Prescription Drug Program Formulary

Prescription Drug Program Formulary Effective October 1, 2015 www.MyAHATPA.com Dear Plan Member: In an effort to continue our commitment to provide...
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Prescription Drug Program Formulary Effective October 1, 2015

www.MyAHATPA.com

Dear Plan Member: In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected drugs that are approved by the U.S. Food and Drug Administration (FDA) and reviewed by our Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. These prescription drugs have been selected for their reported medical effectiveness, safety, and value while providing you with the highest level of coverage under your prescription drug benefits. Our pharmacy benefits manager, FutureScripts®, an independent company, continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as: • prior authorization; • age and gender limits; • quantity limits; • 96-Hour Temporary Supply Program; • coverage for medications not on the formulary. These procedures are designed to optimize your prescription drug benefits by promoting appropriate utilization. They are based on FDA guidelines, and the criteria are endorsed by our Pharmacy and Therapeutics Committee. A detailed description of the procedures that support safe prescribing is included at the end of the formulary list. Please note: Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Brand drugs listed in the formulary with a “3” in the immediate column to the right are available at the highest level of cost-sharing (i.e., the highest cost to you). It is displayed next to the equivalent formulary generic drug that is available at the lowest level of cost-sharing (i.e., the lowest cost to you). For example: amoxicillin is the formulary generic drug available at the lowest level of cost-sharing. Amoxil® is the non-formulary brand available at the highest level of cost-sharing. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary. • Covered generic drugs not listed are formulary and are available at the lowest level of cost-sharing. • Covered brand drugs not listed are non-formulary and are available at the highest level of cost-sharing. Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA), including generic products and those brand products that do not have a generic equivalent are covered without cost-sharing with a doctor’s prescription when provided by a participating retail or mail-order pharmacy. Coverage includes certain products within the following drug categories: (1) aspirin to prevent cardiovascular disease for men age 45-79 and women age 55-79, (2) breast cancer chemotherapy prevention for women, (3) fluoride supplementation for children 6 months thru 6 years, (4) folic acid supplementation for women planning or capable of pregnancy, (5) iron supplementation for children ages 6 to 12 months who are at increased risk for iron deficiency anemia, (6) tobacco interventions for adults who use tobacco products, and (7) vitamin D supplementation for ages 65 and over to prevent falls. Contraceptives, mandated by the Women’s Preventive Services provision of the PPACA, are covered at 100 percent when provided by a participating provider for generic products and for those brand products that do not have a generic equivalent. Brand contraceptive products with a generic equivalent are covered at the brand cost-sharing level for your plan. 1

Dear Physician: This is a listing of formulary drugs to be considered for your patient, a Prescription Drug Program Formulary participant. Please refer to this formulary guide in order to choose a drug. Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does not imply coverage.

This formulary was current at the time of printing and is subject to change. Please understand that this formulary is not intended as a substitute for your independent, professional judgment. Rather, it is offered as a tool to help Plan members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs.

2

1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION GENERIC

Formulary Tier

Generic Available

doxycycline monohydrate flucytosine chloroquine phosphate

1 1 1

Yes Yes Yes

1

Yes

1

Yes

1

Yes

Acticlate Adoxa Ancobon Aralen Atripla Augmentin

Formulary Tier 3 3 3 3 2 3

Augmentin XR

3

Avelox Bactrim, Bactrim DS Baraclude Biaxin Biaxin XL Cedax Ceftin Cipro Cipro oral suspension Cipro XR Cleocin Combivir Complera Cresemba Crixivan Diflucan Doryx EES, Eryped Edurant Emtriva Epivir Epzicom Ery-Tab Erythrocin Factive Famvir Flagyl Flumadine Fuzeon Grifulvin V

3

amoxicillin/clavulanate amoxicillin/clavulanate extendedrelease moxifloxacin hcl

3

sulfamethoxazole/tmp

1

Yes

3 3 3 3 3 3

entecavir clarithromycin clarithromycin SR ceftibuten cefuroxime axetil ciprofloxacin tabs

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

ciprofloxacin ER tabs clindamycin lamivudine/zidovudine

1 1 1

Yes Yes Yes

BRAND

Additional Requirements PA PA

2 3 3 3 2 3 2 3 3 3 2 2 3 2 3 3 3 3 3 3 2 3

PA = Prior authorization must be requested by the physician.

QL, PA fluconazole doxycycline erythromycin ethylsuccinate

1 1 1

Yes Yes Yes

lamivudine

1

Yes

erythromycin delayed release erythromycin stearate

1 1

Yes Yes

PA

PA famciclovir metronidazole rimantadine

1 1 1

Yes Yes Yes

griseofulvin microsize

1

Yes

3

QL = Quantity limits apply.

1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION BRAND Gris-PEG Harvoni Hepsera Hiprex Invirase Isentress Kaletra Keflex Lamisil Tabs Levaquin Lexiva Macrodantin Malarone Mepron Minocin Monodox Moxatag Myambutol Mycobutin Norvir Noxafil Olysio Onmel Oracea Peg-Intron Pegasys Plaquenil Prezista Qualaquin Retrovir Reyataz Ribapak Rifadin Selzentry Sivextro Sovaldi Sporanox Stribild Stromectol

Formulary Tier 3 2 3 3 2 2 2 3 3 3 2 3 3 3 3 3 3 3 3 2 3 3 3 3 2 2 3 2 3 3 2 3 3 2 3 2 3 2 3

PA = Prior authorization must be requested by the physician.

GENERIC griseofulvin ultramicrosize

Formulary Tier 1

Generic Available Yes

Additional Requirements PA

adefovir dipivoxil methenamine hippurate

1 1

Yes Yes

cephalexin terbinafine tabs levofloxacin

1 1 1

Yes Yes Yes

nitrofurantoin macrocrystals atovaquone/proguanil atovaquone minocycline caps doxycycline monohydrate amoxicillin ER ethambutol rifabutin

1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes

PA PA

QL, PA PA PA PA PA PA

doxycycline ir-dr

1

Yes

hydroxychloroquine

1

Yes

quinine sulfate zidovudine

1 1

Yes Yes

PA

moderiba rifampin

1 1

Yes Yes

PA

QL, PA PA itraconazole

1

Yes

ivermectin

1

Yes

4

QL = Quantity limits apply.

1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION BRAND Suprax Susp 100 mg/5 ml, 200 mg/5 ml Sustiva Tamiflu Tindamax Tobi Trizivir Truvada Urelle Uribel Valcyte tab Valtrex Vancocin Vfend Vibramycin Videx EC Viekira Pak Viramune Viramune XR Viread Xifaxan Zerit Ziagen Zithromax Zovirax

Formulary Tier

GENERIC

Formulary Tier

Generic Available

3

cefixime susp 100 mg/5 ml, 200 mg/5 ml

1

Yes

2 2 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 2 2 3 3 3 3

Additional Requirements

QL tinidazole tobramycin abacavir/lamivudine/zidovudine

1 1 1

Yes Yes Yes

Uro-L Uro-MP valganciclovir valacyclovir tab vancomycin voriconazole doxycycline hyclate didanosine

1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes

PA = Prior authorization must be requested by the physician.

PA PA

nevirapine nevirapine XR

1 1

Yes Yes

stavudine abacavir sulfate azithromycin acyclovir amoxicillin ampicillin cefaclor cefaclor ER cefadroxil cefdinir clotrimazole troches dapsone demeclocycline dicloxacillin erythromycin susp w/sulfa isoniazid ketoconazole tabs mebendazole

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

5

QL = Quantity limits apply.

1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION BRAND

Formulary Tier

GENERIC mefloquine minocycline tabs moderiba nystatin ofloxacin penicillin VK primaquine phosphate quinine sulfate tetracycline

PA = Prior authorization must be requested by the physician.

6

Formulary Tier 1 1 1 1 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes Yes Yes Yes Yes

Additional Requirements

PA

PA

QL = Quantity limits apply.

2. CANCER & ORGAN TRANSPLANT DRUGS BRAND Arimidex Aromasin Casodex Cellcept Cytoxan Danocrine Deltasone Emcyt Eulexin Farydak Femara Gilotrif Gleevec Hydrea Ibrance Imbruvica Imuran Lenvima Leukeran Lynparza Lysodren Matulane Megace Myfortic Prograf Protopic Purinethol Rapamune 1mg/ml Sol Rapamune tab Rheumatrex, Trexall tab Sandimmune, Neoral Tabloid Targretin cap Targretin gel Temodar

Formulary Tier 3 3 3 3 3 3 3 2 3 3 3 3 2 3 3 3 3 3 2 3 2 2 3 3 3 3 3

anastrazole exemestane bicalutamide mycophenolate cyclophosphamide danazol prednisone

Formulary Tier 1 1 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes Yes Yes

flutamide

1

Yes

GENERIC

Additional Requirements

PA letrozole

1

Yes PA PA

hydroxyurea

1

Yes PA PA

azathioprine

1

Yes PA PA

megestrol mycophenolic acid tacrolimus tacrolimus mercaptopurine

1 1 1 1 1

Yes Yes Yes Yes Yes

3

sirolimus

1

Yes

3

methotrexate

1

Yes

3

cyclosporine

1

Yes

3 2 2 3

thioguanine

1

Yes

2

PA = Prior authorization must be requested by the physician.

temozolomide

1

7

Yes

PA PA

QL = Quantity limits apply.

