(List of Covered Drugs) - cigna.com · 2014 Comprehensive Formulary – Cigna Medicare Rx Secure‑Max. What is the Cigna Medicare Rx Comprehensive Formulary? A formulary is a list

Cigna Medicare Rx Secure-Max (PDP)

2014 ComprehensiveFormulary(List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When the drug list (formulary) refers to we,us, or our it means Cigna Health and Life Insurance Company. When it refers to plan or our plan it means Cigna Medicare Rx.

This document includes a list of drugs (formulary) for our plan which is current as of 08/2013. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

This formulary was updated on 08/2013. For more recent information or other questions, please contact Cigna Medicare Rx Secure at 18002226700 or, for TTY users, 711, 8 am8 pm, local time, 7 days a week, or visit www.cignamedicarerx.com.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2015.

Cigna Medicare Rx is a PDP plan with a Medicare contract. Enrollment in Cigna Medicare Rx depends on contract renewal.

This information is available for free in other languages. Please call our Customer Service number listed on the front and back cover pages. Customer Service also has free language interpreter services available for nonEnglish speakers.

Esta informacin est disponible sin cargo en otros idiomas. Para obtener informacin adicional, comunquese con el Servicio de atencin al cliente al nmero antes mencionado. Los miembros tambin cuentan con servicios de interpretacin gratuitos para aquellas personas que no hablan ingls.

This information is available for free in a different format, Braille or Large Print.

Last Updated 08/2013

S5617_14_9554 Accepted 823100 g 09/13 HPMS Approved Formulary File Submission ID Version Number 14315.v06

http:www.cignamedicarerx.com

2014 Comprehensive Formulary Cigna Medicare Rx SecureMax

What is the Cigna Medicare Rx Comprehensive Formulary?

A formulary is a list of covered drugs selected by

Cigna Medicare Rx in consultation with a team

of health care providers, which represents the

prescription therapies believed to be a necessary

part of a quality treatment program. Cigna

Medicare Rx will generally cover the drugs listed

in our formulary as long as the drug is medically

necessary, the prescription is filled at a Cigna

Medicare Rx network pharmacy, and other plan

rules are followed. For more information on how

to fill your prescriptions, please review your

Evidence of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2014

formulary that was covered at the beginning

of the year, we will not discontinue or reduce

coverage of the drug during the 2014 coverage

year except when a new, less expensive generic

drug becomes available or when new adverse

information about the safety or effectiveness

of a drug is released. Other types of formulary

changes, such as removing a drug from our

formulary, will not affect members who are

currently taking the drug. It will remain available

at the same costsharing for those members

taking it for the remainder of the coverage year.

We feel it is important that you have continued

access for the remainder of the coverage year to

the formulary drugs that were available when

you chose our plan, except for cases in which

you can save additional money or we can ensure

your safety.

If we remove drugs from our formulary, or

add prior authorization, quantity limits and/

or step therapy restrictions on a drug or move

a drug to a higher costsharing tier, we must

notify affected members of the change at least

60 days before the change becomes effective, or

at the time the member requests a refill of the

drug, at which time the member will receive a

60day supply of the drug. If the Food and Drug

Administration deems a drug on our formulary

to be unsafe or the drugs manufacturer removes

the drug from the market, we will immediately

remove the drug from our formulary and provide

notice to members who take the drug. The

enclosed formulary is current as of 08/2013.

To get updated information about the drugs

covered by Cigna Medicare Rx, please contact

us. Our contact information appears on the front

and back cover pages.

Our plans printed formulary document will be

updated for any midyear, non maintenance

changes via errata sheets in the event that

1


we 1) remove a drug from our formulary,

2) increase the cost share of a formulary drug,

or 3) add utilization management edits to a

formulary drug and no new alternate drug is

offered by our plan as a possible replacement

for any of the previously described formulary

changes. All affected members currently taking

a formulary drug which will have one or more of

the previously described formulary changes will

be exempt from the formulary change(s) for the

remainder of the coverage year.

How do I use the Formulary?

There are two ways to find your drug within

the formulary:

Medical Condition

The formulary begins on page 13. The drugs

in this formulary are grouped into categories

depending on the type of medical conditions

that they are used to treat. For example, drugs

used to treat a heart condition are listed under

the category, Cardiovascular Agents Blood

Pressure/Cholesterol/Heart Medications. If

you know what your drug is used for, look for

the category name in the list that begins on

page 13. Then look under the category name

for your drug.

Alphabetical Listing

If you are not sure what category to look under,

you should look for your drug in the Index

that begins on page 82. The Index provides an

alphabetical list of all of the drugs included in

this document. Both brand name drugs and

generic drugs are listed in the Index. Look in the

Index and find your drug. Next to your drug, you

will see the page number where you can find

coverage information. Turn to the page listed in

the Index and find the name of your drug in the

first column of the list.

What are generic drugs?

Cigna Medicare Rx covers both brand name

drugs and generic drugs. A generic drug is

approved by the FDA as having the same active

ingredient as the brand name drug. Generally,

generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional

requirements or limits on coverage. These

requirements and limits may include:

Prior Authorization: Cigna Medicare Rx

requires you or your physician to get prior

authorization for certain drugs. This means

that you will need to get approval from Cigna

Medicare Rx before you fill your prescriptions.

If you dont get approval, Cigna Medicare Rx

may not cover the drug.

Quantity Limits: For certain drugs, Cigna

Medicare Rx limits the amount of the

drug that Cigna Medicare Rx will cover.

2


For example, Cigna Medicare Rx provides

coverage for up to 1 tablet per day per

prescription for Crestor 10mg tablets. This may

be in addition to a standard onemonth or

threemonth supply.

Step Therapy: In some cases, Cigna Medicare

Rx requires you to first try certain drugs to

treat your medical condition before we will

cover another drug for that condition. For

example, if Drug A and Drug B both treat

your medical condition, Cigna Medicare Rx

may not cover Drug B unless you try Drug A

first. If Drug A does not work for you, Cigna

Medicare Rx will then cover Drug B.

You can find out if your drug has any additional

requirements or limits by looking in the

formulary that begins on page 13. You can also

get more information about the restrictions

applied to specific covered drugs by visiting our

Web site. Our contact information, along with

the date we last updated the formulary, appears

on the front and back cover pages.

You can ask Cigna Medicare Rx to make an

exception to these restrictions or limits or for a

list of other, similar drugs that may treat your

health condition. See the section, How do I

request an exception to the Cigna Medicare Rx

formulary? on page 3 for information about how

to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary

(list of covered drugs), you should first contact

Customer Service and ask if your drug is covered.

If you learn that Cigna Medicare Rx does not

cover your drug, you have two options:

You can ask Customer Service for a list of

similar drugs that are covered by Cigna

Medicare Rx. When you receive the list,

show it to your doctor and ask him or her

to prescribe a similar drug that is covered by

Cigna Medicare Rx.


exception and cover your drug. See below

for information about how to request

an exception.

How do I request an exception to the Cigna Medicare Rx Formulary?


exception to our coverage rules. There are

several types of exceptions that you can ask us

to make.

You can ask us to cover a drug even if it is not

on our formulary. If approved, this drug will

be covered at a predetermined costsharing

level, and you would not be able to ask us to

provide the drug at a lower costsharing level.

3


You can ask us to cover a formulary drug at a

lower costsharing level if this drug is not on

the specialty tier. If approved this would lower

the amount you pay for your drug.

You can ask us to waive coverage restrictions

or limits on your drug. For example, for certain

drugs, Cigna Medicare Rx limits the amount

of the drug that we will cover. If your drug has

a quantity limit, you can ask us to waive the

limit and cover a greater amount.

Generally, Cigna Medicare Rx will only approve

your request for an exception if the alternative

drugs included on the plans formulary, the

lower costsharing drug or additional utilization

restrictions would not be as effective in treating

your condition and/or would cause you to have

adverse medical effects.

You should contact us to ask us for an initial

coverage decision for a formulary, tiering or

utilization restriction exception. When you

request a formulary, tiering or utilization

restriction exception you should submit a

statement from your prescriber or physician

supporting your request. Generally, we must

make our decision within 72 hours of getting

your prescribers supporting statement. You can

request an expedited (fast) exception if you or

your doctor believe that your health could be

seriously harmed by waiting up to 72 hours for a

decision. If your request to expedite is granted,

we must give you a decision no later than

24 hours after we get a supporting statement

from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan,

you may be taking drugs that are not on our

formulary. Or, you may be taking a drug that

is on our formulary but your ability to get it

is limited. For example, you may need a prior

authorization from us before you can fill your

prescription. You should talk to your doctor to

decide if you should switch to an appropriate

drug that we cover or request a formulary

exception so that we will cover the drug you

take. While you talk to your doctor to determine

the right course of action for you, we may cover

your drug in certain cases during the first 90 days

you are a member of our plan.

For each of your drugs that is not on our

formulary or if your ability to get your drugs is

limited, we will cover a temporary 31day supply

(unless you have a prescription written for fewer

days) when you go to a network pharmacy. After

your first 31day supply, we will not pay for these

4


drugs, even if you have been a member of the

plan less than 90 days.

If you are a resident of a longterm care facility,

we will allow you to refill your prescription

until we have provided you with 91 and up

to a 98day transition supply, consistent with

dispensing increment, (unless you have a

prescription written for fewer days). We will

cover more than one refill of these drugs for

the first 90 days you are a member of our

plan. If you need a drug that is not on our

formulary or if your ability to get your drugs

is limited, but you are past the first 90 days of

membership in our plan, we will cover a 31day

emergency supply of that drug (unless you have

a prescription for fewer days) while you pursue

a formulary exception.

Our Transition policy provides additional

coverage in circumstances involving levelofcare

changes. We will override any Refilltoosoon,

NonFormulary, PriorAuthorization, StepTherapy

and Quantity Limit restrictions for Part D eligible

medications in which the customer is changing

from one treatment setting to another. This

transition policy allows coverage for onetime

31day supply of medication, or less if the

prescription is writen for fewer days.

For more information

For more detailed information about your Cigna

Medicare Rx prescription drug coverage, please

review your Evidence of Coverage and other

plan ma terials.

