National Drug List. Drug list Four (4) Tier Drug Plan

Transcription

1 National Drug List Drug list Four (4) Tier Drug Plan Anthem Blue Cross and Blue Shield (Anthem) prescription drug benefits include medications on the Anthem National Drug List. Your coverage has limitations and exclusions. For example, drugs used for cosmetic purposes usually are not covered. Always refer to your Certificate or Evidence of Coverage for details about what s covered and what s not. Then if you have additional questions, call Customer Service at the number on your member ID card. 955MUMENABS

2 Anthem Blue Cross and Blue Shield Drug List Your prescription drug benefit includes coverage for medications that you ll find on the Anthem National Drug List. You can often find more savings when your doctor prescribes medicine on our National Drug List. Here are some commonly asked questions and answers about how the National Drug List works with your prescription drug plan. Q. What is a Drug List? A. The Anthem National Drug List, also called a formulary, has drugs on it that are approved by the U.S. Food and Drug Administration (FDA). This includes brand-name and generic drugs, reviewed and recommended for their quality and for how well they work. The review is done by the National Pharmacy and Therapeutics (P&T) Process. The P&T process involves an independent group of practicing doctors and pharmacists in charge of the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs. They choose the top drugs for our list based on their safety, how they work and their value. Drugs on our list are reviewed from time to time. Sometimes this results in drugs being added or removed. So now and then, it s a good idea to check the status of any drugs you may be taking. You can see the list by going to anthem.com. Also, we will always try to notify you of any changes to the formulary that impact you. Q. How do we determine the tier of a drug? A. Medications on the Anthem National Drug List are grouped into tiers. Drugs on the lowest tier have the lowest cost share, which is what you pay. Drugs on the highest tier cost you more. Several factors determine what tier a drug is placed in, including: }} Clinical considerations. }} Cost of the drug in comparison to other drugs used for the same type of treatment. }} Availability of over-the-counter options. Q. What are clinically equivalent medications? How does this affect my drug coverage? A. When drugs are compared in studies, some drugs are found to be just as effective as others. When one drug works just as well as another for the same purpose, they are said to be clinically equivalent. Part of the P&T process is to review the most current studies to see if multiple drugs used to treat a disease or a condition have the same effect on a patient. When this is the case, the review team may suggest that we cover only the lower-cost drug. (This helps keep the overall cost of health care as low as possible). This is also why your specific prescription drug plan may not cover some drugs (indicated by a CE symbol next to the drug name) that have clinically equivalent options. Q. Is this list a complete listing of all covered drugs under the Anthem National Drug List? A. Yes, this is a complete listing of all covered drugs under the Anthem National Drug List. Preventive care drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

3 For more information about your drug plan, you can do the following: }} Go to anthem.com }} Call Customer Service at the number on your ID card }} Speech and hearing impaired (TDD/TTY users) should call , Monday Friday, 8:0 a.m. 5 p.m. ET Tier definitions Tier drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions. Tier drugs have a medium cost share. These may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier drugs have a higher cost share than Tier. Tier drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier may also include drugs that were recently approved by the FDA. Tier drugs have a higher cost share than Tier. Tier 4 drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or drugs that are used to treat complex, chronic conditions and may need special handling. Member cost share amounts for certain abuse-deterrent opioid analgesics may be lower in the state of Maine due to state laws. For additional information, please call the Customer Service number on your ID card.

4 Anthem National Formulary Four-Tier Table of Contents ANALGESICS... 6 ANESTHETICS... ANTIALLERGY... 4 ANTIARTHRITICS... 4 ANTIASTHMATICS... 6 ANTIBIOTICS... 9 ANTICOAGULANTS... 9 ANTIDOTES... 0 ANTIFUNGALS... ANTIHISTAMINE AND DECONGESTANT COMBINATION... ANTIHISTAMINES... ANTIHYPERGLYCEMICS... 4 ANTIINFECTIVES... 7 ANTIINFECTIVES/MISCELLANEOUS... 6 ANTINEOPLASTICS... 7 ANTI-OBESITY DRUGS... 4 ANTIPARKINSON DRUGS ANTIPLATELET DRUGS ANTIVIRALS AUTONOMIC DRUGS BIOLOGICALS BLOOD CARDIAC DRUGS... 6 CARDIOVASCULAR CNS DRUGS... 7 COLONY STIMULATING FACTORS CONTRACEPTIVES COUGH/COLD PREPARATIONS DIAGNOSTIC... 8 DIURETICS EENT PREPS ELECT/CALORIC/HO GASTROINTESTINAL HORMONES IMMUNOSUPPRESANT... 0 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG... MUSCLE RELAXANTS... PRE-NATAL VITAMINS... 4 PSYCHOTHERAPEUTIC DRUGS... 7 SEDATIVE/HYPNOTICS... SKIN PREPS... 4 SMOKING DETERRENTS... THYROID PREPS... UNCLASSIFIED DRUG PRODUCTS... VITAMINS

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6 Anthem National Formulary Four-Tier ANALGESICS ABSTRAL SUBLINGUAL acetaminophen-caff-dihydroc od oral capsule acetaminophen-codeine oral 0 mg- mg /5 ml (5 ml), 0- mg/5 ml, 00 mg-0 mg /.5 ml acetaminophen-codeine oral tablet 00-5 mg acetaminophen-codeine oral tablet 00-0 mg, mg ACTIQ BUCCAL LOZENGE ON A HANDLE ALFENTANIL INJECTION ALLZITAL ORAL PA; QL QL Tier a Tier a QL; Tier a PA; QL almotriptan malate oral tablet QL ALSUMA PEN INJECTOR AMERGE ORAL ascomp with codeine oral capsule aspirin-caffeine-dihydrocodei n oral capsule ASTRAMORPH-PF INJECTION ST; QL ST; QL AXERT ORAL ST; QL BELBUCA BUCCAL FILM belladonna alkaloids-opium rectal suppository PA; QL belladonna-opium rectal suppository BUPAP ORAL MG BUPRENEX INJECTION buprenorphine hcl injection buprenorphine hcl injection syringe butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-co d oral capsule butalbital-acetaminophen oral tablet butalbital-acetaminophen-caf f oral capsule butalbital-acetaminophen-caf f oral tablet mg butalbital-aspirin-caffeine oral capsule butorphanol tartrate injection butorphanol tartrate nasal spray,non-aerosol BUTRANS TRANSDERMAL PATCH WEEKLY CAFERGOT ORAL CAMBIA ORAL POWDER IN PACKET capacet oral capsule CAPITAL WITH CODEINE ORAL carisoprodol-asa-codeine oral tablet choline,magnesium salicylate oral liquid clonidine (pf) epidural codeine sulfate oral tablet codeine-butalbital-asa-caff oral capsule QL QL PA; QL QL QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 6 Effective 0//6

