2016 Abridged Formulary Guide - Medford High School fileHave questions? We’re here to help. Please contact Security Health Plan if you have questions or need to request a prior authorization

2016

Abridged Formulary Guide

Understanding your pharmacy benefit can save you money

Get the most value out of your pharmacy benefit by reviewing the medications covered under your plan. Taking time to understand how your pharmacy benefit works can help lower your out-of-pocket medication costs. Your pharmacy benefit includes coverage for many medications. We’ve listed some of the most common medications in this abridged formulary.

Tip: Looking for a complete list of medications covered under you plan? Visit www.securityhealth.org. Click on Prescription Tools, then 2016 Group Plans, or 2016 Individual and Family Plans. You can also call our Pharmacy Services Department at 1-877-873-5611 or 715-221-9604.

How the formulary worksA team of on-staff physicians and pharmacists review information on new and existing medications and regularly update the formulary with medications that are safe and effective. Our goal is to ensure that you have access to quality, cost-effective medications.

Medications are assigned to tiers. Each tier has different cost sharing depending on your coverage as noted in the table below:

Medication Tier

Types of medications Cost Sharing

1 Most generics Lowest cost share2 Preferred brands/select generics Middle cost share3 Non-preferred brands/select generics Higher cost share

4** Specialty medications and some very high cost brand/generic medications

Highest cost share

** If your benefit includes a specialty tier, medications with this indication may assess tier 4 (specialty medication) cost share.

*Certain medications are not covered and are considered non-formulary (NF). A member may request a medical exception for a non-formulary prescription medication or medical supply. The exception request may be initiated by the member, or a provider acting on behalf of the member, in writing or by verbal request. For a copy of the formulary exception policy or to start a formulary exception request please contact the Pharmacy Services Department at the number listed below.

You have coverage for preventive medicationsIn addition to a healthy lifestyle, preventive medications are important in helping you avoid many types of illnesses and complications from illnesses. You’ll notice some preventive medications are covered at 100 percent to make it easier for you to get the medications you need for your health.

Filling prescriptions by mail can save you money(Available to members that have a benefit with a mail order option. Refer to your plan documents for details on your coverage.)

Security Health Plan offers you a way to save money by filling your prescriptions through the mail or at a select retail pharmacy. Ordering prescriptions through the mail can reduce the amount of copayments/coinsurance you pay. The same copayment/coinsurance savings are also available by using participating Security Health Plan pharmacies. Contact us at the number below for more information.

Have questions? We’re here to help.Please contact Security Health Plan if you have questions or need to request a prior authorization or a formulary exception.

Security Health Plan Attn: Pharmacy Benefit Specialist 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 54449-8000

Phone: 1-877-873-5611 or 715-221-9604 Fax: 715-221-9989

Note: Benefits vary by plan. Please refer to your plan documents for information specific to your coverage. The formulary listing is subject to change at any time. The formulary may not be all-inclusive for medication covered.

www.securityhealth.org 1

Prescription Formulary Guide 2016

italics= Generic drugs UPPERCASE= Brand name drugs

Tier Medical= medical Preventive= preventive Tier 1= Generic Tier 2= Preferred Brand Tier 3= Non-preferred Brand Tier 4= tier 4 Tier 5= tier 5

Notes AL=Age Limit LA= Limited Access PA= Prior Authorization QL= Quantity Limits SP= Specialty Pharmacy ST= Step Therapy

Drug Tier Notes

abacavir-lamivudine-zidovudine Tier 1

ACANYA Tier 3

acarbose Tier 1

ACCU-CHEK AVIVA Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK COMPACT PLUS CARE Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK COMPACT TEST Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK MULTICLIX LANCET Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK NANO Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK SAFE-T-PRO PLUS Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK SMARTVIEW TEST STRIP Tier 2 Please refer to you plan documents as this may be covered for you at 100%


Drug Tier Notes

ACCU-CHEK SOFTCLIX LANCETS Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ACCU-CHEK VOICEMATE Tier 2 PA; Please refer to you plan documents as this may be covered for you at 100%

acetaminophen-codeine oral tablet Tier 1

acetylcysteine Tier 1

acitretin Tier 1

ACTOPLUS MET XR Tier 2

ACUVAIL (PF) Tier 2

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 mL Tier 1

acyclovir oral tablet Tier 1

acyclovir topical Tier 1

adapalene topical cream Tier 1 PA; Prior authorization > 50 yrs old

adapalene topical gel 0.1 % Tier 1 PA; Prior authorization > 50 yrs old

ADCIRCA Tier 2 PA; QL; SP

ADVAIR DISKUS Tier 2 QL

ADVAIR HFA Tier 2 QL

AFINITOR DISPERZ Tier 2 PA; SP

AFINITOR ORAL TABLET 10 MG, 5 MG Tier 2 PA; SP

AFINITOR ORAL TABLET 2.5 MG, 7.5 MG Tier 2 PA; SP

alclometasone Tier 1

ALDARA Tier 3

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

Tier 1 QL

alfuzosin Tier 1

allegra allergy Tier 1

allopurinol Tier 1

ALOMIDE Tier 2

ALORA Tier 2 QL

ALPHAGAN P OPHTHALMIC DROPS 0.1 % Tier 2

alprazolam Tier 1


Drug Tier Notes

amantadine HCl oral capsule Tier 1

amantadine HCl oral solution Tier 1

amcinonide topical cream Tier 1

amiloride oral Tier 1

amiodarone oral tablet 200 mg, 400 mg Tier 1

amitriptyline Tier 1

amlodipine Tier 1

amlodipine-atorvastatin Tier 1

amlodipine-benazepril Tier 1

amoxapine Tier 1

amoxicillin oral tablet 500 mg Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet Tier 1

amoxicillin-pot clavulanate oral tablet,chewable Tier 1

ampicillin oral capsule 500 mg Tier 1

anagrelide Tier 1

anastrozole Tier 1

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR

Tier 2 PA; QL

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

Tier 2 PA; QL

ANORO ELLIPTA Tier 2 QL

ANZEMET ORAL Tier 2 QL

APOKYN Tier 2

apraclonidine Tier 1

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML

Tier 2 SP

aripiprazole Tier 1

ARMOUR THYROID Tier 2

ASACOL HD Tier 2


Drug Tier Notes

aspirin oral tablet 325 mg Preventive QL; AL; Please refer to you plan documents as this may be covered for you at 100%

aspirin oral tablet,chewable Preventive QL; AL; Please refer to you plan documents as this may be covered for you at 100%

aspirin, buffered Preventive QL; AL; Please refer to you plan documents as this may be covered for you at 100%

aspirin-dipyridamole Tier 1

atenolol Tier 1

atorvastatin Tier 1

ATRALIN Tier 3 PA; Prior authorization > 50 yrs old

atropine ophthalmic Tier 1

AVONEX (WITH ALBUMIN) Tier 2 SP

AVONEX INTRAMUSCULAR SYRINGE KIT Tier 2 SP

azathioprine Tier 1

azelastine ophthalmic Tier 1

AZILECT Tier 2

AZOPT Tier 2

bacitracin ophthalmic Tier 1

baclofen Tier 1

BACTROBAN NASAL Tier 2

BACTROBAN TOPICAL CREAM Tier 3

BANZEL Tier 2

BARACLUDE Tier 2 SP

benazepril Tier 1

benzonatate oral capsule 100 mg, 200 mg Tier 1

benzoyl peroxide topical cleanser 10 %, 5 % Tier 1

betaxolol ophthalmic Tier 1

BETOPTIC S Tier 2

BEYAZ Preventive Please refer to you plan documents as this may be covered for you at 100%

bicalutamide Tier 1


Drug Tier Notes

bisoprolol fumarate Tier 1

BLEPHAMIDE Tier 2

brimonidine Tier 1

bromfenac Tier 1

budesonide inhalation Tier 1

budesonide oral Tier 1

budesonide dr Tier 1

BUFFERED ASPIRIN Preventive QL; AL; Please refer to you plan documents as this may be covered for you at 100%

bupropion HCl oral tablet extended release 150 mg

Tier 1

buspirone Tier 1

butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg

Tier 1

butalbital-acetaminophen Tier 1

butorphanol tartrate nasal Tier 1 QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 2

BYETTA Tier 2

calcipotriene topical ointment Tier 1

calcipotriene topical solution Tier 1

calcipotriene-betamethasone Tier 1

calcitonin (salmon) Tier 1

calcitriol oral Tier 1

CAMRESE Preventive Please refer to you plan documents as this may be covered for you at 100%

CAMRESE LO Preventive Please refer to you plan documents as this may be covered for you at 100%

