[PDF] Assurance Rx (HMO-POS) Essence Rx (HMO-POS) Promise Rx (HMO-POS) Spirit Rx (HMO-POS) Surety Rx (HMO-POS)

1 2017 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN Assurance Rx (HMO-P...

2017

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN

Assurance Rx (HMO-POS) Essence Rx (HMO-POS) Promise Rx (HMO-POS) Spirit Rx (HMO-POS) Surety Rx (HMO-POS) This abridged formulary was updated on July 26, 2016. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Security Health Plan Customer Service at 1-877-998-0998 or, for TTY users, 711, from 8 a.m. to 8 p.m., 7 days a week, or visit https://www.securityhealth.org/medicareadvantage.

Y0117_MC-785-0327-C-08-16 accepted Formulary ID 00017182, v.5

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Security Health Plan. When it refers to “plan” or “our plan,” it means Assurance Rx (HMO-POS), Essence Rx (HMO-POS), Promise Rx (HMO-POS), Spirit Rx (HMOPOS) or Surety Rx (HMO-POS). This document includes a partial list of the drugs (formulary) for our plan which is current as of January 1, 2017. For a complete, updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. Security Health Plan of Wisconsin, Inc., is an HMO, MSA and D-SNP plan with a Medicare contract. Enrollment in Security Health Plan depends on contract renewal. This document is available in alternate formats. Call Customer Service at the number on the covers for more information.

A formulary is a list of covered drugs selected by Security Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Security Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Security Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by Security Health Plan. For a complete listing of all prescription drugs covered by Security Health Plan, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same costsharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2017. To get updated information about the drugs covered by Security Health Plan, please contact us. Our contact information appears on the front and back cover pages.

There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. 1

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 41. The index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list.

Security Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 

Prior Authorization: Security Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Security Health Plan before you fill your prescriptions. If you don’t get approval, Security Health Plan may not cover the drug.



Quantity Limits: For certain drugs, Security Health Plan limits the amount of the drug that your Medicare Advantage plan will cover. For example, Security Health Plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard 1-month or 3-month supply.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Security Health Plan to make an exception to these restrictions or limits or for a list of other drugs that may treat your health condition. See the section, “How do I request an exception to Security Health Plan’s formulary?” on page 3 for information about how to request an exception.

If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. This document includes only a partial list of covered drugs, so Security Health Plan may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 2

If you learn that Security Health Plan does not cover your drug, you have two options: 

You can ask Customer Service for a list of similar drugs that are covered by Security Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Security Health Plan.



You can ask Security Health Plan to make an exception and cover your drug. See below for information about how to request an exception.

You can ask Security Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. 

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.



You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.



You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Security Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Security Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. 3

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. There are times outside of your first 90 days of new membership when the prescription drug transition process will also apply. One of the more common examples would be if you experience a change in your level of care (for example, when you are discharged from a hospital to either your home or to a long-term care facility, or if you end your long-term care facility stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in your level of care.

For more detailed information about your Security Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Security Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Security Health Plan of Wisconsin, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Security Health Plan:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service. If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Security Health Plan Member Advocate, 1515 N Saint Joseph Ave, Marshfield, WI 54449-8000, Phone: 715-221-9596, TTY: 711, Fax: 715-221-9449, or [emailprotected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Security Health Plan’s Member Advocate is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1– 800–368–1019, 800–537–7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-877-998-0998. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-877-998-0998. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电 1-877-998-0998。我们的中文工作人员很乐意帮助您。这是一项免费服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-877-998-0998。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-877-998-0998. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-877-998-0998. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-877-998-0998 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheitsund Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-877-998-0998. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-877-998-0998 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-877-9980998. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: ‫ ليس عليك سوى‬،‫ للحصول على مترجم فوري‬.‫إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا‬ ‫ سيقوم شخص ما يتحدث العربية‬.8990-899-778-1 ‫ هذه خدمة مجانية االتصال بنا على‬.‫بمساعدتك‬. Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब दे ने के लिए हमारे पास मफ् ु त दभ ु ाषिया सेवाएँ

उपिब्ध हैं. एक दभ ु ाषिया प्राप्त करने के लिए, बस हमें 1-877-998-0998 पर फोन करें . कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है . यह एक मफ् ु त सेवा है .

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-877-998-0998. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-877-998-0998. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-877-998-0998. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-877-998-0998. Ta usługa jest bezpłatna. Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、 1-877-998-0998. にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

The abridged formulary that begins on the next page provides coverage information about some of the drugs covered by Security Health Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 41. Remember: This is only a partial list of drugs covered by Security Health Plan. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if Security Health Plan has any special requirements for coverage of your drug.

Assurance Rx (HMO-POS) $350 deductible

Tier 1 – Preferred generic drugs 2 – Generic drugs 3 – Preferred brand drugs 4 – Nonpreferred drugs 5 – Specialty drugs 6 – Select Part D vaccines

Essence Rx Promise Rx (HMO-POS) (HMO-POS) $180 deductible $180 deductible

Spirit Rx (HMO-POS) No deductible

Surety Rx (HMO-POS) $350 deductible

$10

$20

$10

$43

$45

$47

$43

$100

26% coinsurance

25% coinsurance

33% coinsurance

26% coinsurance

PA = Prior authorization required PA NS = Prior authorization required on new starts only PA B vs. D = Prior authorization required for Part B vs. Part D coverage HI = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at 1-877-998-0998, Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711.

LA = Limited access This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-877-998-0998, Monday through Sunday from 8 a.m. – 8 p.m. TTY users should call 711.

QL = Quantity limit 7

Drug Name

Drug Tier

Analgesics acetaminophen-codeine oral tablet

Requirements/Limits

Tier 3

butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg

Tier 3

butalbital-acetaminophen oral tablet

Tier 3

butalbital-acetaminophen-caff oral capsule 50325-40 mg

Tier 3

butalbital-acetaminophen-caff oral tablet 50-32540 mg

Tier 3

butalbital-aspirin-caffeine oral capsule

Tier 3

butorphanol tartrate nasal spray,non-aerosol

Tier 4

celecoxib oral capsule

Tier 3

codeine sulfate oral tablet

Tier 3

diclofenac potassium oral tablet

Tier 2

diclofenac sodium oral tablet extended release 24 hr

Tier 2

diclofenac sodium oral tablet,delayed release (dr/ec)

Tier 2

etodolac oral tablet

Tier 2

etodolac oral tablet extended release 24 hr

Tier 2

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

Tier 3

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Tier 3

hydrocodone-ibuprofen oral tablet 7.5-200 mg

Tier 3

hydromorphone oral tablet

Tier 3

hydromorphone oral tablet extended release 24 hr

Tier 4

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

Tier 1

indomethacin oral capsule

Tier 3

indomethacin oral capsule, extended release

Tier 3

ketorolac oral tablet

Tier 3

meloxicam oral tablet

Tier 1

meperidine oral tablet 50 mg

Tier 3

QL (180 EA per 30 days)

methadone oral tablet

Tier 3

QL (180 EA per 30 days)

morphine oral tablet

Tier 3

QL (180 EA per 30 days)

QL (1 EA per 2 days)

QL (120 EA per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg

Tier 3

QL (120 EA per 30 days)

morphine oral tablet extended release 200 mg

Tier 3

QL (180 EA per 30 days)

nabumetone oral tablet

Tier 2

naproxen oral tablet

Tier 1

naproxen oral tablet,delayed release (dr/ec)

Tier 2

naproxen sodium oral tablet 275 mg, 550 mg

Tier 2

oxycodone oral tablet

Tier 3

QL (360 EA per 30 days)

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG

Tier 3

QL (90 EA per 30 days)

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG

Tier 3

QL (120 EA per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 3

sulindac oral tablet 150 mg

Tier 2

tramadol oral tablet

Tier 3

QL (240 EA per 30 days)

tramadol oral tablet extended release 24 hr 100 mg

Tier 4

QL (90 EA per 30 days)

tramadol oral tablet extended release 24 hr 200 mg

Tier 4

QL (60 EA per 30 days)

tramadol oral tablet, er multiphase 24 hr 300 mg

Tier 4

QL (30 EA per 30 days)

tramadol-acetaminophen oral tablet

Tier 3

QL (240 EA per 30 days)

Anesthetics lidocaine hcl mucous membrane gel

Tier 3

lidocaine topical adhesive patch,medicated

Tier 4

lidocaine topical ointment

Tier 4

lidocaine-prilocaine topical cream

Tier 3

Anti-Addiction/ Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec)

Tier 4

buprenorphine hcl sublingual tablet

Tier 3

buprenorphine-naloxone sublingual tablet

Tier 3

CHANTIX ORAL TABLET disulfiram oral tablet

Tier 4

naltrexone oral tablet

Tier 3

NARCAN NASAL SPRAY,NON-AEROSOL

Tier 4

NICOTROL INHALATION CARTRIDGE

Tier 4

PA NS; QL (90 EA per 30 days)

QL (60 EA per 30 days)

