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Massachusetts Commercial Formulary Prescription Drug List in Alphabetical Order
Last Updated: 3/11/2013
Tier
Key Terms
Tufts Health Plan Drug List
Formulary A formulary is a list of prescription medications developed by a committee of practicing physicians and practicing pharmacists who represent a variety of specialty areas and who are knowledgeable in the diagnosis and treatment of disease. Brand-Name Drugs Brand-name drugs are typically the first products to gain U.S. Food and Drug Administration (FDA) approval. Generic Drugs Generic drugs have the same active ingredients and come in the same strengths and dosage forms as the equivalent brand-name drug. Multiple manufacturers may produce the same generic drug and the product may differ from its brand name counterpart in color, size or shape, but the differences do not alter the effectiveness. Generic versions of brand-name drugs are reviewed and approved by the FDA. The FDA works closely with all pharmaceutical companies to make sure that all drugs sold in the U.S. meet appropriate standards for strength, quality, and purity. 3-Tier Pharmacy Copayment Program (3-Tier Program) To help maintain affordability in the pharmacy benefit, we encourage the use of cost-effective drugs and preferred brand names through the three-tier program. This program gives you and your doctor the opportunity to work together to find a prescription medication that's affordable and appropriate for you. All covered drugs are placed into one of three tiers. Your physician may have the option to write you a prescription for a Tier 1, Tier 2, or Tier 3 drug (as defined below); however, there may be instances when only a Tier 3 drug is appropriate, which will require a higher copayment. Tier 1: Medications on this tier have the lowest copayment. This tier includes many generic drugs. Tier 2: Medications on this tier are subject to the middle copayment. This tier includes some generics and brand-name drugs. Tier 3: This is the highest copayment tier and includes some generics and brand-name covered drugs not selected for Tier 2. Please note that tier placement is subject to change throughout the year.
Copayment A copayment is the fee a member pays for certain covered drugs. A member pays the copayment directly to the provider when he/she receives a covered drug, unless the provider arranges otherwise. Coinsurance Coinsurance requires the member to pay a percentage of the total cost for certain covered drugs.
Boldface - indicates generic availability. SP - Designated Specialty Pharmacy STPA - Step Therapy Prior Authorization SI - Specialty Infusion
PA - Prior Authorization QL - Quantity Limitation Program
NC - Non Covered Drugs NTM - New-to-Market
Tier 1 - Lowest Copayment
Tier 2 - Middle Copayment
Tier 3 - Highest Copayment
Tier Medical Review Process
Tufts Health Plan has pharmacy programs in place to help manage the pharmacy benefit. Requests for medically necessary review for coverage of drugs included in the New-to-Market Drug Evaluation Process (NTM), Prior Authorization Program (PA), Step Therapy Prior Authorization Program (STPA), Quantity Limitations Program (QL), Non-Covered Drugs (NC) With Suggested Alternatives Program should be completed by the physician and sent to Tufts Health Plan. Drugs excluded under your pharmacy benefit will not be covered through this process. The request must include clinical information that supports why the drug is medically necessary for you. Tufts Health Plan will approve the request if it meets coverage guidelines. If Tufts Health Plan does not approve the request, you have the right to appeal. The appeal process is described in your benefit document. Note: Drugs approved through the Medical Review Process will be subject to a Tier 3 copayment. Quantity Limitation (QL) Program Because of potential safety and utilization concerns, Tufts Health Plan has placed quantity limitations on some prescription drugs. You are covered for up to the amount posted in our list of covered drugs. These quantities are based on recognized standards of care as well as from FDA-approved dosing guidelines. If your provider believes it is necessary for you to take more than the QL amount posted on the list, he or she may submit a request for coverage under the Medical Review Process. New-To-Market Drug Evaluation Process (NTM) In an effort to make sure the new-to-market prescription drugs we cover are safe, effective and affordable, we delay coverage of many new drug products until the Plan's Pharmacy and Therapeutics Committee and physician specialists have reviewed them. This review process is usually completed within six months after a drug becomes available. The review process enables us to learn a great deal about these new drugs, including how a physician can safely prescribe these new drugs and how physicians can choose the most appropriate patients for the new therapy. During the review process, if your physician believes you have a medical need for the NewTo-Market drug, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process. If your plan includes the 3-Tier Copayment Program, then you will pay the Tier-3 (highest) copayment if the medication is approved for coverage. Non-Covered Drugs (NC) There are thousands of drugs listed on the Tufts Health Plan covered drug list. In fact, most drugs are covered. There is, however, a list of drugs that Tufts Health Plan currently does not cover. In many cases, these drugs are not covered by Tufts Health Plan because there are safe, comparably effective, and cost effective alternatives available. Our goal is to keep pharmacy benefits as affordable as possible. If your doctor feels that one of the non-covered drugs is needed, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process. Prior Authorization (PA) Program In order to ensure safety and affordability for everyone, some medications require prior authorization. This helps us work with your doctor to ensure that medications are prescribed appropriately. If your doctor feels it is medically necessary for you to take one of the drugs listed below, he/she can submit a request for coverage to Tufts Health Plan under the Medical Review Process.
Tier Step Therapy Prior Authorization (STPA )
Step Therapy is an automated form of Prior Authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and costeffectiveness. Some types of Step Therapy include requiring the use of generics before brand name drugs, preferred before non-preferred brand name drugs, and first-line before second-line therapies. Medications included on step 1- the lowest step-are usually covered without authorization. We have noted the few exceptions, which may require your physician to submit a request to Tufts Health Plan for coverage. Medications on Step 2 or higher are automatically authorized at the point-of-sale if you have taken the required prerequisite drugs. However, if your physician prescribes a medication on a higher step, and you have not yet taken the required medication(s) on a lower step, or if you are a new Tufts Health Plan member and do not have any prescription drug claims history, the prescription will deny at the point-of-sale with a message indicating that a Prior Authorization (PA) is required. Physicians may submit requests for coverage to Tufts Health Plan for members who do not meet the Step Therapy criteria at the point of sale under the Medical Review process. Designated Specialty Pharmacy Program (SP) Tufts Health Plan's goal is to offer you the most clinically appropriate and cost-effective services. As a result, we have designated special pharmacies to supply a select number of medications used in the treatment of complex diseases. These pharmacies are specialized in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency. You can obtain up to a 30-day supply of these medications at a time. Other special designated pharmacies and medications may be identified and added to this program from time to time. Benefits vary; some members may not participate in this program. Please see your benefit document for complete information. Physicians may obtain a select number of specialty medications through a designated SP for administration in the office as an alternative to direct purchase. These medications are covered under the medical benefit, and will be shipped directly to and administered in the office by the members provider. The designated pharmacy will bill Tufts Health Plan directly for the medication. For the most current listing of special designated pharmacies or to find out if your plan includes this program, please call us at the number listed on the back of your member identification card. Designated Specialty Infusion Program for Drugs Covered Under the Medical Benefit (SI) Tufts Health Plan has designated home infusion providers for a select number of specialized pharmacy products and drug administration services. The designated specialty infusion provider offers clinical management of drug therapies, nursing support, and care coordination to members with acute and chronic conditions. Place of service may be in the home or alternate infusion site based on availability of infusion centers and determination of the most clinically appropriate site for treatment. These medications are covered under the medical benefit (not the pharmacy benefit) and generally require support services, medication dose management, and special handling in addition to the drug administration services. Medications include, but are not limited to, medications used in the treatment of hemophilia, pulmonary arterial hypertension, and immune deficiency. Other specialty infusion providers and medications may be identified and added to this program from time to time.
Tier
Generic Focused Formulary The Generic Focused Formulary, which is the formulary used in our Select Network and/or Connector Plans differs from other Tufts Health Plan formularies. Most generic drugs are covered, and only select brand name drugs that have no generic drug equivalent are covered. Brand name drugs with generic equivalents are not covered under this formulary. If the patent of a brand name drug listed expires and a generic version becomes available, the brand will no longer be covered. This change will happen automatically and without notification to members or providers. GFF Formulary Managed Mail (MM) Program Our Managed Mail (MM) Program applies to certain plans. It requires that in order to be covered, prescriptions for most maintenance medications must be filled by our mail order pharmacy. Maintenance medications are those you refill monthly for chronic conditions like asthma, high blood pressure, or diabetes. Under this program, you are allowed an initial fill at a retail pharmacy and a limited number of refills. After that, in order to be covered, you must fill your maintenance prescription through the mail order program offered by CVS Caremark, our pharmacy benefits manager. You may obtain up to a 90-day supply for these maintenance medications at mail order. Please note that some medications may not be appropriate for mail order. These include medications with quantity limitations (QL) of less than 84 or 90 days. If you have questions about this program, please contact us at the number listed on the back of your member identification card. Over-The-Counter Drugs (OTC) When a medication with the same active ingredient or a modified version of an active ingredient that is therapeutically equivalent, becomes available over-the-counter, Tufts Health Plan may exclude coverage of the specific medication or all of the prescription drugs in the class. For more information, please call our Member Services Department at the number listed on the back of your member identification card.
Tier
A
Drug Name
abacavir Abilify Discmelt Abilify solution Abilify tablets Abstral Acanya acarbose Accolate Accu-Chek test strips Accuneb Accupril Accuretic acebutolol Aceon acetazolamide acetazolamide ext-rel acetic acid otic acetic acid/aluminum acetate otic acetic acid/hydrocortisone otic AcipHex Aclovate Actemra Actimmune Actiq Activella Actonel Actoplus Met Actoplus Met XR Actos Acular Acular LS Acuvail acyclovir capsules, tablets Aczone Adalat CC adapalene cream/gel Adcirca Adderall Adderall XR Adipex-P Advair Diskus Advair HFA Advicor Afinitor Aggrenox
Tier
Tier 1
Pharmacy Program
NC Abilify tablets NC Abilify tablets QL STPA 30 tablets/30 days QL 32 tablets/30 days NC clindamycin gel + benzoyl peroxide gel
Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
QL 360 vials/90 days NC quinapril/hydrochlorothiazide tablets
NC QL 90 tablets/90 days, Prilosec OTC, omeprazole, lansoprazole, pantoprazole Tier 3 Medical Benefit Tier 2 PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. NC QL 120 units (lollipops)/30 days, fentanyl lollipop Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 NC benzoyl peroxide gel Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 3 PA Prior Authorization required for members 26 years of age or older. SP PA QL 60 tablets/30 days, Call Accredo at 1866-344-4874 STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. PA QL 3 diskus/90 days QL 6 inhalers/90 days SP PA QL 30 tablets/30 days, Call Curascript at 1877-238-8387 STPA
NC diclofenac eye drops, ketorolac eye drops
Tier
Agrylin albuterol ext-rel albuterol sulfate nebulizer solution albuterol syrup/tablets alclometasone Alcortin A topical gel Aldactazide Aldactone Aldara Aldurazyme alendronate alfuzosin ext-rel Alinia Alkeran allopurinol Alocril Alomide Alora Alphagan P 0.1% Alphagan P 0.15% alprazolam alprazolam ext-rel alprazolam orally disintegrating tablets Alrex Alsuma Altabax Altace Altoprev Aluvea Alvesco amantadine Amaryl Ambien Ambien CR amcinonide cream, lotion Amcinonide ointment Amerge amethia amethia lo amethyst Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
QL 360 vials/90 days or 9 dropper bottles/90 days
NC hydrocortisone/iodoquinol cream NC spironolactone/hydrochlorothiazide NC spironolactone Tier 3 Medical Benefit Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767.
Tier 3 Tier 1 Tier 3
QL STPA 4 injections (4 vials)/30 days QL 1 tube/5 days NC ramipril NC lovastatin tablets NC urea cream QL 80 mcg: 3 inhalers/90 days; 160 mcg: 6 inhalers/90 days
NC QL 10 tablets/30 days, zolpidem tartrate tablets NC QL zolpidem tartrate tablets, zolpidem ext-rel, 10 tablets/30 days
QL STPA 9 tablets/30 days, Step Therapy Prior Authorization applies to brand name drug only.
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
amiloride amiloride/hydrochlorothiazide amiodarone Amitiza amitriptyline amitriptyline/perphenazine amlodipine
Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1
Tier
amlodipine/atorvastatin amlodipine/benazepril ammonium lactate 12% Amnesteem Amoxapine amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ext-rel amphetamine/dextroamphetamine mixed salts amphetamine/dextroamphetamine mixed salts ext-rel ampicillin Ampyra Amrix Amturnide Anafranil anagrelide Analpram E Rectal Kit Anaprox/Anaprox DS anastrozole Androderm AndroGel Angeliq Antabuse Antara Antivert Anzemet tablets Apidra Aplenzin Apokyn apraclonidine 0.5% eye drops apri Apriso Aptivus Aralen aranelle Aranesp Arava Arcalyst Arcapta Neohaler Aricept Arimidex Arixtra Armour Thyroid Aromasin Arthrotec Asacol Asacol HD Asmanex Astelin Astepro Tier 2 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
STPA STPA SP PA QL Call Curascript at 1-877-238-8387, 60 tablets/30 days NC cyclobenzaprine tablets NC clomipramine
Tier 3 Tier 1 NC hydrocortisone/pramoxine rectal cream NC naproxen Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 NC fenofibrate Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 Tier 2 QL 3 tablets/7 days STPA Step Therapy Prior Authorization required for members 18 years of age and older.
SP QL 4 mL/30 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-238-8387 STPA Step Therapy Prior Authorization applies to both brand and generic drug. SP PA QL 5 vials/28 days for initial 28 days, 4 vials/28 days thereafter, Call Caremark at 1-800237-2767 NC Serevent Diskus, Perforomist
Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 2
QL 6 Twisthalers/90 days QL 3 nasal spray units/90 days QL 3 nasal spray units/90 days
Tier
Asthma Supplies Atabex EC Atacand Atacand HCT Atelvia atenolol atenolol/chlorthalidone Ativan atorvastatin 10 mg, 20 mg atorvastatin 40 mg, 80 mg atovaquone/proguanil Atralin Atrapro CP Atripla atropine eye drops, eye ointment atropine/hyoscyamine/scopolamine/phenobarbital Atrovent HFA Atrovent nasal aerosol Aubagio Augmentin Augmentin XR Aurax otic solution Auvi-Q Avalide Avandamet Avandaryl Avandia Avapro Avelox Aviane Tier 2 Tier 3

