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2015
MVP Health Insurance
MARKETPLACE
FORMULARY
New York-Vermont
••••••••••••••••••••••••••••••••••••••••••••••••••••••
Effective January 1, 2015
2015 MARKETPLACE FORMULARY
EFFECTIVE January 1, 2015
This information relates to the Marketplace Formulary, generally, and may not describe your particular coverage. Your
specific Plan documents determine your benefits, including copays, coinsurance, deductibles, out-of-pocket maximums
and any limitations and exclusions. Your physician is the person best suited to help you make decisions about
prescription drugs, and the prescription drug information below is intended for consumer guidance only.
While every effort has been made to insure accuracy, some information may be out of date. The Marketplace Formulary is
subject to change based on decisions made by the Pharmacy & Therapeutics (P&T) committee. New drugs are not
covered until reviewed by the P&T committee. Medications with an over-the-counter equivalent are not a covered benefit.
Drugs entering the market between 1938 and 1962 that were approved for safety but not effectiveness are called “DESI”
drugs. DESI drugs are not covered on the Marketplace Formulary.
In the case of some drugs, the Plan limits coverage to a specific quantity or a specific course of treatment. The Plan may
also require prior authorization on some covered drugs. If you need more information about policies regarding a specific
drug, consult your physician or contact the MVP Customer Care Center. If the medication you take is not listed below,
contact the Customer Care Center at the phone number listed on the back of your MVP ID card.
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
ACE Inhibitors**
(blood pressure
lowering,
includes HCTZ
combination
products)
benazepril
captopril
enalapril
fosinopril
lisinopril
None
Adrenal
Hormones
Oral**
cortisone
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone
prednisone
Accupril
BR
Accuretic
BR
Aceon
BR
Altace
BR
Lotensin
Epaned
BR
Mavik
#,+
Acthar-HP
BR
Cortef
Dexpak
BR
Medrol
Medrol 2mg
Orapred ODT
BR
Pediapred
BR
Prelone
NFNC
Rayos
Adrenergic
Antagonists**
clonidine
doxazosin
guanabenz
guanfacine
#
moexipril
perindopril
quinapril
ramipril
trandolapril
Millipred
methyldopa/
HCTZ
prazosin
reserpine
terazosin
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
clonidine patch
midodrine
q
BR
MEDICAL
(M)
BR
Prinivil
BR
Uniretic
BR
Univasc
BR
Vasotec
BR
Zestril
BR
Zestoretic
BR
Cardura
Cardura XL
BR
Catapres/TTS
BR
Minipress
BR
Tenex
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
2
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Alzheimer’s
Agents**
galantamine
donepezil
ergoloid
Namenda XR
rivastigmine
Aricept/ODT
BR
Exelon
Exelon patch
BR
Razadyne/ER
Androgens
(male hormones)
danazol
q
testosterone inj
Androgel
q
oxandrolone
*,q BR
Testim
ARBs/Renin
Inhibitors**
(includes
combination
products)
candesartan
eprosartan
irbesartan
losartan
telmisartan/amlodipine
Anti-Anxiety
Agents**
alprazolam/ER
buspirone
chlordiazepoxide
clorazepate
diazepam
lorazepam
oxazepam
amiodarone
disopyramide
flecainide
mexiletine
Pacerone
propafenone
quinidine
Sorine
sotalol/AF
Antiarrhythmics**
(heart rhythm)
#
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
*,q
amlodipine/
valsartan
valsartan
alprazolam
intensol
diazepam
Intensol
propafenone
SR
q
MEDICAL
(M)
BR
#
Anadrol-50
# *,q
Androderm
q#
Android
q
Androxy
#
Aveed
#q
Axiron
q BR #
Delatestryl
,q #
Depo-Testerone
q#
Depo-Testosterone 100mg
*,q #
First-Testo Cr
*,q #
Fortesta
q BR #
Oxandrin
q#
Methitest
*,q #
Striant
q
testosterone gel
*,q #
Testred
#
Vogelxo
Amturnide
Exforge BR
BR
BR
Atacand
Hyzaar
BR
Avalide
Micardis/HCT BR
BR
Avapro
Tekamlo
Azor
Tekturna/HCT
BR
Teveten
Benicar/HCT
BR
Cozaar
Teveten HCT
BR
Diovan/HCT
Tribenzor
BR
Twynsta
Edarbi
Edarbyclor
BR
Ativan
BR
Niravam
BR
Tranxene-T
BR
Valium
BR
Xanax/XR
Betapace/AF
BR
Cordarone
Multaq
BR
Norpace
Norpace CR
BR
#
Aveed
q
Testopel
BR
Rythmol/SR
BR
Tambocor
+
Tikosyn
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
3
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Antibiotics
amoxicillin
amoxicillin/ clavulanate
amoxicillin/ clavulanate XR
ampicillin
azithromycin
cefaclorcefadroxil
cefdinir
cefditren
cefpodoxime
cefprozil
cefuroxime
cephalexin
cephradine
ciprofloxacin/ER
clarithromycin/ER
clindamycin
dicloxacillin
ees/sulfisoxazole
