Wood County Employee Health Benefits Select Over-the-Counter (OTC) If approved by the Medical Manager an effective 2015 Formulary Prescription Coverage date will be assigned based upon the date signed The following Over-the-Counter (OTC) by the provider on the Medical Necessity Review The following is a listing of broken down by Schedule of Benefits as of Jan. 1, 2015 are available at no cost to the of Excluded Drugs/ Override form. The Benefits the conditions they are used to treat. Under each Subscriber with a valid prescription. To Coordinator will notify the Subscriber and condition, the drugs are listed in three tiers. Tier I The Plan pays all covered charges incurred in receive the benefit at the retail pharmacy, the Prescription carrier of the effective is the least expensive; followed by Tier 2 which is excess of the co-pay amount. Subscriber must submit a valid prescription at date. Purchases after the effective date may be less expensive; and Tier 3 which is the most the pharmacy counter for payment through eligible for reimbursement allowable under the expensive. Tier 1 drugs always costs the least Benefits apply for prescriptions purchased at the pharmacy benefits. A 90-day supply of Plan. Approvals are subject to the plan design amount and are as effective and safe as Brand Participating Pharmacies only. Visit the employee one of the following OTC medications may and any future plan changes. Drugs. Remember: Select Over-the-Counter website for a listing of participating pharmacies. also be purchased through the mail order drugs with a valid prescription are free to you and program by sending in a valid prescription. save the Plan the most money. When a brand product is dispensed solely at the RxEOB request of the Subscriber and a generic equivalent Nexium 24-Hour, Prilosec OTC Tablets Use RxEOB to shop for the most appropriate and While there are more than 10,000 drugs available is available, the Subscriber is responsible for any 20mg, Zantac OTC, omeprazole OTC, lowest cost drug for you and the Plan. View on the market, this listing provides the most cost differential between the two products in Prevacid OTC, Zegerid OTC pharmacy benefits and get price quotes at frequently prescribed medications. If a drug is not addition to the co-payment. Nasacort OTC www.rxeob.com. To register for this service, included on this list, please contact the Pharmacy visit, www.co.wood.oh.us.employee. The Benefit Manager. Price fluctuations, changes in Zyrtec, Zyrtec D, Claritin Syrup, Claritin RxEOB link is under the Insurance link. Tier levels, and/or method of purchase (retail/mail Retail Pharmacy Co-Pay Amount Tablets, Claritin Reditab, Alavert Tablets, order) may result in higher out of pocket store brand loratadine, Tavist ND Tablets, Maximum 34 day supply Prescription Coverage Contact expenses. Drugs may change throughout the Dimetapp ND Tablets, Claritin-D 12 year. Selected $0 Tablets, Claritin-D 24 Tablets, store brand Information OTC Please note that while a drug may be loratadine-D 24 tablets Pharmacy Benefits Manager Tier 1 $5 Abreva Cream (for cold sores and fever listed in the formulary, the drug may fall blisters) Pharmacy Benefits Direct under the Plan’s excluded and limited Tier 2 $15 plus 20% of the Average Customer Service No. 1.800.806.7859 Wholesale Price (AWP) Alaway, ketotifen, Zaditor (Ophthalmic) services listing as listed on page 8. $35 maximum out-of-pocket Slo-Niacin (for cholesterol) Please contact the Pharmacy Benefit Retail Pharmacies Manager for specific coverage Tier 3 $15 plus 20% of the AWP information. $65 maximum out-of-pocket Mail Order Benefit For a list of participating pharmacies The mail order program allows Subscribers to see the Network Website: It is important that you share this information with Mail Order Co-Pay Amount fill a 90-day prescription. The initial order www.pdmi.com your physician and follow his/her advice. This Maximum 90 day supply requires the original prescription from your information is not meant as a substitute for the doctor. Due to the processing of the order, care of your physician. Rather, it is available to Selected $0 allow 14 days mail time. Mail Order help you and your physician select a less OTC MEDVANTX expensive drug that will work for you. Tier 1 $10 Refills may be obtained by calling a toll free Customer Service: 1.866.744.0621 number or ordering online as noted in the DRUGS FOR Tier 2 $30 plus 20% of the AWP PO Box 5736, Prescription Coverage Contact Information. PENICILLINS $70 maximum out-of-pocket Sioux Falls, SD 57117-5736 Tier 1 ampicillin, amoxicillin, cloxacillin, dicloxacillin, amoxicllin w/ potassium clavulanate, penicillin Tier 3 $30 plus 20% of the AWP Medical Review www.medvantxrx.com CEPHALOSPORINS $130 maximum out of pocket Coverage for excluded and limited services Tier 1 cefaclor, cefadroxil, cefdinir, cefradine, cefpodoxime, cefprozil, cefuroxime,Cephalexin See the Plan Document for a complete list of may be authorized and approved by the Employee Website Medical Manager and/or Plan Administrator Tier 3 Cedax, Spectracef, Suprax Excluded and Limited Services. www.co.wood.oh.us/employee MACROLIDES based on medical necessity. Subscribers Provides links to plan and network Tier 1 azithromycin, clarithromycin, erythromycin ethyl If approved under the Medical Review Process, seeking coverage for a prescription on the information, access to Subscriber Booklet, succinate, erythromycin stearate prescriptions are covered at the following level: Excluded and Limited Services listing shall Tier 2 clarithromycin ER claim, and reimbursement forms, along with Pharmacy: $15 plus 50% of the AWP; complete a Medical Necessity Review form with Tier 3 Dificid, EryPed, PCE, Zmax maximum $150 out-of-pocket physician assistance prior to purchase. Forms wellness program information. TETRACYCLINES Tier 1 doxycycline, minocycline, tetracycline are available from your Group Representative or on-line. Completed forms shall be returned to Tier 3 Adoxa, Doryx, Oracea, Solodyn Mail Order: $30 plus 50% of the AWP: Database of Low Cost/Free QUINOLONES the Benefits Coordinator in the Commissioners’ maximum $300 out-of-pocket Medications Tier 1 ciprofloxacin, levofloxacin, ofloxacin Office for processing. Insufficient or incomplete www.hylant.medtipster.com Tier 2 ciprofloxacin XR, moxifloxacin information may result in a delay or denial of Tier 3 Avelox, Factive, Noroxin claim. Find free or low cost medications at local AMINOGLYCOSIDES pharmacies Tier 1 Neomycin Tablets