7 CONZIP ORAL,ER BIPHASE 4 HR 7-8 CONZIP ORAL,ER BIPHASE 4 HR 5-75 D.H.E.45 INJECTION DEMEROL (PF) INJECTION 00 MG/ ML, 5 MG/0.5 ML, 50 MG/ML, 75 MG/.5 ML demerol (pf) injection 00 mg/ml DEMEROL (PF) INJECTION DEMEROL INJECTION DEMEROL ORAL diclofenac potassium oral tablet diflunisal oral tablet dihydroergotamine injection dihydroergotamine nasal spray,non-aerosol DILAUDID ORAL LIQUID DILAUDID ORAL DILAUDID-HP (PF) INJECTION PA; QL PA; QL PA PA QL diskets oral tablet,soluble QL DOLOPHINE ORAL DURACLON (PF) EPIDURAL DURAGESIC TRANSDERMAL PATCH 7 HOUR duramorph (pf) injection ELMIRON ORAL PA; QL PA; QL EMBEDA ORAL,ORAL ONLY,EXT.REL PELL endocet oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg ERGOMAR SUBLINGUAL ESGIC ORAL ESGIC ORAL EXALGO ER ORAL EXTENDED RELEASE 4 HR fentanyl citrate (pf) injection fentanyl citrate (pf) intravenous syringe 00 mcg/ ml (50 mcg/ml) fentanyl citrate buccal lozenge on a handle fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 7 HOUR 7.5 MCG/HOUR, 6.5 MCG/HOUR, 87.5 MCG/HOUR FENTANYL-BUPIVACAI NE-NACL (PF) INJECTION PREFILLED PUMP RESERVOIR -0.5 MCG/ML-% FENTORA BUCCAL, EFFERVESCENT FIORICET ORAL FIORICET WITH CODEINE ORAL MG FIORINAL ORAL FIORINAL-CODEINE # ORAL PA; QL QL PA; QL PA; QL PA; QL PA; QL PA; QL QL FROVA ORAL ST; QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 7 Effective 0//6

8 frovatriptan oral tablet ST; QL HYCET ORAL hydrocodone-acetaminophen oral 0-5 mg/5 ml(5 ml),.5-67 mg/5 ml, 5-6 mg/7.5ml(7.5ml) HYDROCODONE-ACET AMINOPHEN ORAL MG/5 ML hydrocodone-acetaminophen oral tablet 0-00 mg, 0-5 mg, 5-00 mg, 5-5 mg, mg, mg hydrocodone-acetaminophen oral tablet.5-5 mg hydrocodone-ibuprofen oral tablet 0-00 mg, mg hydrocodone-ibuprofen oral tablet 5-00 mg hydromorphone (pf) injection HYDROMORPHONE IN 0.9 % NACL INJECTION PT CONTROLLED ANALGESIA SYRING 5 MG/5 ML hydromorphone injection HYDROMORPHONE INJECTION 0.5 MG/0.5 ML hydromorphone injection syringe mg/ml, mg/ml, 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 4 hr hydromorphone rectal suppository HYSINGLA ER ORAL,ORAL ONLY,EXT.REL.4 HR IBUDONE ORAL 0-00 MG QL QL QL QL QL PA; QL PA; QL IBUDONE ORAL 5-00 MG ibuprofen-oxycodone oral tablet IMITREX NASAL SPRAY,NON-AEROSOL IMITREX ORAL IMITREX STATDOSE KIT REFILL CARTRIDGE IMITREX STATDOSE PEN PEN INJECTOR IMITREX INFUMORPH P/F INJECTION IONSYS TRANSDERMAL SYSTEM,TRANSDERMA L PCA isometh-dichloral-acetamino phn oral capsule isomethepten-caf-acetaminop hen oral tablet mg KADIAN ORAL,EXTEND.REL EASE PELLETS 0 MG, 00 MG, 0 MG, 00 MG, 0 MG, 40 MG, 50 MG, 60 MG, 80 MG QL QL; Tier a ST; QL ST; QL ST; QL ST; QL ST; QL PA; QL ketorolac injection cartridge QL ketorolac injection QL ketorolac injection syringe 5 mg/ml ketorolac injection syringe 0 mg/ml ketorolac intramuscular ketorolac intramuscular syringe QL QL QL ketorolac oral tablet QL; Tier a LAZANDA NASAL SPRAY,NON-AEROSOL levorphanol tartrate oral tablet Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 8 PA; QL PA Effective 0//6

9 lorcet (hydrocodone) oral tablet QL lorcet hd oral tablet QL lorcet plus oral tablet mg QL lortab 0-5 oral tablet QL lortab 5-5 oral tablet QL lortab oral tablet QL LORTAB ELIXIR ORAL 0-00 MG/5 ML margesic oral capsule marten-tab oral tablet QL MAXALT ORAL QL MAXALT-MLT ORAL,DISINTEGRATI NG mefenamic acid oral capsule meperidine (pf) injection 00 mg/ml, 5 mg/ml, 50 mg/ml meperidine injection cartridge meperidine oral meperidine oral tablet QL methadone injection PA; QL methadone intensol oral concentrate PA; QL methadone oral concentrate PA; QL methadone oral PA; QL methadone oral tablet PA; QL methadone oral tablet,soluble PA; QL methadose oral concentrate QL methadose oral tablet,soluble QL migergot rectal suppository MIGRANAL NASAL SPRAY,NON-AEROSOL morphine (pf) in 0.9 % nacl intravenous syringe 0.5 mg/ml morphine (pf) injection 0.5 mg/ml, mg/ml morphine (pf) intravenous patient control.analgesia soln QL morphine concentrate oral morphine injection 5 mg/ml, 8 mg/ml morphine injection syringe 0 mg/ml, mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml MORPHINE PEN INJECTOR morphine intravenous cartridge 0 mg/ml, 5 mg/ml, mg/ml, 4 mg/ml MORPHINE CARTRIDGE 8 MG/ML morphine intravenous pt controlled analgesia syring morphine intravenous 0 mg/ml, 00 mg/4 ml, 5 mg/ml, 50 mg/0 ml, 50 mg/ml MORPHINE 4 MG/ML, 8 MG/ML MORPHINE 0 MG/ML, 8 MG/ML morphine intravenous syringe mg/ml, 4 mg/ml morphine oral capsule, er multiphase 4 hr morphine oral capsule,extend.release pellets morphine oral morphine oral tablet morphine oral tablet extended release morphine rectal suppository MS CONTIN ORAL EXTENDED RELEASE nalbuphine injection PA; QL PA; QL PA; QL PA; QL naratriptan oral tablet QL nodolor oral capsule NORCO ORAL QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 9 Effective 0//6

