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Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Quantity Limit List Category Analgesics Anti-Emetic Products Antineoplastic Agents Antipsychotic Agents Beta agonist inhalant and nebulizing agents Medication * Stadol Nasal Spray Ultram tablets Anzemet 50mg & 100mg tabs Emend 40mg (non-preferred) Emend 80mg Emend 125mg Zolinza Zydis / Zyprexa All products (e.g. albuterol, metaproterenol) Duoneb Levalbuterol Adderall XR 5mg, 10mg, 15mg (preferred) Adderall XR 20mg, 25mg, 30mg (preferred) Concerta all strengths except 36mg (preferred) Concerta 36mg strength ONLY (preferred) Central Nervous System (CNS) Stimulants (effective 8-1-04) Metadate CD all strengths (non-preferred) Provigil all strengths (non-preferred) Ritalin LA 20mg & 40mg (non-preferred) Ritalin LA 30 mg (non-peferred) Strattera 10mg, 18mg, 25mg, 40mg (Preferred) Strattera 60mg, 80mg, 100mg (Preferred) Vyvanse (all strengths) (non-preferred) COX-2 Sparing Agents Celebrex 50mg, 100mg & 200mg tabs (non-preferred) Estrogen patches Granulocyte Colony-Stimulating Factor HMG-CoA Reductase Inhibitors Insulin Narcotic Analgesics (added per P& T action 1-6-04) Nasal steroid inhalers NSAIDS 68 capsules / month 34 capsules / month 34 capsules / month 68 capsules / month Oxycontin 10mg and 20mg strengths 68 tablets / month 5 tablets / month 5 tablets / month 5 tablets / month 5 tablets / month 90 day supply for 1 copay 5 doses per chemo cycle 5 doses per chemo cycle 5 doses per chemo cycle 34 tablets / month 34 tablets / month 3 vials or 2 boxes of pens / copay 90 Oralets / month 68 capsules / month 11 patches per strength per month 84 tablets 136 capsules / month 204 tablets / month 204 tablets / month 136 tablets / month 180 tablets / month All products (e.g. beclomethasone, flunisolide) 1 inhaler / month Mobic 7.5mg & 15mg tabs (non-preferred) Erectile Dysfunction Agents Quantity Limit 5mL (2 bottles) / month 240 tablets / month 12 tablets / copay - 2 fills per month 5 capsules month 2 caps per month 1 cap per month 120 capsules per month 34 tablets per month 2 inhalers or bottles of solution / month 360 ml / month (120 vials) 288 ml / month (96 vials) 34 capsules per month 68 capsules per month 34 tablets per month 68 tablets per month 34 tablets per month 68 capsules per month (prior notification required) 34 capsules per month 68 capsules / month Cialis (all strengths) Levitra (all strengths) Stendra (all strengths) Viagra (all strengths) Generic products Granix Neupogen Neulasta Caduet (all strengths) (non-preferred) Crestor (all strengths) (non-preferred) All products Actiq (all strengths) Avinza (all strengths) Duragesic patches (all strengths) Fentora Kadian (all strengths) MS Contin (all strengths) Oramorph (all strengths) Oxycontin (EXCEPT 10MG and 20MG) Clarinex 5mg & Clarinex D 24 hr (non-preferred) 34 tablets per month Clarinex D 12 hour Xyzal 5mg (non-preferred) Toradol 10mg tablets 68 tablets per month 34 tablets per month 20 tablets / month Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Quantity Limit List Category Oral Contraceptives Oral Steroid Inhalers Proton Pump Inhibitors Sedative / Hypnotic Agents Medication All products All products Dexilant all strengths (non-preferred PA required) Ambien all strengths (preferred Ambien CR all strengths (non-preferred) Lunesta all strengths (preferred) Rozerem all strengths (non-preferred) Sonata all strengths (preferred) Amerge 1mg & 2.5mg tabs Axert 6.26mg & 12.5mg tabs Frova tabs (all strengths) Imitrex Syringe Imitrex 25mg, 50mg, and 100mg tabs Imitrex