2017 List of Covered - UnitedHealthcare Community Plan [PDF]

2017 List of Covered

DRUGS (Formulary)

UnitedHealthcare Connected® (Medicare-Medicaid Plan)

Toll-Free 1-800-256-6533, TTY 7-1-1 8 a.m. - 8 p.m. local time, Monday - Friday

www.UHCCommunityPlan.com www.myuhc.com/CommunityPlan

Formulary ID Number 00017014, Version 19 H7833_160622_115654_J Approved

Last updated November 1, 2017

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UnitedHealthcare Connected® (Medicare-Medicaid Plan)

2017 List of Covered Drugs (Formulary) This is a list of drugs that members can get in UnitedHealthcare Connected. UnitedHealthcare Connected® (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copays may change on January 1 of each year. You can always check UnitedHealthcare Connected’s up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com. Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. You can get this information for free in other languages. Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al 1-800-256-6533, TTY 7-1-1, de lunes a viernes, de 8 a.m. a 8 p.m., hora local. La llamada es gratuita. You can get this information for free in other formats, such as large print, braille, or audio. Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future.

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

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Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

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What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the List of Covered Drugs that starts on page 9 are the drugs covered by UnitedHealthcare Connected. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.” ® UnitedHealthcare Connected will cover all medically necessary drugs on the Drug List if: · Your doctor or other prescriber says you need them to get better or stay healthy, and · You fill the prescription at a UnitedHealthcare Connected network pharmacy. ® UnitedHealthcare Connected may have additional steps to access certain drugs (see question #5 below). .

You can also see an up-to-date list of drugs that we cover on our website at www.UHCCommunityPlan.com or call Member Services at 1-800-256-6533, TTY 7-1-1.

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Does the Drug List ever change? Yes. UnitedHealthcare Connected may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: · A cheaper drug comes along that works as well as a drug on the Drug List now, or · We learn that a drug is not safe. We may also change our rules about drugs. For example, we could: · Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected before you can get a drug.) · Add or change the amount of a drug you can get (called “quantity limits”). · Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see pages 4, 5 and 9.)

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

4 4 We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. ® You can always check UnitedHealthcare Connected’s up-to-date Drug List online at www.UHCCommunityPlan.com. You can also call Member Services to check the current Drug List at 1-800-256-6533, TTY 7-1-1.

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What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a Medicare Part D drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will get a letter letting you know about the change. Contact your doctor or other prescriber to make sure this cheaper drug will work for you.

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What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options.

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Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: · Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. If you don’t get approval, UnitedHealthcare Connected may not cover the drug. · Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a drug you can get. · Step therapy: Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

5 5 You can find out if your drug has any additional requirements or limits by looking in the tables on pages 10 - 125. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions. ® If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question 11 for more information about exceptions.

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How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The "List of Covered Drugs" on pages 10 - 125 has a column labeled “Necessary actions, restrictions, or limits on use.”

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What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.

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How can you find a drug on the Drug List? There are two ways to find a drug: · You can search alphabetically (if you know how to spell the drug), or · You can search by medical condition.

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

6 6 To search alphabetically, go to the Alphabetical Listing section. You can find it after the “List of Covered Drugs” section. Find the name of your drug. The page number where you can find the drug will be next to it. To search by medical condition, find the section labeled “List of drugs by medical condition” on pages 10 - 125. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

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What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services at 1-800-256-6533, TTY 7-1-1 and ask about it. If you learn that UnitedHealthcare Connected will not cover the drug, you can do one of these things: · Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or · You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

10 What if you are a new UnitedHealthcare Connected member and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected. The temporary supply will be for up to a 30-day supply. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: · You are taking a drug that is not on our Drug List, or · Health plan rules do not let you get the amount ordered by your prescriber, or · The drug requires prior approval by UnitedHealthcare Connected, or · You are taking a drug that is part of a step therapy restriction.

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

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7 If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 and may be up to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that’s not on the drug list, or if it’s difficult for you to get your drugs, you are required to use your plan’s exception process. You may ask for a one-time emergency supply of up to 30 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception.

11 Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. · For example, UnitedHealthcare Connected may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. · Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

12 How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

13 How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception.

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

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14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Connected covers both brand name drugs and generic drugs.

15 What are OTC drugs? OTC stands for “over-the-counter.” UnitedHealthcare Connected covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are covered.

16 Does UnitedHealthcare Connected cover OTC non-drug products? UnitedHealthcare Connected covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected Drug List to see what OTC non-drug products are covered.

17 What is your copay? You can read the UnitedHealthcare Connected Drug List to learn about the copay for each drug. UnitedHealthcare Connected members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. · Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.20 to $3.30, depending on your income. · Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.70 to $8.25, depending on your income. · Tier 3 drugs have a $0 copay. They are OTCs/Non-Part D drugs.

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit www.UHCCommunityPlan.com.

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List of Covered Drugs The List of Covered Drugs that begins on the next page gives you information about the drugs covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the Index that begins on page 126. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Connected has any rules for covering your drug.

Utilization Management Restrictions PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. If you don’t get approval, UnitedHealthcare Connected may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Connected limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. LA - Limited Access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

F 1 or Track Refered Purpose 10

10 MED – Morphine Equivalent Dose Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is calculated based on the number of opioid drugs prescribed for you over a period of time. This cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for those individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. For Track Refered Purpose

Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-800-256-6533, TTY 7-1-1. You can also read the Member Handbook to learn how to appeal a decision.

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Analgesics Analgesics acephen (suppository)* acetaminophen (tablet)* butalbital/acetaminophen (50mg-325mg tablet) butalbital/acetaminophen/caffeine (50mg-325mg-40mg capsule, 50mg-325mg-40mg tablet) butalbital/aspirin/caffeine (capsule) childrens mapap rapid tabs (tablet dispersible)* ed-apap (liquid)* gnp arthritis pain relief (tablet extended-release)* Acephen

Acetaminophen

Butalbital/Acetaminophen

$0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1)

QL QL QL

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL

Butalbital/Acetaminophen/Caffeine

Butalbital/Aspirin/Caffeine

Childrens Mapap Rapid Tabs

ED-APAP

GNP Arthritis Pain Relief

QL QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

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Name of Drug

junior mapap (tablet dispersible)* mapap (160mg/5ml liquid, 325mg tablet, 500mg tablet, 500mg capsule, 80mg tablet chewable)* mapap acetaminophen extra strength (liquid)* mapap arthritis pain (tablet extended-release)* mapap childrens (160mg/5ml suspension)* mapap childrens (80mg tablet dispersible)* pain & fever (tablet)* pain & fever childrens (160mg/5ml oral solution, 160mg/5ml suspension, 80mg tablet chewable)* pain & fever extra strength (tablet)* qc arthritis pain relief (tablet extended-release)* q-pap (160mg/5ml liquid, 325mg tablet)* q-pap childrens (suspension)* q-pap extra strength (tablet)* q-pap infants (oral solution)* tencon (tablet) zebutal (capsule) Junior Mapap

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3)

Mapap

Mapap Acetaminophen Extra Strength

Mapap Arthritis Pain

Mapap Childrens

Mapap Childrens

Pain & Fever

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL QL QL QL

$0 (Tier 3) $0 (Tier 3)

QL QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL QL QL PA, QL

QL

Pain & Fever Childrens

Pain & Fever Extra Strength

QC Arthritis Pain Relief

Q-PAP

Q-PAP Childrens

Q-PAP Extra Strength

Q-PAP Infants

Tencon

Zebutal

Nonsteroidal Anti-inflammatory Drugs all day pain relief (otc only) (tablet)* all day relief (otc only) (tablet)* aspirin (325mg tablet, 325mg tablet delayed-release, 81mg tablet delayed-release, 81mg tablet chewable)* aspirin ec (tablet delayed-release)* aspirin ec low dose (tablet delayed-release)* aspirin low dose (tablet chewable)* aspir-low (tablet delayed-release)* childrens aspirin (tablet chewable)* childrens ibuprofen (otc only) (suspension)* childs ibuprofen (otc only) (suspension)* congestion relief (tablet)* diclofenac potassium (tablet immediate-release) diclofenac sodium (1% gel) diclofenac sodium dr (tablet delayed-release) diclofenac sodium er (tablet extended-release 24 hour) diflunisal (tablet) All Day Pain Relief

All Day Relief

Aspirin

Aspirin EC

Aspirin EC Low Dose

Aspirin Low Dose

Aspir-Low

Childrens Aspirin

Childrens Ibuprofen

Childs Ibuprofen

Congestion Relief

Diclofenac Potassium

Diclofenac Sodium

Diclofenac Sodium DR

Diclofenac Sodium ER

Diflunisal

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA

F 3 or Track Refered Purpose 12

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Name of Drug

effervescent pain relief (tablet effervescent)* enteric coated aspirin (tablet delayed-release)* etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediaterelease) Effervescent Pain Relief

Enteric Coated Aspirin

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL

Etodolac

FLECTOR (PATCH) Flector

flurbiprofen (tablet) gnp ibuprofen (otc only) (tablet)* gnp ibuprofen junior strength (otc only) (tablet chewable)* ibu-200 (tablet)* ibu-drops (suspension)* ibu-drops infants (suspension)* ibuprofen (otc only) (100mg/5ml suspension, 200mg capsule, 200mg tablet)* ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) ibuprofen childrens (otc only) (suspension)* ibuprofen junior strength (otc only) (tablet chewable)* infants ibuprofen (otc only) (suspension)* ketoprofen (capsule immediate-release) ketorolac tromethamine (15mg/ml injection, 30mg/ml injection, 60mg/2ml injection) meloxicam (tablet) migraine formula (tablet)* naproxen (rx only) (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediaterelease, 500mg tablet immediate-release) naproxen dr (rx only) (tablet delayed-release) (generic ec-naprosyn) qc naproxen sodium (otc only) (tablet)* Flurbiprofen

GNP Ibuprofen

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3)

PA, QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL QL

$0 (Tier 3)

QL

QL

GNP Ibuprofen Junior Strength

Ibu-200

Ibu-Drops

Ibu-Drops Infants

Ibuprofen

Ibuprofen

Ibuprofen Childrens

Ibuprofen Junior Strength

Infants Ibuprofen

Ketoprofen

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1)

QL QL QL

Ketorolac Tromethamine

Meloxicam

Migraine Formula

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3)

Naproxen

$1.20-$3.30 (Tier 1)

Naproxen DR

QC Naproxen Sodium

$1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

F 4 or Track Refered Purpose 13

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Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

$3.70-$8.25 (Tier 2)

QL, MED

levorphanol tartrate (tablet) methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution)

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

METHADONE HCL (10MG/ML INJECTION)

$3.70-$8.25 (Tier 2)

morphine sulfate er (100mg tablet extended-release, 15mg tablet extended-release, 200mg tablet extended-release, 30mg tablet extended-release, 60mg tablet extended-release) (generic ms contin)

$1.20-$3.30 (Tier 1)

QL, MED

NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR)

$3.70-$8.25 (Tier 2)

QL, MED

tramadol hcl er (100mg tablet extended-release 24 hour, 200mg tablet extended-release 24 hour, 300mg tablet extended-release 24 hour)

$1.20-$3.30 (Tier 1)

QL, MED

$3.70-$8.25 (Tier 2)

PA, QL

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

sm ibuprofen (otc only) (tablet)* sulindac (tablet) SM Ibuprofen

Sulindac

Opioid Analgesics, Long-acting EMBEDA (CAPSULE EXTENDED-RELEASE) Embeda

fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch 72 hour, 75mcg/hr patch 72 hour) hydromorphone hcl er (12mg tablet extended-release 24 hour abuse-deterrent, 16mg tablet extendedrelease 24 hour abuse-deterrent, 8mg tablet extended-release 24 hour abuse-deterrent) Fentanyl

Hydromorphone HCl ER

HYDROMORPHONE HCL ER (32MG TABLET EXTENDEDRELEASE 24 HOUR ABUSE-DETERRENT) Hydromorphone HCl ER

Levorphanol Tartrate

Methadone HCl

Methadone HCl

Morphine Sulfate ER

Nucynta ER

Tramadol HCl ER

Opioid Analgesics, Short-acting ABSTRAL (TABLET SUBLINGUAL) Abstral

acetaminophen/codeine (120mg-12mg/5ml oral solution, 300mg-15mg tablet, 300mg-30mg tablet, 300mg-60mg tablet) butorphanol tartrate (10mg/ml nasal solution) butorphanol tartrate (1mg/ml injection, 2mg/ml injection) codeine sulfate (tablet) Acetaminophen/Codeine

Butorphanol Tartrate

Butorphanol Tartrate

Codeine Sulfate

DURAMORPH (INJECTION) Duramorph

endocet (tablet) fentanyl citrate oral transmucosal (lollipop) Endocet

Fentanyl Citrate Oral Transmucosal

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL, MED QL, MED PA, QL

F 5 or Track Refered Purpose 14

14

Name of Drug

hydrocodone bitartrate/acetaminophen (7.5mg-325mg/15ml oral solution) hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) hydrocodone/ibuprofen (7.5mg-200mg tablet) hydromorphone hcl (10mg/ml injection, 50mg/5ml injection) hydromorphone hcl (1mg/ml liquid, 2mg tablet immediate-release, 4mg tablet immediate-release, 8mg tablet immediate-release)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Hydrocodone Bitartrate/Acetaminophen

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

Hydrocodone/Acetaminophen

Hydrocodone/Ibuprofen

Hydromorphone HCl

$1.20-$3.30 (Tier 1)

Hydromorphone HCl

HYDROMORPHONE HCL (2MG/ML INJECTION) Hydromorphone HCl

lorcet (tablet) lorcet hd (tablet) lorcet plus (tablet) morphine sulfate (100mg/5ml oral solution, 10mg/ 5ml oral solution, 20mg/5ml oral solution) morphine sulfate (10mg/ml injection, 4mg/ml injection, 8mg/ml injection) Lorcet

Lorcet HD

Lorcet Plus

$1.20-$3.30 (Tier 1)

QL, MED

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL, MED QL, MED QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

Morphine Sulfate

Morphine Sulfate

MORPHINE SULFATE (15MG TABLET IMMEDIATERELEASE, 30MG TABLET IMMEDIATE-RELEASE) MORPHINE SULFATE (2MG/ML INJECTION)

$1.20-$3.30 (Tier 1)

Morphine Sulfate

Morphine Sulfate

nalbuphine hcl (injection) oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediate-release, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) oxycodone/aspirin (tablet) Nalbuphine HCl

$3.70-$8.25 (Tier 2)

QL, MED

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Oxycodone HCl

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

$1.20-$3.30 (Tier 1)

QL, MED

Oxycodone/Acetaminophen

Oxycodone/Aspirin

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

F 6 or Track Refered Purpose 15

15

Name of Drug

oxycodone/ibuprofen (tablet) tramadol hcl (tablet immediate-release) tramadol hcl/acetaminophen (tablet) trezix (capsule) Oxycodone/Ibuprofen

Tramadol HCl

Tramadol HCl/Acetaminophen

Trezix

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL, MED QL, MED QL, MED QL, MED

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA, QL

$1.20-$3.30 (Tier 1)

B/D, PA

Anesthetics Local Anesthetics lidocaine (rx only) (5% ointment) lidocaine (rx only) (5% patch) lidocaine hcl (0.5% injection, 1% injection, 2% injection) lidocaine hcl (4% external solution) lidocaine hcl jelly (rx only) (gel) lidocaine viscous (solution) lidocaine/prilocaine (cream) sore throat & cough lozenges* Lidocaine

Lidocaine

Lidocaine HCl

Lidocaine HCl

Lidocaine HCl Jelly

Lidocaine Viscous

Lidocaine/Prilocaine

Sore Throat & Cough Lozenges

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3)

Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr (tablet delayed-release) disulfiram (tablet) naltrexone hcl (tablet) Acamprosate Calcium DR

Disulfiram

Naltrexone HCl

VIVITROL (INJECTION) Vivitrol

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Opioid Dependence Treatments buprenorphine hcl (0.3mg/ml injection) buprenorphine hcl (2mg tablet sublingual, 8mg tablet sublingual) buprenorphine hcl/naloxone hcl (tablet sublingual) naloxone hcl (injection) Buprenorphine HCl

$1.20-$3.30 (Tier 1)

Buprenorphine HCl

Buprenorphine HCl/Naloxone HCl

Naloxone HCl

NARCAN (LIQUID) Narcan

SUBOXONE (FILM) Suboxone

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

Smoking Cessation Agents bupropion hcl sr (150mg tablet extended-release 12 hour) Bupropion HCl SR

CHANTIX (TABLET) Chantix

CHANTIX CONTINUING MONTH PAK (TABLET) Chantix Continuing Month Pak

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

F 7 or Track Refered Purpose 16

16

Name of Drug

CHANTIX STARTING MONTH PAK (TABLET) Chantix Starting Month Pak

nicoderm cq (patch 24 hour)* nicorelief (gum)* nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* nicorette mini (lozenge)* nicorette starter kit (gum)* nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* nicotine transdermal system (14mg/24hr patch 24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24 hour)* nicotine transdermal system (kit)* NicoDerm CQ

NICOrelief

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3)

QL QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3)

QL QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

Nicorette

Nicorette Mini

Nicorette Starter Kit

Nicotine Polacrilex

Nicotine Transdermal System

Nicotine Transdermal System

NICOTROL INHALER Nicotrol Inhaler

$0 (Tier 3) $3.70-$8.25 (Tier 2)

Antibacterials Aminoglycosides amikacin sulfate (injection) Amikacin Sulfate

BETHKIS (NEBULIZED SOLUTION) Bethkis

gentak (ophthalmic ointment) gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% ophthalmic solution, 10mg/ml injection, 40mg/ml injection) gentamicin sulfate/0.9% sodium chloride (injection) isotonic gentamicin (injection) neomycin sulfate (tablet) paromomycin sulfate (capsule) streptomycin sulfate (injection) Gentak

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

B/D, PA, QL

Gentamicin Sulfate

Gentamicin Sulfate/0.9% Sodium Chloride

Isotonic Gentamicin

Neomycin Sulfate

Paromomycin Sulfate

Streptomycin Sulfate

TOBI PODHALER (CAPSULE) TOBI Podhaler

TOBRADEX (OPHTHALMIC OINTMENT) Tobradex

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

F 8 or Track Refered Purpose 17

17

Name of Drug

What the drug will cost you (tier level)

tobramycin (nebulized solution) tobramycin sulfate (0.3% ophthalmic solution, 10mg/ ml injection, 80mg/2ml injection)

$1.20-$3.30 (Tier 1)

TOBREX (0.3% OPHTHALMIC OINTMENT)

$3.70-$8.25 (Tier 2)

Tobramycin

Necessary actions, restrictions, or limits on use B/D, PA, QL

Tobramycin Sulfate

Tobrex

$1.20-$3.30 (Tier 1)

Antibacterials, Other baciim (injection) bacitracin (otc only) (500unit/gm topical ointment)* bacitracin (rx only) (50000unit injection, 500unit/gm ophthalmic ointment) bacitracin zinc (otc only) (ointment)* bacitracin/neomycin/polymyxin (otc only) (ointment)* BACiiM

Bacitracin

$1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

Bacitracin

Bacitracin Zinc

Bacitracin/Neomycin/Polymyxin

BACTROBAN NASAL (OINTMENT) Bactroban Nasal

chloramphenicol sodium succinate (injection) clindamycin hcl (capsule immediate-release) clindamycin palmitate hcl (oral solution) clindamycin phosphate (2% cream, 300mg/2ml injection, 600mg/4ml injection, 900mg/6ml injection) clindamycin phosphate in d5w (injection) colistimethate sodium (injection) Chloramphenicol Sodium Succinate

Clindamycin HCl

Clindamycin Palmitate HCl

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL PA

Clindamycin Phosphate

Clindamycin Phosphate in D5W

Colistimethate Sodium

CUBICIN (INJECTION) Cubicin

DALVANCE (INJECTION) Dalvance

daptomycin (injection) lincomycin hcl (injection) linezolid (100mg/5ml suspension, 600mg/300ml injection) linezolid (600mg tablet) methenamine hippurate (tablet) metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75% lotion, 250mg tablet immediate-release, 500mg tablet immediate-release) metronidazole in nacl 0.79% (injection) metronidazole vaginal (gel) mupirocin (2% ointment) neomycin/polymyxin b sulfates (irrigation solution) nitrofurantoin (suspension) nitrofurantoin macrocrystals (100mg capsule, 50mg capsule) (generic macrodantin) Daptomycin

Lincomycin HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA

Linezolid

Linezolid

Methenamine Hippurate

$1.20-$3.30 (Tier 1)

PA

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA, QL

Metronidazole

Metronidazole in NaCl 0.79%

Metronidazole Vaginal

Mupirocin

Neomycin/Polymyxin B Sulfates

Nitrofurantoin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Nitrofurantoin Macrocrystals

$1.20-$3.30 (Tier 1)

F 9 or Track Refered Purpose 18

18

Name of Drug

nitrofurantoin monohydrate (100mg capsule) (generic macrobid) polymyxin b sulfate (injection) povidone-iodine (10% external solution, 10% ointment)*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Nitrofurantoin Monohydrate

Polymyxin B Sulfate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Povidone-Iodine

PRIMSOL (ORAL SOLUTION) Primsol

SYNERCID (INJECTION) Synercid

TIGECYCLINE (INJECTION) Tigecycline

tinidazole (tablet) trimethoprim (tablet) triple antibiotic (ointment)* triple antibiotic plus (ointment)* Tinidazole

Trimethoprim

Triple Antibiotic

Triple Antibiotic Plus

TYGACIL (INJECTION) Tygacil

vancomycin hcl (1000mg injection, 10gm injection, 500mg injection, 125mg capsule, 250mg capsule)

$0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2)

QL QL

Vancomycin HCl

VANDAZOLE (GEL) Vandazole

XIFAXAN (TABLET) Xifaxan

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA

Beta-lactam, Cephalosporins cefaclor (250mg capsule immediate-release, 500mg capsule immediate-release) cefadroxil (250mg/5ml suspension, 500mg/5ml suspension, 500mg capsule) cefazolin sodium (1gm injection, 10gm injection, 500mg injection) cefdinir (125mg/5ml suspension, 250mg/5ml suspension, 300mg capsule) cefepime (injection) cefixime (suspension) cefotaxime sodium (injection) cefotetan (injection) Cefaclor

$1.20-$3.30 (Tier 1)

Cefadroxil

$1.20-$3.30 (Tier 1)

Cefazolin Sodium

$1.20-$3.30 (Tier 1)

Cefdinir

Cefepime

Cefixime

Cefotaxime Sodium

Cefotetan

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 10 19 Track Refered Purpose

19

Name of Drug

cefoxitin sodium (10gm injection, 1gm injection, 2gm injection) cefpodoxime proxetil (100mg tablet, 200mg tablet, 100mg/5ml suspension, 50mg/5ml suspension) cefprozil (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) ceftazidime (injection) ceftriaxone sodium (10gm injection, 1gm injection, 2gm injection, 250mg injection, 500mg injection) cefuroxime axetil (tablet) cefuroxime sodium (injection) cephalexin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule, 750mg capsule) suprax (100mg tablet chewable, 200mg tablet chewable)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Cefoxitin Sodium

$1.20-$3.30 (Tier 1)

Cefpodoxime Proxetil

$1.20-$3.30 (Tier 1)

Cefprozil

Ceftazidime

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Ceftriaxone Sodium

Cefuroxime Axetil

Cefuroxime Sodium

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Cephalexin

$1.20-$3.30 (Tier 1)

Suprax

SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) Suprax

tazicef (injection) Tazicef

ZERBAXA (INJECTION) Zerbaxa

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE (INJECTION) Azactam in Iso-Osmotic Dextrose

aztreonam (injection) Aztreonam

DORIBAX (INJECTION) Doribax

imipenem/cilastatin (injection) Imipenem/Cilastatin

INVANZ (INJECTION) Invanz

meropenem (injection) Meropenem

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Beta-lactam, Penicillins amoxicillin (125mg tablet chewable, 250mg tablet chewable, 125mg/5ml suspension, 200mg/5ml suspension, 250mg/5ml suspension, 400mg/5ml suspension, 250mg capsule, 500mg capsule, 500mg tablet, 875mg tablet) Amoxicillin

$1.20-$3.30 (Tier 1)

PA

For 11 20 Track Refered Purpose

20

Name of Drug

amoxicillin/clavulanate potassium (200mg-28.5mg tablet chewable, 400mg-57mg tablet chewable, 200mg/5ml-28.5mg/5ml suspension, 250mg/ 5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml suspension, 600mg/5ml-42.9mg/5ml suspension, 250mg-125mg tablet immediate-release, 500mg-125mg tablet immediate-release, 875mg-125mg tablet immediate-release) (generic augmentin) amoxicillin/clavulanate potassium er (tablet extendedrelease 12 hour) ampicillin (capsule) ampicillin sodium (10gm injection, 125mg injection, 1gm injection) ampicillin-sulbactam (10gm-5gm injection, 1gm-0.5gm injection, 2gm-1gm injection)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Amoxicillin/Clavulanate Potassium

$1.20-$3.30 (Tier 1)

Amoxicillin/Clavulanate Potassium ER

Ampicillin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Ampicillin Sodium

$1.20-$3.30 (Tier 1)

Ampicillin-Sulbactam

BACTOCILL IN DEXTROSE (INJECTION) Bactocill in Dextrose

BICILLIN C-R (INJECTION) Bicillin C-R

BICILLIN L-A (INJECTION) Bicillin L-A

dicloxacillin sodium (capsule) nafcillin sodium (1gm injection, 10gm injection) oxacillin sodium (injection) penicillin g potassium (injection) penicillin g procaine (injection) penicillin g sodium (injection) penicillin v potassium (125mg/5ml oral solution, 250mg/5ml oral solution, 250mg tablet, 500mg tablet) piperacillin/tazobactam (injection) Dicloxacillin Sodium

Nafcillin Sodium

Oxacillin Sodium

Penicillin G Potassium

Penicillin G Procaine

Penicillin G Sodium

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Penicillin V Potassium

Piperacillin/Tazobactam

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Macrolides

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 12 21 Track Refered Purpose

21

Name of Drug

azithromycin (100mg/5ml suspension, 200mg/5ml suspension, 250mg tablet, 500mg tablet, 600mg tablet, 500mg injection) clarithromycin (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) clarithromycin er (tablet extended-release 24 hour)

What the drug will cost you (tier level)

Azithromycin

$1.20-$3.30 (Tier 1)

Clarithromycin

Clarithromycin ER

DIFICID (TABLET) Dificid

E.E.S. GRANULES (SUSPENSION) E.E.S. Granules

ery-tab (tablet delayed-release) Ery-Tab

ERYPED 200 (SUSPENSION) EryPed 200

ERYPED 400 (SUSPENSION) EryPed 400

erythrocin lactobionate (injection) erythromycin (250mg capsule delayed-release, 5mg/ gm ophthalmic ointment) erythromycin base (tablet) erythromycin ethylsuccinate (200mg/5ml suspension, 400mg tablet) Erythrocin Lactobionate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Erythromycin

Erythromycin Base

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Erythromycin Ethylsuccinate

ZMAX (SUSPENSION) Zmax

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Quinolones AVELOX (400MG/250ML-0.8% INJECTION) Avelox

ciprofloxacin (250mg/5ml suspension, 500mg/5ml suspension, 400mg/40ml injection) ciprofloxacin er (tablet extended-release 24 hour) ciprofloxacin hcl (0.3% ophthalmic solution, 100mg tablet immediate-release, 250mg tablet immediaterelease, 500mg tablet immediate-release, 750mg tablet immediate-release) ciprofloxacin i.v. in d5w (injection) levofloxacin (0.5% ophthalmic solution, 250mg tablet, 500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/ml oral solution) levofloxacin in d5w (injection)

$3.70-$8.25 (Tier 2)

Ciprofloxacin

Ciprofloxacin ER

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Ciprofloxacin HCl

Ciprofloxacin I.V. in D5W

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Levofloxacin

Levofloxacin in D5W

MOXEZA (OPHTHALMIC SOLUTION) Moxeza

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

moxifloxacin hcl (0.5% ophthalmic solution, 400mg tablet)

$1.20-$3.30 (Tier 1)

MOXIFLOXACIN HCL (400MG/250ML INJECTION)

$3.70-$8.25 (Tier 2)

ofloxacin (0.3% ophthalmic solution, 0.3% otic solution, 300mg tablet, 400mg tablet)

$1.20-$3.30 (Tier 1)

Moxifloxacin HCl

Moxifloxacin HCl

Ofloxacin

Necessary actions, restrictions, or limits on use

For 13 22 Track Refered Purpose

22

Name of Drug

VIGAMOX (OPHTHALMIC SOLUTION) Vigamox

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2)

Sulfonamides SILVER SULFADIAZINE (CREAM) Silver Sulfadiazine

sodium sulfacetamide (ophthalmic solution) Sodium Sulfacetamide

SSD (CREAM) SSD

sulfacetamide sodium (ophthalmic ointment) sulfadiazine (tablet) sulfamethoxazole/trimethoprim (200mg-40mg/5ml suspension, 400mg-80mg tablet, 400mg-80mg/5ml injection) sulfamethoxazole/trimethoprim ds (tablet) Sulfacetamide Sodium

Sulfadiazine

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Sulfamethoxazole/Trimethoprim

Sulfamethoxazole/Trimethoprim DS

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Tetracyclines demeclocycline hcl (tablet) doxy 100 (injection) doxycycline (suspension) doxycycline hyclate (100mg capsule immediaterelease, 50mg capsule immediate-release, 100mg tablet immediate-release, 20mg tablet immediaterelease) doxycycline monohydrate (100mg capsule, 50mg capsule, 100mg tablet, 50mg tablet, 75mg tablet) minocycline hcl (100mg capsule immediate-release, 50mg capsule immediate-release, 75mg capsule immediate-release) tetracycline hcl (capsule) Demeclocycline HCl

Doxy 100

Doxycycline

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Doxycycline Hyclate

$1.20-$3.30 (Tier 1)

Doxycycline Monohydrate

$1.20-$3.30 (Tier 1)

Minocycline HCl

Tetracycline HCl

VIBRAMYCIN (50MG/5ML SYRUP) Vibramycin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Anticonvulsants Anticonvulsants, Other

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 14 23 Track Refered Purpose

23

Name of Drug BRIVIACT (100MG TABLET, 10MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET, 10MG/ML ORAL SOLUTION, 50MG/5ML INJECTION) FYCOMPA (0.5MG/ML SUSPENSION, 10MG TABLET, 12MG TABLET, 2MG TABLET, 4MG TABLET, 6MG TABLET, 8MG TABLET)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

BRIVIACT

$3.70-$8.25 (Tier 2)

QL

Fycompa

$3.70-$8.25 (Tier 2)

levetiracetam (1000mg tablet immediate-release, 250mg tablet immediate-release, 500mg tablet immediate-release, 750mg tablet immediate-release, 100mg/ml oral solution, 500mg/5ml injection)

$1.20-$3.30 (Tier 1)

LEVETIRACETAM (1000MG/100ML INJECTION, 1500MG/100ML INJECTION, 500MG/100ML INJECTION)

$3.70-$8.25 (Tier 2)

Levetiracetam

Levetiracetam

levetiracetam er (tablet extended-release 24 hour) roweepra (tablet) Levetiracetam ER

Roweepra

SPRITAM (TABLET DISINTEGRATING SOLUBLE) Spritam

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Calcium Channel Modifying Agents CELONTIN (CAPSULE) Celontin

ethosuximide (250mg capsule, 250mg/5ml oral solution) zonisamide (capsule)

$3.70-$8.25 (Tier 2)

Ethosuximide

Zonisamide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT ACUDIAL (GEL) Diastat AcuDial

DIASTAT PEDIATRIC (GEL) Diastat Pediatric

gabapentin (100mg capsule, 300mg capsule, 400mg capsule, 250mg/5ml oral solution, 600mg tablet, 800mg tablet)

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Gabapentin

GABITRIL (12MG TABLET, 16MG TABLET) Gabitril

ONFI (10MG TABLET, 20MG TABLET) Onfi

ONFI (2.5MG/ML SUSPENSION) Onfi

phenobarbital (100mg tablet, 15mg tablet, 16.2mg tablet, 30mg tablet, 32.4mg tablet, 60mg tablet, 64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir) primidone (tablet)

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

Phenobarbital

Primidone

SABRIL (500MG PACKET, 500MG TABLET) Sabril

tiagabine hcl (tablet) valproate sodium (100mg/ml injection) valproic acid (250mg capsule, 250mg/5ml oral solution) Tiagabine HCl

Valproate Sodium

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Valproic Acid

$1.20-$3.30 (Tier 1)

PA, QL, LA

For 15 24 Track Refered Purpose

24

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Glutamate Reducing Agents felbamate (400mg tablet, 600mg tablet, 600mg/5ml suspension) lamotrigine (100mg tablet immediate-release, 150mg tablet immediate-release, 200mg tablet immediaterelease, 25mg tablet immediate-release, 25mg tablet chewable, 5mg tablet chewable) topiramate (100mg tablet immediate-release, 200mg tablet immediate-release, 25mg tablet immediaterelease, 50mg tablet immediate-release, 15mg capsule sprinkle immediate-release, 25mg capsule sprinkle immediate-release) Felbamate

$1.20-$3.30 (Tier 1)

Lamotrigine

$1.20-$3.30 (Tier 1)

Topiramate

$1.20-$3.30 (Tier 1)

Sodium Channel Agents APTIOM (TABLET) BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION) Aptiom

$3.70-$8.25 (Tier 2)

QL

Banzel

carbamazepine (100mg tablet chewable, 100mg/5ml suspension, 200mg tablet immediate-release) carbamazepine er (100mg capsule extended-release 12 hour, 200mg capsule extended-release 12 hour, 300mg capsule extended-release 12 hour, 100mg tablet extended-release 12 hour, 200mg tablet extended-release 12 hour, 400mg tablet extendedrelease 12 hour) dilantin (capsule) dilantin infatabs (tablet chewable) epitol (tablet) fosphenytoin sodium (injection) oxcarbazepine (150mg tablet, 300mg tablet, 600mg tablet, 300mg/5ml suspension)

$3.70-$8.25 (Tier 2)

Carbamazepine

$1.20-$3.30 (Tier 1)

Carbamazepine ER

Dilantin

Dilantin INFATABS

Epitol

Fosphenytoin Sodium

$1.20-$3.30 (Tier 1)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Oxcarbazepine

PEGANONE (TABLET) Peganone

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 16 25 Track Refered Purpose

25

Name of Drug

phenytek (capsule) phenytoin (125mg/5ml suspension, 50mg tablet chewable) phenytoin sodium (injection) phenytoin sodium extended (capsule) Phenytek

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1)

Phenytoin

Phenytoin Sodium

Phenytoin Sodium Extended

VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML ORAL SOLUTION) VIMPAT (200MG/20ML INJECTION)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Vimpat

Vimpat

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

Antidementia Agents Cholinesterase Inhibitors donepezil hcl (10mg tablet immediate-release, 5mg tablet immediate-release) donepezil hcl odt (tablet dispersible) rivastigmine tartrate (capsule immediate-release) rivastigmine transdermal system (patch 24 hour) Donepezil HCl

Donepezil HCl ODT

Rivastigmine Tartrate

Rivastigmine Transdermal System

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL, ST

$1.20-$3.30 (Tier 1)

PA, QL

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2)

PA, QL

$3.70-$8.25 (Tier 2)

PA, QL

N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (10mg tablet, 5mg tablet, 2mg/ml oral solution) Memantine HCl

MEMANTINE HCL TITRATION PAK (TABLET) NAMENDA XR (CAPSULE EXTENDED-RELEASE 24 HOUR) NAMENDA XR TITRATION PACK (CAPSULE EXTENDEDRELEASE 24 HOUR) Memantine HCl Titration Pak

Namenda XR

Namenda XR Titration Pack

Antidepressants Antidepressants, Other bupropion hcl (tablet immediate-release) bupropion hcl sr (100mg tablet extended-release 12 hour, 150mg tablet extended-release 12 hour, 200mg tablet extended-release 12 hour) bupropion hcl xl (tablet extended-release 24 hour) mirtazapine (tablet immediate-release) mirtazapine odt (tablet dispersible) Bupropion HCl

$1.20-$3.30 (Tier 1)

Bupropion HCl SR

Bupropion HCl XL

Mirtazapine

Mirtazapine ODT

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Monoamine Oxidase Inhibitors EMSAM (PATCH 24 HOUR) Emsam

MARPLAN (TABLET) Marplan

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

For 17 26 Track Refered Purpose

26

Name of Drug

phenelzine sulfate (tablet) tranylcypromine sulfate (tablet) Phenelzine Sulfate

Tranylcypromine Sulfate

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hbr (10mg tablet, 20mg tablet, 40mg tablet, 10mg/5ml oral solution) desvenlafaxine er (100mg tablet extended-release 24 hour, 25mg tablet extended-release 24 hour, 50mg tablet extended-release 24 hour) (generic pristiq) escitalopram oxalate (10mg tablet, 20mg tablet, 5mg tablet, 5mg/5ml oral solution) Citalopram HBr

$1.20-$3.30 (Tier 1)

Desvenlafaxine ER

$1.20-$3.30 (Tier 1)

QL

Escitalopram Oxalate

$1.20-$3.30 (Tier 1)

FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) FETZIMA TITRATION PACK (CAPSULE EXTENDEDRELEASE 24 HOUR THERAPY PACK)

$3.70-$8.25 (Tier 2)

QL, ST

$3.70-$8.25 (Tier 2)

ST

fluoxetine dr (capsule delayed-release) fluoxetine hcl (10mg capsule immediate-release, 20mg capsule immediate-release, 40mg capsule immediate-release, 20mg/5ml oral solution) fluvoxamine maleate (tablet) maprotiline hcl (tablet) nefazodone hcl (tablet) paroxetine hcl (tablet immediate-release)

$1.20-$3.30 (Tier 1)

Fetzima

Fetzima Titration Pack

Fluoxetine DR

Fluoxetine HCl

Fluvoxamine Maleate

Maprotiline HCl

Nefazodone HCl

Paroxetine HCl

PAXIL (10MG/5ML SUSPENSION) Paxil

PRISTIQ (TABLET EXTENDED-RELEASE 24 HOUR) Pristiq

sertraline hcl (100mg tablet, 25mg tablet, 50mg tablet, 20mg/ml concentrate) trazodone hcl (tablet)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

Sertraline HCl

Trazodone HCl

TRINTELLIX (TABLET) Trintellix

venlafaxine hcl (tablet immediate-release) Venlafaxine HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 18 27 Track Refered Purpose

27

Name of Drug

venlafaxine hcl er (150mg capsule extended-release 24 hour, 37.5mg capsule extended-release 24 hour, 75mg capsule extended-release 24 hour)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Venlafaxine HCl ER

VIIBRYD (TABLET) Viibryd

VIIBRYD STARTER PACK (KIT) Viibryd Starter Pack

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

Tricyclics amitriptyline hcl (tablet) amoxapine (tablet) clomipramine hcl (capsule) desipramine hcl (tablet) doxepin hcl (100mg capsule, 10mg capsule, 150mg capsule, 25mg capsule, 50mg capsule, 75mg capsule, 10mg/ml concentrate) imipramine hcl (tablet) imipramine pamoate (capsule) nortriptyline hcl (10mg capsule, 25mg capsule, 50mg capsule, 75mg capsule, 10mg/5ml oral solution) protriptyline hcl (tablet) trimipramine maleate (capsule) Amitriptyline HCl

Amoxapine

Clomipramine HCl

Desipramine HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Doxepin HCl

Imipramine HCl

Imipramine Pamoate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Nortriptyline HCl

Protriptyline HCl

Trimipramine Maleate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Antiemetics Antiemetics, Other AKYNZEO (CAPSULE) Akynzeo

anti-nausea (oral solution)* compro (suppository) dimenhydrinate (otc only) (tablet)* formula em (oral solution)* hydroxyzine pamoate (capsule) meclizine hcl (otc only) (tablet)* meclizine hcl (rx only) (tablet) metoclopramide hcl (10mg tablet, 5mg tablet, 5mg/ 5ml oral solution, 5mg/ml injection) perphenazine (tablet) prochlorperazine (suppository) prochlorperazine edisylate (injection) prochlorperazine maleate (tablet) Anti-Nausea

Compro

Dimenhydrinate

Formula EM

Hydroxyzine Pamoate

Meclizine HCl

Meclizine HCl

$3.70-$8.25 (Tier 2) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $1.20-$3.30 (Tier 1)

Metoclopramide HCl

Perphenazine

Prochlorperazine

Prochlorperazine Edisylate

Prochlorperazine Maleate

TRANSDERM-SCOP (PATCH 72 HOUR) Transderm-Scop

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

B/D, PA

QL

For 19 28 Track Refered Purpose

28

Name of Drug

travel sickness (otc only) (25mg tablet chewable)* travel sickness (otc only) (50mg tablet)* Travel Sickness

Travel Sickness

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL

Emetogenic Therapy Adjuncts ALOXI (INJECTION) Aloxi

ANZEMET (TABLET) Anzemet

aprepitant (therapy pack, capsule) Aprepitant

CESAMET (CAPSULE) Cesamet

dronabinol (capsule) Dronabinol

EMEND (125MG CAPSULE, 40MG CAPSULE, 80MG CAPSULE, 125MG SUSPENSION) EMEND (150MG INJECTION)

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

B/D, PA PA PA PA, QL

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA

Emend

Emend

EMEND TRIPACK (THERAPY PACK) Emend Tripack

granisetron hcl (0.1mg/ml injection, 1mg/ml injection, 4mg/4ml injection) granisetron hcl (1mg tablet) ondansetron hcl (24mg tablet, 4mg tablet, 8mg tablet, 4mg/5ml oral solution) ondansetron hcl (4mg/2ml injection) ondansetron odt (tablet dispersible) Granisetron HCl

Granisetron HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

B/D, PA, QL

$1.20-$3.30 (Tier 1)

B/D, PA

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

B/D, PA

Ondansetron HCl

Ondansetron HCl

Ondansetron ODT

SANCUSO (PATCH) Sancuso

Antifungals Antifungals ABELCET (INJECTION) Abelcet

AMBISOME (INJECTION) AmBisome

amphotericin b (injection) antifungal (1% aerosol, 1% cream, 2% cream)* anti-fungal powder (otc only)* Amphotericin B

Antifungal

Anti-Fungal Powder

CANCIDAS (INJECTION) Cancidas

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2)

B/D, PA B/D, PA B/D, PA

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 20 29 Track Refered Purpose

29

Name of Drug

ciclopirox (0.77% gel, 0.77% suspension, 1% shampoo) ciclopirox nail lacquer (external solution) ciclopirox olamine (cream) clotrimazole (otc only) (1% cream)* clotrimazole (otc only) (1% external solution)* clotrimazole (rx only) (1% cream, 1% external solution, 10mg troche) clotrimazole anti-fungal (otc only) (cream)* econazole nitrate (cream)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Ciclopirox

Ciclopirox Nail Lacquer

Ciclopirox Olamine

Clotrimazole

Clotrimazole

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

QL

Clotrimazole

Clotrimazole Anti-Fungal

Econazole Nitrate

ERAXIS (INJECTION) Eraxis

fluconazole (100mg tablet, 150mg tablet, 200mg tablet, 50mg tablet, 10mg/ml suspension, 40mg/ml suspension) fluconazole in nacl (injection) flucytosine (capsule) fungoid tincture (external solution)* griseofulvin microsize (125mg/5ml suspension, 500mg tablet) griseofulvin ultramicrosize (tablet) itraconazole (capsule)

$1.20-$3.30 (Tier 1) $0 (Tier 3) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

QL

Fluconazole

Fluconazole in NaCl

Flucytosine

Fungoid Tincture

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3)

Griseofulvin Microsize

Griseofulvin Ultramicrosize

Itraconazole

JUBLIA (EXTERNAL SOLUTION) Jublia

ketoconazole (2% cream, 2% foam, 2% shampoo, 200mg tablet)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

PA, QL

Ketoconazole

MENTAX (RX ONLY) (CREAM) Mentax

miconazole 3 (suppository) miconazole 7 (suppository)* miconazole nitrate (100mg suppository, 2% cream)* Miconazole 3

