PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

2012PRESCRIPTION DRUGFORMULARYGuide to using your prescription drug coverage (List of Covered Drugs)PLEASE READ: This document contains information about the drugs we cover in this plan.Note to existing members: This formulary has changed since last year. Please review this documenttomake sure that it still contains the drugs you take.

Hometown Health/Preferred Drug List2012Important NoticeThis document lists drug products for Hometown Health Standard Drug Formulary. Allitems listed are includedin the Standard Drug Formulary unless designated as not covered or excluded by themember'sprescription drug benefit plan.DEVELOPMENT OF THE DRUG FORMULARY (PREFERREDMEDICATION LIST)The Drug Formulary (Preferred Medication List) is the cornerstone of drug therapyquality assuranceand cost containment efforts. The Drug Formulary (Preferred Medication List) processhas beensuccessfully used by hospitals and managed care organizations to providecomprehensive,cost-effective pharmacy services.The Hometown Health's Pharmacy and Therapeutics Committee (P&T Committee)developed the DrugFormulary (Preferred Medication List). This committee, composed of physicians fromvarious medicalspecialties, reviewed the medications in all therapeutic categories based on safety,effectiveness, andcost and selected the most cost-effective agent(s) in each class.Formulary (Preferred Medication List) development and maintenance is a dynamicprocess. The P&TCommittee will regularly review new and existing medications to ensure the Formularyremainsresponsive to the needs of our members and providers.As you use the Formulary, we invite your suggestions to improve the format or content.Thank you foryour cooperation.HOW TO USE THE HOMETOWN HEALTH DRUG FORMULARY(PREFERREDMEDICATION LIST)The Drug Formulary (Preferred Medication List) is a listing of preferred, coveredmedications marketedat the time of the Formulary printing and intended for use by the physicians andpharmacy providers for

health plan members. Unless exceptions are noted, all forms (tablet, capsule, liquid,topical) andstrengths of a drug product are included in the Formulary and will be covered by theplan. Medicationsare listed by their brand and generic name. Generic names are listed in lower caseletters.Members that are covered by a 3-tiered pharmacy benefit will be able to obtainmedications not listed,which are non-formulary (non-preferred medication) a.k.a. 3rd tier/level, at the 3rdtier/level copayment.Members with a closed formulary benefit design will be responsible for entire cost ofthose products notlisted, unless an override is granted. See MEDICAL EXCEPTION REQUESTS belowfor the procedure torequest an override for those members.Specific drugs have dispensing quantity limits. The clinical criteria for determining thequantity level limitis based upon FDA approved dosing guidelines as stated in the manufacturer's productpackage insertas well as other medical literature.The Drug Formulary applies only to prescription medications dispensed to outpatientsby participatingpharmacies. The Formulary does not apply to inpatient medications or to medicationsobtained fromii of iv and/or administered by a physician.RELATIVE COST INDEXMost listings are preceded by a "relative cost index," represented by a series of one tofive dollar signs($) or five exclamation points (!!!!!). This is a relative indication of the cost to the healthplan formedications within selected therapeutic categories:$ product A least expensive$$ product B more expensive than "A"$$$ product C more expensive than "B"$$$$ product D more expensive than "C"$$$$$ product E more expensive than "D"!!!!! product F is substantially more expensive than "A-E"Cost ranges are applicable to the therapeutic categories listed below the cost rangelisting. Cost rangesreflect cost/day of therapy or cost/prescription based on prevalent dosing patterns asindicated. Therelative cost index does not necessarily reflect costs that may be incurred by non-healthplan members.PRIOR AUTHORIZATION/STEP THERAPY

GENERIC DRUG POLICYSpecified drugs, which have generic equivalents, are covered at a genericreimbursement level, andshould be prescribed and dispensed in the generic form. These drugs are indicated byusing lower caseletters in the product name listing in the Drug Formulary. Maximum Allowable Cost(MAC) limits ofreimbursement have been established for many of these generic drugs. These drugnames areindicated by an "(M)" following the drug name in the Formulary. Providers are remindedof the following:1. When generic substitution conflicts with state regulations or restrictions, thepharmacist must gainapproval from the prescriber to use the generic equivalent.2. Pharmacists are reminded that a drug name followed by "(M)" indicates one or more(but notnecessarily all) forms of the drug are subject to a MAC.3. If a member insists on the brand name product, or if the physician indicates"Dispense As Written"(DAW) for a prescription of a medication included in the MAC list (drug name followedby an "(M)", thepatient must pay the applicable copay (Tier 3), unless the member's benefit policydictates otherwise. Note: Some plans may require the patient to pay the applicablecopay plusthe cost difference between the brand name product and the MAC amount (ancillarycharge) unless themember's benefit policy dictates otherwise.COPAY DETERMINATION1. Formulary Generic medications will pass generic copay for all members.2. Formulary (Preferred Brand Medications) will pass a brand copay.3. If a prescription is written for a non- formulary (non-preferred) medication and themember has aclosed benefit design, the member will be responsible for the entire cost of theprescription. If themember has a 3 tier copayment plan, the member will pay the highest applicable brandnamecopayment.4. If a member or physician insists on the brand name product for a prescription of amedicationincluded in the MAC list (drug name followed by "(M))", the patient must pay theapplicable copay (Tier 3) unless themember's benefit policy dictates otherwise. Note: Some plans may require the patientto pay the applicable copay plusthe cost difference between the brand name product and the MAC amount (ancillarycharge) unless the

member's benefit policy dictates otherwise.5. If a physician prescribes a drug, which is not covered, and no satisfactory alternativeproduct isavailable, the patient must pay the entire prescription cost.6. Special Pharmaceuticals are typically medications that cost the health plan $200 ormore per prescription.Special Pharmaceuticals (which may include injectables, oral medications, ormedication given by otherroutes of administration) will incur a 20% co-pay for members with this benefit design.NON-PRESCRIPTION MEDICATION (OTC) POLICYOver-the-counter (OTC) products are not covered, but some are listed for informationalpurposes.(When available, non-prescription products may be less costly to the patient than acovered product.)Also, if a prescription product is available in the identical strength, dosage form, andactive ingredient(s)as an OTC product, the prescription product will not be covered. In these instances,physicians andpharmacists should refer members to the OTC equivalent product. If the member orphysician insists onthe prescription equivalent product, the member must pay the entire cost of theprescription.BENEFIT EXCLUSIONS/LIMITATIONSDepending on benefit design, some medications listed may not be covered for somemembers basedon benefit design. Members should consult their benefit contracts for details.Examples of commonly excluded drug classes are:Appetite suppressantsDrugs for cosmetic purposesDesi drugsDrugs for erectile dysfunctionUNAPPROVED USE OF FORMULARY (PREFERRED MEDICATIONS)The member's Certificate of Coverage or appropriate rider states that medications willbe eligible forcoverage only if they are FDA approved medications used for non-experimentalindications except asotherwise required by law. Non-experimental indications include the labeledindication(s)(FDA-approved) and other indications accepted as effective by the balance of currentlyavailablescientific evidence and informed professional opinion.Experimental and investigational drugs, and drugs used for cosmetic purposes, are noteligible for

coverage except as otherwise required by law.MEDICAL EXCEPTION REQUESTS(For members with a closed benefit design) The physicians consulted in Formulary(PreferredMedication List) development attempted to include medications for all therapeuticneeds. If a patientrequires medication that is not covered, the physician may request an exception to allowpayment forthe not covered medication. It is anticipated that such exceptions will be rare, andphysicians should beable to find a Formulary medication for the vast majority of therapeutic needs. PleasecontactHometown Health at 1-800-336-0123 - This service is available M - F 7:30am - 5:30pmPT.PRIOR AUTHORIZATION:To promote the most appropriate utilization, selected high-risk or high-cost medicationsrequire priorauthorization by the health plan to be eligible for coverage. The P&T Committee hasestablished priorauthorization criteria for group plan members with input from plan physicians andconsideration of thecurrent medical literature. Please note: Formulary (Preferred) medications, whichrequire priorauthorization, are indicated in this publication by (PAR) following their name.All prior authorization inquiries should be faxed to Catalyst Rx at: 1-888-852-1832. Youmay alsocontact Catalyst Rx by phone at 1-888-341-8574 24 hours a day, 365 days a year.STEP THERAPY:This is a type of prior authorization that is automated if the member meets certaincriteria. Thesemedications are designated in the Formulary by "(step)." If the member does not meetthe automatedcriteria (history of a certain first line medication used, age, or written by a certainphysician specialty)the process for receiving a traditional prior authorization should be followed. If themember meets theautomated criteria, no additional steps on the part of the physician/pharmacist arerequired.All step therapy inquiries should be faxed to Catalyst Rx at: 1-888-852-1832. You mayalsocontact Catalyst Rx by phone at 1-888-341-8574 24 hours a day, 365 days a year.

If a physician provider requests that a new or existing medication be added to the DrugFormulary, aletter indicating the significant advantages of the drug product over current formulary(Preferred)medications should be mailed or faxed to the Hometown Health Medical Director or toone of its P&TCommittee members at the following address:Hometown HealthMedical Director830 Harvard Way Reno, NV 89502Fax: (775) 982-3220

Hometown Health Commercial FormularyEffective January 1, 2012IntroductionThis document provides a list of covered drugs selected by Hometown Health in consultation with a team ofhealth care providers, which represents the prescription therapies believed to be a necessary part of a qualitytreatment program. For more information on how to fill your prescriptions, please review your Evidence ofCoverage.How to Read the FormularyThe first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) andgeneric drugs are listed in lower-case italics (e.g., lovastatin).The information in the Requirements/Limitations column tells you if there are any special requirements forcoverage of your drug.Notes KeyThe symbol [PAR] next to a drug name indicates that prior authorization may apply.The symbol [PAR-NS] next to a drug name indicates that prior authorizations apply for new start only.The symbol [B/D] next to a drug name indicates that the drug is Part D vs. Part B with prior authorization only.The symbol [ST] next to a drug name indicates that Step Therapy may apply.The symbol [ST-NS] next to a drug name indicates that Step Therapy applies for new start only.The symbol [LA] next to a drug name indicates that it has limited access.The symbol [QLL] next to a drug name indicates that quantities dispensed may be limited.The symbol [OTC] next to a drug name indicates that the drug is an Over-the-Counter medication.The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (thatis, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receivingextra help to pay for your prescriptions, you will not get any extra help to pay for this drug.You will be notified when a generic is available throughout the year for certain BRAND name drugs.We provide some coverage of Generic and Brand-name prescription drugs in the coverage gap. Please referto our Summary of Benefits and the plan you have chosen or your Evidence of Coverage (EOC) for moreinformation about this coverage.Certain prescription drugs related to Home Infusion Therapy that are normally covered under our outpatientprescription drug benefit may instead be covered under our medical benefit. For more information, callCatalyst Rx Member Services Department at 1-888-341-8576, 24 hours a day, seven days a week, TTY userscall 1-888-8041.

Hometown Health Commercial FormularyJanuary 1, 2012Spec. Pharm.=20% Co-pay; Tier 1 (level 1)= generic; Tier 2 (level 2)= BRAND, formulary (preferred); Tier 3 (level 3)= BRAND, non-formulary (non-preferred); Tier 4 (level four)= SpecialPharmaceutical; ST= step therapy, PA= prior authorization, QLL= quantity level limit.SUGGESTED PREFFEREDALTERNATIVESDRUG NAME PA/QLL/ST TIER1 2 3 41.2 TOPICAL ANESTHETICS$ lidocaine hcl viscous (M) X$$ LIDODERM X lidocaine hcl viscous2.1.1 CEPHALOSPORINS$ cefaclor (M) X$ cefaclor er (M) X$ cefadroxil (M) X$ cefdinir (M) X$ cefprozil (M) X$ cefpodoxime tablet (M) X$ cefuroxime (M) X$ cephalexin (M) X$$ SPECTRACEF X cefaclor, cefuroxime$$$ CEDAX X cefdinir, cefpodoxime$$$ CEFTIN* X cefuroxime$$$ CEFZIL* X cefprozil$$$ DURICEF* X cefadroxil$$$ KEFLEX* X cephalexin$$$$ LORABID X cefaclor, cefprozil, cefuroxime$$$ OMNICEF* X cefdinir$$$ SUPRAX X cefdinir$$$ SUPRAX suspension X cefdinir$$$ VANTIN* X cefpodixime tablet$$$ VANTIN suspension X cefdinir2.1.3 CLINDAMYCINS$ clindamycin hcl (M) X$$$ CLEOCIN* X clindamycin2.1.4 ERYTHROMYCINS$ erythrocin stearate (M) X$ erythromycin(M) X$ erythromycin ethylsuccinate (M) X$$ ERYC* X erythromycin$$ ERYPED* X erythromycin ethylsuccinate$$ ERY-TAB X$$ PCE X erythromycin2.1.4.1 OTHER MACROLIDESQLL=8 tabs/RX (250mg); 10/Rx(500mg);15mL x 2 bottles(100mg/5mL);15ml, 22.5ml, 30ml x$ azithromycin(M)3 bottles (200mg/5mL) X$ clarithromycin (M) X$$ clarithromycin XL (M) XQLL=8 tabs/RX (250mg); 10/Rx(500mg);15mL x 2 bottles(100mg/5mL);15ml, 22.5ml, 30ml x$$ ZITHROMAX*3 bottles (200mg/5mL) X$$$ BIAXIN* X clarithromycin$$$ BIAXIN Suspension X clarithromycin$$$ BIAXIN XL * X clarithromycin XL(PAR) Specialty pharmacy - FDAapproved diagnosis$$$ DIFICIDX2.1.5 PENICILLINS$ amoxicillin (M) X$ ampicillin (M) X$ penicillin v potassium (M) X$$ dicloxacillin(M) X$$ amoxicillin clavulanate potassium (M) X$$$ AUGMENTIN* X amoxicillin clavulanate potassium$$ AUGMENTIN ES-600* X amoxicillin clavulanate potassium$$$ AUGMENTIN XR X amoxicillin clavulanate potassium$$ GEOCILLIN X$$$$ MOXATAG NOT COVERED2.1.6 SULFONAMIDES$ erythromycin w/sulfisoxazole (M) X$ sulfamethoxazole/trimethoprim (M) X$$ BACTRIM/BACTRIM DS* X sulfamethoxazole/trimethoprim$ GANTRISIN X$$ PEDIAZOLE* X erythromycin w/sulfisoxazole$$ SEPTRA/SEPTRA DS* X sulfamethoxazole/trimethoprim2.1.7 TETRACYCLINES$ doxycycline hyclate (M) X$ doxycycline monohydrate (M) X doxycycline hyclate$ minocycline hcl (M) X$$$$ minocycline ER (generic SOLODYN) NOT COVERED minocycline$ tetracycline hcl (M) X$$$ DYNACIN* X minocycline$$$ MINOCIN* X minocycline$$$ MONODOX* X doxycycline hyclate$$$$ SOLODYN NOT COVERED minocycline$$ SUMYCIN* X tetracycline$$$ VIBRAMYCIN* X doxycycline hyclate$$$ VIBRATAB* X doxycycline hyclate2.1.8 URINARY ANTIINFECTIVES$ methenamine hipp(M) X$ nitrofurantoin (M) X$ trimethoprim (M) X$$ MACROBID* X nitrofurantoins$$ MACRODANTIN* X nitrofurantoins$$$$ HIPREX*, UREX* X methenamine hipp2.1.9 QUINOLONES$ ciprofloxacin hcl(M) QLL=30 tabs/Rx X$ ciprofloxacin ER(M) X$ levofloxacin X$ ofloxacin tabs (M) X$$$ AVELOX X$$$ AVELOX ABC PACK X$$$$ CIPRO* QLL=30 tabs/Rx X ciprofloxacin$$$$ CIPRO 100mg X nitrofurantoins, ciprofloxacin$$$$ CIPRO XR X ciprofloxacin, ciprofloxacin ER$$$ FLOXIN* X ofloxacin$$$$ LEVAQUIN X1

