Download Prescription Drug Guide

Prescription Drug Guide
The Assurant Health Prescription Drug guide provides summary information. For a complete listing of benefits, exclusions, and limitations, please refer to the
certificate of insurance. In the event there are discrepancies with the information in this brochure, the terms and conditions of the coverage documents will
govern. Plan design, benefits, optional features, provisions, and exclusions may vary by state.
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company.
J-116966 (Rev. 06/2016) © 2016 Assurant, Inc. All rights reserved.
Understanding the 2016 Assurant Health Prescription Drug Guide
To help you determine your cost sharing (the portion you pay for your prescription) on drugs that may
be covered by your plan, we are pleased to provide you with our 2016 Prescription Drug Guide. In this
guide, you will find lists of generic, specialty, preferred brand and non-preferred brand drugs, as well as
a questions and answers section. Since this list includes many drugs, we’ve created an easy-to-navigate
chart to help you quickly find the drug you’re looking for.
Here’s how to get started
•To find out which column you should use to determine your cost sharing (the portion you pay for your
prescription) on covered prescription drugs, please see the sample card below
•If you see two amounts of a prescription drug copay OR no copay at all, please use the green column on the
chart
•For all states except Montana, if you see three amounts of a prescription drug copay, please use the blue
column on the chart
•If you live in Montana and you see three amounts of prescription drug copays, please use the orange column
on the chart
Look here on your ID card to see
which column you should use
for your cost-sharing on covered
prescription drugs.
For example shown, you would use
either the blue or orange column,
depending on where you live.
The keys to your prescription drug coverage.
Not all plans or prescription drugs are alike, so each one may have different requirements. We’ve
created these abbreviations and added them to each drug name to help you understand your
prescription drug coverage.
PA
Prior Authorization. This is a drug that requires prior authorization before it’s considered
for coverage under your prescription benefits. A physician, patient, or a person appointed to
manage the patient’s care must request prior authorization. Additionally, Step Therapy may also
be required as part of the prior authorization process. See definition of Step Therapy below.
For more information on the prior authorization process, call the customer service phone
number on the back of your ID card.
QL
Quantity Limit. Your prescription benefit may limit the amount of a drug you can receive
at one time. Our quantity limits program includes dose efficiency, maximum daily dose,
and quantity limits over time.
ST
Step Therapy. You must try one or more alternate drugs before your plan will cover a Step Therapy
drug. The alternate drugs are FDA-approved, treat the same condition and, may be available to you
at a lower copay or coinsurance amount.
LD
Limited Distribution. This is a specialty medication that is available in limited distribution
and is not available through our designated CVS/Specialty Pharmacy. To determine where
these medications are available, please contact your provider.
DSP
Designated Specialty Pharmacy. This is a specialty medication. You must obtain your specialty
drug through our designated CVS/Specialty Pharmacy to maximize your benefits. If you do not
use CVS/Specialty or your network doctor, you may have limited or no coverage
(depending on your plan).
DSP/DO
Designated Specialty Pharmacy or Doctor’s Office. This is a specialty medication. You must
obtain your prescription through a CVS/Specialty Pharmacy or through your network doctor’s
office to maximize your benefits. If you do not use CVS/Specialty or your network doctor,
you may have limited or no coverage (depending on your plan).
If you would like to learn more about each of these terms, please see the Questions and Answers
section of this guide.
To quickly find a specific drug or a therapeutic class, use the search feature available in Adobe Acrobat Reader (PC
keyboard shortcut: Ctrl+F; Mac keyboard shortcut: Cmd+F).
Please remember this is not a complete list of drugs. Because there are thousands of drugs, Assurant Health only lists the
most commonly prescribed ones. If the drug you are looking for is not listed, please call the customer service number on
the back of your ID card for more information. If the drug is not listed, it may not be covered.
Please note that not all drugs listed in this guide are covered by all pharmacy benefit programs. Check your benefit materials or contact
Assurant Health by calling the customer service number on the back of your medical identification card to determine if a drug is covered.
Determine if your prescription drug is generic, preferred or non-preferred, or if it’s a medical drug.
Knowing this could help you save on out-of-pocket costs when you get your prescription
filled. For example, a generic drug usually costs much less than a brand-name drug. You’ll
see the following prescription benefit abbreviations in the chart for each type of drug:
G
Generic drugs. A generic drug is usually the same chemically as its branded counterparts, and
usually costs less. When filling your prescription, your pharmacist can substitute a generic drug for
a brand-name drug when the generic is rated by the FDA as the same, and where it’s permitted by
your doctor.
P
Preferred drugs. A preferred drug is a brand-name drug with a lower copay or coinsurance
compared to a non-preferred drug, which means you likely will pay less out-of-pocket for this drug.
NP
MED
Non-preferred drugs. A non-preferred drug is a brand-name drug with a higher copay or
coinsurance compared to a generic or preferred brand-name drug, which means you likely will
pay more for this drug.
Medical drugs. A drug listed as a “MED” is subject to the medical deductible and coinsurance,
regardless of plan type. Copays do not apply to this drug.
The Assurant Health Diabetes Program
Assurant Health offers a specialized program for people living with diabetes, with the goals of
helping them best manage their condition, improve their knowledge about how to best care for
themselves and, ultimately, lead their best life. The program offers:
Money-saving medication benefits:
• Many everyday-use supplies, like test strips, lancets and syringes, are provided first-dollar,
meaning there’s no deductible, coinsurance or copay
• All generic diabetes medications are provided at first-dollar, too
• And preferred brand-name drugs are provided at 50% off any applicable deductible,
coinsurance or copay
Support that can make all the difference
There’s also direct access to registered nurses who are certified
health coaches, and offer:
• A personalized, step-by-step plan to help diabetes patients
reduce risk factors and monitor symptoms
• Educational information about diabetes
• Advice and tips on managing diabetes symptoms
Am I eligible for
this program?
The Diabetes Program is
available with the purchase of many
individual major medical and small
group plans, and at no additional
cost. To see if you’re eligible to
enroll, go to assuranthealth.com/
diabetes.
Look for this symbol throughout this guide for the Diabetes
Program prescription drugs and supplies that qualify.
Program availability varies by state. The Assurant Diabetes Program is offered by the Assurant Health Disease Management department and can be
discontinued at any time. For complete details about the Diabetes Program, qualifying plans and information on requirements for program participation,
please visit assuranthealth.com/diabetes.
Questions and Answers about
the Assurant Health Prescription Drug Guide
What is the Assurant Health Prescription Drug Guide?
Our Prescription Drug Guide is meant to give you an overview of the cost-sharing (the portion you pay for your
prescription) and authorization requirements under the prescription benefit of your plan. Changes to the guide
are based on the latest medical findings as well as information from the Food and Drug Administration (FDA)
and drug makers.
This guide includes generic, brand-name and specialty medications, and is updated regularly.
Your plan has different copay or coinsurance for generic, brand-name, specialty, preferred and non-preferred
drugs. Usually, preferred drugs are subject to a lower copay or coinsurance amount than non-preferred, which
means you pay less out-of-pocket for those drugs.
The Assurant Health Prescription Drug Guide may change without notice. Drugs listed in this guide are based on
reliable medical data, safety and cost. When you talk to your doctor about which drug may be right for you, it is
important to remember that you and your doctor are responsible for making the final decision on your drug therapy.
Why is the Assurant Health Prescription Drug Guide subject to change?
The Assurant Health Prescription Drug Guide changes for various reasons:
We may add or remove drugs
• The FDA approves many new drugs throughout the year
• If the FDA removes a drug from the market, it will no longer be covered under your prescription drug benefit
The cost-sharing for a drug may have changed
• As brand-name drugs lose their patents, generic versions may become available. When this happens,
the brand-name drug may move to a higher copay or coinsurance level. The generic drug may be added
to the list and be available at a lower copay or coinsurance level
The requirements may have changed
• Some drugs may no longer require a prescription. If your drug becomes available over-the-counter, the
drug will no longer be covered under your prescription drug benefit
• We may change which drugs require prior authorization, quantity limits, and specialty drug
designation throughout the year
Where required by applicable law, members who have coverage for medications that have a change in terms
including: 1) change in cost-sharing (e.g., drug changed from Preferred to Non-Preferred); 2) change in prior
authorization; 3) change in Step Therapy requirement; or 4) change in Quantity Limit during the plan year, will
continue to have those medications covered under the same terms or cost-sharing that applied under their
plan prior to the change until January 1 of the following calendar year.
Please go to our Current Customers Web page at assuranthealth.com to see if there have been any
updates to the guide.
Why should I use CVS/Caremark, the pharmacy benefit manager?
As your pharmacy benefit manager, CVS/Caremark brings you discounts on prescriptions and processes
prescription claims. Their nationwide network has more than 65,000 independent and chain pharmacies,
including CVS, Target, Walgreens, Walmart and Rite Aid stores.
You can save an average of 30-40% on prescription drugs at a CVS/Caremark participating pharmacy; any drug
discount will already be applied. Your pharmacist will charge you the amount you’re responsible for paying
(such as any applicable copay, coinsurance or deductible). Make sure your plan provides coverage by reviewing
the Prescription Drug Card Program information in your insurance contract, or by contacting us.
In most states, CVS/Caremark will deliver to your home any prescription drugs you’re using on a long-term basis.
It’s convenient, and you may even save money. Call CVS/Caremark or visit caremark.com for more information.
You can learn more about how to manage your prescriptions with CVS Caremark by visiting our Current
Customers Web page at assuranthealth.com.
Why do some drugs have quantity limits?
Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and
pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical
guidelines, FDA approval and guidance from drug makers to set these quantity limits.
What is Step Therapy?
With Step Therapy, you must try one or more alternate drugs before your plan will cover a Step-therapy drug.
The alternate drugs are FDA-approved, treat the same condition(s) and may also be available to you at a lower
copay or coinsurance level.
How does the Prior Authorization program work?
The Prior Authorization program encourages appropriate and cost-effective use of drugs , and:
• A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization
before drugs that require a prior authorization may be considered for coverage under a member’s pharmacy
benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated
with the member’s plan
• The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer
labeling information, and cost
• The drugs requiring prior authorization are subject to change
For more information, call the customer service number on the back of the member ID card.
For a prior authorization request, call the Prior Authorization number on the back of the member ID card.
What are preferred brand and non-preferred brand-name drugs?
• A preferred brand-name drug is considered a preferred brand-name drug based on its proven clinical and
cost effectiveness
• A non-preferred brand-name drug is a medication where there is a more cost-effective drug available that is
clinically the same
What is a generic drug?
Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety,
strength, form and intended use. Generic drugs are only available after the FDA approves them. When filling
your prescription, your pharmacist can substitute a generic drug for a brand-name drug when the generic is
rated by the FDA as equivalent and also where it is permitted by your doctor and state law.
What happens if I use a brand-name drug when a generic is available?
If you choose to use a brand-name drug, rather than its generic or bio-similar equivalent, you will be responsible
for paying the brand-name cost-sharing amount, such as deductibles or copays. You will also be responsible for
paying the difference in cost between the brand-name drug and its generic or bio-similar equivalent (this is called
an ancillary charge). The ancillary charge will not be reimbursed by Assurant Health, nor does it count toward
satisfying any coinsurance, deductible or other out-of-pocket limit. Not applicable in all states.
About Specialty Drugs
Specialty drugs are defined as high-cost drugs that may be injected, infused or taken by mouth and may require
special administration and monitoring. Specialty drugs are used to treat certain rare or chronic diseases, such
as rheumatoid arthritis, HIV/AIDS, multiple sclerosis, cancer, hemophilia and hepatitis C. Usually, they are not
available at a local retail pharmacy.
If you have a complex condition that requires a specialty drug, you can maximize the benefits of your plan by
using Assurant Health’s designated specialty pharmacy, CVS/Specialty Pharmacy.
Specialty drugs are labeled in this guide as LD, DSP or DSP/DO. If you don’t see the specialty drug listed in this
guide, call Assurant Health to find out if a medication you’re taking is a specialty drug (you can call the customer
service number on the back of your ID card).
How do I receive benefits for my specialty drug?
Step 1: Look to see if your specialty drug is listed in this guide
Step 2: Call Assurant Health to verify your benefits and get prior authorization
To ensure you get the most value from your plan and receive benefits for specialty medications, you or your
doctor should call Assurant Health before you begin using a specialty drug. This number is listed as the customer
service number on the back of your ID card.
• We can help you understand your plan coverage and how benefits are paid for your specialty medication
• We can help you find out if your specialty medication requires prior authorization and guide you through
the process, if necessary
Step 3: Use CVS/Specialty Pharmacy
Maximize your benefits by using our designated pharmacy provider, CVS/Specialty Pharmacy. If you do not
fill your medication through CVS/Specialty Pharmacy, you may have limited or no coverage (depending on
your plan).
About CVS/Specialty Pharmacy
CVS/Specialty Pharmacy brings you the opportunity to save through negotiated drug pricing. While specific
medication costs vary, many specialty medications will cost you less through CVS/Specialty Pharmacy. In
addition, you’ll receive personalized care management services:
• Access to an on-call pharmacist 24 hours a day
• Coordination of care with you and your doctor
• Convenient medication delivery to your home or doctor’s office
• Medication-specific and disease-specific education and counseling
• Online support through CVSCaremarkSpecialtyRx.com, with interactive areas to submit questions to
pharmacists and nurses
Note: If your current specialty pharmacy is not CVS/Specialty and you have concerns about continuity of care, please call
us to find out if you have options allowing you to continue receiving your medication from your current specialty provider.
Any amounts that the covered person is responsible for paying are paid on a per-prescription or refill basis and will not
be adjusted if we receive any retrospective volume drug discounts or prescription drug rebates. We may receive and will
retain manufacturer product discounts, also known as rebates, related to certain drug purchases.
Table of Contents
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS . . . . . . . . . . . . . . . . . . . . . . 1-2
DERMATOLOGICALS . . . . . . . . . . . . . . . . . 48-58
AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . 2
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . 58-59
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . 2
ANALGESICS — ANTI-INFLAMMATORY . . . . . . . 2-4
DIAGNOSTIC PRODUCTS . . . . . . . . . . . . . . . . 58
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . 59-60
ANALGESICS — NON-NARCOTIC . . . . . . . . . . . 4-5
ENDOCRINE AND METABOLIC AGENTS —
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . 60-62
ANALGESICS — OPIOID . . . . . . . . . . . . . . . . . 5-7
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . 62-63
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . 7-8
FLUOROQUINOLONES . . . . . . . . . . . . . . . . . . 64
ANORECTAL AGENTS . . . . . . . . . . . . . . . . . . . 8
GASTROINTESTINAL AGENTS —
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . 64-65
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . 8-9
ANTI-ANGINAL AGENTS . . . . . . . . . . . . . . . . . 9
ANTI-ANXIETY AGENTS . . . . . . . . . . . . . . . . 9-10
ANTI-ARRHYTHMICS . . . . . . . . . . . . . . . . . . . 10
ANTI-ASTHMATIC AND
BRONCHODILATOR AGENTS . . . . . . . . . . . . 10-12
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . 12
ANTICONVULSANTS . . . . . . . . . . . . . . . . . 13-15
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . 15-17
ANTIDIABETICS . . . . . . . . . . . . . . . . . . . . . 17-19
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . 19-20
ANTIDOTES . . . . . . . . . . . . . . . . . . . . . . . . 20
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . 20-21
