July Medication Guide PAGE CONTENTS

Transcription

1 July 2010 Medication Guide CONTENTS PAGE CONTENTS PAGE Introduction Preface Pharmacy Benefit Programs Prior Coverage Authorization Responsible Quantity Program Covered Over-The-Counter (OTC) Products Mail Order Pharmacy Using the Medication Guide Medications That Are Not Covered Notice Pharmacy Products Preferred Medication List Analgesics Anesthetics Antibacterials Anticonvulsants Antidementia Agents Antidepressants Antidotes Antiemetics Antifungals Antigout Agents Anti-inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimyobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products Cardiovascular Agents Central Nervous System Agents Dental and Oral Agents Dermatological Agents Enzyme Replacments Gastrointestinal Agents Genitourinary Agents Hormonal Agents Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract Agents Sedatives Skeletal Muscle Relaxants Therapeutic Nutrients Index This Medication Guide was current at time of printing and is subject to change. Please visit our web site, for the most current information FL Prime Therapeutics LLC 06/10

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3 Introduction Blue Cross and Blue Shield of Florida and Health Options, Inc. is pleased to present the Medication Guide. This is a general guide that includes an abbreviated listing of Brand and Generic prescription medications that may be covered under your plan. Since coverage for medication varies by the plan purchased by you or your employer, it s important that you refer to your Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement for complete coverage details. Current members are encouraged to log on to MyBlueService for plan specific details about their prescription medication coverage. On our member site, MyBlueService, you can look up a medication by name and compare your cost at different pharmacies. You ll see notes that indicate if a medication requires a prior authorization or is not covered by your plan. Simply go to log in to MyBlueService and select Drugs & Pharmacy. For questions, please call the customer service number listed on your member ID card. For the hearing impaired, call Florida TTY Relay Service 711. Si desea hablar sobre esta guía en español con uno de nuestros representantes, por favor llame al número de atención al cliente indicado en su tarjeta de asegurado y pida ser transferido a un representante bilingüe. Note: The decision concerning whether a prescription medication should be prescribed must be made by you and your physician. Any and all decisions that require or pertain to independent professional medical judgments or training, or the need for, and dosage of, a prescription medication, must be made solely by you and your treating Physician in accordance with the patient/physician relationship. 1

4 Preface MEDICATION LIST The Medication Guide includes the Preferred Medication List and some commonly prescribed Non Preferred prescription medications. The Preferred Medication List reflects the current recommendations of Blue Cross and Blue Shield of Florida, Inc. and Health Options, Inc. and is developed in conjunction with Prime Therapeutics National Pharmacy & Therapeutics Committee. Note: This is not a complete listing of all covered prescriptions medications. BCBSF reserves the right to modify (add, remove or change) the tier or apply limits of coverage to any prescription medication in this Medication Guide at any time. To reduce your out-of-pocket expenses, please take a copy of this Medication Guide with you each time you visit your Physician. Please consider asking your Physician to prescribe Generic medications, or if necessary, one of the Preferred Brand prescription medications listed in the Medication Guide whenever appropriate. Your cost for Generic and Preferred Brand prescription medications on the Medication List are lower than Non Preferred Brand prescription medications. PHARMACY BENEFIT PROGRAMS There are three types of pharmacy benefit programs; Generic Only, 2 Tier and 3 Tier. To understand which program you have, please refer to your Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement or call the number on your member ID card for more information. GENERIC ONLY BENEFIT Tier 1: Covered Generic Prescription Medications 2 TIER BENEFIT Tier 1: Covered Generic Prescription Medications Tier 2: Covered Brand Prescription Medications 3 TIER BENEFIT Tier 1: Covered Generic Prescription Medications Tier 2: Covered Preferred Brand Prescription Medications Tier 3: Covered Non-Preferred Brand Prescription Medications or Medications not listed on the Preferred Medication List WHAT YOU NEED TO KNOW ABOUT GENERIC MEDICATIONS Blue Cross and Blue Shield of Florida, Inc. and Health Options, Inc. encourages the use of Generic medications as a way to provide high-quality medications at reduced costs. Generic medications are as safe and effective as their Brand Name counterparts, and are usually considerably less expensive. A Food and Drug Administration (FDA) approved Generic medication may be substituted for its Brand Name counterpart because it: Contains the same active ingredient(s) as the Brand medication Is identical in strength, dosage form, and route of administration Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile CHANGES TO THE FORMULARY The medications listed in the Medication Guide are subject to change at any time. The Medication List is reviewed quarterly to examine new medications and new information about medications that are already on the market concerning safety, effectiveness and current use in therapy. The most up to date information about modifications to the medications listed in this Medication Guide can be found at Click on the For Providers tab Under the Pharmacy section, click Medication Guides. Under Medication Guide for Individuals Under 65 and Group, click Medication Guide or Medication Guide Updates. 2

5 There are varying reasons why changes are made to the medications listed in the Medication Guide: The tier level of a Brand prescription medication included on the Medication List may increase (change from Tier 2 to Tier 3) when an FDA-approved bioequivalent Generic prescription medication becomes available. Newly marketed Brand prescription medications are usually introduced on Tier 3 until the opportunity exists to review the medication level, at which time a determination will be made as to which tier will apply based on safety, efficacy and the availability of other products within that class of medications. WHAT IF MY MEDICATION IS NOT LISTED ON THE FORMULARY? Not every prescription medication is listed in the Medication Guide. The most commonly prescribed prescription medications are included in the medication list. If your medication is not included in this formulary, you can get information about the medication in the Drugs & Pharmacy section of MyBlueService. You can also call the customer service number listed on your member ID card. For the hearing impaired, call Florida TTY Relay Service 711. ADDITIONAL REQUIREMENTS OR LIMITS ON COVERAGE Some covered medications may have additional requirements or limits on coverage. This section refers to our Responsible Rx programs including, Responsible Quantity and. PRIOR AUTHORIZATION The program encourages the appropriate, safe and cost-effective use of medication. If you are currently taking or are prescribed a medication that is included in the program list of medications, your physician will need to submit a request in order for your prescription to be considered for coverage. If you do not request and/or receive prior approval, the medication will not be covered. Medications on the Medication List that require for coverage are indicated in the column following the product name. Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to determine if requirements apply to your plan. Coverage details are also available to you by logging into MyBlueService or by calling the customer service number listed on your member ID card. OBTAINING PRIOR COVERAGE AUTHORIZATION Information about and steps for how to obtain a approval can be found on our website, Click on the For Members tab. Click on the Forms tab. Under Prescription Drug Forms, select Forms. Note: Your provider is required to complete and submit the form in order for a coverage determination to be made. 1. Once a decision is made, you and/or your doctor will be informed of the decision. 2. If the decision is made to authorize coverage, the medication(s) and/or supplies may be obtained from a Participating Pharmacy or at the appropriate location if the medication(s) will be administered by a health professional. approval does not waive your financial responsibility. 3. If a decision is made to deny authorization, you are free to purchase the prescription medication, supplies or Over the Counter (OTC) medication, but you will have to pay the full cost of the medication and will not be entitled to reimbursement under your plan. NOTE: You have the right to request an appeal if coverage authorization is denied. Please refer to the How to Appeal an Adverse Benefit Determination subsection of the Claims Processing and Appeal and Grievance Process section or the administrative remedies section in your current Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement for information on how to file an appeal. 3

