2015 MVP Health Insurance

MARKETPLACE FORMULARY New York-Vermont ••••••••••••••••••••••••••••••••••••••••••••••••••••••

Effective January 1, 2015

2015 MARKETPLACE FORMULARY EFFECTIVE January 1, 2015 This information relates to the Marketplace Formulary, generally, and may not describe your particular coverage. Your specific Plan documents determine your benefits, including copays, coinsurance, deductibles, out-of-pocket maximums and any limitations and exclusions. Your physician is the person best suited to help you make decisions about prescription drugs, and the prescription drug information below is intended for consumer guidance only. While every effort has been made to insure accuracy, some information may be out of date. The Marketplace Formulary is subject to change based on decisions made by the Pharmacy & Therapeutics (P&T) committee. New drugs are not covered until reviewed by the P&T committee. Medications with an over-the-counter equivalent are not a covered benefit. Drugs entering the market between 1938 and 1962 that were approved for safety but not effectiveness are called “DESI” drugs. DESI drugs are not covered on the Marketplace Formulary. In the case of some drugs, the Plan limits coverage to a specific quantity or a specific course of treatment. The Plan may also require prior authorization on some covered drugs. If you need more information about policies regarding a specific drug, consult your physician or contact the MVP Customer Care Center. If the medication you take is not listed below, contact the Customer Care Center at the phone number listed on the back of your MVP ID card.

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

ACE Inhibitors** (blood pressure lowering, includes HCTZ combination products)

benazepril captopril enalapril fosinopril lisinopril

None

Adrenal Hormones Oral**

cortisone dexamethasone fludrocortisone hydrocortisone methylprednisolone prednisolone prednisone

Accupril BR Accuretic BR Aceon BR Altace BR Lotensin Epaned BR Mavik #,+ Acthar-HP BR Cortef Dexpak BR Medrol Medrol 2mg Orapred ODT BR Pediapred BR Prelone NFNC Rayos

Adrenergic Antagonists**

clonidine doxazosin guanabenz guanfacine

#

moexipril perindopril quinapril ramipril trandolapril

Millipred

methyldopa/ HCTZ prazosin reserpine terazosin

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

clonidine patch midodrine

q

BR

MEDICAL (M)

BR

Prinivil BR Uniretic BR Univasc BR Vasotec BR Zestril BR Zestoretic

BR

Cardura Cardura XL BR Catapres/TTS BR Minipress BR Tenex

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

2

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Alzheimer’s Agents**

galantamine

donepezil ergoloid Namenda XR rivastigmine

Aricept/ODT BR Exelon Exelon patch BR Razadyne/ER

Androgens (male hormones)

danazol q testosterone inj

Androgel q oxandrolone *,q BR Testim

ARBs/Renin Inhibitors** (includes combination products)

candesartan eprosartan irbesartan losartan telmisartan/amlodipine

Anti-Anxiety Agents**

alprazolam/ER buspirone chlordiazepoxide clorazepate diazepam lorazepam oxazepam amiodarone disopyramide flecainide mexiletine Pacerone propafenone quinidine Sorine sotalol/AF

Antiarrhythmics** (heart rhythm)

#

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

*,q

amlodipine/ valsartan valsartan

alprazolam intensol diazepam Intensol

propafenone SR

q

MEDICAL (M)

BR

#

Anadrol-50 # *,q Androderm q# Android q Androxy # Aveed #q Axiron q BR # Delatestryl ,q # Depo-Testerone q# Depo-Testosterone 100mg *,q # First-Testo Cr *,q # Fortesta q BR # Oxandrin q# Methitest *,q # Striant q testosterone gel *,q # Testred # Vogelxo Amturnide Exforge BR BR BR Atacand Hyzaar BR Avalide Micardis/HCT BR BR Avapro Tekamlo Azor Tekturna/HCT BR Teveten Benicar/HCT BR Cozaar Teveten HCT BR Diovan/HCT Tribenzor BR Twynsta Edarbi Edarbyclor BR Ativan BR Niravam BR Tranxene-T BR Valium BR Xanax/XR

Betapace/AF BR Cordarone Multaq BR Norpace Norpace CR

BR

#

Aveed q Testopel

BR

Rythmol/SR BR Tambocor + Tikosyn

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

3

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Antibiotics

amoxicillin amoxicillin/ clavulanate amoxicillin/ clavulanate XR ampicillin azithromycin cefaclorcefadroxil cefdinir cefditren cefpodoxime cefprozil cefuroxime cephalexin cephradine ciprofloxacin/ER clarithromycin/ER clindamycin dicloxacillin ees/sulfisoxazole Erythrocin erythromycin levofloxacin minocycline/XR neomycin ofloxacin paromomycin penicillin sulfadiazine sulfa/trimeth DS/SS tetracycline heparin Jantoven* warfarin*

Avidoxy Baci-IM inj bacitracin inj cefepime inj # ceftriaxone inj Clindess clindamycin palmitate demeclocycline doxycycline Morgidox moxifloxacin vancomycin

Adoxa BR Augmen/ES/XR BR Avelox BR Bactrim/DS BR Biaxin XL BR Cedax Cefaclor ER BR Ceftin Ceftin susp BR Cipro/XR BR Cleocin Cleocin 75mg Cleocin Vaginal # BR Doryx 150mg # Doryx 200mg doxycycline 20mg Dynabac E.E.S. Susp Eryped Ery-Tab Erythromycin Base Factive

Eliquis* enoxaparin fondaparinux Xarelto*

Arixtra Coumadin* Fragmin Heparin Lock FlushNFNC

carbamazepine clonazepam diazepam rectal divalproex Epitol ethosuximide gabapentin lamotrigine/XR

carbamazepine ER

Aptiom Banzel BR Carbatrol BR Depakene BR Depakote/ER BR Diastat Dilantin BR Felbatol # Fycompa BR Gabitril BR Keppra/XR BR Klonopin BR Lamictal/XR Lamictal ODT Lyrica

