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4 TIER SPECIALTY DRUG LIST
To search this list, click on the drug or therapeutic class below and scroll through the list.
ANESTHETICS
ANTIINFECTIVES
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
CARDIOVASCULAR MEDICATIONS
AUTONOMIC & CNS MEDICATIONS
DERMATOLOGICAL MEDICATIONS
EAR-NOSE-THROAT MEDICATIONS
ENDOCRINE MEDICATIONS
GASTROINTESTINAL MEDICATIONS
Or, click this
Search
button and enter the name of the drug in the pop-up task pane. *
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
MUSCULOSKELETAL MEDICATIONS
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
OPHTHALMIC MEDICATIONS
RESPIRATORY MEDICATIONS
UROLOGICAL MEDICATIONS
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
Tier 2
Tier 3
Tier 4 Specialty
CETACAINE
QUTENZA (PA/QL)
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ANESTHETICS
Topical Anesthetics
lidocaine gel (Anamantle HC)
lidocaine patch (Lidoderm)
lidocaine viscous
lidocaine/prilocaine (Emla)
tetracaine
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 1 of 35
* Please note: If the Search button does not work in the browser you are using, use the search feature within your web browser.
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ANTIINFECTIVES
Oral Antibacterial
Drugs
Oral Antifungal Drugs
 amoxicillin (Amoxil)
amoxicillin/clavulanate
(Augmentin/Augmentin
XR/Augmentin ES Susp)
ampicillin (Principen)
atovaquone (Mepron) (PA)
 azithromycin (Zithromax)
cefaclor (Ceclor/Ceclor CD)
cefadroxil (Duricef)
cefdinir (Omnicef)
cefpodoxime (Vantin)
cefprozil tabs and susp (Cefzil)
cefuroxime (Ceftin)
 cephalexin (Keflex)
cephradine (Velosef)
 ciprofloxacin (Cipro)
ciprofloxacin ER (Cipro XR)
clarithromycin/ER (Biaxin/XL)
clindamycin (Cleocin)
dicloxacillin (Dycill)
 doxycycline (Vibramycin)
 erythromycin (Ery-Tab)
erythromycin/sulfisoxazole
(Pediazole)
levofloxacin (Levaquin)
minocycline (Dynacin)
moxifloxacin (Avelox)
nitrofurantoin (Macrodantin)
ofloxacin (Floxin)
 penicillin VK (Beepen VK)
 sulfamethoxazole/trimethoprim
(Bactrim)
sulfisoxazole (Gantrisin)
tetracycline (Sumycin)
trimethoprim (Trimpex)
vancomycin
clotrimazole troche
(Mycelex Troche)
fluconazole (Diflucan)
griseofulvin (Gris-PEG)
itraconazole (Sporanox) (PA) (QL)
ketoconazole (Nizoral)
nystatin (Mycostatin)
terbinafine (Lamisil)
voriconazole (VFend) (QL)
Use Tier 1 antiinfective agent! i.e.
azithromycin
(Zithromax) for a
lower copayment
VANCOCIN
CEDAX
COARTEM (PA)
DIFICID (PA)
FACTIVE
KETEK
MOXATAG
NOROXIN
SUPRAX
ZMAX
ZYVOX (QL)
LAMISIL GRANULES
NOXAFIL
ORAVIG (ST/QL)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 2 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ANTIINFECTIVES
Oral Antiviral Drugs –
Antiretrovirals for HIV
didanosine (Videx EC)
EMTRIVA
INTELENCE
ISENTRESS
lamivudine (Epivir)
stavudine (Zerit)
SUSTIVA
TIVICAY
VIRAMUNE
VIREAD
ZIAGEN
zidovudine 300mg and
50mg/5ml syrup
(Retrovir)
Oral Antiviral Drugs –
Protease Inhibitors
AGENERASE
APTIVUS
CRIXIVAN
INVIRASE
KALETRA
NORVIR
REYATAZ
VIRACEPT
Oral Antiviral Drugs –
Combinations
ATRIPLA
COMBIVIR
COMPLERA
EPZICOM
PREZISTA
STRIBILD
TRIZIVIR
TRUVADA
CCR5 Antagonist
SELZENTRY
Other Antiviral Drugs
*Dispensing limited to
a 30-day supply
acyclovir (Zovirax Capsules)
amantadine (Symmetrel)
famciclovir (Famvir)
valacyclovir (Valtrex)
P = Preferred
CYTOVENE
RELENZA (QL)
TAMIFLU (QL)
BARACLUDE
HEPSERA
VALCYTE (QL)
EPIVIR HBV
FUZEON (PA)
ribavirin (Copegus) (PA)
ribavirin (Rebetol) (PA)
OLYSIO (PA/SP)* P
RIBAPAK (PA)
(*Pls use Ribavirin*)
SOVALDI (PA/SP)* P
VICTRELIS (PA/SP)*
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 3 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
ALINIA (QL)
COARTEM (PA)
FANSIDAR
IMPAVIDO (PA)
NEBUPENT
SKLICE
SIRTURO
STROMECTOL
TINDAMAX (QL)
XIFAXAN
CAYSTON (PA)
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ANTIINFECTIVES
Other Anti-infective
Drugs
atovaquone/proguanil (Malarone)
(PA)
chloroquine (Aralen) (PA)
ethambutol (Myambutol)
hydroxychloroquine (Plaquenil)
isoniazid
mebendazole (Vermox)
mefloquine (Lariam) (PA)
metronidazole (Flagyl)
neomycin
paromomycin (Humatin)
pyrazinamide
quinine (Qualaquin) (PA)
rifampin (Rifadin)
Topical Antibacterial
Drugs
gentamicin (Garamycin)
mupirocin (Bactroban)
silver sulfadiazine (Silvadene)
ALTABAX
Topical Antifungal
Drugs
ciclopirox 0.77% topical (Loprox)
ciclopirox 8% (Penlac)
clotrimazole/betamethasone
(Lotrisone)
econazole (Spectazole)
ketoconazole (Nizoral)
nystatin (Mycostatin)
nystatin/triamcinolone (Mycolog)
Terbinafine (Lamisil)
CNL Nail Kit (PA)
ECOZA (ST)
ERTACZO
EXELDERM
EXTINA
JUBLIA (PA)
KERYDIN (PA)
LUZU (ST)
NAFTIN
OXISTAT
VUSION (PA)
Topical Antiviral Drugs
DAPSONE
DARAPRIM
MYCOBUTIN
PRIMAQUINE
DENAVIR
ZOVIRAX
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 4 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
Alkylating Agents/
Antimetabolites
mercaptopurine (Purinethol)
Adrogens, Estrogens,
Progestins and
Related Drugs
anastrozole (Arimidex)
bicalutamide (Casodex)
exemestane (Aromasin)
flutamide (Eulexin)
letrozole (Femara)
megestrol (Megace)
tamoxifen (Nolvadex)
Immunosuppressant
Drugs
prednisone (Deltasone)
Allergenic Extracts
CEENU
LEUKERAN
MYLERAN
THIOGUANINE
cyclophosphamide
(Cytoxan)
melphalan (Alkeran)
methotrexate
VALCHLOR (PA/QL)
HALOTESTIN (PA)
MEGACE ES
azathioprine (Imuran)
cyclosporine (Neoral,
Sandimmune)
mycophenolate mofetil
(Cellcept)
MYFORTIC
sirolimus (Rapamune)
tacrolimus (Prograf)
GRASTEK (PA)
ORALAIR (PA)
RAGWITEK (PA)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 5 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
Miscellaneous
Antineoplastic Drugs
anagrelide (Agrylin)
hydroxyurea (Hydrea)
leucovorin
*Dispensing limited to
a 30-day supply
ConnectiCare has a
pharmacy that
specializes in these
medications. Please
call Member Services
to inquire what they
can provide you.
This Formulary List is subject to change.
