2015 FORMULARY (Commercial) EFFECTIVE 01/01/15 Introduction This formulary is a list of generic and brand medications covered by your prescription drug benefit. It is designed to offer you and your doctor cost-effective choices for safe and clinically effective prescription drugs. Coverage for the drugs included on the 2015 PreferredOne Formulary is determined by your benefit plan design. It is important to note that this formulary is not a complete list of medications and not all listed drugs may be covered by your plan. Please refer to the benefit documents provided by your employer or health plan for information on your specific benefit coverage. You may also contact the PreferredOne Customer Service Department at 1-800- 997-1750 or visit PreferredOne.com for more information. How is the formulary developed? This formulary was developed based on the recommendations of an independent Pharmacy and Therapeutics (P&T) Committee comprised of doctors and pharmacists. This committee meets several times a year to review and select safe, clinically sound, cost-effective drugs for the formulary. Ongoing review of clinical literature is conducted to evaluate safety, effectiveness and current use in therapy to determine whether a drug should be included in the formulary. Does the formulary change throughout the year? The 2015 PreferredOne Formulary may change throughout the year as new drugs or clinical information becomes available. Drugs may be added as they are introduced to the marketplace and other drugs may change tier status as generics become available. Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for the most current formulary information. What are formulary tiers? This formulary is made up of different cost levels or tiers. Your health plan or employer determines your out-of-pocket costs for each tier. Check your plan’s benefit documents to understand your benefit structure and out-of-pocket costs. If you are prescribed a drug on a higher tier, discuss the alternative lower tier options with your doctor to help save money on your out of pocket costs. Are generic drugs different than brand drugs? Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to be just as safe and effective as brand drugs. Although they have the same active ingredients, generic drugs generally cost significantly less than brand drugs. You can lower your out-of-pocket expenses by asking your doctor if a generic medication is right for you. How do I fill my specialty medication? Specialty medications are typically used to treat rare or chronic conditions and often require special handling. To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications, your plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty pharmacies provide personalized care and offer convenient delivery to your home or other approved location. Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for the most current formulary information. Are there any restrictions on my coverage? Some medications on the formulary may have additional requirements or limits on coverage. These requirements or limits may include: Prior Authorization — Your benefit plan may require that the medication you have been prescribed receive prior authorization. This means that you will need to get approval from your plan before you fill your prescription. If you don’t get approval, the medication may not be covered by your drug benefit. Quantity Limits — For some drugs, your plan may limit the amount of the drug that is covered by your benefit for a certain time period. Quantities that exceed this limit must be reviewed and approved by your plan before coverage will apply. Step Therapy — In some cases, your plan may require you to first try certain drugs to treat your medical condition before another drug for that condition will be covered. For example, if two drugs are used to treat the same medical condition, you may be required to first try one drug before the second drug is covered. Your doctor can request a prior authorization, a quantity limit override, or a step therapy override approval by submitting the appropriate request form to PreferredOne on your behalf. PreferredOne will review the request and make a determination of coverage for the drug. For more information about the 2015 PreferredOne Formulary: Call the PreferredOne Customer Service Department at 1-800-997-1750 Or, visit PreferredOne.com LEGEND TIER DESCRIPTION 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 