5-Tier Preferred Drug List - Health Plan of Nevada

Preferred Drug List 5-Tier21NVHPN09619

FIVE-Tier Drug Benefit GuideTable of ContentsIntroduction .............................................................. iDrug Benefit Guide .................................................. 1Section 1 Anti-InfectivesSection 2 Cancer and TransplantSection 3 CardiovascularSection 4 Central Nervous SystemSection 5 DermatologicalsSection 6 Endocrine and HormonesSection 7 GastrointestinalsSection 8 GenitourinarySection 9 Musculoskeletal and PainSection 10 Vitamins and HematologicalsSection 11 Eye, Ear, and ThroatSection 12 RespiratorySection 13 SpecialtySection 14 ExclusionsPreferred Alternatives............................................... 48Alphabetical Index ................................................... 51

Five-Tier 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. Non-preferred medications, as well assome medications not listed on the HPN PDL are also covered for a higher (tier 3) copayment. Inaddition, specialty medications are available for the applicable preferred specialty (tier 4) andnon-preferred specialty (tier 5) copayments. Certain medications may have quantity, age ortherapeutic supply limitations based on FDA approved dosages, literature documentation or P&TCommittee 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 XARELOT 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 authorizationi

• QL = quantity limitations• ST = step therapy• 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

FIVE-TIER Drug Benefit GuideThis drug benefit guide is applicable for HPN, and SHLmembers with a 5-tier prescription drug benefitANTI-INFECTIVES (drugs to treat infections)1-A PenicillinsGeneric Name Brand NameTierNotesamoxicillin *AMOXIL 1amoxicillin AMOXIL (400mg chewable) 2amoxicillin DISPERMOX 3amoxicillin MOXATAG 3 QL (10 tablets/50 days)amoxicillin-clavulanate *AUGMENTIN 1amoxicillin-clavulanate SR AUGMENTIN XR 3 QL (40 tablets/month)ampicillin *PRINCIPEN 1ampicillin PRINCIPEN (suspension) 2aztreonam CAYSTON 4 QL (84 mls/42 days) PAdicloxacillin *DYNAPEN 1penicillin V potassium *VEETIDS 11-B CephalosporinsGeneric Name Brand NameTierNotescefaclor ER CECLOR CD 2cefaclor *CECLOR 1cefadroxil *DURICEF 1cefdinir *OMNICEF (suspension) 125mg/5ml 1 QL (24 ml/day)cefdinir *OMNICEF (suspension) 250mg/5ml 1 QL (12 ml/day)cefditoren pivoxil SPECTRACEF 3cefpodoxime *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 3cefuroxime *CEFTIN (tablets) 1 QL (28 tablets/month)cefuroxime *CEFTIN (suspension) 3cephalexin *KEFLEX 11-C MacrolidesGeneric Name Brand NameTierNotesazithromycin ER ZMAX 3 QL (1 dose/fill)azithromycin *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)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 15-Tier Drug Benefit Guide09/01/13

clarithromycin *BIAXIN 1 QL (28 tablets/month)clarithromycin SR *BIAXIN XL 1 QL (28 tablets/month)clindamycin *CLEOCIN 1erythromycin PCE 3erythromycin EC ERY-TAB 2erythromycin ethylsuccinate *EES 1erythromycin ethylsuccinate *ERYPED 1erythromycin stearate ERYTHROCIN 2telithromycin KETEK 3 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 3doxycycline hyclate *PERIOSTAT 1 QL (60 tablets/month)doxycycline monohyclate *VIBRATABS 1 QL (60 tablets/month)doxycycline monohydrate *MONODOX 75mg 3 QL (28 tablets/month)doxycycline monohydrate *MONODOX 100mg 3 QL (28 tablets/month)minocycline *MINOCIN 1 QL (60 tablets/month)tetracycline *SUMYCIN 11-E FluoroquinolonesGeneric Name Brand Nameciprofloxacin *CIPRO 1ciprofloxacin SR *CIPRO XR 1levofloxacin *LEVAQUIN 1moxifloxacin *LEVAQUIN 3norfloxacin NOROXIN 3ofloxacin *FLOXIN 1TierNotesQL (60 tablets/month)QL (14 tablets/month)QL (14 tablets/month)1-F Antimycobacterial AgentsGeneric Name Brand NameTierNotesbedaquiline fumarate SIRTURO 3ethambutol *MYAMBUTOL 1ethionamide TRECATOR-SC 3isoniazid 1isoniazid-rifampin RIFAMATE 3isoniazid-rifampin-pyrazinamide RIFATER 3pyrazinamide 1rifabutin MYCOBUTIN 3rifampin *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 Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 25-Tier Drug Benefit Guide09/01/13

griseofulvin ultramicrosize *GRIS-PEG 2itraconazole *SPORANOX 1ketoconazole *NIZORAL 1miconazole-zinc oxide-white petroleum VUSION 3nystatin BIO-STATIN 2nystatin *MYCOSTATIN susp 1posaconazole NOXAFIL 3terbinafine HCL *LAMISIL 1terbinafine HCL LAMISIL GRANULE PACKET 3voriconazole *VFEND 50mg 1voriconazole *VFEND 200mg 11-H Miscelleanous AntiviralsGeneric Name Brand NameTieracyclovir *ZOVIRAX 1famciclovir *FAMVIR 125mg 1famciclovir *FAMVIR 250mg 1famciclovir *FAMVIR 500mg 1ganciclovir ZIRGAN 3oseltamivir TAMIFLU capsules 3oseltamivir TAMIFLU suspension 3ribavirin *REBETOL capsules/tablets 1ribavirin REBETOL solution 3rimantadine *FLUMADINE 1valacyclovir *VALTREX 500mg 3valacyclovir *VALTREX 1gm 3valganciclovir HCL VALCYTE 4zanamivir RELENZA 3QL (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) PAPAQL (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 5 QL (30 tablets/month) SPabacavir-lamivudine-zidovudine TRIZIVIR 5 SPatazanavir REYATAZ 5 SPdarunavir PREZISTA 75mg 5 QL (60 tablets/month) ST SPdarunavir PREZISTA 150mg 5 QL (60 tablets/month) ST SPdarunavir PREZISTA 300mg 5 QL (120 tablets/month) ST SPdarunavir PREZISTA 400mg 5 QL (120 tablets/month) ST SPdarunavir PREZISTA 600mg 5 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 3 QL (12ml/day)delavirdine RESCRIPTOR 5 SPdidanosine 1 SPdidanosine *VIDEX EC 1 SPefavirenz SUSTIVA 5 SPefavirenz-emtricitabine-tenofovir ATRIPLA 4 SPemtricitabine EMTRIVA 2 QL (30 capsules/month)emtricitabine-rilpivirine-tenofovir COMPLERA 3 SPQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 35-Tier Drug Benefit Guide09/01/13

emtricitabine-tenofovir TRUVADA 5 QL (30 tablets/month) SPenfuvirtide FUZEON 4 SIO SPentecavir BARACLUDE 4 QL (30 tablets/month) SPetravirine INTELENCE 4 QL 120 tablets/month) ST SPIntelence ST = requires 30 day trial fill of other NNRTI (Sustiva, Viramune, Rescriptor) within past 2 yearsfosamprenavir LEXIVA 5 QL (120 tablets/month) SPindinavir sulfate CRIXIVAN 2 SPlamivudine EPIVIR 5 SPlamivudine-zidovudine *Combivir 1 SPlopinavir-ritonavir KALETRA 2 SPmaraviroc SELZENTRY 150mg 4 QL (60 tablets/month) PAmaraviroc SELZENTRY 300mg 4 QL (120 tablets/month) PAnelfinavir mesylate VIRACEPT 5 SPnevirapine *VIRAMUNE 1 SPnevirapine XR VIRAMUNE XR 2 SPraltegravir ISENTRESS 4 QL (60 tablets/month) SPrilpivirine EDURANT 5 SPritonavir NORVIR 5 SPsaquinavir INVIRASE 5 SPstavudine *ZERIT 1 SPtelbivudine TYZEKA 5 QL (30 tablets/month) SPtenofovir VIREAD 2 SPtipranavir APTIVUS capsules 5 QL (120 capsules/month) SPtipranavir APTIVUS suspension 5 QL (300 mls/month) SPzidovudine *RETROVIR 1 SP1-J AntimalarialsGeneric Name Brand NameTierartemether-lumefantrine COARTEM 3atovaquone-proguanil HCL MALARONE 3chloroquine *ARALEN 1hydroxychloroquine *PLAQUENIL 1mefloquine *LARIAM 1primaquine *PRIMAQUINE 1pyrimethamine DARAPRIM 2quinine sulfate 11-K AnthelminticsGeneric Name Brand NameTieralbendazole ALBENZA 3ivermectin STROMECTOL 3mebendazole VERMOX 2praziquantel BILTRICIDE 3thiabendazole MINTEZOL 3NotesQL (24 tablets/60 days)Notes1-L Misc Anti-InfectivesGeneric Name Brand NameTieratovaquone MEPRON 4QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 4Notes5-Tier Drug Benefit Guide09/01/13

dapsone DAPSONE 2dornase alfa PULMOZYME 4EES-sulfisoxazole *PEDIAZOLE 1fidaxomicin DIFICID 3iodoquinol *YODOXIN 1linezolid ZYVOX 3loracarbef LORABID 3metronidazole *FLAGYL tablets 1metronidazole *FLAGYL capsule 1metronidazole CR FLAGYL ER 3neomycin *MYCIFRADIN 1nitazoxanide ALINIA tablets 3nitazoxanide ALINIA suspension 3refaximin XIFAXAN 3XIFAXAN ST = requires failure of lactulose within the past 2 yearsSMZ-TMP *BACTRIM 1SMZ-TMP *SEPTRA 1sulfadiazine 1tobramycin TOBI 4tobramycin TOBI PODHALER 5trimethoprim *TRIMPEX 1vancomycin *VANCOCIN 4PAPAQL (7 tablets/fill)QL (6 tablets/fill)QL (60 mls/fill)QL (60 tablets/month) STPA SPPA SPQL (56 capsules/14 days) PACANCER and TRANSPLANT (drugs to treat cancers and prevent organ rejection)2-A Antineoplastics (cancer drugs)Generic Name Brand NameTierNotesabiraterone acetate ZYTIGA 3 PA SPaltretamine HEXALEN 2anastrozole *ARIMIDEX 1 QL (30 tablets/month)axitinib INLYTA 3 QL PA SPbexarotene TARGRETIN 3 SPbicalutamide *CASODEX 1bosutinib BOSULIF 3 PA SPbusulfan MYLERAN 2cabozantinib COMETRIQ 3 PAcapecitabine XELODA 3 PA SPchlorambucil LEUKERAN 2crizotinib XALKORI 3 PAcyclophosphamide CYTOXAN 2dabrafenib mesylat TAFINLAR 3 PA SPdasatinib SPRYCEL 3 PA SPenzalutamide XTANDI 3 PA SPerlotinib TARCEVA 3 PA SPestramustine EMCYT 2etoposide *VEPESID 1everolimus AFINITOR 3 PA SPexemestane *AROMASIN 1 QL (30 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 55-Tier Drug Benefit Guide09/01/13

fludarabine OFORTA 3flutamide *EULEXIN 1gefitinib IRESSA 3hydroxyurea *HYDREA 1imatinib mesylate GLEEVEC 3lapatinib ditosylate TYKERB 3lenalidomide REVLIMID 3letrozole *FEMARA 2leucovorin calcium *LEUCOVORIN CALCIUM 1leucovorin calcium *WELLCOVORIN 1lomustine CEENU 2megestrol *MEGACE 1megestrol MEGACE ES 3melphalan ALKERAN 2mercaptopurine *PURINETHOL 1mesna MESNEX 4methotrexate 1methotrexate TREXALL 3mitotane LYSODREN 2nilotinib TASIGNA 3nilutamide NILANDRON 3pazopanib VOTRIENT 3pomalidomide POMALYST 3ponatinib hcl ICLUSIG 3procarbazine HCL MATULANE 2regorafenib STIVARGA 3sorafenib tosylate NEXAVAR 3sunitinib SUTENT 3tamoxifen *NOLVADEX 1tamoxifen SOLTAMOX 3temozolomide *TEMODAR 3thalidomide THALOMID 3thioguanine THIOGUANINE 2topotecan HYCAMTIM 3toremifene citrate FARESTON 3trametinib dimethyl sulfoxide MEKINIST 3tretinoin *VESANOID 1vemurafenib ZELBORAF 3vismodegib ERIVEDGE 3vorinostat ZOLINZA 32-B ImmunosuppressivesGeneric Name Brand NameTierazathioprine *IMURAN 1cyclosporine *SANDIMMUNE (NTI) 2cyclosporine modified *GENGRAF 1cyclosporine modified *NEORAL (NTI) 2mycophenlate MYFORTIC 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 6PAQL (30 tablets/month)PA SPPA SPPA SPQL (30 tablets/month)SIOPAPA SPPA SPPA SPPA SPPA SPPA SPPA SPPA SPPA SPPAQL (30 tablets/month)PA SPSPPA SPQL PA SPPA SPNotesSPSPSPQL (120 tablets/month) SP5-Tier Drug Benefit Guide09/01/13

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 23-C Beta BlockersGeneric Name Brand NameTieracebutolol *SECTRAL 1atenolol *TENORMIN 1betaxolol *KERLONE 1bisoprolol *ZEBETA 1carteolol HCL CARTROL 3carvedilol *COREG 3.125mg 1carvedilol *COREG 6.25mg 1carvedilol *COREG 12.5mg 1carvedilol *COREG 25mg 1labetalol *NORMODYNE 1labetalol *TRANDATE 1metoprolol *LOPRESSOR 1metoprolol succinate SR *TOPROL XL 1nadolol *CORGARD 20mg 1nadolol *CORGARD 40mg 1nadolol *CORGARD 80mg 1nadolol *CORGARD 120mg 1nebivolol BYSTOLIC 2.5mg 2nebivolol BYSTOLIC 5mg 2nebivolol BYSTOLIC 10mg 2nebivolol BYSTOLIC 20mg 2penbutolol sulfate LEVATOL 3pindolol *VISKEN 1propranolol *INDERAL 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 7NotesNotesNotesQL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (120 tablets/month)QL (45 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (90 tablets/month)QL (60 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (120 tablets/month)QL (60 tablets/month)5-Tier Drug Benefit Guide09/01/13

propranolol HCL CR *INDERAL LA 1propranolol HCL SR INNOPRAN XL 3sotalol *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 1 Mdiltiazem SR *TIAZAC 1 Mdiltiazem SR 12HR *CARDIZEM SR 1 Mdiltiazem SR 24HR CARDIZEM LA 3 QL (30 tablets/month)felodipine *PLENDIL 1 QL (60 tablets/month)isradipine *DYNACIRC 1 QL (60 tablets/month)isradipine DYNACIRC CR 5mg 3 QL (30 tablets/month)isradipine DYNACIRC CR 10mg 3 QL (60 tablets/month)nicardipine *CARDENE 1nicardipine CARDENE SR 3nifedipine CR *ADALAT CC 1nifedipine CR *PROCARDIA XL 1nifedipine IR *ADALAT CC 1nifedipine IR *PROCARDIA 1nisoldipine SR *SULAR 8.5mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 10mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 17mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 20mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 25.5mg 3 QL (60 tablets/month)nisoldipine SR *SULAR 30mg 3 QL (60 tablets/month)nisoldipine SR *SULAR 34mg 3 QL (30 tablets/month)nisoldipine SR *SULAR 40mg 3 QL (30 tablets/month)verapamil *CALAN 1verapamil CR (controlled onset) COVERA HS 3 QL (60 tablets/month)verapamil SR *CALAN SR 1verapamil SR *VERELAN PM 13-E AntiarrhythmicsGeneric Name Brand NameTierNotesamiodarone *CORDARONE 1disopyramide *NORPACE 1dofetilide TIKOSYN 3 QL (60 capsules/month)dronedarone MULTAQ 3 QL (60 tablets/month)flecainide *TAMBOCOR 1mexiletine *MEXITIL 1propafenone *RYTHMOL 1propafenone *RYTHMOL SR 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 85-Tier Drug Benefit Guide09/01/13

quinidine gluconate 1quinidine sulfate 13-F Angiotensin Converting Enzyme (ACE) InhibitorsGeneric Name Brand NameTierNotesbenazepril *LOTENSIN 1 QL (60 tablets/month)captopril *CAPOTEN 1enalapril *VASOTEC 1 QL (60 tablets/month)fosinopril *MONOPRIL 1 QL (60 tablets/month)lisinopril *PRINIVIL 1 QL (60 tablets/month)lisinopril *ZESTRIL 1 QL (60 tablets/month)moexipril *UNIVASC 1 QL (60 tablets/month)perindopril *ACEON 3 QL (60 tablets/month)quinapril *ACCUPRIL 1 QL (60 tablets/month)ramipril *ALTACE 1 QL (60 capsules/month)trandolapril *MAVIK 1 QL (60 tablets/month)3-G Angiotensin II Receptor Blockers (ARB's)Generic Name Brand NameTierNotesazilsartan medoxomil EDARBI 3 QL (30 tablets/month)candesartan *ATACAND 3 QL (60 tablets/month)eprosartan TEVETEN 400mg 3 QL (60 tablets/month)eprosartan *Teveten 600mg 1 QL (30 tablets/month)irbesartan *AVAPRO 1 QL (30 tablets/month)losartan *COZAAR 25mg 1 QL (60 tablets/month)losartan *COZAAR 50mg 1 QL (60 tablets/month)losartan *COZAAR 100mg 1 QL (30 tablets/month)olmesartan BENICAR 2 QL (30 tablets/month)telmisartan MICARDIS 3 QL (30 tablets/month)valsartan *DIOVAN 40mg 3 QL (30 tablets/month)valsartan *DIOVAN 80mg 3 QL (30 tablets/month)valsartan *DIOVAN 160mg 3 QL (60 tablets/month)valsartan *DIOVAN 320mg 3 QL (30 tablets/month)3-H Miscellaneous AntihypertensivesGeneric Name Brand NameTierNotesaliskiren fumarate TEKTURNA 3 QL (30 tablets/month)ambrisentan LETAIRIS 5 PA SPbosentan TRACLEER 4 QL (60 tablets/month) PA SPclonidine *CATAPRES 1clonidine patch *CATAPRES-TTS 1 QL (8 patches/month)deserpidine-methyclothiazide ENDURONYL 3doxazosin *CARDURA 1 QL (60 tablets/month)guanfacine *TENEX 1hydralazine *APRESOLINE 1iloprost VENTAVIS 4 PA SPmecamylamine VECAMYL 3methyldopa *ALDOMET 1minoxidil *LONITEN 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 95-Tier Drug Benefit Guide09/01/13

