2-Tier Open Preferred Drug List - Health Plan of Nevada

Preferred Drug List 2-Tier Open21NVHPN09616

TWO-Tier (OPEN) Drug Benefit GuideTable of ContentsIntroduction .............................................................. iDrug Benefit Guide .................................................. 1Section 1Section 2Section 3Section 4Section 5Section 6Section 7Section 8Section 9Section 10Section 11Section 12Section 13Section 14Anti-InfectivesCancer and TransplantCardiovascularCentral Nervous SystemDermatologicalsEndocrine and HormonesGastrointestinalsGenitourinaryMusculoskeletal and PainVitamins and HematologicalsEye, Ear, and ThroatRespiratorySelf-Injectable/SpecialtyExclusionsAlphabetical Index ................................................... 48

Two-Tier (OPEN) Drug Benefit GuideIntroductionAs a member of a health plan that includes outpatient prescription drug coverage, you haveaccess to a wide range of effective and affordable medications. The health plan utilizes aPreferred Drug List (PDL) (also known as a drug formulary) as a tool to guide providers toprescribe clinically sound yet cost-effective drugs. This list was established to give you access tothe prescription drugs you need at a reasonable cost. Your out-of-pocket prescription cost islower when you use preferred medications. Please refer to your Prescription Drug Benefit Rideror Evidence of Coverage for specific pharmacy benefit information.The PDL is a list of FDA-approved generic and brand name medications recommended for useby your health plan. The list is developed and maintained by a Pharmacy and Therapeutics(P&T) Committee comprised of actively practicing primary care and specialty physicians,pharmacists and other healthcare professionals. Patient needs, scientific data, drug effectiveness,availability of drug alternatives currently on the PDL and cost are all considerations in selecting"preferred" medications. Due to the number of drugs on the market and the continuousintroduction of new drugs, the PDL is a dynamic and routinely updated document screenedregularly to ensure that it remains a clinically sound tool for our providers.Reading the Drug Benefit GuidePreferred generic and brand name medications are available for the applicable preferred generic(tier 1) or preferred brand name (tier 2) copayment. Certain medications may have quantity, ageor therapeutic supply limitations based on FDA approved dosages, literature documentation orP&T Committee decisions. See your plan documents for a complete list of covered benefits,limitations and exclusions.For your convenience, medications are grouped together based on their therapeutic category (i.e.,Anti-Infectives, Cardiovascular, etc.) and further separated into drug classes (i.e.,Antidepressants, Contraceptives, etc.). Each drug class has a designated section number (i.e., 1-A, 1-B, etc.) and is the reference point noted in the index.The generic or chemical name is listed to the left of the brand or trade name for each drug.Drugs with a generic equivalent available are identified by an asterisk (*) before the commonbrand name of the product (for example, in the listing for ampicillin.....*PRINCIPEN, indicatesthat PRINCIPEN is available as a generic and ampicillin would be dispensed by the pharmacy).Drugs that are not available generically have the brand-name listed in BOLD print (for example,the listing for rivaroxaban.....XARELTO, indicates that there is no generic for XARELTO andthe brand name product will be dispensed).Other abbreviations used throughout the PDL are:• AL = age limitations• NTI = narrow therapeutic index (generic not required)• PA = prior authorization• QL = quantity limitations• SIO = self-injectable/orphan drug• ST = step therapyi

• SP = specialty drug: see www.uhcspecialtyrx.comMandatory Generic Substitution PolicyMost of our prescription drug plans include a mandatory generic requirement, therefore, if apreferred brand name drug is dispensed when a preferred generic equivalent is available, you willbe required to pay the difference between the contracted cost of the generic and brand name drugin addition to the preferred generic (tier 1) copayment. Please note that not all dosage forms orstrengths may be available in a generic form. The asterisk (*) indicates that at least one formor strength of the drug is available as a generic at the time of printing. Check with yourpharmacist for more information.Since this list is to be used in the decision-making process and does not represent standards ofcare for an individual, we encourage you to take this reference to all doctor appointments andverify that the drug he/she prescribes is included on this list. You and your provider shoulddiscuss the best possible treatment plan and medications to meet your needs. Because a drug isincluded on our Preferred Drug List does not guarantee that the provider will prescribe thatmedication. Your copayment is less if the provider prescribes a preferred medication.If you have any questions regarding HPN’s Preferred Drug List or to obtain the most currentversion, please visit our website or contact our Member Services Department. Ourrepresentatives are available from 8 a.m. to 5 p.m., Monday through Friday. We are proud to beyour healthcare provider of choice. Working together, we can achieve our common goal – tokeep you healthy!Health Plan of Nevada, Inc.www.healthplanofnevada.com(702) 242-7300 or (800) 777-1840Sierra Health and Life Insurance Company, Inc.www.sierrahealthandlife.com(702) 242-7700 or (800) 888-2264This summary is not an offer of coverage. If there are any differences between the informationcontained within this document and a specific plan document, the plan documents will govern.Participating pharmacies in our retail and/or mail-order network are independent contractorsand are neither employees nor agents of the health plan or its affiliates. This is not meant toreplace the advice of a healthcare provider. This is a proprietary document and may not becopied or distributed without the express permission the health plan.ii

TWO-TIER OPEN Preferred Drug ListThis Preferred Drug List is applicable to HPNmembers with a 2-tier (open) prescription drug program.ANTI-INFECTIVES (drugs to treat infections)1-A PenicillinsGeneric Name Brand NameTierNotesamoxicillin *AMOXIL 1amoxicillin AMOXIL (400mg chewable) 2amoxicillin DISPERMOX 2amoxicillin MOXATAG 2 QL (10 tablets/50 days)amoxicillin-clavulanate *AUGMENTIN 1amoxicillin-clavulanate SR AUGMENTIN XR 2 QL (40 tablets/month)ampicillin *PRINCIPEN 1ampicillin PRINCIPEN (suspension) 2aztreonam CAYSTON 2 QL (84 mls/42 days) PAdicloxacillin *DYNAPEN 1penicillin V potassium *VEETIDS 11-B CephalosporinsGeneric Name Brand NameTierNotescefaclor *CECLOR 1cefaclor ER CECLOR CD 2cefadroxil *DURICEF 1cefdinir *OMNICEF (suspension) 125mg/5ml 1 QL (24 ml/day)cefdinir *OMNICEF (suspension) 250mg/5ml 1 QL (12 ml/day)cefditoren pivoxil SPECTRACEF 2cefpodoxime *VANTIN 200mg 1 QL (28 tablets/month)cefprozil *CEFZIL 250mg 1 QL (28 tablets/month)cefprozil *CEFZIL 500mg 1 QL (28 tablets/month)cefprozil *CEFZIL 125mg/ml 1 QL (140 mls/month)cefprozil *CEFZIL 250mg/ml 1 QL (140 mls/month)ceftibuten CEDAX 2cefuroxime *CEFTIN (tablets) 1 QL (28 tablets/month)cefuroxime *CEFTIN (suspension) 1cephalexin *KEFLEX 11-C MacrolidesGeneric Name Brand NameTierNotesazithromycin *ZITHROMAX 250mg 1 QL (6 tablets/fill)azithromycin *ZITHROMAX 500mg 1 QL (4 tablets/fill)azithromycin *ZITHROMAX 600mg 1 QL (8 tablets/fill)azithromycin *ZITHROMAX 100mg/ml 1 QL (30 mls/fill)azithromycin *ZITHROMAX 200mg/ml 1 QL (30 mls/fill)azithromycin ER ZMAX 2 QL (1 dose/fill)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 1 2-Tier (open) Drug BenefitGuide 09/01/13

clarithromycin *BIAXIN 1 QL (28 tablets/month)clarithromycin SR *BIAXIN XL 1 QL (28 tablets/month)clindamycin *CLEOCIN 1erythromycin PCE 2erythromycin EC ERY-TAB 2erythromycin ethylsuccinate *EES 1erythromycin ethylsuccinate *ERYPED 1erythromycin stearate ERYTHROCIN 2telithromycin KETEK 2 QL (20 tablets/month) STKetek ST = requires failure/contraindication to erythromycin or azithromycin within the past 60 daysERYTHROMYCIN BASE 21-D TetracyclinesGeneric Name Brand NameTierNotesdoxycycline *VIBRAMYCIN 1doxycycline ORACEA 2doxycycline hyclate *PERIOSTAT 1 QL (60 tablets/month)doxycycline monohyclate *VIBRATABS 1 QL (60 tablets/month)doxycycline monohydrate *MONODOX 75mg 1 QL (28 tablets/month)doxycycline monohydrate *MONODOX 100mg 1 QL (28 tablets/month)minocycline *MINOCIN 1 QL (60 tablets/month)tetracycline *SUMYCIN 11-E FluoroquinolonesGeneric Name Brand NameTierNotesciprofloxacin *CIPRO 1 QL (60 tablets/month)ciprofloxacin SR *CIPRO XR 1 QL (14 tablets/month)levofloxacin *LEVAQUIN 1 QL (14 tablets/month)moxifloxacin AVELOX 2norfloxacin NOROXIN 2ofloxacin *FLOXIN 11-F Antimycobacterial AgentsGeneric Name Brand NameTierNotesbedaquiline fumarate SIRTURO 2ethambutol *MYAMBUTOL 1ethionamide TRECATOR-SC 2isoniazid 1isoniazid-rifampin RIFAMATE 2isoniazid-rifampin-pyrazinamide RIFATER 2pyrazinamide 1rifabutin MYCOBUTIN 2rifampin *RIFADIN 11-G AntifungalsGeneric Name Brand NameTierNotesfluconazole *DIFLUCAN 50mg 1 QL (30 tablets/month)fluconazole *DIFLUCAN 100mg 1 QL (30 tablets/month)fluconazole *DIFLUCAN 150mg 1 QL (1 tablet/fill)fluconazole *DIFLUCAN 200mg 1 QL (30 tablets/month)griseofulvin microsize *GRIFULVIN V 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 2 2-Tier (open) Drug BenefitGuide 09/01/13

griseofulvin ultramicrosize *GRIS-PEG 2itraconazole *SPORANOX 1ketoconazole *NIZORAL 1miconazole-zinc oxide-white petroleum VUSION 2nystatin BIO-STATIN 2nystatin *MYCOSTATIN susp 1posaconazole NOXAFIL 2terbinafine HCL *LAMISIL 1terbinafine HCL LAMISIL GRANULE PACKET 2voriconazole *VFEND 50mg 2voriconazole *VFEND 200mg 21-H Miscelleanous AntiviralsGeneric Name Brand NameTieracyclovir *ZOVIRAX 1famciclovir *FAMVIR 125mg 1famciclovir *FAMVIR 250mg 1famciclovir *FAMVIR 500mg 1ganciclovir ZIRGAN 2oseltamivir TAMIFLU capsules 2oseltamivir TAMIFLU suspension 2ribavirin *REBETOL capsules/tablets 1ribavirin REBETOL solution 2rimantadine *FLUMADINE 1valacyclovir *VALTREX 500mg 1valacyclovir *VALTREX 1gm 1valganciclovir HCL VALCYTE 2zanamivir RELENZA 2QL (14 capsules/month)QL (50 gms/50 days)QL (90 tablets/year)QL (30 packets/month)QL (180 tablets/month)QL (60 tablets/month)NotesQL (60 tablets/month)QL (60 tablets/month)QL (21 tablets/month)QL (5 gm/month)QL (10 capsules/3 months)QL (50 mls/months)QL (180 capsules/tabletsmonth) PA SPPA SPQL (14 pills/fill)QL (60 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (1 diskhaler/month)1-I AntiretroviralsGeneric Name Brand NameTierNotesabacavir sulfate ZIAGEN 2 SPabacavir-lamivudine EPZICOM 2 QL (30 tablets/month) SPabacavir-lamivudine-zidovudine TRIZIVIR 2 SPatazanavir REYATAZ 2 SPdarunavir PREZISTA 75mg 2 QL (60 tablets/month) ST SPdarunavir PREZISTA 150mg 2 QL (60 tablets/month) ST SPdarunavir PREZISTA 300mg 2 QL (120 tablets/month) ST SPdarunavir PREZISTA 400mg 2 QL (120 tablets/month) ST SPdarunavir PREZISTA 600mg 2 QL (60 tablets/month) ST SPPrezista ST = must be > 6 years old; requires at least a 30 day fill of Protease Inhibitor within last 2 yearsdarunavir PREZISTA SUSP 2 QL (12ml/day)delavirdine RESCRIPTOR 2 SPdidanosine 1 SPdidanosine *VIDEX EC 1 SPefavirenz SUSTIVA 2 SPefavirenz-emtricitabine-tenofovir ATRIPLA 2 SPemtricitabine EMTRIVA 2 QL (30 capsules/month) SPemtricitabine-rilpivirine-tenofovir COMPLERA 2 SPQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 3 2-Tier (open) Drug BenefitGuide 09/01/13

emtricitabine-tenofovir TRUVADA 2enfuvirtide FUZEON 2entecavir BARACLUDE 2etravirine INTELENCE 2Intelence ST = requires 30 day trial fill of other NNRTI (Sustiva, Viramune, Rescriptor) within past 2 yearsfosamprenavir LEXIVA 2 QL (120 tablets/month) SPindinavir sulfate CRIXIVAN 2 SPlamivudine EPIVIR 2 SPlamivudine-zidovudine *Combivir 1 SPlopinavir-ritonavir KALETRA 2 SPmaraviroc SELZENTRY 150mg 2 QL (60 tablets/month) PA SPmaraviroc SELZENTRY 300mg 2 QL (120 tablets/month) PA SPnelfinavir mesylate VIRACEPT 2 SPnevirapine *VIRAMUNE 1 SPnevirapine XR VIRAMUNE XR 2 SPraltegravir ISENTRESS 2 QL (60 tablets/month) SPrilpivirine EDURANT 2 SPritonavir NORVIR 2 SPsaquinavir INVIRASE 2 SPstavudine *ZERIT 1 SPtelbivudine TYZEKA 2 SPtenofovir VIREAD 2 SPtipranavir APTIVUS capsules 2 QL (120 capsules/month) SPtipranavir APTIVUS suspension 2 QL (300 mls/month) SPzidovudine *RETROVIR 1 SP1-J AntimalarialsGeneric Name Brand NameTierartemether-lumefantrine COARTEM 2atovaquone-proguanil HCL MALARONE 2chloroquine *ARALEN 1hydroxychloroquine *PLAQUENIL 1mefloquine *LARIAM 1primaquine *PRIMAQUINE 1pyrimethamine DARAPRIM 2quinine sulfate 11-K AnthelminticsGeneric Name Brand NameTieralbendazole ALBENZA 2ivermectin STROMECTOL 2mebendazole VERMOX 2praziquantel BILTRICIDE 2thiabendazole MINTEZOL 2QL (30 tablets/month) SPSIO SPQL (30 tablets/month) SPQL 120 tablets/month) ST SPNotesQL (24 tablets/60 days)Notes1-L Misc Anti-InfectivesGeneric Name Brand NameTieratovaquone MEPRON 2QL - Quantity LimitsAL - Age LimitsNotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 4 2-Tier (open) Drug BenefitGuide 09/01/13

fludarabine OFORTA 2flutamide *EULEXIN 1gefitinib IRESSA 2hydroxyurea *HYDREA 1imatinib mesylate GLEEVEC 2lapatinib ditosylate TYKERB 2lenalidomide REVLIMID 2letrozole *FEMARA 1leucovorin calcium *LEUCOVORIN CALCIUM 1leucovorin calcium *WELLCOVORIN 1lomustine CEENU 2megestrol *MEGACE 1megestrol MEGACE ES 2melphalan ALKERAN 2mercaptopurine *PURINETHOL 1mesna MESNEX 2methotrexate 1methotrexate TREXALL 2mitotane LYSODREN 2nilotinib TASIGNA 2nilutamide NILANDRON 2pazopanib VOTRIENT 2pomalidomide POMALYST 2ponatinib hcl ICLUSIG 2procarbazine HCL MATULANE 2regorafenib STIVARGA 2sorafenib tosylate NEXAVAR 2sunitinib SUTENT 2tamoxifen *NOLVADEX 1tamoxifen SOLTAMOX 2temozolomide *TEMODAR 2thalidomide THALOMID 2thioguanine THIOGUANINE 2topotecan HYCAMTIM 2toremifene citrate FARESTON 2trametinib dimethyl sulfoxide MEKINIST 2tretinoin *VESANOID 1vemurafenib ZELBORAF 2vismodegib ERIVEDGE 2vorinostat ZOLINZA 22-B ImmunosuppressivesGeneric Name Brand NameTierazathioprine *IMURAN 1cyclosporine *SANDIMMUNE (NTI) 2cyclosporine modified *GENGRAF 1cyclosporine modified *NEORAL (NTI) 2mycophenolate MYFORTIC 2QL - Quantity LimitsAL - Age LimitsPA SPQL (30 tablets/month)PA SPPA SPPA SPQL (30 tablets/month)SIOPAPA SPPA SPPA SPPAPA SPPA SPPA SPPA SPPA SPPAQL (30 tablets/month)PA SPSPPA SPQL PA SPPA SPNotesSPSPSPQL (120 tablets/month) SPPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 6 2-Tier (open) Drug BenefitGuide 09/01/13

mycophenolate mofetil *CELLCEPT 1sirolimus RAPAMUNE 2tacrolimus *PROGRAF 1SPSPSPCARDIOVASCULAR (drugs to treat heart conditions)3-A CardiotonicsGeneric Name Brand NameTierdigoxin *LANOXIN (NTI) 23-B AntianginalsGeneric Name Brand NameTierisosorbide dinitrate *ISORDIL 1isosorbide mononitrate *IMDUR 1nitroglycerin ointment *NITROBID 1nitroglycerin patch *MINITRAN 1nitroglycerin patch *NITRO-DUR 1nitroglycerin spray *NITROLINGUAL PUMPSPRAY 1nitroquick *NITROSTAT 2NotesNotesGeneric Name Brand NameTierNotesacebutolol *SECTRAL 1atenolol *TENORMIN 1betaxolol *KERLONE 1bisoprolol *ZEBETA 1carteolol HCL CARTROL 2carvedilol *COREG 3.125mg 1 QL (60 tablets/month)carvedilol *COREG 6.25mg 1 QL (60 tablets/month)carvedilol *COREG 12.5mg 1 QL (60 tablets/month)carvedilol *COREG 25mg 1 QL (120 tablets/month)labetalol *NORMODYNE 1 Mlabetalol *TRANDATE 1 Mmetoprolol *LOPRESSOR 1 Mmetoprolol succinate SR *TOPROL XL 1 QL (45 tablets/month)nadolol *CORGARD 20mg 1 QL (90 tablets/month)nadolol *CORGARD 40mg 1 QL (60 tablets/month)nadolol *CORGARD 80mg 1 QL (90 tablets/month)nadolol *CORGARD 120mg 1 QL (60 tablets/month)nebivolol BYSTOLIC 2.5mg 2 QL (30 tablets/month)nebivolol BYSTOLIC 5mg 2 QL (30 tablets/month)nebivolol BYSTOLIC 10mg 2 QL (120 tablets/month)nebivolol BYSTOLIC 20mg 2 QL (60 tablets/month)penbutolol sulfate LEVATOL 2pindolol *VISKEN 1propranolol *INDERAL 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 7 2-Tier (open) Drug BenefitGuide 09/01/13

propranolol HCL CR *INDERAL LA 1propranolol HCL SR INNOPRAN XL 2sotalol *BETAPACE 1sotalol AF *BETAPACE AF 1timolol maleate *BLOCADREN 1QL (30 capsules/month)3-D Calcium Channel BlockersGeneric Name Brand NameTierNotesamlodipine *NORVASC 1cartia XT 1 QL (60 capsules/month)diltiazem *CARDIZEM 1diltiazem SR *TIAZAC 1diltiazem SR 12HR *CARDIZEM SR 1diltiazem SR 24HR CARDIZEM LA 2 QL (30 tablets/month)felodipine *PLENDIL 1 QL (60 tablets/month)isradipine *DYNACIRC 1 QL (60 tablets/month)isradipine DYNACIRC CR 5mg 2 QL (30 tablets/month)isradipine DYNACIRC CR 10mg 2 QL (60 tablets/month)nicardipine *CARDENE 1nicardipine CARDENE SR 2nifedipine CR *ADALAT CC 1nifedipine CR *PROCARDIA XL 1nifedipine IR *ADALAT 1nifedipine IR *PROCARDIA 1nisoldipine SR *SULAR 8.5mg 1 QL (30 tablets/month)nisoldipine SR *SULAR 10mg 1 QL (30 tablets/month)nisoldipine SR *SULAR 17mg 1 QL (30 tablets/month)nisoldipine SR *SULAR 20mg 1 QL (30 tablets/month)nisoldipine SR *SULAR 25.5mg 1 QL (60 tablets/month)nisoldipine SR *SULAR 30mg 1 QL (60 tablets/month)nisoldipine SR *SULAR 34mg 1 QL (30 tablets/month)nisoldipine SR *SULAR 40mg 1 QL (30 tablets/month)verapamil *CALAN 1verapamil CR (controlled onset) COVERA HS 2 QL (60 tablets/month)verapamil SR *CALAN SR 1verapamil SR *VERELAN PM 13-E AntiarrhythmicsGeneric Name Brand NameTierNotesamiodarone *CORDARONE 1disopyramide *NORPACE 1dofetilide TIKOSYN 2 QL (60 capsules/month)dronedarone MULTAQ 2 QL (60 tablets/month)flecainide *TAMBOCOR 1mexiletine *MEXITIL 1propafenone *RYTHMOL 1propafenone *RYTHMOL SR 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 8 2-Tier (open) Drug BenefitGuide 09/01/13

prazosin *MINIPRESS 1reserpine 1sildenafil *REVATIO 2tadalafil ADCIRCA 2terazosin *HYTRIN 1treprostinil TYVASO 23-I Antihypertensive CombinationsGeneric Name Brand Nameamlodipine-benazepril *LOTREL 1atenolol-chlorthalidone *TENORETIC 1azilsartan-chlorthalidone EDARBYCLOR 2benazepril-HCTZ *LOTENSIN HCT 1bisoprolol-HCTZ *ZIAC 1candesartan-HCTZ *ATACAND HCT 2captopril-HCTZ *CAPOZIDE 1enalapril-felodipine LEXXEL 2enalapril-HCTZ *VASERETIC 1eprosartan-HCTZ TEVETEN HCT 2fosinopril-HCTZ *MONOPRIL HCT 1irbesartan-HCTZ *AVALIDE 1lisinopril-HCTZ *PRINZIDE 1lisinopril-HCTZ *ZESTORETIC 1losartan-HCTZ *HYZAAR 1methyldopa-HCTZ *ALDORIL 1metoprolol-HCTZ DUTOPROL 2moexipril-HCTZ *UNIRETIC 1nadolol-bendroflumethiazide *CORZIDE 1olmesartan-HCTZ BENICAR HCT 2propranolol-HCTZ *INDERIDE 1quinapril-HCTZ *ACCURETIC 1telmisartan-HCTZ MICARDIS HCT 2trandolapril-verapamil *TARKA 1valsartan-HCTZ *DIOVAN-HCT 80-12.5mg & 160-12.5mg 1valsartan-HCTZ *DIOVAN-HCT 160-25mg, 320-12.5mg, & 320-25mg 1PA SPQL (60 tablets/month) PA SPQL (60 capsules/month)QL (30 pouches/month) PA SPTierNotesQL (30 capsules/month)QL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (30 tablets/month)3-J DiureticsGeneric Name Brand NameTierNotesacetazolamide *DIAMOX 1amiloride 1amiloride-HCTZ *MODURETIC 1bumetanide *BUMEX 1chlorothiazide *DIURIL 1chlorthalidone *HYGROTON 1eplerenone *INSPRA 1 QL (30 tablets/month)furosemide *LASIX 1hydrochlorothiazide *HYDRODIURIL 1hydrochlorothiazide *MICROZIDE 1indapamide *LOZOL 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 10 2-Tier (open) Drug BenefitGuide 09/01/13

methazolamide *NEPTAZANE 1methyclothiazide *AQUATENSEN 1metolazone *ZAROXOLYN 1spironolactone *ALDACTONE 1spironolactone-HCTZ *ALDACTAZIDE 1tolvaptan SAMSCA 2torsemide *DEMADEX 1triamterene DYRENIUM 2triamterene-HCTZ *DYAZIDE 1triamterene-HCTZ *MAXZIDE 13-K PressorsGeneric Name Brand NameTierepinephrine inj AUVI-Q 2epinephrine inj EPIPEN 2epinephrine inj EPIPEN JR 2epinephrine inj TWINJECT 2midodrine *PROAMATINE 13-L AntihyperlipidemicsGeneric Name Brand Nameatorvastatin *LIPITOR 1cholestyramine *QUESTRAN 1colesevelam WELCHOL 2colestipol *COLESTID 1ezetimibe ZETIA 2ezetimibe-simvastatin VYTORIN 2fenofibrate *LOFIBRA 1fenofibrate *ANTARA 1fenofibrate FENOGLIDE 40mg 2fenofibrate FENOGLIDE 120mg 2fluvastatin LESCOL 20mg 2fluvastatin LESCOL 40mg 2fluvastatin SR LESCOL XL 2gemfibrozil *LOPID 1lomitapide mesylate JUXTAPID 2lovastatin *MEVACOR 10mg 1lovastatin *MEVACOR 20mg 1lovastatin *MEVACOR 40mg 1lovastatin SR ALTOCOR 2mipomersen sodium KYNAMRO 2niacin SR NIASPAN 2niacin-lovastatin CR ADVICOR 2omega-3-acid ethyl esters LOVAZA 2pitavastatin LIVALO 2pravastatin *PRAVACHOL 1rosuvastatin CRESTOR 2simvastatin *ZOCOR 13-M Miscellaneous CardiovascularQL - Quantity LimitsAL - Age LimitsPA SPTierNotesQL (30 tablets/month)QL (210 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 capsules/month)QL (30 capsules/month)QL (60 tablets/month)QL (30 tablets/month)QL (30 capsules/month)QL (60 capsules/month)QL (30 tablets/month)PAQL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)PANotesQL (60 tablets/month)PA QL (120 capsules/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 11 2-Tier (open) Drug BenefitGuide 09/01/13