If you have questions about Cigna Medicare Rx,

please contact us. Our contact information, along

with the date we last updated the formulary,

appears on the front and back cover pages.

If you have general questions about Medicare

prescription drug coverage, please call Medicare

at 1800MEDICARE (18006334227) 24 hours

a day/7 da ys a week. TTY users should call

18774862048. Or, visit www.medicare.gov.

Cigna Medicare Rx (PDP) Formulary

The comprehensive formulary that begins on

page 13 provides coverage information about

some of the drugs covered by Cigna Medicare Rx.

If you have trouble finding your drug in the list,

turn to the Index that begins on page 82.

The first column of the chart lists the drug name.

Brand name drugs are capitalized (e.g., NEXIUM)

and generic drugs are listed in lowercase italics

(e.g., omeprazole).

The information in the Requirements/Limits

column tells you if Cigna Medicare Rx has any

special requirements for coverage of your drug.

5

http:www.medicare.gov

6


Initial Coverage Level Copays/Coinsurance

State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order

30-Day Non-Preferred

Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

AK 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

AL, TN 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

AR 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

AZ 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

CA 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

7



State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order


Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

CO 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00 CT, MA, RI, VT

3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

DE, DC, MD 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

FL 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

GA 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

8



State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order


Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

HI 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

IA, MN, 2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

MT, ND, 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00 NE, SD, WY 4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

ID, UT 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

IL 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

IN, KY 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

9



State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order


Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

KS 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

LA 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

MI 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

MO 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

MS 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

10



State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order


Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

NC 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

NH, ME 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

NJ 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

NM 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

NV 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

11



State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order


Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

NY 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

OH 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

OK 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

OR, WA 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

PA, WV 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

12



State(s) Tiers

30-Day Preferred

Retail

30-Day Preferred

Mail Order

90-Day Preferred

Retail

90-Day Preferred

Mail Order


Retail


Mail Order


Retail


Mail Order

10-Day Out-of-

Network 31-Day

LTC

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

SC 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

TX 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

VA 3 $25.00 $62.50 $52.50 $45.00 $135.00 $45.00 $45.00

4 $74.00 $185.00 $175.00 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00

2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00

WI 3 $22.00 $55.00 $45.00 $45.00 $135.00 $45.00 $45.00

4 $71.00 $177.50 $167.50 $95.00 $285.00 $95.00 $95.00

5 33% 33% 33% 33% 33% 33% 33%

13


Covered Drugs By Category

Cost-Sharing Tier Description Tier 1: Preferred Generic Drugs. This grouping of prescription drugs represents the lowest cost sharing.

Tier 2: NonPreferred Generic Drugs.

Tier 3: Preferred Brand Drugs.

Tier 4: NonPreferred Brand Drugs.

Tier 5: Specialty Tier. This grouping of prescription drugs represents the highest cost sharing.

Symbol Key Utilization Management Requirements/Limits B vs D: Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are

only covered under Part D when the member is located in a long term care (LTC) setting.

PA: Prior authorization is required.

QL: Quantity limits apply.

RA : Restricted Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 18002226700, 8 am8 pm, local time, 7 days a week. TTY users should call 711.

ST: Step therapy is required.

Generally all medications on the formulary are available through mail order except when special circumstances or situations prohibit mailing a particular medication to your home.

Drug Name Drug Tier Requirements/Limits

Analgesics

acetaminophen/codeine solution 2 QL (5000 ML per 30 days) GC

acetaminophen/codeine tablet 300mg/15mg, 300mg/30mg 2 QL (360 EA per 30 days) GC

acetaminophen/codeine tablet 300mg/60mg 2 QL (240 EA per 30 days) GC

ascomp/codeine 2 QL (180 EA per 30 days) PA GC

butalbital/acetaminophen/caffeine/codeine 2 QL (180 EA per 30 days) PA GC

butorphanol tartrate injection 2 GC

butorphanol tartrate nasal solution 2 QL (5 ML per 30 days) GC

BUTRANS 3 QL (4 EA per 28 days)

co-gesic 2 QL (240 EA per 30 days) GC

codeine sulfate tablet 15mg 2 QL (720 EA per 30 days) GC



DEMEROL INJECTION 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML 4 PA

14




DURAMORPH 4

endocet tablet 325mg/5mg, 325mg/7.5mg, 325mg/10mg 2 QL (360 EA per 30 days) GC

endocet tablet 500mg/7.5mg 2 QL (240 EA per 30 days) GC

endocet tablet 650mg/10mg 2 QL (180 EA per 30 days) GC

fentanyl patch 2 QL (20 EA per 30 days) GC

fentanyl citrate injection 2 BvsD GC

fentanyl citrate oral transmucosal lollipop 200mcg 2 QL (120 EA per 30 days) PA GC

fentanyl citrate oral transmucosal lollipop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg

5 QL (120 EA per 30 days) PA

hydrocodone bitartrate/acetaminophen solution 7.5mg & 325mg/15ml

2 QL (5400 ML per 30 days) GC

hydrocodone bitartrate/acetaminophen tablet 10mg/750mg 2 QL (150 EA per 30 days) GC

hydrocodone/acetaminophen solution 7.5mg & 500mg/15ml 2 QL (3600 ML per 30 days) GC

hydrocodone/acetaminophen tablet 5mg/325mg, 7.5mg/325mg, 10mg/325mg

2 QL (360 EA per 30 days) GC

hydrocodone/acetaminophen tablet 2.5mg/500mg, 5mg/500mg, 7.5mg/500mg, 10mg/500mg


hydrocodone/acetaminophen tablet 7.5mg/650mg,10mg/650mg, 10mg/660mg


hydrocodone/acetaminophen tablet 7.5mg/750mg 2 QL (150 EA per 30 days) GC

hydrocodone/ibuprofen tablet 7.5mg/200mg 2 QL (180 EA per 30 days) GC

hydromorphone hcl injection 500mg/50ml 2 GC

hydromorphone hcl tablet 2 QL (240 EA per 30 days) GC

LAZANDA 4 QL (43.96 GM per 28 days) PA

levorphanol tartrate 2 QL (180 EA per 30 days) GC

maxidone 2 QL (150 EA per 30 days) GC

meperidine hcl injection 25mg/ml, 50mg/ml, 100mg/ml 2 PA GC

meperidine hcl oral solution 2 QL (900 ML per 30 days) PA GC

meperitab 2 QL (180 EA per 30 days) PA GC

methadone hcl concentrate 2 QL (500 ML per 30 days) GC

methadone hcl injection 2 GC

methadone hcl oral solution 5mg/5ml 2 QL (4000 ML per 30 days) GC

15




methadone hcl oral solution 10mg/5ml 2 QL (2000 ML per 30 days) GC

methadone hcl tablet 5mg, 10mg 2 QL (360 EA per 30 days) GC

methadone hcl tablet soluble 40mg 2 QL (90 EA per 30 days) GC

methadose concentrate 2 QL (500 ML per 30 days) GC

methadose tablet soluble 40mg 2 QL (90 EA per 30 days) GC

morphine sulfate er capsule 20mg, 30mg, 50mg, 60mg, 80mg, 100mg 2 QL (60 EA per 30 days) GC

morphine sulfate er tablet 15mg, 30mg 2 QL (180 EA per 30 days) GC

morphine sulfate er tablet 60mg, 100mg, 200mg 2 QL (120 EA per 30 days) GC

morphine sulfate injection 0.5mg/ml, 1mg/ml, 4mg/ml, 10mg/ml, 15mg/ml

2 GC

morphine sulfate oral solution 10mg/5ml 2 QL (5400 ML per 30 days) GC

morphine sulfate oral solution 20mg/5ml 2 QL (2700 ML per 30 days) GC

morphine sulfate oral solution 20mg/ml 2 QL (540 ML per 30 days) GC

morphine sulfate tablet 15mg, 30mg 2 QL (360 EA per 30 days) GC

nalbuphine hcl 2 BvsD GC

ONSOLIS 5 QL (120 EA per 30 days) PA

OPANA ER TABLET 5MG, 7.5MG, 10MG, 15MG, 20MG, 30MG 3 QL (60 EA per 30 days)

OPANA ER TABLET 40MG 3 QL (120 EA per 30 days)

oxycodone hcl capsule, tablet 2 QL (300 EA per 30 days) GC

oxycodone hcl concentrate 20mg/ml 2 QL (360 ML per 30 days) GC

oxycodone hcl solution 5mg/5ml 2 GC

oxycodone/acetaminophen capsule 2 QL (240 EA per 30 days) GC

oxycodone/acetaminophen tablet 2.5mg/325mg, 5mg/325mg, 7.5mg/325mg, 10/325mg


oxycodone/acetaminophen tablet 7.5mg/500mg 2 QL (240 EA per 30 days) GC

oxycodone/acetaminophen tablet 10mg /650mg 2 QL (180 EA per 30 days) GC

oxycodone/aspirin 2 QL (360 EA per 30 days) GC

oxycodone/ibuprofen 2 QL (150 EA per 30 days) GC

OXYCONTIN ER TABLET 10MG, 15MG, 20MG, 30MG, 40MG, 60MG 3 QL (90 EA per 30 days)

OXYCONTIN ER TABLET 80MG 3 QL (120 EA per 30 days)

oxymorphone hcl 2 QL (180 EA per 30 days) GC

16




oxymorphone hcl er tablet 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg 2 QL (60 EA per 30 days) GC

oxymorphone hcl er tablet 40mg 2 QL (120 EA per 30 days) GC

pentazocine/acetaminophen 2 QL (180 EA per 30 days) PA GC

pentazocine/naloxone hcl 2 QL (360 EA per 30 days) PA GC

reprexain 2 QL (180 EA per 30 days) GC

roxicet solution 2 QL (1800 ML per 30 days) GC

roxicet tablet 2 QL (360 EA per 30 days) GC

ROXICODONE TABLET 15MG, 30MG 4 QL (300 EA per 30 days)

stagesic 2 QL (240 EA per 30 days) GC

TALWIN 4 PA

tramadol hcl 2 QL (240 EA per 30 days) GC

tramadol hcl/acetaminophen 2 QL (240 EA per 30 days) GC

Anesthetics

EMLA 4 GC

lidocaine hcl external solution 2 GC

lidocaine hcl injection 0.5%, 1% 2 GC

lidocaine hcl jelly gel 2% 2 GC

lidocaine ointment 2 BvsD GC

lidocaine viscous 2 GC

lidocaine/prilocaine cream 2 BvsD GC

LIDODERM 4 QL (90 EA per 30 days)

