2015

MVP Health Insurance

MARKETPLACE FORMULARY New York-Vermont • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Effective January 1, 2015

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

2

2015 MARKETPLACE FORMULARY

EFFECTIVE January 1, 2015

This information relates to the Marketplace Formulary, generally, and may not describe your particular coverage. Your specific Plan documents determine your benefits, including copays, coinsurance, deductibles, out-of-pocket maximums and any limitations and exclusions. Your physician is the person best suited to help you make decisions about prescription drugs, and the prescription drug information below is intended for consumer guidance only.

While every effort has been made to insure accuracy, some information may be out of date. The Marketplace Formulary is subject to change based on decisions made by the Pharmacy & Therapeutics (P&T) committee. New drugs are not covered until reviewed by the P&T committee. Medications with an over-the-counter equivalent are not a covered benefit.

Drugs entering the market between 1938 and 1962 that were approved for safety but not effectiveness are called “DESI” drugs. DESI drugs are not covered on the Marketplace Formulary.

In the case of some drugs, the Plan limits coverage to a specific quantity or a specific course of treatment. The Plan may also require prior authorization on some covered drugs. If you need more information about policies regarding a specific drug, consult your physician or contact the MVP Customer Care Center. If the medication you take is not listed below, contact the Customer Care Center at the phone number listed on the back of your MVP ID card.

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

ACE Inhibitors** (blood pressure lowering, includes HCTZ combination products)

benazepril captopril enalapril fosinopril lisinopril

moexipril perindopril quinapril ramipril trandolapril

None AccuprilBR AccureticBR AceonBR AltaceBR LotensinBR Epaned MavikBR

PrinivilBR UnireticBR UnivascBR VasotecBR

ZestrilBR ZestoreticBR

Adrenal Hormones Oral**

cortisone dexamethasone fludrocortisone hydrocortisone methylprednisolone prednisolone prednisone

Millipred Acthar-HP#,+ CortefBR Dexpak MedrolBR Medrol 2mg Orapred ODT Pediapred BR Prelone BR

Rayos NFNC

Adrenergic Antagonists**

clonidine doxazosin guanabenz guanfacine

methyldopa/ HCTZ prazosin reserpine terazosin

clonidine patch midodrine

CarduraBR

Cardura XL Catapres/TTSBR MinipressBR TenexBR

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

3

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Alzheimer’s Agents**

galantamine

donepezil ergoloid Namenda XR rivastigmine

Aricept/ODTBR ExelonBR Exelon patch Razadyne/ERBR

Androgens (male hormones)

danazol testosterone injq

Androgel*,q

oxandroloneq Testim*,q BR

Anadrol-50# Androderm# *,q Androidq # Androxyq Aveed# Axiron # q Delatestrylq BR # Depo-Testerone,q # Depo-Testosterone 100mgq # First-Testo Cr*,q # Fortesta*,q # Oxandrinq BR #

Methitestq #

Striant*,q # testosterone gelq Testred*,q #

Vogelxo#

Aveed# Testopelq

ARBs/Renin Inhibitors** (includes combination products)

candesartan eprosartan irbesartan losartan telmisartan/amlodipine

amlodipine/ valsartan valsartan

Amturnide Atacand BR Avalide BR Avapro BR Azor Benicar/HCT Cozaar BR Diovan/HCT BR Edarbi Edarbyclor

Exforge BR Hyzaar BR Micardis/HCT BR Tekamlo Tekturna/HCT Teveten BR Teveten HCT Tribenzor Twynsta BR

Anti -Anxiety Agents**

alprazolam/ER buspirone chlordiazepoxide clorazepate diazepam lorazepam oxazepam

alprazolam intensol diazepam Intensol

AtivanBR NiravamBR Tranxene-TBR ValiumBR Xanax/XRBR

Antiarrhythmics** (heart rhythm)

amiodarone disopyramide flecainide mexiletine Pacerone propafenone quinidine Sorine sotalol/AF

propafenone SR

Betapace/AFBR CordaroneBR Multaq NorpaceBR Norpace CR

Rythmol/SRBR TambocorBR Tikosyn+

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

4

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Antibiotics amoxicillin amoxicillin/ clavulanate amoxicillin/ clavulanate XR ampicillin azithromycin cefaclorcefadroxil cefdinir cefditren cefpodoxime cefprozil cefuroxime cephalexin cephradine ciprofloxacin/ER clarithromycin/ER clindamycin dicloxacillin ees/sulfisoxazole Erythrocin erythromycin levofloxacin minocycline/XR neomycin ofloxacin paromomycin penicillin sulfadiazine sulfa/trimeth DS/SS tetracycline

Avidoxy Baci-IM inj bacitracin inj cefepime inj ceftriaxone inj#

Clindess clindamycin palmitate demeclocycline doxycycline Morgidox moxifloxacin vancomycin

AdoxaBR Augmen/ES/XRBR AveloxBR Bactrim/DSBR Biaxin XLBR CedaxBR Cefaclor ER CeftinBR Ceftin susp Cipro/XRBR CleocinBR Cleocin 75mg Cleocin Vaginal Doryx 150mg# BR

Doryx 200mg# doxycycline 20mg Dynabac E.E.S. Susp Eryped Ery-Tab Erythromycin Base Factive

KeflexBR

Ketek LevaquinBR MinocinBR MonodoxBR Moxatag Noroxin Oracea# Rocephin# BR PCE Sivextro# Solodyn# SpectracefBR Sulfadiazine Suprax Tygacil inj VancocinBR

