HealthPartners Medicare Prescription Drug Program 2010 Formulary (List of Covered Drugs)

PLEASE READ: This document contains information about the drugs we cover in this plan.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

H2462 H9005 S1822_H2422 MSHO1002 440113 (10/10) Last Updated October 1, 2010 Formulary ID 10242, Version 17 HealthPartners Medicare Prescription Drug Program Formulary

What is the HealthPartners Formulary? The enclosed formulary is current as of January 1, 2010. To get updated information about A formulary is a list of covered drugs selected by the drugs covered by HealthPartners, please visit HealthPartners in consultation with a team of our website at healthpartners.com/partdpharmacy healthcare providers, which represents the or call Member Services at the following numbers. prescription therapies believed to be a necessary part of a quality treatment program. HealthPartners HealthPartners® Freedom Plan (Cost) members will generally cover the drugs listed in our should call 952-883-7979 or 1-800-233-9645. formulary as long as the drug is medically necessary, the prescription is filled at a HealthPartners® Classic Plan (HMO) members HealthPartners network pharmacy and other plan should call 952-883-7676 or 1-866-233-8734. rules are followed. For more information on how to fill your prescriptions, please review your Evidence HealthPartners Medicare Part D Plan (PDP) of Coverage. members should call 952-883-7373 or 1-877-816-9539. Can the Formulary change? TTY users should call 952-883-6060 or 1-800-443-0156. Generally, if you are taking a drug on our 2010 formulary that was covered at the beginning of the Member Services representatives are available seven year, we will not discontinue or reduce coverage of days a week between 8 a.m. and 8 p.m. the drug during the 2010 coverage year except when To find out what drugs might have changed, you a new, less expensive generic drug becomes can go to healthpartners.com/partdpharmacy. available or when new adverse information about The formulary is updated monthly to include any the safety or effectiveness of a drug is released. changes. Negative formulary changes are also Other types of formulary changes, such as removing detailed at the bottom of your Explanations of a drug from our formulary, will not affect members Benefits that are sent to you monthly. who are currently taking the drug. It will remain available at the same cost-sharing for those How do I use the Formulary? members taking it for the remainder of the coverage year. We feel it is important that you have continued There are two ways to find your drug within the access for the remainder of the coverage year to the formulary: formulary drugs that were available when you chose Medical Condition our plan, except for cases in which you can save additional money or we can ensure your safety. The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on If we remove drugs from our formulary or add prior the type of medical conditions that they are used to authorization, quantity limits and/or step therapy treat. For example, drugs used to treat a heart restrictions on a drug we must notify affected condition are listed under the category members of the change at least 60 days before the “Cardiovascular Agents.” If you know what your change becomes effective, or at the time the drug is used for, look for the category name in the member requests a refill of the drug, at which time list that begins on page 6. Then look under the the member will receive a 60 day supply of the category name for your drug. drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's Alphabetical Listing manufacturer removes the drug from the market, we will immediately remove the drug from our If you are not sure what category to look under, you formulary and provide notice to members who take should look for your drug in the Index that begins the drug. on page 40. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in 2 HealthPartners Medicare Prescription Drug Program Formulary

the Index. Look in the Index and find your drug. You can ask HealthPartners to make an exception to Next to your drug, you will see the page number these restrictions or limits. See the section, "How do where you can find coverage information. Turn to I request an exception to the HealthPartners the page listed in the Index and find the name of formulary?" on page 3 for information about how to your drug in the first column of the list. request an exception. What are generic drugs? What if my drug is not on the Formulary? HealthPartners covers both brand name drugs and If your drug is not included in this formulary, you generic drugs. A generic drug is approved by the should first contact Member Services and confirm FDA as having the same active-ingredient as the that your drug is not covered. If you learn that brand name drug. Generally, generic drugs cost less HealthPartners does not cover your drug, you have than brand name drugs. two options: Are there any restrictions on my coverage? • You can ask Member Services for a list of similar Some covered drugs may have additional drugs that are covered by HealthPartners. When requirements or limits on coverage. These you receive the list, show it to your doctor and ask requirements and limits may include: him or her to prescribe a similar drug that is covered by HealthPartners. • Prior Authorization: HealthPartners requires you to get prior authorization for certain drugs. This • You can ask HealthPartners to make an exception means that you will need to get approval from and cover your drug. See below for information HealthPartners before you fill your about how to request an exception. prescriptions. If you don't get approval, How do I request an exception to the HealthPartners may not cover the drug. HealthPartners Formulary? • Quantity Limits: For certain drugs, You can ask HealthPartners to make an exception to HealthPartners limits the amount of the drug that our coverage rules. There are several types of HealthPartners will cover. For example, exceptions that you can ask us to make. HealthPartners provides 20 units per prescription for Ergomar. This may be in addition to a standard • You can ask us to cover your drug even if it is not one month or three month supply. on our formulary. • Step Therapy: In some cases, HealthPartners • You can ask us to waive coverage restrictions or requires you to first try certain drugs to treat your limits on your drug. For example, for certain drugs, medical condition before we will cover another drug HealthPartners limits the amount of the drug that we for that condition. For example, if Drug A and Drug will cover. If your drug has a quantity limit, you can B both treat your medical condition, HealthPartners ask us to waive the limit and cover more. may not cover Drug B unless you try Drug A first. Generally, HealthPartners will only approve your If Drug A does not work for you, HealthPartners request for an exception if the alternative drugs will then cover Drug B. included on the plan’s formulary or additional You can find out if your drug has any additional utilization restrictions would not be as effective in requirements or limits by looking in the formulary treating your condition and/or would cause you to that begins on page 8. You can also get more have adverse medical effects. information about the restrictions applied to You should contact us to ask us for an initial coverage specific covered drugs by visiting decision for a formulary or utilization restriction healthpartners.com/partdpharmacy. exception. When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request. 3 HealthPartners Medicare Prescription Drug Program

Generally, we must make our decision within 72 hours Transition process of getting your prescribing physician’s supporting New members in our Plan may be taking drugs that statement. You can request an expedited (fast) aren’t on our formulary or that are subject to certain exception if you or your doctor believe that your restrictions, such as prior authorization or step health could be seriously harmed by waiting up to therapy. Current members may also be affected by 72 hours for a decision. If your request to expedite is changes in our formulary from one year to the next. granted, we must give you a decision no later than Members should talk to their doctors to decide if they 24 hours after we get your prescribing physician’s should switch to a different drug that we cover or supporting statement. request a formulary exception in order to get coverage for the drug. See Section 5 of your Evidence of What do I do before I can talk to my doctor about Coverage under "What is an exception?" to learn changing my drugs or requesting an exception? more about how to request an exception. Please As a new or continuing member in our plan you may contact Member Services if your drug is not on our be taking drugs that are not on our formulary. Or you formulary, is subject to certain restrictions, such as may be taking a drug that is on our formulary but prior authorization or step therapy, or will no longer your ability to get it is limited. For example, you may be on our formulary next year and you need help need a prior authorization from us before you can fill switching to a different drug that we cover or your prescription. You should talk to your doctor to requesting a formulary exception. decide if you should switch to an appropriate drug that we cover or request a formulary exception so that During the period of time members are talking to their we will cover the drug you take. While you talk to doctors to determine the right course of action, we your doctor to determine the right course of action for may provide a temporary supply of the non-formulary you, we may cover your drug in certain cases during drug if those members need a refill for the drug the first 90 days you are a member of our plan. during the first 90 days of new membership in our Plan. If you are a current member affected by a For each of your drugs that is not on our formulary or formulary change from one year to the next, we will if your ability to get your drugs is limited, we will provide you with the opportunity to request a cover a temporary 30 day supply (unless you have a formulary exception in advance for the following year. prescription written for fewer days) when you go to a network pharmacy. After your first 30 day supply, we When a member goes to a network pharmacy and we will not pay for these drugs, even if you have been a provide a temporary supply of a drug that isn’t on our member of the plan less than 90 days. formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will If you are a resident of a long term care facility, we cover a 30-day supply (unless the prescription is will cover a temporary 31 day transition supply written for fewer days). After we cover the temporary (unless you have a prescription written for fewer 30-day supply, we generally will not pay for these days). We will cover more than one refill of these drugs as part of our transition policy again. We will drugs for the first 90 days you are a member of our provide you with a written notice after we cover your plan. If you need a drug that is not on our formulary temporary supply. This notice will explain the steps or your ability to get your drugs is limited, but you are you can take to request an exception and how to work past the first 90 days of membership in our plan, we with your doctor to decide if you should switch to an will cover a 31 day emergency supply of that drug appropriate drug that we cover. (unless you have a prescription for fewer days) while you pursue a formulary exception. If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs 4 HealthPartners Medicare Prescription Drug Program during the first 90 days a new member is enrolled in If you have general questions about Medicare our Plan. If the resident has been enrolled in our Plan prescription drug coverage, please call Medicare at for more than 90 days and needs a drug that isn’t on 1-800-MEDICARE (1-800-633-4227) 24 hours a day/ our formulary or is subject to other restrictions, such as 7 days a week. TTY/TDD users should call step therapy or dosage limits, we will cover a 1-877-486-2048. Or visit medicare.gov. temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the HealthPartners Formulary new member pursues a formulary exception. The formulary that begins on the next page provides coverage information about some of the drugs covered For existing members in our Plan who have changes in by HealthPartners. If you have trouble finding your level of care, such as entering a long-term care facility drug in the list, turn to the Index that begins on page 39. or being discharged from a hospital, we will grant early refills when appropriate. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g. LIDODERM Please note that our transition policy applies only to patch) and generic drugs are listed in lower-case italics those drugs that are "Part D drugs" and bought at a (e.g. salsalate). network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network, The information in the Notes column tells you if unless you qualify for out of network access. See HealthPartners has any special requirements for Section 10 of your Evidence of Coverage for coverage of your drug. information about non-Part D drugs.

For more information For more detailed information about your HealthPartners prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call Member Services between 8 a.m. to 8 p.m., seven days a week.

HealthPartners® Freedom Plan (Cost) members should call 952-883-7979 or 1-800-233-9645.

HealthPartners® Classic Plan (HMO) members should call 952-883-7676 or 1-866-233-8734. HealthPartners Medicare Part D Plan (PDP) members should call 952-883-7373 or 1-877-816-9539. TTY users should call 952-883-6060 or 1-800-443-0156.

5 Drug Category Listing

Category Name page # Category Name page #

ACIDIFYING AGENTS ...... 8 ANTIPRURITICS AND LOCAL ANESTHETICS ...... 22 ADRENALS ...... 8 ANTITHROMBOTIC AGENTS ...... 22 ALKALINIZING AGENTS ...... 8 ANTIULCER AGENTS AND ACID SUPPRESSANTS ...... 22 ALPHA-ADRENERGIC BLOCKING AGENTS ...... 8 ANTIVIRALS (SYSTEMIC) ...... 23 AMMONIA DETOXICANTS ...... 8 ANXIOLYTICS, SEDATIVES AND HYPNOTICS ...... 24 ANALGESICS AND ANTIPYRETICS ...... 9 AUTONOMIC DRUGS, MISCELLANEOUS ...... 24 ANDROGENS ...... 10 BETA-ADRENERGIC BLOCKING AGENTS ...... 24 ANOREXIGENICS, RESPIR., CEREBRAL STIMULANT . . . .10 CALCIUM-CHANNEL BLOCKING AGENTS ...... 24 ANTHELMINTICS ...... 10 CALORIC AGENTS ...... 25 ANTI-INFECTIVES (EENT) - (EARS, EYES, NOSE & CARDIAC DRUGS ...... 25 THROAT) ...... 16 CATHARTICS AND LAXATIVES ...... 25 ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) . . .16 CELL STIMULANTS AND PROLIFERANTS ...... 25 ANTI-INFLAMMATORY AGENTS (EENT) - CENTRAL NERVOUS SYSTEM AGENTS, MISC...... 26 (EARS, EYES, NOSE & THROAT) ...... 17 CHOLELITHOLYTIC AGENTS ...... 26 ANTI-INFLAMMATORY AGENTS (GI DRUGS) - CONTRACEPTIVES ...... 26 (GASTROINTESTINAL) ...... 18 DEPIGMENTING AND PIGMENTING AGENTS ...... 27 ANTI-INFLAMMATORY AGENTS (RESPIRATORY) ...... 18 DEVICES ...... 27 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS) . .18 DIGESTANTS ...... 27 ANTIALLERGIC AGENTS ...... 10 DIURETICS ...... 27 ANTIBACTERIALS ...... 11 EENT DRUGS, MISCELLANEOUS (EARS, EYES, NOSE ANTICHOLINERGIC AGENTS ...... 12 & THROAT) ...... 28 ANTICONVULSANTS ...... 12 EMOLLIENTS, DEMULCENTS, AND PROTECTANTS . . . .28 ANTIDIABETIC AGENTS ...... 13 ENZYMES ...... 28 ANTIDIARRHEA AGENTS ...... 14 ESTROGENS AND ANTIESTROGENS ...... 28 ANTIEMETICS (DRUGS FOR NAUSEA & VOMITING) . . . .14 FIRST GENERATION ANTIHISTAMINES ...... 29 ANTIFUNGAL (SYSTEMIC) ...... 14 GENITOURINARY SMOOTH MUSCLE RELAXANTS . . . . .29 ANTIGLAUCOMA AGENTS ...... 15 GI DRUGS, MISCELLANEOUS (GASTROINTESTINAL) . . .29 ANTIHEMORRHAGIC AGENTS ...... 15 GOLD COMPOUNDS ...... 29 ANTIHYPOGLYCEMIC AGENTS ...... 15 GONADOTROPINS ...... 29 ANTILIPEMIC AGENTS (CHOLESTEROL LOWERING HEAVY METAL ANTAGONISTS ...... 29 MEDICATIONS) ...... 19 HEMATOPOIETIC AGENTS ...... 30 ANTIMANIC AGENTS ...... 19 HEMORRHEOLOGIC AGENTS ...... 30 ANTIMIGRAINE AGENTS ...... 19 HYPOTENSIVE AGENTS ...... 30 ANTIMYCOBACTERIALS ...... 19 ION-REMOVING AGENTS ...... 30 ANTINEOPLASTIC AGENTS (CANCER DRUGS) ...... 20 IRRIGATING SOLUTIONS ...... 30 ANTIPARKINSONIAN AGENTS ...... 21 KERATOPLASTIC AGENTS ...... 30 ANTIPROTOZOALS ...... 22 LOCAL ANESTHETICS (EENT) - (EARS, EYES,

6 Drug Category Listing

Category Name page #

NOSE & THROAT) ...... 30 LOCAL ANESTHETICS (PARENTERAL) ...... 30 MISCELLANEOUS THERAPEUTIC AGENTS ...... 30 MULTIVITAMIN PREPARATIONS ...... 32 MYDRIATICS ...... 32 OPIATE ANTAGONISTS ...... 32 OXYTOCICS ...... 32 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) . . . .33 PARATHYROID AGENTS ...... 33 PHARMACEUTICAL AIDS ...... 33 PITUITARY AGENTS ...... 33 PROGESTINS ...... 33 PROKINETIC AGENTS ...... 33 PSYCHOTHERAPEUTIC AGENTS ...... 33 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ...... 35 REPLACEMENT PREPARATIONS ...... 36 RESPIRATORY SMOOTH MUSCLE RELAXANTS ...... 36 RESPIRATORY TRACT AGENTS, MISCELLANEOUS . . . . .36 SECOND GENERATION ANTIHISTAMINES ...... 36 SERUMS ...... 36 SKELETAL MUSCLE RELAXANTS ...... 36 SKIN AND MUCOUS MEMBRANE AGENTS, MISC...... 37 SOMATOTROPIN AGONISTS AND ANTAGONISTS ...... 37 SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS . . . .37 SYMPATHOMIMETIC (ADRENERGIC) AGENTS ...... 38 THYROID AND ANTITHYROID AGENTS ...... 38 TOXOIDS ...... 38 URICOSURIC AGENTS ...... 38 URINARY ANTI-INFECTIVES ...... 39 VACCINES ...... 39 VASOCONSTRICTORS ...... 39 VASODILATING AGENTS ...... 40 VITAMIN D ...... 40

