIT equiv) (Only covered for members less than year old) CALAN SR TAB CALAN TAB calcipotriene cream (DOVONEX CREA equiv) calcipotriene oint Special Code Tier Category OPHTHALIC AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS COUGH/COLD/ALLERGY ANTIASTHATIC AND BRONCHODILATOR AGENTS NC HEATOPOIETIC AGENTS CI ANTIASTHATIC AND BRONCHODILATOR AGENTS ST NASAL AGENTS SYSTEIC AND TOPICAL CORTICOSTEROIDS CI DIURETICS NC ANALGESICS OPIOID ENDOCRINE AND ETABOLIC AGENTS ISC. 2 ENDOCRINE AND ETABOLIC AGENTS ISC. ANALGESICS OPIOID ANALGESICS OPIOID ANTIDEPRESSANTS SKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS NC ANTIANXIETY AGENTS ANTINEOPLASTICS AND ADJUNCTIVE NC ANALGESICS NONNARCOTIC NC ANALGESICS NONNARCOTIC HYPNOTICS HYPNOTICS ANALGESICS OPIOID ANALGESICS OPIOID CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS ANTIDIABETICS CI 2 BETA BLOCKERS ENDOCRINE AND ETABOLIC AGENTS ISC. NC ANTINEOPLASTICS AND ADJUNCTIVE CARDIOVASCULAR AGENTS ISC. 2 ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS IGRAINE PRODUCTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CALCIU CHANNEL BLOCKERS CALCIU CHANNEL BLOCKERS DERATOLOGICALS DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 0 of 79
Cont. Alphabetical Index calcipotriene soln (DOVONEX SOLN equiv) calcipotriene/ betamethasone oint (TACLONEX equiv) calcitonin nasal spray (IACALCIN equiv) calcitriol cap (ROCALTROL equiv) calcitriol inj (CALCIJEX equiv) calcitriol soln (ROCALTROL equiv) calcium acetate cap (PHOSLO equiv) calcium acetate tab (ELIPHOS equiv) CALIBRATION LIQUID CALOIST NASAL RAY CABIA POWDER PACKET CAPRAL TAB CANASA SUPP CANCIDAS INJ candesartan tab (ATACAND equiv) candesartan/hydrochlorothiazide tab (ATACAND HCT equiv) CANTIL TAB CAPASTAT INJ capecitabine tab (XELODA equiv) CAPEX SHAPOO CAPITAL/CODEINE SU CAPOTEN TAB CAPRELSA TAB (Only available through Biologics 800850406) captopril tab (CAPOTEN equiv) CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB captopril/hydrochlorothiazide tab (CAPOZIDE equiv) CARAC CREA CARAFATE SU CARAFATE TAB CARBAGLU TAB (Only available through Accredo 88877776) carbamazepine chew tab (TEGRETOL equiv) carbamazepine ER cap (CARBATROL equiv) carbamazepine ER tab (TEGRETOL XR equiv) carbamazepine susp (TEGRETOL equiv) carbamazepine tab (TEGRETOL equiv) CARBATROL CAP carbidopa tab (LODOSYN equiv) CARBIDOPA/ LEVODOPA/ ENTACAPONE TAB (STALEVO equiv) carbidopa/levodopa ER tab (SINEET CR equiv) carbidopa/levodopa ODT (PARCOPA equiv) carbidopa/levodopa tab (SINEET equiv) carbinoxamine soln (PALGIC equiv) carbinoxamine tab (PALGIC equiv) CARDENE SR CAP CARDIZE CD CAP Special Code Tier Category DERATOLOGICALS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. CIOTC EDICAL DEVICES AND SUPPLIES NC HEATOPOIETIC AGENTS NC IGRAINE PRODUCTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. 2 GASTROINTESTINAL AGENTS ISC. ANTIFUNGALS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES ULCER DRUGS ANTIYCOBACTERIAL AGENTS ANTINEOPLASTICS AND ADJUNCTIVE DERATOLOGICALS ANALGESICS OPIOID ANTIHYPERTENSIVES LDPA ANTINEOPLASTICS AND ADJUNCTIVE CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES 2 DERATOLOGICALS ULCER DRUGS ULCER DRUGS LDPA ENDOCRINE AND ETABOLIC AGENTS ISC. ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTIPARKINSON AGENTS 2 ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIHISTAINES ANTIHISTAINES CALCIU CHANNEL BLOCKERS CALCIU CHANNEL BLOCKERS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Cont. Alphabetical Index CARDIZE LA TAB CARDIZE TAB CARDURA TAB CARDURA XL TAB carisoprodol tab (SOA equiv) carisoprodol tab 250mg (SOA equiv) carisoprodol/aspirin tab (SOA COPOUND equiv) carisoprodol/aspirin/codeine tab (SOA COPOUND/CODEINE equiv) CAROLHC CREA CARNITOR SOLN CARNITOR TAB carteolol ophth soln (OCUPRESS equiv) carvedilol tab (COREG equiv) CASODEX TAB CATAFLA TAB CATAPRES TAB CATAPRESTTS PATCH CAYSTON INH SOLN (Restricted to Infectious Disease or Pulmonology Specialist; Only available through Walgreens 8884746) CEDAX CAP CEDAX SU CEENU CAP cefaclor cap (CECLOR equiv) CEFACLOR ER TAB CEFACLOR SU cefadroxil cap (DURICEF equiv) cefadroxil susp (DURICEF equiv) cefadroxil tab (DURICEF equiv) cefazolin inj cefdinir cap (ONICEF equiv) cefdinir susp (ONICEF equiv) cefepime inj cefixime susp (SUPRAX equiv) CEFOTAN INJ cefotaxime inj cefotetan inj cefotetan inj (CEFOTAN equiv) cefoxitin inj cefpodoxime proxetil susp (VANTIN equiv) cefpodoxime proxetil tab (VANTIN equiv) cefprozil susp (CEFZIL equiv) cefprozil tab (CEFZIL equiv) ceftazidime inj CEFTIN SU CEFTIN TAB ceftriaxone inj cefuroxime susp (CEFTIN equiv) cefuroxime tab (CEFTIN equiv) Special Code Tier Category CALCIU CHANNEL BLOCKERS CALCIU CHANNEL BLOCKERS ANTIHYPERTENSIVES GENITOURINARY AGENTS ISCELLANEOUS USCULOSKELETAL THERAPY AGENTS NC USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. OPHTHALIC AGENTS CI BETA BLOCKERS ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS ANTIINFLAATORY ANTIHYPERTENSIVES ANTIHYPERTENSIVES LDRS ANTIINFECTIVE AGENTS ISC. CEPHALOORINS CEPHALOORINS 2 ANTINEOPLASTICS AND ADJUNCTIVE CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Cont. Alphabetical Index CELEBREX CAP (= 2 caps/day) celecoxib cap (CELEBREX equiv) (= 2 caps/day) CELEXA SOLN CELEXA TAB CELLCEPT CAP CELLCEPT SU CELLCEPT TAB CELONTIN CAP CENESTIN TAB CENTANY OINT cephalexin cap (KEFLEX equiv) cephalexin susp (KEFLEX equiv) CEPHALEXIN TAB CERDELGA CAP CEREZYE INJ CERVARIX INJ (Vaccines are covered for members 9 years or older) CERVICAL CAP CESAET CAP cesia tab (CYCLESSA equiv) cevimeline cap (EVOXAC equiv) CHANTIX PAK (Limited to 80 days/plan year) CHANTIX TAB (Limited to 80 days/plan year) CHEET CAP CHLORAPHENICOL INJ chlordiazepoxide cap (LIBRIU equiv) chlordiazepoxide/amitriptyline tab (LIBITROL equiv) chlordiazepoxide/clidinium cap (LIBRAX equiv) chlorhexidine gluconate soln (PERIDEX equiv) chloroquine tab (ARALEN equiv) chlorothiazide tab (DIURIL equiv) CHLOROTHIAZIDE TAB 250G chlorpheniramine ER cap chlorpromazine tab (THORAZINE equiv) CHLORPROPAIDE TAB chlorpropamide tab (DIABINESE equiv) CHLORTHALIDONE TAB chlorzoxazone tab (PARAFON FORTE equiv) CHOLBA CAP (Only available through Dohmen LSS 8442465226) cholecalciferol cap 50000 unit cholestyramine lite powder (QUESTRAN LITE equiv) cholestyramine lite powder pack (QUESTRAN LITE equiv) cholestyramine powder (QUESTRAN equiv) cholestyramine powder pack (QUESTRAN equiv) CHOLINE AGNESIU TRISALICYLATE TAB choline magnesium trisalicylate tab (TRILISATE equiv) CHROAGEN FA TAB CIALIS TAB 2.5G, 5G (Prior Authorization for BPH) ciclopirox cream (LOPROX CREA equiv) ciclopirox gel (LOPROX GEL equiv) Special Code Tier Category ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANTIDEPRESSANTS ANTIDEPRESSANTS ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES 2 ANTICONVULSANTS ESTROGENS DERATOLOGICALS CEPHALOORINS CEPHALOORINS CEPHALOORINS NC HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS VAC $0 VACCINES $0 EDICAL DEVICES ANTIEETICS $0 CONTRACEPTIVES OUTH/THROAT/DENTAL AGENTS SKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. SKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. 2 ANTIDOTES ANTIINFECTIVE AGENTS ISC. ANTIANXIETY AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. NC ULCER DRUGS OUTH/THROAT/DENTAL AGENTS ANTIALARIALS CI DIURETICS CI DIURETICS ANTIHISTAINES ANTIPSYCHOTICS/ANTIANIC AGENTS CI ANTIDIABETICS CI ANTIDIABETICS CI DIURETICS USCULOSKELETAL THERAPY AGENTS LDPA GASTROINTESTINAL AGENTS ISC. OTC NC VITAINS CI ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC HEATOPOIETIC AGENTS PA CARDIOVASCULAR AGENTS ISC. DERATOLOGICALS DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Cont. Alphabetical Index ciclopirox nail soln (PENLAC equiv) ciclopirox shampoo (LOPROX SHAPOO equiv) ciclopirox topical susp (LOPROX SU equiv) cidofovir inj cilostazol tab (PLETAL equiv) CILOXAN OPHTH OINT CILOXAN OPHTH SOLN cimetidine soln (TAGAET equiv) cimetidine tab (TAGAET equiv) CIZIA INJ (= 2 inj/28 days) CIPRO HC OTIC SU CIPRO SU CIPRO TAB CIPRO XR TAB CIPRODEX OTIC SU CIPROFLOXACIN 00G TAB ciprofloxacin ER tab (CIPRO XR equiv) ciprofloxacin ophth soln (CILOXAN equiv) CIPROFLOXACIN OTIC SOLN ciprofloxacin susp (CIPRO equiv) ciprofloxacin tab (CIPRO equiv) citalopram soln (CELEXA equiv) citalopram tab (CELEXA equiv) CLARIFOA EF FOA CLARINEX REDITAB CLARINEX SYRUP CLARINEX TAB CLARINEXD TAB clarithromycin ER tab (BIAXIN XL equiv) clarithromycin susp (BIAXIN equiv) clarithromycin tab (BIAXIN equiv) clemastine syrup (TAVIST equiv) clemastine tab (TAVIST equiv) CLEOCIN CAP CLEOCIN SOLN CLEOCIN VAGINAL CREA CLEOCIN VAGINAL SUPP CLEOCINT GEL CLEOCINT LOTION CLEOCINT PAD CLEOCINT SOLN CLIARA PATCH CLIARA PRO PATCH CLINDACIN KIT CLINDAGEL clindamycin cap (CLEOCIN equiv) clindamycin foam (EVOCLIN equiv) clindamycin gel (CLEOCIN GEL equiv) clindamycin lotion (CLEOCIN T equiv) clindamycin pad (CLEOCINT equiv) clindamycin soln (CLEOCIN equiv) Special Code Tier Category DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIVIRALS HEATOLOGICAL AGENTS ISC. OPHTHALIC AGENTS OPHTHALIC AGENTS ULCER DRUGS ULCER DRUGS PA GASTROINTESTINAL AGENTS ISC. OTIC AGENTS FLUOROQUINOLONES FLUOROQUINOLONES FLUOROQUINOLONES 2 OTIC AGENTS FLUOROQUINOLONES FLUOROQUINOLONES OPHTHALIC AGENTS 2 OTIC AGENTS FLUOROQUINOLONES FLUOROQUINOLONES ANTIDEPRESSANTS ANTIDEPRESSANTS DERATOLOGICALS PA ANTIHISTAINES PA ANTIHISTAINES PA ANTIHISTAINES NC COUGH/COLD/ALLERGY ACROLIDES ACROLIDES ACROLIDES ANTIHISTAINES ANTIHISTAINES ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. VAGINAL PRODUCTS VAGINAL PRODUCTS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ESTROGENS ESTROGENS NC DERATOLOGICALS DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. NC DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Cont. Alphabetical Index clindamycin topical soln (CLEOCINT equiv) clindamycin vaginal cream (CLEOCIN equiv) clindamycin/ benzoyl peroxide gel (DUAC GEL equiv) clindamycin/benzoyl peroxide gel (BENZACLIN equiv) CLINDESSE VAGINAL CREA CLINISTIX TEST STRIP CLINORIL TAB clobetasol E foam (OLUX E equiv) clobetasol foam (OLUX equiv) clobetasol lotion (CLOBEX equiv) clobetasol propionate cream (TEOVATE equiv) clobetasol propionate emollient cream (TEOVATE E equiv) clobetasol propionate gel (TEOVATE GEL equiv) clobetasol propionate oint (TEOVATE equiv) clobetasol propionate soln (TEOVATE equiv) clobetasol shampoo (CLOBEX equiv) clobetasol spray (CLOBEX equiv) CLOBEX LOTION CLOBEX SHAPOO CLOBEX RAY CLODER CREA/ CLOCORTOLONE CREA clomipramine cap (ANAFRANIL equiv) clonazepam ODT (KLONOPIN equiv) clonazepam tab (KLONOPIN equiv) clonidine ER tab (KAPVAY equiv) clonidine patch (CATAPRESTTS equiv) clonidine tab (CATAPRES equiv) clopidogrel tab 75mg (PLAVIX equiv) clorazepate tab (TRANXENET equiv) clotrimazole cream (LOTRIIN AF CREA equiv) clotrimazole troches (YCELEX TROCHES equiv) clotrimazole/betamethasone cream (LORTRISONE CREA equiv) clotrimazole/betamethasone lotion (LOTRISONE LOTION equiv) clozapine ODT 25mg, 00mg (CLOZAPINE/FAZACLO equiv) CLOZAPINE ODT/FAZACLO ODT clozapine tab (CLOZARIL equiv) CLOZARIL TAB COARTE TAB CODEINE SULFATE SOLN codeine sulfate tab COLAZAL CAP COLCHICINE TAB (COLCRYS equiv) COLCHICINE/ITIGARE CAP colchicine/probenecid tab (COLBENEID equiv) COLESTID GRANULE COLESTID POWDER PACK COLESTID TAB colestipol granule (COLESTID equiv) colestipol powder packet (COLESTID equiv) colestipol tab (COLESTID equiv) Special Code Tier Category DERATOLOGICALS VAGINAL PRODUCTS DERATOLOGICALS DERATOLOGICALS VAGINAL PRODUCTS CIOTC $0 DIAGNOSTIC PRODUCTS ANALGESICS ANTIINFLAATORY NC DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS DERATOLOGICALS ANTIDEPRESSANTS ANTICONVULSANTS ANTICONVULSANTS NC ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES HEATOLOGICAL AGENTS ISC. ANTIANXIETY AGENTS NC DERATOLOGICALS OUTH/THROAT/DENTAL AGENTS DERATOLOGICALS DERATOLOGICALS ANTIPSYCHOTICS/ANTIANIC AGENTS 2 ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIALARIALS ANALGESICS OPIOID ANALGESICS OPIOID GASTROINTESTINAL AGENTS ISC. 2 GOUT AGENTS NC GOUT AGENTS GOUT AGENTS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Cont. Alphabetical Index COLYYCIN S OTIC SU COLYYCINS OTIC SU COBIGAN OPHTH SOLN COBIPATCH COBIVENT INHALER COBIVENT REIAT INHALER COBIVIR TAB COETRIQ KIT (Only available through Diplomat Pharmacy 87797798) COPLERA TAB COTAN TAB CONCEPTROL GEL CONCERTA TAB CONDYLOX GEL CONDYLOX SOLN CONTRACEPTIVE FIL CONTRACEPTIVE FOA CONTRACEPTIVE GEL CONTRACEPTIVE SUPP COPAXONE INJ COPAXONE INJ 20G/L COPAXONE INJ 40G/L COPEGUS TAB CORDARONE TAB CORDRAN CREA CORDRAN LOTION CORDRAN TAPE COREG CR CAP COREG TAB CORGARD TAB CORLANOR TAB CORTANEB AQUEOUS OTIC SOLN CORTANEB OTIC SOLN CORTEF TAB CORTENEA CORTIFOA CORTISONE ACETATE TAB CORTIORIN CREA CORTIORIN OINT CORTIORIN OPHTH SOLN CORTIORIN OTIC SOLN CORZIDE TAB COSENTYX INJ COSOPT OPHTH SOLN COSOPT PF OPHTH SOLN COTELLIC TAB Special Code Tier Category CI CI LDPASF OTC OTC OTC OTC OTC PA PA 2 NC 2 2 2 $0 2 $0 $0 $0 $0 NC 2 2 NC OTIC AGENTS OTIC AGENTS OPHTHALIC AGENTS ESTROGENS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIVIRALS ANTINEOPLASTICS AND ADJUNCTIVE ANTIVIRALS ANTIPARKINSON AGENTS VAGINAL PRODUCTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS DERATOLOGICALS DERATOLOGICALS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIVIRALS ANTIARRHYTHICS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS BETA BLOCKERS BETA BLOCKERS BETA BLOCKERS CARDIOVASCULAR AGENTS ISC. OTIC AGENTS OTIC AGENTS CORTICOSTEROIDS ANORECTAL AGENTS ANORECTAL AGENTS CORTICOSTEROIDS DERATOLOGICALS DERATOLOGICALS OPHTHALIC AGENTS OTIC AGENTS ANTIHYPERTENSIVES DERATOLOGICALS OPHTHALIC AGENTS OPHTHALIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Cont. Alphabetical Index COUADIN TAB COVERAHS TAB COZAAR TAB CP CAP CREON CAP CRESEBA CAP CRESTOR TAB CRESTOR TAB 20G CRESYLATE OTIC SOLN CRINONE GEL CRIXIVAN CAP CROLO OPHTH SOLN cromolyn conc (GASTROCRO equiv) cromolyn neb soln (INTAL equiv) CROOLYN NEB SOLN cromolyn ophth soln (CROLO equiv) cryselle tab (OGESTREL equiv) CUBICIN INJ CUPRIINE CAP CUTIVATE CREA CUTIVATE LOTION CUTIVATE OINT CUVPOSA SOLN cyanocobalamin inj CYCLESSA TAB CYCLOBENZAPRINE COPOUND KIT cyclobenzaprine tab 0mg (FLEXERIL equiv) cyclobenzaprine tab 5mg (FLEXERIL equiv) cyclobenzaprine tab 7.5mg (FEXID equiv) CYCLOGYL OPHTH SOLN CYCLOYDRIL OPHTH SOLN cyclopentolate ophth soln (CYCLOGYL equiv) CYCLOPHOHAIDE CAP cyclophosphamide tab (CYTOXAN equiv) CYCLOSERINE CAP CYCLOSET TAB cyclosporine cap (SANDIUNE equiv) cyclosporine modified cap (NEORAL equiv) CYCLOORINE ODIFIED CAP 50G cyclosporine modified soln (NEORAL equiv) CYKLOKAPRON INJ CYBALTA CAP (= 2 caps/day) cyproheptadine syrup cyproheptadine tab CYSTAGON CAP (Only available through Pharmacare 800287828) CYSTARAN OPHTH SOLN (= 4 bottles/0 days) CYTOEL TAB Special Code Tier Category ANTICOAGULANTS CALCIU CHANNEL BLOCKERS ANTIHYPERTENSIVES ANTIHISTAINES 2 DIGESTIVE AIDS NC ANTIFUNGALS NC ANTIHYPERLIPIDEICS NC ANTIHYPERLIPIDEICS OTIC AGENTS PA 2 VAGINAL PRODUCTS ANTIVIRALS OPHTHALIC AGENTS GASTROINTESTINAL AGENTS ISC. CI ANTIASTHATIC AND BRONCHODILATOR AGENTS CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS OPHTHALIC AGENTS $0 CONTRACEPTIVES ANTIINFECTIVE AGENTS ISC. NC ASSORTED CLASSES DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS ULCER DRUGS HEATOPOIETIC AGENTS CONTRACEPTIVES NC USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS OPHTHALIC AGENTS 2 OPHTHALIC AGENTS OPHTHALIC AGENTS 2 ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE ANTIYCOBACTERIAL AGENTS ANTIDIABETICS ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES HEOSTATICS ANTIDEPRESSANTS ANTIHISTAINES ANTIHISTAINES LDPA GENITOURINARY AGENTS ISCELLANEOUS PA OPHTHALIC AGENTS THYROID AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Cont. Alphabetical Index CYTOTEC TAB CYTRA SYRUP D.H.E. INJ DAKLINZA TAB (= tab/day) DALIRE TAB danazol cap (DANOCRINE equiv) DANTRIU CAP dantrolene cap (DANTRIU equiv) DARAPRI TAB (Only available through Walgreens 8884746) darifenacin SR tab (ENABLEX equiv) DAYPRO TAB DAYTRANA PATCH DAZIDOX TAB DDAVP INJ DDAVP NASAL SOLN DDAVP NASAL RAY DDAVP TAB DECLOYCIN TAB DECONA ELIXIR DELZICOL CAP DEADEX TAB demeclocycline tab (DECLOYCIN equiv) DEEROL TAB DENAVIR CREA DEPAKENE CAP DEPAKENE SYRUP DEPAKOTE ER TAB DEPAKOTE RINKLE CAP DEPAKOTE TAB DEPEN TITRATAB DEPLIN CAP DEPOPROVERA INJ (= inj/90 days) DEPOPROVERA SC INJ 04G (= inj/90 days) DEPOTESTOSTERONE INJ DERASOOTH/FS OIL DERATOP CREA DERATOP OINT DEROTIC OIL DESCOVY TAB desipramine tab (NORPRAIN equiv) DESLORATADINE ODT desloratadine tab (CLARINEX equiv) desmopressin acetate inj (DDAVP equiv) desmopressin acetate nasal spray (DDAVP equiv) Special Code Tier Category PA LDPA PA PA PA PA 2 2 2 NC $0 ULCER DRUGS GENITOURINARY AGENTS ISCELLANEOUS IGRAINE PRODUCTS ANTIVIRALS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANDROGENSANABOLIC USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS ANTIALARIALS URINARY ANTIASODICS ANALGESICS ANTIINFLAATORY ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANALGESICS OPIOID ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. TETRACYCLINES COUGH/COLD/ALLERGY GASTROINTESTINAL AGENTS ISC. DIURETICS TETRACYCLINES ANALGESICS OPIOID DERATOLOGICALS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ASSORTED CLASSES DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS CONTRACEPTIVES CONTRACEPTIVES ANDROGENSANABOLIC DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS OTIC AGENTS ANTIVIRALS ANTIDEPRESSANTS ANTIHISTAINES ANTIHISTAINES ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Cont. Alphabetical Index desmopressin acetate tab (DDAVP equiv) desmopressin nasal soln (DDAVP equiv) DESOGEN TAB desonide cream desonide lotion desonide oint DESOWEN CREA KIT DESOWEN LOTION KIT DESOWEN OINT KIT desoximetasone cream 0.25% (TOPICORT CREA 0.25% equiv) desoximetasone gel (TOPICORT equiv) desoximetasone oint 0.25% (TOPICORT equiv) DESOXYN TAB DESVENLAFAXINE ER TAB (Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND venlafaxine product) DETROL LA CAP DETROL TAB DEXAETHASONE CONC dexamethasone elixir dexamethasone ophth soln dexamethasone soln DEXAETHASONE TAB dexamethasone tab (DECADRON equiv) DEXCHLORPHENIRAINE SYRUP DEXEDRINE CAP DEXILANT CAP (= cap/day; Step Therapy requires trial of omeprazole, pantoprazole, or rabeprazole) dexmethylphenidate ER cap (FOCALIN XR equiv) dexmethylphenidate tab (FOCALIN equiv) DEXPAK TAB dextroamphetamine ER cap (DEXEDRINE equiv) dextroamphetamine soln (PROCENTRA equiv) dextroamphetamine tab (DEXEDRINE equiv) DIABETA TAB DIABETIC ETER (all other diabetic meters) DIALYVITE TAB dialyvite tab (NEPHROVITE equiv) DIALYVITE/IRON TAB DIALYVITE/ZINC TAB DIAOX SEQUEL CAP DIAPHRAG DIATZ ZN TAB diazepam conc (VALIU equiv) DIAZEPA SOLN diazepam tab (VALIU equiv) Special Code Tier Category ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. CONTRACEPTIVES NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ST ANTIDEPRESSANTS URINARY ANTIASODICS URINARY ANTIASODICS CORTICOSTEROIDS CORTICOSTEROIDS OPHTHALIC AGENTS CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS ANTIHISTAINES ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ST ULCER DRUGS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CORTICOSTEROIDS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIDIABETICS OTC NC EDICAL DEVICES AND SUPPLIES ULTIVITAINS ULTIVITAINS ULTIVITAINS ULTIVITAINS DIURETICS $0 EDICAL DEVICES ULTIVITAINS ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Cont. Alphabetical Index DIAZEPA/DIASTAT RECTAL GEL DIBENZYLINE CAP diclofenac gel (SOLARAZE equiv) diclofenac gel % (VOLTAREN equiv) (= 5 tubes/fill) diclofenac potassium tab (CATAFLA equiv) diclofenac sodium EC tab (VOLTAREN equiv) diclofenac sodium ophth soln (VOLTAREN equiv) diclofenac sodium XR tab (VOLTAREN XR equiv) diclofenac soln.5% (PENNSAID equiv) diclofenac/misoprostol DR tab (ARTHROTEC equiv) dicloxacillin cap (DYNAPEN equiv) dicyclomine cap (BENTYL equiv) dicyclomine soln (BENTYL equiv) dicyclomine tab (BENTYL equiv) didanosine DR cap (VIDEX EC equiv) DIFFERIN CREA DIFFERIN GEL 0.% DIFFERIN GEL 0.% (Acne Only members age 25 or older require Prior Authorization) DIFFERIN LOTION DIFICID TAB (= 20 tabs/fill; Step Therapy requires trial of vancomycin cap) DIFLORASONE CREA diflorasone oint DIFLORASONE OINT (PSORCON equiv) DIFLUCAN SU DIFLUCAN TAB diflunisal tab (DOLOBID equiv) digoxin soln (LANOXIN equiv) digoxin tab (LANOXIN equiv) dihydroergotamine mesylate inj (D.H.E. equiv) DILACOR XR CAP DILANTIN CAP 00G DILANTIN CAP 0G DILANTIN INFATABS DILANTIN SU DILATRATE SR CAP DILAUDID TAB diltiazem ER cap (CARDIZE CD equiv) diltiazem ER cap (CARDIZE SR equiv) diltiazem ER cap (DILACOR XR equiv) diltiazem ER cap (TIAZAC equiv) diltiazem ER tab (CARDIZE LA equiv) diltiazem tab (CARDIZE equiv) DIOVAN HCT TAB DIOVAN TAB DIPENTU CAP diphenhydramine cap 50mg (BENADRYL equiv) (Only 50mg covered) diphenhydramine inj (BENADRYL equiv) diphenoxylate/atropine liquid (LOOTIL equiv) diphenoxylate/atropine tab (LOOTIL equiv) DIPROLENE AF CREA Special Code Tier Category ANTICONVULSANTS ANTIHYPERTENSIVES DERATOLOGICALS DERATOLOGICALS ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY OPHTHALIC AGENTS ANALGESICS ANTIINFLAATORY NC DERATOLOGICALS ANALGESICS ANTIINFLAATORY PENICILLINS ULCER DRUGS ULCER DRUGS ULCER DRUGS ANTIVIRALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS ST 2 ACROLIDES NC DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS ANTIFUNGALS ANTIFUNGALS ANALGESICS NONNARCOTIC CARDIOTONICS CARDIOTONICS IGRAINE PRODUCTS CALCIU CHANNEL BLOCKERS ANTICONVULSANTS 2 ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTIANGINAL AGENTS ANALGESICS OPIOID CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS ANTIHYPERTENSIVES ANTIHYPERTENSIVES GASTROINTESTINAL AGENTS ISC. ANTIHISTAINES ANTIHISTAINES ANTIDIARRHEALS ANTIDIARRHEALS DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 20 of 79
Cont. Alphabetical Index DIPROLENE LOTION DIPROLENE OINT dipyridamole tab (PERSANTINE equiv) disopyramide cap (NORPACE equiv) disopyramide ER cap (NORPACE CR equiv) disulfiram tab (ANTABUSE equiv) DITROPAN XL TAB DIURIL SU divalproex ER tab (DEPAKOTE ER equiv) divalproex sodium DR tab (DEPAKOTE equiv) divalproex sprinkle cap (DEPAKOTE equiv) DIVIGEL/ELESTRIN GEL DOLGIC PLUS TAB DOLOPHINE TAB DOETUSSDX LIQ donepezil ODT (ARICEPT equiv) (= tab/day) donepezil tab (ARICEPT equiv) (= 2 tabs/day) donepezil tab 2mg (ARICEPT equiv) (= tab/day; Step Therapy requires trial of donepezil 0mg) DONNATAL ELIXIR DONNATAL EXTENTABS DORAL TAB DORIBAX INJ DORYX TAB dorzolamide ophth soln (TRUSOPT equiv) dorzolamide/ timolol ophth soln (COSOPT equiv) DOVONEX CREA DOVONEX SOLN doxazosin tab (CARDURA equiv) doxepin cap (SINEQUAN equiv) DOXEPIN CAP 75G doxepin conc (SINEQUAN equiv) DOXEPIN/PRUDOXIN/ZONALON CREA doxercalciferol cap (HECTOROL equiv) doxycycline hyclate cap (VIBRAYCIN equiv) DOXYCYCLINE HYCLATE DR CAP doxycycline hyclate DR tab (DORYX equiv) doxycycline hyclate DR tab 200mg (DORYX equiv) doxycycline hyclate tab (VIBRATAB equiv) doxycycline monohydrate cap 00mg (ONODOX equiv) doxycycline monohydrate cap 50mg (ONODOX equiv) doxycycline monohydrate cap 50mg (ONODOX equiv) doxycycline monohydrate cap 75mg (ONODOX equiv) doxycycline monohydrate tab (ADOXA equiv) doxycycline monohydrate tab 50mg (ADOXA equiv) doxycycline susp (VIBRAYCIN equiv) DOXYCYCLINE/ORACEA CAP DRISDOL CAP Special Code Tier Category DERATOLOGICALS DERATOLOGICALS HEATOLOGICAL AGENTS ISC. ANTIARRHYTHICS ANTIARRHYTHICS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. URINARY ANTIASODICS CI 2 DIURETICS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ESTROGENS NC ANALGESICS NONNARCOTIC ANALGESICS OPIOID NC COUGH/COLD/ALLERGY PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ST PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. NC ULCER DRUGS NC ULCER DRUGS NC HYPNOTICS ANTIINFECTIVE AGENTS ISC. TETRACYCLINES OPHTHALIC AGENTS OPHTHALIC AGENTS DERATOLOGICALS DERATOLOGICALS CI ANTIHYPERTENSIVES ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. TETRACYCLINES TETRACYCLINES TETRACYCLINES NC TETRACYCLINES TETRACYCLINES TETRACYCLINES TETRACYCLINES TETRACYCLINES TETRACYCLINES TETRACYCLINES NC TETRACYCLINES TETRACYCLINES DERATOLOGICALS VITAINS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Cont. Alphabetical Index DRITHOSCALP CREA dronabinol cap (ARINOL equiv) DROXIA CAP DRYSOL SOLN DUAC CS KIT DUAC GEL DUAVEE TAB DUETACT TAB DULERA INHALER duloxetine EC cap (CYBALTA equiv) (= 2 caps/day) DUONEB NEB SOLN DUOPA ENTERAL SU DURAGESIC PATCH DUREZOL OPHTH EULSION dutasteride cap (AVODART equiv) dutasteride/tamsulosin cap (JALYN equiv) DUTOPROL TAB DYAZIDE CAP DYISTA NASAL RAY DYNACIN TAB DYNACIRC CR TAB DYRENIU CAP econazole cream (ECTAZOLE CREA equiv) ECOZA FOA EDARBI TAB EDARBYCLOR TAB EDECRIN TAB EDLUAR SL TAB EDURANT TAB EFFEXOR TAB EFFEXOR XR CAP EFFIENT TAB EFUDEX CREA EFUDEX SOLN EGRIFTA INJ ELAPRASE INJ ELDEPYRL CAP ELELYSO INJ ELESTAT OPHTH SOLN ELIDEL CREA ELIGEN B2 TAB ELIITE CREA ELIPHOS TAB ELIQUIS TAB ELIXOPHYLLIN ELIXIR Special Code Tier Category PA CI CI PA CI CI CI 2 NC 2 NC 2 2 2 NC 2 NC 2 NC 2 NC 2 2 DERATOLOGICALS ANTIEETICS HEATOPOIETIC AGENTS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ESTROGENS ANTIDIABETICS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIDEPRESSANTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIPARKINSON AGENTS ANALGESICS OPIOID OPHTHALIC AGENTS GENITOURINARY AGENTS ISCELLANEOUS GENITOURINARY AGENTS ISCELLANEOUS ANTIHYPERTENSIVES DIURETICS NASAL AGENTS SYSTEIC AND TOPICAL TETRACYCLINES CALCIU CHANNEL BLOCKERS DIURETICS DERATOLOGICALS DERATOLOGICALS ANTIHYPERTENSIVES ANTIHYPERTENSIVES DIURETICS HYPNOTICS ANTIVIRALS ANTIDEPRESSANTS ANTIDEPRESSANTS HEATOLOGICAL AGENTS ISC. DERATOLOGICALS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIPARKINSON AGENTS HEATOPOIETIC AGENTS OPHTHALIC AGENTS DERATOLOGICALS DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS DERATOLOGICALS GASTROINTESTINAL AGENTS ISC. ANTICOAGULANTS ANTIASTHATIC AND BRONCHODILATOR AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 22 of 79
Cont. Alphabetical Index ELLA TAB ELIRON CAP ELOCON CREA ELOCON OINT ELOCON SOLN EADINE OPHTH SOLN EBEDA CAP ECYT CAP EEND CAP (= caps/fill; Restricted to Oncology or Hematology Specialist) EEND PAK (= caps/fill; Restricted to Oncology or Hematology Specialist) ELA CREA ESA PATCH ETRIVA CAP ETRIVA SOLN ENABLEX TAB enalapril tab (VASOTEC equiv) enalapril/hydrochlorothiazide tab (VASERETIC equiv) ENBREL INJ (= 4 inj/28 days) ENBREL SURECLICK INJ (= 4 inj/28 days) ENDOETRIN INSERT ENGERIXB INJ (Vaccines are covered for members 9 years or older) ENGERIXB/RECOBIVAXHB (Vaccines are covered for members 9 years or older) ENJUVIA TAB enoxaparin inj (LOVENOX equiv) (= 7 days supply) enpresse tab (TRILEVELEN equiv) ENSTILAR FOA entacapone tab (COTAN equiv) entecavir tab (BARACLUDE equiv) (= tab/day) ENTOCORT EC CAP ENTRESTO TAB ENVARSUS XR TAB EPIDUO (FORTE) GEL (Acne Only members age 25 or older require Prior Authorization) EPIFOA AEROSOL epinastine opthth soln (ELESTAT equiv) EPINEPHRINE INJ (= 2 inj/fill; Step Therapy requires trial of EPIPEN) EPIPEN INJ (= 2 inj/fill) EPIPENJR INJ (= 2 inj/fill) EPIVIR HBV SOLN EPIVIR HBV TAB EPIVIR SOLN EPIVIR TAB eplerenone tab (INRA equiv) EPOGEN INJ EPROSARTAN TAB EPZICO TAB EQUETRO CAP ERAXIS INJ Special Code Tier Category $0 CONTRACEPTIVES 2 GENITOURINARY AGENTS ISCELLANEOUS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS OPHTHALIC AGENTS ANALGESICS OPIOID 2 ANTINEOPLASTICS AND ADJUNCTIVE RS 2 ANTIEETICS RS 2 ANTIEETICS DERATOLOGICALS ANTIDEPRESSANTS ANTIVIRALS ANTIVIRALS PA URINARY ANTIASODICS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES PA ANALGESICS ANTIINFLAATORY PA ANALGESICS ANTIINFLAATORY PA 2 VAGINAL PRODUCTS VAC $0 VACCINES VAC $0 VACCINES ESTROGENS ANTICOAGULANTS $0 CONTRACEPTIVES NC DERATOLOGICALS ANTIPARKINSON AGENTS ANTIVIRALS CORTICOSTEROIDS NC CARDIOVASCULAR AGENTS ISC. NC ASSORTED CLASSES PA 2 DERATOLOGICALS 2 DERATOLOGICALS OPHTHALIC AGENTS ST VASOPRESSORS 2 VASOPRESSORS 2 VASOPRESSORS ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTIVIRALS CI ANTIHYPERTENSIVES HEATOPOIETIC AGENTS ANTIHYPERTENSIVES ANTIVIRALS 2 ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIFUNGALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Cont. Alphabetical Index ergoloid mesylates tab (HYDERGINE equiv) ERGOLOID ESYLATES TAB ERGOAR SL TAB ERIVEDGE CAP ERTACZO CREA ERYPED SU ERYTAB ERYTHROYCIN CAP erythromycin DR cap (ERYC equiv) erythromycin ethylsuccinate tab (E.E.S. equiv) ERYTHROYCIN ETHYLSUCCINATE TAB erythromycin gel erythromycin ophth oint erythromycin pad erythromycin soln erythromycin stearate tab ERYTHROYCIN TAB (all forms except PCE) erythromycin/benzoyl peroxide gel (BENZAYCIN equiv) erythromycin/sulfisoxazole susp (PEDIAZOLE equiv) ESBRIET CAP (= 9 caps/day) ESCAVITE CHEW TAB escitalopram soln (LEXAPRO equiv) escitalopram tab (LEXAPRO equiv) esomeprazole cap (NEXIU equiv) ESOEPRAZOLE STRONTIU CAP estazolam tab (PROSO equiv) esterified estrogens/methyltestosterone tab (ESTRATEST equiv) ESTRACE TAB ESTRACE VAGINAL CREA estradiol patch (CLIARA equiv) estradiol patch (VIVELLEDOT equiv) estradiol tab (ESTRACE equiv) estradiol/norethindrone tab (ACTIVELLA equiv) ESTRASORB EULSION ESTRATEST TAB ESTRING ( copays per Rx) ESTROPIPATE TAB estropipate tab (OGEN equiv) ESTROSTEP FE TAB eszopiclone tab (LUNESTA equiv) (= tab/day) ethambutol tab (YABUTOL equiv) ethosuximide cap (ZARONTIN equiv) ethosuximide soln (ZARONTIN equiv) ETHYOL INJ etidronate disodium tab 200mg (DIDRONEL equiv) ETIDRONATE DISODIU TAB 400G etodolac cap (LODINE equiv) Special Code Tier Category PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. IGRAINE PRODUCTS PASF ANTINEOPLASTICS AND ADJUNCTIVE DERATOLOGICALS 2 ACROLIDES ACROLIDES ACROLIDES ACROLIDES ACROLIDES 2 ACROLIDES DERATOLOGICALS OPHTHALIC AGENTS DERATOLOGICALS DERATOLOGICALS ACROLIDES ACROLIDES DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. PASF REIRATORY AGENTS ISC. ULTIVITAINS ANTIDEPRESSANTS ANTIDEPRESSANTS PA ULCER DRUGS NC ULCER DRUGS HYPNOTICS NC ESTROGENS ESTROGENS 2 VAGINAL PRODUCTS ESTROGENS ESTROGENS ESTROGENS ESTROGENS ESTROGENS NC ESTROGENS 2 VAGINAL PRODUCTS ESTROGENS ESTROGENS CONTRACEPTIVES HYPNOTICS ANTIYCOBACTERIAL AGENTS ANTICONVULSANTS ANTICONVULSANTS ANTINEOPLASTICS AND ADJUNCTIVE ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANALGESICS ANTIINFLAATORY CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 24 of 79
Cont. Alphabetical Index etodolac ER tab (LODINE XL equiv) etodolac tab etoposide cap (VEPESID equiv) EURAX CREA EURAX LOTION EVAIST RAY EVISTA TAB EVOTAZ TAB EVOXAC CAP EVZIO INJ EXELDER CREA EXELDER SOLN EXELON CAP EXELON PATCH EXELON SOLN exemestane tab (AROASIN equiv) EXFORGE HCT TAB EXFORGE TAB EXJADE TAB EXTAVIA INJ (Step Therapy requires trial of 2: AVONEX, COPAXONE, or PLEGRIDY) FABIOR AEROSOL FOA FABRAZYE INJ FACTIVE TAB FALESSA KIT FALESSA TAB famciclovir tab (FAVIR equiv) famotidine susp (PEPCID equiv) famotidine tab (PEPCID equiv) FAVIR TAB FANAPT TAB (= 2 tabs/day) FANSIDAR TAB FARESTON TAB FARXIGA TAB (= tab/day) FARYDAK CAP (= 6 caps/2 days) FAZACLO ODT 25G, 00G felbamate susp (FELBATOL equiv) felbamate tab (FELBATOL equiv) FELBATOL SU FELBATOL TAB FELDENE CAP felodipine ER tab (PLENDIL equiv) FE PH GEL FEALE CONDOS Special Code Tier Category ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANTINEOPLASTICS 2 DERATOLOGICALS DERATOLOGICALS ESTROGENS ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIVIRALS OUTH/THROAT/DENTAL AGENTS NC ANTIDOTES DERATOLOGICALS DERATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIDOTES ST PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. NC DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. FLUOROQUINOLONES NC CONTRACEPTIVES NC DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS ANTIVIRALS ULCER DRUGS ULCER DRUGS ANTIVIRALS PA ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIALARIALS 2 ANTINEOPLASTICS AND ADJUNCTIVE CI 2 ANTIDIABETICS PA ANTINEOPLASTICS AND ADJUNCTIVE ANTIPSYCHOTICS/ANTIANIC AGENTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS 2 ANTICONVULSANTS ANALGESICS ANTIINFLAATORY CI CALCIU CHANNEL BLOCKERS VAGINAL PRODUCTS OTC $0 EDICAL DEVICES CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 25 of 79
Cont. Alphabetical Index FEARA TAB FECON FE CHEW TAB FEHRT TAB FERING ( copays per Rx) fenofibrate cap (ANTARA equiv) fenofibrate tab (TRICOR equiv) fenofibric acid DR cap (TRILIPIX equiv) FENOFIBRIC TAB/FIBRICOR TAB FENOGLIDE TAB/FENOFIBRATE TAB 40G, 20G fenoprofen calcium tab fentanyl citrate lollipop (ACTIQ equiv) (= 20 lozenges/0 days) fentanyl patch (DURAGESIC equiv) FENTORA TAB (= 20 tabs/0 days) ferrex 50 forte cap ferrex 50 forte cap (NIFEREX 50 FORTE equiv) FERREX 28 TAB FERRIPROX SOLN (Only available through Ferriprox Total Care 866758707) FERRIPROX TAB (Only available through Ferriprox Total Care 866758707) ferrous sulfate elixir (Covered for members year or younger) FERROUS SULFATE LIQUID (Covered for members year or younger) ferrous sulfate soln (Covered for members year or younger) FERROUS SULFATE SYRUP (Covered for members year or younger) FETZIA CAP (= cap/day) FETZIA TITRATION PACK (= cap/day) FEXID TAB FINACEA FOA FINACEA GEL FINACEA PLUS KIT finasteride tab (PROSCAR equiv) finasteride tab (PROPECIA equiv) FIRAGON INJ FIRST DUKES OUTHWASH FIRST ARYS OUTHWASH FIRST OUTHWASH BL FIRST OEPRAZOLE SU FLAGYL CAP FLAGYL ER TAB FLAGYL TAB FLAREX OPHTH SU flavoxate tab (URIAS equiv) flecainide tab (TABOCOR equiv) FLECTOR PATCH (= 0 patches/fill) FLEXERIL TAB FLOAX CAP FLONASE NASAL RAY (= 2 bottles/fill) FLOPRED SU FLORIVA CHEW TAB Special Code Tier Category CI CI NC PA PA LDPA LDPA OTC $0 OTC $0 OTC $0 OTC $0 PA PA 2 2 2 NC PA NC NC ANTINEOPLASTICS AND ADJUNCTIVE CONTRACEPTIVES ESTROGENS VAGINAL PRODUCTS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANALGESICS ANTIINFLAATORY ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS ANTIDOTES ANTIDOTES HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS ANTIDEPRESSANTS ANTIDEPRESSANTS USCULOSKELETAL THERAPY AGENTS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS GENITOURINARY AGENTS ISCELLANEOUS DERATOLOGICALS ANTINEOPLASTICS AND ADJUNCTIVE OUTH/THROAT/DENTAL AGENTS OUTH/THROAT/DENTAL AGENTS OUTH/THROAT/DENTAL AGENTS ULCER DRUGS ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. OPHTHALIC AGENTS URINARY ANTIASODICS ANTIARRHYTHICS DERATOLOGICALS USCULOSKELETAL THERAPY AGENTS GENITOURINARY AGENTS ISCELLANEOUS NASAL AGENTS SYSTEIC AND TOPICAL CORTICOSTEROIDS ULTIVITAINS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 26 of 79