Anti-Addiction/Substance Abuse Treatment Agents

buprenorphine hcl injection 2 GC

buprenorphine hcl tablet sublingual 2 QL (24 EA per 30 days) GC

buprenorphine hcl/naloxone hcl 2 GC

buproban 2 QL (60 EA per 30 days) GC

CAMPRAL 4 QL (180 EA per 30 days)

CHANTIX TABLET 0.5MG, 1MG 3 QL (336 EA per 365 days)

CHANTIX TABLET STARTING MONTH 3 QL (106 EA per 365 days)

depade 2 GC

17




disulfiram 2 GC

naloxone hcl 2 GC

naltrexone hcl 2 GC

NICOTROL INHALER 3

NICOTROL NS 3

REVIA 4

SUBOXONE 3

VIVITROL 5 PA

Anti-inflammatory Agents

CAMBIA 4

CELEBREX 3 QL (60 EA per 30 days)

diclofenac potassium 1 GC

diclofenac sodium dr 1 GC

diclofenac sodium er 1 GC

diflunisal 2 GC

etodolac 1 GC

etodolac er 1 GC

fenoprofen calcium 1 GC

flurbiprofen 1 GC

ibuprofen suspension 1 GC

ibuprofen tablet 400mg, 600mg, 800mg 1 GC

indomethacin & indomethacin er 2 PA GC

ketoprofen 1 GC

ketoprofen er 1 GC

ketorolac tromethamine injection 2 PA GC

ketorolac tromethamine tablet 10mg 2 QL (20 EA per 30 days) PA GC

meclofenamate sodium 1 GC

meloxicam 1 GC

nabumetone 1 GC

naproxen 1 GC

naproxen dr 1 GC

18




naproxen sodium tablet 275mg, 550mg 1 GC

oxaprozin 1 GC

piroxicam 1 GC

salsalate 2 GC

sulindac 1 GC

tolmetin sodium 1 GC

VIMOVO 4 QL (60 EA per 30 days)

Antibacterials

ALTABAX 4 GC

amikacin sulfate 2 GC

amoxicillin 2 GC

amoxicillin/potassium clavulanate 2 GC

ampicillin 2 GC

ampicillin sodium 2 GC

ampicillin-sulbactam 2 GC

AVELOX INJECTION 3 GC

AVELOX TABLET 3 QL (30 EA per 30 days)

AZACTAM 1GM, 2GM 4

AZACTAM IN ISO-OSMOTIC DEXTROSE 1GM 4

AZACTAM IN ISO-OSMOTIC DEXTROSE 2GM 5

AZASITE 3

azithromycin 2 GC

aztreonam 2 GC

baciim 2 GC

bacitracin 2 GC

bacitracin/polymyxin b 2 GC

bactocill in dextrose 2 GC

BICILLIN C-R 4 GC

BICILLIN L-A 4

BLEPH-10 4 GC

CAYSTON 5

19




CEDAX CAPSULE 4

cefaclor & cefaclor er 2 GC

cefadroxil 2 GC

cefazolin sodium 2 GC

cefdinir 2 GC

cefepime 2 GC

cefotaxime sodium 2 GC

cefotetan 2 GC

cefoxitin sodium 2 GC

cefpodoxime proxetil 2 GC

cefprozil 2 GC

ceftazidime 2 GC

ceftriaxone sodium 2 GC

cefuroxime axetil tablet 2 GC

cefuroxime sodium 2 GC

cephalexin 2 GC

chloramphenicol sodium succinate 2 GC

CIPRO I.V. 4

CIPRODEX 3

ciprofloxacin er 1 GC

ciprofloxacin hcl 1 GC

ciprofloxacin i.v. 1 GC

CLAFORAN 4

clarithromycin 2 GC

clarithromycin er 2 GC

CLEOCIN PHOSPHATE INJECTION 4

clindamycin hcl 2 GC

clindamycin phosphate 2 GC

colistimethate sodium 2 GC

COLY-MYCIN M 4

CUBICIN 5 BvsD

20




demeclocycline hcl 2 GC

dicloxacillin sodium 2 GC

DIFICID 3 QL (20 EA per 30 days) PA

DORIBAX 4

doxycycline hyclate 2 GC

doxycycline monohydrate 2 GC

e.e.s. 2 GC

ery 2 GC

ery-tab 2 GC

ERYPED 3 GC

erythrocin lactobionate 2 GC

erythrocin stearate 2 GC

erythromycin base 2 GC

erythromycin ethylsuccinate 2 GC

erythromycin gel, ointment, solution 2 GC

FORTAZ 4

FURADANTIN 4 PA GC

gentak ointment 2 GC

gentamicin sulfate 2 GC

HELIDAC 4

imipenem/cilastatin 2 GC

INVANZ 4

KETEK 4 GC

levofloxacin injection, ophthalmic solution, oral solution 1 GC

levofloxacin tablet 1 QL (30 EA per 30 days) GC

LINCOCIN 3

MACRODANTIN CAPSULE 25MG 4 PA

meropenem 2 GC

MERREM 4

methenamine hippurate 2 GC

METROGEL-VAGINAL 4

21




metronidazole cream, lotion, tablet 1 GC

metronidazole gel 0.75% 1 GC

metronidazole injection 1 GC

metronidazole vaginal 1 GC

minocycline hcl 2 GC

MOXEZA 3

mupirocin 2 GC

nafcillin sodium 2 GC

NALLPEN/DEXTROSE 3

neomycin sulfate tablet 2 GC

neomycin/bacitracin/polymyxin 2 GC

neomycin/polymyxin b sulfates 2 GC

neomycin/polymyxin/bacitracin/hydrocortisone 2 GC

neomycin/polymyxin/gramicidin 2 GC

neomycin/polymyxin/hydrocortisone ophthalmic suspension 2 GC

nitrofurantoin 2 PA GC

nitrofurantoin macrocrystalline 2 PA GC

nitrofurantoin monohydrate 2 PA GC

NOROXIN 4

OCUFLOX 4 GC

ofloxacin 2 GC

ORACEA 4

oxacillin sodium 2 GC

paromomycin sulfate 2 GC

PCE 3

penicillin g potassium 2 GC

penicillin g procaine 2 GC

penicillin g sodium 2 GC

penicillin v potassium 2 GC

pfizerpen-g 2 GC

PHISOHEX 4 GC

22




piperacillin sodium/tazobactam sodium 2 GC

polymyxin b sulfate 2 GC

PRIMAXIN IV 4

PRIMSOL 4 GC

RELAGARD 4

SILVADENE 4

silver sulfadiazine 2 GC

sodium sulfacetamide 2 GC

ssd 2 GC

streptomycin sulfate 2 GC

sulfacetamide sodium ointment 10% 2 GC

sulfadiazine 2 GC

sulfamethoxazole/trimethoprim 2 GC

sulfamethoxazole/trimethoprim ds 2 GC

SULFAMYLON 4 GC

SUPRAX CAPSULE, CHEWABLE TABLET, TABLET 4

SUPRAX SUSPENSION 4 GC

SYNERCID 5

tazicef 2 GC

TEFLARO 4

tetracycline hcl 2 GC

TIMENTIN 4 GC

TOBI 5 BvsD

TOBI PODHALER 5

tobramycin sulfate 2 GC

tobramycin sulfate/sodium chloride 2 GC

trimethoprim 2 GC

trimethoprim sulfate/polymyxin b sulfate 2 GC

TYGACIL 4

vancomycin hcl capsule 125mg 5 QL (40 EA per 10 days)

vancomycin hcl capsule 250mg 5 QL (80 EA per 10 days)

23




vancomycin hcl injection 500mg, 1000mg, 10gm 2 BvsD GC

VANDAZOLE 4 GC

VIGAMOX 3

XIFAXAN TABLET 200MG 4 QL (90 EA per 30 days) PA

XIFAXAN TABLET 550MG 5 QL (60 EA per 30 days) PA

ZMAX 4 QL (120 ML per 30 days)

ZOSYN 3

ZYVOX INJECTION 5

ZYVOX SUSPENSION 5 QL (1680 ML per 60 days)

ZYVOX TABLET 5 QL (56 EA per 60 days)

Anticonvulsants

BANZEL SUSPENSION 4

BANZEL TABLET 200MG 4

BANZEL TABLET 400MG 5

carbamazepine 2 GC

carbamazepine er 2 GC

CARBATROL 4

CELONTIN 4

clonazepam odt 0.125mg, 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

clonazepam odt 2mg 2 QL (300 EA per 30 days) GC

clonazepam tablet 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

clonazepam tablet 2mg 2 QL (300 EA per 30 days) GC

clorazepate dipotassium tablet 3.75mg, 7.5mg 2 QL (90 EA per 30 days) GC

clorazepate dipotassium tablet 15mg 2 QL (120 EA per 30 days) GC

DEPACON 4

diazepam gel 2.5mg 2 QL (10 ML per 30 days) GC

diazepam gel 10mg 2 QL (20 ML per 30 days) GC

diazepam gel 20mg 2 QL (40 ML per 30 days) GC

DILANTIN 4

DILANTIN INFATABS 4

divalproex sodium 2 GC

24




divalproex sodium er 2 GC

epitol 2 GC

ethosuximide 2 GC

felbamate suspension 5

felbamate tablet 2 GC

FELBATOL 5

fosphenytoin sodium 2 GC

gabapentin 2 GC

GABITRIL 4

LAMICTAL CHEWABLE 4

LAMICTAL ODT 3

LAMICTAL TABLET 4

LAMICTAL XR 4

lamotrigine 2 GC

lamotrigine er 2 GC

levetiracetam 2 GC

levetiracetam er 2 GC

LYRICA CAPSULE 25MG, 225MG, 300MG 3 QL (60 EA per 30 days)