6 RESPONSIBLE QUANTITY PROGRAM The Responsible Quantity Program encourages the appropriate, safe and cost-effective use of medication by setting a maximum quantity per month for a medication or supply. The quantity limitations are based on the Food and Drug Administration guidelines and the manufacturer s dosing recommendations. Prescription medications that have limits indicated under the Responsible Quantity Program are listed below. Steps for how to obtain an exception can be found on our website, Click on the For Members tab. Click on the Forms tab. Under Prescription Drug Forms, select Responsible Quantity Limit Authorization Form. RESPONSIBLE QUANTITY MEDICATION LIST Responsible Quantitiy Program Effective 7/1/10 Responsible Quantity Program limits also apply to generic drugs where applicable Brand/Generic Name Strength Dispensing Limit Per Month (unless noted) Abilify 30 tabs Abilify Discmelt 60 tabs Abilify oral solution 750 ml Aciphex 30 tabs Actiq 120 units Actonel 5 mg, 30 mg 30 tabs Actonel 35 mg 4 tabs Actonel 75 mg 2 tabs Actonel 150 mg 1 tab Actonel with Calcium 1 28-day blister pack Adcirca 60 tabs Adderall (amphetamine-dextroamphetamine mixed salts) 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg 60 tabs Adderall (amphetamine-dextroamphetamine mixed salts) 20 mg 90 tabs Adderall XR 30 caps Advair Diskus 60 blisters Advair HFA 1 canister Advicor , , tabs Advicor tabs Aerobid, Aerobid M 3 inhalers Aerospan 2 inhalers Altoprev 30 tabs Alvesco 80 mcg 1 inhaler Alvesco 160 mcg 2 inhalers Ambien (zolpidem) 30 tabs Ambien CR 30 tabs Amerge 1 mg 18 tabs Amerge 2.5 mg 9 tabs Androderm patch 60 patches AndroGel packet 60 packets AndroGel pump 4 pumps Anzemet 50 mg 14 tabs Anzemet 100 mg 7 tabs Arixtra 30 syringes/3 months Asmanex 1 inhaler Astelin 2 inhalers Astepro 2 inhalers Atrovent (ipratropium) 0.03% 2 inhalers Atrovent (ipratropium) 0.06% 3 inhalers Atrovent HFA 2 inhalers Avinza 60 caps Axert 6.25 mg 24 tabs Axert 12.5 mg 12 tabs Beconase AQ 2 inhalers Boniva 2.5 mg 30 tablets Boniva 150 mg 1 tablet Byetta pre-filled pen (60 doses) 1 pen Capital and Codeine 5010 ml Celebrex 50 mg, 100 mg, 200 mg 60 caps Celebrex 400 mg 30 caps 4

7 Brand/Generic Name Strength Dispensing Limit Per Month (unless noted) Cesamet 56 caps Clozaril (clozapine) 25 mg, 50 mg 90 tabs Clozaril (clozapine) 100 mg 270 tabs Clozaril (clozapine) 200 mg 120 tabs Combivent 2 inhalers Concerta 18 mg, 27 mg, 54 mg 30 tabs Concerta 36 mg 60 tabs Crestor 5 mg, 10 mg, 20 mg 45 tabs Crestor 40 mg 30 tabs Cymbalta 20 mg, 30 mg 60 caps Cymbalta 60 mg 30 caps Darvocet N-50 (propoxyphene napsylate-acetaminophen) tabs Darvocet N-100 (propoxyphene napsylate-acetaminophen) tabs Daytrana Detrol Detrol LA Dexedrine Spansule (dextroamphetamine sulfate extrelease) Dexilant Diabetic test strips (all brands) 30 patches 60 tabs 30 caps 90 caps 30 caps 204 strips/discs Ditropan XL (oxybutynin ext-release) 5 mg 30 tabs Ditropan XL (oxybutynin ext-release) 10 mg, 15 mg 60 tabs Dolgic LQ Dolgic Plus 5400 ml 150 tabs Dovonex cream 120 grams Dovonex solution 120 ml DrithoScalp cream 100 grams DrithoCream HP cream 100 grams Duragesic (fentanyl transdermal patch) Edluar Effexor (venlafaxine) 15 patches 30 tabs 90 tabs Effexor XR 37.5 mg, 150 mg 30 caps Effexor XR 75 mg 90 caps Embeda , , 50-2, , tabs Embeda tabs Emend 80 mg 4 caps Emend 125 mg 2 caps Emend Therapy Pack Enablex Endodan (oxycodone-aspirin) 2 Therapy Packs 30 tabs 360 tabs Esgic (butalbital-acetaminophen-caffeine) caps or tabs Esgic Plus (butalbital-acetaminophen-caffeine) caps or tabs Exalgo all strengths 30 tablets Fanapt all strengths 60 tabs Fanapt titration pack FazaClo fentanyl citrate transmucosal Fentora 7 kits 270 tabs 120 units 120 tabs Fioricet (butalbital-acetaminophen-caffeine) tabs Fioricet w/codeine (butalbital/acetaminophen/caffeine/ codeine) caps Fiorinal (butalbital-aspirin-caffeine) tabs Fiorinal (butalbital-aspirin-caffeine) caps Fiorinal w/codeine (butalbital-aspirin-caffeine-codeine) caps Flector patch Flonase (fluticasone) 60 patches 1 inhaler Flovent Diskus 50 mcg, 100 mcg 1 carton Flovent Diskus 250 mcg 4 cartons Flovent HFA 44 mcg, 110 mcg 1 inhaler Flovent HFA 220 mcg 2 inhalers flunisolide nasal soln 25 mcg /spray 3 inhalers Focalin (dexmethylphenidate) 60 tabs Focalin XR all strengths 30 caps Foradil Aerolizer 1 blister pack (12 or 60) Fosamax (alendronate) 5 mg, 10 mg, 40 mg 30 tabs Fosamax (alendronate) 35 mg, 70 mg 4 tabs Fosamax oral soln 300 ml (4 bottles) 5

