1. No category

-1-
Network Health
2015 Preferred Drug List
For the latest version of Network Health Preferred Drug list, log onto
networkhealth.com/formulary
January 2015
S0-010-49-1/15
Please refer to the member’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and Prescription Benefit
Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s PDL and prior authorization
policies govern the rules and restrictions outlined in this document.
-2-
PURPOSE
Network Health developed the Preferred Drug List (PDL) to provide members/participants and
practitioners with a listing of commonly prescribed medications. This listing includes preferred
and non-preferred medications and indicates which copayment/coinsurance tier applies. Tiers 1, 2
and 4 indicate preferred medications. Tiers 3 and 5 indicate non-preferred medications. For
members/participants with a four-tier benefit, tiers 1 and 2 indicate preferred medications, tier 3
indicates non-preferred medications, and tier 4 indicates all specialty products as preferred.
DEVELOPMENT OF THE PREFERRED DRUG LIST
Network Health’s Pharmacy and Therapeutics Committee (P and T Committee) developed the
PDL document. This committee, composed of practitioners and pharmacists from various medical
specialties, reviewed the medications in all therapeutic categories based on safety, effectiveness
and cost.
PDL development and maintenance is a dynamic process. The P and T Committee will regularly
review new and existing medications to ensure the PDL remains responsive to the needs of
members/participants and health care providers. The PDL will be updated periodically. For the
latest version of the Network Health PDL, go to networkhealth.com/formulary or contact Network
Health’s Customer Service Department at 800-826-0940 or 920-720-1300 to request a copy.
Network Health Pharmaceutical Benefits Management Program is based on optimal standards of
medical practice. Network Health’s P and T Committee develops and monitors all pharmaceutical
management policies, procedures, authorization criteria and the PDL.
Network Health delegates to the Pharmacy Benefits Management (PBM) company the approval process
for prior authorization required medications, non-formulary medications, vacation override, quantity
level limits and prescriber status exceptions. A pharmacist reviews all authorization/ exception requests
that do not meet Network Health’s criteria. If the pharmacist determines a denial is warranted, The PBM
provides the verbal and written communication of the denial, and how the denial may be appealed. The
processing of appeals remains a Network Health function.
PREFERRED DRUG LIST MEDICATIONS
The PDL applies to prescription medications provided to outpatients. This is typically limited to
medications obtained from participating pharmacies. Copayments/coinsurances and utilization
management rules may also apply to medications administered in the practitioner’s office. The
PDL does not apply to medications given in the inpatient hospital setting. Please refer to your
Summary of Member/Participant Responsibility Table and your Prescription Drug (Rx) Rider for
which copays apply to your benefit.
UNAPPROVED USE OF PREFERRED DRUG LIST MEDICATIONS
The Certificate of Coverage, Summary Plan Description or policy states a medication will be
eligible for coverage only if it is a Food and Drug Administration (FDA) approved medication
used for non-experimental reasons. Non-experimental uses include the labeled indication(s) (FDAapproved) and other indications accepted as effective by scientific evidence and informed
professional opinion. Experimental and investigational drugs, and drugs used for cosmetic
purposes, such as weight loss or erectile dysfunction are not eligible for coverage.
Members/participants should refer to the Certificate of Coverage, Summary Plan Description or
policy for a detailed list of exclusions.
Please refer to the member’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and Prescription Benefit
Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s PDL and prior authorization
policies govern the rules and restrictions outlined in this document.
-3-
COPAY/COINSURANCE DETERMINATION
The information listed in this document contains the most commonly-prescribed medications and
was current at the time of publishing, however, changes occur frequently. The
member/participant’s actual copayment/coinsurance will be determined at the time the prescription
is filled. The member/participant will only pay the applicable copayment/coinsurance for the
prescription unless one of the following conditions apply:
 GENERIC MEDICATIONS
If the practitioner indicates "Dispense As Written", or if the member/participant requests the
brand name product for a medication where a generic is available, the member/participant must
pay the applicable copayment/coinsurance plus the ancillary charge. The ancillary charge is the
cost difference between the brand name product and the generic product. When a generic
substitution conflicts with state regulations or restrictions, the pharmacist must gain approval
from the prescriber to use the generic equivalent.

NON-PRESCRIPTION MEDICATIONS
Unless a specific exception is made, non-prescription or over-the-counter (OTC) products are
not covered. If a prescription is written for a medication available as an OTC product, the
prescription product will not be covered. If the member/participant or practitioner insists on the
prescription product, the member/participant will be responsible for the entire cost of the
prescription.

SPECIALTY PRODUCTS
The P and T Committee designated certain pharmaceutical products as specialty products. The
PDL lists these products and indicates if they are preferred or non-preferred. For
members/participants with a four-tier benefit, all specialty products will be covered as tier 4.
For members/participants with a five-tier prescription benefit, these products will be covered as
tier 4 (preferred products) and tier 5 (non-preferred products). For members/participants with a
three-tier prescription benefit, these products will be covered as tier 2 (preferred products) and
tier 3 (non-preferred products). Specialty products must be obtained through Network Health’s
contracted specialty pharmacy (unless otherwise indicated in the Network Health PDL, in the
member/participant’s Prescription Drug (RX) Rider, or if the medication is administered in the
practitioner’s office).

COMPOUNDED PRESCRIPTIONS
Approved compounded prescriptions will be covered at the tier 3 copayment/coinsurance
amount. Please refer to the Prescription Benefit Summary of Member/Participant
Responsibility Table located under the Prescription Coverage tab in the Member/Participant
Handbook for specific copay/coinsurance information.
PREFERRED DRUG LIST ORGANIZATION
Medications are grouped by drug-class categories. Please refer to the INDEX section at the back of
the PDL for an alphabetical listing of medications, as well as a reference to the specific page
number each medication falls on. Members/participants will need to locate the medication within
the chapter section to verify which tier the medication falls within, as well as determine if there are
any special requirements or limitations for using the medication. When a medication is only
available as a brand name product, it is listed in CAPITAL LETTERS. When a generic is
Please refer to the member’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and Prescription Benefit
Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s PDL and prior authorization
policies govern the rules and restrictions outlined in this document.
-4-
available, it is listed using the generic name in bolded lowercase letters. It should be noted that
even if a medication is listed, it does not necessarily mean that all strengths and dosage forms have
the same copayment/coinsurance and/or limitations. Some of the common exceptions have been
indicated, however, due to the size of the PDL, a comprehensive listing of all dosage forms and
names was not possible. For information on medications that are not listed, please call Caremark at
855-282-8476 or go to www.caremark.com.
PRIOR AUTHORIZATION, QUANTITY LIMITS, STEP THERAPY
To promote the most appropriate utilization, certain medications have additional restrictions
applied to them. These restrictions have been established by the P and T Committee with input
from local practitioners and consideration of the current medical literature, and are indicated in the
COMMENTS column of the PDL. In the case of medications requiring prior authorization, the
member/participant’s practitioner must request approval for coverage prior to the prescription
being filled. These medications contain the letters “PAR” in the COMMENTS column.
Prescriptions for medications with quantity limits may not be dispensed in quantities greater than
is listed. The COMMENTS column identifies these medications with “QL=” followed by the limit.
Finally, some medications follow step therapy rules. That means different product(s) must be tried
before Network Health will cover the requested medication. These medications are indicated in the
COMMENTS column with the phrase “step therapy required.” If the member/participant and their
practitioner feel that any of the above restrictions do not meet the needs of the member/participant,
the practitioner may call the PBM to have a request for an exception reviewed.
SELF-ADMINISTERED INJECTABLES
Self-administered injectables refer to an injection given by the member/participant or caregiver in
the home. This does not include those drugs delivered via IM (intramuscular), IV (intravenous) or
IA (intra-arterial) injections or any drug administered through infusion. In order to promote the
appropriate level of care, those medications that can safely be self-administered will only be
available under the prescription benefit. If these medications are administered in the office, they
will only be covered for one dose unless it is determined that the member/participant cannot selfinject. These drugs usually require prior authorization. Contact the prior authorization center to
review the clinical and/or location criteria. These medications contain the letters “SA” in the
COMMENTS column. These injections must be obtained with a prescription and from a Network
Health participating specialty pharmacy unless noted on the PDL.
The information listed in this document contains the most commonly prescribed medications
and was current at the time of posting, however, changes occur frequently. The actual
copay/coinsurance will be determined at the time the prescription is filled. Individual and
Family Plan (IFP) members who have a ridered condition may have drugs that are listed in
the PDL that are not covered. For more information about your IFP benefits contact
Network Health Customer Service at 855-275-1400. For additional prescription drug
information, log onto www.caremark.com or call Caremark at 855-282-8476.
Please refer to the member’s Certificate of Coverage, Summary Plan Description, Policy, Prescription Drug Rider, and Prescription Benefit
Summary of Member/Participant Responsibility Table for particular plan design limitations. Network Health’s PDL and prior authorization
policies govern the rules and restrictions outlined in this document.
-5-
TABLE OF CONTENTS
Chapter
Chapter 4
Chapter 8
Chapter 10
Chapter 12
Chapter 20
Chapter 24
Chapter 28
Chapter 32
Chapter 36
Chapter 40
Chapter 44
Chapter 48
Chapter 52
Chapter 56
Chapter 60
Chapter 68
Chapter 76
Chapter 84
Chapter 86
Chapter 88
Chapter 92
SPECIALTY PRODUCTS
Name
ANTIHISTAMINE DRUGS
ANTI-INFECTIVE AGENTS
ANTINEOPLASTIC DRUGS
AUTONOMIC DRUGS
BLOOD FORMATION, COAGULATION, AND
THROMBOSIS
CARDIOVASCULAR DRUGS
CENTRAL NERVOUS SYSTEM AGENTS
CONTRACEPTIVES (FOAMS, DEVICES)
DIAGNOSTIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ENZYMES
RESPIRATORY TRACT AGENTS
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
GASTROINTESTINAL DRUGS
GOLD COMPOUNDS
HORMONES AND SYNTHETIC SUBSTITUES
OXYTOCICS
SKIN AND MUCOUS MEMBRANE AGENTS
SMOOTH MUSCLE RELAXANTS
VITAMINS
MISCELLANEOUS THERAPEUTIC AGENTS
Network Health Plan Preferred Drug List
DRUG NAME
COMMENTS
TIER
CHAPTER 4: ANTIHISTAMINE DRUGS
04:04:04 ETHANOLAMINE DERIVATIVES
clemastine
1
04:04:12 PHENOTHIAZINE DERIVATIVES
promethazine
1
promethazine vc
1
04:04:92 FIRST GENERATION ANTIHISTABINE DERIVATIVES, MISCELLANOUS
cyproheptadine
1
04:08:00 SECOND GENERATION ANTIHISTAMINES
desloratadine
1
levocetirizine
1
SEMPREX-D
3
CHAPTER 8: ANTI-INFECTIVE AGENTS
08:12:02 AMINOGLYCOSIDES
neomycin
1
08:12:06 CEPHALOSPORINS
cefaclor
1
cefaclor er
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
-6DRUG NAME
COMMENTS
TIER
cefadroxil
1
cefdinir
1
cefpodoxime
1
cefprozil
1
ceftibuten
1
CEFTIN SUSPENSION
2
cefuroxime
1
cephalexin
1
SPECTRACEF
3
SUPRAX
3
08:12:12 MACROLIDES
azithromycin
1
clarithromycin
1
clarithromycin er
1
ERYPED
2
erythromycin
1
erythromycin/sulfisoxazole
1
PCE
3
08:12:16 PENICILLINS
amox tr/potassium clavulanate
1
amoxicillin
1
ampicillin
1
dicloxacillin
1
penicillin v potassium
1
08:12:18 QUINOLONES
ciprofloxacin
1
ciprofloxacin er
1
FACTIVE
3
levofloxacin
1
moxifloxacin
1
NOROXIN
3
ofloxacin
1
08:12:20 SULFONAMIDES (SYSTEMIC)
sulfamethoxazole /trimethoprim
1
sulfamethoxazole /trimethoprim ds
1
sulfasalazine
1
sulfasalazine dr
1
08:12:24 TETRACYCLINES
demeclocycline
1
doxycycline hyclate
2
doxycycline hyclate dr
Exclude
doxycycline monohydrate
150 mg is excluded
2
doxycycline suspension
2
minocycline
1
tetracycline
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
-7DRUG NAME
COMMENTS
TIER
08:12:28 ANTIBACTERIALS, MISCELLANEOUS
clindamycin hcl
1
FIRST-VANCOMYCIN
3
vancomycin vial
1
XIFAXAN 200 MG
QL=9 tablets
2
08:14:04 ALLYLAMINES
LAMISIL GRANULES
3
terbinafine
1
08:14:08 AZOLES
fluconazole
itraconazole
1
PAR / capsules: QL=34
1
ketoconazole
1
ONMEL
PAR/ capsules: QL=34
3
SPORANOX
PAR / capsules: QL=34
2
08:14:28 POLYENES
nystatin
1
08:14:32 PYRIMIDINES
flucytosine
1
08:14:92 ANTIFUNGALS, MISCELLANEOUS
griseofulvin
1
08:16:04 ANTITUBERCULOSIS AGENTS
ethambutol
1
isoniazid
1
rifampin
1
08:16:92 ANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone
1
08:18:08:16 HIV NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
EDURANT
2
nevirapine
1
nevirapine xr
1
08:18:08:20 HIV NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS
abacavir
1
EPIVIR
2
lamivudine
1
08:18:28 NEURAMINIDASE INHIBITORS
RELENZA
QL=20 blisters
2
TAMIFLU
capsules: QL=34; 25ml bottle: QL=3
2
08:18:32 NUCLEOSIDES AND NUCLEOTIDES
acyclovir
1
adefovir
famciclovir
3
125mg tablets: QL=21; 250mg tablets: QL=68; 500mg tablets:
QL=21
TYZEKA
valacyclovir
1
2
500mg caplets: QL=34; 1000mg (1gm) caplets: QL=34
1
08:30:04 AMEBICIDES
paromomycin
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
1
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
-8DRUG NAME
COMMENTS
TIER
08:30:08 ANTIMALARIALS
atovaquone/proguanil
PAR
1
chloroquine
PAR
1
COARTEM
PAR
2
DARAPRIM
PAR
2
hydroxychloroquine sulfate
PAR
1
mefloquine
PAR
1
PRIMAQUINE
PAR
2
08:30:92 ANTIPROTOZOALS, MISCELLANEOUS
ALINIA
2
atovaquone
1
metronidazole
1
NEBUPENT
QL=1 container
tinidazole
2
1
08:36:00 URINARY ANTI-INFECTIVES
nitrofurantoin
1
nitrofurantoin suspension
1
trimethoprim
1
CHAPTER 10: ANTINEOPLASTIC AGENTS
10:00:00 ANTINEOPLASTIC AGENTS
ALKERAN TAB
2
anastrozole
1
bicalutamide
1
cyclophosphamide
1
etoposide
1
exemestane
1
hydroxyurea
1
letrozole
1
megestrol
1
mercaptopurine
1
methotrexate
1
tamoxifen citrate
Covered at no cost for females.
1
CHAPTER 12: AUTONOMIC DRUGS
12:04:00 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
bethanechol
1
cevimeline
1
donepezil 5 & 10mg
1
donepezil 23mg
EXELON
3
Patches
2
galantamine
1
galantamine er
1
pyridostigmine
1
rivastigmine
1
12:08:08 ANTIMUSCARINICS/ANTISPASMODICS
ANORO ELLIPTA
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL=60 inhalations
2
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
-9DRUG NAME
ATROVENT HFA
COMMENTS
QL=3 inhalers
belladonna/phenobarbital
TIER
2
1
chlordiazepoxide/clidinium
1
CUVPOSA SOLUTION
3
dicyclomine
1
glycopyrrolate
1
hyoscyamine
1
INCRUSE ELLIPTA
QL=60 inhalations
3
ipratropium nasal spray
QL=0.03%: QL=2; 0.06%: QL=3
1
ipratropium nebulizer
1
NULEV
2
SPIRIVA
2
TUDORZA
QL=2 inhalers
2
12:12:04 ALPHA-ADRENERGIC AGONISTS
midodrine
1
12:12:08 BETA-ADRENERGIC AGONISTS
ADVAIR DISKUS
Step therapy required/ QL=2 inhalers
2
ADVAIR HFA
Step therapy required,/QL=2 inhalers
2
QL=60
3
albuterol nebulizers
ARCAPTA
1
BROVANA
QL=60 inhalations
3
COMBIVENT RESPIMAT
QL=2 inhalers
2
FORADIL
QL=box of 12: QL=1; box of 60: QL=1
2
ipratropium/albuterol nebulizers
QL=205 vials
1
levalbuterol solution
PAR
1
PERFOROMIST
2
PROAIR HFA
QL=2 inhalers
2
PROVENTIL HFA
PAR/QL=2 inhalers
3
SEREVENT DISKUS
Box of 28: QL=1; box of 60: QL=2
2
STRIVERDI RESPIMAT
QL=120 inhalations
3
VENTOLIN HFA
PAR/QL=2 inhalers
3
XOPENEX HFA
PAR / QL=4 inhalers
3
QL=2 kits
2
EPINEPHRINE KIT
QL=2 kits
2
EPIPEN
QL=2 kits
2
EPIPEN JR
QL=2 kits
2
12:12:12 ALPHA-AND BETA-ADRENERGIC AGONISTS
AUVI-Q
12:16:04 ALPHA-ADRENERGIC BLOCKING AGENTS (SYMPATH)
alfuzosin er
1
dihydroergotamine nasal spray
QL=8 inhalers
2
MIGRANAL
QL=8 inhalers
3
RAPAFLO
Step therapy required
3
tamsulosin
1
12:20:04 CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS
carisoprodol
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
1
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 10 DRUG NAME
COMMENTS
TIER
chlorzoxazone
1
cyclobenzaprine
1
cyclobenzaprine er
1
metaxalone
1
methocarbamol
1
tizanidine
1
12:20:12 GABA-DERIVATIVE SKELETAL MUSCLE RELEXANTS
baclofen
1
12:20:92 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
orphenadrine er
1
12:92:00 AUTONOMIC DRUGS, MISCELLEANOUS (SMOKING CESSATION PRODUCTS)
REFER TO YOUR CERTIFICATE OF COVERAGE, POLICY OR SUMMARY PLAN DESCRIPTION FOR COVERAGE OF THESE
PRODUCTS. ONLY THE FOLLOWING PRESCRIPTION AND OTC SMOKING CESSATION PRODUCTS ARE COVERED AT NO
COST FOR UP TO 180 DAYS PER YEAR (THE YEAR IS 365 DAYS FROM YOUR FIRST FILL) BY NETWORK HEALTH PLAN
WITH A PRESCRIPTION WHEN ALLOWED BY YOUR CERTIFICATE OF COVERAGE, POLICY OR SUMMARY PLAN
DESCRIPTION. ALL OTHER MEMBERS/PARTICIPANTS DO NOT HAVE COVERAGE FOR THESE PRODUCTS. IF A BRAND IS
REQUESTED WHEN A GENERIC IS AVAILABLE ANCILLARY FEE APPLIES.