7 Alphabetical by Drug Category

Drug Name Drug Tier Notes

ACIDIFYING AGENTS ammonium chloride intravenous solution Generic Prior Authorization ADRENALS ADVAIR DISKUS FOR ORAL INHALATION - BRAND ADVAIR HFA FOR ORAL INHALATION - BRAND ASMANEX ORAL INHALANT - BRAND AZMACORT ORAL INHALANT - BRAND budesonide 0.25mg & 0.5mg suspension for inhalation - Generic DEXAMETHASONE ORAL CONCENTRATE DROPS - BRAND dexamethasone oral tablet & elixir - Generic dexamethasone sodium phosphate injection Generic DEXPAK DOSEPAK BRAND ENTOCORT EC - BRAND FLOVENT DISKUS ORAL INHALANT - BRAND FLOVENT HFA ORAL INHALANT - BRAND fludrocortisone oral - Generic hydrocortisone 5mg,10mg & 20mg oral - Generic MEDROL 2MG ORAL - BRAND methylprednisolone 4mg, 8mg, 16mg & 32mg oral - Generic methylprednisolone acetate injection Generic MILLIPRED - BRAND prednisolone oral liquid - Generic prednisolone sodium phosphate oral liquid - Generic prednisone 5mg/5ml oral solution - Generic PREDNISONE 5MG/ML CONCENTRATE SOLUTION - BRAND prednisone oral dosepak Generic prednisone oral tablet - Generic PULMICORT FLEXHALER ORAL INHALANT - BRAND PULMICORT RESPULES 1MG - BRAND QVAR ORAL INHALANT - BRAND SYMBICORT FOR ORAL INHALATION - BRAND ALKALINIZING AGENTS potassium citrate tablet - Generic sodium bicarbonate intravenous solution Generic ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin - Generic prazosin - Generic terazosin - Generic AMMONIA DETOXICANTS BUPHENYL ORAL SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT lactulose (constulose, enulose, generlac) - Generic

8 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ANALGESICS AND ANTIPYRETICS acetaminophen w/codeine 120-12mg/5ml elixir - Generic Quantity Limit acetaminophen w/codeine 300mg-15mg, 300mg-30mg, 300-60mg tablet - Generic Quantity Limit butorphanol nasal spray Generic Prior Authorization, Quantity Limit CELEBREX - BRAND STEP THERAPY codeine sulfate tablet - Generic diclofenac sodium regular release - Generic DILAUDID-5 LIQUID BRAND endocet 10-650mg - Generic Quantity Limit endocet 5-325mg, 7.5-325mg, 10-325mg - Generic Quantity Limit endocet 7.5-500mg - Generic Quantity Limit fentanyl patches - Generic flurbiprofen - Generic hydrocodone / ibuprofen 7.5-200mg - Generic hydrocodone w/acetaminophen 10-325mg/cup solution - Generic Quantity Limit hydrocodone w/acetaminophen 2.5-500mg, 5-500mg, 7.5-500mg, 10-500mg - Generic Quantity Limit hydrocodone w/acetaminophen 5-325mg, 7.5-325mg, 10-325mg - Generic Quantity Limit hydrocodone w/acetaminophen 7.5-500mg/15ml elixir - Generic Quantity Limit hydrocodone w/acetaminophen 7.5-650mg, 10-650mg, 10-660mg - Generic Quantity Limit hydrocodone w/acetaminophen 7.5-750mg, 10-750mg - Generic Quantity Limit hydromorphone hcl injection Generic hydromorphone oral - Generic ibuprofen - Generic INDOCIN SUSPENSION - BRAND indomethacin immediate release capsule - Generic ketorolac oral Generic Quantity Limit meloxicam - Generic methadone oral tablet, solution and concentrate Generic morphine regular release oral solution & tablet - Generic morphine sulfate 0.5mg/ml, 1mg/ml, 5mg/ml injection Generic morphine sustained release - Generic naproxen regular release suspension & tablet - Generic naproxen sodium - Generic oxycodone 10mg, 20mg, 40mg & 80mg sustained release - Generic Quantity Limit oxycodone 5mg, 15mg & 30mg regular release - Generic oxycodone w/acetaminophen 10-650mg - Generic Quantity Limit oxycodone w/acetaminophen 5-325mg, 7.5-325mg, 10-325mg - Generic Quantity Limit oxycodone w/acetaminophen 5-325mg/5ml oral solution - Generic Quantity Limit oxycodone w/acetaminophen 5-500mg, 7.5-500mg - Generic Quantity Limit oxycodone w/aspirin - Generic OXYCONTIN - BRAND QUANTITY LIMIT

- Generally available through Mail Order Pharmacy 9 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

piroxicam - Generic roxicet 325-5mg/5ml oral solution - Generic Quantity Limit roxicet 5-500mg tablet - Generic Quantity Limit SUBOXONE BRAND sulindac - Generic tolmetin - Generic tramadol regular release - Generic ANDROGENS ANADROL-50 - BRAND PRIOR AUTHORIZATION ANDRODERM - BRAND PRIOR AUTHORIZATION ANDROGEL - BRAND PRIOR AUTHORIZATION ANDROID - BRAND ANDROXY - BRAND danazol - Generic METHITEST - BRAND oxandrolone oral - Generic Prior Authorization testosterone cypionate injection - Generic Prior Authorization ANOREXIGENICS, RESPIR., CEREBRAL STIMULANT CONCERTA - BRAND dexmethylphenidate immediate release - Generic dextroamphetamine / amphetamine regular release - Generic dextroamphetamine immediate release - Generic dextroamphetamine sustained release - Generic FOCALIN XR - BRAND STEP THERAPY METADATE CD - BRAND STEP THERAPY methylin immediate release - Generic methylin sustained release - Generic methylphenidate immediate release - Generic methylphenidate sustained release - Generic PROVIGIL - BRAND PRIOR AUTHORIZATION VYVANSE - BRAND ANTHELMINTICS ALBENZA BRAND BILTRICIDE BRAND mebendazole Generic STROMECTOL BRAND ANTIALLERGIC AGENTS ALAMAST OPHTHALMIC - BRAND ASTELIN NASAL SPRAY - BRAND azelastine hcl ophthalmic - Generic azelastine nasal spray - Generic ELESTAT OPHTHALMIC - BRAND PATADAY OPHTHALMIC - BRAND PATANOL OPHTHALMIC - BRAND

1010 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ANTIBACTERIALS amikacin sulfate injection Generic Prior Authorization amoxicillin / clavulanate potassium regular release tablet - Generic amoxicillin / clavulanate potassium suspension Generic amoxicillin capsule, chewable tablet, swallow tablet - Generic amoxicillin suspension Generic ampicillin capsule - Generic ampicillin injection Generic ampicillin suspension Generic AUGMENTIN 125MG SUSPENSION BRAND AUGMENTIN 250MG CHEW TAB - BRAND AVELOX - BRAND azithromycin intravenous solution Generic azithromycin suspension & packet Generic azithromycin tablet - Generic cefazolin sodium injection Generic cefdinir capsule - Generic cefdinir suspension Generic cefepime injection Generic cefoxitin sodium intravenous solution Generic cefprozil suspension Generic cefprozil tablet - Generic ceftriaxone injection Generic cefuroxime suspension Generic cefuroxime tablet - Generic cephalexin capsule & tablet - Generic cephalexin suspension Generic chloramphenicol intravenous injection Generic Prior Authorization CIPRO SUSPENSION - BRAND ciprofloxacin regular release tablet - Generic clarithromycin suspension Generic clarithromycin tablet - Generic CLEOCIN 75MG CAPSULE - BRAND CLEOCIN PED SOLUTION BRAND clindamycin capsule - Generic clindamycin phosphate injection Generic Prior Authorization colistimethate sodium injection Generic demeclocycline - Generic dicloxacillin capsule - Generic doxycycline hyclate 20mg - Generic doxycycline hyclate intravenous solution Generic doxycycline hyclate regular release 50mg & 100mg - Generic ERYPED 200MG/5ML & 400MG/5ML FOR SUSPENSION BRAND erytab - Generic erythromycin base - Generic erythromycin ethylsuccinate tablet - Generic

- Generally available through Mail Order Pharmacy 1111 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

erythromycin lactobionate intravenous solution Generic erythromycin stearate - Generic erythromycin/sulfisoxazole suspension Generic GANTRISIN SUSPENSION - BRAND LEVAQUIN INTRAVENOUS SOLUTION BRAND LEVAQUIN ORAL - BRAND metronidazole regular release oral tablet - Generic minocycline capsule - Generic nafcillin 2gm injection Generic neo-fradin - Generic neomycin oral tablet - Generic penicillin g potassium injection Generic penicillin VK suspension & tablet - Generic piperacillin sodium / tazobactam 2.25 gram intravenous Generic piperacillin sodium injection & intravenous solution Generic PRIMAXIN INTRAVENOUS SOLUTION BRAND sulfadiazine - Generic sulfamethoxazole/trimethoprim intravenous solution Generic sulfamethoxazole/trimethoprim oral suspension - Generic sulfamethoxazole/trimethoprim oral tablet - Generic sulfasalazine delayed release - Generic sulfasalazine regular release - Generic SUPRAX TABLET BRAND QUANTITY LIMIT tetracycline capsule - Generic TOBI NEBULIZATION SOLUTION SPECIALTY 30 DAY SUPPLY LIMIT tobramycin injection & intravenous solution Generic Prior Authorization TYGACIL INTRAVENOUS SOLUTION BRAND VANCOCIN ORAL CAPSULE - BRAND vancomycin 5mg & 10gm intravenous solution Generic ZOSYN 40.5 GM INTRAVENOUS SOLUTION BRAND ZYVOX INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION ZYVOX ORAL - BRAND ANTICHOLINERGIC AGENTS ATROVENT HFA ORAL INHALER - BRAND dicyclomine - Generic ipratropium nebulization solution - Generic propantheline 15mg - Generic SPIRIVA ORAL INHALER - BRAND ANTICONVULSANTS BANZEL - BRAND PRIOR AUTHORIZATION carbamazepine 200mg & 400mg extended release tablet - Generic carbamazepine immediate release - Generic CARBATROL - BRAND CELONTIN - BRAND DILANTIN - BRAND DILANTIN-125 - BRAND

1212 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

divalproex sodium 24 hour extended release - Generic divalproex sodium enteric coated tablet - Generic divalproex sodium sprinkle - Generic epitol - Generic ethosuximide - Generic FELBATOL - BRAND PRIOR AUTHORIZATION gabapentin - Generic GABITRIL - BRAND KEPPRA INTRAVENOUS SOLUTION BRAND LAMICTAL ODT - BRAND PRIOR AUTHORIZATION LAMICTAL STARTER KITS BRAND lamotrigine 100mg, 150mg, 200mg tablet - Generic lamotrigine 25mg tablet - Generic Quantity Limit lamotrigine 5mg & 25mg chewable tablet - Generic levetiracetam oral solution & tablet - Generic LYRICA - BRAND STEP THERAPY NEURONTIN ORAL SOLUTION - BRAND oxcarbazepine suspension - Generic oxcarbazepine tablet - Generic PEGANONE - BRAND phenytoin sodium 100mg extended release - Generic phenytoin sodium 200mg & 300mg extended release - Generic phenytoin sodium intravenous solution Generic phenytoin suspension - Generic primidone tablet - Generic SABRIL - BRAND PRIOR AUTHORIZATION TEGRETOL XR 100MG - BRAND topiramate sprinkle - Generic topiramate tablet - Generic valproate sodium intravenous solution Generic valproate sodium oral syrup - Generic valproic acid oral capsule - Generic VIMPAT INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION VIMPAT ORAL - BRAND PRIOR AUTHORIZATION zonisamide - Generic ANTIDIABETIC AGENTS acarbose - Generic ACTOPLUS MET - BRAND STEP THERAPY ACTOS - BRAND STEP THERAPY BYETTA INJECTION - BRAND STEP THERAPY DUETACT - BRAND STEP THERAPY glimepiride - Generic glipizide extended release - Generic glipizide regular release - Generic glyburide / metformin - Generic glyburide - Generic

- Generally available through Mail Order Pharmacy 1313 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

glyburide micronized - Generic GLYSET - BRAND HUMULIN 50/50 - BRAND HUMULIN R U-500 (VIAL) - BRAND JANUMET - BRAND STEP THERAPY JANUVIA - BRAND STEP THERAPY LANTUS - BRAND LEVEMIR - BRAND metformin extended release - Generic metformin regular release - Generic nateglinide - Generic NOVOLIN 70/30 - BRAND NOVOLIN N - BRAND NOVOLIN R - BRAND NOVOLOG - BRAND NOVOLOG MIX - BRAND PRANDIN - BRAND SYMLIN INJECTION - BRAND PRIOR AUTHORIZATION VICTOZA - BRAND PRIOR AUTHORIZATION ANTIDIARRHEA AGENTS diphenoxylate / atropine liquid & tablet - Generic loperamide 2mg capsule - Generic ANTIEMETICS (DRUGS FOR NAUSEA & VOMITING) dronabinol oral - BvD Generic Prior Authorization EMEND - BVD BRAND PRIOR AUTHORIZATION granisetron oral solution & tablet - BvD Generic Prior Authorization granisol oral solution - BvD Generic Prior Authorization metoclopramide oral - Generic ondansetron injection BvD Generic Prior Authorization ondansetron oral dissolve & regular tablet - BvD Generic Prior Authorization ondansetron oral solution - BvD Generic Prior Authorization prochlorperazine edisylate injection Generic prochlorperazine oral - BvD Generic Prior Authorization prochlorperazine rectal suppository - Generic promethazine injection Generic promethazine rectal suppository - Generic promethazine syrup - Generic promethazine tablet - BvD Generic Prior Authorization TRANSDERM SCOP - BRAND PRIOR AUTHORIZATION trimethobenzamide 300mg capsule - BvD Generic Prior Authorization ANTIFUNGAL (SYSTEMIC) amphotericin b injection BvD Generic Prior Authorization ANCOBON - BRAND PRIOR AUTHORIZATION CANCIDAS INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT

1414 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ERAXIS INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION fluconazole intravenous solution Generic Prior Authorization fluconazole oral - Generic GRIFULVIN V 500MG TABLET - BRAND griseofulvin suspension - Generic GRIS-PEG - BRAND itraconazole capsule - Generic Prior Authorization ketoconazole oral - Generic NOXAFIL SPECIALTY 30 DAY SUPPLY LIMIT nystatin oral - Generic SPORANOX SOLUTION - BRAND PRIOR AUTHORIZATION terbinafine oral - Generic VFEND ORAL SPECIALTY 30 DAY SUPPLY LIMIT ANTIGLAUCOMA AGENTS acetazolamide injection Generic Prior Authorization acetazolamide oral sustained release capsule - Generic acetazolamide oral tablet - Generic ALPHAGAN-P OPHTHALMIC - BRAND ALPHAGAN-P OPHTHALMIC - BRAND AZOPT OPHTHALMIC - BRAND betaxolol ophthalmic - Generic BETIMOL OPHTHALMIC - BRAND BETOPTIC-S OPHTHALMIC - BRAND brimonidine 0.2% ophthalmic - Generic carteolol ophthalmic - Generic COMBIGAN OPHTHALMIC - BRAND dorzolamide ophthalmic - Generic dorzolamide/timolol ophthalmic - Generic ISTALOL OPHTHALMIC - BRAND levobunolol ophthalmic - Generic LUMIGAN OPHTHALMIC - BRAND methazolamide oral - Generic PHOSPHOLINE IODIDE OPHTHALMIC - BRAND PILOPINE HS OPHTHALMIC GEL - BRAND timolol maleate ophthalmic gel forming solution - Generic timolol maleate ophthalmic solution - Generic TRAVATAN OPHTHALMIC - BRAND TRAVATAN Z OPHTHALMIC - BRAND ANTIHEMORRHAGIC AGENTS CYKLOKAPRON INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION ANTIHYPOGLYCEMIC AGENTS GLUCAGEN INJECTION - BRAND GLUCAGON INJECTION - BRAND