2. CANCER & ORGAN TRANSPLANT DRUGS BRAND Valchlor VePesid Xeloda Zydelig Zykadia

Formulary Tier 3 3 3 3 3

GENERIC

Formulary Tier

Generic Available

etoposide capecitabine

1 1

Yes Yes PA PA

leucovorin calcium lomustine megestrol acetate tamoxifen temozolomide

PA = Prior authorization must be requested by the physician.

Additional Requirements PA

8

1 1 1 1 1

Yes Yes Yes Yes Yes

PA

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND Abilify Abilify Discmelt Actiq Adasuve

Formulary Tier 2

GENERIC

Formulary Tier

Generic Available

Additional Requirements

fentanyl citrate OTFC

1

Yes

QL, PA PA

1

Yes

QL

1

Yes

QL

1 1

Yes Yes

QL, PA QL, PA

2 3 3

1

Yes

QL, PA

3 3 3 3 3 3

amphetamine aspartate/ amphetamine sulfate/ dextroamphetamine amphetamine aspartate/ amphetamine sulfate/ dextroamphetamine ER sumatriptan succinate zolpidem tartrate zolpidem tartrate controlled release naratriptan cyclobenzaprine clomipramine HCl flurbiprofen donepezil hydrochloride lorazepam

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

QL, PA

3

morphine sulfate ER

1

Yes

QL

3 2 2 3 3 2 3 3 3 3 3 3 3 2 3 3 3 3

morphine sulfate ER

1

Yes

QL, PA QL

Adderall

3

Adderall XR

3

Alsuma Ambien

3 3

Ambien CR

3

Amerge Amrix Anafranil Ansaid Aricept Ativan Avinza 30mg, 45mg, 60mg, 75mg, 90mg Avinza 120mg Avonex Azilect Belsomra Belviq Betaseron Brintellix Bunavail Buspar Cafergot Campral Cataflam Celexa Celontin Chantix Clinoril Clozaril Comtan

PA = Prior authorization must be requested by the physician.

PA

QL, PA PA QL PA QL, PA buspirone ergotamine tartrate/caffeine acamprosate diclofenac potassium citalopram

1 1 1 1 1

Yes Yes Yes Yes Yes QL

sulindac clozapine entacapone

1 1 1 9

Yes Yes Yes QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND Concerta Contrave ER Conzip Copaxone Cymbalta Dantrium Daypro Demerol Depakene Depakote Depakote ER Depakote Sprinkle Caps Desoxyn Desyrel Diastat Diastat AcuDial Dilantin chewable tablets Dilaudid 1 mg/ ml liquid Dilaudid 2mg Dilaudid 4mg, 8mg Dolobid Dolophine Doral Duragesic 12mcg Duragesic 25mcg, 50mcg, 75mcg, 100mcg Effexor Effexor XR Eldepryl Embeda Esgic Esgic Plus Eskalith Eskalith CR, Lithobid Evekeo

methylphenidate

Formulary Tier 1

Generic Available Yes

duloxetine dantrolene oxaprozin meperidine HCl valproic acid divalproex sodium divalproex sodium ER

1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes

3

divalproex sprinkle cap

1

Yes

3 3 3 3

methamphetamine trazodone diazepam rectal gel diazepam rectal gel

1 1 1 1

Yes Yes Yes Yes

2

phenytoin chewable tablets

1

Yes

3

hydromorphone 1 mg/ml liquid

1

Yes

QL

3

hydromorphone HCl

1

Yes

QL

3

hydromorphone HCl

1

Yes

QL, PA

3 3 3

diflunisal methadone quazepam

1 1 1

Yes Yes Yes

PA QL, PA

3

fentanyl transdermal

1

Yes

QL

3

fentanyl transdermal

1

Yes

QL, PA

3 3 3 3 3 3 3

venlafaxine venlafaxine ER selegiline HCl

1 1 1

Yes Yes Yes

butalbital/apap/caffeine butalbital/apap/caffeine, zebutal lithium carbonate

1 1 1

Yes Yes Yes

3

lithium carbonate SR

1

Yes

Formulary Tier 3 3 3 2 3 3 3 3 3 3 3

GENERIC

Additional Requirements QL PA QL, PA QL

QL

QL

QL, PA

3

PA = Prior authorization must be requested by the physician.

QL, PA 10

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND Evzio Exalgo Exelon Fazaclo Felbatol Feldene Fetzima Fioricet Fioricet with codeine Fiorinal Fiorinal with codeine Focalin Focalin XR Gabitril Geodon Halcion Hetlioz Horizant Hycet Hysingla Ibudone Imitrex Intuniv Kadian 10mg, 20mg, 30mg, 40mg, 50mg Kadian 60mg, 80mg, 100mg Kadian 200mg Kapvay Keppra Keppra XR Khedezla Klonopin Lamictal Lamictal ODT Lamictal XR Lexapro Lodine XL

GENERIC

Formulary Tier

Generic Available

hydromorphone ER rivastigmine clozapine ODT felbamate piroxicam

1 1 1 1 1

Yes Yes Yes Yes Yes

Formulary Tier 3 3 3 3 3 3 3 3

Additional Requirements QL, PA QL, PA

butalbital/apap/caffeine

1

Yes

3

butalbital/apap/caffeine/codeine

1

Yes

3

butalbital/aspirin/caffeine

1

Yes

3

butalbital/aspirin/caffeine/codeine

1

Yes

QL

3 3 3 3 3 3 3 3 3 3 3 3

dexmethylphenidate hcl xr dexmethylphenidate hcl xr tiagabine hcl ziprasidone triazolam

1 1 1 1 1

Yes Yes Yes Yes Yes

QL QL

hydrocodone/apap

1

Yes

ibuprofen/oxycodone HCl sumatriptan guanfacine ER

1 1 1

Yes Yes Yes

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

3

morphine extended release

1

Yes

QL

3

morphine extended release

1

Yes

QL, PA

PA

3 3 3 3 3 3 3 3 3 3 3

PA = Prior authorization must be requested by the physician.

clonidine HCl ER levetiracetam levetiracetam desvenlafaxine ER clonazepam lamotrigine lamotrigine ODT lamotrigine escitalopram etodolac 11

1 1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

QL

QL, PA QL, PA

PA

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND Lodosyn Lortab Loxitane Lunesta Luvox CR Maxalt, Maxalt-MLT Mestinon Metadate CD Methylin Chewable Tabs

Formulary GENERIC Tier 3 carbidopa 3 hydrocodone/acetaminophen elixir 3 loxapine 3 eszopiclone 3 fluvoxamine

Formulary Tier 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes

Additional Requirements QL QL, PA

3

rizatriptan benzoate

1

Yes

QL, PA

3 3

1 1

Yes Yes

QL

1

Yes

QL

1

Yes

1 1 1

Yes Yes Yes

QL, PA

Midrin

3

Migranal Mirapex Mirapex ER MS Contin 15mg, 30mg MS Contin 60mg, 100mg, 200mg MSIR Mysoline Nalfon Namenda Naprelan Naprelan CR Naprosyn Nardil Neurontin Neurontin solution Norpramin Nucynta 50mg, 75mg Nucynta 100mg Nucynta ER 50mg, 100mg Nucynta ER 150mg, 200mg, 250mg Opana 5mg Opana 10mg

3 3 3

pyridostigmine methylphenidate hcl methylphenidate hcl chewable tabs isometheptene/ dichloralphenazone/apap dihydroergotamine pramipexole pramipexole ER

3

morphine sulfate, extended release

1

Yes

QL

3

morphine sulfate, extended release

1

Yes

QL, PA

3 3 3 2 3 3 3 3 3

morphine sulfate primidone fenoprofen calcium

1 1 1

Yes Yes Yes

QL

naproxen sodium SA naproxen sodium CR naproxen phenelzine gabapentin

1 1 1 1 1

Yes Yes Yes Yes Yes

3

gabapentin solution

1

Yes

3

desipramine

1

Yes

3

QL QL, PA QL QL, PA 3 3

PA = Prior authorization must be requested by the physician.

oxymorphone oxymorphone 12

1 1

Yes Yes

QL QL, PA

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND

Formulary Tier

GENERIC

Formulary Tier

Generic Available

Additional Requirements

3

oxymorphone

1

Yes

QL

3

oxymorphone

1

Yes

QL, PA

3

ketoprofen

1

Yes

3

oxycodone ER

1

Yes

QL

3

oxycodone ER

1

Yes

QL, PA

3 3 3 3 3 3 3

oxycodone nortriptyline carbidopa/levodopa ODT bromocriptine mesylate tranycypromine sulfate paroxetine paroxetine HCl ext-release oxycodone/acetaminophen, endocet oxycodone/aspirin phenytoin sodium

1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes

QL

1

Yes

QL, PA

1 1

Yes Yes

QL

Opana ER 5mg, 7.5mg, 10mg, 15mg Opana ER 20mg, 30mg, 40mg Orudis Oxycontin 10mg, 15mg, 20mg Oxycontin 30mg, 40mg, 60mg, 80mg OxyIR Pamelor Parcopa Parlodel Parnate Paxil Paxil CR Percocet, Roxicet Percodan Phenytek Plegridy Prodrin Prostigmin Provigil

3 3 2 3 2 3

Prozac Qudexy XR Razadyne Razadyne ER Regimex Relpax Remeron Remeron SolTab Requip Requip XL Restoril Rilutek Risperdal, Risperdal M-Tab

3

QL isometheptene/APAP/caffeine

1

Yes

modafinil

1

Yes

3

fluoxetine

1

Yes

3 3 3 3 2 3 3 3 3 3 3

topiramate ER galantamine galantamine ER

1 1 1

Yes Yes Yes

mirtazapine mirtazapine rapid dissolve tabs ropinirole ropinirole EL temazepam riluzole

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

3

risperidone

1

Yes

PA QL (Weekly only)

PA QL

PA = Prior authorization must be requested by the physician.