bupropion 150 mg SR tab (generic Zyban)
CHANTIX
nicotine gum, lozenge, patch
NICOTROL INHALER
NICOTROL NS
CHAPTER 20: BLOOD FORMATION, COAGULATION, AND THROMBOSIS
20:04:04 IRON PREPARATIONS
iron polysaccharide
1
20:12:04 ANTICOAGULANTS
ELIQUIS
2
enoxaparin sodium
1
fondaparinux
1
FRAGMIN
3
heparin
1
PRADAXA
2
warfarin sodium
1
XARELTO
2
20:12:18 PLATELET-AGGREGATION INHIBITORS
AGGRENOX
2
BRILINTA
2
cilostazol
1
clopidogrel
1
EFFIENT
2
ticlopidine
1
ZONTIVITY
3
20:24:00 HEMORRHEOLOGIC AGENTS
pentoxifylline
1
20:28:16 HEMOSTATICS
aminocaproic acid
1
tranexamic acid
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 11 DRUG NAME
COMMENTS
TIER
CHAPTER 24: CARDIOVASCULAR DRUGS
24:04:04 ANTIARRHYTHMIC AGENTS
amiodarone
1
disopyramide
1
flecainide
1
mexiletine
MULTAQ
1
must be prescribed by a cardiologist to be covered
2
procainamide
1
propafenone
1
propafenone er
1
TIKOSYN
2
24:04:08 CARDIOTONIC AGENTS
digoxin
1
24:04:92 CARDIAC DRUGS, MISCELLANEOUS
RANEXA
3
24:06:04 BILE ACID SEQUESTRANTS
cholestyramine
1
colestipol
1
WELCHOL
2
24:06:05 CHOLESTEROL ABSORPTION INHIBITORS
ZETIA
2
24:06:06 FIBRIC ACID DERIVATIVES
ANTARA
3
fenofibrate
1
fenofibric acid
1
FENOGLIDE
3
gemfibrozil
1
LIPOFEN
3
24:06:08 HMG-COA REDUCTASE INHIBITORS
ADVICOR
Step therapy required
2
ALTOPREV
Step therapy required
3
STB / Step therapy required
2
atorvastatin
CRESTOR
1
fluvastatin
1
LESCOL XL
Step therapy required
3
LIPTRUZET
Step therapy required
3
LIVALO
Step therapy required
3
lovastatin
1
pravastatin
1
SIMCOR
Step therapy required
simvastatin
VYTORIN
3
1
STB / Step therapy required
2
24:06:92 ANTILIPEMIC AGENTS, MISCELLANEOUS
niacin er
1
omega-3-acid
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 12 DRUG NAME
COMMENTS
VASCEPA
TIER
2
24:08:16 CENTRAL ALPHA-AGONISTS
clonidine
Patches: QL=5
1
clonidine er
1
guanfacine
1
methyldopa
1
NEXICLON XR
3
24:08:20 DIRECT VASODILATORS
hydralazine
1
minoxidil
1
24:12:08 NITRATES AND NITRITES
BIDIL
2
isosorbide
1
nitroglycerin
1
24:12:12 PHOSPHODIESTERASE TYPE 5 INHIBITORS
CIALIS 2.5MG & 5MG
QL=30; PAR
CIALIS 10MG & 20MG
excluded
3
24:12:92 VASODILATING AGENTS, MISCELLANEOUS
dipyridamole
1
24:20:00 ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA XL
Step therapy required
3
doxazosin
1
prazosin
1
terazosin
1
24:24:00 BETA-ADRENERGIC BLOCKING AGENTS
acebutolol
1
atenolol
1
atenolol/chlorthalidone
1
betaxolol
1
bisoprolol
1
bisoprolol/hydrochlorothiazide
1
BYSTOLIC
3
carvedilol
1
COREG CR
3
labetalol
1
metoprolol
1
metoprolol er
1
metoprolol/hydrochlorothiazide
1
nadolol
1
pindolol
1
propranolol
1
propranolol er
1
propranolol/hydrochlorothiazide
1
sotalol
1
timolol
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 13 DRUG NAME
COMMENTS
TIER
24:28:08 DIHYDROPYRIDINES
amlodipine
1
amlodipine/benazepril
amlodipine/atorvastatin
1
Exclude
amlodipine/telmisartan
1
amlodipine/valsartan
Step therapy required
1
AZOR
Step therapy required
3
Step therapy required
3
CARDENE SR
EXFORGE HCT
3
felodipine er
1
isradipine
1
nicardipine hcl
1
nifedipine
1
nifedipine er
1
nimodipine
1
nisoldipine
TRIBENZOR
1
Step therapy required
3
24:28:92 CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
CARDIZEM LA
3
cartia xt
1
diltiazem cd
1
diltiazem er
1
diltiazem hcl
1
diltiazem xr
1
verapamil hcl
1
verapamil hcl er
1
24:32:04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
benazepril
1
benazepril/hydrochlorothiazide
1
captopril
1
captopril/hydrochlorothiazide
1
enalapril
1
enalapril/hydrochlorothiazide
1
fosinopril
1
fosinopril/hydrochlorothiazide
1
lisinopril
1
lisinopril/hydrochlorothiazide
1
moexipril
1
moexipril/hydrochlorothiazide
1
perindopril
1
quinapril
1
quinapril/hydrochlorothiazide
1
ramipril
1
trandolapril
1
trandolapril/verapamil
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 14 DRUG NAME
COMMENTS
TIER
24:32:08 ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR
Step therapy required
2
BENICAR HCT
Step therapy required
2
candesartan
1
candesartan/hydrochlorothiazide
1
EDARBI
Step therapy required
3
EDARBYCLOR
Step therapy required
3
eprosartan 600mg
1
irbesartan
1
irbesartan/hydrochlorothiazide
1
losartan
1
losartan/hydrochlorothiazide
1
telmisartan
1
telmisartan/hydrochlorothiazide
1
TEVETEN 400 MG
Step therapy required
3
TEVETEN HCT
Step therapy required
3
valsartan
1
valsartan/hydrochlorothiazide
1
24:32:20 MINERALOCORTICOID (ALDOSTERONE) ANTAGONISTS
eplerenone
Step therapy required
1
INSPRA
Step therapy required
2
spironolactone
1
spironolactone/hydrochlorothiazide
1
24:32:40 RENIN INHIBITORS
TEKAMLO
Step therapy required
3
TEKTURNA
Step therapy required
3
Step therapy required
3
TEKTURNA HCT
CHAPTER 28: CENTRAL NERVOUS SYSTEM AGENTS
28:08:04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
FIRST LINE AGENTS
diclofenac
1
diflunisal
1
etodolac
1
flurbiprofen
1
ibuprofen
1
indomethacin
1
ketoprofen
1
ketorolac
QL=20 tablets
1
meloxicam
1
naproxen
1
piroxicam
1
salsalate
1
sulindac
1
SECOND LINE AGENTS
CELEBREX
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
Step therapy required
2
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 15 DRUG NAME
COMMENTS
TIER
diclofenac sa
Step therapy required
1
diclofenac dr-misoprostol
Step therapy required
1
DUEXIS
Step therapy required
3
etodolac sa
Step therapy required
1
ketoprofen sa
Step therapy required
1
mefenamic acid
Step therapy required
1
nabumetone
Step therapy required
1
naproxen sr
Step therapy required
1
oxaprozin
Step therapy required
1
VIMOVO
Step therapy required
3
VOLTAREN XR
Step therapy required
3
ZIPSOR
Step therapy required
3
ZORVOLEX
Step therapy required
3
MISCELLANEOUS AGENTS
butalbital/aspirin/caffeine
1
CAMBIA
QL=9 packets
3
SPRIX NASAL SPRAY
QL=5
3
28:08:08 OPIATE AGONISTS
acetaminophen/codeine
1
codeine
1
fentanyl
1
hydrocodone/acetaminophen
1
hydrocodone/ibuprofen
1
hydromorphone
1
hydromorphone er
1
KADIAN ER
3
meperidine
1
methadone
1
morphine
1
morphine er
1
NUCYNTA
2
NUCYNTA ER
OPANA ER
2
Crush resistant tablets
3
OXECTA
3
oxycodone
1
oxycodone cr
1
oxycodone/acetaminophen
1
OXYCONTIN
2
oxymorphone
1
oxymorphone er
1
tramadol hcl
1
tramadol hcl er
1
tramadol/acetaminophen
1
XARTEMIS XR
3
ZOHYDRO ER
3
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 16 DRUG NAME
COMMENTS
TIER
28:08:12 OPIATE PARTIAL AGONISTS
buprenorphine
1
buprenorphine/naloxone
butorphanol nasal spray
1
QL=2 bottles
1
BUTRANS PATCH
3
ZUBSOLV
3
28:08:92 ANALGESICS AND ANTIPYRETICS, MISC.
butalbital/acetaminophen
1
butalbital/acetaminophen/caffeine
1
GRALISE ER
3
28:10:00 OPIATE ANTAGONISTS
naltrexone
1
28:12:04 BARBITURATES (ANTICONVULSANTS)
primidone
1
28:12:08 BENZODIAZEPINES (ANTICONVULSANTS)
clonazepam
1
clonazepam odt
1
ONFI
2
28:12:12 HYDANTOINS
PHENYTEK
2
phenytoin
1
phenytoin extended
1
28:12:20 SUCCINIMIDES
ethosuximide
1
28:12:92 ANTICONVULSANTS, MISCELLANEOUS
APTIOM
2
carbamazepine
1
carbamazepine er
1
divalproex
1
divalproex dr
1
divalproex er
1
felbamate
2
FYCOMPA
2
gabapentin
1
HORIZANT
Step therapy required
3
LAMICTAL ODT
2
lamotrigine
1
lamotrigine er
3
levetiracetam
1
levetiracetam er
LYRICA
oxcarbazepine
1
Step therapy required
3
1
POTIGA
2
STAVZOR
3
tiagabine
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 17 DRUG NAME
COMMENTS
TIER
topiramate
1
topiramate er
1
TROKENDI XR
3
valproic acid
1
VIMPAT
Step therapy required
2
zonisamide
1
28:16:04 ANTIDEPRESSANTS Individual and Family Plan (IFP) members may not have coverage for this class
amitriptyline
1
BRISDELLE
3
bupropion
1
bupropion sr, xl
1
citalopram
1
clomipramine
1
desipramine
1
DESVENLAFAXINE ER
3
doxepin
1
duloxetine
1
escitalopram
1
FETZIMA
3
fluoxetine
1
fluvoxamine
1
fluvoxamine er
1
FORFIVO XL
3
imipramine
1
mirtazapine
1
mirtazapine odt
1
nefazodone
1
nortriptyline
1
olanzapine/fluoxetine
1
paroxetine
1
paroxetine er
1
PEXEVA
3
phenelzine
1
PRISTIQ
3
protriptyline
1
SARAFEM
3
sertraline
1
trazodone
1
trimipramine
1
venlafaxine
1
venlafaxine er tablets
3
venlafaxine er capsules
1
VIIBRYD
Step therapy required /QL=34
2
28:16:04:24 SEROTONIN MODULATORS Individual and Family Plan (IFP) members may not have coverage for this class
BRINTELLIX
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
Step therapy required
3
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 18 DRUG NAME
COMMENTS
TIER
28:16:08 ANTIPSYCHOTIC AGENTS Individual and Family Plan (IFP) members may not have coverage for this class
ABILIFY DISCMELT, SOLUTION, VIAL
3
ABILIFY TABLET
2
chlorpromazine
1
clozapine
1
clozapine odt
1
FANAPT
Step therapy required / 1mg, 2mg, 4mg tablets: QL=45; 6mg
tablets: QL=62; titration pack: QL=55
3
FAZACLO ODT
Step therapy required
3
fluphenazine
1
haloperidol
1
INVEGA
Step therapy required
3
LATUDA
Step therapy required
3
olanzapine
Step therapy required
1
olanzapine odt
Step therapy required
1
perphenazine
1
prochlorperazine
1
quetiapine
1
risperidone
1
risperidone odt
SAPHRIS
1
Step therapy required
3
SEROQUEL XR
3
SILENOR
3
thioridazine
1
thiothixene
1
trifluoperazine
1
ziprasidone
1
28:20:04 AMPHETAMINES Individual and Family Plan (IFP) members may not have coverage for this class
amphetamine salt combo
1
amphetamine salt combo xr
1
dextroamphetamine
1
methamphetamine
1
VYVANSE
2
zenzedi
1
28:20:32 RESPIRATORY AND CNS STIMULANTS Individual and Family Plan (IFP) members may not have coverage for this
class
DAYTRANA
3
dexmethylphenidate
1
dexmethylphenidate er
1
FOCALIN
3
FOCALIN XR
3
METADATE ER
3
methylphenidate
1
methylphenidate cd (generic for METADATE CD)
1
methylphenidate er (generic for RITALIN SR & LA)
1
methylphenidate er (generic for CONCERTA)
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
18mg & 27mg tablets: QL=34
1
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 19 DRUG NAME
COMMENTS
TIER
28:20:80 WAKEFULNESS-PROMOTING AGENTS
modafinil
Step therapy required
1
NUVIGIL
Step therapy required
2
28:24:04 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYPNOTICS)
phenobarbital
1
28:24:08 BENZODIAZEPINES (ANXIOLYTIC, SEDATIVE/HYPNOTICS) Individual and Family Plan (IFP) members may not have
coverage for this class
alprazolam
1
alprazolam er
1
alprazolam odt
1
chlordiazepoxide
1
clorazepate
1
diazepam
1
flurazepam
1
lorazepam
1
oxazepam
1
temazepam
1
triazolam
1
28:24:92 ANXIOLYTICS, SEDATIVES & HYPNOTICS, MISC. Individual and Family Plan (IFP) members may not have coverage
for this class
buspirone
1
eszcopiclone
1
hydroxyzine hcl
1
hydroxyzine pamoate
1
INTERMEZZO
PAR/QL=20 tablets
3
ROZEREM
3
SONATA
3
zaleplon
1
zolpidem
1
zolpidem cr
1
ZOLPIMIST
3
28:28:00 ANTIMANIC AGENTS Individual and Family Plan (IFP) members may not have coverage for this class
lithium carbonate
1
lithium carbonate er
1
lithium citrate
1
28:32:28 SELECTIVE SEROTONIN AGONISTS
ALSUMA
Step therapy required /QL=8 injections
3
AXERT
Step therapy required / QL=9 tablets
3
FROVA
Step therapy required / QL=9 tablets
3
IMITREX NASAL SPRAY
PAR on 5mg nasal spray / QL=6 devices
3
naratriptan
QL=9 tablets
1
RELPAX
Step therapy required / QL=9 tablets
3
rizatriptan
QL=9 tablets
1
rizatriptan odt
QL=9 tablets
1
sumatriptan
Tablets: QL=9; Nasal Spray: QL=6; Injectable: QL=8 injections
(PAR on 5mg nasal spray)
1
SUMAVEL
Step therapy required / QL=8 kits
3
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 20 DRUG NAME
COMMENTS
TIER
TREXIMET
Step therapy required / QL=9 tablets
3
zolmitriptan
QL=9 tablets
1
zolmitriptan odt
QL=9 tablets
1
ZOMIG NASAL SPRAY
Step therapy required
2
28:36:04 ADAMANTANES (CNS)
amantadine
1
28:36:08 ANTICHOLINERGIC AGENTS (CNS)
benztropine
1
trihexyphenidyl
1
28:36:12 CATECHOL-O-METHYLTRASFERASE (COMT) INHIBITORS
entacapone
1
28:36:16 DOPAMINE PRECURSORS
carbidopa
1
carbidopa/levodopa
1
carbidopa/levodopa er
1
carbidopa/levodopa/entacapone
1
28:36:20 DOPAMINE RECEPTOR AGONISTS
bromocriptine
1
cabergoline
QL=10 tablets
1
MIRAPEX ER
3
NEUPRO PATCH
2
pramipexole
1
ropinirole
1
ropinirole er
1
28:36:32 MONOAMINE OXIDASE B INHIBITORS Individual and Family Plan (IFP) members may not have coverage for this
class
AZILECT
3
EMSAM
3
selegiline
1
28:40:00 FIBROMYALGIA AGENTS
SAVELLA
2
28:92:00 CENTRAL NERVOUS SYSTEM AGENTS, MISC.
acamprosate
1
INTUNIV
2
NAMENDA SUSPENSION
3
NAMENDA TABLET
2
NAMENDA XR
3
NUEDEXTA
2
STRATTERA
2
CHAPTER 32: CONTRACEPTIVES (FOAMS, DEVICES)
32:00:00 CONTRACEPTIVE-FOAM/DEVICE
REFER TO YOUR FAMILY PLANNING RIDER FOR COVERAGE OF THESE PRODUCTS. ONLY THE FOLLOWING OTC
CONTRACEPTIVES ARE COVERED BY NETWORK HEALTH PLAN WITH A PRESCRIPTION WHEN ALLOWED BY YOUR
FAMILY PLANNING RIDER. ALL OTHER MEMBERS/PARTICIPANTS DO NOT HAVE COVERAGE FOR THESE OTC
PRODUCTS.
female condoms
Covered at no charge
levonorgestrel (PLAN B)
Covered at no charge/QL = 2 tablets
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 21 DRUG NAME
COMMENTS
PLAN B ONE-STEP OTC
Covered at no charge/ QL = 2 tablets
spermicides- foams, gels, suppositories
Covered at no charge
sponges
Covered at no charge
TIER
CHAPTER 36: DIAGNOSTIC AGENTS
36:26:00 DIABETES MELLITUS
ONLY THE FOLLOWING BLOOD GLUCOSE METERS & TEST STRIPS ARE COVERED BY NETWORK HEALTH PLAN. NONPREFERRED GLUCOSE METERS & TEST STRIPS ARE COVERED AT A NON-PREFERRED COPAY/COINSURANCE FOR
THOSE MEMBERS/PARTICIPANTS WITH COVERAGE FOR NON-PREFERRED DIABETIC SUPPLIES. ALL OTHER
MEMBERS/PARTICIPANTS DO NOT HAVE COVERAGE FOR THESE PRODUCTS.