2.2 TOPICAL ANTIBACTERIAL DRUGS$$ chlorhexadine gluconate soln X$ gentamicin (M) X$ mupirocin 2% ointment(M) QLL=1 tube/Rx X$ silver sulfadiazine (M) X$$ AKNE-MYCIN Ointment X$$ ALTABAX X gentamicin, mupirocin 2%$$ BACTROBAN CRM QLL=1 tube/Rx X$$ BACTROBAN Ointment* QLL=1 tube/Rx X mupirocin 2% ointment$$ SILVADENE* X silver sulfadiazine2.3 ORAL ANTIFUNGAL DRUGS$ clotrimazole (M) X$ fluconazole(M)QLL=4 tab/Rx (150mg); (PAR)200mgX$ griseofulvin microsized(M) X$ griseofulvin ultramicrosized(M) X$$ itraconazole(PAR) QLL=30 caps/Rx; Spec.Pharm.; 100mg Cap (4th Tier)X$ ketoconazole (M) X$ nystatin (M) X$$ terbinafine (PAR) XQLL=4 tab/Rx (150mg); (PAR)200mg X fluconazole$ DIFLUCAN *$$ GRIS-PEG X$$ GRIFULVIN V SUSP. X griseofulvin microsized$$ GRIFULVIN V TABS X!!!!! LAMISIL* (PAR) X terbinafine$$$$ MYCELEX* X clotrimazole$$ MYCOSTATIN* X nystatin$$$ NIZORAL* X ketoconazoleAge Edit= must be older than 13years of age X fluconazole, itraconazole$$$ NOXAFIL$$ ORAVIG ST history of oral Nystatin X(PAR) QLL=30 caps/Rx; Spec.Pharm.; 100mg Cap (4th Tier) X itraconazole!!!!! SPORANOX*!!!! VFEND (PAR) X2.4.1 VAGINAL ANTIFUNGALS$ nystatin (M) X$ terconazole(M) X$$ TERAZOL*, TERAZOL 7* X terconazole$$ GYNAZOLE X2.4.2 OTHER TOPICAL ANTIFUNGALS$ ciclopirox 0.77% (M) X$ econazole cream(M) X$ ketoconazole X$ nystatin (M) X$$ ERTACZO X$ EXELDERM Xclotrimazole, ketoconazole,ciclopiroxclotrimazole, ketoconazole,ciclopirox$$$ EXTINA(ST) history of generic topicalketoconazole X ketoconazole$$$ LAMISIL (PAR) X LAMISIL OTC$$ LOPROX* X ciclopirox$$ MENTAX X$$ MYCOSTATIN* X nystatinclotrimazole, ketoconazole,ciclopiroxclotrimazole, ketoconazole,ciclopirox$$ NAFTIN X$$ NYSTOP * (generic nystatin top pwd) Xclotrimazole, ketoconazole,$$ OXISTAT Xciclopiroxclotrimazole, ketoconazole,$$$$ PENLAC (PAR) QLL=1 bottle/Rx Xciclopirox$$ SPECTAZOLE* X econazoleAge edit= patient must be 12 yrs ofclotrimazole, ketoconazole,$$$$ XOLEGELage or olderXciclopirox2.4.3 TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.$ clotrimazole/betamethasone (M) X$ nystatin w/triamcinolone (M) X2.5.1 ANTIRETROVIRALS & PROTEASE INHIBITORS$ didanosine X$ zidovudine X$$$$$ EPIVIR, EPIVIR HBV X!!!!! AGENERASE X!!!!! APTIVUS X!!!!! ATRIPLAAge Edit= 18 years of age andolderX!!!!! COMBIVIR X!!!!! COMPLERA X!!!!! CRIXIVAN X!!!!! EDURANT X!!!!! EMTRIVASpec. Pharm., (ST) history of otherantiretrovirals & protease inhibitors(HIV med), QLL= 30/Rx.X!!!!! FUZEON (PAR) X!!!!! INTELENCE (ST) history of other HIV drugs X!!!!! INVIRASE X!!!!! ISENTRESSAge Edit= 16 years of age andolder; (ST) history of other HIVdrugs; QLL= 60/rxX!!!!! KALETRA X!!!!! LEXIVA(PAR), (ST) history of any otherHIV med. QLL=30/monthX!!!!! NORVIR X!!!!! PREZISTA(ST) showing a history of anyprotease inhibitor.X!!!!! RESCRIPTOR X!!!!! RETROVIR* X zidovudine!!!!! REYATAZ(PAR),(ST) history of any otherantiretrovirals & proteaseinhibitors(HIV med) or any otherantiviral drugs, Spec. Pharm.QLL=60 caps for 150mg and200mg QLL= 30 caps for 100mgX!!!!! SELZENTRY (ST) history of other HIV drugs X!!!!! SUSTIVA X!!!!! TRIZIVIR X2

!!!!! TRUVADA X!!!!! VIDEX, VIDEX EC* X didanosine!!!!! VIRAMUNE X!!!!! VIRACEPT X!!!!! VIREAD X!!!!! ZERIT X!!!!! ZIAGEN X2.5.2 OTHER ANTIVIRAL DRUGS$ acyclovir (M) X$ amantadine hcl (M) X$ ribasphere (M) (PAR) Spec Pharm X$ ribavirin (M) (PAR) Spec Pharm X$ rimantadine hcl (M) X$$$$ valacyclovir QLL=30 tabs/Rx X acyclovir$$ BARACLUDE X$$$ CYTOVENE* X ganciclovir$ FLUMADINE* X amantadine, rimantadine$$$$$ INCIVEK (PAR)$$$ REBETOL* (PAR) X$$ RELENZA X$$ TAMIFLUQLL= 10 capsules/Rx, 50ml/Rxoral suspension. Max 2 fills peryearX$$$ TYZEKA X$$$ HEPSERA Spec. Pharm. X$$$$ COPEGUS (PAR) Spec. Pharm. X(PAR), (ST) history of any otherHIV med or any antivirals (ie.$$$$ VALCYTEAcyclovir, Valtrex)X$$$$ VALTREX* QLL=30 tabs/Rx X$$$$$ VICTRELIS (PAR)$$$$$ FAMVIR2.6 TOPICAL ANTIVIRAL DRUGSQLL=21 tabs/Rx (125mg,500mg);60/Rx (250mg) X acyclovir, VALTREX$$$$$ ZOVIRAX OINTMENT X acyclovir, VALTREX2.7 OTHER ANTI-INFECTIVES$ paromomycin sulfate X$$$ ALINIA X2.7.1 AMEBICIDES$$$ YODOXIN X2.7.2 ANTITUBERCULOSIS DRUGS$ ethambutol X$ isoniazid (M) X$ isoniazid/rifampin X$ pyrazinamide X$ rifampin (M) X$$ MYAMBUTOL* X ethambutol$$$ RIFATER X$$$ SEROMYCIN X$$$ TRECATOR X2.7.3 PLASMODICIDES$ chloroquine phosphate X$ hydroxychloroquine sulfate (M) X$ mefloquine X$ primaquine X X$$$ ARALEN* X chloroquine phosphate$$$ COARTEM X$$$ DARAPRIM X$$$ FANSIDAR X$$$ LARIAM* X mefloquine$$$ PLAQUENIL* X hydroxychloroquine sulfate$$$ QUALAQUIN (PAR) X2.7.5 TRICHOMONOCIDES$ metronidazole (M) X2.8 OTHER ANTIINFECTIVE DRUGS!!!!! ZYVOXQLL= 28 Tabs. (PAR-InfectiousDisease cosult req'd)X3.0 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS$ azathioprine (M) X$$$$ bicalutamide X$ cyclophosphamide X$ cyclosporine (M) X$ etoposide X$ flutamide (M) X$ hydroxyurea X$ ifosfamide/mesna X$ megesterol acetate(M) X$ mercaptopurine (M) X$ methotrexate (M) X$$$$ mycophenolate X$ octreotide(M) X$ tamoxifen citrate (M) X!!!!! AFINITOR (PAR) QLL = 30 Tabs X$$ ALKERAN X!!!!! AMPYRA (PAR); Spec. Pharm. X$$$ ARIMIDEX X$$$$$ CAPRELSA X$$$$$ CASODEX X$$ CEENU X$$$$$ CELLCEPT* X$$$ CYTOXAN* X cyclophosphamide$$$$ EMCYTE X!!!!! ENBREL (PAR); Spec. Pharm. X$$$$ FEMARA X!!!!! GLEEVEC (PAR) X$$$ HEXALEN X!!!!! HUMIRA (PAR); Spec. Pharm. X$$$ IFEX/MESNEX X!!!!! IRESSA (PAR) X$$ LEUKERAN X$$$ LYSODREN X$$$ MATULANE X$$$$ MEGACE* X megesterol acetate!!!!! MESNEX X$$$ MYLERAN X$$$$$ MYFORTIC(ST) history of cyclosporine orprednisoneX$$$$ NEXAVAR (PAR) X3

