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Massachusetts Commercial Formulary Prescription Drug List By Tier

Last Updated: 3/11/2013

Last Updated: 3/11/2013

Key Terms

Tufts Health Plan Drug List

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest 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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest 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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

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

lansoprazole powder for suspension Prevacid Solutab

Proscar test strips

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


amethia amethia lo amethyst 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.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


benazepril/hydrochlorothiazide benzocaine/antipyrine otic benzonatate benzoyl peroxide benztropine betamethasone dipropionate betamethasone dipropionate augmented cream betamethasone dipropionate augmented gel, lotion, ointment betamethasone valerate betamethasone valerate foam betaxolol bethanechol bicalutamide bisoprolol bisoprolol/hydrochlorothiazide brimonidine 0.15% eye drops brimonidine 0.2% eye drops bromfenac sodium eye drops bromocriptine budesonide delayed-release capsules budesonide inhalation suspension 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 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 PA SP Call Curascript at 1-877-238-8387

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


captopril/hydrochlorothiazide carbamazepine carbamazepine ext-rel carbamazepine ext-rel 200 mg, 400 mg carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone carisoprodol 250 mg carisoprodol 350 mg carisoprodol/aspirin carteolol eye drops carvedilol cefaclor cefadroxil cefdinir cefditoren pivoxil cefpodoxime cefprozil cefuroxime axetil cephalexin cevimeline chloral hydrate chlordiazepoxide chlordiazepoxide/clidinium chlorhexidine gluconate chloroquine phosphate chlorpromazine chlorpropamide chlorthalidone chlorzoxazone cholestyramine chorionic gonadotropin 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 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 QL 1 bottle/30 days

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


clarithromycin ext-rel clemastine 2.68 mg clindamycin clindamycin palmitate oral solution clindamycin phosphate foam 1% clindamycin vaginal cream clindamycin/benzoyl peroxide gel clobetasol propionate clobetasol propionate 0.05% clobetasol propionate foam clomiphene clomipramine clonazepam clonidine clonidine transdermal clorazepate clotrimazole clotrimazole (Rx only) clotrimazole troches clotrimazole/betamethasone clozapine codeine sulfate codeine/acetaminophen codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin codeine/guaifenesin/pseudoephedrine codeine/promethazine colestipol Constulose cortisone acetate cromolyn sodium eye drops cromolyn sodium nebulizer solution Cryselle 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 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 QL 360 vials/90 days 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.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


dantrolene dapsone desipramine desmopressin desonide desoximetasone dexamethasone dexamethasone sodium phosphate eye drops, eye ointment Dexferrum dexmethylphenidate dextroamphetamine dextroamphetamine ext-rel dextromethorphan/promethazine diazepam diazepam rectal gel diclofenac potassium diclofenac sodium delayed-rel diclofenac sodium delayed-rel/misoprostol diclofenac sodium eye drops dicloxacillin dicyclomine didanosine delayed-rel diethylpropion diflorasone diacetate diflunisal digoxin dihydroergotamine injection diltiazem diltiazem ext-rel diphenhydramine 50 mg diphenoxylate/atropine dipivefrin eye drops dipyridamole disopyramide disulfiram divalproex sodium delayed-rel divalproex sodium ext-rel divalproex sodium sprinkle donepezil dorzolamide HCl eye drops dorzolamide HCl/timolol maleate eye drops doxazosin doxepin 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 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 PA QL

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

10

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


doxycycline hyclate doxycycline hyclate 20 mg tablets doxycycline monohydrate econazole enalapril enalapril/hydrochlorothiazide enoxaparin enpresse 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.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

11

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


famotidine suspension felbamate felodipine ext-rel fenofibrate 54 mg, 67 mg, 134 mg, 160 mg, 200 mg fenofibric acid fentanyl citrate lollipop fentanyl transdermal finasteride 5 mg flavoxate hydrochloride flecainide fluconazole fludrocortisone flunisolide nasal spray fluocinolone acetonide fluocinolone acetonide oil fluocinonide fluoride drops fluoride tablets fluorometholone eye drops, eye ointment fluorouracil fluoxetine fluoxetine delayed-rel fluphenazine flurazepam flurbiprofen flutamide fluticasone nasal spray fluticasone propionate cream, lotion, ointment fluvoxamine folic acid fondaparinux sodium fosinopril fosinopril/hydrochlorothiazide furosemide gabapentin galantamine galantamine ext-rel ganciclovir gemfibrozil gentamicin gentamicin eye drops, eye ointment gianvi glimepiride 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 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 No copayment required for women age 13 through age 44. QL 3 nasal spray units/90 days QL 3 nasal spray units/90 days QL 120 units (lollipops)/30 days QL 10 patches/30 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