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

NICOTROL NS NASAL SPRAY,NONAEROSOL

Tier 4

SUBOXONE SUBLINGUAL FILM

Tier 4

Antibacterials acetic acid otic solution

Tier 2

amikacin injection solution 500 mg/2 ml

Tier 4

amoxicillin oral capsule

Tier 1

amoxicillin-pot clavulanate oral tablet

Tier 2

ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg

Tier 4

ampicillin-sulbactam injection recon soln 15 gram, 3 gram

Tier 4

azithromycin oral tablet

Tier 1

aztreonam injection recon soln 1 gram

Tier 4

bacitracin ophthalmic ointment

Tier 2

BACTROBAN NASAL NASAL OINTMENT

Tier 4

BESIVANCE OPHTHALMIC DROPS,SUSPENSION

Tier 4

cefaclor oral capsule

Tier 2

cefadroxil oral capsule

Tier 2

cefazolin injection recon soln 1 gram, 10 gram, 500 mg

Tier 4

cefdinir oral capsule

Tier 2

cefepime injection recon soln

Tier 4

cefoxitin intravenous recon soln

Tier 4

cefpodoxime oral tablet

Tier 3

cefprozil oral tablet

Tier 2

ceftazidime injection recon soln

Tier 4

ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg

Tier 4

ceftriaxone intravenous recon soln

Tier 4

cefuroxime axetil oral tablet

Tier 2

cephalexin oral capsule 250 mg, 500 mg

Tier 1

CILOXAN OPHTHALMIC OINTMENT ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Tier 3

ciprofloxacin hcl ophthalmic drops

Tier 2

ciprofloxacin hcl oral tablet

Tier 2

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

clarithromycin oral tablet

Tier 2

clarithromycin oral tablet extended release 24 hr

Tier 2

clindamycin hcl oral capsule

Tier 2

COLISTIN (COLISTIMETHATE NA) INJECTION RECON SOLN

Tier 4

DIFICID ORAL TABLET

Tier 5

PA; QL (20 EA per 10 days)

doxycycline hyclate oral capsule

Tier 2

doxycycline hyclate oral tablet 100 mg, 20 mg

Tier 2

doxycycline monohydrate oral tablet 150 mg, 75 mg

Tier 3

ery-tab oral tablet,delayed release (dr/ec)

Tier 4

erythromycin ophthalmic ointment

Tier 2

erythromycin oral tablet

Tier 4

gatifloxacin ophthalmic drops

Tier 3

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

Tier 4

gentamicin injection solution 40 mg/ml

Tier 4

gentamicin ophthalmic drops

Tier 2

imipenem-cilastatin intravenous recon soln 250 mg

Tier 4

imipenem-cilastatin intravenous recon soln 500 mg

Tier 4

INVANZ INJECTION RECON SOLN levofloxacin in d5w intravenous piggyback 500 mg/100 ml

Tier 4

levofloxacin intravenous solution

Tier 4

levofloxacin ophthalmic drops

Tier 3

levofloxacin oral tablet

Tier 1

linezolid oral tablet

Tier 5

meropenem intravenous recon soln 500 mg

Tier 3

metronidazole oral capsule

Tier 2

metronidazole oral tablet

Tier 2

metronidazole topical cream

Tier 3

metronidazole topical gel

Tier 3

metronidazole topical lotion

Tier 3

metronidazole vagin*l gel

Tier 3

minocycline oral capsule

Tier 2

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

MOXEZA OPHTHALMIC DROPS, VISCOUS

Tier 4

moxifloxacin oral tablet

Tier 3

mupirocin calcium topical cream

Tier 4

mupirocin topical ointment

Tier 2

nafcillin injection recon soln 1 gram, 10 gram

Tier 4

nitrofurantoin monohyd/m-cryst oral capsule

Tier 3

ofloxacin ophthalmic drops

Tier 3

ofloxacin oral tablet 400 mg

Tier 3

ofloxacin otic drops

Tier 3

penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml

Tier 4

penicillin g potassium injection recon soln 5 million unit

Tier 4

penicillin v potassium oral tablet

Tier 2

piperacillin-tazobactam intravenous recon soln 3.375 gram

Tier 4

piperacillin-tazobactam intravenous recon soln 4.5 gram

Tier 4

silver sulfadiazine topical cream

Tier 2

SIVEXTRO ORAL TABLET sulfacetamide sodium ophthalmic drops

Tier 5

sulfamethoxazole-trimethoprim oral tablet

Tier 1

TEFLARO INTRAVENOUS RECON SOLN

Tier 5

TETRACYCLINE ORAL CAPSULE tinidazole oral tablet

Tier 4

Tier 2 HI

Tier 3

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 5

tobramycin ophthalmic drops

Tier 2

tobramycin sulfate injection solution

Tier 4

trimethoprim oral tablet

Tier 2

vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg

Tier 4

VIGAMOX OPHTHALMIC DROPS

Tier 3

XIFAXAN ORAL TABLET 200 MG

Tier 4

XIFAXAN ORAL TABLET 550 MG

Tier 5

Anticonvulsants carbamazepine oral tablet

Tier 2

PA B vs. D

PA B vs. D; HI

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg

Tier 2

clonazepam oral tablet

Tier 2

diazepam oral tablet

Tier 2

DIAZEPAM RECTAL KIT

Tier 3

DILANTIN EXTENDED ORAL CAPSULE

Tier 3

divalproex oral tablet extended release 24 hr

Tier 2

divalproex oral tablet,delayed release (dr/ec)

Tier 2

FYCOMPA ORAL TABLET gabapentin oral capsule

Tier 4

gabapentin oral tablet 600 mg, 800 mg

Tier 2

lamotrigine oral tablet

Tier 2

levetiracetam oral tablet

Tier 2

levetiracetam oral tablet extended release 24 hr

Tier 2

lorazepam oral tablet

Tier 2

LYRICA ORAL CAPSULE

Tier 4

oxcarbazepine oral tablet

Tier 3

phenobarbital oral tablet

Tier 3

phenytoin sodium extended oral capsule 100 mg

Tier 2

primidone oral tablet

Tier 2

topiramate oral tablet

Tier 2

valproic acid oral capsule

Tier 2

VIMPAT ORAL TABLET zonisamide oral capsule

Tier 4

Requirements/Limits

Tier 2

Antidementia Agents donepezil oral tablet 10 mg, 5 mg

Tier 1

donepezil oral tablet,disintegrating

Tier 1

galantamine oral capsule,ext rel. pellets 24 hr

Tier 4

galantamine oral tablet

Tier 2

memantine oral tablet

Tier 1

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 4

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 4

rivastigmine tartrate oral capsule

Tier 3

Antidepressants amitriptyline oral tablet

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

amitriptyline-chlordiazepoxide oral tablet

Tier 3

aripiprazole oral tablet

Tier 3

bupropion hcl oral tablet

Tier 2

bupropion hcl oral tablet extended release 100 mg, 200 mg

Tier 2

bupropion hcl oral tablet extended release 150 mg

Tier 2

bupropion hcl oral tablet extended release 24 hr

Tier 2

citalopram oral tablet

Tier 1

clomipramine oral capsule

Tier 4

desipramine oral tablet

Tier 1

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR

Tier 4

doxepin oral capsule

Tier 3

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

Tier 2

escitalopram oxalate oral tablet

Tier 1

fluoxetine oral capsule

Tier 1

imipramine hcl oral tablet

Tier 3

maprotiline oral tablet

Tier 4

mirtazapine oral tablet

Tier 2

nefazodone oral tablet

Tier 3

nortriptyline oral capsule

Tier 1

paroxetine hcl oral tablet

Tier 1

perphenazine-amitriptyline oral tablet

Tier 3

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline oral tablet

Requirements/Limits

QL (60 EA per 30 days)

Tier 4 Tier 1

SILENOR ORAL TABLET trazodone oral tablet

Tier 4

venlafaxine oral capsule,extended release 24hr

Tier 2

venlafaxine oral tablet

Tier 2

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

VIIBRYD ORAL TABLET

Tier 4

Tier 1

Antiemetics ANZEMET ORAL TABLET

Tier 5

PA B vs. D

EMEND ORAL CAPSULE

Tier 3

PA B vs. D

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

granisetron hcl oral tablet

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

JANUMET ORAL TABLET

Tier 3

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

JANUVIA ORAL TABLET

Tier 3

LANTUS SUBCUTANEOUS SOLUTION

Tier 3

LEVEMIR SUBCUTANEOUS SOLUTION

Tier 3

metformin oral tablet

Tier 1

metformin oral tablet extended release 24 hr

Tier 1

nateglinide oral tablet

Tier 1

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 3

NOVOLIN N SUBCUTANEOUS SUSPENSION

Tier 3

NOVOLIN R INJECTION SOLUTION

Tier 3

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

Tier 3

NOVOLOG SUBCUTANEOUS SOLUTION

Tier 3

ONGLYZA ORAL TABLET pioglitazone oral tablet

Tier 4

pioglitazone-glimepiride oral tablet

Tier 2

pioglitazone-metformin oral tablet

Tier 2

TANZEUM SUBCUTANEOUS PEN INJECTOR

Tier 4

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

Tier 4

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

Tier 4

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

Tier 3

Requirements/Limits

QL (30 EA per 30 days)

