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Home , Epoetin alfa, Icatibant, Lanreotide, Metreleptin, Nivolumab, Oprelvekin

SPECIALTY available through Accredo Health Group, Inc., an Express Scripts specialty pharmacy Call toll-free (800) 803-2523, 8:00 am to 8:00 pm, eastern time, Monday through Friday, to confirm that your is covered. Effective as of January 1, 2018

Abraxane® (paclitaxel protein-bound particles) Avastin® () [PA] [QD] [PA] Avonex® ( beta-1a) [PA] [PICA] Actemra™ () [PA] [QD] [ST] Azacitidine (GENERIC) [PA] [QD] Actemra™ SQ (tocilizumab) [PA] [QD] [PICA] [ST] Bebulin® VH (factor IX complex) [CPA] Actimmune® (-1b) [PA][PICA] Bendeka™(bendamustine) [PA] Adcetris® () [PA] BeneFIX® ( factor IX [recombinant]) Adcirca® (tadalafil) [PA] [ST] [QD] [CPA] Adempas® (riociguat) [PA] Benlysta® () [PA] Advate® (antihemophilic factor [recombinant]) Berinert® (c1 esterase inhibitor []) [PA] [QD] [CPA] Betaseron® (interferon beta-1b) [PA] [PICA] Adynovate™(antihemophilic Factor VIII Bethkis® (tobramycin) [recombinant]) [CPA] Bexarotene (GENERIC) Afinitor® () [PA] [QD] [PICA] Bivigam™ (immune globulin intravenous [human]) Afstyla® (antihemophilic Factor [recombinant]) [PA] [CPA] Bosulif® () [PA] [SF] [QD] Alcensa® () [PA] [PICA] [QD] [SF] Botox® (botulinum toxin type A) [PA] [PICA] Aldurazyme® (laronidase) [CPA] Capecitabine (GENERIC) [PICA] Alphanate® (antihemophilic factor [human]) [CPA] Carbaglu™ () AlphaNine® SD (coagulation factor IX [human]) Carimune® NF (immune globulin intravenous [CPA] [human]) [PA] Alprolix™ (coagulation factor IX [recombinant]) Cayston® (aztreonam) [PA] [QD] [CPA] Cerdelga® ( tartrate) Alunbrig™() [PA] [PICA] Cerezyme® () [CPA] [ST] Ampyra™ (dalfampridine) [PA] [QD] Cimzia® () [ST] [PA] [QD] [PICA] Apokyn® (apomorphine hydrochloride) [QD] Cinryze® (c1 esterase inhibitor) [PA] [QD] Aralast® NP (alpha[1]-proteinase inhibitor [human]) Cabometyx™ (cobozantinib) [PA][QD] [SF] [PA] Copaxone® (glatiramer ) [PA] [PICA] Aranesp® () [PA] [PICA] Copegus® (ribavirin) [PA] [SF] Arcalyst® () [PA] [QD] [PICA] Corifact® (factor XIII [human]) [CPA] *Arixtra® (fondaparinux sodium) [PICA] Cosentyx® () [PA] [PICA] Arranon® (nelarabine) [PA] Cotellic® () [PA] [PICA] [QD] Arzerra® () [PA] Cuvitru™ (immune globulin 20% [human]) Aubagio® (teriflunomide) [PA] [ST] Cyramza® () [PICA]

 If the indication is , and the drug is subject to management by EviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.

*This specialty drug may be filled two (2) times at a retail pharmacy on an emergency basis. Subsequent fills must be made through Accredo’s mail order delivery.

[PICA] = Specialty drug is available through the NYC Municipal Program called PICA. NYC Municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. The symbol [SF] next to a drug name indicates that this medication is subject to the Split-Fill Program.

