2019 LIST OF COVERED DRUGS (FORMULARY)

Transcription

1 2019 LIST OF COVERED DRUGS (FORMULARY) Prescription drug list information UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) Toll-free , TTY a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week) Formulary ID Number , Version 6 H2531_180711_101525_v01.02 Approved Last updated October 1, 2018

2 2 2 UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) 2019 List of Covered Drugs (Formulary) Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Connected for MyCare Ohio. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Connected for MyCare Ohio. Key terms and their definitions appear in the last chapter of the Member Handbook. Table of Contents A. Disclaimers...3 B. Frequently Asked Questions (FAQ) What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.)... 4 B2. Does the Drug List ever change?...4 B3. What happens when there is a change to the Drug List?...5 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?...6 B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?... 7 B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?...7 B7. How can you find a drug on the Drug List?... 7 B8. What if the drug you want to take is not on the Drug List?...8 B9. What if you are a new UnitedHealthcare Connected for MyCare Ohio member and can t find your drug on the Drug List or have a problem getting your drug? Can you ask for an exception to cover your drug? How can you ask for an exception? How long does it take to get an exception? What are generic drugs? What are OTC drugs? What is your copay? C. List of Covered Drugs by Medical Condition...11 D. Index of Covered Drugs...215

3 A. Disclaimers 3 This is a list of drugs that members can get in UnitedHealthcare Connected for MyCare Ohio. v UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. v Benefits and/or copays may change on January 1 of each year. v You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date List of Covered Drugs online at v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected for MyCare Ohio Member Services or read the UnitedHealthcare Connected for MyCare Ohio Member Handbook. v Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). The call is free. v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al , TTY 711, de 8 a.m. a 8 p.m., hora local, de lunes a viernes (correo de voz disponible las 24 horas del día, los 7 días de la semana). La llamada es gratuita. v You can get this document for free in other formats, such as large print, braille, or audio. Call , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). The call is free. v You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future. 3 If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

4 4 4 B. Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 13 are the drugs covered by UnitedHealthcare Connected for MyCare Ohio. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. UnitedHealthcare Connected for MyCare Ohio will cover all medically necessary drugs on the Drug List if: o o Your doctor or other prescriber says you need them to get better or stay healthy, and You fill the prescription at a UnitedHealthcare Connected for MyCare Ohio network pharmacy. UnitedHealthcare Connected for MyCare Ohio may have additional steps to access certain drugs (see question B4 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at , TTY 711. B2. Does the Drug List ever change? Yes. UnitedHealthcare Connected for MyCare Ohio may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected for MyCare Ohio before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see question B4. This section is continued on the next page. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

5 5 5 If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless: A new, cheaper drug comes along that works as well as a drug on the Drug List now, or We learn that a drug is not safe, or A drug is removed from the market. Questions B3 and B6 below have more information on what happens when the Drug List changes. You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date Drug List online at You can also call Member Services to check the current Drug List at , TTY 711. B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example: A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. o o We may not tell you before we make this change, but we will send you information about the specific change or changes we made. You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions 0-2 for more information on exceptions. A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know that. Contact your doctor or other prescriber and ask about your other options. This section is continued on the next page. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

6 6 6 We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: The FDA provides new guidance or there are new clinical guidelines about a drug. We add a generic drug that is not new to the market and Replace a brand name drug currently on the Drug List or Change the coverage rules or limits for the brand name drug. When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can: Get at least a 30-day supply of the drug before the change to the Drug List is made, or Ask for an exception from these changes. Please see questions 0-2 for more information about exceptions. B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. UnitedHealthcare Connected for MyCare Ohio may not cover the drug if you do not get approval. Quantity limits: Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. Step therapy: Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. This section is continued on the next page. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

7 7 7 You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions 0-2 for more information about exceptions. B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on pages has a column labeled. B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/ or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change. B7. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Index of Covered Drugs section that begins on page 215. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. To search by medical condition, find the section labeled List of covered drugs by medical condition on pages The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

