4 Tier Value Drug List

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					                                                                  4 Tier Value Drug List                                  November 2011
                                 Tier 1                                      Tier 2                              Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
                                                                   ANESTHETICS
Topical Anesthetics              lidocaine viscous                                                               CETACAINE
                                 lidocaine gel (Anamantle HC)                                                    LIDODERM
                                 lidocaine/prilocaine (Emla)                                                     QUTENZA (PA/QL)
                                 tetracaine
                                                                  ANTIINFECTIVES
Oral Antibacterial Drugs          amoxicillin (Amoxil)                      Use Tier 1 anti-infective agent!    CEDAX
                                 amoxicillin/clavulanate                     i.e. azithromycin (Zithromax) for   COARTEM (PA)
                                 (Augmentin/Augmentin XR/Augmentin ES        a lower copayment                   DIFICID (PA)
                                 Susp)                                                                           FACTIVE
                                 ampicillin (Principen)                      AVELOX                              KETEK
                                  azithromycin (Zithromax)                  MEPRON (PA)                         MOXATAG
                                 cefaclor (Ceclor/Ceclor CD)                 VANCOCIN                            NOROXIN
                                 cefadroxil (Duricef)                                                            SUPRAX
                                 cefdinir (Omnicef)                                                              ZMAX
                                 cefpodoxime (Vantin)                                                            ZYVOX (QL)
                                 cefprozil tabs and susp (Cefzil)
                                 cefuroxime (Ceftin)
                                  cephalexin (Keflex)
                                 cephradine (Velosef)
                                  ciprofloxacin (Cipro)
                                 ciprofloxacin ER (Cipro XR)
                                 clarithromycin/ER (Biaxin/XL)
                                 clindamycin (Cleocin)
                                 dicloxacillin (Dycill)
                                  doxycycline (Vibramycin)
                                  erythromycin (Ery-Tab)
                                 erythromycin/sulfisoxazole (Pediazole)
                                 levofloxacin (Levaquin)
                                 minocycline (Dynacin)
                                 nitrofurantoin (Macrodantin)
                                 ofloxacin (Floxin)
                                  penicillin VK (Beepen VK)
                                  sulfamethoxazole/trimethoprim (Bactrim)
                                 sulfisoxazole (Gantrisin)
                                 tetracycline (Sumycin)
                                 trimethoprim (Trimpex)
Oral Antifungal Drugs            clotrimazole troche (Mycelex Troche)                                            LAMISIL GRANULES (PA)
                                 fluconazole (Diflucan) (QL on 150mg)                                            NOXAFIL
                                 griseofulvin (Gris-PEG)                                                         ORAVIG
                                 itraconazole (Sporanox) (PA) (QL)
                                 ketoconazole (Nizoral)
                                 nystatin (Mycostatin)
                                 terbinafine (Lamisil)
                                 voriconazole (VFend) (QL)
Oral Antiviral Drugs-            didanosine (Videx EC)                       EMTRIVA                             INTELENCE
Antiretrovirals for HIV          zidovudine 300mg and 50mg/5ml syrup         EPIVIR
                                 (Retrovir)                                  ISENTRESS
                                                                             SUSTIVA
                                                                             VIRAMUNE
                                                                             VIREAD
                                                                             ZERIT
                                                                             ZIAGEN

Page 1 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                   4 Tier Value Drug List               November 2011
                                 Tier 1                                   Tier 2               Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
                                                            ANTIINFECTIVES Continued
Oral Antiviral Drugs-                                                     AGENERASE            APTIVUS
Protease Inhibitors                                                       CRIXIVAN
                                                                          INVIRASE
                                                                          KALETRA
                                                                          NORVIR
                                                                          REYATAZ
                                                                          VIRACEPT

Oral Antiviral Drugs-                                                     COMBIVIR             ATRIPLA
Combinations                                                              TRIZIVIR             EPZICOM
                                                                                               PREZISTA
                                                                                               TRUVADA
CCR5 Antagonist                                                                                SELZENTRY
Other Antiviral Drugs            acyclovir (Zovirax Capsules)             CYTOVENE             BARACLUDE
                                 amantadine (Symmetrel)                   EPIVIR HBV           FUZEON (PA)
                                 famciclovir (Famvir)                     INCIVEK (PA/SP)*     HEPSERA
                                 ribavirin (Rebetol) (PA)                 RELENZA (QL)         RIBAPAK (PA) (*Pls use Ribavirin*)
                                 ribavirin (Copegus) (PA)                 TAMIFLU (QL)         VALCYTE (QL)
                                 valacyclovir (Valtrex)                   VICTRELIS (PA/SP)*


Other Anti-infective             chloroquine (Aralen) (PA)                DAPSONE              ALINIA (QL)
Drugs                            ethambutol (Myambutol)                   DARAPRIM             CAYSTON (PA)
                                 hydroxychloroquine (Plaquenil)           MYCOBUTIN            COARTEM (PA)
                                 isoniazid                                PRIMAQUINE           FANSIDAR
                                 mebendazole (Vermox)                                          MALARONE (PA)
                                 mefloquine (Lariam) (PA)                                      NEBUPENT
                                 metronidazole (Flagyl)                                        QUALAQUIN (PA)
                                 neomycin                                                      STROMECTOL
                                 paromomycin (Humatin)                                         TINDAMAX (QL)
                                 pyrazinamide                                                  XIFAXAN
                                 quinine
                                 rifampin (Rifadin)

Topical Antibacterial            gentamicin (Garamycin)                   BACTROBAN CREAM      ALTABAX
Drugs                            mupirocin ointment (Bactroban)
                                 silver sulfadiazine (Silvadene)

Topical Antifungal Drugs         ciclopirox 0.77% topical (Loprox)                             CNL Nail Kit (PA)
                                 ciclopirox 8% (Penlac)                                        ERTACZO
                                 clotrimazole/betamethasone (Lotrisone)                        EXELDERM
                                 econazole (Spectazole)                                        EXTINA (ST)
                                 ketoconazole (Nizoral)                                        LOPROX
                                 nystatin (Mycostatin)                                         NAFTIN
                                 nystatin/triamcinolone (Mycolog)                              OXISTAT
                                 Terbinafine (Lamisil)                                         VUSION (PA)




Page 2 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                 4 Tier Value Drug List             November 2011
                                 Tier 1                                 Tier 2             Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Topical Antiviral Drugs                                                                    DENAVIR
                                                                                           ZOVIRAX

                                               ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
Alkylating                       cyclophosphamide (Cytoxan)             CEENU
Agents/Antimetabolites           Melphalan (Alkeran)                    LEUKERAN
                                 mercaptopurine (Purinethol)            MYLERAN
                                 methotrexate                           THIOGUANINE


Adrogens, Estrogens,             anastrozole (Arimidex)                                    HALOTESTIN (PA)
Progestins and Related           bicalutamide (Casodex)                                    MEGACE ES
Drugs                            exemestane (Aromasin)
                                 flutamide (Eulexin)
                                 letrozole (Femara)
                                 megestrol (Megace)
                                 tamoxifen (Nolvadex)
Immunosuppressant                azathioprine (Imuran)                  MYFORTIC
Drugs                            cyclosporine (Neoral, Sandimmune)      RAPAMUNE
                                 mycophenolate mofetil (Cellcept)
                                 prednisone (Deltasone)
                                 tacrolimus (Prograf)



Miscellaneous                    anagrelide (Agrylin) (PA)              MATULANE           AFINITOR (PA/SP)*
Antineoplastic Drugs             hydroxyurea (hydrea)                   TARGRETIN (SP)     ARZERRA (PA/MB)
                                 leucovorin                             TEMODAR (PA/SP)*   AVASTIN (PA/MB)
*Dispensing limited to 30                                                                  CAPRELSA (PA/SP)*
days supply                                                                                FOLOTYN (PA/MB)
                                                                                           GLEEVEC (PA/SP)*
ConnectiCare has a                                                                         HYCAMTIN (PA/SP)*
pharmacy (Medmark) that                                                                    IRESSA (PA/SP)*
specializes in these                                                                       ISTODAX (PA/SP)*
medications. Please call                                                                   NEXAVAR (PA/SP)*
member services to                                                                         OFORTA (PA/SP)*
inquire what they can                                                                      REVLIMID (PA/SP)*
provide you.                                                                               SPRYCEL (PA/SP)*
                                                                                           SUTENT (PA/QL/SP)*
                                                                                           SYLATRON (PA/SP)*
                                                                                           TARCEVA (PA/QL/SP)*
                                                                                           TASIGNA (PA/SP)*
                                                                                           THALOMID (PA/QL/SP)*
                                                                                           TORISEL (PA/SP)*
                                                                                           TREANDA (PA/MB)
                                                                                           TYKERB (PA/QL/SP)*
                                                                                           VECTIBIX (PA/MB)
                                                                                           VOTRIENT (PA/SP)*
                                                                                           XELODA (PA/SP)*
                                                                                           ZELBORAF (PA/SP/QL)*
                                                                                           ZOLINZA (PA/SP)*
                                                                                           ZORTRESS (PA/SP)*
                                                                                           ZYTIGA (PA/SP/QL)*