QL 2 spacers/year; 1 peak flow meter/year NC eprosartan, irbesartan, losartan NC losartan/HCTZ, valsartan/HCTZ, candesartan/HCTZ NC alendronate Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 NTM Tier 2 Tier 1 Tier 1 Tier 2 Tier 3 Tier 2 Tier 3 Tier 3 NC antipyrine 5.4%/benzocaine 5.4% NTM NC irbesartan/HCTZ, losartan/HCTZ, valsartan/HCTZ NC pioglitazone + metformin, Janumet, Kombiglyze XR NC pioglitazone + glimepiride, Januvia + glimepiride NC pioglitazone, Januvia, Onglyza NC eprosartan, irbesartan, losartan NC ciprofloxacin, levofloxacin Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL 60 capsules/30 days PA Prior Authorization required for members 26 years of age or older. SP QL 4 syringes/vials/28 days, Call Curascript at 1-877-238-8387 SP QL Call Curascript at 1-877-238-8387, 4 pens/28 days QL STPA 6 tablets/30 days NC Androderm, Androgel Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 QL 1 bottle/7 days NC lorazepam NC STPA NC PA Prior Authorization required for members 26 years of age and older.
QL 6 inhalers/90 days QL 6 nasal spray units/90 days SP PA QL 28 tablets/28 day, Call Curascript at 1877-238-8387
Tier 1
Avinza Avita Avodart Avonex Avonex Pen Axert Axid oral solution Axiron Solution Aygestin Azasite azathioprine azelastine eye drops azelastine spray
QL
Tier
Azelex Azilect azithromycin Azopt Azor Azulfidine Azulfidine EN-Tablets Tier 3 Tier 2 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3
B
Drug Name
b complex + c/folic acid bacitracin eye ointment bacitracin/polymyxin B eye ointment baclofen Bactrim/Bactrim DS Bactroban Bactroban nasal ointment balsalazide balziva Banzel Baraclude Beconase AQ benazepril benazepril/hydrochlorothiazide Benicar Benicar HCT Benlysta Bentyl Benzac AC Benzaclin Gel Benzamycin BenzEFoam BenzEFoam Ultra benzocaine/antipyrine otic benzonatate benzoyl peroxide benztropine Bepreve Berinert Besivance Betagan betamethasone dipropionate betamethasone dipropionate augmented cream betamethasone dipropionate augmented gel, lotion, ointment betamethasone valerate betamethasone valerate foam Betapace Betapace AF Betaseron
Tier
Pharmacy Program
PA QL 200 mg tablets: 1440 tablets/90 days; 400 mg tablets: 720 tablets/90 days; 40 mg/mL suspension: 4 bottles/30 days NC QL 3 nasal spray units/90 days, flunisolide nasal spray, fluticasone nasal spray, Nasonex
Tier 1 Tier 1 Tier 2 Tier 2 Medical Benefit Tier 3 Tier 3 Tier 3 Tier 3
PA Covered under the medical benefit.
NC benzoyl peroxide (OTC) NC benzoyl peroxide (OTC) Tier 1 Tier 1 Tier 1 Tier 1 NC azelastine eye drops, cromolyn sodium eye drops SI For home infusion services call Caremark at 1800-237-2767. Covered under the medical benefit. QL 1 bottle/5 days
Medical Benefit Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2
SP QL 15 vials/30 days, Call Curascript at 1-877238-8387
Tier
betaxolol bethanechol Betimol Betoptic S Beyaz Tier 1 Tier 1 Tier 2 Tier 3 Tier 3
Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Biaxin Biaxin XL bicalutamide BiDil Binosto Bionect bisoprolol bisoprolol/hydrochlorothiazide Bleph-10 Blephamide Boniva 150 mg Boniva IV Bontril PDM Bosulif Botulinum Toxins Bravelle
Tier 3 Tier 3 Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Medical Benefit Tier 3 Tier 2 Medical Benefit Tier 3
SP Call Curascript at 1-877-238-8387 NC alendronate, ibandronate
STPA Step Therapy Prior Authorization applies to both brand and generic drug PA Covered under the medical benefit. PA SP PA QL 100 mg: 120 tablets/30 days; 500 mg: 30 tablets/30 days, Call Curascript at 1-877-2388387 PA Prior Authorization. Examples include Botox, Dysport, Myobloc and Xeomin. Covered under the medical benefit. SP PA SP PA Call Village Pharmacy at 1-877-344 -1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Brevicon
Tier 3
Brilinta brimonidine 0.15% eye drops brimonidine 0.2% eye drops Bromday bromfenac sodium eye drops bromocriptine Brovana budesonide delayed-release capsules budesonide inhalation suspension
Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1
QL 180 vials/90 days QL STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to both brand and generic drug., 180 vials/90 days
bumetanide buprenorphine (Subutex discontinued) Buproban bupropion bupropion ext-rel bupropion HCl SR bupropion SR
Tier 1 Tier 1 PA No copayment QL Annual limit of 180 tablets/90 days Tier 1 Tier 1 Tier 1 No copayment QL Annual limit of 180 tablets/90 days
10
Tier
buspirone butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/aspirin/caffeine butorphanol nasal spray Butrans Bydureon Byetta Bystolic Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 2 Tier 3
QL 3 bottles (9 mL total)/30 days QL 4 patches/30 days
C
Drug Name
Caduet Cafergot Calan Calan SR calcipotriene calcitonin-salmon spray calcitriol calcium acetate Cambia camila Campral camrese
Tier
Tier 3 Tier 3
Pharmacy Program
NC verapamil NC verapamil ext-rel
Tier 1 Tier 1 Tier 1 Tier 1 NC QL diclofenac potassium tablets, 9 packets/30 days Tier 1 Tier 2 Tier 1
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC NC saliva substitute (OTC) PA QL 100 mg: 60 tablets/30 days; 300 mg: 30 tablets/30 days
Canasa candesartan/hydrochlorothiazide Caphosol Capital w/Codeine Caprelsa captopril captopril/hydrochlorothiazide Carafate Carbaglu carbamazepine carbamazepine ext-rel carbamazepine ext-rel 200 mg, 400 mg Carbatrol carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone Cardene SR Cardizem Cardizem CD Cardizem LA Cardura Cardura XL carisoprodol 250 mg carisoprodol 350 mg carisoprodol/aspirin carteolol eye drops
Tier 2 Tier 2 Tier 3 Tier 2 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3
PA
NC diltiazem NC diltiazem ext-rel NC diltiazem ext-rel Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
11
Tier
carvedilol Casodex Cataflam Catapres Catapres-TTS Caverject Cayston Cedax CeeNU cefaclor Cefaclor ER cefadroxil cefdinir cefditoren pivoxil cefpodoxime cefprozil Ceftin cefuroxime axetil Celebrex Celexa Cellcept Cenestin cephalexin Cerezyme Cesamet Cetraxal Cetrotide cevimeline Chantix Chenodal chloral hydrate chlordiazepoxide chlordiazepoxide/clidinium chlorhexidine gluconate chloroquine phosphate chlorpromazine chlorpropamide chlorthalidone chlorzoxazone cholestyramine chorionic gonadotropin Cialis Tier 1 Tier 3

