BLOOD CANCER DRUGS-OTHER (ANTINEOPLASTICS) BLOOD MODIFIERS CANCER DRUGS-OTHER (ANTINEOPLASTICS) anagrelide (P) NEUPOGEN SYLATRON (P) pentoxifylline (M) (P) PROCRIT CANCER DRUGS -ORAL BLOOD THINNERS (ANTICOAGULANTS) (ANTINEOPLASTICS)

COUMADIN (M) CANCER DRUGS -ORAL (ANTINEOPLASTICS) enoxaparin (M) fondaparinux (P) AFINITOR FRAGMIN (M) PRADAXA (P) (M) BOSULIF (P) CAPRELSA (M) STROKE PREVENTION exemestane ERIVEDGE (P) (M) GLEEVEC (P) clopidogrel (P) ticlopidine (M) HYCAMTIN INLYTA (P) (M) CANCER DRUGS-OTHER letrozole NEXAVAR (P) (ANTINEOPLASTICS) (P) REVLIMID (P) CANCER DRUGS-OTHER SPRYCEL (ANTINEOPLASTICS)

JAKAFI (P)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

CANCER DRUGS -ORAL CENTRAL NERVOUS SYSTEM (ANTINEOPLASTICS) ANTI-PARKINSON DRUGS CANCER DRUGS -ORAL (M) (ANTINEOPLASTICS) pramipexole ropinirole (M) STIVARGA (P) selegiline (M) SUTENT (P) TARCEVA (P) ATTENTION DEFICIT DISORDER (ADD), TASIGNA (P) NARCOLEPSY (P) TEMODAR (M) (P) amphetamine/dextroamphetamine THALOMID (M) (P) dexmethylphenidate TYKERB (M) (P) dextroamphetamine VOTRIENT (M) (P) methamphetamine XALKORI (M) (P) methylphenidate sr XELODA (M) XTANDI (P) methylphenidate ZELBORAF (P) (P) SEIZURE MEDICATIONS (ANTICONVULSANTS) ZOLINZA (P) ZYTIGA extended release (M) carbamazepine (M) CENTRAL NERVOUS SYSTEM clonazepam (M) diazepam (M) ALZHEIMER'S DRUGS divalproex (M) (M) (M) divalproex sodium ARICEPT-23 (M) (M) ethosuximide donepezil (M) NAMENDA (M) gabapentin lamotrigine (M) (M) ANTI-PARKINSON DRUGS levetiracetam (M) amantadine (M) (M) APOKYN topiramate (M) bromocriptine (M) valproic acid (M) levodopa/carbidopa (M) zonisamide (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

CENTRAL NERVOUS SYSTEM DIABETES & HIGH BLOOD SUGAR

SLEEP AIDS ANTIDIABETIC DRUGS

temazepam LEVEMIR (M) zaleplon metformin xr (M) zolpidem metformin (M) nateglinide (M) CHEST PAIN & HEART DISEASE NOVO INSULIN (M) NOVOLOG (M) CHEST PAIN & HEART DISEASE ONGLYZA (M) (M) (M) piogliazone/metformin isosorbide dinitrate pioglitazone (M) (M) (M) (M) PRANDIN nitroglycerin sl VICTOZA (M) transdermal nitroglycerin (M) BLOOD SUGAR TEST STRIPS DIABETES & HIGH BLOOD SUGAR ACCU-CHEK meter test strips (Q,M) ANTIDIABETIC DRUGS ONE TOUCH meter test strips (Q,M)

(M) acarbose DISEASES BYETTA (M) (M) glimepiride ARTHRITIS (RHEUMATOID) glipizide extended release (M) glipizide (M) ENBREL (P) glyburide and metformin (M) HUMIRA (P) glyburide (M) leflunomide (M) JANUMET XR (M) methotrexate (M) JANUMET (M) JANUVIA (M) BONE DISEASE KOMBIGLYZE (M) alendronate (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

