2011 Medicare Prescription Drug Formulary

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					Standard Plan

2011 Medicare
Prescription Drug
Formulary
(Comprehensive list of
covered drugs)




 PLEASE READ: THIS DOCUMENT
 CONTAINS INFORMATION ABOUT THE
 DRUGS WE COVER IN THIS PLAN.

 Note to existing members: This formulary
 has changed since last year. Please review
 this document to make sure that it still
 contains the drugs you take.

+ Beneficiaries must use network pharmacies to access their prescription drug benefit.
+ Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may
  change on January 1, 2012.
+ This information may be available in a different format.
  Please contact Customer Service at 1-888-247-4142 (TTY/TDD 1-888-247-4145) if you
  need plan information in another format or language.

Blue Cross and Blue Shield of North Carolina is a Medicare-approved Part-D sponsor.

Y0079_4838, File & Use 09012010                                                       Last updated April 2011
2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary



HPMS Approved Formulary File Submission ID 11228, Version 11



What is the Blue Medicare Rx Standard (PDP) Formulary?

A formulary is a list of covered drugs selected by Blue Medicare Rx Standard in consultation with a
team of health care providers, which represents the prescription therapies believed to be a
necessary part of a quality treatment program. Blue Medicare Rx Standard will generally cover the
drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at
a Blue Medicare Rx network pharmacy, and other plan rules are followed. For more information on
how to fill your prescriptions, please review your Evidence of Coverage.


Can the Formulary change?

Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of
the year, we will not discontinue or reduce coverage of the drug during the 2011 coverage
year except when a new, less expensive generic drug becomes available or when new
adverse information about the safety or effectiveness of a drug is released. Other types of
formulary changes, such as removing a drug from our formulary, will not affect members who
are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you
have continued access for the remainder of the coverage year to the formulary drugs that
were available when you chose our plan, except for cases in which you can save additional
money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify
affected members of the change at least 60 days before the change becomes effective, or at
the time the member requests a refill of the drug, at which time the member will receive a 60-
day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to
be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately
remove the drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of April 2011. To get updated information about the drugs
covered by Blue Medicare Rx Standard, please visit our Web site at
www.bcbsnc.com/member/medicare or call Customer Services at 1-888-247-4142, 7 days a
week, 8:00 am to 8:00 pm. TTY/TDD users should call 1-888-247-4145. If non-maintenance
formulary changes occur during the plan year, members will be provided notice and the
printable formulary will updated and posted on our website at
www.bcbsnc.com/member/medicare.




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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary




How do I use the Formulary?
There are two ways to find your drug within the formulary:


Medical Condition
   The formulary begins on page 15. The drugs in this formulary are grouped into categories
   depending on the type of medical conditions that they are used to treat. For example, drugs
   used to treat a heart condition are listed under the category, Cardiovascular, Hypertension &
   Lipids”. If you know what your drug is used for, look for the category name in the list that
   begins below. Then look under the category name for your drug.


Alphabetical Listing
   If you are not sure what category to look under, you should look for your drug in the Index that
   begins on page 53. The Index provides an alphabetical list of all of the drugs included in this
   document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index
   and find your drug. Next to your drug, you will see the page number where you can find
   coverage information. Turn to the page listed in the Index and find the name of your drug in the
   first column of the list.


What are generic drugs?
   Blue Medicare Rx Standard covers both brand name drugs and generic drugs. A generic drug
   is approved by the FDA as having the same active ingredient as the brand name drug.
   Generally, generic drugs cost less than brand name drugs.


Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:


   •   Prior Authorization: Blue Medicare Rx Standard requires you [or your physician] to get
       prior authorization for certain drugs. This means that you will need to get approval from
       Blue Medicare Rx Standard before you fill your prescriptions. If you don’t get approval, Blue
       Medicare Rx Standard may not cover the drug.


   •   Quantity Limits: For certain drugs, Blue Medicare Rx Standard limits the amount of the
       drug that Blue Medicare Rx Standard will cover. For example, Blue Medicare Rx Standard
       provides 9 tablets per prescription for Imitrex. This may be in addition to a standard one
       month or three month supply.
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary




   •   Step Therapy: In some cases, Blue Medicare Rx Standard requires you to first try certain
       drugs to treat your medical condition before we will cover another drug for that condition.
       For example, if Drug A and Drug B both treat your medical condition, Blue Medicare Rx
       Standard may not cover Drug B unless you try Drug A first. If Drug A does not work for you,
       Blue Medicare Rx Standard will then cover Drug B.


You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 15. You can also get more information about the restrictions
applied to specific covered drugs by visiting our Web site at
www.bcbsnc.com/member/medicare.


You can ask Blue Medicare Rx Standard to make an exception to these restrictions or limits. See
the section, “How do I request an exception to the Blue Medicare Rx Standard’s formulary?” on
page 3 for information about how to request an exception.


What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Customer Services and
confirm that your drug is not covered. If you learn that Blue Medicare Rx Standard does not cover
your drug, you have two options:


   •   You can ask Customer Services for a list of similar drugs that are covered by Blue Medicare
       Rx Standard. When you receive the list, show it to your doctor and ask him or her to
       prescribe a similar drug that is covered by Blue Medicare Rx Standard.


   •   You can ask Blue Medicare Rx Standard to make an exception and cover your drug. See
       below for information about how to request an exception.


How do I request an exception to the Blue Medicare Rx Standard’s Formulary?


You can ask Blue Medicare Rx Standard to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.


   •   You can ask us to cover your drug even if it is not on our formulary.



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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


   •   You can ask us to waive coverage restrictions or limits on your drug. For example, for
       certain drugs, Blue Medicare Rx Standard limit the amount of the drug that we will cover. If
       your drug has a quantity limit, you can ask us to waive the limit and cover more.


You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our
non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the
preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we
grant your request to cover a drug that is not on our formulary, you may not ask us to provide a
higher level of coverage for the drug. Also, you may not ask us to provide a higher level of
coverage for drugs that are in the specialty tier
Generally, Blue Medicare Rx Standard will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have
adverse medical effects.


You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing
physician’s supporting statement. You can request an expedited (fast) exception if you or your
doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get your prescriber’s or prescribing physician’s supporting statement.



What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your doctor
to determine the right course of action for you, we may cover your drug in certain cases during the
first 90 days you are a member of our plan.


For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when
you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even
if you have been a member of the plan less than 90 days.



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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply
(unless you have a prescription written for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.


Transition medications will be provided to enrollees who change treatment settings due to changes
in level of care (e.g. individuals who enter long term care facilities from hospitals or enter an
ambulatory setting from a hospital).



For more information


For more detailed information about your Blue Medicare Rx Standard prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
 If you have questions about Blue Medicare Rx Standard, please call Customer Services at 1-888-
247-4142, 7 days a week, 8:00 am to 8:00 pm. TTY/TDD users should call 1-888-247-4145. Or
visit www.bcbsnc.com/member/medicare.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-
877-486-2048. Or, visit www.medicare.gov.


Blue Medicare Rx’s Formulary

The formulary below provides coverage information about some of the drugs covered by Blue
Medicare Rx Standard. If you have trouble finding your drug in the list, turn to the Index that begins
on page 53.


The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZOCOR)
and generic drugs are listed in lower-case italics (e.g., simvastatin).


The information in the Notes column tells you if Blue Medicare Rx Standard (PDP) has any special
requirements for coverage of your drug. Specific information regarding drugs that may require prior
authorization, step therapy, quantity limitation or limited access are noted in the Requirements /
Limits (Req./Limits) column. The following is a key to abbreviations you will find in this column.




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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information call Customer Service.


PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval before you fill your prescriptions. If
you don’t get approval, we may not cover the drug.


ST: Step Therapy. In some cases, Blue Medicare Rx Standard (PDP) requires you to first try
certain drugs to treat your medical condition before we will cover another drug for that condition.
For example, if Drug A and Drug B both treat your medical condition, Blue Medicare Rx Standard
(PDP) may not cover drug B unless you try Drug A first. If Drug A does not work for you, Blue
Medicare Rx Standard (PDP) will then cover Drug B.


QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
For example, the Plan provides 9 tablets per prescription for Imitrex 100 mg. See the list of drugs
with quantity limits beginning on the next page.




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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


Drugs that have Quantity Limits (QL)

                                                    Quantity Limit Amount
Drug Name                      Drug Strength
                                               per 30 Days     per 90 Days
ACTONEL                        5 MG            30              90
ACTONEL                        30 MG           30              90
ACTONEL                        35 MG           4 per 28 days   12 per 84 days
ACTONEL                        150 MG          1               3
AGGRENOX                       25 MG/200 MG    60              180
alendrondate sodium tab        5 mg            30              90
alendrondate sodium tab        10 mg           30              90
alendrondate sodium tab        35 mg           4 per 28 days   12 per 84 days
alendrondate sodium tab        40 mg           30              90
alendrondate sodium tab        70 mg           4 per 28 days   12 per 84 days
ALTOPREV                       20 MG           30              90
ALTOPREV                       40 MG           30              90
ALTOPREV                       60 MG           30              90
AMERGE                         1 MG            23              69
AMERGE                         2.5 MG          9               27
APLENZIN                       174 MG          30              90
APLENZIN                       348 MG          30              90
APLENZIN                       522 MG          30              90
ARICEPT                        5 MG            30              90
ARICEPT                        10 MG           30              90
ARICEPT                        23 MG           30              90
ARICEPT ODT                    5 MG            30              90
ARICEPT ODT                    10 MG           30              90
ATELVIA                        35 MG           4 per 28 days   12 per 84 days
AXERT                          6.25 MG         16              48
AXERT                          12.5 MG         8               24
BONIVA TAB                     150 MG          1               3
budeprion sr                   100 mg          60              180
budeprion sr                   150 mg          60              180
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                   Quantity Limit Amount
Drug Name                    Drug Strength
                                             per 30 Days       per 90 Days
budeprion xl                 150 mg          90                270
budeprion xl                 300 mg          30                90
bupropion hcl sr             100 mg          60                180
bupropion hcl sr             200 mg          60                180
butorphanol tartrate nasal   10 mg/ml        10 ml             30 ml
CADUET                       2.5 MG/10 MG    30                90
CADUET                       2.5 MG/20 MG    30                90
CADUET                       2.5 MG/40 MG    30                90
CADUET                       5 MG/10 MG      30                90
CADUET                       5 MG/20 MG      30                90
CADUET                       5 MG/40 MG      30                90
CADUET                       5 MG/80 MG      30                90
CADUET                       10 MG/10 MG     30                90
CADUET                       10 MG/20 MG     30                90
CADUET                       10 MG/40 MG     30                90
CADUET                       10 MG/80 MG     30                90
COGNEX                       10 MG           120               360
COGNEX                       20 MG           120               360
COGNEX                       30 MG           120               360
COGNEX                       40 MG           120               360
CRESTOR                      5 MG            30                90
CRESTOR                      10 MG           30                90
CRESTOR                      20 MG           30                90
CRESTOR                      40 MG           30                90
CYMBALTA                     20 MG           60                180
CYMBALTA                     30 MG           60                180
CYMBALTA                     60 MG           30                90
donepezil                    5 mg            30                90
donepezil                    10 mg           30                90
donepezil odt                5 mg            30                90
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                    Quantity Limit Amount
Drug Name                      Drug Strength
                                               per 30 Days     per 90 Days
donepezil odt                  10 mg           30              90
EFFEXOR XR                     37.5 MG         30              90
EFFEXOR XR                     75 MG           30              90
EFFEXOR XR                     150 MG          30              90
EMSAM                          6 MG/24 HR      30              90
EMSAM                          9 MG/24 HR      30              90
EMSAM                          12 MG/24 HR     30              90
EXELON CAP                     1.5 MG          60              180
EXELON CAP                     3 MG            60              180
EXELON CAP                     4.5 MG          60              180
EXELON CAP                     6 MG            60              180
EXELON PATCH                   4.6 MG/24 HR    30              90
EXELON PATCH                   9.5 MG/24 HR    30              90
FOSAMAX TAB                    5 MG            30              90
FOSAMAX TAB                    10 MG           30              90
FOSAMAX TAB                    35 MG           4 per 28 days   12 per 84 days
FOSAMAX TAB                    40 MG           30              90
FOSAMAX TAB                    70 MG           4 per 28 days   12 per 84 days
FOSAMAX SOLN                   70 MG/75 ML     300 ml per 28   900 ml per 84
                                               days            days
FOSAMAX PLUS D                 70 MG/2800      4 per 28 days   12 per 84 days
                               UNIT
FOSAMAX PLUS D                 70 MG/5600      4 per 28 days   12 per 84 days
                               UNIT
FROVA                          2.5 MG          12              36
galantamine hydrobromide er    8 mg            30              90
cap
galantamine hydrobromide er    16 mg           30              90
cap
galantamine hydrobromide er    24 mg           30              90
cap
galantamine hydrobromide tab   4 mg            60              180
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                       Quantity Limit Amount
Drug Name                      Drug Strength
                                                per 30 Days       per 90 Days
galantamine hydrobromide tab   8 mg             60                180
galantamine hydrobromide tab   12 mg            60                180
IMITREX TAB                    25 MG            36                108
IMITREX TAB                    50 MG            18                54
IMITREX TAB                    100 MG           9                 27
IMITREX NASAL                  5 MG             36                108
IMITREX NASAL                  20 MG            9                 27
IMITREX INJ                    6 MG/0.5 ML      4 ml              12 ml
IMITREX STATDOSE REFILL        4 MG/0.5 ML      4 ml              12 ml
IMITREX STATDOSE REFILL        6 MG/0.5 ML      4 ml              12 ml
ketorolac tromethamine tab     10 mg            20                60
LESCOL                         20 MG            60                180
LESCOL                         40 MG            60                180
LESCOL XL                      80 MG            30                90
LIPITOR                        10 MG            30                90
LIPITOR                        20 MG            30                90
LIPITOR                        40 MG            30                90
LIPITOR                        80 MG            30                90
LIVALO                         1 MG             30                90
LIVALO                         2 MG             30                90
LIVALO                         4 MG             30                90
lovastatin                     10 mg            30                90
lovastatin                     20 mg            60                180
lovastatin                     40 mg            60                180
LOVAZA                         375 MG/465 MG/   120               360
                               1 GM
MAXALT                         5 MG             24                72
MAXALT                         10 MG            12                36
MAXALT MLT                     5 MG             24                72
MAXALT MLT                     10 MG            12                36
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                  Quantity Limit Amount
Drug Name                   Drug Strength
                                             per 30 Days       per 90 Days
MEVACOR                     20 MG            60                180
MEVACOR                     40 MG            60                180
mirtazapine tab             7.5 mg           30                90
mirtazapine tab             15 mg            30                90
mirtazapine tab             30 mg            30                90
mirtazapine tab             45 mg            30                90
mirtazapine odt             15 mg            30                90
mirtazapine odt             30 mg            30                90
mirtazapine odt             45 mg            30                90
NAMENDA                     5 MG             90                270
NAMENDA                     10 MG            60                180
naratriptan                 1 mg             23                69
naratriptan                 2.5 mg           9                 27
nefazodone hcl              50 mg            60                180
nefazodone hcl              100 mg           60                180
nefazodone hcl              150 mg           60                180
nefazodone hcl              200 mg           60                180
nefazodone hcl              250 mg           60                180
OLEPTRO                     150 MG           75                225
OLEPTRO                     300 MG           30                90
PLAVIX                      75 MG            30                90
PRAVACHOL                   10 MG            30                90
PRAVACHOL                   20 MG            30                90
PRAVACHOL                   40 MG            60                180
PRAVACHOL                   80 MG            30                90
pravastatin sodium          10 mg            30                90
pravastatin sodium          20 mg            30                90
pravastatin sodium          40 mg            60                180
pravastatin sodium          80 mg            30                90
PRISTIQ                     50 MG            30                90
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                    Quantity Limit Amount
Drug Name                   Drug Strength
                                             per 30 Days       per 90 Days
PRISTIQ                     100 MG           30                90
RAZADYNE                    4 MG             60                180
RAZADYNE                    8 MG             60                180
RAZADYNE                    12 MG            60                180
RAZADYNE ER                 8 MG             30                90
RAZADYNE ER                 16 MG            30                90
RAZADYNE ER                 24 MG            30                90
RELPAX                      20 MG            16                48
RELPAX                      40 MG            8                 24
REMERON                     15 MG            30                90
REMERON                     30 MG            30                90
REMERON                     45 MG            30                90
REMERON SOLTAB              15 MG            30                90
REMERON SOLTAB              30 MG            30                90
REMERON SOLTAB              45 MG            30                90
rivastigmine cap            1.5 mg           60                180
rivastigmine cap            3 mg             60                180
rivastigmine cap            4.5 mg           60                180
rivastigmine cap            6 mg             60                180
simvastatin                 5 mg             30                90
simvastatin                 10 mg            30                90
simvastatin                 20 mg            30                90
simvastatin                 40 mg            30                90
simvastatin                 80 mg            30                90
SKELID                      240 MG           60                180
sumatriptan succinate tab   25 mg            36                108
sumatriptan succinate tab   50 mg            18                54
sumatriptan succinate tab   100 mg           9                 27
sumatriptan succinate inj   4 mg/0.5 ml      4 ml              12 ml
sumatriptan succinate inj   6 mg/0.5 ml      4 ml              12 ml
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                  Quantity Limit Amount
Drug Name                   Drug Strength
                                             per 30 Days       per 90 Days
ticlopidine hcl             250 mg           60                180
TREXIMET                    500 MG/85 MG     9                 27
venlafaxine hcl tab         25 mg            90                270
venlafaxine hcl tab         37.5 mg          90                270
venlafaxine hcl tab         50 mg            90                270
venlafaxine hcl tab         75 mg            90                270
venlafaxine hcl tab         100 mg           90                270
venlafaxine hcl er cap      37.5 mg          30                90
venlafaxine hcl er cap      75 mg            30                90
venlafaxine hcl er cap      150 mg           30                90
VENLAFAXINE HCL ER TAB      37.5 MG          30                90
VENLAFAXINE HCL ER TAB      75 MG            30                90
VENLAFAXINE HCL ER TAB      150 MG           30                90
VENLAFAXINE HCL ER TAB      225 MG           30                90
VYTORIN                     10 MG/10 MG      30                90
VYTORIN                     10 MG/20 MG      30                90
VYTORIN                     10 MG/40 MG      30                90
VYTORIN                     10 MG/80 MG      30                90
WELLBUTRIN SR               100 MG           60                180
WELLBUTRIN SR               150 MG           60                180
WELLBUTRIN SR               200 MG           60                180
WELLBUTRIN XL               150 MG           90                270
WELLBUTRIN XL               300 MG           30                90
ZETIA                       10 MG            30                90
ZOCOR                       5 MG             30                90
ZOCOR                       10 MG            30                90
ZOCOR                       20 MG            30                90
ZOCOR                       40 MG            30                90
ZOCOR                       80 MG            30                90
ZOMIG TAB                   2.5 MG           16                48
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2011 Blue Medicare Rx Standard (PDP) Comprehensive Formulary


