GHC-SCW Mandated Coverage Alphabetical Index Last Updated 8/1/2018

Transcription

1 Search Tip: This is a large document, but you can search quickly and easily by clicking on the binocular icon on your toolbar. It will then display a search box for you to type in the name of the drug you want to locate. If you do not know the correct spelling, you can start your search by entering just the first few letters of the name. GHCSCW Mandated Coverage Alphabetical Index Last Updated 8//08 Drug Name acarbose tab (PRECOSE equiv) ALCOHOL SWABS amethyst tab (LYBREL equiv) (Step Therapy requires a trial of preferred oral contraceptives) apri tab (DESOGEN/ ORTHOCEPT equiv) aranelle tab (TRINORINYL equiv) ASPIRIN CHEW TAB 75MG (Covered for males age 4579 and females age 5579) aspirin chew tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin ec tab 35mg (Covered for males age 4579 and females age 5579) aspirin ec tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin tab 35mg (Covered for males age 4579 and females age 5579) aspirin tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) atorvastatin tab 0mg atorvastatin tab 0mg AVANDAMET TAB AVANDARYL TAB AVANDIA TAB aviane (NORDETTE equiv) bupropion SR tab (ZYBAN equiv) (Limited to 80 days/calendar year) BYDUREON BCISE AUTO INJ BYDUREON INJ BYDUREON PEN INJ CALIBRATION LIQUID CERVICAL CAP cesia tab (CYCLESSA equiv) CHANTIX PAK (Limited to 80 days/plan year) CHANTIX TAB (Limited to 80 days/plan year) chlorpropamide tab cryselle tab DEPOPROVERA SC INJ 04MG (= inj/90 days) DIAPHRAGM ELLA TAB enpresse tab (TRILEVELEN equiv) erythromycin 0.5% ophth ointment (Covered for members days of age or younger) FARXIGA TAB (= tab/day) ferrous sulfate elixir (Covered for members year or younger) FERROUS SULFATE LIQUID (Covered for members year or younger) ferrous sulfate soln (Covered for members year or younger) Special Code Tier Category ST ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. OPHTHALMIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page of 3

2 Drug Name FERROUS SULFATE SYRUP (Covered for members year or younger) FLUORABON SOLN (Covered at for members 5 years or younger) folic acid tab mg (Covered for females only) folic acid tab 400mcg (Covered for females only) folic acid tab 800mcg (Covered for females only) FREESTYLE FREEDOM LITE METER FREESTYLE INSULINX TEST STRIP FREESTYLE LANCETS FREESTYLE LITE METER FREESTYLE LITE TEST STRIP FREESTYLE PRECISION NEO METER FREESTYLE PRECISION NEO TEST STRIP FREESTYLE TEST STRIP glimepiride tab (AMARYL equiv) glipizide ER tab (GLUCOTROL XL equiv) glipizide tab (GLUCOTROL equiv) glipizide/metformin tab GLUCAGON INJ KIT glyburide micronized tab glyburide tab (DIABETA equiv) glyburide/metformin tab (GLUCOVANCE equiv) HUMULIN R INJ U500 HUMULIN R U500 KWIKPEN INJ INSULIN SYRINGE IRON SUSP (Covered for members year or younger) JANUMET TAB (= tabs/day) JANUMET XR TAB (= tabs/day) JANUVIA TAB JARDIANCE TAB (= tab/day) JENTADUETO TAB jolessa tab, amethia tab (SEASONALE, SEASONIQUE equiv) junel FE tab (LOESTRIN FE equiv) junel tab kariva tab (MIRCETTE equiv) kelnor tab KETODIASTIX TEST STRIP KETOSTIX TEST STRIPS LANTUS SOLOSTAR INJ LANTUS VIAL LEVEMIR FLEXTOUCH INJ LEVEMIR INJ levonorgestrel tab (PLAN B equiv) LEVONORGESTREL TAB 0.75MG lovastatin tab MEDISENSE CONTROL SOLN medroxyprogesterone inj (DEPOPROVERA equiv) (= inj/90 days) metformin tab (GLUCOPHAGE equiv) metformin tab er 500mg (GLUCOPHAGE XR equiv) metformin tab er 750mg (GLUCOPHAGE XR equiv) mononessa tab (ORTHOCYCLEN equiv) ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay GHCSCW Mandated Coverage Cont. Alphabetical Index Last Updated 8//08 Special Code Tier Category HEMATOPOIETIC AGENTS MINERALS & ELECTROLYTES HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS ANTIHYPERLIPIDEMICS OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page of 3