Cont. Alphabetical Index FLOVENT DISKUS INHALER FLOVENT HFA INHALER FLUBLOK INJ (Vaccines are covered for members 9 years or older) FLUCELVAX INJ (Vaccines are covered for members 9 years or older) fluconazole susp (DIFLUCAN equiv) fluconazole tab (DIFLUCAN equiv) flucytosine cap (ANCOBON equiv) fludarabine inj fludrocortisone tab (FLORINEF equiv) FLUADINE TAB FLUIST NASAL LIQUID (Vaccines are covered for members 9 years or older) FLUIST QUADRIVALENT NASAL (Vaccines are covered for members 9 years or older) flunisolide nasal spray (NASAREL equiv) (= 2 bottles/fill) fluocinolone acetonide cream fluocinolone acetonide oil (DERASOOTH/FS equiv) fluocinolone acetonide oint fluocinolone acetonide soln fluocinolone otic oil (DEROTIC equiv) fluocinonide cream (LIDEX equiv) fluocinonide emollient cream fluocinonide gel fluocinonide oint fluocinonide soln FLUORABON SOLN (Covered at $0 for members 5 years or younger; All other members covered at preferred brand copay) FLUORAC CREA FLUORADAY CHEW TAB fluorometholone ophth soln (FL LIQUIFIL equiv) FLUOROPLEX CREA fluorouracil cream (EFUDEX CREA equiv) fluorouracil soln (EFUDEX SOLN equiv) fluoxetine cap (PROZAC equiv) FLUOXETINE CAP (PDD) fluoxetine soln (PROZAC equiv) fluoxetine tab (PROZAC equiv) FLUOXETINE TAB 60G fluoxetine weekly cap (PROZAC equiv) fluphenazine tab (PROLIXIN equiv) flurandrenolide Cream (CORDRAN equiv) FLURAZEPA CAP flurbiprofen ophth soln (OCUFEN equiv) flurbiprofen tab (ANSAID equiv) flutamide cap (EULEXIN equiv) fluticasone nasal spray (FLONASE equiv) (= 2 bottles/fill) fluticasone propionate cream (CUTIVATE equiv) Special Code Tier Category CI ANTIASTHATIC AND BRONCHODILATOR AGENTS CI ANTIASTHATIC AND BRONCHODILATOR AGENTS VAC $0 VACCINES VAC $0 VACCINES ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTINEOPLASTICS AND ADJUNCTIVE CORTICOSTEROIDS ANTIVIRALS VAC $0 VACCINES VAC $0 VACCINES NASAL AGENTS SYSTEIC AND TOPICAL DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS OTIC AGENTS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS $0 INERALS & ELECTROLYTES NC DERATOLOGICALS INERALS & ELECTROLYTES OPHTHALIC AGENTS 2 DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIDEPRESSANTS NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIDEPRESSANTS ANTIDEPRESSANTS NC ANTIDEPRESSANTS NC ANTIDEPRESSANTS ANTIPSYCHOTICS/ANTIANIC AGENTS DERATOLOGICALS HYPNOTICS OPHTHALIC AGENTS ANALGESICS ANTIINFLAATORY ANTINEOPLASTICS AND ADJUNCTIVE NASAL AGENTS SYSTEIC AND TOPICAL DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 27 of 79
Cont. Alphabetical Index fluticasone propionate lotion (CUTIVATE equiv) fluticasone propionate oint (CUTIVATE equiv) fluvastatin cap (LESCOL equiv) fluvastatin ER tab (LESCOL XL equiv) FLUVIRIN INJ (Vaccines are covered for members 9 years or older) FLUVIRIN PF INJ (Vaccines are covered for members 9 years or older) fluvoxamine ER cap (LUVOX CR equiv) (Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine) fluvoxamine tab (LUVOX equiv) FLUZONE HIGH DOSE PF INJ (Vaccines are covered for members 9 years or older) FLUZONE INTRADERAL (Vaccines are covered for members 9 years or older) FLUZONE QUADRIVALENT INJ (Vaccines are covered for members 9 years or older) FLUZONE/FLUARIX QUAD INJ (Vaccines are covered for members 9 years or older) FLUZONE/FLULAVAL QUAD INJ (Vaccines are covered for members 9 years or older) FL FORTE OPHTH SU FL LIQUIFLI OPHTH SU FL S.O.P. OPHTH OINT FOCALIN TAB FOCALIN XR CAP FOCALIN XR CAP 25G, 5G folbee plus CZ tab (DIATX ZN equiv) FOLBEE PLUS TAB folbee tab folbic tab (FOLTX equiv) folic acid tab mg (Covered at $0 for females only; All other members covered at generic copay) folic acid tab 400mcg (Covered for females only) folic acid tab 800mcg (Covered for females only) fondaparinux inj (ARIXTRA equiv) FORADIL AEROLIZER FORTAVIT CAP FORTEO INJ FORTESTA GEL/ TESTOSTERONE GEL (= 2 bottles/0 days) FORTICAL NASAL RAY FOSAAX TAB FOSAAX+D TAB FOSCARNET INJ fosinopril tab (ONOPRIL equiv) fosinopril/hydrochlorothiazide tab (ONOPRIL HCT equiv) FOSRENOL CHEW TAB FOSRENOL POWDER PACK FRAGIN INJ Special Code Tier Category NC DERATOLOGICALS DERATOLOGICALS CI ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS VAC $0 VACCINES VAC $0 VACCINES ST ANTIDEPRESSANTS ANTIDEPRESSANTS VAC $0 VACCINES VAC $0 VACCINES VAC $0 VACCINES VAC $0 VACCINES VAC $0 VACCINES OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ULTIVITAINS ULTIVITAINS HEATOPOIETIC AGENTS DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS $0 HEATOPOIETIC AGENTS OTC $0 HEATOPOIETIC AGENTS OTC $0 HEATOPOIETIC AGENTS PA ANTICOAGULANTS CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS ULTIVITAINS ENDOCRINE AND ETABOLIC AGENTS ISC. PA ANDROGENSANABOLIC 2 ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIVIRALS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES 2 GASTROINTESTINAL AGENTS ISC. 2 GASTROINTESTINAL AGENTS ISC. ANTICOAGULANTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 28 of 79
Cont. Alphabetical Index FREESTYLE FREEDO LITE ETER FREESTYLE INSULIN SYRINGE FREESTYLE INSULINX ETER FREESTYLE INSULINX TEST STRIP FREESTYLE LITE ETER FREESTYLE LITE TEST STRIP FREESTYLE TEST STRIP FROVA TAB (= 9 tabs/fill, 2 fills/0 days) frovatriptan tab (FROVA equiv) (= 9 tabs/fill, 2 fills/0 days) FULYZAQ TAB FURADANTIN SU FUROSEIDE SOLN furosemide soln (LASIX equiv) furosemide tab (LASIX equiv) FUZEON INJ FYCOPA TAB gabapentin cap (NEURONTIN equiv) gabapentin soln (NEURONTIN equiv) gabapentin tab (NEURONTIN equiv) GABITRIL TAB GABITRIL TAB 2G, 6G galantamine ER cap (RAZADYNE ER equiv) GALANTAINE SOLN galantamine tab (RAZADYNE equiv) GALZIN CAP GAASTAN S/D INJ GAUNEX INJ GANCICLOVIR CAP GARDASIL 9 INJ (Vaccines are covered for members 9 years or older) GARDASIL INJ (Vaccines are covered for members 9 years or older) GASTROCRO CONC gatifloxacin ophth soln (ZYAXID equiv) (Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA) GATTEX KIT gavilyteh kit GAZYVA INJ GELCLAIR GEL GELNIQUE gemfibrozil tab (LOPID equiv) GENOTROPIN/HUATROPE/ZOACTON INJ gentamicin ophth oint (GARAYCIN equiv) gentamicin ophth soln (GARAYCIN equiv) gentamicin sulfate cream gentamicin sulfate oint GENVOYA TAB GEODON CAP gianvi tab/ ocella tab (YAZ/YASIN equiv) Special Code Tier Category CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 DIAGNOSTIC PRODUCTS CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 DIAGNOSTIC PRODUCTS CIOTC $0 DIAGNOSTIC PRODUCTS IGRAINE PRODUCTS IGRAINE PRODUCTS NC ANTIDIARRHEALS 2 URINARY ANTIINFECTIVES CI DIURETICS CI DIURETICS CI DIURETICS ANTIVIRALS NC ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. 2 INERALS & ELECTROLYTES PASSIVE IUNIZING AGENTS PASSIVE IUNIZING AGENTS 2 ANTIVIRALS VAC $0 VACCINES VAC $0 VACCINES 2 GASTROINTESTINAL AGENTS ISC. ST OPHTHALIC AGENTS NC GASTROINTESTINAL AGENTS ISC. NC LAXATIVES NC ANTINEOPLASTICS AND ADJUNCTIVE NC OUTH/THROAT/DENTAL AGENTS URINARY ANTIASODICS CI ANTIHYPERLIPIDEICS NC ENDOCRINE AND ETABOLIC AGENTS ISC. OPHTHALIC AGENTS OPHTHALIC AGENTS DERATOLOGICALS DERATOLOGICALS ANTIVIRALS ANTIPSYCHOTICS/ANTIANIC AGENTS NC CONTRACEPTIVES CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 29 of 79
Cont. Alphabetical Index GILENYA CAP (= cap/day) GILOTRIF TAB (= tab/day, Only available through Accredo 88877776) GILTUSS LIQUID GILTUSS TR TAB glatopa inj 20mg/ml (COPAXONE equiv) GLEEVEC TAB ( ) GLEOSTINE/LOUSTINE CAP glimepiride tab (AARYL equiv) glipizide ER tab (GLUCOTROL XL equiv) glipizide tab (GLUCOTROL equiv) glipizide/metformin tab (ETAGLIP equiv) GLUCAGEN HYPOKIT INJ GLUCAGEN INJ GLUCAGON INJ KIT GLUCOPHAGE TAB GLUCOPHAGE XR TAB GLUCOTROL TAB GLUCOTROL XL TAB GLUCOVANCE TAB glyburide micronized tab (GLYNASE equiv) glyburide tab (ICRONASE equiv) glyburide/metformin tab (GLUCOVANCE equiv) GLYCATE TAB.5G glycopyrrolate tab (ROBINUL equiv) GLYNASE TAB GLYSET TAB GORDON'S UREA OINT 40% GRALISE TAB granisetron tab (KYTRIL equiv) (= 9 tabs/fill) GRANISOL SOLN (= 60ml/fill) GRANIX INJ GRASTEK SL TAB GRIFULVIN V TAB griseofulvin micro tab (GRIFULVIN V equiv) griseofulvin susp (GRIFULVIN equiv) griseofulvin tab (GRIEG equiv) GRIEG TAB guaifenesin tab (ALLFEN JR equiv) guaifenesin/codeine syrup (TUSSIORGANIDINS equiv) (= 240ml/fill) GUANABENZ TAB guanfacine ER tab (INTUNIV equiv) guanfacine IR tab (TENEX equiv) GUANIDINE TAB GYNAZOLE CREA HALCION TAB Special Code Tier Category PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. LDPA ANTINEOPLASTICS AND ADJUNCTIVE COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PASF ANTINEOPLASTICS AND ADJUNCTIVE 2 ANTINEOPLASTICS AND ADJUNCTIVE CI ANTIDIABETICS CI ANTIDIABETICS CI ANTIDIABETICS CI ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 DIAGNOSTIC PRODUCTS CI 2 ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS CI ANTIDIABETICS CI ANTIDIABETICS CI ANTIDIABETICS NC ULCER DRUGS ULCER DRUGS ANTIDIABETICS ANTIDIABETICS 2 DERATOLOGICALS NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIEETICS ANTIEETICS HEATOPOIETIC AGENTS NC BIOLOGICALS ISC ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS NC COUGH/COLD/ALLERGY OTC COUGH/COLD/ALLERGY ANTIHYPERTENSIVES ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CI ANTIHYPERTENSIVES ANTIYASTHENIC/CHOLINERGIC AGENTS VAGINAL PRODUCTS HYPNOTICS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 0 of 79
Cont. Alphabetical Index HALFLYTELY BOWEL PREP KIT halobetasol propionate cream (ULTRAVATE equiv) halobetasol propionate oint (ULTRAVATE equiv) HALOG CREA HALOG OINT halonate pac kit (ULTRAVATE KIT equiv) haloperidol lactate conc (HALDOL equiv) haloperidol tab (HALDOL equiv) HARVONI TAB (= tab/day) HAVRIX/VAQTA INJ (Vaccines are covered for members 9 years or older) HECTOROL CAP HEANGEOL SOLN HEPSERA TAB HETLIOZ CAP HEXALEN CAP HIPREX TAB HIZENTRA INJ homatropine ophth soln (ISOPTO HOATROPINE equiv) HORIZANT TAB HUALOG INJ (Step Therapy requires trial of NOVOLOG) HUALOG KWIKPEN INJ (Step Therapy requires trial of NOVOLOG) HUALOG IX INJ (Step Therapy requires trial of NOVOLOG) HUALOG IX KWIKPEN INJ (Step Therapy requires trial of NOVOLOG) HUALOG PEN INJ (Step Therapy requires trial of NOVOLOG) HUIRA INJ (= 2 inj/28 days) HUIRA PEN INJ (= 2 inj/28 days) HUULIN IX INJ (Step Therapy requires trial of NOVOLIN) HUULIN IX PEN INJ (Step Therapy requires trial of NOVOLIN) HUULIN N INJ (Step Therapy requires trial of NOVOLIN) HUULIN N PEN INJ (Step Therapy requires trial of NOVOLIN) HUULIN R INJ (Step Therapy requires trial of NOVOLIN) HUULIN R INJ U500 HUULIN R U500 KWIKPEN INJ HYCATIN CAP HYCET SOLN HYCODAN SYRUP HYCOFENIX SOLN hydralazine tab (APRESOLINE equiv) HYDREA CAP hydrochlorothiazide cap (ICROZIDE equiv) hydrochlorothiazide tab (HYDRODIURIL equiv) hydrocodone/acetaminophen cap (LORCET equiv) hydrocodone/acetaminophen soln (HYCET/LORTAB equiv) hydrocodone/acetaminophen tab (LORTAB equiv) hydrocodone/acetaminophen tab 0mg00mg (XODOL equiv) hydrocodone/acetaminophen tab 2.525mg (NORCO equiv) hydrocodone/acetaminophen tab 5mg00mg (XODOL equiv) hydrocodone/acetaminophen tab 7.5mg00mg (XODOL equiv) Special Code Tier Category NC LAXATIVES PA DERATOLOGICALS PA DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS PA ANTIVIRALS VAC $0 VACCINES ENDOCRINE AND ETABOLIC AGENTS ISC. NC BETA BLOCKERS ANTIVIRALS NC HYPNOTICS 2 ANTINEOPLASTICS AND ADJUNCTIVE URINARY ANTIINFECTIVES PASSIVE IUNIZING AGENTS OPHTHALIC AGENTS NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ST ANTIDIABETICS ST ANTIDIABETICS ST ANTIDIABETICS ST ANTIDIABETICS ST ANTIDIABETICS PA ANALGESICS ANTIINFLAATORY PA ANALGESICS ANTIINFLAATORY OTCST ANTIDIABETICS OTCST ANTIDIABETICS OTCST ANTIDIABETICS OTCST ANTIDIABETICS OTCST ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS PA ANTINEOPLASTICS ANALGESICS OPIOID COUGH/COLD/ALLERGY NC COUGH/COLD/ALLERGY CI ANTIHYPERTENSIVES ANTINEOPLASTICS AND ADJUNCTIVE CI DIURETICS CI DIURETICS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID NC ANALGESICS OPIOID ANALGESICS OPIOID NC ANALGESICS OPIOID NC ANALGESICS OPIOID CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Cont. Alphabetical Index hydrocodone/chlorpheniramine CR susp (TUSSIONEX equiv) (= 20ml/fill; 2 fills/0 days) hydrocodone/chlorpheniramine/pseudoephedrine liquid (ZUTRIPRO equiv) (= 20ml/fill, 2 fills/0 days) hydrocodone/homatropine syrup (HYCODAN equiv) hydrocodone/ibuprofen tab (VICOPROFEN equiv) hydrocortisone butyrate cream (LOCOID equiv) hydrocortisone butyrate lipocream (LOCOID equiv) hydrocortisone butyrate oint (LOCOID equiv) hydrocortisone butyrate soln (LOCOID equiv) hydrocortisone cream (PROCTOCORT equiv) hydrocortisone enema (CORTENEA equiv) hydrocortisone lotion (HYTONE equiv) hydrocortisone oint hydrocortisone supp (ANUSOL HC equiv) hydrocortisone tab (CORTEF equiv) hydrocortisone valerate cream hydrocortisone valerate oint (WESTCORT equiv) hydrocortisone/pramoxine cream 2.5% (PRAOSONE equiv) hydromorphone ER tab (EXALGO equiv) HYDROORPHONE SUPP hydromorphone tab (DILAUDID equiv) hydroquinone cream (LUSTRA equiv) hydroxychloroquine tab (PLAQUENIL equiv) hydroxyurea cap (HYDREA equiv) hydroxyzine pamoate cap (VISTARIL equiv) HYDROXYZINE PAOATE CAP 00G hydroxyzine syrup (ATARAX equiv) hydroxyzine tab (ATARAX equiv) hyoscyamine sulfate CR tab (LEVBID equiv) hyoscyamine sulfate elixir (LEVSIN equiv) hyoscyamine sulfate ODT (ANAAZ equiv) hyoscyamine sulfate SL tab (LEVSIN equiv) hyoscyamine sulfate soln (LEVSIN equiv) hyoscyamine sulfate SR cap (LEVSINEX equiv) hyoscyamine tab (LEVSIN equiv) HYPERSAL NEB SOLN HYSINGLA ER TAB (= tab/day) HYTONE LOTION HYTRIN CAP HYZAAR TAB ibandronate tab 50mg (BONIVA equiv) (= tab/0 days; Step Therapy requires trial of alendronate) IBRANCE CAP (= 2 caps/28 days) ibuprofen susp (Rx ONLY) (ADVIL/OTRIN equiv) ibuprofen tab ibuprofen tab (Rx covered Only) ICLUSIG TAB (Only available through Biologics 800850406) ILEVRO OPHTH SU Special Code Tier Category COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY ANALGESICS OPIOID NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS ANORECTAL AGENTS DERATOLOGICALS DERATOLOGICALS NC ANORECTAL AGENTS CORTICOSTEROIDS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID NC DERATOLOGICALS ANTIALARIALS ANTINEOPLASTICS AND ADJUNCTIVE ANTIANXIETY AGENTS 2 ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS URINARY ANTIASODICS COUGH/COLD/ALLERGY 2 ANALGESICS OPIOID DERATOLOGICALS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ST ENDOCRINE AND ETABOLIC AGENTS ISC. PA ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY LDPASF ANTINEOPLASTICS AND ADJUNCTIVE 2 OPHTHALIC AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Cont. Alphabetical Index IBRUVICA CAP (= 4 caps/day; Only available through Diplomat Pharmacy 87797798) IDUR TAB imipenem/cilastin inj imipramine pamoate cap (TOFRANIL P equiv) imipramine tab (TOFRANIL equiv) imiquimod cream (ALDARA equiv) IITREX INJ (= 4 inj/fill, 2 fills/0 days) IITREX TAB (= 9 tabs/fill, 2 fills/0 days) IITREX VIAL INJ (= 5 inj/fill, 2 fills/0 days) IPAVIDO CAP IPLANON/NEXPLANON IPLANT IURAN TAB INCIVEK TAB INCRELEX INJ INCRUSE ELLIPTA INHALER indapamide tab (LOZOL equiv) INDERAL LA CAP INDOCIN SUPP INDOCIN SU indomethacin cap (INDOCIN equiv) indomethacin CR cap (INDOCIN SR equiv) INFERGEN INJ INFLAAK KIT INLYTA TAB (= 8 tabs/day) INNOPRAN XL CAP INRA TAB INSULIN SYRINGE INTELENCE TAB INTRONA INJ INTUNIV TAB (Step Therapy requires trial of guanfacine IR) INVANZ INJ INVEGA SUSTENNA/TRINZ INJ INVEGA TAB INVIRASE TAB INVOKAET TAB (= 2 tabs/day) INVOKANA TAB (= tab/day) IODOFLEX PAD iodoquinol/hydrocortisone cream % (VYTONE equiv) iodoquinol/hydrocortisone cream.9% (VYTONE equiv) IOPIDINE OPHTH SOLN IOPIDINE OPHTH SOLN % ipratropium nasal spray (ATROVENT equiv) ipratropium neb soln (ATROVENT equiv) irbesartan tab (AVAPRO equiv) irbesartan/hydrochlorothiazide tab (AVALIDE equiv) Special Code Tier Category LDPASF ANTINEOPLASTICS AND ADJUNCTIVE ANTIANGINAL AGENTS ANTIINFECTIVE AGENTS ISC. ANTIDEPRESSANTS ANTIDEPRESSANTS DERATOLOGICALS IGRAINE PRODUCTS IGRAINE PRODUCTS IGRAINE PRODUCTS NC ANTIINFECTIVE AGENTS ISC. $0 CONTRACEPTIVES ASSORTED CLASSES PASF ANTIVIRALS ENDOCRINE AND ETABOLIC AGENTS ISC. CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS CI DIURETICS BETA BLOCKERS 2 ANALGESICS ANTIINFLAATORY 2 ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANTIVIRALS NC DERATOLOGICALS PASF ANTINEOPLASTICS AND ADJUNCTIVE BETA BLOCKERS ANTIHYPERTENSIVES OTC EDICAL DEVICES AND SUPPLIES ANTIVIRALS ANTINEOPLASTICS AND ADJUNCTIVE ST ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIINFECTIVE AGENTS ISC. PA ANTIPSYCHOTICS/ANTIANIC AGENTS PA ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIVIRALS PA ANTIDIABETICS PA ANTIDIABETICS NC ANTISEPTICS & DISINFECTANTS NC DERATOLOGICALS NC DERATOLOGICALS OPHTHALIC AGENTS 2 OPHTHALIC AGENTS NASAL AGENTS SYSTEIC AND TOPICAL CI ANTIASTHATIC AND BRONCHODILATOR AGENTS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Cont. Alphabetical Index IRESSA TAB (Only available through Diplomat Pharmacy 87797798) IRON POLYSACCH/THREONIC ACID/B2/FA CAP IRON SU (Covered for members year or younger) ISENTRESS CHEW TAB ISENTRESS POWDER PACK ISENTRESS TAB ISOLYTE INJ isometheptene/caffeine/acetaminophen tab (PRODRIN equiv) ISONIAZID SYRUP isoniazid tab ISOPTO ATROPINE OPHTH SOLN ISOPTO CARBACHOL OPHTH SOLN ISOPTO CARPINE OPHTH SOLN ISOPTO HOATROPINE OPHTH SOLN 2% ISOPTO HOATROPINE OPHTH SOLN 5% ISOPTO HYOSCINE OPHTH SOLN ISORDIL TITRADOSE TAB ISOSORBIDE DINITRATE ER TAB isosorbide dinitrate ER tab (ISOCHRON equiv) isosorbide dinitrate SL tab isosorbide dinitrate tab (ISORDIL equiv) ISOSORBIDE DINITRATE TAB 0G, 40G isosorbide mononitrate ER tab (IDUR equiv) isosorbide mononitrate tab (ONOKET equiv) isotretinoin cap (ACCUTANE equiv) isoxsuprine tab isradipine cap (DYNACIRC equiv) ISTALOL OPHTH SOLN itraconazole cap (ORANOX equiv) ivermectin tab (STROECTOL equiv) JADENU TAB JAKAFI TAB (= 2 tabs/day) JALYN CAP JANUET TAB JANUET XR TAB JANUVIA TAB (= tab/day) JARDIANCE TAB (= tab/day) JENTADUETO TAB (= 2 tabs/day) jinteli tab (FEHRT equiv) jolessa tab/ amethia tab (SEASONALE/SEASONIQUE equiv) ( copays per Rx) JUBLIA SOLN junel FE tab (LOESTRIN FE equiv) junel tab (LOESTRIN equiv) JUXTAPID CAP KADIAN CAP KALETRA SOLN KALETRA TAB KALYDECO PAK (= 2 packets/day) Special Code Tier Category LDPA ANTINEOPLASTICS AND ADJUNCTIVE HEATOPOIETIC AGENTS OTC $0 HEATOPOIETIC AGENTS ANTIVIRALS ANTIVIRALS ANTIVIRALS INERALS & ELECTROLYTES NC IGRAINE PRODUCTS ANTIYCOBACTERIAL AGENTS ANTIYCOBACTERIAL AGENTS OPHTHALIC AGENTS 2 OPHTHALIC AGENTS OPHTHALIC AGENTS 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS DERATOLOGICALS CARDIOVASCULAR AGENTS ISC. CI CALCIU CHANNEL BLOCKERS 2 OPHTHALIC AGENTS PA ANTIFUNGALS ANTHELINTICS ANTIDOTES PA ANTINEOPLASTICS AND ADJUNCTIVE GENITOURINARY AGENTS ISCELLANEOUS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS PA ANTIDIABETICS ESTROGENS $0 CONTRACEPTIVES NC DERATOLOGICALS $0 CONTRACEPTIVES $0 CONTRACEPTIVES NC ANTIHYPERLIPIDEICS ANALGESICS OPIOID ANTIVIRALS ANTIVIRALS PASF REIRATORY AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Cont. Alphabetical Index KALYDECO TAB (= 2 tabs/day) KANAYCIN INJ KAPVAY TAB KARBINAL ER SU kariva tab (IRCETTE equiv) KAYEXALATE POWDER KAZANO/ALOGLIPTINETFORIN TAB (= 2 tabs/day) KEFLEX CAP kelnor tab (DEULEN equiv) KENALOG RAY KEPPRA SOLN KEPPRA TAB KEPPRA XR TAB KERAFOA KERALAC CREA KERLONE TAB KERYDIN SOLN KETEK TAB ketoconazole cream (NIZORAL CREA equiv) ketoconazole shampoo (NIZORAL SHAPOO equiv) ketoconazole tab (NIZORAL equiv) KETODIASTIX TEST STRIP ketoprofen cap (ORUDIS equiv) KETOPROFEN ER CAP KETOROLAC INJ ketorolac inj (TORADOL equiv) ketorolac ophth soln (ACULAR (LS) equiv) ketorolac tab (TORADOL equiv) (= 20 tabs/5 days) KETOSTIX ketotifen ophth soln (ZADITOR equiv) (OTC covered only) KEVEYIS TAB KHEDEZLA ER TAB (Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND venlafaxine product) KINERET INJ (= inj/day; Only available through Rx Crossroads: 8665470644) KLARON LOTION KLONOPIN TAB KLORCON 5 TAB KLORCON POWDER PACKET KLORCON POWDER PACKET 25EQ KLORCON TAB KOBIGLYZE XR TAB KORLY TAB (Only available through Korlym ARK program 8554Korlym (8554567596)) KPHOS NEUTRAL TAB KPHOS TAB KRISTALOSE PACKET KUVAN POWDER PACK KUVAN TAB KYNARO INJ Special Code Tier Category PASF REIRATORY AGENTS ISC. AINOGLYCOSIDES ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS NC ANTIHISTAINES $0 CONTRACEPTIVES ASSORTED CLASSES PA ANTIDIABETICS CEPHALOORINS $0 CONTRACEPTIVES DERATOLOGICALS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS DERATOLOGICALS NC DERATOLOGICALS BETA BLOCKERS NC DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. DERATOLOGICALS DERATOLOGICALS ANTIFUNGALS CIOTC $0 DIAGNOSTIC PRODUCTS ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY NC ANALGESICS ANTIINFLAATORY NC ANALGESICS ANTIINFLAATORY OPHTHALIC AGENTS ANALGESICS ANTIINFLAATORY CIOTC $0 DIAGNOSTIC PRODUCTS OTC OPHTHALIC AGENTS NC DIURETICS ST ANTIDEPRESSANTS LDPA ANALGESICS ANTIINFLAATORY DERATOLOGICALS ANTICONVULSANTS 2 INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES CI 2 ANTIDIABETICS LDPA ANTIDIABETICS INERALS & ELECTROLYTES 2 INERALS & ELECTROLYTES LAXATIVES PA ENDOCRINE AND ETABOLIC AGENTS ISC. PA ENDOCRINE AND ETABOLIC AGENTS ISC. NC ANTIHYPERLIPIDEICS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Cont. Alphabetical Index KYTRIL TAB (= 9 tabs/fill) labetalol tab (NORODYNE equiv) LACHYDRIN CREA LACHYDRIN LOTION LACRISERT OPHTH INSERT lactulose soln LAICTAL CHEW TAB LAICTAL CHEW TAB 2G LAICTAL ODT LAICTAL ODT KIT LAICTAL TAB LAICTAL XR KIT LAICTAL XR TAB LAISIL TAB lamivudine soln (EPIVIR equiv) lamivudine tab (EPIVIR equiv) lamivudine tab 00mg (EPIVIR HBV equiv) lamivudine/zidovudine tab (COBIVIR equiv) lamotrigine chew tab (LAICTAL equiv) lamotrigine ER tab (LAICTAL XR equiv) lamotrigine ODT (LAICTAL equiv) lamotrigine ODT kit (LAICTAL ODT KIT equiv) lamotrigine tab (LAICTAL equiv) LANCET DEVICE LANCET KIT LANCETS LANOXIN TAB LANOXIN TAB 0.0625G, 0.875G lansoprazole cap (PREVACID equiv) LANSOPRAZOLE SU lansoprazole/amoxicillin/clarithromycin kit (PREVPAC equiv) LANTUS INJ LANTUS SOLOSTAR INJ LARIA TAB LASIX TAB LASTACAFT OPHTH SOLN (= ml/0 days) latanoprost ophth soln (XALATAN equiv) (= 2.5ml/0 days) LATUDA TAB (= tab/day) LAZANDA RAY (= 5 bottles/0 days) leflunomide tab (ARAVA equiv) LENVIA CAP (= caps/day; Only available through Accredo 88877776) LESCOL CAP LESCOL XL TAB LETAIRIS TAB (= tab/day) letrozole tab (FEARA equiv) LEUCOVORIN TAB LEUKERAN TAB LEUKINE INJ Special Code Tier Category ANTIEETICS CI BETA BLOCKERS DERATOLOGICALS DERATOLOGICALS 2 OPHTHALIC AGENTS GASTROINTESTINAL AGENTS ISC. ANTICONVULSANTS 2 ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTIFUNGALS ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS CIOTC EDICAL DEVICES AND SUPPLIES CIOTC EDICAL DEVICES AND SUPPLIES CIOTC EDICAL DEVICES AND SUPPLIES CARDIOTONICS NC CARDIOTONICS OTC ULCER DRUGS ULCER DRUGS ULCER DRUGS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS ANTIALARIALS DIURETICS OPHTHALIC AGENTS OPHTHALIC AGENTS NC ANTIPSYCHOTICS/ANTIANIC AGENTS PA ANALGESICS OPIOID ANALGESICS ANTIINFLAATORY LDPA ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS PA CARDIOVASCULAR AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE 2 ANTINEOPLASTICS AND ADJUNCTIVE HEATOPOIETIC AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Cont. Alphabetical Index leuprolide inj (LUPRON equiv) levalbuterol neb soln (XOPENEX equiv) LEVAQUIN SOLN LEVAQUIN TAB LEVATOL TAB LEVBID TAB LEVEIR FLEXPEN/FLEXTOUCH INJ LEVEIR INJ levetiracetam ER tab (KEPPRA XR equiv) levetiracetam soln (KEPPRA equiv) levetiracetam tab (KEPPRA equiv) levobunolol ophth soln (BETAGAN equiv) levocarnitine soln (CARNITOR equiv) levocarnitine tab (CARNITOR equiv) levocetirizine soln (XYZAL equiv) levocetirizine tab (XYZAL equiv) levofloxacin ophth soln (QUIXIN equiv) levofloxacin soln (LEVAQUIN equiv) levofloxacin tab (LEVAQUIN equiv) levonorgestrel tab (PLAN B equiv) LEVONORGESTREL TAB 0.75G LEVORPHANOL TAB levothyroxine tab (SYNTHROID equiv) LEVSIN INJ LEVSIN SOLN LEVSIN TAB LEVSIN/SL TAB LEVSINEX CAP LEXAPRO SOLN LEXAPRO TAB LEXIVA SU LEXIVA TAB LIBRAX CAP LIBRIU CAP LIDOCAINE CREA lidocaine cream % (LIDAANTLE equiv) lidocaine gel (XYLOCAINE equiv) lidocaine lotion (LIDAANTLE equiv) lidocaine oint LIDOCAINE ORAL SOLN 4% lidocaine patch (LIDODER equiv) (= patches/day) lidocaine soln (XYLOCAINE equiv) lidocaine viscous soln lidocaine/hydrocortisone cream (ANAANTLE equiv) lidocaine/prilocaine cream (ELA equiv) LIDOCIN GEL LIDODER PATCH (= patches/day) LIDOLOG KIT Special Code Tier Category INF ANTINEOPLASTICS AND ADJUNCTIVE CI ANTIASTHATIC AND BRONCHODILATOR AGENTS FLUOROQUINOLONES FLUOROQUINOLONES BETA BLOCKERS ULCER DRUGS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS OPHTHALIC AGENTS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIHISTAINES ANTIHISTAINES OPHTHALIC AGENTS FLUOROQUINOLONES FLUOROQUINOLONES OTC $0 CONTRACEPTIVES $0 CONTRACEPTIVES 2 ANALGESICS OPIOID NC THYROID AGENTS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIVIRALS ANTIVIRALS NC ULCER DRUGS ANTIANXIETY AGENTS NC DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS 2 OUTH/THROAT/DENTAL AGENTS DERATOLOGICALS DERATOLOGICALS OUTH/THROAT/DENTAL AGENTS ANORECTAL AGENTS DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS NC CORTICOSTEROIDS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Cont. Alphabetical Index LIBITROL TAB LINCOCIN INJ lincomycin inj (LINCOCIN equiv) lindane lotion LINDANE LOTION lindane shampoo linezolid susp (ZYVOX equiv) (Restricted to Infectious Disease Specialist) linezolid tab (ZYVOX equiv) (Restricted to Infectious Disease Specialist) LINZESS CAP (= cap/day) liothyronine tab (CYTOEL equiv) LIPITOR TAB LIPOFEN CAP/FENOFIBRATE CAP 50G, 50G LIPTRUZET TAB lisinopril tab (PRINIVIL/ZESTRIL equiv) lisinopril/hydrochlorothiazide tab (ZESTORETIC equiv) lithium carbonate cap (ESKALITH ER equiv) lithium carbonate ER tab (LITHOBID equiv) lithium carbonate tab lithium citrate soln LITHOBID TAB LITHOSTAT TAB LIVALO TAB LETHYLFOLATE TAB LO LOESTRIN TAB LO INASTRIN 24 FE CHEW TAB LOCOID CREA LOCOID LIPOCREA LOCOID OINT LOCOID SOLN LODOSYN TAB LOESTRIN 24 FE TAB LOESTRIN FE TAB LOESTRIN TAB LOFIBRA CAP/ANTARA CAP 0G, 90G LOFIBRA/TRIGLIDE TAB LOOTIL LIQUID LOOTIL TAB LONSURF TAB loperamide cap LOPID TAB LOPRESSOR HCT TAB LOPRESSOR TAB LOPROX CREA LOPROX GEL LOPROX SHAPOO lorazepam conc (ATIVAN equiv) lorazepam tab (ATIVAN equiv) LORTAB Special Code Tier Category PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS RS ANTIINFECTIVE AGENTS ISC. RS ANTIINFECTIVE AGENTS ISC. PA GASTROINTESTINAL AGENTS ISC. THYROID AGENTS ANTIHYPERLIPIDEICS NC ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS GENITOURINARY AGENTS ISCELLANEOUS ANTIHYPERLIPIDEICS NC DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS CONTRACEPTIVES CONTRACEPTIVES NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS ANTIPARKINSON AGENTS CONTRACEPTIVES CONTRACEPTIVES CONTRACEPTIVES NC ANTIHYPERLIPIDEICS NC ANTIHYPERLIPIDEICS ANTIDIARRHEALS ANTIDIARRHEALS PA ANTINEOPLASTICS AND ADJUNCTIVE NC ANTIDIARRHEALS ANTIHYPERLIPIDEICS ANTIHYPERTENSIVES BETA BLOCKERS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANALGESICS OPIOID CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Cont. Alphabetical Index LORTAB ELIXIR LORVATUS PHARAPAK KIT LORZONE TAB losartan tab (COZAAR equiv) losartan/hydrochlorothiazide tab (HYZAAR equiv) LOTEAX OPHTH GEL LOTEAX OPHTH OINT LOTENSIN HCT TAB LOTENSIN TAB LOTREL CAP LOTRISONE CREA LOTRISONE LOTION LOTRONEX TAB lovastatin tab (EVACOR equiv) LOVAZA CAP LOVENOX INJ (= 7 days supply) loxapine cap (LOXITANE equiv) LOXITANE CAP LTA 60 KIT LUFYLLIN TAB LUIGAN OPHTH SOLN (= 2.5ml/0 days) LUNESTA TAB (= tab/day) LUPANETA PACK LUPRON DEPOT INJ LUPRON DEPOT PED INJ LUPRON DEPOTPED INJ LURIDE SOLN (Covered at $0 for members 5 years or younger; All other members covered at nonpreferred brand copay) LURIDE TAB (Covered at $0 for members 5 years or younger; All other members covered at nonpreferred brand copay) LUVOX CR CAP (Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine) LUXIQ FOA LUZU CREA LYNPARZA CAP (Only available through Biologics 800850406) LYRICA CAP LYRICA SOLN LYSODREN TAB LYSTEDA TAB ACROBID CAP ACRODANTIN CAP magnesium sulfate inj AKENA INJ ALARONE TAB malathion lotion (OVIDE equiv) (= 2 bottles/fill) maldemar tab (SCOPACE equiv) APROTILINE TAB Special Code Tier Category ANALGESICS OPIOID NC USCULOSKELETAL THERAPY AGENTS NC USCULOSKELETAL THERAPY AGENTS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIHYPERTENSIVES DERATOLOGICALS DERATOLOGICALS GASTROINTESTINAL AGENTS ISC. CI ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTICOAGULANTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS OUTH/THROAT/DENTAL AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS 2 OPHTHALIC AGENTS HYPNOTICS NC ENDOCRINE AND ETABOLIC AGENTS ISC. INF ANTINEOPLASTICS AND ADJUNCTIVE INF ENDOCRINE AND ETABOLIC AGENTS ISC. INF ENDOCRINE AND ETABOLIC AGENTS ISC. $0 INERALS & ELECTROLYTES $0 INERALS & ELECTROLYTES ST ANTIDEPRESSANTS NC DERATOLOGICALS NC DERATOLOGICALS LDPASF ANTINEOPLASTICS AND ADJUNCTIVE 2 ANTICONVULSANTS 2 ANTICONVULSANTS ANTINEOPLASTICS AND ADJUNCTIVE HEOSTATICS URINARY ANTIINFECTIVES URINARY ANTIINFECTIVES INERALS & ELECTROLYTES PA PROGESTINS 2 ANTIALARIALS DERATOLOGICALS ANTIEETICS ANTIDEPRESSANTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Cont. Alphabetical Index ARINOL CAP ARPLAN TAB ATULANE CAP AVIK TAB AXALT LT TAB (= 2 tabs/fill, fills/60 days) AXALT TAB (= 2 tabs/fill, fills/60 days) AXIDEX OPHTH SOLN AXITROL OPHTH OINT AXITROL OPHTH SU AXZIDE TAB mebendazole chew tab (VEROX equiv) meclizine chew tab (BONINE equiv) meclizine tab (ANTIVERT equiv) ECLOFENAATE CAP EDROL DOSE PACK EDROL TAB EDROL TAB medroxyprogesterone inj (DEPOPROVERA equiv) (= inj/90 days) medroxyprogesterone tab (PROVERA equiv) mefenamic acid cap (PONSTEL equiv) mefloquine tab (LARIA equiv) EGACE ES SU EGACE SU megestrol ES susp (EGACE ES equiv) megestrol susp (EGACE equiv) megestrol tab (EGACE equiv) EKINIST TAB ELOXICA COFORT KIT ELOXICA SU meloxicam tab (OBIC equiv) melphalan inj (ALKERAN equiv) memantine sol (NAENDA equiv) memantine tab (NAENDA equiv) ENACTRA INJ (Vaccines are covered for members 9 years or older) ENEST TAB ENHIBRIX INJ (Vaccines are covered for members 9 years or older) ENOUNE A/C/Y/W INJ (Vaccines are covered for members 9 years or older) ENOSTAR PATCH ENTAX CREA ENVEO INJ (Vaccines are covered for members 9 years or older) meperidine tab (DEEROL equiv) EPHYTON TAB meprobamate tab (ILTOWN equiv) EPRON SU Special Code Tier Category PA ANTIEETICS 2 ANTIDEPRESSANTS 2 ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERTENSIVES IGRAINE PRODUCTS IGRAINE PRODUCTS 2 OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS DIURETICS ANTHELINTICS OTC ANTIEETICS OTC ANTIEETICS ANALGESICS ANTIINFLAATORY CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS $0 CONTRACEPTIVES PROGESTINS ANALGESICS ANTIINFLAATORY ANTIALARIALS PROGESTINS ANTINEOPLASTICS AND ADJUNCTIVE PROGESTINS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE PA ANTINEOPLASTICS AND ADJUNCTIVE NC ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANTINEOPLASTICS AND ADJUNCTIVE PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. VAC $0 VACCINES ESTROGENS VAC $0 VACCINES VAC $0 VACCINES ESTROGENS DERATOLOGICALS VAC $0 VACCINES ANALGESICS OPIOID 2 VITAINS ANTIANXIETY AGENTS ANTIINFECTIVE AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 40 of 79
Cont. Alphabetical Index mercaptopurine tab (PURINETHOL equiv) meropenem inj mesalamine enema (ROWASA equiv) ESNEX TAB ESTINON SYRUP ESTINON TAB ESTINON TIEAN TAB ETADATE CD CAP ETAGLIP TAB ETANX CAP ETAPROTERENOL SYRUP ETAPROTERENOL TAB metaxalone tab (SKELAXIN equiv) metformin ER osmotic tab (FORTAET equiv) metformin ER tab (GLUCOPHAGE XR equiv) metformin tab (GLUCOPHAGE equiv) ETHADONE SOLN methadone tab (DOLOPHINE equiv) ETHADOSE CONC methadose tab methamphetamine tab (DESOXYN equiv) methazolamide tab (NEPTAZANE equiv) methenamine hippurate tab (HIPREX equiv) methenamine mandelate tab ETHENAINE ANDELATE TAB ETHERGINE TAB (= 28 tabs/fill, fill/65 days) methimazole tab (TAPAZOLE equiv) ETHITEST TAB methocarbamol tab (ROBAXIN equiv) methotrexate inj methotrexate tab (TREXALL equiv) methoxsalen cap (OXSORALEN ULTRA equiv) methscopolamine tab (PAINE equiv) ETHYCLOTHIAZIDE TAB methyldopa tab (ALDOET equiv) methyldopa/hydrochlorothiazide tab (ALDORIL equiv) ETHYLDOPATE INJ methylergonovine tab (ETHERGINE equiv) (= 28 tabs/fill, fill/65 days) ETHYLIN CHEW TAB ETHYLIN SOLN methylphenidate CD cap (ETADATE CD equiv) Special Code Tier Category CI CI CI CI PA CI CI CI NC NC 2 2 ANTINEOPLASTICS AND ADJUNCTIVE ANTIINFECTIVE AGENTS ISC. GASTROINTESTINAL AGENTS ISC. ANTINEOPLASTICS AND ADJUNCTIVE ANTIYASTHENIC AGENTS ANTIYASTHENIC AGENTS ANTIYASTHENIC/CHOLINERGIC AGENTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIDIABETICS DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS USCULOSKELETAL THERAPY AGENTS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS DIURETICS URINARY ANTIINFECTIVES URINARY ANTIINFECTIVES URINARY ANTIINFECTIVES OXYTOCICS THYROID AGENTS ANDROGENSANABOLIC USCULOSKELETAL THERAPY AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE DERATOLOGICALS ULCER DRUGS DIURETICS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIHYPERTENSIVES OXYTOCICS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Cont. Alphabetical Index methylphenidate chew tab (ETHYLIN equiv) methylphenidate ER cap (RITALIN LA equiv) ETHYLPHENIDATE ER TAB methylphenidate ER tab 0mg, 20mg methylphenidate soln (ETHYLIN equiv) methylphenidate tab (RITALIN equiv) methylprednisolone dose pack (EDROL equiv) methylprednisolone tab (EDROL equiv) methyltestosterone cap (ANDROID/TESTRED equiv) ETIPRANOLOL OPHTH SOLN metoclopramide ODT (ETOZOLV equiv) metoclopramide soln (REGLAN equiv) metoclopramide tab (REGLAN equiv) metolazone tab (ZAROXOLYN equiv) metoprolol ER tab (TOPROL XL equiv) metoprolol tab (LOPRESSOR equiv) ETOPROLOL TARTRATE TAB 7.5G, 75G metoprolol/hydrochlorothiazide tab (LOPRESSOR HCT equiv) ETOZOLV ODT ETROCREA ETROGEL % (Step Therapy requires trial of FINACEA) ETROGEL VAGINAL GEL ETROLOTION metronidazole cap (FLAGYL equiv) metronidazole cream (ETROCREA equiv) metronidazole gel (ETROGEL equiv) metronidazole lotion (ETROLOTION equiv) metronidazole tab (FLAGYL equiv) metronidazole vaginal gel (ETROGEL equiv) EVACOR TAB mexiletine cap (EXITIL equiv) IACALCIN INJ IACALCIN NASAL RAY ICARDIS TAB ICONAZOLE SUPP 200G ICROK CAP ICROZIDE CAP IDAOR TAB midodrine tab (PROAATINE equiv) IDRIN CAP IGERGOT SUPP miglitol tab (GLYSET equiv) IGRANAL/ DIHYDROERGOTAINE RAY (= 8 sprays/fill, 2 fills/0 days) ILLIPRED DP PAK ILLIPRED TAB Special Code Tier Category ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS 2 ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CORTICOSTEROIDS CORTICOSTEROIDS PA ANDROGENSANABOLIC 2 OPHTHALIC AGENTS NC GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. CI DIURETICS CI BETA BLOCKERS CI BETA BLOCKERS NC BETA BLOCKERS CI ANTIHYPERTENSIVES NC GASTROINTESTINAL AGENTS ISC. DERATOLOGICALS ST DERATOLOGICALS VAGINAL PRODUCTS DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. VAGINAL PRODUCTS ANTIHYPERLIPIDEICS ANTIARRHYTHICS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIHYPERTENSIVES VAGINAL PRODUCTS INERALS & ELECTROLYTES DIURETICS DIURETICS VASOPRESSORS NC IGRAINE PRODUCTS 2 IGRAINE PRODUCTS ANTIDIABETICS IGRAINE PRODUCTS CORTICOSTEROIDS CORTICOSTEROIDS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 42 of 79