Anticoagulants

Anticonvulsants** (seizures)

#

phenobarbital phenytoin primidone Topiragen topiramate valproic acid zonisamide

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

Celontin divalproex ER felbamate levetiracetam/SR oxcarbazepine Peganone tiagabine

BR

Keflex Ketek BR Levaquin BR Minocin BR Monodox Moxatag Noroxin # Oracea # BR Rocephin PCE # Sivextro # Solodyn BR Spectracef Sulfadiazine Suprax Tygacil inj BR Vancocin Vibativ BR Vibramycin Vibramycin syrup # Xifaxan 200 mg BR Zithromax Z-Max q Zyvox

BR

Iprivask BR Lovenox #* Pradaxa

#

BR

MEDICAL (M)

#

Dalvance Teflaro # Zyvox Inj

BR

Mysoline BR Neurontin Onfi Oxtellar XR Phenytek BR Potiga + Sabril Stavzor BR Tegretol/ XR BR Topamax BR Trileptal Trokendi XR Vimpat BR Zarontin BR Zonegran

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

4

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Antidepressants**

amitriptyline amoxapine bupropion/SR/XL budeprion/SR/XL citalopram desipramine doxepin escitalopram fluoxetine fluvoxamine/CR hydroxyzine pamoate imipramine imipramine pamoate

maprotiline mirtazapine nefazodone nortriptyline paroxetine/ER phenelzine protriptyline Selfemra sertraline tranylcypromin trazodone trimipramine venlafaxine

clomipramine duloxetine venlafaxine ER olanzepine/ st fluoxetine

Anafranil Aplenzin Brintellix # Brisdelle BR Celexa BR Cymbalta

Compro q ondansetron prochlorperazine promethazine

trimethobenzamid

dronabinol q granisetron

Antiemetics (nausea)

Antifungal Agents

clotrimazole oral fluconazole griseofulvin ketoconazole nystatin q terbinafine

Antihistamines**

Various generics azelastine clemastine cyproheptadine chlorpheniramine Various generics

Antihistamine/ Decongestant Combinations Antihypertensive Combinations** (blood pressure lowering)

Antimalarials

Antimycobacterials** (TB) #

BR

#

itraconazole voriconazole

amlodipine/atorvastatin amlodipine/benazepril atenolol/chlorthalidone Clorpres nadolol/bendroflumethzide trandolapril/verapamil # chloroquine hydroxychloroquine* # mefloquine # quinine sulfate ethambutol rifampin isoniazid rifampin/ pyrazinamide isoniazid

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

desloratadine

Effexor XR Emsam Fetzima Forfivo XL # Khedezla BR Lexapro BR Luvox CR Marplan BR Nardil BR Norpramin Oleptro ER q Anzemet Cesamet Q Diclegis q Emend q Granisol BR Marinol BR Ancobon Cancidas BR Diflucan BR Grifulvin V BR Gris-Peg # Jublia # Kerydin q Lamisil Granules Mycamine inj Various brands BR Astelin Nasal Astepro Brovex #

None

Various brands # Clarinex D

Demser

Bidil BR Caduet BR Corzide BR Lopressor HCT

atovaquone/ # proguanil

Aralen # Coartem # Daraprim # BR Malarone Mycobutin Paser Rifater

Priftin

q

BR

Desvenlafaxine ER

griseofulvin ultra

diphenhydramine hydroxyzine levocetirizine promethazine

BR

#

MEDICAL (M)

Pamelor BR Parnate Paxil susp BR Paxil/CR Pexeva Pristiq ER BR Prozac/Week BR Remeron NFNC Sarafem BR Surmontil st BR Symbyax BR Tofranil/PM Venlafaxine BR ext-rel Tabs Viibryd BR Vivactil Wellbutrin/SR/XLBR BR Zoloft q Sancuso BR Tigan

#

Aloxi # Emend Inj

Transderm-Scop q BR

Zofran/ODT q Zuplenz q BR

Lamisil BR Nizoral Noxafil # Onmel Oravig # BR Sporanox # Sporanox soln BR Vfend BR

Clarinex Clarinex syrup Patanase BR Xyzal #

Semprex-D BR

Lotrel Tarka BR Tenoretic BR Ziac BR

Plaquenil* # Primaquine # BR Qualaquin # Seromycin Sirturo Trecator

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

5

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Antiparasitics

metronidazole paromomycin tinidazole

atovaquone

Antiplatelet Agents**

anagrelide cilostazol clopidogrel

dipyridamole ticlopidine

None

Antipsychotics**

chlorpromazine clozapine/ODT fluphenazine haloperidol lithium loxapine

perphenazine quetiapine risperidone/ODT thioridazine thiothixene trifluoperazine

olanzapine/ODT olanzapine/ st fluoxetine ziprazidone

Antiretrovirals/ HIV

None

Antispasmodic Agents**

#

#

abacavir* abacavir/lamivudine/ zidovudine*

Aptivus* Atripla* Crixivan* didanosine* Emtriva* Epivir soln* Epzicom* Invirase* Isentress* Kaletra* lamivudine* lamivudi/zidov* Lexiva* nevirapine* Norvir* Prezista* Rescriptor* Reyataz* Selzentry* stavudine* Sustiva* Truvada* Viracept* Viread tabs* zidovudine* methscopolomine Myrbetriq tolterodine/ER trospium

bethanechol dicyclomine flavoxate oxybutynin/ER propantheline Symax/SL/SR

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

Albenza Alinia Biltricide Dapsone BR Flagyl Aggrenox BR Agrylin Brilinta Effient st Abilify BR Clozaril Equetro Fanapt BR FazaClo BR Geodon Invega Latuda BR Lithobid BR Combivir* Complera* Edurant* + Egrifta BR Epivir tabs* + Fuzeon Intelence* BR Retrovir* Stribild* Tivicay*

