Preferred Drug List

New Jersey

The Health Republic Insurance Preferred Drug List is a guide to available brand and generic drugs that

are approved by the Food and Drug Administration (FDA) and is covered through your prescription drug

benefit. Generic drugs have the same active ingredient as their brand name counterparts and should be

considered the first line of treatment. If there is no generic available, there may be more than one

brand name medication to treat a condition. The preferred brand name medications are listed to help

identify prescription drugs that are clinically appropriate, safe and cost effective.

When viewed on line from our website, this document represents the most current and up-to-date formulary for Health Republic Insurance of New Jersey. A printed document may not represent the most updated information for your specific prescription benefit plan. For example, your plan may not cover certain products or categories, and certain drugs may or may not have prior authorization rules, step therapy programs, or quantity limits applied to them, regardless of their appearance in this document, as the information may not have been recently updated. Please refer to Health Republic Insurance of New Jersey’s website to obtain the most recent full list of medications that may be covered under your benefit.

Drug List Key:

Brand name drugs are listed in CAPS and generic drugs are lower case.

To search for a specific drug in this document, press the “Control” (Ctrl) and “F” keys at the same time on your keyboard. Enter the name of the drug, and hit “Enter”. If you have questions about this list please contact Health Republic at (888) 990-5706.

Drug Name Tier QLL ST PA

CELEBREX 2 ST

diclofenac sodium 1

diclofenac w/ misoprostol 1

diflunisal 1

etodolac 1

fenoprofen 1 QLL

flurbiprofen 1

ibuprofen 1

indomethacin 1

ketoprofen 1

ketorolac tromethamine 1 QLL

meclofen sod 1

mefenamic acid 1

meloxicam 1

nabumetone 1

naproxen 1

oxaprozin 1

piroxicam 1

sulindac 1

tolmetin sod 1

tolmetin sodium 1

Drug Name Tier QLL ST PA

EXALGO 2

fentanyl 1 QLL

levorphanol 1

methadone 3

morphine sulfate 1 QLL

NUCYNTA 2 QLL PA

NUCYNTA ER 2 QLL PA

oxycodone-ibuprofen 1

OXYCONTIN CR 2 QLL PA

OXYMORPHONE ER 3 PA

oxymorphone sr 3 PA

tramadol biphasic release 1 QLL

tramadol sr 1 QLL

Drug Name Tier QLL ST PA

acetaminophen w/ codeine 1 QLL

butalbital-aspirin-caff w/ codeine 1 QLL

butorphanol tartrate 1

codeine sulf 1

fentanyl citrate 1 QLL

hydroco/apap 1 QLL

Drug Name Tier QLL ST PA

hydrocodone-acetaminophen 1 QLL

hydromorphone 1

Analgesics, Non Steroidal Anti-inflammatory Drugs

Analgesics, Opoid Analgesics, Long-Acting

Analgesics, Opoid Analgesics, Short-Acting

Analgesics, Opoid Analgesics, Short-Acting

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

hydromorphone preservative free 1

meperidine 1

morphine sulfate 1

nalbuphine 1

oxycodone 1 QLL PA

oxycodone w/ acetaminophen 1 QLL PA

oxymorphone 1 PA

TALWIN 3

tramadol 1 QLL

tramadol-acetaminophen 1 QLL

Drug Name Tier QLL ST PA

lidocaine 1

lidocaine-prilocaine 1

LIDODERM 2 PA

SYNERA 3

XYLOCAINE 3

Drug Name Tier QLL ST PA

CAMPRAL 2

disulfiram 1

naltrexone 1

Drug Name Tier QLL ST PA

buprenorphine 1 QLL

butrans 1

naloxone 1

SUBOXONE 3 QLL PA

Drug Name Tier QLL ST PA

BUPROBAN 0

CHANTIX 0 QLL

COMMIT 0 QLL

NICOTINE 0 QLL

NICOTROL 0 QLL

Drug Name Tier QLL ST PA

gentam/nacl 1

gentamicin 1

KANAMYCIN 3

neomycin sulfate 1

TOBI 4 PA

Analgesics, Opoid Analgesics, Short-Acting

Anti-Addiction/Substance Abuse Treatment Agents, Opoid Antagonists

Anti-Addiction/Substance Abuse Treatment Agents, Smoking Cessation

Agents

Antibacterials, Aminoglycosides

Anesthetics, Local Anesthetics

Anti-Addiction/Substance Abuse Treatment Agents, Alcohol

Deterrents/Anti-craving

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

TOBRA/NACL 4 PA

TOBRADEX 3

tobramycin sulfate 4 PA

Drug Name Tier QLL ST PA

ALTABAX 2

BACITRACIN 3

clindamycin 1

clindamycin phosphate 1

CUBICIN 3

LINCOCIN 3

methenamine hippurate 1

metronidazole 1

MONUROL 3

mupirocin 1

neomycin-bacitrac zn-polymyx 1

nitrofurantoin 1

polymyxin b-trimethoprim 1

trimethoprim 1

TYGACIL 3 PA

vancomycin 1

VIBATIV 3

XIFAXAN 3 PA

ZYVOX 2 QLL ST PA

Drug Name Tier QLL ST PA

CEDAX 3

cefaclor 1

cefadroxil 1

cefazolin sodium 1

cefdinir 1 ST

cefepime 1

cefoxitin sodium 1

cefpodoxime proxetil 1

cefprozil 1

cefuroxime axetil 1

cefuroxime sodium 1

cephalexin 1

SUPRAX 2 ST

Drug Name Tier QLL ST PA

aztreonam 1

Drug Name Tier QLL ST PA

amoxicillin 1

amoxicillin & k clavulanate 1

amoxicillin (trihydrate) 1

ampicillin 1

Antibacterials, Aminoglycosides

Antibacterials, Antibacterials, Other

Antibacterials, Beta-lactam, Cephalosporins

Antibacterials, Beta-lactam, Other

Antibacterials, Beta-lactam, Penicillins

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

nafcillin sodium 1

oxacillin sodium 1

penicillin v potassium 1

Drug Name Tier QLL ST PA

AZASITE 3

azithromycin 1 QLL

clarithromycin 1

DIFICID 2

ERY-TAB 3

ERYTHROMYCIN 3

Drug Name Tier QLL ST PA

AVELOX 2

BESIVANCE 3

CIPRO I.V. 3

ciprofloxacin 1

FACTIVE 3

levofloxacin 1 QLL

NOROXIN 3

ofloxacin 1

zymaxid 1

Drug Name Tier QLL ST PA

silver sulfadiazine 1

sulfacetamide sodium 1

sulfadiazine 1

sulfamethoxazole-trimethoprim 1

Drug Name Tier QLL ST PA

demeclocycline 1

doxycycline hyclate 1 QLL

minocycline 1 QLL

tetracycline 1 QLL

Antibacterials, Beta-lactam, Penicillins

Antibacterials, Macrolides

Antibacterials, Quinolones

Antibacterials, Sulfonamides

Antibacterials, Tetracyclines

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

levetiracetam 1 QLL

POTIGA 3

Drug Name Tier QLL ST PA

CELONTIN 3

ethosuximide 1

LYRICA 2 PA

zonisamide 1

Drug Name Tier QLL ST PA

clonazepam 1 QLL

DIAZEPAM 3 QLL

divalproex sodium 1

gabapentin 1

primidone 1

SABRIL 4 QLL PA

tiagabine 1

valproate sodium 1

valproic acid 1

Drug Name Tier QLL ST PA

felbamate 1

lamotrigine 1

topiramate 1

Drug Name Tier QLL ST PA

BANZEL 2 QLL

carbamazepine 1

DILANTIN 2

oxcarbazepine 1

PEGANONE 3

PHENYTEK 3

phenytoin 1

VIMPAT 3 QLL

Drug Name Tier QLL ST PA

ERGOLOID MES 3

Drug Name Tier QLL ST PA

donepezil hydrochloride 1 QLL

galantamine hydrobromide 1 QLL

rivastigmine tartrate 1 QLL

Anticonvulsants, Calcium Channel Modifying Agents

Anticonvulsants, Gamma-aminobutryic Acid (GABA) Augmenting Agents

Anticonvulsants, Glutamate Reducing Agents

Anticonvulsants, Sodium Channel Agents

Antidementia Agents, Antidementia Agents, Other

Antidementia Agents, Cholinesterase Inhibitors

Anticonvulsants, Anticonvulsants, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