LYRICA CAPSULE 50MG, 75MG, 100MG, 150MG, 200MG 3 QL (90 EA per 30 days)

LYRICA SOLUTION 3 QL (900 ML per 30 days)

magnesium sulfate injection 2 GC

NEURONTIN SOLUTION 4

ONFI TABLET 5MG, 10MG 4 QL (60 EA per 30 days)

ONFI TABLET 20MG 4 QL (120 EA per 30 days)

oxcarbazepine 2 GC

PEGANONE 4

phenobarbital 2 PA GC

PHENYTEK 4

phenytoin 2 GC

phenytoin sodium extended 2 GC

POTIGA TABLET 50MG 4 QL (270 EA per 30 days)

25




POTIGA TABLET 200MG, 300MG, 400MG 4 QL (90 EA per 30 days)

primidone 2 GC

SABRIL PACKET 5 QL (200 EA per 30 days)

SABRIL TABLET 5 QL (180 EA per 30 days)

tiagabine hcl 2 GC

topiramate 2 GC

valproate sodium 2 GC

valproic acid 2 GC

VIMPAT INJECTION 3

VIMPAT ORAL SOLUTION 3 QL (1200 ML per 30 days)

VIMPAT TABLET 3 QL (60 EA per 30 days)

zonisamide 2 GC

Antidementia Agents

donepezil hcl odt & tablet 5mg 1 QL (30 EA per 30 days) GC

donepezil hcl odt & tablet 10mg 1 QL (60 EA per 30 days) GC

ergoloid mesylates 2 PA GC

EXELON PATCH 3 QL (30 EA per 30 days)

EXELON SOLUTION 4 QL (180 ML per 30 days)

galantamine hydrobromide solution 2 QL (200 ML per 30 days) GC

galantamine hydrobromide er capsule 2 QL (30 EA per 30 days) GC

galantamine hydrobromide tablet 2 QL (60 EA per 30 days) GC

NAMENDA SOLUTION 3 QL (300 ML per 30 days)

NAMENDA TABLET 5MG 3 QL (90 EA per 30 days)

NAMENDA TABLET 10MG 3 QL (60 EA per 30 days)

NAMENDA TITRATION PAK 3 QL (49 EA per 30 days)

rivastigmine tartrate 2 QL (60 EA per 30 days) GC

Antidepressants

amitriptyline hcl 2 PA GC

amoxapine 2 GC

budeprion sr tablet 100mg 2 QL (60 EA per 30 days) GC

26




budeprion sr tablet 150mg 2 QL (90 EA per 30 days) GC

bupropion hcl 2 GC

bupropion hcl sr tablet 100mg, 200mg 2 QL (60 EA per 30 days) GC

bupropion hcl sr tablet 150mg 2 QL (90 EA per 30 days) GC

bupropion hcl xl tablet 150mg 2 QL (90 EA per 30 days) GC

bupropion hcl xl tablet 300mg 2 QL (30 EA per 30 days) GC

chlordiazepoxide/amitriptyline 2 PA GC

citalopram hydrobromide solution 2 QL (600 ML per 30 days) GC

citalopram hydrobromide tablet 10mg, 20mg 2 QL (60 EA per 30 days) GC

citalopram hydrobromide tablet 40mg 2 QL (30 EA per 30 days) GC

clomipramine hcl 2 PA GC

CYMBALTA 4 QL (60 EA per 30 days)

desipramine hcl 2 GC

doxepin hcl 2 PA GC

EMSAM 5

escitalopram oxalate solution 2 QL (600 ML per 30 days) GC

escitalopram oxalate tablet 2 QL (60 EA per 30 days) GC

fluoxetine hcl capsule 10mg, 20mg, 40mg 2 GC

fluoxetine hcl tablet 10mg, 20mg, 60mg 2 GC

fluoxetine hcl solution 20mg/5ml 2 GC

fluvoxamine maleate 2 GC

imipramine hcl 2 PA GC

imipramine pamoate 2 PA GC

LEXAPRO SOLUTION 4 QL (600 ML per 30 days)

LEXAPRO TABLET 4 QL (60 EA per 30 days)

maprotiline hcl 2 GC

MARPLAN 4

mirtazapine 2 GC

mirtazapine odt 2 GC

nefazodone hcl 2 GC

NORPRAMIN 4 GC

27




nortriptyline hcl capsule 2 GC

olanzapine/fluoxetine 2 QL (30 EA per 30 days) GC

paroxetine hcl 2 QL (60 EA per 30 days) GC

PAXIL SUSPENSION 4 QL (900 ML per 30 days)

perphenazine/amitriptyline 2 PA GC

phenelzine sulfate 2 GC

PRISTIQ 3 QL (30 EA per 30 days)

protriptyline hcl 2 GC

sertraline hcl concentrate 2 QL (300 ML per 30 days) GC

sertraline hcl tablet 25mg, 50mg 2 QL (90 EA per 30 days) GC

sertraline hcl tablet 100mg 2 QL (60 EA per 30 days) GC

tranylcypromine sulfate 2 GC

trazodone hcl 2 GC

trimipramine maleate 2 PA GC

venlafaxine hcl er capsule 37.5mg 2 QL (30 EA per 30 days) GC

venlafaxine hcl er capsule 75mg 2 QL (90 EA per 30 days) GC

venlafaxine hcl er capsule 150mg 2 QL (60 EA per 30 days) GC

venlafaxine hcl tablet 2 GC

VIIBRYD 3 QL (30 EA per 30 days)

Antiemetics

ANTIVERT 4 GC

ANZEMET INJECTION 4 PA

ANZEMET TABLET 4 QL (5 EA per 30 days) BvsD

dronabinol capsule 2.5mg, 5mg 2 BvsD GC

dronabinol capsule 10mg 5 BvsD

EMEND CAPSULE 40MG 3 QL (2 EA per 30 days) BvsD



EMEND CAPSULE TRIFOLD PACK 3 QL (12 EA per 30 days) BvsD

MARINOL CAPSULE 5MG 4 BvsD

MARINOL CAPSULE 10MG 5 BvsD

28




meclizine hcl tablet rx 2 GC

ondansetron hcl injection 2 BvsD GC

ondansetron hcl oral solution 2 QL (900 ML per 30 days) BvsD GC

ondansetron hcl tablet 4mg, 8mg 2 QL (90 EA per 30 days) BvsD GC

ondansetron hcl tablet 24mg 2 QL (5 EA per 30 days) BvsD GC

ondansetron odt tablet 4mg, 8mg 2 QL (90 EA per 30 days) BvsD GC

phenadoz suppository 12.5mg, 25mg 2 PA GC

promethazine hcl suppository 12.5mg, 25mg 2 PA GC

promethegan suppository 12.5mg, 25mg, 50mg 2 PA GC

SANCUSO 4 QL (4 EA per 30 days) PA

TRANSDERM-SCOP 4

trimethobenzamide hcl 2 PA GC

AntifungalsABELCET 5 BvsD

AMBISOME 5 BvsD

amphotericin b 2 BvsD GC

ANCOBON 5

CANCIDAS 5 PA

ciclopirox gel, suspension 2 GC

ciclopirox nail lacquer 2 GC

ciclopirox olamine 2 GC

clotrimazole rx 2 GC

clotrimazole/betamethasone dipropionate 2 GC

econazole nitrate 2 GC

ERAXIS 3

fluconazole 2 GC

flucytosine 5

GRIFULVIN V 3

29




GRIS-PEG 3 GC

griseofulvin microsize 2 GC

griseofulvin ultramicrosize 2 GC

itraconazole 2 GC

ketoconazole cream, shampoo, tablet 2 GC

MENTAX 4 GC

miconazole 3 rx 2 GC

MYCAMINE 5

NAFTIN 4

NATACYN 4

NIZORAL 4 GC

NOXAFIL 5

nyamyc 2 GC

nystatin 2 GC

nystatin/triamcinolone 2 GC

nystop 2 GC

pedi-dri 2 GC

SPORANOX SOLUTION 5

TERAZOL 4 GC

terbinafine hcl tablet 2 GC

terconazole 2 GC

VFEND 5

VFEND IV 4

voriconazole injection 2 GC

voriconazole tablet 5

zazole cream 2 GC

Antigout Agents

allopurinol 1 GC

allopurinol sodium 2 GC

ALOPRIM 4

30




COLCRYS 3

probenecid 2 GC

probenecid/colchicine 2 GC

ULORIC 3 QL (30 EA per 30 days) ST

Antimigraine Agents

D.H.E. 45 5

dihydroergotamine mesylate injection 2 GC

ERGOMAR 4

MAXALT TABLET 5MG 4 QL (27 EA per 30 days)

MAXALT TABLET 10MG 4 QL (18 EA per 30 days)

MAXALT-MLT TABLET DISPERSIBLE 5MG 4 QL (27 EA per 30 days)

MAXALT-MLT TABLET DISPERSIBLE 10MG 4 QL (18 EA per 30 days)

migergot 2 GC

MIGRANAL 4 QL (8 ML per 30 days)

rizatriptan benzoate odt & tablet 5mg 2 QL (27 EA per 30 days) GC

rizatriptan benzoate odt & tablet 10mg 2 QL (18 EA per 30 days) GC

sumatriptan solution 5mg/act 2 QL (36 EA per 30 days) GC

sumatriptan solution 20mg/act 2 QL (12 EA per 30 days) GC

sumatriptan succinate injection 4mg/0.5ml, 6mg/0.5ml cartridge, syringe

2 QL (4 ML per 30 days) GC

sumatriptan succinate injection 6mg/0.5ml vial 2 QL (8 ML per 30 days) GC

sumatriptan succinate tablet 25mg 2 QL (36 EA per 30 days) GC



TREXIMET 4 QL (9 EA per 30 days)

ZOMIG SOLUTION 4 QL (6 EA per 30 days)

ZOMIG TABLET 2.5MG 4 QL (12 EA per 30 days)

ZOMIG TABLET 5MG 4 QL (6 EA per 30 days)