10 NUCYNTA ER ORAL EXTENDED RELEASE HR NUCYNTA ORAL OFIRMEV ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED OPANA ER ORAL,ORAL ONLY,EXT.REL. HR OPANA INJECTION PA; QL QL ST; QL PA; QL OPANA ORAL QL OXAYDO ORAL, ORAL ONLY oxycodone oral capsule oxycodone oral concentrate oxycodone oral OXYCODONE ORAL oxycodone oral tablet OXYCODONE ORAL,ORAL ONLY,EXT.REL. HR oxycodone-acetaminophen oral oxycodone-acetaminophen oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg QL PA; QL QL QL oxycodone-aspirin oral tablet QL OXYCONTIN ORAL,ORAL ONLY,EXT.REL. HR PA; QL oxymorphone oral tablet QL oxymorphone oral tablet extended release hr pentazocine-naloxone oral tablet PERCOCET ORAL 0-5 MG,.5-5 MG, 5-5 MG, MG PA; QL QL PONSTEL ORAL PRIALT INTRATHECAL PRIMLEV ORAL PRODRIN ORAL MG QL RELPAX ORAL QL reprexain oral tablet 0-00 mg,.5-00 mg reprexain oral tablet 5-00 mg RIMSO-50 INTRAVESICAL QL rizatriptan oral tablet QL rizatriptan oral tablet,disintegrating ROXICODONE ORAL SPRIX NASAL SPRAY,NON-AEROSOL SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL SUFENTANIL CITRATE sumatriptan nasal spray,non-aerosol sumatriptan succinate oral tablet sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUMAVEL DOSEPRO NEEDLE-FREE INJECTOR SYNALGOS-DC ORAL QL PA; QL QL QL QL QL QL QL ST; QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 0 Effective 0//6

11 TALWIN INJECTION tencon oral tablet 50-5 mg TRAMADOL ORAL,ER BIPHASE 4 HR 7-8 TRAMADOL ORAL,ER BIPHASE 4 HR 5-75 PA; QL PA; QL tramadol oral tablet QL tramadol oral tablet extended release 4 hr tramadol oral tablet, er multiphase 4 hr tramadol-acetaminophen oral tablet TREXIMET ORAL TREZIX ORAL MG TYLENOL-CODEINE # ORAL TYLENOL-CODEINE #4 ORAL ULTIVA RECON ULTRACET ORAL ULTRAM ER ORAL EXTENDED RELEASE 4 HR 00 MG PA; QL PA; QL QL ST; QL QL QL QL QL PA; QL ULTRAM ORAL QL VANATOL LQ ORAL verdrocet oral tablet vicodin es oral tablet QL vicodin hp oral tablet QL vicodin oral tablet QL XARTEMIS XR ORAL TAB,ORAL ONLY,IR - ER, BIPHASE XODOL 0/00 ORAL XODOL 5/00 ORAL ST; QL QL QL XODOL 7.5/00 ORAL XTAMPZA ER ORAL,SPRINKLE,ER HR TMPRR xylon 0 oral tablet QL PA; QL zamicet oral QL zebutal oral capsule mg ZEMBRACE SYMTOUCH PEN INJECTOR ST; QL ZIPSOR ORAL ST; CE ZOHYDRO ER ORAL, ORAL ONLY, ER HR PA; QL zolmitriptan oral tablet QL zolmitriptan oral tablet,disintegrating ZOMIG NASAL SPRAY,NON-AEROSOL.5 MG ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG QL ST; QL ST ZOMIG ORAL ST; QL ZOMIG ZMT ORAL,DISINTEGRATI NG ANESTHETICS AMIDATE AMIDATE ARTICADENT DENTAL INJECTION CARTRIDGE ASTERO TOPICAL GEL WITH PUMP BREVITAL INJECTION RECON.5 GRAM, 500 MG BUCALSEP MUCOUS MEMBRANE AEROSOL,SPRAY Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 ST; QL Effective 0//6

12 BUCALSEP MUCOUS MEMBRANE bupivacaine (pf) injection bupivacaine injection bupivacaine-dextrose-water( pf) injection bupivacaine-epinephrine (pf) injection BUPIVACAINE-EPINEPH RINE BITART INJECTION CARTRIDGE bupivacaine-epinephrine injection CARBOCAINE (PF) INJECTION 0 MG/ML ( %), 0 MG/ML ( %) carbocaine (pf) injection 5 mg/ml (.5 %) CARBOCAINE INJECTION CITANEST FORTE DENTAL INJECTION CARTRIDGE CITANEST PLAIN DENTAL INJECTION CARTRIDGE cocaine topical DERMACINRX PHN PAK TOPICAL KIT, PATCH, MEDICATED, CREAM dermacinrx prizopak topical kit DERMAZYL KIT TOPICAL KIT, PATCH, MEDICATED, CREAM DIPRIVAN EMULSION etomidate intravenous EXPAREL (PF) LOCAL INFILTRATION forane inhalation liquid glydo mucous membrane jelly in applicator isoflurane inhalation liquid IV INFUSION CPI KIT KETALAR INJECTION KETAMINE IN 0.9 % SOD CHLORIDE 00 MG/0 ML (0 MG/ML), 0 MG/ ML (0 MG/ML) ketamine injection KETAMINE 00 MG/ ML (50 MG/ML) LDO PLUS TOPICAL GEL WITH PUMP lidocaine (pf) in d7.5w intrathecal lidocaine (pf) injection 0 mg/ml ( %), 5 mg/ml (.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) LIDOCAINE (PF) INJECTION 0 MG/ML ( %) lidocaine hcl injection lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane % lidocaine hcl mucous membrane 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine viscous mucous membrane lidocaine-epinephrine (pf) injection Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Tier a Tier a Tier a Effective 0//6

13 LIDOCAINE-EPINEPHRI NE BIT INJECTION CARTRIDGE lidocaine-epinephrine injection lidocaine-prilocaine topical cream lidocaine-prilocaine topical kit LIDOCAINE-TETRACAI NE TOPICAL CREAM LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED lidopril topical kit LIVIXIL PAK TOPICAL KIT lta pre-attached laryngotracheal MARCAINE (PF) INJECTION 0.5 % (.5 MG/ML), 0.5 % (5 MG/ML) marcaine (pf) injection 0.75 % (7.5 mg/ml) MARCAINE INJECTION MARCAINE SPINAL (PF) INJECTION MARCAINE-EPINEPHRI NE (PF) INJECTION MARCAINE-EPINEPHRI NE INJECTION MENTHO-CAINE TOPICAL KIT,OINTMENT AND SPRAY MEPIVACAINE (PF) INJECTION CARTRIDGE midazolam (pf) injection cartridge midazolam (pf) injection midazolam (pf) injection syringe mg/ ml ( mg/ml) Tier a MIDAZOLAM (PF) INJECTION 5 MG/ML midazolam injection NAROPIN (PF) INJECTION NESACAINE INJECTION NESACAINE-MPF INJECTION PAIN EASE TOPICAL AEROSOL,SPRAY phenazopyridine oral tablet 00 mg, 00 mg PLIAGLIS TOPICAL CREAM polocaine injection % (0 mg/ml) POLOCAINE INJECTION % polocaine-mpf injection PONTOCAINE TOPICAL propofol intravenous emulsion PYRIDIUM ORAL relador pak plus topical kit ropivacaine (pf) injection SENSORCAINE INJECTION 0.5 % (.5 MG/ML) sensorcaine injection 0.5 % (5 mg/ml) sensorcaine/epinephrine injection SENSORCAINE-MPF INJECTION SENSORCAINE-MPF SPINAL INJECTION SENSORCAINE-MPF/EPI NEPHRINE INJECTION sevoflurane inhalation liquid Tier a Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Effective 0//6