- Generally available through Mail Order Pharmacy 1515 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

ANTI-INFECTIVES (EENT) - (EARS, EYES, NOSE & THROAT) acetic acid otic Generic AZASITE OPHTHALMIC BRAND bacitracin ophthalmic Generic BLEPHAMIDE OPHTHALMIC BRAND BLEPHAMIDE S.O.P. OPHTHALMIC BRAND chlorhexidine gluconate 0.12% oral solution Generic CILOXAN OPHTHALMIC OINTMENT BRAND CIPRO HC OTIC BRAND CIPRODEX OTIC BRAND ciprofloxacin ophthalmic solution Generic dexamethasone/polymyxin b/neomycin ophthalmic Generic doxycycline hyclate 20mg - Generic erythromycin ophthalmic ointment Generic gentamicin ophthalmic Generic hydrocortisone/polymyxin b/neomycin otic Generic IQUIX OPHTHALMIC BRAND NATACYN OPHTHALMIC BRAND ofloxacin ophthalmic Generic ofloxacin otic Generic polymyxin b/bacitracin ophthalmic Generic polymyxin b/bacitracin/neomycin ophthalmic Generic polymyxin b/gramicidin/neomycin ophthalmic Generic polymyxin b/trimethoprim ophthalmic Generic prednisolone/sulfacetamide ophthalmic drops Generic sulfacetamide ophthalmic drops Generic TOBRADEX OPHTHALMIC OINTMENT BRAND tobramycin ophthalmic solution Generic tobramycin/dexamethasone ophthalmic drops Generic TOBREX OPHTHALMIC OINTMENT BRAND trifluridine ophthalmic Generic VIGAMOX OPHTHALMIC BRAND ZYLET OPHTHALMIC BRAND ZYMAR OPHTHALMIC BRAND ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) alcohol swabs - Generic ALTABAX BRAND STEP THERAPY BACTROBAN CREAM BRAND ciclopirox 0.77% cream, gel & suspension Generic ciclopirox 8% nail lacquer - Generic CLEOCIN VAGINAL SUPPOSITORY BRAND clindamycin 1% topical gel, lotion, solution, swab - Generic clindamycin 2% vaginal cream Generic CLINDESSE VAGINAL CREAM BRAND clotrimazole troche - Generic econazole topical Generic

1616 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

erythromycin 2% topical gel, solution, swab - Generic EURAX BRAND EXELDERM BRAND gentamicin topical Generic ketoconazole 2% cream & shampoo Generic malathion topical lotion - Generic METROGEL 1% TOPICAL GEL & KIT - BRAND metronidazole 0.75% cream, gel, lotion - Generic metronidazole vaginal gel Generic mupirocin ointment Generic NAFTIN CREAM & GEL - BRAND NORITATE - BRAND nystatin topical cream, ointment, powder - Generic permethrin 5% cream Generic selenium sulfide 2.5% topical - Generic silver sulfadiazine topical Generic sulfacetamide sodium 10% topical - Generic terconazole vaginal Generic VEREGEN BRAND PRIOR AUTHORIZATION ZOVIRAX TOPICAL BRAND ANTI-INFLAMMATORY AGENTS (EENT) - (EARS, EYES, NOSE & THROAT) ACULAR PF OPHTHALMIC BRAND ALREX OPHTHALMIC BRAND BLEPHAMIDE OPHTHALMIC BRAND BLEPHAMIDE S.O.P. OPHTHALMIC BRAND CIPRO HC OTIC BRAND CIPRODEX OTIC BRAND cromolyn sodium ophthalmic - Generic DERMOTIC OTIC BRAND dexamethasone/polymyxin b/neomycin ophthalmic Generic diclofenac sodium ophthalmic Generic flunisolide nasal inhalant - Generic fluorometholone 0.1% ophthalmic Generic fluticasone nasal inhalant - Generic FML S.O.P. OPHTHALMIC BRAND hydrocortisone/polymyxin b/neomycin otic Generic ketorolac tromethamine 0.4% & 0.5% ophthalmic - Generic LOTEMAX OPHTHALMIC BRAND NASONEX NASAL INHALANT - BRAND NEVANAC OPHTHALMIC BRAND PRED MILD OPTHALMIC BRAND prednisolone acetate 1% ophthalmic Generic prednisolone sodium phosphate 1% ophthalmic Generic prednisolone/sulfacetamide ophthalmic drops Generic RESTASIS OPHTHALMIC - BRAND

- Generally available through Mail Order Pharmacy 1717 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

TOBRADEX OPHTHALMIC OINTMENT BRAND tobramycin/dexamethasone ophthalmic drops Generic VERAMYST NASAL INHALANT - BRAND XIBROM OPHTHALMIC BRAND ZYLET OPHTHALMIC BRAND ANTI-INFLAMMATORY AGENTS (GI DRUGS) - (GASTROINTESTINAL) ASACOL - BRAND ASACOL HD - BRAND balsalazide - Generic CANASA RECTAL SUPPOSITORY - BRAND mesalamine enema - Generic PENTASA - BRAND ANTI-INFLAMMATORY AGENTS (RESPIRATORY) cromolyn sodium nebulization solution - Generic cromolyn sodium ophthalmic - Generic SINGULAIR - BRAND STEP THERAPY ZYFLO CR - BRAND PRIOR AUTHORIZATION ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS) amcinonide - Generic betamethasone dipropionate - Generic betamethasone dipropionate, augmented - Generic betamethasone valerate - Generic CAPEX - BRAND clobetasol propionate cream, gel, ointment, solution - Generic clobetasol propionate foam - Generic CLOBEX SPRAY - BRAND CORDRAN TAPE - BRAND CORTIFOAM - BRAND DERMA-SMOOTHE/FS - BRAND desonide - Generic desoximetasone - Generic diflorasone - Generic fluocinolone acetonide - Generic fluocinonide - Generic HALOG CREAM & OINTMENT - BRAND hydrocortisone 2.5% rectal cream - Generic hydrocortisone 2.5% topical - Generic hydrocortisone rectal enema - Generic hydrocortisone valerate - Generic LUXIQ - BRAND mometasone topical - Generic OLUX-E - BRAND triamcinolone acetonide topical - Generic triamcinolone in orabase oral paste Generic

1818 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ANTILIPEMIC AGENTS (CHOLESTEROL LOWERING MEDICATIONS) cholestyramine light powder - Generic cholestyramine powder - Generic colestipol tablet - Generic fenofibrate 54mg, 160mg tablets - Generic Step Therapy fenofibrate 67mg, 134mg, 200mg capsules - Generic Step Therapy gemfibrozil - Generic LIPITOR - BRAND QUANTITY LIMIT lovastatin regular release - Generic LOVAZA - BRAND STEP THERAPY NIASPAN - BRAND pravastatin - Generic simvastatin - Generic TRICOR - BRAND STEP THERAPY VYTORIN - BRAND PRIOR AUTHORIZATION ZETIA - BRAND STEP THERAPY ANTIMANIC AGENTS lithium carbonate extended release - Generic lithium carbonate immediate release - Generic lithium citrate - Generic ANTIMIGRAINE AGENTS dihydroergotamine injection Generic divalproex sodium 24 hour extended release - Generic ERGOMAR BRAND QUANTITY LIMIT ergotamine w/caffeine oral tablet Generic Quantity Limit INNOPRAN XL - BRAND STEP THERAPY MAXALT - BRAND QUANTITY LIMIT MAXALT MLT - BRAND QUANTITY LIMIT migergot rectal suppository Generic Quantity Limit MIGRANAL NASAL - BRAND propranolol immediate release - Generic propranolol sustained release - Generic Step Therapy RELPAX - BRAND QUANTITY LIMIT sumatriptan injection (prefilled syringe) - Generic Quantity Limit sumatriptan injection (vial) - Generic Quantity Limit sumatriptan tablet - Generic Quantity Limit ANTIMYCOBACTERIALS CAPASTAT INJECTION BRAND PRIOR AUTHORIZATION dapsone - Generic ethambutol - Generic isoniazid syrup - Generic isoniazid tablet - Generic MYCOBUTIN - BRAND PASER - BRAND PRIOR AUTHORIZATION PRIFTIN ORAL - BRAND

- Generally available through Mail Order Pharmacy 1919 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

pyrazinamide - Generic rifampin - Generic SEROMYCIN - BRAND PRIOR AUTHORIZATION TRECATOR - BRAND PRIOR AUTHORIZATION ANTINEOPLASTIC AGENTS (CANCER DRUGS) AFINITOR SPECIALTY 30 DAY SUPPLY LIMIT anastrozole - Generic ARIMIDEX - BRAND AROMASIN - BRAND ARZERRA BRAND PRIOR AUTHORIZATION bicalutamide - Generic bleomycin sulfate injection BvD Generic Prior Authorization CAMPATH INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT CEENU - BRAND cyclophosphamide oral - BvD Generic Prior Authorization EMCYT - BRAND FARESTON - BRAND FASLODEX INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT FEMARA - BRAND flutamide - Generic GLEEVEC SPECIALTY 30 DAY SUPPLY LIMIT HEXALEN SPECIALTY 30 DAY SUPPLY LIMIT hydroxyurea - Generic IRESSA SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT ISTODAX INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT LEUKERAN - BRAND leuprolide injection - Generic LUPRON DEPOT INJECTION BRAND PRIOR AUTHORIZATION LUPRON DEPOT-PED INJECTION BRAND PRIOR AUTHORIZATION LYSODREN - BRAND MATULANE SPECIALTY 30 DAY SUPPLY LIMIT MEGACE ES - BRAND megestrol acetate - Generic melphalan injection Generic Prior Authorization mercaptopurine - Generic methotrexate 25mg/ml injection - Generic methotrexate oral - Generic mitoxantrone hcl injection Generic Prior Authorization NEXAVAR SPECIALTY 30 DAY SUPPLY LIMIT, LIMITED PHARMACY ACCESS

2020 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

NILANDRON - BRAND ONTAK INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT oxaliplatin injection Generic Prior Authorization PROLEUKIN INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT RHEUMATREX - BRAND RITUXAN INTRAVENOUS SOLUTION BVD SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT SPRYCEL SPECIALTY 30 DAY SUPPLY LIMIT SUTENT SPECIALTY 30 DAY SUPPLY LIMIT tamoxifen citrate - Generic TARCEVA SPECIALTY 30 DAY SUPPLY LIMIT TARGRETIN ORAL SPECIALTY 30 DAY SUPPLY LIMIT TASIGNA SPECIALTY 30 DAY SUPPLY LIMIT THIOGUANINE - BRAND tretinoin oral Specialty 30 Day Supply Limit TRISENOX INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION TYKERB SPECIALTY 30 DAY SUPPLY LIMIT VELCADE INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT VIDAZA INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT VOTRIENT BRAND ZOLINZA SPECIALTY 30 DAY SUPPLY LIMIT ANTIPARKINSONIAN AGENTS amantadine - Generic APOKYN INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT AZILECT - BRAND benztropine - Generic bromocriptine - Generic cabergoline - Generic carbidopa/levodopa immediate release - Generic carbidopa/levodopa sustained release - Generic COMTAN - BRAND LODOSYN - BRAND MIRAPEX 0.75MG - BRAND pramipexole 0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg - Generic ropinirole - Generic selegiline - Generic STALEVO - BRAND trihexyphenidyl - Generic

- Generally available through Mail Order Pharmacy 2121 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

ANTIPROTOZOALS ALINIA - BRAND STEP THERAPY chloroquine phosphate - Generic DARAPRIM - BRAND FANSIDAR - BRAND hydroxychloroquine - Generic MALARONE - BRAND mefloquine - Generic MEPRON - BRAND metronidazole regular release oral tablet - Generic NEUTREXIN INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT paromomycin oral - Generic ANTIPRURITICS AND LOCAL ANESTHETICS EMLA WITH TEGADERM BRAND QUANTITY LIMIT lidocaine / prilocaine topical cream Generic Quantity Limit lidocaine 5% ointment (prescription only) Generic LIDODERM PATCH - BRAND STEP THERAPY ZONALON CREAM BRAND ANTITHROMBOTIC AGENTS anagrelide - Generic ARIXTRA INJECTION BRAND cilostazol - Generic EFFIENT - BRAND PRIOR AUTHORIZATION FRAGMIN INJECTION BRAND heparin injection (excluding heparin flush) Generic jantoven - Generic LOVENOX INJECTION BRAND PLAVIX - BRAND warfarin oral - Generic ANTIULCER AGENTS AND ACID SUPPRESSANTS CARAFATE SUSPENSION - BRAND cimetidine solution & tablet - Generic famotidine swallow tablet - Generic lansoprazole capsule - Generic Step Therapy misoprostol - Generic omeprazole 10mg - Generic Quantity Limit omeprazole 20mg - Generic PEPCID SUSPENSION - BRAND PROTONIX INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION ranitidine syrup & tablet - Generic sucralfate tablet - Generic

2222 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ANTIVIRALS (SYSTEMIC) acyclovir - Generic amantadine - Generic APTIVUS - BRAND ATRIPLA - BRAND BARACLUDE - BRAND COMBIVIR - BRAND CRIXIVAN - BRAND didanosine delayed release - Generic EMTRIVA - BRAND EPIVIR - BRAND EPIVIR HBV - BRAND EPZICOM - BRAND foscarnet intravenous solution BvD Generic Prior Authorization FUZEON INJECTION SPECIALTY 30 DAY SUPPLY LIMIT ganciclovir - Generic HEPSERA SPECIALTY 30 DAY SUPPLY LIMIT INFERGEN INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT INTELENCE - BRAND INTRON-A INJECTION - BRAND INVIRASE - BRAND ISENTRESS - BRAND KALETRA - BRAND LEXIVA - BRAND NORVIR - BRAND PEGASYS INJECTION SPECIALTY 30 DAY SUPPLY LIMIT PEG-INTRON INJECTION SPECIALTY 30 DAY SUPPLY LIMIT PREZISTA - BRAND REBETOL SOLUTION SPECIALTY 30 DAY SUPPLY LIMIT RELENZA BRAND RESCRIPTOR - BRAND RETROVIR INTRAVENOUS SOLUTION BRAND REYATAZ - BRAND ribavirin capsule - Generic ribavirin dosepak Specialty 30 Day Supply Limit ribavirin tablet - Generic rimantadine tablet - Generic SELZENTRY - BRAND stavudine capsule & oral solution - Generic SUSTIVA - BRAND TAMIFLU BRAND TRIZIVIR - BRAND TRUVADA - BRAND

- Generally available through Mail Order Pharmacy 2323 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

TYZEKA - BRAND valacyclovir oral - Generic VALCYTE SPECIALTY 30 DAY SUPPLY LIMIT VIDEX POWDER FOR SOLUTION - BRAND VIRACEPT - BRAND VIRAMUNE - BRAND VIREAD - BRAND ZIAGEN - BRAND zidovudine oral - Generic ANXIOLYTICS, SEDATIVES AND HYPNOTICS AMBIEN CR - BRAND STEP THERAPY buspirone - Generic hydroxyzine hcl - Generic hydroxyzine pamoate capsule - Generic zolpidem regular release - Generic AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX - BRAND NICOTROL NS NASAL SOLUTION - BRAND NICOTROL ORAL INHALER - BRAND BETA-ADRENERGIC BLOCKING AGENTS atenolol - Generic atenolol/chlorthalidone - Generic bisoprolol - Generic bisoprolol/hydrochlorothiazide - Generic carvedilol - Generic COREG CR - BRAND STEP THERAPY INNOPRAN XL - BRAND STEP THERAPY labetalol - Generic metoprolol succinate sustained release - Generic metoprolol tartrate - Generic nadolol - Generic propranolol immediate release - Generic propranolol oral solution - Generic propranolol sustained release - Generic Step Therapy sotalol - Generic sotalol AF - Generic CALCIUM-CHANNEL BLOCKING AGENTS amlodipine - Generic amlodipine/benazepril 2.5-10mg, 5-10mg, 5-20mg, 10-20mg - Generic CARDIZEM CD 360MG - BRAND diltiazem extended release - 24 hour - Generic diltiazem immediate release - Generic diltiazem sustained release - 12 hour - Generic LOTREL 5-40MG & 10-40MG - BRAND nifedipine sustained release - Generic