$$$ NILANDRON X$$ NOLVADEX* X tamoxifen$$$$$ PROGRAF X!!!!! SANDOSTATIN* X octreotide!!!!! SPRYCEL(ST) showing a history ofGLEEVECX!!!!! SUTENT(ST) showing a history ofGLEEVEC.X!!!!! TARCEVA (PAR) X!!!!! TASIGNA (PAR) X!!!!! TEMODAR X!!!!! TESLAC X$$$ THIOGUANINE X!!!!! TYKERB (PAR) X!!!!! VOTRIENT 200mg X!!!!! XALKORI (PAR) - FDA approved diagnosis X!!!!! XELODA (PAR) X!!!!! ZELBORAF(PAR) Specialty pharmacy - FDAapproved diagnosisX!!!!! ZORTRESS (PAR) Renal Transplant Only X(PAR) Specialty pharmacy - FDAapproved diagnosis X!!!!! ZYTIGA4.1 CARDIAC GLYCOSIDES$ Digitek(M) X$ digoxin (M) X$$ LANOXIN* X4.2 CALCIUM ANTAGONISTS$ amlodipine(M) X$ diltiazem er (M) X$ diltiazem hcl (M) X$ diltiazem sa (M) X$ diltiazem xr (M) X$ felodipine(M) X$ nicardipine hcl (M) X$ nifedipine (M) X$ nifedipine sr (M) X$ nimodipine (M) X$ verapamil hcl (M) X$ verapamil sr (M) X$$ SULAR X$$$ CARDIZEM LA X diltiazem xr$$$ COVERA-HS X verapamil sr$$$ DYNACIRC CR X$$$ NORVASC* X amlodipine$$$ PLENDIL* X felodipine$$$ TIAZAC* X verapamil sr, diltiazem xr$$$ VERELAN* X verapamil sr$$$ VERELAN PM X verapamil sr$$$$ CARDENE SR X CARDENE (PLAIN)$$$$ DYNACIRC X nifedipine er, amlodipine4.3.1 LOOP DIURETICS$ bumetanide (M) X$ furosemide (M) X$ torsemide(M) X$$ BUMEX* X bumetanide$$ DEMADEX * X torsemide$$ LASIX* X furosemide4.3.2 THIAZIDE AND RELATED DRUGS$ chlorothiazide(M) X$ chlorthalidone(M) X$ hydrochlorothiazide (M) X$ indapamide (M) X$ metolazone (M) X$$ DIURIL* X chlorothiazide$$ LOZOL* X indapamide$$ ZAROXOLYN* X metolazone4.3.3 POTASSIUM SPARING DIURETICS$ amiloride hcl w/hctz (M) X$ spironolactone (M) X$ spironolactone w/hctz (M) X$ triamterene w/hctz (M) X$$ ALADACTAZIDE* X spironolactone w/hctz$$ ALDACTONE* X spironolactone$$ DYAZIDE* X triamterene w/hctz$$$$$ INSPRA X spironolactone$$ MAXZIDE* X triamterene w/hctz4.4 BETA-ADRENERGIC ANTAGONIST DRUGS$ acebutolol(M) X$ atenolol (M) X$ bisoprolol fumarate(M) X$ carvedilol (M) X$ labetalol(M) X$ metoprolol succinate (M) X$ metoprolol tartrate (M) X$ nadolol(M) X$ pindolol(M) X$ propranolol hcl (M) X$ propranolol er (M) X$ timolol maleate (M) X$$$$ BYSTOLIC X carvedilol$$$$$ COREG * X carvedilol(ST) history of a generic betablockeror Coreg X carvedilol$$$$$ COREG CR$$ CORGARD* X nadolol$$$$$ DUTROPOL NOT COVERED$$ INDERAL LA* X propranolol er$$ INNOPRAN XL X propranolol er$$$ LEVATOL X$$ LOPRESSOR* (M) X metoprolol tartrate$$ SECTRAL* X acebutolol$$ TENORMIN* (M) X atenolol$$ TOPROL XL* X metoprolol succinate$$ TRANDATE* X labetalol$$ ZEBETA* X bisoprolol fumarate4.5.1 VASODILATOR ANTIHYPERTENSIVES$ doxazosin mesylate (M)QLL=30 tabs/Rx (1mg,2mg,4mg);60/Rx (8mg)X$ hydralazine X$$ minoxidil (topical not covered) X4

$ prazosin hcl (M) X$ terazosin hcl (M) X$$ CARDURA* (M) X doxazosin mesylate$$ HYTRIN* (M) X terazosin hcl$$ MINIPRESS* (M) X prazosin hcl4.5.2 CENTRALLY ACTING ANTIHYPERTENSIVES$ clonidine hcl (M) X$ guanfacine X$ methyldopa (M) X$$ CATAPRES* X clonidine hcl$$$ CATAPRES TTS QLL= 4 patches/Rx X$$$ NEXICLON XR (ST) trial and failure with clonidine X clonidine hcl$$ TENEX* X guanfacine4.5.4.1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS$ benazepril hcl (M) X$ captopril (M) X$ enalapril maleate (M) X$ fosinopril(M) X$ lisinopril (M) X$ moexipril(M) X$ quinapril(M) X$$ ramipril (M) X$$ trandolapril (M) X$$$ ACCUPRIL* X quinapril$$$ ACEON X lisinopril, benazepril, enalapril(ST) History of diabeticmedications or history ofantihypertensive medications and55 years old or older X lisinopril, benazepril, enalapril$$ ALTACE *$$ CAPOTEN* (M) X captopril$$ LOTENSIN* (M) X benazepril$$ MAVIK* X trandolapril$$ MONOPRIL* X fosinopril$$$ UNIVASC* X moexipril4.5.4.2 ANGIOTENSIN II RECEPTOR ANTAGONISTS$ losartan (M) QLL=30 tabs/Rx x$$ BENICAR X$$ MICARDIS X BENICAR, DIOVAN$$$ ATACAND X BENICAR, DIOVAN$$$ AVAPRO X BENICAR, DIOVAN$$$ COZAAR X BENICAR, DIOVAN$$$ DIOVAN X$$$ EDARBIQLL=30 tabs/Rx (ST) trial andfailure with ACE, ACE combination x losarten, Benicar, Diovan$$$ TEVETEN X BENICAR, DIOVAN4.5.6 OTHER ANTIHYPERTENSIVES$$ amlodipine/benazepril (M) X$ atenolol /chlorthalidone (M) X$ benazepril/ hctz (M) X$ bisoprolol/hctz(M) X$ captopril/hctz (M) X$ enalapril/hctz (M) X$ fosinopril/hctz X$ hydralazine/hctz X$ lisinopril-hctz (M) X$ moexipril/hctz (M) X$ losartan/hctz (M) X$ propranolol /hctz (M) X$ quinapril/hctz (M) X$$$ ACCURETIC* X quinapril/hctz$$$ Caprelsa (ST) requires (amolodipine, X$$$ ATACAND HCT QLL=30 tabs/Rx X BENICAR HCT, DIOVAN HCT$$$ AVALIDE QLL=30 tabs/Rx X BENICAR HCT, DIOVAN HCT(ST) Trial and Failure with ACE,ACE combination, ARB, or ARB$$$ AZORcombination productX$$ BENICAR HCT QLL=30 tabs/Rx X$$ CAPOZIDE* X captopril/hctz$$$ DIOVAN HCT QLL=30 tabs/Rx X$$$ EXFORGE(ST) Trial and Failure with ACE,ACE combination, ARB, or ARBcombination product QLL=30/RxX$$$ HYZAAR QLL=30 tabs/Rx X BENICAR HCT, DIOVAN HCT$$ INDERIDE* X propranolol/hctz$$$ LEXXEL(ST) history of trial and failure ofone fo the following: benazepril,captopril, enalapril, fosinopril,lisinopril, moexipril, quinapril, ortrandolapril X LOTREL$$ LOTENSIN HCT* X benazepril/hctz$$$$ LOTREL* X benazepril/amlodipine$$ MICARDIS HCT QLL=30 tabs/Rx X BENICAR HCT, DIOVAN HCT$$ MONOPRIL HCT* X fosinopril/hctzQLL=30 tabs/Rx (ST) history of trialand failure of one fo the following:benazepril, captopril, lisinopril,$$$ TARKAmoexipril, trandolaprilX$$ TEKTURNA(ST) Trial and Failure with ACE,ACE combination, ARB, or ARBcombination product QLL=30/RxX$$ TEKTURNA HCT(ST) Trial and Failure with ACE,ACE combination, ARB, or ARBcombination product QLL=30/RxX$$ TENORETIC* X atenolol/chlorthalidone$$ TEVETEN QLL=30 tabs/Rx X BENICAR HCT, DIOVAN HCT$$ TEVETEN HCT QLL=30 tabs/Rx X BENICAR HCT, DIOVAN HCT$$$ TWYNSTA 40/5, 40/10, 80/5, 80/10 mg(ST) history of an ACEI or currentlyon an ARBX(ST) history of an ACEI or currently$$$ TRIBENZORon an ARBX$$ UNIRETIC* X moexipril/hctz$$$ VALTURNA 150/160, 300/320 mg(ST) history of an ACEI or currentlyon an ARBX$$ VASORETIC* X enalapril/hctz$$ ZIAC* X bisoprolol/hctz4.5.7 DRUGS FOR PULMONARY HYPERTENSION!!!!! ADCIRCA (PAR); Spec. Pharm. X!!!!! REVATIO (PAR); Spec. Pharm. X5

!!!!! LETAIRIS (PAR); Spec. Pharm. X!!!!! TRACLEER(PAR) Spec. Pharm. PulmonologistPrescribed OnlyX!!!!! TYVASO (PAR); Spec. Pharm.) X4.6.1 NITRATES$ isosorbide dinitrate (M) X$ isosorbide mononitrate (M) X$ nitroglycerin (M) X$$$$$ DILATRATE-SR X$$$$$ IMDUR* X isosorbide mononitrate$$$ ISORDIL* X isosorbide dinitrate$ NITRO-BID OINTMENT X$$$$$ NITRO-DUR, TRANSDERM-NITRO X$ NITROSTAT* X nitroglycerin4.6.2 OTHER VOSODILATING DRUGS$$$$$ RANEXA(PAR) Prescription must be writtenby a Cardiologist only.X$$$$$ VENTAVIS (PAR); Spec. Pharm.) X4.7.1.1 CLASS 1A$ disopyramide phosphate (M) X$ procainamide X$ quinidine gluconate (M) X$ quinidine sulfate X$$ NORPACE* X diopyramide phosphate$$ NORPACE CR X$$ PRONESTYL* X procainamide4.7.1.2 CLASS 1B$ mexiletine hcl (M) X4.7.1.3 CLASS 1C$ propafenone hcl (M) X$$ RYTHMOL* X proprafenone hcl$$$ RYTHMOL SR X proprafenone hcl4.7.3 OTHER ANTIARRHYTHMICS$ amiodarone hcl (M) X$ sotalol (M) X$$$ BETAPACE*, BETAPACE AF* X sotalol$$$ CORDARONE* X amiodarone$$$ MULTAQ (PAR) QLL= #60/30 days X$$ PACERONE* 400mg tier 3 X X4.8.1 HYPOLIPOPROTEINEMICS$ cholestyramine (M) X$ colestipol(M) X$ fenofibrate X$ gemfibrozil (M) X$$$ COLESTID* X colestipol$$$ FIBRICOR(ST) history of fenofibrate orgemfibrozil X fenofibrate$$$ LOFIBRA(ST) history of fenofibrate orgemfibrozil X fenofibrate$$ LOPID* X gemfibrozil$$$ NIASPAN X$$$ LOVAZA (formerly OMACOR)QLL=120/Rx (ST) Trial and failureof statin or fibrateX$$ PREVALITE* X cholestyramine$$ QUESTRAN*, QUESTRAN LIGHT* X cholestyramine$$$$$ TRICORQLL=30/Rx (ST) showing trial andfailure with generic fenofibrateX(ST) history of fenofibrate or$$$ TRIGLIDEgemfibrozil X fenofibrate$$$ TRILIPIX(ST) history of fenofibrate orgemfibrozil X fenofibrate$$$$$ WELCHOL X$$$$ ZETIAQLL=30 /Rx (ST) showing a historyof lovastatin or simvastatin.X4.8.2 HMG-COA REDUCTASE INHIBITORS$ lovastatin (M) X$ pravastatin (M) QLL=30 tabs/Rx X$ simvastatin (M) QLL=30 tabs/Rx X$$$ atorvastatinQLL = 30 tabs/Rx; 80mg (1st tier)and atorvastatin 10mg, 20mg, and40mg Non-Preffered (3rd tier);atorvastatin 10mg and 20mgrequire a history of lovastatin,pravastatin or simvastatin.Atorvastatin 40mg requires ahistory of Crestor 20mg.atorvastatin 80mg requires ahistory of atorvastatin 40mg,Crestor 40mg X X lovastatin, pravastatin, simvastatin$$$ ALTOPREVQLL=30 tabs/Rx (ST) showing ahistory of lovastatin or simvastatin X lovastatin, pravastatin, simvastatin$$$ CRESTOR(ST) Crestor 5mg and 10mgrequires step therapy showing ahistory of lovastatin or simvastatin.Crestor 40mg requires step therapyshowing a history of Crestor 20mg.X$$ LESCOLQLL=30 caps/Rx (ST) showing ahistory of lovastatin or simvastatin. X lovastatin, pravastatin, simvastatin$$$ LESCOL XLQLL=30 caps/Rx (ST) showing ahistory of lovastatin or simvastatin. X lovastatin, pravastatin, simvastatin$$$$ LIPITORLipitor 80mg Preferred Brand (2ndtier) and Lipitor 10mg, 20mg, and40mg Non-Preffered Brand (3rdtier). QLL=30 tabs/Rx (ST) Lipitor10mg and 20mg require a historyof lovastatin or simvastatin. Lipitor40mg requires a history of Crestor20mg. Lipitor 80mg requires ahistory of Lipitor 40mg, Crestor40mg X X lovastatin, pravastatin, simvastatin$$$$$ PRAVACHOL*(M) QLL=30 tabs/Rx X pravastatin$$$$$ ZOCOR* (M) QLL=30 tabs/Rx X simvastatin4.8.2.1 HMG-COA COMBINATIONS$$$$ ADVICOR X$$$ SIMCOR X6