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SULFONAMIDES COMBINATIONS CARDIOVASCULAR DRUGS MISCELLANEOUS CARDIOVASCULAR DRUGS Tier 1 sulfisoxazole w erythromycin ethylsuccinate Tier 1 estradiol & norethindrone acetate Tier 3 Bidil CARDIOTONICS sulfamethoxazole w trimethoprim (SMX-TMP) esterified & methyltestosterone / Tier 1 Digoxin DRUGS FOR TUBERCULOSIS Tier 2 Premphase, Prempro Tier 1 anagrelide, cilostazol, clopidogrel, dipyridamole, ANTI-ANGINA Tier 1 ethambutol, isoniazid, pyrazinamide, Rifampin Tier 2 Combipatch pentoxifylline, ticlopidine, warfarin Tier 1 isosorbide dinitrate, isosorbide mononitrate Tier 3 Mycobutin, Priftin, Rifamate, Seromycin, Sirturo, Tier 3 Angeliq, Climara Pro, Femhrt, Jinteli, Prefest Tier 3 Aggrenox, Brilinta, Effient, Eliquis, Pradaxa, Tier 2 Nitrostat subligual tabs Trecator PROGESTINS Xarelto, Zontivity Tier 3 Dilatrate-SR, Nitrolingual, Ranexa DRUGS FOR FUNGAL INFECTIONS Tier 1 medroxyprogesterone, megestrol DRUGS FOR MISCELLANEOUS DISORDERS BETA-ADRENERGIC BLOCKERS Tier 1 fluconazole, ketoconazole, nystatin,terbinafine Tier 2 Crinone, Endometrin Tier 1 aminocaproic acid, pentoxyfylline, Tier 1 atenolol, carvedilol, metoprolol, metoprolol XL, Tier 2 itraconazole, voriconazole Tier 3 Prometrium Tier 3 Exjade, Mephyton, Samsca, Soliris propranolol, propranololLA Tier 3 Ancobon,Grifulvin-V, Gris-Peg, Noxafil DRUGS FOR DIABETES Tier 2 Bystolic RESPIRATORY / ASTHMA DRUGS FOR VIRAL INFECTIONS - INFLUENZA & RSV INSULINS Tier 3 Coreg CR, Innopran XL, Levatol DRUGS FOR ALLERGY Tier 1 amantadine, rimantidine Tier 1 Humulin R, N, 70/30 CALCIUM CHANNEL BLOCKERS Oral Antihistamines and Combinations Tier 2 Tamiflu Tier 2 Humalog, Humalog 3ml, Humalog KwikPen, Tier 1 amlodipine,diltiazem, diltiazemCD, diltiazemSR, OTC Alavert, Claritin, loratadine, cetirizine, cetirizine- Tier 3 Relenza, Synagis Humalog Mix, Humalog Mix 3ml, Humulin U500 felodipine, nifedipineXL, verapamil, verapamilSR D, Claritin-D, Zyrtec, Zyrtec D, Tavist ND DRUGS FOR VIRAL INFECTIONS - HERPES Lantus, Lantus 3ml, Lantus Solostar, Tier 2 nisoldipine Tablets, Dimetapp ND Tablets, store brand Tier 1 acyclovir Levemir, Novolog, Novolog 3ml, Novolog Mix, Tier 3 Cardizem LA, Cardene SR loratadine-D 24 tablets Tier 2 famciclovir, valacyclovir Novolog Mix 3ml ANTIARRHYTHMICS Tier 1 montelukast, levocetirizine, fexofenadine DRUGS FOR VIRAL INFECTIONS - HEPATITIS Tier 3 Apidra, Apidra Solostar Tier 1 amiodarone, disopyramide, flecainide, Tier 2 desloratadine, fexofenadine w/pseudoephedrine Tier 2 adefovir dipivoxil, Incivek, Olysio, ribavirin, Novolin R, Novolin 70/30, Novolin N, mexiletine, propafenone, quinidine, sotalol Tier 3 Grastek, Ragwitek Sovaldi, Victrelis ORAL Tier 2 propafenone SR NASAL MEDICATIONS Tier 3 Baraclude, Epivir HBV, Hepsera,Tyzeka, Viread Tier 1 acarbose, glimepiride, glipizide, glipizide XL, Tier 3 Multaq, Norpace CR, Tikosyn OTC Nasacort OTC DRUGS FOR MALARIA glyburide, , metformin XR, ACE INHIBITORS Tier 1 flunisolide, fluticasone, ipratropium nasal, Tier 1 chloroquine, hydroxychloroquine, pioglitazone Tier 1 benazepril, captopril, enalapril, fosinopril, triamcinolone Tier 2 mefloquine, atovaquone-proguanil Tier 1 glyburide w/ metformin, glipizide w/ metformin lisinopril, moexipril, perindopril, quinapril, ramipril, Tier 2 Astapro, azelastine nasal, Dymista Tier 3 Coartem, Daraprim, Halfan, Qualaquin Tier 2 nateglinide, pioglitazone-glimepriride, trandolapril DRUGS FOR ASTHMA / COPD DRUGS FOR PARASITES Repaglinide ANGIOTENSIN II ANTAGONISTS Tier 2 tinidazole Tier 2 Glucagon Tier 1 candasartan, losartan, irbesartan Tier 2 Asmanex, Pulmicort, QVAR, Tier 3 Albenza, Alinia, Biltricide, Mepron, Stromectol, Tier 2 Farxiga, Invokana, Januvia, Onglyza, Riomet Tier 2 Benicar, eprosartan, telmisartan, valsartan Tier 3 Alvesco, Azmacort, Flovent indamax, Yodoxin Tier 2 Janumet, Janumet XR, Kombiglyze XR Tier 3 Atacand, Avapro, Diovan, Edarbi, Sympathomimetics MISCELLANEOUS ANTIINFECTIVES Tier 3 Jardiance, Tradjenta, Nesina Micardis,Teveten Tier 1 albuterol for inhalation Tier 1 clindamycin, metronidazole Tier 3 Jentadueto, Oseni, Kazano DIRECT Tier 2 