NAMENDA 2 QLL

Drug Name Tier QLL ST PA

ABILIFY 2 QLL PA

bupropion 1

mirtazapine 1

NEFAZODONE 3

OLEPTRO 3

SEROQUEL XR 2 PA

trazodone 1

VIIBRYD 2 QLL ST

Drug Name Tier QLL ST PA

EMSAM 3

MARPLAN 2

phenelzine sulfate 1

tranylcypromine sulfate 1

Drug Name Tier QLL ST PA

citalopram hydrobromide 1 QLL

CYMBALTA 2 QLL ST

escitalopram oxalate 1 QLL

fluoxetine 1

fluvoxamine maleate 1

paroxetine 1 QLL

PAXIL 3

PRISTIQ 2 QLL ST

sertraline 1 QLL

venlafaxine 1 QLL

Drug Name Tier QLL ST PA

amitriptyline 1

AMOXAPINE 3

clomipramine 1

desipramine 1

doxepin 1

imipramine 1

nortriptylin 1

PERPHEN/AMIT 3

protriptyline 1

trimipramine maleate 1

Antidementia Agents, N-methyl-D-aspartate (NMDA) Receptor

Antagonist

Antidepressants, Antidepressants, Other

Antidepressants, Monoamine Oxidase Inhibitors

Antidepressants, Serotonin/Norepinephring Reuptake Inhibitors

Antidepressants, Tricyclics

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

chlorpromazine 1

hydroxyzine 1

meclizine 1

metoclopramide 1

perphenazine 1

promethazine 1

trimethobenzamide 1

Drug Name Tier QLL ST PA

ANZEMET 3 PA

CESAMET 3 PA

dronabinol 1

EMEND 2 QLL

granisetron 1

ondansetron 1 QLL

ondansetron 1 QLL

Drug Name Tier QLL ST PA

ciclopirox 1

clotrimazole 1

econazole nitrate 1

ERTACZO 3

EXELDERM 3

fluconazole 1 QLL

flucytosine 1

griseofulvin 1

GYNAZOLE-1 3

itraconazole 1 PA

ketoconazole 1

MICONAZOLE 3 3 QLL

NAFTIN 3

NATACYN 2

NOXAFIL 3

nystatin 1

SPORANOX 3 PA

terbinafine 1

terconazole 1 QLL

voriconazole 1

Drug Name Tier QLL ST PA

allopurinol 1

colchicine w/ probenecid 1

COLCRYS 2 QLL

probenecid 1

ULORIC 3 ST

Antiemetics, Emetogenic Therapy Adjuncts

Antifungals, Antifungals

Antigout Agents, Antigout Agents

Antiemetics, Antiemetics, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

CAFERGOT 2

dihydroergotamine mesylate 2

ERGOMAR 3

ergotamine w/ caffeine 2

MIGRANAL 2

Drug Name Tier QLL ST PA

timolol mal 1

Drug Name Tier QLL ST PA

AXERT 3 QLL

FROVA 3 QLL

naratriptan 1 QLL

RELPAX 3 QLL

rizatriptan benzoate 1 QLL

sumatriptan 1 QLL

ZOMIG 2 QLL

Drug Name Tier QLL ST PA

GUANIDINE 2

MESTINON 2

MYTELASE 3

pyridostigmine bromide 1

Drug Name Tier QLL ST PA

DAPSONE 3 PA

MYCOBUTIN 3 PA

Drug Name Tier QLL ST PA

CAPASTAT SUL 3

ethambutol 1

isoniazid 1

PASER 3

PRIFTIN 3

pyrazinamide 1

RIFAMATE 3

rifampin 1

RIFATER 3

TRECATOR 3

Drug Name Tier QLL ST PA

ALKERAN 2

BUSULFEX 4 PA

CEENU 4 PA

Antimigraine Agents, Ergot Alkaloids

Antimigraine Agents, Prophylactic

Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists

Antimyasthenic Agents, Parasympathomimetics

Antimycobacterials, Antimycobacterials, Other

Antimycobacterials, Antituberculars

Antineoplastics, Alkylating Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

CYCLOPHOSPH 4 PA

HEXALEN 4 PA

LEUKERAN 4 PA

MATULANE 4 PA

melphalan 1

MYLERAN 4 PA

SEROMYCIN 3

Drug Name Tier QLL ST PA

REVLIMID 4 PA

THALOMID 4 PA

Drug Name Tier QLL ST PA

EMCYT 4 PA

FARESTON 2

SOLTAMOX 3 PA

tamoxifen citrate 1

Drug Name Tier QLL ST PA

DROXIA 4 PA

HYDROXYUREA 4

TABLOID 4 PA

Drug Name Tier QLL ST PA

daunorubicin 4 PA

DOXIL 4 PA

doxorubicin liposomal 4 PA

fludarabine phosphate 4 PA

idarubicin 4 PA

leucovorin 1

ABRAXANE 4 PA

ADCETRIS 4 PA

ALIMTA 4 PA

ARIMIDEX 4 PA

AROMASIN 4 PA

ARRANON 4 PA

ARZERRA 4 PA

BEXXAR 4 PA

BICNU 4 PA

bleomycin sulfate 4 PA

BOSULIF 4 PA

CAMPATH 4 PA

CAMPTOSAR 4 PA

carboplatin 4 PA

CASODEX 4 PA

Antineoplastics, Antimetabolites

Antineoplastics, Antineoplastics, Other

Antineoplastics, Antiangiogenic Agents

Antineoplastics, Antiestrogens/Modifiers

Antineoplastics, Alkylating Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

CERUBIDINE 4 PA

cisplatin 4 PA

cladribine 4 PA

CLOLAR 4 PA

COMETRIQ 4 PA

COSMEGEN 4 PA

cytarabine 4 PA

dacarbazine 4 PA

DACOGEN 4 PA

dactinomycin 4 PA

DAUNOXOME 4 PA

DEPOCYT 4 PA

DOCEFREZ 4 PA

DOCETAXEL 4 PA

doxorubicin 4 PA

ELLENCE 4 PA

ELOXATIN 4 PA

ELSPAR 4 PA

epirubicin 4 PA

ERBITUX 4 PA

ERIVEDGE 4 PA

ERWINAZE 4 PA

FASLODEX 4 PA

FEMARA 4 PA

floxuridine 4 PA

FLUDARA 4 PA

fluorouracil 4 PA

FOLOTYN 4 PA

FUDR 4 PA

gemcitabine 4 PA

GEMZAR 4 PA

HALAVEN 4 PA

HYCAMTIN 4 PA

HYDREA 4 PA

IDAMYCIN PFS 4 PA

idarubicin 4 PA

IFEX 4 PA

IFOSFAMIDE 4 PA

irinotecan 4 PA

ISTODAX 4 PA

IXEMPRA 4 PA

JAKAFI 4 PA

JEVTANA 4 PA

KYPROLIS 4 PA

MEGACE 3

mitomycin 4 PA

Antineoplastics, Antineoplastics, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

MUSTARGEN 4 PA

NAVELBINE 4 PA

NIPENT 4 PA

OFORTA 4 PA

ONCASPAR 4 PA

ONTAK 4 PA

oxaliplatin 4 PA

paclitaxel 4 PA

pentostatin 4 PA

PERJETA 4 PA

PHOTOFRIN 4 PA

PROLEUKIN 4 PA

PURINETHOL 4 PA

RHEUMATREX 4 PA

RITUXAN 4 PA

STIVARGA 4 PA

SYNRIBO 4 PA

TAXOTERE 4 PA

TEMODAR 4 PA

THIOTEPA 4 PA

TREANDA 4 PA

TREXALL 4 PA

TRISENOX 4 PA

VALSTAR 4 PA

VECTIBIX 4 PA

VELCADE 4 PA

VIDAZA 4 PA

VINBLASTINE 4 PA

vincristine sulfate 4 PA

vinorelbine tartrate 4 PA

VUMON 4 PA

XELODA 4 PA

XTANDI 4 PA

YERVOY 4 PA

ZALTRAP 4 PA

ZANOSAR 4 PA

ZOLADEX 4 PA

ZOLINZA 4 PA

ZYTIGA 4 PA

Drug Name Tier QLL ST PA

anastrozole 4 PA

exemestane 4 PA

letrozole 4 PA

Antineoplastics, Aromatase Inhibitors, 3rd Generation

Antineoplastics, Antineoplastics, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