                                                            Quantity Limit Amount
Drug Name                         Drug Strength
                                                      per 30 Days        per 90 Days
ZOMIGTAB                          5 MG                8                  24
ZOMIG NASAL                       5 MG                8                  24
ZOMIG ZMT                         2.5 MG              16                 48
ZOMIG ZMT                         5 MG                8                  24




The Drug Table includes a column titled, “Drug Tier.” This column indicates what tier each drug is
listed under. The following copayments are associated with the corresponding tiers if you receive
the drugs at an in-network pharmacy. These copayments apply during the initial coverage phase.
Refer to your Evidence of Coverage for details about your benefits during the coverage gap and
catastrophic coverage.
After the annual $120 deductible has been satisfied, the following copayment amounts apply:

Tier Number        Retail Pharmacy for up    Preferred Mail Order     Long Term Care
                   to and including a 30     Pharmacy for a 90 day    Pharmacy for up to
                   day supply                supply                   and including a 31 day
                                                                      supply

Tier 1 – Generic   $10 copayment             $0 copayment             $10 copayment

Tier 2 -           $45 copayment             $112.50 copayment        $45 copayment
Preferred Brand

Tier 3 – Non-      $95 copayment             $237.50 copayment        $95 copayment
Preferred Brand

Tier 4 – Specialty 30% coinsurance           30% coinsurance          30% coinsurance




                                                                                                14
    Drug Name                         Drug       Reqs.        Drug Name                            Drug       Reqs.
                                      Tier      /Limits                                            Tier      /Limits
    ANTI - INFECTIVES                                          ribasphere cap 200 mg                1
  ANTIFUNGAL AGENTS                                            ribasphere tab 200 mg                1
  Generics                                                     ribavirin cap 200 mg                 1
  amphotericin b inj                      1        PA          ribavirin tab 200 mg                 1
  clotrimazole troche                     1                    rimantadine hcl                      1
  fluconazole                             1                    stavudine                            1
  fluconazole in dextrose                 1                    valacyclovir hcl                     1
  griseofulvin microsize susp             1                    zidovudine                           1
  itraconazole cap                        1                    BRANDS
  ketoconazole tab                        1                    APTIVUS                                 4
  nystatin susp                           1                    ATRIPLA                                 4
  nystatin tab                            1                    BARACLUDE SOLN                          3
  terbinafine hcl tab                     1                    BARACLUDE TAB                           4
  BRANDS                                                       COMBIVIR                                4
  ABELCET                                 4        PA          COPEGUS                                 4
  AMBISOME                                4        PA          CRIXIVAN                                2
  AMPHOTEC                                3        PA          CYTOVENE                                3        PA
  ANCOBON                                 2                    EMTRIVA                                 2
  CANCIDAS                                4                    EPIVIR                                  3
  DIFLUCAN                                3                    EPIVIR HBV                              3
  DIFLUCAN IN NACL                        3                    EPZICOM                                 4
  ERAXIS                                  3                    FAMVIR                                  3
  GRIFULVIN V                             3                    FLUMADINE                               3
  GRIS-PEG                                3                    FUZEON                                  2
  LAMISIL GRANULES                        3                    HEPSERA                                 4
  LAMISIL TAB                             3                    INTELENCE                               4
  MYCAMINE                                4                    INVIRASE                                4
  NOXAFIL                                 4                    ISENTRESS                               4
  ORAVIG                                  3                    KALETRA SOLN                            4
  SPORANOX CAP                            3                    KALETRA TAB 100 MG/25 MG                3
  SPORANOX PULSEPAK                       3                    KALETRA TAB 200 MG/50 MG                4
  SPORANOX SOLN                           3                    LEXIVA SUSP                             3
  VFEND                                   4                    LEXIVA TAB                              4
  VFEND IV                                4                    NORVIR                                  2
                                                               PREZISTA 150 MG                         3
  ANTIVIRALS                                                   PREZISTA 400 MG                         4
  Generics                                                     PREZISTA 600 MG                         4
  acyclovir                               1                    PREZISTA 75 MG                          3
  acyclovir sodium                        1        PA          REBETOL                                 4
  amantadine hcl                          1                    RELENZA DISKHALER                       3
  didanosine                              1                    RESCRIPTOR                              2
  famciclovir                             1                    RETROVIR                                3
  foscarnet sodium                        1        PA          RETROVIR IV INFUSION                    2
  ganciclovir cap                         1                    REYATAZ 100 MG                          3
  ganciclovir sodium inj                  1        PA          REYATAZ 150 MG                          3
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;        15 
 PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 REYATAZ 200 MG                        4                      ceftazidime                            1
 REYATAZ 300 MG                        4                      ceftriaxone sodium                     1
 RIBAPAK                               4                      cefuroxime axetil                      1
 RIBASPHERE TAB 400 MG                 4                      cefuroxime sodium                      1
 RIBASPHERE TAB 600 MG                 4                      cephalexin                             1
 SELZENTRY                             4                      BRANDS
 SUSTIVA                               2                      CEFAZOLIN SODIUM 20 GM                  2
 SYNAGIS                               4                      CEFOTETAN                               2
 TAMIFLU                               3                      CEFTRIAXONE/DEXTROSE                    2
 TRIZIVIR                              4                      CEFUROXIME/DEXTROSE                     2
 TRUVADA                               4                      CLAFORAN 1 GM                           2
 TYZEKA                                3                      FORTAZ 1 GM                             2
 VALCYTE                               4                      FORTAZ 1 GM/50ML; 5%                    2
 VALTREX                               3                      FORTAZ 2 GM/50ML; 5%                    2
 VIDEX EC                              3                      FORTAZ 6 GM                             2
 VIDEX PEDIATRIC                       2                      MAXIPIME 2 GM                           2
 VIRACEPT POWD                         3                      SUPRAX                                  2
 VIRACEPT TAB                          4                      TAZICEF                                 2
 VIRAMUNE                              2                      ZINACEF 1.5 GM                          2
 VIRAZOLE                              4          PA          ZINACEF 750 MG                          2
 VIREAD                                2                      ZINACEF IN ISO-OSMOTIC                  2
 VISTIDE                               4                        DEXTROSE
 ZERIT CAP                             3                      CEDAX                                   3
 ZERIT SOL                             2                      CEFOXITIN SODIUM 1 GM;                  3
 ZIAGEN                                2                        4%
 ZOVIRAX CAP                           3                      CEFOXITIN SODIUM 2 GM;                  3
 ZOVIRAX SUSP                          3                        2.2%
 ZOVIRAX TAB                           3                      CEFTIN                                  3
                                                              CLAFORAN 10 GM                          3
 CEPHALOSPORINS                                               CLAFORAN 2 GM                           3
 Generics                                                     CLAFORAN 500 MG                         3
 cefaclor                                 1                   FORTAZ 2 GM                             3
 cefaclor er                              1                   KEFLEX 250 MG                           3
 cefadroxil                               1                   KEFLEX 500 MG                           3
 cefazolin sodium 1 gm                    1                   KEFLEX 750 MG                           3
 cefazolin sodium 1 gm; 5%                1                   MAXIPIME 1 GM                           3
 cefazolin sodium 500 mg                  1                   OMNICEF                                 3
 cefdinir                                 1                   ROCEPHIN                                3
 cefepime                                 1                   SPECTRACEF                              3
 cefotaxime sodium                        1                   TEFLARO                                 3
 cefoxitin sodium 1 gm                    1                   VANTIN                                  3
 cefoxitin sodium 10 gm                   1                   ZINACEF 7.5 GM                          3
 cefoxitin sodium 2 gm                    1
 cefpodoxime proxetil                     1
 cefprozil                                1
16  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 ERYTHROMYCINS / OTHER                                         gentamicin sulfate 40 mg/ml           1
 MACROLIDES                                                    hydroxychloroquine sulfate            1
 Generics                                                      isonarif                              1
 azithromycin                            1                     isoniazid inj                         1
 clarithromycin                          1                     isoniazid tab                         1
 clarithromycin er                       1                     isotonic gentamicin                   1
 e.e.s. 400                              1                     kanamycin sulfate                     1
 ery-tab 250 mg                          1                     mebendazole                           1
 ery-tab 333 mg                          1                     mefloquine hcl                        1
 erythrocin stearate                     1                     meropenem                             1
 erythromycin /sulfisoxazole             1                     metronidazole                         1
 BRANDS                                                        metronidazole in nacl 0.79%           1
 BIAXIN                                  3                     neomycin sulfate tab                  1
 BIAXIN XL                               3                     paromomycin sulfate                   1
 BIAXIN XL PAC                           3                     polymyxin b sulfate inj               1 
 E.E.S. GRANULES                         3                     pyrazinamide                          1
 ERYPED 200                              3                     rifampin                              1
 ERYPED 400                              3                     tobramycin sulfate 10 mg/ml inj       1
 ERY-TAB 500 MG                          2                     tobramycin sulfate 80 mg/2 ml inj     1
 ERYTHROCIN                              2                     BRANDS
   LACTOBIONATE                                                ALBENZA                                2
 ERYTHROMYCIN BASE TAB                   2                     ALINIA                                 2
 PCE                                     3                     ARALEN                                 3
 ZITHROMAX                               3                     AZACTAM                                2
 ZITHROMAX TRI-PAK                       3                     AZACTAM IN DEXTROSE                    2
 ZITHROMAX Z-PAK                         3                     AZACTAM IN ISO-OSMOTIC                 2
 ZMAX                                    3                       DEXTROSE
                                                               BILTRICIDE                             3
      MISCELLANEOUS ANTIINFECTIVES                             CAPASTAT SULFATE                       2
 Generics                                                      CAYSTON                                4
 amikacin sulfate              1                               CHLORAMPHENICOL                        3
 aztreonam                     1                                 SODIUM SUCCINATE INJ
 baciim                        1                               CLEOCIN CAP                            3
 bacitracin inj                1                               CLEOCIN GALAXY                         3
 chloroquine phosphate         1                               CLEOCIN PEDIATRIC                      2
 clindamycin hcl               1                                 GRANULES
 clindamycin phosphate         1                               CLEOCIN PHOSPHATE INJ                  3
    add-vantage                                                COARTEM                                2
 ethambutol hcl                1                               COLISTIMETHATE SODIUM                  4
 gentamicin sulfate 1 mg/ml;   1                               COLY-MYCIN M INJ                       4
   0.9% sodium chloride                                        CUBICIN                                4         PA
 gentamicin sulfate 1.2 mg/ml; 1                               DAPSONE                                2
   sodium chloride                                             DARAPRIM                               3
 gentamicin sulfate 1.6 mg/ml; 1                               DORIBAX                                2
   0.9% sodium chloride                                        FLAGYL                                 3
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         17 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 FLAGYL ER                             3                      PENICILLINS
 GENTAMICIN SULFATE                    3                      Generics
   0.9 MG/ML; 0.9% SODIUM                                     amoxicillin                             1
   CHLORIDE                                                   amoxicillin/clavulanate                 1 
 GENTAMICIN SULFATE                     3                       potassium
   1.4 MG/ML; 0.9% SODIUM                                     amoxicillin/clavulanate                 1 
   CHLORIDE                                                     potassium er
 GENTAMICIN SULFATE                     3                     ampicillin cap                          1
   10 MG/ML                                                   ampicillin sodium 1 gm                  1
 INVANZ                                 2                     ampicillin sodium 10 gm                 1
 ISONIAZID SYRUP                        2                     ampicillin susp                         1
 KETEK                                  3                     ampicillin-sulbactam                    1
 LINCOCIN                               3                     dicloxacillin sodium                    1
 MALARONE                               3                     nafcillin sodium                        1
 MEPRON                                 4                     penicillin g potassium inj              1
 MERREM                                 2                     penicillin v potassium                  1
 MYAMBUTOL                              3                     pfizerpen-g                             1
 MYCOBUTIN                              3                     piperacillin sodium/ tazobactam         1 
 NEBUPENT                               3         PA            sodium 3 gm/0.375gm
 NEO-FRADIN                             3                     BRANDS
 PASER                                  3                     AMPICILLIN SODIUM 125 MG                2
 PENTAM 300                             3                     AUGMENTIN ES-600                        3
 PLAQUENIL                              3                     BACTOCILL IN DEXTROSE                   2
 PRIFTIN                                3                     BICILLIN C-R                            2
 PRIMAQUINE PHOSPHATE                   2                     BICILLIN L-A                            2
 PRIMAXIN I.M.                          2                     MOXATAG                                 3
 PRIMAXIN IV                            2                     NALLPEN/DEXTROSE                        2
 QUALAQUIN                              3                     OXACILLIN SODIUM                        2
 RIFADIN                                3                     PENICILLIN G POTASSIUM IN               2
 RIFAMATE                               3                       ISO-OSMOTIC DEXTROSE
 RIFATER                                3                     PENICILLIN G PROCAINE                   2
 SEROMYCIN                              3                     PENICILLIN G SODIUM INJ                 2
 STREPTOMYCIN SULFATE                   2                     PIPERACILLIN SODIUM                     2
 STROMECTOL                             3                     TIMENTIN                                2
 SYNERCID                               4                     UNASYN                                  3
 TOBI                                   4         PA          UNASYN BULK PACK                        3
 TOBRAMYCIN SULFATE/                    3                     ZOSYN 3 GM/0.375 GM                     3
   SODIUM CHLORIDE                                            ZOSYN 5%; 2 GM/50ML;                    2
 TRECATOR                               3                       0.25 GM/50ML
 TYGACIL                                4                     ZOSYN 5%; 3GM /50ML;                    2
 XIFAXAN                                3                       0.375 GM/50ML
 ZYVOX                                  4
                                                              QUINOLONES
                                                              Generics
                                                              ciprofloxacin extended-release          1
18  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 ciprofloxacin hcl tab                  1                      DYNACIN                               3
 ciprofloxacin inj                      1                      MINOCIN                               3
 ofloxacin tab                          1                      MONODOX                               3
 BRANDS                                                        ORACEA                                3
 AVELOX                                  2                     PERIOSTAT                             3
 AVELOX ABC PACK                         2                     SOLODYN                               3
 CIPRO I.V.-IN D5W                       3                     VIBRAMYCIN CAP                        3
 CIPRO SUSP                              2                     VIBRAMYCIN SUSP                       3
 CIPRO TAB                               3                     VIBRAMYCIN SYRUP                      2
 FACTIVE                                 3                     VIBRATAB                              3
 LEVAQUIN                                3
 NOROXIN                                 3                     URINARY TRACT AGENTS
 PROQUIN XR                              3                     Generics
                                                               methenamine hippurate                  1
 SULFA'S / RELATED                                             nitrofurantoin macrocrystalline        1
 AGENTS                                                        nitrofurantoin monohydrate             1
 Generics                                                      trimethoprim                           1
 sulfadiazine                            1                     BRANDS
 sulfamethoxazole /trimethoprim          1                     FURADANTIN                             3
 sulfamethoxazole/trimethoprim ds        1                     HIPREX                                 3
 sulfatrim                               1                     MACROBID                               3
 BRANDS                                                        MACRODANTIN                            3
 BACTRIM                                 3                     MONUROL                                3
 BACTRIM DS                              3                     PRIMSOL                                3
 SEPTRA                                  3 
 SEPTRA DS                               3 
                                                               VANCOMYCIN
 TETRACYCLINES                                                 Generics
 Generics                                                      vancomycin hcl 1000 mg inj             1         PA
 demeclocycline hcl                      1                     BRANDS
 doxycycline hyclate cap                 1                     VANCOCIN HCL CAP                       4
 doxycycline hyclate inj                 1                     VANCOMYCIN HCL 10 GM                   3         PA
 doxycycline hyclate tab                 1                      INJ
 doxycycline monohydrate                 1                     VANCOMYCIN HCL ISO-                    3         PA
 minocycline hcl                         1                      OSMOTIC DEXTROSE
 tetracycline hcl                        1                     VIBATIV                                4
 BRANDS
 ADOXA                                   3
 ADOXA PAK 1/100                         3                     ANTIFIBRINOLYTIC AGENTS
 ADOXA PAK 1/150                         3                     HEMOSTATIC
 ADOXA PAK 1/75                          3                     BRANDS
 ADOXA PAK 2/100                         3
 DORYX                                   3                     LYSTEDA                                3
 DOXYCYCLINE HYCLATE                     3
   DELAYED-RELEASE CAP
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         19 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
                                                              cytarabine 500 mg                      1         PA
                                                              cytarabine aqueous 20 mg/ml            1         PA
 ANTINEOPLASTIC /                                             dacarbazine                            1
 IMMUNOSUPPRESSANT                                            doxorubicin hcl                        1         PA
 DRUGS                                                        epirubicin hcl                         1
 ADJUNCTIVE AGENTS                                            etoposide inj                          1
 Generics                                                     fludarabine phosphate inj              1
 leucovorin calcium inj                 1                     fluorouracil inj                       1         PA
 leucovorin calcium tab 25 mg           1                     flutamide                              1
 leucovorin calcium tab 5 mg            1                     gengraf                                1         PA
 mesna inj                              1                     hydroxyurea cap 500 mg                 1
 BRANDS                                                       ifosfamide                             1
 AMIFOSTINE                             4                     ifosfamide/mesna 1 gm / 1 gm           1
 DEXRAZOXANE                            4                     irinotecan                             1
 ELITEK                                 4                     leuprolide acetate 1 mg/0.2 ml         1
 ETHYOL                                 4                     megestrol acetate susp                 1
 KEPIVANCE                              4                     megestrol acetate tab                  1
 LEUCOVORIN CALCIUM TAB                 3                     mercaptopurine                         1
   10 MG                                                      methotrexate sodium 25 mg/ml           1
 LEUCOVORIN CALCIUM TAB                 3                     methotrexate tab                       1
   15 MG                                                      mitomycin                              1
 MESNEX INJ                             4                     mitoxantrone hcl                       1
 MESNEX TAB                             4                     mycophenolate mofetil cap              1         PA
 XGEVA                                  4                     octreotide acetate                     1
 ZINECARD                               4                     paclitaxel                             1
                                                              pentostatin                            1
 ANTINEOPLASTIC /                                             tacrolimus cap                         1         PA
 IMMUNOSUPPRESSANT                                            tamoxifen citrate                      1
 DRUGS                                                        thiotepa                               1
 Generics                                                     toposar                                1
 adriamycin                             1         PA          topotecan                              1
 anastrozole                            1                     tretinoin cap                          1
 azathioprine sodium inj                1         PA          vinblastine sulfate                    1         PA
 azathioprine tab                       1         PA          vincasar pfs                           1         PA
 bicalutamide                           1                     vincristine sulfate                    1         PA
 bleomycin sulfate                      1         PA          vinorelbine tartrate                   1 
 carboplatin                            1 
 cisplatin                              1                     BRANDS
 cyclophosphamide tab                   1         PA          ABRAXANE                                4
 cyclosporine cap                       1         PA          AFINITOR                                4
 cyclosporine modified cap              1         PA          ALIMTA                                  4
   100 mg                                                     ALKERAN INJ                             4
 cyclosporine modified inj              1         PA          ARIMIDEX                                3
 cyclosporine modified soln             1         PA          AROMASIN                                2
   100 mg/ml                                                  ARRANON                                 4