ZOMIG ZMT TABLET 2.5MG 4 QL (12 EA per 30 days)

ZOMIG ZMT TABLET 5MG 4 QL (6 EA per 30 days)

31




Antimyasthenic Agents

guanidine hcl 2 GC

MESTINON SYRUP 3

MESTINON TIMESPAN 3

MYTELASE 3

pyridostigmine bromide 2 GC

REGONOL 4

Antimycobacterials

CAPASTAT SULFATE 3

dapsone 2 GC

ethambutol hcl 2 GC

isoniazid 2 GC

MYCOBUTIN 3

PASER 4 GC

PRIFTIN 4 GC

pyrazinamide 2 GC

rifampin 2 GC

RIFATER 4

SEROMYCIN 3

SIRTURO 5

TRECATOR 3

Antineoplastics

ABRAXANE 5 BvsD

ADRIAMYCIN 4 BvsD

AFINITOR TABLET 2.5MG, 5MG, 7.5MG 5 QL (30 EA per 30 days)

AFINITOR TABLET 10MG 5 QL (60 EA per 30 days)

ALIMTA 5 BvsD

ALKERAN INJECTION 4 BvsD

amifostine 5 BvsD

anastrozole 2 QL (30 EA per 30 days) GC

32




AROMASIN 4

ARRANON 5 BvsD

ARZERRA 5 BvsD

AVASTIN 5 BvsD

BICNU 3 BvsD

bleomycin sulfate 2 BvsD GC

BOSULIF 5

BUSULFEX 3 BvsD

CAMPTOSAR 4 BvsD

CAPRELSA 5

carboplatin 2 BvsD GC

CEENU 3

CERUBIDINE 4 BvsD

cisplatin 2 BvsD GC

cladribine 5 BvsD

CLOLAR 5 BvsD

COMETRIQ 5

COSMEGEN 5 BvsD

cyclophosphamide tablet 2 BvsD GC

cytarabine 2 BvsD GC

cytarabine aqueous 2 BvsD GC

dacarbazine 2 BvsD GC

DACOGEN 5 BvsD

daunorubicin hcl 2 BvsD GC

DAUNOXOME 4 BvsD

dexrazoxane 5 BvsD

DOCEFREZ 5 BvsD

docetaxel 5 BvsD

DOXIL 5 BvsD

doxorubicin hcl 2 BvsD GC

doxorubicin hcl liposome 2 BvsD GC

33




DROXIA 3

ELITEK 5

ELLENCE 5 BvsD

ELOXATIN 5 BvsD

ELSPAR 3 BvsD

EMCYT 3

epirubicin hcl 2 BvsD GC

ERBITUX 5 BvsD

ERIVEDGE 5

ETOPOPHOS 4 BvsD

etoposide injection 2 BvsD GC

exemestane 2 GC

FARESTON 5

FASLODEX 5 BvsD

FLUDARA 5 BvsD

fludarabine phosphate 2 BvsD GC

fluorouracil injection 2 BvsD GC

gemcitabine hcl 5 BvsD

GEMZAR 5 BvsD

GLEEVEC 5

HALAVEN 5

HERCEPTIN 5 BvsD

HEXALEN 5

HYCAMTIN INJECTION 5 BvsD

hydroxyurea 2 GC

ICLUSIG 5

IDAMYCIN PFS 5 BvsD

idarubicin hcl 5 BvsD

IFEX 4 BvsD

ifosfamide 2 BvsD GC

ifosfamide/mesna 5 BvsD

34




INLYTA 5

irinotecan 5 BvsD

ISTODAX 5 BvsD

IXEMPRA KIT 5 BvsD

JAKAFI 5

JEVTANA 5 BvsD

KADCYLA 5 BvsD

letrozole 2 GC

leucovorin calcium injection 2 BvsD GC

leucovorin calcium tablet 2 GC

LEUKERAN 3

MATULANE 5

MEKINIST 5

melphalan hcl 2 BvsD GC

mercaptopurine 2 GC

mesna 2 BvsD GC

MESNEX INJECTION 4 BvsD

MESNEX TABLET 5

mitomycin 2 BvsD GC

mitoxantrone hcl 2 BvsD GC

MUSTARGEN 3 BvsD

NAVELBINE 5 BvsD

NEXAVAR 5 RA

NIPENT 5 BvsD

ONTAK 5 BvsD

oxaliplatin 5 BvsD

paclitaxel 2 BvsD GC

PANRETIN 5

pentostatin 5 BvsD

PERJETA 5 BvsD

POMALYST 5

35




PROLEUKIN 5

REVLIMID 5 QL (28 EA per 28 days) RA

RITUXAN 5 PA

SOLTAMOX 4

SPRYCEL 5

STIVARGA 5

SUTENT 5

SYLATRON 5 PA

SYNRIBO 5 BvsD

TABLOID 4

TAFINLAR 5

tamoxifen citrate 2 GC

TARCEVA 5

TARGRETIN 5

TASIGNA 5

TAXOTERE 5 BvsD

THALOMID 5

thiotepa 2 BvsD GC

toposar 2 BvsD GC

topotecan hcl 5 BvsD

TREANDA 5 BvsD

tretinoin capsule 10mg 5

TRISENOX 4 BvsD

TYKERB 5

VECTIBIX 5 BvsD

VELCADE 5 BvsD

VIDAZA 3

vinblastine sulfate 2 BvsD GC

vincasar pfs 2 BvsD GC

vincristine sulfate 2 BvsD GC

vinorelbine tartrate 2 BvsD GC

36




VOTRIENT 5

VUMON 4 PA

XALKORI 5

YERVOY 5 BvsD

ZALTRAP 5 BvsD

ZANOSAR 4 BvsD

ZELBORAF 5

ZINECARD 5 BvsD

ZOLINZA 5

ZYTIGA 5

Antiparasitics

ALBENZA 4 GC

ALINIA 4 GC

atovaquone/proguanil hcl 2 GC

chloroquine phosphate 2 GC

DARAPRIM 4 GC

EURAX 4 GC

hydroxychloroquine sulfate 2 GC

lindane 2 GC

malathion 2 GC

mefloquine hcl 2 GC

MEPRON 5

NEBUPENT 4 BvsD

OVIDE 4 GC

PENTAM 300 4

permethrin cream rx 2 GC

PRIMAQUINE PHOSPHATE 4

QUALAQUIN 4 PA

quinine sulfate 2 PA GC

SKLICE 4

STROMECTOL 3 GC

37




tinidazole 2 GC

Antiparkinson Agents

APOKYN 5

AZILECT 3

benztropine mesylate injection 2 GC

benztropine mesylate tablet 2 PA GC

bromocriptine mesylate 2 GC

carbidopa/levodopa 2 GC

carbidopa/levodopa er 2 GC

carbidopa/levodopa odt 2 GC

COMTAN 4

entacapone 2 GC

LODOSYN 3

MIRAPEX ER 4

pramipexole dihydrochloride 2 GC

REQUIP XL 4

ropinirole hcl 2 GC

ropinirole hcl er 2 GC

selegiline hcl 2 GC

STALEVO 4

TASMAR 3

trihexyphenidyl hcl 2 PA GC

ZELAPAR 4

Antipsychotics

ABILIFY DISCMELT 3 QL (60 EA per 30 days)

ABILIFY INJECTION 4

ABILIFY MAINTENA 5

ABILIFY ORAL SOLUTION 3 QL (900 ML per 30 days)

ABILIFY TABLET 3 QL (30 EA per 30 days)

chlorpromazine hcl injection, tablet 2 GC

clozapine 2 GC

38




compro 2 GC

FANAPT 4 QL (60 EA per 30 days)

FANAPT TITRATION PACK 4 QL (16 EA per 30 days)

FAZACLO 4

fluphenazine decanoate 2 GC

fluphenazine hcl 2 GC

GEODON CAPSULE 4 QL (60 EA per 30 days)

GEODON INJECTION 4

haloperidol 2 GC

haloperidol decanoate 2 GC

haloperidol lactate 2 GC

INVEGA SUSTENNA 39MG/0.25ML, 78MG/0.5ML 4

INVEGA SUSTENNA 117MG/0.75ML, 156MG/ML, 234MG/1.5ML 5

INVEGA TABLET ER 1.5MG, 3MG 4 QL (30 EA per 30 days)

INVEGA TABLET ER 6MG 4 QL (60 EA per 30 days)

INVEGA TABLET ER 9MG 5 QL (30 EA per 30 days)

LATUDA TABLET 20MG, 40MG, 120MG 3 QL (30 EA per 30 days)

LATUDA TABLET 80MG 3 QL (60 EA per 30 days)

loxapine succinate 2 GC

olanzapine odt 2 QL (30 EA per 30 days) GC

olanzapine injection 2 GC

olanzapine tablet 2 QL (60 EA per 30 days) GC

ORAP 4 GC

perphenazine 2 GC

prochlorperazine 2 GC

prochlorperazine edisylate 2 GC

prochlorperazine maleate 2 GC

quetiapine fumarate tablet 25mg, 50mg, 100mg, 200mg 2 QL (120 EA per 30 days) GC

quetiapine fumarate tablet 300mg, 400mg 2 QL (90 EA per 30 days) GC

RISPERDAL CONSTA INJECTION 12.5MG, 25MG 4

RISPERDAL CONSTA INJECTION 37.5MG, 50MG 5

39




risperidone odt 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days) GC

risperidone odt 4mg 2 QL (120 EA per 30 days) GC

risperidone solution 2 QL (360 ML per 30 days) GC

risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days) GC

risperidone tablet 4mg 2 QL (120 EA per 30 days) GC

SAPHRIS 3 QL (60 EA per 30 days)

SEROQUEL XR TABLET 50MG, 300MG, 400MG 3 QL (60 EA per 30 days)