8 8 8 B8. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at , TTY 711 and ask about it. If you learn that UnitedHealthcare Connected for MyCare Ohio will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions 0 2 for more information about exceptions. B9. What if you are a new UnitedHealthcare Connected for MyCare Ohio member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected for MyCare Ohio. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. We will cover a 30-day supply of your drug if: You are taking a drug that is not on our Drug List, or Health plan rules do not let you get the amount ordered by your prescriber, or The drug requires prior approval by UnitedHealthcare Connected for MyCare Ohio, or You are taking a drug that is part of a step therapy restriction. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away: We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected for MyCare Ohio member. This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Connected for MyCare Ohio. This section is continued on the next page. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

9 9 If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a 31-day temporary supply of the Part D drug you need. This will give you time to talk to your doctor about other treatment options or to try to get an exception. Please see questions 0-2 for more information about exceptions. We will not pay for more of your drug after you get a temporary or emergency supply unless you receive authorization from UnitedHealthcare Connected for MyCare Ohio Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected for MyCare Ohio to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UnitedHealthcare Connected for MyCare Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 1. How can you ask for an exception? To ask for an exception, call Member Services at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions. 2. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

10 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Connected for MyCare Ohio covers both brand name drugs and generic drugs. 4. What are OTC drugs? OTC stands for over-the-counter. UnitedHealthcare Connected for MyCare Ohio covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC drugs are covered. 5. What is your copay? You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to learn about the copay for each drug. UnitedHealthcare Connected for MyCare Ohio members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.25 to $3.40, depending on your income. Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.80 to $8.50, depending on your income. Tier 3 drugs have $0 copay. They are OTC drugs. If you have questions, or need to speak with your care manager please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; (voic available 24 hours a day/7 days a week). If your need is urgent, you may call the Nurseline at , 24 hours a day/7 days a week. These calls are free. For more information, visit

11 For Track Refered Purpose C. List of Covered Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. The following list of covered drugs gives you information about the drugs covered by UnitedHealthcare Connected for MyCare Ohio. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 215. The index alphabetically lists all drugs covered by UnitedHealthcare Connected for MyCare Ohio. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the column tells you if UnitedHealthcare Connected for MyCare Ohio has any rules for covering your drug. Coverage Rules and Limits PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. UnitedHealthcare Connected for MyCare Ohio may not cover the drug if you do not get approval. QL - Quantity limits Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. Other Special Coverage Rules 11 B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. LA - Limited access Drugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. 11 This section is continued on the next page.

12 For 212Track Refered Purpose 12 MME - Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 7D - 7-Day Limit An opioid drug used for the treatment of acute pain may be limited to a 7 day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan. DL - Dispensing limit Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at , TTY 711. You can also read Chapter 9, of the Member Handbook to learn how to appeal a decision. Extra Help Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the Low-Income Subsidy, or LIS.

13 8hr Muscle Aches & Pain Acephen Acetaminophen Acetaminophen ER Acetaminophen Extra Strength Acetaminophen PM Extra Strength Acetaminophen/Diphenhydramine Arthritis Pain Relief Arthritis Pain Reliever Betatemp Childrens Butalbital/Acetaminophen Butalbital/Acetaminophen/Caffeine 50mg-325mg-40mg Tablet, 50mg-325mg-40mg Capsule) Butalbital/Aspirin/Caffeine Childrens Acetaminophen Childrens Apap Childrens Pain Reliever Childrens Silapap For Track Refered Purpose A1 Analgesics 1For 13 Track Refered Purpose 13 Analgesics Hour Arthritis Pain Reliever 8 hour arthritis pain reliever (tablet extendedrelease)* 8hr muscle aches & pain (tablet extended-release)* acephen (suppository)* acetaminophen (powder, 120mg suppository, 650mg suppository, 160mg/5ml liquid, 160mg/5ml oral solution, 325mg/10.15ml oral solution, 650mg/ 20.3ml oral solution, 325mg tablet, 500mg tablet, 80mg tablet chewable)* acetaminophen er (tablet extended-release)* acetaminophen extra strength (500mg tablet, 500mg/15ml liquid)* acetaminophen pm extra strength (tablet)* acetaminophen/diphenhydramine (tablet)* arthritis pain relief (tablet extended-release)* arthritis pain reliever (tablet extended-release)* betatemp childrens (suspension)* butalbital/acetaminophen (50mg-325mg tablet) QL butalbital/acetaminophen/caffeine 50mg-325mg-40mg tablet, 50mg-325mg-40mg QL capsule) butalbital/aspirin/caffeine (50mg-325mg-40mg capsule) QL childrens acetaminophen (suspension)* childrens apap (tablet chewable)* childrens pain reliever (tablet dispersible)* childrens silapap (liquid)* You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