Miconazole 7

Miconazole Nitrate

MYCAMINE (INJECTION) Mycamine

NATACYN (SUSPENSION) Natacyn

NOXAFIL (100MG TABLET DELAYED-RELEASE) Noxafil

NOXAFIL (40MG/ML SUSPENSION) Noxafil

nyamyc (powder) nyata (powder) nystatin (cream, ointment, powder, suspension, tablet) nystop (powder) Nyamyc

Nyata

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL

PA, QL QL

Nystatin

Nystop

ONMEL (TABLET) ONMEL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

PA

For 21 30 Track Refered Purpose

30

Name of Drug

qc tolnaftate (cream)* sm miconazole 7 (cream)* QC Tolnaftate

SM Miconazole 7

SPORANOX (10MG/ML ORAL SOLUTION) Sporanox

terbinafine hcl (1% cream)* terbinafine hcl (rx only) (tablet) terconazole (0.4% cream, 0.8% cream, 80mg suppository) tioconazole-1 (ointment)* tolnaftate (1% cream, 1% powder)* voriconazole (200mg injection, 200mg tablet, 50mg tablet, 40mg/ml suspension) zeasorb-af (powder)* Terbinafine HCl

Terbinafine HCl

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use

PA

Terconazole

Tioconazole-1

Tolnaftate

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

Voriconazole

Zeasorb-AF

$1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

Antigout Agents Antigout Agents allopurinol (tablet) Allopurinol

COLCHICINE (0.6MG CAPSULE, 0.6MG TABLET) Colchicine

probenecid (tablet) probenecid/colchicine (tablet) Probenecid

Probenecid/Colchicine

ULORIC (TABLET) Uloric

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

QL

ST

Antimigraine Agents Ergot Alkaloids cafergot (tablet) dihydroergotamine mesylate (1mg/ml injection) ergotamine tartrate/caffeine (tablet) migergot (suppository) Cafergot

Dihydroergotamine Mesylate

Ergotamine Tartrate/Caffeine

Migergot

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl (tablet) Naratriptan HCl

$1.20-$3.30 (Tier 1)

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 22 31 Track Refered Purpose

31

Name of Drug

rizatriptan benzoate (tablet immediate-release) rizatriptan benzoate odt (tablet dispersible) Rizatriptan Benzoate

Rizatriptan Benzoate ODT

SUMATRIPTAN (NASAL SOLUTION) Sumatriptan

sumatriptan succinate (100mg tablet, 25mg tablet, 50mg tablet, 4mg/0.5ml injection, 6mg/0.5ml injection)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

QL QL QL

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

Sumatriptan Succinate

SUMATRIPTAN SUCCINATE REFILL (INJECTION) Sumatriptan Succinate Refill

SUMAVEL DOSEPRO (INJECTION) Sumavel DosePro

Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL (TABLET) Guanidine HCl

MESTINON (60MG/5ML SYRUP) Mestinon

pyridostigmine bromide (tablet) pyridostigmine bromide er (tablet extended-release) Pyridostigmine Bromide

Pyridostigmine Bromide ER

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Antimycobacterials Antimycobacterials, Other dapsone (tablet) rifabutin (capsule) Dapsone

Rifabutin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Antituberculars CAPASTAT SULFATE (INJECTION) Capastat Sulfate

ethambutol hcl (tablet) isoniazid (100mg tablet, 300mg tablet, 100mg/ml injection, 50mg/5ml syrup) paser (packet) Ethambutol HCl

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Isoniazid

Paser

PRIFTIN (TABLET) Priftin

pyrazinamide (tablet) rifampin (150mg capsule, 300mg capsule, 600mg injection) Pyrazinamide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Rifampin

RIFATER (TABLET) Rifater

SIRTURO (TABLET) Sirturo

TRECATOR (TABLET) Trecator

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Antineoplastics Alkylating Agents BICNU (INJECTION) BiCNU

$3.70-$8.25 (Tier 2)

PA

For 23 32 Track Refered Purpose

32

Name of Drug

busulfan (injection) Busulfan

BUSULFEX (INJECTION) Busulfex

CYCLOPHOSPHAMIDE (CAPSULE) Cyclophosphamide

dacarbazine (injection) Dacarbazine

GLEOSTINE (CAPSULE) Gleostine

HEXALEN (CAPSULE) Hexalen

ifosfamide (injection) Ifosfamide

LEUKERAN (TABLET) Leukeran

MATULANE (CAPSULE) Matulane

melphalan hcl (injection) Melphalan HCl

MUSTARGEN (INJECTION) Mustargen

TREANDA (INJECTION) Treanda

VALCHLOR (GEL) Valchlor

YONDELIS (INJECTION) Yondelis

ZANOSAR (INJECTION) Zanosar

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

B/D, PA

PA

LA

PA PA, LA PA

Antiandrogens bicalutamide (tablet) flutamide (capsule) Bicalutamide

Flutamide

NILANDRON (TABLET) Nilandron

nilutamide (tablet) Nilutamide

XTANDI (CAPSULE) Xtandi

ZYTIGA (TABLET) Zytiga

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL PA, QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL PA, QL, LA PA, QL

Antiangiogenic Agents POMALYST (CAPSULE) Pomalyst

REVLIMID (CAPSULE) Revlimid

THALOMID (CAPSULE) Thalomid

Antiestrogens/Modifiers EMCYT (CAPSULE) Emcyt

$3.70-$8.25 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 24 33 Track Refered Purpose

33

Name of Drug

FARESTON (TABLET) Fareston

FASLODEX (INJECTION) Faslodex

SOLTAMOX (ORAL SOLUTION) Soltamox

tamoxifen citrate (tablet) Tamoxifen Citrate

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Antimetabolites adrucil (injection) Adrucil

ALIMTA (INJECTION) Alimta

cladribine (injection) clofarabine (injection) Cladribine

Clofarabine

CLOLAR (INJECTION) Clolar

cytarabine aqueous (injection) Cytarabine Aqueous

DROXIA (CAPSULE) Droxia

ELITEK (INJECTION) Elitek

fluorouracil (2.5gm/50ml injection) Fluorouracil

FOLOTYN (INJECTION) Folotyn

gemcitabine hcl (injection) hydroxyurea (capsule) Gemcitabine HCl

Hydroxyurea

LONSURF (TABLET) Lonsurf

mercaptopurine (tablet) Mercaptopurine

NIPENT (INJECTION) Nipent

PURIXAN (SUSPENSION) Purixan

TABLOID (TABLET) Tabloid

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

B/D, PA PA B/D, PA

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA B/D, PA PA, QL

B/D, PA

B/D, PA

PA, QL

PA PA

Antineoplastics, Other ABRAXANE (INJECTION) Abraxane

adriamycin (injection) Adriamycin

ALECENSA (CAPSULE) Alecensa

ARRANON (INJECTION) Arranon

azacitidine (injection) Azacitidine

BELEODAQ (INJECTION) Beleodaq

bleomycin sulfate (injection) carboplatin (injection) cisplatin (injection) Bleomycin Sulfate

Carboplatin

Cisplatin

COSMEGEN (INJECTION) Cosmegen

daunorubicin hcl (injection) decitabine (injection) dexrazoxane (injection) Daunorubicin HCl

Decitabine

Dexrazoxane

PA PA B/D, PA

PA

For 25 34 Track Refered Purpose

34

Name of Drug

docetaxel (80mg/4ml injection) Docetaxel

DOCETAXEL (80MG/8ML INJECTION) Docetaxel

DOXIL (INJECTION) Doxil

doxorubicin hcl (injection) doxorubicin hcl liposome (injection) epirubicin hcl (injection) Doxorubicin HCl

Doxorubicin HCl Liposome

Epirubicin HCl

ERWINAZE (INJECTION) Erwinaze

FARYDAK (CAPSULE) Farydak

fludarabine phosphate (injection) Fludarabine Phosphate

FUSILEV (INJECTION) Fusilev

HALAVEN (INJECTION) Halaven

IBRANCE (CAPSULE) Ibrance

idarubicin hcl (injection) irinotecan (injection) Idarubicin HCl

Irinotecan

ISTODAX (OVERFILL) (INJECTION) Istodax

JEVTANA (INJECTION) Jevtana

KISQALI (TABLET) Kisqali

KISQALI FEMARA 200 DOSE (TABLET THERAPY PACK) Kisqali Femara 200 Dose

KISQALI FEMARA 400 DOSE (TABLET THERAPY PACK) Kisqali Femara 400 Dose

KISQALI FEMARA 600 DOSE (TABLET THERAPY PACK) Kisqali Femara 600 Dose

leucovorin calcium (100mg injection, 350mg injection, 10mg tablet, 15mg tablet, 25mg tablet, 5mg tablet) levoleucovorin (50mg injection) levoleucovorin calcium (injection)

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

B/D, PA

PA

PA PA, QL

PA PA PA, QL PA, QL PA, QL PA, QL

Leucovorin Calcium

Levoleucovorin

Levoleucovorin Calcium

LYNPARZA (CAPSULE) Lynparza

mesna (injection) Mesna

MESNEX (400MG TABLET) Mesnex

mitomycin (injection) Mitomycin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 26 35 Track Refered Purpose

35

Name of Drug

mitoxantrone hcl (injection) Mitoxantrone HCl

NINLARO (CAPSULE) Ninlaro

oxaliplatin (iv solution 100mg/20ml) paclitaxel (injection) Oxaliplatin

Paclitaxel

PROLEUKIN (INJECTION) Proleukin

SYNRIBO (INJECTION) Synribo

thiotepa (injection) Thiotepa

TRISENOX (INJECTION) Trisenox

VELCADE (INJECTION) Velcade

VENCLEXTA (TABLET) VENCLEXTA STARTING PACK (TABLET THERAPY PACK) Venclexta

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use PA, QL

PA PA

PA PA, QL

Venclexta Starting Pack

vinblastine sulfate (injection) vincasar pfs (injection) vincristine sulfate (injection) vinorelbine tartrate (injection) Vinblastine Sulfate

Vincasar PFS

Vincristine Sulfate

Vinorelbine Tartrate

ZALTRAP (INJECTION) Zaltrap

ZOLINZA (CAPSULE) Zolinza

ZYDELIG (TABLET) Zydelig

ZYKADIA (CAPSULE) Zykadia

$3.70-$8.25 (Tier 2)

PA

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

B/D, PA B/D, PA B/D, PA PA PA PA, QL PA, QL

Aromatase Inhibitors, 3rd Generation anastrozole (tablet) exemestane (tablet) letrozole (tablet) Anastrozole

Exemestane

Letrozole

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Enzyme Inhibitors ETOPOPHOS (INJECTION) Etopophos

etoposide (injection) Etoposide

KYPROLIS (INJECTION) Kyprolis

RUBRACA (TABLET) Rubraca

toposar (injection) topotecan hcl (injection) Toposar

Topotecan HCl

ZEJULA (CAPSULE) Zejula

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

PA PA, QL

PA, QL

Molecular Target Inhibitors AFINITOR (TABLET) Afinitor

AFINITOR DISPERZ (TABLET SOLUBLE) Afinitor Disperz

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA

For 27 36 Track Refered Purpose

36

Name of Drug

ALUNBRIG (TABLET) Alunbrig

BOSULIF (TABLET) Bosulif

CABOMETYX (TABLET) Cabometyx

CAPRELSA (TABLET) Caprelsa

COMETRIQ (KIT) Cometriq

COTELLIC (TABLET) Cotellic

ERIVEDGE (CAPSULE) Erivedge

GILOTRIF (TABLET) Gilotrif

ICLUSIG (15MG TABLET) Iclusig

ICLUSIG (45MG TABLET) Iclusig

imatinib mesylate (tablet) Imatinib Mesylate

IMBRUVICA (CAPSULE) Imbruvica

INLYTA (TABLET) Inlyta

IRESSA (TABLET) Iressa

JAKAFI (TABLET) Jakafi

LENVIMA (CAPSULE THERAPY PACK) Lenvima

MEKINIST (TABLET) Mekinist

NEXAVAR (TABLET) Nexavar

ODOMZO (CAPSULE) Odomzo

RYDAPT (CAPSULE) Rydapt

SPRYCEL (TABLET) Sprycel

STIVARGA (TABLET) Stivarga

SUTENT (CAPSULE) Sutent

TAFINLAR (CAPSULE) Tafinlar

TARCEVA (TABLET) Tarceva

TASIGNA (CAPSULE) Tasigna

TYKERB (TABLET) Tykerb

VOTRIENT (TABLET) Votrient

XALKORI (CAPSULE) Xalkori

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use PA, QL PA, QL PA, QL PA, LA PA PA, QL, LA PA, QL PA PA, QL, LA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL, LA PA PA PA PA, QL, LA PA, QL PA, QL PA, QL PA, QL PA PA, QL PA, QL PA PA, QL PA, LA

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 28 37 Track Refered Purpose

37

Name of Drug

ZELBORAF (TABLET) Zelboraf

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2)

PA, QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA, LA PA PA PA PA PA PA PA PA PA PA PA PA, QL, LA PA PA PA

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL

Monoclonal Antibodies AVASTIN (INJECTION) Avastin

BAVENCIO (INJECTION) Bavencio

CYRAMZA (INJECTION) Cyramza

DARZALEX (INJECTION) Darzalex

EMPLICITI (INJECTION) Empliciti

ERBITUX (INJECTION) Erbitux

HERCEPTIN (INJECTION) Herceptin

IMFINZI (INJECTION) Imfinzi

KADCYLA (INJECTION) Kadcyla

KEYTRUDA (INJECTION) Keytruda

LARTRUVO (INJECTION) Lartruvo

OPDIVO (INJECTION) Opdivo

PERJETA (INJECTION) Perjeta

RITUXAN (INJECTION) Rituxan

SYLVANT (INJECTION) Sylvant

TAGRISSO (TABLET) Tagrisso

TECENTRIQ (INJECTION) Tecentriq

VECTIBIX (INJECTION) Vectibix

YERVOY (INJECTION) Yervoy

Retinoids bexarotene (capsule) Bexarotene

PANRETIN (GEL) Panretin

TARGRETIN (1% GEL) Targretin

tretinoin (10mg capsule) Tretinoin

PA

Antiparasitics Anthelmintics ALBENZA (TABLET) Albenza

BILTRICIDE (TABLET) Biltricide

ivermectin (tablet) Ivermectin

Antiprotozoals ALINIA (100MG/5ML SUSPENSION, 500MG TABLET) Alinia

atovaquone (suspension) Atovaquone

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

For 29 38 Track Refered Purpose

38

Name of Drug

atovaquone/proguanil hcl (tablet) (generic malarone) chloroquine phosphate (tablet) Atovaquone/Proguanil HCl

Chloroquine Phosphate

COARTEM (TABLET) Coartem

DARAPRIM (TABLET) DARAPRIM

hydroxychloroquine sulfate (tablet) mefloquine hcl (tablet) Hydroxychloroquine Sulfate

Mefloquine HCl

NEBUPENT (INHALATION SOLUTION) Nebupent

PENTAM 300 (INJECTION) Pentam 300

primaquine phosphate (tablet) quinine sulfate (capsule) Primaquine Phosphate

Quinine Sulfate

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use

B/D, PA, QL

PA

Pediculicides/Scabicides lindane (shampoo) malathion (lotion) permethrin (cream) Lindane

Malathion

Permethrin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Antiparkinson Agents Anticholinergics benztropine mesylate (0.5mg tablet, 1mg tablet, 2mg tablet, 1mg/ml injection) trihexyphenidyl hcl (0.4mg/ml elixir, 2mg tablet, 5mg tablet) Benztropine Mesylate

$1.20-$3.30 (Tier 1)

Trihexyphenidyl HCl

$1.20-$3.30 (Tier 1)

Antiparkinson Agents, Other amantadine hcl (100mg capsule, 100mg tablet, 50mg/5ml syrup) entacapone (tablet) tolcapone (tablet) Amantadine HCl

Entacapone

Tolcapone

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

PA, QL

Dopamine Agonists APOKYN (INJECTION) Apokyn

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 30 39 Track Refered Purpose

39

Name of Drug

bromocriptine mesylate (2.5mg tablet, 5mg capsule) Bromocriptine Mesylate

NEUPRO (PATCH 24 HOUR) Neupro

pramipexole dihydrochloride (tablet immediaterelease) ropinirole hcl (tablet immediate-release)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Pramipexole Dihydrochloride

Ropinirole HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa/levodopa (tablet immediate-release) carbidopa/levodopa er (tablet extended-release) carbidopa/levodopa odt (tablet dispersible) Carbidopa/Levodopa

Carbidopa/Levodopa ER

Carbidopa/Levodopa ODT

CARBIDOPA/LEVODOPA/ENTACAPONE (TABLET) Carbidopa/Levodopa/Entacapone

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Monoamine Oxidase B (MAO-B) Inhibitors AZILECT (TABLET) Azilect

rasagiline mesylate (tablet) selegiline hcl (5mg capsule, 5mg tablet) Rasagiline Mesylate

Selegiline HCl

ZELAPAR (TABLET DISPERSIBLE) Zelapar

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Antipsychotics 1st Generation/Typical chlorpromazine hcl (100mg tablet, 10mg tablet, 200mg tablet, 25mg tablet, 50mg tablet, 50mg/2ml injection) fluphenazine decanoate (injection) fluphenazine hcl (10mg tablet, 1mg tablet, 2.5mg tablet, 5mg tablet, 2.5mg/5ml elixir, 2.5mg/ml injection, 5mg/ml concentrate) haloperidol (0.5mg tablet, 10mg tablet, 1mg tablet, 20mg tablet, 2mg tablet, 5mg tablet, 2mg/ml concentrate) haloperidol decanoate (injection) haloperidol lactate (injection) loxapine succinate (10mg capsule, 5mg capsule) loxapine succinate (25mg capsule, 50mg capsule) pimozide (tablet) thioridazine hcl (tablet) thiothixene (capsule) trifluoperazine hcl (tablet) Chlorpromazine HCl

Fluphenazine Decanoate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Fluphenazine HCl

$1.20-$3.30 (Tier 1)

Haloperidol

Haloperidol Decanoate

Haloperidol Lactate

Loxapine Succinate

Loxapine Succinate

Pimozide

Thioridazine HCl

Thiothixene

Trifluoperazine HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL

For 31 40 Track Refered Purpose

40

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

2nd Generation/Atypical ABILIFY MAINTENA (INJECTION) Abilify Maintena

aripiprazole (tablet) aripiprazole odt (tablet dispersible) Aripiprazole

Aripiprazole ODT

ARISTADA (INJECTION) Aristada

FANAPT (TABLET) Fanapt

FANAPT TITRATION PACK (TABLET) Fanapt Titration Pack

GEODON (20MG INJECTION) Geodon

INVEGA SUSTENNA (INJECTION) Invega Sustenna

INVEGA TRINZA (INJECTION) Invega Trinza

LATUDA (TABLET) Latuda

NUPLAZID (TABLET) Nuplazid

olanzapine (10mg injection) olanzapine (10mg tablet immediate-release, 15mg tablet immediate-release, 2.5mg tablet immediaterelease, 20mg tablet immediate-release, 5mg tablet immediate-release, 7.5mg tablet immediate-release) olanzapine odt (tablet dispersible) paliperidone er (tablet extended-release 24 hour) quetiapine fumarate (tablet immediate-release) quetiapine fumarate er (tablet extended-release 24 hour) Olanzapine

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL QL, ST ST

PA QL PA, QL

Olanzapine

Olanzapine ODT

Paliperidone ER

Quetiapine Fumarate

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

Quetiapine Fumarate ER

REXULTI (TABLET) Rexulti

RISPERDAL CONSTA (INJECTION) Risperdal Consta

risperidone (0.25mg tablet immediate-release, 0.5mg tablet immediate-release, 1mg tablet immediaterelease, 2mg tablet immediate-release, 3mg tablet immediate-release, 4mg tablet immediate-release, 1mg/ml oral solution) risperidone odt (tablet dispersible) Risperidone

Risperidone ODT

$1.20-$3.30 (Tier 1)

$1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 32 41 Track Refered Purpose

41

Name of Drug

SAPHRIS (TABLET SUBLINGUAL) SEROQUEL XR (TABLET EXTENDED-RELEASE 24 HOUR) VRAYLAR (1.5MG CAPSULE, 3MG CAPSULE, 4.5MG CAPSULE, 6MG CAPSULE) VRAYLAR (CAPSULE THERAPY PACK) Saphris

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL, ST

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

ST QL

Seroquel XR

Vraylar

Vraylar

ziprasidone hcl (capsule) Ziprasidone HCl

ZYPREXA RELPREVV (INJECTION) Zyprexa Relprevv

Treatment-Resistant clozapine (tablet immediate-release) clozapine odt (100mg tablet dispersible, 25mg tablet dispersible) Clozapine

$1.20-$3.30 (Tier 1)

Clozapine ODT

CLOZAPINE ODT (12.5MG TABLET DISPERSIBLE, 150MG TABLET DISPERSIBLE, 200MG TABLET DISPERSIBLE) VERSACLOZ (SUSPENSION)

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

QL

Clozapine ODT

Versacloz

$3.70-$8.25 (Tier 2)

Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir (injection) ganciclovir (injection) Cidofovir

Ganciclovir

VALCYTE (50MG/ML ORAL SOLUTION) Valcyte

valganciclovir (tablet) valganciclovir hydrochlorde (oral solution) Valganciclovir

Valganciclovir Hydrochlorde

ZIRGAN (GEL) Zirgan

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

B/D, PA

Anti-hepatitis B (HBV) Agents adefovir dipivoxil (tablet) Adefovir Dipivoxil

BARACLUDE (0.05MG/ML ORAL SOLUTION) Baraclude

entecavir (tablet) Entecavir

EPIVIR HBV (5MG/ML ORAL SOLUTION) Epivir HBV

lamivudine (100mg tablet) Lamivudine

VEMLIDY (TABLET) Vemlidy

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL PA, QL PA, QL

Anti-hepatitis C (HCV) Agents DAKLINZA (TABLET) Daklinza

EPCLUSA (TABLET) Epclusa

HARVONI (TABLET) Harvoni

For 33 42 Track Refered Purpose

42

Name of Drug

INTRON A (INJECTION) Intron A

PEGINTRON REDIPEN (INJECTION) PegIntron REDIPEN

PEGASYS (INJECTION) Pegasys

PEGASYS PROCLICK (INJECTION) Pegasys ProClick

PEGINTRON (INJECTION) PegIntron

ribasphere (200mg tablet, 400mg tablet, 600mg tablet) ribavirin (200mg tablet)

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use PA PA PA PA PA

Ribasphere

Ribavirin

SOVALDI (TABLET) Sovaldi

SYLATRON (INJECTION) Sylatron

ZEPATIER (TABLET) Zepatier

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL PA PA, QL

Antiherpetic Agents acyclovir (200mg capsule, 200mg/5ml suspension, 400mg tablet, 800mg tablet) acyclovir sodium (injection) famciclovir (tablet) trifluridine (ophthalmic solution) valacyclovir hcl (tablet) Acyclovir

Acyclovir Sodium

Famciclovir

Trifluridine

Valacyclovir HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

B/D, PA QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL QL QL QL

QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) EVOTAZ (TABLET) Evotaz

GENVOYA (TABLET) ISENTRESS (100MG PACKET, 100MG TABLET CHEWABLE, 25MG TABLET CHEWABLE, 400MG TABLET) PREZCOBIX (TABLET) Genvoya

Isentress

Prezcobix

STRIBILD (TABLET) Stribild

TIVICAY (TABLET) Tivicay

TRIUMEQ (TABLET) Triumeq

TYBOST (TABLET) Tybost

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 34 43 Track Refered Purpose

43

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) ATRIPLA (TABLET) Atripla

COMPLERA (TABLET) Complera

EDURANT (TABLET) Edurant

INTELENCE (TABLET) Intelence

nevirapine (200mg tablet immediate-release) Nevirapine

NEVIRAPINE (50MG/5ML SUSPENSION) Nevirapine

nevirapine er (tablet extended-release 24 hour) Nevirapine ER

ODEFSEY (TABLET) Odefsey

RESCRIPTOR (TABLET) SUSTIVA (200MG CAPSULE, 50MG CAPSULE, 600MG TABLET) Rescriptor

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL QL QL QL QL QL QL QL

$3.70-$8.25 (Tier 2)

QL

Sustiva

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir (tablet) abacavir sulfate/lamivudine/zidovudine (tablet) abacavir/lamivudine (tablet) Abacavir

Abacavir Sulfate/Lamivudine/Zidovudine

Abacavir/Lamivudine

DESCOVY (TABLET) Descovy

didanosine (capsule delayed-release) Didanosine

EMTRIVA (10MG/ML ORAL SOLUTION, 200MG CAPSULE) EPZICOM (TABLET)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL QL QL QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

QL

Emtriva

Epzicom

lamivudine (10mg/ml oral solution, 150mg tablet, 300mg tablet) lamivudine/zidovudine (tablet) Lamivudine

Lamivudine/Zidovudine

RETROVIR IV INFUSION (INJECTION) Retrovir IV Infusion

stavudine (capsule) Stavudine

TRUVADA (TABLET) Truvada

VIDEX PEDIATRIC (ORAL SOLUTION) VIREAD (150MG TABLET, 200MG TABLET, 250MG TABLET, 300MG TABLET, 40MG/GM POWDER) ZERIT (1MG/ML ORAL SOLUTION) Videx Pediatric

QL QL QL

Viread

Zerit

ZIAGEN (20MG/ML ORAL SOLUTION) Ziagen

zidovudine (100mg capsule, 300mg tablet, 50mg/5ml syrup) Zidovudine

Anti-HIV Agents, Other FUZEON (INJECTION) Fuzeon

For 35 44 Track Refered Purpose

44

Name of Drug

SELZENTRY (TABLET) Selzentry

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL

$3.70-$8.25 (Tier 2)

QL

Anti-HIV Agents, Protease Inhibitors APTIVUS (100MG/ML ORAL SOLUTION, 250MG CAPSULE) CRIXIVAN (CAPSULE) Aptivus

Crixivan

INVIRASE (200MG CAPSULE, 500MG TABLET) KALETRA (100MG-25MG TABLET, 200MG-50MG TABLET, 400MG-100MG/5ML ORAL SOLUTION) LEXIVA (50MG/ML SUSPENSION, 700MG TABLET) Invirase

Kaletra

Lexiva

lopinavir/ritonavir (oral solution) Lopinavir/Ritonavir

NORVIR (100MG CAPSULE, 100MG TABLET, 80MG/ML ORAL SOLUTION) PREZISTA (100MG/ML SUSPENSION, 150MG TABLET, 600MG TABLET, 75MG TABLET, 800MG TABLET) REYATAZ (150MG CAPSULE, 200MG CAPSULE, 300MG CAPSULE, 50MG PACKET) VIRACEPT (TABLET) Norvir

Prezista

Reyataz

Viracept

Anti-influenza Agents oseltamivir phosphate (capsule) Oseltamivir Phosphate

RELENZA DISKHALER (AEROSOL POWDER) Relenza Diskhaler

rimantadine hcl (tablet) Rimantadine HCl

TAMIFLU (30MG CAPSULE, 45MG CAPSULE, 75MG CAPSULE, 6MG/ML SUSPENSION) Tamiflu

Anxiolytics Anxiolytics, Other buspirone hcl (tablet) hydroxyzine hcl (10mg tablet, 25mg tablet, 50mg tablet, 10mg/5ml syrup, 25mg/ml injection, 50mg/ml injection) Buspirone HCl

$1.20-$3.30 (Tier 1)

Hydroxyzine HCl

$1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 36 45 Track Refered Purpose

45

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Benzodiazepines alprazolam (tablet immediate-release) chlordiazepoxide hcl (capsule) clonazepam (tablet immediate-release) clonazepam odt (tablet dispersible) clorazepate dipotassium (tablet) diazepam (10mg tablet, 2mg tablet, 5mg tablet) diazepam (1mg/ml oral solution) diazepam intensol (5mg/ml concentrate) lorazepam (tablet) lorazepam intensol (2mg/ml concentrate) Alprazolam

Chlordiazepoxide HCl

Clonazepam

Clonazepam ODT

Clorazepate Dipotassium

Diazepam

Diazepam

Diazepam Intensol

Lorazepam

Lorazepam Intensol

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL QL QL QL

Bipolar Agents Mood Stabilizers divalproex sodium (capsule sprinkle delayed-release) divalproex sodium dr (tablet delayed-release) divalproex sodium er (tablet extended-release 24 hour)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

LITHIUM (ORAL SOLUTION)

$3.70-$8.25 (Tier 2)

Divalproex Sodium

Divalproex Sodium DR

Divalproex Sodium ER

Lithium

lithium carbonate (150mg capsule immediate-release, 300mg capsule immediate-release, 600mg capsule immediate-release, 300mg tablet immediate-release) lithium carbonate er (tablet extended-release)

$1.20-$3.30 (Tier 1)

Lithium Carbonate

Lithium Carbonate ER

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Blood Glucose Regulators Antidiabetic Agents acarbose (tablet) Acarbose

AVANDIA (TABLET) Avandia

BYDUREON PEN (INJECTION) Bydureon Pen

BYDUREON VIAL (INJECTION) Bydureon Vial

BYETTA (INJECTION) Byetta

CYCLOSET (TABLET) Cycloset

FARXIGA (TABLET) Farxiga

glimepiride (tablet) glipizide (tablet immediate-release) glipizide er (tablet extended-release 24 hour) glipizide/metformin hcl (tablet) Glimepiride

Glipizide

Glipizide ER

Glipizide/Metformin HCl

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL PA, QL QL QL QL PA, QL QL QL QL QL QL

For 37 46 Track Refered Purpose

46

Name of Drug

JARDIANCE (TABLET) Jardiance

JENTADUETO (TABLET) JENTADUETO XR (TABLET EXTENDED-RELEASE 24 HOUR) KOMBIGLYZE XR (TABLET EXTENDED-RELEASE 24 HOUR) Jentadueto

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2)

QL

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL QL QL QL QL QL QL QL PA PA QL QL QL

Jentadueto XR

Kombiglyze XR

metformin hcl (tablet immediate-release) metformin hcl er (500mg tablet extended-release 24 hour, 750mg tablet extended-release 24 hour) (generic glucophage xr) nateglinide (tablet) Metformin HCl

Metformin HCl ER

Nateglinide

ONGLYZA (TABLET) Onglyza

pioglitazone hcl (tablet) pioglitazone hcl/glimepiride (tablet) pioglitazone hcl/metformin hcl (tablet) repaglinide (tablet) repaglinide/metformin hcl (tablet) Pioglitazone HCl

Pioglitazone HCl/Glimepiride

Pioglitazone HCl/Metformin HCl

Repaglinide

Repaglinide/Metformin HCl

RIOMET (ORAL SOLUTION) Riomet

SOLIQUA 100/33 (INJECTION) Soliqua 100/33

SYMLINPEN 120 (INJECTION) SymlinPen 120

SYMLINPEN 60 (INJECTION) SymlinPen 60

SYNJARDY (TABLET) Synjardy

TRADJENTA (TABLET) Tradjenta

XIGDUO XR (TABLET EXTENDED-RELEASE 24 HOUR) Xigduo XR

Glycemic Agents GLUCAGEN HYPOKIT (INJECTION) GlucaGen HypoKit

GLUCAGON EMERGENCY KIT (INJECTION) Glucagon Emergency Kit

PROGLYCEM (SUSPENSION) Proglycem

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Insulins

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 38 47 Track Refered Purpose

47

Name of Drug

HUMALOG CARTRIDGE (INJECTION) Humalog Cartridge

HUMALOG KWIKPEN (INJECTION) Humalog KwikPen

HUMALOG MIX 50/50 KWIKPEN (INJECTION) Humalog Mix 50/50 KwikPen

HUMALOG MIX 50/50 VIAL (INJECTION) Humalog Mix 50/50 Vial

HUMALOG MIX 75/25 KWIKPEN (INJECTION) Humalog Mix 75/25 KwikPen

HUMALOG MIX 75/25 VIAL (INJECTION) Humalog Mix 75/25 Vial

HUMALOG VIAL (INJECTION) Humalog Vial

HUMULIN 70/30 KWIKPEN (INJECTION) Humulin 70/30 KwikPen

HUMULIN 70/30 VIAL (INJECTION) Humulin 70/30 Vial

HUMULIN N KWIKPEN (INJECTION) Humulin N KwikPen

HUMULIN N VIAL (INJECTION) Humulin N Vial

HUMULIN R U-500 KWIKPEN (INJECTION) Humulin R U-500 KwikPen

HUMULIN R U-500 VIAL (CONCENTRATED) (INJECTION) Humulin R U-500 Vial

HUMULIN R VIAL (INJECTION) Humulin R Vial

LANTUS SOLOSTAR (INJECTION) Lantus SoloStar

LANTUS VIAL (INJECTION) Lantus Vial

LEVEMIR FLEXTOUCH (INJECTION) Levemir FlexTouch

LEVEMIR VIAL (INJECTION) Levemir Vial

TOUJEO SOLOSTAR (INJECTION) Toujeo SoloStar

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN (TABLET) Coumadin

ELIQUIS (TABLET) Eliquis

enoxaparin sodium (100mg/ml injection, 120mg/ 0.8ml injection, 150mg/ml injection, 30mg/0.3ml injection, 40mg/0.4ml injection, 60mg/0.6ml injection, 80mg/0.8ml injection, 300mg/3ml injection) fondaparinux sodium (injection) heparin sodium (10000unit/ml injection, 20000unit/ml injection, 5000unit/ml injection) heparin sodium (1000unit/ml injection)

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL

$1.20-$3.30 (Tier 1)

QL

Enoxaparin Sodium

Fondaparinux Sodium

$1.20-$3.30 (Tier 1)

Heparin Sodium

Heparin Sodium

HEPARIN SODIUM/D5W (INJECTION) Heparin Sodium/D5W

jantoven (tablet) warfarin sodium (tablet) Jantoven

Warfarin Sodium

XARELTO (TABLET) Xarelto

XARELTO STARTER PACK (TABLET THERAPY PACK) Xarelto Starter Pack

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

B/D, PA

PA, QL PA, QL

For 39 48 Track Refered Purpose

48

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Blood Formation Modifiers anagrelide hcl (capsule) Anagrelide HCl

ARANESP ALBUMIN FREE (INJECTION) Aranesp Albumin Free

LEUKINE (INJECTION) Leukine

MOZOBIL (INJECTION) Mozobil

NEULASTA (INJECTION) Neulasta

PROCRIT (INJECTION) Procrit

PROMACTA (TABLET) Promacta

zarxio (injection) Zarxio

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA PA PA, QL

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

B/D, PA B/D, PA

Blood Products/Modifiers/Volume Expanders ARGATROBAN (125MG/125ML-0.9% INJECTION) Argatroban

argatroban (250mg/2.5ml injection) Argatroban

Coagulants tranexamic acid (1000mg/10ml injection, 650mg tablet) Tranexamic Acid

$1.20-$3.30 (Tier 1)

Platelet Modifying Agents ASPIRIN/DIPYRIDAMOLE (CAPSULE EXTENDEDRELEASE 12 HOUR) BRILINTA (TABLET) Aspirin/Dipyridamole

Brilinta

cilostazol (tablet) clopidogrel (75mg tablet) Cilostazol

Clopidogrel

EFFIENT (TABLET) Effient

$3.70-$8.25 (Tier 2)

QL

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

QL QL QL

Cardiovascular Agents Alpha-adrenergic Agonists

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 40 49 Track Refered Purpose

49

Name of Drug

clonidine hcl (0.1mg tablet immediate-release, 0.2mg tablet immediate-release, 0.3mg tablet immediaterelease, 0.1mg/24hr patch weekly, 0.2mg/24hr patch weekly, 0.3mg/24hr patch weekly) methyldopa (tablet) methyldopate hcl (injection) midodrine hcl (tablet)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Clonidine HCl

Methyldopa

Methyldopate HCl

Midodrine HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Alpha-adrenergic Blocking Agents doxazosin mesylate (tablet) phenoxybenzamine hcl (capsule) prazosin hcl (capsule) Doxazosin Mesylate

Phenoxybenzamine HCl

Prazosin HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Angiotensin II Receptor Antagonists BENICAR (TABLET) Benicar

candesartan cilexetil (tablet) eprosartan mesylate (tablet) irbesartan (tablet) losartan potassium (tablet) olmesartan medoxomil (tablet) telmisartan (tablet) valsartan (tablet) Candesartan Cilexetil

Eprosartan Mesylate

Irbesartan

Losartan Potassium

Olmesartan Medoxomil

Telmisartan

Valsartan

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL QL QL QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (tablet) captopril (tablet) enalapril maleate (tablet) fosinopril sodium (tablet) lisinopril (tablet) moexipril hcl (15mg tablet) moexipril hcl (7.5mg tablet) perindopril erbumine (tablet) quinapril hcl (tablet) ramipril (capsule) trandolapril (tablet) Benazepril HCl

Captopril

Enalapril Maleate

Fosinopril Sodium

Lisinopril

Moexipril HCl

Moexipril HCl

Perindopril Erbumine

Quinapril HCl

Ramipril

Trandolapril

Antiarrhythmics amiodarone hcl (200mg tablet, 50mg/ml injection) dofetilide (capsule) Amiodarone HCl

Dofetilide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL

For 41 50 Track Refered Purpose

50

Name of Drug

flecainide acetate (tablet) mexiletine hcl (capsule) Flecainide Acetate

Mexiletine HCl

MULTAQ (TABLET) Multaq

pacerone (200mg tablet) procainamide hcl (injection) propafenone hcl (tablet) propafenone hcl er (capsule extended-release 12 hour) Pacerone

Procainamide HCl

Propafenone HCl

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use

QL

Propafenone HCl ER

QUINIDINE GLUCONATE (INJECTION) Quinidine Gluconate

quinidine gluconate cr (tablet extended-release) quinidine sulfate (tablet) sotalol hcl (af) (tablet) sotalol hcl (tablet) Quinidine Gluconate CR

Quinidine Sulfate

Sotalol HCl

Sotalol HCl

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Beta-adrenergic Blocking Agents atenolol (tablet) Atenolol

BYSTOLIC (TABLET) Bystolic

carvedilol (tablet immediate-release) labetalol hcl (100mg tablet, 200mg tablet, 300mg tablet, 5mg/ml injection) metoprolol succinate er (tablet extended-release 24 hour) metoprolol tartrate (100mg tablet immediate-release, 25mg tablet immediate-release, 50mg tablet immediate-release, 5mg/5ml injection) nadolol (tablet) pindolol (tablet) Carvedilol

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL

Labetalol HCl

$1.20-$3.30 (Tier 1)

Metoprolol Succinate ER

$1.20-$3.30 (Tier 1)

Metoprolol Tartrate

Nadolol

Pindolol

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 42 51 Track Refered Purpose

51

Name of Drug

propranolol hcl (10mg tablet immediate-release, 20mg tablet immediate-release, 40mg tablet immediate-release, 60mg tablet immediate-release, 80mg tablet immediate-release, 1mg/ml injection, 20mg/5ml oral solution, 40mg/5ml oral solution) propranolol hcl er (capsule extended-release 24 hour) timolol maleate (10mg tablet, 20mg tablet, 5mg tablet)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Propranolol HCl

Propranolol HCl ER

$1.20-$3.30 (Tier 1)

$1.20-$3.30 (Tier 1)

Timolol Maleate

$1.20-$3.30 (Tier 1)

Calcium Channel Blocking Agents amlodipine besylate (tablet) Amlodipine Besylate

CARDENE IV (INJECTION) Cardene IV

cartia xt (capsule extended-release 24 hour) dilt-xr (capsule extended-release 24 hour) diltiazem cd (240mg capsule extended-release 24 hour) (generic cardizem cd) diltiazem hcl (100mg injection, 50mg/10ml injection, 120mg tablet immediate-release, 30mg tablet immediate-release, 60mg tablet immediate-release, 90mg tablet immediate-release) diltiazem hcl er (120mg capsule extended-release 24 hour, 300mg capsule extended-release 24 hour) (generic cardizem cd) nicardipine hcl (2.5mg/ml injection, 20mg capsule, 30mg capsule) nimodipine (capsule) verapamil hcl (120mg tablet immediate-release, 40mg tablet immediate-release, 80mg tablet immediaterelease, 2.5mg/ml injection) verapamil hcl er (120mg tablet extended-release, 180mg tablet extended-release, 240mg tablet extended-release) Cartia XT

Dilt-XR

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Diltiazem CD

$1.20-$3.30 (Tier 1)

Diltiazem HCl

$1.20-$3.30 (Tier 1)

Diltiazem HCl ER

$1.20-$3.30 (Tier 1)

Nicardipine HCl

Nimodipine

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Verapamil HCl

$1.20-$3.30 (Tier 1)

Verapamil HCl ER

$1.20-$3.30 (Tier 1)

Cardiovascular Agents, Other amiloride/hydrochlorothiazide (tablet) amlodipine besylate/atorvastatin calcium (tablet) amlodipine besylate/benazepril hcl (capsule) atenolol/chlorthalidone (tablet) benazepril hcl/hydrochlorothiazide (tablet) Amiloride/Hydrochlorothiazide

Amlodipine Besylate/Atorvastatin Calcium

Amlodipine Besylate/Benazepril HCl

Atenolol/Chlorthalidone

Benazepril HCl/Hydrochlorothiazide

BENICAR HCT (TABLET) Benicar HCT

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

QL QL QL QL

For 43 52 Track Refered Purpose

52

Name of Drug

candesartan cilexetil/hydrochlorothiazide (tablet) captopril/hydrochlorothiazide (tablet) Candesartan Cilexetil/Hydrochlorothiazide

Captopril/Hydrochlorothiazide

CORLANOR (TABLET) Corlanor

DEMSER (CAPSULE) Demser

digitek (tablet) Digitek

DIGOXIN (0.05MG/ML ORAL SOLUTION) Digoxin

digoxin (0.25mg/ml injection, 125mcg tablet, 250mcg tablet) enalapril maleate/hydrochlorothiazide (tablet)

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use QL QL PA, QL

Digoxin

Enalapril Maleate/Hydrochlorothiazide

ENTRESTO (TABLET) Entresto

fosinopril sodium/hydrochlorothiazide (tablet) irbesartan/hydrochlorothiazide (tablet) Fosinopril Sodium/Hydrochlorothiazide

Irbesartan/Hydrochlorothiazide

LANOXIN (187.5MCG TABLET, 62.5MCG TABLET) Lanoxin

lisinopril/hydrochlorothiazide (tablet) losartan potassium/hydrochlorothiazide (tablet) methyldopa/hydrochlorothiazide (tablet) metoprolol/hydrochlorothiazide (tablet) moexipril/hydrochlorothiazide (tablet) Lisinopril/Hydrochlorothiazide

Losartan Potassium/Hydrochlorothiazide

Methyldopa/Hydrochlorothiazide

Metoprolol/Hydrochlorothiazide

Moexipril/Hydrochlorothiazide

NORTHERA (CAPSULE) Northera

olmesartan medoxomil/hydrochlorothiazide (tablet) pentoxifylline er (tablet extended-release) propranolol/hydrochlorothiazide (tablet) quinapril/hydrochlorothiazide (tablet) Olmesartan Medoxomil/Hydrochlorothiazide

Pentoxifylline ER

Propranolol/Hydrochlorothiazide

Quinapril/Hydrochlorothiazide

RANEXA (TABLET EXTENDED-RELEASE 12 HOUR) Ranexa

spironolactone/hydrochlorothiazide (tablet) telmisartan/amlodipine (tablet) telmisartan/hydrochlorothiazide (tablet) triamterene/hydrochlorothiazide (37.5mg-25mg capsule, 50mg-25mg capsule, 37.5mg-25mg tablet, 75mg-50mg tablet) Spironolactone/Hydrochlorothiazide

Telmisartan/Amlodipine

Telmisartan/Hydrochlorothiazide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL QL

QL PA, QL QL

QL QL QL QL

Triamterene/Hydrochlorothiazide

$1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 44 53 Track Refered Purpose

53

Name of Drug

valsartan/hydrochlorothiazide (tablet) Valsartan/Hydrochlorothiazide

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use QL

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide (tablet immediate-release) acetazolamide er (capsule extended-release 12 hour) acetazolamide sodium (injection) methazolamide (tablet) Acetazolamide

