Generic Focused Formulary Prescription Drug List in Alphabetical Order

Generic Focused Formulary Prescription Drug List in Alphabetical Order Last Updated: 12/22/2014 Last Updated: 12/22/2014 Key Terms Generic Focused ...
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Generic Focused Formulary Prescription Drug List in Alphabetical Order Last Updated: 12/22/2014

Last Updated: 12/22/2014

Key Terms Generic Focused Formulary

Tufts Health Plan Drug List

Formulary A formulary is a list of prescription medications developed by a committee of practicing physicians and practicing pharmacists who represent a variety of specialty areas and who are knowledgeable in the diagnosis and treatment of disease. Brand-Name Drugs Brand-name drugs are typically the first products to gain U.S. Food and Drug Administration (FDA) approval. Generic Drugs Generic drugs have the same active ingredients and come in the same strengths and dosage forms as the equivalent brand-name drug. Multiple manufacturers may produce the same generic drug and the product may differ from its brand name counterpart in color, size or shape, but the differences do not alter the effectiveness. Generic versions of brand-name drugs are reviewed and approved by the FDA. The FDA works closely with all pharmaceutical companies to make sure that all drugs sold in the U.S. meet appropriate standards for strength, quality, and purity. 3-Tier Pharmacy Copayment Program (3-Tier Program) To help maintain affordability in the pharmacy benefit, we encourage the use of cost-effective drugs and preferred brand names through the three-tier program. This program gives you and your doctor the opportunity to work together to find a prescription medication that's affordable and appropriate for you. All covered drugs are placed into one of three tiers. Your physician may have the option to write you a prescription for a Tier 1, Tier 2, or Tier 3 drug (as defined below); however, there may be instances when only a Tier 3 drug is appropriate, which will require a higher copayment. • • •

Tier 1: Medications on this tier have the lowest copayment. This tier includes many generic drugs. Tier 2: Medications on this tier are subject to the middle copayment. This tier includes some generics and brand-name drugs. Tier 3: This is the highest copayment tier and includes some generics and brand-name covered drugs not selected for Tier 2. Please note that tier placement is subject to change throughout the year.

Copayment A copayment is the fee a member pays for certain covered drugs. A member pays the copayment directly to the provider when he/she receives a covered drug, unless the provider arranges otherwise.

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

1

Last Updated: 12/22/2014 Coinsurance Coinsurance requires the member to pay a percentage of the total cost for certain covered drugs. Medical Review Process Tufts Health Plan has pharmacy programs in place to help manage the pharmacy benefit. Requests for medically necessary review for coverage of drugs included in the New-to-Market Drug Evaluation Process (NTM), Prior Authorization Program (PA), Step Therapy Prior Authorization Program (STPA), Quantity Limitations Program (QL), Non-Covered Drugs (NC) With Suggested Alternatives Program should be completed by the physician and sent to Tufts Health Plan. Drugs excluded under your pharmacy benefit will not be covered through this process. The request must include clinical information that supports why the drug is medically necessary for you. Tufts Health Plan will approve the request if it meets coverage guidelines. If Tufts Health Plan does not approve the request, you have the right to appeal. The appeal process is described in your benefit document. Note: Drugs approved through the Medical Review Process will be subject to a Tier 3 copayment. Quantity Limitation (QL) Program Because of potential safety and utilization concerns, Tufts Health Plan has placed quantity limitations on some prescription drugs. You are covered for up to the amount posted in our list of covered drugs. These quantities are based on recognized standards of care as well as from FDA-approved dosing guidelines. If your provider believes it is necessary for you to take more than the QL amount posted on the list, he or she may submit a request for coverage under the Medical Review Process. New-To-Market Drug Evaluation Process (NTM) In an effort to make sure the new-to-market prescription drugs we cover are safe, effective and affordable, we delay coverage of many new drug products until the Plan's Pharmacy and Therapeutics Committee and physician specialists have reviewed them. This review process is usually completed within six months after a drug becomes available. The review process enables us to learn a great deal about these new drugs, including how a physician can safely prescribe these new drugs and how physicians can choose the most appropriate patients for the new therapy. During the review process, if your physician believes you have a medical need for the NewTo-Market drug, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process. If your plan includes the 3-Tier Copayment Program, then you will pay the Tier-3 (highest) copayment if the medication is approved for coverage. Non-Covered Drugs (NC) There are thousands of drugs listed on the Tufts Health Plan covered drug list. In fact, most drugs are covered. There is, however, a list of drugs that Tufts Health Plan currently does not cover. In many cases, these drugs are not covered by Tufts Health Plan because there are safe, comparably effective, and cost effective alternatives available. Our goal is to keep pharmacy benefits as affordable as possible. If your doctor feels that one of the non-covered drugs is needed, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process. Prior Authorization (PA) Program In order to ensure safety and affordability for everyone, some medications require prior authorization. This helps us work with your doctor to ensure that medications are prescribed appropriately.

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

2

Last Updated: 12/22/2014 If your doctor feels it is medically necessary for you to take one of the drugs listed below, he/she can submit a request for coverage to Tufts Health Plan under the Medical Review Process.

Step Therapy Prior Authorization (STPA ) Step Therapy is an automated form of Prior Authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and costeffectiveness. Some types of Step Therapy include requiring the use of generics before brand name drugs, preferred before non-preferred brand name drugs, and first-line before second-line therapies. Medications included on step 1- the lowest step-are usually covered without authorization. We have noted the few exceptions, which may require your physician to submit a request to Tufts Health Plan for coverage. Medications on Step 2 or higher are automatically authorized at the point-of-sale if you have taken the required prerequisite drugs. However, if your physician prescribes a medication on a higher step, and you have not yet taken the required medication(s) on a lower step, or if you are a new Tufts Health Plan member and do not have any prescription drug claims history, the prescription will deny at the point-of-sale with a message indicating that a Prior Authorization (PA) is required. Physicians may submit requests for coverage to Tufts Health Plan for members who do not meet the Step Therapy criteria at the point of sale under the Medical Review process. Designated Specialty Pharmacy Program (SP) Tufts Health Plan's goal is to offer you the most clinically appropriate and cost-effective services. As a result, we have designated special pharmacies to supply a select number of medications used in the treatment of complex diseases. These pharmacies are specialized in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency. You can obtain up to a 30-day supply of these medications at a time. Other special designated pharmacies and medications may be identified and added to this program from time to time. Benefits vary; some members may not participate in this program. Please see your benefit document for complete information. Physicians may obtain a select number of specialty medications through a designated SP for administration in the office as an alternative to direct purchase. These medications are covered under the medical benefit, and will be shipped directly to and administered in the office by the member’s provider. The designated pharmacy will bill Tufts Health Plan directly for the medication. For the most current listing of special designated pharmacies or to find out if your plan includes this program, please call us at the number listed on the back of your member identification card. Designated Specialty Infusion Program for Drugs Covered Under the Medical Benefit (SI) Tufts Health Plan has designated home infusion providers for a select number of specialized pharmacy products and drug administration services.

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

3

Last Updated: 12/22/2014 The designated specialty infusion provider offers clinical management of drug therapies, nursing support, and care coordination to members with acute and chronic conditions. Place of service may be in the home or alternate infusion site based on availability of infusion centers and determination of the most clinically appropriate site for treatment. These medications are covered under the medical benefit (not the pharmacy benefit) and generally require support services, medication dose management, and special handling in addition to the drug administration services. Medications include, but are not limited to, medications used in the treatment of hemophilia, pulmonary arterial hypertension, and immune deficiency. Other specialty infusion providers and medications may be identified and added to this program from time to time. Generic Focused Formulary The Generic Focused Formulary, which is the formulary used in our Select Network and/or Connector Plans differs from other Tufts Health Plan formularies. Most generic drugs are covered, and only select brand name drugs that have no generic drug equivalent are covered. Brand name drugs with generic equivalents are not covered under this formulary. If the patent of a brand name drug listed expires and a generic version becomes available, the brand will no longer be covered. This change will happen automatically and without notification to members or providers. GFF Formulary Managed Mail (MM) Program Our Managed Mail (MM) Program applies to certain plans. It requires that in order to be covered, prescriptions for most maintenance medications must be filled by our mail order pharmacy. Maintenance medications are those you refill monthly for chronic conditions like asthma, high blood pressure, or diabetes. Under this program, you are allowed an initial fill at a retail pharmacy and a limited number of refills. After that, in order to be covered, you must fill your maintenance prescription through the mail order program offered by CVS Caremark, our pharmacy benefits manager. You may obtain up to a 90-day supply for these maintenance medications at mail order. Please note that some medications may not be appropriate for mail order. These include medications with quantity limitations (QL) of less than 84 or 90 days. If you have questions about this program, please contact us at the number listed on the back of your member identification card. Over-The-Counter Drugs (OTC) When a medication with the same active ingredient or a modified version of an active ingredient that is therapeutically equivalent, becomes available over-the-counter, Tufts Health Plan may exclude coverage of the specific medication or all of the prescription drugs in the class. For more information, please call our Member Services Department at the number listed on the back of your member identification card.