14 Childrens Tactinal ED-APAP FeverAll Adults FeverAll Childrens FeverAll Infants FeverAll Junior Strength GNP 8 Hour Pain Reliever GNP Arthritis Pain Relief GNP Childrens Easy-Melts GNP Headache PM GNP Infants Pain Relief GNP Infants Pain/Fever GNP Pain & Fever Childrens GNP Pain Relief GNP Pain Relief Extra Strength GNP Pain Relief PM Extra Strength Goodsense Arthritis Pain Goodsense Headache PM Goodsense Pain & Fever Childrens Goodsense Pain & Fever Infants Goodsense Pain Relief Goodsense Pain Relief Extra Strength Goodsense Pain Relief PM Extra Strength Headache PM Headache PM Formula Healthy Mama Eazzze the Pain Healthy Mama Shake That Ache HM Acetaminophen PM Extra Strength HM Arthritis Pain Relief HM Pain & Fever Childrens HM Pain & Fever Infants HM Pain Relief Extra Strength HM Pain Reliever Liquid Pain Relief Little Remedies Fever/Pain Reliever Childrens 14 2For 14 Track Refered Purpose childrens tactinal (tablet chewable)* ed-apap (liquid)* feverall adults (suppository)* feverall childrens (suppository)* feverall infants (suppository)* feverall junior strength (suppository)* gnp 8 hour pain reliever (tablet extended-release)* gnp arthritis pain relief (tablet extended-release)* gnp childrens easy-melts (tablet dispersible)* gnp headache pm (tablet)* gnp infants pain relief (suspension)* gnp infants pain/fever (suspension)* gnp pain & fever childrens (suspension)* gnp pain relief (tablet)* gnp pain relief extra strength (tablet)* gnp pain relief pm extra strength (tablet)* goodsense arthritis pain (tablet extended-release)* goodsense headache pm (tablet)* goodsense pain & fever childrens (suspension)* goodsense pain & fever infants (suspension)* goodsense pain relief (tablet extended-release)* goodsense pain relief extra strength (tablet)* goodsense pain relief pm extra strength (tablet)* headache pm (tablet)* headache pm formula (tablet)* healthy mama eazzze the pain (tablet)* healthy mama shake that ache (tablet)* hm acetaminophen pm extra strength (tablet)* hm arthritis pain relief (tablet extended-release)* hm pain & fever childrens (suspension)* hm pain & fever infants (suspension)* hm pain relief extra strength (tablet)* hm pain reliever (tablet)* liquid pain relief (liquid)* little remedies fever/pain reliever childrens (liquid)*

15 Little Remedies for Fevers Fever/Pain Reliever Infant Mapap Mapap Acetaminophen Extra Strength Mapap Arthritis Pain Mapap Childrens Mapap Extra Strength Mapap PM Medi-Tabs Extra Strength Night Time Pain Medicine Extra Strength Non-Aspirin Non-Aspirin Childrens Non-Aspirin Extra Strength Non-Aspirin Pain Relief Non-Aspirin Pain Relief Extra Strength Nortemp Nortemp Infants Pain & Fever Pain & Fever Childrens Pain & Fever Childrens Dye-Free Pain & Fever Extra Strength Pain & Fever Infants Pain Relief Extra Strength Pain Relief PM Extra Strength Pain Reliever Extra Strength 3For 15 Track Refered Purpose Little Remedies for Fevers Fever/Pain Reliever Childrens little remedies for fevers fever/pain reliever childrens (liquid)* little remedies for fevers fever/pain reliever infant (liquid)* mapap (160mg/5ml liquid, 325mg tablet, 500mg tablet, 500mg capsule, 80mg tablet chewable)* mapap acetaminophen extra strength (liquid)* mapap arthritis pain (tablet extended-release)* mapap childrens (160mg tablet chewable, 160mg/ 5ml suspension, 80mg tablet dispersible)* mapap extra strength (tablet)* mapap pm (tablet)* medi-tabs extra strength (tablet)* night time pain medicine extra strength (tablet)* non-aspirin (tablet)* non-aspirin childrens (suspension)* non-aspirin extra strength (tablet)* non-aspirin pain relief (tablet)* non-aspirin pain relief extra strength (tablet)* nortemp (suspension)* nortemp infants (suspension)* pain & fever (tablet)* pain & fever childrens (160mg/5ml oral solution, 160mg/5ml suspension, 80mg tablet chewable)* pain & fever childrens dye-free (suspension)* pain & fever extra strength (tablet)* pain & fever infants (suspension)* pain relief extra strength (tablet)* pain relief pm extra strength (tablet)* pain reliever extra strength (tablet)* 15 You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

