Wood County Employee Health Benefits Select Over-the-Counter (OTC) If approved by the Medical Manager an effective 2014 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 Schedule of Benefits as of Jan. 1, 2014 are available at no cost to the of Excluded / Override form. The Benefits The following is a listing of drugs broken down by Subscriber with a valid prescription. To Coordinator will notify the Subscriber and the conditions they are used to treat. Under each The Plan pays all covered charges incurred in receive the benefit at the retail pharmacy, the Prescription carrier of the effective date. condition, the drugs are listed in three tiers. Tier I excess of the co-pay amount. Subscriber must submit a valid prescription at Purchases after the effective date may be eligible is the least expensive; followed by Tier 2 which is the pharmacy counter for payment through for reimbursement allowable under the Plan. less expensive; and Tier 3 which is the most Benefits apply for prescriptions purchased at the pharmacy benefits. A 90-day supply of Approvals are subject to the plan design and any expensive. Tier 1 drugs always costs the least Participating Pharmacies only. Visit the employee one of the following OTC medications may future plan changes. amount and are as effective and safe as Brand website for a listing of participating pharmacies. also be purchased through the mail order Drugs. Remember: Select Over-the-Counter program by sending in a valid prescription. When a brand product is dispensed solely at the RxEOB drugs with a valid prescription are free to you and request of the Subscriber and a generic equivalent Prilosec OTC Tablets 20mg, Zantac OTC, save the Plan the most money. Use RxEOB to shop for the most appropriate and is available, the Subscriber is responsible for any omeprazole OTC, Prevacid OTC, Zegerid lowest cost drug for you and the Plan. View cost differential between the two products in While there are more than 10,000 drugs available OTC pharmacy benefits and get price quotes at addition to the co-payment. on the market, this listing provides the most Zyrtec, Zyrtec D, Claritin Syrup, Claritin www.rxeob.com. To register for this service, frequently prescribed medications. If a drug is not Tablets, Claritin Reditab, Alavert Syrup, visit, www.co.wood.oh.us.employee. The included on this list, please contact the Pharmacy Retail Pharmacy Co-Pay Amount Alavert Tablets, store brand loratadine, RxEOB link is under the Insurance link. Benefit Manager. Price fluctuations, changes in Maximum 34 day supply Tavist ND Tablets, Dimetapp ND Tablets, Tier levels, and/or method of purchase (retail/mail Claritin-D 12 Tablets, Claritin-D 24 Tablets, order) may result in higher out of pocket Selected $0 Prescription Coverage Contact store brand loratadine-D 24 tablets expenses. Drugs may change throughout the OTC Abreva Cream (for cold sores and fever Information year. Tier 1 $5 blisters) Pharmacy Benefits Manager Tier 2 $15 plus 20% of the Average Alaway, ketotifen, Zaditor (Ophthalmic) Pharmacy Benefits Direct Please note that while a drug may be listed in the formulary, the drug may fall under the Wholesale Price (AWP) Slo-Niacin (for cholesterol) Customer Service No. 1.800.806.7859 $35 maximum out-of-pocket Plan’s excluded and limited services listing.