3 Drug Name necon tab necon tab 50 (NORYNIL equiv) NEEDLES nicotine gum (Limited to 80 day supply/ calendar year) NICOTINE KIT nicotine lozenge (COMMIT equiv) (Limited to 80 day supply/ calendar year) nicotine patch (NICODERM equiv) (Limited to 80 days/calendar year) NICOTROL INHALER (Limited to 80 days/calendar year) NICOTROL NASAL SPRAY (Limited to 80 days/calendar year) norethindrone tab (NORQD/ ORTHO MICRONOR equiv) nortrel tab (OVCON 35 equiv) NOVOLIN INJ NOVOLOG FLEXPEN INJ, FIASP FLEXTOUCH INJ NOVOLOG INJ, FIASP INJ NOVOLOG MIX FLEXPEN INJ NOVOLOG MIX INJ NOVOLOG PENFILL INJ NUVARING peg 3350/electrolytes soln (Covered at for members 5075 yearslimited to fills/calendar year) PEN NEEDLE pioglitazone tab (ACTOS equiv) pioglitazone/ metformin tab (ACTOPLUS MET equiv) pioglitazone/glimepiride tab (DUETACT equiv) PLAN B TAB pravastatin tab PRECISION XTRA METER PRECISION XTRA TEST STRIP raloxifene tab (Covered at for women 35 years or older) repaglinide tab rosuvastatin tab 0mg rosuvastatin tab 5mg simvastatin tab sodium fluoride cream (Covered at for members 5 years or younger) SODIUM FLUORIDE LOZENGE (Covered at for members 5 years or younger) sodium fluoride soln (Covered at for members 5 years or younger) SODIUM FLUORIDE TAB (Covered at for members 5 years or younger) sodium fluoride tab (LURIDE equiv) (Covered at for members 5 years or younger) SYNJARDY TAB (= tabs/day) SYNJARDY XR TAB 0000MG, 5000MG (= tab/day) SYNJARDY XR TAB 5000MG,.5000MG (= tabs/day) SYRINGE ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay GHCSCW Mandated Coverage Cont. Alphabetical Index Last Updated 8//08 Special Code Tier Category SMKG SMKG SMKG SMKG SMKG SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. LAXATIVES ANTIHYPERLIPIDEMICS ENDOCRINE AND METABOLIC AGENTS MISC. ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS MOUTH/THROAT/DENTAL AGENTS MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 3 of 3

4 GHCSCW Mandated Coverage Cont. Alphabetical Index Last Updated 8//08 Drug Name tamoxifen tab (Covered at for women 35 years or older) tolazamide tab TOLBUTAMIDE TAB TRADJENTA TAB TRESIBA INJ trilegest tab (ESTROSTEP FE equiv) trilyte soln (Covered at for members 5075 years, all other members covered at generic copay; Limited to fills/calendar year) trinessa (LO) tab (ORTHO TRICYCLEN (LO) equiv) VICTOZA INJ vitamin D cap 000unit (Covered for members 65 years or older) vitamin D cap 000IU (Covered for members 65 years or older) vitamin D cap 400unit (Covered for members 65 years or older) vitamin D tab 000IU VITAMIN D TAB 400UNIT (Covered for members 65 years or older) wymzya FE tab XIGDUO XR TAB.5000MG, 5000MG (= tab/day) XIGDUO XR TAB.5000MG, 5000MG (= tabs/day) XIGDUO XR TAB 5500MG, 0500MG, 0000MG (= tab/day) XULANE PATCH YASMIN TAB YAZ TAB Special Code Tier Category ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES LAXATIVES VITAMINS VITAMINS VITAMINS VITAMINS VITAMINS ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 4 of 3

