sign in sign up
<<
Home , Alosetron, Serostim

Premium Prescription Drug List January 2018

Introduction The ProAct Prescription Drug List references the most commonly prescribed medications available to treat a variety of conditions. The medications are placed into levels known as “tiers” that will determine what the cost share will be for the member (see below). Tier 1 = generic medications Tier 2 = preferred or formulary brand medications Tier 3 = non-preferred or non-formulary medications

This is not an all-inclusive list as there may be prescription drug products that do not appear. Generic medications not listed will be considered Tier 1, while brand name medications not listed are considered Tier 3. A medication may move to a lower tier at any time, while a brand name medication may move to a higher tier when a generic becomes available. On a quarterly basis, updates can be made to the formulary which may result in a medication being moved to new tier resulting in a change to the copay. For medication-specific questions please contact the ProAct helpdesk at 1-877-635- 9545.

Medications 1 Drugs are listed according to their therapeutic category or drug class. To distinguish between generic and brand medications, generic drugs will be listed in plain type while brand medications will be in bold. It is important to realize that even though a medication may be listed in this document, plan benefits override this drug listing. Therefore it is possible there may be items included on this list that are EXCluded or subject to other coverage guidelines. For questions regarding specific medications or therapeutic categories please contact the ProAct helpdesk at 1-877-635-9545. Specialty Medications (SP) This formulary document also includes specialty medications. Specialty medications (SP) can be described as drugs that are high cost, highly complex, or typically require specialized administration, handling, or distribution. They are often biology-based and mimic substances found in the body to produce their effects. These medications may process differently depending on your plan design and may require prior authorization and/or have other restrictions. Utilization Management Programs (QL, PA, ST) Some prescription plans may implement other programs that may dictate how medications will process. These include quantity limit (QL), prior authorization (PA), and/or step therapy (ST) programs. If a particular medication is subject to these programs the abbreviation for that program will appear under the notes section for the particular product. For more information on whether or not your plan participates with these programs, or how these programs may affect the medications you are using please contact the ProAct helpdesk. Please note: some plans may not utilize one or more of these (QL, PA, ST) programs. In the case where the plan does not use the program, the medication will not be subject to the terms of that particular program regardless of what is listed in the Notes column. Exclusions Along with medications being placed into a tier structure, the Premium formulary also EXCludes certain products from coverage. These are medications that have been deemed therapeutically equivalent or are in the same pharmacologic class as a clinically similar product that is covered. Products that are excluded will be labeled with “EXC” under the Tier Level section to indicate they are excluded from coverage. Name Tier Tier 2 Notes Drug Name Notes Level Level

Anti-Infectives: Antibiotics Neomycin/Poly/HC Otic 1 Beta-Lactams Nitrofurantoin 1 Xifaxan 3 PA, QL Amoxicillin 1 Amoxicillin/Clavulanate 1 Anti-Infectives: Antifungals Penicillin VK 1 Systemic Cepahlosporns Cresemba 3 PA Cefdinir 1 Fluconazole 1 Cefuroxime 1 Itraconazole 1 PA Macrolides Terbinafine, tab 1 QL Azithromycin 1 Topical Clarithromycin 1 Nystatin 1 E.E.S 3 Anti-Infectives: Antivirals Eryped 3 Herpes Viruses Ery-Tab 3 Acyclovir, oral 1 Dificid 3 Alferon N 2 SP Aminoglycosides Famciclovir 1 Bethkis 2 SP Valacyclovir 1 QL Kitabis EXC Valtrex 3 QL Tobi Inhaler / Neb. EXC Hepatitis: Tobramycin nebulizer soln. 1 SP, ST Adefovir 1 SP Flouroquinolones Baraclude 3 QL, SP Ciprodex Otic Suspension 2 Copegus 3 SP Ciprofloxacin 1 Daklinza 3 PA, QL, SP Levofloxacin 1 Entecavir 1 QL, SP Ofloxacin Otic Solution 1 Epclusa 2 PA, QL, SP Tetracyclines Epivir HBV 2 SP Acticlate EXC Harvoni 2 PA, QL, SP Doxycycline Hyclate 1 Hepsera 3 SP Doxycycline, Monohydrate 1 Intron-A 3 PA, SP Minocycline 1 Mavyret EXC Oracea 3 QL Moderiba 1 SP Solodyn 3 QL Olysio 3 PA, QL, SP Targadox 3 ST Pegasys 2 PA, SP Sulfonamides Peg-Intron 3 PA, SP Sulfameth.-Trimethoprim 1 Rebetol 3 SP Sulfameth.-Trimethoprim DS 1 Ribapak 1 SP Miscellaneous Ribasphere 1 SP Cayston 3 PA, SP Ribatab 1 SP Clindamycin, oral 1 Ribavirin 1 SP Daraprim 3 PA Sovaldi 3 PA,QL,SP,ST Linezolid 1 PA, QL Sylatron 3 PA, SP Metronidazole, oral 1 Technivie 3 PA, QL, SP Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 3 Notes Drug Name Notes Level Level