2424 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

nimodipine - Generic verapamil extended release - Generic verapamil immediate release - Generic verapamil sustained release - Generic CALORIC AGENTS dextrose in sodium chloride 2.5%-0.45%, 5%-0.45%, 5%-0.9% and 10%-0.45% intravenous solution Generic dextrose in water 5% and 10% intravenous solution Generic INTRALIPID 20% & 30% INTRAVENOUS SOLUTION BRAND RENAMIN INTRAVENOUS SOLUTION BRAND CARDIAC DRUGS amiodarone 200mg & 400mg - Generic DIGOXIN ORAL SOLUTION - BRAND digoxin tablet - Generic disopyramide immediate release - Generic flecainide - Generic LANOXIN - BRAND mexiletine - Generic MULTAQ - BRAND PRIOR AUTHORIZATION NORPACE CR - BRAND pacerone - Generic propafenone immediate release - Generic quinidine gluconate - Generic quinidine sulfate extended release - Generic quinidine sulfate immediate release - Generic RANEXA - BRAND PRIOR AUTHORIZATION TIKOSYN - BRAND CATHARTICS AND LAXATIVES AMITIZA - BRAND PRIOR AUTHORIZATION gavilyte-g (GOLYTELY equivalent) Generic gavilyte-n (NULYTELY equivalent) - Generic MOVIPREP BRAND polyethylene glycol oral powder 3350 (MIRALAX equivalent) - Generic polyethylene glycol-electrolyte (COLYTE equivalent) Generic trilyte (NULYTELY equivalent) Generic CELL STIMULANTS AND PROLIFERANTS KEPIVANCE INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT RETIN-A MICRO - BRAND tretinoin topical - Generic

- Generally available through Mail Order Pharmacy 2525 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

CENTRAL NERVOUS SYSTEM AGENTS, MISC. CAMPRAL - BRAND LODOSYN - BRAND NAMENDA - BRAND PRIOR AUTHORIZATION RILUTEK SPECIALTY 30 DAY SUPPLY LIMIT STRATTERA - BRAND XENAZINE SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT, LIMITED PHARMACY ACCESS XYREM SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT, LIMITED PHARMACY ACCESS CHOLELITHOLYTIC AGENTS ursodiol capsule - Generic ursodiol tablet - Generic CONTRACEPTIVES apri (DESOGEN, ORTHO-CEPT equivalent) - Generic aranelle (TRI-NORINYL equivalent) - Generic aviane (ALESSE equivalent) - Generic camila (NOR-QD, ORTHO MICRONOR equivalent) - Generic cesia (CYCLESSA equivalent) - Generic cryselle (LO/OVRAL equivalent) - Generic enpresse (TRIPHASIL equivalent) - Generic errin (NOR-QD, ORTHO MICRONOR equivalent) - Generic gianvi (YAZ equivalent) - Generic jolivette (NOR-QD, ORTHO MICRONOR equivalent) - Generic junel (LOESTRIN equivalent) - Generic junel fe (LOESTRIN FE equivalent) - Generic kariva (MIRCETTE equivalent) - Generic kelnor (DEMULEN 1+35 equivalent) - Generic leena (TRI-NORINYL equivalent) - Generic lessina (ALESSE equivalent) - Generic levora (NORDETTE equivalent) - Generic low-ogestrel (LO/OVRAL equivalent) - Generic lutera (ALESSE equivalent) - Generic LYBREL - BRAND microgestin (LOESTRIN equivalent) - Generic microgestin fe (LOESTRIN FE equivalent) - Generic mononessa (ORTHO-CYCLEN equivalent) - Generic necon 0.5/35 (BREVICON, MODICON equivalent) - Generic necon 1/35, 1/50 (NORINYL 1/35 & 1/50, ORTHO-NOVUM 1/35 & 1/50 equivalents) - Generic necon 10/11 - Generic necon 7/7/7 (ORTHO-NOVUM 7/7/7 equivalent) - Generic next choice (purchase over-the-counter for age 18 and older AND covered for all patient age groups who are covered under a prepaid medical assistance program) Generic

2626 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

nora-be (NOR-QD, ORTHO MICRONOR equivalent) - Generic nortrel 0.5/35 (BREVICON, MODICON equivalent) - Generic nortrel 1/35 (NORINYL 1/35, ORTHO-NOVUM 1/35 equivalent) - Generic nortrel 7/7/7 (ORTHO-NOVUM 7/7/7 equivalent) - Generic NUVARING - BRAND ocella (YASMIN equivalent) - Generic ogestrel - Generic ORTHO EVRA PATCH - BRAND portia (NORDETTE equivalent) - Generic previfem (ORTHO-CYCLEN equivalent) - Generic quasense (SEASONALE equivalent) - Generic reclipsen (DESOGEN, ORTHO-CEPT equivalent) - Generic solia (DESOGEN, ORTHO-CEPT equivalent) - Generic sprintec (ORTHO-CYCLEN equivalent) - Generic sronyx (ALESSE equivalent) - Generic trinessa (ORTHO TRI-CYCLEN equivalent) - Generic tri-previfem (ORTHO TRI-CYCLEN equivalent) - Generic tri-sprintec (ORTHO TRI-CYCLEN equivalent) - Generic trivora (TRIPHASIL equivalent) - Generic velivet (CYCLESSA equivalent) - Generic YAZ - BRAND zovia (DEMULEN equivalent) - Generic DEPIGMENTING AND PIGMENTING AGENTS OXSORALEN LOTION - BRAND OXSORALEN ULTRA ORAL - BRAND DEVICES INSULIN PEN DEVICE - BRAND insulin pen needles - Generic INSULIN SAFETY SYRINGES - BRAND insulin syringes - Generic DIGESTANTS CREON ORAL - BRAND DIURETICS acetazolamide injection Generic Prior Authorization acetazolamide oral sustained release capsule - Generic acetazolamide oral tablet - Generic ALDACTAZIDE 50MG/50MG - BRAND amiloride - Generic amiloride/hydrochlorothiazide - Generic atenolol/chlorthalidone - Generic benazepril/hydrochlorothiazide - Generic bumetanide - Generic chlorothiazide tablet - Generic chlorthalidone - Generic

- Generally available through Mail Order Pharmacy 2727 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

DIURIL SUSPENSION - BRAND EDECRIN - BRAND furosemide injection Generic furosemide oral solution - Generic furosemide oral tablet - Generic hydrochlorothiazide - Generic indapamide - Generic metolazone - Generic spironolactone/hydrochlorothiazide 25mg/25mg - Generic THALITONE 15MG - BRAND torsemide - Generic triamterene/hydrochlorothiazide capsule - Generic triamterene/hydrochlorothiazide tablet - Generic EENT DRUGS, MISCELLANEOUS (EARS, EYES, NOSE & THROAT) carteolol ophthalmic - Generic ipratropium nasal spray - Generic LACRISERT - BRAND EMOLLIENTS, DEMULCENTS, AND PROTECTANTS ammonium lactate 12% cream & lotion (prescription product only) - Generic ENZYMES ADAGEN INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT ALDURAZYME INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT CEREDASE INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT CEREZYME INTRAVENOUS SOLUTION SPECIALTY 30 DAY SUPPLY LIMIT ELAPRASE INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT ELITEK INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT FABRAZYME INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT NAGLAZYME INTRAVENOUS SOLUTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT PROLASTIN INJECTION BRAND PRIOR AUTHORIZATION PULMOZYME NEBULIZATION SOLUTION BRAND SUCRAID ORAL SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT ESTROGENS AND ANTIESTROGENS CLIMARA PRO - BRAND COMBIPATCH - BRAND ESTRACE VAGINAL - BRAND

2828 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ESTRADERM - BRAND estradiol oral - Generic estradiol weekly patch (CLIMARA equivalent) - Generic ESTRING - BRAND estropipate oral - Generic EVISTA - BRAND FEMHRT - BRAND FEMHRT LOW-DOSE - BRAND PREMARIN ORAL - BRAND PREMARIN VAGINAL - BRAND PREMPHASE - BRAND PREMPRO - BRAND VAGIFEM - BRAND VIVELLE DOT - BRAND FIRST GENERATION ANTIHISTAMINES clemastine syrup & tablet (prescription only) - Generic cyproheptadine - Generic diphenydramine 25mg capsule (prescription only) - Generic diphenydramine injection Generic promethazine injection Generic promethazine rectal suppository - Generic promethazine syrup - Generic promethazine tablet - BvD Generic Prior Authorization GENITOURINARY SMOOTH MUSCLE RELAXANTS DETROL - BRAND DETROL LA - BRAND oxybutynin immediate release - Generic oxybutynin sustained release - Generic SANCTURA - BRAND SANCTURA XR - BRAND GI DRUGS, MISCELLANEOUS (GASTROINTESTINAL) LOTRONEX BRAND PRIOR AUTHORIZATION octreotide injection Generic RELISTOR BRAND PRIOR AUTHORIZATION GOLD COMPOUNDS RIDAURA - BRAND GONADOTROPINS chorionic gonadotropin injection Generic Prior Authorization SYNAREL BRAND PRIOR AUTHORIZATION HEAVY METAL ANTAGONISTS CHEMET BRAND CUPRIMINE - BRAND

- Generally available through Mail Order Pharmacy 2929 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

DEPEN - BRAND EXJADE SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT SYPRINE - BRAND HEMATOPOIETIC AGENTS ARANESP INJECTION BVD BRAND PRIOR AUTHORIZATION LEUKINE INJECTION SPECIALTY 30 DAY SUPPLY LIMIT NEULASTA INJECTION SPECIALTY 30 DAY SUPPLY LIMIT NEUMEGA INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT NEUPOGEN INJECTION SPECIALTY 30 DAY SUPPLY LIMIT PROCRIT INJECTION BVD BRAND PRIOR AUTHORIZATION HEMORRHEOLOGIC AGENTS pentoxifylline - Generic HYPOTENSIVE AGENTS clonidine oral - Generic clonidine patch - Generic guanfacine - Generic hydralazine - Generic methyldopa - Generic minoxidil oral - Generic reserpine - Generic ION-REMOVING AGENTS calcium acetate capsule - Generic eliphos - Generic RENAGEL - BRAND RENVELA - BRAND sodium polystyrene sulfonate oral - Generic IRRIGATING SOLUTIONS sodium chloride irrigating solution - Generic water for irrigation - Generic KERATOPLASTIC AGENTS VECTICAL - BRAND PRIOR AUTHORIZATION LOCAL ANESTHETICS (EENT) - (EARS, EYES, NOSE & THROAT) lidocaine 2% jel (prescription only) - Generic lidocaine viscous oral - Generic LOCAL ANESTHETICS (PARENTERAL) lidocaine injection Generic MISCELLANEOUS THERAPEUTIC AGENTS ACTIMMUNE INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT

3030 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

ACTONEL - BRAND STEP THERAPY ACTONEL WITH CALCIUM - BRAND STEP THERAPY alendronate tablet - Generic allopurinol - Generic AMPYRA SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT ANTABUSE - BRAND ATGAM INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT AVODART - BRAND AVONEX INJECTION SPECIALTY STEP THERAPY, 30 DAY SUPPLY LIMIT AZASAN - BVD BRAND PRIOR AUTHORIZATION azathioprine 50mg - BvD Generic Prior Authorization azathioprine injection BvD Generic Prior Authorization BETASERON INJECTION SPECIALTY STEP THERAPY, 30 DAY SUPPLY LIMIT BONIVA INTRAVENOUS SOLUTION BRAND PRIOR AUTHORIZATION bupropion sustained release - 12 hour (smoking deterrent) - Generic CELLCEPT INTRAVENOUS SOLUTION BVD BRAND PRIOR AUTHORIZATION CELLCEPT ORAL SUSPENSION BVD SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT COLCRYS - BRAND COPAXONE INJECTION SPECIALTY 30 DAY SUPPLY LIMIT cyclosporine intravenous solution BvD Generic Prior Authorization cyclosporine modified oral - BvD Generic Prior Authorization cyclosporine oral - BvD Generic Prior Authorization CYSTADANE POWDER FOR ORAL SOLUTION BRAND PRIOR AUTHORIZATION CYSTAGON ORAL BRAND PRIOR AUTHORIZATION ELMIRON - BRAND ENBREL INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT etidronate disodium - Generic finasteride - Generic fluoride chew tablet, cream, gel, rinse - Generic fomepizole intravenous solution Specialty Prior Authorization, 30 Day Supply Limit FOSAMAX ORAL SOLUTION - BRAND STEP THERAPY FOSAMAX PLUS D - BRAND STEP THERAPY gengraf - BvD Generic Prior Authorization HUMIRA INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT KINERET INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT KUVAN SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT

- Generally available through Mail Order Pharmacy 3131 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

leflunomide - Generic leucovorin calcium injection Generic leucovorin calcium oral - Generic levocarnitine (prescription only) - Generic MESNEX TABLET - BRAND methotrexate 25mg/ml injection - Generic methotrexate oral - Generic mycophenolate mofetil - BvD Generic Prior Authorization NEORAL - BVD BRAND PRIOR AUTHORIZATION octreotide injection Generic ORFADIN ORAL SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT PROGRAF INTRAVENOUS SOLUTION BVD BRAND PRIOR AUTHORIZATION PROMACTA SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT RAPAMUNE - BVD BRAND PRIOR AUTHORIZATION REBIF INJECTION SPECIALTY 30 DAY SUPPLY LIMIT REMICADE INJECTION BVD SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT REVLIMID SPECIALTY 30 DAY SUPPLY LIMIT, LIMITED PHARMACY ACCESS RHEUMATREX - BRAND SANDIMMUNE INTRAVENOUS SOLUTION BVD BRAND PRIOR AUTHORIZATION SANDIMMUNE ORAL - BVD BRAND PRIOR AUTHORIZATION SENSIPAR - BRAND tacrolimus oral - BvD Generic Prior Authorization tamsulosin - Generic THALOMID SPECIALTY 30 DAY SUPPLY LIMIT THIOLA - BRAND ULORIC - BRAND PRIOR AUTHORIZATION UROXATRAL - BRAND ZAVESCA ORAL SPECIALTY 30 DAY SUPPLY LIMIT MULTIVITAMIN PREPARATIONS prenatal vitamins with folic acid (generics only) - Generic MYDRIATICS dipivefrin ophthalmic Generic OPIATE ANTAGONISTS naloxone injection Generic naltrexone oral - Generic OXYTOCICS METHERGINE BRAND