$$$$ VYTORINQLL=30/Rx (ST) showing trial andfailure with lovastatin, pravastatin,simvastatinX$$$$$ CADUET QLL= 30 per fill/Rx X amlodipine, simvastatin, CRESTOR4.9 OTHER CARDIOVASCULAR DRUGS$ pentoxifylline (M) X$$ TRENTAL* (M) X pentoxifyllineCHAPTER 5: AUTONOMIC AND CNS MEDICATIONS5.1.1 Non-Narcotic Analgesics$ tramadol hcl (M) X$ tramadol/apap (M) X$$$$ RYZOLT (ST) history of tramadol X tramadol5.1.1.1 CLASS II NARCOTICS$ codeine phosphate X$ codeine sulfate X$$ hydromorphone (M) X$ meperidine hcl (M) X$$ methadone (M) X$ morphine sulfate IR X$$ morphine sulfate SR X$ oxycodone w/acetaminophen (M) X$ oxycodone/aspirin X$$$$ oxycodone ER hcl (M) (ST) history of morphine sulfate ER X$ oxycodone hcl (M) X$$$$$ ABSTRAL (PAR) cancer breakthrough pain X oxycodone!!!!! ACTIQ (PAR); Spec. Pharm. X oxycodone$$$$$ AVINZAQLL=30 tabs/Rx (ST) history ofgeneric long-acting opioid; Spec.Pharm.X$$$$$ BUTRANS NOT COVERED fentanyl$$$ DEMEROL* X meperidine hcl$$$$ DILAUDID* X hydromorphone$$$ DOLOPHINE* X methadoneEMBEDA 20/0.8, 30/1.2, 50/2.0, 60/2.4,100/4.0 MG (PAR) (ST) w/ failure of morphine X morphine$$$$$$$$ EXAGLO 8, 12, 16 mg (PAR) X!!!!! fentanyl Spec. Pharm. X!!!!! FENTORA (PAR)Spec. Pharm. X oxycodone!!!!! KADIAN(ST) history of generic long-actingopioid X morphine sulfate SR$ MSIR* X morphine suflate IR!!!!! MS CONTIN*(ST) history of generic long-actingopioid X morphine sulfate SR!!!!! NUCYNTA ER!!!!! OPANA!!!!! OPANA ERQLL= 180/month 18 years old &older. (ST) of 2 generic short actingnarcoticsoxycodone w/acetaminophen,hydrocodone w/acetaminophen,hydromorphoneXQLL=60 per fill (ST) history ofgeneric long-acting opioidXQLL=60 per fill (ST) history ofgeneric long-acting opioid X morphine sulfate SRQLL=60 tabs/Rx; Spec. Pharm.(ST) history of generic long-actingopioidXmorphine suflate IR, oxycodone,hydromorphone!!!!! OXYCONTIN*$ OXYIR* X oxycodone$$ PERCOCET* X oxycodone w/acetaminophen$$ PERCODAN* X oxycodone/aspirin5.1.1.2 CLASS III NARCOTICS$ acetaminophen w/codeine (M) X$ hydrocodone w/acetaminophen (M) X$ hydrocodone w/ibuprofen* X$$ LORCET* X hydrocodone w/acetaminophen$$ LORTAB* X hydrocodone w/acetaminophen$$ MAXIDONE* X hydrocodone w/acetaminophen$$ NORCO* X hydrocodone w/acetaminophen$$ TYLENOL W/ CODEINE X acetaminophen w/codeine$$ VICODIN* X hydrocodone w/acetaminophen$$ VICOPROFEN* X hydrocodone/ibuprofen5.1.2 DRUGS TO PREVENT AND TREAT HEADACHES$ butalbital/aspirin/caffeine (M) X$ butalbital/aspirin/caffeine/codeine (M) X$ butalbital/acetaminophen/caffeine (M) X$butalbital/acetaminophen/caffeine/codeine (M)X$ ergotamine/caffeine (M) X$ propranolol (M) X!!!!! AMERGEQLL=9 tabs/Rx (ST) history offilling generic sumatriptanQLL=6 tabs/Rx (ST) history ofXsumatriptan tablets, naratriptan,RELPAXsumatriptan tablets, naratriptan,RELPAX$$$$$ AXERTfilling generic sumatriptanX$$ CAFERGOT* X ergotamine/caffeine$$$ ESGIC*/ESGIC PLUS* X butalbital/acetaminophen/caffeine$$ FIORICET* X butalbital/acetaminophen/caffeine$$ FIORICET W/CODEINE Xbutalbital/acetaminophen/caffeine/codeine$$ FIORINAL* X butalbital/aspirin/caffeine$$ FIORINAL W/CODEINE X butalbital/aspirin/caffeine/codeine$$$$$ FROVAQLL=9 tabs/Rx (ST) history offilling generic sumatriptanXsumatriptan tablets, naratriptan,RELPAX!!!!! IMITREX TABLETS AND 12MG/ML VIAL QLL=9 tabs/Rx; X6 units/Rx (nasal Spray); 2vials/Rx!!!!! IMITREX NASAL AND STATDOSE (inj); 1Kit/Rx (inj kit)XQLL=9 tabs/Rx (ST) history of$$$$$ MAXALTfilling generic sumatriptanXQLL=9 tabs/Rx (ST) history of$$$$$ MAXALT MLTfilling generic sumatriptanX$$$$$ MIGRANAL QLL=1 bottle/Rx XQLL=9 tabs/Rx (ST) history of$$$$ naratriptanfilling generic sumatriptanXQLL = 9 tabs/Rx (ST) history of$$$$$ TREXIMETfilling one triptan and one NSAIDXQLL=6 tabs (ST) history of filling$$$$$ RELPAXgeneric sumatriptanXSumatriptan tablets, naratriptan,RELPAXsumatriptan tablets, naratriptan,RELPAXsumatriptan tablets, naratriptan,RELPAXsumatriptan tablets, naratriptan,RELPAX$$$$ sumatriptan tablets and 12mg/ml vial (M) QLL=9 tabs/Rx; 2vials/Rx (inj); XSUMATRIPTAN NASAL AND INJECTION 6 units/Rx (nasal Spray); 2vials/Rx!!!!! KITS(inj); 1Kit/Rx (inj kit)X7

$$$$$ NEURONTIN* X gabapentin$$$$$ SABRIL 500MG x$$$$$ TOPAMAX* X$$$$$ VIMPAT (PAR) Age edit of 17 or older X$$$$ ZARONTIN* X ethosuximide$$$$$ ZONEGRAN*(PAR) QLL=30/Rx for 25mg &50mg; 120/Rx for 100mg. Spec.Pharm. Age Edit 16+ X zonisamide5.5.1.1 TERTIARY AMINES$ amitriptyline hcl (M) X$ amoxapine (M) X$ doxepin hcl (M) X$ imipramine hcl (M) X$$ clomipramine X$ trimipramine X$$$ ANAFRANIL* X clomipramine$$$ SURMONTIL* X trimipramine$$$ TOFRANIL* (M) X imipramine hcl!!!!! TOFRANIL-PM X imipramine hcl5.5.1.2 SECONDARY AMINES$ desipramine hcl (M) X$ nortriptyline hcl (M) X$$ NORPAMIN* (M) X desipramine$$ PAMELOR* (M) X nortriptyline$$$ VIVACTIL* X desipramine, nortriptyline5.5.1.3 SELECTIVE SEROTONIN REUPTAKE INHIBITORSAge Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist.$ citalopram(M)QLL=30/30 daysX$ fluoxetine hcl (M)Age Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist.XFluoxetine HCl tabsAge Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist.(ST) generic fluoxetineX$ paroxetine hcl (M)$ sertraline(M)$$$ LEXAPROAge Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist.QLL=30/30 days (10mg, 20mg,40mg), 60/30 days (30mg).QLL= 30/30 days for 25mg, 60/30days for 50mg, 100mg Age Edit =Not covered for children under ageof 18 unless prescription is writtenby a Psychiatrist.QLL=30 tabs/Rx (ST) history ofparoxetine, fluoxetine, citalopram,sertraline, Prozac, Paxil, Zoloft orCelexa Age Edit = Not covered forchildren under age of 18 unlessprescription is written by aPsychiatrist.XXX$$$ OLEPTRA$$$ PAXIL*$$$$ PAXIL CR$$$$$ PROZAC WEEKLY$$$$ SARAFEM$$$ ZOLOFT*5.5.1.4 OTHER ANTIDEPRESSANTS$ bupropion hcl (M)$ bupropion sr (M)QLL= 30/30 days (ST) history ofparoxetine, fluoxetine, citalopram,sertraline, Prozac, Paxil or Celexa;Age Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist.XQLL=30 tabs/30 days(10mg,20mg,40mg); 60/Rx (30mg)(ST)Age Edit = Not covered forchildren under age of 18 unlessprescription is written by aPsychiatrist. X paroxetine(ST)history of paroxetine,fluoxetine, citalopram, sertraline,Prozac, Paxil, Zoloft or CelexaAgeEdit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist. X paroxetineQLL=4 caps/Rx (ST) history ofparoxetine, fluoxetine, citalopram,sertraline, Prozac, Paxil or Celexa;Age Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist. X fluoxetine hclQLL= 30/30 days (ST) history ofparoxetine, fluoxetine, citalopram,sertraline, Prozac, Paxil or Celexa;Age Edit = Not covered for childrenunder age of 18 unless prescriptionis written by a Psychiatrist. X fluoxetine hclQLL= 30/30 days for 25mg, 60/30days for 50mg, 100mg Age Edit =Not covered for children under ageof 18 unless prescription is writtenby a Psychiatrist. X sertralineQLL= 60/30 days Age Edit = Notcovered for children under age of18 unless prescription is written bya Psychiatrist.QLL= 60/30 days Age Edit = Notcovered for children under age of18 unless prescription is written bya Psychiatrist.XX9

$$$$$ SANCUSO X ondansetron, Kytril, Emend$$$$$ ZOFRAN*QLL=12 tabs/Rx (4mg,8mg); 1/Rx(24mg) X ondansetron!!!!! ZOFRAN IN DEXTROSE X$$$$ ZOFRAN ODT* QLL=12 tabs/Rx (4mg,8mg) X ondansetron ODT5.7.1 ANTIPARKINSON ANTICHOLINERGIC DRUGS$ amantadine hcl (M) X$ benztropine(M) X$ bromocriptine mesylate (M) X$ carbidopa/levodopa (M) X$$$$$ pramipexole X$$$ ropinirole X$ selegiline hcl (M) X$ trihexyphenidyl(M) X!!!!! APOKYN (PAR) Spec. Pharm. QLL=10/Rx X(ST) showing a history of anynondopaminergic antiparkinson!!!!! AZILECTagent.X$$ COGENTIN* X benztropine$$ ELDEPRYL* X selegiline$$$$ MIRAPEX X$$$$(ST) history of carbidopa &MIRAPEX ER 0.375, 0.75, 1.5, 3.0, 4.5 mg levodopaX$$ PARLODEL* X bromocriptine mesylate$$$$$ REQUIP * X ropinirole$$ SINEMET* (M)/ SINEMET CR* X carbidopa/levodopa(ST) history of carbidopa &!!!!! STALEVOlevodopaX$$ SYMMETREL* (M) X amantadine hcl$$$$$ ZELAPAR (ST) history of levodopa products X5.8 ANTIPSYCHOTIC DRUGS5.8.1 CONVENTIONAL (TYPICAL)$ chlorpromazine X$ fluphenazine (M) X$ haloperidol (M) X$$ loxapine succinate(M) X$ perphenazine(M) X$ thioridazine hcl (M) X$ thiothixene(M) X$$ trifluoperazine(M) X$$$ ORAP X5.8.2 NOVEL (ATYPICAL)$ clozapine (M) X$$$ risperidone tabs X$$$ olanzapine X!!!!! ABILIFY QLL= 30/Rx X$$$$$ CLOZARIL* X clozapine$$$$ FANAPT 1,2,4,6,8,10,12 MG (ST) history of risperdal X$$$$ FAZACLO (ST) history of risperdal X(QLL=60 caps/Rx); 80mg isconsidered to be a SpecialPharmaceutical X XGEODON, RISPERDAL,SEROQUEL$$$$$ GEODON$$$$ INVEGA (ST) history of risperdal X risperidone tabs$$$$ LATUDA (ST) history of risperdal X risperidone tabs$$$ RISPERDAL * X risperidone tabs!!!!! RISPERDAL CONSTA X risperidone tabs$$$ RISPERDAL M-TAB X risperidone tabs$$$ SAPHRIS 5, 10 mg (ST) history of risperdal XSpec. Pharm. (4th Tier) forSeroquel 200mg and 300mg. X X$$$ SEROQUEL$$$ SEROQUEL XR X Seroquel$$$$ ZYPREXA X$$$$$ ZYPREXA ZYDIS X olanzapine5.9.1 CNS STIMULANT DRUGS$ amphetamine salt combo (M)PAR for over 17 years of age andother diagnosisX$ dextroamphetamine(M)PAR for over 17 years of age andother diagnosisX$ methamphetamine hcl (M)PAR for over 17 years of age andother diagnosisX$ methylin (M)PAR for over 17 years of age andother diagnosisX$ methylin er (M)PAR for over 17 years of age andother diagnosisX$ methylphenidate er (M)PAR for over 17 years of age andother diagnosisX$ methylphenidate hcl (M)PAR for over 17 years of age andother diagnosisXPAR for over 17 years of age and$$$ ADDERALL* (M)other diagnosis X amphetamine salt comboPAR for over 17 years of age and$$$$ ADDERALL XRother diagnosis QLL=30 tabs/RxX$$$$ CONCERTAPAR for over 17 years of age andother diagnosis QLL=30 tabs/Rx X methylphenidate er (M)$$$ DESOXYNPAR for over 17 years of age andother diagnosisXPAR for over 17 years of age and$$$ DEXEDRINE*other diagnosis X dextroamphetaminePAR for over 17 years of age and$$$ DEXEDRINE SPANSULEother diagnosisX$$ FOCALINPAR for over 17 years of age andother diagnosisXmethylphenidate, ADDERALL XR,CONCERTA, METADATE CD$$$ FOCALIN XRPAR for over 17 years of age andother diagnosisXmethylphenidate, ADDERALL XR,CONCERTA, METADATE CD$$$$ METADATE CD*PAR for over 17 years of age andother diagnosis X methylphenidate er$$$$$ METADATE ER*PAR for over 17 years of age andother diagnosis X methylphenidate er$$$$ NUVIGIL (PAR) QLL=30/Rx X$$$$ PROVIGIL(PAR) Age Edit= 18 yrs old or olderQLL=30/RxX$$$$ RITALIN*PAR for over 17 years of age andother diagnosis X methylphenidate hcl$$$$ RITALIN LAPAR for over 17 years of age andother diagnosisXmethylphenidate er, CONCERTA,METADATE CD/ERPAR for over 17 years of age and$$$$ RITALIN SRother diagnosisX11