8 Brand/Generic Name Strength Dispensing Limit Per Month (unless noted) Fosamax Plus D 4 tabs Fragmin syringe, all strengths 30 syringes/3 months Fragmin vial, all strengths 10 vials/3 months Frova 12 tabs Gelnique 30 sachets Geodon 60 tabs Glucose Test Strips (all brands) 204 strips/discs granisetron 14 tabs Granisol 60 ml Hycet 3600 ml Ibudone tabs Imitrex nasal soln, 5 mg 6 units Imitrex nasal soln, 20 mg 2 units Imitrex (sumatriptan) 25 mg 36 tabs Imitrex (sumatriptan) 50 mg 18 tabs Imitrex (sumatriptan) 100 mg 9 tabs Imitrex syringe, vial 4 mg/0.5 ml 6 ml (12 inj) Imitrex syringe, vial 6 mg/0.5 ml 4 ml (8 inj) Imitrex (sumatriptan) vial, 6 mg/0.5 ml 4 ml (8 inj) Innohep vials, 2 ml 15 vials/3 months Invega 3 mg, 9 mg 30 tabs Invega 6 mg 60 tabs Invega ER 1.5mg 30 tabs Janumet 60 tabs Januvia 30 tabs Kadian 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 200mg 60 caps Kadian 100 mg 120 caps ketorolac 21 tabs Kytril (granisetron) 1 mg 14 tabs Lescol 60 caps Lescol XL 30 tabs Letairis 30 tabs Lipitor 10 mg, 20 mg, 40 mg 45 tabs Lipitor 80 mg 30 tabs Livalo all strengths 30 tabs Lorcet (hydrocodone-acetaminophen) caps Lorcet Plus (hydrocodone-acetaminophen) tabs Lortab (hydrocodone-acetaminophen) , 5-500, tabs Lortab (hydrocodone-acetaminophen) tabs Lortab elixir (hydrocodone-acetaminophen) 3600 ml Lovenox syringe, all strengths 30 syringes/3 months Lovenox vial, 300 mg/3 ml 10 vials/3 months Lumigan 2.5 ml Lunesta 30 tabs Lyrica 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg 90 caps Lyrica 225 mg, 300 mg 60 caps Magnacet 300 tabs Maxair Autohaler 1 canister Maxalt, Maxalt-MLT 5 mg 24 tabs Maxalt, Maxalt-MLT 10 mg 12 tabs Maxidone (hydrocodone/acetaminophen) tabs Metadate CD 30 caps Metadate ER (methylphenidate ext-release) 10 mg, 20 mg 90 caps Mevacor (lovastatin) 60 tabs Migranal 8 ampules MS Contin (morphine sulfate ext-release) 15 mg, 30 mg, 60 mg 120 tabs MS Contin (morphine sulfate ext-release) 100 mg, 200 mg 180 tabs Nasacort AQ 1 inhaler Nasonex 2 inhalers Nexium 20 mg, 40 mg 30 packets/caps Norco (hydrocodone-acetaminophen) 360 tabs Nucynta 180 tabs Nuvigil 30 tabs Omnaris 1 inhaler ondansetron 24 mg 7 tabs Onglyza 30 tabs Onsolis 120 films 6

9 Brand/Generic Name Strength Dispensing Limit Per Month (unless noted) Opana ER 60 tabs Oramorph SR 15 mg, 30 mg, 60 mg 120 tabs Oramorph SR 100 mg 180 tabs oxybutynin ER 5 mg 30 tabs oxybutynin ER 10 mg, 15 mg 60 tabs oxybutynin syrup 600 ml oxybutynin tabs 5 mg 120 tabs OxyContin (oxycodone ext-release) 90 tabs Oxytrol 8 patches Patanase 1 inhaler Pennsaid 150 ml Percocet (oxycodone-acetaminophen) , 5-325, , tabs Percocet (oxycodone-acetaminophen) tabs Percocet (oxycodone-acetaminophen) tabs Percodan (oxycodone-aspirin) 360 tabs Phrenilin Forte 180 caps Pravachol (pravastatin) 10 mg, 20 mg, 40 mg 45 tabs Pravachol (pravastatin) 80 mg 30 tabs Prevacid 30 caps Prevacid Solutab 30 tabs Prilosec (omeprazole delayed-release ) 30 caps Prilosec suspension packet 2.5 mg 60 packs Prilosec suspension packet 10 mg 30 packs Pristiq 30 tabs ProAir HFA 2 inhalers propoxyphene hcl/acetaminophen tabs Protonix (pantoprazole delayed-release) 30 packets/tabs Proventil HFA 2 inhalers Provigil 30 tabs Pulmicort Flexhaler 90 mcg 1 inhaler Pulmicort Flexhaler 180 mcg 2 inhalers Qualaquin 42 capsules/3 months Qvar 40 mcg 1 inhaler Qvar 80 mcg 3 inhalers Relenza 20 discs/6 months Relpax 20 mg 12 tabs Relpax 40 mg 6 tabs Reprexain (hydrocodone-ibuprofen) tabs Revatio 90 tabs Rhinocort Aqua 2 inhalers Risperdal (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 60 tabs Risperdal (risperidone) 4 mg 120 tabs Risperdal oral solution (risperidone) 480 ml Risperdal M-tab (risperidone) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 60 tabs Risperdal M-tab (risperidone) 4 mg 120 tabs Ritalin (methylphenidate) 5 mg, 10 mg 60 tabs Ritalin (methylphenidate) 20 mg 90 tabs Ritalin LA 30 caps Ritalin SR (methylphenidate ext-release) 90 tabs Roxicet (oxycodone-acetaminophen) tabs Roxicet solution 1800 ml Rozerem 30 tabs Ryzolt 30 tabs Samsca 15 mg 30 tabs Samsca 30 mg 60 tabs Sanctura 60 tabs Sanctura XR 30 tabs Sancuso 4 patches Saphris 60 tabs Savella 60 tabs Savella Dosepak 1 pack Seroquel 25 mg, 50 mg, 100 mg, 200 mg 90 tabs Seroquel 300 mg, 400 mg 60 tabs Seroquel XR 50 mg, 300 mg, 400 mg 60 tabs Seroquel XR 150 mg, 200 mg 30 tabs Serevent Diskus 1 package Simcor 60 tabs 7