Flagyl ER # BR Mepron Stromectol BR Tindamax Yodoxin BR Persantine BR Plavix BR Pletal

Anaspaz BR Bentyl Cantil BR Detrol/LA BR Ditropan/XL # Enablex Gelnique BR Levbid

Levsin/SL BR Nulev BR Pamine /Forte BR Robinul/Forte # Sanctura/XR Symax Duotab Toviaz Vesicare

BR

Loxitane Orap BR Risperdal Saphris BR Seroquel st Seroquel XR st BR Symbyax # Versacloz BR Zyprexa

MEDICAL (M)

Abilify # Maintena # Adasuve Invega Sustenna Risperdal Consta Zyprexa Relprevv

Trizivir*BR

Videx * BR Videx EC* BR Viramune* Viramune XR* Viread Powder* BR Zerit* BR Ziagen* Ziagen soln*

BR

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

6

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Antitussives & Expectorants

Various generics benzonatate codeine combinations hydrocod combinations acyclovir amantadine ganciclovir rimantadine valacyclovir azathioprine* hydroxychloroquine* leflunomide* methotrexate* sulfasalazine*

None

All brands # Entex (all) BR # Tussionex

famciclovir q Tamiflu

Denavir BR Famvir BR Flumadine Lidovir # Sitavig #+ Actemra SQ BR Arava* #,+ Cimzia #+ Ilaris #,+ Kineret #,+ Orencia # Otezla # Otrexup

Relenza Valcyte BR Valtrex BR Zovirax Zovirax cr # Rasuvo #,+ Remicade Rheumatrex* #+ Rituxan #,+ Simponi Trexall* #+ Xeljanz

alfluzosin doxazosin finasteride tamsulosin terazosin caps acebutolol atenolol betaxolol bisoprolol carvedilol labetalol

None

Avodart Cardura XL # Cialis 2.5 mg # Cialis 5 mg BR Flomax BR Betapace/AF Bystolic BR Coreg Coreg CR BR Corgard Dutoprol BR Inderal LA Innopran XL + Aranesp + Epogen + Leukine + Mozobil

Jalyn BR Proscar Rapaflo BR Uroxatral

Antiviral Agents

Arthritis Agents

Benign Prostatic Hypertrophy (BPH) Agents** (prostate) Beta-Blocking Agents** (blood pressure Lowering, includes HCTZ combination products)

#,+

Enbrel #,+ Humira Ridaura*

metoprolol/XL nadolol pindolol propranolol/LA satolol/AF timolol

None

+

Blood Modifiers

None

Procrit

Botulinum Toxins

None

None

Dysport

Calcium Channel Blocking Agents (CCB)** (blood pressure lowering)

Afeditab amlodipine Cartia XT Dilt-CD Dilt XR Diltzac diltiazem/ER/XT felodipine isradipine

nimodipine nisoldipine

Adalat CC BR Calan/SR Cardene SR BR Cardizem/CD/LA BR Dilacor XR Nimotop

#

Matzim LA Nicardipine Nifediac CC Nifedical XL nifedipine/ER Taztia XT verapamil/ER/PM

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

MEDICAL (M)

q

#+

Actemra IV #+ Benlysta #,+ Orencia IV Simponi #+ Aria

Levatol

Lopressor/HCTBR BR

Sectral BR Tenormin BR Toprol XL BR Trandate BR Zebeta +

Neulasta + Neumega + Neupogen + NPlate + Promacta

#+

#

Granix

#+

Botox #+ Myobloc #+ Xeomin BR

BR

Norvasc Nymalize BR Procardia/XL BR Sular BR Tiazac BR Verelan/PM

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

7

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Cancer Drugs (oral drugs are covered under the chemotherapy benefit and may be subject to a copayment that differs from the pharmacy benefit)

anastrozole* bicalutamide* cyclophosphamide* etoposide flutamide* hydroxyurea* leucovorin mercaptopurine* methotrexate* tamoxifen* tretinoin

Alkeran* + capecitabine Ceenu* Droxia Emcyt exemestane* Fareston* + Gleevec Hexalen letrozole* Leukeran* Lomustine Lysodren Matulane megestrol* Mesnex Nilandron* Tabloid + temozolomide tretinoin oral

Afinitor BR Arimidex* BR Aromasin* + Bosulif Caprelsa BR Casodex* # Cometriq + Erivedge BR Femara* + Gilotrif + Hycamtin BR Hydrea Iclusig # Imbruvica + Inlyta #+ Jakafi BR Megace* Megace ES* + Mekinist Myleran + Nexavar + Pomalyst

Cardiac Glycosides** (heart) CNS Stimulants (ADHD)

digoxin digoxin elixir

None

Lanoxin

Metadate ER 20mg*

Amphetamine combination/XR* clonidine ER* dexmethylphenida te*

Adderall/XR* BR Concerta* Daytrana* BR Dexedrine* BR Focalin/XR* Intuniv* BR Kapvay* Liquadd* BR Metadate CD

dextroamphetam ine* methylphen/ER/CD

modafinil

Compounds

None

None

coverage for compounded medications is subject to criteria listed in the Compounded (extemporaneous) Medications policy

#

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

+

BR

• •

q

BR

Purinethol* # Purixan Soltamox* + Sprycel + Stivarga + Sutent + Synribo + Sylatron + Tafinlar + Tarceva + Targretin + Tasigna + BR Temodar + Torisel #,+ Tykerb + Votrient + Xalkori +BR Xeloda + Zelboraf #,+ Zolinza #,+ Zydeliq #,+ Zykadia