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . 21-22
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . 22-23
ANTIHYPERTENSIVES . . . . . . . . . . . . . . . . 23-26
ANTI-INFECTIVE AGENTS —
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . 26-27
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . 27
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . 27
ANTIMYASTHENIC/CHOLINERGIC AGENTS . . . . . 27
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . 27-28
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES . . . . . . . . . . . . . . . . . . . . . . . 28-31
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . 31-32
ANTIPSYCHOTICS/ANTIMANIC AGENTS . . . . . 32-34
GENERAL ANESTHETICS . . . . . . . . . . . . . . . . 65
GENITOURINARY AGENTS ­—
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . 65-67
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . 67
HEMATOLOGICAL AGENTS —
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . 67-68
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . 69
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . 69
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . 69-70
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . 70
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . 70-71
MEDICAL DEVICES . . . . . . . . . . . . . . . . . . 71-72
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . 72-74
MINERALS & ELECTROLYTES . . . . . . . . . . . . . 74
MOUTH/THROAT/DENTAL AGENTS . . . . . . . . 74-75
MUSCULOSKELETAL THERAPY AGENTS . . . . . . . 75
NASAL AGENTS — SYSTEMIC AND TOPICAL . . ..75-76
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . 76
OPHTHALMIC AGENTS . . . . . . . . . . . . . . . 76-81
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . 81-82
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . 82
PASSIVE IMMUNIZING AGENTS . . . . . . . . . . . 82-83
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . 83
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . 83-84
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS — MISCELLANEOUS . . . . . . . . . . . . 84-85
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . 34-37
RESPIRATORY AGENTS —
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . 85-86
ASSORTED CLASSES . . . . . . . . . . . . . . . . . 37-38
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . 86
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . 38
THYROID AGENTS . . . . . . . . . . . . . . . . . . 86-87
BIOLOGICALS MISCELLANEOUS . . . . . . . . . . 38-39
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . 87-89
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . 39-40
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . 89
CARDIOTONICS . . . . . . . . . . . . . . . . . . . . . . 40
URINARY ANTISPASMODICS . . . . . . . . . . . . 89-90
CARDIOVASCULAR AGENTS — MISCELLANEOUS .40-41
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . .90-91
CEPHALOSPORINS . . . . . . . . . . . . . . . . . . . . 41
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . 91
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . 41-45
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . 91
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . .45-46
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . 46-48
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ADDERALL
ST,QL
ADDERALL XR CAPSULE
ADZENYS XR
ST,QL
ST,QL
amphetamine-dextroamphet ER
QL
amphetamine-dextroamphetamine
QL
APTENSIO XR QL,ST
CAFCIT
QL
G
G
G
QL
G
G
G
CONCERTA
ST,QL
P
NP
NP
DAYTRANA
ST,QL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
EVEKEO ST,QL
P
NP
NP
FOCALIN
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
methylphenidate chewable QL
G
G
G
methylphenidate ER (CD)
QL
G
G
G
methylphenidate ER (LA) QL
G
G
G
methylphenidate ER
G
G
G
G
G
G
G
G
G
caffeine citrate solution
clonidine ER
DESOXYN
QL
ST,QL
DEXEDRINE
ST,QL
dexmethylphenidate ER
dexmethylphenidate
QL
dextroamphetamine ER
dextroamphetamine
QL
QL
QL
dextroamphetamine sulfate solution
DYANAVEL XR solution
ST,QL
FOCALIN XR
INTUNIV
KAPVAY
QL,ST
ST,QL
ST,QL
ST,QL
METADATE CD
metadate ER
ST,QL
QL
methamphetamine
methylin ER
QL
QL
methylin solution
ST,QL
METHYLIN TABLET CHEWABLE
methylin tablet
QL
QL
methylphenidate solution
methylphenidate tablet
QL
QL
ST,QL
QL
1
DRUG CLASS
DRUG NAME
modafinil
NUVIGIL
COST-SHARING COLUMNS
PA,QL
PA,QL
PROCENTRA
PROVIGIL
ST,QL
PA,QL
QUILLICHEW ER
ST,QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
RITALIN LA
ST,QL
P
NP
NP
RITALIN SR
ST,QL
P
NP
NP
P
P
P
P
P
P
G
G
G
P
P
P
P
NP
NP
KITABIS PA,QL,DSP
P
NP
P
NEO-FRADIN
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
P
P
G
G
G
MED
MED
NP
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
QUILLIVANT XR
STRATTERA
VYVANSE
zenzedi
ST,QL
QL
QL
QL
AMEBICIDES
YODOXIN
QL
AMINOGLYCOSIDES BETHKIS
PA,QL,‌DSP
neomycin
QL
QL
paromomycin
TOBI
QL
ST,PA,QL,‌DSP
TOBI PODHALER
ST, PA,QL,‌DSP
tobramycin inhalation solution
PA,QL
ANALGESICS — ANTI-INFLAMMATORY
ACTEMRA
PA,QL,‌DSP/DO
ANAPROX
QL
ANAPROX DS QL
ARCALYST
PA,QL,‌DSP/DO
ARTHROTEC
CATAFLAM
CELEBREX
QL
QL
COSENTYX
DAYPRO
QL
PA,QL,DSP
QL
diclofenac potassium
diclofenac sodium
QL
QL
diclofenac sodium ER
QL
diclofenac-misoprostol
DUEXIS
ST,QL
QL
2
DRUG CLASS
DRUG NAME
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
MED/P
MED/P
P
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
MED/P
MED/P
P
QL
G
G
G
PA,QL,‌DSP/DO
MED
MED
P
P
P
P
G
G
G
G
G
G
G
G
G
G
G
G
MED
MED
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
EC-NAPROSYN QL
ENBREL
PA,QL,‌DSP
etodolac
QL
etodolac ER
FELDENE
QL
flurbiprofen
HUMIRA
QL
QL
fenoprofen
QL
PA,QL,‌DSP
ibuprofen
ILARIS
INDOCIN SUSPENSION
indomethacin
ketoprofen
ketorolac
QL
QL
indomethacin ER
QL
QL
QL
KINERET PA,QL,‌DSP
leflunomide
QL
mefenamic acid
meloxicam
MOBIC
COST-SHARING COLUMNS
QL
QL
QL
nabumetone
NALFON
QL
QL
NAPRELAN
QL
P
NP
NP
NAPROSYN
QL
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
MED
MED
NP
P
NP
NP
P
NP
NP
MED
MED
NP
naproxen
QL
naproxen delayed release
naproxen sodium
QL
QL
naproxen sodium CR QL
ORENCIA
OTEZLA
PA,QL,‌DSP/DO
PA,QL,‌DSP
OTEZLA STARTER PACK
PA,QL,DSP
OTREXUP
PA,ST,QL, ‌DSP
oxaprozin
QL
G
G
G
piroxicam
QL
G
G
G
P
NP
NP
MED
MED
NP
P
NP
NP
P
NP
NP
PONSTEL
RASUVO
QL
PA,QL,‌DSP
RHEUMATREX
RIDAURA
QL
QL
3
DRUG CLASS
DRUG NAME
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
NP
MED
MED
NP
P
NP
NP
MED
MED
NP
G
G
G
MED
MED
NP
P
NP
NP
QL
G
G
G
ST,QL
P
P
P
SIMPONI ARIA
SIMPONI
SPRIX
PA,QL,‌DSP/DO
PA,QL,‌DSP
QL
STELARA
sulindac
TALTZ
PA,QL,‌DSP
QL
PA,QL,ST,DSP
TIVORBEX
tolmetin
VIMOVO
QL
P
NP
NP
QL
P
NP
NP
PA,QL,‌DSP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
VIVLODEX
QL,ST
VOLTAREN-XR
XELJANZ
XELJANZ XR
ZIPSOR
COST-SHARING COLUMNS
PA,QL,DSP
QL
ZORVOLEX
ST,QL
ANALGESICS — NON-NARCOTIC alagesic capsule
QL
P
NP
NP
QL
ALLZITAL
P
NP
NP
anolor 300 capsule
50-325-40 mg oral QL
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
ALAGESIC LQ SOLUTION
BUPAP
QL
QL
butalbital-acetaminophen
butalbital-APAP-caffeine
butalbital-ASA-caffeine
capacet
QL
QL
QL
QL
choline & mag trisalicylate
diflunisal
QL
EQUAGESIC
QL
QL
P
NP
NP
FIORICET
QL
P
NP
NP
FIORINAL
QL
P
NP
NP
margesic
QL
G
G
G
marten-tab QL
G
G
G
MST 600
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
ESGIC
QL
QL
ORBIVAN CF
QL
PRIALT
PA,QL,‌DSP/DO
REPAN
QL
4
DRUG CLASS
DRUG NAME
salsalate
COST-SHARING COLUMNS
QL
TENCON
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
ZEBUTAL
QL
G
G
G
ABSTRAL
PA,QL
P
NP
NP
acetaminophen-codeine QL
G
G
G
ACTIQ LOLLIPOP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
buprenorphine-naloxone sublingual PA,QL
G
G
G
butalbital compound/codeine
G
G
G
G
G
G
G
G
G
G
G
G
P
P
P
CAPITAL/CODEINE QL
P
P
P
CONZIP
P
NP
NP
ANALGESICS — OPIOID
PA,QL
apap-caff-dihydrocodeine
ascomp-codeine
AVINZA
QL
QL
QL
BELBUCA FILM
BUNAVAIL
PA,QL
PA,ST,QL
buprenorphine sublingual
PA,QL
butalbital-APAP-caff-codeine
butalbital-ASA-caff-codeine
butorphanol nasal spray
BUTRANS PATCH
QL
QL
QL
QL
QL
QL
DEMEROL
QL
P
NP
NP
DILAUDID
QL
P
NP
NP
DOLOPHINE
QL
P
NP
NP
DURAGESIC
QL
P
NP
NP
EMBEDA
QL
P
NP
NP
endocet
QL
G
G
G
G
G
G
P
NP
NP
G
G
G
fentanyl patch QL
G
G
G
FENTORA
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
endodan
EXALGO
QL
QL
fentanyl citrate lollipop
PA,QL
FIORICET/CODEINE
FIORINAL/CODEINE
HYCET
PA,QL
QL
QL
QL
hydrocodone-acetaminophen
hydrocodone-ibuprofen
QL
QL
5
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
HYSINGLA ER QL
P
P
P
IBUDONE
P
NP
NP
hydromorphone
QL
QL
P
NP
NP
PA,QL
P
NP
NP
levorphanol QL
G
G
G
LORCET
G
G
G
G
G
G
LORTAB (325mg)
G
G
G
LORTAB ELIXIR
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
P
P
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
P
P
G
G
G
KADIAN
QL
LAZANDA
QL
LORCET HD
QL
meperidine
meperitab
QL
QL
QL
methadone
QL
METHADOSE
QL
morphine sulfate ER
MS CONTIN
NORCO
QL
QL
NUCYNTA ER
NUCYNTA
OPANA
QL
QL
QL
QL
OPANA ER
OXAYDO
OXECTA
QL
QL
QL
oxycodone
QL
oxycodone-acetaminophen
oxycodone-aspirin
QL
oxycodone-ibuprofen
OXYCONTIN
QL
oxymorphone
QL
QL
QL
G
G
G
PERCOCET
QL
P
NP
NP
PERCODAN
QL
P
NP
NP
P
NP
NP
G
G
G
P
P
P
G
G
G
P
NP
NP
oxymorphone ER
PRIMLEV
QL
QL
reprexain
QL
ROXICET SOLUTION
roxicet tablet
ROXICODONE
QL
QL
QL
6
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
SYANLGOS-DC QL
P
NP
NP
tramadol
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
SUBOXONE FILM
PA,QL
SUBOXONE TABLET
SUBSYS
PA,QL
PA,ST,QL
QL
tramadol ER
QL
tramadol-acetaminophen
TYLENOL WITH CODEINE
ULTRACET
vicodin
QL
QL
ULTRAM ER
ULTRAM
QL
QL
QL
QL
vicodin ES
QL
vicodin HP
QL
VICOPROFEN
QL
XARTEMIS XR
QL
P
NP
NP
ZOHYDRO ER
PA,QL
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
XODOL
QL
XTAMPZA ER
ZAMICET
QL,ST
QL
ZOHYDRO ER
ZOLVIT
QL
QL
ZUBSOLV TABLET
PA,ST,QL
ANDROGENS — ANABOLIC ANADROL-50
PA,QL
P
NP
NP
ANDRODERM
PA,ST,QL
P
NP
NP
P
P
P
P
NP
NP
ANDROID PA,QL
P
NP
NP
androxy
G
G
G
MED
MED
NP
ANDROGEL 1.62%
ANDROGEL 1%
AVEED
PA,QL
PA,QL
PA,QL
PA,QL,‌DSP/DO
AXIRON
PA,ST,QL
P
NP
NP
danazol
QL
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
G
G
G
FIRST TESTOSTERONE CREAM
PA,ST,QL
FIRST TESTOSTERONE OINTMENT
FORTESTA
PA,ST,QL
METHITEST
PA,QL
methyltestosterone PA,QL
PA,ST,QL
7
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
TESTOSTERONE CYPIONATE INJ PA,QL
MED
MED
G
TESTOSTERONE ENANTHATE INJ PA,QL
MED
MED
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
NATESTO
PA,ST,QL
OXANDRIN
PA,QL
oxandrolone
STRIANT
TESTIM
PA,QL
PA,ST,QL
PA,ST,QL
testosterone gel
VOGELXO
PA,QL
PA,ST,QL
ANORECTAL AGENTS
ANALPRAM-HC
anucort-HC
QL
QL
ANUSOL-HC 2.5%
colocort
QL
QL
CORTENEMA
CORTIFOAM
GRx hicort
HC pram
QL
QL
QL
QL
hemorrhoidal-HC
hemril-30
QL
QL
hydrocortisone acetate suppository
hydrocortisone enema
QL
hydrocortisone-pramoxine
lidazone HC
QL
lidocaine-hydrocortisone
lidocort kit
QL
QL
QL
QL
pramcort
QL
G
G
G
PROCORT
QL
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
proctocare-HC
QL
proctocream HC
QL
PROCTOFOAM HC
procto-pak
QL
proctosol HC
QL
proctozone-HC
rectacort-HC
RECTIV
QL
QL
QL
QL
UCERIS AEROSOL QL
ANTHELMINTICS 8
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
P
P
P
NP
NP
CORLANOR QL,ST
P
NP
NP
DILATRATE-SR
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
P
P
G
G
G
P
P
P
G
G
G
G
G
G
G
G
G
ALPRAZOLAM INTENSOL
CONCENTRATE QL
P
NP
NP
alprazolam XR
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
ALBENZA
QL
BILTRICIDE
QL
STROMECTOL
QL
ANTI-ANGINAL AGENTS IMDUR
QL
QL
isochron
QL
isoditrate ER
QL
ISORDIL QL
isosorbide dinitrate
QL
isosorbide dinitrate ER
QL
isosorbide mononitrate
QL
isosorbide mononitrate ER
minitran
QL
QL
NITRO-BID
QL
NITRO-DUR
QL
nitroglycerin ER
QL
nitroglycerin patch
QL
nitroglycerin translingual spray
NITROLINGUAL SPRAY
NITROMIST SPRAY
NITROSTAT
nitro-time
RANEXA
QL
QL
QL
QL
QL
QL
ANTI-ANXIETY AGENTS
alprazolam
QL
alprazolam dispersible tablet
alprazolam ER
ATIVAN
QL
QL
QL
ST,QL
buspirone
QL
chlordiazepoxide
clorazepate
diazepam
QL
QL
QL
DIAZEPAM INTENSOL CONCENTRATE
QL
9
DRUG CLASS
DRUG NAME
hydroxyzine HCL syrup
QL
hydroxyzine HCL tablet
hydroxyzine pamoate
lorazepam
COST-SHARING COLUMNS
QL
QL
QL
LORAZEPAM INTENSOL
CONCENTRATE QL
lorazepam tablet 0.5 mg oral
meprobamate
NIRAVAM
QL
QL
oxazepam
QL
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
VALIUM
QL
P
NP
NP
VISTRIL
QL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
P
P
p
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
ACCOLATE TABLET QL
P
NP
NP
ADVAIR DISKUS
P
P
P
P
P
P
P
NP
NP
TRANXENE-T
XANAX
QL
QL
XANAX XR
QL
ANTI-ARRHYTHMICS amiodarone
QL
CORDARONE
QL
disopyramide
flecainide
QL
mexiletine
MULTAQ
QL
QL
QL
NORPACE
QL
NORPACE CR
pacerone
QL
QL
propafenone
QL
propafenone ER
QL
quinidine gluconate ER
quinidine sulfate
RYTHMOL
QL
RYTHMOL SR
TIKOSYN
QL
QL
PA,QL,‌DSP
QL
ANTI-ASTHMATIC AND BRONCHODILATOR AGENTS
ADVAIR HFA
AEROSPAN
QL
QL
QL
10
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
albuterol sulfate inhalation solutionQL
G
G
G
albuterol sulfate syrup
G
G
G
G
G
G
P
NP
NP
P
P
P
P
NP
NP
P
P
P
P
NP
NP
BREO ELLIPTA QL
P
P
P
BROVANA
P
NP
NP
G
G
G
MED
MED
NP
P
P
P
G
G
G
DALIRESP ST,QL
P
NP
NP
difil-G forte
G
G
G
P
P
P
P
NP
NP
P
NP
NP
P
P
P
FLOVENT HFA QL
P
P
P
FORADIL
P
P
P
P
P
P
G
G
G
ipratropium-albuterol inhalation
solution QL
G
G
G
levalbuterol inhalation solution
G
G
G
P
NP
NP
G
G
G
MED
MED
NP
PERFOROMIST ST,QL
P
NP
NP
PROAIR HFA
P
P
P
P
P
P
P
NP
NP
P
NP
NP
albuterol sulfate ER tablet
QL
albuterol sulfate tablet
ALVESCO
QL
QL
QL
ANORO ELLIPTA QL
ARCAPTA NEOHALER
ASMANEX
ST,QL
QL
ATROVENT HFA
QL
ST,QL
budesonide inhalation suspension
CINQAIR
QL, DSP
COMBIVENT RESPIMAT QL
cromolyn sodium concentrate
QL
QL
DULERA AEROSOL QL
DUONEB INHALATION SOLUTION
ELIXOPHYLLIN
QL
QL
FLOVENT DISKUS
QL
QL
INCRUSE ELLIPTA QL
ipratropium inhalation solution
LUFYLLIN
QL
montelukast
NUCALA
QL
PA,QL,DSP
QL
PROAIR RESPICLICK
PROVENTIL HFA
QL
ST,QL
PULMICORT FLEXHALER
ST,QL
QL
QL
QL
11
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
PULMICORT INHALATION
SUSPENSION QL
P
NP
NP
QVAR
P
P
P
SEEBRI NEOHALER
ST,QL
P
NP
NP
SEREVENT DISKUS
QL
P
P
P
P
NP
NP
P
P
P
P
P
P
SYMBICORT QL
P
P
P
THEO-24
P
P
P
G
G
G
G
G
G
QL
G
G
G
ST,QL
P
NP
NP
P
NP
NP
P
P
P
P
NP
NP
MED
MED
P
P
NP
NP
P
NP
NP
QL
SINGULAIR
QL
SPIRIVA QL
STIOLTO RESPIMAT
QL
QL
theochron
QL
theophylline ER
QL
theophylline solution
TUDORZA PRESSAIR
UTIBRON NEOHALER
VENTOLIN HFA
VOSPIRE ER
XOLAIR
ST,QL
QL
QL
PA,QL,‌DSP/DO
XOPENEX HFA ST,QL
XOPENEX INHALATION SOLUTION
QL
G
G
G
ZYFLO CR TABLET EXTENDED
RELEASE 12 HR QL
P
NP
NP
ZYFLO TABLET QL
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
G
G
G
zafirlukast
QL
ANTICOAGULANTS
ARGATROBAN INJ
ARIXTRA QL
COUMADIN
ELIQUIS
QL
QL
enoxaparin
QL
QL
G
G
G
FRAGMIN
QL
P
NP
NP
IPRIVASK
QL
P
NP
NP
jantoven
QL
G
G
G
fondaparinux
QL
LOVENOX
QL
P
NP
NP
PRADAXA
QL
P
P
P
SAVAYSA QL,ST
P
NP
NP
warfarin
QL
G
G
G
XARELTO
QL
P
P
P
12
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
ANTICONVULSANTS
APTIOM
QL
P
NP
NP
BANZEL
QL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
P
P
P
P
P
G
G
G
G
G
G
P
NP
NP
DEPAKENE SYRUP QL
P
NP
NP
DEPAKOTE DR
P
NP
NP
P
NP
NP
P
NP
NP
DIASTAT ACUDIAL QL
P
P
P
DILANTIN
P
P
P
P
P
P
P
P
P
BRIVIACT QL
carbamazepine ER
QL
carbamazepine chewable tablet
carbamazepine suspension
carbamazepine tablet
CARBATROL
CELONTIN
QL
QL
QL
QL
clonazepam dispersible tablet
clonazepam
DEPAKENE
QL
QL
QL
DEPAKOTE ER QL
DEPAKOTE SPRINKLES
QL
QL
DILANTIN INFATABS
QL
DILANTIN SUSPENSION
QL
QL
QL
divalproex DR
QL
G
G
G
divalproex ER
QL
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
KEPPRA TABLET QL
P
NP
NP
KEPPRA XR
P
NP
NP
divalproex sprinkle
epitol
QL
QL
ethosuximide
QL
ethosuximide solution
felbamate
QL
QL
felbamate suspension
QL
FELBATOL SUSPENSION
FELBATOL TABLET
QL
FYCOMPA QL
gabapentin
QL
GABATRIL QL
KEPPRA SOLUTION
QL
QL
QL
13
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
LAMICTAL ODT KIT QL
P
NP
NP
LAMICTAL ODT
P
NP
NP
LAMICTAL STARTER KIT QL
P
NP
NP
LAMICTAL XR
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
lamotrigine ODT QL
G
G
G
levetiracetam ER
G
G
G
G
G
G
G
G
G
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
P
P
G
G
G
G
G
G
G
G
G
G
G
G
POTIGA TABLET QL
P
NP
NP
QUDEXY XR
P
NP
NP
SABRIL TABLET PA,QL,‌DSP
P
NP
NP
SPRITAM
P
NP
NP
P
NP
NP
P
P
P
P
P
P
P
NP
NP
KLONOPIN
QL
LAMICTAL QL
LAMICTAL CHEWABLE TABLET
QL
QL
QL
LAMICTAL XR KIT QL
lamotrigine chewable tablet
lamotrigine ER
lamotrigine
QL
QL
levetiracetam
QL
QL
levetiracetam solution
QL
LYRICA QL
MYSOLINE
QL
NEURONTIN
QL
NEURONTIN SOLUTION
ONFI
QL
QL
oxcarbazepine
QL
oxcarbazepine suspension
OXTELLAR XR
PEGANONE
PHENYTEK
QL
QL
QL
phenytoin chewable
phenytoin ER
QL
QL
phenytoin infatabs
QL
phenytoin suspension
STAVZOR
QL
QL
ST,QL
QL
TEGRETOL
QL
TEGRETOL SUSPENSION
TEGRETOL-XR
QL
QL
QL
QL
14
DRUG CLASS
DRUG NAME
tiagabine
QL
TOPAMAX
QL
TOPAMAX SPRINKLE
topiragen
QL
QL
topiramate sprinkle
QL
TRILEPTAL SUSPENSION
TRILEPTAL TABLET
TROKENDI XR
valproic acid
QL
QL
QL
QL
valproic acid solution
valproic acid syrup
QL
QL
VIMPAT QL
ZARONTIN
QL
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
ZONEGRAN
QL
P
NP
NP
zonisamide
QL
G
G
G
ZARONTIN SOLUTION
QL
ANTIDEPRESSANTS
G
G
G
QL
P
NP
NP
ST,QL
P
NP
NP
P
NP
NP
amitriptyline oral
ANAFRANIL
APLENZIN
BRINTELLIX
QL
ST,QL
budeprion SR
QL
G
G
G
budeprion XL
QL
G
G
G
G
G
G
bupropion HCL ER (SR)
QL
G
G
G
bupropion HCL ER (XL)
QL
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
EFFEXOR XR QL
P
NP
NP
EMSAM
P
NP
NP
G
G
G
bupropion HCL QL
CELEXA
QL
citalopram
QL
citalopram solution
clomipramine
CYMBALTA
QL
QL
QL
desipramine
QL
DESVENLAFAXINE ER TABLET
doxepin
QL
duloxetine
QL
QL
escitalopram
QL
ST,QL
15
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
KHEDEZLA ST,QL
P
NP
NP
LEXAPRO
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
FETZIMA ST,QL
FETZIMA TITRATION PACK
fluoxetine
ST,QL
QL
fluoxetine delayed release
fluoxetine solution
fluvoxamine
QL
QL
fluvoxamine ER
QL
FORFIVO XL ST,QL
imipramine HCL
QL
imipramine pamoate
IRENKA
ST,QL
QL
LUVOX CR
MARPLAN
QL
QL
mirtazapine
NARDIL
QL
QL
QL
QL
nefazodone
QL
P
NP
NP
NORPRAMIN
QL
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
PROZAC WEEKLY CAPSULE
DELAYED RELEASE QL
P
NP
NP
REMERON
QL
P
NP
NP
sertraline
QL
G
G
G
SURMONTIL QL
P
NP
NP
TOFRANIL
P
NP
NP
P
NP
NP
nortriptyline
PAMELOR
PARNATE
QL
QL
QL
paroxetine
QL
paroxetine ER
PAXIL
QL
QL
PAXIL CR
QL
PEXEVA TABLET
phenelzine
PRISTIQ
QL
ST,QL
protriptyline
PROZAC
ST,QL
QL
QL
QL
TOFRANIL-PM
QL
16
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
VENLAFAXINE HCL ER TABLET ST,QL
P
NP
NP
VIIBRYD
P
NP
NP
VIIBRYD KIT ST,QL
P
NP
NP
VIVACTIL
P
NP
NP
P
NP
NP
P
NP
NP
WELLBUTRIN XL ST,QL
P
NP
NP
ZOLOFT
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
AMARYL QL
P
NP
NP
APIDRA
P
NP
NP
P
NP
NP
P
NP
NP
AVANDARYL QL
P
NP
NP
AVANDIA
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
DIABETA QL
P
NP
NP
DUETACT
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
tranylcypromine
trazodone
QL
QL
TRINTELLIX
QL,ST
venlafaxine
QL
venlafaxine ER capsule
ST,QL
QL
WELLBUTRIN
QL
WELLBUTRIN SR
QL
QL
QL
ANTIDIABETICS
acarbose
QL
ACTOPLUS MET QL
The Diabetes Program
Go to page 4 of this guide to find
out how Assurant Health Diabetes
Program members save on their
prescription drugs.