Mail Order Benefit Please contact the Pharmacy Benefit Manager Tier 3 $15 plus 20% of the AWP Retail Pharmacies for specific coverage information. $65 maximum out-of-pocket The mail order program allows Subscribers to For a list of participating pharmacies fill a 90-day prescription. The initial order It is important that you share this information with Mail Order Co-Pay Amount requires the original prescription from your see the Network Website: your physician and follow his/her advice. This Maximum 90 day supply doctor. Due to the processing of the order, www.pdmi.com information is not meant as a substitute for the allow 14 days mail time. care of your physician. Rather, it is available to Selected $0 OTC Mail Order help you and your physician select a less Refills may be obtained by calling a toll free expensive drug that will work for you. Tier 1 $10 number or ordering online. Refer to the MEDVANTX Prescription Coverage Contact Information in Tier 2 $30 plus 20% of the AWP Customer Service: 1.866.744.0621 DRUGS FOR the back of this booklet. $70 maximum out-of-pocket PO Box 5736, ------Sioux Falls, SD 57117-5736 Penicillins ...... Tier 3 $30 plus 20% of the AWP Medical Review Tier 1 ampicillin, amoxicillin, cloxacillin, dicloxacillin, www.medvantxrx.com $130 maximum out of pocket Coverage for excluded and limited services amoxicllin w/ potassium clavulanate, penicillin may be authorized and approved by the Cephalosporins...... See the Plan Document for a complete list of Tier 1 cefaclor, cefadroxil, cefdinir, cefradine, Excluded and Limited Services. Medical Manager and/or Plan Administrator Employee Website cefpodoxime, cefprozil, cefuroxime, based on medical necessity. Subscribers www.co.wood.oh.us/employee cephalexin If approved under the Medical Review Process, seeking coverage for a prescription on the Provides links to plan and network Tier 3 Cedax, Spectracef, Suprax prescriptions are covered at the following level: Excluded and Limited Services listing shall Macrolides ...... information, access to Subscriber Booklet, Pharmacy: $15 plus 50% of the AWP; complete a Medical Necessity Review form with Tier 1 azithromycin, clarithromycin, erythromycin claim, and reimbursement forms, along with ethyl succinate, erythromycin stearate maximum $150 out-of-pocket physician assistance prior to purchase. wellness program information. Tier 2 clarithromycin ER Forms are available from a Group Tier 3 Dificid, EryPed, PCE, Zmax Mail Order: $30 plus 50% of the AWP: Representative or on-line. Completed forms Tetracyclines...... maximum $300 out-of-pocket shall be returned to the Benefits Coordinator in Database of Low Cost/Free Tier 1 doxycycline, minocycline, tetracycline the Commissioners’ Office for processing. Medications Tier 3 Adoxa, Doryx, Oracea, Solodyn Insufficient or incomplete information may result Quinolones ...... www.hylant.medtipster.com in a delay or denial of claim. Tier 1 ciprofloxacin, levofloxacin, ofloxacin Find free or low cost medications at local Tier 2 Avelox, ciprofloxacin XR pharmacies Tier 3 Factive, Noroxin