CANASA Tier 2

candesartan Tier 1

candesartan-hydrochlorothiazide Tier 1

capecitabine Tier 1 PA; SP


Drug Tier Notes

CAPEX Tier 2

CAPRELSA Tier 2 PA; LA

captopril Tier 1

CARAC Tier 2

CARAFATE ORAL SUSPENSION Tier 2

carbamazepine oral tablet Tier 1

carbidopa Tier 1

CARBATROL Tier 2

carbidopa Tier 1

carbidopa-levodopa Tier 1

carteolol Tier 1

carvedilol Tier 1

cefaclor oral capsule Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral tablet Tier 1

cefdinir Tier 1

cefpodoxime Tier 1

cefprozil Tier 1

cefuroxime axetil oral tablet Tier 1

celecoxib Tier 1

CELLCEPT Tier 2

cephalexin oral capsule 250 mg, 500 mg Tier 1

cephalexin oral suspension for reconstitution Tier 1

cetirizine oral solution 1 mg/mL Tier 1

cetirizine oral tablet Tier 1

cetirizine oral tablet,chewable Tier 1

cevimeline Tier 1

CHANTIX Tier 2 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations

chlordiazepoxide HCl Tier 1

chlorothiazide Tier 1


Drug Tier Notes

chlorpropamide Tier 1

chlorzoxazone Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical suspension Tier 1

CILOXAN OPHTHALMIC OINTMENT Tier 2

cimetidine HCl oral Tier 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 1

CIPRO HC Tier 2

CIPRODEX Tier 2

ciprofloxacin HCl ophthalmic Tier 1

ciprofloxacin HCl oral Tier 1

citalopram Tier 1

clarithromycin Tier 1

clindamycin HCl Tier 1

clindamycin-benzoyl peroxide gel Tier 1

clindamycin palmitate HCl Tier 1

clindamycin phosphate topical gel Tier 1

clindamycin phosphate topical lotion Tier 1

clindamycin phosphate topical solution Tier 1

clindamycin phosphate topical swab Tier 1

clobetasol topical lotion Tier 1

clobetasol topical shampoo Tier 1

clomipramine Tier 1

clonazepam oral tablet Tier 1

clonidine Tier 1

clonidine HCl oral tablet Tier 1

clopidogrel Tier 1

clorpres Tier 1

clotrimazole mucous membrane Tier 1

clotrimazole-betamethasone topical cream Tier 1


Drug Tier Notes

clozapine oral tablet 200 mg Tier 1

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

Tier 2

COARTEM Tier 2

colchicine oral tablet Tier 1

colestipol Tier 1

COLY-MYCIN S Tier 2

COMBIGAN Tier 2

COMBIPATCH Tier 2

cortisone Tier 1

CORTISPORIN-TC Tier 3

COUMADIN ORAL Tier 2

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

CRESTOR Tier 2

cromolyn inhalation Tier 1

cromolyn ophthalmic Tier 1

cyanocobalamin (vitamin B-12) injection Tier 1

cyclobenzaprine oral tablet Tier 1

CYCLOGYL OPHTHALMIC DROPS 0.5 % Tier 2

CYCLOGYL OPHTHALMIC DROPS 1 %, 2 % Tier 3

CYCLOMYDRIL Tier 2

cyclopentolate Tier 1

cyclosporine modified oral capsule 100 mg, 25 mg Tier 1

cyclosporine modified oral solution Tier 1

cyclosporine oral capsule Tier 1

cyproheptadine Tier 1

CYTRA-3 Tier 2

dapsone Tier 2

demeclocycline oral Tier 1

DENAVIR Tier 2

DEPAKOTE Tier 2

DEPAKOTE ER Tier 2


Drug Tier Notes

desonide Tier 1

desoximetasone topical cream Tier 1

desoximetasone topical gel Tier 1

desoximetasone topical ointment 0.25 % Tier 1

desvenlafaxine fumarate Tier 3

dexamethasone oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

DEXILANT Tier 3 PA; ST

dexmethylphenidate oral capsule,ER biphasic 50-50 15 mg, 30 mg, 40 mg

Tier 1

dexmethylphenidate oral tablet Tier 1

dextroamphetamine oral capsule, extended release Tier 1

dextroamphetamine oral tablet Tier 1

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1

DIASTAT Tier 2

DIASTIX Tier 2 Please refer to you plan documents as this may be covered for you at 100%

diazepam oral tablet Tier 1

diazepam rectal Tier 2

diclofenac potassium Tier 1

diclofenac sodium oral tablet extended release 24 hr

Tier 1

diclofenac sodium oral tablet,delayed release (DR/EC) 50 mg, 75 mg

Tier 1

diclofenac-misoprostol Tier 1

dicloxacillin Tier 1

didanosine Tier 1

DIFFERIN TOPICAL GEL 0.3 % Tier 3 PA; Prior authorization > 50 yrs old

DIFFERIN TOPICAL LOTION Tier 2 PA; Prior authorization > 50 yrs old

DIFICID Tier 2 PA; QL

diflorasone Tier 1

diflunisal Tier 1

digoxin oral tablet Tier 1


Drug Tier Notes

DILANTIN EXTENDED Tier 2

DILANTIN INFATABS Tier 2

diltiazem HCl oral capsule, extended release Tier 1

diltiazem HCl oral capsule,ext release degradable Tier 1

diltiazem HCl oral capsule,extended release 12 hr Tier 1

diltiazem HCl oral capsule,extended release 24hr Tier 1

diltiazem HCl oral tablet Tier 1

disopyramide phosphate oral capsule Tier 1

disulfiram Tier 1

donepezil oral tablet 10 mg, 5 mg Tier 1

donepezil oral tablet,disintegrating Tier 1

dorzolamide Tier 1

dorzolamide-timolol Tier 1

doxazosin Tier 1

doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

Tier 1

doxepin oral concentrate Tier 1

doxercalciferol oral Tier 1

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg Tier 1

doxycycline hyclate oral tablet,delayed release (DR/EC)

Tier 1

doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg

Tier 1

dronabinol Tier 1

DUREZOL Tier 2

dutasteride Tier 1

econazole topical Tier 1

EDECRIN Tier 2

ELIDEL Tier 2

ELIQUIS Tier 2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML Tier 2


Drug Tier Notes

ELLA Preventive Please refer to you plan documents as this may be covered for you at 100%

ELMIRON Tier 2

EMCYT Tier 2

EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG

Tier 2 PA; QL

EMEND ORAL CAPSULE,DOSE PACK Tier 2 PA; QL

EMTRIVA ORAL CAPSULE Tier 2

ENABLEX Tier 2 QL

enalapril maleate Tier 1

ENBREL Tier 2 PA; SP

enoxaparin subcutaneous syringe Tier 1

entacapone Tier 1

epinastine Tier 1

EPIVIR HBV ORAL SOLUTION Tier 2

EPIVIR ORAL SOLUTION Tier 2

eplerenone Tier 1

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 2 SP

eprosartan Tier 1

EPZICOM Tier 2

ERIVEDGE Tier 2 PA

erythromycin oral capsule,delayed release(DR/EC)

Tier 1

erythromycin oral tablet Tier 1

erythromycin-benzoyl peroxide Tier 1

escitalopram oxalate Tier 1

esomeprazole Tier 1 PA; ST

estradiol oral Tier 1

estradiol transdermal patch weekly Tier 1

estradiol-norethindrone acet oral tablet 0.5-0.1 mg

Tier 1


Drug Tier Notes

ESTRING Tier 2

estropipate Tier 1

ethosuximide oral capsule Tier 1

etidronate disodium Tier 1

etodolac Tier 1

etoposide oral Tier 1 SP

EVOXAC Tier 3

exemestane Tier 1

EXJADE Tier 2 PA

EXTAVIA SUBCUTANEOUS KIT Tier 2 SP

FABIOR Tier 2 PA

famciclovir Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1

felbamate oral tablet Tier 1

FELBATOL Tier 2

FEMARA Tier 3 PA; Prior authorization > 45 yrs old

FEMHRT LOW DOSE Tier 3

fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 mg

Tier 1

fenofibric acid (choline) Tier 1

fenoprofen oral tablet Tier 1

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

Tier 1 QL

ferrous sulfate oral drops Preventive AL; Please refer to you plan documents as this may be covered for you at 100%

ferrous sulfate oral liquid Preventive AL; Please refer to you plan documents as this may be covered for you at 100%

ferrous sulfate oral solution Preventive AL; Please refer to you plan documents as this may be covered for you at 100%