All rights in the product names of all third-party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Subject to change. CytoGam® (cytomegalovirus immune globulin GamaSTAN® S/D (immune globulin [human]) intravenous [human]) [CPA] Gammagard® Liquid (immune globulin [human]) Cytovene® IV (ganciclovir sodium) [PA] Daklinza™ (daclatasvir) [PA] [QD] [SF] Gammagard® S/D (immune globulin [human]) [PA] Darzalex® () [PA] Gammaked™ (immune globulin, gamma caprylate Decitabine (GENERIC) [IGG]) [PA] Duopa® (levodopa/carbidopa) Gammaplex® (immune globulin [human]) [PA] Dupixent® (duplilumab) [PA] [QD] Gamunex® (immune globulin [human]) [PA] Dysport® (abobotulinumtoxinA) [PA] Ganciclovir (GENERIC) Egrifta® () [PICA] Gattex® () Elaprase® () [CPA] Gazyva™ () [PA] Elelyso™ () Gel-One® (hyaluronate sodium) [PA] Eligard® (leuprolide acetate) [PA][PICA] Gelsyn-3™(hyaluronate sodium) [PA] Eloctate™ (antihemophilic factor [recombinant]) Genotropin® (somatropin [rDNA origin]) [PA] [PICA] [CPA] Gilenya™ () [PA] [ST] Empliciti™() [PA] Gilotrif™ (afatinib) [PA] [PICA] [QD] Enbrel® () [PA] [QD] [PICA][ST] Glassia™ (alpha [1]-proteinase inhibitor [human]) *Enoxaparin sodium (GENERIC) [PICA] [PA] [ST] Entyvio® () [PA] Glatiramer (GENERIC) [PA] [PICA] Epclusa® (sofosbuvir/velpatasvir) [PA][QD][SF] Glatopa® () [PA] [PICA] Epogen® () [PA] [PICA] Granix™ (tbo-) [PA] [PICA] Epoprostenol sodium (GENERIC) [ST] Haegarda® (c1 esterase inhibitor) [PA] [PICA] Erbitux® () [PA] [QD] Halaven™ (eribulin mesylate) [PA] Erivedge™ () [PA] [QD] [SF] Harvoni™ (ledipasvir/sofosbuvir) [PA] [QD] [SF] Esbriet® (pirfenidone) [PA] Helixate® FS (antihemophilic factor [recombinant]) Euflexxa® (sodium hyaluronate) [PA] [QD] [CPA] Exjade® (deferasirox) [SF] Hemofil® M (antihemophilic factor [human]) [CPA] Extavia® (interferon beta-1b) [ST] [PA] [PICA] Herceptin® () [PA] Eylea™ () [PA] Hetlioz™ (tasimelteon) [PA] Fabrazyme® (agalsidase beta) [CPA] Hizentra™ (immune globulin subcutaneous Farydak (panobinostat) [PA] [PICA] [QD] [human]) [PA] Feiba® VH (anti-inhibitor coagulant complex) [CPA] H.P. Acthar® Gel (corticotropin) [PA] [QD] Firazyr® () [PA] [QD] [PICA] Humate-P® (antihemophilic factor/von Willebrand Firmagon® (degarelix) [PA] [PICA] factor complex [human]) [CPA] Flebogamma® (immune globulin [human]) [PA] Humatrope® (somatropin [rDNA origin]) [PA] [PICA] Flolan® (epoprostenol sodium) [PA] Humira® () [PA] [QD] [PICA] Folotyn™ (pralatrexate) [PA] Hyalgan® (sodium hyaluronate) [PA] [QD] *Fondaparinux sodium (GENERIC) [PICA] Hycamtin® capsules (topotecan) [PA] Forteo® ( [rDNA origin]) [PA] [PICA] Hymovis® (hyaluronate sodium) [PA] *Fragmin® (dalteparin sodium) [PICA] HyperRho® S/D (Rho[D] immune globulin [human])

 If the indication is CANCER, and the drug is subject to management by EviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.

*This specialty drug may be filled two (2) times at a retail pharmacy on an emergency basis. Subsequent fills must be made through Accredo’s mail order delivery.

[PICA] = Specialty drug is available through the NYC Municipal Program called PICA. NYC Municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. The symbol [SF] next to a drug name indicates that this medication is subject to the Split-Fill Program.