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Aminoglycosides...... Tier 3 Estrace Vag Cream, Alora, Climara, MISCELLANEOUS ENDOCRINE MISCELLANEOUS CARDIOVASCULAR DRUGS------Tier 1 Neomycin Tablets Estraderm, Estrasorb, Estring, Tier 3 Bidil Tier 2 cabergoline, desmopressin, Zemplar Sulfonamides...... Estrogel, Femring, Menest /------Tier 3 Carnitor, Hectoral Tier 1 sulfisoxazole w erythromycin ethylsuccinate COMBINATIONS------Tier 1 anagrelide, cilostazol, clopidogrel, dipyridamole, sulfamethoxazole w trimethoprim (SMX-TMP) Tier 1 estradiol & norethindrone acetate CARDIOVASCULAR DRUGS pentoxifylline, ticlopidine, warfarin Drugs for Tuberculosis...... ethinyl estradiol & norethindrone acetate CARDIOTONICS ------Tier 2 enoxaparin Tier 1 ethambutol, isoniazid, pyrazinamide, rifampin esterified & methyltestosterone Tier 1 Digoxin Tier 3 Aggrenox, Brilinta, Effient, Pradaxa, Xarelto Tier 3 Mycobutin, Priftin, Rifamate, Seromycin Tier 2 Premphase, Prempro, Combipatch ANTI-ANGINA ------DRUGS FOR MISCELLANEOUS DISORDERS- Sirturo, Trecator Tier 3 Angeliq, Climara Pro, Femhrt, Jinteli, Prefest Tier 1 isosorbide dinitrate, isosorbide mononitrate Tier 1 aminocaproic acid, pentoxyfylline, Drugs for Fungal Infections...... PROGESTINS ------Tier 2 Nitrostat subligual tabs Tier 2 Exjade Tier 1 fluconazole, ketoconazole, nystatin, terbinafine Tier 1 medroxyprogesterone, megestrol Tier 3 Dilatrate-SR, Nitrolingual, Ranexa Tier 3 Mephyton, Samsca Tier 2 itraconazole, voriconazole Tier 2 Crinone, Endometrin BETA-ADRENERGIC BLOCKERS------RESPIRATORY / ASTHMA Tier 3 Ancobon, Grifulvin-V, Gris-Peg, Noxafil Tier 3 Prometrium Tier 1 atenolol, carvedilol, metoprolol, metoprolol XL, DRUGS FOR ALLERGY ------Drugs For Viral Infections - Influenza & RSV ...... propranolol, propranolol LA, DRUGS FOR DIABETES Oral Antihistamines and Combinations...... Tier 1 amantadine, rimantidine Tier 2 Bystolic INSULINS ------OTC Zyrtec, Zyrtec D, Claritin Syrup, Claritin Tablets, Tier 2 Tamiflu Tier 3 Coreg CR, Innopran XL, Levatol Tier 1 Humulin R, N, 70/30 Claritin Reditab, Alavert Syrup, Alavert Tablets, Tier 3 Relenza CALCIUM CHANNEL BLOCKERS ------Tier 2 Humalog, Humalog 3ml, Humalog KwikPen, store brand loratadine, Tavist ND Tablets, Drugs For Viral Infections - Herpes...... Tier 1 amlodipine, diltiazem, diltiazem CD, diltiazem Humalog Mix, Humalog Mix 3ml, Dimetapp ND Tablets, Claritin-D 12 Tablets, Tier 1 acyclovir SR, felodipine, nifedipine XL, verapamil SR Humulin U500, Lantus, Lantus 3ml, Lantus Claritin-D 24 Tablets, store brand loratadine-D Tier 2 famciclovir, valacyclovir Tier 2 nisoldipine Solostar, Levemir 24 tablets Drugs For Viral Infections - Hepatitis...... Tier 3 Cardizem LA, Cardene SR, Tier 3 Apidra, Apidra Solostar, Novolin R, Novolin Tier 1 montelukast, levocetirizine, fexofenadine Tier 2 Incivek, ribavirin, Victrelis, Viread ANTIARRHYTHMICS ------70/30, Novolin N, Novalog, Novolog 3ml, Tier 2 desloratadine, fexofenadine w/pseudoephedrine Tier 3 Baraclude, Epivir HBV, Hepsera, Tyzeka Tier 1 amiodarone, disopyramide, flecainide, Novolog Mix, Novolog Mix 3ml Tier 3 Clarinex, Clarinex-D, Xyzal Drugs for Malaria...... mexiletine, propafenone, quinidine, sotalol ORAL ------NASAL MEDICATIONS ------Tier 1 chloroquine, hydroxychloroquine, Tier 3 Multaq, Norpace CR, Tikosyn Tier 1 acarbose, glimepiride, glipizide, glipizide XL, Tier 1 flunisolide, fluticasone, ipratropium bromide, Tier 2 mefloquine, atovaquone-proguanil, ACE INHIBITORS ------glyburide, , metformin XR, triamcinolone acetonide Tier 3 Coartem, Daraprim, Halfan, Qualaquin Tier 1 benazepril, captopril, enalapril, fosinopril, pioglitazone, glyburide w/ metformin, glipizide Tier 2 Astapro, azelastine nasal, Nasonex, Qnasl Drugs for Parasites...... lisinopril, moexipril, perindopril, quinapril, w/ metformin Tier 3 Beconase AQ, Dymista, Omnaris, Patanase Tier 2 Stromectol, tinidazole ramapril, trandolapril Tier 2 nateglinide, pioglitazone-glimepriride, Rhinocort Aqua, Veramyst, Zetonna Tier 3 Albenza, Alinia, Biltricide, Mepron, ANGIOTENSIN II ANTAGONISTS------repaglinide, Bydureon, Glucagon DRUGS FOR ASTHMA / COPD ------Tindamax,Yodoxin Tier 1 candasartan, losartan, irbesartan Tier 2 Invokana, Januvia, Onglyza, Janumet, ...... Miscellaneous