MEDICAL (M)

+

Adcetris # Beleodaq # Clolar # Cyramza Erwinaze #+ Folotyn #+ Fusilev # Gazyva #+ Halaven + Ixempra #+ Kadcyla Kyprolis Marqibo #+ Perjeta + Temodar IV +,# Treanda + Yervoy + Zaltrap

Methylin q Nuvigil q BR Provigil Quillivant XR Ritalin/ LA/SR* BR RitalinLA 10mg cp* Strattera* Vyvanse* # Xyrem

All compounds > $100 require prior authorization All compounds are tier 3

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

8

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Contraceptives (Oral/Topical/ Other)

Altavera* Alyacen* Amethia/Lo* Amethyst* Apri* Aranelle* Aviane* Azurette* Balziva* Briellyn* Camila* Camrese/Lo* Caziant* Cryselle* Cyclafem Dasetta* Elinest* Emoquette* Enpresse* Enskyce* Errin* Falmina* Gianvi* Gildess/Fe* Heather* Introvale* Jencycla* Jolessa* Jolivette* Junel/Fe* Kariva* Kelnor* Kurvelo* Larin Fe* Leena* Lessina* Levonest* levonorgestrel Levora* Loryna* Low-Ogestrel* Lutera* Marlissa* medroxyprogesterone/inj

Cough/Cold Diabetic Agents: Insulin**

Microgestin/Fe* Mono-Linyah* Mononessa* My Way* Myzilra* Necon* Next Choice/ One Step Nora-Be* norelgest-EE* Nortrel* Ocella* Ogestrel* Orsythia* Philith* Pirmella* Portia* Previfem* Quasense* Reclipsen* Solia* Sprintec* Sronyx* Syeda* Tilia Fe* Trinessa* Tri-Legest Fe* Tri-Linyah*

+

Tri-Lo Sprintec* Tri-Previfem* Tri-Sprintec* Trivora* Velivet* Vestura* Vyfemla* Viorele* Wera* Wymzya Fe* Xulane* Zarah* Zenchent/Fe* Zeosa* Zovia*

Various generics None

All brands PA Humalog/Mix Humulin Mix Humulin N/R

Subject to your medical (NY) OR prescription drug (VT) benefit. See your plan materials for applicable deductible, coinsurance and/or copayment. #

Mirena + Skyla

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

MEDICAL (M)

Alesse* Beyaz* BR Brevicon* BR Cyclessa* BR Depo-Provera Depo-SQ Provera BR Desogen* Ella BR Estrostep FE* BR Femcon Fe* Generess Fe* Levlen* Levlite* BR Loestrin/FE* Lo Loestrin FE* # Lomedia 24 FE* Lo Minastrin FE BR LoSeasonique* BR Micronor* Minastrin 24 FE BR Mircette* BR Modicon* Natazia* + Nexplanon BR Norinyl* Nor-QD* BR Nuvaring* BR Ortho Evra* Ortho Novum* Ortho Tri-Cyclen Lo* Ortho Tri-Cyclen* BR BR Ortho-Cept* BR Ortho-Cyclen* BR Ovcon* BR Plan B OneStep Quartette* Safyral* BR Seasonique* BR Tri-Norinyl* BR Yasmin* BR Yaz*

All brands require PA Apidra/Solostar Levemir

Lantus/Solostar Novolin Mix Novolin N/R Novolog/Mix q

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

9

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs. .

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs

The highest copay choice and includes all other covered brand name drugs

Diabetic Agents: Other**

acarbose glimepiride

Glucagen Glucagon Invokana Janumet/XR Januvia Jentadueto pioglitazone pioglitazonemetformin pioglitazone/ glimepiride repaglinide Tradjenta Victoza

Actoplus Met XR BR Actos BR Amaryl NFNC Avandamet NFNC Avandaryl NFNC Avandia Bydureon Byetta # Cycloset BR Diabeta BR Duetact # Farxiga BR Glucophage/XR BR Glucotrol XL BR Glucovance Glumetza

Glyset BR Glynase # Invokamet # Jardiance # Kazano

Pancreaze Pertyze Ultresa

Viokace Zenpep

Subject to your medical (NY) OR prescription drug (VT) benefit. See your plan materials for applicable deductible, coinsurance and/or copayment.

Diabetic Meters & Strips • Subject to your medical (NY) OR prescription drug (VT) benefit. See your plan materials for applicable deductible, coinsurance and/or copayment. • All test strips are subject to quantity limits • Non-preferred test strips require prior authorization

Digestants/ Enzymes**

#

glipizide ER/metformin glyburide glyburide micro glyburide/metformin metformin/ER nateglinide tolazamide tolbutamide

Preferred Meters: Freestyle Freedom/Lite Freestyle Insulinx Freestyle Navigator Freestyle Sidekick One Touch Ultra Brand Meters One Touch Verio Brand Meters

Preferred Strips: Freestyle Freestyle Insulinx Freestyle Lite Precision One Touch Ultra Test Strips One Touch Verio Test Strips

None

Creon pancrelipase

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

MEDICAL (M)

Kombiglyze XR# #

Nesina # Onglyza # Oseni BR Prandin PrandiMet Proglycem BR Precose NFNC Riomet BR Starlix Symlin # Tanzeum Non-preferred test strips require prior authorization

