Denver Health Medical Plan 2017 Commercial Deductible Enhanced Formulary & Pharmaceutical Management Procedures

Transcription

1 Denver Health Medical Plan 207 Commercial Deductible Enhanced & Pharmaceutical Management Procedures What is the Denver Health Medical Plan (DHMP) Commercial Deductible Enhanced? The DHMP Commercial Deductible Enhanced is a tool to help providers choose safe and effective drugs. If you are a member and have questions please refer to your Member Handbook or call Member Services at DPS (4377) or TTY/TDD users should call 7. The formulary is a closed formulary which means only those drugs listed are covered under the pharmacy benefit. All drugs require a prescription written by a provider to be covered by the pharmacy benefit. How are formulary drugs selected? The drugs are selected by a group doctors and pharmacists known as the Pharmacy and Therapeutics Committee. This committee meets regularly to review and select drugs for our members. During a review, the committee may look at the following for each drug: U.S. Food and Drug Administration (FDA) approval Safety and effectiveness Comparison studies Approved indications Adverse effects Contraindications, warnings and precautions Pharmacokinetics Patient compliance considerations Medical outcome and pharmacoeconomic studies Does the formulary ever change? Changes are made throughout the year. The latest version of the formulary may be viewed online. Provider Website o Member Website o Members and providers may also request a printed copy of the formulary by calling Member Services.

2 What if the pharmacy tells me the drug is not covered? The pharmacy may receive a rejection message that says a Prior Authorization Request (PAR)/exception request is needed to have the drug covered. The pharmacy may contact the provider to have the prescription changed to a formulary alternative, which is also known as a therapeutic substitution. The pharmacy may also request the provider send a completed PAR form to the DHMP Pharmacy Department. Clinical information showing why the requested drug is needed is required on the PAR. What if the drug prescribed is not on the formulary? If the drug is not listed there may be a generic or a formulary approved drug which can be prescribed. If the provider gives a member drug samples to start treatment, the member must find out if the medication is on the formulary or requires PAR approval first. If the samples are taken by the member before asking DHMP to pay for the drug first, it does not mean that DHMP will pay for that drug. Providers may submit a PAR by calling the DHMP Pharmacy Department at or Providers may also send completed PARs by fax to or ManagedCarePAR@dhha.org. If the PAR for a non-formulary drug is approved, then the cost will be a Tier 3 (non-preferred brand-name) copay as shown in the Member Handbook. How are PARs (also called an exception request) processed? The DHMP Pharmacy Department reviews all PARs/exception requests on a case-bycase basis. Decisions are made using certain criteria and guidelines. Drugs listed on the formulary with a Prior Authorization (PA) or Step Therapy (ST) requirement have criteria available on the plan website. If the drug is non-formulary, all reasonable formulary drugs to treat the same condition must be tried first. Generic non-formulary drugs are preferred over brand non-formulary drugs. Other resources may also be used to make a decision, such as guidelines found on the National Guideline Clearinghouse website at The member or provider may request a copy of the criteria or guidelines used for their submitted exception request. After a PAR is submitted, the member and provider will be notified of the decision. An expedited or quicker review for urgent situations may be requested. If you have questions about this process please call the DHMP Pharmacy Department at or For emergent after hour requests, please contact the MedImpact Help Desk at What happens if a request is denied? If a request is denied, the member and provider will receive a letter that will include information about the member s rights and the appeals process. The Member Handbook gives more details about this process. Please refer to the Member Handbook, or call Member Services if you have any questions.

3 What if the member is new to the plan and the drug is not on the formulary? If the member is new to the plan they may be eligible for a transition supply. This may be done for medications that are not on the formulary or if the prescription is for a quantity more than what the formulary allows to be filled. This allows the provider time to prescribe a formulary drug or submit a PAR. What are generic drugs? Generic drugs are FDA-approved for safety and effectiveness. The color and shape may be different from the brand-name drug, but they are made using the same strict FDA standards as brand-name drugs. If a brand-name drug is requested by the member or provider when a generic is available the member must pay the copay (after the deductible has been met) plus the difference in cost unless an exception request is approved. What is generic substitution? Generic substitution is when a generic version of a drug is dispensed in place of a brand-name drug. In most cases generic drugs are preferred on the formulary. When are prescriptions eligible to be refilled? Most prescriptions are eligible for refill once 75% has been used. This is calculated using the original prescription directions. If there is a change in the prescription directions, the pharmacy or provider should be contacted for an updated prescription. Are prescriptions eligible through mail order? Members may get prescriptions through Denver Health Pharmacy by Mail if their prescriptions are written by a Denver Health provider. This service allows a 90 day supply of certain prescriptions to be delivered to the member. Prescriptions must be written for a 90 day supply of drug. Denver Health Pharmacy by Mail Members also have the option to obtain mail order prescriptions through MedVantx. Prescriptions filled by MedVantx will have a higher copay than prescriptions filled by the Denver Health Pharmacy by Mail. However, MedVantx is the only mail order option if the prescriptions are written by providers outside of Denver Health. MedVantx What if my drug is a specialty drug? Some drugs are known as Specialty drugs. Most specialty drugs can only be filled as 30-day supplies. Some specialty drugs can only be filled at specialty pharmacies chosen by DHMP.

4 Are there drugs that are excluded by the pharmacy benefit? Some drugs are not covered at all. These include drugs for the following: Cosmetic use (anti-wrinkle, hair removal, and hair growth products) Dietary supplements Blood or blood plasma (except anti-hemophilic factor VIII & IX are covered) Infertility Over-the-counter drugs (except those listed on the formulary) Pigmenting / De-pigmenting Therapeutic devices or appliances (except for formulary diabetic monitoring supplies) Investigational or experimental treatments Who should be contacted with questions? The member or provider may contact the DHMP Pharmacy Department with any questions about the formulary or pharmacy benefits by calling or , or by at ManagedCarePAR@dhha.org. Member Services may also be contacted. How to use the formulary The formulary is grouped by drug class or disease state sections. Generic drugs are listed by generic name, and brand names are included as a reference. Brand drugs are listed only with brand names. For most drugs all dosage forms and strengths of the brand-name drug listed are covered by the pharmacy benefit. When a strength or dosage form is listed specifically, only that strength or dosage form is included on the formulary. Other strengths and dosage forms of the reference product are not included on the formulary. Modified-release or combination products included on the formulary are defined by the listed brand-name product. Modified-release and combination products are only covered if they are on their own line and are not included if only the immediate-release drug is listed. 4 Tier Tier : Preferred generic drugs Tier 2: Generics and preferred brand-name drugs Tier 3: Non-preferred brand-name drugs and preferred specialty drugs to be filled at the preferred specialty pharmacies chosen by the plan. Tier 4: Specialty drugs to be filled at the preferred specialty pharmacies chosen by the plan. Copay: A dollar amount that a member is required to pay. The copay cost will never be higher than the dollar amount listed for that tier in the Member Handbook.