ACCU-CHEK ACTIVE TEST STRIPS
2
ACCU-CHEK ADVANTAGE TEST STRIPS
2
ACCU-CHEK AVIVA METER
2
ACCU-CHEK AVIVA PLUS TEST STRIPS
2
ACCU-CHEK AVIVA TEST STRIPS
2
ACCU-CHEK COMFORT CURVE TEST STRIPS
2
ACCU-CHEK COMPACT CARE KIT
2
ACCU-CHEK COMPACT TEST DRUM
2
ACCU-CHEK COMPACT TEST STRIPS
2
ACCU-CHEK COMPLETE METER
2
ACCU-CHEK INSTANT TEST STRIPS
2
ACCU-CHEK NANO SMARTVIEW METER
2
ACCU-CHEK SMARTVIEW TEST STRIPS
2
ACCU-CHEK SIMPLICITY TEST STRIPS
2
ACCU-CHEK VOICEMATE METER
2
ACCU-CHEK VOICEMATE METER
2
MULTICLIX
2
NOVOFINE 32G NEEDLES
2
NOVOFINE AUTOCOVER
2
ONETOUCH BASIC SYSTEM KIT
2
ONETOUCH FASTTAKE METER
2
ONETOUCH FASTTAKE TEST STRIPS
2
ONETOUCH PROFILE SYSTEM KIT
2
ONETOUCH SURESTEP SYSTEM
2
ONETOUCH SURESTEP TEST STRIPS
2
ONETOUCH TEST STRIPS
2
ONETOUCH ULTRA SYSTEM KIT
2
ONETOUCH ULTRA TEST STRIPS
2
ONETOUCH ULTRASMART METER
2
PRODIGY PEN NEEDLE
2
SOFT TOUCH
2
SOFTCLIX
2
CHAPTER 40: ELECTROLYTE, CALORIC, AND WATER BALANCE
40:10:00 AMMONIA DETOXICANTS
KRISTALOSE
3
lactulose
1
40:12:00 REPLACEMENT PREPARATIONS
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 22 DRUG NAME
COMMENTS
TIER
calcium acetate
1
potassium chloride
1
40:18:18 POTASSIUM-REMOVING AGENTS
sodium polystyrene
1
40:28:08 LOOP DIURETICS
bumetanide
1
furosemide
1
torsemide
1
40:28:16 POTASSIUM-SPARING DIURETICS
amiloride
1
amiloride/hydrochlorothiazide
1
DYRENIUM
3
triamterene/hydrochlorothiazide
1
40:28:20 THIAZIDE DIURETICS
chlorothiazide
1
hydrochlorothiazide
1
40:28:24 THIAZIDE-LIKE DIURETICS
chlorothalidone
1
indapamide
1
metolazone
1
40:40:00 URICOSURIC AGENTS
probenecid
1
CHAPTER 48: RESPIRATORY TRACT AGENTS
48:08:00 ANTITUSSIVES
benzonatate
1
guaifenesin ac
1
guaifenex pse
1
hydrocodone/chlorpheniramine
1
promethazine/codeine
1
promethazine/dm
1
promethazine vc/codeine
1
48:10:24 LEUKOTRIENE MODIFIERS
montelukast
1
zafirlukast
1
ZYFLO
Step therapy required
3
ZYFLO CR
Step therapy required
3
48:10:32 MAST-CELL STABILIZERS
cromolyn nebulizers
1
48:32:00 PHOSPHODIESTERASE TYPE 4 INHIBITORS
DALIRESP
2
CHAPTER 52: EYE, EAR, NOSE, AND THROAT PREPARATIONS
52:02:00 ANTIALLERGIC AGENTS
ALAMAST
3
ALOCRIL
2
ALOMIDE
3
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 23 DRUG NAME
azelastine spray
COMMENTS
QL=3 inhalers
TIER
1
azelastine ophth
1
BEPREVE
2
cromolyn
1
DYMISTA
Step therapy required /QL=2 inhalers
3
EMADINE
3
epinastine hcl
1
LASTACAFT
3
OPTIVAR
3
PATADAY
2
PATANASE
QL=4 inhalers
PATANOL
3
2
52:04:04 ANTIBACTERIALS (EENT)
ARESTIN
3
AZASITE
3
bacitracin
1
BESIVANCE
3
CILOXAN
2
ciprofloxacin
1
erythromycin
1
gatifloxacin
1
gentamicin
1
IQUIX
3
levofloxacin
1
ofloxacin
1
polymyxin b sul/trimethoprim
1
sulfacetamide sodium
1
tobramycin sulfate
1
VIGAMOX
2
ZYMAR
2
52:04:20 ANTIVIRALS (EENT)
trifluridine
1
52:08:08 CORTICOSTEROIDS (EENT)
ALREX
BECONASE AQ
3
Step therapy required / QL=2 inhalers
BLEPHAMIDE
budesonide
3
2
Step therapy required / QL=2 inhalers
2
CIPRO HC
2
CIPRODEX
2
dexamethasone
1
DUREZOL
3
FLAREX
3
flunisolide
QL=2 inhalers
1
fluocinolone oil ear drops
1
fluorometholone
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 24 DRUG NAME
fluticasone
COMMENTS
QL=2 inhalers
hydrocortisone/acetic acid ear drops
1
1
LOTEMAX
NASONEX
TIER
2
Step therapy required / QL=2 inhalers
2
neomycin/bacitracin/poly/hc
1
neomycin/polymyxin/dexameth
1
neomycin/polymyxin/hc
1
OMNARIS
Step therapy required / QL=4 inhalers
3
PRED-G
3
prednisolone
1
QNASL
Step therapy required / QL=2 inhalers
3
sulfacetamide/prednisolone
1
TOBRADEX
2
tobramycin/dexamethasone
1
VERAMYST
Step therapy required / QL=2 inhalers
ZETONNA
Step therapy required / QL=2 inhalers
3
3
VEXOL
3
ZYLET
3
52:08:20 EENT NONSTEROIDLA ANTI-INFLAMMATORY AGENTS
ACUVAIL
3
bromfenac
1
diclofenac
1
flurbiprofen
1
ketorolac
1
NEVANAC
2
PROLENSA
3
52:08:92 EENT ANTI-INFLAMMATORY AGENTS, MISCELLANEOUS
RESTASIS
QL=68 single use vials
3
52:16:00 LOCAL ANESTHETICS (EENT)
antipyrine/benzocaine
1
52:24:00 MYDRIATICS
atropine
1
cyclopentolate
1
52:40:04 ALPHA-ADRENERGIC AGONISTS (EENT)
ALPHAGAN P
2
brimonidine
1
COMBIGAN
3
SIMBRINZA
3
52:40:08 BETA-ADRENERGIC BLOCKING AGENTS (EENT)
betaxolol
1
BETIMOL
3
BETOPTIC-S
2
levobunolol
1
metipranolol
1
timolol
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 25 DRUG NAME
COMMENTS
TIER
52:40:12 CARBONIC ANHYDRASE INHIBITORS (EENT)
acetazolamide
1
AZOPT
2
COSOPT PF
2
dorzolamide
1
dorzolamide/timolol
1
52:40:20 MIOTICS
pilocarpine
1
52:40:28 PROSTAGLANDIN ANALOGS
latanoprost
1
LUMIGAN
Step therapy required
2
RESCULA
Step therapy required
3
TRAVATAN Z
Step therapy required
2
travoprost
Step therapy required
1
ZIOPTAN
Step therapy required
3
52:92:00 EENT DRUGS, MISCELLANEOUS
acetic acid
1
apraclonidine
1
LACRISERT
2
CHAPTER 56: GASTROINTESTINAL DRUGS
56:08:00 ANTIDIARRHEA AGENTS
diphenoxylate/atropine
1
FULYZAQ
3
56:12:00 CATHARTICS AND LAXATIVES
COLYTE
3
GOLYTELY
3
HALFLYTELY-BISACODYL
3
MOVIPREP
3
NULYTELY
3
peg3350/electrolyte soln
1
56:14:00 CHOLELITHOLYTIC AGENTS
URSO
2
ursodiol
1
56:16:00 DIGESTANTS
CREON
2
PANCREAZE
2
PANCRELIPASE 5,000
3
ZENPEP
3
56:22:08 ANTIHISTAMINES (GI DRUGS)
trimethobenzamide
1
prochlorperazine
1
56:22:20 5-HT3 RECEPTOR ANTAGONISTS
ANZEMET
tablets: QL=1
3
granisetron
tablets: QL=2; 30ml bottle: QL=1
1
ondansetron
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
1
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 26 DRUG NAME
SANCUSO
COMMENTS
TIER
QL = 1 patch
3
ZUPLENZ
3
56:22:92 ANTIEMETICS, MISCELLANEOUS
CESAMET
3
DICLEGIS
3
dronabinol
1
EMEND
40mg capsules: QL=1; 80mg capsules: QL=2; 125mg
capsules: QL=1; Trifold Pack: QL=1
2
TRANSDERM/SCOPOLAMINE
PAR
3
56:28:12 HISTAMINE H2-ANTAGONISTS
cimetidine
1
nizatidine
1
ranitidine syrup
1
56:28:28 PROSTAGLANDINS
misoprostol
1
56:28:32 PROTECTANTS
sucralfate
1
56:28:36 PROTON-PUMP INHIBITORS
ACIPHEX SPRINKLES
PAR
3
DEXILANT
PAR
3
ESOMEPRAZOLE STRONTIUM
PAR
3
FIRST-LANSOPRAZOLE
PAR
3
FIRST-OMEPRAZOLE
PAR
3
lansoprazole
lansoprazole/amoxicillin/clarithromycin
1
QL=1 pack (14 units)
1
NEXIUM 40 MG
PAR / 20mg: excluded
3
omeprazole
10mg: QL=34
1
pantoprazole
20mg: QL=34
1
PREVACID SOLUTAB
PAR
3
rabeprazole
PAR
1
56:28:92 ANTIULCER AGENTS AND ACID SUPPRESSANTS, MISCELLANEOUS
HELIDAC
3
56:32:00 PROKINETIC AGENTS
metoclopramide
1
56:36:00 ANTI-INFLAMMATORY AGENTS (GI DRUGS)
APRISO
2
ASACOL HD
2
balsalazide
1
CANASA
2
COLAZAL
3
DELZICOL DR
2
DIPENTUM
3
LIALDA
3
LOTRONEX
2
mesalamine
1
PENTASA
2
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 27 DRUG NAME
COMMENTS
TIER
SFROWASA
2
56:92:00 GI DRUGS, MISCELLANEOUS
AMITIZA
3
LINZESS
2
PYLERA
3
CHAPTER 60: GOLD COMPOUNDS
60:00:00 GOLD COMPOUNDS
RIDAURA
2
CHAPTER 68: HORMONES AND SYNTHETIC SUBSTITUTES
68:04:00 ADRENALS
AEROSPAN
QL=8.9gm=2; 5.1gm=4
3
ALVESCO
QL=2 inhalers
3
ASMANEX
QL=120 inhalations
2
BREO ELLIPTA
QL=2 inhalers
3
budesonide respules
1
cortisone tablets
1
dexamethasone
1
DULERA
Step therapy required / QL=2 inhalers
2
FLOVENT DISKUS
QL=2 inhalers
2
FLOVENT HFA
QL=2 inhalers
2
fludrocortisone
1
hydrocortisone
1
methylprednisolone
1
MILLIPRED
3
ORAPRED ODT
3
prednisolone
1
prednisone
1
PULMICORT FLEXHALER
QL=180mcg=3 inhalers; 90mcg=2 inhalers
3
QVAR
QL=3 inhalers
3
Step therapy required / QL=2 inhalers
2
ANDRODERM
PAR
3
ANDROGEL
PAR
2
RAYOS
SYMBICORT
3
68:08:00 ANDROGENS
AVEED
3
AXIRON
PAR
3
FIRST-TESTOSTERONE
PAR
3
oxandrolone
STRIANT
1
PAR
3
TESTOPEL
PAR
3
testosterone
PAR
1
VOGELXO
PAR
3
68:12:00 CONTRACEPTIVES
REFER TO YOUR FAMILY PLANNING RIDER FOR COVERAGE OF THESE PRODUCTS. IF YOUR PLAN PROVIDES FOR FREE
CONTRACEPTIVE COVERAGE THE FOLLOWING GENERIC CONTRACEPTIVES AND BRANDS WHEN A GENERIC IS NOT
AVAILABLE ARE COVERED AT NO COST. AS A REMINDER FOR ALL MEMBERS/PARTICIPANTS AN ANCILLARY FEE STILL
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 28 DRUG NAME
COMMENTS
TIER
APPLIES WHEN A BRAND IS REQUESTED AND A GENERIC IS AVAILABLE.