Tyzeka 3 SP Truvada 2 SP Viekira 3 PA, QL, SP Tybost 2 SP Vosevi EXC Videx EC 3 SP Zepatier 3 PA, QL, SP Viracept 2 SP HIV/AIDS Viramune suspension 3 SP Abacavir 1 SP Viread 2 SP Abacavir/lamivudine 1 SP Vitekta 2 SP Abacavir/lamivduine/zidovudine 1 SP Zerit 2 SP Aptivus 2 SP Ziagen 2 SP Atripla 2 SP Zidovudine 1 SP Combivir 3 SP Influenza Infection: Complera 2 SP Oseltamivir 1 QL Crixivan 2 SP Tamiflu EXC Descovy 2 SP Blood Disorders Didanosine 1 SP Bleeding Disorders: Edurant 2 SP Advate 2 SP Emtriva 2 SP Alphanate 2 SP Epzicom 3 SP Alphanine SD 2 SP Evotaz 2 SP Alprolix 3 SP Fosamprenavir 1 SP Bebulin 2 SP Fuzeon 2 QL, SP Benefix 2 SP Genvoya 2 SP Corifact 2 SP Intelence 2 SP Eloctate 3 SP Invirase 2 SP Feiba 2 SP Isentress 2 SP Helixate 2 SP Kaletra 3 SP Hemofil M 2 SP Lamivudine 1 SP Humate-P 2 SP Lamivudine/zidovudine 1 SP Idelvion 3 SP Lexiva 3 SP Ixinity 3 SP Nevirapine 1 SP Koate-DVI 2 SP Norvir 2 SP Kogenate 3 SP Odefsey 2 SP Lysteda 3 QL Prezcobix 2 SP Monoclate-P 2 SP Prezista 2 SP Mononine 2 SP Rescriptor 2 SP Novoseven 2 SP Retrovir 3 SP Novoeight 3 SP Reyataz 2 SP Nuwiq 3 SP Selzentry 2 PA, SP Obizur 3 SP Stavudine 1 SP Profilnine 2 SP Stribild 2 SP Recombinate 3 SP Sustiva 2 SP Rixubis 3 SP Tivicay 2 SP Tretten 3 SP Triumeq 2 SP Wilate 2 SP Trizivir 3 SP Xyntha 3 SP Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 4 Notes Drug Name Notes Level Level

Hereditary Angioedema: Perjeta 2 PA, SP Berinert 2 PA, SP Portrazza 3 PA, SP Cinryze 2 PA, SP Rituxan 2 PA, SP Firazyr 2 PA, SP Yervoy 2 PA, SP Haegarda EXC Anthracyclines: Kalbitor 3 PA, SP Adriamycin 1 SP Ruconest 3 PA, SP Daunorubicin 1 SP Anemia: Daunoxaome 2 SP Aranesp EXC Doxil 3 SP Epogen EXC Doxorubicin 1 SP Mircera 3 PA, SP Ellence 3 SP Omontys 3 PA, SP Epirubicin 1 SP Procrit 2 PA, SP Idamycin 3 SP Iron Toxicity: Idarubicin 1 SP Exjade 3 PA, SP Lipodox 1 SP Ferriprox 3 PA, SP Antimetabolites: Jadenu 3 PA, SP Adrucil inj. 1 SP Neutropenia: Alimta 2 PA, SP Granix 2 PA, SP Arranon 2 SP Leukine 3 PA, SP Azacitidine inj. 1 SP Neulasta 3 PA, SP Capecitabine 1 SP Neupogen 2 PA, SP 1 SP Zarxio 2 PA, SP Clolar 2 SP Miscellaneous: Cytarabine 1 SP Dacogen 3 SP Mozobil 2 PA, QL, SP Decitabine 1 SP Neumega 2 PA, SP Floxuridine 1 SP Nplate 2 PA, SP Fludara 3 SP Promacta 3 PA, SP Fludarabine 1 SP Soliris 2 PA, SP Fluorouracil 1 SP Cancer Folotyn 2 PA, SP Microtubule Inhibitors: Gemcitabine 1 SP Abraxane 2 PA, SP Gemzar 3 SP Monoclonal Antibodies: Lonsurf 3 PA, QL, SP Adcetris 2 PA, SP Nipent 3 SP Arzerra 2 PA, SP Purixan 3 PA, SP Avastin 2 PA, SP Vidaza 3 SP Bexxar 2 SP Xeloda 3 PA, SP Blincyto 3 PA, SP Biologic Response Modifiers: Erbitux 2 PA, SP Afinitor 3 QL, PA, SP Gazyva 3 PA, SP Beleodaq inj 3 PA, SP Keytruda 3 PA, SP Alecensa 3 PA, QL, SP Lemtrada 3 PA, SP Bosulif tab 3 PA, QL, SP Opdivo 3 PA, SP Cabometyx 3 PA, SP Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 5 Notes Drug Name Notes Level Level

Caprelsa tab 2 PA, QL, SP Zelboraf 3 PA, QL, SP Cometriq 3 PA, QL, SP Zevalin 3 SP Cyramza 3 PA, SP Zolinza 2 PA, QL, SP Erivedge 2 PA, QL, SP Zydelig 3 PA, QL, SP Farydak 3 PA, QL, SP Zykadia 3 PA, QL, SP Gilotrif 3 PA, QL, SP Alkylating Agents: Gleevec 3 PA, QL, SP Alkeran 3 SP Herceptin 2 PA, SP Bendeka 3 PA, SP Ibrance 3 PA, QL, SP Bicnu 2 SP Iclusig 3 PA, QL, SP Busulfex inj. 2 SP Imatinib 1 PA, QL, SP Carboplatin 1 SP Imbruvica 3 PA, QL, SP Cisplatin 1 SP Inlyta 3 PA, QL, SP Cyclophosphamide 1 Iressa 3 PA, QL, SP Dacarbazine 1 SP Istodax 2 PA, SP Eloxatin 3 SP Jakafi 2 PA, QL, SP Gleostine 3 SP Kadcyla 3 PA, SP Ifex 3 SP Kyprolis 2 PA, SP Ifosfamide 1 SP Lenvima 3 PA, QL, SP Lomustine 1 SP Lynparza 3 PA, SP Melphalan 1 SP Mekinist 2 PA, QL, SP Mustargen 2 SP Nexavar 2 PA, QL, SP Oxaliplatin 1 SP Pomalyst 3 PA, QL, SP Temodar 3 PA, SP Proleukin 2 PA, SP Temozolomide 1 PA, SP Provenge 2 PA Treanda 2 PA Revlimid 3 PA, QL, SP Valchlor gel 3 PA, SP Rydapt EXC PA, QL, SP Zanosar 2 SP Sprycel 2 PA, SP Chemotherapy Protectants: Stivarga 3 PA, QL, SP Amifostine inj 1 SP Sutent 3 PA, SL, SP Dexrazoxane 1 PA, SP Sylvant 3 PA, SP Ethyol 3 SP Tafinlar 3 PA, QL, SP Fusilev 3 SP Tarceva 3 PA, QL, SP Mesna 1 SP Tasigna 3 PA, QL, SP Mesnex 3 SP Thalomid 2 PA, QL, SP Totect 3 PA, SP Theracys 2 SP Xuriden 3 PA, QL, SP Tice BCG 2 SP Hormones and Hormone Modifiers: Torisel 2 PA, QL, SP Anastrazole 1 Tykerb 2 PA, QL, SP Eligard 3 QL, PA, SP Unituxin 3 PA, SP Faslodex 2 SP Vectibix 3 PA, SP Firmagon 3 QL, PA, SP Velcade 2 PA, SP Letrozole 1 PA Votrient 3 PA, QL, SP Supprelin LA 2 SP Xalkori 2 PA, QL, SP Tamoxifen 1 Zaltrap 2 PA, SP Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 6 Notes Drug Name Notes Level Level

