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Formulary A formulary is a list of prescription medications developed by a committee of practicing physicians and practicing pharmacists who represent a variety of specialty areas and who are knowledgeable in the diagnosis and treatment of disease. Brand-Name Drugs Brand-name drugs are typically the first products to gain U.S. Food and Drug Administration (FDA) approval. Generic Drugs Generic drugs have the same active ingredients and come in the same strengths and dosage forms as the equivalent brand-name drug. Multiple manufacturers may produce the same generic drug and the product may differ from its brand name counterpart in color, size or shape, but the differences do not alter the effectiveness. Generic versions of brand-name drugs are reviewed and approved by the FDA. The FDA works closely with all pharmaceutical companies to make sure that all drugs sold in the U.S. meet appropriate standards for strength, quality, and purity. 3-Tier Pharmacy Copayment Program (3-Tier Program) To help maintain affordability in the pharmacy benefit, we encourage the use of cost-effective drugs and preferred brand names through the three-tier program. This program gives you and your doctor the opportunity to work together to find a prescription medication that's affordable and appropriate for you. All covered drugs are placed into one of three tiers. Your physician may have the option to write you a prescription for a Tier 1, Tier 2, or Tier 3 drug (as defined below); however, there may be instances when only a Tier 3 drug is appropriate, which will require a higher copayment. Tier 1: Medications on this tier have the lowest copayment. This tier includes many generic drugs. Tier 2: Medications on this tier are subject to the middle copayment. This tier includes some generics and brand-name drugs. Tier 3: This is the highest copayment tier and includes some generics and brand-name covered drugs not selected for Tier 2. Please note that tier placement is subject to change throughout the year.
Copayment A copayment is the fee a member pays for certain covered drugs. A member pays the copayment directly to the provider when he/she receives a covered drug, unless the provider arranges otherwise. Coinsurance Coinsurance requires the member to pay a percentage of the total cost for certain covered drugs.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
Last Updated: 3/11/2013 Medical Review Process Tufts Health Plan has pharmacy programs in place to help manage the pharmacy benefit. Requests for medically necessary review for coverage of drugs included in the New-to-Market Drug Evaluation Process (NTM), Prior Authorization Program (PA), Step Therapy Prior Authorization Program (STPA), Quantity Limitations Program (QL), Non-Covered Drugs (NC) With Suggested Alternatives Program should be completed by the physician and sent to Tufts Health Plan. Drugs excluded under your pharmacy benefit will not be covered through this process. The request must include clinical information that supports why the drug is medically necessary for you. Tufts Health Plan will approve the request if it meets coverage guidelines. If Tufts Health Plan does not approve the request, you have the right to appeal. The appeal process is described in your benefit document. Note: Drugs approved through the Medical Review Process will be subject to a Tier 3 copayment. Quantity Limitation (QL) Program Because of potential safety and utilization concerns, Tufts Health Plan has placed quantity limitations on some prescription drugs. You are covered for up to the amount posted in our list of covered drugs. These quantities are based on recognized standards of care as well as from FDA-approved dosing guidelines. If your provider believes it is necessary for you to take more than the QL amount posted on the list, he or she may submit a request for coverage under the Medical Review Process. New-To-Market Drug Evaluation Process (NTM) In an effort to make sure the new-to-market prescription drugs we cover are safe, effective and affordable, we delay coverage of many new drug products until the Plan's Pharmacy and Therapeutics Committee and physician specialists have reviewed them. This review process is usually completed within six months after a drug becomes available. The review process enables us to learn a great deal about these new drugs, including how a physician can safely prescribe these new drugs and how physicians can choose the most appropriate patients for the new therapy. During the review process, if your physician believes you have a medical need for the NewTo-Market drug, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process. If your plan includes the 3-Tier Copayment Program, then you will pay the Tier-3 (highest) copayment if the medication is approved for coverage. Non-Covered Drugs (NC) There are thousands of drugs listed on the Tufts Health Plan covered drug list. In fact, most drugs are covered. There is, however, a list of drugs that Tufts Health Plan currently does not cover. In many cases, these drugs are not covered by Tufts Health Plan because there are safe, comparably effective, and cost effective alternatives available. Our goal is to keep pharmacy benefits as affordable as possible. If your doctor feels that one of the non-covered drugs is needed, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process. Prior Authorization (PA) Program In order to ensure safety and affordability for everyone, some medications require prior authorization. This helps us work with your doctor to ensure that medications are prescribed appropriately. If your doctor feels it is medically necessary for you to take one of the drugs listed below, he/she can submit a request for coverage to Tufts Health Plan under the Medical Review Process.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