Erythrocin
erythromycin
levofloxacin
minocycline/XR
neomycin
ofloxacin
paromomycin
penicillin
sulfadiazine
sulfa/trimeth DS/SS
tetracycline
heparin
Jantoven*
warfarin*
Avidoxy
Baci-IM inj
bacitracin inj
cefepime inj
#
ceftriaxone inj
Clindess
clindamycin
palmitate
demeclocycline
doxycycline
Morgidox
moxifloxacin
vancomycin
Adoxa
BR
Augmen/ES/XR
BR
Avelox
BR
Bactrim/DS
BR
Biaxin XL
BR
Cedax
Cefaclor ER
BR
Ceftin
Ceftin susp
BR
Cipro/XR
BR
Cleocin
Cleocin 75mg
Cleocin Vaginal
# BR
Doryx 150mg
#
Doryx 200mg
doxycycline 20mg
Dynabac
E.E.S. Susp
Eryped
Ery-Tab
Erythromycin Base
Factive
Eliquis*
enoxaparin
fondaparinux
Xarelto*
Arixtra
Coumadin*
Fragmin
Heparin Lock
FlushNFNC
carbamazepine
clonazepam
diazepam rectal
divalproex
Epitol
ethosuximide
gabapentin
lamotrigine/XR
carbamazepine
ER
Aptiom
Banzel
BR
Carbatrol
BR
Depakene
BR
Depakote/ER
BR
Diastat
Dilantin
BR
Felbatol
#
Fycompa
BR
Gabitril
BR
Keppra/XR
BR
Klonopin
BR
Lamictal/XR
Lamictal ODT
Lyrica
Anticoagulants
Anticonvulsants**
(seizures)
#
phenobarbital
phenytoin
primidone
Topiragen
topiramate
valproic acid
zonisamide
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
Celontin
divalproex ER
felbamate
levetiracetam/SR
oxcarbazepine
Peganone
tiagabine
BR
Keflex
Ketek
BR
Levaquin
BR
Minocin
BR
Monodox
Moxatag
Noroxin
#
Oracea
# BR
Rocephin
PCE
#
Sivextro
#
Solodyn
BR
Spectracef
Sulfadiazine
Suprax
Tygacil inj
BR
Vancocin
Vibativ
BR
Vibramycin
Vibramycin syrup
#
Xifaxan 200 mg
BR
Zithromax
Z-Max
q
Zyvox
BR
Iprivask
BR
Lovenox
#*
Pradaxa
#
BR
MEDICAL
(M)
#
Dalvance
Teflaro
#
Zyvox Inj
BR
Mysoline
BR
Neurontin
Onfi
Oxtellar XR
Phenytek BR
Potiga
+
Sabril
Stavzor
BR
Tegretol/ XR
BR
Topamax
BR
Trileptal
Trokendi XR
Vimpat
BR
Zarontin
BR
Zonegran
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
4
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Antidepressants**
amitriptyline
amoxapine
bupropion/SR/XL
budeprion/SR/XL
citalopram
desipramine
doxepin
escitalopram
fluoxetine
fluvoxamine/CR
hydroxyzine pamoate
imipramine
imipramine pamoate
maprotiline
mirtazapine
nefazodone
nortriptyline
paroxetine/ER
phenelzine
protriptyline
Selfemra
sertraline
tranylcypromin
trazodone
trimipramine
venlafaxine
clomipramine
duloxetine
venlafaxine ER
olanzepine/
st
fluoxetine
Anafranil
Aplenzin
Brintellix
#
Brisdelle
BR
Celexa
BR
Cymbalta
Compro
q
ondansetron
prochlorperazine
promethazine
trimethobenzamid
dronabinol
q
granisetron
Antiemetics
(nausea)
Antifungal
Agents
clotrimazole oral
fluconazole
griseofulvin
ketoconazole
nystatin
q
terbinafine
Antihistamines**
Various generics
azelastine
clemastine
cyproheptadine
chlorpheniramine
Various generics
Antihistamine/
Decongestant
Combinations
Antihypertensive
Combinations**
(blood pressure
lowering)
Antimalarials
Antimycobacterials**
(TB)
#
BR
#
itraconazole
voriconazole
amlodipine/atorvastatin
amlodipine/benazepril
atenolol/chlorthalidone
Clorpres
nadolol/bendroflumethzide
trandolapril/verapamil
#
chloroquine
hydroxychloroquine*
#
mefloquine
#
quinine sulfate
ethambutol
rifampin
isoniazid
rifampin/
pyrazinamide
isoniazid
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
desloratadine
Effexor XR
Emsam
Fetzima
Forfivo XL
#
Khedezla
BR
Lexapro
BR
Luvox CR
Marplan
BR
Nardil
BR
Norpramin
Oleptro ER
q
Anzemet
Cesamet
Q
Diclegis
q
Emend
q
Granisol
BR
Marinol
BR
Ancobon
Cancidas
BR
Diflucan
BR
Grifulvin V
BR
Gris-Peg
#
Jublia
#
Kerydin
q
Lamisil Granules
Mycamine inj
Various brands
BR
Astelin Nasal
Astepro
Brovex
#
None
Various brands
#
Clarinex D
Demser
Bidil
BR
Caduet
BR
Corzide
BR
Lopressor HCT
atovaquone/
#
proguanil
Aralen
#
Coartem
#
Daraprim
# BR
Malarone
Mycobutin
Paser
Rifater
Priftin
q
BR
Desvenlafaxine ER
griseofulvin ultra
diphenhydramine
hydroxyzine
levocetirizine
promethazine
BR
#
MEDICAL
(M)
Pamelor
BR
Parnate
Paxil susp
BR
Paxil/CR
Pexeva
Pristiq ER
BR
Prozac/Week
BR
Remeron
NFNC
Sarafem
BR
Surmontil
st BR
Symbyax
BR
Tofranil/PM
Venlafaxine
BR
ext-rel Tabs
Viibryd
BR
Vivactil
Wellbutrin/SR/XLBR
BR
Zoloft
q
Sancuso
BR
Tigan
#
Aloxi
#
Emend Inj
Transderm-Scop
q BR
Zofran/ODT
q
Zuplenz
q BR
Lamisil
BR
Nizoral
Noxafil
#
Onmel
Oravig
# BR
Sporanox
#
Sporanox soln
BR
Vfend
BR
Clarinex
Clarinex syrup
Patanase
BR
Xyzal
#
Semprex-D
BR
Lotrel
Tarka
BR
Tenoretic
BR
Ziac
BR
Plaquenil*
#
Primaquine
# BR
Qualaquin
#
Seromycin
Sirturo
Trecator
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
5
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Antiparasitics