Cont. Alphabetical Index INASTRIN CHEW TAB INIPRESS CAP INOCIN CAP minocycline cap (INOCIN equiv) minocycline ER tab (SOLODYN equiv) minocycline tab (DYNACIN equiv) minoxidil tab (LONITEN equiv) IRAPEX ER TAB IRAPEX ER TAB.75G IRAPEX TAB IRCERA INJ IRCETTE TAB IRENA IUD mirtazapine ODT (REERON equiv) mirtazapine tab (REERON equiv) IRVASO GEL misoprostol tab (CYTOTEC equiv) R II INJ (Vaccines are covered for members 9 years or older) OBIC TAB modafinil tab (PROVIGIL equiv) (= 2 tabs/day) moexipril tab (UNIVASC equiv) moexipril/hydrochlorothiazide tab (UNIRETIC equiv) mometasone cream (ELOCON equiv) mometasone nasal spray (NASONEX equiv) mometasone oint (ELOCON equiv) mometasone soln (ELOCON equiv) ONODOX CAP mononessa tab (ORTHOCYCLEN equiv) ONOPRIL HCT TAB ONOPRIL TAB montelukast chew tab (SINGULAIR equiv) montelukast granule pack (SINGULAIR equiv) montelukast tab (SINGULAIR equiv) ONUROL GRANULE PACK ORPHINE SULFATE ER BEAD CAP (= 2 caps/day) morphine sulfate ER cap (KADIAN equiv) morphine sulfate ER tab (S CONTIN equiv) morphine sulfate soln morphine sulfate supp morphine sulfate tab OTOFEN TAB OTRIN SU OVANTIK TAB OVIPREP SOLN (= bottle/fill) OXATAG TAB 775G OXEZA OPHTH SOLN/ VIGAOX OPHTH SOLN moxifloxacin tab (AVELOX equiv) Special Code Tier Category CONTRACEPTIVES ANTIHYPERTENSIVES TETRACYCLINES TETRACYCLINES NC TETRACYCLINES TETRACYCLINES CI ANTIHYPERTENSIVES ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS NC HEATOPOIETIC AGENTS CONTRACEPTIVES $0 CONTRACEPTIVES ANTIDEPRESSANTS ANTIDEPRESSANTS NC DERATOLOGICALS ULCER DRUGS VAC $0 VACCINES ANALGESICS ANTIINFLAATORY PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES DERATOLOGICALS NC NASAL AGENTS SYSTEIC AND TOPICAL DERATOLOGICALS DERATOLOGICALS TETRACYCLINES $0 CONTRACEPTIVES ANTIHYPERTENSIVES ANTIHYPERTENSIVES CI ANTIASTHATIC AND BRONCHODILATOR AGENTS CI ANTIASTHATIC AND BRONCHODILATOR AGENTS CI ANTIASTHATIC AND BRONCHODILATOR AGENTS URINARY ANTIINFECTIVES ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANTIDIARRHEALS ANALGESICS ANTIINFLAATORY NC GASTROINTESTINAL AGENTS ISC. 2 LAXATIVES NC PENICILLINS 2 OPHTHALIC AGENTS FLUOROQUINOLONES CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Cont. Alphabetical Index OZOBIL INJ S CONTIN TAB ULTAQ TAB multigen folic tab (CHROAGEN FA equiv) multigen plus tab (CHROAGEN FORTE equiv) multigen tab (CHROAGEN equiv) multivitamin tab ULTIVITAIN TAB multivitamin w/ minerals tab (STROVITE equiv) mupirocin cream (BACTROBAN equiv) mupirocin oint (BACTROBAN OINT equiv) YALEPT INJ YABUTOL TAB YCAINE INJ YCELEX TROCHES YCOBUTIN CAP mycophenolate DR tab (YFORTIC equiv) mycophenolate mofetil cap (CELLCEPT equiv) mycophenolate mofetil susp (CELLCEPT SU equiv) mycophenolate mofetil tab (CELLCEPT equiv) YDFRIN OPHTH SOLN YDRIACYL OPHTH SOLN YFORTIC TAB YLERAN TAB YOZYE INJ YRBETRIQ TAB YSOLINE TAB YTELASE TAB nabumetone tab (RELAFEN equiv) nadolol tab (CORGARD equiv) nadolol/bendroflumethiazide tab (CORZIDE equiv) nafcillin inj NAFTIFINE CREA % naftifine cream 2% (NAFTIN equiv) NAFTIN CREA NAFTIN GEL NAFTIN GEL 2% NAGLAZYE INJ nalbuphine inj NALFON CAP NALOXONE INJ naltrexone tab (REVIA equiv) NAENDA SOL NAENDA TAB NAENDA XR CAP Special Code Tier Category CI CI 2 NC 2 2 2 NC 2 HEATOPOIETIC AGENTS ANALGESICS OPIOID ANTIARRHYTHICS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS ULTIVITAINS DERATOLOGICALS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIYCOBACTERIAL AGENTS ANTIFUNGALS OUTH/THROAT/DENTAL AGENTS ANTIYCOBACTERIAL AGENTS ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES OPHTHALIC AGENTS OPHTHALIC AGENTS ASSORTED CLASSES ANTINEOPLASTICS AND ADJUNCTIVE ENDOCRINE AND ETABOLIC AGENTS ISC. URINARY ANTIASODICS ANTICONVULSANTS ANTIYASTHENIC AGENTS ANALGESICS ANTIINFLAATORY BETA BLOCKERS ANTIHYPERTENSIVES PENICILLINS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. ANALGESICS OPIOID ANALGESICS ANTIINFLAATORY ANTIDOTES ANTIDOTES PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 44 of 79
Cont. Alphabetical Index NAZARIC CAP (Step Therapy requires trial of donepezil and memantine) naphazoline ophth soln NAPROSYN EC TAB NAPROSYN SU NAPROSYN TAB NAPROXEN CREA COPOUND KIT naproxen EC tab (NAPROSYN EC equiv) naproxen sodium CR tab (NAPRELAN CR equiv) naproxen sodium tab (ANAPROX equiv) naproxen susp (NAPROSYN equiv) NAPROXEN SU naproxen tab (NAPROSYN equiv) naratriptan tab (AERGE equiv) (= 9 tabs/fill, 2 fills/0 days) NARCAN NASAL RAY NARDIL TAB NASACORT AQ NASAL RAY (= 2 bottles/fill) NASACORT OTC NASAL RAY (= 2 bottles/fill) NASCOBAL NASAL RAY NASONEX NASAL RAY (= 2 bottles/fill) NATACYN OPHTH SU NATAZIA TAB nateglinide tab (STARLIX equiv) NATPARA INJ (Only available through Walgreens 8884746) NATROBA SU (= bottle/fill) NATURE THROID/AROUR THYROID TAB NAVANE CAP NEBUPENT NEB SOLN NEBUSAL NEB SOLN necon tab (ORTHONOVU equiv) necon tab /50 (NORYNIL equiv) NEFAZODONE TAB nefazodone tab 50mg, 250mg neomycin tab neomycin/ polymyxin b/ gramicidin ophth soln (NEOORIN equiv) neomycin/ polymyxin/ dexamethasone ophth oint (AXITROL equiv) neomycin/ polymyxin/ dexamethasone ophth soln (AXITROL equiv) neomycin/ polymyxin/ hydrocortisone ophth soln (CORTIORIN equiv) neomycin/polymixin/hydrocoritisone otic soln (CORTIORIN equiv) neomycin/polymixin/hydrocoritisone otic susp (CORTIORIN equiv) NEORAL CAP NEORAL SOLN NEOSALUS FOA NEOORIN OPHTH SOLN NEOSYNALAR CREA NEOTUSSD LIQUID NEPHROCAP NEPHRON FA TAB Special Code Tier Category ST 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OPHTHALIC AGENTS ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY NC DERATOLOGICALS ANALGESICS ANTIINFLAATORY NC ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY 2 ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY IGRAINE PRODUCTS NC ANTIDOTES 2 ANTIDEPRESSANTS NASAL AGENTS SYSTEIC AND TOPICAL OTC NASAL AGENTS SYSTEIC AND TOPICAL HEATOPOIETIC AGENTS NASAL AGENTS SYSTEIC AND TOPICAL NC OPHTHALIC AGENTS CONTRACEPTIVES CI ANTIDIABETICS LDPA ENDOCRINE AND ETABOLIC AGENTS ISC. DERATOLOGICALS THYROID AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS 2 ANTIINFECTIVE AGENTS ISC. 2 COUGH/COLD/ALLERGY $0 CONTRACEPTIVES $0 CONTRACEPTIVES ANTIDEPRESSANTS ANTIDEPRESSANTS AINOGLYCOSIDES OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS OTIC AGENTS OTIC AGENTS ASSORTED CLASSES ASSORTED CLASSES NC DERATOLOGICALS OPHTHALIC AGENTS NC DERATOLOGICALS COUGH/COLD/ALLERGY ULTIVITAINS 2 HEATOPOIETIC AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 45 of 79
Cont. Alphabetical Index NEPHROVITE TAB NEPTAZANE TAB NESINA/ALOGLIPTIN TAB (= tab/day) NEULASTA INJ NEUEGA INJ NEUPOGEN INJ NEUPRO PATCH NEURONTIN CAP NEURONTIN SOLN NEURONTIN TAB NEVANAC OPHTH SU nevirapine ER tab (VIRAUNE XR equiv) (Step Therapy requires trial of nevirapine) NEVIRAPINE SU (VIRAUNE equiv) nevirapine tab (VIRAUNE equiv) NEXAVAR TAB NEXICLON XR SU NEXICLON XR TAB NEXIU 24HR TAB NEXIU GRANULE PACK NEXIU OTC CAP niacin cap niacin CR tab (SLONIACIN equiv) niacin ER tab (NIAAN equiv) niacin tab NIACIN TR TAB niacinamide tab NIACOR TAB NIAAN ER TAB nicardipine cap (CARDENE equiv) NICODER PATCH NICORETTE NICORETTE LOZENGE nicotine gum (NICORETTE equiv) NICOTINE KIT nicotine lozenge (COIT equiv) nicotine patch (NICODER equiv) NICOTROL INHALER (Limited to 80 days/plan year) NICOTROL NASAL RAY (Limited to 80 days/plan year) nifedipine cap (PROCARDIA equiv) nifedipine ER tab (ADALAT CC equiv) NILANDRON TAB nimodipine cap (NIOTOP equiv) NIOTOP CAP Special Code Tier Category ULTIVITAINS DIURETICS PA ANTIDIABETICS HEATOPOIETIC AGENTS HEATOPOIETIC AGENTS NC HEATOPOIETIC AGENTS ANTIPARKINSON AGENTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS 2 OPHTHALIC AGENTS ST ANTIVIRALS ANTIVIRALS ANTIVIRALS PASF ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERTENSIVES ANTIHYPERTENSIVES NC ULCER DRUGS PA ULCER DRUGS OTC NC ULCER DRUGS OTC VITAINS OTC VITAINS NC ANTIHYPERLIPIDEICS OTC VITAINS OTC VITAINS OTC VITAINS CI ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI CALCIU CHANNEL BLOCKERS OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. OTCSKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. SKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. SKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS ANTINEOPLASTICS AND ADJUNCTIVE CI CALCIU CHANNEL BLOCKERS CALCIU CHANNEL BLOCKERS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 46 of 79
Cont. Alphabetical Index NINLARO CAP NIRAVA ODT nisoldipine ER tab (SULAR equiv) NISOLDIPINE ER TAB 25.5G NITROBID OINT NITRODUR PATCH NITRODUR PATCH 0.G/HR, 0.8G/HR nitrofurantoin macrocrystals cap (ACRODANTIN equiv) nitrofurantoin monohydrate cap (ACROBID equiv) nitrofurantoin susp (FURADANTIN equiv) nitroglycerin lingual spray (NITROLINGUAL equiv) nitroglycerin patch (NITRODUR equiv) nitroglycerin SR cap NITROLINGUAL PUP RAY NITROIST RAY NITROSTAT SL TAB nizatidine cap (AXID equiv) nizatidine soln (AXID equiv) NIZORAL SHAPOO NORDITROPIN INJ norethindrone tab (NORAQD equiv) norethindrone tab (AYGESTIN equiv) NORINYL TAB /50 NORITATE CREA (Step Therapy requires trial of FINACEA) NOROXIN TAB NORPACE CAP NORPACE CR CAP NORPRAIN TAB NORQD TAB NORTHERA CAP nortrel tab (OVCON 5 equiv) nortriptyline cap (PAELOR equiv) NORTRIPTYLINE SOLN NORVASC TAB NORVIR CAP NORVIR SOLN NORVIR TAB NOVOFINE PEN NEEDLE NOVOLIN INJ NOVOLOG FLEXPEN INJ NOVOLOG INJ NOVOLOG IX FLEXPEN INJ NOVOLOG IX INJ NOVOLOG PENFILL INJ NOVOTWIST PEN NEEDLE NOXAFIL SU NOXAFIL TAB np thyroid tab (NATURE THROID/AROUR THYROID equiv) NUCORT LOTION Special Code Tier Category NC ANTINEOPLASTICS AND ADJUNCTIVE ANTIANXIETY AGENTS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS ANTIANGINAL AGENTS ANTIANGINAL AGENTS 2 ANTIANGINAL AGENTS URINARY ANTIINFECTIVES URINARY ANTIINFECTIVES URINARY ANTIINFECTIVES ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS 2 ANTIANGINAL AGENTS ULCER DRUGS ULCER DRUGS DERATOLOGICALS PA ENDOCRINE AND ETABOLIC AGENTS ISC. $0 CONTRACEPTIVES PROGESTINS CONTRACEPTIVES ST DERATOLOGICALS FLUOROQUINOLONES ANTIARRHYTHICS 2 ANTIARRHYTHICS ANTIDEPRESSANTS CONTRACEPTIVES NC VASOPRESSORS $0 CONTRACEPTIVES ANTIDEPRESSANTS ANTIDEPRESSANTS CALCIU CHANNEL BLOCKERS ANTIVIRALS ANTIVIRALS ANTIVIRALS CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS CIOTC $0 EDICAL DEVICES AND SUPPLIES 2 ANTIFUNGALS NC ANTIFUNGALS THYROID AGENTS DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 47 of 79
Cont. Alphabetical Index NUCYNTA ER TAB (= 2 tabs/day) NUCYNTA TAB NUEDEXTA CAP (= 2 caps/day) NULOJIX INJ NUPLAZID TAB NUTRITIONAL SUPPLEENT POWDER NUTROPIN AQ/ONITROPE INJ NUVARING NUVIGIL TAB (= tab/day) NYATA KIT nystatin cream (YCOSTATIN CREA equiv) nystatin oint nystatin powder nystatin susp nystatin tab nystatin topical powder NYSTATIN VAGINAL TAB nystatin/triamcinolone cream nystatin/triamcinolone oint octreotide inj (SANDOSTATIN equiv) OCUFEN OPHTH SOLN OCUFLOX OPHTH SOLN ODEFSEY TAB ODOZO CAP (= cap/day) OFEV CAP (= 2 caps/day) ofloxacin ophth soln (OCUFLOX equiv) ofloxacin otic soln (FLOXIN equiv) ofloxacin tab (FLOXIN equiv) OFLOXACIN TAB 400G OGESTREL TAB olanzapine ODT (ZYPREXA equiv) olanzapine tab (ZYPREXA equiv) olanzapine/ fluoxetine cap (SYBYAX equiv) OLEPTRO TAB olopatadine nasal spray (PATANASE equiv) olopatadine ophth soln (PATANOL equiv) OLUX FOA OLYSIO CAP omedia otic soln (AERICAINE equiv) omegaacid ethyl esters cap (LOVAZA equiv) omeprazole DR cap (PRILOSEC equiv) OEPRAZOLE TAB omeprazole/sodium bicarbonate cap (ZEGERID equiv) ONARIS NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) ONICEF SU Special Code Tier Category 2 ANALGESICS OPIOID ANALGESICS OPIOID 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ASSORTED CLASSES NC ANTIPSYCHOTICS/ANTIANIC AGENTS PA DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS NC ENDOCRINE AND ETABOLIC AGENTS ISC. $0 CONTRACEPTIVES PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS NC DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS ANTIFUNGALS OUTH/THROAT/DENTAL AGENTS ANTIFUNGALS DERATOLOGICALS VAGINAL PRODUCTS DERATOLOGICALS DERATOLOGICALS ENDOCRINE AND ETABOLIC AGENTS ISC. OPHTHALIC AGENTS OPHTHALIC AGENTS ANTIVIRALS PASF ANTINEOPLASTICS AND ADJUNCTIVE PASF REIRATORY AGENTS ISC. OPHTHALIC AGENTS OTIC AGENTS FLUOROQUINOLONES 2 FLUOROQUINOLONES CONTRACEPTIVES ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIDEPRESSANTS NASAL AGENTS SYSTEIC AND TOPICAL OPHTHALIC AGENTS PA DERATOLOGICALS NC ANTIVIRALS OTIC AGENTS CI ANTIHYPERLIPIDEICS ULCER DRUGS OTC NC ULCER DRUGS NC ULCER DRUGS ST NASAL AGENTS SYSTEIC AND TOPICAL CEPHALOORINS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 48 of 79
Cont. Alphabetical Index ondansetron ODT (ZOFRAN equiv) ondansetron soln (ZOFRAN equiv) ondansetron tab (ZOFRAN equiv) ONFI SU ONFI TAB ONGLYZA TAB (= tab/day) ONZETRA XSAIL OPANA ER TAB OPANA ER TAB (CRUSH RESISTANT) OPANA TAB opium tincture OPSUIT TAB (= tab/day, Only available through Walgreens 8884746) OPTIVAR OPHTH SOLN ORACIT SOLN ORALAIR SL TAB ORAP TAB ORAPRED ODT ORAPRED ODT ORAPRED SOLN ORAVIG TAB ORAXYL CAP ORENCIA INJ ORENCIA SC INJ (= 4 inj/28 days) ORENITRA TAB ORFADIN CAP (Only available through Dohmen LSS 8442465226) ORKABI TAB (= 4 tabs/day) orphenadrine citrate ER tab (NORFLEX equiv) orphenadrine/aspirin/caffeine tab (NORGESIC FORTE equiv) ORPHENADRINE/AIRIN/CAFFEINE TAB ORTHO TRICYCLEN (LO) TAB ORTHOCLONE OKT INJ ORTHOCYCLEN TAB ORTHOEVRA PATCH OSENI/ALOGLIPTINPIOGLITAZONE TAB (= tab/day) OSOPREP TAB OHENA TAB OTEZLA STARTER PACK OTEZLA TAB otomaxhc otic soln (CORTANEB equiv) OTOZIN OTIC DROPS OVACE PLUS CREA OVACE PLUS GEL OVACE PLUS LOTION OVACE PLUS SHAPOO OVACE PLUS FOA OVACE WASH OVCON 5 TAB Special Code Tier Category ANTIEETICS ANTIEETICS ANTIEETICS NC ANTICONVULSANTS PA ANTICONVULSANTS CI 2 ANTIDIABETICS NC IGRAINE PRODUCTS NC ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANTIDIARRHEALS LDPA CARDIOVASCULAR AGENTS ISC. OPHTHALIC AGENTS GENITOURINARY AGENTS ISCELLANEOUS NC BIOLOGICALS ISC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. 2 CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS OUTH/THROAT/DENTAL AGENTS TETRACYCLINES ANALGESICS ANTIINFLAATORY PA ANALGESICS ANTIINFLAATORY NC CARDIOVASCULAR AGENTS ISC. LDPA ENDOCRINE AND ETABOLIC AGENTS ISC. PASF REIRATORY AGENTS ISC. USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS CONTRACEPTIVES ASSORTED CLASSES CONTRACEPTIVES CONTRACEPTIVES PA ANTIDIABETICS LAXATIVES NC ENDOCRINE AND ETABOLIC AGENTS ISC. NC ANALGESICS ANTIINFLAATORY NC ANALGESICS ANTIINFLAATORY NC OTIC AGENTS OTIC AGENTS DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS CONTRACEPTIVES CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 49 of 79
Cont. Alphabetical Index OVIDE LOTION (= 2 bottles/fill) oxacillin inj OXANDRIN TAB oxandrolone tab (OXANDRIN equiv) oxaprozin tab (DAYPRO equiv) oxazepam cap (SERAX equiv) oxcarbazepine susp (TRILEPTAL equiv) oxcarbazepine tab (TRILEPTAL equiv) oxiconazole nitrate cream (OXISTAT equiv) OXISTAT CREA OXISTAT LOTION OXSORALEN ULTRA CAP oxybutynin ER tab (DITROPAN XL equiv) oxybutynin syrup oxybutynin tab (DITROPAN equiv) oxycodone cap (OXYIR equiv) oxycodone conc (ROXICODONE equiv) oxycodone ER tab (OXYCONTIN equiv) oxycodone soln (ROXICODONE equiv) oxycodone tab (ROXICODONE equiv) oxycodone/acetaminophen cap (TYLOX equiv) oxycodone/acetaminophen tab (PERCOCET equiv) oxycodone/aspirin tab (PERCODAN equiv) oxycodone/ibuprofen tab (COBUNOX equiv) OXYCONTIN CR TAB (= 20 tabs/0 days) OXYIR CAP oxymorphone tab (OPANA equiv) OXYTROL PATCH PALGIC SOLN PALGIC TAB paliperidone ER tab (INVEGA equiv) PAELOR CAP pamidronate inj PAINE TAB PANCREAZE CAP (Step Therapy requires trial of CREON) PANCRELIPASE CAP (Step Therapy requires trial of CREON) PANDEL CREA PANRETIN GEL pantoprazole EC tab (PROTONIX equiv) PARAFON FORTE TAB PARAGARD IUD PARCOPA ODT PAREGORIC TINCTURE paricalcitol cap (ZEPLAR equiv) PARLODEL CAP PARLODEL TAB PARNATE TAB paromomycin cap (HUATIN equiv) paroxetine ER tab (PAXIL CR equiv) Special Code Tier Category DERATOLOGICALS PENICILLINS ANDROGENSANABOLIC ANDROGENSANABOLIC ANALGESICS ANTIINFLAATORY ANTIANXIETY AGENTS ANTICONVULSANTS ANTICONVULSANTS DERATOLOGICALS DERATOLOGICALS 2 DERATOLOGICALS DERATOLOGICALS URINARY ANTIASODICS URINARY ANTIASODICS URINARY ANTIASODICS ANALGESICS OPIOID ANALGESICS OPIOID NC ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID 2 ANALGESICS OPIOID 2 ANALGESICS OPIOID ANALGESICS OPIOID PA URINARY ANTIASODICS ANTIHISTAINES ANTIHISTAINES PA ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIDEPRESSANTS ENDOCRINE AND ETABOLIC AGENTS ISC. ULCER DRUGS ST DIGESTIVE AIDS ST DIGESTIVE AIDS DERATOLOGICALS PA DERATOLOGICALS ULCER DRUGS USCULOSKELETAL THERAPY AGENTS $0 CONTRACEPTIVES ANTIPARKINSON AGENTS NC ANTIDIARRHEALS ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIDEPRESSANTS AINOGLYCOSIDES ANTIDEPRESSANTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 50 of 79
Cont. Alphabetical Index paroxetine tab (PAXIL equiv) PASER GRANULE PATADAY OPHTH SOLN (= 2.5ml/0 days; Step Therapy requires trial of olopatadine ophth soln) PATANASE NASAL RAY PATANOL OPHTH SOLN PAXIL CR TAB PAXIL SU PAXIL TAB PAZEO OPHTH SOLN 0.7% PCE TAB PEAK FLOW ETER PEDIATEX TD SU pediatric multiple vitamins/fluoride chew tab pediatric multiple vitamins/fluoride soln pediatric multiple vitamins/fluoride/iron soln PEDIAZOLE SU peg 50/electrolytes soln (COLYTE equiv) (Covered at $0 for members 5075 yearslimited to 2 fills/calendar year; All other members covered at generic copay) PEGANONE TAB PEGASYS INJ (Step Therapy requires trial of PEGINTRON; Required thru specialty pharmacy. Apothecary by Design 877848447) PEGASYS INJ KIT (Step Therapy requires trial of PEGINTRON; Required thru specialty pharmacy. Apothecary by Design 877848447) PEGINTRON INJ PEN NEEDLE PENICILLIN G PRICAINE INJ PENICILLIN G SODIU INJ penicillin vk soln (VEETIDS equiv) penicillin vk tab (VEETIDS equiv) PENNSAID SOLN PENNSAID SOLN.5% PENTASA CAP (Step Therapy requires trial of ASACOL (HD), DELZICOL, or LIALDA) pentazocine/acetaminophen tab (TALACEN equiv) pentazocine/naloxone tab (TALWIN NX equiv) pentoxifylline ER tab (TRENTAL equiv) PEPCID SU PEPCID TAB PERCOCET TAB PERCODAN TAB PERFOROIST NEB SOLN PERIDEX SOLN perindopril tab (ACEON equiv) permethrin cream (ELIITE CREA equiv) perphenazine tab (TRILAFON equiv) PERPHENAZINE/ AITRIPTYLINE TAB PERSANTINE TAB PERTZYE CAP (Step Therapy requires trial of CREON) Special Code Tier Category ANTIDEPRESSANTS ANTIYCOBACTERIAL AGENTS ST 2 OPHTHALIC AGENTS NC CIOTC $0 2 ST ST OTC NC NC ST 2 CI ST NASAL AGENTS SYSTEIC AND TOPICAL OPHTHALIC AGENTS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS OPHTHALIC AGENTS ACROLIDES EDICAL DEVICES AND SUPPLIES COUGH/COLD/ALLERGY ULTIVITAINS ULTIVITAINS ULTIVITAINS ANTIINFECTIVE AGENTS ISC. LAXATIVES ANTICONVULSANTS ANTIVIRALS ANTIVIRALS ANTIVIRALS EDICAL DEVICES AND SUPPLIES PENICILLINS PENICILLINS PENICILLINS PENICILLINS DERATOLOGICALS DERATOLOGICALS GASTROINTESTINAL AGENTS ISC. ANALGESICS OPIOID ANALGESICS OPIOID HEATOLOGICAL AGENTS ISC. ULCER DRUGS ULCER DRUGS ANALGESICS OPIOID ANALGESICS OPIOID ANTIASTHATIC AND BRONCHODILATOR AGENTS OUTH/THROAT/DENTAL AGENTS ANTIHYPERTENSIVES DERATOLOGICALS ANTIPSYCHOTICS/ANTIANIC AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. HEATOLOGICAL AGENTS ISC. DIGESTIVE AIDS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Cont. Alphabetical Index PEXEVA TAB (Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine) PFIZERPEN G INJ phenazopyridine tab (PYRIDIU equiv) phenelzine tab (NARDIL equiv) phenobarbital elixir phenobarbital tab phenoxybenzamine cap (DIBENZYLINE equiv) phenylephrine ophth soln (YDFRIN equiv) phenytoin cap (DILANTIN equiv) phenytoin chew tab (DILANTIN equiv) phenytoin susp (DILANTIN equiv) PHISOHEX LIQUID PHOSLO CAP PHOSLYRA SOLN phospha 250 neutral tab (KPHOS NEUTRAL equiv) PHOHOLINE OPHTH SOLN physiosol inj PICATO GEL (= box/fill) pilocarpine ophth soln (ISOPTO CARPINE equiv) pilocarpine tab (SALAGEN equiv) PILOPINE HS OPHTH GEL pimozide tab pindolol tab (VISKEN equiv) pioglitazone tab (ACTOS TAB equiv) pioglitazone/glimepiride tab (DUETACT equiv) pioglitazone/metformin tab (ACTOPLUS ET equiv) piperacillin/tazobactam inj piroxicam cap (FELDENE equiv) PLAN B TAB PLAQUENIL TAB PLASALYTE INJ PLAVIX TAB 75G PLEGRIDY INJ PLEGRIDY PEN INJ PLENDIL TAB PLETAL TAB PLEXION LOTION PLEXION SCT CREA PNEUOVAX INJ (Vaccines are covered for members 9 years or older) PODOCON SOLN podofilox soln (CONDYLOX equiv) POLYCITRA CRYSTAL PACK POLYCITRALC SOLN polyethylene glycol 50 powder (IRALAX equiv) POLYETHYLENE GLYCOL 8000 GRANULES polymyxin B inj Special Code Tier Category ST ANTIDEPRESSANTS PENICILLINS GENITOURINARY AGENTS ISCELLANEOUS ANTIDEPRESSANTS HYPNOTICS HYPNOTICS CI ANTIHYPERTENSIVES OPHTHALIC AGENTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTISEPTICS & DISINFECTANTS GASTROINTESTINAL AGENTS ISC. 2 GASTROINTESTINAL AGENTS ISC. INERALS & ELECTROLYTES 2 OPHTHALIC AGENTS ASSORTED CLASSES DERATOLOGICALS OPHTHALIC AGENTS OUTH/THROAT/DENTAL AGENTS OPHTHALIC AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. CI BETA BLOCKERS CI ANTIDIABETICS CI ANTIDIABETICS CI ANTIDIABETICS PENICILLINS ANALGESICS ANTIINFLAATORY OTC $0 CONTRACEPTIVES ANTIALARIALS INERALS & ELECTROLYTES HEATOLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. CALCIU CHANNEL BLOCKERS HEATOLOGICAL AGENTS ISC. DERATOLOGICALS DERATOLOGICALS VAC $0 VACCINES 2 DERATOLOGICALS DERATOLOGICALS GENITOURINARY AGENTS ISCELLANEOUS GENITOURINARY AGENTS ISCELLANEOUS NC LAXATIVES 2 PHARACEUTICAL ADJUVANTS ANTIINFECTIVE AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 52 of 79
Cont. Alphabetical Index polymyxin b/ trimethoprim ophth soln (POLYTRI equiv) POLYTRI OPHTH SOLN POLYTUSSIN D SYRUP POALYST CAP PONSTEL CAP POTABA CAP POTABA POWDER PACKET POTABA TAB potassium bicarbonate effer tab (KLYTE equiv) potassium chloride effer tab (KLYTE/CL equiv) potassium chloride ER cap (ICROK equiv) POTASSIU CHLORIDE ER TAB potassium chloride ER tab (KLORCON equiv) potassium chloride inj potassium chloride micro tab (KDUR equiv) potassium chloride powder packet (KLORCON equiv) potassium citrate CR tab (UROCITK TAB equiv) potassium citrate/citric acid powder pack (POLYCITRA equiv) potassium citrate/citric acid soln (POLYCITRAK equiv) POTIGA TAB (= tabs/day) POTIGA TAB 50G (= 9 tabs/day) PRADAXA CAP PRALUENT INJ pramipexole ER tab (IRAPEX ER equiv) pramipexole tab (IRAPEX equiv) PRAOSONE CREA % PRAOSONE CREA 2.5% PRAOSONE E CREA PRAOSONE LOTION PRAOSONE OINT pramoxine/hydrocortisone cream (ANALPRAHC equiv) pramoxine/hydrocortisone cream kit (ANALPRAHC equiv) pramoxinehc AQ otic soln (CORTANEB AQUEOUS equiv) PRANDIET TAB PRANDIN TAB PRASCION RA CREA PRAVACHOL TAB pravastatin tab (PRAVACHOL equiv) prazosin cap (INIPRESS equiv) PRECISION INSULIN SYRINGE PRECISION XTRA ETER PRECISION XTRA TEST STRIP PRECOSE TAB PRED FORTE OPHTH SU PRED ILD OPHTH SOLN PREDG OPHTH SOLN prednicarbate cream (DERATOP equiv) prednicarbate oint (DERATOP equiv) Special Code Tier Category OPHTHALIC AGENTS OPHTHALIC AGENTS NC COUGH/COLD/ALLERGY NC ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS ANTIINFLAATORY VITAINS 2 VITAINS 2 VITAINS INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES GENITOURINARY AGENTS ISCELLANEOUS GENITOURINARY AGENTS ISCELLANEOUS GENITOURINARY AGENTS ISCELLANEOUS 2 ANTICONVULSANTS 2 ANTICONVULSANTS 2 ANTICOAGULANTS NC ANTIHYPERLIPIDEICS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS 2 DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS DERATOLOGICALS 2 DERATOLOGICALS NC ANORECTAL AGENTS ANORECTAL AGENTS OTIC AGENTS NC ANTIDIABETICS ANTIDIABETICS 2 DERATOLOGICALS ANTIHYPERLIPIDEICS CI ANTIHYPERLIPIDEICS CI ANTIHYPERTENSIVES CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 EDICAL DEVICES AND SUPPLIES CIOTC $0 DIAGNOSTIC PRODUCTS ANTIDIABETICS OPHTHALIC AGENTS 2 OPHTHALIC AGENTS 2 OPHTHALIC AGENTS DERATOLOGICALS DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Cont. Alphabetical Index prednisolone ODT (ORAPRED equiv) prednisolone ophth soln (PRED FORTE equiv) PREDNISOLONE SODIU PHOHATE OPHTH SOLN prednisolone soln (PEDIAPRED equiv) prednisolone syrup (PRELONE equiv) PREDNISONE PAK PREDNISONE SOLN PREDNISONE TAB prednisone tab (DELTASONE equiv) PREFEST TAB pregnyl inj (PROFASI equiv) PRELONE SYRUP PREARIN TAB PREARIN VAGINAL CREA PREPHASE/PREPRO TAB PRENATAL VITAINS (NONPREFERRED) PRENATAL VITAINS (PRENATAL PLUS/ PREPLUS/PRENAPLUS) PREPOPIK PAK PRESTALIA TAB PREVACID OTC CAP PREVACID SOLUTAB PREVIDENT CREA (Covered at $0 for members 5 years or younger; All other members covered at preferred brand copay) PREVIDENT GEL PREVIDENT PASTE PREVIDENT RINSE PREVNAR INJ (Vaccines are covered for members 9 years or older) PREVPAC KIT PREZCOBIX TAB PREZISTA SU PREZISTA TAB PRIFTIN TAB PRILOSEC OTC DR TAB PRIAQUINE TAB primidone tab (YSOLINE equiv) PRISOL SOLN PRINIVIL TAB/ ZESTRIL TAB PRISTIQ TAB (Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND venlafaxine product) PROAIR HFA INHALER PROAATINE TAB probenecid tab (BENEID equiv) PROCAINAIDE INJ PROCARDIA CAP PROCENTRA SOLN prochlorperazine supp (COPAZINE equiv) prochlorperazine tab (COPAZINE equiv) PROCORT CREA PROCRIT INJ Special Code Tier Category CORTICOSTEROIDS OPHTHALIC AGENTS 2 OPHTHALIC AGENTS CORTICOSTEROIDS CORTICOSTEROIDS 2 CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS ESTROGENS INF ENDOCRINE AND ETABOLIC AGENTS ISC. CORTICOSTEROIDS 2 ESTROGENS 2 VAGINAL PRODUCTS 2 ESTROGENS ULTIVITAINS VITAINS NC LAXATIVES NC ANTIHYPERTENSIVES OTC ULCER DRUGS 2 ULCER DRUGS $0 OUTH/THROAT/DENTAL AGENTS 2 OUTH/THROAT/DENTAL AGENTS 2 OUTH/THROAT/DENTAL AGENTS 2 OUTH/THROAT/DENTAL AGENTS VAC $0 VACCINES ULCER DRUGS ANTIVIRALS ANTIVIRALS ANTIVIRALS 2 ANTIYCOBACTERIAL AGENTS NC ULCER DRUGS 2 ANTIALARIALS ANTICONVULSANTS ANTIINFECTIVE AGENTS ISC. ANTIHYPERTENSIVES ST ANTIDEPRESSANTS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS VASOPRESSORS GOUT AGENTS ANTIARRHYTHICS CALCIU CHANNEL BLOCKERS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS NC ANORECTAL AGENTS HEATOPOIETIC AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 54 of 79
Cont. Alphabetical Index PROCTOCORT CREA PROCTOFOA HC FOA proctosol HC cream (ANUSOL HC equiv) PRODRIN TAB progesterone cap (PROETRIU equiv) progesterone oil inj PROGESTERONE SUPP PROGLYCE SU PROGRAF CAP PROLENSA OPHTH SOLN PROLEUKIN INJ PROLIA INJ PROACTA TAB promethazine D syrup promethazine supp (PHENERGAN equiv) promethazine syrup promethazine tab (PHENERGAN equiv) promethazine VC syrup (PHENERGAN VC equiv) promethazine VC w/codeine syrup (PHENERGAN VC W/CODIENE equiv) promethazine w/codeine syrup (PHENERGAN W/CODIENE equiv) PROETRIU CAP propafenone ER cap (RYTHOL SR equiv) propafenone tab (RYTHOL equiv) PROPANTHELINE TAB proparacaine ophth soln (ALCAINE equiv) propranolol ER cap (INDERAL LA equiv) PROPRANOLOL SOLN propranolol tab (INDERAL equiv) propranolol/hydrochlorothiazide tab (INDERIDE equiv) propylthiouracil tab PROSCAR TAB PROSO TAB PROSTIGIN TAB PROTHELIAL PASTE PROTONIX PAK PROTOPIC OINT protriptyline tab (VIVACTIL equiv) PROVENTIL HFA INHALER PROVERA TAB PROVIGIL TAB (= 2 tabs/day) PROZAC CAP PROZAC SOLN PROZAC TAB PULICORT FLEXHALER PULICORT INH SU PULOZYE INH SOLN Special Code Tier Category DERATOLOGICALS 2 ANORECTAL AGENTS ANORECTAL AGENTS NC IGRAINE PRODUCTS PROGESTINS NC PROGESTINS PA VAGINAL PRODUCTS ANTIDIABETICS ASSORTED CLASSES 2 OPHTHALIC AGENTS 2 ANTINEOPLASTICS AND ADJUNCTIVE ENDOCRINE AND ETABOLIC AGENTS ISC. PA HEATOPOIETIC AGENTS COUGH/COLD/ALLERGY ANTIHISTAINES ANTIHISTAINES ANTIHISTAINES COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY PROGESTINS ANTIARRHYTHICS ANTIARRHYTHICS 2 ULCER DRUGS OPHTHALIC AGENTS CI BETA BLOCKERS CI BETA BLOCKERS CI BETA BLOCKERS CI ANTIHYPERTENSIVES THYROID AGENTS GENITOURINARY AGENTS ISCELLANEOUS HYPNOTICS 2 ANTIYASTHENIC AGENTS NC OUTH/THROAT/DENTAL AGENTS NC ULCER DRUGS DERATOLOGICALS ANTIDEPRESSANTS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS PROGESTINS PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS REIRATORY AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 55 of 79
Cont. Alphabetical Index PUREFOLIX TAB PURINETHOL TAB PURIXAN SU PYLERA CAP pyrazinamide tab PYRIDIU TAB pyridostigmine CR tab (ESTINON equiv) pyridostigmine tab (ESTINON equiv) QNASL NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) QUALAQUIN CAP QUARTETTE TAB QUDEXY XR/TOPIRAATE ER CAP QUESTRAN LITE POWDER QUESTRAN LITE POWDER PACK QUESTRAN POWDER QUESTRAN POWDER PACK quetiapine tab (SEROQUEL equiv) QUFLORA PEDIATRIC CHEW TAB QUFLORA PEDIATRIC DROP QUILLIVANT XR SU quinapril tab (ACCUPRIL equiv) quinapril/hydrochlorothiazide tab (ACCURETIC equiv) quinidine gluconate CR tab QUINIDINE SULFATE ER TAB QUINIDINE SULFATE TAB quinine sulfate cap (QUALAQUIN equiv) QVAR INHALER rabeprazole EC tab (ACIPHEX equiv) RAGWITEK SL TAB raloxifene tab (EVISTA equiv) (Covered at $0 for women 5 years or older; All other members covered at generic copay) ramipril cap (ALTACE equiv) RANEXA TAB ranitidine cap (ZANTAC equiv) ranitidine syrup (ZANTAC equiv) ranitidine tab (Rx Only) (ZANTAC equiv) RAPAFLO CAP (Restricted to Urology Specialist) RAPAUNE SOLN RAPAUNE TAB RAVICTI LIQUID RAYOS TAB RAZADYNE ER CAP RAZADYNE SOLN Special Code Tier Category ST CI CI CI RS NC NC NC NC NC NC NC $0 2 2 NC NC HEATOPOIETIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE ULCER DRUGS ANTIYCOBACTERIAL AGENTS GENITOURINARY AGENTS ISCELLANEOUS ANTIYASTHENIC/CHOLINERGIC AGENTS ANTIYASTHENIC AGENTS NASAL AGENTS SYSTEIC AND TOPICAL ANTIALARIALS CONTRACEPTIVES ANTICONVULSANTS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS ANTIPSYCHOTICS/ANTIANIC AGENTS ULTIVITAINS ULTIVITAINS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIARRHYTHICS ANTIARRHYTHICS ANTIARRHYTHICS ANTIALARIALS ANTIASTHATIC AND BRONCHODILATOR AGENTS ULCER DRUGS BIOLOGICALS ISC ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIHYPERTENSIVES ANTIANGINAL AGENTS ULCER DRUGS ULCER DRUGS ULCER DRUGS GENITOURINARY AGENTS ISCELLANEOUS ASSORTED CLASSES ASSORTED CLASSES ENDOCRINE AND ETABOLIC AGENTS ISC. CORTICOSTEROIDS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 56 of 79
Cont. Alphabetical Index RAZADYNE TAB REBETOL CAP REBETOL SOLN REBIF INJ RECLAST INJ RECTIV OINT REGLAN TAB REGRANEX GEL (= 0gm/fill) RELENZA DISKHALER (= inhaler/fill) RELISTOR INJ RELISTOR INJ KIT RELPAX TAB (= 9 tabs/fill, 2 fills/0 days) REERON SOLUTAB REERON TAB REICADE INJ RENAGEL TAB renaphro cap (NEPHROCAP equiv) RENOVA CREA RENVELA PACKET RENVELA TAB repaglinide tab (PRANDIN equiv) REPATHA INJ REPREXAIN TAB REQUIP TAB REQUIP XL TAB RESCON TAB RESCRIPTOR TAB RESERPINE TAB RESTASIS OPHTH EULSION (Restricted to Ophthalmology or Optometry Specialist) RESTORIL CAP 5G RESTORIL CAP 22.5G RESTORIL CAP 0G RESTORIL CAP 7.5G RETINA CREA RETINA GEL RETINA ICRO GEL 0.04%, 0.% (Acne Only members age 25 or older require Prior Authorization) RETINA ICRO GEL 0.08% RETROVIR CAP RETROVIR SYRUP RETROVIR TAB REVATIO SU REVATIO TAB REVIA TAB REVLIID CAP (= cap/day) REXAPHENAC CREA REXULTI TAB REYATAZ CAP Special Code Tier Category PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIVIRALS ANTIVIRALS PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANORECTAL AGENTS GASTROINTESTINAL AGENTS ISC. 2 DERATOLOGICALS 2 ANTIVIRALS PA GASTROINTESTINAL AGENTS ISC. PA GASTROINTESTINAL AGENTS ISC. IGRAINE PRODUCTS ANTIDEPRESSANTS ANTIDEPRESSANTS GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. ULTIVITAINS NC DERATOLOGICALS 2 GASTROINTESTINAL AGENTS ISC. 2 GASTROINTESTINAL AGENTS ISC. CI ANTIDIABETICS NC ANTIHYPERLIPIDEICS ANALGESICS OPIOID ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS COUGH/COLD/ALLERGY ANTIVIRALS ANTIHYPERTENSIVES RS 2 OPHTHALIC AGENTS HYPNOTICS HYPNOTICS HYPNOTICS HYPNOTICS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS NC DERATOLOGICALS ANTIVIRALS ANTIVIRALS ANTIVIRALS NC CARDIOVASCULAR AGENTS ISC. PA CARDIOVASCULAR AGENTS ISC. ANTIDOTES PA ASSORTED CLASSES NC DERATOLOGICALS NC ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIVIRALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 57 of 79
Cont. Alphabetical Index REYATAZ POWDER PACK REZIRA SOLN RHEUATREX TAB RHINOCORT AQUA NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) RIBAPAK TAB RIBATAB ribavirin cap (REBETOL equiv) ribavirin tab (COPEGUS equiv) RIDAURA CAP rifabutin cap (YCOBUTIN equiv) RIFADIN CAP RIFAATE CAP rifampin cap (RIFADIN equiv) RIFATER TAB riluzole tab (RILUTEK equiv) rimantadine tab (FLUADINE equiv) ringers irrigation soln RIOET SOLN risedronate DR tab (ATELVIA equiv) (Step Therapy requires trial of alendronate) risedronate tab (ACTONEL equiv) RIERDAL ODT RIERDAL SOLN RIERDAL TAB risperidone ODT (RIERDAL equiv) risperidone soln (RIERDAL equiv) risperidone tab (RIERDAL equiv) RITALIN LA CAP RITALIN LA CAP 0G RITALIN LA CAP 60G RITALIN SR TAB RITALIN TAB RITUXAN INJ rivastigmine cap (EXELON equiv) rivastigmine patch (EXELON equiv) rizatriptan ODT (AXALT equiv) (= 2 tabs/fill, fills/60 days) rizatriptan tab (AXALT equiv) (= 2 tabs/fill, fills/60 days) ROBAXIN TAB ROBINUL TAB ROCALTROL CAP ROCALTROL SOLN ropinirole ER tab (REQUIP XL equiv) ropinirole tab (REQUIP equiv) Special Code Tier Category ANTIVIRALS COUGH/COLD/ALLERGY ANALGESICS ANTIINFLAATORY ST NASAL AGENTS SYSTEIC AND TOPICAL NC ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTIVIRALS 2 ANALGESICS ANTIINFLAATORY ANTIYCOBACTERIAL AGENTS ANTIYCOBACTERIAL AGENTS 2 ANTIYCOBACTERIAL AGENTS ANTIYCOBACTERIAL AGENTS PA ANTIYCOBACTERIAL AGENTS NEUROUSCULAR AGENTS ANTIVIRALS ASSORTED CLASSES ANTIDIABETICS ST ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTINEOPLASTICS AND ADJUNCTIVE PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. IGRAINE PRODUCTS IGRAINE PRODUCTS USCULOSKELETAL THERAPY AGENTS ULCER DRUGS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 58 of 79
Cont. Alphabetical Index ROSADAN KIT ROSULA EULSION ROSULA GEL ROSULA PAD ROSULA WASH rosuvastatin tab (CRESTOR equiv) (= tab/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, simvastatin or pravastatin) rosuvastatin tab 20mg (CRESTOR equiv) (=.5 tabs/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, simvastatin or pravastatin) ROWASA KIT ROXICET SOLN 25G/5L ROXICET TAB ROXICODONE TAB ROZERE TAB (= tab/day) RYBIX ODT RYTARY CAP (Step Therapy requires trial of carbidopa/levodopa ER) RYTHOL SR CAP RYTHOL TAB SABRIL POWDER PACK (Only available through SHARE program 88845SHARE (888457427)) SABRIL TAB (Only available through SHARE program 88845SHARE (888457427)) SAFYRAL TAB SAIZEN/SEROSTI INJ SALAGEN TAB SALEX SHAPOO salicylic acid shampoo (SALEX equiv) salsalate tab (DISALCID equiv) SASCA TAB SANCTURA TAB SANCTURA XR CAP SANCUSO PATCH (= 4 patches/fill) SANDIUNE CAP SANDIUNE SOLN 00G/L SANDOSTATIN INJ SANDOSTATIN LAR INJ KIT SANTYL OINT SAPHRIS SL TAB (= 2 tabs/day) SAVELLA PAK SAVELLA TAB (= 2 tabs/day) SEASONIQUE TAB sebprev cream (OVACE CREA equiv) SECONAL CAP SECTRAL CAP SEEBRI NEOHALER CAP selegiline cap (ELDEPRYL equiv) selegiline tab (ELDEPRYL equiv) Special Code Tier Category NC DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS CIST ANTIHYPERLIPIDEICS CIST ANTIHYPERLIPIDEICS NC GASTROINTESTINAL AGENTS ISC. 2 ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID HYPNOTICS NC ANALGESICS OPIOID ST ANTIPARKINSON AGENTS ANTIARRHYTHICS ANTIARRHYTHICS LDPA ANTICONVULSANTS LDPA ANTICONVULSANTS NC CONTRACEPTIVES NC ENDOCRINE AND ETABOLIC AGENTS ISC. OUTH/THROAT/DENTAL AGENTS DERATOLOGICALS DERATOLOGICALS ANALGESICS NONNARCOTIC ENDOCRINE AND ETABOLIC AGENTS ISC. URINARY ANTIASODICS PA URINARY ANTIASODICS ANTIEETICS ASSORTED CLASSES ASSORTED CLASSES ENDOCRINE AND ETABOLIC AGENTS ISC. NC ENDOCRINE AND ETABOLIC AGENTS ISC. 2 DERATOLOGICALS PA ANTIPSYCHOTICS/ANTIANIC AGENTS 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. CONTRACEPTIVES DERATOLOGICALS 2 HYPNOTICS BETA BLOCKERS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 59 of 79