SP Call Curascript at 1-877-238-8387 NC diclofenac NC clonidine NC clonidine patch
Tier 3 Tier 2 Tier 3 Tier 2 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Medical Benefit Tier 3 Tier 3 Tier 2
SP Call Curascript at 1-877-238-8387
PA NC citalopram
PA SI Covered under the medical benefit., For home infusion services call Coram Healthcare at 1800-422-7312 or Caremark at 1-800-237-2767. QL 18 capsules/7 days SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500
Tier 1 No copayment QL Annual limit of 24 weeks NC ursodiol Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 QL Erectile Dysfunction: 4 tablets/30 days total for any combination of Viagra, Cialis, Levitra, Stendra, and Staxyn; Not covered for men 18 years of age or younger, or for women. (No exceptions); Symptomatic Benign Prostatic Hyperplasia: 30 tablets/30 days QL 1 bottle/30 days
ciclopirox ciclopirox topical solution 8% cilostazol
12
Tier
Ciloxan cimetidine Cimzia Tier 3 Tier 1 Tier 2
Cinryze Cipro Cipro HC Otic Ciprodex ciprofloxacin ciprofloxacin ext-rel ciprofloxacin eye drops, eye ointment citalopram Citranatal Rx Claravis Clarifoam EF clarithromycin clarithromycin ext-rel clemastine 2.68 mg Cleocin Cleocin Pediatric Cleocin T Cleocin vaginal cream Cleocin vaginal suppositories Climara Climara Pro clindamycin clindamycin 1%/benzoyl peroxide 5% clindamycin palmitate oral solution clindamycin phosphate foam 1% clindamycin vaginal cream clindamycin/benzoyl peroxide gel Clindesse Clinoril clobetasol propionate clobetasol propionate 0.05% clobetasol propionate foam clobetasol propionate/emollient Clobex Clobex spray clomiphene clomipramine clonazepam clonidine clonidine transdermal clopidogrel clorazepate clotrimazole clotrimazole (Rx only) clotrimazole troches clotrimazole/betamethasone
Medical Benefit Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
SP PA QL Cimzia syringes are covered under the pharmacy benefit only, prior authorization applies. Cimzia vials are covered under the medical benefit only, prior authorization applies. Available to providers through Curascript, call 1-877-2388387., 2 injections (syringes/vials)/28 days, Call Curascript at 1-877-238-8387 PA SI For home infusion services call Caremark at 1-800-237-2767., Covered under the medical benefit.
NC NC clobetasol lotion
13
Tier
clozapine Clozaril Coartem codeine sulfate codeine/acetaminophen codeine/chlorpheniramine/pseudoephedrine codeine/guaifenesin codeine/guaifenesin/pseudoephedrine codeine/promethazine Coenzyme Q10 Colazal Colcrys Colestid colestipol Colyte Combigan CombiPatch Combivent Respimat Combivir Cometriq Complera Comtan Concept DHA Concept OB Concerta Condylox Constulose Conzip Copaxone Copegus Cordarone Cordran Coreg Coreg CR Corgard Cortef Cortifoam cortisone acetate Cortisporin Corvite 150 Cosopt Cosopt PF Coumadin Cozaar Creon Crestor Crinone Crixivan cromolyn sodium eye drops cromolyn sodium nebulizer solution Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 NTM Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 NC losartan Tier 2
QL 24 tablets/180 days
PA QL 60 tablets/30 days NC colestipol
QL 10 mL/30 days QL 6 inhalers/90 days
STPA Step Therapy Prior Authorization applies to brand name drug only.
NC tramadol, tramadol ext-rel SP QL 1 kit (30 syringes)/30 days, Call Curascript at 1-877-238-8387 SP Call Caremark at 1-800-237-2767
NC carvedilol tablets
NC simvastatin, atorvastatin, pravastatin Tier 3 Tier 2 Tier 1 Tier 1
QL 360 vials/90 days
14
Tier
Cryselle Tier 1

Cuprimine Cutivate Cuvposa Solution cyanocobalamin injection Cyclessa
Tier 2 Tier 3 NC QL 1 bottle/30 days, glycopyrrolate tablets Tier 1 Tier 3 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
cyclobenzaprine Cyclogyl cyclopentolate eye drops cyclophosphamide tablets Cycloset cyclosporine cyclosporine, modified Cymbalta
Tier 1 Tier 3 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 3
QL STPA 20 mg: 60 capsules/30 days; 30 mg: 60 capsules/30 days; 60 mg: 30 capsules/30 days, Step Therapy Prior Authorization required for members 18 years of age and older.
cyproheptadine Cytomel Cytotec
D
Drug Name
D.H.E. 45 Daliresp danazol Dantrium dantrolene dapsone Daraprim Daypro Daytrana DDAVP Delestrogen Delos Delzicol Demadex Demerol Depakene Depakote Depakote ER Depakote Sprinkle Deplin Deprizine suspension Dermotic desipramine desmopressin
Tier
Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 NTM Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
Pharmacy Program
NC oxaprozin STPA
15
Tier
Desogen Tier 3

Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC desonide cream or lotion
Desonate desonide Desowen desoximetasone Detrol Detrol LA dexamethasone dexamethasone sodium phosphate eye drops, eye ointment Dexferrum Dexilant dexmethylphenidate dextroamphetamine dextroamphetamine ext-rel dextromethorphan/promethazine DiaBeta Diabetic Test Strips, Other
STPA Step Therapy Prior Authorization applies to brand name drug only. STPA
NC QL 90 capsules/90 days, Prilosec OTC, omeprazole, lansoprazole, pantoprazole Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 NC OneTouch Test Strips, Accu-Chek Test Strips, OneTouch and Accu-Chek are the preferred, covered, test strips. Examples of noncovered test strips include, but are not limited to: Ascensia, BD, FreeStyle, Precision, TrueTrack test strips Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 NC hydromorphone Tier 1 QL 1 kit (2 units)/30 days QL
Diamox Sequels Diastat/Diastat AcuDial diazepam diazepam rectal gel diclofenac potassium diclofenac sodium delayed-rel diclofenac sodium delayed-rel/misoprostol diclofenac sodium eye drops dicloxacillin Dicopanol suspension dicyclomine didanosine delayed-rel Didronel diethylpropion Differin cream/gel Differin lotion Dificid diflorasone diacetate Diflucan diflunisal Digex NF digoxin dihydroergotamine injection Dilacor XR Dilantin Dilantin Infatabs Dilaudid diltiazem
PA PA Prior Authorization required for members 26 years of age or older. PA Prior Authorization required for members 26 years of age or older. PA
NC diltiazem ext-rel
16
Tier
diltiazem ext-rel Diovan Diovan HCT Dipentum diphenhydramine 50 mg diphenoxylate/atropine dipivefrin eye drops Diprolene Diprolene AF dipyridamole disopyramide disulfiram Ditropan XL divalproex sodium delayed-rel divalproex sodium ext-rel divalproex sodium sprinkle Divigel donepezil Donnatal Doryx dorzolamide HCl eye drops dorzolamide HCl/timolol maleate eye drops Dovonex doxazosin doxepin doxycycline hyclate doxycycline hyclate 20 mg tablets doxycycline monohydrate Drisdol Duac Duetact Duexis Dulera DuoNeb Duragesic Duragesic Durezol Dutoprol Dyazide Dymista Dynacin Tier 1 Tier 2 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3
Tier 3 Tier 3
NC ibuprofen + famotidine OTC NC QL Advair, Symbicort, 3 inhalers/90 days QL 360 vials/90 days NC QL 10 patches/30 days, fentanyl patch NC QL 10 patches/30 days, fentanyl patch NC diclofenac eye drops, prednisolone acetate eye drops
Tier 3 Tier 3 NC QL fluticasone nasal spray + azelastine nasal spray, 3 nasal sprays/90 days NC minocycline
E
Drug Name
E.E.S. 200 suspension EC-Naprosyn econazole Edarbi Edarbyclor Edecrin Edex Edluar
Tier
Pharmacy Program
NC eprosartan, irbesartan, losartan NC irbesartan/HCTZ, losartan/HCTZ, valsartan/HCTZ Tier 3 Tier 3 NC QL zolpidem tartrate tablets, 10 sublingual tablets/30 days
17
Tier
Edurant Effer-K 10 mEq, 20 mEq Effexor XR Effient Efudex Egrifta Elaprase Eldepryl Elelyso Elestat Elestrin Eletone Elidel Eliquis Elixophyllin Ella Tier 2 Tier 3
NC venlafaxine ext-rel Tier 3 Tier 3 Tier 3 Medical Benefit Tier 3 Medical Benefit Tier 3 Tier 3 Tier 3 Tier 3 NTM Tier 2 Tier 3
SP PA Call Curascript at 1-877-238-8387 SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. PA Covered under the medical benefit.
STPA
QL 1 tablet/fill, Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Elmiron Elocon Emadine Emcyt Emend Emsam Emtriva Enablex enalapril enalapril/hydrochlorothiazide Enbrel Endometrin Enjuvia Enovarx-Ibuprofen cream enoxaparin enpresse
Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 2 Tier 2 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 NTM Tier 1 Tier 1
SP Call Curascript at 1-877-238-8387 QL 40 mg: 1 capsule/7 days; 80 mg: 2 capsules/7 days; 125 mg: 1 capsule/7 days; 1 dosepack/7 days STPA Step Therapy Prior Authorization required for members 18 years of age and older.
SP PA QL 25 mg: 8 vials/syringes/28 days; 50 mg: 4 syringes/28 days, Call Curascript at 1-877238-8387
entacapone Entocort EC Enulose Epiduo epinastine eye drops epinephrine Epipen Epipen Jr.
Tier 1 Tier 3 Tier 1 NC adapalene 0.1% gel + benzoyl peroxide 2.5% gel Tier 1 Tier 1 Tier 2 Tier 2 QL 2 injectors/each fill QL 2 injectors/each fill QL 2 injectors/each fill
18
Tier
Episil Epivir tablets Epivir-HBV eplerenone Epogen epoprostenol sodium eprosartan Epzicom Equetro ergocalciferol (D2) Erivedge errin Tier 2 Tier 3 Tier 2 Tier 1 Tier 2 Medical Benefit Tier 2 Tier 2 Tier 3 Tier 1 Tier 2 Tier 1

QL 4 bottles/30 days
STPA Step Therapy Prior Authorization applies to both brand and generic drug. SP QL 10 vials/14 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-238-8387 PA SI For home infusion services call Accredo at 1-866-344-4874, Covered under the medical benefit. NC
SP PA Call Curascript at 1-877-238-8387 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Ertaczo Ery-Tab erythromycin delayed-rel erythromycin ethylsuccinate tablets erythromycin eye ointment erythromycin gel erythromycin solution erythromycin stearate erythromycin/benzoyl peroxide erythromycin/sulfisoxazole escitalopram estazolam Estrace Estrace cream estradiol estradiol transdermal estradiol valerate estradiol/norethindrone acetate Estrasorb Estring Estrogel estropipate Estrostep Fe
Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 3 Tier 1 Tier 3
STPA
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
ethambutol ethosuximide etidronate etodolac etodolac ext-rel etoposide capsules
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
19
Tier
Euflexxa Eurax Evamist Evista Evoclin 1% Evoxac Exalgo Exelon capsules Exelon Patch Exelon solution exemestane Exforge Exforge HCT Exjade Extavia Extina foam 2% Medical Benefit Tier 2 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2

SP PA Call Curascript at 1-877-238-8387, Covered under the medical benefit. QL 1 bottle/each fill
NC QL hydromorphone tablets, 30 tablets/30 days
SP QL 15 vials/30 days, Call Curascript at 1-877238-8387 NC ketoconazole foam
F
Drug Name
Fabrazyme Factive Factor Products, various
Tier
Medical Benefit
Pharmacy Program
PA SI For home infusion services call Coram Healthcare at 1-800-422-7312 or Caremark at 1800-237-2767., Covered under the medical benefit. NC ciprofloxacin, levofloxacin, ofloxacin PA SI Covered under the medical benefit., Examples include, but are not limited to: Advate, BeneFix, Corifact, Feiba, Helixate FS, Hemofil M, Kogenate FS, NovoSeven RT, Recombinate, Wilate, Xyntha; For home infusion services call Caremark at 1-800-237-2767.
Medical Benefit
famciclovir famotidine famotidine suspension Famvir Fanapt Fanatrex Fazaclo felbamate Felbatol Feldene felodipine ext-rel Femara Femhrt 0.5 mg/2.5 mcg Femring Femtrace fenofibrate 48 mg, 145 mg fenofibrate 54 mg, 67 mg, 134 mg, 160 mg, 200 mg fenofibric acid Fenoglide fentanyl citrate lollipop fentanyl transdermal Fentora Feriva Ferralet 90
Tier 1 Tier 1 Tier 1 Tier 3 NC olanzapine, quetiapine, risperidone NC gabapentin solution Tier 2 Tier 1 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1
NC
NC fenofibrate tablets or capsules QL 120 units (lollipops)/30 days QL 10 patches/30 days NC QL 28 buccal tablets/30 days, fentanyl citrate lollipop
Tier 3 Tier 3
20
Tier
Ferriprox Fexmid Fibricor Finacea finasteride 5 mg Fioricet Fiorinal Firazyr First-BXN First-Duke's Mouthwash First-Lansoprazole First-Mary's Mouthwash First-Omeprazole First-Progesterone VGS Flagyl Flagyl 375 mg Flagyl ER Flarex flavoxate hydrochloride flecainide Flector Flexeril Flolan Flomax Flonase Flo-Pred Flovent Diskus Flovent HFA fluconazole fludrocortisone Flumadine flunisolide nasal spray fluocinolone acetonide fluocinolone acetonide oil fluocinonide fluoride drops fluoride tablets fluorometholone eye drops, eye ointment Fluoroplex fluorouracil fluoxetine fluoxetine delayed-rel fluphenazine flurazepam flurbiprofen flutamide fluticasone nasal spray fluticasone propionate cream, lotion, ointment fluvastatin fluvoxamine FML Tier 2

