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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