Generic Name Brand NameTierisosorbide dinitrate-hydralazine BIDIL 2ranolazine RANEXA 2NotesQL (60 tablets/month)CENTRAL NERVOUS SYSTEM (drugs that affect the brain)4-A Antianxiety AgentsGeneric Name Brand NameTierNotesalprazolam *NIRAVAM 2alprazolam *XANAX 1alprazolam SR *XANAX XR 0.5mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 1mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 2mg 1 QL (30 tablets/month)alprazolam SR *XANAX XR 3mg 1 QL (60 tablets/month)buspirone BUSPAR (7.5mg) 2buspirone *BUSPAR 10mg 1 QL (60 tablets/month)buspirone *BUSPAR 15mg 1 QL (120 tablets/month)chlordiazepoxide *LIBRIUM 1clorazepate *TRANXENE 1diazepam *VALIUM 1hydroxyzine HCL *ATARAX 1hydroxyzine pamoate *VISTARIL 1lorazepam *ATIVAN 1meprobamate 1oxazepam *SERAX 14-B AntidepressantsGeneric Name Brand NameTierNotesamitriptyline *ELAVIL 1amoxapine *ASENDIN 1bupropion *WELLBUTRIN 75mg 1 QL (180 tablets/month)bupropion *WELLBUTRIN 100mg 1 QL (120 tablets/month)bupropion SR *WELLBUTRIN SR 100mg 1 QL (60 tablets/month)bupropion SR *WELLBUTRIN SR 150mg 1 QL (60 tablets/month)bupropion SR *WELLBUTRIN SR 200mg 1 QL (60 tablets/month)bupropion XL *WELLBUTRIN XL 1 QL (30 tablets/month)citalopram *CELEXA 1 QL (45 tablets/month)clomipramine *ANAFRANIL 1desipramine *NORPRAMIN 1desvenlafaxine PRISTIQ 2 QL (30 tablets/month) STPristiq ST = requires 60 day consistent trial of 2 the following agents (fluoxetine, paroxetine, citalopram,sertraline, bupropion/SR, venlafaxine) in the past 2 yearsdoxepin *SINEQUAN 1duloxetine CYMBALTA 20mg 2 QL (60 capsules/month) STduloxetine CYMBALTA 30mg 2 QL (60 capsules/month) STduloxetine CYMBALTA 60mg 2 QL (30 capsules/month) STCymbalta ST = (depression) requires 60 day consistent trial of 2 the following agents (fluoxetine,paroxetine, citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 years; (fibromyalgia, DPN)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 12 2-Tier (open) Drug BenefitGuide 09/01/13

equires 30 day trial of Gabapentin in the past 2 years; (chronic pain) requires 30 day trial of genericNSAIDS and generic narcotics in the past 2 yearsescitalopram *LEXAPRO 5mg 1 QL (45 tablets/month)escitalopram *LEXAPRO 10mg 1 QL (45 tablets/month)escitalopram *LEXAPRO 20mg 1 QL (30 tablets/month)fluoxetine *PROZAC 10mg 1 QL (30 capsules/month)fluoxetine *PROZAC 20mg 1 QL (120 capsules/month)fluoxetine *PROZAC 40mg 1 QL (60 capsules/month)fluoxetine *PROZAC WEEKLY 2 QL (4 capsules/month) STProzac Weekly ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsfluoxetine SARAFEM 2 QL (30 capsules/month) STSarafem ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsfluvoxamine *LUVOX 1fluvoxamine *LUVOX CR 100mg 1fluvoxamine *LUVOX CR 150mg 1imipramine *TOFRANIL 1imipramine pamoate TOFRANIL PM 2maprotiline *LUDIOMIL 1mirtazapine *REMERON 1mirtazapine soltabs *REMERON SOLTABS 1nefazodone HCL *SERZONE 1 Mnortriptyline *PAMELOR 1 Mparoxetine HCL *PAXIL 10mg 1paroxetine HCL *PAXIL 20mg 1paroxetine HCL *PAXIL 30mg 1paroxetine HCL *PAXIL 40mg 1paroxetine HCL SR *PAXIL CR 12.5mg 1paroxetine HCL SR *PAXIL CR 25mg 1paroxetine HCL SR *PAXIL CR 37.5mg 1QL (90 tablets/month)QL (30 capsules/month)QL (60 capsules/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (45 tablets/month)QL (30 tablets/month) STQL (60 tablets/month) STQL (60 tablets/month) STPaxil CR ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsparoxetine mes PEXEVA 10mg 2 QL (30 tablets/month) STparoxetine mes PEXEVA 20mg 2 QL (30 tablets/month) STparoxetine mes PEXEVA 30mg 2 QL (60 tablets/month) STparoxetine mes PEXEVA 40mg 2 QL (45 tablets/month) STPexeva ST = requires 60 day consistent trial of 2 of the following agents (fluoxetine, paroxetine,citalopram, sertraline, bupropion/SR, venlafaxine) in the past 2 yearsphenelzine sulfate *NARDIL 1protriptyline *VIVACTIL 1sertraline HCL *ZOLOFT 25mg 1sertraline HCL *ZOLOFT 50mg 1sertraline HCL *ZOLOFT 100mg 1trazodone *DESYREL 1trimipramine maleate *SURMONTIL 1trimipramine maleate SURMONTIL 2QL - Quantity LimitsAL - Age LimitsQL (45 tablets/month)QL (45 tablets/month)QL (60 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 13 2-Tier (open) Drug BenefitGuide 09/01/13

venlafaxine *EFFEXOR 1 QL (90 tablets/month)venlafaxine SR *EFFEXOR XR (cap) 37.5mg 1 QL (90 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 75mg 1 QL (90 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 150mg 1 QL (60 capsules/month)venlafaxine SR *EFFEXOR XR (cap) 225mg 1 QL (30 capsules/month)venlafaxine SR *VENLAFAXINE XR (tab) 37.5mg 1 QL (90 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 75mg 1 QL (90 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 150mg 1 QL (60 tablets/month)venlafaxine SR *VENLAFAXINE XR (tab) 225mg 1 QL (30 tablets/month)vilazodone VIIBRYD 2 QL (30 tablets/month) STViibryd ST = requires 60 day consistent trial of 2 the following agents (fluoxetine, paroxetine, citalopram,sertraline, bupropion/SR, venlafaxine) in the past 2 years4-C Hypnotics (Sleep Aids)Generic Name Brand NameTierNoteschloral hydrate SOMNOTE 2estazolam *PROSOM 1eszopiclone LUNESTA 2 QL (30 tablets/month) STLunesta ST = requires 30 day fill of zolpidem in the past 2 yearsflurazepam *DALMANE 1phenobarbital 1ramelteon ROZEREM 2 QL (30 tablets/month) STRozerem ST = requires 30 day fill of zolpidem in the past 2 yearstemazepam *RESTORIL 1 QL (30 capsules/month)triazolam *HALCION 1 QL (15 tablets/fill; 2 fills/month)zaleplon *SONATA 5mg 1 QL (30 capsules/month)zaleplon *SONATA 10mg 1 QL (60 capsules/month)zolpidem *AMBIEN 1 QL (30 tablets/month)zolpidem CR *AMBIEN CR 1 QL (30 tablets/month)4-D AntipsychoticsGeneric Name Brand NameTierNotesaripiprazole ABILIFY 2 QL (30 tablets/month)asenapine SAPHRIS 2 PA ST QL (60 tablets/month)Saphris ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearschlorpromazine *THORAZINE 1clozapine *FAZACLO 2 PA STFazaclo ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsclozapine *CLOZARIL (NTI) 2 PA STClozaril ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsfluphenazine *PROLIXIN 1haloperidol *HALDOL 1iloperidone FANAPT 2 QL (60 tablets/month) PA STFanapt ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis inpast 2 yearslithium carbonate *ESKALITH 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 14 2-Tier (open) Drug BenefitGuide 09/01/13

lithium carbonate CR *ESKALITH CR 1lithium carbonate CR *LITHOBID 1loxapine *LOXITANE 1lurasidone LATUDA 2olanzapine *ZYPREXA 2olanzapine *ZYPREXA ZYDIS 2paliperidone INVEGA 2QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month) PA STInvega ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis inpast 2 yearspaliperidone palmitate INVEGA SUSTENNA 2 QL (1 syringe/month)perphenazine *TRILAFONE 1prochlorperazine *COMPAZINE 1quetiapine fumarate *SEROQUEL 25mg 1 QL (90 tablets/month)quetiapine fumarate *SEROQUEL 100mg 1 QL (90 tablets/month)quetiapine fumarate *SEROQUEL 200mg 1 QL (120 tablets/month)quetiapine fumarate *SEROQUEL 300mg 1 QL (90 tablets/month)quetiapine fumarate SEROQUEL XR 200mg 2 QL (30 tablets/month)quetiapine fumarate SEROQUEL XR 300mg 2 QL (60 tablets/month)quetiapine fumarate SEROQUEL XR 400mg 2 QL (60 tablets/month)risperidone *RISPERDAL 1risperidone *RISPERDAL M 1thioridazine 1thiothixene *NAVANE 1trifluoperazine *STELAZINE 1ziprasidone HCL *GEODON 2 QL (60 capsules/month)4-E StimulantsGeneric Name Brand NameTierNotesamphetamine-d-amphetamine *ADDERALL 1amphetamine-d-amphetamine SR ADDERALL XR 5mg 2 QL (30 capsules/month)amphetamine-d-amphetamine SR ADDERALL XR 10mg 2 QL (30 capsules/month)amphetamine-d-amphetamine SR ADDERALL XR 15mg 2 QL (30 capsules/month)amphetamine-d-amphetamine SR ADDERALL XR 20mg 2 QL (60 capsules/month)amphetamine-d-amphetamine SR ADDERALL XR 25mg 2 QL (30 capsules/month)amphetamine-d-amphetamine SR ADDERALL XR 30mg 2 QL (30 capsules/month)amphetamine-d-amphetamine SR AMPHETAMINE-D-AMPHETAMINE SR 2 STAmphetamine-D-Amphetamine SR ST = requires 90 day trial of brand Adderall XR in past 2 yearsarmodafinil NUVIGIL 2 QL (30 tablets/month) PAatomoxetine STRATTERA 2 QL (30 capsules/month)dexmethylphenidate *FOCALIN 1 QL (60 tablets/month)dexmethylphenidate SR FOCALIN XR 2 QL (30 capsules/month)dextroamphetamine *DEXEDRINE 1dextroamphetamine *DEXEDRINE SPANSULES 1dextroamphetamine solution *LIQUADD 1 QL (1200 mls/month) PAlisdexamfetamine dimesylate VYVANSE 2 QL (30 capsules/month)methamphetamine *DESOXYN 1 QL (150 tablets/month)methylphenidate METHYLIN (chewable) 2.5mg 2 QL (60 tablets/month)methylphenidate METHYLIN (chewable) 5mg 2 QL (180 tablets/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 15 2-Tier (open) Drug BenefitGuide 09/01/13

methylphenidate METHYLIN (chewable) 10mg 2methylphenidate METHYLIN (suspension) 5mg/ml 2methylphenidate METHYLIN (suspension) 10mg/ml 2methylphenidate *METHYLIN (tablets) 5mg 1methylphenidate *METHYLIN (tablets) 10mg 1methylphenidate *METHYLIN (tablets) 20mg 1methylphenidate *METHYLIN ER 1methylphenidate *RITALIN 5mg 1methylphenidate *RITALIN 10mg 1methylphenidate *RITALIN 20mg 1methylphenidate CR *RITALIN SR 1methylphenidate CR *METADATE CD 2methylphenidate SA *CONCERTA 18mg 2methylphenidate SA *CONCERTA 27mg 2methylphenidate SA *CONCERTA 36mg 2methylphenidate SA *CONCERTA 54mg 2methylphenidate SR *Ritalin LA 10mg 1methylphenidate SR *Ritalin LA 20mg 1methylphenidate SR *Ritalin LA 30mg 1methylphenidate SR *Ritalin LA 40mg 1modafinil *PROVIGIL 100mg 2modafinil *PROVIGIL 200mg 2sodium oxybate XYREM 24-F Misc Psychotherapeutic and Neurological AgentsGeneric Name Brand NameTieramitriptyline-chlordiazepoxide LIMBITROL 2disulfiram *ANTABUSE 1dextromethorphan quindine NUEDEXTA 2donepezil *ARICEPT 1ergoloid mesylates *HYDERGINE 1galantamine *RAZADYNE 1galantamine *RAZADYNE ER 1guanfacine INTUNIV 2menantine NAMENDA 2olanzapine-fluoxetine *SYMBYAX 2QL (180 tablets/month)QL (1800 mls/month)QL (900 mls/month)QL (180 tablets/month)QL (180 tablets/month)QL (60 tablets/month)QL (90 tablets/month)QL (180 tablets/month)QL (180 tablets/month)QL (90 tablets/month)QL (90 tablets/month)QL (30 capsules/month)QL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (30 capsules/month)QL (30 capsules/month)QL (60 capsules/month)QL (30 capsules/month)PA QL (30 tablets/month)PA QL (60 tablets/month)PANotesQL (30 tablets/month)QL (60 tablets/month)QL (30 capsules/month)QL (30 tablets/month)QL (60 tablets/month)STSymbyax ST = requires failure of either Risperidone and Quetiapine or Seroquel XR OR failure to two preferredantidepressants (depending on diagnosis)perphenazine-amitriptyline *ETRAFON 1pimozide ORAP 2rivastigmine *EXELON 1 QL (60 capsules/month)rivastigmine EXELON PATCH 2 QL (30 patches/month)tacrine COGNEX 2tetrabenazine XENAZINE 24-G AnticonvulsantsGeneric Name Brand NameTierNotescarbamazepine *TEGRETOL (NTI) 2carbamazepine SR *CARBATROL 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 16 2-Tier (open) Drug BenefitGuide 09/01/13

carbamazepine SR *TEGRETOL XR 1clobazam ONFI 2clonazepam *KLONOPIN 1diazepam rectal *DIASTAT 1divalproex sodium EC *DEPAKOTE 1ethosuximide *ZARONTIN 1ethotoin PEGANONE 2ezogabine POTIGA 2gabapentin *GABARONE 1gabapentin *NEURONTIN 100mg 1gabapentin *NEURONTIN 300mg 1gabapentin *NEURONTIN 400mg 1gabapentin *NEURONTIN 600mg 1gabapentin *NEURONTIN 800mg 1gabapentin NEURONTIN (solution) 2lacosamide VIMPAT 2lacosamide VIMPAT (solution) 2lamotrigine *LAMICTAL 1lamotrigine LAMICTAL ODT 2lamotrigine LAMICTAL ODT KIT 2lamotrigine *LAMICTAL STARTER KIT 1lamotrigine *LAMICTAL XR 1lamotrigine *LAMICTAL XR KIT 1levetiracetam *KEPPRA 1levetiracetam *KEPPRA XR 2methsuximide CELONTIN 2milnacipran SAVELLA 2milnacipran SAVELLA TITRATION PAK 2oxcarbazepine *TRILEPTAL 100mg 1oxcarbazepine *TRILEPTAL 300mg 1oxcarbazepine *TRILEPTAL 600mg 1phenytoin *DILANTIN (NTI) 2pregabalin LYRICA 25mg 2pregabalin LYRICA 50mg 2pregabalin LYRICA 75mg 2pregabalin LYRICA 100mg 2pregabalin LYRICA 150mg 2pregabalin LYRICA 200mg 2pregabalin LYRICA 225mg 2pregabalin LYRICA 300mg 2pregabalin LYRICA SOLUTION 2QL - Quantity LimitsLyrica ST = requires 30 day trial of Gabapentin in the past 2 yearsprimidone *MYSOLINE 1rufinamide BANZEL 2rufinamide BANZEL suspension 2 QL (80 mls/day)tiagabine *GABITRIL 1topiramate *TOPAMAX 1AL - Age LimitsPAQL (1 kit/month)QL (240 capsules/month)QL (360 capsules/month)QL (270 capsules/month)QL (180 tablets/month)QL (120 tablets/month)QL (60 tablets/month)QL (1 kit/month)QL (1 kit/month)QL (1 kit/month)QL (60 capsules/month)QL (1 kit/month)QL (60 tablets/month)QL (90 tablets/month)QL (120 tablets/month)QL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (90 capsules/month) STQL (60 capsules/month) STQL (60 capsules/month) STQL STQL (90 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 17 2-Tier (open) Drug BenefitGuide 09/01/13

topiramate *TOPAMAX SPRINKLES 1valproic acid *DEPAKENE 1valproic acid STAVZOR 2vigabatrin SABRIL 2zonisamide *ZONEGRAN 25mg 1zonisamide *ZONEGRAN 50mg 1zonisamide *ZONEGRAN 100mg 14-H Antiparkinsonian AgentsGeneric Name Brand Nameapomorphine APOKYN 2benztropine *COGENTIN 1bromocriptine (tablets) *PARLODEL 1carbidopa-levodopa *SINEMET 1carbidopa-levodopa *PARCOPA 1carbidopa-levodopa CR *SINEMET CR 1carbidopa-levodopa-entacapone STALEVO 2entacapone *COMTAN 2pramipexole *MIRAPEX 1ropinirole *REQUIP 1trihexyphenidyl *ARTANE 1AMANTADINE (Symmetrel) 2*SELEGILINE 1QL (120 capsules/month)QL (60 capsules/month)QL (180 tablets/month)QL (120 capsules/month)QL (120 capsules/month)QL (180 capsules/month)TierSIO SPNotesQL (240 tablets/month)QL (240 tablets/month)QL (90 tablets/month)QL (90 tablets/month)DERMATOLOGICALS (drugs to treat skin disorders or conditions)5-A AnorectalGeneric Name Brand NameTierNoteshydrocortisone rectal *ANUSOL-HC 1hydrocortisone-pramoxine rectal *ANALPRAM-HC 1hydrocortisone-pramoxine rectal PROCTOFOAM-HC 25-B Acne ProductsGeneric Name Brand NameTierNotesadapalene DIFFERIN 0.1% cream 2 QL (45 gm/60 days) ALadapalene DIFFERIN 0.1% lotion 2 QL (1 bottle/60 days) ALadapalene *DIFFERIN 0.1% cream/gel 1 STDifferin 0.1% generic ST = requires trial of BRAND Differin cream/gel the past 120 daysazelaic acid AZELEX 2azelaic acid FINACEA 2benzoyl peroxide-adapalene EPIDUO 2 QL (45 gm/month)benzoyl peroxide-erythromycin gel *BENZAMYCIN 1 QL (60 gm/month)benzoyl peroxide-urea ZODERM 5.75% cleanser 2 QL (473 mls/month)benzoyl peroxide-urea ZODERM cleanser 2 QL (400 mls/month)benzoyl peroxide-urea ZODERM cream 2 QL (125 mls/month)benzoyl peroxide-urea ZODERM gel 2 QL (125 mls/month)benzoyl peroxide-vit E INOVA KIT 2benzoyl peroxide-vit E-salicylic acid INOVA 4/1 KIT 2clindamycin topical *CLEOCIN-T 1clindamycin-benzoyl peroxide gel *BENZACLIN 1 QL (50 gm/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 18 2-Tier (open) Drug BenefitGuide 09/01/13

clindamycin-benzoyl peroxide gel *DUAC 2dapsone ACZONE 2erythromycin topical *ERYGEL 1isotretinoin *ACCUTANE 1 QL (60 capsules/month) PAisotretinoin *AMNESTEEM 1 QL (60 capsules/month) PAisotretinoin *CLARAVIS 1 QL (60 capsules/month) PAisotretinoin *SOTRET 1 QL (60 capsules/month) PAmetronidazole cream *METROCREAM 1 QL (60 gm/month)metronidazole cream NORITATE** 2 QL (60 gm/month)metronidazole gel *METROGEL** 1 QL (60 gm/month)metronidazole gel *METROGEL PUMP** 1 QL (55 gm/month)metronidazole lotion *METROLOTION 1sulfacetamide lotion (acne) *KLARON 1sulfacetamide-sulfur emulsion *PLEXION 1tretinoin *RETIN-A ** 1 AL** Larger tube sizes (55 grams or above) will be subject to a 60-day supply limit and 2 copays will apply5-C Topical AntibioticsGeneric Name Brand NameTierNotesbac-polymy-neomycin HC oint CORTISPORIN OINTMENT 2erythromycin ointment AKNE-MYCIN 2gentamicin topical *GARAMYCIN 1mupirocin *BACTROBAN 1mupirocin *BACTROBAN CREAM 1mupirocin BACTROBAN NASAL OINTMENT 2neomycin-polymyxin-HC cream CORTISPORIN CREAM 2retapamuln ALTABAX 2 QL (15 gm/month)silver sulfadiazine *SILVADENE 15-D Topical AntifungalsGeneric Name Brand NameTierNotesbutenafine MENTAX 2ciclopirox *LOPROX 1ciclopirox solution *PENLAC 1 QL (7 ml/month)ciclopirox solution 8% PEDIPIROX 2clotrimazole-betamethasone *LOTRISONE 1 QL (30 ml/month)econazole *SPECTAZOLE 1ketoconazole shampoo *NIZORAL SHAMPOO 1ketoconazole topical 1naftifine NAFTIN 2nystatin topical *MYCOSTATIN topical 1nystatin-triamcinolone *MYCOLOG II 1oxiconazole OXISTAT 2setraconazole ERTACZO 2 QL (1 tube/month)5-E Topical AntiviralsGeneric Name Brand NameTierNotesacyclovir topical *ZOVIRAX topical 1penciclovir DENAVIR 2 QL (1 tube/month)5-F AntipsoriaticsQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 19 2-Tier (open) Drug BenefitGuide 09/01/13

Generic Name Brand NameTierNotesacitretin *SORIATANE 2acitretin *SORIATANE CK kit 2 QL (1 kit/month)anthralin *PSORIATEC 1calcipotriene *DOVONEX 1 QL (1 tube/month)calcitriol ointment *VECTICAL 1 QL (100 gm/month)methoxsalen OXSORALEN-ULTRA 2tazarotene TAZORAC ** 2 QL (1 tube/month) AL** Larger tube sizes (60 grams or above) will be subject to a 60-day supply limit and 2 copays will apply5-G Scabicides and PediculicidesGeneric Name Brand NameTierNotescrotamiton EURAX 2lindane shampoo *KWELL 1permethrin *ELIMITE 1spinosad *NATROBA 25-H Topical CorticosteroidsGeneric Name Brand NameTierNotesalclometasone *ACLOVATE 1amcinonide *CYCLOCORT 1augmented betamethasone *DIPROLENE 1augmented betamethasone *DIPROLENE AF 1betamethasone dipropionate *DIPROSONE 1betamethasone foam *LUXIQ 2betamethasone valerate *VALISONE 1clobetasol foam *OLUX 1clobetasol propionate *TEMOVATE 1clocortolone CLODERM 2desonide *DESOWEN 1desonide foam VERDESO 2 QL (50 gm/60 days)desoximetasone *TOPICORT 1diclofenac gel VOLTAREN GEL 2 QL (500 gm/month)diflorasone diacetate PSORCON 2 QL (60 gm/month)flucinolone oil DERMA-SMOOTH FS 2fluocinolone acetonide *SYNALAR 1fluocinolone shampoo CAPEX 2fluocinonide *LIDEX 1fluocinonide VANOS 2 QL (1 tube/month)flurandrenolide patch CORDRAN 2fluticasone *CUTIVATE ** 1halcinonide HALOG 2halobetasol *ULTRAVATE 1halobetasol ULTRAVATE KIT 2 QL (1 kit/month)hc lot 2% sal acid sulfur 2-2% SCALACORT DK KIT 2hydrocortisone butyrate *LOCOID CREAM 1 QL (45 gm/month)hydrocortisone butyrate LOCOID LOTION 2hydrocortisone valerate *WESTCORT 1mometasone *ELOCON 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 20 2-Tier (open) Drug BenefitGuide 09/01/13

pramoxine-HC cream *PRAMOSONE 1pramoxine-HC foam EPIFOAM 2prednicarbate *DERMATOP 1sodium hyaluronate *HYLIRA 1triamcinolone acetonide *KENALOG 1** Larger tube sizes will be subject to a 60-day supply limit and 2 copays will apply5-I Miscellaneous TopicalsGeneric Name Brand NameTierNotesalefacept AMEVIVE 2aluminum chloride *DRYSOL 1aluminum chloride-alcohol XERAC-AC 2becaplermin REGRANEX 2 PAcollagenase SANTYL 2fluorouracil *EFUDEX 1fluorouracil CARAC 2fluorouracil FLUOROPLEX 2imiquimod *ALDARA 1 QL (12 packets/month)lidocaine (topical) *XYLOCAINE 1lidocaine patch LIDODERM 2 PAlidocaine-hydrocortisone *ANAMANTLE 1lidocaine-tetracaine SYNERA PATCH 2 QL (4 patches/month)lidocaine-prilocaine *EMLA cream 1 QL (30 gm/month)pimecrolimus ELIDEL 2 QL (1 tube/month)podofilox *CONDYLOX 2podophyllum resin PODOCON 2selenium sulfide shampoo *SELSUN 1sulfacetamide *OVACE 1sulfacetamide *OVACE PLUS SHAMPOO 1% 1sulfacetamide-urea lotion *CARMOL SCALP 1tacrolimus topical PROTOPIC 2 QL (1 tube/month)trypsin-castor oil-peruvian balsam *XENADERM 1urea *KERALAC 1urea *VANAMIDE 1urea KERAFOAM 2 QL (60 gm/month)urea (carbamide) *CARMOL 40 1urea in zinc KEROL AD 2ENDOCRINE AND HORMONES (drugs to treat metabolic or hormone conditions, ie diabetes)6-A CorticosteroidsGeneric Name Brand NameTiercortisone acetate *CORTONE 1dexamethasone *DECADRON 1fludrocortisone *FLORINEF 1hydrocortisone acetate *CORTEF 1methylprednisolone *MEDROL 1prednisolone MILIPRED DP PAK 2prednisolone *PRELONE 1QL - Quantity LimitsAL - Age LimitsNotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 21 2-Tier (open) Drug BenefitGuide 09/01/13

prednisolone PREDNISOLONE 5MG 2prednisolone sodium *ORAPRED 1prednisolone sodium *PEDIAPRED 1prednisolone sodium phosphate VERIPRED 2prednisone 16-B AndrogensGeneric Name Brand NameTierdanazol *DANOCRINE 1methyltestosterone ANDROID 2methyltestosterone METHITEST 2testosterone ANDRODERM 2testosterone FORTESTA 2testosterone TESTIM 2testosterone buccal system STRIANT 2testosterone TD sol AXIRON 26-C EstrogensGeneric Name Brand Nameesterified estrogens 1esterified estrogens MENEST 2estradiol *ESTRACE 1estradiol gel ESTROGEL 2estradiol patch *CLIMARA 1estradiol patch VIVELLE 2estradiol patch VIVELLE DOT 2estradiol patch ALORA 2estradiol patch ESCLIM 2estradiol patch ESTRADERM 2estradiol patch MENOSTAR 2estradiol spray EVAMIST 2estradiol TD gel DIVIGEL 2estradiol transdermal ESTRASORB 2estradiol-levonorgestrel patch CLIMARA PRO 2estradiol-norethindrone ACTIVELLA 2estradiol-norethindrone patch COMBIPATCH 2estradiol-norgestimate ORTHO-PREFEST 2estrogens (conjugated) PREMARIN 2estrogens (conjugated synthetic) CENESTIN 2estrogens (conjugated synthetic) ENJUVIA 2estrogen-medroxyprogesterone PREMPHASE 2estrogen-medroxyprogesterone PREMPRO 2estrogens-methyltestosterone *ESTRATEST 1estrogens-methyltestosterone *ESTRATEST HS 1estropipate *OGEN 1ethinyl estradiol-norethindrone FEMHRT 2ospemifene OSPHENA 26-D ContraceptivesGeneric Name Brand NameQL - Quantity LimitsAL - Age LimitsTierTierNotesQL (30 patches/month) PAPAPAPA QL (60 patches/month)PANotesMMQL (93gm/month)QL (4 patches/month)QL (8 patches/month)QL (8 patches/month)QL (8 patches/month)QL (8 patches/month)QL (4 patches/month)QL (9 ml/month)QL (1 tube/month)QL (56 packets/month)QL (4 patches/month)QL (1 dialpak/month)QL (8 patches/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (1 dialpak/month)QL (1 dialpak/month)QL (1 dialpak/month)NotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 22 2-Tier (open) Drug BenefitGuide 09/01/13