10 Brand/Generic Name Strength Dispensing Limit Per Month (unless noted) Spiriva Handihaler 30 caps Sonata (zaleplon) 30 caps Strattera 10 mg, 18 mg, 25 mg, 40 mg, 60 mg 60 caps Strattera 80 mg, 100 mg 30 caps Striant 60 systems Suboxone 90 tablets Subutex (buprenorphine) 160 mg/3 months Sumatriptan nasal soln, 5 mg 6 units Sumatriptan nasal soln, 20 mg 2 units Sumatriptan syringe, 6 mg/0.5ml 4 ml/8 injections Sumatriptan syringe, 4 mg/0.5 ml 6 ml/12 injections sumatriptan 25 mg 36 tabs sumatriptan 50 mg 18 tabs sumatriptan 100 mg 9 tabs sumatriptan vial, 4 mg/0.5 ml 6 ml/12 injections Sumavel DosePro 12 injections Symbicort 1 inhaler Symbyax 30 caps Taclonex ointment 120 grams Taclonex suspension 120 ml Tamiflu susp, 12 mg/ml 75 ml/6 months Tamiflu 30 mg 20 caps/6 months Tamiflu 45 mg, 75 mg 10 caps/6 months Tazorac cream 120 grams Tazorac gel 100 grams Testim 60 tubes Toviaz 30 tabs tramadol ER all strengths 30 tabs Tracleer 60 tabs Travatan, Travatan Z 2.5 ml Treximet 18 tabs Tylenol w/codeine (acetaminophen-codeine) 360 tabs Tylenol w/codeine elixir (acetaminophen-codeine) 5010 ml Tylox (oxycodone-acetaminophen) caps Ultram ER 30 tabs Vectical 200 grams Venlafaxine ER 75 mg 90 tabs Venlafaxine ER 37.5 mg, 150 mg, 225 mg 30 tabs Ventolin HFA 2 canisters Veramyst 1 inhaler Vesicare 30 tabs Vicodin (hydrocodone-acetaminophen) 5-500, tabs Vicodin ES (hydrocodone-acetaminophen) tabs Vicodin HP (hydrocodone-acetaminophen) tabs Vicoprofen (hydrocodone-ibuprofen) 150 tabs Voltaren gel 300 grams Vytorin 10-10, 10-20, tabs Vytorin tabs Vyvanse 30 caps Xalatan 2.5 ml Xopenex HFA 2 canisters Zegerid 20 mg, 40 mg 30 packets/caps Zetia 30 tabs Zithranol RR 90 grams Zocor (simvastatin) 5 mg, 10 mg, 40 mg 45 tabs Zocor (simvastatin) 20 mg 60 tabs Zocor (simvastatin) 80 mg 30 tabs Zofran (ondansetron) oral soln 100 ml (2 bottles) Zofran, Zofran ODT (ondansetron) 4 mg 42 tabs Zofran, Zofran ODT (ondansetron) 8 mg 21 tabs Zomig nasal soln 12 units Zomig, Zomig ZMT 2.5 mg 18 tabs Zomig, Zomig ZMT 5 mg 9 tabs Zydone 300 tabs Zyprexa, Zyprexa Zydis 30 tabs 8

11 RESPONSIBLE STEPS PROGRAM The program promotes the appropriate, safe, and effective use of medications and helps you save on prescriptions. is based on nationally recognized therapeutic guidelines, clinical evidence, and research. Prescription medications included in the program are not covered unless you have tried one or more covered alternative medications first. If you are taking a medication in the Program, please contact your physician/provider to discuss what medication options are best for you. Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription medication endorsement to determine if requirements apply to your plan. Coverage details are also available to you by logging into MyBlueService or by calling the customer service number listed on your Member ID card. EXCEPTION REQUESTS If for medical reasons, you cannot use one of the alternative medications and require the medication listed in the program, your physician may submit an exception request as described below. Information about the Program and steps for how to obtain an exception can be found on our website, Click on the For Members tab. Click on the Forms tab. Under Prescription Drug Forms, select Authorization Forms. COVERED OVER THE COUNTER (OTC) MEDICATIONS An over-the-counter medication can be an appropriate treatment for some conditions and may offer a lower cost alternative to some commonly prescribed medications. Your pharmacy benefit may provide coverage for select OTC medications. Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription medication endorsement to determine if OTC medications are covered under your plan. Only those OTC medications prescribed by your physician and designated on the Medication List with OTC in parenthesis following the medication name are eligible for coverage. THREE MONTH SUPPLY Some plans allow you to purchase up to a three-month supply of medications. Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription medication endorsement to determine if your plan includes this benefit. In addition to being able to obtain up to a three month supply of medication through our mail order pharmacy, you may be able to receive up to a three month supply of your medication through a participating retail pharmacy. Please refer to your Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement for complete coverage details. MAIL ORDER PHARMACY Obtaining prescription medications through the Mail Order Pharmacy may reduce the cost you pay for your prescription medications. Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription medication endorsement to determine if your plan provides a mail order pharmacy benefit. Members who have pharmacy benefits through BCBSF can access and print out the Mail Order Pharmacy Form on our website, Click on the For Members tab. Click on the Forms tab. Under Prescription Drug Forms, select the Pharmacy Mail Order Form. Note: If the original prescription was filled at a pharmacy other than the Mail Order Pharmacy, you must submit a new, original three month supply prescription with a quantity of up to a three month supply and not less than a two month supply along with the Registration and Prescription Order Form. Prescriptions may not be transferred from a retail pharmacy to the Mail Order Pharmacy. 9

12 USING THE MEDICATION GUIDE The Medication List is organized into broad categories (e.g., Antibacterials) The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface (e.g., metformin) Brand name medications are capitalized (e.g., ACTOS) Separate medication entries are required for some dosage forms or routes of administration including extended-release, delayed-release, rectal, injectable, otic, ophthalmic, vaginal, nasal, orally disintegrating, patches, and topical products. Note: Self-administered injectable medications are designated in the Medication List with inj following the medication name (e.g., Arixtra inj). 2 The second column indicates the Tier level: 1 (Lowest Cost): Covered Generic Prescription Medications 2 (Higher Cost): Covered Preferred Brand Prescription Medications 3 (Highest Cost): Covered Non-Preferred Brand Prescription Medications 3 The third column indicates if the medication is a Self-Administered specialty medication. Note: Additional information about Pharmacy Medications can be found at the end of this section of the Medication Guide. 4 The remaining columns indicate the Responsible Rx Pharmacy program(s) that apply to the prescription medication (e.g.,, Responsible Quantity, and ). If an indicator is present in the column(s), then the Responsible Rx Program applies. Key caps capsules chew tabs chewable tablets conc concentrate crm cream delayed-release enteric-coated ext-release extended-release inj injection lotn lotion neb nebulization NP non-preferred ODT orally disintegrating tabs Key OTC over-the-counter drug oint ointment PA prior authorization required QL Responsible Quantity Program quantity limit applies RS Program prerequisite drug required SI self injectable drug program soln solution SP Drug supp suppositories susp suspension tabs tablets 10