5 Deductible: A total dollar amount that must be paid by the member before the plan will cover a portion of the costs. The plan-specific deductible must be paid before the copay or coinsurance percentage applies, as listed for that tier in the Member Handbook. Please refer to the Member Handbook for the deductible amount. Preventive Drugs (available for $0 copay) Preventive drugs are available for $0 copay when filled with a prescription. These drugs are identified in the formulary on the tier. Notice The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of Denver Health Medical Plan, Inc. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with Denver Health Medical Plan, Inc. Please be advised that this formulary is updated periodically. managed by: Denver Health Medical Plan, Inc. 777 Bannock Street, Mail Code 6000 Denver, CO Phone: ManagedCarePAR@dhha.org Abbreviations ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions Preventive Medication This drug is available at a $0 copay. PA QL ST Prior Authorization Restriction Quantity Limit Restriction Step Therapy Restriction The member or provider is required to get prior authorization from DHMP before this drug may be filled. Without prior approval, DHMP may not cover this drug. DHMP limits the amount of this drug that is covered per prescription, or within a specific time frame. Before DHMP will provide coverage for this drug, the member must first try another drug(s) to treat their medical condition. This drug may only be covered if the other drug(s) does not work.

6 Strength and Dosage Form Abbreviations ABBREVIATION DESCRIPTION aer pow aerosol, powder aer pow ba aerosol powder, breath activated ampul ampule cap er 2h capsule, 2 hour extended release cap er 24h capsule, 24 hour extended release cap er deg capsule, extended release degradable cap sprink capsule, sprinkle capsule dr capsule, delayed release capsule er capsule, extended release cpmp 2hr capsule, 2 hour multiphasic cream(g), cream(gm) cream (grams) cream/appl cream with applicator disp syrin disposable syringe drops susp drops, suspension g gram gel (gm) gel (grams) jel jelly jel/pf app jelly with pre-filled applicator mcg microgram milligram ml milliliter oral conc oral concentrate oral susp oral suspension paste (g) paste (grams) patch td24 24 hour transdermal patch pen injctr pen injector powd pack powder pack spray/pump spray with pump supp.rect suppository, rectal susp recon suspension, reconstituted tab chew tablet, chewable tab er 2h tablet, 2 hour extended release tab er 24h tablet, 24 hour extended release tab er prt tablet, extended release particles tab er 24 tablet, 24 hour extended release tab mphase tablet, multiphasic tab rapdis tablet, rapid disintegrating tab subl tablet, sublingual tab.sr 24h tablet, 24 hour sustained release tablet dr tablet, delayed release tablet, er tablet, extended release

7 Table of Contents Analgesics... 3 Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 6 Antianxiety Agents... 7 Antibacterials... 8 Anticancer Agents... Anticholinergic Agents... 2 Anticonvulsants... 2 Antidementia Agents... 3 Antidepressants... 4 Antidiabetic Agents... 5 Antifungals... 8 Antihistamines... 9 Anti-Infectives (Skin And Mucous Membrane)... 9 Antimigraine Agents... 9 Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents... 2 Antipsychotic Agents... 2 Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products... 4 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

8 Dental And Oral Agents... 4 Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents... 6 Hormonal Agents, Stimulant/Replacement/Modifying... 6 Immunological Agents Inflammatory Bowel Disease Agents... 7 Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

9 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20- (Acetaminophen With AGE (Min 6 Years) 2 /5 ml Codeine) acetaminophen-codeine oral tablet 300-5, , (Tylenol-Codeine No.3) QL (400 per 30 days); AGE (Min 6 Years) butalbital-acetaminophen-caff oral (Fioricet) QL (80 per 30 days) capsule butalbital-acetaminophen-caff oral tablet (Fioricet) QL (80 per 30 days) butalbital-aspirin-caffeine oral capsule (Fiorinal) QL (80 per 30 days) capacet oral capsule (Fioricet) QL (80 per 30 days) codeine sulfate oral tablet 5, 30, 60 (Codeine Sulfate) QL (390 per 30 days); AGE (Min 6 Years) co-gesic oral tablet (Norco) QL (240 per 30 days) endocet oral tablet 0-325, (Percocet) QL (240 per 30 days), 5-325, , endocet oral tablet (Percocet) QL (80 per 30 days) endodan oral tablet (Percodan) QL (80 per 30 days) fentanyl transdermal patch 72 hour 00 (Duragesic) QL (0 per 30 days) mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution (Lortab) QL (200 per 30 days) /5 ml hydrocodone-acetaminophen oral solution (Lortab) QL (3600 per 30 days) /5 ml hydrocodone-acetaminophen oral tablet 0-325, , , 5-325, 5-500, , (Norco) QL (240 per 30 days) hydrocodone-ibuprofen oral tablet (Ibudone) QL (40 per 30 days) hydromorphone oral tablet 2, 4, 8 (Dilaudid) QL (20 per 30 days) margesic oral capsule (Fioricet) QL (80 per 30 days) methadone intensol oral concentrate 0 /ml (Methadose) (For the treatment of pain); QL (240 per 30 days) 3 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