fexofenadine oral tablet 180 mg, 60 mg Tier 1

fexofenadine-pseudoephedrine Tier 1

FINACEA TOPICAL GEL Tier 3


Drug Tier Notes

finasteride oral tablet 5 mg Tier 1 GR

FLAGYL ER Tier 2

FLAREX Tier 2

FLOVENT DISKUS Tier 2

FLOVENT HFA Tier 2

fluconazole Tier 1

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical ointment Tier 1

fluocinolone topical solution Tier 1

fluocinonide Tier 1

fluorometholone Tier 1

fluorouracil topical cream 5 % Tier 1

fluorouracil topical solution 5 % Tier 1

fluoxetine oral capsule 10 mg, 20 mg Tier 1

fluoxetine oral capsule,delayed release(DR/EC) Tier 1

fluoxetine oral tablet 10 mg, 20 mg Tier 1

flurazepam Tier 1

flurbiprofen Tier 1

fluticasone nasal Tier 1 QL

fluticasone topical cream Tier 1

fluticasone topical ointment Tier 1

fluvastatin oral capsule Tier 1

fluvoxamine oral capsule,extended release 24hr 150 mg

Tier 1

FML FORTE Tier 2

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 5 MG, 35mg

Tier 2

folic acid oral tablet 400 mcg, 800 mcg Preventive QL; AL; Please refer to you plan documents as this may be covered for you at 100%

folic acid-vit B6-vit B12 oral tablet 2.2-25-0.5 mg Tier 1

fondaparinux Tier 1


Drug Tier Notes

FORTEO Tier 2 PA; SP

fosinopril Tier 1

furosemide oral tablet Tier 1

gabapentin oral capsule Tier 1

gabapentin oral solution 250 mg/5 mL Tier 1

gabapentin oral tablet 600 mg, 800 mg Tier 1

GABITRIL ORAL TABLET 12 MG, 16 MG Tier 2

gemfibrozil oral Tier 1

gentamicin topical Tier 1

GILENYA Tier 3 PA; QL; SP

GLATOPA Tier 1

GLEEVEC Tier 2 PA; SP

glimepiride Tier 1

glipizide Tier 1

glipizide-metformin Tier 1

GLUCAGEN HYPOKIT Tier 2 Please refer to you plan documents as this may be covered for you at 100%

GLUCAGON EMERGENCY KIT (HUMAN) Tier 2 Please refer to you plan documents as this may be covered for you at 100%

glyburide Tier 1

glyburide micronized Tier 1

glyburide-metformin Tier 1

granisetron HCl oral Tier 1

griseofulvin microsize oral suspension Tier 1

griseofulvin ultramicrosize Tier 1

haloperidol Tier 1

heparin lock flush (porcine) intravenous solution 100 unit/mL

Tier 1

HEPSERA Tier 3

HUMIRA Tier 2 PA; SP; LA

hydralazine oral Tier 1


Drug Tier Notes

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 mL

Tier 1

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

Tier 1

hydrocodone-chlorpheniramine Tier 1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 mL

Tier 1

hydrocodone-ibuprofen oral tablet 7.5-200 mg Tier 1

hydrocortisone butyrate Tier 1

hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg

Tier 1 QL

hydroquinone Tier 1

hydroxyurea Tier 1

hydroxyzine HCl oral solution 10 mg/5 mL Tier 1

hydroxyzine HCl oral tablet Tier 1

ibandronate oral Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

imipramine HCl Tier 1

IMITREX NASAL SPRAY,NON-AEROSOL 20 MG/ACTUATION, 5 MG/ACTUATION

Tier 2 QL

INCRELEX Tier 2 PA

indomethacin oral Tier 1

INLYTA Tier 2 PA; SP

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

Tier 2 PA; SP

INTUNIV ER Tier 3

iodoquinol-HC Tier 1

IOPIDINE OPHTHALMIC DROPPERETTE Tier 2

IOPIDINE OPHTHALMIC DROPS Tier 3

ipratropium bromide nasal Tier 1

irbesartan Tier 1

irbesartan-hydrochlorothiazide Tier 1

ISENTRESS ORAL TABLET Tier 2 QL

ISENTRESS ORAL TABLET,CHEWABLE Tier 2


Drug Tier Notes

ISORDIL Tier 2

isosorbide dinitrate oral Tier 1

isosorbide mononitrate Tier 1

ISTALOL Tier 2

itraconazole Tier 1 PA

JANUMET Tier 2 QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG

Tier 2 QL

JANUVIA Tier 2 QL

KALETRA Tier 2

KEPPRA ORAL Tier 2

ketoconazole oral Tier 1

ketoconazole topical cream Tier 1

ketoconazole topical shampoo Tier 1

KETO-DIASTIX Tier 2 Please refer to you plan documents as this may be covered for you at 100%

ketoprofen oral capsule Tier 1

ketorolac intramuscular solution Tier 1

ketorolac ophthalmic Tier 1

ketorolac oral Tier 1 QL

KETOSTIX Tier 2 Please refer to you plan documents as this may be covered for you at 100%

KINERET Tier 2 PA; SP; LA

KLOR-CON/25 Tier 2

labetalol oral Tier 1

lactulose oral solution 10 gram/15 mL Tier 1

LAMICTAL ODT Tier 2

LAMICTAL ORAL TABLET Tier 2

lamivudine oral tablet Tier 1

lamivudine-zidovudine Tier 1

lamotrigine oral tablet Tier 1


Drug Tier Notes

lamotrigine oral tablet extended release 24hr Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

LANOXIN ORAL TABLET 125 MCG, 250 MCG Tier 2

lansoprazole oral capsule,delayed release(DR/EC) Tier 1

LANTUS Tier 2 Please refer to you plan documents as this may be covered for you at 100%

LANTUS SOLOSTAR Tier 2 Please refer to you plan documents as this may be covered for you at 100%

latanoprost Tier 1

leflunomide Tier 1

letrozole Tier 1 PA

leucovorin calcium oral tablet 25 mg, 5 mg Tier 1

LEUKINE INJECTION RECON SOLN Tier 2 PA; SP

leuprolide subcutaneous kit Tier 1 SP

levalbuterol HCl Tier 1

LEVEMIR Tier 2

levetiracetam intravenous Tier 1

levetiracetam oral tablet extended release 24 hr Tier 1

levofloxacin ophthalmic Tier 1

levofloxacin oral Tier 1

levorphanol tartrate Tier 1 QL

levothyroxine oral Tier 1

LEXIVA Tier 2

lidocaine HCl mucous membrane Tier 1

lidocaine 5% adhesive patch Tier 1 QL

lindane Tier 1

linezolid oral tablet Tier 1 PA

LINZESS Tier 2

liothyronine oral Tier 1

lisinopril Tier 1

lomustine oral capsule 100 mg, 40 mg Tier 2

loratadine Tier 1


Drug Tier Notes

lorazepam oral tablet Tier 1

losartan Tier 1

losartan-hydrochlorothiazide Tier 1

LOTRONEX Tier 3 PA; QL

lovastatin Tier 1

LUMIGAN OPHTHALMIC DROPS 0.01 % Tier 3

LYSODREN Tier 2

malathion Tier 1

maprotiline Tier 1

MEDROL ORAL TABLET 2 MG Tier 2

medroxyprogesterone oral Tier 1

megestrol oral suspension 625 mg/5 mL Tier 1

megestrol oral tablet Tier 1

memantine oral tablet Tier 1

memantine oral tablets,dose pack Tier 1

MENOSTAR Tier 2

MEPHYTON Tier 2

meprobamate Tier 1

mercaptopurine Tier 1

mesalamine rectal Tier 1

metaproterenol oral tablet Tier 1

metaxalone oral tablet 800 mg Tier 1

metformin oral tablet Tier 1

metformin oral tablet extended release 24hr 1,000 mg

Tier 1

methadone oral tablet Tier 1 QL

methazolamide oral Tier 1

methimazole oral tablet 10 mg, 5 mg Tier 1

METHITEST Tier 2

methocarbamol oral Tier 1

methotrexate sodium Tier 1

methylphenidate oral capsule, ER biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg

Tier 1


Drug Tier Notes

methylphenidate oral capsule,ER biphasic 50-50 Tier 1

methylphenidate oral solution Tier 1

methylphenidate oral tablet Tier 1

methylphenidate oral tablet extended release 20 mg

Tier 1

methylphenidate oral tablet extended release 24hr Tier 1

methylprednisolone Tier 1

metoclopramide HCl oral tablet Tier 1

metoprolol succinate Tier 1

metoprolol tartrate oral Tier 1

metronidazole oral Tier 1

metronidazole topical cream Tier 1

metronidazole topical gel Tier 1

metronidazole topical lotion Tier 1

metronidazole vaginal Tier 1

mexiletine Tier 1

MIACALCIN INJECTION Tier 2

midazolam oral syrup 2 mg/mL Tier 1

MIGRANAL Tier 3 QL

minocycline oral capsule Tier 1

minoxidil oral Tier 1

misoprostol Tier 1

modafinil oral tablet 100 mg, 200 mg Tier 1 PA; QL

moexipril Tier 1

mometasone Tier 1

montelukast oral tablet Tier 1 QL

montelukast oral tablet,chewable Tier 1 QL

morphine concentrate oral solution Tier 1

morphine oral tablet Tier 1 QL

morphine rectal suppository 5 mg Tier 1

moxifloxacin Tier 1

MOZOBIL Tier 2 PA; SP

mupirocin Tier 1


Drug Tier Notes

mycophenolate sodium Tier 1

MYFORTIC Tier 3

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG

Tier 1

nadolol Tier 1

NAMENDA ORAL SOLUTION Tier 2

NAMENDA XR Tier 2

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (DR/EC) Tier 1

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

naratriptan Tier 1 QL

NARDIL Tier 3

NASCOBAL Tier 2

NASONEX Tier 2

NATACYN Tier 2

NATAZIA Preventive Please refer to you plan documents as this may be covered for you at 100%

nefazodone Tier 1

neomycin Tier 1

neomycin-polymyxin-HC otic Tier 1

NEORAL Tier 2

NEULASTA SUBCUTANEOUS SYRINGE Tier 2 PA; SP

NEUPOGEN Tier 2 PA; SP

NEVANAC Tier 2

NEXAVAR Tier 2 PA; SP

nexium 24hr otc Tier 1

niacin oral tablet extended release 1,000 mg, 500 mg, 750 mg

Tier 1

nicardipine oral Tier 1

NICODERM CQ Tier 3 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations


Drug Tier Notes

NICORETTE BUCCAL GUM Tier 3 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations

nicotine Tier 1 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations

nicotine (polacrilex) Tier 1 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations

NICOTROL Tier 2 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations

NICOTROL NS Tier 2 Most plans allow 100% coverage for 180 days per calendar year. Please contact Security Health Plan for your specific plan limitations

nimodipine Tier 1

nisoldipine Tier 1

NITRO-BID Tier 2

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Tier 1

nitrofurantoin monohyd/m-cryst Tier 1

nitrofurantoin oral suspension Tier 1

nitroglycerin oral Tier 1

nitroglycerin transdermal patch 24 hour Tier 1

nitroglycerin translingual spray,non-aerosol Tier 1

nizatidine Tier 1

NORDITROPIN FLEXPRO Tier 2 PA; SP

norethindrone acetate Tier 1

nortriptyline Tier 1

NOVOLIN 70/30 Tier 2 Please refer to you plan documents as this may be covered for you at 100%


Drug Tier Notes

NOVOLIN N Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOLIN R Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOLOG Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOLOG FLEXPEN Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOLOG MIX 70-30 Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOLOG MIX 70-30 FLEXPEN Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOLOG PENFILL Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOVOPEN ECHO Tier 2 Please refer to you plan documents as this may be covered for you at 100%

NOXAFIL ORAL SUSPENSION Tier 2 PA

NUEDEXTA Tier 2 PA; QL

NUVARING Preventive Please refer to you plan documents as this may be covered for you at 100%

NUVIGIL ORAL TABLET 150 MG, 250 MG, 50 MG

Tier 2 PA; QL

nystatin oral Tier 1

octreotide acetate injection solution Tier 1 PA; SP

ofloxacin ophthalmic Tier 1

ofloxacin otic Tier 1

OGESTREL (28) Preventive

olanzapine oral Tier 1

omeprazole Tier 1


Drug Tier Notes

ondansetron Tier 1

ondansetron HCl oral Tier 1

ONETOUCH SURESOFT LANCING DEV Tier 2

ONETOUCH ULTRA CONTROL Tier 2

ONETOUCH ULTRA2 Tier 2

ONETOUCH ULTRAMINI Tier 2

ONETOUCH ULTRASOFT LANCETS Tier 2

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

Tier 2 QL

oxaprozin Tier 1

oxazepam Tier 1

oxcarbazepine Tier 1

OXISTAT Tier 2

oxybutynin chloride oral Tier 1

oxycodone oral tablet 5 mg, 30 mg, 15 mg Tier 1 QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

Tier 2 QL

oxymorphone oral tablet Tier 1 QL

PANCREAZE Tier 2

pantoprazole oral Tier 1

paroxetine HCl oral tablet Tier 1

paroxetine HCl oral tablet extended release 24 hr Tier 1

PATADAY Tier 2

PATANOL Tier 2

PAXIL ORAL SUSPENSION Tier 2

PEGASYS SUBCUTANEOUS SOLUTION Tier 2 PA; SP

PEGINTRON Tier 3 PA; SP

penicillin V potassium Tier 1

PENTASA Tier 2

perindopril erbumine Tier 1

permethrin Tier 1

phenazopyridine oral tablet 100 mg, 200 mg Tier 1


Drug Tier Notes

phenelzine Tier 1

phenobarbital oral elixir Tier 1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg

Tier 1

phenytoin oral suspension Tier 1

phenytoin oral tablet,chewable Tier 1

PHOSPHOLINE IODIDE Tier 2

pilocarpine HCl ophthalmic drops 1 %, 2 %, 4 % Tier 1

pindolol Tier 1

pioglitazone Tier 1

pioglitazone-glimepiride Tier 1

pioglitazone-metformin Tier 1

piroxicam Tier 1

PLAN B ONE-STEP Tier 3

podofilox Tier 1

polyethylene glycol 3350 Tier 3

polyethylene glycol 3350 oral Tier 1

potassium bicarb-citric acid Tier 1

potassium chloride oral capsule, extended release Tier 1

potassium chloride oral liquid Tier 1

potassium chloride oral tablet extended release 10 mEq, 8 mEq

Tier 1

potassium chloride oral tablet,ER particles/crystals

Tier 1

PRADAXA Tier 2 QL

pramipexole Tier 1

pramipexole er Tier 1

PRANDIMET Tier 2

PRANDIN Tier 3

pravastatin Tier 1

prazosin oral Tier 1

PRED FORTE Tier 2

PRED MILD Tier 2


Drug Tier Notes

prednisolone oral solution 15 mg/5 mL Tier 1

prednisolone sodium phosphate oral solution 15 mg/5 mL, 5 mg base/5 mL (6.7 mg/5 mL)

Tier 1

prednisone oral tablet Tier 1

PREFEST Tier 2

PREMARIN ORAL Tier 2

PREMARIN VAGINAL Tier 2

PREMPHASE Tier 2

PREMPRO Tier 2

PREZISTA ORAL SUSPENSION Tier 2

PREZISTA ORAL TABLET 800 MG Tier 2

PRILOSEC OTC Tier 1

primidone Tier 1

PROAIR HFA Tier 2

PROAIR RESPICLICK Tier 2

prochlorperazine Tier 1

PROCRIT Tier 2 SP

progesterone micronized Tier 1

PROGLYCEM Tier 2

PROGRAF ORAL Tier 2

PROMACTA ORAL TABLET 25 MG, 50 MG Tier 2

promethazine-codeine Tier 1

PROMETRIUM Tier 3

propafenone Tier 1

propranolol oral tablet Tier 1

propylthiouracil Tier 1

PROTOPIC Tier 2

PULMOZYME Tier 2 SP

QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION

Tier 2

QUALAQUIN Tier 3 PA

quetiapine Tier 1

quinapril Tier 1


Drug Tier Notes

rabeprazole Tier 1

raloxifene Tier 1

ramipril Tier 1

ranitidine HCl oral capsule Tier 1

ranitidine HCl oral syrup Tier 1

ranitidine HCl oral tablet 300 mg Tier 1

RAPAMUNE ORAL SOLUTION Tier 2

RAPAMUNE ORAL TABLET 0.5 MG Tier 3

RAPAMUNE ORAL TABLET 1 MG, 2 MG Tier 2

RELENZA DISKHALER Tier 2

repaglinide oral tablet 1 mg, 2 mg Tier 1

RESCRIPTOR Tier 2

RESTASIS Tier 2

RETIN-A MICRO Tier 3 PA; Prior authorization required > 50 years old

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 %

Tier 3 PA; Prior authorization required > 50 years old

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG

Tier 2 PA; LA

RHEUMATREX Tier 2

ribavirin oral capsule Tier 1 SP

ribavirin oral tablet 200 mg Tier 1 SP

RIDAURA Tier 2

rifabutin Tier 1

rifampin oral Tier 1

riluzole Tier 1

rimantadine Tier 1

risedronate Tier 1 QL

risperidone oral tablet Tier 1

risperidone oral tablet,disintegrating 0.25 mg Tier 1

rivastigmine tartrate Tier 1

rivastigmine transdermal patch Tier 1

rizatriptan Tier 1 QL


Drug Tier Notes

rizatripatan disintegrating tablet Tier 1I QL

ropinirole oral tablet Tier 1

salsalate Tier 1

SANCUSO Tier 2 PA; QL

SANDIMMUNE ORAL Tier 2

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT

Tier 2 PA; SP

selenium sulfide Tier 1

SENSIPAR Tier 2

SEREVENT DISKUS Tier 2 QL

SEROQUEL Tier 3 ST

sertraline Tier 1

sildenafil 20mg tablet Tier 1 QL

silver sulfadiazine Tier 1

simvastatin Tier 1

SINGULAIR ORAL TABLET Tier 3 QL

SINGULAIR ORAL TABLET,CHEWABLE 5 MG

Tier 3 QL

sirolimus oral tablet 0.5 mg Tier 1

sodium chloride inhalation solution for nebulization 0.9 %, 7 %

Tier 1

sodium fluoride oral drops Preventive AL; Please refer to you plan documents as this may be covered for you at 100%