Page 3 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                   4 Tier Value Drug List                                November 2011
                                 Tier 1                                      Tier 2                             Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
                                                        CARDIOVASCULAR MEDICATIONS
Antiarrhythmics                  digitek
                                 digoxin (Lanoxin)
Calcium Antagonists              amlodipine (Norvasc)                       Consider Best Buy options first!   Consider Best Buy options first!
                                  diltiazem (Cardizem)                      CARDIZEM LA                        CARDENE SR
                                 diltiazem er/sr/xr (Cardizem SR/Dilacor                                        DYNACIRC CR
                                 XR/Tiazac)
                                 diltiazem LA (Cardizem LA)
                                 Felodipine/er (Plendil)
                                 nicardipine (Cardene)
                                 nifedipine (Procardia)
                                 nifedipine er/xl (Procardia XL/Adalat CC)
                                 nimodipine (Nimotop) (PA)
                                 nisoldipine (Sular)
                                  verapamil (Calan)
                                 verapamil sr (Calan SR/Covera HS/Verelan)

Diuretics                        amiloride (Midamore)                                                           EDECRIN
                                 amiloride/hctz (Moduretic)
                                 bumetanide (Bumex)
                                  clorthalidone (Hygroton)
                                 eplerenone (Inspra)
                                  furosemide (Lasix)
                                  hydrochlorothiazide
                                 indapamide (Lozol)
                                 metolazone (Zaroxolyn)
                                 spironolactone (Aldactone)
                                 spironolactone/hctz (Aldactazide)
                                 torsemide (Demadex)
                                  triamterene/hctz (Dyazide)
Beta-Adrenergic                  acebutolol (Sectral)                        Consider Tier 1 & Best Buy
Antagonist Drugs                  atenolol (Tenormin)                       options first!
                                 atenolol/chlorthalidone (Tenoretic)
                                 bisoprolol (Zebeta)                         BYSTOLIC
                                 Bisoprolol/hctz (Ziac)                      INNOPRAN XL
                                  metoprolol (Lopressor)
                                 metoprolol/hctz (Lopressor HCT)
                                 metoprolol succinate (Toprol XL)
                                 nadolol (Corgard)
                                 pindolol (Visken)
                                 propranolol/propranolol ER (Inderal/LA)
                                 sotalol (Betapace)

Alpha-Beta Antagonists           carvedilol (Coreg)                                                             COREG CR (PA) Use generic
                                 labetalol (Trandate)                                                           carvedilol
Other Antihypertensive           clonidine (Catapres/TTS)                                                       NEXICLON XR
Drugs                            doxazosin (Cardura)                                                            TEKAMLO (ST)
                                 guanabenz (Wytensin)                                                           TEKTURNA (ST)
                                 guanfacine (tenex)                                                             VALTURNA (ST)
                                 methyldopa (Aldomet)
                                 hydralazine (Apresoline)
                                 prazosin (Minipres)
                                 terazosin (Hytrin)


Page 4 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                      4 Tier Value Drug List                             November 2011
                                 Tier 1                                     Tier 2                              Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
CARDIOVASCULAR MEDICATIONS continued
Angiotensin Converting           captopril (Capoten)                        Use Tier 1 ACE inhibitors ! i.e.    Use Tier 1 ACE inhibitors ! i.e.
Enzyme Inhibitors                benazepril (Lotensin)                      Lisinopril (Zestril) for a lower    Lisinopril (Zestril) for a lower
And                              enalapril (Vasotec)                        copayment                           copayment
Angiotensin II Receptor          fosinopril (Monopril)                      AVAPRO (ST)                         ALTACE TABLETS (PA)
Antagonists                      lisinopril (Prinvil, Zestril)             BENICAR (ST)                        AMTURNIDE (ST)
                                 losartan (Cozaar)                                                             ATACAND (ST)
                                 losartan HCTZ (Hyzaar)                                                        DIOVAN (ST)
                                 moexipril (Univasc)                                                            EDARBI (ST)
                                 quinapril (Accupril)                                                           MICARDIS (ST)
                                 ramipril (Altace)                                                              TEVETEN (ST)
                                 trandolapril (Mavik)
Antihypertensive                 amlodipine/benazepril (Lotrel)            Use Tier 1 Combination              Use Tier 1 Combination products, like
Combinations                     atenolol/chlorthalidone (Tenoretic)        products, like generic Zestoretic   generic Zestoretic or generic Lotrel
                                 benazepril/HCTZ (Lotensin HCT)             or generic Lotrel for a lower       for a lower copayment!
                                 bisoprolol/hctz (Ziac)                     copayment!                          ATACAND HCT (ST)
                                 captopril/hctz (Capozide)                  AZOR (ST)                           BIDIL
                                 enalapril/HCTZ (Vaseretic)                 AVALIDE (ST)                        DIOVAN HCT (ST)
                                 fosinopril/HCTZ (Monopril HCT)             BENICAR/HCT (ST)                    EXFORGE (ST)
                                 hydralazine/hctz (Apresazide)              TRIBENZOR (ST)                      EXFORGE HCT (ST)
                                 lisinopril/hctz (Prinzide, Zestoretic)                                        MICARDIS HCT (ST)
                                 methyldopa/hctz (Aldoril)                                                      TEVETEN HCT (ST)
                                 metoprolol/HCTZ (Lopressor HCT)                                                TWYNSTA (ST)
                                 moexipril/HCTZ (Uniretic)
                                 propranolol/hctz (Inderide)
                                 quinaretic (Accuretic)
                                 trandolapril/verapamil (Tarka)
Vasodilating Drugs               dipyridamole (Persantine)                  NITROLINGUAL SPRAY
                                 isosorbide dinitrate (Isordil)             RANEXA
                                 isosorbide mononitrate (Ismo)
                                 nitroglycerin (Nitrobid, Nitro-Dur)
                                 papaverine (Pavabid)
Antidysrhythmic Drugs            amiodarone (Cordarone)                     MULTAQ                              RYTHMOL SR
                                 disopyramide/CR (Norpace/CR)                                                   TIKOSYN
                                 flecainide (Tambocor)
                                 mexiletine (Mexitil)
                                 procainamide/SR (Procan/SR)
                                 propafenone (Rythmol)
                                 sotalol (Betapace)
Antilipidemic Drugs-             lovastatin (Mevacor)                      Use generic options first !         Use generic options first !
HMG-CoA Reductase                pravastatin (Pravachol)                   ADVICOR                             ALTOPREV (ST)
Inhibitors/Combinations          simvastatin (Zocor)                       CRESTOR                             CADUET
                                                                            LIPITOR                             LESCOL/XL (ST/QL)
(ST) Step Therapy= prior                                                                                        LIVALO (ST/QL)
use of simvastatin,                                                                                             VYTORIN (ST/QL)
pravastatin or lovastatin
required.