Tier 1

Blood Products/ Modifiers/ Volume Expanders anagrelide oral capsule

Tier 2

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML

Tier 5

PA B vs. D

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML

Tier 5

PA B vs. D

ASPIRIN-DIPYRIDAMOLE ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

BRILINTA ORAL TABLET

Tier 3

clopidogrel oral tablet 75 mg

Tier 1

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

COUMADIN ORAL TABLET

Tier 3

dipyridamole oral tablet

Tier 3

EFFIENT ORAL TABLET

Tier 3

ELIQUIS ORAL TABLET enoxaparin subcutaneous syringe 150 mg/ml

Tier 3

GRANIX SUBCUTANEOUS SYRINGE jantoven oral tablet

Tier 5

NEULASTA SUBCUTANEOUS SYRINGE

Tier 5

NEUPOGEN INJECTION SYRINGE

Tier 5

PRADAXA ORAL CAPSULE 150 MG, 75 MG

Tier 4

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 4

PA B vs. D

Tier 5

PA B vs. D

Tier 5 PA

Tier 2

PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML warfarin oral tablet

Tier 1

XARELTO ORAL TABLET

Tier 3

Cardiovascular Agents acetazolamide oral tablet

Tier 2

amiloride oral tablet

Tier 1

amiloride-hydrochlorothiazide oral tablet

Tier 1

amiodarone oral tablet 200 mg

Tier 1

amlodipine oral tablet

Tier 1

amlodipine-atorvastatin oral tablet

Tier 2

amlodipine-benazepril oral capsule

Tier 2

amlodipine-valsartan oral tablet 10-160 mg

Tier 2

amlodipine-valsartan oral tablet 10-320 mg, 5160 mg, 5-320 mg

Tier 3

atenolol oral tablet

Tier 1

atenolol-chlorthalidone oral tablet

Tier 1

atorvastatin oral tablet

Tier 1

benazepril oral tablet

Tier 1

benazepril-hydrochlorothiazide oral tablet

Tier 2

bisoprolol fumarate oral tablet

Tier 2

bisoprolol-hydrochlorothiazide oral tablet

Tier 2

bumetanide oral tablet

Tier 1

BYSTOLIC ORAL TABLET

Tier 4

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

candesartan oral tablet

Tier 2

candesartan-hydrochlorothiazid oral tablet

Tier 2

captopril oral tablet

Tier 2

captopril-hydrochlorothiazide oral tablet

Tier 2

cartia xt oral capsule,extended release 24hr

Tier 3

carvedilol oral tablet

Tier 1

chlorothiazide oral tablet

Tier 2

chlorthalidone oral tablet 25 mg, 50 mg

Tier 1

clonidine hcl oral tablet

Tier 2

clonidine transdermal patch weekly

Tier 3

colestipol oral tablet

Tier 3

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR digitek oral tablet

Requirements/Limits

Tier 4 Tier 2

digoxin oral tablet

Tier 2

diltiazem hcl oral capsule,extended release 12 hr

Tier 2

diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg

Tier 2

diltiazem hcl oral tablet

Tier 2

doxazosin oral tablet

Tier 2

EDECRIN ORAL TABLET

Tier 4

enalapril maleate oral tablet

Tier 1

enalapril-hydrochlorothiazide oral tablet

Tier 1

ENTRESTO ORAL TABLET felodipine oral tablet extended release 24 hr

Tier 3 Tier 2

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Tier 2

fenofibrate oral tablet 160 mg, 54 mg

Tier 2

fluvastatin oral capsule

Tier 2

fosinopril oral tablet

Tier 1

fosinopril-hydrochlorothiazide oral tablet

Tier 1

furosemide oral tablet

Tier 1

gemfibrozil oral tablet

Tier 2

guanfacine oral tablet

Tier 3

hydralazine oral tablet

Tier 2

hydrochlorothiazide oral tablet

Tier 1

indapamide oral tablet

Tier 1

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

irbesartan oral tablet

Tier 1

irbesartan-hydrochlorothiazide oral tablet

Tier 1

isosorbide dinitrate oral tablet

Tier 2

isosorbide dinitrate oral tablet extended release

Tier 2

isosorbide mononitrate oral tablet 20 mg

Tier 2

isosorbide mononitrate oral tablet extended release 24 hr

Tier 2

lisinopril oral tablet

Tier 1

lisinopril-hydrochlorothiazide oral tablet

Tier 1

losartan oral tablet

Tier 1

losartan-hydrochlorothiazide oral tablet

Tier 1

lovastatin oral tablet

Tier 1

methazolamide oral tablet

Tier 3

methyldopa oral tablet

Tier 3

metolazone oral tablet

Tier 2

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1

mexiletine oral capsule

Tier 2

minoxidil oral tablet

Tier 2

MULTAQ ORAL TABLET

Tier 3

nadolol oral tablet

Tier 3

niacin oral tablet extended release 24 hr

Tier 3

niacor oral tablet

Tier 2

nifedipine oral tablet extended release 24hr

Tier 2

nitroglycerin transdermal patch 24 hour

Tier 2

NITROSTAT SUBLINGUAL TABLET

Tier 3

omega-3 acid ethyl esters oral capsule

Tier 4

pacerone oral tablet 100 mg, 200 mg

Tier 1

pentoxifylline oral tablet extended release

Tier 2

pravastatin oral tablet

Tier 1

prazosin oral capsule

Tier 2

propranolol oral capsule,extended release 24 hr

Tier 2

propranolol oral tablet

Tier 1

propranolol-hydrochlorothiazid oral tablet

Tier 1

quinapril oral tablet

Tier 1

Requirements/Limits

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

quinapril-hydrochlorothiazide oral tablet

Tier 1

ramipril oral capsule

Tier 2

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

simvastatin oral tablet

Tier 1

spironolactone oral tablet

Tier 2

spironolacton-hydrochlorothiaz oral tablet

Tier 2

taztia xt oral capsule, extended release

Tier 3

telmisartan oral tablet

Tier 2

telmisartan-hydrochlorothiazid oral tablet

Tier 2

terazosin oral capsule

Tier 2

torsemide oral tablet

Tier 2

trandolapril oral tablet

Tier 1

triamterene-hydrochlorothiazid oral capsule

Tier 2

triamterene-hydrochlorothiazid oral tablet

Tier 2

valsartan oral tablet

Tier 1

valsartan-hydrochlorothiazide oral tablet

Tier 1

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

Tier 3

verapamil oral tablet

Tier 2

verapamil oral tablet extended release 180 mg, 240 mg

Tier 2

VYTORIN 10-10 ORAL TABLET

Tier 4

VYTORIN 10-20 ORAL TABLET

Tier 4

VYTORIN 10-40 ORAL TABLET

Tier 4

VYTORIN 10-80 ORAL TABLET

Tier 4

ZETIA ORAL TABLET

Tier 4

Requirements/Limits

Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 5

PA; LA

AUBAGIO ORAL TABLET

Tier 5

PA; LA

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

Tier 5

BETASERON SUBCUTANEOUS KIT

Tier 5

clonidine hcl oral tablet extended release 12 hr

Tier 4

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

Tier 5

dexmethylphenidate oral tablet

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

dextroamphetamine oral capsule, extended release

Tier 4

dextroamphetamine oral tablet

Tier 3

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 4

dextroamphetamine-amphetamine oral tablet

Tier 3

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

Tier 2

EXTAVIA SUBCUTANEOUS KIT

Tier 5

GILENYA ORAL CAPSULE

Tier 5

glatopa subcutaneous syringe

Tier 5

LYRICA ORAL CAPSULE

Tier 4

methylphenidate oral capsule, er biphasic 30-70 30 mg

Tier 4

methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg

Tier 4

methylphenidate oral tablet

Tier 3

methylphenidate oral tablet extended release 20 mg

Tier 4

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 5

SAVELLA ORAL TABLET

Tier 3

STRATTERA ORAL CAPSULE

Tier 4

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 5

VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

Tier 4

Dental And Oral Agents cevimeline oral capsule

Requirements/Limits

Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 2

doxycycline hyclate oral capsule

Tier 2

doxycycline monohydrate oral tablet 150 mg, 75 mg

Tier 3

minocycline oral capsule

Tier 2

periogard mucous membrane mouthwash

Tier 2

triamcinolone acetonide dental paste

Tier 2

Dermatological Agents adapalene topical cream

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

adapalene topical gel

Tier 3

ammonium lactate topical cream

Tier 3

ammonium lactate topical lotion

Tier 3

AZELEX TOPICAL CREAM calcipotriene scalp solution

Tier 4

CALCIPOTRIENE TOPICAL OINTMENT claravis oral capsule

Tier 4

clindamycin-benzoyl peroxide topical gel 1-5 %

Tier 4

clotrimazole-betamethasone topical cream

Tier 3

diclofenac sodium topical gel 1 %

Tier 2

ELIDEL TOPICAL CREAM

Tier 4

erythromycin-benzoyl peroxide topical gel

Tier 3

FINACEA TOPICAL GEL

Tier 4

fluocinonide topical cream 0.1 %

Tier 3

fluorouracil topical cream 5 %

Tier 3

fluticasone topical cream

Tier 3

fluticasone topical ointment

Tier 3

podofilox topical solution

Tier 3

REGRANEX TOPICAL GEL

Tier 5

selenium sulfide topical lotion

Tier 2

STELARA SUBCUTANEOUS SYRINGE

Tier 5

TAZORAC TOPICAL CREAM tretinoin topical cream

Tier 4

Tier 3

tretinoin topical gel 0.01 %, 0.025 %

Tier 3

Tier 4 Tier 4

Enzyme Replacement/ Modifiers CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,0009,500- 15,000 UNIT, 6,000-19,000 -30,000 UNIT