Vibativ VibramycinBR Vibramycin syrup Xifaxan 200 mg# ZithromaxBR Z-Max Zyvoxq

Dalvance# Teflaro Zyvox Inj#

Anticoagulants heparin Jantoven* warfarin*

Eliquis* enoxaparin fondaparinux Xarelto*

ArixtraBR Coumadin* Fragmin Heparin Lock FlushNFNC

Iprivask LovenoxBR Pradaxa# *

Anticonvulsants** (seizures)

carbamazepine clonazepam diazepam rectal divalproex Epitol ethosuximide gabapentin lamotrigine/XR

phenobarbital phenytoin primidone Topiragen topiramate valproic acid zonisamide

carbamazepine ER Celontin divalproex ER felbamate levetiracetam/SR oxcarbazepine Peganone tiagabine

Aptiom# Banzel CarbatrolBR DepakeneBR Depakote/ERBR DiastatBR Dilantin FelbatolBR

Fycompa# GabitrilBR

Keppra/XRBR KlonopinBR Lamictal/XRBR Lamictal ODT Lyrica

MysolineBR NeurontinBR Onfi Oxtellar XR Phenytek BR Potiga Sabril+ Stavzor Tegretol/ XRBR TopamaxBR TrileptalBR Trokendi XR Vimpat ZarontinBR ZonegranBR

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

5

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Antidepressan ts**

amitriptyline amoxapine bupropion/SR/XL budeprion/SR/XL citalopram desipramine doxepin escitalopram fluoxetine fluvoxamine/CR hydroxyzine pamoate imipramine imipramine pamoate

maprotiline mirtazapine nefazodone nortriptyline paroxetine/ER phenelzine protriptyline Selfemra sertraline tranylcypromin trazodone trimipramine venlafaxine

clomipramine duloxetine venlafaxine ER olanzepine/ fluoxetinest

AnafranilBR Aplenzin Brintellix Brisdelle# CelexaBR CymbaltaBR Desvenlafaxine ER Effexor XRBR Emsam Fetzima Forfivo XL Khedezla# LexaproBR Luvox CRBR Marplan NardilBR NorpraminBR

Oleptro ER

PamelorBR ParnateBR Paxil susp Paxil/CRBR Pexeva Pristiq ER Prozac/WeekBR RemeronBR SarafemNFNC SurmontilBR Symbyaxst BR Tofranil/PMBR Venlafaxine ext-rel TabsBR Viibryd VivactilBR Wellbutrin/SR/XLBR ZoloftBR

Antiemetics (nausea)

Compro ondansetronq prochlorperazine promethazine

trimethobenzamid dronabinol granisetronq

Anzemetq Cesamet DiclegisQ Emendq Granisolq MarinolBR

Sancusoq TiganBR Transderm-Scop Zofran/ODTq BR Zuplenzq

Aloxi# Emend Inj#

Antifungal Agents

clotrimazole oral fluconazole griseofulvin ketoconazole nystatin terbinafineq

griseofulvin ultra itraconazole#

voriconazole

AncobonBR

Cancidas DiflucanBR Grifulvin VBR Gris-PegBR Jublia# Kerydin# Lamisil Granulesq Mycamine inj

Lamisilq BR NizoralBR Noxafil Onmel# Oravig Sporanox# BR Sporanox soln# VfendBR

Antihistamines** Various generics azelastine clemastine cyproheptadine chlorpheniramine

diphenhydramine hydroxyzine levocetirizine promethazine

desloratadine

Various brands Astelin NasalBR

Astepro Brovex

ClarinexBR Clarinex syrup Patanase XyzalBR

Antihistamine/ Decongestant Combinations

Various generics None Various brands# Clarinex D#

Semprex-D#

Antihypertensive Combinations** (blood pressure lowering)

amlodipine/atorvastatin amlodipine/benazepril atenolol/chlorthalidone Clorpres nadolol/bendroflumethzide trandolapril/verapamil

Demser Bidil CaduetBR CorzideBR Lopressor HCTBR

LotrelBR Tarka TenoreticBR ZiacBR

Antimalarials chloroquine# hydroxychloroquine* mefloquine# quinine sulfate#

atovaquone/ proguanil#

Aralen# Coartem# Daraprim#

Malarone# BR

Plaquenil* BR Primaquine# Qualaquin# BR

Seromycin#

Anti -mycobacterials** (TB)

ethambutol isoniazid pyrazinamide

rifampin rifampin/ isoniazid

Priftin Mycobutin Paser Rifater

Sirturo Trecator

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

6

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Antiparasitics metronidazole paromomycin tinidazole

atovaquone# Albenza Alinia Biltricide Dapsone FlagylBR

Flagyl ER Mepron# BR Stromectol TindamaxBR Yodoxin

Antiplatelet Agents**

anagrelide cilostazol clopidogrel

dipyridamole ticlopidine

None Aggrenox AgrylinBR Brilinta Effient

PersantineBR PlavixBR PletalBR

Antipsychotics** chlorpromazine clozapine/ODT fluphenazine haloperidol lithium loxapine

perphenazine quetiapine risperidone/ODT thioridazine thiothixene trifluoperazine

olanzapine/ODT olanzapine/ fluoxetinest ziprazidone

Abilifyst

ClozarilBR Equetro Fanapt FazaCloBR GeodonBR Invega Latuda LithobidBR

LoxitaneBR Orap RisperdalBR Saphris SeroquelBR Seroquel XRst Symbyaxst BR Versacloz# ZyprexaBR

Abilify Maintena# Adasuve# Invega Sustenna Risperdal Consta Zyprexa Relprevv

Antiretrovirals/ HIV

None abacavir* abacavir/lamivudine/zidovudine*

Aptivus* Atripla* Crixivan* didanosine* Emtriva* Epivir soln* Epzicom* Invirase* Isentress* Kaletra* lamivudine* lamivudi/zidov* Lexiva* nevirapine* Norvir* Prezista* Rescriptor* Reyataz* Selzentry* stavudine* Sustiva* Truvada* Viracept* Viread tabs* zidovudine*