3232 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) ARICEPT - BRAND ARICEPT ODT - BRAND bethanechol - Generic EVOXAC - BRAND galantamine extended release - Generic Prior Authorization galantamine regular release tablet & oral solution - Generic Prior Authorization guanidine hcl - Generic MESTINON SYRUP - BRAND MESTINON TIMESPAN - BRAND pilocarpine oral - Generic pyridostigmine tablet - Generic PARATHYROID AGENTS calcitonin salmon nasal - Generic FORTEO INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT fortical nasal - Generic PHARMACEUTICAL AIDS alcohol swabs - Generic gauze - Generic PITUITARY AGENTS bromocriptine - Generic cabergoline - Generic desmopressin nasal - Generic Prior Authorization desmopressin oral tablet - Generic Prior Authorization LUPRON DEPOT-PED INJECTION BRAND PRIOR AUTHORIZATION NORDITROPIN INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT OMNITROPE INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT SEROSTIM INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT PROGESTINS DEPO-PROVERA 400MG/ML INJECTION BRAND PRIOR AUTHORIZATION medroxyprogesterone oral - Generic norethindrone oral - Generic PROMETRIUM - BRAND PROKINETIC AGENTS metoclopramide oral - Generic PSYCHOTHERAPEUTIC AGENTS ABILIFY - BRAND ABILIFY DISCMELT - BRAND PRIOR AUTHORIZATION ABILIFY INJECTION BRAND

- Generally available through Mail Order Pharmacy 3333 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes

amitriptyline - Generic amoxapine - Generic bupropion extended release - 24 hour - Generic bupropion immediate release - Generic bupropion sustained release - 12 hour (smoking deterrent) - Generic bupropion sustained release - 12 hour - Generic chlorpromazine injection Generic chlorpromazine oral - Generic citalopram - Generic clomipramine - Generic clozapine tablet - Generic CYMBALTA - BRAND STEP THERAPY desipramine - Generic doxepin - Generic EMSAM - BRAND PRIOR AUTHORIZATION FANAPT - BRAND PRIOR AUTHORIZATION FAZACLO - BRAND PRIOR AUTHORIZATION fluoxetine 10mg & 20mg capsule, 10mg tablet, oral solution - Generic fluphenazine deconate injection Generic fluphenazine hcl injection Generic fluphenazine oral - Generic fluvoxamine regular release - Generic GEODON INJECTION BRAND GEODON ORAL - BRAND haloperidol decanoate injection Generic haloperidol lactate injection Generic haloperidol lactate oral concentrate - Generic haloperidol oral - Generic imipramine hcl - Generic INVEGA ORAL - BRAND PRIOR AUTHORIZATION INVEGA SUSTENNA BRAND PRIOR AUTHORIZATION LEXAPRO - BRAND STEP THERAPY loxapine - Generic maprotiline - Generic MARPLAN - BRAND mirtazapine dissolve tablet - Generic Prior Authorization mirtazapine regular tablet - Generic MOBAN - BRAND NARDIL - BRAND nefazodone - Generic Prior Authorization nortriptyline - Generic ORAP - BRAND PRIOR AUTHORIZATION paroxetine hcl regular release tablet - Generic

3434 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes

paroxetine hcl suspension - Generic perphenazine oral - Generic PRISTIQ - BRAND PRIOR AUTHORIZATION prochlorperazine edisylate injection Generic prochlorperazine oral - BvD Generic Prior Authorization prochlorperazine rectal suppository - Generic protriptyline - Generic RISPERDAL CONSTA INJECTION BRAND risperidone dissolve tablet - Generic Prior Authorization risperidone tablet & oral solution - Generic SAPHRIS - BRAND PRIOR AUTHORIZATION SAVELLA - BRAND STEP THERAPY SEROQUEL - BRAND SEROQUEL XR - BRAND sertraline - Generic SURMONTIL - BRAND thioridazine - Generic thiothixene - Generic tranylcypromine - Generic trazodone - Generic trifluoperazine oral - Generic trimipramine 25mg & 50mg - Generic venlafaxine extended release tablet - Generic Step Therapy venlafaxine regular release - Generic Step Therapy ZYPREXA INJECTION BRAND ZYPREXA ORAL - BRAND ZYPREXA ZYDIS - BRAND PRIOR AUTHORIZATION RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE 50MG/50MG - BRAND amlodipine/benazepril 2.5-10mg, 5-10mg, 5-20mg, 10-20mg - Generic AVALIDE - BRAND STEP THERAPY, QUANTITY LIMIT AVAPRO - BRAND STEP THERAPY, QUANTITY LIMIT benazepril - Generic benazepril/hydrochlorothiazide - Generic captopril - Generic enalapril - Generic eplerenone - Generic Prior Authorization lisinopril - Generic lisinopril/hydrochlorothiazide - Generic

- Generally available through Mail Order Pharmacy 3535 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes LOTREL 5-40MG & 10-40MG - BRAND MICARDIS - BRAND STEP THERAPY, QUANTITY LIMIT MICARDIS HCT - BRAND STEP THERAPY, QUANTITY LIMIT ramipril capsule - Generic spironolactone - Generic spironolactone/hydrochlorothiazide 25mg/25mg - Generic TEKTURNA - BRAND PRIOR AUTHORIZATION TEKTURNA HCT - BRAND PRIOR AUTHORIZATION REPLACEMENT PREPARATIONS dextrose 5% in lactated ringers intravenous solution Generic ISOLYTE-S INTRAVENOUS SOLUTION BRAND klor-con, klor-con m - Generic LACTATED RINGERS INTRAVENOUS SOLUTION BRAND potassium chloride in dextrose 5% & sodium chloride 0.45% intravenous solution Generic potassium chloride intravenous solution Generic potassium chloride sustained release capsule & tablet - Generic sodium chloride intravenous solution Generic RESPIRATORY SMOOTH MUSCLE RELAXANTS aminophylline oral - Generic theophylline 12 hour sustained release - Generic theophylline 24 hour sustained release (UNIPHYL equivalent) - Generic RESPIRATORY TRACT AGENTS, MISCELLANEOUS acetylcysteine nebulization solution - BvD Generic Prior Authorization SECOND GENERATION ANTIHISTAMINES ALLEGRA SUSPENSION - BRAND cetirizine oral solution - Generic fexofenadine - Generic SERUMS GAMASTAN INJECTION BVD BRAND PRIOR AUTHORIZATION GAMMAGARD INTRAVENOUS SOLUTION BVD SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT SKELETAL MUSCLE RELAXANTS baclofen - Generic chlorzoxazone - Generic cyclobenzaprine - Generic dantrolene - Generic methocarbamol - Generic orphenadrine - Generic Prior Authorization tizanadine tablet only - Generic

36 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes SKIN AND MUCOUS MEMBRANE AGENTS, MISC. adapalene 0.1% cream & gel - Generic amnesteem - Generic AZELEX - BRAND calcipotriene solution - Generic CARAC - BRAND claravis - Generic CONDYLOX GEL - BRAND DIFFERIN CREAM, GEL & LOTION - BRAND DOVONEX CREAM - BRAND ELIDEL - BRAND FINACEA - BRAND FLUOROPLEX - BRAND fluorouracil 2% & 5% topical solution - Generic fluorouracil 5% cream - Generic imiquimod - Generic isotretinoin oral (amnesteem, claravis, sotret) - Generic PANRETIN TOPICAL - BRAND podofilox solution - Generic PROTOPIC - BRAND REGRANEX BRAND PRIOR AUTHORIZATION SANTYL - BRAND SOLARAZE - BRAND SORIATANE - BRAND SORIATANE CK - BRAND sotret - Generic TACLONEX - BRAND PRIOR AUTHORIZATION TARGRETIN TOPICAL SPECIALTY 30 DAY SUPPLY LIMIT TAZORAC - BRAND QUANTITY LIMIT SOMATOTROPIN AGONISTS AND ANTAGONISTS INCRELEX INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT SOMAVERT INJECTION SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS DIBENZYLINE - BRAND dihydroergotamine injection Generic ergoloid mesylates oral - Generic ERGOMAR BRAND QUANTITY LIMIT ergotamine w/caffeine oral tablet Generic Quantity Limit migergot rectal suppository Generic Quantity Limit MIGRANAL NASAL - BRAND

- Generally available through Mail Order Pharmacy 37 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS FOR ORAL INHALATION - BRAND ADVAIR HFA FOR ORAL INHALATION - BRAND albuterol immediate release syrup & tablet - Generic albuterol nebulization solution - Generic albuterol sustained release - Generic albuterol/ipratropium nebulization solution - Generic COMBIVENT ORAL INHALER - BRAND EPIPEN INJECTOR - BRAND EPIPEN-JR INJECTOR - BRAND MAXAIR AUTOHALER ORAL INHALER - BRAND midodrine - Generic PROAIR HFA ORAL INHALER - BRAND SEREVENT DISKUS FOR ORAL INHALATION - BRAND SYMBICORT FOR ORAL INHALATION - BRAND terbutaline oral - Generic TWINJECT INJECTOR - BRAND VENTOLIN HFA - BRAND THYROID AND ANTITHYROID AGENTS levothroid - Generic levothyroxine - Generic liothyronine oral - Generic methimazole - Generic propylthiouracil - Generic SYNTHROID - BRAND TOXOIDS ADACEL BRAND BOOSTRIX BRAND DAPTACEL BRAND DECAVAC BRAND DIPHTHERIA / TETANUS TOXOID (ADULT & PEDIATRIC) BRAND INFANRIX BRAND TETANUS TOXOID, ADSORBED BVD BRAND PRIOR AUTHORIZATION TRIHIBIT BRAND TRIPEDIA BRAND URICOSURIC AGENTS probenecid - Generic probenecid/colchicine - Generic

38 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category Drug Name Drug Tier Notes URINARY ANTI-INFECTIVES FURADANTIN - BRAND MACRODANTIN 25MG - BRAND nitrofurantoin macrocrystalline (MACRODANTIN equivalent) - Generic nitrofurantoin monohydrate macrocrystalline (MACROBID equivalent) - Generic trimethoprim - Generic VACCINES ACTHIB BRAND ATTENUVAX BRAND COMVAX BRAND ENGERIX-B BVD BRAND PRIOR AUTHORIZATION GARDASIL BRAND HAVIRX BRAND IMOVAX RABIES (H.D.C.V.) BVD BRAND PRIOR AUTHORIZATION IPOL BRAND JE-VAX BRAND MENACTRA BRAND MENOMUNE BRAND MERUVAX II BRAND M-M-R II BRAND PEDIARIX BRAND PEDVAX HIB BRAND PROQUAD BRAND RABAVERT BVD BRAND PRIOR AUTHORIZATION RECOMBIVAX-HB BVD BRAND PRIOR AUTHORIZATION ROTATEQ ORAL BRAND TWINRIX BRAND TYPHIM VI BRAND VAQTA BRAND VARIVAX BRAND VIVOTIF BERNA ORAL (TYPHOID VACCINE) BRAND YF-VAX BRAND ZOSTAVAX VACCINE (FDA-APPROVED AND COVERED ONLY FOR AGE 60 AND ABOVE) BRAND VASOCONSTRICTORS naphazoline hcl ophthalmic solution - Generic TYZINE NASAL SPRAY - BRAND

- Generally available through Mail Order Pharmacy 39 BvD = Drug could pay under Part B or Part D Alphabetical by Drug Category

Drug Name Drug Tier Notes VASODILATING AGENTS ADCIRCA SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT AGGRENOX - BRAND DILITRATE-SR 40MG - BRAND dipyridamole - Generic ISORDIL 40MG - BRAND isosorbide dinitrate sublingual & regular release tablet - Generic isosorbide dinitrate sustained release - Generic isosorbide mononitrate immediate release - Generic isosorbide mononitrate sustained release - Generic LETAIRIS SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT minitran patch - Generic NITRO-DUR 0.3MG & 0.8MG PATCH - BRAND nitroglycerin 0.1mg, 0.2mg, 0.4mg, 0.6mg patch - Generic NITROSTAT - BRAND REVATIO SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT TRACLEER SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT, LIMITED PHARMACY ACCESS VENTAVIS BVD SPECIALTY PRIOR AUTHORIZATION, 30 DAY SUPPLY LIMIT VITAMIN D calcitriol oral - Generic ZEMPLAR - BRAND PRIOR AUTHORIZATION

40 - Generally available through Mail Order Pharmacy BvD = Drug could pay under Part B or Part D Alphabetical Index

ABILIFY - ...... 33 ALTABAX ...... 16 ABILIFY DISCMELT - ...... 33 amantadine - ...... 21, 23 ABILIFY injection ...... 33 AMBIEN CR - ...... 24 acarbose - ...... 13 amcinonide - ...... 18 acetaminophen w/codeine 120-12mg/5ml elixir - . . . . .9 amikacin sulfate injection ...... 11 acetaminophen w/codeine 300mg-15mg, amiloride - ...... 27 300mg-30mg, 300-60mg tablet - ...... 9 amiloride/hydrochlorothiazide - ...... 27 acetazolamide injection ...... 15, 27 aminophylline oral - ...... 36 acetazolamide oral sustained release capsule - . . .15, 27 amiodarone 200mg & 400mg - ...... 25 acetazolamide oral tablet - ...... 15, 27 AMITIZA - ...... 25 acetic acid otic ...... 16 amitriptyline - ...... 34 acetylcysteine nebulization solution - BvD ...... 36 amlodipine - ...... 24 ACTHIB ...... 39 amlodipine/benazepril 2.5-10mg, 5-10mg, 5-20mg, ACTIMMUNE injection ...... 30 10-20mg - ...... 24, 35 ACTONEL - ...... 31 ammonium chloride intravenous solution ...... 8 ACTONEL WITH CALCIUM - ...... 31 ammonium lactate 12% cream & lotion (prescription ACTOPLUS MET - ...... 13 product only) - ...... 28 ACTOS - ...... 13 amnesteem - ...... 37 ACULAR PF ophthalmic ...... 17 amoxapine - ...... 34 acyclovir - ...... 23 amoxicillin / clavulanate potassium regular ADACEL ...... 38 release tablet - ...... 11 ADAGEN injection ...... 28 amoxicillin / clavulanate potassium suspension ...... 11 adapalene 0.1% cream & gel - ...... 37 amoxicillin capsule, chewable tablet, swallow tablet - 11 ADCIRCA ...... 40 amoxicillin suspension ...... 11 ADVAIR DISKUS for oral inhalation - ...... 8, 38 amphotericin b injection BvD ...... 14 ADVAIR HFA for oral inhalation - ...... 8, 38 ampicillin capsule - ...... 11 AFINITOR ...... 20 ampicillin injection ...... 11 AGGRENOX - ...... 40 ampicillin suspension ...... 11 ALAMAST ophthalmic - ...... 10 AMPYRA ...... 31 ALBENZA ...... 10 ANADROL-50 - ...... 10 albuterol immediate release syrup & tablet - ...... 38 anagrelide - ...... 22 albuterol nebulization solution - ...... 38 anastrozole - ...... 20 albuterol sustained release - ...... 38 ANCOBON - ...... 14 albuterol/ipratropium nebulization solution - ...... 38 ANDRODERM - ...... 10 alcohol swabs - ...... 16, 33 ANDROGEL - ...... 10 ALDACTAZIDE 50mg/50mg - ...... 27, 35 ANDROID - ...... 10 ALDURAZYME intravenous solution ...... 28 ANDROXY - ...... 10 alendronate tablet - ...... 31 ANTABUSE - ...... 31 ALINIA - ...... 22 APOKYN injection ...... 21 ALLEGRA SUSPENSION - ...... 36 apri (DESOGEN, ORTHO-CEPT equivalent) - ...... 26 allopurinol - ...... 31 APTIVUS - ...... 23 ALPHAGAN-P ophthalmic - ...... 15 aranelle (TRI-NORINYL equivalent) - ...... 26 ALREX ophthalmic ...... 17 ARANESP injection BvD ...... 30

- Generally available through Mail Order Pharmacy 41 BvD = Drug could pay under Part B or Part D Alphabetical Index