metronidazole
paromomycin
tinidazole
atovaquone
Antiplatelet
Agents**
anagrelide
cilostazol
clopidogrel
dipyridamole
ticlopidine
None
Antipsychotics**
chlorpromazine
clozapine/ODT
fluphenazine
haloperidol
lithium
loxapine
perphenazine
quetiapine
risperidone/ODT
thioridazine
thiothixene
trifluoperazine
olanzapine/ODT
olanzapine/
st
fluoxetine
ziprazidone
Antiretrovirals/
HIV
None
Antispasmodic
Agents**
#
#
abacavir*
abacavir/lamivudine/
zidovudine*
Aptivus*
Atripla*
Crixivan*
didanosine*
Emtriva*
Epivir soln*
Epzicom*
Invirase*
Isentress*
Kaletra*
lamivudine*
lamivudi/zidov*
Lexiva*
nevirapine*
Norvir*
Prezista*
Rescriptor*
Reyataz*
Selzentry*
stavudine*
Sustiva*
Truvada*
Viracept*
Viread tabs*
zidovudine*
methscopolomine
Myrbetriq
tolterodine/ER
trospium
bethanechol
dicyclomine
flavoxate
oxybutynin/ER
propantheline
Symax/SL/SR
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
Albenza
Alinia
Biltricide
Dapsone
BR
Flagyl
Aggrenox
BR
Agrylin
Brilinta
Effient
st
Abilify
BR
Clozaril
Equetro
Fanapt
BR
FazaClo
BR
Geodon
Invega
Latuda
BR
Lithobid
BR
Combivir*
Complera*
Edurant*
+
Egrifta
BR
Epivir tabs*
+
Fuzeon
Intelence*
BR
Retrovir*
Stribild*
Tivicay*
Flagyl ER
# BR
Mepron
Stromectol
BR
Tindamax
Yodoxin
BR
Persantine
BR
Plavix
BR
Pletal
Anaspaz
BR
Bentyl
Cantil
BR
Detrol/LA
BR
Ditropan/XL
#
Enablex
Gelnique
BR
Levbid
Levsin/SL
BR
Nulev
BR
Pamine /Forte
BR
Robinul/Forte
#
Sanctura/XR
Symax Duotab
Toviaz
Vesicare
BR
Loxitane
Orap
BR
Risperdal
Saphris
BR
Seroquel
st
Seroquel XR
st BR
Symbyax
#
Versacloz
BR
Zyprexa
MEDICAL
(M)
Abilify
#
Maintena
#
Adasuve
Invega
Sustenna
Risperdal
Consta
Zyprexa
Relprevv
Trizivir*BR
Videx *
BR
Videx EC*
BR
Viramune*
Viramune XR*
Viread Powder*
BR
Zerit*
BR
Ziagen*
Ziagen soln*
BR
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
6
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Antitussives &
Expectorants
Various generics
benzonatate
codeine combinations
hydrocod combinations
acyclovir
amantadine
ganciclovir
rimantadine
valacyclovir
azathioprine*
hydroxychloroquine*
leflunomide*
methotrexate*
sulfasalazine*
None
All brands
#
Entex (all)
BR #
Tussionex
famciclovir
q
Tamiflu
Denavir
BR
Famvir
BR
Flumadine
Lidovir
#
Sitavig
#+
Actemra SQ
BR
Arava*
#,+
Cimzia
#+
Ilaris
#,+
Kineret
#,+
Orencia
#
Otezla
#
Otrexup
Relenza
Valcyte
BR
Valtrex
BR
Zovirax
Zovirax cr
#
Rasuvo
#,+
Remicade
Rheumatrex*
#+
Rituxan
#,+
Simponi
Trexall*
#+
Xeljanz
alfluzosin
doxazosin
finasteride
tamsulosin
terazosin caps
acebutolol
atenolol
betaxolol
bisoprolol
carvedilol
labetalol
None
Avodart
Cardura XL
#
Cialis 2.5 mg
#
Cialis 5 mg
BR
Flomax
BR
Betapace/AF
Bystolic
BR
Coreg
Coreg CR
BR
Corgard
Dutoprol
BR
Inderal LA
Innopran XL
+
Aranesp
+
Epogen
+
Leukine
+
Mozobil
Jalyn
BR
Proscar
Rapaflo
BR
Uroxatral
Antiviral Agents
Arthritis Agents
Benign Prostatic
Hypertrophy
(BPH) Agents**
(prostate)
Beta-Blocking
Agents**
(blood pressure
Lowering,
includes HCTZ
combination
products)
#,+
Enbrel
#,+
Humira
Ridaura*
metoprolol/XL
nadolol
pindolol
propranolol/LA
satolol/AF
timolol
None
+
Blood Modifiers
None
Procrit
Botulinum Toxins
None
None
Dysport
Calcium Channel
Blocking Agents
(CCB)**
(blood pressure
lowering)
Afeditab
amlodipine
Cartia XT
Dilt-CD
Dilt XR
Diltzac
diltiazem/ER/XT
felodipine
isradipine
nimodipine
nisoldipine
Adalat CC
BR
Calan/SR
Cardene SR
BR
Cardizem/CD/LA
BR
Dilacor XR
Nimotop
#
Matzim LA
Nicardipine
Nifediac CC
Nifedical XL
nifedipine/ER
Taztia XT
verapamil/ER/PM
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
MEDICAL
(M)
q
#+
Actemra IV
#+
Benlysta
#,+
Orencia IV
Simponi
#+
Aria
Levatol
Lopressor/HCTBR
BR
Sectral
BR
Tenormin
BR
Toprol XL
BR
Trandate
BR
Zebeta
+
Neulasta
+
Neumega
+
Neupogen
+
NPlate
+
Promacta
#+
#
Granix
#+
Botox
#+
Myobloc
#+
Xeomin
BR
BR
Norvasc
Nymalize
BR
Procardia/XL
BR
Sular
BR
Tiazac
BR
Verelan/PM
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
7
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Cancer Drugs
(oral drugs are
covered under the
chemotherapy
benefit and may be
subject to a
copayment that
differs from the
pharmacy benefit)
anastrozole*
bicalutamide*
cyclophosphamide*
etoposide
flutamide*
hydroxyurea*
leucovorin
mercaptopurine*
methotrexate*
tamoxifen*
tretinoin
Alkeran*
+
capecitabine
Ceenu*
Droxia
Emcyt
exemestane*
Fareston*
+
Gleevec
Hexalen
letrozole*
Leukeran*
Lomustine
Lysodren
Matulane
megestrol*
Mesnex
Nilandron*