16 Pain Reliever PM Pain Reliever PM Extra Strength Pediacare Children Pharbetol Pharbetol Extra Strength Px Arthritis Pain Relief Px Childrens Pain Relief Px Pain Relief Extra Strength Px Pain Relief PM Extra Strength QC Acetaminophen 8 Hours QC Arthritis Pain Relief QC Non-Aspirin Childrens QC Non-Aspirin Extra Strength QC Non-Aspirin Jr Strength QC Pain Relief QC Pain Relief Childrens QC Pain Relief Extra Strength QC Pain Relief Infants SB Arthritis Pain Relief SB Non-Aspirin SB Non-Aspirin Extra Strength SB Non-Aspirin Nighttime SB Pain Reliever Childrens SB Pain Reliever Extra Strength Sm 8 Hour Pain Relief Sm Arthritis Pain Relief SM Pain & Fever Childrens SM Pain & Fever Infants Sm Pain Relief Extra Strength SM Pain Reliever SM Pain Reliever Extra Strength SM Pain Reliever PM Extra Strength Tactinal Tactinal Extra Strength Tencon 16 4For 16 Track Refered Purpose pain reliever pm (tablet)* pain reliever pm extra strength (tablet)* pediacare children (suspension)* pharbetol (tablet)* pharbetol extra strength (tablet)* px arthritis pain relief (tablet extended-release)* px childrens pain relief (suspension)* px pain relief extra strength (tablet)* px pain relief pm extra strength (tablet)* qc acetaminophen 8 hours (tablet extendedrelease)* qc arthritis pain relief (tablet extended-release)* qc non-aspirin childrens (suspension)* qc non-aspirin extra strength (tablet)* qc non-aspirin jr strength (tablet dispersible)* qc pain relief (tablet)* qc pain relief childrens (suspension)* qc pain relief extra strength (tablet)* qc pain relief infants (suspension)* sb arthritis pain relief (tablet extended-release)* sb non-aspirin (tablet)* sb non-aspirin extra strength (tablet)* sb non-aspirin nighttime (tablet)* sb pain reliever childrens (suspension)* sb pain reliever extra strength (tablet)* sm 8 hour pain relief (tablet extended-release)* sm arthritis pain relief (tablet extended-release)* sm pain & fever childrens (suspension)* sm pain & fever infants (suspension)* sm pain relief extra strength (tablet)* sm pain reliever (tablet)* sm pain reliever extra strength (500mg capsule, 500mg tablet)* sm pain reliever pm extra strength (tablet)* tactinal (tablet)* tactinal extra strength (tablet)* tencon (tablet) QL