12

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


glipizide glipizide ext-rel glipizide/metformin glyburide glyburide, micronized glyburide/metformin granisetron tablets griseofulvin microsize griseofulvin microsize suspension griseofulvin ultramicrosize guanfacine Guiatuss AC Guiatuss DAC halobetasol propionate haloperidol hydralazine hydrochlorothiazide hydrocodone polistirex/chlorpheniramine polistirex hydrocodone/acetaminophen hydrocodone/acetaminophen 10/650 hydrocodone/acetaminophen 2.5/500 hydrocodone/acetaminophen 7.5/300 hydrocodone/acetaminophen 7.5/500 hydrocodone/acetaminophen 7.5/650 hydrocodone/acetaminophen tablets hydrocodone/homatropine hydrocodone/ibuprofen hydrocortisone hydrocortisone (prescription only) hydrocortisone butyrate hydrocortisone cream hydrocortisone enema hydrocortisone valerate hydrocortisone/aloe polysaccharide/iodoquinol hydromorphone hydroxychloroquine hydroxyzine HCl hydroxyzine pamoate hyoscyamine sulfate hyoscyamine sulfate ext-rel ibandronate 150 mg ibuprofen (Rx Only) imipramine HCl 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 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 STPA Step Therapy Prior Authorization applies to both brand and generic drug. QL 6 tablets/7 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

13

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


imiquimod indapamide indomethacin indomethacin ext-rel indomethacin suppositories ipratropium nasal spray ipratropium nebulizer solution ipratropium/albuterol nebulizer solution iron dextran isoniazid isosorbide dinitrate ext-rel tablets isosorbide mononitrate ext-rel isradipine itraconazole capsules Jinteli jolessa 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. PA QL 6 nasal spray units/90 days QL 360 vials/90 days QL 360 vials/90 days

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

14

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


leucovorin calcium leuprolide acetate 1 mg kit levalbuterol inhalation solution levetiracetam levobunolol eye drops levofloxacin eye drops levora Levothroid levothyroxine Levoxyl lidocaine viscous lidocaine/prilocaine cream Lidocort Rectal kit lindane liothyronine lisinopril lisinopril/hydrochlorothiazide lithium carbonate lithium carbonate ext-rel tablets 300 mg lithium carbonate ext-rel tablets 450 mg loperamide lorazepam losartan losartan/hydrochlorothiazide lovastatin Low-Ogestrel 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 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. No copayment required for children age 6 months through age 6. 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 1 tube/30 days QL STPA 270 vials/90 days, Step Therapy Prior Authorization applies to both brand and generic drug.

loxapine Luride drops Lutera

Tier 1 Tier 1 Tier 1

malathion maprotiline meclizine meclofenamate medroxyprogesterone acetate mefenamic acid mefloquine megestrol acetate meloxicam

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

15

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


meperidine mercaptopurine mesalamine rectal suspension metaproterenol syrup/tablets metformin metformin ext-rel methadone methamphetamine methazolamide methimazole methocarbamol methotrexate methyldopa methylergonovine tablets methylphenidate methylphenidate ext-rel methylphenidate ext-rel 10 mg tablets methylphenidate ext-rel 20 mg, 30 mg, 40 mg methylphenidate ext-rel capsules methylphenidate oral solution methylprednisolone metoclopramide metolazone metoprolol metoprolol ext-rel metoprolol/hydrochlorothiazide metronidazole metronidazole 375 mg capsules metronidazole cream metronidazole gel 0.75% metronidazole lotion metronidazole tablets metronidazole vaginal gel mexiletine microgestin 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 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. 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 STPA STPA

microgestin fe

Tier 1

midodrine minocycline capsules minocycline tablets

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

16

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


mirtazapine misoprostol moexipril moexipril/hydrochlorothiazide mometasone mononessa morphine morphine ext-rel morphine sulfate ext-rel 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg morphine suppositories 5 mg, 10 mg, 20 mg mupirocin mycophenolate mofetil nabumetone nadolol naltrexone naphazoline eye drops naproxen naproxen delayed-rel naproxen sodium naratriptan nateglinide necon 0.5/35 necon 1/35 necon 1/50 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. QL STPA 9 tablets/30 days QL 90 tablets/30 days QL