14 SPRAY AND STRETCH TOPICAL AEROSOL,SPRAY SUPRANE INHALATION LIQUID SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING terrell inhalation liquid tetracaine hcl (pf) injection ULTANE INHALATION LIQUID xylocaine dental-epinephrine injection cartridge XYLOCAINE INJECTION XYLOCAINE-EPINEPHR INE INJECTION XYLOCAINE-MPF INJECTION 0 MG/ML ( %), 5 MG/ML (.5 %), 0 MG/ML ( %), 5 MG/ML (0.5 %) XYLOCAINE-MPF/EPIN EPHRINE INJECTION ZINGO INTRADERMAL PEN INJECTOR ANTIALLERGY cromolyn oral concentrate GASTROCROM ORAL CONCENTRATE ANTIARTHRITICS allopurinol oral tablet Tier a aloprim intravenous recon soln ANAPROX DS ORAL ARAVA ORAL ARTHROTEC 50 ORAL,IR,DELAYED REL,BIPHASIC ARTHROTEC 75 ORAL,IR,DELAYED REL,BIPHASIC ST ST CALDOLOR RECON CELEBREX ORAL ST; QL celecoxib oral capsule ST; QL COLCHICINE ORAL COLCHICINE ORAL colchicine-probenecid oral tablet COLCRYS ORAL CUPRIMINE ORAL DAYPRO ORAL DEPEN TITRATABS ORAL diclofenac sodium oral tablet extended release 4 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic DISALCID ORAL PA; QL PA; QL PA; QL ST DUEXIS ORAL ST; CE; QL DYLOJECT EC-NAPROSYN ORAL,DELAYED RELEASE (DR/EC) ELITEK RECON ENBREL RECON ENBREL ENBREL SURECLICK PEN INJECTOR etodolac oral capsule etodolac oral tablet Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 4 4 PA; QL 4 PA; QL 4 PA; QL Effective 0//6

15 etodolac oral tablet extended release 4 hr EUFLEXXA INTRA-ARTICULAR FELDENE ORAL FENOPROFEN ORAL ST fenoprofen oral tablet ST FENORTHO ORAL flurbiprofen oral tablet GEL-ONE INTRA-ARTICULAR GELSYN- INTRA-ARTICULAR GENVISC 850 INTRA-ARTICULAR HUMIRA PEDIATRIC CROHN'S START KIT HUMIRA PEN CROHN'S-UC-HS START PEN INJECTOR KIT HUMIRA PEN PSORIASIS-UVEITIS PEN INJECTOR KIT HUMIRA PEN PEN INJECTOR KIT HUMIRA KIT HYALGAN INTRA-ARTICULAR HYALGAN INTRA-ARTICULAR HYMOVIS INTRA-ARTICULAR ST; CE 4 PA 4 PA; QL 4 PA; QL 4 PA; QL 4 PA; QL 4 PA; QL ibuprofen oral suspension Tier a ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL INDOCIN RECTAL SUPPOSITORY indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg KINERET KRYSTEXXA leflunomide oral tablet meclofenamate oral capsule Tier a ST ST 4 PA; QL; Tier 5 meloxicam oral suspension QL meloxicam oral tablet QL MITIGARE ORAL PA; QL MOBIC ORAL QL MONOVISC INTRA-ARTICULAR nabumetone oral tablet NALFON ORAL 400 MG NAPRELAN CR ORAL, ER MULTIPHASE 4 HR NAPROSYN ORAL NAPROSYN ORAL 500 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg 4 PA ST; CE Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 5 Effective 0//6

16 naproxen sodium oral tablet, er multiphase 4 hr ORENCIA (WITH MALTOSE) RECON ORENCIA CLICKJECT AUTO-INJECTOR ORENCIA ORTHOVISC INTRA-ARTICULAR 4 PA; QL; Tier 5 4 PA; QL; Tier 5 4 PA OTEZLA ORAL 4 PA; QL; Tier 5 OTEZLA STARTER ORAL S,DOSE PACK OTREXUP (PF) AUTO-INJECTOR 0 MG/0.4 ML,.5 MG/0.4 ML, 5 MG/0.4 ML, 0 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML OTREXUP (PF) AUTO-INJECTOR 7.5 MG/0.4 ML,.5 MG/0.4 ML oxaprozin oral tablet piroxicam oral capsule probenecid oral tablet RASUVO (PF) AUTO-INJECTOR RHEUMATREX ORAL S,DOSE PACK RIDAURA ORAL salsalate oral tablet SIMPONI ARIA SIMPONI PEN INJECTOR 4 PA; QL; Tier 5 4 PA; QL; Tier 5 4 PA; QL 4 PA 4 PA; QL SIMPONI sulindac oral tablet SUPARTZ FX INTRA-ARTICULAR SYNVISC INTRA-ARTICULAR SYNVISC-ONE INTRA-ARTICULAR TIVORBEX ORAL tolmetin oral capsule tolmetin oral tablet 4 PA; QL 4 PA 4 PA ST; CE; QL ULORIC ORAL ST VIMOVO ORAL,IR,DELAYED REL,BIPHASIC VIVLODEX ORAL VOLTAREN-XR ORAL EXTENDED RELEASE 4 HR XELJANZ ORAL XELJANZ XR ORAL EXTENDED RELEASE 4 HR ST; CE; QL PA; QL 4 PA; QL; Tier 5 4 PA; QL; Tier 5 XENAFLAMM KIT QL ZORVOLEX ORAL ZURAMPIC ORAL ZYLOPRIM ORAL ANTIASTHMATICS ACCOLATE ORAL acetylcysteine ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ST; CE; QL QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 6 Effective 0//6

17 ADVAIR HFA INHALATION HFA AEROSOL INHALER AEROSPAN INHALATION HFA AEROSOL INHALER albuterol sulfate inhalation for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release hr ALVESCO INHALATION HFA AEROSOL INHALER aminophylline intravenous 50 mg/0 ml AMINOPHYLLINE 500 MG/0 ML ANORO ELLIPTA INHALATION BLISTER WITH DEVICE ARCAPTA NEOHALER INHALATION, W/INHALATION DEVICE ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (0 DOSES), 0 MCG (0 DOSES), 0 MCG (0 DOSES), 0 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (7 DOSES), 0 MCG (4 DOSES) QL QL QL QL QL QL QL QL ATROVENT HFA INHALATION HFA AEROSOL INHALER BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER BREO ELLIPTA INHALATION BLISTER WITH DEVICE BROVANA INHALATION FOR NEBULIZATION budesonide inhalation suspension for nebulization CINQAIR COMBIVENT RESPIMAT INHALATION MIST cromolyn inhalation for nebulization DALIRESP ORAL DULERA INHALATION HFA AEROSOL INHALER ELIXOPHYLLIN ORAL ELIXIR 80 MG/5 ML FLOVENT DISKUS INHALATION BLISTER WITH DEVICE FLOVENT HFA INHALATION HFA AEROSOL INHALER FORADIL AEROLIZER INHALATION, W/INHALATION DEVICE INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE ipratropium bromide inhalation ipratropium-albuterol inhalation for nebulization levalbuterol hcl inhalation for nebulization metaproterenol oral syrup Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 7 QL QL QL QL QL QL QL QL QL QL QL QL Effective 0//6