Cont. Alphabetical Index selenium sulfide lotion selenium sulfide shampoo (SELSEB equiv) SELRX SHAPOO 2.% SELZENTRY TAB SEPREXD CAP SENSIPAR TAB SEREVENT DISKUS INHALER SERNIVO RAY SEROQUEL TAB SEROQUEL XR TAB sertraline conc (ZOLOFT equiv) sertraline tab (ZOLOFT equiv) SEVELAER CARBONATE TAB SFROWASA ENEA SHOHLS SOLN SIGNIFOR INJ (= 2 vials/day; Only available through Accredo 88877776) sildenafil tab (REVATIO equiv) SILENOR TAB SILVADENE CREA silver sulfadiazine cream (SILVADENE CREA equiv) SILVERA PAD SIBRINZA OPHTH SU SICOR TAB SIPONI ARIA INJ SIPONI INJ (= inj/28 days) SIULECT INJ simvastatin tab (ZOCOR equiv) (80mg is Not Covered) SINEET CR TAB SINEET TAB SINGULAIR CHEW TAB SINGULAIR GRANULE PACK SINGULAIR TAB sirolimus tab (RAPAUNE equiv) SIRTURO TAB SITAVIG TAB SIVEXTRO TAB (= 6 tabs/fill; Restricted to Infectious Disease Specialist) SKELAXIN TAB SKELID TAB SKLICE LOTION (= tube/fill) SLONIACIN TAB smz/tmp (DS) tab (BACTRI DS equiv) smz/tmp susp (BACTRI/SEPTRA equiv) sodium chloride 0.9% irr soln sodium chloride inj sodium chloride neb soln (HYPERSAL equiv) Special Code Tier Category DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS ANTIVIRALS COUGH/COLD/ALLERGY 2 ENDOCRINE AND ETABOLIC AGENTS ISC. CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS NC DERATOLOGICALS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIDEPRESSANTS ANTIDEPRESSANTS 2 GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. 2 GENITOURINARY AGENTS ISCELLANEOUS LDPA ENDOCRINE AND ETABOLIC AGENTS ISC. PA CARDIOVASCULAR AGENTS ISC. NC HYPNOTICS DERATOLOGICALS DERATOLOGICALS NC DERATOLOGICALS 2 OPHTHALIC AGENTS NC ANTIHYPERLIPIDEICS NC ANALGESICS ANTIINFLAATORY PA ANALGESICS ANTIINFLAATORY ASSORTED CLASSES CI ANTIHYPERLIPIDEICS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ASSORTED CLASSES NC ANTIYCOBACTERIAL AGENTS NC ANTIVIRALS RS 2 ANTIINFECTIVE AGENTS ISC. USCULOSKELETAL THERAPY AGENTS ENDOCRINE AND ETABOLIC AGENTS ISC. PA DERATOLOGICALS OTC VITAINS ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. GENITOURINARY AGENTS ISCELLANEOUS INERALS & ELECTROLYTES COUGH/COLD/ALLERGY CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 60 of 79
Cont. Alphabetical Index sodium citrate/citric acid soln (BICITRA equiv) sodium fluoride cream (PREVIDENT equiv) (Covered at $0 for members 5 years or younger; All other members covered at generic copay) sodium fluoride gel (PREVIDENT equiv) SODIU FLUORIDE LOZENGE (Covered at $0 for members 5 years or younger; All other members covered at generic copay) sodium fluoride paste (PREVIDENT equiv) sodium fluoride rinse (PREVIDENT equiv) sodium fluoride soln (LURIDE equiv) (Covered at $0 for members 5 years or younger; All other members covered at generic copay) SODIU FLUORIDE TAB (Covered at $0 for members 5 years or younger; All other members covered at generic copay) sodium fluoride tab (LURIDE equiv) (Covered at $0 for members 5 years or younger; All other members covered at generic copay) sodium fluoride/potassium nitrate paste (PREVIDENT equiv) sodium phenylbutyrate powder (BUPHENYL equiv) sodium polystyrene powder (KAYEXALATE equiv) sodium polystyrene susp (S equiv) sodium sulfacetamide gel (OVACE PLUS equiv) sodium sulfacetamide lotion (KLARON equiv) sodium sulfacetamide shampoo (OVACE equiv) sodium sulfacetamide wash (OVACE WASH equiv) sodium sulfacetamide/ urea pad (ROSULA equiv) sodium sulfacetamide/sulfur cream (PLEXION SCT equiv) SODIU SULFACETAIDE/SULFUR EULSION sodium sulfacetamide/sulfur emulsion (ROSAC WASH equiv) sodium sulfacetamide/sulfur emulsion (ROSULA equiv) sodium sulfacetamide/sulfur foam (CLARIFOA EF equiv) sodium sulfacetamide/sulfur gel (ROSULA equiv) sodium sulfacetamide/sulfur lotion (SULFACET R equiv) sodium sulfacetamide/sulfur pad (PLEXION CLEANSING CLOTH equiv) sodium sulfacetamide/sulfur susp (SUAXIN equiv) sodium sulfacetamide/sulfur wash (SUAXIN equiv) sodium sulfacetamide/sunscreen kit (SUADEN XLT equiv) SOLAICE PATCH SOLARAZE GEL SOLARCAINE EXTRA GEL SOA TAB SOATULINE INJ SOAVERT INJ (Only available through Walgreens 8884746) SONOTE CAP SONATA CAP SORIATANE CAP SORIATANE CK KIT SORILUX FOA sotalol AF tab (BETAPACE AF equiv) sotalol tab (BETAPACE equiv) SOTYLIZE SOLN SOVALDI TAB (= tab/day) ECTRACEF TAB Special Code Tier Category $0 $0 $0 $0 $0 NC NC PA LDPA 2 CI CI NC PA GENITOURINARY AGENTS ISCELLANEOUS OUTH/THROAT/DENTAL AGENTS OUTH/THROAT/DENTAL AGENTS INERALS & ELECTROLYTES OUTH/THROAT/DENTAL AGENTS OUTH/THROAT/DENTAL AGENTS INERALS & ELECTROLYTES INERALS & ELECTROLYTES INERALS & ELECTROLYTES OUTH/THROAT/DENTAL AGENTS ENDOCRINE AND ETABOLIC AGENTS ISC. ASSORTED CLASSES ASSORTED CLASSES DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS USCULOSKELETAL THERAPY AGENTS ENDOCRINE AND ETABOLIC AGENTS ISC. ENDOCRINE AND ETABOLIC AGENTS ISC. HYPNOTICS HYPNOTICS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS BETA BLOCKERS BETA BLOCKERS BETA BLOCKERS ANTIVIRALS CEPHALOORINS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Cont. Alphabetical Index INOSAD SU (= bottle/fill) IRIVA HANDIHALER (For use with Handihaler device) IRIVA REIAT INHALER IRIVA REIAT INHALER.25CG/ACT (Step Therapy requires trial of inhaled corticosteroid) spironolactone tab (ALDACTONE equiv) spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv) ORANOX CAP ORANOX SOLN RITA TAB RIX NASAL RAY RYCEL TAB SSKI SOLN STARLIX TAB stavudine cap (ZERIT equiv) stavudine soln (ZERIT equiv) STAVZOR CAP STELARA INJ STIATE NASAL SOLN STIOLTO INHALER STIVARGA TAB (= 4 tabs/day) STRATTERA CAP STRENSIQ INJ STREPTOYCIN INJ STRIBILD TAB STRIVERDI REIAT INHALER (= inhaler/0 days) STROECTOL TAB STROVITE TAB SUBOXONE SL FIL SUBOXONE SL TAB SUBSYS RAY SUCLEAR KIT SUCRAID SOLN sucralfate tab (CARAFATE equiv) SULAR TAB sulfacetamide sodium ophth soln (BLEPH0 equiv) sulfacetamide sodium/ prednisolone ophth soln (VASOCIDIN equiv) SULFADIAZINE TAB SULFAYLON CREA sulfasalazine EC tab (AZULFIDINE equiv) sulfasalazine tab (AZULFIDINE equiv) sulindac tab (CLINORIL equiv) sumatriptan inj (IITREX equiv) (= 4 inj/fill, 2 fills/0 days) SUATRIPTAN INJ 6G/0.5L (= 4 inj/fill, 2 fills/0 days) sumatriptan tab (IITREX equiv) (= 9 tabs/fill, 2 fills/0 days) Special Code Tier Category 2 DERATOLOGICALS CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS CIST 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS CI DIURETICS CI DIURETICS PA ANTIFUNGALS PA ANTIFUNGALS NC ANTICONVULSANTS NC ANALGESICS ANTIINFLAATORY PASF ANTINEOPLASTICS AND ADJUNCTIVE 2 INERALS & ELECTROLYTES ANTIDIABETICS ANTIVIRALS ANTIVIRALS NC ANTICONVULSANTS NC DERATOLOGICALS 2 ENDOCRINE AND ETABOLIC AGENTS ISC. CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS NC ENDOCRINE AND ETABOLIC AGENTS ISC. AINOGLYCOSIDES ANTIVIRALS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTHELINTICS ULTIVITAINS 2 ANALGESICS OPIOID ANALGESICS OPIOID NC ANALGESICS OPIOID NC LAXATIVES NC DIGESTIVE AIDS ULCER DRUGS CALCIU CHANNEL BLOCKERS OPHTHALIC AGENTS OPHTHALIC AGENTS SULFONAIDES 2 DERATOLOGICALS GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. ANALGESICS ANTIINFLAATORY IGRAINE PRODUCTS IGRAINE PRODUCTS IGRAINE PRODUCTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 62 of 79
Cont. Alphabetical Index sumatriptan vial inj (IITREX equiv) (= 5 inj/fill, 2 fills/0 days) SUATRIPTAN/ IITREX NASAL RAY (= 6 sprays/fill, 2 fills/0 days) SUAVEL DOSEPRO INJ (= 6 inj/fill, 2 fills/0 days) SUAXIN PAD SUAXIN TS SU SUAXIN WASH SUPRAX CAP SUPRAX CHEW TAB SUPRAX SU SUPRAX SU 500G/5L SUPRAX TAB SUPREP SOLN (Step therapy requires trial of OVIPREP) SURONTIL CAP SUSTIVA CAP SUSTIVA TAB SUTENT CAP SUTTAR SF SYRUP SYLATRON INJ SYAX DUOTAB SYBICORT INHALER SYBYAX CAP SYLINPEN INJ SYNAGIS INJ SYNAREL NASAL SOLN SYNERA PATCH SYNJARDY TAB (= 2 tabs/day) SYNRIBO INJ SYNTHROID TAB SYNVEXIA TC CREA SYPRINE CAP TABLOID TAB TACLONEX OINT TACLONEX SCALP SU tacrolimus cap (PROGRAF equiv) tacrolimus oint (PROTOPIC OINT equiv) TAFINLAR CAP (= 4 caps/day) TAGAET TAB TAGRISSO TAB TALTZ INJ TABOCOR TAB TAIFLU CAP (= 0 caps/fill) TAIFLU CAP 0G (= 20 caps/fill) TAIFLU SU 6G/L (= 250ml/fill) tamoxifen tab (NOLVADEX equiv) (Covered at $0 for women 5 years or older; All other members covered at generic copay) Special Code Tier Category ST PASF PA PA CI PA PASF 2 NC 2 2 NC 2 NC NC 2 2 2 $0 IGRAINE PRODUCTS IGRAINE PRODUCTS IGRAINE PRODUCTS DERATOLOGICALS DERATOLOGICALS DERATOLOGICALS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS CEPHALOORINS LAXATIVES ANTIDEPRESSANTS ANTIVIRALS ANTIVIRALS ANTINEOPLASTICS AND ADJUNCTIVE COUGH/COLD/ALLERGY ANTINEOPLASTICS AND ADJUNCTIVE ULCER DRUGS ANTIASTHATIC AND BRONCHODILATOR AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIDIABETICS PASSIVE IUNIZING AGENTS ENDOCRINE AND ETABOLIC AGENTS ISC. DERATOLOGICALS ANTIDIABETICS ANTINEOPLASTICS AND ADJUNCTIVE THYROID AGENTS DERATOLOGICALS ASSORTED CLASSES ANTINEOPLASTICS AND ADJUNCTIVE DERATOLOGICALS DERATOLOGICALS ASSORTED CLASSES DERATOLOGICALS ANTINEOPLASTICS AND ADJUNCTIVE ULCER DRUGS ANTINEOPLASTICS AND ADJUNCTIVE DERATOLOGICALS ANTIARRHYTHICS ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTINEOPLASTICS AND ADJUNCTIVE CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Cont. Alphabetical Index tamsulosin cap (FLOAX equiv) TANZEU INJ TAPAZOLE TAB TARCEVA TAB TARGRETIN CAP TARGRETIN GEL TARKA TAB TASIGNA CAP TASAR TAB TAZORAC CREA TAZORAC GEL TECFIDERA CAP TECFIDERA STARTER PACK TECHNIVIE TAB TEFLARO INJ TEGRETOL CHEW TAB TEGRETOL SU TEGRETOL TAB TEGRETOL XR TAB TEKALO TAB TEKTURNA HCT TAB TEKTURNA TAB telmisartan tab (ICARDIS equiv) telmisartan/amlodipine tab (TWYNSTA equiv) telmisartan/hydrochlorothiazide tab (ICARDIS HCT equiv) temazepam cap 5mg (RESTORIL equiv) temazepam cap 22.5mg (RESTORIL equiv) temazepam cap 0mg (RESTORIL equiv) temazepam cap 7.5mg (RESTORIL equiv) TEODAR CAP TEOVATE CREA TEOVATE GEL TEOVATE OINT TEOVATE SOLN TEOVATEE CREA temozolomide cap (TEODAR equiv) TENEX TAB TENORETIC TAB TENORIN TAB TERAZOL CREA TERAZOL SUPP terazosin cap (HYTRIN equiv) terbinafine tab (LAISIL equiv) terbutaline sulfate tab (BRETHINE equiv) terconazole cream (TERAZOL equiv) Special Code Tier Category GENITOURINARY AGENTS ISCELLANEOUS NC ANTIDIABETICS THYROID AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE PASF ANTINEOPLASTICS AND ADJUNCTIVE DERATOLOGICALS ANTIHYPERTENSIVES PASF ANTINEOPLASTICS AND ADJUNCTIVE ANTIPARKINSON AGENTS DERATOLOGICALS DERATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. NC ANTIVIRALS CEPHALOORINS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES NC ANTIHYPERTENSIVES HYPNOTICS HYPNOTICS HYPNOTICS HYPNOTICS ANTINEOPLASTICS AND ADJUNCTIVE PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERTENSIVES ANTIHYPERTENSIVES BETA BLOCKERS VAGINAL PRODUCTS VAGINAL PRODUCTS CI ANTIHYPERTENSIVES ANTIFUNGALS CI ANTIASTHATIC AND BRONCHODILATOR AGENTS VAGINAL PRODUCTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 64 of 79
Cont. Alphabetical Index terconazole supp (TERAZOL equiv) TESSALON CAP TEST STRIP (all other test strips) TESTI GEL/ TESTOSTERONE GEL (= 2 packets/day) testosterone cypionate inj (DEPOTESTOSTERONE equiv) testosterone gel % 25mg (ANDROGEL equiv) (= packet/day) TESTOSTERONE GEL % 25G (= packet/day) testosterone gel % 50mg (ANDROGEL equiv) (= 2 packets/day) TESTOSTERONE GEL % 50G (= 2 packets/day) testosterone gel % pump (ANDROGEL equiv) (= 4 bottles/0 days) TESTOSTERONE GEL PUP (= 4 bottles/0 days) TETANUSDIPHTHERIA TOXOID INJ (Vaccines are covered for members 9 years or older) tetrabenazine tab (XENAZINE equiv) ( ) tetracycline cap TETRACYCLINE CAP TEVETEN HCT TAB TEVETEN TAB TEXACORT SOLN THALOID CAP THEO24 CAP theophylline CR tab (QUIBRONT equiv) theophylline ER tab (UNIPHYL equiv) theophylline soln THIOLA TAB thioridazine tab (ELLARIL equiv) thiothixene cap (NAVANE equiv) THYOGLOBULIN INJ THYROLAR TAB tiagabine tab (GABITRIL equiv) TIAZAC CAP TICANASE PAK TICLOPIDINE TAB ticlopidine tab (TICLID equiv) TIGAN CAP TIKOSYN CAP TIENTIN INJ timolol maleate ophth gel (TIOPTICXE equiv) timolol maleate ophth soln (TIOPTIC equiv) timolol maleate tab (BLOCADREN equiv) TIOPTIC OCUDOSE OPHTH SOLN TIOPTIC OPHTH SOLN TIOPTICXE OPHTH GEL TINDAAX TAB tinidazole tab (TINDAAX equiv) TIROSINT CAP Special Code Tier Category VAGINAL PRODUCTS COUGH/COLD/ALLERGY OTC NC DIAGNOSTIC PRODUCTS PA ANDROGENSANABOLIC ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA 2 ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA 2 ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA 2 ANDROGENSANABOLIC VAC $0 TOXOIDS PA PA CI CI CI NC 2 NC 2 CI PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. TETRACYCLINES TETRACYCLINES ANTIHYPERTENSIVES ANTIHYPERTENSIVES DERATOLOGICALS ASSORTED CLASSES ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS GENITOURINARY AGENTS ISCELLANEOUS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ASSORTED CLASSES THYROID AGENTS ANTICONVULSANTS CALCIU CHANNEL BLOCKERS NASAL AGENTS SYSTEIC AND TOPICAL HEATOLOGICAL AGENTS ISC. HEATOLOGICAL AGENTS ISC. ANTIEETICS ANTIARRHYTHICS PENICILLINS OPHTHALIC AGENTS OPHTHALIC AGENTS BETA BLOCKERS OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. THYROID AGENTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 65 of 79
Cont. Alphabetical Index TIVICAY TAB (= 2 tabs/day) tizanidine cap (ZANAFLEX equiv) TIZANIDINE COFORT KIT tizanidine tab (ZANAFLEX equiv) TOBI NEB SOLN (Restricted to Infectious Disease or Pulmonology Specialist) TOBI PODHALER (Restricted to Infectious Disease or Pulmonology Specialist) TOBRADEX OPHTH OINT TOBRADEX OPHTH SOLN TOBRADEX ST OPHTH SU tobramycin neb soln (TOBI equiv) (Restricted to Infectious Disease or Pulmonology Specialist) tobramycin ophth soln (TOBREX equiv) tobramycin/ dexamethasone ophth soln (TOBRADEX equiv) TOBREX OPHTH OINT TOBREX OPHTH SOLN TODAY ONGE TOFRANIL P CAP TOFRANIL TAB tolazamide tab (TOLINASE equiv) TOLBUTAIDE TAB tolcapone tab (TASAR equiv) tolmetin cap (TOLECTIN DS equiv) TOLETIN TAB tolterodine SR cap (DETROL LA equiv) tolterodine tab (DETROL equiv) TOPAAX RINKLE CAP TOPAAX TAB TOPICORT CREA 0.25% TOPICORT GEL TOPICORT OINT 0.25% TOPICORT/DESOXIETASONE CREA 0.05% TOPICORT/DESOXIETASONE OINT 0.05% topiramate sprinkle cap (TOPAAX equiv) topiramate tab (TOPAAX equiv) TOPROL XL TAB TORISEL INJ torsemide tab (DEADEX equiv) TOUJEO SOLOSTAR INJ TOVIAZ TAB TRACLEER TAB (= 2 tabs/day) TRADJENTA TAB (= tab/day) TRAADOL COPOUND KIT tramadol ER tab (ULTRA ER equiv) tramadol tab (ULTRA equiv) tramadol/acetaminophen tab (ULTRACET equiv) TRANDATE TAB trandolapril tab (AVIK equiv) trandolapril/verapamil ER tab (TARKA equiv) tranexamic acid inj (CYKLOKAPRON equiv) tranexamic acid tab (LYSTEDA equiv) Special Code Tier Category ANTIVIRALS USCULOSKELETAL THERAPY AGENTS NC USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS RS AINOGLYCOSIDES RS AINOGLYCOSIDES 2 OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS RS AINOGLYCOSIDES OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS OPHTHALIC AGENTS OTC $0 VAGINAL PRODUCTS ANTIDEPRESSANTS ANTIDEPRESSANTS CI ANTIDIABETICS CI 2 ANTIDIABETICS ANTIPARKINSON AGENTS ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY URINARY ANTIASODICS URINARY ANTIASODICS ANTICONVULSANTS ANTICONVULSANTS DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS 2 DERATOLOGICALS NC DERATOLOGICALS ANTICONVULSANTS ANTICONVULSANTS BETA BLOCKERS ANTINEOPLASTICS AND ADJUNCTIVE CI DIURETICS CI 2 ANTIDIABETICS PA URINARY ANTIASODICS PA CARDIOVASCULAR AGENTS ISC. PA ANTIDIABETICS NC DERATOLOGICALS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID BETA BLOCKERS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES HEOSTATICS HEOSTATICS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 66 of 79
Cont. Alphabetical Index TRANSDERSCOP PATCH TRANXENET TAB tranylcypromine tab (PARNATE equiv) TRAVATAN Z OPHTH SOLN (= 5ml/0 days) trazodone tab (DESYREL equiv) trazodone tab 00mg (DESYREL equiv) TREANDA INJ TRECATOR TAB TRELSTAR INJ TRENTAL TAB TRESIBA INJ tretinoin cap (VESANOID equiv) tretinoin cream (Acne Only members age 25 or older require Prior Authorization) tretinoin gel (RETINA GEL equiv) (Acne Only members age 25 or older require Prior Authorization) TRETINX CREA TREXALL TAB TREXIET TAB TREZIX CAP triamcinolone cream triamcinolone in orabase paste (KENALOG/ORABASE equiv) triamcinolone lotion triamcinolone nasal spray (NASACORT equiv) (= 2 bottles/fill) triamcinolone oint triamcinolone OTC nasal spray (NASACORT equiv) (= 2 bottles/fill) triamcinolone spray (KENALOG equiv) triamterene/hydrochlorothiazide cap (DYAZIDE equiv) TRIATERENE/HYDROCHLOROTHIAZIDE CAP 5025mg triamterene/hydrochlorothiazide tab (AXZIDE equiv) TRIANEX OINT TRIAZOLA TAB triazolam tab (HALCION equiv) TRIBENZOR TAB tricitrates soln (POLYCITRALC equiv) tricon cap (TRINSICON equiv) TRICOR TAB trifluoperazine tab (STELAZINE equiv) trifluridine ophth soln (VIROPTIC equiv) trihexyphenidyl elixir (ARTANE equiv) trihexyphenidyl tab (ARTANE equiv) trilegest tab (ESTROSTEP FE equiv) TRILEPTAL SU TRILEPTAL TAB TRILIPIX CAP TRILUA CREA Special Code Tier Category ANTIEETICS ANTIANXIETY AGENTS ANTIDEPRESSANTS 2 OPHTHALIC AGENTS ANTIDEPRESSANTS NC ANTIDEPRESSANTS ANTINEOPLASTICS AND ADJUNCTIVE PA ANTIYCOBACTERIAL AGENTS ANTINEOPLASTICS AND ADJUNCTIVE HEATOLOGICAL AGENTS ISC. NC ANTIDIABETICS ANTINEOPLASTICS PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS 2 ANTINEOPLASTICS AND ADJUNCTIVE NC IGRAINE PRODUCTS ANALGESICS OPIOID DERATOLOGICALS OUTH/THROAT/DENTAL AGENTS DERATOLOGICALS NASAL AGENTS SYSTEIC AND TOPICAL DERATOLOGICALS OTC NASAL AGENTS SYSTEIC AND TOPICAL DERATOLOGICALS CI DIURETICS CI 2 DIURETICS CI DIURETICS DERATOLOGICALS HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS HYPNOTICS ANTIHYPERTENSIVES GENITOURINARY AGENTS ISCELLANEOUS HEATOPOIETIC AGENTS ANTIHYPERLIPIDEICS ANTIPSYCHOTICS/ANTIANIC AGENTS OPHTHALIC AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS $0 CONTRACEPTIVES 2 ANTICONVULSANTS ANTICONVULSANTS CI ANTIHYPERLIPIDEICS NC DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 67 of 79
Cont. Alphabetical Index trilyte soln (NULYTELY equiv) (Covered at $0 for members 5075 yearslimited to 2 fills/calendar year; All other members covered at generic copay) trimethobenzamide cap (TIGAN equiv) trimethoprim tab (PROLOPRI equiv) trimipramine cap (SURONTIL equiv) trinessa (LO) tab (ORTHO TRICYCLEN (LO) equiv) TRINORINYL TAB TRINTELLIX TAB (= tab/day) TRIUEQ TAB trivit/iron/fluoride drop TRIZIVIR TAB TROKENDI XR CAP tropicamide ophth soln (YDRIACYL equiv) trospium chloride SR cap (SANCTURA XR equiv) trospium tab (SANCTURA equiv) TRULICITY INJ TRUENBA INJ (Vaccines are covered for members 9 years or older) TRUSOPT OPHTH SOLN TRUVADA TAB TUDORZA PRESSAIR INHALER TUSNEL CAP TUSNEL SYRUP TUSSICAPS (= 20 caps/fill, 2 fills/0 days) tussigon tab (HYCODAN equiv) TUSSIONEX SU (= 20ml/fill; 2 fills/0 days) TUSSIORGANI SYRUP (= 240ml/fill) TUZISTRA XR SU TWINRIX INJ (Vaccines are covered for members 9 years or older) TWYNSTA TAB TYBOST TAB TYKERB TAB TYLENOL/CODEINE TAB TYSABRI INJ TYVASO INH SOLN (Only available through Accredo 88877776) TYZEKA TAB TYZINE NASAL SOLN UCERIS RECTAL FOA UCERIS TAB (= tab/day) UCORT CREA ULESFIA LOTION (= 4 bottles/fill) ULORIC TAB (Step Therapy requires trial of allopurinol) ULTRACET TAB ULTRA ER TAB ULTRA TAB ULTRAVATE CREA ULTRAVATE LOTION ULTRAVATE OINT Special Code Tier Category $0 LAXATIVES ANTIEETICS ANTIINFECTIVE AGENTS ISC. ANTIDEPRESSANTS $0 CONTRACEPTIVES CONTRACEPTIVES PA ANTIDEPRESSANTS ANTIVIRALS ULTIVITAINS ANTIVIRALS NC ANTICONVULSANTS OPHTHALIC AGENTS PA URINARY ANTIASODICS URINARY ANTIASODICS ANTIDIABETICS VAC $0 VACCINES OPHTHALIC AGENTS PA ANTIVIRALS NC ANTIASTHATIC AND BRONCHODILATOR AGENTS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY NC COUGH/COLD/ALLERGY VAC $0 VACCINES ANTIHYPERTENSIVES NC ANTIVIRALS PA ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS OPIOID PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. LDPA CARDIOVASCULAR AGENTS ISC. PA ANTIVIRALS NASAL AGENTS SYSTEIC AND TOPICAL PA ANORECTAL AGENTS PA CORTICOSTEROIDS 2 DERATOLOGICALS DERATOLOGICALS ST 2 GOUT AGENTS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID PA DERATOLOGICALS PA DERATOLOGICALS PA DERATOLOGICALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 68 of 79
Cont. Alphabetical Index ULTRESA CAP (Step Therapy requires trial of CREON) UECTA EULSION UECTA SU UNIPHYL TAB UNIRETIC TAB UNIVASC TAB UPTRAVI TAB UPTRAVI THERAPY PACK URAAXIN CREA URAAXIN GEL urea cream urea gel (URAAXIN equiv) UREA NAIL KIT urea susp 40% (UECTA equiv) URECHOLINE TAB URELIEF PLUS TAB UROCITK TAB UROQID #2 TAB UROXATRAL TAB URSO FORTE TAB ursodiol cap (ACTIGALL equiv) ursodiol tab (URSO (FORTE) equiv) UTA cap UTIBRON NEOHALER CAP VAGIFE TAB (= 8 tabs/28 days (8 tabs on first fill)) valacyclovir tab (VALTREX equiv) VALCHLOR GEL (= 4 tubes/0 days; Only available through Accredo 88877776) VALCYTE SOLN VALCYTE TAB valganciclovir tab (VALCYTE equiv) VALIU TAB valproic acid cap (DEPAKENE equiv) valproic acid syrup (DEPAKENE equiv) valsartan tab (DIOVAN equiv) valsartan/hydrochlorothiazide tab (DIOVAN HCT equiv) VALTREX TAB VALTURNA TAB VANCOCIN CAP (= 56 caps/fill; Step Therapy requires trial of vancomycin soln) vancomycin cap (VANCOCIN equiv) (= 56 caps/fill; Step Therapy requires trial of vancomycin soln) VANCOYCIN SOLN KIT VANIQA CREA VANOS CREA VANTIN TAB VARIVAX INJ (Vaccines are covered for members 9 years or older) VARUBI TAB VASCEPA CAP Special Code Tier Category ST DIGESTIVE AIDS NC DERATOLOGICALS NC DERATOLOGICALS ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES NC CARDIOVASCULAR AGENTS ISC. NC CARDIOVASCULAR AGENTS ISC. NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS URINARY ANTIASODICS NC URINARY ANTIASODICS GENITOURINARY AGENTS ISCELLANEOUS URINARY ANTIINFECTIVES 2 GENITOURINARY AGENTS ISCELLANEOUS GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. GASTROINTESTINAL AGENTS ISC. NC URINARY ANTIINFECTIVES NC ANTIASTHATIC AND BRONCHODILATOR AGENTS VAGINAL PRODUCTS ANTIVIRALS LDPA DERATOLOGICALS 2 ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTIANXIETY AGENTS ANTICONVULSANTS ANTICONVULSANTS CI ANTIHYPERTENSIVES CI ANTIHYPERTENSIVES ANTIVIRALS ANTIHYPERTENSIVES ST ANTIINFECTIVE AGENTS ISC. ST ANTIINFECTIVE AGENTS ISC. 2 ANTIINFECTIVE AGENTS ISC. NC DERATOLOGICALS DERATOLOGICALS CEPHALOORINS VAC $0 VACCINES NC ANTIEETICS NC ANTIHYPERLIPIDEICS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 69 of 79
Cont. Alphabetical Index VASERETIC TAB vasolex oint (XENADER equiv) VASOTEC TAB vcf vaginal gel (CONCEPTROL equiv) VECTICAL OINT VELPHORO CHEW TAB VELTASSA POWDER VELTIN/ ZIANA GEL VENCLEXTA TAB VENCLEXTA TAB STARTER PACK venlafaxine ER cap (EFFEXOR XR equiv) venlafaxine ER tab VENLAFAXINE ER TAB VENLAFAXINE ER TAB 225G venlafaxine tab (EFFEXOR equiv) VENTAVIS INH SOLN (Only available through Accredo 88877776) VENTOLIN HFA INHALER (= 2 inhalers/fill, 2 fills/0 days) VERAYST NASAL RAY (= 2 bottles/fill) verapamil SR cap (VERELAN P equiv) verapamil SR cap (VERELAN SR equiv) verapamil SR tab (CALAN SR/ISOPTIN SR equiv) verapamil tab (CALAN equiv) VERDESO FOA VEREGEN OINT VERELAN CAP VERELAN P CAP VERIPRED SOLN VERSACLOZ SU VESICARE TAB VEXOL OPHTH SU VFEND SU (Restricted to Infectious Disease Specialist) VFEND TAB (Restricted to Infectious Disease Specialist) VGO INJ KIT (= kit/day) VIBERZI TAB VIBRAYCIN CAP VIBRAYCIN SU VIBRAYCIN SYRUP VICOPROFEN TAB VICTOZA INJ (= 9ml/0 days) VICTRELIS CAP VIDEX EC CAP VIDEX SOLN VIIBRYD STARTER KIT VIIBRYD TAB VIOVO TAB VIPAT SOLN VIPAT TAB (= 2 tabs/day) VIRACEPT POWDER Special Code Tier Category ANTIHYPERTENSIVES NC DERATOLOGICALS ANTIHYPERTENSIVES OTC $0 VAGINAL PRODUCTS 2 DERATOLOGICALS GASTROINTESTINAL AGENTS ISC. NC ASSORTED CLASSES DERATOLOGICALS NC ANTINEOPLASTICS AND ADJUNCTIVE NC ANTINEOPLASTICS AND ADJUNCTIVE ANTIDEPRESSANTS ANTIDEPRESSANTS 2 ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS LDPA CARDIOVASCULAR AGENTS ISC. CI 2 ANTIASTHATIC AND BRONCHODILATOR AGENTS 2 NASAL AGENTS SYSTEIC AND TOPICAL CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS CI CALCIU CHANNEL BLOCKERS DERATOLOGICALS DERATOLOGICALS CALCIU CHANNEL BLOCKERS CALCIU CHANNEL BLOCKERS CORTICOSTEROIDS NC ANTIPSYCHOTICS/ANTIANIC AGENTS 2 URINARY ANTIASODICS 2 OPHTHALIC AGENTS RS ANTIFUNGALS RS ANTIFUNGALS CI 2 EDICAL DEVICES AND SUPPLIES NC GASTROINTESTINAL AGENTS ISC. TETRACYCLINES TETRACYCLINES TETRACYCLINES ANALGESICS OPIOID CI 2 ANTIDIABETICS PASF ANTIVIRALS ANTIVIRALS ANTIVIRALS NC ANTIDEPRESSANTS ANTIDEPRESSANTS NC ANALGESICS ANTIINFLAATORY 2 ANTICONVULSANTS 2 ANTICONVULSANTS ANTIVIRALS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 70 of 79
Cont. Alphabetical Index VIRACEPT TAB VIRAUNE SU VIRAUNE TAB VIRAUNE XR TAB (Step Therapy requires trial of nevirapine) VIREAD TAB VIROPTIC OPHTH SOLN VISICOL TAB VISTARIL CAP VISTIDE INJ VISTOGARD PAK vitamin D cap (Rx covered Only) vitamin D cap 000unit (Covered for members 65 years or older) vitamin D cap 400unit (Covered for members 65 years or older) VITAIN D TAB 400UNIT (Covered for members 65 years or older) VITAREA TAB VITEKTA TAB VIVACTIL TAB VIVELLEDOT PATCH VIVITROL INJ VIVLODEX CAP VIVOTIF CAP (= 4 caps/fill; Vaccines are covered for members 9 years or older) VOLTAREN GEL (= 5 tubes/fill) VOLTAREN OPTH SOLN VOLTAREN TAB VOLTAREN XR TAB VOPAC 5 CREA VOPAC CREA VOPAC GB CREA voriconazole susp (VFEND equiv) (Restricted to Infectious Disease Specialist) voriconazole tab (VFEND equiv) (Restricted to Infectious Disease Specialist) VOSOL HC OTIC SOLN VOSOL OTIC SOLN VOIRE ER TAB VOTRIENT TAB VPRIV INJ VRAYLAR CAP VRAYLAR PACK VSL # CAP VYTORIN TAB (= tab/day (0/80mg is Not Covered)) VYTORIN TAB 080G VYVANSE CAP warfarin tab (COUADIN equiv) WELCHOL PAK WELCHOL TAB WELLBUTRIN SR TAB WELLBUTRIN TAB WELLBUTRIN XL TAB Special Code Tier Category ANTIVIRALS ANTIVIRALS ANTIVIRALS ST ANTIVIRALS ANTIVIRALS OPHTHALIC AGENTS LAXATIVES ANTIANXIETY AGENTS ANTIVIRALS NC ANTIDOTES VITAINS OTC $0 VITAINS OTC $0 VITAINS OTC $0 VITAINS DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS ANTIVIRALS ANTIDEPRESSANTS ESTROGENS PA ANTIDOTES NC ANALGESICS ANTIINFLAATORY VAC $0 VACCINES DERATOLOGICALS OPHTHALIC AGENTS ANALGESICS ANTIINFLAATORY ANALGESICS ANTIINFLAATORY NC DERATOLOGICALS NC DERATOLOGICALS NC DERATOLOGICALS RS ANTIFUNGALS RS ANTIFUNGALS OTIC AGENTS OTIC AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE HEATOPOIETIC AGENTS NC ANTIPSYCHOTICS/ANTIANIC AGENTS NC ANTIPSYCHOTICS/ANTIANIC AGENTS NC ANTIDIARRHEALS ANTIHYPERLIPIDEICS NC ANTIHYPERLIPIDEICS 2 ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTICOAGULANTS CI 2 ANTIHYPERLIPIDEICS CI 2 ANTIHYPERLIPIDEICS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Cont. Alphabetical Index WESTCORT OINT wymzya FE tab (FECON FE equiv) XALATAN OPHTH SOLN (= 2.5ml/0 days) XALKORI CAP XANAX TAB XANAX XR TAB XARELTO STARTER PACK XARELTO TAB XARTEIS XR TAB XELJANZ TAB (= 2 tabs/day) XELJANZ XR TAB (= tab/day) XELODA TAB XENADER OINT XENAZINE TAB XERESE CREA XIFAXAN TAB 200G (= 9 tabs/ days) XIFAXAN TAB 550G (= 2 tabs/day) XIGDUO XR TAB (= tab/day) XIGDUO XR TAB 5000G (= 2 tabs/day) XOLEGEL XOPENEX HFA INHALER (= 2 inhalers/fill, 2 fills/0 days; Step Therapy requires trial of VENTOLIN HFA) XOPENEX NEB SOLN XTAPZA ER CAP XTANDI CAP (= 4 caps/day) XULANE PATCH XURIDEN POWDER XYLOCAINE SOLN XYRE SOLN (= 540ml/0 days; Only available through Xyrem Central Pharmacy 866997688) XYZAL SOLN XYZAL TAB XYZBAC TAB YASIN TAB YAZ TAB YERVOY INJ YODOXIN TAB zafirlukast tab (ACCOLATE equiv) zaleplon cap (SONATA equiv) ZANAFLEX CAP ZANAFLEX TAB ZANOSAR INJ ZANTAC CAP ZANTAC EFFER TAB ZANTAC GRANULE PACKET Special Code Tier Category NC DERATOLOGICALS $0 CONTRACEPTIVES OPHTHALIC AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE ANTIANXIETY AGENTS ANTIANXIETY AGENTS 2 ANTICOAGULANTS 2 ANTICOAGULANTS NC ANALGESICS OPIOID PA ANALGESICS ANTIINFLAATORY PA ANALGESICS ANTIINFLAATORY ANTINEOPLASTICS AND ADJUNCTIVE NC DERATOLOGICALS NC PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. DERATOLOGICALS ANTIINFECTIVE AGENTS ISC. PA ANTIINFECTIVE AGENTS ISC. CI 2 ANTIDIABETICS CI 2 ANTIDIABETICS NC DERATOLOGICALS ST ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS NC ANALGESICS OPIOID PASF ANTINEOPLASTICS AND ADJUNCTIVE $0 CONTRACEPTIVES NC ENDOCRINE AND ETABOLIC AGENTS ISC. DERATOLOGICALS LDPA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ANTIHISTAINES ANTIHISTAINES NC ULTIVITAINS $0 CONTRACEPTIVES $0 CONTRACEPTIVES ANTINEOPLASTICS AND ADJUNCTIVE AEBICIDES CI ANTIASTHATIC AND BRONCHODILATOR AGENTS HYPNOTICS USCULOSKELETAL THERAPY AGENTS USCULOSKELETAL THERAPY AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ULCER DRUGS ULCER DRUGS ULCER DRUGS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 72 of 79
Cont. Alphabetical Index ZANTAC SYRUP ZANTAC TAB ZARONTIN CAP ZARONTIN SOLN ZAROXOLYN TAB ZARXIO INJ ZAVESCA CAP (Only available through Accredo 88877776) ZEBETA TAB ZECUITY PAD ZEGERID CAP OTC ZEGERID POWDER PACK (Covered at Tier 2 if less than 2 years old) ZELAPAR ODT ZELBORAF TAB ZEBRACE SYTOUCH INJ ZEPLAR CAP ZENPEP CAP (Step Therapy requires trial of CREON) ZENZEDI TAB zenzedi tab 5mg (DEXEDRINE equiv) ZEPATIER TAB ZERIT CAP ZERIT SOLN ZESTORETIC TAB ZETIA TAB (= tab/day) ZETONNA NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) ZIAC TAB ZIAGEN TAB zidovudine cap (RETROVIR equiv) zidovudine syrup (RETROVIR equiv) zidovudine tab (RETROVIR equiv) zinc sulfate cap ZIOPTAN OPHTH SOLN (= bottle/day; Step Therapy requires trial of latanaprost) ziprasidone cap (GEODON equiv) ZIRGAN OPHTH GEL ZITHROAX POWDER PACK ZITHROAX SU ZITHROAX TAB ZAX SU ZOCOR TAB ZOFRAN ODT ZOFRAN SOLN ZOFRAN TAB ZOHYDRO ER CAP zoledronic acid inj (RECLAST equiv) ZOLINZA CAP zolmitriptan ODT (ZOIG equiv) (= 9 tabs/fill, 2 fills/0 days) Special Code Tier Category ULCER DRUGS ULCER DRUGS ANTICONVULSANTS ANTICONVULSANTS DIURETICS HEATOPOIETIC AGENTS LDPA HEATOPOIETIC AGENTS BETA BLOCKERS NC IGRAINE PRODUCTS OTC ULCER DRUGS ULCER DRUGS ANTIPARKINSON AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE NC IGRAINE PRODUCTS ENDOCRINE AND ETABOLIC AGENTS ISC. ST DIGESTIVE AIDS NC ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS NC ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS NC ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTIHYPERTENSIVES CI 2 ANTIHYPERLIPIDEICS ST NASAL AGENTS SYSTEIC AND TOPICAL ANTIHYPERTENSIVES ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTIVIRALS INERALS & ELECTROLYTES ST OPHTHALIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS 2 OPHTHALIC AGENTS ACROLIDES ACROLIDES ACROLIDES ACROLIDES ANTIHYPERLIPIDEICS ANTIEETICS ANTIEETICS ANTIEETICS NC ANALGESICS OPIOID ENDOCRINE AND ETABOLIC AGENTS ISC. PASF ANTINEOPLASTICS AND ADJUNCTIVE IGRAINE PRODUCTS CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Cont. Alphabetical Index zolmitriptan tab (ZOIG equiv) (= 9 tabs/fill, 2 fills/0 days) ZOLOFT CONC ZOLOFT TAB zolpidem ER tab (ABIEN CR equiv) zolpidem tab 0mg (ABIEN equiv) (ale = tab/day; Female = 0.5 tab/day) zolpidem tab 5mg (ABIEN equiv) (= tab/day) zolpidem tartrate SL tab (INTEREZZO equiv) ZOLPIIST RAY ZOETA INJ ZOIG NASAL RAY (= 6 sprays/fill, 2 fills/0 days) ZOIG TAB (= 9 tabs/fill, 2 fills/0 days) ZOIG ZT (= 9 tabs/fill, 2 fills/0 days) ZONEGRAN CAP zonisamide cap (ZONEGRAN equiv) ZONTIVITY TAB (Restricted to Cardiology Specialist) ZORPRIN TAB ZORTRESS TAB ZORVOLEX CAP ZOSTAVAX INJ (Covered for members age 50 or older) ZOVIRAX CAP ZOVIRAX CREA ZOVIRAX OINT ZOVIRAX SU ZOVIRAX TAB ZUPLENZ SL FIL ZUTRIPRO LIQUID (= 20ml/fill, 2 fills/0 days) ZYBAN TAB (Limited to 80 days/plan year) ZYCLARA CREA ZYDELIG TAB (Only available through Diplomat Pharmacy 87797798) ZYFLO CR TAB ZYFLO TAB ZYKADIA CAP ZYLET OPHTH SU (= 5ml/fill (0ml bottle is Not Covered)) ZYLOPRI TAB ZYAXID OPHTH SOLN (Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA) ZYPREXA TAB ZYPREXA ZYDIS TAB ZYTIGA TAB ZYVOX SU (Restricted to Infectious Disease Specialist) ZYVOX TAB (Restricted to Infectious Disease Specialist) Special Code Tier Category IGRAINE PRODUCTS ANTIDEPRESSANTS ANTIDEPRESSANTS NC HYPNOTICS HYPNOTICS HYPNOTICS NC HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS NC HYPNOTICS ENDOCRINE AND ETABOLIC AGENTS ISC. IGRAINE PRODUCTS IGRAINE PRODUCTS IGRAINE PRODUCTS ANTICONVULSANTS ANTICONVULSANTS RS HEATOLOGICAL AGENTS ISC. ANALGESICS NONNARCOTIC PA ASSORTED CLASSES NC ANALGESICS ANTIINFLAATORY VAC $0 VACCINES ANTIVIRALS DERATOLOGICALS DERATOLOGICALS ANTIVIRALS ANTIVIRALS NC ANTIEETICS COUGH/COLD/ALLERGY SKG $0 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. NC DERATOLOGICALS LDPASF ANTINEOPLASTICS AND ADJUNCTIVE ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIASTHATIC AND BRONCHODILATOR AGENTS NC ANTINEOPLASTICS AND ADJUNCTIVE 2 OPHTHALIC AGENTS GOUT AGENTS ST OPHTHALIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIPSYCHOTICS/ANTIANIC AGENTS PASF ANTINEOPLASTICS AND ADJUNCTIVE RS ANTIINFECTIVE AGENTS ISC. RS ANTIINFECTIVE AGENTS ISC. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 74 of 79
Category/Class DrugName Special Code Tier APHETAINES ADHD/ANTINARCOLEPSY/ANTIOBESITY/ANOREXIANTS ADDERALL XR CAP amphetamine/dextroamphetamine tab (ADDERALL equiv) dextroamphetamine ER cap (DEXEDRINE equiv) dextroamphetamine soln (PROCENTRA equiv) dextroamphetamine tab (DEXEDRINE equiv) methamphetamine tab (DESOXYN equiv) VYVANSE CAP 2 ADDERALL TAB DESOXYN TAB DEXEDRINE CAP PROCENTRA SOLN ADZENYS XR TAB NC amphetamine ER cap (ADDERALL XR equiv) NC ZENZEDI TAB NC zenzedi tab 5mg (DEXEDRINE equiv) NC ANALEPTICS caffeine citrate soln (CAFCIT equiv) (Only covered for members less than year old) CAFCIT SOLN 2 ATTENTIONDEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS guanfacine ER tab (INTUNIV equiv) INTUNIV TAB (Step Therapy requires trial of guanfacine IR) ST KAPVAY TAB STRATTERA CAP clonidine ER tab (KAPVAY equiv) NC STIULANTS ISC. dexmethylphenidate ER cap (FOCALIN XR equiv) dexmethylphenidate tab (FOCALIN equiv) methylphenidate CD cap (ETADATE CD equiv) methylphenidate chew tab (ETHYLIN equiv) methylphenidate ER cap (RITALIN LA equiv) methylphenidate ER tab 0mg, 20mg methylphenidate soln (ETHYLIN equiv) methylphenidate tab (RITALIN equiv) modafinil tab (PROVIGIL equiv) (= 2 tabs/day) PA CONCERTA TAB 2 ETHYLIN SOLN 2 ETHYLPHENIDATE ER TAB 2 DAYTRANA PATCH FOCALIN TAB FOCALIN XR CAP FOCALIN XR CAP 25G, 5G ETADATE CD CAP ETHYLIN CHEW TAB NUVIGIL TAB (= tab/day) PA PROVIGIL TAB (= 2 tabs/day) PA RITALIN LA CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 75 of 79