PROGESTIN ONLY
generic progestin only contraceptives
1
ELLA
2
PLAN B PRESCRIPTION
QL = 2 tablets
3
MONO-PHASIC
generic mono-phasic contraceptives
1
amethia
one dispenser = 3 copayments
1
camrese
one dispenser = 3 copayments
1
GENERESS FE
3
BI-PHASIC
generic bi-phasic contraceptives
1
TRI-PHASIC
generic tri-phasic contraceptives
1
ORTHO TRI-CYCLEN LO
2
FOUR-PHASIC
NATAZIA
3
OTHER CONTRACEPTIVES
generic contraceptives
1
NUVARING
2
SKYLA
2
68:16:04 ESTROGENS
ALORA
QL=10 patches
2
ANGELIQ
3
CENESTIN
2
CLIMARA PRO
QL=5 patches
2
COMBIPATCH
2
DELESTROGEN
3
DIVIGEL
QL=34 packets
ELESTRIN
QL= 144 gm
3
3
ENJUVIA
3
ESTRACE
2
estradiol
1
estradiol/norethidrone
1
ESTRING
2
ESTROGEL
3
estrogen/methyltestosterone
1
estrogen/methyltestosterone hs
1
estropipate
1
EVAMIST
2
FEMHRT
2
FEMRING
3
jinteli
1
MENEST
3
MENOSTAR
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL=5 patches
3
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 29 DRUG NAME
MINIVELLE
COMMENTS
QL=10 patches
TIER
3
PREMARIN
2
PREMPHASE
2
PREMPRO
2
VAGIFEM
2
VIVELLE-DOT
QL=10 patches
2
68:16:12 ESTROGEN AGONIST-ANTAGONISTS
DUAVEE
2
OSPHENA
3
raloxifene
1
68:20:02 ALPHA-GLUCOSIDASE INHIBITORS
acarbose
Step therapy required
1
68:20:03 AMYLINOMIMETICS
SYMLINPEN
3
68:20:04 BIGUANIDES
metformin
1
metformin er
1000 mg is excluded
1
RIOMET
Step therapy required
3
68:20:05 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUMET
2
JANUMET XR
2
JANUVIA
2
JENTADUETO
2
KAZANO
PAR
3
KOMBIGLYZE XR
PAR
3
NESINA
PAR
3
ONGLYZA
PAR
3
OSENI
PAR
3
TRADJENTA
2
68:20:06 INCRETIN MIMETICS
BYDUREON
2
BYETTA
3
TANZEUM
3
VICTOZA
2
68:20:08 INSULINS
APIDRA
PAR
3
HUMALOG KWIKPEN, PEN, VIAL
PAR
3
HUMALOG MIX 50/50 KWIKPEN, PEN, VIAL
PAR
3
HUMALOG MIX 75/25 KWIKPEN, PEN, VIAL
PAR
3
HUMULIN 50/50 VIAL
PAR
3
HUMULIN 70/30 PEN, VIAL
PAR
3
HUMULIN N PEN, VIAL
PAR
3
HUMULIN R U-100 VIAL
PAR
3
HUMULIN R U-500 VIAL
2
LANTUS PEN, VIAL
2
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 30 DRUG NAME
COMMENTS
TIER
LEVEMIR FLEXPEN, VIAL
2
NOVOLIN 70/30 VIAL
2
NOVOLIN N VIAL
2
NOVOLIN R VIAL
2
NOVOLOG, FLEXPEN, VIAL
2
NOVOLOG MIX 70/30, FLEXPEN, VIAL
2
68:20:16 MEGLITINIDES
nateglinide
1
PRANDIMET
Step therapy required
3
repaglinide
Step therapy required
1
68:20:18 SODIUM GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
FARXIGA
Step therapy required
2
INVOKAMET
Step therapy required
3
INVOKANA
Step therapy required
2
JARDIANCE
Step therapy required
3
68:20:20 SULFONYLUREAS
glimepiride
1
glipizide
1
glipizide xl
1
glipizide/metformin
1
glyburide
1
glyburide/metformin
1
68:20:28 THIAZOLIDINEDIONES
ACTOPLUS MET XR
Step therapy required
3
AVANDAMET
Step therapy required
3
AVANDARYL
Step therapy required
3
AVANDIA
Step therapy required
2
glimiperide/pioglitazone
Step therapy required
1
pioglitazone
Step therapy required / QL=34 tablets
1
pioglitazone/metformin
Step therapy required
1
68:20:92 ANTIDIABETIC AGENTS, MISCELLANEOUS
CYCLOSET
3
68:22:12 GLYCOGENOLYTIC AGENTS
GLUCAGON
2
68:24:00 PARATHYROID
calcitonin-salmon nasal
1
68:28:00 PITUITARY
desmopressin acetate tab
1
68:32:00 PROGESTINS
CRINONE
PAR – 8% only
DEPO-PROVERA
ENDOMETRIN
2
2
PAR
3
medroxyprogesterone acetate
1
MEGACE ES
3
norethindrone acetate
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 31 DRUG NAME
COMMENTS
progesterone
Vial, suppository, and gel=PAR
TIER
1
68:36:04 THYROID AGENTS
ARMOUR THYROID
3
CYTOMEL
2
levothroid
1
levothyroxine sodium
1
levoxyl
1
SYNTHROID
2
TIROSINT
3
unithroid
1
68:36:08 ANTITHYROID AGENTS
methimazole
1
propylthiouracil
1
CHAPTER 76: OXYTOCICS
76:00:00 OXYTOCICS
methylergonovine
1
CHAPTER 84: SKIN AND MUCOUS MEMBRANE AGENTS
84:04:04 ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
ACANYA
2
ALTABAX
3
BACTROBAN NASAL OINTMENT
2
BENZACLIN GEL
2
clindamycin phosphate
1
DUAC CS
3
erythromycin base
1
gentamicin
1
metronidazole
1
mupirocin cream and ointment
1
NORITATE
2
sodium sulfacetamide
1
84:04:06 ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
acyclovir ointment
1
DENAVIR
3
ZOVIRAX
2
84:04:08 ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
ciclopirox kit
1
clotrimazole lozenge
1
clotrimazole/betamethasone
1
econazole
1
ERTACZO
3
EXELDERM
3
ketoconazole
1
LAMISIL SOLUTION
3
LUZU
3
MENTAX
3
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 32 DRUG NAME
COMMENTS
TIER
NAFTIN
2
nystatin
1
ORAVIG
3
OXISTAT
2
PENLAC
TERAZOL
3
suppositories: QL=1 box (3 suppositories); 20g cream: QL=1
tube; 45g cream: QL=1 tube
terconazole
2
1
84:04:12 SCABICIDES AND PEDICULICIDES
EURAX
2
lindane
1
NATROBA
PAR
2
SKLICE
PAR
2
spinosad
PAR
1
ULESFIA
2
84:04:92 LOCAL ANTI-INFECTIVES, MISCELLANEOUS
selenium sulfide
1
silver sulfadiazine
1
84:06:00 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
alclometasone
1
betamethasone dipropionate
1
calcipotriene/betamethasone
1
clobetasol propionate
1
clocortolone
1
CORDRAN TAPE
QL=2 rolls
3
desonide
1
desoximetasone
1
diflorasone diacetate
1
fluocinolone
1
fluocinonide
1
fluticasone
1
halobetasol propionate
1
HALOG
2
HALOG-E
2
hydrocortisone
1
mometasone
1
nystatin/triamcinolone
1
pramoxine-hc
1
TACLONEX
3
triamcinolone acetonide
1
VERDESO
3
84:08:00 ANTIPRURITICS AND LOCAL ANESTHETICS
ANALPRAM HC
2
hydrocortisone/pramoxine
1
lidocaine
1
lidocaine/hydrocortisone
1
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 33 DRUG NAME
COMMENTS
TIER
lidocaine/prilocaine
1
phenazopyridine hcl
1
84:16:00 CELL STIMULANTS AND PROLIFERANTS
ATRALIN
3
RETIN-A MICRO
2
RETIN-A TOPICAL
2
tretinoin topical
1
84:28:00 KERATOLYTIC AGENTS
salicylic acid
1
sodium sulfacetamide/sulfur
1
urea
1
84:92:00 SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLEANOUS
ACZONE
3
adapalene
1
amnesteem
1
AZELEX
3
calcipotriene
1
calcitriol
1
claravis
1
CONDYLOX
2
diclofenac
3
DIFFERIN
2
ELIDEL
2
EPIDUO
FABIOR
2
PAR
FINACEA
3
2
FLECTOR
3
imiquimod
1
KLARON
2
minocycline er
1
MIRVASO
3
myorisan
PANRETIN
1
PAR
3
PENNSAID
3
PICATO
3
PROTOPIC
2
RECTIV
2
REGRANEX
QL=1 tube
SANTYL
SORILUX
TAZORAC
VELTIN
2
3
2
PAR
2
3
VOLTAREN GEL
2
ZIANA
3
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 34 DRUG NAME
COMMENTS
TIER
CHAPTER 86: SMOOTH MUSCLE RELAXANTS
86:12:04 ANTIMUSCARINICS
ENABLEX
Step therapy required
3
GELNIQUE
Step therapy required
3
oxybutynin chloride
1
oxybutynin chloride er
1
tolterodine
1
tolterodine er
1
TOVIAZ
Step therapy required
trospium
3
1
trospium er
Step therapy required
1
VESICARE
Step therapy required
3
Step therapy required
3
86:12:08:12 SELECTIVE B3-ADRENERGIC AGONISTS
MYRBETRIQ ER
86:16:00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
theophylline
1
CHAPTER 88: VITAMINS
88:08:00 VITAMIN B COMPLEX
cyanocobalamin (vitamin B12)
1
folic acid
1
FOLTX
2
NASCOBAL
3
88:16:00 VITAMIN D
calcitriol
1
doxercalciferol
1
paricalcitol
3
vitamin d 50,000 unit
1
88:24:00 VITAMIN K ACTIVITY
MEPHYTON
2
88:28:00 MULTIVITAMIN PREPARATAIONS
generic prenatal vitamin
1
CHAPTER 92: MISCELLANEOUS THERAPEUTIC AGENTS
92:04:00 ALCOHOL DETERRENTS
disulfiram
1
92:08:00 5-ALPHA-REDUCTASE INHIBITORS
AVODART
finasteride 1mg
3
excluded
finasteride 5mg
JALYN
1
Step therapy required
3
92:16:00 ANTIGOUT AGENTS
allopurinol
1
COLCRYS
2
MITIGARE
3
ULORIC
2
92:24:00 BONE RESORPTION INHIBITORS
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
- 35 DRUG NAME
COMMENTS
TIER
alendronate
Step therapy required / 5mg tablets: QL=34; 30mg tablets:
QL=34; 35mg tablets: QL=5
5mg tablets: QL=34; 10mg tablets: QL=34; 35mg tablets:
QL=5; 40mg tablets: QL=34; 70mg tablets: QL=5
ATELVIA
Step therapy required / QL=5
BINOSTO
Step therapy required / QL=5
ACTONEL
etidronate
FOSAMAX PLUS D
2
1
3
3
1
QL=5 tablets
3
ibandronate
Step therapy required
1
PROLIA
Step therapy required
3
risedronate
Step therapy required
1
92:36:00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
leflunomide
10mg tablets: QL=34; 20mg tablets: QL=34
1
OTREXUP
SA/PAR
3
92:44:00 IMMUNOSUPPRESSIVE AGENTS
azathioprine
1
cyclosporine
1
mycophenolate
1
mycophenolic
1
tacrolimus
1
92:56:00 PROTECTIVE AGENTS
MESNEX
2
92:92:00 OTHER MISCELLANEOUS THERAPEUTIC AGENTS
levocarnitine
SENSIPAR 30MG
Tier 1 = generic drug
Tier 2 = Preferred Brand Drug
Tier 3 = Non-Preferred Brand Drug
1
QL=31
2
QL = Quantity Limit per Fill
PAR = Prior Authorization Required
STB = Split the Bill
-36-
DRUG NAME
COMMENTS
Non-Preferred
Preferred
Network Health Plan Specialty Products List
SPECIALTY PRODUCTS
UNLESS OTHERWISE SPECIFIED BELOW OR IN YOUR PRESCRIPTION DRUG (RX) RIDER, OR ADMINISTERED IN THE OFFICE
OR BY HOME INFUSION, ALL SPECIALTY PRODUCTS MUST BE OBTAINED FROM CAREMARK SPECIALTY PHARMACY AT 1800-237-2767. FOR MINISTRY EAST PARTICIPANTS, ALL SPECIALTY PRODUCTS MUST BE OBTAINED FROM SAINT JOSEPH’S
HOSPITAL OUTPATIENT PHARMACY AT 1-877-905-4054.
FOR MEMBERS/PARTICIPANTS WITH A 4 TIER BENEFIT ALL SPECIALTY PRODUCTS ARE CONSIDERED TIER 4.
08:12:02 AMINOGLYCOSIDES
BETHKIS (tobramycin)
QL=56 ampules
X
TOBI PODHALER (tobramycin)
QL=224 capsules
X
tobramycin
QL=56 ampules
X
08:12:07 MISCELLANEOUS B-LACTAM ANTIBIOTICS
CAYSTON (aztreonam lysine)
X
08:12:12 MACROLIDES
DIFICID( fidaxomicin)
PAR/ QL=20 tablets / not restricted to Caremark
X
08:12:28 ANTIBACTERIALS, MISCELLANEOUS
ORBACTIV (oritavancin disphosphate)
not restricted to Caremark
X
SIVEXTRO (tedizolid)
PAR/ not restricted to Caremark
X
vancomycin capsule
not restricted to Caremark
X
XIFAXAN 550 MG (rifaximin)
not restricted to Caremark
X
ZYVOX (linezolid)
not restricted to Caremark
X
NOXAFIL (posaconazole)
not restricted to Caremark
X
voriconazole
not restricted to Caremark
X
08:14:08 AZOLES
08:16:04 ANTITUBERCULOSIS AGENTS
SIRTURO (bedaquiline fumarate)
X
08:18:08:04 HIV ENTRY AND FUSION INHIBITORS
FUZEON (enfuvirtide)
not restricted to Caremark
X
SELZENTRY (maraviroc)
not restricted to Caremark
X
APTIVUS (tipranavir)
not restricted to Caremark
X
INVIRASE (saquinavir)
not restricted to Caremark
X
KALETRA (lopinavir/ritonavir)
not restricted to Caremark
X
LEXIVA (fosamprenavir)
not restricted to Caremark
X
NORVIR (ritonavir)
not restricted to Caremark
X
PREZISTA (darunavir)
not restricted to Caremark
X
REYATAZ (atazanavir)
not restricted to Caremark
X
ISENTRESS (raltegravir)
STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir
disoproxil fumarate)
not restricted to Caremark
X
not restricted to Caremark
X
TIVICAY (dolutegravir)
not restricted to Caremark
X
08:18:08:08 HIV PROTEASE INHIBITORS
08:18:08:12 HIV INTEGRASE INHIBITORS
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
Non-Preferred
Preferred
- 37 -
08:18:08:16 HIV NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
COMPLERA (emtricitabine/relpivirine/tenofovir)
not restricted to Caremark
X
INTELENCE (etravirine)
not restricted to Caremark
X
SUSTIVA (efavirenz)
not restricted to Caremark
X
08:18:08:20 HIV NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS
abacavir/lamivudine/zidovudine
not restricted to Caremark
X
ATRIPLA (emtricitabine/tenofovir/efavir)
not restricted to Caremark
X
COMBIVIR (lamivudine/zidovudine)
not restricted to Caremark
EPZICOM (abacavir/lamivudine)
not restricted to Caremark
X
X
lamivudine-zidovudine
not restricted to Caremark
X
TRIUMEQ (abacavir/dolutegravir/lamivudine)
not restricted to Caremark
TRUVADA (emtricitabin/tenofovir)
not restricted to Caremark
X
VIREAD (tenofovir disoproxil fumarate)
not restricted to Caremark
X
X
08:18:08:92 MISCELLANEOUS ANTIRETROVIRALS
TYBOST (cobicistat)
not restricted to Caremark
X
08:18:20 INTERFERONS
INFERGEN (interferon alfacon-1)
SA /PAR/ QL=12
X
PEG-INTRON (peginterferon alfa-2b)
SA/ PAR
X
PEG-INTRON (peginterferon alfa-2b) REDIPEN
SA/ PAR
X
PEGASYS (peginterferon alfa-2a)
SA/ PAR
X
PLEGRIDY (interferon beta-1a)
SA/PAR
X
08:18:24 MONOCLONAL ANTIBODIES
SYNAGIS (palivizumab)
X
08:18:32 NUCLEOSIDES & NUCLEOTIDES
entecavir
not restricted to Caremark
X
ganciclovir
not restricted to Caremark
X
REBETOL SOLN (ribavirin)
not restricted to Caremark
X
RIBAPAK (ribavirin)
not restricted to Caremark
ribavirin
not restricted to Caremark
SITAVIG (acyclovir)
not restricted to Caremark
VALCYTE (valganciclovir)
not restricted to Caremark
X
VIRAZOLE (ribavirin inhalation solution)
not restricted to Caremark
X
X
X
X
08:18:40 HCV ANTIVIRALS
08:18:40:16 HCV POLYMERASE INHIBITORS
HARVONI (ledipasvir/sofosbuvir)
X
SOVALDI (sofosbuvir)
X
08:18:40:20 HCV PROTEASE INHIBITORS
OLYSIO (simeprevir)
X
VICTRELIS (boceprevir)
PAR
X
10:00:00 ANTINEOPLASTIC AGENTS
ABRAXANE (paclitaxel)
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
X
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
ADCETRIS (brentuximab)
X
AFINITOR (everolimus)
X
ALFERON N (interferon alfa-n3)
X
ALIMTA (pemetrexed disodium)
X
ARZERRA (ofatumumab)
X
AVASTIN (bevacizumab)
X
azacitidine
X
BELEODAQ (belinostat)
X
BOSULIF (bosutinib)
X
BUSULFEX(busulfan)
X
capecitabine
X
CAPRELSA (vandetanib)
X
cladribine
X
COMETRIQ (cabozantinib)
X
CYRAMZA (ramucirumab)
X
dactinomycin
X
daunorubicin
X
decitabine
X
DEPOCYT (cytarabine)
X
docetaxel
X
doxorubicin
X
ELIGARD (leuprolide)
X
ELLENCE (epirubicin hcl)
X
epirubicin
X
ERIVEDGE (vismodegib)
X
ERWINAZE (asperaginase)
X
EVZIO (mercaptopurine)
not restricted to Caremark
X
FASLODEX (fulvestrant)
X
FIRMAGON (degarelix)
X
fludarabine
X
FOLOTYN (pralatrexate)
X
gemcitabine
X
GAZYVA (obinutuzumab)
GILOTRIF (afatinib)
X
PAR
GLEEVEC (imatinib mesylate)
X
X
HALAVEN (eribulin)
X
HERCEPTIN (trastuzumab)
X
HYCAMTIN (topotecan)
X
ICLUSIG (ponatinib)
X
IMBRUVICA (ibrutinib)
X
idarubicin
X
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
Non-Preferred
Preferred
- 38 -
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
INLYTA (axitinib)
Non-Preferred
Preferred
- 39 -
X
INTRON A (interferon alfa-2b)
SA/ PAR
irinotecan
X
X
ISTODAX (romidepsin)
X
IXEMPRA (ixabepilone)
X
JAKAFI (ruxolitinib)
X
JEVTANA (cabazitaxel)
X
KADCYLA (trastuzumab emtansine)
X
KEYTRUDA (pembrolizumab)
X
KYPROLIS (carfilzomib)
X
leuprolide
PAR
lomustine
X
X
LUPANETA (leuprolide/norethindrone)
X
LUPRON DEPOT (leuprolide acetate)
X
MARQIBO (vincristine lipsome)
X
MATULANE (procarbazine)
X
MEKINIST (trametinib dimethyl sulfoxide)
PAR
X
melphalan vial
not restricted to Caremark
X
mitoxantrone
X
NEXAVAR (sorafenib)
X
OFORTA (fludarabine)
X
ONCASPAR (pegaspargase)
X
ONTAK (denileukin diftitox)
X
oxaliplatin
X
paclitaxel
X
pentostatin
X
PERJETA (pertuzumab)
X
PHOTOFRIN (porfimer)
X
POMALYST (pomalidomide)
X
PROLEUKIN (aldesleukin)
PAR
X
REVLIMID (lenalidomide)
X
RITUXAN (rituximab)
X
SPRYCEL (dasatinib)
X
STIVARGA (regorafenib)
not restricted to Caremark
X
SA/ PAR
X
SUTENT (sunitinib malate)
X
SYLATRON KITS, PACKS (peginterferon alfa-2b)
SYLVANT (siltuximab)
X
SYNRIBO (omacetaxine mepesuccinate)
TAFINLAR (dabrafenib mesylate)
X
PAR
TARCEVA (erlotinib)
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
X
X
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
TARGRETIN (bexarotene)
not restricted to Caremark
TASIGNA (nilotinib hydrochloride)
Non-Preferred
Preferred
- 40 -
X
X
temozolomide
X
thiotepa
X
topotecan
X
TORISEL (temsirolimus)
X
TREANDA (bendamustine)
X
TRELSTAR (triptorelin)
X
TRELSTAR DEPOT (triptorelin)
X
TRELSTAR LA (triptorelin)
X
tretinoin capsule
X
TYKERB (lapatinib)
X
VALSTAR (valrubicin)
X
VANDETANIB (vandetanib)
not restricted to Caremark
VANTAS (histrelin ac)
X
X
VECTIBIX (panitumumab)
X
VELCADE (bortezmib)
X
VOTRIENT (pazopanib)
X
VUMON (teniposide)
X
XALKORI (crizotinib)
PAR
X
XTANDI (enzalutamide)
X
ZALTRAP (aflibercept)
X
ZANOSAR (streptozocin)
X
ZELBORAF (vemurafenib)
PAR/ not restricted to Caremark
X
ZOLADEX (goserelin acetate)
X
ZOLINZA (vorinostat)
X
ZYDELIG (idelalisib)