Tier 3

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,00068,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 5,000-17,000 -27,000 UNIT

Tier 3

Gastrointestinal Agents alosetron oral tablet

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

AMITIZA ORAL CAPSULE

Tier 4

budesonide oral capsule,delayed,extend.release

Tier 5

cimetidine oral tablet

Tier 2

dicyclomine oral capsule

Tier 2

diphenoxylate-atropine oral tablet

Tier 2

enulose oral solution

Tier 2

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg

Tier 3

famotidine oral tablet 20 mg, 40 mg

Tier 2

generlac oral solution

Tier 2

glycopyrrolate oral tablet

Tier 4

lactulose oral solution 10 gram/15 ml

Tier 2

lansoprazole oral capsule,delayed release(dr/ec)

Tier 3

LINZESS ORAL CAPSULE

Tier 4

loperamide oral capsule

Tier 2

metoclopramide hcl oral tablet

Tier 2

misoprostol oral tablet

Tier 3

omeprazole oral capsule,delayed release(dr/ec)

Tier 1

pantoprazole oral tablet,delayed release (dr/ec)

Tier 1

polyethylene glycol 3350 oral powder

Tier 2

proctozone-hc rectal cream

Tier 2

rabeprazole oral tablet,delayed release (dr/ec)

Tier 3

ranitidine hcl oral tablet 150 mg, 300 mg

Tier 1

sucralfate oral tablet

Tier 2

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY ursodiol oral capsule

Requirements/Limits

Tier 3 Tier 4

ursodiol oral tablet

Tier 4

VIBERZI ORAL TABLET

Tier 4

Genitourinary Agents alfuzosin oral tablet extended release 24 hr

Tier 2

calcium acetate oral capsule

Tier 3

CIALIS ORAL TABLET 2.5 MG, 5 MG

Tier 4

doxazosin oral tablet

Tier 2

dutasteride oral capsule

Tier 2

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

finasteride oral tablet 5 mg

Requirements/Limits

Tier 1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR oxybutynin chloride oral tablet

Tier 4 Tier 2

oxybutynin chloride oral tablet extended release 24hr

Tier 2

PHOSLO ORAL CAPSULE

Tier 4

prazosin oral capsule

Tier 2

RENVELA ORAL TABLET

Tier 4

tamsulosin oral capsule,extended release 24hr

Tier 1

terazosin oral capsule

Tier 2

tolterodine oral capsule,extended release 24hr

Tier 3

tolterodine oral tablet

Tier 2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR trospium oral capsule,extended release 24hr

Tier 4 Tier 2

trospium oral tablet

Tier 2

VESICARE ORAL TABLET

Tier 3

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) betamethasone dipropionate topical cream

Tier 3

betamethasone dipropionate topical ointment

Tier 3

clobetasol scalp solution

Tier 3

clobetasol topical gel

Tier 3

clobetasol topical ointment

Tier 3

desonide topical ointment

Tier 3

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg

Tier 2

fludrocortisone oral tablet

Tier 2

fluocinolone topical cream

Tier 3

fluocinolone topical ointment

Tier 3

fluocinonide topical gel

Tier 3

fluocinonide topical ointment

Tier 3

fluticasone topical cream

Tier 3

fluticasone topical ointment

Tier 3

halobetasol propionate topical cream

Tier 4

halobetasol propionate topical ointment

Tier 4

hydrocortisone oral tablet 20 mg, 5 mg

Tier 2

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

hydrocortisone topical cream 2.5 %

Tier 2

hydrocortisone topical ointment 2.5 %

Tier 2

methylprednisolone oral tablet 4 mg

Tier 2

methylprednisolone oral tablets,dose pack

Tier 2

mometasone topical cream

Tier 3

mometasone topical ointment

Tier 3

prednisone oral tablet

Tier 1

proctozone-hc rectal cream

Tier 2

triamcinolone acetonide topical cream

Tier 2

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Tier 2

Requirements/Limits

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin nasal spray,non-aerosol

Tier 3

desmopressin oral tablet

Tier 3

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

Tier 5

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 5 MG/2 ML (2.5 MG/ML)

Tier 5

NUTROPIN AQ SUBCUTANEOUS CARTRIDGE

Tier 5

STIMATE NASAL SPRAY,NON-AEROSOL

Tier 3

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) budesonide oral capsule,delayed,extend.release

Tier 4

PA NS; QL (60 EA per 30 days)

Tier 3

PA NS; QL (150 GM per 30 days)

Tier 5

danazol oral capsule

Tier 4

estrace vagin*l cream

Tier 3

estradiol oral tablet

Tier 3

estradiol transdermal patch semiweekly 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

Tier 3

estradiol transdermal patch weekly

Tier 3

estropipate oral tablet

Tier 3

jinteli oral tablet

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

medroxyprogesterone oral tablet

Tier 2

megestrol oral suspension 400 mg/10 ml (40 mg/ml)

Tier 3

megestrol oral tablet

Tier 3

norethindrone acetate oral tablet

Tier 2

PREMARIN ORAL TABLET

Tier 3

PREMARIN vagin*L CREAM

Tier 3

PREMPHASE ORAL TABLET

Tier 4

PREMPRO ORAL TABLET progesterone micronized oral capsule

Tier 4

raloxifene oral tablet

Tier 2

testosterone cypionate intramuscular oil 200 mg/ml

Tier 4

PA NS

testosterone enanthate intramuscular oil

Tier 4

PA NS; QL (4.5 ML per 30 days)

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %)

Tier 3

PA NS; QL (300 GM per 30 days)

VAGIFEM vagin*L TABLET

Tier 3

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) levothyroxine oral tablet

Tier 1

Tier 2

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 2

liothyronine oral tablet

Tier 2

SYNTHROID ORAL TABLET

Tier 4

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Tier 3

Hormonal Agents, Suppressant (Pituitary) bromocriptine oral tablet

Tier 3

leuprolide subcutaneous kit

Tier 4

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml

Tier 5

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml

Tier 5

Tier 4

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 90 MG/0.3 ML

Requirements/Limits

Tier 5

Hormonal Agents, Suppressant (Thyroid) methimazole oral tablet 10 mg, 5 mg

Tier 2

propylthiouracil oral tablet

Tier 2

Immunological Agents ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 6

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

Tier 6

AFINITOR ORAL TABLET 2.5 MG

Tier 5

PA NS

azathioprine oral tablet

Tier 2

PA B vs. D

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 6

CELLCEPT ORAL CAPSULE cyclosporine oral capsule

Tier 5

PA B vs. D

Tier 3

PA B vs. D

ELIDEL TOPICAL CREAM

Tier 4

ENBREL SUBCUTANEOUS SYRINGE

Tier 5

GARDASIL (PF) INTRAMUSCULAR SYRINGE

Tier 3

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 3

gengraf oral capsule 100 mg, 25 mg

Tier 3

PA B vs. D

HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML

Tier 5

PA; QL (6 EA per 28 days)

leflunomide oral tablet

Tier 1

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 3

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN mercaptopurine oral tablet