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.

next choice one dose nicardipine nifedipine 10 mg nifedipine ext-rel

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

17

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


nimodipine nisoldipine ext-rel nitrofurantoin ext-rel nitrofurantoin macrocrystals nitrofurantoin suspension nitroglycerin oral spray nitroglycerin transdermal nizatidine capsules nizatidine oral solution norethindrone acetate nortrel 0.5/35 nortrel 1/35 nortrel 7/7/7 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. SP PA SP 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

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

18

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


paroxetine HCl paroxetine HCl ext-rel peg 3350/electrolytes peg 3350/electrolytes disposable jug penicillin VK pentazocine/naloxone pentoxifylline ext-rel perindopril permethrin 5% perphenazine phenazopyridine phendimetrazine phendimetrazine ext-rel phenobarbital phentermine phenytoin sodium phenytoin sodium ext-rel pilocarpine pindolol piroxicam podofilox polymyxin B/trimethoprim eye drops portia 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. PA PA PA

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.

prenatal vitamins w/folic acid previfem

Tier 1 Tier 1

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

19

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


primidone probenecid prochlorperazine Proctocream-HC 2.5% progesterone, micronized promethazine propafenone propafenone ext-rel propantheline 15 mg propranolol propranolol ext-rel propylthiouracil Prudoxin pyrazinamide pyridostigmine Quasense 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.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

20

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


sotalol sotalol AF spinosad spironolactone spironolactone/hydrochlorothiazide sprintec 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

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

21

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


tizanidine tobramycin eye drops, eye ointment tobramycin/dexamethasone 0.3%/0.1% eye suspension tolterodine topiramate torsemide tramadol tramadol ext-rel tramadol/acetaminophen trandolapril tranexamic acid tranylcypromine trazodone tretinoin tretinoin capsules tretinoin cream/gel triamcinolone acetonide triamcinolone paste triamterene/hydrochlorothiazide capsules 37.5/25 triamterene/hydrochlorothiazide capsules 50/25 triamterene/hydrochlorothiazide tablets 37.5/25 triamterene/hydrochlorothiazide tablets 75/50 triazolam trifluoperazine trifluridine eye drops trihexyphenidyl tri-legest fe trimethobenzamide capsules trimethoprim trimipramine trinessa tri-previfem 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 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. 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. PA SP Call Curascript at 1-877-238-8387 PA Prior Authorization required for members 26 years of age and older. QL 30 tablets/28 days STPA

tri-sprintec

Tier 1

trivora

Tier 1

trospium trospium ext-rel

Tier 1 Tier 1

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

22

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


ubidecarenone Unithroid ursodiol valacyclovir valproic acid Vandazole velivet venlafaxine venlafaxine ext-rel capsules venlafaxine ext-rel tablets verapamil verapamil ext-rel vitamin B-12 voriconazole warfarin zafirlukast zaleplon zidovudine zolpidem zolpidem tartrate CR zonisamide Zovia 1/35e 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. 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 QL QL 10 capsules/30 days QL 50 mg: 56 tablets/14 days; 200 mg: 28 tablets/14 days STPA PA

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

SP PA QL Call Curascript at 1-877-238-8387, 60 tablets/30 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

23

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Androderm AndroGel Anzemet tablets Apidra Apokyn Apriso Aptivus Aranesp Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 SP QL 4 mL/30 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-2388387 SP PA QL 5 vials/28 days for initial 28 days, 4 vials/28 days thereafter, Call Caremark at 1-800-237-2767 QL 3 tablets/7 days

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 QL 15 vials/30 days, Call Curascript at 1-877-238-8387