ETOPOPHOS 4 PA

etoposide 4 PA

topotecan 4 PA

Drug Name Tier QLL ST PA

AFINITOR 4 PA

CAPRELSA 4 PA

GLEEVEC 4 PA

INLYTA 4 PA

NEXAVAR 4 PA

SPRYCEL 4 PA

SUTENT 4 PA

TARCEVA 4 PA

TASIGNA 4 PA

TYKERB 4 PA

VOTRIENT 4 PA

XALKORI 4 PA

ZELBORAF 4 PA

ZORTRESS 4 PA

Drug Name Tier QLL ST PA

AVASTIN 4 PA

HERCEPTIN 4 PA

RITUXAN 4 PA

Drug Name Tier QLL ST PA

PANRETIN 3

TARGRETIN 4 PA

tretinoin 1

Drug Name Tier QLL ST PA

ALBENZA 3 PA

BILTRICIDE 3 PA

STROMECTOL 3 PA

Drug Name Tier QLL ST PA

ALINIA 2

atovaq/progu 1

atovaquone-proguanil 1

chloroquine phosphate 1

COARTEM 2

DARAPRIM 3

hydroxychloroquine sulfate 1

mefloquine 1

MEPRON 3

Antineoplastics, Enzyme Inhibitors

Antineoplastics, Molecular Target Inhibitors

Antineoplastics, Monoclonal Antibodies

Antineoplastics, Retinoids

Antiparasitics, Anthelmintics

Antiparasitics, Antiprotozoals

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

NEBUPENT 3

PENTAM 300 3

PRIMAQUINE 3

quinine sulfate 1

Drug Name Tier QLL ST PA

EURAX 3

lindane 3 PA

malathion 1

permethrin 1

SKLICE 3 PA

ULESFIA 3

Drug Name Tier QLL ST PA

benztropine mesylate 1

trihexyphenidyl 1

Drug Name Tier QLL ST PA

amantadine 1

COMTAN 2 QLL

TASMAR 3

Drug Name Tier QLL ST PA

APOKYN 4 PA

bromocriptine mesylate 1

NEUPRO 2

pramipexole dihydrochloride 1

ropinirole hydrochloride 1

Drug Name Tier QLL ST PA

carb/levo 1

carbidopa & levodopa 1

LODOSYN 3

Drug Name Tier QLL ST PA

AZILECT 2 QLL PA

selegiline 1

Drug Name Tier QLL ST PA

CHLORPROMAZ 3

fluphenazine 1

haloperidol 1

haloperidol decanoate 1

Antiparkinson Agents, Dopamine Agonists

Antiparkinson Agents, Dopamine Precursors/L-Amino Acid

Decarboxylase Inhibitors

Antiparkinson Agents, Monomine Oxidase B (MAO-B) Inhibitors

Antipsychotics, 1st Generation/Typical

Antiparasitics, Pediculicides/Scabicides

Antiparkinson Agents, Anticholinergics

Antiparkinson Agents, Antiparkinson Agents, Other

Antiparasitics, Antiprotozoals

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

loxapine succinate 1

ORAP 3

prochlorperazine 1

thioridazine 1

thiothixene 1

trifluoperazine 1

Drug Name Tier QLL ST PA

ABILIFY 2 PA

FANAPT 2 QLL

INVEGA 2 QLL

LATUDA 3

olanzapine 1

quetiapine fumarate 1

RISPERDAL 2

risperidone 1

SAPHRIS 2

ziprasidone 1

Drug Name Tier QLL ST PA

clozapine 1

Drug Name Tier QLL ST PA

baclofen 1

diazepam 1 QLL

tizanidine 1

XEOMIN 3

Drug Name Tier QLL ST PA

FOSCARNET 3

VALCYTE 2 PA

Drug Name Tier QLL ST PA

BARACLUDE 4 PA

EPIVIR HBV 4 PA

HEPSERA 4 PA

INCIVEK 4 PA

INFERGEN 4 PA

INTRON-A 4 PA

PEGASYS 4 PA

PEG-INTRON 4 PA

REBETOL 4 PA

ribavirin 1

SYLATRON 4 PA

TYZEKA 4 PA

Antipsychotics, 2nd Generation/Atypical

Antipsychotics, Treatment-Resistant

Antipsychotics, 1st Generation/Typical

Antispasticity Agents, Antispasticity Agents

Antivirals, Anti-cytomegalovirus (CMV) Agents

Antivirals, Antihepititis Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

VICTRELIS 4 PA

VIREAD 2

Drug Name Tier QLL ST PA

acyclovir 1

DENAVIR 3

famciclovir 1 QLL

valacyclovir 1 QLL

ZOVIRAX 3 QLL

Drug Name Tier QLL ST PA

ATRIPLA 2

EDURANT 2

INTELENCE 2

nevirapine 1

RESCRIPTOR 2

SUSTIVA 2

VIRAMUNE XR 2

Drug Name Tier QLL ST PA

abacavir sulfate 1

didanosine 1

EMTRIVA 2

EPIVIR 4 PA

EPZICOM 2

lamivudine 4

lamivudine-zidovudine 1

retrovir 1

stavudine 1

TRIZIVIR 2

TRUVADA 2

VIREAD 2

zidovudine 1

Drug Name Tier QLL ST PA

FUZEON 4 PA

ISENTRESS 2

SELZENTRY 2

Drug Name Tier QLL ST PA

APTIVUS 2

CRIXIVAN 2

Antivirals, Anti-HIV Agents, Other

Antivirals, Anti-HIV Agents, Protease Inhibitors

Antivirals, Antiherpetic Agents

Antivirals, Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors

Antivirals, Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors

Antivirals, Antihepititis Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

INVIRASE 2

KALETRA 2

LEXIVA 2

NORVIR 2

PREZISTA 2

REYATAZ 2

VIRACEPT 2

Drug Name Tier QLL ST PA

RELENZA 2 QLL

rimantadine hydrochloride 1

TAMIFLU 2

Drug Name Tier QLL ST PA

alprazolam 1 QLL

buspirone 1

lorazepam 1 QLL

meprobamate 1

Drug Name Tier QLL ST PA

EQUETRO 3

lithium carbonate 1

lithium citr 1

Drug Name Tier QLL ST PA

acarbose 1 QLL

ACTOPLUS MET 2 QLL

ACTOS 2 QLL

AVANDIA 3 QLL

BYETTA 2 QLL

chlorpropam 1 QLL

CYCLOSET 3 QLL

glimepiride 1 QLL

glipizide 1 QLL

glipizide-metformin 1 QLL

glyburide 1 QLL

glyburide-metformin 1 QLL

GLYSET 3 QLL

JANUVIA 2 QLL ST

metformin 1 QLL

nateglinide 1 QLL

ONGLYZA 3 QLL ST

PRANDIMET 3 QLL

PRANDIN 2 QLL

SYMLINPEN 2 QLL PA

Antivirals, Anti-influenza Agents

Anxiolytics, Anxiolytics, Other

Bipolar Agents, Mood Stabilizers

Blood Glucose Regulators, Antidiabetic Agents

Antivirals, Anti-HIV Agents, Protease Inhibitors

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

SYMLNPEN 2 QLL PA

tolazamide 1 QLL

tolbutamide 1 QLL

TRADJENTA 2 QLL ST

VICTOZA 2 QLL ST

WELCHOL 2 QLL

Drug Name Tier QLL ST PA

GLUCAGEN 3 QLL

GLUCAGON 3 QLL

PROGLYCEM 3 QLL

Drug Name Tier QLL ST PA

APIDRA 3 QLL

HUMALOG 2 QLL

HUMULIN 3 QLL