phenoxybenzamine DIBENZYLINE 3prazosin *MINIPRESS 1reserpine 3sildenafil *REVATIO 4tadalafil ADCIRCA 3terazosin *HYTRIN 1treprostinil TYVASO 33-I Antihypertensive CombinationsGeneric Name Brand NameTieramlodipine-benazepril *LOTREL 1atenolol-chlorthalidone *TENORETIC 1azilsartan-chlorthalidone EDARBYCLOR 3benazepril-HCTZ *LOTENSIN HCT 1bisoprolol-HCTZ *ZIAC 1candesartan-HCTZ *ATACAND HCT 3captopril-HCTZ *CAPOZIDE 1enalapril-felodipine LEXXEL 3enalapril-HCTZ *VASERETIC 1eprosartan-HCTZ TEVETEN HCT 3fosinopril-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 3trandolapril-verapamil *TARKA 3valsartan-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 SPNotesQL (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 3 QL (30 tablets/month)furosemide *LASIX 1hydrochlorothiazide *HYDRODIURIL 1hydrochlorothiazide *MICROZIDE 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 105-Tier Drug Benefit Guide09/01/13

indapamide *LOZOL 1methazolamide *NEPTAZANE 1methyclothiazide *AQUATENSEN 1metolazone *ZAROXOLYN 1spironolactone *ALDACTONE 1spironolactone-HCTZ *ALDACTAZIDE 1tolvaptan SAMSCA 3torsemide *DEMADEX 1triamterene DYRENIUM 3triamterene-HCTZ *DYAZIDE 1triamterene-HCTZ *MAXZIDE 13-K PressorsGeneric Name Brand NameTierepinephrine inj AUVI-Q 3epinephrine inj EPIPEN 2epinephrine inj EPIPEN JR 2epinephrine inj TWINJECT 3midodrine *PROAMATINE 13-L AntihyperlipidemicsGeneric Name Brand NameTieratorvastatin *LIPITOR 1cholestyramine *QUESTRAN 1colesevelam WELCHOL 3colestipol *COLESTID 1ezetimibe ZETIA 3ezetimibe-simvastatin VYTORIN 3fenofibrate *LOFIBRA 1fenofibrate *ANTARA 1fenofibrate FENOGLIDE 40mg 3fenofibrate FENOGLIDE 120mg 3fluvastatin LESCOL 20mg 3fluvastatin LESCOL 40mg 3fluvastatin SR LESCOL XL 3gemfibrozil *LOPID 1lomitapide mesylate JUXTAPID 3lovastatin *MEVACOR 10mg 1lovastatin *MEVACOR 20mg 1lovastatin *MEVACOR 40mg 1lovastatin SR ALTOCOR 3lovastatin SR ALTOPREV 20mg 3lovastatin SR ALTOPREV 40mg 3lovastatin SR ALTOPREV 60mg 3mipomersen sodium KYNAMRO 3niacin SR NIASPAN 3niacin-lovastatin CR ADVICOR 3omega-3-acid ethyl esters LOVAZA 3pitavastatin LIVALO 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 11PA SPNotesNotesQL (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)QL (30 tablets/month)QL (60 tablets/month)QL (30 tablets/month)PAQL (60 tablets/month)PA QL (120 capsules/month)QL (30 tablets/month)5-Tier Drug Benefit Guide09/01/13

pravastatin *PRAVACHOL 1rosuvastatin CRESTOR 2simvastatin *ZOCOR 13-M Miscellaneous CardiovascularGeneric Name Brand NameTierisosorbide dinitrate-hydralazine BIDIL 3ranolazine RANEXA 2QL (30 tablets/month)QL (30 tablets/month)NotesQL (60 tablets/month)CENTRAL NERVOUS SYSTEM (drugs that affect the brain)4-A Antianxiety AgentsGeneric Name Brand NameTierNotesalprazolam *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)alprazolam *NIRAVAM 3buspirone 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 3 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 3 QL (60 capsules/month) STduloxetine CYMBALTA 30mg 3 QL (60 capsules/month) STQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 125-Tier Drug Benefit Guide09/01/13

duloxetine CYMBALTA 60mg 3QL (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)requires 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 3 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 3 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 3maprotiline *LUDIOMIL 1mirtazapine *REMERON 1mirtazapine soltabs *REMERON SOLTABS 1nefazodone HCL *SERZONE 1nortriptyline *PAMELOR 1paroxetine HCL *PAXIL 10mg 1paroxetine HCL *PAXIL 20mg 1paroxetine HCL *PAXIL 30mg 1paroxetine HCL *PAXIL 40mg 1paroxetine HCL SR *PAXIL CR 12.5mg 3paroxetine HCL SR *PAXIL CR 25mg 3paroxetine HCL SR *PAXIL CR 37.5mg 3QL (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 3 QL (30 tablets/month) STparoxetine mes PEXEVA 20mg 3 QL (30 tablets/month) STparoxetine mes PEXEVA 30mg 3 QL (60 tablets/month) STparoxetine mes PEXEVA 40mg 3 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 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 13QL (45 tablets/month)QL (45 tablets/month)5-Tier Drug Benefit Guide09/01/13

sertraline HCL *ZOLOFT 100mg 1 QL (60 tablets/month)trazodone *DESYREL 1trimipramine maleate *SURMONTIL 1trimipramine maleate SURMONTIL 3venlafaxine *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 3 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 3 QL (30 tablets/month) STLunesta ST = requires 30 day fill of zolpidem in the past 2 yearsflurazepam *DALMANE 1phenobarbital 1ramelteon ROZEREM 3 QL (30 tablets/month) STRozerem ST = requires 30 day fill of zolpidem in the past 2 yearstemazepam *RESTORIL 22.5mg 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 3 QL (30 tablets/month)4-D AntipsychoticsGeneric Name Brand NameTierNotesaripiprazole ABILIFY 3 QL (30 tablets/month)asenapine SAPHRIS 3 QL (60 tablets/month) PA STSaphris ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearschlorpromazine *THORAZINE 1clozapine *FAZACLO 3 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 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 145-Tier Drug Benefit Guide09/01/13

iloperidone FANAPT 3 QL (60 tablets/month) PA STFanapt ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis inthe past 2 yearslithium carbonate *ESKALITH 1lithium carbonate CR *ESKALITH CR 1lithium carbonate CR *LITHOBID 1loxapine *LOXITANE 1lurasidone LATUDA 3olanzapine *ZYPREXA 3 QL (30 tablets/month) STZyprexa ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis in thepast 2 yearsolanzapine *ZYPREXA ZYDIS 3 QL (30 tablets/month) STZyprexa Zydis ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis inthe past 2 yearspaliperidone INVEGA 3 QL (30 tablets/month)PA STInvega ST = requires failure/contraindication to Risperidone and Quetiapine AND supported diagnosis inpast 2 yearspaliperidone palmitate INVEGA SUSTENNA 4 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 3 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 3 STAmphetamine-D-Amphetamine SR ST = requires 90 day trial of brand Adderall XR in past 2 yearsarmodafinil NUVIGIL 3 QL (30 tablets/month) PAatomoxetine STRATTERA 3 QL (30 capsules/month)dexmethylphenidate *FOCALIN 1 QL (60 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 155-Tier Drug Benefit Guide09/01/13

dexmethylphenidate SR FOCALIN XR 3dextroamphetamine *DEXEDRINE 1dextroamphetamine *DEXEDRINE SPANSULES 1dextroamphetamine solution *LIQUADD 3lisdexamfetamine dimesylate VYVANSE 2methamphetamine *DESOXYN 1methylphenidate METHYLIN (chewable) 2.5mg 3methylphenidate METHYLIN (chewable) 5mg 3methylphenidate METHYLIN (chewable) 10mg 3methylphenidate METHYLIN (suspension) 5mg/ml 3methylphenidate METHYLIN (suspension) 10mg/ml 3methylphenidate *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 3methylphenidate SA *CONCERTA 18mg 3methylphenidate SA *CONCERTA 27mg 3methylphenidate SA *CONCERTA 36mg 3methylphenidate SA *CONCERTA 54mg 3methylphenidate SR *Ritalin LA 10mg 1methylphenidate SR *Ritalin LA 20mg 1methylphenidate SR *Ritalin LA 30mg 1methylphenidate SR *Ritalin LA 40mg 1modafinil *PROVIGIL 100mg 3modafinil *PROVIGIL 200mg 3sodium oxybate XYREM 44-F Misc Psychotherapeutic and Neurological AgentsGeneric Name Brand NameTieramitriptyline-chlordiazepoxide LIMBITROL 2disulfiram *ANTABUSE 1dextromethorphan quindine NUEDEXTA 3donepezil *ARICEPT 1ergoloid mesylates *HYDERGINE 1galantamine *RAZADYNE 1galantamine *RAZADYNE ER 1guanfacine INTUNIV 3menantine NAMENDA 3olanzapine-fluoxetine *SYMBYAX 3QL (30 capsules/month)QL (1200 mls/month) PAQL (30 capsules/month)QL (150 tablets/month)QL (60 tablets/month)QL (180 tablets/month)QL (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 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 165-Tier Drug Benefit Guide09/01/13

ivastigmine *EXELON 1rivastigmine EXELON PATCH 3tacrine COGNEX 3tetrabenazine XENAZINE 34-G AnticonvulsantsGeneric Name Brand NameTiercarbamazepine *TEGRETOL (NTI) 2carbamazepine SR *TEGRETOL XR 1carbamazepine SR *CARBATROL 1clobazam ONFI 3clonazepam *KLONOPIN 1diazepam rectal *DIASTAT 3divalproex sodium EC *DEPAKOTE 1ethosuximide *ZARONTIN 1ethotoin PEGANONE 3ezogabine POTIGA 3gabapentin *GABARONE 1gabapentin *NEURONTIN 100mg 1gabapentin *NEURONTIN 300mg 1gabapentin *NEURONTIN 400mg 1gabapentin *NEURONTIN 600mg 1gabapentin *NEURONTIN 800mg 1gabapentin NEURONTIN (solution) 3lacosamide VIMPAT 3lacosamide VIMPAT (solution) 3lamotrigine *LAMICTAL 1lamotrigine LAMICTAL ODT 3lamotrigine LAMICTAL ODT KIT 3lamotrigine *LAMICTAL STARTER KIT 1lamotrigine *LAMICTAL XR 1lamotrigine *LAMICTAL XR KIT 1levetiracetam *KEPPRA 1levetiracetam *KEPPRA XR 3methsuximide CELONTIN 3milnacipran SAVELLA 3milnacipran SAVELLA TITRATION PAK 3oxcarbazepine *TRILEPTAL 100mg 1oxcarbazepine *TRILEPTAL 300mg 1oxcarbazepine *TRILEPTAL 600mg 1phenytoin *DILANTIN (NTI) 2pregabalin LYRICA 25mg 3pregabalin LYRICA 50mg 3pregabalin LYRICA 75mg 3pregabalin LYRICA 100mg 3pregabalin LYRICA 150mg 3pregabalin LYRICA 200mg 3pregabalin LYRICA 225mg 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 17QL (60 capsules/month)QL (30 patches/month)PAQL (1 kit/month)QL (1 kit/month)QL (1 kit/month)NotesQL (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 (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) ST5-Tier Drug Benefit Guide09/01/13

pregabalin LYRICA 300mg 3 QL (60 capsules/month) STpregabalin LYRICA SOLUTION 3 QL STLyrica ST = requires 30 day trial of Gabapentin in the past 2 yearsprimidone *MYSOLINE 1 Mrufinamide BANZEL 3rufinamide BANZEL suspension 3tiagabine *GABITRIL 1topiramate *TOPAMAX SPRINKLES 1 QL (120 capsules/month)topiramate *TOPAMAX 1 QL (90 tablets/month)valproic acid *DEPAKENE 1valproic acid STAVZOR 3 QL (60 capsules/month)vigabatrin SABRIL 3 QL (180 tablets/month)zonisamide *ZONEGRAN 25mg 1 QL (120 capsules/month)zonisamide *ZONEGRAN 50mg 1 QL (120 capsules/month)zonisamide *ZONEGRAN 100mg 1 QL (180 capsules/month)4-H Antiparkinsonian AgentsGeneric Name Brand NameTierNotesAMANTADINE (Symmetrel) 2apomorphine APOKYN 4 SIO SPbenztropine *COGENTIN 1bromocriptine (tablets) *PARLODEL 1carbidopa-levodopa *SINEMET 1carbidopa-levodopa *PARCOPA 1carbidopa-levodopa CR *SINEMET CR 1carbidopa-levodopa-entacapone STALEVO 3 QL (240 tablets/month)entacapone *COMTAN 2 QL (240 tablets/month)pramipexole *MIRAPEX 1 QL (90 tablets/month)ropinirole *REQUIP 1 QL (90 tablets/month)trihexyphenidyl *ARTANE 1*SELEGILINE 1DERMATOLOGICALS (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 3 QL (45 gm/60 days) ALadapalene DIFFERIN 0.1% lotion 3 QL (1 bottle/60 days) ALadapalene *DIFFERIN 0.1% cream/gel 3 STDifferin 0.1% generic ST = requires trial of BRAND Differin cream/gel the past 120 daysazelaic acid AZELEX 3azelaic acid FINACEA 3benzoyl peroxide-vit E INOVA KIT 3benzoyl peroxide-salicylic acid-vit E INOVA 4/1 KIT 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 185-Tier Drug Benefit Guide09/01/13

enzoyl peroxide-adapalene EPIDUO 3 QL (45 gm/month)benzoyl peroxide-erythromycin gel *BENZAMYCIN 1 QL (60 gm/month)benzoyl peroxide-urea ZODERM 5.75% cleanser 3 QL (473 mls/month)benzoyl peroxide-urea ZODERM cleanser 3 QL (400 mls/month)benzoyl peroxide-urea ZODERM cream 3 QL (125 mls/month)benzoyl peroxide-urea ZODERM gel 3 QL (125 mls/month)clindamycin topical *CLEOCIN-T 1clindamycin-benzoyl peroxide gel *BENZACLIN 1 QL (50 gm/month)clindamycin-benzoyl peroxide gel *DUAC 3dapsone ACZONE 3erythromycin topical *ERYGEL 1isotretinoin *ACCUTANE 3 QL (60 capsules/month) PAisotretinoin *AMNESTEEM 3 QL (60 capsules/month) PAisotretinoin *CLARAVIS 3 QL (60 capsules/month) PAisotretinoin *SOTRET 3 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 3gentamicin topical *GARAMYCIN 1mupirocin *BACTROBAN 1mupirocin *BACTROBAN CREAM 1mupirocin BACTROBAN NASAL OINTMENT 2neomycin-polymyxin-HC cream CORTISPORIN CREAM 2retapamuln ALTABAX 3 QL (15 gm/month)silver sulfadiazine *SILVADENE 15-D Topical AntifungalsGeneric Name Brand NameTierNotesbutenafine MENTAX 3ciclopirox *LOPROX 1ciclopirox solution *PENLAC 1 QL (7 ml/month)clotrimazole-betamethasone *LOTRISONE 1 QL (30 ml/month)econazole *SPECTAZOLE 1ketoconazole shampoo *NIZORAL SHAMPOO 1ketoconazole topical 1naftifine NAFTIN 3nystatin topical *MYCOSTATIN topical 1nystatin-triamcinolone *MYCOLOG II 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 195-Tier Drug Benefit Guide09/01/13

oxiconazole OXISTAT 3setraconazole ERTACZO 3 QL (1 tube/month)5-E Topical AntiviralsGeneric Name Brand NameTierNotesacyclovir topical *ZOVIRAX topical 1penciclovir DENAVIR 3 QL (1 tube/month)5-F AntipsoriaticsGeneric Name Brand NameTierNotesanthralin *PSORIATEC 1acitretin *SORIATANE 3acitretin *SORIATANE CK kit 3 QL (1 kit/month)calcipotriene *DOVONEX 1 QL (1 tube/month)calcitriol ointment *VECTICAL 1 QL (100 gm/month)methoxsalen OXSORALEN-ULTRA 3tazarotene TAZORAC ** 3 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 3lindane shampoo *KWELL 1permethrin *ELIMITE 1spinosad *NATROBA 35-H Topical CorticosteroidsGeneric Name Brand Namealclometasone *ACLOVATE 1amcinonide *CYCLOCORT 3augmented betamethasone *DIPROLENE 1augmented betamethasone *DIPROLENE AF 1betamethasone dipropionate *DIPROSONE 1betamethasone foam *LUXIQ 3betamethasone valerate *VALISONE 1clobetasol foam *OLUX 1clobetasol propionate *TEMOVATE 1clocortolone CLODERM 3desonide *DESOWEN 1desonide foam VERDESO 3desoximetasone *TOPICORT 1diclofenac gel VOLTAREN GEL 3diflorasone diacetate PSORCON 2flucinolone oil DERMA-SMOOTH FS 3fluocinolone acetonide *SYNALAR 1fluocinolone shampoo CAPEX 3fluocinonide *LIDEX 1fluocinonide VANOS 3flurandrenolide patch CORDRAN 3fluticasone *CUTIVATE ** 1halcinonide HALOG 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 20TierQL (50 gm/60 days)QL (500 gm/month)QL (60 gm/month)QL (1 tube/month)Notes5-Tier Drug Benefit Guide09/01/13