DISEASES ENT (EAR/NOSE/THROAT)

BONE DISEASE ALLERGIES & COLDS (NASAL)

calcitonin salmon nasal spray (M) propionate (M) etidronate (M) (M) EVISTA (M) ibandronate (M) ALLERGIES (ORAL)

(M) GOUT desloratadine levocetirizine (M) allopurinol (M) COLCRYS (M) MISCELLANEOUS

HEPATITIS lidocaine viscous

INTRON A (M) EYE PEGASYS (P) ribavirin ANTI-INFLAMMATORY DROPS

MULTIPLE SCLEROSIS DRUGS

COPAXONE (P,M) COMBINATION EYE INFECTION DROPS REBIF (P,M) /neomycin/polymyxin THYROID DISEASE dexamethasone/tobramycin

(M) EYE INFECTION DROPS liothyronine (M) methimazole (M) ciprofloxacin propylthiouracil (M) ENT (EAR/NOSE/THROAT)

ALLERGIES & COLDS (NASAL)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

EYE EYE

EYE INFECTION DROPS MISCELLANEOUS DRUGS

ofloxacin ketorolac tromethamine 0.5% polymyxin b/bacitracin RESTASIS (M) polymyxin b/trimethoprim polymyxin/neomycin/gramicidin sol. HEART RHYTHM DISORDERS sodium sulfacetamide tobramycin drops HEART RHYTHM DISORDERS

trifluridine (M) VIGAMOX acebutolol (M) (M) GLAUCOMA DRUGS digoxin disopyramide controlled release (M) acetazolamide (M) disopyramide (M) ALPHAGAN P 0.1% (M) propafenone (M) AZOPT (M) sotalol (M) brimonidine 0.15% (M) COMBIGAN (M) HIGH BLOOD PRESSURE & HEART (M) dorzolamide/timolol DISEASE dorzolamide (M) (M) latanoprost ACE INHIBITORS levobunolol (M) LUMIGAN (M) benazepril (M) methazolamide (M) enalapril (M) pilocarpine (M) lisinopril (M) timolol (M) moexipril (M) quinapril (M) MISCELLANEOUS DRUGS trandolapril (M)

atropine ALPHA BETA BLOCKERS flurbiprofen ketoralac tromethamine, 0.4 % (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

HIGH BLOOD PRESSURE & HEART HIGH BLOOD PRESSURE & HEART DISEASE DISEASE

ALPHA BETA BLOCKERS CALCIUM CHANNEL BLOCKERS

doxazosin (M) (M) labetalol (M) verapamil extended release (M) prazosin (M) verapamil (M) ANGIOTENSIN II BLOCKERS COMBINATION DRUGS

DIOVAN (M) /benazepril (M) EDARBI (M) /chlorthalidone (M) irbesartan (M) benazepril/hctz (M) losartan (M) bisoprolol/hctz (M) EDARBYCLOR (M) BETA BLOCKERS irbesartan/hctz (M) (M) (M) lisinopril/hctz acebutolol (M) (M) losartan/hctz atenolol (M) (M) moexipril/hct BYSTOLIC valsartan/hctz (M) metoprolol xl (M) (M) metoprolol SYMPATHOLYTICS nadolol (M) propranolol extended rel. (M) clonidine (M) propranolol (M) guanfacine (M)

CALCIUM CHANNEL BLOCKERS WATER PILLS OR DIURETICS

amlodipine (M) furosemide (M) diltiazem extended release (M) hydrochlorothiazide (M) diltiazem (M) metolazone (M) extended release (M) (M) nifedipine sustained release (M) torsemide (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