Arcapta, Foradil, levalbuterol for inhalation, Tier 2 vancomycin Xifaxan 550mg Tier 3 Actos, Glyset, Prandin, ActoPlus Met, Duetact, Tier 3 Tekturna ProAir HFA, Ventolin HFA Tier 3 Dapsone, Lamprene, NebuPent, TOBI, Prandimet ANTI-ADRENERGIC BLOCKERS–CENTRAL Tier 3 Perforomist, Proventil HFA, Vancocin, Zyvox DIABETES RELATED DRUGS & SUPPLIES Tier 1 clonidine, clonidine Transdermal Patch Serevent Diskus, Striverdi, Xopenex HFA DRUGS FOR CANCER Tier 2 Meters and Test Strips: COMBINATION ANTIHYPERTENSIVES Combination Drugs and Others Tier 1 anastrozole, bicalutamide, cyclophosphamide, Freestyle Test Strips, One Touch Basic, Tier 1 benazepril w/HCTZ, captopril w/HCTZ, Tier 1 ipratropium bromide for inhalation etoposide, exemestane, flutamide, hydroxyurea, One Touch FastTake, One Touch Surestep, enalapril w/ HCTZ, fosinopril w/HCTZ, ipratropium w/ albuterol letrozole, leucovorin, leuprolide acetate, OneTouch Ultra, One Touch Ultra2, lisinopril w/ HCTZ, moexipril w/HCTZ, Tier 2 Adcirca, Adempas, Advair, Anoro, Bethkis, Breo, tretinoin, megestrol, methotrexate, , One Touch UltraMini, One Touch Ultrasmart, quinapril w HCTZ,candesartan w/ HCTZ, Dulera, Letairis, Opsumit, sildenafil, Spiriva, venorelbine tartrate One Touch Verio, One Touch VerioIQ rbesartan w/ HCTZ, losartan w/ HCTZ, Symbicort, Tracleer Tier 2 Bosulif, Inlyta, Sprycel, Sutent, Trelstar, Zytiga Tier 3 Supplies : valsartan/ HCTZ, amlodipine w/ benazepril Tier 3 Atrovent HFA, Combivent, Daliresp, Intal, Tier 3 Afinitor, Alkeran, CeeNu, Emcyt, Fareston, AccuChek Lancets, Fastclix, Multicix, Soft Tier 2 amlodipine w/ atorvastatin Pulmozyme, Revatio, Tudorza, Tyvaso, Ventavis Gleevec, Hexalen, Hycamtin, Leukeran, Touch, Softclix, NovoFine Insulin Syringes, Tier 2 Benicar HCT, telmisartan wHCT Antileukotrienes Lysodren, Matulane, Myleran, Nexavar, Novofine Needles, NovoTwist, Softclix Device Tier 3 Amturnide, Atacand HCT, Avalide, Azor, Tier 1 montelukast, zafirlukast Nilandron, Tabloid, Tarceva, Temodar, Tasigna, All Accu-Chek Meters and Test Strips Caduet, Diovan HCT, Edarbyclor, Exforge, Tier 3 Singulair, Zyflo CR Teslac, Thioguanine, Tykerb, Vesanoid, Zolinza BD Insullin Syringes, BD Penneedles, xforge HCT, Micardis HCT, Tarka, Tekamlo, Theophyllines HORMONES Boeh-Mann Lancets, Lifescan Misc., Minimed Teveten HCT, Tribenzor, Twynsta Tier 1 theophylline SR THYROID AND ANTITHYROID AGENTS GASTROINTESTINAL Tier 1 acetazolamide ER, amiloride, bumetanide, Tier 1 levothyroxine, liothyronine Tier 1 dexamethasone, methylprednisolone, furosemide, HCTZ, triamterene w/ HCTZ, ANTIULCER Tier 1 methimazole, propylthiouracil prednisolone, prednisone indapamide, spironolactone, torsemide OTC Nexium 24 Hour, Prilosec OTC Tablets 20mg, Tier 3 Celestone, Rayos, Uceris DRUGS FOR OSTEOPOROSIS Tier 2 eplerenone Zantac OTC, omeprazole OTC, Prevacid OTC, Zegerid OTC ANDROGENS Tier 1 alendronate sodium (generic for Fosamax) ANTILIPEMICS Tier 1 cimetidine, dicyclomine, famotidine, Tier 3 Androderm, Androgel, Android, Axiron, Fortesta, Ibandronate sodium (generic for Boniva) OTC Slo-Niacin misoprostol, omeprazole, pantoprazole, Testim calcitonin nasal, calcitriol, Tier 1 atorvastatin, lovastatin, gemfibrozil, ranitidine, sucralfate ESTROGENS Tier 3 Actonel, Actonel-D, Atelvia, Boniva, Evista, cholestyramine, colestipol, fenofibrate, Tier 2 lansoprazole, nizatidine Pylera Tier 1 estradiol, estropipate, estradiol patch Fortical, Fosamax-D, Didronel, Hectoral, pravastatin, simvastatin Tier 3 Axid Solution, Bentyl Syrup, PrevPac Tier 2 Divigel, Enjuvia, Evamist, Premarin, Menostar, Skelid Tier 2 fluvastatin, Crestor, niacin ER oral tablet, Tier 2 Premarin Vag Cream,Vagifem Vag Tab /ANTIVERTIGO MISCELLANEOUS ENDOCRINE Simcor Estrace Vag Cream, Vivelle DOT Tier 3 Advicor, Altoprev, Antara, Lescol, Lescol XL, Tier 1 granisetron, meclizine, ondansetron, Tier 2 cabergoline, Cetrotide, desmopressin Tier 3 Alora, Climara, Estraderm, Estrasorb, Estring, Lipofen, Liptruzent, Livalo, Lovaza, Tricor, prochlorperazine, promethazine, Tier 3 Carnitor, Hectoral, Zemplar Estrogel, Femring, Menest TriLipix, Triglide, Vascepa, Vytorin, Welchol, Zetia trimethobenzamide