Last Updated: 3/11/2013 Step Therapy Prior Authorization (STPA ) Step Therapy is an automated form of Prior Authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and costeffectiveness. Some types of Step Therapy include requiring the use of generics before brand name drugs, preferred before non-preferred brand name drugs, and first-line before second-line therapies. Medications included on step 1- the lowest step-are usually covered without authorization. We have noted the few exceptions, which may require your physician to submit a request to Tufts Health Plan for coverage. Medications on Step 2 or higher are automatically authorized at the point-of-sale if you have taken the required prerequisite drugs. However, if your physician prescribes a medication on a higher step, and you have not yet taken the required medication(s) on a lower step, or if you are a new Tufts Health Plan member and do not have any prescription drug claims history, the prescription will deny at the point-of-sale with a message indicating that a Prior Authorization (PA) is required. Physicians may submit requests for coverage to Tufts Health Plan for members who do not meet the Step Therapy criteria at the point of sale under the Medical Review process. Designated Specialty Pharmacy Program (SP) Tufts Health Plan's goal is to offer you the most clinically appropriate and cost-effective services. As a result, we have designated special pharmacies to supply a select number of medications used in the treatment of complex diseases. These pharmacies are specialized in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency. You can obtain up to a 30-day supply of these medications at a time. Other special designated pharmacies and medications may be identified and added to this program from time to time. Benefits vary; some members may not participate in this program. Please see your benefit document for complete information. Physicians may obtain a select number of specialty medications through a designated SP for administration in the office as an alternative to direct purchase. These medications are covered under the medical benefit, and will be shipped directly to and administered in the office by the members provider. The designated pharmacy will bill Tufts Health Plan directly for the medication. For the most current listing of special designated pharmacies or to find out if your plan includes this program, please call us at the number listed on the back of your member identification card. Designated Specialty Infusion Program for Drugs Covered Under the Medical Benefit (SI) Tufts Health Plan has designated home infusion providers for a select number of specialized pharmacy products and drug administration services. The designated specialty infusion provider offers clinical management of drug therapies, nursing support, and care coordination to members with acute and chronic conditions. Place of service may be in the home or alternate infusion site based on availability of infusion centers and determination of the most clinically appropriate site for treatment. These medications are covered under the medical benefit (not the pharmacy benefit) and generally require support services, medication dose management, and special handling in addition to the drug administration services. Medications include, but are not limited to, medications used in the treatment of hemophilia, pulmonary arterial hypertension, and immune deficiency. Other specialty infusion providers and medications may be identified and added to this program from time to time.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
Generic Focused Formulary The Generic Focused Formulary, which is the formulary used in our Select Network and/or Connector Plans differs from other Tufts Health Plan formularies. Most generic drugs are covered, and only select brand name drugs that have no generic drug equivalent are covered. Brand name drugs with generic equivalents are not covered under this formulary. If the patent of a brand name drug listed expires and a generic version becomes available, the brand will no longer be covered. This change will happen automatically and without notification to members or providers. GFF Formulary Managed Mail (MM) Program Our Managed Mail (MM) Program applies to certain plans. It requires that in order to be covered, prescriptions for most maintenance medications must be filled by our mail order pharmacy. Maintenance medications are those you refill monthly for chronic conditions like asthma, high blood pressure, or diabetes. Under this program, you are allowed an initial fill at a retail pharmacy and a limited number of refills. After that, in order to be covered, you must fill your maintenance prescription through the mail order program offered by CVS Caremark, our pharmacy benefits manager. You may obtain up to a 90-day supply for these maintenance medications at mail order. Please note that some medications may not be appropriate for mail order. These include medications with quantity limitations (QL) of less than 84 or 90 days. If you have questions about this program, please contact us at the number listed on the back of your member identification card. Over-The-Counter Drugs (OTC) When a medication with the same active ingredient or a modified version of an active ingredient that is therapeutically equivalent, becomes available over-the-counter, Tufts Health Plan may exclude coverage of the specific medication or all of the prescription drugs in the class. For more information, please call our Member Services Department at the number listed on the back of your member identification card.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
Drug Name
Diabetic Test Strips, Other
Tier
Pharmacy Program
OneTouch Test Strips, Accu-Chek Test Strips, OneTouch and Accu-Chek are the preferred, covered, test strips. Examples of non-covered test strips include, but are not limited to: Ascensia, BD, FreeStyle, Precision, TrueTrack test strips QL Covered for members 12 years of age and younger. Quantity Limitations apply., 300 mL/30 days, omeprazole, lansoprazole, pantoprazole QL QL 90 solutabs/90 days, Prilosec OTC, omeprazole, lansoprazole, pantoprazole. Prevacid Solutab and generic lansoprazole soluble tablets are covered for members 12 years of age and younger. Quantity Limitations apply., Prevacid Solutab and generic lansoprazole soluble tablets are covered for members 12 years of age and younger. Quantity Limitations apply. finasteride 5 mg.