Tabloid
+
temozolomide
tretinoin oral
Afinitor
BR
Arimidex*
BR
Aromasin*
+
Bosulif
Caprelsa
BR
Casodex*
#
Cometriq
+
Erivedge
BR
Femara*
+
Gilotrif
+
Hycamtin
BR
Hydrea
Iclusig
#
Imbruvica
+
Inlyta
#+
Jakafi
BR
Megace*
Megace ES*
+
Mekinist
Myleran
+
Nexavar
+
Pomalyst
Cardiac
Glycosides**
(heart)
CNS Stimulants
(ADHD)
digoxin
digoxin elixir
None
Lanoxin
Metadate ER 20mg*
Amphetamine
combination/XR*
clonidine ER*
dexmethylphenida
te*
Adderall/XR*
BR
Concerta*
Daytrana*
BR
Dexedrine*
BR
Focalin/XR*
Intuniv*
BR
Kapvay*
Liquadd*
BR
Metadate CD
dextroamphetam
ine*
methylphen/ER/CD
modafinil
Compounds
None
None
coverage for
compounded
medications is
subject to criteria
listed in the
Compounded
(extemporaneous)
Medications policy
#
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
+
BR
•
•
q
BR
Purinethol*
#
Purixan
Soltamox*
+
Sprycel
+
Stivarga
+
Sutent
+
Synribo
+
Sylatron
+
Tafinlar
+
Tarceva
+
Targretin
+
Tasigna
+ BR
Temodar
+
Torisel
#,+
Tykerb
+
Votrient
+
Xalkori
+BR
Xeloda
+
Zelboraf
#,+
Zolinza
#,+
Zydeliq
#,+
Zykadia
MEDICAL
(M)
+
Adcetris
#
Beleodaq
#
Clolar
#
Cyramza
Erwinaze
#+
Folotyn
#+
Fusilev
#
Gazyva
#+
Halaven
+
Ixempra
#+
Kadcyla
Kyprolis
Marqibo
#+
Perjeta
+
Temodar IV
+,#
Treanda
+
Yervoy
+
Zaltrap
Methylin
q
Nuvigil
q BR
Provigil
Quillivant XR
Ritalin/ LA/SR* BR
RitalinLA 10mg cp*
Strattera*
Vyvanse*
#
Xyrem
All compounds > $100 require
prior authorization
All compounds are tier 3
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
8
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Contraceptives
(Oral/Topical/
Other)
Altavera*
Alyacen*
Amethia/Lo*
Amethyst*
Apri*
Aranelle*
Aviane*
Azurette*
Balziva*
Briellyn*
Camila*
Camrese/Lo*
Caziant*
Cryselle*
Cyclafem
Dasetta*
Elinest*
Emoquette*
Enpresse*
Enskyce*
Errin*
Falmina*
Gianvi*
Gildess/Fe*
Heather*
Introvale*
Jencycla*
Jolessa*
Jolivette*
Junel/Fe*
Kariva*
Kelnor*
Kurvelo*
Larin Fe*
Leena*
Lessina*
Levonest*
levonorgestrel
Levora*
Loryna*
Low-Ogestrel*
Lutera*
Marlissa*
medroxyprogesterone/inj
Cough/Cold
Diabetic Agents:
Insulin**
Microgestin/Fe*
Mono-Linyah*
Mononessa*
My Way*
Myzilra*
Necon*
Next Choice/
One Step
Nora-Be*
norelgest-EE*
Nortrel*
Ocella*
Ogestrel*
Orsythia*
Philith*
Pirmella*
Portia*
Previfem*
Quasense*
Reclipsen*
Solia*
Sprintec*
Sronyx*
Syeda*
Tilia Fe*
Trinessa*
Tri-Legest Fe*
Tri-Linyah*
+
Tri-Lo Sprintec*
Tri-Previfem*
Tri-Sprintec*
Trivora*
Velivet*
Vestura*
Vyfemla*
Viorele*
Wera*
Wymzya Fe*
Xulane*
Zarah*
Zenchent/Fe*
Zeosa*
Zovia*
Various generics
None
All brands PA
Humalog/Mix
Humulin Mix
Humulin N/R
Subject to your medical
(NY) OR prescription drug
(VT) benefit. See your
plan materials for
applicable deductible,
coinsurance and/or
copayment.
#
Mirena
+
Skyla
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
MEDICAL
(M)
Alesse*
Beyaz*
BR
Brevicon*
BR
Cyclessa*
BR
Depo-Provera
Depo-SQ Provera
BR
Desogen*
Ella
BR
Estrostep FE*
BR
Femcon Fe*
Generess Fe*
Levlen*
Levlite*
BR
Loestrin/FE*
Lo Loestrin FE*
#
Lomedia 24 FE*
Lo Minastrin FE
BR
LoSeasonique*
BR
Micronor*
Minastrin 24 FE
BR
Mircette*
BR
Modicon*
Natazia*
+
Nexplanon
BR
Norinyl*
Nor-QD* BR
Nuvaring*
BR
Ortho Evra*
Ortho Novum*
Ortho Tri-Cyclen Lo*
Ortho Tri-Cyclen* BR
BR
Ortho-Cept*
BR
Ortho-Cyclen*
BR
Ovcon*
BR
Plan B OneStep
Quartette*
Safyral*
BR
Seasonique*
BR
Tri-Norinyl*
BR
Yasmin*
BR
Yaz*
All brands require PA
Apidra/Solostar
Levemir
Lantus/Solostar
Novolin Mix
Novolin N/R
Novolog/Mix
q
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
9
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs
The highest copay choice and includes all other
covered brand name drugs
Diabetic Agents:
Other**
acarbose
glimepiride
Glucagen
Glucagon
Invokana
Janumet/XR
Januvia
Jentadueto
pioglitazone
pioglitazonemetformin
pioglitazone/
glimepiride
repaglinide
Tradjenta
Victoza
Actoplus Met XR
BR
Actos
BR
Amaryl
NFNC
Avandamet
NFNC
Avandaryl
NFNC
Avandia
Bydureon
Byetta
#
Cycloset
BR
Diabeta
BR
Duetact
#
Farxiga
BR
Glucophage/XR
BR
Glucotrol XL
BR
Glucovance
Glumetza
Glyset
BR
Glynase
#
Invokamet
#
Jardiance
#
Kazano
Pancreaze
Pertyze
Ultresa
Viokace
Zenpep
Subject to your medical
(NY) OR prescription drug
(VT) benefit. See your
plan materials for
applicable deductible,
coinsurance and/or
copayment.
Diabetic Meters &
Strips
• Subject to your
medical (NY) OR
prescription drug (VT)
benefit. See your plan
materials for
applicable deductible,
coinsurance and/or
copayment.