halobetasol *ULTRAVATE 1halobetasol ULTRAVATE KIT 3 QL (1 kit/month)hc lot 2% sal acid sulfur 2-2% SCALACORT DK KIT 3hydrocortisone butyrate *LOCOID CREAM 1 QL (45 gm/month)hydrocortisone butyrate LOCOID LOTION 3hydrocortisone valerate *WESTCORT 1mometasone *ELOCON 1pramoxine-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 5aluminum chloride *DRYSOL 1aluminum chloride/alcohol XERAC-AC 3becaplermin REGRANEX 3 PAcollagenase SANTYL 3fluorouracil *EFUDEX 1fluorouracil CARAC 3fluorouracil FLUOROPLEX 3imiquimod *ALDARA 1 QL (12 packets/month)lidocaine (topical) *XYLOCAINE 1lidocaine patch LIDODERM 3 PAlidocaine/hydrocortisone *ANAMANTLE 1lidocaine/tetracaine SYNERA PATCH 3 QL (4 patches/month)lidocaine-prilocaine *EMLA cream 1 QL (30 gm/month)pimecrolimus ELIDEL 3 QL (1 tube/month)podofilox *CONDYLOX 3podophyllum resin PODOCON 2selenium sulfide shampoo *SELSUN 1sulfacetamide *OVACE 3sulfacetamide *OVACE PLUS SHAMPOO 1% 3sulfacetamide-urea lotion *CARMOL SCALP 1tacrolimus topical PROTOPIC 2 QL (1 tube/month)trypsin-castor oil-peruvian balsam *XENADERM 1urea *KERALAC 1urea *VANAMIDE 1urea KERAFOAM 3 QL (60 gm/month)urea (carbamide) *CARMOL 40 1urea in zinc KEROL AD 3ENDOCRINE AND HORMONES (drugs to treat metabolic or hormone conditions, ie diabetes)6-A CorticosteroidsQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 215-Tier Drug Benefit Guide09/01/13

Generic Name Brand NameTierNotescortisone acetate *CORTONE 1dexamethasone *DECADRON 1fludrocortisone *FLORINEF 1hydrocortisone acetate *CORTEF 1methylprednisolone *MEDROL 1prednisolone MILIPRED DP PAK 3prednisolone *PRELONE 1prednisolone PREDNISOLONE 5MG 2prednisolone sod phosphate VERIPRED 3prednisolone sodium *ORAPRED 1prednisolone sodium *PEDIAPRED 1prednisone 16-B AndrogensGeneric Name Brand NameTierNotesdanazol *DANOCRINE 1methyltestosterone ANDROID 3methyltestosterone METHITEST 3testosterone ANDRODERM 3 QL (30 patches/month) PAtestosterone FORTESTA 3 PAtestosterone TESTIM 3 PAtestosterone TD sol AXIRON 3 PAtestosterone buccal system STRIANT 3 PA QL (60 patches/month)6-C EstrogensGeneric Name Brand NameTierNotesesterified estrogens 1esterified estrogens MENEST 3estradiol *ESTRACE 1estradiol gel ESTROGEL 3 QL (93gm/month)estradiol patch *CLIMARA 1 QL (4 patches/month)estradiol patch VIVELLE 2 QL (8 patches/month)estradiol patch VIVELLE DOT 2 QL (8 patches/month)estradiol patch ALORA 3 QL (8 patches/month)estradiol patch ESCLIM 3estradiol patch ESTRADERM 3 QL (8 patches/month)estradiol patch MENOSTAR 3 QL (4 patches/month)estradiol spray EVAMIST 3 QL (9 ml/month)estradiol TD gel DIVIGEL 2 QL (1 tube/month)estradiol transdermal ESTRASORB 3 QL (56 packets/month)estradiol-levonorgestrel patch CLIMARA PRO 3 QL (4 patches/month)estradiol-norethindrone ACTIVELLA 3 QL (1 dialpak/month)estradiol-norethindrone patch COMBIPATCH 3 QL (8 patches/month)estradiol-norgestimate ORTHO-PREFEST 2estrogen-medroxyprogesterone PREMPHASE 2 QL (1 dialpak/month)estrogen-medroxyprogesterone PREMPRO 2 QL (1 dialpak/month)estrogens (conjugated synthetic) CENESTIN 2 QL (30 tablets/month)estrogens (conjugated synthetic) ENJUVIA 2 QL (30 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 225-Tier Drug Benefit Guide09/01/13

estrogens (conjugated) PREMARIN 3 QL (30 tablets/month)estrogens-methyltestosterone *ESTRATEST 1estrogens-methyltestosterone *ESTRATEST HS 1estropipate *OGEN 1ethinyl estradiol-norethindrone FEMHRT 3 QL (1 dialpak/month)ospemifene OSPHENA 36-D ContraceptivesGeneric Name Brand NameTierNotesMONOPHASIC 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 3 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 3 QL (28 tablets/month)Junel Fe, Gildess Fe, Microgestin Fe *LOESTRIN FE 1 QL (28 tablets/21 days)Microgestin, Junel *LOESTRIN 3 QL (28 tablets/21 days)Balziva, Zenchent FE, Briellyn *OVCON-35 3 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, 3 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 3 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 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 23QL (28 tablets/month)5-Tier Drug Benefit Guide09/01/13

EE-levonorgestrel/EECamrese Lo, Amethia Lo *LOSEASONIQUE 1Camrese, Amethia, *SEASONIQUE 1EE/norethindrone-EE/norethindroneNecon 10/11 *ORTHO NOVUM 10/11 1LO LOESTRIN FE 3TRIPHASIC PRODUCTSEE/norethindrone-EE/norethindrone-EE/norethindroneAranelle, Leena *TRI-NORINYL 1ORTHO-NOVUM 7/7/7 1, Necon 7/7/7, Nortrel 7/7/7, Cyclafem 3Alyacen, 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 QL (28 tablets/21 days)/desogestrel-EE/desogestrel-EE/desogestrelCesia, Velivet, Caziant *CYCLESSA 1 QL (28 tablets/21 days)orgestimate-EE/norgestimate-EE/norgestimateORTHO TRI CYCLEN 1 QL (28 tablets/21 days)Tri-Sprintec,Tri-Previfem,Trinessa 3 QL (28 tablets/21 days) STTri-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 3 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 3DIAPHRAMS 1FEMCAP 3QL (28 tablets/21 days)QL (91 tablets/3 months)QL (28 tablets/21 days)QL (28 tablets/month)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 NameTierhydroxyprogesterone caproate MAKENA 3 PAQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 24Notes5-Tier Drug Benefit Guide09/01/13

medroxyprogesterone *PROVERA 1norethindrone *AYGESTIN 1progesterone micronized PROMETRIUM 3progesterone vaginal CRINONE 36-F Oral Antidiabetics (diabetes)Generic Name Brand NameTieracarbose *PRECOSE 1alogliptin benzoate NESINA 3NotesQL (90 tablets/month)STNESINA ST = requires fill of metformin within the past 2 yearsalogliptin-metformin KAZANO 3 STKAZANO ST = requires fill of metformin within the past 2 yearsalogliptin-pioglitazone OSENI 3 STOSENI ST = requires fill of metformin within the past 2 yearscanagliflozin INVOKANA 3chlorpropamide *DIABINESE 1 Mbromocriptine CYCLOSET 3 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 3 QL (120 tablets/month)metformin GLUMETZA 1000mg 3 QL (60 tablets/month)metformin RIOMET 3 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 3 QL (120 tablets/month)metformin SR FORTAMET 1000mg 3 QL (75 tablets/month)miglitol GLYSET 3 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 3 QL (30 tablets/month) STActoPlus Met XR ST = requires 60 day trial of Actos AND metformin or ActoPlus Met in past 2 yearsrepaglinide *PRANDIN 1 QL (120 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 25PA5-Tier Drug Benefit Guide09/01/13

epaglinide-metformin PRANDIMET 2rosiglitazone AVANDIA 3 QL (30 tablets/month) STAvandia ST = requires 90 day trial of either sulfonylurea or biguanide in past 2 yearsrosiglitazone maleate-glimepiride AVANDARYL 4/1mg 3 QL (60 tablets/month) STrosiglitazone maleate-glimepiride AVANDARYL 4/2mg 3 QL (60 tablets/month) STrosiglitazone maleate-glimepiride AVANDARYL 4/4mg 3 QL (30 tablets/month) STAvandaryl ST = requires 90 day trial of either Avandia or glimipride in past 2 yearsrosiglitazone-metformin AVANDAMET 1/500mg 3 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 2/500mg 3 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 4/500mg 3 QL (120 tablets/month) STrosiglitazone-metformin AVANDAMET 2/1000mg 3 QL (60 tablets/month) STrosiglitazone-metformin AVANDAMET 4/1000mg 3 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 3 QL (30 tablets/month) STJanuvia ST = requires fill of metformin within the past 2 yearssitaglipin-metformin JANUMET 3 QL (60 tablets/month) STJanumet ST = requires fill of metformin within the past 2 yearssitaglipin-metformin JANUMET XR 3 QL (30 tablets/month) STJanumet ST = requires fill of metformin within the past 2 yearstolazamide *TOLINASE 1tolbutamide *TOLBUTAMIDE 16-G InsulinsGeneric Name Brand NameTierNotesinsulin (human) NOVOLIN 3 STNOVOLIN ST = requires failure of a Lilly product within the last 2 yearsinsulin (human) HUMULIN 1insulin (human) HUMULIN PEN 2insulin (human) RELION 3insulin aspart NOVOLOG 3 STNOVOLOG ST = requires failure of a Lilly product within the last 2 yearsinsulin aspart mix NOVOLOG MIX 3 STNOVOLOG MIX ST = requires failure of a Lilly product within the last 2 yearsinsulin detemir LEVEMIR 2insulin glargine LANTUS 2insulin glulisine APIDRA 3insulin 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 AgentsGeneric Name Brand NameTierNoteslevothroid 1 QL (60 tablets/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 265-Tier Drug Benefit Guide09/01/13

levothyroxine 1levothyroxine TIROSINT 2levothyroxine *SYNTHROID (NTI) 2levoxyl 2liothyronine *CYTOMEL 1liotrix THYROLAR 3methimazole *TAPAZOLE 1methimazole NORTHYX 2propylthiouracil *PTU 1thyroid ARMOUR THYROID 2thyroid NATURE-THROID 2thyroid WESTHROID-P 3unithroid 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 3caberoline *DOSTINEX 1calcitonin MIACALCIN 2calcitonin (salmon) nasal *FORTICAL 1carglumic acid CARBAGLU 3cinacalcet SENSIPAR 30mg 3cinacalcet SENSIPAR 60mg 3cinacalcet SENSIPAR 90mg 3desmopressin (nasal) *DDAVP 1desmopressin (nasal) STIMATE 3desmopressin (oral) *DDAVP 0.1mg 1desmopressin (oral) *DDAVP 0.2mg 1etidronate *DIDRONEL 1exenatide BYDUREON 3exenatide BYETTA 2ibandronate *BONIVA 3levocarnitine *CARNITOR 1liraglutide VICTOZA 3pramlintide SYMLIN AMYLIN ANALOG 2QL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (60 tablets/month)QL (90 tablets/month)QL (90 tablets/month)QL (60 tablets/month)TierNotesQL (30 tablets/month)QL (30 tablets/month)QL (4 tablets/month)QL (4 tablets/month)QL (4 tablets/month)QL (4 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)STSymlin ST = requires concurrent mealtime insulin therapy (rapid or fast acting)raloxifene EVISTA 2 QL (30 tablets/month)risedronate ACTONEL 5mg 3 QL (30 tablets/month)risedronate ACTONEL 30mg 3 QL (4 tablets/month)risedronate ACTONEL 35mg 3 QL (4 tablets/month)risedronate ACTONEL 150mg 3 QL (1 tablet/month)risedronate-calcium ACTONEL with CALCIUM 3 QL (30 tablets/month)sapropterin KUVAN 4 PA SPQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 275-Tier Drug Benefit Guide09/01/13

6-K Diabetic Suppliesulipristal ELLA 3ACCU-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 1ACCU-CHEK COMPACT CARE KIT 1ACCU-CHEK COMPACT TEST STRIPS 1ACCU-CHEK METER 1ASCENSIA AUTODISC TEST STRIPS 3ASCENSIA BREEZE 2 TEST STRIPS 3ASCENSIA ELITE TEST STRIPS 3CONTOUR TEST STRIPS 3FREESTYLE FLASH SYSTEM 3FREESTYLE FREEDOM LITE METER 3FREESTYLE FREEDOM METER 3FREESTYLE LITE METER 3FREESTYLE SYSTEM 3FREESTYLE TEST STRIPS 3GLUCOMETER DEX TEST STRIPS 3ONE 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 3PRECISION XTRA TEST STRIPS 3SMARTVIEW TEST STRIPS 1SURESTEP SYSTEM 3SURESTEP TEST STRIPS 3VERIO STRIPS 1VERIO IQ STRIPS 1GASTROINTESTINAL (drugs to treat stomach or intestinal conditions, ie reflux, constipation, etc)7-A LaxativesGeneric Name Brand NameTierlactulose 1na sulf-k sulf-mg sulf & peg 3350 SUCLEAR 3PEG electrolyte *COLYTE 1PEG electrolyte GOLYTELY 2PEG 3350 MOVIPREP 3peg(high)-electrolyte *NULYTELY 1sod sulf-pot sulf-mag sulfate SUPREP 3sod phos mon-sod phos di VISICOL 3QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 28Notes5-Tier Drug Benefit Guide09/01/13

7-B AntidiarrhealsGeneric Name Brand NameTierNotesdiphenoxylate-atropine *LOMOTIL 1opium tincture *OPIUM TINCTURE 3 QL (72 mls/month)paregoric 37-C Miscelleanous Ulcer DrugsGeneric Name Brand NameTierNotesdicyclomine *BENTYL 1amoxicillin-clarithro-lansopraz CR PREVPAC 3 QL (1 pak/year)bismuth subcit-metronidazole-tetracycline PYLERA 3 QL (2 paks/year)chlordiazepoxide-methscopolamine LIBRAX 3glycopyrrolate *ROBINUL 1glycopyrrolate *ROBINUL FORTE 1hyoscyamine *LEVSIN 1hyoscyamine *LEVBID 1hyoscyamine *NULEV 1methscopolamine PAMINE 3metronidazole-tetracycline-bismuth HELIDAC 3misoprostol *CYTOTEC 1 QL (120 tablets/month)phenobarbital-belladonna *DONNATAL 1propantheline PRO-BANTHINE 2sucralfate CARAFATE 27-D H2 BlockersGeneric Name Brand NameTierNotescimetidine *TAGAMET 1famotidine *PEPCID 1nizatadine *AXID 1ranitidine *ZANTAC 17-E Proton Pump Inhibitors (PPI)Generic Name Brand NameTierNotesdexlansoprazole DEXILANT 3 QL (30 capsules/month)lansoprazole *PREVACID 3 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 3 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 3 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 3 QL (30 capsules/month)pantoprazole *PROTONIX 1 QL (30 tablets/month)rabeprazole ACIPHEX 3 QL (30 tablets/month)7-F AntiemeticsQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 295-Tier Drug Benefit Guide09/01/13