MATULANE
TARGRETIN (SP)
AFINITOR (PA/SP)*
ARZERRA (PA/MB)
AVASTIN (PA/MB)
BOSULIF (PA/SP/QL)*
capecitabine (Xeloda)
(PA/SP)*
CAPRELSA (PA/SP)*
COMETRIQ
(PA/QL/SP)*
ERIVEDGE
(PA/SP/QL)*
FOLOTYN (PA/MB)
GAZYVA (PA/SP)*
GILOTRIF (PA/SP/QL)*
GLEEVEC (PA/SP)*
HYCAMTIN (PA/SP)*
IMBRUVICA
(PA/SP/QL)*
INLYTA (PA/SP/QL)*
ICLUSIG (PA/QL/SP)*
ISTODAX (PA/SP)*
JAKAFI (PA/SP/QL)*
MEKINIST (PA/SP)*
NEXAVAR (PA/SP)*
OFORTA (PA/SP)*
POMALYST (PA/SP)*
REVLIMID (PA/SP)*
SPRYCEL (PA/SP)*
STIVARGA
(PA/QL/SP)*
SUTENT (PA/QL/SP)*
SYLATRON (PA/SP)*
SYNRIBO (PA/QL/SP)*
TAFLINAR (PA/SP)*
TARCEVA (PA/QL/SP)*
TASIGNA (PA/SP)*
temozolomide
(Temodar) (PA/SP)*
THALOMID
(PA/QL/SP)*
TORISEL (PA/SP)*
TREANDA (PA/MB)
TYKERB (PA/QL/SP)*
VECTIBIX (PA/MB)
VOTRIENT (PA/SP)*
XALKORI (PA/SP)*
XOFIGO (PA/MB/)*
XTANDI (PA/SP)*
ZALTRAP (PA/MB)
ZELBORAF
(PA/SP/QL)*
ZOLINZA (PA/SP)*
ZORTRESS (PA/SP)*
ZYDELIG (PA/SP)*
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ZYKADIA (PA/SP)*
4 Tier Specialty
Drug List | Effective Oct 2014
Z
Page 6 of 35
Z
ZYTIGA (PA/SP/QL)*
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
CARDIOVASCULAR MEDICATIONS
Antiarrhythmics
digitek
digoxin (Lanoxin)
Calcium Antagonists
 amlodipine (Norvasc)
diltiazem (Cardizem)
diltiazem er/sr/xr (Cardizem
CD/Cartia XT/ Diltiazem CD)
felodipine/er (Plendil)
nicardipine (Cardene)
nifedipine (Procardia)
 nifedipine er/xl
(Procardia XL)
nimodipine (Nimotop) (PA)
nisoldipine (Sular)
verapamil (Calan)
verapamil sr
(Calan SR)
Diuretics
amiloride (Midamore)
amiloride/hctz (Moduretic)
chlorthalidone (Hygroton)
bumetanide (Bumex)
eplerenone (Inspra)
 furosemide (Lasix)
 hydrochlorothiazide
metolazone (Zaroxolyn)
indapamide (Lozol)
spironolactone (Aldactone)
spironolactone/hctz (Aldactazide)
torsemide (Demadex)
 triamterene/hctz (Dyazide)
Beta-Adrenergic
Antagonist Drugs
acebutolol (Sectral)
 atenolol (Tenormin)
bisoprolol (Zebeta)
 metoprolol (Lopressor)
metoprolol succinate (Toprol XL)
nadolol (Corgard)
pindolol (Visken)
propranolol/propranolol ER
(Inderal/LA)
sotalol (Betapace)
Alpha-Beta
Antagonists
 carvedilol (Coreg)
labetalol (Trandate)
Consider Best Buy
options first!
CARDIZEM LA
Consider Best Buy
options first!
CARDENE SR
DYNACIRC CR
EDECRIN
Consider Tier 1 &
Best Buy options
first!
INDERAL XL (ST)
BYSTOLIC
DUTOPROL
INNOPRAN XL
COREG CR (PA) Use
generic carvedilol
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 7 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
CARDIOVASCULAR MEDICATIONS
Other
Antihypertensive
Drugs
clonidine (Catapres/TTS)
 doxazosin (Cardura)
guanfacine (tenex)
methyldopa (Aldomet)
hydralazine (Apresoline)
prazosin (Minipres)
terazosin (Hytrin)
Angiotensin
Converting Enzyme
Inhibitors
and
Angiotensin II
Receptor Antagonists
captopril (Capoten)
 benazepril (Lotensin)
enalapril (Vasotec)
Antihypertensive
Combinations
Vasodilating Drugs
TEKAMLO (ST)
TEKTURNA (ST)
VALTURNA (ST)
Use Tier 1 ACE
inhibitors ! i.e.
Lisinopril (Zestril) for
a lower copayment
candesartan
(Atacand)
BENICAR (ST)
valsartan (Diovan)
Use Tier 1 ACE
inhibitors ! i.e.
Lisinopril (Zestril) for a
lower copayment
EDARBI (ST)
 amlodipine/benazepril (Lotrel)
atenolol/chlorthalidone (Tenoretic)
 benazepril/HCTZ (Lotensin
HCT)
bisoprolol/hctz (Ziac)
captopril/hctz (Capozide)
enalapril/HCTZ (Vaseretic)
fosinopril/HCTZ (Monopril HCT)
hydralazine/hctz (Apresazide)
irbesartan/HCTZ (Avalide)
 lisinopril/hctz (Prinzide,
Zestoretic)
 losartan HCTZ (Hyzaar)
methyldopa/hctz (Aldoril)
metoprolol/HCTZ (Lopressor HCT)
moexipril/HCTZ (Uniretic)
propranolol/hctz (Inderide)
quinapril/hctz (Accuretic)
telmisartan/amlodipine (Twynsta)
telmisartan/HCTZ (Micardis HCT)
trandolapril/verapamil (Tarka)
 valsartan/hctz (Diovan HCT)
Use Tier 1
Combination
products, like
generic Zestoretic
for a lower
copayment!
AZOR (ST)
BENICAR/HCT (ST)
candesartan/hctz
(Atacand HCT)
EXFORGE (ST)
EXFORGE HCT
(ST)
TRIBENZOR (ST)
Use Tier 1
Combination products,
like generic Zestoretic
for a lower copayment!
AMTURNIDE (ST)
BIDIL
EDARBYCLOR (ST)
TEVETEN HCT (ST)
dipyridamole (Persantine)
isosorbide dinitrate (Isordil)
isosorbide mononitrate (Ismo)
nitroglycerin (Nitrobid, Nitro-Dur)
papaverine (Pavabid)
NITROLINGUAL
SPRAY
RANEXA
eprosartan (Teveten)
irbesartan (Avapro)
fosinopril (Monopril)
 lisinopril (Prinvil, Zestril)
 losartan (Cozaar)
moexipril (Univasc)
quinapril (Accupril)
ramipril (Altace)
telmisartan (Micardis)
trandolapril (Mavik)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 8 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
CARDIOVASCULAR MEDICATIONS
Antidysrhythmic
Drugs
amiodarone (Cordarone)
disopyramide/CR (Norpace/CR)
flecainide (Tambocor)
mexiletine (Mexitil)
procainamide/SR (Procan/SR)
propafenone/ER (Rythmol/SR)
sotalol (Betapace)
Antilipidemic DrugsHMG-CoA Reductase
Inhibitors/
Combinations
 atorvastatin (Lipitor)
atorvastatin/amlodipine (Caduet)
 lovastatin (Mevacor)
 pravastatin (Pravachol)
 simvastatin (Zocor)
Use generic options
first!
ADVICOR
CRESTOR (ST/QL)
Use generic options
first!