First-Lansoprazole
Tier 1
Drug Name
abacavir acarbose acebutolol acetazolamide acetazolamide ext-rel acetic acid otic acetic acid/aluminum acetate otic acetic acid/hydrocortisone otic acyclovir capsules, tablets adapalene cream/gel albuterol ext-rel albuterol sulfate nebulizer solution albuterol syrup/tablets alclometasone alendronate alfuzosin ext-rel allopurinol alprazolam alprazolam ext-rel alprazolam orally disintegrating tablets amantadine amcinonide cream, lotion
Tier
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Pharmacy Program
PA Prior Authorization required for members 26 years of age or older. QL 360 vials/90 days or 9 dropper bottles/90 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
amiloride amiloride/hydrochlorothiazide amiodarone amitriptyline amitriptyline/perphenazine amlodipine amlodipine/benazepril ammonium lactate 12% Amnesteem amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ext-rel amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts ext-rel ampicillin anagrelide anastrozole apraclonidine 0.5% eye drops apri aranelle atenolol atenolol/chlorthalidone atropine eye drops, eye ointment atropine/hyoscyamine/scopolamine/phenobarbital Aviane
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA STPA
azathioprine azelastine eye drops azelastine spray azithromycin b complex + c/folic acid bacitracin eye ointment bacitracin/polymyxin B eye ointment baclofen balsalazide balziva benazepril
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
bumetanide buprenorphine (Subutex discontinued) bupropion bupropion ext-rel bupropion HCl SR buspirone butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/aspirin/caffeine butorphanol nasal spray calcipotriene calcitonin-salmon spray calcitriol calcium acetate camila camrese
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL 3 bottles (9 mL total)/30 days
captopril
Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
ciclopirox ciclopirox topical solution 8% cilostazol cimetidine ciprofloxacin ciprofloxacin ext-rel ciprofloxacin eye drops, eye ointment citalopram Claravis clarithromycin
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
cyanocobalamin injection cyclobenzaprine cyclopentolate eye drops cyclophosphamide tablets cyclosporine cyclosporine, modified cyproheptadine danazol
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 SP Call Curascript at 1-877-238-8387
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
10
entacapone Enulose epinastine eye drops epinephrine eplerenone ergocalciferol (D2) errin
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL 2 injectors/each fill STPA Step Therapy Prior Authorization applies to both brand and generic drug.