Tier 3 Tier 3

methotrexate sodium (pf) injection solution

Tier 4

methotrexate sodium oral tablet

Tier 1

mycophenolate mofetil oral capsule

Tier 3

PA B vs. D

mycophenolate mofetil oral tablet

Tier 3

PA B vs. D

OTEZLA ORAL TABLET

Tier 5

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

Tier 6

RIDAURA ORAL CAPSULE

Tier 5

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

SIMPONI SUBCUTANEOUS PEN INJECTOR

Requirements/Limits

Tier 5

Tier 4

PA B vs. D

tacrolimus oral capsule

Tier 3

PA B vs. D

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 6

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 6

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 6

TYPHIM VI INTRAMUSCULAR SOLUTION

Tier 3

XELJANZ ORAL TABLET

Tier 5

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 6

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML sirolimus oral tablet

Inflammatory Bowel Disease Agents ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 4

balsalazide oral capsule

Tier 4

budesonide oral capsule,delayed,extend.release

Tier 5

colocort rectal enema

Tier 4

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg

Tier 2

DIPENTUM ORAL CAPSULE hydrocortisone oral tablet 20 mg, 5 mg

Tier 5

hydrocortisone rectal enema

Tier 4

methylprednisolone oral tablet 4 mg

Tier 2

methylprednisolone oral tablets,dose pack

Tier 2

PENTASA ORAL CAPSULE, EXTENDED RELEASE

Tier 4

prednisolone acetate ophthalmic drops,suspension

Tier 2

prednisone oral tablet

Tier 1

proctosol hc rectal cream

Tier 2

sulfasalazine oral tablet

Tier 1

sulfasalazine oral tablet,delayed release (dr/ec)

Tier 2

Metabolic Bone Disease Agents alendronate oral tablet 10 mg, 40 mg, 5 mg

Tier 1

QL (30 EA per 30 days)

alendronate oral tablet 35 mg, 70 mg

Tier 1

QL (4 EA per 28 days)

Tier 2

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

calcitonin (salmon) nasal spray,non-aerosol

Tier 3

calcitriol oral capsule

Tier 2

doxercalciferol oral capsule

Tier 4

etidronate disodium oral tablet

Tier 3

FORTEO SUBCUTANEOUS PEN INJECTOR

Tier 5

ibandronate oral tablet

Tier 2

QL (1 EA per 28 days)

paricalcitol oral capsule

Tier 4

risedronate oral tablet 150 mg

Tier 3

QL (1 EA per 28 days)

risedronate oral tablet 30 mg, 5 mg

Tier 3

QL (30 EA per 30 days)

risedronate oral tablet,delayed release (dr/ec)

Tier 3

QL (4 EA per 28 days)

Ophthalmic Agents acetazolamide oral tablet

Tier 2

ALOMIDE OPHTHALMIC DROPS

Tier 3

ALPHAGAN P OPHTHALMIC DROPS 0.1 %

Tier 3

ATROPINE OPHTHALMIC DROPS azelastine ophthalmic drops

Tier 3

bacitracin-polymyxin b ophthalmic ointment

Tier 2

betaxolol ophthalmic drops

Tier 3

BETOPTIC S OPHTHALMIC DROPS,SUSPENSION bimatoprost ophthalmic drops

Tier 4 Tier 2

brimonidine ophthalmic drops

Tier 2

COMBIGAN OPHTHALMIC DROPS

Tier 4

cromolyn ophthalmic drops

Tier 2

dexamethasone sodium phosphate ophthalmic drops

Tier 2

diclofenac sodium ophthalmic drops

Tier 2

dorzolamide ophthalmic drops

Tier 2

dorzolamide-timolol ophthalmic drops

Tier 2

DUREZOL OPHTHALMIC DROPS

Tier 3

epinastine ophthalmic drops

Tier 3

flurbiprofen sodium ophthalmic drops

Tier 2

ketorolac ophthalmic drops

Tier 2

latanoprost ophthalmic drops

Tier 1

levobunolol ophthalmic drops 0.5 %

Tier 2

LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet

Tier 4 Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

neomycin-bacitracin-poly-hc ophthalmic ointment

Tier 3

neomycin-bacitracin-polymyxin ophthalmic ointment

Tier 3

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

Tier 3

neomycin-polymyxin-hc ophthalmic drops,suspension

Tier 3

olopatadine ophthalmic drops

Tier 3

PATADAY OPHTHALMIC DROPS pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %

Tier 4

polymyxin b sulf-trimethoprim ophthalmic drops

Tier 2

PRED MILD OPHTHALMIC DROPS,SUSPENSION

Tier 3

prednisolone acetate ophthalmic drops,suspension

Tier 2

prednisolone sodium phosphate ophthalmic drops

Tier 2

RESTASIS OPHTHALMIC DROPPERETTE sulfacetamide sodium ophthalmic ointment

Tier 3

sulfacetamide-prednisolone ophthalmic drops

Tier 2

timolol maleate ophthalmic drops

Tier 2

timolol maleate ophthalmic gel forming solution

Tier 2

tobramycin-dexamethasone ophthalmic drops,suspension

Tier 2

Requirements/Limits

Tier 2

TRAVATAN Z OPHTHALMIC DROPS travoprost (benzalkonium) ophthalmic drops

Tier 3 Tier 3

ZIOPTAN (PF) OPHTHALMIC DROPPERETTE

Tier 3

Otic Agents CIPRODEX OTIC DROPS,SUSPENSION

Tier 3

hydrocortisone-acetic acid otic drops

Tier 3

neomycin-polymyxin-hc otic drops,suspension

Tier 3

neomycin-polymyxin-hc otic solution

Tier 3

Respiratory Tract/ Pulmonary Agents ADCIRCA ORAL TABLET

Tier 5

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 3

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 3

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

Tier 2

albuterol sulfate oral tablet

Tier 3

albuterol sulfate oral tablet extended release 12 hr

Tier 3

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 4

ATROVENT HFA INHALATION HFA AEROSOL INHALER

Tier 4

azelastine nasal aerosol,spray

Tier 3

azelastine nasal spray,non-aerosol

Tier 3

BREO ELLIPTA INHALATION BLISTER WITH DEVICE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

Requirements/Limits PA B vs. D

Tier 4 Tier 4

COMBIVENT RESPIMAT INHALATION MIST desloratadine oral tablet

PA B vs. D

Tier 3 Tier 2

DULERA INHALATION HFA AEROSOL INHALER epinephrine injection auto-injector 0.15 mg/0.15 ml

Tier 4 Tier 3

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

Tier 3

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 3

FLOVENT HFA INHALATION HFA AEROSOL INHALER fluticasone nasal spray,suspension

Tier 3 Tier 1

hydroxyzine hcl oral tablet

Tier 3

ipratropium bromide inhalation solution

Tier 2

ipratropium bromide nasal spray,non-aerosol

Tier 2

ipratropium-albuterol inhalation solution for nebulization

Tier 1

LETAIRIS ORAL TABLET levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml

Tier 5

levocetirizine oral tablet

Tier 1

montelukast oral tablet

Tier 1

Tier 4

PA B vs. D

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

olopatadine nasal spray,non-aerosol

Tier 3

PROAIR HFA INHALATION HFA AEROSOL INHALER

Tier 4

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3

promethazine oral tablet

Tier 3

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE sildenafil oral tablet

Requirements/Limits

Tier 3 Tier 2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3

STIOLTO RESPIMAT INHALATION MIST

Tier 4

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION terbutaline oral tablet

Tier 3 Tier 2

theophylline oral tablet extended release

Tier 2

theophylline oral tablet extended release 12 hr

Tier 2

TRACLEER ORAL TABLET

Tier 5

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 4

VENTOLIN HFA INHALATION HFA AEROSOL INHALER zafirlukast oral tablet

Tier 3 Tier 3

Skeletal Muscle Relaxants carisoprodol oral tablet 350 mg

Tier 3

chlorzoxazone oral tablet

Tier 3

cyclobenzaprine oral tablet 10 mg, 5 mg

Tier 3

methocarbamol oral tablet

Tier 3

orphenadrine citrate oral tablet extended release

Tier 3

PA PA

Sleep Disorder Agents BELSOMRA ORAL TABLET eszopiclone oral tablet

Tier 4

flurazepam oral capsule

Tier 2

modafinil oral tablet 100 mg

Tier 3

PA; QL (90 EA per 30 Days)

modafinil oral tablet 200 mg

Tier 3

PA; QL (60 EA per 30 Days)

temazepam oral capsule

Tier 2

Tier 3

QL (30 EA per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Drug Name

Drug Tier

Requirements/Limits

Therapeutic Nutrients/ Minerals/ Electrolytes doxercalciferol oral capsule

Tier 4

EXJADE ORAL TABLET, DISPERSIBLE

Tier 5

PA; LA

FERRIPROX ORAL TABLET

Tier 5

JADENU ORAL TABLET klor-con 10 oral tablet extended release

Tier 5

klor-con 8 oral tablet extended release

Tier 2

klor-con m20 oral tablet,er particles/crystals

Tier 2

potassium chloride oral capsule, extended release

Tier 2

potassium chloride oral liquid

Tier 2

potassium chloride oral tablet,er particles/crystals 10 meq

Tier 2

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

Index

A abacavir .................................. 20 abacavir-lamivudine-zidovudine ............................................ 20 acamprosate .............................. 9 acarbose .................................. 22 acetaminophen-codeine ............ 8 acetazolamide ................... 24, 36 acetic acid ............................... 10 ACTHIB (PF) ......................... 34 acyclovir ................................. 20 ADACEL(TDAP ADOLESN/ADULT)(PF) .. 34 adapalene .......................... 28, 29 ADCIRCA .............................. 37 ADVAIR DISKUS ................. 37 ADVAIR HFA ....................... 37 AFINITOR ....................... 17, 34 albuterol sulfate ...................... 38 alendronate ............................. 35 alfuzosin ................................. 30 allopurinol .............................. 15 ALMOTRIPTAN MALATE.. 16 alogliptin................................. 22 alogliptin-metformin .............. 22 alogliptin-pioglitazone ........... 22 ALOMIDE ............................. 36 alosetron ................................. 29 ALPHAGAN P ....................... 36 alprazolam .............................. 21 amantadine hcl.................. 18, 20 amikacin ................................. 10 amiloride................................. 24 amiloride-hydrochlorothiazide24 amiodarone ............................. 24 AMITIZA ............................... 30 amitriptyline ........................... 13 amitriptyline-chlordiazepoxide ............................................ 14 amlodipine .............................. 24 amlodipine-atorvastatin .......... 24 amlodipine-benazepril ............ 24 amlodipine-valsartan .............. 24 ammonium lactate .................. 29 amoxicillin.............................. 10 amoxicillin-pot clavulanate .... 10 ampicillin sodium ................... 10