Combivir* BR Complera* Edurant* Egrifta+ Epivir tabs* BR Fuzeon+ Intelence* Retrovir* BR Stribild* Tivicay*

Trizivir*BR Videx * Videx EC* BR Viramune* BR Viramune XR* Viread Powder* Zerit* BR Ziagen* BR Ziagen soln*

Antispasmodic Agents**

bethanechol dicyclomine flavoxate oxybutynin/ER propantheline Symax/SL/SR

methscopolomine Myrbetriq

tolterodine/ER trospium

Anaspaz BentylBR Cantil Detrol/LABR Ditropan/XLBR Enablex# Gelnique LevbidBR

Levsin/SLBR NulevBR Pamine /ForteBR Robinul/ForteBR Sanctura/XR# Symax Duotab Toviaz Vesicare

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

7

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Antitussives & Expectorants

Various generics benzonatate codeine combinations hydrocod combinations

None All brands Entex# (all) TussionexBR #

Antiviral Agents acyclovir amantadine ganciclovir rimantadine valacyclovir

famciclovir Tamifluq

Denavir FamvirBR FlumadineBR Lidovir Sitavig#

Relenzaq Valcyte ValtrexBR ZoviraxBR Zovirax cr

Arthritis Agents azathioprine* hydroxychloroquine* leflunomide* methotrexate* sulfasalazine*

Enbrel#,+ Humira#,+

Ridaura*

Actemra SQ#+ Arava* BR Cimzia#,+ Ilaris#+ Kineret#,+ Orencia#,+

Otezla# Otrexup#

Rasuvo# Remicade#,+ Rheumatrex* Rituxan#+ Simponi#,+ Trexall* Xeljanz#+

Actemra IV#+ Benlysta#+

Orencia IV#,+

Simponi Aria# +

Benign Prostatic Hypertrophy (BPH) Agents** (prostate)

alfluzosin doxazosin finasteride tamsulosin terazosin caps

None Avodart Cardura XL Cialis 2.5 mg# Cialis 5 mg# Flomax BR

Jalyn ProscarBR Rapaflo UroxatralBR

Beta-Blocking Agents** (blood pressure Lowering, includes HCTZ combination products)

acebutolol atenolol betaxolol bisoprolol carvedilol labetalol

metoprolol/XL nadolol pindolol propranolol/LA satolol/AF timolol

None Betapace/AFBR Bystolic CoregBR Coreg CR CorgardBR Dutoprol Inderal LABR Innopran XL

Levatol Lopressor/HCTBR SectralBR TenorminBR Toprol XLBR TrandateBR ZebetaBR

Blood Modifiers None Procrit+ Aranesp+ Epogen+ Leukine+ Mozobil+

Neulasta+ Neumega+ Neupogen+ NPlate+ Promacta+

Granix#

Botulinum Toxins None None Dysport#+

Botox#+ Myobloc#+ Xeomin#+

Calcium Channel Blocking Agents (CCB)** (blood pressure lowering)

Afeditab amlodipine Cartia XT Dilt-CD Dilt XR Diltzac diltiazem/ER/XT felodipine isradipine

Matzim LA Nicardipine Nifediac CC Nifedical XL nifedipine/ER Taztia XT verapamil/ER/PM

nimodipine nisoldipine

Adalat CCBR Calan/SRBR Cardene SR Cardizem/CD/LA

BR Dilacor XRBR Nimotop

NorvascBR

Nymalize Procardia/XLBR SularBR TiazacBR Verelan/PMBR

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

8

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Cancer Drugs (oral drugs are covered under the chemotherapy benefit and may be subject to a copayment that differs from the pharmacy benefit)

anastrozole* bicalutamide* cyclophosphamide* etoposide flutamide* hydroxyurea* leucovorin mercaptopurine* methotrexate* tamoxifen* tretinoin

Alkeran* capecitabine+ Ceenu* Droxia Emcyt exemestane* Fareston* Gleevec+ Hexalen letrozole* Leukeran* Lomustine Lysodren Matulane megestrol* Mesnex Nilandron* Tabloid temozolomide+ tretinoin oral

Afinitor+ Arimidex* BR Aromasin* BR Bosulif+ Caprelsa Casodex* BR Cometriq# Erivedge+ Femara* BR Gilotrif+ Hycamtin+

HydreaBR

Iclusig Imbruvica# Inlyta+ Jakafi#+

Megace* BR

Megace ES* Mekinist+ Myleran Nexavar+ Pomalyst+

Purinethol* BR Purixan# Soltamox* Sprycel+ Stivarga+ Sutent+

Synribo+ Sylatron+ Tafinlar+ Tarceva+ Targretin+ Tasigna+

Temodar+ BR

Torisel+ Tykerb#,+ Votrient+ Xalkori+ Xeloda+BR Zelboraf+ Zolinza#,+

Zydeliq#,+ Zykadia#,+

Adcetris+ Beleodaq# Clolar# Cyramza# Erwinaze Folotyn#+ Fusilev#+

Gazyva#

Halaven#+ Ixempra+ Kadcyla#+ Kyprolis Marqibo Perjeta#+ Temodar IV+ Treanda+,# Yervoy+

Zaltrap+

Cardiac Glycosides** (heart)

digoxin digoxin elixir

None Lanoxin

CNS Stimulants (ADHD)