erythromycin delayed-rel erythromycin ethylsuccinate tablets erythromycin eye ointment erythromycin gel erythromycin solution erythromycin stearate erythromycin/benzoyl peroxide erythromycin/sulfisoxazole estazolam estradiol estradiol transdermal estradiol valerate estradiol/norethindrone acetate estropipate ethambutol ethosuximide etidronate etodolac etodolac ext-rel etoposide capsules exemestane famciclovir famotidine
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 SP Call Curascript at 1-877-238-8387
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
11
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
12
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
13
jolivette junel junel fe kariva ketoconazole ketoconazole 2% ketorolac 0.4% eye drops ketorolac 0.5% eye drops ketorolac tablets labetalol lactulose lamivudine lamivudine/zidovudine lamotrigine latanoprost latanoprost eye drops leena
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA Step Therapy Prior Authorization applies to both brand and generic drug. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
leflunomide Lessina
Tier 1 Tier 1
letrozole
Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
14
malathion maprotiline meclizine meclofenamate medroxyprogesterone acetate mefenamic acid mefloquine megestrol acetate meloxicam
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
15
microgestin fe
Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
16
necon 7/7/7 nefazodone neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment neomycin/polymyxin B/dexamethasone eye drops, eye ointment neomycin/polymyxin B/gramicidin eye drops neomycin/polymyxin B/hydrocortisone eye drops neomycin/polymyxin B/hydrocortisone otic nevirapine Next Choice
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
17
nortriptyline Novarel
Tier 1 Tier 1
nystatin nystatin/triamcinolone ocella ofloxacin ofloxacin eye drops ofloxacin otic Ogestrel
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL 90 capsules/90 days QL oral solution: 90 mL/7 days; tablets/ODT tablets: 4 mg: 9 tablets/7 days; 8 mg: 9 tablets/7 days; 24 mg: 1 tablet/7 days
omeprazole delayed-rel ondansetron orphenadrine ext-rel orphenadrine/aspirin/caffeine oxaprozin oxazepam oxcarbazepine oxybutynin oxybutynin ext-rel oxycodone oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen oxymorphone paromomycin
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
18
potassium chloride ext-rel potassium chloride liquid potassium chloride/potassium bicarbonate/citric acid effervescent tablets 25 mE pramipexole pravastatin prazosin prednisolone acetate 1% eye drops prednisolone sodium phosphate prednisolone sodium phosphate 5 mg/5 mL prednisolone syrup prednisone Pregnyl
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Tier 1 Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
19
quinapril quinapril/hydrochlorothiazide quinine sulfate ramipril ranitidine reclipsen Refissa ribavirin rifampin rimantadine risperidone risperidone orally disintegrating tablets rivastigmine capsules ropinirole salicylic acid salsalate selegiline capsules selegiline tablets selenium sulfide shampoo 2.25% selenium sulfide shampoo 2.5% sertraline sildenafil 20 mg silver sulfadiazine simvastatin
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 SP PA QL Call Accredo at 1-866-344-4874, 90 tablets/30 days STPA STPA PA Prior Authorization required for members 26 years of age and older. SP Call Caremark at 1-800-237-2767
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
20
stavudine sucralfate sulfacetamide 10% eye drops sulfacetamide sodium 10% sulfacetamide/prednisolone phosphate eye drops, eye ointment sulfacetamide/sulfur sulfamethoxazole/trimethoprim sulfasalazine sulfasalazine delayed-rel sulindac sumatriptan
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL STPA tablets: 9 tablets/30 days; injection: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; nasal spray: 5 mg: 2 boxes (12 spray unit devices)/30 days; 20 mg: 1 box (6 spray unit devices)/30 days
tacrolimus capsules tamoxifen tamsulosin temazepam terazosin terbinafine tablets terbutaline tablets terconazole cream terconazole suppositories testosterone cypionate testosterone enanthate tetracycline theophylline ext-rel tablets thioridazine thiothixene tiagabine ticlopidine tilia fe timolol maleate eye drops timolol maleate gel forming solution tinidazole