All rights in the product names of all third-party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Subject to change. Hyqvia™ (immune globulin infusion 10% [human] Letairis® () [PA] [QD] with recombinant) [PA] Leukine® () [PA] [PICA] Ibrance® () [PA] [PICA] [QD] Leuprolide acetate (GENERIC) [PICA] Idelvion® (coagulation factor IX [recombinant]) LilettaTM (levonorgestrel-releasing intrauterine [CPA] device) Idhifa® () [PICA] Lonsurf® (tipiracil/trifluridine) [PA] [PICA] Ilaris® () [PA] [QD] *Lovenox® (enoxaparin sodium) [PICA] Iluvien® (Fluocinolone) Lucentis® (ranibizumab) [PA]  (GENERIC) [PA] [PICA] [QD] Lumizyme™ () [CPA] Imfinzi™ () [PA] Lupaneta™ (leuprolide acetate) [PICA] Increlex® ( [rDNA origin]) [PA] [PICA] Lupron Depot® (leuprolide acetate) [PA] [PICA] Inflectra™(-dyyb) [PA] [ST] Lupron Depot-PED® (leuprolide acetate) [PA] Inlyta® () [PA] [QD] [PICA] [SF] [PICA] Intron® A (-2b) [PA][PICA] Lynparza™ (olaparib) [PA][SF][PICA] *Iprivask® (desirudin) Macugen® (pegaptanib sodium injection) [PA] Iressa® [PA] [PICA] [QD] [SF] Makena™ (hydroxyprogesterone caproate) [PA] Istodax® (romidepsin) [PA] [QD] Mavyret™ (glecaprevir/pibrentasvir) [QD] [SF] [PA] Ixempra® (ixabepilone) [PA] Mekinist™ () [PA] [PICA] [QD] Ixinity® (coagulation factor IX [recombinant]) [CPA] MICRhoGAM® (Rho[D] immune globulin [human]) Jadenu™ (deferasirox) [SF] Mitoxantrone HCl (GENERIC) Jakafi™ () [PA] [SF] [QD] Moderiba™ (ribavirin) [PA] Jevtana® (cabazitaxel) [PA] [QD] Monoclate-P® (antihemophilic factor [human]) Juxtapid® (lomitapide) [CPA] Kadcyla™ (ado-) [PA] Mononine® (coagulation factor IX [human]) [CPA] Kalbitor® () [PA] [QD] Mozobil® () [QD] [PA] [PICA] Kalydeco™ (ivacaftor) [PA] [SF] Myalept™ () [PA] [PICA] Kanuma™ () Myobloc® (botulinum toxin type B) [PA] [PICA] Kevzara® () [QD] [PA] [PICA] Naglazyme® (galsulfase) [CPA] Kisqali® (ribociclib) [PA] [QD] [PICA] Natpara® (parathyroid ) [PA] [PICA] Kitabis Pak® (Tobramycin) Nerlynx™ () [PICA] Koate®-DVI (antihemophilic factor [human]) [CPA] Neulasta® () [PA] [PICA] Kogenate® FS (antihemophilic factor [recombinant]) Neumega® (oprelvekin) [PICA] [CPA] Neupogen® (filgrastim) [PA] [PICA] Kovaltry® (antihemophilic factor VIII) [CPA] Nexavar® () [PA] [QD] [PICA] [SF] Krystexxa™ (pegloticase) [PA] Ninlaro® (ixazomib) [PA] [PICA] [QD] Kuvan® (sapropterin dihydrochloride) [PA] Norditropin® (somatropin [rDNA origin]) [PA] [PICA] Kynamro™ (mipomersen sodium) Norditropin/Nordiflex® (somatropin [rDNA origin]) Lartruvo™ () [PA] [PA] [PICA] Lemtrada™() [PA] Northera® (droxidopa) [PA] Lenvima™ () [PA] [PICA] [SF]

 If the indication is CANCER, and the drug is subject to management by EviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.

*This specialty drug may be filled two (2) times at a retail pharmacy on an emergency basis. Subsequent fills must be made through Accredo’s mail order delivery.

[PICA] = Specialty drug is available through the NYC Municipal Program called PICA. NYC Municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. The symbol [SF] next to a drug name indicates that this medication is subject to the Split-Fill Program.