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

10

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Diuretics**

acetazolamide amiloride/HCTZ bumetanide chlorothiazide furosemide hydrochlorothiazide indapamide methazolamide methyclothiazide metolazone spironolactone/HCTZ torsemide triamterene/HCTZ All products not listed in the MVP policy require prior authorization

eplerenone

Aldactone BR Demadex BR Diamox caps Diuril BR Dyazide Dyrenium Edecrin

All products not listed in the MVP policy require prior authorization None

All products not listed in the MVP policy require prior authorization

Enteral Therapy

BR

yohimbine

Fertility Agents

clomiphene

HCG #+ leuprolide + Novarel #+ Follistim AQ

Bravelle #+ Cetrotide #+ Ganirelix #+ Gonal-F # BR+ Lupron SQ

Gaucher’s Disease

None

None

Zavesca

GI: Ulcer/ Heartburn Agents**

cimetidine famotidine q lansoprazole nizatidine

Carafate susp

Aciphex BR Axid BR Carafate tab q,# Dexilant

#

+

omeprazole q pantoprazole ranitidine

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

lanso/amox/clarit q

Nexium omeprazole/ q sod bicarb q rabeprazole sucralfate

BR

Inspra BR Lasix BR Maxzide BR Microzide BR Neptazane Thalitone BR Zaroxolyn

q

Erectile Dysfunction

All products not listed in the MVP policy require prior authorization

q

Caverject q Cialis # Cialis 2.5 mg # Cialis 5 mg q Edex

Levitra q Muse q Staxyn q# Stendra q Viagra

#+

#+

Lutrepulse #+ Menopur + Ovidrel + Pregnyl #+ Repronex

#

#+

Cerezyme #+ Ceredase # Elelyso #+ Vpriv

q,# BR

q#

First-Lansoprazole# First-Omeprazole # Omeclamox BR Pepcid Prevpac

MEDICAL (M)

#

Prevacid Tabs Prevacid Capq,#, BR q,#, BR Prilosec q,#, BR Protonix Pylera BR Tagamet BR Zantac #,q, BR Zegerid

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

11

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

GI: Inflammatory Bowel & Misc.

balsalazide* metoclopramide* misoprostol* sulfasalazine/EN*

budesonide cevimeline cromolyn Delzicol* Kristalose Lialda* mesalamine ursodiol*

Actigall* Amitiza Apriso* Asacol HD* BR Azulfidine/EN* Canasa* Chenodal #,+ Cimzia BR Colazal* BR Cortenema Cortifoam BR Cytotec* Dipentum* BR Entocort EC*

Gout**

allopurinol probenecid/colchicine None

None

Colcrys # Uloric #,+ Genotropin #,+ Humatrope #,+ Increlex #,+ Norditropin

Hormone Replacement Therapy**

estradiol estradiol/norethindrone estradiol patch estropipate Jinteli medroxyprogesterone Mimvey/Lo norethindrone progesterone cr/oral

Estring

Immunoglobulin Therapy Obtain through specialty pharmacy

None

None

Growth Failure Agents

#

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

Nutropin/AQ/ #,+ Nuspin

q

BR

q

BR

Activella Alora Angeliq Cenestin BR Climara Climara Pro Combipatch Crinone Divigel # Duavee Elestrin Gel Endometrin Enjuvia BR Estrace Estrace Vaginal Estrasorb Estrogel Evamist FemHRT # Hizentra

BR

Evoxac Fulyzaq BR Gastrocrom Gattex Giazo* Linzess Lotronex Metozolv ODT* Pentasa* Proctofoam/HC Relistor BR Rowasa* Uceris BR Urso/Forte* Visicol BR Zyloprim

MEDICAL (M)

Entyvio

#

Krystexxa

#+

#,+

Omnitrope #,+ Saizen #,+ Serostim #,+ Tev-Tropin + Zorbtive Femring Menest Menostar Minivelle BR Ogen Osphena Progesterone supp Prefest Premarin Premphase Prempro Prochieve BR Prometrium BR Provera Vagifem Vivelle-Dot

Makena

+

#

Carimune # Flebogamma # Gamastan # Gammagard # Gamunex/C # Iveegam # Octagam # Privigen # Vivaglobin

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

12

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Immunomodulators Immunosuppresants**

None

None

azathioprine

Interferons/ Others for Hepatitis

adefovir dipivoxil + lamivudine #+ Moderiba

cyclosporine/ modified Gengraf Hecoria mycophenolate mycophenolic acid sirolimus tacrolimus entecavir #,+ Pegasys #,+ Ribasphere #,+ ribavirin Viread*

Thalomid + Revlimid Astagraf XL Azasan BR Cellcept BR Imuran BR Myfortic

Intranasal Corticosteroids**

flunisolide fluticasone triamcinolone

Nasonex

Beconase AQ # Dymista # BR Flonase # Omnaris

Lipid/CholesterolLowering Agents**

atorvastatin cholestyramine colestipol fenofibrate fenofibric acid gemfibrozil lovastatin niacinpravastatin Prevalite simvastatin

Crestor fluvastatin niacin ER Zetia

Advicor Altocor Altoprev BR Antara BR Colestid Fenoglide BR Fibricor # Juxtapid #+ Kynamro BR Lescol Lescol XL BR Lipitor Lipofen Liptruzet Livalo BR Lofibra

Migraine Agents

butalbit/apap/caff/cod Migergot supp q naratriptan q zolmitriptan

dihydroergotamine q rizatriptan q sumatriptan

Alsuma # q BR Amerge #,q Axert Cafergot q Cambia BR DHEA-45 Ergomar BR Esgic/Plus BR Fioricet BR Fiorinal #,q Frova # q BR Imitrex

#

+

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

MEDICAL (M)

+

Neoral Nulojix BR Prograf BR Rapamune Sandimmune + Zortress

+ BR

Baraclude #,+ Copegus BR+ Epivir-HBV BR+ Hepsera #,+ Incivek #,+ Infergen + Intron-A #+ Moderiba #

q BR

#,+

Olysio #,+ Peg-Intron #,+ Rebetol #,+, BR Ribatab #+ Ribapak #,+ Sovaldi + Tyzeka #,+ Victrelis Viread Powder* # Qnasl # BR Rhinocort AQ # Veramyst # Zetonna BR