ALTOPREV (ST)
LESCOL/XL (ST/QL)
LIPTRUZET (ST/QL)
LIVALO (ST/QL)
VYTORIN (ST/QL)
Antilipidemic Drugs –
Other
cholestyramine (Questran)
colestipol (Colestid)
 fenofibrate 54mg, 160mg or
200mg
fenofibrate micronized (Lofibra)
(ST)
gemfibrozil (Lopid)
omega-3 acid ethyl esters (Lovaza)
(PA)
fenofibrate 48mg,
145 mg (Tricor)
fenofibric acid
(Trilipix)
nicotinic acid
(Niaspan)
SIMCOR
WELCHOL (ST)
ZETIA (QL)
ANTARA (ST)
EPANOVA (PA)
FENOGLIDE (ST)
FIBRICOR (ST)
JUXTAPID (PA)
KYNAMRO (PA)
LIPOFEN
OMTRYG (PA)
TRIGLIDE (ST)
VASCEPA (PA)
Other Cardiovascular
Drugs
midodrine (Proamatine)
pentoxifylline (Trental)
LETAIRIS
(PA/QL/SP)* P
*Dispensing limited to
a 30-day supply
P = Preferred
MULTAQ
RYTHMOL SR
TIKOSYN
JUXTAPID (PA)
ADCIRCA (PA/SP)*
ADEMPAS (PA/SP)*
NORTHERA (PA)
OPSUMIT (PA/SP)*
ORENITRAM (PA/SP)*
REMODULIN (PA/SP)*
sildenafil (Revatio)
(PA/QL/SP)*
TRACLEER (ST/QL/SP)*
TYVASO (PA/QL)*
VENTAVIS (PA/SP)*
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 9 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
AUTONOMIC & CNS MEDICATIONS
Non-narcotic
Analgesics
 tramadol (Ultram)
tramadol/acetaminophen (Ultracet)
tramadol ER
(Ultram ER) (PA)
Use tramadol first
PRIALT (PA)
Class II Narcotics—
Short Acting
codeine
fentanyl lozenge (Actiq) (PA/QL)
hydromorphone (Dilaudid)
levorphanol
meperidine (Demerol)
methadone
morphine sulfate
oxycodone (Roxicodone)
oxycodone/acetaminophen
(Percocet/Tylox)
oxycodone/aspirin (Percodan)
oxycodone/ibuprofen (Combunox)
(QL)
oxymorphone (Opana)
ABSTRAL (PA/QL)
FENTORA (PA)
LAZANDA (PA/QL)
NUCYNTA
OXECTA
SUBSYS (PA/QL)
ONSOLIS (PA/QL)
Class II Narcotics—
Long Acting
fentanyl patch (Duragesic)
 morphine sulfate ER (MS
Contin)
 oxymorpone ER (Opana ER)
OPANA ER (crush
resistant)
OXYCONTIN (QL)
AVINZA
EXALGO (ST/QL)
KADIAN
NUCYNTA ER
OXYCODONE AG (PA)
XARTEMIS XR (ST)
ZOHYDRO ER (PA/QL)
Class III Narcotics
acetaminophen/codeine
(Tylenol #2/#3/#4)
aspirin/codeine (Empirin #2/#3/#4)
buprenorphine (Subutex)
hydrocodone/apap
(Vicodin/Lortab)
hydrocodone/aspirin (Lortab ASA)
hydrocodone/ibuprofen
(Vicoprofen)
BUTRANS (QL)
SUBOXONE FILM
BUNAVAIL
buprenorphine/naloxone
(Suboxone Tabs)
ZUBSOLV
Class IV Narcotics
pentazocine/apap (Talwin)
pentazocine/naloxone (Talwin NX)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 10 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
AUTONOMIC & CNS MEDICATIONS
Drugs to Treat and
Prevent Headaches
acetaminophen/butalbital
(Phrenilin)
acetaminophen/caff/butalbital
(Fioricet)
aspirin/caffeine/butalbital (Fiorinal)
butorphanol (Stadol) (QL)
ergotamine/caffeine (Cafergot)
isometh/dicloral/acetaminophen
(Midrin)
naratriptan (Amerge) (QL)
rizatriptan (Maxalt/Maxalt MLT)
(QL)
 sumatriptan tabs (Imitrex) (QL)
zolmitriptan (Zomig/Zomig ZMT)
(QL)
Anxiolytics
alprazolam (Xanax )
alprazolam ER (Xanax XR)
buspirone (Buspar)
chlordiazepoxide (Librium)
clonazepam (Klonopin)
clonazepam wafer
(Klonopin Wafers) (PA)
diazepam (Valium)
lorazepam (Ativan)
meprobamate (Equanil)
oxazepam (Serax)
ALPRAZOLAMINTENSOL
Sedative Hypnotic
Drugs
chloral hydrate
estazolam (Prosom)
eszopiclone (Lunesta) (PA/QL)
flurazepam (Dalmane)
hydroxyzine (Atarax/Vistaril)
temazepam (Restoril)
triazolam (Halcion)
zalepon (Sonata)
 zolpidem (Ambien)
zolpidem CR
(Ambien CR) (PA/QL)
Use generic AmbienTier 1!
BELSOMRA (PA)
EDLUAR (PA)
INTERMEZZO (PA)
ROZEREM (QL)
SILENOR (PA)
ZOLPIMIST (PA)
Antimania Drugs
lithium carbonate
(Eskalith/Lithobid)
MIGRANAL (QL)
sumatriptan nasal
spray/injection (QL)
ZOMIG NASAL
SPRAY (QL)
ALSUMA (PA/QL)
AXERT (ST/QL)
CAMBIA (PA/QL)
FROVA (ST/QL)
RELPAX (ST/QL)
SUMAVEL DosePro
(PA/QL)
TREXIMET (ST/QL)
ZECUITY (ST/QL)
NIRAVAM
ONFI
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 11 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
AUTONOMIC & CNS MEDICATIONS
Anticonvulsant Drugs
carbamazepine
(Tegretol)
Carbamazepine Ext Rel
(Tegretol XR)
clonazepam (Klonopin)
divalproex sodium (Depakote/ER)
ethosuximide (Zarontin)
felbamate (Felbatol)
gabapentin (Neurontin)
lamotrigine (Lamictal)
lamotrigine XR (Lamictal XR) (PA)
levetiracetam (Keppra)
levetiracetam ER (Keppra XR)
oxcarbazepine (Trileptal)
phenobarbital
phenytoin (Dilantin)
primidone (Mysoline)
tiagabine (Gabitril)
topiramate (Topamax)
valproic acid (Depakene)
zonisamide capsules (Zonegran)
Antidepressant Drugs
amitriptyline (Elavil)
amitriptyline/perphenazine (Triavil)
amoxapine (Ascendin)
clomipramine (Anafranil)
desipramine (Norpramin)
doxepin (Sinequan)
imipramine (Tofranil)
imipramine pamoate
(Tofranil PM)
nortriptyline (Pamelor)
protriptyline (Vivactil)
Antidepressant Drugs –
SSRIs
 citalopram (Celexa)
 escitalopram (Lexapro) (QL)
 fluoxetine (Prozac)
fluoxetine PMDD (Sarafem) (ST)
fluvoxamine (Luvox)
fluvoxamine (Luvox CR) (ST)
paroxetine (Paxil)
 sertraline (Zoloft)
ST = Prior use of a
generic SSRI is required
CELONTIN
DIASTAT
PHENYTEK
APTIOM
EQUETRO
FYCOMPA
HORIZANT (ST/QL)
LAMICTAL ODT (PA)
LYRICA (PA)
OXTELLAR XR (ST)
POTIGA
QUDEXY XR (ST)
STAVZOR (PA)
TROKENDI XR (ST)
VIMPAT
Use Tier 1 choice (i.e.
generic Celexa) for a
lower copayment
paroxetine CR (Paxil
CR)
VIIBRYD (ST)
BRISDELLE (PA)
Fluoxetine 60mg (ST)
PEXEVA (ST)
PROZAC WEEKLY
(ST)
SABRIL
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 12 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
AUTONOMIC & CNS MEDICATIONS
Antidepressant Drugs –
Other
bupropion
 bupropion SR/XL (Wellbutrin
SR/XL)
duloxetine (Cymbalta) (QL)
maprotiline (Ludiomil)
mirtazapine (Remeron/Soltab)
nefazodone (Serzone)
trazodone (Desyrel)
 venlafaxine Extended Release
Caps (Effexor XR)
Antidepressant Drugs –
MAO Inhibitors
phenelzine (Nardil)
tranylcypromine (Parnate)
EMSAM
Antivertigo and
Antiemetic Drugs
dronabinol (Marinol) (PA)
meclizine (Antivert)
granisetron (Kytril) (ST/QL)
 ondansetron (Zofran)
prochlorperazine (Compazine)
promethazine (Phenergan)
trimethobenzamide (Tigan)
Use ondansetron firstTier 1!