Trelstar Depot 3 PA, SP Odomzo 3 PA, QL, SP Vantas 3 PA, QL, SP Oncaspar 2 SP Xtandi 3 PA, QL, SP Onivyde 3 SP Zoladex 3 QL, SP Pamidronate 1 SP Zytiga 3 PA, SP Photofrin 3 SP Retinoids: Synribo 3 PA, SP Bexarotene 1 PA, SP Teniposide 1 SP Targretin 3 PA, SP Toposar 1 SP Tretinoin cap 1 SP Topotecan 1 SP Anti-tumor Antibiotics: Trisenox 2 PA, SP Bleomycin inj. 1 SP Xgeva 2 PA, QL, SP Mitomycin 1 SP Xofigo 2 Yondelis 3 SP Vinca Alkaloids: Zinecard 3 PA, SP Marqibo 3 PA, SP Zoledronic acid 1 SP Navelbine 3 SP Zometa 3 SP Vinblastine 1 SP Vincasar 1 SP Cardiovascular: Blood Thinners Vincristine 1 SP Antiplatelets: Vinorelbine 1 SP Aggrenox 3 QL Anthracenediones: Aspirin/dipyridamole 1 QL Mitoxantron 1 PA, SP Brilinta 2 QL Taxanes: Clopidigrel 1 QL Docefrez 3 SP Dipyridamole 1 QL Docetaxel 1 SP Durlaza 3 QL Jevtana 2 PA, SP Effient 2 QL Paclitaxel 1 SP Prasugrel 1 Taxotere 3 SP Anticoagulants: : Arixtra 3 SP, QL Emend Cap 3 PA, QL Coumadin 2 Emend Solution 3 Eliquis 3 QL Varubi 3 PA, QL Enoxaparin 1 SP, QL Fondaparinux 1 SP, QL Miscellaneous: Fragmin 3 SP, QL Camptosar Inj 3 SP Lovenox 3 SP, QL Cosmegen 3 SP Pradaxa 2 QL Elspar 2 SP Savaysa 3 QL Erwinaze 2 SP Warfarin 1 Etopophos 3 SP Xarelto 2 QL Etoposide 1 SP Halaven 2 PA, SP Cardiovascular: High Blood Pressure Hycamtin 3 PA, SP ACE Inhibitors: Imlygic 3 SP Benazepril 1 Irinotecan 1 SP Enalapril 1 Ixempra 2 SP Fosinopril 1 Lisinopril 1 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 7 Notes Drug Name Notes Level Level

Quinapril 1 Amlodipine/valsartan/HCTZ 1 Ramipril 1 QL Atenolol/chlorthalidone 1 Trandolapril 1 Azor EXC Calcium Channel Blockers: Benazepril/HCTZ 1 Amlodipine 1 QL Benicar-HCT EXC Cartia-XT 1 QL /HCTZ 1 Felodipine 1 QL Diovan-HCT EXC Nifedipine ER 1 Dutoprol 3 QL Norvasc EXC Edarbyclor 3 QL, ST Verapamil 1 Exforge 3 QL Verapamil ER 1 Exforge-HCT 3 QL Beta-Blockers: Irbesartan/HCTZ 1 Atenolol 1 Lisinopril/HCTZ 1 Bisoprolol 1 Losartan/HCTZ 1 Bystolic 2 QL Olmesartan/amlodipine/HCTZ 1 Carvedilol 1 Tarka 3 Coreg-CR 3 QL, ST Tekturna-HCT 2 QL, ST Labetalol 1 QL Trandolapril/verapamil 1 Metoprolol succinate 1 Triamterene/HCTZ 1 Metoprolol tartrate 1 Tribenzor EXC Nadolol 1 Valsartan/HCTZ 1 1 Miscellaneous: Propranolol ER 1 Clonidine tab 1 Toprol-XL EXC Clonidine Patch 1 QL Angiotensin Receptor Blockers: Doxazosin 1 Benicar EXC tab 1 Diovan EXC Hydralazine 1 Edarbi 3 QL, ST Tekturna 2 QL, ST Irbesartan 1 Terazosin 1 Losartan 1 Vecamyl 3 PA Olmesartan 1 Cardiovascular: High Cholesterol Telmisartan 1 HMG Co-A Reductase Inhibitors: Valsartan 1 Altoprev 3 Diuretics: Atorvastatin 1 QL Bumetanide 1 Crestor EXC Chlorthalidone 1 Lovastatin 1 Furosemide 1 Lescol 3 Hydrochlorothiazide (HCTZ) 1 Lescol-XL 3 Spironolactone 1 Lipitor EXC Torsemide tab 1 Livalo 3 Combination Tablets: Mevacor 3 Amlodipine/benazepril 1 Pravachol 3 Amlodipine/olmesartan 1 Pravastatin 1 Amlodipine/valsartan 1 Rosuvastatin 1 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 8 Notes Drug Name Notes Level Level