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

24

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Caprelsa Carbaglu Cayston CeeNU Cefaclor ER Cetrotide Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 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 SP PA QL Cimzia syringes are covered under the pharmacy benefit only, prior authorization applies. Cimzia vials are covered under the medical benefit only, prior authorization applies. Available to providers through Curascript, call 1-877238-8387., 2 injections (syringes/vials)/28 days, Call Curascript at 1-877-238-8387 SP Call Curascript at 1-877-238-8387 PA QL 100 mg: 60 tablets/30 days; 300 mg: 30 tablets/30 days PA

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

25

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


eprosartan Epzicom Erivedge Ery-Tab escitalopram Estrace cream Estring etonogestrel/EE ring Eurax Evista Exjade Extavia Fazaclo Femring fenofibrate 48 mg, 145 mg Ferriprox Finacea Firazyr First-Progesterone VGS Flovent Diskus Flovent HFA Fluoroplex fluvastatin Foradil Aerolizer Forteo Fosrenol Fuzeon Galzin Gelclair Gelnique Gilenya Gleevec Glucagon Golytely packets Gonal-F 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 Tier 2 Tier 2 Tier 2 Tier 2 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 SP PA QL 28 tablets/28 days, Call Curascript at 1-877-2388387 SP Call Curascript at 1-877-238-8387 SP Call Curascript at 1-877-238-8387 NC QL 3 inhalers/90 days SP PA Call Curascript at 1-877-238-8387 QL 6 diskus/90 days QL 6 inhalers/90 days SP PA QL 1 unit (3 mL)/fill, Call Caremark at 1-800-237-2767 NC PA QL 30 tablets/30 days SP QL 15 vials/30 days, Call Curascript at 1-877-238-8387 STPA SP PA Call Curascript at 1-877-238-8387 NC

Halflytely Hectorol Hepsera Humalog

Tier 2 Tier 2 Tier 2 Tier 2

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

26

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Humira Tier 2 SP PA QL Call Curascript at 1-877-238-8387, 2 syringes/28 days; One Crohn's Disease / Ulcerative Colitis starter pack (6 pens) as a one-time fill only; One Psoriasis starter pack (4 pens) as a one-time fill only SP PA QL 0.25 mg: 15 capsules/21 days; 1 mg: 25 capsules/21 days, Call Curascript at 1-877-238-8387 SP PA Call Caremark at 1-800-237-2767 SP PA SP PA Call Caremark at 1-800-237-2767 SP PA Call Curascript at 1-877-238-8387

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

Lantus Letairis Leukeran Leukine

Tier 2 Tier 2 Tier 2 Tier 2

Levemir levetiracetam ext-rel levofloxacin levofloxacin tablets Lexiva Lidoderm

Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 PA QL 30 patches/30 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

27

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Lithium Citrate Lodosyn Lotronex Matulane Menopur Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Drug is available through Accredo 1-866-344-4874 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

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

Nexavar Niaspan Nifedipine 20 mg Nitrostat Norditropin Products

Tier 2 Tier 2 Tier 2 Tier 2 Tier 2

SP PA Call Caremark at 1-800-237-2767. Applies to all Norditropin products including Norditropin Flexpro and Norditropin Nordiflex.

norethindrone/EE Norvir Novolin Novolog Nuedexta

Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 PA

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

28

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Nuvaring Tier 2 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 STPA 90 tablets/90 days STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization applies to both brand and generic drug.

Nuvigil olanzapine olanzapine orally disintegrating tablets olanzapine/fluoxetine OneTouch test strips Onglyza Onsolis Orfadin Ovidrel

Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

29

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Promacta Pulmozyme Pylera quetiapine 100 mg, 200 mg, 300 mg, 400 mg quetiapine 25 mg, 50 mg QVAR Ranexa Rapamune Rebif Regranex Relenza Relistor Renagel Renvela Repronex 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 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 SP PA Call Curascript at 1-877-238-8387 QL 20 units/365 days SP QL Call Curascript at 1-877-238-8387, 12 syringes/28 days STPA PA QL 6 inhalers/90 days SP PA QL 30 tablets/30 days, Call Curascript at 1-877-2388387