ANZEMET (ST/QL)
CESAMET (PA)
DICLEGIS (QL)
EMEND (QL)
SANCUSO (ST/QL)
ZUPLENZ (PA/QL)
ST = Prior use of
ondansetron is required
Antiparkinson Drugs
*Dispensing limited to a
30-day supply
amantadine (Symmetrel)
benztropine (Cogentin)
bromocriptine (Parlodel)
carbidopa/levodopa (Sinemet)
entacapone (Comtan)
pramipexole (Mirapex)
ropinirole/ER (Requip/XL) (QL)
selegiline (Eldepryl)
trihexyphenidyl (Artane)
Misc. Neurologic
Conventional (Typical)
Antipsychotic Drugs
chlorpromazine (Thorazine)
fluphenazine (Prolixin)
haloperidol (Haldol)
loxapine (Loxitane)
perphenazine (Trilafon)
thioridazine (Mellaril)
thiothixene (Navane)
trifluoperazine (Stelazine)
PRISTIQ (ST/QL)
APLENZIN (PA)
BRINTELLIX (PA/QL)
desvenlafaxine
fumarate (PA)
FETZIMA (ST/QL)
FORFIVO XL (PA)
KHEDEZLA (PA)
OLEPTRO (PA)
Venlafaxine Extended
Release Tabs (ST)
AZILECT
MIRAPEX
MIRAPEX ER
NEUPRO
STALEVO
TASMAR
ZELAPAR
APOKYN (PA/QL)*
SAVELLA
GRALISE (ST)
XENAZINE (PA)
ADASUVE (PA)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 13 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
AUTONOMIC & CNS MEDICATIONS
Novel (Atypical)
Antipsychotic Drugs
clozapine (Clozaril)
 olanzapine (Zyprexa) (QL)
 quetiapine (Seroquel) (QL)
 risperidone (Riperdal)
 ziprasidone (Geodon) (QL)
Antipsychotic/
Depression
olanzapine/fluoxetine (Symbyax)
CNS Stimulants/ADHD
Drugs
amphetamine salts (Adderall)
clonidine ER (Kapvay ER)
dextroamphetamine (Dexadrine)
dexmethylphenidate/XR
(Focalin/XR)
methamphetamine (Desoxyn)
methylphenidate CD (Metadate
CD)
methylphenidate/ER (Ritalin/SR)
methylphenidate ER (Concerta)
modafinil (Provigil) (PA/QL)
pemoline (Cylert)
Other CNS/Autonomic
Drugs
bupropion (Zyban)
disulfiram (Antabuse)
naltrexone (Revia)
Pyridostigmine (Mestinon)
Alzheimer’s Drugs
donepezil (Aricept)
galantamine (Razadyne/ER)
rivastigmine (Exelon)
SEROQUEL XR (QL)
ABILIFY (ST/QL on
Tablets)
ABILIFY MAINTENNA
(ST)
ADASUVE
FANAPT (ST/QL)
INVEGA (ST/QL)
INVEGA SUSTENNA
(ST)
LATUDA (ST/QL)
RISPERDAL CONSTA
(ST/QL)
SAPHRIS (ST/QL)
VERSACLOZ (PA)
amphetamine salts
ER
(Adderall XR)
DAYTRANA
INTUNIV(ST)
NUVIGIL (PA/QL)
QUILLIVANT XR
RITALIN LA
STRATTERA (ST)
VYVANSE
ZENZEDI (ST)
CAMPRAL (PA)
CHANTIX
GUANIDINE
NUEDEXTA (PA)
EXELON PATCH
(ST)
EVZIO (PA/QL)
HETLIOZ (PA)
VIVITROL (PA)
XYREM (PA)
ARICEPT 23 (PA)
NAMENDA
(PA for age<50)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 14 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
AUTONOMIC & CNS MEDICATIONS
Drugs to Treat Multiple
Sclerosis
*Drugs limited to a 30day supply
P = Preferred
*AMPYRA (PA/QL)
*AUBAGIO (PA/SP/QL)
*AVONEX (PA/QL/SP) P
*BETASERON
(PA/QL/SP) P
*COPAXONE
(PA/QL/SP) P
*GILENYA (PA/QL/SP) P
*TECFIDERA (PA/SP) P
*EXTAVIA (PA/ST/SP)
(*Pls use Betaseron)
*PLEGRIDY (PA/SP)
*REBIF (PA/QL/ST/SP)
*TYSABRI (PA/ST/SP)
Rx benefit
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 15 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
DERMATOLOGICAL MEDICATIONS
Topical Corticosteroid
Drugs – Very High
Potency
augmented betamethasone
(Diprolene AF)
clobetasol (Temovate)
clobetasol foam (Olux) (ST/QL)
diflorasone acetate
halobetasol (Ultravate)
CLOBEX (ST)
(Use clobetasol first)
OLUX E (ST)
Topical Corticosteroid
Drugs – High Potency
amcinonide (Cyclocort)
betamethasone dipropionate
(Diprolene)
betamethasone valerate (Valisone)
desoximetasone (Topicort)
diflorasone (Florone)
fluocinolone (Synalar)
fluocinonide (Lidex)
HALOG/HALOG E
VANOS (ST)
Topical Corticosteroid
Drugs – Medium
Potency
betamethasone foam (Luxiq) (ST)
flurandrenolide (Cordran lotion)
fluticasone (Cutivate)
hydrocortisone butyrate (Locoid)
hydrocortisone valerate (Westcort)
mometasone (Elocon)
prednicarbate (Dermatop E)
triamcinolone (Kenalog)
CLODERM
CORDRAN Tape (QL)
PANDEL
Topical Corticosteroid
Drugs – Low Potency
alclometasone dipropionate
(Aclovate)
desonide (DesOwen)
hydrocortisone (Hytone)
Note: 0.5% and 1% available
without a prescription-OTC
VERDESO (ST)
(Use desonide first)
Oral Antipruritic
Agents
cyproheptadine (Periactin)
hydroxyzine (Atarax/Vistaril)
Drugs to treat
Psoriasis and Eczema
calcipotriene (Dovonex) (QL)
methotrexate
selenium sulfide (Selsun)
*Dispensing limited to
a 30-day supply
P = Preferred
Oral Dermatological
Drugs
 doxycycline
doxycycline monohydrate (Adoxa)
(PA)
doxycycline hyclate (Doryx) (PA)
 minocycline
minocycline (Dynacin) (PA)
ATOPICLAIR
DOVONEX (ST)
FABIOR
SORIATANE
TACLONEX (QL)
TAZORAC
VECTICAL (QL)
AMEVIVE (PA/QL/SP)*
ENBREL (PA/QL/SP)* P
HUMIRA (PA/QL/SP)* P
OTREXUP (PA)
SORILUX (ST)
STELARA
(PA/ST/QL/SP)*
AMNESTEEM
ABSORICA (PA)
CLARAVIS
ORACEA (PA)
Minocycline ER
XIMINO (PA)
(Solodyn) (PA)
MYORISAN
OXSORALEN-ULTRA
ZENATANE
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 16 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
DERMATOLOGICAL MEDICATIONS
Topical Acne and
Rosacea Drugs
adapalene
(Differin 0.1% cream or gel)
benzoyl peroxide/clindamycin
(Benzaclin/Duac)
clindamycin (Cleocin)
erythromycin (Emgel)
erythromycin/benzamycin