Specialty Generics 5 Specialty Preferred Brands 6 Specialty Non-Preferred Brands Non-Specialty Injectable 7 Generics Non-Specialty Injectable 8 Preferred Brands Non-Specialty Injectable Non 9 Preferred Brands TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame. You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition. This medication is preferred by 2015 PREFERRED ONE HEALTH Preferred Drug PLAN over other medications in the same Tier that are used to treat the same condition(s) PAGE 4 LAST UPDATED 10/2014 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Analgesics Nonsteroidal Anti-inflammatory Drugs ANAPROX 275 MG TABLET 3 naproxen sodium ANAPROX DS 550 MG TABLET 3 naproxen sodium ANSAID 100 MG TABLET 3 flurbiprofen ARTHROTEC 50 MG-200 MCG TAB 3 diclofenac sodium/misoprostol ARTHROTEC 75 MG-200 MCG TAB 3 diclofenac sodium/misoprostol aspirin ec 975 mg tablet 1 CALDOLOR 400 MG/4 ML VIAL 9 QL 960 / 30 days ibuprofen CALDOLOR 800 MG/8 ML VIAL 9 QL 960 / 30 days ibuprofen CAMBIA 50 MG POWDER PACKET 3 diclofenac potassium CATAFLAM 50 MG TABLET 3 diclofenac potassium CELEBREX 100 MG CAPSULE QL 90 / 30 days 2 celecoxib ST CELEBREX 200 MG CAPSULE QL 120 / 30 days 2 celecoxib ST CELEBREX 400 MG CAPSULE QL 60 / 30 days 2 celecoxib ST CELEBREX 50 MG CAPSULE QL 150 / 30 days 2 celecoxib ST choline mag trisal liquid 1 COMFORT PAC-MELOXICAM KIT 3 meloxicam/irritants counter-irritants combination no.2 COMFORT PAC-NAPROXEN KIT 3 naproxen/irritants counter-irritants combination #2 PAGE 5 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DAYPRO 600 MG CAPLET 3 oxaprozin diclofenac pot 50 mg tablet 1 diclofenac sod dr 25 mg tab 1 diclofenac sod dr 50 mg tab 1 diclofenac sod dr 50 mg tab 1 diclofenac sod dr 75 mg tab 1 diclofenac sod dr 75 mg tab 1 diclofenac sod ec 25 mg tab 1 diclofenac sod ec 50 mg tab 1 diclofenac sod ec 75 mg tab 1 diclofenac sod er 100 mg tab 1 diclofenac-misoprost 50-0.2 tb 1 diclofenac-misoprost 50-0.2 tb 1 diclofenac-misoprost 50-200 tb 1 diclofenac-misoprost 75-0.2 tb 1 diclofenac-misoprost 75-0.2 tb 1 diclofenac-misoprost 75-200 tb 1 diflunisal 500 mg tablet 1 DUEXIS 800-26.6 MG TABLET 3 ibuprofen/famotidine EC-NAPROSYN EC 375 MG TABLET 3 naproxen etodolac 200 mg capsule 1 etodolac 300 mg capsule 1 etodolac 400 mg tablet 1 etodolac 400 mg tablet 1 etodolac 500 mg tablet 1 etodolac er 400 mg tablet 1 PAGE 6 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS etodolac er 400 mg tablet 1 etodolac er 500 mg tablet 1 etodolac er 500 mg tablet 1 etodolac er 600 mg tablet 1 etodolac er 600 mg tablet 1 FELDENE 10 MG CAPSULE 3 piroxicam FELDENE 20 MG CAPSULE 3 piroxicam fenoprofen 600 mg tablet 1 fenoprofen calcium 400 mg cap 1 FLECTOR 1.3% PATCH 3 diclofenac epolamine flurbiprofen 100 mg tablet 1 flurbiprofen 50 mg tablet 1 ibuprofen 100 mg/5 ml susp 1 ibuprofen 400 mg tablet 1 ibuprofen 400 mg tablet 1 ibuprofen 600 mg tablet 1 ibuprofen 600 mg tablet 1 ibuprofen 800 mg tablet 1 ibuprofen 800 mg tablet 1 INDOCIN 25 MG/5 ML SUSPENSION 3 indomethacin INDOCIN 50 MG SUPPOSITORY 3 indomethacin INDOCIN I.V. 1 MG VIAL 9 indomethacin sodium indomethacin 1 mg vial 7 indomethacin 1 mg vial 7 indomethacin 25 mg capsule 1 PAGE 7 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS indomethacin 50 mg capsule 1 indomethacin er 75 mg capsule 1 ketoprofen 50 mg capsule 1 ketoprofen 75 mg capsule 1 ketoprofen er 200 mg capsule 1 ketorolac 10 mg tablet 1 QL 20 / 30 days ketorolac 15 mg/ml carpuject 7 ketorolac 15 mg/ml isecure syr 7 ketorolac 15 mg/ml vial 7 ketorolac 15 mg/ml vial 7 ketorolac 30 mg/ml carpuject 7 ketorolac 30 mg/ml isecure syr 7 ketorolac 30 mg/ml vial 7 ketorolac 30 mg/ml vial 7 ketorolac 300 mg/10 ml vial 7 ketorolac 60 mg/2 ml vial 7 ketorolac 60 mg/2 ml vial 7 LEVACET CAPLET 3 aspirin/salicylamide/acetaminophen/caffeine meclofenamate 100 mg capsule 1 meclofenamate 50 mg capsule 1 mefenamic acid 250 mg capsule 1 mefenamic acid 250 mg capsule 1 meloxicam 15 mg tablet 1 meloxicam 15 mg tablet 1 meloxicam 7.5 mg tablet 1 meloxicam 7.5 mg/5 ml susp 3 MOBIC 15 MG TABLET 3 PAGE 8 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS meloxicam MOBIC 7.5 MG TABLET 3 meloxicam MOBIC 7.5 MG/5 ML SUSPENSION 3 meloxicam nabumetone 500 mg tablet 1 nabumetone 500 mg tablet 1 nabumetone 750 mg tablet 1 nabumetone 750 mg tablet 1 NALFON 400 MG CAPSULE 3 fenoprofen calcium NAPRELAN CR 375 MG TABLET 3 naproxen sodium NAPRELAN CR 375 MG TABLET 3 naproxen