ARICEPT - ...... 33 benazepril/hydrochlorothiazide - ...... 27, 35 ARICEPT ODT - ...... 33 benztropine - ...... 21 ARIMIDEX - ...... 20 betamethasone dipropionate - ...... 18 ARIXTRA injection ...... 22 betamethasone dipropionate, augmented - ...... 18 AROMASIN - ...... 20 betamethasone valerate - ...... 18 ARZERRA ...... 20 BETASERON injection ...... 31 ASACOL - ...... 18 betaxolol ophthalmic - ...... 15 ASACOL HD - ...... 18 bethanechol - ...... 33 ASMANEX oral inhalant - ...... 8 BETIMOL ophthalmic - ...... 15 ASTELIN nasal spray - ...... 10 BETOPTIC-S ophthalmic - ...... 15 atenolol - ...... 24 bicalutamide - ...... 20 atenolol/chlorthalidone - ...... 24, 27 BILTRICIDE ...... 10 ATGAM injection ...... 31 bisoprolol - ...... 24 ATRIPLA - ...... 23 bisoprolol/hydrochlorothiazide - ...... 24 ATROVENT HFA oral inhaler - ...... 12 bleomycin sulfate injection BvD ...... 20 ATTENUVAX ...... 39 BLEPHAMIDE ophthalmic ...... 16-17 AUGMENTIN 125mg suspension ...... 11 BLEPHAMIDE S.O.P. ophthalmic ...... 16-17 AUGMENTIN 250mg chew tab - ...... 11 BONIVA intravenous solution ...... 31 AVALIDE - ...... 35 BOOSTRIX ...... 38 AVAPRO - ...... 35 brimonidine 0.2% ophthalmic - ...... 15 AVELOX - ...... 11 bromocriptine - ...... 21, 33 aviane (ALESSE equivalent) - ...... 26 budesonide 0.25mg & 0.5mg suspension for AVODART - ...... 31 inhalation - ...... 8 AVONEX injection ...... 31 bumetanide - ...... 27 AZASAN - BvD ...... 31 BUPHENYL oral ...... 8 AZASITE ophthalmic ...... 16 bupropion extended release - 24 hour - ...... 34 azathioprine 50mg - BvD ...... 31 bupropion immediate release - ...... 34 azathioprine injection BvD ...... 31 bupropion sustained release - 12 hour (smoking azelastine hcl ophthalmic - ...... 10 deterrent) - ...... 31, 34 azelastine nasal spray - ...... 10 bupropion sustained release - 12 hour - ...... 34 AZELEX - ...... 37 buspirone - ...... 24 AZILECT - ...... 21 butorphanol nasal spray ...... 9 azithromycin intravenous solution ...... 11 BYETTA injection - ...... 13 azithromycin suspension & packet ...... 11 cabergoline - ...... 21, 33 azithromycin tablet - ...... 11 calcipotriene solution - ...... 37 AZMACORT oral inhalant - ...... 8 calcitonin salmon nasal - ...... 33 AZOPT ophthalmic - ...... 15 calcitriol oral - ...... 40 bacitracin ophthalmic ...... 16 calcium acetate capsule - ...... 30 baclofen - ...... 36 camila (NOR-QD, ORTHO MICRONOR equivalent) - . . . .26 BACTROBAN cream ...... 16 CAMPATH injection ...... 20 balsalazide - ...... 18 CAMPRAL - ...... 26 BANZEL - ...... 12 CANASA rectal suppository - ...... 18 BARACLUDE - ...... 23 CANCIDAS intravenous solution ...... 14 benazepril - ...... 35 CAPASTAT injection ...... 19

Generally available through Mail Order Pharmacy 42 - BvD = Drug could pay under Part B or Part D Alphabetical Index

CAPEX - ...... 18 cholestyramine light powder - ...... 19 captopril - ...... 35 cholestyramine powder - ...... 19 CARAC - ...... 37 chorionic gonadotropin injection ...... 29 CARAFATE suspension - ...... 22 ciclopirox 0.77% cream, gel & suspension ...... 16 carbamazepine 200mg & 400mg extended ciclopirox 8% nail lacquer - ...... 16 release tablet - ...... 12 cilostazol - ...... 22 carbamazepine immediate release - ...... 12 CILOXAN ophthalmic ointment ...... 16 CARBATROL - ...... 12 cimetidine solution & tablet - ...... 22 carbidopa/levodopa immediate release - ...... 21 CIPRO HC otic ...... 16-17 carbidopa/levodopa sustained release - ...... 21 CIPRO suspension - ...... 11 CARDIZEM CD 360mg - ...... 24 CIPRODEX otic ...... 16-17 carteolol ophthalmic - ...... 15, 28 ciprofloxacin ophthalmic solution ...... 16 carvedilol - ...... 24 ciprofloxacin regular release tablet - ...... 11 CEENU - ...... 20 citalopram - ...... 34 cefazolin sodium injection ...... 11 claravis - ...... 37 cefdinir capsule - ...... 11 clarithromycin suspension ...... 11 cefdinir suspension ...... 11 clarithromycin tablet - ...... 11 cefepime injection ...... 11 clemastine syrup & tablet (prescription only) - ...... 29 cefoxitin sodium intravenous solution ...... 11 CLEOCIN 75mg capsule - ...... 11 cefprozil suspension ...... 11 CLEOCIN PED solution ...... 11 cefprozil tablet - ...... 11 CLEOCIN vaginal suppository ...... 16 ceftriaxone injection ...... 11 CLIMARA PRO - ...... 28 cefuroxime suspension ...... 11 clindamycin 1% topical gel, lotion, solution, swab - . . .16 cefuroxime tablet - ...... 11 clindamycin 2% vaginal cream ...... 16 CELEBREX - ...... 9 clindamycin capsule - ...... 11 CELLCEPT intravenous solution BvD ...... 31 clindamycin phosphate injection ...... 11 CELLCEPT oral suspension BvD ...... 31 CLINDESSE vaginal cream ...... 16 CELONTIN - ...... 12 clobetasol propionate cream, gel, ointment, solution - .18 cephalexin capsule & tablet - ...... 11 clobetasol propionate foam - ...... 18 cephalexin suspension ...... 11 CLOBEX spray - ...... 18 CEREDASE intravenous solution ...... 28 clomipramine - ...... 34 CEREZYME intravenous solution ...... 28 clonidine oral - ...... 30 cesia (CYCLESSA equivalent) - ...... 26 clonidine patch - ...... 30 cetirizine oral solution - ...... 36 clotrimazole troche - ...... 16 CHANTIX - ...... 24 clozapine tablet - ...... 34 CHEMET ...... 29 codeine sulfate tablet - ...... 9 chloramphenicol intravenous injection ...... 11 COLCRYS - ...... 31 chlorhexidine gluconate 0.12% oral solution ...... 16 colestipol tablet - ...... 19 chloroquine phosphate - ...... 22 colistimethate sodium injection ...... 11 chlorothiazide tablet - ...... 27 COMBIGAN ophthalmic - ...... 15 chlorpromazine injection ...... 34 COMBIPATCH - ...... 28 chlorpromazine oral - ...... 34 COMBIVENT oral inhaler - ...... 38 chlorthalidone - ...... 27 COMBIVIR - ...... 23 chlorzoxazone - ...... 36 COMTAN - ...... 21

- Generally available through Mail Order Pharmacy 43 BvD = Drug could pay under Part B or Part D Alphabetical Index

COMVAX ...... 39 dexamethasone/polymyxin b/neomycin ophthalmic . .16-17 CONCERTA - ...... 10 dexmethylphenidate immediate release - ...... 10 CONDYLOX gel - ...... 37 DEXPAK dosepak ...... 8 COPAXONE injection ...... 31 dextroamphetamine / amphetamine regular release - .10 CORDRAN tape - ...... 18 dextroamphetamine immediate release - ...... 10 COREG CR - ...... 24 dextroamphetamine sustained release - ...... 10 CORTIFOAM - ...... 18 dextrose 5% in lactated ringers intravenous solution . . . .36 CREON oral - ...... 27 dextrose in sodium chloride 2.5%-0.45%, 5%-0.45%, CRIXIVAN - ...... 23 5%-0.9% and 10%-0.45% intravenous solution ...... 25 cromolyn sodium nebulization solution - ...... 18 dextrose in water 5% and 10% intravenous solution . . . .25 cromolyn sodium ophthalmic - ...... 17-18 DIBENZYLINE - ...... 37 cryselle (LO/OVRAL equivalent) - ...... 26 diclofenac sodium ophthalmic ...... 17 CUPRIMINE - ...... 29 diclofenac sodium regular release - ...... 9 cyclobenzaprine - ...... 36 dicloxacillin capsule - ...... 11 cyclophosphamide oral - BvD ...... 20 dicyclomine - ...... 12 cyclosporine intravenous solution BvD ...... 31 didanosine delayed release - ...... 23 cyclosporine modified oral - BvD ...... 31 DIFFERIN cream, gel & lotion - ...... 37 cyclosporine oral - BvD ...... 31 diflorasone - ...... 18 CYKLOKAPRON intravenous solution ...... 15 DIGOXIN oral solution - ...... 25 CYMBALTA - ...... 34 digoxin tablet - ...... 25 cyproheptadine - ...... 29 dihydroergotamine injection ...... 19, 37 CYSTADANE powder for oral solution ...... 31 DILANTIN - ...... 12 CYSTAGON oral ...... 31 DILANTIN-125 - ...... 12 danazol - ...... 10 DILAUDID-5 liquid ...... 9 dantrolene - ...... 36 DILITRATE-SR 40mg - ...... 40 dapsone - ...... 19 diltiazem extended release - 24 hour - ...... 24 DAPTACEL ...... 38 diltiazem immediate release - ...... 24 DARAPRIM - ...... 22 diltiazem sustained release - 12 hour - ...... 24 DECAVAC ...... 38 diphenoxylate / atropine liquid & tablet - ...... 14 demeclocycline - ...... 11 diphenydramine 25mg capsule (prescription only) - . . .29 DEPEN - ...... 30 diphenydramine injection ...... 29 DEPO-PROVERA 400mg/ml injection ...... 33 DIPHTHERIA / TETANUS TOXOID (ADULT & PEDIATRIC) . . .38 DERMA-SMOOTHE/FS - ...... 18 dipivefrin ophthalmic ...... 32 DERMOTIC otic ...... 17 dipyridamole - ...... 40 desipramine - ...... 34 disopyramide immediate release - ...... 25 desmopressin nasal - ...... 33 DIURIL suspension - ...... 28 desmopressin oral tablet - ...... 33 divalproex sodium 24 hour extended release - . . . .13, 19 desonide - ...... 18 divalproex sodium enteric coated tablet - ...... 13 desoximetasone - ...... 18 divalproex sodium sprinkle - ...... 13 DETROL - ...... 29 dorzolamide ophthalmic - ...... 15 DETROL LA - ...... 29 dorzolamide/timolol ophthalmic - ...... 15 DEXAMETHASONE oral concentrate drops - ...... 8 DOVONEX cream - ...... 37 dexamethasone oral tablet & elixir - ...... 8 doxazosin - ...... 8 dexamethasone sodium phosphate injection ...... 8 doxepin - ...... 34

Generally available through Mail Order Pharmacy 44 - BvD = Drug could pay under Part B or Part D Alphabetical Index doxycycline hyclate 20mg - ...... 11, 16 erythromycin lactobionate intravenous solution ...... 12 doxycycline hyclate intravenous solution ...... 11 erythromycin ophthalmic ointment ...... 16 doxycycline hyclate regular release 50mg & 100mg - .11 erythromycin stearate - ...... 12 dronabinol oral - BvD ...... 14 erythromycin/sulfisoxazole suspension ...... 12 DUETACT - ...... 13 ESTRACE vaginal - ...... 28 econazole topical ...... 16 ESTRADERM - ...... 29 EDECRIN - ...... 28 estradiol oral - ...... 29 EFFIENT - ...... 22 estradiol weekly patch (CLIMARA equivalent) - ...... 29 ELAPRASE intravenous solution ...... 28 ESTRING - ...... 29 ELESTAT ophthalmic - ...... 10 estropipate oral - ...... 29 ELIDEL - ...... 37 ethambutol - ...... 19 eliphos - ...... 30 ethosuximide - ...... 13 ELITEK intravenous solution ...... 28 etidronate disodium - ...... 31 ELMIRON - ...... 31 EURAX ...... 17 EMCYT - ...... 20 EVISTA - ...... 29 EMEND - BvD ...... 14 EVOXAC - ...... 33 EMLA with TEGADERM ...... 22 EXELDERM ...... 17 EMSAM - ...... 34 EXJADE ...... 30 EMTRIVA - ...... 23 FABRAZYME intravenous solution ...... 28 enalapril - ...... 35 famotidine swallow tablet - ...... 22 ENBREL injection ...... 31 FANAPT - ...... 34 endocet 10-650mg - ...... 9 FANSIDAR - ...... 22 endocet 5-325mg, 7.5-325mg, 10-325mg - ...... 9 FARESTON - ...... 20 endocet 7.5-500mg - ...... 9 FASLODEX injection ...... 20 ENGERIX-B BvD ...... 39 FAZACLO - ...... 34 enpresse (TRIPHASIL equivalent) - ...... 26 FELBATOL - ...... 13 ENTOCORT EC - ...... 8 FEMARA - ...... 20 EPIPEN injector - ...... 38 FEMHRT - ...... 29 EPIPEN-JR injector - ...... 38 FEMHRT LOW-DOSE - ...... 29 epitol - ...... 13 fenofibrate 54mg, 160mg tablets - ...... 19 EPIVIR - ...... 23 fenofibrate 67mg, 134mg, 200mg capsules - ...... 19 EPIVIR HBV - ...... 23 fentanyl patches - ...... 9 eplerenone - ...... 35 fexofenadine - ...... 36 EPZICOM - ...... 23 FINACEA - ...... 37 ERAXIS intravenous solution ...... 15 finasteride - ...... 31 ergoloid mesylates oral - ...... 37 flecainide - ...... 25 ERGOMAR ...... 19, 37 FLOVENT DISKUS oral inhalant - ...... 8 ergotamine w/caffeine oral tablet ...... 19, 37 FLOVENT HFA oral inhalant - ...... 8 errin (NOR-QD, ORTHO MICRONOR equivalent) - . . . . .26 fluconazole intravenous solution ...... 15 ERYPED 200mg/5ml & 400mg/5ml for suspension . . . . .11 fluconazole oral - ...... 15 erytab - ...... 11 fludrocortisone oral - ...... 8 erythromycin 2% topical gel, solution, swab - ...... 17 flunisolide nasal inhalant - ...... 17 erythromycin base - ...... 11 fluocinolone acetonide - ...... 18 erythromycin ethylsuccinate tablet - ...... 11 fluocinonide - ...... 18