(Benzamycin)
metronidazole (Metrogel 0.75%)
tretinoin (Retin-A)
Topical Dermatological aluminum chloride
Drugs
Hydroquinone (Lustra/AF)
imiquimod (Aldara) (QL)
lindane (Qwell)
permethrin (Acticin)
podofilox topical solution
(Condylox)
urea (Carmol, Keralac)
EPIDUO
NORITATE
RETIN-A MICRO
ACANYA
ACZONE
AZELEX
CLINAC BPO
CLINDAGEL
DIFFERIN LOTION,
0.3% GEL (ST)
FINACEA
METROGEL/METRO
LOTION
PLEXION
ROSAC
ZIANA
CONDYLOX GEL
EURAX
CARAC
DERMA-CAS
DERMA-SMOOTHE/FS
(QL)
ELIDEL (QL)
EVOCLIN
NATROBA
OXSORALEN
PICATO (QL)
PROTOPIC (QL)
REGRANEX (PA)
SANTYL
SILVER NITRATE
SOLARAZE
XERAC AC
ZYCLARA (QL)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 17 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
EAR-NOSE-THROAT MEDICATIONS
Drugs Affecting the
Ear
acetic acid
acetic acid/hydrocortisone
(VoSol HC Otic)
antipyrine/benzocaine
(Auralgan Otic)
neomycin/polymix/hc otic
(Cortisporin Otic)
ofloxacin otic
Drugs Affecting the
Nose
azelastine (Astelin)
azelastine 0.15% (Astepro) (ST)
budesonide AQ (Rhinocort AQ)
flunisolide (Nasalide)
 fluticasone (Flonase)
triamcinolone nasal (Nasacort AQ)
NASACORT OTC
NASONEX
VERAMYST
Drugs Affecting the
Mouth
triamcinolone (Kenalog in Orabase)
EVOXAC
CIPRO HC
CIPRODEX
COLY-MYCIN
BECONASE/AQ (ST)
DYMISTA (ST)
NASAREL (ST)
OMNARIS (ST)
PATANASE (ST)
QNASL (ST)
ZETONNA (ST)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 18 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ENDOCRINE MEDICATIONS
Insulin
HUMALOG
HUMULIN
LANTUS SOLOSTAR
LANTUS VIALS
LEVEMIR
APIDRA (PA)
AFREZZA (ST)
NOVOLIN (PA)
NOVOLOG (PA)
Misc. Diabetic Drugs
BYDUREON (ST/QL)
BYETTA (ST/QL)
VICTOZA (ST/QL)
SYMLIN (ST/QL)
TANZEUM (PA/QL)
Oral Diabetic Drugs —
Thiazolidinediones
(Glitazones)
pioglitazone (Actos) (QL)
AVANDIA (QL/ST)
Oral Diabetic Drugs —
DPP4’s
JANUVIA
TRADJENTA
NESINA (ST)
ONGLYZA (ST)
Oral Diabetic Drugs —
DPP4 Combination
products
JANUMET/XR
JENTADUETO
JUVISYNC
KAZANO (ST)
KOMBIGLYZE XR (ST)
OSENI (ST)
Oral Diabetic Drugs —
Metformin
 metformin/XR
(Glucophage/XR)
Oral Diabetic Drugs —
Combination products
glipizide/metformin (Metaglip)
glyburide/metformin
(Glucovance)
pioglitazone/glimepiride (Duetact)
(ST/QL)
repaglinide/metformin (Prandimet)
Oral Diabetic Drugs —
Sulfonylureas
chlorpropamide (Diabenese)
glimepiride (Amaryl)
 glipizide/ER (Glucotrol/XL)
glyburide (Diabeta/Micronase)
tolazamide (Tolinase)
tolbutamide (Orinase)
Oral Diabetic Drugs —
Other
acarbose (Precose)
nateglinide (Starlix)
repaglinide (Prandin)
Glucocorticoid and
Mineralcorticoid Drugs
dexamethasone (Decadron)
fludrocortisone acetate (Florinef)
hydrocortisone (Hydrocortone)
methylprednisolone (Medrol)
prednisolone (Orapred/Prelone)
prednisone (Deltasone)
triamcinolone (Aristocort)
FORTAMET ER (ST)
GLUMETZA (ST)
pioglitazonemetformin (ActoPlus
Met) (QL)
ActoplusMet XR
(ST/QL)
INVOKAMET (ST)
INVOKANA (ST)
WELCHOL (ST)
CYCLOSET
FARXIGA (ST)
GLYSET
JARDIANCE (ST)
RAYOS (PA)
AVANDAMET (ST/QL)
AVANDARYL (ST/QL)
ACTHAR GEL (PA)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 19 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Use alendronate 1st-Tier
1!
ATELVIA (ST)
BINOSTO (ST)
FOSAMAX PLUS D
2800/5600
BONIVA INJECTION
(ST)
FORTEO
PROLIA (PA/QL)
zoledronic acid
(Reclast)
ANDRODERM (ST/QL)
AXIRON (ST)
FORTESTA (ST)
NATESTO (ST)
STRIANT (ST/QL)
TESTIM (ST/QL)
testosterone
transdermal gel (ST)
VOGELXO (ST)
AVEED (ST/QL)
TESTOPEL (ST)
KORLYM (PA)
SAMSCA (PA)
ALDURAZYME (PA)
ARCALYST (PA)
CERDELGA (PA)
CEREZYME (PA)
desmopressin (DDAVP)
ELELYSO (PA)
FABRAZYME (PA/SP)*
ILARIS (PA/QL/SP)*
KALYDECO
(PA/QL/SP)*
KUVAN (PA)
MYOZYME (PA)
NAGLAZYME (PA)
SIGNIFOR (PA)
SUCRAID (PA)
VIMIZIM (PA/SP)*
VPRIV (PA)
ZAVESCA (PA)
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
ENDOCRINE MEDICATIONS
Osteoporosis Drugs
 alendronate (Fosamax)
calcitonin-salmon (Miacalcin)
etidronate disodium tabs
(Didronel)
raloxifene (Evista)
Use alendronate 1stTier 1!
ACTONEL (ST)
ACTONEL +
CALCIUM (ST)
ibandronate (Boniva
tablets)
Thyroid and Antithyroid
Drugs
levothyroxine (Synthroid/Levoxyl)
liothyronine (Cytomel)
methimazole (Tapazole)
propylthiouracil (PTU)
SYNTHROID
thyroid
(Armour Thyroid)
Androgen Drugs
danazol (Danocrine)
fluoxymesterone (PA/QL)
methyltestosterone (Methitest)
(PA/QL)
ANDROGEL (PA/QL)
Other Endocrine Drugs
cabergoline tablets (Dostinex)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 20 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
GASTROINTESTINAL MEDICATIONS
Antidiarrheal Drugs
diphenoxylate/atropine (Lomotil)
loperamide (Immodium)
paregoric
Irritable Bowel Drugs
AMITIZA (QL)
LINZESS (QL)
Antispasmodics/Drugs
Affecting GI Motility
dicyclomine (Bentyl)
hyoscyamine (Levsin)
metoclopramide (Reglan)
H2 Antagonists
cimetidine (Tagamet)
famotidine (Pepcid)
nizatidine (Axid)
ranitidine (Zantac)
Note: All of the H2 drugs
below are also available
without a prescription
(OTC)
Proton Pump
Inhibitors
*PA for age>15;
Use Prilosec or
Prevacid OTC at
generic copay first!