Acetazolamide ER

Acetazolamide Sodium

Methazolamide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Diuretics, Loop bumetanide (0.25mg/ml injection, 0.5mg tablet, 1mg tablet, 2mg tablet) furosemide (10mg/ml injection) furosemide (10mg/ml oral solution, 8mg/ml oral solution, 20mg tablet, 40mg tablet, 80mg tablet) torsemide (tablet) Bumetanide

Furosemide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

B/D, PA

Furosemide

Torsemide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Diuretics, Potassium-sparing amiloride hcl (tablet) eplerenone (tablet) spironolactone (tablet) Amiloride HCl

Eplerenone

Spironolactone

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Diuretics, Thiazide chlorothiazide (tablet) chlorothiazide sodium (injection) chlorthalidone (tablet) Chlorothiazide

Chlorothiazide Sodium

Chlorthalidone

DIURIL (SUSPENSION) Diuril

hydrochlorothiazide (12.5mg capsule, 12.5mg tablet, 25mg tablet, 50mg tablet) indapamide (tablet) methyclothiazide (tablet) metolazone (tablet)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

B/D, PA

Hydrochlorothiazide

Indapamide

Methyclothiazide

Metolazone

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dyslipidemics, Fibric Acid Derivatives fenofibrate (160mg tablet, 54mg tablet) gemfibrozil (tablet) Fenofibrate

Gemfibrozil

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium (tablet) Atorvastatin Calcium

CRESTOR (TABLET) Crestor

fluvastatin (capsule immediate-release) Fluvastatin

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL QL

For 45 54 Track Refered Purpose

54

Name of Drug

LIVALO (TABLET) Livalo

lovastatin (tablet immediate-release) pravastatin sodium (tablet) rosuvastatin calcium (tablet) simvastatin (tablet) Lovastatin

Pravastatin Sodium

Rosuvastatin Calcium

Simvastatin

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use QL QL QL QL QL

Dyslipidemics, Other cholestyramine light (4gm packet, 4gm/dose powder) colestipol hcl (1gm tablet, 5gm granules) ezetimibe (tablet) ezetimibe/simvastatin (tablet) Cholestyramine Light

Colestipol HCl

Ezetimibe

Ezetimibe/Simvastatin

JUXTAPID (CAPSULE) Juxtapid

KYNAMRO (INJECTION) Kynamro

niacin (100mg tablet, 50mg tablet)* niacin (500mg tablet)* niacin er (rx only) (tablet extended-release) niacor (tablet) omega-3-acid ethyl esters (capsule) (generic lovaza) Niacin

Niacin

Niacin ER

Niacor

Omega-3-Acid Ethyl Esters

PRALUENT (INJECTION) Praluent

prevalite (powder) ra niacin (100mg tablet)* ra niacin (500mg tablet)* Prevalite

RA Niacin

RA Niacin

REPATHA (INJECTION) Repatha

REPATHA PUSHTRONEX SYSTEM (INJECTION) Repatha Pushtronex System

REPATHA SURECLICK (INJECTION) Repatha SureClick

VASCEPA (CAPSULE) Vascepa

VYTORIN (TABLET) Vytorin

WELCHOL (3.75GM PACKET, 625MG TABLET) Welchol

ZETIA (TABLET) Zetia

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL PA PA PA PA, QL

QL PA, QL PA PA, QL PA, QL PA, QL PA, QL QL QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 46 55 Track Refered Purpose

55

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Vasodilators, Direct-acting Arterial hydralazine hcl (100mg tablet, 10mg tablet, 25mg tablet, 50mg tablet, 20mg/ml injection) minoxidil (tablet) Hydralazine HCl

Minoxidil

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate (tablet immediate-release) isosorbide dinitrate er (tablet extended-release) isosorbide mononitrate (tablet immediate-release) isosorbide mononitrate er (tablet extended-release 24 hour) minitran (patch 24 hour) nitro-bid (ointment) nitroglycerin (0.3mg tablet sublingual, 0.4mg tablet sublingual, 0.6mg tablet sublingual, 5mg/ml injection) nitroglycerin lingual (translingual solution) nitroglycerin transdermal (patch 24 hour) Isosorbide Dinitrate

Isosorbide Dinitrate ER

Isosorbide Mononitrate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Isosorbide Mononitrate ER

Minitran

Nitro-Bid

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Nitroglycerin

Nitroglycerin Lingual

Nitroglycerin Transdermal

NITROSTAT (TABLET SUBLINGUAL) Nitrostat

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine (10mg capsule extended-release 24 hour, 15mg capsule extendedrelease 24 hour, 20mg capsule extended-release 24 hour, 25mg capsule extended-release 24 hour, 30mg capsule extended-release 24 hour, 5mg capsule extended-release 24 hour, 10mg tablet immediaterelease, 12.5mg tablet immediate-release, 15mg tablet immediate-release, 20mg tablet immediaterelease, 30mg tablet immediate-release, 5mg tablet immediate-release, 7.5mg tablet immediate-release) dextroamphetamine sulfate (tablet immediate-release) Amphetamine/Dextroamphetamine

Dextroamphetamine Sulfate

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1)

QL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines atomoxetine (capsule) clonidine hcl er (tablet extended-release 12 hour) dexmethylphenidate hcl (tablet immediate-release) dexmethylphenidate hcl er (capsule extended-release 24 hour) Atomoxetine

Clonidine HCl ER

Dexmethylphenidate HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dexmethylphenidate HCl ER

$1.20-$3.30 (Tier 1)

QL, ST PA QL

For 47 56 Track Refered Purpose

56

Name of Drug

What the drug will cost you (tier level)

guanfacine er (tablet extended-release 24 hour) methylphenidate hcl (10mg tablet immediate-release, 20mg tablet immediate-release, 5mg tablet immediate-release) (generic ritalin), (10mg/5ml oral solution, 5mg/5ml oral solution) methylphenidate hcl er (10mg tablet extendedrelease, 20mg tablet extended-release)

$1.20-$3.30 (Tier 1)

STRATTERA (CAPSULE)

Guanfacine ER

Necessary actions, restrictions, or limits on use

Methylphenidate HCl

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

QL, ST

$3.70-$8.25 (Tier 2)

PA, QL

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA PA, QL

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

QL

Methylphenidate HCl ER

Strattera

Central Nervous System, Other NAMZARIC (THERAPY PACK, CAPSULE EXTENDEDRELEASE 24 HOUR) NUEDEXTA (CAPSULE) Namzaric

Nuedexta

riluzole (tablet) tetrabenazine (tablet) Riluzole

Tetrabenazine

Fibromyalgia Agents duloxetine hcl (20mg capsule delayed-release, 30mg capsule delayed-release, 60mg capsule delayedrelease) Duloxetine HCl

LYRICA (100MG CAPSULE, 150MG CAPSULE, 200MG CAPSULE, 225MG CAPSULE, 25MG CAPSULE, 300MG CAPSULE, 50MG CAPSULE, 75MG CAPSULE, 20MG/ML ORAL SOLUTION) SAVELLA (TABLET) Lyrica

Savella

SAVELLA TITRATION PACK Savella Titration Pack

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Multiple Sclerosis Agents AMPYRA (TABLET EXTENDED-RELEASE 12 HOUR) Ampyra

AUBAGIO (TABLET) Aubagio

AVONEX (INJECTION) Avonex

AVONEX PEN (INJECTION) Avonex Pen

BETASERON (INJECTION) Betaseron

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 48 57 Track Refered Purpose

57

Name of Drug

COPAXONE (INJECTION) Copaxone

GILENYA (CAPSULE) Gilenya

glatopa (injection) Glatopa

REBIF (INJECTION) Rebif

REBIF REBIDOSE (INJECTION) Rebif Rebidose

REBIF REBIDOSE TITRATION PACK (INJECTION) Rebif Rebidose Titration Pack

REBIF TITRATION PACK (INJECTION) Rebif Titration Pack

TECFIDERA (CAPSULE DELAYED-RELEASE) Tecfidera

TECFIDERA STARTER PACK Tecfidera Starter Pack

TYSABRI (INJECTION) Tysabri

ZINBRYTA (INJECTION) Zinbryta

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use QL

QL PA PA

Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate (solution) Chlorhexidine Gluconate

KEPIVANCE (INJECTION) Kepivance

periogard (solution) pilocarpine hcl (5mg tablet, 7.5mg tablet) triamcinolone in orabase (paste) Periogard

Pilocarpine HCl

Triamcinolone in Orabase

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dermatological Agents Dermatological Agents acitretin (capsule) acne medication 10 (otc only) (10% gel)* acne medication 10 (otc only) (10% lotion)* acne medication 5 (otc only) (gel)* adapalene (0.1% cream, 0.1% gel) ammonium lactate (rx only) (12% cream, 12% lotion) anu-med (suppository)* benzoyl peroxide (otc only) (10% gel, 5% gel)* benzoyl peroxide (otc only) (2.5% gel, 5.3% foam, 9.8% foam)* blue gel (gel)* calcipotriene (0.005% cream, 0.005% external solution)

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

CALCITRIOL (3MCG/GM OINTMENT)

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Acitretin

Acne Medication 10

Acne Medication 10

Acne Medication 5

Adapalene

Ammonium Lactate

Anu-Med

Benzoyl Peroxide

QL QL

QL

Benzoyl Peroxide

Blue Gel

$0 (Tier 3) $0 (Tier 3)

Calcipotriene

Calcitriol

claravis (capsule) Claravis

$1.20-$3.30 (Tier 1) PA

For 49 58 Track Refered Purpose

58

Name of Drug

clindamycin phosphate (1% external solution, 1% gel, 1% lotion, 1% swab) clindamycin/benzoyl peroxide (1%-5% gel) (generic benzaclin) clotrimazole/betamethasone dipropionate (1%-0.05% cream, 1%-0.05% lotion) coats aloe creme (cream)* coats aloe gelly (gel)* coats aloe moisturizing lotion (lotion)* dibucaine (ointment)* diclofenac sodium (3% gel)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Clindamycin Phosphate

$1.20-$3.30 (Tier 1)

Clindamycin/Benzoyl Peroxide

$1.20-$3.30 (Tier 1)

Clotrimazole/Betamethasone Dipropionate

Coats Aloe Creme

Coats Aloe Gelly

Coats Aloe Moisturizing Lotion

Dibucaine

Diclofenac Sodium

DOXEPIN HCL (CREAM) Doxepin HCl

dr smiths diaper (ointment)* dr smiths diaper rash spray (aerosol)* dr smiths rash + skin (aerosol)* Dr Smiths Diaper

Dr Smiths Diaper Rash Spray

Dr Smiths Rash + Skin

ELIDEL (CREAM) Elidel

ery (2% pad) erythromycin (2% external solution, 2% gel) erythromycin/benzoyl peroxide (gel) Ery

Erythromycin

Erythromycin/Benzoyl Peroxide

FINACEA (15% FOAM, 15% GEL) Finacea

fluorouracil (2% external solution, 5% external solution, 5% cream) hemorrhoidal (suppository)* imiquimod (cream) major-prep hemorrhoidal (ointment)* medicated body powder* methoxsalen (capsule)

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

PA QL QL QL ST

Fluorouracil

Hemorrhoidal

Imiquimod

Major-Prep Hemorrhoidal

Medicated Body Powder

Methoxsalen

MIRVASO (GEL) Mirvaso

OXSORALEN ULTRA (CAPSULE) Oxsoralen Ultra

PICATO (GEL) Picato

$1.20-$3.30 (Tier 1) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 50 59 Track Refered Purpose

59

Name of Drug

podofilox (external solution) Podofilox

PRUDOXIN (CREAM) PRUDOXIN

REGRANEX (GEL) Regranex

SANTYL (OINTMENT) Santyl

selenium sulfide (lotion) tacrolimus (0.03% ointment, 0.1% ointment) tazarotene (cream) Selenium Sulfide

Tacrolimus

Tazarotene

TAZORAC (0.05% CREAM, 0.1% CREAM) Tazorac

thera-gesic (cream)* tretinoin (0.01% gel, 0.025% gel, 0.025% cream, 0.05% cream, 0.1% cream) tretinoin microsphere (gel) trixaicin (cream)* trixaicin hp (cream)* vitamin a & d (ointment)* white petrolatum (otc only) (gel)* zinc oxide (ointment)* Thera-Gesic

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

PA

ST PA PA

Tretinoin

Tretinoin Microsphere

Trixaicin

Trixaicin HP

Vitamin A & D

White Petrolatum

Zinc Oxide

ZYCLARA (CREAM) Zyclara

ZYCLARA PUMP (CREAM) Zyclara Pump

$1.20-$3.30 (Tier 1)

PA

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA QL

QL PA PA

Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN (INJECTION) Adagen

ALDURAZYME (INJECTION) Aldurazyme

BUPHENYL (500MG TABLET) Buphenyl

CEREZYME (INJECTION) Cerezyme

CREON (CAPSULE DELAYED-RELEASE) Creon

CYSTADANE (POWDER) Cystadane

CYSTAGON (CAPSULE) Cystagon

ELAPRASE (INJECTION) Elaprase

ELELYSO (INJECTION) Elelyso

FABRAZYME (INJECTION) KUVAN (100MG PACKET, 500MG PACKET, 100MG TABLET SOLUBLE) LUMIZYME (INJECTION) Fabrazyme

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Kuvan

Lumizyme

NAGLAZYME (INJECTION) Naglazyme

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

LA

PA

LA PA, LA

For 51 60 Track Refered Purpose

60

Name of Drug ORFADIN (10MG CAPSULE, 20MG CAPSULE, 2MG CAPSULE, 5MG CAPSULE, 4MG/ML SUSPENSION) PROCYSBI (CAPSULE DELAYED-RELEASE)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Orfadin

Procysbi

RAVICTI (LIQUID) RAVICTI

sodium phenylbutyrate (powder) Sodium Phenylbutyrate

STRENSIQ (INJECTION) Strensiq

SUCRAID (ORAL SOLUTION) Sucraid

VPRIV (INJECTION) VPRIV

ZAVESCA (CAPSULE) Zavesca

ZENPEP (CAPSULE DELAYED-RELEASE) Zenpep

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

LA QL PA, LA LA PA PA, LA

Gastrointestinal Agents Antispasmodics, Gastrointestinal ATROPINE SULFATE (INJECTION) Atropine Sulfate

CUVPOSA (ORAL SOLUTION) Cuvposa

dicyclomine hcl (10mg capsule, 10mg/5ml oral solution, 20mg tablet) glycopyrrolate (4mg/20ml injection) methscopolamine bromide (tablet)

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Dicyclomine HCl

Glycopyrrolate

Methscopolamine Bromide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Gastrointestinal Agents, Other acid gone (suspension)* actidose/sorbitol (liquid)* almacone (200mg-200mg-25mg tablet chewable, 200mg/5ml-200mg/5ml-20mg/5ml suspension)* almacone double strength (suspension)* aluminum hydroxide (suspension)* antacid calcium extra strength (tablet chewable)* antacid calcium regular strength (tablet chewable)* antacid extra strength (tablet chewable)* Acid Gone

Actidose/Sorbitol

$0 (Tier 3) $0 (Tier 3)

Almacone

Almacone Double Strength

Aluminum Hydroxide

Antacid Calcium Extra Strength

Antacid Calcium Regular Strength

Antacid Extra Strength

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 52 61 Track Refered Purpose

61

Name of Drug

antacid maximum strength (suspension)* antacid plus anti-gas relief (suspension)* anti-diarrheal (otc only) (tablet)* bismatrol (262mg tablet chewable, 262mg/15ml suspension)* bismatrol maximum strength (suspension)* calcium antacid (tablet chewable)* calcium antacid extra strength (tablet chewable)* calcium carbonate (500mg tablet chewable)* calcium carbonate (648mg tablet)* cal-gest antacid (tablet chewable)* chenodal (tablet) chewable antacid (tablet chewable)* Antacid Maximum Strength

Antacid Plus Anti-Gas Relief

Anti-Diarrheal

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL QL

Bismatrol

Bismatrol Maximum Strength

Calcium Antacid

Calcium Antacid Extra Strength

Calcium Carbonate

Calcium Carbonate

Cal-Gest Antacid

Chenodal

Chewable Antacid

CHOLBAM (CAPSULE) Cholbam

cromolyn sodium (rx only) (100mg/5ml concentrate) cvs laxative dietary supplement (tablet)* cvs magnesium (500mg tablet)* diocto (50mg/5ml liquid, 60mg/15ml syrup)* diphenoxylate/atropine (2.5mg-0.025mg tablet, 2.5mg-0.025mg/5ml liquid) docusol kids (enema)* enemeez mini (enema)* gas relief (180mg capsule, 20mg/0.3ml suspension)* gas relief (80mg tablet chewable)* gas relief extra strength (capsule)* gas relief maximum strength (tablet chewable)* Cromolyn Sodium

CVS Laxative Dietary Supplement

CVS Magnesium

Diocto

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL PA, QL PA QL QL PA PA PA QL

Diphenoxylate/Atropine

Docusol Kids

Enemeez Mini

Gas Relief

Gas Relief

Gas Relief Extra Strength

Gas Relief Maximum Strength

GATTEX (INJECTION) Gattex

gnp antacid anti-gas (suspension)* gnp masanti maximum strength (suspension)* gnp masanti regular strength (suspension)* infants gas relief (suspension)* infants simethicone (suspension)* kao-tin (262mg/15ml suspension)* loperamide hcl (1mg/5ml liquid)* loperamide hcl (1mg/7.5ml suspension)* loperamide hcl (rx only) (capsule) magnesium (500mg tablet)* GNP Antacid Anti-Gas

GNP Masanti Maximum Strength

GNP Masanti Regular Strength

Infants Gas Relief

Infants Simethicone

Kao-Tin

Loperamide HCl

Loperamide HCl

Loperamide HCl

Magnesium

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

QL QL PA QL QL QL

QL PA

For 53 62 Track Refered Purpose

62

Name of Drug

magnesium oxide (241.3mg tablet)* magnesium oxide (400mg tablet)* magnesium oxide (420mg tablet)* mi-acid (suspension)* mi-acid gas relief (tablet chewable)* mi-acid maximum strength (suspension)* milk of magnesia concentrate (suspension)* mintox maximum strength (suspension)* mytab gas (tablet chewable)* mytab gas maximum strength (tablet chewable)* Magnesium Oxide

Magnesium Oxide

Magnesium Oxide

Mi-Acid

Mi-Acid Gas Relief

Mi-Acid Maximum Strength

Milk of Magnesia Concentrate

Mintox Maximum Strength

MYTAB GAS

MYTAB GAS Maximum Strength

OCALIVA (TABLET) Ocaliva

peptic relief (tablet chewable)* pink bismuth (tablet chewable)* qc anti-diarrheal (otc only) (tablet)* ra magnesium (capsule)* Peptic Relief

Pink Bismuth

QC Anti-Diarrheal

RA Magnesium

RELISTOR (12MG/0.6ML INJECTION, 8MG/0.4ML INJECTION)

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL PA QL QL QL QL QL QL PA, QL

PA

Relistor

rulox (suspension)* Rulox

SEROSTIM (INJECTION) Serostim

simethicone (180mg capsule, 40mg/0.6ml suspension)* sm antacid anti-gas (suspension)* sm anti-diarrheal (otc only) (tablet)* sodium bicarbonate (tablet)* ursodiol (250mg tablet, 500mg tablet, 300mg capsule)

$3.70-$8.25 (Tier 2)

PA

$0 (Tier 3) $3.70-$8.25 (Tier 2)

QL PA

Simethicone

SM Antacid Anti-Gas

SM Anti-Diarrheal

Sodium Bicarbonate

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL

Ursodiol

ZORBTIVE (INJECTION) Zorbtive

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

PA

$0 (Tier 3)

QL

Histamine2 (H2) Receptor Antagonists acid reducer maximum strength (otc only) (tablet)* Acid Reducer Maximum Strength

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 54 63 Track Refered Purpose

63

Name of Drug

cimetidine (rx only) (tablet) cimetidine hcl (rx only) (oral solution) famotidine (10mg tablet)* famotidine (rx only) (20mg tablet, 40mg tablet, 20mg/ 2ml injection) famotidine premixed (injection) ranitidine 150 maximum strength (otc only) (tablet)* ranitidine 75 (tablet)* ranitidine hcl (rx only) (150mg tablet, 300mg tablet, 50mg/2ml injection) ranitidine maximum strength (otc only) (tablet)* Cimetidine

Cimetidine HCl

Famotidine

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

QL

Famotidine

Famotidine Premixed

Ranitidine 150 Maximum Strength

Ranitidine 75

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

QL QL

Ranitidine HCl

Ranitidine Maximum Strength

$1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA QL QL

Irritable Bowel Syndrome Agents alosetron hcl (tablet) Alosetron HCl

AMITIZA (CAPSULE) Amitiza

LINZESS (CAPSULE) Linzess

Laxatives bisacodyl ec (tablet delayed-release)* biscolax (suppository)* constulose (oral solution) doc-q-lace (capsule)* doc-q-lax (tablet)* docusate sodium & senna stimulant laxative/stool softener (tablet)* docusol plus mini-enema* dok (100mg capsule)* dok (100mg tablet)* dok plus (tablet)* enema ready-to-use* enemeez plus (enema)* enulose (oral solution) fiber laxative (capsule)* fiber tabs (tablet)* fiber-lax (tablet)* fleet pediatric (enema)* gavilyte-c (oral solution) gavilyte-g (oral solution) Bisacodyl EC

Biscolax

Constulose

Doc-Q-Lace

Doc-Q-Lax

$0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

QL QL QL

Docusate Sodium & Senna Stimulant Laxative/Stool Softener

Docusol Plus Mini-Enema

DOK

DOK

DOK PLUS

Enema Ready-To-Use

Enemeez Plus

Enulose

Fiber Laxative

Fiber Tabs

Fiber-Lax

Fleet Pediatric

GaviLyte-C

GaviLyte-G

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL QL QL QL

QL

For 55 64 Track Refered Purpose

64

Name of Drug

What the drug will cost you (tier level)

gavilyte-n/flavor pack (oral solution) generlac (oral solution) lactulose (oral solution) laxative (suppository)* milk of magnesia (suspension)* natural fiber therapy (powder)* peg 3350 (otc only) (packet)* peg 3350 (otc only) (powder)*

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PEG-3350/ELECTROLYTES (ORAL SOLUTION) (GENERIC GOLYTELY)

$3.70-$8.25 (Tier 2)

GaviLyte-N/Flavor Pack

Generlac

Lactulose

Laxative

Milk of Magnesia

Natural Fiber Therapy

PEG 3350

PEG 3350

Necessary actions, restrictions, or limits on use

QL

QL QL

PEG-3350/Electrolytes

peg-3350/nacl/na bicarbonate/kcl (oral solution) (generic nulytely) polyethylene glycol 3350 powder (rx only) (generic miralax) reguloid (capsule)* sani-supp adult (suppository)* sani-supp pediatric (suppository)* senexon (8.6mg tablet)* senexon (8.8mg/5ml liquid)* senna (syrup)* senna lax (tablet)* senna plus (tablet)* sennalax-s (tablet)* stimulant laxative (tablet delayed-release)* stool softener (capsule)* PEG-3350/NaCl/Na Bicarbonate/KCl

$1.20-$3.30 (Tier 1)

Polyethylene Glycol 3350 Powder

Reguloid

Sani-Supp Adult

Sani-Supp Pediatric

Senexon

Senexon

Senna

Senna Lax

Senna Plus

Sennalax-S

Stimulant Laxative

Stool Softener

SUPREP BOWEL PREP KIT (ORAL SOLUTION) Suprep Bowel Prep Kit

trilyte (oral solution) TriLyte

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL QL QL QL QL

Protectants CARAFATE (1GM/10ML SUSPENSION) Carafate

$3.70-$8.25 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 56 65 Track Refered Purpose

65

Name of Drug

misoprostol (tablet) sucralfate (tablet) Misoprostol

Sucralfate

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Proton Pump Inhibitors esomeprazole magnesium (rx only) (capsule delayedrelease) (generic nexium) esomeprazole sodium (injection) gnp omeprazole (otc only) (tablet delayed-release)* heartburn treatment 24 hour (otc only) (capsule delayed-release)* lansoprazole (otc only) (capsule delayed-release)* Esomeprazole Magnesium

Esomeprazole Sodium

GNP Omeprazole

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

Heartburn Treatment 24 Hour

Lansoprazole

NEXIUM (10MG PACKET, 2.5MG PACKET, 20MG PACKET, 40MG PACKET, 5MG PACKET) NEXIUM (RX ONLY) (20MG CAPSULE DELAYEDRELEASE, 40MG CAPSULE DELAYED-RELEASE) Nexium

$3.70-$8.25 (Tier 2)

Nexium

omeprazole (otc only) (20mg tablet delayed-release)* omeprazole (rx only) (10mg capsule delayed-release, 40mg capsule delayed-release) omeprazole (rx only) (20mg capsule delayed-release) pantoprazole sodium (20mg tablet delayed-release, 40mg tablet delayed-release) Omeprazole

$3.70-$8.25 (Tier 2)

QL

$0 (Tier 3)

QL

$1.20-$3.30 (Tier 1)

QL

Omeprazole

Omeprazole

$1.20-$3.30 (Tier 1)

Pantoprazole Sodium

$1.20-$3.30 (Tier 1)

QL

Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ (TABLET EXTENDED-RELEASE 24 HOUR) Myrbetriq

oxybutynin chloride (5mg tablet immediate-release, 5mg/5ml syrup) oxybutynin chloride er (tablet extended-release 24 hour)

$3.70-$8.25 (Tier 2)

Oxybutynin Chloride

$1.20-$3.30 (Tier 1)

Oxybutynin Chloride ER

VESICARE (TABLET) Vesicare

$1.20-$3.30 (Tier 1)

QL

$3.70-$8.25 (Tier 2)

QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL

Benign Prostatic Hypertrophy Agents alfuzosin hcl er (tablet extended-release 24 hour) finasteride (5mg tablet) (generic proscar) Alfuzosin HCl ER

Finasteride

RAPAFLO (CAPSULE) Rapaflo

tamsulosin hcl (capsule) terazosin hcl (capsule) Tamsulosin HCl

Terazosin HCl

Genitourinary Agents, Other bethanechol chloride (tablet) Bethanechol Chloride

$1.20-$3.30 (Tier 1)

For 57 66 Track Refered Purpose

66

Name of Drug

CUPRIMINE (CAPSULE) Cuprimine

DEPEN TITRATABS (TABLET) Depen Titratabs

ELMIRON (CAPSULE) Elmiron

LITHOSTAT (TABLET) Lithostat

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use PA

Phosphate Binders AURYXIA (TABLET) Auryxia

calcium acetate (667mg capsule, 667mg tablet) eliphos (tablet) Calcium Acetate

Eliphos

FOSRENOL (1000MG PACKET, 750MG PACKET, 1000MG TABLET CHEWABLE, 500MG TABLET CHEWABLE, 750MG TABLET CHEWABLE) PHOSLYRA (ORAL SOLUTION)

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Fosrenol

Phoslyra

RENAGEL (TABLET) RENVELA (0.8GM PACKET, 2.4GM PACKET, 800MG TABLET) VELPHORO (TABLET CHEWABLE) Renagel

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

ST

Renvela

Velphoro

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ala-cort (rx only) (cream) alclometasone dipropionate (0.05% cream, 0.05% ointment) augmented betamethasone dipropionate (0.05% gel, 0.05% lotion, 0.05% ointment) betamethasone dipropionate (0.05% cream, 0.05% lotion, 0.05% ointment) betamethasone valerate (0.1% cream, 0.1% lotion, 0.1% ointment) clobetasol propionate (0.05% external solution, 0.05% gel, 0.05% ointment, 0.05% shampoo) Ala-Cort

$1.20-$3.30 (Tier 1)

Alclometasone Dipropionate

$1.20-$3.30 (Tier 1)

Augmented Betamethasone Dipropionate

$1.20-$3.30 (Tier 1)

Betamethasone Dipropionate

$1.20-$3.30 (Tier 1)

Betamethasone Valerate

$1.20-$3.30 (Tier 1)

Clobetasol Propionate

$1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 58 67 Track Refered Purpose

67

Name of Drug

clobetasol propionate e (cream) cormax scalp application (external solution) cortisone acetate (tablet) Clobetasol Propionate E

Cormax Scalp Application

Cortisone Acetate

DEPO-MEDROL (20MG/ML INJECTION) Depo-Medrol

desonide (0.05% ointment) desoximetasone (0.05% cream, 0.25% cream) dexamethasone (0.5mg tablet, 0.75mg tablet, 1.5mg tablet, 1mg tablet, 2mg tablet, 4mg tablet, 6mg tablet, 0.5mg/5ml elixir) dexamethasone intensol (1mg/ml concentrate) dexamethasone sodium phosphate (10mg/ml injection, 120mg/30ml injection) fludrocortisone acetate (tablet) fluocinolone acetonide (0.01% cream, 0.025% cream, 0.01% external solution, 0.025% ointment) fluocinonide (0.05% external solution, 0.05% gel, 0.05% ointment) fluocinonide emulsified base (cream) fluticasone propionate (rx only) (0.005% ointment, 0.05% cream) halobetasol propionate (0.05% cream, 0.05% ointment) hydrocortisone (otc only) (0.5% cream, 1% cream, 1% ointment)* hydrocortisone (otc only) (0.5% ointment)* hydrocortisone (rx only) (1% cream, 2.5% cream, 1% ointment, 2.5% ointment, 10mg tablet, 20mg tablet, 5mg tablet, 2.5% lotion) hydrocortisone butyrate (0.1% ointment) hydrocortisone valerate (0.2% cream, 0.2% ointment) hydrocortisone/aloe (cream)* Desonide

Desoximetasone

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dexamethasone

Dexamethasone Intensol

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Dexamethasone Sodium Phosphate

Fludrocortisone Acetate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Fluocinolone Acetonide

$1.20-$3.30 (Tier 1)

Fluocinonide

Fluocinonide Emulsified Base

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Fluticasone Propionate

$1.20-$3.30 (Tier 1)

Halobetasol Propionate

$1.20-$3.30 (Tier 1)

Hydrocortisone

Hydrocortisone

$0 (Tier 3) $0 (Tier 3)

Hydrocortisone

Hydrocortisone Butyrate

Hydrocortisone Valerate

Hydrocortisone/Aloe

KENALOG-10 (INJECTION) Kenalog-10

KENALOG-40 (INJECTION) Kenalog-40

methylprednisolone (tablet) methylprednisolone acetate (injection) methylprednisolone dose pack (tablet therapy pack) methylprednisolone sodium succinate (injection) Methylprednisolone

Methylprednisolone Acetate

Methylprednisolone Dose Pack

Methylprednisolone Sodium Succinate

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL

For 59 68 Track Refered Purpose

68

Name of Drug

mometasone furoate (0.1% cream, 0.1% external solution, 0.1% ointment)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Mometasone Furoate

PREDNICARBATE (0.1% CREAM) Prednicarbate

prednicarbate (0.1% ointment) prednisolone sodium phosphate (10mg/5ml oral solution, 15mg/5ml oral solution, 20mg/5ml oral solution, 25mg/5ml oral solution, 5mg/5ml oral solution) prednisone (10mg tablet therapy pack, 5mg tablet therapy pack, 10mg tablet, 1mg tablet, 2.5mg tablet, 20mg tablet, 50mg tablet, 5mg tablet, 5mg/5ml oral solution) prednisone intensol (5mg/ml concentrate) Prednicarbate

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Prednisolone Sodium Phosphate

$1.20-$3.30 (Tier 1)

Prednisone

Prednisone Intensol

SOLU-CORTEF (INJECTION) Solu-Cortef

SOLU-MEDROL (2GM INJECTION) Solu-Medrol

triamcinolone acetonide (0.025% cream, 0.1% cream, 0.5% cream, 0.025% lotion, 0.1% lotion, 0.025% ointment, 0.1% ointment, 0.5% ointment) triderm (cream)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Triamcinolone Acetonide

Triderm

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) CHORIONIC GONADOTROPIN (INJECTION) DESMOPRESSIN ACETATE (0.01% NASAL RHINAL TUBE SOLUTION) Chorionic Gonadotropin

$3.70-$8.25 (Tier 2)

PA

Desmopressin Acetate

desmopressin acetate (0.01% nasal spray solution, 0.1mg tablet, 0.2mg tablet, 4mcg/ml injection)

$3.70-$8.25 (Tier 2)

Desmopressin Acetate

GENOTROPIN (12MG INJECTION, 5MG INJECTION) Genotropin

GENOTROPIN MINIQUICK (INJECTION) Genotropin Miniquick

HUMATROPE (INJECTION) Humatrope

HUMATROPE COMBO PACK (INJECTION) Humatrope Combo Pack

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 60 69 Track Refered Purpose

69

Name of Drug

INCRELEX (INJECTION) Increlex

NORDITROPIN FLEXPRO (INJECTION) Norditropin FlexPro

NOVAREL (INJECTION) Novarel

NUTROPIN AQ (INJECTION) PREGNYL W/DILUENT BENZYL ALCOHOL/NACL (INJECTION) SAIZEN (INJECTION) Nutropin AQ

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA

Pregnyl w/Diluent Benzyl Alcohol/NaCl

Saizen

ZOMACTON (10MG INJECTION) Zomacton

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM (TABLET) Korlym

$3.70-$8.25 (Tier 2)

PA, QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Androgens ANADROL-50 (TABLET) Anadrol-50

ANDRODERM (PATCH 24 HOUR) Androderm

ANDROGEL (1.62% PACKET GEL) AndroGel

ANDROGEL PUMP (1.62% GEL) AndroGel Pump

danazol (capsule) oxandrolone (tablet) testosterone cypionate (injection) testosterone enanthate (injection) Danazol

Oxandrolone

Testosterone Cypionate

Testosterone Enanthate

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Estrogens alyacen 1/35 (tablet) amethia (tablet) amethia lo (tablet) apri (tablet) aranelle (tablet) ashlyna (tablet) aubra (tablet) aviane (tablet) balziva (tablet) bekyree (tablet) blisovi 24 fe (tablet) blisovi fe 1.5/30 (tablet) Alyacen 1/35

Amethia

Amethia Lo

Apri

Aranelle

Ashlyna

Aubra

Aviane

Balziva

Bekyree

Blisovi 24 Fe

Blisovi Fe 1.5/30

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA QL

PA, QL

For 61 70 Track Refered Purpose

70

Name of Drug

blisovi fe 1/20 (tablet) briellyn (tablet) Blisovi Fe 1/20

Briellyn

CAMRESE LO (TABLET) Camrese Lo

caziant (tablet) Caziant

CLIMARA PRO (PATCH WEEKLY) Climara Pro

cryselle-28 (tablet) cyclafem (tablet) delyla (tablet) desogestrel/ethinyl estradiol (tablet) drospirenone/ethinyl estradiol (tablet) Cryselle-28

Cyclafem

Delyla

Desogestrel/Ethinyl Estradiol

Drospirenone/Ethinyl Estradiol

DUAVEE (TABLET) Duavee

ELESTRIN (GEL) Elestrin

emoquette (tablet) enpresse-28 (tablet) estradiol (0.025mg/24hr patch weekly, 0.05mg/24hr patch weekly, 0.06mg/24hr patch weekly, 0.075mg/ 24hr patch weekly, 0.1mg/24hr patch weekly, 37.5mcg/24hr patch weekly) estradiol (0.5mg tablet, 1mg tablet, 2mg tablet) (generic estrace) estradiol valerate (injection) Emoquette

Enpresse-28

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Estradiol

$1.20-$3.30 (Tier 1)

QL

Estradiol

Estradiol Valerate

ESTRING (RING) Estring

ethynodiol diacetate/ethinyl estradiol (tablet) falmina (tablet) femynor (tablet) Ethynodiol Diacetate/Ethinyl Estradiol

Falmina

Femynor

GIANVI (TABLET) Gianvi

gildagia (tablet) introvale (tablet) isibloom (tablet) jinteli (tablet) Gildagia

Introvale

Isibloom

Jinteli

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 62 71 Track Refered Purpose

71

Name of Drug

juleber (tablet) junel 1.5/30 (tablet) junel 1/20 (tablet) junel fe 1.5/30 (tablet) junel fe 1/20 (tablet) junel fe 24 (tablet) kaitlib fe (tablet chewable) kariva (tablet) kelnor 1/35 (tablet) kimidess (tablet) larin 1.5/30 (tablet) larin 1/20 (tablet) larin fe 1.5/30 (tablet) larin fe 1/20 (tablet) larissia (tablet) Juleber

Junel 1.5/30

Junel 1/20

Junel Fe 1.5/30

Junel Fe 1/20

Junel Fe 24

Kaitlib Fe

Kariva

Kelnor 1/35

Kimidess

LARIN 1.5/30

LARIN 1/20

LARIN Fe 1.5/30

LARIN Fe 1/20

Larissia

LAYOLIS FE (TABLET CHEWABLE) Layolis Fe

LEENA (TABLET) Leena

lessina (tablet) levonest (tablet) levonorgestrel and ethinyl estradiol (tablet) levonorgestrel/ethinyl estradiol (tablet) levora 0.15/30-28 (tablet) lomedia 24 fe (tablet) loryna (tablet) low-ogestrel (tablet) lutera (tablet) marlissa (tablet) menest (tablet) mibelas 24 fe (tablet chewable) Lessina

Levonest

Levonorgestrel and Ethinyl Estradiol

Levonorgestrel/Ethinyl Estradiol

Levora 0.15/30-28

Lomedia 24 Fe

Loryna

Low-Ogestrel

Lutera

Marlissa

Menest

Mibelas 24 Fe

MICROGESTIN 1.5/30 (TABLET) Microgestin 1.5/30

MICROGESTIN 1/20 (TABLET) Microgestin 1/20

MICROGESTIN FE (TABLET) Microgestin Fe

MICROGESTIN FE 1.5/30 (TABLET) Microgestin Fe 1.5/30

MONONESSA (TABLET) MonoNessa

necon 0.5/35-28 (tablet) Necon 0.5/35-28

NECON 1/50-28 (TABLET) Necon 1/50-28

NECON 7/7/7 (TABLET) Necon 7/7/7

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

For 63 72 Track Refered Purpose

72

Name of Drug

nikki (tablet) norethindrone acetate/ethinyl estradiol (20mcg-1mg tablet) Nikki

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1)

Norethindrone Acetate/Ethinyl Estradiol

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/ FERROUS FUMARATE (20MCG-75MG-1MG TABLET CHEWABLE)

$1.20-$3.30 (Tier 1)

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

norethindrone acetate/ethinyl estradiol/ferrous fumarate (20mcg-75mg-1mg tablet) norethindrone/ethinyl estradiol/ferrous fumarate (0.8mg-25mcg tablet chewable) norgestimate/ethinyl estradiol (tablet) nortrel 0.5/35 (28) (tablet) nortrel 1/35 (tablet) nortrel 7/7/7 (tablet)

$3.70-$8.25 (Tier 2)

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

$1.20-$3.30 (Tier 1)

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate

Norgestimate/Ethinyl Estradiol

Nortrel 0.5/35

Nortrel 1/35

Nortrel 7/7/7

NUVARING (RING) NuvaRing

OCELLA (TABLET) Ocella

ogestrel (tablet) orsythia (tablet) pimtrea (tablet) pirmella 1/35 (tablet) portia-28 (tablet) Ogestrel

Orsythia

Pimtrea

Pirmella 1/35

Portia-28

PREMARIN (0.3MG TABLET, 0.45MG TABLET, 0.625MG TABLET, 0.9MG TABLET, 1.25MG TABLET) PREMARIN (VAGINAL CREAM)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Premarin

Premarin

PREMPHASE (TABLET) Premphase

PREMPRO (TABLET) Prempro

previfem (tablet) quasense (tablet) reclipsen (tablet) setlakin (tablet) Previfem

Quasense

Reclipsen

Setlakin

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 64 73 Track Refered Purpose

73

Name of Drug

sprintec 28 (tablet) sronyx (tablet) tarina fe 1/20 (tablet) tri-legest fe (tablet) tri-lo-estarylla (tablet) tri-lo-sprintec (tablet) tri-previfem (tablet) tri-sprintec (tablet) Sprintec 28

Sronyx

Tarina Fe 1/20

Tri-Legest Fe

Tri-Lo-Estarylla

Tri-Lo-Sprintec

Tri-Previfem

Tri-Sprintec

TRINESSA (TABLET) Trinessa

trivora-28 (tablet) velivet (tablet) vestura (tablet) vienva (tablet) vyfemla (tablet) Trivora-28

Velivet

Vestura

Vienva

Vyfemla

WYMZYA FE (TABLET CHEWABLE) WYMZYA Fe

zarah (tablet) zenchent (tablet) zenchent fe (tablet chewable) zovia 1/35e (tablet) zovia 1/50e (tablet) Zarah

Zenchent

Zenchent Fe

Zovia 1/35E

Zovia 1/50E

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Progestins camila (tablet) Camila

CRINONE (GEL) Crinone

deblitane (tablet) Deblitane

DEPO-PROVERA (INJECTION) Depo-Provera

econtra ez (otc only) (tablet)* errin (tablet) fallback solo (otc only) (tablet)* hydroxyprogesterone caproate (injection) Econtra EZ

Errin

Fallback Solo

Hydroxyprogesterone Caproate

JOLIVETTE (TABLET) Jolivette

lyza (tablet) Lyza

MAKENA (INJECTION) Makena

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

medroxyprogesterone acetate (10mg tablet, 2.5mg tablet, 5mg tablet, 150mg/ml injection)

$1.20-$3.30 (Tier 1)

MEGACE ES (SUSPENSION)

$3.70-$8.25 (Tier 2)

Medroxyprogesterone Acetate

Megace ES

PA

QL QL PA

PA

For 65 74 Track Refered Purpose

74

Name of Drug

megestrol acetate (20mg tablet, 40mg tablet, 40mg/ ml suspension, 625mg/5ml suspension) my way (otc only) (tablet)* next choice one dose (otc only) (tablet)*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Megestrol Acetate

My Way

Next Choice One Dose

NORA-BE (TABLET) Nora-BE

norethindrone (0.35mg tablet) norethindrone acetate (5mg tablet) norlyroc (tablet) opcicon one-step (otc only) (tablet)* sharobel (tablet) Norethindrone

Norethindrone Acetate

Norlyroc

Opcicon One-Step

Sharobel

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $1.20-$3.30 (Tier 1)

QL QL

$1.20-$3.30 (Tier 1)

QL

QL

Selective Estrogen Receptor Modifying Agents raloxifene hcl (tablet) Raloxifene HCl

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) LEVOTHYROXINE SODIUM (100MCG INJECTION)

$3.70-$8.25 (Tier 2)

levothyroxine sodium (100mcg tablet, 112mcg tablet, 125mcg tablet, 137mcg tablet, 150mcg tablet, 175mcg tablet, 200mcg tablet, 25mcg tablet, 300mcg tablet, 50mcg tablet, 75mcg tablet, 88mcg tablet)

$1.20-$3.30 (Tier 1)

LEVOXYL (TABLET)

$3.70-$8.25 (Tier 2)

liothyronine sodium (10mcg/ml injection, 25mcg tablet, 50mcg tablet, 5mcg tablet)

$1.20-$3.30 (Tier 1)

Levothyroxine Sodium

Levothyroxine Sodium

Levoxyl

Liothyronine Sodium

SYNTHROID (TABLET) Synthroid

UNITHROID (TABLET) Unithroid

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN (TABLET) Lysodren

$3.70-$8.25 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 66 75 Track Refered Purpose

75

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR (TABLET) Sensipar

$3.70-$8.25 (Tier 2)