- Generally available through Mail Order Pharmacy 45 BvD = Drug could pay under Part B or Part D Alphabetical Index

fluoride chew tablet, cream, gel, rinse - ...... 31 GEODON oral - ...... 34 fluorometholone 0.1% ophthalmic ...... 17 gianvi (YAZ equivalent) - ...... 26 FLUOROPLEX - ...... 37 GLEEVEC ...... 20 fluorouracil 2% & 5% topical solution - ...... 37 glimepiride - ...... 13 fluorouracil 5% cream - ...... 37 glipizide extended release - ...... 13 fluoxetine 10mg & 20mg capsule, 10mg tablet, glipizide regular release - ...... 13 oral solution - ...... 34 GLUCAGEN injection - ...... 15 fluphenazine deconate injection ...... 34 GLUCAGON injection - ...... 15 fluphenazine hcl injection ...... 34 glyburide - ...... 13 fluphenazine oral - ...... 34 glyburide / metformin - ...... 13 flurbiprofen - ...... 9 glyburide micronized - ...... 14 flutamide - ...... 20 GLYSET - ...... 14 fluticasone nasal inhalant - ...... 17 granisetron oral solution & tablet - BvD ...... 14 fluvoxamine regular release - ...... 34 granisol oral solution - BvD ...... 14 FML S.O.P. ophthalmic ...... 17 GRIFULVIN V 500mg tablet - ...... 15 FOCALIN XR - ...... 10 GRIS-PEG - ...... 15 fomepizole intravenous solution ...... 31 griseofulvin suspension - ...... 15 FORTEO injection ...... 33 guanfacine - ...... 30 fortical nasal - ...... 33 guanidine hcl - ...... 33 FOSAMAX oral solution - ...... 31 HALOG cream & ointment - ...... 18 FOSAMAX PLUS D - ...... 31 haloperidol decanoate injection ...... 34 foscarnet intravenous solution BvD ...... 23 haloperidol lactate injection ...... 34 FRAGMIN injection ...... 22 haloperidol lactate oral concentrate - ...... 34 FURADANTIN - ...... 39 haloperidol oral - ...... 34 furosemide injection ...... 28 HAVIRX ...... 39 furosemide oral solution - ...... 28 heparin injection (excluding heparin flush) ...... 22 furosemide oral tablet - ...... 28 HEPSERA ...... 23 FUZEON injection ...... 23 HEXALEN ...... 20 gabapentin - ...... 13 HUMIRA injection ...... 31 GABITRIL - ...... 13 HUMULIN 50/50 - ...... 14 galantamine extended release - ...... 33 HUMULIN R U-500 (VIAL) - ...... 14 galantamine regular release tablet & oral solution - . . .33 hydralazine - ...... 30 GAMASTAN injection BvD ...... 36 hydrochlorothiazide - ...... 28 GAMMAGARD intravenous solution BvD ...... 36 hydrocodone / ibuprofen 7.5-200mg - ...... 9 ganciclovir - ...... 23 hydrocodone w/acetaminophen 10-325mg/cup GANTRISIN suspension - ...... 12 solution - ...... 9 GARDASIL ...... 39 hydrocodone w/acetaminophen 2.5-500mg, 5-500mg, gauze - ...... 33 7.5-500mg, 10-500mg - ...... 9 gavilyte-g (GOLYTELY equivalent) ...... 25 hydrocodone w/acetaminophen 5-325mg, 7.5-325mg, gavilyte-n (NULYTELY equivalent) - ...... 25 10-325mg - ...... 9 gemfibrozil - ...... 19 hydrocodone w/acetaminophen 7.5-500mg/15ml gengraf - BvD ...... 31 elixir - ...... 9 gentamicin ophthalmic ...... 16 hydrocodone w/acetaminophen 7.5-650mg, 10-650mg, gentamicin topical ...... 17 10-660mg - ...... 9 GEODON injection ...... 34

Generally available through Mail Order Pharmacy 46 - BvD = Drug could pay under Part B or Part D Alphabetical Index hydrocodone w/acetaminophen 7.5-750mg, ISORDIL 40mg - ...... 40 10-750mg - ...... 9 isosorbide dinitrate sublingual & regular release hydrocortisone 2.5% rectal cream - ...... 18 tablet - ...... 40 hydrocortisone 2.5% topical - ...... 18 isosorbide dinitrate sustained release - ...... 40 hydrocortisone 5mg,10mg & 20mg oral - ...... 8 isosorbide mononitrate immediate release - ...... 40 hydrocortisone rectal enema - ...... 18 isosorbide mononitrate sustained release - ...... 40 hydrocortisone valerate - ...... 18 isotretinoin oral (amnesteem, claravis, sotret) - ...... 37 hydrocortisone/polymyxin b/neomycin otic ...... 16-17 ISTALOL ophthalmic - ...... 15 hydromorphone hcl injection ...... 9 ISTODAX injection ...... 20 hydromorphone oral - ...... 9 itraconazole capsule - ...... 15 hydroxychloroquine - ...... 22 jantoven - ...... 22 hydroxyurea - ...... 20 JANUMET - ...... 14 hydroxyzine hcl - ...... 24 JANUVIA - ...... 14 hydroxyzine pamoate capsule - ...... 24 JE-VAX ...... 39 ibuprofen - ...... 9 jolivette (NOR-QD, ORTHO MICRONOR equivalent) - . . .26 imipramine hcl - ...... 34 junel (LOESTRIN equivalent) - ...... 26 imiquimod - ...... 37 junel fe (LOESTRIN FE equivalent) - ...... 26 IMOVAX RABIES (H.D.C.V.) BvD ...... 39 KALETRA - ...... 23 INCRELEX injection ...... 37 kariva (MIRCETTE equivalent) - ...... 26 indapamide - ...... 28 kelnor (DEMULEN 1+35 equivalent) - ...... 26 INDOCIN suspension - ...... 9 KEPIVANCE intravenous solution ...... 25 indomethacin immediate release capsule - ...... 9 KEPPRA intravenous solution ...... 13 INFANRIX ...... 38 ketoconazole 2% cream & shampoo ...... 17 INFERGEN injection ...... 23 ketoconazole oral - ...... 15 INNOPRAN XL - ...... 19, 24 ketorolac oral ...... 9 INSULIN PEN DEVICE - ...... 27 ketorolac tromethamine 0.4% & 0.5% ophthalmic - . .17 insulin pen needles - ...... 27 KINERET injection ...... 31 INSULIN SAFETY SYRINGES - ...... 27 klor-con, klor-con m - ...... 36 insulin syringes - ...... 27 KUVAN ...... 31 INTELENCE - ...... 23 labetalol - ...... 24 INTRALIPID 20% & 30% intravenous solution ...... 25 LACRISERT - ...... 28 INTRON-A injection - ...... 23 LACTATED RINGERS intravenous solution ...... 36 INVEGA oral - ...... 34 lactulose (constulose, enulose, generlac) - ...... 8 INVEGA SUSTENNA ...... 34 LAMICTAL ODT - ...... 13 INVIRASE - ...... 23 LAMICTAL STARTER KITS ...... 13 IPOL ...... 39 lamotrigine 100mg, 150mg, 200mg tablet - ...... 13 ipratropium nasal spray - ...... 28 lamotrigine 25mg tablet - ...... 13 ipratropium nebulization solution - ...... 12 lamotrigine 5mg & 25mg chewable tablet - ...... 13 IQUIX ophthalmic ...... 16 LANOXIN - ...... 25 IRESSA ...... 20 lansoprazole capsule - ...... 22 ISENTRESS - ...... 23 LANTUS - ...... 14 ISOLYTE-S intravenous solution ...... 36 leena (TRI-NORINYL equivalent) - ...... 26 isoniazid syrup - ...... 19 leflunomide - ...... 32 isoniazid tablet - ...... 19 lessina (ALESSE equivalent) - ...... 26

- Generally available through Mail Order Pharmacy 47 BvD = Drug could pay under Part B or Part D Alphabetical Index

LETAIRIS ...... 40 LUXIQ - ...... 18 leucovorin calcium injection ...... 32 LYBREL - ...... 26 leucovorin calcium oral - ...... 32 LYRICA - ...... 13 LEUKERAN - ...... 20 LYSODREN - ...... 20 LEUKINE injection ...... 30 M-M-R II ...... 39 leuprolide injection - ...... 20 MACRODANTIN 25mg - ...... 39 LEVAQUIN intravenous solution ...... 12 MALARONE - ...... 22 LEVAQUIN oral - ...... 12 malathion topical lotion - ...... 17 LEVEMIR - ...... 14 maprotiline - ...... 34 levetiracetam oral solution & tablet - ...... 13 MARPLAN - ...... 34 levobunolol ophthalmic - ...... 15 MATULANE ...... 20 levocarnitine (prescription only) - ...... 32 MAXAIR AUTOHALER oral inhaler - ...... 38 levora (NORDETTE equivalent) - ...... 26 MAXALT - ...... 19 levothroid - ...... 38 MAXALT MLT - ...... 19 levothyroxine - ...... 38 mebendazole ...... 10 LEXAPRO - ...... 34 MEDROL 2mg oral - ...... 8 LEXIVA - ...... 23 medroxyprogesterone oral - ...... 33 lidocaine / prilocaine topical cream ...... 22 mefloquine - ...... 22 lidocaine 2% jel (prescription only) - ...... 30 MEGACE ES - ...... 20 lidocaine 5% ointment (prescription only) ...... 22 megestrol acetate - ...... 20 lidocaine injection ...... 30 meloxicam - ...... 9 lidocaine viscous oral - ...... 30 melphalan injection ...... 20 LIDODERM patch - ...... 22 MENACTRA ...... 39 liothyronine oral - ...... 38 MENOMUNE ...... 39 LIPITOR - ...... 19 MEPRON - ...... 22 lisinopril - ...... 35 mercaptopurine - ...... 20 lisinopril/hydrochlorothiazide - ...... 35 MERUVAX II ...... 39 lithium carbonate extended release - ...... 19 mesalamine enema - ...... 18 lithium carbonate immediate release - ...... 19 MESNEX tablet - ...... 32 lithium citrate - ...... 19 MESTINON syrup - ...... 33 LODOSYN - ...... 21, 26 MESTINON TIMESPAN - ...... 33 loperamide 2mg capsule - ...... 14 METADATE CD - ...... 10 LOTEMAX ophthalmic ...... 17 metformin extended release - ...... 14 LOTREL 5-40mg & 10-40mg - ...... 24, 36 metformin regular release - ...... 14 LOTRONEX ...... 29 methadone oral tablet, solution and concentrate ...... 9 lovastatin regular release - ...... 19 methazolamide oral - ...... 15 LOVAZA - ...... 19 METHERGINE ...... 32 LOVENOX injection ...... 22 methimazole - ...... 38 low-ogestrel (LO/OVRAL equivalent) - ...... 26 METHITEST - ...... 10 loxapine - ...... 34 methocarbamol - ...... 36 LUMIGAN ophthalmic - ...... 15 methotrexate 25mg/ml injection - ...... 20, 32 LUPRON DEPOT injection ...... 20 methotrexate oral - ...... 20, 32 LUPRON DEPOT-PED injection ...... 20, 33 methyldopa - ...... 30 lutera (ALESSE equivalent) - ...... 26 methylin immediate release - ...... 10

Generally available through Mail Order Pharmacy 48 - BvD = Drug could pay under Part B or Part D Alphabetical Index methylin sustained release - ...... 10 NAGLAZYME intravenous solution ...... 28 methylphenidate immediate release - ...... 10 naloxone injection ...... 32 methylphenidate sustained release - ...... 10 naltrexone oral - ...... 32 methylprednisolone 4mg, 8mg, 16mg & 32mg oral - . . .8 NAMENDA - ...... 26 methylprednisolone acetate injection ...... 8 naphazoline hcl ophthalmic solution - ...... 39 metoclopramide oral - ...... 14, 33 naproxen regular release suspension & tablet - ...... 9 metolazone - ...... 28 naproxen sodium - ...... 9 metoprolol succinate sustained release - ...... 24 NARDIL - ...... 34 metoprolol tartrate - ...... 24 NASONEX nasal inhalant - ...... 17 METROGEL 1% topical gel & kit - ...... 17 NATACYN ophthalmic ...... 16 metronidazole 0.75% cream, gel, lotion - ...... 17 nateglinide - ...... 14 metronidazole regular release oral tablet - ...... 12, 22 necon 0.5/35 (BREVICON, MODICON equivalent) - . . . .26 metronidazole vaginal gel ...... 17 necon 1/35, 1/50 (NORINYL 1/35 & 1/50, mexiletine - ...... 25 ORTHO-NOVUM 1/35 & 1/50 equivalents) - ...... 26 MICARDIS - ...... 36 necon 10/11 - ...... 26 MICARDIS HCT - ...... 36 necon 7/7/7 (ORTHO-NOVUM 7/7/7 equivalent) - . . . . .26 microgestin (LOESTRIN equivalent) - ...... 26 nefazodone - ...... 34 microgestin fe (LOESTRIN FE equivalent) - ...... 26 neo-fradin - ...... 12 midodrine - ...... 38 neomycin oral tablet - ...... 12 migergot rectal suppository ...... 19, 37 NEORAL - BvD ...... 32 MIGRANAL nasal - ...... 19, 37 NEULASTA injection ...... 30 MILLIPRED - ...... 8 NEUMEGA injection ...... 30 minitran patch - ...... 40 NEUPOGEN injection ...... 30 minocycline capsule - ...... 12 NEURONTIN oral solution - ...... 13 minoxidil oral - ...... 30 NEUTREXIN intravenous solution ...... 22 MIRAPEX 0.75MG - ...... 21 NEVANAC ophthalmic ...... 17 mirtazapine dissolve tablet - ...... 34 NEXAVAR ...... 20 mirtazapine regular tablet - ...... 34 next choice ...... 26 misoprostol - ...... 22 NIASPAN - ...... 19 mitoxantrone hcl injection ...... 20 NICOTROL NS nasal solution - ...... 24 MOBAN - ...... 34 NICOTROL oral inhaler - ...... 24 mometasone topical - ...... 18 nifedipine sustained release - ...... 24 mononessa (ORTHO-CYCLEN equivalent) - ...... 26 NILANDRON - ...... 21 morphine regular release oral solution & tablet - ...... 9 nimodipine - ...... 25 morphine sulfate 0.5mg/ml, 1mg/ml, 5mg/ml injection . . .9 NITRO-DUR 0.3mg & 0.8mg patch - ...... 40 morphine sustained release - ...... 9 nitrofurantoin macrocrystalline (MACRODANTIN MOVIPREP ...... 25 equivalent) - ...... 39 MULTAQ - ...... 25 nitrofurantoin monohydrate macrocrystalline mupirocin ointment ...... 17 (MACROBID equivalent) - ...... 39 MYCOBUTIN - ...... 19 nitroglycerin 0.1mg, 0.2mg, 0.4mg, 0.6mg patch - . . .40 mycophenolate mofetil - BvD ...... 32 NITROSTAT - ...... 40 nadolol - ...... 24 nora-be (NOR-QD, ORTHO MICRONOR equivalent) - . . .27 nafcillin 2gm injection ...... 12 NORDITROPIN injection ...... 33 NAFTIN cream & gel - ...... 17 norethindrone oral - ...... 33

- Generally available through Mail Order Pharmacy 49 BvD = Drug could pay under Part B or Part D Alphabetical Index

NORITATE - ...... 17 oxycodone 5mg, 15mg & 30mg regular release - . . . . .9 NORPACE CR - ...... 25 oxycodone w/acetaminophen 10-650mg - ...... 9 nortrel 0.5/35 (BREVICON, MODICON equivalent) - . . .27 oxycodone w/acetaminophen 5-325mg, 7.5-325mg, nortrel 1/35 (NORINYL 1/35, ORTHO-NOVUM 10-325mg - ...... 9 1/35 equivalent) - ...... 27 oxycodone w/acetaminophen 5-325mg/5ml oral nortrel 7/7/7 (ORTHO-NOVUM 7/7/7 equivalent) - . . . . .27 solution - ...... 9 nortriptyline - ...... 34 oxycodone w/acetaminophen 5-500mg, 7.5-500mg - . .9 NORVIR - ...... 23 oxycodone w/aspirin - ...... 9 NOVOLIN 70/30 - ...... 14 OXYCONTIN - ...... 9 NOVOLIN N - ...... 14 pacerone - ...... 25 NOVOLIN R - ...... 14 PANRETIN topical - ...... 37 NOVOLOG - ...... 14 paromomycin oral - ...... 22 NOVOLOG MIX - ...... 14 paroxetine hcl regular release tablet - ...... 34 NOXAFIL ...... 15 paroxetine hcl suspension - ...... 35 NUVARING - ...... 27 PASER - ...... 19 nystatin oral - ...... 15 PATADAY ophthalmic - ...... 10 nystatin topical cream, ointment, powder - ...... 17 PATANOL ophthalmic - ...... 10 ocella (YASMIN equivalent) - ...... 27 PEDIARIX ...... 39 octreotide injection ...... 29, 32 PEDVAX HIB ...... 39 ofloxacin ophthalmic ...... 16 PEG-INTRON injection ...... 23 ofloxacin otic ...... 16 PEGANONE - ...... 13 ogestrel - ...... 27 PEGASYS injection ...... 23 OLUX-E - ...... 18 penicillin g potassium injection ...... 12 omeprazole 10mg - ...... 22 penicillin VK suspension & tablet - ...... 12 omeprazole 20mg - ...... 22 PENTASA - ...... 18 OMNITROPE injection ...... 33 pentoxifylline - ...... 30 ondansetron injection BvD ...... 14 PEPCID suspension - ...... 22 ondansetron oral dissolve & regular tablet - BvD . . . . .14 permethrin 5% cream ...... 17 ondansetron oral solution - BvD ...... 14 perphenazine oral - ...... 35 ONTAK injection ...... 21 phenytoin sodium 100mg extended release - ...... 13 ORAP - ...... 34 phenytoin sodium 200mg & 300mg extended ORFADIN oral ...... 32 release - ...... 13 orphenadrine - ...... 36 phenytoin sodium intravenous solution ...... 13 ORTHO EVRA patch - ...... 27 phenytoin suspension - ...... 13 oxaliplatin injection ...... 21 PHOSPHOLINE IODIDE ophthalmic - ...... 15 oxandrolone oral - ...... 10 pilocarpine oral - ...... 33 oxcarbazepine suspension - ...... 13 PILOPINE HS ophthalmic gel - ...... 15 oxcarbazepine tablet - ...... 13 piperacillin sodium / tazobactam 2.25 gram intravenous .12 OXSORALEN lotion - ...... 27 piperacillin sodium injection & intravenous solution . . . . .12 OXSORALEN ULTRA oral - ...... 27 piroxicam - ...... 10 oxybutynin immediate release - ...... 29 PLAVIX - ...... 22 oxybutynin sustained release - ...... 29 podofilox solution - ...... 37 oxycodone 10mg, 20mg, 40mg & 80mg sustained polyethylene glycol oral powder 3350 release - ...... 9 (MIRALAX equivalent) - ...... 25