Simvastatin 1 QL Antianginals: Simvastatin 80mg 1 PA, QL Amlodipine/atorvastatin 1 QL Zocor 3 Isosorbide dinitrate 1 PCSK9 Inhibitors: Isosorbide mononitrate 1 Praluent 2 PA, QL, SP Nitrostat EXC Repatha 3 PA,QL,SP,ST Nitroglycerin SL Tablets 2 Homozygous Familial Ranexa 2 ST Hypercholesterolemia TX: Rectiv 3 Juxtapid 3 PA, QL, SP Cardiovascular: Pulmonary Hypertension Kynamro 3 PA, SP, QL Adcirca 3 PA, QL, SP Hypertriglyceridemia TX: Adempas 2 PA, QL, SP Fenofibrate (EXCept 40, 120mg) 1 QL Epoprostenol 1 PA, SP Fenobiric Acid 1 QL Flolan 3 PA, SP Fibricor 3 QL Letairis 2 PA, QL, SP Gemfibrozil 1 QL Opsumit 2 PA, QL, SP Lipofen 3 QL Orenitram 3 PA, SP Lovaza EXC Remodulin 2 PA, SP Niacin ER tab 1 QL Sildenafil 20mg tab 1 PA, QL, SP Niaspan 3 QL Tracleer 2 PA, QL, SP Omega-3 Acid Cap 1 gm 1 QL Tyvaso 3 PA, QL, SP Vascepa 2 QL Uptravi 3 PA, QL, SP Bile Acid Sequestrants: Veletri 3 PA, SP Ventavis 3 PA, QL, SP Welchol 2 QL Central Nervous System: ADHD Cholesterol Absorption Inhibitors: Ezetimibe 1 Stimulants: Zetia EXC Adzenys-XR 3 PA, QL, ST Combination Products: Aptensio XR 3 PA, QL, ST Concerta EXC Ezetimibe-simvastatin 1 Dexmethylphenidate 1 PA, QL Simcor 2 QL Focalin-XR 3 PA, QL, ST Vytorin EXC Methylphenidate cap 1 PA, QL Cardiovascular: Methylphenidate ER 1 PA, QL Antiarrhythmics: Methylphenidate tab 1 PA, QL Amiodarone 1 Quillichew ER 3 PA, QL, ST Digoxin 1 Ritalin LA 3 PA, QL, ST Dofetilide 1 Vyvanse 2 PA, QL Flecainide 1 Zenzedi 3 PA, QL, ST Tikosyn 3 Combination Products: Sotalol 1 Adderall XR Cap EXC Heart Failure TX: /dextroamphet. 1 PA, QL Corlanor 3 PA, QL Entresto 3 PA, QL

Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 9 Notes Drug Name Notes Level Level

Non-Stimulant: 1 QL Clonidine, ER 1 QL Frova 3 QL Guanfacine ER tab 1 QL Imitrex 3 QL Intuniv 3 QL Maxalt 3 QL Kapvay 3 QL, ST Maxalt-MLT 3 QL Strattera 2 QL 1 QL Central Nervous System: Depression Relpax 3 QL SNRIs: 1 QL 1 QL Cymbalta EXC Sumavel 3 QL Desvenlafaxine, succinate 1 QL tab 1 QL Duloxetine 1 QL Zomig/Zomig-ZMT EXC Effexor/Effexor XR EXC Zomig Nasal Spray 2 QL Pristiq EXC Venlafaxine 1 Ergot Alkaloids: Venlafaxine ER 1 QL Cafergot 3 Wellbutin EXC Ergomar 3 Wellbutrin SR / XL EXC Migranal 3 QL SSRIs: Barbiturate Combinations: Citalopram 1 QL Butalbital/APAP/caffeine 1 QL Escitalopram 1 QL Phrenilin 3 QL 1 Central Nervous System: Multiple Sclerosis Lexapro EXC Ampyra 2 PA, QL, SP Paroxetine 1 Aubagio 3 PA, QL, SP Prozac EXC Avonex Kit 2 PA, QL, SP Sertraline 1 Avonex Pen Kit 2 PA, QL, SP Zoloft EXC Avonex Prefill Kit 2 PA, QL, SP Tricyclic : Betaseron 2 1 Copaxone 2 PA, QL, SP 1 Extavia EXC 1 Gilenya 3 PA,QL,SP,ST Other: Glatopa 1 PA, QL, SP Rebif EXC Budeprion XL 1 QL Rebif Titrtn EXC 1 QL Plegridy EXC Bupropion SR 1 QL Tecfidera 2 PA, QL, SP Forfivo XL 2 QL Tysabri 3 PA, SP 1 1 Central Nervous System: Other Viibryd 3 QL, ST Antipsychotics: Central Nervous System: Migraine Abilify Disc 3 QL : Abilify Solution 2 QL 1 QL Abilify tab 3 QL Amerge 3 QL 1 QL Axert 3 QL Invega 3 QL Latuda 3 QL, ST Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 10 Notes Drug Name Notes Level Level

Olanzapine tab 1 QL Huntington’s Disease Agents: Prochloperazine 1 Tetrabenazine 1 PA, SP 1 QL Xenazine 3 PA, SP Quetiapine XR 1 QL Tardive Dyskinesia: Risperdone tab 1 QL Ingrezza EXC PA, QL Saphris 2 QL Seroquel 3 QL Central Nervous System: Seroquel XR 3 QL Sedative/Hypnotic cap 1 QL Ambien/Ambien-CR EXC Antianxiolytics: Eszopiclone tab 1 QL Alprazolam 1 QL Lunesta EXC 1 Rozerem 3 QL Diazepam tab 1 Silenor 3 QL Hetlioz 3 PA, QL, SP Temazepam 1 QL HCl 1 Triazolam 1 QL Hydroxyzine pamoate 1 Zolpidem 1 QL tab 1 QL Zolpidem ER 1 QL Valium EXC Central Nervous System: Seizure Xanax/Xanax-XR EXC Disorder Antiparkinsonians: Carbamazepine tab 1 Apokyn 2 QL, PA, SP Carbatrol 2 QL Benztropine 1 Clonazepam 1 QL 1 PA Depakote 2 Carbidopa/levodopa 1 Depakote ER 2 Myobloc 3 PA, SP Depakote Sprinkles 2 Pramipexole/ER 1 Dilantin 2 Ropinirole 1 Divalproex DR 1 Tolcapone 1 Divalproex ER 1 Zelapar 3 Ethosuximide 1 Narcolepsy Agents: Gabapentin 1 Armodafinil 1 PA, QL Keppra 2 Modafinil 1 PA, QL Keppra-XR 2 QL Nuvigil EXC Lamictal 3 Xyrem 3 PA, QL, SP Lamictal ODT 3 Alzheimers Agents: Lamictal XR 3 QL Donepezil tab 1 QL Lamotrigine 1 1 QL Lamotrigine ER 1 QL Namenda tab 2 QL Levetiracetam 1 Namzaric 2 QL Levetiracetam ER 1 QL Namenda-XR 2 QL Lyrica 2 QL Bipolar Disorder Agents: Neurontin Solution 2 Lithium carbonate 1 Onfi 3 PA Vraylar 3 QL, ST Oxcarbazepine 1 Phenytoin 1 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 11 Notes Drug Name Notes Level Level