17 TGT Acetaminophen Childrens TGT Acetaminophen Extra Strength TGT Acetaminophen Extra Strength Quick Release TGT Arthritis Pain Relief TGT Childrens Acetaminophen Tylenol Tylenol Childrens Tylenol Extra Strength Tylenol Infants Pain+fever Zebutal Adult Aspirin Regimen Advil Advil Junior Strength Advil Migraine Aleve Aleve Arthritis All Day Pain Relief All Day Relief Aspir-81 Aspirin Aspirin Adult Low Dose Aspirin Adult Low Strength 5For 17 Track Refered Purpose 17 tgt acetaminophen childrens (suspension)* tgt acetaminophen extra strength (tablet)* tgt acetaminophen extra strength quick release (tablet)* tgt arthritis pain relief (tablet extended-release)* tgt childrens acetaminophen (suspension)* tylenol (tablet)* tylenol childrens (suspension)* tylenol extra strength (tablet)* tylenol infants pain+fever (suspension)* zebutal (capsule) QL Nonsteroidal Anti-inflammatory Drugs adult aspirin regimen (tablet delayed-release)* advil (200mg capsule, 200mg tablet)* advil junior strength (100mg tablet, 100mg tablet chewable)* advil migraine (capsule)* aleve (tablet)* aleve arthritis (tablet)* all day pain relief (tablet)* all day relief (tablet)* aspir-81 (tablet delayed-release)* aspirin (powder, 300mg suppository, 600mg suppository, 325mg tablet, 325mg tablet delayedrelease, 81mg tablet delayed-release, 81mg tablet chewable, 81mg tablet delayed-release)* aspirin adult low dose (81mg tablet chewable, 81mg tablet delayed-release)* aspirin adult low strength (81mg tablet chewable, 81mg tablet delayed-release)* You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

18 Aspirin Childrens Aspirin EC Aspirin EC Low Dose Aspirin Enteric Coated Adult Low Strength Aspirin Low Dose Aspirin Low Strength Aspir-Low Bayer Aspirin Bayer Aspirin EC Low Dose Bayer Aspirin Extra Strength Bayer Chewable Low Dose Bayer Low Dose Childrens Advil Childrens Aspirin Childrens Aspirin Low Strength Childrens Ibuprofen Childs Ibuprofen Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium DR Diclofenac Sodium ER Diflunisal Ec-81 Aspirin Ecotrin Low Strength Ecotrin Regular Strength Ecpirin Enteric Coated Aspirin EQ Aspirin EC Eq Naproxen Sodium EQL Naproxen Sodium Etodolac Flanax Pain Relief 18 6For 18 Track Refered Purpose aspirin childrens (tablet chewable)* aspirin ec (tablet delayed-release)* aspirin ec low dose (tablet delayed-release)* aspirin enteric coated adult low strength (tablet delayed-release)* aspirin low dose (81mg tablet chewable, 81mg tablet delayed-release)* aspirin low strength (tablet chewable)* aspir-low (tablet delayed-release)* bayer aspirin (tablet)* bayer aspirin ec low dose (tablet delayed-release)* bayer aspirin extra strength (tablet)* bayer chewable low dose (tablet chewable)* bayer low dose (tablet delayed-release)* childrens advil (suspension)* childrens aspirin (tablet chewable)* childrens aspirin low strength (tablet chewable)* childrens ibuprofen (otc only) (suspension)* childs ibuprofen (otc only) (suspension)* diclofenac potassium (tablet) diclofenac sodium (1% gel) PA diclofenac sodium dr (tablet delayed-release) diclofenac sodium er (tablet extended-release 24 hour) diflunisal (tablet) ec-81 aspirin (tablet delayed-release)* ecotrin low strength (tablet delayed-release)* ecotrin regular strength (tablet delayed-release)* ecpirin (tablet delayed-release)* enteric coated aspirin (tablet delayed-release)* eq aspirin ec (tablet delayed-release)* eq naproxen sodium (tablet)* eql naproxen sodium (tablet)* etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediaterelease) flanax pain relief (tablet)*