$$$$$ STRATTERA(PAR) for patient over 18 yrs ofage QLL=30/30 days$$$$ VYVANSE ST history of generic Adderall XR X(PAR) Spec. Pharm. Neurologist,Pulmonoligist, or Psychiatrist!!!!! XYREMPrescribed OnlyX5.9.2 ALCOHOL ANTAGONIST$$ disulfiram (M) X$$$ CAMPRAL X disulfiram5.9.3 ANTIDEMENTIA DRUGS$$ donepezil X$$ donepezil odt X$$$$$ ARICEPT X$$$$$ ARICEPT ODT X$$$$$ ARICEPT 23mg ST history of generic Donepezil X donepezil$$$$$ EXELON X$$$$$ NAMENDA X$$$$$ NAMENDA XR ST history of generic Donepezil X donepezil$$$$$ RAZADYNE X5.9.4 DRUGS TO TREAT MULTIPLE SCLEROSIS!!!!! AVONEX (PAR) Spec. Pharm. X!!!!! AMPYRA 10mg (PAR) Spec. Pharm. X!!!!! BETASERON Spec. Pharm. QLL=15/Rx X!!!!! COPAXONE (PAR) Spec. Pharm X!!!!! GILENYA (PAR) Spec. Pharm X5.9.5 SMOKING CESSATION PRODUCTS$ bupropion hcl SR$$$ CHANTIX$$$$ ZYBAN*5.9.6 MISCELLANEOUS CNS AGENTSQLL= 180 tablets per lifetime;Member must be enrolled in asmoking cessation supportprogram.(PAR) Member must be enrolled ina smoking cessation supportprogram.QLL= 180 tablets per lifetime;Member must be enrolled in asmoking cessation supportprogram.X(PAR) must be presribed by aneurologist XXXXmethylphenidate er, CONCERTA,AdderallSee tobacco cessation programinformation belowSee tobacco cessation programinformation belowSee tobacco cessation programinformation below!!!!! XENAZINE6.1 TOPICAL CORTICOSTEROID DRUGSLOW POTENCY$ alclometasone dipropionate X$ hydrocortisone X$$ ACLOVATE* X alclometasone dipropionateMEDIUM POTENCY$ betamethasone dipropionate (M) X$ betamethasone valerate X$ desoximetasone (M) X$ fluticasone propionate 0.005% ointment X$ hydrocortisone butyrate crm X$ hydrocortisone valerate X$ mometasone furoate X$ triamcinolone acetonide (M) X$$ ARISTOCORT A* X triamcinolone acetonidebetamethasone, triamcinolone,$ CLODERM Xfluticasonebetamethasone, triamcinolone,fluticasone$ CORDRAN QLL=2 units/Rx for Cordran Tape X$$ CUTIVATE* X fluticasone propionate$$ ELOCON* X mometasone furoate$$ LOCOID (crm)* X hydrocortisone butyrate crm$$$ LUXIQ X$$ TOPICORT* X desoximetasone$$ TOPICORT LP* X desoximetasone$$ WESTCORT* X hydrocortisone valerateHIGH POTENCY$ amcinonide (M) X$betamethasone dipropionateaugmented(M)X$ diflorasone(M) X$$ fluocinolone(M) X$$ fluocinonide(M) X$$$ CYCLOCORT* X amcinonide$$$ DIPROLENE* Xbetamethasone dipropionateaugmented$$$ DIPROLENE AF* Xbetamethasone dipropionateaugmented$$ HALOG X$$ LIDEX* X fluocinonide$$$ LIDEX-E* X fluocinonide$$$ PANDEL Xbetamethasone, triamcinolone,fluocinonide$$$ PSORCON E* X diflorasone$$$ SYNALAR* X fluocinolone$$$ SYNALAR HP X(ST) history of desonide.Medication therapy limited to 4weeksbetamethasone, triamcinolone,fluocinonide$$$$ VERDESOXVERY HIGH POTENCY$ clobetasol propionate (M) X$ halobetasol(M) X$$ CORMAX* X clobetasol propionate$$ TEMOVATE* X clobetasol propionate$$ ULTRAVATE* X halobetasol6.2 ANTIPRURITIC DRUGS$ cyproheptadine (M) X$ hydroxyzine hcl (M) X$ hydroxyzine pamoate (M) X6.3 ANTIACNE DRUGS$ clindamycin phosphate (M) X$ erythromycin base (M) X$ erythromycin-benzoyl peroxide (M) X$ metronidazole 0.75% X$ sod.sulfacetamide/sulfur tf(M) X$ tretinoin (M) (PAR) age >30; QLL=1 unit/Rx X$$$ AVITA* (PAR)age>30 QLL=1 unit/Rx X$$$ AZELEX X tretinoin, AVITA, DIFFERIN12

$$$ BENZAC AC* X$$$ BENZAC W* Xbenzoyl peroxide +clindamycin(topical)$$$$ BENZACLIN X$$$$ BENZAMYCIN* X erythromycin-benzoyl peroxide$$$ CLEOCIN T* X clindamycin phosphate$$$$ CLINDAGEL X$$$ DESQUAM-E X$$$ DESQUAM-X X$$$$ DIFFERIN (PAR) age >30 QLL=1unit/Rx X$$$$ DUAC X benzoyl peroxide + clindamycin$$$ EPIDUO x$$ ERYGEL* X erythromycin base$$ FINACEA X tretinoin, AVITA, DIFFERIN$$ METROCREAM* X metronidazole 0.75%$$$ METROGEL X$$ METROLOTION* X metronidazole 0.75%$$$$ NORITATE X metronidazole 0.75%(ST) history of minocycline,tetracycline, doxycyclinemonohydrate or doxycyclinehyclate ; Limited to 16 weeksminocycline, tetracycline,doxycycline monohydrate ordoxycycline hyclate$$$ ORACEAX$$$ OCUDOX KIT (ST) history of doxycycline X$$ PANOXYL X$$$ PLEXION* X sod.sulfacetamide/sulfur tf$$$ PLEXION SCT* X sod.sulfacetamide/sulfur tf$$$ PLEXION TS* X sod.sulfacetamide/sulfur tf$$$$ RETIN-A* (PAR) age >30; QLL=1 unit/Rx X tretinoin$$$$ RETIN-A MICRO (PAR) age >30 QLL= 1unit/Rx X$$$$ REZAMID X$$$$ ROZEX X$$$ SULFACET-R* X sod.sulfacetamide/sulfur$$ SULFOXYL X$$$ TRIAZ X$$$$ ZIANA6.3.1 ACCUTANES$$$$$isotretinoin (M)--AMNESTEEM,CLARAVIS, SOTRET(ST) history of clindamycin ortretinoin cream. Age edit= must beolder than 12 years of age(PAR) Two (2) or more topicalmedications (e.g., topical retinoids,topical antibiotics, benzoylperoxide) AND one (1) oralantibiotic (e.g., minocycline) over aperiod of 30 or more days for eachdrug before PAR approval.Xtretinoin, AVITA, DIFFERIN,clindamycinSpec.Pharm. X tretinoin, RETIN-Atretinoin, RETIN-A; I believe thisproduct has been discontinued$$$$$ ACCUTANE* X6.7 KERATOLYTIC DRUGS$$ podofilox soln X!!!!! CONDYLOX GEL X podofilox soln6.8 ANTIPSORIASIS AND ANTIECZEMA DRUGS$ selenium sulfide (M) X!!!!! DOVONEX 0.005% Oint X$$$$$ KLARON X selenium sulfide$$$$$ PSORIATEC X$$$$$ TAZORAC X DOVONEX$$$$$ ZITHRANOL-RR 1.2% X6.9.2 TOPICAL DERMATOLOGICAL DRUGS$ aluminum chloride (M) X$ fluorouracil(M) X$ hydroquinone(M) X$$$$ ALDARA X$$$$ CARAC X$ DRYSOL* X aluminum chloride$$$$$ EFUDEX* X fluorouracil$$$$ ELIDELQLL=1 unit/Rx (ST) history oftopical corticosteriod therapyX$$$ FLUOROPLEX X$$$$$ LUSTRA-AF* X hydroquinone$$$$$ PROTOPICQLL=1 unit/Rx (ST) history oftopical corticosteriod therapyX$$$ SOLAQUIN X$$$ SOLAQUIN FORTE* X hydroquinone$$$$$ SOLARAZE X ALDARA, EFUDEX$$$$ VECTICAL (PAR) X$$$$ XOLEGELAge edit= must be older than 12years of age X ketoconazole6.9.3 SCABICIDES$ lindane X$$ ULESFIA XCHAPTER 7: EAR-NOSE-THROAT MEDICATIONS7.1 DRUGS AFFECTING THE EAR$ acetic acid X$ antipyrine/benzocaine X$ neomycin/polymyxin/hc X$$$$$ CIPRO HC(ST) history of neomycin, polymixinHC or if Rx is written by an earspecialistX$$$$$ CIPRODEX OTIC(ST) history of neomycin, polymixinHC or if Rx is written by an earspecialistX$$ CORTISPORIN OTIC* X$$$$ FLOXIN ear drops X$$ PEDIOTIC* X7.2 DRUGS AFFECTING THE NOSE$ flunisolide QLL=3 inhalers/Rx X$$ fluticasone QLL=2 inhalers/Rx X$$$$ ASTELIN QLL=2 inhalers/Rx X$$$$ ASTEPRO QLL=2 inhalers/Rx X$$$$$ BECONASE AQ QLL=2 inhalers/Rx X fluticasone, Nasonex$$$$ FLONASE* QLL=2 inhalers/Rx X fluticasone$$$$$ NASACORT AQ QLL=2 inhalers/Rx X fluticasone, NASONEX$$$ NASAREL QLL=3 inhalers/Rx X fluticasone, NASONEX$$$$ NASONEX QLL=2 inhalers/Rx XQLL=1 inhaler/Rx (ST) history oftrial of either fluticasone orflunisolide. Age Edit = Patient must$$$$ OMNARISbe over 6 years of age X fluticasone, flunisolide13

$$$$ PATANASEQLL= 1 inhaler/30 days Age edit=Patient must be over 12 years ofage X ASTELIN$$$$$ RHINOCORT AQUA QLL=3 inhalers/Rx X fluticasone, NASONEX$$$$ VERAMYST QLL=2 inhalers/Rx X fluticasone, NASONEXCHAPTER 8: ENDOCRINE MEDICATIONS8.1.1 INSULIN$$$ APIDRA X HUMALOG, NOVOLOG$$$$ HUMALOG X$$$$$ HUMALOG MIX 75/25 X$$ HUMULIN 50/50 X$$ HUMULIN 70/30 X$$ HUMULIN N X$$ HUMULIN R X$$$ LANTUS X$$ NOVOLIN N X$$ NOVOLIN R X$$$ NOVOLIN 70/30 X$$$$$ NOVOLOG X$$$$$ NOVOLOG MIX 70/30 X$$ RELION N X$$ RELION R X$$ RELION 70/30 X8.1.1.2 OTHER INJECTABLE DIABETIC DRUGS$$$$$ BYDUREON(ST) history of metformin,sulfonylurea, or combination ofbothX$$$$$ BYETTA(ST) history of metformin,sulfonylurea, or combination ofbothX$$$$$ SYMLIN (ST) history of any insulin X$$$$$ VICTOZA 18mg/3ml(ST) history of Metformin, asulfonylurea, or combination ofbothX8.1.2 ORAL HYPOGLYCEMIC DRUGS$ acarbose (M) X$ chlorpropamide(M) X$ glimepiride(M) X$ glipizide (M) X$ glipizide er (M) X$ glipizide-metformin(M) X$ glyburide (M) X$ glyburide-metformin (M) X$ metformin er (M) X$ metformin hcl (M) X$ tolbutamide(M) X$$ AMARYL* X glimepiride$$ CYCLOSET(PAR) trial and failure with 3 oralantidiabeticsX$$ DIABETA* X glyburide$$ DIABINESE* X chlorpropamide$$ GLUCOPHAGE* X metformin$$ GLUCOPHAGE XR* X metformin er$$ GLUCOTROL* X glipizide$$ GLUCOTROL XL* X glipizide er$$ GLUCOVANCE* X glyburide-metformin$$ GLYNASE* X glyburide$$$ GLYSET X PRECOSE$$$$$ JANUMET (ST) history of metformin X$$$$$ JANUMET XR (ST) history of metformin X$$$$$ JANUVIA (ST) history of metformin X$$$$$ JENTADUETO (ST) history of metformin X$$$$$ JUVISYNC(ST) history of metformin andsimvastatinX$$$$$ KOMBIGLYZE ER (ST) history of metformin X$$$ METAGLIP* X glipizide-metformin$$ MICRONASE* X glyburide$$$$$ ONGLYZA 2.5, 5.0 mg (ST) history of metformin X$$$ PRECOSE* X acarbose$$$$ PRANDIN(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide.X$$$$$ TRADJENTA (ST) history of metformin X$$$$ STARLIX8.1.3 INSULIN SENSITIZERS(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide. X PRANDIN$$$$$ ACTOS$$$$$ ACTOPLUS MET(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide.QLL= 30/30 days(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide. QLL=30/daysXX14