Generic Name Brand NameTierdolasetron ANZEMET 4doxylamine-pyridoxine DICLEGIS 3dronabinol *MARINOL 4granisetron *KYTRIL 1ondansetron *ZOFRAN 4mg 1ondansetron *ZOFRAN 8mg 1ondansetron *ZOFRAN 24mg 1ondansetron *ZOFRAN ODT 4mg 1ondansetron *ZOFRAN ODT 8mg 1scopolamine patch TRANSDERM-SCOP 3trimethobenzamide *TIGAN 17-G Digestive AidsGeneric Name Brand NameTieramylase-lipase-protease PANCREASE MT 2amylase-lipase-protease KU-ZYME 3amylase-lipase-protease KU-ZYME-HP 3amylase-lipase-protease CREON 2amylase-lipase-protease VIOKASE 2amy-lip-prot dr ULTRASE 2amy-lip-prot dr ULTRASE MT 2miglustat ZAVESCA 4pancrelipase ZENPEP 2pegademase ADAGEN 4sacrosidase SUCRAID 4sodium phenylbutyrate BUPHENYL 4NotesQL (1 tablet/fill; 2 fills/month)PAQL (2 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (15 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (30 tablets/fill; 2 fills/month)QL (10 patches/month)Notes7-H Miscelleanous GastrointestinalGeneric Name Brand NameTierNotesBXN MOUTHWASH 3balsalazide *COLAZAL 1 QL (270 capsules/month)adefovir HEPSERA 5 QL (30 tablets/month) SPalosetron LOTRONEX 3 QL (60 tablets/month) PAbudesonide SR *ENTOCORT EC 1 QL (90 capsules/month)budesonide SR UCERIS 3 PAcalcium acetate (phosphate binder) *PHOSLO 1calcium acetate (phosphate binder) ELIPHOS 2crofelemer FULYZAQ 3 PAcysteamine bitartrate PROCYSBI 3 PA SPglycopyrroate CUVPOSA 3 AL (limited to 16 years of age and under)hycosamine-phenyltoloxamine DIGEX NF 3lamivudine (hepatitis) EPIVIR HBV 2 QL (30 tablets/month) SPlanthanum FOSRENOL 500mg 2 QL (150 tablets/month)lanthanum FOSRENOL 750mg 2 QL (150 tablets/month)lanthanum FOSRENOL 1000mg 2 QL (120 tablets/month)linaclotide LINZESS 3lubiprostone AMITIZA 2 QLQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 305-Tier Drug Benefit Guide09/01/13

mesalamine CANASA 2mesalamine LIALDA 3mesalamine CR APRISO 2mesalamine CR PENTASA 3mesalamine enema *ROWASA 1methylnaltrexone bromide RELISTOR 3metoclopramide *REGLAN 1sevelamer RENAGEL 3sevelamer RENVELA 3sulfasalazine *AZULFIDINE 1sulfasalazine EC *AZULFIDINE EN 1ursodiol *ACTIGALL 1ursodiol *URSO 3ursodiol *URSO FORTE 3DIPENTUM 3QL (120 tablets/month)PAGENITOURINARY (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 3 QL (30 tablets/month)fexoterodine TOVIAZ 3 QL (30 tablets/month)flavoxate *URISPAS 1 QL (240 tablets/month)mirabegron MYRBETRIQ 3oxybutynin *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 3 QL (8 patches/month)solifenacin VESICARE 3 QL (30 tablets/month)tolterodine DETROL 3 QL (60 tablets/month)trospium *SANCTURA 3 QL (60 tablets/month)8-C Vaginal ProductsGeneric Name Brand NameTierNotesclindamycin vaginal *CLEOCIN vaginal cream 1clindamycin vaginal CLINDESSE 3 QL (6 gm/fill)estradiol vaginal ESTRACE vaginal 2estradiol vaginal VAGIFEM 3estradiol vaginal ring ESTRING 3 QL (1 ring/3 months)estradiol vaginal ring FEMRING 3 QL (1 ring/3 months)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 315-Tier Drug Benefit Guide09/01/13

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 NameTiercitric acid-sodium citrate *BICITRA 1citric acid-D-gluconic acid RENACIDIN 3dutasteride AVODART 3finasteride *PROSCAR 1methylergonovine METHERGINE 3oxybutynin gel GELNIQUE 3pentosan polysulfate sodium ELMIRON 2phenazopyridine *PYRIDIUM 1potassium citrate CR *UROCIT-K 1potassium phosphate K-PHOS 2POTASSIUM CHLORIDE 2silodosin RAPAFLO 3tadalafil CIALIS 3tamsulosin *FLOMAX 1tiopronin THIOLA 3NotesQL (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)DIFLUNISAL 2APAP-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 19-B Analgesics-NarcoticGeneric Name Brand NameTierNotesCODEINE SULFATE 2METHADONE 2APAP-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)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 325-Tier Drug Benefit Guide09/01/13

APAP-hydrocodone *VICODIN ES 1 QL (150 tablets/month)APAP-hydrocodone *VICODIN HP 1 QL (180 tablets/month)APAP-hydrocodone ZAMICET 3 QL (360 mls/month)APAP-hydrocodone ZYDONE 2 QL (300 mls/month)ASA-caffeine-but-codeine *FIORINAL w/CODEINE 1ASA-codeine *EMPIRIN w/CODEINE 1buprenorphine BUTRANS 3 STButrans ST = Requires a 30 day trial of at least 2 of the following within thepast 6 months: hydrocodone/apap, tramadol, apap with codeine, oxycodone/apap,and/or morphine IR.buprenorphine *SUBUTEX 3 PAbuprenorphine naloxone SUBOXONE FILM TAB 2 PAbuprenorphine naloxone SUBOXONE TABLETS 3 PAbutorphanol *STADOL NS 1 QL (1 bottle/month)dihydrocodeine compound SYNALGOS DC 3fentanyl citrate nasal LAZANDA 3 PAfentanyl citrate SL ABSTRAL 3 PAfentanyl lollipop *ACTIQ 4 QL (120 lozenges/month) PAfentanyl patch *DURAGESIC 1 QL (10 patches/month) STDuragesic ST = requires 30 day trial fill of MSSR in past 2 yearsfentanyl transmucosal film ONSOLIS 5 PAfentanyl transmucosal lozenge FENTORA 3 QL (120 lozenges/month) PAhydromorphone *DILAUDID 2mg 1 QL (360 tablets/month)hydromorphone *DILAUDID 4mg 1 QL (360 tablets/month)hydromorphone *DILAUDID 8mg 1 QL (360 tablets/month)hydromorphone ER EXALGO 3 QL (30 tablets/month)ibuprofen-hydrocodone *VICOPROFEN 1 QL (480 tablets/month)ibuprofen-hydrocodone *REPREXAIN 3 QL (480 tablets/month)ketorolac tromethamine nasal SPRIX NASAL 3meperidine *DEMEROL 1 QL (360 tablets/month)morphine AVINZA 30mg 3 QL (30 capsules/month) STmorphine AVINZA 60mg 3 QL (30 capsules/month) STmorphine AVINZA 90mg 3 QL (60 capsules/month) STmorphine AVINZA 120mg 3 QL (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 3 PAoxycodone *OXYIR 1oxycodone *ROXICODONE 1 QL (360 tablets/month)oxycodone SR OXYCONTIN 3 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)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 33QL (1 bottle/day; 1 box/5 bottles per month )5-Tier Drug Benefit Guide09/01/13

oxycodone-APAP *PERCOCET 10-650mg 1oxycodone-ASA *PERCODAN 1oxycodone-ibuprofen COMBUNOX 3oxymorphone *OPANA 3oxymorphone ER OPANA ER 2pentazocine-naloxone *TALWIN NX 1propoxyphene-APAP DARVOCET A 3propoxyphene napsylate DARVON-N 3tapentadol NUCYNTA 3tapentadol SR NUCYNTA ER 3tramadol *ULTRAM 1tramadol ER ULTRAM ER 100mg 3tramadol ER ULTRAM ER 200mg 3tramadol ER ULTRAM ER 300mg 3tramadol-APAP ULTRACET 29-C Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)Generic Name Brand NameTiercelecoxib CELEBREX 50mg 3celecoxib CELEBREX 100mg 3celecoxib CELEBREX 200mg 3celecoxib CELEBREX 400mg 3diclofenac *VOLTAREN 25mg 1diclofenac *VOLTAREN 50mg 1diclofenac *VOLTAREN 75mg 1diclofenac potassium *CATAFLAM 1diclofenac SR *VOLTAREN XR 1diclofenac-misoprostol *ARTHROTEC 3etodolac *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 3ketorolac *TORADOL 1lansoprazole-naproxen PREVACID NAP KIT 3meclofenamate *MECLOMEN 1mefenamic acid *PONSTEL 3meloxicam *MOBIC 7.5mg 1meloxicam *MOBIC 15mg 1nabumetone *RELAFEN 1naproxen *NAPROSYN 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 34QL (180 tablets/month)QL (360 tablets/month)QL (7 day treatment; 4 tablets/day)QL (180 tablets/month)QL (60 tablets/month)QL (240 tablets/month)QL (180 tablets/month)QL (180 tablets/month)QL (60 tablets/month)QL (240 tablets/month)QL (90 tablets/month)QL (30 tablets/month)QL (30 tablets/month)QL (240 tablets/month)NotesQL (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)5-Tier Drug Benefit Guide09/01/13

naproxen sodium *ANAPROX 1oxaprozin *DAYPRO 1piroxicam *FELDENE 1sulindac *CLINORIL 1tolmetin sodium *TOLECTIN 19-D Anti-Rheumatic AgentsGeneric Name Brand NameTierauranofin RIDAURA 2deferasirox EXJADE 4leflunomide *ARAVA 1methotrexate 1penicillamine CUPRIMINE 2penicillamine DEPEN 29-E Migraine ProductsGeneric Name Brand NameTieralmotriptan AXERT 3NotesQL (6 tablets/fill; 2 fills/month) STAxert ST = requires one fill of sumatriptan AND Relpax in past 2 yearsQL (240 tablets/month)APAP-isometh-caffeine PRODRIN 3APAP-isometh-dichlor hydrate *MIDRIN 1dihydroergotamine (nasal) *MIGRANAL 3divalproex sodium (migraine) *DEPAKOTE ER 1eletriptan RELPAX 2ergotamine-caffeine *CAFERGOT 1ergotamine-phenobarb-belladona 1frovatriptan FROVA 3QL (90 tablets/month)PA SPQL (30 tablets/month)QL (6 tablets/fill; 2 fills/month)QL (40 tablets/month)QL (6 tablets/fill; 2 fills/month) STFrova ST = requires one fill of sumatriptan AND Relpax in past 2 yearsnaratriptan *AMERGE 3rizatriptan *MAXALT 3rizatriptan *MAXALT MLT 3sumatriptan *IMITREX 1sumatriptan *IMITREX NASAL 1sumatriptan SUMATRIPTAN INJ 2zolmitriptan *ZOMIG 3zolmitriptan ZOMIG NASAL 3 QL (6 vials/month)NotesQL (6 tablets/fill; 2 fills/month)QL (6 tablets/fill; 2 fills/month)QL (6 tablets/fill; 2 fills/month)QL (9 tablets/fill; 2 fills/month)QL (6 vials/month)QL (2 kits/fill, 2 fills/month)QL (6 tablets/fill; 2 fills/month)Zomig Nasal ST = requires one fill of sumatriptan AND Relpax in past 2 yearszolmitriptan *ZOMIG ZMT 3 QL (6 tablets/fill; 2 fills/month)9-F GoutGeneric Name Brand NameTierNotesallopurinol *ZYLOPRIM 1colchicine COLCRYS 3colchicine-probenecid *COLBENEMID 1febuxostat ULORIC 3 QL (30 tablets/month) STUloric ST = requires fill of 2 consecutive months of allopurinol in past 120 daysglycerol phenylbutyrate RAVICTI 3probenecid *BENEMID 19-G Musculoskeletal Therapy AgentsGeneric Name Brand NameTierNotesQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 355-Tier Drug Benefit Guide09/01/13

aclofen *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 3 QL (90 tablets/month) STFexmid ST = requires 2 fills of generic cyclobenzaprine in past 2 yearsdantrolene *DANTRIUM 1metaxalone SKELAXIN 3 QL (240 tablets/month)methocarbamol *ROBAXIN 1orphenadrine citrate *NORFLEX 1tizanidine *ZANAFLEX 19-H Miscelleanous Neuromuscular AgentsGeneric Name Brand NameTierNotespyridostigmine *MESTINON 1riluzole *RILUTEK 3 QL (60 tablets/month)VITAMINS & HEMATOLOGICALS (drugs to treat vitamin deficiencies and other blood disorders)10-A VitaminsGeneric Name Brand NameTierNotescalcitriol *ROCALTROL 1docercalciferol HECTOROL 3ergocalciferol [vitamin D] *CALCIFEROL 1paricalcitol [vitamin D] ZEMPLAR 2 QL (30 capsules/month) SPphytonadione MEPHYTON 2potassium aminobenzoate POTABA 210-B MultivitaminsGeneric Name Brand NameTierNotesB complex-vit C-FA *NEPHROCAPS 1fe bisglycin-fe polysac NIFEREX GOLD 3 QL (30 tablets/month)multi vitamin TANDEM F 3ped 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 3 QL (30 tablets/month)prenat-fe poly cmplx-fe heme PREFERA OB + DHA 3 QL (60 tablets/month)prenatal mv w/fe poly-fa SELECT-OB+DHA 3prenatal 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 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 365-Tier Drug Benefit Guide09/01/13

prenatal vitamins-FE-FA *PRECARE 1prenatal vitamins-iron carbonyl-FA *NESTABS 1prenatal w/dss iron carbonyl-fa ATABEX EC 3prenatal w/fe fum-l methylfolate NEEVO DHA 3prenate w/fe fum-fe poly-fa omega 3 CONCEPT DHA 3prenate w/o a w/fe fum-fe poly-fa CONCEPT OB 3prenate w/o Vit A w/ FE NATELLE ONE 3prenate vitamin FE-Fum-Lmethylfol-FA-CA *PRENATE DHA 1prenate w/o a w/fecbn-egl-dss-fa & dha CITRANATAL ASSURE PAK 310-C MineralsGeneric Name Brand NameTiercyanocobalamin (nasal) NASCOBAL 3cyanocobalamin 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 3FE fum-fe poly-fa-c-b3 INTEGRA F 3FE fum-iron polysacch complex INTEGRA PLUS 3FE fum-vit C-vit B12-FA *CHROMAGEN FORTE 3folic acid 1L-methylfolate ZERVALX 3L-methylfolate B12 B6 METANX CAPSULES 3L-methylfolate B12 B6 *METANX TABLETS 1L-methylfolate B12 B6 B2 CEREFOLIN 3QL (30 tablets/month)QL (60 tablets/month)NotesQL (30 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)10-D AnticoagulantsGeneric Name Brand NameTierNotesapixaban ELIQUIS 3 PAdibigatran PRADAXA 3 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 1dipyridamole *PERSANTINE 1dipyridamole-aspirin SR AGGRENOX 3 QL (60 capsules/month)pentoxifylline *TRENTAL 1 QL (90 tablets/month)prasugrel EFFIENT 3 QL (30 tablets/month)sodium polystyrene sulfonate *KAYEXALATE 1ticagrelor BRILINTA 3ticlopidine *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)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 375-Tier Drug Benefit Guide09/01/13

11-A Ophthalmic Anti-infectivesGeneric Name Brand NameTierazithromycin ophth AZASITE 3bacitracin ophth 1bacitracin-polymyxin B ophth *POLYSPORIN ophth 1besifloxacin ophth BESIVANCE 3ciprofloxacin ophth *CILOXAN 1gatifloxacin ophth ZYMAR 3gatifloxacin ophth ZYMAXID 3gentamycin sulfate ophth *GENTAMICIN OINT 3% 1levofloxacin ophth *QUIXIN 1moxifloxacin ophth MOXEZA 3moxifloxacin ophth VIGAMOX 3neomycin-polymyxin B-gramacidin ophth *NEOSPORIN ophth 1ofloxacin ophth *OCUFLOX 1sulfacetamide sodium ophth *BLEPH-10 1tobramycin ophth *TOBREX 1trifluridine ophth *VIROPTIC 1trimethoprim-polymy B ophth *POLYTRIM ophth 111-B Ophthalmics Beta-BlockerGeneric Name Brand NameTierbetaxolol HCL ophth BETOPTIC-S 3brimonidine timolol ophth COMBIGAN 2carteolol ophth *OCUPRESS 1dorzolamide-timolol ophth *COSOPT 1dorzolamide-timolol ophth COSOPT PF 3levobunolol ophth *BETAGAN 1metipranolol ophth *OPTIPRANOLOL 1timolol ophth BETIMOL 2timolol maleate ophth *TIMOPTIC 1timolol maleate ophth *TIMOPTIC XE 111-C Ophthalmic SteroidsGeneric Name Brand NameTierdexamethasone ophth MAXIDEX 3dexamethasone phosphate ophth *DECADRON ophth 1difluprednate ophth DUREZOL 3fluorometholone ophth FML FORTE 2fluorometholone ophth *FML LIQUIFILM 1fluorometholone ophth FML SOP 2fluorometholone ophth FLAREX 3loteprednol etb-tobramycin ophth ZYLET 3loteprednol ophth ALREX 3loteprednol ophth LOTEMAX 3neomycin-polymyxin-HC ophth *CORTISPORIN OPHTH 1prednisolone ophth *PRED FORTE 1rimexolone ophth VEXOL 2sulfacetamide-prednisolone ophth *BLEPHAMIDE 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 38NotesQL (5 ml/month)QL (5 ml/month)QL (5 ml/month)QL (5 ml/month)QL (3 ml/month)QL (3 ml/month)QL (10 ml/month)QL (5 ml/month)NotesQL (60 sing-use vials per month)QL (5 ml/month)QL (5 ml/month)QL (5 ml/month)QL (10 ml/month)Notes5-Tier Drug Benefit Guide09/01/13

tobramycin-dexamethasone ophth *TOBRADEX 1QL (5 ml/month)11-D Ophthalmic ProstaglandinGeneric Name Brand NameTierNotesbimatoprost ophth LUMIGAN 2 QL (2.5 ml/month)tafluprost opth soln ZIOPTAN 3 QL (1 carton (30 vials) per month (QD)latanoprost ophth *XALATAN 1 QL (2.5 ml/month)travaprost ophth TRAVATAN Z 2 QL (2.5 ml/month)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 3tropicamide 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 3brimonidine 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 3bromfenac ophth *XIBROM 3cromolyn sodium ophth *CROLOM ophth 1cyclosporine ophth RESTASIS 3cysteamine CYSTARAN 3diclofenac ophth *VOLTAREN ophth 1diclofenac ophth VOLTAREN ophth gel 3dorzolamide ophth *TRUSOPT 1flurbiprofen ophth *OCUFEN 1ketorolac ophth *ACULAR 1ketorolac ophth *ACULAR LS 1lidocaine ophth AKTEN GEL 3lodoxamide ophth ALOMIDE 3nedocromil ophth ALOCRIL 3nepafenac ophth NEVANAC 2pemirolast ophth ALAMAST 3TierNotesQL (10 ml/month)QL (2.5 ml/month)PA QL (60 vials(1 box)/month)QL (5ml per month)QL (3 ml/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 395-Tier Drug Benefit Guide09/01/13