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL 30 tablets/30 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
21
tri-sprintec
Tier 1
trivora
Tier 1
Tier 1 Tier 1
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
22
zovia 1/50e
Tier 1
Tier 2
Drug Name
Accu-Chek test strips Actimmune Adcirca Advair Diskus Advair HFA Afinitor Alkeran Alrex Amcinonide ointment amlodipine/atorvastatin Amoxapine Ampyra
Tier
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Pharmacy Program
SP PA QL 60 tablets/30 days, Call Accredo at 1-866-344-4874 QL 3 diskus/90 days QL 6 inhalers/90 days SP PA QL 30 tablets/30 days, Call Curascript at 1-877-2388387
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
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Arcalyst Armour Thyroid Asacol Asacol HD Asmanex Astepro Asthma Supplies atorvastatin 10 mg, 20 mg atorvastatin 40 mg, 80 mg atovaquone/proguanil Atripla Atrovent HFA Aubagio Avodart Avonex Avonex Pen Azilect Azopt Banzel Baraclude Benicar Benicar HCT Betaseron Betimol BiDil Bosulif Bydureon Byetta Campral Canasa candesartan/hydrochlorothiazide
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
QL 6 Twisthalers/90 days QL 3 nasal spray units/90 days QL 2 spacers/year; 1 peak flow meter/year NC STPA NC
QL 6 inhalers/90 days SP PA QL 28 tablets/28 day, Call Curascript at 1-877-238-8387 SP QL 4 syringes/vials/28 days, Call Curascript at 1-877-2388387 SP QL Call Curascript at 1-877-238-8387, 4 pens/28 days
PA QL 200 mg tablets: 1440 tablets/90 days; 400 mg tablets: 720 tablets/90 days; 40 mg/mL suspension: 4 bottles/30 days
SP PA QL 100 mg: 120 tablets/30 days; 500 mg: 30 tablets/30 days, Call Curascript at 1-877-238-8387
NC
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
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Cimzia
Tier 2
Ciprodex clindamycin 1%/benzoyl peroxide 5% clobetasol propionate/emollient clopidogrel Coartem Colcrys Combivent Respimat Complera Copaxone Cortifoam Creon Crixivan Cuprimine Cycloset Daraprim Diovan Dipentum Edurant Elixophyllin Emcyt Emtriva Enablex Enbrel Epipen Epipen Jr. Episil Epivir-HBV Epogen
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SP QL 10 vials/14 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-2388387 SP PA QL 25 mg: 8 vials/syringes/28 days; 50 mg: 4 syringes/28 days, Call Curascript at 1-877-238-8387 QL 2 injectors/each fill QL 2 injectors/each fill QL 4 bottles/30 days SP Call Curascript at 1-877-238-8387 SP QL 1 kit (30 syringes)/30 days, Call Curascript at 1-877-238 -8387 QL 24 tablets/180 days QL 60 tablets/30 days QL 6 inhalers/90 days NC
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
25
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
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Humulin Hycamtin oral capsules Increlex Infergen Inlyta Insulin Pen Needles Intelence Intron A irbesartan irbesartan/hydrochlorothiazide Isentress Jakafi Janumet Janumet XR Januvia Juvisync Kaletra Kalydeco ketoconazole foam 2% Kineret Kombiglyze XR Korlym Kuvan lamotrigine ext-rel
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SP PA QL 120 tablets/30 days, Call Curascript at 1-877-2388387 SP PA Call Curascript at 1-877-238-8387 QL 25 mg: 90 tablets/90 days; 50 mg:90 tablets/90 days; 100 mg: 90 tablets/90 days; 200 mg: 270 tablets/90 days; 250 mg: 180 tablets/90 days; 300 mg: 180 tablets/90 days SP PA Call Accredo at 1-866-344-4874 SP Call Curascript at 1-877-238-8387 SP QL Call Curascript at 1-877-238-8387, 6 vials/14 days; Covered under the Prescription Drug Benefit when selfadministered. NC NC PA QL 60 tabs/30 days NC SP PA QL 28 syringes/28 days, Call Curascript at 1-877-2388387 SP Call Curascript at 1-877-238-8387 or Caremark at 1-800237-2767 NC NC QL 120 tablets/30 days; Chewable tablets: 100 mg: 180 tablets/30 days; 25 mg: 720 tablets/30 days SP PA Call Curascript at 1-877-238-8387
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
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Mephyton Mepron Mestinon Timespan Methylin chewable tablets methylphenidate HCl ER Miacalcin inj Migergot suppository modafinil montelukast Morphine suppositories 30 mg Myleran tablets Namenda Nascobal Nasonex Nebusal 6% Necon 10/11