10 methadone oral solution 0 /5 ml, 5 /5 ml (Methadone Hcl) (For the treatment of pain); QL (200 per 30 days) methadone oral tablet 0, 5 (Dolophine Hcl) (For the treatment of pain); QL (240 per 30 days) morphine concentrate oral solution 00 (Morphine Sulfate) QL (270 per 30 days) /5 ml (20 /ml) morphine oral solution 0 /5 ml (Morphine Sulfate) QL (2700 per 30 days) morphine oral solution 20 /5 ml (4 (Morphine Sulfate) QL (350 per 30 days) /ml) MORPHINE ORAL TABLET 5 MG, 30 QL (80 per 30 days) MG morphine oral tablet extended release 00 (Ms Contin) QL (90 per 30 days), 60 morphine oral tablet extended release 5 (Ms Contin) QL (20 per 30 days), 30 morphine oral tablet extended release 200 (Ms Contin) QL (60 per 30 days) oxycodone oral capsule 5 (Oxycodone Hcl) QL (20 per 30 days) oxycodone oral solution 5 /5 ml (Oxycodone Hcl) QL (240 per 30 days) oxycodone oral tablet 0, 20 (Roxicodone) QL (20 per 30 days) oxycodone oral tablet 5, 30, 5 (Roxicodone) (5 capsules; 4, 0, 5, 20, 30 tablets); QL (20 per 30 days) oxycodone-acetaminophen oral capsule 5- (Tylox) QL (240 per 30 days) 500 oxycodone-acetaminophen oral tablet 0- (Percocet) QL (240 per 30 days) 325, , 5-325, , oxycodone-acetaminophen oral tablet 0- (Percocet) QL (80 per 30 days) 650 oxycodone-aspirin oral tablet (Percodan) QL (80 per 30 days) repan oral tablet (Fioricet) QL (80 per 30 days) roxicet oral tablet (Percocet) QL (240 per 30 days) stagesic oral capsule (Hydrocodone/Acetamin QL (240 per 30 days) ophen) tencon oral tablet (Tencon) QL (80 per 30 days) 4 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

11 tramadol oral tablet 50 (Ultram) QL (240 per 30 days) zebutal oral capsule (Fioricet) QL (80 per 30 days) Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet 325 (Ecotrin) QL (00 per day); AGE (Min 44 Years) aspirin oral tablet,chewable 8 (Bayer Chewable Aspirin) QL (00 per day); AGE (Min 44 Years) aspirin oral tablet,delayed release (dr/ec) (Ecotrin) QL (00 per day) 325 aspirin oral tablet,delayed release (dr/ec) 8 (Ecotrin) QL (00 per day); AGE (Min 44 Years) aspirin, buffered oral tablet 325 (Aspirin/Calcium Carbonate/Mag) QL (00 per day); AGE (Min 44 Years) aspir-low oral tablet,delayed release (dr/ec) 8 (Ecotrin) QL (00 per day); AGE (Min 44 Years) celecoxib oral capsule 00, 200, (Celebrex) 2 QL (60 per 30 days) 400, 50 diclofenac potassium oral tablet 50 (Cataflam) diclofenac sodium oral tablet extended (Voltaren-Xr) release 24 hr 00 diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 25, 50, 75 diclofenac sodium topical gel % (Voltaren) QL (300 per 30 days) e.c. prin oral tablet,delayed release (dr/ec) (Ecotrin) QL (00 per day); 325 AGE (Min 44 Years) ecotrin oral tablet,delayed release (dr/ec) 325 (Ecotrin) QL (00 per day); AGE (Min 44 Years) HALFPRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 62 MG QL (00 per day); AGE (Min 44 Years) halfprin oral tablet,delayed release (dr/ec) 8 (Ecotrin) QL (00 per day); AGE (Min 44 Years) ibuprofen oral tablet 400, 600, 800 (Ibuprofen) INDOCIN ORAL SUSPENSION 25 2 MG/5 ML indomethacin oral capsule 25, 50 (Indomethacin) indomethacin oral capsule, extended (Indomethacin) release 75 ketoprofen oral capsule 50, 75 (Ketoprofen) 5 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

12 meloxicam oral suspension 7.5 /5 ml (Mobic) meloxicam oral tablet 5, 7.5 (Mobic) miniprin oral tablet,delayed release (dr/ec) 8 (Ecotrin) QL (00 per day); AGE (Min 44 Years) naproxen oral suspension 25 /5 ml (Naprosyn) naproxen oral tablet 250, 375, 500 (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375, 500 naproxen sodium oral tablet 550 (Anaprox Ds) piroxicam oral capsule 0, 20 (Feldene) salsalate oral tablet 500, 750 (Disalcid) 2 st joseph aspirin oral tablet,chewable 8 (Bayer Chewable Aspirin) QL (00 per day); AGE (Min 44 Years) st. joseph aspirin oral tablet,delayed (Ecotrin) QL (00 per day) release (dr/ec) 8 sulindac oral tablet 50, 200 (Sulindac) Anesthetics Local Anesthetics anecream topical cream 4 % (Lmx 4) lidocaine hcl mucous membrane jelly 2 % (Lidocaine Hcl) lidocaine topical adhesive (Lidoderm) 2 QL (30 per 30 days) patch,medicated 5 % lidocaine topical cream 4 % (Lmx 4) lidocaine topical ointment 5 % (Lidocaine) 2 QL (00 per 30 days) lidocaine viscous mucous membrane (Xylocaine) solution 2 % lidocaine-prilocaine topical cream % (Emla) 2 lidocaine-prilocaine topical kit % (Relador Pak) 2 lidocream topical cream 4 % (Lmx 4) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 (Campral) (Suboxone) 2 QL (90 per 30 days) 6 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

13 bupropion hcl (smoking deter) oral tablet extended release 50 (Zyban) CHANTIX CONTINUING MONTH QL (280 per 365 days) BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG QL (56 per 365 days) CHANTIX ORAL TABLET MG QL (280 per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) QL (56 per 365 days) disulfiram oral tablet 250, 500 (Antabuse) naloxone injection solution 0.4 /ml (Naloxone Hcl) naloxone injection syringe 0.4 /ml, (Naloxone Hcl) /ml naltrexone oral tablet 50 (Revia) (tablet) nicorelief buccal gum 2, 4 (Nicorette) nicorelief buccal lozenge 2, 4 (Nicorette) nicotine (polacrilex) buccal gum 2, 4 (Nicorette) nicotine (polacrilex) buccal lozenge 2, (Nicorette) 4 nicotine transdermal patch 24 hour 4 (Nicoderm Cq) QL (90 per 365 days) /24 hr, 2 /24 hr, 22 /24 hr nicotine transdermal patch 24 hour 7 (Nicoderm Cq) /24 hr VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG 3 PA; QL ( per 28 days) Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, (Xanax) QL (50 per 30 days), 2 alprazolam oral tablet extended release 24 (Xanax Xr) QL (30 per 30 days) hr 0.5,, 2, 3 chlordiazepoxide hcl oral capsule 0, 25, 5 (Chlordiazepoxide Hcl) QL (20 per 30 days) clonazepam oral tablet 0.5,, 2 (Klonopin) QL (20 per 30 days) clorazepate dipotassium oral tablet 5, (Tranxene T-Tab) QL (30 per 30 days) 3.75, 7.5 diazepam intensol oral concentrate 5 /ml (Diazepam) QL (200 per 30 days) 7 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