13 MEDICATIONS THAT ARE NOT COVERED Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are: The medication has been shown to have excessive adverse effects and/or safer alternatives The medication has a preferred formulary alternative or over-the-counter (OTC) alternative The medication is no longer marketed The medication has a widely available/distributed AB rated generic equivalent formulation Medications that are not covered as of July 1, 2010 are listed below: Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to determine the Medication Exclusions that apply to your plan. Coverage details may also be available to you by logging into MyBlueService or by calling the customer service number listed on your member ID card. Medications that are Not Covered 7/1/10 Drugs Not covered Aciphex, Prevacid, Prevacid Solutab, Protonix, Zegerid Adoxa CK Kit, Adoxa TT Kit, Alodox Kit, Avidoxy Kit, Nutridox Kit Allegra, Allegra-D, Clarinex, Clarinex-D, Xyzal, Zyrtec, Zyrtec-D Beconase AQ, Flonase, Nasacort AQ, Omnaris, Rhinocort AQ, Veramyst Benzoyl Peroxide Wash Kit, Brevoxyl Complete Kit, Breze Kit, Inova Kit, Lavoclen Kit, Neobenz Micro Plus Kit, Zacare Kit Carmol Scalp Kit, Scalp Treatment Kit Cleeravue-M Kit, Minocin Kit, Minocin Pac Kit Cyclobenzaprine Comfort Pac or Kit Desowen Kit Ibuprofen Comfort Kit Metozolv Naproxen Comfort Pac Pamine FQ Kit Rinnovi Nail System Kit Rosaderm Kit, Rosanil Kit, Rosula CLK Kit, Sodium Sulfacetamide/ Sulfur Kit Rowasa Kit Salex Kit, Salicylic Acid Kit Scalacort DK Kit Tretin-X Kit Treximet Ultravate Kit Vanoxide HC Kit Xolegel Corepak Kit Xolegel Duo Kit Z-clinz Kit Zytopic Kit Zypram Covered Alternatives Omeprazole (Rx and OTC), Dexilant, Nexium, Prilosec OTC doxycycline fexofenadine, loratadine, loratadine-pseudoephedrine ext-release flunisolide, fluticasone benzoyl peroxide (Rx only) sulfacetamide sodium/urea minocycline cyclobenzaprine desonide ibuprofen (Rx only) metoclopramide naproxen (Rx only) methscopolamine no covered alternatives sulfacetamide sodium/sulfur mesalamine enema salicylic acid lotion,cream hydrocortisone lotion (Rx only) tretinoin naproxen (Rx only), sumatriptan, Maxalt halobetasol benzoyl peroxide, (Rx only) hydrocortisone (Rx only) Xolegel Xolegel Duac CS triamcinolone hydrocortisone/pramoxine 11

14 FORMULARY ADDITION REQUEST Physicians may request the addition of a medication to the Medication List by submitting a written request to Blue Cross and Blue Shield of Florida and Health Options, Inc. Please mail to: Blue Cross and Blue Shield of Florida and Health Options, Inc. Attn: Pharmacy Programs P.O. Box 1798 Jacksonville, FL NOTICE This Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions, limitations, or conditions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement. In the event of any inconsistencies between the Medication Guide and the provisions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement, the provisions contained in the Policy, Benefit Booklet, Certificate of Coverage or Pharmacy Program Endorsement shall control to the extent necessary to effectuate the intent of Blue Cross and Blue Shield of Florida and Health Options, Inc. 12

15 Pharmacy Medications Pharmacy medications are high-cost injectable, infused, oral or inhaled medications that generally require close supervision and monitoring of the patient s therapy. Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement for information on how Pharmacy medications are covered on your plan. Coverage details are also available to you by logging into MyBlueService or by calling the customer service number listed on your member ID card. Medications are divided into two categories: Self-Administered Patients self administer these Pharmacy medications themselves. Because these medications are intended to be self-administered, these medications may not be covered if administered in a physician s office. Provider-Administered These medications require the administration to be performed by a physician. The Pharmacy medications are ordered by a provider and administered in an office or outpatient setting. Provider-administered Pharmacy medications are covered under your medical benefit. Note: We have noted medications that may be covered as either Self-Administered and/or Provider-Administered. These Pharmacy products can be obtained in either setting. Participating Pharmacy Provider If you are currently taking a Pharmacy medication, then your network for Pharmacies is limited to the following participating Pharmacy providers. Unless indicated below, any other pharmacy is considered a non-participating Pharmacy even if it participates in BCBSFL s/hoi s networks for non- Pharmacy medications. Caremark Pharmacy Services All Products Phone: Fax: Caremark Hemophilia Services Hemophilia Products Telephone: (Mon-Fri., 9:00 a.m. to 7:30 p.m. EST) Fax: Note: If Pharmacy medications are purchased at a pharmacy other than the Pharmacy listed above, your cost share may be higher. Pharmacy medications are not covered when purchased through the Mail Order Pharmacy. 13

16 Self Administered Products Actimmune PA, QL Adcirca Advate PA Alphanate VWB PA Alphanine SD PA Aranesp PA ** Arcalyst PA Avonex Bebulin VH PA Benefix PA Betaseron Bravelle PA Cetrotide PA chorionic gonadotropin (Novarel, Pregnyl) PA Cimzia Pen PA Cinryze PA Copaxone Cystadane Enbrel PA Epogen PA ** Exjade Extavia Feiba VH Immuno PA Follistim AQ PA Forteo PA Fuzeon Genotropin PA Geref PA Gonal-F PA Helixate FS PA Hemofil M PA Hizentra PA Humate-P PA Humatrope PA Humira PA Increlex PA Infergen PA Intron A PA Kineret PA Koate DVI PA Kogenate FS PA Kuvan PA Letairis PA Leukine PA ** Lupron (leuprolide) PA Monarc M PA Monoclate-P PA Mononine PA Neulasta PA ** Neumega PA Neupogen PA ** Norditropin PA NovoSeven PA NovoSeven RT PA Nutropin PA Nutropin AQ PA Omnitrope PA Orfadin Ovidrel PA Pegasys PA Peg-Intron PA Procrit PA ** Profilnine SD PA Promacta PA Pulmozyme Rebif Recombinate PA ReFacto PA Repronex PA Revatio PA,QL Revlimid PA Saizen PA Sandostatin (octreotide) PA Serostim PA Simponi PA Somavert Synarel PA Tev-Tropin PA Tracleer PA,QL Tyvaso PA Ventavis PA Vivaglobin PA Wilate PA Xenazine PA Xyntha PA Xyrem PA Zavesca PA Zorbtive PA * These drugs are available from Accredo Health at ** These drugs are covered as Self-Administered or Provider-Administered Pharmacy drugs: Aranesp, Epogen, Leukine, Neulasta, Neupogen, and Procrit. PA Drug may require that specific clinical criteria are met before the drugs will be covered under your pharmacy and/or medical benefits See PRIOR AUTHORIZATION QL Drug limited to a maximum quantity per one month for one co-payment or coinsurance see RESPONSIBLE QUANTITY PROGRAM RS Drug requires you to try another designated or prerequisite drug first see RESPONSIBLE STEPS PROGRAM 14