Metadate ER 20mg*

Amphetamine combination/XR* clonidine ER* dexmethylphenidate* dextroamphetamine* methylphen/ER/CD

modafinilq

Adderall/XR* BR Concerta* BR Daytrana* Dexedrine* BR Focalin/XR* BR Intuniv* Kapvay*BR

Liquadd* Metadate CDBR

Methylin Nuvigilq

Provigilq BR

Quillivant XR Ritalin/ LA/SR* BR RitalinLA 10mg cp* Strattera* Vyvanse* Xyrem#

Compounds coverage for compounded medications is subject to criteria listed in the Compounded (extemporaneous) Medications policy

None

None

• All compounds > $100 require prior authorization

• All compounds are tier 3

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

9

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Contraceptives (Oral/Topical/ Other)

Altavera* Alyacen* Amethia/Lo* Amethyst* Apri* Aranelle* Aviane* Azurette* Balziva* Briellyn* Camila* Camrese/Lo* Caziant* Cryselle* Cyclafem Dasetta* Elinest* Emoquette* Enpresse* Enskyce* Errin* Falmina* Gianvi* Gildess/Fe* Heather* Introvale* Jencycla* Jolessa* Jolivette* Junel/Fe* Kariva* Kelnor* Kurvelo* Larin Fe* Leena* Lessina* Levonest* levonorgestrel Levora* Loryna* Low-Ogestrel* Lutera* Marlissa* medroxy- progesterone/inj

Microgestin/Fe* Mono-Linyah* Mononessa* My Way* Myzilra* Necon* Next Choice/ One Step Nora-Be* norelgest-EE* Nortrel* Ocella* Ogestrel* Orsythia* Philith* Pirmella* Portia* Previfem* Quasense* Reclipsen* Solia* Sprintec* Sronyx* Syeda* Tilia Fe* Trinessa* Tri-Legest Fe* Tri-Linyah* Tri-Lo Sprintec* Tri-Previfem* Tri-Sprintec* Trivora* Velivet* Vestura* Vyfemla* Viorele* Wera* Wymzya Fe* Xulane* Zarah* Zenchent/Fe* Zeosa* Zovia*

Mirena+ Skyla+

Alesse* Beyaz* Brevicon* BR Cyclessa* BR Depo-Provera BR Depo-SQ Provera Desogen* BR Ella Estrostep FE* BR Femcon Fe* BR Generess Fe* Levlen* Levlite* Loestrin/FE* BR Lo Loestrin FE* Lomedia 24 FE*# Lo Minastrin FE LoSeasonique* BR Micronor* BR Minastrin 24 FE Mircette* BR Modicon* BR Natazia* Nexplanon+ Norinyl* BR Nor-QD* BR Nuvaring* Ortho Evra*BR Ortho Novum* Ortho Tri-Cyclen Lo* Ortho Tri-Cyclen* BR Ortho-Cept* BR Ortho-Cyclen* BR Ovcon* BR Plan B OneStepBR Quartette* Safyral* Seasonique* BR Tri-Norinyl* BR Yasmin* BR Yaz* BR

Cough/Cold Various generics All brands PA All brands require PA Diabetic Agents: Insulin** Subject to your medical (NY) OR prescription drug (VT) benefit. See your plan materials for applicable deductible, coinsurance and/or copayment.

None Humalog/Mix Humulin Mix Humulin N/R Lantus/Solostar Novolin Mix Novolin N/R Novolog/Mix

Apidra/Solostar Levemir

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

10

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs. .

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Diabetic Agents: Other** Subject to your medical (NY) OR prescription drug (VT) benefit. See your plan materials for applicable deductible, coinsurance and/or copayment.

acarbose glimepiride glipizide ER/metformin glyburide glyburide micro glyburide/metformin metformin/ER nateglinide tolazamide tolbutamide

Glucagen Glucagon Invokana Janumet/XR Januvia Jentadueto pioglitazone pioglitazone-metformin pioglitazone/ glimepiride repaglinide Tradjenta Victoza

Actoplus Met XR ActosBR AmarylBR AvandametNFNC AvandarylNFNC

AvandiaNFNC Bydureon Byetta Cycloset# DiabetaBR DuetactBR

Farxiga# Glucophage/XRBR Glucotrol XLBR GlucovanceBR Glumetza

Glyset GlynaseBR Invokamet# Jardiance# Kazano# Kombiglyze XR# Nesina# Onglyza# Oseni#

PrandinBR PrandiMet Proglycem Precose BR RiometNFNC StarlixBR Symlin Tanzeum#

Diabetic Meters & Strips

• Subject to your medical (NY) OR prescription drug (VT) benefit. See your plan materials for applicable deductible, coinsurance and/or copayment.

• All test strips are subject to quantity limits

• Non-preferred test strips require prior authorization

Preferred Meters: Freestyle Freedom/Lite Freestyle Insulinx Freestyle Navigator Freestyle Sidekick One Touch Ultra Brand Meters One Touch Verio Brand Meters

Preferred Strips: Freestyle Freestyle Insulinx Freestyle Lite Precision One Touch Ultra Test Strips One Touch Verio Test Strips

Non-preferred test strips require prior authorization

Digestants/ Enzymes**

None Creon pancrelipase

Pancreaze Pertyze Ultresa

Viokace Zenpep

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

11

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Diuretics** acetazolamide amiloride/HCTZ bumetanide chlorothiazide furosemide hydrochlorothiazide indapamide methazolamide methyclothiazide metolazone spironolactone/HCTZ torsemide triamterene/HCTZ

eplerenone

AldactoneBR DemadexBR Diamox capsBR Diuril DyazideBR Dyrenium Edecrin

InspraBR LasixBR MaxzideBR MicrozideBR

NeptazaneBR Thalitone ZaroxolynBR

Enteral Therapy All products not listed in the MVP policy require prior authorization