PA QL 30 tablets/30 days NC cyclobenzaprine tablets NC fenofibric acid tablets or capsules
Tier 2 Tier 1 NC butalbital/acetaminophen/caffeine NC butalbital/aspirin/caffeine SP PA QL 1 unit (3 mL)/fill, Call Caremark at 1800-237-2767
NC QL Covered for members 12 years of age and younger. Quantity Limitations apply., 300 mL/30 days, omeprazole, lansoprazole, pantoprazole Tier 3 Tier 3 Tier 2 Tier 3 QL 300 mL/30 days
NC metronidazole 375 mg NC metronidazole tablets Tier 3 Tier 1 Tier 1 NC diclofenac tablets, Voltaren gel, Pennsaid NC cyclobenzaprine PA SI Covered under the medical benefit., For home infusion services call Accredo at 1-866-3444874. NC QL 3 nasal spray units/90 days, fluticasone nasal spray NC prednisolone 15 mg/5 mL solution QL 6 diskus/90 days QL 6 inhalers/90 days
Medical Benefit Tier 3
Tier 2 Tier 2 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3
QL 3 nasal spray units/90 days
QL 3 nasal spray units/90 days NC
21
Tier
Focalin Focalin XR folic acid Follistim AQ fondaparinux sodium Foradil Aerolizer Forfivo XL Fortamet Forteo Fortesta Gel Fortical Fosamax Fosamax Plus D fosinopril fosinopril/hydrochlorothiazide Fosrenol Fragmin Freshkote Frova Furadantin suspension 25 mg/5 mL furosemide Fusion Plus Fuzeon Tier 3 Tier 1 Tier 3 Tier 1 Tier 2 Tier 3 Tier 2 Tier 3

NC dexmethylphenidate STPA No copayment required for women age 13 through age 44. SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 QL 3 inhalers/90 days STPA NC metformin ext-rel tablets SP PA Call Curascript at 1-877-238-8387 NC Androderm, Androgel NC alendronate NC alendronate + vitamin D (OTC) Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 NTM Tier 2
QL STPA 9 tablets/30 days
G
Drug Name
gabapentin Gabitril galantamine galantamine ext-rel Galzin ganciclovir Ganirelix Gattex Gelclair Gelnique gemfibrozil Generess Fe
Tier
Tier 1 Tier 3 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3 NTM Tier 2 Tier 2 Tier 1 Tier 3
Pharmacy Program
SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500
Genotropin gentamicin gentamicin eye drops, eye ointment Geodon Gesticare DHA gianvi Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP NC Call Caremark at 1-800-237-2767, Norditropin FlexPro, Norditropin Nordiflex
STPA Step Therapy Prior Authorization applies to both brand and generic drug.
22
Tier
Gilenya Gleevec glimepiride glipizide glipizide ext-rel glipizide/metformin Glucagon Glucophage Glucophage XR Glucotrol Glucotrol XL Glucovance Glumetza glyburide glyburide, micronized glyburide/metformin Glynase Glyset Golytely Golytely packets Gonal-F Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2

SP PA QL 28 tablets/28 days, Call Curascript at 1877-238-8387 SP Call Curascript at 1-877-238-8387
NC metformin ext-rel tablets
Gralise granisetron tablets Granisol oral solution Grifulvin V tablets griseofulvin microsize griseofulvin microsize suspension griseofulvin ultramicrosize Gris-Peg guanfacine Guiatuss AC Guiatuss DAC
Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1
SP PA SP PA Call Village Pharmacy at 1-877-344 -1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500 NC gabapentin QL 6 tablets/7 days QL 45 mL/7 days
H
Drug Name
Halcion Halflytely halobetasol propionate haloperidol Hectorol Helidac Hepsera Horizant Humalog Humatrope Humira
Tier
Pharmacy Program
NC triazolam
QL 60 tablets/30 days SP NC Norditropin FlexPro, Norditropin Nordiflex, Call Caremark at 1-800-237-2767 SP PA QL Call Curascript at 1-877-238-8387, 2 syringes/28 days; One Crohn's Disease / Ulcerative Colitis starter pack (6 pens) as a one-time fill only; One Psoriasis starter pack (4 pens) as a one-time fill only
Tier 2
Humulin
Tier 2
23
Tier
Hycamtin oral capsules hydralazine Hydro 35 Hydro 40 hydrochlorothiazide hydrocodone polistirex/chlorpheniramine polistirex hydrocodone/acetaminophen hydrocodone/acetaminophen 10/650 hydrocodone/acetaminophen 2.5/500 hydrocodone/acetaminophen 7.5/300 hydrocodone/acetaminophen 7.5/500 hydrocodone/acetaminophen 7.5/650 hydrocodone/acetaminophen tablets hydrocodone/homatropine hydrocodone/ibuprofen hydrocortisone hydrocortisone (prescription only) hydrocortisone butyrate hydrocortisone cream hydrocortisone enema hydrocortisone valerate hydrocortisone/aloe polysaccharide/iodoquinol hydromorphone hydroxychloroquine hydroxyzine HCl hydroxyzine pamoate hyoscyamine sulfate hyoscyamine sulfate ext-rel Hyzaar Tier 2 Tier 1

SP PA QL 0.25 mg: 15 capsules/21 days; 1 mg: 25 capsules/21 days, Call Curascript at 1-877-2388387 NC urea lotion/cream NC urea lotion/cream Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 NC losartan/hydrochlorothiazide
I
Drug Name
ibandronate 150 mg ibuprofen (Rx Only) ibuprofen (Rx Only) Iclusig Ilaris Imdur imipramine HCl imiquimod Imitrex
Tier
Tier 1
Pharmacy Program
STPA Step Therapy Prior Authorization applies to both brand and generic drug.
Tier 1 NTM Medical Benefit Tier 3 Tier 1 Tier 1 Tier 3
SP Call Curascript at 1-877-238-8387 PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387.
Immune Globulin (IVIG, SCIG)
Medical Benefit
QL STPA Step Therapy Prior Authorization applies to brand name drug only., Tablets: 9 tablets/30 days; Injection: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; Nasal Spray: 5 mg: 2 boxes (12 spray unit devices)/30 days; 20 mg: 1 box (6 spray unit devices)/30 days PA SI Covered under the medical benefit., Examples include, but are not limited to: Carimune, Flebogamma, Gammagard S/D, Gammaplex, Gamunex-C, Hizentra, Privigen; For home infusion services call Coram Healthcare at 1800-422-7312 or Caremark at 1-800-237-2767.
24
Tier
Imuran Incivek Increlex indapamide Inderal LA indomethacin indomethacin ext-rel indomethacin suppositories Infed Infergen Inlyta Innopran XL Inova Inspra Insulin Pen Needles Integra F Integra Plus Intelence Intermezzo Intron A Intuniv Invega Invega Sustenna Iopidine 0.5% Iopidine 1% ipratropium nasal spray ipratropium nebulizer solution ipratropium/albuterol nebulizer solution Iprivask irbesartan irbesartan/hydrochlorothiazide iron dextran Irospan Isentress isoniazid isosorbide dinitrate ext-rel tablets isosorbide mononitrate ext-rel isradipine itraconazole capsules Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3

SP PA Call Caremark at 1-800-237-2767 SP PA Call Caremark at 1-800-237-2767 NC propranolol ext-rel
SP PA SP PA Call Caremark at 1-800-237-2767 SP PA Call Curascript at 1-877-238-8387 NC benzoyl peroxide wash (OTC), Stridex (OTC) STPA Step Therapy Prior Authorization applies to both brand and generic drug.
NC QL 10 tablets/30 days, zolpidem SP Call Curascript at 1-877-238-8387 or Caremark at 1-800-237-2767 QL 90 tablets/90 days NC olanzapine, quetiapine, risperidone NC Risperdal Consta, risperidone
Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
QL QL QL NC NC NC
6 nasal spray units/90 days 360 vials/90 days 360 vials/90 days enoxaparin, fondaparinux sodium
QL 120 tablets/30 days; Chewable tablets: 100 mg: 180 tablets/30 days; 25 mg: 720 tablets/30 days
PA
J
Drug Name
Jakafi Jalyn Janumet Janumet XR Januvia Jentadueto jinteli
Tier
Pharmacy Program
SP PA Call Curascript at 1-877-238-8387
STPA
25
Tier
Jolessa Tier 1

jolivette junel junel fe Juvisync Juxtapid
Tier 1 Tier 1 Tier 1 Tier 2 NTM
K
Drug Name
Kadian 10 mg, 200 mg Kadian 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg Kaletra Kalydeco Kapvay kariva Kazano Keflex Keppra Keppra XR Kerafoam Keralyt Kerlone ketoconazole ketoconazole 2% ketoconazole foam 2% Ketophene ketorolac 0.4% eye drops ketorolac 0.5% eye drops ketorolac tablets Kineret Klaron Klonopin Kombiglyze XR Korlym Krystexxa Kuvan
Tier
Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 1 NTM Tier 3 Tier 3
Pharmacy Program
QL 60 capsules/30 days QL 60 capsules/30 days PA QL 60 tabs/30 days
NC levetiracetam, levetiracetam ext-rel NC urea lotion/cream Tier 3 Tier 3 Tier 1 Tier 1 Tier 2 NTM Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 NC clonazepam tablets Tier 2 Tier 2 Medical Benefit Tier 2 SP PA QL 120 tablets/30 days, Call Curascript at 1-877-238-8387 PA Covered under the medical benefit. SP PA Call Curascript at 1-877-238-8387
NC
SP PA QL 28 syringes/28 days, Call Curascript at 1-877-238-8387
L
Drug Name
labetalol Lac-Hydrin lactulose Lamictal Lamictal ODT
Tier
Tier 1 Tier 3 Tier 1 Tier 3 Tier 3
Pharmacy Program
26
Tier
Lamictal XR Tier 3