14 diazepam oral solution 5 /5 ml ( (Diazepam) QL (200 per 30 days) /ml) diazepam oral tablet 0, 2, 5 (Valium) QL (20 per 30 days) diazepam rectal kit , (Diastat Acudial) 2.5, flurazepam oral capsule 5, 30 (Flurazepam Hcl) QL (30 per 30 days) lorazepam oral tablet 0.5,, 2 (Ativan) QL (50 per 30 days) midazolam injection solution /ml (Midazolam Hcl) QL (25 per 30 days) midazolam injection solution 5 /ml (Midazolam Hcl) QL (5 per 30 days) temazepam oral capsule 5, 7.5 (Restoril) QL (60 per 30 days) temazepam oral capsule 22.5, 30 (Restoril) QL (30 per 30 days) triazolam oral tablet 0.25, 0.25 (Halcion) QL (30 per 30 days) Antibacterials Antibacterials, Miscellaneous clindamycin hcl oral capsule 50, 300 (Cleocin Hcl), 75 clindamycin palmitate hcl oral recon soln (Cleocin Palmitate) 2 75 /5 ml metronidazole oral tablet 250, 500 (Flagyl) MONUROL ORAL PACKET 3 GRAM 2 ( packet = 3 grams: therefore QL is 3 packets; brand name for fosfomycin); QL (9 per 90 days) nitrofurantoin macrocrystal oral capsule (Macrodantin) 00, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) capsule 00 PRIMSOL ORAL SOLUTION 50 MG/5 2 ML trimethoprim oral tablet 00 (Trimethoprim) vancomycin oral capsule 25, 250 (Vancocin Hcl) 2 XIFAXAN ORAL TABLET 200 MG 3 ST; QL (80 per 30 days) XIFAXAN ORAL TABLET 550 MG 3 ST; QL (60 per 30 days) Cephalosporins cefaclor oral capsule 250, 500 (Cefaclor) cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml (Cefaclor) 8 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

15 cefdinir oral capsule 300 (Cefdinir) cefdinir oral suspension for reconstitution (Cefdinir) 25 /5 ml, 250 /5 ml ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 /5 ml CEFTIN ORAL SUSPENSION FOR 2 RECONSTITUTION 25 MG/5 ML, 250 MG/5 ML cefuroxime axetil oral tablet 250, 500 (Ceftin) cephalexin oral capsule 250, 500 (Keflex) cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml (Cephalexin) SUPRAX ORAL CAPSULE 400 MG 2 QL ( per 30 days) SUPRAX ORAL TABLET 400 MG 2 QL ( per 30 days) SUPRAX ORAL TABLET,CHEWABLE 2 AGE (Max 8 Years) 00 MG, 200 MG Macrolides azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml (Biaxin) clarithromycin oral tablet 250, 500 (Biaxin) e.e.s. 400 oral tablet 400 (Erythromycin Ethylsuccinate) ery-tab oral tablet,delayed release (dr/ec) (Erythromycin Base) 250, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG 2 erythrocin (as stearate) oral tablet 250 (Erythromycin Stearate) erythromycin ethylsuccinate oral tablet (Erythromycin 400 Ethylsuccinate) erythromycin oral tablet 250, 500 (Erythromycin Base) erythromycin-sulfisoxazole oral suspension for reconstitution /5 ml (Ery E- Succ/Sulfisoxazole) 9 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

16 Penicillins amoxicillin oral capsule 250, 500 (Amoxicillin) amoxicillin oral suspension for (Amoxicillin) reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 (Amoxicillin) amoxicillin oral tablet,chewable 25, (Amoxicillin) 250, 400 amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , , amoxicillin-pot clavulanate oral tablet (Augmentin Xr) extended release 2 hr, amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable , Clav) ampicillin oral capsule 250, 500 (Ampicillin Trihydrate) ampicillin oral suspension for (Ampicillin Trihydrate) reconstitution 25 /5 ml, 250 /5 ml dicloxacillin oral capsule 250, 500 (Dicloxacillin Sodium) penicillin v potassium oral recon soln 25 (Penicillin V Potassium) /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, (Penicillin V Potassium) 500 Quinolones ciprofloxacin hcl oral tablet 00, 250 (Cipro), 500, 750 ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin oral solution 250 /0 ml (Levaquin) levofloxacin oral tablet 250, 500, (Levaquin) 750 Sulfonamides sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension /5 ml ethoprim) sulfamethoxazole-trimethoprim oral tablet , (Bactrim Ds) 0 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

17 sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 500 sulfatrim oral suspension /5 ml (Sulfamethoxazole/Trim ethoprim) Tetracyclines doxycycline hyclate oral capsule 00, (Vibramycin) QL (28 per 90 days) 50 doxycycline hyclate oral tablet 00, 20 (Doryx) QL (28 per 90 days) doxycycline monohydrate oral capsule 00 (Monodox) QL (28 per 90 days), 50 doxycycline monohydrate oral tablet 00 (Avidoxy) QL (28 per 90 days), 50 minocycline oral capsule 00, 50, 75 (Minocin) QL (60 per 30 days) Anticancer Agents Anticancer Agents ALKERAN ORAL TABLET 2 MG 3 anastrozole oral tablet (Arimidex) bexarotene oral capsule 75 (Targretin) 3 bicalutamide oral tablet 50 (Casodex) 2 capecitabine oral tablet 50, 500 (Xeloda) 3 cyclophosphamide oral tablet 25, 50 (Cyclophosphamide) 3 etoposide oral capsule 50 (Etoposide) 3 exemestane oral tablet 25 (Aromasin) 2 FARESTON ORAL TABLET 60 MG 3 flutamide oral capsule 25 (Flutamide) HEXALEN ORAL CAPSULE 50 MG 3 hydroxyurea oral capsule 500 (Hydrea) letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG 3 lomustine oral capsule 0, 00, 40 (Ceenu) 3 LYSODREN ORAL TABLET 500 MG 3 MATULANE ORAL CAPSULE 50 MG 3 megestrol oral tablet 20, 40 (Megestrol Acetate) mercaptopurine oral tablet 50 (Purinethol) 2 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