SEROQUEL XR TABLET 150MG, 200MG 3 QL (30 EA per 30 days)

thioridazine hcl 2 PA GC

thiothixene 2 GC

trifluoperazine hcl 2 GC

ziprasidone hcl 2 QL (60 EA per 30 days) GC

Antispasticity Agents

baclofen 2 GC

tizanidine hcl 2 GC

Antivirals

abacavir 2 GC

acyclovir capsule, suspension, tablet 2 GC

acyclovir sodium injection 2 BvsD GC

amantadine hcl 2 GC

APTIVUS 5

ATRIPLA 5

BARACLUDE 3

cidofovir 5

COMPLERA 5

COPEGUS 5

CRIXIVAN 3

DENAVIR 3

didanosine 2 GC

EDURANT 5

EMTRIVA 4

40




EPIVIR 4

EPIVIR HBV 4

EPZICOM 5

famciclovir 2 GC

foscarnet sodium 2 BvsD GC

FUZEON 5

ganciclovir 2 BvsD GC

HEPSERA 5

INCIVEK 5 PA

INFERGEN 5 PA

INTELENCE TABLET 25MG 4

INTELENCE TABLET 100MG, 200MG 5

INTRON-A 4

INVIRASE CAPSULE 200MG 4

INVIRASE TABLET 500MG 5

ISENTRESS TABLET CHEWABLE 25MG, 100MG 3

ISENTRESS TABLET 400MG 5

KALETRA 5

lamivudine 2 GC

lamivudine/zidovudine 5

LEXIVA SUSPENSION 4

LEXIVA TABLET 5

nevirapine tablet 2 GC

NORVIR 4

PEG-INTRON 5 PA

PREZISTA SUSPENSION 4

PREZISTA TABLET 75MG, 150MG 4

PREZISTA TABLET 400MG, 600MG, 800MG 5

REBETOL CAPSULE 5

REBETOL SOLUTION 3

RELENZA DISKHALER 4 QL (120 EA per 365 days)

41




RESCRIPTOR 4

RETROVIR IV INFUSION 4

REYATAZ 3

ribapak tablet 5

ribasphere capsule 200mg 2 GC

ribasphere tablet 200mg, 400mg 2 GC

ribasphere tablet 600mg 5

ribavirin capsule, tablet 200mg 2 GC

rimantadine hcl 2 GC

SELZENTRY 5

stavudine 2 GC

STRIBILD 5

SUSTIVA 3

TAMIFLU CAPSULE 30MG 3 QL (120 EA per 365 days)



TAMIFLU SUSPENSION 3

trifluridine 2 GC

TRIZIVIR 5

TRUVADA 5

TYZEKA 5

valacyclovir hcl 2 GC

VICTRELIS 5 PA

VIDEX PEDIATRIC 3

VIRACEPT 5

VIRAMUNE 4

VIRAMUNE XR 4

VIREAD 5

VIROPTIC 4 GC

VISTIDE 5

ZERIT SOLUTION 4

42




ZIAGEN 4

zidovudine 2 GC

Anxiolytics

alprazolam er tablet 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days) GC

alprazolam intensol 2 QL (300 ML per 30 days) GC

alprazolam odt 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

alprazolam odt 2mg 2 QL (150 EA per 30 days) GC

alprazolam tablet 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

alprazolam tablet 2mg 2 QL (150 EA per 30 days) GC

buspirone hcl 2 GC

diazepam injection 2 GC

diazepam intensol 2 QL (240 ML per 30 days) GC

diazepam oral solution 1mg/ml 2 QL (1200 ML per 30 days) GC

diazepam tablet 2mg, 5mg, 10mg 2 QL (120 EA per 30 days) GC

lorazepam injection 2 GC

lorazepam intensol 2 QL (150 ML per 30 days) GC

lorazepam tablet 2 QL (120 EA per 30 days) GC

meprobamate 2 PA GC

oxazepam 2 QL (120 EA per 30 days) GC

Bipolar Agents

EQUETRO 4 GC

lithium carbonate 2 GC

lithium carbonate er 2 GC

lithium citrate 2 GC

LITHOBID 4

Blood Glucose Regulators

acarbose 2 GC

ACTOPLUS MET 4 QL (90 EA per 30 days)

ACTOS 4 QL (30 EA per 30 days)

ALCOHOL PREP PADS 3

43




APIDRA 4 ST

APIDRA SOLOSTAR 4 ST

AVANDAMET 4 QL (60 EA per 30 days)

AVANDARYL TABLET 1MG/4MG, 2MG/4MG, 4MG/4MG 4 QL (60 EA per 30 days)

AVANDARYL TABLET 2MG/8MG, 4MG/8MG 4 QL (30 EA per 30 days)

AVANDIA TABLET 2MG, 4MG 4 QL (60 EA per 30 days)

AVANDIA TABLET 8MG 4 QL (30 EA per 30 days)

BD INSULIN SYRINGE 3

BD PEN NEEDLE 3

BYDUREON 3 QL (2.6 ML per 28 days)

BYETTA 3 QL (3 ML per 30 days)

chlorpropamide 1 PA GC

GAUZE PADS 2X2 3

DUETACT 4 QL (30 EA per 30 days)

glimepiride 1 GC

glipizide 1 GC

glipizide er 1 GC

glipizide/metformin hcl 1 GC

GLUCAGEN HYPOKIT 3

GLUCAGON EMERGENCY KIT 3

GLUCOTROL 4 GC

GLUCOTROL XL 4 GC

GLUMETZA 4 GC

glyburide 1 PA GC

glyburide micronized 1 PA GC

glyburide/metformin hcl 1 PA GC

GLYSET 4

HUMALOG 3

HUMALOG MIX 50/50 3

HUMALOG MIX 75/25 3

HUMULIN 70/30 3

44




HUMULIN N 3

HUMULIN R 3

INSULIN SYRINGE & PEN NEEDLE 3

JANUMET 3 QL (60 EA per 30 days)

JANUMET XR TABLET 500MG/50MG, 1000MG/50MG 3 QL (60 EA per 30 days)

JANUMET XR TABLET 1000MG/100MG 3 QL (30 EA per 30 days)

JANUVIA 3 QL (30 EA per 30 days)

JENTADUETO 3 QL (60 EA per 30 days)

JUVISYNC 3 QL (30 EA per 30 days)

LANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3

LEVEMIR FLEXPEN 3

metformin hcl 1 GC

metformin hcl er 1 GC

nateglinide 1 GC

NOVOFINE & NOVOTWIST PEN NEEDLE 3

pioglitazone hcl 1 QL (30 EA per 30 days) GC

pioglitazone hcl/glimepiride 1 QL (30 EA per 30 days) GC

pioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days) GC

PRANDIN 4

PROGLYCEM 4

RIOMET 3 GC

SYMLINPEN 60 4 QL (12 ML per 30 days)

SYMLINPEN 120 4 QL (10.8 ML per 30 days)

tolazamide 2 GC

tolbutamide 2 GC

TRADJENTA 3 QL (30 EA per 30 days)

V-GO 4

VICTOZA 3 QL (9 ML per 30 days)

45




Blood Products/Modifiers/Volume Expanders

AGGRENOX 3 QL (60 EA per 30 days)

aminocaproic acid tablet 2 GC

anagrelide hcl 2 GC

ARANESP 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML

3 PA

ARANESP 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 150MCG/0.75ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML

5 PA

BRILINTA 3 QL (60 EA per 30 days)

cilostazol 1 GC

clopidogrel tablet 75mg 1 GC

clopidogrel tablet 300mg 1 QL (1 EA per 30 days) GC

COUMADIN 4

CYKLOKAPRON 3

dipyridamole tablet 2 PA GC

EFFIENT TABLET 5MG 3 QL (42 EA per 30 days)

EFFIENT TABLET 10MG 3 QL (36 EA per 30 days)

ELIQUIS 3 QL (60 EA per 30 days)

enoxaparin sodium injection 30mg/0.3ml 2 QL (18 ML per 365 days) GC




enoxaparin sodium injection 100mg/ml 2 QL (60 ML per 365 days) GC

enoxaparin sodium injection 120mg/0.8ml 5 QL (48 ML per 365 days)

enoxaparin sodium injection 150mg/ml 5 QL (60 ML per 365 days)

enoxaparin sodium injection 300mg/3ml 2 QL (90 ML per 365 days) GC

EPOGEN 4 PA

fondaparinux sodium injection 2.5mg/0.5ml 2 QL (32 ML per 365 days) GC

fondaparinux sodium injection 5mg/0.4ml 5 QL (12 ML per 365 days)

fondaparinux sodium injection 7.5mg/0.6ml 5 QL (18 ML per 365 days)

46




fondaparinux sodium injection 10mg/0.8ml 5 QL (24 ML per 365 days)

heparin sodium injection 1000unit/ml 2 BvsD GC

heparin sodium injection 2000unit/ml, 2500unit/ml, 5000unit/ml, 10000unit/ml, 20000unit/ml

2 GC

heparin sodium/d5w injection 5%/40unit/ml 2 GC

heparin sodium/nacl 0.45% 2 GC

heparin sodium/sodium chloride 0.9% premix 2 GC

jantoven 1 GC

LEUKINE 5

MOZOBIL 5

NEULASTA 5

NEUMEGA 5 PA

NEUPOGEN 5

PLAVIX TABLET 75MG 4

PRADAXA 4 QL (60 EA per 30 days)

PROCRIT 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML, 10000UNIT/ML

3 PA

PROCRIT 20000UNIT/ML, 40000UNIT/ML 5 PA

PROMACTA 5

ticlopidine hcl 2 PA GC

tranexamic acid injection 2 GC

warfarin sodium 1 GC

XARELTO TABLET 10MG, 20MG 3 QL (30 EA per 30 days)

XARELTO TABLET 15MG 3 QL (60 EA per 30 days)

Cardiovascular Agents

ACCUPRIL 4 GC

acebutolol hcl 1 GC

acetazolamide sodium 2 GC

ADALAT CC 4 GC

afeditab cr 1 GC

ALDACTONE 4 GC

47




amiloride hcl 2 GC

amiloride/hctz 1 GC

amiodarone hcl 1 GC

amlodipine besylate tablet 2.5mg 1 QL (90 EA per 30 days) GC

amlodipine besylate tablet 5mg , 10mg 1 QL (60 EA per 30 days) GC

amlodipine besylate/atorvastatin calcium 2 QL (30 EA per 30 days) GC

amlodipine besylate/benazepril hcl 1 QL (30 EA per 30 days) GC

AMTURNIDE 4 QL (30 EA per 30 days)