19 Flector Flurbiprofen GNP Adult Aspirin Low Strength GNP All Day Pain Relief GNP Aspirin GNP Aspirin Low Dose GNP Childrens Ibuprofen GNP Ibuprofen GNP Ibuprofen Infants GNP Ibuprofen Junior Strength GNP Naproxen Sodium Goodsense Aspirin Goodsense Aspirin Adult Low Strength Goodsense Aspirin Low Dose Goodsense Ibuprofen Goodsense Ibuprofen Childrens Goodsense Ibuprofen Infants Goodsense Ibuprofen Junior Strength Goodsense Naproxen Sodium HM Aspirin HM Aspirin EC HM Aspirin EC Low Dose HM Ibuprofen HM Ibuprofen Childrens 7For 19 Track Refered Purpose 19 FLECTOR (PATCH) $3.80-$8.50 (Tier 2) PA, QL flurbiprofen (tablet) gnp adult aspirin low strength (tablet chewable)* gnp all day pain relief (tablet)* gnp aspirin (325mg tablet, 325mg tablet delayedrelease, 81mg tablet delayed-release)* gnp aspirin low dose (tablet delayed-release)* gnp childrens ibuprofen (otc only) (suspension)* gnp ibuprofen (otc only) (tablet)* gnp ibuprofen infants (suspension)* gnp ibuprofen junior strength (otc only) (tablet chewable)* gnp naproxen sodium (220mg capsule, 220mg tablet)* goodsense aspirin (325mg tablet, 81mg tablet chewable)* goodsense aspirin adult low strength (tablet chewable)* goodsense aspirin low dose (tablet delayed-release)* goodsense ibuprofen (tablet)* goodsense ibuprofen childrens (suspension)* goodsense ibuprofen infants (suspension)* goodsense ibuprofen junior strength (tablet chewable)* goodsense naproxen sodium (tablet)* hm aspirin (325mg tablet, 81mg tablet chewable)* hm aspirin ec (tablet delayed-release)* hm aspirin ec low dose (tablet delayed-release)* hm ibuprofen (200mg capsule, 200mg tablet)* hm ibuprofen childrens (suspension)* You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

20 HM Ibuprofen IB HM Ibuprofen Infants HM Naproxen Sodium Ibu Ibu-200 Ibu-Drops Infants Ibuprofen Ibuprofen Ibuprofen Childrens Ibuprofen Junior Strength Indomethacin Infants Advil Infants Ibuprofen Kls Naproxen Sodium KP Aspirin KS Ibuprofen Medi-Profen Mediproxen Meijer Ibuprofen Meloxicam Motrin IB Naproxen Naproxen DR Naproxen Sodium Provil Px All Day Relief PX Aspirin Px Childrens Profen IB Px Ibuprofen Px Ibuprofen Junior Strength Px Infants Profen IB 20 8For 20 Track Refered Purpose hm ibuprofen ib (otc only) (tablet)* hm ibuprofen infants (otc only) (suspension)* hm naproxen sodium (220mg capsule, 220mg tablet)* ibu (rx only) (tablet) ibu-200 (tablet)* ibu-drops infants (suspension)* ibuprofen (otc only) (200mg capsule, 200mg tablet)* ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) ibuprofen childrens (suspension)* ibuprofen junior strength (tablet chewable)* indomethacin (25mg capsule, 50mg capsule) infants advil (suspension)* infants ibuprofen (otc only) (suspension)* kls naproxen sodium (tablet)* kp aspirin (tablet delayed-release)* ks ibuprofen (capsule)* medi-profen (suspension)* mediproxen (tablet)* meijer ibuprofen (tablet)* meloxicam (tablet) motrin ib (tablet)* naproxen (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediate-release, 500mg tablet immediate-release) naproxen dr (tablet delayed-release) (generic ecnaprosyn) naproxen sodium (otc only) (220mg capsule, 220mg tablet)* provil (tablet)* px all day relief (tablet)* px aspirin (325mg tablet, 81mg tablet chewable)* px childrens profen ib (suspension)* px ibuprofen (tablet)* px ibuprofen junior strength (tablet chewable)* px infants profen ib (suspension)*