11-I Otic (Ear) MedicationsGeneric Name Brand NameTierchloroxylenol-pramoxine-zinc acetate otic ZINOTIC 3chloroxylenol-pramoxine-zinc acetate otic ZINOTIC ES 3ciprofloxacin-dexamethasone CIPRODEX 3ciprofloxacin-HC otic CETRAXAL 3ciprofloxacin-HC otic CIPRO HC OTIC 3hydrocortisone-acetic acid otic *VOSOL-HC 1neomycin-polymyxin-HC otic *CORTISPORIN otic 1neomycin-colistin-HC-thonzonium otic CORTISPORIN-TC 3ofloxacin otic *FLOXIN OTIC 111-J Mouth and ThroatGeneric Name Brand NameTieramlexanox oral paste APHTHASOL 3cevimeline *EVOXAC 3chlorhexidine *PERIDEX 1clotrimazole troche *MYCELEX TROCHE 1lidocaine *VISCOUS LIDOCAINE 1oral hydrogel wafer MUCOTROL 3pilocarpine *SALAGEN 5mg 1pilocarpine *SALAGEN 7.5mg 1sodium fluoride *KARIGEL 1sodium fluoride *KARIGEL-N 1triamcinolone/orabase *KENALOG-ORABASE 1NotesQL (15 ml/month)QL (15 ml/month)QL (8 ml/month)QL (10 ml/month)QL (10 ml/month)NotesQL (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 3 QL (120 ml/month)triprolidine tannate ZYMINE XR SYRUP 3 QL (120 ml/month)12-B Topical Nasal ProductsGeneric Name Brand NameTierNotesazelastine nasal *ASTELIN 1 QL (1 inhaler/month)azelastine nasal ASTEPRO 2 QL (1 inhaler/month)beclomethasone nasal BECONASE AQ 3 QL (2 inhalers/month)budesonide nasal RHINOCORT AQUA 3 QL (2 inhalers/month)ciclesonide nasal OMNARIS 3 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 3 QL (1 inhaler/month)olopatadine nasal PATANASE 3 QL (1 inhaler/month)triamcinolone nasal NASACORT 3 QL (1 inhaler/month)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 405-Tier Drug Benefit Guide09/01/13

triamcinolone nasal NASACORT AQ 3triamcinolone nasal TRI-NASAL 312-C Cough/Cold/AllergyGeneric Name Brand NameTieracetylcysteine *MUCOMYST 1acrivastine-PSE SEMPREX-D 3benzonatate *TESSALON 1bromphen-PSE_DM BROMOXAFED 3cardec DM *RONDEC DM 1chlorpheniramine *ED CHLORPED 1chlorpheniramine-PSE *DECONAMINE 1guaifenesin-DM HUMIBID-DM 3hydrocodone-homatropine *HYCODAN 1phenylephrine-guaifenesin MAXIPHEN-G 3promethazine 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 312-D Asthma/COPDGeneric Name Brand NameTieraclidinium bromide TUDORZA 3albuterol nebulizer *PROVENTIL (nebulizer) 1albuterol tablets *PROVENTIL (tablets) 1albuterol HFA inhaler PROAIR HFA 3albuterol HFA inhaler PROVENTIL HFA 3albuterol HFA inhaler VENTOLIN HFA 2albuterol SR tablets *VOSPIRE ER 4mg 1albuterol SR tablets *VOSPIRE ER 8mg 1albuterol-ipratropium inhaler COMBIVENT RESPIMAT 3albuterol-ipratropium nebulizer *DUONEB 1aminophylline 1arformoterol tartrate nebulizer BROVANA 3budesonide formoterol inhaler SYMBICORT 2cromolyn sodium nebulizer *INTAL (nebulizer) 1fluticasone furoate-vilanterol aero powd BREO ELLIPTA 3formoterol fumarate inhaler PERFOROMIST 3formoterol inhaler FORADIL 2ipratropium nebulizer *ATROVENT (nebulizer) 1ipratropium HFA inhaler ATROVENT HFA 2levalbuterol nebulizer *XOPENEX 0.31mg/3ml 3levalbuterol nebulizer *XOPENEX 0.63mg/3ml 3levalbuterol nebulizer *XOPENEX 1.25mg/3ml 3levalbuterol nebulizer *XOPENEX 1.25 mg/0.5 ml 3levalbuterol inhaler XOPENEX HFA 3metaproterenol nebulizer *ALUPENT (nebulizer) 1QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 41QL (2 inhalers/month)QL (1 inhaler/month)NotesNotesQL (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)5-Tier Drug Benefit Guide09/01/13

metaproterenol tablets *ALUPENT (tablets) 1montelukast *SINGULAIR 4mg 1 QL (30 tablets/month)montelukast *SINGULAIR 5mg 1 QL (30 tablets/month)montelukast *SINGULAIR 10mg 1 QL (30 tablets/month)montelukast *SINGULAIR 4mg Granules 2 QL (30 packets/month)mometasone-formoterol inhalers DULERA 3 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 3 QL (2 inhalers/month)roflumilast DALIRESP 3 PA QL (30 tablets/month)salmeterol inhaler SEREVENT DISKUS 3 QL (1 inhaler/month)salmeterol-fluticasone inhaler ADVAIR 3 QL (1 inhaler/month) STAdvair 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 yearssodium chloride soln nebu 7% HYPER-SAL NEBULIZER 2terbutaline *BRETHINE 1theophylline 1theophylline SLO-PHYLLIN 2theophylline THEOLAIR 2theophylline CR *UNIPHYL 1theophylline SR THEO-24 3tiotropium inhaler SPIRIVA 2zafirlukast *ACCOLATE 112-E Steroid InhalersGeneric Name Brand Namebeclomethasone HFA inhaler QVAR 40mcg 2beclomethasone HFA inhaler QVAR 80mcg 2budesonide inhaler PULMICORT FLEXIHALER 3budesonide nebulizer PULMICORT RESPULES 0.25mg 3budesonide nebulizer PULMICORT RESPULES 0.5mg 3ciclesonide inhaler ALVESCO 3flunisolide inhaler AEROBID 3flunisolide inhaler AEROBID-M 3fluticasone inhaler FLOVENT DISKUS 3fluticasone inhaler FLOVENT HFA 3mometasone inhaler ASMANEX 2triamcinolone inhaler AZMACORT 313-A AnticoagulantsGeneric Name Brand NameTierdalteparin sodium FRAGMIN 4enoxaparin sodium *LOVENOX 1fondaparinux sodium *ARIXTRA 5 PA SIOtinzaparin sodium INNOHEP 5 PA SIO13-B Growth HormonesGeneric Name Brand NameTierQL (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)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 42NotesSIO (covered up to 21 days without prior auth)SIO (covered up to 21 days without prior auth)Notes5-Tier Drug Benefit Guide09/01/13

mecasermin INCRELEX 5 PA SIO SPsomatropin (non-refrigerated) SAIZEN 4 PA SIO SPsomatropin TEV-TROPIN 4 PA SIO SPsomatropin NUTROPIN AQ 5 PA SIO SPsomatropin NUTROPIN AQ NUSPIN 5 PA SIO SPsomatropin NUTROPIN 5 PA SIO SPsomatropin SEROSTIM 4 PA SIO SPsomatropin ZORBTIVE 5 PA SIO SPtesamorelin EGRIFTA 5 PA SIO SP13-C Hematopoietic AgentsGeneric Name Brand NameTierdarbepoetin alpha ARANESP 4 PA SIO SPeltrombopag PROMACTA 5 PA SPepoetin alfa EPOGEN 5 PA SIO SPepoetin alfa PROCRIT 5 PA SIO SPfilgrastim NEUPOGEN 4 PA SIO SPpegfilgrastim NEULASTA 4 PA SIO SPpeginesatide acetate soln OMONTYS 4 PA SIOsargramostim LEUKINE 5 PA SIO SP13-D Hepatitis C AgentsGeneric Name Brand NameTierboceprevir VICTRELIS 5 PA SPinterferon alfacon-1 INFERGEN 5 PA SIO SPpeginterferon alfa-2A PEGASYS 4 PA SIO SPpeginterferon alfa-2A PEGASYS PROCLICK 4 PA SIO SPpeginterferon alfa-2B PEG-INTRON 5 PA SIO SP STpeginterferon alfa-2B PEG-INTRON REDIPEN 5 PA SIO SP STPeg-Intron ST = requires trial of Pegasystelaprevir INCIVEK 2 PA SPREBETRON 5 PA SPROFERON A 5 PA SIO SPNotesNotes13-E Multiple Sclerosis AgentsGeneric Name Brand NameTierNotesdalfampridine AMPYRA 5 QL (60 tablets/month) PA SPdimethyl fumarate TECFIDERA 3 PA SPglatiramer acetate COPAXONE 4 PA SIO SPfingolimod GILENYA 5 PA SP STGilenya ST= requires trial to 1 formulary alternative: Avonex, Copaxone and/or Rebifinterferon beta-1A REBIF 4 PA SIO SPinterferon beta-1A AVONEX 4 PA SIO SPinterferon beta-1A AVONEX ADMINISTRATION PACK 4 PA SIO SPinterferon beta-1B BETASERON 5 PA SIO SP STBetaseron ST= requires trial to Rebifteriflunomide AUBAGIO 3 PA SIO SP13-F Osteoporosis AgentsQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 435-Tier Drug Benefit Guide09/01/13

Generic Name Brand NameTierNotesteriparatide (recombinant) FORTEO 4 PA SIO SP13-G Somatostatin AnalogsGeneric Name Brand NameTierNoteslanreotide acetate SOMATULINE DEPOT 4 PA SIOnafarelin SYNAREL 4 PAoctreotide acetate *OCTREOTIDE 4 PA SIO SPoctreotide acetate release SANDOSTATIN LAR 4 PA SIO SPpegvisomant SOMAVERT 4 PA SIO SP13-H ImmunomodulatorsGeneric Name Brand NameTierNotesadalimumab HUMIRA 5 PA SIO SP STHumira ST = requires trial of 1 formulary alternative: Enbrel, Simponi, and/or Cimziaanakinra subcutaneous KINERET 5 PA SIO SPcertolizumab pegol CIMZIA 4 PA SIO SPetanercept for subcutaneous ENBREL 4 PA SIO SPgolimumab SIMPONI 4 QL (1 unit/month) PA SIO SPtofacitinib XELJANZ 3 PA STXELJANZ ST- requires trial of 2 formulary alternatives: Enbrel, Simponi, and/or Cimzia13-I Miscellaneous SpecialtyGeneric Name Brand NameTierNotesabatacept ORENCIA 3 PA SPcorticotropin ACTHAR HP 4 PA SIO SPicatibant acetate FIRAZYR 5 PA SPinterferon alfa-2B INTRON-A 5 PA SIOinterferon gamma-1B ACTIMMUNE 4 PA SIO SPleuprolide acetate ELIGARD 5 PA SIOleuprolide acetate LUPRON 2 SIOleuprolide acetate LUPRON DEPOT 2 SIOleuprolide acetate LUPRON DEPOT-PED 2 SIOnitisinone ORFADIN 4 PAoprelvekin NEUMEGA 4 PA SPoxandralone OXANDRALONE 4 PAoxymetholone ANADROL-50 4palonosetron ALOXI (tablets) 4 PApeginterferon alfa-2B SYLATRON 5 PA SIO SPpeginterferon alfa-2B SYLATRON 4-PACK 5 PA SIO SPrilonacept ARCALYST 4 PA SIO14-A Excluded From CoverageGeneric Name Brand Nameacyclovir hydrocortisone XERESEalcaftadine LASTACAFTalendronate BINOSTOamilodipine-atorvastatin CADUETamlodipine-aliskiren TEKAMLOEXCLUSIONS (excluded drugs)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 44TierNotes5-Tier Drug Benefit Guide09/01/13

amlodipine-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 OPTIVARazelastine 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 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)QL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 455-Tier Drug Benefit Guide09/01/13

clonidine SR NEXICLON XR (tablet)clotrimazole LOTRIMIN 1%dermatological GENADUR KITdesloratadine CLARINEXdesonide DESONILdesoximetasone TOPICORT SPRAYdesvenlafaxine er DESVENLAFAXdextroamphetamine sulfate ZENZEDIdiclofenac CAMBIAdiclofenac patch FLECTORdiclofenac 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 HYTONEhydrocortisone topical NUCORThydrocortisone topical HYDROCORTISONE 0.05%hydrocortisone topical HYDROCORTISONE 1%hydrocortisone-pramoxine PROCORTibuprofen-famotidine DUEXISicosapent ethyl VASCEPAimiquimod ZYCLARAinterferon beta-1B EXTAVIAQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 465-Tier Drug Benefit Guide09/01/13

isotretinoin ABSORICAitraconazole ONMELketoconazole-hydrocortisone KETOCONketorolac ophth ACUVAILketotifen ZADITORketotifen ZADITOR OTCl-mehylfolate DEPLINlactic acid LAC-HYDRINlevocetirizine XYZALlevonor-eth es QUARTETTElidocaine gel LIDORXloperamide IMODIUMloratadine CLARITINlorcaserin hcl BELVIQloteprednol etabonate LOTEMAX GELmemantine 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 ULTRASEparoxetine mesylate BRISDELLEpramipexole SR MIRAPEX ERprednisone RAYOSprednisolone sodium phosphate ASMALPREDribavirin RIBAPAKrisedronate ATELVIAropinirole SR REQUIP XLQL - Quantity Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 475-Tier Drug Benefit Guide09/01/13

serum-derived bovine ENTERAGAMsomatropin GENOTROPINsomatropin HUMATROPEsomatropin NORDITROPINsomatropin NORDITROPIN FLEXPROsomatropin NORDITROPIN NORDIFLEXsomatropin OMNITROPEsulfacetamide sodium-sulfur pad SUMAXIN CP KITsulfacetamide sodium sulfur SSS 10-4sulfacetamide 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 TWYNSTAtestosterone ANDROGELTERMINEXtobramycin-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 Limits AL - Age LimitsPA - Prior Authorization RequiredST - Step Therapy RequiredSIO - Self-Injectable OrphanSP- Specialty Drugs 485-Tier Drug Benefit Guide09/01/13