X
ZYKADIA (ceritinib)
Step therapy required
ZYTIGA (abiraterone acetate)
X
X
12:12:12 ALPHA AND BETA-ADRENERGIC AGONIST
NORTHERA (droxidopa)
X
12:20:08 DIRECT ACTING SKELETAL MUSCLE RELAXANTS
RYANODEX (dantrolene)
not restricted to Caremark
X
20:04:04 IRON PREPARATIONS
INJECTAFER (ferric carboxymaltose)
X
20:12:04 ANTICOAGULANTS
CEPROTEIN (protein c concentrate [human])
X
IPRIVASK (desirudin)
X
REFLUDAN (lepirudin)
not restricted to Caremark
X
THROMBATE III (antithrombin III [human])
not restricted to Caremark
X
20:16:00 HEMATOPOIETIC AGENTS
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
ARANESP (darbepoetin alfa)
SA / PAR
EPOGEN (epoetin alfa)
SA / PAR
GRANIX (tbo-filgrastim)
Step therapy required
LEUKINE (sargramostim)
SA/ PAR
Non-Preferred
Preferred
- 41 -
X
X
X
X
MOZOBIL (plerixafor)
X
NEULASTA (pegfilgrastim)
SA/ PAR
X
NEUMEGA (oprelvekin)
SA / PAR/ QL=21 vials
X
NEUPOGEN (filgrastim)
SA/ PAR
X
NPLATE (romiplostim)
PAR
X
PROCRIT (epoetin alfa)
SA / PAR
X
PROMACTA (eltrombopag olamine)
PAR
X
20:28:16 HEMOSTATICS
ADVATE (antihemophilic factor [recombinant])
X
ALPHANATE (antihemophilic factor [human])
X
ALPHANINE (coagulation factor IX [recombinant])
X
ALPROLIX (coagulation factor IX [recombinant])
X
BEBULIN (coagulation factor IX [recombinant])
X
BEBULIN VH (coagulation factor IX [recombinant])
X
BENEFIX (coagulation factor IX [recombinant])
X
CORIFACT KIT(coagulation factor XIII)
ELOCTATE (antihemophilic factor [recombinant] Fc
Fusion Protein)
X
FEIBA NF (anti-inhibitor coagulant complex)
X
FEIBA VH (anti-inhibitor coagulant complex)
X
HELIXATE FS (antihemophilic factor [recombinant])
HEMOFIL M (antihemophilic factor [monoclonal], factor
VIII)
X
HUMATE-P (von Willebrand factor complex [human])
X
X
X
KCENTRA (prothrombin complex concentrate)
X
KOATE-DVI (antihemophilic factor [human])
X
KOGENATE FS (antihemophilic factor [human])
MONOCLATE P(antihemophilic factor [monoclonal],
factor VIII)
X
X
MONONINE (coagulation factor IX [recombinant])
X
NOVOSEVEN (coagulation factor VIIa [recombinant])
X
PROFILNINE (coagulation factor IX [recombinant]))
X
RECOMBINATE (antihemophilic factor [recombinant])
X
REFACTO (factor VIII [antihemophl])
X
RIXUBIS (coagulation factor IX [recombinant]))
X
TRETTEN (factor XII a-subunit [recombinant])
X
WILATE (factor XIII)
X
XYNTHA (factor VIII [antihemophl])
X
XYNTHA SOLOFUSE (factor VIII [antihemophl])
X
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
Non-Preferred
Preferred
- 42 -
24:06:92 ANTILIPEMIC AGENTS, MISCELLANEOUS
JUXTAPID (lomitapide)
PAR
X
KYNAMRO (mipomersen)
PAR
X
PAR
X
24:12:12 PHOSPHODIESTERASE TYPE 5 INHIBITORS
ADCIRCA (tadalafil)
REVATIO SUSP (sildenafil)
PAR
X
sildenafil citrate (generic for Revatio)
PAR
X
26:00:00 CELLULAR THERAPY
PROVENGE (sipuleucel-t)
X
28:08:08 OPIATE AGONISTS
LAZANDA (fentanyl citrate)
not restricted to Caremark
X
ONSOLIS (fentanyl citrate)
X
28:08:92 ANALGESICS AND ANTIPYRETEICS, MISCELLANEOUS
ILARIS (canakinumab)
SA / PAR
X
PRIALT (ziconotide)
X
28:10:00 OPIATE ANTAGONISTS
PURIXAN (naloxone)
not restricted to Caremark
VIVITROL (naltrexone)
not restricted to Caremark
X
X
28:12:92 ANTICONVULSANTS, MISCELLANEOUS
BANZEL (rufinamide)
not restricted to Caremark
X
SABRIL (vigabatrin)
X
28:16:08 ANTIPSYCHOTIC AGENTS
ABILIFY MAINTENA ER (aripiprazole)
Step therapy required / not restricted to Caremark
X
INVEGA SUSTENNA (paliperidone)
Step therapy required / not restricted to Caremark
X
RISPERDAL CONSTA (risperidone long-acting)
not restricted to Caremark
VERSACLOZ (clozapine)
Step therapy required
X
X
ZYPREXA RELPREVV (olanzapine pamoate)
Step therapy required / not restricted to Caremark
X
28:24:92 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS, MISCELLANEOUS
HETLIOZ (tasimelteon)
X
28:36:20 DOPAMINE RECEPTOR AGONISTS
APOKYN (apomorphine hcl)
X
28:92:00 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS
riluzole
PAR
X
XENAZINE (tetrabenazine)
PAR
X
XYREM (sodium oxybate)
not restricted to Caremark
X
36:60:00 THYROID FUNCTION
THYROGEN (thyrotropine)
X
40:10:00 AMMONIA DETOXICANTS
BUPHENYL (sodium phenylbutyrate)
not restricted to Caremark
X
CARBAGLU (carglumic acid)
X
RAVICTI (glycerol phenylbutyrate)
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
X
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
Non-Preferred
Preferred
- 43 -
40:18:19 PHOSPHATE-REMOVING AGENTS
FOSRENOL (lanthanum)
not restricted to Caremark
X
RENAGEL (sevelamer)
not restricted to Caremark
X
RENVELA (sevelamer)
not restricted to Caremark
X
VELPHORO (sucroferric oxyhydroxide)
X
40:28:28 VASOPRESSNIG ANTAGONISTS
SAMSCA (tolvaptan)
PAR
X
44:00:00 ENZYMES
ADAGEN (pegademase bovine)
not restricted to Caremark
X
ALDURAZYME (laronidase)
X
CEREDASE (alglucerase)
X
CEREZYME (imiglucerase)
X
ELAPRASE (idursulfase)
X
ELELYSO (taliglucerase)
X
ELITEK (rasburicase)
X
FABRAZYME (agalsidase beta)
X
LUMIZYME (alglucosidase alfa)
restricted to patients greater than or equal to eight years old
X
MYOZYME (alglucosidase alfa)
restricted to patients less than or equal to seven years old
X
NAGLAZYME (galsulfase)
X
VIMIZIM (elosulfase)
X
VPRIV (velaglucerase)
X
XIAFLEX (collagenase clostridium)
X
48:14:12 CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR POTENTIATORS
KALYDECO (ivacaftor)
PAR
X
48:24:00 MUCOLYTIC AGENTS
PULMOZYME (dornase alfa)
X
48:36:00 PULMONARY SURFACTANTS
SURAFXIN (rlucinactant)
X
48:48:00 VASODILATING AGENTS
ADEMPAS (riociguat)
X
epoprostenol
X
LETAIRIS (ambrisentan)
X
OPSUMIT (macitentan)
X
ORENITRAM (treprostinil er)
X
REMODULIN (treprostinil)
X
TRACLEER (bosentan)
X
TYVASO (treprostinil)
X
VELETRI (epoprostenol)
X
VENTAVIS (iloprost)
X
48:92:00 RESPIRATORY TRACT AGENTS, MISCELLANEOUS
ARALAST (alpha1-proteinase inhibitor [human])
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
X
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
ARALAST NP (alpha1-proteinase inhibitor [human])
Non-Preferred
Preferred
- 44 -
X
ESBRIET (pirfenidone)
X
GLASSIA (alpha1-proteinase inhibitor [human]))
X
OFEV (nintedanib)
X
PROLASTIN (alpha1-proteinase inhibitor [human])
not restricted to Caremark
X
PROLASTIN C (alpha1-proteinase inhibitor [human])
not restricted to Caremark
X
XOLAIR (omalizumab)
PAR
X
ZEMAIRA (alpha1-proteinase inhibitor [human])
not restricted to Caremark
X
52:04:20 ANTIVIRALS (EENT)
VITRASERT (ganciclovir)
not restricted to Caremark
ZIRGAN (ganciclovir)
not restricted to Caremark
X
X
52:92:00 EENT DRUGS, MISCELLANEOUS
CYSTARAN (cysteamine)
X
EYLEA (aflibercept)
X
JETREA (ocriplasmin)
X
LUCENTIS (ranibizumab)
X
MACUGEN (pegaptanib)
X
VISUDYNE (verteporfin)
X
56:14:00 CHOLELITHOLYTIC AGENTS
CHENODAL (chenodiol)
X
56:36:00 ANTI-INFLAMMATORY AGENTS (GI DRUGS)
GIAZO (balsalazide)
Step therapy required
X
56:92:00 GI DRUGS, MISCELLANEOUS
ENTYVIO (vedolizumab)
X
GATTEX (teduglutide)
SA/PAR
X
RELISTOR (methylnaltrexone)
X
64:00:00 HEAVY METAL ANTAGONISTS
EXJADE (deferasirox)
X
FERRIPROX (deferiprone)
not restricted to Caremark
X
must be prescribed by a gastroenterologist to be covered
X
68:04:00 ADRENALS
budesonide ec
UCERIS (budesonide)
X
68:20:92 ANTIDIABETIC AGENTS, MISCELLANEOUS
KORLYM (mifepristone)
not restricted to Caremark
X
68:24:00 PARATHYROID
FORTEO (teriparatide [Rdna origin])
SA/ PAR/ Step therapy required
X
ACTHAR H.P (corticotropin)
PAR
X
desmopressin acetate vial
not restricted to Caremark
X
STIMATE (desmopressin nasal)
not restricted to Caremark
X
68:28:00 PITUITARY
68:30:04 SOMATOTROPIN AGONISTS
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
Non-Preferred
Preferred
- 45 -
DRUG NAME
COMMENTS
EGRIFTA (tesamorelin acetate [Rdna origin])
SA / PAR
X
GENOTROPIN (somatropin [Rdna origin])
SA / PAR
X
GENOTROPIN MINIQUICK (somatropin [Rdna origin])
SA / PAR
X
HUMATROPE (somatropin [Rdna origin])
SA / PAR
INCRELEX (mecasermin [Rdna origin])
SA / PAR
NORDITROPIN (somatropin [Rdna origin])
SA / PAR
X
NORDITROPIN NORDIFLEX (somatropin [Rdna origin])
SA / PAR
X
NUTROPIN (somatropin [Rdna origin])
SA / PAR
X
NUTROPIN AQ (somatropin [Rdna origin])
SA / PAR
X
OMNITROPE (somatropin [Rdna origin])
SA / PAR
X
SAIZEN (somatropin [Rdna origin])
SA / PAR
X
SEROSTIM (somatropin [Rdna origin])
SA / PAR
X
TEV-TROPIN (somatropin [Rdna origin])
SA / PAR
X
ZORBTIVE (somatropin [Rdna origin])
SA / PAR
X
X
X
68:30:08 SOMATOTROPIN ANTAGONISTS
SIGNIFOR (pasireotide)
SA/PAR
SOMAVERT (pegvisomant)
X
X
68:32:00 PROGESTINS
MAKENA (hydroxyprogesterone caproate)
X
68:40:00 LEPTINS
MYALEPT (metreleptin)
SA/PAR
X
78:00:00 RADIOACTIVE AGENTS
XOFIGO (radium Ra 223 dichloride)
X
80:04:00 SERUMS
ANASCORP
X
BIVIGAM
X
CARIMUNE NF
X
CYTOGAM
X
FLEBOGAMMA
X
GAMASTAN S/D
X
GAMMAGARD LIQUID
X
GAMMAGARD S/D
X
GAMMAKED
X
GAMMAPLEX
X
GAMUNEX-C
X
HIZENTRA
SA/PAR
X
HYQVIA
SA/PAR
X
OCTAGAM
X
PRIVIGEN
X
WINRHO SDF
X
80:12:00 VACCINES
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
THERACYS (BCG vaccine)
Non-Preferred
Preferred
- 46 -
X
84:50:06 PIGMENTING AGENTS
methoxsalen
not restricted to Caremark
X
84:92:00 SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS
acitretin
not restricted to Caremark
STELARA (ustekinumab)
SA/PAR
TARGRETIN (bexarotene)
not restricted to Caremark
X
X
X
VALCHLOR (mechlorethamine)
X
92:12:00 ANTIDOTES
VORAXAZE (glucarpidase)
X
92:16:00 ANTIGOUT AGENTS
KRYSTEXXA (pegloticase)
X
92:20:00 IMMUNOMODULATORY AGENTS
ACTIMMUNE (interferon gamma-1b)
SA/PAR
X
AUBAGIO (teriflunomide)
X
AVONEX (interferon beta-1a)
QL=4 vials
X
BETASERON (interferon beta-1b)
SA / PAR
X
COPAXONE (glatiramer acetate)
SA / PAR/ QL=1 kit (32 vials)
X
EXTAVIA (interferon beta-1b)
SA/ PAR
X
GILENYA (fingolimod hydrochloride)
X
REBIF (interferon beta-1a)
SA / PAR/ QL=15 syringes
X
TECFIDERA (dimethyl fumarate)
X
THALOMID (thalidomide)
X
TYSABRI (natalizumab)
X
92:24:00 BONE RESORPTION INHIBITORS
pamidronate disodium
not restricted to Caremark
X
XGEVA (denosumab)
X
zoledronic acid (generic for Reclast)
X
zoledronic acid (generic for Zometa)
X
92:32:00 COMPLEMENT INHIBITORS
BERINERT (esterase inhibitor)
CINRYZE (esterase inhibitor)
X
PAR
X
FIRAZYR (icatibant)
X
KALBITOR (ecallantide)
X
RECONEST (c1esterase inhibitor)
X
SOLIRIS (eculizumab)
X
92:36:00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ACTEMRA (tocilizumab)
SA / PAR
CIMZIA (certolizumab pegol)
SA / PAR
ENBREL (etanercept)
SA / PAR
SA / PAR / QL=2 injections; Psoriasis starter pack QL=1 pack;
Crohns starter pack QL=1 pack; Pediatric Crohns starter pack
HUMIRA (adalimumab)
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
X
X
X
X
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
DRUG NAME
COMMENTS
KINERET (anakinra)
SA / PAR
X
ORENCIA (abatacept)
PAR
X
ORENCIA SYRINGE(abatacept)
SA / PAR
X
OTEZLA (apremilast)
Non-Preferred
Preferred
- 47 QL=1 pack
X
RASUVO (methotrexate)
SA / PAR
X
REMICADE (infliximab)
X
SIMPONI (golimumab)
SA / PAR / QL=1 injections
SIMPONI ARIA (golimumab)
PAR
X
X
XELJANZ (tofacitinib)
PAR
X
92:44:00 IMMUNOSUPRESSIVE AGENTS
ASTAGRAF XL (tacrolimus er)
X
ATGAM
X
BENLYSTA(belimumab)
X
NULOJIX (belatacept)
X
RAPAMUNE (sirolimus)
X
SIMULECT (basiliximab)
not restricted to Caremark
X
sirolimus
X
THYMOGLOBULIN
X
ZORTRESS (everolimus)
X
92:56:00 PROTECTIVE AGENTS
amifostine
X
dexrazoxane
X
TOTECT
X
92:92:00 OTHER MISCELLANEOUS THERAPEUTIC AGENTS
AMPYRA ER (dalfampridine)
must be prescribed by a neurologist to be covered
ARCALYST (rilonacept)
SA / PAR
BOTOX (botulinum toxin type a)
PAR
X
X
X
CERDELGA (eliglustat)
X
DYSPORT (abobotulinumtoxina)
PAR
KUVAN (sapropterin dihydrochloride)
PAR
X
X
MYOBLOC (botulinum toxin type b)
X
octreotide
X
PROCYSBI (cysteamine bitrate dr)
X
SANDOSTATIN LAR (octreotide)
X
SENSIPAR (cinacalcet) 60MG & 90MG
not restricted to Caremark
X
PAR
X
SOMATULINE (lanreotide acetate)
XEOMIN (incobotulinumtoxin a)
X
ZAVESCA (miglustat)
For Members with a 3 Tier Benefit:
Preferred = Tier 2
Non-Preferred = Tier 3
For Members with a 4 Tier Benefit:
Preferred and Non-Preferred = Tier 4
X
SA = Self Administered, Office Administration Requires Prior Authorization
PAR = Prior Authorization Required
QL = Quantity Limit per Fill
For Members with a 5 Tier Benefit:
Preferred = Tier 4
Non-Preferred = Tier 5
- 48 -
INDEX
DRUG NAME
PAGE NUMBER(S)
abacavir ............................................................. 7
abacavir/lamivudine/zidovudine ................... 37
ABILIFY ............................................................ 18
ABILIFY MAINTENA ER .................................. 42
ABRAXANE ...................................................... 37
acamprosate ................................................... 20
ACANYA........................................................... 31
acarbose.......................................................... 29
ACCU-CHEK .................................................... 21
acebutolol ....................................................... 12
acetaminophen/codeine ................................ 15
acetazolamide ................................................. 25
acetic acid ....................................................... 25
ACIPHEX.......................................................... 26
acitretin ........................................................... 46
ACTEMRA ........................................................ 46
ACTHAR H.P. .................................................. 44
ACTIMMUNE ................................................... 46
ACTONEL ........................................................ 35
ACTOPLUS MET XR ....................................... 30
ACUVAIL .......................................................... 24
acyclovir ............................................................ 7
acyclovir ointment ......................................... 31
ACZONE .......................................................... 33
ADAGEN .......................................................... 43
adapalene ........................................................ 33
ADCETRIS ....................................................... 38
ADCIRCA ......................................................... 42
adefovir ............................................................. 7
ADEMPAS ........................................................ 43
ADVAIR DISKUS ............................................... 9
ADVAIR HFA ...................................................... 9
ADVATE ........................................................... 41
ADVICOR ......................................................... 11
AEROSPAN ..................................................... 27
AFINITOR......................................................... 38
AGGRENOX .................................................... 10
ALAMAST......................................................... 22
albuterol ............................................................ 9
alclometasone ................................................ 32
ALDURAZYME ................................................. 43
alendronate ..................................................... 35
ALFERON N ..................................................... 38
alfuzosin er ....................................................... 9
ALIMTA ............................................................ 38
ALINIA ................................................................ 8
ALKERAN TAB .................................................. 8
allopurinol ....................................................... 34
ALOCRIL .......................................................... 22
Check in body for specific drug coverage.