Category/Class DrugName Special Code Tier ADHD/ANTINARCOLEPSY/ANTIOBESITY/ANOREXIANTS Cont. RITALIN LA CAP 0G RITALIN LA CAP 60G RITALIN SR TAB RITALIN TAB QUILLIVANT XR SU NC AEBICIDES AEBICIDES YODOXIN TAB AINOGLYCOSIDES AINOGLYCOSIDES neomycin tab paromomycin cap (HUATIN equiv) amikacin inj KANAYCIN INJ STREPTOYCIN INJ BETHKIS NEB SOLN NC TOBI NEB SOLN (Restricted to Infectious Disease or Pulmonology Specialist) RS TOBI PODHALER (Restricted to Infectious Disease or Pulmonology Specialist) RS tobramycin neb soln (TOBI equiv) (Restricted to Infectious Disease or Pulmonology Specialist) RS ANALGESICS ANTIINFLAATORY ANTIRHEUATIC ENZYE INHIBITORS XELJANZ TAB (= 2 tabs/day) PA XELJANZ XR TAB (= tab/day) PA ANTIRHEUATIC ANTIETABOLITES RHEUATREX TAB ANTITNFALPHA ONOCLONAL ANTIBODIES SIPONI ARIA INJ NC HUIRA INJ (= 2 inj/28 days) PA HUIRA PEN INJ (= 2 inj/28 days) PA SIPONI INJ (= inj/28 days) PA GOLD COPOUNDS RIDAURA CAP 2 INTERLEUKIN RECEPTOR ANTAGONIST (ILRA) KINERET INJ (= inj/day; Only available through Rx Crossroads: 8665470644) LDPA INTERLEUKIN6 RECEPTOR INHIBITORS ACTERA IV INJ ACTERA SC INJ (= 2 inj/28 days) PA NONSTEROIDAL ANTIINFLAATORY AGENTS (NSAIDS) celecoxib cap (CELEBREX equiv) (= 2 caps/day) diclofenac potassium tab (CATAFLA equiv) diclofenac sodium EC tab (VOLTAREN equiv) diclofenac sodium XR tab (VOLTAREN XR equiv) diclofenac/misoprostol DR tab (ARTHROTEC equiv) etodolac cap (LODINE equiv) etodolac ER tab (LODINE XL equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 76 of 79
Category/Class DrugName Special Code Tier ANALGESICS ANTIINFLAATORY Cont. etodolac tab fenoprofen calcium tab flurbiprofen tab (ANSAID equiv) ibuprofen susp (Rx ONLY) (ADVIL/OTRIN equiv) ibuprofen tab ibuprofen tab (Rx covered Only) indomethacin cap (INDOCIN equiv) indomethacin CR cap (INDOCIN SR equiv) ketoprofen cap (ORUDIS equiv) ketorolac tab (TORADOL equiv) (= 20 tabs/5 days) ECLOFENAATE CAP mefenamic acid cap (PONSTEL equiv) meloxicam tab (OBIC equiv) nabumetone tab (RELAFEN equiv) naproxen EC tab (NAPROSYN EC equiv) naproxen sodium tab (ANAPROX equiv) naproxen susp (NAPROSYN equiv) naproxen tab (NAPROSYN equiv) oxaprozin tab (DAYPRO equiv) piroxicam cap (FELDENE equiv) sulindac tab (CLINORIL equiv) tolmetin cap (TOLECTIN DS equiv) TOLETIN TAB INDOCIN SUPP 2 INDOCIN SU 2 NAPROXEN SU 2 ANAPROX TAB ARTHROTEC TAB CATAFLA TAB CELEBREX CAP (= 2 caps/day) CLINORIL TAB DAYPRO TAB FELDENE CAP KETOPROFEN ER CAP ELOXICA SU OBIC TAB OTRIN SU NALFON CAP NAPROSYN EC TAB NAPROSYN SU NAPROSYN TAB PONSTEL CAP VOLTAREN TAB VOLTAREN XR TAB KETOROLAC INJ NC ketorolac inj (TORADOL equiv) NC ELOXICA COFORT KIT NC naproxen sodium CR tab (NAPRELAN CR equiv) NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 77 of 79
Category/Class DrugName Special Code Tier ANALGESICS ANTIINFLAATORY Cont. RIX NASAL RAY NC VIOVO TAB NC VIVLODEX CAP NC ZORVOLEX CAP NC PHOHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA STARTER PACK NC OTEZLA TAB NC PYRIIDINE SYNTHESIS INHIBITORS leflunomide tab (ARAVA equiv) ARAVA TAB SELECTIVE COSTIULATION ODULATORS ORENCIA INJ ORENCIA SC INJ (= 4 inj/28 days) PA SOLUBLE TUOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ (= 4 inj/28 days) PA ENBREL SURECLICK INJ (= 4 inj/28 days) PA ANALGESICS NONNARCOTIC ANALGESIC COBINATIONS butalbital/acetaminophen/caffeine tab (FIORICET equiv) NC BUTALBITAL/AIRIN/CAFFEINE TAB NC DOLGIC PLUS TAB NC SALICYLATES AIRIN CHEW TAB 75G (Covered for males age 4579 and females age 5579) OTC $0 aspirin chew tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) OTC $0 aspirin ec tab 25mg (Covered for males age 4579 and females age 5579) OTC $0 aspirin ec tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) OTC $0 aspirin tab 25mg (Covered for males age 4579 and females age 5579) OTC $0 aspirin tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) OTC $0 CHOLINE AGNESIU TRISALICYLATE TAB choline magnesium trisalicylate tab (TRILISATE equiv) diflunisal tab (DOLOBID equiv) salsalate tab (DISALCID equiv) ZORPRIN TAB ANALGESICS OPIOID OPIOID AGONISTS codeine sulfate tab fentanyl citrate lollipop (ACTIQ equiv) (= 20 lozenges/0 days) PA fentanyl patch (DURAGESIC equiv) HYDROORPHONE SUPP hydromorphone tab (DILAUDID equiv) meperidine tab (DEEROL equiv) ETHADONE SOLN methadone tab (DOLOPHINE equiv) methadose tab morphine sulfate ER cap (KADIAN equiv) morphine sulfate ER tab (S CONTIN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 78 of 79
Category/Class DrugName Special Code Tier ANALGESICS OPIOID Cont. morphine sulfate soln morphine sulfate supp morphine sulfate tab oxycodone cap (OXYIR equiv) oxycodone conc (ROXICODONE equiv) oxycodone soln (ROXICODONE equiv) oxycodone tab (ROXICODONE equiv) oxymorphone tab (OPANA equiv) tramadol ER tab (ULTRA ER equiv) tramadol tab (ULTRA equiv) HYSINGLA ER TAB (= tab/day) 2 LEVORPHANOL TAB 2 NUCYNTA ER TAB (= 2 tabs/day) 2 OXYCONTIN CR TAB (= 20 tabs/0 days) 2 OXYIR CAP 2 ABSTRAL SL TAB (= 20 tabs/0 days) PA ACTIQ LOZENGE (= 20 lozenges/0 days) PA AVINZA CAP (= 2 caps/day) CODEINE SULFATE SOLN DAZIDOX TAB DEEROL TAB DILAUDID TAB DOLOPHINE TAB DURAGESIC PATCH EBEDA CAP FENTORA TAB (= 20 tabs/0 days) PA KADIAN CAP LAZANDA RAY (= 5 bottles/0 days) PA ETHADOSE CONC ORPHINE SULFATE ER BEAD CAP (= 2 caps/day) S CONTIN TAB NUCYNTA TAB OPANA ER TAB (CRUSH RESISTANT) OPANA TAB ROXICODONE TAB ULTRA ER TAB ULTRA TAB hydromorphone ER tab (EXALGO equiv) NC OPANA ER TAB NC oxycodone ER tab (OXYCONTIN equiv) NC RYBIX ODT NC SUBSYS RAY NC XTAPZA ER CAP NC ZOHYDRO ER CAP NC OPIOID COBINATIONS acetaminophen/caffeine/dihydrocodeine cap (TREZIX equiv) acetaminophen/codeine soln acetaminophen/codeine tab (TYLENOL/CODEINE equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 79 of 79
Category/Class DrugName Special Code Tier ANALGESICS OPIOID Cont. aspirin/codeine tab hydrocodone/acetaminophen cap (LORCET equiv) hydrocodone/acetaminophen soln (HYCET/LORTAB equiv) hydrocodone/acetaminophen tab (LORTAB equiv) hydrocodone/acetaminophen tab 2.525mg (NORCO equiv) hydrocodone/ibuprofen tab (VICOPROFEN equiv) oxycodone/acetaminophen cap (TYLOX equiv) oxycodone/acetaminophen tab (PERCOCET equiv) oxycodone/aspirin tab (PERCODAN equiv) oxycodone/ibuprofen tab (COBUNOX equiv) pentazocine/acetaminophen tab (TALACEN equiv) tramadol/acetaminophen tab (ULTRACET equiv) ROXICET SOLN 25G/5L 2 ACETAINOPHEN/CAFFEINE/DIHYDROCODEINE TAB CAPITAL/CODEINE SU HYCET SOLN LORTAB LORTAB ELIXIR PERCOCET TAB PERCODAN TAB REPREXAIN TAB ROXICET TAB TREZIX CAP TYLENOL/CODEINE TAB ULTRACET TAB VICOPROFEN TAB hydrocodone/acetaminophen tab 0mg00mg (XODOL equiv) NC hydrocodone/acetaminophen tab 5mg00mg (XODOL equiv) NC hydrocodone/acetaminophen tab 7.5mg00mg (XODOL equiv) NC XARTEIS XR TAB NC OPIOID PARTIAL AGONISTS buprenorphine SL tab (SUBUTEX equiv) buprenorphine/naloxone SL tab (SUBOXONE equiv) butorphanol nasal spray (STADOL equiv) (= bottle/fill, 2 fills/0 days) pentazocine/naloxone tab (TALWIN NX equiv) SUBOXONE SL FIL 2 BUTRANS PATCH (= 4 patches/28 days) SUBOXONE SL TAB nalbuphine inj BELBUCA FIL NC BUNAVAIL SL FIL NC ANDROGENSANABOLIC ANABOLIC STEROIDS oxandrolone tab (OXANDRIN equiv) ANADROL TAB OXANDRIN TAB ANDROGENS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 80 of 79
Category/Class DrugName Special Code Tier ANDROGENSANABOLIC Cont. danazol cap (DANOCRINE equiv) methyltestosterone cap (ANDROID/TESTRED equiv) PA testosterone cypionate inj (DEPOTESTOSTERONE equiv) testosterone gel % 25mg (ANDROGEL equiv) (= packet/day) PA testosterone gel % 50mg (ANDROGEL equiv) (= 2 packets/day) PA testosterone gel % pump (ANDROGEL equiv) (= 4 bottles/0 days) PA ANDRODER PATCH (= patch/day) PA 2 ANDROGEL.62%.25G (= packet/day) PA 2 ANDROGEL.62% 2.5G (= 2 packets/day) PA 2 ANDROGEL PUP.62% (= 2 bottles/0 days) PA 2 ANDROXY TAB 2 TESTOSTERONE GEL % 25G (= packet/day) PA 2 TESTOSTERONE GEL % 50G (= 2 packets/day) PA 2 TESTOSTERONE GEL PUP (= 4 bottles/0 days) PA 2 ANDROGEL % 25G (= packet/day) PA ANDROGEL % 50G (= 2 packets/day) PA ANDROGEL PUP % (= 4 bottles/0 days) PA ANDROID/TESTRED CAP PA AXIRON SOLN (= 2 bottles/0 days) PA DEPOTESTOSTERONE INJ FORTESTA GEL/ TESTOSTERONE GEL (= 2 bottles/0 days) PA ETHITEST TAB PA TESTI GEL/ TESTOSTERONE GEL (= 2 packets/day) PA ANORECTAL AGENTS INTRARECTAL STEROIDS hydrocortisone enema (CORTENEA equiv) CORTENEA CORTIFOA UCERIS RECTAL FOA PA RECTAL COBINATIONS lidocaine/hydrocortisone cream (ANAANTLE equiv) pramoxine/hydrocortisone cream kit (ANALPRAHC equiv) PROCTOFOA HC FOA 2 ANALPRAE KIT ANALPRAHC CREA NC pramoxine/hydrocortisone cream (ANALPRAHC equiv) NC PROCORT CREA NC RECTAL STEROIDS proctosol HC cream (ANUSOL HC equiv) ANUSOLHC CREA ANUSOLHC SUPP NC hydrocortisone supp (ANUSOL HC equiv) NC VASODILATING AGENTS RECTIV OINT ANTHELINTICS ANTHELINTICS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Category/Class DrugName Special Code Tier ANTHELINTICS Cont. ivermectin tab (STROECTOL equiv) mebendazole chew tab (VEROX equiv) BILTRICIDE TAB 2 ALBENZA TAB PA STROECTOL TAB ANTIANGINAL AGENTS ANTIANGINALSOTHER RANEXA TAB 2 NITRATES ISOSORBIDE DINITRATE ER TAB isosorbide dinitrate ER tab (ISOCHRON equiv) isosorbide dinitrate SL tab isosorbide dinitrate tab (ISORDIL equiv) isosorbide mononitrate ER tab (IDUR equiv) isosorbide mononitrate tab (ONOKET equiv) nitroglycerin lingual spray (NITROLINGUAL equiv) nitroglycerin patch (NITRODUR equiv) nitroglycerin SR cap NITRODUR PATCH 0.G/HR, 0.8G/HR 2 NITROSTAT SL TAB 2 DILATRATE SR CAP IDUR TAB ISORDIL TITRADOSE TAB ISOSORBIDE DINITRATE TAB 0G, 40G NITROBID OINT NITRODUR PATCH NITROLINGUAL PUP RAY NITROIST RAY ANTIANXIETY AGENTS ANTIANXIETY AGENTS ISC. buspirone tab (BUAR equiv) hydroxyzine pamoate cap (VISTARIL equiv) hydroxyzine syrup (ATARAX equiv) hydroxyzine tab (ATARAX equiv) meprobamate tab (ILTOWN equiv) HYDROXYZINE PAOATE CAP 00G 2 BUAR TAB VISTARIL CAP buspirone tab 0mg (BUAR equiv) NC BENZODIAZEPINES alprazolam ER tab (XANAX XR equiv) alprazolam ODT (NIRAVA equiv) alprazolam tab (XANAX equiv) chlordiazepoxide cap (LIBRIU equiv) clorazepate tab (TRANXENET equiv) diazepam conc (VALIU equiv) DIAZEPA SOLN Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 82 of 79
Category/Class DrugName Special Code Tier ANTIANXIETY AGENTS Cont. diazepam tab (VALIU equiv) lorazepam conc (ATIVAN equiv) lorazepam tab (ATIVAN equiv) oxazepam cap (SERAX equiv) ATIVAN TAB LIBRIU CAP NIRAVA ODT TRANXENET TAB VALIU TAB XANAX TAB XANAX XR TAB ANTIARRHYTHICS ANTIARRHYTHICS TYPE IA disopyramide cap (NORPACE equiv) disopyramide ER cap (NORPACE CR equiv) quinidine gluconate CR tab QUINIDINE SULFATE TAB NORPACE CR CAP 2 NORPACE CAP QUINIDINE SULFATE ER TAB PROCAINAIDE INJ ANTIARRHYTHICS TYPE IB mexiletine cap (EXITIL equiv) ANTIARRHYTHICS TYPE IC flecainide tab (TABOCOR equiv) propafenone ER cap (RYTHOL SR equiv) propafenone tab (RYTHOL equiv) RYTHOL SR CAP RYTHOL TAB TABOCOR TAB ANTIARRHYTHICS TYPE III amiodarone tab (CORDARONE equiv) ULTAQ TAB 2 TIKOSYN CAP 2 CORDARONE TAB ANTIASTHATIC AND BRONCHODILATOR AGENTS ANTIINFLAATORY AGENTS cromolyn neb soln (INTAL equiv) CI CROOLYN NEB SOLN CI 2 BRONCHODILATORS ANTICHOLINERGICS ipratropium neb soln (ATROVENT equiv) CI ATROVENT HFA INHALER CI 2 INCRUSE ELLIPTA INHALER CI 2 IRIVA HANDIHALER (For use with Handihaler device) CI 2 IRIVA REIAT INHALER CI 2 IRIVA REIAT INHALER.25CG/ACT (Step Therapy requires trial of inhaled corticosteroid) CIST 2 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Category/Class DrugName Special Code Tier ANTIASTHATIC AND BRONCHODILATOR AGENTS Cont. SEEBRI NEOHALER CAP NC TUDORZA PRESSAIR INHALER NC LEUKOTRIENE ODULATORS montelukast chew tab (SINGULAIR equiv) CI montelukast granule pack (SINGULAIR equiv) CI montelukast tab (SINGULAIR equiv) CI zafirlukast tab (ACCOLATE equiv) CI ACCOLATE TAB SINGULAIR CHEW TAB SINGULAIR GRANULE PACK SINGULAIR TAB ZYFLO CR TAB ZYFLO TAB SELECTIVE PHOHODIESTERASE 4 (PDE4) INHIBITORS DALIRE TAB STEROID INHALANTS ARNUITY ELLIPTA INHALER CI ASANEX HFA INHALER CI ASANEX INHALER CI budesonide inh susp (PULICORT equiv) CI FLOVENT DISKUS INHALER CI FLOVENT HFA INHALER CI PULICORT INH SU AEROAN HFA INHALER NC ALVESCO INHALER NC PULICORT FLEXHALER NC QVAR INHALER NC SYPATHOIETICS albuterol neb soln 0.08% (PROVENTIL equiv) CI albuterol neb soln 0.5% (VENTOLIN equiv) CI albuterol neb soln 0.6mg (ACCUNEB equiv) CI albuterol neb soln.25mg (ACCUNEB equiv) CI albuterol sulfate ER tab (VOIRE ER equiv) CI albuterol sulfate syrup CI albuterol sulfate tab CI albuterol/ipratropium neb soln (DUONEB equiv) CI levalbuterol neb soln (XOPENEX equiv) CI ETAPROTERENOL SYRUP CI terbutaline sulfate tab (BRETHINE equiv) CI ADVAIR DISKUS INHALER CI 2 ADVAIR HFA INHALER CI 2 BREO ELLIPTA INHALER CI 2 COBIVENT INHALER CI 2 COBIVENT REIAT INHALER CI 2 DULERA INHALER CI 2 FORADIL AEROLIZER CI 2 SEREVENT DISKUS INHALER CI 2 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 84 of 79
Category/Class DrugName Special Code Tier ANTIASTHATIC AND BRONCHODILATOR AGENTS Cont. STIOLTO INHALER CI 2 VENTOLIN HFA INHALER (= 2 inhalers/fill, 2 fills/0 days) CI 2 ACCUNEB NEB SOLN ARCAPTA NEOHALER BRETHINE TAB BROVANA NEB SOLN DUONEB NEB SOLN ETAPROTERENOL TAB PERFOROIST NEB SOLN STRIVERDI REIAT INHALER (= inhaler/0 days) VOIRE ER TAB XOPENEX HFA INHALER (= 2 inhalers/fill, 2 fills/0 days; Step Therapy requires trial of VENTOLIN HFA) ST XOPENEX NEB SOLN ANORO ELLIPTA INHALER NC PROAIR HFA INHALER NC PROVENTIL HFA INHALER NC SYBICORT INHALER NC UTIBRON NEOHALER CAP NC XANTHINES aminophylline tab CI theophylline CR tab (QUIBRONT equiv) CI theophylline ER tab (UNIPHYL equiv) CI theophylline soln CI ELIXOPHYLLIN ELIXIR CI 2 LUFYLLIN TAB THEO24 CAP UNIPHYL TAB ANTICOAGULANTS COUARIN ANTICOAGULANTS warfarin tab (COUADIN equiv) COUADIN TAB DIRECT FACTOR XA INHIBITORS ELIQUIS TAB 2 XARELTO STARTER PACK 2 XARELTO TAB 2 HEPARINS AND HEPARINOIDLIKE AGENTS enoxaparin inj (LOVENOX equiv) (= 7 days supply) fondaparinux inj (ARIXTRA equiv) PA ARIXTRA INJ PA FRAGIN INJ LOVENOX INJ (= 7 days supply) THROBIN INHIBITORS PRADAXA CAP 2 ANTICONVULSANTS APA GLUTAATE RECEPTOR ANTAGONISTS FYCOPA TAB NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 85 of 79
Category/Class DrugName Special Code Tier ANTICONVULSANTS BENZODIAZEPINES ANTICONVULSANTS Cont. clonazepam ODT (KLONOPIN equiv) clonazepam tab (KLONOPIN equiv) DIAZEPA/DIASTAT RECTAL GEL KLONOPIN TAB ONFI TAB PA ONFI SU NC ANTICONVULSANTS ISC. carbamazepine chew tab (TEGRETOL equiv) carbamazepine ER cap (CARBATROL equiv) carbamazepine ER tab (TEGRETOL XR equiv) carbamazepine susp (TEGRETOL equiv) carbamazepine tab (TEGRETOL equiv) gabapentin cap (NEURONTIN equiv) gabapentin soln (NEURONTIN equiv) gabapentin tab (NEURONTIN equiv) lamotrigine chew tab (LAICTAL equiv) lamotrigine ER tab (LAICTAL XR equiv) lamotrigine ODT (LAICTAL equiv) lamotrigine ODT kit (LAICTAL ODT KIT equiv) lamotrigine tab (LAICTAL equiv) levetiracetam ER tab (KEPPRA XR equiv) levetiracetam soln (KEPPRA equiv) levetiracetam tab (KEPPRA equiv) oxcarbazepine susp (TRILEPTAL equiv) oxcarbazepine tab (TRILEPTAL equiv) primidone tab (YSOLINE equiv) topiramate sprinkle cap (TOPAAX equiv) topiramate tab (TOPAAX equiv) zonisamide cap (ZONEGRAN equiv) BANZEL SU 2 BANZEL TAB 2 LAICTAL CHEW TAB 2G 2 LYRICA CAP 2 LYRICA SOLN 2 POTIGA TAB (= tabs/day) 2 POTIGA TAB 50G (= 9 tabs/day) 2 TRILEPTAL SU 2 VIPAT SOLN 2 VIPAT TAB (= 2 tabs/day) 2 CARBATROL CAP KEPPRA SOLN KEPPRA TAB KEPPRA XR TAB LAICTAL CHEW TAB LAICTAL ODT LAICTAL ODT KIT Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 86 of 79
Category/Class DrugName Special Code Tier ANTICONVULSANTS Cont. LAICTAL TAB LAICTAL XR KIT LAICTAL XR TAB YSOLINE TAB NEURONTIN CAP NEURONTIN SOLN NEURONTIN TAB TEGRETOL CHEW TAB TEGRETOL SU TEGRETOL TAB TEGRETOL XR TAB TOPAAX RINKLE CAP TOPAAX TAB TRILEPTAL TAB ZONEGRAN CAP APTIO TAB NC BRIVIACT INJ 50G/5L NC BRIVIACT SOLN 0G/L NC BRIVIACT TAB NC QUDEXY XR/TOPIRAATE ER CAP NC RITA TAB NC TROKENDI XR CAP NC CARBAATES felbamate susp (FELBATOL equiv) felbamate tab (FELBATOL equiv) FELBATOL TAB 2 FELBATOL SU GABA ODULATORS tiagabine tab (GABITRIL equiv) GABITRIL TAB GABITRIL TAB 2G, 6G SABRIL POWDER PACK (Only available through SHARE program 88845SHARE (888457427)) LDPA SABRIL TAB (Only available through SHARE program 88845SHARE (888457427)) LDPA HYDANTOINS phenytoin cap (DILANTIN equiv) phenytoin chew tab (DILANTIN equiv) phenytoin susp (DILANTIN equiv) DILANTIN CAP 0G 2 PEGANONE TAB 2 DILANTIN CAP 00G DILANTIN INFATABS DILANTIN SU SUCCINIIDES ethosuximide cap (ZARONTIN equiv) ethosuximide soln (ZARONTIN equiv) CELONTIN CAP 2 ZARONTIN CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 87 of 79
Category/Class DrugName Special Code Tier ANTICONVULSANTS Cont. ZARONTIN SOLN VALPROIC ACID divalproex ER tab (DEPAKOTE ER equiv) divalproex sodium DR tab (DEPAKOTE equiv) divalproex sprinkle cap (DEPAKOTE equiv) valproic acid cap (DEPAKENE equiv) valproic acid syrup (DEPAKENE equiv) DEPAKENE CAP DEPAKENE SYRUP DEPAKOTE ER TAB DEPAKOTE RINKLE CAP DEPAKOTE TAB STAVZOR CAP NC ANTIDEPRESSANTS ALPHA2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine ODT (REERON equiv) mirtazapine tab (REERON equiv) REERON SOLUTAB REERON TAB ANTIDEPRESSANTS ISC. bupropion ER tab (WELLBUTRIN equiv) bupropion tab (WELLBUTRIN equiv) bupropion XL tab (WELLBUTRIN XL equiv) APROTILINE TAB WELLBUTRIN SR TAB WELLBUTRIN TAB WELLBUTRIN XL TAB APLENZIN TAB NC ODIFIED CYCLICS NEFAZODONE TAB nefazodone tab 50mg, 250mg trazodone tab (DESYREL equiv) OLEPTRO TAB TRINTELLIX TAB (= tab/day) PA VIIBRYD TAB trazodone tab 00mg (DESYREL equiv) NC ONOAINE OXIDASE INHIBITORS (AOIS) phenelzine tab (NARDIL equiv) tranylcypromine tab (PARNATE equiv) ARPLAN TAB 2 NARDIL TAB 2 ESA PATCH PARNATE TAB SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram soln (CELEXA equiv) citalopram tab (CELEXA equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 88 of 79
Category/Class DrugName Special Code Tier ANTIDEPRESSANTS Cont. escitalopram soln (LEXAPRO equiv) escitalopram tab (LEXAPRO equiv) fluoxetine cap (PROZAC equiv) fluoxetine soln (PROZAC equiv) fluoxetine tab (PROZAC equiv) fluvoxamine ER cap (LUVOX CR equiv) (Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or ST fluvoxamine) fluvoxamine tab (LUVOX equiv) paroxetine ER tab (PAXIL CR equiv) paroxetine tab (PAXIL equiv) sertraline conc (ZOLOFT equiv) sertraline tab (ZOLOFT equiv) CELEXA SOLN CELEXA TAB LEXAPRO SOLN LEXAPRO TAB LUVOX CR CAP (Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine) ST PAXIL CR TAB PAXIL SU PAXIL TAB PEXEVA TAB (Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine) ST PROZAC CAP PROZAC SOLN PROZAC TAB ZOLOFT CONC ZOLOFT TAB FLUOXETINE TAB 60G NC fluoxetine weekly cap (PROZAC equiv) NC SEROTONIN ODULATORS VIIBRYD STARTER KIT NC SEROTONINNOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) duloxetine EC cap (CYBALTA equiv) (= 2 caps/day) venlafaxine ER cap (EFFEXOR XR equiv) venlafaxine ER tab VENLAFAXINE ER TAB 225G venlafaxine tab (EFFEXOR equiv) VENLAFAXINE ER TAB 2 CYBALTA CAP (= 2 caps/day) DESVENLAFAXINE ER TAB (Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine ST AND venlafaxine product) EFFEXOR TAB EFFEXOR XR CAP FETZIA CAP (= cap/day) PA FETZIA TITRATION PACK (= cap/day) PA KHEDEZLA ER TAB (Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND ST venlafaxine product) PRISTIQ TAB (Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND ST venlafaxine product) TRICYCLIC AGENTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 89 of 79
Category/Class DrugName Special Code Tier ANTIDEPRESSANTS Cont. amitriptyline tab (ELAVIL equiv) AOXAPINE TAB clomipramine cap (ANAFRANIL equiv) desipramine tab (NORPRAIN equiv) doxepin cap (SINEQUAN equiv) DOXEPIN CAP 75G doxepin conc (SINEQUAN equiv) imipramine pamoate cap (TOFRANIL P equiv) imipramine tab (TOFRANIL equiv) nortriptyline cap (PAELOR equiv) NORTRIPTYLINE SOLN protriptyline tab (VIVACTIL equiv) trimipramine cap (SURONTIL equiv) ANAFRANIL CAP NORPRAIN TAB PAELOR CAP SURONTIL CAP TOFRANIL P CAP TOFRANIL TAB VIVACTIL TAB ANTIDIABETICS ALPHAGLUCOSIDASE INHIBITORS acarbose tab (PRECOSE equiv) CI miglitol tab (GLYSET equiv) GLYSET TAB PRECOSE TAB ANTIDIABETIC AYLIN ANALOGS SYLINPEN INJ ANTIDIABETIC COBINATIONS glipizide/metformin tab (ETAGLIP equiv) CI glyburide/metformin tab (GLUCOVANCE equiv) CI pioglitazone/glimepiride tab (DUETACT equiv) CI pioglitazone/metformin tab (ACTOPLUS ET equiv) CI AVANDAET TAB CI 2 AVANDARYL TAB CI 2 JANUET TAB CI 2 JANUET XR TAB CI 2 KOBIGLYZE XR TAB CI 2 SYNJARDY TAB (= 2 tabs/day) CI 2 XIGDUO XR TAB (= tab/day) CI 2 XIGDUO XR TAB 5000G (= 2 tabs/day) CI 2 ACTOPLUS ET TAB ACTOPLUS ET XR TAB DUETACT TAB GLUCOVANCE TAB INVOKAET TAB (= 2 tabs/day) PA JENTADUETO TAB (= 2 tabs/day) PA Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 90 of 79
Category/Class DrugName Special Code Tier ANTIDIABETICS Cont. KAZANO/ALOGLIPTINETFORIN TAB (= 2 tabs/day) PA ETAGLIP TAB OSENI/ALOGLIPTINPIOGLITAZONE TAB (= tab/day) PA PRANDIET TAB NC BIGUANIDES metformin ER tab (GLUCOPHAGE XR equiv) CI metformin tab (GLUCOPHAGE equiv) CI GLUCOPHAGE TAB GLUCOPHAGE XR TAB RIOET SOLN metformin ER osmotic tab (FORTAET equiv) NC DIABETIC OTHER GLUCAGEN HYPOKIT INJ CI 2 GLUCAGON INJ KIT CI 2 PROGLYCE SU KORLY TAB (Only available through Korlym ARK program 8554Korlym (8554567596)) LDPA DIPEPTIDYL PEPTIDASE4 (DPP4) INHIBITORS JANUVIA TAB (= tab/day) CI 2 ONGLYZA TAB (= tab/day) CI 2 NESINA/ALOGLIPTIN TAB (= tab/day) PA TRADJENTA TAB (= tab/day) PA DOPAINE RECEPTOR AGONISTS ANTIDIABETIC CYCLOSET TAB INCRETIN IETIC AGENTS (GLP RECEPTOR AGONISTS) BYDUREON INJ (= 4 inj/28 days) CI 2 BYDUREON PEN INJ (= 4 inj/28 days) CI 2 VICTOZA INJ (= 9ml/0 days) CI 2 BYETTA INJ TRULICITY INJ TANZEU INJ NC INSULIN HUULIN R INJ U500 CI 2 HUULIN R U500 KWIKPEN INJ CI 2 LANTUS INJ CI 2 LANTUS SOLOSTAR INJ CI 2 LEVEIR FLEXPEN/FLEXTOUCH INJ CI 2 LEVEIR INJ CI 2 NOVOLIN INJ CIOTC 2 NOVOLOG FLEXPEN INJ CI 2 NOVOLOG INJ CI 2 NOVOLOG IX FLEXPEN INJ CI 2 NOVOLOG IX INJ CI 2 NOVOLOG PENFILL INJ CI 2 TOUJEO SOLOSTAR INJ CI 2 APIDRA INJ (Step Therapy requires trial of NOVOLOG) ST APIDRA SOLOSTAR INJ (Step Therapy requires trial of NOVOLOG) ST HUALOG INJ (Step Therapy requires trial of NOVOLOG) ST Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Category/Class DrugName Special Code Tier ANTIDIABETICS Cont. HUALOG KWIKPEN INJ (Step Therapy requires trial of NOVOLOG) ST HUALOG IX INJ (Step Therapy requires trial of NOVOLOG) ST HUALOG IX KWIKPEN INJ (Step Therapy requires trial of NOVOLOG) ST HUALOG PEN INJ (Step Therapy requires trial of NOVOLOG) ST HUULIN IX INJ (Step Therapy requires trial of NOVOLIN) OTCST HUULIN IX PEN INJ (Step Therapy requires trial of NOVOLIN) OTCST HUULIN N INJ (Step Therapy requires trial of NOVOLIN) OTCST HUULIN N PEN INJ (Step Therapy requires trial of NOVOLIN) OTCST HUULIN R INJ (Step Therapy requires trial of NOVOLIN) OTCST TRESIBA INJ NC INSULIN SENSITIZING AGENTS pioglitazone tab (ACTOS TAB equiv) CI AVANDIA TAB CI 2 ACTOS TAB EGLITINIDE ANALOGUES nateglinide tab (STARLIX equiv) CI repaglinide tab (PRANDIN equiv) CI PRANDIN TAB STARLIX TAB SODIUGLUCOSE COTRANORTER 2 (SGLT2) INHIBITORS FARXIGA TAB (= tab/day) CI 2 JARDIANCE TAB (= tab/day) CI 2 INVOKANA TAB (= tab/day) PA SULFONYLUREAS CHLORPROPAIDE TAB CI chlorpropamide tab (DIABINESE equiv) CI glimepiride tab (AARYL equiv) CI glipizide ER tab (GLUCOTROL XL equiv) CI glipizide tab (GLUCOTROL equiv) CI glyburide micronized tab (GLYNASE equiv) CI glyburide tab (ICRONASE equiv) CI tolazamide tab (TOLINASE equiv) CI TOLBUTAIDE TAB CI 2 AARYL TAB DIABETA TAB GLUCOTROL TAB GLUCOTROL XL TAB GLYNASE TAB ANTIDIARRHEALS ANTIDIARRHEAL CHLORIDE CHANNEL ANTAGONISTS FULYZAQ TAB NC ANTIDIARRHEAL AGENTS ISC. VSL # CAP NC ANTIPERISTALTIC AGENTS diphenoxylate/atropine liquid (LOOTIL equiv) diphenoxylate/atropine tab (LOOTIL equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 92 of 79
Category/Class DrugName Special Code Tier ANTIDIARRHEALS Cont. opium tincture LOOTIL LIQUID LOOTIL TAB OTOFEN TAB loperamide cap NC PAREGORIC TINCTURE NC ANTIDOTES ANTIDOTES VISTOGARD PAK NC ANTIDOTES CHELATING AGENTS CHEET CAP 2 EXJADE TAB FERRIPROX SOLN (Only available through Ferriprox Total Care 866758707) LDPA FERRIPROX TAB (Only available through Ferriprox Total Care 866758707) LDPA JADENU TAB OPIOID ANTAGONISTS NALOXONE INJ naltrexone tab (REVIA equiv) REVIA TAB EVZIO INJ NC NARCAN NASAL RAY NC VIVITROL INJ PA ANTIEETICS 5HT RECEPTOR ANTAGONISTS granisetron tab (KYTRIL equiv) (= 9 tabs/fill) ondansetron ODT (ZOFRAN equiv) ondansetron soln (ZOFRAN equiv) ondansetron tab (ZOFRAN equiv) ANZEET TAB (= 9 tabs/fill) GRANISOL SOLN (= 60ml/fill) KYTRIL TAB (= 9 tabs/fill) SANCUSO PATCH (= 4 patches/fill) ZOFRAN ODT ZOFRAN SOLN ZOFRAN TAB ALOXI INJ ZUPLENZ SL FIL NC ANTIEETICS ANTICHOLINERGIC ANTIVERT TAB maldemar tab (SCOPACE equiv) meclizine chew tab (BONINE equiv) OTC meclizine tab (ANTIVERT equiv) OTC trimethobenzamide cap (TIGAN equiv) TIGAN CAP TRANSDERSCOP PATCH ANTIEETICS ISCELLANEOUS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Category/Class DrugName Special Code Tier ANTIEETICS Cont. dronabinol cap (ARINOL equiv) PA AKYNZEO CAP (= cap/fill; Restricted to Oncology or Hematology Specialist) RS 2 CESAET CAP ARINOL CAP PA SUBSTANCE P/NEUROKININ (NK) RECEPTOR ANTAGONISTS EEND CAP (= caps/fill; Restricted to Oncology or Hematology Specialist) RS 2 EEND PAK (= caps/fill; Restricted to Oncology or Hematology Specialist) RS 2 VARUBI TAB NC ANTIFUNGALS ANTIFUNGAL GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS INJ ERAXIS INJ YCAINE INJ ANTIFUNGALS flucytosine cap (ANCOBON equiv) griseofulvin micro tab (GRIFULVIN V equiv) griseofulvin susp (GRIFULVIN equiv) griseofulvin tab (GRIEG equiv) nystatin powder nystatin tab terbinafine tab (LAISIL equiv) ANCOBON CAP GRIFULVIN V TAB GRIEG TAB LAISIL TAB ABISOE INJ APHOTERICIN B INJ IIDAZOLERELATED ANTIFUNGALS fluconazole susp (DIFLUCAN equiv) fluconazole tab (DIFLUCAN equiv) itraconazole cap (ORANOX equiv) PA ketoconazole tab (NIZORAL equiv) voriconazole susp (VFEND equiv) (Restricted to Infectious Disease Specialist) RS voriconazole tab (VFEND equiv) (Restricted to Infectious Disease Specialist) RS NOXAFIL SU 2 DIFLUCAN SU DIFLUCAN TAB ORANOX CAP PA ORANOX SOLN PA VFEND SU (Restricted to Infectious Disease Specialist) RS VFEND TAB (Restricted to Infectious Disease Specialist) RS CRESEBA CAP NC NOXAFIL TAB NC ANTIHISTAINES ANTIHISTAINES ALKYLAINES chlorpheniramine ER cap Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 94 of 79
Category/Class DrugName Special Code Tier ANTIHISTAINES Cont. CP CAP DEXCHLORPHENIRAINE SYRUP ANTIHISTAINES ETHANOLAINES carbinoxamine soln (PALGIC equiv) carbinoxamine tab (PALGIC equiv) clemastine syrup (TAVIST equiv) clemastine tab (TAVIST equiv) diphenhydramine cap 50mg (BENADRYL equiv) (Only 50mg covered) diphenhydramine inj (BENADRYL equiv) PALGIC SOLN PALGIC TAB KARBINAL ER SU NC ANTIHISTAINES NONSEDATING desloratadine tab (CLARINEX equiv) PA levocetirizine soln (XYZAL equiv) levocetirizine tab (XYZAL equiv) CLARINEX REDITAB PA CLARINEX SYRUP PA CLARINEX TAB PA DESLORATADINE ODT PA XYZAL SOLN XYZAL TAB ANTIHISTAINES PHENOTHIAZINES promethazine supp (PHENERGAN equiv) promethazine syrup promethazine tab (PHENERGAN equiv) ANTIHISTAINES PIPERIDINES cyproheptadine syrup cyproheptadine tab ANTIHYPERLIPIDEICS ANTIHYPERLIPIDEICS COBINATIONS LIPTRUZET TAB VYTORIN TAB (= tab/day (0/80mg is Not Covered)) VYTORIN TAB 080G NC ANTIHYPERLIPIDEICS ISC. omegaacid ethyl esters cap (LOVAZA equiv) CI LOVAZA CAP KYNARO INJ NC VASCEPA CAP NC BILE ACID SEQUESTRANTS cholestyramine lite powder (QUESTRAN LITE equiv) CI cholestyramine lite powder pack (QUESTRAN LITE equiv) CI cholestyramine powder (QUESTRAN equiv) CI cholestyramine powder pack (QUESTRAN equiv) CI colestipol granule (COLESTID equiv) CI colestipol powder packet (COLESTID equiv) CI Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 95 of 79
Category/Class DrugName Special Code Tier ANTIHYPERLIPIDEICS Cont. colestipol tab (COLESTID equiv) CI WELCHOL PAK CI 2 WELCHOL TAB CI 2 COLESTID GRANULE COLESTID POWDER PACK COLESTID TAB QUESTRAN LITE POWDER QUESTRAN LITE POWDER PACK QUESTRAN POWDER QUESTRAN POWDER PACK FIBRIC ACID DERIVATIVES fenofibrate cap (ANTARA equiv) CI fenofibrate tab (TRICOR equiv) CI gemfibrozil tab (LOPID equiv) CI TRILIPIX CAP CI ANTARA CAP FENOFIBRIC TAB/FIBRICOR TAB FENOGLIDE TAB/FENOFIBRATE TAB 40G, 20G LOPID TAB TRICOR TAB fenofibric acid DR cap (TRILIPIX equiv) NC LIPOFEN CAP/FENOFIBRATE CAP 50G, 50G NC LOFIBRA CAP/ANTARA CAP 0G, 90G NC LOFIBRA/TRIGLIDE TAB NC HG COA REDUCTASE INHIBITORS atorvastatin tab (LIPITOR equiv) CI fluvastatin cap (LESCOL equiv) CI fluvastatin ER tab (LESCOL XL equiv) lovastatin tab (EVACOR equiv) CI pravastatin tab (PRAVACHOL equiv) CI rosuvastatin tab (CRESTOR equiv) (= tab/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, CIST simvastatin or pravastatin) rosuvastatin tab 20mg (CRESTOR equiv) (=.5 tabs/day; Step Therapy requires trial of atorvastatin, lovastatin, CIST fluvastatin, simvastatin or pravastatin) simvastatin tab (ZOCOR equiv) (80mg is Not Covered) CI ALTOPREV TAB LESCOL CAP LESCOL XL TAB LIPITOR TAB LIVALO TAB EVACOR TAB PRAVACHOL TAB ZOCOR TAB ADVICOR TAB NC CRESTOR TAB NC CRESTOR TAB 20G NC SICOR TAB NC INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 96 of 79
Category/Class DrugName Special Code Tier ANTIHYPERLIPIDEICS Cont. ZETIA TAB (= tab/day) CI 2 ICROSOAL TRIGLYCERIDE TRANSFER PROTEIN (TP) INHIBITORS JUXTAPID CAP NC NICOTINIC ACID DERIVATIVES NIACOR TAB CI NIAAN ER TAB CI niacin ER tab (NIAAN equiv) NC PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT INJ NC REPATHA INJ NC ANTIHYPERTENSIVES ACE INHIBITORS benazepril tab (LOTENSIN equiv) CI captopril tab (CAPOTEN equiv) CI enalapril tab (VASOTEC equiv) CI fosinopril tab (ONOPRIL equiv) CI lisinopril tab (PRINIVIL/ZESTRIL equiv) CI moexipril tab (UNIVASC equiv) CI perindopril tab (ACEON equiv) CI quinapril tab (ACCUPRIL equiv) CI ramipril cap (ALTACE equiv) CI trandolapril tab (AVIK equiv) CI ACCUPRIL TAB ACEON TAB ALTACE CAP ALTACE TAB CAPOTEN TAB LOTENSIN TAB AVIK TAB ONOPRIL TAB PRINIVIL TAB/ ZESTRIL TAB UNIVASC TAB VASOTEC TAB AGENTS FOR PHEOCHROOCYTOA phenoxybenzamine cap (DIBENZYLINE equiv) CI DIBENZYLINE CAP ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan tab (ATACAND equiv) CI irbesartan tab (AVAPRO equiv) CI losartan tab (COZAAR equiv) CI telmisartan tab (ICARDIS equiv) CI valsartan tab (DIOVAN equiv) CI BENICAR TAB CI 2 AVAPRO TAB COZAAR TAB DIOVAN TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 97 of 79
Category/Class DrugName Special Code Tier ANTIHYPERTENSIVES Cont. EDARBI TAB EPROSARTAN TAB ICARDIS TAB TEVETEN TAB ANTIADRENERGIC ANTIHYPERTENSIVES clonidine patch (CATAPRESTTS equiv) CI clonidine tab (CATAPRES equiv) CI doxazosin tab (CARDURA equiv) CI guanfacine IR tab (TENEX equiv) CI methyldopa tab (ALDOET equiv) CI prazosin cap (INIPRESS equiv) CI terazosin cap (HYTRIN equiv) CI CARDURA TAB CATAPRES TAB CATAPRESTTS PATCH GUANABENZ TAB HYTRIN CAP INIPRESS CAP NEXICLON XR SU NEXICLON XR TAB RESERPINE TAB TENEX TAB ETHYLDOPATE INJ ANTIHYPERTENSIVE COBINATIONS amlodipine/ valsartan tab (EXFORGE equiv) CI amlodipine/benazepril cap (LOTREL equiv) CI amlodipine/valsartan/hydrochlorothiazide tab (EXFORGE HCT equiv) CI atenolol/chlorthalidone tab (TENORETIC equiv) CI benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv) CI bisoprolol/hydrochlorothiazide tab (ZIAC equiv) CI candesartan/hydrochlorothiazide tab (ATACAND HCT equiv) CI CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB CI captopril/hydrochlorothiazide tab (CAPOZIDE equiv) CI enalapril/hydrochlorothiazide tab (VASERETIC equiv) CI fosinopril/hydrochlorothiazide tab (ONOPRIL HCT equiv) CI irbesartan/hydrochlorothiazide tab (AVALIDE equiv) CI lisinopril/hydrochlorothiazide tab (ZESTORETIC equiv) CI losartan/hydrochlorothiazide tab (HYZAAR equiv) CI methyldopa/hydrochlorothiazide tab (ALDORIL equiv) CI metoprolol/hydrochlorothiazide tab (LOPRESSOR HCT equiv) CI moexipril/hydrochlorothiazide tab (UNIRETIC equiv) CI nadolol/bendroflumethiazide tab (CORZIDE equiv) CI propranolol/hydrochlorothiazide tab (INDERIDE equiv) CI quinapril/hydrochlorothiazide tab (ACCURETIC equiv) CI telmisartan/amlodipine tab (TWYNSTA equiv) CI trandolapril/verapamil ER tab (TARKA equiv) CI valsartan/hydrochlorothiazide tab (DIOVAN HCT equiv) CI Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 98 of 79
Category/Class DrugName Special Code Tier ANTIHYPERTENSIVES Cont. DUTOPROL TAB CI 2 ACCURETIC TAB ATURNIDE TAB ATACAND HCT TAB AVALIDE TAB AZOR TAB CORZIDE TAB DIOVAN HCT TAB EDARBYCLOR TAB EXFORGE HCT TAB EXFORGE TAB HYZAAR TAB LOPRESSOR HCT TAB LOTENSIN HCT TAB LOTREL CAP ONOPRIL HCT TAB TARKA TAB TEKALO TAB TEKTURNA HCT TAB TENORETIC TAB TEVETEN HCT TAB TRIBENZOR TAB TWYNSTA TAB UNIRETIC TAB VALTURNA TAB VASERETIC TAB ZESTORETIC TAB ZIAC TAB BENICAR HCT TAB NC PRESTALIA TAB NC telmisartan/hydrochlorothiazide tab (ICARDIS HCT equiv) NC DIRECT RENIN INHIBITORS TEKTURNA TAB SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab (INRA equiv) CI INRA TAB VASODILATORS hydralazine tab (APRESOLINE equiv) CI minoxidil tab (LONITEN equiv) CI ANTIINFECTIVE AGENTS ISC. ANTIINFECTIVE AGENTS ISC. metronidazole cap (FLAGYL equiv) metronidazole tab (FLAGYL equiv) tinidazole tab (TINDAAX equiv) trimethoprim tab (PROLOPRI equiv) vancomycin cap (VANCOCIN equiv) (= 56 caps/fill; Step Therapy requires trial of vancomycin soln) ST NEBUPENT NEB SOLN 2 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 99 of 79
Category/Class DrugName Special Code Tier ANTIINFECTIVE AGENTS ISC. Cont. VANCOYCIN SOLN KIT 2 FLAGYL CAP FLAGYL ER TAB FLAGYL TAB PRISOL SOLN TINDAAX TAB VANCOCIN CAP (= 56 caps/fill; Step Therapy requires trial of vancomycin soln) ST XIFAXAN TAB 200G (= 9 tabs/ days) XIFAXAN TAB 550G (= 2 tabs/day) PA IPAVIDO CAP NC CAYSTON INH SOLN (Restricted to Infectious Disease or Pulmonology Specialist; Only available through Walgreens LDRS 8884746) ANTIINFECTIVE ISC. COBINATIONS erythromycin/sulfisoxazole susp (PEDIAZOLE equiv) smz/tmp (DS) tab (BACTRI DS equiv) smz/tmp susp (BACTRI/SEPTRA equiv) BACTRI DS TAB PEDIAZOLE SU ANTIPROTOZOAL AGENTS atovaquone susp (EPRON equiv) ALINIA SU 2 ALINIA TAB 2 EPRON SU CARBAPENES DORIBAX INJ imipenem/cilastin inj INVANZ INJ meropenem inj CHLORAPHENICOLS CHLORAPHENICOL INJ CYCLIC LIPOPEPTIDES CUBICIN INJ KETOLIDES KETEK TAB LINCOSAIDES clindamycin cap (CLEOCIN equiv) clindamycin soln (CLEOCIN equiv) CLEOCIN CAP CLEOCIN SOLN LINCOCIN INJ lincomycin inj (LINCOCIN equiv) OXAZOLIDINONES linezolid susp (ZYVOX equiv) (Restricted to Infectious Disease Specialist) RS linezolid tab (ZYVOX equiv) (Restricted to Infectious Disease Specialist) RS SIVEXTRO TAB (= 6 tabs/fill; Restricted to Infectious Disease Specialist) RS 2 ZYVOX SU (Restricted to Infectious Disease Specialist) RS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 00 of 79