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP QL Call Curascript at 1-877-238-8387, 1 syringe/14 days; Covered under the Prescription Drug Benefit when selfadministered. SP QL 10 vials (1 mL and 1.6 mL)/14 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-238-8387 SP PA QL 120 tablets/30 days, Call Curascript at 1-877-2388387 QL 6 nasal spray units/90 days SP Call Curascript at 1-877-238-8387 NC QL STPA 180 tablets/90 days STPA
Neulasta
Tier 2
Neumega Neupogen
Tier 2 Tier 2
SP PA Call Caremark at 1-800-237-2767. Applies to all Norditropin products including Norditropin Flexpro and Norditropin Nordiflex.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
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Nuvigil olanzapine olanzapine orally disintegrating tablets olanzapine/fluoxetine OneTouch test strips Onglyza Onsolis Orfadin Ovidrel
SP QL 60 buccal films/30 days, Call Curascript at 1-877-2388387 SP PA Call Accredo at 1-866-344-4874 SP Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1866-657-0500
Oxistat Oxsoralen-Ultra OxyContin oxymorphone ext-rel 7.5 mg, 15 mg Oxytrol Pacnex Pegasys Pentasa Perforomist Phoslyra Pilopine HS gel pioglitazone pioglitazone/metformin Prandin Pred Mild Pred-G Prednisolone Phosphate 1% Prefest Prevpac Prezista Pristiq ProAir HFA procarbazine Procrit
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SP QL 10 vials/14 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-2388387 STPA Step Therapy Prior Authorization required for members 18 years of age and older. QL 6 inhalers/90 days QL 180 vials/90 days SP PA QL Call Caremark at 1-800-237-2767, 4 individual vials/28 days; 1 kit (4 vials/syringes)/28 days; 4 pens/28 days QL 120 tablets/30 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
29
Revlimid Reyataz Rheumatrex Ridaura rizatriptan ropinirole ext-rel Sabril Savella Selzentry Sensipar Serevent Diskus Serostim Simcor Simponi Skelid Soriatane Spiriva Sprycel
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
QL STPA orally disintegrating tablets: 9 tablets/30 days; tablets: 9 tablets/30 days QL QL STPA 180 tablets/90 days QL 150 mg: 60 tablets/30 days; 300 mg: 120 tablets/30 days QL 3 diskus/90 days SP PA Call Caremark at 1-800-237-2767 SP PA QL 1 pre-filled syringe or SmartJect autoinjector (50 mg or 0.5 mL)/28 days, Call Curascript at 1-877-238-8387
QL 3 HandiHalers/90 days SP PA QL 20 mg, 50 mg, 70 mg, 80 mg: 60 tablets/30 days; 100 mg, 140 mg: 30 tablets/30 days, Call Curascript at 1-877238-8387 SP PA QL 84 tablets/28 days, Call Curascript at 1-877-2388387 QL 10 mg, 18 mg, 25 mg, 40 mg, 60 mg: 60 capsules/30 days; 80 mg & 100 mg: 30 capsules/30 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
30
Theo-24 Tikosyn TOBI Tracleer triamcinolone nasal spray Trizivir Truvada Tykerb Tyzeka Vagifem Valcyte valsartan/hydrochlorothiazide vancomycin Venofer Vesicare Vexol Vfend oral suspension Vimpat Viracept Viramune XR Viread Vivelle-Dot Votrient Vytorin Vytorin 10/80 mg
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SP PA QL 120 tablets/30 days, Call Curascript at 1-877-2388387 STPA PA QL 150 mL/14 days PA QL oral solution: 1200 mL/30 days; tablets: 180 tablets/90 days QL 10 vials/30 days SP PA QL 180 tablets/30 days, Call Curascript at 1-877-2388387 QL 30 tablets/30 days SP PA Call Accredo at 1-866-344-4874 NC QL 3 nasal spray units/90 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
31
Tier 3
Drug Name
Abilify tablets Abstral Accolate Accuneb Accupril Aceon Aclovate Activella Actonel Actoplus Met Actoplus Met XR Actos Acular Acular LS Adalat CC Adderall Adderall XR Adipex-P Advicor Aggrenox Agrylin
Tier
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Pharmacy Program
QL STPA 30 tablets/30 days QL 32 tablets/30 days QL 360 vials/90 days
STPA
STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. PA
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
32
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
33
Biaxin Biaxin XL Bionect Bleph-10 Blephamide Boniva 150 mg Bontril PDM Bravelle
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 STPA Step Therapy Prior Authorization applies to both brand and generic drug PA SP PA SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Brevicon