18 metaproterenol oral tablet montelukast oral granules in packet QL montelukast oral tablet QL montelukast oral tablet,chewable NUCALA RECON PERFOROMIST INHALATION FOR NEBULIZATION PROAIR HFA INHALATION HFA AEROSOL INHALER PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED PROVENTIL HFA INHALATION HFA AEROSOL INHALER PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED PULMICORT INHALATION FOR NEBULIZATION QVAR INHALATION AEROSOL SEEBRI NEOHALER INHALATION, W/INHALATION DEVICE SEREVENT DISKUS INHALATION BLISTER WITH DEVICE SINGULAIR ORAL GRANULES IN PACKET SINGULAIR ORAL SINGULAIR ORAL,CHEWABLE SPIRIVA RESPIMAT INHALATION MIST QL QL QL QL QL QL QL QL QL QL QL QL QL QL SPIRIVA WITH HANDIHALER INHALATION, W/INHALATION DEVICE STIOLTO RESPIMAT INHALATION MIST STRIVERDI RESPIMAT INHALATION MIST SYMBICORT INHALATION HFA AEROSOL INHALER terbutaline oral tablet terbutaline subcutaneous THEO-4 ORAL,EXTENDED RELEASE 4HR theochron oral tablet extended release hr theophylline in dextrose 5 % intravenous parenteral 00 mg/00 ml, 00 mg/50 ml, 400 mg/50 ml, 400 mg/500 ml, 800 mg/50 ml theophylline oral elixir theophylline oral theophylline oral tablet extended release hr theophylline oral tablet extended release 4 hr TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED UTIBRON NEOHALER INHALATION, W/INHALATION DEVICE VENTOLIN HFA INHALATION HFA AEROSOL INHALER VOSPIRE ER ORAL EXTENDED RELEASE HR XOLAIR RECON QL QL QL QL QL QL QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 8 Effective 0//6

19 XOPENEX CONCENTRATE INHALATION FOR NEBULIZATION XOPENEX HFA INHALATION HFA AEROSOL INHALER XOPENEX INHALATION FOR NEBULIZATION zafirlukast oral tablet ZYFLO CR ORAL, ER MULTIPHASE HR ZYFLO ORAL ANTIBIOTICS ACTICLATE ORAL amikacin injection,000 mg/4 ml, 500 mg/ ml QL QL QL ST; CE amoxicillin oral capsule Tier a amoxicillin oral suspension for reconstitution Tier a amoxicillin oral tablet Tier a AMOXICILLIN ORAL, ER MULTIPHASE 4 HR amoxicillin oral tablet,chewable 5 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release hr amoxicillin-pot clavulanate oral tablet,chewable Tier a ampicillin oral capsule Tier a ampicillin oral suspension for reconstitution ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln Tier a ampicillin-sulbactam injection recon soln ampicillin-sulbactam intravenous recon soln AUGMENTIN ES-600 ORAL FOR RECONSTITUTION AUGMENTIN ORAL FOR RECONSTITUTION 5-.5 MG/5 ML AUGMENTIN ORAL FOR RECONSTITUTION MG/5 ML AUGMENTIN ORAL MG, MG AUGMENTIN XR ORAL EXTENDED RELEASE HR AVELOX ABC PACK ORAL AVELOX IN NACL (ISO-OSMOTIC) PIGGYBACK QL AVELOX ORAL QL avidoxy oral tablet AVYCAZ RECON AZACTAM IN DEXTROSE (ISO-OSM) PIGGYBACK AZACTAM INJECTION RECON AZASITE OPHTHALMIC DROPS azithromycin intravenous recon soln azithromycin oral packet QL azithromycin oral suspension for reconstitution QL azithromycin oral tablet QL aztreonam injection recon soln Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 9 Effective 0//6

20 azuphen mb oral capsule baciim intramuscular recon soln bacitracin intramuscular recon soln bacitracin ophthalmic ointment bacitracin-polymyxin b ophthalmic ointment BACTRIM DS ORAL BACTRIM ORAL BACTROBAN NASAL NASAL OINTMENT BACTROBAN TOPICAL CREAM BENZAMYCIN TOPICAL GEL BENZAMYCINPAK TOPICAL GEL BESIVANCE OPHTHALMIC DROPS, BETHKIS INHALATION FOR NEBULIZATION BIAXIN ORAL FOR RECONSTITUTION 50 MG/5 ML BIAXIN ORAL BICILLIN C-R BICILLIN L-A BLEPH-0 OPHTHALMIC DROPS BLEPHAMIDE OPHTHALMIC DROPS, BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT bp 0- topical cleanser Tier a ST 4 Tier 5 CAPASTAT INJECTION RECON CAYSTON INHALATION FOR NEBULIZATION CEDAX ORAL CEDAX ORAL FOR RECONSTITUTION 80 MG/5 ML cefaclor oral capsule cefaclor oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet CEFAZOLIN IN 0.9% SOD CHLORIDE PIGGYBACK GRAM/50 ML cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml CEFAZOLIN IN DEXTROSE (ISO-OS) PIGGYBACK GRAM/00 ML cefazolin injection recon soln cefazolin intravenous recon soln cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet CEFEPIME IN DEXTROSE 5 % PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefepime injection recon soln Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 0 4 Tier 5 Effective 0//6

21 cefixime oral suspension for reconstitution CEFOTAN INJECTION RECON cefotaxime injection recon soln CEFOTETAN IN DEXTROSE, ISO-OSM PIGGYBACK cefotetan injection recon soln cefotetan intravenous recon soln cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet CEFTAZIDIME IN D5W PIGGYBACK ceftazidime injection recon soln ceftibuten oral capsule ceftibuten oral suspension for reconstitution CEFTIN ORAL FOR RECONSTITUTION CEFTIN ORAL 500 MG ceftriaxone in dextrose,iso-os intravenous piggyback ceftriaxone injection recon soln gram, 0 gram, gram, 50 mg, 500 mg CEFTRIAXONE INJECTION RECON 00 GRAM ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln.5 gram, 750 mg cefuroxime sodium intravenous recon soln CENTANY TOPICAL OINTMENT cephalexin oral capsule Tier a cephalexin oral suspension for reconstitution Tier a cephalexin oral tablet Tier a CETRAXAL OTIC DROPPERETTE chloramphenicol sod succinate intravenous recon soln CILOXAN OPHTHALMIC DROPS CILOXAN OPHTHALMIC OINTMENT CIPRO HC OTIC DROPS, CIPRO IN D5W PIGGYBACK 400 MG/00 ML CIPRO ORAL,MICROCA PSULE RECON CIPRO ORAL 50 MG, 500 MG CIPRO XR ORAL, ER MULTIPHASE 4 HR CIPRODEX OTIC DROPS, ciprofloxacin (mixture) oral tablet, er multiphase 4 hr ciprofloxacin hcl ophthalmic drops QL QL Tier a ciprofloxacin hcl oral tablet QL ciprofloxacin hcl otic dropperette ciprofloxacin in 5 % dextrose intravenous piggyback ciprofloxacin lactate intravenous Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Effective 0//6