FULYZAQ
 lansoprazole (Prevacid)
Nexium 24hr OTC
 omeprazole (Prilosec)
 pantoprazole (Protonix)
 Prevacid OTC
 Prilosec/omeprazole OTC
 Zegerid OTC
LOTRONEX (QL) (PA
for Males)
METOZOLV (PA)
rabeprazole (Aciphex)
(ST)*
Use Tier 1 options
first!
esomeprazole strontium
(ST)*
DEXILANT (preferred
brand) (ST/QL)*
PROTONIX (brand
name) (ST)*
NEXIUM (ST)* (QL on
20mg)
Rx-PREVACID (ST)*
(QL on 15mg)
ZEGERID (ST)*
Helicobacter Pylori
Drugs
PYLERA
Other Antiulcer Drugs
misoprostol (Cytotec)
sucralfate (Carafate)
Laxatives and
Cathartics
electrolyte solution
(Golytely/Nulytely)
HELIDAC
PREVPAC
MOVIPREP
PREPOPIK
RELISTOR (PA)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 21 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
GASTROINTESTINAL MEDICATIONS
Other GI Drugs
(Crohn’s Disease,
Ulcerative Colitis)
P = Preferred
balsalazide (Colazal)
budesonide (Entocort EC)
glycopyrrolate (Robinul)
lipram
pangestyme
sulfasalazine
(Azulfidine/EN)
ursodiol (Actigall/Urso)
ASACOL/HD
CREON
DELZICOL
LIALDA
PANCREASE MT
PANCRELIPASE
ZENPEP
APRISO
DIPENTUM
GASTROCROM (PA)
PENTASA
ULTRASE/ULTRASE
MT
UCERIS
VIOKASE
Blood Modifiers
ARANESP (QL)*
EPOGEN (QL)*
EXJADE (PA)*
FERRIPROX
GRANIX (QL)*
NEULASTA (QL)*
NEUPOGEN (QL)*
PROCRIT (QL)*
VIDAZA (PA)
*Dispensing limited to
a 30-day supply
Growth Hormones and
Related Drugs
EGRIFTA (PA)
GENOTROPIN
(PA/ST/SP)*
HUMATROPE
(PA/ST/SP)*
INCRELEX (PA/SP)*
NORDITROPIN (PA/SP)*
P
NUTROPIN/AQ
(PA/ST/SP)*
OMNITROPE
(PA/ST/SP)*
SAIZEN (PA/ST/SP)*
SEROSTIM (PA/SP)*
TEVTROPIN
(PA/ST/SP)*
ZORBTIVE (PA/SP)*
*Dispensing limited to
a 30-day supply
P = Preferred
Interferons
*ACTIMMUNE (PA/SP)
*INFERGEN (PA/QL/SP)
*INTRON-A (PA/SP)
*PEGASYS (PA/QL/SP) P
*PEG-INTRON
(PA/QL/SP)
*ROFERON-A (PA/SP)
*Dispensing limited to
a 30-day supply
P = Preferred
Interleukins
CIMZIA (PA/ST/QL/SP)*
CUVPOSA (PA)
GATTEX (PA)
ENBREL (PA/QL/SP)* P
ENTYVIO (PA/ST/SP)*
HUMIRA (PA/QL/SP)* P
SANDOSTATIN/LAR
(PA/QL)
SOMATULINE DEPOT
TYSABRI (PA/SP)*
PROLEUKIN (PA)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 22 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
MUSCULOSKELETAL MEDICATIONS
Salicylates and
Related Drugs
choline mag trisalicylate (Trilisate)
diflunisal (Dolobid)
salsalate (Disalcid)
Non-Steroidal
Antiinflammatory
Agents (NSAIDS)
 diclofenac/ER (Voltaren/XR)
etodolac/XL (Lodine/XL)
 ibuprofen (Motrin)
ZORVOLEX (ST)
Try a Tier 1 choice first,
like naproxyn or
ibuprofen
ARTHROTEC (PA)
CELEBREX (PA/QL)
DUEXIS (PA/QL)
FLECTOR PATCH (PA)
NAPRELAN (ST)
PENNSAID (ST/QL)
SPRIX NS (ST/QL)
TIVORBEX (ST)
VIMOVO (PA)
VOLTAREN GEL (PA)
ZIPSOR (PA)
CUPRIMINE
RIDAURA
OTREXUP (PA)
suspension available OTC
indomethacin/SR (Indocin/SR)
ketoprofen (Orudis)
ketorolac (Toradol) (QL)
meclofenamate (Meclomen)
 meloxicam (Mobic)
mefenamic acid (Ponstel) (PA)
nabumetone (Relafen)
 naproxen/CR
(Anaprox/Naprosyn/EC)
naproxen DR
oxaprozin (Daypro)
piroxican (Feldene)
sulindac (Clinoril)
Other Drugs for
Arthritis
hydroxychloroquine (Plaquenil)
leflunamide (Arava)
methotrexate
*Dispensing limited to
a 30-day supply
P = Preferred
Hyaluronic Acids
P = Preferred
ACTEMRA
(PA/ST/MB)*
CIMZIA (PA/ST/QL/SP)
ENBREL (PA/QL/SP)*
P
HUMIRA (PA/QL/SP)* P
KINERET (PA/QL)*
ORENCIA IV/SQ
(PA/SP/MB)*
OTEZLA (PA/ST/SP)*
REMICADE (PA/MB)
RITUXAN
(PA/ST/SP/MB)*
SIMPONI (PA/ST/SP)*
XELJANZ
(PA/ST/QL/SP)*
EUFLEXXA (PA) P
GEL-ONE (PA/ST)
HYALGAN (PA/ST)
MONOVISC (PA/ST)
ORTHOVISC (PA/ST)
SUPARTZ (PA/ST)
SYNVISC (PA) P
SYNVISC ONE (PA) P
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 23 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
MUSCULOSKELETAL MEDICATIONS
Drugs to Treat and
Prevent Gout
allopurinol (Zyloprim)
colchicine
probenecid (Benemid)
probenecid & colchicine
(Co-Benemid)
Skeletal Muscle
Relaxants
baclofen (Lioresal) (QL)
carisoprodol (Soma)
carisoprodol/aspirin
(Soma Compound)
chlorzoxazone (Parafon Forte)
chlorzoxazone/acetaminophen
(Flexaphen)
cyclobenzaprine (Flexeril)
cyclobenzaprine ER (Amrix/Fexmid)
(PA/QL)
dantrolene (Dantrium)
diazepam (Valium)
metaxalone (Skelaxin)
methocarbamol (Robaxin)
methocarbamol/aspirin (Robaxisal)
orphenadrine (Norflex)
tizanide tablets (Zanaflex tabs)
COLCRYS
ULORIC (ST)
KRYSTEXXA (PA)
ZANAFLEX CAPSULES
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 24 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
Therapeutic Vitamins
and Minerals
calcium acetate (Phoslo)
calcitriol (Rocaltrol)
cyanocobalamin (Vitamin B12)
folbic (Foltx)
ergocalciferol (Vitamin D)
folic acid (Folate)
sodium fluoride (Luride)
Potassium
Supplements
potassium bicarbonate/chloride
(K-lyte)
potassium chloride (K-Dur)
potassium gluconate (Kaon)
Potassium Removing
Resins
sodium polystyrene sulfonate
(Kayexalate)
CALCIFEROL
HECTOROL
NASCOBAL
ZEMPLAR
Calcimimetic Agent
Oral Anticoagulants
and Vitamin K
SENSIPAR
Warfarin (Coumadin)
ELIQUIS (QL)
MEPHYTON
XARELTO
PRADAXA (QL)
Injectible
Anticoagulants
fondaparinux (Arixtra)
(QL)*
Enoxaparin (Lovenox)*
FRAGMIN (QL)*
INNOHEP (QL)*
IPRIVASK (QL)
*Dispensing limited to
a 30-day supply
Antiplatelet Drugs
cilostazol (Pletal)
clopidogrel (Plavix)
dipyridamole (Persantine)
ticlopidine (Ticlid)
BRILINTA
EFFIENT
AGGRENOX
ZONTIVITY (PA)
Platelet Stimulators
Blood Detoxicants
NPLATE (PA/SP)
PROMACTA (PA/SP)
lactulose (Cephulac)
RENAGEL (QL)
RENVELA (QL)
FOSRENOL
VELPHORO (PA)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 25 of 35
4 TIER SPECIALTY DRUG LIST
Hemophilia Blood
Factor Products
(zero copay applies)
*30 day max fill
HYATE-C (PA/SP)*
MONARC-M (PA/SP)*
ADVATE (PA/SP)*
ALPHANATE (PA/SP)*
ALPROLIX (PA/SP)*
BENEFIX (PA/SP)*
ELOCTATE (PA/SP)*
HUMATE-P (PA/SP)*
HYATE-C (PA/SP)*
KOGENATE (PA/SP)*
MONARC-M (PA/SP)*
MONOCLATE-P
(PA/SP)*
NOVOSEVEN (PA/SP)*
RECOMBINATE
(PA/SP)*
XYNTHA (PA/SP)*