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

4

Last Updated: 12/22/2014

Drug Name

Tier

Pharmacy Program

Drug Name

Tier

Pharmacy Program

abacavir abacavir/lamivudine/zidovudine Abilify (tablets only) Abstral

Tier 1 Tier 1 Tier 3

MM MM QL STPA 30 tablets/30 days QL Drug is not covered, but if covered through medical review process, QL of 32 tablets/30 days will apply.

acamprosate acarbose Accu-Chek Accuneb

Tier 1 Tier 1 Tier 2

acebutolol acetazolamide acetazolamide ext-rel acetic acid otic acetic acid/aluminum acetate otic acetic acid/hydrocortisone otic acitretin Actemra prefilled syringe

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2

Actemra vial Actimmune Actonel acyclovir adapalene cream, gel 0.1%

Medical Benefit Tier 3 Tier 3 Tier 1 Tier 1

Adcirca adefovir dipivoxil Adempas Advair Diskus Advair HFA Aerospan Afinitor

Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2

Afinitor Disperz

Tier 2

Aggrenox albuterol solution albuterol sulfate

Tier 3

A

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

Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM MM QL Drug is not covered, but if covered through medical review process, QL of 360 unit-dose vials/90 days will apply. MM MM MM

SP PA QL 4 syringes/28 days, Call Accredo at 1877-238-8387 PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. STPA MM PA Prior Authorization required for members 26 years of age or older. SP PA Call Accredo at 1-866-344-4874 MM SP PA Call Accredo at 1-866-344-4874 QL MM 3 diskus/90 days QL MM 6 inhalers/90 days QL 6 inhalers/90 days SP PA QL 30 tablets/30 days, Call Accredo at 1877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP PA QL Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-238-8387, 60 tablets/30 days MM QL MM

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

Tier 3 - Highest Copayment/Coinsurance

5

Last Updated: 12/22/2014 albuterol sulfate ext-rel albuterol sulfate nebulizer solution

Tier 1

albuterol sulfate nebulizer solution

Tier 1

alclometasone cream, ointment 0.05% Aldara

Tier 1

Aldurazyme

Medical Benefit

alendronate tablets alfuzosin ext-rel Alkeran

Tier 1 Tier 1 Tier 2

allopurinol Alora Alphagan P

Tier 1 Tier 3

alprazolam alprazolam ext-rel Alsuma

Tier 1 Tier 1

Alvesco

amantadine Ambien

Tier 1

Ambien CR amcinonide cream, lotion 0.1% Amcinonide ointment Amerge

Tier 1 Tier 2

Amethia Lo

Tier 1

Amethyst

Tier 1

amiloride amiloride/hydrochlorothiazide amiodarone Amitiza

Tier 1 Tier 1 Tier 1 Tier 3

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM QL 360 unit-dose vials/90 days or 9 dropper bottles (180 mL)/90 days QL MM 360 unit-dose vials/90 days or 9 dropper bottles (180 mL)/90 days QL Drug is not covered, but if covered through medical review process, QL of 1 box (12 treatments)/28 days will apply. SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. MM MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM QL MM 24 patches/84 days QL Drug is not covered, but if covered through medical review process, QL of 30 mL/90 days will apply.

QL Drug is not covered, but if covered through medical review process, QL of 4 injections (4 vials)/30 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 80 mcg: 3 inhalers/90 days; 160 mcg: 6 inhalers/90 days will apply. MM QL Drug is not covered, but if covered through medical review process, QL of 30 tablets/90 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 30 tablets/90 days will apply.

QL Drug is not covered, but if covered through medical review process, QL of 9 tablets/30 days will apply. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM MM

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

Tier 3 - Highest Copayment/Coinsurance

6

Last Updated: 12/22/2014 amitriptyline amlodipine amlodipine/atorvastatin amlodipine/benazepril ammonium lactate 12% Amnesteem Amoxapine amoxicillin amoxicillin/clavulanate amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts ext-rel ampicillin Ampyra

Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2

Amturnide anagrelide Analpram-HC anastrozole

Tier 3 Tier 1 Tier 3 Tier 1

AndroGel Anzemet

Tier 3 Tier 3

Apidra Aplenzin

Tier 2 Tier 3

Apokyn Apri

Tier 3 Tier 1

Apriso Aptivus Aranelle

Tier 2 Tier 2 Tier 1

Aranesp

Tier 3

Arcalyst

Tier 2

Armour Thyroid Asacol HD Asmanex atenolol atenolol/chlorthalidone atorvastatin atovaquone/proguanil Atripla Atrovent HFA Atrovent Nasal Aerosol

Tier 2 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM MM MM

SP PA QL 60 tablets/30 days, Call Accredo at 1877-238-8387 MM MM MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL tablets: 3 tablets/7 days; injection: 5 mL/7 days MM STPA Step Therapy Prior Authorization required for members 18 years of age or older. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP QL 4 mL/30 days, Call Accredo at 1-877-2388387 SP PA QL Call Caremark at 1-800-237-2767, 5 vials/initial 28 days; thereafter, 4 vials/28 days MM MM QL MM 6 Twisthalers/90 days MM MM MM MM QL MM 6 inhalers/90 days QL Drug is not covered, but if covered through medical review process, QL of 6 nasal spray units/90 days will apply.

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

Tier 3 - Highest Copayment/Coinsurance

7

Last Updated: 12/22/2014 Aubagio

Tier 2

Auvi-Q Avandia

Tier 3

Avandia

Tier 3

Aviane

Tier 1

Avita

Tier 1

Avodart Avonex

Tier 3 Tier 3

Avonex Pen

Tier 3

Axert AzaSite azathioprine azelastine eye drops azelastine spray Azelex azithromycin Azopt

Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3

SP PA QL 28 tablets/28 days, Call Accredo at 1877-238-8387 QL 2 units/fill QL Drug is not covered, but if covered through medical review process, QL of 2 mg: 180 tablets/90 days; 4 mg: 180 tablets/90 days; 8 mg: 90 tablets/90 days, Drug is not covered, but if covered through medical review process, QL of 2 mg: 180 tablets/90 days; 4 mg: 180 tablets/90 days; 8 mg: 90 tablets/90 days QL Drug is not covered, but if covered through medical review process, QL of 2 mg: 180 tablets/90 days; 4 mg: 180 tablets/90 days; 8 mg: 90 tablets/90 days, Drug is not covered, but if covered through medical review process, QL of 2 mg: 180 tablets/90 days; 4 mg: 180 tablets/90 days; 8 mg: 90 tablets/90 days MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. PA Prior Authorization required for members 26 years of age or older. MM SP QL 4 syringes or 4 vials/28 days, Call Accredo at 1-877-238-8387 SP QL Call Accredo at 1-877-238-8387, 4 pens/28 days QL Drug is not covered, but if covered through medical review process, QL of 6 tablets/30 days will apply. QL 1 bottle/7 days MM QL 3 nasal spray units/90 days QL 90 grams/90 days QL MM 30 mL/90 days

B Drug Name

Tier

bacitracin eye ointment baclofen balsalazide Banzel

Tier 1 Tier 1 Tier 1 Tier 2

Baraclude BD insulin syringes and needles Beconase AQ

Tier 2 Tier 2

benazepril benazepril/hydrochlorothiazide Benicar

Tier 1 Tier 1 Tier 2

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

Pharmacy Program MM QL MM 200 mg tablets: 1440 tablets/90 days; 400 mg tablets: 720 tablets/90 days; 40 mg/mL suspension: 4 bottles/30 days MM MM QL Drug is not covered, but if covered through medical review process, QL of 3 nasal spray units/90 days will apply. MM MM MM

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

Tier 3 - Highest Copayment/Coinsurance

8

Last Updated: 12/22/2014 Benlysta

Medical Benefit

Benzaclin

QL Drug is not covered, but if covered through medical review process, QL of 75 grams/90 days will apply.

benzocaine/antipyrine otic benzonatate benzoyl peroxide benztropine Berinert

Tier 1 Tier 1 Tier 1 Tier 1 Medical Benefit

Besivance betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel, ointment 0.05% betamethasone dipropionate cream, lotion, ointment 0.05% betamethasone valerate cream, lotion, ointment 0.1% betamethasone valerate foam 0.12% Betaseron

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3

betaxolol bethanechol Bethkis Betoptic S Beyaz

Tier 1 Tier 1 Tier 3 Tier 3 Tier 3

bicalutamide

Tier 1

BiferaRx bisoprolol bisoprolol/hydrochlorothiazide Blephamide SOP Boniva IV

Tier 3 Tier 1 Tier 1 Tier 3 Medical Benefit Tier 2

Bosulif

Botulinum Toxins

Medical Benefit

Bravelle

Tier 3

Brilinta brimonidine brimonidine eye drops 0.15%

Tier 3

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

PA Covered under the medical benefit.

Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM SI For home infusion services call Caremark at 1800-237-2767. Covered under the medical benefit. QL Drug is not covered, but if covered through medical review process, QL of 1 bottle/5 days will apply.

SP QL 15 vials/30 days, Call Accredo at 1-877238-8387 MM

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM PA Covered under the medical benefit. SP PA QL 100 mg: 120 tablets/30 days; 500 mg: 30 tablets/30 days, Call Accredo at 1-877-2388387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. PA Prior Authorization. Examples include Botox, Dysport, Myobloc and Xeomin. Covered under the medical benefit. SP PA SP PA Call Village Pharmacy at 1-866-890 -8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500 MM QL QL MM 30 mL/90 days

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

Tier 3 - Highest Copayment/Coinsurance

9

Last Updated: 12/22/2014 brimonidine eye drops 0.2% bromfenac sodium eye drops bromocriptine budesonide delayed-release capsules budesonide inhalation suspension budesonide inhalation suspension bumetanide buprenorphine buprenorphine/naloxone SL tablets Buproban (generic of Zyban) bupropion bupropion (generic of Zyban)

Tier 1 Tier 1 Tier 1 Tier 1

MM MM

QL Step Therapy Prior Authorization required for members 18 years of age or older., 180 unit-dose vials/90 days Tier 1 QL MM Step Therapy Prior Authorization required for members 18 years of age or older., 180 unit-dose vials/90 days Tier 1 MM Tier 1 PA Tier 1 PA No copayment QL Annual limit of 180 tablets/90 days Tier 1 No copayment QL Annual limit of 180 tablets/90 days

bupropion ext-rel bupropion XL buspirone butalbital compound butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/aspirin/caffeine butorphanol nasal spray Butrans

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

Bydureon Byetta

Tier 3 Tier 3

QL 3 bottles (9 mL total)/30 days QL Drug is not covered, but if covered through medical review process, QL or 4 patches/30 days will apply. MM MM

Drug Name

Tier

Pharmacy Program

cabergoline calcipotriene topical calcitonin-salmon nasal spray calcitriol (1,25-D3) calcitriol ointment calcium acetate capsules Cambia

Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1

Camila

Tier 1

Canasa candesartan candesartan/hydrochlorothiazide

Tier 3 Tier 2 Tier 2

C

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 1 tube or 1 bottle/day MM MM QL Drug is not covered, but if covered through medical review process, QL of 9 packets/30 days will apply. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM

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

Tier 3 - Highest Copayment/Coinsurance

10

Last Updated: 12/22/2014 capecitabine

Tier 1

Caprelsa

Tier 2

captopril captopril/hydrochlorothiazide Carac Carbaglu carbamazepine carbamazepine ext-rel carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone carisoprodol carvedilol Cayston cefaclor Cefaclor ext-rel cefadroxil cefdinir cefepime cefpodoxime suspension cefpodoxime tablets cefprozil cefuroxime axetil Celebrex Cenestin cephalexin Cerezyme

Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Medical Benefit

Cesamet Cetrotide

Tier 3 Tier 3

cevimeline Chantix

Tier 1 No copayment QL Annual limit of 24 weeks

chloral hydrate chlordiazepoxide chlordiazepoxide/clidinium chlorhexidine gluconate chloroquine chlorpromazine chlorthalidone chlorzoxazone cholestyramine

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP QL 150 mg: 84 capsules/14 days; 500 mg: 168 capsules/14 days, Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. PA QL 100 mg: 60 tablets/30 days; 300 mg: 30 tablets/30 days, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM PA MM MM MM MM MM MM

PA MM PA SI Covered under the medical benefit., For home infusion services call Coram Healthcare at 1800-422-7312 or Caremark at 1-800-237-2767. QL 18 capsules/7 days SP PA Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500

MM MM

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

Tier 3 - Highest Copayment/Coinsurance

11

Last Updated: 12/22/2014 chorionic gonadotropin

Tier 1

ciclopirox cream, lotion ciclopirox topical solution 8% ciclopirox topical solution 8% cilostazol cimetidine Cimzia prefilled syringe

Tier 1

Cimzia prefilled syringe

Tier 3

Cimzia vial

Medical Benefit

Cinryze

Medical Benefit

Cipro HC Otic Cipro suspension Ciprodex ciprofloxacin ext-rel ciprofloxacin eye drops, eye ointment ciprofloxacin tablets citalopram Claravis clarithromycin clarithromycin ext-rel clemastine 2.68 mg Climara Pro clindamycin clindamycin 1%/benzoyl peroxide 5% clindamycin gel, lotion, solution clindamycin palmitate oral solution clindamycin phosphate foam 1% clindamycin vaginal cream clindamycin/benzoyl peroxide clindamycin/benzoyl peroxide gel Clindesse clobetasol propionate 0.05%/emollient foam clobetasol propionate cream, ointment 0.05% clobetasol propionate foam 0.05% clobetasol propionate lotion, shampoo 0.05% clocortolone pivalate cream 0.1% clomiphene clomipramine clonazepam clonidine clonidine ext-rel

Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

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

Tier 1 Tier 1 Tier 1 Tier 2

Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 QL 1 bottle/30 days QL 1 bottle/30 days

SP PA QL 2 injections/28 days, Cimzia syringes are covered under the pharmacy benefit, prior authorization applies. Cimzia vials are covered under the medical benefit only, prior authorization applies., Call Accredo at 1-877-238-8387 SP PA QL 2 injections/28 days, Cimzia syringes are covered under the pharmacy benefit, prior authorization applies. Cimzia vials are covered under the medical benefit only, prior authorization applies., Call Accredo at 1-877-238-8387 PA Cimzia vials are covered under the medical benefit, prior authorization applies. Available to providers through Accredo, call 1-877-238-8387. Cimzia syringes are covered under the pharmacy benefit, prior authorization applies. PA SI Covered under the medical benefit., For home infusion services call Caremark at 1-800-237 -2767.

QL MM 12 patches/84 days

QL QL 100 grams/90 days

MM

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

Tier 3 - Highest Copayment/Coinsurance

12

Last Updated: 12/22/2014 clonidine patch clopidogrel clorazepate clotrimazole clotrimazole troches clotrimazole/betamethasone clozapine Coartem codeine sulfate codeine/acetaminophen codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin codeine/guaifenesin/pseudoephedrine codeine/promethazine colchicine/probenecid Colcrys colestipol Colocort CombiPatch Combivent Respimat Cometriq

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2

Complera Copaxone 20 mg/mL prefilled syringe

Tier 2 Tier 3

Cortifoam cortisone acetate Corvite 150 Cosopt

Tier 3 Tier 1 Tier 3

Cosopt PF Creon Crixivan cromolyn sodium eye drops cromolyn sodium nebulizer solution Cuprimine Cuvposa Solution

Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 3

cyanocobalamin injection cyclobenzaprine cyclophosphamide tablets

Tier 1 Tier 1 Tier 1

cyclosporine cyclosporine, modified cyproheptadine Cystaran Cyto-Q

Tier 1 Tier 1 Tier 1 Tier 2 Tier 3

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

MM MM

QL 24 tablets/180 days

MM QL MM 60 tablets/30 days MM MM QL MM 6 inhalers/90 days PA Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM SP QL Call Accredo at 1-877-238-8387, 1 kit (30 syringes)/30 days

QL Drug is not covered, but if covered through medical review process, QL of 30 mL/90 days will apply. MM MM MM QL MM 360 unit-dose vials/90 days QL Drug is not covered, but if covered through medical review process, QL of 3 bottles/90 days will apply.

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM SP Call Accredo at 1-877-238-8387

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

Tier 3 - Highest Copayment/Coinsurance

13

Last Updated: 12/22/2014

D Drug Name

Tier

Pharmacy Program

Daliresp danazol dantrolene dapsone Daytrana Delzicol desipramine desmopressin spray, tablets desonide cream, lotion, ointment 0.05% desoximetasone cream, ointment 0.05% desoximetasone cream, ointment 0.25%, gel 0.05% Detrol LA dexamethasone dexamethasone sodium phosphate eye drops, eye ointment Dexferrum

Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Medical Benefit

MM

Dexilant Tier 1 Tier 2

Dificid diflorasone diacetate cream 0.05% diflorasone diacetate ointment 0.05% diflunisal digoxin digoxin ped elixir dihydroergotamine injection dihydroergotamine spray diltiazem diltiazem ext-rel Diovan Dipentum diphenoxylate/atropine

Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 1

Tier 1 - Lowest Copayment

MM

STPA MM

QL Drug is not covered, but if covered through medical review process, QL of 90 capsules/90 days will apply.

dexmethylphenidate dexmethylphenidate ext-rel 15mg, 30mg (Focalin XR 15mg, 30mg = NC) dextroamphetamine dextroamphetamine ext-rel dextroamphetamine solution dextromethorphan/brompheniramine/pseudoephedrine dextromethorphan/promethazine diazepam diazepam rectal gel diclofenac potassium diclofenac sodium 3% gel diclofenac sodium delayed-rel diclofenac sodium delayed-rel/misoprostol diclofenac sodium eye drops dicloxacillin dicyclomine didanosine delayed-rel Differin lotion 0.1%

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

STPA

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 1 kit (2 units)/30 days

MM PA Prior Authorization required for members 26 years of age or older. PA

MM MM QL 1 box (8 vials)/30 days MM MM MM MM

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

Tier 3 - Highest Copayment/Coinsurance

14

Last Updated: 12/22/2014 dipivefrin eye drops dipyridamole disopyramide disulfiram divalproex sodium delayed-rel divalproex sodium ext-rel divalproex sodium sprinkle 125 mg donepezil dorzolamide HCl dorzolamide HCl eye drops dorzolamide HCl/timolol maleate dorzolamide HCl/timolol maleate eye drops doxazosin doxepin doxercalciferol doxycycline hyclate doxycycline monohydrate dronabinol Droxia

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2

Dulera duloxetine delayed-rel

Tier 2

Duoneb Duragesic Dymista

MM MM MM MM MM MM QL QL MM 30 mL/90 days QL QL MM 30 mL/90 days MM MM

Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL MM Drug is not covered, but if covered through medical review process, QL of 3 inhalers/90 days will apply. QL 20 mg: 180 capsules/90 days; 30 mg: 270 capsules/90 days; 60 mg: 180 capsules/90 days QL Drug is not covered, but if covered through medical review process, QL of 360 unit-dose vials/90 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 10 patches/30 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 3 nasal sprays/90 days will apply.

E Drug Name

Tier

E.E.S. 200 suspension econazole Edluar

Tier 3 Tier 1

Edurant Effer-K Effient Egrifta Elaprase

Tier 2 Tier 3 Tier 3 Tier 3 Medical Benefit

Elelyso

Medical Benefit Tier 3 Tier 2

Elidel Eligard

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

Pharmacy Program QL STPA Drug is not covered, but if covered through medical review process, QL of 10 capsules/30 days will apply. MM MM MM SP PA Call Accredo at 1-877-238-8387 SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. PA Covered under the medical benefit. QL STPA 1 tube/day

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

Tier 3 - Highest Copayment/Coinsurance

15

Last Updated: 12/22/2014 Eliquis Ella

Tier 3 Tier 3

Elmiron Emcyt

Tier 3 Tier 2

Emend

Tier 3

Emsam

Tier 3

Emtriva Enablex enalapril enalapril/hydrochlorothiazide Enbrel

Tier 2 Tier 3 Tier 1 Tier 1 Tier 3

Enjuvia enoxaparin Enpresse

Tier 3 Tier 1 Tier 1

entacapone Epaned epinastine eye drops epinephrine EpiPen EpiPen Jr. Episil Epivir-HBV solution eplerenone Epogen

Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2 Tier 1 Tier 3

epoprostenol sodium eprosartan Epzicom Equetro ergocalciferol (D2) Erivedge

Medical Benefit Tier 1 Tier 2 Tier 3 Tier 1 Tier 2

Errin

Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL MM 60 tablets/30 days QL 1 tablet/fill, Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-2388387 QL 40 mg: 1 capsule/7 days; 80 mg: 2 capsules/7 days; 125 mg: 1 capsule/7 days; 1 dosepack/7 days STPA Step Therapy Prior Authorization required for members 18 years of age and older. MM MM MM MM SP PA QL 25 mg: 8 vials/28 days; 50 mg: 4 syringes/28 days, Call Accredo at 1-877-238-8387 MM QL 60 ampules or syringes/30 days MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM

QL 2 injectors/fill QL 2 single-dose auto-injectors/fill QL 2 single-dose auto-injectors/fill QL 4 bottles/30 days MM MM SP QL 10 vials/14 days, Call Accredo at 1-877238-8387 PA SI Call Accredo at 1-866-344-4874, Covered under the medical benefit. MM MM MM SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

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

Tier 3 - Highest Copayment/Coinsurance

16

Last Updated: 12/22/2014 Eryped erythromycin ethylsuccinate tablets erythromycin eye ointment erythromycin gel 2% erythromycin solution erythromycin/benzoyl peroxide erythromycin/sulfisoxazole erythromycins escitalopram esomeprazole strontium delayed-rel 49.3 mg estazolam Estrace cream estradiol estradiol/norethindrone acetate estrogens, esterified/methyltestosterone estropipate ethambutol ethosuximide etidronate etodolac etodolac ext-rel etoposide capsules

Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

Euflexxa

Medical Benefit

Eurax Evamist Evista

Tier 3 Tier 3 Tier 2

Exalgo Exelon Patch Exelon solution exemestane

Tier 2 Tier 2 Tier 1

Extavia

Tier 3

MM MM MM MM MM MM

SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP PA Call Accredo at 1-877-238-8387, Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. QL MM 1 bottle/fill MM No copayment required for women under Preventive Services QL Drug is not covered, but if covered through medical review process, QL of 30 tablets/30 days will apply. MM MM MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP QL 15 vials/30 days, Call Accredo at 1-877238-8387

F Drug Name

Tier

Pharmacy Program

Fabior

Tier 3

Fabrazyme

Medical Benefit

PA Prior Authorization required for members 26 years of age or older. PA SI Covered under the medical benefit., For home infusion services call Coram Healthcare at 1800-422-7312 or Caremark at 1-800-237-2767.

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

17

Last Updated: 12/22/2014 Factor Products, various

Medical Benefit

famciclovir

Tier 1

famotidine Fareston

Tier 1 Tier 2

Faslodex felbamate felodipine ext-rel Femhrt 0.5 mg/2.5 mcg fenofibrate 43 mg, 130 mg fenofibrate 48 mg, 145 mg fenofibrate 54 mg, 67 mg, 134 mg, 160 mg, 200 mg fenofibric acid delayed-rel fentanyl citrate lollipop fentanyl transdermal fentanyl transdermal patch Fentora

Tier 2 Tier 1 Tier 1 Tier 3 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1

Ferriprox finasteride 5 mg

Tier 2 Tier 1

Firazyr

Tier 2

First-BXN Compounding Kit First-Duke's Mouthwash First-Mary's Mouthwash First-Omeprazole flavoxate flecainide Flolan

Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Medical Benefit

Tier 1

Flonase Flovent Diskus Flovent HFA fluconazole fludrocortisone flunisolide nasal spray fluocinolone acetonide cream, ointment 0.025% fluocinolone acetonide solution 0.01% fluocinonide cream 0.1% fluocinonide cream, gel, ointment, solution 0.05% fluoride drops

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

Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

PA SI Examples include, but are not limited to: Advate, BeneFix, Corifact, Feiba, Helixate FS, Hemofil M, Kogenate FS, NovoSeven RT, Recombinate, Rixubis, Wilate, Xyntha; Call Caremark at 1-800-237-2767., Covered under the medical benefit. QL 125 mg: 21 tablets/7 days; 250 mg: 60 tablets/30 days; 500 mg: 21 tablets/7 days MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM MM MM MM MM QL 120 units (lollipops)/30 days QL QL 10 patches/30 days QL Drug is not covered, but if covered through medical review process, QL of 28 buccal tablets/30 days will apply. PA QL 30 tablets/30 days MM Covered for men only, all ages. Not covered for women (no exceptions). SP PA QL 1 unit (3 mL)/fill, Call Caremark at 1800-237-2767

QL 300 mL/30 days MM PA SI Call Accredo at 1-866-344-4874, Covered under the medical benefit. QL Drug is not covered, but if covered through medical review process, QL of 3 nasal spray units/90 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 6 diskus/90 days will apply. QL MM 6 inhalers/90 days

QL MM 3 nasal spray units/90 days

No copayment required for children age 6 months through age 6.

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

Tier 3 - Highest Copayment/Coinsurance

18

Last Updated: 12/22/2014 fluoride tablets

Tier 1

fluorometholone eye drops, eye ointment Fluoroplex fluorouracil fluoxetine Fluoxetine 60 mg fluoxetine delayed-rel fluphenazine flurazepam flurbiprofen flurbiprofen eye drops flutamide

Tier 1 Tier 3 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

fluticasone nasal spray fluticasone nasal spray fluticasone propionate cream, lotion 0.05%, ointment 0.005% fluvastatin fluvoxamine fluvoxamine ext-rel Focalin XR 15mg, 30mg = NC (dexmethylphenidate ext-rel 15mg, 30mg) Focalin XR 5 mg, 10 mg, 20 mg, 25 mg, 35 mg, 40 mg folic acid 1 mg

Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 1

Follistim AQ

Tier 3

fondaparinux Foradil Forfivo XL

Tier 1 Tier 3 Tier 3

Forteo Fortical fosinopril fosinopril/hydrochlorothiazide Fosrenol Fragmin Frova Fulyzaq furosemide Fuzeon

Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3

No copayment required for children age 6 months through age 6.

Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL 3 nasal spray units/90 days QL MM 3 nasal spray units/90 days MM

STPA MM No copayment required for women age 12 through age 52. SP PA Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 QL 30 syringes/30 days QL MM 3 units/90 days STPA Step Therapy Prior Authorization required for members 18 years of age and older. SP PA Call Accredo at 1-877-238-8387 MM MM MM QL 30 syringes or 4 MDV/30 days QL STPA 9 tablets/30 days PA MM SP Call Accredo at 1-877-238-8387

G Drug Name

Tier

Pharmacy Program

gabapentin galantamine galantamine ext-rel galantamine oral solution Galzin ganciclovir

Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1

MM MM MM MM

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM

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

Tier 3 - Highest Copayment/Coinsurance

19

Last Updated: 12/22/2014 Ganirelix

Tier 3

gastrinex NF gatifloxacin eye drops Gattex

Tier 1 Tier 2 Tier 2

Gel-One

Medical Benefit

gemfibrozil Generess Fe

Tier 1 Tier 3

gentamicin gentamicin eye drops, eye ointment Gianvi

Tier 1 Tier 1 Tier 1

Gilenya

Tier 2

Gilotrif

Tier 2

Gleevec

Tier 2

glimepiride glipizide glipizide ext-rel glipizide/metformin Glucagon glyburide glyburide, micronized glyburide/metformin Glyset Gonal-F

Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3

granisetron tablets Granisol Granix prefilled syringe

Tier 1 Tier 2 Tier 2

griseofulvin microsize griseofulvin ultramicrosize

Tier 1 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP PA Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 QL 1 bottle/7 days SP PA QL Call Accredo at 1-877-238-8387, 30 vials/30 days (either 1 kit of 30 vials or 30 individual 1-vial kits) SP Call Accredo at 1-877-238-8387. Drug is not covered, but if covered through medical review process, SP program applies. Medical benefit only. Please refer to the Medical Necessity Guidelines for Viscosupplements for Osteoarthritis. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP PA QL Call Accredo at 1-877-238-8387, 28 tablets/28 days SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-2388387 MM MM MM MM MM MM MM MM SP PA SP PA Call Village Pharmacy at 1-866-890 -8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500 QL 6 tablets/7 days QL 45 mL/7 days SP QL 10 syringes/14 days, Call Accredo at 1-877 -238-8387

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

Tier 3 - Highest Copayment/Coinsurance

20

Last Updated: 12/22/2014 guanfacine

Tier 1

MM

Drug Name

Tier

Pharmacy Program

halobetasol propionate cream, ointment 0.05% haloperidol Humalog Humira

Tier 1 Tier 1 Tier 2 Tier 3

Humulin Hyalgan

Tier 2 Medical Benefit

Hycamtin capsules

Tier 2

hydralazine hydrochlorothiazide hydrocodone polistirex/chlorpheniramine polistirex hydrocodone/acetaminophen hydrocodone/homatropine hydrocortisone hydrocortisone butyrate cream, ointment, solution 0.1% hydrocortisone butyrate lipid cream 0.1% hydrocortisone cream hydrocortisone cream 2.5% hydrocortisone enema hydrocortisone lotion 1% hydrocortisone valerate cream, ointment 0.2% hydrocortisone/pramoxine/emollient kit hydromorphone hydroxychloroquine hydroxyurea

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1

hydroxyzine HCl hyoscyamine sulfate hyoscyamine sulfate ext-rel

Tier 1 Tier 1 Tier 1

H

MM SP PA QL Call Accredo at 1-877-238-8387, 2 syringes/28 days; One Crohn's Disease / Ulcerative Colitis starter pack (6 pens) as a one-time fill only; One Psoriasis starter pack (4 pens) as a one-time fill only. MM SP Call Accredo at 1-877-238-8387. Drug is not covered, but if covered through medical review process, SP program applies. Medical benefit only. Please refer to the Medical Necessity Guidelines for Viscosupplements for Osteoarthritis. SP PA QL Call Accredo at 1-877-238-8387, 0.25 mg: 15 capsules/21 days; 1 mg: 25 capsules/21 days, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM

Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group.