Nasal Spray 5mg & 20mg Selective Serotonin Receptor Agonist Imitrex Vials Maxalt 5mg & 10mg tablets & disintegrating tabs Relpax 20mg & 40mg tablets Zomig 2.5mg tablets Zomig Nasal Spray Zomig 5mg tablets & Zomig ZMT 5mg Citalopram 40mg tablets (preferred) fluoxetine 10mg (preferred) fluoxetine 20mg (preferred) fluoxetine 40mg (non-preferred) Luvox and fluvoxamine 25mg tab (non-preferred) Luvox and fluvoxamine 50mg tab (nonpreferred) Luvox and fluvoxamine 100mg tab (non-preferred) Luvox CR 100mg & 150mg Selective Serotonin Reuptake Inhibitor Paxil 10mg tablets (non-preferred) Medicaion Class / Antipsychotics Paxil 20mg, 30mg, & 40mg tablets (nonpreferred) Paroxetine 20mg, 30mg, & 40mg tablets (preferred) Paxil CR 12.5mg, 25mg, & 37.5mg (non-preferred) (effective 2-1-06) Smoking Cessation Products * Generic products are subject to quantity limits Quantity Limit 3 month supply / 3 copays 2 inhalers / month 34 capsules / month 34 capsules / month 34 capsules / month 34 capsules / month 34 capsules / month 34 capsules / month 9 tablets / Rx; 18 tablets / month 6 tablets / Rx; 12 tablets / month 9 tablets / Rx; 18 tablets / month 1 Kit (2 syringes) / Rx; 2 fills per month 9 tablets (each strength) / Rx; 18 tablets month 6 spray bottles (1 box) / month 5 vials (1 pack) per Rx; 10 vials/ per month 12 tablets / Rx; 24 tablets / month 6 tablets per fill / 12 tablets per month 6 tablets / 12 month 1 box of 6 UD sprays per month 3 tablets / month 45 tablets / month 34 tablets / month 90 capsules / month 68 tablets / month 34 tablets / month 68 tablets / month 102 tablets / month 34 tablets / month 34 tablets / month 68 tablets / month 68 tablets / month 68 tablets / month Prozac 10mg tab/cap (non-preferred) 34 tablets / month Prozac 20mg caps (non-preferred) 90 capsules / month Prozac 40mg caps (non-preferred) 34 capsules / month 4 capsules / month Prozac 90mg caps (non-preferred) Symbyax all strengths (non-preferred) Chantix (preferred) 34 capsules / month up to 6 months per calendar year Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Preferred Drug List Preferred (Tier 1 or 2) Category SSRI's Central Nervous System (CNS) Stimulants Congestive Heart Failure Agents Diabetic Agents HMG-CoA Reductase Agents (Including combination products) and the fenofibrate Agents fluoxetine 10mg & 20mg citalopram sertraline paroxetine Celexa Lexapro Luvox Paxil Paxil CR Prozac Sarafem Symbyax Viibryd (PA REQUIRED) methylphenidate methylphenidate SR amphetamine salts and Adderall XR Strattera Concerta (effective 6-1-05) Daytrana Focalin Metadate CD Nuvigil (not covered) Provigil (requires prior notification) Ritalin LA Vyvanse Agents except BiDil BiDil glimepiride Avandia Avandaryl Exubera (Prior notification approval required) Glumetza Kombiglyze XR Prandimet (ind. Products are preferred) Insulin Symlin Bydureon (Prior notification & step edit) Byetta (Prior Notification Required) Victoza (not a covered benefit) fenofibrate generic products Pravachol lovastatin Lipitor 40mg & 80mg Vytorin Zetia Zocor(simvastatin) (effective 5-1-05) Advicor Antara (step edit required generic fenofibrate) Caduet Crestor Lescol Lipitor 10mg & 20mg (step edit - simvastatin) Livalo (not a covered benefit) Mevacor Pravigard PAC Simcor Tricor (step edit requires generic fenofibrate) Trilipix (step edit requires generic fenofibrate) Non Preferred (Tier 3) X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Preferred Drug List Category Preferred (Tier 1 or 2) Fluticasone propionate Flunisolide Beconase AQ (Step edit - use of generic product) Flonase (Step edit - use of generic product) Nasacort AQ (Step edit - use of generic product) Nasonex (Step edit - use of generic product) Rhinocoft Aqua (Step edit - use of generic product) Omnaris (Step edit - use of generic product) Veramyst (Step edit - use of generic product) Acetic Acid Agents (indomethacin capsule, sulindac, diclofenac delayed release tablet, tolmetin) X X X X X X X Fenemates (meclofenamate) Oxicams (piroxicam) Proprionic Acid Agents (flurbiprofen, ibuprofen, naprosyn sodium tablet, fenoprofen, ketoprofen) Pyranocarboxylic Acid (etodolac tablet) Misc (nabumetone) Celebrex Clarinex Clarinex D 12 hour and 24 hour Xyzal X X Leukotriene Receptor Antagonist (step Advair (available at tier 1 copay) X edit for class =use of nasal steroid inhaler OR other asthma medication within previous 12 months) Zyflo X Antiviral Agents Acyclovir Famvir- Step Edit - acyclovir first line therapy Valtrex - Step Edit - acyclovir first line therapy Epivir Baraclude Inhaled Nasal Steroids Step edit requires use of generic product prior to using a brand name agent. NSAID Agents Non-Sedating Antihistamine (note the step edit for nasal steroid inhalers {fluticasone or flunisolide} is use of one generic nasal steroid inhaler before using a brand name product) Hepatitis B Agents Non Preferred (Tier 3) X X X X X X X X X X Zyflo CR X X X X X X (Tier 2 if patient had a 60 trial of Epivir within the previous 90 days) Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Preferred Drug List Category Sedative Hypnotics - Non Barbiturate Combination Products Preferred (Tier 1 or 2) Flurazepam Temazepam Triazolam Sonata Ambien Ambien CR Lunesta Rozerem ibuprofen and oxycodone individually X metformin and glipizide X pravastatin and aspirin X X X X Combunox (ibuprofen/oxycodone) X Exforge (amlodipine / valsartan) X Metaglip (metformin and glipizide) X Pravigard PAC (pravastatin and aspirin) Antispasmodic Agents X Ditropan & Ditropan XL Detrol & Detrol LA X Enablex X X Sanctura & Sanctura XR X Toviaz X Bisphosphonates - alendronate (Bone resorption suppression agents) risedronate X Forteo (PA required) X X Atelvia not a covered benefit Boniva Neuropathic Pain Agents (effective 9- Non Preferred (Tier 3) X X X X X Neurontin 15-05) X X X Lyrica (Tier 2 if patient has had a 60 day trial of Neurontin (gabapentin) in the last 90 days) Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Preferred Drug List Preferred (Tier 1 or 2) Category Misc Agents Actoplus Met XR Altabax Alvesco HFA Inhaler / Alvesco Inhaler (step edit trial of all formulary inhaled steroid asthma products) Non Preferred (Tier 3) X X X Amturnide Antara Apriso X X X Astragraf XL (step edit = immediate release tacrilimus X Azilect Azor B-Nexa Breo Ellipta Bepreve Brovana Calafol RX Centany Citranatal Products Clarifoam EF Cleeravue -M Clobeta + Plus Coartem Combigan Coreg CR Cosopt PF Dificid (Step edit - course of oral Vancomycin) Dulera Dutoprol Edarbi Epidou Equetro Exalgo Fexmid Gelnique Horizant Jentadueto Keppra XR Kombiglyze XR Lamictal XR Lavoclen-4 and Lavoclen-8 Lovaza Maxaron Forte Metrogel Combo Package Metvixia Moviprep Multaq Nesina Nicomide Omnaris Omontys Onglyza Onsolis Otosporin Ostiva Otosporin Oxandrin Patanase Nasal Spray Prepopik Pristiq Profera OB Pyrlex and Pyrlex PD Rapaflo Remesense Renvela Requip XL Rosac Saphris X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Brand Name Products available at the Generic Tier 1 ($7.00) Copay Rate Excluded Products Savella (step edit) Seradex Seroquel XR Servira Signafor X Sklice (step edit - use of Lindane or permethrin) Somatuline