ACTOPLUS MET XR
ACTOS
QL
QL
AFREZZA
QL
QL
APIDRA SOLOSTAR
AVANDAMET
QL
QL
BYDUREON
BYETTA
QL
QL
QL
chlorpropamide
CYCLOSET
QL
QL
QL
FARXIGA QL
FORTAMET
QL,ST
glimepiride
QL
The Diabetes Program
glipizide
Go to page 4 of this guide to find
out how Assurant Health Diabetes
Program members save on their
prescription drugs.
glipizide ER
QL
G
G
G
glipizide XL
QL
G
G
G
G
G
G
QL
glipizide-metformin
QL
17
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
GLUCAGON KIT QL
P
P
P
GLUCOPHAGE
P
NP
NP
P
NP
NP
P
NP
NP
GLUCOTROL XL QL
P
NP
NP
GLUCOVANCE
P
NP
NP
GLUMETZA ST,QL
P
NP
NP
glyburide
G
G
G
GLUCAGEN
QL
QL
GLUCOPHAGE XR
GLUCOTROL
QL
QL
QL
QL
glyburide micronized
QL
G
G
G
glyburide-metformin
QL
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
INVOKAMET QL
P
P
P
JANUMET
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
NP
NP
P
P
P
P
NP
NP
glycron
QL
GLYNASE
QL
GLYSET QL
GLYXAMBI
QL
HUMALOG KWIKPEN
QL
HUMALOG MIX 50/50
QL
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 50/50 PEN
HUMALOG MIX 75/25
QL
QL
HUMALOG MIX 75/25 KWIKPEN
HUMALOG MIX 75/25 PEN
HUMALOG PEN
HUMULIN 70/30 KWIKPEN
HUMULIN N KWIKPEN
HUMULIN N PEN
QL
HUMULIN R U-500
INVOKANA
P
QL
QL
JANUMET XR
The Diabetes Program
Go to page 4 of this guide to find
out how Assurant Health Diabetes
Program members save on their
prescription drugs.
JANUVIA
QL
JENTADUETO
KAZANO
QL
QL
JARDIANCE
QL
ST,QL
KOMBIGLYZE XR
KORLYM
PA,QL,LD
QL
QL
HUMULIN 70/30 PEN
QL
QL
QL
QL
QL
QL
QL
18
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
P
P
P
P
P
P
P
P
P
P
P
G
G
G
G
G
G
G
G
G
P
NP
NP
P
P
P
P
P
P
P
P
P
P
P
P
ONGLYZA QL
P
P
P
OSENI
P
NP
NP
G
G
G
G
G
G
G
G
G
PRANDIMET QL
P
NP
NP
PRANDIN
QL
P
NP
NP
PRECOSE
QL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
RIOMET QL
P
NP
NP
STARLIX
P
NP
NP
P
P
P
P
P
P
P
NP
NP
G
G
G
P
P
P
P
P
P
P
NP
NP
TRULICITY QL
P
P
P
VICTOZA QL
P
P
P
XIGDUO
P
NP
NP
P
NP
NP
LANTUS
QL
LANTUS SOLOSTAR
LEVEMIR
QL
QL
LEVEMIR FLEXPEN
metformin
QL
QL
metformin ER
nateglinide
QL
QL
NESINA ST,QL
NOVOLOG FLEXPEN
QL
NOVOLOG MIX 70/30
QL
NOVOLOG MIX 70/30 FLEXPEN
NOVOLOG
QL
ST,QL
pioglitazone
QL
pioglitazone-glimepiride
pioglitazone-metformin
PROGLYCEM
repaglinide
QL
QL
QL
SYNJARDY QL
SYMLIN PEN
TANZEUM
QL
ST,QL
tolazamide
QL
TOUJEO SOLO
QL
TRADJENTA QL
TRESIBA FLEXTOUCH
QL
QL
QL
repaglinide-metformin
ST,QL
QL
QL
ANTIDIARRHEALS
FULYZAQ
QL
19
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
G
G
G
LOMOTIL QL
P
NP
NP
lonox
G
G
G
P
NP
NP
G
G
G
P
P
P
MED
MED
G
G
G
G
MED
MED
NP
P
P
P
EXJADE PA,QL,‌DSP
P
NP
NP
FERRIPROX
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
P
P
P
NP
NP
MED
MED
NP
ANZEMET QL
P
NP
NP
AKYNZEO
P
NP
NP
CESAMET QL
P
NP
NP
DICLEGIS
P
NP
NP
G
G
G
P
P
P
G
G
G
P
NP
NP
P
NP
NP
G
G
G
ondansetron ODT QL
G
G
G
SANCUSO
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
diphenatol
QL
diphenoxylate-atropine
lofene
QL
QL
QL
MOTOFEN
QL
opium tincture 10 mg/ml
QL
ANTIDOTES
CHEMET QL
deferoxamine mesylate
depade
QL
DESFERAL PA,QL,‌DSP/DO
EVZIO
QL
JADENU
PA,QL,DSP
LYNPARZA
NP
PA,QL,‌DSP
QL,LD
naltrexone tablet
NARCAN SPRAY
QL
RADIOGARDASE
REVIA
QL
QL
QL
VIVITROL PA,QL,‌DSP
PA,QL,‌DSP/DO
ANTIEMETICS
ST,QL
QL
dronabinol
EMEND
QL
QL
granisetron
QL
GRANISOL SOLUTION
QL
MARINOL QL
ondansetron
TIGAN
QL
QL
QL
TRANSDERM-SCOP
QL
trimethobenzamide
QL
20
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
MED
MED
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
LAMISIL QL
P
NP
NP
NOXAFIL
P
NP
NP
G
G
G
G
G
G
VARUBI
QL
ZOFRAN
QL
ZOFRAN ODT
ZUPLENZ
QL
QL
ANTIFUNGALS
BIO-STATIN CAPSULE
QL
bio-statin oral powder
QL
CRESEMBA QL
CRESEMBA INJ
QL
DIFLUCAN 150 MG
QL
DIFLUCAN SUSPENSION
QL
DIFLUCAN TABLET
(ALL OTHER STRENGTHS)
fluconazole 150 mg
QL
QL
fluconazole suspension
QL
fluconazole tablet (all other strengths)
QL
flucytosine
QL
GRIFULVIN V
QL
griseofulvin microsize suspension
griseofulvin microsize tablet
QL
griseofulvin ultramicrosize tablet
GRIS-PEG
QL
itraconazole
QL
ketoconazole
QL
QL
NYSTATIN ORAL POWDER
NYSTATIN TABLET
QL
QL
QL
QL
P
NP
NP
SPORANOX
QL
P
NP
NP
terbinafine
QL
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
ONMEL QL
VFEND
QL
voriconazole
QL
ANTIHISTAMINES
arbinoxa
QL
carbinoxamine maleate
CLARINEX
QL
QL
21
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
G
G
G
G
G
G
desloratadine ODT QL
G
G
G
DOXYTEK
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
CLARINEX REDITABS
QL
clemastine fumarate
cyproheptadine
desloratadine
QL
QL
QL
ED-CHLOR-TAN
KARBINAL ER
QL
QL
levocetirizine
PALGIC
QL
QL
QL
phenadoz suppository
QL
promethazine HCL QL
promethazine HCL suppository
QL
promethegan suppository 12.5 mg,
25 mg QL
PROMETHEGAN SUPPOSITORY 50 MG
RESPA-BR
XYZAL
QL
QL
QL
ANTIHYPERLIPIDEMICS
ADVICOR
QL
ALTOPREV
ANTARA
ST,QL
QL
atorvastatin
QL
cholestyramine light
QL
COLESTID
QL
P
NP
NP
colestipol
QL
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
MED
MED
NP
P
NP
NP
P
NP
NP
CRESTOR
QL
fenofibrate
QL
fenofibrate micronized
fenofibric acid
FENOGLIDE
FIBRICOR
QL
ST,QL
QL
fluvastatin
QL
fluvastatin ER
gemfibrozil
QL
QL
JUXTAPID
PA,ST,QL,‌DSP
KYNAMRO
PA,ST,QL,‌DSP/DO
LESCOL
ST,QL
LESCOL XL ST,QL
QL
22
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
PRAVACHOL QL
P
NP
NP
pravastatin
G
G
G
G
G
G
P
NP
NP
QUESTRAN LIGHT QL
P
NP
NP
rosuvastatin
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
LIPITOR
ST,QL
LIPOFEN
QL
LIPTRUZET
LIVALO
ST,QL
LOFIBRA
LOPID
QL
QL
QL
lovastatin
QL
LOVAZA QL
MEVACOR
QL
micronized colestipol
niacin ER
NIASPAN
QL
QL
QL
omega-3-acid ethyl esters
prevalite
QL
QUESTRAN
SIMCOR
QL
QL
QL
QL
simvastatin
TRICOR
QL
QL
TRIGLIDE
QL
QL
TRILIPIX
QL
P
NP
NP
Vascepa
QL
P
P
P
P
NP
NP
P
NP
NP
ZETIA QL
P
P
P
ZOCOR
P
NP
NP
ACCUPRIL QL
P
NP
NP
ACCURETIC
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
P
P
P
NP
NP
P
NP
NP
VYTORIN
QL
WELCHOL
QL
QL
ANTIHYPERTENSIVES
ACEON
QL
ALTACE
QL
QL
amlodipine-benazepril
amlodipine-valsartan
AMTURNIDE
ATACAND
QL
QL
QL
QL
23
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
ATACAND HCT QL
atenolol-chlorthalidone
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
AVALIDE
QL
P
NP
NP
AVAPRO
QL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
QL
G
G
G
CARDURA QL
P
NP
NP
CATAPRES
P
NP
NP
CATAPRES-TTS QL
P
NP
NP
clonidine
G
G
G
G
G
G
P
NP
NP
P
NP
NP
AZOR
ST,QL
benazepril
QL
benazepril-hydrochlorothiazide
BENICAR
QL
ST,QL
BENICAR HCT ST,QL
bisoprolol-hydrochlorothiazide
candesartan
QL
candesartan-HCTZ
captopril
QL
QL
QL
clonidine patch
CLORPRES
CORZIDE
QL
QL
QL
QL
COZAAR
QL
P
NP
NP
DEMSER
QL
P
NP
NP
P
NP
NP
P
NP
NP
DIOVAN HCT QL
P
NP
NP
doxazosin
G
G
G
DUTOPROL QL
P
NP
NP
EDARBI
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
P
P
EXFORGE HCT QL
P
P
P
fosinopril
G
G
G
DIBENZYLINE
DIOVAN
QL
ST,QL
QL
QL
EDARBYCLOR
enalapril
QL
QL
enalapril-hydrochlorothiazide
EPANED
QL
eplerenone
eprosartan
EXFORGE
QL
QL
QL
QL
QL
24
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
LOPRESSOR HCT QL
P
NP
NP
losartan
G
G
G
G
G
G
P
NP
NP
LOTENSIN HCT QL
P
NP
NP
LOTREL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
fosinopril-HCTZ
guanfacine
QL
hydralazine
HYZAAR
INSPRA
QL
QL
QL
QL
irbesartan
QL
irbesartan-HCTZ
lisinopril
QL
QL
lisinopril-hydrochlorothiazide
QL
losartan-HCTZ
LOTENSIN
MAVIK
QL
QL
QL
ST,QL
QL
methyldopa
QL
metoprolol-hydrochlorothiazide
MINIPRESS
QL
QL
minoxidil
QL
G
G
G
moexipril
QL
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
PRESTALIA QL
P
NP
NP
prazosin
QL
G
G
G
PRINIVIL QL
P
NP
NP
PRINZIDE
QL
P
NP
NP
quinapril
QL
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
TEKTURNA HCT QL
P
NP
NP
TENEX
P
NP
NP
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
perindopril
QL
QL
phenoxybenzamine
QL
quinapril-hydrochlorothiazide
ramipril
TARKA
QL
QL
TEKAMLO
QL
TEKTURNA
QL
QL
QL
QL
25
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
QL
G
G
G
TEVETEN QL
P
NP
NP
TEVETEN HCT QL
P
NP
NP
trandolapril
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
QL
P
NP
NP
ST,QL
P
NP
NP
VECAMYL ST,QL
P
NP
NP
ZESTORETIC
P
NP
NP
ZESTRIL QL
P
NP
NP
ZIAC
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
QL
P
NP
NP
CAYSTON
PA,QL,‌DSP,LD
P
NP
NP
CLEOCIN
QL
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
erythromycin-sulfisoxazole
suspension QL
G
G
G
FIRST-VANCOMYCIN
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
P
P
TENORETIC
terazosin
QL
QL
trandolapril-verapamil
TRIBENZOR
UNIRETIC
UNIVASC
QL
ST,QL
QL
QL
valsartan-HCTZ
VASERETIC
VASOTEC
QL
QL
QL
ANTI-INFECTIVE AGENTS — MISCELLANEOUS
ALINIA QL
atovaquone
BACTRIM
QL
QL
BACTRIM DS
clindamycin
QL
colistimethate sodium
COLY-MYCIN M
QL
E.S.P. suspension
FLAGYL QL
FLAGYL ER
IMPAVIDO
KETEK
QL
QL
QL
linezolid oral
MEPRON
QL
QL
metronidazole
NEBUPENT
QL
QL
QL
QL
QL
26
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
sulfamethoxazole-trimethoprim
suspension QL
G
G
G
sulfamethoxazole-trimethoprim
tablet QL
G
G
G
sulfatrim pediatric suspension
G
G
G
PRIMSOL QL
SEPTRA QL
SEPTRA DS
SIVEXTRO
QL
QL
SMZ-TMP DS
QL
sulfamethoxazole-TMP DS
QL
QL
TINDAMAX
QL
P
NP
NP
tinidazole
QL
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
ZYVOX ORAL QL
P
NP
NP
ARALEN
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
P
P
G
G
G
trimethoprim
VANCOCIN
QL
vancomycin
XIFAXAN
QL
QL
QL
ANTIMALARIALS
QL
atovaquone-proguanil
chloroquine
COARTEM
QL
QL
QL
DARAPRIM
QL
hydroxychloroquine
QL
MALARONE
QL
P
NP
NP
mefloquine
QL
G
G
G
PLAQUENIL QL
P
NP
NP
QUALAQUIN
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
QL
quinine sulfate
QL
ANTIMYASTHENIC AGENTS
MESTINON
QL
ANTIMYASTHENIC/CHOLINERGIC AGENTS
pyridostigmine bromide
QL
pyridostigmine bromide ER
QL
ANTIMYCOBACTERIAL AGENTS
ethambutol
isoniazid
QL
QL
27
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MYAMBUTOL QL
P
NP
NP
PASER PACKET QL
P
NP
NP
PRIFTIN
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
PA,QL,‌DSP
MED
MED
NP
ADCETRIS
PA,QL,‌DSP/DO
MED
MED
NP
AFINITOR
PA,QL,‌DSP
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
P
P
P
G
G
G
P
NP
NP
P
NP
NP
ARZERRA PA,QL,‌DSP/DO
MED
MED
NP
AVASTIN
MED
MED
NP
MED
MED
P
MED
MED
NP
MED
MED
NP
G
G
G
QL
G
G
G
PA,QL,‌DSP
P
NP
NP
P
NP
NP
G
G
G
CAPRELSA PA,QL,LD
P
NP
NP
CASODEX
P
NP
NP
COMETRIQ KIT PA,QL,LD
P
NP
NP
COTELLIC
P
NP
NP
CYRAMZA PA,QL,‌DSP
MED
MED
NP
DACOGEN
MED
MED
NP
MED
MED
NP
QL
pyrazinamide
RIFADIN
QL
RIFAMATE
rifampin
RIFATER
QL
QL
QL
QL
SIRTURO
QL,‌DSP
TRECATOR
QL
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
ACTIMMUNE
AFINITOR DISPERZ
PA,QL,DSP
ALECENSA QL,DSP
ALFERON N
ALKERAN
PA,QL,‌DSP
QL,‌DSP/DO
anastrozole
ARIMIDEX
QL
ST,QL
AROMASIN
QL
PA,QL,‌DSP/DO
AZACITIDINE
BELEODAQ
PA,QL,‌DSP/DO
QL,DSP/DO
BENDEKA QL,DSP
bexarotene
QL,DSP
bicalutamide
BOSULIF
CABOMETYX
QL,DSP
capecitabine
PA,QL,‌DSP
QL
QL,DSP
PA,QL,‌DSP/DO
DARZALEX INTRAVENOUS
QL,DSP/DO
28
DRUG CLASS
DRUG NAME
decitabine
PA,QL,‌DSP/DO
ELIGARD KIT
PA,QL, DSP/DO
3 RX COPAYS
WITHIN MT
MED
MED
G
MED
MED
NP
P
P
MED
MED
NP
PA,QL,‌DSP/DO
MED
MED
NP
P
NP
NP
MED
MED
NP
G
G
G
QL
P
NP
NP
DSP,QL
P
NP
NP
MED
MED
NP
P
NP
NP
MED
MED
NP
G
G
G
MED
MED
NP
MED
MED
NP
ERIVEDGE
PA,QL,‌DSP
ERWINAZE
PA,QL,‌DSP,LD
exemestane
FARESTON
FARYDAK
FASLODEX
QL
QL,‌DSP/DO
QL
FIRMAGON
PA,QL,‌DSP
flutamide
QL
FOLOTYN
PA,QL,‌DSP/DO
FUSILEV
3 RX COPAYS
OUTSIDE MT
P
EMPLICITI
FEMARA
2 RX COPAYS OR
NO COPAY
QL,DSP/DO
EMCYT QL
ERBITUX
COST-SHARING COLUMNS
QL, DSP/DO
MED
MED
NP
GILOTRIF
PA,QL,‌DSP
P
NP
NP
GLEEVEC
ST,QL,‌DSP
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
NP
P
P
P
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
P
P
NP
NP
MED
MED
NP
GAZYVA PA,QL,‌DSP/DO
GLEOSTINE
HALAVEN
QL
PA,QL,DSP/DO
HERCEPTIN
HEXALEN
PA,QL,DSP/DO
QL
HYCAMTIN CAPSULE
hydroxyurea
IBRANCE
ICLUSIG
QL
DSP,QL
PA,ST,QL,‌DSP
IMBRUVICA
PA,QL,‌DSP
INLYTA PA,QL,‌DSP
INTRON-A
PA,QL,‌DSP/DO
IRESSA QL,DSP
IXEMPRA
PA,QL,‌DSP/DO
PA,QL,‌DSP
P
NP
NP
PA,QL,‌DSP/DO
MED
MED
NP
KADCYLA PA,QL,‌DSP/DO
MED
MED
NP
KEYTRUDA
MED
MED
NP
MED
MED
NP
P
NP
NP
JAKAFI
PA,QL,‌DSP
JEVTANA
KYPROLIS
LENVIMA
PA,QL,‌DSP/DO
PA,QL,‌DSP/DO
LD,QL
29
DRUG CLASS
DRUG NAME
letrozole
QL
leucovorin calcium
LEUKERAN
QL,DSP/DO
QL
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
MED
MED
G
P
P
P
leuprolide acetate kit
PA,QL,‌DSP
MED
MED
G
LEVOLEUCOVORIN INJ
QL,DSP/DO
MED
MED
NP
P
NP
NP
MED
MED
P
P
NP
NP
P
P
P
P
NP
NP
G
G
G
P
NP
NP
G
G
G
MED
MED
NP
G
G
G
MED
MED
G
P
P
P
LONSURF
QL,DSP
LUPRON DEPOT KIT
LYSODREN
PA,QL,‌DSP/DO
QL
MATULANE
QL
MEGACE ORAL QL
megestrol acetate
QL
MEKINIST PA,QL,‌DSP
mercaptopurine
MESNEX
QL
QL,DSP/DO
methotrexate
QL,‌DSP
mitoxantrone
PA,QL,‌DSP/DO
MYLERAN
QL
P
NP
NP
QL
P
P
P
NINLARO
QL,DSP
P
NP
NP
ODOMZO
QL,DSP
P
NP
NP
MED
MED
NP
MED
MED
NP
MED
MED
NP
P
NP
NP
PORTRAZZA QL,DSP
MED
MED
NP
PROLEUKIN
MED
MED
NP
PURINETHOL QL
P
NP
NP
PURIXAN
ST,QL,DSP
P
NP
NP
RITUXAN
PA,QL,‌DSP/DO
MED
MED
NP
P
NP
NP
SPRYCEL PA,ST,QL,‌DSP
P
NP
NP
STIVARGA
P
NP
NP
P
P
P
MED
MED
NP
MED
MED
NP
P
P
P
P
NP
NP
NEXAVAR
PA,QL,‌DSP
NILANDRON
ONCASPAR
OPDIVO
PA,QL,‌DSP/DO
QL,DSP/DO
PERJETA PA,QL,‌DSP/DO
POMALYST
SOLTAMOX
PA,QL,‌DSP
PA,QL,‌DSP/DO
QL
PA,QL,‌DSP
SUTENT PA,QL,‌DSP
SYLATRON KIT
PA,QL,‌DSP/DO
SYNRIBO