Antiinfectives...... Tier 2 Benicar, valsartan Janumet XR, Kombiglyze XR, Juvisync, Tier 2 Asmanex, Pulmicort, QVAR, Tier 1 clindamycin, metronidazole, Tier 3 Atacand, Avapro, Edarbi, Micardis,Teveten Tier 3 Tradjenta, Nesina, Jentadueto, Oseni, Tier 3 Alvesco, Azmacort, Breo Elipta, Flovent Tier 2 vancomycin DIRECT ------Kazano, Actos, ActoPlus Met, Duetact, Glyset, Sympathomimetics...... Tier 3 Dapsone, Lamprene, NebuPent, TOBI, Tier 3 Tekturna Prandin, Prandimet Tier 1 albuterol for inhalation Vancocin, Xifaxan, Zyvox ANTI-ADRENERGIC BLOCKERS–CENTRAL------DIABETES RELATED DRUGS & SUPPLIES------Tier 2 Arcapta, Foradil, levalbuterol for inhalation, Tier 1 clonidine, clonidine Transdermal Patch DRUGS FOR CANCER Tier 2 Meters and Test Strips : ProAir HFA, Ventolin HFA COMBINATION ANTIHYPERTENSIVES------Tier 1 anastrozole, bicalutamide, cyclophosphamide, One Touch Basic, One Touch FastTake, One Tier 3 Perforomist, Proventil HFA, Tier 1 benazepril w/HCTZ, captopril w/HCTZ, etoposide, exemestane, flutamide, hydroxyurea, Touch Surestep, OneTouch Ultra, One Touch Serevent Diskus, Xopenex HFA enalapril w/ HCTZ, fosinopril w/HCTZ, letrozole, leucovorin, leuprolide acetate, Ultra2, One Touch UltraMini, One Touch Combination Drugs and Others...... lisinopril w/ HCTZ, moexipril w/HCTZ, quinapril tretinoin, megestrol, methotrexate, , Ultrasmart, One Touch Verio, Tier 1 ipratropium bromide for inhalation w HCTZ, irbesartan w/ HCTZ, losartan w/ venorelbine tartrate One Touch V erioIQ ipratropium w/ albuterol HCTZ, valsartan w/ HCTZ, Tier 2 Zytiga Supplies : Tier 2 Adcirca, Dulera, Letairis, sildenafil, Spiriva, amlodipine w/ benazepril AccuChek Lancets, Fastclix, Multicix, Soft Symbicort, Tracleer, Tudorza Tier 3 Afinitor, Alkeran, CeeNu, Emcyt, Fareston, Tier 2 amlodipine w/ atorvastatin, Benicar HCT Touch, Softclix Tier 3 Advair, Atrovent HFA, Combivent, Daliresp, Gleevec, Hexalen, Hycamtin, Leukeran, Tier 3 Amturnide, Atacand, HCT, Avalide, Azor, NovoFine Insulin Syringes, Novofine Needles, Intal, Pulmozyme, Revatio, Tyvaso, Ventavis Lysodren. Matulane, Myleran, Nexavar, Caduet, Diovan HCT, Edarbyclor, Exforge, NovoTwist, Softclix Device Antileukotrienes...... Nilandron, Sprycel, Sutent, Tabloid, Tarceva, Exforge HCT, Micardis HCT, Tarka, Tekamlo, Tier 3 All Accu-Chek Meters and Test Strips Tier 1 montelukast, zafirlukast Temodar, Tasigna, Teslac, Thioguanine, Tykerb, Teveten HCT, Tribenzor, Twynsta Freestyle Test Strips Tier 3 Singulair, Zyflo CR Vesanoid, Zolinza ------BD Insullin Syringes, BD Penneedles, Theophyllines ...... HORMONES Tier 1 acetazolamide ER, amiloride, bumetanide, Boeh-Mann Lancets, Lifescan Misc., Minimed Tier 1 theophylline SR ------furosemide, HCTZ, triamterene w/HCTZ, Tier 1 dexamethasone, methylprednisolone, THYROID AND ANTITHYROID AGENTS indapamide, spironolactone, torsemide GASTROINTESTINAL prednisolone, prednisone THYROID ------Tier 2 eplerenone ANTIULCER ------Tier 2 Uceris Tier 1 levothyroxine, liothyronine, methimazole, ANTILIPEMICS ------OTC Prilosec OTC Tablets 20mg, Zantac OTC, Tier 3 Celestone propylthiouracil OTC Slo-Niacin omeprazole OTC, Prevacid OTC, Zegerid OTC ANDROGENS------DRUGS FOR OSTEOPOROSIS Tier 1 atorvastatin, lovastatin, gemfibrozil, Tier 1 cimetidine, dicyclomine, famotidine, Tier 3 Androderm, Androgel, Android, Axiron, cholestyramine, colestipol, fenofibrate, misoprostol, omeprazole, pantoprazole, Tier 1 alendronate sodium (generic for Fosamax) Fortesta, Testim pravastatin, simvastatin ranitidine, sucralfate, Ibandronate sodium (generic for Boniva) ESTROGENS ------Tier 2 fluvastatin, Crestor, niacin ER oral tablet, Tier 2 Axid Solution, Bentyl Syrup, nizatidine, calcitonin (salmon) nasal solution, calcitriol Tier 1 estradiol, estropipate, estradiol patch Simcor lansoprazole, Nexium, Pylera Tier 3 Actonel, Actonel-D, Atelvia, Boniva, Evista, Tier 2 Cenestin, Divigel, Enjuvia, Evamist, Premarin, Tier 3 Advicor, Altoprev, Antara, Lescol, Lescol XL, Tier 3 Aciphex, Dexilant, PrevPac, Zegerid Fortical, Fosamax-D, Didronel, Hectoral, Vivelle DOT, Premarin Vag Cream,Vagifem Lipofen, Liptruzent, Livalo, Lovaza, Niaspan, /ANTIVERTIGO ------Menostar, Skelid Vag Tab Tricor, TriLipix, Triglide, Vascepa, Vytorin, Tier 1 granisetron, meclizine, ondansetron,