HIGH BLOOD PRESSURE & HEART HIV & AIDS DISEASE COMBINATION DRUGS WATER PILLS OR DIURETICS KALETRA (M) (M) triamterene/hctz (M) lamivudine/zidovudine STRIBILD (M) TRIZIVIR (M) HIGH CHOLESTEROL DRUGS (M) (ANTILIPEMICS) TRUVADA NON-NUCLEOSIDE REVERSE TRANSCRIPTASE HIGH CHOLESTEROL DRUGS INHIBITORS (ANTILIPEMICS) (M) (M) EDURANT atorvastatin (M) (M) INTELENCE cholestyramine (M) (M) colestipol (M) (M) RESCRIPTOR fluvastatin (M) (M) SUSTIVA gemfibrozil (M) (M) NUCLEOSIDE REVERSE TRANSCRIPTASE pravastatin INHIBITORS (M) abacavir (M) HIV & AIDS didanosine (M) EMTRIVA (M) MISCELLANEOUS FUZEON (M) HIVID (M) (M) ATRIPLA lamivudine (M) (M) ISENTRESS stavudine (M) (M) SELZENTRY VIDEX Powder (M) VIREAD (M) COMBINATION DRUGS zidovudine capsules (M) zidovudine tablets and syrup (M) COMPLERA (M) (M) EPZICOM PROTEASE INHIBITORS

APTIVUS (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

HIV & AIDS HORMONES

PROTEASE INHIBITORS MISCELLANEOUS

CRIXIVAN (M) desmopressin acetate tablets (M) FORTOVASE, INVIRASE (M) LEXIVA (M) REPLACEMENT MEDICATION NORVIR (M) PREZISTA (M) REYATAZ (M) VIRACEPT (M) IMMUNE SYSTEM HORMONES ANTI-REJECTION (IMMUNOSUPPRESSANTS) azathioprine (M) GROWTH cyclosporine (M) (M) (P) mercaptopurine NORDITROPIN (M) SEROSTIM (P) mycophenolate RAPAMUNE (M) (M) HORMONE REPLACEMENT DRUGS

ethinyl estradiol/norethindrone (M) INFECTIONS

MALE BACTERIAL (CEPHALOSPORINS)

ANDRODERM (M) cefuroxime AXIRON (M) cephalexin capsules oxandrolone BACTERIAL (COMBINATION ANTIBIOTICS) MISCELLANEOUS trimethoprim/sulfamethoxazole desmopressin acetate nasal spray (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

INFECTIONS INFECTIONS BACTERIAL (FLUROQUINOLONES) FUNGAL ( DRUGS)

ciprofloxacin er itraconazole ciprofloxacin levofloxacin terbinafine

BACTERIAL (MACROLIDES) MISCELLANEOUS ANTI-INFECTIVE DRUGS

azithromycin suspension (Q) atovaquone/proguanil azithromycin tablets (Q) chloroquine phosphate clarithromycin extended release hydroxychloroquine clarithromycin ZYVOX ethylsuccinate TUBERCULOSIS (ANTITUBERCULOSIS DRUG) BACTERIAL (MISCELLANEOUS (M) ANTIBIOTICS) ethambutol isoniazid/rifampin (M) metronidazole URINARY TRACT

BACTERIAL (PENICILLINS) nitrofurantoin (macrocrystals) nitrofurantoin exten. rel. amoxicillin/clavulanate amoxicillin/pot.clavulanate VIRAL (ANTIVIRAL DRUGS)

BACTERIAL () acyclovir famciclovir doxycycline monohydrate valacyclovir doxycycline VALCYTE MENTAL HEALTH FUNGAL (ANTIFUNGAL DRUGS) ANTIDEPRESSANTS fluconazole bupropion xl 150mg (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