All products not listed in the MVP policy require prior authorization

All products not listed in the MVP policy require prior authorization

All products not listed in the MVP policy require prior authorization

Erectile Dysfunction

yohimbine None Caverjectq Cialisq Cialis 2.5 mg# Cialis 5 mg#

Edexq

Levitraq Museq Staxynq

Stendraq # Viagraq

Fertility Agents clomiphene

HCG+ leuprolide#+

Novarel+ Follistim AQ#+

Bravelle#+ Cetrotide# + Ganirelix#+ Gonal-F#+

Lupron SQ# BR+

Lutrepulse#+ Menopur#+ Ovidrel+ Pregnyl+ Repronex#+

Gaucher’s Disease

None None Zavesca# Cerezyme#+ Ceredase#+ Elelyso# Vpriv#+

GI: Ulcer/ Heartburn Agents**

cimetidine famotidine lansoprazoleq nizatidine

omeprazole pantoprazoleq ranitidine

Carafate susp lanso/amox/clarit Nexiumq

omeprazole/ sod bicarbq

rabeprazoleq

sucralfate

Aciphexq,# BR Axid BR Carafate tabBR Dexilantq,#

First-Lansoprazole# First-Omeprazole# Omeclamox# Pepcid BR Prevpac

Prevacid Tabsq # Prevacid Capq,#, BR Prilosecq,#, BR Protonixq,#, BR Pylera Tagamet BR Zantac BR Zegerid#,q, BR

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

12

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

GI: Inflammatory Bowel & Misc.

balsalazide* metoclopramide* misoprostol* sulfasalazine/EN*

budesonide cevimeline cromolyn Delzicol* Kristalose Lialda* mesalamine ursodiol*

Actigall* BR Amitiza Apriso* Asacol HD* Azulfidine/EN*BR Canasa* Chenodal Cimzia #,+ Colazal* BR CortenemaBR Cortifoam Cytotec* BR Dipentum* Entocort EC*BR

EvoxacBR Fulyzaq GastrocromBR Gattex Giazo* Linzess Lotronex Metozolv ODT* Pentasa* Proctofoam/HC Relistor Rowasa* BR Uceris Urso/Forte* BR Visicol

Entyvio#

Gout** allopurinol probenecid/colchicine

None Colcrysq Uloric#

ZyloprimBR Krystexxa#+

Growth Failure Agents

None Nutropin/AQ/ Nuspin#,+

Genotropin#,+ Humatrope#,+ Increlex#,+ Norditropin#,+

Omnitrope#,+ Saizen#,+ Serostim#,+ Tev-Tropin#,+ Zorbtive+

Hormone Replacement Therapy**

estradiol estradiol/norethindrone estradiol patch estropipate Jinteli medroxyprogesterone Mimvey/Lo norethindrone progesterone cr/oral

Estring

ActivellaBR Alora Angeliq Cenestin ClimaraBR Climara Pro Combipatch Crinone Divigel Duavee# Elestrin Gel Endometrin Enjuvia EstraceBR

Estrace Vaginal Estrasorb Estrogel Evamist FemHRT

Femring Menest Menostar Minivelle OgenBR Osphena Progesterone supp Prefest Premarin Premphase Prempro Prochieve PrometriumBR ProveraBR Vagifem Vivelle-Dot

Makena+

Immunoglobulin Therapy Obtain through specialty pharmacy

None None Hizentra#

Carimune# Flebogamma# Gamastan# Gammagard# Gamunex/C# Iveegam# Octagam# Privigen# Vivaglobin#

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

13

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Immuno - modulators

None None Thalomid+ Revlimid +

Immuno -suppresants**

azathioprine

cyclosporine/ modified Gengraf Hecoria mycophenolate mycophenolic acid sirolimus tacrolimus

Astagraf XL Azasan Cellcept BR ImuranBR MyforticBR

Neoral Nulojix PrografBR RapamuneBR Sandimmune Zortress+

Interferons/ Others for Hepatitis

adefovir dipivoxil+ lamivudine+ Moderiba#+

entecavir Pegasys#,+

Ribasphere#,+

ribavirin#,+ Viread*

Baraclude+ BR Copegus#,+ Epivir-HBV BR+ Hepsera BR+ Incivek#,+ Infergen#,+ Intron-A+ Moderiba#+

Olysio#,+ Peg-Intron#,+ Rebetol#,+ Ribatab#,+, BR Ribapak#+ Sovaldi#,+ Tyzeka+ Victrelis#,+ Viread Powder*

Intranasal Corticosteroids**

flunisolide fluticasone triamcinolone

Nasonex Beconase AQ# Dymista# Flonase# BR Omnaris#

Qnasl# Rhinocort AQ# BR Veramyst# Zetonna#

Lipid/Cholesterol -Lowering Agents**

atorvastatin cholestyramine colestipol fenofibrate fenofibric acid gemfibrozil lovastatin niacinpravastatin Prevalite simvastatin

Crestor fluvastatin niacin ER Zetia

Advicor Altocor Altoprev AntaraBR Colestid BR Fenoglide Fibricor BR Juxtapid# Kynamro#+ LescolBR Lescol XL LipitorBR Lipofen Liptruzet Livalo LofibraBR

LopidBR Lovaza# BR

Niacor NiaspanBR PravacholBR Pravigard PAC Questran/LightBR Simcor TricorBR Triglide TriLipixBR Vascepa#

Vytorin Welchol ZocorBR

Migraine Agents butalbit/apap/caff/cod Migergot supp naratriptanq zolmitriptanq

dihydroergotamine rizatriptanq sumatriptanq

Alsumaq BR Amerge# q BR Axert#,q Cafergot Cambiaq DHEA-45BR Ergomar Esgic/PlusBR Fioricet BR Fiorinal BR Frova#,q Imitrex# q BR