13

QL, PA

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND Ritalin LA Ritalin SR Robaxin Roxicodone 15mg Roxicodone 30mg Rozerem Ryzolt Saphris Saxenda Seroquel Seroquel XR Sinemet Sinemet CR Soma Sonata Stalevo Strattera Suboxone Sublingual Film Sylatron Symbyax Synalgos-DC Tecfidera Tegretol Tegretol XR Tofranil Topamax Topamax Sprinkle Capsules Tranxene T Trezix Trileptal Ultracet Ultram Ultram ER Valium Vicodin ES Vicoprofen

methylphenidate ER methylphenidate SR methocarbamol

Formulary Tier 1 1 1

Generic Available Yes Yes Yes

Additional Requirements QL QL

3

oxycodone

1

Yes

QL

3

oxycodone

1

Yes

QL, PA

Formulary Tier 3 3 3

3 3 3 3 3 2 3 3 3 3 3 2

GENERIC

QL tramadol ER

1

Yes PA PA

quetiapine fumarate

1

Yes

carbidopa/levodopa carbidopa/levodopa CR carisoprodol zaleplon carbidopa/levodopa/entacapone

1 1 1 1 1

Yes Yes Yes Yes Yes

QL, PA QL

1

QL

3 3 3 3 3 3 3 3

PA olanzapine/fluoxetine hcl dihydrocodeine/aspirin/caffeine

1 1

Yes Yes

carbamazepine carbamazepine XR imipramine topiramate

1 1 1 1

Yes Yes Yes Yes

3

topiramate sprinkle cap

1

Yes

3 3 3 3 3 3 3 3 3

clorazepate dipotassium

1

Yes QL

oxcarbazepine tramadol/acetaminophen tramadol tramadol ER diazepam hydrocodone/acetaminophen ES hydrocodone/ibuprofen

PA = Prior authorization must be requested by the physician.

14

1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes

QL QL QL PA QL QL

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND Voltaren XR Vyvanse Wellbutrin Wellbutrin SR Wellbutrin XL Xanax Xanax XR Xartemis XR Xodol, Norco, Maxidone, Lortab, Lorcet, Lorcet Plus, Zydone Zanaflex Zarontin Zenzedi 2mg, 7.5mg, 15mg, 20mg, 30mg Zenzedi 5mg, 10mg Zohydro ER Zoloft Zomig, Zomig ZMT

Formulary Tier 3 2 3 3 3 3 3 3

GENERIC diclofenac sodium

Formulary Tier 1

Generic Available Yes

QL bupropion bupropion SR bupropion XR alprazolam alprazolam ER

1 1 1 1 1

Yes Yes Yes Yes Yes

PA PA QL

3

hydrocodone/acetaminophen

1

Yes

3 3

tizanidine ethosuximide

1 1

Yes Yes

3 3

Additional Requirements

QL

QL dextroamphetamine

1

Yes

3 3

sertraline

1

Yes

3

zolmitriptan

1

Yes

QL QL, PA QL, PA

Zomig Nasal Spray

3

Zonegran

3

Zorvolex

3

PA

Zubsolv Zyban Zyprexa Zyprexa Zydis

3 3 3 3

QL, PA QL

PA = Prior authorization must be requested by the physician.

QL, PA zonsinamide

1

bupropion olanzapine olanzapine ODT acetaminophen/butalbital acetaminophen/codeine acetazolamide amantadine amitriptyline amoxapine aspirin with codeine

15

1 1 1 1 1 1 1 1 1 1

Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

QL

QL

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND

Formulary Tier

GENERIC benztropine buprenorphine buprenorphine hcl/naloxone hcl butorphanol tartrate nasal chlordiazepoxide chlorpromazine HCl choline magnesium trisalicylate clonidine HCL ER codeine tabs, 30mg/5ml solution desvenlafaxine ER diflunisal dihydroergotamine mesylate doxepin duraxin estazolam fentanyl citrate OTFC fluphenazine flurazepam fluvoxamine haloperidol hydromorphone ER ketoprofen ketorolac maprotiline meclofenamate meprobamate methadone migergot modafinil nabumetone nefazodone

PA = Prior authorization must be requested by the physician.

16

Formulary Tier 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Additional Requirements QL, PA QL, PA QL

QL QL, PA QL

QL

QL QL, PA QL

PA

PA PA

QL = Quantity limits apply.

3. PAIN, NERVOUS SYSTEM, & PSYCH BRAND

Formulary Tier

GENERIC oxazepam oxycodone-ibuprofen pentazocine-acetaminophen pentazocine-naloxone perphenazine phenobarbital phenytoin salsalate sulindac thioridazine thiothixene tolmetin sodium trifluoperazine trihexyphenidyl trimipramine vicodin, vicodin es, vicodin hp zgesic

PA = Prior authorization must be requested by the physician.

17

Formulary Tier 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Additional Requirements QL

QL

QL = Quantity limits apply.

4. HEART, BLOOD PRESSURE, & CHOLESTEROL

Accupril Accuretic Aceon Adalat CC Adcirca

3

PA

Adempas

3

PA

Advate Agrylin Aldactazide Aldactone Altace Alphanate Alphanine SD Alprolix Amturnide Antara Arixtra Atacand Atacand HCT Avalide Avapro Azor Bebulin BeneFIX Benicar Benicar HCT Betapace AF Bystolic Caduet Calan Calan SR Cardizem Cardizem CD Cardizem LA Cardizem SR Cardura

2 3 3 3 3 3 2 3 3 3 3 3 3 3 3 2 3 2 2 2 3 2 3 3 3 3 3 3 3 3

PA

GENERIC quinapril HCl quinapril/HCTZ perindopril nifedipine ER

anagrelide spironolactone/HCTZ spironolactone ramipril

Formulary Tier 1 1 1 1

Generic Available Yes Yes Yes Yes

Formulary Tier 3 3 3 3

BRAND

1 1 1 1

Additional Requirements

Yes Yes Yes Yes PA PA PA PA

fenofibrate fondaparinux candesartan candesartan/hydrochlorothiazide irbesartan/hydrochlorothiazide irbesartan

PA = Prior authorization must be requested by the physician.

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

PA PA PA PA PA PA

sotalol HCl

1

Yes

atorvastatin/amlodipine verapamil HCl verapamil HCl ER diltiazem HCl diltiazem HCl CD diltiazem HCl LA diltiazem HCl SR doxazosin mesylate

1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes

18

QL = Quantity limits apply.

4. HEART, BLOOD PRESSURE, & CHOLESTEROL Formulary Tier Cartia XT 1 Catapres tablets 3 Catapres-TTS 3 Colestid 3 Cordarone 3 Coreg 3 Corgard 3 Corifact 3 Corlanor 3 Corzide 3 Coumadin 2 Cozaar 3 Crestor 2 Demadex 3 Diamox 3 Sequels Dilacor XR 3 Dilt-CD 1 Diltzac ER 1 Diovan 3 Diovan HCT 3 Dyazide 3 Edarbi 3 Edarbyclor 3 Edecrin 2 Eloctate 3 Entresto 3 Exforge 3 Exforge HCT 3 Feiba 2 Fibricor 3 Helixate FS 2 Hemofil M 3 Humate-P 2 Hyzaar 3 Imdur 3 Inderal LA 3 Inspra 3 Isordil 3 Titradose Tabs BRAND

PA = Prior authorization must be requested by the physician.

GENERIC diltiazem HCl ER clonidine clonidine patch colestipol HCl amiodarone HCl carvedilol nadolol

Formulary Tier 1 1 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes Yes Yes

Additional Requirements

PA PA nadolol-bendroflume thiazide warfarin losartan

1 1 1

Yes Yes Yes

torsemide

1

Yes

acetazolamide ER

1

Yes

diltiazem HCl ER diltiazem HCl CD diltiazem HCl ER valsartan valsartan/hydrochlorothiazide triamterene/HCTZ

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

PA

PA PA PA PA

amlodipine/valsartan amlodipine/valsartan/HCTZ

1 1

Yes Yes

fenofibric acid

1

Yes

losartan-HCTZ isosorbide mononitrate ER propranolol ER eplerenone

1 1 1 1

Yes Yes Yes Yes

isosorbide dinitrate

1

Yes

19

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

QL = Quantity limits apply.