Tier 3
Brilinta Bromday Brovana Butrans Bystolic Caduet Cafergot Capital w/Codeine Carafate Carbatrol Cardene SR Cardura Cardura XL Casodex Caverject
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 SP Call Curascript at 1-877-238-8387 QL 180 vials/90 days QL 4 patches/30 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
34
Ciloxan Cipro Cipro HC Otic Citranatal Rx Clarifoam EF Cleocin Cleocin Pediatric Cleocin T Cleocin vaginal cream Cleocin vaginal suppositories Climara Climara Pro Clindesse Clinoril Clobex Clozaril Coenzyme Q10 Colazal Colyte Combigan CombiPatch Combivir Comtan Concept DHA Concept OB Concerta Condylox Copegus Cordarone Cordran Coreg Corgard
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 SP Call Caremark at 1-800-237-2767 STPA Step Therapy Prior Authorization applies to brand name drug only. QL 10 mL/30 days PA
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
35
Cyclogyl Cymbalta
Tier 3 Tier 3
Cytomel Cytotec D.H.E. 45 Daliresp Dantrium Daytrana DDAVP Delestrogen Delos Demadex Demerol Depakene Depakote Depakote ER Depakote Sprinkle Deplin Deprizine suspension Dermotic Desogen
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA Step Therapy Prior Authorization applies to brand name drug only. STPA STPA
Desowen Detrol Detrol LA DiaBeta Diamox Sequels Diastat/Diastat AcuDial Dicopanol suspension
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 1 kit (2 units)/30 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
36
Elmiron
Tier 3
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
37
Evamist Evoclin 1% Evoxac Exelon capsules Exelon Patch Exelon solution Exforge Exforge HCT Famvir Felbatol Feldene Femara Femhrt 0.5 mg/2.5 mcg Femtrace Feriva Ferralet 90 First-BXN First-Duke's Mouthwash First-Mary's Mouthwash First-Omeprazole Flagyl Flarex Flomax
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
38
Forfivo XL Fortical Fragmin Freshkote Frova Furadantin suspension 25 mg/5 mL Gabitril Ganirelix
SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA Step Therapy Prior Authorization applies to both brand and generic drug.
Generess Fe
Tier 3
Geodon Gesticare DHA Glucophage Glucophage XR Glucotrol Glucotrol XL Glucovance Glynase Glyset Golytely Granisol oral solution Grifulvin V tablets Gris-Peg Helidac Horizant Imdur Imitrex
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
QL 45 mL/7 days
QL 60 tablets/30 days QL STPA Step Therapy Prior Authorization applies to brand name drug only., Tablets: 9 tablets/30 days; Injection: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; Nasal Spray: 5 mg: 2 boxes (12 spray unit devices)/30 days; 20 mg: 1 box (6 spray unit devices)/30 days SP PA Call Caremark at 1-800-237-2767
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 STPA Step Therapy Prior Authorization applies to both brand and generic drug.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
39
Lamisil oral granules packet Lamisil tablets Lanoxin lansoprazole delayed-rel lansoprazole soluble tablets
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 4 tablets/30 days total for any combination of Viagra, Cialis, and Levitra; Not covered for men 18 years of age or younger, or for women. (No exceptions)
Tier 3 Tier 3 Tier 3 STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to brand name drug only. QL 1 kit/30 days
Lidovir Lithobid
Tier 3 Tier 3
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
40
Locoid Loestrin
Tier 3 Tier 3
Loestrin 24 Fe
Tier 3
Loestrin Fe
Tier 3
Lomotil Lopressor Lopressor HCT Loprox Lorcet 10/650 Lorcet Plus Lortab 7.5/500 LoSeasonique
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Lotemax Lotensin Lovenox Lumigan Lunesta Luride Lozi-Tabs Luxiq Lyrica Lysteda Macrobid Macrodantin Magnacet Malarone Marnatal-F Mavik Maxair Autohaler
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 3 inhalers/90 days STPA QL 30 tablets/28 days STPA QL STPA 10 tablets/30 days No copayment required for children age 6 months through age 6.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
41
Mobic Modicon
Tier 3 Tier 3
Monurol MoviPrep Moxeza Multaq MUSE Myambutol Myfortic Myrbetriq Mysoline Nalfon Natazia
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL 1 bottle/fill STPA QL 1 bottle/10 days
Natroba
Tier 3