sodium fluoride oral tablet,chewable Preventive AL; Please refer to you plan documents as this may be covered for you at 100%

sodium polystyrene sulfonate oral powder Tier 1

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

Tier 3

sotalol oral Tier 1

SOVALDI Tier 2 PA; SP

SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

Tier 2

SPIRIVA WITH HANDIHALER Tier 2


Drug Tier Notes

spironolactone Tier 1

SPORANOX Tier 3 PA

SPRYCEL Tier 2 PA; SP

stavudine Tier 1

STRATTERA Tier 2

SUBOXONE SUBLINGUAL FILM Tier 2

sucralfate oral tablet Tier 1

sulfacetamide sodium (acne) Tier 1

sulfacetamide sodium ophthalmic drops Tier 1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)

Tier 1

sulfamethoxazole-trimethoprim oral Tier 1

SULFAMYLON TOPICAL PACKET Tier 3

sulfasalazine Tier 1

sumatriptan nasal spray Tier 2 QL

sumatriptan succinate oral Tier 1 QL

sumatriptan succinate subcutaneous cartridge Tier 1 QL

sumatriptan succinate subcutaneous pen injector Tier 1 QL

sumatriptan succinate subcutaneous solution Tier 1 QL

SURMONTIL Tier 3

SUSTIVA Tier 2

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG

Tier 2 PA; SP

SYMBICORT Tier 2 QL

SYMLINPEN 120 Tier 2

SYMLINPEN 60 Tier 2

SYNTHROID Tier 3

tacrolimus oral Tier 1

TAMIFLU ORAL CAPSULE Tier 2

tamoxifen Tier 1 May be covered under preventive benefit for women at increased risk of breast cancer

tamsulosin Tier 1

TASIGNA ORAL CAPSULE 150 MG Tier 2 PA; SP


Drug Tier Notes

TASIGNA ORAL CAPSULE 200 MG Tier 2 PA; SP

TASMAR ORAL TABLET 100 MG Tier 3

TAZORAC Tier 2 PA; Prior authorization required > 50 years old

TECFIDERA Tier 2 SP

TEGRETOL ORAL SUSPENSION Tier 2

TEGRETOL ORAL TABLET Tier 2

TEGRETOL XR Tier 2

telmisartan Tier 1

telmisartan-hydrochlorothiazide oral tablet 40-12.5 mg, 80-25 mg

Tier 1

temazepam oral capsule 15 mg, 30 mg Tier 1

TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG

Tier 3 PA; SP

terazosin Tier 1

terbinafine HCl oral Tier 1

terconazole Tier 1

TESTIM Tier 3 PA

testosterone transdermal gel in packet 1% (25mg/2.5gram), 1% (50mg/5 gram)

Tier 1 PA; QL

testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)

Tier 1 PA; QL

tetracycline Tier 1

THALOMID Tier 2 PA; SP

thiothixene Tier 1

THYROLAR-1 Tier 2

tiagabine Tier 1

TIKOSYN Tier 2 QL

timolol maleate Tier 1

tinidazole Tier 1

tizanidine Tier 1 QL

TOBI Tier 3 LA

TOBRADEX OPHTHALMIC OINTMENT Tier 2

TOBREX OPHTHALMIC OINTMENT Tier 2


Drug Tier Notes

tolazamide oral tablet 250 mg Tier 1

tolbutamide Tier 1

tolcapone Tier 1

tolterodine oral tablet Tier 1

tolterodine er oral tablet Tier 1

topiramate Tier 1

tramadol oral tablet Tier 1 QL

tramadol oral tablet extended release 24 hr Tier 1 QL

tramadol-acetaminophen Tier 1 QL

trandolapril Tier 1

tranexamic acid oral Tier 1

TRANSDERM-SCOP Tier 2

TRAVATAN Z Tier 2

travoprost (benzalkonium) Tier 1

trazodone Tier 1

tretinoin microspheres topical gel Tier 1 PA; Prior authorization required > 50 years old

tretinoin topical cream Tier 1 PA; Prior authorization required > 50 years old

tretinoin topical gel 0.01 %, 0.025 % Tier 1 PA; Prior authorization required > 50 years

triazolam Tier 1

TRIBENZOR Tier 3 QL

trimethobenzamide oral Tier 1

TRIZIVIR Tier 3

TRUVADA Tier 2

TUDORZA PRESSAIR Tier 2

TUSSIONEX PENNKINETIC ER Tier 3

TYKERB Tier 2 PA; LA

TYVASO Tier 2 LA

TYVASO REFILL KIT Tier 2 LA

TYVASO STARTER KIT Tier 2 LA

TYZEKA Tier 2


Drug Tier Notes

ULESFIA Tier 2

ULORIC Tier 2

valacyclovir Tier 1

VALCYTE Tier 2

valsartan Tier 1

VECTICAL Tier 2

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg

Tier 1

venlafaxine oral tablet Tier 1

VENTAVIS Tier 2 LA

VENTOLIN HFA Tier 2

VERAMYST Tier 3 ST

verapamil oral Tier 1

VEREGEN Tier 2

VEXOL Tier 2

VICTOZA 2-PAK Tier 2

VICTOZA 3-PAK Tier 2

VIGAMOX Tier 2

VIMPAT ORAL TABLET Tier 2 QL

VIRAMUNE Tier 3

VIRAZOLE Tier 2

VIREAD ORAL TABLET 300 MG Tier 2

VIVELLE-DOT Tier 2

VIVOTIF BERNA VACCINE Preventive Please refer to you plan documents as this may be covered for you at 100%

voriconazole oral tablet Tier 1 PA

VOTRIENT Tier 2 PA; SP

warfarin Tier 1

WELCHOL ORAL TABLET Tier 2 QL

XALKORI Tier 2 PA; LA

XARELTO ORAL TABLET Tier 2

XTANDI Tier 2 PA; SP


Drug Tier Notes

XULANE Preventive Please refer to you plan documents as this may be covered for you at 100%

YAZ (28) Tier 3

zafirlukast Tier 1

zaleplon Tier 1 QL

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG Tier 3

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG

Tier 1

ZETIA Tier 2 QL

ZIAGEN ORAL SOLUTION Tier 2

ZIAGEN ORAL TABLET Tier 3

zidovudine Tier 1

ZIOPTAN (PF) Tier 2

ziprasidone HCl Tier 1

ZIRGAN Tier 2

ZOLINZA Tier 2 PA; SP

zolpidem oral tablet 10 mg, 5 mg Tier 1 QL

zolpidem oral tablet,ext release multiphase 6.25 mg

Tier 1 QL

zonisamide Tier 1

ZORTRESS Tier 2

ZOVIRAX TOPICAL CREAM Tier 2

ZOVIRAX TOPICAL OINTMENT Tier 3

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION

Tier 2 PA


Index A abacavir-lamivudine-

zidovudine .......................... 1 ACANYA ............................... 1 acarbose .................................. 1 ACCU-CHEK AVIVA ........... 1 ACCU-CHEK COMPACT