Imitrex Inj# q BR Imitrex Nasalq # BR Maxalt/MLT# q BR Migranalq

Relpaxq # Sumavel DosePro#,q Treximet#,q Zomig/ZMT#,q, BR

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

14

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Miscellaneous Agents (in various classes)

deferoxamine+ riluzole sevelamer tranexamic acid triamcinolone dental vitamin K inj

aminocaproic acid ammonium Cl cabergoline calcitriol chromic Cl Cystagon+ desmopressin doxercalciferol Epipenq

K-Phos/No 2 levocarnitine manganese Cl manganese sul ocetreotide+ paricalcitrol phytonadione pilocarpine tab Stimate Synarel

Acetic acid NFNC Actimmune Adagen# Adrenaclickq # aminocaproic 1gm Amino-Cerv NFNC Aquoral Alferon N+ Arcalyst#+ Auvi-Qq #

Brisdelle Cafcit BR Cancidas vial Carbaglu# Cleocin Vag Supp Cuprimine* Cuvposa DDAVPBR Desferal+ Dificid Eliphos Exjade#+ Ferriprox Firazyr#+ Formaldehyde NFNC Fosrenol* Gelclair Gralise# Grastek# Gynazole-1 HectorolBR Horizant

Kalbitor#+ Korlym+ Kuvan#,+

Lupaneta Pack# LystedaBR Methyton Myalept# Mycamine vial Nascobal Nebupent Northera# Nuedexta Oralair# Phoslo BR Phoslyra Prepopik Procysbi# Ragwitek# Ravicti# + Renacidin NFNC Renagel* Renvela*BR Rezira# Samsca+ Sandostatin+ Savella Sensipar+ Signifor#

Somatuline Depot+

Somavert+ Suclear Suprep Velphoro# Xenazine+ ZemplarBR Zontivity# Zutripro#

Aldurazyme#+ Aralast NP+ Berinert#+ Ceprotin#,+ Cinryze#,+ Elaprase#+ Fabrazyme+ Feraheme Glassia+

Injectafer# Kcentra# Lumizyme#+

Myozyme#+ Naglazyme#+ Prolastin-C Sandostatin LAR

+

Soliris#,+ Supprelin-LA+ Sylvant# Vimizim# Vivitrol Voraxaze Xiaflex+ Zemaira

MS Agents None Avonex+ Copaxone+

Tecfidera,+

Ampyra#,+ Aubagio# + Betaseron+ #

Extavia#,+ Gilenya#,+ Rebif+ #

Tysabri#,+

Muscle Relaxants baclofen carisoprodol/cmpd chlorzoxazone

meprobamate methocarbamol tizanidine

carisoprodol cmpd w cod cyclobenzaprinedantrolene metaxalone orphenadrine cmp

Amrix NFNC DantriumBR Fexmid BR Parafon Forte DSC

BR

Lorzone

RobaxinBR SkelaxinBR SomaBR ZanaflexBR

Narcotic Antagonists/ Addiction Treatments

disulfiram naltrexone

acamprosate buprenorphine buprenorphine/naloxone

Antabuse BR Campral BR ReviaBR

Suboxone Film Zubsolv

Nitrates/Angina Others** (heart)

isosorbide dinitrate isosorbide mononitrate nitroglycerin SL nitroglycer patch

nitroglycerin spr Nitrostat

Dilatrate-SR ImdurBR Isordil TitradoseBR Isordil 40mg Minitran

Nitro-Dur NitromistBR

Nitrolingual SprayBR Ranexa Transderm-Nitro

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

15

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

NSAIDS** (pain & inflammation, arthritis)

diclofenac/misoprostol etodolac/XL flurbiprofen ibuprofen indomethacin ketoprofen meloxicam

nabumetone naproxen oxaprozin piroxicam salsalate sulindac tolmetin

fenoprofen ketoprofen ER ketorolac meclofenamate mefenamic acid Vimovo

Anaprox/DSBR ArthrotecBR CataflamBR Celebrex Daypro BR Duexis FeldeneBR Indocin MobicBR Nalfon

Naprelan NaprosynBR Pennsaid PonstelBR Sprix# Voltaren Gel Voltaren XR Zipsor Zorvolex

Opthalmic: Anti -Infective Agents

bac/neo/polym/HC bacitracin chloramphenicol ciprofloxacin erythromycin gentamicin levofloxacin

Ocudox ofloxacin polym/trimeth sulfacetamide tobramycin trifluridine

Vigamox AzaSite Besivance Bleph-10 Blephamide CiloxanBR Ciloxan oint Iquix Moxeza Natacyn

OcufloxBR PolytrimBR TobrexBR

Tobrex oint ViropticBR Zirgan Zymaxid BR

Opthalmic: Glaucoma Agents**

apraclonidine betaxolol brimonidine carbachol carteolol dorzolamide latanoprost levobunolol

metipranolol pilocarpine timolol/XE timolol/ dorzolamide

Lumigan Phospholine Iodide

Alphagan P.1% Azopt BetaganBR Betimol Betoptic-S Combigan CosoptBR Cosopt PF Iopidine BR

Isopto Carpine BR Istalol Pilopine-HS Simbrinza

Timoptic/XEBR Travatan Z TrusoptBR XalatanBR Zioptan

Opthalmic: Steroids, Antiinflammatory & Misc. Agents

azelastine bromfenac cromolyn dexamethasone diclofenac epinastine fluorometholone flurbiprofen naphazoline prednisolone tobramycin/dexameth

ketorolac Patanol

Acular/LS BR Acuvail Alocril Alomide Alrex Bepreve Betadine Bromday BR Cystaran#,+ Durezol ElestatBR Emadine Flarex FML BR FML Forte/SOP Ilevro Lastacaft Lotemax