Sabril 3 PA, QL, SP Cloderm 3 Tegretol 2 Desonide cream 1 Tegretol-XR 2 Enstilar 3 PA, QL Topamax 2 Fluocinonide cream, gel, oint. 1 Topiramate tab 1 Hydrocortisone cream 2.5% 1 Trileptal 2 Mometasone 1 Trokendi XR EXC QL Triamcinolone 1 Vigabatrin 1 PA, SP Antipsoriatic Agents: Zarontin 2 Cosentyx 3 PA, SP Dermatology (Acne, etc.) Otezla 2 PA, QL, SP Retinoids: Oxsoralen-UI 2 PA Accutane 3 PA Taclonex EXC Adapalene-Benzoyl Peroxide 1 PA, QL Taltz EXC PA, SP Atralin 3 PA, QL Vectical 3 Differin 3 PA, QL Antifungal Agents: Epiduo 3 PA, QL Econazole cream 1 Retin-A Micro EXC Ketoconazole cream, shampoo 1 PA Tazorac 3 PA Nystatin cream, oint., powder 1 Tazarotene 1 QL Nystatin/triamcin. cream, oint. 1 Tretinoin microsphere gel 1 PA, QL Eczema Agents: Zenatane 1 PA Dupixent 2 PA, QL, SP Ziana EXC Elidel 2 QL, ST Antiinfectives: Combination Products: Acanya gel EXC Clotrimazole/betameth. cream 1 Aczone gel 3 Clotrimazole/betameth. lotion 1 Benzaclin EXC Other: Benzamycin gel EXC Carac 3 Clindamycin gel, lotion, solution 1 Dysport 3 PA, SP Clindamycin/benzoyl gel 1-5% 1 QL Lorenza Pad 4-1% 3 QL Duac EXC Permethrin cream 5% 1 Finacea 3 ST Picato gel 3 ST Metrogel 3 Protoptic oint. 2 QL, ST Metronidazole gel 0.75% 1 Zyclara 3 QL Mupirocin 1 QL Diabetes/Endocrine: Glucose Silver sulfadiazine cream 1% 1 Topical Antivirals: Monitoring Acyclovir oint. 5% 1 Accu-Chek Products EXC Condylox 3 Bayer Breeze Products EXC Zovirax, oral EXC Bayer Contour Products EXC Zovirax cream 2 Fastclix lancets 2 ST Zovirax ointment EXC Freestyle Products EXC Topical Corticosteroids: Glucocard test strips 3 QL, ST Insulin pen needle 2 Clobetasol cream, gel, oint 1 Insulin syringe/needle 2 Clobex 3 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 12 Notes Drug Name Notes Level Level

Novofine Auto 3 Regular/Short-acting: Novofine 3 Humulin R U-500 2 Novotwist 3 Humulin R vials 2 One Touch Ultra Smart kit 2 Novolin R vials EXC One Touch Ultra kit 2 Intermediate-acting: One Touch Ultra 2 kit 2 Humulin N vials 2 One Touch Ultra Mini 2 Humulin N pen 2 One Touch Verio IQ kit 2 Novolin N vials EXC One Touch test strips 2 QL Combination: One Touch Ultra Blue strips 2 QL Humulin 70/30 vials 2 One Touch Verio IQ test strips 2 QL Humulin 70/30 pen 2 One Touch Verio test strips 2 QL Novolin 70/30 vials EXC Precision Products EXC Soft Touch lancets 2 ST Diabetes/Endocrine: Non-Insulin Softclix lancet device 2 ST Injectables: Softclix lancets 2 ST Bydureon 2 QL, ST Surestep test strips (not Pro) 2 QL, ST Byetta 2 QL, ST TrueTest Products EXC Tanzeum EXC TrueTrackTest Products EXC Trulicity EXC Diabetes/Endocrine: Insulin Victoza 2 QL, ST Long-acting: Sulfonylureas: Glimepiride 1 Lantus Solostar 2 Glipizide 1 Lantus vials 2 Glipizide ER 1 Levemir FlexTouch EXC Glipizide XL 1 Levemir vials EXC Glyburide 1 Toujeo 2 Tresiba EXC TZDs: Pioglitazone 1 QL Rapid-acting: DPP-IV Inhibitors: Afrezza 3 PA Januvia 2 QL, ST Apidra EXC Nesina EXC Humalog vials 2 Onglyza EXC Humalog Kwik pen 2 Tradjenta 2 Humalog Mix 50/50 Kwik pen 2 Humalog Mix 50/50 vials 2 SGLT-2 Inhibitors: Humalog Mix 75/25 Kwik pen 2 Farxig EXC Humalog Mix 75/25 vials 2 Invokana 2 QL, ST Humalog 200 units/ml 3 Jardiance 2 QL, ST Novolog Flexpen EXC Biguanides: Novolog Mix Flexpen EXC Glumetza EXC Novolog Mix 70/30 vials EXC 1 Novolog Penfill EXC Metformin ER 1 Novolog vials EXC Alpha-glucosidase Inhibitors: Glyset 3 ST Miglitol 1 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 13 Notes Drug Name Notes Level Level