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

Stivarga Strattera Stribild Sustiva

Tier 2 Tier 2 Tier 2 Tier 2

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

30

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Sutent Sylatron Symbicort Synarel Tabloid Tamiflu capsules Tarceva Targretin Tasigna Tasmar Tazorac Tegretol-XR 100 mg Temodar 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 5 mg & 140 mg: 15 capsules/21 days; 20 mg & 100 mg: 20 capsules/21 days; 180 mg & 250 mg: 10 capsules/21 days, Call Curascript at 1-877-238-8387 PA Prior Authorization required for members 26 years of age and older. SP Call Curascript at 1-877-238-8387 QL 10 capsules/365 days SP QL 150 mg & 100 mg: 30 tablets/30 days; 25 mg: 90 tablets/30 days, Call Curascript at 1-877-238-8387 SP Call Curascript at 1-877-238-8387 SP PA Call Curascript at 1-877-238-8387 SP PA Call Curascript at 1-877-238-8387 SP PA QL Call Curascript at 1-877-238-8387, 4 vials/28 days QL 6 inhalers/90 days

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

31

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Xalkori Xeloda Xenazine Xtandi Zavesca Zelboraf Zemplar ziprasidone HCl Zolinza Zorbtive Zortress Zovirax cream/ointment Zytiga Zyvox 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 STPA Step Therapy Prior Authorization applies to both brand and generic drug. SP PA Call Curascript at 1-877-238-8387 SP PA Call Caremark at 1-800-237-2767 QL 180 tablets/90 days QL 1 tube/30 days SP PA QL 120 tablets/30 days, Call Curascript at 1-877-2388387 SP PA Call Curascript at 1-877-238-8387 SP QL Call Curascript at 1-877-238-8387, 150 mg: 84 capsules/14 days; 500 mg: 168 capsules/14 days SP PA QL 12.5 tablets: 90 tablets/30 days; 25 mg tablets: 120 tablets/30 days, Call Caremark at 1-800-237-2767 SP PA QL 120 capsules/30 days, Call Curascript at 1-877-2388387 SP PA Call Curascript at 1-877-238-8387 SP PA Call Curascript at 1-877-238-8387

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

32

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Aldara Alinia Alocril Alomide Alora Alphagan P 0.1% Alphagan P 0.15% Alsuma Altabax Alvesco Amaryl Amerge Amitiza Amturnide Angeliq Antabuse Antivert Aplenzin Aralen Arava Aricept Arimidex Arixtra Aromasin Arthrotec Astelin Atabex EC Atralin Atrovent nasal aerosol Augmentin Augmentin XR Avinza Avita Axert Axid oral solution Aygestin Azasite Azelex Azor Azulfidine 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 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 1 bottle/7 days QL 60 capsules/30 days PA Prior Authorization required for members 26 years of age or older. QL STPA 6 tablets/30 days PA Prior Authorization required for members 26 years of age and older. QL 6 nasal spray units/90 days QL 3 nasal spray units/90 days STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization required for members 18 years of age and older. QL STPA 9 tablets/30 days, Step Therapy Prior Authorization applies to brand name drug only. QL STPA 4 injections (4 vials)/30 days QL 1 tube/5 days QL 80 mcg: 3 inhalers/90 days; 160 mcg: 6 inhalers/90 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

33

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Azulfidine EN-Tablets Bactrim/Bactrim DS Bactroban Bactroban nasal ointment Bentyl Benzac AC Benzaclin Gel Benzamycin Besivance Betagan Betapace Betapace AF Betoptic S Beyaz 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 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/5 days

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

34

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Cedax Ceftin Celebrex Cellcept Cenestin Cesamet Cetraxal Cialis Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL Erectile Dysfunction: 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); Symptomatic Benign Prostatic Hyperplasia: 30 tablets/30 days QL 18 capsules/7 days PA

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

35

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Cortef Cortisporin Corvite 150 Cosopt Cosopt PF Coumadin Crinone Cutivate Cyclessa 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. QL STPA 20 mg: 60 capsules/30 days; 30 mg: 60 capsules/30 days; 60 mg: 30 capsules/30 days, Step Therapy Prior Authorization required for members 18 years of age and older.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