MONOPHASIC PRODUCTSethinyl estradiol (EE) /desogestrel productsApri, Emoquette, Reclipsen, Solia *ORTHO CEPT 1 QL (28 tablets/21 days)DESOGEN 2 QL (28 tablets/21 days)mestranol/norethindroneNecon 1/150 *NORINYL 1 QL (28 tablets/21 days)EE/norgestimate productsORTHO CYCLEN 1 QL (28 tablets/21 days)Sprintec, Previfem, Mononessa 2 QL (28 tablets/21 days) STSprintec, Previfem, Mononessa ST = requires trial of brand Ortho Cyclen within the last 120 daysEE/norethindrone productsrtrel,Cyclafem,Necon,Norinyl,Alyacen *ORTHO NOVUM 1/35 1 QL (28 tablets/21 days)LOESTRIN 24 2 QL (28 tablets/month)Junel Fe, Gildess Fe, Microgestin Fe *LOESTRIN FE 1 QL (28 tablets/21 days)Microgestin, Junel *LOESTRIN 2 QL (28 tablets/21 days)Balziva, Zenchent FE, Briellyn *OVCON-35 2 QL (28 tablets/21 days)Nortrel, Necon, Brevicon *MODICON 1 QL (28 tablets/21 days)EE/drospirenone productsYAZ 2 QL (28 tablets/21 days)Gianvi, Loryna, 2 QL (28 tablets/21 days) STGianvi, Loryna, ST = requires trial of brand Yaz within the last 120 daysYASMIN 1 QL (28 tablets/21 days)Ocella, Zarah, Syeda 2 QL (28 tablets/21 days) STOcella , Zarah, Syeda ST = requires trial of brand Yasmin in past 120 daysEE/norgestrel productsLow-ogestrel, Cryselle *LO/OVRAL 1 QL (28 tablets/21 days)EE/ethynodiol productsKelnor 1 QL (28 tablets/21 days)Zovia 1/35 1 QL (28 tablets/21 days)EE/levonorgestrel productsAltavera, Levora, Marlissa, Portia *NORDETTE 1 QL (28 tablets/21 days)Aviane,Lessina,Lutera,Sronyx,Orsythia *ALESSE 1 QL (28 tablets/21 days)Jolessa, Introvale, Quasense *SEASONALE 1 QL (91 tablets/3 months)Amethyst *LYBREL 1 QL (28 tablets/21 days)BIPHASIC PRODUCTSEE-desogestrel/EEKariva, Azurette, Viorele *MIRCETTE 2EE-levonorgestrel/EECamrese Lo, Amethia Lo *LOSEASONIQUE 1Camrese, Amethia, *SEASONIQUE 1EE/norethindrone-EE/norethindroneNecon 10/11 *ORTHO NOVUM 10/11 1LO LOESTRIN FE 2TRIPHASIC PRODUCTSEE/norethindrone-EE/norethindrone-EE/norethindroneQL - Quantity LimitsAL - Age LimitsQL (28 tablets/month)QL (28 tablets/21 days)QL (91 tablets/3 months)QL (28 tablets/21 days)QL (28 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 23 2-Tier (open) Drug BenefitGuide 09/01/13

Aranelle, Leena *TRI-NORINYL 1 QL (28 tablets/21 days)ORTHO-NOVUM 7/7/7 1 QL (28 tablets/21 days), Necon 7/7/7, Nortrel 7/7/7, Cyclafem 2 QL (28 tablets/21 days) STAlyacen, Necon 7/7/7, Nortrel 7/7/7, Cyclafem ST = requires failure of brand Ortho Novum 7/7/7Tilia FE, Tri Legest FE *ESTROSTEP (FE) 1 QL (28 tablets/21 days)EE/levonogestrel-EE/Levonorgestrel-EE/LevonorgestrelTrivora, Myzilra *ENPRESSE 1/desogestrel-EE/desogestrel-EE/desogestrelCesia, Velivet, Caziant *CYCLESSA 1orgestimate-EE/norgestimate-EE/norgestimateORTHO TRI CYCLEN 1Tri-Sprintec,Tri-Previfem,Trinessa 2Tri-Sprintec, Tri-Previfem, Trinessa ST= requires trial of brand Ortho Tri Cyclenwithin the last 120 daysORTHO TRI CYCLEN LO 2 QL (28 tablets/21 days)4-PHASIC PRODUCTSestradiol-estradiol/dienogest-estradiol/dienogest-estradiolNATAZIA 1 QL (28 tablets/21 days)PROGESTIN ONLY-PRODUCTSNorethindroneORTHO MICRONOR 1 QL (28 tablets/month)Camila, Errin, Heather, Jolivette, Nora Be 2 QL (28 tablets/month) STCamila, Errin, Heather, Jolivette, Nora Be requires failure to brand Ortho MicronorMISCELLANEOUSLevonorgestrelUlipristalEtonogestrel/EENorelgestromin/EENext choice *PLAN B 1PLAN B ONE-STEP 1ELLA 1NUVARING 2ORTHO EVRA 2DIAPHRAMS 1FEMCAP 2QL (28 tablets/21 days)QL (28 tablets/21 days)QL (28 tablets/21 days)QL (28 tablets/21 days) STQL (28 tablets/21 days)QL (1 ring/month)QL (3 patches/month)QL (1 cap/year)6-E ProgestinsGeneric Name Brand NameTierNoteshydroxyprogesterone caproate MAKENA 2 PAmedroxyprogesterone *PROVERA 1norethindrone *AYGESTIN 1progesterone micronized *PROMETRIUM 2progesterone vaginal CRINONE 2 PA6-F Oral Antidiabetics (diabetes)Generic Name Brand NameTierNotesacarbose *PRECOSE 1 QL (90 tablets/month)alogliptin benzoate NESINA 2 STQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 24 2-Tier (open) Drug BenefitGuide 09/01/13

NESINA ST = requires fill of metformin within the past 2 yearsalogliptin-metformin KAZANO 2 STKAZANO ST = requires fill of metformin within the past 2 yearsalogliptin-pioglitazone OSENI 2 STOSENI ST = requires fill of metformin within the past 2 yearscanagliflozin INVOKANA 2chlorpropamide *DIABINESE 1bromocriptine CYCLOSET 2 STCycloset ST = requires fill of metformin within the past 2 yearsglimepiride *AMARYL 1 QL (60 tablets/month)glipizide *GLUCOTROL 5mg 1 QL (90 tablets/month)glipizide *GLUCOTROL 10mg 1 QL (60 tablets/month)glipizide CR *GLUCOTROL XL 2.5mg 1 QL (90 tablets/month)glipizide CR *GLUCOTROL XL 5mg 1 QL (60 tablets/month)glipizide CR *GLUCOTROL XL 10mg 1 QL (60 tablets/month)glipizide-metformin *METAGLIP 1 QL (120 tablets/month)glyburide *DIABETA 1glyburide-metformin *GLUCOVANCE 1 QL (120 tablets/month)glyburide micronized *GLYNASE 1 QL (60 tablets/month)linagliptin TRADJENTA 2linagliptin-metformin JENTADUETO 2 QL (60 tablets/month)metformin *GLUCOPHAGE 500mg 1 QL (150 tablets/month)metformin *GLUCOPHAGE 850mg 1 QL (90 tablets/month)metformin *GLUCOPHAGE 1000mg 1 QL (75 tablets/month)metformin GLUMETZA 500mg 2 QL (120 tablets/month)metformin GLUMETZA 1000mg 2 QL (60 tablets/month)metformin RIOMET 2 QL (750 mls/month)metformin SR *GLUCOPHAGE XR 500mg 1 QL (120 tablets/month)metformin SR *GLUCOPHAGE XR 750mg 1 QL (90 tablets/month)metformin SR FORTAMET 500mg 2 QL (120 tablets/month)metformin SR FORTAMET 1000mg 2 QL (75 tablets/month)miglitol GLYSET 2 QL (120 tablets/month)nateglinide *STARLIX 1 QL (90 tablets/month)piolitazone *ACTOS 1 QL (30 tablets/month)piolitazone-glimepiride *DUETACT 1 QL (30 tablets/month)piolitazone-metformin *ACTOPLUS MET 1 QL (90 tablets/month)piolitazone-metformin ACTOPLUS MET XR 2 QL (30 tablets/month) STActoPlus Met XR ST = requires 60 day trial of Actos AND metformin or ActoPlus Met in past 2 yearsrepaglinide *PRANDIN 1repaglinide-metformin PRANDIMET 2rosiglitazone AVANDIA 2 QL (30 tablets/month) STAvandia ST = requires 90 day trial of either sulfonylurea or biguanide in past 2 yearsrosiglitazone maleate-glimepiride AVANDARYL 4/1mg 2 QL (60 tablets/month) STrosiglitazone maleate-glimepiride AVANDARYL 4/2mg 2 QL (60 tablets/month) STrosiglitazone maleate-glimepiride AVANDARYL 4/4mg 2 QL (30 tablets/month) STAvandaryl ST = requires 90 day trial of either Avandia or glimipride in past 2 yearsrosiglitazone-metformin AVANDAMET 1/500mg 2 QL (120 tablets/month) STQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 25 2-Tier (open) Drug BenefitGuide 09/01/13

osiglitazone-metformin AVANDAMET 2/500mg 2 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 4/500mg 2 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 2/1000mg 2 QL (60 tablets/month) STrosiglitazone-metformin AVANDAMET 4/1000mg 2 QL (60 tablets/month) STAvandamet ST = requires 90 day trial of either Avandia or metformin in past 2 yearssaxagliptin ONGLYZA 2 QL (30 tablets/month)saxagliptin-metformin KOMBIGLYZE XR 2 QL (30 tablets/month)sitaglipin JANUVIA 2 QL (30 tablets/month) STJanuvia ST = requires fill of metformin within the past 2 yearssitaglipin-metformin JANUMET 2 QL (60 tablets/month) STJanumet ST = requires fill of metformin within the past 2 yearssitaglipin-metformin JANUMET XR 2 QL (30 tablets/month) STJanumet XR ST = requires fill of metformin within the past 2 yearstolazamide *TOLINASE 1tolbutamide *TOLBUTAMIDE 16-G InsulinsGeneric Name Brand NameTierNotesinsulin (human) HUMULIN 1insulin (human) HUMULIN PEN 2insulin (human) NOVOLIN 2NOVOLIN ST = requires failure of a Lilly product within the last 2 yearsinsulin (human) RELION 2insulin aspart NOVOLOG 2NOVOLOG ST = requires failure of a Lilly product within the last 2 yearsinsulin aspart mix NOVOLOG MIX 2NOVOLOG MIX ST = requires failure of a Lilly product within the last 2 yearsinsulin detemir LEVEMIR 2insulin glargine LANTUS 2insulin glulisine APIDRA 2insulin lispro HUMALOG 1insulin lispro HUMALOG PEN 2insulin lispro mix HUMALOG MIX 1insulin lispro mix HUMALOG MIX PEN 26-H GlucagonGeneric Name Brand NameTierNotesGLUCAGON 2 QL (2 kits/month6-I Thyroid AgentsQL - Quantity LimitsGeneric Name Brand Namelevothroid 1levothyroxine 1levothyroxine TIROSINT 2levothyroxine *SYNTHROID (NTI) 2levoxyl 2liothyronine *CYTOMEL 1liotrix THYROLAR 2methimazole *TAPAZOLE 1methimazole NORTHYX 2AL - Age LimitsTierNotesQL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (90 tablets/month)QL (90 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 26 2-Tier (open) Drug BenefitGuide 09/01/13

propylthiouracil *PTU 1thyroid ARMOUR THYROID 2thyroid NATURE-THROID 2thyroid WESTHROID-P 2unithroid 16-J Miscellaneous EndocrineGeneric Name Brand Namealendronate * FOSAMAX 5mg 1alendronate * FOSAMAX 10mg 1alendronate * FOSAMAX 35mg 1alendronate * FOSAMAX 40mg 1alendronate * FOSAMAX 70mg 1alendronate-cholecalciferol FOSAMAX PLUS D 2caberoline *DOSTINEX 1calcitonin MIACALCIN 2calcitonin (salmon) nasal *FORTICAL 1carglumic acid CARBAGLU 2cinacalcet SENSIPAR 30mg 2cinacalcet SENSIPAR 60mg 2cinacalcet SENSIPAR 90mg 2desmopressin (nasal) *DDAVP 1desmopressin (nasal) STIMATE 2desmopressin (oral) *DDAVP 0.1mg 1desmopressin (oral) *DDAVP 0.2mg 1etidronate *DIDRONEL 1exenatide BYDUREON 2exenatide BYETTA 2ibandronate *BONIVA 2levocarnitine *CARNITOR 1liraglutide VICTOZA 2pramlintide SYMLIN AMYLIN ANALOG 26-K Diabetic SuppliesQL - Quantity LimitsTierNotesQL (30 tablets/month)QL (30 tablets/month)QL (4 tablets/month)QL (4 tablets/month)QL (4 tablets/month)QL (4 tablets/month)Symlin ST = requires concurrent mealtime insulin therapy (rapid or fast acting)raloxifene EVISTA 2 QL (30 tablets/month)risedronate ACTONEL 5mg 2 QL (30 tablets/month)risedronate ACTONEL 30mg 2 QL (4 tablets/month)risedronate ACTONEL 35mg 2 QL (4 tablets/month)risedronate ACTONEL 150mg 2 QL (1 tablet/month)risedronate-calcium ACTONEL with CALCIUM 2 QL (30 tablets/month)sapropterin KUVAN 2ulipristal ELLA 2AL - Age LimitsACCU-CHEK ACTIVE CARE KIT 1ACCU-CHEK ACTIVE TEST STRIPS 1ACCU-CHEK ADVANTAGE CARE KIT 1ACCU-CHEK AVIVA CARE KIT 1ACCU-CHEK AVIVA TEST STRIPS 1ACCU-CHEK COMFORT CURVE TEST STRIPS 1QL (60 tablets/month)QL (2 bottles/month)QL (2 bottles/month)PAQL (60 tablets/month) SPQL (60 tablets/month) SPQL (120 tablets/month) SPQL (1 bottle/month)QL (1 bottle/month)QL (30 tablets/month)QL (90 tablets/month)QL (1 tablet/month)QL (2 pens/month)STPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 27 2-Tier (open) Drug BenefitGuide 09/01/13

ACCU-CHEK COMPACT CARE KIT 1ACCU-CHEK COMPACT TEST STRIPS 1ACCU-CHEK METER 1ASCENSIA AUTODISC TEST STRIPS 2ASCENSIA BREEZE 2 TEST STRIPS 2ASCENSIA ELITE TEST STRIPS 2CONTOUR TEST STRIPS 2FREESTYLE FLASH SYSTEM 2FREESTYLE FREEDOM LITE METER 2FREESTYLE FREEDOM METER 2FREESTYLE LITE METER 2FREESTYLE SYSTEM 2FREESTYLE TEST STRIPS 2GLUCOMETER DEX TEST STRIPS 2ONE TOUCH SYSTEM 1ONE TOUCH TEST STRIPS 1ONE TOUCH ULTRA 2 SYSTEM 1ONE TOUCH ULTRA MINI SYSTEM 1ONE TOUCH ULTRA SYSTEM 1ONE TOUCH ULTRA TEST STRIPS 1PRECISION XTRA METER 2PRECISION XTRA TEST STRIPS 2SMARTVIEW TEST STRIPS 1SURESTEP SYSTEM 2SURESTEP TEST STRIPS 2VERIO STRIPS 1VERIO IQ STRIPS 1GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)7-A LaxativesGeneric Name Brand NameTierNoteslactulose 1na sulf-k sulf-mg sulf & peg 3350 SUCLEAR 2PEG electrolyte *COLYTE 1PEG electrolyte GOLYTELY 2PEG 3350 MOVIPREP 2peg(high)-electrolyte *NULYTELY 1sodium sulf-pot sulf-mag sulfate SUPREP 2sod phos mon-sod phos di VISICOL 27-B AntidiarrhealsGeneric Name Brand NameTierNotesdiphenoxylate-atropine *LOMOTIL 1opium tincture *OPIUM TINCTURE 1 QL (72 mls/month)paregoric 17-C Miscelleanous Ulcer DrugsGeneric Name Brand NameTierNotesamoxicillin-clarithro-lansopraz CR PREVPAC 2 QL (1 pak/year)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 28 2-Tier (open) Drug BenefitGuide 09/01/13

ismuth subcit-metronidazole-tetracycline PYLERA 2chlordiazepoxide-methscopolamine LIBRAX 2dicyclomine *BENTYL 1glycopyrrolate *ROBINUL 1glycopyrrolate *ROBINUL FORTE 1hyoscyamine *LEVSIN 1hyoscyamine *LEVBID 1hyoscyamine *NULEV 1methscopolamine PAMINE 2metronidazole-tetracycline-bismuth HELIDAC 2misoprostol *CYTOTEC 1phenobarbital-belladonna *DONNATAL 1propantheline PRO-BANTHINE 2sucralfate CARAFATE 27-D H2 BlockersGeneric Name Brand NameTiercimetidine *TAGAMET 1famotidine *PEPCID 1nizatadine *AXID 1ranitidine *ZANTAC 17-E Proton Pump Inhibitors (PPI)Generic Name Brand NameTierdexlansoprazole DEXILANT 2lansoprazole *PREVACID 1QL (2 paks/year)QL (120 tablets/month)NotesNotesQL (30 capsules/month)QL (30 capsules/month) STPrevacid ST = requires 30 day trial of at least 2 of the following: Aciphex, Dexilant, Omeprazole,Pantoprazole, or omeprazole-sodium bicarblansoprazole *PREVACID SOLUTAB 1 QL (30 tablets/month) STPrevacid Solutab ST = requires 30 day trial of at least 2 of the following: Aciphex, Dexilant, Omeprazole,Pantoprazole, or omeprazole-sodium bicarbomeprazole *PRILOSEC 20mg capsules 1 QL (60 capsules/month)omeprazole *PRILOSEC 20mg tablets 1 QL (30 tablets/month)omeprazole *PRILOSEC 40mg 1 QL (30 capsules/month)omeprazole PRILOSEC POWDER SUSPENSION 2 STPrilosec Powder ST = requires 30 day trial of at least 2 of the following: Aciphex, Dexilant, Omeprazole,Pantoprazole, or omeprazole-sodium bicarbomeprazole-sodium bicarb *ZEGERID 2 QL (30 capsules/month)pantoprazole *PROTONIX 1 QL (30 tablets/month)rabeprazole ACIPHEX 2 QL (30 tablets/month)7-F AntiemeticsGeneric Name Brand NameTierNotesdolasetron ANZEMET 2 QL (1 tablet/fill; 2 fills/month)doxylamine-pyridoxine DICLEGIS 2dronabinol *MARINOL 1 PAgranisetron *KYTRIL 1 QL (2 tablets/fill; 2 fills/month)ondansetron *ZOFRAN 4mg 1 QL (30 tablets/fill; 2 fills/month)ondansetron *ZOFRAN 8mg 1 QL (30 tablets/fill; 2 fills/month)ondansetron *ZOFRAN 24mg 1 QL (15 tablets/fill; 2 fills/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 29 2-Tier (open) Drug BenefitGuide 09/01/13

ondansetron *ZOFRAN ODT 4mg 1ondansetron *ZOFRAN ODT 8mg 1scopolamine patch TRANSDERM-SCOP 2trimethobenzamide *TIGAN 17-G Digestive AidsGeneric Name Brand NameTieramylase-lipase-protease PANCREASE MT 2amylase-lipase-protease KU-ZYME 2amylase-lipase-protease KU-ZYME-HP 2amylase-lipase-protease CREON 2amylase-lipase-protease VIOKASE 2amy-lip-prot dr ULTRASE 2amy-lip-prot dr ULTRASE MT 2miglustat ZAVESCA 2pancrelipase ZENPEP 2pegademase ADAGEN 2sacrosidase SUCRAID 2sodium phenylbutyrate BUPHENYL 27-H Miscelleanous GastrointestinalGeneric Name Brand Nameadefovir HEPSERA 2alosetron LOTRONEX 2balsalazide *COLAZAL 1budesonide SR *ENTOCORT EC 1budesonide SR UCERIS 2calcium acetate (phosphate binder) *PHOSLO 1calcium acetate (phosphate binder) ELIPHOS 2crofelemer FULYZAQ 2cysteamine bitartrate PROCYSBI 2glycopyrroate CUVPOSA 2hycosamine-phenyltoloxamine DIGEX NF 2lamivudine (hepatitis) EPIVIR HBV 2lanthanum FOSRENOL 500mg 2lanthanum FOSRENOL 750mg 2lanthanum FOSRENOL 1000mg 2linaclotide LINZESS 2lubiprostone AMITIZA 2mesalamine CANASA 2mesalamine LIALDA 2mesalamine CR APRISO 2mesalamine CR PENTASA 2mesalamine enema *ROWASA 1methylnaltrexone bromide RELISTOR 2metoclopramide *REGLAN 1sevelamer RENAGEL 2sevelamer RENVELA 2sulfasalazine *AZULFIDINE 1QL - Quantity LimitsAL - Age LimitsQL (30 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (10 patches/month)TierNotesQL (30 tablets/month) SPQL (60 tablets/month) PAQL (270 capsules/month)QL (90 capsules/month)PAQLPANotesPAPA SPAL (limited to 16 years of age and under)QL (30 tablets/month) SPQL (150 tablets/month)QL (150 tablets/month)QL (120 tablets/month)QL (120 tablets/month)PA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 30 2-Tier (open) Drug BenefitGuide 09/01/13