4. HEART, BLOOD PRESSURE, & CHOLESTEROL Formulary Tier Jantoven 1 Juxtapid 3 Koate-DVI 3 Kogenate FS 2 Kynamro 3 Lanoxin 3 Lasix 3 Lescol 3 Letairis 3 Lipitor 3 Lipofen 3 Liptruzet 2 Livalo 3 Lofibra 3 Lopid 3 Lopressor HCT 3 Lotensin 3 Lotrel 3 Lovaza 3 Lovenox 3 Mavik 3 Maxzide 3 Mevacor 3 Micardis 3 Micardis HCT 3 Microzide 3 Minipress 3 Monoclate-P 3 Mononine 2 Multaq 2 Niaspan 3 Nifedical XL 1 Nitro-Bid 2 Nitro-Dur 3 Nitromist 3 Nitrostat SL 1 Norpace 3 Northera 3 Norvasc 3

Formulary Tier 1

GENERIC

BRAND

warfarin

Generic Available Yes

Additional Requirements PA PA PA PA

digoxin furosemide fluvastatin sodium atorvastatin fenofibrate

1 1 1 1 1

Yes Yes Yes Yes Yes

PA PA

PA fenofibrate gemfibrozil metoprolol tartrate/HCT benazepril amlodipine/benazepril omega-3 acid ethyl esters enoxaparin trandolapril triamterene/HCTZ lovastatin telmisartan telmisartan/hydrochlorothiazide hydrochlorothiazide prazosin

PA = Prior authorization must be requested by the physician.

1 1 1 1 1 1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

PA PA

PA PA niacin ER nifedipine ER

1 1

Yes Yes

nitroglycerin patches nitroglycerin spray nitroglycerin SL disopyramide

1 1 1 1

Yes Yes Yes Yes PA

amlodipine

1

20

Yes

QL = Quantity limits apply.

4. HEART, BLOOD PRESSURE, & CHOLESTEROL Formulary Tier Novoeight 3 Novoseven RT 3 Opsumit 3 Orenitram 3 Pacerone 1 Persantine 3 Plavix 3 Pletal 3 Pravachol 3 Prevalite 1 Prinivil 3 Procardia 3 Procardia XL 3 Procrit 2 Profilnine 3 Questran 3 Questran Light 3 Recombinate 2 Revatio 3 Rixubis 3 Rythmol 3 Rythmol SR 3 Samsca 3 Sectral 3 Sular 3 Tarka 3 Taztia XT 1 Tekamlo 3 Tekturna/ 3 Tekturna HCT Tenex 3 Tenoretic 3 Tenormin 3 Teveten 3 Teveten HCT 3 Tiazac 3 Toprol XL 3 Tracleer 2 Trandate 3 BRAND

PA = Prior authorization must be requested by the physician.

GENERIC

Formulary Tier

Generic Available

amiodarone HCl dipyridamole clopidogrel cilostazol pravastatin cholestyramine light lisinopril nifedipine nifedipine ER

1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Additional Requirements PA PA PA PA

PA cholestyramine cholestyramine light

1 1

Yes Yes

sildenafil citrate

1

Yes

propafenone propafenone SR

1 1

Yes Yes

PA PA PA

PA acebutolol nisoldipine ER trandolapril/verapamil ER diltiazem HCl ER

1 1 1 1

Yes Yes Yes Yes PA PA

guanfacine atenolol/chlorthalidone atenolol eprosartan

1 1 1 1

Yes Yes Yes Yes

diltiazem HCl ER metoprolol succinate

1 1

Yes Yes

labetalol HCl

1

Yes

21

PA PA PA PA

QL = Quantity limits apply.

4. HEART, BLOOD PRESSURE, & CHOLESTEROL BRAND Tretten Tribenzor Tricor Trilipix Twynsta Tyvaso Uniretic Univasc Vascepa Vaseretic Vasotec Vecamyl Ventavis Verelan ER, PM Vytorin Wilate Xarelto Xyntha Zaroxolyn Zebeta Zestoretic Zestril Zetia Ziac Zocor

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

PA = Prior authorization must be requested by the physician.

GENERIC

Formulary Tier

Generic Available

fenofibrate nanocrystallized fenofibric acid telmisartan-amlodipine

1 1 1

Yes Yes Yes

moexipril/HCTZ moexipril

1 1

Yes Yes

enalapril/HCTZ enalapril

1 1

Yes Yes

Additional Requirements PA

PA PA

PA PA verapamil HCl ER

1

Yes PA PA

metolazone bisoprolol lisinopril/HCTZ lisinopril

1 1 1 1

Yes Yes Yes Yes

bisoprolol/HCTZ simvastatin acetazolamide amiloride amiloride/HCTZ aminocaproic acid benazepril/HCTZ betaxolol bumetanide captopril captopril/HCTZ chlorothiazide chlorthalidone digoxin solution felodipine ER

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

22

QL = Quantity limits apply.

4. HEART, BLOOD PRESSURE, & CHOLESTEROL BRAND

Formulary Tier

GENERIC flecainide fosinopril fosinopril/HCTZ hydralazine indapamide isosorbide dinitrate ER isosorbide mononitrate isradipine lisinopril/HCTZ methyldopa metoprolol tartrate mexiletine HCl minoxidil nicardipine nimodipine nitroglycerin ER pentoxifylline ER pindolol ER propranolol/HCTZ propranolol solution sildenafil citrate ticlopidine HCl timolol

PA = Prior authorization must be requested by the physician.

23

Formulary Tier 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Additional Requirements

PA

QL = Quantity limits apply.

5. SKIN MEDICATIONS BRAND Absorica Acanya Aldara Aurstat Avar-E LS Bactroban cream Bactroban ointment Benzaclin Benzamycin gel Carac Carmol scalp lotion Ciclodan 0.77% cream Ciclodan 8% solution Cleocin T Clobex Cloderm Condylox Cosentyx Cutivate Cyclocort Dermatop Differin 0.1% cream, gel Differin 0.3% gel Differin 0.1% lotion Diprolene, Diprolene AF Dovonex cream Drithrocreme HP Duac Efudex cream Elimite Elocon Emla cream Epiduo

isotretinoin

Formulary Tier 1

Generic Available Yes

imiquimod cream MB hydrogel sulfacetamide sodium/sulfur

1 1 1

Yes Yes Yes

3

mupirocin cream

1

Yes

3

mupirocin ointment

1

Yes

3 3 3

clindamycin-benzoyl peroxide gel benzoyl peroxide/erythromycin fluorouracil cream

1 1 1

Yes Yes Yes

3

sulfacetamide sodium/urea lotion

1

Yes

3

ciclopirox 0.77% cream

1

Yes

PA

3

ciclopirox 8% solution

1

Yes

PA

3 3 3 3 3 3 3 3

clindamycin clobetasol propionate clocortolone pivalate podofilox soln

1 1 1 1

Yes Yes Yes Yes

fluticasone propionate amcinonide prednicarbate ointment

1 1 1

Yes Yes Yes

3

adapalene cream, gel

1

Yes

PA

3

adapalene 0.3% gel

1

Yes

PA

3

adapalene 0.1% lotion

1

Yes

3

betamethasone dipropionate

1

Yes

3

calcipotriene cream

1

Yes

3

anthralin

1

Yes

3 3 3 3 3 2

clindamycin/benzoyl peroxide fluorouracil cream permethrin mometasone cream prilocaine/lidocaine

1 1 1 1 1

Yes Yes Yes Yes Yes

Formulary Tier 3 2 3 3 3

GENERIC

PA = Prior authorization must be requested by the physician.

Additional Requirements PA

PA

24

QL = Quantity limits apply.

5. SKIN MEDICATIONS Formulary Tier Erygel 3 Evoclin 3 Jublia 3 Kenalog Spray 3 Keralac 47% 3 cream Kerydin 3 Klaron 3 Lidoderm 3 Locoid 3 Locoid 3 Lipocream

GENERIC

BRAND

erythromycin gel clindamycin phosphate

Formulary Tier 1 1

Generic Available Yes Yes

PA triamcinolone acetonide

1

Yes

urea 47% cream

1

Yes PA

sodium sulfacetamide suspension lidocaine hydrocortisone butyrate 0.1%

1 1 1

Yes Yes Yes

hydrocortisone butyrate/emoll

1

Yes

1

Yes

3 3 3 3 3 3

ciclopirox cream, gel, shampoo, suspension betamethasone/clotrimazole betamethasone valerate metronidazole cream metronidazole topical gel metronidazole lotion spinosad

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

3

ketoconazole shampoo

1

Yes

3 3

sulfacetamide sodium malathion lotion

1 1

Yes Yes

methoxsalen ciclopirox solution

1 1

Yes Yes

tretinoin tretinoin gel silver sulfadiazine acitretin mafenide acetate fluocinolone acetonide cream, soln calcipotriene-betamethasone dp

1 1 1 1 1

Yes Yes Yes Yes Yes

1

Yes

1

Yes

clobetasol cream, ointment, solution

1

Yes

Loprox

3

Lotrisone Luxiq MetroCream Metrogel Metrolotion Natroba Nizoral shampoo Ovace Plus Ovide Oxsoralen lotion 1% Oxsoralen Ultra Penlac Proctofoam HC Retin-A, Avita Retin-A Micro Silvadene Soritane Sulfamylon

3 3 2 3 3 3 3 3

Synalar

3

Taclonex Targretin gel Tazorac

3 2 2

Temovate

3

Additional Requirements

2

PA = Prior authorization must be requested by the physician.

25

PA PA PA

PA PA

QL = Quantity limits apply.