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-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-Dalclometasone 5-H515-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionALDACTAZIDE 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-Halogliptin benzoate 6-Falogliptin-metformin 6-Falogliptin-pioglitazone 6-FALOMIDE 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 3-Laltretamine 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-G525-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionamy-lip-prot dr 7-GANADROL-50 13-IANAFRANIL 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 7-HASACOL HD 7-HASCENSIA AUTODISC TEST STRIPS 6-KASCENSIA BREEZE 2 TEST STRIPS 6-KASCENSIA ELITE TEST STRIPS 6-Kasenapine 4-DASENDIN 4-BASMALPRED 14-AASMANEX 12-EASTAGRAF XL 14-AASTELIN 12-BASTEPRO 12-BATABEX EC 10-BATACAND 3-GATACAND HCT 3-IATARAX 4-Aatazanavir 1-IATELVIA 14-Aatenolol 3-C535-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionatenolol-chlorthalidone 3-IATIVAN 4-Aatomoxetine 4-Eatorvastatin 3-Latovaquone 1-Latovaquone-proguanil HCL 1-JATRALIN 14-AATRAPRO CP 14-AATRIPLA 1-Iatropine ophth 11-EATROVENT 12-DATROVENT HFA 12-DATROVENT NASAL 12-BAUBAGIO 13-Eaugmented betamethasone 5-HAUGMENTIN 1-AAUGMENTIN XR 1-AAURALGAN 14-Aauranofin 9-DAUVI-Q 14-AAVALIDE 3-IAVANDAMET 6-FAVANDARYL 6-FAVANDIA 6-FAVAPRO 3-GAVC vaginal 8-CAVELOX 1-EAviane 6-DAVINZA 9-BAVODART 8-DAVONEX 13-EAVONEX ADMINISTRATION PACK 13-EAXID 7-DAXIRON 6-Baxitinib 2-AAYGESTIN 6-EAZASITE 11-Aazatadine-pseudoephedrine CR 12-Cazathioprine 2-Bazelaic acid 5-Bazelastine 14-Aazelastine nasal 14-AAZELEX 5-Bazilsartan medoxomil 3-Gazilsartan-chlorthalidone 3-Iazithromycin 1-Cazithromycin ER 1-Cazithromycin ophth 11-AAZMACORT 12-EAZOPT 11-HAZOR 3-Iaztreonam 1-AAZULFIDINE 7-HAZULFIDINE EN 7-HB complex-vit C-FA 10-Bbacitracin ophth 11-Abacitracin-polymyxin B ophth 11-Abaclofen 9-Gbac-polymy-neomycin HC oint 5-CBACTRIM 1-LBACTROBAN 5-CBACTROBAN CREAM 5-CBACTROBAN NASAL OINTMENT 5-Cbalsalazide 7-HBANZEL 4-GBARACLUDE 1-Ibecaplermin 5-Ibeclomethasone HFA inhaler 12-Ebeclomethasone nasal 12-BBECONASE AQ 12-Bbenazepril 3-Fbenazepril-HCTZ 3-IBENEMID 9-FBENICAR 3-GBENICAR HCT 3-IBENTYL 7-CBENZACLIN 5-BBENZACLIN CARE KIT 14-A545-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionBENZAMYCIN 5-BBENZEFOAM AER 14-ABENZEFOAM ULTRA 14-Abenzocaine-antipyrine otic 14-Abenzonatate 12-Cbenzonatate 14-Abenzoyl peroxide 14-Abenzoyl peroxide cleansing pad 14-Abenzoyl peroxide foam 14-Abenzoyl peroxide-adapalene 5-Bbenzoyl peroxide-erythromycin gel 5-Bbenzoyl peroxide-salicylic acid-vit E 5-Bbenzoyl peroxide-urea 5-Bbenzoyl peroxide-vit E 5-Bbenztropine 4-Hbepotastine ophth 11-HBEPREVE 11-Hbesifloxacin ophth 11-ABESIVANCE 11-ABETAGAN 11-Bbetamethasone dipropionate 5-Hbetamethasone foam 5-Hbetamethasone valerate 5-HBETAPACE 3-CBETAPACE AF 3-CBETASERON 13-Ebetaxolol 3-Cbetaxolol HCL ophth 11-Bbethanechol 8-BBETIMOL 11-BBETOPTIC-S 11-Bbexarotene 2-ABEYAZ 14-ABIAXIN 1-CBIAXIN XL 1-Cbicalutamide 2-ABICITRA 8-DBIDIL 3-MBILTRICIDE 1-Kbimatoprost ophth 11-DBIO-STATIN 1-Gbismuth subcit-metronidazole-tetracycline 7-Cbisoprolol 3-Cbisoprolol-HCTZ 3-IBLEPH-10 11-ABLEPHAMIDE 11-CBLOCADREN 3-Cboceprevir 13-DBONIVA 6-Jbosentan 3-HBOSULIF 2-ABREO ELLIPTA 12-DBRETHINE 12-DBREVICON 6-DBREVOXYL 14-ABRILINTA 10-Ebrimonidine ophth 11-Gbrimonidine timolol ophth 11-Bbrinzolamide ophth 11-HBRISDELLE 14-ABROMDAY 11-Hbromfenac ophth 11-Hbromocriptine 6-Fbromocriptine (tablets) 4-HBROMOXAFED 12-Cbromphen-PSE-DM 12-CBROVANA 12-Dbuconazole vaginal 8-Cbudesonide formoterol inhaler 12-Dbudesonide inhaler 12-Ebudesonide nasal 12-Bbudesonide nebulizer 12-Ebudesonide SR 7-Hbumetanide 3-JBUMEX 3-JBUPHENYL 7-Gbuprenorphine 9-Bbuprenorphine naloxone 9-Bbupropion 4-Bbupropion SR 4-B555-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionbupropion SR 14-Abupropion XL 4-BBUSPAR 4-Abuspirone 4-Abusulfan 2-Abutenafine 5-Dbutorphanol 9-BBUTRANS 9-BBXN MOUTHWASH 7-HBYDUREON 6-JBYETTA 6-JBYSTOLIC 3-Ccaberoline 6-Jcabozantinib 2-ACADUET 14-ACAFERGOT 9-ECALAN 3-DCALAN SR 3-DCALCIFEROL 10-Acalcipotriene 5-Fcalcitonin 6-Jcalcitonin (salmon) nasal 6-Jcalcitriol 10-Acalcitriol ointment 5-Fcalcium acetate (phosphate binder) 7-Hcalcium acetate (phosphate binder) 7-HCAMBIA 14-ACamila 6-DCANASA 7-Hcandesartan 3-Gcandesartan-HCTZ 3-Icapecitabine 2-ACAPEX 5-HCAPOTEN 3-FCAPOZIDE 3-Icaptopril 3-Fcaptopril-HCTZ 3-ICARAC 5-ICARAFATE 7-CCARBAGLU 6-Jcarbamazepine 4-Gcarbamazepine SR 4-GCARBATROL 4-Gcarbidopa-levodopa 4-Hcarbidopa-levodopa CR 4-Hcarbidopa-levodopa-entacapone 4-Hcarbinoxamine-PSE 12-Ccarbinoxamine-PSE-DM 12-Ccardec DM 12-CCARDENE 3-DCARDENE SR 3-DCARDIZEM 3-DCARDIZEM LA 3-DCARDIZEM SR 3-DCARDURA 3-Hcarglumic acid 6-Jcarisoprodol 9-Gcarisoprodol-ASA 9-Gcarisoprodol-ASA-codeine 9-GCARMOL 40 5-ICARMOL SCALP 5-ICARNITOR 6-Jcarteolol HCL 3-Ccarteolol ophth 11-Bcartia XT 3-DCARTROL 3-Ccarvedilol 3-Ccarvedilol 14-ACASODEX 2-ACATAFLAM 9-CCATAPRES 3-HCATAPRES-TTS 3-HCAYSTON 1-ACECLOR 1-BCECLOR CD 1-BCEDAX 1-BCEENU 2-Acefaclor 1-Bcefaclor ER 1-Bcefadroxil 1-B565-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectioncefdinir 1-Bcefditoren pivoxil 1-Bcefpodoxime 1-Bcefprozil 1-Bceftibuten 1-BCEFTIN 1-Bcefuroxime 1-BCEFZIL 1-BCELEBREX 9-Ccelecoxib 9-CCELEXA 4-BCELLCEPT 2-BCELONTIN 4-GCENESTIN 6-CCENTANY AT 14-Acephalexin 1-BCEREFOLIN 10-Ccertolizumab pegol 13-Hcetirizine 14-ACETRAXAL 11-Icevimeline 11-Jchloral hydrate 4-Cchlorambucil 2-Achlordiazepoxide 4-Achlordiazepoxide-methscopolamine 7-Cchlorhexidine 11-Jchloroquine 1-Jchlorothiazide 3-Jchloroxylenol-pramoxine-zinc acetate otic 11-Ichlorpheniramine 12-Cchlorpheniramine-PSE 12-Cchlorphen-pyrilamine-PE 12-Cchlorpromazine 4-Dchlorpropamide 6-Fchlorthalidone 3-Jchlorzoxazone 9-Gcholestyramine 3-Lcholine-mag salicylates 9-ACHROMAGEN FORTE 10-CCIALIS 8-Dciclesonide inhaler 12-Eciclesonide nasal 12-BCICLODAN KIT 14-Aciclopirox 14-Aciclopirox 14-Aciclopirox solution 5-Dciclopirox solution 8% 3-Icilostazol 10-ECILOXAN 11-Acimetidine 7-DCIMZIA 13-Hcinacalcet 6-JCIPRO 1-ECIPRO HC OTIC 11-ICIPRO XR 1-ECIPRODEX 11-Iciprofloxacin 1-Eciprofloxacin ophth 11-Aciprofloxacin SR 1-Eciprofloxacin-dexamethasone 11-Iciprofloxacin-HC otic 11-Icitalopram 4-BCITRANATAL PAK ASSURANCE 10-Bcitric acid-D-gluconic acid 8-Dcitric acid-sodium citrate 8-DCLARAVIS 5-BCLARINEX 14-Aclarithromycin 1-Cclarithromycin SR 1-CCLARITIN 14-ACLEOCIN 1-CCLEOCIN vaginal cream 8-CCLEOCIN-T 5-BCLIMARA 6-CCLIMARA PRO 6-CCLINDACIN PAC 14-ACLINDACIN-P 14-Aclindamycin 1-C575-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionclindamycin phosphate 14-Aclindamycin phosphate swab 14-Aclindamycin topical 5-Bclindamycin vaginal 8-Cclindamycin-benzoyl peroxide gel 5-Bclindamycin-benzoyl peroxide gel 14-Aclindamycin-tretinoin 14-ACLINDESSE 8-CCLINORIL 9-Cclobazam 4-GCLOBETA 14-Aclobetasol 14-Aclobetasol foam 5-Hclobetasol propionate 5-HCLOBEX SHAMPOO 14-Aclocortolone 5-HCLODERM 5-Hclomipraminedesipramine 4-Bclonazepam 4-Gclonidine 3-Hclonidine 14-Aclonidine patch 3-Hclonidine SR 14-Aclopidogrel 10-Eclorazepate 4-Aclotrimazole 14-Aclotrimazole troche 11-Jclotrimazole-betamethasone 5-Dclozapine 4-DCLOZARIL 4-DCOARTEM 1-JCOCET PLUS 14-ACODEINE PHOSPHATE 9-BCODEINE SULFATE 9-BCODIMAL DH 12-CCOGENTIN 4-HCOGNEX 4-FCOLAZAL 7-HCOLBENEMID 9-Fcolchicine 9-Fcolchicine-probenecid 9-FCOLCRYS 9-Fcolesevelam 3-LCOLESTID 3-Lcolestipol 3-Lcollagenase 5-ICOLYTE 7-ACOMBIGAN 11-BCOMBIPATCH 6-CCOMBIVENT 12-DCOMBIVIR 1-ICOMBUNOX 9-BCOMETRIQ 2-ACOMPAZINE 4-DCOMPLERA 1-ICOMTAN 4-HCONCEPT DHA 10-BCONCEPT OB 10-BCONCERTA 4-ECONDYLOX 5-ICONTOUR TEST STRIPS 6-KCONZIP 14-ACOPAXONE 13-ECORDARONE 3-ECORDRAN 5-HCOREG 3-CCOREG CR 14-ACORGARD 3-CCORTEF 6-Acorticotropin 13-Icortisone acetate 6-ACORTISPORIN CREAM 5-CCORTISPORIN OINTMENT 5-CCORTISPORIN OPHTH 11-CCORTISPORIN otic 11-ICORTISPORIN-TC 11-ICORTONE 6-ACORZIDE 3-ICOSOPT 11-BCOTAZYM 7-G585-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionCOUMADIN 10-DCOVERA HS 3-DCOZAAR 3-GCREON 7-GCRESTOR 3-LCRINONE 6-ECRIXIVAN 1-Icrizotinib 2-ACROLOM ophth 11-Hcromolyn sodium inhaler 12-Dcromolyn sodium nebulizer 12-Dcromolyn 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-ACYTOMEL 6-ICYTOTEC 7-CCYTOXAN 2-Adalfampridine 13-EDALIRESP 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-IDELOS 14-ADEMADEX 3-JDEMEROL 9-BDEMULEN 6-DDENAVIR 5-EDEPAKENE 4-GDEPAKOTE 4-GDEPAKOTE ER 9-EDEPEN 9-DDEPLIN 10-CDERMA-SMOOTH FS 5-HDERMATOP 5-Hdeserpidine-methyclothiazide 3-Hdesipramine 4-Bdesloratadine 14-Adesmopressin (nasal) 6-Jdesmopressin (oral) 6-JDESOGEN 6-Ddesonide 5-H595-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiondesonide 14-Adesonide foam 5-HDESONIL 14-ADESOWEN 5-Hdesoximetasone 5-HDESOXYN 4-Edesvenlafaxine 4-BDESYREL 4-BDETROL 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-Ddiclofenac 9-Cdiclofenac 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-DDIOVAN 3-GDIOVAN-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-C605-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiondocercalciferol 10-Adofetilide 3-Edolasetron 7-Fdonepezil 4-Fdonepezil 14-ADONNATAL 7-Cdornase 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 14-ADYNACIRC 3-DDYNACIRC CR 3-DDYNAPEN 1-ADYRENIUM 3-Jeconazole 5-DED CHLORPED 12-CEDARBI 3-GEDARBYCLOR 3-IEDLUAR 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 10-DELLA 6-JELMIRON 8-DELOCON 5-Heltrombopag 13-CEMADINE 14-AEMBEDA 9-BEMCYT 2-Aemedastine 14-AEMLA cream 5-IEMPIRIN w/CODEINE 9-B615-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionemtricitabine 1-Iemtricitabine-rilpivirine-tenofovir 1-Iemtricitabine-tenofovir 1-IEMTRIVA 1-IENABLEX 8-Benalapril 3-Fenalapril-felodipine 3-Ienalapril-HCTZ 3-IENBREL 13-HENDURONYL 3-Henfuvirtide 1-IENJUVIA 6-Cenoxaparin sodium 13-AEnpresse 6-Dentacapone 4-Hentecavir 1-IENTERAGAM 14-AENTOCORT EC 7-HENTUSS 12-CEPIDUO 5-BEPIFOAM 5-Hepinastine 14-Aepinephrine inj 14-AEPIPEN 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-EERIVEDGE 2-Aerlotinib 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-C625-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionESTRATEST 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-CESTROSTEP 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 3-IEXJADE 9-DEXTAVIA 14-Aezetimibe 3-Lezetimibe-simvastatin 3-Lezogabine 4-Gfamciclovir 1-Hfamotidine 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 14-Afentanyl 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-L635-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionfilgrastim 13-CFINACEA 5-Bfinasteride 8-Dfingolimod 13-EFIORICET 9-AFIORINAL 9-AFIORINAL w/CODEINE 9-BFIRAZYR 13-IFLAGYL 1-LFLAGYL 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-K645-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionFROVA 9-Efrovatriptan 9-EFURADANTIN 8-Afurosemide 3-JFUZEON 1-Igabapentin 4-Ggabapentin enacarbil 14-AGABARONE 4-GGABITRIL 4-Ggalantamine 4-Fganciclovir 1-HGANTANOL 1-LGANTRISIN 1-LGARAMYCIN 5-Cgatifloxacin ophth 11-Agefitinib 2-AGELNIQUE 8-Dgemfibrozil 3-LGENADUR 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-Fglycopyrroate 7-Hglycopyrrolate 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 wipekit14-AHECTOROL 10-AHELIDAC 7-CHEPSERA 7-HHEXALEN 2-AHIVID 1-Ihomatropine ophth 11-EHORIZANT 14-AHUMALOG 6-GHUMALOG MIX 6-GHUMALOG MIX PEN 6-G655-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionHUMALOG PEN 6-GHUMATROPE 14-AHUMIBID-DM 12-CHUMIRA 13-HHUMULIN 6-GHUMULIN PEN 6-GHYCAMTIM 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-Jhydroxyurea 2-Ahydroxyzine 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 2-Ailoperidone 4-Diloprost 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-DINLYTA 2-AINNOHEP 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-G665-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectioninsulin glargine 6-Ginsulin glulisine 6-Ginsulin lispro 6-Ginsulin lispro mix 6-GINTAL 12-DINTEGRA F 10-CINTEGRA 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-IINTRON-A 13-IINTUNIV 4-FINVEGA 4-DINVEGA SUSTENNA 4-DINVIRASE 1-Iiodoquinol 1-LIOPIDINE 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-FJANUVIA 6-FJolivette 6-DJune1 6-DJunel FE 6-DJUXTAPID 3-LKADIAN 14-AKALETRA 1-IKAPVAY 14-AKARIGEL 11-JKARIGEL-N 11-JKariva 6-DKAYEXALATE 10-EKAZANO 6-FKEFLEX 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-A675-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionketotifen 14-AKINERET 13-HKLARON 5-BKLONOPIN 4-GKOMBIGLYZE XR 6-FK-PHOS 8-DKUVAN 6-JKU-ZYME 7-GKU-ZYME-HP 7-GKWELL 5-GKYTRIL 7-Flabetalol 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-Bleflunomide 9-Dlenalidomide 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-H685-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionlidocaine 11-Jlidocaine (topical) 5-Ilidocaine ophth 11-Hlidocaine patch 5-Ilidocaine-hydrocortisone 5-Ilidocaine-prilocaine 5-Ilidocaine-tetracaine 5-ILIDODERM 5-ILIMBITROL 4-Flinaclotide 7-Hlinagliptin 6-Flindane shampoo 5-Glinezolid 1-LLINZESS 7-HLIORESAL 9-Gliothyronine 6-Iliotrix 6-ILIPITOR 3-LLIQUADD 4-Eliraglutide 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-Llomitapide mesylate 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-D695-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionLUNESTA 4-CLUPRON 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 6-EMALARONE 1-Jmaprotiline 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-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 12-Dmetaproterenol 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-D705-Tier 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-GMINIPRESS 3-HMINITRAN 3-BMINOCIN 1-Dminocycline 1-Dminocycline 14-Aminoxidil 3-HMINTEZOL 1-KmirabegronMIRAPEX8-B4-HMIRAPEX ER 14-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-Emometasone nasal 12-Bmometasone-formoterol inhalers 12-D715-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionMOMEXIN 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-AMYRBETRIQMYSOLINE8-B4-Gnabumetone 9-Cnadolol 3-Cnadolol-bendroflumethiazide 3-Inafarelin 13-Gnaftifine 5-DNAFTIN 5-DNALFON 9-Cnaltrexone 9-BNAMENDA 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-Dnedocromil inhaler 12-Dnedocromil ophth 11-HNEEVO DHA 10-B725-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionnefazodone 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-JNESINA 6-FNESTABS 10-BNEULASTA 13-CNEUMEGA 13-INEUPOGEN 13-CNEURONTIN 4-GNEVANAC 11-Hnevirapine 1-INEXAVAR 2-Anevirapine XR 1-INEXICLON 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-INortrel 6-DNortrel 7/7/7 6-Dnortriptyline 4-BNORVASC 3-DNORVIR 1-INOVAHISTINE 12-CNOVOLIN 6-G735-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionNOVOLOG 6-GNOVOLOG MIX 6-GNOXAFIL 1-GNUCORT 14-ANUCYNTA 9-BNUCYNTA ER 9-BNUEDEXTA 4-FNULEV 7-CNULYTELY 7-ANUTROPIN 13-BNUTROPIN AQ 13-BNUTROPIN AQ NUSPIN 13-BNUVARING 6-DNUVIGIL 4-Enystatin 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-KONFI 4-GONGLYZA 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-JORAP 4-FORAPRED 6-AORBIVAN 14-AORENCIA 13-IORFADIN 13-Iorphenadrine citrate 9-GORTHO CEPT 6-DORTHO CYCLEN 6-DORTHO EVRA 6-DORTHO MICRONOR 6-DORTHO NOVUM 1/35 6-D745-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionORTHO 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-HOSENI 6-FOTIC CARE 14-AOVACE 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 14-Aoxybutynin 8-Boxybutynin 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-CPEDIATEX DM 12-CPEDIAZOLE 1-LPEDIPIROX 14-A755-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPEG electrolyte 7-Apeg(high)-electrolyte 7-APEG 3350 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-EPERTZYE 14-APEXEVA 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-Ipodophyllum resin 5-IPOLYSPORIN ophth 11-A765-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPOLYTRIM ophth 11-APOLY-VI-FLOR 10-BPOLY-VI-FLOR-FE 10-Bponatinib hcl 2-APONSTEL 9-CPortia 6-Dposaconazole 1-GPOTABA 10-Apotassium aminobenzoate 10-APOTASSIUM CHLORIDE 8-Dpotassium citrate CR 8-Dpotassium phosphate 8-DPOTIGA 4-GPRADAXA 10-Dpramipexole 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-Jprimidone 4-GPRINCIPEN 1-APRINIVIL 3-FPRINZIDE 3-I775-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPRISTIQ 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-EPROGRAF 2-BPROLIXIN 4-DPROMACTA 13-Cpromethazine 12-Apromethazine VC 12-Cpromethazine VC- codeine 12-Cpromethazine-codeine 12-CPROMETRIUM 6-EPRONESTYL 3-Epropafenone 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 14-Aquinapril 3-Fquinapril-HCTZ 3-Iquinidine gluconate 3-Equinidine sulfate 3-Equinine sulfate 1-JQUIXIN 11-AQVAR 12-Erabeprazole 7-E785-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionraloxifene 6-Jraltegravir 1-Iramelteon 4-Cramipril 3-FRANEXA 3-Mranitidine 7-Dranolazine 3-MRAPAFLO 8-DRAPAMUNE 2-BRAPTIVA 13-HRAZADYNE 4-FRAZADYNE ER 4-FREBETOL 1-HREBETRON 13-DREBIF 13-EReclipsen 6-Drefaximin 1-LREGLAN 7-HREGRANEX 5-IRELAFEN 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-Irivaroxaban 10-Drivastigmine 4-Frizatriptan 9-EROBAXIN 9-GROBAXISAL 9-GROBINUL 7-CROBINUL FORTE 7-CROCALTROL 10-A795-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionROFERON 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-CSIMPONI 13-Hsimvastatin 3-LSINEMET 4-HSINEMET CR 4-HSINEQUAN 4-BSINGULAIR 12-Dsirolimus 2-Bsitaglipin 6-F805-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionsitaglipin-metformin 6-FSKELAXIN 9-GSLO-PHYLLIN 12-DSMZ-TMP 1-Lsod sulf-pot sulf-mag sulfate 7-Asod 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-ESolia 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 2-ASORIATANE 5-FSORIATANE CK kit 5-Fsotalol 3-Csotalol AF 3-CSOTRET 5-BSURMONTIL 4-BSPECTAZOLE 5-DSPECTRACEF 1-Bspinosad 5-GSPIRIVA 12-Dspironolactone 3-Jspironolactone-HCTZ 3-JSPORANOX 1-GSprintec 6-DSPRIX NASAL 14-ASPRYCEL 2-ASroynx 6-DSSS 10-4 14-ASTADOL NS 9-BSTALEVO 4-HSTARLIX 6-Fstavudine 1-ISTAVZOR 4-GSTAXYN 14-ASTELAZINE 4-DSTIMATE 6-JSTIVARGA 2-ASTRATTERA 4-ESTRIANT 6-BSTROMECTOL 1-KSTUARTNATAL 10-BSUBOXONE FILM TAB 9-BSUBOXONE TABLETS 9-BSUBUTEX 9-BSUCRAID 7-Gsucralfate 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-Asulfacetamide-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-F815-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionsulfisoxazole 1-Lsulindac 9-CSUMADAN 14-Asumatriptan 9-Esumatriptan auto-injection 14-ASUMATRIPTAN INJ 9-Esumatriptan-naproxen sodium 14-ASUMAXIN TS 14-ASUMYCIN 1-Dsunitinib 2-ASUPREPSURESTEP SYSTEM 6-KSURESTEP TEST STRIPS 6-KSUSTIVA 1-ISUTENT 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-HTAGAMET 7-DTALWIN NX 9-BTAMBOCOR 3-ETAMIFLU 1-Htamoxifen 2-Atamsulosin 8-DTANAFED DM 12-CTANDEM F 10-BTAPAZOLE 6-Itapentadol 9-Btapentadol SR 14-ATARCEVA 2-ATARGRETIN 2-ATARKA 3-ITASIGNA 2-Atazarotene 5-FTAZORAC 5-FTEBAMIDE 7-FTEGRETOL 4-GTEGRETOL 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-ITENORMIN 3-CTERAZOL 8-Cterazosin 3-Hterbinafine HCL 1-Gterbutaline 12-Dterconazole vaginal 8-Cteriparatide (recombinant) 13-FTERMINEX 14-Ateriflunomide 13-Etesamorelin 13-BTESLAC 2-ATESSALON 12-CTESTIM 6-Btestolactone 2-Atestosterone 6-B825-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiontestosterone 14-Atestosterone buccal system 6-Btestosterone TD sol 6-Btetrabenaziine 4-Ftetracycline 1-DTEVETEN 3-GTEVETEN HCT 3-ITEV-TROPIN 13-Bthalidomide 2-ATHALOMID 2-ATHEO-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-LTOBRADEX 11-CTOBRADEX ST 14-Atobramycin 1-Ltobramycin ophth 11-Atobramycin-dexamethasone ophth 14-Atobramycin-dexamethasone ophth 11-CTOBREX 11-Atocainide 3-Etofacitinib citrate 9-DTOFRANIL 4-BTOFRANIL PM 4-Btolazamide 6-Ftolbutamide 6-FTOLBUTAMIDE 6-FTOLECTIN 9-CTOLINASE 6-Ftolmetin sodium 9-Ctolterodine 8-Btolterodine SR 14-Atolvaptan 3-JTONOCARD 3-ETOPAMAX 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-B835-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiontramadol 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 4-BTRIMPEX 1-LTRINALIN 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-ITUDORZATWINJECT12-D3-KTWYNSTA 14-ATYKERB 2-ATYLENOL w/CODEINE 9-BTYVASO 3-HTYZEKA 1-Iulipristal 6-JULORIC 9-FULTRACET 9-BULTRAM 9-BULTRAM ER 9-BULTRASE 7-G845-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionULTRASE MT 7-GULTRAVATE 5-HULTRAVATE KIT 5-HUMECTA EMOLLIENT 14-AUNIPHYL 12-DUNIRETIC 3-Iunithroid 6-IUNIVASC 3-Furea 5-Iurea (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-FVECTICAL 5-FVEETIDS 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-DVIBRATABS 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-I855-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionVIRAMUNE 1-IVIRAMUNE XR 1-IVIREAD 1-IVIROPTIC 11-AVISCOUS LIDOCAINE 11-JVISICOL 7-AVISKEN 3-Cvismodegib 2-AVISTARIL 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-HXALATAN 11-DXALKORI 2-AXANAX 4-AXANAX XR 4-AXARELTO 10-DXELJANZ 9-DXELODA 2-AXENADERM 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-GZAROXOLYN 3-JZAVESCA 7-GZEBETA 3-CZEGERID 7-EZELBORAF 2-AZEMPLAR 10-AZENPEP 7-GZERIT 1-IZERVALX 10-CZESTORETIC 3-IZESTRIL 3-FZETIA 3-LZETONNA 14-AZIAC 3-IZIAGEN 1-IZIANA 14-A865-Tier Drug Benefit Guide 09/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionzidovudine 1-IZINOTIC 11-IZINOTIC ES 11-Iziprasidone HCL 4-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-L875-Tier Drug Benefit Guide 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-D515-Tier Drug Benefit Guide 08/01/13