sulfasalazine EC *AZULFIDINE EN 1ursodiol *ACTIGALL 1ursodiol *URSO 1ursodiol *URSO FORTE 1BXN MOUTHWASH 2DIPENTUM 2GENITOURINARY (drugs to treat genital and bladder or kidney conditions)8-A Urinary Anti-InfectivesGeneric Name Brand NameTierNotesfosfomycin MONUROL 2 QL (1 packet/month)methenamine-NA biphosphate *UROQID 1nitrofurantoin macro *MACROBID 1nitrofurantoin macrocrystals *MACRODANTIN 1nitrofurantoin susp FURADANTIN 28-B Urinary AntispasmodicsGeneric Name Brand NameTierNotesbethanechol *URECHOLINE 1darifenacin ENABLEX 2 QL (30 tablets/month)fexoterodine TOVIAZ 2 QL (30 tablets/month)flavoxate *URISPAS 1 QL (240 tablets/month)mirabegron MYRBETRIQ 2oxybutynin *DITROPAN 1 QL (240 tablets/month)oxybutynin CR *DITROPAN XL 5mg 1 QL (30 tablets/month)oxybutynin CR *DITROPAN XL 10mg 1 QL (60 tablets/month)oxybutynin CR *DITROPAN XL 15mg 1 QL (60 tablets/month)oxybutynin patches OXYTROL 2 QL (8 patches/month)solifenacin VESICARE 2 QL (30 tablets/month)tolterodine DETROL 2 QL (60 tablets/month)trospium *SANCTURA 1 QL (60 tablets/month)8-C Vaginal ProductsGeneric Name Brand NameTierNotesclindamycin vaginal *CLEOCIN vaginal cream 1clindamycin vaginal CLINDESSE 2 QL (6 gm/fill)estradiol vaginal ESTRACE vaginal 2estradiol vaginal VAGIFEM 2estradiol vaginal ring ESTRING 2 QL (1 ring/3 months)estradiol vaginal ring FEMRING 2 QL (1 ring/3 months)estrogens (conjugated) vaginal PREMARIN vaginal 2metronidazole vaginal *METROGEL vaginal 1metronidazole vaginal *VANDAZOLE 1nystatin vaginal 1sulfanilamide vaginal AVC vaginal 2terconazole vaginal TERAZOL 2triple sulfas vaginal 18-D Miscelleanous Genitourinary AgentsGeneric Name Brand NameTierNotesQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 31 2-Tier (open) Drug BenefitGuide 09/01/13

citric acid-D-gluconic acid RENACIDIN 2citric acid-sodium citrate *BICITRA 1dutasteride AVODART 2finasteride *PROSCAR 1methylergonovine METHERGINE 2oxybutynin gel GELNIQUE 2pentosan polysulfate sodium ELMIRON 2phenazopyridine *PYRIDIUM 1potassium citrate CR *UROCIT-K 1potassium phosphate K-PHOS 2silodosin RAPAFLO 2tadalafil CIALIS 2tamsulosin *FLOMAX 1tiopronin THIOLA 2POTASSIUM CHLORIDE 2QL (30 capsules/month)QL (30 tablets/month)QL (30 packets/month)QL (90 capsules/month)QL (30 capsules/month)PAQL (60 capsules/month)MUSCULOSKELETAL AND PAIN (drugs to treat pain and muscle conditions)9-A Analgesics-Non-NarcoticGeneric Name Brand NameTierNotesAPAP-butalbital *PHRENILIN 1 QL (360 tablets/month)APAP-caffeine-butalbital *ESGIC PLUS 1 QL (360 tablets/month)APAP-caffeine-butalbital *FIORICET 1 QL (360 tablets/month)ASA-caffeine-butalbital *FIORINAL 1choline-mag salicylates *TRILISATE 1salsalate *DISALCID 1DIFLUNISAL 29-B Analgesics-NarcoticGeneric Name Brand NameTierNotesAPAP-codeine *TYLENOL w/CODEINE 1 QL (390 tablets/month)APAP-hydrocodone *LORCET 10/650mg 1 QL (180 tablets/month)APAP-hydrocodone *LORTAB 1 QL (240 tablets/month)APAP-hydrocodone *MAXIDONE 1 QL (150 tablets/month)APAP-hydrocodone *NORCO 1 QL (360 tablets/month)APAP-hydrocodone *VICODIN 1 QL (240 tablets/month)APAP-hydrocodone *VICODIN ES 1 QL (150 tablets/month)APAP-hydrocodone *VICODIN HP 1 QL (180 tablets/month)APAP-hydrocodone ZAMICET 2 QL (360 mls/month)APAP-hydrocodone ZYDONE 2 QL (300 mls/month)ASA-codeine *EMPIRIN w/CODEINE 1ASA-caffeine-but-codeine *FIORINAL w/CODEINE 1buprenorphine BUTRANS 2 STButrans ST = Requires a 30 day trial of at least 2 of the following within the past 6 months:hydrocodone/apap, tramadol, apap with codeine, oxycodone/apap,and/or morphine IR.buprenorphine *SUBUTEX 1 PAbuprenorphine naloxone SUBOXONE FILM TAB 2 PAbuprenorphine naloxone SUBOXONE TABLETS 2 PAbutorphanol *STADOL NS 1 QL (1 bottle/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 32 2-Tier (open) Drug BenefitGuide 09/01/13

dihydrocodeine compound SYNALGOS DC 2fentanyl citrate nasal LAZANDA 2fentanyl citrate SL ABSTRAL 2fentanyl lollipop *ACTIQ 1fentanyl patch *DURAGESIC 1PAPAQL (120 lozenges/month) PAQL (10 patches/month) STDuragesic ST = requires 30 day trial fill of MSSR in past 2 yearsPAQL (120 lozenges/month) PAQL (360 tablets/month)QL (360 tablets/month)QL (360 tablets/month)QL (30 tablets/month)QL (480 tablets/month)QL (480 tablets/month)fentanyl transmucosal film ONSOLIS 2fentanyl transmucosal lozenge FENTORA 2hydromorphone *DILAUDID 2mg 1hydromorphone *DILAUDID 4mg 1hydromorphone *DILAUDID 8mg 1hydromorphone ER EXALGO 2ibuprofen-hydrocodone *VICOPROFEN 1ibuprofen-hydrocodone *REPREXAIN 1ketorolac tromethamine nasal SPRIX NASAL 2meperidine *DEMEROL 1morphine AVINZA 30mg 2morphine AVINZA 60mg 2morphine AVINZA 90mg 2morphine AVINZA 120mg 2QL (1 bottle/day; 1 box/5 bottles per month )QL (360 tablets/month)QL (30 capsules/month) STQL (30 capsules/month) STQL (60 capsules/month) STQL (90 capsules/month) STAvinza ST = requires 30 day trial fill of BOTH MSSR and Opana ER in the past 2 yearmorphine sulfate *ROXANOL 1morphine sulfate SR *MS CONTIN 1naltrexone *REVIA 1naltrexone VIVITROL 2 PAoxycodone *OXYIR 1oxycodone *ROXICODONE 1 QL (360 tablets/month)oxycodone SR OXYCONTIN 2 QL (60 tablets/month) STOxycontin ST = requires 30 day trial fill of BOTH MSSR and Opana ER in the past 2 yearoxycodone-APAP *PERCOCET 2.5-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 5-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 7.5-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 10-325mg 1 QL (360 tablets/month)oxycodone-APAP *PERCOCET 7.5-500mg 1 QL (240 tablets/month)oxycodone-APAP *PERCOCET 10-650mg 1 QL (180 tablets/month)oxycodone-ASA *PERCODAN 1 QL (360 tablets/month)oxycodone-ibuprofen COMBUNOX 2 QL (7 day treatment; 4 tablets/day)oxymorphone *OPANA 2 QL (180 tablets/month)oxymorphone ER OPANA ER 2 QL (60 tablets/month)pentazocine-naloxone *TALWIN NX 1propoxyphene-APAP DARVOCET A 2 QL (240 tablets/month)propoxyphene napsylate DARVON-N 2 QL (180 tablets/month)tapentadol NUCYNTA 3 QL (180 tablets/month)tapentadol SR NUCYNTA ER 3 QL (60 tablets/month)tramadol *ULTRAM 1 QL (240 tablets/month)tramadol-APAP ULTRACET 2 QL (240 tablets/month)tramadol ER ULTRAM ER 100mg 2 QL (90 tablets/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 33 2-Tier (open) Drug BenefitGuide 09/01/13

tramadol ER ULTRAM ER 200mg 2tramadol ER ULTRAM ER 300mg 2CODEINE SULFATE 2METHADONE 29-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)Generic Name Brand Namecelecoxib CELEBREX 50mg 2celecoxib CELEBREX 100mg 2celecoxib CELEBREX 200mg 2celecoxib CELEBREX 400mg 2diclofenac *VOLTAREN 25mg 1diclofenac *VOLTAREN 50mg 1diclofenac *VOLTAREN 75mg 1diclofenac misoprostol *ARTHROTEC 2diclofenac potassium *CATAFLAM 1diclofenac SR *VOLTAREN XR 1etodolac *LODINE 200mg 1etodolac *LODINE 300mg 1etodolac *LODINE 400mg 1etodolac *LODINE 500mg 1etodolac SR *LODINE XL 600mg 1fenoprofen *NALFON 1flurbiprofen *ANSAID 1ibuprofen *MOTRIN 1indomethacin *INDOCIN 1indomethacin CR *INDOCIN SR 1ketoprofen ORUDIS 2ketoprofen SR ORUVAIL 2ketorolac *TORADOL 1lansoprazole-naproxen PREVACID NAP KIT 2meclofenamate *MECLOMEN 1mefenamic acid *PONSTEL 1meloxicam *MOBIC 7.5mg 1meloxicam *MOBIC 15mg 1nabumetone *RELAFEN 1naproxen *NAPROSYN 1naproxen sodium *ANAPROX 1oxaprozin *DAYPRO 1piroxicam *FELDENE 1sulindac *CLINORIL 1tolmetin sodium *TOLECTIN 1QL (30 tablets/month)QL (30 tablets/month)TierNotesQL (60 capsules/month)QL (60 capsules/month)QL (60 capsules/month)QL (30 capsules/month)QL (240 tablets/month)QL (120 tablets/month)QL (90 tablets/month)QL (120 tablets/month)QL (120 tablets/month)QL (90 capsules/month)QL (90 capsules/month)QL (90 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (60 capsules/month)QL (20 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (90 tablets/month)9-D Anti-Rheumatic AgentsGeneric Name Brand NameTierNotesauranofin RIDAURA 2deferasirox EXJADE 2 PA SPleflunomide *ARAVA 1 QL (30 tablets/month)methotrexate 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 34 2-Tier (open) Drug BenefitGuide 09/01/13

penicillamine CUPRIMINE 2penicillamine DEPEN 29-E Migraine ProductsGeneric Name Brand NameTierNotesalmotriptan AXERT 2 QL (6 tablets/fill; 2 fills/month) STAxert ST = requires one fill of sumatriptan AND Relpax in past 2 yearsAPAP-isometh-caffeine PRODRIN 2 QL (240 tablets/month)APAP-isometh-dichlor hydrate *MIDRIN 1dihydroergotamine (nasal) *MIGRANAL 2divalproex sodium (migraine) *DEPAKOTE ER 1eletriptan RELPAX 2 QL (6 tablets/fill; 2 fills/month)ergotamine-caffeine *CAFERGOT 1 QL (40 tablets/month)ergotamine-phenobarb-belladona 1frovatriptan FROVA 2 QL (6 tablets/fill; 2 fills/month) STFrova ST = requires one fill of sumatriptan AND Relpax in past 2 yearsnaratriptan *AMERGE 1 QL (6 tablets/fill; 2 fills/month)rizatriptan *MAXALT 2 QL (6 tablets/fill; 2 fills/month)rizatriptan *MAXALT MLT 2 QL (6 tablets/fill; 2 fills/month)sumatriptan *IMITREX 2 QL (9 tablets/fill; 2 fills/month)sumatriptan *IMITREX NASAL 1 QL (6 vials/month)sumatriptan SUMATRIPTAN INJ 2 QL (2 kits/fill; 2 fills/month)zolmitriptan *ZOMIG 2 QL (6 tablets/fill; 2 fills/month)zolmitriptan ZOMIG NASAL 2 QL (6 vials/month)Zomig Nasal ST = requires one fill of sumatriptan AND Relpax in past 2 yearszolmitriptan *ZOMIG ZMT 2 QL (6 tablets/fill; 2 fills/month)9-F GoutGeneric Name Brand NameTierNotesallopurinol *ZYLOPRIM 1colchicine COLCRYS 2colchicine-probenecid *COLBENEMID 1febuxostat ULORIC 2 QL (30 tablets/month) STUloric ST = requires fill of 2 consecutive months of allopurinol in past 120 daysglycerol phenylbutyrate RAVICTI 2probenecid *BENEMID 19-G Musculoskeletal Therapy AgentsGeneric Name Brand NameTierNotesbaclofen *LIORESAL 1carisoprodol *SOMA 1 QL (120 tablets/month)carisoprodol-ASA *SOMA COMPOUND 1 QL (120 tablets/month)carisoprodol-ASA-codeine *SOMA CPD w/CODEINE 1 QL (120 tablets/month)chlorzoxazone *PARAFON FORTE 1cyclobenzaprine *FLEXERIL 5mg 1 QL (90 tablets/month)cyclobenzaprine *FLEXERIL 10mg 1cyclobenzaprine *AMRIX 1 QL (30 capsules/month)cyclobenzaprine *FEXMID 2 QL (90 tablets/month) STFexmid ST = requires 2 fills of generic cyclobenzaprine in past 2 yearsdantrolene *DANTRIUM 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 35 2-Tier (open) Drug BenefitGuide 09/01/13

metaxalone SKELAXIN 2methocarbamol *ROBAXIN 1orphenadrine citrate *NORFLEX 1tizanidine *ZANAFLEX 19-H Miscelleanous Neuromuscular AgentsGeneric Name Brand NameTierpyridostigmine *MESTINON 1riluzole *RILUTEK 2QL (240 tablets/month)NotesQL (60 tablets/month)VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)10-A VitaminsGeneric Name Brand NameTierNotescalcitriol *ROCALTROL 1docercalciferol HECTOROL 2ergocalciferol [vitamin D] *CALCIFEROL 1paricalcitol [vitamin D] ZEMPLAR 2 QL (30 capsules/month) SPphytonadione MEPHYTON 2potassium aminobenzoate POTABA 2 M10-B MultivitaminsGeneric Name Brand NameTierNotesB complex-vit C-FA *NEPHROCAPS 1fe bisglycin-fe polysac NIFEREX GOLD 2 QL (30 tablets/month)multi vitamin TANDEM F 2ped multi vitamin-fluoride *POLY-VI-FLOR 1ped multi vitamin-fluoride-FE *POLY-VI-FLOR-FE 1ped vitamins ACD-fluoride *TRI-VI-FLOR 1ped vitamins ACD-fluoride-FE *TRI-VI-FLOR-FE 1pnv-select 1prenatal FE-CBN-DSS-Methylfol-FA *PRENATE ELITE 1prenatal low iron 1prenat-fe poly cmplx-fe heme PREFERA OB 2 QL (30 tablets/month)prenat-fe poly cmplx-fe heme PREFERA OB + DHA 2 QL (60 tablets/month)prenatal mv w/fe poly-fa SELECT-OB+DHA 2prenatal vitamin-FE-bisglycinate-FA *NATELLE C 1 QL (30 tablets/month)prenatal vitamins-fe- bis-fe prot succ-fa-ca- *DUET DHA EC 1prenatal vitamins-FE-FA *STUARTNATAL 1prenatal vitamins-FE-FA *PRECARE 1prenatal vitamins-iron carbonyl-FA *NESTABS 1prenatal w/dss iron carbonyl-fa ATABEX EC 2prenatal w/fe fum-l methylfolate NEEVO DHA 2prenate w/fe fum-fe poly-fa omega 3 CONCEPT DHA 2prenate w/o a w/fe fum-fe poly-fa CONCEPT OB 2prenate w/o Vit A w/ FE NATELLE ONE 2prenate vitamin FE-Fum-Lmethylfol-FA-CA *PRENATE DHA 1 QL (30 tablets/month)prenate w/o a w/fecbn-egl-dss-fa & dha CITRANATAL ASSURE PAK 2 QL (60 tablets/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 36 2-Tier (open) Drug BenefitGuide 09/01/13

10-C MineralsGeneric Name Brand NameTiercyanocobalamin (nasal) NASCOBAL 2cyanocobalamin inj 1FA-vit B6-vit B12 *FOLBEE 1FA-vit B6-vit B12 *FOLGARD RX 1FA-vit B6-vit B12 *FOLTX TABLETS 1FE fum-FA-DSS-B complex-vit C NEPHRON FA 2FE fum-fe poly-fa-c-b3 INTEGRA F 2FE fum-iron polysacch complex INTEGRA PLUS 2FE fum-vit C-vit B12-FA *CHROMAGEN FORTE 2folic acid 1L-methylfolate ZERVALX 2L-methylfolate B12 B6 METANX CAPSULES 2L-methylfolate B12 B6 *METANX TABLETS 1L-methylfolate B12 B6 B2 CEREFOLIN 2NotesQL (30 tablets/month)QL (30 tablets/month)QL (60 tablets/month)MQL (30 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (30 tablets/month)10-D AnticoagulantsGeneric Name Brand NameTierNotesapixaban ELIQUIS 2 PAdibigatran PRADAXA 2 PArivaroxaban XARELTO 2 QLwarfarin *COUMADIN (NTI) 210-E Miscelleanous HematologicalsGeneric Name Brand NameTierNotesaminocaproic acid *AMICAR 1anagrelide *AGRYLIN 1cilostazol *PLETAL 1 QL (60 tablets/month)clopidogrel *PLAVIX 1 Mdipyridamole *PERSANTINE 1 Mdipyridamole-aspirin SR AGGRENOX 2 QL (60 capsules/month)pentoxifylline *TRENTAL 1 QL (90 tablets/month)prasugrel EFFIENT 2 QL (30 tablets/month)sodium polystyrene sulfonate *KAYEXALATE 1ticagrelor BRILINTA 2ticlopidine *TICLID 1 QL (60 tablets/month)tranexamic acid *LYSTEDA 1 QL (5 days therapy/28 days)EYE, EAR AND THROAT (drugs to treat eye, ear and throat conditions)11-A Ophthalmic Anti-infectivesGeneric Name Brand NameTierNotesazithromycin ophth AZASITE 2 QL (5 ml/month)bacitracin ophth 1bacitracin-polymyxin B ophth *POLYSPORIN ophth 1besifloxacin ophth BESIVANCE 2 QL (5 ml/month)ciprofloxacin ophth *CILOXAN 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 37 2-Tier (open) Drug BenefitGuide 09/01/13

gatifloxacin ophth ZYMAR 2 QL (5 ml/month)gatifloxacin ophth ZYMAXID 2 QL (2.5 ml/month)gentamycin sulfate ophth *GENTAMICIN OINT 3% 1levofloxacin ophth *QUIXIN 1moxifloxacin ophth MOXEZA 2 QL (3 ml/month)moxifloxacin ophth VIGAMOX 2 QL (3 ml/month)neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth 1ofloxacin ophth *OCUFLOX 1 QL (10 ml/month)sulfacetamide sodium ophth *BLEPH-10 1tobramycin ophth *TOBREX 1trifluridine ophth *VIROPTIC 1trimethoprim-polymy B ophth *POLYTRIM ophth 111-B Ophthalmics Beta-BlockerGeneric Name Brand NameTierNotesbetaxolol HCL ophth BETOPTIC-S 2brimonidine timolol ophth COMBIGAN 2 QL (5 ml/month)carteolol ophth *OCUPRESS 1dorzolamide-timolol ophth *COSOPT 1dorzolamide-timolol ophth COSOPT PF 2 QL (60 sing-use vials per month)levobunolol ophth *BETAGAN 1metipranolol ophth *OPTIPRANOLOL 1timolol ophth BETIMOL 2 QL (5 ml/month)timolol maleate ophth *TIMOPTIC 1timolol maleate ophth *TIMOPTIC XE 111-C Ophthalmic SteroidsGeneric Name Brand NameTierNotesdexamethasone ophth MAXIDEX 2dexamethasone phosphate ophth *DECADRON ophth 1difluprednate ophth DUREZOL 2fluorometholone ophth FML FORTE 2fluorometholone ophth *FML LIQUIFILM 1fluorometholone ophth FML SOP 2fluorometholone ophth FLAREX 2loteprednol etb-tobramycin ophth ZYLET 2 QL (5 ml/month)loteprednol ophth ALREX 2 QL (5 ml/month)loteprednol ophth LOTEMAX 2 QL (10 ml/month)neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH 1prednisolone ophth *PRED FORTE 1rimexolone ophth VEXOL 2sulfacetamide-prednisolone ophth *BLEPHAMIDE 1tobramycin-dexamethasone ophth *TOBRADEX 1 QL (5 ml/month)11-D Ophthalmic ProstaglandinGeneric Name Brand NameTierNotesbimatoprost ophth LUMIGAN 2 QL (2.5 ml/month)latanoprost ophth *XALATAN 1 QL (2.5 ml/month)tafluprost opth soln ZIOPTAN 2 QL (1 carton (30 vials) per month (QD)travaprost ophth TRAVATAN Z 2 QL (2.5 ml/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 38 2-Tier (open) Drug BenefitGuide 09/01/13

travaprost ophth 1 QL (2.5 ml/month)11-E Ophthalmic CycloplegicsGeneric Name Brand NameTierNotesatropine ophth *ISOPTO ATROPINE 1cyclopentolate ophth *CYCLOGYL 1homatropine ophth *ISOPTO HOMATROPINE 1scopolamine ophth ISOPTO HYOSCINE 2tropicamide ophth *MYDRIACYL 111-F Ophthalmics MioticsGeneric Name Brand NameTierNotespilocarpine ophth *ISOPTO CARPINE 1pilocarpine ophth PILOPINE HS 211-G Ophthalmics Adrenergic AgentsGeneric Name Brand NameTierNotesapraclonidine ophth *IOPIDINE 1brimonidine ophth ALPHAGAN P 0.1% 2 QL (10ml per month)brimonidine ophth *ALPHAGAN P 0.2% 1 QL (10ml per month)brimonidine ophth *ALPHAGAN P 0.15% 1 QL (10ml per month)11-H Ophthalmics MiscelleanousGeneric Name Brand Namebrinzolamide ophth AZOPT 2bromfenac ophth *XIBROM 2cromolyn sodium ophth *CROLOM ophth 1cyclosporine ophth RESTASIS 2cysteamine CYSTARAN 2diclofenac ophth *VOLTAREN ophth 1diclofenac ophth VOLTAREN ophth gel 2dorzolamide ophth *TRUSOPT 1flurbiprofen ophth *OCUFEN 1ketorolac ophth *ACULAR 1ketorolac ophth *ACULAR LS 1lidocaine ophth AKTEN GEL 2lodoxamide ophth ALOMIDE 2nedocromil ophth ALOCRIL 2nepafenac ophth NEVANAC 2pemirolast ophth ALAMAST 2TierNotesQL (10 ml/month)QL (2.5 ml/month)PA QL (60 vials(1 box)/month)QL (5ml per month)QL (3 ml/month)11-I Otic (Ear) MedicationsGeneric Name Brand NameTierNoteschloroxylenol-pramoxine-zinc acetate otic ZINOTIC 2 QL (15 ml/month)chloroxylenol-pramoxine-zinc acetate otic ZINOTIC ES 2 QL (15 ml/month)ciprofloxacin-dexamethasone CIPRODEX 2 QL (8 ml/month)ciprofloxacin-HC otic CETRAXAL 2ciprofloxacin-HC otic CIPRO HC OTIC 2 QL (10 ml/month)hydrocortisone-acetic acid otic *VOSOL-HC 1neomycin-polymyxin-HC otic *CORTISPORIN otic 1neomycin-colistin-HC-thonzonium otic CORTISPORIN-TC 2ofloxacin otic *FLOXIN OTIC 1 QL (10 ml/month)QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 39 2-Tier (open) Drug BenefitGuide 09/01/13