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
42
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
norelgestromin/EE transdermal norethindrone acetate/EE 1/10 and EE 10 norethindrone acetate/EE/iron norethindrone/EE/iron norgestimate/EE Norinyl 1+35
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Novaferrum oral solution Nucort Nulytely Nulytely with Flavor Packs Numoisyn OB Complete caplet
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
43
Ortho Evra
Tier 3
Ortho Micronor
Tier 3
Ortho Tri-Cyclen
Tier 3
Ortho Tri-Cyclen Lo
Tier 3
Ortho-Cept
Tier 3
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
44
Ortho-Novum 1/35
Tier 3
Ortho-Novum 7/7/7
Tier 3
Otozin Ovcon 35
Tier 3 Tier 3
Ovide Pancreaze Pandel Panretin pantoprazole delayed-rel Parafon Forte DSC Parcopa Parlodel Patanol PCE PegIntron Penlac Pennsaid Pepcid suspension Peridex Persantine Pertyze Pexeva PhosLo Picato
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL Picato 0.05%: 1 carton/2-day supply; Picato 0.015%: 1 carton/3-day supply STPA Step Therapy Prior Authorization required for members 18 years of age and older. SP PA QL 4 syringes/vials/28 days, Call Caremark at 1-800237-2767 QL 1 bottle/30 days QL 1 bottle/30 days QL STPA 90 tablets/90 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
45
Plaquenil Plavix Pletal Polytrim Ponstel Potiga Pradaxa Pramosone E PrandiMet Precose Pred Forte Prednisone Intensol Prelone Syrup Premarin Premarin cream Premphase Prempro Prenatal Vitamins Prenexa Preque 10 Prevalite Primsol Prinivil Prinzide Procardia Procentra ProctoFoam-HC Prograf Prometrium Prosed/DS Protopic Proventil HFA Provera Pulmicort Flexhaler Pulmicort Respules
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 6 inhalers/90 days QL STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to both brand and generic drug., 180 vials/90 days STPA QL 6 inhalers/90 days STPA PA PA
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
46
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
47
Select-OB + DHA Selsun Seroquel 100 mg, 200 mg, 300 mg, 400 mg Seroquel 25 mg, 50 mg Seroquel XR Silvadene Silvrstat Sinemet Sinemet CR Singulair Sklice Solaraze Soma 350 mg Somavert Spectracef Sporanox capsules Stalevo Starlix Stavzor Staxyn
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 4 tablets/30 days total for any combination of Viagra, Cialis, Levitra, Stendra, and Staxyn; Not covered for men 18 years of age or younger, or for women. (No exceptions) PA QL sublingual tablets 8 mg/2 mg: 120 sublingual tablets/30 days; sublingual tablets 2 mg/0.5 mg: 90 sublingual tablets/30 days; film 12 mg/3 mg: 60 films/30 days; film 8 mg/2 mg: 90 films/30 days; film 4 mg/1 mg: 90 films/30 days; film 2 mg/0.5 mg: 90 films/30 days QL 30 bottles/30 days QL STPA 4 injections/30 days PA PA PA QL 1 bottle/fill STPA PA STPA
Striant Suboxone
Tier 3 Tier 3
STPA Step Therapy Prior Authorization applies to both brand and generic drug.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
48
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
49
Trusopt Tudorza Pressair Tussionex Ulesfia ulipristal Uloric Ultravate Ultresa Uniretic Univasc Urecholine Uribel Uroxatral Urso Urso Forte Valtrex Vancocin Vanos Vaseretic Vasotec Venlafaxine OSM ER
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to brand name drug only. QL 6 inhalers/90 days QL 9 dropper bottles/90 days QL 50 mg: 56 tablets/14 days; 200 mg: 28 tablets/14 days SP PA QL Prior Authorization required for diagnosis of Pulmonary Hypertension., 4 tablets/30 days total for any combination of Viagra, Cialis, Levitra, Stendra, and Staxyn; Not covered for men 18 years of age or younger, or for women. (No exceptions), Call Accredo at 1-866-344-4874; PA and QL required for diagnosis of Pulmonary Hypertension.
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 1 bottle/10 days SP PA Call Caremark at 1-800-237-2767
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
50
YAZ
Tier 3
Zamicet Zanaflex Zantac Zarontin Zaroxolyn Zebeta Zenpep Zerit Zestoretic Zestril Zetia Ziac Ziagen Zioptan Zirgan Zithromax
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL STPA 90 single-use containers/90 days
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
51
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment
52