MENTAL HEALTH MENTAL HEALTH

ANTIDEPRESSANTS MANIC-DEPRESSION OR BIPOLAR DRUGS

bupropion (M) lithium carbonate ext. rel. (M) citalopram (M) clomipramine (M) MISCELLANEOUS DRUGS desipramine (M) escitilopram (M) MISCELLANEOUS DRUGS fluoxetine (M) (M) Novofine needles (M) imipramine (M) mirtapazine orally disintegrating (M) Novotwist needles mirtazapine (M) nortriptyline (M) MUSCLE RELAXERS paroxetine controlled release (M) paroxetine (M) MUSCLE RELAXERS phenelzine (M) protriptyline (M) carisoprodol sertraline (M) cyclobenzaprine tranylcypromine (M) metaxalone venlafaxine (M) methocarbamol tizanidine ANTIPSYCHOTIC DRUGS NARCOLEPSY olanzapine (M) quetiapine fumurate (M) NARCOLEPSY risperidone (M) (P) thiothixene (M) modafinil ziprasidone (M) OB-GYN ANXIETY BIRTH CONTROL PILLS (MONOPHASIC alprazolam CONTRACEPTIVES) diazepam 0.03mg ethinyl estradiol/ 0.15mg levonorgestrel (Q,M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

OB-GYN OB-GYN

BIRTH CONTROL PILLS (MONOPHASIC BREAST CANCER (ANTI-ESTROGENS) CONTRACEPTIVES) (M) 30 mcg ethinyl estradiol/0.15 mg levonorgestrel (M) FEMALE HORMONES (ESTROGENS) (M) drospirenone/ethinyl estradiol (M) (M) estradiol patch drospirenone/ (M) (M) estradiol ethinyl estradiol/ (M) (M) estropipate ethinyl estradiol/norethindrone (M) (M) PREMARIN VAGINAL CREAM ethinyl estradiol/norgestimate (M) ethinylestradiol 30 mcg/desogestrel 0.15 PREMARIN mg (M) (M) FEMALE HORMONES (PROGESTINS) low-ogestrel (M) mestranol/norethindrone (M) (M) medroxyprogesterone acetate necon micronized (M) zovia (M) FEMALE HORMONES (REPLACEMENT BIRTH CONTROL PILLS (PROGESTIN ONLY) COMBINATIONS) (Q) medroxyprogesterone injection (M) (M) FEMHRT norethindrone 0.35 mg PREMPHASE (M) PREMPRO (M) BIRTH CONTROL PILLS (TRIPHASIC CONTRACEPTIVES) FERTILITY (M) desogestrel/ethinylestradiol (P) (M) BRAVELLE desogestril/ethinyl estradiol (P) (M) chorionic gonadotropin ethinyl estradiol+norethindrone clomiphene ethinyl estradiol/norethindrone acetate (M) CETROTIDE (P) ethinyl estradiol/norethindrone (M) ganirelix acetate (P) norgestinate-ethinyl estradiol (M) ORTHO TRI-CYCLEN LO (M)

BREAST CANCER (ANTI-ESTROGENS)

FARESTON (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

OB-GYN PAIN MANAGEMENT (ANALGESICS)

FERTILITY PAIN MANAGEMENT (ANALGESICS)

GONAL-F (P) lozenge (P) MENOPUR (P) fentanyl transdermal progesterone in oil (P) hydromorphone REPRONEX (P) ibuprofen/hydrocodone (M) ibuprofen (M) UTERINE CONTRACTIONS & BLEEDING indomethacin (M) ketorolac methylergonovine meloxicam (M) meperidine YEAST OR BACTERIAL INFECTIONS (P) morphine sulfate clindamycin morphine sulfate morphine, sustained release metronidazole vaginal gel (M) nabumetone naproxen (M) (Q) PAIN MANAGEMENT (ANALGESICS) naratriptan oxaprozin (M) PAIN MANAGEMENT (ANALGESICS) oxycodone/apap oxycodone/aspirin (M) acetaminophen/codeine piroxicam (M) apap/dichloral-phenazone/isometheptene (M) sulindac (Q) butalbital/caffeine/aspirin sumatriptan (M) butorphanol (Q) tramadol diclofenac sodium xr (M) diclofenac sodium (M) RESPIRATORY PROBLEMS diclofenac/misoprostol (M) dihydroergotamine mesylate (M) & COPD (MISCELLANEOUS ergotamine/caffeine (M) INHALERS) ADVAIR (M) COMBIVENT (M) DULERA (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