11-J Mouth and ThroatGeneric Name Brand NameTieramlexanox oral paste APHTHASOL 2cevimeline *EVOXAC 2chlorhexidine *PERIDEX 1clotrimazole troche *MYCELEX TROCHE 1lidocaine *VISCOUS LIDOCAINE 1oral hydrogel wafer MUCOTROL 2pilocarpine *SALAGEN 5mg 1pilocarpine *SALAGEN 7.5mg 1sodium fluoride *KARIGEL 1sodium fluoride *KARIGEL-N 1triamcinolone/orabase *KENALOG-ORABASE 1NotesQL (90 capsules/month)QL (120 wafers/month)QL (180 tablets/month)QL (120 tablets/month)RESPIRATORY (drugs to treat breathing conditions, ie asthma and allergies)12-A AntihistaminesGeneric Name Brand NameTierNotescyproheptadine *PERIACTIN 1promethazine *PHENERGAN 1pyrilamine tannate PYRLEX SYRUP 2 QL (120 ml/month)triprolidine tannate ZYMINE XR SYRUP 2 QL (120 ml/month)12-B Topical Nasal ProductsGeneric Name Brand NameTierNotesazelastine nasal *ASTELIN 1 QL (1 inhaler/month)beclomethasone nasal BECONASE AQ 2 QL (2 inhalers/month)budesonide nasal RHINOCORT AQUA 2 QL (2 inhalers/month)ciclesonide nasal OMNARIS 2 QL (1 inhaler/month)flunisolide nasal *NASALIDE 1 QL (3 inhalers/month)flunisolide nasal *NASAREL 1 QL (3 inhalers/month)fluticasone nasal *FLONASE 1ipratropium nasal *ATROVENT 0.03% NASAL 1 QL (1 inhaler/month)ipratropium nasal *ATROVENT 0.06% NASAL 1 QL (2 inhalers/month)mometasone nasal NASONEX 2 QL (1 inhaler/month)olopatadine nasal PATANASE 2 QL (1 inhaler/month)triamcinolone nasal NASACORT 2 QL (1 inhaler/month)triamcinolone nasal NASACORT AQ 2 QL (2 inhalers/month)triamcinolone nasal TRI-NASAL 2 QL (1 inhaler/month)12-C Cough/Cold/AllergyGeneric Name Brand NameTierNotesacetylcysteine *MUCOMYST 1acrivastine-PSE SEMPREX-D 2benzonatate *TESSALON 1bromphen-PSE-DM BROMOXAFED 2cardec DM *RONDEC DM 1QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 40 2-Tier (open) Drug BenefitGuide 09/01/13

chlorpheniramine *ED CHLORPED 1chlorpheniramine-PSE *DECONAMINE 1guaifenesin-DM HUMIBID-DM 2hydrocodone-homatropine *HYCODAN 1phenylephrine-guaifenesin MAXIPHEN-G 2promethazine VC PHENERGAN VC 1promethazine VC- codeine PHENERGAN VC w/CODEINE 1promethazine-codeine *PHENERGAN w/CODEINE 1PSE-guaifenesin-codeine *NOVAHISTINE 1PSE-methscopolamine *ALLERX-D 1pseudoephed-chlorphen-DM TANAFED DM 212-D Asthma/COPDGeneric Name Brand NameTieraclidinium bromide TUDORZA 2albuterol nebulizer *PROVENTIL (nebulizer) 1albuterol tablets *PROVENTIL (tablets) 1albuterol HFA inhaler PROAIR HFA 2albuterol HFA inhaler PROVENTIL HFA 2albuterol HFA inhaler VENTOLIN HFA 2albuterol SR tablets *VOSPIRE ER 4mg 1albuterol SR tablets *VOSPIRE ER 8mg 1albuterol-ipratropium inhaler COMBIVENT RESPIMAT 2albuterol-ipratropium nebulizer *DUONEB 1aminophylline 1arformoterol tartrate nebulizer BROVANA 2budesonide formoterol inhaler SYMBICORT 2cromolyn sodium nebulizer *INTAL (nebulizer) 1fluticasone furoate-vilanterol aero powd BREO ELLIPTA 2formoterol fumarate inhaler PERFOROMIST 2formoterol inhaler FORADIL 2ipratropium nebulizer *ATROVENT (nebulizer) 1ipratropium HFA inhaler ATROVENT HFA 2levalbuterol nebulizer *XOPENEX 0.31mg/3ml 2levalbuterol nebulizer *XOPENEX 0.63mg/3ml 2levalbuterol nebulizer *XOPENEX 1.25mg/3ml 2levalbuterol nebulizer *XOPENEX 1.25 mg/0.5 ml 2levalbuterol inhaler XOPENEX HFA 2metaproterenol nebulizer *ALUPENT (nebulizer) 1metaproterenol tablets *ALUPENT (tablets) 1montelukast *SINGULAIR 4mg 1montelukast *SINGULAIR 5mg 1montelukast *SINGULAIR 10mg 1montelukast *SINGULAIR 4mg Granules 2mometasone-formoterol inhalers DULERA 2QL - Quantity LimitsNotesQL (2 inhalers/month)QL (2 inhalers/month)QL (2 inhalers/month)QL (60 tablets/month)QL (120 tablets/month)QL (2 inhalers/month)QL (540 mls/month)MQL (60 vials/month (2ml/vial)QL (1 inhaler/month)QL (120 vials/month)QL (60 vials/month)QL (60 capsules/month)QL (450 mls/month)QL (2 inhalers/month)QL (270 mls/month (1 vial = 3 ml)QL (270 mls/month (1 vial = 3 ml)QL (270 mls/month (1 vial = 3 ml)QL (90 mls/month (1 vial = 3 ml)QL (2 inhalers/month)QL (120 vials/month (300 ml/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (30 packets/month)STDulera ST = (asthma) requires 60 day therapy of ICS or Symbicort in past 2 years;(COPD) requires 60 day therapy of LABA, Spiriva or Symbicort in past 2 yearspirbuterol inhaler MAXAIR 2 QL (2 inhalers/month)AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 41 2-Tier (open) Drug BenefitGuide 09/01/13

oflumilast DALIRESP 2 PA QL (30 tablets/month)salmeterol inhaler SEREVENT DISKUS 2 QL (1 inhaler/month)salmeterol-fluticasone inhaler ADVAIR 2 QL (1 inhaler/month) STAdvair ST = (asthma) requires 60 day therapy of ICS or Symbicort in past 2 years;sodium chloride soln nebu 7% HYPER-SAL NEBULIZER 2terbutaline *BRETHINE 1theophylline 1theophylline SLO-PHYLLIN 2theophylline THEOLAIR 2theophylline CR *UNIPHYL 1theophylline SR THEO-24 2tiotropium inhaler SPIRIVA 2zafirlukast *ACCOLATE 112-E Steroid InhalersGeneric Name Brand Namebeclomethasone HFA inhaler QVAR 40mcg 2beclomethasone HFA inhaler QVAR 80mcg 2budesonide inhaler PULMICORT FLEXIHALER 2budesonide nebulizer PULMICORT RESPULES 0.25mg 2budesonide nebulizer PULMICORT RESPULES 0.5mg 2ciclesonide inhaler ALVESCO 2flunisolide inhaler AEROBID 2flunisolide inhaler AEROBID-M 2fluticasone inhaler FLOVENT DISKUS 2fluticasone inhaler FLOVENT HFA 2mometasone inhaler ASMANEX 2triamcinolone inhaler AZMACORT 2QL (30 tablets/month)QL (1 inhaler/month)QL (60 tablets/month)TierNotesQL (1 inhaler/month)QL (2 inhaler/month)QL (1 inhaler/month)QL (120 respules/month)QL (60 respules/month)QL (3 inhaler/month)QL (3 inhaler/month)QL (1 diskus/month)QL (2 inhaler/month)QL (1 inhaler/month)QL (2 inhaler/month)SELF-INJECTABLE/SPECIALTY (injectable drugs)13-A AnticoagulantsGeneric Name Brand NameTierdalteparin sodium FRAGMIN 2enoxaparin sodium *LOVENOX 1fondaparinux sodium *ARIXTRA 1 PAtinzaparin sodium INNOHEP 2 PA SIO13-B Growth HormonesGeneric Name Brand NameTiermecasermin INCRELEX 2 PA SIO SPsomatropin TEV-TROPIN 2 PA SIO SPsomatropin NUTROPIN AQ 2 PA SIO SPsomatropin NUTROPIN AQ NUSPIN 2 PA SIO SPsomatropin NUTROPIN 2 PA SIO SPsomatropin SEROSTIM 2 PA SIO SPsomatropin ZORBTIVE 2 PA SIO SPsomatropin (non-refrigerated) SAIZEN 2 PA SIO SPtesamorelin EGRIFTA 2 PA SIO SPQL - Quantity Limits(COPD) requires 60 day therapy of LABA, Spiriva or Symbicort in past 2 yearsAL - Age LimitsNotesSIO (covered up to 21 days without prior auth)SIO (covered up to 21 days without prior auth)NotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 42 2-Tier (open) Drug BenefitGuide 09/01/13

13-C Hematopoietic AgentsGeneric Name Brand NameTierNotesdarbepoetin alpha ARANESP 2 PA SIO SPeltrombopag PROMACTA 2 PA SPepoetin alfa EPOGEN 2 PA SIO SPepoetin alfa PROCRIT 2 PA SIO SPfilgrastim NEUPOGEN 2 PA SIO SPpegfilgrastim NEULASTA 2 PA SIO SPpeginesatide acetate soln OMONTYS 2 PA SIOsargramostim LEUKINE 2 PA SIO SP13-D Hepatitis C AgentsGeneric Name Brand NameTierNotesboceprevir VICTRELIS 2 PA SPinterferon alfacon-1 INFERGEN 2 PA SIO SPpeginterferon alfa-2A PEGASYS 2 PA SIO SPpeginterferon alfa-2A PEGASYS PROCLICK 2 PA SIO SPpeginterferon alfa-2B PEG-INTRON 2 PA SIO SP STpeginterferon alfa-2B PEG-INTRON REDIPEN 2 PA SIO SP STPeg-Intron ST = requires trial of Pegasystelaprevir INCIVEK 2 PA SPREBETRON 2 PA SPROFERON A 2 PA SIO SP13-E Multiple Sclerosis AgentsGeneric Name Brand NameTierNotesdalfampridine AMPYRA 2 QL (60 tablets/month) PA SPdimethyl fumarate TECFIDERA 2 PA SPglatiramer acetate COPAXONE 2 PA SIO SPfingolimod GILENYA 2 PA SP STGilenya ST= requires trial to 1 formulary alternative: Avonex, Copaxone and/or Rebifinterferon beta-1A REBIF 2 PA SIO SPinterferon beta-1A AVONEX 2 PA SPinterferon beta-1A AVONEX ADMINISTRATION PACK 2 PA SIO SPinterferon beta-1B BETASERON 2 PA SIO SP STBetaseron ST= requires trial to Rebifteriflunomide AUBAGIO 2 PA SIO SP13-F Osteoporosis AgentsGeneric Name Brand NameTierNotesteriparatide (recombinant) FORTEO 2 PA SIO SP13-G Somatostatin AnalogsGeneric Name Brand NameTierNoteslanreotide acetate SOMATULINE DEPOT 2 PA SIO SPnafarelin SYNAREL 2 PAoctreotide acetate *OCTREOTIDE 2 PA SIO SPoctreotide acetate release SANDOSTATIN LAR 2 PA SIO SPpegvisomant SOMAVERT 2 PA SIO SP13-H ImmunomodulatorsQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 43 2-Tier (open) Drug BenefitGuide 09/01/13

Generic Name Brand NameTierNotesadalimumab HUMIRA 2 PA SIO SP STHumira ST = requires trial of 1 formulary alternative: Enbrel, Simponi, and/or Cimziaanakinra subcutaneous KINERET 2 PA SIO SPcertolizumab pegol CIMZIA 2 PA SIO SPetanercept for subcutaneous ENBREL 2 PA SIO SPgolimumab SIMPONI 2 QL (1 unit/month) PA SIO SPtofacitinib XELJANZ 2 PA STXELJANZ ST- requires trial of 2 formulary alternatives: Enbrel, Simponi, and/or Cimzia13-I Miscellaneous SpecialtyGeneric Name Brand NameTierNotesabatacept ORENCIA 2 PA SPcorticotropin ACTHAR HP 2 PA SIO SPicatibant acetate FIRAZYR 2 PA SPinterferon alfa-2B INTRON-A 2 PA SIOinterferon gamma-1B ACTIMMUNE 2 PA SIO SPleuprolide acetate ELIGARD 2 PA SIOleuprolide acetate LUPRON 2 SIOleuprolide acetate LUPRON DEPOT 2 SIOleuprolide acetate LUPRON DEPOT-PED 2 SIOnitisinone ORFADIN 2 PAoprelvekin NEUMEGA 2 PA SPoxandralone OXANDRALONE 2 PAoxymetholone ANADROL-50 2 PApalonosetron ALOXI (tablets) 2 PApeginterferon alfa-2B SYLATRON 2 PA SIO SPpeginterferon alfa-2B SYLATRON 4-PACK 2 PA SIO SPrilonacept ARCALYST 2 PA SIOEXCLUSIONS (excluded drugs)14-A Excluded From CoverageGeneric Name Brand Nameacyclovir hydrocortisone XERESEalcaftadine LASTACAFTalendronate BINOSTOamilodipine-atorvastatin CADUETamlodipine-aliskiren TEKAMLOamlodipine-aliskiren-hctz AMTURNIDEamlodipine-olmesartan AZORamlodipine-valsartan EXFORGEamlodipine-valsartan-hctz EXFORGE HCTantipyrine-benzocaine-polycosanol OTIC CAREantiseborrheic PROMISEB COMPLETE KITAPAP-caffeine-butalbital ORBIVANAPAP-codeine COCET PLUSAPAP-hydrocodone ZOLVITazelastine OPTIVARQL - Quantity LimitsAL - Age LimitsTierNotesPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 44 2-Tier (open) Drug BenefitGuide 09/01/13

azelastine hcl-fluticasone DYMISTAazelastine nasal ASTEPRObalsalazide disodium GIAZObenzocaine-antipyrine otic AURALGANbenzonatate ZONATUSSbenzoyl peroxide BREVOXYLbenzoyl peroxide DELOSbenzoyl peroxide NEOBENZ MICRO KIT PLUSbenzoyl peroxide TRIAZbenzoyl peroxide cleansing pad PACNEX HPbenzoyl peroxide cleansing pad PACNEX LPbenzoyl peroxide foam BENZEFOAM AERbenzoyl peroxide foam BENZEFOAM ULTRAbepotastine ophth BEPREVEbrinzolamide-brimonidine tartrate SIMBRINZAbromfenac ophth BROMDAYbromfenac sodium PROLENSAbuprenorphine hcl-naloxone ZUBSOLVbupropion SR APLENZINbupropion SR FORFIVO XLcarvedilol COREG CRcefixime SUPRAX CHEWcetirizine ZYRTECciclesonide nasal ZETONNAciclopirox CICLODAN KITciclopirox soln PEDIPIROXclindamycin phosphate CLINDACIN PACclindamycin phosphate swab CLINDACIN-Pclindamycin-benzoyl peroxide gel BENZACLIN CARE KITclindamycin-tretinoin VELTINclindamycin-tretinoin ZIANAclindamycin-tretinoin ACANYAclobetasol CLOBETAclobetasol CLOBEX SHAMPOOclobetasol OLUX-CPclonidine KAPVAYclonidine SR NEXICLON XR (suspension)clonidine SR NEXICLON XR (tablet)clotrimazole *LOTRIMIN 1%dermatological GENADUR KITdesloratadine CLARINEXdesonide DESONILdesoximetasone TOPICORT SPRAYdesvenlafaxine er DESVENLAFAXdextroamphetamine sulfate ZENZEDIdiclofenac CAMBIAdiclofenac patch FLECTORQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 45 2-Tier (open) Drug BenefitGuide 09/01/13

diclofenac potassium ZIPSORdiclofenac sol PENNSAIDdonepezil ARICEPT 23mgdoxepin SILENORdoxycycline hyclate DORYXdoxycycline hyclate MORGIDOXdoxycycline monohydrate ADOXAdoxycycline monohydrate Brand MONODOXdrospirenone-ethyinal-levomefolate BEYAZdrospirenone-ethyinyl SAFYRALdutasteride-tamsulosin JALYNemedastine EMADINEepinastine ELESTATepinephrine inj ADRENACLICKesomeprazole NEXIUMezetimibe-atorvastatin LIPTRUZETfelbamate FELBATOLfenofibrate TRICORfenofibric acid TRILIPIXferric subsulfate soln MONSELSfexofenadine ALLEGRAfexofenadine-pseudoephedrine ALLEGRA Dfluocinolone acetonide soln SYNALAR TSfluticasone furoate nasal VERAMYSTgabapentin GRALISEgabapentin enacarbil HORIZANTgranisetron patch SANCUSOhc-pramoxine cr-diet manage prod tab-cleans wipe kit ANALPRAM ADVANCED KIThydrocortisone topical HYDROCORTISONE 0.05%hydrocortisone topical HYDROCORTISONE 1%hydrocortisone topical HYTONEhydrocortisone topical NUCORThydrocortisone-pramoxine PROCORTibuprofen-famotidine DUEXISicosapent ethyl VASCEPAimiquimod ZYCLARAinterferon beta-1B EXTAVIAisotretinoin ABSORICAitraconazole ONMELketoconazole-hydrocortisone KETOCONketorolac ophth ACUVAILketotifen ZADITORketotifen ZADITOR OTCl-mehylfolate DEPLINlactic acid LAC-HYDRINlevocetirizine XYZALlevonor-eth es QUARTETTEQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 46 2-Tier (open) Drug BenefitGuide 09/01/13

lidocaine gel LIDORXloperamide IMODIUMloratadine CLARITINlorcaserin hcl BELVIQloteprednol etabonate LOTEMAX GELlovastatin SR ALTOPREVmemantine NAMENDA XRmesalamine DELZICOLmesalamine EC ASACOL HDmethylphenidate hcl susp QUILLIVANT XRmetoclopramide METOZOLV ODTmiconazole nitrate MICONAZOLE NITRATEminocycline SOLODYNmometasone MOMEXIN KITmorphine KADIANmupurocin oint kit CENTANY ATnaproxen NAPRELAN CR DOSE CARDnaproxen esomeprazole VIMOVOnimodipine NYMALIZEnorethindone ace-eth estradiol-fe MINASTRIN 24 FEnorethindrone-ethinyl estradiol-fe GENERESS FEnystatin cream-diaper rash cream kit PEDIADERM AFolmesartan-amlodipine-HCTZ TRIBENZORolopatadine PATANOLolopatadine PATADAYondansetron oral soluble film ZUPLENZoral wound care gel GELXoral wound care liquid EPISILoxcarbazepine OXTELLAR XRpancrelipase PERTZYEpancrelipase ULTRESAparoxetine mesylate BRISDELLEpramipexole SR MIRAPEX ERprednisone RAYOSprednisolone sodium phosphate ASMALPREDribavirin RIBAPAKrisedronate ATELVIAropinirole SR REQUIP XLserum-derived bovine ENTERAGAMsomatropin GENOTROPINsomatropin HUMATROPEsomatropin NORDITROPINsomatropin NORDITROPIN FLEXPROsomatropin NORDITROPIN NORDIFLEXsomatropin OMNITROPEsulfacetamide sodium-sulfur pad SUMAXIN CP KITsulfacetamide sodium sulfur SSS 10-4QL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 47 2-Tier (open) Drug BenefitGuide 09/01/13