All rights in the product names of all third-party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Subject to change. NovoEight® (antihemophilic factor VIII Profilnine® SD (factor IX complex [human]) [CPA] [recombinant]) [CPA] Proleukin® (aldesleukin) [PA] NovoSeven® RT (coagulation factor VIIa Prolia™ () [PA] [QD] [recombinant]) [CPA] Promacta® () [PA] [QD] Nplate® () [PA] ProThelial™ (sucralfate) Nucala™ () [PA] Pulmozyme® (dornase alfa) Nuplazid™[SF] Ravicti™ (glycerol phenylbuterate) Nutropin® (somatropin [rDNA origin]) [PA] [PICA] Rebetol® (ribavirin) [PA] Nutropin AQ® (somatropin [rDNA origin]) [PA] Rebif® (interferon beta-1a) [PA] [PICA] [PICA] Recombinate™ (antihemophilic factor Nuwiq® (antihemophilic Factor VIII [recombinant]) [recombinant]) [CPA] [CPA] Remicade® (infliximab) [PA] Ocaliva™(obeticholic acid) [PA][QD] Remodulin® (treprostinil sodium) [ST] Ocrevus™() [PA] [ST] Repatha™(evolocumab) [PA] Octagam® (immune globulin intraveous [human]) Retisert® (fluocinolone acetonide) [QD] [PA] Revatio® injection (sildenafil citrate) [PA] [QD] acetate (GENERIC) Revatio® tablets (sildenafil citrate) [PA] [QD] Odomzo® () [PA][PICA] Revlimid® () [PA] [QD] [PICA] Ofev® () [PA] RhoGAM® (RHo[D] immune globulin [human)] Olysio™ (simeprevir) [PA] [SF] Rhophylac® (RHo[D] immune globulin intravenous Omnitrope® (somatropin) [PA] [PICA] [human]) Opdivo® (Nivolumab) [PA] RiaSTAP® () Opsumit® () [PA] RibaPak® (GENERIC) [PA] Orencia® IV (abatacept intravenous) [PA] [PICA] Ribasphere® (GENERIC) [PA] [SF] Orencia® SC (abatacept subcutaneous) [ST] [PA] Ribavirin (GENERIC) [PA] [SF] [QD] [PICA] Rituxan® () [PA] Orenitram™ (treprostinil) [PA] Rixubis™ (coagulation factor IX [recombinant]) Orkambi® (lumacaftor/ivacaftor) [PA] [CPA] OrthoVisc® (hyaluronate sodium) [PA] Ruconest™ (c1 Esterase Inhibitor [recombinant]) Otezla® (apremilast) [PA] [ST] [PA] Ozurdex™ (dexamethasone) Rydapt® () [PA Pegasys® (peginterferon alfa-2a) [PA] [PICA] [SF] Sabril® (vigabatrin) Perjeta™ () [PA] Saizen® (somatropin [rDNA origin]) [PA] [PICA] Plegridy™ (peginterferon Beta-1A) [PA] [PICA] Samsca® (tolvaptan) [QD] Pomalyst® (pomalidomide) [PA] [PICA] Sandostatin® (octreotide acetate) [PICA] Portrazza® () [PICA] Sandostatin LAR® (octreotide/IM) [PICA] Praluent® (alirocumab) [PA] Serostim® (somatropin [rDNA origin]) [PA] [PICA] Privigen® (immune globulin intravenous [human]) [PA] Signifor® ( dispartate) [PA] Procrit® (epoetin alfa] [PA] [PICA] Signifor® LAR (pasireotide pamoate) [PA] [PICA] Procysbi™ ( bitartrate) Sildenafil (GENERIC) [ST] [QD]

 If the indication is CANCER, and the drug is subject to management by EviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.

*This specialty drug may be filled two (2) times at a retail pharmacy on an emergency basis. Subsequent fills must be made through Accredo’s mail order delivery.

[PICA] = Specialty drug is available through the NYC Municipal Program called PICA. NYC Municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. The symbol [SF] next to a drug name indicates that this medication is subject to the Split-Fill Program.