Category/Class DrugName Special Code Tier ANTIINFECTIVE AGENTS ISC. Cont. ZYVOX TAB (Restricted to Infectious Disease Specialist) RS POLYYXINS polymyxin B inj ANTIALARIALS ANTIALARIAL COBINATIONS atovaquone/proguanil tab (ALARONE equiv) ALARONE TAB 2 COARTE TAB FANSIDAR TAB ANTIALARIALS chloroquine tab (ARALEN equiv) hydroxychloroquine tab (PLAQUENIL equiv) mefloquine tab (LARIA equiv) quinine sulfate cap (QUALAQUIN equiv) PRIAQUINE TAB 2 ARALEN TAB LARIA TAB PLAQUENIL TAB QUALAQUIN CAP DARAPRI TAB (Only available through Walgreens 8884746) LDPA ANTIYASTHENIC AGENTS ANTIYASTHENIC AGENTS pyridostigmine tab (ESTINON equiv) PROSTIGIN TAB 2 ESTINON SYRUP ESTINON TAB YTELASE TAB ANTIYASTHENIC/CHOLINERGIC AGENTS ANTIYASTHENIC/CHOLINERGIC AGENTS pyridostigmine CR tab (ESTINON equiv) GUANIDINE TAB ESTINON TIEAN TAB ANTIYCOBACTERIAL AGENTS ANTI TB COBINATIONS RIFAATE CAP 2 RIFATER TAB PA ANTIYCOBACTERIAL AGENTS ethambutol tab (YABUTOL equiv) ISONIAZID SYRUP isoniazid tab pyrazinamide tab rifabutin cap (YCOBUTIN equiv) rifampin cap (RIFADIN equiv) PRIFTIN TAB 2 CYCLOSERINE CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 0 of 79
Category/Class DrugName Special Code Tier ANTIYCOBACTERIAL AGENTS Cont. YABUTOL TAB YCOBUTIN CAP PASER GRANULE RIFADIN CAP TRECATOR TAB PA CAPASTAT INJ SIRTURO TAB NC ANTINEOPLASTICS ANTINEOPLASTICS ISC. tretinoin cap (VESANOID equiv) ITOTIC INHIBITORS etoposide cap (VEPESID equiv) TOPOISOERASE I INHIBITORS HYCATIN CAP PA ANTINEOPLASTICS AND ADJUNCTIVE ALKYLATING AGENTS cyclophosphamide tab (CYTOXAN equiv) ALKERAN TAB 2 CEENU CAP 2 CYCLOPHOHAIDE CAP 2 GLEOSTINE/LOUSTINE CAP 2 HEXALEN CAP 2 LEUKERAN TAB 2 BUSULFEX INJ melphalan inj (ALKERAN equiv) TREANDA INJ ZANOSAR INJ AFINITOR TAB (= tab/day) PASF YLERAN TAB TEODAR CAP temozolomide cap (TEODAR equiv) ANTIETABOLITES mercaptopurine tab (PURINETHOL equiv) methotrexate inj methotrexate tab (TREXALL equiv) TABLOID TAB 2 TREXALL TAB 2 PURINETHOL TAB fludarabine inj PURIXAN SU NC capecitabine tab (XELODA equiv) XELODA TAB ANTINEOPLASTIC ANTIBODIES ARZERRA INJ RITUXAN INJ YERVOY INJ Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 02 of 79
Category/Class DrugName Special Code Tier ANTINEOPLASTICS AND ADJUNCTIVE Cont. GAZYVA INJ NC ANTINEOPLASTIC BCL2 INHIBITORS VENCLEXTA TAB NC VENCLEXTA TAB STARTER PACK NC ANTINEOPLASTIC HEDGEHOG PATHWAY INHIBITORS ERIVEDGE CAP PASF ODOZO CAP (= cap/day) PASF ANTINEOPLASTIC HORONAL AGENTS tamoxifen tab (NOLVADEX equiv) (Covered at $0 for women 5 years or older; All other members covered at generic $0 copay) anastrozole tab (ARIIDEX equiv) bicalutamide tab (CASODEX equiv) exemestane tab (AROASIN equiv) flutamide cap (EULEXIN equiv) letrozole tab (FEARA equiv) megestrol susp (EGACE equiv) megestrol tab (EGACE equiv) ECYT CAP 2 FARESTON TAB 2 ARIIDEX TAB AROASIN TAB CASODEX TAB FEARA TAB EGACE SU LYSODREN TAB ZYTIGA TAB PASF ANTINEOPLASTIC HORONAL AND RELATED AGENTS FIRAGON INJ TRELSTAR INJ leuprolide inj (LUPRON equiv) INF LUPRON DEPOT INJ INF NILANDRON TAB XTANDI CAP (= 4 caps/day) PASF ANTINEOPLASTIC IUNOODULATORS POALYST CAP NC ANTINEOPLASTIC COBINATIONS LONSURF TAB PA ANTINEOPLASTIC ENZYE INHIBITORS TORISEL INJ ALECENSA CAP NC CABOETYX TAB NC COTELLIC TAB NC NINLARO CAP NC TAGRISSO TAB NC ZYKADIA CAP NC AFINITOR DIERZ (= tab/day) PASF BOSULIF TAB PASF Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 0 of 79
Category/Class DrugName Special Code Tier ANTINEOPLASTICS AND ADJUNCTIVE Cont. CAPRELSA TAB (Only available through Biologics 800850406) LDPA COETRIQ KIT (Only available through Diplomat Pharmacy 87797798) LDPASF FARYDAK CAP (= 6 caps/2 days) PA GILOTRIF TAB (= tab/day, Only available through Accredo 88877776) LDPA GLEEVEC TAB ( ) PASF IBRANCE CAP (= 2 caps/28 days) PA ICLUSIG TAB (Only available through Biologics 800850406) LDPASF IBRUVICA CAP (= 4 caps/day; Only available through Diplomat Pharmacy 87797798) LDPASF INLYTA TAB (= 8 tabs/day) PASF IRESSA TAB (Only available through Diplomat Pharmacy 87797798) LDPA JAKAFI TAB (= 2 tabs/day) PA LENVIA CAP (= caps/day; Only available through Accredo 88877776) LDPA LYNPARZA CAP (Only available through Biologics 800850406) LDPASF EKINIST TAB PA NEXAVAR TAB PASF RYCEL TAB PASF STIVARGA TAB (= 4 tabs/day) PASF SUTENT CAP PASF TAFINLAR CAP (= 4 caps/day) PASF TARCEVA TAB PASF TASIGNA CAP PASF TYKERB TAB PA VOTRIENT TAB PASF XALKORI CAP PASF ZELBORAF TAB PASF ZOLINZA CAP PASF ZYDELIG TAB (Only available through Diplomat Pharmacy 87797798) LDPASF ANTINEOPLASTICS ISC. hydroxyurea cap (HYDREA equiv) ATULANE CAP 2 PROLEUKIN INJ 2 HYDREA CAP SYNRIBO INJ ACTIUNE INJ ALFERONN INJ bexarotene cap (TARGRETIN equiv) PASF INTRONA INJ SYLATRON INJ PA TARGRETIN CAP PASF CHEOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN TAB amifostine inj ETHYOL INJ ESNEX TAB ANTIPARKINSON AGENTS ANTIPARKINSON ADJUVANTS carbidopa tab (LODOSYN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 04 of 79
Category/Class DrugName Special Code Tier ANTIPARKINSON AGENTS Cont. LODOSYN TAB ANTIPARKINSON ANTICHOLINERGICS benztropine tab trihexyphenidyl elixir (ARTANE equiv) trihexyphenidyl tab (ARTANE equiv) ANTIPARKINSON COT INHIBITORS entacapone tab (COTAN equiv) tolcapone tab (TASAR equiv) COTAN TAB TASAR TAB ANTIPARKINSON DOPAINERGICS amantadine cap (SYETREL equiv) amantadine syrup (SYETREL equiv) bromocriptine cap (PARLODEL equiv) bromocriptine tab (PARLODEL equiv) carbidopa/levodopa ER tab (SINEET CR equiv) carbidopa/levodopa ODT (PARCOPA equiv) carbidopa/levodopa tab (SINEET equiv) pramipexole ER tab (IRAPEX ER equiv) pramipexole tab (IRAPEX equiv) ropinirole ER tab (REQUIP XL equiv) ropinirole tab (REQUIP equiv) CARBIDOPA/ LEVODOPA/ ENTACAPONE TAB (STALEVO equiv) 2 AANTADINE TAB IRAPEX ER TAB IRAPEX ER TAB.75G IRAPEX TAB NEUPRO PATCH PARCOPA ODT PARLODEL CAP PARLODEL TAB REQUIP TAB REQUIP XL TAB RYTARY CAP (Step Therapy requires trial of carbidopa/levodopa ER) ST SINEET CR TAB SINEET TAB DUOPA ENTERAL SU NC APOKYN INJ (Only available through Walgreens 8884746) LD ANTIPARKINSON ONOAINE OXIDASE INHIBITORS selegiline cap (ELDEPRYL equiv) selegiline tab (ELDEPRYL equiv) AZILECT TAB 2 ELDEPYRL CAP ZELAPAR ODT ANTIPSYCHOTICS/ANTIANIC AGENTS ANTIANIC AGENTS lithium carbonate cap (ESKALITH ER equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 05 of 79
Category/Class DrugName Special Code Tier ANTIPSYCHOTICS/ANTIANIC AGENTS Cont. lithium carbonate ER tab (LITHOBID equiv) lithium carbonate tab lithium citrate soln LITHOBID TAB ANTIPSYCHOTICS ISC. ziprasidone cap (GEODON equiv) EQUETRO CAP 2 GEODON CAP LATUDA TAB (= tab/day) NC NUPLAZID TAB NC VRAYLAR CAP NC VRAYLAR PACK NC BENZISOXAZOLES paliperidone ER tab (INVEGA equiv) PA risperidone ODT (RIERDAL equiv) risperidone soln (RIERDAL equiv) risperidone tab (RIERDAL equiv) FANAPT TAB (= 2 tabs/day) PA INVEGA TAB PA RIERDAL ODT RIERDAL SOLN RIERDAL TAB INVEGA SUSTENNA/TRINZ INJ PA BUTYROPHENONES haloperidol lactate conc (HALDOL equiv) haloperidol tab (HALDOL equiv) DIBENZAPINES clozapine ODT 25mg, 00mg (CLOZAPINE/FAZACLO equiv) clozapine tab (CLOZARIL equiv) loxapine cap (LOXITANE equiv) olanzapine ODT (ZYPREXA equiv) olanzapine tab (ZYPREXA equiv) quetiapine tab (SEROQUEL equiv) CLOZAPINE ODT/FAZACLO ODT 2 CLOZARIL TAB FAZACLO ODT 25G, 00G LOXITANE CAP SAPHRIS SL TAB (= 2 tabs/day) PA SEROQUEL TAB SEROQUEL XR TAB ZYPREXA TAB ZYPREXA ZYDIS TAB ADASUVE INHALER NC VERSACLOZ SU NC PHENOTHIAZINES chlorpromazine tab (THORAZINE equiv) fluphenazine tab (PROLIXIN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 06 of 79
Category/Class DrugName Special Code Tier ANTIPSYCHOTICS/ANTIANIC AGENTS Cont. perphenazine tab (TRILAFON equiv) prochlorperazine supp (COPAZINE equiv) prochlorperazine tab (COPAZINE equiv) thioridazine tab (ELLARIL equiv) trifluoperazine tab (STELAZINE equiv) QUINOLINONE DERIVATIVES aripiprazole tab (ABILIFY equiv) ABILIFY DISCELT (= 2 tabs/day) PA ABILIFY SOLN PA ABILIFY TAB REXULTI TAB NC ABILIFY AINTENA INJ PA THIOXANTHENES thiothixene cap (NAVANE equiv) NAVANE CAP ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS PHISOHEX LIQUID IODINE ANTISEPTICS IODOFLEX PAD NC ANTIVIRALS ANTIRETROVIRALS didanosine DR cap (VIDEX EC equiv) lamivudine soln (EPIVIR equiv) lamivudine tab (EPIVIR equiv) nevirapine tab (VIRAUNE equiv) stavudine cap (ZERIT equiv) stavudine soln (ZERIT equiv) zidovudine cap (RETROVIR equiv) zidovudine syrup (RETROVIR equiv) zidovudine tab (RETROVIR equiv) TYBOST TAB NC abacavir tab (ZIAGEN equiv) abacavir/ lamivudine/ zidovudine tab (TRIZIVIR equiv) APTIVUS CAP APTIVUS SOLN ATRIPLA TAB COBIVIR TAB COPLERA TAB CRIXIVAN CAP DESCOVY TAB PA EDURANT TAB ETRIVA CAP ETRIVA SOLN EPIVIR SOLN EPIVIR TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 07 of 79
Category/Class DrugName Special Code Tier ANTIVIRALS Cont. EPZICO TAB EVOTAZ TAB FUZEON INJ GENVOYA TAB INTELENCE TAB INVIRASE TAB ISENTRESS CHEW TAB ISENTRESS POWDER PACK ISENTRESS TAB KALETRA SOLN KALETRA TAB lamivudine/zidovudine tab (COBIVIR equiv) LEXIVA SU LEXIVA TAB nevirapine ER tab (VIRAUNE XR equiv) (Step Therapy requires trial of nevirapine) ST NEVIRAPINE SU (VIRAUNE equiv) NORVIR CAP NORVIR SOLN NORVIR TAB ODEFSEY TAB PREZCOBIX TAB PREZISTA SU PREZISTA TAB RESCRIPTOR TAB RETROVIR CAP RETROVIR SYRUP RETROVIR TAB REYATAZ CAP REYATAZ POWDER PACK SELZENTRY TAB STRIBILD TAB SUSTIVA CAP SUSTIVA TAB TIVICAY TAB (= 2 tabs/day) TRIUEQ TAB TRIZIVIR TAB TRUVADA TAB PA VIDEX EC CAP VIDEX SOLN VIRACEPT POWDER VIRACEPT TAB VIRAUNE SU VIRAUNE TAB VIRAUNE XR TAB (Step Therapy requires trial of nevirapine) ST VIREAD TAB VITEKTA TAB ZERIT CAP ZERIT SOLN Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 08 of 79
Category/Class DrugName Special Code Tier ANTIVIRALS Cont. ZIAGEN TAB CV AGENTS valganciclovir tab (VALCYTE equiv) GANCICLOVIR CAP 2 VALCYTE SOLN 2 VALCYTE TAB cidofovir inj FOSCARNET INJ VISTIDE INJ HEPATITIS AGENTS lamivudine tab 00mg (EPIVIR HBV equiv) ribavirin cap (REBETOL equiv) ribavirin tab (COPEGUS equiv) OLYSIO CAP NC RIBAPAK TAB NC TECHNIVIE TAB NC ZEPATIER TAB NC adefovir dipivoxil tab (HEPSERA equiv) BARACLUDE TAB (= tab/day) COPEGUS TAB DAKLINZA TAB (= tab/day) PA entecavir tab (BARACLUDE equiv) (= tab/day) EPIVIR HBV SOLN EPIVIR HBV TAB HARVONI TAB (= tab/day) PA HEPSERA TAB INCIVEK TAB PASF INFERGEN INJ PEGASYS INJ (Step Therapy requires trial of PEGINTRON; Required thru specialty pharmacy. Apothecary by Design ST 877848447) PEGASYS INJ KIT (Step Therapy requires trial of PEGINTRON; Required thru specialty pharmacy. Apothecary by Design ST 877848447) PEGINTRON INJ REBETOL CAP REBETOL SOLN RIBATAB SOVALDI TAB (= tab/day) PA TYZEKA TAB PA VICTRELIS CAP PASF HERPES AGENTS acyclovir cap (ZOVIRAX equiv) acyclovir susp (ZOVIRAX equiv) acyclovir tab (ZOVIRAX equiv) famciclovir tab (FAVIR equiv) valacyclovir tab (VALTREX equiv) FAVIR TAB VALTREX TAB ZOVIRAX CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 09 of 79
Category/Class DrugName Special Code Tier ANTIVIRALS Cont. ZOVIRAX SU ZOVIRAX TAB SITAVIG TAB NC INFLUENZA AGENTS rimantadine tab (FLUADINE equiv) RELENZA DISKHALER (= inhaler/fill) 2 TAIFLU CAP (= 0 caps/fill) 2 TAIFLU CAP 0G (= 20 caps/fill) 2 TAIFLU SU 6G/L (= 250ml/fill) 2 FLUADINE TAB ASSORTED CLASSES CHELATING AGENTS DEPEN TITRATAB 2 CUPRIINE CAP NC SYPRINE CAP PA IUNOODULATORS REVLIID CAP (= cap/day) PA THALOID CAP PA IUNOSUPPRESSIVE AGENTS azathioprine tab (IURAN equiv) AZASAN TAB IURAN TAB ATGA INJ NULOJIX INJ ORTHOCLONE OKT INJ SIULECT INJ THYOGLOBULIN INJ ENVARSUS XR TAB NC CELLCEPT CAP CELLCEPT SU CELLCEPT TAB cyclosporine cap (SANDIUNE equiv) cyclosporine modified cap (NEORAL equiv) CYCLOORINE ODIFIED CAP 50G cyclosporine modified soln (NEORAL equiv) mycophenolate DR tab (YFORTIC equiv) mycophenolate mofetil cap (CELLCEPT equiv) mycophenolate mofetil susp (CELLCEPT SU equiv) mycophenolate mofetil tab (CELLCEPT equiv) YFORTIC TAB NEORAL CAP NEORAL SOLN PROGRAF CAP RAPAUNE SOLN RAPAUNE TAB SANDIUNE CAP SANDIUNE SOLN 00G/L Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 0 of 79
Category/Class DrugName Special Code Tier ASSORTED CLASSES Cont. sirolimus tab (RAPAUNE equiv) tacrolimus cap (PROGRAF equiv) ZORTRESS TAB PA IRRIGATION SOLUTIONS physiosol inj ringers irrigation soln POTASSIU REOVING RESINS sodium polystyrene powder (KAYEXALATE equiv) sodium polystyrene susp (S equiv) KAYEXALATE POWDER VELTASSA POWDER NC BETA BLOCKERS ALPHABETA BLOCKERS carvedilol tab (COREG equiv) CI labetalol tab (NORODYNE equiv) CI COREG CR CAP COREG TAB TRANDATE TAB BETA BLOCKERS CARDIOSELECTIVE acebutolol cap (SECTRAL equiv) CI atenolol tab (TENORIN equiv) CI betaxolol tab (KERLONE equiv) CI bisoprolol tab (ZEBETA equiv) CI metoprolol ER tab (TOPROL XL equiv) CI metoprolol tab (LOPRESSOR equiv) CI BYSTOLIC TAB CI 2 KERLONE TAB LOPRESSOR TAB SECTRAL CAP TENORIN TAB TOPROL XL TAB ZEBETA TAB ETOPROLOL TARTRATE TAB 7.5G, 75G NC BETA BLOCKERS NONSELECTIVE nadolol tab (CORGARD equiv) CI pindolol tab (VISKEN equiv) CI propranolol ER cap (INDERAL LA equiv) CI PROPRANOLOL SOLN CI propranolol tab (INDERAL equiv) CI sotalol AF tab (BETAPACE AF equiv) CI sotalol tab (BETAPACE equiv) CI timolol maleate tab (BLOCADREN equiv) CI BETAPACE AF TAB BETAPACE TAB CORGARD TAB INDERAL LA CAP INNOPRAN XL CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Category/Class DrugName Special Code Tier BETA BLOCKERS Cont. LEVATOL TAB HEANGEOL SOLN NC SOTYLIZE SOLN NC BIOLOGICALS ISC ALLERGENIC EXTRACTS GRASTEK SL TAB NC ORALAIR SL TAB NC RAGWITEK SL TAB NC BIOLOGICALS ISC ADAGEN INJ CALCIU CHANNEL BLOCKERS CALCIU CHANNEL BLOCKERS amlodipine tab (NORVASC equiv) CI diltiazem ER cap (CARDIZE CD equiv) CI diltiazem ER cap (CARDIZE SR equiv) CI diltiazem ER cap (DILACOR XR equiv) CI diltiazem ER cap (TIAZAC equiv) CI diltiazem ER tab (CARDIZE LA equiv) CI diltiazem tab (CARDIZE equiv) CI felodipine ER tab (PLENDIL equiv) CI isradipine cap (DYNACIRC equiv) CI nicardipine cap (CARDENE equiv) CI nifedipine cap (PROCARDIA equiv) CI nifedipine ER tab (ADALAT CC equiv) CI nimodipine cap (NIOTOP equiv) CI nisoldipine ER tab (SULAR equiv) CI NISOLDIPINE ER TAB 25.5G CI verapamil SR cap (VERELAN P equiv) CI verapamil SR cap (VERELAN SR equiv) CI verapamil SR tab (CALAN SR/ISOPTIN SR equiv) CI verapamil tab (CALAN equiv) CI ADALAT CC TAB CALAN SR TAB CALAN TAB CARDENE SR CAP CARDIZE CD CAP CARDIZE LA TAB CARDIZE TAB COVERAHS TAB DILACOR XR CAP DYNACIRC CR TAB NIOTOP CAP NORVASC TAB PLENDIL TAB PROCARDIA CAP SULAR TAB TIAZAC CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Category/Class DrugName Special Code Tier CALCIU CHANNEL BLOCKERS Cont. VERELAN CAP VERELAN P CAP CARDIOTONICS CARDIAC GLYCOSIDES digoxin soln (LANOXIN equiv) digoxin tab (LANOXIN equiv) LANOXIN TAB LANOXIN TAB 0.0625G, 0.875G NC CARDIOVASCULAR AGENTS ISC. CARDIOVASCULAR AGENTS ISC. COBINATIONS amlodipine/atorvastatin tab (CADUET equiv) CI CADUET TAB ENTRESTO TAB NC IPOTENCE AGENTS CIALIS TAB 2.5G, 5G (Prior Authorization for BPH) PA PERIPHERAL VASODILATORS isoxsuprine tab PROSTAGLANDIN VASODILATORS ORENITRA TAB NC TYVASO INH SOLN (Only available through Accredo 88877776) LDPA VENTAVIS INH SOLN (Only available through Accredo 88877776) LDPA PULONARY HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TAB (= tab/day) PA OPSUIT TAB (= tab/day, Only available through Walgreens 8884746) LDPA TRACLEER TAB (= 2 tabs/day) PA PULONARY HYPERTENSION PHOHODIESTERASE INHIBITORS sildenafil tab (REVATIO equiv) PA REVATIO TAB PA REVATIO SU NC ADCIRCA TAB PA PULONARY HYPERTENSION PROSTACYCLIN RECEPTOR AGONIST UPTRAVI TAB NC UPTRAVI THERAPY PACK NC PULONARY HYPERTENSION SOL GUANYLATE CYCLASE STIULATOR ADEPAS TAB (= tabs/day; Only available through Accredo 88877776) LDPA SINUS NODE INHIBITORS CORLANOR TAB PA CEPHALOORINS CEPHALOORINS ST GENERATION cefadroxil cap (DURICEF equiv) cefadroxil susp (DURICEF equiv) cefadroxil tab (DURICEF equiv) cephalexin cap (KEFLEX equiv) cephalexin susp (KEFLEX equiv) CEPHALEXIN TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Category/Class DrugName Special Code Tier CEPHALOORINS Cont. KEFLEX CAP cefazolin inj CEPHALOORINS 2ND GENERATION cefaclor cap (CECLOR equiv) cefprozil susp (CEFZIL equiv) cefprozil tab (CEFZIL equiv) cefuroxime susp (CEFTIN equiv) cefuroxime tab (CEFTIN equiv) CEFACLOR ER TAB CEFACLOR SU CEFTIN SU CEFTIN TAB CEFOTAN INJ cefotetan inj cefotetan inj (CEFOTAN equiv) cefoxitin inj CEPHALOORINS RD GENERATION cefdinir cap (ONICEF equiv) cefdinir susp (ONICEF equiv) cefixime susp (SUPRAX equiv) cefpodoxime proxetil susp (VANTIN equiv) cefpodoxime proxetil tab (VANTIN equiv) CEDAX CAP CEDAX SU ONICEF SU ECTRACEF TAB SUPRAX CAP SUPRAX CHEW TAB SUPRAX SU SUPRAX SU 500G/5L SUPRAX TAB VANTIN TAB cefotaxime inj ceftazidime inj ceftriaxone inj CEPHALOORINS 4TH GENERATION cefepime inj CEPHALOORINS 5TH GENERATION TEFLARO INJ CONTRACEPTIVES COBINATION CONTRACEPTIVES ORAL amethyst tab (LYBREL equiv) $0 apri tab (DESOGEN equiv) $0 aranelle tab (TRINORINYL equiv) $0 aviane tab (ALESSE equiv) $0 BEYAZ TAB $0 cesia tab (CYCLESSA equiv) $0 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Category/Class DrugName Special Code Tier CONTRACEPTIVES Cont. cryselle tab (OGESTREL equiv) $0 enpresse tab (TRILEVELEN equiv) $0 jolessa tab/ amethia tab (SEASONALE/SEASONIQUE equiv) ( copays per Rx) $0 junel FE tab (LOESTRIN FE equiv) $0 junel tab (LOESTRIN equiv) $0 kariva tab (IRCETTE equiv) $0 kelnor tab (DEULEN equiv) $0 mononessa tab (ORTHOCYCLEN equiv) $0 necon tab (ORTHONOVU equiv) $0 necon tab /50 (NORYNIL equiv) $0 nortrel tab (OVCON 5 equiv) $0 trilegest tab (ESTROSTEP FE equiv) $0 trinessa (LO) tab (ORTHO TRICYCLEN (LO) equiv) $0 wymzya FE tab (FECON FE equiv) $0 YASIN TAB $0 YAZ TAB $0 CYCLESSA TAB DESOGEN TAB ESTROSTEP FE TAB FECON FE CHEW TAB LO LOESTRIN TAB LO INASTRIN 24 FE CHEW TAB LOESTRIN 24 FE TAB LOESTRIN FE TAB LOESTRIN TAB INASTRIN CHEW TAB IRCETTE TAB NATAZIA TAB NORINYL TAB /50 OGESTREL TAB ORTHO TRICYCLEN (LO) TAB ORTHOCYCLEN TAB OVCON 5 TAB SEASONIQUE TAB TRINORINYL TAB FALESSA KIT NC gianvi tab/ ocella tab (YAZ/YASIN equiv) NC QUARTETTE TAB NC SAFYRAL TAB NC COBINATION CONTRACEPTIVES TRANSDERAL XULANE PATCH $0 ORTHOEVRA PATCH COBINATION CONTRACEPTIVES VAGINAL NUVARING $0 COPPER CONTRACEPTIVES IUD (NEW) PARAGARD IUD $0 EERGENCY CONTRACEPTIVES Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Category/Class DrugName Special Code Tier CONTRACEPTIVES Cont. ELLA TAB $0 levonorgestrel tab (PLAN B equiv) OTC $0 LEVONORGESTREL TAB 0.75G $0 PLAN B TAB OTC $0 PROGESTIN CONTRACEPTIVES IPLANTS IPLANON/NEXPLANON IPLANT $0 PROGESTIN CONTRACEPTIVES INJECTABLE DEPOPROVERA SC INJ 04G (= inj/90 days) $0 medroxyprogesterone inj (DEPOPROVERA equiv) (= inj/90 days) $0 DEPOPROVERA INJ (= inj/90 days) PROGESTIN CONTRACEPTIVES IUD IRENA IUD $0 PROGESTIN CONTRACEPTIVES ORAL norethindrone tab (NORAQD equiv) $0 NORQD TAB CORTICOSTEROIDS GLUCOCORTICOSTEROIDS budesonide SR cap (ENTOCORT EC equiv) CORTEF TAB DEXAETHASONE CONC dexamethasone elixir dexamethasone soln DEXAETHASONE TAB dexamethasone tab (DECADRON equiv) hydrocortisone tab (CORTEF equiv) EDROL TAB methylprednisolone dose pack (EDROL equiv) methylprednisolone tab (EDROL equiv) prednisolone ODT (ORAPRED equiv) prednisolone soln (PEDIAPRED equiv) prednisolone syrup (PRELONE equiv) PREDNISONE SOLN PREDNISONE TAB prednisone tab (DELTASONE equiv) CORTISONE ACETATE TAB 2 ORAPRED ODT 2 PREDNISONE PAK 2 DEXPAK TAB ENTOCORT EC CAP EDROL DOSE PACK EDROL TAB ILLIPRED DP PAK ILLIPRED TAB ORAPRED ODT ORAPRED SOLN PRELONE SYRUP UCERIS TAB (= tab/day) PA Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Category/Class DrugName Special Code Tier CORTICOSTEROIDS Cont. VERIPRED SOLN FLOPRED SU NC LIDOLOG KIT NC RAYOS TAB NC INERALOCORTICOIDS fludrocortisone tab (FLORINEF equiv) COUGH/COLD/ALLERGY ANTITUSSIVES benzonatate cap (TESSALON equiv) hydrocodone/homatropine syrup (HYCODAN equiv) tussigon tab (HYCODAN equiv) HYCODAN SYRUP TESSALON CAP COUGH/COLD/ALLERGY COBINATIONS guaifenesin/codeine syrup (TUSSIORGANIDINS equiv) (= 240ml/fill) OTC hydrocodone/chlorpheniramine CR susp (TUSSIONEX equiv) (= 20ml/fill; 2 fills/0 days) hydrocodone/chlorpheniramine/pseudoephedrine liquid (ZUTRIPRO equiv) (= 20ml/fill, 2 fills/0 days) promethazine D syrup promethazine VC syrup (PHENERGAN VC equiv) promethazine VC w/codeine syrup (PHENERGAN VC W/CODIENE equiv) promethazine w/codeine syrup (PHENERGAN W/CODIENE equiv) ALBATUSSIN LIQUID BRONCOPECTOL SYRUP DECONA ELIXIR GILTUSS LIQUID GILTUSS TR TAB NEOTUSSD LIQUID PEDIATEX TD SU RESCON TAB REZIRA SOLN SEPREXD CAP SUTTAR SF SYRUP TUSNEL CAP TUSNEL SYRUP TUSSICAPS (= 20 caps/fill, 2 fills/0 days) TUSSIONEX SU (= 20ml/fill; 2 fills/0 days) TUSSIORGANI SYRUP (= 240ml/fill) ZUTRIPRO LIQUID (= 20ml/fill, 2 fills/0 days) CLARINEXD TAB NC DOETUSSDX LIQ NC HYCOFENIX SOLN NC POLYTUSSIN D SYRUP NC TUZISTRA XR SU NC EXPECTORANTS guaifenesin tab (ALLFEN JR equiv) NC ISC. REIRATORY INHALANTS sodium chloride neb soln (HYPERSAL equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Category/Class DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. NEBUSAL NEB SOLN 2 HYPERSAL NEB SOLN UCOLYTICS acetylcysteine soln (UCOYST equiv) DERATOLOGICALS ACNE PRODUCTS adapalene cream (DIFFERIN equiv) (Acne Only members age 25 or older require Prior Authorization) PA adapalene gel 0.% (DIFFERIN equiv) (Acne Only members age 25 or older require Prior Authorization) PA clindamycin gel (CLEOCIN GEL equiv) clindamycin lotion (CLEOCIN T equiv) clindamycin pad (CLEOCINT equiv) clindamycin topical soln (CLEOCINT equiv) clindamycin/ benzoyl peroxide gel (DUAC GEL equiv) clindamycin/benzoyl peroxide gel (BENZACLIN equiv) DIFFERIN GEL 0.% (Acne Only members age 25 or older require Prior Authorization) PA erythromycin gel erythromycin pad erythromycin soln erythromycin/benzoyl peroxide gel (BENZAYCIN equiv) isotretinoin cap (ACCUTANE equiv) RETINA ICRO GEL 0.04%, 0.% (Acne Only members age 25 or older require Prior Authorization) PA sodium sulfacetamide lotion (KLARON equiv) sodium sulfacetamide/sulfur cream (PLEXION SCT equiv) SODIU SULFACETAIDE/SULFUR EULSION sodium sulfacetamide/sulfur emulsion (ROSAC WASH equiv) sodium sulfacetamide/sulfur emulsion (ROSULA equiv) sodium sulfacetamide/sulfur foam (CLARIFOA EF equiv) sodium sulfacetamide/sulfur gel (ROSULA equiv) sodium sulfacetamide/sulfur lotion (SULFACET R equiv) sodium sulfacetamide/sulfur pad (PLEXION CLEANSING CLOTH equiv) sodium sulfacetamide/sulfur susp (SUAXIN equiv) sodium sulfacetamide/sulfur wash (SUAXIN equiv) tretinoin cream (Acne Only members age 25 or older require Prior Authorization) PA tretinoin gel (RETINA GEL equiv) (Acne Only members age 25 or older require Prior Authorization) PA ADAPALENE LOTION (Acne Only members age 25 or older require Prior Authorization) PA 2 AVAR GEL 2 EPIDUO (FORTE) GEL (Acne Only members age 25 or older require Prior Authorization) PA 2 PRASCION RA CREA 2 ACANYA/ONEXTON GEL AKNEYCIN OINT AVAR AEROSOL FOA AZELEX CREA PA BENZACLIN GEL BENZAYCIN GEL BENZAYCIN GEL PACK CLARIFOA EF FOA CLEOCINT GEL Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. CLEOCINT LOTION CLEOCINT PAD CLEOCINT SOLN CLINDAGEL DIFFERIN CREA PA DIFFERIN GEL 0.% PA DIFFERIN LOTION PA DUAC CS KIT DUAC GEL KLARON LOTION PLEXION LOTION PLEXION SCT CREA RETINA CREA PA RETINA GEL PA ROSULA EULSION ROSULA GEL SUAXIN PAD SUAXIN TS SU SUAXIN WASH TRETINX CREA PA VELTIN/ ZIANA GEL ABSORICA CAP NC ACZONE GEL NC AVAR PAD NC CLINDACIN KIT NC clindamycin foam (EVOCLIN equiv) NC FABIOR AEROSOL FOA NC RETINA ICRO GEL 0.08% NC ROSULA WASH NC sodium sulfacetamide/sunscreen kit (SUADEN XLT equiv) NC AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS VEREGEN OINT AGENTS FOR FACIAL WRINKLES RENOVA CREA NC ANALGESICS TOPICAL BACLOFEN CREA COPOUND KIT NC TRAADOL COPOUND KIT NC ANTIBIOTICS TOPICAL gentamicin sulfate cream gentamicin sulfate oint mupirocin cream (BACTROBAN equiv) mupirocin oint (BACTROBAN OINT equiv) ALTABAX OINT BACTROBAN CREA BACTROBAN OINT CENTANY OINT CORTIORIN CREA Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. CORTIORIN OINT NEOSYNALAR CREA NC ANTIFUNGALS TOPICAL ciclopirox cream (LOPROX CREA equiv) ciclopirox gel (LOPROX GEL equiv) ciclopirox nail soln (PENLAC equiv) ciclopirox shampoo (LOPROX SHAPOO equiv) ciclopirox topical susp (LOPROX SU equiv) clotrimazole/betamethasone cream (LORTRISONE CREA equiv) clotrimazole/betamethasone lotion (LOTRISONE LOTION equiv) econazole cream (ECTAZOLE CREA equiv) ketoconazole cream (NIZORAL CREA equiv) ketoconazole shampoo (NIZORAL SHAPOO equiv) naftifine cream 2% (NAFTIN equiv) nystatin cream (YCOSTATIN CREA equiv) nystatin oint nystatin topical powder nystatin/triamcinolone cream nystatin/triamcinolone oint oxiconazole nitrate cream (OXISTAT equiv) NAFTIFINE CREA % 2 NAFTIN GEL 2 OXISTAT LOTION 2 ERTACZO CREA EXELDER CREA EXELDER SOLN LOPROX CREA LOPROX GEL LOPROX SHAPOO LOTRISONE CREA LOTRISONE LOTION ENTAX CREA NAFTIN CREA NIZORAL SHAPOO OXISTAT CREA clotrimazole cream (LOTRIIN AF CREA equiv) NC ECOZA FOA NC iodoquinol/hydrocortisone cream % (VYTONE equiv) NC iodoquinol/hydrocortisone cream.9% (VYTONE equiv) NC JUBLIA SOLN NC KERYDIN SOLN NC LUZU CREA NC NAFTIN GEL 2% NC NYATA KIT NC XOLEGEL NC ANTIINFLAATORY AGENTS TOPICAL diclofenac gel % (VOLTAREN equiv) (= 5 tubes/fill) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 20 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. FLECTOR PATCH (= 0 patches/fill) VOLTAREN GEL (= 5 tubes/fill) diclofenac soln.5% (PENNSAID equiv) NC INFLAAK KIT NC NAPROXEN CREA COPOUND KIT NC PENNSAID SOLN NC PENNSAID SOLN.5% NC REXAPHENAC CREA NC VOPAC 5 CREA NC VOPAC CREA NC VOPAC GB CREA NC ANTINEOPLASTIC OR PREALIGNANT LESION AGENTS TOPICAL diclofenac gel (SOLARAZE equiv) fluorouracil cream (EFUDEX CREA equiv) fluorouracil soln (EFUDEX SOLN equiv) CARAC CREA 2 FLUOROPLEX CREA 2 EFUDEX CREA EFUDEX SOLN PICATO GEL (= box/fill) SOLARAZE GEL FLUORAC CREA NC PANRETIN GEL PA TARGRETIN GEL VALCHLOR GEL (= 4 tubes/0 days; Only available through Accredo 88877776) LDPA ANTIPRURITICS TOPICAL DOXEPIN/PRUDOXIN/ZONALON CREA ANTIPSORIATICS acitretin cap (SORIATANE equiv) calcipotriene cream (DOVONEX CREA equiv) calcipotriene oint calcipotriene soln (DOVONEX SOLN equiv) methoxsalen cap (OXSORALEN ULTRA equiv) 8OP CAP 2 SORIATANE CK KIT 2 VECTICAL OINT 2 DOVONEX CREA DOVONEX SOLN DRITHOSCALP CREA OXSORALEN ULTRA CAP SORIATANE CAP SORILUX FOA TAZORAC CREA TAZORAC GEL AEVIVE INJ STELARA INJ NC TALTZ INJ NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. COSENTYX INJ PA ANTISEBORRHEIC PRODUCTS sebprev cream (OVACE CREA equiv) selenium sulfide lotion selenium sulfide shampoo (SELSEB equiv) sodium sulfacetamide gel (OVACE PLUS equiv) sodium sulfacetamide shampoo (OVACE equiv) sodium sulfacetamide wash (OVACE WASH equiv) sodium sulfacetamide/ urea pad (ROSULA equiv) OVACE PLUS CREA OVACE PLUS GEL OVACE PLUS SHAPOO OVACE WASH ROSULA PAD OVACE PLUS LOTION NC OVACE PLUS FOA NC SELRX SHAPOO 2.% NC ANTIVIRALS TOPICAL ZOVIRAX OINT DENAVIR CREA 2 XERESE CREA ZOVIRAX CREA acyclovir oint (ZOVIRAX OINT equiv) NC BURN PRODUCTS silver sulfadiazine cream (SILVADENE CREA equiv) SULFAYLON CREA 2 SILVADENE CREA CORTICOSTEROIDS TOPICAL alclometasone cream (ACLOVATE equiv) alclometasone oint (ACLOVATE OINT equiv) betamethasone augmented cream (DIPROLENE AF CREA equiv) betamethasone augmented gel (DIPROLENE GEL equiv) betamethasone augmented lotion (DIPROLENE LOTION equiv) betamethasone augmented oint (DIPROLENE OINT equiv) betamethasone diproprionate cream (DIPROSONE CREA equiv) betamethasone diproprionate lotion betamethasone diproprionate oint (DIPROSONE OINT equiv) betamethasone valerate cream betamethasone valerate lotion betamethasone valerate oint calcipotriene/ betamethasone oint (TACLONEX equiv) clobetasol foam (OLUX equiv) PA clobetasol lotion (CLOBEX equiv) PA clobetasol propionate cream (TEOVATE equiv) PA clobetasol propionate emollient cream (TEOVATE E equiv) PA clobetasol propionate gel (TEOVATE GEL equiv) PA clobetasol propionate oint (TEOVATE equiv) PA Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 22 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. clobetasol propionate soln (TEOVATE equiv) PA clobetasol shampoo (CLOBEX equiv) PA clobetasol spray (CLOBEX equiv) PA desoximetasone cream 0.25% (TOPICORT CREA 0.25% equiv) diflorasone oint fluocinolone acetonide cream fluocinolone acetonide oil (DERASOOTH/FS equiv) fluocinolone acetonide oint fluocinolone acetonide soln fluocinonide cream (LIDEX equiv) fluocinonide emollient cream fluocinonide gel fluocinonide oint fluocinonide soln flurandrenolide Cream (CORDRAN equiv) fluticasone propionate cream (CUTIVATE equiv) fluticasone propionate oint (CUTIVATE equiv) halobetasol propionate cream (ULTRAVATE equiv) PA halobetasol propionate oint (ULTRAVATE equiv) PA hydrocortisone cream (PROCTOCORT equiv) hydrocortisone lotion (HYTONE equiv) hydrocortisone oint mometasone cream (ELOCON equiv) mometasone oint (ELOCON equiv) mometasone soln (ELOCON equiv) prednicarbate cream (DERATOP equiv) prednicarbate oint (DERATOP equiv) triamcinolone cream triamcinolone lotion triamcinolone oint triamcinolone spray (KENALOG equiv) TRIANEX OINT EPIFOA AEROSOL 2 PRAOSONE CREA % 2 PRAOSONE OINT 2 TOPICORT/DESOXIETASONE CREA 0.05% 2 UCORT CREA 2 ACLOVATE CREA ACLOVATE OINT CAPEX SHAPOO CAROLHC CREA CLOBEX LOTION PA CLOBEX SHAPOO PA CLOBEX RAY PA CLODER CREA/ CLOCORTOLONE CREA CORDRAN CREA CORDRAN LOTION CORDRAN TAPE Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. CUTIVATE CREA CUTIVATE OINT DERASOOTH/FS OIL DERATOP CREA DERATOP OINT DIPROLENE AF CREA DIPROLENE LOTION DIPROLENE OINT ELOCON CREA ELOCON OINT ELOCON SOLN HALOG CREA HALOG OINT HYTONE LOTION KENALOG RAY NUCORT LOTION OLUX FOA PA PANDEL CREA PRAOSONE LOTION PROCTOCORT CREA TACLONEX OINT TACLONEX SCALP SU TEOVATE CREA PA TEOVATE GEL PA TEOVATE OINT PA TEOVATE SOLN PA TEOVATEE CREA PA TEXACORT SOLN TOPICORT CREA 0.25% ULTRAVATE CREA PA ULTRAVATE LOTION PA ULTRAVATE OINT PA VANOS CREA VERDESO FOA ACINONIDE CREA 0.% NC ACINONIDE LOTION NC ACINONIDE OINT NC APEXICON E CREA (PSORCON E equiv) NC betamethasone valerate foam (LUXIQ FOA equiv) NC clobetasol E foam (OLUX E equiv) NC CUTIVATE LOTION NC desonide cream NC desonide lotion NC desonide oint NC DESOWEN CREA KIT NC DESOWEN LOTION KIT NC DESOWEN OINT KIT NC desoximetasone gel (TOPICORT equiv) NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 24 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. desoximetasone oint 0.25% (TOPICORT equiv) NC DIFLORASONE CREA NC DIFLORASONE OINT (PSORCON equiv) NC ENSTILAR FOA NC fluticasone propionate lotion (CUTIVATE equiv) NC halonate pac kit (ULTRAVATE KIT equiv) NC hydrocortisone butyrate cream (LOCOID equiv) NC hydrocortisone butyrate lipocream (LOCOID equiv) NC hydrocortisone butyrate oint (LOCOID equiv) NC hydrocortisone butyrate soln (LOCOID equiv) NC hydrocortisone valerate cream NC hydrocortisone valerate oint (WESTCORT equiv) NC hydrocortisone/pramoxine cream 2.5% (PRAOSONE equiv) NC LOCOID CREA NC LOCOID LIPOCREA NC LOCOID OINT NC LOCOID SOLN NC LUXIQ FOA NC PRAOSONE CREA 2.5% NC PRAOSONE E CREA NC SERNIVO RAY NC TOPICORT GEL NC TOPICORT OINT 0.25% NC TOPICORT/DESOXIETASONE OINT 0.05% NC WESTCORT OINT NC EOLLIENT/KERATOLYTIC AGENTS GORDON'S UREA OINT 40% 2 KERAFOA KERALAC CREA NC UECTA EULSION NC UECTA SU NC URAAXIN CREA NC URAAXIN GEL NC urea cream NC urea gel (URAAXIN equiv) NC UREA NAIL KIT NC urea susp 40% (UECTA equiv) NC EOLLIENTS ammonium lactate cream (LACHYDRIN equiv) ammonium lactate lotion (LACHYDRIN equiv) LACHYDRIN CREA LACHYDRIN LOTION ENZYES TOPICAL SANTYL OINT 2 vasolex oint (XENADER equiv) NC XENADER OINT NC HAIR GROWTH AGENTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 25 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. finasteride tab (PROPECIA equiv) NC HAIR REDUCTION AGENTS VANIQA CREA NC IUNOODULATING AGENTS TOPICAL imiquimod cream (ALDARA equiv) ALDARA CREA ZYCLARA CREA NC IUNOSUPPRESSIVE AGENTS TOPICAL tacrolimus oint (PROTOPIC OINT equiv) ELIDEL CREA 2 PROTOPIC OINT KERATOLYTIC/ANTIITOTIC AGENTS podofilox soln (CONDYLOX equiv) salicylic acid shampoo (SALEX equiv) PODOCON SOLN 2 CONDYLOX GEL CONDYLOX SOLN SALEX SHAPOO LOCAL ANESTHETICS TOPICAL lidocaine cream % (LIDAANTLE equiv) lidocaine gel (XYLOCAINE equiv) lidocaine oint lidocaine patch (LIDODER equiv) (= patches/day) lidocaine soln (XYLOCAINE equiv) lidocaine/prilocaine cream (ELA equiv) ELA CREA LIDODER PATCH (= patches/day) SOLARCAINE EXTRA GEL SYNERA PATCH XYLOCAINE SOLN ADAZIN CREA NC LIDOCAINE CREA NC lidocaine lotion (LIDAANTLE equiv) NC LIDOCIN GEL NC SILVERA PAD NC SOLAICE PATCH NC SYNVEXIA TC CREA NC ISC. DERATOLOGICAL PRODUCTS NEOSALUS FOA NC ISC. TOPICAL aluminum chloride soln (DRYSOL equiv) DRYSOL SOLN PIGENTINGDEPIGENTING AGENTS hydroquinone cream (LUSTRA equiv) NC TRILUA CREA NC ROSACEA AGENTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 26 of 79
Category/Class DrugName Special Code Tier DERATOLOGICALS Cont. metronidazole cream (ETROCREA equiv) metronidazole gel (ETROGEL equiv) metronidazole lotion (ETROLOTION equiv) FINACEA FOA 2 FINACEA GEL 2 FINACEA PLUS KIT 2 DOXYCYCLINE/ORACEA CAP ETROCREA ETROGEL % (Step Therapy requires trial of FINACEA) ST ETROLOTION NORITATE CREA (Step Therapy requires trial of FINACEA) ST IRVASO GEL NC ROSADAN KIT NC SCABICIDES & PEDICULICIDES lindane lotion lindane shampoo malathion lotion (OVIDE equiv) (= 2 bottles/fill) permethrin cream (ELIITE CREA equiv) EURAX CREA 2 INOSAD SU (= bottle/fill) 2 ELIITE CREA EURAX LOTION LINDANE LOTION NATROBA SU (= bottle/fill) OVIDE LOTION (= 2 bottles/fill) SKLICE LOTION (= tube/fill) PA ULESFIA LOTION (= 4 bottles/fill) WOUND CARE PRODUCTS REGRANEX GEL (= 0gm/fill) 2 BIAFINE EULSION NC DIAGNOSTIC PRODUCTS DIAGNOSTIC DRUGS GLUCAGEN INJ CI 2 DIAGNOSTIC PRODUCTS, ISC. FREESTYLE LITE TEST STRIP CIOTC $0 DIAGNOSTIC TESTS ACCUCHEK AVIVA PLUS TEST STRIP CIOTC $0 ACCUCHEK SARTVIEW TEST STRIP CIOTC $0 ACCUCHEK TEST STRIP CIOTC $0 CLINISTIX TEST STRIP CIOTC $0 FREESTYLE INSULINX TEST STRIP CIOTC $0 FREESTYLE TEST STRIP CIOTC $0 KETODIASTIX TEST STRIP CIOTC $0 KETOSTIX CIOTC $0 PRECISION XTRA TEST STRIP CIOTC $0 TEST STRIP (all other test strips) OTC NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 27 of 79
Category/Class DrugName Special Code Tier DIETARY PRODUCTS/DIETARY ANAGEENT PRODUCTS DIETARY ANAGEENT PRODUCTS folbic tab (FOLTX equiv) VITAREA TAB DEPLIN CAP NC ELIGEN B2 TAB NC FALESSA TAB NC LETHYLFOLATE TAB NC ETANX CAP NC NUTRITIONAL SUPPLEENTS NUTRITIONAL SUPPLEENT POWDER PA DIGESTIVE AIDS DIGESTIVE ENZYES CREON CAP 2 PANCREAZE CAP (Step Therapy requires trial of CREON) ST PANCRELIPASE CAP (Step Therapy requires trial of CREON) ST PERTZYE CAP (Step Therapy requires trial of CREON) ST ULTRESA CAP (Step Therapy requires trial of CREON) ST ZENPEP CAP (Step Therapy requires trial of CREON) ST SUCRAID SOLN NC DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide ER cap (DIAOX SEQUEL equiv) CI acetazolamide tab CI ACETAZOLAIDE TAB 25G CI methazolamide tab (NEPTAZANE equiv) CI DIAOX SEQUEL CAP NEPTAZANE TAB KEVEYIS TAB NC DIURETIC COBINATIONS amiloride/hydrochlorothiazide tab (ODURETIC equiv) CI spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv) CI triamterene/hydrochlorothiazide cap (DYAZIDE equiv) CI triamterene/hydrochlorothiazide tab (AXZIDE equiv) CI TRIATERENE/HYDROCHLOROTHIAZIDE CAP 5025mg CI 2 ALDACTAZIDE TAB ALDACTAZIDE TAB 5050G DYAZIDE CAP AXZIDE TAB LOOP DIURETICS bumetanide tab (BUEX equiv) CI FUROSEIDE SOLN CI furosemide soln (LASIX equiv) CI furosemide tab (LASIX equiv) CI torsemide tab (DEADEX equiv) CI EDECRIN TAB CI 2 DEADEX TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 28 of 79