PLUS CARE ...................... 1 ACCU-CHEK COMPACT

TEST .................................. 1 ACCU-CHEK MULTICLIX

LANCET ............................ 1 ACCU-CHEK NANO ............ 1 ACCU-CHEK SAFE-T-PRO

PLUS .................................. 1 ACCU-CHEK SMARTVIEW

TEST STRIP ...................... 1 ACCU-CHEK SOFTCLIX

LANCETS .......................... 2 ACCU-CHEK VOICEMATE 2 acetaminophen-codeine .......... 2 acetylcysteine ......................... 2 acitretin ................................... 2 ACTOPLUS MET XR ........... 2 ACUVAIL (PF) ...................... 2 acyclovir ................................. 2 adapalene ................................ 2 ADCIRCA .............................. 2 ADVAIR DISKUS ................. 2 ADVAIR HFA ....................... 2 AFINITOR ............................. 2 AFINITOR DISPERZ ............ 2 alclometasone ......................... 2 ALDARA ............................... 2 alendronate ............................. 2 alfuzosin ................................. 2 allegra allergy ......................... 2 allopurinol .............................. 2 ALOMIDE ............................. 2 ALORA .................................. 2 ALPHAGAN P ....................... 2 alprazolam .............................. 2 amantadine HCl ...................... 3 amcinonide ............................. 3 amiloride ................................ 3 amiodarone ............................. 3 amitriptyline ........................... 3

amlodipine .............................. 3 amlodipine-atorvastatin .......... 3 amlodipine-benazepril ............ 3 amoxapine .............................. 3 amoxicillin .............................. 3 amoxicillin-pot clavulanate .... 3 ampicillin ................................ 3 anagrelide ............................... 3 anastrozole .............................. 3 ANDRODERM ...................... 3 ANDROGEL .......................... 3 ANORO ELLIPTA ................ 3 ANZEMET ............................. 3 APOKYN ............................... 3 apraclonidine .......................... 3 ARANESP (IN

POLYSORBATE) .............. 3 aripiprazole ............................. 3 ARMOUR THYROID ........... 3 ASACOL HD ......................... 3 aspirin ..................................... 4 aspirin, buffered ...................... 4 aspirin-dipyridamole .............. 4 atenolol ................................... 4 atorvastatin ............................. 4 ATRALIN .............................. 4 atropine ................................... 4 AVONEX ............................... 4 AVONEX (WITH ALBUMIN)

............................................ 4 azathioprine ............................ 4 azelastine ................................ 4 AZILECT ............................... 4 AZOPT ................................... 4 B bacitracin ................................ 4 baclofen .................................. 4 BACTROBAN ....................... 4 BANZEL ................................ 4 BARACLUDE ....................... 4 benazepril ............................... 4 benzonatate ............................. 4 benzoyl peroxide .................... 4 betaxolol ................................. 4 BETOPTIC S .......................... 4 BEYAZ ................................... 4 bicalutamide ........................... 4

bisoprolol fumarate ................. 5 BLEPHAMIDE ...................... 5 brimonidine ............................. 5 bromfenac ............................... 5 budesonide .............................. 5 budesonide dr………………..5 BUFFERED ASPIRIN ........... 5 bupropion HCl ........................ 5 buspirone ................................ 5 butalbital-acetaminop-caf-cod 5 butalbital-acetaminophen ....... 5 butorphanol tartrate ................ 5 BYDUREON .......................... 5 BYETTA ................................ 5 C calcipotriene ........................... 5 calcipotriene-betamethasone .. 5 calcitonin (salmon) ................. 5 calcitriol .................................. 5 CAMRESE ............................. 5 CAMRESE LO ....................... 5 CANASA ................................ 5 candesartan ............................. 5 candesartan-hydrochlorothiazid

............................................ 5 capecitabine…………………5 CAPEX ................................... 6 CAPRELSA ............................ 6 captopril .................................. 6 CARAC .................................. 6 CARAFATE ........................... 6 carbamazepine ........................ 6 CARBATROL ........................ 6 carbidopa-levodopa ................ 6 carteolol .................................. 6 carvedilol ................................ 6 cefaclor ................................... 6 cefadroxil ................................ 6 cefdinir .................................... 6 cefpodoxime ........................... 6 cefprozil .................................. 6 cefuroxime axetil .................... 6 celecoxib ................................. 6 CELLCEPT ............................ 6 cephalexin ............................... 6 cetirizine ................................. 6 cevimeline ............................... 6


CHANTIX .............................. 6 chlordiazepoxide HCl ............. 6 chlorothiazide ......................... 6 chlorpropamide ...................... 7 chlorzoxazone ........................ 7 ciclopirox ................................ 7 CILOXAN .............................. 7 cimetidine ............................... 7 cimetidine HCl ....................... 7 CIPRO HC ............................. 7 CIPRODEX ............................ 7 ciprofloxacin HCl ................... 7 citalopram ............................... 7 clarithromycin ........................ 7 clindamycin-benzoyl peroxide7 clindamycin HCl .................... 7 clindamycin palmitate HCl .... 7 clindamycin phosphate ........... 7 clobetasol ................................ 7 clomipramine .......................... 7 clonazepam ............................. 7 clonidine ................................. 7 clonidine HCl ......................... 7 clopidogrel .............................. 7 CLORPRES ............................ 7 clotrimazole ............................ 7 clotrimazole-betamethasone ... 7 clozapine ................................ 8 COARTEM ............................ 8 colchicine ............................... 8 colestipol ................................ 8 COLY-MYCIN S ................... 8 COMBIGAN .......................... 8 COMBIPATCH ...................... 8 cortisone ................................. 8 CORTISPORIN-TC ............... 8 COUMADIN .......................... 8 CREON .................................. 8 CRESTOR .............................. 8 cromolyn ................................ 8 cyanocobalamin (vitamin B-

12) ...................................... 8 cyclobenzaprine ...................... 8 CYCLOGYL .......................... 8 CYCLOMYDRIL .................. 8 cyclopentolate ........................ 8 cyclosporine ........................... 8 cyclosporine modified ............ 8 cyproheptadine ....................... 8

CYTRA-3 ............................... 8 D dapsone ................................... 8 demeclocycline ....................... 8 DENAVIR .............................. 8 DEPAKOTE ........................... 8 DEPAKOTE ER ..................... 8 desonide .................................. 9 desoximetasone ...................... 9 desvenlafaxine fumarate ......... 9 dexamethasone ....................... 9 DEXILANT ............................ 9 dexmethylphenidate ................ 9 dextroamphetamine ................ 9 dextroamphetamine-

amphetamine ...................... 9 DIASTAT ............................... 9 DIASTIX ................................ 9 diazepam ................................. 9 diclofenac potassium .............. 9 diclofenac sodium ................... 9 diclofenac-misoprostol ........... 9 dicloxacillin ............................ 9 didanosine ............................... 9 DIFFERIN .............................. 9 DIFICID ................................. 9 diflorasone .............................. 9 diflunisal ................................. 9 digoxin .................................... 9 DILANTIN EXTENDED ..... 10 DILANTIN INFATABS ...... 10 diltiazem HCl ....................... 10 disopyramide phosphate ....... 10 disulfiram ............................. 10 donepezil .............................. 10 dorzolamide .......................... 10 dorzolamide-timolol ............. 10 doxazosin .............................. 10 doxepin ................................. 10 doxercalciferol ...................... 10 doxycycline hyclate .............. 10 doxycycline monohydrate .... 10 dronabinol ............................. 10 DUREZOL ........................... 10 dutasteride………………….10 E econazole .............................. 10 EDECRIN ............................. 10

ELIDEL ................................ 10 ELIQUIS ............................... 10 ELIXOPHYLLIN ................. 10 ELLA .................................... 11 ELMIRON ............................ 11 EMCYT ................................ 11 EMEND ................................ 11 EMTRIVA ............................ 11 ENABLEX ........................... 11 enalapril maleate ................... 11 ENBREL ............................... 11 enoxaparin ............................ 11 entacapone ............................ 11 epinastine .............................. 11 EPIVIR ................................. 11 EPIVIR HBV ........................ 11 eplerenone ............................. 11 EPOGEN .............................. 11 eprosartan ............................. 11 EPZICOM ............................. 11 ERIVEDGE .......................... 11 erythromycin ......................... 11 erythromycin-benzoyl peroxie

.......................................... 11 escitalopram oxalate ............. 11 esomeprazole………………11 estradiol ................................ 11 estradiol-norethindrone acet . 11 ESTRING ............................. 12 estropipate ............................. 12 ethosuximide ......................... 12 etidronate disodium .............. 12 etodolac ................................. 12 etoposide ............................... 12 EVOXAC ............................. 12 exemestane ........................... 12 EXJADE ............................... 12 EXTAVIA ............................ 12 F FABIOR ............................... 12 famciclovir ............................ 12 famotidine ............................. 12 felbamate .............................. 12 FELBATOL .......................... 12 FEMARA ............................. 12 FEMHRT LOW DOSE ........ 12 fenofibrate micronized .......... 12 fenofibric acid (choline) ....... 12 fenoprofen ............................. 12


fentanyl ................................. 12 ferrous sulfate ....................... 12 fexofenadine ......................... 12 fexofenadine-pseudoephedrine

