SAVE MONEY WITH TIER 1 GENERIC ALTERNATIVE MEDICATIONS

You can save money when you choose a generic alternative prescription drug that is covered at the Tier 1 copayment level. Talk to your doctor about whether there is a Tier 1 medication available for your Tier 2 or Tier 3 prescriptions.

Please note, this is not a comprehensive list. If you have questions about your pharmacy benefit, please visit tuftshealthplan.com/gic or call GIC Member Services at 1-800-870-9488.

Drugs Covered with a Tier 2 Tier 1 Alternatives That Help You Save Money or a Tier 3 Copayment

ALPHAGAN P 0.1% brimonidine

amoxicillin 775 mg amoxicillin 500 mg aripiprazole* risperidone AVODART tamsulosin AXERT* sumatriptan AZOPT dorzolamide eye drops BENICAR losartan, valsartan BENICAR HCT losartan/HCTZ, valsartan/HCTZ BETIMOL timolol eye drops budesonide nasal spray fluticasone nasal spray BUNAVAIL± buprenorphine/naloxone tablets± BYSTOLIC atenolol, metoprolol calcipotriene - betamethasone calcipotriene dipropionate ointment calcitriol ointment calcipotriene candesartan eprosartan, irbesartan, losartan, valsartan irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, candesartan / HCTZ valsartan/hydrochlorothiazide celecoxib meloxicam CIPRODEX ciprofloxacin otic

clobetasol spray clobetasol cream, gel, ointment

CRESTOR± simvastatin, atorvastatin

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GIC-TIER-RX-LIST-06/15 Drugs Covered with a Tier 2 Tier 1 Alternatives That Help You Save Money or a Tier 3 Copayment cyclobenzaprine 7.5 mg cyclobenzaprine 10 mg DAYTRANA* methylphenidate tablets dexmethylphenidate ext-rel dexmethylphenidate duloxetine sertraline, citalopram, fluoxetine ELIQUIS warfarin ENABLEX oxybutynin entecavir tablets adefovir esomeprazole omeprazole, pantoprazole, lansoprazole estradiol patch estradiol tablets eszopiclone* zolpidem fenofibrate 145mg, 48mg fenofibrate 54 mg, 67 mg, 134 mg, 160 mg, 200 mg, fenofibric acid fenofibrate 50mg & 150 mg capsules fenofibrate 54 mg, 67 mg, 134 mg, 160 mg, 200 mg, fenofibric acid fluvoxamine ext-rel fluvoxamine FOCALIN XR* 20MG, 25MG, 30MG dexmethylphenidate FROVA* sumatriptan gatifloxacin ophthalmic drops ofloxacin eye drops, levofloxacin eye drops guanfacine ext-rel guanfacine lamotrigine ext-rel lamotrigine lamotrigine ODT lamotrigine LANOXIN 0.0625MG, 0.1875MG, digoxin 0.375MG, 0.5MG LATUDA* risperidone, olanzapine*, quetiapine* (only 100, 200, 300, 400mg IR tabs) LUMIGAN* latanoprost LYRICA* gabapentin methylphenidate SR methylphenidate minocyline 45 & 90 mg SR minocycline modafinil* amphetamine salts MOVIPREP PEG3350/electrolytes moxifloxacin levofloxacin, ciprofloxacin, ofloxacin NASONEX fluticasone nasal spray NITROSTAT nitroglycerin sublingual spray, transdermal patch NUVIGIL* amphetamine salts olopatadine nasal spray fluticasone nasal spray OSMOPREP PEG3350/electrolytes OXTELLAR XR oxcarbazepine PATANOL azelastine, cromolyn PRADAXA warfarin

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GIC-TIER-RX-LIST-06/15 Drugs Covered with a Tier 2 Tier 1 Alternatives That Help You Save Money or a Tier 3 Copayment PRADAXA warfarin PREPOPIK PEG3350/electrolytes PRISTIQ ER* venlafaxine ext-rel PROLENSA bromfenac sodium eye drops rabeprazole omeprazole, pantoprazole, lansoprazole RELPAX* sumatriptan risedronate 150 mg* alendronate salicylic acid in ammonia latate salicylic acid vehicle 6% foam SUBOXONE FILM± buprenorphine/naloxone tablets± sulfacetamide sodium w/sulfur cleanser 10-2% sulfacetamide/sulfur sulfacetamide sodium w/sulfur susp 8-4% sulfacetamide/sulfur SUPREP PEG3350/electrolytes tacrolimus* clobetasol, betamethasone telmisartan eprosartan, irbesartan, losartan, valsartan telmisartan/amlodipine amlodipine/valsartan irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, telmisartan/HCTZ valsartan/hydrochlorothiazide TIMOPTIC OCUDOSE timolol eye drops tolterodine ext-rel tolterodine topiramate ext-rel topiramate TRAVATAN Z* latanoprost triamcinolone nasal spray fluticasone nasal spray urea cream 45% urea cream urea foam 40% urea cream urea in lactic acid vehicle foam 35% urea cream VAGIFEM estradiol tablets VESICARE oxybutynin VIGAMOX ofloxacin eye drops VIIBRYD* citalopram, sertraline, venlafaxine VYVANSE* amphetamine salts, methylphenidate, dexmethylphenidate ziprasidone* risperidone zolmitriptan sumatriptan zolmitriptan sumatriptan ZUBSOLV± buprenorphine/naloxone tablets±

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GIC-TIER-RX-LIST-06/15 ±Prior Authorization: To promote safety and affordability for everyone, Tufts Health Plan requires prior authorization for certain drugs. This helps us work with physicians to see that medications are prescribed appropriately. Our Pharmacy & Therapeutics Committee reviews all prior authorization criteria annually and as new information becomes available. If your drug requires prior authorization, contact the provider who has written your prescription. If your provider believes a drug with a PA is necessary for your treatment, he or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form--available at tuftshealthplan.com/providers-—to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.

*Step Therapy Prior Authorization: Step therapy promotes the use of the most therapeutically appropriate and cost-effective drugs first, before other drugs may be covered. If you have not previously taken the steps required by our pharmacy coverage guidelines, and your provider believes the drug prescribed for you is medically necessary, he or she may request coverage by submitting a Universal Pharmacy Medical Review Request Form.

GIC-TIER-RX-LIST-06/15