QL

Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline (tablet) Cabergoline

EGRIFTA (INJECTION) Egrifta

FIRMAGON (INJECTION) Firmagon

leuprolide acetate (injection) Leuprolide Acetate

LUPANETA PACK (KIT) Lupaneta Pack

LUPRON DEPOT (1-MONTH) (INJECTION) Lupron Depot

LUPRON DEPOT (3-MONTH) (INJECTION) Lupron Depot

LUPRON DEPOT (4-MONTH) (INJECTION) Lupron Depot

LUPRON DEPOT (6-MONTH) (INJECTION) Lupron Depot

LUPRON DEPOT-PED (1-MONTH) (INJECTION) Lupron Depot-Ped

octreotide acetate (injection) Octreotide Acetate

SANDOSTATIN LAR DEPOT (INJECTION) Sandostatin LAR Depot

SIGNIFOR (INJECTION) Signifor

SOMATULINE DEPOT (INJECTION) Somatuline Depot

SOMAVERT (INJECTION) Somavert

SYNAREL (NASAL SOLUTION) Synarel

TRELSTAR MIXJECT (INJECTION) Trelstar Mixject

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA PA PA PA PA PA PA PA PA PA PA, QL PA

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (tablet) propylthiouracil (tablet) Methimazole

Propylthiouracil

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Immunological Agents Angioedema (HAE) Agents BERINERT (INJECTION) Berinert

CINRYZE (INJECTION) Cinryze

FIRAZYR (INJECTION) Firazyr

RUCONEST (INJECTION) Ruconest

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, LA PA, LA PA, QL PA

For 67 76 Track Refered Purpose

76

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Immune Suppressants azathioprine (100mg injection, 50mg tablet) Azathioprine

CELLCEPT INTRAVENOUS (INJECTION) Cellcept Intravenous

CIMZIA (INJECTION) Cimzia

COSENTYX (INJECTION) Cosentyx

COSENTYX SENSOREADY PEN (INJECTION) Cosentyx Sensoready Pen

cyclosporine (100mg capsule, 25mg capsule) cyclosporine (50mg/ml injection) cyclosporine modified (100mg capsule, 25mg capsule, 50mg capsule, 100mg/ml oral solution) Cyclosporine

Cyclosporine

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

B/D, PA PA PA PA PA B/D, PA

$1.20-$3.30 (Tier 1)

B/D, PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA

$1.20-$3.30 (Tier 1)

B/D, PA

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA PA

$1.20-$3.30 (Tier 1)

PA

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

B/D, PA PA

Cyclosporine Modified

ENBREL (INJECTION) Enbrel

ENBREL SURECLICK (INJECTION) Enbrel SureClick

gengraf (100mg capsule, 25mg capsule, 50mg capsule, 100mg/ml oral solution) Gengraf

HUMIRA (INJECTION) HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK (INJECTION) HUMIRA PEN (INJECTION) HUMIRA PEN CROHNS DISEASE STARTER PACK (INJECTION) HUMIRA PEN-PSORIASIS STARTER (INJECTION) Humira

Humira Pediatric Crohns Disease Starter Pack

Humira Pen

Humira Pen Crohns Disease Starter Pack

Humira Pen-Psoriasis Starter

KINERET (INJECTION) Kineret

methotrexate (tablet) methotrexate sodium (injection) mycophenolate mofetil (200mg/ml suspension, 250mg capsule, 500mg injection, 500mg tablet) mycophenolic acid dr (tablet delayed-release) Methotrexate

Methotrexate Sodium

Mycophenolate Mofetil

Mycophenolic Acid DR

NULOJIX (INJECTION) Nulojix

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 68 77 Track Refered Purpose

77

Name of Drug ORENCIA (125MG/ML INJECTION, 50MG/0.4ML INJECTION, 87.5MG/0.7ML INJECTION, 250MG INJECTION) ORENCIA CLICKJECT (INJECTION)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Orencia

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

PA PA B/D, PA PA B/D, PA PA PA B/D, PA

STELARA (130MG/26ML INJECTION, 45MG/0.5ML INJECTION, 90MG/ML INJECTION)

$3.70-$8.25 (Tier 2)

PA

tacrolimus (0.5mg capsule, 1mg capsule, 5mg capsule)

$1.20-$3.30 (Tier 1)

PA

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA, QL PA, QL PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA PA

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA PA PA PA PA

Orencia Clickject

PROGRAF (5MG/ML INJECTION) Prograf

RAPAMUNE (1MG/ML ORAL SOLUTION) Rapamune

REMICADE (INJECTION) Remicade

SANDIMMUNE (100MG/ML ORAL SOLUTION) Sandimmune

SIMPONI (INJECTION) Simponi

SIMPONI ARIA (INJECTION) Simponi Aria

sirolimus (tablet) Sirolimus

Stelara

Tacrolimus

TORISEL (INJECTION) Torisel

trexall (tablet) Trexall

XATMEP (ORAL SOLUTION) Xatmep

XELJANZ (TABLET) Xeljanz

XELJANZ XR (TABLET EXTENDED-RELEASE 24 HOUR) Xeljanz XR

ZORTRESS (TABLET) Zortress

Immunizing Agents, Passive ATGAM (INJECTION) Atgam

BIVIGAM (INJECTION) BIVIGAM

CARIMUNE NANOFILTERED (INJECTION) Carimune Nanofiltered

FLEBOGAMMA DIF (INJECTION) Flebogamma DIF

GAMASTAN S/D (INJECTION) Gamastan S/D

GAMMAGARD LIQUID (INJECTION) GAMMAGARD S/D IGA LESS THAN 1 MCG/ML (INJECTION) GAMMAKED (INJECTION) Gammagard Liquid

Gammagard S/D IGA Less Than 1 mcg/ml

Gammaked

GAMMAPLEX (INJECTION) Gammaplex

GAMUNEX-C (INJECTION) Gamunex-C

OCTAGAM (INJECTION) Octagam

PRIVIGEN (INJECTION) Privigen

THYMOGLOBULIN (INJECTION) Thymoglobulin

VARIZIG (INJECTION) Varizig

For 69 78 Track Refered Purpose

78

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Immunomodulators ACTEMRA (162MG/0.9ML INJECTION, 200MG/10ML INJECTION, 400MG/20ML INJECTION, 80MG/4ML INJECTION) ACTIMMUNE (INJECTION) Actemra

Actimmune

ARCALYST (INJECTION) Arcalyst

BENLYSTA (INJECTION) Benlysta

ILARIS (INJECTION) Ilaris

leflunomide (tablet) Leflunomide

OTEZLA (TABLET THERAPY PACK, 30MG TABLET) Otezla

RIDAURA (CAPSULE) Ridaura

SIMULECT (INJECTION) Simulect

SYNAGIS (INJECTION) Synagis

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA

PA, LA PA PA, QL, LA PA

PA

Vaccines ACTHIB (INJECTION) ActHIB

ADACEL (INJECTION) Adacel

BCG VACCINE (INJECTION) BCG Vaccine

BEXSERO (INJECTION) Bexsero

BOOSTRIX (INJECTION) Boostrix

DAPTACEL (INJECTION) DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC (INJECTION) ENGERIX-B (INJECTION) Daptacel

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Diphtheria/Tetanus Toxoids Adsorbed Pediatric

Engerix-B

GARDASIL 9 (INJECTION) Gardasil 9

HAVRIX (INJECTION) Havrix

HIBERIX (INJECTION) Hiberix

IMOVAX RABIES (H.D.C.V.) (INJECTION) Imovax Rabies

INFANRIX (INJECTION) Infanrix

IPOL INACTIVATED IPV (INJECTION) IPOL Inactivated IPV

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

B/D, PA

B/D, PA

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 70 79 Track Refered Purpose

79

Name of Drug

IXIARO (INJECTION) Ixiaro

KINRIX (INJECTION) Kinrix

M-M-R II (INJECTION) M-M-R II

MENACTRA (INJECTION) Menactra

MENVEO (INJECTION) Menveo

PEDIARIX (INJECTION) Pediarix

PEDVAX HIB (INJECTION) Pedvax HIB

PROQUAD (INJECTION) ProQuad

QUADRACEL (INJECTION) Quadracel

RABAVERT (INJECTION) Rabavert

RECOMBIVAX HB (INJECTION) Recombivax HB

ROTARIX (SUSPENSION) Rotarix

ROTATEQ (ORAL SOLUTION) RotaTeq

TENIVAC (INJECTION) TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT (INJECTION) TRUMENBA (INJECTION) Tenivac

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

B/D, PA B/D, PA

Tetanus/Diphtheria Toxoids-Adsorbed Adult

Trumenba

TWINRIX (INJECTION) Twinrix

TYPHIM VI (INJECTION) Typhim Vi

VAQTA (INJECTION) VAQTA

VARIVAX (INJECTION) Varivax

YF-VAX (INJECTION) YF-Vax

ZOSTAVAX (INJECTION) Zostavax

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA

Inflammatory Bowel Disease Agents Aminosalicylates APRISO (CAPSULE EXTENDED-RELEASE 24 HOUR) Apriso

balsalazide disodium (capsule) Balsalazide Disodium

CANASA (SUPPOSITORY) Canasa

DIPENTUM (CAPSULE) Dipentum

LIALDA (TABLET DELAYED-RELEASE) Lialda

mesalamine (kit) mesalamine dr (1.2gm tablet delayed-release) Mesalamine

Mesalamine DR

SFROWASA (ENEMA) sfRowasa

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Glucocorticoids budesonide (3mg capsule delayed-release) Budesonide

$1.20-$3.30 (Tier 1)

QL

QL QL QL

For 71 80 Track Refered Purpose

80

Name of Drug

colocort (enema) Colocort

HYDROCORTISONE (RX ONLY) (100MG/60ML ENEMA) Hydrocortisone

procto-med hc (cream) procto-pak (cream) proctosol hc (cream) proctozone-hc (cream) Procto-Med HC

Procto-Pak

Proctosol HC

Proctozone-HC

UCERIS (9MG TABLET EXTENDED-RELEASE 24 HOUR) Uceris

What the drug will cost you (tier level) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

ST

Sulfonamides sulfasalazine (500mg tablet delayed-release, 500mg tablet immediate-release) Sulfasalazine

$1.20-$3.30 (Tier 1)

Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium (10mg tablet, 35mg tablet, 40mg tablet, 5mg tablet, 70mg tablet) alendronate sodium (70mg/75ml oral solution) Alendronate Sodium

Alendronate Sodium

BINOSTO (TABLET EFFERVESCENT) Binosto

calcitonin-salmon (nasal solution) calcitriol (0.25mcg capsule, 0.5mcg capsule, 1mcg/ ml injection, 1mcg/ml oral solution) doxercalciferol (0.5mcg capsule, 1mcg capsule, 2.5mcg capsule) doxercalciferol (4mcg/2ml injection) etidronate disodium (tablet) Calcitonin-Salmon

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL

$1.20-$3.30 (Tier 1)

B/D, PA

$1.20-$3.30 (Tier 1)

B/D, PA, QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

B/D, PA

Calcitriol

Doxercalciferol

Doxercalciferol

Etidronate Disodium

FORTEO (INJECTION) Forteo

MIACALCIN (INJECTION) Miacalcin

NATPARA (INJECTION) Natpara

pamidronate disodium (injection) paricalcitol (1mcg capsule, 2mcg capsule) Pamidronate Disodium

Paricalcitol

PA, QL PA PA B/D, PA B/D, PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 72 81 Track Refered Purpose

81

Name of Drug

paricalcitol (2mcg/ml injection, 5mcg/ml injection, 4mcg capsule)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Paricalcitol

PROLIA (INJECTION) Prolia

TYMLOS (INJECTION) Tymlos

XGEVA (INJECTION) ZEMPLAR (2MCG/ML INJECTION, 5MCG/ML INJECTION) Xgeva

$1.20-$3.30 (Tier 1)

B/D, PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL PA

$3.70-$8.25 (Tier 2)

B/D, PA

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

B/D, PA PA

Zemplar

zoledronic acid (4mg/5ml injection) zoledronic acid (5mg/100ml injection) Zoledronic Acid

Zoledronic Acid

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents 1st tier unilet comfortouch lancets 28g* 1st tier unilet comfortouch lancets 30g* accu-chek aviva (strip)* accu-chek aviva plus (strip)* accu-chek compact plus (strip)* accu-chek fastclix lancet device kit* accu-chek fastclix lancets* accu-chek multiclix lancet device kit* accu-chek multiclix lancets* accu-chek smartview strips* accu-chek soft touch lancets* accu-chek softclix lancet device kit* accu-chek softclix lancets* accutrend glucose (strip)* acura blood glucose test strips* advocate lancets* advocate redi-code (strip)* advocate redi-code+ test strips* advocate test strips* agamatrix amp no code test strips* agamatrix jazz test strips* agamatrix presto test strips* agamatrix ultra-thin lancets 33g* alcohol prep pads (otc only) assure 4 test strips* 1st Tier Unilet Comfortouch Lancets 28g

1st Tier Unilet Comfortouch Lancets 30g

Accu-Chek Aviva

Accu-Chek Aviva Plus

Accu-Chek Compact Plus

Accu-Chek Fastclix Lancet Device Kit

Accu-Chek Fastclix Lancets

Accu-Chek Multiclix Lancet Device Kit

Accu-Chek Multiclix Lancets

Accu-Chek Smartview Strips

Accu-Chek Soft Touch Lancets

Accu-Chek Softclix Lancet Device Kit

Accu-Chek Softclix Lancets

Accutrend Glucose

Acura Blood Glucose Test Strips

Advocate Lancets

Advocate Redi-Code

Advocate Redi-Code+ Test Strips

Advocate Test Strips

Agamatrix Amp No Code Test Strips

Agamatrix Jazz Test Strips

Agamatrix Presto Test Strips

Agamatrix Ultra-Thin Lancets 33g

Alcohol Prep Pads

Assure 4 Test Strips

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3)

QL QL QL QL QL QL QL QL QL

For 73 82 Track Refered Purpose

82

Name of Drug

assure lance lancets* assure lance plus safety lancets 25g* assure lance plus safety lancets 30g* assure platinum test strips* assure prism multi test strips* assure pro test strips* autolet impression* autolet impression lancing device* bayer breeze 2 test disc (disk)* bayer contour blood glucose test strips* bayer contour next blood glucose test (strip)* bayer microlet 2 lancing device* bg star blood glucose test (strip)* blood glucose test strips* blood glucose test strips premium* Assure Lance Lancets

Assure Lance Plus Safety Lancets 25g

Assure Lance Plus Safety Lancets 30g

Assure Platinum Test Strips

Assure Prism Multi Test Strips

Assure Pro Test Strips

Autolet Impression

Autolet Impression Lancing Device

Bayer Breeze 2 Test Disc

Bayer Contour Blood Glucose Test Strips

Bayer Contour Next Blood Glucose Test

Bayer Microlet 2 Lancing Device

BG Star Blood Glucose Test

Blood Glucose Test Strips

Blood Glucose Test Strips Premium

BOTOX (INJECTION) Botox

careone blood glucose test strips/premium* careone blood glucose test strips/value* caresens n blood glucose test strips* clever chek auto-code test strips* clever chek auto-code voice test strips* clever chek lancets ultrathin 30g* clever chek test strips* clever choice auto-code pro test strips* clever choice micro test strips* control ast (strip)* control test strips* cvs advanced glucose meter test strips* cvs lancets micro thin 33g* Careone Blood Glucose Test Strips/Premium

Careone Blood Glucose Test Strips/Value

Caresens N Blood Glucose Test Strips

Clever Chek Auto-Code Test Strips

Clever Chek Auto-Code Voice Test Strips

Clever Chek Lancets Ultrathin 30g

Clever Chek Test Strips

Clever Choice Auto-Code Pro Test Strips

Clever Choice Micro Test Strips

Control AST

Control Test Strips

CVS Advanced Glucose Meter Test Strips

CVS Lancets Micro Thin 33g

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

QL QL QL

PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 74 83 Track Refered Purpose

83

Name of Drug

cvs lancets thin 26g* cvs lancets ultra thin 30g* cvs lancing device* diatrue plus blood glucose test strips* easy plus ii blood glucose test (strip)* easy step test strips* easy talk blood glucose test strips* easy touch glucose test strips* easy touch lancets 26g/pressure activated* easy touch lancets 28g/twist* easy touch lancets 30g/twist* easy touch lancets 32g/twist* easy touch lancets 33g/twist* easy touch safety lancets26g/pressure activated* easy touch safety lancets28g/button activated* easy touch safety lancets28g/pressure activated* easy trak blood glucose test strips* easygluco (strip)* easymax 15 test strips* easymax test strips* element compact test strips* element test strips* embrace blood glucose test strips* embrace evo blood glucose test strips* embrace pro blood glucose test strips* evencare + blood glucose test strip* evencare blood glucose test strip* evencare g2 test strips* evencare g3 test strips* evolution autocode (strip)* CVS Lancets Thin 26g

CVS Lancets Ultra Thin 30g

CVS Lancing Device

Diatrue Plus Blood Glucose Test Strips

Easy Plus II Blood Glucose Test

Easy Step Test Strips

Easy Talk Blood Glucose Test Strips

Easy Touch Glucose Test Strips

Easy Touch Lancets 26g/Pressure Activated

Easy Touch Lancets 28g/Twist

Easy Touch Lancets 30g/Twist

Easy Touch Lancets 32g/Twist

Easy Touch Lancets 33g/Twist

Easy Touch Safety Lancets26g/Pressure Activated

Easy Touch Safety Lancets28g/Button Activated

Easy Touch Safety Lancets28g/Pressure Activated

Easy Trak Blood Glucose Test Strips

EasyGluco

EASYMax 15 Test Strips

EASYMax Test Strips

Element Compact Test Strips

Element Test Strips

Embrace Blood Glucose Test Strips

Embrace Evo Blood Glucose Test Strips

Embrace Pro Blood Glucose Test Strips

EvenCare + Blood Glucose Test Strip

EvenCare Blood Glucose Test Strip

EvenCare G2 Test Strips

EvenCare G3 Test Strips

Evolution Autocode

EXONDYS 51 (INJECTION) Exondys 51

e-z ject lancets color* e-z ject lancets super thin 30g* e-z ject lancets thin 26g* ez smart blood glucose test strips* ez smart plus blood glucose test strips* fifty50 glucose test strip 2.0* E-Z Ject Lancets Color

E-Z Ject Lancets Super Thin 30g

E-Z Ject Lancets Thin 26g

Ez Smart Blood Glucose Test Strips

Ez Smart Plus Blood Glucose Test Strips

Fifty50 Glucose Test Strip 2.0

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

QL QL

PA, LA

For 75 84 Track Refered Purpose

84

Name of Drug

fine 30* fomepizole (injection) fora d10 blood glucose test strips* fora d15g blood glucose test strips* fora d20 blood glucose test strips* fora g20 blood glucose test strips* fora g30a blood glucose test strips* fora gd20 test strips* fora lancets* fora v10 blood glucose test strips* fora v12 blood glucose test strips* fora v20 blood glucose test strips* fora v30a blood glucose test strips* foracare gd40 (strip)* foracare premium v10 test strips* foracare test n go test strips* freestyle insulinx blood glucose test (strip)* freestyle insulinx blood glucose test strips* freestyle lancets* freestyle lite test strips* freestyle test strips* freestyle unistick ii lancets* gauze (non-medicated 2x2) ge100 blood glucose test strips* glucocard 01 sensor plus test strips* glucocard expression blood glucose test strips* glucocard vital test strips* glucocom test strips* glucolet 2 automatic lancing device* Fine 30

Fomepizole

Fora D10 Blood Glucose Test Strips

Fora D15g Blood Glucose Test Strips

Fora D20 Blood Glucose Test Strips

Fora G20 Blood Glucose Test Strips

Fora G30a Blood Glucose Test Strips

Fora GD20 Test Strips

Fora Lancets

Fora V10 Blood Glucose Test Strips

Fora V12 Blood Glucose Test Strips

Fora V20 Blood Glucose Test Strips

Fora V30a Blood Glucose Test Strips

ForaCare GD40

ForaCare Premium V10 Test Strips

ForaCare Test N Go Test Strips

FreeStyle Insulinx Blood Glucose Test

FreeStyle Insulinx Blood Glucose Test Strips

FreeStyle Lancets

FreeStyle Lite Test Strips

FreeStyle Test Strips

FreeStyle Unistick II Lancets

Gauze

GE100 Blood Glucose Test Strips

Glucocard 01 Sensor Plus Test Strips

Glucocard Expression Blood Glucose Test Strips

Glucocard Vital Test Strips

GlucoCom Test Strips

Glucolet 2 Automatic Lancing Device

What the drug will cost you (tier level) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 76 85 Track Refered Purpose

85

Name of Drug

gluconavii blood glucose test strips* gmate blood glucose test strips* health care lancing device* hypolance ast lancing kit* infinity blood glucose test strips* insulin syringes, needles iosat (tablet)* GlucoNavii Blood Glucose Test Strips

Gmate Blood Glucose Test Strips

Health Care Lancing Device

Hypolance AST Lancing Kit

Infinity Blood Glucose Test Strips

Insulin Syringes, Needles

Iosat

KANUMA (INJECTION) Kanuma

kroger blood glucose test strips* kroger premium blood glucose test strips* kroger test strips* lancets ultra thin* liberty test strips* live better advanced lancing device* maxima blood glucose test strips* medlance plus lancets* meijer blood glucose test strips* meijer premium blood glucose test strips* microdot test strips* Kroger Blood Glucose Test Strips

Kroger Premium Blood Glucose Test Strips

Kroger Test Strips

Lancets Ultra Thin

Liberty Test Strips

Live Better Advanced Lancing Device

Maxima Blood Glucose Test Strips

Medlance Plus Lancets

Meijer Blood Glucose Test Strips

Meijer Premium Blood Glucose Test Strips

Microdot Test Strips

MYALEPT (INJECTION) Myalept

myglucohealth blood glucose test (strip)* neutek 2tek test strips* nova max glucose test strips* nova sureflex lancets* nova sureflex lancing device* on call express blood glucose test strips* on call plus blood glucose test (strip)* on call vivid blood glucose test (strip)* on call vivid blood glucose test strips* onetouch delica lancets extra fine 33g* onetouch delica lancets fine 30g* onetouch delica lancing device* onetouch suresoft lancing device/18g* onetouch suresoft lancing device/21g* onetouch suresoft lancing device/28g* onetouch ultra blue (strip)* onetouch verio test strips* MyGlucoHealth Blood Glucose Test

Neutek 2Tek Test Strips

Nova Max Glucose Test Strips

Nova Sureflex Lancets

Nova Sureflex Lancing Device

On Call Express Blood Glucose Test Strips

On Call Plus Blood Glucose Test

On Call Vivid Blood Glucose Test

On Call Vivid Blood Glucose Test Strips

Onetouch Delica Lancets Extra Fine 33g

Onetouch Delica Lancets Fine 30g

Onetouch Delica Lancing Device

Onetouch Suresoft Lancing Device/18g

Onetouch Suresoft Lancing Device/21g

Onetouch Suresoft Lancing Device/28g

Onetouch Ultra Blue

Onetouch Verio Test Strips

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL

PA PA

QL QL

PA QL

QL QL QL QL QL QL QL QL QL QL QL

For 77 86 Track Refered Purpose

86

Name of Drug

one-way valved expiratory mouthpiece/disposable (otc only)* one-way valved inspiratory mouthpiece/disposable (otc only)* optium test strips* optiumez test strips* optumrx blood glucose test (strip)* panda mask large (otc only)* panda mask medium (otc only)* panda mask small (otc only)* pantothenic acid (tablet)* pediatric medium mask (otc only)* pediatric mouthpiece/disposable (otc only)* pediatric panda mask (otc only)* pediatric small mask (otc only)* penlet ii automatic blood sampler (kit)* pharmacist choice autocode blood glucose test strips* pharmacist choice ultra thin lancets* pharmacist choice ultra thin lancets 28g* pharmacist choice ultra thin lancets 30g* pharmacist choice ultra thin lancets 31g* precision pcx (strip)* precision pcx plus test strips* precision point of care test strips* precision qid test strips* precision xtra blood glucose test strips* prodigy no coding blood glucose test strips* prodigy pressure activated safety lancets* prodigy twist top lancets*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

One-Way Valved Expiratory Mouthpiece/Disposable

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL QL QL QL QL PA QL QL QL QL

One-Way Valved Inspiratory Mouthpiece/Disposable

Optium Test Strips

OptiumEZ Test Strips

OptumRx Blood Glucose Test

Panda Mask Large

Panda Mask Medium

Panda Mask Small

Pantothenic Acid

Pediatric Medium Mask

Pediatric Mouthpiece/Disposable

Pediatric Panda Mask

Pediatric Small Mask

Penlet II Automatic Blood Sampler

Pharmacist Choice Autocode Blood Glucose Test Strips

Pharmacist Choice Ultra Thin Lancets

Pharmacist Choice Ultra Thin Lancets 28g

Pharmacist Choice Ultra Thin Lancets 30g

Pharmacist Choice Ultra Thin Lancets 31g

Precision PCX

Precision PCX Plus Test Strips

Precision Point of Care Test Strips

Precision QID Test Strips

Precision Xtra Blood Glucose Test Strips

Prodigy No Coding Blood Glucose Test Strips

Prodigy Pressure Activated Safety Lancets

Prodigy Twist Top Lancets

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL QL QL QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 78 87 Track Refered Purpose

87

Name of Drug

px advanced lancing device* quintet ac blood glucose test strips* quintet blood glucose test strips* ra truetest strips* refuah plus blood glucose test strips* relion confirm/micro test strips* relion prime blood glucose test strips* relion ultima blood glucose test strips* reveal blood glucose test (strip)* rexall blood glucose test strips* rightest gl300 lancets* rightest gs100 blood glucose test strips* rightest gs300 blood glucose test strips* rightest gs550 blood glucose test strips* safety lancet 28g/pressure activated* sidestream pediatric face mask/tucker the turtle (otc only)* smart sense color lancets universal 33g* smart sense premium bloodglucose strips* smart sense super thin lancets universal 30g* smart sense thin lancets universal 26g* smart sense value blood glucose strips* smartest blood glucose test strips* solus v2 audible test (strip)* solus v2 lancing device* solus v2 twist lancets 30g* sterilance pa* PX Advanced Lancing Device

Quintet AC Blood Glucose Test Strips

Quintet Blood Glucose Test Strips

RA TrueTest Strips

Refuah Plus Blood Glucose Test Strips

Relion Confirm/Micro Test Strips

Relion Prime Blood Glucose Test Strips

Relion Ultima Blood Glucose Test Strips

Reveal Blood Glucose Test

Rexall Blood Glucose Test Strips

Rightest Gl300 Lancets

Rightest GS100 Blood Glucose Test Strips

Rightest GS300 Blood Glucose Test Strips

Rightest GS550 Blood Glucose Test Strips

Safety Lancet 28g/Pressure Activated

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL QL QL

QL QL

Sidestream Pediatric Face Mask/Tucker the Turtle

Smart Sense Color Lancets Universal 33g

Smart Sense Premium Bloodglucose Strips

Smart Sense Super Thin Lancets Universal 30g

Smart Sense Thin Lancets Universal 26g

Smart Sense Value Blood Glucose Strips

Smartest Blood Glucose Test Strips

Solus V2 Audible Test

Solus V2 Lancing Device

Solus V2 Twist Lancets 30g

Sterilance PA

STERILE WATER IRRIGATION (SOLUTION) Sterile Water Irrigation

sure edge blood glucose test strips* surechek blood glucose test strips* sure-test easyplus mini blood glucose test strips* suspendol-s (liquid)* techlite lancets* techlite lancets 30g* telcare blood glucose test strips* tgt advanced lancing device* tgt blood glucose test strips* Sure Edge Blood Glucose Test Strips

Surechek Blood Glucose Test Strips

Sure-Test Easyplus Mini Blood Glucose Test Strips

Suspendol-S

TechLite Lancets

Techlite Lancets 30g

Telcare Blood Glucose Test Strips

TGT Advanced Lancing Device

TGT Blood Glucose Test Strips

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL

QL

For 79 88 Track Refered Purpose

88

Name of Drug

tgt blood glucose test strips premium* tgt lancet micro thin 33g* tgt lancet thin 26g* tgt lancet ultra thin 30g* tgt lancing device* thyrosafe (tablet)* thyroshield (oral solution)* true metrix blood glucose test strips* true metrix self monitoring blood glucose strips* trueplus lancets 26g* trueplus lancets 28g* trueplus lancets 30g* trueplus lancets 33g* truetest blood glucose test strips* truetest strips* truetrack blood glucose test strips* truetrack test strips* ultilet classic lancets* ultilet lancets* ultima test strips* ultralance* ultratrak pro test strips* ultratrak ultimate test strips* unilet comfortouch lancet* unilet excelite ii* unilet gp 28 ultra thin* unilet lancets micro-thin33g* unilet lancets super-thin30g* unilet lancets ultra-thin 28g* TGT Blood Glucose Test Strips Premium

TGT Lancet Micro Thin 33g

TGT Lancet Thin 26g

TGT Lancet Ultra Thin 30g

TGT Lancing Device

ThyroSafe

ThyroShield

True Metrix Blood Glucose Test Strips

True Metrix Self Monitoring Blood Glucose Strips

TruePlus Lancets 26g

TruePlus Lancets 28g

TruePlus Lancets 30g

TruePlus Lancets 33g

TrueTest Blood Glucose Test Strips

TrueTest Strips

TrueTrack Blood Glucose Test Strips

TrueTrack Test Strips

Ultilet Classic Lancets

Ultilet Lancets

Ultima Test Strips

Ultralance

Ultratrak Pro Test Strips

Ultratrak Ultimate Test Strips

Unilet Comfortouch Lancet

Unilet Excelite II

Unilet GP 28 Ultra Thin

Unilet Lancets Micro-Thin33g

Unilet Lancets Super-Thin30g

Unilet Lancets Ultra-Thin 28g

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

PA PA QL QL QL QL QL QL QL QL QL QL

QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 80 89 Track Refered Purpose

89

Name of Drug

unistik 2* unistik 2 comfort* unistik 2 extra* unistik 2 normal* unistik 2 super* unistik 3 comfort* unistik 3 extra* unistik 3 neonatal* unistik 3 normal* unistik czt comfort* unistik czt normal* unistik safety lancets 28g* unistik safety lancets 30g* unistrip1 generic (strip)* universal 1 lancets ultra thin 30g* victory agm-4000 test strips* vocal point blood glucose test strips* wavesense presto test strips* Unistik 2

Unistik 2 Comfort

Unistik 2 Extra

Unistik 2 Normal

Unistik 2 Super

Unistik 3 Comfort

Unistik 3 Extra

Unistik 3 Neonatal

Unistik 3 Normal

Unistik CZT Comfort

Unistik CZT Normal

Unistik Safety Lancets 28g

Unistik Safety Lancets 30g

Unistrip1 Generic

Universal 1 Lancets Ultra Thin 30g

Victory Agm-4000 Test Strips

Vocal Point Blood Glucose Test Strips

Wavesense Presto Test Strips

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use

QL

Ophthalmic Agents Ophthalmic Agents, Other akwa tears (ointment)* artificial tears (ointment)* artificial tears (otc only) (ophthalmic solution)* bacitracin/polymyxin b (ophthalmic ointment) Akwa Tears

Artificial Tears

Artificial Tears

Bacitracin/Polymyxin B

BLEPHAMIDE (SUSPENSION) Blephamide

blephamide s.o.p. (ointment) Blephamide S.O.P.

CYSTARAN (OPHTHALMIC SOLUTION) Cystaran

eye drops (ophthalmic solution)* freshkote (ophthalmic solution)* isopto tears (ophthalmic solution)* Eye Drops

Freshkote

Isopto Tears

LACRISERT (INSERT) Lacrisert

LASTACAFT (OPHTHALMIC SOLUTION) Lastacaft

lubricating plus eye drops (ophthalmic solution)* muro 128 (2% ophthalmic solution)* muro 128 (5% ophthalmic solution)* natural balance tears (ophthalmic solution)* Lubricating Plus Eye Drops

Muro 128

Muro 128

Natural Balance Tears

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL

QL

QL QL

For 81 90 Track Refered Purpose

90

Name of Drug

natures tears (ophthalmic solution)* neomycin/bacitracin/polymyxin (ointment) neomycin/polymyxin/bacitracin/hydrocortisone (ophthalmic ointment) neomycin/polymyxin/dexamethasone (0.1% ophthalmic ointment, 0.1% ophthalmic suspension) neomycin/polymyxin/gramicidin (ophthalmic solution) neomycin/polymyxin/hydrocortisone (1% ophthalmic suspension) opti-clear (ophthalmic solution)* polymyxin b sulfate/trimethoprim sulfate (ophthalmic solution) proparacaine hcl (ophthalmic solution) puralube (ointment)* refresh celluvisc (ophthalmic solution)* refresh lacri-lube (ophthalmic ointment)* refresh plus (ophthalmic solution)* Natures Tears

Neomycin/Bacitracin/Polymyxin

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $1.20-$3.30 (Tier 1)

Neomycin/Polymyxin/Bacitracin/Hydrocortisone

$1.20-$3.30 (Tier 1)

Neomycin/Polymyxin/Dexamethasone

Neomycin/Polymyxin/Gramicidin

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Neomycin/Polymyxin/Hydrocortisone

Opti-Clear

$1.20-$3.30 (Tier 1) $0 (Tier 3)

QL

Polymyxin B Sulfate/Trimethoprim Sulfate

Proparacaine HCl

Puralube

Refresh Celluvisc

Refresh Lacri-Lube

Refresh Plus

RESTASIS (EMULSION) Restasis

sodium chloride (5% ophthalmic ointment)* sodium chloride (5% ophthalmic solution)* sulfacetamide sodium/prednisolone sodium phosphate (ophthalmic solution) Sodium Chloride

Sodium Chloride

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3)

QL QL QL QL

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

TOBRADEX ST (OPHTHALMIC SUSPENSION) Tobradex ST

tobramycin/dexamethasone (ophthalmic suspension) Tobramycin/Dexamethasone

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Ophthalmic Anti-allergy Agents azelastine hcl (0.05% ophthalmic solution) Azelastine HCl

BEPREVE (OPHTHALMIC SOLUTION) Bepreve

cromolyn sodium (rx only) (4% ophthalmic solution) epinastine hcl (ophthalmic solution) olopatadine hcl (ophthalmic solution) Cromolyn Sodium

Epinastine HCl

Olopatadine HCl

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 82 91 Track Refered Purpose

91

Name of Drug

PATADAY (OPHTHALMIC SOLUTION) Pataday

PAZEO (OPHTHALMIC SOLUTION) Pazeo

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Ophthalmic Antiglaucoma Agents ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) Alphagan P

apraclonidine (ophthalmic solution) betaxolol hcl (ophthalmic solution) Apraclonidine

Betaxolol HCl

BETIMOL (OPHTHALMIC SOLUTION) Betimol

brimonidine tartrate (0.2% ophthalmic solution) carteolol hcl (ophthalmic solution) Brimonidine Tartrate

Carteolol HCl

COMBIGAN (OPHTHALMIC SOLUTION) Combigan

COSOPT PF (OPHTHALMIC SOLUTION) Cosopt PF

dorzolamide hcl (ophthalmic solution) dorzolamide hcl/timolol maleate (ophthalmic solution) levobunolol hcl (ophthalmic solution) metipranolol (ophthalmic solution) Dorzolamide HCl

Dorzolamide HCl/Timolol Maleate

Levobunolol HCl

Metipranolol

PHOSPHOLINE IODIDE (OPHTHALMIC SOLUTION) PILOCARPINE HCL (1% OPHTHALMIC SOLUTION, 2% OPHTHALMIC SOLUTION, 4% OPHTHALMIC SOLUTION) Phospholine Iodide

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Pilocarpine HCl

$3.70-$8.25 (Tier 2)

timolol maleate (0.25% ophthalmic solution, 0.5% ophthalmic solution)

$1.20-$3.30 (Tier 1)

TIMOLOL MALEATE OPHTHALMIC GEL FORMING (SOLUTION)

$3.70-$8.25 (Tier 2)

Timolol Maleate

Timolol Maleate Ophthalmic Gel Forming

Ophthalmic Anti-inflammatories dexamethasone sodium phosphate (0.1% ophthalmic solution) diclofenac sodium (0.1% ophthalmic solution) Dexamethasone Sodium Phosphate

Diclofenac Sodium

DUREZOL (EMULSION) Durezol

FLUOROMETHOLONE (OPHTHALMIC SUSPENSION) Fluorometholone

flurbiprofen sodium (ophthalmic solution) Flurbiprofen Sodium

ILEVRO (SUSPENSION) Ilevro

ketorolac tromethamine (0.4% ophthalmic solution, 0.5% ophthalmic solution)

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

Ketorolac Tromethamine

LOTEMAX (0.5% GEL, 0.5% OINTMENT, 0.5% SUSPENSION) NEVANAC (SUSPENSION) PREDNISOLONE ACETATE (OPHTHALMIC SUSPENSION)

$1.20-$3.30 (Tier 1)

Lotemax

Nevanac

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Prednisolone Acetate

$3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

For 83 92 Track Refered Purpose

92

Name of Drug

What the drug will cost you (tier level)

prednisolone sodium phosphate (1% ophthalmic solution)

$1.20-$3.30 (Tier 1)

PROLENSA (OPHTHALMIC SOLUTION)

$3.70-$8.25 (Tier 2)

Necessary actions, restrictions, or limits on use

Prednisolone Sodium Phosphate

Prolensa

Ophthalmic Prostaglandin and Prostamide Analogs latanoprost (ophthalmic solution) Latanoprost

LUMIGAN (OPHTHALMIC SOLUTION) Lumigan

TRAVATAN Z (OPHTHALMIC SOLUTION) Travatan Z

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

Otic Agents Otic Agents acetic acid (otic solution) earwax treatment drops (otic solution)* fluocinolone acetonide (0.01% otic oil) hydrocortisone/acetic acid (otic solution) neomycin/polymyxin/hydrocortisone (1% otic solution, 1% otic suspension) Acetic Acid

Earwax Treatment Drops

Fluocinolone Acetonide

Hydrocortisone/Acetic Acid

$1.20-$3.30 (Tier 1) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Neomycin/Polymyxin/Hydrocortisone

$1.20-$3.30 (Tier 1)

Respiratory Tract/Pulmonary Agents Antihistamines aceta-gesic (tablet)* acetaminophen/diphenhydramine (tablet)* ala-hist ir (tablet)* ala-hist pe (tablet)* all day allergy (tablet)* all day allergy childrens (tablet chewable)* all day allergy-d (tablet extended-release 12 hour)* aller-chlor (2mg/5ml syrup, 4mg tablet)* allergy (10mg tablet dispersible, 10mg tablet, 4mg tablet)* Aceta-Gesic

Acetaminophen/Diphenhydramine

Ala-Hist IR

Ala-Hist PE

All Day Allergy

All Day Allergy Childrens

All Day Allergy-D

Aller-Chlor

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL PA PA QL QL QL QL

$0 (Tier 3)

QL

Allergy

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 84 93 Track Refered Purpose

93

Name of Drug

allergy relief (tablet)* allergy relief child (syrup)* allergy relief d-24 (tablet extended-release 24 hour)* azelastine hcl (0.1% nasal solution) azelastine hcl (0.15% nasal solution) banophen (otc only) (capsule)* brotapp (liquid)* cetirizine hcl (otc only) (10mg tablet chewable, 5mg tablet chewable, 10mg tablet, 5mg tablet)* cetirizine hcl (rx only) (syrup) cetirizine hcl allergy childrens (otc only) (oral solution)* cetirizine hcl childrens allergy (otc only) (syrup)* cetirizine hcl/pseudoephedrine hcl er (otc only) (tablet extended-release 12 hour)* childrens allergy (liquid)* childrens loratadine (5mg/5ml oral solution, 5mg/5ml syrup)* chlorphen sr (tablet extended-release)* chlorpheniramine maleate (tablet extended-release)* complete allergy medicine (otc only) (capsule)* cyproheptadine hcl (4mg tablet) dallergy (1mg-5mg tablet, 1mg/ml-2.5mg/ml liquid)* dimaphen childrens (elixir)* diphenhist (liquid)* diphenhydramine hcl (otc only) (capsule)* diphenhydramine hcl (rx only) (50mg/ml injection) ed a-hist (liquid)* ed chlorped (liquid)* ed chlorped d (liquid)* ed chlorped jr (syrup)* ed chlortan (tablet)* fexofenadine hcl (tablet)* fexofenadine hcl childrens allergy (suspension)* gnp all day allergy (tablet)* gnp allergy (tablet)* gnp dayhist allergy (tablet)* Allergy Relief

Allergy Relief Child

Allergy Relief D-24

Azelastine HCl

Azelastine HCl

Banophen

Brotapp

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

QL QL QL QL

$0 (Tier 3)

QL

QL PA

Cetirizine HCl

Cetirizine HCl

$1.20-$3.30 (Tier 1)

Cetirizine HCl Allergy Childrens

Cetirizine HCl Childrens Allergy

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL QL

Cetirizine HCl/Pseudoephedrine HCl ER

Childrens Allergy

Childrens Loratadine

Chlorphen SR

Chlorpheniramine Maleate

Complete Allergy Medicine

Cyproheptadine HCl

Dallergy

Dimaphen Childrens

Diphenhist

Diphenhydramine HCl

Diphenhydramine HCl

ED A-Hist

ED Chlorped

ED Chlorped D

ED Chlorped Jr

ED Chlortan

Fexofenadine HCl

Fexofenadine HCl Childrens Allergy

GNP All Day Allergy

GNP Allergy

GNP Dayhist Allergy

PA, QL PA QL QL B/D, PA PA, QL PA QL PA, QL QL QL QL QL QL

For 85 94 Track Refered Purpose

94

Name of Drug

gnp loratadine (10mg tablet, 5mg/5ml syrup)* histex (syrup)* histex pd (liquid)* j-tan d pd (liquid)* j-tan pd (liquid)* levocetirizine dihydrochloride (5mg tablet) lodrane d (capsule)* lohist-d (liquid)* loratadine (tablet)* loratadine childrens (5mg/5ml oral solution, 5mg/5ml syrup)* loratadine hives relief (oral solution)* loratadine-d 12hr (tablet extended-release 12 hour)* loratadine-d 24hr (tablet extended-release 24 hour)* lortuss lq (liquid)* mapap pm (tablet)* nasopen pe (liquid)* night time sleep aid (tablet)* nohist-lq (liquid)* pain reliever pm extra strength (tablet)* phenadoz (suppository) phenergan (12.5mg suppository, 25mg suppository) poly-hist pd (liquid)* promethazine hcl (12.5mg suppository, 25mg suppository, 12.5mg tablet, 25mg tablet, 50mg tablet, 25mg/ml injection, 50mg/ml injection, 6.25mg/5ml syrup) promethegan (25mg suppository) qc loratadine allergy relief (tablet)* qc loratadine-d (tablet extended-release 24 hour)* GNP Loratadine

Histex

Histex PD

J-TAN D PD

J-TAN PD

Levocetirizine Dihydrochloride

Lodrane D

LoHist-D

Loratadine

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL QL PA PA QL PA, QL PA, QL QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3)

QL QL QL PA, QL QL PA, QL QL PA, QL QL

Loratadine Childrens

Loratadine Hives Relief

Loratadine-D 12hr

Loratadine-D 24hr

Lortuss LQ

Mapap PM

Nasopen PE

Night Time Sleep Aid

NoHist-LQ

Pain Reliever PM Extra Strength

Phenadoz

Phenergan

Poly-Hist PD

PA, QL

Promethazine HCl

Promethegan

QC Loratadine Allergy Relief

QC Loratadine-D

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3)

QL QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 86 95 Track Refered Purpose

95

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL QL PA, QL QL PA, QL PA, QL PA PA QL PA, QL QL QL QL QL

ARNUITY ELLIPTA (AEROSOL POWDER)

$3.70-$8.25 (Tier 2)

QL

budesonide (0.25mg/2ml suspension, 0.5mg/2ml suspension, 1mg/2ml suspension)

$1.20-$3.30 (Tier 1)

B/D, PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

QL QL

q-dryl (liquid)* quenalin (syrup)* rescon (tablet)* restfully sleep (tablet)* ru-hist d (tablet)* rymed (tablet)* rynex pe (elixir)* rynex pse (liquid)* siladryl allergy (liquid)* silphen cough (syrup)* sm allergy 4 hour (tablet)* sm allergy relief (1.34mg tablet, 12.5mg/5ml liquid)* sm loratadine (syrup)* sm lorata-dine d (tablet extended-release 24 hour)* sm sleep aid (tablet)* sudogest sinus & allergy (tablet)* vanahist pd (liquid)* Q-Dryl