5. SKIN MEDICATIONS BRAND

Formulary Tier

Topicort

3

Vanos Vanoxide-HC Vectical Westcort Xylocaine Zovirax cream Zovirax oint

3 3 3 3 3 2 3

GENERIC desoximetasone cream, gel, ointment fluocinonide benzoyl peroxide/hydrocortisone calcitriol ointment hydrocortisone valerate 0.2% lidocaine solution acyclovir alclometasone cream, ointment benzoyl peroxide gel benzoyl peroxide/urea cream diflorasone diacetate econazole erythromycin solution erythromycin swabs fluocinonide cream, gel, ointment gentamicin topical cream, ointment hydrocortisone 2.5% hydrocortisone/lidocaine HCl ketoconazole cream nystatin/triamcinolone cream, ointment selenium sulfide sodium sulfacetamide/sulfur sulfacetamide sodium triamcinolone cream, ointment urea cream, ointment

PA = Prior authorization must be requested by the physician.

26

Formulary Tier

Generic Available

1

Yes

1 1 1 1 1

Yes Yes Yes Yes Yes

1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes

1

Yes

1 1 1

Yes Yes Yes

1

Yes

1 1 1 1 1

Yes Yes Yes Yes Yes

Additional Requirements

QL = Quantity limits apply.

6. EAR, NOSE, THROAT MEDICATIONS BRAND Astelin Astepro Atrovent nasal spray Bactroban nasal oint Beconase AQ Cetraxal Ciprodex Cortisporin Otic Dermotic Evoxac Flonase Nasacort AQ Nasonex Omnaris Patanase Qnasl Rhinocort AQ Salagen Trioxin Veramyst Vosol HC Zetonna

azelastine azelastine

Formulary Tier 1 1

Generic Available Yes Yes

ipratropium

1

Yes

Formulary Tier 3 3

GENERIC

3

Additional Requirements

2 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

PA ciprofloxacin

1

Yes

neomycin/polymyxin/ hydrocortisone fluocinolone acetonide oil cevimeline hcl fluticasone propionate nasal susp triamcinolone acetonide

1

Yes

1 1 1 1

Yes Yes Yes Yes

olopatadine

1

Yes

budesonide pilocarpine HCl myoxin

1 1 1

Yes Yes Yes

PA PA PA PA PA PA

PA acetasol HC, acetic acid HC otic

1

Yes PA

aero otic HC aurodex otic benzotic, benzocaine/antipyrine cortane B otic drops flunisolide ofloxacin otic oticin otic

PA = Prior authorization must be requested by the physician.

27

1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes

QL = Quantity limits apply.

7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES BRAND Actos Afrezza Amaryl Androderm patch Androgel 1% Packet, Pump Androgel 1.62% Packet, Pump Apidra Solostar Axiron Bd Insulin Syringe MicroFine Breeze 2 Test Strips Bydureon Byetta Contour Next Test Strips Contour Test Strips Cortef Cytomel DDAVP Decadron Diabeta Duetact Farxiga First Testosterone Fortamet Fortesta Freestyle InsuLinx Test Strips Freestyle Lite Test Strips Freestyle Test Strips

Formulary Tier 3 3 3

Formulary Tier 1

GENERIC pioglitazone

Generic Available Yes

PA glimepiride

1

Yes

3 3

Additional Requirements

PA testosterone 1% packet

1

Yes

PA

2

PA

3 2

PA PA

2

QL

2

QL

2 2 2

QL

2

QL

3 3 3 3 3 3 3

hydrocortisone liothyronine desmopressin acetate dexamethasone glyburide pioglitazone/glimepiride

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes PA

3 3 3

PA metformin ER testosterone

1 1

Yes Yes

PA

2

QL

2

QL

2

QL

PA = Prior authorization must be requested by the physician.

28

QL = Quantity limits apply.

7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES BRAND Genotropin Glucophage Glucophage XR Glucotrol Glucotrol XL Glucovance Glumetza ER tablet Glynase Glyxambi Hectorol Humalog Humatrope Humulin Increlex Invokamet Invokana Janumet Janumet XR Januvia Jardiance Jentadueto tablet Kazano tablet Keynote Strips Kombiglyze XR Korlym tablet Lantus Levemir Levoxyl, Synthroid, Unithroid Medrol Micronase Myalept Natesto Natpara Nesina tablet Norditropin

Formulary Tier 3 3

GENERIC

Formulary Tier

Generic Available

metformin

1

Yes

3

metformin ER

1

Yes

3 3 3

glipizide glipizide ER metformin/glyburide

1 1 1

Yes Yes Yes

3 3 3 3 3 3 3 3 2 2 2 2 2 3

Additional Requirements PA

PA glyburide micronized

1

Yes PA

doxercalciferol

1

Yes PA PA PA PA PA PA

PA

3

PA

3 3

PA QL, PA

2 3 3 2

PA PA

3

levothyroxine

1

Yes

3 3 3 3 3 3 2

methylprednisolone glyburide

1 1

Yes Yes

PA = Prior authorization must be requested by the physician.

PA PA PA PA PA 29

QL = Quantity limits apply.

7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES BRAND Novolin Novolog Novolog mix Nutropin AQ Onglyza Oseni Oxandrin Pediapred, Orapred, Orapred ODT Prandin Precision XTRA Test Strips Precose Prelone Rocaltrol capsules Saizen Sensipar Serostim Signifor Starlix Striant buccal system Symlin Tanzeum Tapazole Testim Gel Tradjenta tablet Trulicity Victoza Vogelxo Xigduo XR Zemplar

Formulary Tier

Generic Available

Formulary Tier 2 2 2 3 2 3 3

oxandrolone

1

Yes

3

prednisolone sodium phosphate

1

Yes

3

repaglinide

1

Yes

GENERIC

Additional Requirements

PA PA

2

QL

3 3

acarbose prednisolone syrup

1 1

Yes Yes

3

calcitriol capsules

1

Yes

3 2 3 3 3

PA PA PA nateglinide

1

Yes

3

PA

2 3 3 3 3 3 2 3 3 3

PA PA

PA = Prior authorization must be requested by the physician.

methimazole testosterone

1 1

Yes Yes

testosterone

1

Yes

paricalcitol danazol fludrocortisone acetate propylthiouracil tolbutamide

1 1 1 1 1

Yes Yes Yes Yes Yes

30

PA PA PA PA PA

QL = Quantity limits apply.

8. STOMACH, ULCER, & BOWEL MEDS BRAND Aciphex Aciphex Sprinkle Actigall Analpram E Kit Anusol-HC Azulfidine Bentyl Canasa supp Carafate susp Carafate tabs Cholbam Colazal Colocort Compazine suppository Creon Cytotec Delzicol Dexilant

Formulary Tier 3

Formulary Tier 1

GENERIC rabeprazole

Generic Available Yes

3

QL, PA ursodiol hydrocortisone/pramoxine kit hydrocortisone sulfasalazine dicyclomine

1 1 1 1 1

Yes Yes Yes Yes Yes

sucralfate tabs

1

Yes

3 3 3 3 3 2 2 3 3 3 3

balsalazide hydrocortisone retention enema

1 1

Yes Yes

3

prochlorperazine suppository

1

Yes

misoprostol

1

Yes

PA

2 3 2 3

Donnatal

3

Emend Entocort EC Esomeprazole Strontium FirstLansoprazole FirstOmeprazole Gastrocrom Levsin, Levbid Lialda Lomotil Marinol Metozolv ODT Nexium Nulytely Pentasa Pepcid tabs, suspension

3 3

Additional Requirements QL, PA

QL, PA phenobarb/hyoscyamine/atropine/ scopolamine

1

Yes QL

budesonide

1

Yes

3

QL, PA

3

QL, PA

3

omeprazole suspension

1

Yes

3 3 2 3 3 3 3 3 2

cromolyn sodium solution hyoscyamine

1 1

Yes Yes

diphenoxylate HCl/atropine dronabinol metoclopramide HCl esomeprazole PEG 3350 & electrolytes

1 1 1 1 1

Yes Yes Yes Yes Yes

famotidine 40mg tab, suspension

1

Yes

3

PA = Prior authorization must be requested by the physician.

31

QL, PA

QL, PA

QL = Quantity limits apply.

8. STOMACH, ULCER, & BOWEL MEDS BRAND Phenergan Prevacid, Prevacid SoluTab Prilosec caps Prilosec suspension Proctofoam-HC Protonix Reglan Rowasa Tagamet Tigan Vimovo Zantac Zegerid Zenpep Zofran

Generic Available Yes

Additional Requirements

promethazine

Formulary Tier 1

3

lansoprazole tabs, ODT

1

Yes

QL, PA

3

omeprazole

1

Yes

QL, PA

3

omeprazole suspension

1

Yes

QL, PA

pantoprazole metoclopramide mesalamine rectal susp cimetidine trimethobenzamide

1 1 1 1 1

Yes Yes Yes Yes Yes

QL, PA

Formulary Tier 3

2 3 3 3 3 3 3 3 3 2 3

GENERIC

PA ranitidine 300mg omeprazole-sodium bicarbonate

1 1

Yes Yes

ondansetron HCl chlordiazepoxide/clidinium granisetron lactulose soln nizatidine solution pancrelipase EC/SA prochlorperazine tabs

1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes

PA = Prior authorization must be requested by the physician.

32

QL, PA

QL = Quantity limits apply.

