Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs THIS DOCUMENT HAS INFORMATION ABOUT THE PRESCRIPTION DRUGS WE COVER FOR QUALIFIED HEALTH PLANS. Qualified Health Plans (QHP) are Affordable Care Act-compliant plans that cover essential health benefits and follow established limits on cost-sharing. In addition to frequently asked questions regarding our drug formulary and prescription coverage, the actual list of covered drugs for our health plans is also included herein. This list is current as of January 2018. For more information If you have questions about your health plan, please call a Customer Service specialist at one of the phone numbers listed below or log in at hap.org and send us a message. Personal Alliance Qualified Health Plans HMO Plans: (800) 759-3436 PPO Plans: (800) 944-9399 Hours: Monday through Friday from 8 a.m. to 8 p.m. Saturday from 8 a.m. to noon Small Group Qualified Health Plans HMO Plans: (800) 422-4641 Hours: Monday through Friday from 7 a.m. to 7 p.m. Saturday from 8 a.m. to noon PPO Plans: (888) 999-4347 Hours: Monday through Friday from 8 a.m. to 5 p.m. Saturday from 8 a.m. to noon If you are deaf, hard of hearing or unable to speak, please use our TTY/TDD line at 711. Please note: A drug's formulary status may change prior to being updated in this document. The listing of a drug does not imply coverage for all benefits. Some dosage forms or strengths of an existing formulary drug may not be covered. Please contact us for more details.
What is the drug formulary? A formulary is a list of covered prescription drugs. Prescription drugs are self-administered medications that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered prescription drugs is selected with a team of health care providers. This represents the prescription therapies believed to be a necessary part of a quality treatment program. We will cover the drug listed in our formulary as long as it is medically necessary, the prescription is filled at an in-network pharmacy and other rules of the health plan are followed. Formulary list can change over time. We may add new drugs as they are approved by the FDA and likewise we may remove drugs as new information about safety and effectiveness is available. We may also change the tier which reflects your cost-share for the drug. We may update our rules for coverage meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage. The Qualified Health Plan Formulary is available at hap.org/formulary. How do I use the drug formulary? The formulary has a list of covered generic and brand name drugs and is organized by categories. Each category depends on the type of medical conditions that the drugs are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what a drug is used for, look for the category name in the list. Then look under the category name for the drug. If you are not sure what category to look under, you should look for your drug in the Index that is at the end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document. If you are using a computer, you can search for a specific drug within the formulary, just select Ctrl-F and enter the name of the drug in the search box. The cursor will highlight the drug you are looking for. What is a generic substitution? When an FDA approved generic drug is available, your prescription will be filled with the generic form of the medication. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your health plan less money than a brand name drug.. What are specialty drugs? Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy. For this reason we contract with Pharmacy Advantage, a specialty pharmacy, from whom you can obtain specialty drugs. Specialty drugs require prior authorization and Pharmacy Advantage can help you and your doctor submit a request. You or your doctor can contact Pharmacy Advantage at (800) 456-2112. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. The coverage requirements are listed on the drug formulary. These requirements and limits may include: Prior Authorization Some medications on our formulary have criteria you must meet before we cover them. This means that you will need to get approval from us before you fill your prescriptions for these drugs. Step Therapy In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Quantity Limits Certain drugs have quantity limits. A quantity limit is the maximum quantity that can be dispensed on each fill of medication or the maximum number of fills allowed for
treatment of certain conditions. Specialty/injectable drugs (except insulin) and select oral drugs (e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugs require a 15-day supply for the first fill. Benefit limitations Our drug formulary applies to drugs used in an outpatient setting. It does not include medication administered in the doctor s office or while in the hospital. These are known as medical drugs. Note that some medical drugs are listed on this formulary because they are part of our Specialty Program. Please refer to what are specialty drug? section for information about these medications The following are general drug coverage exclusions that apply to all members: Over-the-counter (OTC) medications and their equivalents are not covered unless specified in the formulary or on the rider Drug products used for cosmetic purposes are not covered Experimental drugs and/or any drug products used in an experimental manner are not covered Replacement of lost or stolen medication is not covered Since the selected drug packages and coverage vary for each Qualified Health Plan, check your Summary of Benefits and Coverage (SBC) for your cost-sharing and exclusions. What if my drug is not on the drug formulary? When your drug is not listed on the formulary it is considered non-formulary. You or your doctor can ask us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist if one of the formulary alternatives will work for you. Exception approvals for standard non-formulary medications will process at the highest non specialty copayment. Exception approvals for non-formulary specialty drugs will process at the highest Specialty copayment. Non-formulary drugs when approved by plan are limited for up to 30 day supply at a time. Non-formulary specialty drugs when approved for use by the health plan can be required to be dispensed by Pharmacy Advantage. How do I request prior authorization or drug formulary exception? You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us to cover a drug not included on our formulary or ask us to exempt you from a formulary requirement through the exception process. Your doctor must submit a request to us indicating why formulary requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us information when requesting either prior authorization or exception to the formulary. What is included in the drug formulary? The name of the covered drug is listed in the first column. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case (e.g., gabapentin). When a generic drug is listed on the formulary, only the generic is covered. The second column represents the drug s cost-sharing level, or Tier. Every drug on the formulary is in one of six cost-sharing Tiers. The following table will translate how the six Tiers shown on the formulary are applicable to your health plan s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your cost-sharing information.