PA,QL,DSP
TABLOID
QL
TAFINLAR
PA,QL,‌DSP
30
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
TAGRISSO
QL,LD
P
NP
NP
tamoxifen
QL
G
G
G
P
P
P
P
NP
NP
P
NP
NP
TARCEVA
PA,QL,‌DSP
TARGRETIN
TASIGNA
QL,DSP
PA,ST,QL,‌DSP
TEMODAR
ST,PA,QL,‌DSP
P
NP
NP
TEMODAR
ST,PA,QL,‌DSP
MED
MED
NP
G
G
G
MED
MED
NP
TREANDA PA,QL,‌DSP/DO
MED
MED
NP
TRELSTAR DEPOT
MED
MED
NP
MED
MED
NP
MED
MED
NP
G
G
G
P
NP
NP
temozolomide
TORISEL
PA,QL,‌DSP
PA,QL,‌DSP/DO
PA,QL,‌DSP/DO
TRELSTAR LA PA,QL,DSP/DO
TRELSTAR LA MIXJECT
tretinoin capsule
TREXALL
TYKERB
PA,QL,‌DSP/DO
QL
QL
P
NP
NP
QL,DSP/DO
MED
MED
NP
PA,QL,‌DSP/DO
MED
MED
NP
MED
MED
NP
PA,QL,‌DSP
UNITUXIN
VALSTAR
VANTAS KIT
PA,QL,DSP/DO
VECTIBIX
PA,QL,‌DSP/DO
MED
MED
NP
VELCADE
PA,QL,‌DSP/DO
MED
MED
NP
P
NP
NP
MED
MED
NP
VOTRIENT PA,QL,‌DSP
P
NP
NP
XALKORI
P
NP
NP
XELODA ST,PA,QL,‌DSP
P
NP
NP
XTANDI
P
NP
NP
YERVOY PA,QL,‌DSP/DO
MED
MED
NP
YONDELIS
MED
MED
NP
VENCLEXTA QL,LD
VIDAZA
PA,QL,‌DSP/DO
PA,QL,‌DSP
PA,QL,‌DSP
QL,DSP/DO
MED
MED
NP
PA,QL,‌DSP
P
NP
NP
ZOLADEX IMPLANT PA,QL,‌DSP/DO
ZALTRAP PA,QL,‌DSP/DO
ZELBORAF
MED
MED
NP
ZOLINZA
PA,QL,‌DSP
P
NP
NP
ZYDELIG
PA,QL,‌DSP
P
NP
NP
ZYKADIA
PA,QL,‌DSP/DO
P
NP
NP
ZYTIGA PA,QL,‌DSP
P
P
P
amantadine
G
G
G
ANTIPARKINSON AGENTS
QL
31
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
NP
P
P
P
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
QL
P
NP
NP
DUOPA QL,LD
P
NP
NP
ELDEPRYL QL
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
REQUIP QL
P
NP
NP
REQUIP XL QL
P
NP
NP
ropinirole
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
G
G
G
G
G
G
MED
MED
NP
G
G
G
G
G
G
APOKYN
PA,QL,‌DSP
AZILECT QL
benztropine mesylate
QL
bromocriptine mesylate
carbidopa-levodopa
QL
QL
carbidopa-levodopa dispersible
carbidopa-levodopa ER
COMTAN
NP
entacapone
MIRAPEX
QL
QL
QL
MIRAPEX ER
QL
NEUPRO PATCH
QL
PARLODEL QL
pramipexole
QL
pramipexole ER
QL
QL
ropinirole ER
QL
RYTARY QL
selegiline
QL
SINEMET CR
STALEVO
TASMAR
QL
QL
QL
tolcapone
QL
trihexyphenidyl
ZELAPAR
QL
QL
QL
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ABILIFY ST,QL
ABILIFY MAINTENA INJ
ABILIFY SOLUTION
aripiprazole
ST,QL
QL
aripiprazole solution
ARISTADA QL
chlorpromazine
clozapine
QL
QL
QL
QL
32
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
INVEGA SUSTENNA QL
MED
MED
NP
INVEGA TRINZA
MED
MED
NP
P
P
P
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
clozapine ODT QL
CLOZARIL ST,QL
compazine suppository
compro suppository
EQUETRO
QL
QL
QL
FANAPT ST,QL
FANAPT TITRATION PACK
FAZACLO
ST,QL
fluphenazine
GEODON
QL
ST,QL
haloperidol
QL
haloperidol concentrate
INVEGA
ST,QL
QL
ST,QL
QL
LATUDA QL
lithium carbonate
QL
lithium carbonate ER
LITHOBID
loxapine
QL
QL
molindone
QL
olanzapine
QL
olanzapine ODT
paliperidone
QL
QL
perphenazine
QL
prochlorperazine
quetiapine
REXULTI
QL
QL
QL
ST,QL
RISPERDAL
ST,QL
RISPERDAL CONSTA QL
RISPERDAL M
ST,QL
RISPERDAL SOLUTION
risperidone
ST,QL
QL
risperidone ODT QL
risperidone solution
SAPHRIS
ST,QL
SEROQUEL
ST,QL
QL
33
DRUG CLASS
DRUG NAME
SEROQUEL XR
thioridazine
thiothixene
QL
QL
QL
trifluoperazine
VERSACLOZ
VRAYLAR
COST-SHARING COLUMNS
QL
ST,QL
ST,QL
ziprasidone
QL
ZYPREXA ST,QL
ZYPREXA RELPREVV
ZYPREXA ZYDIS
QL
ST,QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
P
P
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
MED
MED
NP
P
NP
NP
G
G
G
G
G
G
ANTIVIRALS
abacavir
QL,‌DSP
abacavir-lamivudine-zidovudine
QL,‌DSP
G
G
G
adefovir
QL,‌DSP
G
G
G
APTIVUS
QL,‌DSP
P
P
P
ATRIPLA
QL,‌DSP
P
P
P
P
NP
NP
P
NP
NP
MED
MED
G
P
NP
NP
COMPLERA QL,‌DSP
P
P
P
COPEGUS
PA,QL,‌DSP
P
NP
NP
CRIXIVAN
QL,‌DSP
P
NP
NP
MED
MED
NP
DAKLINZA PA,QL,DSP
P
NP
NP
DESCOVY
P
NP
NP
G
G
G
P
NP
NP
P
P
P
P
NP
NP
P
P
P
P
P
P
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
acyclovir
QL
BARACLUDE
QL,‌DSP
BARACLUDE SOLUTION
cidofovir
QL,DSP
QL
COMBIVIR
QL,‌DSP
CYTOVENE
PA,QL,‌DSP/DO
QL
didanosine
EDURANT
QL,‌DSP
QL,‌DSP
EMTRIVA QL,‌DSP
EMTRIVA SOLUTION
entecavir
QL,DSP
QL,‌DSP
EPIVIR HBV
QL,DSP
EPIVIR HBV SOLUTION
EPIVIR
QL,DSP
EPIVIR SOLUTION
EPZICOM
QL,‌DSP
QL,‌DSP
QL,‌DSP
34
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
P
MED
MED
G
GENVOYA QL,DSP
P
NP
NP
HARVONI
P
P
P
HEPSERA QL,‌DSP
P
NP
NP
INTELENCE
P
NP
NP
P
NP
NP
P
P
P
P
P
P
G
G
G
G
G
G
G
G
G
LEXIVA QL,‌DSP
P
P
P
MODERIBA
P
NP
NP
G
G
G
G
G
G
P
P
P
P
NP
NP
MED
MED
P
MED
MED
NP
P
P
P
P
P
P
REBETOL PA,QL,‌DSP
P
NP
NP
RELENZA
P
NP
NP
P
NP
NP
P
NP
NP
RETROVIR SYRUP QL,DSP
P
NP
NP
REYATAZ
QL,‌DSP
P
P
P
RIBAPAK
ST,PA,QL,‌DSP
EVOTAZ
QL,‌DSP
famciclovir
FAMVIR
QL
QL
FLUMADINE
FOSCAVIR
FUZEON
QL
QL
PA,QL,‌DSP
ganciclovir
QL
PA,QL,‌DSP
INVIRASE
QL,‌DSP
QL,‌DSP
ISENTRESS
KALETRA
QL,‌DSP
QL,‌DSP
lamivudine
QL,‌DSP
lamivudine HBV
QL,DSP
lamivudine-zidovudine
ST,PA,QL,‌DSP
nevirapine
QL,‌DSP
nevirapine ER
NORVIR
QL,‌DSP
QL,DSP
QL,‌DSP
ODEFSEY
QL
PEGASYS
PA,QL,‌DSP
PEG-INTRON
PREZCOBIX
PREZISTA
PA,QL,‌DSP
QL,DSP
QL,‌DSP
QL
RESCRIPTOR
RETROVIR
QL,‌DSP
QL,‌DSP
P
NP
NP
PA,QL,‌DSP
P
P
P
RIBASPHERE TABLET 200 MG
ORAL PA,QL,‌DSP
P
P
P
RIBASPHERE TABLET 400 MG,
600 MG PA,QL,‌DSP
P
NP
NP
RIBASPHERE CAPSULE
35
DRUG CLASS
DRUG NAME
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
G
G
G
SELZENTRY QL,‌DSP
P
NP
NP
SOVALDI
P
P
P
G
G
G
G
G
G
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
TIVICAY QL,‌DSP
P
P
P
TRIUMEQ
P
P
P
P
NP
NP
P
P
P
TYBOST QL,‌DSP
P
NP
NP
TYZEKA
P
NP
NP
G
G
G
VALCYTE SOLUTION
P
P
P
VALCYTE TABLET
P
NP
NP
VALTREX
P
NP
NP
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
VIRAMUNE TABLET QL,‌DSP
P
NP
NP
VIRAMUNE XR TABLET
P
NP
NP
QL
P
NP
NP
QL,‌DSP
P
P
P
MED
MED
NP
P
P
P
P
NP
NP
P
P
P
ZIAGEN TABLET QL,‌DSP
P
NP
NP
zidovudine
G
G
G
RIBATAB
PA,QL,‌DSP
ribavirin
PA,QL,‌DSP
rimantadine
QL
PA,QL,‌DSP
stavudine capsule
stavudine solution
STRIBILD
SUSTIVA
QL,‌DSP
QL,‌DSP
QL,‌DSP
QL,‌DSP
TAMIFLU
QL
TECHNIVIE
TRIZIVIR
PA,QL,DSP
QL,‌DSP
QL,‌DSP
TRUVADA
QL,‌DSP
QL,‌DSP
valacyclovir
QL
QL
VIDEX EC
QL,‌DSP
VIDEX SOLUTION
QL,‌DSP
VIRACEPT QL,‌DSP
VIRAMUNE SUSPENSION
VIRAZOLE
VIREAD
VITEKTA
DSP
ZERIT QL,‌DSP
ZIAGEN SOLUTION
QL,‌DSP
QL,‌DSP
QL,‌DSP
VISTIDE
NP
COST-SHARING COLUMNS
QL,‌DSP
36
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
MED
MED
NP
P
NP
NP
MED
MED
NP
P
NP
NP
G
G
G
MED
MED
NP
CELLCEPT QL,DSP
P
NP
NP
CUPRIMINE
P
NP
NP
G
G
G
G
G
G
P
P
P
P
NP
NP
G
G
G
P
P
P
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
QL,‌DSP
P
NP
NP
PA,QL,‌DSP
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
P
NP
NP
MED
MED
NP
P
NP
NP
zidovudine syrup
ZOVIRAX
QL,DSP
QL
ASSORTED CLASSES
AMEVIVE
QL,DSP/DO
ASTAGRAF XL
ATGAM
QL,‌DSP
QL
AZASAN
QL
azathioprine
BENLYSTA
QL
PA,QL,‌DSP/DO
QL
cyclosporine modified
cyclosporine
QL,‌DSP
DEPEN TITRATABS
ENVARSUS XR
gengraf
QL
QL,DSP
QL,DSP
HECORIA
IMURAN
QL,‌DSP
QL
kalexate
QL
KAYEXALATE
kionex
QL,DSP
QL
QL
mycophenolate mofetil
mycophenolic acid
MYFORTIC
NEORAL
NULOJIX
QL,‌DSP
QL
QL,‌DSP
QL,DSP
QL,‌DSP/DO
PROGRAF
QL,‌DSP
RAPAMUNE
REVLIMID
SANDIMMUNE
SIMULECT
QL,DSP
QL
sodium polystyrene sulfonate
SPS SUSPENSION
SYLVANT
SYPRINE
QL
PA,QL,‌DSP
QL
QL
tacrolimus
QL,‌DSP
G
G
G
THALOMID
PA,QL,‌DSP
P
NP
NP
37
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
NP
P
NP
NP
MED
MED
P
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
bisoprolol QL
G
G
G
BYSTOLIC
P
P
P
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
INDERAL LA QL
P
NP
NP
INDERAL XL
P
NP
NP
THYMOGLOBULIN
QL
VELTASSA POWDER
XIAFLEX
QL,DSP
QL,‌DSP/DO
ZORTRESS
QL,‌DSP
BETA BLOCKERS
acebutolol
atenolol
QL
QL
BETAPACE
QL
BETAPACE AF
betaxolol
QL
QL
carvedilol
COREG
QL
QL
QL
COREG CR
CORGARD
QL
QL
QL
KERLONE
QL
P
NP
NP
labetalol
QL
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
LEVATOL QL
LOPRESSOR
QL
metoprolol succinate ER
metoprolol tartrate
nadolol
QL
propranolol
QL
propranolol ER
SECTRAL
sorine
sotalol
QL
QL
QL
QL
QL
QL
P
NP
NP
QL
P
NP
NP
TOPROL XL QL
P
NP
NP
TRANDATE
P
NP
NP
P
NP
NP
MED
MED
P
P
NP
NP
SOTYLIZE
QL
TENORMIN
QL
ZEBETA QL
BIOLOGICALS MISCELLANEOUS ADAGEN
PA,QL,‌DSP
GRASTEK
PA,QL
38
DRUG CLASS
DRUG NAME
ORALAIR
PA,QL,‌DSP
RAGWITEK
PA,QL
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
CALCIUM CHANNEL BLOCKERS ADALAT CC
afeditab
QL
QL
amlodipine
CALAN
QL
QL
CALAN SR
QL
P
NP
NP
CARDIZEM
QL
P
NP
NP
P
NP
NP
P
NP
NP
CARDIZEM LA QL
P
NP
NP
cartia XT QL
G
G
G
DILACOR XT QL
P
NP
NP
dilt-CD
G
G
G
G
G
G
CARDENE SR
QL
CARDIZEM CD
ST,QL
QL
diltiazem
QL
diltiazem CD
QL
G
G
G
diltiazem ER
QL
G
G
G
dilt-XR
QL
G
G
G
diltzac
QL
G
G
G
G
G
G
QL
P
NP
NP
matzim LA QL
G
G
G
nicardipine
QL
G
G
G
nifediac CC
QL
G
G
G
nifedical XL QL
G
G
G
nifedipine
G
G
G
QL
G
G
G
QL,‌DSP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
PROCARDIA QL
P
NP
NP
PROCARDIA XL QL
P
NP
NP
SULAR
P
NP
NP
G
G
G
felodipine
QL
ISOPTIN SR
QL
nifedipine ER
nimodipine
nisoldipine ER
nisoldipine
NORVASC
QL
QL
QL
NYMALYZE
QL
QL
taztia XT QL
39
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
BIDIL QL
P
NP
NP
CADUET QL
P
NP
NP
CAVERJECT (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
CIALIS (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
P
P
EDEX (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
ENTRESTO
P
P
P
MED
MED
G
MED
MED
NP
P
P
P
LEVITRA (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
MUSE (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
OPSUMIT PA,QL,‌DSP
P
NP
NP
P
MED
P
MED
G
NP
MED
NP
MED
G
NP
NP
NP
NP
G
STAXYN (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
STENDRA (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
TRACLEER
P
P
P
P
NP
NP
TIAZAC
QL
verapamil
QL
verapamil ER
VERELAN
QL
QL
VERELAN PM
QL
CARDIOTONICS digox
QL
digoxin
QL
LANOXIN
QL
CARDIOVASCULAR AGENTS — MISCELLANEOUS ADCIRCA ST,PA,QL,‌DSP
ADEMPAS
PA,QL,‌DSP
amlodipine-atorvastatin
PA,QL
epoprostenol
FLOLAN
PA,QL,DSP
PA,QL,‌DSP
LETAIRIS
PA,QL,‌DSP
ORENITRAM
PA,QL,‌DSP
REMODULIN
PA,QL,‌DSP
REVATIO
ST,PA,QL,‌DSP
REVATIO INTRAVENOUS
sildenafil citrate
TYVASO
QL
PA,QL,‌DSP
PA,QL,‌DSP
ST,PA,QL,‌DSP
PA,QL,‌DSP
UPTRAVI
PA,QL,LD
P
NP
NP
VELETRI
PA,QL,‌DSP
MED
MED
NP
40
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
VIAGRA (APPLIES ONLY TO PLANS WITH
ERECTILE DYSFUNCTION COVERAGE) QL
P
NP
NP
CEDAX
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
VENTAVIS
PA,QL,‌DSP
CEPHALOSPORINS
QL
cefaclor
QL
cefadroxil
cefdinir
QL
QL
cefpodoxime
cefprozil
CEFTIN
QL
QL
QL
cefuroxime
cephalexin
KEFLEX
QL
QL
QL
SPECTRACEF
SUPRAX
QL
QL
CONTRACEPTIVES
altavera
alyacen
QL
QL
amethia lo
amethia
apri
QL
QL
QL
aranelle
aubra
QL
QL
aviane
QL
azurette
balziva
BEYAZ
QL
QL
ST,QL
BREVICON
briellyn
camila
ST,QL
QL
QL
camrese
QL
camrese lo
caziant
cesia
QL
QL
QL
chateal
QL
G
G
G
cryselle
QL
G
G
G
G
G
G
cyclafem
QL
41
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
CYCLESSA ST,QL
P
NP
NP
dasetta
G
G
G
G
G
G
MED
MED
NP
MED
MED
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
FALESSA ST,QL
P
NP
NP
falmina
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
MED
MED
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
daysee
QL
QL
DEPO PROVERA INJ
QL
DEPO-SUBQ PROVERA INJ
DESOGEN
QL
ST,QL
desogestrel-ethinyl estradiol
QL
drospirenone-ethinyl estradiol
elinest
QL
emoquette
enpresse
enskyce
errin
QL
QL
QL
QL
estarylla
QL
ESTROSTEP FE
QL
FEMCON FE
ST,QL
GENERESS FE
gianvi
ST,QL
ST,QL
QL
gildagia
gildess
QL
QL
gildess FE
heather
QL
QL
IMPLANON IMPLANT 68 MG
SUBCUTANEOUS QL,DSP/DO
introvale
jencycla
jolessa
QL
QL
jolivette
junel
QL
QL
QL
junel FE
QL
QL
kariva
QL
G
G
G
kelnor
QL
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
kurvelo
larin
QL
QL
larin Fe
leena
QL
QL
42
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
MED
MED
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
MED
MED
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
NATAZIA ST,QL
P
NP
NP
necon
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
lessina
QL
levonest
QL
levonorgest-Eth Estrad 91-Day
QL
levonorgestrel-ethinyl estradiol
levora
QL
QL
LILETTA QL,DSP/DO
LOESTRIN
ST,QL
LOESTRIN FE
ST,QL
LO LOESTRIN FE
loryna
QL
LOSEASONIQUE
low-ogestrel
lutera
lyza
ST,QL
ST,QL
QL
QL
QL
marlissa
QL
medroxyprogesterone acetate INJ
microgestin
QL
microgestin Fe
QL
MINASTRIN 24 FE
MIRCETTE
ST,QL
ST,QL
MIRENA INTRAUTERINE DEVICE 20
MCG/24 HR INTRAUTERINE QL,DSP/DO
MODICON
ST,QL
mono-linyah
mononessa
myzilra
QL
QL
QL
QL
NECON 1/50
ST,QL
NECON 10/11
ST,QL
NEXPLANON IMPLANT 68 MG
SUBCUTANEOUS QL,‌DSP/DO
nora-be
QL
QL
G
G
G
norethindrone-ethinyl estradiol FE
chewable QL
G
G
G
norgestimate-eth estradiol
G
G
G
G
G
G
P
NP
NP
norethindrone
QL
norgestim-eth estrad
NORINYL ST,QL
QL
QL
43
DRUG CLASS
DRUG NAME
NOR-QD
nortrel
ST,QL
QL
NUVARING
ocella
COST-SHARING COLUMNS
ST,QL
QL
orsythia
QL
ORTHO EVRA PATCH
ORTHO MICRONOR
ORTHO-NOVUM
ST,QL
ST,QL
ST,QL
ORTHO TRI-CYCLEN
ST,QL
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ST,QL
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON
ST,QL
ST,QL
ST,QL
ST,QL
PARAGARD INTRAUTERINE COPPER
INTRAUTERINE DEVICE INTRAUTERINE
philith
QL
pimtrea
QL
pirmella
portia
QL
QL
QL
previfem
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
P
P
P
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
quasense
QL