9. BONE, JOINT, & MUSCLE BRAND Actemra SC Actonel 5mg, 30mg, 35mg Actonel 150mg Anaprox Anaprox DS Ansaid Arava Arthrotec Atelvia Binosto Boniva Cataflam Celebrex Colcrys Dantrium Daypro Enbrel Evista Feldene Fexmid Flector Patch Fosamax Fosamax Plus D Humira Kineret

Formulary Tier 3

Formulary Tier

GENERIC

Generic Available

2

QL risedronate naproxen sodium naproxen sodium flurbiprofen leflunomide diclofenac/misoprostol

3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 2 3

Miacalcin

3

Mitigare Mobic Nalfon Naprosyn Orencia Otezla Otrexup Parafon Forte Pennsaid Rasuvo Robaxin Simponi Skelaxin

3 3 3 3 3 3 3 3 3 3 3 3 3

Additional Requirements QL, PA

ibandronate diclofenac potassium celecoxib colchicine dantrolene oxaprozin

1 1 1 1 1 1

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes

QL

QL QL QL PA

PA raloxifene hcl piroxicam cyclobenzaprine alendronate

calcitonin-salmon (rDNA origin) nasal spray colchicine meloxicam fenoprofen calcium naproxen

PA = Prior authorization must be requested by the physician.

1 1 1

Yes Yes Yes

1

Yes

1

Yes

1 1 1 1

Yes Yes Yes Yes

QL, PA QL QL PA PA

PA PA PA chlorzoxazone diclofenac sodium

1 1

Yes Yes

methocarbamol

1

Yes

PA PA PA

metaxalone

1 33

Yes QL = Quantity limits apply.

9. BONE, JOINT, & MUSCLE BRAND Solaraze Soma Viibryd Voltaren Gel Voltaren XR Xeljanz Zanaflex Zipsor Zyloprim

Formulary Tier 3 3 3 3 3 3 3 3 3

PA = Prior authorization must be requested by the physician.

Formulary Tier 1 1

GENERIC diclofenac carisoprodol

Generic Available Yes Yes

Additional Requirements PA PA PA

diclofenac sodium ER

1

Yes PA

tizanidine

1

Yes QL, PA

allopurinol baclofen colchicine/probenecid cyclobenzaprine diflunisal etidronate disodium etodolac ibuprofen indomethacin indomethacin SR ketoprofen ketoprofen SR ketorolac meclofenamate nabumetone naproxen sodium SA orphenadrine ER probenecid sulindac tolmetin

34

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

QL = Quantity limits apply.

10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL The Injectable Fertility Agents in this section are covered only under certain benefits programs. Please check your handbook to determine coverage. Generic Formulary Formulary Additional BRAND GENERIC Available Tier Tier Requirements Yes Aygestin 3 norethindrone acetate 1 Beyaz 2 Bravelle 2 QL Cenestin 2 Yes Cleocin vaginal 3 clindamycin cream 1 Yes Climara patch 3 estradiol transdermal 1 Depo SubqQ 3 QL Provera Depo-Provera 3 medroxyprogesterone QL Yes Desogen 3 apri 1 Yes Diflucan 3 fluconazole 150mg 1 Yes Eemt 3 covaryx/covaryx hs 1 Yes Estrace 3 estradiol 1 Estring 2 norethindrone acetate/ethinyl Yes Estrostep FE 3 1 estradiol/ferrous fumarate Yes Evista 3 raloxifene 1 Yes Femcon FE 3 ethinyl estradiol/norethindrone 1 First progesterone 2 vaginal supps Follistim AQ 2 QL Yes Generess FE 3 noreth-ethinyl estradiol/iron 1 Yes Loseasonique 3 amethia lo/camrese lo 1 Lo Loestrin FE 2 Menopur 2 Metrogel Yes 3 metronidazole vaginal gel 1 vaginal Minastrin 24 2 FE Natazia 2 Nuvaring 2 QL Yes Ogen 3 estropipate 1 Ortho All-flex 3 QL diaphragm Yes Ortho Evra 3 Xulane 1 QL Ortho Yes Micronor/Nor 3 camila 1 QD Yes Ortho Novum 3 necon/cyclafem/alyacen 1 PA = Prior authorization must be requested by the physician.

35

QL = Quantity limits apply.

10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL The Injectable Fertility Agents in this section are covered only under certain benefits programs. Please check your handbook to determine coverage. Generic Formulary Formulary Additional BRAND GENERIC Available Tier Tier Requirements Ortho TriYes 2 tri-lo-sprintec 1 Cyclen Lo Yes Plan B One-Step 3 levonorgestrel/my way/next dose 1 QL Premarin 2 Premarin 2 vaginal cream Premphase 2 Prempro 2 Yes Prometrium 3 progesterone, micronized 1 Yes Provera 3 medroxyprogesterone acetate 1 Yes Seasonique 3 amethia 1 Yes Serophene 3 clomiphene citrate 1 Yes Terazol 3 3 terconazole cream 1 Yes Tri-norinyl 3 aranelle 1 Yes Vandazole 3 metronidazole 1 Yes Vivelle Dot 3 estradiol 1 Yes Yasmin 3 ethinyl estradiol/drospirenone 1 Gianvi, ethinyl estradiol/ Yes YAZ 3 1 drospirenone altavera/portia/levora 28/chateal/ Yes 1 marlissa/kurvelo Yes amethyst 1 Yes aviane 1 Yes desogestrel/ethinyl estradiol 1 esterified estrogens/ Yes 1 methyltestosterone Yes levonorgestrel/ethinyl estradiol 1 Yes lomedia 24 Fe 1 Yes norethindrone 1 Yes norethindrone/ethinyl estradiol 1 norethindrone/ethinyl estradiol, Yes 1 Fe Yes norethindrone/mestranol 1 Yes norgestimate/ethinyl estradiol 1 Yes norgestrel/ethinyl estradiol 1

PA = Prior authorization must be requested by the physician.

36

QL = Quantity limits apply.

11. EYE MEDICATIONS Formulary Tier Acular/Acular LS 3 Alcaine 3 Alphagan P 3 Alrex 2 Azopt 2 Besivance 2 Betagan 3 Betimol 2 Betoptic S 2 Bleph 10 3 Blephamide 2 S.O.P. ointment Ciloxan Sol. 3 Cosopt 3 Cyclogyl 3 Diamox 3 Sequels Elestat 3 Fml 3 Gentak 3 Iopidine 3 Isopto Atropine 3 Isopto 3 Carbachol 3% Isopto Carpine 3 Isopto 3 Homatropine Istalol Drops 2 Lotemax 2 Lumigan 2 BRAND

Maxitrol

3

Mydriacyl Neosporin soln Ocufen Ocuflox Omnipred Optivar Patanol

3 3 3 3 3 3 2

PA = Prior authorization must be requested by the physician.

ketorolac opth soln proparacaine brimonidine tartrate

Formulary Tier 1 1 1

Generic Available Yes Yes Yes

levobunolol

1

Yes

sulfacetamide

1

Yes

ciprofloxacin dorzolamide-timolol cyclopentolate HCl

1 1 1

Yes Yes Yes

acetazolamide ER

1

Yes

epinastine HCl fluorometholone gentamicin ophth apraclonidine atropine sulfate

1 1 1 1 1

Yes Yes Yes Yes Yes

carbachol 3%

1

Yes

pilocarpine

1

Yes

homatropine 5%

1

Yes

1

Yes

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

GENERIC

neomycin/polymyxin B/ dexamethasone tropicamide polymyxin B/neo/gramicidin flurbiprofen ofloxacin prednisolone azelastine HCL drops

37

Additional Requirements

QL = Quantity limits apply.

11. EYE MEDICATIONS BRAND

Formulary Tier

Phospholine Iodide Pilopine HS gel Polysporin Polytrim Pred-Forte Restasis Timoptic Timoptic XE Tobradex Tobrex Travatan Z Trusopt

2 2 3 3 3 3 3 3 3 3 2 3

Vasocidin oint

3

Vexol Vigamox Viroptic Voltaren Xalatan Zioptan Zymaxid

2 2 3 3 3 3 3

GENERIC

Formulary Tier

Generic Available

bacitracin/polymyxin B ophth oint trimethoprim sulfate/polymyxin B prednisolone acetate

1 1 1

Yes Yes Yes

Additional Requirements

QL timolol ophth timolol XE tobramycin-dexamethasone tobramycin

1 1 1 1

Yes Yes Yes Yes

dorzolamide HCl 2% prednisolone/sodium sulfacetamide

1

Yes

1

Yes

trifluridine diclofenac sodium latanoprost

1 1 1

Yes Yes Yes PA

gatifloxacin acetazolamide bacitracin ophth betaxolol carteolol cromolyn ophth

1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes

dexamethasone ophth

1

Yes

erythromycin

1

Yes

methazolamide

1

Yes

polymyxin B/neo/bacitracin

1

Yes

prednisolone sodium phosphate

1

Yes

PA = Prior authorization must be requested by the physician.

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QL = Quantity limits apply.