Maxidex MaxitrolBR MydfrinBR Nevanac Ocufen BR Omnipred BR Optivar BR Pataday Pred Forte BR Pred Mild Pred-G Prolensa Restasis Tobradex Susp BR Tobradex oint Tobradex ST Vexol Zylet

Eylea+ Jetrea Lucentis+

Retisert#+

Osteoporosis/ Paget’s Agents

alendronate* etidronate* ibandronate*

calcitonin spray* Fortical* risedronate 150mg

Actonel* Actonel 150mg*BR Atelvia* Binosto* Boniva Tabs* BR Evista*BR Forteo+

Fosamax* BR Fosamax + D* Miacalcin Nasal* BR Xgeva+

Boniva IV Prolia+ Reclast+ zoledronic acid+

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

16

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Otic Preparations (ear)

acetic acid/ hydrocortisone antipyrine/benzo/glyceri benzocaine carbamide peroxide

ciprofloxacin fluocinolone neo/polym/HC ofloxacin

None Cerumenex Cetraxal Ciprodex Cipro HC Coly-Mycin S

Cortisporin-TC Cresylate Dermotic BR Trioxin

Pain Relievers (narcotic)

apap/codeine butorphanolq codeine hydrocodone/apap hydrocodone/ibuprofen hydromorphone levorphanol meperidine morphine IR/rectal oxycodone/APAP oxycodone/aspirin oxycodone/ERq,st oxycodone/ibuprofen pentazocine/naloxone Roxicet tabs tramadol tramadol ERq

Trezix Vicodin/ES/HP

fentanyl patchq,st fentanyl oralq,# methadone morphine ERq,st morphine 24HRq,st oxymorphone/ER

All brands Abstralq,# Actiqq,# BR Avinzaq,st, BR

Butransq,st

Capital w codeine Codeine sulf soln Conzipq DemerolBR DilaudidBR Dolophine BR Duragesicq,st BR

Embedaq,st

Exalgoq,st

Fentoraq,#

Fioricet /w cod BR Fiorinal/w cod BR Ibudone 5/200 Kadianq,st

Lazanda# Lortab BR Magnacet MS Continq,st BR Norco BR

Nucynta

Nucynta ERq Onsolisq,# Opana BR

Opana ERq,st Oxecta Oxycontinq,st

Percocet BR Percodan BR Primlev Reprexain RMS Supp Roxanol Roxicodone BR Roxicet soln Rybix Subsys# Synalgos-DC Tylenol w cod BR Tramadol 150 Ultracet BR Ultram/ERq BR Vicoprofen BR Xartemis XR# Zohydro ER# Zolvit Zydone

Pain Relievers: Miscellaneous**

choline mag trisalicylat diflunisal salsalate

None All brands Dolgic Plus Dologesic

Frenadol

Parkinson’s Agents

amantadine* benztropine* bromocriptine* carbidopa* carbidopa/levodopa/ER* entacapone* selegiline* trihexyphenidyl*

carbidopa/ levodopa/ entacapone* pramipexole* ropinirole/XL*

Apokyn# Azilect* Comtan* BR Eldepryl* BR Lodosyn* BR Mirapex* BR Mirapex ER* Neupro*

Parcopa* BR

Parlodel* BR Requip/XL* BR Sinemet/CR* BR Stalevo* BR Tasmar* Zelapar*

Potassium Supplements**

Various generics None All brands Kaochlor-Eff K-Tab

Prostate Cancer None Lupron Depot+

Xtandi#+ Zytiga#,+

Eligard+ Firmagon+ Jevtana#+ Provenge# Trelstar+ Vantas+ Viadur Xofigo# Zoladex+

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

17

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Respiratory: Beta Agonists (Oral, Inhaled)

albuterol isoetharine isoproterenol ipratropium/albuterol metaproterenol terbutaline*

levalbuterol Foradil* ProAir HFA Spiriva* Ventolin HFA

Accuneb BR Alupent Anoro Ellipta# Arcapta Brovana* Duoneb BR Perforomist

Proventil/HFA Serevent* Tudorza Vospire ER* BR Xopenex NebBR Xopenex HFA

Respiratory: Inhaled Corticosteroids**

None Asmanex budesonide Dulera Qvar Symbicort

Advair/HFA# Aerospan# Alvesco# Breo Ellipta

Flovent/HFA# Pulmicort Neb BR Pulmicort Inher

Xolair#,+

Respiratory: Leukotriene Modifiers**

montelukast zafirlukast

None Accolate BR Singulair BR

Zyflo CR

Respiratory: Miscellaneous

aminophylline* ipratropium soln* theophylline* Veletri#

Atrovent HFA* Combivent* cromolyn* Elixophyllin* epoprostenol#+ sildenafil# +

tobramycin inh#,+

Adcirca#,+ Adempas#,+ Cayston# Daliresp* Flolan#+ Kalydeco#,+ Letairis#,+

Lufyllin* Orenitram XR# +

Opsumit#,+ Pulmozyme#,+ Revatio#,+ BR Theo-24* Theo-Dur* TOBI#,+ BR Tracleer#,+ Tyvaso#,+ Ventavis#,+