20  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 ARZERRA                                4         PA           HYCAMTIN                              4
 AVASTIN                                4                      HYDREA                                3
 AZASAN                                 3         PA           IDAMYCIN PFS                          4
 BICNU                                  2                      IDARUBICIN HCL                        4
 BUSULFEX                               2                      IFEX                                  3
 CAMPATH                                4                      IFOSFAMIDE/MESNA 3000                 2
 CAMPTOSAR                              4                        MG / 1000 MG
 CASODEX                                3                      IMURAN                                 3         PA
 CEENU                                  2                      IRESSA                                 4
 CELLCEPT CAP 250 MG                    3         PA           ISTODAX                                4
 CELLCEPT INTRAVENOUS                   2         PA           IXEMPRA KIT                            4
 CELLCEPT SUSP                          2         PA           JEVTANA                                4
 CELLCEPT TAB 500 MG                    3         PA           LEUKERAN                               2
 CERUBIDINE                             3                      LEUSTATIN                              4         PA
 CLADRIBINE INJ                         4         PA           LUPRON DEPOT 11.25 MG                  4
 CLOLAR                                 2                      LUPRON DEPOT 22.5 MG                   4
 COSMEGEN                               4                      LUPRON DEPOT 3.75 MG                   3
 CYCLOSPORINE MODIFIED                  2         PA           LUPRON DEPOT 30 MG                     4
  CAP 50 MG                                                    LUPRON DEPOT 7.5 MG                    4
 CYTARABINE AQUEOUS                      2        PA           LUPRON DEPOT-PED                       4
  100 MG/ML                                                    LYSODREN                               2
 DACOGEN                                 4                     MATULANE                               4
 DAUNORUBICIN HCL                        2                     MEGACE ES                              3
 DAUNOXOME                               3                     MEGACE ORAL SUSP                       3
 DOXIL                                   4        PA           MELPHALAN                              4
 DROXIA                                  2                       HYDROCHLORIDE INJ
 ELIGARD                                 2                     METHOTREXATE SODIUM                    2
 ELLENCE                                 4                       1 GM
 ELOXATIN                                4                     MUSTARGEN                              2
 ELSPAR                                  2                     MYFORTIC                               2         PA
 EMCYT                                   3                     NEORAL                                 2         PA
 ERBITUX                                 4                     NEXAVAR                                4         LA
 ETOPOPHOS                               4                     NILANDRON                              3
 FARESTON                                2                     NIPENT                                 4
 FASLODEX                                4                     NOVANTRONE                             4
 FEMARA                                  2                     ONCASPAR                               4
 FIRMAGON 120 MG                         4                     ONTAK                                  4
 FIRMAGON 80 MG                          3                     ORTHOCLONE OKT3                        4         PA
 FLUDARA                                 4                     OXALIPLATIN                            4
 GEMCITABINE HCL                         4                     PHOTOFRIN                              4
 GEMZAR                                  4                     PROGRAF CAP                            3         PA
 GLEEVEC                                 4                     PROGRAF INJ                            2         PA
 HALAVEN                                 4                     PURINETHOL                             3
 HERCEPTIN                               4                     RAPAMUNE                               2         PA
 HEXALEN                                 4                     REVLIMID                               4         LA
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         21 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 RHEUMATREX                            3                      lamotrigine                            1
 RITUXAN                               2          PA          levetiracetam                          1
 SANDIMMUNE                            2          PA          oxcarbazepine                          1
 SANDOSTATIN                           4                      phenytoin                              1
 SANDOSTATIN LAR DEPOT                 4                      phenytoin sodium extended              1
 SIMULECT                              4          PA          primidone                              1
 SOMATULINE DEPOT                      4                      topiramate                             1
 SPRYCEL                               4                      valproate sodium                       1
 SUTENT                                4                      valproic acid                          1
 TABLOID                               2                      zonisamide                             1
 TARCEVA                               4                      BRANDS
 TARGRETIN                             4                      BANZEL                                  3
 TASIGNA                               4                      CARBATROL                               2
 TAXOTERE                              4                      CELONTIN                                3
 THALOMID                              4          PA          CEREBYX                                 3
 TORISEL                               4          PA          DEPACON                                 3
 TREANDA                               4                      DEPAKENE                                3
 TRELSTAR DEPOT MIXJECT                2                      DEPAKOTE                                3
 TRELSTAR LA                           2                      DEPAKOTE ER                             3
 TRELSTAR LA MIXJECT                   2                      DEPAKOTE SPRINKLES                      3
 TREXALL                               3                      DILANTIN                                2
 TRISENOX                              3                      DILANTIN INFATABS                       2
 TYKERB                                4          LA          EQUETRO                                 3
 VECTIBIX                              4                      FELBATOL                                2
 VELCADE                               4                      GABITRIL                                2
 VIDAZA                                4                      KEPPRA                                  3
 VOTRIENT                              4                      KEPPRA XR                               3
 ZANOSAR                               4                      LAMICTAL                                3
 ZOLINZA                               4                      LAMICTAL CHEWABLE                       3
 ZORTRESS                              3          PA            DISPERSIBLE
                                                              LAMICTAL ODT                            3
 AUTONOMIC / CNS                                              LAMICTAL STARTER/                       3
                                                                TAKING VALPROATE
 DRUGS, NEUROLOGY /
                                                              LAMICTAL STARTER/NOT                    3
 PSYCH                                                          TAKING CARBAMAZEPINE
 ANTICONVULSANTS                                              LAMICTAL STARTER/                       3
 Generics                                                       TAKING CARBAMAZEPINE/
 carbamazepine                          1                       NOT TAKING VALPROATE
 carbamazepine er                       1                     LAMICTAL XR                             3
 divalproex sodium                      1                     LYRICA                                  3
 divalproex sodium er                   1                     MYSOLINE                                3
 epitol                                 1                     NEURONTIN                               3
 ethosuximide                           1                     PEGANONE                                3
 fosphenytoin sodium                    1                     PHENYTEK                                2
 gabapentin                             1                     PHENYTOIN SODIUM INJ                    2
22  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 SABRIL                                 4                      TASMAR                                3
 STAVZOR                                3                      ZELAPAR                               3
 TEGRETOL                               2                      MIGRAINE / CLUSTER
 TEGRETOL-XR                            2                      HEADACHE THERAPY
 TOPAMAX                                3                      Generics
 TOPAMAX SPRINKLE                       3                      dihydroergotamine mesylate inj         1
 TRILEPTAL                              3                      ergotamine tartrate/caffeine tab       1
 VIMPAT                                 3                      migergot                               1
 ZARONTIN                               3                      naratriptan hcl                        1         QL
 ZONEGRAN                               3                      sumatriptan succinate inj              1         QL
                                                                 6 mg/0.5 ml
 ANTIPARKINSONISM                                              sumatriptan succinate tab              1         QL
 AGENTS                                                        BRANDS
 Generics                                                      AMERGE                                 3         QL
 benztropine mesylate                    1                     AXERT                                  3         QL
 bromocriptine mesylate                  1                     CAFERGOT TAB                           3
 carbidopa/levodopa cr                   1                     D.H.E. 45                              3
 carbidopa/levodopa odt                  1                     ERGOMAR                                3
 carbidopa/levodopa sr                   1                     FROVA                                  2         QL
 carbidopa/levodopa tab                  1                     IMITREX                                3         QL
 pramipexole dihydrochloride             1                     IMITREX STATDOSE REFILL                3         QL
 ropinirole hcl                          1                     MAXALT                                 2         QL
 selegiline hcl                          1                     MAXALT-MLT                             2         QL
 trihexyphenidyl hcl                     1                     MIGRANAL                               3
 BRANDS                                                        RELPAX                                 2         QL
 APOKYN                                  4        LA           SUMATRIPTAN SUCCINATE                  2         QL
 AZILECT                                 3                       INJ 4 MG/0.5 ML
 COGENTIN                                3                     TREXIMET                               3         QL
 COMTAN                                  2                     ZOMIG                                  3         QL
 ELDEPRYL                                3                     ZOMIG ZMT                              3         QL
 LODOSYN                                 2
 MIRAPEX                                 3                     MISCELLANEOUS
 MIRAPEX ER                              3                     NEUROLOGICAL THERAPY
 PARCOPA                                 3                     Generics
 PARLODEL                                3                     donepezil hcl                          1         QL
 REQUIP                                  3                     galantamine hydrobromide               1         QL
 REQUIP XL                               2                     rivastigmine cap                       1         QL
 SINEMET                                 3                     BRANDS
 SINEMET CR                              3                     AMPYRA                                 4         PA
 STALEVO 100                             3                     ARICEPT 10 MG                          3         QL
 STALEVO 125                             3                     ARICEPT 23 MG                          2         QL
 STALEVO 150                             3                     ARICEPT 5 MG                           3         QL
 STALEVO 200                             3                     ARICEPT ODT                            3         QL
 STALEVO 50                              3                     COGNEX                                 3         QL
 STALEVO 75                              3                     COPAXONE                               4
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         23 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 EXELON CAP                            2          QL          ROBAXIN TAB                            3
 EXELON PATCH                          2          QL          SKELAXIN                               3
 EXELON SOLN                           2                      SOMA 250 MG                            3
 GILENYA                               4                      SOMA 350 MG                            3
 MYTELASE                              3
 NAMENDA                               2          QL          NARCOTIC ANALGESICS
 NAMENDA TITRATION PAK                 2                      Generics
 NUEDEXTA                              3                      acetaminophen/caffeine/                 1 
 RAZADYNE                              3          QL            dihydrocodeine bitartrate
 RAZADYNE ER                           3          QL          acetaminophen/codeine                   1
 TYSABRI                               4          LA          acetaminophen/codeine #3                1
 XENAZINE                              4          LA          acetaminophen/codeine #4                1
                                                              ascomp/codeine                          1
 MUSCLE RELAXANTS /                                           buprenorphine hcl inj                   1
 ANTISPASMODIC THERAPY                                        buprenorphine hcl sl tab                1
 Generics                                                     butalbital /apap /caffeine              1 
 baclofen                                 1                     /codeine
 carisoprodol                             1                   codeine sulfate tab                      1
 carisoprodol /aspirin                    1                   duramorph                                1        PA
 carisoprodol /aspirin /codeine           1                   endocet                                  1
 chlorzoxazone                            1                   endodan                                  1
 cyclobenzaprine hcl                      1                   fentanyl citrate inj                     1        PA
 dantrolene sodium                        1                   fentanyl patch                           1
 meprobamate                              1                   hydrocodone /acetaminophen               1
 metaxalone                               1                   hydrocodone /acetaminophen-hs            1
 methocarbamol                            1                   hydrocodone /ibuprofen                   1
 orphenadrine /asa /caffeine              1                   hydrocodone bitartrate/                  1 
 orphenadrine citrate                     1                     acetaminophen
 orphenadrine citrate er                  1                   hydromorphone hcl inj                    1        PA
 orphenadrine compound ds                 1                   hydromorphone hcl tab                    1
 pyridostigmine bromide                   1                   levorphanol tartrate                     1
 regonol                                  1                   margesic-h                               1
 tizanidine hcl tab                       1                   meperidine hcl inj 10 mg/ml              1        PA
 BRANDS                                                       meperidine hcl inj 25 mg/ml              1        PA
 AMRIX                                    3                   meperidine hcl inj 50 mg/ml              1        PA
 DANTRIUM                                 3                   meperidine hcl soln                      1
 DANTRIUM                                 3                   meperidine hcl tab                       1
 FEXMID                                   3                   methadone hcl soln 10 mg/ml              1
 FLEXERIL                                 3                   methadone hcl tab                        1
 MESTINON SYRUP                           2                   methadose                                1
 MESTINON TAB                             3                   morphine sulfate er                      1
 MESTINON TIMESPAN                        2                   morphine sulfate inj                     1        PA
 NORFLEX                                  3                   morphine sulfate soln                    1
 PARAFON FORTE DSC                        3                   morphine sulfate tab                     1
 ROBAXIN INJ                              3                   oxycodone /acetaminophen                 1
24  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 oxycodone /aspirin                     1                      MAXIDONE                              3
 oxycodone /ibuprofen                   1                      MEPERIDINE HCL INJ                    3          PA
 oxycodone hcl tab                      1                       100 MG/ML
 oxycodone-apap                         1                      MEPERIDINE HCL INJ                     3         PA
 oxymorphone hcl                        1                       75 MG/ML
 reprexain tab 10 mg/200 mg             1                      METHADONE HCL SOLN                     2
 roxicet tab 5 mg/325 mg                1                       10 MG/5 ML
 stagesic                               1                      METHADONE HCL SOLN                     2
 zerlor                                 1                       5 MG/5 ML
 BRANDS                                                        MS CONTIN                              3
 ABSTRAL                                 4        PA           NORCO                                  3
 ACTIQ                                   4        PA           ONSOLIS                                4         PA
 ASTRAMORPH                              3        PA           OPANA                                  3
 AVINZA                                  3                     OPANA ER                               3
 BUPRENEX                                3                     ORAMORPH SR                            3
 CAPITAL/CODEINE                         3                     OXYCONTIN                              2
 CO-GESIC                                3                     PANLOR DC                              3
 COMBUNOX                                3                     PANLOR SS                              3
 DEMEROL INJ                             3        PA           PERCOCET                               3
 DEMEROL TAB                             3                     PERCODAN                               3
 DILAUDID                                3        PA           REPREXAIN TAB 2.5 MG/                  3
 DILAUDID INJ                            3        PA            200 MG
 DILAUDID TAB                            3                     REPREXAIN TAB 5 MG/                    3
 DILAUDID-5                              2                      200 MG
 DILAUDID-HP                             3        PA           ROXICET SOLN                           3
 DOLOPHINE                               3                     ROXICET TAB 5 MG/500 MG                3
 DURAGESIC                               4                     ROXICODONE                             3
 EMBEDA                                  3                     SUBUTEX                                3
 EXALGO                                  3                     SYNALGOS-DC                            3
 FENTANYL CITRATE ORAL                   4        PA           TYLENOL/CODEINE #3                     3
   TRANSMUCOSAL LOZENGE                                        TYLENOL/CODEINE #4                     3
 FENTORA                                 4        PA           TYLOX 3                                3
 FIORICET /CODEINE                       3                     VICODIN                                3
 FIORINAL/CODEINE #3                     3                     VICODIN ES                             3
 HYCET                                   3                     VICODIN HP                             3
 INFUMORPH 200                           2        PA           VICOPROFEN                             3
 INFUMORPH 500                           2        PA           XODOL                                  3
 KADIAN                                  3                     ZAMICET                                3
 LORCET 10/650                           3                     ZYDONE                                 3
 LORCET PLUS                             3
 LORTAB                                  3                     NON-NARCOTIC
 LORTAB 10                               3                     ANALGESICS
 LORTAB 5                                3                     Generics
 LORTAB 7.5                              3                     butorphanol tartrate inj               1
 MAGNACET                                3                     butorphanol tartrate nasal soln        1         QL
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         25 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 depade                                1                       EC-NAPROSYN                           3
 diclofenac potassium                  1                       FELDENE                               3
 diclofenac sodium ec                  1                       FLECTOR                               3
 diclofenac sodium xr                  1                       INDOCIN SUSP                          3
 diflunisal                            1                       MOBIC                                 3
 etodolac                              1                       NALFON                                3
 etodolac er                           1                       NAPRELAN                              3
 fenoprofen calcium                    1                       NAPROSYN                              3
 flurbiprofen tab                      1                       NUCYNTA                               3
 ibuprofen                             1                       PENNSAID                              3
 indomethacin cap                      1                       PONSTEL                               3
 indomethacin er                       1                       REVIA                                 3
 ketoprofen                            1                       RYZOLT                                3
 ketoprofen er                         1                       STADOL INJ                            3
 ketorolac tromethamine inj            1                       SUBOXONE                              2
 ketorolac tromethamine tab            1            QL         TALACEN                               3
 meclofenamate sodium                  1                       TALWIN                                3
 mefenamic acid                        1                       TALWIN NX                             3
 meloxicam                             1                       ULTRACET                              3
 nabumetone                            1                       ULTRAM                                3
 nalbuphine hcl inj                    1                       ULTRAM ER                             3
 naloxone hcl inj                      1                       VIMOVO                                3
 naltrexone hcl tab                    1                       VIVITROL                              4
 naproxen                              1                       VOLTAREN GEL                          3
 naproxen dr                           1                       VOLTAREN TAB                          3
 naproxen sodium                       1                       VOLTAREN-XR                           3
 oxaprozin                             1                       ZIPSOR                                3
 pentazocine /acetaminophen            1 
 pentazocine/naloxone hcl              1                       PSYCHOTHERAPEUTIC
 piroxicam                             1                       DRUGS
 sulindac                              1                       Generics
 tolmetin sodium                       1                       amitriptyline hcl                       1
 tramadol hcl                          1                       amoxapine                               1
 tramadol hcl er                       1                       amphetamine                             1 
 tramadol hydrochloride/               1                         /dextroamphetamine
   acetaminophen                                               budeprion sr                            1        QL
 BRANDS                                                        budeprion xl                            1        QL
 ANAPROX                                  3                    bupropion hcl                           1
 ANAPROX DS                               3                    bupropion hcl sr                        1        QL
 ARTHROTEC 50                             3                    buspirone hcl                           1
 ARTHROTEC 75                             3                    chlordiazepoxide /amitriptyline         1
 CATAFLAM                                 3                    chlorpromazine hcl                      1
 CELEBREX                                 2                    citalopram hydrobromide                 1
 CLINORIL                                 3                    clomipramine hcl                        1
 DAYPRO                                   3
26  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 clozapine 100 mg                       1                      risperidone odt 3 mg                  1
 clozapine 25 mg                        1                      risperidone odt 4 mg                  1
 clozapine 50 mg                        1                      selfemra                              1
 desipramine hcl                        1                      sertraline hcl                        1
 dexmethylphenidate hcl                 1                      thioridazine hcl                      1
 dextroamphetamine sulfate              1                      thiothixene                           1
 dextroamphetamine sulfate er           1                      tranylcypromine sulfate               1
 doxepin hcl                            1                      trazodone hcl                         1
 ergoloid mesylates                     1                      trifluoperazine hcl                   1
 fluoxetine dr                          1                      venlafaxine hcl er cap                1          QL
 fluoxetine hcl                         1                      venlafaxine hcl tab                   1          QL
 fluphenazine decanoate                 1                      zaleplon                              1
 fluphenazine hcl                       1                      zolpidem tartrate                     1
 fluvoxamine maleate                    1                      BRANDS                                   
 haloperidol                            1                      ABILIFY                                2
 haloperidol decanoate                  1                      ABILIFY DISCMELT                       3
 haloperidol lactate soln               1                      ADDERALL                               3
 imipramine hcl                         1                      ADDERALL XR                            3
 imipramine pamoate                     1                      AMBIEN                                 3
 lithium carbonate cap 150 mg           1                      AMBIEN CR                              3
 lithium carbonate cap 300 mg           1                      ANAFRANIL                              3
 lithium carbonate er                   1                      APLENZIN                               3         QL
 lithium carbonate tab 300 mg           1                      BUSPAR                                 3
 lithium citrate syrup                  1                      CELEXA                                 3
 loxapine succinate                     1                      CLOZAPINE 200 MG                       2
 maprotiline hcl                        1                      CLOZARIL                               2
 metadate er 20 mg                      1                      CONCERTA                               3
 methamphetamine hcl 5 mg               1                      CYMBALTA                               3         QL
 methylin er                            1                      DAYTRANA                               3
 methylin tab                           1                      DESOXYN                                3
 methylphenidate hcl                    1                      DEXEDRINE                              3
 methylphenidate hcl sr                 1                      EDLUAR                                 3
 mirtazapine                            1         QL           EFFEXOR                                3
 mirtazapine odt                        1         QL           EFFEXOR XR                             3         QL
 nefazodone hcl                         1         QL           EMSAM                                  3         QL
 nortriptyline hcl                      1                      FANAPT                                 3
 paroxetine hcl                         1                      FANAPT TITRATION PACK                  3
 paroxetine hcl er                      1                      FAZACLO                                3
 perphenazine                           1                      FOCALIN                                3
 perphenazine /amitriptyline            1                      FOCALIN XR                             3
 protriptyline hcl                      1                      GEODON                                 2
 risperidone                            1                      GUANIDINE HCL                          3
 risperidone odt 0.5 mg                 1                      HALDOL                                 2
 risperidone odt 1 mg                   1                      HALDOL DECANOATE 100                   2
 risperidone odt 2 mg                   1                      HALDOL DECANOATE 50                    2
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         27 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 INTUNIV                               3                      RISPERDAL CONSTA 25 MG                 2
 INVEGA                                3                      RISPERDAL CONSTA 37.5 MG               4
 INVEGA SUSTENNA                       4                      RISPERDAL CONSTA 50 MG                 4
  117 MG/0.75 ML                                              RISPERDAL M-TAB                        3
 INVEGA SUSTENNA                        4                     RISPERIDONE ODT 0.25 MG                2
  156 MG/ML                                                   RITALIN                                3
 INVEGA SUSTENNA                        4                     RITALIN LA                             3
  234 MG/1.5 ML                                               RITALIN SR                             3
 INVEGA SUSTENNA                        3                     ROZEREM                                3
  39 MG/0.25 ML                                               SAPHRIS                                3
 INVEGA SUSTENNA 78 MG/                 3                     SARAFEM                                3
  0.5 ML                                                      SEROQUEL                               2
 LATUDA                                 3                     SEROQUEL XR                            2
 LEXAPRO                                3                     SONATA                                 3
 LITHIUM CARBONATE CAP                  2                     STRATTERA                              3
  600 MG                                                      SURMONTIL                              3
 LITHOBID                               2                     SYMBYAX                                3
 LOXITANE                               3                     TOFRANIL                               3
 LUNESTA                                3                     TOFRANIL-PM                            3
 LUVOX CR                               3                     VENLAFAXINE HCL ER                     2         QL
 MARPLAN                                3                      TAB-24
 METADATE CD                            3                     VIVACTIL                                3
 METHYLIN CHEW                          3                     VYVANSE                                 3
 METHYLIN SOLN                          3                     WELLBUTRIN                              3
 NARDIL                                 3                     WELLBUTRIN SR                           3       QL
 NAVANE CAP                             3                     WELLBUTRIN XL                           3       QL
 NORPRAMIN                              3                     XYREM                                   4      PA LA
 NUVIGIL                                3         PA          ZOLOFT                                  3
 OLEPTRO                                3         QL          ZOLPIMIST                               3
 ORAP                                   3                     ZYPREXA                                 2
 PAMELOR                                4                     ZYPREXA ZYDIS                           3
 PARNATE                                3
 PAXIL TAB                              3
                                                              CARDIOVASCULAR,
 PAXIL SUSP                             2
 PAXIL CR                               3
                                                              HYPERTENSION /
 PEXEVA                                 3                     LIPIDS
 PRISTIQ                                3         QL          ANTIARRHYTHMIC
 PROVIGIL                               3         PA          AGENTS
 PROZAC                                 3                     Generics
 PROZAC WEEKLY                          3                     amiodarone hcl                          1
 RAPIFLUX                               3                     disopyramide phosphate                  1
 REMERON                                3                     flecainide acetate                      1
 REMERON SOLTAB                         3         QL          mexiletine hcl                          1
 RISPERDAL                              3                     pacerone 200 mg                         1
 RISPERDAL CONSTA 12.5 MG               2                     procainamide hcl inj                    1