RESPIRATORY PROBLEMS SKIN ASTHMA & COPD (MISCELLANEOUS ACNE INHALERS) benzoyl peroxide/erythromycin (M) clindamycin phos/benzyl peroxide SPIRIVA (M) clindamycin/tretinoin (P) SYMBICORT (M) clindamycin tretinoin cream and gel (P) ASTHMA () ANTI-INFLAMMATORY OR levabuterol (M) PROAIR HFA (M) cream & oint. SEREVENT (M) aug. diprop. cream VENTOLIN HFA (M) aug. betamethasone diprop. oint. betamethasone diprop. ASTHMA (STEROID INHALERS) propionate

(M) ASMANEX halobetasol propionate (M) (M) hydrocortisone valerate FLOVENT HFA furoate PULMICORT FLEXHALER (M) DISEASES-ECZEMA & PSORIASIS MISCELLANEOUS DRUGS calcipotriene cream EPIPEN JR. (Q) (M) PROTOPIC TAZORAC (P) zafirlukast (M) GENITAL WARTS SKIN imiquimod ACNE podofilox sol'n

(P) adapalene LICE AND SCABIES TREATMENT

cream

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

SKIN STOMACH & DIGESTIVE DISORDERS

MISCELLANEOUS ACID & STOMACH ULCERS

ciclopirox famotidine 40 mg (M) fluorouracil lansoprazole (M) misoprostol (M) TOPICAL ANTIBIOTICS nizatidine (M) 10mg & 40mg (P,M) clindamycin topical pantoprazole (M) metronidazole topical gel ranitidine 300 mg (M) mupirocin ointment sucralfate silver sulfadiazine ANTI-DIARRHEAL DRUGS TOPICAL ANTIFUNGAL DRUGS diphenoxylate/atropine ciclopirox olamine /betamethasone ANTI-NAUSEA nystatin ZOVIRAX CREAM AND OINTMENT dronabinol EMEND (ORAL ANTI- granisetron INFLAMMATORY DRUGS) ondansetron BOWEL & COLON DISEASE STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS) ASACOL HD (M) ASACOL (M) (M) budesonide (micronized) prednisolone sodium hydrocortisone/pramoxine hydrocortisone STOMACH & DIGESTIVE DISORDERS LIALDA (M) mesalamine rectal susp (M) ACID & STOMACH ULCERS

cimetidine (M)

KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

STOMACH & DIGESTIVE DISORDERS SUPPLEMENTS

IRRITABLE BOWEL SYNDROME VITAMIN D

dicyclomine calcitriol capsules (M) calcitriol suspension (M) MALABSORPTION DISEASE HECTOROL (M)

(M) pancrelipase UROLOGY

MISCELLANEOUS BLADDER CONTROL (ANTISPASMODICS)

peg/electrolyte soln. (M) (M) DETROL LA sulfasalazine (M) (M) hyoscyamine ursodiol oxybutynin sr (M) oxybutynin (M) SEVERE HEARTBURN & REFLUX tolterodine (M) metoclopramide (M) BLADDER CONTROL (CHOLINERGIC AGENTS)

SUBSTANCE ABUSE bethanechol chloride (M)

DRUG ADDICTION IMPOTENCE (ERECTILE DYSFUNCTION) (P) buprenorphine tab VIAGRA (Q) naltrexone (P) SUBOXONE PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY) QUIT SMOKING AIDS AVODART (M) bupropion sr doxazosin (M) finasteride (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

UROLOGY

PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY)

JALYN (M) tamsulosin (M) terazosin (M)

URINARY TRACT PAIN (ANESTHETICS)

phenazopyridine

KEY: Preferred Brand-Name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication

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