Welchol, Zetia prochlorperazine, promethazine,

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

OTC Alavert

OTC Alaway

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

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Tier 1 donepezil ODT (Aricept ODT) Tier 3 Evista Tier 1 gentamicin ophthalmic K Tier 1 donepezil-23 Tier 3 Exalgo Tier 3 Geodon Tier 3 Kadian Tier 3 Doryx Tier 3 Exelderm Tier 3 Gleevec Tier 3 Kapvay Tier 1 dorzolamide (Trusopt) Tier 3 Exelon Patch Tier 1 glimepiride Tier 3 Kazano Tier 1 dorzolamide/timolol (Cosopt) Tier 1 exemestane (Aromasin) Tier 1 glipizide, glipizide XL Tier 3 Kemadrin Tier 3 Dovonex Tier 3 Exforge, Exforge HCT Tier 1 glipizide w metformin Tier 1 ketorolac (Acular, Acular LS) Tier 1 doxazosin Tier 2 Exjade Tier 1 glyburide (Diabeta, Micronase) OTC ketotifen Tier 1 doxepin Tier 1 glyburide w metformin Tier 1 ketoconazole Tier 1 doxycycline F Tier 3 Glyset Tier 2 Kombiglyze XR Tier 3 Duac, Duac CS Tier 3 Factive Tier 2 Gonal-F Tier 2 Kristalose Tier 3 Duetact Tier 2 famciclovir (Famvir) Tier 1 granisetron Tier 2 Dulera Tier 1 famotidine Tier 3 Grifulvin-V L Tier 3 Duexis Tier 3 Fanapt Tier 3 Gris-Peg Tier 3 Lacrisert Tier 2 Durezol Tier 3 Fareston Tier 3 Gynazole Tier 1 lactulose Tier 3 Dymista Tier 3 FastTake Monitoring Tier 1 lamotrigine (Lamictal) Tier 3 FastTake Test Strips H Tier 3 Lamprene E Tier 3 Fazaclo Tier 3 Halog Tier 1 lamotrigine Tier 3 Edarbi Tier 3 Felbatol Tier 1 haloperidol Tier 2 lansoprazole (Prevacid) Tier 3 Edarbyclor Tier 1 felodipine (Plendil) Tier 3 Halfan Tier 2 Lantus, Lantus Solostar Tier 3 Edluar Tier 3 Femhrt Tier 3 Hectoral Tier 3 Lastacaft Tier 3 Effient Tier 3 Femring Tier 3 Hepsera Tier 1 latanoprost (Xalatan) Tier 1 epinastine (Elestat) Tier 1 fenofibrate micronized (Lofibra) Tier 3 Hexalen Tier 2 Latuda Tier 2 Elidel Tier 1 fentanyl patch (Duragesic) Tier 2 Humalog, Humalog Mix 75/25 Tier 3 Lescol, Lescol XL Tier 3 Eliquis Tier 3 Fentora Tier 2 Humatrope (PA) Tier 2 Letairis Tier 3 Elmiron Tier 1 fexofenadine (Allegra) Tier 1 Humulin N, R, 70/30 Tier 1 letrozole (Femara) Tier 3 Emadine Tier 2 fexofendine w/ PSE (Allegra-D) Tier 2 Humulin 500 Tier 1 leucovorin Tier 3 Embeda Tier 3 Finacea Tier 3 Hycamtin Tier 3 Leukeran Tier 3 Emcyt Tier 1 finasteride (Proscar) Tier 1 hydrochlorothiazide or “HCTZ” Tier 1 leuprolide acetate Tier 3 Emend Tier 3 Flarex Tier 1 hydroxyurea Tier 2 levalbuterol for inhalation Tier 3 Emsam Tier 1 flecainide Tier 3 Levatol Tier 2 Emtriva Tier 3 Flector Patch I Tier 2 Levemir Tier 3 Enablex Tier 3 Flovent Tier 1 ibandronate Tier 1 levetiracetam (Keppra) Tier 