• All test strips are
subject to quantity
limits
• Non-preferred test
strips require prior
authorization
Digestants/
Enzymes**
#
glipizide ER/metformin
glyburide
glyburide micro
glyburide/metformin
metformin/ER
nateglinide
tolazamide
tolbutamide
Preferred Meters:
Freestyle Freedom/Lite
Freestyle Insulinx
Freestyle Navigator
Freestyle Sidekick
One Touch Ultra Brand
Meters
One Touch Verio Brand
Meters
Preferred
Strips:
Freestyle
Freestyle
Insulinx
Freestyle Lite
Precision
One Touch
Ultra Test
Strips
One Touch
Verio Test
Strips
None
Creon
pancrelipase
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
MEDICAL
(M)
Kombiglyze XR#
#
Nesina
#
Onglyza
#
Oseni
BR
Prandin
PrandiMet
Proglycem
BR
Precose
NFNC
Riomet
BR
Starlix
Symlin
#
Tanzeum
Non-preferred test strips require prior
authorization
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
10
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Diuretics**
acetazolamide
amiloride/HCTZ
bumetanide
chlorothiazide
furosemide
hydrochlorothiazide
indapamide
methazolamide
methyclothiazide
metolazone
spironolactone/HCTZ
torsemide
triamterene/HCTZ
All products not listed in the MVP policy
require prior authorization
eplerenone
Aldactone
BR
Demadex
BR
Diamox caps
Diuril
BR
Dyazide
Dyrenium
Edecrin
All products
not listed in the
MVP policy
require prior
authorization
None
All products not listed in the MVP
policy require prior authorization
Enteral Therapy
BR
yohimbine
Fertility Agents
clomiphene
HCG
#+
leuprolide
+
Novarel
#+
Follistim AQ
Bravelle
#+
Cetrotide
#+
Ganirelix
#+
Gonal-F
# BR+
Lupron SQ
Gaucher’s
Disease
None
None
Zavesca
GI: Ulcer/
Heartburn
Agents**
cimetidine
famotidine
q
lansoprazole
nizatidine
Carafate susp
Aciphex
BR
Axid
BR
Carafate tab
q,#
Dexilant
#
+
omeprazole
q
pantoprazole
ranitidine
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
lanso/amox/clarit
q
Nexium
omeprazole/
q
sod bicarb
q
rabeprazole
sucralfate
BR
Inspra
BR
Lasix
BR
Maxzide
BR
Microzide
BR
Neptazane
Thalitone
BR
Zaroxolyn
q
Erectile
Dysfunction
All products not
listed in the
MVP policy
require prior
authorization
q
Caverject
q
Cialis
#
Cialis 2.5 mg
#
Cialis 5 mg
q
Edex
Levitra
q
Muse
q
Staxyn
q#
Stendra
q
Viagra
#+
#+
Lutrepulse
#+
Menopur
+
Ovidrel
+
Pregnyl
#+
Repronex
#
#+
Cerezyme
#+
Ceredase
#
Elelyso
#+
Vpriv
q,# BR
q#
First-Lansoprazole#
First-Omeprazole
#
Omeclamox
BR
Pepcid
Prevpac
MEDICAL
(M)
#
Prevacid Tabs
Prevacid Capq,#, BR
q,#, BR
Prilosec
q,#, BR
Protonix
Pylera
BR
Tagamet
BR
Zantac
#,q, BR
Zegerid
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
11
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
GI: Inflammatory
Bowel & Misc.
balsalazide*
metoclopramide*
misoprostol*
sulfasalazine/EN*
budesonide
cevimeline
cromolyn
Delzicol*
Kristalose
Lialda*
mesalamine
ursodiol*
Actigall*
Amitiza
Apriso*
Asacol HD*
BR
Azulfidine/EN*
Canasa*
Chenodal
#,+
Cimzia
BR
Colazal*
BR
Cortenema
Cortifoam
BR
Cytotec*
Dipentum*
BR
Entocort EC*
Gout**
allopurinol
probenecid/colchicine
None
None
Colcrys
#
Uloric
#,+
Genotropin
#,+
Humatrope
#,+
Increlex
#,+
Norditropin
Hormone
Replacement
Therapy**
estradiol
estradiol/norethindrone
estradiol patch
estropipate
Jinteli
medroxyprogesterone
Mimvey/Lo
norethindrone
progesterone cr/oral
Estring
Immunoglobulin
Therapy
Obtain through
specialty pharmacy
None
None
Growth Failure
Agents
#
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
Nutropin/AQ/
#,+
Nuspin
q
BR
q
BR
Activella
Alora
Angeliq
Cenestin
BR
Climara
Climara Pro
Combipatch
Crinone
Divigel
#
Duavee
Elestrin Gel
Endometrin
Enjuvia
BR
Estrace
Estrace Vaginal
Estrasorb
Estrogel
Evamist
FemHRT
#
Hizentra
BR
Evoxac
Fulyzaq
BR
Gastrocrom
Gattex
Giazo*
Linzess
Lotronex
Metozolv ODT*
Pentasa*
Proctofoam/HC
Relistor
BR
Rowasa*
Uceris
BR
Urso/Forte*
Visicol
BR
Zyloprim
MEDICAL
(M)
Entyvio
#
Krystexxa
#+
#,+
Omnitrope
#,+
Saizen
#,+
Serostim
#,+
Tev-Tropin
+
Zorbtive
Femring
Menest
Menostar
Minivelle
BR
Ogen
Osphena
Progesterone
supp
Prefest
Premarin
Premphase
Prempro
Prochieve
BR
Prometrium
BR
Provera
Vagifem
Vivelle-Dot
Makena
+
#
Carimune
#
Flebogamma
#
Gamastan
#
Gammagard
#
Gamunex/C
#
Iveegam
#
Octagam
#
Privigen
#
Vivaglobin
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
12
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Immunomodulators
Immunosuppresants**
None
None
azathioprine
Interferons/
Others for
Hepatitis
adefovir dipivoxil
+
lamivudine
#+
Moderiba
cyclosporine/
modified
Gengraf
Hecoria
mycophenolate
mycophenolic
acid
sirolimus
tacrolimus
entecavir
#,+
Pegasys
#,+
Ribasphere
#,+
ribavirin
Viread*
Thalomid
+
Revlimid
Astagraf XL
Azasan
BR
Cellcept
BR
Imuran
BR
Myfortic
Intranasal
Corticosteroids**
flunisolide
fluticasone
triamcinolone
Nasonex
Beconase AQ
#
Dymista
# BR
Flonase
