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