DRUG NAME
PAGE NUMBER(S)
ALOMIDE ......................................................... 22
ALORA ............................................................. 28
ALPHAGAN P .................................................. 24
ALPHANATE.................................................... 41
ALPHANINE..................................................... 41
alprazolam ...................................................... 19
alprazolam er .................................................. 19
alprazolam odt................................................ 19
ALPROLIX ....................................................... 41
ALREX ............................................................. 23
ALSUMA .......................................................... 19
ALTABAX ......................................................... 31
ALTOPREV ...................................................... 11
ALVESCO ........................................................ 27
amantadine ..................................................... 20
amethia ........................................................... 28
amifostine ....................................................... 47
amiloride ......................................................... 22
amiloride/hydrochlorothiazide ..................... 22
aminocaproic acid ......................................... 10
amiodarone..................................................... 11
AMITIZA ........................................................... 27
amitriptyline.................................................... 17
amlodipine ...................................................... 13
amlodipine/atorvastatin ................................ 13
amlodipine/benazepril ................................... 13
amlodipine/telmisartan .................................. 13
amnesteem ..................................................... 33
amox tr/potassium clavulanate ...................... 6
amoxicillin ........................................................ 6
amphetamine salt combo.............................. 18
amphetamine salt combo xr ......................... 18
ampicillin .......................................................... 6
AMPYRA ER .................................................... 47
ANALPRAM HC ............................................... 32
ANASCORP ..................................................... 45
anastrozole ....................................................... 8
ANDRODERM ................................................. 27
ANDROGEL ..................................................... 27
ANGELIQ ......................................................... 28
ANORO ELLIPTA .............................................. 8
ANTARA .......................................................... 11
antipyrine/benzocaine ................................... 24
ANZEMET ........................................................ 25
APIDRA............................................................ 29
APOKYN .......................................................... 42
apraclonidine.................................................. 25
APRISO ........................................................... 26
APTIOM ........................................................... 16
- 49 -
APTIVUS .......................................................... 36
ARALAST ......................................................... 43
ARALAST NP ................................................... 44
ARANESP ........................................................ 41
ARCALYST ...................................................... 47
ARCAPTA .......................................................... 9
ARESTIN .......................................................... 23
ARMOUR THYROID ........................................ 31
ARZERRA ........................................................ 38
ASACOL HD .................................................... 26
ASMANEX ........................................................ 27
ASTAGRAF XL ................................................ 47
ATELVIA........................................................... 35
atenolol............................................................ 12
atenolol/chlorthalidone.................................. 12
ATGAM............................................................. 47
atorvastatin ..................................................... 11
atovaquone ....................................................... 8
atovaquone proguanil...................................... 8
ATRALIN .......................................................... 33
ATRIPLA .......................................................... 37
atropine ........................................................... 24
ATROVENT HFA ............................................... 9
AUBAGIO ......................................................... 46
AUVI-Q ............................................................... 9
AVANDAMET ................................................... 30
AVANDARYL ................................................... 30
AVANDIA.......................................................... 30
AVASTIN .......................................................... 38
AVEED ............................................................. 27
AVODART ........................................................ 34
AVONEX .......................................................... 46
AXERT ............................................................. 19
AXIRON............................................................ 27
azacitidine ....................................................... 38
AZASITE .......................................................... 23
azathioprine .................................................... 35
azelastine ophth ............................................. 23
azelastine spray ............................................. 23
AZELEX............................................................ 33
AZILECT........................................................... 20
azithromycin ..................................................... 6
AZOPT ............................................................. 25
AZOR ............................................................... 13
bacitracin ........................................................ 23
baclofen........................................................... 10
BACTROBAN NASAL OINTMENT .................. 31
balsalazide ...................................................... 26
BANZEL ........................................................... 42
BEBULIN .......................................................... 41
BEBULIN VH .................................................... 41
BECONASE AQ ............................................... 23
BELEODAQ ..................................................... 38
belladonna/phenobarbital ............................... 9
benazepril........................................................ 13
benazepril/hydrochlorothiazide .................... 13
Check in body for specific drug coverage.
BENEFIX.......................................................... 41
BENICAR ......................................................... 14
BENICAR HCT................................................. 14
BENLYSTA ...................................................... 47
BENZACLIN GEL............................................. 31
benzonatate .................................................... 22
benztropine..................................................... 20
BEPREVE ........................................................ 23
BERINERT ....................................................... 46
BESIVANCE .................................................... 23
betamethasone dipropionate........................ 32
BETASERON ................................................... 46
betaxolol ................................................... 12, 24
bethanechol ...................................................... 8
BETHKIS.......................................................... 36
BETIMOL ......................................................... 24
BETOPTIC-S ................................................... 24
bicalutamide ..................................................... 8
BIDIL ................................................................ 12
BINOSTO ......................................................... 35
bisoprolol........................................................ 12
bisoprolol/hydrochlorothiazide .................... 12
BIVIGAM .......................................................... 45
BLEPHAMIDE .................................................. 23
BOSULIF.......................................................... 38
BOTOX ............................................................ 47
BREO ELLIPTA ............................................... 27
BRILINTA ......................................................... 10
brimonidine .................................................... 24
BRINTELLIX .................................................... 17
BRISDELLE ..................................................... 17
bromfenac....................................................... 24
bromocriptine ................................................. 20
BROVANA ......................................................... 9
budesonide ..................................................... 23
budesonide ec ................................................ 44
budesonide respules ..................................... 27
bumetanide ..................................................... 22
BUPHENYL...................................................... 42
buprenorphine................................................ 16
buprenorphine/naloxone ............................... 16
bupropion ....................................................... 17
bupropion 150 mg SR tab (generic Zyban) . 10
bupropion sr, xl .............................................. 17
buspirone........................................................ 19
BUSULFEX ...................................................... 38
butalbital/acetaminophen ............................. 16
butalbital/acetaminophen/caffeine ............... 16
butalbital/aspirin/caffeine ............................. 15
butorphanol nasal spray ............................... 16
BUTRANS ........................................................ 16
BYDUREON..................................................... 29
BYETTA ........................................................... 29
BYSTOLIC ....................................................... 12
cabergoline ..................................................... 20
calcipotriene ................................................... 33
- 50 -
calcipotriene/betamethasone ....................... 32
calcitonin-salmon nasal ................................ 30
calcitriol.....................................................33, 34
calcium acetate .............................................. 22
CAMBIA............................................................ 15
camrese ........................................................... 28
CANASA........................................................... 26
candesartan .................................................... 14
candesartan/hydrochlorothiazide ................ 14
capecitabine ................................................... 38
CAPRELSA ...................................................... 38
captopril .......................................................... 13
captopril/hydrochlorothiazide ...................... 13
CARBAGLU ..................................................... 42
carbamazepine ............................................... 16
carbamazepine er ........................................... 16
carbidopa ........................................................ 20
carbidopa/levodopa ....................................... 20
carbidopa/levodopa er ................................... 20
carbidopa/levodopa/entacapone .................. 20
CARDENE SR .................................................. 13
CARDIZEM LA ................................................. 13
CARDURA XL .................................................. 12
CARIMUNE NF ................................................ 45
carisoprodol ..................................................... 9
cartia xt............................................................ 13
carvedilol......................................................... 12
CAYSTON ........................................................ 36
cefaclor.............................................................. 5
cefaclor er ......................................................... 5
cefadroxil .......................................................... 6
cefdinir .............................................................. 6
cefpodoxime ..................................................... 6
cefprozil............................................................. 6
ceftibuten .......................................................... 6
CEFTIN SUSPENSION...................................... 6
cefuroxime ........................................................ 6
CELEBREX ...................................................... 14
CENESTIN ....................................................... 28
cephalexin ......................................................... 6
CEPROTEIN .................................................... 40
CEREDASE ..................................................... 43
CEREZYME ..................................................... 43
CESAMET ........................................................ 26
cevimeline ......................................................... 8
CHANTIX.......................................................... 10
CHENODAL ..................................................... 44
chlordiazepoxide ............................................ 19
chlordiazepoxide/clidinium ............................. 9
chloroquine ....................................................... 8
chlorothalidone .............................................. 22
chlorothiazide ................................................. 22
chlorpromazine .............................................. 18
chlorzoxazone ................................................ 10
cholestyramine ............................................... 11
CIALIS 10MG & 20MG ..................................... 12
Check in body for specific drug coverage.
CIALIS 2.5MG & 5MG ..................................... 12
ciclopirox kit ................................................... 31
cilostazol......................................................... 10
CILOXAN ......................................................... 23
cimetidine ....................................................... 26
CIMZIA ............................................................. 46
CINRYZE ......................................................... 46
CIPRO HC ....................................................... 23
CIPRODEX ...................................................... 23
ciprofloxacin............................................... 6, 23
ciprofloxacin er ................................................ 6
citalopram ....................................................... 17
cladribine ........................................................ 38
claravis ............................................................ 33
clarithromycin .................................................. 6
clarithromycin er .............................................. 6
clemastine .......................................................... 5
CLIMARA PRO ................................................ 28
clindamycin hcl ................................................ 7
clindamycin phosphate ................................. 31
clobetasol propionate ................................... 32
clocortolone ................................................... 32
clomipramine.................................................. 17
clonazepam .................................................... 16
clonazepam odt .............................................. 16
clonidine ......................................................... 12
clonidine er ..................................................... 12
clopidogrel...................................................... 10
clorazepate ..................................................... 19
clotrimazole .................................................... 31
clotrimazole/betamethasone ........................ 31
clozapine......................................................... 18
clozapine odt .................................................. 18
COARTEM ......................................................... 8
codeine ........................................................... 15
COLAZAL......................................................... 26
COLCRYS........................................................ 34
colestipol ........................................................ 11
COLYTE........................................................... 25
COMBIGAN ..................................................... 24
COMBIPATCH ................................................. 28
COMBIVENT RESPIMAT .................................. 9
COMBIVIR ....................................................... 37
COMETRIQ...................................................... 38
COMPLERA ..................................................... 37
CONDYLOX ..................................................... 33
COPAXONE..................................................... 46
CORDRAN TAPE ............................................ 32
COREG CR...................................................... 12
CORIFACT KIT ................................................ 41
cortisone ......................................................... 27
COSOPT PF .................................................... 25
CREON ............................................................ 25
CRESTOR ....................................................... 11
CRINONE ........................................................ 30
cromolyn ......................................................... 23
- 51 -
cromolyn nebulizers ...................................... 22
CUVPOSA .......................................................... 9
cyanocobalamin (vitamin B12) ....................... 34
cyclobenzaprine ............................................. 10
cyclobenzaprine er......................................... 10
cyclopentolate ................................................ 24
cyclophosphamide........................................... 8
CYCLOSET ...................................................... 30
cyclosporine ................................................... 35
cyproheptadine ................................................ 5
CYRAMZA ........................................................ 38
CYSTARAN ...................................................... 44
CYTOGAM ....................................................... 45
CYTOMEL ........................................................ 31
dactinomycin .................................................. 38
DALIRESP........................................................ 22
dapsone............................................................. 7
DARAPRIM ........................................................ 8
daunorubicin .................................................. 38
DAYTRANA ...................................................... 18
decitabine........................................................ 38
DELESTROGEN .............................................. 28
DELZICOL DR ................................................. 26
demeclocycline ................................................ 6
DENAVIR ......................................................... 31
DEPOCYT ........................................................ 38
DEPO-PROVERA ............................................ 30
DERDELGA ..................................................... 47
desipramine .................................................... 17
desloratadine .................................................... 5
desmopressin acetate tab ............................. 30
desmopressin acetate vial ............................ 44
desonide.......................................................... 32
desoximetasone ............................................. 32
DESVENLAFAXINE ER ................................... 17
dexamethasone ........................................23, 27
DEXILANT ........................................................ 26
dexmethylphenidate ...................................... 18
dexmethylphenidate er .................................. 18
dexrazoxane ................................................... 47
dextroamphetamine ....................................... 18
diazepam ......................................................... 19
DICLEGIS......................................................... 26
diclofenac............................................14, 24, 33
diclofenac dr-misoprostol ............................. 15
diclofenac sa .................................................. 15
dicloxacillin ....................................................... 6
dicyclomine ...................................................... 9
DIFFERIN ......................................................... 33
DIFICID ............................................................ 36
diflorasone diacetate ..................................... 32
diflunisal.......................................................... 14
digoxin............................................................. 11
dihydroergotamine nasal spray ...................... 9
diltiazem cd ..................................................... 13
diltiazem er ..................................................... 13
Check in body for specific drug coverage.
diltiazem hcl ................................................... 13
diltiazem xr ..................................................... 13
DIPENTUM ...................................................... 26
diphenoxylate/atropine ................................. 25
dipyridamole................................................... 12
disopyramide.................................................. 11
disulfiram ........................................................ 34
divalproex ....................................................... 16
divalproex dr .................................................. 16
divalproex er................................................... 16
DIVIGEL ........................................................... 28
docetaxel ........................................................ 38
donepezil .......................................................... 8
dorzolamide .................................................... 25
dorzolamide/timolol ....................................... 25
doxazosin ....................................................... 12
doxepin ........................................................... 17
doxercalciferol ............................................... 34
doxorubicin .................................................... 38
doxycycline hyclate ......................................... 6
doxycycline hyclate dr .................................... 6
doxycycline monohydrate .............................. 6
dronabinol ...................................................... 26
DUAC CS ......................................................... 31
DUAVEE .......................................................... 29
DUEXIS............................................................ 15
DULERA .......................................................... 27
duloxetine ....................................................... 17
DUREZOL ........................................................ 23
DYMISTA ......................................................... 23
DYRENIUM ...................................................... 22
DYSPORT........................................................ 47
econazole........................................................ 31
EDARBI............................................................ 14
EDARBYCLOR ................................................ 14
EDURANT.......................................................... 7
EFFIENT .......................................................... 10
EGRIFTA ......................................................... 45
ELAPRASE ...................................................... 43
ELELYSO......................................................... 43
ELESTRIN ....................................................... 28
ELIDEL ............................................................. 33
ELIGARD ......................................................... 38
ELIQUIS ........................................................... 10
ELITEK ............................................................. 43
ELLA ................................................................ 28
ELLENCE......................................................... 38
ELOCTATE ...................................................... 41
EMADINE......................................................... 23
EMEND ............................................................ 26
EMSAM ............................................................ 20
ENABLEX ........................................................ 34
enalapril .......................................................... 13
enalapril/hydrochlorothiazide....................... 13
ENBREL........................................................... 46
ENDOMETRIN ................................................. 30
- 52 -
ENJUVIA .......................................................... 28
enoxaparin sodium ........................................ 10
entacapone ..................................................... 20
entecavir.......................................................... 37
ENTYVIO.......................................................... 44
EPIDUO............................................................ 33
epinastine hcl ................................................. 23
EPINEPHRINE KIT ............................................ 9
EPIPEN .............................................................. 9
epirubicin ........................................................ 38
EPIVIR................................................................ 7
eplerenone ...................................................... 14
EPOGEN .......................................................... 41
epoprostenol .................................................. 43
eprosartan 600mg .......................................... 14
EPZICOM ......................................................... 37
ERIVEDGE ....................................................... 38
ERTACZO ........................................................ 31
ERWINAZE ...................................................... 38
ERYPED............................................................. 6
erythromycin ..............................................6, 23
erythromycin base ......................................... 31
erythromycin/sulfisoxazole ............................. 6
ESBRIET .......................................................... 44
escitalopram ................................................... 17
ESOMEPRAZOLE ........................................... 26
ESTRACE ........................................................ 28
estradiol .......................................................... 28
estradiol/norethindrone ................................. 28
ESTRING ......................................................... 28
ESTROGEL ...................................................... 28
estrogen/methyltestosterone ........................ 28
estrogen/methyltestosterone hs .................. 28
estropipate ...................................................... 28
eszcopiclone ................................................... 19
ethambutol ........................................................ 7
ethosuximide .................................................. 16
etidronate ........................................................ 35
etodolac........................................................... 14
etodolac sa ..................................................... 15
etoposide .......................................................... 8
EURAX ............................................................. 32
EVAMIST.......................................................... 28
EVZIO............................................................... 38
EXELDERM ..................................................... 31
EXELON ............................................................. 8
exemestane ....................................................... 8
EXFORGE HCT ............................................... 13
EXJADE ........................................................... 44
EXTAVIA .......................................................... 46
EYLEA .............................................................. 44
FABIOR ............................................................ 33
FABRAZYME ................................................... 43
FACTIVE ............................................................ 6
famciclovir ........................................................ 7
FANAPT ........................................................... 18
Check in body for specific drug coverage.