5 GHCSCW Mandated Coverage Category/Class Last Updated* 8//08 DrugName Special Code Tier SALICYLATES ANALGESICS NONNARCOTIC ASPIRIN CHEW TAB 75MG (Covered for males age 4579 and females age 5579) aspirin chew tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin ec tab 35mg (Covered for males age 4579 and females age 5579) aspirin ec tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) aspirin tab 35mg (Covered for males age 4579 and females age 5579) aspirin tab 8mg (Covered for males age 4579; Covered for females (no age restriction) ) ALPHAGLUCOSIDASE INHIBITORS acarbose tab (PRECOSE equiv) ANTIDIABETIC COMBINATIONS glipizide/metformin tab glyburide/metformin tab (GLUCOVANCE equiv) AVANDAMET TAB AVANDARYL TAB JANUMET TAB (= tabs/day) JANUMET XR TAB (= tabs/day) JENTADUETO TAB pioglitazone/ metformin tab (ACTOPLUS MET equiv) pioglitazone/glimepiride tab (DUETACT equiv) SYNJARDY TAB (= tabs/day) SYNJARDY XR TAB 0000MG, 5000MG (= tab/day) SYNJARDY XR TAB 5000MG,.5000MG (= tabs/day) XIGDUO XR TAB.5000MG, 5000MG (= tab/day) XIGDUO XR TAB.5000MG, 5000MG (= tabs/day) XIGDUO XR TAB 5500MG, 0500MG, 0000MG (= tab/day) BIGUANIDES metformin tab (GLUCOPHAGE equiv) metformin tab er 500mg (GLUCOPHAGE XR equiv) metformin tab er 750mg (GLUCOPHAGE XR equiv) DIABETIC OTHER GLUCAGON INJ KIT DIPEPTIDYL PEPTIDASE4 (DPP4) INHIBITORS JANUVIA TAB TRADJENTA TAB INCRETIN MIMETIC AGENTS (GLP RECEPTOR AGONISTS) BYDUREON BCISE AUTO INJ BYDUREON INJ BYDUREON PEN INJ VICTOZA INJ INSULIN HUMULIN R INJ U500 HUMULIN R U500 KWIKPEN INJ LANTUS SOLOSTAR INJ LANTUS VIAL Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 5 of 3

6 GHCSCW Mandated Coverage Category/Class Last Updated* 8//08 DrugName Special Code Tier Cont. LEVEMIR FLEXTOUCH INJ LEVEMIR INJ NOVOLIN INJ NOVOLOG FLEXPEN INJ, FIASP FLEXTOUCH INJ NOVOLOG INJ, FIASP INJ NOVOLOG MIX FLEXPEN INJ NOVOLOG MIX INJ NOVOLOG PENFILL INJ TRESIBA INJ INSULIN SENSITIZING AGENTS pioglitazone tab (ACTOS equiv) AVANDIA TAB MEGLITINIDE ANALOGUES repaglinide tab SODIUMGLUCOSE COTRANSPORTER (SGLT) INHIBITORS FARXIGA TAB (= tab/day) JARDIANCE TAB (= tab/day) SULFONYLUREAS chlorpropamide tab glimepiride tab (AMARYL equiv) glipizide ER tab (GLUCOTROL XL equiv) glipizide tab (GLUCOTROL equiv) glyburide micronized tab glyburide tab (DIABETA equiv) tolazamide tab TOLBUTAMIDE TAB ANTIHYPERLIPIDEMICS HMG COA REDUCTASE INHIBITORS atorvastatin tab 0mg atorvastatin tab 0mg lovastatin tab pravastatin tab rosuvastatin tab 0mg rosuvastatin tab 5mg simvastatin tab ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC HORMONAL AND RELATED AGENTS tamoxifen tab (Covered at for women 35 years or older) COMBINATION ORAL amethyst tab (LYBREL equiv) (Step Therapy requires a trial of preferred oral contraceptives) ST apri tab (DESOGEN/ ORTHOCEPT equiv) aranelle tab (TRINORINYL equiv) aviane (NORDETTE equiv) cesia tab (CYCLESSA equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 6 of 3