18 methotrexate sodium (pf) injection recon (Methotrexate soln gram Sodium/Pf) methotrexate sodium injection solution 25 (Methotrexate Sodium) /ml methotrexate sodium oral tablet 2.5 (Methotrexate Sodium) MYLERAN ORAL TABLET 2 MG 3 TABLOID ORAL TABLET 40 MG 3 tamoxifen oral tablet 0, 20 (Tamoxifen Citrate) TEMODAR ORAL CAPSULE 20 MG 3 temozolomide oral capsule 00, 40 (Temodar) 3, 80, 20, 250, 5 tretinoin (chemotherapy) oral capsule 0 (Tretinoin) 3 Anticholinergic Agents Antimuscarinics/Antispasmodics phenobarb-hyoscy-atropine-scop oral (Phenobarb/Hyoscy/Atro tablet pine/scop) propantheline oral tablet 5 (Propantheline Bromide) Anticonvulsants Anticonvulsants carbamazepine oral capsule, er multiphase 2 hr 00, 200, 300 (Carbatrol) carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 200 (Tegretol) carbamazepine oral tablet extended (Tegretol Xr) release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 (Carbamazepine) DILANTIN ORAL CAPSULE 30 MG 2 divalproex oral capsule, sprinkle 25 (Depakote Sprinkle) divalproex oral tablet extended release 24 (Depakote Er) 2 hr 250, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 25, 250, 500 epitol oral tablet 200 (Tegretol) ethosuximide oral capsule 250 (Zarontin) 2 ethosuximide oral solution 250 /5 ml (Zarontin) 2 felbamate oral suspension 600 /5 ml (Felbatol) 2 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

19 felbamate oral tablet 400, 600 (Felbatol) gabapentin oral capsule 00, 300, (Neurontin) 400 gabapentin oral solution 250 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 00, 50, (Lamictal) QL (60 per 30 days) 200, 25 lamotrigine oral tablet, chewable (Lamictal) QL (60 per 30 days) dispersible 25, 5 levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 250 (Keppra) QL (20 per 30 days), 500, 750 oxcarbazepine oral suspension 300 /5 ml (Trileptal) oxcarbazepine oral tablet 50, 300, (Trileptal) QL (60 per 30 days) 600 phenobarbital oral elixir 20 /5 ml (4 (Phenobarbital) /ml) phenobarbital oral tablet 00, 5, (Phenobarbital) 6.2, 30, 32.4, 60, 64.8, 97.2 phenytoin oral suspension 25 /5 ml (Dilantin-25) phenytoin oral tablet,chewable 50 (Dilantin) phenytoin sodium extended oral capsule (Dilantin) 00, 200, 300 primidone oral tablet 250, 50 (Mysoline) topiragen oral tablet 00, 200, 25 (Topamax), 50 topiramate oral capsule, sprinkle 5, (Topamax) 25 topiramate oral tablet 00, 200, 25 (Topamax), 50 valproic acid (as sodium salt) oral (Depakene) solution 250 /5 ml valproic acid oral capsule 250 (Depakene) zonisamide oral capsule 00, 25, 50 (Zonegran) QL (20 per 30 days) Antidementia Agents Antidementia Agents 3 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

20 donepezil oral tablet 0, 23, 5 (Aricept) Antidepressants Antidepressants amitriptyline oral tablet 0, 00, (Amitriptyline Hcl) 50, 25, 50, 75 budeprion sr oral tablet extended release (Wellbutrin Sr) 00 budeprion sr oral tablet extended release (Wellbutrin Sr) 50 buproban oral tablet extended release 50 (Wellbutrin Sr) bupropion hcl oral tablet 00, 75 (Wellbutrin Sr) bupropion hcl oral tablet extended release (Wellbutrin Sr) 00, 200 bupropion hcl oral tablet extended release (Wellbutrin Sr) 50 bupropion hcl oral tablet extended release (Wellbutrin Xl) 24 hr 50, 300 citalopram oral solution 0 /5 ml (Citalopram Hydrobromide) citalopram oral tablet 0, 20 (Celexa) QL (45 per 30 days) citalopram oral tablet 40 (Celexa) QL (30 per 30 days) clomipramine oral capsule 25, 50, (Anafranil) 2 75 desipramine oral tablet 0, 00, (Norpramin) 50, 25, 50, 75 doxepin oral capsule 0, 00, 50 (Doxepin Hcl), 25, 50, 75 doxepin oral concentrate 0 /ml (Doxepin Hcl) duloxetine oral capsule,delayed (Cymbalta) 2 ST; QL (60 per 30 days) release(dr/ec) 20, 30, 60 escitalopram oxalate oral tablet 0, 20 (Lexapro) QL (30 per 30 days) escitalopram oxalate oral tablet 5 (Lexapro) QL (90 per 30 days) fluoxetine oral capsule 0, 20, 40 (Prozac) fluoxetine oral solution 20 /5 ml (4 (Fluoxetine Hcl) /ml) fluvoxamine oral tablet 00, 25, 50 (Fluvoxamine Maleate) 4 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

21 imipramine hcl oral tablet 0, 25, (Tofranil) 50 mirtazapine oral tablet 5, 30, 45 (Remeron), 7.5 mirtazapine oral tablet,disintegrating 5 (Remeron), 30, 45 nortriptyline oral capsule 0, 25, (Pamelor) 50, 75 nortriptyline oral solution 0 /5 ml (Nortriptyline Hcl) paroxetine hcl oral tablet 0, 20, (Paxil) 30, 40 sertraline oral concentrate 20 /ml (Zoloft) sertraline oral tablet 00, 25, 50 (Zoloft) trazodone oral tablet 00, 50, 300 (Trazodone Hcl), 50 venlafaxine oral capsule,extended release (Effexor Xr) QL (30 per 30 days) 24hr 50 venlafaxine oral capsule,extended release (Effexor Xr) QL (90 per 30 days) 24hr 37.5, 75 venlafaxine oral tablet 00, 25, 37.5, 50, 75 (Venlafaxine Hcl) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00, 25, 50 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML).2 ML JANUMET ORAL TABLET 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG metformin oral tablet,000, 500, 850 metformin oral tablet extended release 24 hr 500, 750 (Precose) (Glucophage) (Glucophage Xr) Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