sulfacetamide sodium-sulfur susp SUMAXIN TSsulfacetamide w/ sulfur wash SUMADANsulfacetamide sod-sulfur wash SODIUM SULFACETAMIDE/Sulfur Kitsumatriptan auto-injection ALSUMAsumatriptan-naproxen sodium TREXIMETtacrolimus ASTAGRAF XLtelmisartan-amlodipine TWYNSTATERMINEXtestosterone ANDROGELtobramycin-dexamethasone ophth TOBRADEX STtolterodine SR DETROL LAtramadol ER CONZIPtramadol ER RYZOLTtrazodone SR OLEPTROtretinoin ATRALINtretinoin RETIN-A MICROtretinoin RETIN-A PUMPtretinoin TRETIN-Xtriamcinolone TRIANEXtriamcinolone cream-emollient cream kit PEDIADERM TAurea emulsion UMECTA EMOLLIENTurea solution URAMAXIN GT KITvalsartan aliskiren VALTURNAvardenafil STAXYNwound dressings ATRAPRO CPzolpidem EDLUARzolpidem INTERMEZZOzolpidem ZOLPIMISTQL - Quantity LimitsAL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 48 2-Tier (open) Drug BenefitGuide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionabacavir sulfate 1-Iabacavir-lamivudine 1-Iabacavir-lamivudine-zidovudine 1-Iabatacept 13-IABILIFY 4-Dabiraterone acetate 2-AABSTRAL 9-BACANYA 14-Aacarbose 6-FACCOLATE 12-DACCU-CHEK ACTIVE CARE KIT 6-KACCU-CHEK ACTIVE TEST STRIPS 6-KACCU-CHEK ADVANTAGE CARE KIT 6-KACCU-CHEK AVIVA CARE KIT 6-KACCU-CHEK AVIVA TEST STRIPS 6-KACCU-CHEK COMFORT CURVE TEST STRIPS6-KACCU-CHEK COMPACT CARE KIT 6-KACCU-CHEK COMPACT TEST STRIPS 6-KACCUPRIL 3-FACCURETIC 3-IACCUTANE 5-BACCUZYME 5-Iacebutolol 3-CACEON 3-Facetazolamide 3-Jacetylcysteine 12-CACIPHEX 7-Eacitretin 5-FAclidinium bromideACLOVATE12-D5-Hacrivastine-PSE 12-CACTHAR HP 13-IACTIGALL 7-HACTIMMUNE 13-IACTIQ 9-BACTIVELLA 6-CACTONEL 6-JACTONEL with CALCIUM 6-JACTOPLUS MET 6-FACTOPLUS MET XR 6-FACTOS 6-FACULAR 11-HACULAR LS 11-HACUVAIL 14-Aacyclovir 1-Hacyclovir hydrocortisone 14-Aacyclovir topical 5-EACZONE 5-BADAGEN 7-GADALAT 3-DADALAT CC 3-Dadalimumab 13-Hadapalene 5-BADCIRCA 3-HADDERALL 4-EADDERALL XR 4-Eadefovir 7-HADOXA 14-AADRENACLICK 14-AADVAIR 12-DADVICOR 3-LAEROBID 12-EAEROBID-M 12-EAEROLATE 12-DAFINITOR 2-AAGENERASE 1-IAGGRENOX 10-EAGRYLIN 10-EAKNE-MYCIN 5-CAKTEN GEL 11-HALAMAST 11-Halbendazole 1-KALBENZA 1-Kalbuterol CR tablets 12-Dalbuterol HFA inhaler 12-Dalbuterol nebulizer 12-Dalbuterol SR tablets 12-Dalbuterol tablets 12-Dalbuterol-ipratropium inhaler 12-Dalbuterol-ipratropium nebulizer 12-D48 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionalclometasone 5-HALDACTAZIDE 3-JALDACTONE 3-JALDARA 5-IALDOMET 3-HALDORIL 3-Ialefacept 5-Ialendronate 6-Jalendronate-cholecalciferol 6-JALESSE 6-DALINIA 1-Laliskiren fumarate 3-HALKERAN 2-AALLEGRA 14-AALLEGRA D 14-AALLERX-D 12-Callopurinol 9-Falmotriptan 9-EALOCRIL 11-HALOMIDE 11-HALORA 6-Calosetron 7-HALOXI 13-IALPHAGAN P 11-Galprazolam 4-Aalprazolam SR 4-AALREX 11-CALSUMA 14-AALTABAX 5-CALTACE 3-FALTOCOR 3-LALTOPREV 14-Aaltretamine 2-Aaluminum chloride 5-Ialuminum chloride-alcohol 5-IALUPENT 12-DALVESCO 12-EAMANTADINE (Symmetrel) 4-HAMARYL 6-FAMBIEN 4-CAMBIEN CR 4-Cambrisentan 3-Hamcinonide 5-HAMERGE 9-EAMEVIVE 5-IAMICAR 10-Eamilodipine-atorvastatin 14-Aamiloride 3-Jamiloride-HCTZ 3-Jaminocaproic acid 10-Eaminophylline 12-Damiodarone 3-EAMITIZA 7-Hamitriptyline 4-Bamitriptyline-chlordiazepoxide 4-Famlexanox oral paste 11-Jamlodipine 3-Damlodipine-aliskiren 14-Aamlodipine-aliskiren-hctz 14-Aamlodipine-benazepril 3-Iamlodipine-olmesartan 3-Iamlodipine-valsartan 3-IAMNESTEEM 5-Bamoxapine 4-Bamoxicillin 1-Aamoxicillin-clarithro-lansopraz CR 7-Camoxicillin-clavulanate 1-Aamoxicillin-clavulanate SR 1-AAMOXIL 1-Aamphetamine-d-amphetamine 4-Eamphetamine-d-amphetamine SR 4-EAMPHETAMINE-D-AMPHETAMINE SR 4-Eampicillin 1-Aamprenavir 1-IAMPYRA 13-EAMRIX 9-GAMTURNIDE 14-Aamylase-lipase-protease 7-Gamy-lip-prot dr 7-GANADROL-50 13-I49 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionANAFRANIL 4-Banagrelide 10-Eanakira subcutaneous 13-HANALPRAM ADVANCED KIT 14-AANALPRAM-HC 5-AANAMANTLE 5-IANAPROX 9-Canastrozole 2-AANDRODERM 6-BANDROGEL 14-AANDROID 6-BANSAID 9-CANTABUSE 4-FANTARA 3-Lanthralin 5-Fantipyrine-benzocaine-polycosanol 14-AANUSOL-HC 5-AANZEMET 7-FAPAP-butalbital 9-AAPAP-caffeine-butalbital 9-AAPAP-caffeine-butalbital 14-AAPAP-codeine 14-AAPAP-codeine 9-BAPAP-hydrocodone 14-AAPAP-hydrocodone 9-BAPAP-isometh-caffeine 9-EAPAP-isometh-dichlor hydrate 9-EAPHTHASOL 11-JAPIDRA 6-Gapixaban 10-DAPLENZIN 14-AAPOKYN 4-Hapomorphine 4-Hapraclonidine ophth 11-GAPRESOLINE 3-HApri 6-DAPRISO 7-HAPTIVUS 1-IAQUATENSEN 3-JARALEN 1-JARANESP 13-CARAVA 9-DARCALYST 13-Iarformoterol tartrate nebulizer 12-DARICEPT 4-FARICEPT 14-AARIMIDEX 2-Aaripiprazole 4-DARIXTRA 13-Aarmodafinil 4-EARMOUR THYROID 6-IAROMASIN 2-AARTANE 4-Hartemether-lumefantrine 1-JARTHROTEC 9-CASA-caffeine-butalbital 9-AASA-caffeine-but-codeine 9-BASA-codeine 9-BASACOL HD 14-AASCENSIA AUTODISC TEST STRIPS 7-HASCENSIA BREEZE 2 TEST STRIPS 6-KASCENSIA ELITE TEST STRIPS 6-Kasenapine 6-KASENDIN 4-DASMALPRED 4-BASMANEX 14-AASTAGRAF XL 14-AASTELIN 12-EASTEPRO 12-BATABEX EC 14-AATACAND 10-BATACAND HCT 3-GATARAX 3-Iatazanavir 4-AATELVIA 1-Iatenolol 14-Aatenolol-chlorthalidone 3-CATIVAN 3-Iatomoxetine 4-Aatorvastatin 4-E50 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionatovaquone 3-Latovaquone-proguanil HCL 1-LATRALIN 1-JATRIPLA 14-Aatropine ophth 1-IATROVENT 11-EATROVENT HFA 12-DATROVENT NASAL 12-DAUBAGIO 12-Baugmented betamethasone 13-EAUGMENTIN 5-HAUGMENTIN XR 1-AAURALGAN 1-Aauranofin 14-AAVALIDE 9-DAVANDAMET 3-IAVANDARYL 6-FAVANDIA 6-FAVAPRO 6-FAVC vaginal 3-GAVELOX 8-CAviane 1-EAVINZA 6-DAVODART 9-BAVONEX 8-DAVONEX ADMINISTRATION 13-EPACKAXID 13-EAXIRON 7-DAYGESTIN 6-BAZASITE 6-Eazatadine-pseudoephedrine CR 11-Aazathioprine 12-Cazelaic acid 2-Bazelastine 5-Bazelastine nasal 14-AAZELEX 14-Aazilsartan medoxomil 5-Bazithromycin 3-Gazithromycin ER 1-Cazithromycin ophth 1-CAZMACORT 11-AAZOPT 12-EAZOR 11-Haztreonam 14-AAZULFIDINE 1-AAZULFIDINE EN 7-HB complex-vit C-FA 7-Hbacitracin ophth 10-Bbacitracin-polymyxin B ophth 11-Abaclofen 11-Abac-polymy-neomycin HC oint 9-GBACTRIM 5-CBACTROBAN 1-LBACTROBAN CREAM 5-CBACTROBAN NASAL OINTMENT 5-Cbalsalazide 5-CBANZEL 7-HBARACLUDE 4-Gbecaplermin 1-Ibeclomethasone HFA inhaler 5-Ibeclomethasone nasal 12-EBECONASE AQ 12-BBELVIQ 12-Bbenazepril 14-Abenazepril-HCTZ 3-FBENEMID 3-IBENICAR 9-FBENICAR HCT 3-GBENTYL 3-IBENZACLIN 7-CBENZACLIN CARE KIT 5-BBENZAMYCIN 14-ABENZEFOAM AER 5-BBENZEFOAM ULTRA 14-Abenzocaine-antipyrine otic 14-Abenzonatate 14-Abenzonatate 12-Cbenzoyl peroxide 14-Abenzoyl peroxide cleansing pad 14-A51 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionbenzoyl peroxide foam 14-Abenzoyl peroxide-adapalene 14-Abenzoyl peroxide-erythromycin gel 5-Bbenzoyl peroxide-salicylic acid-vit E 5-Bbenzoyl peroxide-urea 5-Bbenzoyl peroxide-vit E 5-Bbenztropine 5-Bbepotastine ophth 4-HBEPREVE 11-Hbesifloxacin ophth 14-ABESIVANCE 11-ABETAGAN 11-Abetamethasone dipropionate 11-Bbetamethasone foam 5-Hbetamethasone valerate 5-HBETAPACE 5-HBETAPACE AF 3-CBETASERON 3-Cbetaxolol 13-Ebetaxolol HCL ophth 3-Cbethanechol 11-BBETIMOL 8-BBETOPTIC-S 11-Bbexarotene 11-BBEYAZ 2-ABIAXIN 14-ABIAXIN XL 1-Cbicalutamide 1-CBICITRA 2-ABIDIL 8-DBILTRICIDE 3-Mbimatoprost ophth 1-KBIO-STATIN 11-Dbismuth subcit-metronidazole-tetracycline 1-Gbisoprolol 7-Cbisoprolol-HCTZ 3-CBLEPH-10 3-IBLEPHAMIDE 11-ABLOCADREN 11-Cboceprevir 3-CBONIVA 13-Dbosentan 6-JBOSULIF 3-Hbosutinib2-ABREO ELLIPTABRETHINE 2-ABREVICON 12-DBREVOXYL 6-DBRILINTA 14-Abrimonidine ophth 10-Ebrimonidine timolol ophth 11-Gbrinzolamide ophth 11-BBRISDELLE 14-ABROMDAY 11-Hbromfenac ophth 14-Abromocriptine 11-Hbromocriptine (tablets) 6-FBROMOXAFED 4-Hbromphen-PSE-DM 12-CBROVANA 12-Cbuconazole vaginal 12-Dbudesonide formoterol inhaler 8-Cbudesonide inhaler 12-Dbudesonide nasal 12-Ebudesonide nebulizer 12-Bbudesonide SR 12-Ebumetanide 7-HBUMEX 3-JBUPHENYL 3-Jbuprenorphine 7-Gbuprenorphine naloxone 9-Bbupropion 9-Bbupropion SR 4-Bbupropion SR 4-Bbupropion XL 14-ABUSPAR 4-Bbuspirone 4-Abusulfan 4-Abutenafine 2-Abutorphanol 5-D52 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionBUTRANS 9-BBXN MOUTHWASH 9-BBYDUREON 7-HBYETTA 6-JBYSTOLIC 6-Jcaberoline 3-CCADUET 6-JCAFERGOT 14-ACALAN 9-ECALAN SR 3-DCALCIFEROL 3-Dcalcipotriene 10-Acalcitonin 5-Fcalcitonin (salmon) nasal 6-Jcalcitriol 6-Jcalcitriol ointment 10-Acalcium acetate (phosphate binder) 5-Fcalcium acetate (phosphate binder) 7-HCAMBIA 7-HCamila 14-ACANASA 6-Dcandesartan 7-Hcandesartan-HCTZ 3-Gcapecitabine 3-ICAPEX 2-ACAPOTEN 5-HCAPOZIDE 3-Fcaptopril 3-Icaptopril-HCTZ 3-FCARAC 3-ICARAFATE 5-ICARBAGLU 7-Ccarbamazepine 6-Jcarbamazepine SR 4-GCARBATROL 4-Gcarbidopa-levodopa 4-Gcarbidopa-levodopa CR 4-Hcarbidopa-levodopa-entacapone 4-Hcarbinoxamine-PSE 4-Hcarbinoxamine-PSE-DM 12-Ccardec DM 12-CCARDENE 12-CCARDENE SR 3-DCARDIZEM 3-DCARDIZEM LA 3-DCARDIZEM SR 3-DCARDURA 3-Dcarglumic acid 3-Hcarisoprodol 6-Jcarisoprodol-ASA 9-Gcarisoprodol-ASA-codeine 9-GCARMOL 40 9-GCARMOL SCALP 5-ICARNITOR 5-Icarteolol HCL 6-Jcarteolol ophth 3-Ccartia XT 11-BCARTROL 3-Dcarvedilol 3-Ccarvedilol 3-CCASODEX 14-ACATAFLAM 2-ACATAPRES 9-CCATAPRES-TTS 3-HCAYSTON 3-HCECLOR 1-ACECLOR CD 1-BCEDAX 1-BCEENU 1-Bcefaclor 2-Acefaclor ER 1-Bcefadroxil 1-Bcefdinir 1-Bcefditoren pivoxil 1-Bcefpodoxime 1-Bcefprozil 1-Bceftibuten 1-BCEFTIN 1-Bcefuroxime 1-BCEFZIL 1-B53 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionCELEBREX 1-Bcelecoxib 9-CCELEXA 9-CCELLCEPT 4-BCELONTIN 2-BCENESTIN 4-GCENTANY AT 6-Ccephalexin 14-ACEREFOLIN 1-Bcertolizumab pegol 10-Ccetirizine 13-HCETRAXAL 14-Acevimeline 11-Ichloral hydrate 11-Jchlorambucil 4-Cchlordiazepoxide 2-Achlordiazepoxide-methscopolamine 4-Achlorhexidine 7-Cchloroquine 11-Jchlorothiazide 1-Jchloroxylenol-pramoxine-zinc acetate otic 3-Jchlorpheniramine 11-Ichlorpheniramine-PSE 12-Cchlorphen-pyrilamine-PE 12-Cchlorpromazine 12-Cchlorpropamide 4-Dchlorthalidone 6-Fchlorzoxazone 3-Jcholestyramine 9-Gcholine-mag salicylates 3-LCHROMAGEN FORTE 9-ACIALIS 10-Cciclesonide inhaler 8-Dciclesonide nasal 12-ECICLODAN KIT 12-Bciclopirox 14-Aciclopirox 5-Dciclopirox solution 14-Acilostazol 5-DCILOXAN 10-Ecimetidine 11-ACIMZIA 7-Dcinacalcet 13-HCIPRO 6-JCIPRO HC OTIC 1-ECIPRO XR 11-ICIPRODEX 1-Eciprofloxacin 11-Iciprofloxacin ophth 1-Eciprofloxacin SR 11-Aciprofloxacin-dexamethasone 1-Eciprofloxacin-HC otic 11-Icitalopram 11-ICITRANATAL PAK ASSURANCE 4-Bcitric acid-D-gluconic acid 10-Bcitric acid-sodium citrate 8-DCLARAVIS 8-DCLARINEX 5-Bclarithromycin 14-Aclarithromycin SR 1-CCLARITIN 1-CCLEOCIN 14-ACLEOCIN vaginal cream 1-CCLEOCIN-T 8-CCLIMARA 5-BCLIMARA PRO 6-CCLINDACIN PAC 6-CCLINDACIN-P 14-Aclindamycin 14-Aclindamycin phosphate 1-Cclindamycin phosphate swab 14-Aclindamycin topical 14-Aclindamycin vaginal 5-Bclindamycin-benzoyl peroxide gel 8-Cclindamycin-benzoyl peroxide gel 5-Bclindamycin-tretinoin 14-ACLINDESSE 14-ACLINORIL 8-CCLOBETA 9-Cclobetasol 14-A54 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionclobetasol foam 14-Aclobetasol propionate 5-HCLOBEX SHAMPOO 5-Hclocortolone 14-ACLODERM 5-Hclomipraminedesipramine 5-Hclonazepam 4-Bclonidine 4-Gclonidine 3-Hclonidine patch 14-Aclonidine SR 3-Hclopidogrel 14-Aclorazepate 10-Eclotrimazole 4-Aclotrimazole troche 14-Aclotrimazole-betamethasone 11-Jclozapine 5-DCLOZARIL 4-DCOARTEM 4-DCOCET PLUS 1-JCODEINE PHOSPHATE 14-ACODEINE SULFATE 9-BCODIMAL DH 9-BCOGENTIN 12-CCOGNEX 4-HCOLAZAL 4-FCOLBENEMID 7-Hcolchicine 9-Fcolchicine-probenecid 9-FCOLCRYS 9-Fcolesevelam 9-FCOLESTID 3-Lcolestipol 3-Lcollagenase 3-LCOLYTE 5-ICOMBIGAN 7-ACOMBIPATCH 11-BCOMBIVENT 6-CCOMBIVIR 12-DCOMBUNOX 1-ICOMPAZINE 9-BCOMPLERA 4-DCOMTAN 1-ICONCEPT DHA 4-HCONCEPT OB 10-BCONCERTA 10-BCONDYLOX 4-ECONTOUR TEST STRIPS 5-ICONZIP 6-KCOPAXONE 14-ACORDARONE 13-ECORDRAN 3-ECOREG 5-HCOREG CR 3-CCORGARD 14-ACORTEF 3-Ccorticotropin 6-Acortisone acetate 13-ICORTISPORIN CREAM 6-ACORTISPORIN OINTMENT 5-CCORTISPORIN OPHTH 5-CCORTISPORIN otic 11-CCORTISPORIN-TC 11-ICORTONE 11-ICORZIDE 6-ACOSOPT 3-ICOSOPT PF 11-BCOTAZYM 11-BCOUMADIN 7-GCOVERA HS 10-DCOZAAR 3-DCREON 3-GCRESTOR 7-GCRINONE 3-LCRIXIVAN 6-Ecrizotinib 2-Acrofelemer 11-HCROLOM ophth 7-Hcromolyn sodium inhaler 12-Dcromolyn sodium nebulizer 12-D55 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectioncromolyn sodium ophth 11-Hcrotamiton 5-GCUPRIMINE 9-DCUTIVATE 5-HCUVPOSA 7-Hcyanocobalamin (nasal) 10-Ccyanocobalamin inj 10-CCYCLESSA 6-Dcyclobenzaprine 9-GCYCLOCORT 5-HCYCLOGYL 11-Ecyclopentolate ophth 11-Ecyclophosphamide 2-ACYCLOSET 6-Fcyclosporine 2-Bcyclosporine modified 2-Bcyclosporine ophth 11-HCYLERT 4-FCYMBALTA 4-Bcyproheptadine 12-ACYSTARAN 6-ICYTOMEL 11-HCYTOTEC 7-CCYTOXAN 2-Adabrafenib mesylate 13-Edalfampridine 2-ADALIRESP 12-DDALMANE 4-Cdalteparin sodium 13-Adanazol 6-BDANOCRINE 6-BDANTRIUM 9-Gdantrolene 9-Gdapsone 1-LDAPSONE 1-Ldapsone 5-BDARAPRIM 1-Jdarbepoetin alpha 13-Cdarifenacin 8-Bdarunavir 1-IDARVOCET A 9-BDARVOCET N 9-BDARVON 9-BDARVON-N 9-Bdasatinib 2-ADAYPRO 9-CDDAVP 6-JDECADRON 6-ADECADRON ophth 11-CDECONAMINE 12-Cdeferasirox 9-Ddelavirdine 1-IDELZICOL 14-ADELOS 14-ADEMADEX 3-JDEMEROL 9-BDEMULEN 6-DDENAVIR 5-EDEPAKENE 4-GDEPAKOTE 4-GDEPAKOTE ER 9-EDEPEN 9-DDEPLIN 10-CDERMA-SMOOTH FS 14-ADERMATOP 5-Hdeserpidine-methyclothiazide 3-Hdesipramine 4-Bdesloratadine 14-Adesmopressin (nasal) 6-Jdesmopressin (oral) 6-JDESOGEN 6-Ddesonide 5-Hdesonide 14-Adesonide foam 5-HDESONIL 14-ADESOWEN 5-Hdesoximetasone 5-HDESOXYN 4-Edesvenlafaxine 4-BDESYREL 4-B56 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionDETROL 8-BDETROL LA 14-Adexamethasone 6-Adexamethasone ophth 11-Cdexamethasone phosphate ophth 11-CDEXEDRINE 4-EDEXEDRINE SPANSULES 4-EDEXILANT 7-Edexlansoprazole 7-Edexmethylphenidate 4-Edexmethylphenidate SR 4-Edextroamphetamine 4-Edextroamphetamine solution 4-Edextromethorphan quindine 4-FDIABETA 6-FDIABINESE 6-FDIAMOX 3-JDIASTAT 4-Gdiazepam 4-Adiazepam rectal 4-GDIBENZYLINE 3-Hdibigatran 10-DDICLEGIS 9-Cdiclofenac 7-Fdiclofenac 14-Adiclofenac gel 5-Hdiclofenac misoprostol 9-Cdiclofenac ophth 11-Hdiclofenac patch 14-Adiclofenac potassium 9-Cdiclofenac potassium 14-Adiclofenac sol 14-Adiclofenac SR 9-Cdicloxacillin 1-Adicyclomine 7-Cdidanosine 1-IDIDRONEL 6-JDIFFERIN 5-BDIFICID 1-Ldiflorasone diacetate 5-HDIFLUCAN 1-GDIFLUNISAL 9-Adifluprednate ophth 11-CDIGEX NF 7-Hdigoxin 3-Adihydrocodeine compound 9-Bdihydroergotamine (nasal) 9-EDILANTIN 4-GDILAUDID 9-Bdiltiazem 3-Ddiltiazem SR 3-Ddiltiazem SR 12HR 3-Ddiltiazem SR 24HR 3-Ddimethyl fumarate 3-GDIOVAN 13-EDIOVAN-HCT 3-IDIPENTUM 7-Hdiphenoxylate-atropine 7-Bdipivefrin ophth 11-GDIPROLENE 5-HDIPROLENE AF 5-HDIPROSONE 5-Hdipyridamole 10-Edipyridamole-aspirin SR 10-EDISALCID 9-Adisopyramide 3-EDISPERMOX 1-Adisulfiram 4-FDITROPAN 8-BDITROPAN XL 8-BDIURIL 3-Jdivalproex sodium (migraine) 9-Edivalproex sodium EC 4-GDIVIGEL 6-Cdocercalciferol 10-Adofetilide 3-Edolasetron 7-Fdonepezil 4-Fdonepezil 14-ADONNATAL 7-C57 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiondornase alfa 1-LDORYX 14-Adorzolamide ophth 11-Hdorzolamide-timolol ophth 11-BDOSTINEX 6-JDOVONEX 5-Fdoxazosin 3-Hdoxepin 4-Bdoxepin 14-Adoxycycline 1-Ddoxycycline hyclate 1-Ddoxycycline hyclate 14-Adoxycycline monohyclate 1-Ddoxycycline monohydrate 14-Adronabinol 7-Fdronedarone 3-Edrospirenone-ethyinal-levomefolate 14-Adrospirenone-ethyinyl 14-Adrospirenone-ethyinyl 6-DDRYSOL 5-IDUAC 5-BDUET DHA 10-BDUET DHA EC 10-BDUETACT 6-FDUEXIS 14-ADULERA 12-Dduloxetine 4-BDUONEB 12-DDURAGESIC 9-BDUREZOL 11-CDURICEF 1-Bdutasteride 8-Ddutasteride-tamsulosin 14-ADUTOPROL 14-ADYAZIDE 3-JDYMISTA 3-DDYNACIRC 14-ADYNACIRC CR 3-DDYNAPEN 1-ADYRENIUM 3-Jeconazole 5-DED CHLORPED 12-CEDARBI 3-GEDLUAR 14-AEDURANT 1-IEES 1-CEES-sulfisoxazole 1-Lefalizumab 13-Hefavirenz 1-Iefavirenz-emtricitabine-tenofovir 1-IEFFEXOR 4-BEFFEXOR XR 4-BEFFIENT 10-EEFUDEX 5-IEGRIFTA 13-BELAVIL 4-BELESTAT 14-Aeletriptan 9-EELIDEL 5-IELIGARD 13-IELIMITE 5-GELIPHOS 7-HELIQUIS 6-JELLA10DELMIRON 8-DELOCON 5-Heltrombopag 13-CEMADINE 14-AEMCYT 9-Bemedastine 14-AEMLA cream 5-IEMPIRIN w/CODEINE 9-Bemtricitabine 1-Iemtricitabine-rilpivirine-tenofovir 1-Iemtricitabine-tenofovir 1-IEMTRIVA 1-IENABLEX 8-Benalapril 3-Fenalapril-felodipine 3-Ienalapril-HCTZ 3-I58 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionENBREL 13-HENDURONYL 3-Henfuvirtide 1-IENJUVIA 6-Cenoxaparin sodium 13-AEnpresse 6-Dentacapone 4-Hentecavir 1-IENTOCORT EC 7-HENTUSS 12-CEPIDUO 5-BEPIFOAM 5-Hepinastine 14-Aepinephrine inj 3-KEPIPEN 3-KEPIPEN JR 3-KEPIVIR 1-IEPIVIR HBV 7-Heplerenone 3-Jepoetin alfa 13-CEPOGEN 13-Ceprosartan 3-Geprosartan-HCTZ 3-IEPZICOM 1-Iergocalciferol [vitamin D] 10-Aergoloid mesylates 4-Fergotamine-caffeine 9-Eergotamine-phenobarb-belladona 9-Eerlotinib 2-AErrin 6-DERTACZO 5-DERYGEL 5-BERYPED 1-CERY-TAB 1-CERYTHROCIN 1-Cerythromycin 1-CERYTHROMYCIN BASE 1-Cerythromycin EC 1-Cerythromycin estolate 1-Cerythromycin ethylsuccinate 1-Cerythromycin ointment 5-Cerythromycin stearate 1-Cerythromycin topical 5-Bescitalopram 4-BESCLIM 6-CESGIC PLUS 9-AESKALITH 