7 GHCSCW Mandated Coverage Category/Class Last Updated* 8//08 DrugName Special Code Tier Cont. cryselle tab enpresse tab (TRILEVELEN equiv) jolessa tab, amethia tab (SEASONALE, SEASONIQUE equiv) junel FE tab (LOESTRIN FE equiv) junel tab kariva tab (MIRCETTE equiv) kelnor tab mononessa tab (ORTHOCYCLEN equiv) necon tab necon tab 50 (NORYNIL equiv) nortrel tab (OVCON 35 equiv) trilegest tab (ESTROSTEP FE equiv) trinessa (LO) tab (ORTHO TRICYCLEN (LO) equiv) wymzya FE tab YASMIN TAB YAZ TAB COMBINATION TRANSDERMAL XULANE PATCH COMBINATION VAGINAL NUVARING EMERGENCY ELLA TAB levonorgestrel tab (PLAN B equiv) LEVONORGESTREL TAB 0.75MG PLAN B TAB PROGESTIN INJECTABLE DEPOPROVERA SC INJ 04MG (= inj/90 days) medroxyprogesterone inj (DEPOPROVERA equiv) (= inj/90 days) PROGESTIN ORAL norethindrone tab (NORQD/ ORTHO MICRONOR equiv) DIAGNOSTIC TESTS FREESTYLE INSULINX TEST STRIP FREESTYLE LITE TEST STRIP FREESTYLE PRECISION NEO TEST STRIP FREESTYLE TEST STRIP KETODIASTIX TEST STRIP KETOSTIX TEST STRIPS PRECISION XTRA TEST STRIP ENDOCRINE AND METABOLIC AGENTS MISC. HORMONE RECEPTOR MODULATORS raloxifene tab (Covered at for women 35 years or older) HEMATOPOIETIC AGENTS FOLIC ACID/FOLATES folic acid tab mg (Covered for females only) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 7 of 3

8 GHCSCW Mandated Coverage Category/Class Last Updated* 8//08 DrugName Special Code Tier HEMATOPOIETIC AGENTS Cont. folic acid tab 400mcg (Covered for females only) folic acid tab 800mcg (Covered for females only) IRON ferrous sulfate elixir (Covered for members year or younger) FERROUS SULFATE LIQUID (Covered for members year or younger) ferrous sulfate soln (Covered for members year or younger) FERROUS SULFATE SYRUP (Covered for members year or younger) IRON SUSP (Covered for members year or younger) LAXATIVES LAXATIVE COMBINATIONS peg 3350/electrolytes soln (Covered at for members 5075 yearslimited to fills/calendar year) trilyte soln (Covered at for members 5075 years, all other members covered at generic copay; Limited to fills/calendar year) CERVICAL CAP DIAPHRAGM DIABETIC SUPPLIES FREESTYLE FREEDOM LITE METER FREESTYLE LITE METER FREESTYLE PRECISION NEO METER PRECISION XTRA METER CALIBRATION LIQUID FREESTYLE LANCETS MEDISENSE CONTROL SOLN MISC. DEVICES ALCOHOL SWABS PARENTERAL THERAPY SUPPLIES INSULIN SYRINGE NEEDLES PEN NEEDLE SYRINGE MINERALS & ELECTROLYTES FLUORIDE FLUORABON SOLN (Covered at for members 5 years or younger) SODIUM FLUORIDE LOZENGE (Covered at for members 5 years or younger) sodium fluoride soln (Covered at for members 5 years or younger) SODIUM FLUORIDE TAB (Covered at for members 5 years or younger) sodium fluoride tab (LURIDE equiv) (Covered at for members 5 years or younger) MOUTH/THROAT/DENTAL AGENTS DENTAL PRODUCTS sodium fluoride cream (Covered at for members 5 years or younger) OPHTHALMIC AGENTS OPHTHALMIC ANTIINFECTIVES Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 8 of 3

9 GHCSCW Mandated Coverage Category/Class Last Updated* 8//08 DrugName Special Code Tier OPHTHALMIC AGENTS Cont. erythromycin 0.5% ophth ointment (Covered for members days of age or younger) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMOKING DETERRENTS bupropion SR tab (ZYBAN equiv) (Limited to 80 days/calendar year) SMKG CHANTIX PAK (Limited to 80 days/plan year) SMKG CHANTIX TAB (Limited to 80 days/plan year) SMKG nicotine gum (Limited to 80 day supply/ calendar year) SMKG NICOTINE KIT SMKG nicotine lozenge (COMMIT equiv) (Limited to 80 day supply/ calendar year) SMKG nicotine patch (NICODERM equiv) (Limited to 80 days/calendar year) SMKG NICOTROL INHALER (Limited to 80 days/calendar year) SMKG NICOTROL NASAL SPRAY (Limited to 80 days/calendar year) SMKG VITAMINS OIL SOLUBLE VITAMINS vitamin D cap 000unit (Covered for members 65 years or older) vitamin D cap 000IU (Covered for members 65 years or older) vitamin D cap 400unit (Covered for members 65 years or older) vitamin D tab 000IU VITAMIN D TAB 400UNIT (Covered for members 65 years or older) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. ** drugs are not a covered benefit. Tier = Generic Copay Tier = Brand Copay OvertheCounter Quantity Limit SMKG Smoking Cessation Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 9 of 3