LANTUS 3 QLL

LEVEMIR 3 QLL

NOVOLIN 2 QLL

NOVOLOG 3 QLL

Drug Name Tier QLL ST PA

COUMADIN 3

enoxaparin sodium 4 QLL PA

hep sod/nacl 1

heparin 1

PRADAXA 2 QLL PA

warfarin 1

XARELTO 2 PA

Drug Name Tier QLL ST PA

anagrelide 1

ARANESP 4 ST PA

EPOGEN 4 ST PA

LEUKINE 4 PA

MOZOBIL 4 PA

NEULASTA 4 PA

NEUPOGEN 4 QLL PA

NPLATE 4 PA

PROCRIT 4 ST PA

PROMACTA 4 PA

Drug Name Tier QLL ST PA

tranexamic acid 1

Blood Glucose Regulators, Antidiabetic Agents

Blood Glucose Regulators, Glycemic Agents

Blood Glucose Regulators, Insulins

Blood Products/Modifiers/Volume Expanders, Anticoagulants

Blood Products/Modifiers/Volume Expanders, Blood Formation

Modifiers

Blood Products/Modifiers/Volume Expanders, Coagulants

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

AGGRENOX 2

cilostazol 1

clopidogrel bisulfate 1

dipyridamole 1

EFFIENT 2

REOPRO 3 ST

ticlopidine 1

Drug Name Tier QLL ST PA

clonidine 1 QLL

guanfacine 1 QLL

methyldopa 1 QLL

midodrine 1

Drug Name Tier QLL ST PA

DIBENZYLINE 3 QLL

doxazosin 1 QLL

prazosin 1 QLL

terazosin 1

Drug Name Tier QLL ST PA

ATACAND 3 QLL ST

BENICAR 2 QLL ST

DIOVAN 2 QLL

EDARBI 3 QLL ST

irbesartan 1 QLL

losartan potassium 1 QLL

TEVETEN 3 QLL ST

Drug Name Tier QLL ST PA

benazepril 1

captopril 1

enalapril 1

fosinopril 1

lisinopril 1

moexipril 1

perindopril erbumine 1

quinapril 1

ramipril 1

trandolapril 1

Drug Name Tier QLL ST PA

amiodarone 1

Cardiovascular Agents, Alpha-adrenergic Agonists

Cardiovascular Agents, Alpha-adrenergic Blocking Agents

Cardiovascular Agents, Angiotensin II Receptor Antagonists

Cardiovascular Agents, Angiotensin-converting Enzyme (ACE) Inhibitors

Cardiovascular Agents, Antiarrhythmics

Blood Products/Modifiers/Volume Expanders, Platelet Modifying Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

disopyramide phosphate 1

flecainide 1

mexiletine 1

MULTAQ 4 PA

PACERONE 3

procainamide 1 QLL

propafenone 1 QLL

sotalol 1 QLL

TIKOSYN 2

Drug Name Tier QLL ST PA

acebutolol 1

atenolol 1

betaxolol 1

bisoprolol 1

BYSTOLIC 2 QLL ST

carvedilol 1

labetalol 1

LEVATOL 3 QLL ST

metoprolol succinate 1

metoprolol tartrate 1

nadolol 1

pindolol 1

propranolol 1

propranolol 1

Drug Name Tier QLL ST PA

amlodipine besylate 1

diltiazem 1

diltiazem 1

felodipine 1

isradipine 1

nicardipine 1

nifedipine 1

nimodipine 1

nisoldipine 1

verapamil 1

verapamil 1

Drug Name Tier QLL ST PA

digoxin 1

pentoxifylline 1 QLL

RANEXA 2 QLL PA

TEKTURNA 2 QLL ST

Cardiovascular Agents, Antiarrhythmics

Cardiovascular Agents, Beta-adrenergic Blocking Agents

Cardiovascular Agents, Calcium Channel Blocking Agents

Cardiovascular Agents, Cardiovascular Agents, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

acetazolamid 1 QLL

methazolamide 1 QLL

Drug Name Tier QLL ST PA

bumetanide 1 QLL

EDECRIN 3 QLL

furosemide 1

torsemide 1

Drug Name Tier QLL ST PA

amiloride 1

DYRENIUM 3 QLL PA

eplerenone 1

spironolactone 1

Drug Name Tier QLL ST PA

chlorothiazide 1

chlorthalid 1

hydrochlorothiazide 1 QLL

indapamide 1 QLL

methyclothia 1

metolazone 1 QLL

Drug Name Tier QLL ST PA

fenofibrate 1 QLL

gemfibrozil 1

Drug Name Tier QLL ST PA

atorvastatin calcium 1 QLL

CRESTOR 2 QLL ST

fluvastatin sodium 2 QLL

LIVALO 3 QLL

lovastatin 1 QLL

pravastatin sodium 1 QLL

simvastatin 1 QLL

Drug Name Tier QLL ST PA

ADVICOR 3

cholestyramine 1

colestipol 1

LOVAZA 2

NIASPAN 2

SIMCOR 2

VYTORIN 2 ST

ZETIA 2 ST

Cardiovascular Agents, Dyslipidemics, Fibric Acid Derivatives

Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors

Cardiovascular Agents, Dyslipidemics, Other

Cardiovascular Agents, Diuretics, Carbonic Anhydrase Inhibitors

Cardiovascular Agents, Diuretics, Loop

Cardiovascular Agents, Diuretics, Potassium-sparing

Cardiovascular Agents, Diuretics, Thiazide

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

BIDIL 2

hydralazine 1

minoxidil 1

RECTIV 3

Drug Name Tier QLL ST PA

isosorbide 1

NITRO-BID 3

nitroglycerin 1

NITROSTAT 2 QLL

Drug Name Tier QLL ST PA

amphetamine-dextroamphetamine 1

dextroamphetamine sulfate 1

methamphetamine 3 QLL

VYVANSE 2 QLL

Drug Name Tier QLL ST PA

dexmethylphenidate 1

INTUNIV 2 QLL

methylphenidate 1

STRATTERA 2 QLL

Drug Name Tier QLL ST PA

butalbital-acetaminophen-caff w/ cod 1 QLL

HORIZANT 3

NUEDEXTA 3

RILUTEK 3

XENAZINE 4 PA

Drug Name Tier QLL ST PA

SAVELLA 2 PA

Drug Name Tier QLL ST PA

AMPYRA 4 PA

AVONEX 4 PA

BETASERON 4 PA

COPAXONE 4 PA

EXTAVIA 4 PA

GILENYA 4 PA

REBIF 4 PA

Cardiovascular Agents, Vasodilators, Direct-acting Arterial

Cardiovascular Agents, Vasodilators, Direct-acting Arterial/Venous

Central Nervous System Agents, Attention Deficit Hyperactivity Disorder

Agents, Amphetamines

Central Nervous System Agents, Attention Deficit Hyperactivity Disorder

Agents, Non-amphetamines

Central Nervous System Agents, Central Nervous System, Other

Central Nervous System Agents, Fibromyalgia Agents

Central Nervous System Agents, Multiple Sclerosis Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