FARXIGA ......................................................... 30
FASLODEX ...................................................... 38
FAZACLO ODT ................................................ 18
FEIBA NF ......................................................... 41
FEIBA VH......................................................... 41
felbamate ........................................................ 16
felodipine er.................................................... 13
female condoms............................................. 20
FEMHRT .......................................................... 28
FEMRING ........................................................ 28
fenofibrate ...................................................... 11
fenofibric acid ................................................ 11
FENOGLIDE .................................................... 11
fentanyl ........................................................... 15
FERRIPROX .................................................... 44
FETZIMA.......................................................... 17
FINACEA ......................................................... 33
finasteride ....................................................... 34
FIRAZYR.......................................................... 46
FIRMAGON...................................................... 38
FIRST-LANSOPRAZOLE ................................ 26
FIRST-OMEPRAZOLE .................................... 26
FIRST-TESTOSTERONE ................................ 27
FIRST-VANCOMYCIN ....................................... 7
FLAREX ........................................................... 23
FLEBOGAMMA................................................ 45
flecainide ........................................................ 11
FLECTOR ........................................................ 33
FLOVENT DISKUS .......................................... 27
FLOVENT HFA ................................................ 27
fluconazole ....................................................... 7
flucytosine ........................................................ 7
fludarabine...................................................... 38
fludrocortisone............................................... 27
flunisolide ....................................................... 23
fluocinolone.................................................... 32
fluocinolone oil ear drops ............................. 23
fluocinonide.................................................... 32
fluorometholone............................................. 23
fluoxetine ........................................................ 17
fluphenazine ................................................... 18
flurazepam ...................................................... 19
flurbiprofen ............................................... 14, 24
fluticasone ................................................ 24, 32
fluvastatin ....................................................... 11
fluvoxamine .................................................... 17
fluvoxamine er................................................ 17
FOCALIN ......................................................... 18
FOCALIN XR ................................................... 18
folic acid ......................................................... 34
FOLOTYN ........................................................ 38
FOLTX ............................................................. 34
fondaparinux .................................................. 10
FORADIL ........................................................... 9
FORFIVO XL.................................................... 17
FORTEO .......................................................... 44
- 53 -
FOSAMAX PLUS D.......................................... 35
fosinopril ......................................................... 13
fosinopril/hydrochlorothiazide ..................... 13
FOSRENOL ..................................................... 43
FRAGMIN ......................................................... 10
FROVA ............................................................. 19
FULYZAQ ......................................................... 25
furosemide ...................................................... 22
FUZEON........................................................... 36
FYCOMPA........................................................ 16
gabapentin ...................................................... 16
galantamine ...................................................... 8
galantamine er .................................................. 8
GAMASTAN S/D .............................................. 45
GAMMAGARD LIQUID .................................... 45
GAMMAGARD S/D .......................................... 45
GAMMAKED .................................................... 45
GAMMAPLEX .................................................. 45
GAMUNEX ....................................................... 45
ganciclovir ...................................................... 37
gatifloxacin ..................................................... 23
GATTEX ........................................................... 44
GAZYVA ........................................................... 38
GELNIQUE ....................................................... 34
gemcitabine .................................................... 38
gemfibrozil ...................................................... 11
GENERESS FE ................................................ 28
generic bi-phasic contraceptives ................. 28
generic contraceptives .................................. 28
generic mono-phasic contraceptives .......... 28
generic prenatal vitamin ................................ 34
generic progestin only contraceptives ........ 28
generic tri-phasic contraceptives ................. 28
GENOTROPIN ................................................. 45
GENOTROPIN MINIQUICK ............................. 45
gentamicin ................................................23, 31
GIAZO .............................................................. 44
GILENYA .......................................................... 46
GILOTRIF ......................................................... 38
GLASSIA .......................................................... 44
GLEEVEC ........................................................ 38
glimepiride ...................................................... 30
glimiperide/pioglitazone ................................ 30
glipizide ........................................................... 30
glipizide xl ....................................................... 30
glipizide/metformin ........................................ 30
GLUCAGON ..................................................... 30
glyburide ......................................................... 30
glyburide/metformin ...................................... 30
glycopyrrolate .................................................. 9
GOLYTELY ...................................................... 25
GRALISE ER .................................................... 16
granisetron ..................................................... 25
GRANIX............................................................ 41
griseofulvin ....................................................... 7
guaifenesin ac ................................................ 22
Check in body for specific drug coverage.
guaifenex pse ................................................. 22
guanfacine ...................................................... 12
HALAVEN ........................................................ 38
HALFLYTELY-BISACODYL ............................ 25
halobetasol propionate ................................. 32
HALOG ............................................................ 32
haloperidol...................................................... 18
HARVONI......................................................... 37
HELIDAC ......................................................... 26
HELIXATE FS .................................................. 41
HEMOFIL M ..................................................... 41
heparin ............................................................ 10
HERCEPTIN .................................................... 38
HETLIOZ .......................................................... 42
HIZENTRA ....................................................... 45
HORIZANT....................................................... 16
HUMALOG ....................................................... 29
HUMATE-P ...................................................... 41
HUMATROPE .................................................. 45
HUMIRA ........................................................... 46
HUMULIN......................................................... 29
HUMULIN......................................................... 29
HUMULIN......................................................... 29
HUMULIN......................................................... 29
HYCAMTIN ...................................................... 38
hydralazine ..................................................... 12
hydrochlorothiazide....................................... 22
hydrocodone/acetaminophen....................... 15
hydrocodone/chlorpheniramine ................... 22
hydrocodone/ibuprofen ................................ 15
hydrocortisone ......................................... 27, 32
hydrocortisone/acetic acid ear drops .......... 24
hydrocortisone/pramoxine ........................... 32
hydromorphone ............................................. 15
hydromorphone er ......................................... 15
hydroxychloroquine sulfate............................ 8
hydroxyurea ..................................................... 8
hydroxyzine hcl .............................................. 19
hydroxyzine pamoate .................................... 19
hyoscyamine .................................................... 9
HYQVIA ........................................................... 45
ibandronate .................................................... 35
ibuprofen ........................................................ 14
ICLUSIG........................................................... 38
idarubicin ........................................................ 38
ILARIS .............................................................. 42
IMBRUVICA ..................................................... 38
imipramine ...................................................... 17
imiquimod ....................................................... 33
IMITREX .......................................................... 19
INCRELEX ....................................................... 45
INCRUSE ELLIPTA ........................................... 9
indapamide ..................................................... 22
indomethacin.................................................. 14
INFERGEN ...................................................... 37
INJECTAFER ................................................... 40
- 54 -
INLYTA ............................................................. 39
INSPRA ............................................................ 14
INTELENCE ..................................................... 37
INTERMEZZO .................................................. 19
INTRON A ........................................................ 39
INTUNIV ........................................................... 20
INVEGA ............................................................ 18
INVEGA SUSTENNA ....................................... 42
INVIRASE......................................................... 36
INVOKAMET .................................................... 30
INVOKANA ....................................................... 30
IPIVASK ........................................................... 40
ipratropium ....................................................... 9
ipratropium/albuterol ....................................... 9
IQUIX................................................................ 23
irbesartan ........................................................ 14
irbesartan/hydrochlorothiazide .................... 14
irinotecan ........................................................ 39
iron polysaccharide ....................................... 10
ISENTRESS ..................................................... 36
isoniazid ............................................................ 7
isosorbide ....................................................... 12
isradipine ........................................................ 13
ISTODAX.......................................................... 39
itraconazole ...................................................... 7
IXEMPRA ......................................................... 39
JAKAFI ............................................................. 39
JALYN .............................................................. 34
JANUMET ........................................................ 29
JANUMET XR .................................................. 29
JANUVIA .......................................................... 29
JARDIANCE ..................................................... 30
JENTADUETO ................................................. 29
JETREA............................................................ 44
JEVTANA ......................................................... 39
jinteli ................................................................ 28
JUXTAPID ........................................................ 42
KADCYLA......................................................... 39
KADIAN ER ...................................................... 15
KALBITOR........................................................ 46
KALETRA ......................................................... 36
KALYDECO ...................................................... 43
KAZANO........................................................... 29
KCENTRA ........................................................ 41
ketoconazole ..............................................7, 31
ketoprofen ....................................................... 14
ketoprofen sa .................................................. 15
ketorolac ...................................................14, 24
KEYTRUDA ...................................................... 39
KINERET .......................................................... 47
KLARON........................................................... 33
KOATE-DVI ...................................................... 41
KOGENATE FS ................................................ 41
KOMBIGLYZE XR ............................................ 29
KORLYM .......................................................... 44
KRISTALOSE ................................................... 21
Check in body for specific drug coverage.
KRYSTEXXA ................................................... 46
KUVAN ............................................................. 47
KYNAMRO ....................................................... 42
KYPROLIS ....................................................... 39
labetalol .......................................................... 12
LACRISERT ..................................................... 25
lactulose ......................................................... 21
LAMICTAL ODT ............................................... 16
LAMISIL GRANULES ........................................ 7
LAMISIL SOLUTION ........................................ 31
lamivudine ........................................................ 7
lamivudine-zidovudine .................................. 37
lamotrigine...................................................... 16
lamotrigine er ................................................. 16
lansoprazole ................................................... 26
lansoprazole/amoxicillin/clarithromycin ..... 26
LANTUS ........................................................... 29
LASTACAFT .................................................... 23
latanoprost ..................................................... 25
LATUDA ........................................................... 18
LAZANDA ........................................................ 42
leflunomide ..................................................... 35
LESCOL XL ..................................................... 11
LETAIRIS ......................................................... 43
letrozole ............................................................ 8
LEUKINE.......................................................... 41
leuprolide ........................................................ 39
levalbuterol solution ........................................ 9
LEVEMIR ......................................................... 30
levetiracetam .................................................. 16
levetiracetam er.............................................. 16
levobunolol ..................................................... 24
levocarnitine ................................................... 35
levocetirizine .................................................... 5
levofloxacin ................................................ 6, 23
levonorgestrel (PLAN B) ................................ 20
levothroid........................................................ 31
levothyroxine sodium .................................... 31
levoxyl ............................................................. 31
LEXIVA ............................................................ 36
LIALDA............................................................. 26
lidocaine ......................................................... 32
lidocaine/hydrocortisone .............................. 32
lidocaine/prilocaine ....................................... 33
lindane ............................................................ 32
LINZESS .......................................................... 27
LIPOFEN.......................................................... 11
LIPTRUZET ..................................................... 11
lisinopril .......................................................... 13
lisinopril/hydrochlorothiazide ...................... 13
lithium carbonate ........................................... 19
lithium carbonate er ...................................... 19
lithium citrate ................................................. 19
LIVALO ............................................................ 11
lomustine ........................................................ 39
lorazepam ....................................................... 19
- 55 -
losartan ........................................................... 14
losartan/hydrochlorothiazide ........................ 14
LOTEMAX ........................................................ 24
LOTRONEX ..................................................... 26
lovastatin......................................................... 11
LUCENTIS........................................................ 44
LUMIGAN ......................................................... 25
LUMIZYME ....................................................... 43
LUPANETA ...................................................... 39
LUPRON DEPOT ............................................. 39
LUZU ................................................................ 31
LYRICA ............................................................ 16
MACUGEN ....................................................... 44
MAKENA .......................................................... 45
MARQIBO ........................................................ 39
MATULANE ...................................................... 39
medroxyprogesterone acetate ...................... 30
mefenamic acid .............................................. 15
mefloquine ........................................................ 8
MEGACE ES .................................................... 30
megestrol .......................................................... 8
MEKINIST ........................................................ 39
meloxicam ....................................................... 14
melphalan........................................................ 39
MENEST .......................................................... 28
MENOSTAR ..................................................... 28
MENTAX .......................................................... 31
meperidine ...................................................... 15
MEPHYTON ..................................................... 34
mercaptopurine ................................................ 8
mesalamine ..................................................... 26
MESNEX .......................................................... 35
METADATE ER ................................................ 18
metaxalone ..................................................... 10
metformin ........................................................ 29
metformin er ................................................... 29
methadone ...................................................... 15
methamphetamine ......................................... 18
methimazole ................................................... 31
methocarbamol .............................................. 10
methotrexate ..................................................... 8
methoxsalen ................................................... 46
methyldopa ..................................................... 12
methylergonovine .......................................... 31
methylphenidate............................................. 18
methylphenidate er ........................................ 18
methylprednisolone ....................................... 27
metipranolol .................................................... 24
metoclopramide ............................................. 26
metolazone ..................................................... 22
metoprolol ....................................................... 12
metoprolol er .................................................. 12
metoprolol/hydrochlorothiazide ................... 12
metronidazole .............................................8, 31
mexiletine ........................................................ 11
midodrine .......................................................... 9
Check in body for specific drug coverage.
MIGRANAL ........................................................ 9
MILLIPRED ...................................................... 27
MINIVELLE ...................................................... 29
minocycline ...................................................... 6
minocycline er ................................................ 33
minoxidil ......................................................... 12
MIRAPEX ER ................................................... 20
mirtazapine ..................................................... 17
mirtazapine odt .............................................. 17
MIRVASO ........................................................ 33
misoprostol .................................................... 26
MITIGARE........................................................ 34
mitoxantrone .................................................. 39
modafinil ......................................................... 19
moexipril ......................................................... 13
moexipril/hydrochlorothiazide ..................... 13
mometasone ................................................... 32
MONOCLATE-P............................................... 41
MONONINE ..................................................... 41
montelukast .................................................... 22
morphine......................................................... 15
morphine er .................................................... 15
MOVIPREP ...................................................... 25
moxifloxacin ..................................................... 6
MOZOBIL ......................................................... 41
MULTAQ .......................................................... 11
MULTICLIX ...................................................... 21
mupirocin cream and ointment .................... 31
MYALEPT ........................................................ 45
mycophenolate............................................... 35
mycophenolic ................................................. 35
MYOBLOC ....................................................... 47
myorisan ......................................................... 33
MYOZYME ....................................................... 43
MYRBETRIQ ER.............................................. 34
nabumetone.................................................... 15
nadolol ............................................................ 12
NAFTIN ............................................................ 32
NAGLAZYME ................................................... 43
naltrexone ....................................................... 16
NAMENDA SUSPENSION .............................. 20
NAMENDA TABLET ........................................ 20
NAMENDA XR ................................................. 20
naproxen ......................................................... 14
naproxen sr .................................................... 15
naratriptan ...................................................... 19
NASCOBAL ..................................................... 34
NASONEX ....................................................... 24
NATAZIA .......................................................... 28
nateglinide ...................................................... 30
NATROBA........................................................ 32
NEBUPENT ....................................................... 8
nefazodone ..................................................... 17
neomycin .......................................................... 5
neomycin/bacitracin/poly/hc ........................ 24
neomycin/polymyxin/dexameth ................... 24
- 56 -
neomycin/polymyxin/hc ................................ 24
NESINA ............................................................ 29
NEULASTA ...................................................... 41
NEUMEGA ....................................................... 41
NEUPOGEN ..................................................... 41
NEUPRO PATCH............................................. 20
NEVANAC ........................................................ 24
nevirapine ......................................................... 7
nevirapine xr ..................................................... 7
NEXAVAR ........................................................ 39
NEXICLON XR ................................................. 12
NEXIUM ........................................................... 26
niacin er........................................................... 11
nicardipine hcl ................................................ 13
nicotine gum, lozenge, patch ........................ 10
NICOTROL INHALER ...................................... 10
NICOTROL NS ................................................. 10
nifedipine ........................................................ 13
nifedipine er .................................................... 13
nimodipine ...................................................... 13
nisoldipine ...................................................... 13
nitrofurantoin .................................................... 8
nitrofurantoin suspension............................... 8
nitroglycerin ................................................... 12
nizatidine ......................................................... 26
NORDITROPIN ................................................ 45
NORDITROPIN NORDIFLEX .......................... 45
norethindrone acetate ................................... 30
NORITATE ....................................................... 31
NOROXIN........................................................... 6
NORTHERA ..................................................... 40
nortriptyline .................................................... 17
NORVIR ........................................................... 36
NOVOFINE 32G NEEDLES ............................. 21
NOVOFINE AUTOCOVER............................... 21
NOVOLIN ......................................................... 30
NOVOLOG ....................................................... 30
NOVOSEVEN .................................................. 41
NOXAFIL .......................................................... 36
NPLATE ........................................................... 41
NUCYNTA ........................................................ 15
NUCYNTA ER .................................................. 15
NUEDEXTA ...................................................... 20
NULEV ............................................................... 9
NULOJIX .......................................................... 47
NULYTELY ....................................................... 25
NUTROPIN....................................................... 45
NUTROPIN AQ ................................................ 45
NUVARING ...................................................... 28
NUVIGIL ........................................................... 19
nystatin........................................................7, 32
nystatin/triamcinolone ................................... 32
OCTAGAM ....................................................... 45
octreotide ........................................................ 47
OFEV................................................................ 44
ofloxacin......................................................6, 23
Check in body for specific drug coverage.