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 26 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
Prenatal Vitamins
Citranatal Rx
Complete Natal DHA
Complete-RF Prenatal
PR Natal 400
Prenaplus
Prenatal Plus Iron Tablets
Prenatal 19
Prenatal AD
Prenatabs Rx
Select OB
Ultra Natalcare
Vinate GT
Vinate M
Vinate Ultra
Vinate II
Vitafol OB
Vol-Tab Rx
Vol-Plus
Specialized OB/GYN
Drugs
methylergonovine (Methergine)
terbutaline (Brethine)
OB/GYN Topical
Antiinfectives
clindamycin vaginal cream
(Cleocin)
triple sulfa vaginal
MetroGel vaginal
Infertility
clomiphene citrate (Clomid) (PA)
Branded Prenatal
Vitamins
SYNAREL (PA)
LYSTEDA
BRAVELLE (PA/SP) P
CETROTIDE (PA/SP)
chorionic gonadotropin
(PA/SP)
FOLLISTIM (PA/SP) P
GANIRELIX (PA/SP)
GONAL-F (PA/SP)
LUVERIS (PA/SP)
MENOPUR (PA/SP)
OVIDREL (PA/SP)
Novarel (PA/SP)
REPRONEX (PA/SP)
P = Preferred
Oral Estrogen Drugs
estradiol (Estrace)
estropipate (Ogen, Ortho-Est)
leuprolide (Lupron)
LUPRON DEPOT
ESTRATEST/HS
PREMARIN
CENESTIN
DUAVEE
ENJUVIA
MENEST
OSPHENA
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 27 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
Topical Estrogen
Drugs
estradiol transdermal patch
(Climara/Vivelle DOT/Estraderm)
Estrogen/Progestin
Combinations
Progestin Drugs
medroxyprogesterone (Provera)
Contraceptives
altavera (Nordette)
alyacen (Norinyl)
amethia (Seasonique)
apri (Desogen)
aranelle (Tri-Norinyl)
aviane (Alesse)
azurette (Mircette)
balziva (Ovcon)
briellyn (Ovcon)
camila (Nor-QD)
camrese (Seasonique)
caziant (Cyclessa)
cesia (Cyclessa)
cryselle (Lo/Ovral)
cyclafem (Ortho-Novum)
emoquette (Desogen)
enpresse (Tri-Levlen)
gildesse FE (Lo-estrin FE)
errin (Ortho Micronor)
heather (Nor QD)
jolessa (Seasonale)
jolivette (Ortho Micronor)
junel/FE (Loestrin/Fe)
kariva (Mircette)
kelnor (Demulen)
leena (Tri-Norinyl)
lessina (Alesse)
levonorgestrel-ethinyl estradiol (LoSeasonique)
levora (Nordette)
low-ogestrel (Lo-Ovral)
lutera (Alesse)
microgestin/FE (Loestrin/FE)
mononessa (Ortho-Cyclen)
necon (Ortho-Novum)
nora be (Nor-QD)
Tier 1 options and
those marked # are
now Zero Cost where
applicable — per
Health Care Reform
Legislation
ESTRACE VAGINAL
CREAM
EVAMIST
PREMARIN VAGINAL
CREAM
VAGIFEM
DIVIGEL
ELESTRIN
ESTROGEL
ESTRASORB
MENOSTAR
COMBIPATCH
PREMPHASE
PREMPRO
ACTIVELLA
CLIMARA PRO
FEMHRT
PREFEST
Ask your doctor to try
a Tier 1 choice first!
# gianvi (Yaz)
# loryna (Yaz)
# OCELLA (Yasmin)
#SAFYRAL (Yasmin)
# syeda (Yasmin)
# vestura (Yaz)
# zarah (Yasmin)
CRINONE (PA)
ENDOMETRIN (PA)
MAKENA (PA)
PROMETRIUM
Ask your doctor to try a
Tier 1 choice first!
#BEYAZ
ESTROSTEP FE
FALESSA
#GENERESS FE
LYBREL
#LoLOESTRIN
#LOESTRIN-24 FE
LOSEASONQUE
LYBREL
MINASTRIN 24 FE
*MODICON
#NATAZIA
#NUVARING
*ORTHO-CEPT
*ORTHO-CYCLEN
#ORTHO DIAPHRAGM
#ORTHO EVRA
*ORTHO MICRONOR
*ORTHO-NOVUM
*ORTHO TRI-CYCLEN
#*ORTHO TRICYCLEN LO
#*OVCON
OVRETTE
QUARTETTE
SEASONIQUE
YASMIN
YAZ
#IMPLANON (PA)
#MIRENA (PA) (Medical
Benefit)
#NEXPLANON (PA)
#SKYLA (PA) (Medical
Benefit)
*See Tier 1 equivalent
drug!
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 28 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
norethindrone (Nor-QD)
norethinedrone-ethinyl estradiol
(Ovcon)
nortrel (Modicon)
ogestrel (Ovral)
orsythia (Alesse)
portia (Nordette)
previfem (Ortho-Cyclen)
quasense (Nordette)
reclipsen (Desogen)
solia (Ortho Cept)
sprintec (Ortho Cyclen)
sronyx (Alesse)
tilia FE (Estrostep FE)
tri-legest FE (Estrostep FE)
tri-nessa (Ortho Tri-Cyclen)
tri-previfem (Ortho Tri-Cyclen)
tri-sprintec (Ortho Tri-Cyclen)
trivora (Tri-Levlen)
velivet (Cyclessa)
zenchent (Ovcon)
zeosa (Ovcon)
zovia (Demulen)
Emergency
Contraception
Tier 1 options are now
Zero Cost where
applicable — per
Health Care Reform
Legislation
levonorgestrel (Plan B) OTC if
age>17
Next Choice (Plan B) OTC if
age>17
#ELLA
#PLAN B ONE STEP
(OTC if age >17)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 29 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
OPHTHALMIC MEDICATIONS
Ophthalmic Topical
Antibacterial Drugs
bacitracin (AK-Tracin)
chloramphenicol (AK-Chlor)
ciprofloxacin (Ciloxan)
erythromycin (Ilotycin)
gentamicin (Garamycin)
neomycin/bacitracin/polymixin
(Neosporin)
neomycin/gramicidin/polymixin
(Neosporin)
ofloxacin (Ocuflox)
polymixin/trimethoprim (Polytrim)
sulfacetamide (Bleph-10)
tobramycin (Tobrex)
Ophthalmic Topical
Antiviral Drugs
trifluridine (Viroptic)
Ophthalmic
Corticosteroid Drugs
dexamethasone (Decadron)
fluorometholone (FML)
prednisolone (Pred-Forte)
VEXOL
LOTEMAX
Ophthalmic
Antiinfective/
Corticosteroid Drugs
neomycin/bacitracin/polymixin
/hydrocortisone
(Cortisporin Ointment)
neomycin/dexamethasone
(NeoDecadron)
neomycin/polymixin/
dexamethasone (Maxitrol)
neomycin/polymixin/
hydrocortisone
(Cortisporin Suspension)
sulfacetamide/prednisolone
(Blephamide)
tobramycin-dexamethasone
(Tobradex)
PRED-G
ZYLET
DUREZOL
TOBRADEX ST
Oral Antiglaucoma
Drugs
acetazolamide (Diamox)
methazolamide (Neptazane)
Topical Antiglaucoma
Drugs
betaxolol
brimonidine (Alphagan)
carteolol
dipivefrin (Propine)
dorzolamide (Trusopt)
dorzolamide/timolol (Cosopt)
latanoprost (Xalatan)
levobunolol (Betagan)
metipranolol (Optipranolol)
pilocarpine (Pilocar)
timolol (Timoptic/XE)
ALPHAGAN P
LUMIGAN (ST)
AZOPT
BETOPIC S
COMBIGAN
TRAVATAN (ST)
TRAVATAN Z (ST)
ZIOPTAN (ST)
BESIVANCE
MOXEZA
QUIXIN
VIGAMOX
ZYMAR
ZYMAXID
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 30 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
ACUVAIL
ALAMAST (QL)
ALREX (QL)
BEPREVE
ELESTAT (QL)
EMADINE (QL)
LASTACAFT
PATADAY (QL)
OPTIVAR (QL)
VOLTAREN
EYLEA
LUCENTIS
MACUGEN (PA)
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
OPHTHALMIC MEDICATIONS
Other Ophthalmic
Drugs
Zaditor OTC
Alaway OTC
Atropine
bromfenac (Xibrom)
cromolyn (Crolom) (QL)
cyclopentolate (Cyclogyl)