22 ciprofloxacin oral suspension,microcapsule recon CLAFORAN IN DEXTROSE(ISO-OSM) PIGGYBACK CLAFORAN INJECTION RECON GRAM, 0 GRAM, GRAM CLAFORAN RECON clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 4 hr cleansing wash topical cleanser CLEOCIN IN 5 % DEXTROSE PIGGYBACK CLEOCIN INJECTION cleocin intravenous 00 mg/ ml CLEOCIN 600 MG/4 ML, 900 MG/6 ML CLEOCIN ORAL CLEOCIN ORAL RECON CLEOCIN T TOPICAL GEL CLEOCIN T TOPICAL LOTION CLEOCIN T TOPICAL CLEOCIN T TOPICAL SWAB CLEOCIN VAGINAL CREAM CLEOCIN VAGINAL SUPPOSITORY QL CLIN SINGLE USE INJECTION KIT CLINDAGEL TOPICAL GEL clindamycin hcl oral capsule clindamycin in 5 % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection clindamycin phosphate intravenous clindamycin phosphate topical foam clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical clindamycin phosphate topical swab clindamycin phosphate vaginal cream CLINDESSE VAGINAL CREAM,EXTENDED RELEASE colistin (colistimethate na) injection recon soln COLY-MYCIN M PARENTERAL INJECTION RECON COLY-MYCIN S OTIC DROPS, CORTISPORIN TOPICAL CREAM CORTISPORIN TOPICAL OINTMENT CUBICIN RECON CUBICIN RF RECON Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 ST; CE Effective 0//6

23 CYCLOSERINE ORAL DALVANCE dapsone oral tablet demeclocycline oral tablet dicloxacillin oral capsule DIFICID ORAL DORIBAX RECON DORYX MPC ORAL,DELAYED RELEASE (DR/EC) DORYX ORAL,DELAYED RELEASE (DR/EC) 00 MG, 50 MG doxy-00 intravenous recon soln doxycycline hyclate intravenous recon soln doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 00 mg, 50 mg, 00 mg, 75 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 50 mg doxycycline monohydrate oral capsule DOXYCYCLINE MONOHYDRATE ORAL,IR - DELAY REL,BIPHASE doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet e.e.s. 400 oral tablet CE ST; CE ST ST; CE E.E.S. GRANULES ORAL FOR RECONSTITUTION ery pads topical swab erygel topical gel ERYPED 00 ORAL FOR RECONSTITUTION ERYPED 400 ORAL FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 50 mg, mg ERY-TAB ORAL,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN RECON erythromycin ethylsuccinate oral tablet erythromycin ophthalmic ointment erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin with ethanol topical gel erythromycin with ethanol topical erythromycin with ethanol topical swab erythromycin-benzoyl peroxide topical gel ethambutol oral tablet EVOCLIN TOPICAL FOAM FACTIVE ORAL FLAGYL ER ORAL EXTENDED RELEASE Tier a QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Effective 0//6

24 FLAGYL ORAL FLAGYL ORAL floxin otic drops FORTAZ IN DEXTROSE 5 % PIGGYBACK FORTAZ INJECTION RECON FORTAZ RECON FURADANTIN ORAL gatifloxacin ophthalmic drops gentak ophthalmic ointment Tier a gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml GENTAMICIN IN NACL (ISO-OSM) PIGGYBACK 00 MG/50 ML, 0 MG/00 ML gentamicin injection gentamicin ophthalmic drops Tier a gentamicin ophthalmic ointment gentamicin sulfate (ped) (pf) injection gentamicin sulfate (pf) intravenous 00 mg/0 ml GENTAMICIN SULFATE (PF) 60 MG/6 ML gentamicin topical cream gentamicin topical ointment HIPREX ORAL hyolev mb oral tablet hyophen oral tablet ILOTYCIN OPHTHALMIC OINTMENT Tier a imipenem-cilastatin intravenous recon soln INDIOMIN MB ORAL INVANZ INJECTION RECON INVANZ RECON isoniazid injection Tier a isoniazid oral Tier a isoniazid oral tablet Tier a KEFLEX ORAL KETEK ORAL KITABIS PAK INHALATION FOR NEBULIZATION LEVAQUIN ORAL levofloxacin in d5w intravenous piggyback levofloxacin intravenous levofloxacin ophthalmic drops LEVOFLOXACIN ORAL 4 Tier 5 QL QL levofloxacin oral tablet QL LINCOCIN INJECTION lincomycin injection linezolid intravenous parenteral linezolid oral suspension for reconstitution PA; QL linezolid oral tablet PA; QL linezolid-0.9% sodium chloride intravenous parenteral MACROBID ORAL MACRODANTIN ORAL MAXIPIME INJECTION RECON Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 4 Effective 0//6

25 MAXIPIME RECON MAXITROL OPHTHALMIC DROPS, MAXITROL OPHTHALMIC OINTMENT MEFOXIN IN DEXTROSE (ISO-OSM) PIGGYBACK meropenem intravenous recon soln MEROPENEM-0.9% SODIUM CHLORIDE PIGGYBACK MERREM RECON methenamine hippurate oral tablet methenamine mandelate oral tablet methen-sod phos-meth blue-hyos oral tablet metro i.v. intravenous piggyback METROGEL VAGINAL VAGINAL GEL metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral capsule Tier a metronidazole oral tablet Tier a metronidazole vaginal gel MINOCIN RECON MINOCIN ORAL ST ST; CE minocycline oral capsule ST minocycline oral tablet ST minocycline oral tablet extended release 4 hr mondoxyne nl oral capsule ST MONODOX ORAL MONUROL ORAL PACKET MORGIDOX X 50 KIT morgidox oral capsule MOXATAG ORAL, ER MULTIPHASE 4 HR MOXEZA OPHTHALMIC DROPS, VISCOUS ST; CE moxifloxacin oral tablet QL MOXIFLOXACIN-SOD.A CE,SUL-WATER PIGGYBACK mupirocin calcium topical cream mupirocin topical ointment MYAMBUTOL ORAL 400 MG MYCOBUTIN ORAL nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln nafcillin intravenous recon soln neomycin oral tablet Tier a neomycin-bacitracin-poly-hc ophthalmic ointment neomycin-bacitracin-polymy xin ophthalmic ointment neomycin-polymyxin b-dexameth ophthalmic drops,suspension neomycin-polymyxin b-dexameth ophthalmic ointment neomycin-polymyxin-gramic idin ophthalmic drops neomycin-polymyxin-hc ophthalmic drops,suspension neomycin-polymyxin-hc otic drops,suspension neomycin-polymyxin-hc otic Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 5 Tier a Tier a Effective 0//6