17 Provider-Administered Pharmacy Products Actemra PA Adagen* Aldurazyme Alferon N PA Aloxi PA Amevive PA Aralast PA Aralast NP PA Aranesp PA ** Avastin PA Berinert PA Boniva PA Botox PA Calcium EDTA PA Ceredase PA Cerezyme PA Cimzia PA Cinryze PA Dysport PA Elaprase Eligard PA Epogen PA ** Fabrazyme PA Firmagon Flolan (epoprostenol) PA Herceptin PA Ilaris PA Immune Globulin (IV) PA Kalbitor PA Leukine PA ** Lucentis PA Lupron Depot PA Macugen PA Myobloc PA Myozyme Naglazyme Neulasta PA ** Neupogen PA ** Nplate PA Orencia PA Procrit PA ** progesterone in oil PA Prolastin PA Reclast PA Remicade PA Remodulin PA Riastap Rituxan PA Sandostatin LAR Depot PA Soliris PA Somatuline Depot PA Supprelin LA PA Synagis PA Thyrogen Trelstar Depot PA Trelstar LA PA Tysabri Vantas PA Viadur PA Vidaza PA Visudyne PA Vivitrol PA Vpriv PA Xolair PA Zemaira PA Zoladex PA Zometa PA ** These drugs are covered as Self-Administered or Provider-Administered Pharmacy drugs: Aranesp, Epogen, Leukine, Neulasta, Neupogen, and Procrit. PA Drug may require that specific clinical criteria are met before the drugs will be covered under your pharmacy and/or medical benefits See PRIOR AUTHORIZATION QL Drug limited to a maximum quantity per one month for one co-payment or coinsurance see RESPONSIBLE QUANTITY PROGRAM RS Drug requires you to try another designated or prerequisite drug first see RESPONSIBLE STEPS PROGRAM 15

18 2010 Analgesics acetaminophen/codeine 1 ACTIQ 3 AVINZA 3 buprenorphine 1 CAPITAL and CODEINE 3 CELEBREX 3 CYMBALTA 3 DARVOCET-N 3 DIFLUNISAL 2 DURAGESIC 3 EMBEDA 3 etodolac 1 EXALGO 3 fentanyl citrate transmucosal 1 fentanyl transdermal 1 FENTORA 3 FLECTOR transdermal 3 HYCET 3 hydrocodone/acetaminophen 1 hydrocodone/ibuprofen 1 hydromorphone tabs 1 IBUDONE 3 ibuprofen 1 KADIAN 3 ketoprofen 1 ketorolac tabs 1 LORCET/PLUS 3 LORTAB 3 MAGNACET 3 MAXIDONE 3 methadone conc, tabs 1 METHADONE soln 2 morphine sulfate conc, 20 mg/ ml; tabs 1 morphine sulfate ER 1 MORPHINE SULFATE soln, 20 mg/5 ml; supp, 30 mg 2 MS CONTIN 3 naproxen 1 naproxen sodium 1 NORCO 3 NUCYNTA 3 ONSOLIS 3 OPANA ER 3 ORAMORPH SR 3 oxycodone 1 OXYCODONE 2 oxycodone/acetaminophen 1 oxycodone/aspirin Endodan 1 oxycodone/ibuprofen 1 OXYCONTIN 2 PERCOCET 3 PERCODAN 3 propoxyphene hcl/acetaminophen 1 propoxyphene napsylate/acetaminophen 1 REPREXAIN 3 ROXICET soln 2 ROXICET tabs, 5/500 mg 3 RYZOLT 3 SUBOXONE 2 tramadol 1 tramadol ER 1 tramadol/acetaminophen 1 TYLENOL/CODEINE 3 TYLOX 3 ULTRAM ER 3 VICODIN/ES/HP 3 VICOPROFEN 3 VOLTAREN gel 3 ZYDONE 3 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 16

19 2010 Anesthetics 1 lidocaine viscous 1 lidocaine/prilocaine 1 Antibacterials ADOXA/CK/TT 3 ALODOX 3 amoxicillin 1 AMOXICILLIN chew tabs, 400 mg; NP = 200 mg amoxicillin/potassium clavulanate 1 amoxicillin/potassium clavulanate ER 1 ampicillin caps 1 AMPICILLIN susp 2 AUGMENTIN susp, 125 mg/5 ml 2 AVELOX 2 AVIDOXY/DK 3 azithromycin 1 CAYSTON 2 cefadroxil 1 cefdinir 1 cefpodoxime 1 cefprozil 1 cefuroxime 1 cephalexin 1 CIPRO susp 2 ciprofloxacin 1 clarithromycin 1 clarithromycin ER 1 CLEOCIN supp 2 CLEOCIN PEDIATRIC 2 clindamycin 1 clindamycin vaginal crm 1 demeclocycline 1 dicloxacillin 1 DORYX 3 doxycycline hyclate 1 2 DOXYCYCLINE HYCLATE caps, 75 mg, 100 mg doxycycline monohydrate caps, tabs 1 3 DYNACIN 3 ERY-TAB 2 ERYTHROMYCIN DR caps 2 erythromycin ethylsuccinate 1 erythromycin/sulfisoxazole 1 FURADANTIN 2 metronidazole crm, gel, lotn, 0.75% 1 metronidazole tabs 1 metronidazole vaginal gel 1 MINOCIN/PAC 3 minocycline 1 minocycline ER 1 MONODOX 3 neomycin sulfate 1 nitrofurantoin macrocrystals 1 nitrofurantoin monohydrate/ macrocrystals ORAXYL 3 penicillin v potassium 1 PERIOSTAT 3 PREVPAC 2 PRIMSOL 2 SOLODYN 3 sulfamethoxazole/trimethoprim 1 SUPRAX 2 tetracycline 1 TOBI 2 trimethoprim 1 VANCOCIN 2 VIBRAMYCIN 3 VIBRATAB 3 ZITHROMAX packets, 1 g 2 ZYVOX 2 1 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 17