Tier 2 Sancuso

Tier 3 Anzemet, Emend, Transderm-Scop

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DIGESTANTS CEREBRAL / ADD-ADHD RELAXANTS FUNGICIDES Tier 1 multiple medicines w/ generic Tier 1 methylphenidate, amphetamine combo Tier 1 baclofen, carisoprodol, cyclobenzaprine Tier 1 ciclopirox, clotrimazole, ketoconazole, Tier 2 Creon, Zenpep Dexmethylphenidate dantrolene, methocarbamol, tizanidine, etc. clotrimazole/betamethasone, nystatin Tier 3 Pancreaze DR, Viokase Tier 2 amphetamine combination CR Tier 3 Amrix, Skelaxin Tier 3 Exelderm, Mentax, Naftin, Oxistat, Xolegel OTHER GI PRODUCTS methylphenidate ER Capsules OPHTHALMIC TOPICAL ANTI-INFLAMMATORY AGENTS Tier 1 balsalazide, lactulose, mesalamine rectal methylphenidate SR OSM Tablets Tier 1 mometasone misoprostol, sulfasalazine, ursodiol Tier 2 Intuniv, modafinil, Strattera ANTI-ALLERGIC & RELATED AGENTS Tier 3 Clobex, Capex, Halog, Ultravate, Vanos Tier 2 Amitiza, Asacol HD, budesonide EC Tier 3 Daytrana, Focalin XR, Kapvay, Metadate-CD OTC Alaway, ketotifen, Zaditor TOPICAL SCABICIDES/PEDICULICIDES calcium acetate (phosphate binder), Canasa, Nuvigil, Provigil, Quillivant XR, Ritalin-LA, Tier 1 azelastine, epinastine Tier 1 permethrin, Eurax Delzicol, Fosrenol, Kristalose, Lialda, Pentasa, Vyvanse, Xyrem Tier 2 Pataday, Patanol Tier 2 lindane lotion or shampoo, malathion lotion Rectiv, Renvela, DRUGS FOR ALZHEIMER’S DISEASE Tier 3 Alocril, Alomide, Bepreve, Emadine, Lacrisert, Tier 3 Ulesfia Tier 3 Apriso, Dipentum, Linzess, Lotronex, Metozolv Tier 1 donepezil, donepezil ODT, donepezil-23 Lastacaft, Restasis OTHER DERMATOLOGICALS ODT, Phoslo, Phoslyra, Renagel, Tier 2 galantamine, galantamine ER, Namenda, ANTI-GLAUCOMA AGENTS Tier 1 fluorouracil SfRowasa, Uceris, URSO, URSO Forte Namenda XR Tier 1 brimonidine, dipivefrin, betaxolol, carteolol Tier 2 calcipotriene, Elidel, imiquimod, lidocaine patch, dorzolamide, dorzolamide/timolol, latanoprost, GENITO-URINARY Tier 3 Aricept-23, Cognex, Exelon Patch Taclonex MISCELLANEOUS DRUGS FOR CNS levobunolol, metipranolol, timolol, timolol gel Tier 3 Analpram ADV, Analpram E, Analpram HC ANTI-INFECTIVES Tier 1 pyridostigmine forming solution Anamantle HC, Anamantle HC Forte, Anusol HC, Tier 1 nitrofurantoin macro and other generic Tier 2 Ampyra, cevimeline Extavia, Gilenya, Tier 2 Alphagan P, Travatan Z Atopiclair, Condylox, Dovonex, Fluoroplex, INCONTINENCE AGENTS Tecfidera Tier 3 Azopt, Betimol, Betoptic S, Combigan, Lumigan, Lidoderm, Ovace, Picato, Pramosone, Protopic, Tier 1 oxybutynin, oxybutynin XL TIer 3 Evoxac, Mestinon, Nuedexta Zioptan Solaraze, Soriatane, Synera, Targretin, Tazorac, Tier 2 Myrbetriq, tolterodine, Toviaz, trospium, , NARCOTIC ANTI-INFECTIVE AGENTS Vectical, Zyclara trospium SR, Vesicare Tier 1 ciprofloxacin, erythromycin, gentamicin Tier 1 morphine IR, oxycodone IR, fentanyl patch, MISCELLANEOUS Tier 3 Detrol, Detrol LA, Enablex, Gelnique, Oxytrol morphine CR Tabs ofloxacin, sulfacetamide, tobramycin Patch, Sanctura XR, Tier 2 butorphanol nasal spray, morphine ER cap, Tier 2 Besivance, Moxeza, Vigamox, Tier 2 Epipen, Epipen Jr, VAGINAL ANTIINFECTIVES Nucynta, Nucynta ER, oxycodone SR, Tier 3 Azasite, Zirgan, Zymaxid Tier 3 Auvi-Q, Buphenyl, Chemet, Orfadin, Regranex, Tier 1 clindamycin cream, nystatin, metronidazole, Opana ER, Oxycontin ANTI-INFLAMMATORY AGENTS Terconazole Tier 3 Actiq, Avinza, Butrans, Embeda, Exalgo, Tier 1 dexamethasone, prednisolone Tier 3 AVC Cream, Cleocin Vaginal Tab, Gynazole, Fentora, Kadian Tier 2 Alrex, Durezol, Lotemax, Ilevro, Nevanac MetroGel Prolensa Alphabetical Listing ANALGESICS, NSAIDs DRUGS FOR BPH Tier 1 diclofenac, diflunisal, etodolac, ibuprofen, Tier 3 Flarex, FML, FML Forte, A Tier 1 alfuzosin, doxazosin, tamsulosin, terazosin indomethacin, meloxicam, naproxen, ANTI-INFECTIVE AND ANTI-INFLAMMATORY Tier 3 Avodart, Jalyn, Rapaflo naproxen sodium, oxaprozin, etc. COMBINATIONS Tier 2 Abilify MISCELLANEOUS UROLOGICALS Tier 2 celecoxi, Vimovo Tier 1 tobramycin-dexamethasone OTC Abreva Tier 3 Cystagon, Elmiron, Lysteda Tier 3 Arthrotec, Celebrex, Duexis, Flector Patch, Tier 2 Tobradex, Tobradex ST, Zylet Tier 2 Acanya CENTRAL Pennsaid, Prevacid Naprapac, Sprix, Voltaren Tier 3 Blephamide, Pred-G Tier 1 acarbose (Precose) NSAIDS Tier 3 Accu-Chek Test Strips PSYCHOTHERAPEUTIC AGENTS Gel, Zipsor Tier 1 diclofenac, flurbiprofen, ketorolac Tier 3 Accu-Chek Active ANALGESICS, MISCELLANEOUS Tier 3 Accu-Chek Advantage Tier 1 amitriptyline, bupropion, SR, XL, citalopram, Tier 1 allopurinol, naltrexone HCl, tramadol OTIC Tier 3 Accu-Chek Aviva doxepin, escitalopram, fluoxetine, imipramine, Tier 2 Colcrys, tramadol ER Tablet ANTI-INFECTIVE AND ANTI-INFLAMMATORY Tier 3 Accu-Chek Aviva Plus mirtazapine, nortriptyline, paroxetine, paroxetine Tier 3 Cuprimine, Gralise, Ridaura, Ryzolt, Savella, COMBINATIONS Tier 3 Accu-Chek Comfort Curve CR, protriptyline, trazodone, sertraline, Uloric Tier 1 multiple medicines w/ generics, ofloxacin Tier 3 Accu-Chek Compact venlafaxine, venlafaxine XR PramOtic Tier 3 Accu-Chek Meter Tier 2 duloxetine, Pristiq, Viibryd Tier 1 carbamazepine, carbamazepine XR Tier 2 Ciprode Tier 3 Accu-Chek Lancets Tier 3 Cymbalta, Emsam, Lexapro, Oleptro, Pexeva, clonazepam, divalproex DR, divalproex ER, Tier 3 Cetraxal, Cipro HC Oticin Tier 3 Accu-Chek Fastclix Sarafem ethosuximide, gabapentin, lamotrigine, DERMATOLOGICALS Tier 3 Accu-Chek Multiclix Agents levetiracetam, oxcarbazepine, phenytoin, Tier 3 Accu-Chek Soft Touch Tier 1 chlorpromazine, haloperidol, olanzapine, primidone, topiramate, valproic acid, ACNE Tier 3 Accu-Chek Softclix olanzapine/fluoxetine, perphenazine, quetiapine, zonisamide Tier 1 adapalene, metronidazole lotion Tier 1 acetazolamide ER (Diamox Sequels) risperidone Tier 2 Fycompa, Lyrica, Vimpat, Potiga Sulfacetamide sodium external suspension Tier 3 Actiq Tier 2 Abilify, clozapine, Latuda, risperidone ODT, Tier 3 Banzel, Carbatrol, Celontin, Diastat, Felbatol, sulfacetamide w sulfur external emulsion Tier 3 Actonel, Actonel-D quetiapine XR, ziprasidone Gabitril, Lamictal ODT, Peganone, Onfi, Tier 2 Acanya, Aczone Tier 3 ActoPlus Met Tier 3 Equetro, Fanapt, Fazaclo, Geodon, Invega, Sabril benzoyl peroxide w clindamycin, Tier 3 Actos Saphris, Seroquel, Seroquel XR DRUGS FOR DEPENDENCY clindamycin foam, isotretinoin (oral), Tier 1 acyclovir , , AND Tier 1 disulfiram, methadone tretinoin microsphere gel Tier 2 Aczone Tier 1 alprazolam, buspirone, eszopiclone, lorazepam, Tier 2 Suboxone SL Film Tier 3 Azelex, Atralin, BenzaClin, Clindareach, Tier 1 adapalene (Differin) temazepam, triazolam, zaleplon, zolpidem Tier 3 Campral Differin, Differin gel, Duac, Duac CS, Epiduo, Tier 2 Adcirca tartrate DRUGS FOR PARKINSONS DISEASE Finacea, Metrogel, Retin-A Micro, Veltin, Ziana Tier 2 adefovir dipivoxil Tier 2 zolpidem tartrate CR Tier 1 benztropine, bromocriptine, Tier 2 Adempas Tier 3 Edluar, Intermezzo, Lunesta, Rozerem, Silenor, arbidopa/levodopa, entacapone, pramipexole, Tier 1 erythromycin, clindamycin, metronidazole, Tier 3 Adoxa Zolpimist ropinirole, selegiline, trihexyphenidyl mupirocin Tier 2 Advair Tier 2 Azilect, carbidopa/entacapone/levodopa, Tier 3 Altabax, Bactroban Nasal Ointment, Noritate Tier 3 Advicor ropinirole XL, Zelapar ANTIVIRALS Tier 3 Afinitor Tier 3 Apokyn, COMTan, Kemadrin, MirapexER, OTC Abreva Tier 3 Aggrenox Requip XL, Stalevo, Tasmar OTC Alavert