26 neo-polycin hc ophthalmic ointment neo-polycin ophthalmic ointment NEOSPORIN (NEO-POLYM-GRAMICI D) OPHTHALMIC DROPS NEO-SYNALAR KIT TOPICAL CREAM NEO-SYNALAR TOPICAL CREAM nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension NUVESSA VAGINAL GEL OCUFLOX OPHTHALMIC DROPS ofloxacin ophthalmic drops Tier a ofloxacin oral tablet 400 mg QL ofloxacin otic drops ORACEA ORAL,IR - DELAY REL,BIPHASE ORBACTIV RECON OTIPRIO INTRATYMPANIC OTOVEL OTIC oxacillin in dextrose(iso-osm) intravenous piggyback oxacillin injection recon soln oxacillin intravenous recon soln PASER ORAL GRANULES DR FOR SUSP IN PACKET PCE ORAL, PARTICLES/CRYSTALS PENICILLIN G POT IN DEXTROSE PIGGYBACK penicillin g potassium injection recon soln penicillin g procaine intramuscular syringe penicillin g sodium injection recon soln penicillin v potassium oral recon soln penicillin v potassium oral tablet pfizerpen-g injection recon soln phosphasal oral tablet piperacillin-tazobactam intravenous recon soln polycin ophthalmic ointment Tier a polymyxin b sulfate injection recon soln polymyxin b sulf-trimethoprim ophthalmic drops POLYTRIM OPHTHALMIC DROPS PRED-G OPHTHALMIC DROPS, PRED-G S.O.P. OPHTHALMIC OINTMENT PRIFTIN ORAL PRIMAXIN IV RECON PRIMSOL ORAL pyrazinamide oral tablet rifabutin oral capsule RIFADIN RECON RIFADIN ORAL RIFAMATE ORAL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 6 Tier a Effective 0//6

27 rifampin intravenous recon soln rifampin oral capsule RIFATER ORAL SILVADENE TOPICAL CREAM silver sulfadiazine topical cream SIRTURO ORAL SIVEXTRO RECON SIVEXTRO ORAL SOLODYN ORAL EXTENDED RELEASE 4 HR 05 MG, 5 MG, 55 MG, 65 MG, 80 MG SPECTRACEF ORAL 400 MG Tier a PA; QL ST; CE ssd topical cream Tier a sss 0-5 topical foam STREPTOMYCIN RECON sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment sulfacetamide sodium-sulfur topical cleanser 0- %, % sulfacetamide sodium-sulfur topical cleanser 9-4 %, % sulfacetamide sodium-sulfur topical cream 0- % sulfacetamide sodium-sulfur topical cream 0-5 % (w/w), % sulfacetamide sodium-sulfur topical foam sulfacetamide sodium-sulfur topical lotion PA PA sulfacetamide sodium-sulfur topical pads, medicated 0-4 % sulfacetamide sodium-sulfur topical suspension 0-5 % sulfacetamide sodium-sulfur topical suspension 8-4 % sulfacetamide sod-sulfur-urea topical cleanser sulfacetamide-prednisolone ophthalmic drops sulfacetamide-sulfur-cleansr topical kit sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream sulfadiazine oral tablet sulfamethoxazole-trimethopri m intravenous sulfamethoxazole-trimethopri m oral suspension sulfamethoxazole-trimethopri m oral tablet SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET PA PA PA Tier a Tier a sulfatrim oral suspension Tier a SUPRAX ORAL SUPRAX ORAL FOR RECONSTITUTION SUPRAX ORAL,CHEWABLE SYNERCID RECON TARGADOX ORAL TAZICEF INJECTION RECON TAZICEF RECON Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 7 Effective 0//6

28 TEFLARO RECON tetracycline oral capsule THALOMID ORAL PA; QL thermazene topical cream Tier a TOBI INHALATION FOR NEBULIZATION TOBI PODHALER INHALATION TOBI PODHALER INHALATION, W/INHALATION DEVICE TOBRADEX OPHTHALMIC DROPS, TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST OPHTHALMIC DROPS, tobramycin in 0.5 % nacl inhalation for nebulization tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml 4 Tier 5 4 Tier 5 4 Tier 5 tobramycin ophthalmic drops Tier a tobramycin sulfate injection recon soln tobramycin sulfate injection tobramycin-dexamethasone ophthalmic drops,suspension TOBREX OPHTHALMIC DROPS TOBREX OPHTHALMIC OINTMENT TRECATOR ORAL trimethoprim oral tablet Tier a TYGACIL RECON 4 UNASYN INJECTION RECON ur n-c oral tablet uramit mb oral capsule URELLE ORAL uretron d-s oral tablet mg URIBEL ORAL urimar-t oral tablet urin ds oral tablet uro-458 oral tablet urogesic-blue oral tablet uro-l oral tablet urolet mb oral tablet uro-mp oral capsule urophen mb oral tablet uryl oral tablet ustell oral capsule UTA ORAL utira-c oral tablet VANCOCIN ORAL VANCOMYCIN IN 0.9% SODIUM CL PIGGYBACK VANCOMYCIN IN 0.9% SODIUM CL.5 GRAM/500 ML, 750 MG/50 ML VANCOMYCIN IN DEXTROSE 5 % PIGGYBACK vancomycin intravenous recon soln,000 mg, 0 gram, 5 gram, 500 mg VANCOMYCIN RECON 750 MG PA PA PA PA vancomycin oral capsule PA vandazole vaginal gel Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 8 Effective 0//6

29 VIBATIV RECON VIBRAMYCIN ORAL 00 MG VIBRAMYCIN ORAL FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP VIGAMOX OPHTHALMIC DROPS XIFAXAN ORAL ZERBAXA RECON ZINACEF IN STERILE WATER PIGGYBACK ZINACEF INJECTION RECON ZINACEF RECON ZITHROMAX RECON ZITHROMAX ORAL PACKET ZITHROMAX ORAL FOR RECONSTITUTION ZITHROMAX ORAL ZITHROMAX TRI-PAK ORAL ZITHROMAX Z-PAK ORAL ZMAX ORAL,EXTENDE D REL RECON ZOSYN IN DEXTROSE (ISO-OSM) PIGGYBACK ZOSYN RECON ST; CE PA; QL QL QL QL QL QL QL ZYLET OPHTHALMIC DROPS, ZYMAXID OPHTHALMIC DROPS ZYVOX PARENTERAL ZYVOX ORAL FOR RECONSTITUTION PA; QL ZYVOX ORAL PA; QL ANTICOAGULANTS ACD ACD-A ANGIOMAX RECON ANTICOAG CITRATE PHOS DEXTROSE ARGATROBAN IN 0.9 % SOD CHLOR PARENTERAL ARGATROBAN IN 0.9 % SOD CHLOR ARGATROBAN IN NACL (ISO-OS) ARGATROBAN ARIXTRA BIVALIRUDIN RECON COUMADIN ORAL 4 Tier 5 ELIQUIS ORAL QL enoxaparin subcutaneous enoxaparin subcutaneous syringe 4 4 Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 9 Effective 0//6