ARESTIN 4 PA

chlorhexidine gluconate 1

KEPIVANCE 4

pilocarpine 1

triamcinolone acetonide 1

Drug Name Tier QLL ST PA

adapalene 1

AMEVIVE 4

AZELEX 3

benzoyl peroxide 1

benzoyl peroxide-erythromycin 1 QLL

calcipotrien 1 QLL

calcipotriene 1 QLL

calcitriol 1 QLL

claravis 1

clindamycin phosphate 1

clindamycin phosphate-benzoyl peroxide 1

clotrimazole w/ betamethasone 1

cortisporin 1

DIFFERIN 2 PA

ELIDEL 2 QLL ST

erythromycin 1

FINACEA 2

fluorouracil 1 QLL

imiquimod 1

isotretinoin 1 QLL

lactic acid (ammonium lactate) 1

LAVOCLEN-4 3

nystat/triam 1

nystatin-triamcinolone 1

OXSORALEN-UL 2 QLL

PICATO 2

podofilox 1

PROTOPIC 2 ST

SANTYL 3

selenium sulfide 1 QLL

SOLARAZE 2 QLL

SORIATANE 2 QLL

spinosad 1

STELARA 4 PA

sulfacetamide sodium 1 QLL

TACLONEX 3

TAZORAC 2 PA

tretinoin 1 PA

UVADEX 4

VEREGEN 3

VOLTAREN 2

ZONALON 3

Dental and Oral Agents, Dental and Oral Agents

Dermatological Agents, Dermatological Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