OTC Alaway

This document is in effect January 1, 2015. Printed 12/30/2014 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ Page 3 of 8

Tier 3 Albenza Tier 3 Avapro Tier 2 calcium acetate (Phoslo) Tier 1 clotrimazole Tier 1 albuterol inhalation (Accuneb) Tier 3 AVC Cream Tier 3 Campral Tier 1 clotrimazole w/ betamethasone Tier 1 alendronate (Fosamax) Tier 3 Avelox, Avelox ABC Tier 2 Canasa Tier 1 cloxacillin Tier 1 alfuzosin (Uroxatral) Tier 3 Avinza Tier 1 Candesartan, Candesartan w/ HCTZ Tier 2 clozapine (Clozaril) Tier 3 Alinia Tier 3 Avodart Tier 3 Capex Tier 3 Coartem Tier 3 Alkeran Tier 3 Axid Solution Tier 1 captopril (Capoten) Tier 3 Cognex Tier 1 allopurinol Tier 3 Axiron Tier 1 captopril w HCTZ (Capozide) Tier 2 Colcrys Tier 3 Alora Tier 3 Azasite Tier 1 carbamazepine (Tegretol) Tier 1 colestipol (Colestid 1Gm Tab) Tier 2 Alphagan P Tier 1 azelastine ophthalmic Tier 1 carbamazepine XR (Tegretol XR) Tier 3 Combigan Tier 1 alprazolam Tier 2 azelastine nasal Tier 3 Carbatrol Tier 2 Combipatch Tier 2 Alrex Tier 3 Azelex Tier 1 carbidopa w levodopa Tier 3 Combivent Tier 3 Altabax Tier 2 Azilect Tier 2 carbidopa/entacapone/levodopa Tier 3 COMTan Tier 3 Altoprev Tier 1 azithromycin Tier 3 Cardene SR Tier 3 Condylox Tier 3 Alvesco Tier 3 Azmacort Tier 3 Cardizem LA Tier 3 Coreg CR Tier 1 amantadine Tier 3 Azopt Tier 1 carisoprodol Tier 2 Creon Tier 1 amiloride Tier 3 Azor Tier 3 Carnitor Tier 2 Crestor Tier 1 aminocaproic acid Tier 1 carteolol Tier 2 Crinone Tier 1 amiodarone (Cordarone) B Tier 1 carvedilol Tier 3 Cuprimine Tier 2 Amitiza Tier 1 baclofen Tier 3 Cedax Tier 1 cyclobenzaprine (Flexeril) Tier 1 amitriptyline Tier 3 Bactroban Nasal Ointment Tier 3 CeeNu Tier 1 cyclophosphamide Tier 1 amlodipine (Norvasc) Tier 1 balsalazide (Colazal) Tier 1 cefaclor Tier 3 Cymbalta Tier 2 amlodipine w/ atoravastatin Tier 3 Banzel Tier 1 cefadroxil Tier 3 Cystagon Tier 1 amlodipine w/ benzaepril (Lotrel) Tier 3 Baraclude Tier 1 cefdinir Tier 1 amoxicillin Tier 3 BD Insulin Syringes Tier 1 cefpodoxime D Tier 1 amoxicillin w/ potassium clavulanate Tier 3 BD Penneedles Tier 1 cefprozil Tier 3 Daliresp Tier 1 ampicillin Tier 1 benazepril (Lotensin) Tier 1 cefradine Tier 1 dantrolene (Dantrium) Tier 1 amphetamine combination Tier 1 benazepril w HCT (Lotensin HCT) Tier 1 cefuroxime Tier 3 Dapsone Tier 2 amphetamine combination SR Tier 2 Benicar, Benicar HCT Tier 3 Celebrex Tier 3 Daraprim Tier 2 Ampyra Tier 3 Bentyl Syrup Tier 2 celecoxib Tier 3 Daytrana Tier 3 Amrix Tier 3 BenzaClin Tier 3 Celestone Tier 2 Delzicol Tier 3 Amturnide Tier 2 benzoyl peroxide w/ clindamycin Tier 3 Celontin Tier 3 Depo-Provera Tier 1 anagrelide (Agrylin) Tier 1 benztropine (Cogentin) Tier 1 cephalexin Tier 2 desloratadine (Clarinex) Tier 3 Anamantle HC Tier 2 Besivance Tier 1 cetirizine, cetirizine-D Tier 2 desmopressin spray/tabs (DDAVP) Tier 3 Anamantle HC Forte Tier 1 betaxolol Tier 3 Cetraxal Tier 3 Detrol, Detrol LA Tier 3 Analpram ADV Tier 2 Bethkis Tier 2 cevimeline Tier 1 dexamethasone Tier 3 Analpram E Tier 3 Betimol Tier 3 Chemet Tier 1 dexamethasone ophthalmic Tier 3 Analpram HC Tier 3 Betoptic – S Tier 3 Chemstrip K Tier 1 dexmethylphenidate (Focalin) Tier 1 anastrozole (Arimidex) Tier 1 bicalutamide (Casodex) Tier 1 chloroquine Tier 3 Diastat Tier 3 Ancobon Tier 3 Bidil Tier 1 chlorpromazine Tier 1 diclofenac, diclofenac ophthalmic Tier 3 Androderm Tier 3 Biltricide Tier 1 cholestyramine Tier 1 dicloxacillin Tier 3 Android Tier 3 Blephamide Tier 1 ciclopirox (Loprox) Tier 1 dicylomine Tier 3 Androgel Tier 3 Boeh-Mann Lancets Tier 1 ciclopirox (Penlac) Tier 3 Didronel Tier 3 Angeliq Tier 3 Boniva Tier 1 cilostazol Tier 3 Differin. Differin gel .3% Tier 2 Anoro Tier 2 Bosulif Tier 1 cimetidine Tier 3 Dificid Tier 3 Antara Tier 2 Breo Elipta Tier 1 ciprofloxacin Tier 1 diflunisal Tier 3 Anusol/HC Tier 3 Brilinta Tier 2 ciprofloxacin XR Tier 1 digoxin (Lanoxin) Tier 3 Anzemet Tier 1 brimonidine Tier 1 ciprofloxacin Ophthalmic (Ciloxan) Tier 3 Dilatrate-SR Tier 3 Apidra, Apidra Solostar Tier 1 bromocriptine Tier 3 Cipro HC Otic Tier 1 diltiazem Tier 3 Apriso Tier 2 budesonide EC (Entocort EC) Tier 2 Ciprodex Otic Tier 1 diltiazem CD Tier 2 Arcapta Tier 1 bumetanide Tier 1 citalopram (Celexa) Tier 1 dilitazem SR Tier 3 Aricept-23 Tier 3 Buphenyl OTC Claritin, Claritin-D Tier 3 Diovan, Diovan HCT Tier 3 Arthrotec Tier 1 bupropion (Wellbutrin) Tier 1 clarithromycin Tier 3 Dipentum Tier 2 Asacol HD Tier 1 bupropion SR (Wellbutrin SR) Tier 2 clarithromycin ER (Biaxin XL) Tier 1 dipivefrin Tier 2 Asmanex Tier 1 bupropion SR (Zyban) Tier 3 Cleocin Vaginal Tablet Tier 1 dipyridamole Tier 2 Astepro Tier 1 bupropion XL (Wellbutrin XL) Tier 3 Climara Tier 1 disopyramide (Norpace) Tier 3 Atacand, Atacand HCT Tier 1 buspirone (Buspar) Tier 3 Climara Pro Tier 1 disulfiram (Antabuse) Tier 3 Atelvia Tier 3 Butrans Tier 1 clindamycin Tier 1 divalproex DR (Depakote) Tier 1 atenolol Tier 2 Bystolic Tier 2 clindamycin foam (Evoclin) Tier 1 divalproex ER (Depakote) Tier 3 Atopiclair Tier 1 clindamycin Vag Cream (Cleocin) Tier 2 Divigel Tier 1 atorvastatin (Lipitor) C Tier 3 Clindareach Tier 1 donepezil (Aricept) Tier 2 atovaquone-proguanil (Malarone) Tier 2 cabergoline (Dostinex) Tier 3 Clobex Tier 1 donepezil ODT (Aricept ODT) Tier 3 Atralin Tier 3 Caduet Tier 1 clonazepam Tier 1 donepezil-23 Tier 3 Atrovent HFA Tier 2 calcipotriene (Dovonex) Tier 1 clonidine Tier 3 Doryx Tier 3 Auvi-Q Tier 1 calcitonin nasal (Miacalcin) Tier 1 clonidine patch (Catapres TTS) Tier 1 dorzolamide (Trusopt) Tier 3 Avalide Tier 1 calcitriol Tier 1 clopidogrel (Plavix) Tier 1 dorzolamide/timolol (Cosopt)