Lopid # BR Lovaza Niacor BR Niaspan BR Pravachol Pravigard PAC Questran/LightBR Simcor BR Tricor Triglide BR TriLipix # Vascepa Vytorin Welchol BR Zocor # q BR

Imitrex Inj Imitrex q # BR Nasal # q BR Maxalt/MLT q Migranal q# Relpax Sumavel #,q DosePro #,q Treximet #,q, BR Zomig/ZMT

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

13

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Miscellaneous Agents (in various classes)

deferoxamine riluzole sevelamer tranexamic acid triamcinolone dental vitamin K inj

aminocaproic acid ammonium Cl cabergoline calcitriol chromic Cl + Cystagon desmopressin doxercalciferol q Epipen K-Phos/No 2 levocarnitine manganese Cl manganese sul + ocetreotide paricalcitrol phytonadione pilocarpine tab Stimate Synarel

Acetic acid Actimmune # Adagen q# Adrenaclick aminocaproic 1gm NFNC Amino-Cerv Aquoral + Alferon N #+ Arcalyst q# Auvi-Q Brisdelle BR Cafcit Cancidas vial # Carbaglu Cleocin Vag Supp Cuprimine* Cuvposa BR DDAVP + Desferal Dificid Eliphos #+ Exjade Ferriprox #+ Firazyr Formaldehyde NFNC Fosrenol* Gelclair # Gralise # Grastek Gynazole-1 BR Hectorol Horizant #+ Kalbitor + Korlym #,+ Kuvan #,+ Ampyra #+ Aubagio + # Betaseron NFNC Amrix BR Dantrium BR Fexmid BR Parafon Forte DSC Lorzone

+

MS Agents

None

Muscle Relaxants

baclofen carisoprodol/cmpd chlorzoxazone

Narcotic Antagonists/ Addiction Treatments Nitrates/Angina Others** (heart)

#

+

methocarbamol

Avonex + Copaxone ,+ Tecfidera carisoprodol cmpd w cod

tizanidine

cyclobenzaprine

meprobamate

dantrolene metaxalone orphenadrine cmp acamprosate buprenorphine buprenorphine/ naloxone

disulfiram naltrexone

nitroglycerin spr

isosorbide dinitrate isosorbide mononitrate nitroglycerin SL nitroglycer patch

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

Nitrostat

q

NFNC

BR

#

Lupaneta Pack BR Lysteda Methyton # Myalept Mycamine vial Nascobal Nebupent # Northera Nuedexta # Oralair Phoslo BR Phoslyra Prepopik # Procysbi # Ragwitek #+ Ravicti NFNC Renacidin Renagel* BR Renvela* # Rezira + Samsca + Sandostatin Savella + Sensipar # Signifor Somatuline Depot+ + Somavert Suclear Suprep # Velphoro + Xenazine BR Zemplar # Zontivity # Zutripro #,+

Extavia #,+ Gilenya +# Rebif BR Robaxin BR Skelaxin BR Soma BR Zanaflex

Antabuse BR Campral BR Revia

Suboxone Film Zubsolv

Dilatrate-SR BR Imdur BR Isordil Titradose Isordil 40mg Minitran

Nitro-Dur BR Nitromist Nitrolingual SprayBR Ranexa Transderm-Nitro

MEDICAL (M)

#+

Aldurazyme + Aralast NP #+ Berinert #,+ Ceprotin #,+ Cinryze #+ Elaprase + Fabrazyme Feraheme + Glassia # Injectafer # Kcentra #+ Lumizyme #+ Myozyme #+ Naglazyme Prolastin-C Sandostatin LAR

+

#,+

Soliris + Supprelin-LA # Sylvant # Vimizim Vivitrol Voraxaze + Xiaflex Zemaira

Tysabri

#,+

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

14

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

NSAIDS** (pain & inflammation, arthritis)

diclofenac/misoprostol etodolac/XL flurbiprofen ibuprofen indomethacin ketoprofen meloxicam

nabumetone naproxen oxaprozin piroxicam salsalate sulindac tolmetin

fenoprofen ketoprofen ER ketorolac meclofenamate mefenamic acid Vimovo

Opthalmic: AntiInfective Agents

bac/neo/polym/HC bacitracin chloramphenicol ciprofloxacin erythromycin gentamicin levofloxacin

Ocudox ofloxacin polym/trimeth sulfacetamide tobramycin trifluridine

Vigamox

Opthalmic: Glaucoma Agents**

apraclonidine betaxolol brimonidine carbachol carteolol dorzolamide latanoprost levobunolol

metipranolol pilocarpine timolol/XE timolol/ dorzolamide

Lumigan Phospholine Iodide

Opthalmic: Steroids, Antiinflammatory & Misc. Agents

azelastine bromfenac cromolyn dexamethasone diclofenac epinastine fluorometholone flurbiprofen naphazoline prednisolone tobramycin/dexameth

Anaprox/DS BR Arthrotec BR Cataflam Celebrex BR Daypro Duexis BR Feldene Indocin BR Mobic Nalfon AzaSite Besivance Bleph-10 Blephamide BR Ciloxan Ciloxan oint Iquix Moxeza Natacyn Alphagan P.1% Azopt BR Betagan Betimol Betoptic-S Combigan BR Cosopt Cosopt PF BR Iopidine BR Acular/LS Acuvail Alocril Alomide Alrex Bepreve Betadine BR Bromday #,+ Cystaran Durezol BR Elestat Emadine Flarex BR FML FML Forte/SOP Ilevro Lastacaft Lotemax Actonel* BR Actonel 150mg* Atelvia* Binosto* BR Boniva Tabs* BR Evista* + Forteo