28  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 propafenone hcl                        1                      carvedilol                            1            
 quinidine gluconate cr                 1                      chlorothiazide sodium inj             1            
 quinidine sulfate                      1                      chlorothiazide tab                    1            
 quinidine sulfate er                   1                      chlorthalidone                        1            
 sorine                                 1                      clonidine hcl patch                   1            
 sotalol hcl                            1                      clonidine hcl tab                     1            
 BRANDS                                                        dilt-cd                               1            
 BETAPACE                                3                     diltiazem cd cap24                    1            
 BETAPACE AF                             3                     diltiazem hcl cap24                   1            
 CORDARONE                               3                     diltiazem hcl er cap12                1            
 MULTAQ                                  3                     diltiazem hcl er cap24                1            
 NORPACE                                 3                     diltiazem hcl er tab24                1            
 NORPACE CR                              2                     diltiazem hcl inj 25 mg/5 ml          1            
 PACERONE 100 MG                         3                     diltiazem hcl tab                     1            
 PACERONE 400 MG                         3                     dilt-xr                               1            
 QUINIDINE GLUCONATE                     2                     diltzac                               1            
 RYTHMOL                                 3                     doxazosin mesylate tab                1            
 RYTHMOL SR                              2                     enalapril maleate                     1            
 SOTALOL HCL INJ                         3                     enalapril maleate/                    1            
 TAMBOCOR                                3                       hydrochlorothiazide
 TIKOSYN                                 3                     eplerenone                             1           
                                                               felodipine er                          1           
 ANTIHYPERTENSIVE                                              fosinopril sodium                      1           
 THERAPY                                                       fosinopril sodium/                     1           
 Generics                                                        hydrochlorothiazide
 acebutolol hcl                          1                     furosemide inj                         1           
 afeditab cr                             1                     furosemide soln 10 mg/ml               1           
 amiloride /hydrochlorothiazide          1                     furosemide tab                         1           
 amiloride hcl                           1                     guanabenz acetate                      1           
 amlodipine besylate                     1                     guanfacine hcl                         1           
 amlodipine besylate/benazepril          1                     hydralazine hcl                        1           
   hydrochloride                                               hydrochlorothiazide                    1           
 atenolol                                1                     indapamide                             1           
 atenolol/chlorthalidone                 1                     isradipine                             1           
 benazepril hcl                          1                     labetalol hcl                          1           
 benazepril                              1                     lisinopril                             1           
   hcl/hydrochlorothiazide                                     lisinopril /hydrochlorothiazide        1           
 betaxolol hcl tab                       1                     losartan potassium                     1           
 bisoprolol fumarate                     1                     losartan potassium/                    1           
 bisoprolol fumarate/                    1                       hydrochlorothiazide
   hydrochlorothiazide                                         methyclothiazide                       1           
 bumetanide                              1                     methyldopa                             1           
 captopril                               1                     methyldopa /hydrochlorothiazide        1           
 captopril/hydrochlorothiazide           1                     methyldopate hcl                       1           
 cartia xt                               1                     metolazone                             1           

Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         29 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                              Drug      Reqs.
                                      Tier      /Limits                                               Tier    /Limits
 metoprolol /hydrochlorothiazide       1                       ALTACE                                  3
 metoprolol succinate er               1                       AMTURNIDE                               3
 metoprolol tartrate                   1                       ATACAND                                 3        ST
 minoxidil tab                         1                       ATACAND HCT                             3        ST
 moexipril /hydrochlorothiazide        1                       AVALIDE                                 3        ST
 moexipril hcl                         1                       AVAPRO                                  3        ST
 nadolol                               1                       AZOR                                    3
 nadolol/bendroflumethiazide           1                       BENICAR                                 3        ST
 nicardipine hcl cap                   1                       BENICAR HCT                             3        ST
 nifediac cc                           1                       BIDIL                                   3
 nifedical xl                          1                       BYSTOLIC                                3
 nifedipine cap                        1                       CALAN                                   3
 nifedipine er                         1                       CALAN SR                                3
 nisoldipine                           1                       CARDIZEM                                3
 perindopril erbumine                  1                       CARDIZEM CD 120 MG                      3
 pindolol                              1                       CARDIZEM CD 180 MG                      3
 prazosin hcl                          1                       CARDIZEM CD 240 MG                      3
 propranolol /hydrochlorothiazide      1                       CARDIZEM CD 300 MG                      3
 propranolol hcl                       1                       CARDIZEM CD 360 MG                      2
 propranolol hcl er                    1                       CARDIZEM LA                             3
 quinapril /hydrochlorothiazide        1                       CARDURA                                 3
 quinapril hcl                         1                       CARDURA XL                              3
 ramipril cap                          1                       CATAPRES                                3
 reserpine                             1                       CATAPRES-TTS-1                          3
 spironolactone                        1                       CATAPRES-TTS-2                          3
 spironolactone                        1                       CATAPRES-TTS-3                          3
   /hydrochlorothiazide                                        CLORPRES                                3
 taztia xt                                1                    COREG                                   3
 terazosin hcl                            1                    COREG CR                                2
 timolol maleate tab                      1                    CORGARD                                 3
 torsemide tab                            1                    CORZIDE                                 3
 trandolapril                             1                    COVERA-HS                               3
 trandolapril/verapamil hcl               1                    COZAAR                                  3        ST
 triamterene /hydrochlorothiazide         1                    DEMADEX                                 3
   cap                                                         DEMSER                                  2
 triamterene /hydrochlorothiazide         1                    DIBENZYLINE                             2
   tab                                                         DILACOR XR                              3
 verapamil hcl                            1                    DILTIAZEM HCL INJ 100 MG                3
 BRANDS                                                        DIOVAN                                  2
 ACCUPRIL                                 3                    DIOVAN HCT                              2
 ACCURETIC                                3                    DIURIL IV                               3
 ACEON                                    3                    DIURIL SUSP                             3
 ADALAT CC                                3                    DYAZIDE                                 3
 ALDACTAZIDE                              3                    DYNACIRC CR                             3
 ALDACTONE                                3                    DYRENIUM                                3
30  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 EDARBI                                 3         ST           TEVETEN                               3         ST
 EDECRIN                                2                      TEVETEN HCT                           3         ST
 EXFORGE                                3                      THALITONE                             3
 EXFORGE HCT                            3                      TIAZAC                                3
 FUROSEMIDE SOLN 8 MG/ML                2                      TOPROL XL                             3
 HYZAAR                                 3          ST          TORSEMIDE INJ                         3
 INDERAL LA                             3                      TRANDATE                              3
 INNOPRAN XL                            3                      TRIBENZOR                             3
 INSPRA                                 3                      TWYNSTA                               3
 ISOPTIN SR                             3                      UNIRETIC                              3
 KERLONE                                3                      UNIVASC                               3
 LASIX TAB                              3                      VALTURNA                              3
 LEVATOL                                3                      VASERETIC                             3
 LOPRESSOR                              3                      VASOTEC                               3
 LOPRESSOR HCT                          3                      VERELAN                               3
 LOTENSIN                               3                      VERELAN PM                            3
 LOTENSIN HCT                           3                      ZAROXOLYN                             3
 LOTREL                                 3                      ZEBETA                                3
 MAVIK                                  3                      ZESTORETIC                            3
 MAXZIDE                                3                      ZESTRIL                               3
 MAXZIDE-25                             3                      ZIAC                                  3
 MICARDIS                               2
 MICARDIS HCT                           2                      CARDIAC GLYCOSIDES
 MICROZIDE                              3                      Generics
 MINIPRESS                              3                      digoxin inj                            1
 MONOPRIL                               3                      digoxin soln                           1
 NICARDIPINE HCL INJ                    3                      digoxin tab                            1
 NIMODIPINE                             4                      BRANDS
 NORVASC                                3                      LANOXIN                                2 
 PRINIVIL                               3
 PRINZIDE                               3                      COAGULATION THERAPY
 PROCARDIA                              3                      Generics
 PROCARDIA XL                           3                      cilostazol                             1
 REMODULIN                              4         PA           dipyridamole                           1
 SECTRAL                                3                      enoxaparin sodium                      1
 SODIUM EDECRIN                         2                      heparin sodium 10,000 unit/ml          1
 SULAR                                  3                      heparin sodium 1000 unit/ml            1
 TARKA                                  3                      heparin sodium 5000 unit/ml            1
 TEKAMLO                                3                      heparin sodium dcu 20,000              1 
 TEKTURNA                               3                        unit/ml
 TEKTURNA HCT                           3                      heparin sodium/d5w                     1
 TENEX                                  3                      heparin sodium/sodium chloride         1 
 TENORETIC 100                          3                        0.9% premix
 TENORETIC 50                           3                      jantoven                               1
 TENORMIN                               3                      pentopak                               1
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         31 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 pentoxifylline er                     1                      colestipol hcl                         1
 ticlopidine hcl                       1          QL          fenofibrate micronized cap             1 
 warfarin sodium                       1                        200 mg
 BRANDS                                                       fenofibrate micronized cap 67 mg        1
 AGGRENOX                               3         QL          fenofibrate tab 160 mg                  1
 ARIXTRA 10 MG/0.8 ML                   4                     fenofibrate tab 54 mg                   1
 ARIXTRA 2.5 MG/0.5 ML                  3                     gemfibrozil                             1
 ARIXTRA 5 MG/0.4 ML                    4                     lovastatin                              1        QL
 ARIXTRA 7.5 MG/0.6 ML                  4                     pravastatin sodium                      1        QL
 COUMADIN                               2                     prevalite                               1
 CYKLOKAPRON                            2                     simvastatin                             1        QL
 EFFIENT                                3                     BRANDS
 FRAGMIN 10,000 UNIT/ML                 4                     ADVICOR                                 3
 FRAGMIN 25,000 UNIT/ML                 4                     ALTOPREV                                3       QL ST
 FRAGMIN 2500 UNIT/0.2 ML               3                     ANTARA                                  3
 FRAGMIN 5000 UNIT/0.2 ML               3                     CADUET                                  3        QL
 FRAGMIN 7500 UNIT/0.3 ML               3                     COLESTID                                3
 HEPARIN SODIUM                         2                     CRESTOR                                 2        QL
   100 UNIT/ML; NACL 0.45%                                    FENOGLIDE                               3
 HEPARIN SODIUM                         2                     LESCOL                                  3       QL ST
   2000 UNIT/ML                                               LESCOL XL                               3       QL ST
 HEPARIN SODIUM                         2                     LIPITOR                                 2        QL
   2500 UNIT/ML                                               LIPOFEN                                 3
 HEPARIN SODIUM                         2                     LIVALO                                  3       QL ST
   50 UNIT/ML; NACL 0.45%                                     LOFIBRA                                 3
 INNOHEP                                3                     LOPID                                   3
 LOVENOX 100 MG/ML                      4                     LOVAZA                                  3        QL
 LOVENOX 120 MG/0.8 ML                  4                     MEVACOR                                 3       QL ST
 LOVENOX 150 MG/ML                      4                     NIACOR                                  2
 LOVENOX 30 MG/0.3 ML                   3                     NIASPAN                                 2
 LOVENOX 300 MG/3 ML                    4                     PRAVACHOL                               3       QL ST
 LOVENOX 40 MG/0.4 ML                   3                     QUESTRAN                                3
 LOVENOX 60 MG/0.6 ML                   3                     SIMCOR                                  2
 LOVENOX 80 MG/0.8 ML                   3                     TRICOR                                  3
 PERSANTINE                             3                     TRIGLIDE                                3
 PLAVIX 75 MG                           2         QL          TRILIPIX                                3
 PLAVIX 300 MG                          2                     VYTORIN                                 3       QL ST
 PLETAL                                 3                     WELCHOL                                 3
 PRADAXA                                3                     ZETIA                                   3        QL
 PROMACTA                               4         LA          ZOCOR                                   3       QL ST
 TRENTAL                                3
                                                               MISCELLANEOUS CARDIOVASCULAR
  LIPID/CHOLESTEROL LOWERING AGENTS                            AGENTS
 Generics                                                      BRANDS
 cholestyramine light     1                                    RANEXA                                  2
32  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 NITRATES                                                      MISCELLANEOUS
 Generics                                                      DERMATOLOGICALS
 isosorbide dinitrate                    1                     Generics
 isosorbide mononitrate                  1                     ammonium lactate                       1
 nitro-bid oint                          1                     fluorouracil cre                       1
 nitroglycerin inj                       1                     fluorouracil soln                      1
 nitroglycerin patch                     1                     imiquimod 5%                           1
 BRANDS                                                        laclotion                              1
 DILATRATE SR                            3                     podofilox                              1
 IMDUR                                   3                     BRANDS
 ISMO                                    3                     8-MOP                                  2
 ISOCHRON                                3                     ALDARA                                 3
 ISORDIL TITRADOSE                       3                     CARAC                                  3
 MINITRAN                                2                     CARMOL-HC                              3
 MONOKET                                 3                     CONDYLOX                               3
 NITRO-DUR                               2                     EFUDEX                                 3
 NITROLINGUAL PUMPSPRAY                  3                     ELIDEL                                 3
 NITROMIST                               3                     FLUOROPLEX                             3
 NITROSTAT                               2                     LAC-HYDRIN                             3
                                                               OXSORALEN                              3
 DERMATOLOGICALS/                                              OXSORALEN ULTRA                        4
 TOPICAL THERAPY                                               PANRETIN                               4
 ANTIPSORIATIC /                                               PROTOPIC                               3
 ANTISEBORRHEIC                                                REGRANEX                               3
 Generics                                                      SOLARAZE                               3
 calcipotriene                           1                     U-CORT                                 3
 selenium sulfide 2.5% lot               1                     UVADEX                                 3
 BRANDS                                                        VEREGEN                                3
 AMEVIVE                                 4        PA           ZONALON                                3
 DOVONEX                                 3                     ZYCLARA                                3
 SELSUN SHAMPOO                          3
 SORIATANE                               2                     THERAPY FOR ACNE
 STELARA                                 4        PA           Generics
 TACLONEX                                3                     adapalene                              1
 TACLONEX SCALP                          3                     amnesteem                              1
 VECTICAL                                3                     avita cre 0.025%                       1
                                                               claravis                               1
 BURN THERAPY                                                  clindamycin phosphate                  1
 Generics                                                      clindamycin/benzoyl peroxide           1
 silver sulfadiazine                     1                     ery pads                               1
 ssd                                     1                     erythromycin gel                       1
 thermazene                              1                     erythromycin soln                      1
 BRANDS                                                        erythromycin/benzoyl peroxide          1
 SILVADENE                               3                     metronidazole 0.75%                    1
                                                               sotret                                 1
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         33 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 tretinoin                             1                      ALTABAX                                3
 BRANDS                                                       BACTROBAN                              3
 ACANYA                                 3                     CORTISPORIN CRE                        3
 ACZONE                                 3                     CORTISPORIN OINT                       3
 AKNE-MYCIN                             3                     KLARON                                 3
 ATRALIN                                3                     PHISOHEX                               3
 AVITA GEL 0.025%                       3                     SULFAMYLON                             3
 AZELEX                                 3
 BENZACLIN CARE KIT                     3                     TOPICAL ANTIFUNGALS
 BENZAMYCIN                             3                     Generics
 CLEOCIN-T                              3                     ciclopirox                              1
 CLINDAGEL                              3                     ciclopirox nail lacquer                 1
 DIFFERIN                               3                     ciclopirox olamine cre                  1
 EPIDUO                                 3                     ciclopirox shampoo                      1
 EVOCLIN                                3                     clotrimazole/betamethasone              1 
 FINACEA                                3                       dipropionate
 METROCREAM                             3                     econazole nitrate                       1
 METROGEL                               3                     ketoconazole cre                        1
 METROLOTION                            3                     ketoconazole shampoo                    1
 NORITATE                               3                     kuric                                   1
 RETIN-A                                3                     nyamyc                                  1
 RETIN-A MICRO                          3                     nystatin                                1
 TAZORAC                                3                     nystatin/triamcinolone                  1
 TRETIN-X                               3                     nystop                                  1
 ZIANA                                  3                     pedi-dri                                1
                                                              BRANDS
 TOPICAL ANESTHETICS                                          ERTACZO                                 3
 Generics                                                     EXELDERM                                3
 anestacon                              1                     EXTINA                                  3
 lidocaine hcl                          1                     LOPROX                                  3
 lidocaine viscous                      1                     LOPROX SHAMPOO                          3 
 lidocaine/prilocaine                   1                     LOTRISONE                               3
 BRANDS                                                       NAFTIN                                  3
 EMLA                                   3                     NIZORAL SHAMPOO                         3
 LIDODERM                               3                     OXISTAT                                 3
 SYNERA                                 3                     PENLAC NAIL LACQUER                     3
 XYLOCAINE                              3                     XOLEGEL                                 3

 TOPICAL                                                       TOPICAL ANTIVIRALS
 ANTIBACTERIALS                                                BRANDS
 Generics                                                      DENAVIR                                 3
 gentamicin sulfate                       1                    ZOVIRAX                                 3
 mupirocin oint                           1 
 sodium sulfacetamide lot                 1 
 BRANDS
34  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 TOPICAL                                                       CREAM/CETAPHIL LOTION
 CORTICOSTEROIDS                                               DESOWEN                                3
 Generics                                                      LOTION/CETAPHIL
 ala cort cre                            1                      CREAM
 ala-cort lot                            1                     DESOWEN OINTMENT/                      3
 alclometasone dipropionate              1                      CETAPHIL LOTION
 amcinonide                              1                     DIPROLENE                              3
 augmented betamethasone                 1                     DIPROLENE AF                           3
   dipropionate                                                ELOCON                                 3
 betamethasone dipropionate              1                     HALOG                                  3
 betamethasone valerate                  1                     KENALOG AERS                           3
 beta-val                                1                     LOCOID                                 3
 clobetasol propionate                   1                     LOCOID LIPOCREAM                       3
 clobetasol propionate e                 1                     LOKARA                                 3
 desonide                                1                     LUXIQ                                  3
 desoximetasone                          1                     OLUX-E                                 3
 diflorasone diacetate                   1                     PANDEL                                 3
 fluocinolone acetonide                  1                     TEMOVATE                               3
 fluocinonide                            1                     TOPICORT                               3
 fluocinonide emollient base             1                     TOPICORT LP                            3
 fluticasone propionate                  1                     TRIAMCINOLONE                          2
 hydrocortisone                          1                      ACETONIDE IN
 hydrocortisone butyrate                 1                      ABSORBASE
 hydrocortisone valerate                 1                     ULTRAVATE                              3
 mometasone furoate                      1                     VANOS                                  3
 prednicarbate                           1                     VERDESO                                3
 triamcinolone acetonide cre             1                     WESTCORT                               3
 triamcinolone acetonide lot             1 
 triamcinolone acetonide oint            1                     TOPICAL ENZYMES
 triderm                                 1                     BRANDS
 BRANDS                                                        SANTYL                                 2
 ACLOVATE                                3
 ALA SCALP                               3                     TOPICAL SCABICIDES /
 CAPEX                                   2                     PEDICULICIDES
 CLOBEX                                  3                     Generics
 CLODERM                                 3                     acticin                                1
 CORDRAN                                 3                     malathion lot                          1
 CORDRAN SP                              3                     permethrin cre                         1
 CORDRAN TAPE                            3                     BRANDS
 CUTIVATE                                3                     EURAX                                  2
 DERMA-SMOOTHE/FS                        3                     LINDANE                                3
   BODY OIL                                                    OVIDE                                  3
 DERMATOP                                3                     ULESFIA                                3
 DESONATE                                3
 DESOWEN                                 3
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         35 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 DIAGNOSTICS /                                                CAMPRAL                                2
 MISCELLANEOUS                                                CARNITOR INJ                           3         PA
 AGENTS                                                       CARNITOR SOLN                          3
 IRRIGATING SOLUTIONS                                         CARNITOR TAB                           3
 Generics                                                     CHEMET                                 3
 lactated ringers irrigation            1                     CLINIMIX 4.25%/                        2         PA
                                        1                      DEXTROSE 5%
 neomycin/polymyxin b sulfates
   irrigation                                                 CLINIMIX E 2.75%/                       2        PA
                                        1                      DEXTROSE 10%
 ringers irrigation
                                                              CLINIMIX E 2.75%/                       2        PA
 BRANDS
                                                               DEXTROSE 5%
 PHYSIOLYTE                             3 
                                                              DEXTROSE 10%/NACL 0.45%                 2        PA
 PHYSIOSOL IRRIGATION                   3 
                                                              DEXTROSE 10%/NACL 0.2%                  2        PA
 TIS-U-SOL                              3 
                                                              DEXTROSE 5%/NACL 0.33%                  2
                                                              DIDRONEL                                3
 MISCELLANEOUS AGENTS
                                                              EVOXAC                                  2
 Generics
                                                              EXJADE                                  4        LA
 alcohol 5%/dextrose 5%                 1         PA
                                                              FOSAMAX 40 MG                           3       QL ST
 alendronate sodium 40 mg               1         QL
                                                              FOSRENOL                                2
 anagrelide hydrochloride               1 
                                                              GLASSIA                                 4
 dextrose 10% flex container            1         PA
                                                     