G
G
G
reclipsen
QL
G
G
G
ST,QL
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
Quartette
SAFYRAL
ST,QL
SEASONIQUE
ST,QL
SKYLA INTRAUTERINE DEVICE 13.5 MG
INTRAUTERINE QL,‌DSP/DO
solia
QL
sprintec
sronyx
syeda
QL
QL
QL
tilia Fe
QL
tri-estarylla
QL
tri-legest Fe
tri-linyah
trinessa
QL
QL
QL
TRI-NORINYL
tri-previfem
ST,QL
QL
44
DRUG CLASS
DRUG NAME
tri-sprintec
QL
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
trivora
QL
G
G
G
velivet
QL
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
dexamethasone intensol
concentrate QL
P
NP
NP
dexamethasone tablet
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
vestura
viorele
QL
QL
vyfemla
wera
QL
QL
wymzya Fe
QL
xulane patch
YASMIN
YAZ
QL
ST,QL
ST,QL
zarah
QL
zenchent
QL
zenchent Fe
zeosa
zovia
QL
QL
QL
CORTICOSTEROIDS
asmalpred
QL
asmalpred plus
baycadron
QL
budesonide ER
CORTEF
QL
QL
QL
dexamethasone elixir
DEXPAK
QL
QL
QL
ENTOCORT EC
FLO-PRED
ST,QL
QL
fludrocortisone
QL
hydrocortisone tablet
MEDROL PAK
QL
QL
MEDROL TABLET
QL
methylprednisolone pak
QL
methylprednisolone tablet
MILLIPRED
QL
MILLIPRED DP
QL
ORAPRED ODT QL
QL
45
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
prednisolone sodium phosphate
solution QL
G
G
G
prednisolone solution
G
G
G
ORAPRED SOLUTION
QL
PEDIAPRED SOLUTION
QL
QL
G
G
G
PREDNISONE INTENSOL
CONCENTRATE QL
P
NP
NP
prednisone
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
prednisolone syrup
QL
prednisone pak
QL
PRELONE SYRUP
RAYOS
QL
QL
ST,QL
UCERIS
QL
VERIPRED
QL
COUGH/COLD/ALLERGY
acetylcysteine solution
ALBATUSSIN
QL
QL
ALBATUSSIN NN LIQUID
benzonatate
QL
QL
bromfed DM syrup
QL
CARBAPEH 12 Ped SUSPENSION
CARBAPHEN PED SUSPENSION
cheratussin AC
QL
QL
QL
G
G
G
CLARINEX-D 12 Hour
QL
P
NP
NP
CLARINEX-D 24 Hour
QL
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
cheratussin DAC solution
CPB WC LIQUID
DECON-A ELIXIR
QL
QL
DECON-G LIQUID
QL
dimetane DX syrup
EXACTUSS LIQUID
QL
gani-tuss NR liquid
GILPHEX TR
QL
QL
QL
GILTUSS LIQUID
QL
GILTUSS PED-C LIQUID
GILTUSS TR
QL
QL
guaiatussin AC syrup
QL
guaifenesin AC syrup
QL
guaifenesin DAC syrup
QL
QL
46
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
TGQ 30PSE/3BRM/15DM SYRUP QL
P
NP
NP
TRICODE AR LIQUID
P
NP
NP
guaifenesin-codeine solution
guaifenesin-codeine syrup
guiatuss AC syrup
HISTEX AC
QL
QL
QL
QL
HYCOFENIX
QL
hydrocod Polst-CPM polst ER liquid
hydrocodone-homatropine syrup
QL
hydrocodone-homatropine tablet
hydromet syrup
QL
QL
QL
HYPERSAL NEBULIZATION SOLUTION
iophen C-NR liquid
QL
m-clear WC solution
myci-GC solution
QL
QL
mytussin AC syrup
QL
mytussin DAC solution
QL
nebusal nebulization solution
NEOTUSS PLUS LIQUID
NEOTUSS-D LIQUID
QL
QL
QL
NORTUSS-EX LIQUID
QL
PEDIATEX TDM SUSPENSION
PHENYLHISTINE DH LIQUID
QL
QL
promethazine-codeine syrup
promethazine-DM syrup
QL
QL
pseudoeph-bromphen-DM syrup
pulmosal nebulization solution
relcof C solution
RELHIST
QL
QL
QL
QL
RESCON-JR
RESCON-MX
QL
QL
REZIRA SOLUTION
robafen AC syrup
QL
QL
romilar AC solution
SEMPREX-D
QL
QL
sodium chloride nebulization
solution QL
TESSALON PERLES
QL
TGQ 30PSE/150GFN/15DM SYRUP
QL
QL
QL
47
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
TUSNEL PED-C SYRUP QL
P
NP
NP
TUSSICAPS
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
ABSORICA QL
P
NP
NP
ACANYA QL
P
NP
NP
acitretin
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
ALDARA QL
P
NP
NP
aliclen
G
G
G
TUSNEL QL
tussigon
QL
QL
TUSSIONEX
QL
TUSSO-DMR
QL
TUZISTRA XR
QL
virtussin A/C solution
VITUZ SOLUTION
QL
Z-COF I SUSPENSION
ZONATUSS
QL
QL
QL
DERMATOLOGICALS
QL
ACLOVATE
acticin
QL
QL
ACTICLATE
QL
acyclovir ointment
ACZONE
QL
QL
adapalene
QL
AKNE-MYCIN
QL
ALA QUIN CREAM
alclometasone
ALCORTIN A
QL
QL
QL
QL
P
NP
NP
QL
G
G
G
ALTABAX OINTMENT QL
P
NP
NP
ALUVEA
P
NP
NP
ALOQUIN
QL
alphatrex
QL
amcinonide
QL
G
G
G
amnesteem
QL
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
ANACAINE
QL
antifungal cream
apexicon
QL
APEXICON E
QL
QL
48
DRUG CLASS
DRUG NAME
ATRALIN
ST,QL
avar cleanser
QL
AVAR LS CLEANSER LIQUID
AVAR LS PAD
AVAR PAD
QL
QL
QL
avar-e emollient cream
avar-e green
QL
QL
AVAR-E LS CREAM
avita
COST-SHARING COLUMNS
QL
QL
AZELEX
QL
BACTROBAN
QL
baza antifungal cream
BENSAL HP
QL
BENZACLIN
QL
BENZAMYCIN
QL
QL
benzepro foam
QL
benzepro short contact foam
BENZIQ
QL
QL
BENZIQ LS
QL
benzoyl peroxide external
QL
benzoyl peroxide-erythromycin
QL
betamethasone dipropionate aug
betamethasone dipropionate
betamethasone valerate
beta-val
BP 10-1
QL
QL
QL
BP cleansing wash emulsion
BP foam external
BPO EXTERNAL
calcipotriene
QL
QL
QL
QL
CAPEX SHAMPOO
CARAC
QL
QL
QL,ST
carmol 40
QL
carrington antifungal cream
CEM-UREA
QL
CENTANY QL
cerisa wash emulsion
cerovel
QL
QL
QL
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
49
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
clindacin-P QL
G
G
G
CLINDAGEL
P
NP
NP
G
G
G
G
G
G
clindamycin phos-benzoyl perox
external QL
G
G
G
clobetasol propionate
G
G
G
G
G
G
clobetasol propionate emulsion
foam QL
G
G
G
clobetasol propionate foam
QL
G
G
G
clobetasol propionate spray
QL
G
G
G
P
NP
NP
G
G
G
P
NP
NP
CONDYLOX EXTERNAL QL
P
NP
NP
CORDRAN LOTION
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
P
P
P
P
P
P
NP
NP
P
NP
NP
DERMA-SMOOTHE/FS BODY OIL QL
P
NP
NP
DERMA-SMOOTHE/FS SCALP OIL
P
NP
NP
DERMASORB AF KIT QL
P
NP
NP
DERMASORB XM KIT
P
NP
NP
DERMATOPP QL
P
NP
NP
dermazene
G
G
G
P
NP
NP
ciclodan
QL
ciclopirox
claravis
QL
QL
claris clarifying wash emulsion
clenia
QL
QL
CLEOCIN-T QL
clindacin ETZ
clindamax
QL
QL
QL
clindamycin external
QL
QL
clobetasol propionate E
CLOBEX
QL
QL
clotrimazole-betamethasone
CNL8 NAIL KIT
QL
CORDRAN TAPE
cormax
QL
cortalo
QL
CORTANE-B
QL
QL
QL
CORTISPORIN CREAM
QL
CORTISPORIN OINTMENT
CUTIVATE
DENAVIR
QL
QL
QL
QL
DESONATE
QL
QL
QL
QL
50
DRUG CLASS
DRUG NAME
desonide
COST-SHARING COLUMNS
QL
DESOWEN
QL
desoximetasone
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
G
G
G
G
G
G
DIFFERIN 0.1%
QL
P
NP
NP
DIFFERIN 0.3%
QL
P
P
P
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
8-MOP QL
P
NP
NP
ELIDEL
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
P
P
P
diclofenac Sodium 3% transdermal
diflorasone
QL
DIPROLENE
QL
DIPROLENE AF
DOVONEX
QL
QL
DRITHO-CRÈME HP
DUAC
QL
QL
econazole
QL
ECOZA FOAM
EFUDEX
QL
QL
PA,QL
ELIMITE
QL
ELOCON
QL
EMLA QL
ENSTILAR
EPIDUO
QL
QL
EPIDUO FORTE
QL
QL
EPIFOAM
QL
P
NP
NP
ERTACZA
QL
P
NP
NP
ery pad
QL
G
G
G
ERYGEL
QL
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
erythromycin external
erythromycin pad
EURAX
QL
EVOCLIN
QL
EXELDERM
exoderm
QL
QL
EXTINA FOAM
FABIOR
QL
QL
FINACEA QL
FLECTOR PATCH
QL
QL
QL
51
DRUG CLASS
DRUG NAME
fluocinolone acetonide
COST-SHARING COLUMNS
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
fluocinolone acetonide body oil
QL
G
G
G
fluocinolone acetonide scalp oil
QL
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
fluocinonide
QL
fluocinonide-E
FLUOROPLEX
fluorouracil
QL
QL
QL,‌DSP/DO
fluticasone propionate external
gentamicin sulfate
QL
GORDOFILM SOLUTION
GORDONS UREA
QL
QL
grafco silver nit applicator
halobetasol propionate
HALOG
QL
QL
QL
QL
HALOTIN
QL
hydrocortisone
QL
hydrocortisone ace-pramoxine
cream QL
hydrocortisone acetate-aloe
QL
hydrocortisone butyr lipo base
hydrocortisone butyrate
QL
hydrocortisone-iodoquinol
hydrocortisone valerate
hygel
QL
HYLIRA QL
hypercare
QL
imiquimod
isovate
QL
QL
JUBLIA QL
KENALOG EXTERNAL
KERALAC
QL
KERFOAM 42
QL
ketoconazole
ketodan foam
KLARON
QL
QL
QL
QL
KP miconazole nitrate
kuric
QL
lactic acid external
latrix
QL
QL
QL
QL
QL
QL
52
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
LAVARE WOULD WASH EXTERNAL QL
P
NP
NP
LEVULAN KERASTICK
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
QL
lidocaine HCL external
lidocaine patch
QL
lidocaine-prilocaine
LIDODERM PATCH
lindane external
lokara
QL
QL
QL
LOTROSONE
LUZU
QL
QL
LOPROX
LUXIQ
QL
QL
LOCOID LIPOCREAM
LOCOID
QL
QL
QL
QL
mafenide acetate packet
malathion external
METROCREAM
QL
QL
QL
P
NP
NP
QL
P
NP
NP
metronidazole external cream,
lotion QL
G
G
G
METVIXIA QL
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
METROGEL QL
METROLOTION
mexar wash
micaderm
MICATIN
QL
QL
QL
miconazole nitrate
micro guard
MIRVASO
QL
QL
QL
mometasone furoate
mupirocin external
myorisan
NAFTIN
QL
QL
QL
QL
G
G
G
NATROBA EXTERNAL
QL
P
NP
NP
neosporin AF cream
QL
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
naftifine
QL
NIZORAL SHAMPOO
NORITATE
QL
NOVACORT
QL
QL
53
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
NUCORT QL
P
NP
NP
NUOX EXTERNAL QL
P
NP
NP
nuzole
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
OVIDE EXTERNAL QL
P
NP
NP
OXISTAT
P
NP
NP
OXSORALEN ULTRA QL
P
NP
NP
PANDEL
P
NP
NP
P
P
P
G
G
G
QL
nyamyc powder
nystatin
QL
QL
nystatin-triamcinolone
nystop powder
OLUX
QL
QL
QL
OLUX-E
QL
OPTASE
QL
ORACEA ORAL
OVACE
QL
QL
OVACE PLUS
QL
QL
QL
PANRETIN
QL
pedi-dri powder
QL
P
NP
NP
PENNSAID SOLUTION
ST,QL
P
NP
NP
permethrin external
QL
G
G
G
P
P
P
P
NP
NP
P
NP
NP
PENLAC
PICATO
QL
QL
PLEXION CLOTH
ST,QL
PLEXION CREAM/LIQUID/LOTION
QL
PLIAGLIS
QL
P
NP
NP
podactin
QL
G
G
G
PODOCON EXTERNAL QL
P
NP
NP
podofilox external
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
P
P
G
G
G
PRAMOSONE
QL
PRAMOSONE E
QL
prascion emulsion
prascion fc pad
prednicarbate
prudoxin
PA,QL
QL
QL
QL
prascion ra cream
PROTOPIC
QL
QL
QL
54
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
QUTENZA PATCH KIT QL
P
NP
NP
RA antifungal cream
G
G
G
G
G
G
RE 10 wash
QL
QL
RE 40
QL
G
G
G
RE SA
QL
G
G
G
RE urea 40
QL
G
G
G
RE urea 50
QL
G
G
G
REGENECARE EXTERNAL QL
P
NP
NP
REGRANEX EXTERNAL
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
SALVAX DUO PLUS KIT QL
P
NP
NP
SANTYL
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
QL
remedy antifungal cream
remeven
QL
RETIN-A MICRO
RETIN-A
revina
QL
QL
QL
QL
RIAX FOAM
ST,QL
rosadan external
QL
rosaderm emulsion
QL
rosanil cleanser emulsion
salacyn
QL
QL
Salicylic acid external
SALKERA FOAM
QL
QL
QL
scalacort
QL
SE 10-5 SS
SEB-PREV
QL
QL
seb-prev wash
QL
secura antifungal cream
QL
secura antifungal extra thick cream
selenium sulfide lotion
SELRX SHAMPOO
SERNIVO
QL
QL
QL
SILVADENE CREAM
QL
silver sulfadiazine cream
SKLICE EXTERNAL
QL
QL
SM antifungal miconazole cream
QL
QL
55
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
P
NP
NP
P
NP
NP
SOOLANTRA QL
P
NP
NP
soothe & cool INZO
antifungal cream QL
G
G
G
SORIATANE
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
sulfacetamide sodium liquid 10%
external QL
G
G
G
sulfacetamide sodium-sulfur
external QL
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
P
P
P
P
P
G
G
G
sodium hyaluronate external
QL,DSP/DO
sodium sulfacetamide shampoo
SODIUM SULFACETAMIDE WASH
SOLARAZE 3% TRANSDERMAL
QL
QL
QL
SORILUX FOAM
sotret
QL
QL
ST,QL
SSD AF cream
SSD cream
QL
QL
sulfacetamide sodium 10% (cleans)
sulfacetamide sodium external
sulfacleanse 8/4 suspension
SULFAMYLON
QL
SULFOAM SHAMPOO
suphera cream
SYNALAR
QL
QL
QL
SYNERA PATCH
TACLONEX
QL
QL
tacrolimus ointment
TARGRETIN
TAZORAC
PA,QL,‌DSP
QL
TBC aerosol
QL
PA,QL
QL
QL
QL
P
NP
NP
TEMOVATE E
QL
P
NP
NP
TERSI FOAM
QL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
TEMOVATE
TEXACORT
QL
QL
thermazene
TL urea
TOLAK
QL
QL
QL
TOPICORT
QL
topisulf cream
QL
tretinoin external
QL
56
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
ULESFIA EXTERNAL QL
P
NP
NP
ULTRAVATE
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
VECTICAL QL
P
NP
NP
VELTIN
P
NP
NP
P
NP
NP
VEREGEN OINTMENT QL
P
NP
NP
versiclear LOTION 25-1% EXTERNAL QL
G
G
G
virti-sulf cream
G
G
G
QL
G
G
G
VOLTAREN GEL QL
P
P
P
VUSION
P
NP
NP
P
NP
NP
WESTCORT QL
P
NP
NP
XERAC AC
P
NP
NP
P
NP
NP
tretinoin microsphere external
TRETIN-X
ST,QL
triamcinolone acetonide
QL
triamcinolone aerosol spray
TRIANEX
u-Cort
QL
QL
TRI-CHLOR LIQUID
triderm
QL
QL
QL
QL
U-kera E
QL
QL
UMECTA QL
UMECTA PD
QL
URAMAXIN FOAM
urea external
QL
QL
urea hydrating foam
QL
urea in zn undecyl-lactic acid
UREA Nail KIT 40 & 0.2%
urea nail
urea-C40
QL
QL
QL
VALCHLOR
PA,QL,‌DSP
VANOXIDE-HC LOTION
vasolex
QL
QL
ST,QL
VERDESO
vitazol
QL
QL
UREA Nail STICK 50%
UTOPIC
QL
VYTONE
QL
QL
QL
XERESE QL
QL
QL
57
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
XOLEGEL QL
X-viate
QL
XYLOCAINE SOLUTION
QL
ZACLIR CLEANSING LOTION
zenatane
QL
zencia liquid
QL
ZITHRANOL SHAMPOO
ZITHRANOL-RR CREAM
ZONALON
QL
QL
QL
QL
ZOVIRAX CREAM
QL
ZOVIRAX OINTMENT
QL
ZYCLARA QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
DIAGNOSTIC PRODUCTS
G
G
G
BRAND BLOOD GLUCOSE CALIBRATION
SOLUTION (PREFERRED) QL
BRAND BLOOD GLUCOSE CALIBRATION
SOLUTION (NON-PREFERRED) QL
P
P
P
P
NP
NP
EXACTECH
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
NP
NP
MED
MED
NP
P
P
P
P
P
P
P
P
P
PRECISION PCX PLUS TEST STRIP IN
VITRO QL
P
P
P
PRECISION PCX STRIP IN VITRO
P
P
P
PRECISION POINT OF CARE TEST STRIP
IN VITRO QL
P
P
P
PRECISION QID TEST STRIP IN VITRO
blood glucose calibration solution
The Diabetes Program
Go to page 4 of this guide to find
out how Assurant Health Diabetes
Program members save on their
prescription drugs.