.......................................... 12 FINACEA ............................ 12 finasteride ............................. 13 FLAGYL ER ........................ 13 FLAREX .............................. 13 FLOVENT DISKUS ............ 13 FLOVENT HFA ................... 13 fluconazole ........................... 13 flunisolide ............................. 13 fluocinolone .......................... 13 fluocinonide .......................... 13 fluorometholone ................... 13 fluorouracil .......................... 13 fluoxetine .............................. 13 flurazepam ............................ 13 flurbiprofen .......................... 13 fluticasone ............................ 13 fluvastatin ............................. 13 fluvoxamine .......................... 13 FML FORTE ........................ 13 FOCALIN XR ...................... 13 folic acid ............................... 13 folic acid-vit B6-vit B12 ...... 13 fondaparinux ........................ 13 FORTEO .............................. 14 fosinopril .............................. 14 furosemide ............................ 14 G gabapentin ............................ 14 gemfibrozil ........................... 14 gentamicin ............................ 14 GILENYA ............................ 14 GLATOPA ........................... 14 GLEEVEC ............................ 14 glimepiride ........................... 14 glipizide ................................ 14 glipizide-metformin .............. 14 GLUCAGEN HYPOKIT ..... 14 GLUCAGON EMERGENCY

KIT (HUMAN) ................ 14 glyburide .............................. 14 glyburide micronized ........... 14 glyburide-metformin ............ 14 granisetron HCl .................... 14 griseofulvin microsize .......... 14

griseofulvin ultramicrosize ... 14 haloperidol ............................ 14 heparin lock flush (porcine) . 14 HEPSERA ............................ 15 HUMIRA .............................. 14 hydralazine ........................... 14 hydrocodone-acetaminophen 15 hydrocodone-chlorpheniramine

.......................................... 15 hydrocodone-homatropine .... 15 hydrocodone-ibuprofen ........ 15 hydrocortisone butyrate ........ 15 hydromorphone .................... 15 hydroquinone ........................ 15 hydroxyurea .......................... 15 hydroxyzine HCl .................. 15 I ibandronate ........................... 15 ibuprofen .............................. 15 imipramine HCl .................... 15 IMITREX NASAL ............... 15 INCRELEX .......................... 15 indomethacin ........................ 15 INLYTA ............................... 15 INTRON A ........................... 15 INTUNIV ER ....................... 15 iodoquinol-HC ...................... 15 IOPIDINE ............................. 15 ipratropium bromide ............. 15 irbesartan .............................. 15 irbesartan-hydrochlorothiazide

.......................................... 15 ISENTRESS ......................... 15 ISORDIL .............................. 16 isosorbide dinitrate ............... 16 isosorbide mononitrate ......... 16 ISTALOL ............................. 16 itraconazole .......................... 16 J JANUMET ........................... 16 JANUMET XR ..................... 16 JANUVIA ............................. 16 K KALETRA ........................... 16 KEPPRA ............................... 16 ketoconazole ......................... 16 KETO-DIASTIX .................. 16 ketoprofen ............................. 16

ketorolac ............................... 16 KETOSTIX ........................... 16 KINERET ............................. 16 KLOR-CON/25 .................... 16 L labetalol ................................ 16 lactulose ................................ 16 LAMICTAL ......................... 16 LAMICTAL ODT ................ 16 lamivudine ............................ 16 lamivudine-zidovudine…….16 lamotrigine ....................... 16,17 LANOXIN ............................ 17 lansoprazole .......................... 17 LANTUS .............................. 17 LANTUS SOLOSTAR ......... 17 latanoprost ............................ 17 leflunomide ........................... 17 letrozole ................................ 17 leucovorin calcium ............... 17 LEUKINE ............................. 17 leuprolide .............................. 17 levalbuterol HCl ................... 17 LEVEMIR ............................ 17 levetiracetam ......................... 17 levofloxacin .......................... 17 levorphanol tartrate ............... 17 levothyroxine ........................ 17 LEXIVA ............................... 17 lidocaine HCl ........................ 17 lidocaine patch……………..17 lindane .................................. 17 linezolid……………………17 LINZESS .............................. 17 liothyronine ........................... 17 lisinopril ................................ 17 lomustine .............................. 17 loratadine .............................. 17 lorazepam ............................. 18 losartan ................................. 18 losartan-hydrochlorothiazide 18 LOTRONEX ......................... 18 lovastatin ............................... 18 LUMIGAN ........................... 18 LYSODREN ......................... 18 M malathion .............................. 18 maprotiline ............................ 18 MEDROL ............................. 18


medroxyprogesterone ........... 18 megestrol .............................. 18 memantine ............................ 18 MENOSTAR ........................ 18 MEPHYTON ........................ 18 meprobamate ........................ 18 mercaptopurine ..................... 18 mesalamine ........................... 18 metaproterenol ...................... 18 metaxalone ........................... 18 metformin ............................. 18 methadone ............................ 18 methazolamide ..................... 18 methimazole ......................... 18 METHITEST ........................ 18 methocarbamol ..................... 18 methotrexate sodium ............ 18 methylphenidate .............. 18,19 methylprednisolone .............. 19 metoclopramide HCl ............ 19 metoprolol succinate ............ 19 metoprolol tartrate ................ 19 metronidazole ....................... 19 mexiletine ............................. 19 MIACALCIN ....................... 19 midazolam ............................ 19 MIGRANAL ........................ 19 minocycline .......................... 19 minoxidil .............................. 19 misoprostol ........................... 19 modafinil .............................. 19 moexipril .............................. 19 mometasone .......................... 19 montelukast .......................... 19 morphine .............................. 19 morphine concentrate ........... 19 moxifloxacin ........................ 19 MOZOBIL ............................ 19 mupirocin ............................. 19 mycophenolate sodium ......... 20 MYFORTIC ......................... 20 MYORISAN ........................ 20 N nadolol .................................. 20 NAMENDA ......................... 20 NAMENDA XR ................... 20 naproxen ............................... 20 naproxen sodium .................. 20 naratriptan ............................ 20

NARDIL ............................... 20 NASCOBAL ........................ 20 NASONEX ........................... 20 NATACYN .......................... 20 NATAZIA ............................ 20 nefazodone ............................ 20 neomycin .............................. 20 neomycin-polymyxin-HC ..... 20 NEORAL .............................. 20 NEULASTA ......................... 20 NEUPOGEN ........................ 20 NEVANAC .......................... 20 NEXAVAR .......................... 20 NEXIUM 24HR ................... 20 niacin .................................... 20 nicardipine ............................ 20 NICODERM CQ .................. 20 NICORETTE ........................ 21 nicotine ................................. 21 nicotine (polacrilex) ............. 21 NICOTROL .......................... 21 NICOTROL NS .................... 21 nimodipine ............................ 21 nisoldipine ............................ 21 NITRO-BID ......................... 21 nitrofurantoin macrocrystal .. 21 nitrofurantoin monohyd/m-

cryst .................................. 21 nitrofurantoin susp…………21 nitroglycerin ......................... 21 nizatidine .............................. 21 NORDITROPIN FLEXPRO 21 norethindrone acetate ........... 21 nortriptyline .......................... 21 NOVOLIN 70/30 .................. 21 NOVOLIN N ........................ 22 NOVOLIN R ........................ 22 NOVOLOG .......................... 22 NOVOLOG FLEXPEN ........ 22 NOVOLOG MIX 70-30 ....... 22 NOVOLOG MIX 70-30

FLEXPEN ........................ 22 NOVOLOG PENFILL ......... 22 NOVOPEN ECHO ............... 22 NOXAFIL ............................ 22 NUEDEXTA ........................ 22 NUVARING ......................... 22 NUVIGIL ............................. 22 nystatin ................................. 22

O octreotide acetate .................. 22 ofloxacin ............................... 22 OGESTREL (28) .................. 22 olanzapine ............................. 22 omeprazole ........................... 22 ondansetron ........................... 23 ondansetron HCl ................... 23 ONETOUCH SURESOFT