1 enalapril (Vasotec) Tier 1 fluconazole Tier 1 ibuprofen Tier 1 levobunolol Tier 1 enalapril w HCTZ (Vaseretic) Tier 3 Fluoroplex Tier 2 Ilevro Tier 1 levofloxacin (Levaquin) Tier 2 Endometrin Tier 1 flunisolide nasal (Nasarel) Tier 1 imipramine (Tofranil) Tier 1 levothyroxine (Synthroid) Tier 2 Enjuvia Tier 1 fluorouracil (Efudex) Tier 2 imiquimod (Aldara) Tier 1 levocetirizine Tier 1 entacapone Tier 1 fluoxetine (Prozac) Tier 2 Incivek Tier 3 Lexapro Tier 3 Epiduo Tier 1 flurbiprofen ophth (Ocufen) Tier 1 indapamide Tier 2 Lialda Tier 2 Epi-Pen, Epi-Pen Jr. Tier 1 flutamide Tier 1 Indomethacin Tier 2 lidocaine patch Tier 1 epinastine (Elestat) Tier 1 fluticasone (Flonase) Tier 3 Innopran XL Tier 2 Lidoderm Tier 3 Epivir HBV Tier 2 fluvastatin Tier 3 Intal Tier 3 Lifescan Miscellaneous Tier 2 eplerenone (Inspra) Tier 3 FML Tier 2 Intron-A Tier 2 lindane 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(ST) Tier 1 ipratropium nasal (Atrovent) Tier 3 Lipsovir Tier 1 erythromycin stearate Tier 3 Fortical Tier 1 ipratropium bromide for inhalation Tier 3 Liptruzent Tier 1 escitalopram Tier 3 Fosamax-D Tier 1 ipratropium w albuterol (Duoneb) Tier 1 lisinopirl (Prinivil, Zestril) Tier 3 Estrace Vag Cr Tier 1 fosinopril (Monopril) Tier 1 irbesartan Tier 1 lisinopril wHCT(PrinzideZestoretic) Tier 3 Estraderm Tier 1 fosinopril w HCTZ (Monopril HCT) Tier 1 irbesartan w/ HCTZ Tier 3 Livalo Tier 1 estradiol (Estrace) Tier 2 Fosrenol Tier 1 isoniazid OTC loratadine (Claritin) Tier 1 estradiol patch Tier 3 Fragmin Tier 1 isosorbide dinitrate Tier 1 lorazepam Tier 1 estradiol/norethindrone (Activella) Tier 3 Freestyle Test Strips Tier 1 isosorbide mono (Imdur) Tier 1 losartan Tier 1 estradiol/norethindrone (FemHRT) Tier 3 Frova Tier 2 isotretinoin (Amnesteem) Tier 1 losartan w HCTZ (Hyzaar) Tier 3 Estrasorb Tier 3 Furadantin Tier 2 isotretinoin (Claravis, Sotret) Tier 2 Lotemax Tier 1 est. estrogens w m/testos(Estratest) Tier 1 furosemide Tier 2 itraconazole (Sporanox) Tier 3 Lotronex Tier 1 estropipate Tier 1 lovastatin Tier 3 Estring Vaginal Ring G J Tier 3 Lovaza Tier 3 Estrogel Tier 1 gabapentin (Neurontin) Tier 3 Jalyn Tier 3 Lumigan Tier 1 ethambutol (Myambutol) Tier 3 Gabitril Tier 2 Januvia Tier 3 Lunesta Tier 1 ethosuximide (Zarontin) Tier 2 galantamine (Razadyne) Tier 2 Janumet, Janumet XR Tier 3 Lybrel Tier 1 etodolac Tier 2 galantamine ER (Razadyne ER) Tier 3 Jentadueto Tier 2 Lyrica Tier 1 etoposide Tier 3 Gelnique Tier 3 Jinteli Tier 3 Lysodren(PA) Tier 1 Eurax Tier 1 gemfibrozil (Lopid) Tier 2 Juvisync Tier 2 Lysteda Tier 2 Evamist Tier 2 Genotropin