Category/Class DrugName Special Code Tier DIURETICS Cont. LASIX TAB POTASSIU ARING DIURETICS amiloride tab (IDAOR equiv) CI spironolactone tab (ALDACTONE equiv) CI DYRENIU CAP CI 2 ALDACTONE TAB IDAOR TAB THIAZIDES AND THIAZIDELIKE DIURETICS chlorothiazide tab (DIURIL equiv) CI CHLOROTHIAZIDE TAB 250G CI CHLORTHALIDONE TAB CI hydrochlorothiazide cap (ICROZIDE equiv) CI hydrochlorothiazide tab (HYDRODIURIL equiv) CI indapamide tab (LOZOL equiv) CI ETHYCLOTHIAZIDE TAB CI metolazone tab (ZAROXOLYN equiv) CI DIURIL SU CI 2 ICROZIDE CAP ZAROXOLYN TAB ENDOCRINE AND ETABOLIC AGENTS ISC. BONE DENSITY REGULATORS alendronate tab (FOSAAX equiv) ETIDRONATE DISODIU TAB 400G ibandronate tab 50mg (BONIVA equiv) (= tab/0 days; Step Therapy requires trial of alendronate) ST risedronate DR tab (ATELVIA equiv) (Step Therapy requires trial of alendronate) ST risedronate tab (ACTONEL equiv) ALENDRONATE TAB 40G 2 FORTICAL NASAL RAY 2 ACTONEL TAB ATELVIA TAB (Step Therapy requires trial of alendronate) ST BONIVA TAB 50G (= tab/0 days; Step Therapy requires trial of alendronate) ST FOSAAX+D TAB SKELID TAB pamidronate inj PROLIA INJ RECLAST INJ zoledronic acid inj (RECLAST equiv) ZOETA INJ NATPARA INJ (Only available through Walgreens 8884746) LDPA CALCIU REGULATORS ISC. calcitonin nasal spray (IACALCIN equiv) etidronate disodium tab 200mg (DIDRONEL equiv) ALENDRONATE SOLN FOSAAX TAB IACALCIN NASAL RAY FORTEO INJ IACALCIN INJ Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 29 of 79
Category/Class DrugName Special Code Tier FERTILITY REGULATORS ENDOCRINE AND ETABOLIC AGENTS ISC. Cont. pregnyl inj (PROFASI equiv) INF GROWTH HORONE RECEPTOR ANTAGONISTS SOAVERT INJ (Only available through Walgreens 8884746) LDPA GROWTH HORONE RELEASING HORONES (GHRH) EGRIFTA INJ NC GROWTH HORONES GENOTROPIN/HUATROPE/ZOACTON INJ NC NUTROPIN AQ/ONITROPE INJ NC SAIZEN/SEROSTI INJ NC NORDITROPIN INJ PA HORONE RECEPTOR ODULATORS raloxifene tab (EVISTA equiv) (Covered at $0 for women 5 years or older; All other members covered at generic copay) $0 EVISTA TAB OHENA TAB NC INSULINLIKE GROWTH FACTORS (SOATOEDINS) INCRELEX INJ LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS SYNAREL NASAL SOLN 2 LUPANETA PACK NC LUPRON DEPOT PED INJ INF LUPRON DEPOTPED INJ INF ETABOLIC ODIFIERS calcitriol cap (ROCALTROL equiv) calcitriol soln (ROCALTROL equiv) doxercalciferol cap (HECTOROL equiv) levocarnitine soln (CARNITOR equiv) levocarnitine tab (CARNITOR equiv) paricalcitol cap (ZEPLAR equiv) sodium phenylbutyrate powder (BUPHENYL equiv) BUPHENYL TAB 2 SENSIPAR TAB 2 BUPHENYL POWDER CARNITOR SOLN CARNITOR TAB HECTOROL CAP ORFADIN CAP (Only available through Dohmen LSS 8442465226) LDPA ROCALTROL CAP ROCALTROL SOLN ZEPLAR CAP ALDURAZYE INJ ELAPRASE INJ FABRAZYE INJ YOZYE INJ NAGLAZYE INJ YALEPT INJ NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 0 of 79
Category/Class DrugName Special Code Tier ENDOCRINE AND ETABOLIC AGENTS ISC. Cont. RAVICTI LIQUID NC STRENSIQ INJ NC XURIDEN POWDER NC calcitriol inj (CALCIJEX equiv) CARBAGLU TAB (Only available through Accredo 88877776) LDPA KUVAN POWDER PACK PA KUVAN TAB PA POSTERIOR PITUITARY HORONES desmopressin acetate inj (DDAVP equiv) desmopressin acetate nasal spray (DDAVP equiv) desmopressin acetate tab (DDAVP equiv) desmopressin nasal soln (DDAVP equiv) STIATE NASAL SOLN 2 DDAVP INJ DDAVP NASAL SOLN DDAVP NASAL RAY DDAVP TAB PROLACTIN INHIBITORS cabergoline tab (DOSTINEX equiv) SOATOSTATIC AGENTS SANDOSTATIN LAR INJ KIT NC octreotide inj (SANDOSTATIN equiv) SANDOSTATIN INJ SIGNIFOR INJ (= 2 vials/day; Only available through Accredo 88877776) LDPA SOATULINE INJ PA VASOPRESSIN RECEPTOR ANTAGONISTS SASCA TAB ESTROGENS ESTROGEN COBINATIONS estradiol/norethindrone tab (ACTIVELLA equiv) jinteli tab (FEHRT equiv) PREPHASE/PREPRO TAB 2 ACTIVELLA TAB ANGELIQ TAB CLIARA PRO PATCH COBIPATCH FEHRT TAB PREFEST TAB DUAVEE TAB NC esterified estrogens/methyltestosterone tab (ESTRATEST equiv) NC ESTRATEST TAB NC ESTROGENS estradiol patch (CLIARA equiv) estradiol patch (VIVELLEDOT equiv) estradiol tab (ESTRACE equiv) ESTROPIPATE TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Category/Class DrugName Special Code Tier ESTROGENS Cont. estropipate tab (OGEN equiv) PREARIN TAB 2 ALORA PATCH CENESTIN TAB CLIARA PATCH DIVIGEL/ELESTRIN GEL ENJUVIA TAB ESTRACE TAB ESTRASORB EULSION EVAIST RAY ENEST TAB ENOSTAR PATCH VIVELLEDOT PATCH FLUOROQUINOLONES FLUOROQUINOLONES ciprofloxacin ER tab (CIPRO XR equiv) ciprofloxacin susp (CIPRO equiv) ciprofloxacin tab (CIPRO equiv) levofloxacin soln (LEVAQUIN equiv) levofloxacin tab (LEVAQUIN equiv) moxifloxacin tab (AVELOX equiv) ofloxacin tab (FLOXIN equiv) OFLOXACIN TAB 400G 2 AVELOX TAB CIPRO SU CIPRO TAB CIPRO XR TAB CIPROFLOXACIN 00G TAB FACTIVE TAB LEVAQUIN SOLN LEVAQUIN TAB NOROXIN TAB GASTROINTESTINAL AGENTS ISC. BILE ACID SYNTHESIS DISORDER AGENTS CHOLBA CAP (Only available through Dohmen LSS 8442465226) LDPA GALLSTONE SOLUBILIZING AGENTS ursodiol cap (ACTIGALL equiv) ursodiol tab (URSO (FORTE) equiv) ACTIGALL CAP URSO FORTE TAB GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn conc (GASTROCRO equiv) GASTROCRO CONC 2 GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AITIZA CAP PA GASTROINTESTINAL STIULANTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 2 of 79
Category/Class DrugName Special Code Tier GASTROINTESTINAL AGENTS ISC. Cont. metoclopramide soln (REGLAN equiv) metoclopramide tab (REGLAN equiv) REGLAN TAB metoclopramide ODT (ETOZOLV equiv) NC ETOZOLV ODT NC INFLAATORY BOWEL AGENTS balsalazide cap (COLAZAL equiv) mesalamine enema (ROWASA equiv) sulfasalazine EC tab (AZULFIDINE equiv) sulfasalazine tab (AZULFIDINE equiv) APRISO CAP 2 ASACOL (HD)/LIALDA TAB 2 CANASA SUPP 2 DELZICOL CAP 2 AZULFIDINE ENTABS AZULFIDINE TAB COLAZAL CAP DIPENTU CAP PENTASA CAP (Step Therapy requires trial of ASACOL (HD), DELZICOL, or LIALDA) ST SFROWASA ENEA REICADE INJ ROWASA KIT NC CIZIA INJ (= 2 inj/28 days) PA INTESTINAL ACIDIFIERS lactulose soln IRRITABLE BOWEL SYNDROE (IBS) AGENTS alosetron tab (LOTRONEX equiv) LINZESS CAP (= cap/day) PA LOTRONEX TAB VIBERZI TAB NC PERIPHERAL OPIOID RECEPTOR ANTAGONISTS OVANTIK TAB NC RELISTOR INJ PA RELISTOR INJ KIT PA PHOHATE BINDER AGENTS calcium acetate cap (PHOSLO equiv) calcium acetate tab (ELIPHOS equiv) FOSRENOL CHEW TAB 2 FOSRENOL POWDER PACK 2 PHOSLYRA SOLN 2 RENVELA PACKET 2 RENVELA TAB 2 SEVELAER CARBONATE TAB 2 AURYXIA TAB ELIPHOS TAB PHOSLO CAP RENAGEL TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page of 79
Category/Class DrugName Special Code Tier GASTROINTESTINAL AGENTS ISC. Cont. VELPHORO CHEW TAB SHORT BOWEL SYNDROE (SBS) AGENTS GATTEX KIT NC GENITOURINARY AGENTS ISCELLANEOUS ALKALINIZERS CYTRA SYRUP ORACIT SOLN potassium citrate CR tab (UROCITK TAB equiv) potassium citrate/citric acid powder pack (POLYCITRA equiv) potassium citrate/citric acid soln (POLYCITRAK equiv) sodium citrate/citric acid soln (BICITRA equiv) tricitrates soln (POLYCITRALC equiv) SHOHLS SOLN 2 POLYCITRA CRYSTAL PACK POLYCITRALC SOLN UROCITK TAB CYSTINOSIS AGENTS CYSTAGON CAP (Only available through Pharmacare 800287828) LDPA GENITOURINARY IRRIGANTS sodium chloride 0.9% irr soln INTERSTITIAL CYSTITIS AGENTS ELIRON CAP 2 PROSTATIC HYPERTROPHY AGENTS alfuzosin SR tab (UROXATRAL equiv) dutasteride cap (AVODART equiv) dutasteride/tamsulosin cap (JALYN equiv) finasteride tab (PROSCAR equiv) tamsulosin cap (FLOAX equiv) RAPAFLO CAP (Restricted to Urology Specialist) RS 2 UROXATRAL TAB 2 AVODART CAP CARDURA XL TAB FLOAX CAP JALYN CAP PROSCAR TAB URINARY ANALGESICS phenazopyridine tab (PYRIDIU equiv) PYRIDIU TAB URINARY STONE AGENTS LITHOSTAT TAB THIOLA TAB NC GOUT AGENTS GOUT AGENT COBINATIONS colchicine/probenecid tab (COLBENEID equiv) GOUT AGENTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Category/Class DrugName Special Code Tier GOUT AGENTS Cont. allopurinol tab (ZYLOPRI equiv) COLCHICINE TAB (COLCRYS equiv) 2 ULORIC TAB (Step Therapy requires trial of allopurinol) ST 2 ZYLOPRI TAB COLCHICINE/ITIGARE CAP NC URICOSURICS probenecid tab (BENEID equiv) HEATOLOGICAL AGENTS ISC. HEATORHEOLOGIC AGENTS pentoxifylline ER tab (TRENTAL equiv) TRENTAL TAB PLATELET AGGREGATION INHIBITORS anagrelide cap (AGRYLIN equiv) cilostazol tab (PLETAL equiv) clopidogrel tab 75mg (PLAVIX equiv) dipyridamole tab (PERSANTINE equiv) TICLOPIDINE TAB ticlopidine tab (TICLID equiv) AGGRENOX/AIRINDIPYRIDAOLE CAP 2 EFFIENT TAB 2 AGRYLIN CAP BRILINTA TAB (Restricted to Cardiology Specialist) RS PERSANTINE TAB PLAVIX TAB 75G PLETAL TAB ZONTIVITY TAB (Restricted to Cardiology Specialist) RS HEATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE CEREZYE INJ ELELYSO INJ VPRIV INJ CERDELGA CAP NC ZAVESCA CAP (Only available through Accredo 88877776) LDPA AGENTS FOR SICKLE CELL ANEIA DROXIA CAP 2 COBALAINS cyanocobalamin inj NASCOBAL NASAL RAY CALOIST NASAL RAY NC FOLIC ACID/FOLATES folic acid tab mg (Covered at $0 for females only; All other members covered at generic copay) $0 folic acid tab 400mcg (Covered for females only) OTC $0 folic acid tab 800mcg (Covered for females only) OTC $0 HEATOPOIETIC GROWTH FACTORS IRCERA INJ NC NEUPOGEN INJ NC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Category/Class DrugName Special Code Tier HEATOPOIETIC AGENTS Cont. ARANE INJ (Step Therapy requires trial of PROCRIT) ST EPOGEN INJ GRANIX INJ LEUKINE INJ NEULASTA INJ NEUEGA INJ PROCRIT INJ PROACTA TAB PA ZARXIO INJ HEATOPOIETIC IXTURES ferrex 50 forte cap ferrex 50 forte cap (NIFEREX 50 FORTE equiv) folbee tab IRON POLYSACCH/THREONIC ACID/B2/FA CAP multigen folic tab (CHROAGEN FA equiv) multigen plus tab (CHROAGEN FORTE equiv) multigen tab (CHROAGEN equiv) multivitamin tab tricon cap (TRINSICON equiv) NEPHRON FA TAB 2 CHROAGEN FA TAB FERREX 28 TAB ULTIVITAIN TAB BIFERARX TAB NC BSERENE PAD NC PUREFOLIX TAB NC IRON ferrous sulfate elixir (Covered for members year or younger) OTC $0 FERROUS SULFATE LIQUID (Covered for members year or younger) OTC $0 ferrous sulfate soln (Covered for members year or younger) OTC $0 FERROUS SULFATE SYRUP (Covered for members year or younger) OTC $0 IRON SU (Covered for members year or younger) OTC $0 STE CELL OBILIZERS OZOBIL INJ HEOSTATICS HEOSTATICS SYSTEIC aminocaproic acid syrup (AICAR equiv) aminocaproic acid tab (AICAR equiv) tranexamic acid tab (LYSTEDA equiv) AICAR SYRUP AICAR TAB AINOCAPROIC ACID TAB LYSTEDA TAB CYKLOKAPRON INJ tranexamic acid inj (CYKLOKAPRON equiv) AICAR SOLN NC HYPNOTICS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 6 of 79
Category/Class DrugName Special Code Tier BARBITURATE HYPNOTICS HYPNOTICS Cont. phenobarbital elixir phenobarbital tab SECONAL CAP 2 BUTISOL ELIXIR BUTISOL TAB HYPNOTICS TRICYCLIC AGENTS SILENOR TAB NC NONBARBITURATE HYPNOTICS estazolam tab (PROSO equiv) eszopiclone tab (LUNESTA equiv) (= tab/day) FLURAZEPA CAP temazepam cap 5mg (RESTORIL equiv) temazepam cap 22.5mg (RESTORIL equiv) temazepam cap 0mg (RESTORIL equiv) temazepam cap 7.5mg (RESTORIL equiv) triazolam tab (HALCION equiv) zaleplon cap (SONATA equiv) zolpidem tab 0mg (ABIEN equiv) (ale = tab/day; Female = 0.5 tab/day) zolpidem tab 5mg (ABIEN equiv) (= tab/day) ABIEN TAB 0G (ale = tab/day; Female = 0.5 tab/day) ABIEN TAB 5G (= tab/day) HALCION TAB LUNESTA TAB (= tab/day) PROSO TAB RESTORIL CAP 5G RESTORIL CAP 22.5G RESTORIL CAP 0G RESTORIL CAP 7.5G SONOTE CAP SONATA CAP DORAL TAB NC EDLUAR SL TAB NC zolpidem ER tab (ABIEN CR equiv) NC ZOLPIIST RAY NC OREXIN RECEPTOR ANTAGONISTS BELSORA TAB NC SELECTIVE ELATONIN RECEPTOR AGONISTS ROZERE TAB (= tab/day) HETLIOZ CAP NC HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS NONBARBITURATE HYPNOTICS TRIAZOLA TAB zolpidem tartrate SL tab (INTEREZZO equiv) NC LAXATIVES LAXATIVE COBINATIONS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 7 of 79
Category/Class DrugName Special Code Tier LAXATIVES Cont. peg 50/electrolytes soln (COLYTE equiv) (Covered at $0 for members 5075 yearslimited to 2 fills/calendar year; All other members covered at generic copay) trilyte soln (NULYTELY equiv) (Covered at $0 for members 5075 yearslimited to 2 fills/calendar year; All other members covered at generic copay) $0 $0 OVIPREP SOLN (= bottle/fill) 2 SUPREP SOLN (Step therapy requires trial of OVIPREP) ST gavilyteh kit NC HALFLYTELY BOWEL PREP KIT NC PREPOPIK PAK NC SUCLEAR KIT NC LAXATIVES ISCELLANEOUS lactulose soln KRISTALOSE PACKET polyethylene glycol 50 powder (IRALAX equiv) NC SALINE LAXATIVES OSOPREP TAB VISICOL TAB ACROLIDES AZITHROYCIN azithromycin susp (ZITHROAX equiv) azithromycin tab (ZITHROAX equiv) ZITHROAX POWDER PACK ZITHROAX SU ZITHROAX TAB ZAX SU CLARITHROYCIN clarithromycin ER tab (BIAXIN XL equiv) clarithromycin susp (BIAXIN equiv) clarithromycin tab (BIAXIN equiv) BIAXIN SU BIAXIN TAB BIAXIN XL TAB ERYTHROYCINS ERYTAB ERYTHROYCIN CAP erythromycin DR cap (ERYC equiv) erythromycin ethylsuccinate tab (E.E.S. equiv) erythromycin stearate tab ERYPED SU 2 ERYTHROYCIN ETHYLSUCCINATE TAB 2 ERYTHROYCIN TAB (all forms except PCE) PCE TAB FIDAXOICIN DIFICID TAB (= 20 tabs/fill; Step Therapy requires trial of vancomycin cap) ST 2 EDICAL DEVICES CONTRACEPTIVES CERVICAL CAP $0 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 8 of 79
Category/Class DrugName Special Code Tier EDICAL DEVICES Cont. DIAPHRAG $0 FEALE CONDOS OTC $0 EDICAL DEVICES AND SUPPLIES DIABETIC SUPPLIES ACCUCHEK AVIVA PLUS ETER CIOTC $0 ACCUCHEK NANO ETER CIOTC $0 ACCUCHEK NANO SARTVIEW ETER CIOTC $0 FREESTYLE FREEDO LITE ETER CIOTC $0 FREESTYLE INSULINX ETER CIOTC $0 FREESTYLE LITE ETER CIOTC $0 PRECISION XTRA ETER CIOTC $0 CALIBRATION LIQUID CIOTC LANCET DEVICE CIOTC LANCET KIT CIOTC LANCETS CIOTC VGO INJ KIT (= kit/day) CI 2 DIABETIC ETER (all other diabetic meters) OTC NC ISC. DEVICES ALCOHOL SWABS CIOTC $0 PARENTERAL THERAPY SUPPLIES BD INSULIN SYRINGE CIOTC $0 BD PEN NEEDLE CIOTC $0 FREESTYLE INSULIN SYRINGE CIOTC $0 NOVOFINE PEN NEEDLE CIOTC $0 NOVOTWIST PEN NEEDLE CIOTC $0 PRECISION INSULIN SYRINGE CIOTC $0 INSULIN SYRINGE OTC PEN NEEDLE OTC REIRATORY THERAPY SUPPLIES PEAK FLOW ETER CIOTC AEROCHABER (= spacer/year) CIOTC 2 AEROCHABER SUPPLIES CI 2 IGRAINE PRODUCTS IGRAINE COBINATIONS IGERGOT SUPP 2 CAFERGOT TAB acetaminophen/isometheptene/dichloral cap (IDRIN equiv) NC isometheptene/caffeine/acetaminophen tab (PRODRIN equiv) NC IDRIN CAP NC PRODRIN TAB NC TREXIET TAB NC IGRAINE PRODUCTS dihydroergotamine mesylate inj (D.H.E. equiv) D.H.E. INJ ERGOAR SL TAB IGRANAL/ DIHYDROERGOTAINE RAY (= 8 sprays/fill, 2 fills/0 days) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 9 of 79
Category/Class DrugName Special Code Tier IGRAINE PRODUCTS NSAIDS IGRAINE PRODUCTS Cont. CABIA POWDER PACKET NC SEROTONIN AGONISTS almotriptan tab (AXERT equiv) (= 9 tabs/fill, 2 fills/0 days) frovatriptan tab (FROVA equiv) (= 9 tabs/fill, 2 fills/0 days) naratriptan tab (AERGE equiv) (= 9 tabs/fill, 2 fills/0 days) rizatriptan ODT (AXALT equiv) (= 2 tabs/fill, fills/60 days) rizatriptan tab (AXALT equiv) (= 2 tabs/fill, fills/60 days) sumatriptan inj (IITREX equiv) (= 4 inj/fill, 2 fills/0 days) SUATRIPTAN INJ 6G/0.5L (= 4 inj/fill, 2 fills/0 days) sumatriptan tab (IITREX equiv) (= 9 tabs/fill, 2 fills/0 days) sumatriptan vial inj (IITREX equiv) (= 5 inj/fill, 2 fills/0 days) zolmitriptan ODT (ZOIG equiv) (= 9 tabs/fill, 2 fills/0 days) zolmitriptan tab (ZOIG equiv) (= 9 tabs/fill, 2 fills/0 days) SUATRIPTAN/ IITREX NASAL RAY (= 6 sprays/fill, 2 fills/0 days) 2 ALSUA INJ (= 4 inj/fill, 2 fills/0 days) AERGE TAB (= 9 tabs/fill, 2 fills/0 days) AXERT TAB (= 9 tabs/fill, 2 fills/0 days) FROVA TAB (= 9 tabs/fill, 2 fills/0 days) IITREX INJ (= 4 inj/fill, 2 fills/0 days) IITREX TAB (= 9 tabs/fill, 2 fills/0 days) IITREX VIAL INJ (= 5 inj/fill, 2 fills/0 days) AXALT LT TAB (= 2 tabs/fill, fills/60 days) AXALT TAB (= 2 tabs/fill, fills/60 days) RELPAX TAB (= 9 tabs/fill, 2 fills/0 days) SUAVEL DOSEPRO INJ (= 6 inj/fill, 2 fills/0 days) ZOIG NASAL RAY (= 6 sprays/fill, 2 fills/0 days) ZOIG TAB (= 9 tabs/fill, 2 fills/0 days) ZOIG ZT (= 9 tabs/fill, 2 fills/0 days) ONZETRA XSAIL NC ZECUITY PAD NC ZEBRACE SYTOUCH INJ NC INERALS & ELECTROLYTES CHLORIDE AONIU CHLORIDE INJ ELECTROLYTE IXTURES ISOLYTE INJ PLASALYTE INJ FLUORIDE FLUORABON SOLN (Covered at $0 for members 5 years or younger; All other members covered at preferred brand $0 copay) LURIDE SOLN (Covered at $0 for members 5 years or younger; All other members covered at nonpreferred brand copay) $0 LURIDE TAB (Covered at $0 for members 5 years or younger; All other members covered at nonpreferred brand copay) $0 SODIU FLUORIDE LOZENGE (Covered at $0 for members 5 years or younger; All other members covered at generic $0 copay) sodium fluoride soln (LURIDE equiv) (Covered at $0 for members 5 years or younger; All other members covered at generic $0 copay) SODIU FLUORIDE TAB (Covered at $0 for members 5 years or younger; All other members covered at generic copay) $0 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 40 of 79
Category/Class DrugName Special Code Tier INERALS & ELECTROLYTES Cont. sodium fluoride tab (LURIDE equiv) (Covered at $0 for members 5 years or younger; All other members covered at generic copay) $0 FLUORADAY CHEW TAB IODINE PRODUCTS SSKI SOLN 2 AGNESIU magnesium sulfate inj PHOHATE phospha 250 neutral tab (KPHOS NEUTRAL equiv) KPHOS TAB 2 KPHOS NEUTRAL TAB POTASSIU potassium bicarbonate effer tab (KLYTE equiv) potassium chloride effer tab (KLYTE/CL equiv) potassium chloride ER cap (ICROK equiv) POTASSIU CHLORIDE ER TAB potassium chloride ER tab (KLORCON equiv) potassium chloride micro tab (KDUR equiv) potassium chloride powder packet (KLORCON equiv) KLORCON 5 TAB 2 KLORCON POWDER PACKET KLORCON POWDER PACKET 25EQ KLORCON TAB ICROK CAP potassium chloride inj SODIU sodium chloride inj ZINC zinc sulfate cap GALZIN CAP 2 OUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL lidocaine viscous soln LIDOCAINE ORAL SOLN 4% 2 FIRST OUTHWASH BL LTA 60 KIT ANTIALLERGY AGENTS OUTH/THROAT APHTHASOL PASTE 2 ANTIINFECTIVES THROAT clotrimazole troches (YCELEX TROCHES equiv) nystatin susp FIRST DUKES OUTHWASH FIRST ARYS OUTHWASH YCELEX TROCHES ORAVIG TAB ANTISEPTICS OUTH/THROAT Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Category/Class DrugName Special Code Tier OUTH/THROAT/DENTAL AGENTS Cont. chlorhexidine gluconate soln (PERIDEX equiv) PERIDEX SOLN DENTAL PRODUCTS PREVIDENT CREA (Covered at $0 for members 5 years or younger; All other members covered at preferred brand copay) sodium fluoride cream (PREVIDENT equiv) (Covered at $0 for members 5 years or younger; All other members covered at generic copay) $0 $0 sodium fluoride gel (PREVIDENT equiv) sodium fluoride paste (PREVIDENT equiv) sodium fluoride rinse (PREVIDENT equiv) sodium fluoride/potassium nitrate paste (PREVIDENT equiv) PREVIDENT GEL 2 PREVIDENT PASTE 2 PREVIDENT RINSE 2 STEROIDS OUTH/THROAT triamcinolone in orabase paste (KENALOG/ORABASE equiv) THROAT PRODUCTS ISC. cevimeline cap (EVOXAC equiv) pilocarpine tab (SALAGEN equiv) EVOXAC CAP SALAGEN TAB GELCLAIR GEL NC PROTHELIAL PASTE NC ULTIVITAINS BCOPLEX W/ FOLIC ACID DIALYVITE TAB dialyvite tab (NEPHROVITE equiv) DIALYVITE/IRON TAB DIALYVITE/ZINC TAB folbee plus CZ tab (DIATX ZN equiv) FOLBEE PLUS TAB renaphro cap (NEPHROCAP equiv) DIATZ ZN TAB NEPHROCAP NEPHROVITE TAB ULTIPLE VITAINS W/ INERALS multivitamin w/ minerals tab (STROVITE equiv) FORTAVIT CAP STROVITE TAB ULTIVITAINS XYZBAC TAB NC PED ULTI VITAINS W/FL & FE pediatric multiple vitamins/fluoride/iron soln trivit/iron/fluoride drop ESCAVITE CHEW TAB PED V W/ FLUORIDE pediatric multiple vitamins/fluoride chew tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 42 of 79
Category/Class DrugName Special Code Tier ULTIVITAINS Cont. pediatric multiple vitamins/fluoride soln QUFLORA PEDIATRIC CHEW TAB QUFLORA PEDIATRIC DROP PEDIATRIC ULTIPLE VITAINS & INERALS W/ FLUORIDE FLORIVA CHEW TAB NC PRENATAL VITAINS PRENATAL VITAINS (NONPREFERRED) USCULOSKELETAL THERAPY AGENTS CENTRAL USCLE RELAXANTS baclofen tab carisoprodol tab (SOA equiv) chlorzoxazone tab (PARAFON FORTE equiv) cyclobenzaprine tab 0mg (FLEXERIL equiv) cyclobenzaprine tab 5mg (FLEXERIL equiv) cyclobenzaprine tab 7.5mg (FEXID equiv) metaxalone tab (SKELAXIN equiv) methocarbamol tab (ROBAXIN equiv) orphenadrine citrate ER tab (NORFLEX equiv) tizanidine cap (ZANAFLEX equiv) tizanidine tab (ZANAFLEX equiv) FEXID TAB FLEXERIL TAB PARAFON FORTE TAB ROBAXIN TAB SKELAXIN TAB SOA TAB ZANAFLEX CAP ZANAFLEX TAB carisoprodol tab 250mg (SOA equiv) NC CYCLOBENZAPRINE COPOUND KIT NC LORZONE TAB NC DIRECT USCLE RELAXANTS dantrolene cap (DANTRIU equiv) DANTRIU CAP USCLE RELAXANT COBINATIONS carisoprodol/aspirin tab (SOA COPOUND equiv) carisoprodol/aspirin/codeine tab (SOA COPOUND/CODEINE equiv) orphenadrine/aspirin/caffeine tab (NORGESIC FORTE equiv) ORPHENADRINE/AIRIN/CAFFEINE TAB LORVATUS PHARAPAK KIT NC TIZANIDINE COFORT KIT NC NASAL AGENTS SYSTEIC AND TOPICAL NASAL AGENT COBINATIONS DYISTA NASAL RAY PA AZENASE PAK NC NASAL AGENTS ISC. Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 4 of 79
Category/Class DrugName Special Code Tier NASAL AGENTS SYSTEIC AND TOPICAL Cont. TICANASE PAK NC NASAL ANTIALLERGY azelastine nasal spray (ASTELIN/ASTEPRO equiv) olopatadine nasal spray (PATANASE equiv) ASTELIN/ASTEPRO NASAL RAY PATANASE NASAL RAY NASAL ANTICHOLINERGICS ipratropium nasal spray (ATROVENT equiv) ATROVENT NASAL RAY NASAL ANTIINFECTIVES BACTROBAN NASAL OINT NASAL STEROIDS budesonide nasal spray (RHINOCORT AQUA equiv) (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, ST flunisolide, VERAYST, or NASONEX) flunisolide nasal spray (NASAREL equiv) (= 2 bottles/fill) fluticasone nasal spray (FLONASE equiv) (= 2 bottles/fill) NASACORT OTC NASAL RAY (= 2 bottles/fill) OTC NASONEX NASAL RAY (= 2 bottles/fill) triamcinolone nasal spray (NASACORT equiv) (= 2 bottles/fill) triamcinolone OTC nasal spray (NASACORT equiv) (= 2 bottles/fill) OTC VERAYST NASAL RAY (= 2 bottles/fill) 2 BECONASE AQ NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or ST NASONEX) FLONASE NASAL RAY (= 2 bottles/fill) NASACORT AQ NASAL RAY (= 2 bottles/fill) ONARIS NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or ST NASONEX) QNASL NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or ST NASONEX) RHINOCORT AQUA NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, ST VERAYST, or NASONEX) ZETONNA NASAL RAY (= 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX) ST mometasone nasal spray (NASONEX equiv) NC SYPATHOIETIC DECONGESTANTS TYZINE NASAL SOLN NEUROUSCULAR AGENTS ALS AGENTS riluzole tab (RILUTEK equiv) NEUROUSCULAR BLOCKING AGENT NEUROTOXINS BOTOX INJ OPHTHALIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS LACRISERT OPHTH INSERT 2 BETABLOCKERS OPHTHALIC betaxolol ophth soln (BETOPTICS equiv) carteolol ophth soln (OCUPRESS equiv) dorzolamide/ timolol ophth soln (COSOPT equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 44 of 79
Category/Class DrugName Special Code Tier OPHTHALIC AGENTS Cont. levobunolol ophth soln (BETAGAN equiv) timolol maleate ophth gel (TIOPTICXE equiv) timolol maleate ophth soln (TIOPTIC equiv) BETIOL OPHTH SOLN 2 BETOPTICS OPHTH SOLN 2 COBIGAN OPHTH SOLN 2 COSOPT PF OPHTH SOLN 2 ISTALOL OPHTH SOLN 2 ETIPRANOLOL OPHTH SOLN 2 BETAGAN OPHTH SOLN COSOPT OPHTH SOLN TIOPTIC OCUDOSE OPHTH SOLN TIOPTIC OPHTH SOLN TIOPTICXE OPHTH GEL CYCLOPLEGIC YDRIATICS atropine ophth oint atropine ophth soln (ISOPTO ATROPINE equiv) cyclopentolate ophth soln (CYCLOGYL equiv) homatropine ophth soln (ISOPTO HOATROPINE equiv) tropicamide ophth soln (YDRIACYL equiv) CYCLOYDRIL OPHTH SOLN 2 ISOPTO HOATROPINE OPHTH SOLN 2% 2 ISOPTO HOATROPINE OPHTH SOLN 5% 2 ISOPTO HYOSCINE OPHTH SOLN 2 CYCLOGYL OPHTH SOLN ISOPTO ATROPINE OPHTH SOLN YDRIACYL OPHTH SOLN IOTICS pilocarpine ophth soln (ISOPTO CARPINE equiv) ISOPTO CARBACHOL OPHTH SOLN 2 PHOHOLINE OPHTH SOLN 2 ISOPTO CARPINE OPHTH SOLN PILOPINE HS OPHTH GEL OPHTHALIC ADRENERGIC AGENTS apraclonidine ophth soln (IOPIDINE equiv) brimonidine ophth soln (ALPHAGAN P equiv) ALPHAGAN P OPHTH SOLN 2 ALPHAGAN P OPHTH SOLN 0.% 2 IOPIDINE OPHTH SOLN % 2 SIBRINZA OPHTH SU 2 IOPIDINE OPHTH SOLN OPHTHALIC ANTIINFECTIVES bacitracin/ neomycin/ polymyxin b ophth oint (NEOORIN equiv) bacitracin/ polymyxin b ophth oint (POLYORIN equiv) ciprofloxacin ophth soln (CILOXAN equiv) erythromycin ophth oint Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 45 of 79
Category/Class DrugName Special Code Tier OPHTHALIC AGENTS Cont. gatifloxacin ophth soln (ZYAXID equiv) (Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or ST VIGAOX/OXEZA) gentamicin ophth oint (GARAYCIN equiv) gentamicin ophth soln (GARAYCIN equiv) levofloxacin ophth soln (QUIXIN equiv) neomycin/ polymyxin b/ gramicidin ophth soln (NEOORIN equiv) ofloxacin ophth soln (OCUFLOX equiv) polymyxin b/ trimethoprim ophth soln (POLYTRI equiv) sulfacetamide sodium ophth soln (BLEPH0 equiv) tobramycin ophth soln (TOBREX equiv) trifluridine ophth soln (VIROPTIC equiv) AZASITE SOLN 2 BACITRACIN OPHTH OINT 2 OXEZA OPHTH SOLN/ VIGAOX OPHTH SOLN 2 ZIRGAN OPHTH GEL 2 BESIVANCE OPHTH SU (Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA) ST BLEPH0 OPHTH SOLN CILOXAN OPHTH OINT CILOXAN OPHTH SOLN NEOORIN OPHTH SOLN OCUFLOX OPHTH SOLN POLYTRI OPHTH SOLN TOBREX OPHTH OINT TOBREX OPHTH SOLN VIROPTIC OPHTH SOLN ZYAXID OPHTH SOLN (Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA) ST NATACYN OPHTH SU NC OPHTHALIC DECONGESTANTS naphazoline ophth soln phenylephrine ophth soln (YDFRIN equiv) YDFRIN OPHTH SOLN OPHTHALIC IUNOODULATORS RESTASIS OPHTH EULSION (Restricted to Ophthalmology or Optometry Specialist) RS 2 OPHTHALIC LOCAL ANESTHETICS proparacaine ophth soln (ALCAINE equiv) ALCAINE OPHTH SOLN OPHTHALIC STEROIDS bacitracin/ polymyxin/ neomycin/ hydrocortisone ophth oint (CORTIORIN equiv) dexamethasone ophth soln fluorometholone ophth soln (FL LIQUIFIL equiv) neomycin/ polymyxin/ dexamethasone ophth oint (AXITROL equiv) neomycin/ polymyxin/ dexamethasone ophth soln (AXITROL equiv) neomycin/ polymyxin/ hydrocortisone ophth soln (CORTIORIN equiv) prednisolone ophth soln (PRED FORTE equiv) sulfacetamide sodium/ prednisolone ophth soln (VASOCIDIN equiv) tobramycin/ dexamethasone ophth soln (TOBRADEX equiv) ALREX OPHTH SU/ LOTEAX OPHTH SU 2 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 46 of 79
Category/Class DrugName Special Code Tier OPHTHALIC AGENTS Cont. BLEPHAIDE OPHTH SOLN 2 DUREZOL OPHTH EULSION 2 LOTEAX OPHTH GEL 2 LOTEAX OPHTH OINT 2 AXIDEX OPHTH SOLN 2 PRED ILD OPHTH SOLN 2 PREDG OPHTH SOLN 2 PREDNISOLONE SODIU PHOHATE OPHTH SOLN 2 TOBRADEX OPHTH OINT 2 VEXOL OPHTH SU 2 ZYLET OPHTH SU (= 5ml/fill (0ml bottle is Not Covered)) 2 BLEPHAIDE S.O.P. OPHTH OINT CORTIORIN OPHTH SOLN FLAREX OPHTH SU FL FORTE OPHTH SU FL LIQUIFLI OPHTH SU FL S.O.P. OPHTH OINT AXITROL OPHTH OINT AXITROL OPHTH SU PRED FORTE OPHTH SU TOBRADEX OPHTH SOLN TOBRADEX ST OPHTH SU OPHTHALICS ISC. azelastine ophth soln (OPTIVAR equiv) bromfenac ophth soln (BRODAY equiv) BROFENAC OPHTH SOLN 0.09% (TWICE DAILY) cromolyn ophth soln (CROLO equiv) diclofenac sodium ophth soln (VOLTAREN equiv) dorzolamide ophth soln (TRUSOPT equiv) epinastine opthth soln (ELESTAT equiv) flurbiprofen ophth soln (OCUFEN equiv) ketorolac ophth soln (ACULAR (LS) equiv) ketotifen ophth soln (ZADITOR equiv) (OTC covered only) OTC olopatadine ophth soln (PATANOL equiv) ALAAST OPHTH SOLN 2 ALOCRIL OPHTH SOLN 2 ALOIDE OPHTH SOLN 2 AZOPT OPHTH SU 2 ILEVRO OPHTH SU 2 NEVANAC OPHTH SU 2 PATADAY OPHTH SOLN (= 2.5ml/0 days; Step Therapy requires trial of olopatadine ophth soln) ST 2 PROLENSA OPHTH SOLN 2 ACULAR (LS) OPHTH SOLN ACUVAIL OPHTH SOLN BEPREVE OPHTH SOLN CROLO OPHTH SOLN ELESTAT OPHTH SOLN EADINE OPHTH SOLN Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 47 of 79
Category/Class DrugName Special Code Tier OPHTHALIC AGENTS Cont. LASTACAFT OPHTH SOLN (= ml/0 days) OCUFEN OPHTH SOLN OPTIVAR OPHTH SOLN PATANOL OPHTH SOLN TRUSOPT OPHTH SOLN VOLTAREN OPTH SOLN PAZEO OPHTH SOLN 0.7% NC CYSTARAN OPHTH SOLN (= 4 bottles/0 days) PA PROSTAGLANDINS OPHTHALIC latanoprost ophth soln (XALATAN equiv) (= 2.5ml/0 days) LUIGAN OPHTH SOLN (= 2.5ml/0 days) 2 TRAVATAN Z OPHTH SOLN (= 5ml/0 days) 2 XALATAN OPHTH SOLN (= 2.5ml/0 days) ZIOPTAN OPHTH SOLN (= bottle/day; Step Therapy requires trial of latanaprost) ST OTIC AGENTS OTIC AGENTS ISCELLANEOUS acetic acid otic soln (VOSOL equiv) ACETIC ACID/ALUINU ACETATE OTIC SOLN CRESYLATE OTIC SOLN VOSOL OTIC SOLN OTIC ANALGESICS omedia otic soln (AERICAINE equiv) OTIC ANTIINFECTIVES ofloxacin otic soln (FLOXIN equiv) CIPROFLOXACIN OTIC SOLN 2 OTIC COBINATIONS neomycin/polymixin/hydrocoritisone otic soln (CORTIORIN equiv) neomycin/polymixin/hydrocoritisone otic susp (CORTIORIN equiv) pramoxinehc AQ otic soln (CORTANEB AQUEOUS equiv) CIPRODEX OTIC SU 2 COLYYCIN S OTIC SU 2 CIPRO HC OTIC SU CORTANEB AQUEOUS OTIC SOLN CORTIORIN OTIC SOLN OTOZIN OTIC DROPS antipyrine/benzocaine otic soln (AURALGAN equiv) NC COLYYCINS OTIC SU NC CORTANEB OTIC SOLN NC otomaxhc otic soln (CORTANEB equiv) NC OTIC STEROIDS acetic acid/hydrocoritisone otic soln (VOSOL HC equiv) fluocinolone otic oil (DEROTIC equiv) ACETASOL HC OTIC SOLN DEROTIC OIL VOSOL HC OTIC SOLN OXYTOCICS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 48 of 79
Category/Class DrugName Special Code Tier OXYTOCICS OXYTOCICS Cont. methylergonovine tab (ETHERGINE equiv) (= 28 tabs/fill, fill/65 days) ETHERGINE TAB (= 28 tabs/fill, fill/65 days) 2 PASSIVE IUNIZING AGENTS IUNE SERUS GAASTAN S/D INJ GAUNEX INJ HIZENTRA INJ ONOCLONAL ANTIBODIES SYNAGIS INJ PA PENICILLINS AINOPENICILLINS amoxicillin cap (TRIOX equiv) amoxicillin chew tab (AOXIL equiv) AOXICILLIN CHEW TAB 250G amoxicillin susp (TRIOX equiv) amoxicillin tab (AOXIL equiv) ampicillin cap (PRINCIPEN equiv) ampicillin susp (PRINCIPEN equiv) OXATAG TAB 775G NC NATURAL PENICILLINS penicillin vk soln (VEETIDS equiv) penicillin vk tab (VEETIDS equiv) PENICILLIN G PRICAINE INJ PENICILLIN G SODIU INJ PFIZERPEN G INJ PENICILLIN COBINATIONS amoxicillin/clavulanate chew tab (AUGENTIN equiv) amoxicillin/clavulanate ER tab (AUGENTIN XR equiv) amoxicillin/clavulanate susp (AUGENTIN ES equiv) amoxicillin/clavulanate tab (AUGENTIN equiv) AUGENTIN ES600 SU AUGENTIN SU AUGENTIN TAB AUGENTIN XR TAB ampicillin/sulbactam inj piperacillin/tazobactam inj TIENTIN INJ PENICILLINASERESISTANT PENICILLINS dicloxacillin cap (DYNAPEN equiv) nafcillin inj oxacillin inj PHARACEUTICAL ADJUVANTS SEI SOLID VEHICLES POLYETHYLENE GLYCOL 8000 GRANULES 2 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 49 of 79
Category/Class DrugName Special Code Tier PROGESTINS PROGESTINS medroxyprogesterone tab (PROVERA equiv) megestrol ES susp (EGACE ES equiv) norethindrone tab (AYGESTIN equiv) progesterone cap (PROETRIU equiv) AYGESTIN TAB EGACE ES SU PROETRIU CAP PROVERA TAB progesterone oil inj NC AKENA INJ PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. AGENTS FOR CHEICAL DEPENDENCY acamprosate calcium DR tab (CAPRAL equiv) disulfiram tab (ANTABUSE equiv) ANTABUSE TAB 2 CAPRAL TAB ANTICATAPLECTIC AGENTS XYRE SOLN (= 540ml/0 days; Only available through Xyrem Central Pharmacy 866997688) LDPA ANTIDEENTIA AGENTS donepezil ODT (ARICEPT equiv) (= tab/day) donepezil tab (ARICEPT equiv) (= 2 tabs/day) donepezil tab 2mg (ARICEPT equiv) (= tab/day; Step Therapy requires trial of donepezil 0mg) ST galantamine ER cap (RAZADYNE ER equiv) GALANTAINE SOLN galantamine tab (RAZADYNE equiv) memantine sol (NAENDA equiv) memantine tab (NAENDA equiv) rivastigmine cap (EXELON equiv) rivastigmine patch (EXELON equiv) EXELON SOLN 2 NAENDA XR CAP 2 NAZARIC CAP (Step Therapy requires trial of donepezil and memantine) ST 2 ARICEPT ODT (= tab/day) ARICEPT TAB (= 2 tabs/day) ARICEPT TAB 2G (= tab/day; Step Therapy requires trial of donepezil 0mg) ST EXELON CAP EXELON PATCH NAENDA SOL NAENDA TAB RAZADYNE ER CAP RAZADYNE SOLN RAZADYNE TAB COBINATION PSYCHOTHERAPEUTICS chlordiazepoxide/amitriptyline tab (LIBITROL equiv) olanzapine/ fluoxetine cap (SYBYAX equiv) PERPHENAZINE/ AITRIPTYLINE TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 50 of 79
Category/Class DrugName Special Code Tier PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. Cont. LIBITROL TAB SYBYAX CAP FIBROYALGIA AGENTS SAVELLA PAK 2 SAVELLA TAB (= 2 tabs/day) 2 HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) AGENTS ADDYI TAB NC OVEENT DISORDER DRUG THERAPY XENAZINE TAB NC tetrabenazine tab (XENAZINE equiv) ( ) PA ULTIPLE SCLEROSIS AGENTS APYRA TAB (= 2 tabs/day) PA TYSABRI INJ BETASERON INJ NC glatopa inj 20mg/ml (COPAXONE equiv) NC AUBAGIO TAB (= tab/day) PA AVONEX INJ COPAXONE INJ COPAXONE INJ 20G/L COPAXONE INJ 40G/L EXTAVIA INJ (Step Therapy requires trial of 2: AVONEX, COPAXONE, or PLEGRIDY) ST GILENYA CAP (= cap/day) PA PLEGRIDY INJ PLEGRIDY PEN INJ REBIF INJ PA TECFIDERA CAP TECFIDERA STARTER PACK POSTHERPETIC NEURALGIA (PHN) AGENTS GRALISE TAB NC PREENSTRUAL DYHORIC DISORDER (PDD) AGENTS FLUOXETINE CAP (PDD) NC PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP (= 2 caps/day) 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. ergoloid mesylates tab (HYDERGINE equiv) pimozide tab ERGOLOID ESYLATES TAB ORAP TAB RESTLESS LEG SYNDROE (RLS) AGENTS HORIZANT TAB NC SOKING DETERRENTS bupropion SR tab (ZYBAN equiv) (Limited to 80 days/plan year) SKG $0 CHANTIX PAK (Limited to 80 days/plan year) SKG $0 CHANTIX TAB (Limited to 80 days/plan year) SKG $0 NICODER PATCH OTCSKG $0 NICORETTE OTCSKG $0 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Category/Class DrugName Special Code Tier PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ISC. Cont. NICORETTE LOZENGE OTCSKG $0 nicotine gum (NICORETTE equiv) OTCSKG $0 NICOTINE KIT OTCSKG $0 nicotine lozenge (COIT equiv) OTCSKG $0 nicotine patch (NICODER equiv) OTCSKG $0 NICOTROL INHALER (Limited to 80 days/plan year) SKG $0 NICOTROL NASAL RAY (Limited to 80 days/plan year) SKG $0 ZYBAN TAB (Limited to 80 days/plan year) SKG $0 VASOOTOR SYPTO AGENTS BRISDELLE CAP NC REIRATORY AGENTS ISC. ALPHAPROTEINASE INHIBITOR (HUAN) ARALAST/PROLASTIN/ZEAIRA INJ CYSTIC FIBROSIS AGENTS KALYDECO PAK (= 2 packets/day) PASF KALYDECO TAB (= 2 tabs/day) PASF ORKABI TAB (= 4 tabs/day) PASF PULOZYE INH SOLN PULONARY FIBROSIS AGENTS ESBRIET CAP (= 9 caps/day) PASF OFEV CAP (= 2 caps/day) PASF SULFONAIDES SULFONAIDES SULFADIAZINE TAB TETRACYCLINES TETRACYCLINES demeclocycline tab (DECLOYCIN equiv) doxycycline hyclate cap (VIBRAYCIN equiv) doxycycline hyclate DR tab (DORYX equiv) doxycycline hyclate tab (VIBRATAB equiv) doxycycline monohydrate cap 00mg (ONODOX equiv) doxycycline monohydrate cap 50mg (ONODOX equiv) doxycycline monohydrate cap 50mg (ONODOX equiv) doxycycline monohydrate cap 75mg (ONODOX equiv) doxycycline monohydrate tab (ADOXA equiv) doxycycline susp (VIBRAYCIN equiv) minocycline cap (INOCIN equiv) minocycline tab (DYNACIN equiv) tetracycline cap ADOXA TAB DECLOYCIN TAB DORYX TAB DOXYCYCLINE HYCLATE DR CAP DYNACIN TAB INOCIN CAP ONODOX CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 52 of 79