Antilipidemic Drugs-             cholestyramine (Questran)                  NIASPAN                             ANTARA (ST)
Other                            colestipol (Colestid)                      SIMCOR                              FIBRICOR (ST)
                                 fenofibrate 160mg or 200mg                TRICOR                              LIPOFEN
                                 gemfibrozil (Lopid)                       TRILIPIX                            LOFIBRA (ST)
                                                                            WELCHOL (ST)                        LOVAZA (formerly OMACOR) (PA)
                                                                                                                TRIGLIDE (ST)ZETIA (QL)
Page 5 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                     4 Tier Value Drug List                      November 2011
                                 Tier 1                                     Tier 2                      Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Other Cardiovascular             midodrine (Proamatine)                     LETAIRIS (PA/QL/SP)*        ADCIRCA (PA/SP)*
Drugs                            pentoxifylline (Trental)                                               ILARIS (PA/QL/SP)*
                                                                                                        REMODULIN (PA/SP)*
*Dispensing limited to 30                                                                               REVATIO (PA/QL/SP)*
days supply                                                                                             TRACLEER (ST/QL/SP)*
                                                                                                        TYVASO (PA/QL)*
                                                                                                        VENTAVIS (PA/SP)*
                                                       AUTONOMIC AND CNS MEDICATIONS
Non-narcotic Analgesics          tramadol (Ultram)                                                      PRIALT
                                 tramadol/acetaminophen (Ultracet)                                      RYBIX ODT (PA)
                                                                                                        tramadol ER (Ultram ER) (PA) Use
                                                                                                        tramadol first
Class II Narcotics               codeine                                    MSIR                        ABSTRAL (PA/QL)
                                 fentanyl patch (Duragesic)                 OPANA ER                    AVINZA (ST)
                                 fentanyl lozenge (Actiq) (PA/QL)           OXYCONTIN (QL)              EMBEDA
                                 hydromorphone (Dilaudid)                                               EXALGO (ST/QL)
                                 meperidine (Demerol/Mepergan)                                          FENTORA (PA)
                                 methadone                                                              KADIAN (ST)
                                 morphine sulfate                                                       LAZANDA (PA/QL)
                                 oxycodone (Roxicodone)                                                 LEVORPHANOL
                                 oxycodone/acetaminophen (Percocet/Tylox)                               NUCYNTA
                                 oxycodone/aspirin (Percodan)                                           ONSOLIS (PA/QL)
                                 oxycodone/ibuprofen (Combunox) (QL)                                    ORAMORPH
                                 oxymorphone (Opana)
Class III Narcotics              acetaminophen/codeine (Tylenol #2/#3/#4)                               BUTRANS (QL)
                                 aspirin/codeine (Empirin #2/#3/#4)                                     SUBOXONE FILM (ST)
                                 buprenorphine (Subutex)                                                SUBOXONE TABS
                                 hydrocodone/apap (Vicodin/Lortab)                                      VOPAC (QL)
                                 hydrocodone/aspirin (Lortab ASA)
                                 hydrocodone/ibuprofen (Vicoprofen)

Class IV Narcotics               pentazocine/apap (Talwin)
                                 pentazocine/naloxone (Talwin NX)


Drugs To Treat and               acetaminophen/butalbital (Phrenilin)       naratriptan (Amerge) (QL)   AXERT (ST/QL)
Prevent Headaches                acetaminophen/caff/butalbital (Fioricet)   MAXALT/MAXALT MLT           CAMBIA (PA/QL)
                                 aspirin/caffeine/butalbital (Fiorinal)     (ST/QL)                     FROVA (ST/QL)
                                 butorphanol (Stadol) (QL)                  MIGRANAL (QL)               RELPAX (ST/QL)
                                 ergotamine/caffeine (Cafergot)             sumatriptan nasal           SUMAVEL DosePro (PA/QL)
                                 isometh/dicloral/acetaminophen (Midrin)    spray/injection (QL)        TREXIMET (ST/QL)
                                 sumatriptan tabs (Imitrex) (QL)            ZOMIG/ZOMIG ZMT (ST/QL)

Anxiolytics                      alprazolam (Xanax, Niravam (PA) )                                      ALPRAZOLAM INTENSOL
                                 alprazolam ER (Xanax XR)                                               NIRAVAM (PA)
                                 buspirone (Buspar)
                                 chlordiazepoxide (Librium)
                                 clonazepam (Klonopin)
                                 clonazepam wafer (Klonopin Wafers) (PA)
                                 diazepam (Valium)
                                 lorazepam (Ativan)
                                 meprobamate (Equanil)
                                 oxazepam (Serax)

Page 6 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                 4 Tier Value Drug List                                   November 2011
                                 Tier 1                                        Tier 2                            Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Sedative Hypnotic Drugs          chloral hydrate                                                                 Use generic Ambien-Tier 1!
                                 estazolam (Prosom)                                                              EDLUAR (PA)
                                 flurazepam (Dalmane)                                                            LUNESTA (PA/QL)
                                 hydroxyzine (Atarax/Vistaril)                                                   ROZEREM (QL)
                                 temazepam (Restoril)                                                            SILENOR (PA)
                                 triazolam (Halcion)                                                             ZOLPIMIST (PA)
                                 zalepon (Sonata)
                                 zolpidem (Ambien)
                                 zolpidem CR (Ambien CR) (PA/QL)
Antimania Drugs                  lithium carbonate (Eskalith/Lithobid)
Anticonvulsant Drugs             carbamazepine (Tegretol, Carbatrol)           CELONTIN                          EQUETRO
                                 Carbamazepine Ext Rel (Tegretol XR)           DIASTAT                           HORIZANT (ST/QL)
                                 clonazepam (Klonopin)                         GABITRIL                          KEPPRA XR (PA)
                                 divalproex sodium (Depakote/ER)               PHENYTEK                          LAMICTAL ODT (PA)
                                 ethosuximide (Zarontin)                                                         LAMICTAL XR (PA)
                                 felbamate (Felbatol)                                                            LYRICA (PA)
                                 gabapentin (Neurontin)                                                          SABRIL
                                 lamotrigine (Lamictal)                                                          STAVZOR (PA)
                                 levetiracetam (Keppra)                                                          VIMPAT
                                 oxcarbazepine (Trileptal)
                                 phenobarbital
                                 phenytoin (Dilantin)
                                 primidone (Mysoline)
                                 topiramate (Topamax)
                                 valproic acid (Depakene)
                                 zonisamide capsules (Zonegran)
Antidepressant Drugs-            amitriptyline (Elavil)
                                 amitriptyline/perphenazine (Triavil)
                                 amoxapine (Ascendin)
                                 clomipramine (Anafranil)
                                 desipramine (Norpramin)
                                 doxepin (Sinequan)
                                 imipramine (Tofranil)
                                 imipramine pamoate (Tofranil PM) (PA)
                                 nortriptyline (Pamelor)
                                 protriptyline (Vivactil)

Antidepressant Drugs-             citalopram (Celexa)                         Use Tier 1 choice (i.e. generic   LUVOX CR (ST)
SSRIs                            fluoxetine (Prozac)                          Celexa) for a lower copayment     PEXEVA (ST)
                                 fluvoxamine (Luvox)                           LEXAPRO (ST/QL)                   PROZAC WEEKLY (ST)
ST=Prior use of a generic        paroxetine (Paxil)                            paroxetine CR (Paxil CR) (ST)     SARAFEM (ST)
SSRI is required                  sertraline (Zoloft)                                                           VIIBRYD (ST)
Antidepressant Drugs-            bupropion (/)                                 PRISTIQ (ST/QL)                   APLENZIN (PA)
Other                            bupropion SR/XL (Wellbutrin SR/XL) (PA for                                     CYMBALTA (ST/QL)
                                 smoking cessation)                                                              OLEPTRO (PA)
                                 maprotiline (Ludiomil)                                                          Venlafaxine Extended Release Tabs
                                 mirtazapine (Remeron/Soltab)                                                    (ST)
                                 nefazodone (Serzone)
                                 trazodone (Desyrel)
                                  venlafaxine Extended Release Caps
                                 (Effexor XR)

Antidepressant Drugs-            phenelzine (Nardil)                                                             EMSAM
MAO Inhibitors                   tranylcypromine (Parnate)

Page 7 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                   4 Tier Value Drug List                          November 2011
                                 Tier 1                                   Tier 2                          Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Antivertigo and                  dronabinol (Marinol) (PA)                Use ondansetron first-Tier 1!   Use ondansetron first-Tier 1!
Antiemetic Drugs                 meclizine (Antivert)                     ANZEMET (ST/QL)                 CESAMET (PA)
                                 granisetron (Kytril) (PA/QL)                                             EMEND (QL)
ST= Prior use of                 ondansetron (Zofran) (QL)                                               SANCUSO (ST/QL)
ondansetron is required          prochlorperazine (Compazine)                                             ZUPLENZ (PA/QL)
                                 promethazine (Phenergan)
                                 trimethobenzamide (Tigan)
Antiparkinson Drugs              amantadine (Symmetrel)                   AZILECT                         APOKYN (PA/QL)*
                                 benztropine (Cogentin)                   COMTAN                          MIRAPEX ER
*Dispensing limited to 30        bromocriptine (Parlodel)                 MIRAPEX                         REQUIP XL (ST)
days supply                      carbidopa/levodopa (Sinemet/Parcopa)                                     STALEVO
                                 pramipexole (Mirapex)                                                    TASMAR
                                 ropinirole (Requip) (QL)                                                 ZELAPAR
                                 selegiline (Eldepryl)
                                 trihexyphenidyl (Artane)