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Tier 3 Dovonex Tier 1 exemestane (Aromasin) Tier 1 glyburide (Diabeta, Micronase) Tier 3 Kemadrin Tier 1 doxazosin Tier 3 Exforge, Exforge HCT Tier 1 glyburide w metformin Tier 1 ketorolac (Acular, Acular LS) Tier 1 doxepin Tier 3 Exjade Tier 3 Glyset OTC ketotifen Tier 1 doxycycline Tier 3 Gralise Tier 1 ketoconazole Tier 3 Duac, Duac CS F Tier 1 granisetron Tier 2 Kombiglyze XR Tier 3 Duetact Tier 3 Factive Tier 3 Grastek Tier 2 Kristalose Tier 2 Dulera Tier 2 famciclovir (Famvir) Tier 3 Grifulvin-V Tier 3 Duexis Tier 1 famotidine Tier 3 Gris-Peg L Tier 2 duloxetine Tier 3 Fanapt Tier 3 Gynazole Tier 3 Lacrisert Tier 2 Durezol Tier 3 Fareston Tier 1 lactulose Tier 2 Dymista Tier 2 Farxiga H Tier 3 Lamictal ODT Tier 3 Fazaclo Tier 3 Halog Tier 1 lamotrigine (Lamictal) E Tier 3 Felbatol Tier 1 haloperidol Tier 3 Lamprene Tier 3 Edarbi Tier 1 felodipine (Plendil) Tier 3 Halfan Tier 1 lamotrigine Tier 3 Edarbyclor Tier 3 Femhrt Tier 3 Hectoral Tier 2 lansoprazole (Prevacid) Tier 3 Edluar Tier 3 Femring Tier 3 Hepsera Tier 2 Lantus, Lantus Solostar Tier 3 Effient Tier 1 fenofibrate micronized (Lofibra) Tier 3 Hexalen Tier 1 latanoprost (Xalatan) Tier 2 Elidel Tier 1 fentanyl patch (Duragesic) Tier 2 Humalog, Humalog Mix 75/25 Tier 2 Latuda Tier 3 Eliquis Tier 3 Fentora Tier 1 Humulin N, R, 70/30 Tier 3 Lescol, Lescol XL Tier 3 Elmiron Tier 1 fexofenadine (Allegra) Tier 2 Humulin 500 Tier 2 Letairis Tier 3 Embeda Tier 2 fexofendine w/ PSE (Allegra-D) Tier 3 Hycamtin Tier 1 letrozole (Femara) Tier 3 Emcyt Tier 3 Finacea Tier 1 hydrochlorothiazide or “HCTZ” Tier 1 leucovorin Tier 3 Emend Tier 1 finasteride (Proscar) Tier 1 hydroxyurea Tier 3 Leukeran Tier 3 Emsam Tier 3 Flarex Tier 2 levalbuterol for inhalation Tier 3 Enablex Tier 1 flecainide I Tier 3 Levatol Tier 1 enalapril Tier 3 Flector Patch Tier 1 ibandronate Tier 2 Levemir Tier 1 enalapril w HCTZ Tier 3 Flovent Tier 1 ibuprofen Tier 1 levetiracetam (Keppra) Tier 2 Endometrin Tier 1 fluconazole Tier 2 Ilevro Tier 1 levobunolol Tier 2 Enjuvia Tier 3 Fluoroplex Tier 1 imipramine (Tofranil) Tier 1 levocetirizine Tier 1 entacapone Tier 1 flunisolide nasal (Nasarel) Tier 2 imiquimod (Aldara) Tier 1 levofloxacin (Levaquin) Tier 3 Epiduo Tier 1 fluorouracil (Efudex) Tier 2 Incivek Tier 1 levothyroxine (Synthroid) Tier 2 Epi-Pen, Epi-Pen Jr. Tier 1 fluoxetine (Prozac) Tier 1 indapamide Tier 3 Lexapro Tier 1 epinastine (Elestat) Tier 1 flurbiprofen ophth (Ocufen) Tier 1 Indomethacin Tier 2 Lialda Tier 3 Epivir HBV Tier 1 flutamide Tier 2 Inlyta Tier 2 lidocaine patch Tier 2 eplerenone (Inspra) Tier 1 fluticasone (Flonase) Tier 3 Innopran XL Tier 3 Lidoderm Tier 2 eprosartan Tier 2 fluvastatin Tier 3 Intal Tier 3 Lifescan Miscellaneous Tier 3 Equetro Tier 3 FML Tier 3 Intermezzo Tier 2 lindane lotion or shampoo Tier 3 EryPed Tier 3 FML Forte Tier 2 Intuniv Tier 3 Linzess Tier 1 erythromycin Tier 3 Focalin XR Tier 3 Invega Tier 1 liothyronine (Cytomel) Tier 1 erythromycin ophthalmic Tier 2 Foradil Tier 2 Invokana Tier 3 Lipofen Tier 1 erythromycin ethyl succinate (EES) Tier 3 Fortesta Tier 1 ipratropium nasal (Atrovent) Tier 3 Liptruzent Tier 1 erythromycin stearate Tier 3 Fortical Tier 1 ipratropium bromide for inhalation Tier 1 lisinopirl (Prinivil, Zestril) Tier 1 escitalopram Tier 3 Fosamax-D Tier 1 ipratropium w albuterol (Duoneb) Tier 1 lisinopril wHCT(PrinzideZestoretic) Tier 2 Estrace Vag Cream Tier 1 fosinopril (Monopril) Tier 1 irbesartan Tier 3 Livalo Tier 3 Estraderm Tier 1 fosinopril w HCTZ (Monopril HCT) Tier 1 irbesartan w/ HCTZ OTC loratadine (Claritin) Tier 1 estradiol (Estrace) Tier 2 Fosrenol Tier 1 isoniazid Tier 1 lorazepam Tier 1 estradiol patch Tier 2 Freestyle Test Strips Tier 1 isosorbide dinitrate Tier 1 losartan Tier 1 estradiol/norethindrone Tier 1 furosemide Tier 1 isosorbide mono (Imdur) Tier 1 losartan w HCTZ (Hyzaar) Tier 3 Estrasorb Tier 2 Fycompa Tier 2 isotretinoin (Amnesteem) Tier 2 Lotemax Tier 1 esterified estrogens w m/testos Tier 2 isotretinoin (Claravis, Sotret) Tier 3 Lotronex Tier 1 estropipate G Tier 2 itraconazole (Sporanox) Tier 1 lovastatin Tier 3 Estring Vaginal Ring Tier 1 gabapentin (Neurontin) Tier 3 Lovaza Tier 3 Estrogel Tier 3 Gabitril J Tier 3 Lumigan Tier 2 eszopiclone Tier 2 galantamine (Razadyne) Tier 3 Jalyn Tier 3 Lunesta Tier 1 ethambutol (Myambutol) Tier 2 galantamine ER (Razadyne ER) Tier 2 Januvia Tier 2 Lyrica Tier 1 ethosuximide (Zarontin) Tier 3 Gelnique Tier 2 Janumet, Janumet XR Tier 3 Lysodren Tier 1 etodolac Tier 1 gemfibrozil (Lopid) Tier 3 Jardiance Tier 3 Lysteda Tier 1 etoposide Tier 1 gentamicin ophthalmic Tier 3 Jentadueto Tier 1 Eurax Tier 3 Geodon Tier 3 Jinteli M Tier 2 Evamist Tier 3 Gleevec Tier 2 malathion (Ovide) Tier 3 Evista Tier 2 Gilenya K Tier 3 Matulane Tier 3 Evoxac Tier 1 glimepiride Tier 3 Kadian Tier 1 meclizine Tier 3 Exalgo Tier 1 glipizide, glipizide XL Tier 3 Kapvay Tier 1 medroxyprogesterone Tier 3 Exelderm Tier 1 glipizide w metformin Tier 3 Kazano Tier 2 mefloquine Tier 3 Exelon Patch Tier 2 Glucagon Tier 1 megestrol