Combination Tablets: Proglycem 2 ActoPlus Met 3 QL Sensipar 3 PA Duetact 3 QL Endocrine: Thyroid Hormones Glyburide/metformin 1 Armour Thyroid 2 Glyxambi 3 QL, ST Cytomel EXC Invokamet 2 QL, ST 1 Janumet 2 QL, ST Liothyronine 1 Janumet XR 2 QL, ST Methimazole 1 Jentadueto 2 NP Thyroid 1 Kazano EXC Synthroid 2 Kombiglyze EXC Tirosint 3 Oseni EXC Unithroid 1 Synjardy 2 ST Eye Conditions: Allergy Xigduo XR EXC Azelastine solution 1 Endocrine: Olopatadine solution 1 QL Egrifta 3 PA, QL, SP Pataday 2 Genotropin EXC Patanol 3 QL Humatrope EXC Eye Conditions: Antibiotic Increlex 2 PA, SP Ciprofloxacin 1 QL Norditropin 2 PA, SP Erythromycin ointment 1 Nutropin AQ 2 PA, SP Gentamicin 1 Nutropin 2 PA, SP Moxeza 2 QL Omnitrope EXC Moxifloxacin Opth Sol 1 QL EXC Polymyxin B/trimethoprim 1 Serostim 2 PA, QL, SP Ofloxacin 1 QL Somatuline 3 PA, SP Tobradex EXC Tev-Tropin 3 PA, ST Tobramycin 1 Zomacton EXC Tobramycin/dexamethasone 1 Endocrine: Other Vigamox 3 QL Calcitriol cap 1 Eye Conditions: Glaucoma Dexamethasone tab 1 Alphagan-P EXC Leuprolide 1 PA, SP Azopt 2 QL Lupaneta kit 3 PA, QL, SP Bimatoprost soln. 1 QL Lupron Depot 3.75mg 3 PA, SP Brimonidine 1 Lupron Depot 11.25mg 3 PA, SP Combigan 2 QL Lupron Depot 7.5mg 2 PA, SP Dorzolamide/timolol 1 Lupron Depot 22.5mg 2 PA, SP Latanoprost 1 QL Lupron Depot 30mg 2 PA, SP Lumigan 2 QL Lupron Depot 45mg 2 PA, SP Rescula EXC Methylprednisolone tab 1 Timolol 1 Natapara 3 PA, SP Timoptic Ocudose 2 Prednisolone 1 Travatan Z 2 QL Prednisone 5mg/5ml 1 Zioptan EXC Prednisone 15mg/5ml 1 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 14 Notes Drug Name Notes Level Level

Eye Conditions: Other Gastrointestinal: Other Cystaran 3 PA, SP Anti-diarrheal: Eylea 3 SP Diphenoxylate/ 1 Jetrea 3 PA, SP Colonoscopy Prep: Ketorolac solution 1 QL Halflytely kit 3 QL Lotemax 3 QL Moviprep 3 QL Lucentis 2 SP Prepopik 3 Macugen 3 SP Suclear bowel prep 3 QL Prednisolone ophthalmic 1 Suprep bowel prep 3 QL Restasis 2 PA IBS: Visudyne 3 SP Alosetron 1 QL, PA Xiidra 2 PA Amitiza 2 QL, ST Ear Conditions: Dicyclomine 1 Antipyrine/benzocaine otic 1 Linzess 2 QL, ST Gastrointestinal: Acid Suppression Lotronex 3 QL, PA Proton Pump Inhibitors: and Crohn’s: Aciphex EXC Apriso 2 Dexilant 2 QL Asacol HD EXC Esomeprazole 1 QL Canasa 2 QL Lansoprazole 1 Delzicol EXC Nexium EXC Entyvio 3 PA, SP Omeprazole (Rx Only) 1 QL Lialda EXC QL Omeprazole/Sod. Bicarbonate 1 Mesalamine 800mg 3 ST Pantoprazole 1 QL Mesalamine 1.2gm 1 QL Prevacid EXC Pentasa 3 QL Rabeprazole 1 QL Uceris 3 Zegerid EXC Other: H2 Blockers: Creon 2 Famotidine 1 Gattex 3 PA, SP Ranitidine cap, syrup, tab 1 Movantik EXC Other: Omeclamox pak 2 QL Carafate EXC Pancreaze EXC Sucralfate tab 1 Polyethylene glycol 3350 1 QL Gastrointestinal: Nausea/Vomiting Pylera 2 QL Aloxi inj. 2 Serostim 2 PA, QL, SP 1 QL Solesta 2 SP 1 Zenpep (not 5,000 units) 2 1 QL Zorbtive 3 PA, QL, SP 1 QL Infertility Relistor 3 PA, QL Bravelle EXC patch 1 Cetrotide 2 SP Transderm-Scop 3 Chorionic gonadotropin 1 QL, QLPA, SP Clomiphene 1

Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 15 Notes Drug Name Notes Level Level

Follistim-AQ EXC Doxazosin 1 Ganirelix AC 3 QL, SP Dutasteride 1 QL Gonal-F RFF 2 PA, SP Dutasteride/tamsulosin 1 QL Gonal-F 2 PA, SP Finasteride 5mg 1 QL Menopur 3 PA, QL, SP Jalyn 3 QL Novarel 1 PA,QL, SP Rapaflo 2 QL Ovidrel 3 SP Tamsulosin 1 QL Pregnyl 1 PA, QL, SP Terazosin 1 Repronex 3 PA, QL, SP Men’s Health: Testosterone Inflammatory Conditions Androderm 2 PA, QL Actemra 3 QL, PA, SP Androgel 1% EXC Cimzia 2 PA, QL, SP Androgel 1.62% 2 PA, QL Enbrel 3 PA,QL,SP,ST Aveed 3 PA Enbrel SureClick 3 PA,QL,SP,ST Axiron EXC Humira kit 2 PA, QL, SP Depo-Testosterone EXC Humira Pen kit 2 PA, QL, SP Fortesta EXC Humira Pen kit Crohns 2 PA, QL, SP Natesto gel 2 PA, QL Humira Pen kit Psoriasis 2 PA, QL, SP Testim EXC Hydroxychloroquine 1 Testopel 3 PA Kineret 3 PA, QL, SP Testosterone gel 1% EXC Methotrexate tab 1 Testosterone injection 1 PA Orencia 3 PA,QL,SP,ST Vogelxo EXC Otrexup 3 PA,QL, ST Miscellaneous: Rasuvo 2 PA, QL Gout: Simponi 2 PA, QL, SP Allopurinol 1 Stelara 2 PA, QL, SP Colcrys 2 QL Tremfya 2 PA, SP Krystexxa inj 3 PA, QL, SP Xeljanz 3 PA, QL, SP Uloric 2 QL, ST Xeljanz-XR 3 PA, QL, SP Common Cold/Cough Suppressants: Men’s Health: Erectile Dysfunction Benzonatate 1 Caverject 3 QL Cheratussin 1 Cialis 2 QL Hydromet 1 Edex 3 QL DM, Codeine 1 Levitra EXC Rezira 3 Muse 3 QL Zutripro 3 Revatio, oral 2 QL, PA, SP Adrenal Disorders: Revatio Injection 3 QL, PA, SP Acthrel 3 SP Sildenafil tab 20mg 1 PA, QL, SP Staxyn EXC Genetic Disorders: Stendra EXC Actimmune 2 SP Viagra 2 Adagen 2 SP Men’s Health: Prostate Aldurazyme 2 PA, SP Aralast NP 3 PA, SP Alfuzosin 1 QL Buphenyl 3 SP Avodart 3 QL Carbaglu 3 SP Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 16 Notes Drug Name Notes Level Level