ADAGEN 4 QLL PA

ALDURAZYME 4 QLL PA

BUPHENYL 3 QLL

CREON 2 QLL

CYSTADANE 4 QLL PA

CYSTAGON 3 QLL

KUVAN 4 QLL PA

ORFADIN 4 PA

Drug Name Tier QLL ST PA

atropine sulfate 1 QLL

dicyclomine 1 QLL

glycopyrrolate 1

methscopolamine bromide 1

TRANSDERM-SC 2

Drug Name Tier QLL ST PA

diphenoxylate w/ atropine 1

ENTEREG 3 PA

loperamide 1

metoclopramide 1 QLL

MOTOFEN 3 PA

RELISTOR 2 PA

ursodiol 1

XIFAXAN 3 ST PA

Drug Name Tier QLL ST PA

cimetidine 1

famotidine 1

nizatidine 1

ranitidine 1

Drug Name Tier QLL ST PA

AMITIZA 2

LOTRONEX 2

Drug Name Tier QLL ST PA

lactulose 1

MOVIPREP 2

OSMOPREP 3

PREPOPIK 3

Drug Name Tier QLL ST PA

CARAFATE 2

misoprostol 1

sucralfate 1

Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers

Gastrointestinal Agents, Antispasmodics, Gastrointestinal

Gastrointestinal Agents, Gastrointestinal Agents, Other

Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists

Gastrointestinal Agents, Irritable Bowel Syndrome Agents

Gastrointestinal Agents, Laxatives

Gastrointestinal Agents, Protectants

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

ACIPHEX 3 QLL ST

DEXILANT 2 QLL ST

lansoprazole 1 QLL

NEXIUM 2 QLL ST

omeprazole 1 QLL

pantoprazole sodium 1 QLL

Drug Name Tier QLL ST PA

DETROL LA 3 ST

ENABLEX 3 ST

flavoxate 1

oxybutynin chloride 1

tolterodine tartrate 1

TOVIAZ 3 ST

trospium chloride 1

VESICARE 2 ST

Drug Name Tier QLL ST PA

alfuzosin 1

AVODART 2 QLL ST

CIALIS 3 PA

finasteride 1

RAPAFLO 2 ST

tamsulosin 1

Drug Name Tier QLL ST PA

bethanechol chloride 1 QLL

CUPRIMINE 3

ELMIRON 2

Drug Name Tier QLL ST PA

calcium acetate 1

FOSRENOL 2 ST

PHOSLYRA 2

RENAGEL 3

Drug Name Tier QLL ST PA

alclometasone 1

AMCINONIDE 3

betamethasone 1

budesonide 1

clobetasol propionate 1

CLODERM 3

CORDRAN 3

cortisone ac 1

DEPO-MEDROL 3

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal),

Glucorticoids/Mineralocorticoids

Gastrointestinal Agents, Proton Pump Inhibitors

Genitourinary Agents, Antospasmodics, Urinary

Genitourinary Agents, Benign Prostatic Hypertrophy Agents

Genitourinary Agents, Genitourinary Agents, Other

Genitourinary Agents, Phosphate Binders

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

desonide 1

desoximetas 1

desoximetasone 1

dexamethasone 1

diflorasone 1

fludrocortisone 1

fluocinolone 1

fluocinonide 1

fluticasone 1

halobetasol 1

HALOG 3

hydrocortisone 1

methylprednisolone 1

MILLIPRED 3

mometasone furoate 1

ORAPRED 3

prednicarbate 1

prednisolone 1

prednisolone sod phosphate 1

prednisone 1

SOLU-CORTEF 3

SOLU-MEDROL 3

triamcinolone acetonide 1

VERIPRED 20 3

Drug Name Tier QLL ST PA

chorionic gonadotropin 4

desmopressin 1

GENOTROPIN 4 PA

HUMATROPE 4 PA

INCRELEX 4 PA

NORDITROPIN 4 PA

NUTROPIN 4 PA

OMNITROPE 4 PA

SAIZEN 4 PA

SEROSTIM 4 PA

STIMATE 4 PA

TEV-TROPIN 4 PA

ZORBTIVE 4 PA

Drug Name Tier QLL ST PA

ANADROL-50 3

oxandrolone 1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal),

Glucorticoids/Mineralocorticoids

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary),

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Anabolic Steroids

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

ANDRODERM 2 PA

ANDROXY 3 PA

danazol 1 PA

METHITEST 3 PA

Drug Name Tier QLL ST PA

AMETHIA 0

AMETHYST 0

APRI 0

ARANELLE 0

AVIANE 0

AZURETTE 0

BALZIVA 0

BRIELLYN 0

CAMRESE 0

CAZIANT 0

CENESTIN 3

CESIA 0

CLIMARA PRO 3 QLL

CRYSELLE-28 0

CYCLAFEM 0

DASETTA 0

DEPO-ESTRADI 3

DIVIGEL 3

ELESTRIN 3

ELINEST 0

EMOQUETTE 0

ENJUVIA 3

ENPRESSE-28 0

ESTRACE VAG 3

estradiol 1

ESTRASORB 3

ESTROGEL 3

estropipate 1

EVAMIST 3

FEMRING 3

GIANVI 0

JOLESSA 0

JUNEL 0

KARIVA 0

KELNOR 0

KURVELO 0

LEENA 0

LESSINA 0

LEVONEST 0

LEVORA-28 0

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Androgens

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Estrogens