flurbiprofen (Ocufen)
ketoralac (Acular)
ketotifen fumarate (Zaditor) (QL)
naphazoline (AK-Con)
phenylephrine (Neo-Synephrine)
tropicamide (Mydriacyl)
ALOCRIL (QL)
ALOMIDE (QL)
PATANOL (QL)
RESTASIS (QL)
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 31 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
RESPIRATORY MEDICATIONS
Oral Beta-2 Adrenergic
Drugs
albuterol (Proventil/Ventolin)
albuterol sa (Proventil /Volmax)
terbutaline (Brethine)
Inhaled Beta-2
Adrenergic Drugs
albuterol solution
(Proventil/Ventolin)
levalbuterol nebs (Xopenex) ( QL)
metaproterenol (Alupent)
Methylxanthine Drugs
aminophylline
theophylline (Theodur)
Other Drugs for
Asthma
cromolyn (Crolom)
PROAIR HFA
SEREVENT
BROVANA (PA)
FORADIL
MAXAIR/
AUTOHALER
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA
ADVAIR (QL)
DULERA
SYMBICORT
Corticosteroid Inhalers budesonide neb (Pulmicort
Respule) (QL)
FLOVENT DISKUS
FLOVENT HFA
PULMICORT (QL)
QVAR
Spacer Devices
AEROCHAMBER
INSPIREASE
XOLAIR (PA/SP)*
ALVESCO
ARNUITY ELLIPTA
(ST)
ASMANEX (QL)
Leukotriene Modifiers
montelukast (Singulair)
zafirlukast (Accolate)
Antihistamines
 Cetirizine OTC (Zyrtec)
cyproheptadine (Periactin)
desloratadine (Clarinex) (PA/QL)
fexofenadine (Allegra) (QL)
hydroxyzine (Atarax/Vistaril)
levocetirizine (Xyzal)
 Loratadine OTC(Claritin)
promethazine (Phenergan)
ALAVERT OTC
ALLEGRA (Brand)
OTC
CLARITIN (Brand)
OTC
ZYRTEC (Brand)
OTC
Try
loratadine/cetirizine
OTC first Tier 1!
ALLERX (PA)
KARBINAL ER (PA)
Antihistamine/
Decongestant
Combinations
all generic
antihistamine/decongestant
combinations, including
loratadine-D (Claritin-D) (OTC)
cetirizine-D (Zyrtec-D) (OTC)
ALAVERT D (OTC)
ALLEGRA-D (Brand)
OTC
CLARITIN D (OTC)
ZYRTEC D (OTC)
fexofenadine-D
(Allegra-D) (QL)
CLARINEX-D (PA/QL)
Antitussive and
Expectorant Drugs
all generic narcotic and nonnarcotic containing antitussive and
expectorant drugs
*OTC = over-thecounter
ZYFLO
ZYFLO CR (PA)
TUSSIONEX
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 32 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
ATROVENT HFA
INHALER
AUVI-Q (QL)
EPIPEN (QL)
Epinephrine autoinjector (ST/QL)
TWINJECT (QL)
ARALAST (PA)
GLASSIA (PA)
PROLASTIN (PA)
PULMOZYME*
tobramycin nebulizing
solution (Tobi)*
ZEMAIRA (PA)
COMBIVENT/
RESPIMAT
SPIRIVA (QL)
TUDORZA
ANORO ELLIPTA
ARCAPTA
BREO ELLIPTA (ST)
BROVANA (PA)
DALIRESP (ST/QL)
INCRUSE ELLIPTA
(ST)
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
RESPIRATORY MEDICATIONS
Other Respiratory
Drugs
acetylcysteine (Mucomyst)
ipratropium nebulizer solution and
nasal spray(Atrovent)
*Limited to a 30-day
supply
Drugs for COPD
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 33 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
UROLOGICAL MEDICATIONS
Anticholinergic
Antispasmodics
ST = Prior use of
oxybutynin is required
flavoxate (Urispas)
hyoscamine (Levsin)
oxybutynin (Ditropan)
oxybutynin XL (Ditropan XL)
tolterodine (Detrol) (ST)
VESICARE (ST)
DETROL LA (ST)
ENABLEX (ST)
GELNIQUE (ST)
MYRBETRIQ (ST)
OXYTROL (ST)
Trospium/ER
(Sanctura/XR) (ST)
TOVIAZ (ST)
Other Genitourinary
Products
bethanachol (Urecholine)
generic Bicitra
generic Polycitra
phenazopyridine (Pyridum)
Drugs for BPH
alfuzosin (Uroxatral)
doxazosin (Cardura)
prazosin (Minipres)
finasteride (Proscar)
tamsulosin (Flomax)
terazosin (Hytrin)
CIALIS (PA/QL)
RAPAFLO (ST)
AVODART (ST/QL)
CARDURA XL
JALYN
Erectile Dysfunction
yohimbine (QL)
CIALIS (QL)
LEVITRA (QL)
CAVERJECT (QL)
EDEX (QL)
MUSE (QL)
STAXYN (QL)
STENDRA (QL)
VIAGRA (QL)
(if covered by plan)
ELMIRON
RENACIDIN
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This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 34 of 35
4 TIER SPECIALTY DRUG LIST
Tier 1
 Best Buy Drug
 Value Drug
ST: Step Therapy
PA: PreAuthorization
QL: Quantity Limit
SP: Fill at a specialty
pharmacy
MB: Medical Benefit
See last page for explanation
of these abbreviations
Tier 2
Tier 3
Tier 4 Specialty
Most Tier 1 drugs are
generics, and the name
listed first below in lower
case is the generic name.
The branded names in ( )
are provided for reference
only. Check your benefit
materials to determine cost
share if the brand is filled.
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
Miscellaneous
Medications
ergoloid mesylates
CHEMET
ALL COMPOUNDED
DRUGS (PA)
MOST INJECTABLE
DRUGS (PA)
Diabetic Test Strips
ACCU-CHEK (QL)
FREESTYLE (QL)
PRECISION (QL)
SOF-TACT (QL)
Misc Diabetic Supplies
GLUCAGON KIT
NOVOFINE
NEEDLES/SYRINGES
PRODIGY
NEEDLES/SYRINGES
SOFT TOUCH
LANCETS
SOFTCLIX LANCETS
ORFADIN (PA)
Use Tier 2 Meter/Strips
First
ASCENSIA (ST/QL)
ONE TOUCH (ST/QL)
SURESTEP (QL)
TRACER BG (QL)
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ABBREVIATIONS GUIDE:
ST: Step Therapy—For medications marked with “ST,” members are encouraged to try a less expensive, similar drug first.
Your doctor can request authorization of the stepped (ST) medication and it will be approved if it meets our criteria.
PA: Pre-Authorization—ConnectiCare requires these drugs to be submitted for authorization to ensure that the medication
is being prescribed and used appropriately.
QL: Quantity Limit—These medications have restrictions on the number of tablets/capsules/packages that are dispensed,
to ensure they are being prescribed in the correct quantities and/or dosages.
SP: Fill at a specialty pharmacy—These medications are best filled at a designated Specialty Pharmacy, which has more
knowledge of the clinical use and handling of these lesser used, more costly drugs.
MB: Medical Benefit—These prescriptions are typically supplied and administered by a physician in their office, and are
not filled by the member at a pharmacy.
This Formulary List is subject to change.
4 Tier Specialty Drug List | Effective Oct 2014
Page 35 of 35