I Drug Name

Tier

Pharmacy Program

ibandronate ibuprofen (Rx Only)

Tier 1 Tier 1

MM

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

21

Last Updated: 12/22/2014 Iclusig

Tier 2

Ilaris

Medical Benefit Tier 2

Imbruvica

imipramine HCl imiquimod Imitrex

Tier 1 Tier 1

Immune Globulin (IVIG, SCIG), various

Medical Benefit

Incivek Increlex indapamide indomethacin indomethacin ext-rel Infed Inlyta

Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Medical Benefit Tier 2

Insulin Pen Needles Intelence Intron A

Tier 2 Tier 2 Tier 3

Intuniv Invirase Invokana ipratropium nasal spray ipratropium nasal spray ipratropium nebulizer solution ipratropium/albuterol nebulizer solution ipratropium/albuterol nebulizer solution irbesartan irbesartan/hydrochlorothiazide iron dextran

Tier 3 Tier 2 Tier 3

Irospan

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

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Medical Benefit Tier 3

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

PA QL 15 mg: 60 tablets/30 days; 45 mg: 30 tablets/30 days, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your sponsor/employer about applicability and effective date for your group. PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. PA Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL 1 box: 12 single-use packets/28 days QL Drug is not covered, but if covered through medical review process, QL will apply. Injectable: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; Nasal spray: 2 boxes = 12 units/30 days (5 mg); 1 box = 6 units/30 days (20 mg); Tablets: 9 tablets/30 days. PA SI Covered under the medical benefit., Examples include, but are not limited to: Bivigam, Carimune, Flebogamma, Gammagard S/D, Gammaplex, Gamunex-C, Hizentra, Privigen; For home infusion services call Coram Healthcare at 1800-422-7312 or Caremark at 1-800-237-2767. SP PA Call Caremark at 1-800-237-2767 SP PA Call Caremark at 1-800-237-2767 MM

SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM SP PA Call Accredo at 1-877-238-8387 or Caremark at 1-800-237-2767 QL MM 90 tablets/90 days MM QL 6 nasal spray units/90 days QL MM 6 nasal spray units/90 days QL MM 360 unit-dose vials/90 days QL 360 unit-dose vials/90 days QL MM 360 unit-dose vials/90 days MM MM

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

Tier 3 - Highest Copayment/Coinsurance

22

Last Updated: 12/22/2014 Isentress

Tier 2

QL MM 360 tablets/90 days; Chewable tablets: 100 mg: 180 chewable tablets/30 days; 25 mg: 720 chewable tablets/30 days

isoniazid Isopto Carpine 8% isosorbide dinitrate ext-rel tablets isosorbide mononitrate ext-rel itraconazole capsules

Tier 1 Tier 3 Tier 1 Tier 1 Tier 1

MM MM MM PA

Drug Name

Tier

Pharmacy Program

Jakafi

Tier 2

Januvia Jentadueto Jinteli Jolessa

Tier 3 Tier 2 Tier 1 Tier 1

SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL MM 90 tablets/90 days

Junel

Tier 1

Junel Fe

Tier 1

Juxtapid

Tier 2

J

MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. PA QL 5 mg, 10 mg: 28 capsules/38 days; 20 mg: 84 capsules/28 days

K Drug Name

Tier

Pharmacy Program

Kadian 10 mg, 200 mg Kaletra Kalydeco Kariva

Tier 3 Tier 2 Tier 2 Tier 1

QL 60 capsules/30 days MM PA QL 60 tablets/30 days MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

ketoconazole ketoconazole shampoo ketorolac tromethamine eye drops Kineret

Tier 1 Tier 1 Tier 1 Tier 3

Korlym Krystexxa

Tier 2 Medical Benefit

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP PA QL 28 syringes/28 days, Call Accredo at 1877-238-8387 PA QL 120 tablets/30 days PA Covered under the medical benefit.

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

Tier 3 - Highest Copayment/Coinsurance

23

Last Updated: 12/22/2014 Kuvan Kynamro

Tier 2 Tier 2

SP PA Call Accredo at 1-877-238-8387 SP PA QL Call Accredo at 1-877-238-8387, 4 vials or prefilled syringes/28 days

Drug Name

Tier

Pharmacy Program

labetalol lactulose Lamisil Oral Granules

Tier 1 Tier 1 Tier 3

MM

lamivudine lamivudine tablets lamivudine/zidovudine lamotrigine - chewable dispersible tablets lamotrigine dispersible tablets lamotrigine ext-rel

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2

lamotrigine tablets lansoprazole delayed-rel lansoprazole soluble tablets Lantus latanoprost eye drops Latuda

Tier 1 Tier 3 Tier 3 Tier 2 Tier 1

L

Lazanda leflunomide Letairis letrozole

Tier 1 Tier 2 Tier 1

leucovorin

Tier 1

Leukeran

Tier 2

Leukine

Tier 3

leuprolide acetate levalbuterol nebulizer solution Levemir levetiracetam

Tier 1 Tier 1 Tier 2 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 125 mg packets: 56 packets/28 days; 187.5 mg packets: 28 packets/28 days. Annual limit of 12 weeks applies. MM MM MM MM MM QL MM 25 mg: 90 tablets/90 days; 50 mg:90 tablets/90 days; 100 mg: 90 tablets/90 days; 200 mg: 270 tablets/90 days; 250 mg: 180 tablets/90 days; 300 mg: 180 tablets/90 days MM

MM QL MM 15 mL/90 days QL Drug is not covered, but if covered through medical review process, QL of 30 tablets/30 days (20 mg), 30 tablets/30 days (40 mg); 30 tablets/30 days (60 mg); 60 tablets/30 days (80 mg); 30 tablets/30 days (120 mg) will apply. QL Drug is not covered, but if covered through medical review process, QL of 1 box (4 bottles)/28 days will apply. SP PA Call Accredo at 1-866-344-4874 MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP QL Call Accredo at 1-877-238-8387, 6 vials/14 days QL MM 270 unit-dose vials/90 days MM MM

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

Tier 3 - Highest Copayment/Coinsurance

24

Last Updated: 12/22/2014 levetiracetam ext-rel levobunolol eye drops levocarnitine levofloxacin levofloxacin eye drops Levora

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

Levothroid levothyroxine Levoxyl Lexiva Lialda lidocaine patch 5% lidocaine viscous lidocaine/prilocaine cream Lidovir lindane Linzess liothyronine lisinopril lisinopril/hydrochlorothiazide lithium carbonate lithium carbonate ext-rel Lithium Citrate Lo Loestrin Fe

Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3

Lo Minastrin Fe

Tier 3

Lomedia 24 Fe

Tier 1

lomustine

Tier 1

loperamide lorazepam losartan losartan/hydrochlorothiazide Lotemax lovastatin Low-Ogestrel

Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1

loxapine

Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM MM

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM MM MM QL 30 patches/30 days QL 1 tube/30 days QL 1 kit/30 days QL 30 capsules/30 days MM MM

Contraceptive covered without copayment under Women’s Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group.

MM MM MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

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

Tier 3 - Highest Copayment/Coinsurance

25

Last Updated: 12/22/2014 Lumigan Lumizyme

Tier 3 Medical Benefit

QL STPA MM 15 mL/90 days SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. QL STPA 30 tablets/90 days

Lunesta Lupron Depot Lutera

Tier 3 Tier 3 Tier 1

Lyrica

Tier 3

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA MM

Drug Name

Tier

Pharmacy Program

Makena

PA Covered under the medical benefit.

malathion lotion 0.5% maprotiline Marplan Matulane

Medical Benefit Tier 1 Tier 1 Tier 3 Tier 2

Maxair Autohaler Maxaron Forte meclizine meclofenamate medroxyprogesterone acetate medroxyprogesterone acetate 150 mg/mL

Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1

mefenamic acid mefloquine megestrol acetate

Tier 1 Tier 1 Tier 1

Mekinist

Tier 2

meloxicam Menopur

Tier 1 Tier 3

Mephyton

Tier 3

M

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

Drug is available through Accredo 1-866-3444874. Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL MM 3 units/90 days

MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL 90 tablets/90 days SP PA Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500

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

Tier 3 - Highest Copayment/Coinsurance

26

Last Updated: 12/22/2014 mercaptopurine

Tier 1

mesalamine rectal suspension Mestinon Timespan metaproterenol tablets metaxalone 800 mg metformin metformin ext-rel methadone methamphetamine methazolamide methimazole methocarbamol methotrexate

Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

methyldopa methylergonovine Methylin chewable tablets methylphenidate methylphenidate ext-rel methylphenidate HCl ER (generic for Concerta) methylphenidate oral solution methylprednisolone metipranolol eye drops metoclopramide metolazone metoprolol metoprolol succinate ext-rel metoprolol/hydrochlorothiazide metronidazole metronidazole cream, gel, lotion metronidazole vaginal cream mexiletine Microgestin

Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

Microgestin Fe

Tier 1

midodrine Minastrin 24 Fe

Tier 1 Tier 3

minocycline minocycline SR mirtazapine

Tier 1 Tier 2 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group.

MM MM MM

MM MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM

MM MM MM MM MM

MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

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

Tier 3 - Highest Copayment/Coinsurance

27

Last Updated: 12/22/2014 mirtazapine orally disintegrating misoprostol modafinil moexipril moexipril/hydrochlorothiazide mometasone cream, lotion, ointment 0.1% Mononessa

Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1

montelukast morphine sulfate morphine sulfate beads morphine sulfate ext-rel

Tier 1 Tier 1 Tier 1 Tier 1

morphine sulfate suppositories 5 mg, 10 mg, 20 mg Morphine suppositories 30 mg Moxeza

Tier 1 Tier 2

moxifloxacin Mozobil

Tier 2 Medical Benefit

QL MM 180 tablets/90 days MM MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL MM 90 tablets/90 days QL 60 capsules/30 days QL 90 tablets/30 days; 60 capsules/30 days (20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg)

QL Drug is not covered, but if covered through medical review process, QL of 1 bottle/10 days will apply.