20 2010 Anticonvulsants carbamazepine 1 carbamazepine ER 200 mg, 400 mg 1 CELONTIN 2 clonazepam 1 DIASTAT 2 DILANTIN 30 mg 2 DILANTIN INFATABS 2 divalproex DR 1 divalproex ER 1 ethosuximide 1 FELBATOL 2 gabapentin 1 GABITRIL 2 lamotrigine 1 levetiracetam 1 LYRICA 3 NEURONTIN soln 2 oxcarbazepine 1 PEGANONE 2 phenobarbital 1 PHENOBARBITAL 64.8 mg; NP = 97.2 mg 2 phenytoin sodium extended 1 phenytoin susp 1 primidone 1 SABRIL 2 TEGRETOL-XR 100 mg 2 topiramate sprinkle caps, tabs 1 valproic acid 1 zonisamide 1 Antidementia Agents ARICEPT 2 ARICEPT ODT 2 EXELON 2 NAMENDA 2 Antidepressants amitriptyline 1 AMOXAPINE 2 APLENZIN 3 bupropion hcl 1 bupropion hcl ER 12 hr, 24 hr 1 CELEXA 3 citalopram 1 clomipramine 1 CYMBALTA 3 desipramine 1 doxepin 1 DOXEPIN caps, 150 mg 2 EFFEXOR 3 EFFEXOR XR 3 fluoxetine 1 imipramine hcl 1 LEXAPRO 2 LUVOX CR 3 mirtazapine 1 NARDIL 2 nortriptyline 1 OLEPTRO 3 paroxetine hcl 1 paroxetine hcl ER, 12.5 mg, 25 mg 1 PAXIL 3 PAXIL CR 3 PEXEVA 3 PRISTIQ 3 PROZAC 3 REMERON/SOLTAB 3 sertraline 1 SYMBYAX 3 tranylcypromine 1 trazodone 1 venlafaxine 1 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 18

21 2010 VENLAFAXINE ER 2 WELLBUTRIN/SR/XL 3 ZOLOFT 3 Antidotes, Deterrents, and Toxicologic Agents ANTABUSE 2 bupropion hcl ER (smoking deterrent) 1 CHANTIX 2 CHEMET 2 EXJADE 2 X naltrexone tabs 1 sodium polystyrene sulfonate 1 SYPRINE 2 Antiemetics 1 ANZEMET 3 CESAMET 3 chlorpromazine 1 EMEND caps 2 GRANISOL 3 granisetron tabs 1 hydroxyzine hcl 1 hydroxyzine pamoate 1 KYTRIL tabs 3 meclizine 12.5 mg, 25 mg 1 metoclopramide 1 ondansetron 1 prochlorperazine 1 promethazine 1 SANCUSO 3 trimethobenzamide caps 1 ZOFRAN soln, tabs 3 ZOFRAN ODT 3 Antifungals 1 ANCOBON 2 AVC 2 fluconazole 1 GRIFULVIN V tabs 2 griseofulvin microsize susp 1 itraconazole 1 ketoconazole 1 LAMISIL granules 2 NOXAFIL 2 nystatin oral susp, tabs 1 NYSTATIN VAGINAL 2 SPORANOX soln 2 terbinafine tabs 1 terconazole vaginal crm, supp 1 VFEND 2 Antigout Agents 1 allopurinol 1 colchicine 1 probenecid 1 probenecid/colchicine 1 Anti-inflammatory Agents CELEBREX 3 diclofenac sodium DR 1 diclofenac sodium ER 1 DICLOFENAC SODIUM DR 25 mg 2 DIFLUNISAL 2 etodolac 1 ibuprofen 1 indomethacin 1 ketoprofen 1 meloxicam tabs 1 nabumetone 1 naproxen 1 naproxen sodium 1 PENNSAID 3 piroxicam 1 salsalate 1 sulindac 1 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 19

22 2010 Antimigraine Agents 1 TIMOLOL 2 acetaminophen/isometheptene/ dichloralphenazone AMERGE 3 AXERT 3 butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1 butalbital/aspirin/caffeine 1 butalbital/aspirin/caffeine/codeine 1 divalproex DR 1 divalproex ER 1 DOLGIC LQ 3 DOLGIC PLUS 3 ERGOMAR 2 ESGIC/PLUS 3 FIORICET 3 FIORICET w/codeine 3 FIORINAL 3 FIORINAL w/codeine 3 FROVA 3 IMITREX inj kit 2 IMITREX nasal, tabs 2 INNOPRAN XL 2 MAXALT 2 MAXALT-MLT 2 MIGRANAL 2 PHRENILIN FORTE 3 propranolol ER 1 PROPRANOLOL soln 2 propranolol tabs 1 RELPAX 3 sumatriptan inj, 4 mg/0.5 ml, 6 mg/0.5 ml; tabs SUMATRIPTAN inj, 4 mg/0.5 ml, 6 mg/0.5 ml SUMATRIPTAN nasal spray 3 SUMAVEL DOSEPRO inj 3 topiramate sprinkle caps, tabs 1 TREXIMET 3 ZOMIG nasal, tabs 3 ZOMIG ZMT 3 Antimyasthenic Agents 2 MESTINON syrup 2 MESTINON TIMESPAN 2 MYTELASE 2 neostigmine inj 1 PROSTIGMIN 2 PROSTIGMIN inj 3 pyridostigmine 1 Antimycobacterials 1 DAPSONE 2 ethambutol 1 ISONIAZID syrup 2 isoniazid tabs 1 isoniazid/rifampin 1 MYCOBUTIN 2 pyrazinamide 1 rifampin 1 Antineoplastics 2 ACTIMMUNE 2 X AFINITOR 2 ALKERAN tabs 2 CEENU 2 CYCLOPHOSPHAMIDE tabs 2 DROXIA 2 ETOPOSIDE caps 2 GLEEVEC 2 HEXALEN 2 HYCAMTIN 2 hydroxyurea 1 INTRON A 2 X IRESSA 2 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 20

23 2010 leucovorin calcium tabs, 5 mg, 25 mg 1 LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg LEUKERAN 2 MATULANE 2 mercaptopurine 1 MESNEX tabs 2 methotrexate tabs 1 MYLERAN 2 NEXAVAR 2 OFORTA 2 PROLEUKIN 2 REVLIMID 2 X SPRYCEL 2 SUTENT 2 TABLOID 2 TARCEVA 2 TARGRETIN 2 TASIGNA 2 TEMODAR 2 TRETINOIN caps 2 TYKERB 2 VOTRIENT 2 XELODA 2 ZOLINZA 2 Antiparasitics 2 ALBENZA 2 ALINIA 2 BILTRICIDE 2 chloroquine phosphate 1 COARTEM 2 DARAPRIM 2 FANSIDAR 2 hydroxychloroquine 1 lindane lotn 1 MALARONE 2 malathion 1 2 MEBENDAZOLE 2 mefloquine 1 MEPRON 2 NEBUPENT 2 paromomycin 1 permethrin crm, 5% 1 PRIMAQUINE 2 QUALAQUIN 3 ULESFIA 2 YODOXIN 2 Antiparkinson Agents 1 amantadine caps, syrup 1 AZILECT 2 benztropine 1 bromocriptine 1 carbidopa/levodopa 1 carbidopa/levodopa ER 1 carbidopa/levodopa ODT 1 COMTAN 2 pramipexole mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg ropinirole 1 selegiline 1 TASMAR 2 trihexyphenidyl 1 Antipsychotics 3 ABILIFY/DISCMELT 3 chlorpromazine 1 clozapine 1 CLOZARIL 3 FANAPT 3 FAZACLO 3 FLUPHENAZINE HCL soln, 2.5 mg/5 ml, 5 mg/ml fluphenazine hcl tabs 1 GEODON 2 haloperidol lactate oral soln KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 21