ampicillin-sulbactam .............. 10 AMPYRA ............................... 27 anagrelide ............................... 23 anastrozole .............................. 17 ANDRODERM ...................... 32 ANDROGEL .......................... 32 ANORO ELLIPTA................. 38 ANZEMET ............................. 14 ARANESP (IN POLYSORBATE) .............. 23 aripiprazole ....................... 14, 19 ASACOL HD ......................... 35 ASPIRIN-DIPYRIDAMOLE . 23 atenolol ................................... 24 atenolol-chlorthalidone ........... 24 atorvastatin ............................. 24 atovaquone-proguanil ............. 18 ATROPINE ............................ 36 ATROVENT HFA ................. 38 AUBAGIO.............................. 27 AVONEX (WITH ALBUMIN) ............................................ 27 azathioprine ............................ 34 azelastine .......................... 36, 38 AZELEX ................................ 29 AZILECT ............................... 18 azithromycin ........................... 10 aztreonam ............................... 10 B bacitracin ................................ 10 bacitracin-polymyxin b........... 36 baclofen .................................. 19 BACTROBAN NASAL ......... 10 balsalazide .............................. 35 BELSOMRA .......................... 39 benazepril ............................... 24 benazepril-hydrochlorothiazide ............................................ 24 benztropine ............................. 18 BESIVANCE.......................... 10 betamethasone dipropionate .. 15, 31 BETASERON ........................ 27 betaxolol ................................. 36 BETOPTIC S.......................... 36 bicalutamide ........................... 17 bimatoprost ............................. 36

bisoprolol fumarate ................. 24 bisoprolol-hydrochlorothiazide ............................................ 24 BLEPHAMIDE ...................... 16 BOOSTRIX TDAP ................. 34 BREO ELLIPTA .................... 38 BRILINTA ............................. 23 brimonidine............................. 36 bromocriptine ................... 18, 33 budesonide ............ 30, 32, 35, 38 bumetanide ............................. 24 buprenorphine hcl ..................... 9 buprenorphine-naloxone ........... 9 bupropion hcl .......................... 14 buspirone ................................ 21 butalbital-acetaminop-caf-cod .. 8 butalbital-acetaminophen ......... 8 butalbital-acetaminophen-caff .. 8 butalbital-aspirin-caffeine......... 8 butorphanol tartrate .................. 8 BYDUREON .......................... 22 BYETTA ................................ 22 BYSTOLIC............................. 24 C calcipotriene ........................... 29 CALCIPOTRIENE ................. 29 calcitonin (salmon) ................. 36 calcitriol .................................. 36 calcium acetate ....................... 30 candesartan ............................. 25 candesartan-hydrochlorothiazid ............................................ 25 CAPRELSA............................ 17 captopril .................................. 25 captopril-hydrochlorothiazide 25 carbamazepine ............ 12, 13, 22 carbidopa ................................ 18 carbidopa-levodopa ................ 18 CARBIDOPA-LEVODOPAENTACAPONE ................. 18 carisoprodol ............................ 39 cartia xt ................................... 25 carvedilol ................................ 25 cefaclor ................................... 10 cefadroxil ................................ 10 cefazolin ................................. 10 cefdinir .................................... 10

cefepime ................................. 10 cefoxitin .................................. 10 cefpodoxime ........................... 10 cefprozil .................................. 10 ceftazidime ............................. 10 ceftriaxone .............................. 10 cefuroxime axetil .................... 10 celecoxib............................. 8, 16 CELLCEPT ............................ 34 cephalexin............................... 10 cevimeline .............................. 28 CHANTIX ................................ 9 chlorhexidine gluconate ......... 28 chloroquine phosphate............ 18 chlorothiazide ......................... 25 chlorpromazine ....................... 19 chlorthalidone ......................... 25 chlorzoxazone......................... 39 CIALIS ................................... 30 ciclopirox ................................ 15 CILOXAN .............................. 10 cimetidine ............................... 30 CIPRODEX ............................ 37 ciprofloxacin (mixture) .......... 10 ciprofloxacin hcl ..................... 10 citalopram ............................... 14 claravis ................................... 29 clarithromycin ........................ 11 clindamycin hcl ...................... 11 clindamycin-benzoyl peroxide29 clobetasol ................................ 31 clomipramine .......................... 14 clonazepam ....................... 13, 21 clonidine ................................. 25 clonidine hcl ..................... 25, 27 clopidogrel .............................. 23 clotrimazole ............................ 15 clotrimazole-betamethasone ... 29 clozapine................................. 19 codeine sulfate .......................... 8 COLCHICINE ........................ 15 colchicine-probenecid ............ 15 colestipol ................................ 25 COLISTIN (COLISTIMETHATE NA) 11 colocort ................................... 35 COMBIGAN .......................... 36 COMBIVENT RESPIMAT ... 38 COMBIVIR ............................ 20 COMETRIQ ........................... 17

COPAXONE .......................... 27 COREG CR ............................ 25 COUMADIN .......................... 24 CREON .................................. 29 CRIXIVAN ............................ 20 cromolyn ................................. 36 cyclobenzaprine ...................... 39 cyclophosphamide .................. 17 cyclosporine............................ 34 D DAKLINZA ........................... 20 danazol.................................... 32 dantrolene ............................... 19 dapsone ................................... 17 DARAPRIM ........................... 18 DENAVIR .............................. 20 desipramine ............................ 14 desloratadine ........................... 38 desmopressin .......................... 32 desonide .................................. 31 DESVENLAFAXINE ............ 14 dexamethasone ........... 16, 31, 35 dexamethasone sodium phosphate ............................ 36 dexmethylphenidate................ 27 dextroamphetamine ................ 28 dextroamphetamineamphetamine ...................... 28 DIASTAT ............................... 21 diazepam ........................... 13, 21 DIAZEPAM ........................... 13 diclofenac potassium .......... 8, 16 diclofenac sodium... 8, 16, 29, 36 dicyclomine ............................ 30 didanosine............................... 20 DIFICID ................................. 11 digitek ..................................... 25 digoxin .................................... 25 DILANTIN EXTENDED....... 13 diltiazem hcl ........................... 25 DIPENTUM ........................... 35 diphenoxylate-atropine ........... 30 dipyridamole........................... 24 disulfiram.................................. 9 divalproex ......................... 13, 22 donepezil ................................ 13 dorzolamide ............................ 36 dorzolamide-timolol ............... 36 doxazosin .......................... 25, 30 doxepin ............................. 14, 21

doxercalciferol .................. 36, 40 doxycycline hyclate .......... 11, 28 doxycycline monohydrate 11, 28 DULERA ................................ 38 duloxetine ................... 14, 21, 28 DUREZOL ............................. 36 dutasteride............................... 30 dutasteride-tamsulosin ............ 30 E econazole ................................ 15 EDECRIN ............................... 25 EFFIENT ................................ 24 ELIDEL ............................ 29, 34 ELIQUIS................................. 24 EMCYT .................................. 17 EMEND .................................. 14 EMTRIVA .............................. 20 enalapril maleate ..................... 25 enalapril-hydrochlorothiazide. 25 ENBREL................................. 34 enoxaparin .............................. 24 entacapone .............................. 19 entecavir ................................. 20 ENTRESTO ............................ 25 enulose .................................... 30 epinastine ................................ 36 epinephrine ............................. 38 EPIPEN 2-PAK ...................... 38 ery-tab ..................................... 11 erythromycin........................... 11 erythromycin-benzoyl peroxide ............................................ 29 escitalopram oxalate ......... 14, 21 esomeprazole magnesium ....... 30 estrace ..................................... 32 estradiol .................................. 32 estropipate............................... 32 eszopiclone ............................. 39 etidronate disodium ................ 36 etodolac............................... 8, 16 exemestane ............................. 17 EXJADE ................................. 40 EXTAVIA .............................. 28 F famciclovir .............................. 20 famotidine ............................... 30 FANAPT................................. 19 FARESTON ........................... 17 felodipine ................................ 25 fenofibrate............................... 25