                                                              INCRELEX                                4        LA
 dextrose 2.5%/sodium chloride          1 
                                                              KAYEXALATE POWD                         3
   0.45%
 dextrose 5% inj                        1                     LEVOCARNITINE INJ                       2        PA
                                                     
                                                               200 MG/ML
 dextrose 5%/nacl 0.2%                  1 
                                                     
                                                              ORFADIN                                 4        LA
 dextrose 5%/nacl 0.225%                1 
                                                     
                                                              PROAMATINE                              3
 dextrose 5%/nacl 0.45%                 1 
                                                     
                                                              PROLASTIN                               4        LA
 dextrose 5%/nacl 0.9%                  1 
                                                     
                                                              RECLAST                                 3
 etidronate disodium                    1 
                                                     
                                                              RENAGEL                                 2
 kionex                                 1 
                                                     
                                                              RENVELA                                 2
 levocarnitine soln 1 gm/10 ml          1 
                                                     
                                                              RILUTEK                                 2
 levocarnitine tabs                     1 
                                                     
                                                              SALAGEN                                 3
 midodrine hcl                          1 
                                                     
                                                              SKELID                                  3        QL
 pilocarpine hcl tab                    1 
                                                     
                                                              SYPRINE                                 3
 sodium chloride 0.9% irrigation        1 
                                                     
                                                              ZEMAIRA                                 4
 sodium chloride 0.9% inj               1 
 sodium polystyrene sulfonate           1            
                                                     
                                                              SMOKING DETERRENTS
 sterile water irrigation               1 
                                                              Generics
 BRANDS
                                                              buproban                                1
 ACTONEL 30 MG                          3       QL ST
                                                              BRANDS
 ADAGEN                                 4        LA
                                                              CHANTIX                                 2
 AGRYLIN                                3
                                                              NICOTROL INHALER                        2
 ANTABUSE                               2
                                                              NICOTROL NS                             2
 ARALAST NP                             4
                                                              ZYBAN                                   3
 BUPHENYL                               3