#
Omnaris
Lipid/CholesterolLowering
Agents**
atorvastatin
cholestyramine
colestipol
fenofibrate
fenofibric acid
gemfibrozil
lovastatin
niacinpravastatin
Prevalite
simvastatin
Crestor
fluvastatin
niacin ER
Zetia
Advicor
Altocor
Altoprev
BR
Antara
BR
Colestid
Fenoglide
BR
Fibricor
#
Juxtapid
#+
Kynamro
BR
Lescol
Lescol XL
BR
Lipitor
Lipofen
Liptruzet
Livalo
BR
Lofibra
Migraine Agents
butalbit/apap/caff/cod
Migergot supp
q
naratriptan
q
zolmitriptan
dihydroergotamine
q
rizatriptan
q
sumatriptan
Alsuma
# q BR
Amerge
#,q
Axert
Cafergot
q
Cambia
BR
DHEA-45
Ergomar
BR
Esgic/Plus
BR
Fioricet
BR
Fiorinal
#,q
Frova
# q BR
Imitrex
#
+
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
MEDICAL
(M)
+
Neoral
Nulojix
BR
Prograf
BR
Rapamune
Sandimmune
+
Zortress
+ BR
Baraclude
#,+
Copegus
BR+
Epivir-HBV
BR+
Hepsera
#,+
Incivek
#,+
Infergen
+
Intron-A
#+
Moderiba
#
q BR
#,+
Olysio
#,+
Peg-Intron
#,+
Rebetol
#,+, BR
Ribatab
#+
Ribapak
#,+
Sovaldi
+
Tyzeka
#,+
Victrelis
Viread Powder*
#
Qnasl
# BR
Rhinocort AQ
#
Veramyst
#
Zetonna
BR
Lopid
# BR
Lovaza
Niacor
BR
Niaspan
BR
Pravachol
Pravigard PAC
Questran/LightBR
Simcor
BR
Tricor
Triglide
BR
TriLipix
#
Vascepa
Vytorin
Welchol
BR
Zocor
# q BR
Imitrex Inj
Imitrex
q # BR
Nasal
# q BR
Maxalt/MLT
q
Migranal
q#
Relpax
Sumavel
#,q
DosePro
#,q
Treximet
#,q, BR
Zomig/ZMT
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
13
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Miscellaneous
Agents (in
various classes)
deferoxamine
riluzole
sevelamer
tranexamic acid
triamcinolone dental
vitamin K inj
aminocaproic
acid
ammonium Cl
cabergoline
calcitriol
chromic Cl
+
Cystagon
desmopressin
doxercalciferol
q
Epipen
K-Phos/No 2
levocarnitine
manganese Cl
manganese sul
+
ocetreotide
paricalcitrol
phytonadione
pilocarpine tab
Stimate
Synarel
Acetic acid
Actimmune
#
Adagen
q#
Adrenaclick
aminocaproic 1gm
NFNC
Amino-Cerv
Aquoral
+
Alferon N
#+
Arcalyst
q#
Auvi-Q
Brisdelle
BR
Cafcit
Cancidas vial
#
Carbaglu
Cleocin Vag Supp
Cuprimine*
Cuvposa
BR
DDAVP
+
Desferal
Dificid
Eliphos
#+
Exjade
Ferriprox
#+
Firazyr
Formaldehyde NFNC
Fosrenol*
Gelclair
#
Gralise
#
Grastek
Gynazole-1
BR
Hectorol
Horizant
#+
Kalbitor
+
Korlym
#,+
Kuvan
#,+
Ampyra
#+
Aubagio
+ #
Betaseron
NFNC
Amrix
BR
Dantrium
BR
Fexmid
BR
Parafon Forte DSC
Lorzone
+
MS Agents
None
Muscle Relaxants
baclofen
carisoprodol/cmpd
chlorzoxazone
Narcotic
Antagonists/
Addiction
Treatments
Nitrates/Angina
Others** (heart)
#
+
methocarbamol
Avonex
+
Copaxone
,+
Tecfidera
carisoprodol
cmpd w cod
tizanidine
cyclobenzaprine
meprobamate
dantrolene
metaxalone
orphenadrine cmp
acamprosate
buprenorphine
buprenorphine/
naloxone
disulfiram
naltrexone
nitroglycerin spr
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin SL
nitroglycer patch
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
Nitrostat
q
NFNC
BR
#
Lupaneta Pack
BR
Lysteda
Methyton
#
Myalept
Mycamine vial
Nascobal
Nebupent
#
Northera
Nuedexta
#
Oralair
Phoslo BR
Phoslyra
Prepopik
#
Procysbi
#
Ragwitek
#+
Ravicti
NFNC
Renacidin
Renagel*
BR
Renvela*
#
Rezira
+
Samsca
+
Sandostatin
Savella
+
Sensipar
#
Signifor
Somatuline Depot+
+
Somavert
Suclear
Suprep
#
Velphoro
+
Xenazine
BR
Zemplar
#
Zontivity
#
Zutripro
#,+
Extavia
#,+
Gilenya
+#
Rebif
BR
Robaxin
BR
Skelaxin
BR
Soma
BR
Zanaflex
Antabuse
BR
Campral
BR
Revia
Suboxone Film
Zubsolv
Dilatrate-SR
BR
Imdur
BR
Isordil Titradose
Isordil 40mg
Minitran
Nitro-Dur
BR
Nitromist
Nitrolingual SprayBR
Ranexa
Transderm-Nitro
MEDICAL
(M)
#+
Aldurazyme
+
Aralast NP
#+
Berinert
#,+
Ceprotin
#,+
Cinryze
#+
Elaprase
+
Fabrazyme
Feraheme
+
Glassia
#
Injectafer
#
Kcentra
#+
Lumizyme
#+
Myozyme
#+
Naglazyme
Prolastin-C
Sandostatin
LAR
+
#,+
Soliris
+
Supprelin-LA
#
Sylvant
#
Vimizim
Vivitrol
Voraxaze
+
Xiaflex
Zemaira
Tysabri
#,+
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
14
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
NSAIDS** (pain &
inflammation,
arthritis)
diclofenac/misoprostol
etodolac/XL
flurbiprofen
ibuprofen
indomethacin
ketoprofen
meloxicam
nabumetone
naproxen
oxaprozin
piroxicam
salsalate
sulindac
tolmetin
fenoprofen
ketoprofen ER
ketorolac
meclofenamate
mefenamic
acid
Vimovo
Opthalmic: AntiInfective Agents
bac/neo/polym/HC
bacitracin
chloramphenicol
ciprofloxacin
erythromycin
gentamicin
levofloxacin
Ocudox
ofloxacin
polym/trimeth
sulfacetamide
tobramycin
trifluridine
Vigamox
Opthalmic:
Glaucoma
Agents**
apraclonidine
betaxolol
brimonidine
carbachol
carteolol
dorzolamide
latanoprost
levobunolol
metipranolol
pilocarpine
timolol/XE
timolol/
dorzolamide
Lumigan
Phospholine
Iodide
Opthalmic:
Steroids,
Antiinflammatory
& Misc. Agents
azelastine
bromfenac
cromolyn
dexamethasone
diclofenac
epinastine
fluorometholone
flurbiprofen
naphazoline
prednisolone