4-DESKALITH CR 4-Desomeprazole 14-Aestazolam 4-Cesterified estrogens 6-CESTRACE 6-CESTRACE vaginal 8-CESTRADERM 6-Cestradiol 6-Cestradiol gel 6-Cestradiol patch 6-Cestradiol spray 6-Cestradiol TD gel 6-Cestradiol transdermal 6-Cestradiol vaginal 8-Cestradiol vaginal ring 8-Cestradiol valerate-dienogest 6-Destradiol-levonorgestrel patch 6-Cestradiol-norethindrone 6-Cestradiol-norethindrone patch 6-Cestradiol-norgestimate 6-Cestramustine 2-AESTRASORB 6-CESTRATEST 6-CESTRATEST HS 6-CESTRING 8-CESTROGEL 6-Cestrogen-medroxyprogesterone 6-Cestrogens (conjugated synthetic) 6-Cestrogens (conjugated) 6-Cestrogens (conjugated) vaginal 8-Cestrogens-methyltestosterone 6-Cestropipate 6-Cestropipate vaginal 8-C59 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionENTERAGAM 14-AESTROSTEP FE 6-Deszopiclone 4-Cetanercept for subcutaneous 13-Hethambutol 1-Fethinyl estradiol-norethindrone 6-Cethionamide 1-FETHMOZINE 3-Eethosuximide 4-Gethotoin 4-Getidronate 6-Jetodolac 9-Cetodolac SR 9-Cetoposide 2-AETRAFON 4-Fetravirine 1-IEULEXIN 2-AEURAX 5-GEVAMIST 6-Ceverolimus 2-AEVISTA 6-JEVOXAC 11-JEXALGO 9-BEXELON 4-FEXELON PATCH 4-Fexemestane 2-Aexenatide 6-JEXFORGE 3-IEXFORGE HCT 14-AEXJADE 14-AEXTAVIA 14-Aezetimibe 3-Lezetimibe-simvastatin 3-Lezogabine 1-Hfamciclovir 4-Gfamotidine 7-DFAMVIR 1-HFANAPT 4-DFARESTON 2-AFA-vit B6-vit B12 10-CFAZACLO 4-Dfe bisglycin-fe polysac 10-BFE fum-FA-DSS-B complex-vit C 10-CFE fum-fe poly-fa-c-b3 10-CFE fum-iron polysacch complex 10-CFE fum-vit C-vit B12-FA 10-Cfebuxostat 9-Ffelbamate 14-AFELBATOL 14-AFELDENE 9-Cfelodipine 3-DFEMARA 2-AFEMCAP 6-DFEMHRT 6-CFEMRING 8-Cfenofibrate 3-Lfenofibrate 14-Afenofibric acid 14-AFENOGLIDE 3-Lfenoprofen 9-Cfentanyl citrate SL 9-Bfentanyl lollipop 9-Bfentanyl patch 9-Bfentanyl transmucosal film 9-Bfentanyl transmucosal lozenge 9-BFENTORA 9-BFEXMID 9-Gfexofenadine 14-Afexofenadine-pseudoephedrine 14-Afexoterodine 8-Bfidaxomicin 1-Lfilgrastim 13-CFINACEA 5-Bfinasteride 8-Dfingolimod 13-EFIORICET 9-AFIORINAL 9-AFIORINAL w/CODEINE 9-BFIRAZYR 13-IFLAGYL 1-L60 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionFLAGYL ER 1-LFLAREX 11-Cflavoxate 8-Bflecainide 3-EFLECTOR 14-AFLEXERIL 9-GFLOMAX 8-DFLONASE 12-BFLORINEF 6-AFLOVENT DISKUS 12-EFLOVENT HFA 12-EFLOXIN 1-EFLOXIN OTIC 11-Iflucinolone oil 5-Hfluconazole 1-Gfludarabine 2-Afludrocortisone 6-AFLUMADINE 1-Hflunisolide inhaler 12-Eflunisolide nasal 12-Bfluocinolone acetonide 5-Hfluocinolone shampoo 5-Hfluocinonide 5-Hfluorometholone ophth 11-CFLUOROPLEX 5-Ifluorouracil 5-Ifluoxetine 4-Bfluphenazine 4-Dflurandrenolide patch 5-Hflurazepam 4-Cflurbiprofen 9-Cflurbiprofen ophth 11-Hflutamide 2-Afluticasone 5-Hfluticasone furoate nasal 14-Afluticasone inhaler 12-Efluticasone nasal 12-Bfluvastatin 3-Lfluvastatin SR 3-Lfluvoxamine 4-BFML FORTE 11-CFML LIQUIFILM 11-CFML SOP 11-CFOCALIN 4-EFOCALIN XR 4-EFOLBEE 10-CFOLGARD RX 10-Cfolic acid 10-CFOLTX 10-Cfondaparinux sodium 13-AFORADIL 12-Dformoterol fumarate inhaler 12-Dformoterol inhaler 12-DFORTAMET 6-FFORTEO 13-FFORTESTA 6-BFORTICAL 6-JFOSAMAX 6-JFOSAMAX PLUS D 6-Jfosamprenavir 1-Ifosfomycin 8-Afosinopril 3-Ffosinopril-HCTZ 3-IFOSRENOL 7-HFRAGMIN 13-AFREESTYLE FLASH SYSTEM 6-KFREESTYLE FREEDOM LITE METER 6-KFREESTYLE FREEDOM METER 6-KFREESTYLE LITE METER 6-KFREESTYLE SYSTEM 6-KFREESTYLE TEST STRIPS 6-KFROVA 9-Efrovatriptan 9-EFULYZAQ 8-AFURADANTIN 7-Hfurosemide 3-JFUZEON 1-Igabapentin 4-Ggabapentin enacarbil 14-AGABARONE 4-G61 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionGABITRIL 4-Ggalantamine 4-Fganciclovir 1-HGANTANOL 1-LGANTRISIN 1-LGARAMYCIN 5-Cgatifloxacin ophth 11-Agefitinib 2-AGELNIQUE 8-DGELX 3-Lgemfibrozil 14-AGENADUR KIT 14-AGENERESS FE 14-AGENGRAF 2-BGENOTROPIN 14-AGENTAMICIN OINT 3% 11-Agentamicin topical 5-Cgentamycin sulfate ophth 11-AGEODON 4-DGESTICARE DHA 10-BGIANVI 6-DGILENYA 13-Eglatiramer acetate 13-EGLEEVEC 2-Aglimepiride 6-Fglipizide 6-Fglipizide CR 6-Fglipizide-metformin 6-FGLUCAGON 6-HGLUCOMETER DEX TEST STRIPS 6-KGLUCOPHAGE 6-FGLUCOPHAGE XR 6-FGLUCOTROL 6-FGLUCOTROL XL 6-FGLUCOVANCE 6-FGLUMETZA 6-Fglyburide 6-Fglyburide micronized 6-Fglyburide-metformin 6-Fglycerol phenylbutyrate 7-Hglycopyrroate 9-Fglycopyrrolate 7-CGLYNASE 6-FGLYSET 6-Fgolimumab 13-HGOLYTELY 7-Agranisetron 7-Fgranisetron patch 14-AGRIFULVIN V 1-Ggriseofulvin microsize 1-Ggriseofulvin ultramicrosize 1-GGRIS-PEG 1-Gguaifenesin-DM 12-Cguanfacine 3-Hguanfacine 4-FGYNAZOLE-1 8-Chalcinonide 5-HHALCION 4-CHALDOL 4-Dhalobetasol 5-HHALOG 5-Hhaloperidol 4-Dhc lot 2% sal acid sulfur 2-2% 5-Hhc-pramoxine cr-diet manage prod tab-cleans wipe kit14-AHECTOROL 10-AHELIDAC 7-CHEPSERA 7-HHEXALEN 2-AHIVID 1-Ihomatropine ophth 11-EHORIZANT 14-AHUMALOG 6-GHUMALOG MIX 6-GHUMALOG MIX PEN 6-GHUMALOG PEN 6-GHUMATROPE 14-AHUMIBID-DM 12-CHUMIRA 13-HHUMULIN 6-GHUMULIN PEN 6-G62 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionHYCAMTIM 2-AHYCODAN 12-Chycosamine-phenyltoloxamine 7-HHYDERGINE 4-Fhydralazine 3-HHYDREA 2-Ahydrochlorothiazide 3-Jhydrocodone-guaifenesin 12-Chydrocodone-homatropine 12-CHYDROCORTISONE 14-Ahydrocortisone acetate 6-Ahydrocortisone butyrate 5-Hhydrocortisone rectal 5-Ahydrocortisone topical 14-Ahydrocortisone valerate 5-Hhydrocortisone-acetic acid otic 11-Ihydrocortisone-pramoxine 14-Ahydrocortisone-pramoxine rectal 5-AHYDRODIURIL 3-Jhydromorphone 9-Bhydromorphone ER 9-Bhydroxychloroquine 1-Jhydroxyprogesterone caproate 2-Ahydroxyurea 6-Ehydroxyzine HCL 4-Ahydroxyzine pamoate 4-AHYGROTON 3-JHYLIRA 5-Hhyoscyamine 7-Chyoscyamine SR 7-CHYPER-SAL NEBULIZER 12-DHYTONE 14-AHYTRIN 3-HHYZAAR 3-Iibandronate 6-Jibuprofen 9-Cibuprofen-famotidine 14-Aibuprofen-hydrocodone 9-Bicatibant acetate 13-IICLUSIG 4-Diloperidone2Ailoprost 3-HILOSONE 1-Cimatinib mesylate 2-AIMDUR 3-Bimipramine 4-Bimipramine pamoate 4-Bimiquimod 5-Iimiquimod 14-AIMITREX 9-EIMITREX NASAL 9-EIMODIUM 14-AIMURAN 2-BINCIVEK 13-DINCRELEX 13-Bindapamide 3-JINDERAL 3-CINDERAL LA 3-CINDERIDE 3-Iindinavir sulfate 1-IINDOCIN 9-CINDOCIN SR 9-Cindomethacin 9-Cindomethacin CR 9-CINFERGEN 13-DINNOHEP 13-AINNOPRAN XL 3-CINOVA 4/1 KIT 5-BINOVA KIT 5-BINSPRA 3-Jinsulin (human) 6-Ginsulin aspart 6-Ginsulin aspart mix 6-Ginsulin detemir 6-Ginsulin glargine 6-Ginsulin glulisine 6-Ginsulin lispro 6-Ginsulin lispro mix 6-GINTAL 12-DINTEGRA F 10-C63 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionINTEGRA PLUS 10-CINTELENCE 1-Iinterferon alfa-2B 13-Iinterferon alfacon-1 13-Dinterferon beta-1A 13-Einterferon beta-1B 13-Einterferon beta-1B 14-Ainterferon gamma-1B 13-IINTERMEZZO 14-AINTRON-A 13-IINTUNIV 4-FINVEGA 4-DINVEGA SUSTENNA 4-DINVIRASE 1-IINVOKANA 1-Liodoquinol 6-FIOPIDINE 11-Gipratropium HFA inhaler 12-Dipratropium inhaler 12-Dipratropium nasal 12-Bipratropium nebulizer 12-Dirbesartan 3-Girbesartan-HCTZ 3-IIRESSA 2-AISENTRESS 1-Iisoniazid 1-Fisoniazid-rifampin 1-Fisoniazid-rifampin-pyrazinamide 1-FISOPTO ATROPINE 11-EISOPTO CARPINE 11-FISOPTO HOMATROPINE 11-EISOPTO HYOSCINE 11-EISORDIL 3-Bisosorbide dinitrate 3-Bisosorbide dinitrate-hydralazine 3-Misosorbide mononitrate 3-Bisotretinoin 5-Bisradipine 3-Ditraconazole 1-Givermectin 1-KJALYN 14-AJANUMET 6-FJANUMET XR 6-FJANUVIA 6-FJolivette 6-DJune1 6-DJunel FE 6-DKADIAN 14-AKALETRA 1-IKAPVAY 14-AKARIGEL 11-JKARIGEL-N 11-JKariva 6-DKAYEXALATE 10-EKEFLEX 1-BKENALOG 5-HKENALOG-ORABASE 11-JKEPPRA 4-GKEPPRA XR 4-GKERAFOAM 5-IKERALAC 5-IKERLONE 3-CKEROL AD 5-IKETEK 1-CKETOCON 14-Aketoconazole 1-Gketoconazole shampoo 5-Dketoconazole topical 5-Dketoconazole-hydrocortisone 14-Aketoprofen 9-Cketoprofen SR 9-Cketorolac 9-Cketorolac ophth 11-Hketorolac ophth 14-Aketorolac tromethamine nasal 14-Aketotifen 14-AKINERET 13-HKLARON 5-BKLONOPIN 4-GKOMBIGLYZE XR 6-F64 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionK-PHOS 8-DKUVAN 6-JKU-ZYME 7-GKU-ZYME-HP 7-GKWELL 5-GKYNAMRO 7-FKYTRIL 3-Llabetalol 3-CLAC-HYDRIN 14-Alacosamide 4-Glactic acid 14-Alactulose 7-ALAMICTAL 4-GLAMICTAL ODT 4-GLAMICTAL ODT KIT 4-GLAMICTAL STARTER KIT 4-GLAMICTAL XR 4-GLAMICTAL XR KIT 4-GLAMISIL 1-GLAMISIL GRANULE PACKET 1-Glamivudine 1-Ilamivudine (hepatitis) 7-Hlamivudine-zidovudine 1-Ilamotrigine 4-GLANOXIN 3-Alanreotide acetate 13-Glansoprazole 7-Elansoprazole-naproxen 9-Clanthanum 7-HLANTUS 6-Glapatinib ditosylate 2-ALARIAM 1-JLASIX 3-Jlatanoprost ophth 11-DLATUDA 4-DLAZANDA 9-Dleflunomide 9-Blenalidomide 2-ALESCOL 3-LLESCOL XL 3-LLessina 6-DLETAIRIS 3-Hletrozole 2-ALEUCOVORIN CALCIUM 2-Aleucovorin calcium 2-ALEUKERAN 2-ALEUKINE 13-Cleuprolide acetate 13-Ilevalbuterol inhaler 12-Dlevalbuterol nebulizer 12-DLEVAQUIN 1-ELEVATOL 3-CLEVBID 7-CLEVEMIR 6-Glevetiracetam 4-GLEVLEN 6-DLEVLITE 6-Dlevobunolol ophth 11-Blevocarnitine 6-Jlevocetirizine 14-Alevofloxacin 1-Elevofloxacin ophth 11-ALevora 6-Dlevothroid 6-Ilevothyroxine 6-Ilevothyroxine 6-Ilevoxyl 6-ILEVSIN 7-CLEVSINEX 7-CLEXAPRO 4-BLEXIVA 1-ILEXXEL 3-ILIALDA 7-HLIBRAX 7-CLIBRIUM 4-ALIDEX 5-Hlidocaine 11-Jlidocaine (topical) 5-Ilidocaine ophth 11-Hlidocaine patch 5-I65 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionlidocaine-hydrocortisone 5-Ilidocaine-prilocaine 5-Ilidocaine-tetracaine 5-ILIDODERM 5-ILIDORX 4-FLIMBITROL 14-Alinaclotide 6-Flinagliptin 7-Hlindane shampoo 5-Glinezolid 1-LLINZESS 9-GLIORESAL 7-Hliothyronine 6-Iliotrix 6-ILIPITOR 3-LLIPTRUZET 4-ELIQUADD 14-Aliraglutide 6-Jlisdexamfetamine dimesylate 4-Elisinopril 3-Flisinopril-HCTZ 3-Ilithium carbonate 4-Dlithium carbonate CR 4-DLITHOBID 4-DLIVALO 3-LL-methylfolate 10-CL-methylfolate B12 B6 10-CL-methylfolate B12 B6 B2 10-CLO LOESTRIN FE 6-DLOCOID 5-HLODINE 9-CLODINE XL 9-Clodoxamide ophth 11-HLOESTRIN 6-DLOESTRIN 24 FE 6-DLOESTRIN FE 6-DLOFIBRA 3-LLOMOTIL 7-Blomustine 2-ALONITEN 3-HLO-OVRAL 6-Dloperamide 14-ALOPID 3-Llopinavir-ritonavir 1-ILOPRESSOR 3-CLOPROX 5-DLORABID 1-Lloracarbef 1-Lloratadine 14-Alorazepam 4-ALORCET 9-BLORTAB 9-BLORYNA 6-Dlosartan 3-Glosartan-HCTZ 3-ILOSEASONIQUE 6-DLOTEMAX 11-CLOTENSIN 3-FLOTENSIN HCT 3-Iloteprednol etb-tobramycin ophth 11-Cloteprednol ophth 11-CLOTREL 3-ILOTRIMIN 1% 14-ALOTRISONE 5-DLOTRONEX 7-Hlovastatin 3-Llovastatin SR 3-LLOVAZA 3-LLOVENOX 13-ALow-Ogestrel 6-Dloxapine 4-DLOXITANE 4-DLOZOL 3-Jlubiprostone 7-HLUDIOMIL 4-BLUMIGAN 11-DLUNESTA 4-C66 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionLUPRON 13-ILUPRON DEPOT 13-ILUPRON DEPOT-PED 13-Ilurasidone 4-DLutera 6-DLUVOX 4-BLUVOX CR 4-BLUXIQ 5-HLYBREL 6-DLYRICA 4-GLYSODREN 2-ALYSTEDA 10-EMACROBID 8-AMACRODANTIN 8-AMAKENA 1-JMALARONE 6-Emaprotiline 4-Bmaraviroc 1-IMARINOL 7-FMATULANE 2-AMAVIK 3-FMAXAIR 12-DMAXALT 9-EMAXALT MLT 9-EMAXIDEX 11-CMAXIDONE 9-BMAXIPHEN-G 12-CMAXZIDE 3-JMEBARAL 4-Cmebendazole 1-Kmecasermin 13-Bmeclofenamate 9-CMECLOMEN 9-CMEDROL 6-Amedroxyprogesterone 6-Emefenamic acid 9-Cmefloquine 1-JMEGACE 2-AMEGACE ES 2-Amegestrol 2-AMEKINIST 2-Ameloxicam 9-Cmelphalan 2-Amenantine 4-FMENEST 6-CMENOSTAR 6-CMENTAX 5-Dmeperidine 9-Bmephobarbital 4-CMEPHYTON 10-Ameprobamate 4-AMEPRON 1-Lmercaptopurine 2-Amesalamine 7-Hmesalamine CR 7-Hmesalamine EC 7-Hmesalamine enema 7-Hmesna 2-AMESNEX 2-AMESTINON 9-HMETADATE CD 4-EMETAGLIP 6-FMETANX 10-Cmetaproterenol inhaler 10-Cmetaproterenol nebulizer 12-Dmetaproterenol tablets 12-Dmetaxalone 9-Gmetformin 6-Fmetformin SR 6-FMETHADONE 9-Bmethamphetamine 4-Emethazolamide 3-Jmethenamine-NA biphosphate 8-AMETHERGINE 8-Dmethimazole 6-IMETHITEST 6-Bmethocarbamol 9-Gmethocarbamol-ASA 9-Gmethotrexate 2-Amethotrexate 9-D67 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionmethoxsalen 5-Fmethscopolamine 7-Cmethsuximide 4-Gmethyclothiazide 3-Jmethyldopa 3-Hmethyldopa-HCTZ 3-Imethylergonovine 8-DMETHYLIN 4-EMETHYLIN ER 4-Emethylnaltrexone bromide 7-Hmethylphenidate 4-Emethylphenidate CR 4-Emethylphenidate SA 4-Emethylphenidate SR 4-Emethylprednisolone 6-Amethyltestosterone 6-Bmetipranolol ophth 11-Bmetoclopramide 7-Hmetoclopramide 14-Ametolazone 3-Jmetoprolol 3-Cmetoprolol succinate SR 3-Cmetoprolol/hctz 14-AMETOZOLV ODT 14-AMETROCREAM 5-BMETROGEL 5-BMETROGEL vaginal 8-CMETROLOTION 5-Bmetronidazole 1-Lmetronidazole CR 1-Lmetronidazole cream 5-Bmetronidazole gel 5-Bmetronidazole lotion 5-Bmetronidazole vaginal 8-Cmetronidazole-tetracycline-bismuth 7-CMEVACOR 3-Lmexiletine 3-EMEXITIL 3-EMIACALCIN 6-JMICARDIS 3-GMICARDIS HCT 3-Imiconazole nitrate 14-AMICONAZOLE NITRATE 14-Amiconazole-zinc oxide-white petroleum 1-GMicrogestin 6-DMicrogestin FE 6-DMICROZIDE 3-Jmidodrine 3-KMIDRIN 9-Emiglitol 6-Fmiglustat 7-GMIGRANAL 9-EMILIPRED DP PAK 6-Amilnacipran 4-GMINASTRIN 24 FE 3-HMINIPRESS 14-AMINITRAN 3-BMINOCIN 1-Dminocycline 1-Dminocycline 14-Aminoxidil 3-HMINTEZOL 1-Kmipomersen sodium 4-Hmirabegron3-LMIRAPEXMIRAPEX ER 8-B14-AMIRCETTE 6-Dmirtazapine 4-Bmirtazapine soltabs 4-Bmisoprostol 7-Cmitotane 2-AMOBIC 9-Cmodafinil 4-EMODICON 6-DMODURETIC 3-Jmoexipril 3-Fmoexipril-HCTZ 3-Imometasone 5-Hmometasone 14-Amometasone inhaler 12-E68 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionmometasone nasal 12-Bmometasone-formoterol inhalers 12-DMOMEXIN KIT 14-AMONODOX 1-DMononessa 6-DMONOPRIL 3-FMONOPRIL HCT 3-IMONSELS 14-Amontelukast 12-DMONUROL 8-AMORGIDOX 14-Amoricizine 3-Emorphine 9-Bmorphine 14-Amorphine sulfate 9-Bmorphine sulfate SR 9-Bmorphine-naltraxone 9-BMOTRIN 9-CMOVIPREP 7-AMOXATAG 1-AMOXEZA 11-Amoxifloxacin 1-Emoxifloxacin ophth 11-AMS CONTIN 9-BMUCOMYST 12-CMUCOTROL 11-JMULTAQ 3-Emulti vitamin 10-Bmupirocin 5-Cmupurocin oint kit 14-AMYAMBUTOL 1-FMYCELEX TROCHE 11-JMYCIFRADIN 1-LMYCOBUTIN 1-FMYCOLOG II 5-Dmycophenolate 2-Bmycophenolate mofetil 2-BMYCOSTATIN 1-GMYCOSTATIN topical 5-DMYDRIACYL 11-EMYFORTIC 2-BMYLERAN 2-AMYRBETRIQ4-GMYSOLINEnabumetone 8-B9-Cnadolol 3-Cnadolol-bendroflumethiazide 3-Inafarelin 13-Gnaftifine 5-DNAFTIN 5-DNALFON 9-Cnaltrexone 9-BNAMENDA 4-FNAMENDA XR 4-FNAPRELAN CR DOSE CARD 14-ANAPROSYN 9-Cnaproxen 9-Cnaproxen 14-Anaproxen esomeprazole 14-Anaproxen sodium 9-Cnaratriptan 9-ENARDIL 4-BNASACORT 12-BNASACORT AQ 12-BNASALIDE 12-BNASAREL 12-BNASCOBAL 10-CNASONEX 12-BNATALCARE 10-BNATAZIA 6-Dnateglinide 6-FNATELLE C 10-BNATELLE ONE 10-BNATROBA 5-GNATURE-THROID 6-INAVANE 4-Dnebivolol 3-CNecon 6-DNecon 10/11 6-DNecon 7/7/7 6-D69 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionnedocromil inhaler 12-Dnedocromil ophth 11-HNEEVO DHA 10-Bnefazodone HCL 4-Bnelfinavir mesylate 1-INEOBENZ MICRO KIT PLUS 14-Aneomycin 1-Lneomycin-colistin-HC-thonzonium otic 11-Ineomycin-polymyxin B-gramacidin ophth 11-Aneomycin-polymyxin-HC cream 5-Cneomycin-polymyxin-HC ophth 11-Cneomycin-polymyxin-HC otic 11-INEORAL 2-BNEOSPORIN ophth 11-Anepafenac ophth 11-HNEPHROCAPS 10-BNEPHRON FA 10-CNEPTAZANE 3-JNESTABS 10-BNEULASTA 13-CNEUMEGA 13-INEUPOGEN 13-CNEURONTIN 4-GNEVANAC 11-Hnevirapine 1-INEXAVAR 1-Inevirapine XR 2-ANEXICLON XR 14-ANEXIUM 14-Aniacin SR 3-Lniacin-lovastatin CR 3-LNIASPAN 3-Lnicardipine 3-Dnifedipine CR 3-Dnifedipine IR 3-DNIFEREX GOLD 10-BNILANDRON 2-Anilotinib 2-Anilutamide 2-ANIRAVAM 4-Anisoldipine SR 3-Dnitazoxanide 1-Lnitisinone 13-INITROBID 3-BNITRO-DUR 3-Bnitrofurantoin macro 8-Anitrofurantoin macrocrystals 8-Anitrofurantoin susp 8-Anitroglycerin ointment 3-Bnitroglycerin patch 3-Bnitroglycerin spray 3-BNITROLINGUAL PUMPSPRAY 3-Bnitroquick 3-BNITROSTAT 3-Bnizatadine 7-DNIZORAL 1-GNIZORAL SHAMPOO 5-DNOLVADEX 2-ANora-Be 6-DNORCO 9-BNORDETTE 6-DNORDITROPIN 14-ANORDITROPIN FLEXPRO 14-ANORDITROPIN NORDIFLEX 14-Anorethindrone 6-Enorethindrone-ethinyl estradiol-fe 14-ANORFLEX 9-Gnorfloxacin 1-ENORINYL 6-DNORITATE 5-BNORMODYNE 3-CNOROXIN 1-ENORPACE 3-ENORPRAMIN 4-BNORTHYX 6-DNortrel 6-DNortrel 7/7/7 6-Dnortriptyline 4-BNORVASC 3-DNORVIR 1-I70 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionNOVAHISTINE 12-CNOVOLIN 6-GNOVOLOG 6-GNOVOLOG MIX 6-GNOXAFIL 1-GNUCORT 14-ANUCYNTA 9-BNUCYNTA ER 9-BNUEDEXTA 9-BNULEV 7-CNULYTELY 7-ANUTROPIN 13-BNUTROPIN AQ 13-BNUTROPIN AQ NUSPIN 13-BNUVARING 6-DNUVIGIL 4-ENYMALIZE 14-Anystatin 1-Gnystatin cream-diaper rash cream kit 14-Anystatin topical 5-Dnystatin vaginal 8-Cnystatin-triamcinolone 5-DOCELLA 6-DOCTREOTIDE 13-Goctreotide acetate 13-Goctreotide acetate release 13-GOCUFEN 11-HOCUFLOX 11-AOCUPRESS 11-Bofloxacin 1-Eofloxacin ophth 11-Aofloxacin otic 11-IOFORTA 2-AOGEN 6-COGEN vaginal 8-COgestrel 6-Dolanzapine 4-Dolanzapine-fluoxetine 4-FOLEPTRO 14-Aolmesartan 3-Golmesartan-amlodipine-HCTZ 14-Aolmesartan-HCTZ 3-Iolopatadine 14-Aolopatadine nasal 12-BOLUX-CP 14-AOLUX 5-Homega-3-acid ethyl esters 3-Lomeprazole 7-Eomeprazole-sodium bicarb 7-EOMNARIS 12-BOMNICEF 1-BOMNITROPE 14-Aondansetron 7-Fondansetron oral soluble film 14-AONE TOUCH SYSTEM 6-KONE TOUCH TEST STRIPS 6-KONE TOUCH ULTRA 2 SYSTEM 6-KONE TOUCH ULTRA MINI SYSTEM 6-KONE TOUCH ULTRA SYSTEM 6-KONE TOUCH ULTRA TEST STRIPS 6-KONGLYZA 6-FONSOLIS 9-BOPANA 9-BOPANA ER 9-Bopium tincture 7-BOPIUM TINCTURE 7-Boprelvekin 13-IOPTIPRANOLOL 11-BOPTIVAR 14-AORACEA 1-Doral hydrogel wafer 11-Joral wound care gel 4-FORAP 14-AORAPRED 6-AORBIVAN 14-AORENCIA 13-IORFADIN 13-Iorphenadrine