Misc. Neurologic                                                          SAVELLA                         XENAZINE (PA)

Conventional (Typical)           chlorpromazine (Thorazine)
Antipsychotic Drugs              fluphenazine (Prolixin)
                                 haloperidol (Haldol)
                                 loxapine (Loxitane)
                                 perphenazine (Trilafon)
                                 thioridazine (Mellaril)
                                 thiothixene (Navane)
                                 trifluoperazine (Stelazine)

Novel (Atypical)                 clozapine (Clozaril)                     olanzapine (Zyprexa) (QL)       ABILIFY (QL on Tablets)
Antipsychotic Drugs              risperidone (Riperdal)                   SEROQUEL (QL)                   FANAPT (QL)
                                                                          SEROQUEL XR (QL)                GEODON (QL)
                                                                                                          INVEGA (QL)
                                                                                                          INVEGA SUSTENNA
                                                                                                          LATUDA (QL)
                                                                                                          RISPERDAL CONSTA / M-TAB (QL)
                                                                                                          SAPHRIS (QL)

Antipsychotic/Depression                                                                                  SYMBYAX
CNS Stimulants/ADHD              amphetamine salts (Adderall)             Amphetamine salts ER            DAYTRANA
Drugs                            dextroamphetamine (Dexadrine)            (Adderall XR)                   FOCALIN XR
                                 dexmethylphenidate (Focalin)             Methylphenidate ER              INTUNIV(ST)
                                 methamphetamine (Desoxyn)                (Concerta)                      KAPVAY ER (ST)
                                 methylphenidate/ER (Ritalin/SR)                                          METADATE CD
                                 pemoline (Cylert)                                                        NUVIGIL (PA/QL)
                                                                                                          PROVIGIL (PA/QL)
                                                                                                          RITALIN LA
                                                                                                          STRATTERA (PA)
                                                                                                          VYVANSE
Other CNS/Autonomic              bupropion (Zyban) PA                                                     CAMPRAL (PA)
Drugs                            disulfiram (Antabuse)                                                    CHANTIX (PA after initial 30 days)
                                 naltrexone (Revia)                                                       GUANIDINE
                                 Pyridostigmine (Mestinon)                                                NUEDEXTA (PA)
                                                                                                          VIVITROL (PA)
                                                                                                          XYREM (PA)


Page 8 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                 4 Tier Value Drug List                                November 2011
                                 Tier 1                                       Tier 2                          Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in small
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference. If filled with the brand
pharmacy                         name, and not the generic, the
MB: Medical Benefit              prescription is treated as a Tier 3
See last pg for explanation of
these abbreviations              drug.
Alzheimer’s Drugs                donepezil (Aricept) (PA for age<50)                                          ARICEPT 23 (PA)
                                 galantamine (Razadyne/ER) (PA for age <50)                                   EXELON PATCH (ST)
                                 rivastigmine (Exelon) (PA for age<50)                                        NAMENDA (PA for age<50)

Drugs to Treat Multiple                                                       *AVONEX (PA/QL/SP)              *AMPYRA (PA/QL)
Sclerosis                                                                     *BETASERON (PA/QL/SP)           *EXTAVIA (PA/SP) (*Pls use
*Drugs limited to 30 days                                                     *COPAXONE (PA/QL/SP)            Betaseron)
                                                                                                              *GILENYA (PA/SP)
                                                                                                              *REBIF (PA/QL/SP)
                                                                                                              *TYSABRI (PA/SP)
                                                         DERMATOLOGICAL MEDICATIONS
Topical Corticosteroid           augmented betamethasone (Diprolene AF)                                       CLOBEX (ST) (Use clobetasol first)
Drugs-Very High Potency          clobetasol (Temovate)                                                        PSORCON-E
                                 clobetasol foam (Olux) (ST/QL)                                               OLUX E (ST)
                                 diflorasone acetate (Psorcon)
                                 halobetasol (Ultravate)

Topical Corticosteroid           amcinonide (Cyclocort)                                                       HALOG/HALOG E
Drugs- High Potency              betamethasone dipropionate (Diprolene)                                       LUXIQ (ST)(Use betamethasone
                                 betamethasone valerate (Valisone)                                            first)
                                 desoximetasone (Topicort)                                                    VANOS
                                 diflorasone (Florone)
                                 fluocinolone (Synalar)
                                 fluocinonide (Lidex)
Topical Corticosteroid           Flurandrenolide (Cordran lotion)                                             CLODERM
Drugs-Medium Potency             fluticasone (Cutivate)                                                       CORDRAN Tape (QL)
                                 hydrocortisone butyrate (Locoid)                                             PANDEL
                                 hydrocortisone valerate (Westcort)
                                 mometasone (Elocon)
                                 Prednicarbate (Dermatop E)
                                 triamcinolone (Kenalog)

Topical Corticosteroid           alclometasone dipropionate (Aclovate)                                        VERDESO (ST) (Use desonide first)
Drugs- Low Potency               desonide (DesOwen)
                                 hydrocortisone (Hytone) Note: 0.5% and 1%
                                 available without a prescription-OTC

Oral Antipruritic Agents         cyproheptadine (Periactin)
                                 hydroxyzine (Atarax/Vistaril)

Drugs to treat Psoriasis         calcipotriene (Dovonex) (QL)                 SORIATANE                       AMEVIVE (PA/QL/SP)*
and Eczema                       methotrexate                                                                 ATOPICLAIR
                                 selenium sulfide (Selsun)                                                    ENBREL (PA/QL/SP)*
*Dispensing limited to 30                                                                                     HUMIRA (PA/QL/SP)*
days supply                                                                                                   STELARA (PA/QL/SP)*
                                                                                                              TACLONEX (QL)
                                                                                                              TAZORAC
                                                                                                              VECTICAL (QL)

Oral Dermatological              doxycycline (Adoxa) (PA)                     AMNESTEEM                       DORYX (PA)
Drugs                            minocycline (Dynacin) (PA)                   CLARAVIS                        ORACEA (PA)
                                                                              Minocycline ER (Solodyn) (PA)   SOLODYN ER (PA)
                                                                              OXSORALEN-ULTRA

Page 9 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                    4 Tier Value Drug List                   November 2011
                                 Tier 1                                        Tier 2               Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Topical Acne and                 adapalene (Differin 0.1% cream or gel)        EPIDUO               ACANYA
Rosacea Drugs                    benzoyl peroxide/clindamycin (Benzaclin)      NORITATE             ACZONE
                                 clindamycin (Cleocin)                         RETIN-A MICRO        AZELEX
                                 erythromycin (Emgel)                                               CLINAC BPO
                                 erythromycin/benzamycin (Benzamycin)                               CLINDAGEL (ST)
                                 metronidazole (Metrocream/Metrogel 0.75%)                          DIFFERIN LOTION, 0.3% GEL (ST)
                                 tretinoin (Retin-A)                                                DUAC
                                                                                                    FINACEA
                                                                                                    METROGEL/METROLOTION
                                                                                                    PLEXION
                                                                                                    ROSAC
                                                                                                    ZIANA
Topical Dermatological           aluminum chloride                             CONDYLOX GEL         CARAC
Drugs                            Hydroquinone (Lustra/AF)                      EURAX                DERMA-CAS
                                 imiquimod (Aldara) (QL)                                            DERMA-SMOOTHE/FS (QL)
                                 lindane (Qwell)                                                    ELIDEL (QL) (PA age<2years old)
                                 permethrin (Acticin)                                               EVOCLIN (ST)
                                 podofilox (Condylox) topical solution                              NATROBA
                                 urea (Carmol, Keralac)                                             OXSORALEN
                                                                                                    PROTOPIC (QL) (PA age <2 years)
                                                                                                    REGRANEX (PA)
                                                                                                    SANTYL
                                                                                                    SILVER NITRATE
                                                                                                    SOLARAZE
                                                                                                    XERAC AC
                                                                                                    ZYCLARA (QL)
                                                         EAR-NOSE-THROAT MEDICATIONS
Drugs Affecting The Ear          acetic acid                                                        CIPRO HC
                                 acetic acid/hydrocortisone (VoSol HC Otic)                         CIPRODEX
                                 antipyrine/benzocaine (Auralgan Otic)                              COLY-MYCIN
                                 neomycin/polymix/hc otic (Cortisporin Otic)
                                 ofloxacin otic
Drugs Affecting The Nose         azelastine (Astelin)                          NASONEX              ASTEPRO (ST)
                                 flunisolide (Nasalide)                        VERAMYST             BECONASE/AQ (PA)
                                  fluticasone (Flonase)                                            NASAREL (PA)
                                 triamcinolone nasal (Nasacort AQ)                                  OMNARIS (PA)
                                                                                                    PATANASE (ST)
                                                                                                    RHINOCORT AQUA (PA)