All rights in the product names of all third-party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Subject to change. Siliq ()™ [QD] [PA] [PICA] Tretten® (coagulation factor XIII A-subunit Simponi™ () [ST] [PA] [QD] [PICA] [recombinant]) [CPA] Simponi™ ARIA™ (golimumab) [ST] [PA] [QD] Tykerb® () [PA] [QD] [PICA] [PICA] Tymlos™ () [PA] [PICA] Soliris® () Tysabri® () [PA] [QD] Somatuline Depot® () [PICA] Tyvaso® (treprostinil) [PA] Somavert® () Uptravi® (selexipag) Sovaldi™ (sofosbuvir) [PA] [QD] [SF] Valchlor™ (mechlorethamine) [PA] Spinraza™ (nusinersen) [PA] Vantas® (histrelin) [PA] Sprycel® () [PA] [QD] [PICA] [SF] Vectibix® () [PA] Stelara™ () [PA] [QD] [PICA] Velcade® (bortezomib) [PA] Stimate® (desmopressin acetate) Veletri® (epoprostenol sodium) Stivarga® () [PA] [QD] Veltassa™ (paitromer) Supartz® (sodium hyaluronate) [PA] [QD] Ventavis® (iloprost) [PA] [QD] Supprelin® LA (histrelin acetate) Verzenio™ (abemaciclib) [PICA] [SF] Sutent® capsules ( malate) [PICA] [QD] Vidaza® (azacitidine) [PA] [QD] [PICA] Sylatron™ (peginterferon alfa-2b) Viekira Pak (ombitasvir/paritaprevir/ritonavir co- Sylvant™ () packed with dasabuvir) [PA] [QD] [SF] Synagis® (palivizumab) [PA] [QD] Vigabatrin (GENERIC) Synvisc®/Synvisc-ONE® (hylan G-F 20) [PA] [QD] Vimizim™ (elosulfase alfa) [CPA] Tafinlar® () [PA] [PICA] [QD] [SF] Visudyne® (verteporfin) Tagrisso™() [PA] [PICA] [QD] Vivitrol® (naltrexone) Taltz® () [PA] [QD] [PICA] [ST] Vosevi® (sofosbuvir/velpatasvir/voxilaprevir) [QD] Tarceva® () [PA] [QD] [PICA] [SF] [SF] [PA] Tasigna® () [PA] [QD] [PICA] [SF] Votrient® () [PA] [QD] [PICA] [SF] Tecentriq™ () [PA] Vpriv™ () [CPA] Tecfidera™ (dimethyl fumarate) [PA] [ST] Wilate® (von Willebrand factor/coagulation factor Technivie™(ombitasvir/paritaprevir/ritonavir) [PA] VIII complex [human]) [CPA] [SF] WinRho SDF® (Rho[D] immune globulin Temodar® (temozolomide) [PA] [PICA] intravenous [human]) Temozolomide (GENERIC) [PICA] Xalkori® () [PA] [QD] [PICA] [SF] Tetrabenazine (GENERIC) Xeljanz® ( citrate) [PA] Thalomid® (thalidomide) [PA] [PICA] Xeljanz XR® (tofacitinib) [PA] Tobi® (tobramycin) Xenazine® (tetrabenazine) [PA] [QD] [SF] Tobi-Podhaler® (tobramycin) Xeomin® (incobotulinumtoxinA) [PA] Tobramycin (GENERIC) Xgeva™ (denosumab) [QD] Torisel® () [PA] Xolair® () [PA] [QD] Tracleer® () [PA] [QD] Xtandi® (enzalutamide) [PA] [QD] [SF] Treanda® (bendamustine) [PA] Xyntha® (antihemophilic factor [recombinant]) Tremfya™ () [PA] [ST] [PICA] [CPA]

 If the indication is CANCER, and the drug is subject to management by EviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.

*This specialty drug may be filled two (2) times at a retail pharmacy on an emergency basis. Subsequent fills must be made through Accredo’s mail order delivery.

[PICA] = Specialty drug is available through the NYC Municipal Program called PICA. NYC Municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. The symbol [SF] next to a drug name indicates that this medication is subject to the Split-Fill Program.

All rights in the product names of all third-party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Subject to change. Yervoy™ () [PA] [QD] Zaltrap® (aflibercept) [PA] Zarxio (GENERIC) [PA] [PICA] Zavesca® () [QD][CPA] Zelboraf™ () [PA] [QD] [PICA] [SF] Zemaira® (alpha [1]-proteinase inhibitor [human]) [PA] Zepatier™ (elbasvir/grazoprevir) [PA] [QD] [SF] Zinbryta™() [PA] [PICA] Zoladex® (goserelin acetate) [PA] [PICA] Zolinza® (vorinostat) [PA] [QD] [PICA] [SF] Zomacton® (somatropin [rDNA origin]) [PA] [PICA] Zorbtive® (somatropin [rDNA origin]) [PA] [PICA] Zykadia™ () [PA] [PICA] [QD] [SF] Zytiga™ (abiraterone acetate) [PA] [QD] [PICA] [SF]

 If the indication is CANCER, and the drug is subject to management by EviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.

*This specialty drug may be filled two (2) times at a retail pharmacy on an emergency basis. Subsequent fills must be made through Accredo’s mail order delivery.

[PICA] = Specialty drug is available through the NYC Municipal Program called PICA. NYC Municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

The symbol [PA] next to a drug name indicates that this medication is subject to the Prior Authorization Program. The symbol [ST] next to a drug name indicates that this medication is subject to the Step Therapy Program. The symbol [QD] next to a drug name indicates that this medication is subject to the Quantity Duration Program. The symbol [CPA] next to a drug name indicates that this medication is subject to the Client Prior Authorization Program. The symbol [SF] next to a drug name indicates that this medication is subject to the Split-Fill Program.

All rights in the product names of all third-party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. Subject to change.