Category/Class DrugName Special Code Tier TETRACYCLINES Cont. ORAXYL CAP TETRACYCLINE CAP VIBRAYCIN CAP VIBRAYCIN SU VIBRAYCIN SYRUP ACTICLATE TAB NC doxycycline hyclate DR tab 200mg (DORYX equiv) NC doxycycline monohydrate tab 50mg (ADOXA equiv) NC minocycline ER tab (SOLODYN equiv) NC THYROID AGENTS ANTITHYROID AGENTS methimazole tab (TAPAZOLE equiv) propylthiouracil tab TAPAZOLE TAB THYROID HORONES liothyronine tab (CYTOEL equiv) NATURE THROID/AROUR THYROID TAB np thyroid tab (NATURE THROID/AROUR THYROID equiv) SYNTHROID TAB THYROLAR TAB 2 CYTOEL TAB TIROSINT CAP levothyroxine tab (SYNTHROID equiv) NC TOXOIDS TOXOID COBINATIONS ADACEL/BOOSTRIX INJ (Vaccines are covered for members 9 years or older) VAC $0 TETANUSDIPHTHERIA TOXOID INJ (Vaccines are covered for members 9 years or older) VAC $0 ULCER DRUGS ANTIASODICS dicyclomine cap (BENTYL equiv) dicyclomine soln (BENTYL equiv) dicyclomine tab (BENTYL equiv) glycopyrrolate tab (ROBINUL equiv) hyoscyamine sulfate CR tab (LEVBID equiv) hyoscyamine sulfate elixir (LEVSIN equiv) hyoscyamine sulfate ODT (ANAAZ equiv) hyoscyamine sulfate SL tab (LEVSIN equiv) hyoscyamine sulfate soln (LEVSIN equiv) hyoscyamine sulfate SR cap (LEVSINEX equiv) hyoscyamine tab (LEVSIN equiv) methscopolamine tab (PAINE equiv) BELLADONNA ALKALOID/OPIU SUPP 2 PROPANTHELINE TAB 2 ANAAZ ODT BENTYL CAP BENTYL SYRUP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 5 of 79
Category/Class DrugName Special Code Tier ULCER DRUGS Cont. BENTYL TAB CANTIL TAB CUVPOSA SOLN LEVBID TAB LEVSIN INJ LEVSIN SOLN LEVSIN TAB LEVSIN/SL TAB LEVSINEX CAP PAINE TAB ROBINUL TAB SYAX DUOTAB ATROPINE INJ bdonna tab (DONNATAL equiv) NC chlordiazepoxide/clidinium cap (LIBRAX equiv) NC DONNATAL ELIXIR NC DONNATAL EXTENTABS NC GLYCATE TAB.5G NC LIBRAX CAP NC H2 ANTAGONISTS cimetidine soln (TAGAET equiv) cimetidine tab (TAGAET equiv) famotidine susp (PEPCID equiv) famotidine tab (PEPCID equiv) nizatidine cap (AXID equiv) nizatidine soln (AXID equiv) ranitidine cap (ZANTAC equiv) ranitidine syrup (ZANTAC equiv) ranitidine tab (Rx Only) (ZANTAC equiv) PEPCID SU 2 AXID CAP AXID SOLN PEPCID TAB TAGAET TAB ZANTAC CAP ZANTAC EFFER TAB ZANTAC GRANULE PACKET ZANTAC SYRUP ZANTAC TAB ISC. ANTIULCER CARAFATE SU sucralfate tab (CARAFATE equiv) CARAFATE TAB PROTON PUP INHIBITORS lansoprazole cap (PREVACID equiv) OTC omeprazole DR cap (PRILOSEC equiv) pantoprazole EC tab (PROTONIX equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 54 of 79
Category/Class DrugName Special Code Tier ULCER DRUGS Cont. PREVACID OTC CAP OTC rabeprazole EC tab (ACIPHEX equiv) PREVACID SOLUTAB 2 DEXILANT CAP (= cap/day; Step Therapy requires trial of omeprazole, pantoprazole, or rabeprazole) ST esomeprazole cap (NEXIU equiv) PA FIRST OEPRAZOLE SU LANSOPRAZOLE SU NEXIU GRANULE PACK PA ACIPHEX RINKLE CAP NC ESOEPRAZOLE STRONTIU CAP NC NEXIU 24HR TAB NC NEXIU OTC CAP OTC NC OEPRAZOLE TAB OTC NC PRILOSEC OTC DR TAB NC PROTONIX PAK NC ULCER DRUGS PROSTAGLANDINS misoprostol tab (CYTOTEC equiv) CYTOTEC TAB ULCER THERAPY COBINATIONS lansoprazole/amoxicillin/clarithromycin kit (PREVPAC equiv) ZEGERID CAP OTC OTC PREVPAC KIT PYLERA CAP ZEGERID POWDER PACK (Covered at Tier 2 if less than 2 years old) omeprazole/sodium bicarbonate cap (ZEGERID equiv) NC URINARY ANTIINFECTIVES URINARY ANTIINFECTIVE COBINATIONS UROQID #2 TAB UTA cap NC URINARY ANTIINFECTIVES methenamine hippurate tab (HIPREX equiv) methenamine mandelate tab nitrofurantoin macrocrystals cap (ACRODANTIN equiv) nitrofurantoin monohydrate cap (ACROBID equiv) nitrofurantoin susp (FURADANTIN equiv) FURADANTIN SU 2 HIPREX TAB ACROBID CAP ACRODANTIN CAP ETHENAINE ANDELATE TAB ONUROL GRANULE PACK URINARY ANTIASODICS BETA ADRENERGIC AGONISTS YRBETRIQ TAB 2 URINARY ANTIASODIC ANTIUSCARINICS (ANTICHOLIN) (NEW) oxybutynin ER tab (DITROPAN XL equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 55 of 79
Category/Class DrugName Special Code Tier URINARY ANTIASODICS Cont. oxybutynin syrup oxybutynin tab (DITROPAN equiv) tolterodine tab (DETROL equiv) trospium chloride SR cap (SANCTURA XR equiv) PA trospium tab (SANCTURA equiv) VESICARE TAB 2 DETROL TAB DITROPAN XL TAB GELNIQUE OXYTROL PATCH PA SANCTURA TAB SANCTURA XR CAP PA TOVIAZ TAB PA URINARY ANTIASODIC ANTIUSCARINICS (ANTICHOLINERGIC) darifenacin SR tab (ENABLEX equiv) PA tolterodine SR cap (DETROL LA equiv) DETROL LA CAP ENABLEX TAB PA URINARY ANTIASODIC COBINATIONS URELIEF PLUS TAB NC URINARY ANTIASODICS hyoscyamine tab (LEVSIN equiv) URINARY ANTIASODICS CHOLINERGIC AGONISTS (NEW) bethanechol tab (URECHOLINE equiv) URECHOLINE TAB URINARY ANTIASODICS DIRECT USCLE RELAXANTS (NEW) flavoxate tab (URIAS equiv) PA VACCINES BACTERIAL VACCINES BEXSERO INJ (Vaccines are covered for members 9 years or older) VAC $0 ENACTRA INJ (Vaccines are covered for members 9 years or older) VAC $0 ENHIBRIX INJ (Vaccines are covered for members 9 years or older) VAC $0 ENOUNE A/C/Y/W INJ (Vaccines are covered for members 9 years or older) VAC $0 ENVEO INJ (Vaccines are covered for members 9 years or older) VAC $0 PNEUOVAX INJ (Vaccines are covered for members 9 years or older) VAC $0 PREVNAR INJ (Vaccines are covered for members 9 years or older) VAC $0 TRUENBA INJ (Vaccines are covered for members 9 years or older) VAC $0 VIVOTIF CAP (= 4 caps/fill; Vaccines are covered for members 9 years or older) VAC $0 VIRAL VACCINES AFLURIA INJ (Vaccines are covered for members 9 years or older) VAC $0 AFLURIA/FLUZONE INJ (Vaccines are covered for members 9 years or older) VAC $0 CERVARIX INJ (Vaccines are covered for members 9 years or older) VAC $0 ENGERIXB INJ (Vaccines are covered for members 9 years or older) VAC $0 ENGERIXB/RECOBIVAXHB (Vaccines are covered for members 9 years or older) VAC $0 FLUBLOK INJ (Vaccines are covered for members 9 years or older) VAC $0 FLUCELVAX INJ (Vaccines are covered for members 9 years or older) VAC $0 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 56 of 79
Category/Class DrugName Special Code Tier VACCINES Cont. FLUIST NASAL LIQUID (Vaccines are covered for members 9 years or older) VAC $0 FLUIST QUADRIVALENT NASAL (Vaccines are covered for members 9 years or older) VAC $0 FLUVIRIN INJ (Vaccines are covered for members 9 years or older) VAC $0 FLUVIRIN PF INJ (Vaccines are covered for members 9 years or older) VAC $0 FLUZONE HIGH DOSE PF INJ (Vaccines are covered for members 9 years or older) VAC $0 FLUZONE INTRADERAL (Vaccines are covered for members 9 years or older) VAC $0 FLUZONE QUADRIVALENT INJ (Vaccines are covered for members 9 years or older) VAC $0 FLUZONE/FLUARIX QUAD INJ (Vaccines are covered for members 9 years or older) VAC $0 FLUZONE/FLULAVAL QUAD INJ (Vaccines are covered for members 9 years or older) VAC $0 GARDASIL 9 INJ (Vaccines are covered for members 9 years or older) VAC $0 GARDASIL INJ (Vaccines are covered for members 9 years or older) VAC $0 HAVRIX/VAQTA INJ (Vaccines are covered for members 9 years or older) VAC $0 R II INJ (Vaccines are covered for members 9 years or older) VAC $0 TWINRIX INJ (Vaccines are covered for members 9 years or older) VAC $0 VARIVAX INJ (Vaccines are covered for members 9 years or older) VAC $0 ZOSTAVAX INJ (Covered for members age 50 or older) VAC $0 VAGINAL PRODUCTS ISCELLANEOUS VAGINAL PRODUCTS ACIDIC VAGINAL JELLY 2 FE PH GEL ERICIDES CONCEPTROL GEL OTC $0 CONTRACEPTIVE FIL OTC $0 CONTRACEPTIVE FOA OTC $0 CONTRACEPTIVE GEL OTC $0 CONTRACEPTIVE SUPP OTC $0 TODAY ONGE OTC $0 vcf vaginal gel (CONCEPTROL equiv) OTC $0 VAGINAL ANTIINFECTIVES clindamycin vaginal cream (CLEOCIN equiv) metronidazole vaginal gel (ETROGEL equiv) NYSTATIN VAGINAL TAB terconazole cream (TERAZOL equiv) terconazole supp (TERAZOL equiv) AVC VAGINAL CREA 2 CLEOCIN VAGINAL CREA CLEOCIN VAGINAL SUPP CLINDESSE VAGINAL CREA ETROGEL VAGINAL GEL ICONAZOLE SUPP 200G TERAZOL CREA TERAZOL SUPP GYNAZOLE CREA VAGINAL ESTROGENS ESTRACE VAGINAL CREA 2 ESTRING ( copays per Rx) 2 PREARIN VAGINAL CREA 2 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 57 of 79
Category/Class DrugName Special Code Tier VAGINAL PRODUCTS Cont. FERING ( copays per Rx) VAGIFE TAB (= 8 tabs/28 days (8 tabs on first fill)) VAGINAL PROGESTINS CRINONE GEL PA 2 ENDOETRIN INSERT PA 2 PROGESTERONE SUPP PA VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS EPIPEN INJ (= 2 inj/fill) 2 EPIPENJR INJ (= 2 inj/fill) 2 ADRENACLICK INJ (= 2 inj/fill; Step Therapy requires trial of EPIPEN) ST AUVIQ INJ (= 2 inj/fill; Step Therapy requires trial of EPIPEN) ST EPINEPHRINE INJ (= 2 inj/fill; Step Therapy requires trial of EPIPEN) ST NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) AGENTS NORTHERA CAP NC VASOPRESSORS midodrine tab (PROAATINE equiv) PROAATINE TAB VITAINS ISC. NUTRITIONAL FACTORS PRENATAL VITAINS (PRENATAL PLUS/ PREPLUS/PRENAPLUS) PRENATAL VITAINS (NONPREFERRED) OIL SOLUBLE VITAINS vitamin D cap 000unit (Covered for members 65 years or older) OTC $0 vitamin D cap 400unit (Covered for members 65 years or older) OTC $0 VITAIN D TAB 400UNIT (Covered for members 65 years or older) OTC $0 vitamin D cap (Rx covered Only) EPHYTON TAB 2 DRISDOL CAP cholecalciferol cap 50000 unit OTC NC WATER SOLUBLE VITAINS niacin cap OTC niacin CR tab (SLONIACIN equiv) OTC niacin tab OTC NIACIN TR TAB OTC niacinamide tab OTC POTABA POWDER PACKET 2 POTABA TAB 2 POTABA CAP SLONIACIN TAB OTC Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. CI Chronic Illness Support Program INF Infertility LD edical Benefit andatory Specialty Pharmacy Program OTC SF Limited to two 5 day fills per month for first months SKG Smoking Cessation OvertheCounter Page 58 of 79
Prior Authorization Drug List Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. ABILIFY DISCELT ABILIFY AINTENA INJ ABILIFY SOLN ABSTRAL SL TAB ACTERA SC INJ ACTIQ LOZENGE adapalene cream adapalene gel 0.% ADAPALENE LOTION 2 ADCIRCA TAB ADEPAS TAB AFINITOR DIERZ AFINITOR TAB ALBENZA TAB AITIZA CAP APYRA TAB ANDRODER PATCH 2 ANDROGEL % 25G ANDROGEL % 50G ANDROGEL.62%.25G 2 ANDROGEL.62% 2.5G 2 ANDROGEL PUP % ANDROGEL PUP.62% 2 ANDROID/TESTRED CAP ARIXTRA INJ AUBAGIO TAB AXIRON SOLN AZELEX CREA bexarotene cap BOSULIF TAB CAPRELSA TAB CARBAGLU TAB CHOLBA CAP CIALIS TAB 2.5G, 5G CIZIA INJ CLARINEX REDITAB CLARINEX SYRUP CLARINEX TAB clobetasol foam clobetasol lotion clobetasol propionate cream clobetasol propionate emollient cream clobetasol propionate gel clobetasol propionate oint clobetasol propionate soln Tier # for Drug Copay (if prior auth is approved) Page 59 of 79
cont. Prior Authorization Drug List Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. clobetasol shampoo clobetasol spray CLOBEX LOTION CLOBEX SHAPOO CLOBEX RAY COETRIQ KIT CORLANOR TAB COSENTYX INJ CRINONE GEL 2 CYSTAGON CAP CYSTARAN OPHTH SOLN DAKLINZA TAB DARAPRI TAB darifenacin SR tab DESCOVY TAB DESLORATADINE ODT desloratadine tab DIFFERIN CREA DIFFERIN GEL 0.% DIFFERIN GEL 0.% DIFFERIN LOTION dronabinol cap DYISTA NASAL RAY ENABLEX TAB ENBREL INJ ENBREL SURECLICK INJ ENDOETRIN INSERT 2 EPIDUO (FORTE) GEL 2 ERIVEDGE CAP ESBRIET CAP esomeprazole cap FANAPT TAB FARYDAK CAP fentanyl citrate lollipop FENTORA TAB FERRIPROX SOLN FERRIPROX TAB FETZIA CAP FETZIA TITRATION PACK flavoxate tab fondaparinux inj FORTESTA GEL/ TESTOSTERONE GEL GILENYA CAP GILOTRIF TAB GLEEVEC TAB Tier # for Drug Copay (if prior auth is approved) Page 60 of 79
cont. Prior Authorization Drug List Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. halobetasol propionate cream halobetasol propionate oint HARVONI TAB HUIRA INJ HUIRA PEN INJ HYCATIN CAP IBRANCE CAP ICLUSIG TAB IBRUVICA CAP INCIVEK TAB INLYTA TAB INVEGA SUSTENNA/TRINZ INJ INVEGA TAB INVOKAET TAB INVOKANA TAB IRESSA TAB itraconazole cap JAKAFI TAB JENTADUETO TAB KALYDECO PAK KALYDECO TAB KAZANO/ALOGLIPTINETFORIN TAB KINERET INJ KORLY TAB KUVAN POWDER PACK KUVAN TAB LAZANDA RAY LENVIA CAP LETAIRIS TAB LINZESS CAP LONSURF TAB LYNPARZA CAP AKENA INJ ARINOL CAP EKINIST TAB ETHITEST TAB methyltestosterone cap modafinil tab NATPARA INJ NESINA/ALOGLIPTIN TAB NEXAVAR TAB NEXIU GRANULE PACK NORDITROPIN INJ NUTRITIONAL SUPPLEENT POWDER NUVIGIL TAB Tier # for Drug Copay (if prior auth is approved) Page 6 of 79
cont. Prior Authorization Drug List Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. ODOZO CAP OFEV CAP OLUX FOA ONFI TAB OPSUIT TAB ORENCIA SC INJ ORFADIN CAP ORKABI TAB OSENI/ALOGLIPTINPIOGLITAZONE TAB OXYTROL PATCH paliperidone ER tab PANRETIN GEL PROGESTERONE SUPP PROACTA TAB PROVIGIL TAB REBIF INJ RELISTOR INJ RELISTOR INJ KIT RETINA CREA RETINA GEL RETINA ICRO GEL 0.04%, 0.% REVATIO TAB REVLIID CAP RIFATER TAB SABRIL POWDER PACK SABRIL TAB SANCTURA XR CAP SAPHRIS SL TAB SIGNIFOR INJ sildenafil tab SIPONI INJ SKLICE LOTION SOATULINE INJ SOAVERT INJ SOVALDI TAB ORANOX CAP ORANOX SOLN RYCEL TAB STIVARGA TAB SUTENT CAP SYLATRON INJ SYNAGIS INJ SYPRINE CAP TAFINLAR CAP TARCEVA TAB Tier # for Drug Copay (if prior auth is approved) Page 62 of 79
cont. Prior Authorization Drug List Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. TARGRETIN CAP TASIGNA CAP TEOVATE CREA TEOVATE GEL TEOVATE OINT TEOVATE SOLN TEOVATEE CREA TESTI GEL/ TESTOSTERONE GEL testosterone gel % 25mg testosterone gel % 50mg testosterone gel % pump TESTOSTERONE GEL PUP 2 tetrabenazine tab THALOID CAP TOVIAZ TAB TRACLEER TAB TRADJENTA TAB TRECATOR TAB tretinoin cream tretinoin gel TRETINX CREA TRINTELLIX TAB trospium chloride SR cap TRUVADA TAB TYKERB TAB TYVASO INH SOLN TYZEKA TAB UCERIS RECTAL FOA UCERIS TAB ULTRAVATE CREA ULTRAVATE LOTION ULTRAVATE OINT VALCHLOR GEL VENTAVIS INH SOLN VICTRELIS CAP VIVITROL INJ VOTRIENT TAB XALKORI CAP XELJANZ TAB XELJANZ XR TAB XIFAXAN TAB 550G XTANDI CAP XYRE SOLN ZAVESCA CAP ZELBORAF TAB Tier # for Drug Copay (if prior auth is approved) Page 6 of 79
cont. Prior Authorization Drug List Some products on the Formulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. ZOLINZA CAP ZORTRESS TAB ZYDELIG TAB ZYTIGA TAB Tier # for Drug Copay (if prior auth is approved) Page 64 of 79
(Cost Savings Enabled by Tablet Splitting) Tablet splitting helps control prescription drug benefit costs and can provide significant savings for members. Participation in the program is voluntary. Through this program, members pay up to onehalf of their usual copayment on a select group of prescription drugs. Drugs included in this program are based on the following criteria: The drug product is on the formulary. The drug product is recognized as an appropriate product to split by the Pharmacy & Therapeutics Committee. The drug is flat priced (i.e. various strengths of the medication must be comparably priced). The medication must have oncedaily dosing. An example of the savings that can be realized through this program is illustrated below: Product & Strength Quantity ember Copay ember Annual Savings Without Tablet Splitting Drug A 40 mg tab 0 $5.00 With Tablet Splitting Drug A 80 mg tab 5 $7.50 $90 As the example illustrates, tablet splitting allows members to receive the same dose in a fewer number of tablets; thus, the overall cost of the medication is reduced. embers may obtain tabletsplitting devices free of charge by contacting Customer Service. Program edications AZILECT TAB BYSTOLIC TAB entecavir tab galantamine tab irbesartan tab JANUVIA TAB ONGLYZA TAB rosuvastatin tab rosuvastatin tab 20mg tolterodine tab ULORIC TAB VESICARE TAB Page 65 of 79
OvertheCounter (OTC) The following OTC drugs are a covered benefit with a prescription OvertheCounter (OTC) edications ACCUCHEK AVIVA PLUS ETER ACCUCHEK AVIVA PLUS TEST STRIP ACCUCHEK NANO ETER ACCUCHEK NANO SARTVIEW ETER ACCUCHEK SARTVIEW ACCUCHEK TEST STRIP AEROCHABER ALCOHOL SWABS TEST STRIP AIRIN CHEW TAB 75G aspirin chew tab 8mg aspirin ec tab 25mg aspirin ec tab 8mg aspirin tab 25mg AIRIN TAB 8G BD INSULIN SYRINGE BD PEN NEEDLE CALIBRATION LIQUID CLINISTIX TEST STRIP CONCEPTROL GEL CONTRACEPTIVE FIL CONTRACEPTIVE FOA CONTRACEPTIVE GEL CONTRACEPTIVE SUPP FEALE CONDOS ferrous sulfate elixir FERROUS SULFATE LIQUID ferrous sulfate soln FERROUS SULFATE SYRUP folic acid tab 400mcg folic acid tab 800mcg FREESTYLE FREEDO LITE ETER FREESTYLE INSULIN SYRINGE FREESTYLE INSULINX ETER FREESTYLE INSULINX TEST STRIP FREESTYLE LITE ETER FREESTYLE LITE TEST STRIP FREESTYLE TEST STRIP guaifenesin/codeine syrup HUULIN IX INJ HUULIN IX PEN INJ HUULIN N INJ HUULIN N PEN INJ HUULIN R INJ INSULIN SYRINGE IRON SU KETODIASTIX TEST KETOSTIX ketotifen ophth soln STRIP LANCET DEVICE LANCET KIT LANCETS lansoprazole cap levonorgestrel tab meclizine chew tab meclizine tab NASACORT OTC NASAL RAY niacin cap niacin CR tab niacin tab NIACIN TR TAB niacinamide tab NICODER PATCH NICORETTE NICORETTE LOZENGE nicotine gum NICOTINE KIT nicotine lozenge nicotine patch NOVOFINE PEN NEEDLE NOVOLIN INJ NOVOTWIST PEN NEEDLE PEAK FLOW ETER PEN NEEDLE PLAN B TAB PRECISION INSULIN PRECISION XTRA ETER SYRINGE PRECISION XTRA TEST PREVACID OTC CAP SLONIACIN TAB TODAY ONGE STRIP triamcinolone OTC nasal vcf vaginal gel vitamin D cap 000unit vitamin D cap 400unit spray VITAIN D TAB 400UNIT ZEGERID CAP OTC Page 66 of 79
andatory Specialty Pharmacy () Specialty drugs are only available for a one month supply due to their high cost and use The following drugs are required to be filled through a Specialty Pharmacy provider. andatory Specialty Pharmacy () edications ABILIFY AINTENA INJ ACTERA SC INJ ACTIUNE INJ ADCIRCA TAB adefovir dipivoxil tab ADEPAS TAB AFINITOR DIERZ AFINITOR TAB ALFERONN INJ APYRA TAB APOKYN INJ ARANE INJ AUBAGIO TAB AVONEX INJ bexarotene cap calcitriol inj capecitabine tab CAPRELSA TAB CARBAGLU TAB CAYSTON INH SOLN CHOLBA CAP CIZIA INJ COETRIQ KIT COPAXONE INJ COPAXONE INJ 20G/L COPAXONE INJ 40G/L COPEGUS TAB COSENTYX INJ CYSTAGON CAP CYSTARAN OPHTH SOLN DAKLINZA TAB DARAPRI TAB ENBREL INJ ENBREL SURECLICK INJ EPOGEN INJ ERIVEDGE CAP ESBRIET CAP etoposide cap EXJADE TAB EXTAVIA INJ FARYDAK CAP FERRIPROX SOLN FERRIPROX TAB FORTEO INJ FUZEON INJ GILENYA CAP GILOTRIF TAB GLEEVEC TAB GRANIX INJ HARVONI TAB HEPSERA TAB HIZENTRA INJ HUIRA INJ HUIRA PEN INJ HYCATIN CAP IBRANCE CAP ICLUSIG TAB IBRUVICA CAP INCIVEK TAB INCRELEX INJ INFERGEN INJ INLYTA TAB INTRONA INJ INVEGA SUSTENNA/TRINZ INJ IRESSA TAB JADENU TAB JAKAFI TAB KALYDECO PAK KALYDECO TAB KINERET INJ KORLY TAB KUVAN POWDER PACK KUVAN TAB LENVIA CAP LEUKINE INJ LONSURF TAB LYNPARZA CAP LYSODREN TAB AKENA INJ EKINIST TAB ESNEX TAB IACALCIN INJ YLERAN TAB NATPARA INJ NEULASTA INJ NEUEGA INJ NEXAVAR TAB NILANDRON TAB NORDITROPIN INJ octreotide inj ODOZO CAP OFEV CAP OPSUIT TAB ORENCIA SC INJ ORFADIN CAP ORKABI TAB PEGASYS INJ PEGASYS INJ KIT PEGINTRON INJ PLEGRIDY INJ PLEGRIDY PEN INJ PROCRIT INJ PROACTA TAB PULOZYE INH SOLN REBETOL CAP REBETOL SOLN REBIF INJ RELISTOR INJ RELISTOR INJ KIT REVLIID CAP RIBATAB ribavirin cap ribavirin tab SABRIL POWDER PACK SABRIL TAB SANDOSTATIN INJ SIGNIFOR INJ SIPONI INJ SOAVERT INJ SOVALDI TAB RYCEL TAB STIVARGA TAB SUTENT CAP SYLATRON INJ SYNAGIS INJ SYPRINE CAP TAFINLAR CAP TARCEVA TAB TARGRETIN CAP TARGRETIN GEL TASIGNA CAP TECFIDERA CAP TECFIDERA STARTER TEODAR CAP temozolomide cap tetrabenazine tab PACK THALOID CAP TOBI NEB SOLN TOBI PODHALER tobramycin neb soln tretinoin cap TYKERB TAB TYVASO INH SOLN VALCHLOR GEL VENTAVIS INH SOLN VICTRELIS CAP VIVITROL INJ VOTRIENT TAB XALKORI CAP XELJANZ TAB XELJANZ XR TAB XELODA TAB XTANDI CAP XYRE SOLN ZARXIO INJ ZAVESCA CAP Page 67 of 79
ZELBORAF TAB ZOLINZA CAP ZYDELIG TAB ZYTIGA TAB Page 68 of 79
Step Therapy (ST) The following drugs are covered on the formulary with a Step Therapy. Step Therapy (ST) edications ADRENACLICK INJ APIDRA INJ APIDRA SOLOSTAR INJ ARANE INJ ARICEPT TAB 2G ATELVIA TAB AUVIQ INJ BECONASE AQ NASAL RAY BESIVANCE OPHTH SU BONIVA TAB 50G budesonide nasal spray DESVENLAFAXINE ER TAB DEXILANT CAP DIFICID TAB donepezil tab 2mg EPINEPHRINE INJ EXTAVIA INJ fluvoxamine ER cap gatifloxacin ophth soln HUALOG INJ HUALOG KWIKPEN INJ HUALOG IX INJ HUALOG IX KWIKPEN INJ HUALOG PEN INJ HUULIN IX INJ HUULIN IX PEN INJ HUULIN N INJ HUULIN N PEN INJ HUULIN R INJ ibandronate tab 50mg INTUNIV TAB KHEDEZLA ER TAB Step Therapy Requirements = 2 inj/fill; Step Therapy requires trial of EPIPEN Step Therapy requires trial of NOVOLOG Step Therapy requires trial of NOVOLOG Step Therapy requires trial of PROCRIT = tab/day; Step Therapy requires trial of donepezil 0mg Step Therapy requires trial of alendronate = 2 inj/fill; Step Therapy requires trial of EPIPEN = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA = tab/0 days; Step Therapy requires trial of alendronate = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND venlafaxine product = cap/day; Step Therapy requires trial of omeprazole, pantoprazole, or rabeprazole = 20 tabs/fill; Step Therapy requires trial of vancomycin cap = tab/day; Step Therapy requires trial of donepezil 0mg = 2 inj/fill; Step Therapy requires trial of EPIPEN Step Therapy requires trial of 2: AVONEX, COPAXONE, or PLEGRIDY Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA Step Therapy requires trial of NOVOLOG Step Therapy requires trial of NOVOLOG Step Therapy requires trial of NOVOLOG Step Therapy requires trial of NOVOLOG Step Therapy requires trial of NOVOLOG Step Therapy requires trial of NOVOLIN Step Therapy requires trial of NOVOLIN Step Therapy requires trial of NOVOLIN Step Therapy requires trial of NOVOLIN Step Therapy requires trial of NOVOLIN = tab/0 days; Step Therapy requires trial of alendronate Step Therapy requires trial of guanfacine IR Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND venlafaxine product Page 69 of 79
Cont. Step Therapy (ST) The following drugs are covered on the formulary with a Step Therapy. Step Therapy (ST) edications LUVOX CR CAP ETROGEL % NAZARIC CAP nevirapine ER tab NORITATE CREA ONARIS NASAL RAY PANCREAZE CAP PANCRELIPASE CAP PATADAY OPHTH SOLN PEGASYS INJ PEGASYS INJ KIT PENTASA CAP PERTZYE CAP PEXEVA TAB PRISTIQ TAB QNASL NASAL RAY RHINOCORT AQUA NASAL RAY risedronate DR tab rosuvastatin tab rosuvastatin tab 20mg RYTARY CAP IRIVA REIAT INHALER.25CG/ACT SUPREP SOLN ULORIC TAB ULTRESA CAP VANCOCIN CAP vancomycin cap VIRAUNE XR TAB XOPENEX HFA INHALER ZENPEP CAP Step Therapy Requirements Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine Step Therapy requires trial of FINACEA Step Therapy requires trial of donepezil and memantine Step Therapy requires trial of nevirapine Step Therapy requires trial of FINACEA = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX Step Therapy requires trial of CREON Step Therapy requires trial of CREON = 2.5ml/0 days; Step Therapy requires trial of olopatadine ophth soln Step Therapy requires trial of PEGINTRON; Required thru specialty pharmacy. Apothecary by Design 877848447 Step Therapy requires trial of PEGINTRON; Required thru specialty pharmacy. Apothecary by Design 877848447 Step Therapy requires trial of ASACOL (HD), DELZICOL, or LIALDA Step Therapy requires trial of CREON Step Therapy requires trial of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine Step Therapy requires trial of citalopram, sertraline, fluoxetine, fluvoxamine or paroxetine AND venlafaxine product = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX Step Therapy requires trial of alendronate = tab/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, simvastatin or pravastatin =.5 tabs/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, simvastatin or pravastatin Step Therapy requires trial of carbidopa/levodopa ER Step Therapy requires trial of inhaled corticosteroid Step therapy requires trial of OVIPREP Step Therapy requires trial of allopurinol Step Therapy requires trial of CREON = 56 caps/fill; Step Therapy requires trial of vancomycin soln = 56 caps/fill; Step Therapy requires trial of vancomycin soln Step Therapy requires trial of nevirapine = 2 inhalers/fill, 2 fills/0 days; Step Therapy requires trial of VENTOLIN HFA Step Therapy requires trial of CREON Page 70 of 79
Cont. Step Therapy (ST) The following drugs are covered on the formulary with a Step Therapy. Step Therapy (ST) edications ZETONNA NASAL RAY ZIOPTAN OPHTH SOLN ZYAXID OPHTH SOLN Step Therapy Requirements = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX = bottle/day; Step Therapy requires trial of latanaprost Step Therapy requires trial of ciprofloxacin, levofloxacin, ofloxacin or VIGAOX/OXEZA Page 7 of 79
Smoking Cessation Agents bupropion SR tab( Limited to 80 days/plan year) CHANTIX PAK( Limited to 80 days/plan year) CHANTIX TAB( Limited to 80 days/plan year) NICODER PATCH NICORETTE NICORETTE LOZENGE NICOTINE GU NICOTINE KIT NICOTINE LOZENGE NICOTINE PATCH NICOTROL INHALER( Limited to 80 days/plan year) NICOTROL NASAL RAY( Limited to 80 days/plan year) ZYBAN TAB( Limited to 80 days/plan year) Tier # for Drug Copay $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Page 72 of 79
Infertility Drug List leuprolide inj LUPRON DEPOT INJ LUPRON DEPOT PED INJ LUPRON DEPOTPED INJ pregnyl inj Tier # for Drug Copay Page 7 of 79
Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Quantity Limit () edications Quantity Limit ABILIFY DISCELT = 2 tabs/day ABSTRAL SL TAB = 20 tabs/0 days ACTERA SC INJ = 2 inj/28 days ACTIQ LOZENGE = 20 lozenges/0 days ADEPAS TAB = tabs/day; Only available through Accredo 88877776 ADRENACLICK INJ = 2 inj/fill; Step Therapy requires trial of EPIPEN AEROCHABER = spacer/year AFINITOR DIERZ = tab/day AFINITOR TAB = tab/day AKYNZEO CAP = cap/fill; Restricted to Oncology or Hematology Specialist almotriptan tab = 9 tabs/fill, 2 fills/0 days ALSUA INJ = 4 inj/fill, 2 fills/0 days ABIEN TAB 0G ale = tab/day; Female = 0.5 tab/day ABIEN TAB 5G = tab/day AERGE TAB = 9 tabs/fill, 2 fills/0 days APYRA TAB = 2 tabs/day ANDRODER PATCH = patch/day ANDROGEL % 25G = packet/day ANDROGEL % 50G = 2 packets/day ANDROGEL.62%.25G = packet/day ANDROGEL.62% 2.5G = 2 packets/day ANDROGEL PUP % = 4 bottles/0 days ANDROGEL PUP.62% = 2 bottles/0 days ANZEET TAB = 9 tabs/fill ARICEPT ODT = tab/day ARICEPT TAB = 2 tabs/day ARICEPT TAB 2G = tab/day; Step Therapy requires trial of donepezil 0mg AUBAGIO TAB = tab/day AUVIQ INJ = 2 inj/fill; Step Therapy requires trial of EPIPEN AVINZA CAP = 2 caps/day AXERT TAB = 9 tabs/fill, 2 fills/0 days AXIRON SOLN = 2 bottles/0 days BARACLUDE TAB = tab/day BECONASE AQ NASAL RAY = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX BONIVA TAB 50G = tab/0 days; Step Therapy requires trial of alendronate budesonide nasal spray = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX bupropion SR tab Limited to 80 days/plan year butorphanol nasal spray = bottle/fill, 2 fills/0 days BUTRANS PATCH = 4 patches/28 days BYDUREON INJ = 4 inj/28 days BYDUREON PEN INJ = 4 inj/28 days CELEBREX CAP = 2 caps/day celecoxib cap = 2 caps/day Page 74 of 79
Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Quantity Limit () edications Quantity Limit CHANTIX PAK Limited to 80 days/plan year CHANTIX TAB Limited to 80 days/plan year CIZIA INJ = 2 inj/28 days CYBALTA CAP = 2 caps/day CYSTARAN OPHTH SOLN = 4 bottles/0 days DAKLINZA TAB = tab/day DEPOPROVERA INJ = inj/90 days DEPOPROVERA SC INJ 04G = inj/90 days DEXILANT CAP = cap/day; Step Therapy requires trial of omeprazole, pantoprazole, or rabeprazole diclofenac gel % = 5 tubes/fill DIFICID TAB = 20 tabs/fill; Step Therapy requires trial of vancomycin cap donepezil ODT = tab/day donepezil tab = 2 tabs/day donepezil tab 2mg = tab/day; Step Therapy requires trial of donepezil 0mg duloxetine EC cap = 2 caps/day EEND CAP = caps/fill; Restricted to Oncology or Hematology Specialist EEND PAK = caps/fill; Restricted to Oncology or Hematology Specialist ENBREL INJ = 4 inj/28 days ENBREL SURECLICK INJ = 4 inj/28 days enoxaparin inj = 7 days supply entecavir tab = tab/day EPINEPHRINE INJ = 2 inj/fill; Step Therapy requires trial of EPIPEN EPIPEN INJ = 2 inj/fill EPIPENJR INJ = 2 inj/fill ESBRIET CAP = 9 caps/day eszopiclone tab = tab/day FANAPT TAB = 2 tabs/day FARXIGA TAB = tab/day FARYDAK CAP = 6 caps/2 days fentanyl citrate lollipop = 20 lozenges/0 days FENTORA TAB = 20 tabs/0 days FETZIA CAP = cap/day FETZIA TITRATION PACK = cap/day FLECTOR PATCH = 0 patches/fill FLONASE NASAL RAY = 2 bottles/fill flunisolide nasal spray = 2 bottles/fill fluticasone nasal spray = 2 bottles/fill FORTESTA GEL/ TESTOSTERONE GEL = 2 bottles/0 days FROVA TAB = 9 tabs/fill, 2 fills/0 days frovatriptan tab = 9 tabs/fill, 2 fills/0 days GILENYA CAP = cap/day GILOTRIF TAB = tab/day, Only available through Accredo 88877776 granisetron tab = 9 tabs/fill GRANISOL SOLN = 60ml/fill Page 75 of 79
Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Quantity Limit () edications Quantity Limit guaifenesin/codeine syrup = 240ml/fill HARVONI TAB = tab/day HUIRA INJ = 2 inj/28 days HUIRA PEN INJ = 2 inj/28 days hydrocodone/chlorpheniramine CR susp = 20ml/fill; 2 fills/0 days hydrocodone/chlorpheniramine/pseudoeph = 20ml/fill, 2 fills/0 days edrine liquid HYSINGLA ER TAB = tab/day ibandronate tab 50mg = tab/0 days; Step Therapy requires trial of alendronate IBRANCE CAP = 2 caps/28 days IBRUVICA CAP = 4 caps/day; Only available through Diplomat Pharmacy 87797798 IITREX INJ = 4 inj/fill, 2 fills/0 days IITREX TAB = 9 tabs/fill, 2 fills/0 days IITREX VIAL INJ = 5 inj/fill, 2 fills/0 days INLYTA TAB = 8 tabs/day INVOKAET TAB = 2 tabs/day INVOKANA TAB = tab/day JAKAFI TAB = 2 tabs/day JANUVIA TAB = tab/day JARDIANCE TAB = tab/day JENTADUETO TAB = 2 tabs/day KALYDECO PAK = 2 packets/day KALYDECO TAB = 2 tabs/day KAZANO/ALOGLIPTINETFORIN TAB = 2 tabs/day ketorolac tab = 20 tabs/5 days KINERET INJ = inj/day; Only available through Rx Crossroads: 8665470644 KYTRIL TAB = 9 tabs/fill LASTACAFT OPHTH SOLN = ml/0 days latanoprost ophth soln = 2.5ml/0 days LAZANDA RAY = 5 bottles/0 days LENVIA CAP = caps/day; Only available through Accredo 88877776 LETAIRIS TAB = tab/day lidocaine patch = patches/day LIDODER PATCH = patches/day LINZESS CAP = cap/day LOVENOX INJ = 7 days supply LUIGAN OPHTH SOLN = 2.5ml/0 days LUNESTA TAB = tab/day malathion lotion = 2 bottles/fill AXALT LT TAB = 2 tabs/fill, fills/60 days AXALT TAB = 2 tabs/fill, fills/60 days medroxyprogesterone inj = inj/90 days ETHERGINE TAB = 28 tabs/fill, fill/65 days methylergonovine tab = 28 tabs/fill, fill/65 days Page 76 of 79
Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Quantity Limit () edications Quantity Limit IGRANAL/ DIHYDROERGOTAINE = 8 sprays/fill, 2 fills/0 days RAY modafinil tab = 2 tabs/day ORPHINE SULFATE ER BEAD CAP = 2 caps/day OVIPREP SOLN = bottle/fill naratriptan tab = 9 tabs/fill, 2 fills/0 days NASACORT AQ NASAL RAY = 2 bottles/fill NASACORT OTC NASAL RAY = 2 bottles/fill NASONEX NASAL RAY = 2 bottles/fill NATROBA SU = bottle/fill NESINA/ALOGLIPTIN TAB = tab/day NICOTROL INHALER Limited to 80 days/plan year NICOTROL NASAL RAY Limited to 80 days/plan year NUCYNTA ER TAB = 2 tabs/day NUEDEXTA CAP = 2 caps/day NUVIGIL TAB = tab/day ODOZO CAP = cap/day OFEV CAP = 2 caps/day ONARIS NASAL RAY = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX ONGLYZA TAB = tab/day OPSUIT TAB = tab/day, Only available through Walgreens 8884746 ORENCIA SC INJ = 4 inj/28 days ORKABI TAB = 4 tabs/day OSENI/ALOGLIPTINPIOGLITAZONE TAB = tab/day OVIDE LOTION = 2 bottles/fill OXYCONTIN CR TAB = 20 tabs/0 days PATADAY OPHTH SOLN = 2.5ml/0 days; Step Therapy requires trial of olopatadine ophth soln peg 50/electrolytes soln Covered at $0 for members 5075 yearslimited to 2 fills/calendar year; All other members covered at generic copay PICATO GEL = box/fill POTIGA TAB = tabs/day POTIGA TAB 50G = 9 tabs/day PROVIGIL TAB = 2 tabs/day QNASL NASAL RAY = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX REGRANEX GEL = 0gm/fill RELENZA DISKHALER = inhaler/fill RELPAX TAB = 9 tabs/fill, 2 fills/0 days REVLIID CAP = cap/day RHINOCORT AQUA NASAL RAY = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX rizatriptan ODT = 2 tabs/fill, fills/60 days rizatriptan tab = 2 tabs/fill, fills/60 days Page 77 of 79
Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Quantity Limit () edications Quantity Limit rosuvastatin tab = tab/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, simvastatin or pravastatin rosuvastatin tab 20mg =.5 tabs/day; Step Therapy requires trial of atorvastatin, lovastatin, fluvastatin, simvastatin or pravastatin ROZERE TAB = tab/day SANCUSO PATCH = 4 patches/fill SAPHRIS SL TAB = 2 tabs/day SAVELLA TAB = 2 tabs/day SIGNIFOR INJ = 2 vials/day; Only available through Accredo 88877776 SIPONI INJ = inj/28 days SIVEXTRO TAB = 6 tabs/fill; Restricted to Infectious Disease Specialist SKLICE LOTION = tube/fill SOVALDI TAB = tab/day INOSAD SU = bottle/fill STIVARGA TAB = 4 tabs/day STRIVERDI REIAT INHALER = inhaler/0 days sumatriptan inj = 4 inj/fill, 2 fills/0 days SUATRIPTAN INJ 6G/0.5L = 4 inj/fill, 2 fills/0 days sumatriptan tab = 9 tabs/fill, 2 fills/0 days sumatriptan vial inj = 5 inj/fill, 2 fills/0 days SUATRIPTAN/ IITREX NASAL RAY = 6 sprays/fill, 2 fills/0 days SUAVEL DOSEPRO INJ = 6 inj/fill, 2 fills/0 days SYNJARDY TAB = 2 tabs/day TAFINLAR CAP = 4 caps/day TAIFLU CAP = 0 caps/fill TAIFLU CAP 0G = 20 caps/fill TAIFLU SU 6G/L = 250ml/fill TESTI GEL/ TESTOSTERONE GEL = 2 packets/day testosterone gel % 25mg = packet/day testosterone gel % 50mg = 2 packets/day testosterone gel % pump = 4 bottles/0 days TESTOSTERONE GEL PUP = 4 bottles/0 days TIVICAY TAB = 2 tabs/day TRACLEER TAB = 2 tabs/day TRADJENTA TAB = tab/day TRAVATAN Z OPHTH SOLN = 5ml/0 days triamcinolone nasal spray = 2 bottles/fill triamcinolone OTC nasal spray = 2 bottles/fill trilyte soln Covered at $0 for members 5075 yearslimited to 2 fills/calendar year; All other members covered at generic copay TRINTELLIX TAB = tab/day TUSSICAPS = 20 caps/fill, 2 fills/0 days TUSSIONEX SU = 20ml/fill; 2 fills/0 days TUSSIORGANI SYRUP = 240ml/fill UCERIS TAB = tab/day Page 78 of 79
Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Quantity Limit () edications Quantity Limit ULESFIA LOTION = 4 bottles/fill VAGIFE TAB = 8 tabs/28 days (8 tabs on first fill) VALCHLOR GEL = 4 tubes/0 days; Only available through Accredo 88877776 VANCOCIN CAP = 56 caps/fill; Step Therapy requires trial of vancomycin soln vancomycin cap = 56 caps/fill; Step Therapy requires trial of vancomycin soln VENTOLIN HFA INHALER = 2 inhalers/fill, 2 fills/0 days VERAYST NASAL RAY = 2 bottles/fill VGO INJ KIT = kit/day VICTOZA INJ = 9ml/0 days VIPAT TAB = 2 tabs/day VIVOTIF CAP = 4 caps/fill; Vaccines are covered for members 9 years or older VOLTAREN GEL = 5 tubes/fill VYTORIN TAB = tab/day (0/80mg is Not Covered) XALATAN OPHTH SOLN = 2.5ml/0 days XELJANZ TAB = 2 tabs/day XELJANZ XR TAB = tab/day XIFAXAN TAB 200G = 9 tabs/ days XIFAXAN TAB 550G = 2 tabs/day XIGDUO XR TAB = tab/day XIGDUO XR TAB 5000G = 2 tabs/day XOPENEX HFA INHALER = 2 inhalers/fill, 2 fills/0 days; Step Therapy requires trial of VENTOLIN HFA XTANDI CAP = 4 caps/day XYRE SOLN = 540ml/0 days; Only available through Xyrem Central Pharmacy 866997688 ZETIA TAB = tab/day ZETONNA NASAL RAY = 2 bottles/fill; Step Therapy requires trial of 2: fluticasone, flunisolide, VERAYST, or NASONEX ZIOPTAN OPHTH SOLN = bottle/day; Step Therapy requires trial of latanaprost zolmitriptan ODT = 9 tabs/fill, 2 fills/0 days zolmitriptan tab = 9 tabs/fill, 2 fills/0 days zolpidem tab 0mg ale = tab/day; Female = 0.5 tab/day zolpidem tab 5mg = tab/day ZOIG NASAL RAY = 6 sprays/fill, 2 fills/0 days ZOIG TAB = 9 tabs/fill, 2 fills/0 days ZOIG ZT = 9 tabs/fill, 2 fills/0 days ZUTRIPRO LIQUID = 20ml/fill, 2 fills/0 days ZYBAN TAB Limited to 80 days/plan year ZYLET OPHTH SU = 5ml/fill (0ml bottle is Not Covered) Page 79 of 79