24 2010 haloperidol tabs 1 GANCICLOVIR 2 INVEGA/ER 3 HEPSERA 2 loxapine 1 INTELENCE 2 MOBAN 2 INVIRASE 2 ORAP 2 ISENTRESS 2 perphenazine 1 KALETRA 2 RISPERDAL soln 3 LEXIVA 2 RISPERDAL M-TAB 3 NORVIR 2 risperidone 1 PREZISTA 2 risperidone ODT 1 RELENZA 3 RISPERIDONE ODT 0.25 mg 2 RESCRIPTOR 2 SAPHRIS 3 REYATAZ 2 SEROQUEL 2 ribavirin caps, tabs 1 SEROQUEL XR 2 SELZENTRY 2 thiothixene 1 stavudine 1 trifluoperazine 1 SUSTIVA 2 ZYPREXA/ZYDIS 3 TAMIFLU 2 Antispasticity Agents 1 TRIZIVIR 2 baclofen 1 TRUVADA 2 dantrolene 1 valacyclovir 1 tizanidine tabs 1 VALCYTE 2 Antivirals 2 VIDEX 2 acyclovir 1 VIRACEPT 2 amantadine caps, syrup 1 VIRAMUNE 2 APTIVUS 2 VIREAD 2 ATRIPLA 2 ZIAGEN 2 BARACLUDE 2 zidovudine 1 COMBIVIR 2 Anxiolytics 1 CRIXIVAN 2 alprazolam 1 didanosine DR 1 ALPRAZOLAM INTENSOL 2 EMTRIVA 2 buspirone 1 EPIVIR 2 BUSPIRONE 7.5 mg 2 EPIVIR-HBV 2 diazepam 1 EPZICOM 2 DIAZEPAM soln 2 famciclovir 1 DIAZEPAM INTENSOL 2 FUZEON 2 doxepin 1 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 22

25 2010 DOXEPIN caps, 150 mg 2 hydroxyzine hcl 1 hydroxyzine pamoate 1 LEXAPRO 2 lorazepam 1 paroxetine hcl 1 paroxetine hcl ER, 12.5 mg, 25 mg 1 PAXIL 3 PAXIL CR 3 PEXEVA 3 sertraline 1 ZOLOFT 3 Bipolar Agents 1 ABILIFY/DISCMELT 3 divalproex DR 1 divalproex ER 1 GEODON 2 lamotrigine 1 lithium carbonate 1 lithium carbonate ER 1 LITHIUM CARBONATE tabs, 300 mg; NP = caps, 150 mg LITHIUM CITRATE 2 RISPERDAL soln 3 RISPERDAL M-TAB 3 risperidone 1 risperidone ODT 1 RISPERIDONE ODT 0.25 mg 2 SEROQUEL 2 SEROQUEL XR 2 ZYPREXA/ZYDIS 3 Blood Glucose Regulators 3 acarbose 1 ACTOPLUS MET/XR 3 ACTOS 2 APIDRA inj 2 AVANDAMET 3 2 AVANDARYL 3 AVANDIA 3 BAYER AUTODISC/BREEZE 2/CONTOUR test strips BAYER BREEZE 2/CONTOUR/DIDGET blood glucose meters 2 BYETTA inj 2 DUETACT 3 glimepiride 1 glipizide 1 glipizide ER 1 GLUCAGON inj 2 GLYBURIDE, distributor of Diabeta 2 glyburide, generics of Micronase 1 glyburide micronized 1 glyburide/metformin 1 GLYSET 2 HUMALOG inj 2 HUMALOG MIX 50/50 inj 2 HUMALOG MIX 75/25 inj 2 HUMULIN 50/50 inj 2 HUMULIN 70/30 inj 2 HUMULIN N inj 2 HUMULIN R inj 2 INSULIN PEN NEEDLES BD ULTRAFINE; NOVOFINE; VARIOUS JANUMET 2 JANUVIA 2 LANCETS - VARIOUS 2 LANCET DEVICES VARIOUS 2 LANTUS inj 2 LEVEMIR inj 2 metformin 1 metformin ER 1 nateglinide 1 NOVOLIN 70/30 inj 2 NOVOLIN N inj KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 23

26 2010 NOVOLIN R inj 2 NOVOLOG inj 2 NOVOLOG MIX 70/30 inj 2 ONETOUCH BASIC/PROFILE/FASTTAKE/ ULTRA/SURESTEP test strips ONETOUCH BASIC/ULTRA/ULTRA MINI/ ULTRALINK/ULTRASMART/SURESTEP/ SURESTEP PRO blood glucose meters 2 ONGLYZA 2 PRANDIN 2 PROGLYCEM 2 RELION 70/30 inj 2 RELION N inj 2 RELION R inj 2 SYMLIN inj 2 SYRINGES BD; VARIOUS 2 VICTOZA 3 Blood Products/Modifiers/Volume Expanders ADVATE 3 X ALPHANATE VWB 3 X ALPHANINE SD 3 X anagrelide 1 ARANESP 2 X ARIXTRA inj 3 BEBULIN VH 3 X BENEFIX 3 X cilostazol 1 cyanocobalamin inj 1 DROXIA 2 EPOGEN 3 X FEIBA VH IMMUNO 3 X FERRLECIT 3 folic acid tabs, 1 mg 1 FRAGMIN inj 3 HELIXATE FS 3 X HEMOFIL M 3 X HUMATE-P 3 X 2 INNOHEP inj 3 iron dextran Dexferrum, Infed 3 KOATE-DVI 3 X KOGENATE FS 3 X LEUKINE 2 X LOVENOX inj 2 MONARC-M 3 X MONOCLATE-P 3 X MONONINE 3 X NEULASTA 2 X NEUMEGA 2 X NEUPOGEN 2 X NOVOSEVEN/RT 3 X pentoxifylline ER 1 PLAVIX 75 mg 2 PROCRIT 2 X PROFILNINE SD 3 X PROMACTA 3 X RECOMBINATE 3 X REFACTO 3 X VENOFER 3 warfarin 1 WILATE 3 X XYNTHA 3 X Cardiovascular Agents 1 ACCUPRIL 3 ACCURETIC 3 acebutolol 1 ACEON 3 acetazolamide 1 acetazolamide ER 1 ADCIRCA 2 X ADVICOR 3 ALTACE 3 ALTOPREV 3 amiloride 1 KEY Tier 1 = Covered generic drugs 3 = Non-preferred brand drugs X = Self-Administered Medication 2 = Preferred brand drugs = Responsible Rx Program 24