Osteoporosis/ Paget’s Agents

#

ketorolac Patanol

calcitonin spray*

alendronate* etidronate* ibandronate*

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

Fortical* risedronate 150mg

q

BR

MEDICAL (M)

Naprelan BR Naprosyn Pennsaid BR Ponstel # Sprix Voltaren Gel Voltaren XR Zipsor Zorvolex BR

Ocuflox BR Polytrim BR Tobrex Tobrex oint BR Viroptic Zirgan Zymaxid BR

Isopto Carpine BR Istalol Pilopine-HS Simbrinza BR Timoptic/XE Travatan Z BR Trusopt BR Xalatan Zioptan Maxidex BR Maxitrol BR Mydfrin Nevanac BR Ocufen BR Omnipred BR Optivar Pataday BR Pred Forte Pred Mild Pred-G Prolensa Restasis

+

Eylea Jetrea + Lucentis #+ Retisert

Tobradex Susp BR Tobradex oint Tobradex ST Vexol Zylet BR Fosamax* Fosamax + D* Miacalcin Nasal* BR + Xgeva

Boniva IV + Prolia + Reclast zoledronic + acid

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

15

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Otic Preparations (ear)

acetic acid/ hydrocortisone antipyrine/benzo/glyceri benzocaine carbamide peroxide apap/codeine q butorphanol codeine hydrocodone/apap hydrocodone/ibuprofen hydromorphone levorphanol meperidine morphine IR/rectal oxycodone/APAP oxycodone/aspirin q,st oxycodone/ER oxycodone/ibuprofen pentazocine/naloxone Roxicet tabs tramadol q tramadol ER Trezix Vicodin/ES/HP

None

Cerumenex Cetraxal Ciprodex Cipro HC Coly-Mycin S All brands q,# Abstral q,# BR Actiq q,st, BR Avinza q,st Butrans Capital w codeine Codeine sulf soln q Conzip BR Demerol BR Dilaudid BR Dolophine q,st BR Duragesic q,st Embeda q,st Exalgo q,# Fentora BR Fioricet /w cod BR Fiorinal/w cod Ibudone 5/200 q,st Kadian # Lazanda BR Lortab Magnacet q,st BR MS Contin BR Norco Nucynta

Pain Relievers (narcotic)

Pain Relievers: Miscellaneous** Parkinson’s Agents

Potassium Supplements** Prostate Cancer

#

ciprofloxacin fluocinolone neo/polym/HC ofloxacin

fentanyl q,st patch q,# fentanyl oral methadone morphine ERq,st morphine 24HRq,st oxymorphone/ER

choline mag trisalicylat diflunisal salsalate amantadine* benztropine* bromocriptine* carbidopa* carbidopa/levodopa/ER* entacapone* selegiline* trihexyphenidyl* Various generics

None

None

Lupron Depot

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

carbidopa/ levodopa/ entacapone* pramipexole* ropinirole/XL*

None

q

+

All brands Dolgic Plus Dologesic # Apokyn Azilect* BR Comtan* BR Eldepryl* BR Lodosyn* BR Mirapex* Mirapex ER* Neupro* All brands Kaochlor-Eff K-Tab #+ Xtandi #,+ Zytiga

MEDICAL (M)

Cortisporin-TC Cresylate BR Dermotic Trioxin q

Nucynta ER q,# Onsolis BR Opana q,st Opana ER Oxecta q,st Oxycontin BR Percocet BR Percodan Primlev Reprexain RMS Supp Roxanol BR Roxicodone Roxicet soln Rybix # Subsys Synalgos-DC BR Tylenol w cod Tramadol 150 BR Ultracet q BR Ultram/ER BR Vicoprofen # Xartemis XR # Zohydro ER Zolvit Zydone Frenadol BR

Parcopa* BR Parlodel* BR Requip/XL* BR Sinemet/CR* BR Stalevo* Tasmar* Zelapar*

+

Eligard + Firmagon #+ Jevtana # Provenge + Trelstar + Vantas Viadur # Xofigo + Zoladex

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

16

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Respiratory: Beta Agonists (Oral, Inhaled)

albuterol isoetharine isoproterenol ipratropium/albuterol metaproterenol terbutaline*

levalbuterol Foradil* ProAir HFA Spiriva* Ventolin HFA

Respiratory: Inhaled Corticosteroids**

None

Respiratory: Leukotriene Modifiers** Respiratory: Miscellaneous

montelukast zafirlukast

Asmanex budesonide Dulera Qvar Symbicort None

Accuneb Alupent # Anoro Ellipta Arcapta Brovana* BR Duoneb Perforomist # Advair/HFA # Aerospan # Alvesco Breo Ellipta

RSV Sedative/ Hypnotics (sleep aids)

None chloral hydrate q estazolam q flurazepam hydroxyzine q temazepam

Smoking Cessation Agents Thyroid**

bupropion SR

Topical Antifungals

econazole ketoconazole nystatin

#

aminophylline* ipratropium soln* theophylline* # Veletri

q

triazolam q zaleplon q zolpidem/CR

q

levothyroxine Levoxyl liothyronine methimazole

None q,st Rozerem

None q,st BR Ambien/CR Butisol q Doral q,st Edluar q BR Halcion # Hetlios q Nictrol q BR Zyban Armour ThyroidNFNC BR Cytomel Nature-Throid Synthroid BR Tapazole # Ecoza Ertaczo Exelderm BR Extina BR Loprox BR Lotrisone Naftin

None

ciclopirox olam # ciclopirox soln

q

#,+

Adcirca #,+ Adempas # Cayston Daliresp* #+ Flolan #,+ Kalydeco #,+ Letairis Lufyllin* #+ Orenitram XR

q

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

BR

Accolate BR Singulair

Atrovent HFA* Combivent* cromolyn* Elixophyllin* #+ epoprostenol #+ sildenafil tobramycin #,+ inh