MS Contin

PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. QL Drug is not covered, but if covered through medical review process, QL of 90 tablets/30 days will apply. MM

Multaq mupirocin mycophenolate mofetil mycophenolate sodium Myleran tablets

Tier 3 Tier 1 Tier 1 Tier 1 Tier 2

Myozyme

Medical Benefit

Myrbetriq

Tier 3

MM MM SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. STPA

Drug Name

Tier

Pharmacy Program

nabumetone nadolol Naglazyme

Tier 1 Tier 1 Medical Benefit

naltrexone Namenda Namenda XR naphazoline eye drops naproxen naproxen sodium naratriptan

Tier 1 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1

N

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

MM SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. MM

QL 9 tablets/30 days

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

28

Last Updated: 12/22/2014 naratriptan Nasonex

Tier 1

Natazia

Tier 3

nateglinide Nebusal 6% Necon 0.5/35

Tier 1 Tier 2 Tier 1

Necon 1/35

Tier 1

Necon 1/50

Tier 1

Necon 10/11

Tier 2

Necon 7/7/7

Tier 1

nefazodone neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment neomycin/polymyxin B/dexamethasone eye drops, eye ointment neomycin/polymyxin B/gramicidin eye drops neomycin/polymyxin B/hydrocortisone eye drops neomycin/polymyxin B/hydrocortisone otic Neulasta

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3

Neumega Neupogen

Tier 3 Tier 3

Neupro Nevanac nevirapine Nexavar

Tier 3 Tier 3 Tier 1 Tier 2

Nexium

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 9 tablets/30 days QL Drug is not covered, but if covered through medical review process, QL of 6 nasal spray units/90 days will apply. Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

SP QL Call Accredo at 1-877-238-8387, 1 syringe/14 days SP QL Call Accredo at 1-877-238-8387, 10 vials (1 mL and 1.6 mL)/14 days QL MM 30 patches/30 days MM SP PA QL Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., 120 tablets/30 days QL Drug is not covered, but if covered through medical review process, QL of 90 capsules/90 days will apply.

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

Tier 3 - Highest Copayment/Coinsurance

29

Last Updated: 12/22/2014 Next Choice

niacin ext-rel nicardipine Nicotrol Inhaler

Coverage only for members 16 years of age and under. Tier 1 Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Tier 2 MM Tier 1 MM No copayment QL Annual limit: 90 days/year; Max 168 units/fill

Nicotrol NS Spray

No copayment QL Annual limit: 90 days/year; Max 4 units/fill

nifedipine nifedipine ext-rel Nilandron

Tier 1 Tier 1 Tier 2

nimodipine nisoldipine ext-rel Nitro-Dur 0.3 mg/hr, 0.8 mg/hr nitrofurantoin nitrofurantoin macrocrystals nitrofurantoin suspension nitroglycerin transdermal Nitrostat nizatidine Norditropin Products

Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3

norethindrone acetate Norpace CR Nortrel 0.5/35

Tier 1 Tier 3 Tier 1

Nortrel 1/35

Tier 1

Nortrel 7/7/7

Tier 1

nortriptyline Norvir Novarel

Tier 1 Tier 2 Tier 1

Novolin Novolog Nplate

Tier 2 Tier 2 Medical Benefit

Next Choice One Dose

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

Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM MM

MM

SP PA Call Caremark at 1-800-237-2767. Applies to all Norditropin products including Norditropin Flexpro and Norditropin Nordiflex. MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM SP PA SP Call Village Pharmacy at 1-866-8908930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500 MM MM PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387.

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

Tier 3 - Highest Copayment/Coinsurance

30

Last Updated: 12/22/2014 Nucynta Nucynta ER Nuedexta Numoisyn NuvaRing Nuvigil Nymalize nystatin nystatin/triamcinolone

Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1

QL Drug is not covered, but if covered through medical review process, QL of 30 tablets/30 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 60 tablets/30 days will apply. PA MM MM QL STPA MM 90 tablets/90 days

O Drug Name

Tier

Pharmacy Program

Ocella

Tier 1

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

ofloxacin ofloxacin eye drops ofloxacin otic Ogestrel

Tier 1 Tier 1 Tier 1 Tier 1

olanzapine olanzapine/fluoxetine Olysio omeprazole delayed-rel omeprazole/sodium bicarbonate ondansetron

Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1

OneTouch Onfi Onfi Oral Suspension Onmel Onsolis

Tier 2 Tier 3 Tier 3 Tier 3 Tier 2

Opsumit Orencia prefilled syringe

Tier 2 Tier 3

Orencia vial

Medical Benefit

Orfadin

Tier 3

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

SP PA Call Caremark at 1-800-237-2767

QL oral solution: 90 mL/7 days; 4 mg and 8 mg ODT tablets: 9 tablets/7 days; 4 mg and 8 mg tablets: 9 tablets/7 days; 24 mg tablets: 1 tablet/7 days MM PA MM PA PA QL 28 tablets/28 days SP QL Call Accredo at 1-877-238-8387, 60 buccal films/30 days SP PA Call Accredo at 1-866-344-4874 SP PA QL Call Accredo at 1-877-238-8387, 4 syringes/28 days, Orencia syringes are covered under the pharmacy benefit only, prior authorization applies. Orencia vials are covered under the medical benefit only, prior authorization applies. PA Orencia vials are covered under the medical benefit only, prior authorization applies. Available to providers through Accredo, call 1-877-2388387. Orencia syringes are covered under the pharmacy benefit only, prior authorization applies. SP PA Call Accredo at 1-866-344-4874

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

Tier 3 - Highest Copayment/Coinsurance

31

Last Updated: 12/22/2014 orphenadrine/aspirin/caffeine Ortho Evra

Tier 1 Tier 3

Ortho Tri-Cyclen Lo

Tier 3

Orthovisc

Medical Benefit

Osphena Otozin Ovidrel

Tier 3 Tier 3 Tier 3

oxandrolone oxaprozin oxazepam oxcarbazepine Oxsoralen Oxsoralen-Ultra oxybutynin oxybutynin ext-rel oxycodone ext-rel oxycodone immediate release oxycodone/acetaminophen oxycodone/aspirin OxyContin oxymorphone oxymorphone ext-rel Oxytrol

Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 2 Tier 3

Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP Call Accredo at 1-877-238-8387. Drug is not covered, but if covered through medical review process, SP program applies. Medical benefit only. Please refer to the Medical Necessity Guidelines for Viscosupplements for Osteoarthritis.

SP Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500

MM

MM MM QL 120 tablets/30 days

QL 120 tablets/30 days

MM

P Drug Name

Tier

Pharmacy Program

Pancreaze pantoprazole delayed-rel pantoprazole delayed-rel paricalcitol paroxetine HCl paroxetine HCl ext-rel Patanase

Tier 2

MM QL

peg 3350/electrolytes Pegasys/Pegasys ProClick

Tier 1 Tier 3

PegIntron

Tier 3

penicillin VK

Tier 1

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

Tier 1 Tier 1 Tier 1 Tier 1

MM

QL Drug is not covered, but if covered through medical review process, QL of 3 nasal spray units/90 days will apply.

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP PA QL 4 individual vials/28 days; 1 kit (4 vials/syringes)/28 days; 4 pens/28 days, Call Caremark at 1-800-237-2767 SP PA QL Call CVS Caremark at 1-800-2372767, 4 syringes or vials/28 days

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

Tier 3 - Highest Copayment/Coinsurance

32

Last Updated: 12/22/2014 Penlac Pennsaid Pentasa pentoxifylline ext-rel perindopril Perjeta permethrin 5% perphenazine Pertzye phenazopyridine phenelzine phenobarbital phenylephrine eye drops phenylephrine/guaifenesin phenytoin phenytoin sodium ext-rel capsules Phoslyra Picato

Tier 3 Tier 2 Tier 1 Tier 1 Medical Benefit Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3

pilocarpine pilocarpine eye drops pindolol pioglitazone pioglitazone/glimepiride pioglitazone/metformin piroxicam podofilox polymyxin B/bacitracin eye ointment polymyxin B/trimethoprim eye drops Pomalyst

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2

Portia

Tier 1

potassium chloride ext-rel potassium chloride liquid potassium citrate Potiga Pradaxa pramipexole pravastatin prazosin Pred Mild prednisolone acetate 1% eye drops prednisolone sodium phosphate prednisolone syrup prednisone

Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL Drug is not covered, but if covered through medical review process, QL of 1 bottle/30 days will apply. QL 1 bottle/30 days MM MM PA Covered under the medical benefit.

MM

MM

MM MM MM QL Picato 0.05%: 1 carton/2-day supply; Picato 0.015%: 1 carton/3-day supply MM MM MM MM

SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM PA MM QL MM 180 tablets/90 days MM MM MM

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

Tier 3 - Highest Copayment/Coinsurance

33

Last Updated: 12/22/2014 Pregnyl

Tier 1

Premarin Premarin cream Premphase Prempro Prempro prenatal vitamins w/folic acid Prepopik Prevacid

Tier 3 Tier 3 Tier 3

Prezista Prilosec

Tier 2

primidone Pristiq

Tier 1 Tier 2

ProAir HFA probenecid prochlorperazine Procrit

Tier 2 Tier 1 Tier 1 Tier 3

ProctoFoam-HC progesterone, micronized Prolensa Prolia

Tier 3 Tier 1 Tier 3 Medical Benefit Tier 2

Promacta

Tier 3 Tier 1 Tier 3

promethazine propafenone propafenone ext-rel propantheline propranolol propranolol ext-rel propylthiouracil Protonix

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

Protopic Provenge

Tier 3 Medical Benefit Tier 1 Tier 1 Tier 3

Prudoxin pseudoephedrine/guaifenesin Pulmicort Flexhaler Pulmicort Respules Pulmozyme pyrazinamide pyridostigmine

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

SP PA Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 MM MM MM MM MM

QL Drug is not covered, but if covered through medical review process, QL of 90 capsules/90 days will apply. MM QL Drug is not covered, but if covered through medical review process, QL of 90 capsules/90 days will apply. MM STPA Step Therapy Prior Authorization required for members 18 years of age or older. QL MM 6 inhalers/90 days MM SP QL 10 vials/14 days, Call Accredo at 1-877238-8387

PA Covered under the medical benefit. SP PA QL 30 tablets/30 days, Call Accredo at 1877-238-8387 MM MM MM MM MM QL Drug is not covered, but if covered through medical review process, QL of 90 tablets/90 days will apply. QL STPA 1 tube/day PA Covered under the medical benefit.