Quenalin

Rescon

Restfully Sleep

Ru-Hist D

Rymed

Rynex PE

Rynex PSE

Siladryl Allergy

Silphen Cough

SM Allergy 4 Hour

SM Allergy Relief

SM Loratadine

SM Lorata-Dine D

SM Sleep Aid

Sudogest Sinus & Allergy

Vanahist PD

PA, QL QL

Anti-inflammatories, Inhaled Corticosteroids Arnuity Ellipta

Budesonide

FLOVENT DISKUS (AEROSOL POWDER) Flovent Diskus

FLOVENT HFA (AEROSOL) Flovent HFA

flunisolide (nasal solution) fluticasone propionate (rx only) (50mcg/act suspension) triamcinolone acetonide (rx only) (55mcg/act aerosol) Flunisolide

Fluticasone Propionate

Triamcinolone Acetonide

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

Antileukotrienes montelukast sodium (10mg tablet, 4mg packet, 4mg tablet chewable, 5mg tablet chewable) zafirlukast (tablet) zileuton er (tablet extended-release 12 hour) Montelukast Sodium

Zafirlukast

Zileuton ER

ZYFLO (TABLET) Zyflo

ZYFLO CR (TABLET EXTENDED-RELEASE 12 HOUR) Zyflo CR

$1.20-$3.30 (Tier 1)

QL

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL ST ST ST

Bronchodilators, Anticholinergic ATROVENT HFA (AEROSOL SOLUTION) Atrovent HFA

$3.70-$8.25 (Tier 2)

For 87 96 Track Refered Purpose

96

Name of Drug

INCRUSE ELLIPTA (AEROSOL POWDER) Incruse Ellipta

ipratropium bromide (0.02% inhalation solution) ipratropium bromide (0.03% nasal solution, 0.06% nasal solution) Ipratropium Bromide

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use QL B/D, PA

Ipratropium Bromide

SPIRIVA HANDIHALER (CAPSULE) Spiriva HandiHaler

SPIRIVA RESPIMAT (AEROSOL SOLUTION) Spiriva Respimat

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL QL

$1.20-$3.30 (Tier 1)

B/D, PA

Bronchodilators, Sympathomimetic albuterol sulfate (0.083% nebulized solution, 0.5% nebulized solution, 0.63mg/3ml nebulized solution, 1.25mg/3ml nebulized solution) albuterol sulfate (2mg tablet immediate-release, 4mg tablet immediate-release) Albuterol Sulfate

Albuterol Sulfate

BROVANA (NEBULIZED SOLUTION) EPINEPHRINE (0.15MG/0.3ML INJECTION, 0.3MG/0.3ML INJECTION) (GENERIC EPIPEN) EPIPEN (INJECTION) Brovana

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

B/D, PA, QL

Epinephrine

EpiPen

levalbuterol (nebulized solution) metaproterenol sulfate (10mg tablet, 20mg tablet, 10mg/5ml syrup) Levalbuterol

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

B/D, PA

Metaproterenol Sulfate

PERFOROMIST (NEBULIZED SOLUTION) Perforomist

PROAIR HFA (AEROSOL SOLUTION) ProAir HFA

PROAIR RESPICLICK (AEROSOL POWDER) ProAir RespiClick

s2 (nebulized solution)* S2

SEREVENT DISKUS (AEROSOL POWDER) Serevent Diskus

terbutaline sulfate (1mg/ml injection) Terbutaline Sulfate

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

B/D, PA, QL

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, LA PA, QL PA, QL, LA

QL

Cystic Fibrosis Agents CAYSTON (INHALATION SOLUTION) Cayston

KALYDECO (50MG PACKET, 75MG PACKET) Kalydeco

ORKAMBI (TABLET) Orkambi

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 88 97 Track Refered Purpose

97

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Mast Cell Stabilizers cromolyn sodium (5.2mg/act aerosol solution)* Cromolyn Sodium

$0 (Tier 3)

QL

Phosphodiesterase Inhibitors, Airways Disease aminophylline (injection) Aminophylline

DALIRESP (TABLET) Daliresp

theophylline (oral solution) theophylline cr (tablet extended-release 12 hour) theophylline er (300mg tablet extended-release 12 hour, 450mg tablet extended-release 12 hour, 400mg tablet extended-release 24 hour, 600mg tablet extended-release 24 hour) Theophylline

Theophylline CR

$1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA, QL

Theophylline ER

$1.20-$3.30 (Tier 1)

Pulmonary Antihypertensives ADCIRCA (TABLET) Adcirca

ADEMPAS (TABLET) Adempas

LETAIRIS (TABLET) Letairis

OPSUMIT (TABLET) ORENITRAM (0.125MG TABLET EXTENDED-RELEASE, 0.25MG TABLET EXTENDED-RELEASE, 1MG TABLET EXTENDED-RELEASE) ORENITRAM (2.5MG TABLET EXTENDED-RELEASE, 5MG TABLET EXTENDED-RELEASE) REMODULIN (INJECTION) Opsumit

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, QL PA PA, QL, LA PA, LA

$3.70-$8.25 (Tier 2)

PA, QL

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA, LA PA PA, QL PA, QL PA, QL, LA

$0 (Tier 3) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3)

B/D, PA QL QL PA, QL PA, QL QL PA, QL PA, QL

Orenitram

Orenitram

Remodulin

sildenafil (10mg/12.5ml injection) sildenafil (20mg tablet) (generic revatio) Sildenafil

Sildenafil

TRACLEER (TABLET) Tracleer

VENTAVIS (INHALATION SOLUTION) Ventavis

Respiratory Tract Agents, Other 12 hour decongestant (tablet extended-release)* acetylcysteine (inhalation solution) 12 Hour Decongestant

Acetylcysteine

ADVAIR DISKUS (AEROSOL POWDER) Advair Diskus

ADVAIR HFA (AEROSOL) Advair HFA

alahist dm (liquid)* all-nite multi-symptom cold/flu relief (liquid)* Alahist DM

All-Nite Multi-Symptom Cold/Flu Relief

ANORO ELLIPTA (AEROSOL POWDER) Anoro Ellipta

ap-hist dm (liquid)* aprodine (tablet)* AP-Hist DM

Aprodine

For 89 98 Track Refered Purpose

98

Name of Drug

ARALAST NP (INJECTION) Aralast NP

benzonatate (100mg capsule, 200mg capsule)* benzonatate (150mg capsule)* Benzonatate

Benzonatate

BEVESPI AEROSPHERE (AEROSOL) Bevespi Aerosphere

BREO ELLIPTA (AEROSOL POWDER) Breo Ellipta

bromfed dm (rx only) (syrup)* bromphen/pseudoephedrine hcl/dextromethorphan hbr (rx only) (2mg/5ml-10mg/5ml-30mg/5ml syrup)* bromphen/pseudoephedrine hcl/dextromethorphan hbr (rx only) (syrup)* brotapp dm (liquid)* cheratussin ac (syrup)* cheratussin dac (oral solution)* chest congestion relief (tablet)* chest congestion relief pe (tablet)* childrens silfedrine (liquid)* chlo tuss (liquid)* chlo tuss ex (liquid)* codeine/guaifenesin (oral solution)* cold/cough dm childrens (elixir)* cough dm (suspension extended-release)* cough syrup (syrup)* cromolyn sodium (rx only) (20mg/2ml nebulized solution) day time multi-symptom cold/flu relief (capsule)* deconex dmx (tablet)* deconex ir (tablet)* deep sea nasal spray (nasal solution)* delsym (suspension extended-release)* delsym cough + chest congestion dm (liquid)* Bromfed DM

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3)

PA, LA PA, QL

$0 (Tier 3)

QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL PA PA, QL QL PA, QL PA, QL PA, QL PA PA, QL PA

$1.20-$3.30 (Tier 1)

B/D, PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA PA

QL QL PA, QL

Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr

Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr

Brotapp DM

Cheratussin AC

Cheratussin DAC

Chest Congestion Relief

Chest Congestion Relief PE

Childrens Silfedrine

Chlo Tuss

Chlo Tuss EX

Codeine/Guaifenesin

Cold/Cough DM Childrens

Cough DM

Cough Syrup

Cromolyn Sodium

Day Time Multi-Symptom Cold/Flu Relief

Deconex DMX

Deconex IR

Deep Sea Nasal Spray

Delsym

Delsym Cough + Chest Congestion DM

PA, QL PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 90 99 Track Refered Purpose

99

Name of Drug

delsym cough + chest congestion dm childrens (liquid)* delsym cough + cold daytime (liquid)* delsym cough + cold nighttime (liquid)* delsym cough + cold nighttime childrens (liquid)* dextromethorphan polistirex (suspension extendedrelease)* duraflu (tablet)* ed a-hist (4mg-10mg tablet)* ed a-hist dm (otc only) (liquid)* ed a-hist dm (tablet)* ed a-hist pse (tablet)* ed bron gp (liquid)* endacof-dm (liquid)*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Delsym Cough + Chest Congestion DM Childrens

Delsym Cough + Cold Daytime

Delsym Cough + Cold Nighttime

Delsym Cough + Cold Nighttime Childrens

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL PA PA, QL PA PA, QL

$3.70-$8.25 (Tier 2)

PA, QL, LA

$0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, LA PA PA, QL PA, QL PA, QL

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL

Dextromethorphan Polistirex

Duraflu

ED A-Hist

ED A-Hist DM

ED A-Hist DM

ED A-Hist PSE

ED Bron GP

EndaCof-DM

ESBRIET (267MG CAPSULE, 267MG TABLET, 801MG TABLET) Esbriet

extra action cough (syrup)* Extra Action Cough

GLASSIA (INJECTION) Glassia

gnp tussin (syrup)* gnp tussin dm (liquid)* guaiatussin ac (syrup)* guaifenesin ac (syrup)* guaifenesin and pseudoephedrine hcl (otc only) (tablet extended-release 12 hour)* guaifenesin er (otc only) (tablet extended-release 12 hour)* guaifenesin/codeine (oral solution)* histaflex (tablet)* histex-dm (syrup)* histex-pe (syrup)* hydrocodone bitartrate/chlorpheniramine maleate/ pse (oral solution)* hydrocodone bitartrate/homatropine methylbromide (1.5mg-5mg tablet, 1.5mg/5ml-5mg/5ml syrup)* hydrocodone polistirex/chlorpheniramine polistirex (suspension extended-release)* hydrocodone/homatropine (syrup)* hydromet (syrup)* GNP Tussin

GNP Tussin DM

Guaiatussin AC

Guaifenesin AC

Guaifenesin and Pseudoephedrine HCl

Guaifenesin ER

Guaifenesin/Codeine

Histaflex

Histex-DM

Histex-PE

PA, QL PA, QL

Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE

Hydrocodone Bitartrate/Homatropine Methylbromide

Hydrocodone Polistirex/Chlorpheniramine Polistirex

Hydrocodone/Homatropine

Hydromet

For 91 100Track Refered Purpose

100

Name of Drug

iophen c-nr (liquid)* iophen dm-nr (liquid)* iophen-nr (liquid)* j-max (syrup)* Iophen C-NR

Iophen DM-NR

Iophen-NR

J-Max

KALYDECO (150MG TABLET) Kalydeco

kidkare cough/cold (liquid)* lohist-dm (syrup)* lortuss dm (liquid)* lortuss ex (liquid)* mapap cold formula multi-symptom (tablet)* mapap sinus maximum strength congestion and pain (tablet)* m-end dmx (liquid)* m-end max d (liquid)* mucaphed (tablet)* mucinex (otc only) (tablet extended-release 12 hour)* mucinex chest congestion childrens (liquid)* mucinex childrens cold cough & sore throat (liquid)* mucinex childrens multi-symptom cold & fever (liquid)* mucinex childrens multi-symptom cold (liquid)* mucinex congestion & cough childrens (liquid)* mucinex cough childrens (liquid)* mucinex cough for kids (packet)* mucinex d (otc only) (tablet extended-release 12 hour)* mucinex d maximum strength (tablet extendedrelease 12 hour)* mucinex dm (otc only) (tablet extended-release 12 hour)* Kidkare Cough/Cold

LoHist-DM

Lortuss DM

Lortuss EX

Mapap Cold Formula Multi-Symptom

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA PA, QL PA PA PA, QL PA, QL PA

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA

$0 (Tier 3)

PA

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

Mapap Sinus Maximum Strength Congestion and Pain

M-END DMX

M-END Max D

Mucaphed

Mucinex

Mucinex Chest Congestion Childrens

Mucinex Childrens Cold Cough & Sore Throat

Mucinex Childrens Multi-Symptom Cold & Fever

Mucinex Childrens Multi-Symptom Cold

Mucinex Congestion & Cough Childrens

Mucinex Cough Childrens

Mucinex Cough for Kids

Mucinex D

Mucinex D Maximum Strength

Mucinex DM

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 92 101Track Refered Purpose

101

Name of Drug

mucinex dm maximum strength (tablet extendedrelease 12 hour)* mucinex fast-max cold & sinus (tablet)* mucinex fast-max cold flu & sore throat (tablet, liquid)* mucinex fast-max day time/night time (liquid)* mucinex fast-max day/night maximum strength* mucinex fast-max dm max (liquid)* mucinex fast-max night time cold & flu (tablet, liquid)* mucinex fast-max severe cold (325mg-10mg-200mg-5mg tablet, 325mg/ 10ml-10mg/10ml-200mg/10ml-5mg/10ml liquid)* mucinex fast-max severe congestion & cough (tablet, liquid)* mucinex for kids (packet)* mucinex maximum strength (tablet extended-release 12 hour)* mucinex multi-symptom cold day/night pack (liquid)* mucinex multi-symptom cold night time childrens (liquid)* mucinex sinus-max day/night* mucinex sinus-max full force (nasal solution)* mucinex sinus-max pressure & pain (tablet)* mucinex sinus-max severe congestion relief (tablet)* mucinex stuffy nose & cold childrens (liquid)* mucus relief (tablet)* mucus relief sinus (tablet)* mucus-er (otc only) (tablet extended-release 12 hour)* nasal decongestant (1% nasal solution)* nasal decongestant (30mg/5ml syrup)* nasal decongestant pe (tablet)* nasal decongestant spray (nasal solution)* night time multi-symptom cold/flu relief (capsule)* ninjacof (liquid)* ninjacof-a (liquid)* ninjacof-xg (liquid)* nohist-dm (liquid)*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Mucinex DM Maximum Strength

Mucinex Fast-Max Cold & Sinus

$0 (Tier 3)

PA

$0 (Tier 3)

Mucinex Fast-Max Cold Flu & Sore Throat

Mucinex Fast-Max Day Time/Night Time

Mucinex Fast-Max Day/Night Maximum Strength

Mucinex Fast-Max DM Max

Mucinex Fast-Max Night Time Cold & Flu

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA PA PA, QL PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA QL

Mucinex Fast-Max Severe Cold

Mucinex Fast-Max Severe Congestion & Cough

Mucinex for Kids

Mucinex Maximum Strength

Mucinex Multi-Symptom Cold Day/Night Pack

Mucinex Multi-Symptom Cold Night Time Childrens

Mucinex Sinus-Max Day/Night

Mucinex Sinus-Max Full Force

Mucinex Sinus-Max Pressure & Pain

Mucinex Sinus-Max Severe Congestion Relief

Mucinex Stuffy Nose & Cold Childrens

Mucus Relief

Mucus Relief Sinus

Mucus-ER

Nasal Decongestant

Nasal Decongestant

Nasal Decongestant PE

Nasal Decongestant Spray

Night Time Multi-Symptom Cold/Flu Relief

NinjaCof

NinjaCof-A

NinjaCof-XG

NoHist-DM

PA PA, QL PA, QL PA, QL PA, QL PA, QL

For 93 102Track Refered Purpose

102

Name of Drug

nrs nasal relief (nasal solution)* NRS Nasal Relief

OFEV (CAPSULE) Ofev

organ-i nr (tablet)* pain relief sinus pe daytime (tablet)* pediatric cough/cold (liquid)* phenylephrine hcl/pyrilamine maleate (tablet)* phenylhistine dh (liquid)* poly-hist dm (liquid)* poly-vent dm (tablet)* poly-vent ir (tablet)* pro-chlo (liquid)* pro-clear ac (syrup)* Organ-I NR

Pain Relief Sinus PE Daytime

Pediatric Cough/Cold

Phenylephrine HCl/Pyrilamine Maleate

Phenylhistine DH

Poly-Hist DM

Poly-Vent DM

Poly-Vent IR

Pro-Chlo

Pro-Clear AC

PROLASTIN-C (INJECTION) Prolastin-C

promethazine vc/codeine (syrup)* promethazine/codeine (syrup)* promethazine/dextromethorphan (syrup)* promethazine-dm (syrup)* pseudoephedrine hcl (otc only) (tablet)* pulmosal (nebulized solution)* Promethazine VC/Codeine

Promethazine/Codeine

Promethazine/Dextromethorphan

Promethazine-DM

Pseudoephedrine HCl

Pulmosal

PULMOZYME (INHALATION SOLUTION) Pulmozyme

qc cough/sore throat nighttime (liquid)* q-tussin (oral solution)* q-tussin dm (syrup)* ra calcium/boron (tablet)* rescon dm (syrup)* rescon-gg (liquid)* respaire-30 (capsule)* rezira (oral solution)* robafen (syrup)* QC Cough/Sore Throat Nighttime

Q-Tussin

Q-Tussin DM

RA Calcium/Boron

Rescon DM

Rescon-GG

Respaire-30

Rezira

Robafen

What the drug will cost you (tier level) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use PA PA, QL, LA PA, QL PA PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA PA, LA PA, QL PA, QL PA, QL PA, QL QL B/D, PA, QL PA PA, QL PA, QL PA PA PA PA PA PA

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 94 103Track Refered Purpose

103

Name of Drug

robafen cough (capsule)* robafen dm (syrup)* robafen dm cough clear (syrup)* rynex dm (liquid)* siltussin dm das (liquid)* siltussin sa (syrup)* siltussin-dm (syrup)* sm nasal decongestant maximum strength (otc only) (tablet)* sm nasal spray 12 hour (nasal solution)* sm tussin (syrup)* sm tussin dm (syrup)* sm tussin dm cough/chest congestion (syrup)* sodium chloride (7% nebulized solution)* stahist ad (tablet, liquid)* Robafen Cough

Robafen DM

Robafen DM Cough Clear

Rynex DM

Siltussin DM DAS

Siltussin SA

Siltussin-DM

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA, QL PA PA, QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2)

PA PA PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL PA, QL PA, LA PA PA, QL

SM Nasal Decongestant Maximum Strength

SM Nasal Spray 12 Hour

SM Tussin

SM Tussin DM

SM Tussin DM Cough/Chest Congestion

Sodium Chloride

Stahist AD

STIOLTO RESPIMAT (AEROSOL SOLUTION) Stiolto Respimat

sudogest (otc only) (tablet)* sudogest 12 hour (tablet extended-release)* sudogest pe (tablet)* Sudogest

Sudogest 12 Hour

Sudogest PE

SYMBICORT (AEROSOL) Symbicort

tussin dm (10mg/5ml-100mg/5ml liquid, 10mg/ 5ml-100mg/5ml syrup)* tussin dm clear (liquid)* tussionex pennkinetic extended-release (suspension extended-release)* vanacof (liquid)* vanacof dm (liquid)* vanacof-8 (liquid)* virtussin a/c (oral solution)*

PA, QL QL QL

QL

Tussin DM

Tussin DM Clear

Tussionex Pennkinetic Extended-Release

VanaCof

VanaCof DM

VanaCof-8

Virtussin A/C

ZEMAIRA (INJECTION) Zemaira

zonatuss (capsule)* zutripro (oral solution)* Zonatuss

Zutripro

Respiratory Tract/Pulmonary Agents COMBIVENT RESPIMAT (AEROSOL SOLUTION)

$3.70-$8.25 (Tier 2)

ipratropium bromide/albuterol sulfate (inhalation solution)

$1.20-$3.30 (Tier 1)

B/D, PA

XOLAIR (INJECTION)

$3.70-$8.25 (Tier 2)

PA

Combivent Respimat

Ipratropium Bromide/Albuterol Sulfate

Xolair

For 95 104Track Refered Purpose

104

Name of Drug

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (tablet) cyclobenzaprine hcl (10mg tablet, 5mg tablet) cyclobenzaprine hcl (7.5mg tablet) dantrolene sodium (capsule) Baclofen

Cyclobenzaprine HCl

Cyclobenzaprine HCl

Dantrolene Sodium

GABLOFEN (INJECTION) Gablofen

LIORESAL INTRATHECAL (INJECTION) Lioresal Intrathecal

orphenadrine citrate (injection) tizanidine hcl (2mg tablet, 4mg tablet) Orphenadrine Citrate

Tizanidine HCl

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

PA B/D, PA B/D, PA

Sleep Disorder Agents GABA Receptor Modulators temazepam (15mg capsule, 30mg capsule) zaleplon (capsule) zolpidem tartrate (10mg tablet immediate-release, 5mg tablet immediate-release) Temazepam

Zaleplon

$1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1)

QL QL, HRM

$1.20-$3.30 (Tier 1)

QL, HRM

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

QL PA, QL PA, QL QL PA, QL, LA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA

Zolpidem Tartrate

Sleep Disorders, Other BELSOMRA (TABLET) Belsomra

HETLIOZ (CAPSULE) Hetlioz

modafinil (tablet) Modafinil

ROZEREM (TABLET) Rozerem

XYREM (ORAL SOLUTION) Xyrem

Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers CHEMET (CAPSULE) Chemet

EXJADE (TABLET SOLUBLE) Exjade

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 96 105Track Refered Purpose

105

Name of Drug FERRIPROX (100MG/ML ORAL SOLUTION, 500MG TABLET) JADENU (TABLET)

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

Ferriprox

Jadenu

JADENU SPRINKLE (PACKET) Jadenu Sprinkle

kionex (powder) my kidz iron 10 (suspension)* Kionex

My Kidz Iron 10

SAMSCA (TABLET) Samsca

sodium polystyrene sulfonate (suspension) sps (suspension) Sodium Polystyrene Sulfonate

SPS

SYPRINE (CAPSULE) Syprine

$3.70-$8.25 (Tier 2)

PA

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2)

PA PA PA PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL PA PA, QL PA, QL PA PA, QL PA, QL PA, QL PA PA, QL PA PA, QL PA, QL QL PA, QL PA, QL PA PA PA, QL PA PA, QL PA, QL PA, QL PA, QL PA, QL

PA

Electrolyte/Mineral Replacement baby darlings pediatric electrolyte (solution)* calcet petites (tablet)* calci-chew (tablet chewable)* calcitrate (315mg-250unit tablet)* calcitrate (950mg tablet)* calcium (tablet)* calcium + d3 (tablet)* calcium 500/d (200unit-500mg tablet)* calcium 500/d (400unit-500mg tablet chewable)* calcium 600 (tablet)* calcium 600+d (600mg-400unit tablet)* calcium 600+d (600mg-800unit tablet)* calcium carbonate (1250mg tablet, 600mg tablet)* calcium carbonate (1250mg/5ml suspension)* calcium carbonate/d3 (tablet)* calcium carbonate/vitamin d (600mg-200unit tablet)* calcium carbonate/vitamin d (600mg-400unit tablet)* calcium citrate malate/vitamin d (tablet)* calcium citrate/vitamin d (315mg-200unit tablet)* calcium citrate+d (200mg-125unit tablet)* calcium citrate+d (315mg-250unit tablet)* calcium gluconate (tablet)* calcium high potency (tablet)* calcium high potency + vitamin d (tablet)* calcium oyster shell (tablet)* Baby Darlings Pediatric Electrolyte

Calcet Petites

Calci-Chew

Calcitrate

Calcitrate

Calcium

Calcium + D3

Calcium 500/D

Calcium 500/D

Calcium 600

Calcium 600+D

Calcium 600+D

Calcium Carbonate

Calcium Carbonate

Calcium Carbonate/D3

Calcium Carbonate/Vitamin D

Calcium Carbonate/Vitamin D

Calcium Citrate Malate/Vitamin D

Calcium Citrate/Vitamin D

Calcium Citrate+D

Calcium Citrate+D

Calcium Gluconate

Calcium High Potency

Calcium High Potency + Vitamin D

Calcium Oyster Shell

For 97 106Track Refered Purpose

106

Name of Drug

calcium/magnesium/zinc (tablet)* calcium/vitamin d (500mg-200unit tablet, 600mg-200unit tablet, 600mg-400unit tablet)* calcium/vitamin d (600mg-400unit tablet)* calcium/vitamin d3 (250mg-125unit tablet)* caltrate 600+d (600mg-800unit tablet)* caltrate 600+d plus minerals (tablet chewable, tablet immediate-release)* caltrate 600+d3 soft chews (tablet chewable)* Calcium/Magnesium/Zinc

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL

$0 (Tier 3)

PA

$0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA LA PA, QL PA, QL PA PA, QL PA, QL PA, QL PA, QL PA, QL PA PA, QL PA, QL PA QL PA PA, QL PA PA, QL QL QL

Calcium/Vitamin D

Calcium/Vitamin D

Calcium/Vitamin D3

Caltrate 600+D

Caltrate 600+D Plus Minerals

Caltrate 600+D3 Soft Chews

CARBAGLU (TABLET) Carbaglu

chewable calcium (tablet chewable)* citrus calcium+d (tablet)* coral calcium (capsule)* cvs calcium (tablet)* cvs calcium 600 & vitamin d3 (tablet)* cvs calcium 600 + d/minerals (tablet)* cvs calcium 600+d (tablet)* cvs calcium carbonate (tablet)* cvs calcium chewables 600plus (tablet chewable)* cvs calcium citrate + d (tablet)* cvs calcium citrate+d/magnesium (tablet)* cvs calcium/magnesium/zinc (tablet)* cvs electrolyte solution (oral solution)* cvs iron (27mg tablet)* cvs iron (325mg tablet)* cvs magnesium (250mg tablet)* cvs oyster shell calcium w/ vitamin d (tablet)* cvs pediatric electrolyte (oral solution)* cvs pediatric electrolyte freezer pops (oral solution)* Chewable Calcium

Citrus Calcium+D

Coral Calcium

CVS Calcium

CVS Calcium 600 & Vitamin D3

CVS Calcium 600 + D/Minerals

CVS Calcium 600+D

CVS Calcium Carbonate

CVS Calcium Chewables 600plus

CVS Calcium Citrate + D

CVS Calcium Citrate+D/Magnesium

CVS Calcium/Magnesium/Zinc

CVS Electrolyte Solution

CVS Iron

CVS Iron

CVS Magnesium

CVS Oyster Shell Calcium w/ Vitamin D

CVS Pediatric Electrolyte

CVS Pediatric Electrolyte Freezer Pops

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 98 107Track Refered Purpose

107

Name of Drug

cvs zinc (tablet)* duofer (tablet)* enfamil enfalyte (oral solution)* eql pediatric electrolyte (solution)* ezfe 200 (capsule)* ferate (tablet)* fergon (tablet)* fer-in-sol (oral solution)* fer-iron (oral solution)* ferosul (elixir)* ferretts (tablet)* ferretts ips (oral solution)* ferrex 150 (capsule)* ferric x-150 (capsule)* ferrimin 150 (tablet)* ferrous drops (oral solution)* ferrous fumarate 324 (tablet)* ferrous gluconate (240mg tablet)* ferrous gluconate (324mg tablet, 325mg tablet)* ferrous sulfate (140mg tablet extended-release, 220mg/5ml elixir, 220mg/5ml liquid, 300mg/5ml syrup)* ferrous sulfate (15mg/ml oral solution, 324mg tablet delayed-release, 325mg tablet delayed-release, 325mg tablet immediate-release)* ferrousul (tablet)* folitab 500 (tablet extended-release)* gnp calcium (tablet)* gnp calcium 1200 (tablet chewable)* gnp calcium 500/d (tablet)* gnp calcium 500+d3 (tablet)* gnp calcium 600/d (tablet)* gnp calcium citrate+d maximum (tablet)* gnp calcium citrate+d3 (tablet)* gnp calcium/magnesium/zinc (tablet)* gnp calcuim/vitamin d/minerals (tablet chewable)* CVS Zinc

Duofer

Enfamil Enfalyte

EQL Pediatric Electrolyte

EZFE 200

Ferate

Fergon

Fer-In-Sol

Fer-Iron

Ferosul

Ferretts

Ferretts IPS

Ferrex 150

Ferric X-150

Ferrimin 150

Ferrous Drops

Ferrous Fumarate 324

Ferrous Gluconate

Ferrous Gluconate

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA QL QL PA, QL PA PA PA, QL PA, QL PA PA, QL PA, QL PA, QL PA, QL PA PA, QL PA PA PA, QL

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA PA, QL PA PA, QL PA PA PA, QL PA, QL PA PA

Ferrous Sulfate

Ferrous Sulfate

Ferrousul

Folitab 500

GNP Calcium

GNP Calcium 1200

GNP Calcium 500/D

GNP Calcium 500+D3

GNP Calcium 600/D

GNP Calcium Citrate+D Maximum

GNP Calcium Citrate+D3

GNP Calcium/Magnesium/Zinc

GNP Calcuim/Vitamin D/Minerals

For 99 108Track Refered Purpose

108

Name of Drug

gnp iron (200mg tablet, 45mg tablet extendedrelease)* gnp magnesium (tablet)* gnp pediatric electrolyte (oral solution)* gnp zinc (tablet)* h-e-b oral electrolyte solution (solution)* hemocyte (tablet)* hm pediatric electrolyte (solution)* i.l.x. b-12 (otc only) (elixir)* iferex 150 (capsule)* infed (injection)* iron (tablet)* iron supplement childrens (oral solution)*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

GNP Iron

GNP Magnesium

GNP Pediatric Electrolyte

GNP Zinc

H-E-B Oral Electrolyte Solution

Hemocyte

HM Pediatric Electrolyte

I.L.X. B-12

Iferex 150

Infed

Iron

Iron Supplement Childrens

ISOLYTE-S (INJECTION) Isolyte-S

KLOR-CON 10 (TABLET EXTENDED-RELEASE) Klor-Con 10

KLOR-CON 8 (TABLET EXTENDED-RELEASE) Klor-Con 8

klor-con m10 (tablet extended-release) klor-con m15 (tablet extended-release) klor-con m20 (tablet extended-release) klor-con sprinkle (capsule extended-release) kp ferrous gluconate (tablet)* kp ferrous sulfate (tablet)* liquid calcium/vitamin d (capsule)* magnesium (250mg tablet)* magnesium 27 (tablet)* magnesium elemental (otc only) (300mg capsule, 30mg tablet)* Klor-Con M10

Klor-Con M15

Klor-Con M20

Klor-Con Sprinkle

KP Ferrous Gluconate

KP Ferrous Sulfate

Liquid Calcium/Vitamin D

Magnesium

Magnesium 27

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA QL PA QL PA QL PA PA, QL

$0 (Tier 3)

PA

PA PA, QL

PA PA, QL PA PA PA

Magnesium Elemental

MAGNESIUM SULFATE (1GM/2ML-50% INJECTION) Magnesium Sulfate

magnesium sulfate (5gm/10ml-50% injection) Magnesium Sulfate

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 100 109Track Refered Purpose

109

Name of Drug

mag-tab sr (otc only) (tablet extended-release)* monocal (tablet)* myferon 150 (capsule)* Mag-Tab SR

Monocal

Myferon 150

NORMOSOL-R (INJECTION) Normosol-R

novaferrum 125 (liquid)* novaferrum 50 (capsule)* novaferrum pediatric drops (liquid)* nu-iron 150 (capsule)* nu-mag (tablet delayed-release)* oralyte (oral solution)* oralyte freezer pops (oral solution)* orazinc (110mg tablet)* orazinc (220mg capsule)* os-cal (tablet chewable)* os-cal calcium + d3 (tablet)* os-cal extra d3 (tablet)* osteo-poretical (tablet)* oysco 500 (tablet)* oysco 500+d (tablet)* oysco d (tablet)* oyst-cal-d 500 (tablet)* oyster calcium (tablet)* oyster shell calcium (tablet)* oyster shell calcium + d (tablet)* oyster shell calcium + d3 (tablet)* oyster shell calcium + vitamin d (tablet)* oyster shell calcium 500 + d (tablet)* oyster shell calcium plus vitamin d (tablet)* oyster shell calcium/d (tablet)* oyster shell calcium/vitamin d (250mg-125unit-tablet, 500mg-200unit tablet)* oyster shell calcium/vitamin d (500mg-400unit tablet)* pa oyster shell calcium (tablet)* pedialyte (oral solution)* pedialyte advanced care (solution)* pedialyte freezer pops (oral solution)* NovaFerrum 125

NovaFerrum 50

NovaFerrum Pediatric Drops

Nu-Iron 150

Nu-Mag

Oralyte

Oralyte Freezer Pops

Orazinc

Orazinc

OS-CAL

OS-CAL Calcium + D3

OS-CAL Extra D3

Osteo-Poretical

Oysco 500

Oysco 500+D

Oysco D

Oyst-Cal-D 500

Oyster Calcium

Oyster Shell Calcium

Oyster Shell Calcium + D

Oyster Shell Calcium + D3

Oyster Shell Calcium + Vitamin D

Oyster Shell Calcium 500 + D

Oyster Shell Calcium Plus Vitamin D

Oyster Shell Calcium/D

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL QL QL QL

PA, QL PA QL QL PA PA, QL PA PA, QL PA PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA PA PA, QL PA, QL PA, QL PA, QL

Oyster Shell Calcium/Vitamin D

Oyster Shell Calcium/Vitamin D

PA Oyster Shell Calcium

Pedialyte

Pedialyte Advanced Care

Pedialyte Freezer Pops

For 101 110Track Refered Purpose

110

Name of Drug

pedialyte singles (oral solution)* pediatric electrolyte (oral solution)* pediatric electrolyte freeze pops (solution)* pediatric electrolyte freezer pops (oral solution)* pediatric electrolyte/zinc (oral solution)* Pedialyte Singles

Pediatric Electrolyte

Pediatric Electrolyte Freeze Pops

Pediatric Electrolyte Freezer Pops

Pediatric Electrolyte/Zinc

PHYSIOLYTE (IRRIGATION SOLUTION) Physiolyte

PHYSIOSOL IRRIGATION (SOLUTION) Physiosol Irrigation

PLASMA-LYTE A (INJECTION) Plasma-Lyte A

PLASMA-LYTE-148 (INJECTION) Plasma-Lyte-148

poly-iron 150 (capsule)* Poly-Iron 150

POTASSIUM CHLORIDE (10% ORAL SOLUTION, 20% ORAL SOLUTION) POTASSIUM CHLORIDE (10MEQ/100ML INJECTION, 20MEQ/100ML INJECTION, 40MEQ/100ML INJECTION)

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3)

Necessary actions, restrictions, or limits on use QL QL QL QL QL

PA, QL

Potassium Chloride

$3.70-$8.25 (Tier 2)

Potassium Chloride

potassium chloride (2meq/ml injection) potassium chloride er (10meq capsule extendedrelease, 8meq capsule extended-release, 10meq tablet extended-release, 20meq tablet extendedrelease, 8meq tablet extended-release) potassium chloride/sodium chloride (20meq/l-0.45% injection) Potassium Chloride

$3.70-$8.25 (Tier 2)

B/D, PA

$1.20-$3.30 (Tier 1)

B/D, PA

Potassium Chloride ER

$1.20-$3.30 (Tier 1)

Potassium Chloride/Sodium Chloride

$1.20-$3.30 (Tier 1)

B/D, PA

POTASSIUM CHLORIDE/SODIUM CHLORIDE (20MEQ/ L-0.9% INJECTION, 40MEQ/L-0.9% INJECTION)

$3.70-$8.25 (Tier 2)

B/D, PA

potassium citrate er (tablet extended-release) profe (capsule)* qc calcium fast dissolution (tablet)* qc calcium/minerals/vitamin d (tablet)* ra calcium 600 (tablet)* ra calcium 600 plus vitamin d-3 (tablet)* ra calcium 600/vitamin d/minerals (tablet)* ra calcium citrate plus vitamin d-3 (tablet)*

$1.20-$3.30 (Tier 1) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL

Potassium Chloride/Sodium Chloride

Potassium Citrate ER

ProFe

QC Calcium Fast Dissolution

QC Calcium/Minerals/Vitamin D

RA Calcium 600

RA Calcium 600 Plus Vitamin D-3

RA Calcium 600/Vitamin D/Minerals

RA Calcium Citrate Plus Vitamin D-3

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 102 111Track Refered Purpose

111

Name of Drug

ra calcium/magnesium/zinc/copper (tablet)* ra coral calcium (capsule)* ra hi cal (tablet)* ra hi-cal plus vitamin d (tablet)* ra high potency iron (tablet)* ra iron (tablet)* ra natural magnesium (tablet)* ra oyster shell calcium/vitamin d (125unit-250mg tablet)* ra oyster shell calcium/vitamin d (200unit-500mg tablet)* ra pediatric electrolyte (oral solution)* ra pediatric electrolyte freezer pops (oral solution)* ra slow release iron (tablet extended-release)* ra zinc (tablet)* risacal-d (tablet)* sb pediatric electrolyte (solution)* selenium (tablet extended-release)* slow-mag (tablet delayed-release)* sm calcium 500/vitamin d3 (tablet)* sm calcium 600/vitamin d (tablet)* sm calcium citrate with vitamin d3 (tablet)* sm calcium/magnesium/zinc (tablet)* sm calcium/vitamin d (tablet)* sm iron (tablet)* sm magnesium (tablet)* sm oyster shell calcium/vitamin d (tablet)* sm oyster shell calcium/vitamin d3 (tablet)* sm pediatric electrolyte (oral solution)* sm slow release iron (tablet extended-release)* sm zinc (tablet)* sodium chloride (rx only) (0.9% injection) RA Calcium/Magnesium/Zinc/Copper

RA Coral Calcium

RA Hi Cal

RA Hi-Cal Plus Vitamin D

RA High Potency Iron

RA Iron

RA Natural Magnesium

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA, QL PA, QL PA PA, QL PA

$0 (Tier 3)

PA

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $1.20-$3.30 (Tier 1)

QL QL PA PA PA QL PA PA PA PA PA, QL PA PA, QL PA, QL PA PA PA QL PA PA

RA Oyster Shell Calcium/Vitamin D

RA Oyster Shell Calcium/Vitamin D

RA Pediatric Electrolyte

RA Pediatric Electrolyte Freezer Pops

RA Slow Release Iron

RA Zinc

Risacal-D

SB Pediatric Electrolyte

Selenium

Slow-Mag

SM Calcium 500/Vitamin D3

SM Calcium 600/Vitamin D

SM Calcium Citrate with Vitamin D3

SM Calcium/Magnesium/Zinc

SM Calcium/Vitamin D

SM Iron

SM Magnesium

SM Oyster Shell Calcium/Vitamin D

SM Oyster Shell Calcium/Vitamin D3

SM Pediatric Electrolyte

SM Slow Release Iron

SM Zinc

Sodium Chloride

SODIUM CHLORIDE (RX ONLY) (2.5MEQ/ML INJECTION, 3% INJECTION, 5% INJECTION) SODIUM CHLORIDE 0.45% (INJECTION) Sodium Chloride

Sodium Chloride 0.45%

SODIUM CHLORIDE 0.9% (IRRIGATION SOLUTION) Sodium Chloride 0.9%

sodium fluoride (tablet) Sodium Fluoride

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

For 103 112Track Refered Purpose

112

Name of Drug

tandem (capsule)* zinc (tablet)* zinc 15 (tablet)* zinc chelated (tablet)* zinc gluconate (tablet)* zinc sulfate (220mg capsule)* zinc sulfate (220mg tablet)* zinc-220 (capsule)* Tandem

Zinc

Zinc 15

Zinc Chelated

Zinc Gluconate

Zinc Sulfate

Zinc Sulfate

Zinc-220

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA, QL PA PA, QL PA PA, QL

$0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

PA B/D, PA B/D, PA B/D, PA B/D, PA B/D, PA B/D, PA B/D, PA

$0 (Tier 3)

PA

Therapeutic Nutrients/Minerals/Electrolytes alba-lybe nr (liquid)* Alba-Lybe NR

AMINOSYN 7%/ELECTROLYTES (INJECTION) Aminosyn 7%/Electrolytes

AMINOSYN 8.5%/ELECTROLYTES (INJECTION) Aminosyn 8.5%/Electrolytes

AMINOSYN II (10% INJECTION) Aminosyn II

AMINOSYN II 8.5%/ELECTROLYTES (INJECTION) Aminosyn II 8.5%/Electrolytes

AMINOSYN-HBC (INJECTION) Aminosyn-HBC

AMINOSYN-PF (INJECTION) Aminosyn-PF

AMINOSYN-RF (INJECTION) Aminosyn-RF

cvs slow release iron (143mg tablet extendedrelease)* CVS Slow Release Iron

DEXTROSE 10% (INJECTION) Dextrose 10%

DEXTROSE 10%/NACL 0.2% (INJECTION) Dextrose 10%/NaCl 0.2%

DEXTROSE 10%/NACL 0.45% (INJECTION) Dextrose 10%/NaCl 0.45%

DEXTROSE 2.5%/NACL 0.45% (INJECTION) Dextrose 2.5%/NaCl 0.45%

DEXTROSE 5% (INJECTION) Dextrose 5%

DEXTROSE 5%/LACTATED RINGERS (INJECTION) Dextrose 5%/Lactated Ringers

DEXTROSE 5%/NACL 0.2% (INJECTION) Dextrose 5%/NaCl 0.2%

DEXTROSE 5%/NACL 0.225% (INJECTION) Dextrose 5%/NaCl 0.225%

DEXTROSE 5%/NACL 0.33% (INJECTION) Dextrose 5%/NaCl 0.33%

DEXTROSE 5%/NACL 0.45% (INJECTION) Dextrose 5%/NaCl 0.45%

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 104 113Track Refered Purpose

113

Name of Drug

DEXTROSE 5%/NACL 0.9% (INJECTION) Dextrose 5%/NaCl 0.9%

FREAMINE HBC 6.9% (INJECTION) FreAmine HBC 6.9%

HEPATAMINE (INJECTION) HepatAmine

icar pediatric (suspension)* ICAR Pediatric

INTRALIPID (INJECTION) Intralipid

IONOSOL-B/DEXTROSE 5% (INJECTION) Ionosol-B/Dextrose 5%

IONOSOL-MB/DEXTROSE 5% (INJECTION) Ionosol-MB/Dextrose 5%

ISOLYTE-P/DEXTROSE 5% (INJECTION) Isolyte-P/Dextrose 5%

KCL 0.075%/D5W/NACL 0.45% (INJECTION) KCl 0.075%/D5W/NaCl 0.45%

KCL 0.15%/D5W/NACL 0.2% (INJECTION) KCl 0.15%/D5W/NaCl 0.2%

KCL 0.15%/D5W/NACL 0.225% (INJECTION) KCl 0.15%/D5W/NaCl 0.225%

KCL 0.15%/D5W/NACL 0.9% (INJECTION) KCl 0.15%/D5W/NaCl 0.9%

KCL 0.3%/D5W/NACL 0.45% (INJECTION) KCl 0.3%/D5W/NaCl 0.45%

KCL 0.3%/D5W/NACL 0.9% (INJECTION) KCl 0.3%/D5W/NaCl 0.9%

LACTATED RINGERS IRRIGATION (SOLUTION) Lactated Ringers Irrigation

LACTATED RINGERS VIAFLEX (INJECTION) Lactated Ringers Viaflex

levocarnitine (1gm/10ml oral solution, 330mg tablet) Levocarnitine

NEPHRAMINE (INJECTION) Nephramine

NORMOSOL-M IN D5W (INJECTION) Normosol-M in D5W

NORMOSOL-R IN D5W (INJECTION) Normosol-R in D5W

NUTRILIPID (INJECTION) Nutrilipid

plenamine (injection) Plenamine

POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% (INJECTION) POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% (INJECTION) POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% (INJECTION) POTASSIUM CHLORIDE/DEXTROSE (INJECTION) POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS (INJECTION)

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1)

Necessary actions, restrictions, or limits on use B/D, PA B/D, PA PA B/D, PA

B/D, PA

B/D, PA B/D, PA

Potassium Chloride 0.15% D5W/NaCl 0.33%

$3.70-$8.25 (Tier 2)