36

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Didronel Differin cream/gel Differin lotion Dificid Diflucan Digex NF Dilantin Dilantin Infatabs Diovan HCT Diprolene Diprolene AF Ditropan XL Divigel Donnatal Doryx Dovonex Drisdol drospirenone/EE/levomefolate 0.3/30 and levomefola drospirenone/EE/levomefolate and levomefolate Duac Duetact DuoNeb Duragesic Dutoprol Dyazide E.E.S. 200 suspension EC-Naprosyn Edecrin Edex Effer-K 10 mEq, 20 mEq Effient Efudex Egrifta Eldepryl Elestat Elestrin Eletone Elidel Ella 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 Tier 3 Tier 3 Tier 3 Tier 3 STPA QL 1 tablet/fill, 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 PA Call Curascript at 1-877-238-8387 QL 360 vials/90 days NC QL 10 patches/30 days, fentanyl patch PA Prior Authorization required for members 26 years of age or older. PA Prior Authorization required for members 26 years of age or older. PA

Elmiron

Tier 3

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

37

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Elocon Emadine Emend Emsam Endometrin Enjuvia Entocort EC Epivir tablets Equetro Ertaczo Estrace estradiol valerate and dienogest/estradiol valerat Estrasorb Estrogel Estrostep Fe 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., 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 1 bottle/each fill QL 40 mg: 1 capsule/7 days; 80 mg: 2 capsules/7 days; 125 mg: 1 capsule/7 days; 1 dosepack/7 days STPA Step Therapy Prior Authorization required for members 18 years of age and older.

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

QL 300 mL/30 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

38

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Flumadine FML Focalin XR Follistim AQ Tier 3 Tier 3 Tier 3 Tier 3 STPA 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 STPA

Forfivo XL Fortical Fragmin Freshkote Frova Furadantin suspension 25 mg/5 mL Gabitril Ganirelix

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3

QL STPA 9 tablets/30 days

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

Imuran Incivek Infed Innopran XL Inspra

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

39

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Integra F Integra Plus Intuniv Iopidine 0.5% Iopidine 1% Irospan Jalyn Jentadueto Kadian 10 mg, 200 mg Kadian 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg Kapvay Keflex Keppra Keralyt Kerlone Klaron Lac-Hydrin Lamictal Lamictal ODT Lamictal XR 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 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 QL 125 mg packets: 56 packets/28 days; 187.5 mg packets: 28 packets/28 days QL 30 tablets/30 days QL STPA 90 capsules/90 days NC QL STPA 90 solutabs/90 days, Prevacid Solutab and generic lansoprazole soluble tablets are covered for members 12 years of age and younger. Quantity Limitations apply. QL 1 box (4 bottles)/28 days STPA QL 60 capsules/30 days QL 60 capsules/30 days QL 90 tablets/90 days

Lamisil oral granules packet Lamisil tablets Lanoxin lansoprazole delayed-rel lansoprazole soluble tablets

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3

Lasix Lazanda Levatol Levbid Levitra

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)

levofloxacin eye drops Levsin Lexapro

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

40

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Lo Loestrin Fe 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. 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. 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., 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.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

41

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Maxalt/Maxalt-MLT Maxaron Forte Maxitrol Maxzide Maxzide-25 Medrol Megace suspension Menest Menostar Mestinon Metadate CD Metozolv ODT MetroCream MetroGel 1% MetroGel-Vaginal MetroLotion Miacalcin nasal Migranal Millipred Minipress Mirapex Mirapex ER Mircette 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 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. QL 1 box (8 vials)/30 days STPA Step Therapy Prior Authorization applies to brand name drug only. QL 120 tablets/30 days QL STPA 9 tablets/30 days

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

42

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Neevo DHA Neoral Neosporin Nephrocaps Neupogen/Single-Ject Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 SP QL Call Curascript at 1-877-238-8387, 10 syringes/14 days; Covered under the Prescription Drug Benefit when selfadministered. QL 30 patches/30 days

Neupro Neurontin Nevanac Next Choice

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.

Niron Komplete Nitro-Dur Nitrolingual Nizoral shampoo Nordette

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.

Noritate Noroxin Norpace Norpace CR Nor-QD

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

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

43

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


OB Complete DHA Obtrex DHA Ocuflox Oleptro ER Olux foam 0.05% omeprazole/sodium bicarbonate capsules Onfi Optase Optivar Orapred Orapred ODT Orbivan Orbivan CF Orencia 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 PA QL 4 syringes/28 days, Orencia vials only are covered under the medical benefit, prior authorization applies. Available through Curascript, call 1-877-238-8387., Call Curascript at 1877-238-8387 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., 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., 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. 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. NC QL STPA 90 capsules/90 days PA STPA Step Therapy Prior Authorization required for members 18 years of age and older.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

44

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Ortho-Cyclen 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., 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. 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. 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.