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

LOESTRIN 24 0

LORYNA 0

LOW-OGESTREL 0

LUTERA 0

MENEST 3

MENOSTAR 3

MICROGESTIN 0

MONO-LINYAH 0

MONONESSA 0

MYZILRA 0

NATAZIA 0

NECON 0

NORTREL 0

NUVARING 0

OCELLA 0

OGESTREL 3

ORTHO EVRA 0

ORTHO TRI- 0

PHILITH 0

PORTIA-28 0

PREMARIN 2

PREMPHASE 2

PREMPRO 2 QLL

PREVIFEM 0

QUASENSE 0

RECLIPSEN 0

SAFYRAL 0

SPRINTEC 28 0

SRONYX 0

SYEDA 0

TILIA FE 0

TRI-LEGEST 0

TRINESSA 0

TRI-PREVIFEM 0

TRI-SPRINTEC 0

TRIVORA-28 0

VELIVET 0

VESTURA 0

VIVELLE-DOT 3

WERA 0

ZARAH 0

ZENCHENT 0

ZEOSA 0

ZOVIA 0

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Estrogens

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

CAMILA 0

CRINONE 3

ELLA 0

ENDOMETRIN 2

HEATHER 0

JOLIVETTE 0

levonorgestrel 0

MEDROXYPR 4

medroxyprogesterone 1 PA

MEGACE ES 4 PA

megestrol 4 PA

NORETHIN ACE 0

PROCHIEVE 3

progesterone 1

Drug Name Tier QLL ST PA

EVISTA 2 QLL

Drug Name Tier QLL ST PA

levothyroxin 1

levothyroxine 1

liothyronine 1

THYROLAR 3

Drug Name Tier QLL ST PA

LYSODREN 4 PA

Drug Name Tier QLL ST PA

SENSIPAR 4 PA

cabergoline 1

Drug Name Tier QLL ST PA

ELIGARD 4 PA

leuprolide 4 PA

LUPR DEP-PED 4 PA

LUPRON DEPOT 4 PA

octreotide 4 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Progestins

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Selective Estrogen Receptor Modifying Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid),

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Suppressant (Adrenal), Hormonal Agents,

Suppressant (Adrenal)

Hormonal Agents, Suppressant (Parathyroid), Hormonal Agents,

Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Pituitary), Hormonal Agents,

Suppressant (Pituitary)

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

SOMATULINE 4 PA

SOMAVERT 4 PA

SYNAREL 4 PA

TRELSTAR 4 PA

Drug Name Tier QLL ST PA

bicalutamide 4 PA

finasteride 1

flutamide 4 PA

NILANDRON 3 QLL

Drug Name Tier QLL ST PA

methimazole 1

propylthiouracil 1

Drug Name Tier QLL ST PA

AZASAN 3

azathioprine 1

CIMZIA 4 PA

cyclosporine 1

ENBREL 4 PA

HUMIRA 4 PA

mercaptopurine 4 PA

methotrexate 1

mycophenolate 1

MYFORTIC 2

NULOJIX 4 PA

ORENCIA 4 PA

PROGRAF 2

RAPAMUNE 2

tacrolimus 1

Drug Name Tier QLL ST PA

GAMMAGARD 4 PA

Drug Name Tier QLL ST PA

ACTEMRA 4 PA

ACTIMMUNE 4 PA

ARCALYST 4 PA

leflunomide 1 QLL

RIDAURA 3 PA

Drug Name Tier QLL ST PA

APRISO 2

Hormonal Agents, Suppressant (Pituitary), Hormonal Agents,

Suppressant (Pituitary)

Hormonal Agents, Suppressant (Thyroid), Antithyroid Agents

Immunological Agents, Immune Suppressants

Immunological Agents, Immunizing Agents, Passive

Immunological Agents, Immunomodulators

Inflammatory Bowel Disease Agents, Aminosalicylates

Hormonal Agents, Suppressant (Sex Hormones/Modifiers),

Antiandrogens

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

ASACOL 2 QLL

balsalazide 1

CANASA 2

DIPENTUM 2

LIALDA 2

mesalamine 1

PENTASA 2

Drug Name Tier QLL ST PA

KENALOG-40 3

MEDROL 3

methylprednisolone 1

Drug Name Tier QLL ST PA

sulfasalazine 1

Drug Name Tier QLL ST PA

alendronate 1 QLL

BONIVA 4 PA

calcitonin 1 QLL

etidron 1

FORTEO 4 PA

HECTOROL 2

ibandronate 1

pamidronate 4 PA

PROLIA 4 PA

SKELID 3

XGEVA 4 PA

ZEMPLAR 4 PA

Drug Name Tier QLL ST PA

latanoprost 1

LUMIGAN 3 ST

TRAVATAN Z 2 ST

Drug Name Tier QLL ST PA

naphazoline 1

proparacaine 1

RESTASIS 2 PA

tropicamide 1

Drug Name Tier QLL ST PA

ALOCRIL 3 PA

ALOMIDE 3 PA

azelastine 1

Inflammatory Bowel Disease Agents, Aminosalicylates

Inflammatory Bowel Disease Agents, Glucocorticoids

Inflammatory Bowel Disease Agents, Sulfonamides

Metabolic Bone Disease Agents, Metabolic Bone Disease Agents

Ophthalmic Agents, Ophthalmic Prostaglandin and Prostamide Analogs

Ophthalmic Agents, Ophthalmic Agents, Other

Ophthalmic Agents, Ophthalmic Anti-Allergy Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