QL MM 6 inhalers/90 days QL Drug is not covered, but if covered through medical review process, QL of 180 vials/90 days will apply.

Tier 3 Tier 1 Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

34

Last Updated: 12/22/2014

Q Drug Name

Tier

Qnasl Quartette

Tier 3

Quasense

Tier 1

quetiapine 100 mg, 200 mg, 300 mg, 400 mg quetiapine 25 mg, 50 mg Quillivant XR quinapril quinapril/hydrochlorothiazide quinidine gluconate ext-rel quinidine sulfate quinidine sulfate ext-rel quinine sulfate 324 mg QVAR

Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2

Pharmacy Program QL Drug is not covered, but if covered through medical review process, QL or 3 nasal spray units/90 days will apply. Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. PA STPA MM MM MM MM MM QL MM 6 inhalers/90 days

R Drug Name

Tier

rabeprazole delayed-rel ramipril Ranexa ranitidine Rapamune 1 mg, Rapamune 2 mg Ravicti Rayos

Tier 2 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3

Rebetol solution Rebif/Rebif Rebidose

Tier 3 Tier 3

Reclast

Medical Benefit Tier 1

Reclipsen

Rectiv Ointment Refissa

Tier 1

Relenza Relistor

Tier 2 Tier 3

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

Pharmacy Program MM MM MM PA QL Drug is not covered, but if covered through medical review process, QL or 30 tablets/30 days will apply. SP Call Caremark at 1-800-237-2767 SP QL 12 syringes Or autoinjectors/28 days, Call Accredo at 1-877-238-8387 PA Covered under the medical benefit. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL Drug is not covered, but if covered through medical review process, QL of 1 tube/30 days will apply. PA Prior Authorization required for members 26 years of age and older. QL 1 package (20 doses)/365 days

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

Tier 3 - Highest Copayment/Coinsurance

35

Last Updated: 12/22/2014 Relpax Remicade

QL Drug is not covered, but if covered through medical review process, QL of 6 tablets/30 days will apply. PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. PA SI Covered under the medical benefit., Call Accredo at 1-866-344-4874. MM MM MM SP PA Call Village Pharmacy at 1-866-890-8930 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 MM PA MM SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM QL Drug is not covered, but if covered through medical review process, QL of 3 nasal spray units/90 days will apply. SP Call Caremark at 1-800-237-2767 SP Call Caremark at 1-800-237-2767

Renagel Renvela repaglinide Repronex

Medical Benefit Medical Benefit Tier 3 Tier 2 Tier 1 Tier 3

Rescriptor Restasis Revlimid

Tier 2 Tier 3 Tier 3

Reyataz Rhinocort Aqua

Tier 2

ribasphere ribavirin Ridaura rifampin riluzole rimantadine risperidone risperidone orally disintegrating tablets risperidone solution Ritalin LA 10 mg Rituxan rivastigmine rizatriptan

Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Medical Benefit Tier 1 Tier 1

ropinirole ropinirole ext-rel Rozerem

Tier 1 Tier 1 Tier 3

MM QL orally disintegrating tablets: 9 tablets/30 days; tablets: 9 tablets/30 days MM QL MM 90 tablets/90 days QL STPA 30 tablets/90 days

Drug Name

Tier

Pharmacy Program

Sabril Safyral

Tier 2 Tier 3

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

salicylic acid salicylic acid liquid 27.5% salsalate Samsca

Tier 1 Tier 1 Tier 1 Tier 3

Remodulin

STPA PA Covered under the medical benefit.

S

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 14 tablets/7 days

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

Tier 3 - Highest Copayment/Coinsurance

36

Last Updated: 12/22/2014 Sancuso Savella Savella selegiline selenium sulfide shampoo Selzentry

Tier 2 Tier 1 Tier 1 Tier 2

Sensipar Serevent Diskus Serophene Seroquel XR Serostim sertraline Signifor

Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 1 Tier 2

sildenafil 20 mg tablets silver sulfadiazine Silvrstat Simbrinza Simponi

Tier 1 Tier 1 Tier 3 Tier 3 Tier 2

Simponi Aria

Medical Benefit Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 1 Medical Benefit Tier 2

simvastatin sirolimus 0.5 mg Sirturo Skelid Sklice sodium chloride 0.9% for inhalation (Rx Only) Soliris Soltamox

Somavert Sonata

Tier 3

sotalol sotalol AF Sovaldi spinosad Spiriva spironolactone spironolactone/hydrochlorothiazide Sporanox oral solution Sprintec

Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL Drug is not covered, but if covered through medical review process, QL of 1 patch/7 days will apply. QL STPA MM 180 tablets/90 days QL STPA MM 180 tablets/90 days MM QL MM 150 mg: 60 tablets/30 days; 300 mg: 120 tablets/30 days MM QL MM 3 diskus/90 days STPA SP PA Call Caremark at 1-800-237-2767 SP PA QL Call Accredo at 1-877-238-8387, 60 ampules/30 days SP PA Call Accredo at 1-866-344-4874

SP PA QL 1 pre-filled syringe or SmartJect autoinjector (50 mg or 100 mg)/28 days, Call Accredo at 1-877-238-8387 PA Covered under the medical benefit. MM MM PA QL 1 bottle/fill PA Covered under the medical benefit. Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. No copayment required for women under Preventive Services. PA QL Drug is not covered, but if covered through medical review process, QL of 30 capsules/90 days will apply. MM MM SP PA Call Caremark at 1-800-237-2767 QL 1 bottle/fill QL MM 90 capsules (3 units)/90 days MM MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

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

Tier 3 - Highest Copayment/Coinsurance

37

Last Updated: 12/22/2014 Sprycel

Tier 2

stavudine Stavzor Staxyn

Tier 1 Tier 3

Stelara Stelara prefilled syringe

Medical Benefit Tier 2

Stivarga

Tier 2

Strattera

Tier 3

Striant Stribild Suboxone film sucralfate sulfacetamide 10% eye drops sulfacetamide sodium lotion 10% sulfacetamide sodium wash 10% sulfacetamide/prednisolone phosphate eye drops, eye ointment sulfacetamide/sulfur sulfadiazine sulfamethoxazole/trimethoprim sulfasalazine sulfasalazine delayed-rel sulfisoxazole sulindac sumatriptan

Tier 3 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

sumatriptan

Tier 1

Sumavel Dosepro

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP PA QL Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., 20 mg, 50 mg, 70 mg, 80 mg: 60 tablets/30 days: 60 tablets/30 days (for any combination of strengths); 100 mg, 140 mg: 30 tablets/30 days MM MM QL Drug is not covered, but if covered through medical review process, QL or 4 tablets/30 days will apply. PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. SP PA QL 1 injection (prefilled syringe)/84 days, Call Accredo at 1-877-238-8387 SP PA QL Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., 84 tablets/28 days QL 10 mg, 18 mg, 25 mg, 40 mg, 60 mg: 180 capsules/90 days; 80 mg & 100 mg: 90 capsules/90 days MM PA

MM MM

QL injection: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; nasal spray: 2 boxes (12 spray unit devices)/30 days (5 mg) or 1 box (6 spray unit devices)/30 days (20 mg); tablets: 9 tablets/30 days QL injection: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; nasal spray: 2 boxes (12 spray unit devices)/30 days (5 mg) or 1 box (6 spray unit devices)/30 days (20 mg); tablets: 9 tablets/30 days QL Drug is not covered, but if covered through medical review process, QL of 4 injections/30 days will apply.

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

Tier 3 - Highest Copayment/Coinsurance

38

Last Updated: 12/22/2014 Supartz

Medical Benefit

Sustiva Sutent

Tier 2 Tier 2

Sylatron

Tier 2

Symbicort SymlinPen Synagis

Tier 2 Tier 3 Medical Benefit

Synarel Synvisc

Tier 3 Medical Benefit

Synvisc-One

Medical Benefit

SP Call Accredo at 1-877-238-8387. Drug is not covered, but if covered through medical review process, SP program applies. Medical benefit only. Please refer to the Medical Necessity Guidelines for Viscosupplements for Osteoarthritis. MM SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. SP PA QL Call Accredo at 1-877-238-8387, 4 vials/28 days QL MM 6 inhalers/90 days MM SP PA Covered under the medical benefit. Available through Accredo, call 1-877-482-5927., Call Accredo at 1-877-238-8387 SP Call Accredo at 1-877-238-8387. Drug is not covered, but if covered through medical review process, SP program applies. Medical benefit only. Please refer to the Medical Necessity Guidelines for Viscosupplements for Osteoarthritis. SP Call Accredo at 1-877-238-8387. Drug is not covered, but if covered through medical review process, SP program applies. Medical benefit only. Please refer to the Medical Necessity Guidelines for Viscosupplements for Osteoarthritis.