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Tier 1 meloxicam Tier 3 Nilandron Tier 1 penicillin Tier 1 quinapril w HCTZ (Accuretic) Tier 3 Menest Tier 2 nisoldipine (Sular) Tier 3 Pennsaid Tier 2 QVAR Tier 3 Menostar Tier 1 nitrofurantoin macro Tier 1 pentoxifylline Tier 3 Mentax Tier 2 Nitrostat sublingual tabs Tier 2 Pentasa R Tier 3 Mephyton Tier 3 Nitrolingual Tier 3 Perforomist Tier 3 Ragwitek Tier 3 Mepron Tier 2 nizatidine (Axid) Tier 1 permethrin Tier 1 raloxifene Tier 1 mesalamine rectal (Rowasa) Tier 3 Noritate Tier 1 perphenazine Tier 1 ramipril (Altace) Tier 3 Mestinon Tier 3 Noroxin Tier 1 perindopril (Aceon) Tier 3 Ranexa Tier 3 Metadate-CD Tier 3 Norpace CR Tier 3 Pexeva Tier 1 ranitidine Tier 1 metformin, metformin XR Tier 1 nortriptyline Tier 3 Phenytek Tier 3 Rapaflo Tier 1 methadone Tier 3 Novolin R, N, 70/30 Tier 1 phenytoin (Dilantin) Tier 3 Rayos Tier 1 methimazole Tier 2 Novolog, Novolog Mix Tier 3 Phoslo Tier 2 Rectiv Tier 1 metipranolol Tier 3 Novofine Insulin Syringes Tier 3 Phoslyra Tier 3 Regranex Tier 1 methocarbamol Tier 3 Novofine Needles Tier 3 Picato Tier 3 Relenza Tier 1 methotrexate Tier 3 Novo Penneedles Tier 1 pioglitazone Tier 3 Renagel Tier 1 methylphenidate (Ritalin) Tier 3 NovoTwist Tier 2 pioglitazone w glimepride Tier 2 Renvela Tier 2 methylphenidate ER Capsules Tier 3 Noxafil Tier 2 Potiga Tier 2 repaglinide Tier 2 methylphenidate SR OSM Tablets Tier 2 Nucynta, Nucynta ER Tier 3 Pradaxa Tier 3 Requip XL Tier 1 methylprednisolone Tier 3 Nuedexta Tier 1 pramipexole (Mirapex) Tier 3 Restasis Tier 1 metroprolol, metoprolol XL Tier 3 Nuvigil Tier 3 Pramosone Tier 3 Retin-A Micro Tier 3 Metozolv ODT Tier 1 nystatin oral, vaginal, topical Tier 1 PramOtic Tier 3 Revatio Tier 3 MetroGel Tier 3 Prandimet Tier 1 ribavirin (Copegus, Rebetol) Tier 1 metronidazole tablets O Tier 3 Prandin Tier 3 Ridaura Tier 1 metronidazole lotion (MetroLotion) Tier 1 ofloxacin oral Tier 1 pravastatin (Pravachol) Tier 3 Rifamate Tier 1 metronidazole vaginal cream Tier 1 ofloxacin otic Tier 3 Pred G Tier 1 rifampin Tier 1 mexiletine Tier 1 ofloxacin (Ocuflox) Tier 1 prednisolone Tier 2 Riomet Tier 3 Micardis, Micardis HCT Tier 1 olanzapine (Zyprexa) Tier 1 prednisolone ophthalmic Tier 1 rimantidine (Flumadine) Tier 3 Migranal Tier 1 olanzapine/fluoxetine (Symbyax) Tier 1 prednisone Tier 1 risperidone (Risperdal) Tier 3 Minimed Tier 3 Oleptro Tier 3 Prefest Tier 2 risperidone ODT (Risperdal) Tier 1 minocycline Tier 2 Olysio Tier 2 Premarin Tier 3 Ritalin-LA Tier 3 Mirapex ER OTC omeprazole OTC (Prilosec) Tier 2 Premarin Vaginal Cream Tier 1 ropinirole (Requip) Tier 1 mirtazepine (Remeron) Tier 1 ondansetron Tier 2 Premphase Tier 2 ropinirole XL Tier 1 misoprostol (Cytotec) Tier 2 One Touch Basic Tier 2 Prempro Tier 3 Rozerem Tier 2 modafinil Tier 2 One Touch Fasttake OTC Prevacid-24 Tier 3 Ryzolt Tier 1 moexepril (Univasc) Tier 2 One Touch Surestep Tier 3 PrevPac Tier 1 moexepril w HCTZ (Uniretic) Tier 2 One Touch Ultra, Ultra2 Tier 3 Priftin S Tier 1 mometasone (Elocon) Tier 2 One Touch Ultramini OTC Prilosec OTC Tier 3 Sabril Tier 1 montelukast (Singulair) Tier 2 One Touch Ultrasmart Tier 1 primidone Tier 3 Samsca Tier 2 morphine ER Cap (Kadian) Tier 2 One Touch Verio, Verio IQ Tier 2 Pristiq Tier 3 Sanctura XR Tier 1 morphine CR Tab (MS Contin) Tier 3 Onfi Tier 2 ProAir HFA Tier 2 Sancuso Tier 1 morphine IR Tier 2 Onglyza Tier 1 prochlorperazine Tier 3 Saphris Tier 2 Moxeza Tier 2 Opana ER Tier 2 Prolensa Tier 3 Sarafem Tier 2 moxifloxacin Tier 2 Opsumit Tier 1 promethazine Tier 3 Savella Tier 3 Multaq Tier 3 Oracea Tier 3 Prometrium Tier 1 selegiline Tier 1 mupirocin (Bactroban) Tier 3 Oseni Tier 1 propafenone Tier 3 Serevent Diskus Tier 3 Mycobutin Tier 3 Orfadin Tier 2 propafenone SR Tier 3 Seromycin Tier 3 Myleran Tier 3 Oticin Otic Tier 1 propranolol (Inderal) Tier 3 Seroquel, Seroquel XR Tier 2 Myrbetriq Tier 3 Ovace Tier 1 propranolol LA (Inderal LA) Tier 1 sertraline (Zoloft) Tier 1 oxaprozin Tier 1 propylthiouracil Tier 3 Sfrowasa N Tier 1 oxcarbazepine (Trileptal) Tier 3 Protopic Tier 2 sildenafil (Revatio) Tier 3 Naftin Tier 3 Oxistat Tier 1 protriptyline Tier 3 Silenor Tier 1 naltrexone HCl (Revia) Tier 1 oxybutynin (Ditropan) Tier 3 Proventil HFA Tier 2 Simcor Tier 2 Namenda, Namenda XR Tier 1 oxybutynin XL (Ditropan XL) Tier 3 Provigil Tier 1 simvastatin (Zocor) Tier 1 naproxen (Naprosyn) Tier 1 oxycodone IR (OxyIR) Tier 2 Pulmicort, Pulmicort Flexhaler Tier 3 Singulair Tier 1 naproxen sodium (Anaprox) Tier 2 oxycodone SR Tier 3 Pulmozyme Tier 3 Sirturo OTC Nasacort OTC Tier 2 Oxycontin Tier 2 Pylera Tier 3 Skelaxin Tier 2 nateglinide (Starlix) Tier 3 Oxytrol Patch Tier 1 pyrazinamide Tier 3 Skelid Tier 3 NebuPent Tier 1 pyridostigmine Tier 1 SMX-TMP (Bactrim, Bactrim DS) Tier 1 Neomycin Tablets P OTC Slo-Niacin Tier 3 Nesina Tier 3 Pancreaze DR Q Tier 3 Softclix Device Tier 2 Nevanac Tier 1 pantoprazole (Protonix) Tier 3 Qualaquin Tier 3 Solaraze Tier 3 Nexavar Tier 1 paroxetine (Paxil) Tier 1 quetiapine, quetiapine XR Tier 3 Soliris OTC Nexium 24 Hour Tier 1 paroxetine CR (Paxil CR) Tier 3 Quillivant XR Tier 3 Solodyn Tier 2 niacin ER oral tablet Tier 3 PCE Dispersetabs Tier 1 quinadine Tier 3 Soriatane Tier 1 nifedipine XL (Procardia XL) Tier 3 Peganone Tier 1 quinapril (Accupril) Tier 1 sotalol