BEPREVE 3 PA

cromolyn 1

EMADINE 3 PA

epinastine 1

LASTACAFT 2 PA

PATADAY 2

PATANOL 3 PA

Drug Name Tier QLL ST PA

apraclonidine 1

AZOPT 2 QLL

betaxolol 1 QLL

brimonidine 1 QLL

carteolol 1

COMBIGAN 2

dorzolamide 1 QLL

dorzolamide -timolol 1 QLL

IOPIDINE 3

levobunolol 1 QLL

metipranolol 1

PHOSPHOLINE 3

pilocarpine 1

timolol 1

ZIOPTAN 3

Drug Name Tier QLL ST PA

ALREX 2

BROMDAY 2

BROMFENAC 3

CIPRODEX 2

dexamethasone sodium phosphate 1

DUREZOL 2

fluorometholone 1

flurbiprofen 1

FML 3

FML FORTE 3

ILEVRO 3

LOTEMAX 2

MAXIDEX 3

neomycin-polymyxin-dexamethasone 1

NEVANAC 3

PRED 3

prednisolone 1

VEXOL 3

Drug Name Tier QLL ST PA

acetic acid 1

antipyrine-benzocaine 1

Ophthalmic Agents, Ophthalmic Anti-Allergy Agents

Ophthalmic Agents, Ophthalmic Antiglaucoma Agents

Ophthalmic Agents, Ophthalmic Anti-inflammatories

Otic Agents, Otic Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

CIPRO HC 3

COLY-MYCIN 3

CORTISPORIN 3

DERMOTIC 2

hydrocortisone w/ acetic acid 1

neo/poly/hc 1

neomycin-polymyxin-hc 1

Drug Name Tier QLL ST PA

ASTEPRO 2

azelastine 1 QLL

carbinoxamine 1

clemastine fumarate 1

cyproheptadine 1

desloratadine 1

DEXCHLORPHEN 3

levocetirizine dihydrochloride 1 QLL

Drug Name Tier QLL ST PA

ADVAIR 2 QLL

ALVESCO 3

ASMANEX 2

budesonide 3

FLOVENT HFA 3 QLL

flunisolide 1 QLL

NASONEX 2

PULMICORT 2

QVAR 2

RHINOCORT 2 ST

Drug Name Tier QLL ST PA

montelukast 1

zafirlukast 1 QLL

ZYFLO CR 3 QLL

Drug Name Tier QLL ST PA

ATROVENT HFA 3 QLL

ipratropium bromide 1 QLL

SPIRIVA 2 QLL

Drug Name Tier QLL ST PA

LUFYLLIN 3

theophylline 1

Otic Agents, Otic Agents

Respiratory Tract Agents, Antihistamines

Respiratory Tract Agents, Anti-inflammatories, Inhaled Corticosteroids

Respiratory Tract Agents, Antileukotrienes

Respiratory Tract Agents, Bronchodilators, Anticholinergic

Respiratory Tract Agents, Bronchodilators, Phosphodiesterase Inhibitors

(Xanthines)

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

albuterol 1

ARCAPTA 2

BROVANA 3

epinephrine 1

EPIPEN 2 QLL

FORADIL 2

levalbuterol 1

MAXAIR 3

metaproteren 1

PROVENTIL 2

SEREVENT 2 QLL

terbutaline sulfate 1

VENTOLIN HFA 3 QLL

XOPENEX HFA 3 QLL ST

Drug Name Tier QLL ST PA

cromolyn 1 QLL

Drug Name Tier QLL ST PA

ADCIRCA 4 PA

LETAIRIS 4 PA

REVATIO 4 PA

sildenafil 4 PA

TRACLEER 4 QLL PA

Drug Name Tier QLL ST PA

acetylcysteine 1

ARALAST 4 PA

PULMOZYME 4 PA

SURFAXIN 4 PA

TYZINE 3

XOLAIR 4 PA

Drug Name Tier QLL ST PA

carisoprodol 1

chlorzoxazone 1

cyclobenzaprine 1 QLL

metaxalone 1

methocarbamol 1

orphenadrine 1

Drug Name Tier QLL ST PA

LUNESTA 3 QLL ST

zaleplon 1 QLL

zolpidem 1 QLL

Skeletal Muscle Relaxants, Skeletal Muscle Relaxants

Sleep Disorder Agents, GABA Receptor Modulators

Respiratory Tract Agents, Bronchodilators, Sympathomimetic

Respiratory Tract Agents, Mast Cell Stabilizers

Respiratory Tract Agents, Pulmonary Antihypertensives

Respiratory Tract Agents, Respiratory Tract Agents, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.

Drug Name Tier QLL ST PA

modafinil 1 QLL PA

NUVIGIL 2 QLL PA

phenobarb 1

phenobarbital 1

ROZEREM 3 QLL ST

XYREM 4 QLL PA

Drug Name Tier QLL ST PA

EXJADE 4 PA

FERRIPROX 3

KIONEX 1

SAMSCA 4 PA

sodium polystyrene sulfonate 1

SYPRINE 3

Drug Name Tier QLL ST PA

acetic acid irrigation 1

AMMONIUM 3

calcium 1

CLINIMIX 3

d5w/lytes 1

dextrose 1

dianeal 1

glycine irrigation 1

hypersal 1

ionosol 1

isolyte 1

kcl 1

kcl/d10/nacl 1

kcl/d5w 1

kcl/d5w/nacl 1

klor-con 1

k-tabs 1

lactated 1

magnesium 1

nebusal 1

normosol 1

physiolyte 1

physiosol 1

plasma-lyte 1

potassium 1

ultrabag/ 1

Sleep Disorder Agents, Sleep Disorders, Other

Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral

Modifiers

Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral

Replacement

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's member handbook or website.