36  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
   EAR, NOSE / THROAT MEDICATIONS                              ENDOCRINE/DIABETES
 MISCELLANEOUS AGENTS                                          ADRENAL HORMONES
 Generics                                                      Generics
 azelastine hcl nasal                    1                     a-hydrocort                            1           
 chlorhexidine gluconate                 1                     a-methapred                            1           
   oral rinse                                                  cortisone acetate                      1           
 ipratropium bromide nasal               1                     dexamethasone elixir                   1           
 periogard                               1                     dexamethasone sodium                   1           
 triamcinolone in orabase                1                       phosphate inj
 BRANDS                                                        dexamethasone tab 0.5 mg               1           
 APHTHASOL                               3                     dexamethasone tab 0.75 mg              1           
 ASTELIN                                 3                     dexamethasone tab 1.5 mg               1           
 ASTEPRO                                 2                     dexamethasone tab 4 mg                 1           
 ATROVENT NASAL                          3                     dexamethasone tab 6 mg                 1           
 BACTROBAN NASAL                         3                     fludrocortisone acetate tab            1           
 TYZINE                                  2                     hydrocortisone tab                     1           
 TYZINE PEDIATRIC NASAL                  3                     methylprednisolone acetate inj         1           
   DROPS                                                       methylprednisolone sodium              1           
                                                                 succinate inj 125 mg
 MISCELLANEOUS OTIC                                            methylprednisolone sodium              1           
 PREPARATIONS                                                    succinate inj 40 mg
 Generics                                                      methylprednisolone tab                 1           
 acetasol hc                             1                     millipred tab                          1           
 acetic acid otic                        1                     prednisolone sodium phosphate          1           
 acetic acid/ hydrocortisone             1                       soln
 borofair                                1                     prednisolone syrup                     1           
 ofloxacin otic                          1                     prednisone tab                         1           
 BRANDS                                                        solu-medrol inj 500 mg                 1           
 DERMOTIC                                2                     BRANDS
                                                               CELESTONE                              3
 OTIC STEROID /                                                CORTEF                                 3
 ANTIBIOTIC                                                    DEPO-MEDROL SUSP                       2
 Generics                                                      DEXAMETHASONE                          3
 cortomycin                              1                     INTENSOL
 neomycin /polymyxin                     1                     DEXAMETHASONE TAB                      3
  /hydrocortisone otic                                           1 MG
 BRANDS                                                        DEXAMETHASONE TAB                      3
 CIPRO HC                                3                       2 MG
 CIPRODEX                                3                     DEXPAK                                 3
 COLY-MYCIN S                            3                     MEDROL DOSEPAK                         3
 CORTISPORIN OTIC                        3                     MEDROL TAB                             3
 CORTISPORIN-TC                          3                     METHYLPREDNISOLONE                     2
                                                                 SODIUM SUCCINATE INJ
                                                                 1000 MG
                                                               MILLIPRED SOLN 10MG/5ML                3
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         37 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 ORAPRED ODT                           3                      APIDRA SOLOSTAR                        2         PA
 ORAPRED SOLN                          3                      AVANDAMET                              2
 PEDIAPRED                             3                      AVANDARYL                              2
 PREDNISONE INTENSOL                   3                      AVANDIA                                2
 PRELONE                               3                      BD INSULIN SYRINGE                     2
 SOLU-CORTEF                           2                       SAFETYGLIDE/1ML/29G X
 SOLU-MEDROL INJ 125 MG                2                       1/2"
 SOLU-MEDROL INJ 2 GM                  2                      BD INSULIN SYRINGE                      2
 SOLU-MEDROL INJ 40 MG                 2                       ULTRAFINE/0.3ML/31G X
 VERIPRED 20                           3                       5/16"
                                                              BD INSULIN SYRINGE                      2
 ANTITHYROID AGENTS                                            ULTRAFINE/0.5ML/30G X
 Generics                                                      1/2"
 methimazole                            1                     BD INSULIN SYRINGE                      2
 propylthiouracil                       1                      ULTRAFINE/1ML/31G X
 BRANDS                                                        5/16"
 TAPAZOLE                               3                     BD PEN NEEDLE/                          2
                                                               ULTRAFINE/29G X 12.7MM
                                                              BYETTA                                  2
 DIABETES THERAPY                                             CURITY GAUZE PADS 2"X2"                 2
 Generics                                                     CYCLOSET                                3
 acarbose                               1                     DIABETA                                 3
 chlorpropamide                         1                     DUETACT                                 2
 glimepiride                            1                     FORTAMET                                3
 glipizide                              1                     GLUCAGEN HYPOKIT                        2
 glipizide er                           1                     GLUCAGON EMERGENCY                      2
 glipizide xl                           1                      KIT
 glipizide/metformin hcl                1                     GLUCOPHAGE                              3
 glyburide                              1                     GLUCOPHAGE XR                           3
 glyburide micronized                   1                     GLUCOTROL                               3
 glyburide/metformin hcl                1                     GLUCOTROL XL                            3
 glycron 1.5 mg                         1                     GLUCOVANCE                              3
 glycron 3 mg                           1                     GLUMETZA                                3
 metformin hcl                          1                     GLYCRON 4.5 MG                          2
 metformin hcl er                       1                     GLYCRON 6 MG                            3
 nateglinide                            1                     GLYNASE                                 3
 tolazamide                             1                     GLYSET                                  3
 tolbutamide                            1                     HUMALOG                                 2        PA
 BRANDS                                                       HUMALOG MIX 50/50                       2
 ACTOPLUS MET                           2                     HUMALOG MIX 50/50 PEN                   2
 ACTOPLUS MET XR                        2                     HUMALOG MIX 75/25                       2
 ACTOS                                  2                     HUMALOG MIX 75/25 PEN                   2
 ALCOHOL PREPS                          2                     HUMALOG PEN                             2        PA
 AMARYL                                 3                     HUMULIN 70/30                           2
 APIDRA                                 2         PA          HUMULIN 70/30 PEN                       2
38  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 HUMULIN N                              2                      danazol                               1
 HUMULIN N U-100 PEN                    2                      desmopressin acetate                  1
 HUMULIN R                              2         PA           fortical                              1
 HUMULIN R U-500                        2         PA           oxandrolone                           1          PA
  (CONCENTRATED)                                               pamidronate disodium inj              1          PA
 JANUMET                                 2                       30 mg/10 ml
 JANUVIA                                 2                     pamidronate disodium inj               1         PA
 KOMBIGLYZE XR                           3                       90 mg/10 ml
 LANTUS                                  2                     testosterone cypionate                 1         PA
 LANTUS SOLOSTAR                         2                     testosterone enanthate                 1         PA
 LEVEMIR                                 2                     BRANDS
 LEVEMIR FLEXPEN                         2                     ALDURAZYME                             4        LA
 METAGLIP                                3                     ANADROL-50                             4        PA
 NOVOLIN 70/30                           2                     ANDRODERM                              3       PA ST
 NOVOLIN 70/30 INNOLET                   2                     ANDROGEL                               2        PA
 NOVOLIN N                               2                     ANDROID                                3        PA
 NOVOLIN N INNOLET                       2                     AREDIA INJ 30 MG                       3        PA
 NOVOLIN R                               2        PA           AREDIA INJ 90 MG                       4        PA
 NOVOLOG                                 2        PA           CALCIJEX                               3        PA
 NOVOLOG FLEXPEN                         2        PA           CALCITRIOL INJ 2 MCG/ML                2        PA
 NOVOLOG MIX 70/30                       2                     CEREDASE                               4
 NOVOLOG MIX 70/30                       2                     CEREZYME                               4         LA
 PREFILLED FLEXPEN                                             DDAVP                                  3
 ONGLYZA                                 3                     DELATESTRYL                            3         PA
 PRANDIMET                               3                     DEPO-TESTOSTERONE                      3         PA
 PRANDIN                                 3                     ELAPRASE                               4
 PRECOSE                                 3                     FABRAZYME                              4        LA
 PROGLYCEM                               3                     FORTESTA                               3       PA ST
 RELION R                                2        PA           HECTOROL CAP                           3
 RIOMET                                  2                     HECTOROL INJ                           3         PA
 STARLIX                                 3                     KUVAN                                  4         LA
 SYMLIN                                  2                     METHITEST                              3         PA
 SYMLINPEN 120                           2                     MIACALCIN                              3         PA
 SYMLINPEN 60                            2                     MYOZYME                                4
 VICTOZA                                 3                     NAGLAZYME                              4         LA
                                                               OXANDRIN                               3         PA
 MISCELLANEOUS                                                 PAMIDRONATE DISODIUM                   2         PA
 HORMONES                                                        INJ 6 MG/ML
 Generics                                                      ROCALTROL                              3
 androxy                                 1        PA           SAMSCA                                 4
 cabergoline                             1                     SENSIPAR                               2
 calcitonin-salmon nasal                 1                     SOMAVERT                               4
 calcitriol cap                          1                     STIMATE                                3
 calcitriol inj 1 mcg/ml                 1        PA           STRIANT                                3         PA
 calcitriol soln                         1                     SYNAREL                                4
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         39 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                              Drug      Reqs.
                                      Tier      /Limits                                               Tier    /Limits
 TESTIM                                3         PA ST             MISCELLANEOUS GASTROINTESTINAL
 TESTRED                               3          PA                                  AGENTS
 VPRIV                                 4                       Generics
 ZAVESCA                               4            LA         balsalazide disodium                    1
 ZEMPLAR CAP                           3                       compro                                  1
 ZEMPLAR INJ                           3            PA         constulose                              1
 ZOMETA                                4            PA         dronabinol                              1        PA
                                                               enulose                                 1
 THYROID HORMONES                                              gavilyte-c                              1
 Generics                                                      gavilyte-g                              1
 levothyroxine sodium                     1                    gavilyte-n/flavor pack                  1
 levoxyl                                  1                    generlac                                1
 liothyronine sodium                      1                    granisetron hcl inj                     1
 unithroid                                1                    granisetron hcl tab                     1        PA
 BRANDS                                                        hydrocortisone enema                    1
 CYTOMEL                                  3                    lactulose                               1
 LEVOTHROID                               2                    meclizine hcl                           1
 SYNTHROID                                2                    mesalamine enema                        1
 THYROLAR-1                               3                    metoclopramide hcl                      1
 THYROLAR-1/4                             3                    ondansetron hcl inj                     1
 THYROLAR-2                               3                    ondansetron hcl soln                    1        PA
 THYROLAR-3 3                             3                    ondansetron hcl tab                     1        PA
                                                               ondansetron odt                         1        PA
 GASTROENTEROLOGY                                              polyethylene glycol 3350                1
 ANTIDIARRHEALS /                                              prochlorperazine edisylate              1
 ANTISPASMODICS                                                prochlorperazine maleate tab            1
 Generics                                                      prochlorperazine supp                   1
 atropine sulfate inj 0.1 mg/ml           1                    procto-pak                              1
 dicyclomine hcl                          1                    proctosol hc                            1
 diphenoxylate/atropine                   1                    proctozone-hc                           1
 glycopyrrolate                           1                    sulfasalazine                           1
 loperamide hcl                           1                    sulfazine ec                            1
 methscopolamine bromide                  1                    trilyte                                 1
 BRANDS                                                        trimethobenzamide hcl                   1
 ATROPINE SULFATE INJ                     2                    ursodiol                                1
   0.05 MG/ML                                                  BRANDS
 BENTYL                                   3                    ACTIGALL                                3
 CANTIL                                   3                    ALOXI                                   3
 LOMOTIL                                  3                    AMITIZA                                 3
 MOTOFEN                                  3                    ANTIVERT                                3
 PAMINE                                   3                    ANUSOL-HC CRE                           3
 PAMINE FORTE                             3                    ANZEMET INJ                             3
 ROBINUL                                  3                    ANZEMET TAB                             4        PA
 ROBINUL FORTE                            3                    APRISO                                  2
                                                               ASACOL                                  2
40  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 ASACOL HD                              2                      URSO FORTE                            3
 AZULFIDINE                             3                      VISICOL                               3
 AZULFIDINE EN-TABS                     3                      ZENPEP                                2
 CANASA                                 2                      ZOFRAN INJ                            3
 CESAMET                                3         PA           ZOFRAN ODT                            4          PA
 CIMZIA                                 4         PA           ZOFRAN SOLN                           4          PA
 COLAZAL                                3                      ZOFRAN TAB                            4          PA
 COLOCORT                               3                      ZUPLENZ                               3          PA
 COLYTE-FLAVOR PACKS                    3
 CORTENEMA                              3                      ULCER THERAPY
 CORTIFOAM                              2                      Generics
 CREON                                  2                      cimetidine                             1           
 CYSTADANE                              3                      famotidine                             1           
 DIPENTUM                               2                      famotidine premixed                    1           
 EMEND                                  3         PA           lansoprazole                           1           
 ENTOCORT EC                            3                      misoprostol                            1           
 GASTROCROM                             3                      nizatidine                             1           
 GOLYTELY                               3                      omeprazole                             1           
 GRANISOL                               3         PA           omeprazole-sodium bicarbonate          1           
 HALFLYTELY BOWEL PREP                  3                      pantoprazole sodium                    1           
 KRISTALOSE                             3                      ranitidine hcl                         1           
 KYTRIL INJ                             4                      sucralfate                             1           
 KYTRIL TAB                             4         PA           BRANDS
 LIALDA                                 2                      ACIPHEX                                3         ST
 LOTRONEX                               2                      AXID                                   3
 MARINOL 10 MG                          4         PA           CARAFATE                               3
 MARINOL 2.5 MG                         3         PA           CYTOTEC                                3
 MARINOL 5 MG                           4         PA           DEXILANT                               3         ST
 METOZOLV ODT                           3                      HELIDAC                                3
 MOVIPREP                               3                      NEXIUM                                 2
 NULYTELY/FLAVOR PACKS                  3                      NEXIUM I.V.                            2
 OSMOPREP                               3                      PEPCID                                 3
 PANCREAZE                              3                      PEPCID I.V.                            3
 PENTASA                                2                      PEPCID PREMIXED                        3
 PROCTOCORT                             3                      PREVACID                               3         ST
 PROCTOCREAM-HC                         3                      PREVACID SOLUTAB                       3         ST
 REGLAN                                 3                      PREVPAC                                3
 RELISTOR                               3                      PRILOSEC                               3         ST
 REMICADE                               4         PA           PROTONIX INJ                           3
 ROWASA                                 3                      PROTONIX PACKET                        3         ST
 SANCUSO                                4                      PROTONIX TABLET                        3         ST
 SUPREP                                 3                      PYLERA                                 2
 TIGAN                                  3                      ZANTAC                                 3
 TRANSDERM-SCOP                         3                      ZANTAC EFFEREVES TAB                   3
 URSO 250                               3                      ZEGERID                                3         ST
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         41 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
        IMMUNOLOGY, VACCINES /                                GENOTROPIN 5 MG                        4         PA
           BIOTECHNOLOGY                                      GENOTROPIN MINIQUICK                   3         PA
 BIOTECHNOLOGY DRUGS                                           0.2 MG
 BRANDS                                                       GENOTROPIN MINIQUICK                    4        PA
 ACTIMMUNE                              4         LA           0.4 MG
 ARANESP ALBUMIN FREE                   4         PA          GENOTROPIN MINIQUICK                    4        PA
  100 MCG/0.5 ML                                               0.6 MG
 ARANESP ALBUMIN FREE                   4         PA          GENOTROPIN MINIQUICK                    4        PA
  100 MCG/ML                                                   0.8 MG
 ARANESP ALBUMIN FREE                   4         PA          GENOTROPIN MINIQUICK                    4        PA
  150 MCG/0.3 ML                                               1 MG
 ARANESP ALBUMIN FREE                   4         PA          GENOTROPIN MINIQUICK                    4        PA
  200 MCG/0.4 ML                                               1.2 MG
 ARANESP ALBUMIN FREE                   4         PA          GENOTROPIN MINIQUICK                    4        PA
  200 MCG/ML                                                   1.4 MG
 ARANESP ALBUMIN FREE                   3         PA          GENOTROPIN MINIQUICK                    4        PA
  25 MCG/0.42 ML                                               1.6 MG
 ARANESP ALBUMIN FREE                   3         PA          GENOTROPIN MINIQUICK                    4        PA
  25 MCG/ML                                                    1.8 MG
 ARANESP ALBUMIN FREE                   4         PA          GENOTROPIN MINIQUICK                    4        PA
  300 MCG/0.6 ML                                               2 MG
 ARANESP ALBUMIN FREE                   4         PA          HUMATROPE                               4        PA
  300 MCG/ML                                                  HUMATROPE COMBO PACK                    4        PA
 ARANESP ALBUMIN FREE                   3         PA          INFERGEN                                4
  40 MCG/0.4 ML                                               INTRON-A                                4
 ARANESP ALBUMIN FREE                   3         PA          INTRON-A W/DILUENT                      4
  40 MCG/ML                                                   LEUKINE                                 4         PA
 ARANESP ALBUMIN FREE                   4         PA          MOZOBIL                                 4
  500 MCG/ML                                                  NEULASTA                                4         PA
 ARANESP ALBUMIN FREE                   3         PA          NEUMEGA                                 4
  60 MCG/0.3 ML                                               NEUPOGEN                                2        PA
 ARANESP ALBUMIN FREE                   3         PA          NORDITROPIN NORDIFLEX                   4        PA
  60 MCG/ML                                                    PEN
 ARCALYST                               4         LA          NORDITROPIN CARTRIDGE                   4        PA
 AVONEX                                 4                     NUTROPIN                                4        PA
 BETASERON                              4                     NUTROPIN AQ                             4        PA
 EGRIFTA                                4         LA          NUTROPIN AQ NUSPIN                      4        PA
 EPOGEN 10,000 UNIT/ML                  4         PA          NUTROPIN AQ PEN                         4        PA
 EPOGEN 20,000 UNIT/ML                  4         PA          OMNITROPE                               4        PA
 EPOGEN 2000 UNIT/M                     3         PA          PEGASYS                                 4        PA
 EPOGEN 3000 UNIT/ML                    3         PA          PEG-INTRON                              4        PA
 EPOGEN 40,000 UNIT/ML                  4         PA          PEG-INTRON REDIPEN                      4        PA
 EPOGEN 4000 UNIT/ML                    3         PA          PROCRIT 10,000 UNIT/ML                  3        PA
 EXTAVIA                                4                     PROCRIT 20,000 UNIT/ML                  4        PA
 GENOTROPIN 12 MG                       4         PA          PROCRIT 2000 UNIT/ML                    3        PA
42  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 PROCRIT 3000 UNIT/ML                   3         PA           MENOMUNE-A/C/Y/W-135                  2
 PROCRIT 40,000 UNIT/ML                 4         PA           MENVEO A-C-Y-W-135-DIP                2
 PROCRIT 4000 UNIT/ML                   3         PA           MERUVAX II W/DILUENT                  2
 PROLEUKIN                              4                       10 DOSE
 REBIF                                  4                      M-M-R II W/DILUENT 10                  2
 REBIF TITRATION PACK                   4                       DOSE
 SAIZEN                                 4         PA           PEDIARIX                               2
 SAIZEN CLICK.EASY                      4         PA           PEDVAX HIB                             2
 SEROSTIM                               4         PA           PRIVIGEN                               4         PA
 TEV-TROPIN                             4         PA           PROQUAD                                2
                                                               RABAVERT                               2
 VACCINES / MISCELLANEOUS                                      RECOMBIVAX HB                          2         PA
 IMMUNOLOGICALS                                                ROTATEQ                                2
 Generics                                                      TETANUS/DIPHTHERIA                     2
 fomepizole                              1                      TOXOIDS-ADSORBED
                                                                ADULT
 tetanus toxoid adsorbed                 1 
                                                               THYMOGLOBULIN                          2         PA
 BRANDS
                                                               TRIHIBIT                               2
 ACTHIB                                  2
                                                               TRIPEDIA                               2
 ADACEL                                  2
                                                               TWINRIX                                2
 ANTIZOL                                 4
                                                               TYPHIM VI                              2
 ATGAM                                   2        PA
                                                               VAQTA                                  2
 ATTENUVAX                               2
                                                               VARIVAX                                2
 BOOSTRIX                                2
                                                               VIVAGLOBIN                             4         PA
 CARIMUNE NANOFILTERED                   4        PA
                                                               YF-VAX                                 2
 CERVARIX                                2
                                                               ZOSTAVAX                               2
 COMVAX                                  2
 DAPTACEL                                2
 DECAVAC                                 2                     MUSCULOSKELETAL /
 DIPHTHERIA/TETANUS                      2                     RHEUMATOLOGY
   TOXOID PEDIATRIC                                            GOUT THERAPY
 ENGERIX-B                               2        PA           Generics
 GAMASTAN S/D                            3        PA           allopurinol                            1
 GAMMAGARD LIQUID                        4        PA           probenecid                             1
 GAMMAPLEX                               4        PA           probenecid/colchicine                  1
 GAMUNEX                                 4        PA           BRANDS
 GARDASIL                                2                     ALLOPURINOL SODIUM INJ                 3
 HAVRIX                                  2                     ALOPRIM                                3
 HIZENTRA                                4        PA           COLCRYS                                2
 IMOVAX RABIES (H.D.C.V.)                2                     ULORIC                                 3
 INFANRIX                                2                     ZYLOPRIM                               3
 IPOL INACTIVATED IPV                    2
 IXIARO                                  2
 JE-VAX                                  2                     OSTEOPOROSIS THERAPY
 MENACTRA                                2                     Generics
                                                               alendronate sodium tab                 1         QL
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         43 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 BRANDS                                                       jolivette                              1            
 ACTONEL                                3       QL ST         medroxyprogesterone acetate            1            
 ATELVIA                                3       QL ST           150 mg/ml
 BONIVA INJ                             2        PA           medroxyprogesterone acetate tab         1           
 BONIVA TAB 150 MG                      2        QL           nora-be                                 1           
 EVISTA                                 2                     norethindrone acetate                   1           
 FORTEO                                 4                     ortho-est                               1           
 FOSAMAX PLUS D                         3       QL ST         BRANDS
 FOSAMAX SOLN                           3       QL ST         ACTIVELLA                               3
 FOSAMAX TAB                            3       QL ST         ALORA                                   3
 PROLIA                                 3                     ANGELIQ                                 3
                                                              AYGESTIN                                3
 OTHER                                                        CLIMARA                                 3
 RHEUMATOLOGICALS                                             CLIMARA PRO                             3
 Generics                                                     COMBIPATCH                              3
 leflunomide                            1                     CRINONE                                 3
 BRANDS                                                       DELESTROGEN                             3
 ACTEMRA                                4         PA          DEPO-ESTRADIOL                          3
 ARAVA                                  3                     DEPO-PROVERA 400 MG/ML                  2
 CUPRIMINE                              2                     DEPO-PROVERA                            3
 DEPEN TITRATABS                        2                       CONTRACEPTIVE
 ENBREL                                 4         PA          DEPO-SUBQ PROVERA 104                   2
 HUMIRA                                 4         PA          DIVIGEL                                 3
 HUMIRA PEN-CROHNS                      4         PA          ELESTRIN                                3
   DISEASE STARTER                                            ENJUVIA                                 3
 KINERET                                4         PA          ESTRACE                                 3
 ORENCIA                                4         PA          ESTRADERM                               3
 RIDAURA                                2                     ESTRING                                 3
 SAVELLA                                3                     EVAMIST                                 3
 SAVELLA TITRATION PACK                 3                     FEMHRT 1/5                              3
 SIMPONI                                4         PA          FEMHRT LOW DOSE                         3
                                                              FEMRING                                 3
                                                              FEMTRACE                                3
 OBSTETRICS /
                                                              GYNODIOL                                3
 GYNECOLOGY                                                   MENEST                                  3
 ESTROGENS / PROGESTINS                                       MENOSTAR                                3
 Generics                                                     NOR-QD                                  3
 camila                                 1            
                                                              OGEN                                    3
 errin                                  1            
                                                              ORTHO MICRONOR                          3
 estradiol patch                        1            
                                                              PREFEST                                 3
 estradiol tab                          1            
                                                              PREMARIN                                2
 estradiol valerate                     1            
                                                              PREMARIN W/APPLICATOR                   2
 estradiol/norethindrone acetate        1            
                                                              PREMPHASE                               2
   1 mg/0.5 mg
                                                              PREMPRO                                 2
 estropipate tab                        1            
                                                              PROCHIEVE                               3
44  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 PROMETRIUM                             2                      levora 0.15/30-28                     1            
 PROVERA TAB                            3                      low-ogestrel                          1            
 VAGIFEM 10 MCG                         3                      lutera                                1            
 VIVELLE-DOT                            3                      microgestin 1.5/30                    1            
                                                               microgestin 1/20                      1            
 MISCELLANEOUS OB/GYN                                          microgestin fe                        1            
 Generics                                                      microgestin fe 1.5/30                 1            
 clindamycin phosphate vag cre           1                     mononessa                             1            
 metronidazole vaginal                   1                     necon 0.5/35-28                       1            
 miconazole 3 vag supp                   1                     necon 1/35-28                         1            
 terconazole                             1                     necon 10/11-28                        1            
 vandazole                               1                     necon 7/7/7                           1            
 zazole vag cre 0.4%                     1                     next choice                           1            
 zazole vag supp                         1                     nortrel 0.5/35 (28)                   1            
 BRANDS                                                        nortrel 1/35 (21)                     1            
 CLEOCIN VAG                             3                     nortrel 1/35 (28)                     1            
 CLINDESSE                               3                     nortrel 7/7/7                         1            
 GYNAZOLE-1                              3                     ocella                                1            
 METROGEL-VAGINAL                        3                     ogestrel                              1            
 NUVARING                                2                     portia-28                             1            
 ORTHO EVRA                              2                     previfem                              1            
 TERAZOL 3                               3                     quasense                              1            
 TERAZOL 7                               3                     reclipsen                             1            
 ZAZOLE VAG CRE 0.8%                     3                     solia                                 1            
                                                               sprintec 28                           1            
 ORAL CONTRACEPTIVES /                                         sronyx                                1            
 RELATED AGENTS                                                tri-legest fe                         1            
 Generics                                                      trinessa                              1            
 apri                                    1                     tri-previfem                          1            
 aranelle                                1                     tri-sprintec                          1            
 aviane                                  1                     trivora-28                            1            
 balziva                                 1                     velivet                               1            
 cesia                                   1                     zovia 1/35e                           1            
 cryselle-28                             1                     zovia 1/50e                           1            
 cyclafem                                1                     BRANDS                                             
 enpresse-28                             1                     BEYAZ                                  3           
 gianvi                                  1                     BREVICON-28                            3           
 junel 1.5/30                            1                     CYCLESSA                               3
 junel 1/20                              1                     DESOGEN                                3
 junel fe 1.5/30                         1                     ELLA                                   3
 junel fe 1/20                           1                     ESTROSTEP FE                           3
 kariva                                  1                     LO/OVRAL-28                            3
 kelnor 1/35                             1                     LOESTRIN 1.5/30-21                     3
 leena                                   1                     LOESTRIN 1/20-21                       3
 lessina-28                              1                     LOESTRIN 24 FE                         2
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         45 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 LOESTRIN FE 1.5/30                    3                      BRANDS
 LOESTRIN FE 1/20                      3                      AZASITE                                 3
 LOSEASONIQUE                          3                      BESIVANCE                               3
 LYBREL                                3                      CILOXAN                                 3
 MODICON-28                            3                      IQUIX                                   3
 NORDETTE-28                           3                      NATACYN                                 3
 NORINYL 1+35                          3                      NEOSPORIN OPH DROPS                     3
 ORTHO TRI-CYCLEN LO                   3                      OCUFLOX                                 3
 ORTHO-CEPT-28                         3                      POLYTRIM                                3
 ORTHO-CYCLEN                          3                      QUIXIN                                  3
 ORTHO-NOVUM 7/7/7-28                  3                      TOBREX                                  3
 OVCON-35                              3                      VIGAMOX                                 3
 OVCON-50 28                           3                      ZYMAR                                   3
 SEASONALE                             3                      ZYMAXID                                 3
 SEASONIQUE                            3
 TRI-NORINYL 28                        3                      ANTIVIRALS                                
 YASMIN 28                             3                      Generics
 YAZ                                   3                      trifluridine                            1
                                                              BRANDS
 OXYTOCICS                                                    VIROPTIC                                3
 BRANDS                                                       ZIRGAN                                  3
 METHERGINE                             2
                                                              BETA-BLOCKERS
 OPHTHALMOLOGY                                                Generics
 ANTIBIOTICS                                                  betaxolol hcl oph drops                  1          
 Generics                                                     carteolol hcl oph drops                  1          
 ak-tob                                   1                   levobunolol hcl                          1          
 bacitracin oph oint                      1                   metipranolol                             1          
 bacitracin/polymyxin b oph oint          1                   timolol maleate oph drops                1          
 ciprofloxacin hcl oph drops              1                   timolol maleate ophthalmic               1          
 erythromycin oph oint                    1                     gel forming
 gentak                                   1                   BRANDS
 gentamicin sulfate oph drops             1                   BETAGAN                                  3
 gentasol                                 1                   BETIMOL                                  2
 neomycin /bacitracin /polymyxin          1                   BETOPTIC-S                               2
   oph oint                                                   ISTALOL                                  3
 neomycin /polymyxin /gramicidin          1                   OPTIPRANOLOL                             3
   oph soln                                                   TIMOPTIC OCUDOSE                         3
 ofloxacin oph drops                      1                   TIMOPTIC-XE                              3
 polycin b                                1           
 romycin                                  1           
 tobramycin sulfate oph drops             1                       CHOLINESTERASE INHIBITOR MIOTICS
 tobrasol                                 1                    BRANDS
 trimethoprim sulfate/polymyxin b         1                    PHOSPHOLINE IODIDE                      2
   sulfate oph drops
46  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name             Drug                     Reqs.
                                       Tier     /Limits                               Tier                   /Limits
 CYCLOPLEGIC MYDRIATICS                                        ORAL DRUGS FOR GLAUCOMA
 Generics                                                      Generics
 mydral                                  1                     acetazolamide           1
 tropicamide                             1                     acetazolamide sodium    1
 BRANDS                                                        methazolamide           1
 MYDRIACYL                               3                     BRANDS
                                                               DIAMOX                  3
 DIRECT ACTING MIOTICS
 BRANDS                                                        OTHER GLAUCOMA DRUGS
 PILOPINE HS                             2                     Generics
                                                               dorzolamide hcl                        1
 MISCELLANEOUS                                                 dorzolamide hcl/timolol maleate        1
 OPHTHALMOLOGICS                                               BRANDS
 Generics                                                      AZOPT                                  2
 azelastine hcl oph drops                1                     COMBIGAN                               3
 cromolyn sodium oph drops               1                     COSOPT                                 3
 BRANDS                                                        LUMIGAN                                3         ST
 ALAMAST                                 3                     TRAVATAN Z                             2
 ALOCRIL                                 3                     TRUSOPT                                3
 ALOMIDE                                 3                     XALATAN                                2
 BEPREVE                                 3
 ELESTAT                                 3                     STEROID-ANTIBIOTIC
 EMADINE                                 3                     COMBINATIONS
 LACRISERT                               2                     Generics
 LASTACAFT                               3                     dexasporin                             1
 OPTIVAR                                 3                     neomycin /polymyxin /bacitracin        1 
 PATADAY                                 3                       /hydrocortisone oph oint
 PATANOL                                 3                     neomycin /polymyxin                    1 
 RESTASIS                                3                       /dexamethasone oph drops
                                                               neomycin /polymyxin                    1 
 NON-STEROIDAL ANTI-                                             /dexamethasone oph oint
 INFLAMMATORY AGENTS                                           neomycin /polymyxin                    1
 Generics                                                        /hydrocortisone oph drops
 diclofenac sodium oph drops             1                     poly-dex                               1
 flurbiprofen sodium oph drops           1                     tobramycin /dexamethasone              1
 ketorolac tromethamine oph              1                     BRANDS
   drops                                                       MAXITROL                               3
 BRANDS                                                        POLY-PRED                              3
 ACULAR                                  3                     PRED-G                                 3
 ACULAR LS                               3                     PRED-G S.O.P.                          3
 ACUVAIL                                 3                     TOBRADEX OPH DROPS                     3
 NEVANAC                                 3                     TOBRADEX OPH OINT                      2
 OCUFEN                                  3                     TOBRADEX ST                            3
 VOLTAREN OPH DROPS                      3                     ZYLET                                  3
 XIBROM                                  3
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         47 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
                                                              ALPHAGAN P 0.15%                       3
                                                              IOPIDINE                               3
 STEROIDS
                                                              PROPINE                                3
 Generics
 dexamethasone sodium phosphate         1 
   oph drops                                                  VASOCONSTRICTOR
 fluorometholone                        1                     DECONGESTANTS
 prednisolone acetate oph drops         1                     Generics
                                                              ak-con                                  1
 prednisolone sodium phosphate          1 
   oph drops                                                  naphazoline hcl oph drops 0.1%          1
 BRANDS
 ALREX                                  3                     RESPIRATORY AND
 DUREZOL                                3                     ALLERGY
 FLAREX                                 3                     ANTIHISTAMINE /
 FML                                    3                     ANTIALLERGENIC AGENTS
 FML FORTE                              3                     Generics
 FML LIQUIFILM                          3                     carbinoxamine maleate liq 4 mg/         1 
 LOTEMAX                                3                       5 ml
 MAXIDEX                                3                     carbinoxamine maleate tab 4 mg          1
 OMNIPRED                               3                     clemastine fumarate syrup               1
 PRED FORTE                             3                     clemastine fumarate tab 2.68 mg         1
 PRED MILD                              3                     cyproheptadine hcl                      1
 VEXOL                                  3                     dexchlorpheniramine maleate             1 
                                                                syrup
 STEROID-SULFONAMIDE                                          diphenhydramine hcl cap 50 mg           1           
 COMBINATIONS                                                 diphenhydramine hcl inj                 1           
 Generics                                                     epinephrine hcl inj 0. mg/ml            1           
 sulfacetamide sodium/                  1                     fexofenadine hcl                        1           
   prednisolone sodium phosphate                              hydroxyzine hcl                         1           
   oph drops                                                  hydroxyzine pamoate                     1           
 BRANDS                                                       levocetirizine                          1           
 BLEPHAMIDE                             3                     palgic liq 4 mg/5 ml                    1           
 BLEPHAMIDE S.O.P.                      2                     phenadoz                                1           
                                                              promethazine hcl                        1           
 SULFONAMIDES                                                 promethazine vc                         1           
 Generics                                                     promethegan                             1           
 sodium sulfacetamide oph drops         1                     BRANDS
 BRANDS                                                       CLARINEX                                3
 BLEPH-10                               3                     CLARINEX REDITABS                       3
 SYMPATHOMIMETICS                                             CLARINEX-D 12 HOUR                      3
 Generics                                                     CLARINEX-D 24 HOUR                      3
 apraclonidine                          1                     EPIPEN 2-PAK                            2
 brimonidine tartrate 0.2%              1                     EPIPEN-JR 2-PAK                         2
 BRANDS                                                       PALGIC TAB                              3
 ALPHAGAN P 0.1%                        2                     PHENERGAN INJ                           3
48  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 SEMPREX-D                              3                      FLOVENT DISKUS                        2
 TWINJECT                               2                      FLOVENT HFA                           2
 VISTARIL                               3                      FORADIL AEROLIZER                     2
 XYZAL                                  3                      LETAIRIS                              4        PA LA
                                                               LUFYLLIN                              3
 PULMONARY AGENTS                                              MAXAIR AUTOHALER                      3
 Generics                                                      NASACORT AQ                           3          ST
 acetylcysteine                          1        PA           NASONEX                               2
 albuterol sulfate er tab                1                     OMNARIS                               3          ST
 albuterol sulfate nebu                  1        PA           PERFOROMIST                           3          PA
 albuterol sulfate syrup                 1                     PROAIR HFA                            2
                                                               PROVENTIL HFA                         3
 albuterol sulfate tab                   1 
                                                               PULMICORT FLEXHALER                   2
 aminophylline                           1 
                                                               PULMICORT NEBU                        3          PA
 budesonide nebu                         1        PA
                                                               PULMOZYME                             4          PA
 cromolyn sodium nebu                    1        PA
                                                               QVAR                                  2
 flunisolide nasal                       1 
                                                               REVATIO                               4          PA
 fluticasone propionate nasal            1 
                                                               RHINOCORT AQUA                        3          ST
 ipratropium bromide nebu                1        PA
                                                               SEREVENT DISKUS                       2
 ipratropium bromide/albuterol           1        PA
                                                               SINGULAIR                             3
   sulfate nebu
                                                               SPIRIVA HANDIHALER                    2
 levalbuterol nebu                       1        PA
                                                     