22 metformin oral tablet extended release 24hr,000, 500 metformin oral tablet,er gast.retention 24 hr,000, 500 pioglitazone oral tablet 5, 30, 45 Insulins HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 00 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (75-25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 00 UNIT/ML (75-25) HUMALOG SUBCUTANEOUS CARTRIDGE 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R INJECTION SOLUTION 00 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML (Glucophage Xr) (Glumetza) (Actos) 3 QL (30 per 28 days) 3 QL (30 per 30 days) QL (40 per 28 days) 3 QL (30 per 30 days) QL (40 per 28 days) 3 QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) 3 QL (2 per 30 days) 2 QL (20 per 28 days) 6 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

23 LANTUS SOLOSTAR 2 QL (30 per 30 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS 2 QL (40 per 28 days) SOLUTION 00 UNIT/ML LEVEMIR FLEXTOUCH 2 QL (30 per 30 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LEVEMIR SUBCUTANEOUS 2 QL (40 per 30 days) SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION QL (40 per 28 days) 00 UNIT/ML NOVOLOG FLEXPEN 3 QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX FLEXPEN 3 QL (30 per 30 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL 3 QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 00 UNIT/ML Sulfonylureas chlorpropamide oral tablet 00, 250 (Chlorpropamide) glimepiride oral tablet, 2, 4 (Amaryl) glipizide oral tablet 0, 5 (Glucotrol) glipizide oral tablet extended release 24hr 0, 2.5, 5 (Glucotrol Xl) QL (30 per 30 days) glipizide-metformin oral tablet , , (Glipizide/Metformin Hcl) 7 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

24 glyburide micronized oral tablet.5, 3 (Glynase), 6 glyburide oral tablet.25, 2.5, 5 (Glyburide) glyburide-metformin oral tablet (Glucovance), , Antifungals Antifungals ciclopirox topical cream 0.77 % (Ciclodan) QL (90 per 30 days) ciclopirox topical solution 8 % (Penlac) clotrimazole mucous membrane troche 0 (Clotrimazole) clotrimazole-betamethasone topical cream (Lotrisone) % clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth % asone Dip) econazole topical cream % (Econazole Nitrate) 2 QL (85 per 30 days) fluconazole oral suspension for (Diflucan) reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, (Diflucan) 200, 50 griseofulvin microsize oral suspension 25 (Griseofulvin, 2 /5 ml Microsize) griseofulvin microsize oral tablet 500 (Grifulvin V) 2 griseofulvin ultramicrosize oral tablet 25 (Gris-Peg) 2, 250 ketoconazole oral tablet 200 (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical foam 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) nyamyc topical powder 00,000 unit/gram (Nystatin) NYSTATIN (BULK) POWDER 50 MILLION UNIT, 500 MILLION UNIT nystatin oral suspension 00,000 unit/ml (Nystatin) nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 00,000 unit/gram (Nystatin) nystatin topical ointment 00,000 unit/gram (Nystatin) nystatin topical powder 00,000 unit/gram (Nystatin) 8 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

25 nystatin-triamcinolone topical cream 00, unit/g-% nystatin-triamcinolone topical ointment 00, unit/gram-% (Nystatin/Triamcin) 2 (Nystatin/Triamcin) 2 nystop topical powder 00,000 unit/gram (Nystatin) pedi-dri topical powder 00,000 unit/gram (Nystatin) terbinafine hcl oral tablet 250 (Lamisil) QL (90 per 365 days) Antihistamines Antihistamines clemastine oral tablet 2.68 (Clemastine Fumarate) cyproheptadine oral syrup 2 /5 ml (Cyproheptadine Hcl) cyproheptadine oral tablet 4 (Cyproheptadine Hcl) diphenhydramine hcl oral capsule 50 (Diphenhydramine Hcl) (Rx products only) promethazine oral syrup 6.25 /5 ml (Promethazine Hcl) Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 (Terazol 3) Antimigraine Agents Antimigraine Agents ergotamine-caffeine oral tablet -00 (Ergotamine Tartrate/Caffeine) isometh-dichloral-acetaminophn oral capsule (Isomethept/Dichlphn/A cetaminop) 2 RELPAX ORAL TABLET 20 MG, 40 3 ST; QL (6 per 30 days) MG sumatriptan nasal spray,non-aerosol 20 /actuation, 5 /actuation (Imitrex) 2 (nasal spray); QL (6 per 30 days) sumatriptan succinate oral tablet 00, (Imitrex) QL (9 per 30 days) 50 sumatriptan succinate oral tablet 25 (Imitrex) QL (8 per 30 days) sumatriptan succinate subcutaneous (Imitrex) ST; QL (3 per 30 days) cartridge 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml (Imitrex) ST; QL (3 per 30 days) 9 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

26 sumatriptan succinate subcutaneous (Imitrex) ST; QL (3 per 30 days) solution 6 /0.5 ml sumatriptan succinate subcutaneous (Sumatriptan Succinate) ST; QL (3 per 30 days) syringe 6 /0.5 ml zolmitriptan oral tablet 2.5, 5 (Zomig) QL (6 per 30 days) zolmitriptan oral tablet,disintegrating 2.5, 5 (Zomig Zmt) QL (6 per 30 days) Antimycobacterials Antimycobacterials dapsone oral tablet 00, 25 (Dapsone) ethambutol oral tablet 00, 400 (Myambutol) 2 isoniazid oral solution 50 /5 ml (Isoniazid) isoniazid oral tablet 00, 300 (Isoniazid) pyrazinamide oral tablet 500 (Pyrazinamide) rifabutin oral capsule 50 (Mycobutin) rifampin oral capsule 50, 300 (Rifadin) Antinausea Agents Antinausea Agents compro rectal suppository 25 (Compazine) meclizine oral tablet 2.5, 25 (Meclizine Hcl) ondansetron hcl oral solution 4 /5 ml (Zofran) ondansetron hcl oral tablet 4, 8 (Zofran) QL (30 per 30 days) ondansetron oral tablet,disintegrating 4 (Zofran Odt) QL (30 per 30 days), 8 phenadoz rectal suppository 2.5, 25 (Phenergan) prochlorperazine maleate oral tablet 0, 5 (Compazine) prochlorperazine rectal suppository 25 (Compazine) promethazine oral tablet 2.5, 25, (Promethazine Hcl) 50 promethazine rectal suppository 2.5, (Phenergan) 25, 50 promethegan rectal suppository 2.5, 25, 50 (Phenergan) trimethobenzamide oral capsule 300 (Tigan) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG 2 20 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