LANCING DEV ............... 23 ONETOUCH ULTRA

CONTROL ....................... 23 ONETOUCH ULTRA2 ........ 23 ONETOUCH ULTRAMINI . 23 ONETOUCH ULTRASOFT

LANCETS ........................ 23 OPANA ER .......................... 23 oxaprozin .............................. 23 oxazepam .............................. 23 oxcarbazepine ....................... 23 OXISTAT ............................. 23 oxybutynin chloride .............. 23 oxycodone ............................. 23 OXYCONTIN ...................... 23 oxymorphone ........................ 23 P PANCREAZE ....................... 23 pantoprazole ......................... 23 paroxetine HCl ...................... 23 PATADAY ........................... 23 PATANOL ........................... 23 PAXIL .................................. 23 PEGASYS ............................ 23 PEGINTRON ....................... 23 penicillin V potassium .......... 23 PENTASA ............................ 23 perindopril erbumine ............ 23 permethrin ............................. 23 phenazopyridine ................... 23 phenelzine ............................. 24 phenobarbital ........................ 24 phenytoin .............................. 24 PHOSPHOLINE IODIDE .... 24 pilocarpine HCl .................... 24 pindolol ................................. 24 pioglitazone .......................... 24 pioglitazone-glimepiride…...24 pioglitazone-metformin ........ 24 piroxicam .............................. 24


PLAN B ONE-STEP ............ 24 podofilox .............................. 24 polyethylene glycol 3350 ..... 24 potassium bicarb-citric acid . 24 potassium chloride ............... 24 PRADAXA .......................... 24 pramipexole………………..24 PRANDIMET ...................... 24 PRANDIN ............................ 24 pravastatin ............................ 24 prazosin ................................ 24 PRED FORTE ...................... 24 PRED MILD ........................ 24 prednisolone ......................... 25 prednisolone sodium phosphate

.......................................... 25 prednisone ............................ 25 PREFEST ............................. 25 PREMARIN ......................... 25 PREMPHASE ...................... 25 PREMPRO ........................... 25 PREZISTA ........................... 25 PRILOSEC OTC .................. 25 primidone ............................. 25 PROAIR HFA ...................... 25 PROAIR RESPICLICK ....... 25 prochlorperazine ................... 25 PROCRIT ............................. 25 progesterone micronized ...... 25 PROGLYCEM ..................... 25 PROGRAF ........................... 25 PROMACTA ........................ 25 promethazine-codeine .......... 25 PROMETRIUM ................... 25 propafenone .......................... 25 propranolol ........................... 25 propylthiouracil .................... 25 PROTOPIC .......................... 25 PULMOZYME .................... 25 Q QNASL ................................ 25 QUALAQUIN ...................... 25 quetiapine ............................. 25 quinapril ............................... 25 R rabeprazole ........................... 26 raloxifene .............................. 26 ramipril ................................. 26 ranitidine HCl ....................... 26

RAPAMUNE ....................... 26 RELENZA DISKHALER .... 26 repaglinide ............................ 26 RESCRIPTOR ...................... 26 RESTASIS ........................... 26 RETIN-A MICRO ................ 26 RETIN-A MICRO PUMP .... 26 REVLIMID .......................... 26 RHEUMATREX .................. 26 ribavirin ................................ 26 RIDAURA ............................ 26 rifabutin ................................ 26 rifampin ................................ 26 riluzole .................................. 26 rimantadine ........................... 26 risedronate ............................ 26 risperidone ............................ 26 rivastigmine tartrate .............. 26 rivastigmine patch………….26 rizatriptan……………….26,27 ropinirole .............................. 27 S salsalate ................................ 27 SANCUSO ........................... 27 SANDIMMUNE .................. 27 SANDOSTATIN LAR

DEPOT ............................. 27 selenium sulfide .................... 27 SENSIPAR ........................... 27 SEREVENT DISKUS .......... 27 SEROQUEL ......................... 27 sertraline ............................... 27 silver sulfadiazine ................. 27 sildenafil…………………...27 simvastatin ............................ 27 SINGULAIR ........................ 27 sirolimus ............................... 27 sodium chloride .................... 27 sodium fluoride .................... 27 sodium polystyrene sulfonate

.......................................... 27 SORIATANE ....................... 27 sotalol ................................... 27 SOVALDI ............................ 27 spinosad ................................ 27 SPIRIVA RESPIMAT .......... 27 SPIRIVA WITH

HANDIHALER ................ 27 spironolactone ...................... 28

SPORANOX ........................ 28 SPRYCEL ............................ 28 stavudine ............................... 28 STRATTERA ....................... 28 SUBOXONE ........................ 28 sucralfate ............................... 28 sulfacetamide sodium ........... 28 sulfacetamide sodium (acne) 28 sulfacetamide sodium-sulfur 28 sulfamethoxazole-trimethoprim

.......................................... 28 SULFAMYLON ................... 28 sulfasalazine ......................... 28 sumatriptan ........................... 28 sumatriptan succinate ........... 28 SURMONTIL ....................... 28 SUSTIVA ............................. 28 SUTENT ..... 279SYMBICORT

.......................................... 28 SYMLINPEN 120 ................ 28 SYMLINPEN 60 .................. 28 SYNTHROID ....................... 28 T tacrolimus ............................. 28 TAMIFLU ............................ 28 tamoxifen .............................. 28 tamsulosin ............................. 28 TASIGNA ........................ 28,29 TASMAR ............................. 29 TAZORAC ........................... 29 TECFIDERA ........................ 29 TEGRETOL ......................... 29 TEGRETOL XR ................... 29 telmisartan ............................ 29 telmisartan-hydrochlorothiazid

.......................................... 29 temazepam ............................ 29 TEMODAR .......................... 29 terazosin ................................ 29 terbinafine HCl ..................... 29 terconazole ............................ 29 TESTIM ................................ 29 testosterone ........................... 29 tetracycline ........................... 29 THALOMID ......................... 29 thiothixene ............................ 29 THYROLAR-1 ..................... 29 tiagabine ............................... 29 TIKOSYN ............................. 29


timolol maleate ..................... 29 tinidazole .............................. 29 tizanidine .............................. 29 TOBI .................................... 29 TOBRADEX ........................ 29 TOBREX .............................. 29 tolazamide ............................ 30 tolbutamide ........................... 30 tolcapone .............................. 30 tolterodine ............................ 30 tolterodine er……………….30 topiramate ............................. 30 tramadol ................................ 30 tramadol-acetaminophen ...... 30 trandolapril ........................... 30 tranexamic acid .................... 30 TRANSDERM-SCOP .......... 30 TRAVATAN Z .................... 30 travoprost (benzalkonium) ... 30 trazodone .............................. 30 tretinoin ................................ 30 tretinoin microspheres .......... 30 triazolam ............................... 30 TRIBENZOR ....................... 30 trimethobenzamide ............... 30 TRIZIVIR ............................. 30 TRUVADA .......................... 30 TUDORZA PRESSAIR ....... 30 TUSSIONEX PENNKINETIC

ER ..................................... 30

TYKERB .............................. 30 TYVASO .............................. 30 TYVASO REFILL KIT ....... 30 TYVASO STARTER KIT ... 30 TYZEKA .............................. 30 U ULESFIA ............................. 31 ULORIC ............................... 31 V valacyclovir .......................... 31 VALCYTE ........................... 31 valsartan ................................ 31 VECTICAL .......................... 31 venlafaxine ........................... 31 VENTAVIS .......................... 31 VENTOLIN HFA ................. 31 VERAMYST ........................ 31 verapamil .............................. 31 VEREGEN ........................... 31 VEXOL ................................ 31 VICTOZA 2-PAK ................ 31 VICTOZA 3-PAK ................ 31 VIGAMOX ........................... 31 VIMPAT ............................... 31 VIRAMUNE ........................ 31 VIRAZOLE .......................... 31 VIREAD ............................... 31 VIVELLE-DOT .................... 31 VIVOTIF BERNA VACCINE

.......................................... 31

voriconazole ......................... 31 VOTRIENT .......................... 31 W warfarin ................................. 31 WELCHOL ........................... 31 X XALKORI ............................ 31 XARELTO ........................... 31 XTANDI ............................... 31 XULANE .............................. 32 Y YAZ (28) .............................. 32 Z zafirlukast ............................. 32 zaleplon ................................. 32 ZEMPLAR ........................... 32 ZENATANE ......................... 32 ZETIA ................................... 32 ZIAGEN ............................... 32 zidovudine ............................ 32 ZIOPTAN (PF) ..................... 32 ziprasidone HCl .................... 32 ZIRGAN ............................... 32 ZOLINZA ............................. 32 zolpidem ............................... 32 zonisamide ............................ 32 ZORTRESS .......................... 32 ZOVIRAX ............................ 32

1515 North Saint Joseph Avenue PO Box 8000 Marshfield, Wisconsin 54449-8000

1-800-472-2363 715-221-9555 Fax 715-221-9500

www.securityhealth.org

HP-00115-01 (01/16) © 2004-2016 Security Health Plan of Wisconsin, Inc. HP-785-0186-M-01-16

Documents

2016 Abridged Formulary Guide - Medford High School fileHave questions? We’re here to help. Please contact Security Health Plan if you have questions or need to request a prior authorization