fenofibrate micronized ........... 25 fentanyl ..................................... 8 FERRIPROX .......................... 40 FINACEA............................... 29 finasteride ............................... 31 FLECTOR .............................. 16 FLOVENT DISKUS .............. 38 FLOVENT HFA ..................... 38 fluconazole ............................. 15 fludrocortisone ....................... 31 fluocinolone............................ 31 fluocinonide...................... 29, 31 fluorouracil ............................. 29 fluoxetine................................ 14 fluphenazine hcl ..................... 19 flurazepam .............................. 39 flurbiprofen sodium ................ 36 flutamide................................. 17 fluticasone .................. 29, 31, 38 fluvastatin ............................... 25 FORTEO ................................ 36 fosinopril ................................ 25 fosinopril-hydrochlorothiazide ............................................ 25 frovatriptan ............................. 16 furosemide .............................. 25 FYCOMPA ............................ 13 G gabapentin .............................. 13 galantamine ............................ 13 GARDASIL (PF).................... 34 GARDASIL 9 (PF)................. 34 gatifloxacin ............................. 11 gauze pad ................................ 22 gemfibrozil ............................. 25 generlac .................................. 30 gengraf .................................... 34 gentamicin .............................. 11 gentamicin in nacl (iso-osm) .. 11 GENVOYA ............................ 20 GILENYA .............................. 28 GILOTRIF .............................. 17 glatopa .................................... 28 glimepiride ............................. 22 glipizide .................................. 22 glipizide-metformin ................ 22 GLUCAGON EMERGENCY KIT (HUMAN) .................. 22 glycopyrrolate......................... 30 granisetron hcl ........................ 15

GRANIX ................................ 24 guanfacine .............................. 25 H halobetasol propionate ............ 31 haloperidol .............................. 19 HARVONI.............................. 20 HEXALEN ............................. 17 HUMIRA ................................ 34 hydralazine ............................. 25 hydrochlorothiazide ................ 25 hydrocodone-acetaminophen.... 8 hydrocodone-ibuprofen ............ 8 hydrocortisone ...... 16, 31, 32, 35 hydrocortisone-acetic acid ...... 37 hydromorphone ........................ 8 hydroxychloroquine................ 18 hydroxyurea ............................ 17 hydroxyzine hcl .......... 15, 21, 38 I ibandronate ............................. 36 IBRANCE .............................. 17 ibuprofen ............................ 8, 16 ICLUSIG ................................ 17 imatinib................................... 17 IMBRUVICA ......................... 17 imipenem-cilastatin ................ 11 imipramine hcl ........................ 14 indapamide ............................. 25 indomethacin ...................... 8, 16 insulin syringe-needle u-100 .. 22 INTRON A ............................. 20 INVANZ ................................. 11 INVEGA SUSTENNA ........... 19 INVIRASE ............................. 20 INVOKAMET ........................ 22 INVOKANA .......................... 22 ipratropium bromide ............... 38 ipratropium-albuterol.............. 38 irbesartan ................................ 26 irbesartan-hydrochlorothiazide ............................................ 26 isoniazid.................................. 17 isosorbide dinitrate ................. 26 isosorbide mononitrate ........... 26 itraconazole ............................ 15 J JADENU ................................ 40 JAKAFI .................................. 17 jantoven .................................. 24 JANUMET ............................. 23

JANUMET XR ....................... 23 JANUVIA ............................... 23 jinteli ....................................... 32 K KALETRA ............................. 20 ketoconazole ........................... 15 ketorolac ....................... 8, 16, 36 klor-con 10.............................. 40 klor-con 8................................ 40 klor-con m20 .......................... 40 L lactulose .................................. 30 lamivudine .............................. 20 lamivudine-zidovudine ........... 20 lamotrigine........................ 13, 22 lansoprazole ............................ 30 LANTUS ................................ 23 latanoprost .............................. 36 LATUDA ................................ 19 leflunomide ............................. 34 LENVIMA .............................. 17 LETAIRIS .............................. 38 letrozole .................................. 17 leucovorin calcium ................. 17 LEUKERAN........................... 17 leuprolide ................................ 33 levalbuterol hcl ....................... 38 LEVEMIR .............................. 23 levetiracetam........................... 13 levobunolol ............................. 36 levocetirizine .......................... 38 levofloxacin ............................ 11 levofloxacin in d5w ................ 11 levothyroxine .......................... 33 levoxyl .................................... 33 lidocaine ................................... 9 lidocaine hcl.............................. 9 lidocaine-prilocaine .................. 9 lindane .................................... 18 linezolid .................................. 11 LINZESS ................................ 30 liothyronine............................. 33 lisinopril.................................. 26 lisinopril-hydrochlorothiazide 26 lithium carbonate .................... 22 loperamide .............................. 30 lorazepam ......................... 13, 21 losartan ................................... 26 losartan-hydrochlorothiazide .. 26 lovastatin................................. 26

LUMIGAN ............................. 36 LUPRON DEPOT .................. 33 LYRICA ........................... 13, 28 M maprotiline ............................. 14 meclizine ................................ 15 medroxyprogesterone ............. 33 mefloquine.............................. 18 megestrol ................................ 33 meloxicam .......................... 8, 16 memantine .............................. 13 MENACTRA (PF) ................. 34 MENOMUNE - A/C/Y/W-135 (PF) ..................................... 34 meperidine ................................ 8 meprobamate .......................... 21 mercaptopurine ....................... 34 meropenem ............................. 11 MESTINON TIMESPAN ...... 17 metformin ............................... 23 methadone ................................ 8 methazolamide ................. 26, 36 methimazole ........................... 34 methocarbamol ....................... 39 methotrexate sodium .............. 34 methotrexate sodium (pf) ....... 34 methyldopa ............................. 26 methylphenidate ..................... 28 methylprednisolone .... 16, 32, 35 metoclopramide hcl .......... 15, 30 metolazone ............................. 26 metoprolol succinate .............. 26 metoprolol tartrate .................. 26 metronidazole ......................... 11 mexiletine ............................... 26 migergot ................................. 16 minocycline ...................... 11, 28 minoxidil ................................ 26 mirtazapine ............................. 14 misoprostol ............................. 30 modafinil ................................ 39 molindone ............................... 19 mometasone............................ 32 montelukast ............................ 38 morphine............................... 8, 9 MOXEZA ............................... 12 moxifloxacin........................... 12 MULTAQ ............................... 26 mupirocin ............................... 12 mupirocin calcium .................. 12

mycophenolate mofetil ........... 34 MYRBETRIQ ........................ 31 N nabumetone ........................ 9, 16 nadolol .................................... 26 nafcillin ................................... 12 naltrexone ................................. 9 NAMENDA XR ..................... 13 NAMZARIC ........................... 13 naproxen ............................. 9, 16 naproxen sodium ...................... 9 naratriptan ............................... 16 NARCAN ................................. 9 nateglinide .............................. 23 NEBUPENT ........................... 18 nefazodone.............................. 14 neomycin-bacitracin-poly-hc.. 37 neomycin-bacitracin-polymyxin ............................................ 37 neomycin-polymyxin bdexameth ............................ 37 neomycin-polymyxin-hc ........ 37 NEULASTA ........................... 24 NEUPOGEN .......................... 24 nevirapine ............................... 20 NEXAVAR ............................ 17 niacin ...................................... 26 niacor ...................................... 26 NICOTROL .............................. 9 NICOTROL NS ...................... 10 nifedipine ................................ 26 NILANDRON ........................ 18 nitrofurantoin monohyd/m-cryst ............................................ 12 nitroglycerin ........................... 26 NITROSTAT .......................... 26 NORDITROPIN FLEXPRO .. 32 norethindrone acetate ............. 33 nortriptyline ............................ 14 NORVIR ................................. 20 NOVOLIN 70/30 .................... 23 NOVOLIN N .......................... 23 NOVOLIN R .......................... 23 NOVOLOG ............................ 23 NOVOLOG MIX 70-30 ......... 23 NOXAFIL .............................. 15 NUTROPIN AQ ..................... 32 NUTROPIN AQ NUSPIN...... 32 nystatin ................................... 15