Description of Tier Preventive generic preventive prescription drugs that are covered at zero cost share per the Affordable Care Act when Health Care Reform (HCR) rules are met. Preferred Generic non-brand name drugs that have the lowest copay Generic- non brand name drugs that are designated by Us to be Non Preferred Generic Preferred Brand brand name formulary drugs that have the lowest brand copay Non-Preferred Brand brand name formulary drugs that are designated by Us to be Non Preferred Brand Preferred Specialty Drugs biologics or drugs that require close monitoring for safety and efficacy and as designated by us to be a specialty drug Non Preferred Specialty Drug biologics or drugs that are designated by us to be Non Preferred Specialty drug Medical Drugs - These are drugs that are infused or administered in doctor s office or facility, are covered under your medical benefit, and may be required by Us to be obtained from Specialty Pharmacy. Copay Tier 0 (Zero Cost Share) Tier 1 A (Medical Coinsurance) The third column lists the requirements or limits that must be met for coverage of your drug. The explanations for the abbreviations are as follows: (Prior Authorization) You or your doctor is required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL (Quantity Limit) We limit the amount of these drugs that are covered for each prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. ST (Step Therapy) Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. SP (Specialty Pharmacy) This specialty drug can only be obtained from Pharmacy Advantage by calling them at (800) 456 2112. HCR (Health Care Reform) You must meet the Health Care Reform requirements for preventive use to obtain the drug at zero cost sharing.
2018 QHP Formulary Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*... 5 *AMINOGLYCOSIDES*...6 *ANALGESICS - ANTI-INFLAMMATORY*...6 *ANALGESICS - NONNARCOTIC*... 9 *ANALGESICS - OPIOID*...9 *ANDROGENS-ANABOLIC*...12 *ANORECTAL AGENTS*... 12 *ANTHELMINTICS*...12 *ANTIANGINAL AGENTS*...12 *ANTIANXIETY AGENTS*... 13 *ANTIARRHYTHMICS*...13 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*...14 *ANTICOAGULANTS*...17 *ANTICONVULSANTS*...18 *ANTIDEPRESSANTS*... 20 *ANTIDIABETICS*...22 *ANTIDIARRHEALS*...25 *ANTIDOTES*...25 *ANTIEMETICS*...26 *ANTIFUNGALS*... 26 *ANTIHISTAMINES*...27 *ANTIHYPERLIPIDEMICS*... 27 *ANTIHYPERTENSIVES*...29 *ANTI-INFECTIVE AGENTS - MISC.*...31 *ANTIMALARIALS*...32 *ANTIMYASTHENIC AGENTS*...32 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*...33 *ANTIMYCOBACTERIAL AGENTS*...33 *ANTINEOPLASTIC - BCL-2 INHIBITORS***... 33 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*... 33 *ANTIRKINSON AGENTS*... 37 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*...39 *ANTIRETROVIRALS ADJUVANTS***...41 *ANTIVIRALS*... 41 *ASSORTED CLASSES*...44 *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***...45 *BETA BLOCKERS*... 46 *BILE ACID SYNTHESIS DISORDER AGENTS***... 46 *CALCIUM CHANNEL BLOCKERS*...46 *CARDIOTONICS*...47 *CARDIOVASCULAR AGENTS - MISC.*...47 *CEPHALOSPORINS*...48 *CONTRACEPTIVES*... 49 *CORTICOSTEROIDS*...54 *COUGH/COLD/ALLERGY*... 54 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***...55 *CYSTIC FIBROSIS AGENT - COMBINATIONS***... 55 *DERMATOLOGICALS*...55 *DIAGNOSTIC PRODUCTS*... 61 *DIGESTIVE AIDS*... 62 *DIRECT-ACTING P2Y12 INHIBITORS***...62 *DIURETICS*...62 *ENDOCRINE AND METABOLIC AGENTS - MISC.*... 63 *ESTROGENS*... 66 1
*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***... 67 *FARNESOID X RECEPTOR (FXR) AGONISTS***... 67 *FLUOROQUINOLONES*...67 *GASTROINTESTINAL AGENTS - MISC.*... 67 *GENITOURINARY AGENTS - MISCELLANEOUS*...69 *GOUT AGENTS*...69 *HEMATOLOGICAL AGENTS - MISC.*...70 *HEMATOPOIETIC AGENTS*... 72 *HEMOSTATICS*... 74 *HETITIS C AGENT - COMBINATIONS***...74 *HYPNOTICS*...74 *INTEGRIN RECEPTOR ANTAGONISTS***... 75 *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAP)***...75 *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAP)***...75 *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***...75 *LAXATIVES*...75 *LEPTIN ANALOGUES***... 76 *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***...76 *MACROLIDES*... 