Cerdelga 3 PA, QL, SP Renvela 3 Cerezyme 2 PA, SP Sevelamer 1 Cholbam 3 PA, SP Complications in pregnancy: Cuprimine 3 PA, SP Makena 2 PA, SP Elaprase 2 PA, SP Micrhogam PL 2 SP Elelyso 3 PA, SP Rhogam Plus 2 Fabrazyme 2 PA, SP Rhophylac 2 Glassia 3 PA, SP Winrho SDF 2 SP Kanuma 3 PA, SP Other: Kuvan 2 PA, SP Bivigam 2 PA, SP Lumizyme 2 PA, SP Botox 100, 200 unit injection 2 PA, SP Myozyme 2 PA, SP Carimune 2 PA, SP Naglazyme 2 PA, SP Chlorhexidine gluconate 1 Orfadin 3 SP Cytogam 2 SP Phenylbutyr. sodium powder 1 SP Esbriet 3 PA, QL, SP Procysbi 3 PA, SP Euflexxa 2 PA, SP Prolastin-C 3 PA, SP Flebogamma 2 PA, SP Sucraid 3 SP Gamastan 2 PA, SP Vimizim 3 PA, SP Gammagard 2 PA, SP Vpriv 3 PA, SP Gammaked 2 PA, SP Zavesca 3 PA, SP Gammaplex 2 PA, SP Opiod Dependence: Gamunex-C 2 PA, SP Suboxone Film 2 PA, QL H.P. Acthar 2 PA, SP Vivitrol 3 PA, SP Hizentra 2 PA, SP Zubsolv 2 PA, QL Hyalgan 3 PA, SP Cystic Fibrosis: Hydrocortisone sup. 25mg 1 Kalydeco 3 PA, QL, SP Hyperrab S/D 2 Orkambi 3 PA, QL, SP Hyperrho S/D 2 Pulmozyme 2 PA, SP Hyqvia 3 PA, SP Lupus: Ilaris 2 PA, QL, SP Benlysta 3 PA, SP Imogam Rabies 2 SP Cushing’s Disease: Kepivance 2 SP Sandostatin 3 PA, SP Monovisc 3 PA, SP Signifor 3 PA, QL, SP Myalept 3 PA, SP Octreotide 1 PA, SP Natpara 3 PA, QL, SP Allergic Reactions: Northera 3 PA, QL, SP Octagam 2 PA, SP Adrenaclick EXC Ofev 3 PA, QL, SP Auvi-Q EXC Orthovisc 3 PA, SP Epipen Jr. EXC Phenazopyridine (Rx-only) 1 Epipen EXC Privigen 2 PA, SP Epinephrine Inj (Mylan Generic) 2 Ravicti 3 PA, SP Renal Dysfunction: Riastap 2 SP Fosrenol 3 Samsca 2 PA, QL, SP Lanthanum 1 Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 17 Notes Drug Name Notes Level Level

Somavert 3 PA, SP Sprix 3 PA, QL Strensiq 3 PA, SP Tivorbex 3 QL, ST Supartz 3 PA, SP Vimovo EXC Synagis 2 PA, SP Zorvolex EXC Synvisc 2 PA, SP Opiods: Thyrogen 2 SP Abstral EXC Xeomin 3 PA, SP Butorphanol sol. 10mg/ml 1 QL Xiaflex 2 PA, SP Duragesic patch EXC Zemaira 3 PA, SP Exalgo 3 QL Musculoskeletal: Osteoporosis Fentanyl patch 1 QL Actonel 3 QL Fentora EXC Alendronate tab 1 QL Hydromorphone tab 1 QL Atelvia 3 QL Hysingla ER 2 QL Boniva tab 3 QL Kadian EXC Evista 3 QL Lazanda EXC Forteo 2 PA, SP Methadone tab 1 Ibandronate tab 1 QL Morphine sulfate IR 1 QL Prolia 2 PA, QL, SP Morphine sulfate ER 1 QL Raloxifene 1 QL Opana ER EXC Reclast 3 SP Oxycodone tab 1 Risedronate 1 QL Oxycodone ER tab 1 QL Tymlos 2 PA, SP Oxycontin 2 QL Musculoskeletal: Other Subsys EXC Baclofen tab 1 Zohydro ER EXC Carisoprodol 1 Combination Products: 5, 10mg 1 Acetaminophen w/codeine 1 QL Gablofen 2 Embeda 2 Lioresal intrathecal inj. 2 Endocet tab 1 QL Metaxalone 1 Hydrocodone/ibuprofen 1 QL Methocarbamol 1 Hydrocodone/APAP 1 QL Tizanidine 1 Norco EXC Musculoskeletal: Pain Relief Oxycodone/APAP 1 QL NSAIDS: Percocet EXC Celebrex EXC /APAP 1 QL Celecoxib 1 QL Vicodin 1 QL Diclofenac tab 1 QL Vicodin ES 1 QL Duexis EXC Other: Cambia EXC Gralise 3 QL, ST Etodolac 1 QL Lidocaine patch 5% 1 QL Ibuprofen (Rx-only) 1 QL Lidocaine, viscous 2% 1 Indomethacin cap 1 QL Lidoderm patch EXC Meloxicam 1 QL Nucynta 3 QL Nabumetone 1 QL Nucynta ER EXC Naproxen (Rx-only) 1 QL Prialt inj. 2 SP Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 18 Notes Drug Name Notes Level Level