O octreotide acetate .................... 33 ofloxacin ................................. 12 olanzapine ......................... 19, 22 olopatadine ....................... 37, 39 OLYSIO ................................. 20 omega-3 acid ethyl esters ....... 26 omeprazole ............................. 30 ondansetron............................. 15 ondansetron hcl ....................... 15 ONGLYZA ............................. 23 orphenadrine citrate ................ 39 OTEZLA................................. 34 oxcarbazepine ......................... 13 oxybutynin chloride ................ 31 oxycodone................................. 9 OXYCODONE ......................... 9 oxycodone-acetaminophen ....... 9 P pacerone .................................. 26 PALIPERIDONE ................... 19 PANCREAZE......................... 29 pantoprazole ........................... 30 paricalcitol .............................. 36 paroxetine hcl ................... 14, 21 PATADAY ............................. 37 PEGINTRON REDIPEN........ 20 penicillin g pot in dextrose ..... 12 penicillin g potassium ............. 12 penicillin v potassium ............. 12 PENTASA .............................. 35 pentoxifylline .......................... 26 periogard ................................. 28 permethrin............................... 18 perphenazine ..................... 15, 19 perphenazine-amitriptyline ..... 14 phenobarbital .......................... 13 phenytoin sodium extended .... 13 PHOSLO................................. 31 pilocarpine hcl ........................ 37 pioglitazone ............................ 23 pioglitazone-glimepiride......... 23 pioglitazone-metformin .......... 23 piperacillin-tazobactam .......... 12 podofilox................................. 29 polyethylene glycol 3350 ....... 30 polymyxin b sulf-trimethoprim ............................................ 37 potassium chloride .................. 40 PRADAXA ............................. 24

pramipexole ............................ 19 pravastatin .............................. 26 prazosin ............................ 26, 31 PRED MILD .................... 16, 37 prednisolone acetate ... 16, 35, 37 prednisolone sodium phosphate ...................................... 16, 37 prednisone .................. 16, 32, 35 PREMARIN ........................... 33 PREMPHASE ........................ 33 PREMPRO ............................. 33 PREZISTA ............................. 20 primidone ............................... 13 PROAIR HFA ........................ 39 PROAIR RESPICLICK ......... 39 probenecid .............................. 15 prochlorperazine maleate . 15, 19 PROCRIT ............................... 24 proctosol hc ............................ 35 proctozone-hc ................... 30, 32 progesterone micronized ........ 33 promethazine .......................... 39 propranolol ............................. 26 propranolol-hydrochlorothiazid ............................................ 26 propylthiouracil ...................... 34 PULMICORT FLEXHALER 39 pyridostigmine bromide ......... 17 Q QUADRACEL (PF) ............... 34 quetiapine ......................... 19, 22 quinapril ................................. 26 quinapril-hydrochlorothiazide 27 quinine sulfate ........................ 18 R rabeprazole ............................. 30 raloxifene ................................ 33 ramipril ................................... 27 RANEXA ............................... 27 ranitidine hcl ........................... 30 REBIF TITRATION PACK .. 28 REGRANEX .......................... 29 RELENZA DISKHALER ...... 20 RENVELA ............................. 31 RESTASIS ............................. 37 REVLIMID ............................ 18 REYATAZ ............................. 20 ribasphere ............................... 20 ribavirin .................................. 20 RIDAURA .............................. 34

rifabutin .................................. 17 rifampin .................................. 17 rimantadine ............................. 20 risedronate .............................. 36 RISPERDAL CONSTA ......... 19 risperidone ........................ 19, 22 rivastigmine tartrate ................ 13 rizatriptan................................ 16 ropinirole ................................ 19 S SAVELLA .............................. 28 selegiline hcl ........................... 19 selenium sulfide...................... 29 SELZENTRY ......................... 21 SEREVENT DISKUS ............ 39 SEROQUEL XR............... 14, 22 sertraline ........................... 14, 21 sildenafil ................................. 39 SILENOR ............................... 14 silver sulfadiazine ................... 12 SIMPONI................................ 35 simvastatin .............................. 27 sirolimus ................................. 35 SIVEXTRO ............................ 12 SOMATULINE DEPOT ........ 34 SOVALDI .............................. 21 SPIRIVA WITH HANDIHALER .................. 39 spironolactone ........................ 27 spironolacton-hydrochlorothiaz ............................................ 27 SPRYCEL .............................. 18 stavudine................................. 21 STELARA .............................. 29 STIMATE............................... 32 STIOLTO RESPIMAT........... 39 STRATTERA ......................... 28 STRIBILD .............................. 21 SUBOXONE .......................... 10 sucralfate ................................ 30 sulfacetamide sodium ....... 12, 37 sulfacetamide-prednisolone ... 16, 37 sulfamethoxazole-trimethoprim ............................................ 12 sulfasalazine ........................... 35 sulindac............................... 9, 16 sumatriptan succinate ............. 16 SUSTIVA ............................... 21 SUTENT................................. 18

SYMBICORT ......................... 39 SYNTHROID ......................... 33 T tacrolimus ............................... 35 TAMIFLU .............................. 21 tamoxifen ................................ 18 tamsulosin ............................... 31 TANZEUM............................. 23 TARCEVA ............................. 18 TASIGNA............................... 18 TAZORAC ............................. 29 taztia xt ................................... 27 TECFIDERA .......................... 28 TECHNIVIE ........................... 21 TEFLARO .............................. 12 TEGRETOL ........................... 22 telmisartan .............................. 27 telmisartan-hydrochlorothiazid ............................................ 27 temazepam .............................. 39 TENIVAC (PF) ...................... 35 terazosin ............................ 27, 31 terbinafine hcl ......................... 15 terbutaline ............................... 39 terconazole .............................. 15 TESTOSTERONE .................. 33 testosterone cypionate ............ 33 testosterone enanthate ............. 33 TETANUS,DIPHTHERIA TOX PED(PF) ............................. 35 TETANUS-DIPHTHERIA TOXOIDS-TD .................... 35 TETRACYCLINE .................. 12 THALOMID ........................... 18 theophylline ............................ 39 thioridazine ............................. 19 thiothixene .............................. 19 timolol maleate ....................... 37 tinidazole ................................ 12 TIVICAY ................................ 21 tizanidine ................................ 19 tobramycin .............................. 12 tobramycin in 0.225 % nacl .... 12 tobramycin sulfate .................. 12 tobramycin-dexamethasone .... 37 tolterodine ............................... 31 topiramate ............................... 13 torsemide ................................ 27 TOVIAZ ................................. 31 TRACLEER ........................... 39

tramadol .................................... 9 tramadol-acetaminophen .......... 9 trandolapril ............................. 27 TRANSDERM-SCOP ...... 15, 30 TRAVATAN Z ...................... 37 travoprost (benzalkonium) ..... 37 trazodone ................................ 14 TRESIBA FLEXTOUCH U-100 ............................................ 23 TRESIBA FLEXTOUCH U-200 ............................................ 23 tretinoin ............................ 18, 29 triamcinolone acetonide ... 28, 32 triamterene-hydrochlorothiazid ............................................ 27 trifluoperazine ........................ 19 trihexyphenidyl....................... 19 trimethoprim ........................... 12 trospium.................................. 31 TRUVADA ............................ 21 TUDORZA PRESSAIR ......... 39 TYKERB ................................ 18 TYPHIM VI ........................... 35 TYZEKA ................................ 21 U ULORIC ................................. 15 UNITHROID .......................... 33

ursodiol ................................... 30 V VAGIFEM .............................. 33 valacyclovir ............................ 21 valganciclovir ......................... 21 valproic acid ..................... 13, 22 valsartan.................................. 27 valsartan-hydrochlorothiazide 27 vancomycin ............................ 12 venlafaxine ....................... 14, 21 VENLAFAXINE .............. 14, 22 VENTOLIN HFA ................... 39 verapamil ................................ 27 VESICARE ............................ 31 VIBERZI ................................ 30 VICTOZA 3-PAK .................. 23 VIEKIRA PAK....................... 21 VIGAMOX ............................. 12 VIIBRYD ............................... 14 VIMPAT................................. 13 VIRACEPT ............................ 21 VIREAD ................................. 21 voriconazole ........................... 15 VOTRIENT ............................ 18 VRAYLAR ....................... 19, 22 VYTORIN 10-10 .................... 27 VYTORIN 10-20 .................... 27

VYTORIN 10-40 .................... 27 VYTORIN 10-80 .................... 27 VYVANSE ............................. 28 W warfarin................................... 24 X XALKORI .............................. 18 XARELTO ............................. 24 XELJANZ............................... 35 XIFAXAN .............................. 12 XTANDI ................................. 18 Z zafirlukast ............................... 39 ZELBORAF ........................... 18 ZENPEP ................................. 29 ZEPATIER ............................. 21 ZETIA..................................... 27 zidovudine .............................. 21 ZIOPTAN (PF) ....................... 37 ziprasidone hcl .................. 19, 22 ZIRGAN ................................. 21 zolmitriptan............................. 17 zonisamide .............................. 13 ZOSTAVAX (PF) .................. 35 ZOVIRAX .............................. 21 ZYTIGA ................................. 18

1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000 1-877-998-0998 | 715-221-9897 TTY 711 Fax 715-221-9500 8 a.m. – 8 p.m., 7 days a week https://www.securityhealth.org/medicareadvantage

This abridged formulary was updated on July 26, 2016. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Security Health Plan Customer Service at 1-877-998-0998 or, for TTY users, 711, from 8 a.m. to 8 p.m., 7 days a week, or visit https://www.securityhealth.org/medicareadvantage.

HP-00154-62-02 (08/16)

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