Depot Sprycel Stavzor Supervite EC Symbicort Taclonex Tasigna Tribenzor Trilpix Tudorza Pressair Twynsta Udamin Ultram ER Vascepa Veramyst Voltaren Gel Xerese Xeljanz (step edit - MTX) Ziana Zioptan Zymine XR and DXR Zyclara Accolate Advair Diskus Alphagan P 5mL botlle ONLY (Quantity limit of 2 bottles / copay) Aricept Atacand Auvi-Q Auto-Injector Copaxone 20mg (Copaxone 40mg is not a covered benefit) EpiPen and EpiPen Jr (Quantity limit of 2 pens / copay) Flovent Nexium (caps tier 1, susp tier 2) Novolin R, N and 70/30 Vials ONLY Accuhist products Ala-Hist products Alcortin A Aldex products Allfen products Allerx products Aldex products Alodox Aloquin Ambifed Products Amrix Analpram P and Advanced Aplenzin Aquoral Asmalpred Plus Atelvia Avidoxy DK Bifillin G Biomed Brisdelle Brovex Products Bystolic Capcof Carbaphen Cardiotek Products Centratex Cleanse and Treat products Clindareach X X X X x X X X X X X X X X X X X X X X X X X X X X X Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk CNL 8 topical Codiclear DH Comfort PAC - Meloxicam Copaxone 40mg (Copaxone 20mg is covered on the tier 1) Cotab products Coraz Corvite FE Corzall Dallergy products Desonil + Plus Desowen Dexall Dexodryl Dailyvite 5000 Neudexta Dexilant Diclegis Differin products for members > 29 yrs of age. Tier 3 for all others Digex NF Doryx Duac CS Duet DHA Stuartnatal Duexis Duovit DHA Dytan CD Egrifta Embeda Endal CD Endometrin Entereg Entex Epiceram Evamist Extendryl products Fanapt Ferralet 90 Flector Patch Folbee Plus Fosteum Fovex Fulyzaq Gattex Gralise Hemangeol Hetlioz HC Guai Hyaltopic Hydrocortisone /Lidocaine in Coleus Kit Ibudone IC400; IC 800 Intermezzo Iprivask J-Coff DHC J-Max Products J-Tan D HC Jalyn Juvisync Juxtapid Kapidex / Dexilant Kerol Products Lazanda LidoCort KIT Limbrel Livalo Lycelle M-End Max Manuvit SP Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Maxichlor PSE DM Maxifed products / Maxiflu products / Maxiphen products Medent-DMI Mi-Omega NF Minocin Kits Momexin Momexin Moxatag Myalept Nalfrx Nasofed / Nasotuss Nasohist products Natelle Plus Neo HC Neutrahist Products Niravam Notuss product line Nucynta / Nucynta ER Nuvigil Nutridox Nutrestore Obagi - C Omeclamox-Pak Optinate Oraxyl Orenitram Ortho-Nesic Papfyll Pediatex TDM Pedipirox-4 Pennsaid Topical Peranex HC PhenFlu products Physician Therapeutics products Polytussin DHC Pramine FQ Prefera-OB Prenate products Prenatal vitamins with DHA supplements Probarimin QT Prolinia Protect Cardio / Protect CMB2/Ceramide/Protect Iron/ Protect Bone Pryflex Pylera Quinzyme Radigel Rayos Re Dualvit products Relcof DN PE Renatabs with Iron Reocyte Plus Respi-tann products Rezyst IM Rhinahist Rinnovi Rosadan Rosula products Rowasa KITS Rybix ODT Ryzolt (tramadol preferred; Ultram ER tier 3) Salex Salvax Duo products Samsca Scalacort DK Solaraze Gel Solotuss Strovite Advance + D Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Subsys Sudates-G Sumadan / Sumaxin CP Sympak products Tachosil Tandem DHA Tear Again Terbinex Tersi Foam Tirosint Tozal Treximet Trital SR Tussicaps Tizanidine (Comfort Pac) Ultravate PAC Uloric Umecta Vanacof products Vanoxide HC Kit V-Hist / V-Cof Velphoro Vimizim Vimovo Viravan products Vitamax Vitaphil Viva DHA Xolegel DUO and Corepak Xyralid products Zamicet Zenieva Z-Care Zinotic Zinx Zotex-D Z Tuss 2 Zypram Zytaze Zytopic Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Benefit Exclusions Compounded Products Cosmetic Agents - Medications used for cosmetic purposes are not covered. (e.g. Propecia) Vitamins - OTC Vitamins are not covered - Prescription