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-I525-Tier Drug Benefit Guide 08/01/13

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 6-KASCENSIA BREEZE 2 TEST STRIPS 6-KASCENSIA ELITE TEST STRIPS 6-Kasenapine 4-DASENDIN 4-BASMALPRED 14-AASMANEX 12-EASTELIN 12-BASTEPRO 14-AATABEX EC 10-BATACAND 3-GATACAND HCT 3-IATARAX 4-Aatazanavir 1-IATELVIA 14-Aatenolol 3-Catenolol-chlorthalidone 3-IATIVAN 4-Aatomoxetine 4-Eatorvastatin 3-Latovaquone 1-L535-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionatovaquone-proguanil HCL 1-JATRALIN 14-AATRIPLA 1-Iatropine ophth 11-EATROVENT 12-DATROVENT HFA 12-DATROVENT NASAL 12-BAUBAGIO 13-Eaugmented betamethasone 5-HAUGMENTIN 1-AAUGMENTIN XR 1-AAURALGAN 14-Aauranofin 9-DAVALIDE 3-IAVANDAMET 6-FAVANDARYL 6-FAVANDIA 6-FAVAPRO 3-GAVC vaginal 8-CAVELOX 1-EAviane 6-DAVINZA 9-BAVODART 8-DAVONEX 13-EAVONEX ADMINISTRATION PACK 13-EAXID 7-DAXIRON 6-Baxitinib 2-AAYGESTIN 6-EAZASITE 11-Aazatadine-pseudoephedrine CR 12-Cazathioprine 2-Bazelaic acid 5-Bazelastine 14-Aazelastine nasal 14-AAZELEX 5-Bazilsartan medoxomil 3-Gazilsartan-chlorthalidone 3-Iazithromycin 1-Cazithromycin ER 1-Cazithromycin ophth 11-AAZMACORT 12-EAZOPT 11-HAZOR 14-Aaztreonam 1-AAZULFIDINE 7-HAZULFIDINE EN 7-HB complex-vit C-FA 10-Bbacitracin ophth 11-Abacitracin-polymyxin B ophth 11-Abaclofen 9-Gbac-polymy-neomycin HC oint 5-CBACTRIM 1-LBACTROBAN 5-CBACTROBAN CREAM 5-CBACTROBAN NASAL OINTMENT 5-Cbalsalazide 7-HBANZEL 4-GBARACLUDE 1-Ibecaplermin 5-Ibeclomethasone HFA inhaler 12-Ebeclomethasone nasal 12-BBECONASE AQ 12-BBELVIQ 14-Abenazepril 3-Fbenazepril-HCTZ 3-IBENEMID 9-FBENICAR 3-GBENICAR HCT 3-IBENTYL 7-CBENZACLIN 5-BBENZACLIN CARE KIT 14-ABENZAMYCIN 5-BBENZEFOAM AER 14-ABENZEFOAM ULTRA 14-Abenzocaine-antipyrine otic 14-Abenzonatate 12-Cbenzonatate 14-Abenzoyl peroxide 14-A545-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionbenzoyl peroxide cleansing pad 14-Abenzoyl peroxide foam 14-Abenzoyl peroxide-adapalene 5-Bbenzoyl peroxide-erythromycin gel 5-Bbenzoyl peroxide-salicylic acid-vit E 5-Bbenzoyl peroxide-urea 5-Bbenzoyl peroxide-vit E 5-Bbenztropine 4-Hbepotastine ophth 11-HBEPREVE 14-Abesifloxacin ophth 11-ABESIVANCE 11-ABETAGAN 11-Bbetamethasone dipropionate 5-Hbetamethasone foam 5-Hbetamethasone valerate 5-HBETAPACE 3-CBETAPACE AF 3-CBETASERON 13-Ebetaxolol 3-Cbetaxolol HCL ophth 11-Bbethanechol 8-BBETIMOL 11-BBETOPTIC-S 11-Bbexarotene 2-ABEYAZ 14-ABIAXIN 1-CBIAXIN XL 1-Cbicalutamide 2-ABICITRA 8-DBIDIL 3-MBILTRICIDE 1-Kbimatoprost ophth 11-DBIO-STATIN 1-Gbismuth subcit-metronidazole-tetracycline 7-Cbisoprolol 3-Cbisoprolol-HCTZ 3-IBLEPH-10 11-ABLEPHAMIDE 11-CBLOCADREN 3-Cboceprevir 13-DBONIVA 6-Jbosentan 3-HBOSULIF 2-ABRETHINE 12-DBREVICON 6-DBREVOXYL 14-ABRILINTA 10-Ebrimonidine ophth 11-Gbrimonidine timolol ophth 11-Bbrinzolamide ophth 11-HBROMDAY 14-Abromfenac ophth 11-Hbromocriptine 6-Fbromocriptine (tablets) 4-HBROMOXAFED 12-Cbromphen-PSE-DM 12-CBROVANA 12-Dbuconazole vaginal 8-Cbudesonide formoterol inhaler 12-Dbudesonide inhaler 12-Ebudesonide nasal 12-Bbudesonide nebulizer 12-Ebudesonide SR 7-Hbumetanide 3-JBUMEX 3-JBUPHENYL 7-Gbuprenorphine 9-Bbuprenorphine naloxone 9-Bbupropion 4-Bbupropion SR 4-Bbupropion SR 14-Abupropion XL 4-BBUSPAR 4-Abuspirone 4-Abusulfan 2-Abutenafine 5-Dbutorphanol 9-BBUTRANS 9-BBXN MOUTHWASH 7-H555-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionBYDUREON 6-JBYETTA 6-JBYSTOLIC 3-Ccaberoline 6-JCADUET 14-ACAFERGOT 9-ECALAN 3-DCALAN SR 3-DCALCIFEROL 10-Acalcipotriene 5-Fcalcitonin 6-Jcalcitonin (salmon) nasal 6-Jcalcitriol 10-Acalcitriol ointment 5-Fcalcium acetate (phosphate binder) 7-Hcalcium acetate (phosphate binder) 7-HCAMBIA 14-ACamila 6-DCANASA 7-Hcandesartan 3-Gcandesartan-HCTZ 3-Icapecitabine 2-ACAPEX 5-HCAPOTEN 3-FCAPOZIDE 3-Icaptopril 3-Fcaptopril-HCTZ 3-ICARAC 5-ICARAFATE 7-CCARBAGLU 6-Jcarbamazepine 4-Gcarbamazepine SR 4-GCARBATROL 4-Gcarbidopa-levodopa 4-Hcarbidopa-levodopa CR 4-Hcarbidopa-levodopa-entacapone 4-Hcarbinoxamine-PSE 12-Ccarbinoxamine-PSE-DM 12-Ccardec DM 12-CCARDENE 3-DCARDENE SR 3-DCARDIZEM 3-DCARDIZEM LA 3-DCARDIZEM SR 3-DCARDURA 3-Hcarglumic acid 6-Jcarisoprodol 9-Gcarisoprodol-ASA 9-Gcarisoprodol-ASA-codeine 9-GCARMOL 40 5-ICARMOL SCALP 5-ICARNITOR 6-Jcarteolol HCL 3-Ccarteolol ophth 11-Bcartia XT 3-DCARTROL 3-Ccarvedilol 3-Ccarvedilol 14-ACASODEX 2-ACATAFLAM 9-CCATAPRES 3-HCATAPRES-TTS 3-HCAYSTON 1-ACECLOR 1-BCECLOR CD 1-BCEDAX 1-BCEENU 2-Acefaclor 1-Bcefaclor ER 1-Bcefadroxil 1-Bcefdinir 1-Bcefditoren pivoxil 1-Bcefpodoxime 1-Bcefprozil 1-Bceftibuten 1-BCEFTIN 1-Bcefuroxime 1-BCEFZIL 1-BCELEBREX 9-Ccelecoxib 9-C565-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionCELEXA 4-BCELLCEPT 2-BCELONTIN 4-GCENESTIN 6-CCENTANY AT 14-Acephalexin 1-BCEREFOLIN 10-Ccertolizumab pegol 13-Hcetirizine 14-ACETRAXAL 11-Icevimeline 11-Jchloral hydrate 4-Cchlorambucil 2-Achlordiazepoxide 4-Achlordiazepoxide-methscopolamine 7-Cchlorhexidine 11-Jchloroquine 1-Jchlorothiazide 3-Jchloroxylenol-pramoxine-zinc acetate otic 11-Ichlorpheniramine 12-Cchlorpheniramine-PSE 12-Cchlorphen-pyrilamine-PE 12-Cchlorpromazine 4-Dchlorpropamide 6-Fchlorthalidone 3-Jchlorzoxazone 9-Gcholestyramine 3-Lcholine-mag salicylates 9-ACHROMAGEN FORTE 10-CCIALIS 8-Dciclesonide inhaler 12-Eciclesonide nasal 12-BCICLODAN KIT 14-Aciclopirox 14-Aciclopirox 14-Aciclopirox solution 5-Dciclopirox solution 8% 3-Icilostazol 10-ECILOXAN 11-Acimetidine 7-DCIMZIA 13-Hcinacalcet 6-JCIPRO 1-ECIPRO HC OTIC 11-ICIPRO XR 1-ECIPRODEX 11-Iciprofloxacin 1-Eciprofloxacin ophth 11-Aciprofloxacin SR 1-Eciprofloxacin-dexamethasone 11-Iciprofloxacin-HC otic 11-Icitalopram 4-BCITRANATAL PAK ASSURANCE 10-Bcitric acid-D-gluconic acid 8-Dcitric acid-sodium citrate 8-DCLARAVIS 5-BCLARINEX 14-Aclarithromycin 1-Cclarithromycin SR 1-CCLARITIN 14-ACLEOCIN 1-CCLEOCIN vaginal cream 8-CCLEOCIN-T 5-BCLIMARA 6-CCLIMARA PRO 6-CCLINDACIN PAC 14-ACLINDACIN-P 14-Aclindamycin 1-Cclindamycin phosphate 14-Aclindamycin phosphate swab 14-Aclindamycin topical 5-Bclindamycin vaginal 8-Cclindamycin-benzoyl peroxide gel 5-Bclindamycin-benzoyl peroxide gel 14-Aclindamycin-tretinoin 14-ACLINDESSE 8-CCLINORIL 9-CCLOBETA 14-Aclobetasol 14-A575-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionclobetasol foam 5-Hclobetasol propionate 5-HCLOBEX SHAMPOO 14-Aclocortolone 5-HCLODERM 5-Hclomipraminedesipramine 4-Bclonazepam 4-Gclonidine 3-Hclonidine 14-Aclonidine patch 3-Hclonidine SR 14-Aclopidogrel 10-Eclorazepate 4-Aclotrimazole 14-Aclotrimazole troche 11-Jclotrimazole-betamethasone 5-Dclozapine 4-DCLOZARIL 4-DCOARTEM 1-JCOCET PLUS 14-ACODEINE PHOSPHATE 9-BCODEINE SULFATE 9-BCODIMAL DH 12-CCOGENTIN 4-HCOGNEX 4-FCOLAZAL 7-HCOLBENEMID 9-Fcolchicine 9-Fcolchicine-probenecid 9-FCOLCRYS 9-Fcolesevelam 3-LCOLESTID 3-Lcolestipol 3-Lcollagenase 5-ICOLYTE 7-ACOMBIGAN 11-BCOMBIPATCH 6-CCOMBIVENT 12-DCOMBIVIR 1-ICOMBUNOX 9-BCOMPAZINE 4-DCOMPLERA 1-ICOMTAN 4-HCONCEPT DHA 10-BCONCEPT OB 10-BCONCERTA 4-ECONDYLOX 5-ICONTOUR TEST STRIPS 6-KCONZIP 14-ACOPAXONE 13-ECORDARONE 3-ECORDRAN 5-HCOREG 3-CCOREG CR 14-ACORGARD 3-CCORTEF 6-Acorticotropin 13-Icortisone acetate 6-ACORTISPORIN CREAM 5-CCORTISPORIN OINTMENT 5-CCORTISPORIN OPHTH 11-CCORTISPORIN otic 11-ICORTISPORIN-TC 11-ICORTONE 6-ACORZIDE 3-ICOSOPT 11-BCOSOPT PF 11-BCOTAZYM 7-GCOUMADIN 10-DCOVERA HS 3-DCOZAAR 3-GCREON 7-GCRESTOR 3-LCRINONE 6-ECRIXIVAN 1-Icrizotinib 2-Acrofelemer 7-HCROLOM ophth 11-Hcromolyn sodium inhaler 12-Dcromolyn sodium nebulizer 12-D585-Tier Drug Benefit Guide 08/01/13