$$$$$ AVANDAMET$$$$$ AVANDARYL$$$$$ AVANDIA(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide.(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide.(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide.QLL= 30/RxXXX$$$$$ DUETACT(ST) history of oral hypoglycemics:AMARYL, PRECOSE, DIABINESE,GLUCOTROL, GLUCOTROL XL,DIABETA, MICRONASE,GLUCOPHAGE, GLUCOVANCE,ORINASE, metformin, glyburide orglipizide.X8.2 GLUCOSE ELEVATING DRUGS$$$ GLUCAGON X8.3.1 GLUCOCORTICOID DRUGS$ dexamethasone (M) X$ hydrocortisone (M) X$ methylprednisolone (M) X$ prednisolone(M) X$ prednisone (M) X$$ CORTEF* X hydrocortisone$$ DEXPAK X$$ MEDROL* X methylprednisolone$$ ORAPRED* X prednisonolone$$ PEDIAPRED* X prednisonolone$$ PRELONE* X prednisonolone8.3.2 MINERALOCORTICOID DRUGS$ fludrocortisone acetate (M) X$$ FLORINEF* X fludrocortisone acetate8.4.1 THYROID SUPPLEMENTS$ levothyroxine sodium (M) X$ levoxyl X$ thyroid X$ unithroid X$$ ARMOUR THYROID X$$ CYTOMEL X$$ LEVOTHROID X levothyroxine sodium$$ SYNTHROID* X levothyroxine sodium$$ THYROLAR X8.4.2 ANTITHYROID DRUGS$ methimazole(M) X$ propylthiouracil(M) X$$ TAPAZOLE* X methimazole8.6 OTHER ENDOCRINE DRUGS$ alendronateQLL=30 tabs/Rx(5mg,10mg,40mg); 4/Rx(35mg,70mg)X$ cabergoline (M) X$ desmopressin acetate (M) (PAR) Spec. Pharm. XQLL=4 tabs/Rx (35mg); 30/Rx$$$ ACTONEL(5mg,30mg) 1/RX (150mg)X$$$ ACTONEL w/ CALCIUM X$$$ ATELVIA (ST) history of alendronate X$$$ BONIVA X alendronate, ACTONEL$$$$$ DDAVP TABS/NS* X$$$$ DIDRONEL X alendronate, ACTONEL$$$ DOSTINEX* X cabergoline!!!!! FORTEO (PAR) Spec. Pharm. XQLL=30 tabs/Rx(5mg,10mg,40mg); 4/Rx$$$ FOSAMAX *(35mg,70mg); 300ml/Rx Liquid X alendronate, ACTONEL$$$ MIACALCIN X alendronate, ACTONEL!!!!! SENSIPAR (PAR) X$$$$$ SKELID X alendronate, ACTONEL$$$$$ ZAVESCA XCHAPTER 9: GASTROINTESTINAL MEDICATIONS9.2 ANTIDIARRHEAL DRUGS$ diphenoxylate w/atropine (M) X$$ LOMOTIL* X diphenoxylate w/atropine9.3 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY$$ bethanechol(M) X$ dicyclomine hcl (M) X$ hyoscyamine sulfate (M) X$ metoclopramide hcl (M) X$$ ANASPAZ* X hyoscyamine sulfate$$ BENTYL* X dicyclomine hcl$$ LEVSIN* X hyoscyamine sulfate$$ LEVSIN SL* X hyoscyamine sulfate$$ LEVSINEX* X hyoscyamine sulfate$$ NULEV* X hyoscyamine sulfate$$ REGLAN* X metoclopramide hcl$$$ URECHOLINE* X bethanechol9.4 ANTIULCER DRUGS$ cimetidine (M) X$ famotidine(M) X$ nizatidine (M) X$ ranitidine hcl (M) X$$$$ AXID* X nizatidine15

$$ PEPCID* X famotidine$$$ TAGAMET* X cimetidine$$$ ZANTAC* X ranitidine9.4.1 OTHER ANTIULCER DRUGS$ misoprostol (M) X$ sucralfate (M) X$$ CARAFATE* X sucralfate$$ CYTOTEC* X misoprostol9.4.2 PROTON PUMP INHIBITORS$$$ lansoprazole QLL=30 caps/Rx X$ omeprazole 10, 20 and 40mg XRequires a prescription to apply 1st$ omeprazole OTCtier copayXQLL=30 tabs/Rx (ST) history ofomeprazole or Prilosec OTC or$$ pantoprazolelansoprazoleXNOT COVERED - locked out$$$$ ACIPHEXeffective 9/1/2011$$$$ DEXILANT NOT COVERED$$$$ NEXIUM NOT COVEREDQLL=30 caps/Rx for 15mg (ST)history of omeprazole or Prilosec$$$$ PREVACID*OTC$$$$$ PRILOSEC* (brand only)$ PRILOSEC OTCQLL= 60/ month (20mg), 30caps/Rx (10mg, 40mg) (ST) historyof omeprazole or Prilosec OTCRequires a prescription to apply 1sttier copayRequires a prescription to apply 1sttier copay. QLL= 60/monthQLL=30 tabs/Rx (ST) history ofomeprazole or Prilosec OTCXXXomeprazole, PRILOSEC OTC,PREVACID OTC pantoprazole - islansoprazole Step Therapy?omeprazole, PRILOSEC OTC,PREVACID OTC pantoprazoleomeprazole, PRILOSEC OTC,PREVACID OTC pantoprazoleomeprazole, PRILOSEC OTC,PREVACID OTC pantoprazoleomeprazole, PRILOSEC OTC,PREVACID OTC pantoprazoleomeprazole, PRILOSEC OTC,PREVACID OTC pantoprazole$ PREVACID OTCXomeprazole, PRILOSEC OTC,$$$ PROTONIX *XPREVACID OTC pantoprazoleomeprazole, PRILOSEC OTC,$$$ ZEGERID OTC NOT COVEREDPREVACID OTC pantoprazole9.4.3 HELICOBACTER PYLORI DRUGS$$$$$ HELIDAC X PREVPAC!!!!! PREVPAC XAge Edit= 18 years of age andolderX!!!!! PYLERA9.6 OTHER GI DRUGS$ glycolax (M) X$ hydrocortisone (M) X$ lactulose (M) X$ mesalamine (M) X$ PEG 3350/ electrolyte (M) X$ sulfasalazine (M) X!!!!! ACTIGALL Spec. Pharm. X(ST) Showing a history of lactuloseand propylene glycol type laxative.Age Edit= patient must be 18 yearsof age or older X lactulose, PEG3350/electrolyte$$$$$ AMITIZA$$ ANUSOL-HC* CREAM X hydrocortisone$$$$$ APRISO QLL= 120 Caps/Rx X$$$$$ ASACOL/HD X$$$ AZULFIDINE* X sulfasalazine$$$ AZULFIDINE ENTABS* X sulfasalazine$$$$$ CANASA X!!!!! COLAZAL X ASACOL, APRISO, PENTASA$$ COLYTE* X PEG 3350/ electrolyte$$ CORTIFOAM X!!!!! CREON* X$$$$$ DIPENTUM X ASACOL, APRISO, PENTASA!!!!! GOLYTELY* QLL=1 unit/Rx X PEG 3350/ electrolyte$$ HALFLYTELY X$$ KU-ZYME X$$$ LIALDA X ASACOL, APRISO, PENTASA$$ LIPRAM X$ NULYTELY* X PEG 3350/ electrolyte$ NULYTELY WITH FLAVOR PACKS X PEG 3350/ electrolyte$ SUPREP X$$ PANCREALIPASE X$$ PANCREASE X$$ PANCRON X$$ PANGESTYME X!!!!! PENTASA X$$ PROCTOCORT X$$ PROCTO-KIT X!!!!! RELISTOR(PAR) QLL= #24 if weight > 114kgand #12 if weight < 114 kgX$$ ROWASA* X mesalamine$$$$ ULTRASE X!!!!! ULTRASE MT X!!!!! URSO Spec. Pharm. X$$ VIOKASE XCHAPTER 10: IMMUNOLOGICALS AND VACCINES10.2.1 MYELOID STIMULANTS$$$$ LEUKINE (PAR) X$$$$ NEULASTA (PAR) X$$$ NEUPOGEN (PAR) X!!!!! MOZOBIL (PAR) X10.2.2 ERYTHROID STIMULANTS$$ ARANESP (PAR) Spec. Pharm. X$$ EPOGEN (PAR)Spec. Pharm. X$$ PROCRIT (PAR) Spec. Pharm. X10.2.3 INTERFERONS$$ ACTIMMUNE (PAR) Spec. Pharm. X$$ ALFERON N (PAR)Spec. Pharm. X$$ AVONEX ADMINISTRATION PACK(PAR); QLL=4 UNITS/Rx Spec.PharmX$$ BETASERON(PAR); QLL=15vials/Rx Spec.PharmX$$ INFERGEN(PAR); QLL 6/Rx 15mcg; 3.6/Rx9mcgSpec. PharmX16

$$$ INTRON A(PAR) Spec. Pharm.; 10mmu InjPen (4th Tier)X$$$$$ PEGASYS(PAR); QLL=5 units/Rx Spec.Pharm.X$$$$$ PEG-INTRON(PAR); QLL=5 units/Rx Spec.Pharm.;X$$ REBIF(PAR); QLL=15/30 days Spec.Pharm.X$ ROFERON-A (PAR) X10.2.4 INTERLEUKINS$$$ NEUMEGA X!!!!! PROLEUKIN Spec. Pharm. X10.2.5 THROMBOPOIETIN STIMULANTS!!!!! NPLATE NOT COVERED!!!!! PROMACTA (PAR); Spec. Pharm. XCHAPTER 11: MUSCULOSKELETAL MEDICATIONS11.1.1 SALICYLATES AND RELATED DRUGS$ choline mag. trisalicylate X$ salsalate (M) X11.1.2 NON-STEROIDAL ANTIINFLAMMATORY AGENTS$ diclofenac potassium(M) X$ diclofenac sodium (M) X$ etodolac (M) X$ fenoprofen(M) X$ flurbiprofen(M) X$ ibuprofen (M) X$ indomethacin (M) X$ ketoprofen (M) X$ ketorolac(M) QLL= 20/Rx X$ meclofenamate(M) X$ meloxicam (M) X$ nabumetone X$ naproxen (M) X$ naproxen sodium (M) X$ oxaprozin (M) X$ piroxicam(M) X$ sulindac(M) X$ tolmentin(M) X$$$ ANAPROX* X naproxen sodium$$ ANSAID* X flurbiprofen$$$ CATAFLAM* X diclofenac potassium$$$$$ CELEBREXQLL=30 caps/Rx (ST) history ofTWO of the following NSAIDS:diclofenac sodium, etodolac,ibuprofen, indomethacin,ketoprofen, naproxen, piroxicam,sulindac OR prednisone, warfarin,CoumadinX$$ CLINORIL* X sulindac$$$ EC-NAPROSYN* X naproxen$$$ FELDENE* X piroxicam$$$$$ FLECTORQLL=30 patches per month (ST)history of two generic or OTCNSAIDS. Age edit 6 years old orolder X diclofenac sodium$$$$$ MOBIC* X meloxicam$$$ MOTRIN* X ibuprofen$$$ NALFON* X fenoprofen$$$ NAPROSYN* X naproxen$$$ VOLTAREN* X diclofenac sodium$$$ VOLTAREN GEL NOT COVERED11.1.3 OTHER DRUGS FOR ARTHRITIS$$ methotrexate (M) X$$$ hydroxychloroquine (M) X!!!!! CIMZIA (PAR) Spec. Pharm X!!!!! CUPRIMINE (PAR) Spec. Pharm X!!!!! ENBREL (PAR) Spec. Pharm X!!!!! HUMIRA (PAR) Spec. Pharm X!!!!! KINERET (PAR) Spec. Pharm X!!!!! ORENCIA SUB-Q INJECTION (PAR) Spec. Pharm X!!!!! RIDAURA Spec. Pharm X!!!!! SIMPONI (PAR) Spec. Pharm X$$ TREXALL X11.1.4 DRUGS FOR PSORIASIS!!!!! ENBREL (PAR) Spec. Pharm X(PAR) (ST) Spec. PharmDermatologist prescribed onlyX!!!!! RAPTIVA11.2 DRUGS TO PREVENT AND TREAT GOUT$ allopurinol (M) X$ colchicine (M) X$ probenecid (M) X$ probenecid/ colchicine X$$$ ULORICQLL= 30/month Age Edit= 18 yearsof age and older (ST) history ofgeneric allopurinolX$$ ZYLOPRIM* X allopurinol11.3.1 DIRECT MUSCLE RELAXANTS$ baclofen (M) X$ diazepam(M) X$$$ VALIUM* X diazepam11.3.2 CNS MUSCLE RELAXANTS$ carisoprodol (M) X$ chlorzoxazone (M) X$ cyclobenzaprine hcl (M) X$ methocarbamol (M) X$ orphenadrine (M) X$$$ AMRIX QLL= #30 per month X$$ FLEXERIL* X cyclobenzaprine hcl$$ LORZONE (ST) generic chlorzoxazone chlorzoxazone$$ PARAFON FORTE DSC* X chlorzoxazone$$$ ROBAXIN* X methocarbamol$$$$$ SKELAXIN X$$$$$ SOMA* X carisoprodol12.1.2 VITAMINS & MINERALS & RELATED PRODUCTS$ multi-vit/fluoride X$ multi-vit/fluoride w/iron X$ tri-vit/fluoride X$ tri-vit/fluoride w/iron X$$ FOLBEE X17