Remodulin#+ Revatio Inj#,+ Veletri+

RSV None None None Synagis#,+ Sedative/ Hypnotics (sleep aids)

chloral hydrate estazolamq flurazepamq hydroxyzine temazepamq

triazolamq zaleplonq zolpidem/CRq

Rozeremq,st Ambien/CRq,st BR Butisol Doralq Edluarq,st

Halcionq BR Hetlios#

Intermezzoq,st Lunestaq,st

Restorilq BR Silenor#

Sonataq,st BR Zolpimistq,st

Smoking Cessation Agents

bupropion SRq Chantixq Nictrolq Zybanq BR

Thyroid** levothyroxine Levoxyl liothyronine methimazole

NP Thyroid propylthiouracil Unithroid

None Armour ThyroidNFNC Cytomel BR Nature-Throid Synthroid Tapazole BR

Thyrolar Tirosint Westhroid WP Thyroid

Topical Antifungals

econazole ketoconazole nystatin

ciclopirox olam ciclopirox soln#

Ecoza# Ertaczo Exelderm Extina BR Loprox BR Lotrisone BR

Naftin

Luzu# Nizoral BR Oxistat Penlac# BR Vusion Xolegel

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

18

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Topical Anti -Infectives

erythromycin gentamicin mupirocin

None Alcortin A Altabax Bactroban Nasal Centany Cortisporin oint/cr

Klaron PhisoHex

Topical/Oral/ Injectable Antipsoriatic & Antiseborrheic

anthralin selenium sulfide

acitretin calcipotriene calcipotriene/ betamethasone calcitrene Enbrel#,+

Capitrol Dovonex BR Dritho-Scalp EpiFoam Exsel

Remicade#,+ SoriataneBR

Sorilux Taclonex BR Vectical BR

Stelara#,+

Topical Miscellaneous

aluminum chloride soln lidocaine Prudoxin

diclofenac gel imiquimod lidocaine patch urea/lactic ac/ salicylic urea/lactic ac/ zn undecylenat urea/hyaluronic acid

Aldara BR Carac Condylox gel Condylox soln BR Drysol BR Efudex BR Elidel

EpiCeramNFNC FlectorNFNC Iodosorb Kerafoam Lidoderm BR Mirvaso Noritate Picato Podocon-25 Prothelial#

Protopic Rectiv RegranexNFNC SantylNFNC Solaraze BR Sulfamylon Umecta/PD Valchlor# Veregen Xerac AC Xerese Zonalon Zyclara

Topical Scabicides/ Pediculicides

permethrin spinosad

lindane malathion

Eurax Natroba BR Ovide BR

Sklice Ulesfia

Topical Steroids 1 Low Potency 2 Medium Potency 3 High Potency 4 Very High Potency

alclometasone1 betamethasone dip/aug2,4 betamethasone valerate3,4 clobetasol4 Cormax4 fluocinolone1,2

fluocinonide3

fluticasone2 hydrocortisone1

hydrocortisone butyrate2 hydrocortisone valerate2 mometasone2 prednicarbate2 triamcinolone2,3

amcinonide3 desonide1 desoximetasone2,3

diflorasone3,4

fluocinolone oil halobetasol4

Alphatrex3 Capex Shampoo1 Clobex 4 BR Clobex Spray4 Cloderm2 Cordran/SP2 Cutivate2 BR Cutivate Lotion2 Derma-Smoothe/FSBR Dermatop2 BR Desonate1 Desowen1 BR Diprolene/AF3,4 BR Elocon2 BR

Halog3

Kenalog Spray

Locoid BR Locoid Lotion Luxiq2 BR Olux/E4 BR Pandel2 Temovate4 BR Texacort1 Topicort BR Ultravate4 BR Ultravate-X Vanos3 Verdeso1 Westcort2 BR

#Requires prior authorization q Subject to quantity limits *Drug is available through Mail Order if your benefit allows st Step therapy edits apply (must have failed on a specific drug per policy) **All drugs in the category are available through MailOrder M Does not require prescription coverage but + Obtain through CVS Caremark Specialty Pharmacy may be subject to prior authorization or step therapy as BR Brand drug that has an FDA approved generic equivalent indicated NFNC-Non formulary, not covered-Must be approved by MVP

19

DRUG CATEGORY

TIER 1 The lowest copay choice and usually includes generic drugs.

TIER 2 The mid-range copay choice and includes covered brand name drugs because of their overall value. Also includes high cost generic drugs.

TIER 3 The highest copay choice and includes all other covered brand name drugs

MEDICAL (M)

Topical/Oral Acne Products

clindamycin clindamycin/benzoyl peroxide erythromycin metronidazole Sotret sulfacetamide tretinoin

adapalene Amnesteem Claravis Myorisan Nuox Panretin sulfaceta/urea/sulfur tretinoin micro

Absorica Acanya Aczone Akne-Mycin Atralin Avar/E/LS Avita NFNC Azelex Bensal HP Benzaclin Benzamycinpak Clarifoam EF Cleocin-T BR Clindagel Differin BR Differin Lotion Duac BR Epiduo Evoclin BR

Fabior# Finacea KlaronBR

Lavoclen

Metrocream BR Metrogel BR Metrolotion BR Ovace BR Ovace Plus Pacnex HP/ LP/MX

Panretin Retin-A BR Retin-A Micro BR Tazorac Tretin-X Vanoxide HC BR Veltin Ziana

Urinary Tract Agents

methenamine nitrofurantoin trimethoprim

potassium citrate ER

Elmiron Furadantin BR Hiprex BR Macrobid BR MacrodantinBR

Macrodantin 25mg Monurol Primsol Prosed-DS Urocit-K

Weight Management Agents

benzphetamine diethylpropion phendimetrazine phentermine

None Adipex-P# BR Belviq# Bontril-DPM# BR Didrex# BR Qsymia#

Regimex# Suprenza# Xenical#

2015010v1