10 GHCSCW Mandated Coverage Last Updated* 8//08 OvertheCounter () The following drugs are a covered benefit with a prescription OvertheCounter () Medications ALCOHOL SWABS ASPIRIN CHEW TAB 75MG aspirin chew tab 8mg aspirin ec tab 35mg aspirin ec tab 8mg aspirin tab 35mg aspirin tab 8mg CALIBRATION LIQUID ferrous sulfate elixir FERROUS SULFATE LIQUID ferrous sulfate soln FERROUS SULFATE SYRUP folic acid tab 400mcg folic acid tab 800mcg FREESTYLE FREEDOM LITE METER FREESTYLE INSULINX TEST STRIP FREESTYLE LANCETS FREESTYLE LITE METER FREESTYLE LITE TEST STRIP FREESTYLE PRECISION NEO METER FREESTYLE PRECISION FREESTYLE TEST STRIP INSULIN SYRINGE IRON SUSP NEO TEST STRIP KETODIASTIX TEST STRIP KETOSTIX TEST STRIPS levonorgestrel tab MEDISENSE CONTROL SOLN NEEDLES nicotine gum NICOTINE KIT nicotine lozenge nicotine patch NOVOLIN INJ PEN NEEDLE PLAN B TAB PRECISION XTRA METER PRECISION XTRA TEST SYRINGE vitamin D cap 000unit STRIP vitamin D cap 000IU vitamin D cap 400unit vitamin D tab 000IU VITAMIN D TAB 400UNIT ** drugs are not a covered benefit. Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 0 of 3

11 GHCSCW Mandated Coverage Last Updated* 8//08 Step Therapy (ST) The following drugs are covered on the formulary with a Step Therapy. Step Therapy (ST) Medications Drug Name amethyst tab Step Therapy Requirements Step Therapy requires a trial of preferred oral contraceptives ** drugs are not a covered benefit. Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page of 3

12 GHCSCW Mandated Coverage Smoking Cessation Agents Last Updated* 8//08 Drug Name bupropion SR tab( Limited to 80 days/calendar year) CHANTIX PAK( Limited to 80 days/plan year) CHANTIX TAB( Limited to 80 days/plan year) nicotine gum( Limited to 80 day supply/ calendar year) NICOTINE KIT nicotine lozenge( Limited to 80 day supply/ calendar year) nicotine patch( Limited to 80 days/calendar year) NICOTROL INHALER( Limited to 80 days/calendar year) NICOTROL NASAL SPRAY( Limited to 80 days/calendar year) Tier # for Drug Copay ** drugs are not a covered benefit. Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page of 3

13 GHCSCW Mandated Coverage Last Updated* 8//08 Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Drug Name bupropion SR tab CHANTIX PAK CHANTIX TAB DEPOPROVERA SC INJ 04MG FARXIGA TAB JANUMET TAB JANUMET XR TAB JARDIANCE TAB medroxyprogesterone inj nicotine gum NICOTINE KIT nicotine lozenge nicotine patch NICOTROL INHALER NICOTROL NASAL SPRAY peg 3350/electrolytes soln SYNJARDY TAB SYNJARDY XR TAB 0000MG, 5000MG SYNJARDY XR TAB 5000MG,.5000MG trilyte soln XIGDUO XR TAB.5000MG, 5000MG XIGDUO XR TAB 5500MG, 0500MG, 0000MG Quantity Limit () Medications Quantity Limit Limited to 80 days/calendar year Limited to 80 days/plan year Limited to 80 days/plan year = inj/90 days = tab/day = tabs/day = tabs/day = tab/day = inj/90 days Limited to 80 day supply/ calendar year Limited to 80 day supply/ calendar year Limited to 80 days/calendar year Limited to 80 days/calendar year Limited to 80 days/calendar year Covered at for members 5075 yearslimited to fills/calendar year = tabs/day = tab/day = tabs/day Covered at for members 5075 years, all other members covered at generic copay; Limited to fills/calendar year = tabs/day = tab/day ** drugs are not a covered benefit. Coverage of medications, including those not otherwise identified by qualifiers such as, may be subject to safety screenings and other clinical edits in the course of claims Page 3 of 3