QL 25 mg: 90 tablets/90 days; 50 mg: 90 tablets/90 days; 100 mg: 90 tablets/90 days; 200 mg: 270 tablets/90 days; 250 mg: 180 tablets/90 days; 300 mg: 180 tablets/90 days QL 125 mg packets: 56 packets/28 days; 187.5 mg packets: 28 packets/28 days QL 30 tablets/30 days
Lamisil oral granules packet Lamisil tablets lamivudine lamivudine/zidovudine lamotrigine lamotrigine ext-rel
lamotrigine ext-rel
Tier 2
QL 25 mg: 90 tablets/90 days; 50 mg:90 tablets/90 days; 100 mg: 90 tablets/90 days; 200 mg: 270 tablets/90 days; 250 mg: 180 tablets/90 days; 300 mg: 180 tablets/90 days QL 25 mg: 90 tablets/90 days; 50 mg:90 tablets/90 days; 100 mg: 90 tablets/90 days; 200 mg: 270 tablets/90 days; 250 mg: 180 tablets/90 days; 300 mg: 180 tablets/90 days QL STPA 90 capsules/90 days NC QL STPA 90 solutabs/90 days, Prevacid Solutab and generic lansoprazole soluble tablets are covered for members 12 years of age and younger. Quantity Limitations apply.
Lanoxin lansoprazole delayed-rel lansoprazole soluble tablets
Lantus Lasix Lastacaft latanoprost latanoprost eye drops Latuda Lazanda leena
Tier 2 Tier 3 NC azelastine, epinastine Tier 1 Tier 1 NC QL olanzapine, quetiapine, risperidone, 30 tablets/30 days; 80 mg: 60 tablets/30 days QL 1 box (4 bottles)/28 days Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA Step Therapy Prior Authorization applies to both brand and generic drug. NC simvastatin, atorvastatin, fluvastatin NC fluvastatin, simvastatin, atorvastatin Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP PA Call Accredo at 1-866-344-4874
Tier 3 Tier 1
leflunomide Lescol Lescol XL Lessina
Tier 1
Tier 1
Letairis letrozole leucovorin calcium Leukeran Leukine leuprolide acetate 1 mg kit levalbuterol inhalation solution Levaquin Levatol
SP Call Curascript at 1-877-238-8387 SP QL Call Curascript at 1-877-238-8387, 6 vials/14 days; Covered under the Prescription Drug Benefit when self-administered. QL STPA 270 vials/90 days, Step Therapy Prior Authorization applies to both brand and generic drug. NC ciprofloxacin, levofloxacin
Tier 3
27
Tier
Levbid Levemir levetiracetam levetiracetam ext-rel levetiracetam ext-rel Levitra Tier 3 Tier 2 Tier 1 Tier 2 Tier 3
NC QL 4 tablets/30 days total for any combination of Viagra, Cialis, and Levitra; Not covered for men 18 years of age or younger, or for women. (No exceptions) NC
levobunolol eye drops levofloxacin levofloxacin eye drops levofloxacin eye drops levofloxacin tablets levora Levothroid levothyroxine Levoxyl Levsin Lexapro
STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to brand name drug only. NC Apriso, Asacol NC chlordiazepoxide/clidinium
Lexiva Lialda Librax lidocaine viscous lidocaine/prilocaine cream Lidocort Rectal kit Lidoderm Lidovir lindane Linzess liothyronine Lipitor 10 mg, 20 mg Lipitor 40 mg, 80 mg Lipofen lisinopril lisinopril/hydrochlorothiazide lithium carbonate lithium carbonate ext-rel tablets 300 mg lithium carbonate ext-rel tablets 450 mg Lithium Citrate Lithobid Livalo Lo Loestrin Fe
Tier 2
Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 1 NTM Tier 1
QL 1 tube/30 days PA QL 30 patches/30 days QL 1 kit/30 days SP
NC STPA Step Therapy Prior Authorization applies to generic drug only. Brand drug is not covered., atorvastatin NC atorvastatin NC fenofibrate Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 NC fluvastatin, simvastatin, atorvastatin Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Locoid Lodosyn
Tier 3 Tier 2
28
Tier
Loestrin Tier 3

Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC fenofibrate
Loestrin 24 Fe
Tier 3
Loestrin Fe
Tier 3
Lofibra Lomotil loperamide Lopid Lopressor Lopressor Lopressor HCT Loprox lorazepam Lorcet 10/650 Lorcet Plus Lortab 7.5/500 Lorzone losartan losartan/hydrochlorothiazide LoSeasonique
Tier 3 Tier 1 NC gemfibrozil NC Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 NC chlorzoxazone Tier 1 Tier 1 Tier 3
Lotemax Lotemax Gel Lotensin Lotensin HCT Lotrel Lotronex lovastatin Lovaza Lovenox low-ogestrel
Tier 3 NTM Tier 3 NC benazepril/hydrochlorothiazide tablets NC amlodipine/benazepril Tier 2 Tier 1 NC omega-3 fish oil (OTC) Tier 3 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA
loxapine Lumigan
Tier 1 Tier 3
29
Tier
Lumizyme Lunesta Luride drops Luride Lozi-Tabs lutera Medical Benefit Tier 3 Tier 1 Tier 3 Tier 1

SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767. QL STPA 10 tablets/30 days No copayment required for children age 6 months through age 6. No copayment required for children age 6 months through age 6. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC fluvoxamine tablets STPA QL 30 tablets/28 days
Luvox CR Luxiq Lyrica Lysteda
M
Drug Name
Macrobid Macrodantin Magnacet Makena Malarone malathion maprotiline Marnatal-F Matulane Mavik Maxair Autohaler Maxalt/Maxalt-MLT Maxaron Forte Maxitrol Maxzide Maxzide-25 meclizine meclofenamate Medrol medroxyprogesterone acetate mefenamic acid mefloquine Megace ES Megace suspension megestrol acetate meloxicam Menest Menopur
Tier
Tier 3 Tier 3 Tier 3 Medical Benefit Tier 3 Tier 1 Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 2
Pharmacy Program
Drug is available through Accredo 1-866-3444874 QL 3 inhalers/90 days QL STPA 9 tablets/30 days
NC megestrol acetate oral suspension
SP PA SP PA Call Village Pharmacy at 1-877-344 -1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500
Menostar meperidine Mephyton Mepron
Tier 3 Tier 1 Tier 2 Tier 2
30
Tier
mercaptopurine mesalamine rectal suspension Mestinon Mestinon Timespan Metadate CD metaproterenol syrup/tablets metformin metformin ext-rel methadone methamphetamine methazolamide methimazole methocarbamol methotrexate methyldopa methylergonovine tablets Methylin chewable tablets Methylin oral solution methylphenidate methylphenidate ext-rel methylphenidate ext-rel 10 mg tablets methylphenidate ext-rel 20 mg, 30 mg, 40 mg methylphenidate ext-rel capsules methylphenidate HCl ER methylphenidate oral solution methylprednisolone metoclopramide metolazone metoprolol metoprolol ext-rel metoprolol/hydrochlorothiazide Metozolv ODT MetroCream MetroGel 1% MetroGel-Vaginal MetroLotion metronidazole metronidazole 375 mg capsules metronidazole cream metronidazole gel 0.75% metronidazole lotion metronidazole tablets metronidazole vaginal gel Mevacor mexiletine Miacalcin inj Miacalcin nasal Micardis Micardis HCT microgestin Tier 1 Tier 1 Tier 3 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3
STPA Step Therapy Prior Authorization applies to brand name drug only.
NC methylphenidate STPA STPA STPA STPA STPA
NC lovastatin tablets
Tier 1
NC irbesartan, losartan, valsartan NC irbesartan/HCTZ, losartan/HCTZ, valsartan/HCTZ Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
31
Tier
microgestin fe Tier 1

midodrine Migergot suppository Migranal Millipred Minipress Minocin minocycline capsules minocycline tablets Mirapex Mirapex ER Mircette
QL 1 box (8 vials)/30 days
NC minocycline capsules
mirtazapine misoprostol Mobic modafinil Modicon
NC QL STPA 180 tablets/90 days Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
moexipril moexipril/hydrochlorothiazide mometasone Monodox mononessa montelukast Monurol morphine morphine ext-rel morphine sulfate ext-rel 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg Morphine suppositories 30 mg morphine suppositories 5 mg, 10 mg, 20 mg MoviPrep Moxatag Moxeza Mozobil MS Contin Multaq mupirocin MUSE Myambutol mycophenolate mofetil Myfortic Myleran tablets Myozyme
Tier 1 Tier 1 Tier 1 NC doxycycline monohydrate Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3 Tier 3 Medical Benefit Tier 3 Tier 1 Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Medical Benefit
QL 90 tablets/30 days QL
NC amoxicillin 500 mg, amoxicillin 875 mg QL 1 bottle/10 days PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. NC QL 90 tablets/30 days, morphine sulfate extrel
SP Call Curascript at 1-877-238-8387 SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767.
32
Tier
Myrbetriq Mysoline Tier 3 Tier 3 STPA
N
Drug Name
nabumetone nadolol Naglazyme Nalfon naltrexone Namenda naphazoline eye drops Naprelan Naprosyn naproxen naproxen delayed-rel naproxen sodium naratriptan Nasacort AQ Nascobal Nasonex Natazia
Tier
Tier 1 Tier 1 Medical Benefit Tier 3 Tier 1 Tier 2 Tier 1
Pharmacy Program
SI Covered under the medical benefit. For home infusion services call Coram Healthcare at 1-800422-7312 or Caremark at 1-800-237-2767.
NC naproxen sodium ext-rel tablets NC naproxen Tier 1 Tier 1 Tier 1 Tier 1
QL STPA 9 tablets/30 days NC QL 3 nasal spray units/90 days, flunisolide nasal spray, fluticasone nasal spray, Nasonex QL 6 nasal spray units/90 days Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL 1 bottle/fill
nateglinide Natroba Nebusal 6% necon 0.5/35 necon 1/35 necon 1/50
Necon 10/11
Tier 2
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
necon 7/7/7 Neevo DHA nefazodone neomycin/polymyxin B/bacitracin/hydrocortisone eye ointment neomycin/polymyxin B/dexamethasone eye drops, eye ointment neomycin/polymyxin B/gramicidin eye drops neomycin/polymyxin B/hydrocortisone eye drops neomycin/polymyxin B/hydrocortisone otic Neoral Neosporin Nephrocaps Nesina
Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 NTM
33
Tier
Neulasta Neumega Neupogen Tier 2 Tier 2 Tier 2

SP QL Call Curascript at 1-877-238-8387, 1 syringe/14 days; Covered under the Prescription Drug Benefit when self-administered. SP QL 10 vials (1 mL and 1.6 mL)/14 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-2388387 SP QL Call Curascript at 1-877-238-8387, 10 syringes/14 days; Covered under the Prescription Drug Benefit when self-administered. QL 30 patches/30 days NC OTC saliva substitute Tier 3 Tier 1 Tier 2
Neupogen/Single-Ject Neupro Neurontin Neutrasal Nevanac nevirapine Nexavar Nexium
Next Choice
Tier 1
Next Choice
Tier 3
SP PA QL 120 tablets/30 days, Call Curascript at 1-877-238-8387 NC QL 90 capsules/90 days; 90 oral packets/90 days, Prilosec OTC, omeprazole, lansoprazole, pantoprazole; Nexium Oral Packets are covered for members 12 years of age and younger. Quantity Limitations apply. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
next choice one dose Niaspan nicardipine Nicotrol Inhaler Nicotrol NS Spray nifedipine 10 mg Nifedipine 20 mg nifedipine ext-rel nimodipine Niron Komplete nisoldipine ext-rel Nitro-Dur nitrofurantoin ext-rel nitrofurantoin macrocrystals nitrofurantoin suspension nitroglycerin oral spray nitroglycerin transdermal Nitrolingual Nitrostat nizatidine capsules nizatidine oral solution Nizoral shampoo Norco
Tier 1 Tier 2 Tier 1 No copayment QL 90 days/year; Max 168 units/fill No copayment QL 90 days/year; Max 4 units/fill Tier 1 Tier 2 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 3 NC hydrocodone/acetaminophen
34
Tier
Nordette Tier 3

Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP PA Call Caremark at 1-800-237-2767. Applies to all Norditropin products including Norditropin Flexpro and Norditropin Nordiflex. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Norditropin Products norethindrone acetate Norinyl 1+35
Noritate Noroxin Norpace Norpace CR Norpramin Nor-QD
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 NC desipramine Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
nortrel 0.5/35 nortrel 1/35 nortrel 7/7/7
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC amlodipine
nortriptyline Norvasc Norvir Novaferrum oral solution Novarel
SP PA SP Call Village Pharmacy at 1-877-3441610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-6570500
Novolin Novolog Noxafil Nplate Nucort Nucynta Nucynta ER Nuedexta Nulytely Nulytely with Flavor Packs Numoisyn Nutropin
Tier 2 Tier 2 NC fluconazole oral suspension, itraconazole, voriconazole PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. NC QL 30 capsules/30 days, tramadol, oxycodone NC QL tramadol, Oxycontin, 60 tablets/30 days PA
Medical Benefit Tier 3
SP NC Norditropin FlexPro, Norditropin Nordiflex, Call Caremark at 1-800-237-2767
35
Tier
Nutropin AQ Nutropin AQ Nuspin Nuvaring Tier 2