21 QC Aspirin Low Dose QC Chewable Aspirin Low Dose QC Childrens Ibuprofen QC Enteric Aspirin QC Ibuprofen QC Ibuprofen IB QC Ibuprofen Infants QC Naproxen Sodium SB Aspirin SB Aspirin Adult Low Strength SB Childrens Aspirin SB Ibuprofen SB Infants Ibuprofen SB Low Dose Asa EC SB Naproxen Sodium SM Aspirin SM Aspirin Adult Low Strength SM Aspirin EC Low Strength SM Aspirin Enteric Coated SM Aspirin Low Dose SM Childrens Aspirin SM Childrens Ibuprofen SM Ibuprofen SM Ibuprofen IB QC Aspirin qc aspirin (325mg tablet, 325mg tablet delayedrelease)* 9For 21 Track Refered Purpose qc aspirin low dose (tablet delayed-release)* qc chewable aspirin low dose (tablet chewable)* qc childrens ibuprofen (suspension)* qc enteric aspirin (tablet delayed-release)* qc ibuprofen (otc only) (tablet)* qc ibuprofen ib (tablet)* qc ibuprofen infants (suspension)* qc naproxen sodium (otc only) (tablet)* sb aspirin (325mg tablet, 81mg tablet delayedrelease)* sb aspirin adult low strength (tablet delayedrelease)* sb childrens aspirin (tablet chewable)* sb ibuprofen (tablet)* sb infants ibuprofen (suspension)* sb low dose asa ec (tablet delayed-release)* sb naproxen sodium (tablet)* sm aspirin (tablet)* sm aspirin adult low strength (81mg tablet chewable, 81mg tablet delayed-release)* sm aspirin ec low strength (tablet delayed-release)* sm aspirin enteric coated (tablet delayed-release)* sm aspirin low dose (tablet chewable)* sm childrens aspirin (tablet chewable)* sm childrens ibuprofen (otc only) (suspension)* sm ibuprofen (200mg capsule, 200mg tablet)* sm ibuprofen ib (100mg tablet chewable, 200mg tablet)* 21 You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

22 SM Ibuprofen Jr SM Infants Ibuprofen SM Naproxen Sodium Sulindac TGT Aspirin TGT Aspirin Low Dose TGT Childrens Aspirin TGT Childrens Ibuprofen TGT Enteric-Coated Aspirin TGT Ibuprofen TGT Ibuprofen Childrens TGT Ibuprofen Junior Strength TGT Naproxen Sodium Hydromorphone HCl ER Morphine Sulfate ER 22 For Track Refered Purpose sm ibuprofen jr (tablet)* sm infants ibuprofen (otc only) (suspension)* sm naproxen sodium (tablet)* sulindac (tablet) tgt aspirin (325mg tablet, 81mg tablet chewable)* tgt aspirin low dose (tablet delayed-release)* tgt childrens aspirin (tablet chewable)* tgt childrens ibuprofen (suspension)* tgt enteric-coated aspirin (tablet delayed-release)* tgt ibuprofen (200mg capsule, 200mg tablet)* tgt ibuprofen childrens (suspension)* tgt ibuprofen junior strength (tablet chewable)* tgt naproxen sodium (tablet)* Opioid Analgesics, Long-acting Embeda EMBEDA (CAPSULE EXTENDED-RELEASE) $3.80-$8.50 (Tier 2) Fentanyl fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch 72 hour, 75mcg/hr patch 72 hour) hydromorphone hcl er (tablet extended-release 24 hour abuse-deterrent) Hysingla ER HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR ABUSE-DETERRENT) $3.80-$8.50 (Tier 2) Levorphanol Tartrate levorphanol tartrate (tablet) Methadone HCl methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution) morphine sulfate er (100mg tablet extended-release, 15mg tablet extended-release, 200mg tablet extended-release, 30mg tablet extended-release, 60mg tablet extended-release) (generic ms contin) Nucynta ER NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.80-$8.50 (Tier 2) Tramadol HCl ER tramadol hcl er (100mg tablet extended-release 24 hour, 200mg tablet extended-release 24 hour, 300mg tablet extended-release 24 hour) Xtampza ER XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12 HOUR ABUSE-DETERRENT) $3.80-$8.50 (Tier 2) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME

23 Abstral Acetaminophen/Codeine Duramorph Hydrocodone Bitartrate/Acetaminophen Hydrocodone/Acetaminophen Hydromorphone HCl Hydromorphone HCl For Track Refered Purpose 23 Opioid Analgesics, Short-acting ABSTRAL (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2) DL, PA, QL acetaminophen/codeine (120mg-12mg/5ml oral 7D, DL, QL, solution, 300mg-15mg tablet, 300mg-30mg tablet, MME 300mg-60mg tablet) Butorphanol Tartrate butorphanol tartrate (nasal solution) 7D, DL, QL, MME Codeine Sulfate codeine sulfate (tablet) 7D, DL, QL, MME DURAMORPH (INJECTION) $3.80-$8.50 (Tier 2) 7D, DL Endocet endocet (tablet) 7D, DL, QL, MME Fentanyl Citrate Oral Transmucosal fentanyl citrate oral transmucosal (lozenge on a handle) hydrocodone bitartrate/acetaminophen (7.5mg-325mg/15ml oral solution) hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) DL, PA, QL Hydrocodone/Ibuprofen hydrocodone/ibuprofen (7.5mg-200mg tablet) Hydromorphone HCl hydromorphone hcl (10mg/ml injection, 50mg/5ml injection) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL hydromorphone hcl (1mg/ml liquid, 2mg tablet 7D, DL, QL, immediate-release, 4mg tablet immediate-release, MME 8mg tablet immediate-release) HYDROMORPHONE HCL (2MG/ML INJECTION) $3.80-$8.50 (Tier 2) 7D, DL Lorcet lorcet (tablet) 7D, DL, QL, MME Lorcet HD lorcet hd (tablet) 7D, DL, QL, MME You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

24 Morphine Sulfate Oxycodone HCl Oxycodone/Acetaminophen Lidocaine Lidocaine Lidocaine HCl Lidocaine HCl Lidocaine Viscous Lidocaine/Prilocaine 24 For Track Refered Purpose Lorcet Plus lorcet plus (tablet) Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/ 5ml oral solution, 20mg/5ml oral solution) morphine sulfate (10mg/ml injection, 4mg/ml injection, 8mg/ml injection) Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE- RELEASE, 30MG TABLET IMMEDIATE-RELEASE) Morphine Sulfate MORPHINE SULFATE (2MG/ML INJECTION, 5MG/ML INJECTION) oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediaterelease, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL $3.80-$8.50 (Tier 2) 7D, DL, QL, MME $3.80-$8.50 (Tier 2) 7D, DL Oxycodone/Aspirin oxycodone/aspirin (tablet) Oxycodone/Ibuprofen oxycodone/ibuprofen (tablet) Tramadol HCl tramadol hcl (tablet immediate-release) Tramadol HCl/Acetaminophen tramadol hcl/acetaminophen (tablet) Trezix trezix (capsule) A1 Anesthetics Local Anesthetics 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME lidocaine (rx only) (5% ointment) QL lidocaine (rx only) (5% patch) PA, QL lidocaine hcl (gel) lidocaine hcl (rx only) (external solution) lidocaine viscous (solution) lidocaine/prilocaine (cream) A1 Anti-Addiction/Substance Abuse Treatment Agents

25 Acamprosate Calcium DR Disulfiram Naltrexone HCl Vivitrol Buprenorphine HCl Buprenorphine HCl/Naloxone HCl Suboxone Naloxone HCl Narcan Chantix Chantix Continuing Month Pak Chantix Starting Month Pak EQ Nicotine Lozenges GNP Nicotine Gum GNP Nicotine Mini Lozenge GNP Nicotine Polacrilex GNP Nicotine Polacrilex Mini GNP Nicotine Transdermal System Goodsense Nicotine Gum Goodsense Nicotine Polacrilex For Track Refered Purpose 25 Alcohol Deterrents/Anti-craving acamprosate calcium dr (tablet delayed-release) disulfiram (tablet) naltrexone hcl (tablet) VIVITROL (INJECTION) $3.80-$8.50 (Tier 2) Opioid Dependence Treatments buprenorphine hcl (tablet sublingual) QL buprenorphine hcl/naloxone hcl (tablet sublingual) QL SUBOXONE (FILM) $3.80-$8.50 (Tier 2) QL Opioid Reversal Agents naloxone hcl (injection) NARCAN (LIQUID) $3.80-$8.50 (Tier 2) Smoking Cessation Agents Bupropion HCl SR bupropion hcl sr (150mg tablet extended-release 12 hour smoking-deterrent) CHANTIX (TABLET) $3.80-$8.50 (Tier 2) CHANTIX CONTINUING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2) CHANTIX STARTING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2) eq nicotine lozenges* gnp nicotine gum* gnp nicotine mini lozenge* gnp nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* gnp nicotine polacrilex mini (lozenge)* gnp nicotine transdermal system (patch 24 hour)* goodsense nicotine gum* goodsense nicotine polacrilex (lozenge)* You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.