citrate 9-GORTHO CEPT 6-DORTHO CYCLEN 6-D71 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionORTHO EVRA 6-DORTHO MICRONOR 6-DORTHO NOVUM 1/35 6-DORTHO NOVUM 1/50 6-DORTHO NOVUM 10/11 6-DORTHO NOVUM 7/7/7 6-DORTHO TRI-CYCLEN 6-DORTHO TRI-CYCLEN LO 6-DORTHO-PREFEST 6-CORUDIS 9-CORUVAIL 9-Coseltamivir 1-HOSPHENA 14-AOTIC CARE 6-COVACE 5-IOVACE PLUS SHAMPOO 1% 5-IOVCON 6-DOVRAL 6-DOVRETTE 6-Doxandralone 13-IOXANDRALONE 13-Ioxaprozin 9-Coxazepam 4-Aoxcarbazepine 4-Goxiconazole 5-DOXISTAT 5-DOXSORALEN-ULTRA 5-FOXTELLAR XR 8-Boxybutynin 14-Aoxybutynin CR 8-Boxybutynin gel 8-Doxybutynin patches 8-Boxycodone 9-Boxycodone SR 9-Boxycodone-APAP 9-Boxycodone-ASA 9-Boxycodone-ibuprofen 9-BOXYCONTIN 9-BOXYIR 9-Boxymetholone 13-Ioxymorphone 9-Boxymorphone ER 9-BOXYTROL 8-BPACNEX HP 14-APACNEX LP 14-Apaliperidone 4-Dpaliperidone palmitate 4-Dpalonosetron 13-IPAMELOR 4-BPAMINE 7-CPANCREASE MT 7-GPANCRECARB 7-Gpancrelipase 7-Gpantoprazole 7-Epapain-urea 5-Ipapain-urea-chlorophyllin foam 5-IPAPFYLL 5-IPARAFON FORTE 9-GPARCOPA 4-Hparegoric 7-Bparicalcitol [vitamin D] 10-APARLODEL 4-Hparoxetine HCL 4-Bparoxetine HCL SR 4-Bparoxetine mes 4-BPATADAY 14-APATANASE 12-BPATANOL 14-APAXIL 4-BPAXIL CR 4-Bpazopanib 2-APCE 1-Cped multi vitamin-fluoride 10-Bped multi vitamin-fluoride-FE 10-Bped vitamins ACD-fluoride 10-Bped vitamins ACD-fluoride-FE 10-BPEDIADERM AF 14-APEDIADERM TA 14-APEDIAPRED 6-APEDIATEX D 12-C72 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPEDIATEX DM 12-CPEDIAZOLE 1-LPEDIPIROX 14-APEG 3350 7-APEG electrolyte 7-Apeg(high)-electrolyte 7-Apegademase 7-GPEGANONE 4-GPEGASYS 13-DPEGASYS PROCLICK 13-Dpegfilgrastim 13-Cpeginterferon alfa-2A 13-Dpeginterferon alfa-2B 13-Ipeginterferon alfa-2B 13-DPEG-INTRON 13-DPEG-INTRON REDIPEN 13-Dpegvisomant 13-Gpemirolast ophth 11-Hpemoline 4-Fpenbutolol sulfate 3-Cpenciclovir 5-Epenicillamine 9-Dpenicillin V potassium 1-APENLAC 5-DPENNSAID 14-APENTASA 7-Hpentazocine-naloxone 9-Bpentosan polysulfate sodium 8-Dpentoxifylline 10-EPEPCID 7-DPE-pyrilamine-hydrocodone 12-CPERCOCET 9-BPERCODAN 9-BPERFOROMIST 12-Dpergolide 4-HPERIACTIN 12-APERIDEX 11-Jperindopril 3-FPERIOSTAT 1-DPERMAX 4-Hpermethrin 5-Gperphenazine 4-Dperphenazine-amitriptyline 4-FPERSANTINE 10-EPEXEVA 4-Bphenazopyridine 8-Dphenelzine sulfate 4-BPHENERGAN 12-APHENERGAN VC 12-CPHENERGAN VC w/CODEINE 12-CPHENERGAN w/CODEINE 12-Cphenobarbital 4-Cphenobarbital-belladonna 7-Cphenoxybenzamine 3-Hphenylephrine-guaifenesin 12-Cphenytoin 4-GPHOSLO 7-HPHRENILIN 9-Aphytonadione 10-Apilocarpine 11-Jpilocarpine ophth 11-FPILOPINE HS 11-FPILOPTIC-1/2 11-FPILOPTIC-3 11-Fpimecrolimus 5-Ipimozide 4-Fpindolol 3-Cpiolitazone 6-Fpiolitazone-glimepiride 6-Fpiolitazone-metformin 6-Fpirbuterol inhaler 12-Dpiroxicam 9-Cpitavastatin 3-LPLAQUENIL 1-JPLAVIX 10-EPLENDIL 3-DPLETAL 10-EPLEXION 5-BPODOCON 5-Ipodofilox 5-I73 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionpodophyllum resin 5-IPOLYSPORIN ophth 11-APOLYTRIM ophth 11-APOLY-VI-FLOR 10-BPOLY-VI-FLOR-FE 10-Bpomalidomide 9-CPOMALYST 2-Aponatinib hcl 2-APONSTEL 2-APortia 6-Dposaconazole 1-GPOTABA 10-Apotassium aminobenzoate 10-APOTASSIUM CHLORIDE 8-Dpotassium citrate CR 8-Dpotassium phosphate 8-DPOTIGA 10-DPRADAXA 4-Gpramipexole 4-Hpramipexole SR 14-Apramlintide 6-JPRAMOSONE 5-Hpramoxine-HC cream 5-Hpramoxine-HC foam 5-HPRANDIMET 6-FPRANDIN 6-Fprasugrel 10-EPRAVACHOL 3-Lpravastatin 3-Lpraziquantel 1-Kprazosin 3-HPRECARE 10-BPRECISION XTRA METER 6-KPRECISION XTRA TEST STRIPS 6-KPRECOSE 6-FPRED FORTE 11-Cprednicarbate 5-Hprednisolone 6-APREDNISOLONE 6-Aprednisolone ophth 11-Cprednisolone sodium 6-Aprednisolone sodium phosphate 6-Aprednisolone sodium phosphate 14-Aprednisone 6-APREFERA OB 10-BPREFERA OB + DHA 10-Bpregabalin 4-GPRELONE 6-APREMARIN 6-CPREMARIN vaginal 8-CPREMPHASE 6-CPREMPRO 6-Cprenatal FE-CBN-DSS-Methylfol-FA 10-Bprenatal mv w/fe fum-fa 10-Bprenatal vitamin-FE-bisglycinate-FA 10-Bprenatal vitamins-fe- bis-fe prot succ-fa-ca- 10-Bprenatal vitamins-FE-FA 10-Bprenatal vitamins-FE-FA-CA-omega 10-Bprenatal vitamins-iron carbonyl-FA 10-Bprenatal w/dss iron carbonyl-fa 10-Bprenatal w/fe fum-l methylfolate 10-BPRENATE DHA 10-BPRENATE ELITE 10-Bprenate vitamin FE-Fum-Lmethylfol-FA-CA 10-Bprenate w/fe fum-fe poly-fa omega 3 10-Bprenate w/o a w/fe fum-fe poly-fa 10-Bprenate w/o a w/fecbn-egl-dss-fa & dha 10-Bprenate w/o Vit A w/ FE 10-Bprenat-fe poly cmplx-fe heme 10-BPREVACID 7-EPREVACID NAP KIT 9-CPREVACID SOLUTAB 7-EPrevifem 6-DPREVPAC 7-CPREZISTA 1-IPRILOSEC 7-EPRILOSEC POWDER SUSPENSION 7-EPRIMACARE 10-Bprimaquine 1-JPRIMAQUINE 1-J74 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionprimidone 4-GPRINCIPEN 1-APRINIVIL 3-FPRINZIDE 3-IPRISTIQ 4-BPROAIR HFA 12-DPROAMATINE 3-KPRO-BANTHINE 7-Cprobenecid 9-Fprocainamide 3-Eprocainamide SR 3-EPROCANBID 3-Eprocarbazine HCL 2-APROCARDIA 3-DPROCARDIA XL 3-Dprochlorperazine 4-DPROCORT 14-APROCRIT 13-CPROCTOFOAM-HC 5-APRODRIN 9-Eprogesterone micronized 6-Eprogesterone vaginal 2-BPROGRAF 6-EPROLENSA 4-DPROLIXIN 14-APROMACTA 13-Cpromethazine 12-Apromethazine VC 12-Cpromethazine VC- codeine 12-Cpromethazine-codeine 12-CPROMETRIUM 6-EPromiseb Complete Kit 3-EPRONESTYL 14-Apropafenone 3-Epropantheline 7-CPROPINE 11-Gpropoxyphene 9-Bpropoxyphene nap-APAP 9-Bpropoxyphene napsylate 9-Bpropoxyphene-APAP 9-Bpropranolol 3-Cpropranolol HCL CR 3-Cpropranolol HCL SR 3-Cpropranolol-HCTZ 3-Ipropylthiouracil 6-IPROSCAR 8-DPROSOM 4-CPROTONIX 7-EPROTOPIC 5-Iprotriptyline 4-BPROVENTIL 12-DPROVENTIL HFA 12-DPROVENTIL REPETABS 12-DPROVERA 6-EPROVIGIL 4-EPROZAC 4-BPROZAC WEEKLY 4-BPSE-guaifenesin-codeine 12-CPSE-methscopolamine 12-Cpseudoephed-chlorphen-DM 12-CPSORCON 5-HPSORIATEC 5-FPTU 6-IPULMICORT FLEXIHALER 12-EPULMICORT RESPULES 12-EPULMOZYME 1-LPURINETHOL 2-APYLERA 7-Cpyrazinamide 1-FPYRIDIUM 8-Dpyridostigmine 9-Hpyrilamine tannate 12-Apyrilamine-phenyleph 12-Cpyrimethamine 1-JPYRLEX SYRUP 12-AQUARTETTE 14-AQUESTRAN 3-Lquetiapine fumarate 4-DQUILLIVANT XR 3-Fquinapril 14-A75 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionquinapril-HCTZ 3-Iquinidine gluconate 3-Equinidine sulfate 3-Equinine sulfate 1-JQUIXIN 11-AQVAR 12-Erabeprazole 7-Eraloxifene 6-Jraltegravir 1-Iramelteon 4-Cramipril 3-FRANEXA 3-M ranitidine 7-Dranolazine 3-MRAPAFLO 8-DRAPAMUNE 2-BRAVICTI 13-HRAZADYNE 9-FRAZADYNE ER 4-FREBETOL 1-HREBETRON 13-DREBIF 13-EReclipsen 6-Drefaximin 1-LREGLAN 7-Hregorafenib 5-IREGRANEX 2-ARELAFEN 9-CRELENZA 1-HRELION 6-GRELISTOR 7-HRELPAX 9-EREMERON 4-BREMERON SOLTABS 4-BRENACIDIN 8-DRENAGEL 7-HRENVELA 7-Hrepaglinide 6-Frepaglinide-metformin 6-FREPREXAIN 9-BREQUIP 4-HREQUIP XL 14-ARESCRIPTOR 1-Ireserpine 3-HRESTASIS 11-HRESTORIL 4-Cretapamuln 5-CRETIN-A 5-BRETIN-A MICRO 14-ARETIN-A PUMP 14-ARETROVIR 1-IREVATIO 3-HREVIA 9-BREVLIMID 2-AREYATAZ 1-IRHINOCORT AQUA 12-Bribavirin 1-HRIDAURA 9-Drifabutin 1-FRIFADIN 1-FRIFAMATE 1-Frifampin 1-FRIFATER 1-Frilonacept 13-Irilpivirine 1-IRILUTEK 9-Hriluzole 9-Hrimantadine 1-Hrimexolone ophth 11-CRIOMET 6-Frisedronate 14-Arisedronate 6-Jrisedronate-calcium 6-JRISPERDAL 4-DRISPERDAL M 4-Drisperidone 4-DRITALIN 4-ERITALIN LA 4-ERITALIN SR 4-Eritonavir 1-I76 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionrivaroxaban 10-Drivastigmine 4-Frizatriptan 9-EROBAXIN 9-GROBAXISAL 9-GROBINUL 7-CROBINUL FORTE 7-CROCALTROL 10-AROFERON A 13-Droflumilast 12-DRONDEC 12-CRONDEC DM 12-Cropinirole 4-Hropinirole SR 14-Arosiglitazone 6-Frosiglitazone maleate-glimepiride 6-Frosiglitazone-metformin 6-Frosuvastatin 3-LROWASA 7-HROXANOL 9-BROXICODONE 9-BROZEREM 4-Crufinamide 4-GRYNA-12 12-CRYNATAN-S 12-CRYTHMOL 3-ERYTHMOL SR 3-ERYZOLT 14-ASABRIL 4-Gsacrosidase 7-GSAFYRAL 14-ASAIZEN 13-BSALAGEN 11-Jsalmeterol inhaler 12-Dsalmeterol-fluticasone inhaler 12-Dsalsalate 9-ASAMSCA 3-JSANCTURA 8-BSANCUSO 14-ASANDIMMUNE 2-BSANDOSTATIN LAR 13-GSANTYL 5-ISAPHRIS 4-Dsapropterin 6-Jsaquinavir 1-ISARAFEM 4-Bsargramostim 13-CSAVELLA 4-GSAVELLA TITRATION PAK 4-Gsaxagliptin 6-Fsaxagliptin-metformin 6-FSCALACORT DK KIT 5-HSCOPACE 7-Fscopolamine ophth 11-Escopolamine oral 7-Fscopolamine patch 7-FSEASONALE 6-DSEASONIQUE 6-DSECTRAL 3-CSELECT-OB+DHA 10-BSELEGILINE 4-Hselenium sulfide shampoo 5-ISELSUN 5-ISELZENTRY 1-ISEMPREX-D 12-CSENSIPAR 6-JSEPTRA 1-LSERAX 4-ASEREVENT DISKUS 12-DSEROQUEL 4-DSEROSTIM 13-Bsertraline HCL 4-BSERZONE 4-Bsetraconazole 5-Dsevelamer 7-Hsildenafil 3-HSILENOR 14-Asilodosin 8-DSILVADENE 5-Csilver sulfadiazine 5-C77 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionSIMBRINZA 13-HSIMPONI 14-Asimvastatin 3-LSINEMET 4-HSINEMET CR 4-HSINEQUAN 4-BSINGULAIR 12-DSIRTURO 2-Bsirolimus 1-Fsitaglipin 6-Fsitaglipin-metformin 6-FSKELAXIN 9-GSLO-PHYLLIN 12-DSMZ-TMP 1-Lsod phos mon-sod phos di 7-Asodium chloride soln nebu 7% 12-Dsodium fluoride 11-Jsodium hyaluronate 5-Hsodium oxybate 4-Esodium phenylbutyrate 7-Gsodium polystyrene sulfonate 10-Esodium sulfate-pot sulf-mag sulf 7-ASolia 6-Dsolifenacin 8-BSOLODYN 14-ASOLTAMOX 2-ASOMA 9-GSOMA COMPOUND 9-GSOMA CPD w/CODEINE 9-Gsomatropin 13-Bsomatropin 14-Asomatropin (non-refrigerated) 13-BSOMATULINE DEPOT 13-GSOMAVERT 13-GSOMNOTE 4-CSONATA 4-Csorafenib tosylate 5-FSORIATANE 2-ASORIATANE CK kit 5-Fsotalol 3-Csotalol AF 3-CSOTRET 5-BSPECTAZOLE 5-DSPECTRACEF 1-Bspinosad 5-GSPIRIVA 12-Dspironolactone 3-Jspironolactone-HCTZ 3-JSPORANOX 1-GSprintec 6-DSPRIX NASAL 14-ASPRYCEL 9-BSroynx 6-DSSS 10-4 14-ASTADOL NS 9-BSTALEVO 4-HSTARLIX 6-Fstavudine 1-ISTAVZOR 4-GSTAXYN 14-ASTELAZINE 4-DSTIMATE 6-JSTIVARGA 4-ESTRATTERA 2-ASTRIANT 6-BSTROMECTOL 1-KSTUARTNATAL 10-BSUBOXONE FILM TAB 9-BSUBOXONE TABLETS 9-BSUBUTEX 9-BSUCLEAR 7-GSUCRAID 7-Asucralfate 7-CSULAR 3-Dsulfacetamide 5-Isulfacetamide lotion (acne) 5-Bsulfacetamide sodium ophth 11-Asulfacetamide sodium sulfur 14-Asulfacetamide sodium-sulfur susp 14-Asulfacetamide w/ sulfur wash 14-A78 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionsulfacetamide-prednisolone ophth 11-Csulfacetamide-sulfur emulsion 5-Bsulfacetamide-urea lotion 5-Isulfadiazine 1-Lsulfamethoxazole 1-Lsulfanilamide vaginal 8-Csulfasalazine 7-Hsulfasalazine EC 7-Hsulfinpyrazone 9-FSULFINPYRAZONE 9-Fsulfisoxazole 1-Lsulindac 9-CSUMADAN 14-Asumatriptan 9-Esumatriptan auto-injection 14-ASUMATRIPTAN INJ 9-Esumatriptan-naproxen sodium 14-ASUMAXIN CP 14-ASUMAXIN TS 14-ASUMYCIN 1-Dsunitinib 2-ASUPREP 7-ASURESTEP SYSTEM 6-KSURESTEP TEST STRIPS 6-KSURMONTIL 1-ISUSTIVA 4-BSUTENT 2-ASYLATRON 13-ISYLATRON 4-PACK 13-ISYMBICORT 12-DSYMBYAX 4-FSYMLIN AMYLIN ANALOG 6-JSYNALAR 5-HSYNALGOS DC 9-BSYNAREL 13-GSYNERA PATCH 5-ISYNTHROID 6-Itacrine 4-Ftacrolimus 2-Btacrolimus topical 5-Itadalafil 8-Dtadalafil 3-HTAFINLAR 7-DTAGAMET 2-ATALWIN NX 9-BTAMBOCOR 3-ETAMIFLU 1-Htamoxifen 2-Atamsulosin 8-DTANAFED DM 12-CTANDEM F 10-BTAPAZOLE 6-Itapentadol 9-Btapentadol SR 9-BTARCEVA 2-ATARGRETIN 2-ATARKA 3-ITASIGNA 2-Atazarotene 5-FTAZORAC 5-FTEBAMIDE 7-FTECFIDERA 4-GTEGRETOL 13-ETEGRETOL XR 4-GTEKAMLO 14-ATEKTURNA 3-Htelaprevir 13-Dtelbivudine 1-Itelithromycin 1-Ctelmisartan 3-Gtelmisartan-amlodipine 14-Atelmisartan-HCTZ 3-Itemazepam 4-CTEMODAR 2-ATEMOVATE 5-Htemozolomide 2-ATENEX 3-Htenofovir 1-ITENORETIC 3-I79 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionTENORMIN 3-CTERAZOL 8-Cterazosin 3-Hterbinafine HCL 1-Gterbutaline 12-Dterconazole vaginal 8-Cteriflunomide 13-Fteriparatide (recombinant) 13-ETERMINEX 14-Atesamorelin 13-BTESLAC 2-ATESSALON 12-CTESTIM 6-Btestolactone 2-Atestosterone 6-Btestosterone 14-Atestosterone buccal system 6-Btestosterone TD sol 6-Btetrabenaziine 4-Ftetracycline 1-DTEVETEN 3-GTEVETEN HCT 3-ITEV-TROPIN 13-BTHEO-24 12-DTHEOLAIR 12-Dtheophylline 12-Dtheophylline CR 12-Dtheophylline SR 12-Dthiabendazole 1-Kthioguanine 2-ATHIOGUANINE 2-ATHIOLA 8-Dthioridazine 4-Dthiothixene 4-DTHORAZINE 4-Dthyroid 6-ITHYROLAR 6-Itiagabine 4-GTIAZAC 3-Dticagrelor 10-ETICLID 10-Eticlopidine 10-ETIGAN 7-FTIKOSYN 3-ETILADE 12-DTilia FE 6-Dtimolol maleate 3-Ctimolol maleate ophth 11-Btimolol ophth 11-BTIMOPTIC 11-BTIMOPTIC XE 11-Btinzaparin sodium 13-Atiopronin 8-Dtiotropium inhaler 12-Dtipranavir 1-ITIROSINT 6-Itizanidine 9-GTOBI 1-LTOBI PODHALER 1-LTOBRADEX 1-LTOBRADEX ST 14-Atobramycin 1-Ltobramycin ophth 11-Atobramycin-dexamethasone ophth 14-Atobramycin-dexamethasone ophth 11-CTOBREX 11-Atocainide 3-Etofacitinib citrate 4-BTOFRANIL 9-DTOFRANIL PM 4-Btolazamide 6-Ftolbutamide 6-FTOLBUTAMIDE 6-FTOLECTIN 9-CTOLINASE 6-Ftolmetin sodium 9-Ctolterodine 8-Btolterodine SR 14-Atolvaptan 3-JTONOCARD 3-E80 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionTOPAMAX 4-GTOPAMAX SPRINKLES 4-GTOPICORT 5-Htopiramate 4-Gtopotecan 2-ATOPROL XL 3-CTORADOL 9-Ctoremifene citrate 2-Atorsemide 3-JTOVIAZ 8-BTRACLEER 3-HTRADJENTA 6-Ftramadol 9-Btramadol ER 9-Btramadol ER 14-Atramadol-APAP 9-BTRANDATE 3-Ctrandolapril 3-Ftrandolapril-verapamil 3-Itranexamic acid 10-ETRANSDERM-SCOP 7-FTRANXENE 4-Atravaprost ophth 11-DTRAVATAN 11-Dtrazodone 4-Btrazodone SR 14-ATRECATOR-SC 1-FTRENTAL 10-Etreprostinil 3-Htretinoin 2-Atretinoin 5-Btretinoin 14-ATREXALL 2-ATREXIMET 14-Atriamcinolone 14-Atriamcinolone acetonide 5-Htriamcinolone cream-emollient cream kit 14-Atriamcinolone inhaler 12-Etriamcinolone nasal 12-Btriamcinolone/orabase 11-Jtriamterene 3-Jtriamterene-HCTZ 3-JTRIAZ 14-Atriazolam 4-CTRIBENZOR 14-ATRICOR 14-Atrifluoperazine 4-Dtrifluridine ophth 11-Atrihexyphenidyl 4-HTRILAFONE 4-DTri-Legest FE 6-DTRILEPTAL 4-GTRI-LEVLEN 6-DTRILIPIX 14-ATRILISATE 9-Atrimethobenzamide 7-Ftrimethobenzamide-benzocaine 7-Ftrimethoprim 1-Ltrimethoprim-polymy B ophth 11-Atrimipramine maleate 1-LTRIMPEX 4-BTRINALIN 12-CTRI-NASAL 12-BTrinessa 6-DTRI-NORINYL 6-DTRIPHASIL 6-Dtriple sulfas vaginal 8-CTri-Previfem 6-Dtriprolidine tannate 12-ATri-sprintec 6-DTRI-VI-FLOR 10-BTRI-VI-FLOR-FE 10-BTrivora 6-DTRIZIVIR 1-Itropicamide ophth 11-Etrospium 8-BTRUSOPT 11-HTRUVADA 1-ITRYCET 9-Btrypsin-castor oil-peruvian balsam 5-I81 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionTUDORZA3-KTWINJECTTWYNSTA 12-D14-ATYKERB 2-ATYLENOL w/CODEINE 9-BTYVASO 3-HTYZEKA 1-IUCERISulipristal 6-JULORIC 9-FULTRACET 9-BULTRAM 9-BULTRAM ER 9-BULTRASE 7-GULTRASE MT 7-GULTRAVATE 5-HULTRAVATE KIT 5-HUMECTA EMOLLIENT 14-AUNIPHYL 12-DUNIRETIC 3-Iunithroid 6-IUNIVASC 3-FUramaxin GT kit 5-Iurea 14-Aurea (carbamide) 5-Iurea emulsion 14-Aurea in zinc 5-IURECHOLINE 8-BURISPAS 8-BUROCIT-K 8-DUROQID 8-AURSO 7-HURSO FORTE 7-Hursodiol 7-HVAGIFEM 8-Cvalacyclovir 1-HVALCYTE 1-Hvalganciclovir HCL 1-HVALISONE 5-HVALIUM 4-Avalproic acid 4-Gvalsartan 3-Gvalsartan aliskiren 14-Avalsartan-HCTZ 3-IVALTREX 1-HVALTURNA 14-AVANAMIDE 5-IVANCOCIN 2-Avancomycin 1-LVANDAZOLE 8-CVANOS 5-HVANTIN 1-Bvardenafil 14-AVASERETIC 3-IVASOTEC 3-FVECAMYL 5-FVECTICAL 3-HVEETIDS 1-AVELOSEF 1-BVELTIN 14-Avemurafenib 2-Avenlafaxine 4-Bvenlafaxine SR 4-BVENLAFAXINE XR 4-BVENTAVIS 3-HVENTOLIN HFA 12-DVEPESID 2-AVERAMYST 14-Averapamil 3-Dverapamil CR (controlled onset) 3-Dverapamil SR 3-DVERDESO 5-HVERELAN PM 3-DVERIPRED 6-AVERMOX 1-KVESANOID 2-AVESICARE 8-BVEXOL 11-CVFEND 1-GVIBRAMYCIN 1-D82 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionVIBRATABS 1-DVICODIN 9-BVICODIN ES 9-BVICODIN HP 9-BVICOPROFEN 9-BVICTOZA 6-JVICTRELIS 13-DVIDEX EC 1-Ivigabatrin 4-GVIGAMOX 11-AVIIBRYD 4-Bvilazodone 4-BVIMOVO 14-AVIMPAT 4-GVIOKASE 7-GVIRACEPT 1-IVIRAMUNE 1-IVIRAMUNE XR 1-IVIREAD 1-IVIROPTIC 11-AVISCOUS LIDOCAINE 11-JVISICOL 7-AVISKEN 3-CVISTARIL 4-AVIVACTIL 4-BVIVELLE 6-CVIVELLE DOT 6-CVIVITROL 9-BVOLTAREN 9-CVOLTAREN GEL 5-HVOLTAREN ophth 11-HVOLTAREN ophth gel 11-HVOLTAREN XR 9-Cvoriconazole 1-Gvorinostat 2-AVOSOL-HC 11-IVOSPIRE ER 12-DVOTRIENT 2-AVUSION 1-GVYTORIN 3-LVYVANSE 4-Ewarfarin 10-DWELCHOL 3-LWELLBUTRIN 4-BWELLBUTRIN SR 4-BWELLBUTRIN XL 4-BWELLCOVORIN 2-AWESTCORT 5-HWESTHROID-P 11-DXALATAN 6-IXALKORI 2-AXANAX 4-AXANAX XR 4-AXARELTO 10-DXELJANZ 2-AXELODA 13-HXENADERM 5-IXENAZINE 4-FXERAC-AC 5-IXERESE 14-AXIBROM 11-HXIFAXAN 1-LXOPENEX 12-DXYLOCAINE 5-IXYREM 4-EXYZAL 14-AYASMIN 6-DYAZ 6-DYODOXIN 1-LZADITOR 14-AZADITOR OTC 14-Azafirlukast 12-Dzalcitabine 1-Izaleplon 4-CZAMICET 9-BZANAFLEX 9-Gzanamivir 1-HZANTAC 7-DZARAH 6-DZARONTIN 4-G83 2-Tier (open) Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionZAROXOLYN 3-JZAVESCA 7-GZEBETA 3-CZEGERID 7-EZELBORAF 2-AZEMPLAR 10-AZENPEP 7-GZENZEDI 1-IZERIT 14-AZERVALX 10-CZESTORETIC 3-IZESTRIL 3-FZETIA 3-LZIAC 3-IZIAGEN 1-IZIANA 14-Azidovudine 1-IZINOTIC 11-IZINOTIC ES 11-IZIOPTAN 4-Dziprasidone HCL 11-DZIPSOR 14-AZIRGAN 1-HZITHROMAX 1-CZMAX 1-CZOCOR 3-LZODERM 5-BZOFRAN 7-FZOFRAN ODT 7-FZOLINZA 2-Azolmitriptan 9-EZOLOFT 4-Bzolpidem 4-Czolpidem 14-Azolpidem CR 4-CZOLPIMIST 14-AZOLVIT 14-AZOMIG 9-EZOMIG NASAL 9-EZOMIG ZMT 9-EZONATUSS 14-AZONEGRAN 4-Gzonisamide 4-GZORBTIVE 13-BZOVIRAX 1-HZOVIRAX topical 5-EZUBSOLV 14-AZUPLENZ 14-AZYCLARA 14-AZYDONE 9-BZYLET 11-CZYLOPRIM 9-FZYMAR 11-AZYMAXID 11-AZYMINE XR SYRUP 12-AZYPREXA 4-DZYPREXA ZYDIS 4-DZYRTEC 14-AZYTIGA 2-AZYVOX 1-L84 2-Tier (open) Drug Benefit Guide 09/01/13