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

45

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Plan B One-Step 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.

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

Purinethol Pyridium Qsymia

Tier 3 Tier 3 Tier 3 PA

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

46

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Qualaquin Radiogardase Razadyne Razadyne ER Rebetol Rectiv Ointment Regimex Reglan Relpax Remeron Remeron Soltab Requip Requip XL Restasis Retin-A Retin-A Micro Retrovir Revatio Revia Rifadin Risperdal Risperdal M-Tab Ritalin Ritalin LA Ritalin-SR Robaxin Rocaltrol Rowasa Rozerem Rythmol Rythmol SR Safyral 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 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 STPA 10 tablets/30 days STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. SP PA QL 90 tablets/30 days, Call Accredo at 1-866-344-4874 QL 90 tablets/90 days PA PA Prior Authorization required for members 26 years of age and older. PA Prior Authorization required for members 26 years of age and older. QL STPA 6 tablets/30 days SP Call Caremark at 1-800-237-2767 QL 1 tube/30 days PA

Salagen Salex Samsca Sanctura Sanctura XR

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 QL 14 tablets/7 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

47

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Sancuso Sandimmune Sarafem tablets Seasonique Tier 3 Tier 3 Tier 3 Tier 3 STPA Step Therapy Prior Authorization required for members 18 years of age and older. 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. QL 1 patch/7 days

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

Subsys Sumavel Dosepro Suprax Suprenza Suprep Surmontil Symbyax

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.

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

48

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


SymlinPen Synthroid Tambocor Tamiflu suspension Tandem DHA Tandem OB Tapazole Tarka Tegretol Tegretol-XR Tekamlo Tekturna Tekturna HCT Temovate Terazol 3 suppositories Terazol Vaginal cream Tessalon Perles Testim Thalomid Tigan capsules Timoptic Timoptic-XE Tindamax Tirosint Tobradex Tobradex ointment Tobradex ST Tobrex Topamax Topicort Toprol-XL Tradjenta Trandate Transderm Scop Travatan Z Trental Tretin-X Tricare DHA Trileptal 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 Tier 3 Tier 3 Tier 3 Tier 3 PA Prior Authorization required for members 26 years of age and older. STPA STPA SP Call Curascript at 1-877-238-8387 QL 180 mL/365 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

49

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Tri-Norinyl 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. QL 3 inhalers/90 days QL 6 bottles/7 days QL STPA

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.

Ventolin HFA Ventolin nebulizer solution Veripred 20 Vfend tablets Viagra

Tier 3 Tier 3 Tier 3 Tier 3 Tier 3

Vibramycin Victoza Victrelis Videx EC Vigamox Viokace Viramune

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

50

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Viroptic Vistaril Vitafol-OB + DHA Viva DHA Vol-Tab Rx Voltaren gel 1% Voltaren ophthalmic solution Vospire ER Vyvanse Welchol Westcort Xarelto 10 mg Xarelto 15 mg, 20 mg Xclair Xenical Xifaxan Xodol Xopenex HFA Xopenex inhalation solution Xyrem Yasmin 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 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. QL 6 inhalers/90 days QL STPA Step Therapy Prior Authorization applies to both brand and generic drug., 270 vials/90 days PA PA QL 200 mg tablets: 9 tablets/30 days; 550 mg tablets: 60 tablets/30 days QL 35 tablets/fill QL 15 mg: 60 tablets/30 days; 20 mg: 30 tablets/30 days STPA QL 2 tubes/each fill

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

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

51

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013


Zmax Zolvit Zomig/Zomig-ZMT Zonalon Zonegran Zovirax Zuplenz Zyclara Cream Zyflo Zylet Zyloprim Zyprexa Zyprexa Zydis 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 applies to both brand and generic drug. STPA Step Therapy Prior Authorization applies to both brand and generic drug. QL 10 films/7 days QL 1 box or 1 pump bottle/30 days QL STPA 2.5 mg: 6 tablets/30 days; 5 mg: 3 tablets/30 days; Nasal spray: 1 box (6 spray units)/30 days

Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion Tier 1 - Lowest Copayment

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

52

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

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