ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member is at least two years of age AND, the member has filled a prescription for at least one topical corticosteroid of medium or higher potency (at least a 14 day supply within the past 180 ) FANAPT 657-D FANAPT, FANAPT TITRATION PACK GRALISE 656-D GRALISE, GRALISE STARTER Coverage will be provided if the member has filled a prescription for gabapentin (at least a 30 day supply within the past 120 ) HPGST SABA 408-D XOPENEX HFA Coverage will be provided if the member has filled a prescription for ProAir HFA, Proventil HFA or Ventolin HFA (at least a 30 day supply within the past 365 ) INTUNIV 781-D GUANFACINE ER Coverage will be provided if the member has filled a prescription for an amphetamine-dextroamphetamine, dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate or dexmethylphenidate product (at least a 30 day supply within the past 180 ) Updated 09/01/2016 1
LATUDA 657-D LATUDA LYRICA 656-D LYRICA Coverage will be provided if the member has filled a prescription for gabapentin (at least a 30 day supply within the past 120 ) PDPD AUTOIMMUNE ACTEMRA, CIMZIA, CIMZIA STARTER KIT, KINERET, ORENCIA, ORENCIA CLICKJET, REMICADE, SIMPONI, SIMPONI ARIA, STELARA, XELJANZ Must try Enbrel or Humira PDPD GH GENOTROPIN, GENOTROPIN MINIQUICK, NUTROPIN, NUTROPIN AQ NUSPIN 10, NUTROPIN AQ NUSPIN 5, NUTROPIN AQ PEN, OMNITROPE, SAIZEN, SAIZEN CLICK.EASY Must try Norditropin or Humatrope PROTOPIC 177-F TACROLIMUS Protopic 0.03%: Coverage will be provided if the member is at least two years of age AND filled a prescription for at least one topical corticosteroid of medium or higher potency (at least a 14 day supply within 180 ) Protopic 0.1%: Coverage will be provided if the member is at least 16 years of age AND filled a prescription for at least one topical corticosteroid of medium or higher potency (at lease a 14 day supply within 180 ) RANEXA 658-D RANEXA Coverage will be provided if the member has filled a prescription for a nitrate plus a beta blocker or a calcium channel blocker (at least a 30 day supply within the past 365 ) Updated 09/01/2016 2
SAPHRIS 657-D SAPHRIS SEROQUEL/SEROQUEL XR 657-D SEROQUEL XR SIMVA 80MG 981-D SIMVASTATIN Coverage will be provided if the member has filled a prescription for 80mg strength of simvastatin (Zocor) (at least a 290 day supply within the past 365 ) TGST ACNE 771-D ACANYA, AZELEX acne product (at least a 30 day supply within the past 180 ) TGST ARB/RI 376-D BENICAR, EDARBI, TEKTURNA ACE, ACE/HCTZ combination, ARB, or ARB/HCTZ combination (at least a 30 day supply within the past 365 ) TGST BISPHOSPHONATES 377-D FOSAMAX PLUS D bisphosphonate product (at least a 28 day supply within the past 365 ) Updated 09/01/2016 3
TGST BPH-ALPHA1 BLCK 606-D CARDURA XL, RAPAFLO Benign Prostatic Hyperplasia (BPH) agent (e.g., alfuzosin ext-rel, doxazosin, tamsulosin, terazosin) (at least a 30 supply within the past 365 ) TGST NSAID 378-D VOLTAREN Coverage will be provided if member has filled a prescription for a generic NSAID product (at least a 30 day supply within the past 180 ) TGST PPI 383-D DEXILANT proton pump inhibitor (at least a 30 day supply within the past 180 ) TGST PROSTAGL ANALOG 613-D LUMIGAN, TRAVATAN Z, ZIOPTAN prostaglandin analogue (at least a 30 day supply within the past 365 ) TGST SLEEP AGENTS 382-D ROZEREM nonbenzodiazepine hypnotic (at least a 30 day supply within the past 180 ) TGST SSRI 384-D VIIBRYD, VIIBRYD STARTER PACK SSRI product (at least a 30 day supply within the past 365 ) TGST TRIPTANS 391-D RELPAX 5HT 1 Agonist (triptan) (at least a 30 day supply within the past 180 ) Updated 09/01/2016 4
TGST URINARY ANTISPASMODICS 385-D GELNIQUE, MYRBETRIQ, OXYTROL, TOVIAZ, VESICARE urinary antispasmodic (at least a 30 day supply within the past 180 ) ULORIC 540-D ULORIC Coverage will be provided if the member has filled a prescription for allopurinol (at least a 30 day supply within the past 180 ) VANCOCIN 513-E VANCOMYCIN HCL Coverage will be provided if the member has filled a prescription for metronidazole (at least a 10 day supply within the past 60 ) OR, Vancocin capsules - vancomycin hydrochloride (at least a 7 day supply within the past 60 ) Updated 09/01/2016 5