Drugs Affecting The              triamcinolone (Kenalog in Orabase)            EVOXAC
Mouth
                                                              ENDOCRINE MEDICATIONS
Insulin                                                                        HUMALOG VIALS/PENS   APIDRA
                                                                               HUMULIN VIALS        HUMULIN PENS
                                                                               LANTUS VIALS         HUMALOG CARTRIDGE
                                                                               LEVEMIR VIALS/PENS   LANTUS SOLOSTAR
                                                                               NOVOLIN VIALS/PENS   NOVOLIN INNOLET/PENFILL
                                                                               NOVOLOG VIALS/PENS
Misc. Diabetic Drugs                                                           BYETTA (QL/PA)       SYMLIN (QL/PA)
                                                                                                    VICTOZA (QL/PA)




Page 10 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                     4 Tier Value Drug List                       November 2011
                                 Tier 1                                     Tier 2                       Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Oral Diabetic Drugs              acarbose (Precose)                         ACTOS (QL/ST)                AVANDIA (QL/ST)
                                 acetohexamide (Dymelor)                    ACTOplusMet/XR (QL/ST)       AVANDAMET (QL/ST)
                                 chlorpropamide (Diabenese)                 DUETACT (QL/ST)              AVANDARYL (QL/ST)
ST=Use metformin first           glimepiride (Amaryl)                       JANUVIA                      CYCLOSET
                                 glipizide/ER (Glucotrol/XL)               JANUMET                      FORTAMET ER (ST)
                                 glipizide/metformin (Metaglip)             WELCHOL (ST)                 GLUMETZA (ST)
                                 glyburide/metformin (Glucovance)                                        GLYSET
                                 gluburide (Diabeta/Micronase)                                          KOMBIGLYZE XR (ST)
                                 metformin/XR (Glucophage/XR)                                           ONGLYZA (ST)
                                 nateglinide (Starlix)                                                   PRANDIN
                                 tolazamide (Tolinase)                                                   PRANDIMET (ST)
                                 tolbutamide (Orinase)                                                   TRADJENTA (ST)


Glucocorticoid and               dexamethasone (Decadron)                                                ACTHAR GEL (PA)
Mineralcorticoid Drugs           fludrocortisone acetate (Florinef)
                                 hydrocortisone (Hydrocortone)
                                 methylprednisolone (Medrol)
                                 prednisolone (Orapred/Prelone/Pediapred)
                                 prednisone (Deltasone)
                                 triamcinolone (Aristocort)
                                                                                              st                           st
Osteoporosis Drugs               alendronate (Fosamax)                     Use alendronate 1 -Tier 1!   Use alendronate 1 -Tier 1!
                                 calcitonin-salmon (Miacalcin)              ACTONEL (ST)                 ATELVIA (ST)
                                 etidronate disodium tabs (Didronel)        ACTONEL + CALCIUM (ST)       BONIVA tablet/injection (ST)
                                                                            FORTEO                       EVISTA
                                                                                                         FOSAMAX PLUS D 2800/5600 (PA)
                                                                                                         FOSAMAX Solution
                                                                                                         PROLIA (PA/QL)
                                                                                                         RECLAST (PA)

Thyroid and Antithyroid          levothyroxine (Synthroid,Levoxyl)          SYNTHROID
Drugs                            liothyronine (Cytomel)                     thyroid (Armour Thyroid)
                                 methimazole (Tapazole)
                                 propylthiouracil (PTU)

Androgen Drugs                   danazol (Danocrine)                        ANDRODERM (PA/QL)            AXIRON (PA)
                                 fluoxymesterone (PA/QL)                    ANDROGEL (PA/QL)             FORTESTA (PA)
                                 methyltestosterone (Methitest) (PA/QL)                                  STRIANT (PA/QL)
                                                                                                         TESTIM (PA/QL)
                                                                                                         TESTOPEL (PA)

Other Endocrine Drugs            cabergoline tablets (Dostinex) (PA/QL)                                  ALDURAZYME (PA)
                                 desmopressin (DDAVP)                                                    ARCALYST (PA)
                                                                                                         CEREZYME (PA)
                                                                                                         FABRAZYME (PA)
                                                                                                         KUVAN (PA)
                                                                                                         MYOZYME (PA)
                                                                                                         NAGLAZYME (PA)
                                                                                                         SAMSCA (PA)
                                                                                                         SUCRAID (PA)
                                                                                                         VPRIV (PA)
                                                                                                         ZAVESCA (PA)


Page 11 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                      4 Tier Value Drug List                       November 2011
                                 Tier 1                                      Tier 2                       Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in small
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference. If filled with the brand
pharmacy                         name, and not the generic, the
MB: Medical Benefit              prescription is treated as a Tier 3
See last pg for explanation of
these abbreviations              drug.
                                                         GASTROINTESTINAL MEDICATIONS
Antidiarrheal Drugs              diphenoxylate/atropine (Lomotil)
                                 loperamide (Immodium)
                                 paregoric
Irritable Bowel Drugs                                                                                     LOTRONEX (QL) (PA for Males)
Antispasmodics/Drugs             dicyclomine (Bentyl)                                                     METOZOLV (PA)
Affecting GI Motility            hyoscyamine (Levsin)
                                 metoclopramide (Reglan)

H2 Antagonists                   cimetidine (Tagamet)
Note: All of the H2 drugs        famotidine (Pepcid)
below are also available         nizatidine (Axid)
without a prescription (OTC)     ranitidine (Zantac)

Proton Pump Inhibitors           omeprazole (Prilosec)                       Use Tier 1 omeprazole,       Use Tier 1 omeprazole, Prilosec
                                 pantoprazole (Protonix)                     Prilosec OTC or Prevacid     OTC or Prevacid OTC first!
*PA for age>15;                  Prevacid OTC                                OTC first!
Use Prilosec or Prevacid         Prilosec/omeprazole OTC covered!            lansoprazole                 ACIPHEX (ST)*
OTC at generic copay             Zegerid OTC                                 DEXILANT (preferred brand)   PROTONIX (brand name) (ST)* (QL
first!                                                                       (ST/QL)*                     on 20mg)
                                                                                                          NEXIUM (ST)* (QL on 20mg)
                                                                                                          Rx-PREVACID (ST)*
                                                                                                          (QL on 15mg)
                                                                                                          ZEGERID (ST)*

Helicobacter Pylori Drugs                                                    PREVPAC                      HELIDAC
                                                                                                          PYLERA


Other Antiulcer Drugs            misoprostol (Cytotec)
                                 sucralfate (Carafate)

Laxatives and Cathartics         electrolyte solution (Golytely, Nulytely)                                AMITIZA (QL)
                                                                                                          RELISTOR (PA)



Other GI Drugs                   balsalazide (Colazal)                       ASACOL/HD                    CUVPOSA (PA)
                                 glycopyrrolate (Robinul)                    CREON                        DIPENTUM
                                 lipram                                      LIALDA                       ENTOCORT EC
                                 pangestyme                                  PANCREASE MT                 GASTROCROM (PA)
                                 sulfasalazine (Azulfidine, Azulfidine EN)   PANCRELIPASE                 PENTASA
                                 ursodiol (Actigall)                         URSO                         SANDOSTATIN/LAR (PA/QL)
                                                                             ZENPEP                       SOMATULINE DEPOT
                                                                                                          ULTRASE/ULTRASE MT
                                                                                                          VIOKASE

Blood Modifiers                                                              ARANESP (QL)*                EPOGEN (QL)*
*Dispensing limited to a 30                                                  NEUPOGEN (QL)*               EXJADE (PA)*
day supply                                                                   PROCRIT (QL)*                NEULASTA (QL)*
                                                                                                          VIDAZA (PA)