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

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Tier 2 sildenafil (Revatio) Tier 3 Tekamlo Tier 2 Tudorza W Tier 3 Silenor Tier 3 Tekturna Tier 3 Twynsta Tier 1 warfarin (Coumadin) Tier 2 Simcor Tier 1 temazepam (Restoril) Tier 3 Tykerb Tier 3 Welchol Tier 1 simvastatin (Zocor) Tier 3 Temodar Tier 3 Tyvaso Tier 3 Singulair Tier 1 terazosin Tier 3 Tyzeka X Tier 3 Sirturo Tier 1 terbinafine (Lamisil) Tier 3 Xarelto Tier 3 Skelaxin Tier 1 terconazole Vag Cream (Terazol) U Tier 3 Xeloda Tier 3 Skelid Tier 3 Teslac Tier 2 Uceris Tier 3 Xeljanz Tier 1 SMX-TMP (Bactrim, Bactrim DS) Tier 3 Testim Tier 2 Ulesfia Tier 3 Xifaxan OTC Slo-Niacin Tier 1 tetracycline Tier 3 Uloric Tier 3 Xolegel Tier 2 Softclix Device Tier 3 Teveten, Teveten HCT Tier 1 ursodiol (Actigall) Tier 3 Xopenex HFA Tier 3 Solaraze Tier 1 theophylline SR (Theo-Dur) Tier 3 Ultravate Kit Tier 3 Xyrem Tier 3 Soliris Tier 3 Thioguanine Tier 3 URSO, URSO Forte Tier 3 Xyzal Tier 3 Solodyn Tier 1 ticlopidine Tier 3 Soriatane Tier 3 Tikosyn V Y Tier 1 sotalol Tier 1 timolol ophthalmic solution Tier 2 Vagifem Vaginal Tab Tier 3 Yodoxin Tier 3 Spectracef Tier 1 timolol ophth gel foaming solution Tier 2 valacyclovir (Valtrex) Tier 2 Spiriva Tier 3 Tindamax Tier 1 valproic acid (Depakene) Z Tier 1 spironolactone Tier 2 tinidazole Tier 2 valsartan Tier 3 Sprix Tier 1 tizanidine (Zanaflex) OTC Zaditor Tier 1 valsartan w/HCTZ Tier 1 zafirlukast (Accolate) Tier 3 Sprycel Tier 3 TOBI Tier 3 Valturna Tier 3 Stalevo Tier 1 tobramycin-dexamethasone Tier 1 zaleplon (Sonata) Tier 3 Vancocin OTC Zantac OTC Tier 2 Strattera Tier 2 Tobradex Tier 2 vancomycin Tier 2 Stromectol Tier 2 Tobradex Tier 3 Zegerid Tier 3 Vanos OTC Zegerid OTC Tier 2 Suboxone (SL Film) Tier 1 tobramycin opthalmic Tier 3 Vascepa Tier 1 sucralfate Tier 2 tolterodine (Detrol) Tier 2 Zelapar Tier 3 Vectical Tier 2 Zemplar Tier 1 sulfacetamide suspension (Klaron) Tier 1 topiramate (Topamax) Tier 1 venlafaxine (Effexor) Tier 1 sulfacetamide w sulfur (Plexion) Tier 1 torsemide Tier 2 Zenpep Tier 1 venlafaxine XR (Effexor XR) Tier 3 Zetia Tier 1 sulfasalazine (Azulfidine) Tier 2 Toviaz Tier 3 Veltin Tier 1 sulfisoxasole w/ EES Tier 2 Tracleer Tier 3 Zetonna Tier 1 venorelbine Tier 3 Ziana Tier 3 Sumavel Tier 3 Tradjenta Tier 3 Ventavis Tier 1 sumatriptan (Imitrex Tabs) Tier 1 tramadol Tier 3 Zioptan Tier 2 Ventolin HFA Tier 2 ziprasidone Tier 3 Suprax Tier 2 tramadol ER tablet Tier 3 Veramyst Tier 3 Surestep Tier 1 trandolapril (Mavik) Tier 3 Zipsor Ti er 1 verapamil Tier 3 Zirgan Tier 3 Surestep Meter Tier 3 Transderm-Scop Tier 1 verapamil SR Tier 3 Sutent Tier 2 Travatan Z Tier 3 Zmax Tier 3 Vesanoid Tier 3 Zolinza Tier 2 Symbicort Tier 1 trazodone (Desyrel) Tier 2 Vesicare Tier 3 Synera Tier 1 tretinoin Tier 1 zolmitriptan tabs Tier 2 Victrelis Tier 1 zolpidem tartrate(Ambien) Tier 2 tretinoin microsphere gel Tier 2 Vigamox T Tier 3 Trecator Tier 2 zolpidem tartrate CR (Ambien CR) Tier 2 Viibryd Tier 3 Zomig, Zomig ZMT Tier 3 Tabloid Tier 3 Treximet Tier 2 Vimovo Tier 1 zonisamide (Zonegran) Tier 2 Taclonex Tier 1 Triamcinolone acetonide Tier 2 Vimpat Tier 3 Zovirax Cream, Zovirax Ointment Tier 2 Tamiflu Tier 1 triamterene w HCTZ (Maxzide) Tier 3 Viokase Tier 3 Zyclara Tier 1 tamoxifen Tier 1 triazolam Tier 2 Vivelle DOT Tier 3 Zyflo CR Tier 1 tamsulosin (Flomax) Tier 3 Tribenzor Tier 3 Voltaren Gel Tier 2 Zylet Tier 3 Tarceva Tier 3 Tricor Tier 2 voriconazole (Vfend) Tier 2 Zymaxid Tier 3 Targretin Tier 3 Triglide Tier 3 Vytorin OTC Zyrtec, Zyrtec-D Tier 3 Tarka (generic Tier 1) Tier 1 trihexyphenidyl Tier 3 Vyvanse Tier 2 Zytiga Tier 3 Tasigna Tier 3 TriLipix Tier 3 Zyvox Tier 3 Tasmar Tier 1 trimethobenzamide