Chantix NP Thyroid propylthiouracil Unithroid

BR

MEDICAL (M)

Proventil/HFA Serevent* Tudorza BR Vospire ER* BR Xopenex Neb Xopenex HFA #

Flovent/HFA Pulmicort Neb BR Pulmicort Inher

Xolair

#,+

Zyflo CR #,+

Opsumit #,+ Pulmozyme #,+ BR Revatio Theo-24* Theo-Dur* #,+ BR TOBI #,+ Tracleer #,+ Tyvaso #,+ Ventavis

#+

Remodulin #,+ Revatio Inj + Veletri

Synagis

#,+

q,st

Intermezzo q,st Lunesta q BR Restoril # Silenor q,st BR Sonata q,st Zolpimist

Thyrolar Tirosint Westhroid WP Thyroid #

Luzu BR Nizoral Oxistat # BR Penlac Vusion Xolegel

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

17

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Topical AntiInfectives

erythromycin gentamicin mupirocin

None

Topical/Oral/ Injectable Antipsoriatic & Antiseborrheic

anthralin selenium sulfide

Topical Miscellaneous

aluminum chloride soln lidocaine Prudoxin

acitretin calcipotriene calcipotriene/ betamethasone calcitrene #,+ Enbrel diclofenac gel imiquimod lidocaine patch urea/lactic ac/ salicylic urea/lactic ac/ zn undecylenat urea/hyaluronic acid

Alcortin A Altabax Bactroban Nasal Centany Cortisporin oint/cr Capitrol BR Dovonex Dritho-Scalp EpiFoam Exsel

Topical Scabicides/ Pediculicides

permethrin spinosad

lindane malathion

Topical Steroids 1 Low Potency 2 Medium Potency 3 High Potency 4 Very High Potency

alclometasone betamethasone 2,4 dip/aug betamethasone 3,4 valerate 4 clobetasol 4 Cormax 1,2 fluocinolone 3 fluocinonide

#

1

2

3

fluticasone

hydrocortisone1 hydrocortisone 2 butyrate hydrocortisone 2 valerate 2 mometasone 2 prednicarbate

triamcinolone2,3

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

amcinonide 1 desonide desoximetasone2,3 3,4 diflorasone fluocinolone oil 4 halobetasol

BR

Aldara Carac Condylox gel BR Condylox soln BR Drysol BR Efudex Elidel NFNC EpiCeram NFNC Flector Iodosorb Kerafoam BR Lidoderm Mirvaso Noritate Picato Podocon-25 # Prothelial Eurax BR Natroba BR Ovide 3

Alphatrex 1 Capex Shampoo 4 BR Clobex 4 Clobex Spray 2 Cloderm 2 Cordran/SP 2 BR Cutivate 2 Cutivate Lotion Derma-Smoothe/FSBR 2 BR Dermatop 1 Desonate 1 BR Desowen 3,4 BR Diprolene/AF 2 BR Elocon 3 Halog

MEDICAL (M)

Klaron PhisoHex

#,+

Remicade BR Soriatane Sorilux BR Taclonex BR Vectical

#,+

Stelara

Protopic Rectiv NFNC Regranex NFNC Santyl BR Solaraze Sulfamylon Umecta/PD # Valchlor Veregen Xerac AC Xerese Zonalon Zyclara

Sklice Ulesfia

Kenalog Spray BR Locoid Locoid Lotion 2 BR Luxiq 4 BR Olux/E 2 Pandel 4 BR Temovate 1 Texacort BR Topicort 4 BR Ultravate Ultravate-X 3 Vanos 1 Verdeso 2 BR Westcort

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

18

DRUG CATEGORY

TIER 1

TIER 2

TIER 3

The lowest copay choice and usually includes generic drugs.

The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

The highest copay choice and includes all other covered brand name drugs

Topical/Oral Acne Products

clindamycin clindamycin/benzoyl peroxide erythromycin metronidazole Sotret sulfacetamide tretinoin

adapalene Amnesteem Claravis Myorisan Nuox Panretin sulfaceta/urea/ sulfur tretinoin micro

Absorica Acanya Aczone Akne-Mycin Atralin Avar/E/LS NFNC Avita Azelex Bensal HP Benzaclin Benzamycinpak Clarifoam EF BR Cleocin-T Clindagel BR Differin Differin Lotion BR Duac Epiduo BR Evoclin

Fabior Finacea BR Klaron Lavoclen BR Metrocream BR Metrogel BR Metrolotion BR Ovace Ovace Plus Pacnex HP/ LP/MX Panretin BR Retin-A BR Retin-A Micro Tazorac Tretin-X BR Vanoxide HC Veltin Ziana

Urinary Tract Agents

methenamine nitrofurantoin trimethoprim

potassium citrate ER

Macrodantin 25mg

Weight Management Agents

benzphetamine diethylpropion phendimetrazine phentermine

None

Elmiron BR Furadantin BR Hiprex BR Macrobid BR Macrodantin # BR Adipex-P # Belviq # BR Bontril-DPM # BR Didrex # Qsymia

MEDICAL (M)

#

Monurol Primsol Prosed-DS Urocit-K # Regimex # Suprenza # Xenical

2015010v1

#

Requires prior authorization *Drug is available through Mail Order if your benefit allows **All drugs in the category are available through MailOrder M Does not require prescription coverage but may be subject to prior authorization or step therapy as indicated

q

Subject to quantity limits Step therapy edits apply (must have failed on a specific drug per policy)

st + BR

Obtain through CVS Caremark Specialty Pharmacy Brand drug that has an FDA approved generic equivalent -Non formulary, not covered-Must be approved by MVP

NFNC

19