76 *MEDICAL DEVICES*... 76 *MIGRAINE PRODUCTS*...77 *MINERALS & ELECTROLYTES*... 78 *MOUTH/THROAT/DENTAL AGENTS*...78 *MUSCULOSKELETAL THERAPY AGENTS*... 79 *NASAL AGENTS - SYSTEMIC AND TOPICAL*...80 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***...80 *NEUROMUSCULAR AGENTS*...80 *OPHTHALMIC AGENTS*... 80 *OREXIN RECEPTOR ANTAGONISTS***...83 *OTIC AGENTS*... 84 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***...84 *SSIVE IMMUNIZING AGENTS - COMBINATIONS***... 84 *SSIVE IMMUNIZING AGENTS*... 84 *PCSK9 INHIBITORS***...85 *PENICILLINS*... 86 *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***...86 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***... 86 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***... 87 *POLY (ADP-RIBOSE) POLYMERASE (RP) INHIBITORS**...87 *POLY (ADP-RIBOSE) POLYMERASE (RP) INHIBITORS***...87 *POTASSIUM REMOVING AGENTS***... 87 *PROGESTINS*... 87 *PROTEASE-ACTIVATED RECEPTOR-1 (R-1) ANTAGONISTS***... 88 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*... 88 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***... 90 *PULMONARY FIBROSIS AGENTS***...91 *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***... 91 *RESPIRATORY AGENTS - MISC.*... 91 *SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG***...91 *SEROTONIN MODULATORS***...91 *SINUS NODE INHIBITORS**... 91 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***...92 *SULFONAMIDES*...92 *TETRACYCLINES*...92 *THYROID AGENTS*...92 *TRYPTOPHAN HYDROXYLASE INHIBITORS***... 93 *ULCER DRUGS*...93 2
*URINARY ANTI-INFECTIVES*... 94 *URINARY ANTISSMODICS*...95 *VACCINES*... 96 *VAGINAL PRODUCTS*... 96 *VASOPRESSORS*...97 *VITAMINS*...97 3
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2018 QHP Formulary CURRENT AS OF 1/1/2018 DRUG NAME DRUG TIER NOTES *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg QL (1 tablet per 1 day) QL (2 capsules per 1 day) QL (2 tablets per 1 day) QL (4 capsules per 1 day) dextroamphetamine sulfate oral tablet 10 mg, 5 mg QL (6 capsules per 1 day) methamphetamine hcl oral tablet 5 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Anorexiants Non-Amphetamine*** benzphetamine hcl oral tablet 50 mg phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg phentermine hcl oral tablet 37.5 mg *Lipase Inhibitors*** XENICAL ORAL CAPSULE 120 MG *Serotonin 2C Receptor Agonists*** BELVIQ ORAL TABLET 10 MG BELVIQ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 5
*Stimulants - Misc.*** armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg DAYTRANA TRANSDERMAL TCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 20 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml QL (3 tablets per 1 day) QL (3 capsules per 1 day) QL (2 capsules per 1 day) QL (2 capsules per 1 day) QL (2 tablets per 1 day) QL (1 tablet per 1 day) QL (2 tablets per 1 day) QL (10 ML per 1 day) methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg QL (7 tablets per 1 day) modafinil oral tablet 100 mg, 200 mg QL (1 tablet per 1 day) *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg tobramycin inhalation nebulization solution 300 mg/5ml *ANALGESICS - ANTI-INFLAMMATORY* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ ORAL TABLET 5 MG A XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG A Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 6
*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML SIMPONI SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.5ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML SIMPONI SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/ML, 50 MG/0.5ML A A A A A Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 7
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.5ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Gold Compounds*** A RIDAURA ORAL CAPSULE 3 MG *Interleukin-1 Blockers*** ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG *Interleukin-6 Receptor Inhibitors*** ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral tablet 400 mg, 500 mg A A FENOPROFEN CALCIUM ORAL TABLET 600 MG flurbiprofen oral tablet 100 mg, 50 mg indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketoprofen oral capsule 50 mg, 75 mg MECLOFENAMATE SODIUM ORAL CAPSULE 100 MG, 50 MG mefenamic acid oral capsule 250 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg QL (2 capsules per 1 day) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 8
naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg tolmetin sodium oral tablet 200 mg, 600 mg *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg *Selective Costimulation Modulators*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-apap-caffeine oral capsule 50-300-40 mg QL (5 capsules per 1 day) *Salicylates*** aspirin childrens oral tablet chewable 81 mg Tier 0 HCR; QL (1 tablet per 1 day) aspirin ec oral tablet delayed release 325 mg Tier 0 HCR; QL (1 tablet per 1 day) aspirin low dose oral tablet chewable 81 mg Tier 0 HCR; QL (1 tablet per 1 day) aspirin oral tablet 325 mg Tier 0 HCR aspirin oral tablet delayed release 325 mg, 81 mg Tier 0 HCR; QL (1 tablet per 1 day) diflunisal oral tablet 500 mg QL (3 tablets per 1 day) *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300-15 mg QL (10 tablets per 1 day) acetaminophen-codeine #3 oral tablet 300-30 mg QL (10 tablets per 1 day) acetaminophen-codeine #4 oral tablet 300-60 mg QL (10 tablets per 1 day) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 9
acetaminophen-codeine oral solution 120-12 mg/5ml QL (4500 ML per 30 days) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg butalbital-apap-caff-cod oral capsule 50-325-40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 5-200 mg QL (6 capsules per 1 day) QL (3600 ML per 30 days) QL (8 tablets per 1 day) lorcet hd oral tablet 10-325 mg QL (8 tablets per 1 day) lorcet oral tablet 5-325 mg QL (8 tablets per 1 day) lorcet plus oral tablet 7.5-325 mg QL (8 tablets per 1 day) *Opioid Agonists*** codeine sulfate oral tablet 15 mg, 30 mg, 60 mg QL (6 tablets per 1 day) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr HYDROMORPHONE HCL ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 12 MG, 16 MG, 8 MG hydromorphone hcl oral liquid 1 mg/ml QL (10 patches per 30 days) hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg QL (4 tablets per 1 day) levorphanol tartrate oral tablet 2 mg QL (6 tablets per 1 day) meperidine hcl oral tablet 100 mg, 50 mg methadone hcl oral solution 10 mg/5ml, 5 mg/5ml QL methadone hcl oral tablet 10 mg, 5 mg QL (6 tablets per 1 day) morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral capsule extended release 24 hour 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg QL (450 ML per 30 days) QL (3 tablets per 1 day) morphine sulfate oral solution 10 mg/5ml QL (2700 ML per 30 days) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 10
morphine sulfate oral solution 20 mg/5ml QL (1350 ML per 30 days) MORPHINE SULFATE ORAL TABLET 15 MG, 30 MG NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (4 tablets per 1 day) oxycodone hcl oral solution 5 mg/5ml QL (500 ML per 30 days) oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG OXYMORPHONE HCL ER ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG oxymorphone hcl oral tablet 10 mg, 5 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg QL (4 tablets per 1 day) QL (2 tablets per 1 day) tramadol hcl oral tablet 50 mg QL (12 tablets per 1 day) *Opioid Combinations*** oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg QL (4 tablets per 1 day) oxycodone-ibuprofen oral tablet 5-400 mg QL (10 tablets per 1 day) *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg butorphanol tartrate nasal solution 10 mg/ml QL (5 ML per 30 days) BUTRANS TRANSDERMAL TCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR pentazocine-naloxone hcl oral tablet 50-0.5 mg QL (6 tablets per 1 day) *Tramadol Combinations*** tramadol-acetaminophen oral tablet 37.5-325 mg QL (8 tablets per 1 day) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 11
*ANDROGENS-ANABOLIC* *Anabolic Steroids*** ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 10 mg, 2.5 mg *Androgens*** ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) danazol oral capsule 100 mg, 200 mg, 50 mg testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%) *ANORECTAL AGENTS* *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % *Rectal Steroids*** hydrocortisone rectal cream 1 % QL hydrocortisone rectal cream 2.5 % QL (30 GM per 30 days) *ANTHELMINTICS* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG BILTRICIDE ORAL TABLET 600 MG EMVERM ORAL TABLET CHEWABLE 100 MG *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 12
nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg NITROGLYCERIN TRANSLINGUAL AEROSOL SOLUTION 400 MCG/SPRAY nitro-time oral capsule extended release 2.5 mg, 6.5 mg, 9 mg *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 50 mg hydroxyzine hcl oral tablet 25 mg QL (4 tablets per 1 day) HYDROXYZINE MOATE ORAL CAPSULE 100 MG hydroxyzine pamoate oral capsule 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg DIAZEM ORAL SOLUTION 1 MG/ML diazepam oral tablet 10 mg, 2 mg, 5 mg lorazepam oral tablet 0.5 mg, 1 mg, 2 mg oxazepam oral capsule 10 mg, 15 mg, 30 mg *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg quinidine gluconate er oral tablet extended release 324 mg Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 13
quinidine gluconate er oral tablet extended release 324 mg QUINIDINE SULFATE ORAL TABLET 200 MG, 300 MG QUINIDINE SULFATE ORAL TABLET 200 MG, 300 MG *Antiarrhythmics Type I-B*** Covered for Malaria Treatment, not prophylaxis. Covered for Malaria Treatment, not prophylaxis. mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg QL (3 capsules per 1 day) *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl er oral capsule extended release 12 hour 225 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg, 200 mg QL (2 capsules per 1 day) amiodarone hcl oral tablet 400 mg QL (1 tablet per 1 day) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg QL (4 capsules per 1 day) MULTAQ ORAL TABLET 400 MG QL (2 tablets per 1 day) pacerone oral tablet 100 mg, 200 mg pacerone oral tablet 400 mg QL (1 tablet per 1 day) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *5-Lipoxygenase Inhibitors*** zileuton er oral tablet extended release 12 hour 600 mg *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH ; QL (4 tablets per 1 day) QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) ; Covered Alternatives: Breo Ellipta, Arcapta Neohaler, Advair, Symbicort Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 14
COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml Tier 1 albuterol sulfate oral tablet 2 mg, 4 mg ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 mg/5ml metaproterenol sulfate oral tablet 10 mg, 20 mg PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) QL (1 capsule per 1 day) ; Covered Alternatives: Perforomist inhalation solution ; Covered Alternatives: ProAir HFA QL (4 ML per 1 day) QL (2 inhalers per 30 days) QL (2 inhalers per 30 days) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 15
PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.02 % SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT *Leukotriene Receptor Antagonists*** QL (2 inhalers per 30 days) QL (1 diskus per 30 days) QL (2 inhalers per 30 days) QL (2 inhalers per 30 days) QL (1 capsule per 30 days) QL (1 inhaler per 30 days) montelukast sodium oral packet 4 mg QL (1 packet per 1 day) montelukast sodium oral tablet 10 mg QL (1 tablet per 1 day) montelukast sodium oral tablet chewable 4 mg, 5 mg QL (1 tablet per 1 day) zafirlukast oral tablet 10 mg, 20 mg *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET 500 MCG *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) QL (1 inhaler per 30 days) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 16
ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT *Xanthines*** THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG theochron oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors*** Tier 1 QL (1 inhaler per 30 days) QL QL QL QL (1 inhaler per 30 days) ELIQUIS ORAL TABLET 2.5 MG, 5 MG QL (2.5 tablets per 1 day) XARELTO ORAL TABLET 10 MG, 20 MG QL (1 tablet per 1 day) XARELTO ORAL TABLET 15 MG QL (2 tablets per 1 day) XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml QL enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML QL QL Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 17
*Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 150 MG, 75 MG QL (2.5 capsules per 1 day) *ANTICONVULSANTS* *Ampa Glutamate Receptor Antagonists*** FYCOM ORAL SUSPENSION 0.5 MG/ML FYCOM ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg ONFI ORAL TABLET 10 MG, 20 MG *Anticonvulsants - Misc.*** APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 500 mg QL (8 capsules per 1 day) QL (1 tablet per 1 day) QL (4 tablets per 1 day) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 18
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG oxcarbazepine oral suspension 300 mg/5ml ; Covered Alternatives: Gabapentin oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg QL (8 tablets per 1 day) primidone oral tablet 250 mg, 50 mg TOPIRAMATE ORAL CAPSULE SPRINKLE 15 MG, 25 MG topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg VIMT ORAL SOLUTION 10 MG/ML VIMT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg *Carbamates*** felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg *Gaba Modulators*** SABRIL ORAL TABLET 500 MG tiagabine hcl oral tablet 2 mg, 4 mg vigabatrin oral packet 500 mg *Hydantoins*** DILANTIN ORAL CAPSULE 30 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg *Succinimides*** ST; QL; QL (8 capsules per 1 day) CELONTIN ORAL CAPSULE 300 MG QL (4 capsules per 1 day) ethosuximide oral capsule 250 mg QL (7 capsules per 1 day) *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 19
valproic acid oral capsule 250 mg *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 mg QL (4 tablets per 1 day) mirtazapine oral tablet 7.5 mg QL (2 tablets per 1 day) mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg MAPROTILINE HCL ORAL TABLET 25 MG, 50 MG, 75 MG *Modified Cyclics*** nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL TCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR ; Covered Alternatives: citalopram, fluoxetine, sertraline, paroxetine MARPLAN ORAL TABLET 10 MG QL (6 tablets per 1 day) phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg escitalopram oxalate oral solution 5 mg/5ml Tier 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg QL (2 tablets per 1 day) fluoxetine hcl oral capsule 40 mg Tier 1 Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 20
fluoxetine hcl oral solution 20 mg/5ml fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg paroxetine hcl oral tablet 20 mg, 30 mg, 40 mg Tier 1 QL (1 tablet per 1 day) sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 100 mg, 25 mg, 50 mg *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg *Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg QL (1 tablet per 1 day) QL (2 capsules per 1 day) QL (2 capsules per 1 day) QL (3 tablets per 1 day) QL (4 capsules per 1 day) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 21
*ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg miglitol oral tablet 100 mg, 25 mg, 50 mg *Antidiabetic - Amylin Analogs*** SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Tier 1 *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** QL (4 tablets per 1 day) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG QL (1 tablet per 1 day) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG ONGLYZA ORAL TABLET 2.5 MG, 5 MG TRADJENTA ORAL TABLET 5 MG *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET 0.8 MG *Human Insulin*** HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 UNIT/ML QL (2 tablets per 1 day) QL (1 tablet per 1 day) ; Covered Alternatives: Novolog ; Covered Alternatives: Novolin/Novolog ; Covered Alternatives: Novolog Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 22
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML lantus solostar subcutaneous solution pen-injector 100 unit/ml ; Covered Alternatives: Novolin/Novolog ; Covered Alternatives: Novolog ; Covered Alternatives: Novolin/Novolog ; Covered Alternatives: Novolog ; Covered Alternatives: Novolog ; Covered Alternatives: Novolog ; Covered Alternatives: Novolin ; Covered Alternatives: Novolin ; Covered Alternatives: Novolin ; Covered Alternatives: Novolin N, Novolin R ; Covered Alternatives: Novolin QL (60 ML per 30 days) lantus subcutaneous solution 100 unit/ml QL (60 ML per 30 days) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML QL (60 ML per 30 days) QL (2 ML per 1 day) QL (60 ML per 30 days) QL (2 ML per 1 day) QL (2 ML per 1 day) QL (60 ML per 30 days) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 23
NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (9 ML per 30 days) ; Covered Alternatives: Trulicity (), Victoza () ; Covered Alternatives: Trulicity (), Victoza () ; Covered Alternatives: Trulicity (), Victoza () repaglinide oral tablet 0.5 mg, 1 mg, 2 mg QL (8 tablets per 1 day) *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 10 MG, 5 MG INVOKANA ORAL TABLET 100 MG, 300 MG ; Covered Alternatives: Jardiance (ST), Synjardy XR (ST) ; Covered Alternatives: Jardiance (ST), Synjardy XR (ST) JARDIANCE ORAL TABLET 10 MG, 25 MG ST; Covered Alternatives: Metformin Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 24
*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg *Sulfonylureas*** chlorpropamide oral tablet 100 mg, 250 mg glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1 glipizide er oral tablet extended release 24 hour 2.5 mg Tier 1 glipizide oral tablet 10 mg, 5 mg Tier 1 glipizide xl oral tablet extended release 24 hour 2.5 mg Tier 1 glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Tier 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg *Thiazolidinediones*** QL (4 tablets per 1 day) QL (4 tablets per 1 day) AVANDIA ORAL TABLET 2 MG, 4 MG QL (2 tablets per 1 day) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Tier 1 QL (1 tablet per 1 day) *ANTIDIARRHEALS* *Antiperistaltic Agents*** DIPHENOXYLATE-ATROPINE ORAL LIQUID 2.5-0.025 MG/5ML diphenoxylate-atropine oral tablet 2.5-0.025 mg loperamide hcl oral capsule 2 mg QL (2 capsules per 1 day) *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL TABLET 500 MG Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 25
JADENU ORAL TABLET 180 MG, 360 MG, 90 MG *Opioid Antagonists*** NALOXONE HCL INJECTION SOLUTION 0.4 MG/ML, 4 MG/10ML naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID 4 MG/0.1ML VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** ANZEMET ORAL TABLET 100 MG, 50 MG ST; QL (3 tablets per 21 days) granisetron hcl oral tablet 1 mg ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml ondansetron hcl oral solution 4 mg/5ml QL (15 ML per 1 day) ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg ondansetron oral tablet dispersible 4 mg *Antiemetic Combinations*** AKYNZEO ORAL CAPSULE 300-0.5 MG DICLEGIS ORAL TABLET DELAYED RELEASE 10-10 MG *Antiemetics - Anticholinergic*** A scopolamine transdermal patch 72 hour 1 mg/3days QL (4 patches per 30 days) trimethobenzamide hcl oral capsule 300 mg QL (2 capsules per 1 day) *Antiemetics - Miscellaneous*** CESAMET ORAL CAPSULE 1 MG dronabinol oral capsule 10 mg, 2.5 mg, 5 mg QL (2 capsules per 1 day) *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125 mg, 40 mg QL (1 capsule per 1 fill) aprepitant oral capsule 80 mg QL (2 capsules per 1 fill) *ANTIFUNGALS* *Antifungals*** flucytosine oral capsule 250 mg, 500 mg A griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 26
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg *Imidazoles*** ketoconazole oral tablet 200 mg *Triazoles*** CRESEMBA ORAL CAPSULE 186 MG fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg itraconazole oral capsule 100 mg NOXAFIL ORAL SUSPENSION 40 MG/ML SPORANOX ORAL SOLUTION 10 MG/ML QL (300 ML per 16 days) voriconazole oral tablet 200 mg, 50 mg *ANTIHISTAMINES* *Antihistamines - Ethanolamines*** CLEMASTINE FUMARATE ORAL TABLET 2.68 MG *Antihistamines - Phenothiazines*** phenadoz rectal suppository 25 mg phenergan rectal suppository 25 mg, 50 mg promethazine hcl oral solution 6.25 mg/5ml promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 50 mg promethegan rectal suppository 25 mg, 50 mg *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 mg/5ml cyproheptadine hcl oral tablet 4 mg *ANTIHYPERLIPIDEMICS* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm QL (4 capsules per 1 day) *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm QL (8 GM per 1 day) Tier 0= Zero Cost Share, Tier 1= Preferred Generic, = Generic, = Preferred Brand, = Non-Preferred Brand, = Specialty Preferred, A= Specialty Non-Preferred 27