ATACAND 4 QL (30 EA per 30 days)

ATACAND HCT 4 QL (30 EA per 30 days)

atenolol 1 GC

atenolol/chlorthalidone 1 GC

atorvastatin calcium 1 QL (30 EA per 30 days) GC

benazepril hcl 1 GC

benazepril hcl/hctz 1 GC

BENICAR 3 QL (30 EA per 30 days)

BENICAR HCT 3 QL (30 EA per 30 days)

betaxolol hcl tablet 10mg, 20mg 1 GC

BIDIL 4

bisoprolol fumarate 1 GC

bisoprolol fumarate/hctz 1 GC

bumetanide 1 GC

BYSTOLIC TABLET 2.5MG, 5MG 3 QL (90 EA per 30 days)

BYSTOLIC TABLET 10MG 3 QL (120 EA per 30 days)

BYSTOLIC TABLET 20MG 3 QL (60 EA per 30 days)

CALAN 4 GC

candesartan cilexetil/hctz 1 QL (30 EA per 30 days) GC

captopril 1 GC

captopril/hctz 1 GC

cartia xt 1 GC

48




carvedilol 1 GC

chlorothiazide 2 GC

chlorothiazide sodium 2 GC

chlorthalidone 1 GC

cholestyramine light packet 2 GC

clonidine hcl tablet 1 GC

colestipol hcl 2 GC

COREG CR 3 QL (30 EA per 30 days)

CORZIDE 4 GC

CRESTOR 3 QL (30 EA per 30 days)

DEMADEX 4 GC

digoxin 1 PA GC

dilacor xr 1 GC

DILATRATE SR 4 GC

dilt-cd 1 GC

dilt-xr 1 GC

diltiazem cd 1 GC

diltiazem hcl er 1 GC

diltiazem hcl injection, tablet 1 GC

diltzac 1 GC

DIOVAN HCT 4 QL (30 EA per 30 days)

DIOVAN TABLET 40MG, 80MG, 160MG 4 QL (60 EA per 30 days)

DIOVAN TABLET 320MG 4 QL (30 EA per 30 days)

disopyramide phosphate 2 PA GC

doxazosin mesylate 1 GC

DUTOPROL 4 QL (60 EA per 30 days)

DYAZIDE 4 GC

DYRENIUM 4 GC

enalapril maleate 1 GC

enalapril maleate/hctz 1 GC

eplerenone 2 GC

49




EXFORGE 3 QL (30 EA per 30 days)

EXFORGE HCT 3 QL (30 EA per 30 days)

felodipine er 2 QL (60 EA per 30 days) GC

fenofibrate micronized 2 QL (30 EA per 30 days) GC

fenofibrate tablet 48mg, 54mg 2 QL (60 EA per 30 days) GC

fenofibrate tablet 145mg, 160mg 2 QL (30 EA per 30 days) GC

flecainide acetate 2 GC

fluvastatin capsule 20mg 1 QL (30 EA per 30 days) GC

fluvastatin capsule 40mg 1 QL (60 EA per 30 days) GC

fosinopril sodium 1 GC

fosinopril sodium/hctz 2 GC

furosemide 1 GC

gemfibrozil 1 GC

guanfacine hcl 1 PA GC

hydralazine hcl 1 GC

hydrochlorothiazide 1 GC

indapamide 1 GC

INNOPRAN XL 4

irbesartan 1 QL (30 EA per 30 days) GC

irbesartan/hctz 1 QL (30 EA per 30 days) GC

isosorbide dinitrate 1 GC

isosorbide dinitrate er 1 GC

isosorbide mononitrate 1 GC

isosorbide mononitrate er 1 GC

isradipine 2 GC

JUXTAPID 5

KYNAMRO 5

labetalol hcl 1 GC

LANOXIN 3 PA

LANOXIN PEDIATRIC 3 PA

LASIX 4 GC

50




LESCOL XL 4 QL (30 EA per 30 days)

lisinopril 1 GC

lisinopril/hctz 1 GC

LOPRESSOR HCT 4 GC

losartan potassium/hctz tablet 50mg/12.5mg 1 QL (60 EA per 30 days) GC

losartan potassium/hctz tablet 100mg/12.5mg, 100mg/25mg 1 QL (30 EA per 30 days) GC

losartan potassium tablet 25mg 1 QL (90 EA per 30 days) GC



LOTENSIN 4 GC

LOTENSIN HCT 4 GC

lovastatin tablet 10mg, 20mg 1 QL (90 EA per 30 days) GC

lovastatin tablet 40mg 1 QL (60 EA per 30 days) GC

LOVAZA 3

MAVIK 4 GC

MAXZIDE 4 GC

MAXZIDE-25 4 GC

methazolamide 2 GC

methyclothiazide 2 GC

methyldopa 2 PA GC

methyldopa/hctz 2 PA GC

methyldopate hcl 2 PA GC

metolazone 2 GC

metoprolol succinate er tablet 25mg, 50mg, 100mg 1 QL (90 EA per 30 days) GC

metoprolol succinate er tablet 200mg 1 QL (60 EA per 30 days) GC

metoprolol tartrate 1 GC

metoprolol/hctz 1 GC

mexiletine hcl 2 GC

MICARDIS 4 QL (30 EA per 30 days)

MICARDIS HCT 4 QL (30 EA per 30 days)

midodrine hcl 2 GC

51




MINIPRESS 4 GC

minitran 2 GC

minoxidil 2 GC

moexipril hcl 1 GC

moexipril/hctz 1 GC

MULTAQ 3 QL (60 EA per 30 days)

nadolol 1 GC

nadolol/bendroflumethiazide 1 GC

NIASPAN TABLET ER 500MG 4 QL (30 EA per 30 days)

NIASPAN TABLET ER 750MG, 1000MG 4 QL (60 EA per 30 days)

nicardipine hcl 2 GC

nifediac cc 1 GC

nifedical xl 1 GC

nifedipine 2 PA GC

nifedipine er 1 GC

nimodipine 2 GC

nisoldipine 2 QL (30 EA per 30 days) GC

nisoldipine er 2 QL (30 EA per 30 days) GC

NITRO-BID 4

NITRO-DUR 4 GC

nitroglycerin transdermal patch 1 GC

nitroglycerin injection 2 GC

NITROLINGUAL PUMPSPRAY 3

NITROSTAT 3 GC

pacerone 1 GC

pentoxifylline er 1 GC

perindopril erbumine 2 GC

pindolol 2 GC

pravastatin sodium tablet 10mg, 20mg 1 QL (90 EA per 30 days) GC

pravastatin sodium tablet 40mg 1 QL (60 EA per 30 days) GC

pravastatin sodium tablet 80mg 1 QL (30 EA per 30 days) GC

52




prazosin hcl 2 GC

prevalite powder 2 GC

PRINIVIL 4 GC

procainamide hcl 2 GC

propafenone hcl 2 GC

propranolol hcl 2 GC

propranolol hcl er 2 GC

propranolol/hctz 1 GC

quinapril hcl 1 GC

quinapril/hctz 2 GC

quinidine gluconate 2 GC

quinidine gluconate cr 2 GC

quinidine sulfate 2 GC

quinidine sulfate er 2 GC

ramipril 1 GC

RANEXA 3

RECTIV 4

reserpine 2 PA GC

SIMCOR TABLET ER 500MG/20MG, 500MG/40MG, 1000MG/40MG

3 QL (30 EA per 30 days)

SIMCOR TABLET ER 750MG/20MG, 1000MG/20MG 3 QL (60 EA per 30 days)

simvastatin tablet 5mg, 10mg, 20mg 1 QL (90 EA per 30 days) GC

simvastatin tablet 40mg 1 QL (45 EA per 30 days) GC

simvastatin tablet 80mg 1 QL (30 EA per 30 days) GC

sorine 1 GC

sotalol hcl 1 GC

sotalol hcl (af) 1 GC

spironolactone 1 GC

spironolactone/hctz 1 GC

TARKA TABLET ER 1MG/240MG, 2MG/180MG, 2MG/240MG 4 QL (30 EA per 30 days)

TARKA TABLET ER 4MG/240MG 4 QL (60 EA per 30 days)

53




taztia xt 1 GC

TEKAMLO 4 QL (30 EA per 30 days)

TEKTURNA 4 QL (30 EA per 30 days)

TEKTURNA HCT 4 QL (30 EA per 30 days)

terazosin hcl 1 GC

TIKOSYN 4

timolol maleate tablet 1 GC

TOPROL XL TABLET ER 25MG, 50MG, 100MG 4 QL (90 EA per 30 days)

TOPROL XL TABLET ER 200MG 4 QL (60 EA per 30 days)

torsemide 1 GC

trandolapril 1 GC

triamterene/hctz 1 GC

TRILIPIX CAPSULE 45MG 4 QL (60 EA per 30 days)

TRILIPIX CAPSULE 135MG 4 QL (30 EA per 30 days)

TWYNSTA 4 QL (30 EA per 30 days)

UNIRETIC 4 GC

valsartan/hctz 1 QL (30 EA per 30 days) GC

verapamil hcl 1 GC

verapamil hcl er 1 GC

verapamil hcl sr 1 GC

VYTORIN 4 QL (30 EA per 30 days)

WELCHOL 3

ZETIA 3 QL (30 EA per 30 days)

Central Nervous System Agents

ADDERALL XR CAPSULE 5MG, 10MG, 15MG 4 QL (30 EA per 30 days)