Page 12 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                 4 Tier Value Drug List                           November 2011
                                 Tier 1                                  Tier 2                          Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Growth Hormones and                                                                                      EGRIFTA (PA)
Related Drugs                                                            NORDITROPIN (PA/SP)*            GENOTROPIN (PA/SP)*
*Dispensing limited to a 30                                              Norditropin is ConnectiCare’s   HUMATROPE (PA/SP)*
days supply                                                              preferred somatropin product.   INCRELEX (PA/SP)*
                                                                                                         NUTROPIN/AQ (PA/SP)*
                                                                                                         OMNITROPE (PA/SP)*
                                                                                                         SAIZEN (PA/SP)*
                                                                                                         SEROSTIM (PA/SP)*
                                                                                                         TEVTROPIN (PA/SP)*
                                                                                                         ZORBTIVE (PA/SP)*
Interferons                                                              *ACTIMMUNE (PA/SP)              *INFERGEN (PA/QL/SP)
*Dispensing limited to a 30                                              *INTRON-A (PA/SP)               *PEGASYS (PA/QL/SP) Preferred
days supply                                                              *ROFERON-A (PA/SP)              *PEG-INTRON (PA/QL/SP)
                                                                                                         *REBETRON (PA/QL/SP)
Interleukins                                                                                             PROLEUKIN (PA)
                                                            MUSCULOSKELETAL MEDICATIONS
Salicylates and Related          choline mag trisalicylate (Trilisate)
Drugs                            diflunisal (Dolobid)
                                 salsalate (Disalcid)
Non-Steroidal                    diclofenac/ER (Voltaren/XR)                                            Try a Tier 1 choice first, like naproxyn
Antiinflammatory Agents          etodolac/XL (Lodine/XL)                                                 or ibuprofen
(NSAIDS)                         ibuprofen (Motrin) suspension available OTC                            ARTHROTEC (PA)
                                 indomethacin/SR (Indocin/SR)                                            CELEBREX (PA/QL)
                                 ketoprofen (Orudis, Oruvail)                                            DUEXIS (PA/QL)
                                 ketorolac (Toradol) (QL)                                                FLECTOR PATCH (PA)
                                 meclofenamate (Meclomen)                                                PENNSAID (ST/QL)
                                 meloxicam (Mobic)                                                      PREVACID NAPRAPAC (PA)
                                 mefenamic acid (Ponstel) (PA)                                           VIMOVO (PA)
                                 nabumetone (Relafen)                                                    VOLTAREN GEL (PA)
                                 naproxen/CR (Naprosyn/EC)                                              ZIPSOR (PA)
                                 naproxen ER (Naprelen)
                                 oxaprozin (Daypro)
                                 piroxican (Feldene)
                                 sulindac (Clinoril)
Other Drugs for Arthritis        hydroxychloroquine (Plaquenil)               CUPRIMINE                  ACTEMRA (PA/MB)*
*Dispensing limited to a 30      leflunamide (Arava)                          RIDAURA                    CIMZIA (PA/QL/SP)
day supply                       methotrexate                                                            ENBREL (PA/QL/SP)*
                                                                                                         HUMIRA (PA/QL/SP)*
                                                                                                         KINERET (PA/QL)*
                                                                                                         ORENCIA (PA/SP/MB)*
                                                                                                         REMICADE (PA/MB)
                                                                                                         RITUXAN RA (PA/SP/MB)*
                                                                                                         SIMPONI (PA/SP)*
Hyaluronic Acids                                                                                         EUFLEXXA (PA) Preferred
                                                                                                         HYALGAN (PA/ST)
                                                                                                         ORTHOVISC (PA/ST)
                                                                                                         SUPARTZ (PA/ST)
                                                                                                         SYNVISC (PA) Preferred
                                                                                                         SYNVISC ONE (PA) Preferred
Drugs to Treat and               allopurinol (Zyloprim)                  COLCRYS                         KRYSTEXXA (PA)
Prevent Gout                     colchicine                                                              ULORIC (ST)
                                 probenacid (Benemid)
                                 probenacid & colchicine (Co-Benemid)


Page 13 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                  4 Tier Value Drug List                           November 2011
                                 Tier 1                                      Tier 2                       Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Skeletal Muscle                  baclofen (Lioresal) (QL)                                                 AMRIX (PA/QL)
Relaxants                        carisoprodol (Soma) (250mg PA)                                           FEXMID (ST)
                                 carisoprodol/aspirin (Soma Compound)                                     ZANAFLEX CAPSULES (PA)
                                 chlorzoxazone (Parafon Forte)
                                 chlorzoxazone/acetaminophen (Flexaphen)
                                 cyclobenzaprine (Flexeril)
                                 dantrolene (Dantrium)
                                 diazepam (Valium)
                                 metaxalone (Skelaxin)
                                 methocarbamol (Robaxin)
                                 methocarbamol/aspirin (Robaxisal)
                                 orphenadrine (Norflex)
                                 tizanide tablets (Zanaflex tabs)
                                               NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
Therapeutic Vitamins and         calcitriol (Rocaltrol)                      PHOSLO                       CALCIFEROL
Minerals                         cyanocobalamin (Vitamin B12)                                             HECTOROL
                                 folbic (Foltx)                                                           NASCOBAL
                                 ergocalciferol (Vitamin D)                                               ZEMPLAR
                                 folic acid (Folate)
                                 sodium fluoride (Luride)
Potassium Supplements            potassium bicarbonate/chloride (K-lyte)
                                 potassium chloride (K-Dur)
                                 potassium gluconate (Kaon)
Potassium Removing               sodium polystyrene sulfonate (Kayexalate)
Resins

Calcimimetic Agent                                                                                        SENSIPAR
Oral Anticoagulants and          warfarin                                    COUMADIN                     LYSTEDA
Vitamin K                                                                    MEPHYTON                     PRADAXA (PA/QL)
                                                                                                          XARELTO (QL)
Injectible Anticoagulants                                                    Enoxaparin (Lovenox) (QL)*   ARIXTRA (QL)*
*Dispensing limited to 30                                                                                 FRAGMIN (QL)*
days supply                                                                                               INNOHEP (QL)*
                                                                                                          IPRIVASK (QL)
Antiplatelet Drugs               cilostazol (Pletal)                         PLAVIX                       AGGRENOX
                                 dipyridamole (Persantine)                                                BRILINTA
                                 ticlopidine (Ticlid)                                                     EFFIENT
Platelet Stimulators                                                                                      NPLATE (PA/SP)
                                                                                                          PROMACTA (PA/SP)
Blood Detoxicants                lactulose (Cephulac)                        RENAGEL (QL)                 FOSRENOL
                                                                             RENVELA (QL)
Hemophilia Blood Factor                                                                                   ADVATE (PA/SP)*
Products                                                                                                  ALPHANATE (PA/SP)*
(zero copay applies)                                                                                      BENEFIX (PA/SP)*
                                                                                                          HUMATE-P (PA/SP)*
*30 day max fill                                                                                          HYATE-C (PA/SP)*
                                                                                                          KOGENATE (PA/SP)*
                                                                                                          MONARC-M (PA/SP)*
                                                                                                          MONOCLATE-P (PA/SP)*
                                                                                                          NOVOSEVEN (PA/SP)*
                                                                                                          RECOMBINATE (PA/SP)*
                                                                                                          XYNTHA (PA/SP)*


Page 14 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                    4 Tier Value Drug List                  November 2011
                                 Tier 1                                   Tier 2                   Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
                                              OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
Prenatal Vitamins                Vitafol OB                                                        Branded Prenatal Vitamins
                                 Edge OB
                                 Prenatal Plus Iron Tablets
                                 Select OB
                                 Prenatal 19
                                 Prenatal AD
                                 Prenatal Rx 1
                                 Prenatabs Rx
                                 Vinate GT
                                 Vinate M
                                 Vinate Ultra
                                 Vinate II
                                 Cal-Nate
                                 Citranatal Rx
                                 Ultra Natalcare
                                 Natalcare Rx
                                 Natalcare Plus
                                 Complete-RF Prenatal
                                 Prenaplus
                                 Renate
                                 Duet Stuartnatal
Specialized OB/GYN               isoxsuprine (Vasodilan)                  SYNAREL (PA)             LUPRON DEPOT
Drugs                            leuprolide (Lupron)
                                 methylergonovine (Methergine)
                                 terbutaline (Brethine)