vitamins may be covered SPHN covers the following Over-the-Counter Medications ($5.00 Copay for a 28-34 days supply, depending on package size) Nicotine Patches, Lozenges, and Gum (quantity limit of 2 boxes per fill) OTC Prilosec and OTC omeprazole loratadine tablets and liquid Prior Notification Medications (all Specialty Pharmacy Medications require prior notification) Medication Abstral Actemra Adempas Adcirca Afinitor Ampyra Arcalyst Aplenzin Information Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Astagraf XL (step edit - generic tacrolimus) Submit request to MedImpact. If approved, covered on Tier 3 Aubagio Benlysta Bosulif Brilinta Brintellix Submit request to MedImpact. If approved, covered on Tier 3 Brovana Submit request to MedImpact. If approved, covered on Tier 3 Submit request to PHP Submit request to MedImpact. If approved, covered on Tier 3 Submit request to Plan. If approved, covered on Tier 3 Submit request to Plan. If approved, covered on Tier 3 Bydureon Submit request to MedImpact. If approved, covered on Tier 3 Butrans Submit request to MedImpact. If approved, covered on Tier 3 Byetta Submit request to MedImpact. If approved, covered on Tier 3 Carbaglu Submit request to MedImpact. If approved, covered on Tier 3 Castagon Submit request to MedImpact. If approved, covered on Tier 3 Chemotherapy oral brand name agents Submit request to PHP - Health Helps Cimzia Submit request to MedImpact. If approved, covered on Tier 2 Compounded Prescriptions Not a covered beneft with the exception of oral liquids, which may be covered. Cometriq Submit request to MedImpact. If approved, covered on Tier 3 Daliresp Submit request to MedImpact. If approved, covered on Tier 3 Dificid Submit request to MedImpact. If approved, covered on Tier 3 (requires tx with oral vanco first) Duavee Submit request to MedImpact. If approved, covered on Tier 3 Egrifta Submit request to MedImpact. If approved, covered on Tier 2 Emend 40mg Submit request to MedImpact. If approved, covered on Tier 3 Emsam Submit request to MedImpact. If approved, covered under Tier 3. Oral seligiline is preferred Enbrel Submit request to MedImpact. If approved, covered on Tier 2 Erivedge Submit request to MedImpact. If approved, covered on Tier 3 ESA Agents Prior Authorization Required. Submit request to Plan Exalago Submit request to MedImpact. If approved, covered on Tier 3 Famvir Submit request to MedImpact. If approved, covered on Tier 3. Fentora Submit request to MedImpact. If approved, covered under Tier 3. Fetzima Submit request to MedImpact. If approved, covered under Tier 3. Firazyr Submit request to MedImpact. If approved, covered under Tier 3. Flolan Submit request to MedImpact. If approved, covered on Tier 2 Forteo Submit request to MedImpact. If approved, covered on Tier 2 Fortesta Submit request to MedImpact. If approved, covered under Tier 3. Fycompa Submit request to MedImpact. If approved, covered under Tier 3. Gilenya Submit request to MedImpact. If approved, covered under Tier 3. Gilotrig Submit request to MedImpact. If approved, covered under Tier 3. Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Grastek Submit request to MedImpact. If approved, covered under Tier 3. Growth Hormones Submit request to MedImpact. If approved, covered under Tier 3. Hizentra Submit request to MedImpact. If approved, covered on Tier 2 Humira Submit request to MedImpact. If approved, covered on Tier 2 Iclusig Submit request to MedImpact. If approved, covered under Tier 3. Imbruvica Submit request to MedImpact. If approved, covered under Tier 3. Incivek Submit request to Plan. If approved, covered on Tier 2 Inlyta Submit request to MedImpact. If approved, covered under Tier 3. Isentress Submit request to MedImpact. If approved, covered under Tier 3. Jakafi Submit request to MedImpact. If approved, covered under Tier 3. Jublia Submit request to MedImpact. If approved, covered under Tier 3. Kalbitor Submit request to the Plan. If approved it is covered under the medical side. Kalydeco Submit request to MedImpact. If approved, covered under Tier 3. Kuvan Submit request to MedImpact. If approved covered on Tier 3. Need diagnosis verification Latuda Submit request to MedImpact. If approved, covered under Tier 3. Letairis Submit request to MedImpact. Lipichol Submit request to MedImpact. If approved, covered under Tier 3. Mervasco Submit request to MedImpact. If approved, covered under Tier 3. Myrbetriq Submit request to MedImpact. If approved, covered under Tier 3. Neupogen Submit request to MedImpact. If approved, covered on Tier 2 Neulasta Submit request to MedImpact. If approved, covered on Tier 2 NPlate Submit request to PHP Olysio Submit request to MedImpact. If approved, covered under Tier 3. Onfi Submit request to MedImpact. If approved, covered under Tier 3. Onsolis Submit request to MedImpact. If approved, covered on Tier 3 Opana Submit request to MedImpact, include documentation showing superiority over other opioids. If approved, covered under Tier 3. Opsumit Submit request to MedImpact, include documentation showing superiority over other opioids. If approved, covered under Tier 3. Oralair Submit request to MedImpact. If approved, covered on Tier 3 Orencia SUBQ Submit request to MedImpact. If approved, covered on Tier 3 Otezla Submit request to MedImpact. If approved, covered on Tier 3 Otrexup Submit request to MedImpact. If approved, covered on Tier 3 Pertzye Submit request to MedImpact. If approved, covered on Tier 3 Picato Submit request to MedImpact. If approved, covered on Tier 3 Potiga Submit request to MedImpact. If approved, covered on Tier 3 Prilosec Submit request to MedImpact. If approved, covered on Tier 3 Procysbi Submit request to MedImpact. If approved, covered on Tier 3 Promacta Submit request to PHP Promalyst Submit request to MedImpact. If approved, covered on Tier 3 Provigil Submit request to MedImpact. If approved, covered on Tier 3 Ragwitek Submit request to MedImpact. If approved, covered on Tier 3 Ranexa Submit request to MedImpact. If approved, covered on Tier 3 Ravicti Submit request to MedImpact. If approved, covered on Tier 3 Relistor Submit request to MedImpact. If approved, covered on Tier 3 Remodulin Submit request to MedImpact. If approved, covered on Tier 2 Revatio Submit request to MedImpact. If approved, covered on Tier 2 Samsca Submit request to MedImpact. If approved, covered on Tier 3 Sancuso Submit request to MedImpact. If approved, covered on Tier 3 Simponi Submit request to MedImpact. If approved, covered on Tier 2 Signifor Submit request to MedImpact. If approved, covered on Tier 3 Sirturo Submit request to MedImpact. If approved, covered on Tier 3 Sovaldi Submit request to MedImpact. If approved, covered on Tier 3 Stelara Submit request to MedImpact. If approved, covered on Tier 3 Stivarga Submit request to MedImpact. If approved, covered on Tier 3 Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Suboxone Submit request to MedImpact. If approved, covered on Tier 2 Synalar TS Submit request to MedImpact. If approved, covered on Tier 3 Tafinlar Submit request to MedImpact. If approved, covered on Tier 3 Tanzeum