tobramycin/dexameth
Anaprox/DS
BR
Arthrotec
BR
Cataflam
Celebrex
BR
Daypro
Duexis
BR
Feldene
Indocin
BR
Mobic
Nalfon
AzaSite
Besivance
Bleph-10
Blephamide
BR
Ciloxan
Ciloxan oint
Iquix
Moxeza
Natacyn
Alphagan P.1%
Azopt
BR
Betagan
Betimol
Betoptic-S
Combigan
BR
Cosopt
Cosopt PF
BR
Iopidine
BR
Acular/LS
Acuvail
Alocril
Alomide
Alrex
Bepreve
Betadine
BR
Bromday
#,+
Cystaran
Durezol
BR
Elestat
Emadine
Flarex
BR
FML
FML Forte/SOP
Ilevro
Lastacaft
Lotemax
Actonel*
BR
Actonel 150mg*
Atelvia*
Binosto*
BR
Boniva Tabs*
BR
Evista*
+
Forteo
Osteoporosis/
Paget’s Agents
#
ketorolac
Patanol
calcitonin spray*
alendronate*
etidronate*
ibandronate*
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
Fortical*
risedronate 150mg
q
BR
MEDICAL
(M)
Naprelan
BR
Naprosyn
Pennsaid
BR
Ponstel
#
Sprix
Voltaren Gel
Voltaren XR
Zipsor
Zorvolex
BR
Ocuflox
BR
Polytrim
BR
Tobrex
Tobrex oint
BR
Viroptic
Zirgan
Zymaxid BR
Isopto Carpine BR
Istalol
Pilopine-HS
Simbrinza
BR
Timoptic/XE
Travatan Z
BR
Trusopt
BR
Xalatan
Zioptan
Maxidex
BR
Maxitrol
BR
Mydfrin
Nevanac
BR
Ocufen
BR
Omnipred
BR
Optivar
Pataday
BR
Pred Forte
Pred Mild
Pred-G
Prolensa
Restasis
+
Eylea
Jetrea
+
Lucentis
#+
Retisert
Tobradex Susp BR
Tobradex oint
Tobradex ST
Vexol
Zylet
BR
Fosamax*
Fosamax + D*
Miacalcin Nasal* BR
+
Xgeva
Boniva IV
+
Prolia
+
Reclast
zoledronic
+
acid
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
15
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Otic Preparations
(ear)
acetic acid/
hydrocortisone
antipyrine/benzo/glyceri
benzocaine
carbamide peroxide
apap/codeine
q
butorphanol
codeine
hydrocodone/apap
hydrocodone/ibuprofen
hydromorphone
levorphanol
meperidine
morphine IR/rectal
oxycodone/APAP
oxycodone/aspirin
q,st
oxycodone/ER
oxycodone/ibuprofen
pentazocine/naloxone
Roxicet tabs
tramadol
q
tramadol ER
Trezix
Vicodin/ES/HP
None
Cerumenex
Cetraxal
Ciprodex
Cipro HC
Coly-Mycin S
All brands
q,#
Abstral
q,# BR
Actiq
q,st, BR
Avinza
q,st
Butrans
Capital w codeine
Codeine sulf soln
q
Conzip
BR
Demerol
BR
Dilaudid
BR
Dolophine
q,st BR
Duragesic
q,st
Embeda
q,st
Exalgo
q,#
Fentora
BR
Fioricet /w cod
BR
Fiorinal/w cod
Ibudone 5/200
q,st
Kadian
#
Lazanda
BR
Lortab
Magnacet
q,st BR
MS Contin
BR
Norco
Nucynta
Pain Relievers
(narcotic)
Pain Relievers:
Miscellaneous**
Parkinson’s
Agents
Potassium
Supplements**
Prostate Cancer
#
ciprofloxacin
fluocinolone
neo/polym/HC
ofloxacin
fentanyl
q,st
patch
q,#
fentanyl oral
methadone
morphine ERq,st
morphine 24HRq,st
oxymorphone/ER
choline mag trisalicylat
diflunisal
salsalate
amantadine*
benztropine*
bromocriptine*
carbidopa*
carbidopa/levodopa/ER*
entacapone*
selegiline*
trihexyphenidyl*
Various generics
None
None
Lupron Depot
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
carbidopa/
levodopa/
entacapone*
pramipexole*
ropinirole/XL*
None
q
+
All brands
Dolgic Plus
Dologesic
#
Apokyn
Azilect*
BR
Comtan*
BR
Eldepryl*
BR
Lodosyn*
BR
Mirapex*
Mirapex ER*
Neupro*
All brands
Kaochlor-Eff
K-Tab
#+
Xtandi
#,+
Zytiga
MEDICAL
(M)
Cortisporin-TC
Cresylate
BR
Dermotic
Trioxin
q
Nucynta ER
q,#
Onsolis
BR
Opana
q,st
Opana ER
Oxecta
q,st
Oxycontin
BR
Percocet
BR
Percodan
Primlev
Reprexain
RMS Supp
Roxanol
BR
Roxicodone
Roxicet soln
Rybix
#
Subsys
Synalgos-DC
BR
Tylenol w cod
Tramadol 150
BR
Ultracet
q BR
Ultram/ER
BR
Vicoprofen
#
Xartemis XR
#
Zohydro ER
Zolvit
Zydone
Frenadol
BR
Parcopa*
BR
Parlodel*
BR
Requip/XL*
BR
Sinemet/CR*
BR
Stalevo*
Tasmar*
Zelapar*
+
Eligard
+
Firmagon
#+
Jevtana
#
Provenge
+
Trelstar
+
Vantas
Viadur
#
Xofigo
+
Zoladex
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
16
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Respiratory: Beta
Agonists (Oral,
Inhaled)
albuterol
isoetharine
isoproterenol
ipratropium/albuterol
metaproterenol
terbutaline*
levalbuterol
Foradil*
ProAir HFA
Spiriva*
Ventolin HFA
Respiratory:
Inhaled
Corticosteroids**
None
Respiratory:
Leukotriene
Modifiers**
Respiratory:
Miscellaneous
montelukast
zafirlukast
Asmanex
budesonide
Dulera
Qvar
Symbicort
None
Accuneb
Alupent
#
Anoro Ellipta
Arcapta
Brovana*
BR
Duoneb
Perforomist
#
Advair/HFA
#
Aerospan
#
Alvesco
Breo Ellipta
RSV
Sedative/
Hypnotics (sleep
aids)
None
chloral hydrate
q
estazolam
q
flurazepam
hydroxyzine
q
temazepam
Smoking
Cessation Agents
Thyroid**
bupropion SR
Topical
Antifungals
econazole
ketoconazole
nystatin
#
aminophylline*
ipratropium soln*
theophylline*
#
Veletri
q
triazolam
q
zaleplon
q
zolpidem/CR
q
levothyroxine
Levoxyl
liothyronine
methimazole
None
q,st
Rozerem
None
q,st BR
Ambien/CR
Butisol
q
Doral
q,st
Edluar
q BR
Halcion
#
Hetlios
q
Nictrol
q BR
Zyban
Armour ThyroidNFNC
BR
Cytomel
Nature-Throid
Synthroid
BR
Tapazole
#
Ecoza
Ertaczo
Exelderm
BR
Extina
BR
Loprox
BR
Lotrisone
Naftin
None
ciclopirox olam
#
ciclopirox soln