SP NC Call Caremark at 1-800-237-2767, Norditropin FlexPro, Norditropin Nordiflex SP NC Norditropin FlexPro, Norditropin Nordiflex, Call Caremark at 1-800-237-2767 Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. QL STPA 90 tablets/90 days
Nuvigil nystatin nystatin/triamcinolone
O
Drug Name
OB Complete caplet OB Complete DHA Obtrex DHA ocella Ocuflox ofloxacin ofloxacin eye drops ofloxacin otic Ogestrel
Tier
Pharmacy Program
olanzapine olanzapine orally disintegrating tablets olanzapine/fluoxetine Oleptro ER Olux foam 0.05% Olux-E Omeclamox-Pak omeprazole delayed-rel omeprazole/sodium bicarbonate capsules Omnaris Omnitrope Omontys ondansetron OneTouch test strips Onfi Onglyza Onmel
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization required for members 18 years of age and older. NC clobetasol 0.05% foam, clobetasol 0.05% foam/emollient NC omeprazole + clarithromycin + amoxicillin, PrevPac QL 90 capsules/90 days NC QL STPA 90 capsules/90 days NC QL azelastine nasal spray, fluticasone nasal spray, flunisolide nasal spray, 3 nasal spray units/90 days SP NC Norditropin FlexPro, Norditropin Nordiflex, Call Caremark at 1-800-237-2767 PA Covered under the medical benefit. QL oral solution: 90 mL/7 days; tablets/ODT tablets: 4 mg: 9 tablets/7 days; 8 mg: 9 tablets/7 days; 24 mg: 1 tablet/7 days PA
Tier 1 Tier 3
Medical Benefit Tier 1 Tier 2 Tier 3 Tier 2 NTM
36
Tier
Onsolis Opana Opana ER Optase Optivar Oracea Orapred Orapred ODT Orbivan Orbivan CF Orencia Tier 2

SP QL 60 buccal films/30 days, Call Curascript at 1-877-238-8387 NC hydromorphone tablets, oxycodone tablets, oxymorphone NC morphine sulfate SR, oxymorphone ext-rel
Tier 3 Tier 3 NC doxycycline Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Orfadin orphenadrine ext-rel orphenadrine/aspirin/caffeine Ortho Evra
SP PA QL 4 syringes/28 days, Orencia vials only are covered under the medical benefit, prior authorization applies. Available through Curascript, call 1-877-238-8387., Call Curascript at 1-877-238-8387 SP PA Call Accredo at 1-866-344-4874
Ortho Micronor
Tier 3
Ortho Tri-Cyclen
Tier 3
Ortho Tri-Cyclen Lo
Tier 3
Ortho-Cept
Tier 3
Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
37
Tier
Ortho-Cyclen Tier 3

Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Ortho-Novum 1/35
Tier 3
Ortho-Novum 7/7/7
Tier 3
Oseni Otozin Ovcon 35
NTM Tier 3 Tier 3
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500
Ovide Ovidrel oxaprozin oxazepam oxcarbazepine Oxecta 5 mg, 7.5 mg Oxistat Oxsoralen-Ultra Oxtellar XR oxybutynin oxybutynin ext-rel oxycodone oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen OxyContin oxymorphone oxymorphone ext-rel 7.5 mg, 15 mg Oxytrol
NC oxycodone Tier 2 Tier 2 NTM Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 2 Tier 2
38
Tier
P
Drug Name
Pacnex Pacnex HP Pacnex LP Pacnex MX Pamelor Pancreaze Pandel Panretin pantoprazole delayed-rel Parafon Forte DSC Parcopa Parlodel Parnate paromomycin paroxetine HCl paroxetine HCl ext-rel Pataday Patanase Patanol Paxil Paxil CR PCE peg 3350/electrolytes peg 3350/electrolytes disposable jug Pegasys PegIntron penicillin VK Penlac Pennsaid Pentasa pentazocine/naloxone pentoxifylline ext-rel Pepcid Pepcid suspension Percocet Percodan Perforomist Peridex perindopril Perjeta permethrin 5% perphenazine Persantine Pertyze Pexeva phenazopyridine phendimetrazine phendimetrazine ext-rel
Tier
Tier 2
Pharmacy Program
NC NC NC NC benzoyl peroxide pad benzoyl peroxide pad benzoyl peroxide (OTC) nortriptyline
QL STPA 90 tablets/90 days
NC tranylcypromine
NC Zaditor (OTC), azelastine, epinastine NC azelastine nasal spray, Astepro Tier 3 NC paroxetine NC paroxetine, paroxetine ext-rel Tier 3 Tier 1 Tier 1 Tier 2 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 3 NC oxycodone/acetaminophen NC oxycodone/aspirin QL 180 vials/90 days
SP PA QL Call Caremark at 1-800-237-2767, 4 individual vials/28 days; 1 kit (4 vials/syringes)/28 days; 4 pens/28 days SP PA QL 4 syringes/vials/28 days, Call Caremark at 1-800-237-2767 QL 1 bottle/30 days QL 1 bottle/30 days
NC cimetidine, famotidine, or ranitidine
Tier 2 Tier 3 Tier 1 Medical Benefit Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1
STPA Step Therapy Prior Authorization required for members 18 years of age and older. PA PA
39
Tier
phenobarbital phentermine phenytoin sodium phenytoin sodium ext-rel PhosLo Phoslyra Picato pilocarpine Pilopine HS gel pindolol pioglitazone pioglitazone/metformin piroxicam Plan B One-Step Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 3 Tier 1 Tier 2 Tier 1 Tier 2 Tier 2 Tier 1 Tier 3 PA
QL Picato 0.05%: 1 carton/2-day supply; Picato 0.015%: 1 carton/3-day supply
Plaquenil Plavix Pletal Pliaglis podofilox polymyxin B/trimethoprim eye drops Polytrim Pomalyst Ponstel portia
Tier 3 Tier 3 Tier 3 NTM Tier 1 Tier 1 Tier 3 NTM Tier 3 Tier 1
potassium chloride ext-rel potassium chloride liquid potassium chloride/potassium bicarbonate/citric acid effervescent tablets 25 mE Potiga Pradaxa pramipexole Pramosone E PrandiMet Prandin Pravachol pravastatin prazosin Precose Pred Forte Pred Mild Pred-G prednisolone acetate 1% eye drops Prednisolone Phosphate 1% prednisolone sodium phosphate prednisolone sodium phosphate 5 mg/5 mL prednisolone syrup
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 PA PA
NC pravastatin tablets
40
Tier
prednisone Prednisone Intensol Prefest Pregnyl Prelone Syrup Premarin Premarin cream Premphase Prempro Prenatal Vitamins prenatal vitamins w/folic acid Prenexa Prepopik Preque 10 Prevacid Prevacid Solutab Tier 1 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 NTM Tier 3
SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500
NC QL Prilosec OTC, omeprazole, lansoprazole, pantoprazole, 90 capsules/90 days NC QL 90 solutabs/90 days, Prilosec OTC, omeprazole, lansoprazole, pantoprazole. Prevacid Solutab and generic lansoprazole soluble tablets are covered for members 12 years of age and younger. Quantity Limitations apply., Prevacid Solutab and generic lansoprazole soluble tablets are covered for members 12 years of age and younger. Quantity Limitations apply. Tier 3 Tier 1 Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Prevalite previfem
Prevpac Prezista Prilosec Prilosec Oral Suspension primidone Primsol Prinivil Prinzide Pristiq ProAir HFA probenecid Procardia Procardia XL Procentra prochlorperazine Procort Procrit Proctocream-HC 2.5% ProctoFoam-HC progesterone, micronized
Tier 2 Tier 2 NC QL Prilosec OTC, omeprazole, lansoprazole, or pantoprazole, 90 capsules/90 days NC QL 90 packets/90 days, omeprazole, lansoprazole, pantoprazole Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 1 Tier 3 Tier 3 Tier 1 Tier 2 Tier 1 Tier 3 Tier 1
STPA Step Therapy Prior Authorization required for members 18 years of age and older. QL 6 inhalers/90 days
NC nifedipine ext-rel STPA NC hydrocortisone/pramoxine cream SP QL 10 vials/14 days; Covered under the Prescription Drug Benefit when self-administered., Call Curascript at 1-877-238-8387
41
Tier
Prograf Prolia Promacta promethazine Prometrium propafenone propafenone ext-rel propantheline 15 mg propranolol propranolol ext-rel propylthiouracil Proscar Prosed/DS Protonix Protonix Oral Suspension Tier 3 Medical Benefit Tier 2 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

PA Covered under the medical benefit. SP PA QL 30 tablets/30 days, Call Curascript at 1877-238-8387
NC finasteride 5 mg. Tier 3 NC QL 90 tablets/90 days, Prilosec OTC, omeprazole, lansoprazole, pantoprazole NC QL omeprazole, lansoprazole, pantoprazole. Protonix Oral Suspension is covered for members 12 years of age and younger. Quantity Limitations apply., 90 packets/90 days STPA PA Covered under the medical benefit. QL 6 inhalers/90 days NC QL 180 tablets/90 days, modafinil, Nuvigil NC fluoxetine NC fluoxetine, fluoxetine delayed-release Tier 1 Tier 3 Tier 3 QL 6 inhalers/90 days QL STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to both brand and generic drug., 180 vials/90 days
Protopic Provenge Proventil HFA Provera Provigil Prozac Prozac Weekly Prudoxin Pulmicort Flexhaler Pulmicort Respules
Tier 3 Medical Benefit Tier 3 Tier 3
Pulmozyme Purinethol Pylera pyrazinamide Pyridium pyridostigmine
Q
Drug Name
Qnasl Qsymia Qualaquin quasense Tier 3 Tier 3 Tier 1
Tier
Pharmacy Program
NC QL 3 nasal spray units/90 days, fluticasone nasal spray, flunisolide nasal spray, Nasonex PA Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC cholestyramine STPA PA
Questran/Questran Light quetiapine 100 mg, 200 mg, 300 mg, 400 mg quetiapine 25 mg, 50 mg
Tier 2 Tier 2
42
Tier
Quillivant XR quinapril quinapril/hydrochlorothiazide quinine sulfate QVAR NTM Tier 1 Tier 1 Tier 1 Tier 2
QL 6 inhalers/90 days
R
Drug Name
Radiogardase ramipril Ranexa ranitidine Rapaflo Rapamune Ravicti Rayos Razadyne Razadyne ER Rebetol Rebif Reclast reclipsen Rectiv Ointment Refissa Regimex Reglan Regranex Relenza Relistor Relpax Remeron Remeron Soltab Remicade Remodulin Renagel Renvela Repronex Requip Requip XL Restasis Restoril Retin-A Retin-A Micro Retrovir
Tier
Pharmacy Program
NC alfuzosin ext-rel, doxazosin, tamsulosin Tier 2 NTM NC QL prednisone, 30 tablets/30 days Tier 3 Tier 3 Tier 3 Tier 2 Medical Benefit Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Medical Benefit Medical Benefit Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
SP Call Caremark at 1-800-237-2767 SP QL Call Curascript at 1-877-238-8387, 12 syringes/28 days PA Covered under the medical benefit.
QL 1 tube/30 days PA Prior Authorization required for members 26 years of age and older. PA
QL 20 units/365 days QL STPA 6 tablets/30 days
PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. PA SI Covered under the medical benefit., For home infusion services call Accredo at 1-866-3444874.
SP PA Call Village Pharmacy at 1-877-344-1610 or Freedom Drug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLC at 1-866-657-0500 QL 90 tablets/90 days PA NC temazepam PA Prior Authorization required for members 26 years of age and older. PA Prior Authorization required for members 26 years of age and older.
43
Tier
Revatio Revia Revlimid Reyataz Rheumatrex Rhinocort Aqua ribavirin Ridaura Rifadin rifampin rimantadine Risperdal Risperdal M-Tab risperidone risperidone orally disintegrating tablets Ritalin Ritalin LA Ritalin-SR Rituxan rivastigmine capsules rizatriptan Robaxin Rocaltrol ropinirole ropinirole ext-rel Rowasa Roxicodone Rozerem Rybix ODT Rythmol Rythmol SR Tier 3 Tier 3 Tier 2 Tier 2 Tier 2