Tier 3 Tazorac Tier 2 trospium (Sanctura) Tier 2 trospium SR (Sanctura SR)

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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, Twinject. 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 2014 Formulary

The following brand medicines have been moved from Tier 3 to Tier 2: Azasite Ilevro Nucynta, Nucynta ER Rectiv Uceris Crinone Invokana Prolensa Strattera Vesicare Endometrin Myrbetriq Pylera Suboxone Zytiga Fosrenol Nevanac Qnasl Tudorza

The following Tier 2 generics will be moved to Tier 1: Pioglitazone

The following drugs have been moved from Tier 1 or Tier 2 to Tier 3 status due to unavailability or expiration of manufacturer contracts, or the availability of lower cost alternatives at Tier 1 or Tier 2: Accu-Chek (All) Betoptic-S Exalgo Omnaris Veramyst Alinia Climara Fortical Pancreaze DR Xopenex HFA Alvesco Climara Pro Hectorol Phoslyra Zetonna Ancobon Condylox Hepsera Picato Zovirax Topical Apidra Embeda Lacrisert Rhinocort Aqua Avinza Enablex Lamprene Seromycin Azopt Epivir HBV Mycobutin Tasmar Baraclude Estrace Vaginal Novolog Urso, Urso Forte

The following generics will be assigned a Tier 2 copayment due to high cost: Niacin ER Oral Tablets sildenafil pioglitazone-glimepiride tretinoin microsphere gel 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: Adoxa Azasan Metrogel External Gel Pholso Aricept 23 Doryx Metrogel Vaginal Gel Revatio Atacand, Atacand, HCT Maxalt, Maxalt MLT Oracea Zomig, Zomig ZMT The following drugs are no longer on the market: Aerobid, Aerobid M Dynacirc CR Covera HS Insulin Innolet Subutex Travatan

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