$$ FOLGARD RX 2.2 X$$ FOLTX X$$ POLY-VI-FLOR X$$ POLY-VI-FLOR W/IRON X$$ TRI-VI-FLOR X12.1.3 THERAPEUTIC VITAMINS & MINERALS$ folic acid (M) X$$$$ calcitriol X$$ CALDEROL X$$ DHT X$$ FOSRENOL X!!!!! HYTAKEROL X$$$ PHOSLO X!!!!! ROCALTROL* X calcitriol$$$$ ZEMPLAR X calcitriol12.1.4 FLUORIDE PRODUCTS$ sodium fluoride X$$ FLORICAL X$$ LURIDE* X sodium fluoride$$ MONOCAL X12.2 POTASSIUM SUPPLEMENTS$ potassium chloride (M) X$$ KLOR-CON X$$ KLOTRIX X$$ K-LYTE X$$ K-TAB X12.3.1 ORAL ANTICOAGULANTS, VITAMIN K$ warfarin sodium (M) X$$ COUMADIN* X warfarin sodium$ JANTOVEN (M) X$$ MEPHYTON X$$$$ PRADAXA (PAR) trial of warfarin X warfarin sodium$$$$ XARELTO (PAR) trial of warfarin; QLL X warfarin sodium12.3.2 HEPARIN AND HEPARIN ANTAGONISTS$$$$ enoxaparin QLL = 14 day supply X!!!!! ARIXTRA (PAR) Spec. Pharm. X!!!!! FRAGMIN (PAR) Spec. Pharm. X!!!!! LOVENOX Spec. Pharm.QLL=14 day supply X12.4 ANTIPLATELET DRUGS$ dipyridamole (M) X$ ticlodipine X!!!!! AGGRENOX X dipyridamole + aspirin$$$$$ EFFIENT (PAR) QLL=30/rx X$$$$ PERSANTINE* X dipyridamole$$$$$ PLAVIX X$$$$ TICLID* X ticlodipine12.7 BLOOD DETOXICANTS$ lactulose (M) X$$$$$ EXJADE Spec. Pharm X$$$ KRISTALOSE X lactulose$$$$ PHOSLO X$$$$ RENAGEL X$$$$ RENVELAAge Edit= 16 years of age andolderX(PAR) Spec. Pharm. Rx must beprescribed by Nephrologist or!!!!! SENSIPAREndocrinologistX12.8 PHENYLKETONURIA AGENTS!!!!! KUVAN (PAR); Spec. Pharm. X13.1.1 PRENATAL VITAMINS$ advanced natalcare X$ inatal advance X$ inatal gt X$ inatal ultra X$ mynatal advance X$ mynatal plus X$ mynatal ultra X$ mynatal z X$ mynate 90 plus X$ natalcare pic X$ natalcare pic forte X$ natalcare plus (M) X$ natalcare rx X$ natalcare three X$ natatab cfe X$ natatab rx X$ nutrinate X$ prenetabs obn X$ prenatal 1 plus 1 X$ prenatal advantage X$ prenatal plus X$ prenatal plus iron X$ prenatal plus nf X$ prenatal rx (M) X$ prenatal z X$ ultra-natal X$ ultra natalcare (M) X$ vinate gt X$ vinate ultra X$$ CITRANATAL X$$ CITRANATAL 90 DHA X$$ CITRANATAL DHA X$$ NESTABS CBF* X natatab cfe$$ NESTABS RX* X natatab rx$$ NATACHEW* X nutrinate$$ NATAFORT X$$ NATELLE PLUS w/ DHA X$$ NICOMIDE X$$ PRECARE X$$ PREMESIS RX X$$ PRENATA CHEW X$$ PRENATE DHA$$ PRENATE ELITE$$ PRENATE ESSENTIAL$$ PREQUE 10 X$$ STRONGSTART X$$ VITAFOL-OB X$$ VITAFOL-PN X18

13.1.2 SPECIALIZED OB/GYN DRUGS$ terbutaline sulfate(M) X$$$ BRETHINE* X terbutaline sulfate$$$ LYSTEDA(PAR) Treatment limit 90 days perPARX13.3 ANDROGEN DRUGS$$$ danazol (M) X$$$ methyltestosterone (M) (PAR) X$$ oxandrolone (M) X$$ testosterone cypionate X$$$$ ANDRODERM (PAR) X$$$$$ ANDROGEL (PAR) X$$$$ ANDROID (PAR) X$$$$ ANDROXY (PAR) X$$$$ AXIRON (PAR) X$$$$ FORTESTA GEL (PAR) X$$$ METHITEST (PAR) X$$$$ OXANDRIN* (PAR) X$$$$$ TESTIM (PAR) X$$$$ TESTRED (PAR) X13.4 ESTROGEN DRUGS$ estradiol (M) X$ estradiol transdermal patch (M) QLL=4 patches/Rx X$ estropipate (M) X$$ ALORA* QLL=8 patches/Rx X estradiol transdermal patch$$$$$ ANGELIQ X$$ CENESTIN X$$ CLIMARA* QLL=4 patches/Rx X estradiol transdermal patch$$$$ DIVIGEL X estradiol transdermal patch$$$$ ELESTRIN GEL X estradiol transdermal patch$$$$ EVAMIST X estradiol transdermal patch$$$$ ENJUVIA X$$$$ ESCLIM X estradiol transdermal patch$$ ESTRACE* X estradiol$$$ ESTRADERM* QLL=8 patches/Rx X estradiol transdermal patch$$$$$ ESTROGEL X estradiol$$$ ESTRASORB X estradiol$$ FEMRING X VAGIFEM$ MENEST X PREMARIN$$$ OGEN* X estropipate$$ ORTHO-EST* X estropipate$$$ PREMARIN X$$ VAGIFEM X$$ VIVELLE QLL=8 patches/Rx X estradiol transdermal patch$$$ VIVELLE-DOT* QLL=8 patches/Rx X estradiol transdermal patch13.4.1 ESTROGEN/PROGESTIN COMBINATIONS$$ ACTIVELLA X PREMPRO, PREMPHASE$$ CLIMARA PRO X COMBIPATCH$$$ COMBIPATCH X$$$ FEMHRT X$$ PREFEST X$$$ PREMPHASE X$$$ PREMPRO X13.4.3 SELECTIVE ESTROGEN RECEPTOR MODULATOR$$$$$ EVISTA X13.5 PROGESTIN DRUGS$ medroxyprogesterone acetate (M) X$ norethindrone acetate (M) X$$$ AYGESTIN* X norethindrone acetate$$$ PROMETRIUM X$$$ PROVERA* X medroxyprogesterone acetate13.7 CONTRACEPTIVES$ apri (M) X$ aranelle (M) X$ aviane (M) X$ balziva (M) X$ camila (M) X$ cesia (M) X$ cryselle (M) X$ ennpresse (M) X$ errin (M) X$ jolessa (M) X$ jolivette (M) X$ junel 1/20 (fe) (M) X$ junel 1.5/30 (fe) (M) X$ kariva (M) X$ kelnor 1/35 (M) X$ leena (M) X$ lessina (M) X$ levora (M) X$ low-ogestrel (M) X$$$ LYBREL X quasense$ medroxyprogesterone acetate inj(M) X$ microgestin 1/20 (fe) (M) X$ microgestin 1.5/30 (fe) (M) X$ mononessa (M) X$ necon 0.5/35 (M) X$ necon 1/35 (M) X$ necon 1/50 (M) X$ necon 7/7/7 (M) X$ necon 10/11-21 (M) X$ nora-be (M) X$ nor-qd (M) X$ nortrel 0.5/35 (M) X$ nortrel 1/35 (M) X$ notrel 7/7/7 (M) X$ portia (M) X$ previfem (M) X$ quasense (M) X$ reclipsen (M) X$ solia (M) X$ sprintec (M) X$ trinessa (M) X$$ tri-lo sprintec X$ tri-previfem (M) X$ tri-sprintec tablet (M) X$ trivora-28 (M) X$ velivet (M) X$ zenchent X19

$ zovia 1/35e X$ zovia 1/50e X$$ ALESSE* X aviane, lessina$$ BREVICON* X nortrel 0.5/35, necon 0.5/35$$ BEYAZ X$$ CYCLESSA* X cesia, velivet$$ DEMULEN 1/35 X zovia 1/35, kelnor 1/35$$ DEMULEN 1/50* X zovia 1/50$$ DEPO-PROVERA* X medroxyprogesterone acetate inj$$ DESOGEN* X apri, reclipsen, solia$$$ ESTROSTEP FE Xnortrel 0.5/35, necon 0.5/35 + ironsupplement$$ FEMCON FE X$$ LEVLEN* X levora, portia$$ LEVLITE* X aviane, lessina$$ LO/OVRAL* X cryselle, low-ogestrel$$ LOESTRIN* Xjunel 1/20, junel 1/50, microgestin1/20, microgestin 1/50junel fe 1/20, junel fe 1/50,microgestin fe 1/20, microgestin fe1/50$$ LOESTRIN FE* X$$ LOSEASONIQUE X jolessa, quasense$$ MIRCETTE* X kariva$$ MODICON* X nortrel 0.5/35, necon 0.5/35$$ NATAZIA X$$ NECON 10/11-28 X$$ NORDETTE* X levora, portia, LEVLEN$$ NUVARING X ORTHO EVRA$$ OCELLA X$$ OGESTREL X$$ ORTHO-CEPT* X apri, reclipsen, solia$$ ORTHO-CYCLEN* X mononessa, sprintec$$ ORTHO EVRA X$$ ORTHO MICRONOR* Xcamila, errin, jolivette, nora-be, norqdnortrel 1/35, nortrel 7/7/7, necon1/35, necon 1/50, necon 7/7/7$$ ORTHO-NOVUM* X$$ ORTHO TRI-CYCLEN* X tri-previfem, trinessa, tri-sprintec$$ ORTHO TRI-CYCLEN LO* X$$ OVCON FE X balziva, zenchent$$$ OVCON-50 X necon 1/50$$$$$ SEASONALE* X jolessa, quasense!!!!! SEASONIQUE X jolessa, quasense$$ TRI-LEVLEN* X enpresse, trivora$$ TRI-NORINYL X aranelle, leena$$ TRIPHASIL* X enpresse, trivora$$ YASMIN * X drosperinone/ethinyl estrad.$$ YAZ X14.1.1 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS$ bacitracin (M) X$ bacitracin/polymyxin (M) X$ ciprofloxacin hcl 0.30% (M) X$ erythromycin (M) X$ gentamicin(M) X$ neomycin/bacitracin/polymyxin(M) X$ ofloxacin 0.3% eye drops(M) X$ polymyxin b sul/trimethoprim (M) X$ sulfacetamide sodium (M) X$ tobramycin sulfate (M) X$$$ AZASITE X$$ BLEPH-10 X$$$ CILOXAN* X ciprofloxacin hcl 0.30% (soln)$$$ MOXEZA(ST) clinical trial and failure withVigamoxX$$ NEOSPORIN* X neomycin/bacitracin/polymyxin$$$ OCUFLOX* X ofloxacin 0.3% eye drops$$ POLYTRIM* X bacitracin/polymyxin$$$ QUIXIN X ciprofloxacin, ofloxacin$$ TOBREX OINMENT X$$$ TOBREX SOLUTION* X tobramycin sulfate$$$ VIGAMOX QLL= 1 bottle/Rx X$$$ ZYMAR X$$$ ZYMAXID X14.1.2 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS$$ trilfuridine X!!!!! VIROPTIC* X trilfuridine14.2 OPHTHALMIC CORTICOSTEROID DRUGS$ dexamethasone (M) X$ fluorometholone (M) X$ prednisolone acetate (M) X$$$ ALREX X prednisolone acetate$$$$ DUREZOL QLL= 2 bottles/Rx X prednisolone acetate$$$ ECONOPRED PLUS* X prednisolone acetate$$$ FLAREX X$$ FML FORTE X fluoromethalone$$ FML LIQUIFILM* X fluoromethalone$$ FML S.O.P. X$$$ LOTEMAX X$$$ MAXIDEX X$$ PRED FORTE* X prednisolone acetate$$ PRED MILD X$$$ VEXOL X VOLTAREN, LOTEMAX14.3 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS$ neomycin/bacitracin/polymyxin/hc (M) X$ neomycin/polymyxin/dexameth (M) X$ neomycin/polymyxin/hc (M) X$$ BESIVANCE 0.6% x$$ BLEPHAMIDE X$$ MAXITROL* X neomycin/polymyxin/dexameth$$$ POLY-PRED X PRED-G, TOBRADEX$$$ PRED-G X$$$ TOBRADEX X$$$ TOBRADEX ST SUSPENSION(ST) clinical trial and failure withgeneric alternativesX$$$ ZYLET X PRED-G, TOBRADEX14.5 ANTIGLAUCOMA DRUGS$ betaxolol (M) X$ brimonidine tartrate (M) X$ dipivefrin (M) X20