OB/GYN Topical                   clindamycin vaginal cream (Cleocin)
Antiinfectives                   triple sulfa vaginal
                                 MetroGel vaginal

Infertility                      chorionic gonadotropin (PA/SP)           BRAVELLE (PA/SP)         CETROTIDE (PA/SP)
                                 clomiphene citrate (Clomid) (PA)         FOLLISTIM (PA/SP)        GONAL-F (PA/SP)
                                 Novarel (PA/SP)                          GANIRELIX (PA/SP)        LUVERIS (PA/SP)
                                                                          MENOPUR (PA/SP)          OVIDREL (PA/SP)
                                                                          REPRONEX (PA/SP)


Oral Estrogen Drugs              estradiol (Estrace)                      ESTRATEST/HS             CENESTIN
                                 estropipate (Ogen, Ortho-Est)            PREMARIN                 ENJUVIA
                                                                                                   MENEST


Topical Estrogen Drugs           estradiol transdermal patch              ESTRACE VAGINAL CREAM    DIVIGEL
                                 (Alora/Climara/Vivelle DOT/Estraderm)    EVAMIST                  ELESTRIN
                                                                          PREMARIN VAGINAL CREAM   ESTROGEL (2 copayments apply)
                                                                          VAGIFEM                  ESTRASORB
                                                                                                   MENOSTAR




Page 15 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                  4 Tier Value Drug List                            November 2011
                                 Tier 1                                  Tier 2                            Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS Continued
Estrogen/Progestin                                                       COMBIPATCH                        ACTIVELLA
Combinations                                                             PREMPHASE                         CLIMARA PRO
                                                                         PREMPRO                           FEMHRT
                                                                                                           PREFEST

Progestin Drugs                  medroxyprogesterone (Provera)                                             CRINONE (PA)
                                                                                                           ENDOMETRIN (PA)
                                                                                                           MAKENA (PA)
                                                                                                           PROMETRIUM

Contraceptives                   aranelle (Tri-Norinyl)                  Ask your doctor to try a Tier 1   Ask your doctor to try a Tier 1 choice
                                 apri (Ortho-Cept, Desogen)              choice first!                     first!
                                 aviane (Alesse, Levlite)                GIANVI (generic Yaz)              BEYAZ
                                 balziva (Ovcon)                         OCELLA (generic Yasmin)           ESTROSTEP FE
                                 camila (Nor-QD)                         YAZ                               GENERESS FE
                                 cryselle (Lo/Ovral)                                                       IMPLANON (PA)
                                 enpresse (Tri-Levlen, Triphasil)                                          LYBREL
                                 errin (Ortho Micronor)                                                    LoLOESTRIN
                                 jolessa (Seasonale)                                                       LOESTRIN-24 FE
                                 jolivette (Ortho Micronor)                                                LOSEASONQUE
                                 junel/FE (Loestrin/Fe)                                                    LYBREL
                                 kariva (Mircette)                                                         MIRENA (PA) (Medical Benefit)
                                 kelnor (Demulen)                                                          *MODICON
                                 leena (Tri-Norinyl)                                                       NATAZIA
                                 lessina (Alesse, Levlite)                                                 NUVARING
                                 levora (Levlen, Nordette, Seasonale)                                      *ORTHO-CEPT
                                 low-ogestrel (Lo/Ovral)                                                   *ORTHO-CYCLEN
                                 mononessa (Ortho-Cyclen)                                                  ORTHO DIAPHRAGM
                                 microgestin/FE (Loestrin/FE)                                              ORTHO EVRA
                                 necon (Modicon/Ortho-Novum)                                               *ORTHO MICRONOR
                                 nora be (Nor-QD)                                                          *ORTHO-NOVUM
                                 nortrel (Brevicon/Modicon)                                                *ORTHO TRI-CYCLEN
                                 ogestrel (Ovral)                                                          *ORTHO TRI-CYCLEN LO
                                 portia (Levlen, Nordette, Seasonale)                                      *OVCON
                                 Previfem (Ortho-Cyclen)                                                   OVRETTE
                                 Quasense (Seasonale)                                                      SEASONIQUE
                                 reclipsen (Ortho Cept/Desogen)                                            YASMIN
                                 solia (Ortho Cept)
                                 sprintec (Ortho Cyclen)
                                 sronyx (Alesse)
                                 tri-nessa (Ortho Tri-Cyclen)                                              *See Tier 1 equivalent drug!
                                 trivora (Tri-Levlen, Triphasil)
                                 tri-Lo-Sprintec (Ortho Tri-Cyclen Lo)
                                 tri-previfem (Ortho Tri-Cyclen)
                                 tri-sprintec (Ortho Tri-Cyclen)
                                 velivet (Cyclessa)
                                 zovia (Demulen)
Emergency                        levonorgestrel (Plan B) OTC if age>17                                     PLAN B ONE STEP (OTC if age >17)
Contraception




Page 16 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                  4 Tier Value Drug List                November 2011
                                 Tier 1                                         Tier 2         Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
                                                            OPHTHALMIC MEDICATIONS
Ophthalmic Topical               bacitracin (AK-Tracin)                                        BESIVANCE
Antibacterial Drugs              chloramphenicol (AK-Chlor)                                    QUIXIN
                                 ciprofloxacin (Ciloxan)                                       VIGAMOX
                                 erythromycin (Ilotycin)                                       ZYMAR
                                 gentamicin (Garamycin)                                        ZYMAXID
                                 neomycin/bacitracin/polymixin (Neosporin)
                                 neomycin/gramicidin/polymixin (Neosporin)
                                 ofloxacin (Ocuflox)
                                 polymixin/trimethoprim (Polytrim)
                                 sulfacetamide (Bleph-10)
                                 tobramycin (Tobrex)

Ophthalmic Topical               trifluridine (Viroptic)
Antiviral Drugs
Ophthalmic                       dexamethasone (Decadron)                       VEXOL          LOTEMAX
Corticosteroid Drugs             fluorometholone (FML)
                                 prednisolone (AK-Pred, Pred-Forte)




Ophthalmic antiinfective/        neomycin/bacitracin/polymixin/hydrocortisone   PRED-G         DUREZOL
corticosteroid Drugs             (Cortisporin Ointment)                         ZYLET          TOBRADEX ST
                                 neomycin/dexamethasone (NeoDecadron)
                                 neomycin/polymixin/dexamethasone
                                 (Maxitrol)
                                 neomycin/polymixin/hydrocortisone
                                 (Cortisporin Suspension)
                                 sulfacetamide/prednisolone (Blephamide)
                                 tobramycin-dexamethasone (Tobradex)



Oral Antiglaucoma Drugs          acetazolamide (Diamox)
                                 methazolamide (Neptazane)
Topical Antiglaucoma             betaxolol                                      ALPHAGAN P     AZOPT
Drugs                            brimonidine (Alphagan)                         COSOPT         BETOPIC S
                                 carteolol                                      LUMIGAN (ST)   COMBIGAN
                                 dipivefrin (Propine)                           TRUSOPT        TRAVATAN (ST)
                                 dorzolamide (Trusopt)                                         TRAVATAN Z (ST)
                                 dorzolamide/timolol (Cosopt)
                                 latanoprost (Xalatan)
                                 levobunolol (Betagan)
                                 metipranolol (Optipranolol)
                                 pilocarpine (Pilocar)
                                 timolol (Timoptic/XE, Betimol)




Page 17 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                     4 Tier Value Drug List                 November 2011
                                 Tier 1                                    Tier 2                  Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Other Ophthalmic Drugs           Zaditor OTC                               ALOCRIL (QL)            ACUVAIL
                                 Alaway OTC                                ALOMIDE (QL)            ALAMAST (QL)
                                 atropine                                  PATANOL (QL)            ALREX (QL)
                                 cromolyn (Crolom) (QL)                                            BEPREVE
                                 cyclopentolate (Cyclogyl)                                         ELESTAT (QL)
                                 flurbiprofen (Ocufen)                                             EMADINE (QL)
                                 ketoralac (Acular)                                                LASTACAFT
                                 ketotifen fumarate (Zaditor) (QL)                                 PATADAY (QL)
                                 naphazoline (AK-Con)                                              LUCENTIS (PA)
                                 phenylephrine (Neo-Synephrine)                                    MACUGEN (PA)
                                 tropicamide (Mydriacyl)                                           OPTIVAR (QL)
                                                                                                   RESTASIS (QL)
                                                                                                   VOLTAREN
                                                                                                   XIBROM
                                                             RESPIRATORY MEDICATIONS
Oral Beta-2 Adrenergic           albuterol (Proventil/Ventolin)
Drugs                            albuterol sa (Proventil /Volmax)
                                 terbutaline (Brethine)