Potassium Chloride 0.15% D5W/NaCl 0.45%

$3.70-$8.25 (Tier 2)

Potassium Chloride 0.22% D5W/NaCl 0.45%

Potassium Chloride/Dextrose

$3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

B/D, PA

Potassium Chloride/Dextrose/Lactated Ringers

premasol (injection) Premasol

PROCALAMINE (INJECTION) Procalamine

proferrin es (tablet)* Proferrin ES

PROSOL (INJECTION) Prosol

RINGERS INJECTION Ringers Injection

RINGERS IRRIGATION (SOLUTION) Ringers Irrigation

SODIUM LACTATE (INJECTION) Sodium Lactate

$3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $3.70-$8.25 (Tier 2) $0 (Tier 3) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2)

B/D, PA B/D, PA PA B/D, PA

For 105 114Track Refered Purpose

114

Name of Drug

TPN ELECTROLYTES (INJECTION) TPN Electrolytes

TRAVASOL (INJECTION) Travasol

TROPHAMINE (10% INJECTION) Trophamine

vp-pnv-dha (capsule) wee care (suspension)* VP-PNV-DHA

Wee Care

What the drug will cost you (tier level) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $3.70-$8.25 (Tier 2) $1.20-$3.30 (Tier 1) $0 (Tier 3)

Necessary actions, restrictions, or limits on use B/D, PA B/D, PA PA

Vitamins acerola c 500 (wafer)* actical (otc only) (capsule)* advanced stress formula/zinc (tablet)* animal shapes (tablet chewable)* animal shapes + iron (tablet chewable)* apatate forte (otc only) (liquid)* apetex (elixir)* apetigen (elixir)* apetigen-plus (225mg-6mcg-10mg-300mg-80mg-20mg-8mg-8.5mg15mg-30unit-18mg tablet, 25mcg/15ml-12.5mg/ 15ml-790mg/15ml-200mg/15ml-20mg/15ml-2mg/ 15ml-10mg/15ml-10mg/15ml-16.9mg/15ml oral solution)* aquadeks (otc only) (capsule)* aquadeks (tablet chewable)* aqueous vitamin d infants (liquid)* aqueous vitamin e (oral solution)* ascorbic acid (250mg tablet, 500mg tablet)* ascorbic acid (powder)* b complex (capsule)* b complex/folic acid (tablet)* b-6 (tablet)* Acerola C 500

Actical

Advanced Stress Formula/Zinc

Animal Shapes

Animal Shapes + Iron

Apatate Forte

Apetex

Apetigen

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA PA, QL PA, QL PA PA PA

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL

Apetigen-Plus

AquADEKs

AquADEKs

Aqueous Vitamin D Infants

Aqueous Vitamin E

Ascorbic Acid

Ascorbic Acid

B Complex

B Complex/Folic Acid

B-6

PA, QL PA, QL PA PA PA PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 106 115Track Refered Purpose

115

Name of Drug

balance b-100 (tablet)* balance b-50 (tablet)* balanced b-100 (tablet)* balanced b-50 (tablet)* b-complex (capsule)* b-complex formula 1 (tablet)* b-complex plus vitamin c (tablet)* b-complex with b-12 (tablet)* bee zee (tablet)* beta carotene (capsule)* biocal (otc only) (capsule)* biosupp (otc only) (liquid)* biotin (1000mcg tablet, 300mcg tablet, 5000mcg capsule)* biovol (syrup)* c 1000/bioflavonoids/rosehips (capsule)* c 250 (tablet)* c 500/rose hips (tablet)* c complex (tablet extended-release)* c-1000/rose hips (tablet)* c-500 (tablet chewable)* calcium & magnesium (tablet)* centamin (otc only) (liquid)* centrum (otc only) (liquid)* centrum (tablet chewable)* centrum adults (otc only) (tablet)* centrum kids complete (tablet chewable)* centrum silver (otc only) (tablet)* centrum silver adult 50+ (otc only) (tablet)* centrum silver ultra womens (otc only) (tablet)* centrum specialist heart (otc only) (tablet)* centrum ultra mens (otc only) (tablet)* cerovite advanced formula (otc only) (liquid)* cerovite advanced formula (otc only) (tablet)* cerovite jr (tablet chewable)* certavite senior/antioxidant nutrients (otc only) (tablet)* Balance B-100

Balance B-50

Balanced B-100

Balanced B-50

B-Complex

B-Complex Formula 1

B-Complex Plus Vitamin C

B-Complex with B-12

Bee Zee

Beta Carotene

Biocal

Biosupp

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA PA PA PA PA PA PA PA PA PA

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA, QL PA, QL PA PA, QL PA, QL PA PA, QL QL PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA PA, QL PA, QL

$0 (Tier 3)

PA, QL

Biotin

Biovol

C 1000/Bioflavonoids/Rosehips

C 250

C 500/Rose Hips

C Complex

C-1000/Rose Hips

C-500

Calcium & Magnesium

Centamin

Centrum

Centrum

Centrum Adults

Centrum Kids Complete

Centrum Silver

Centrum Silver Adult 50+

Centrum Silver Ultra Womens

Centrum Specialist Heart

Centrum Ultra Mens

Cerovite Advanced Formula

Cerovite Advanced Formula

Cerovite Jr

Certavite Senior/Antioxidant Nutrients

For 107 116Track Refered Purpose

116

Name of Drug

certavite/antioxidants (otc only) (liquid)* certavite/antioxidants (otc only) (tablet)* chewable vite childrens (tablet chewable)* chewable vite with iron/childrens (tablet chewable)* childrens chewable vitamin (tablet chewable)* childrens chewable vitamins (tablet chewable)* childrens chewable vitamins/iron (tablet chewable)* compete (otc only) (tablet)* complete (otc only) (tablet)* complex b-100 (tablet extended-release)* cvs b complex plus c (tablet)* cvs b-1 (tablet)* cvs b-12 (1000mcg/15ml liquid, 500mcg tablet)* cvs b-6 (tablet)* cvs balanced b-100 (tablet)* cvs balanced b-50 (tablet)* cvs beta carotene (capsule)* cvs biotin (capsule)* cvs biotin high potency (tablet)* cvs childrens chewable complete (tablet chewable)* cvs childrens chewable multivitamin/iron (tablet chewable)* cvs daily energy (otc only) (tablet)* cvs daily multiple (tablet)* cvs daily multiple for men (otc only) (tablet)* cvs daily multiple for men 50+ (otc only) (tablet)* cvs daily multiple for women (otc only) (tablet)* cvs daily multiple for women 50+ (otc only) (tablet)* Certavite/Antioxidants

Certavite/Antioxidants

Chewable Vite Childrens

Chewable Vite with Iron/Childrens

Childrens Chewable Vitamin

Childrens Chewable Vitamins

Childrens Chewable Vitamins/Iron

Compete

Complete

Complex B-100

CVS B Complex Plus C

CVS B-1

CVS B-12

CVS B-6

CVS Balanced B-100

CVS Balanced B-50

CVS Beta Carotene

CVS Biotin

CVS Biotin High Potency

CVS Childrens Chewable Complete

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA PA PA, QL PA PA, QL PA PA PA PA PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA PA, QL PA, QL PA, QL PA, QL

CVS Childrens Chewable Multivitamin/Iron

CVS Daily Energy

CVS Daily Multiple

CVS Daily Multiple for Men

CVS Daily Multiple for Men 50+

CVS Daily Multiple for Women

CVS Daily Multiple for Women 50+

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 108 117Track Refered Purpose

117

Name of Drug

cvs daily multiple plus iron/calcium/zinc (otc only) (tablet)* cvs e oil (100unit/0.25ml oil)* cvs gummy dinos (tablet chewable)* cvs hair skin & nails/antioxidants (otc only) (tablet)* cvs spectravite adult 50+ (otc only) (tablet)* cvs spectravite advanced formula (otc only) (tablet)* cvs spectravite senior (otc only) (tablet)* cvs spectravite ultra health mens (otc only) (tablet)* cvs spectravite ultra mens health (otc only) (tablet)* cvs spectravite ultra women (otc only) (tablet)* cvs spectravite ultra womens health (otc only) (tablet)* cvs spectravite ultra womens health senior (otc only) (tablet)* cvs super b complex/c (tablet)* cvs vitamin a (capsule)* cvs vitamin b12 (tablet)* cvs vitamin b-12 (tablet)* cvs vitamin b-12 tr (tablet extended-release)* cvs vitamin b-6 (tablet)* cvs vitamin c (1000mg tablet chewable, 1000mg tablet, 500mg tablet, 500mg-25mg-14mg tablet)* cvs vitamin c/rose hips (tablet)* cvs vitamin e (capsule)* daily multiple vitamin (tablet)* daily multiple vitamin/iron (tablet)* daily multiple vitamins (tablet)* daily vitamins (tablet)* daily vite (tablet)* daily-vite/iron/beta-carotene (tablet)* dialyvite 800 (tablet)* dino-life (tablet chewable)* dino-life with extra c (tablet chewable)* dino-life with iron & zinc (tablet chewable)* drisdol (capsule)* e-400 (capsule)*

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

CVS Daily Multiple Plus Iron/Calcium/Zinc

CVS E Oil

CVS Gummy Dinos

CVS Hair Skin & Nails/Antioxidants

CVS Spectravite Adult 50+

CVS Spectravite Advanced Formula

CVS Spectravite Senior

CVS Spectravite Ultra Health Mens

CVS Spectravite Ultra Mens Health

CVS Spectravite Ultra Women

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA PA PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA PA PA, QL PA PA PA PA, QL PA, QL PA, QL PA, QL PA QL PA

CVS Spectravite Ultra Womens Health

CVS Spectravite Ultra Womens Health Senior

CVS Super B Complex/C

CVS Vitamin A

CVS Vitamin B12

CVS Vitamin B-12

CVS Vitamin B-12 TR

CVS Vitamin B-6

CVS Vitamin C

CVS Vitamin C/Rose Hips

CVS Vitamin E

Daily Multiple Vitamin

Daily Multiple Vitamin/Iron

Daily Multiple Vitamins

Daily Vitamins

Daily Vite

Daily-Vite/Iron/Beta-Carotene

Dialyvite 800

Dino-Life

Dino-Life with Extra C

Dino-Life with Iron & Zinc

Drisdol

E-400

For 109 118Track Refered Purpose

118

Name of Drug

ecee plus (tablet)* eql one daily essential (tablet)* ergocalciferol (oral solution)* fe c (tablet)* folic acid (injection)* folic acid (rx only) (1mg tablet)* foltabs 800 (tablet)* fosfree (otc only) (tablet)* fruity c (tablet chewable)* fruity chewables multivitamin (tablet chewable)* full spectrum b/vitamin c (tablet)* gnp animal shapes (tablet chewable)* gnp animal shapes plus extra c (tablet chewable)* gnp animal shapes plus iron (tablet chewable)* gnp b-50 balanced (tablet)* gnp century (otc only) (tablet)* gnp century adults 50+ senior (otc only) (tablet)* gnp century cardio healthformula (otc only) (tablet)* gnp century ultimate mens complete (otc only) (tablet)* gnp century ultimate womens complete (otc only) (tablet)* gnp century ultimate womens senior formula (otc only) (tablet)* gnp childrens chewables/extra c (tablet chewable)* gnp childrens chewables/iron (tablet chewable)* gnp essential one daily (tablet)* gnp hair/skin/nails (otc only) (tablet)* gnp little ones childrens (tablet chewable)* gnp mega multi for men (otc only) (tablet)* Ecee Plus

EQL One Daily Essential

Ergocalciferol

Fe C

Folic Acid

Folic Acid

Foltabs 800

Fosfree

Fruity C

Fruity Chewables Multivitamin

Full Spectrum B/Vitamin C

GNP Animal Shapes

GNP Animal Shapes Plus Extra C

GNP Animal Shapes Plus Iron

GNP B-50 Balanced

GNP Century

GNP Century Adults 50+ Senior

GNP Century Cardio Healthformula

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use PA PA QL PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

QL PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA QL QL PA, QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3)

QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA PA, QL PA, QL PA, QL

GNP Century Ultimate Mens Complete

GNP Century Ultimate Womens Complete

GNP Century Ultimate Womens Senior Formula

GNP Childrens Chewables/Extra C

GNP Childrens Chewables/Iron

GNP Essential One Daily

GNP Hair/Skin/Nails

GNP Little Ones Childrens

GNP Mega Multi for Men

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 110 119Track Refered Purpose

119

Name of Drug

gnp mega multi for women (otc only) (tablet)* gnp niacin tr (tablet extended-release)* gnp one daily maximum (otc only) (tablet)* gnp one daily mens health 50+ (otc only) (tablet)* gnp one daily plus iron (tablet)* gnp one daily womens health 50+ (otc only) (tablet)* gnp opti-vitamins (otc only) (tablet)* gnp therapeutic-m (otc only) (tablet)* gnp vitamin a (capsule)* gnp vitamin b-12 (tablet)* gnp vitamin b-12 tr (tablet extended-release)* gnp vitamin b-6 (tablet)* gnp vitamin c (1000mg tablet, 250mg tablet, 500mg tablet, 500mg tablet chewable, 500mg-tablet chewable)* gnp vitamin c drops (lozenge)* gnp vitamin c tr (tablet extended-release)* gnp vitamin c with rose hips (tablet)* gnp vitamin c with rose hips tr (tablet extendedrelease)* gnp vitamin e (capsule)* gnp zoo chews gummies (tablet chewable)* hard nails (capsule)* honey bears (tablet chewable)* honey bears with iron and zinc (tablet chewable)* i-caps areds formula (otc only) (tablet)* i-caps mv (otc only) (tablet)* i-caps plus (otc only) (tablet)* icar-c (tablet)* integra (capsule)* iron 100/c (tablet)* kp adults 50+ daily formula (otc only) (tablet)* kp adults daily formula (otc only) (tablet)* kp b complex/c (otc only) (tablet)* kp mens 50+ daily formula (otc only) (tablet)* kp mens daily formula (otc only) (tablet)* kp vitamin e (capsule)* GNP Mega Multi for Women

GNP Niacin TR

GNP One Daily Maximum

GNP One Daily Mens Health 50+

GNP One Daily Plus Iron

GNP One Daily Womens Health 50+

GNP Opti-Vitamins

GNP Therapeutic-M

GNP Vitamin A

GNP Vitamin B-12

GNP Vitamin B-12 TR

GNP Vitamin B-6

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA PA, QL PA, QL PA, QL QL PA, QL PA, QL PA, QL PA PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA PA, QL PA PA, QL PA, QL PA, QL PA PA PA PA, QL PA, QL PA PA, QL PA, QL PA

GNP Vitamin C

GNP Vitamin C Drops

GNP Vitamin C TR

GNP Vitamin C with Rose Hips

GNP Vitamin C with Rose Hips TR

GNP Vitamin E

GNP Zoo Chews Gummies

Hard Nails

Honey Bears

Honey Bears with Iron and Zinc

I-Caps Areds Formula

I-Caps MV

I-Caps Plus

ICAR-C

Integra

Iron 100/C

KP Adults 50+ Daily Formula

KP Adults Daily Formula

KP B Complex/C

KP Mens 50+ Daily Formula

KP Mens Daily Formula

KP Vitamin E

For 111 120Track Refered Purpose

120

Name of Drug

kp womens 50+ daily formula (otc only) (tablet)* kp womens daily formula (otc only) (tablet)* life pack mens* life pack womens* lysiplex plus (otc only) (liquid)* mega multiple with chelated minerals (tablet)* mega multivitamin for men (otc only) (tablet)* mega multivitamin for women (otc only) (tablet)* mephyton (tablet)* meribin (capsule)* multi-day vitamins (tablet)* multi-delyn (liquid)* multi-delyn/iron (liquid)* multilex (otc only) (tablet)* multilex t&m (otc only) (tablet)* multiple vitamins (tablet)* multiple vitamins plain (tablet)* multiple vitamins/iron (tablet chewable)* multi-vitamin (tablet)* multi-vitamin hp/minerals (capsule)* multi-vitamin/minerals (otc only) (tablet)* multi-vitamins (tablet)* my kidz iron (suspension)* my-vitalife (otc only) (capsule)* nephronex (liquid)* nephro-vite (tablet)* niacin (250mg capsule extended-release, 500mg tablet extended-release)* niacin er (otc only) (capsule extended-release)* KP Womens 50+ Daily Formula

KP Womens Daily Formula

Life Pack Mens

Life Pack Womens

Lysiplex Plus

Mega Multiple with Chelated Minerals

Mega Multivitamin for Men

Mega Multivitamin for Women

Mephyton

Meribin

Multi-Day Vitamins

Multi-Delyn

Multi-Delyn/Iron

Multilex

Multilex T&M

Multiple Vitamins

Multiple Vitamins Plain

Multiple Vitamins/Iron

Multi-Vitamin

Multi-Vitamin HP/Minerals

Multi-Vitamin/Minerals

Multi-Vitamins

My Kidz Iron

My-Vitalife

Nephronex

Nephro-Vite

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA PA PA PA PA, QL PA, QL QL PA PA PA, QL PA, QL PA, QL PA, QL PA PA PA, QL PA PA PA, QL PA PA PA PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

Niacin

Niacin ER

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 112 121Track Refered Purpose

121

Name of Drug

niacin sr (capsule extended-release)* niacin tr (250mg capsule extended-release, 500mg tablet extended-release)* niacin tr (250mg tablet extended-release)* no iron multiple vitamin/minerals (otc only) (tablet)* once daily (tablet)* once daily/iron (tablet)* oncovite (otc only) (tablet)* one daily (tablet)* one daily mens (otc only) (tablet)* one daily plus iron (otc only) (tablet)* one daily plus minerals (otc only) (tablet)* one-daily multi vitamins (tablet)* pa b-complex with b-12 (tablet)* pa biotin (capsule)* pa vitamin b-12 tr (tablet extended-release)* pa vitamin e (capsule)* peridin-c (otc only) (tablet)* poly vitamin (tablet chewable)* poly-vita drops (oral solution)* poly-vita/iron drops (oral solution)* polyvitamin (oral solution)* polyvitamin/iron (oral solution, tablet chewable)* prevent (otc only) (capsule)* protexin (syrup)* pyridoxine hcl (tablet)* qc childrens chewable vitamins/extra c (tablet chewable)* qc maximum daily multivitamin/multimineral (otc only) (tablet)* qc multi-vite (otc only) (tablet)* qc womens daily multivitamin (otc only) (tablet)* ra balanced b-100 (tablet)* ra balanced b-50 (tablet)* ra b-complex (tablet)* ra b-complex with b-12 (tablet)* ra b-complex/vitamin c tr (tablet extended-release)* Niacin SR

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA PA, QL PA, QL PA PA, QL PA, QL PA, QL PA PA PA PA PA PA PA, QL PA, QL PA, QL PA, QL PA, QL PA PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA PA PA PA PA

Niacin TR

Niacin TR

No Iron Multiple Vitamin/Minerals

Once Daily

Once Daily/Iron

Oncovite

One Daily

One Daily Mens

One Daily Plus Iron

One Daily Plus Minerals

One-Daily Multi Vitamins

PA B-Complex with B-12

PA Biotin

PA Vitamin B-12 TR

PA Vitamin E

Peridin-C

Poly Vitamin

Poly-Vita Drops

Poly-Vita/Iron Drops

Polyvitamin

Polyvitamin/Iron

Prevent

Protexin

Pyridoxine HCl

QC Childrens Chewable Vitamins/Extra C

QC Maximum Daily Multivitamin/Multimineral

QC Multi-Vite

QC Womens Daily Multivitamin

RA Balanced B-100

RA Balanced B-50

RA B-Complex

RA B-Complex with B-12

RA B-Complex/Vitamin C TR

For 113 122Track Refered Purpose

122

Name of Drug

ra beta carotene (capsule)* ra biotin (capsule)* ra calcium soft chews (tablet chewable)* ra central-vite (otc only) (tablet)* ra central-vite cardio (otc only) (tablet)* ra central-vite energy (otc only) (tablet)* ra central-vite performance (otc only) (tablet)* ra central-vite select mature (otc only) (tablet)* ra central-vite senior (otc only) (tablet)* ra central-vite under 50 mens (otc only) (tablet)* ra central-vite under 50 womens (otc only) (tablet)* ra central-vite womens mature (otc only) (tablet)* ra central-vite/antioxidants (otc only) (tablet)* ra natural vitamin e (capsule)* ra one daily energy formula (otc only) (tablet)* ra one daily essential (tablet)* ra one daily maximum (otc only) (tablet)* ra one daily mens 50+ with vitamin d-3 (otc only) (tablet)* ra one daily multi-vitamin (tablet)* ra one daily multi-vitamin plus iron (tablet)* ra stress formula advanced (otc only) (tablet)* ra stress formula energy (otc only) (tablet)* ra therapeutic m plus beta carotene (otc only) (tablet)* ra vitamin a (capsule)* ra vitamin b-1 (tablet)* ra vitamin b12 (tablet extended-release)* ra vitamin b-12 (tablet immediate-release)* RA Beta Carotene

RA Biotin

RA Calcium Soft Chews

RA Central-Vite

RA Central-Vite Cardio

RA Central-Vite Energy

RA Central-Vite Performance

RA Central-Vite Select Mature

RA Central-Vite Senior

RA Central-Vite Under 50 Mens

RA Central-Vite Under 50 Womens

RA Central-Vite Womens Mature

RA Central-Vite/Antioxidants

RA Natural Vitamin E

RA One Daily Energy Formula

RA One Daily Essential

RA One Daily Maximum

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA PA PA, QL PA PA, QL PA PA, QL PA, QL PA, QL PA, QL PA, QL PA, QL PA PA, QL PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA PA

RA One Daily Mens 50+ with Vitamin D-3

RA One Daily Multi-Vitamin

RA One Daily Multi-Vitamin Plus Iron

RA Stress Formula Advanced

RA Stress Formula Energy

RA Therapeutic M Plus Beta Carotene

RA Vitamin A

RA Vitamin B-1

RA Vitamin B12

RA Vitamin B-12

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 114 123Track Refered Purpose

123

Name of Drug

ra vitamin b-12 tr (tablet extended-release)* ra vitamin b-6 (tablet)* ra vitamin c (250mg tablet, 500mg tablet, 500mgtablet chewable)* ra vitamin c drops (lozenge)* ra vitamin c tr (1000mg-25mg tablet extendedrelease)* ra vitamin c tr (500mg tablet extended-release)* ra vitamin c/acerola (tablet chewable)* ra vitamin c/rose hips (tablet)* ra vitamin c/rose hips tr (tablet extended-release)* ra vitamin e (capsule)* ra whole source complete formula for men (otc only) (tablet)* ra whole source dietary (otc only) (tablet)* ra whole source dietary for men (otc only) (tablet)* ra whole source dietary mature (otc only) (tablet)* rabano yodado (liquid)* rena-vite (tablet)* senior tabs (otc only) (tablet)* sentry (otc only) (tablet)* sentry senior (otc only) (tablet)* slo-niacin (250mg tablet extended-release)* slo-niacin (500mg tablet extended-release)* sm balanced b-50 (tablet)* sm calcium soft chews (tablet chewable)* sm chewable c (tablet chewable)* sm complete (otc only) (tablet)* sm complete advanced formula (otc only) (tablet)* sm complete senior formula (otc only) (tablet)* sm multiple vitamins essential (tablet)* sm multiple vitamins/iron (tablet)* sm super b complex-vitamin c (tablet)* sm vitamin b-12 (tablet)* sm vitamin b-6 (tablet)* sm vitamin c (1000mg tablet, 250mg tablet, 500mg tablet chewable)* RA Vitamin B-12 TR

RA Vitamin B-6

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3)

PA PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA, QL PA

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA PA, QL PA, QL PA, QL PA, QL PA PA, QL PA PA PA, QL PA, QL PA, QL PA, QL PA PA, QL PA PA PA, QL

$0 (Tier 3)

PA, QL

RA Vitamin C

RA Vitamin C Drops

RA Vitamin C TR

RA Vitamin C TR

RA Vitamin C/Acerola

RA Vitamin C/Rose Hips

RA Vitamin C/Rose Hips TR

RA Vitamin E

RA Whole Source Complete Formula for Men

RA Whole Source Dietary

RA Whole Source Dietary for Men

RA Whole Source Dietary Mature

Rabano Yodado

Rena-Vite

Senior Tabs

Sentry

Sentry Senior

Slo-Niacin

Slo-Niacin

SM Balanced B-50

SM Calcium Soft Chews

SM Chewable C

SM Complete

SM Complete Advanced Formula

SM Complete Senior Formula

SM Multiple Vitamins Essential

SM Multiple Vitamins/Iron

SM Super B Complex-Vitamin C

SM Vitamin B-12

SM Vitamin B-6

SM Vitamin C

For 115 124Track Refered Purpose

124

Name of Drug

sm vitamin c/rose hips (tablet)* sm vitamin e (capsule)* sm vitamin e blended (capsule)* stress formula (tablet)* stress formula with iron (tablet)* stress formula/iron (tablet)* stress formula/zinc (tablet)* super b with c (capsule)* super thera vite m (otc only) (tablet)* superplex-t (tablet)* suplevit (liquid)* tab-a-vite (tablet)* tab-a-vite maximum (otc only) (tablet)* tab-a-vite with beta carotene (tablet)* tab-a-vite/iron (tablet)* thera (tablet)* thera m plus (otc only) (tablet)* thera/beta-carotene (tablet)* thera-m (otc only) (tablet)* therapeutic liquid (otc only) (oral solution)* thera-tabs (tablet)* theratrum complete (otc only) (tablet)* therems (tablet)* therems-h (otc only) (tablet)* therems-m (otc only) (tablet)* thiamine hcl (tablet)* total b/c (tablet)* totalday multiple (tablet extended-release)* tri-vi-sol (oral solution)* SM Vitamin C/Rose Hips

SM Vitamin E

SM Vitamin E Blended

Stress Formula

Stress Formula with Iron

Stress Formula/Iron

Stress Formula/Zinc

Super B with C

Super Thera Vite M

Superplex-T

Suplevit

TAB-A-VITE

TAB-A-VITE Maximum

TAB-A-VITE with Beta Carotene

TAB-A-VITE/Iron

Thera

Thera M Plus

Thera/Beta-Carotene

Thera-M

Therapeutic Liquid

Thera-Tabs

Theratrum Complete

Therems

Therems-H

Therems-M

Thiamine HCl

Total B/C

Totalday Multiple

Tri-Vi-Sol

What the drug will cost you (tier level) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

Necessary actions, restrictions, or limits on use PA, QL PA PA PA PA, QL PA, QL PA PA PA, QL PA PA PA PA, QL PA PA, QL PA PA, QL PA PA, QL PA PA PA, QL PA PA, QL PA, QL PA, QL PA PA PA, QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

For 116 125Track Refered Purpose

125

Name of Drug

tri-vita (oral solution)* tri-vitamin (oral solution)* unicomplex-m (otc only) (tablet)* vita-bee/c (otc only) (tablet)* vitamin a (capsule)* vitamin b complex (tablet)* vitamin b complex-c (capsule)* vitamin b-1 (tablet)* vitamin b12 (1000mcg tablet extended-release, 100mcg tablet, 500mcg tablet)* vitamin b-12 (1000mcg tablet, 100mcg tablet, 250mcg tablet, 500mcg tablet, 2500mcg tablet sublingual)* vitamin b-2 (tablet)* vitamin b6 (tablet)* vitamin b-6 (tablet)* vitamin c (1000mg tablet, 250mg tablet, 500mg tablet, 250mg tablet chewable, 500mg tablet chewable, 500mg/5ml syrup)* vitamin c sr (capsule extended-release)* vitamin c tr (1500mg tablet extended-release, 500mg capsule extended-release)* vitamin c/rose hips (tablet)* vitamin d (capsule)* vitamin e (capsule)* vitamin e water dispersible (capsule)* vitamin e water soluble (capsule)* vitamin e/d-alpha (capsule)* vitamin k1 (injection)* vitamins & minerals (otc only) (tablet)* vitamins for hair (otc only) (tablet)* womens one daily (otc only) (tablet)* zinc/vitamin c (lozenge)* zoo friends (tablet chewable)* zoo friends complete (tablet chewable)* zoo friends plus extra c (tablet chewable)* zoo friends plus iron (tablet chewable)* Tri-Vita

Tri-Vitamin

Unicomplex-M

Vita-Bee/C

Vitamin A

Vitamin B Complex

Vitamin B Complex-C

Vitamin B-1

What the drug will cost you (tier level)

Necessary actions, restrictions, or limits on use

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL PA, QL PA, QL PA PA, QL PA PA PA, QL

$0 (Tier 3)

PA

$0 (Tier 3)

PA

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA PA, QL PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3)

PA, QL

$0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3)

PA, QL QL PA PA PA PA

Vitamin B12

Vitamin B-12

Vitamin B-2

Vitamin B6

Vitamin B-6

Vitamin C

Vitamin C SR

Vitamin C TR

Vitamin C/Rose Hips

Vitamin D

Vitamin E

Vitamin E Water Dispersible

Vitamin E Water Soluble

Vitamin E/D-Alpha

Vitamin K1

Vitamins & Minerals

Vitamins for Hair

Womens One Daily

Zinc/Vitamin C

Zoo Friends

Zoo Friends Complete

Zoo Friends Plus Extra C

Zoo Friends Plus Iron

PA, QL PA PA, QL PA PA, QL PA, QL PA, QL PA, QL

126 126 For Track Refered Purpose

Index of Drugs #

Accutrend Glucose............. 81

Adriamycin...........................33

12 Hour Decongestant........97

Acephen...............................10

Adrucil.................................. 33

1st Tier Unilet Comfortouch Lancets 28g.......................81

Acerola C 500....................114

Advair Diskus.......................97

Aceta-Gesic..........................92

Advair HFA...........................97

1st Tier Unilet Comfortouch Lancets 30g.......................81

Acetaminophen................... 10

Advanced Stress Formula/ Zinc.................................. 114

A Abacavir............................... 43 Abacavir Sulfate/Lamivudine/ Zidovudine.........................43

Acetaminophen/Codeine... 13 Acetaminophen/ Diphenhydramine............. 92

Advocate Lancets............... 81

Acetazolamide.....................53

Advocate Redi-Code...........81

Abacavir/Lamivudine..........43

Acetazolamide ER...............53

Advocate Redi-Code+ Test Strips..................................81

Abelcet................................. 28

Acetazolamide Sodium.......53

Advocate Test Strips...........81

Abilify Maintena...................40

Acetic Acid...........................92

Afinitor..................................35

Abraxane..............................33

Acetylcysteine..................... 97

Afinitor Disperz....................35

Abstral.................................. 13

Acid Gone............................ 60

Acamprosate Calcium DR..15

Acid Reducer Maximum Strength............................. 62

Agamatrix Amp No Code Test Strips......................... 81

Acarbose..............................45 Accu-Chek Aviva................. 81 Accu-Chek Aviva Plus......... 81 Accu-Chek Compact Plus.. 81 Accu-Chek Fastclix Lancet Device Kit...........................81

Acitretin................................57 Acne Medication 10............ 57 Acne Medication 5.............. 57 Actemra................................78 ActHIB.................................. 78

Accu-Chek Fastclix Lancets ............................................81

Actical................................ 114

Accu-Chek Multiclix Lancet Device Kit...........................81

Actimmune.......................... 78

Accu-Chek Multiclix Lancets ............................................81

Actidose/Sorbitol................ 60 Acura Blood Glucose Test Strips..................................81 Acyclovir...............................42

Accu-Chek Smartview Strips ............................................81

Acyclovir Sodium................ 42

Accu-Chek Soft Touch Lancets.............................. 81

Adagen.................................59

Accu-Chek Softclix Lancet Device Kit...........................81 Accu-Chek Softclix Lancets ............................................81

Adacel.................................. 78 Adapalene............................57 Adcirca.................................97 Adefovir Dipivoxil................ 41 Adempas..............................97

Agamatrix Jazz Test Strips. 81 Agamatrix Presto Test Strips ............................................81 Agamatrix Ultra-Thin Lancets 33g..................................... 81 Akwa Tears.......................... 89 Akynzeo............................... 27 Ala-Cort................................ 66 Ala-Hist IR............................ 92 Ala-Hist PE........................... 92 Alahist DM............................97 Alba-Lybe NR.................... 112 Albenza................................ 37 Albuterol Sulfate..................96 Alclometasone Dipropionate ............................................66 Alcohol Prep Pads.............. 81 Aldurazyme..........................59 Alecensa.............................. 33 Alendronate Sodium........... 80

127 127 Alfuzosin HCl ER................. 65 Alimta................................... 33 Alinia.....................................37 All Day Allergy..................... 92 All Day Allergy Childrens.... 92 All Day Allergy-D..................92 All Day Pain Relief...............11

Aminosyn 7%/Electrolytes ......................................... 112

AndroGel..............................69

Aminosyn 8.5%/Electrolytes ......................................... 112

Animal Shapes.................. 114

Aminosyn II........................ 112 Aminosyn II 8.5%/Electrolytes ......................................... 112 Aminosyn-HBC.................. 112

AndroGel Pump...................69 Animal Shapes + Iron....... 114 Anoro Ellipta........................ 97 Antacid Calcium Extra Strength............................. 60

Aminosyn-PF..................... 112

Antacid Calcium Regular Strength............................. 60

Aminosyn-RF..................... 112

Antacid Extra Strength........60

Amiodarone HCl..................49

Antacid Maximum Strength61

Amitiza................................. 63 Amitriptyline HCl................. 27

Antacid Plus Anti-Gas Relief ............................................61

Amlodipine Besylate........... 51

Anti-Diarrheal....................... 61

Amlodipine Besylate/ Atorvastatin Calcium........ 51

Anti-Fungal Powder.............28

Almacone.............................60

Amlodipine Besylate/ Benazepril HCl.................. 51

Antifungal.............................28

Almacone Double Strength 60

Ammonium Lactate.............57

Alosetron HCl...................... 63

Amoxapine...........................27

Aloxi......................................28

Amoxicillin............................19

Alphagan P.......................... 91

Amoxicillin/Clavulanate Potassium..........................20

All Day Relief....................... 11 All-Nite Multi-Symptom Cold/ Flu Relief............................97 Aller-Chlor............................ 92 Allergy.................................. 92 Allergy Relief........................93 Allergy Relief Child..............93 Allergy Relief D-24...............93 Allopurinol............................30

Alprazolam...........................45 Aluminum Hydroxide.......... 60 Alunbrig................................36 Alyacen 1/35....................... 69 Amantadine HCl.................. 38 AmBisome........................... 28 Amethia................................69 Amethia Lo...........................69 Amikacin Sulfate................. 16 Amiloride HCl...................... 53 Amiloride/ Hydrochlorothiazide......... 51 Aminophylline......................97

Amoxicillin/Clavulanate Potassium ER....................20

Anti-Nausea......................... 27 Anu-Med...............................57 Anzemet............................... 28 AP-Hist DM...........................97 Apatate Forte.....................114 Apetex................................114 Apetigen............................ 114 Apetigen-Plus.................... 114

Amphetamine/ Dextroamphetamine......... 55

Apokyn................................. 38

Amphotericin B................... 28

Aprepitant............................ 28

Ampicillin............................. 20

Apri....................................... 69

Ampicillin Sodium............... 20

Apriso................................... 79

Ampicillin-Sulbactam.......... 20

Aprodine.............................. 97

Ampyra.................................56

Aptiom..................................24

Anadrol-50........................... 69

Aptivus................................. 44

Anagrelide HCl.................... 48

AquADEKs......................... 114

Anastrozole..........................35

Aqueous Vitamin D Infants ......................................... 114

Androderm...........................69

Apraclonidine...................... 91

128 128 Aqueous Vitamin E............114

Atorvastatin Calcium...........53

Aralast NP............................ 98

Atovaquone......................... 37

B-Complex Plus Vitamin C ......................................... 115

Aranelle................................ 69

Atovaquone/Proguanil HCl 38

B-Complex with B-12........ 115

Aranesp Albumin Free........ 48

Atripla................................... 43

Arcalyst................................ 78

Atropine Sulfate...................60

Baby Darlings Pediatric Electrolyte........................105

Argatroban...........................48

Atrovent HFA....................... 95

Aripiprazole..........................40

Aubagio................................56

Aripiprazole ODT.................40

Aubra....................................69

Aristada................................ 40 Arnuity Ellipta.......................95

Augmented Betamethasone Dipropionate..................... 66

Arranon................................ 33

Auryxia................................. 66

Artificial Tears......................89

Autolet Impression.............. 82

Ascorbic Acid.................... 114

Autolet Impression Lancing Device................................ 82

Ashlyna.................................69

BACiiM................................. 17 Bacitracin.............................17 Bacitracin Zinc.................... 17 Bacitracin/Neomycin/ Polymyxin.......................... 17 Bacitracin/Polymyxin B...... 89 Baclofen.............................104 Bactocill in Dextrose........... 20 Bactroban Nasal..................17

Avandia................................ 45

Balance B-100................... 115

Avastin..................................37

Balance B-50..................... 115

Avelox...................................21

Balanced B-100.................115

Aviane...................................69

Balanced B-50................... 115

Avonex................................. 56

Balsalazide Disodium......... 79

Avonex Pen..........................56

Balziva.................................. 69

Azacitidine........................... 33

Banophen............................ 93

Azactam in Iso-Osmotic Dextrose............................ 19

Banzel.................................. 24

Assure Lance Lancets........ 82 Assure Lance Plus Safety Lancets 25g.......................82

Azathioprine.........................76

Bavencio.............................. 37

Assure Lance Plus Safety Lancets 30g.......................82

Azelastine HCl............... 90, 93

Bayer Breeze 2 Test Disc... 82

Azilect...................................39

Bayer Contour Blood Glucose Test Strips.......... 82

Aspir-Low............................. 11 Aspirin.................................. 11 Aspirin EC............................ 11 Aspirin EC Low Dose.......... 11 Aspirin Low Dose................ 11 Aspirin/Dipyridamole..........48 Assure 4 Test Strips............81

Assure Platinum Test Strips ............................................82

Azithromycin........................21 Aztreonam........................... 19

B

Assure Prism Multi Test Strips..................................82

B Complex......................... 114

Assure Pro Test Strips........ 82

B Complex/Folic Acid...... 114

Atenolol................................ 50

B-6...................................... 114

Atenolol/Chlorthalidone..... 51

B-Complex......................... 115

Atgam...................................77

B-Complex Formula 1....... 115

Atomoxetine........................ 55

Baraclude.............................41

Bayer Contour Next Blood Glucose Test..................... 82 Bayer Microlet 2 Lancing Device................................ 82 BCG Vaccine....................... 78 Bee Zee..............................115 Bekyree................................ 69 Beleodaq..............................33 Belsomra............................104

129 129 Benazepril HCl.....................49

Bisacodyl EC....................... 63

Buprenorphine HCl............. 15

Benazepril HCl/ Hydrochlorothiazide......... 51

Biscolax................................63

Buprenorphine HCl/Naloxone HCl..................................... 15

Benicar.................................49

Bupropion HCl.....................25

Benicar HCT........................ 51

Bismatrol Maximum Strength ............................................61

Benlysta............................... 78

BIVIGAM.............................. 77

Bupropion HCl XL............... 25

Benzonatate.........................98

Bleomycin Sulfate............... 33

Buspirone HCl..................... 44

Benzoyl Peroxide................ 57

Blephamide......................... 89

Busulfan............................... 32

Benztropine Mesylate......... 38

Blephamide S.O.P...............89

Busulfex............................... 32

Bepreve................................90

Blisovi 24 Fe........................ 69

Butalbital/Acetaminophen. 10

Berinert................................ 75

Blisovi Fe 1.5/30................. 69

Beta Carotene................... 115

Blisovi Fe 1/20.....................70

Butalbital/Acetaminophen/ Caffeine............................. 10

Betamethasone Dipropionate ............................................66

Blood Glucose Test Strips..82

Butalbital/Aspirin/Caffeine.10 Butorphanol Tartrate...........13

Betamethasone Valerate.... 66

Blood Glucose Test Strips Premium............................ 82

Betaseron.............................56

Blue Gel............................... 57

Bydureon Vial...................... 45

Betaxolol HCl.......................91

Boostrix................................ 78

Byetta................................... 45

Bethanechol Chloride......... 65

Bosulif.................................. 36

Bystolic.................................50

Bethkis................................. 16

Botox.................................... 82

C

Betimol................................. 91

Breo Ellipta.......................... 98

Bevespi Aerosphere............98

Briellyn................................. 70

C 1000/Bioflavonoids/ Rosehips......................... 115

Bexarotene.......................... 37

Brilinta.................................. 48

Bexsero................................ 78

Brimonidine Tartrate........... 91

BG Star Blood Glucose Test ............................................82

BRIVIACT.............................23

Bicalutamide........................32

Bromocriptine Mesylate..... 39

Bicillin C-R........................... 20 BiCNU.................................. 31

Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr ............................................98

Biltricide............................... 37

Brotapp................................ 93

Cal-Gest Antacid................. 61

Binosto................................. 80

Brotapp DM......................... 98

Calcet Petites.................... 105

Biocal................................. 115

Brovana................................96

Calci-Chew.........................105

Biosupp..............................115

Budesonide................... 79, 95

Calcipotriene....................... 57

Biotin.................................. 115

Bumetanide......................... 53

Calcitonin-Salmon............... 80

Biovol................................. 115

Buphenyl..............................59

Calcitrate............................105

Bicillin L-A............................ 20

Bismatrol..............................61

Bromfed DM........................ 98

Bupropion HCl SR........ 15, 25

Bydureon Pen......................45

C 250..................................115 C 500/Rose Hips...............115 C Complex.........................115 C-1000/Rose Hips............ 115 C-500..................................115 Cabergoline......................... 75 Cabometyx...........................36 Cafergot............................... 30

130 130 Calcitriol.........................57, 80

Cancidas.............................. 28

Cefepime............................. 18

Calcium..............................105

Candesartan Cilexetil..........49

Cefixime............................... 18

Calcium & Magnesium..... 115

Cefotaxime Sodium............ 18

Calcium + D3.....................105

Candesartan Cilexetil/ Hydrochlorothiazide......... 52

Calcium 500/D.................. 105

Capastat Sulfate.................. 31

Cefoxitin Sodium.................19

Calcium 600...................... 105

Caprelsa...............................36

Cefpodoxime Proxetil......... 19

Calcium 600+D..................105

Captopril.............................. 49

Cefprozil...............................19

Calcium Acetate.................. 66

Captopril/ Hydrochlorothiazide......... 52

Ceftazidime..........................19

Calcium Antacid.................. 61 Calcium Antacid Extra Strength............................. 61

Carafate................................64 Carbaglu............................ 106

Calcium Carbonate.....61, 105

Carbamazepine................... 24

Calcium Carbonate/D3.... 105

Carbamazepine ER............. 24

Calcium Carbonate/Vitamin D.......................................105

Carbidopa/Levodopa......... 39

Calcium Citrate Malate/ Vitamin D......................... 105

Carbidopa/Levodopa ODT.39

Carbidopa/Levodopa ER... 39

Calcium Citrate+D.............105

Carbidopa/Levodopa/ Entacapone....................... 39

Calcium Citrate/Vitamin D105

Carboplatin.......................... 33

Calcium Gluconate........... 105

Cardene IV........................... 51

Calcium High Potency...... 105

Careone Blood Glucose Test Strips/Premium.................82

Calcium High Potency + Vitamin D......................... 105

Cefotetan............................. 18

Ceftriaxone Sodium............ 19 Cefuroxime Axetil................ 19 Cefuroxime Sodium............ 19 Cellcept Intravenous........... 76 Celontin................................23 Centamin........................... 115 Centrum............................. 115 Centrum Adults................. 115 Centrum Kids Complete...115 Centrum Silver...................115 Centrum Silver Adult 50+. 115 Centrum Silver Ultra Womens ......................................... 115 Centrum Specialist Heart. 115