$ levobunolol hcl (M) X$ metipranolol (M) X$ pilocarpine hcl (M) X$ timolol maleate (M) X$$$$$ ALPHAGAN P X$$$$ AZOPT X$$$ BETAGAN* X levobunolol hcl$$$ BETIMOL X levobunolol, timolol$$$ BETOPTIC S X$$$$$ COSOPT X timolol + AZOPT$$$$$ COMBIGAN X timolol + brimonidine$$$$$ IOPIDINE X$$ ISOPTO CARBACHOL X$$ ISOPTO-CARPINE X$$$$$ LUMIGAN X TRAVATAN, XALATAN$$$ OPTIPRANOLOL* X metipranolol$$ PHOSPHOLINE IODIDE X$$ PILOPINE HS X$$ PROPINE* X dipivefrin$$$$ RESCULA X TRAVATAN, XALATAN$$$ TIMOPTIC* X timolol maleate$$$$$ TRAVATAN X$$$$$ TRAVATAN Z X$$$ TRUSOPT X AZOPT$$$$ XALATAN X14.6 OTHER OPHTHALMIC DRUGS$ atropine sulfate (M) X$ azelastine x$ bromefenac x$ cromolyn sodium (M) X$ flucaine (M) X$ flurbiprofen sodium (M) X$ tropicamide (M) X$$$$$ ACULAR X$$$$ ACULAR LS X$$$$$ ACULAR PF X$$$$ ACUVAIL 0.45% X$$$$ ALAMAST X cromolyn sodium, PATANOL$$$$$ ALOCRIL X cromolyn sodium, PATANOL$$$$$ ALOMIDE X ACULAR/PF, LIVOSTIN(ST) history of bromefenac,diclofenac or flurbiprofen X bromefenac, diclofenac, flurbiprofen$$$$$ BROMDAY$$$ CROLOM* X cromolyn sodium$$$$$ ELESTAT X$$$$ EMADINE X PATANOL$$ ISOPTO HOMATROPINE X$$$$$ LACRISERT(PAR) Ophthalmologist Prescribedonly and trial of OTC artificial tears X OTC artificial tears$$$$$ LASTACAFT (ST) history of azelastine X$$$$$ LATISSE Not Covered$$$$ LIVOSTIN X$$$ NEVANAC X VOLTAREN$$$ OCUFEN* X flurbiprofen sodium$$$$ OPTIVAR X PATANOL$$$$$ PATADAY X PATANOL$$$$$ PATANOL X$$$$$ RESTASIS(PAR) Ophthalmologist Prescribedonly X OTC products for dry eyes$$$ VOLTAREN X$$$$ ZADITOR Not Covered OTC ALAWAY15.1.1 BETA-2 ADRENERGIC DRUGS$ albuterol (M) QLL=2 inhalers/Month X$ albuterol sulfate (M) X$ metaproterenol (M) X$ terbutaline sulfate (M) X$$$ ACCUNEB X albuterol sulfate$$$ ALUPENT QLL= 3 inhalers/Rx X PROVENTIL HFA$$$ BRETHINE* X terbutaline sulfate$$$$$ BROVANA (PAR) QLL= 60 vials/Rx X$$$$$ FORADIL QLL=120 caps/Rx X$$$$$ MAXAIR AUTOHALER QLL=2 inhalers/Rx X albuterol, PROVENTIL HFA$$$$$ PERFOROMIST (PAR) QLL=60 vials/Rx XBROVANA, FORADIL, SEREVENTDISKUS$$$ PROAIR HFA QLL=2 inhalers/Month X$$$ PROVENTIL HFA QLL=2 inhalers/Month X!!!!! SEREVENT DISKUS QLL=120 disks/Rx X$$$ VENTOLIN HFA QLL=2 inhalers/Month X PROVENTIL HFA$$$ VOSPIRE* X albuterol sulfate!!!!! XOPENEX X albuterol$$$$ XOPENEX HFA X PROVENTIL HFA15.1.2 METHYL XANTHINE DRUGS$ aminophylline (M) X$ theophylline (M) X$ theophylline anhydrous (M) X$$ LUFYLLIN X$$ THEO-24 X theophylline, theophylline anhydrous$$$ UNIPHYL* X theophylline15.1.3 OTHER DRUGS FOR ASTHMA$ cromolyn sodium (M) X$ ipratropium bromide (M) X!!!!! ADVAIR DISKUSQLL=60 disks/Rx (ST) history ofFLOVENT (HFA) and albuterol(PAR) required 500/50 age edit >50X!!!!! ADVAIR HFAQLL= 1 inhalers/Rx (ST) history ofFLOVENT (HFA) and albuterolX$$$ AEROBID QLL=3 inhalers/Rx X ASMANEX, FLOVENT HFA$$$ AEROBID-M QLL=3 inhalers/Rx X ASMANEX, FLOVENT HFA$$$ ALVESCOQLL=2 inhalers/Rx (ST) history ofFLOVENT (HFA) Age edit of 12and older X ASMANEX, FLOVENT HFA(ST) History of treatment with$$$$$ ARCAPTA NEOHALERalbuterolX$$$ ASMANEX QLL=2 inhalers/Rx X$$$$$ ATROVENT HFA QLL=3 inhalers/Rx X$$$$$ COMBIVENT QLL=3 inhalers/Rx X21

$$$$$ DALIRESP(PAR) History of treatment withalbuterol and inhaled corticosteroidX(ST) History of treatment withalbuterol and inhaled corticosteroidQLL=2 inhalers/Rx Age Edit=$$$ DULERACovered for 12 years of age andolderX$$$$ DUONEB X albuterol + ipratropium$$$ FLOVENT HFA QLL=2 inhalers/Rx X$$ FLOVENT ROTADISK QLL=120 disks/Rx X$$$$$ INTAL* X cromolyn sodium!!!!! PULMICORT QLL=2 inhalers/Rx; X ASMANEX, FLOVENT HFA!!!!! PULMICORT RESPULESAge Edit= only covered for childrenbetween 1- 8 years of ageX$$ QVAR QLL=3 inhalers/Rx X!!!!! SPIRIVA (ST) history of albuterol X(ST) History of treatment withalbuterol and inhaled corticosteroidQLL=2 inhalers/Rx Age Edit=!!!!! SYMBICORTCovered for 12 years of age andolderX$$$$$ TILADE X15.1.4 LEUKOTRIENE MODIFIERS$$ zafirlukast X$$$$$ ACCOLATE(ST) history of FLOVENT or anyoral inhaled corticosteroidX!!!!! SINGULAIRQLL=30 tabs/Rx (ST)history of anyoral inhaled corticosteroid or anynasal steroid Age Edit= memberbetween 2 -14 yrs 2nd Tier;member >14yrs 3rd Tier X X ACCOLATE!!!!! ZYFLO(ST) history of Flovent or any oralinahled corticosteroidX15.2.1 ANTIHISTAMINES$ carbinoxamine maleate X$ cetirizine OTCRequires a prescription to apply 1sttier copayX$ chlorpheniramine (SA 12mg) (M) X$ cyproheptadine hcl (M) XNOT COVERED effective$ fexofenadine OTC (M)11/1/2011 X OTC loratadine, OTC cetirizine$$ hydroxyzine hcl (M) X$$ hydroxyzine pamoate (M) X$ loratadine OTCRequires a prescription to apply 1sttier copayX$ promethazine hcl (M) (PAR) chidlren

$$ UROXATRAL(ST) history of doxazosin orterazosinX$$$ VIAGRA NOT COVERED18.1 DIABETIC SUPPLIES$$ ASCENSIA AUTODISC TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ ASCENSIA CONTOUR TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ ASCENSIA ELITE TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ AT LAST TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ BIOSCANNER GLUCOSE STRIPS X$$ CHEMSTRIP UGK X$$ CLINITEST REAGENT TABLET X$$ CLINISTIX REAGENT STRIPS X$$ DIASTIX X$$ EXCEL G TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ FAST TAKE TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X(ST) history of use of Bayer orASCENSIA , FAST TAKE, ONE$$$ FREESTYLE TEST STRIPSLifescan products(ST) history of use of Bayer or$$$ GLUCOMETER ENCORELifescan products$$ GLUCOSTIX REAGENT STRIPS X$$ HEMA-CHECK PATIENT DISP PAK X$$ HEMA-COMBISTIX STRIPS X$$ HEMASTIX STRIPS X$$ HEMATEST REAGENT TABLET X$$ Insulin syringes (various) X$$ KETO-DIASTIX REAGENT STRIPS X$$ MULTISTIX REAGENT STRIPS X$$ ONE TOUCH BASIC SYSTEM X$$ ONE TOUCH PROFILE SYSTEM X$$ ONE TOUCH TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ ONE TOUCH ULTRA SYSTEM X$$ ONE TOUCH ULTRA TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ OPTIUM TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ NOVOFINE 30 X$$$ PRECISION Q-I-D(ST) history of use of Bayer orLifescan products(ST) history of use of Bayer or$$$ PRECISION SOF-TACTLifescan productsPRECISION XTRA BLOOD GLUCOSE QLL=150/Rx (ST) history of any$$STRIPSinsulinXQLL=150/Rx For meters call 1-800-$$ SURESTEP PRO TEST STRIPS 336-0123 X$$ SURESTEP TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X18.1 MISCELLANEOUS DRUG$$$$$ AMPYRA (PAR) X$$$$$ GILENYA (PAR); Spec. Pharm. XCHAPTER 19: PREVENTIVE SERVICES under the PATIENT PROTECTION and AFFORDABLE CARE ACTASPIRINAspirin to prevent cardiovasculardisease (CVD): MenHometown Health CoverageThe U.S. Preventative Services TaskForce (USPSTF) recommends the use ofaspirin for men age 45 to 79 years whenthe potential benefit due to a reduction inmyocardial infarctions outweighs thepotential harm due to an increase ingastrointestinal hemorrhage.· Age limit greaterthan or equal to 45(menand women)· Quantity Limit1/day· Generic Only· OTC (requires aprescription)Aspirin to prevent cardiovascularProduct Descriptiondisease: WomenThe USPSTF recommends the use ofaspirin for women age 55 to 79 yearswhen the potential benefit of a reduction inAspirin products up to 325mgischemic strokes outweighs the potentialharm or an increase in gastrointestinalhemorrhage.· Aspirin 81mg –325mg· Aspirin Chew 81mg– 325mg· Aspirin DelayedRelease 81mg – 325mg· Aspirin dispersibletab 81mgCO-PAY $0.00FLUORIDEPrevention of dental caries (cavities) Hometown Health CoverageThe USPSTF recommends that primarycare clinicians prescribe oral fluoridesupplementation at currently· Age limit less thanrecommended doses to preschool childrenor equal to 5 yearsolder than 6 months of age whose primarywater source is deficient in fluoride.XXXXCO-PAY $0.00CO-PAY $0.00TOUCHASCENSIA , FAST TAKE, ONETOUCHASCENSIA , FAST TAKE, ONETOUCHASCENSIA , FAST TAKE, ONETOUCHSupplementation with folic acid· Prescriptionproducts onlyProduct DescriptionSodium fluoride products only, notin combination· Sodium fluoride tab 0.5mg· Sodium fluoride chew tab0.25mg – 0.5mg· Sodium fluoride solutionFOLIC ACIDHometown Health Coverage23

The USPSTF recommends that all womenplanning or capable of pregnancy take adaily supplement containing 0.4 to 0.8 mg(400 to 800 mcg) of folic acid.· Women· Age limit less thanor equal to 55 years ofageCO-PAY $0.00Iron supplementation in childrenThe USPSTF recommends routine ironsupplementation for asymptomaticchildren aged 6 to 12 months who are atincreased risk for iron deficiency anemia.· Quantity limit 1/day· OTC (requires aprescription)Product DescriptionFolic acid products only, not incombination· Folic Acid tab 0.4mg and0.8mgIRON SUPPLEMENTSHometown Health Coverage· Age limit 0-1 year· Prescription orOTC (requires aprescription)Product Description· Iron Suspension· Ferrous sulfateelixir, syrup and solutionCO-PAY $0.00TOBACCO CESSATIONCounseling for tobacco use: adults Hometown Health CoverageThe USPSTF recommends that cliniciansask all adults about tobacco use and· Annual limit of 2provide tobacco cessation interventions forthose who use tobacco products.cycles (12 weeks percycle)Immunizations: VaccinesThe USPSTF recommends immunizationsfor routine use in children, adolescentsand adults that are recommended by theAdvisory Committee on ImmunizationPractices of the Centers for DiseaseControl and Prevention (CDC) on the CDCImmunization Schedules· OTC generics only· Generic Zybanonly· Rx or OTC(requires a prescriptionProduct Description· Nicotrol Inhalerand Nasal Spray· Nicotine polacrilexgum· Nicotine polacrilexlozenge· Nicotine TD patch24hr kits· Bupropion HCL tabSR· Varenicline(CHANTIX) tabsIMMUNIZATIONSHometown Health Coverage· Children: 0-18years of agePrior Authorization Required for Enrollment into theHometown Health Stop Smoking Program.Once enrolled, $0.00 CO-PAY for these products.CO-PAY $0.00· Adults greater thanor equal to 18 years ofage· Rx OnlyProduct DescriptionChildren· Haemophilusinfluenza type b· Hepatitis A· Hepatitis B· HumanPapillomavirus· InactivatedPoliovirus· Influenza· Measles, Mumps,Rubella· Meningococcal· Pneumococcal· Rotavirus· Tetaunus,Diptheria, Pertussis· VaricellaAdults· Hepatitis A· Hepatitis B· HumanPapillomavirus· Influenza· Measles, Mumps,Rubella· Meningococcal· Pneumococcal· Tetanus, Diptheria,Pertussis· Varicella· Zoster (HerpesZoster)24