30 fondaparinux subcutaneous syringe FRAGMIN FRAGMIN hep flush-0 (pf) intravenous HEPARIN (PORCINE) IN 0.9% NACL PARENTERAL 4000 UNIT/000 ML (4 UNIT/ML) heparin (porcine) in 5 % dex intravenous parenteral heparin (porcine) in nacl (pf) intravenous parenteral,000 unit/500 ml,,000 unit/,000 ml heparin (porcine) injection cartridge heparin (porcine) injection heparin flush intravenous kit heparin flush(porcine)-0.9nacl intravenous kit heparin lock flush (porcine) intravenous heparin lock flush (porcine) intravenous syringe heparin lock flush intravenous heparin lock flush intravenous syringe heparin lock intravenous heparin lockflush(porcine)(pf) intravenous syringe HEPARIN(PORCINE) IN 0.45% NACL PARENTERAL,500 UNIT/50 ML heparin(porcine) in 0.45% nacl intravenous parenteral 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection heparin, porcine (pf) injection syringe heparin, porcine (pf) intravenous 00 unit/ml ( ml) heparin, porcine (pf) intravenous syringe IPRIVASK RECON 4 Tier 5 jantoven oral tablet Tier a LOVENOX LOVENOX monoject prefill (pf) intravenous syringe PRADAXA ORAL SAVAYSA ORAL SODIUM CITRATE TRICITRASOL INJECTION CONCENTRATE 4 Tier 5 4 Tier 5 QL QL warfarin oral tablet Tier a XARELTO ORAL XARELTO ORAL S,DOSE PACK ANTIDOTES EVZIO INJECTION AUTO-INJECTOR QL ST; QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 0 Effective 0//6

31 MOVANTIK ORAL naloxone injection QL naloxone injection syringe QL naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL RELISTOR ORAL RELISTOR RELISTOR REVIA ORAL ANTIFUNGALS ABELCET AMBISOME FOR RECONSTITUTION amphotericin b injection recon soln ANCOBON ORAL CANCIDAS RECON ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical ciclopirox topical suspension clotrimazole mucous membrane troche clotrimazole topical cream clotrimazole topical clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion QL CRESEMBA RECON CRESEMBA ORAL DIFLUCAN ORAL FOR RECONSTITUTION DIFLUCAN ORAL econazole topical cream PA; QL PA; QL ECOZA TOPICAL FOAM ST ERAXIS(WATER DILUENT) RECON ERTACZO TOPICAL CREAM EXELDERM TOPICAL CREAM EXELDERM TOPICAL EXODERM TOPICAL LOTION EXTINA TOPICAL FOAM fluconazole in dextrose(iso-o) intravenous piggyback FLUCONAZOLE IN NACL (ISO-OSM) PIGGYBACK 00 MG/50 ML fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 400 mg/00 ml fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet ST ST ST Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Effective 0//6

32 GRIS-PEG (ULTRAMICROSIZE) ORAL GYNAZOLE- VAGINAL CREAM itraconazole oral capsule PA JUBLIA TOPICAL WITH APPLICATOR KERYDIN TOPICAL WITH APPLICATOR ketoconazole oral tablet ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo LAMISIL ORAL LOPROX (AS OLAMINE) TOPICAL CREAM LOPROX KIT TOPICAL COMBO PACK LOPROX TOPICAL SHAMPOO LOTRISONE TOPICAL CREAM ST LUZU TOPICAL CREAM ST MENTAX TOPICAL CREAM miconazole- vaginal suppository MYCAMINE RECON NAFTIFINE TOPICAL CREAM % naftifine topical cream % NAFTIN TOPICAL CREAM % ST ST NAFTIN TOPICAL GEL ST NATACYN OPHTHALMIC DROPS, NIZORAL TOPICAL SHAMPOO ST NOXAFIL NOXAFIL ORAL NOXAFIL ORAL,DELAYED RELEASE (DR/EC) nyamyc topical powder nystatin oral powder nystatin oral suspension nystatin oral tablet nystatin topical cream nystatin topical ointment nystatin topical powder nystatin-triamcinolone topical cream nystatin-triamcinolone topical ointment nystop topical powder PA; QL PA; QL ONMEL ORAL PA ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL oxiconazole topical cream OXISTAT TOPICAL CREAM OXISTAT TOPICAL LOTION PENLAC TOPICAL SPORANOX ORAL SPORANOX ORAL SPORANOX PULSEPAK ORAL TERAZOL VAGINAL CREAM TERAZOL 7 VAGINAL CREAM terbinafine hcl oral tablet terconazole vaginal cream terconazole vaginal suppository ST ST ST PA; QL PA; QL PA; QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Effective 0//6

33 TRIACETIN LIQUID QL TRIPLE DYE TOPICAL SWAB VFEND IV VFEND ORAL FOR RECONSTITUTION PA; QL VFEND ORAL PA; QL voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet VUSION TOPICAL OINTMENT XOLEGEL TOPICAL GEL ANTIHISTAMINE AND DECONGESTANT COMBINATION ALLEGRA-D 4 HOUR ORAL EXTENDED RELEASE 4 HR centergy oral drops CLARINEX-D HOUR ORAL, ER MULTIPHASE HR promethazine vc oral syrup promethazine-phenylephrine oral syrup SEMPREX-D ORAL ANTIHISTAMINES arbinoxa oral liquid arbinoxa oral tablet ST; CE ST; CE ST; CE azelastine ophthalmic drops QL BEPREVE OPHTHALMIC DROPS carbinoxamine maleate oral liquid carbinoxamine maleate oral tablet ST; CE; QL cetirizine oral mg/ml CLARINEX ORAL SYRUP CLARINEX ORAL clemastine oral tablet.68 mg CYPROHEPTADINE ORAL SYRUP cyproheptadine oral tablet QL ST; CE ST; CE desloratadine oral tablet QL desloratadine oral tablet,disintegrating diphenhydramine hcl injection 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule 50 mg diphenhydramine hcl oral elixir ELESTAT OPHTHALMIC DROPS EMADINE OPHTHALMIC DROPS QL ST; CE; QL ST; CE; QL epinastine ophthalmic drops QL hydroxyzine hcl intramuscular HYDROXYZINE HCL ORAL 0 MG/5 ML hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule KARBINAL ER ORAL,EXTENDE D REL HR LASTACAFT OPHTHALMIC DROPS Tier a ST; CE; QL levocetirizine oral QL levocetirizine oral tablet QL olopatadine ophthalmic drops ST; QL PATADAY OPHTHALMIC DROPS ST; CE; QL Tier a = This drug may have a lower member cost share based on your plan design, effective //7 Tier 5 = This drug may have a higher member cost share based on your plan design, effective //7 Effective 0//6