27 atovaquone-proguanil oral tablet (Malarone) 2, BILTRICIDE ORAL TABLET 600 MG 3 chloroquine phosphate oral tablet 250, 500 (Chloroquine Phosphate) DARAPRIM ORAL TABLET 25 MG 3 hydroxychloroquine oral tablet 200 (Plaquenil) 2 ivermectin oral tablet 3 (Stromectol) 2 mefloquine oral tablet 250 (Mefloquine Hcl) paromomycin oral capsule 250 (Paromomycin Sulfate) PRIMAQUINE ORAL TABLET 26.3 MG 2 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 (Amantadine Hcl) amantadine hcl oral solution 50 /5 ml (Amantadine Hcl) benztropine oral tablet 0.5,, 2 (Benztropine Mesylate) bromocriptine oral capsule 5 (Parlodel) 2 bromocriptine oral tablet 2.5 (Parlodel) 2 carbidopa-levodopa oral tablet 0-00 (Sinemet 25-00), 25-00, carbidopa-levodopa oral tablet extended (Sinemet Cr) release 25-00, pramipexole oral tablet 0.25, 0.25, 0.5, 0.75,,.5 (Mirapex) trihexyphenidyl oral elixir 0.4 /ml (Trihexyphenidyl Hcl) trihexyphenidyl oral tablet 2, 5 (Trihexyphenidyl Hcl) Antipsychotic Agents Antipsychotic Agents aripiprazole oral solution /ml (Abilify) 2 ST aripiprazole oral tablet 0, 5, 2, 20, 30, 5 (Abilify) 2 ST; QL (30 per 30 days) chlorpromazine oral tablet 0, 00, (Chlorpromazine Hcl) 2 200, 25, 50 clozapine oral tablet 00, 200, 25 (Clozaril), 50 fluphenazine decanoate injection solution (Fluphenazine 25 /ml Decanoate) fluphenazine hcl injection solution 2.5 /ml (Fluphenazine Hcl) 2 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

28 fluphenazine hcl oral concentrate 5 /ml (Fluphenazine Hcl) fluphenazine hcl oral elixir 2.5 /5 ml (Fluphenazine Hcl) fluphenazine hcl oral tablet, 0, (Fluphenazine Hcl) 2.5, 5 haloperidol decanoate intramuscular (Haloperidol Decanoate) solution 00 /ml haloperidol decanoate intramuscular (Haldol Decanoate 00) solution 50 /ml haloperidol lactate oral concentrate 2 (Haloperidol Lactate) /ml haloperidol oral tablet 0.5,, 0 (Haloperidol), 2, 20, 5 loxapine succinate oral capsule 0, 25 (Loxitane), 5, 50 olanzapine oral tablet 0, 5, 2.5 (Zyprexa) 2 QL (30 per 30 days), 20, 5, 7.5 perphenazine oral tablet 6, 2, 4 (Perphenazine) 2, 8 quetiapine oral tablet 00, 200, 25 (Seroquel) 2 QL (90 per 30 days), 300, 400, 50 risperidone oral solution /ml (Risperdal) risperidone oral tablet 0.25, 0.5, (Risperdal), 2, 3, 4 thioridazine oral tablet 0, 00, 25 (Thioridazine Hcl), 50 thiothixene oral capsule, 0, 2 (Thiothixene), 5 trifluoperazine oral tablet, 0, 2 (Trifluoperazine Hcl) 2, 5 ziprasidone hcl oral capsule 20, 40, 60, 80 (Geodon) 2 QL (60 per 30 days) Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 (Ziagen) 2 abacavir-lamivudine oral tablet (Epzicom) 2 abacavir-lamivudine-zidovudine oral (Trizivir) 2 tablet ATRIPLA ORAL TABLET MG 3 22 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

29 COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, MG DESCOVY ORAL TABLET MG 3 didanosine oral capsule,delayed (Videx Ec) 2 release(dr/ec) 25, 200, 250, 400 EMTRIVA ORAL CAPSULE 200 MG 4 EMTRIVA ORAL SOLUTION 0 4 MG/ML EPIVIR HBV ORAL SOLUTION 25 4 MG/5 ML (5 MG/ML) GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, MG, 25 MG INVIRASE ORAL CAPSULE 200 MG 4 INVIRASE ORAL TABLET 500 MG 4 ISENTRESS ORAL TABLET 400 MG 4 KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 /ml (Epivir) 2 lamivudine oral tablet 00, 50, (Epivir Hbv) lamivudine-zidovudine oral tablet (Combivir) 2 LEXIVA ORAL SUSPENSION 50 4 MG/ML LEXIVA ORAL TABLET 700 MG 4 nevirapine oral suspension 50 /5 ml (Viramune) 2 nevirapine oral tablet 200 (Viramune) 2 NORVIR ORAL CAPSULE 00 MG 4 NORVIR ORAL SOLUTION 80 MG/ML 4 NORVIR ORAL TABLET 00 MG 4 ODEFSEY ORAL TABLET MG 3 23 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

30 PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 3 MG/ML PREZISTA ORAL TABLET 50 MG, MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG 4 RESCRIPTOR ORAL TABLET, 4 DISPERSIBLE 00 MG REYATAZ ORAL CAPSULE 00 MG, 3 50 MG, 200 MG, 300 MG stavudine oral capsule 5, 20, 30 (Zerit) 2, 40 stavudine oral recon soln /ml (Zerit) 2 STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 4 MG SUSTIVA ORAL TABLET 600 MG 4 TIVICAY ORAL TABLET 0 MG, 25 4 QL (30 per 30 days) MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL 4 RECON SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, MG VIREAD ORAL POWDER 40 3 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, MG, 250 MG, 300 MG ZIAGEN ORAL SOLUTION 20 MG/ML 4 zidovudine oral capsule 00 (Retrovir) 2 zidovudine oral syrup 0 /ml (Retrovir) 2 zidovudine oral tablet 300 (Zidovudine) 2 Antivirals, Miscellaneous TAMIFLU ORAL CAPSULE 30 MG 2 QL (20 per 30 days) 24 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