12. ALLERGY, COUGH & COLD, LUNG MEDS Formulary Tier Accolate 3 Adcirca 3 AdrenaClick 3 Advair Diskus 3 Advair HFA 3 Aerospan 3 Alvesco 3 Anoro Ellipta 3 Arnuity Ellipta 3 Asmanex 2 Astelin Nasal 3 Spray Atrovent HFA 2 Breo Ellipta 3 Bromfed DM 1 Cheratussin AC 1 Cheratussin 1 DAC Clarinex 3 Combivent 2 Respimat Dulera 2 Duoneb 3 Elixophyllin 3 Elixir EpiPen 2 EpiPen Jr. 2 Esbriet 3 Flovent Diskus 3 Flovent HFA 3 Foradil 2 Grastek 3 Guiatuss AC 3 Hydromet 1 Iophen C-NR 1 Obredon 3 Ofev 3 Oralair 3 Proair HFA 2 Proair 2 RespiClick Proventil HFA 3 BRAND

PA = Prior authorization must be requested by the physician.

Formulary Tier 1

GENERIC zafirlukast

Generic Available Yes

Additional Requirements PA PA PA PA PA PA PA PA

azelastine nasal spray

1

Yes PA

desloratadine

1

Yes

ipratropium-albuterol

1

Yes

theophylline elixir

1

Yes

PA PA PA PA guaifenesin/codeine

1

Yes

QL PA PA

PA 39

QL = Quantity limits apply.

12. ALLERGY, COUGH & COLD, LUNG MEDS BRAND

Formulary Tier

Pulmicort Flexhaler Pulmicort Respules Pulmozyme Qvar Ragwitek Serevent Diskus Singulair Spiriva Symbicort Tessalon Perles Theo-24 Theochron Tracleer

3

Tussionex

3

Ventolin HFA Vistaril Vituz VoSpire ER Xopenex Xopenex HFA Xyzal Zutripro

3 3 3 3 3 3 3 3

Formulary Tier

GENERIC

Generic Available

Additional Requirements PA

budesonide

3

1

Yes

2 2 3

PA

2 3 2 2 3 2 1 2

montelukast sodium

1

Yes

benzonatate

1

Yes

theophylline extended release

1

Yes PA

hydrocodone-chlorpheniramine susp

1

Yes

QL PA

hydroxyzine pamoate

1

Yes QL

albuterol sulfate er levalbuterol

1 1

Yes Yes PA

levocetirizine dihydrochloride hydrocod-cpm-pseudoephedrine acetylcysteine albuterol sulfate soln, syrup, tab aminophylline tabs carbinoxamine clemastine cromolyn inhalation soln cyproheptadine flunisolide guaifenesin/hydrocodone guaifenesin/pseudoephedrine/ codeine hydrocodone/homatropine syrup hydroxyzine HCl ipratropium inhalation soln metaproterenol tabs, syrup, inh soln

PA = Prior authorization must be requested by the physician.

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1 1 1 1 1 1 1 1 1 1 1

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

1

Yes

1 1 1

Yes Yes Yes

1

Yes

QL

QL = Quantity limits apply.

12. ALLERGY, COUGH & COLD, LUNG MEDS BRAND

Formulary Tier

GENERIC phenylephrine/cpm/hydrocodone promethazine promethazine/codeine promethazine/dextromethorphan promethazine/phenylephrine promethazine/phenylephrine/ codeine pseudoephedrine/ chlorpheniramine/codeine pseudoephedrine/guaifenesin extended release terbutaline sulfate tabs

PA = Prior authorization must be requested by the physician.

41

Formulary Tier 1 1 1 1 1

Generic Available Yes Yes Yes Yes Yes

1

Yes

1

Yes

1

Yes

1

Yes

Additional Requirements

QL = Quantity limits apply.

13. URINARY & PROSTATE MEDS

Cardura Cialis Detrol Detrol LA Ditropan Ditropan XL Edex Enablex Flomax Levitra Muse Myrbetriq Proscar

Formulary Tier 3 2 3 3 3 3 3 2 3 3 2 2 3

Prosed-DS tab

3

Rapaflo Sanctura XR Staxyn Stendra Urecholine Urocit-K Uroxatral VESIcare Viagra

2 3 3 3 3 3 3 2 3

BRAND

GENERIC doxazosin mesylate

Generic Available Yes

Additional Requirements QL, PA

tolterodine tartrate tolterodine tartrate LA oxybutynin oxybutynin ER

1 1 1 1

Yes Yes Yes Yes QL, PA

tamsulosin

1

Yes QL, PA QL, PA

finasteride methenamine/methylene blue/ benzoic acid/salicylic acid/ atropine

1

Yes

1

Yes

trospium chloride

1

Yes QL, PA QL, PA

bethanechol potassium citrate alfuzosin

1 1 1

Yes Yes Yes QL, PA

flavoxate phenazopyridine terazosin

PA = Prior authorization must be requested by the physician.

Formulary Tier 1

42

1 1 1

Yes Yes Yes

QL = Quantity limits apply.

14. VITAMINS & ELECTROLYTES BRAND Calciferol Icar K-Tab Klor-Con Mephyton Tri-Vi-Flor, Poly-Vi-Flor with and without iron

Formulary Tier 3 3 3 1 2 3

ergocalciferol iron, carbonyl 15mg potassium chloride potassium chloride

Formulary Tier 1 1 1 1

Generic Available Yes Yes Yes Yes

multivitamin with fluoride drops, tabs

1

Yes

fluoride

1

Yes

Multigen

1

Yes

Multigen plus potassium bicarbonate/potassium citrate effervescent sodium fluoride drops

1

Yes

1

Yes

1

Yes

GENERIC

PA = Prior authorization must be requested by the physician.

43

Additional Requirements

QL = Quantity limits apply.

15. DIAGNOSTICS & MISCELLANEOUS AGENTS BRAND Cerdelga Chemet Jadenu Novarel PhosLo Pregnyl Proamatine Renvela Repronex Zavesca

Formulary Tier 3 2 3 3 3 3 3 3 3 2

PA = Prior authorization must be requested by the physician.

Formulary Tier

GENERIC

chorionic gonadotropin calcium acetate chorionic gonadotropin midodrine HCl sevelamer carbonate

1 1 1 1 1

Generic Available

Yes Yes Yes Yes Yes

Additional Requirements PA PA PA PA

QL PA

44

QL = Quantity limits apply.

PROCEDURES THAT SUPPORT SAFE PRESCRIBING AmeriHealth Administrators utilizes an independent pharmacy benefits management (PBM) company, FutureScripts, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers. Prior authorization Prior authorization is a requirement that your physician obtain approval from your health plan for coverage of, or payment for, prescription drugs. AmeriHealth Administrators requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to FDA guidelines. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized. Without prior authorization, the member’s prescription will not be covered at the retail or mail-order pharmacy. The prior authorization process may take up to two business days once complete information from the prescribing physician has been received. Incomplete information will result in a delayed decision. Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue.

45

Prior authorization applies to all formulations of specific drugs, including but not limited to, tablet, capsule, and oral suspension.* Absorica™ Abstral® Aciphex® Actemra® SC Acticlate™ Actiq® Adasuve® Adcirca™ Adempas® Adipex-P® Adoxa® Adrenaclick® Advair® Advate® Aerospan™ Afrezza® Afinitor® Alodox® Alphanate® Alphanine® SD Alprolix™ Alsuma® Altabax™ Alvesco® Ambien® Ambien CR® Amerge® Ampyra™ Amturnide™ Androderm® Androgel® Anoro™Ellipta™ Apidra® Apidra® SoloSTAR® Arnuity Ellipta® Atacand® (HCT) Ativan® Aubagio® Auvi-Q® Avapro®/Avalide® Avidoxy™ Avinza® 120mg Avita® Axert® Axiron® Bebulin® Beconase AQ® Belsomra® Belviq® BeneFIX® Bosulif® Breo™ Ellipta™

Brintellix® Bunavail™ buprenorphine buprenorphine/naloxone Caprelsa® Carbaglu® Caverject® Cayston™ Celebrex® Cerdelga™ Cholbam® Cialis® Ciclodan® Cimzia® clonidine HCl ER Cometriq™ Contrave ER® Conzip™ Copegus® Corifact® Corlanor® Cosentyx™ Cozaar®/Hyzaar® Cresemba® Cystaran™ Daytrana™ Dexilant™ Diabetic test strips* diclofenac gel Differin® Cream/Gel Dilaudid® 4mg, 8mg Diovan® (HCT) Dolophine® Doral® Doryx® DR Duragesic® 25mcg, 50mcg, 75mcg, 100mcg Edarbi™ Edarbyclor™ Edex® Edluar™ Eloctate™ Embeda® Enbrel® Entresto™ Erivedge™ Esbriet® esomeprazole eszopiclone 3mg Evekeo™ Evzio™ Exalgo™

Exforge® (HCT) Exjade® Extavia® Factive® Fanapt™ Farxiga™ Farydak® Feiba® fentanyl citrate-OTFC fentanyl transdermal 25mcg, 37.5 mcg, 50mcg, 62.5 mcg, 75mcg, 87.5 mcg, 100mcg Fentora® Ferriprox® Fetzima™ Firazyr® First Testosterone® First® Lansoprazole First® Omeprazole Flector® patch Flonase® Flovent® Forteo™ Fortesta™ Frova® Fulyzaq™ Gattex® Genotropin® Gilenya® Gilotrif™ Gleevec® Glumetza™ Glyxambi® Gralise™ Grastek® guanfacine ER Halcion® Harvoni™ Helixate® FS Hemofil® M Hetlioz™ Horizant™ Humalog® Humate-P® Humatrope® Humira® Humulin® HYCAMTIN® capsules hydromorphone 4mg, 8mg hydromorphone ER 46