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-ACYTOMEL 6-ICYTOTEC 7-CCYTOXAN 2-Adabrafenib mesylate 2-Adalfampridine 13-EDALIRESP 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-IDELOS 14-ADELZICOL 14-ADEMADEX 3-JDEMEROL 9-BDEMULEN 6-DDENAVIR 5-EDEPAKENE 4-GDEPAKOTE 4-GDEPAKOTE ER 9-EDEPEN 9-DDEPLIN 14-ADERMA-SMOOTH FS 5-HDERMATOP 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-BDETROL 8-B595-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionDETROL 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-Ddiclofenac 9-Cdiclofenac 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 13-EDIOVAN 3-GDIOVAN-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-Cdornase alfa 1-LDORYX 14-A605-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiondorzolamide 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 14-ADYNACIRC 3-DDYNACIRC CR 3-DDYNAPEN 1-ADYRENIUM 3-Jeconazole 5-DED CHLORPED 12-CEDARBI 3-GEDARBYCLOR 3-IEDLUAR 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 10-DELLA 6-JELMIRON 8-DELOCON 5-Heltrombopag 13-CEMADINE 14-AEMCYT 2-Aemedastine 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-IENBREL 13-H615-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionENDURONYL 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-EERIVEDGE 2-Aerlotinib 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-C625-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionESTROSTEP 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 14-AEXFORGE HCT 14-AEXJADE 9-DEXTAVIA 14-Aezetimibe 3-Lezetimibe-simvastatin 3-Lezogabine 4-Gfamciclovir 1-Hfamotidine 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 14-Afentanyl 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-LFLAGYL ER 1-L635-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionFLAREX 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 7-HFURADANTIN 8-Afurosemide 3-JFUZEON 1-Igabapentin 4-Ggabapentin enacarbil 14-AGABARONE 4-GGABITRIL 4-G645-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectiongalantamine 4-Fganciclovir 1-HGANTANOL 1-LGANTRISIN 1-LGARAMYCIN 5-Cgatifloxacin ophth 11-Agefitinib 2-AGELNIQUE 8-DGELX 14-Agemfibrozil 3-LGENERESS 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 9-Fglycopyrroate 7-Hglycopyrrolate 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 wipekit14-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-GHYCAMTIM 2-AHYCODAN 12-C655-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionhycosamine-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-Jhydroxyurea 2-Ahydroxyzine 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 2-Ailoperidone 4-Diloprost 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-DINLYTA 2-AINNOHEP 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-CINTEGRA PLUS 10-CINTELENCE 1-I665-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectioninterferon alfa-2B 13-Iinterferon alfacon-1 13-Dinterferon beta-1A 13-Einterferon beta-1B 13-Einterferon beta-1B 14-Ainterferon gamma-1B 13-IINTRON-A 13-IINTERMEZZO 14-AINTUNIV 4-FINVEGA 4-DINVEGA SUSTENNA 4-DINVIRASE 1-IINVOKANA 6-Fiodoquinol 1-LIOPIDINE 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-FK-PHOS 8-DKUVAN 6-J675-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionKU-ZYME 7-GKU-ZYME-HP 7-GKWELL 5-GKYNAMRO 3-LKYTRIL 7-Flabetalol 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-Bleflunomide 9-Dlenalidomide 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-Ilidocaine-hydrocortisone 5-Ilidocaine-prilocaine 5-I685-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionlidocaine-tetracaine 5-ILIDODERM 5-ILIDORX 14-ALIMBITROL 4-Flinaclotide 7-Hlinagliptin 6-Flindane shampoo 5-Glinezolid 1-LLINZESS 7-HLIORESAL 9-Gliothyronine 6-Iliotrix 6-ILIPITOR 3-LLIPTRUZET 14-ALIQUADD 4-Eliraglutide 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-CLUPRON 13-ILUPRON DEPOT 13-ILUPRON DEPOT-PED 13-Ilurasidone 4-DLutera 6-D695-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionLUVOX 4-BLUVOX CR 4-BLUXIQ 5-HLYBREL 6-DLYRICA 4-GLYSODREN 2-ALYSTEDA 10-EMACROBID 8-AMACRODANTIN 8-AMAKENA 6-EMALARONE 1-Jmaprotiline 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 12-Dmetaproterenol 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-Dmethoxsalen 5-Fmethscopolamine 7-Cmethsuximide 4-Gmethyclothiazide 3-Jmethyldopa 3-H705-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionmethyldopa-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 14-AMINIPRESS 3-HMINITRAN 3-BMINOCIN 1-Dminocycline 1-Dminocycline 14-Aminoxidil 3-HMINTEZOL 1-Kmipomersen sodium 3-LmirabegronMIRAPEX8-B4-HMIRAPEX ER 14-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-Emometasone nasal 12-Bmometasone-formoterol inhalers 12-DMOMEXIN KIT 14-AMONODOX 1-DMononessa 6-D715-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionMONOPRIL 3-FMONOPRIL HCT 3-Imontelukast 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-AMYRBETRIQMYSOLINE8-B4-Gnabumetone 9-Cnadolol 3-Cnadolol-bendroflumethiazide 3-Inafarelin 13-Gnaftifine 5-DNAFTIN 5-DNALFON 9-Cnaltrexone 9-BNAMENDA 4-FNAMENDA XR 14-ANAPRELAN 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-Dnedocromil inhaler 12-Dnedocromil ophth 11-HNEEVO DHA 10-Bnefazodone HCL 4-Bnelfinavir mesylate 1-INEOBENZ MICRO KIT PLUS 14-A725-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionneomycin 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 2-Anevirapine XR 1-INEXICLON 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-INortrel 6-DNortrel 7/7/7 6-Dnortriptyline 4-BNORVASC 3-DNORVIR 1-INOVAHISTINE 12-CNOVOLIN 6-GNOVOLOG 6-GNOVOLOG MIX 6-GNOXAFIL 1-GNUCORT 14-A735-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionNUCYNTA 9-BNUCYNTA ER 9-BNUEDEXTA 4-FNULEV 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 14-AORAP 4-FORAPRED 6-AORBIVAN 14-AORENCIA 13-IORFADIN 13-Iorphenadrine citrate 9-GORTHO CEPT 6-DORTHO CYCLEN 6-DORTHO 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-D745-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionORTHO TRI-CYCLEN 6-DORTHO TRI-CYCLEN LO 6-DORTHO-PREFEST 6-CORUDIS 9-CORUVAIL 9-Coseltamivir 1-HOTIC CARE 14-AOVACE 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 14-Aoxybutynin 8-Boxybutynin 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-CPEDIATEX DM 12-CPEDIAZOLE 1-LPEDIPIROX 14-APEG electrolyte 7-Apeg(high)-electrolyte 7-APEG 3350 7-Apegademase 7-G755-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPEGANONE 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-EPERTZYE 14-APEXEVA 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-Ipodophyllum resin 5-IPOLYSPORIN ophth 11-APOLYTRIM ophth 11-APOLY-VI-FLOR 10-BPOLY-VI-FLOR-FE 10-Bpomalidomide 2-A765-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPOMALYST 2-Aponatinib hcl 2-APONSTEL 9-CPortia 6-Dposaconazole 1-GPOTABA 10-Apotassium aminobenzoate 10-APOTASSIUM CHLORIDE 8-Dpotassium citrate CR 8-Dpotassium phosphate 8-DPOTIGA 4-GPRADAXA 10-Dpramipexole 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-Jprimidone 4-GPRINCIPEN 1-APRINIVIL 3-FPRINZIDE 3-IPRISTIQ 4-BPROAIR HFA 12-D775-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionPROAMATINE 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-EPROGRAF 2-BPROLENSA 14-APROLIXIN 4-DPROMACTA 13-Cpromethazine 12-Apromethazine VC 12-Cpromethazine VC- codeine 12-Cpromethazine-codeine 12-CPROMETRIUM 6-EPromiseb Complete Kit 14-APRONESTYL 3-Epropafenone 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-AQUESTRAN 3-Lquetiapine fumarate 4-DQUILLIVANT XR 14-Aquinapril 3-Fquinapril-HCTZ 3-Iquinidine gluconate 3-Equinidine sulfate 3-Equinine sulfate 1-JQUIXIN 11-AQVAR 12-Erabeprazole 7-Eraloxifene 6-J785-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionraltegravir 1-Iramelteon 4-Cramipril 3-FRANEXA 3-Mranitidine 7-Dranolazine 3-MRAPAFLO 8-DRAPAMUNE 2-BRAVICTI 9-FRAZADYNE 4-FRAZADYNE ER 4-FREBETOL 1-HREBETRON 13-DREBIF 13-EReclipsen 6-Drefaximin 1-LREGLAN 7-HREGRANEX 5-IRELAFEN 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-Irivaroxaban 10-Drivastigmine 4-Frizatriptan 9-EROBAXIN 9-GROBAXISAL 9-GROBINUL 7-CROBINUL FORTE 7-CROCALTROL 10-AROFERON A 13-D795-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionroflumilast 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-CSIMBRINZA 14-ASIMPONI 13-Hsimvastatin 3-LSINEMET 4-HSINEMET CR 4-HSINEQUAN 4-BSINGULAIR 12-Dsirolimus 2-Bsitaglipin 6-F805-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL Sectionsitaglipin-metformin 6-FSKELAXIN 9-GSLO-PHYLLIN 12-DSMZ-TMP 1-Lsod sulf-pot sulf-mag sulfate 7-Asod 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-ESolia 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 2-ASORIATANE 5-FSORIATANE CK kit 5-Fsotalol 3-Csotalol AF 3-CSOTRET 5-BSURMONTIL 4-BSPECTAZOLE 5-DSPECTRACEF 1-Bspinosad 5-GSPIRIVA 12-Dspironolactone 3-Jspironolactone-HCTZ 3-JSPORANOX 1-GSprintec 6-DSPRIX NASAL 9-BSPRYCEL 2-ASroynx 6-DSSS 10-4 14-ASTADOL NS 9-BSTALEVO 4-HSTARLIX 6-Fstavudine 1-ISTAVZOR 4-GSTAXYN 14-ASTELAZINE 4-DSTIMATE 6-JSTIVARGA 2-ASTRATTERA 4-ESTRIANT 6-BSTROMECTOL 1-KSTUARTNATAL 10-BSUBOXONE FILM TAB 9-BSUBOXONE TABLETS 9-BSUBUTEX 9-BSUCLEAR 7-ASUCRAID 7-Gsucralfate 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-Asulfacetamide-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-F815-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionSULFINPYRAZONE 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-ASUPREPSURESTEP SYSTEM 6-KSURESTEP TEST STRIPS 6-KSUSTIVA 1-ISUTENT 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 2-ATAGAMET 7-DTALWIN NX 9-BTAMBOCOR 3-ETAMIFLU 1-Htamoxifen 2-Atamsulosin 8-DTANAFED DM 12-CTANDEM F 10-BTAPAZOLE 6-Itapentadol 9-Btapentadol SR 14-ATARCEVA 2-ATARGRETIN 2-ATARKA 3-ITASIGNA 2-Atazarotene 5-FTAZORAC 5-FTEBAMIDE 7-FTECFIDERA 13-ETEGRETOL 4-GTEGRETOL 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-ITENORMIN 3-CTERAZOL 8-Cterazosin 3-Hterbinafine HCL 1-Gterbutaline 12-Dterconazole vaginal 8-Cteriparatide (recombinant) 13-FTERMINEX 14-Ateriflunomide 13-Etesamorelin 13-BTESLAC 2-A825-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionTESSALON 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-Bthalidomide 2-ATHALOMID 2-ATHEO-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 11-CTOBRADEX ST 14-Atobramycin 1-Ltobramycin ophth 11-Atobramycin-dexamethasone ophth 14-Atobramycin-dexamethasone ophth 11-CTOBREX 11-Atocainide 3-Etofacitinib citrate 9-DTOFRANIL 4-BTOFRANIL PM 4-Btolazamide 6-Ftolbutamide 6-FTOLBUTAMIDE 6-FTOLECTIN 9-CTOLINASE 6-Ftolmetin sodium 9-Ctolterodine 8-Btolterodine SR 14-Atolvaptan 3-JTONOCARD 3-ETOPAMAX 4-GTOPAMAX SPRINKLES 4-GTOPICORT 5-Htopiramate 4-Gtopotecan 2-ATOPROL XL 3-CTORADOL 9-Ctoremifene citrate 2-Atorsemide 3-J835-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionTOVIAZ 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 4-BTRIMPEX 1-LTRINALIN 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-ITUDORZATWINJECT12-D3-KTWYNSTA 14-ATYKERB 2-ATYLENOL w/CODEINE 9-BTYVASO 3-HTYZEKA 1-IUCERIS 7-Hulipristal 6-J845-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionULORIC 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 14-Aurea 5-Iurea (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-FVECTICAL 5-FVEETIDS 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-DVIBRATABS 1-DVICODIN 9-BVICODIN ES 9-BVICODIN HP 9-BVICOPROFEN 9-BVICTOZA 6-JVICTRELIS 13-DVIDEX EC 1-Ivigabatrin 4-GVIGAMOX 11-A855-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionVIIBRYD 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-Cvismodegib 2-AVISTARIL 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 6-IXALATAN 11-DXALKORI 2-AXANAX 4-AXANAX XR 4-AXARELTO 10-DXELJANZ 13-HXELODA 2-AXENADERM 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-GZAROXOLYN 3-JZAVESCA 7-GZEBETA 3-CZEGERID 7-EZELBORAF 2-AZEMPLAR 10-AZENPEP 7-GZENZEDI 14-AZERIT 1-I865-Tier Drug Benefit Guide 08/01/13

Alphabetical IndexDrug Name PDL Section Drug Name PDL SectionZERVALX 10-CZESTORETIC 3-IZESTRIL 3-FZETIA 3-LZETONNA 14-AZIAC 3-IZIAGEN 1-IZIANA 14-Azidovudine 1-IZINOTIC 11-IZINOTIC ES 11-IZIOPTAN 11-Dziprasidone HCL 4-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-EZUPLENZ 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-L875-Tier Drug Benefit Guide 08/01/13