31 TAMIFLU ORAL CAPSULE 45 MG, 75 2 QL (0 per 30 days) MG TAMIFLU ORAL SUSPENSION FOR 2 QL (50 per 30 days) RECONSTITUTION 6 MG/ML Hcv Antivirals EPCLUSA ORAL TABLET MG 4 PA; QL (28 per 28 days) HARVONI ORAL TABLET MG 4 PA; (20% coinsurance for this drug); QL (28 per 28 days) ZEPATIER ORAL TABLET MG 4 PA; QL (28 per 28 days) Interferons PEGASYS PROCLICK 3 SUBCUTANEOUS PEN INJECTOR 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS 3 SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS 3 SYRINGE 80 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 200 (Zovirax) acyclovir oral suspension 200 /5 ml (Zovirax) acyclovir oral tablet 400, 800 (Zovirax) ribasphere oral capsule 200 (Rebetol) ribasphere oral tablet 200 (Copegus) ribavirin oral capsule 200 (Rebetol) ribavirin oral tablet 200 (Copegus) valacyclovir oral tablet gram, 500 (Valtrex) valganciclovir oral tablet 450 (Valcyte) 3 VEMLIDY ORAL TABLET 25 MG 3 Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin subcutaneous solution 300 /3 ml enoxaparin subcutaneous syringe 00 /ml, 50 /ml enoxaparin subcutaneous syringe 20 /0.8 ml, 80 /0.8 ml (Lovenox) 3 QL (3 per 30 days) (Lovenox) 3 QL (60 per 30 days) (Lovenox) 3 QL (48 per 30 days) 25 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

32 enoxaparin subcutaneous syringe 30 (Lovenox) 3 QL (8 per 30 days) /0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) 3 QL (24 per 30 days) /0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) 3 QL (36 per 30 days) /0.6 ml FRAGMIN SUBCUTANEOUS 4 QL (3.8 per 30 days) SOLUTION 25,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS 4 QL (30 per 30 days) SYRINGE 0,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS 4 QL (5 per 30 days) SYRINGE 2,500 ANTI-XA UNIT/0.5 ML FRAGMIN SUBCUTANEOUS 4 QL (8 per 30 days) SYRINGE 5,000 ANTI-XA UNIT/0.6 ML FRAGMIN SUBCUTANEOUS 4 QL (2.6 per 30 days) SYRINGE 8,000 ANTI-XA UNIT/0.72 ML FRAGMIN SUBCUTANEOUS 4 QL (2.8 per 30 days) SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML FRAGMIN SUBCUTANEOUS 4 QL (4.2 per 30 days) SYRINGE 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) injection solution,000 (Heparin unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml Sodium,Porcine) heparin, porcine (pf) injection solution (Heparin 5,000 unit/0.5 ml Sodium,Porcine/Pf) heparin, porcine (pf) injection syringe (Monoject Prefill 5,000 unit/0.5 ml Advanced) jantoven oral tablet, 0, 2, (Coumadin) 2.5, 3, 4, 5, 6, 7.5 warfarin oral tablet, 0, 2, (Coumadin) 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 3 QL (42 per 365 days) MG XARELTO ORAL TABLET 20 MG 3 ST; QL (30 per 30 days) Blood Formation Modifiers 26 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

33 ARANESP (IN POLYSORBATE) 4 PA INJECTION SOLUTION 00 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) 4 PA INJECTION SYRINGE 0 MCG/0.4 ML, 00 MCG/0.5 ML, 50 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML LEUKINE INJECTION RECON SOLN 4 PA 250 MCG LEUKINE INJECTION SOLUTION PA MCG/ML NEUPOGEN INJECTION SOLUTION 3 PA 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE PA MCG/0.5 ML, 480 MCG/0.8 ML Platelet-Aggregation Inhibitors cilostazol oral tablet 00, 50 (Pletal) clopidogrel oral tablet 300, 75 (Plavix) dipyridamole oral tablet 25, 50, 75 (Persantine) pentoxifylline oral tablet extended release 400 (Trental) Caloric Agents Caloric Agents glucose oral tablet,chewable 4 gram (Dextrose) Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0., 0.2, (Catapres) 0.3 clonidine transdermal patch weekly 0. (Catapres-Tts 3) /24 hr, 0.2 /24 hr, 0.3 /24 hr doxazosin oral tablet, 2, 4, 8 (Cardura) guanfacine oral tablet, 2 (Tenex) methyldopa oral tablet 250, 500 (Methyldopa) midodrine oral tablet 0, 2.5, 5 (Midodrine Hcl) 2 prazosin oral capsule, 2, 5 (Minipress) 27 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207

34 Angiotensin Ii Receptor Antagonists irbesartan oral tablet 50, 300, 75 (Avapro) QL (30 per 30 days) irbesartan-hydrochlorothiazide oral tablet , (Avalide) QL (30 per 30 days) losartan oral tablet 00, 25, 50 (Cozaar) QL (30 per 30 days) losartan-hydrochlorothiazide oral tablet (Hyzaar) QL (30 per 30 days) , 00-25, valsartan oral tablet 60, 320, 40 (Diovan), 80 valsartan-hydrochlorothiazide oral tablet (Diovan Hct) , 60-25, , , Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0, 20, 40 (Lotensin) QL (30 per 30 days), 5 benazepril-hydrochlorothiazide oral tablet (Lotensin Hct) 0-2.5, , 20-25, captopril oral tablet 00, 2.5, 25 (Captopril), 50 lisinopril oral tablet 0, 2.5, 20 (Zestril), 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 0-2.5, , Antiarrhythmic Agents amiodarone oral tablet 00, 200, (Cordarone) 400 flecainide oral tablet 00, 50, 50 (Tambocor) pacerone oral tablet 00, 200, 400 (Cordarone) propafenone oral capsule,extended release (Rythmol Sr) 2 hr 225, 325, 425 propafenone oral tablet 50, 225, (Rythmol) 300 Beta-Adrenergic Blocking Agents atenolol oral tablet 00, 25, 50 (Tenormin) 28 Denver Health Medical Plan 207 Commercial Deductible Enhanced Effective: January 0, 207