QL
QL
EXACTECH R-S-G
QL
FreeStyle InsuLinx Test STRIP IN
VITRO QL
FreeStyle Lite Test STRIP IN VITRO
FreeStyle Test STRIP IN VITRO
QL
QL
GLUCOSE TEST STRIP (ANY OTHER
BRAND NAME) ST,QL
Hyskon SOLUTION 32-10%
QL
ONETOUCH TEST STRIP IN VITRO
QL
ONETOUCH ULTRA BLUE STRIP IN VITRO
ONETOUCH VERIO STRIP IN VITRO
QL
QL
QL
P
P
P
PRECISION SOF-TACT TEST STRIP IN
VITRO QL
P
P
P
PRECISION XTRA BLOOD GLUCOSE
STRIP IN VITRO QL
P
P
P
MED
MED
P
P
P
P
QL
THYROGEN SOLUTION RECONSTITUTED
1.1 MG INTRAMUSCULAR QL,‌DSP/DO
DIGESTIVE AIDS
CREON
QL
58
DRUG CLASS
DRUG NAME
PANCREAZE
COST-SHARING COLUMNS
ST,QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
PERTZYE
ST,QL
P
NP
NP
SUCRAID
QL
P
NP
NP
ULTRESA ST,QL
P
NP
NP
VIOKASE
P
NP
NP
P
P
P
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
ST,QL
ZENPEP QL
DIURETICS
acetazolamide
QL
acetazolamide ER
ALDACTAZIDE
ALDACTONE
amiloride
QL
QL
QL
QL
amiloride-hydrochlorothiazide
bumetanide
QL
chlorothiazide
DEMADEX
DIAMOX
QL
QL
QL
DIURIL QL
DYAZIDE
QL
DYRENIUM
EDECRIN
QL
QL
furosemide
QL
hydrochlorothiazide
indapamide
INTROL
QL
QL
KEVEYIS
LASIX
QL
QL,LD
QL
MAXZIDE
QL
MAXZIDE-25
QL
methazolamide
metolazone
MICROZIDE
NEPTAZANE
QL
QL
QL
QL
spironolactone
QL
spironolactone-HCTZ
torsemide
QL
triamterene-HCTZ
QL
QL
QL
59
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
MED
MED
NP
P
NP
NP
MED
MED
P
G
G
G
MED
MED
NP
ATELVIA QL
P
P
P
BINOSTO
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
NP
P
NP
NP
BUPHENYL TABLET PA,QL,‌DSP
P
P
P
cabergoline
G
G
G
ZAROXOLYN
QL
ENDOCRINE AND METABOLIC AGENTS — MISCELLANEOUS
ACTHAR HP PA,QL,‌DSP/DO
ACTONEL QL
ALDURAZYME
alendronate
PA,QL,‌DSP
QL
AMMONUL SOLUTION INTRAVENOUS
QL
ST,QL
BONIVA ORAL QL
BONIVA INJ
BRAVELLE
QL,‌DSP/DO
PA,QL,‌DSP
BUPHENYL POWDER
PA,QL,‌DSP
QL
G
G
G
QL
G
G
G
PA,QL,‌DSP
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
P
NP
NP
MED
MED
G
P
NP
NP
G
G
G
P
P
P
P
NP
NP
P
NP
NP
G
G
G
desmopressin ace spray refrig
solution nasal QL
G
G
G
desmopressin acetate spray
solution nasal QL
G
G
G
G
G
G
MED
MED
NP
MED
MED
P
P
P
P
MED
MED
P
MED/P
MED/P
P
calcitonin (salmon) nasal solution
calcitriol oral
CARBAGLU
CARNITOR
QL
CARNITOR SF
CETROTIDE
CHOLBAM
NP
QL
PA,QL,‌DSP
PA,QL,LD
chorionic gonadotropin
CLOMID
QL
PA,QL,‌DSP
QL
clomiphene citrate
CYSTADANE
QL
QL,‌DSP
DDAVP SOLUTION
QL
DDAVP TABLET QL
desmopressin ace rhinal tube nasal
desmopressin acetate tablet
EGRIFTA
PA,QL,‌DSP
ELAPRASE
EVISTA
PA,QL,‌DSP
QL
FABRAZYME
PA,QL,‌DSP/DO
FOLLISTIM AQ
PA,QL,‌DSP
QL
QL
60
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
NP
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
NP
MED
MED
NP
MED
MED
NP
MED/P
MED/P
P
G
G
G
MED
MED
G
MED
MED
P
MED
MED
NP
P
P
P
G
G
G
MED
MED
NP
MED
MED
NP
MED
MED
P
MED
MED
NP
P
NP
NP
MED
MED
NP
G
G
G
MYALEPT PA,QL,‌DSP
MED
MED
NP
MYOZYME
MED
MED
NP
MED
MED
P
MED
MED
NP
MED/P
MED/P
P
MED
MED
NP
MED
MED
NP
MED
MED
G
MED
MED
NP
P
P
P
MED
MED
NP
MED
MED
G
FORTEO
PA,QL,‌DSP
FOSAMAX PLUS D
FOSAMAX
QL
QL
GANIRELIX ACETATE
GANITE
PA,QL,‌DSP
QL
GENOTROPIN
GONAL-F
PA,QL,‌DSP
PA,QL,‌DSP
HUMATROPE PA,QL,‌DSP
ibandronate oral
ibandronate inj
INCRELEX
QL
QL,‌DSP/DO
PA,QL,‌DSP/DO
KANUMA QL,LD
KUVAN
PA,QL,‌DSP
levocarnitine
LUMIZYME
QL
PA,QL,‌DSP
LUPANETA PACK
PA,QL,‌DSP
LUPRON DEPOT-PED KIT
MENOPUR
PA,QL,‌DSP/DO
PA,QL,‌DSP
MIACALCIN NASAL SOLUTION
QL
MIACALCIN SOLUTION INJECTABLE
minirin solution nasal
QL
PA,QL,‌DSP
NAGLAZYME
PA,QL,‌DSP
NATPARA INJ
PA,QL,DSP
NORDITROPIN
NOVAREL
PA,QL,‌DSP
PA,QL,‌DSP
NUTROPIN AQ, NUTROPIN
PA,QL,‌DSP
octreotide acetate injection
OMNITROPE
ORFADIN
QL
PA,QL,‌DSP
PA,QL,‌DSP
OVIDREL PA,QL,‌DSP
pamidronate inj
QL,‌DSP/DO
paricalcitol oral
QL
PA,QL,‌DSP/DO
G
G
G
PA,QL,‌DSP
MED
MED
NP
PROLIA PA,QL,‌DSP/DO
MED
MED
NP
P
NP
NP
MED
MED
NP
PREGNYL
RAVICTI
PA,QL,‌DSP
RECLAST PA,QL,‌DSP/DO
61
DRUG CLASS
DRUG NAME
REPRONEX PA,QL,‌DSP
risedronate
QL
ROCALTROL ORAL
SAIZEN
QL
PA,QL,‌DSP
SAMSCA
PA,QL,‌DSP,LD
SANDOSTATIN
PA,QL,‌DSP/DO
SANDOSTATIN LAR DEPOT
SENSIPAR
PA,QL,‌DSP
serophene
QL
SEROSTIM
PA,QL,‌DSP
SIGNIFOR
PA,QL,LD
SIGNIFOR LAR
SKELID
PA,QL,‌DSP/DO
LD,PA,QL
QL
sodium phenylbutyrate
SOMATULINE DEPOT
QL,‌DSP
PA,QL,‌DSP/DO
SOMAVERT PA,QL,‌DSP
STIMATE SOLUTION NASAL
STRENSIQ
PA,QL,‌DSP
QL,LD
SUPPRELIN LA KIT
PA,QL,‌DSP/DO
SYNAREL QL
TEV-TROPIN
PA,QL,‌DSP
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
NP
G
G
G
P
NP
NP
MED
MED
NP
P
P
P
MED
MED
NP
MED
MED
NP
P
NP
NP
G
G
G
MED
MED
NP
MED
MED
NP
MED
MED
NP
P
NP
NP
G
G
G
MED
MED
NP
MED
MED
NP
P
NP
NP
MED
MED
NP
MED
MED
P
P
NP
NP
MED
MED
NP
VIADUR
QL,DSP/DO
MED
MED
NP
VIMIZIM
PA,QL,‌DSP
MED
MED
P
P
P
P
MED
MED
NP
P
P
P
MED
MED
NP
ZEMPLAR ORAL QL
P
NP
NP
zoledronic acid
G
G
G
ZOMETA PA,QL,‌DSP/DO
MED
MED
NP
ZOMACTON INJ
MED
MED
NP
MED
MED
NP
ACTIVELLA QL
P
NP
NP
ALORA
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
VISTOGARD
XGEVA
QL
PA,QL,‌DSP/DO
XURIDEN
QL,LD
ZEMPLAR INTRAVENOUS
ZORBTIVE
QL
PA,QL,‌DSP/DO
PA,QL,DSP
PA,QL,‌DSP
ESTROGENS
QL
ANGELIQ
QL
CENESTIN
QL
CLIMARA QL
62
DRUG CLASS
DRUG NAME
CLIMARA PRO
COMBIPATCH
covaryx
COST-SHARING COLUMNS
QL
QL
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
G
G
G
G
G
G
DIVIGEL
QL
P
NP
NP
DUAVEE
QL
P
P
P
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
covaryx HS
EEMT
QL
QL
EEMT HS
QL
ELESTRIN
QL
ENJUVIA QL
essian H.S. table 0.625-1.25 mg oral
essian table 1.25-2.5 mg oral
est estrogens-methyltest
QL
QL
QL
est estrogens-methyltest DS
QL
G
G
G
est estrogens-methyltest HS
QL
G
G
G
ESTRACE TABLET QL
P
NP
NP
ESTRADERM
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
QL
estradiol patch
estradiol tablet
QL
QL
estradiol-norethindrone acet
ESTROGEL
QL
QL
ESTRASORB
QL
P
NP
NP
estropipate
QL
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
PREMARIN TABLET QL
P
P
P
PREMPHASE
P
P
P
P
P
P
P
P
P
EVAMIST QL
FEMHRT LOW DOSE
QL
MENEST QL
MENOSTAR
QL
methyltest-est estrogens
QL
methyltest-est estrogens HS
mimvey
QL
MINIVELLE
ortho-est
PREFEST
QL
QL
QL
PREMPRO
QL
QL
VIVELLE-DOT
QL
QL
63
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
CIPRO ORAL QL
P
NP
NP
CIPRO XR
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
FLUOROQUINOLONES
QL
ciprofloxacin oral
QL
ciprofloxacin-ciproflox HCL ER
FACTIVE
QL
QL
LEVAQUIN ORAL
QL
G
G
G
NOROXIN
QL
P
NP
NP
ofloxacin
QL
G
G
G
ACTIGALL QL
P
NP
NP
alosetron
G
G
G
AMITIZA QL
P
P
P
APRISO
P
P
P
P
P
P
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
P
P
P
P
NP
NP
MED
MED
NP
P
NP
NP
G
G
G
P
P
P
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
P
P
P
P
P
P
P
NP
NP
MED
MED
NP
G
G
G
P
NP
NP
G
G
G
levofloxacin oral
QL
GASTROINTESTINAL AGENTS — MISCELLANEOUS
PA,QL
QL
ASACOL HD
QL
AZULFIDINE
ST,QL
AZULFIDINE ENTAB
ST,QL
balsalazide disodium capsule
QL
calcium acetate (phos binder)
calcium acetate oral capsule
QL
QL
CANASA QL
CHENODAL
QL
CIMZIA PA,QL,‌DSP
COLAZAL
ST,QL
cromolyn sodium concentrate oral
DELZICOL
QL
DIPENTUM
ELIPHOS
ST,QL
QL
ENTYVIO
enulose
QL
PA,QL,‌DSP/DO
QL
FOSRENOL CHEWABLE
QL
FOSRENOL POWDER PACKET
QL
GASTROCROM CONCENTRATE ORAL QL
GATTEX KIT
generlac
GIAZO
PA,QL,‌DSP/DO
QL
ST,QL
lactulose encephalopathy
QL
64
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
P
P
P
P
P
P
NP
NP
G
G
G
G
G
G
metoclopramide ODT QL
G
G
G
METOZOLV ODT
P
NP
NP
P
P
P
P
NP
NP
PENTASA QL
P
P
P
PHOSLO
P
NP
NP
PHOSLYRA QL
P
P
P
REGLAN
P
NP
NP
P
P
P
P
P
P
MED
MED
NP
P
NP
NP
P
P
P
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
G
MED
MED
G
MED
MED
G
MED
MED
NP
MED
MED
G
MED
MED
NP
MED
MED
G
G
G
G
LIALDA QL
LINZESS
QL
LOTRONEX
PA,QL
mesalamine enema
metoclopramide
MOVANTIK
OCALIVA
QL
QL
QL
QL
QL,ST, DSP
QL
QL
RELISTOR
PA,QL
RELISTOR KIT
REMICADE
PA,QL
PA,QL,‌DSP/DO
RENAGEL
QL
RENVELA QL
SF ROWASA ENEMA
sulfasalazine
QL
QL
sulfasalazine delayed release
sulfazine EC
URSO
QL
QL
URSO FORTE
ursodiol
QL
QL
VELPHORO
QL
VIBERZI
ST,QL
FORANE
QL
QL
GENERAL ANESTHETICS
isoflurane
QL
sevoflurane
sojourn
QL
SUPRANE
terrell
QL
QL
QL
ULTANE
QL
GENITOURINARY AGENTS — MISCELLANEOUS
acetic acid irrigation
alfuzosin
QL
QL
65
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
G
MED
MED
G
P
NP
NP
CARDURA XL QL
P
NP
NP
CIALIS 2.5MG, CIALIS 5 MG (for BPH
USE) PA,QL
P
P
P
citric acid-sodium citrate solution
oral QL
G
G
G
CITROLITH
P
NP
NP
MED
MED
G
P
NP
NP
aminoacetic acid irrigation
QL
argyle sterile saline irrigation
AVODART
QL
QL
QL
curity sterile saline irrigation
CYSTAGON
QL
PA,QL,‌DSP
cytra K crystals
QL
G
G
G
cytra-2 solution
QL
G
G
G
CYTRA-3 SYRUP QL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
P
P
G
G
G
P
NP
NP
MED
MED
G
MED
MED
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
MED
MED
NP
ORACIT QL
P
NP
NP
phenazo
G
G
G
G
G
G
G
G
G
POTASSIUM CITRATE-CITRIC ACID
SOLUTION QL
P
NP
NP
PROCYSBI
P
NP
NP
CYTRA-K SOLUTION
dutasteride
QL
QL
dutasteride-tamsulosin
ELMIRON
QL
finasteride
FLOMAX
QL
QL
QL
glycine irrigation
QL
glycine urologic irrigation
JALYN
QL
QL
K-PHOS No 2
QL
LITOSTAT QL
neomycin-polymyxin b gu irrigation
NEOPORIN GU IRRIGATION
QL
QL
QL
phenazopyridine
QL
potassium citrate-citric acid packet
QL
PA,ST,QL,‌DSP
PROSCAR
QL
P
NP
NP
RAPAFLO
QL
P
P
P
MED
MED
NP
RESECTISOL SOLUTION IRRIGATION
QL
MED
MED
NP
sodium chloride solution irrigation
QL
MED
MED
G
RENACIDIN SOLUTION IRRIGATION
QL
66
DRUG CLASS
DRUG NAME
tamsulosin
QL
taron-crystals packet
THIOLA
QL
QL
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
G
G
G
P
NP
NP
P
NP
NP
QL
P
NP
NP
UROXATRAL QL
P
NP
NP
allopurinol
G
G
G
P
P
P
G
G
G
G
G
G
MED
MED
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
P
MED
MED
NP
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
NP
MED
MED
NP
G
G
G
G
G
G
MED
MED
NP
MED
MED
NP
MED
MED
NP
MED
MED
NP
BRILINTA QL
P
P
P
CEPROTIN
MED
MED
NP
G
G
G
MED
MED
P
G
G
G
MED
MED
NP
MED
MED
NP
UROCIT-K 10
UROCIT-K 5
QL
GOUT AGENTS
COLCRYS
QL
QL
colchicine
QL
colchicine-probenecid
QL
KRYSTEXXA PA,QL,‌DSP/DO
MITIGARE
ST,QL
probenecid
ULORIC
QL
QL
ZYLOPRIM
QL
HEMATOLOGICAL AGENTS — MISCELLANEOUS
ACTIVASE
ADVATE
PA,QL,‌DSP
PA,QL,‌DSP
ADYNOVATE
AGGRENOX
AGRYLIN
PA,QL,DSP
QL
QL
ALPHANATE/VWF
ALPHANINE SD
ALPROLIX
PA,QL,‌DSP
PA,QL,‌DSP
PA,QL,‌DSP
anagrelide
QL
aspirin-dipyridamole
BEBULIN
PA,QL,DSP
BEBULIN VH
BENEFIX
PA,QL,‌DSP
BERINERT
cilostazol
CINRYZE
PA,QL,‌DSP
PA,QL,‌DSP
PA,QL,‌DSP/DO
QL
PA,QL,‌DSP/DO
clopidogrel
QL
COAGADEX
QL,LD
CORIFACT PA,QL,‌DSP
QL
67
DRUG CLASS
DRUG NAME
dipyridamole
QL
EFFIENT QL
ELOCTATE
PA,QL,‌DSP
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
P
P
MED
MED
NP
MED
MED
G
FEIBA NF
PA,QL,‌DSP
MED
MED
P
FEIBA VH
PA,QL,‌DSP
MED
MED
P
MED
MED
P
MED
MED
NP
MED
MED
NP
HUMATE-P PA,QL,‌DSP
MED
MED
NP
INDELVION
MED
MED
NP
MED
MED
NP
MED
MED
NP
KCENTRA PA,QL
MED
MED
NP
KOATE-DVI
MED
MED
NP
MED
MED
NP
MED
MED
NP
KOVALTRY PA,QL,DSP
MED
MED
NP
MONOCLATE-P
MED
MED
P
MED
MED
P
MED
MED
P
NOVOEIGHT PA,QL,‌DSP
MED
MED
NP
NUWIQ
MED
MED
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
EPTIFIBATIDE
FIRAZYR
QL,DSP
PA,QL,‌DSP
HELIXATE FS
HEMOFIL M
IXINITY INJ
KALBITOR
PA,QL,‌DSP
PA,QL,‌DSP
PA,QL,DSP
PA,QL,DSP
PA,QL,‌DSP
PA,QL,‌DSP
KOGENATE FS
PA,QL,‌DSP
KOGENATE FS BIO-SET
MONONINE
PA,QL,‌DSP
PA,QL,‌DSP
NOVOSEVEN RT
PA,QL,DSP
pentopak
QL
pentoxifylline
PERSANTIN
PLAVIX
PA,QL,‌DSP
QL
QL
QL
PLETAL QL
PROFILNINE SD
PA,QL,‌DSP
PA,QL,DSP
MED
MED
NP
RIASTAP
PA,QL,‌DSP/DO
MED
MED
P
RIXUBIS
PA,QL,‌DSP/DO
MED
MED
NP
MED
MED
NP
MED
MED
P
G
G
G
TRETTEN PA,QL,‌DSP
MED
MED
NP
WILATE
MED
MED
NP
RECOMBINATE
RUCONEST
SOLIRIS
PA,QL,‌DSP
PA,QL,‌DSP/DO
PA,QL,‌DSP/DO
ticlopidine
QL
PA,QL,‌DSP
68
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
XYNTHA PA,QL,‌DSP
MED
MED
NP
XYNTHA SOLOFUSE KIT PA,QL,DSP
MED
MED
NP
ARANESP (ALBUMIN FREE)
MED
MED
P
MED
MED
P
DROXIA QL
P
NP
NP
ELELYSO
PA,QL,‌DSP
MED
MED
NP
EPOGEN
PA,QL,‌DSP/DO
MED
MED
NP
MED
MED
NP
HEMATOPOIETIC AGENTS
CEREZYME
GRANIX
PA,QL,‌DSP
PA,QL,‌DSP/DO
PA,QL,‌DSP/DO
LEUKINE
PA,QL,‌DSP/DO
MED
MED
NP
MIRCERA
PA,QL,LD
MED
MED
NP
MOZOBIL PA,QL,‌DSP/DO
MED
MED
NP
NEULASTA
PA,QL,‌DSP/DO
MED
MED
P
NEUMEGA PA,QL,‌DSP/DO
MED
MED
NP
NEUPOGEN
MED
MED
NP
MED
MED
NP
MED
MED
NP
MED
MED
P
P
NP
NP
MED
MED
P
MED
MED
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
BUTISOL QL
P
NP
NP
DORAL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