Generally available through Mail Order Pharmacy 50 - BvD = Drug could pay under Part B or Part D Alphabetical Index polyethylene glycol-electrolyte (COLYTE equivalent) . . . . .25 PROGRAF intravenous solution BvD ...... 32 polymyxin b/bacitracin ophthalmic ...... 16 PROLASTIN injection ...... 28 polymyxin b/bacitracin/neomycin ophthalmic ...... 16 PROLEUKIN injection ...... 21 polymyxin b/gramicidin/neomycin ophthalmic ...... 16 PROMACTA ...... 32 polymyxin b/trimethoprim ophthalmic ...... 16 promethazine injection ...... 14, 29 portia (NORDETTE equivalent) - ...... 27 promethazine rectal suppository - ...... 14, 29 potassium chloride in dextrose 5% & sodium chloride promethazine syrup - ...... 14, 29 0.45% intravenous solution ...... 36 promethazine tablet - BvD ...... 14, 29 potassium chloride intravenous solution ...... 36 PROMETRIUM - ...... 33 potassium chloride sustained release capsule & propafenone immediate release - ...... 25 tablet - ...... 36 propantheline 15mg - ...... 12 potassium citrate tablet - ...... 8 propranolol immediate release - ...... 19, 24 pramipexole 0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg - 21 propranolol oral solution - ...... 24 PRANDIN - ...... 14 propranolol sustained release - ...... 19, 24 pravastatin - ...... 19 propylthiouracil - ...... 38 prazosin - ...... 8 PROQUAD ...... 39 PRED MILD opthalmic ...... 17 PROTONIX intravenous solution ...... 22 prednisolone acetate 1% ophthalmic ...... 17 PROTOPIC - ...... 37 prednisolone oral liquid - ...... 8 protriptyline - ...... 35 prednisolone sodium phosphate 1% ophthalmic ...... 17 PROVIGIL - ...... 10 prednisolone sodium phosphate oral liquid - ...... 8 PULMICORT FLEXHALER oral inhalant - ...... 8 prednisolone/sulfacetamide ophthalmic drops ...... 16-17 PULMICORT RESPULES 1MG - ...... 8 prednisone 5mg/5ml oral solution - ...... 8 PULMOZYME nebulization solution ...... 28 PREDNISONE 5mg/ml concentrate solution - ...... 8 pyrazinamide - ...... 20 prednisone oral dosepak ...... 8 pyridostigmine tablet - ...... 33 prednisone oral tablet - ...... 8 quasense (SEASONALE equivalent) - ...... 27 PREMARIN oral - ...... 29 quinidine gluconate - ...... 25 PREMARIN vaginal - ...... 29 quinidine sulfate extended release - ...... 25 PREMPHASE - ...... 29 quinidine sulfate immediate release - ...... 25 PREMPRO - ...... 29 QVAR oral inhalant - ...... 8 prenatal vitamins with folic acid (generics only) - . . . . .32 RABAVERT BvD ...... 39 previfem (ORTHO-CYCLEN equivalent) - ...... 27 ramipril capsule - ...... 36 PREZISTA - ...... 23 RANEXA - ...... 25 PRIFTIN oral - ...... 19 ranitidine syrup & tablet - ...... 22 PRIMAXIN intravenous solution ...... 12 RAPAMUNE - BvD ...... 32 primidone tablet - ...... 13 REBETOL solution ...... 23 PRISTIQ - ...... 35 REBIF injection ...... 32 PROAIR HFA oral inhaler - ...... 38 reclipsen (DESOGEN, ORTHO-CEPT equivalent) - . . . . .27 probenecid - ...... 38 RECOMBIVAX-HB BvD ...... 39 probenecid/colchicine - ...... 38 REGRANEX ...... 37 prochlorperazine edisylate injection ...... 14, 35 RELENZA ...... 23 prochlorperazine oral - BvD ...... 14, 35 RELISTOR ...... 29 prochlorperazine rectal suppository - ...... 14, 35 RELPAX - ...... 19 PROCRIT injection BvD ...... 30 REMICADE injection BvD ...... 32

- Generally available through Mail Order Pharmacy 51 BvD = Drug could pay under Part B or Part D Alphabetical Index

RENAGEL - ...... 30 sertraline - ...... 35 RENAMIN intravenous solution ...... 25 silver sulfadiazine topical ...... 17 RENVELA - ...... 30 simvastatin - ...... 19 RESCRIPTOR - ...... 23 SINGULAIR - ...... 18 reserpine - ...... 30 sodium bicarbonate intravenous solution ...... 8 RESTASIS ophthalmic - ...... 17 sodium chloride intravenous solution ...... 36 RETIN-A MICRO - ...... 25 sodium chloride irrigating solution - ...... 30 RETROVIR intravenous solution ...... 23 sodium polystyrene sulfonate oral - ...... 30 REVATIO ...... 40 SOLARAZE - ...... 37 REVLIMID ...... 32 solia (DESOGEN, ORTHO-CEPT equivalent) - ...... 27 REYATAZ - ...... 23 SOMAVERT injection ...... 37 RHEUMATREX - ...... 21, 32 SORIATANE - ...... 37 ribavirin capsule - ...... 23 SORIATANE CK - ...... 37 ribavirin dosepak ...... 23 sotalol - ...... 24 ribavirin tablet - ...... 23 sotalol AF - ...... 24 RIDAURA - ...... 29 sotret - ...... 37 rifampin - ...... 20 SPIRIVA oral inhaler - ...... 12 RILUTEK ...... 26 spironolactone - ...... 36 rimantadine tablet - ...... 23 spironolactone/hydrochlorothiazide 25mg/25mg - .28, 36 RISPERDAL CONSTA injection ...... 35 SPORANOX solution - ...... 15 risperidone dissolve tablet - ...... 35 sprintec (ORTHO-CYCLEN equivalent) - ...... 27 risperidone tablet & oral solution - ...... 35 SPRYCEL ...... 21 RITUXAN intravenous solution BvD ...... 21 sronyx (ALESSE equivalent) - ...... 27 ropinirole - ...... 21 STALEVO - ...... 21 ROTATEQ oral ...... 39 stavudine capsule & oral solution - ...... 23 roxicet 325-5mg/5ml oral solution - ...... 10 STRATTERA - ...... 26 roxicet 5-500mg tablet - ...... 10 STROMECTOL ...... 10 SABRIL - ...... 13 SUBOXONE ...... 10 SANCTURA - ...... 29 SUCRAID oral ...... 28 SANCTURA XR - ...... 29 sucralfate tablet - ...... 22 SANDIMMUNE intravenous solution BvD ...... 32 sulfacetamide ophthalmic drops ...... 16 SANDIMMUNE oral - BvD ...... 32 sulfacetamide sodium 10% topical - ...... 17 SANTYL - ...... 37 sulfadiazine - ...... 12 SAPHRIS - ...... 35 sulfamethoxazole/trimethoprim intravenous solution . . . .12 SAVELLA - ...... 35 sulfamethoxazole/trimethoprim oral suspension - . . . .12 selegiline - ...... 21 sulfamethoxazole/trimethoprim oral tablet - ...... 12 selenium sulfide 2.5% topical - ...... 17 sulfasalazine delayed release - ...... 12 SELZENTRY - ...... 23 sulfasalazine regular release - ...... 12 SENSIPAR - ...... 32 sulindac - ...... 10 SEREVENT DISKUS for oral inhalation - ...... 38 sumatriptan injection (prefilled syringe) - ...... 19 SEROMYCIN - ...... 20 sumatriptan injection (vial) - ...... 19 SEROQUEL - ...... 35 sumatriptan tablet - ...... 19 SEROQUEL XR - ...... 35 SUPRAX TABLET ...... 12 SEROSTIM injection ...... 33 SURMONTIL - ...... 35

Generally available through Mail Order Pharmacy 52 - BvD = Drug could pay under Part B or Part D Alphabetical Index

SUSTIVA - ...... 23 tobramycin/dexamethasone ophthalmic drops ...... 16, 18 SUTENT ...... 21 TOBREX ophthalmic ointment ...... 16 SYMBICORT for oral inhalation - ...... 8, 38 tolmetin - ...... 10 SYMLIN injection - ...... 14 topiramate sprinkle - ...... 13 SYNAREL ...... 29 topiramate tablet - ...... 13 SYNTHROID - ...... 38 torsemide - ...... 28 SYPRINE - ...... 30 TRACLEER ...... 40 TACLONEX - ...... 37 tramadol regular release - ...... 10 tacrolimus oral - BvD ...... 32 TRANSDERM SCOP - ...... 14 TAMIFLU ...... 23 tranylcypromine - ...... 35 tamoxifen citrate - ...... 21 TRAVATAN ophthalmic - ...... 15 tamsulosin - ...... 32 TRAVATAN Z ophthalmic - ...... 15 TARCEVA ...... 21 trazodone - ...... 35 TARGRETIN oral ...... 21 TRECATOR - ...... 20 TARGRETIN topical ...... 37 tretinoin oral ...... 21 TASIGNA ...... 21 tretinoin topical - ...... 25 TAZORAC - ...... 37 tri-previfem (ORTHO TRI-CYCLEN equivalent) - ...... 27 TEGRETOL XR 100mg - ...... 13 tri-sprintec (ORTHO TRI-CYCLEN equivalent) - ...... 27 TEKTURNA - ...... 36 triamcinolone acetonide topical - ...... 18 TEKTURNA HCT - ...... 36 triamcinolone in orabase oral paste ...... 18 terazosin - ...... 8 triamterene/hydrochlorothiazide capsule - ...... 28 terbinafine oral - ...... 15 triamterene/hydrochlorothiazide tablet - ...... 28 terbutaline oral - ...... 38 TRICOR - ...... 19 terconazole vaginal ...... 17 trifluoperazine oral - ...... 35 testosterone cypionate injection - ...... 10 trifluridine ophthalmic ...... 16 TETANUS TOXOID, ADSORBED BvD ...... 38 trihexyphenidyl - ...... 21 tetracycline capsule - ...... 12 TRIHIBIT ...... 38 THALITONE 15mg - ...... 28 trilyte (NULYTELY equivalent) ...... 25 THALOMID ...... 32 trimethobenzamide 300mg capsule - BvD ...... 14 theophylline 12 hour sustained release - ...... 36 trimethoprim - ...... 39 theophylline 24 hour sustained release trimipramine 25mg & 50mg - ...... 35 (UNIPHYL equivalent) - ...... 36 trinessa (ORTHO TRI-CYCLEN equivalent) - ...... 27 THIOGUANINE - ...... 21 TRIPEDIA ...... 38 THIOLA - ...... 32 TRISENOX intravenous solution ...... 21 thioridazine - ...... 35 trivora (TRIPHASIL equivalent) - ...... 27 thiothixene - ...... 35 TRIZIVIR - ...... 23 TIKOSYN - ...... 25 TRUVADA - ...... 23 timolol maleate ophthalmic gel forming solution - . . . .15 TWINJECT injector - ...... 38 timolol maleate ophthalmic solution - ...... 15 TWINRIX ...... 39 tizanadine tablet only - ...... 36 TYGACIL intravenous solution ...... 12 TOBI nebulization solution ...... 12 TYKERB ...... 21 TOBRADEX ophthalmic ointment ...... 16, 18 TYPHIM VI ...... 39 tobramycin injection & intravenous solution ...... 12 TYZEKA - ...... 24 tobramycin ophthalmic solution ...... 16 TYZINE nasal spray - ...... 39

- Generally available through Mail Order Pharmacy 53 BvD = Drug could pay under Part B or Part D Alphabetical Index

ULORIC - ...... 32 XIBROM ophthalmic ...... 18 UROXATRAL - ...... 32 XYREM ...... 26 ursodiol capsule - ...... 26 YAZ - ...... 27 ursodiol tablet - ...... 26 YF-VAX ...... 39 VAGIFEM - ...... 29 ZAVESCA oral ...... 32 valacyclovir oral - ...... 24 ZEMPLAR - ...... 40 VALCYTE ...... 24 ZETIA - ...... 19 valproate sodium intravenous solution ...... 13 ZIAGEN - ...... 24 valproate sodium oral syrup - ...... 13 zidovudine oral - ...... 24 valproic acid oral capsule - ...... 13 ZOLINZA ...... 21 VANCOCIN oral capsule - ...... 12 zolpidem regular release - ...... 24 vancomycin 5mg & 10gm intravenous solution ...... 12 ZONALON cream ...... 22 VAQTA ...... 39 zonisamide - ...... 13 VARIVAX ...... 39 ZOSTAVAX vaccine (FDA-approved and covered only for age VECTICAL - ...... 30 60 and above) ...... 39 VELCADE intravenous solution ...... 21 ZOSYN 40.5 gm intravenous solution ...... 12 velivet (CYCLESSA equivalent) - ...... 27 zovia (DEMULEN equivalent) - ...... 27 venlafaxine extended release tablet - ...... 35 ZOVIRAX topical ...... 17 venlafaxine regular release - ...... 35 ZYFLO CR - ...... 18 VENTAVIS BvD ...... 40 ZYLET ophthalmic ...... 16, 18 VENTOLIN HFA - ...... 38 ZYMAR ophthalmic ...... 16 VERAMYST nasal inhalant - ...... 18 ZYPREXA injection ...... 35 verapamil extended release - ...... 25 ZYPREXA oral - ...... 35 verapamil immediate release - ...... 25 ZYPREXA ZYDIS - ...... 35 verapamil sustained release - ...... 25 ZYVOX intravenous solution ...... 12 VEREGEN ...... 17 ZYVOX oral - ...... 12 VFEND oral ...... 15 VICTOZA - ...... 14 VIDAZA injection ...... 21 VIDEX powder for solution - ...... 24 VIGAMOX ophthalmic ...... 16 VIMPAT intravenous solution ...... 13 VIMPAT oral - ...... 13 VIRACEPT - ...... 24 VIRAMUNE - ...... 24 VIREAD - ...... 24 VIVELLE DOT - ...... 29 VIVOTIF BERNA oral (typhoid vaccine) ...... 39 VOTRIENT ...... 21 VYTORIN - ...... 19 VYVANSE - ...... 10 warfarin oral - ...... 22 water for irrigation - ...... 30 XENAZINE ...... 26

Generally available through Mail Order Pharmacy 54 - BvD = Drug could pay under Part B or Part D