Inhaled Beta-2                   albuterol solution (Proventil/Ventolin)   PROAIR HFA              BROVANA (PA)
Adrenergic Drugs                 albuterol CFC(Proventil/Ventolin)         SEREVENT                FORADIL
                                 metaproterenol (Alupent)                                          MAXAIR/AUTOHALER
                                                                                                   PROVENTIL HFA
                                                                                                   VENTOLIN HFA
                                                                                                   XOPENEX NEB (QL)
                                                                                                   XOPENEX HFA
Methylxanthine Drugs             aminophylline
                                 theophylline (Theodur)
Other Drugs for Asthma           cromolyn (Crolom)                         ADVAIR (QL)             DULERA
                                                                           COMBIVENT               XOLAIR (PA/SP)*
                                                                           SYMBICORT

Corticosteroid Inhalers          budesonide neb (Pulmicort Respule) (QL)   FLOVENT DISKUS          ALVESCO
                                                                           FLOVENT HFA             ASMANEX (QL)
                                                                           PULMICORT (QL)          AZMACORT
                                                                           QVAR
Spacer Devices                                                             AEROCHAMBER
                                                                           INSPIREASE

Leukotriene Modifiers            Zafirlukast (Accolate)                    SINGULAIR               ZYFLO
                                                                                                   ZYFLO CR (PA)
Antihistamines                   Cetirizine OTC (Zyrtec)                  ALAVERT (Brand) OTC     Try loratadine/cetirizine OTC first
                                 cyproheptadine (Periactin)                ALLEGRA (Brand) OTC     Tier 1!
*OTC= over-the-counter           Fexofenadine (Allegra) (QL)               CLARITIN (Brand) OTC    ALLERX (PA)
                                 hydroxyzine (Atarax/Vistaril)             ZYRTEC (Brand) OTC      CLARINEX (PA/QL)
                                 levocetirizine (Xyzal) (PA)
                                 Loratadine OTC(Claritin)
                                 promethazine (Phenergan)
Antihistamine/                   all generic antihistamine/decongestant    ALAVERT D (OTC)         fexofenadine-D (Allegra-D) (QL)
Decongestant                     combinations, including                   ALLEGRA-D (Brand) OTC   CLARINEX-D (PA/QL)
Combinations                     loratadine-D (Claritin-D) (OTC)           CLARITIN D (OTC)
                                 cetirizine-D (Zyrtec-D) (OTC)             ZYRTEC D (OTC)


Page 18 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                                   4 Tier Value Drug List                             November 2011
                                 Tier 1                                         Tier 2                       Tier 3
 Best Buy Drug                  Most Tier 1 drugs are generics, and
ST: Step Therapy                 the name listed first below in lower
PA: Pre-Authorization            case is the generic name. The
QL: Quantity Limit               branded names in ( ) are provided
SP: Fill at a specialty          for reference only. Check your
pharmacy                         benefit materials to determine cost
MB: Medical Benefit              share if the brand is filled.
See last pg for explanation of
these abbreviations
Antitussive and                  all generic narcotic and non-narcotic                                       TUSSIONEX
expectorant Drugs                containing antitussive and expectorant drugs
Other Respiratory Drugs          acetylcysteine (Mucomyst)                      ANA-KIT                      ANA-GUARD
                                 ipratropium nebulizer solution and nasal       ATROVENT HFA INHALER         ARALAST (PA)
* Limited to a 30 day supply     spray(Atrovent)                                EPI AUTO-JECT (Greenstone)   DALIRESP (ST/QL)
                                                                                (QL)                         EPIPEN (QL)
                                                                                PULMOZYME*                   GLASSIA (PA)
                                                                                SPIRIVA (QL)                 PROLASTIN (PA)
                                                                                TOBI*                        TWINJECT (QL)
                                                                                                             ZEMAIRA (PA)
                                                              UROLOGICAL MEDICATIONS
Anticholinergic                  flavoxate (Urispas)                                                         DETROL (ST)
Antispasmodics                   hyoscamine (Levsin)                                                         DETROL LA (ST)
                                 oxybutynin (Ditropan)                                                       ENABLEX (ST)
ST=Prior use of oxybutynin       oxybutynin XL (Ditropan XL)                                                 GELNIQUE (ST)
is required                                                                                                  OXYTROL (ST)
                                                                                                             SANCTURA XR (ST)
                                                                                                             Trospium (Sanctura) (ST)
                                                                                                             TOVIAZ (ST)
                                                                                                             VESICARE (ST)

Other Genitourinary              bethanachol (Urecholine)                                                    ELMIRON
Products                         generic Bicitra                                                             RENACIDIN
                                 generic Polycitra
                                 phenazopyridine (Pyridum)
Drugs for BPH                    alfuzosin (Uroxatral) (QL)                     AVODART (QL) (PA <age 55)    CARDURA XL (PA) use doxazosin 1st
                                 doxazosin (Cardura)                            CIALIS (PA/QL)               JALYN
                                 prazosin (Minipres)                                                         RAPAFLO (ST)
                                 finasteride (Proscar)
                                 tamsulosin (Flomax)
                                 terazosin (Hytrin)
Erectile Dysfunction             yohimbine (QL)                                 CIALIS (QL)                  CAVERJECT (QL)
(if covered by plan)                                                            LEVITRA (QL)                 EDEX (QL)
                                                                                                             MUSE (QL)
                                                                                                             STAXYN (QL)
                                                                                                             VIAGRA (QL)
                                                DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
Miscellaneous                    ergoloid mesylates                                                          CHEMET
Medications                                                                                                  ORFADIN (PA)
                                                                                                             ALL COMPOUNDED DRUGS (PA)
                                                                                                             MOST INJECTABLE DRUGS (PA)
Diabetic Test Strips                                                            ACCU-CHEK (QL)               Use Tier 2 Meter/Strips FIrst
                                                                                FREESTYLE (QL)               ASCENSIA (PA/QL)
                                                                                PRECISION (QL)               ONE TOUCH (PA/QL)
                                                                                SOF-TACT (QL)                SURESTEP (QL)
                                                                                                             TRACER BG (QL)
Misc Diabetic Supplies                                                          GLUCAGON KIT
                                                                                NOVOFINE
                                                                                NEEDLES/SYRINGES
                                                                                PRODIGY
                                                                                NEEDLES/SYRINGES
                                                                                SOFT TOUCH LANCETS
                                                                                SOFTCLIX LANCETS

Page 19 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members
                                                   4 Tier Value Drug List                       November 2011



Tier 4 : All color coded drugs.

Legend to color coding:

Applies to:    HOCC + SCC HDHP members
Applies to:    HOCC + SCC HDHP member
               HOCC HMO + POS members and CCHA members
Applies to:    HOCC HMO + POS and CCHA members,
               HOCC + SCC HDHP members
               CCI HDHP members

HOCC=Hospital of Central Connecticut
SCC=Southington Care Center
CCHA=Central CT Health Alliance
CCI=ConnectiCare
HDHP=High deductible health plan


ABBREVIATIONS GUIDE:
ST: Step Therapy—For medications marked with “ST”, members are encouraged to try a less expensive, similar drug
first . Your doctor can request authorization of the stepped (ST) medication and it will be approved if it meets our
criteria
PA: Pre-Authorization-- ConnectiCare requires these drugs to be submitted for authorization to ensure that the
medication is being prescribed and used appropriately.
QL: Quantity Limit—These medications have restrictions on the number of tablets/capsules/packages that are
dispensed, to ensure they are being prescribed in the correct quantities and/or dosages.
SP: Fill at a specialty pharmacy—These medications are best filled at a designated Specialty Pharmacy, which has
more knowledge of the clinical use and handling of these lesser used, more costly drugs.
MB: Medical Benefit—These prescriptions are typically supplied and administered by a physician in their office, and are
not filled by the member at a pharmacy.




Page 20 of 20
See "Tier 4 legend" on the last page of document for color definitions (Drug, Drug, Drug) The information in
this document applies only to members in groups specified in the “legend” at the bottom of this document. The
information in this document does not apply to ConnectiCare VIP plan members

				
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