NPLATE
PA,QL,‌DSP/DO
PA,QL,‌DSP/DO
OMONTYS
PA,QL
PROCRIT PA,QL,‌DSP/DO
PROMACTA
VPRIV
PA,QL,‌DSP
PA,QL,‌DSP/DO
ZARXIO
PA,QL,DSP/DO
ZAVESCA PA,QL,DSP/DO
HEMOSTATICS
AMICAR
QL
aminocaproic acid
LYSTEDA QL
tranexamic acid
QL
QL
HYPNOTICS
AMBIEN
QL
AMBIEN CR
BELSOMRA
QL
QL,ST
QL
EDLUAR
ST,QL
estazolam
QL
eszopiclone
flurazepam
QL
QL
69
DRUG CLASS
DRUG NAME
HALCION
QL
HETLIOZ
PA,QL,‌DSP
INTERMEZZO
COST-SHARING COLUMNS
ST,QL
LUNESTA QL
midazolam syrup
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
RESTORIL
QL
P
NP
NP
ROZEREM
ST,QL
phenobarbital soution, tablet
QL
P
NP
NP
SECONAL
QL
P
NP
NP
SILENOR
ST,QL
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
QL
G
G
G
ST,QL
P
NP
NP
P
NP
NP
SONATA
QL
temazepam
triazolam
zaleplon
QL
QL
QL
zolpidem
QL
zolpidem ER
ZOLPIMIST
LAXATIVES
COLYTE WITH FLAVOR PACKS
QL
constulose
QL
G
G
G
gaviLyte-C
QL
G
G
G
gaviLyte-G
QL
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
P
P
P
NP
NP
P
NP
NP
G
G
G
G
G
G
PREPOPIK PACKET QL
P
NP
NP
SUCLEAR KIT
P
NP
NP
SUPREP BOWEL PREP QL
P
P
P
triLyte
G
G
G
G
G
G
gaviLyte-N with flavor pack
QL
GOLYTELY QL
KRISTALOSE
lactulose
QL
QL
MOVIPREP
QL
NULYTELY WITH FLAVOR PACKS
OSMOPREP
QL
peg 3350/electrolytes
QL
peg3350-kcl-na bicarb-nacl
QL
QL
QL
QL
MACROLIDES
azithromycin
QL
70
DRUG CLASS
DRUG NAME
BIAXIN
COST-SHARING COLUMNS
QL
BIAXIN XL PAC
BIAXIN XL
QL
QL
clarithromycin ER
clarithromycin
DIFICID
QL
QL
QL
E.E.S. 400 TABLET
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
ERYPED 200
QL
P
NP
NP
ERYPED 400
QL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
P
P
BRAND ALCOHOL SWABS 9NON-PREFERRED) QL
P
NP
NP
BD INSULIN SYRINGES
P
P
P
P
P
P
P
P
P
BRAND INSULIN SYRINGES (ANY OTHER
BRAND NAME) QL
P
NP
NP
BRAND LANCETS (ANY OTHER BRAND
NAME) QL
P
NP
NP
BRAND PEN NEEDLES (ANY OTHER
BRAND NAME) QL
P
NP
NP
FEMCAP DEVICE 22 MM VAGINAL QL
P
NP
NP
FEMCAP DEVICE 26 MM VAGINAL
QL
P
NP
NP
FEMCAP DEVICE 30 MM VAGINAL QL
P
NP
NP
insulin syringes (any generic)
G
G
G
E.E.S. GRANULES
ERY-TAB
QL
QL
ERYTHROCIN STEARATE
erythromycin base
PCE
QL
QL
QL
ZITHROMAX
ZMAX
QL
QL
MEDICAL DEVICES
alcohol swabs
The Diabetes Program
Go to page 4 of this guide to find
out how Assurant Health Diabetes
Program members save on their
prescription drugs.
QL
BRAND ALCOHOL SWABS (PREFERRED)
BD LANCETS
QL
QL
QL
BD PEN NEEDLES
QL
QL
G
G
G
OMNIFLEX DIAPHRAGM DIAPHRAGM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM COIL KIT 50 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM COIL KIT 100 MM
VAGINAL QL
P
NP
NP
lancets (any generic)
QL
71
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
ORTHO DIAPHRAGM COIL KIT 105 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 55 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 60 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 65 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 70 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 75 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 80 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 85 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 90 MM
VAGINAL QL
P
NP
NP
ORTHO DIAPHRAGM FLAT KIT 95 MM
VAGINAL QL
P
NP
NP
pen needles (any generic)
G
G
G
PRENTIF CAVITY-RIM CERV CAP DEVICE
22 MM VAGINAL QL
P
NP
NP
PRENTIF CAVITY-RIM CERV CAP DEVICE
25 MM VAGINAL QL
P
NP
NP
PRENTIF CAVITY-RIM CERV CAP DEVICE
28 MM VAGINAL QL
P
NP
NP
PRENTIF CAVITY-RIM CERV CAP DEVICE
31 MM VAGINAL QL
P
NP
NP
PRENTIF FITTING SET VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 60 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 65 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 70 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 75 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 80 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 85 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 90 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
WIDE-SEAL DIAPHRAGM 95 DIAPHRAGM
2% VAGINAL QL
P
NP
NP
QL
MIGRAINE PRODUCTS
72
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
ALSUMA ST,QL
P
NP
NP
AMERGE
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
dihydroergotamine mesylate
solution QL
G
G
G
epidrin
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
MAXALT-MLT QL
P
NP
NP
MIGERGOT
P
NP
NP
migragesic IDA QL
G
G
G
MIGRAL
P
NP
NP
almotriptan
QL
QL
AXERT ST,QL
CAFERGOT
QL
CAMBIA QL
D.H.E. 45 SOLUTION
QL
ERGOMAR
FROVA
QL
QL
ST,QL
frovatriptan
IMITREX
QL
QL
isometheptene-APAP-dichloral
MAXALT
QL
QL
QL
QL
MIGRALAM
QL
P
NP
NP
MIGRANAL
QL,ST
P
NP
NP
G
G
G
G
G
G
ONZETRA QL,ST
P
NP
NP
PRODRIN
P
NP
NP
P
NP
NP
G
G
G
rizatriptan MLT QL
G
G
G
sumatriptan
G
G
G
SUMAVEL ST,QL
P
NP
NP
TREXIMET
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
naratriptan
nodolor
RELPAX
QL
QL
QL
ST,QL
rizatriptan
QL
QL
ST,QL
ZECUITY PA,QL,DSP
ZEMBRACE SYMTOUCH
zolmitriptan
QL
zolmitriptan ZMT
ZOMIG
ST,QL
QL
QL
ZOMIG NASAL SPRAY
ST,QL
73
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
ZOMIG ZMT QL
P
NP
NP
EFFER-K
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
MINERALS & ELECTROLYTES
QL
effervescent pot chloride
kaon-Cl-10
QL
QL
K-effervescent
klor-con M10
QL
KLOR-CON M15
klor-con M20
QL
QL
QL
klor-con packet 20 meq
QL
KLOR-CON PACKET 25 MEQ ORAL
QL
klor-con tablet extended release
klor-con/EF
QL
QL
K-PHOS
QL
P
NP
NP
k-prime
QL
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
potassium chloride liquid 20
MEQ/15ML QL
G
G
G
potassium chloride packet
k-vescent
MICRO-K
QL
QL
phospha 250 neutral
QL
pot bicarb-pot chloride
QL
potassium bicarbonate oral
potassium chloride crys ER
QL
QL
G
G
G
potassium chloride solution 20
MEQ/15ML QL
G
G
G
SSKI SOLUTION
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
QL
QL
MOUTH/THROAT/DENTAL AGENTS
cevimeline
QL
chlorhexidine gluconate solution
mouth/throat QL
clotrimazole lozenge mouth/throat
EVOXAC
QL
QL
lidocaine HCL mouth/throat
lidocaine viscous
QL
QL
LTA 360 KIT QL
nystatin suspension mouth/throat
oralone paste dental
ORAVIG
QL
QL
QL
74
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
PERIDEX MOUTH/THROAT QL
P
NP
NP
periogard mouth/throat
G
G
G
G
G
G
P
NP
NP
triamcinolone acetonide paste
dental QL
G
G
G
AMRIX
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
MED
MED
P
P
NP
NP
MED
MED
NP
MED
MED
NP
P
NP
NP
G
G
G
G
G
G
MED
MED
NP
G
G
G
G
G
G
MED
MED
P
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
NP
G
G
G
P
NP
NP
P
NP
NP
pilocarpine oral
SALAGEN
QL
QL
QL
MUSCULOSKELETAL THERAPY AGENTS
ST,QL
baclofen oral
QL
carisoprodol oral
QL
carisoprodol-aspirin oral
QL
carisoprodol-aspirin-codeine oral
chlorzoxazone oral
QL
cyclobenzaprine oral
DANTRIUM
ed baclofen
FEXMID
QL
QL
dantrolene oral
EUFLEXXA
QL
QL
QL
PA,QL,‌DSP/DO
QL
GEL-ONE
PA,QL,‌DSP
HYALGAN
PA,QL,‌DSP/DO
LORZONE
QL
metaxalone oral
QL
methocarbamol oral
MONOVISC
QL
PA,QL,‌DSP/DO
orphenadrine ER oral
QL
orphenadrine-aspirin-caffeine oral
ORTHOVISC
PA,QL,‌DSP/DO
PARAFON FORTE DSC
ROBAXIN
QL
SKELAXIN
SOMA
QL
QL
QL
SUPARTZ
PA,QL,‌DSP/DO
SYNVISC ONE
PA,QL,‌DSP/DO
tizanidine oral
ZANAFLEX
QL
QL
QL
NASAL AGENTS — SYSTEMIC AND TOPICAL
ADRENALIN SOLUTION NASAL QL
75
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
ATROVENT NASAL QL
P
NP
NP
azelastine nasal
G
G
G
BACTROBAN OINTMENT NASAL QL
P
NP
NP
BECONASE AQ NASAL
P
NP
NP
G
G
G
P
NP
NP
G
G
G
ASTEPRO QL
QL
ST,QL
budesonide suspension nasal
DYMISTA
QL
QL
flunisolide solution nasal
QL
ipratropium bromide nasal
QL
G
G
G
mometasone furoate nasal
QL
G
G
G
NASONEX SUSPENSION NASAL QL
P
P
P
olopatadine nasal
G
G
G
P
NP
NP
PATANASE NASAL QL
P
NP
NP
QNASL CHILD
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
QL
OMNARIS SUSPENSION NASAL
QL
QL
QNASL SOLUTION NASAL QL
triamcinolone acetonide nasal
QL
TYZINE SOLUTION NASAL QL
VERAMYST SUSPENSION NASAL
QL
ZETONNA SOLUTION NASAL ST,QL
NEUROMUSCULAR AGENTS
MED
MED
P
DYSPORT SOLUTION
INTRAMUSCULAR PA,QL,‌DSP/DO
MED
MED
NP
MYOBLOC
MED
MED
NP
P
NP
NP
G
G
G
XEOMIN SOLUTION
INTRAMUSCULAR PA,QL,‌DSP/DO
MED
MED
NP
ACULAR LS OPHTHALMIC
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
BOTOX SOLUTION INJECTION
RILUTEK
riluzole
PA,QL,‌DSP
QL
QL
PA,QL,‌DSP/DO
OPHTHALMIC AGENTS
ACUVAIL OPHTHALMIC
QL
QL
AK-pentolate ophthalmic
AK-poly-bac ophthalmic
AKTEN OPHTHALMIC
QL
QL
QL
ALCAINE OPHTHALMIC
QL
P
NP
NP
ALOCRIL OPHTHALMIC
QL
P
NP
NP
P
NP
NP
ALOMIDE OPHTHALMIC
QL
76
DRUG CLASS
DRUG NAME
ALPHAGAN P OPHTHALMIC
ALREX OPHTHALMIC
COST-SHARING COLUMNS
QL
QL
altacaine ophthalmic
QL
apraclonidine ophthalmic
QL
atropine sulfate ophthalmic
atropine-care ophthalmic
QL
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
P
P
P
P
P
G
G
G
G
G
G
G
G
G
G
G
G
AZASITE OPHTHALMIC
QL
P
P
P
azelastine ophthalmic
QL
G
G
G
P
P
P
G
G
G
bacitra-neomycin-polymyxin-HC
ophthalmic QL
G
G
G
BEPREVE OPHTHALMIC
P
NP
NP
P
NP
NP
BETADINE OPHTHALMIC PREP
SOLUTION QL
P
NP
NP
BETAGAN OPHTHALMIC
P
NP
NP
G
G
G
P
P
P
P
P
P
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
P
P
P
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
AZOPT OPHTHALMIC
QL
bacitracin-polymyxin B ophthalmic
QL
BESIVANCE OPHTHALMIC
betaxolol ophthalmic
QL
QL
QL
BETIMOL OPHTHALMIC
QL
BETOPTIC-S OPHTHALMIC
bimatoprost ophthalmic
QL
QL
BLEPHAMIDE OPHTHALMIC
QL
BLEPHAMIDE S.O.P. OPHTHALMIC
brimonidine ophthalmic
QL
carteolol HCL ophthalmic
CILOXIN OPHTHALMIC
QL
ciprofloxacin ophthalmic
COMBIGAN OPHTHALMIC
COSOPT OPHTHALMIC
QL
QL
QL
QL
COSOPT PF OPHTHALMIC
QL
cromolyn sodium ophthalmic
CYCLOGYL OPHTHALMIC
QL
CYCLOMYDRIL OPHTHALMIC
cyclopentolate ophthalmic
cylate ophthalmic
QL
QL
QL
QL
CYSTARAN OPHTHALMIC
PA,QL,‌DSP
dexamethasone ophthalmic
diclofenac ophthalmic
QL
QL
QL
QL
77
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
dorzolamide HCL-timolol mal
ophthalmic QL
G
G
G
dorzolamide ophthalmic
G
G
G
P
P
P
P
NP
NP
DUREZOL OPHTHALMIC
ELESTAT OPHTHALMIC
QL
QL
QL
EMADINE OPHTHALMIC
QL
P
NP
NP
epinastine ophthalmic
QL
G
G
G
G
G
G
MED
MED
P
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
MED
MED
NP
P
NP
NP
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
erythromycin ophthalmic
QL
EYLEA INTRAOCULAR
PA,QL,DSP/DO
FLAREX OPHTHALMIC
QL
fluorometholone ophthalmic
fluor-op ophthalmic
QL
QL
flurbiprofen ophthalmic
QL
FML FORTE OPHTHALMIC
QL
FML LIQUIFILM OPHTHALMIC
FML OINTMENT OPHTHALMIC
QL
QL
garamycin ointment ophthalmic
QL
GARAMYCIN SOLUTION OPHTHALMIC
gatifloxacin ophthalmic
GELFILM OPHTHALMIC
gentak ophthalmic
QL
QL
QL
gentamicin ophthalmic
gentasol ophthalmic
QL
QL
homatropaire ophthalmic
homatropine ophthalmic
ilotycin ophthalmic
ILUVIEN
QL
QL
QL
QL
QL,DSP/DO
ILVERO OPHTHALMIC
QL
IOPIDINE OPHTHALMIC
QL
ISOPTO CARBACHOL OPHTHALMIC
QL
ISOPTO HOMATROPINE OPHTHALMIC
ISOPTO HYOSINE OPHTHALMIC
ISTALOL OPHTHALMIC
QL
QL
JETREA SOLUTION INTRAOCULAR
ketorolac ophthalmic
QL
QL
LASTACAFT OPHTHALMIC
latanoprost ophthalmic
QL
QL
levobunolol HCL ophthalmic
levofloxacin ophthalmic
QL
QL
QL,LD
78
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
P
P
MED
MED
P
P
P
P
MED
MED
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
neomycin-bacitracin zn-polymyx
ophthalmic QL
G
G
G
neomycin-polymyxin-dexameth
ophthalmic QL
G
G
G
neomycin-polymyxin-gramicidin
ophthalmic QL
G
G
G
neo-polycin HC ophthalmic
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
MED
MED
P
G
G
G
LOTEMAX OPHTHALMIC
QL
LUCENTIS INTRAOCULAR
LUMIGAN OPHTHALMIC
PA,QL,‌DSP/DO
QL
MACUGEN INTRAOCULAR
MAXIDEX OPHTHALMIC
PA,QL,‌DSP/DO
QL
MAXITROL OPHTHALMIC
QL
METIPRANOLOL OPHTHALMIC
MITOSOL KIT OPHTHALMIC
MOXEZA OPHTHALMIC
mydral ophthalmic
QL
QL
QL
MYDRIACYL OPHTHALMIC
NATACYN OPHTHALMIC
QL
QL
neo-polycin ophthalmic
NEOSPORIN
QL
QL
QL
QL
NEVANAC OPHTHALMIC
OCUFEN OPHTHALMIC
QL
QL
OCUFLOX OPHTHALMIC
ofloxacin ophthalmic
olopatadine drop
QL
QL
QL
OMNIPRED OPHTHALMIC
QL
OPTIPRANOLOL OPHTHALMIC
OPTIVAR OPHTHALMIC
QL
QL
OZUDEX IMPLANT INTRAOCULAR
parcaine ophthalmic
QL
QL
PATADAY OPHTHALMIC
QL
P
P
P
PATANOL OPHTHALMIC
QL
P
NP
NP
P
P
P
P
P
P
G
G
G
P
NP
NP
G
G
G
G
G
G
PAZEO
QL
PHOSPHOLINE IODIDE OPHTHALMIC
pilocarpine ophthalmic
PILOPINE OPHTHALMIC
polycin b ophthalmic
polycin ophthalmic
QL
QL
QL
QL
QL