Qutenza patch 3 PA, QL, SP Combination Products: Other: Tramadol tab 1 QL Advair Diskus 2 QL Voltaren gel EXC Advair HFA 2 QL Overactive Bladder AirDuo Respiclick EXC QL, ST Darifenacin 1 Anoro Ellipta 2 QL Enablex 3 Breo Ellipta 2 QL Myrbetriq 2 Combivent Respimat 2 QL Oxybutynin 1 Dulera EXC Oxybutynin ER 1 QL Fluticasone/salmeterol EXC QL, ST Tolterodine ER 1 QL Ipratropium/albuterol 1 QL Toviaz 3 QL Stiolto Respimat 2 QL Vesicare 2 QL Symbicort 2 QL Respiratory: Asthma/COPD Utibron 3 QL, ST : Other: Incruse Elipta 2 QL Montelukast 1 QL Seebri Neohaler 3 QL, ST Nucala 3 PA, QL, SP Spiriva 2 QL Singulair EXC Spiriva Respimat 2 QL Xolair 2 PA, SP Tudorza Pressair EXC Respiratory: Allergies, Nasal Short-Acting Beta-Agonists: Azelastine spray 1 QL Albuterol nebulizer soln. 1 QL Dymista spray 2 QL Levalbuterol nebulizer soln. 1 QL Fluticasone spray 1 ProAir HFA 2 QL Ipratropium spray 1 QL ProAir RespiClick 2 QL Mometasone Nasal Spray 1 QL Proventil HFA EXC Nasonex EXC Ventolin HFA 2 QL Omnaris 3 QL Xopenex HFA EXC Qnasl 3 QL Long-Acting Beta-Agonists: Triamcinolone Spray 1 QL Foradil 2 QL Veramyst 3 QL Perforomist 3 QL Zetonna 3 QL Serevent Diskus 2 QL Respiratory: Allergies, Oral Inhaled Steroids: Promethazine tab 1 Aerospan 3 QL Desloratadine 1 QL Alvesco EXC Levocetirizine 1 QL Arnuity Ellipta EXC Smoking/Tobacco Cessation Asmanex/HFA EXC Bupropion SR (smoking cess.) 1 Budesonide 1 QL Chantix 3 QL Flovent Diskus 2 QL Nicotrol inhaler 3 QL Flovent HFA 2 QL Nicotrol nasal spray 3 QL Pulmicort Flexhaler 2 QL Zyban 3 QL Pulmicort Suspension EXC Qvar EXC

Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 19 Notes Drug Name Notes Level Level

Transplant Generess Fe chewable 3 Astagraf XL 3 SP Gianvi 1 Atgam 2 SP Gildess Fe 1 Azathioprine 1 Implanon implant 3 SP Cellcept tab 3 SP Jolivette 1 Cellcept suspension 3 SP Junel Fe 1 Cyclosporine cap 1 SP Kariva 1 Envarsus XR 3 SP Levora 1 Gengraf 1 SP Lo Loestrin 3 Hecoria 1 SP Loryna 1 Mycophenolate cap/tab 1 SP Low-Ogestrel 1 Mycophenolic acid 1 SP Lutera 1 Myfortic 3 SP Medroxyprogesterone injection 1 QL Nulojix 3 PA, SP Melodetta chewable 24 FE 1 Neoral 3 SP Microgestin 1 Prograf cap 3 SP Microgestin Fe 1 Rapamune 3 SP Minastrin 24 Fe chewable EXC Sandimmune 3 SP Mirena IUD 3 SP Sirolimus 1 SP Mononessa 1 Tacrolimus cap 1 SP Natazia 2 Zortress 3 PA, SP Necon 1 Vitamins/Electrolytes Nexplanon implant 3 SP Cyanocobalamin inj. 1 Nortrel 1 Folic acid 1mg 1 Nuvaring 2 Multi-vit + Fluoride 1 Ocella 1 Potassium chloride (Rx-only) 1 Orsythia 1 Vitafol EXC Ortho-Evra patch 3 Vitamin D 50,000 unit (Rx-only) 1 Ortho Tri Cyclen / Lo EXC Weight Loss (Anorexiants) Previfem 1 Reclipsen 1 Belviq 3 PA, QL Rivesla 1 QL Contrave 3 PA, QL Safyral 3 Diethylpropion 1 PA Sprintec 1 Phendimetrazine 1 PA Trinessa 1 Phentermine 1 PA Tri-Sprintec 1 Qsymia 3 PA, QL Vestura 1 Saxenda 3 PA, QL Viorele 1 Xenical 3 PA Xulane patch 1 Women’s Health: Contraceptives Yaz EXC Apri 1 Aviane 1 Beyaz EXC Cryselle-28 1 Depo-Provera injection 3 QL Fayosim 1 QL Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy

Name Tier Tier 20 Notes Drug Name Notes Level Level

Women’s Health: Hormone Replacement Yuvafem 1 Estrogens: Progestins: Alora 3 QL Medroxyprogesterone tab 1 Climara Pro 2 QL Progesterone cap 1 Divigel 3 Combination Products: Enjuvia 3 QL Estradiol/norethindrone tab 1 QL Estrace vaginal cream 3 Premphase 2 QL Estradiol tab 1 QL Prempro 2 QL Evamist 3 QL Women’s Health: Misc Premarin tab 2 QL Addyi 3 PA, QL Premarin vaginal cream 2 Metronidazole vaginal gel 1 Vagifem EXC Terconazole vaginal cream 1 QL Vivelle-Dot EXC

Plain type = generic medication PA = Prior authorization required QL = Subject to quantity limits Bold type = brand medication SP = Specialty medication ST = Medication subject to step therapy