Submit request to MedImpact. If approved, covered on Tier 3 Tecfidera Submit request to MedImpact. If approved, covered on Tier 3 Thalomid Submit request to MedImpact. If approved, covered on Tier 3 Thelin Submit request to MedImpact. If approved, covered on Tier 2 Tivicay Submit request to MedImpact. If approved, covered on Tier 3 Tracleer Submit request to MedImpact. If approved, covered on Tier 2 Tykerb Submit request to MedImpact. If approved, covered on Tier 3 Valchlor Submit request to MedImpact. If approved, covered on Tier 2 Valtrex (step edit - acyclovir) Submit request to MedImpact. If approved, covered on Tier 3 Vandetanib Submit request to MedImpact. If approved, covered on Tier 2 Ventavis Submit request to MedImpact. If approved, covered on Tier 3 Victrelis Submit request to Plan. If approved, covered on Tier 2 Victoza (step edit - Byetta/Bydureon) Submit request to MedImpact. If approved, covered on Tier 3 Viibryd Submit request to MedImpact. If approved, covered on Tier 2 Vimpat Submit request to MedImpact. If approved, covered on Tier 3 Votrient Submit request to MedImpact. If approved, covered on Tier 2 Weight Loss Medications (Legend only) Submit request to MedImpact Xalkori Submit request to MedImpact. If approved, covered on Tier 3 Xenazine Submit request to MedImpact. If approved, covered on Tier 2 Zegerid Submit request to MedImpact. If approved, covered on Tier 3 Zelboraf Submit request to MedImpact. If approved, covered on Tier 3 Zithranol Submit request to MedImpact. If approved, covered on Tier 2 Zontivity Submit request to MedImpact. If approved, covered on Tier 3 Zykadia Submit request to MedImpact. If approved, covered on Tier 3 Zytiga Submit request to MedImpact. If approved, covered on Tier 3 Sparrow Health System Employee Benefit Rider (current through 7/30/2014 Updated 7/3/2014 srk Medication Extended Supply List Please Note: Generic dispensed when available. Brand name in most cases only listed for name recognition. *Asterisked agents do not currently have a generic available. I. 100 Units or 34 days supply, whichever is greater Antidiabetic Agents Chlorpropamide (eg. Diabinese) Glipizide (Glucotrol) Glyburide (Micronase/Diabeta) Metformin (Glucophage) Antihypertensives Atenolol (eg. Tenormin) Diltiazem (Dilacor XR only) Hydrochlorothiazide / Triamterene (eg.Dyazide/Maxzide) Nifedipine (Adalate CC only) Nitroglycerine (eg. Nitrobid/Nitrostat) Propranolol (eg. Inderal) Verapamil (Verapamil SR only) Cardiac Agents Digoxin Procainamide HCl (Procan/Pronestyl) Quinidine Diuretics Bumetanide (Bumex) Chlorthalidone (eg. Hygroton) Chlorothiazide (eg. Diuril) Furosemide (eg. Lasix) Hydrochlorothiazide (eg. Hydrodiuril) Estrogen and Hormone Therapy Esterified Estrogens (eg. Estratab, Estrace, Ortho-est) Conjugated Estrogens Maximum 3 packs Anti-inflamatory agents Ibuprofen (eg. Motrin) Naproxen (eg. Naprosyn) Naproxen Sodium (eg. Anaprox) Anti-Lipid Agents Atorvastatin (Lipitor) Fluvastatine (Lescol)* Gemfibrozil (Lopid) Lovastatin (Mevacor) Pravastatin (Pravachol) Simvastatin (Zocor) (eg. Premarin*, Premaphase*, Prempro*) Medroxyprogesterone (Provera) H2 Blockers Cimetidine Ranitidine Hyperuricemia/Gout agents Allopurinol (eg. Zyloprim) Potassium Chloride (eg. Kay Ciel/Slow K/K Dur/ Micro K/Klotrix) Bronchodilators Theophylline (eg. Theodur/Slo-bid) II. 200 Units or 34 day supply, whichever is greater Isoniazid (eg. INH) Levothyroxine (eg. Levothroid/Synthroid) Para-Aminosalicylic acid (eg. PAS) Phenytoin (eg. Dilantin) Primidone (eg. Mysoline) Propylthiouricil (eg. PTU) Thyroid (eg. Armour Thyroid)