T Drug Name

Tier

Pharmacy Program

Tabloid

Tier 2

tacrolimus Tafinlar

Tier 1 Tier 2

Tamiflu capsules Tamiflu suspension tamoxifen

Tier 2 Tier 3 Tier 1

tamsulosin

Tier 1

SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL 10 capsules/365 days QL 180 mL/365 days MM Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. No copayment required for women under Preventive Services. MM

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

39

Last Updated: 12/22/2014 Tarceva

Tier 2

Targretin capsules

Tier 2

Targretin gel Tarka Tasigna

Tier 2 Tier 3 Tier 2

Tazorac

Tier 3

Tecfidera

Tier 2

Tekamlo Tekturna Tekturna HCT telmisartan telmisartan/amlodipine telmisartan/hydrochlorothiazide temazepam temozolomide

Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1

terazosin terbinafine tablets

Tier 1 Tier 1

terbutaline terconazole Testim tetracycline Thalomid

Tier 1 Tier 1 Tier 3 Tier 1 Tier 3

Theo-24 theophylline theophylline ext-rel

Tier 3 Tier 1 Tier 1

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP QL Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., 25 mg: 90 tablets/30 days; 100 mg: 30 tablets/30 days; 150 mg: 30 tablets/30 days SP Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-2388387 SP Call Accredo at 1-877-238-8387 MM SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. PA Prior Authorization required for members 26 years of age or older. SP PA QL 60 capsules/30 days, Call Accredo at 1877-238-8387 MM MM MM MM MM MM SP QL 5 mg: 15 capsules/21 days; 20 mg: 20 capsules/21 days; 100 mg: 20 capsules/21 days; 140 mg: 15 capsules/21 days; 180 mg: 10 capsules/21 days; 250 mg: 10 capsules/21 days, Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM QL 30 tablets/30 days. Annual limit of 90 days applies. MM

SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM MM

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

Tier 3 - Highest Copayment/Coinsurance

40

Last Updated: 12/22/2014 thioridazine thiothixene tiagabine Tikosyn Tilia Fe

Tier 1 Tier 1 Tier 1 Tier 3 Tier 1

timolol maleate eye drops timolol maleate gel tinidazole Tirosint Tivicay tizanidine TOBI Podhaler Tobradex 0.3%/0.05% eye drops tobramycin eye drops, eye ointment tobramycin/dexamethasone 0.3%/0.1% eye drops tolterodine topiramate torsemide Tracleer Tradjenta tramadol tramadol ext-rel trandolapril tranexamic acid Transderm Scop tranylcypromine Travatan Z travoprost eye drops trazodone Trelstar Depot Trelstar LA tretinoin capsules

Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1

tretinoin gel microsphere

Tier 1

tretinoin topical Tretin-X

Tier 1 Tier 3

Trexall

Tier 2

Treximet triamcinolone acetonide cream 0.5% triamcinolone acetonide cream, lotion 0.025% triamcinolone acetonide cream, lotion, ointment 0.1%

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

MM MM MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM MM MM

MM MM MM SP PA Call Accredo at 1-866-344-4874 MM

MM QL 30 tablets/28 days

QL STPA MM 15 mL/90 days QL MM 15 mL/90 days

SP Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. PA Prior Authorization required for members 26 years of age or older. PA PA Prior Authorization required for members 26 years of age or older. Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL Drug is not covered, but if covered through medical review process, QL of 9 tablets/30 days will apply.

Tier 1 Tier 1 Tier 1

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

41

Last Updated: 12/22/2014 triamcinolone nasal spray triamcinolone paste triamterene/hydrochlorothiazide triazolam trifluoperazine trifluridine eye drops trihexyphenidyl trimethobenzamide trimethoprim trimipramine Trinessa

Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

Tri-Sprintec

Tier 1

Trivora

Tier 1

trospium trospium ext-rel Trusopt

Tier 1 Tier 1

Truvada Tudorza Pressair Tykerb

Tier 2 Tier 3 Tier 2

Tysabri

Medical Benefit Medical Benefit Tier 2

MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM MM QL Drug is not covered, but if covered through medical review process, QL of 30 mL/90 days will apply. MM QL 3 inhalers/90 days SP PA QL 180 tablets/30 days, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-2388387 PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. PA SI Covered under the medical benefit., Call Accredo at 1-866-344-4874 QL MM 30 tablets/30 days

Drug Name

Tier

Pharmacy Program

ubidecarenone Uceris Ulesfia Uloric Unithroid ursodiol

Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1

PA

Tyvaso Tyzeka

QL MM 3 nasal spray units/90 days MM

MM

U

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 6 bottles/7 days STPA MM MM

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

Tier 3 - Highest Copayment/Coinsurance

42

Last Updated: 12/22/2014

V Drug Name

Tier

valacyclovir valacyclovir Valchlor Valcyte valproate sodium valproic acid valsartan/hydrochlorothiazide Valtrex

Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1

vancomycin Veletri Velivet

venlafaxine venlafaxine ext-rel capsules venlafaxine ext-rel tablets Venofer Ventavis

Tier 1 Medical Benefit Tier 1

Tier 1 Tier 1 Tier 1 Medical Benefit Medical Benefit

Ventolin Ventolin HFA Ventolin nebulizer solution

Tier 3

Veramyst verapamil verapamil ext-rel Versacloz Vesicare Victoza Victrelis Videx Vimovo

Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2

Vimpat

Tier 2

Viracept Viramune XR Viread Vivelle-Dot Vivitrol

Tier 2 Tier 2 Tier 2 Tier 3 Medical Benefit Tier 3

Voltaren gel

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

Pharmacy Program QL 90 tablets/90 days QL 90 tablets/90 days PA MM MM MM MM QL Drug is not covered, but if covered through medical review process, QL of 90 tablets/90 days will apply. PA SI Covered under the medical benefit., Call Accredo at 1-866-344-4874. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.

PA SI Call Accredo at 1-866-344-4874., Covered under the medical benefit. QL Drug is not covered, but if covered through medical review process, QL of 6 inhalers/90 days will apply. QL MM 6 inhalers/90 days QL Drug is not covered, but if covered through medical review process, QL of 9 dropper bottles (180 mL total)/90 days will apply. QL Drug is not covered, but if covered through medical review process, QL of 3 nasal spray units/90 days will apply. MM MM MM MM SP PA Call Caremark at 1-800-237-2767 MM QL Drug is not covered, but if covered through medical review process, QL of 60 tablets/30 days will apply. PA QL MM oral solution: 1200 mL/30 days; tablets: 180 tablets/90 days MM MM MM QL MM 24 patches/84 days

QL 2 tubes/1 day

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

Tier 3 - Highest Copayment/Coinsurance

43

Last Updated: 12/22/2014 voriconazole tablets

Tier 1

Votrient

Tier 2

Vpriv

Medical Benefit

Vytorin Vyvanse

Tier 2 Tier 3

QL 50 mg: 56 tablets/14 days; 200 mg: 28 tablets/14 days SP PA QL 200 mg tablets: 120 tablets/30 days; 400 mg tablets: 60 tablets/30 days, Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. PA SI Call Coram Healthcare at 1-800-422-7312 or Caremark at 1-800-237-2767, Covered under the medical benefit. MM STPA

Drug Name

Tier

Pharmacy Program

warfarin Welchol

Tier 1 Tier 3

MM MM

Drug Name

Tier

Pharmacy Program

Xalkori

Tier 2

Xarelto

Tier 3

Xeljanz

Tier 2

Xenazine

Tier 2

Xgeva

Medical Benefit Medical Benefit Tier 3

SP PA Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-2388387 QL MM 10 mg: 35 tablets/fill; 15 mg: 60 tablets/30 days; 20 mg: 30 tablets/30 days SP PA QL Call Accredo at 1-877-238-8387, 60 tablets/30 days SP PA QL 12.5 mg: 90 tablets/30 days; 25 mg: 120 tablets/30 days, Call Caremark at 1-800-2372767 PA Covered under the medical benefit.

W

X

Xiaflex Xifaxan Xolair Xopenex HFA Xopenex inhalation solution, 0.31 mg/3 mL, 0.63 mg/3 mL, 1 Xtandi

Medical Benefit Tier 3 Tier 3 Tier 2

Xyrem

Tier 3

PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. PA QL 200 mg: 9 tablets/30 days; 550 mg: 60 tablets/30 days PA Covered under the medical benefit. Available through Accredo, call 1-877-238-8387. QL MM 6 inhalers/90 days QL STPA MM SP PA QL Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., 120 capsules/30 days

Z Drug Name

Tier

Pharmacy Program

zafirlukast

Tier 1

QL MM 180 tablets/90 days

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

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

Tier 3 - Highest Copayment/Coinsurance

44

Last Updated: 12/22/2014 zaleplon zaleplon Zavesca Zegerid

Tier 1 Tier 3

Zelboraf

Tier 2

Zenpep Zetia Zetonna

Tier 3 Tier 3

zidovudine Zioptan ziprasidone ziprasidone Zirgan Zoladex zoledronic acid (generic of Reclast) zoledronic acid 4 mg/5 mL IV Zolinza

Tier 1 Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 1 Medical Benefit Tier 2

zolmitriptan

Tier 2

zolpidem zolpidem tartrate CR Zolpimist 5 mg Spray

Tier 1 Tier 1

Zometa zonisamide Zorbtive Zortress Zovia 1/35

Medical Benefit Tier 1 Tier 3 Tier 3 Tier 1

Zovia 1/50

Tier 1

Zubsolv Zuplenz

Tier 3

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

QL 30 capsules/90 days QL 30 capsules/90 days SP PA Call Accredo at 1-877-238-8387 QL Drug is not covered, but if covered through medical review process, QL of 90 capsules/packets/90 days will apply. SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. MM MM QL Drug is not covered, but if covered through medical review process, QL of 3 nasal sprays/90 days will apply. MM QL STPA MM 90 single-use containers/90 days

PA Covered under the medical benefit. PA Covered under the medical benefit. SP PA Call Accredo at 1-877-238-8387, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group. QL 2.5 mg: 6 tablets/30 days; 5 mg: 6 tablets/30 days QL 30 tablets/90 days QL 10 tablets/30 days QL Drug is not covered, but if covered through medical review process, QL of 1 metered spray unit/30 days will apply. PA Covered under the medical benefit. MM SP PA Call Caremark at 1-800-237-2767 QL MM 180 tablets/90 days MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. MM Contraceptive covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. PA QL Drug is not covered, but if covered through medical review process, QL of 10 films/7 days will apply.

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

Tier 3 - Highest Copayment/Coinsurance

45

Last Updated: 12/22/2014 Zytiga

Tier 2

Zyvox

Tier 3

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

PA - Prior Authorization QL - Quantity Limitation Program MM - Managed Mail Tier 2 - Middle Copayment/Coinsurance

SP PA QL 120 tablets/30 days, Oral cancer medications may be covered without copayment under the Massachusetts oral cancer therapy mandate. Please contact your plan sponsor/employer about applicability and effective date for your group., Call Accredo at 1-877-2388387 QL 56 tablets/28 days

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

Tier 3 - Highest Copayment/Coinsurance

46