ADDERALL XR CAPSULE 20MG, 25MG, 30MG 4 QL (60 EA per 30 days)

amphetamine/dextroamphetamine capsule er 5mg, 10mg, 15mg 2 QL (30 EA per 30 days) GC

amphetamine/dextroamphetamine capsule er 20mg, 25mg, 30mg 2 QL (60 EA per 30 days) GC

amphetamine/dextroamphetamine tablet 2 GC

AMPYRA 5 QL (60 EA per 30 days) PA

AUBAGIO 5 QL (30 EA per 30 days) PA

54




AVONEX 5 PA

COPAXONE 5 PA

DAYTRANA 4 QL (30 EA per 30 days)

dexmethylphenidate hcl 2 GC

dextroamphetamine sulfate er 2 GC

dextroamphetamine sulfate tablet 2 GC

EXTAVIA 5 PA

GILENYA 5 QL (30 EA per 30 days) PA

INTUNIV 4 QL (30 EA per 30 days) PA

metadate er 2 GC

methamphetamine hcl 2 PA GC

METHYLIN TABLET CHEWABLE 4

methylphenidate hcl 2 GC

methylphenidate hcl cd capsule 10mg, 20mg, 30mg, 40mg, 50mg, 60mg

2 GC

methylphenidate hcl er capsule 20mg, 30mg, 40mg 2 GC

methylphenidate hcl er tablet 10mg, 20mg 2 GC

methylphenidate hcl er tablet 18mg, 27mg, 36mg, 54mg 2 QL (30 EA per 30 days) GC

NUEDEXTA 3 QL (60 EA per 30 days)

procentra 2 GC

REBIF 5 PA

REBIF TITRATION PACK 5 PA

riluzole 2 GC

SAVELLA 3 QL (60 EA per 30 days)

SAVELLA TITRATION PACK 3 QL (55 EA per 30 days)

STRATTERA CAPSULE 10MG, 18MG, 25MG, 40MG 3 QL (60 EA per 30 days)

STRATTERA CAPSULE 60MG, 80MG, 100MG 3 QL (30 EA per 30 days)

XENAZINE 5 RA

Dental and Oral Agents

chlorhexidine gluconate oral rinse 2 GC

KEPIVANCE 5

55




periogard 2 GC

pilocarpine hcl tablet 2 GC

triamcinolone in orabase 2 GC

Dermatological Agents

8-MOP 3

ammonium lactate rx 2 GC

amnesteem 2 GC

calcipotriene 2 GC

CARAC 4

claravis 2 GC

clindamycin phosphate foam 1% 2 GC

clindamycin phosphate gel 1% 2 GC

clindamycin phosphate lotion 1% 2 GC

clindamycin phosphate solution 1% 2 GC

clindamycin phosphate swab 1% 2 GC

CONDYLOX GEL 4 GC

DOVONEX 4 GC

ELIDEL 4

erythromycin/benzoyl peroxide 2 GC

fluorouracil cream 5% 2 GC

fluorouracil topical solution 2%, 5% 2 GC

imiquimod 2 GC

KLARON 4 GC

myorisan 2 GC

OXSORALEN 4

OXSORALEN ULTRA 3

podofilox 2 GC

PRUDOXIN 3

REGRANEX 5 QL (30 GM per 30 days) PA

SANTYL 3

selenium sulfide lotion 2 GC

56




SOLARAZE 3

SORIATANE 5

sulfacetamide sodium suspension 10% 2 GC

TAZORAC 4

tretinoin cream 0.025%, 0.05%, 0.1% 2 PA GC

tretinoin gel 0.01%, 0.025% 2 PA GC

UVADEX 3 BvsD

VOLTAREN 3

ZONALON 3

ZYCLARA 3

ZYCLARA PUMP 3

Enzyme Replacement/Modifiers

ADAGEN 5

ALDURAZYME 5

BUPHENYL 5

CEREZYME 5

CREON 3

CYSTADANE 5

CYSTAGON 3

ELAPRASE 5

ELELYSO 5

FABRAZYME 5

KUVAN 5

LUMIZYME 5

MYOZYME 5

NAGLAZYME 5

ORFADIN 5

PANCRELIPASE 4

RAVICTI 5

sodium phenylbutyrate 2 GC

SUCRAID 5

57




VPRIV 5 BvsD

XIAFLEX 5 PA

ZAVESCA 5

ZENPEP 3

Gastrointestinal Agents

ACIPHEX 4 QL (60 EA per 30 days)

AMITIZA 3 QL (60 EA per 30 days)

atropine sulfate 2 GC

CARAFATE 4

CHENODAL 5

cimetidine 1 GC

cimetidine hcl 1 GC

constulose 2 GC

cromolyn sodium concentrate 100mg/5ml 2 GC

CUVPOSA 4

DEXILANT 4 QL (60 EA per 30 days)

dicyclomine hcl 2 GC

diphenoxylate/atropine 2 GC

enulose 2 GC

famotidine injection 1 GC

famotidine tablet 20mg, 40mg rx 1 GC

GATTEX 5 PA

gavilyte-c 2 GC

gavilyte-g 2 GC

gavilyte-n/flavor pack 2 GC

generlac 2 GC

glycopyrrolate 2 GC

GOLYTELY 3 GC

HALFLYTELY BOWEL PREP/FLAVOR PACKS 3

lactulose 2 GC

lansoprazole 2 QL (60 EA per 30 days) GC

58




loperamide hcl capsule rx 2 GC

LOTRONEX 5 PA

methscopolamine bromide 2 GC

metoclopramide hcl 2 GC

misoprostol 2 GC

MOVIPREP 4

NEXIUM 3 QL (60 EA per 30 days)

NEXIUM I.V. 3

NULYTELY/FLAVOR PACKS 3 GC

omeprazole capsule delayed release rx 1 QL (60 EA per 30 days) GC

OSMOPREP 4 GC

pantoprazole sodium injection 1 GC

pantoprazole sodium tablet delayed release 1 QL (60 EA per 30 days) GC

polyethylene glycol 3350 powder 2 GC

propantheline bromide 2 GC

ranitidine hcl capsule, injection, syrup 1 GC

ranitidine hcl tablet 150mg, 300mg rx 1 GC

RELISTOR 3

sucralfate tablet 1 GC

ursodiol 2 GC

Genitourinary Agents

alfuzosin hcl er 2 QL (30 EA per 30 days) GC

AVODART 3 QL (30 EA per 30 days)

bethanechol chloride 2 GC

calcium acetate capsule 2 GC

CIALIS TABLET 2.5MG, 5MG 3 QL (30 EA per 30 days) PA

DETROL LA 4 QL (30 EA per 30 days) ST

eliphos 2 GC

ELMIRON 4

finasteride tablet 5mg 2 GC

flavoxate hcl 2 GC

59




FOSRENOL 3

GELNIQUE GEL 3% 3 QL (92 GM per 30 days)

GELNIQUE GEL 10% 3 QL (30 GM per 30 days)

JALYN 3 QL (30 EA per 30 days)

MYRBETRIQ 4 QL (30 EA per 30 days)

oxybutynin chloride 2 GC

oxybutynin chloride er tablet 5mg 2 QL (30 EA per 30 days) GC

oxybutynin chloride er tablet 10mg, 15mg 2 QL (60 EA per 30 days) GC

PHOSLO 3

PHOSLYRA 3

RAPAFLO 3 QL (30 EA per 30 days) ST

RENVELA 3

tamsulosin hcl 2 GC

tolterodine tartrate 2 QL (60 EA per 30 days) GC

TOVIAZ 4 QL (30 EA per 30 days) ST

trospium chloride 2 QL (60 EA per 30 days) GC

trospium chloride er 2 QL (30 EA per 30 days) GC

VESICARE 3 QL (30 EA per 30 days)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

a-hydrocort 2 BvsD GC

A-METHAPRED 2 BvsD GC

ala cort 2 GC

alclometasone dipropionate 2 GC

amcinonide 2 GC

ANUSOL-HC CREAM 4 GC

ARISTOSPAN INTRA-ARTICULAR 4

ARISTOSPAN INTRALESIONAL 4

augmented betamethasone dipropionate 2 GC

betamethasone dipropionate 2 GC

betamethasone valerate cream, lotion, ointment 2 GC

clobetasol propionate foam, gel, lotion, ointment, shampoo, solution 2 GC

60




clobetasol propionate e cream 2 GC

cortisone acetate 2 GC

DEPO-MEDROL 4 BvsD

DERMATOP 4 GC

desonide 2 GC

desoximetasone 2 GC

dexamethasone 2 GC

dexamethasone intensol 2 GC

dexamethasone sodium phosphate 2 GC

diflorasone diacetate 2 GC

ELOCON 4 GC

fludrocortisone acetate 2 GC

fluocinolone acetonide 2 GC

fluocinolone acetonide body 2 GC

fluocinonide 2 GC

fluocinonide-e 2 GC

fluticasone propionate cream 0.05% 2 GC

fluticasone propionate lotion 0.05% 2 GC

fluticasone propionate ointment 0.005% 2 GC

halobetasol propionate 2 GC

hydrocortisone cream 1%, 2.5% 2 GC

hydrocortisone lotion 2.5% 2 GC

hydrocortisone ointment 1%, 2.5% 2 GC

hydrocortisone tablet 2 GC

hydrocortisone butyrate 2 GC

hydrocortisone valerate 2 GC

lokara 2 GC

LOTRISONE 4 GC

MEDROL DOSEPAK 4 GC

methylprednisolone 2 GC

methylprednisolone acetate 2 BvsD GC

61




methylprednisolone dose pack 2 GC

methylprednisolone sodium succinate injection 2 BvsD GC

mometasone furoate cream, ointment, solution 2 GC

PANDEL 3

prednicarbate 2 GC

prednisolone sodium phosphate solution 5mg/5ml, 15mg/5ml 2 GC

prednisone 2 GC

prednisone intensol 2 GC

procto-pak 2 GC

PROCTOCORT CREAM 4

proctocream hc 2 GC

proctosol hc 2 GC

proctozone-hc 2 GC

SOLU-CORTEF 3 BvsD

SOLU-MEDROL 3 BvsD

triamcinolone acetonide cream 0.025%, 0.1%, 0.5% 2 GC

triamcinolone acetonide lotion 0.025%, 0.1% 2 GC

triamcinolone acetonide ointment 0.025%, 0.1%, 0.5% 2 GC

triderm 2 GC

Documents

(List of Covered Drugs) - cigna.com · 2014 Comprehensive Formulary – Cigna Medicare Rx Secure‑Max. What is the Cigna Medicare Rx Comprehensive Formulary? A formulary is a list