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Tier 2 Sovaldi Tier 1 theophylline SR (Theo-Dur) U W Tier 3 Spectracef Tier 3 Thioguanine Tier 3 Uceris Tier 1 warfarin (Coumadin) Tier 2 Spiriva Tier 1 ticlopidine Tier 3 Ulesfia Tier 3 Welchol Tier 1 spironolactone Tier 3 Tikosyn Tier 3 Uloric Tier 3 Sprix Tier 1 timolol ophthalmic solution Tier 1 ursodiol (Actigall) X Tier 2 Sprycel Tier 1 timolol ophth gel foaming solution Tier 3 Ultravate Kit Tier 3 Xarelto Tier 3 Stalevo Tier 3 Tindamax Tier 3 URSO, URSO Forte Tier 3 Xeloda Tier 2 Strattera Tier 2 tinidazole Tier 2 Xifaxan 550mg Tier 3 Striverdi Tier 1 tizanidine (Zanaflex) V Tier 3 Xolegel Tier 3 Stromectol Tier 3 TOBI Tier 2 Vagifem Vaginal Tab Tier 3 Xopenex HFA Tier 2 Suboxone (SL Film) Tier 1 tobramycin-dexamethasone Tier 2 valacyclovir (Valtrex) Tier 3 Xyrem Tier 1 sucralfate Tier 2 Tobradex Tier 1 valproic acid (Depakene) Tier 1 sulfacetamide suspension (Klaron) Tier 2 Tobradex Tier 2 valsartan Y Tier 1 sulfacetamide w sulfur (Plexion) Tier 1 tobramycin opthalmic Tier 1 valsartan w/HCTZ Tier 3 Yodoxin Tier 1 sulfasalazine (Azulfidine) Tier 2 tolterodine (Detrol) Tier 3 Vancocin Tier 1 sulfisoxasole w/ EES Tier 1 topiramate (Topamax) Tier 2 vancomycin Z Tier 3 Suprax Tier 1 torsemide Tier 3 Vanos Tier 2 Sutent Tier 2 Toviaz OTC Zaditor OTC Tier 3 Vascepa OTC Zantac OTC Tier 2 Symbicort Tier 2 Tracleer Tier 3 Vectical Tier 3 Synera Tier 3 Tradjenta Tier 1 zafirlukast (Accolate) Tier 1 venlafaxine (Effexor) Tier 1 zaleplon (Sonata) Tier 1 tramadol Tier 1 venlafaxine XR (Effexor XR) T Tier 2 tramadol ER tablet OTC Zegerid OTC Tier 3 Veltin Tier 2 Zelapar Tier 3 Tabloid Tier 1 trandolapril (Mavik) Tier 1 venorelbine Tier 3 Zemplar Tier 2 Taclonex Tier 3 Transderm-Scop Tier 3 Ventavis Tier 2 Zenpep Tier 2 Tamiflu Tier 2 Travatan Z Tier 2 Ventolin HFA Tier 3 Zetia Tier 1 tamoxifen Tier 1 trazodone (Desyrel) Tier 1 verapamil Tier 3 Ziagen Tier 1 tamsulosin (Flomax) Tier 3 Trecator Tier 1 verapamil SR Tier 3 Ziana Tier 3 Tarceva Tier 2 Trelstar Tier 3 Vesanoid Tier 3 Zioptan Tier 3 Targretin Tier 1 tretinoin Tier 2 Vesicare Tier 2 ziprasidone Tier 3 Tarka (generic Tier 1) Tier 2 tretinoin microsphere gel Tier 2 Victrelis Tier 3 Zipsor Tier 3 Tasigna Tier 1 Triamcinolone acetonide Tier 2 Vigamox Tier 3 Zirgan Tier 3 Tasmar Tier 1 triamterene w HCTZ (Maxzide) Tier 2 Viibryd Tier 3 Zmax Tier 3 Tazorac Tier 1 triazolam Tier 2 Vimovo Tier 3 Zolinza Tier 2 Tecfidera Tier 3 Tribenzor Tier 2 Vimpat Tier 1 zolpidem tartrate(Ambien) Tier 3 Tekamlo Tier 3 Tricor Tier 3 Viokase Tier 2 zolpidem tartrate CR (Ambien CR) Tier 3 Tekturna Tier 3 Triglide Tier 2 Vivelle DOT Tier 3 Zolpimist Tier 2 telmisartan Tier 1 trihexyphenidyl Tier 3 Voltaren Gel Tier 1 zonisamide (Zonegran) Tier 2 telmisartan w HCTZ Tier 3 TriLipix Tier 2 voriconazole (Vfend) Tier 3 Zontivity Tier 1 temazepam Tier 1 trimethobenzamide Tier 3 Vytorin Tier 3 Zyclara Tier 3 Temodar Tier 2 trospium (Sanctura) Tier 3 Vyvanse Tier 3 Zyflo CR Tier 1 terazosin Tier 2 trospium SR (Sanctura SR) Tier 2 Zylet Tier 1 terbinafine (Lamisil) Tier 3 Tudorza Tier 3 Zymaxid Tier 1 terconazole Vag Cream (Terazol) Tier 3 Twynsta OTC Zyrtec, Zyrtec-D Tier 3 Teslac Tier 3 Tykerb Tier 2 Zytiga Tier 3 Testim Tier 3 Tyvaso Tier 3 Zyvox Tier 1 tetracycline Tier 3 Tyzeka

Tier 3 Teveten, Teveten HCT

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Excluded and Limited Services

1. Drugs not requiring a prescription by federal 8. , including Legend vitamins (other 16. Any prescription filled in excess of the Plan 21. All drugs for erectile dysfunction regardless of law unless otherwise noted under Covered than prenatal vitamins prescribed by a limits, the number specified by the physician, cause. Services (including drugs requiring a licensed provider). or any refill dispensed after one year from the 22. All drugs for irritable bowel syndrome may be prescription by state law, but not by federal 9. Charges for growth hormones. physician's original order or exceeding the subject to prior approval before dispensing. law). recommended maximum daily dosage, and 10. Immunosuppressants. 23. Drugs over $1,000 will be subject to prior 2. The cost differential between brand-name any quantity limits defined in the formulary. 11. . approval before dispensing, compounded product dispensed and the available generic 17. Any drug for the treatment of alopecia (hair 12. Therapeutic devices or appliances, including medications have a limit of $150. equivalent when the brand product is loss). 24. Neuraminidase (Flu) inhibitors – 2 treatment dispensed solely at the request of the support garments and other non-medicinal 18. Charges incurred on or after the date courses per year – retail pharmacy setting member. substances, hypodermic needles and syringes except in conjunction with insulin. coverage under this Plan is terminated. only. 3. Injectable drugs other than insulin, Epi-Pen, 19. Medication which is to be taken by or 25. Any charges above Usual/Customary/ Ana-Kit, Ana-Guard/Glucagon. 13. Charges for immunization agents, , allergy extracts, biological sera, blood or blood administered to an individual, in whole or in Reasonable (UCR) amount. 4. Topical products for cosmetic purposes with part, while he or she is a patient in a licensed components. 26. Drugs purchased at non-preferred providers. the exception of drugs for the treatment of hospital, rest home, sanitarium, extended care acne for those under age 23. 14. Prescriptions that eligible Participants are facility, convalescent hospital, nursing home 27. Contraceptives for purposes. entitled to receive without charge from any 5. Charges for drugs classed as dietary aids or or similar institution which operates on its 28. Soaps/Shampoos. Workers' Compensation Laws, and municipal, premises, or allows to be operated on its 29. Cox-2 inhibitors may be subject to step edit food supplements. state, or federal program. 6. Anorexics (any drug used for the purpose of premises, a facility for dispensing criteria. 15. Drugs labeled: "Caution: Limited by Federal pharmaceuticals. 30. All drugs newly on the market may be weight control). Law to investigational use", or experimental 7. Smoking cessation or deterrent drugs. (May 20. Oral medications for migraine will have a excluded for three years from approval by the drugs, even though a charge is made to the quantity limit per 30 calendar days. Migraine be available through the Wellness Program.) FDA. Participant. nasal spray and injectable drugs are excluded.

Notable Changes for the 2015 Formulary

The following brand medicines have been moved from Tier 3 to Tier 2:

Aczone Breo Freestyle Test Strips Olysio Sprycel Adempas Delzicol Fycompa Opsumit Sutent Advair Dymista Gilenya Pentasa Xifaxan 550mg Anoro Estrace Vag Cream Inlyta Potiga Zytiga Bethkis Farxiga Novolog Sancuso Bosulif Follistim Novolog Mix Sovaldi

The following drugs have been moved from Tier 1 or Tier 2 to Tier 3 status due to unavailability or expiration of manufacturer contracts:

Accu-Chek Lancets Novofine Syringes Axid Solution Oticin Ulesfia Accu-Chek Fastclix Novofine Needles Azasite Peganone Zemplar Accu-Chek Multiclix Novo Penneedles Bentyl Syrup Rayos Zymaxid Accu-Chek Soft Touch NovoTwist Exjade Stromectol Accu-Chek Softclix Softclix Device Lysteda Tudorza ChemStrip Apriso Mestinon Uceris The following generics will be assigned a Tier 2 copayment due to high cost:

Adefovir dipivoxil Duloxetine Propafenone SR Tretinoin Microsphere Gel Azelastine nasal Eprosartan Quetiapine SR Telmisartan Celecoxib Moxifloxacin Repaglinide Telmisartan w HCTZ With the availability of generic options at Tier 1 or Tier 2 the brand versions of these medicines will be assigned a Tier 3 copay where applicable:

Alelox, Celebrex, Lidoderm The following drugs are no longer on the market:

Cenestin, Fortovase, Fuzeon, Hivid, Juvasync, Mycelex, Mycostatin, Onsolis, Prostigmin, Twinject

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