OFORTA .......................................................... 39
olanzapine ...................................................... 18
olanzapine odt ................................................ 18
olanzapine/fluoxetine .................................... 17
OLYSIO............................................................ 37
omega-3-acid .................................................. 11
omeprazole ..................................................... 26
OMNARIS ........................................................ 24
OMNITROPE ................................................... 45
ONCASPAR ..................................................... 39
ondansetron ................................................... 25
ONETOUCH .................................................... 21
ONETOUCH ULTRA........................................ 21
ONFI ................................................................ 16
ONGLYZA ........................................................ 29
ONMEL .............................................................. 7
ONSOLIS ......................................................... 42
ONTAK............................................................. 39
OPANA ER ...................................................... 15
OPSUMIT......................................................... 43
OPTIVAR ......................................................... 23
ORAPRED ODT............................................... 27
ORAVIG ........................................................... 32
ORBACTIV....................................................... 36
ORENCIA......................................................... 47
ORENITRAM ................................................... 43
orphenadrine er.............................................. 10
ORTHO TRI-CYCLEN LO ............................... 28
OSENI .............................................................. 29
OSPHENA ....................................................... 29
OTEZLA ........................................................... 47
OTREXUP........................................................ 35
oxaliplatin ....................................................... 39
oxandrolone ................................................... 27
oxaprozin ........................................................ 15
oxazepam........................................................ 19
oxcarbazepine ................................................ 16
OXECTA .......................................................... 15
OXISTAT.......................................................... 32
oxybutynin chloride ....................................... 34
oxybutynin chloride er .................................. 34
oxycodone ...................................................... 15
oxycodone cr.................................................. 15
oxycodone/acetaminophen .......................... 15
OXYCONTIN.................................................... 15
oxymorphone ................................................. 15
oxymorphone er ............................................. 15
paclitaxel......................................................... 39
pamidronate disodium .................................. 46
PANCREAZE ................................................... 25
PANCRELIPASE 5,000 ................................... 25
PANRETIN ....................................................... 33
pantoprazole................................................... 26
paricalcitol ...................................................... 34
paromomycin ................................................... 7
paroxetine ....................................................... 17
- 57 -
paroxetine er ................................................... 17
PATADAY......................................................... 23
PATANASE ...................................................... 23
PATANOL......................................................... 23
PCE .................................................................... 6
peg3350/electrolyte soln ............................... 25
PEGASYS ........................................................ 37
PEG-INTRON ................................................... 37
PEG-INTRON REDIPEN.................................. 37
penicillin v potassium...................................... 6
PENLAC ........................................................... 32
PENNSAID ....................................................... 33
PENTASA......................................................... 26
pentostatin ...................................................... 39
pentoxifylline .................................................. 10
PERFOROMIST ................................................. 9
perindopril....................................................... 13
PERJETA ......................................................... 39
perphenazine .................................................. 18
PEXEVA ........................................................... 17
phenazopyridine hcl ...................................... 33
phenelzine ....................................................... 17
phenobarbital ................................................. 19
PHENYTEK ...................................................... 16
phenytoin ........................................................ 16
phenytoin extended ....................................... 16
PHOTOFRIN .................................................... 39
PICATO ............................................................ 33
pilocarpine ...................................................... 25
pindolol ........................................................... 12
pioglitazone .................................................... 30
pioglitazone/metformin.................................. 30
piroxicam ........................................................ 14
PLAN B ONE-STEP OTC ................................ 21
PLAN B PRESCRIPTION ................................ 28
PLEGRIDY ....................................................... 37
polymyxin b sul/trimethoprim ....................... 23
POMALYST ...................................................... 39
potassium chloride ........................................ 22
POTIGA ............................................................ 16
PRADAXA ........................................................ 10
pramipexole .................................................... 20
pramoxine-hc .................................................. 32
PRANDIMET .................................................... 30
pravastatin ...................................................... 11
prazosin........................................................... 12
PRED-G ........................................................... 24
prednisolone .............................................24, 27
prednisone ...................................................... 27
PREMARIN ...................................................... 29
PREMPHASE ................................................... 29
PREMPRO ....................................................... 29
PREVACID ....................................................... 26
PREZISTA ........................................................ 36
PRIALT ............................................................. 42
PRIMAQUINE .................................................... 8
Check in body for specific drug coverage.
primidone........................................................ 16
PRISTIQ........................................................... 17
PRIVIGEN ........................................................ 45
PROAIR HFA ..................................................... 9
probenecid...................................................... 22
procainamide.................................................. 11
prochlorperazine ...................................... 18, 25
PROCRIT ......................................................... 41
PROCYSBI ...................................................... 47
PRODIGY PEN NEEDLE ................................ 21
PROFILNINE ................................................... 41
progesterone .................................................. 31
PROLASTIN..................................................... 44
PROLASTIN C ................................................. 44
PROLENSA ..................................................... 24
PROLEUKIN .................................................... 39
PROLIA ............................................................ 35
PROMACTA..................................................... 41
promethazine.................................................... 5
promethazine vc............................................... 5
promethazine vc/codeine .............................. 22
promethazine/codeine ................................... 22
promethazine/dm ........................................... 22
propafenone ................................................... 11
propafenone er ............................................... 11
propranolol ..................................................... 12
propranolol er................................................. 12
propranolol/hydrochlorothiazide ................. 12
propylthiouracil .............................................. 31
PROTOPIC ...................................................... 33
protriptyline .................................................... 17
PROVENGE..................................................... 42
PROVENTIL HFA .............................................. 9
PULMICORT FLEXHALER .............................. 27
PULMOZYME .................................................. 43
PURIXAN ......................................................... 42
PYLERA ........................................................... 27
pyridostigmine ................................................. 8
QNASL ............................................................. 24
quetiapine ....................................................... 18
quinapril .......................................................... 13
quinapril/hydrochlorothiazide ...................... 13
QVAR ............................................................... 27
rabeprazole ..................................................... 26
raloxifene ........................................................ 29
ramipril ............................................................ 13
RANEXA .......................................................... 11
ranitidine syrup .............................................. 26
RAPAFLO .......................................................... 9
RAPAMUNE..................................................... 47
RASUVO .......................................................... 47
RAVICTI ........................................................... 42
RAYOS ............................................................ 27
REBETOL SOLN ............................................. 37
REBIF .............................................................. 46
RECOMBINATE............................................... 41
- 58 -
RECONEST ..................................................... 46
RECTIV ............................................................ 33
REFACTO ........................................................ 41
REFLUDAN ...................................................... 40
REGRANEX ..................................................... 33
RELENZA ........................................................... 7
RELISTOR ....................................................... 44
RELPAX ........................................................... 19
REMICADE ...................................................... 47
REMODULIN .................................................... 43
RENAGEL ........................................................ 43
RENVELA......................................................... 43
repaglinide ...................................................... 30
RESCULA ........................................................ 25
RESTASIS........................................................ 24
RETIN-A MICRO .............................................. 33
RETIN-A TOPICAL .......................................... 33
REVATIO.......................................................... 42
REVLIMID ........................................................ 39
REYATAZ ......................................................... 36
RIBAPAK .......................................................... 37
ribavirin ........................................................... 37
RIDAURA ......................................................... 27
rifampin ............................................................. 7
riluzole ............................................................. 42
RIOMET ........................................................... 29
risedronate ...................................................... 35
RISPERDAL CONSTA ..................................... 42
risperidone ...................................................... 18
risperidone odt ............................................... 18
RITUXAN.......................................................... 39
rivastigmine ...................................................... 8
RIXUBIS ........................................................... 41
rizatriptan ........................................................ 19
rizatriptan odt ................................................. 19
ropinirole ......................................................... 20
ropinirole er .................................................... 20
ROZEREM ....................................................... 19
RYANODEX ..................................................... 40
SABRIL............................................................. 42
SAIZEN ............................................................ 45
salicyclic acid ................................................. 33
salsalate .......................................................... 14
SAMSCA .......................................................... 43
SANCUSO........................................................ 26
SANDOSTATIN LAR........................................ 47
SANTYL ........................................................... 33
SAPHRIS.......................................................... 18
SARAFEM ........................................................ 17
SAVELLA ......................................................... 20
selegiline ......................................................... 20
selenium sulfide ............................................. 32
SELZENTRY .................................................... 36
SEMPREX-D ...................................................... 5
SENSIPAR .................................................35, 47
SEREVENT DISKUS ......................................... 9
Check in body for specific drug coverage.
SEROQUEL XR ............................................... 18
SEROSTIM ...................................................... 45
sertraline ......................................................... 17
SFROWASA .................................................... 27
SIGNIFOR........................................................ 45
sildenafil citrate.............................................. 42
SILENOR ......................................................... 18
silver sulfadiazine .......................................... 32
SIMBRINZA ..................................................... 24
SIMCOR........................................................... 11
SIMPONI .......................................................... 47
SIMULECT ....................................................... 47
simvastatin ..................................................... 11
sirolimus ......................................................... 47
SIRTURO ......................................................... 36
SITAVIG ........................................................... 37
SIVEXTRO ....................................................... 36
SKLICE ............................................................ 32
SKYLA ............................................................. 28
sodium polystyrene ....................................... 22
sodium sulfacetamide ................................... 31
sodium sulfacetamide/sulfur ........................ 33
SOFT TOUCH.................................................. 21
SOFTCLIX ....................................................... 21
SOLIRIS ........................................................... 46
SOMATULINE.................................................. 47
SOMAVERT ..................................................... 45
SONATA .......................................................... 19
SORILUX ......................................................... 33
sotalol ............................................................. 12
SOVALDI ......................................................... 37
SPECTRACEF ................................................... 6
spermicides-foams, gels, suppositories ..... 21
spinosad ......................................................... 32
SPIRIVA ............................................................. 9
spironolactone ............................................... 14
spironolactone/hydrochlorothiazide............ 14
sponges .......................................................... 21
SPORANOX....................................................... 7
SPRIX .............................................................. 15
SPRYCEL ........................................................ 39
STAVZOR ........................................................ 16
STELARA......................................................... 46
STIMATE ......................................................... 44
STIVARGA ....................................................... 39
STRATTERA.................................................... 20
STRIANT.......................................................... 27
STRIBILD ......................................................... 36
STRIVERDI RESPIMAT .................................... 9
sucralfate ........................................................ 26
sulfacetamide sodium ................................... 23
sulfacetamide/prednisolone ......................... 24
sulfamethoxazole /trimethoprim .................... 6
sulfamethoxazole /trimethoprim ds ............... 6
sulfasalazine..................................................... 6
sulfasalazine dr ................................................ 6
- 59 -
sulindac ........................................................... 14
sumatriptan ..................................................... 19
SUMAVEL ........................................................ 19
SUPRAX............................................................. 6
SURFAXIN ....................................................... 43
SUSTIVA .......................................................... 37
SUTENT ........................................................... 39
SYLATRON ...................................................... 39
SYLVANT ......................................................... 39
SYMBICORT .................................................... 27
SYMLINPEN .................................................... 29
SYNAGIS ......................................................... 37
SYNRIBO ......................................................... 39
SYNTHROID .................................................... 31
TACLONEX ...................................................... 32
tacrolimus ....................................................... 35
TAFINLAR ........................................................ 39
TAMIFLU ............................................................ 7
tamoxifen citrate .............................................. 8
tamsulosin ........................................................ 9
TANZEUM ........................................................ 29
TARCEVA ........................................................ 39
TARGRETIN ..............................................40, 46
TASIGNA.......................................................... 40
TAZORAC ........................................................ 33
TECFIDERA ..................................................... 46
TEKAMLO ........................................................ 14
TEKTURNA ...................................................... 14
TEKTURNA HCT ............................................. 14
telmisartan ...................................................... 14
telmisartan/hydrochlorothiazide .................. 14
temazepam ...................................................... 19
temozolomide ................................................. 40
TERAZOL ......................................................... 32
terazosin.......................................................... 12
terbinafine ......................................................... 7
terconazole ..................................................... 32
TESTOPEL ...................................................... 27
testosterone .................................................... 27
tetracycline ....................................................... 6
TEVETEN ......................................................... 14
TEVETEN HCT ................................................ 14
TEV-TROPIN ................................................... 45
THALOMID ....................................................... 46
theophylline .................................................... 34
THERACYS ...................................................... 46
thioridazine ..................................................... 18
thiotepa ........................................................... 40
thiothixene ...................................................... 18
THROMBATE III ............................................... 40
THYMOGLOBULIN .......................................... 47
THYROGEN ..................................................... 42
tiagabine.......................................................... 16
ticlopidine ....................................................... 10
TIKOSYN.......................................................... 11
timolol........................................................12, 24
Check in body for specific drug coverage.
tinidazole .......................................................... 8
TIROSINT ........................................................ 31
TIVICAY ........................................................... 36
tizanidine ........................................................ 10
TOBI PODHALER ............................................ 36
TOBRADEX ..................................................... 24
tobramycin...................................................... 36
tobramycin sulfate ......................................... 23
tobramycin/dexamethason ........................... 24
tolteroldine ..................................................... 34
tolteroldine er ................................................. 34
topiramate....................................................... 17
topiramate er .................................................. 17
topotecan ........................................................ 40
TORISEL.......................................................... 40
torsemide ........................................................ 22
TOTECT........................................................... 47
TOVIAZ ............................................................ 34
TRACLEER ...................................................... 43
TRADJENTA .................................................... 29
tramadol hcl.................................................... 15
tramadol hcl er ............................................... 15
tramadol/acetaminophen .............................. 15
trandolapril ..................................................... 13
trandolapril/verapamil ................................... 13
tranexamic acid .............................................. 10
TRANSDERM/SCOPOLAMINE....................... 26
TRAVATAN Z................................................... 25
travoprost ....................................................... 25
trazodone ........................................................ 17
TREANDA ........................................................ 40
TRELSTAR ...................................................... 40
TRELSTAR DEPOT ......................................... 40
TRELSTAR LA ................................................. 40
tretinoin ........................................................... 40
tretinoin topical .............................................. 33
TRETTEN ........................................................ 41
TREXIMET ....................................................... 20
triamcinolone acetonide ............................... 32
triamterene/hydrochlorothiazide .................. 22
triazolam ......................................................... 19
TRIBENZOR .................................................... 13
trifluoperazine ................................................ 18
trifluridine ....................................................... 23
trihexyphenidyl .............................................. 20
trimethobenzamide ........................................ 25
trimethoprim ..................................................... 8
trimipramine ................................................... 17
TRIUMEQ ........................................................ 37
TROKENDI XR ................................................ 17
trospium.......................................................... 34
trospium er ..................................................... 34
TRUVADA ........................................................ 37
TUDORZA.......................................................... 9
TYBOST........................................................... 37
TYKERB........................................................... 40
- 60 -
TYSABRI .......................................................... 46
TYVASO ........................................................... 43
TYZEKA ............................................................. 7
UCERIS ............................................................ 44
ULESFIA .......................................................... 32
ULORIC ............................................................ 34
unithroid .......................................................... 31
urea .................................................................. 33
URSO ............................................................... 25
ursodiol ........................................................... 25
VAGIFEM ......................................................... 29
valacyclovir ....................................................... 7
VALCHLOR ...................................................... 46
VALCYTE ......................................................... 37
valproic acid ................................................... 17
valsartan.......................................................... 14
valsartan/hydrochlorothiazide ...................... 14
VALSTAR ......................................................... 40
vancomycin capsule ...................................... 36
vancomycin vial ............................................... 7
VANDETANIB .................................................. 40
VANTAS ........................................................... 40
VASCEPA ........................................................ 12
VECTIBIX ......................................................... 40
VELCADE......................................................... 40
VELETRI .......................................................... 43
VELPHORO ..................................................... 43
VELTIN ............................................................. 33
venlafaxine ...................................................... 17
venlafaxine er capsules ................................. 17
venlafaxine er tablets..................................... 17
VENTAVIS........................................................ 43
VENTOLIN HFA ................................................. 9
VERAMYST ..................................................... 24
verapamil hcl .................................................. 13
verapamil hcl er .............................................. 13
VERDESO ........................................................ 32
VERSACLOZ ................................................... 42
VESICARE ....................................................... 34
VEXOL ............................................................. 24
VICTOZA .......................................................... 29
VICTRELIS ....................................................... 37
VIGAMOX......................................................... 23
VIIBRYD ........................................................... 17
VIMIZIM ............................................................ 43
VIMOVO ........................................................... 15
VIMPAT ............................................................ 17
VIRAZOLE........................................................ 37
VIREAD ............................................................ 37
VISUDYNE ....................................................... 44
vitamin d 50,000 unit ...................................... 34
VITRASERT ..................................................... 44
VIVELLE-DOT .................................................. 29
VIVITROL ......................................................... 42
VOGELXO ........................................................ 27
VOLTAREN GEL .............................................. 33
Check in body for specific drug coverage.
VOLTAREN XR................................................ 15
VORAXAZE ..................................................... 46
voriconazole ................................................... 36
VOTRIENT ....................................................... 40
VPRIV .............................................................. 43
VUMON ............................................................ 40
VYTORIN ......................................................... 11
VYVANSE ........................................................ 18
warfarin sodium ............................................. 10
WELCHOL ....................................................... 11
WILATE............................................................ 41
WINRHO SDF .................................................. 45
XALKORI ......................................................... 40
XARELTO ........................................................ 10
XARTEMIS XR................................................. 15
XELJANZ ......................................................... 47
XENAZINE ....................................................... 42
XEOMIN ........................................................... 47
XGEVA ............................................................. 46
XIAFLEX .......................................................... 43
XIFAXAN 200 mg............................................... 7
XIFAXAN 550 MG ............................................ 36
XOFIGO ........................................................... 45
XOLAIR ............................................................ 44
XOPENEX.......................................................... 9
XTANDI ............................................................ 40
XYNTHA .......................................................... 41
XYREM ............................................................ 42
zafirlukast ....................................................... 22
zaleplon........................................................... 19
ZALTRAP ......................................................... 40
ZANOSAR........................................................ 40
ZAVESCA ........................................................ 47
ZELBORAF ...................................................... 40
ZEMAIRA ......................................................... 44
ZENPEP........................................................... 25
zenzedi ............................................................ 18
ZETIA ............................................................... 11
ZETONNA ........................................................ 24
ZIANA .............................................................. 33
ZIOPTAN ......................................................... 25
ziprasidone ..................................................... 18
ZIPSOR ............................................................ 15
ZIRGAN ........................................................... 44
ZOHYDRO ER ................................................. 15
ZOLADEX ........................................................ 40
zoledronic acid ............................................... 46
ZOLINZA .......................................................... 40
zolmitriptan..................................................... 20
zolmitriptan odt .............................................. 20
zolpidem ......................................................... 19
zolpidem cr ..................................................... 19
ZOLPIMIST ...................................................... 19
ZOMIG ............................................................. 20
zonisamide ..................................................... 17
ZONTIVITY ...................................................... 10
- 61 -
ZORBTIVE ....................................................... 45
ZORTRESS ...................................................... 47
ZORVOLEX ...................................................... 15
ZOVIRAX.......................................................... 31
ZUBSOLV......................................................... 16
ZUPLENZ ......................................................... 26
ZYDELIG .......................................................... 40
ZYFLO .............................................................. 22
Check in body for specific drug coverage.
ZYFLO CR ....................................................... 22
ZYKADIA.......................................................... 40
ZYLET .............................................................. 24
ZYMAR ............................................................ 23
ZYPREXA RELPREVV .................................... 42
ZYTIGA ............................................................ 40
ZYVOX ............................................................. 36