79
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
polymyxin B-trimethoprim
ophthalmic QL
G
G
G
POLYTRIM
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
poly-dex ophthalmic
QL
QL
PRED FORTE OPHTHALMIC
PRED MILD OPHTHALMIC
PRED-G OPHTHALMIC
QL
QL
QL
PRED-G S.O.P. OPHTHALMIC
prednisolone ophthalmic
PROLENSA OPHTHALMIC
QL
QL
QL
G
G
G
RESCULA OPHTHALMIC
ST,QL
P
NP
NP
RESTASIS OPHTHALMIC
QL
P
P
P
G
G
G
P
NP
NP
G
G
G
sulfacetamide-prednisolone
ophthalmic QL
G
G
G
tetcaine ophthalmic
G
G
G
G
G
G
G
G
G
timolol maleate gel forming solution
ophthalmic QL
G
G
G
timolol maleate ophthalmic
G
G
G
P
NP
NP
P
NP
NP
TIMOPTIC-XE GEL FORMING
OPHTHALMIC QL
P
NP
NP
TOBRADEX OPHTHALMIC
P
NP
NP
P
NP
NP
G
G
G
tobramycin-dexamethasone
ophthalmic QL
G
G
G
tobrasol ophthalmic
G
G
G
P
NP
NP
P
P
P
G
G
G
G
G
G
G
G
G
proparacaine ophthalmic
romycin ophthalmic
QL
QL
SIMBRINZA OPHTHALMIC
QL
sulfacetamide sodium ophthalmic
QL
QL
tetravisc forte ophthalmic
tetravisc ophthalmic
QL
QL
QL
TIMOPTIC OCUDOSE OPHTHALMIC
TIMOPTIC OPHTHALMIC
QL
QL
TOBRADEX ST QL
tobramycin ophthalmic
QL
QL
TOBREX OPHTHALMIC
QL
TRAVATAN Z OPHTHALMIC
travoprost ophthalmic
trifluridine ophthalmic
QL
QL
QL
triple antibiotic ophthalmic
QL
QL
80
DRUG CLASS
DRUG NAME
tropicamide ophthalmic
TRUSOPT OPHTHALMIC
VEXOL OPHTHALMIC
COST-SHARING COLUMNS
QL
QL
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
P
NP
NP
VIGAMOX OPHTHALMIC
QL
P
NP
NP
VIROPTIC OPHTHALMIC
QL
P
NP
NP
MED
MED
NP
P
NP
NP
VISUDYNE
PA,QL,‌DSP/DO
XALATAN OPHTHALMIC
ST,QL
ZIOPTAN OPTHALMIC
ST,QL
P
NP
NP
ZIRGAN OPHTHALMIC
QL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
ZYLET OPHTHALMIC
QL
ZYMAXID OPHTHALMIC
QL
OTIC AGENTS
a/b otic
QL
acetasol HC otic
acetic acid otic
aero otic HC
QL
QL
QL
antibiotic ear solution
QL
antipyrine-benzocaine otic
AURALGAN OTIC
aurax otic
QL
QL
aurodex otic
QL
auroguard otic
auroto otic
QL
QL
CETRAXAL OTIC
QL
CIPRO HC OTIC
QL
CIPRODEX OTIC
QL
COLY-MYCIN S OTIC
CORTANE-B OTIC
cortic-ND otic
QL
QL
QL
CORTISPORIN OTIC
QL
CORTISPORIN-TC OTIC
cortomycin otic
QL
QL
CRESYLATE OTIC
cyotic otic
QL
QL
QL
DERMOTIC OIL OTIC
exotic-HC otic
QL
QL
fluocinolone acetonide oil otic
QL
81
DRUG CLASS
DRUG NAME
hydrocortisone-acetic otic
MYOXIN OTIC
COST-SHARING COLUMNS
QL
QL
neomycin-polymyxin-HC otic
QL
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
G
G
G
ofloxacin otic
QL
G
G
G
otic care otic
QL
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
PA,QL,‌DSP
MED
MED
NP
CARIMUNE NF SOLUTION
RECONSTITUTED
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
CYTOGAM INJECTABLE
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
P
FLEBOGAMMA DIF SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
FLEBOGAMMA SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
GAMASTAN S/D INJECTABLE
INTRAMUSCULAR PA,QL,‌DSP/DO
MED
MED
NP
GAMMAGARD INJECTION
OTIC EDGE OTIC
QL
OTICIN HC NR OTIC
oticin OTIC
otirx otic
QL
QL
QL
oto-end 10 otic
otomar otic
QL
QL
otomax-HC solution
OTOZIN OTIC
QL
QL
PINNACAINE OTIC
QL
pramoxine-chloroxylenol otic
QL
pramoxine-HC-chloroxylenol AQ otic
RE BENZOTIC OTIC
QL
RE pramoxine-HC otic
VOSOL HC OTIC
zotane HC otic
QL
QL
QL
QL
OXYTOCICS
methylergonovine maleate
QL
PASSIVE IMMUNIZING AGENTS
BIVIGAM
MED
MED
NP
GAMMAGARD S/D SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
GAMMAKED SOLUTION
MED
MED
NP
MED
MED
NP
PA,QL,‌DSP/DO
PA,QL,‌DSP/DO
GAMMAPLEX SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
82
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
GAMUNEX SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
HEPAGAM B SOLUTION
INJECTION QL,‌DSP/DO
MED
MED
P
HIZENTRA SOLUTION
SUBCUTANEOUS PA,QL,‌DSP/DO
MED
MED
NP
HYPERHEP B S/D SOLUTION
INTRAMUSCULAR PA,QL,‌DSP
MED
MED
NP
HYPERRHO S/D INJECTABLE
INTRAMUSCULAR PA,QL,‌DSP/DO
MED
MED
NP
HYPERTET S/D INJECTABLE
INTRAMUSCULAR QL
MED
MED
P
HYQVIA INJECTABLE
MED
MED
NP
MICRHOGAM ULTRA-FILTERED PLUS
INJECTABLE INTRAMUSCULAR QL,‌DSP/DO
MED
MED
NP
NABI-HB SOLUTION
INTRAMUSCULAR QL,‌DSP
MED
MED
NP
OCTAGAM SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
PRIVIGEN SOLUTION
INTRAVENOUS PA,QL,‌DSP/DO
MED
MED
NP
RHOGAM ULTRA-FILTERED PLUS
INJECTABLE INTRAMUSCULAR QL,‌DSP/DO
MED
MED
NP
RHOPHYLAC SOLUTION
INJECTION QL,‌DSP/DO
MED
MED
P
SYNAGIS SOLUTION
INTRAMUSCULAR PA,QL,‌DSP/DO
MED
MED
P
VARIZIG SOLUTION RECONSTITUTED
INJECTION QL,‌DSP
MED
MED
NP
WINRHO SDF SOLUTION
INJECTION PA,QL,‌DSP/DO
MED
MED
NP
G
G
G
G
G
G
G
G
G
G
G
G
P
P
P
P
P
P
AUGMETIN TABLET QL
P
NP
NP
AUGMENTIN XR TABLET QL
P
NP
NP
dicloxacillin sodium
G
G
G
P
NP
NP
G
G
G
PA,QL,DSP/DO
PENICILLINS
amoxicillin
QL
amoxicillin-pot clavulanate ER
amoxicillin-pot clavulanate
ampicillin
QL
AUGMENTIN SUSPENSION
QL
AUGMENTIN ES SUSPENSION
MOXATAG
QL
QL
penicillin V potassium
PROGESTINS
QL
QL
QL
QL
83
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
MED
MED
NP
G
G
G
P
NP
NP
G
G
G
norethindrone acetate tablet 5 mg
oral QL
G
G
G
progesterone micronized capsule
oral QL
G
G
G
MED
MED
G
PROMETRIUM ORAL QL
P
NP
NP
PROVERA
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
AYGESTIN
QL
MAKENA OIL INTRAMUSCULAR
PA,QL,‌DSP
medroxyprogesterone acetate
MEGACE ES
QL
QL
megestrol acetate suspension
QL
progesterone oil intramuscular
QL
QL
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS — MISCELLANEOUS
acamprosate calcium
AMPYRA
QL
PA,QL,‌DSP
ANTABUSE
QL
P
NP
NP
QL
P
NP
NP
PA,QL,‌DSP
P
NP
NP
MED
MED
NP
MED
MED
P
P
NP
NP
bupropion ER (Smoking Det)
EXTENDED RELEASE 12 HR QL
G
G
G
CAMPRAL QL
P
NP
NP
CHANTIX
P
NP
NP
MED/P
MED/P
P
MED/P
MED/P
P
G
G
G
G
G
G
G
G
G
EXELON ORAL QL
P
NP
NP
EXELON PATCH
P
NP
NP
MED/P
MED/P
P
G
G
G
G
G
G
G
G
G
P
P
P
MED
MED
G
P
NP
NP
ARICEPT QL
ARICEPT ODT
AUBAGIO
AVONEX
PA,QL,‌DSP
BETASERON
BRISDELLE
PA,QL,‌DSP
QL
QL
COPAXONE
PA,QL,‌DSP
COPAXONE KIT PA,QL,DSP
disulfiram
QL
donepezil
QL
donepezil ODT
QL
QL
EXTAVIA PA,QL,DSP
fluoxetine (PMDD)
galantamine
QL
galantamine ER
GILENYA PA,QL,‌DSP
glatopa
PA,QL,‌DSP
GRALISE
ST,QL
QL
QL
84
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
HORIZANT ST,QL
P
NP
NP
memantine
G
G
G
P
NP
NP
P
NP
NP
P
P
P
P
P
P
P
P
P
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
NUEDEXTA QL
P
P
P
NUPLAZID
P
NP
NP
G
G
G
P
NP
NP
G
G
G
MED/P
MED/P
P
P
NP
NP
P
NP
NP
MED
MED
NP
MED
MED
NP
MED
MED
NP
G
G
G
G
G
G
P
P
P
P
P
P
P
NP
NP
P
P
P
G
G
G
MED
MED
NP
P
NP
NP
P
NP
NP
P
NP
NP
GRALISE STARTER PACK
ST,QL
QL
NAMENDA QL
NAMENDA TITRATION PACK
NAMENDA XR
QL
QL
NAMENDA XR TITRATION PACK
NAMZARIC
PA,QL
NICORETTE GUM
QL
NICORETTE LOZENGE
QL
NICORETTE STARTER KIT
NICOTROL INHALER
QL
QL,DSP
olanzapine-fluoxetine
QL
QL
pimozide
QL
PLEGRIDY
PA,QL,‌DSP
RAZADYNE
QL
RAZADYNE ER
REBIF
QL
QL
NICOTROL NASAL SPRAY
ORAP
QL
QL
PA,QL,‌DSP
REBIF REBIDOSE
PA,QL,DSP
REBIF TITRATION PACK
rivastigmine
SARAFEM
SAVELLA
PA,QL,DSP
QL
QL
QL
SAVELLA TITRATION PACK
SYMBAX
QL
TECFIDERA
PA,QL,‌DSP
tetrabenazine
TYSABRI
PA,QL,DSP
PA,QL,‌DSP/DO
XENAZINE
XYREM
QL
PA,QL,‌DSP
PA,QL
ZYBAN EXTENDED RELEASE 12 HR
QL
RESPIRATORY AGENTS — MISCELLANEOUS
85
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
MED
MED
NP
MED
MED
NP
P
NP
NP
GLASSIA SOLUTION
INTRAVENOUS PA,QL,‌DSP
MED
MED
NP
INFASURF SUSPENSION 35-0.9 MG/ML
-% INHALATION QL
MED
MED
NP
P
NP
NP
P
NP
NP
P
NP
NP
PROLASTIN SOLUTION
INTRAVENOUS PA,QL,LD
MED
MED
NP
PROLASTIN-C SOLUTION
INTRAVENOUS PA,QL,LD
MED
MED
NP
P
P
P
SCLEROSOL INTRAPLEURAL AEROSOL QL
MED
MED
NP
STERILE TALC POWDER
INTRAPLEURAL QL
MED
MED
NP
ZEMAIRA SOLUTION
INTRAVENOUS PA,QL,LD
MED
MED
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
ARALAST NP SOLUTION
INTRAVENOUS PA,QL,‌DSP
CUROSULF SUSPENSION INHALATION
QL
ESBRIET PA,QL
KALYDECO
OFEV
PA,QL,‌DSP
PA,QL,DSP
ORKAMBI
PA,QL,‌DSP
PULMOZYME
PA,QL,‌DSP
TETRACYCLINES
ADOXA PAK
ADOXA
QL
QL
avidoxy
QL
demeclocycline
DORYX
QL
QL
doxycycline
QL
doxycycline hyclate
QL
doxycycline monohydrate
MINOCIN
QL
minocycline
QL
minocycline ER
MONODOX
QL
QL
QL
morgidox
QL
G
G
G
SOLODYN
QL
P
NP
NP
P
NP
NP
tetracycline
QL
G
G
G
VIBRAMYCIN
QL
P
NP
NP
TARGADOX
QL
THYROID AGENTS
86
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
CYTOMEL QL
P
NP
NP
levothroid
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
TIROSINT QL
P
NP
NP
unithroid
G
G
G
G
G
G
P
NP
NP
WESTHROID-P QL
P
NP
NP
WP THYROID
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
BENTYL QL
P
NP
NP
CANTIL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
CUVPOSA QL
P
NP
NP
CYTOTEC
P
NP
NP
P
P
P
G
G
G
DONNATAL QL
P
NP
NP
ed-spaz
G
G
G
G
G
G
ARMOUR THYROID
QL
QL
levothyroxine sodium
levoxyl
QL
QL
liothyronine sodium
methimazole
QL
NATURE-THROID
NP thyroid
QL
QL
propylthiouracil
SYNTHROID
TAPAZOLE
QL
QL
QL
QL
THYROLAR
QL
QL
unithroid direct
WESTHROID
QL
QL
QL
ULCER DRUGS
ACIPHEX SPRINKLE
ST,QL
ACIPHEX TABLET ST,QL
amoxicill-clarithro-lansopraz
QL
QL
CARAFATE SUSPENSION
CARAFATE TABLET
QL
QL
clidinium-chlordiazepoxide
colidrops solution oral
QL
QL
QL
DEXILANT QL
dicyclomine
QL
QL
esomeprazole magnesium 40 mg
QL
87
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
G
G
G
hyomax-FT QL
G
G
G
hyomax-SL
QL
G
G
G
hyomax-SR
QL
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
P
P
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
G
G
G
G
G
G
ESOMEPRAZOLE STRONTIUM
GASTRINEX NF CAPSULE
GLYCATE
QL
QL
glycopyrrolate
hyomax
ST,QL
QL
QL
hyoscyamine sulfate ER
QL
hyoscyamine sulfate oral
QL
hyoscyamine sulfate sublingual
hyosyne
QL
QL
KP omeprazole magnesium capsule
lansoprazole
QL
methscopolamine bromide
misoprostol tablet
NEXIUM GRANULE
QL
QL
NEXIUM 40 MG capsule
nulev ODT
QL
ST,QL
QL
OMECLAMOX-PAK
omeprazole
QL
QL
omeprazole-sodium bicarbonate
oscimin oral
oscimin SR
QL
QL
oscimin sublingual
PAMINE
QL
QL
PAMINE FORTE
pantoprazole
PREVACID
QL
QL
ST,QL
PREVACID SOLUTAB
PREVPAK
ST,QL
ST,QL
PRILOSEC
PROTONIX
QL
QL
PYLERA QL
rabeprazole
QL
RE chlordiazepoxide/clidinium
QL
QL
QL
88
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
RONINUL-FORTE ORAL QL
P
NP
NP
sucralfate tablet
G
G
G
P
NP
NP
G
G
G
symax-SL QL
G
G
G
symax-SR
QL
G
G
G
ST,QL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
NP
NP
ROBINUL ORAL QL
SYMAX DUOTAB
symax fastabs
ZEGERID
QL
QL
QL
URINARY ANTI-INFECTIVES
FURADANTAN SUSPENSION
HIPREX
QL
QL
hyophen
QL
MACROBID
QL
MACRODANTIN
QL
G
G
G
methenamine mandelate
tablet 1 gm oral QL
G
G
G
MONUROL PACKET QL
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
methenamine hippurate
QL
nitrofurantoin macrocrystal
QL
nitrofurantoin monohyd macro
nitrofurantoin suspension
phosenamine
phosphasal
ur n-c
QL
QL
URELLE
UREX
QL
QL
QL
URIBEL QL
URIMAR-T
urin DS
QL
QL
UROQID #2
uryl
QL
ustell
uta
QL
QL
QL
uticap
utira-c
QL
QL
utrona-c
QL
QL
QL
URINARY ANTISPASMODICS
bethanechol chloride
QL
89
DRUG CLASS
DRUG NAME
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
G
G
G
P
NP
NP
DETROL LA ST,QL
P
NP
NP
DITROPAN XL
P
NP
NP
P
NP
NP
P
NP
NP
P
P
P
G
G
G
G
G
G
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
P
P
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
P
P
P
P
P
ESTRACE CREAM VAGINAL QL
P
NP
NP
ESTRING
QL
P
NP
NP
FEMRING
QL
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
NP
NP
P
P
P
darifenacin hydrobromide ER
DETROL
ST,QL
ENABLEX
ST,QL
QL,ST
GELNIQUE
ST,QL
MYRBETRIQ
oxybutynin
QL
QL
oxybutynin chloride ER
OXYTROL (RX)
QL
ST,QL
SANCTURA, SANCTURA XR
tolterodine
TOVIAZ
ST,QL
QL
ST,QL
trospium
QL
trospium er
QL
URECHOLINE
VESICARE
QL
QL
QL
VAGINAL PRODUCTS
AVC
QL
CLEOCIN VAGINAL
QL
clindamycin vaginal
CLINDESSE
CRINONE
QL
QL
QL
ENDOMETRIN
GYNAZOLE-1
QL
QL
METRO-GEL VAGINAL QL
metronidazole vaginal
QL
NUVESSA QL
PREMARIN CREAM VAGINAL
QL
P
P
P
TERAZOLE 3
QL
P
NP
NP
TERAZOLE 7
QL
P
NP
NP
terconazole
QL
G
G
G
PROCHIEVE
QL
90
DRUG CLASS
DRUG NAME
VAGIFEM
QL
vandazole
zazole
QL
QL
COST-SHARING COLUMNS
2 RX COPAYS OR
NO COPAY
3 RX COPAYS
OUTSIDE MT
3 RX COPAYS
WITHIN MT
P
NP
NP
G
G
G
G
G
G
P
NP
NP
P
P
P
VASOPRESSORS
ADRENACLICK
AUVI-Q
QL
EPIPEN
QL
ST,QL
P
P
P
EPIPEN JR
QL
P
P
P
midodrine
QL
G
G
G
P
NP
NP
P
NP
NP
P
NP
NP
G
G
G
P
P
P
P
NP
NP
G
G
G
NORTHERA
PA,QL,‌DSP
TWINJECT QL
VITAMINS
DRISDOL QL
ergocalciferol
MEPHYTON
POTABA
QL
QL
QL
vitamin D (ergocalciferol)
QL
91