q
#,+
Adcirca
#,+
Adempas
#
Cayston
Daliresp*
#+
Flolan
#,+
Kalydeco
#,+
Letairis
Lufyllin*
#+
Orenitram XR
q
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
BR
Accolate
BR
Singulair
Atrovent HFA*
Combivent*
cromolyn*
Elixophyllin*
#+
epoprostenol
#+
sildenafil
tobramycin
#,+
inh
Chantix
NP Thyroid
propylthiouracil
Unithroid
BR
MEDICAL
(M)
Proventil/HFA
Serevent*
Tudorza
BR
Vospire ER*
BR
Xopenex Neb
Xopenex HFA
#
Flovent/HFA
Pulmicort Neb BR
Pulmicort Inher
Xolair
#,+
Zyflo CR
#,+
Opsumit
#,+
Pulmozyme
#,+ BR
Revatio
Theo-24*
Theo-Dur*
#,+ BR
TOBI
#,+
Tracleer
#,+
Tyvaso
#,+
Ventavis
#+
Remodulin
#,+
Revatio Inj
+
Veletri
Synagis
#,+
q,st
Intermezzo
q,st
Lunesta
q BR
Restoril
#
Silenor
q,st BR
Sonata
q,st
Zolpimist
Thyrolar
Tirosint
Westhroid
WP Thyroid
#
Luzu
BR
Nizoral
Oxistat
# BR
Penlac
Vusion
Xolegel
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
17
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Topical AntiInfectives
erythromycin
gentamicin
mupirocin
None
Topical/Oral/
Injectable
Antipsoriatic &
Antiseborrheic
anthralin
selenium sulfide
Topical
Miscellaneous
aluminum chloride soln
lidocaine
Prudoxin
acitretin
calcipotriene
calcipotriene/
betamethasone
calcitrene
#,+
Enbrel
diclofenac gel
imiquimod
lidocaine patch
urea/lactic ac/
salicylic
urea/lactic ac/
zn undecylenat
urea/hyaluronic
acid
Alcortin A
Altabax
Bactroban Nasal
Centany
Cortisporin oint/cr
Capitrol
BR
Dovonex
Dritho-Scalp
EpiFoam
Exsel
Topical
Scabicides/
Pediculicides
permethrin
spinosad
lindane
malathion
Topical Steroids
1
Low Potency
2
Medium Potency
3
High Potency
4
Very High
Potency
alclometasone
betamethasone
2,4
dip/aug
betamethasone
3,4
valerate
4
clobetasol
4
Cormax
1,2
fluocinolone
3
fluocinonide
#
1
2
3
fluticasone
hydrocortisone1
hydrocortisone
2
butyrate
hydrocortisone
2
valerate
2
mometasone
2
prednicarbate
triamcinolone2,3
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
amcinonide
1
desonide
desoximetasone2,3
3,4
diflorasone
fluocinolone oil
4
halobetasol
BR
Aldara
Carac
Condylox gel
BR
Condylox soln
BR
Drysol
BR
Efudex
Elidel
NFNC
EpiCeram
NFNC
Flector
Iodosorb
Kerafoam
BR
Lidoderm
Mirvaso
Noritate
Picato
Podocon-25
#
Prothelial
Eurax
BR
Natroba
BR
Ovide
3
Alphatrex
1
Capex Shampoo
4 BR
Clobex
4
Clobex Spray
2
Cloderm
2
Cordran/SP
2 BR
Cutivate
2
Cutivate Lotion
Derma-Smoothe/FSBR
2 BR
Dermatop
1
Desonate
1 BR
Desowen
3,4 BR
Diprolene/AF
2 BR
Elocon
3
Halog
MEDICAL
(M)
Klaron
PhisoHex
#,+
Remicade
BR
Soriatane
Sorilux
BR
Taclonex
BR
Vectical
#,+
Stelara
Protopic
Rectiv
NFNC
Regranex
NFNC
Santyl
BR
Solaraze
Sulfamylon
Umecta/PD
#
Valchlor
Veregen
Xerac AC
Xerese
Zonalon
Zyclara
Sklice
Ulesfia
Kenalog Spray
BR
Locoid
Locoid Lotion
2 BR
Luxiq
4 BR
Olux/E
2
Pandel
4 BR
Temovate
1
Texacort
BR
Topicort
4 BR
Ultravate
Ultravate-X
3
Vanos
1
Verdeso
2 BR
Westcort
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
18
DRUG
CATEGORY
TIER 1
TIER 2
TIER 3
The lowest copay choice and usually includes generic
drugs.
The mid-range
copay choice and
includes covered
brand name drugs
because of their
overall value. Also
includes high cost
generic drugs.
The highest copay choice and includes all other
covered brand name drugs
Topical/Oral
Acne Products
clindamycin
clindamycin/benzoyl
peroxide
erythromycin
metronidazole
Sotret
sulfacetamide
tretinoin
adapalene
Amnesteem
Claravis
Myorisan
Nuox
Panretin
sulfaceta/urea/
sulfur
tretinoin micro
Absorica
Acanya
Aczone
Akne-Mycin
Atralin
Avar/E/LS
NFNC
Avita
Azelex
Bensal HP
Benzaclin
Benzamycinpak
Clarifoam EF
BR
Cleocin-T
Clindagel
BR
Differin
Differin Lotion
BR
Duac
Epiduo
BR
Evoclin
Fabior
Finacea
BR
Klaron
Lavoclen
BR
Metrocream
BR
Metrogel
BR
Metrolotion
BR
Ovace
Ovace Plus
Pacnex HP/ LP/MX
Panretin
BR
Retin-A
BR
Retin-A Micro
Tazorac
Tretin-X
BR
Vanoxide HC
Veltin
Ziana
Urinary Tract
Agents
methenamine
nitrofurantoin
trimethoprim
potassium
citrate ER
Macrodantin 25mg
Weight
Management
Agents
benzphetamine
diethylpropion
phendimetrazine
phentermine
None
Elmiron
BR
Furadantin
BR
Hiprex
BR
Macrobid
BR
Macrodantin
# BR
Adipex-P
#
Belviq
# BR
Bontril-DPM
# BR
Didrex
#
Qsymia
MEDICAL
(M)
#
Monurol
Primsol
Prosed-DS
Urocit-K
#
Regimex
#
Suprenza
#
Xenical
2015010v1
#
Requires prior authorization
*Drug is available through Mail Order if your benefit allows
**All drugs in the category are available through MailOrder
M
Does not require prescription coverage but
may be subject to prior authorization or step therapy as
indicated
q
Subject to quantity limits
Step therapy edits apply (must have failed on a specific drug per policy)
st
+
BR
Obtain through CVS Caremark Specialty Pharmacy
Brand drug that has an FDA approved generic equivalent
-Non formulary, not covered-Must be approved by MVP
NFNC
19