SP PA QL 90 tablets/30 days, Call Accredo at 1866-344-4874 SP PA Call Curascript at 1-877-238-8387
Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Medical Benefit Tier 1 Tier 2 Tier 3 Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
NC QL 3 nasal spray units/90 days, flunisolide nasal spray, fluticasone nasal spray, Nasonex SP Call Caremark at 1-800-237-2767
STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. STPA STPA STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. STPA Step Therapy Prior Authorization applies to brand name drug only. PA Covered under the medical benefit.
QL STPA orally disintegrating tablets: 9 tablets/30 days; tablets: 9 tablets/30 days
QL NC oxycodone QL STPA 10 tablets/30 days NC tramadol
S
Drug Name
Sabril Safyral
Tier
Tier 2 Tier 3
Pharmacy Program
Covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. SP NC Call Caremark at 1-800-237-2767, Norditropin FlexPro, Norditropin Nordiflex
Saizen Salagen Salex salicylic acid Salkera Foam salsalate Salvax 6% Foam Salvax Duo Plus Combo Pack Tier 3 Tier 3 Tier 1
NC salicylic acid cream, foam, lotion Tier 1 NC salicylic acid cream, foam, lotion NC salicylic acid foam + urea lotion
44
Tier
Samsca Sanctura Sanctura XR Sancuso Sandimmune Saphris Sarafem tablets Savella Seasonique Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3

QL 1 patch/7 days NC olanzapine, quetiapine, risperidone STPA Step Therapy Prior Authorization required for members 18 years of age and older. QL STPA 180 tablets/90 days Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC acebutolol
Sectral Select-OB + DHA selegiline capsules selegiline tablets selenium sulfide shampoo 2.25% selenium sulfide shampoo 2.5% Selsun Selzentry Sensipar Serevent Diskus Seroquel 100 mg, 200 mg, 300 mg, 400 mg Seroquel 25 mg, 50 mg Seroquel XR Serostim sertraline sildenafil 20 mg Silenor Silvadene silver sulfadiazine Silvrstat Simcor Simponi simvastatin Sinemet Sinemet CR Singulair Skelaxin Skelid Sklice Skyla Solaraze Soliris Solodyn Soma 250 mg
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1 Tier 1
QL 150 mg: 60 tablets/30 days; 300 mg: 120 tablets/30 days QL 3 diskus/90 days STPA PA STPA SP PA Call Caremark at 1-800-237-2767 SP PA QL Call Accredo at 1-866-344-4874, 90 tablets/30 days NC zolpidem, zaleplon, Rozerem
SP PA QL 1 pre-filled syringe or SmartJect autoinjector (50 mg or 0.5 mL)/28 days, Call Curascript at 1-877-238-8387
NC cyclobenzaprine, dantrolene, tizanidine Tier 2 Tier 3 NTM Tier 3 Medical Benefit QL 1 bottle/fill
PA Covered under the medical benefit. NC minocycline tablets NC carisoprodol tablets
45
Tier
Soma 350 mg Somavert Sonata Soriatane Sorilux sotalol sotalol AF Spectracef spinosad Spiriva spironolactone spironolactone/hydrochlorothiazide Sporanox capsules sprintec Tier 3 Tier 3 Tier 2

PA NC QL 10 capsules/30 days, zaleplon NC calcipotriene topical solution, cream or ointment Tier 1 Tier 1 Tier 3 Tier 1 Tier 2 Tier 1 Tier 1 Tier 3 Tier 1
QL QL 3 HandiHalers/90 days
Sprix Sprycel Stalevo Starlix stavudine Stavzor Staxyn
PA Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC ketorolac SP PA QL 20 mg, 50 mg, 70 mg, 80 mg: 60 tablets/30 days; 100 mg, 140 mg: 30 tablets/30 days, Call Curascript at 1-877-238-8387
Stelara Stivarga Strattera Striant Stribild Suboxone
Medical Benefit Tier 2 Tier 2 Tier 3 Tier 2 Tier 3
QL 4 tablets/30 days total for any combination of Viagra, Cialis, Levitra, Stendra, and Staxyn; Not covered for men 18 years of age or younger, or for women. (No exceptions) PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. SP PA QL 84 tablets/28 days, Call Curascript at 1877-238-8387 QL 10 mg, 18 mg, 25 mg, 40 mg, 60 mg: 60 capsules/30 days; 80 mg & 100 mg: 30 capsules/30 days
Subsys sucralfate Sular sulfacetamide 10% eye drops sulfacetamide sodium 10% sulfacetamide/prednisolone phosphate eye drops, eye ointment sulfacetamide/sulfur sulfamethoxazole/trimethoprim sulfasalazine sulfasalazine delayed-rel sulindac Sumadan
PA QL sublingual tablets 8 mg/2 mg: 120 sublingual tablets/30 days; sublingual tablets 2 mg/0.5 mg: 90 sublingual tablets/30 days; film 12 mg/3 mg: 60 films/30 days; film 8 mg/2 mg: 90 films/30 days; film 4 mg/1 mg: 90 films/30 days; film 2 mg/0.5 mg: 90 films/30 days QL 30 bottles/30 days NC amlodipine, felodipine, nisoldipine ext-rel
NC sodium sulfacetamide/sulfur wash
46
Tier
sumatriptan Tier 1

QL STPA tablets: 9 tablets/30 days; injection: 4 injections (2 kits)/30 days or 4 injections (4 vials)/30 days; nasal spray: 5 mg: 2 boxes (12 spray unit devices)/30 days; 20 mg: 1 box (6 spray unit devices)/30 days QL STPA 4 injections/30 days NC sulfacetamide sodium 10% + sulfur 5% Med Pads NC sodium sulfacetamide/sulfur 10/5% PA
Sumavel Dosepro Sumaxin Sumaxin TS Suprax Suprenza Suprep Surmontil Sustiva Sutent Sylatron Symbicort Symbyax SymlinPen Synagis Synalar Kit Synarel Synthroid
Tier 3
Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Medical Benefit NTM Tier 2 Tier 3
SP PA Call Curascript at 1-877-238-8387 SP PA QL Call Curascript at 1-877-238-8387, 4 vials/28 days QL 6 inhalers/90 days STPA Step Therapy Prior Authorization applies to both brand and generic drug. SP PA Covered under the medical benefit., Call Curascript at 1-866-297-0933
T
Drug Name
Tabloid Taclonex Taclonex Scalp tacrolimus capsules Tambocor Tamiflu capsules Tamiflu suspension tamoxifen tamsulosin Tandem DHA Tandem OB Tapazole Tarceva Targretin Tarka Tasigna Tasmar Tazorac Tegretol Tegretol-XR Tegretol-XR 100 mg Tekamlo Tier 1 Tier 3 Tier 2 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 2 Tier 3
Tier
Tier 2
Pharmacy Program
SP Call Curascript at 1-877-238-8387 NC betamethasone dipropionate + calcipotriene ointment NC betamethasone dipropionate + calcipotriene solution
QL 10 capsules/365 days QL 180 mL/365 days
SP QL 150 mg & 100 mg: 30 tablets/30 days; 25 mg: 90 tablets/30 days, Call Curascript at 1-877238-8387 SP Call Curascript at 1-877-238-8387 SP PA Call Curascript at 1-877-238-8387 PA Prior Authorization required for members 26 years of age and older.
47
Tier
Tekturna Tekturna HCT temazepam Temodar Tier 3 Tier 3 Tier 1 Tier 2
SP QL 5 mg & 140 mg: 15 capsules/21 days; 20 mg & 100 mg: 20 capsules/21 days; 180 mg & 250 mg: 10 capsules/21 days, Call Curascript at 1-877238-8387 NC guanfacine NC atenolol/chlorthalidone NC atenolol
Temovate Tenex Tenoretic Tenormin Terazol 3 suppositories Terazol Vaginal cream terazosin terbinafine tablets terbutaline tablets terconazole cream terconazole suppositories Tersi Foam Tessalon Perles Testim testosterone cypionate testosterone enanthate tetracycline Teveten Teveten HCT Tev-Tropin Thalomid Theo-24 theophylline ext-rel tablets thioridazine thiothixene tiagabine Tiazac ticlopidine Tigan capsules Tikosyn tilia fe timolol maleate eye drops timolol maleate gel forming solution Timoptic Timoptic-XE Tindamax tinidazole Tirosint tizanidine TOBI Tobradex Tobradex ointment Tobradex ST tobramycin eye drops, eye ointment tobramycin/dexamethasone 0.3%/0.1% eye suspension Tobrex Tofranil tolterodine
Tier 3
Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1
NC selenium sulfide shampoo
Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1
NC eprosartan, irbesartan, losartan NC irbesartan/HCTZ, losartan/HCTZ, valsartan/HCTZ SP NC Norditropin FlexPro, Norditropin Nordiflex, Call Caremark at 1-800-237-2767 SP Call Curascript at 1-877-238-8387
NC diltiazem ext-rel
NC imipramine STPA
48
Tier
Topamax Topicort topiramate Toprol-XL torsemide Toviaz Tracleer Tradjenta tramadol tramadol ext-rel tramadol/acetaminophen Trandate trandolapril tranexamic acid Transderm Scop Tranxene T-Tab tranylcypromine Travatan Z trazodone Trental tretinoin tretinoin capsules tretinoin cream/gel Tretin-X Treximet triamcinolone acetonide triamcinolone nasal spray triamcinolone paste triamterene/hydrochlorothiazide capsules 37.5/25 triamterene/hydrochlorothiazide capsules 50/25 triamterene/hydrochlorothiazide tablets 37.5/25 triamterene/hydrochlorothiazide tablets 75/50 triazolam Tribenzor Tricare DHA Tricor trifluoperazine trifluridine eye drops Triglide trihexyphenidyl tri-legest fe Trileptal Trilipix trimethobenzamide capsules trimethoprim trimipramine trinessa Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3
NC oxybutynin ER, trospium, tolterodine SP PA Call Accredo at 1-866-344-4874 STPA
QL 30 tablets/28 days NC clorazepate STPA
PA SP Call Curascript at 1-877-238-8387 PA Prior Authorization required for members 26 years of age and older. PA Prior Authorization required for members 26 years of age and older. NC QL 9 tablets/30 days, sumatriptan + naproxen sodium NC QL 3 nasal spray units/90 days
NC Benicar, amlodipine, HCTZ NC fenofibrate Tier 1 Tier 1 NC fenofibrate Tier 1 Tier 1 Tier 3 NC fenofibrate Tier 1 Tier 1 Tier 1 Tier 1
49
Tier
Tri-Norinyl Tier 3

Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group., Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. NC MyOxin Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
TriOxin tri-previfem
Tier 1
tri-sprintec
Tier 1
trivora
Tier 1
Trizivir trospium trospium ext-rel Trusopt Truvada Tudorza Pressair Tussionex Twynsta Tykerb Tylenol w/Codeine Tylox Tysabri Tyvaso Tyzeka
QL 3 inhalers/90 days NC amlodipine + ARB, Azor, Exforge SP PA QL 180 tablets/30 days, Call Curascript at 1-877-238-8387 NC acetaminophen/codeine NC oxycodone/acetaminophen PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. PA SI Covered under the medical benefit., For home infusion services call Accredo at 1-866-3444874 QL 30 tablets/30 days
Medical Benefit Medical Benefit Tier 2
U
Drug Name
ubidecarenone Uceris Ulesfia Uloric Ultracet Ultram Ultram ER Ultravate Ultravate X Ultresa Umecta PD
Tier
Tier 1 NTM Tier 3 Tier 3
Pharmacy Program
PA
QL 6 bottles/7 days STPA NC tramadol/acetaminophen NC tramadol NC tramadol, tramadol ext-rel NC halobetasol + lactic acid cream
Tier 3 Tier 3 NC urea lotion or cream
50
Tier
Uniretic Unithroid Univasc Uramaxin Urecholine Uribel Uroxatral Urso Urso Forte ursodiol Tier 3 Tier 1 Tier 3
NC urea cream, gel or lotion Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
V
Drug Name
Vagifem valacyclovir Valcyte Valium valproic acid valsartan/hydrochlorothiazide Valtrex Vancocin vancomycin Vandazole Vanos Vaseretic Vasotec Vectical Veletri velivet Veltin Gel venlafaxine venlafaxine ext-rel capsules venlafaxine ext-rel tablets Venlafaxine OSM ER
Tier
Pharmacy Program
NC diazepam tablets Tier 1 Tier 2 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Medical Benefit Tier 1 NC clindamycin + tretinoin gel Tier 1 Tier 1 Tier 1 Tier 3 NC calcitriol ointment PA SI Covered under the medical benefit., For home infusion services call Accredo at 1-866-3444874
Venofer Ventavis Ventolin HFA Ventolin nebulizer solution Veramyst verapamil verapamil ext-rel Verdeso Veregen Verelan Verelan PM Veripred 20 Vesicare
Tier 2 Medical Benefit Tier 3 Tier 3
STPA STPA Step Therapy Prior Authorization required for members 18 years of age and older. Step Therapy Prior Authorization applies to brand name drug only. QL 10 vials/30 days PA SI Covered under the medical benefit., For home infusion services call Accredo at 1-866-3444874. QL 6 inhalers/90 days QL 9 dropper bottles/90 days NC QL 3 nasal spray units/90 days, flunisolide nasal spray, fluticasone propionate nasal spray, Nasonex
Tier 1 Tier 1 NC NC NC NC Tier 3 Tier 2 desonide cream/lotion imiquimod, podofilox, Condylox verapamil ext-rel verapamil ext-rel
51
Tier
Vexol Vfend oral suspension Vfend tablets Viagra Tier 2 Tier 2 Tier 3 Tier 3

QL 150 mL/14 days QL 50 mg: 56 tablets/14 days; 200 mg: 28 tablets/14 days SP PA QL Prior Authorization required for diagnosis of Pulmonary Hypertension., 4 tablets/30 days total for any combination of Viagra, Cialis, Levitra, Stendra, and Staxyn; Not covered for men 18 years of age or younger, or for women. (No exceptions), Call Accredo at 1-866-344-4874; PA and QL required for diagnosis of Pulmonary Hypertension. NC hydrocodone/acetaminophen NC hydrocodone/acetaminophen NC hydrocodone/ibuprofen tablets Tier 3 Tier 3 Tier 3 Tier 3 SP PA Call Caremark at 1-800-237-2767 QL 1 bottle/10 days NC citalopram, fluoxetine, venlafaxine NC citalopram, fluoxetine, venlafaxine NC QL naproxen + omeprazole, 60 tablets/30 days PA QL oral solution: 1200 mL/30 days; tablets: 180 tablets/90 days
Vibramycin Vicodin Vicodin ES Vicoprofen Victoza Victrelis Videx EC Vigamox Viibryd Viibryd Titration Pack Vimovo Vimpat Viokace Viracept Viramune Viramune XR Virasal Viread Viroptic Vistaril Vitafol-OB + DHA vitamin B-12 Viva DHA Vivelle-Dot Vol-Tab Rx Voltaren gel 1% Voltaren ophthalmic solution voriconazole Vospire ER Votrient Vpriv
Tier 3
NC salicylic acid (OTC) Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Medical Benefit
QL 2 tubes/each fill QL 50 mg: 56 tablets/14 days; 200 mg: 28 tablets/14 days SP PA QL 120 tablets/30 days, Call Curascript at 1-877-238-8387 PA SI For home infusion services call Coram Healthcare at 1-800-422-7312 or Caremark at 1800- 237-2767., Covered under the medical benefit. NC miconazole nitrate + zinc oxide (OTC) STPA PA STPA
Vusion Vytorin Vytorin 10/80 mg Vyvanse
W
Drug Name
warfarin
Tier
Tier 1
Pharmacy Program
52
Tier
Welchol Wellbutrin Wellbutrin SR Wellbutrin XL Westcort Tier 3

NC bupropion NC bupropion ext-rel or bupropion SR NC bupropion XL Tier 3
X
Drug Name
Xalatan Xalkori Xanax Xanax XR Xarelto 10 mg Xarelto 15 mg, 20 mg Xclair Xeljanz Xeloda Xenazine Xenical Xerese Cream 5-1% Xgeva Xiaflex Xifaxan Xodol Xolair Xolegel Xopenex HFA Xopenex inhalation solution Xtandi Xyrem
Tier
Tier 2
Pharmacy Program
NC latanoprost SP PA Call Curascript at 1-877-238-8387 NC alprazolam tablets NC alprazolam extended-release tablets QL 35 tablets/fill QL 15 mg: 60 tablets/30 days; 20 mg: 30 tablets/30 days SP Call Curascript at 1-877-238-8387 SP QL Call Curascript at 1-877-238-8387, 150 mg: 84 capsules/14 days; 500 mg: 168 capsules/14 days SP PA QL 12.5 tablets: 90 tablets/30 days; 25 mg tablets: 120 tablets/30 days, Call Caremark at 1800-237-2767 PA NC Denavir, Zovirax PA Covered under the medical benefit. PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. PA QL 200 mg tablets: 9 tablets/30 days; 550 mg tablets: 60 tablets/30 days PA Covered under the medical benefit. Available through Curascript, call 1-877-238-8387. NC ketoconazole cream QL 6 inhalers/90 days QL STPA Step Therapy Prior Authorization applies to both brand and generic drug., 270 vials/90 days SP PA QL 120 capsules/30 days, Call Curascript at 1-877-238-8387
Tier 3 Tier 3 Tier 3 NTM Tier 2 Tier 2 Tier 3 Medical Benefit Medical Benefit Tier 3 Tier 3 Medical Benefit Tier 3 Tier 3 Tier 2 Tier 3
Y
Drug Name
Yasmin
Tier
Tier 3
Pharmacy Program
Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
YAZ
Tier 3
53
Tier
Z
Drug Name
zafirlukast zaleplon Zamicet Zanaflex Zantac Zarontin Zaroxolyn Zavesca Zebeta Zegerid capsules
Tier
Pharmacy Program
QL 10 capsules/30 days
SP PA Call Curascript at 1-877-238-8387 NC QL STPA Prilosec OTC, omeprazole, lansoprazole, pantoprazole, omeprazole/sodium bicarbonate, Step Therapy Prior Authorization applies to generic drug only. Brand drug is nov covered., 90 capsules/90 days NC QL Prilosec OTC, omeprazole, lansoprazole, pantoprazole, omeprazole/sodium bicarbonate, 90 packets/90 days NC selegiline tablets SP PA Call Curascript at 1-877-238-8387
Zegerid oral packets Zelapar Zelboraf Zemplar Zenpep Zerit Zestoretic Zestril Zetia Zetonna Ziac Ziagen Ziana zidovudine Zioptan ziprasidone HCl Zipsor Zirgan Zithranol Zithranol-RR Zithromax Zmax Zocor Zofran Zolinza Zoloft zolpidem zolpidem tartrate CR Zolpimist 5 mg Spray Zolvit Zometa
NC QL fluticasone nasal spray, flunisolide nasal spray, triamcinolone nasal spray, 3 nasal sprays/90 days Tier 3 Tier 3 NC tretinoin gel + clindamycin gel Tier 1 Tier 3 Tier 2 QL STPA 90 single-use containers/90 days STPA Step Therapy Prior Authorization applies to both brand and generic drug. NC diclofenac tablets NC calcipotriene solution NC Drithocreme HP Tier 3 Tier 3 NC simvastatin tablets NC QL ondansetron, oral solution: 90 mL/7 days; tablets/ODT tablets: 4 mg: 9 tablets/7 days; 8 mg: 9 tablets/7 days SP PA Call Curascript at 1-877-238-8387 NC sertraline QL QL NC QL 1 metered spray unit/30 days, zolpidem tartrate tablets PA Covered under the medical benefit.
Tier 3
Tier 3 Medical Benefit
54
Tier
Zomig/Zomig-ZMT Zonalon Zonegran zonisamide Zorbtive Zortress zovia 1/35e Tier 3 Tier 3 Tier 3 Tier 1 Tier 2 Tier 2 Tier 1

QL STPA 2.5 mg: 6 tablets/30 days; 5 mg: 3 tablets/30 days; Nasal spray: 1 box (6 spray units)/30 days
Zovia 1/50e
Tier 1
SP PA Call Caremark at 1-800-237-2767 QL 180 tablets/90 days Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group. Generic product covered without copayment under Women's Health Preventive Services Initiative. Please contact your plan sponsor / employer about applicability and effective date for your group.
Zovirax Zovirax cream/ointment Zuplenz Zyban Zyclara Cream Zyflo Zyflo CR Zylet Zyloprim Zymaxid Zyprexa Zyprexa Zydis Zytiga Zyvox
Tier 3 Tier 2 QL 1 tube/30 days Tier 3 QL 10 films/7 days No copayment QL Annual limit of 180 tablets/90 days Tier 3 Tier 3 Tier 3 Tier 3 NC QL ciprofloxacin drops, levofloxacin drops, ofloxacin drops, 1 bottle/7 days STPA Step Therapy Prior Authorization applies to both brand and generic drug. STPA Step Therapy Prior Authorization applies to both brand and generic drug. SP PA QL 120 tablets/30 days, Call Curascript at 1-877-238-8387 QL 1 box or 1 pump bottle/30 days NC montelukast, zafirlukast
55

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Massachusetts Commercial Formulary Prescription Drug List in Alphabetical Order

Last Updated: 3/11/2013

Last Updated: 3/11/2013

Tufts Health Plan Drug List

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Tier Medical Review Process

Last Updated: 3/11/2013

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Tier Step Therapy Prior Authorization (STPA )

Last Updated: 3/11/2013

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

QL 360 vials/90 days NC quinapril/hydrochlorothiazide tablets

NC diclofenac eye drops, ketorolac eye drops

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

QL 360 vials/90 days or 9 dropper bottles/90 days

Tier 3 Tier 1 Tier 3

amiloride amiloride/hydrochlorothiazide amiodarone Amitiza amitriptyline amitriptyline/perphenazine amlodipine

Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3

PA - Prior Authorization QL - Quantity Limitation Program

NC - Non Covered Drugs NTM - New-to-Market

Tier 1 - Lowest Copayment

Tier 2 - Middle Copayment

Tier 3 - Highest Copayment

Last Updated: 3/11/2013

PA Covered under the medical benefit.