Calcium Oyster Shell........ 105

Careone Blood Glucose Test Strips/Value.......................82

Calcium/Magnesium/Zinc ......................................... 106

Caresens N Blood Glucose Test Strips......................... 82

Cephalexin...........................19

Calcium/Vitamin D............106

Carimune Nanofiltered....... 77

Calcium/Vitamin D3..........106

Carteolol HCl....................... 91

Cerovite Advanced Formula ......................................... 115

Caltrate 600+D.................. 106

Cartia XT.............................. 51

Cerovite Jr......................... 115

Caltrate 600+D Plus Minerals ......................................... 106

Carvedilol............................. 50

Certavite Senior/Antioxidant Nutrients.......................... 115

Caltrate 600+D3 Soft Chews ......................................... 106

Caziant................................. 70

Camila.................................. 73

Cefadroxil.............................18

Camrese Lo......................... 70

Cefazolin Sodium................ 18

Canasa................................. 79

Cefdinir.................................18

Cayston................................ 96 Cefaclor................................18

Centrum Ultra Mens..........115 Cerezyme.............................59

Certavite/Antioxidants...... 116 Cesamet...............................28 Cetirizine HCl.......................93 Cetirizine HCl Allergy Childrens........................... 93

131 131 Cetirizine HCl Childrens Allergy................................93 Cetirizine HCl/ Pseudoephedrine HCl ER 93

Chlo Tuss EX....................... 98

Clarithromycin ER............... 21

Chloramphenicol Sodium Succinate...........................17

Clever Chek Auto-Code Test Strips..................................82

Chlordiazepoxide HCl.........45

Clever Chek Auto-Code Voice Test Strips......................... 82

Chantix................................. 15

Chlorhexidine Gluconate....57

Chantix Continuing Month Pak..................................... 15

Chloroquine Phosphate......38

Chantix Starting Month Pak ............................................16

Chlorothiazide Sodium....... 53

Chemet.............................. 104 Chenodal............................. 61 Cheratussin AC................... 98 Cheratussin DAC.................98 Chest Congestion Relief.....98 Chest Congestion Relief PE ............................................98

Chlorothiazide..................... 53 Chlorphen SR...................... 93 Chlorpheniramine Maleate.93

Clever Chek Lancets Ultrathin 30g..................................... 82 Clever Chek Test Strips...... 82 Clever Choice Auto-Code Pro Test Strips......................... 82

Chlorpromazine HCl........... 39

Clever Choice Micro Test Strips..................................82

Chlorthalidone..................... 53

Climara Pro.......................... 70

Cholbam.............................. 61

Clindamycin HCl..................17

Cholestyramine Light..........54

Clindamycin Palmitate HCl.17

Chorionic Gonadotropin.....68

Clindamycin Phosphate.....17, 58

Chewable Antacid............... 61

Ciclopirox.............................29

Chewable Calcium............106

Ciclopirox Nail Lacquer...... 29

Chewable Vite Childrens.. 116

Ciclopirox Olamine..............29

Chewable Vite with Iron/ Childrens......................... 116

Cidofovir...............................41

Childrens Allergy................. 93

Cimetidine............................63

Childrens Aspirin.................11

Cimetidine HCl.................... 63

Childrens Chewable Vitamin ......................................... 116

Cimzia.................................. 76

Childrens Chewable Vitamins ......................................... 116

Ciprofloxacin....................... 21

Childrens Chewable Vitamins/Iron...................116

Ciprofloxacin HCl................ 21

Cilostazol............................. 48

Cinryze................................. 75 Ciprofloxacin ER................. 21

Childrens Ibuprofen............ 11

Ciprofloxacin I.V. in D5W....21

Childrens Loratadine.......... 93

Cisplatin............................... 33

Childrens Mapap Rapid Tabs ............................................10

Citalopram HBr....................26

Childrens Silfedrine.............98

Cladribine............................ 33

Childs Ibuprofen..................11

Claravis................................ 57

Chlo Tuss.............................98

Clarithromycin..................... 21

Citrus Calcium+D.............. 106

Clindamycin Phosphate in D5W................................... 17 Clindamycin/Benzoyl Peroxide............................ 58 Clobetasol Propionate........ 66 Clobetasol Propionate E.....67 Clofarabine.......................... 33 Clolar.................................... 33 Clomipramine HCl...............27 Clonazepam.........................45 Clonazepam ODT................45 Clonidine HCl...................... 49 Clonidine HCl ER................ 55 Clopidogrel.......................... 48 Clorazepate Dipotassium... 45 Clotrimazole.........................29 Clotrimazole Anti-Fungal.... 29 Clotrimazole/Betamethasone Dipropionate..................... 58

132 132 Clozapine............................. 41

Cosmegen........................... 33

Clozapine ODT.................... 41

Cosopt PF............................ 91

CVS Calcium Chewables 600plus............................106

Coartem............................... 38

Cotellic................................. 36

CVS Calcium Citrate + D.. 106

Coats Aloe Creme............... 58

Cough DM............................98

Coats Aloe Gelly..................58

Cough Syrup........................98

CVS Calcium Citrate+D/ Magnesium..................... 106

Coats Aloe Moisturizing Lotion.................................58

Coumadin............................ 47

Codeine Sulfate...................13

Crestor................................. 53

Codeine/Guaifenesin..........98

Crinone................................ 73

Colchicine............................ 30

Crixivan................................ 44

Cold/Cough DM Childrens.98

CVS Daily Energy.............. 116

Colestipol HCl......................54

Cromolyn Sodium..61, 90, 97, 98

Colistimethate Sodium....... 17

Cryselle-28........................... 70

Colocort............................... 80

Cubicin.................................17

CVS Daily Multiple for Men ......................................... 116

Combigan............................ 91

Cuprimine............................ 66

Combivent Respimat........ 103

Cuvposa............................... 60

Cometriq.............................. 36 Compete............................ 116

CVS Advanced Glucose Meter Test Strips.............. 82

Complera............................. 43

CVS B Complex Plus C.... 116

Complete........................... 116

CVS B-1..............................116

Complete Allergy Medicine 93

CVS B-12............................116

CVS Daily Multiple Plus Iron/ Calcium/Zinc.................. 117

Complex B-100..................116

CVS B-6..............................116

CVS E Oil........................... 117

Compro................................ 27

CVS Balanced B-100........ 116

CVS Electrolyte Solution.. 106

Congestion Relief................11

CVS Balanced B-50.......... 116

CVS Gummy Dinos........... 117

Constulose...........................63

CVS Beta Carotene...........116

Control AST......................... 82

CVS Biotin..........................116

CVS Hair Skin & Nails/ Antioxidants.................... 117

Control Test Strips.............. 82

CVS Biotin High Potency..116

CVS Iron.............................106

Copaxone............................ 57

CVS Calcium..................... 106

Coral Calcium....................106

CVS Calcium 600 & Vitamin D3.....................................106

CVS Lancets Micro Thin 33g ............................................82

Corlanor............................... 52 Cormax Scalp Application..67 Cortisone Acetate............... 67 Cosentyx.............................. 76 Cosentyx Sensoready Pen. 76

Creon....................................59

CVS Calcium/Magnesium/ Zinc.................................. 106 CVS Childrens Chewable Complete.........................116 CVS Childrens Chewable Multivitamin/Iron.............116 CVS Daily Multiple............ 116

CVS Daily Multiple for Men 50+................................... 116 CVS Daily Multiple for Women............................ 116 CVS Daily Multiple for Women 50+.....................116

CVS Lancets Thin 26g........ 83

CVS Calcium 600 + D/ Minerals........................... 106

CVS Lancets Ultra Thin 30g ............................................83

CVS Calcium 600+D......... 106

CVS Lancing Device........... 83

CVS Calcium Carbonate.. 106

CVS Laxative Dietary Supplement.......................61

133 133 CVS Magnesium......... 61, 106

Cyclosporine........................76

Deconex IR.......................... 98

CVS Oyster Shell Calcium w/ Vitamin D......................... 106

Cyclosporine Modified........76

Deep Sea Nasal Spray........ 98

Cyproheptadine HCl........... 93

Delsym................................. 98

CVS Pediatric Electrolyte. 106

Cyramza............................... 37

CVS Pediatric Electrolyte Freezer Pops................... 106

Cystadane............................59

Delsym Cough + Chest Congestion DM................. 98

CVS Slow Release Iron.....112 CVS Spectravite Adult 50+ ......................................... 117

Cystagon..............................59 Cystaran............................... 89 Cytarabine Aqueous........... 33

D

Delsym Cough + Chest Congestion DM Childrens99 Delsym Cough + Cold Daytime..............................99

CVS Spectravite Advanced Formula........................... 117

Dacarbazine.........................32

CVS Spectravite Senior.... 117

Daily Multiple Vitamin....... 117

CVS Spectravite Ultra Health Mens................................ 117

Daily Multiple Vitamin/Iron ......................................... 117

CVS Spectravite Ultra Mens Health.............................. 117

Daily Multiple Vitamins..... 117

Demeclocycline HCl............22

Daily Vitamins.................... 117

Demser.................................52

CVS Spectravite Ultra Women............................ 117

Daily Vite............................ 117

Depen Titratabs...................66

Daily-Vite/Iron/Beta-Carotene ......................................... 117

Depo-Medrol........................67

CVS Spectravite Ultra Womens Health.............. 117 CVS Spectravite Ultra Womens Health Senior.. 117 CVS Super B Complex/C. 117 CVS Vitamin A................... 117 CVS Vitamin B-12..............117 CVS Vitamin B-12 TR........117 CVS Vitamin B-6................ 117 CVS Vitamin B12...............117 CVS Vitamin C................... 117 CVS Vitamin C/Rose Hips117 CVS Vitamin E................... 117 CVS Zinc............................ 107

Daklinza................................41 Daliresp................................ 97 Dallergy................................ 93 Dalvance.............................. 17

Delsym Cough + Cold Nighttime........................... 99 Delsym Cough + Cold Nighttime Childrens..........99 Delyla....................................70

Depo-Provera.......................73 Descovy................................43 Desipramine HCl................. 27 Desmopressin Acetate....... 68

Danazol................................ 69

Desogestrel/Ethinyl Estradiol ............................................70

Dantrolene Sodium........... 104

Desonide..............................67

Dapsone...............................31

Desoximetasone..................67

Daptacel...............................78

Desvenlafaxine ER.............. 26

Daptomycin......................... 17

Dexamethasone.................. 67

DARAPRIM.......................... 38

Dexamethasone Intensol.... 67

Darzalex............................... 37

Dexamethasone Sodium Phosphate................... 67, 91

Daunorubicin HCl................33

Cyclafem.............................. 70

Day Time Multi-Symptom Cold/Flu Relief.................. 98

Cyclobenzaprine HCl........104

Deblitane..............................73

Dexmethylphenidate HCl ER ............................................55

Cyclophosphamide.............32

Decitabine............................33

Dexrazoxane........................ 33

Cycloset............................... 45

Deconex DMX......................98

Dexmethylphenidate HCl....55

134 134 Dextroamphetamine Sulfate ............................................55

Digitek.................................. 52

Dofetilide..............................49

Digoxin................................. 52

DOK......................................63

Dextromethorphan Polistirex ............................................99

Dihydroergotamine Mesylate ............................................30

DOK PLUS........................... 63

Dextrose 10%.................... 112

Dilantin................................. 24

Dextrose 10%/NaCl 0.2%.112

Donepezil HCl ODT.............25

Dilantin INFATABS.............. 24

Dextrose 10%/NaCl 0.45% ......................................... 112

Doribax.................................19

Dilt-XR.................................. 51

Dorzolamide HCl................. 91

Diltiazem CD........................ 51 Diltiazem HCl....................... 51

Dorzolamide HCl/Timolol Maleate.............................. 91

Diltiazem HCl ER................. 51

Doxazosin Mesylate............ 49

Dimaphen Childrens........... 93

Doxepin HCl.................. 27, 58

Dimenhydrinate................... 27

Doxercalciferol.................... 80

Dextrose 5%/NaCl 0.2%... 112

Dino-Life.............................117

Doxil..................................... 34

Dextrose 5%/NaCl 0.225% ......................................... 112

Dino-Life with Extra C....... 117

Doxorubicin HCl.................. 34

Dino-Life with Iron & Zinc. 117

Doxorubicin HCl Liposome 34

Dextrose 5%/NaCl 0.33%.112

Diocto...................................61

Doxy 100.............................. 22

Dextrose 5%/NaCl 0.45%.112

Dipentum............................. 79

Doxycycline..........................22

Dextrose 5%/NaCl 0.9%... 113

Diphenhist............................93

Doxycycline Hyclate............22

Dialyvite 800...................... 117

Diphenhydramine HCl........ 93

Doxycycline Monohydrate..22

Diastat AcuDial.................... 23

Diphenoxylate/Atropine......61

Dr Smiths Diaper................. 58

Diastat Pediatric.................. 23

Diphtheria/Tetanus Toxoids Adsorbed Pediatric...........78

Dr Smiths Diaper Rash Spray ............................................58

Disulfiram.............................15

Dr Smiths Rash + Skin........ 58

Diazepam............................. 45

Diuril..................................... 53

Drisdol................................117

Diazepam Intensol...............45

Divalproex Sodium..............45

Dronabinol........................... 28

Dibucaine.............................58

Divalproex Sodium DR....... 45

Diclofenac Potassium......... 11

Divalproex Sodium ER........45

Drospirenone/Ethinyl Estradiol.............................70

Diclofenac Sodium. 11, 58, 91

Doc-Q-Lace.......................... 63

Droxia................................... 33

Diclofenac Sodium DR....... 11

Doc-Q-Lax............................ 63

Duavee................................. 70

Diclofenac Sodium ER........11

Docetaxel............................. 34

Duloxetine HCl.....................56

Dicloxacillin Sodium........... 20

Docusate Sodium & Senna Stimulant Laxative/Stool Softener............................. 63

Duofer................................ 107

Docusol Kids....................... 61

Durezol................................. 91

Dextrose 2.5%/NaCl 0.45% ......................................... 112 Dextrose 5%...................... 112 Dextrose 5%/Lactated Ringers............................ 112

Diatrue Plus Blood Glucose Test Strips......................... 83

Dicyclomine HCl..................60 Didanosine...........................43 Dificid................................... 21 Diflunisal.............................. 11

Docusol Plus Mini-Enema...63

Donepezil HCl......................25

Duraflu..................................99 Duramorph...........................13

135 135

E

EASYMax Test Strips.......... 83

Emcyt................................... 32

E-400.................................. 117

Ecee Plus........................... 118

Emend..................................28

E-Z Ject Lancets Color........83

Econazole Nitrate................ 29

Emend Tripack.................... 28

E-Z Ject Lancets Super Thin 30g..................................... 83

Econtra EZ........................... 73

Emoquette........................... 70

ED A-Hist........................93, 99

Empliciti............................... 37

ED A-Hist DM....................... 99

Emsam................................. 25

ED A-Hist PSE......................99

Emtriva................................. 43

ED Bron GP......................... 99

Enalapril Maleate.................49

ED Chlorped........................ 93 ED Chlorped D.................... 93

Enalapril Maleate/ Hydrochlorothiazide......... 52

ED Chlorped Jr....................93

Enbrel................................... 76

ED Chlortan......................... 93

Enbrel SureClick................. 76

Easy Touch Glucose Test Strips..................................83

ED-APAP.............................. 10

EndaCof-DM........................ 99

Edurant.................................43

Endocet................................13

Easy Touch Lancets 26g/ Pressure Activated............83

Effervescent Pain Relief......12

Enema Ready-To-Use......... 63

Effient................................... 48

Enemeez Mini...................... 61

Easy Touch Lancets 28g/ Twist...................................83

Egrifta................................... 75

Enemeez Plus......................63 Enfamil Enfalyte.................107

Easy Touch Lancets 30g/ Twist...................................83

Elaprase............................... 59 Elelyso.................................. 59

Engerix-B..............................78

Easy Touch Lancets 32g/ Twist...................................83

Element Compact Test Strips ............................................83

Enoxaparin Sodium.............47

Easy Touch Lancets 33g/ Twist...................................83

Element Test Strips.............83

Entacapone..........................38

Elestrin................................. 70

Entecavir.............................. 41

Easy Touch Safety Lancets26g/Pressure Activated............................83

Elidel.....................................58

Enteric Coated Aspirin........12

Eliphos................................. 66

Entresto................................52

Eliquis...................................47

Enulose................................ 63

Elitek.....................................33

Epclusa................................ 41

Elmiron................................. 66

Epinastine HCl.....................90

Easy Touch Safety Lancets28g/Pressure Activated............................83

Embeda................................13

Epinephrine......................... 96

Embrace Blood Glucose Test Strips..................................83

EpiPen..................................96

Easy Trak Blood Glucose Test Strips......................... 83

Embrace Evo Blood Glucose Test Strips......................... 83

Epitol.................................... 24

EasyGluco............................83

Embrace Pro Blood Glucose Test Strips......................... 83

Eplerenone.......................... 53

E-Z Ject Lancets Thin 26g..83 E.E.S. Granules....................21 Earwax Treatment Drops....92 Easy Plus II Blood Glucose Test.................................... 83 Easy Step Test Strips..........83 Easy Talk Blood Glucose Test Strips......................... 83

Easy Touch Safety Lancets28g/Button Activated............................83

EASYMax 15 Test Strips.....83

Enpresse-28.........................70

Epirubicin HCl..................... 34 Epivir HBV............................41

136 136 Eprosartan Mesylate........... 49

Etodolac............................... 12

Faslodex...............................33

Epzicom............................... 43

Etopophos........................... 35

Fe C.................................... 118

EQL One Daily Essential...118

Etoposide.............................35

Felbamate............................ 24

EQL Pediatric Electrolyte..107

EvenCare + Blood Glucose Test Strip........................... 83

Femynor............................... 70

EvenCare Blood Glucose Test Strip........................... 83

Fentanyl................................13

Eraxis....................................29 Erbitux.................................. 37 Ergocalciferol.................... 118

Fenofibrate...........................53

EvenCare G2 Test Strips.... 83

Fentanyl Citrate Oral Transmucosal....................13

EvenCare G3 Test Strips.... 83

Fer-In-Sol............................107

Erivedge............................... 36

Evolution Autocode.............83

Fer-Iron...............................107

Errin...................................... 73

Evotaz...................................42

Ferate................................. 107

Erwinaze...............................34

Exemestane......................... 35

Fergon................................107

Ery.........................................58

Exjade................................ 104

Ferosul............................... 107

Ery-Tab................................. 21

Exondys 51.......................... 83

Ferretts...............................107

EryPed 200.......................... 21

Extra Action Cough............. 99

Ferretts IPS........................ 107

EryPed 400.......................... 21

Eye Drops............................ 89

Ferrex 150..........................107

Erythrocin Lactobionate..... 21

Ez Smart Blood Glucose Test Strips..................................83

Ferric X-150....................... 107

Erythromycin Base.............. 21

Ez Smart Plus Blood Glucose Test Strips......................... 83

Ferriprox............................ 105

Erythromycin Ethylsuccinate ............................................21

Ezetimibe............................. 54

Erythromycin/Benzoyl Peroxide............................ 58

EZFE 200........................... 107

Ergotamine Tartrate/Caffeine ............................................30

Erythromycin................. 21, 58

Esbriet.................................. 99 Escitalopram Oxalate..........26 Esomeprazole Magnesium.65 Esomeprazole Sodium........65 Estradiol............................... 70 Estradiol Valerate................ 70 Estring.................................. 70 Ethambutol HCl................... 31 Ethosuximide....................... 23 Ethynodiol Diacetate/Ethinyl Estradiol.............................70 Etidronate Disodium........... 80

Ezetimibe/Simvastatin........ 54

Ferrimin 150...................... 107 Ferrous Drops................... 107 Ferrous Fumarate 324...... 107 Ferrous Gluconate............ 107

F

Ferrous Sulfate.................. 107

Fabrazyme........................... 59

Ferrousul............................107

Fallback Solo....................... 73

Fetzima.................................26

Falmina.................................70

Fetzima Titration Pack........ 26

Famciclovir...........................42

Fexofenadine HCl................93

Famotidine........................... 63

Fexofenadine HCl Childrens Allergy................................93

Famotidine Premixed..........63 Fanapt.................................. 40 Fanapt Titration Pack..........40 Fareston............................... 33 Farxiga................................. 45 Farydak................................ 34

Fiber Laxative...................... 63 Fiber Tabs............................63 Fiber-Lax.............................. 63 Fifty50 Glucose Test Strip 2.0 ............................................83 Finacea.................................58

137 137 Finasteride........................... 65

Folotyn................................. 33

FreAmine HBC 6.9%......... 113

Fine 30................................. 84

Foltabs 800........................ 118

Firazyr...................................75

Fomepizole.......................... 84

FreeStyle Insulinx Blood Glucose Test..................... 84

Firmagon..............................75

Fondaparinux Sodium........ 47

Flebogamma DIF.................77

Fora D10 Blood Glucose Test Strips..................................84

Flecainide Acetate.............. 50

FreeStyle Insulinx Blood Glucose Test Strips.......... 84 FreeStyle Lancets................84

Fora D15g Blood Glucose Test Strips......................... 84

FreeStyle Lite Test Strips....84

Fora D20 Blood Glucose Test Strips..................................84

FreeStyle Unistick II Lancets ............................................84

Fora G20 Blood Glucose Test Strips..................................84

Freshkote............................. 89

Flucytosine...........................29

Fora G30a Blood Glucose Test Strips......................... 84

Fruity Chewables Multivitamin..................... 118

Fludarabine Phosphate...... 34

Fora GD20 Test Strips........ 84

Fludrocortisone Acetate..... 67

Fora Lancets........................84

Full Spectrum B/Vitamin C ......................................... 118

Flunisolide............................95

Fora V10 Blood Glucose Test Strips..................................84

Fungoid Tincture................. 29

Fora V12 Blood Glucose Test Strips..................................84

Fusilev.................................. 34

Fora V20 Blood Glucose Test Strips..................................84

Fycompa.............................. 23

Flector.................................. 12 Fleet Pediatric......................63 Flovent Diskus..................... 95 Flovent HFA......................... 95 Fluconazole......................... 29 Fluconazole in NaCl............ 29

Fluocinolone Acetonide.....67, 92 Fluocinonide........................ 67 Fluocinonide Emulsified Base ............................................67

FreeStyle Test Strips...........84

Fruity C...............................118

Furosemide..........................53 Fuzeon................................. 43

G

Fora V30a Blood Glucose Test Strips......................... 84

Gabapentin.......................... 23

ForaCare GD40................... 84

Gabitril..................................23

ForaCare Premium V10 Test Strips..................................84

Gablofen............................ 104 Gammagard Liquid............. 77

Fluphenazine HCl................39

ForaCare Test N Go Test Strips..................................84

Flurbiprofen......................... 12

Formula EM......................... 27

Gammagard S/D IGA Less Than 1 mcg/ml..................77

Flurbiprofen Sodium........... 91

Forteo................................... 80

Gammaked.......................... 77

Flutamide............................. 32

Fosfree............................... 118

Gammaplex......................... 77

Fluticasone Propionate 67, 95

Fosinopril Sodium............... 49

Gamunex-C.......................... 77

Fluvastatin............................53

Ganciclovir........................... 41

Fluvoxamine Maleate.......... 26

Fosinopril Sodium/ Hydrochlorothiazide......... 52

Folic Acid........................... 118

Fosphenytoin Sodium.........24

Gas Relief............................ 61

Folitab 500.........................107

Fosrenol............................... 66

Gas Relief Extra Strength... 61

Fluorometholone................. 91 Fluorouracil....................33, 58 Fluoxetine DR...................... 26 Fluoxetine HCl..................... 26 Fluphenazine Decanoate....39

Gamastan S/D.....................77

Gardasil 9.............................78

138 138 Gas Relief Maximum Strength............................. 61

Glucocard 01 Sensor Plus Test Strips......................... 84

GNP Century Adults 50+ Senior.............................. 118

Gattex...................................61 Gauze................................... 84

Glucocard Expression Blood Glucose Test Strips.......... 84

GNP Century Cardio Healthformula................. 118

GaviLyte-C............................63

Glucocard Vital Test Strips.84

GaviLyte-G........................... 63

GlucoCom Test Strips........ 84

GNP Century Ultimate Mens Complete.........................118

GaviLyte-N/Flavor Pack...... 64

Glucolet 2 Automatic Lancing Device................................ 84

GNP Century Ultimate Womens Complete.........118

GlucoNavii Blood Glucose Test Strips......................... 85

GNP Century Ultimate Womens Senior Formula ......................................... 118

GE100 Blood Glucose Test Strips..................................84 Gemcitabine HCl................. 33 Gemfibrozil.......................... 53 Generlac...............................64 Gengraf................................ 76 Genotropin...........................68 Genotropin Miniquick......... 68 Gentak..................................16

Glycopyrrolate..................... 60 Gmate Blood Glucose Test Strips..................................85 GNP All Day Allergy............ 93 GNP Allergy......................... 93 GNP Animal Shapes......... 118

Gentamicin Sulfate..............16

GNP Animal Shapes Plus Extra C............................. 118

Gentamicin Sulfate/0.9% Sodium Chloride............... 16

GNP Animal Shapes Plus Iron ......................................... 118

Genvoya............................... 42

GNP Antacid Anti-Gas........ 61

Geodon................................ 40

GNP Arthritis Pain Relief.... 10

Gianvi................................... 70

GNP B-50 Balanced..........118

Gildagia................................ 70

GNP Calcium.....................107

Gilenya................................. 57

GNP Calcium 1200........... 107

Gilotrif...................................36

GNP Calcium 500+D3...... 107

Glassia..................................99

GNP Calcium 500/D......... 107

Glatopa.................................57

GNP Calcium 600/D......... 107

Gleostine..............................32 Glimepiride.......................... 45

GNP Calcium Citrate+D Maximum.........................107

Glipizide............................... 45

GNP Calcium Citrate+D3..107

Glipizide ER......................... 45

GNP Calcium/Magnesium/ Zinc.................................. 107

Glipizide/Metformin HCl.....45 GlucaGen HypoKit.............. 46 Glucagon Emergency Kit....46

GNP Calcuim/Vitamin D/ Minerals........................... 107 GNP Century..................... 118

GNP Childrens Chewables/ Extra C............................. 118 GNP Childrens Chewables/ Iron...................................118 GNP Dayhist Allergy............93 GNP Essential One Daily.. 118 GNP Hair/Skin/Nails.........118 GNP Ibuprofen.................... 12 GNP Ibuprofen Junior Strength............................. 12 GNP Iron............................ 108 GNP Little Ones Childrens ......................................... 118 GNP Loratadine...................94 GNP Magnesium...............108 GNP Masanti Maximum Strength............................. 61 GNP Masanti Regular Strength............................. 61 GNP Mega Multi for Men..118 GNP Mega Multi for Women ......................................... 119 GNP Niacin TR.................. 119 GNP Omeprazole................ 65 GNP One Daily Maximum.119

139 139 GNP One Daily Mens Health 50+................................... 119 GNP One Daily Plus Iron.. 119

H H-E-B Oral Electrolyte Solution........................... 108

Humalog Mix 50/50 KwikPen ............................................47 Humalog Mix 50/50 Vial..... 47

GNP One Daily Womens Health 50+....................... 119

Halaven................................ 34 Halobetasol Propionate...... 67

Humalog Mix 75/25 KwikPen ............................................47

GNP Opti-Vitamins............ 119

Haloperidol.......................... 39

Humalog Mix 75/25 Vial..... 47

GNP Pediatric Electrolyte.108

Haloperidol Decanoate.......39

Humalog Vial....................... 47

GNP Therapeutic-M.......... 119

Haloperidol Lactate.............39

Humatrope...........................68

GNP Tussin..........................99

Hard Nails.......................... 119

Humatrope Combo Pack....68

GNP Tussin DM...................99

Harvoni................................. 41

Humira..................................76

GNP Vitamin A...................119

Havrix................................... 78

GNP Vitamin B-12............. 119

Health Care Lancing Device ............................................85

Humira Pediatric Crohns Disease Starter Pack........ 76

GNP Vitamin B-12 TR....... 119

Humira Pen.......................... 76

Heartburn Treatment 24 Hour ............................................65

Humira Pen Crohns Disease Starter Pack.......................76

Hemocyte...........................108 Hemorrhoidal.......................58

Humira Pen-Psoriasis Starter ............................................76

Heparin Sodium.................. 47

Humulin 70/30 KwikPen.....47

Heparin Sodium/D5W........ 47

Humulin 70/30 Vial............. 47

GNP Vitamin C with Rose Hips TR............................119

HepatAmine.......................113

Humulin N KwikPen............ 47

Herceptin............................. 37

Humulin N Vial.....................47

GNP Vitamin E...................119

Hetlioz................................ 104

Humulin R U-500 KwikPen. 47

GNP Zinc........................... 108

Hexalen................................ 32

Humulin R U-500 Vial..........47

GNP Zoo Chews Gummies ......................................... 119

Hiberix.................................. 78

Humulin R Vial.....................47

Histaflex............................... 99

Hydralazine HCl...................55

Granisetron HCl...................28

Histex................................... 94

Hydrochlorothiazide............53

Griseofulvin Microsize........ 29

Histex PD............................. 94

Griseofulvin Ultramicrosize 29

Histex-DM.............................99

Hydrocodone Bitartrate/ Acetaminophen.................14

Guaiatussin AC....................99

Histex-PE..............................99

Guaifenesin AC................... 99

HM Pediatric Electrolyte...108

Guaifenesin and Pseudoephedrine HCl...... 99

Honey Bears...................... 119

GNP Vitamin B-6............... 119 GNP Vitamin C.................. 119 GNP Vitamin C Drops....... 119 GNP Vitamin C TR............ 119 GNP Vitamin C with Rose Hips..................................119

Guaifenesin ER....................99

Honey Bears with Iron and Zinc.................................. 119

Guaifenesin/Codeine..........99

Humalog Cartridge..............47

Guanfacine ER.................... 56

Humalog KwikPen...............47

Guanidine HCl..................... 31

Hydrocodone Bitartrate/ Chlorpheniramine Maleate/ PSE.................................... 99 Hydrocodone Bitartrate/ Homatropine Methylbromide.................. 99 Hydrocodone Polistirex/ Chlorpheniramine Polistirex ............................................99

140 140 Hydrocodone/ Acetaminophen.................14

ICAR-C............................... 119

Invega Trinza....................... 40

Iclusig................................... 36

Invirase................................. 44

Hydrocodone/Homatropine ............................................99

Idarubicin HCl......................34

Ionosol-B/Dextrose 5%.....113

Iferex 150........................... 108

Ionosol-MB/Dextrose 5%..113

Ifosfamide............................ 32

Iophen C-NR...................... 100

Ilaris...................................... 78

Iophen DM-NR...................100

Ilevro.....................................91

Iophen-NR..........................100

Imatinib Mesylate................ 36

Iosat......................................85

Imbruvica............................. 36

IPOL Inactivated IPV........... 78

Imfinzi................................... 37

Ipratropium Bromide...........96

Imipenem/Cilastatin............19 Imipramine HCl....................27

Ipratropium Bromide/ Albuterol Sulfate............. 103

Imipramine Pamoate...........27

Irbesartan.............................49

Imiquimod............................58

Irbesartan/ Hydrochlorothiazide......... 52

Hydrocodone/Ibuprofen.....14 Hydrocortisone..............67, 80 Hydrocortisone Butyrate.....67 Hydrocortisone Valerate..... 67 Hydrocortisone/Acetic Acid ............................................92 Hydrocortisone/Aloe...........67 Hydromet............................. 99 Hydromorphone HCl...........14 Hydromorphone HCl ER.....13 Hydroxychloroquine Sulfate ............................................38

Imovax Rabies..................... 78

Hydroxyprogesterone Caproate............................73

Increlex.................................69

Hydroxyurea........................ 33

Indapamide..........................53

Hydroxyzine HCl..................44

Infanrix................................. 78

Hydroxyzine Pamoate......... 27

Infants Gas Relief................ 61

Hypolance AST Lancing Kit ............................................85

Infants Ibuprofen................. 12

I I-Caps Areds Formula....... 119

Incruse Ellipta...................... 96

Infants Simethicone............ 61 Infed................................... 108

I-Caps MV.......................... 119

Infinity Blood Glucose Test Strips..................................85

I-Caps Plus.........................119

Inlyta..................................... 36

I.L.X. B-12...........................108

Insulin Syringes, Needles... 85

Ibrance................................. 34

Integra................................ 119

Ibu-200................................. 12

Intelence.............................. 43

Ibu-Drops............................. 12

Intralipid............................. 113

Ibu-Drops Infants................. 12

Intron A.................................42

Ibuprofen............................. 12

Introvale............................... 70

Ibuprofen Childrens............ 12

Invanz................................... 19

Ibuprofen Junior Strength.. 12

Invega Sustenna..................40

ICAR Pediatric...................113

Iressa....................................36 Irinotecan............................. 34 Iron..................................... 108 Iron 100/C......................... 119 Iron Supplement Childrens ......................................... 108 Isentress...............................42 Isibloom............................... 70 Isolyte-P/Dextrose 5%...... 113 Isolyte-S..............................108 Isoniazid............................... 31 Isopto Tears.........................89 Isosorbide Dinitrate.............55 Isosorbide Dinitrate ER.......55 Isosorbide Mononitrate.......55 Isosorbide Mononitrate ER.55 Isotonic Gentamicin............ 16 Istodax..................................34 Itraconazole......................... 29 Ivermectin............................ 37

141 141 Ixiaro.....................................79

J J-Max..................................100 J-TAN D PD..........................94 J-TAN PD..............................94 Jadenu............................... 105 Jadenu Sprinkle................ 105 Jakafi.................................... 36

KCl 0.15%/D5W/NaCl 0.2% ......................................... 113

KP Adults 50+ Daily Formula ......................................... 119

KCl 0.15%/D5W/NaCl 0.225%.............................113

KP Adults Daily Formula...119

KCl 0.15%/D5W/NaCl 0.9% ......................................... 113

KP Ferrous Gluconate...... 108

KCl 0.3%/D5W/NaCl 0.45% ......................................... 113

KP B Complex/C...............119 KP Ferrous Sulfate............ 108 KP Mens 50+ Daily Formula ......................................... 119

Jantoven...............................47

KCl 0.3%/D5W/NaCl 0.9% ......................................... 113

Jardiance............................. 46

Kelnor 1/35..........................71

Jentadueto...........................46

Kenalog-10...........................67

Jentadueto XR.....................46

Kenalog-40...........................67

Jevtana.................................34

Kepivance............................ 57

Jinteli.................................... 70

Ketoconazole.......................29

Jolivette................................ 73

Ketoprofen........................... 12

Kroger Blood Glucose Test Strips..................................85

Jublia....................................29 Juleber................................. 71

Ketorolac Tromethamine...12, 91

Kroger Premium Blood Glucose Test Strips.......... 85

Junel 1.5/30.........................71

Keytruda...............................37

Kroger Test Strips............... 85

Junel 1/20............................71

Kidkare Cough/Cold.........100

Kuvan................................... 59

Junel Fe 1.5/30................... 71

Kimidess.............................. 71

Kynamro...............................54

Junel Fe 1/20.......................71

Kineret..................................76

Kyprolis................................ 35

Junel Fe 24.......................... 71

Kinrix.................................... 79

L

Junior Mapap...................... 11

Kionex................................ 105

Labetalol HCl....................... 50

Juxtapid............................... 54

Kisqali...................................34

Lacrisert............................... 89

Kisqali Femara 200 Dose....34

Lactated Ringers Irrigation ......................................... 113

K Kadcyla................................ 37

Kisqali Femara 400 Dose....34

Kaitlib Fe.............................. 71

Kisqali Femara 600 Dose....34

Kaletra.................................. 44

Klor-Con 10........................108

Kalydeco......................96, 100

Klor-Con 8..........................108

Kanuma................................85

Klor-Con M10.................... 108

Kao-Tin................................. 61

Klor-Con M15.................... 108

Kariva................................... 71

Klor-Con M20.................... 108

KCl 0.075%/D5W/NaCl 0.45%...............................113

Klor-Con Sprinkle.............. 108 Kombiglyze XR.................... 46 Korlym.................................. 69

KP Mens Daily Formula.... 119 KP Vitamin E......................119 KP Womens 50+ Daily Formula........................... 120 KP Womens Daily Formula ......................................... 120

Lactated Ringers Viaflex...113 Lactulose............................. 64 Lamivudine.................... 41, 43 Lamivudine/Zidovudine......43 Lamotrigine..........................24 Lancets Ultra Thin............... 85 Lanoxin.................................52 Lansoprazole....................... 65 Lantus SoloStar................... 47

142 142 Lantus Vial........................... 47

Levoleucovorin Calcium..... 34

LARIN 1.5/30.......................71

Levonest...............................71

LARIN 1/20..........................71

Levonorgestrel and Ethinyl Estradiol.............................71

Lodrane D............................ 94

Levonorgestrel/Ethinyl Estradiol.............................71

LoHist-DM.......................... 100

Levora 0.15/30-28............... 71

Lonsurf................................. 33

Levorphanol Tartrate.......... 13

Loperamide HCl.................. 61

Levothyroxine Sodium........ 74

Lopinavir/Ritonavir..............44

Levoxyl................................. 74

Loratadine............................94

Lexiva................................... 44

Loratadine Childrens.......... 94

Lialda....................................79

Loratadine Hives Relief.......94

Liberty Test Strips............... 85

Loratadine-D 12hr............... 94

Lidocaine............................. 15

Loratadine-D 24hr............... 94

Lidocaine HCl...................... 15

Lorazepam...........................45

Lidocaine HCl Jelly............. 15

Lorazepam Intensol............ 45

Lidocaine Viscous............... 15

Lorcet................................... 14

Lidocaine/Prilocaine...........15

Lorcet HD.............................14

Life Pack Mens..................120

Lorcet Plus...........................14

Life Pack Womens............ 120

Lortuss DM........................ 100

Lincomycin HCl................... 17

Lortuss EX..........................100

Lindane................................ 38

Lortuss LQ........................... 94

Linezolid...............................17

Loryna.................................. 71

Linzess................................. 63

Losartan Potassium............ 49

Lioresal Intrathecal............104 Liothyronine Sodium...........74

Losartan Potassium/ Hydrochlorothiazide......... 52

Liquid Calcium/Vitamin D 108

Lotemax............................... 91

Lisinopril...............................49

Lovastatin.............................54

Levocarnitine..................... 113

Lisinopril/ Hydrochlorothiazide......... 52

Low-Ogestrel....................... 71

Levocetirizine Dihydrochloride................ 94

Lithium................................. 45

Lubricating Plus Eye Drops89

Lithium Carbonate.............. 45

Lumigan............................... 92

Lithium Carbonate ER........ 45

Lumizyme.............................59

Lithostat............................... 66

Lupaneta Pack.................... 75

Livalo.................................... 54

Lupron Depot...................... 75

LARIN Fe 1.5/30................. 71 LARIN Fe 1/20.....................71 Larissia................................. 71 Lartruvo................................ 37 Lastacaft.............................. 89 Latanoprost..........................92 Latuda.................................. 40 Laxative................................ 64 Layolis Fe............................. 71 Leena................................... 71 Leflunomide.........................78 Lenvima................................36 Lessina................................. 71 Letairis..................................97 Letrozole.............................. 35 Leucovorin Calcium............ 34 Leukeran.............................. 32 Leukine................................ 48 Leuprolide Acetate..............75 Levalbuterol......................... 96 Levemir FlexTouch..............47 Levemir Vial......................... 47 Levetiracetam...................... 23 Levetiracetam ER................ 23 Levobunolol HCl..................91

Levofloxacin.........................21 Levofloxacin in D5W........... 21 Levoleucovorin.................... 34

Live Better Advanced Lancing Device................. 85 LoHist-D............................... 94 Lomedia 24 Fe.....................71

Loxapine Succinate............ 39

143 143 Lupron Depot-Ped...............75

Mesna...................................34

Lutera................................... 71

Maxima Blood Glucose Test Strips..................................85

Lynparza.............................. 34

Meclizine HCl.......................27

Mestinon.............................. 31

Lyrica....................................56

Medicated Body Powder.... 58

Metaproterenol Sulfate....... 96

Lysiplex Plus......................120

Medlance Plus Lancets...... 85

Metformin HCl..................... 46

Lysodren.............................. 74

Medroxyprogesterone Acetate...............................73

Metformin HCl ER............... 46

Lyza...................................... 73

M M-END DMX.......................100 M-END Max D.................... 100 M-M-R II................................ 79 Mag-Tab SR.......................109

Mefloquine HCl....................38 Mega Multiple with Chelated Minerals........................... 120 Mega Multivitamin for Men ......................................... 120

Mesnex.................................34

Methadone HCl................... 13 Methazolamide....................53 Methenamine Hippurate.....17 Methimazole........................ 75 Methotrexate........................76 Methotrexate Sodium......... 76

Magnesium..................61, 108

Mega Multivitamin for Women............................ 120

Magnesium 27...................108

Megace ES.......................... 73

Methscopolamine Bromide60

Magnesium Elemental...... 108

Megestrol Acetate............... 74

Methyclothiazide................. 53

Magnesium Oxide............... 62

Meijer Blood Glucose Test Strips..................................85

Methyldopa..........................49

Magnesium Sulfate........... 108 Major-Prep Hemorrhoidal... 58 Makena................................ 73 Malathion............................. 38 Mapap.................................. 11 Mapap Acetaminophen Extra Strength............................. 11 Mapap Arthritis Pain........... 11 Mapap Childrens.................11 Mapap Cold Formula MultiSymptom......................... 100

Meijer Premium Blood Glucose Test Strips.......... 85 Mekinist................................36 Meloxicam........................... 12 Melphalan HCl.....................32 Memantine HCl....................25 Memantine HCl Titration Pak ............................................25 Menactra.............................. 79 Menest................................. 71

Methoxsalen........................ 58

Methyldopa/ Hydrochlorothiazide......... 52 Methyldopate HCl............... 49 Methylphenidate HCl.......... 56 Methylphenidate HCl ER.... 56 Methylprednisolone............ 67 Methylprednisolone Acetate ............................................67 Methylprednisolone Dose Pack................................... 67

Mapap PM........................... 94

Mentax................................. 29

Methylprednisolone Sodium Succinate...........................67

Mapap Sinus Maximum Strength Congestion and Pain.................................. 100

Menveo................................ 79

Metipranolol.........................91

Mephyton...........................120

Metoclopramide HCl...........27

Mercaptopurine...................33

Metolazone.......................... 53

Maprotiline HCl....................26

Meribin............................... 120

Metoprolol Succinate ER....50

Marlissa................................71

Meropenem......................... 19

Metoprolol Tartrate............. 50

Marplan................................ 25

Mesalamine......................... 79

Matulane.............................. 32

Mesalamine DR................... 79

Metoprolol/ Hydrochlorothiazide......... 52

144 144 Metronidazole......................17

Moexipril HCl....................... 49

Metronidazole in NaCl 0.79% ............................................17

Moexipril/ Hydrochlorothiazide......... 52

Metronidazole Vaginal........ 17

Mometasone Furoate..........68

Mexiletine HCl..................... 50

Monocal............................. 109

Mi-Acid................................. 62

MonoNessa..........................71

Mi-Acid Gas Relief...............62

Montelukast Sodium...........95

Mi-Acid Maximum Strength62

Morphine Sulfate.................14

Miacalcin..............................80

Morphine Sulfate ER...........13

Mibelas 24 Fe...................... 71

Moxeza.................................21

Miconazole 3....................... 29

Moxifloxacin HCl................. 21

Mucinex Fast-Max Severe Congestion & Cough......101

Miconazole 7....................... 29

Mozobil.................................48

Mucinex for Kids............... 101

Miconazole Nitrate.............. 29

Mucaphed..........................100

Microdot Test Strips........... 85

Mucinex............................. 100

Mucinex Maximum Strength ......................................... 101

Microgestin 1.5/30..............71

Mucinex Chest Congestion Childrens......................... 100

Microgestin 1/20.................71 Microgestin Fe.....................71 Microgestin Fe 1.5/30.........71 Midodrine HCl..................... 49 Migergot...............................30 Migraine Formula................ 12 Milk of Magnesia................. 64 Milk of Magnesia Concentrate.......................62

Mucinex Childrens Cold Cough & Sore Throat..... 100 Mucinex Childrens MultiSymptom Cold................ 100 Mucinex Childrens MultiSymptom Cold & Fever.. 100 Mucinex Congestion & Cough Childrens.............100 Mucinex Cough Childrens100