Hysingla™ Ibrance® Iclusig™ Imbruvica™ Imitrex® Increlex® Inderal® LA Inlynta® Intermezzo® Intuniv™ Invega™ Invokamet™ Invokana™ Jadenu™ Jakafi™ Jardiance® Jentadueto™ Jublia® Juxtapid™ Kadian® 60mg, 80mg, 100mg, 200mg Kalydeco™ Kapvay® Kazano® Kerydin™ Khedezla® Kineret® Koate®-DVI Kogenate® FS Korlym™ Kynamro® Lantus® Latuda® Lazanda® Lenvima™ Letairis® Levitra® Lipitor® Livalo® Lunesta® Lynparza™ Lyrica® Maxalt® (MLT) Mekinist® methadone Micardis® (HCT) Migranal® Minocin® modafinil moderiba Monoclate-P® Monodox®

Mononine® morphine sulfate 30mg IR morphine sulfate ER 60mg, 80mg, 100mg, 120mg, 200mg MS Contin® 60mg, 100mg, 200mg MUSE® Myalept™ Nasacort® AQ Nasonex® Natesto™ Natpara® Nesina® Nexavar® Nexium® Norditropin® Northera™ Novarel® Novoeight® Novoseven® RT Noxafil® Nucynta ER® 150mg, 200mg, 250mg Nucynta® 100mg Nuedexta™ Nutropin® (AQ) Nuvigil® Ofev® Olysio™ Omnaris® Omnitrope® Onmel™ Opana® 10mg Opana ER® 20mg, 30mg, 40mg Opsumit® Oracea® Oralair® Orencia® SQ Orenitram™ Oseni® Otezla™ Otrexup™ oxycodone ER 30mg, 40mg, 60mg, 80mg oxycodone IR 30mg

Oxycontin 30mg, 40mg, 60mg, 80mg oxymorphone 10mg Peg-Intron® Pegasys® (ProClick) Penlac® Percocet® Picato® Pomalyst® Pregnyl® Prevacid® Prilosec® Pristiq™ Procysbi® Profilnine® Protonix® Proventil® HFA Provigil® Pulmicort Flexhaler® Qnasl™ Qualaquin® quinine sulfate Qysmia™ Ragwitek™ Rasuvo™ Ravicti™ Rebetol® Rebif® Recombinate™ Regimex® ReliOn® Rescula® Restoril® Retin-A® (Micro) Revatio™ Revlimid® Rhinocort Aqua® RibaPak® Ribasphere® RibaTab® Rixubis™ Roxicodone 30mg Saizen® Samsca™ Saphris® Saxenda® Serostim® Signifor®

sildenafil Silenor® Simponi™ Sirturo™ Sivextro™ Solaraze® Gel Solodyn® Sonata® Sovaldi™ Sprycel® Staxyn™ Stendra™ Stivarga® Striant® Subsys® Sumavel™ Suprenza ODT™ Sutent® Sylatron™ Symlin® Synagis® Taclonex® Taclonex Scalp® Suspension Tafinlar® Tanzeum™ Tarceva® Targretin® Gel Tasigna® Tekamlo™ Tekturna® (HCT) Temodar® Oral temozolomide Tenoretic® Tenormin® Testim® testosterone gel Tev-Tropin® Teveten® (HCT) Thalomid® Toviaz™ Tradjenta™ Tretten® Treximet™ Twynsta® Tykerb® Tyvaso® Valchlor™

Valium® Vecamyl™ Ventavis® Ventolin® HFA Veramyst™ Viagra® Vibramycin® Viekira Pak™ Viibryd® Vimovo® Vimpat™ Vogelxo® Voltaren® Gel Votrient™ Wellbutrin® XL Wilate® Xalkori® Xanax® Xeljanz® Xenazine™ Xenical® Xigduo XR™ Xolair® Xopenex HFA® Xtandi® Xyntha® Xyrem® Zavesca® Zegerid® Zelboraf® Zetonna™ Zioptan™ Zipsor™ Zmax™ Zohydro™ ER Zolinza® Zolpidem 10mg Zolpidem CR 12.5mg Zolpimist™ Zomig® (ZMT) Zorbtive™ Zorvolex® Zubsolv® Zydelig® Zykadia™ Zytiga™ Zyvox®

* All diabetic test strips require prior authorization except for the following: Breeze® 2, Contour®, Contour® Next, Freestyle®, Freestyle InsuLinx®, Freestyle Lite®, and Precision XTRA® * Compound products containing any prescription bulk chemical * Compound products with total ingredient cost equal to or greater than $75 per prescription 47

Age and gender limits The FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and to ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals age 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request consideration for preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the Pharmacy and Therapeutics Committee. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7013. Quantity limits Quantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity limits that are explained in detail below. • Rolling 30-day period  This quantity limit is based on dosing guidelines over a rolling 30-day period. For example, if a member went to the pharmacy on January 1, 2015, for one of these medications, the computer system would have looked back 30 days to December 1, 2014, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling. Examples of quantity limits per rolling 30-day period are: ◦ Emend® (four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule, two 80mg capsules]); Boniva® (one 150mg tablet); Avonex® (one kit, four injections); Copaxone® (30 vials); Fosamax Plus DTM (four tablets); and Rebif® (12 injections); ◦ migraine drugs, such as Amerge® (nine 2.5mg tablets), Imitrex® (18 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), and Zomig® (nine 5mg tablets); ◦ sedative hypnotic drugs, such as Sonata® (30 capsules) and Ambien® (30 tablets); ◦ oral narcotic drugs, such as OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units). • Refill too soon  With this quantity limit, if a member used less than 75 percent of the total day supply dispensed, the claim will be rejected at the pharmacy. This will ensure that the drug is being taken in accordance with the prescribed dose and frequency of administration. • Therapeutic drug class  This quantity limit applies to some classes of drugs, such as narcotics (i.e., short-acting and long-acting). If a member uses more than one drug within the same class, he or she may be unsafely duplicating drugs and would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month. If a physician requires that a member uses a drug therapy that exceeds any of the quantity limits described above, the physician must request consideration for a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override.

48

Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue. To determine if a covered prescription drug prescribed for you has a quantity limit, call FutureScripts at 1-888-678-7013. 96-Hour Temporary Supply Program The 96-Hour Temporary Supply Program applies to the following covered drugs: • most drugs that require prior authorization; • drugs that are subject to age limits (pre-approval required for ages outside of recommended ranges); • migraine drugs with quantity limits, such as Amerge®, Imitrex®, Maxalt®, Migranal®, and Zomig® (preapproval of quantity override required for amounts over the quantity limits). Under the 96-Hour Temporary Supply Program, if a member’s physician writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity limit for a medication, and prior authorization has not been obtained by the physician, the following steps will occur: 1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the member with no out-of-pocket cost-sharing (i.e., no cost to the member) at that time.* 2. By the next business day, FutureScripts will contact the member’s physician to request that he or she submit the necessary documentation of medical necessity or medical appropriateness for review. 3. Once the completed medical documentation is received by FutureScripts, the review will be completed, and the medication will be approved or denied. 4. If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied.* 5. If denied, notification will be sent to both the physician and the member. Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some drugs are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations such as Retin-A® (tube), Enbrel® (two-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible under the 96-Hour Temporary Supply Program.

*Members with an integrated drug benefit (e.g., Comprehensive Major Medical and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if approved) at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.

49

The process for requesting a prior authorization/preapproval or override is as follows: • The physician prescribing the drug completes a prior authorization form or writes a letter of medical necessity and submits it to FutureScripts by fax at 1-888-671-5285. The forms are available online at: www.futurescripts.com/for_health_care_professionals/prior_authorization. The form must be completed and submitted by the physician, not the member. • FutureScripts will review the prior authorization request or letter of medical necessity. If a clinical pharmacist cannot approve the request based on established criteria, a medical director will review the document. • A decision is made regarding the request. • If approved, the prescribing physician will be notified of approval via fax or telephone, and the claims system will be coded with the approval. The member may call the Customer Service phone number on his or her ID card to determine if the prescription is approved. • If denied, the prescribing physician will be notified via letter, fax, or telephone. The member is also notified of all denied requests via letter. The appeals process will be detailed within the denial letters sent to the member and physician. Coverage for drugs not on the formulary (specific to Select Drug Program members only) Providers may request consideration for formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form, providing detail to support use of the covered non-formulary medication, and fax the request to 1-888-671-5285. If the non-formulary exception request is approved, the drug will be paid at the appropriate formulary level of cost-sharing. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether an appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate non-formulary level of cost-sharing. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs. Appealing a decision If a request for prior authorization/preapproval or exception results in a denial, the member, or physician on the member’s behalf, may file an appeal. Both the member and his or her physician will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeals process to provide the required medical information for the basis of the appeal. Prescription drug program provider payment information FutureScripts administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. FutureScripts also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. AmeriHealth Administrators anticipates that it will pass along a high percentage of the expected rebates it receives from FutureScripts through reductions in the overall cost of pharmacy benefits. Under most benefits plans, prescription drugs are subject to a member cost-sharing.

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FutureScripts provides pharmacy benefit management services for AmeriHealth Administrators. ©2015 AmeriHealth Administrators, Inc. All rights reserved. No part of this publication may be reproduced or distributed without the prior written permission of AmeriHealth Administrators. 10/15 AHAwPA