Mucinex Fast-Max Day Time/ Night Time.......................101 Mucinex Fast-Max Day/Night Maximum Strength......... 101 Mucinex Fast-Max DM Max ......................................... 101 Mucinex Fast-Max Night Time Cold & Flu........................101 Mucinex Fast-Max Severe Cold................................. 101

Mucinex Multi-Symptom Cold Day/Night Pack...............101 Mucinex Multi-Symptom Cold Night Time Childrens..... 101 Mucinex Sinus-Max Day/ Night................................ 101 Mucinex Sinus-Max Full Force................................101 Mucinex Sinus-Max Pressure & Pain.............................. 101 Mucinex Sinus-Max Severe Congestion Relief........... 101

Minitran................................ 55

Mucinex Cough for Kids...100

Minocycline HCl.................. 22

Mucinex D..........................100

Mucinex Stuffy Nose & Cold Childrens......................... 101

Minoxidil...............................55

Mucus Relief......................101

Mintox Maximum Strength. 62

Mucinex D Maximum Strength...........................100

Mirtazapine.......................... 25

Mucinex DM...................... 100

Mirtazapine ODT................. 25

Mucinex DM Maximum Strength...........................101

Mirvaso.................................58 Misoprostol.......................... 65 Mitomycin............................ 34 Mitoxantrone HCl................ 35 Modafinil............................ 104

Mucinex Fast-Max Cold & Sinus................................ 101 Mucinex Fast-Max Cold Flu & Sore Throat..................... 101

Mucus Relief Sinus........... 101 Mucus-ER.......................... 101 Multaq.................................. 50 Multi-Day Vitamins............ 120 Multi-Delyn......................... 120 Multi-Delyn/Iron.................120 Multi-Vitamin......................120

145 145 Multi-Vitamin HP/Minerals120 Multi-Vitamin/Minerals......120

Namenda XR Titration Pack ............................................25

Neomycin/Polymyxin/ Hydrocortisone........... 90, 92

Multi-Vitamins.................... 120

Namzaric..............................56

Nephramine.......................113

Multilex...............................120

Naproxen............................. 12

Nephro-Vite........................120

Multilex T&M......................120

Naproxen DR....................... 12

Nephronex......................... 120

Multiple Vitamins...............120

Naratriptan HCl....................30

Neulasta............................... 48

Multiple Vitamins Plain..... 120

Narcan..................................15

Neupro................................. 39

Multiple Vitamins/Iron...... 120

Nasal Decongestant......... 101

Neutek 2Tek Test Strips..... 85

Mupirocin.............................17

Nasal Decongestant PE....101

Nevanac............................... 91

Muro 128..............................89

Nasal Decongestant Spray ......................................... 101

Nevirapine............................43

Nasopen PE.........................94

Nexavar................................ 36

Natacyn................................ 29

Nexium................................. 65

Nateglinide...........................46

Next Choice One Dose....... 74

Natpara................................ 80

Niacin...........................54, 120

Natural Balance Tears........ 89

Niacin ER.....................54, 120

Natural Fiber Therapy......... 64

Niacin SR........................... 121

Natures Tears...................... 90

Niacin TR........................... 121

Nebupent............................. 38

Niacor...................................54

Necon 0.5/35-28................. 71

Nicardipine HCl................... 51

Necon 1/50-28.....................71

NicoDerm CQ...................... 16

Necon 7/7/7........................ 71

NICOrelief............................ 16

Myrbetriq..............................65

Nefazodone HCl.................. 26

Nicorette.............................. 16

MYTAB GAS........................ 62

Neomycin Sulfate................ 16

Nicorette Mini...................... 16

MYTAB GAS Maximum Strength............................. 62

Neomycin/Bacitracin/ Polymyxin.......................... 90

Nicorette Starter Kit............ 16

N

Neomycin/Polymyxin B Sulfates..............................17

Mustargen............................32 My Kidz Iron.......................120 My Kidz Iron 10................. 105 My Way.................................74 My-Vitalife.......................... 120 Myalept................................ 85 Mycamine............................ 29 Mycophenolate Mofetil....... 76 Mycophenolic Acid DR.......76 Myferon 150...................... 109 MyGlucoHealth Blood Glucose Test..................... 85

Nadolol.................................50 Nafcillin Sodium.................. 20 Naglazyme........................... 59 Nalbuphine HCl................... 14 Naloxone HCl...................... 15 Naltrexone HCl.................... 15 Namenda XR....................... 25

Neomycin/Polymyxin/ Bacitracin/Hydrocortisone ............................................90 Neomycin/Polymyxin/ Dexamethasone................ 90 Neomycin/Polymyxin/ Gramicidin......................... 90

Nevirapine ER......................43

Nicotine Polacrilex.............. 16 Nicotine Transdermal System ............................................16 Nicotrol Inhaler.................... 16 Night Time Multi-Symptom Cold/Flu Relief................101 Night Time Sleep Aid..........94 Nikki..................................... 72 Nilandron............................. 32 Nilutamide............................32

146 146 Nimodipine.......................... 51

Normosol-R........................109

Ocella................................... 72

NinjaCof............................. 101

Normosol-R in D5W.......... 113

Octagam.............................. 77

NinjaCof-A..........................101

Northera............................... 52

Octreotide Acetate.............. 75

NinjaCof-XG....................... 101

Nortrel 0.5/35...................... 72

Odefsey................................43

Ninlaro..................................35

Nortrel 1/35......................... 72

Odomzo............................... 36

Nipent...................................33

Nortrel 7/7/7........................72

Ofev.................................... 102

Nitro-Bid............................... 55

Nortriptyline HCl..................27

Ofloxacin.............................. 21

Nitrofurantoin.......................17

Norvir....................................44

Ogestrel................................72

Nitrofurantoin Macrocrystals ............................................17

Nova Max Glucose Test Strips..................................85

Olanzapine...........................40

Nitrofurantoin Monohydrate ............................................18

Nova Sureflex Lancets........85

Olmesartan Medoxomil...... 49

Nitroglycerin........................ 55

Nova Sureflex Lancing Device................................ 85

Olmesartan Medoxomil/ Hydrochlorothiazide......... 52

Nitroglycerin Lingual...........55

NovaFerrum 125............... 109

Olopatadine HCl..................90

Nitroglycerin Transdermal..55

NovaFerrum 50..................109

Omega-3-Acid Ethyl Esters.54

Nitrostat................................55

NovaFerrum Pediatric Drops ......................................... 109

Omeprazole......................... 65

No Iron Multiple Vitamin/ Minerals........................... 121

Novarel................................. 69

NoHist-DM......................... 101

Noxafil.................................. 29

NoHist-LQ............................ 94

NRS Nasal Relief...............102

Nora-BE................................74

Nu-Iron 150........................ 109

Norditropin FlexPro.............69

Nu-Mag.............................. 109

Norethindrone..................... 74

Nucynta ER..........................13

Norethindrone Acetate....... 74

Nuedexta..............................56

Norethindrone Acetate/ Ethinyl Estradiol................ 72

Nulojix.................................. 76

Norethindrone Acetate/ Ethinyl Estradiol/Ferrous Fumarate........................... 72

Nutrilipid............................ 113

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate ............................................72 Norgestimate/Ethinyl Estradiol.............................72 Norlyroc............................... 74 Normosol-M in D5W..........113

Nuplazid............................... 40 Nutropin AQ.........................69 NuvaRing............................. 72 Nyamyc................................ 29 Nyata.................................... 29 Nystatin................................ 29 Nystop.................................. 29

O Ocaliva................................. 62

Olanzapine ODT..................40

On Call Express Blood Glucose Test Strips.......... 85 On Call Plus Blood Glucose Test.................................... 85 On Call Vivid Blood Glucose Test.................................... 85 On Call Vivid Blood Glucose Test Strips......................... 85 Once Daily......................... 121 Once Daily/Iron................. 121 Oncovite.............................121 Ondansetron HCl................ 28 Ondansetron ODT...............28 One Daily........................... 121 One Daily Mens................. 121 One Daily Plus Iron........... 121 One Daily Plus Minerals....121 One-Daily Multi Vitamins...121 One-Way Valved Expiratory Mouthpiece/Disposable...86

147 147 One-Way Valved Inspiratory Mouthpiece/Disposable...86

Orphenadrine Citrate........ 104

Oyster Shell Calcium/D.... 109

Orsythia................................72

Onetouch Delica Lancets Extra Fine 33g................... 85

OS-CAL.............................. 109

Oyster Shell Calcium/Vitamin D.......................................109

P

Onetouch Delica Lancets Fine 30g.............................85

OS-CAL Calcium + D3...... 109 OS-CAL Extra D3...............109

Onetouch Delica Lancing Device................................ 85

Oseltamivir Phosphate........44 Osteo-Poretical..................109

Onetouch Suresoft Lancing Device/18g........................ 85

Otezla................................... 78

Onetouch Suresoft Lancing Device/21g........................ 85

Oxaliplatin............................ 35

Onetouch Suresoft Lancing Device/28g........................ 85

Oxcarbazepine.................... 24

Onetouch Ultra Blue........... 85 Onetouch Verio Test Strips 85 Onfi....................................... 23 Onglyza................................ 46 ONMEL.................................29 Opcicon One-Step...............74 Opdivo..................................37 Opsumit............................... 97 Opti-Clear.............................90 Optium Test Strips.............. 86 OptiumEZ Test Strips......... 86 OptumRx Blood Glucose Test.................................... 86 Oralyte................................109 Oralyte Freezer Pops........ 109 Orazinc...............................109 Orencia.................................77 Orencia Clickject................. 77 Orenitram............................. 97 Orfadin................................. 60 Organ-I NR.........................102 Orkambi............................... 96

Oxacillin Sodium................. 20 Oxandrolone........................ 69 Oxsoralen Ultra....................58 Oxybutynin Chloride........... 65 Oxybutynin Chloride ER..... 65

PA B-Complex with B-12.. 121 PA Biotin............................ 121 PA Oyster Shell Calcium.. 109 PA Vitamin B-12 TR.......... 121 PA Vitamin E......................121 Pacerone..............................50 Paclitaxel..............................35 Pain & Fever.........................11 Pain & Fever Childrens....... 11 Pain & Fever Extra Strength ............................................11

Oxycodone HCl................... 14

Pain Relief Sinus PE Daytime ......................................... 102

Oxycodone/Acetaminophen ............................................14

Pain Reliever PM Extra Strength............................. 94

Oxycodone/Aspirin............. 14

Paliperidone ER.................. 40

Oxycodone/Ibuprofen........ 15

Pamidronate Disodium....... 80

Oysco 500..........................109

Panda Mask Large.............. 86

Oysco 500+D.....................109

Panda Mask Medium.......... 86

Oysco D............................. 109

Panda Mask Small.............. 86

Oyst-Cal-D 500...................109

Panretin................................37

Oyster Calcium..................109

Pantoprazole Sodium......... 65

Oyster Shell Calcium........ 109

Pantothenic Acid.................86

Oyster Shell Calcium + D. 109

Paricalcitol..................... 80, 81

Oyster Shell Calcium + D3 ......................................... 109

Paromomycin Sulfate..........16

Oyster Shell Calcium + Vitamin D......................... 109

Paser.................................... 31

Oyster Shell Calcium 500 + D ......................................... 109 Oyster Shell Calcium Plus Vitamin D......................... 109

Paroxetine HCl.....................26 Pataday................................ 91 Paxil...................................... 26 Pazeo................................... 91 Pedialyte............................ 109

148 148 Pedialyte Advanced Care. 109

Perforomist.......................... 96

Pilocarpine HCl............. 57, 91

Pedialyte Freezer Pops.....109

Peridin-C............................ 121

Pimozide.............................. 39

Pedialyte Singles...............110

Perindopril Erbumine..........49

Pimtrea.................................72

Pediarix................................ 79

Periogard............................. 57

Pindolol................................ 50

Pediatric Cough/Cold.......102

Perjeta.................................. 37

Pink Bismuth....................... 62

Pediatric Electrolyte.......... 110

Permethrin........................... 38

Pioglitazone HCl..................46

Pediatric Electrolyte Freeze Pops.................................110

Perphenazine.......................27

Pioglitazone HCl/Glimepiride ............................................46

Pediatric Electrolyte Freezer Pops.................................110 Pediatric Electrolyte/Zinc.110

Pharmacist Choice Autocode Blood Glucose Test Strips ............................................86

Pioglitazone HCl/Metformin HCl..................................... 46 Piperacillin/Tazobactam.....20

Pediatric Medium Mask......86

Pharmacist Choice Ultra Thin Lancets.............................. 86

Pediatric Mouthpiece/ Disposable.........................86

Pharmacist Choice Ultra Thin Lancets 28g.......................86

Plasma-Lyte A....................110

Pediatric Panda Mask.........86

Pharmacist Choice Ultra Thin Lancets 30g.......................86

Plenamine..........................113

Pediatric Small Mask.......... 86 Pedvax HIB.......................... 79 PEG 3350.............................64 PEG-3350/Electrolytes........64 PEG-3350/NaCl/Na Bicarbonate/KCl............... 64 Peganone.............................24 Pegasys................................42 Pegasys ProClick................ 42 PegIntron............................. 42 PegIntron REDIPEN............ 42 Penicillin G Potassium........ 20 Penicillin G Procaine...........20 Penicillin G Sodium.............20

Pharmacist Choice Ultra Thin Lancets 31g.......................86

Pirmella 1/35....................... 72 Plasma-Lyte-148................ 110 Podofilox.............................. 59 Poly Vitamin.......................121

Phenadoz.............................94

Poly-Hist DM...................... 102

Phenelzine Sulfate.............. 26

Poly-Hist PD......................... 94

Phenergan........................... 94

Poly-Iron 150......................110

Phenobarbital...................... 23

Poly-Vent DM..................... 102

Phenoxybenzamine HCl..... 49

Poly-Vent IR....................... 102

Phenylephrine HCl/ Pyrilamine Maleate......... 102

Poly-Vita Drops..................121

Phenylhistine DH...............102 Phenytek.............................. 25

Polyethylene Glycol 3350 Powder...............................64

Phenytoin............................. 25

Polymyxin B Sulfate............ 18

Phenytoin Sodium...............25

Polymyxin B Sulfate/ Trimethoprim Sulfate........90

Poly-Vita/Iron Drops..........121

Penicillin V Potassium.........20

Phenytoin Sodium Extended ............................................25

Penlet II Automatic Blood Sampler............................. 86

Phoslyra............................... 66

Polyvitamin/Iron................ 121

Phospholine Iodide............. 91

Pomalyst.............................. 32

Physiolyte...........................110

Portia-28...............................72

Physiosol Irrigation........... 110

Potassium Chloride...........110

Pentam 300......................... 38 Pentoxifylline ER................. 52 Peptic Relief........................ 62

Picato................................... 58

Polyvitamin........................ 121

149 149 Potassium Chloride 0.15% D5W/NaCl 0.33%............113

Premarin...............................72 Premasol............................113

Prodigy Pressure Activated Safety Lancets...................86

Potassium Chloride 0.15% D5W/NaCl 0.45%............113

Premphase.......................... 72

Prodigy Twist Top Lancets.86 ProFe..................................110

Potassium Chloride 0.22% D5W/NaCl 0.45%............113

Prempro............................... 72 Prevalite............................... 54

Proferrin ES....................... 113

Prevent...............................121

Proglycem............................46

Previfem............................... 72

Prograf................................. 77

Prezcobix............................. 42

Prolastin-C......................... 102

Prezista................................ 44

Prolensa............................... 92

Priftin.................................... 31

Proleukin.............................. 35

Primaquine Phosphate....... 38

Prolia.................................... 81

Primidone.............................23

Promacta..............................48

Primsol................................. 18

Promethazine HCl............... 94

Pristiq................................... 26

Promethazine VC/Codeine ......................................... 102

Potassium Chloride ER.....110 Potassium Chloride/Dextrose ......................................... 113 Potassium Chloride/ Dextrose/Lactated Ringers ......................................... 113 Potassium Chloride/Sodium Chloride........................... 110 Potassium Citrate ER........110 Povidone-Iodine...................18 Praluent................................54 Pramipexole Dihydrochloride ............................................39

Privigen................................ 77 Pro-Chlo............................. 102 Pro-Clear AC......................102

Promethazine-DM............. 102 Promethazine/Codeine.... 102 Promethazine/ Dextromethorphan......... 102

Pravastatin Sodium............. 54

ProAir HFA........................... 96

Prazosin HCl........................ 49

ProAir RespiClick................ 96

Precision PCX......................86

Probenecid.......................... 30

Precision PCX Plus Test Strips..................................86

Probenecid/Colchicine.......30

Precision Point of Care Test Strips..................................86

Procalamine.......................113

Precision QID Test Strips... 86

Prochlorperazine Edisylate.27

Precision Xtra Blood Glucose Test Strips......................... 86

Prochlorperazine Maleate.. 27

Propranolol/ Hydrochlorothiazide......... 52

Procrit...................................48

Propylthiouracil................... 75

Procto-Med HC....................80

ProQuad...............................79

Procto-Pak........................... 80

Prosol................................. 113

Proctosol HC....................... 80

Protexin..............................121

Proctozone-HC.................... 80

Protriptyline HCl.................. 27

Procysbi............................... 60

PRUDOXIN...........................59

Prodigy No Coding Blood Glucose Test Strips.......... 86

Pseudoephedrine HCl...... 102

Prednicarbate...................... 68 Prednisolone Acetate......... 91 Prednisolone Sodium Phosphate................... 68, 92 Prednisone...........................68 Prednisone Intensol............ 68 Pregnyl w/Diluent Benzyl Alcohol/NaCl.....................69

Procainamide HCl............... 50 Prochlorperazine.................27

Promethegan....................... 94 Propafenone HCl.................50 Propafenone HCl ER...........50 Proparacaine HCl................90 Propranolol HCl...................51 Propranolol HCl ER.............51

Pulmosal............................ 102

150 150 Pulmozyme........................ 102

QC Tolnaftate...................... 30

RA Calcium/Boron............102

Puralube...............................90

QC Womens Daily Multivitamin..................... 121

RA Calcium/Magnesium/ Zinc/Copper....................111

PX Advanced Lancing Device ............................................87

Quadracel............................ 79

RA Central-Vite.................. 122

Quasense.............................72

RA Central-Vite Cardio......122

Pyrazinamide....................... 31

Quenalin...............................95

RA Central-Vite Energy..... 122

Pyridostigmine Bromide..... 31

Quetiapine Fumarate.......... 40

Pyridostigmine Bromide ER ............................................31

Quetiapine Fumarate ER.... 40

RA Central-Vite Performance ......................................... 122

Pyridoxine HCl...................121

Q

Quinapril/ Hydrochlorothiazide......... 52

Q-Dryl....................................95

Quinidine Gluconate........... 50

Q-PAP...................................11

Quinidine Gluconate CR.....50

Q-PAP Childrens................. 11

Quinidine Sulfate.................50

Q-PAP Extra Strength..........11

Quinine Sulfate.................... 38

Q-PAP Infants...................... 11

Quintet AC Blood Glucose Test Strips......................... 87

Purixan................................. 33

Q-Tussin.............................102 Q-Tussin DM......................102 QC Anti-Diarrheal................ 62 QC Arthritis Pain Relief....... 11 QC Calcium Fast Dissolution ......................................... 110

Quinapril HCl....................... 49

Quintet Blood Glucose Test Strips..................................87

R RA B-Complex...................121 RA B-Complex with B-12.. 121

RA Central-Vite Select Mature ......................................... 122 RA Central-Vite Senior...... 122 RA Central-Vite Under 50 Mens................................ 122 RA Central-Vite Under 50 Womens.......................... 122 RA Central-Vite Womens Mature............................. 122 RA Central-Vite/Antioxidants ......................................... 122 RA Coral Calcium..............111 RA Hi Cal........................... 111 RA Hi-Cal Plus Vitamin D..111 RA High Potency Iron....... 111

QC Calcium/Minerals/ Vitamin D......................... 110

RA B-Complex/Vitamin C TR ......................................... 121

QC Childrens Chewable Vitamins/Extra C.............121

RA Balanced B-100...........121

RA Magnesium....................62

RA Balanced B-50.............121

RA Natural Magnesium.... 111

QC Cough/Sore Throat Nighttime......................... 102

RA Beta Carotene............. 122

RA Natural Vitamin E........ 122

RA Biotin............................122

RA Niacin............................. 54

QC Loratadine Allergy Relief ............................................94

RA Calcium 600................ 110

RA One Daily Energy Formula ......................................... 122

QC Loratadine-D..................94

RA Calcium 600 Plus Vitamin D-3....................................110

QC Maximum Daily Multivitamin/Multimineral ......................................... 121

RA Calcium 600/Vitamin D/ Minerals........................... 110

QC Multi-Vite......................121

RA Calcium Citrate Plus Vitamin D-3...................... 110

QC Naproxen Sodium.........12

RA Calcium Soft Chews... 122

RA Iron............................... 111

RA One Daily Essential..... 122 RA One Daily Maximum... 122 RA One Daily Mens 50+ with Vitamin D-3...................... 122 RA One Daily Multi-Vitamin ......................................... 122

151 151 RA One Daily Multi-Vitamin Plus Iron.......................... 122

RA Zinc.............................. 111 Rabano Yodado................ 123

Relion Ultima Blood Glucose Test Strips......................... 87

RA Oyster Shell Calcium/ Vitamin D......................... 111

Rabavert...............................79

Relistor................................. 62

Raloxifene HCl.....................74

Remicade.............................77

Ramipril................................49

Remodulin........................... 97

Ranexa................................. 52

Rena-Vite............................123

Ranitidine 150 Maximum Strength............................. 63

Renagel................................66

Ranitidine 75........................63

Repaglinide..........................46

Ranitidine HCl..................... 63

Repaglinide/Metformin HCl ............................................46

RA Pediatric Electrolyte....111 RA Pediatric Electrolyte Freezer Pops................... 111 RA Slow Release Iron....... 111 RA Stress Formula Advanced ......................................... 122 RA Stress Formula Energy ......................................... 122 RA Therapeutic M Plus Beta Carotene..........................122

Ranitidine Maximum Strength ............................................63

Repatha................................54

RA TrueTest Strips..............87

Rapamune........................... 77

Repatha Pushtronex System ............................................54

RA Vitamin A..................... 122

Rasagiline Mesylate............ 39

Repatha SureClick.............. 54

RA Vitamin B-1.................. 122

RAVICTI............................... 60

Rescon................................. 95

RA Vitamin B-12................ 122

Rebif..................................... 57

Rescon DM........................102

RA Vitamin B-12 TR.......... 123

Rebif Rebidose....................57

Rescon-GG........................ 102

RA Vitamin B-6.................. 123

Rebif Rebidose Titration Pack................................... 57

Rescriptor............................ 43

Rebif Titration Pack............ 57

Restasis................................90

Reclipsen............................. 72

Restfully Sleep.....................95

Recombivax HB...................79

Retrovir IV Infusion..............43

Refresh Celluvisc................ 90

Reveal Blood Glucose Test87

Refresh Lacri-Lube..............90

Revlimid............................... 32

Refresh Plus........................ 90

Rexall Blood Glucose Test Strips..................................87

RA Vitamin B12................. 122 RA Vitamin C..................... 123 RA Vitamin C Drops..........123 RA Vitamin C TR............... 123 RA Vitamin C/Acerola...... 123 RA Vitamin C/Rose Hips.. 123 RA Vitamin C/Rose Hips TR ......................................... 123 RA Vitamin E......................123

Rapaflo.................................65

Renvela................................ 66

Refuah Plus Blood Glucose Test Strips......................... 87

Respaire-30....................... 102

Rexulti.................................. 40

Regranex..............................59

Reyataz................................ 44

Reguloid...............................64

Rezira................................. 102

RA Whole Source Dietary.123

Relenza Diskhaler............... 44

Ribasphere.......................... 42

RA Whole Source Dietary for Men.................................. 123

Relion Confirm/Micro Test Strips..................................87

Ribavirin............................... 42

RA Whole Source Dietary Mature............................. 123

Relion Prime Blood Glucose Test Strips......................... 87

Rifabutin...............................31

RA Whole Source Complete Formula for Men............. 123

Ridaura.................................78 Rifampin...............................31

152 152 Rifater...................................31

Ruconest..............................75

Sentry................................. 123

Rightest Gl300 Lancets...... 87

Rulox.................................... 62

Sentry Senior..................... 123

Rightest GS100 Blood Glucose Test Strips.......... 87

Rydapt..................................36

Serevent Diskus.................. 96

Rymed..................................95

Seroquel XR.........................41

Rightest GS300 Blood Glucose Test Strips.......... 87

Rynex DM.......................... 103

Serostim...............................62

Rightest GS550 Blood Glucose Test Strips.......... 87

Rynex PE..............................95

Sertraline HCl...................... 26

Rynex PSE........................... 95

Setlakin................................ 72

Riluzole................................ 56 Rimantadine HCl................. 44 Ringers Injection............... 113

S

sfRowasa............................. 79

S2......................................... 96

Sharobel...............................74

Sabril.................................... 23

Sidestream Pediatric Face Mask/Tucker the Turtle....87

Ringers Irrigation...............113

Safety Lancet 28g/Pressure Activated............................87

Riomet..................................46

Saizen...................................69

Risacal-D............................111

Siladryl Allergy.....................95

Samsca.............................. 105

Risperdal Consta.................40

Sildenafil.............................. 97

Sancuso............................... 28

Risperidone......................... 40

Silphen Cough.....................95

Sandimmune....................... 77

Risperidone ODT................ 40

Siltussin DM DAS.............. 103

Sandostatin LAR Depot...... 75

Rituxan................................. 37

Siltussin SA........................103

Sani-Supp Adult.................. 64

Rivastigmine Tartrate..........25

Siltussin-DM.......................103

Sani-Supp Pediatric............ 64

Rivastigmine Transdermal System............................... 25

Silver Sulfadiazine............... 22

Santyl....................................59

Simethicone.........................62

Saphris................................. 41

Simponi................................ 77

Savella..................................56

Simponi Aria........................ 77

Savella Titration Pack......... 56

Simulect............................... 78

SB Pediatric Electrolyte.... 111

Simvastatin.......................... 54

Selegiline HCl...................... 39

Sirolimus.............................. 77

Selenium............................ 111

Sirturo...................................31

Selenium Sulfide................. 59

Slo-Niacin...........................123

Selzentry.............................. 44

Slow-Mag........................... 111

Senexon............................... 64

SM Allergy 4 Hour............... 95

Senior Tabs....................... 123

SM Allergy Relief.................95

Senna................................... 64

SM Antacid Anti-Gas...........62

Senna Lax............................ 64

SM Anti-Diarrheal................ 62

Senna Plus...........................64

SM Balanced B-50............ 123

Sennalax-S........................... 64

SM Calcium 500/Vitamin D3 ......................................... 111

Rizatriptan Benzoate...........31 Rizatriptan Benzoate ODT..31 Robafen............................. 102 Robafen Cough.................103 Robafen DM...................... 103 Robafen DM Cough Clear103 Ropinirole HCl..................... 39 Rosuvastatin Calcium......... 54 Rotarix.................................. 79 RotaTeq............................... 79 Roweepra.............................23 Rozerem............................ 104 Ru-Hist D.............................. 95 Rubraca............................... 35

Sensipar............................... 75

Signifor.................................75

153 153 SM Calcium 600/Vitamin D ......................................... 111 SM Calcium Citrate with Vitamin D3.......................111

SM Tussin DM................... 103

Solus V2 Audible Test.........87

SM Tussin DM Cough/Chest Congestion......................103

Solus V2 Lancing Device....87

SM Vitamin B-12................123

Solus V2 Twist Lancets 30g ............................................87

SM Calcium Soft Chews...123

SM Vitamin B-6..................123

Somatuline Depot............... 75

SM Calcium/Magnesium/ Zinc.................................. 111

SM Vitamin C.....................123

Somavert..............................75

SM Vitamin C/Rose Hips..124 SM Vitamin E..................... 124

Sore Throat & Cough Lozenges........................... 15

SM Vitamin E Blended......124

Sotalol HCl........................... 50

SM Zinc..............................111

Sovaldi..................................42

Smart Sense Color Lancets Universal 33g.................... 87

Spiriva HandiHaler.............. 96

Smart Sense Premium Bloodglucose Strips......... 87

Spironolactone.................... 53

SM Calcium/Vitamin D..... 111 SM Chewable C................ 123 SM Complete.....................123 SM Complete Advanced Formula........................... 123 SM Complete Senior Formula ......................................... 123 SM Ibuprofen.......................13 SM Iron...............................111 SM Lorata-Dine D................ 95

Smart Sense Super Thin Lancets Universal 30g...... 87

Spiriva Respimat................. 96 Spironolactone/ Hydrochlorothiazide......... 52 Sporanox..............................30

Smart Sense Thin Lancets Universal 26g.................... 87

Sprintec 28.......................... 73

SM Miconazole 7.................30

Smart Sense Value Blood Glucose Strips...................87

Sprycel................................. 36

SM Multiple Vitamins Essential.......................... 123

Smartest Blood Glucose Test Strips..................................87

SM Multiple Vitamins/Iron123

Sodium Bicarbonate........... 62

SSD...................................... 22

SM Nasal Decongestant Maximum Strength......... 103

Sodium Chloride 90, 103, 111

Stahist AD.......................... 103

Sodium Chloride 0.45%....111

Stavudine............................. 43

SM Nasal Spray 12 Hour.. 103

Sodium Chloride 0.9%......111

Stelara.................................. 77

SM Oyster Shell Calcium/ Vitamin D......................... 111

Sodium Fluoride................111

Sterilance PA....................... 87

Sodium Lactate................. 113

Sterile Water Irrigation........ 87

SM Oyster Shell Calcium/ Vitamin D3.......................111

Sodium Phenylbutyrate...... 60

Stimulant Laxative............... 64

Sodium Polystyrene Sulfonate......................... 105

Stiolto Respimat................103

SM Pediatric Electrolyte... 111 SM Sleep Aid.......................95

Sodium Sulfacetamide....... 22

Stool Softener......................64

SM Slow Release Iron.......111

Soliqua 100/33....................46

Strattera............................... 56

SM Super B Complex-Vitamin C.......................................123

Soltamox.............................. 33

Strensiq................................60

Solu-Cortef...........................68

Streptomycin Sulfate.......... 16

Solu-Medrol......................... 68

Stress Formula.................. 124

SM Loratadine..................... 95 SM Magnesium................. 111

SM Tussin.......................... 103

Spritam.................................23 SPS.....................................105 Sronyx.................................. 73

Stivarga................................ 36

154 154 Stress Formula with Iron...124 Stress Formula/Iron.......... 124 Stress Formula/Zinc......... 124 Stribild.................................. 42 Suboxone.............................15 Sucraid.................................60 Sucralfate.............................65 Sudogest............................103 Sudogest 12 Hour.............103 Sudogest PE......................103 Sudogest Sinus & Allergy... 95 Sulfacetamide Sodium....... 22 Sulfacetamide Sodium/ Prednisolone Sodium Phosphate......................... 90

Sure-Test Easyplus Mini Blood Glucose Test Strips ............................................87 Surechek Blood Glucose Test Strips......................... 87 Suspendol-S........................ 87 Sustiva..................................43 Sutent................................... 36 Sylatron................................ 42 Sylvant..................................37 Symbicort...........................103 SymlinPen 120.................... 46 SymlinPen 60.......................46 Synagis.................................78 Synarel................................. 75

Targretin...............................37 Tarina Fe 1/20..................... 73 Tasigna.................................36 Tazarotene........................... 59 Tazicef..................................19 Tazorac................................ 59 Tecentriq..............................37 Tecfidera.............................. 57 Tecfidera Starter Pack........ 57 TechLite Lancets.................87 Techlite Lancets 30g.......... 87 Telcare Blood Glucose Test Strips..................................87 Telmisartan.......................... 49 Telmisartan/Amlodipine..... 52

Sulfadiazine......................... 22

Synercid............................... 18

Sulfamethoxazole/ Trimethoprim.....................22

Synjardy............................... 46

Telmisartan/ Hydrochlorothiazide......... 52

Synribo................................. 35

Temazepam.......................104

Sulfamethoxazole/ Trimethoprim DS.............. 22

Synthroid..............................74

Tencon................................. 11

Syprine............................... 105

Sulfasalazine........................80

Tenivac.................................79

T

Sulindac............................... 13

Terazosin HCl...................... 65

TAB-A-VITE........................ 124

Sumatriptan......................... 31

TAB-A-VITE Maximum...... 124

Sumatriptan Succinate....... 31

TAB-A-VITE with Beta Carotene..........................124

Sumatriptan Succinate Refill ............................................31

TAB-A-VITE/Iron................124

Sumavel DosePro................31

Tabloid................................. 33

Super B with C.................. 124

Tacrolimus.....................59, 77

Super Thera Vite M........... 124

Tafinlar................................. 36

Superplex-T....................... 124

Tagrisso............................... 37

Suplevit.............................. 124

Tamiflu................................. 44

Suprax.................................. 19

Tamoxifen Citrate................33

Suprep Bowel Prep Kit....... 64

Tamsulosin HCl................... 65

Sure Edge Blood Glucose Test Strips......................... 87

Tandem..............................112 Tarceva................................ 36

Terbinafine HCl................... 30 Terbutaline Sulfate..............96 Terconazole......................... 30 Testosterone Cypionate..... 69 Testosterone Enanthate..... 69 Tetanus/Diphtheria ToxoidsAdsorbed Adult.................79 Tetrabenazine......................56 Tetracycline HCl.................. 22 TGT Advanced Lancing Device................................ 87 TGT Blood Glucose Test Strips..................................87 TGT Blood Glucose Test Strips Premium................. 88

155 155 TGT Lancet Micro Thin 33g ............................................88

Tizanidine HCl................... 104

Trecator................................31

TOBI Podhaler.....................16

Trelstar Mixject.................... 75

TGT Lancet Thin 26g.......... 88

Tobradex..............................16

Tretinoin.........................37, 59

TGT Lancet Ultra Thin 30g. 88

Tobradex ST........................ 90

Tretinoin Microsphere........ 59

TGT Lancing Device........... 88

Tobramycin..........................17

Trexall...................................77

Thalomid.............................. 32

Tobramycin Sulfate............. 17

Trezix....................................15

Theophylline........................ 97

Tri-Legest Fe........................73

Theophylline CR..................97

Tobramycin/Dexamethasone ............................................90

Theophylline ER.................. 97

Tobrex.................................. 17

Tri-Lo-Sprintec..................... 73

Thera.................................. 124

Tolcapone............................38

Tri-Previfem..........................73

Thera M Plus..................... 124

Tolnaftate............................. 30

Tri-Sprintec.......................... 73

Thera-Gesic......................... 59

Topiramate...........................24

Tri-Vi-Sol.............................124

Thera-M..............................124

Toposar................................35

Tri-Vita................................ 125

Thera-Tabs.........................124

Topotecan HCl.................... 35

Tri-Vitamin..........................125

Thera/Beta-Carotene........ 124

Torisel...................................77

Therapeutic Liquid............124

Torsemide............................53

Triamcinolone Acetonide.. 68, 95

Theratrum Complete........ 124

Total B/C........................... 124

Triamcinolone in Orabase.. 57

Therems.............................124

Totalday Multiple...............124

Therems-H......................... 124

Toujeo SoloStar...................47

Triamterene/ Hydrochlorothiazide......... 52

Therems-M.........................124

TPN Electrolytes................114

Triderm.................................68

Thiamine HCl.....................124

Tracleer................................ 97

Trifluoperazine HCl............. 39

Thioridazine HCl..................39

Tradjenta..............................46

Trifluridine............................42

Thiotepa............................... 35

Tramadol HCl...................... 15

Trihexyphenidyl HCl............38

Thiothixene.......................... 39

Tramadol HCl ER................ 13

TriLyte.................................. 64

Thymoglobulin.....................77

Trimethoprim....................... 18

ThyroSafe.............................88

Tramadol HCl/ Acetaminophen.................15

ThyroShield..........................88

Trandolapril......................... 49

Trinessa................................73

Tiagabine HCl......................23

Tranexamic Acid................. 48

Trintellix................................26

Tigecycline...........................18

Transderm-Scop..................27

Triple Antibiotic................... 18

Timolol Maleate.............51, 91

Tranylcypromine Sulfate.....26

Triple Antibiotic Plus...........18

Timolol Maleate Ophthalmic Gel Forming.......................91

Travasol............................. 114

Trisenox............................... 35

Travatan Z............................ 92

Triumeq................................42

Tinidazole.............................18

Travel Sickness................... 28

Trivora-28............................. 73

Tioconazole-1...................... 30

Trazodone HCl.................... 26

Trixaicin................................59

Tivicay.................................. 42

Treanda................................32

Trixaicin HP..........................59

Tri-Lo-Estarylla..................... 73

Trimipramine Maleate.........27

156 156 Trophamine....................... 114

Ultratrak Pro Test Strips..... 88

Valganciclovir...................... 41

True Metrix Blood Glucose Test Strips......................... 88

Ultratrak Ultimate Test Strips ............................................88

Valganciclovir Hydrochlorde ............................................41

True Metrix Self Monitoring Blood Glucose Strips........88

Unicomplex-M................... 125

Valproate Sodium................23

Unilet Comfortouch Lancet 88

Valproic Acid....................... 23

TruePlus Lancets 26g.........88

Unilet Excelite II................... 88

Valsartan.............................. 49

TruePlus Lancets 28g.........88

Unilet GP 28 Ultra Thin....... 88

TruePlus Lancets 30g.........88 TruePlus Lancets 33g.........88

Unilet Lancets Micro-Thin33g ............................................88

Valsartan/ Hydrochlorothiazide......... 53

TrueTest Blood Glucose Test Strips..................................88

Unilet Lancets Super-Thin30g ............................................88

VanaCof DM...................... 103

TrueTest Strips.................... 88

Unilet Lancets Ultra-Thin 28g ............................................88

Vanahist PD......................... 95

TrueTrack Blood Glucose Test Strips......................... 88

Unistik 2............................... 89

TrueTrack Test Strips......... 88

Unistik 2 Comfort................ 89

Trumenba............................ 79

Unistik 2 Extra......................89

Truvada................................ 43

Unistik 2 Normal..................89

Tussin DM..........................103

Unistik 2 Super.................... 89

Tussin DM Clear................103

Unistik 3 Comfort................ 89

Tussionex Pennkinetic Extended-Release...........103

Unistik 3 Extra......................89

Twinrix..................................79

Unistik 3 Normal..................89

Tybost.................................. 42

Unistik CZT Comfort........... 89

Tygacil..................................18

Unistik CZT Normal.............89

Tykerb.................................. 36

Unistik Safety Lancets 28g.89

Tymlos..................................81

Unistik Safety Lancets 30g.89

Typhim Vi............................. 79

Unistrip1 Generic................ 89

Tysabri..................................57

Unithroid.............................. 74

U Uceris................................... 80

Universal 1 Lancets Ultra Thin 30g.............................89

Uloric.................................... 30

Ursodiol................................62

Ultilet Classic Lancets.........88

Unistik 3 Neonatal............... 89

V

VanaCof............................. 103 VanaCof-8.......................... 103 Vancomycin HCl..................18 Vandazole............................ 18 VAQTA................................. 79 Varivax..................................79 Varizig...................................77 Vascepa............................... 54 Vectibix................................ 37 Velcade................................ 35 Velivet...................................73 Velphoro...............................66 Vemlidy................................ 41 Venclexta............................. 35 Venclexta Starting Pack......35 Venlafaxine HCl................... 26 Venlafaxine HCl ER............. 27 Ventavis................................97 Verapamil HCl......................51 Verapamil HCl ER................51 Versacloz............................. 41

Ultilet Lancets......................88

Valacyclovir HCl.................. 42

Vesicare............................... 65

Ultima Test Strips................88

Valchlor................................ 32

Vestura................................. 73

Ultralance.............................88

Valcyte..................................41

Vibramycin........................... 22

157 157 Victory Agm-4000 Test Strips ............................................89

Vitamin E/D-Alpha.............125

Xyrem................................. 104

Vitamin K1......................... 125

Y

Videx Pediatric.................... 43

Vitamins & Minerals.......... 125

Yervoy.................................. 37

Vienva...................................73

Vitamins for Hair................125

YF-Vax.................................. 79

Vigamox............................... 22

Vivitrol...................................15

Yondelis............................... 32

Viibryd.................................. 27

Z

Viibryd Starter Pack............ 27

Vocal Point Blood Glucose Test Strips......................... 89

Zafirlukast............................ 95

Vimpat.................................. 25

Voriconazole........................ 30

Zaleplon............................. 104

Vinblastine Sulfate.............. 35

Votrient.................................36

Zaltrap.................................. 35

Vincasar PFS....................... 35

VP-PNV-DHA......................114

Zanosar................................ 32

Vincristine Sulfate............... 35

VPRIV................................... 60

Zarah.................................... 73

Vinorelbine Tartrate............ 35

Vraylar.................................. 41

Zarxio................................... 48

Viracept................................44

Vyfemla................................ 73

Zavesca................................60

Viread................................... 43

Vytorin.................................. 54

Zeasorb-AF.......................... 30

Virtussin A/C..................... 103

W

Zebutal................................. 11

Vita-Bee/C......................... 125

Warfarin Sodium................. 47

Zejula....................................35

Vitamin A............................125

Wavesense Presto Test Strips ............................................89

Zelapar................................. 39

Wee Care........................... 114

Zemaira.............................. 103

Welchol................................ 54

Zemplar................................81

White Petrolatum.................59

Zenchent..............................73

Womens One Daily........... 125

Zenchent Fe.........................73

WYMZYA Fe........................ 73

Zenpep.................................60

Vitamin A & D.......................59 Vitamin B Complex........... 125 Vitamin B Complex-C........125 Vitamin B-1........................ 125 Vitamin B-12...................... 125 Vitamin B-2........................ 125 Vitamin B-6........................ 125 Vitamin B12....................... 125 Vitamin B6......................... 125 Vitamin C........................... 125 Vitamin C SR..................... 125 Vitamin C TR..................... 125 Vitamin C/Rose Hips........ 125 Vitamin D........................... 125 Vitamin E............................125 Vitamin E Water Dispersible ......................................... 125 Vitamin E Water Soluble...125

X Xalkori.................................. 36 Xarelto.................................. 47 Xarelto Starter Pack............ 47 Xatmep.................................77 Xeljanz..................................77 Xeljanz XR............................77 Xgeva....................................81 Xifaxan..................................18 Xigduo XR............................ 46 Xolair.................................. 103 Xtandi................................... 32

Zelboraf................................37

Zepatier................................42 Zerbaxa................................ 19 Zerit...................................... 43 Zetia......................................54 Ziagen.................................. 43 Zidovudine........................... 43 Zileuton ER.......................... 95 Zinbryta................................ 57 Zinc.................................... 112 Zinc 15............................... 112 Zinc Chelated.................... 112

158 158 Zinc Gluconate..................112

Zomacton.............................69

Zovia 1/50E......................... 73

Zinc Oxide............................59

Zonatuss............................ 103

Zutripro.............................. 103

Zinc Sulfate........................112

Zonisamide.......................... 23

Zyclara..................................59

Zinc-220............................. 112

Zoo Friends....................... 125

Zyclara Pump...................... 59

Zinc/Vitamin C.................. 125

Zoo Friends Complete......125

Zydelig................................. 35

Ziprasidone HCl.................. 41

Zoo Friends Plus Extra C..125

Zyflo......................................95

Zirgan................................... 41

Zoo Friends Plus Iron....... 125

Zyflo CR............................... 95

Zmax.................................... 21

Zorbtive................................ 62

Zykadia.................................35

Zoledronic Acid................... 81

Zortress................................ 77

Zyprexa Relprevv................ 41

Zolinza..................................35

Zostavax...............................79

Zytiga....................................32

Zolpidem Tartrate............. 104

Zovia 1/35E......................... 73

If you have questions, please call UnitedHealthcare Connected Member Services at: Toll-Free 1-800-256-6533, TTY 7-1-1 8 a.m. - 8 p.m. local time, Monday - Friday www.UHCCommunityPlan.com www.myuhc.com/CommunityPlan

Formulary ID Number 00017014, Version 19 H7833_160622_115654_J Approved UHTX17HM3877793_010

Last Updated November 1, 2017