                                                               SYMBICORT                             2
 metaproterenol sulfate syrup            1 
                                                     
                                                               THEO-24                               3
 metaproterenol sulfate tab              1 
                                                     
                                                               TRACLEER                              4        PA LA
 terbutaline sulfate                     1 
                                                     
                                                               UNIPHYL                               2
 theochron                               1 
                                                     
                                                               VENTAVIS                              4          PA
 theophylline er                         1 
                                                     
                                                               VENTOLIN HFA                          2
 zafirlukast                             1
                                                               VERAMYST                              3          ST
 BRANDS
                                                               VOSPIRE ER                            3
 ACCOLATE                                2
                                                               XOLAIR                                4
 ACCUNEB                                 3        PA
                                                               XOPENEX HFA                           3
 ADCIRCA                                 4        PA
                                                               XOPENEX NEBU                          3          PA
 ADVAIR DISKUS                           2
                                                               ZYFLO CR                              3
 ADVAIR HFA                              2
 AEROBID-M                               3
 ALVESCO                                 3                     UROLOGICALS
 ASMANEX                                 2                     ANTICHOLINERGICS /
 ATROVENT HFA                            2                     ANTISPASMODICS
 BECONASE AQ                             3        ST           Generics
 BROVANA                                 3        PA           flavoxate hcl                          1
 COMBIVENT                               2                     oxybutynin chloride                    1
 DULERA                                  3                     oxybutynin chloride er                 1
 DUONEB                                  3        PA           trospium chloride                      1
 ELIXOPHYLLIN                            2                     BRANDS
 FLONASE                                 3         ST          DETROL                                 3
                                                               DETROL LA                              3
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         49 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.        Drug Name                             Drug      Reqs.
                                      Tier      /Limits                                             Tier     /Limits
 DITROPAN XL                           3                      kcl 0.15%/d5w/lr                       1         PA
 ENABLEX                               3                      kcl 0.15%/d5w/nacl 0.9%                1
 GELNIQUE                              3                      kcl 0.3%/d5w/lr iv lac ring            1         PA
 OXYTROL                               3                      kcl 0.3%/d5w/nacl 0.45%                1
 SANCTURA                              3                      kcl 0.3%/d5w/nacl 0.9%                 1
 SANCTURA XR                           3                      klor-con 10                            1
 TOVIAZ                                3                      klor-con 8                             1
 VESICARE                              2                      klor-con m20                           1
                                                              plasma-lyte-r                          1         PA
 BENIGN PROSTATIC                                             potassium chloride 0.15%               1 
 HYPERPLASIA(BPH)                                               d5w/nacl 0.33%
 THERAPY                                                      potassium chloride 0.15%                1 
 Generics                                                       d5w/nacl 0.45% viaflex
 finasteride tab 5 mg                   1                     potassium chloride 0.15%                1 
 tamsulosin hcl                         1                       nacl 0.9%
 BRANDS                                                       potassium chloride 0.224%/d5w           1
 AVODART                                2                     potassium chloride                      1 
 FLOMAX                                 3                       0.224%d5w/nacl 0.33%
                                                              potassium chloride 0.3%/d5w             1           
 JALYN                                  3
                                                              potassium chloride cr                   1           
 PROSCAR                                3 
                                                              potassium chloride er cap               1           
 RAPAFLO                                3 
                                                              potassium chloride er tab               1           
 UROXATRAL                              3 
                                                              potassium chloride inj 10 meq/          1           
                                                                100 ml
 CHOLINERGIC STIMULANTS
                                                              potassium chloride inj 10 meq/          1           
 Generics
                                                                50 ml
 bethanechol chloride                   1
                                                              potassium chloride inj 2 meq/ml         1           
 BRANDS
                                                              potassium chloride sr                   1           
 URECHOLINE                             3
                                                              ringers injection                       1           
                                                              sodium bicarbonate inj                  1           
 MISCELLANEOUS UROLOGICALS
                                                              sodium chloride 0.45% viaflex           1           
 Generics
                                                              sodium chloride inj                     1           
 potassium citrate extended- 1
                                                                2.5 meq/ml
  release
                                                              sodium chloride inj 3%                  1           
 BRANDS
                                                              sodium chloride inj 5%                  1           
 AMMONIUM CHLORIDE INJ       2
                                                              sodium lactate inj                      1           
 CYSTAGON                    3                    LA
                                                              BRANDS
 ELMIRON                     3 
                                                              DEXTROSE 5%/POTASSIUM                   2
          VITAMINS, HEMATINICS /                                CHLORIDE 0.075%
              ELECTROLYTES                                    KAON-CL-10                              3
 ELECTROLYTES                                                 KCL 0.15%/D5W/NACL 0.2%                 2
 Generics                                                     KCL 0.15%/D5W/NACL 0.225%               2
 calcium acetate cap                      1                   KCL 0.3%/D5W/NACL 0.2%                  2
 eliphos                                  1                   KLOR-CON M15                            3
 kcl 0.075%/d5w/nacl 0.45%                1                   K-TABS                                  3
50  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
 Drug Name                             Drug      Reqs.         Drug Name                            Drug      Reqs.
                                       Tier     /Limits                                             Tier     /Limits
 LACTATED RINGERS INJ                   2         PA            DEXTROSE 10%
 MAGNESIUM SULFATE IN                   2                      AMINOSYN II 4.25/                      2         PA
  D5W                                                           DEXTROSE 20%
 MAGNESIUM SULFATE INJ                   2                     AMINOSYN II 4.25/                      2         PA
 NORMOSOL-R IN D5W                       2        PA            DEXTROSE 25%
 PHOSLO                                  3                     AMINOSYN II 5%/                        2         PA
 POTASSIUM CHLORIDE                      2                      DEXTROSE 25%
  0.075%/D5W/NACL 0.225%                                       AMINOSYN II 7%                         2         PA
 POTASSIUM CHLORIDE                      2                     AMINOSYN II 8.5%                       2         PA
  0.15% /NACL 0.45%VIAFLEX                                     AMINOSYN II                            2         PA
 POTASSIUM CHLORIDE                      2                      8.5%/ELECTROLYTES
  0.15%/D5W                                                    AMINOSYN II M                          2         PA
 POTASSIUM CHLORIDE                      2                      3.5%/DEXTROSE 5%
  0.22% D5W/NACL 0.45%                                         AMINOSYN M                             2         PA
 POTASSIUM CHLORIDE 0.3%/                2                     AMINOSYN-HBC                           2         PA
  NACL 0.9%                                                    AMINOSYN-HF                            2         PA
 POTASSIUM CHLORIDE INJ                  2                     AMINOSYN-PF                            2         PA
  0.4 MEQ/ML                                                   AMINOSYN-PF 7%                         2         PA
 POTASSIUM CHLORIDE INJ                  2                     CLINIMIX 2.75%/                        2         PA
  30 MEQ/100 ML                                                 DEXTROSE 5%
 TPN ELECTROLYTES FTV                    3        PA           CLINIMIX 4.25%/                        2         PA
                                                                DEXTROSE 10%
 MISCELLANEOUS                                                 CLINIMIX 4.25%/                        2         PA
 NUTRITION PRODUCTS                                             DEXTROSE 20%
 Generics                                                      CLINIMIX 4.25%/                        2         PA
 aminosyn ii 15%                         1        PA            DEXTROSE 25%
 aminosyn ii 4.25/dextrose25%            1        PA           CLINIMIX 5%/                           2         PA
 intralipid 2.25%/20%                    1        PA            DEXTROSE 15%
 novamine                                1        PA           CLINIMIX 5%/                           2         PA
 premasol 10%                            1        PA            DEXTROSE 20%
 travasol                                1        PA           CLINIMIX 5%/                           2         PA
 BRANDS                                                         DEXTROSE 25%
 AMINOSYN                                2        PA
                                                               CLINIMIX E 4.25%/                      2         PA
 AMINOSYN                                2        PA            DEXTROSE 25%
   7%/ELECTROLYTES
 AMINOSYN 8.5%/                          3        PA           CLINIMIX E 4.25%/                      2         PA
   ELECTROLYTES                                                 DEXTROSE 5%
 AMINOSYN II 10%                         2        PA           CLINIMIX E 5%/                         2         PA
 AMINOSYN II 3.5%/                       2        PA            DEXTROSE 15%
   DEXTROSE 25%                                                CLINIMIX E 5%/                         2         PA
 AMINOSYN II 3.5%/                       2        PA            DEXTROSE 20%
   DEXTROSE 5%                                                 CLINIMIX E 5%/                         2         PA
 AMINOSYN II 3.5/                        2        PA            DEXTROSE 25%
   DEXTROSE 25%                                                CLINISOL SF 15%                        3         PA
 AMINOSYN II 4.25/                       2        PA           DEXTROSE 5%                            2         PA

Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         51 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
 Drug Name                            Drug       Reqs.
                                      Tier      /Limits
   /ELECTROLYTE #48
   VIAFLEX
 DEXTROSE 25%
 FREAMINE HBC 6.9%                      2         PA
 FREAMINE III                           2         PA
 FREAMINE III 3%                        2         PA
 HEPATAMINE                             2         PA
 HEPATASOL                              2         PA
 INTRALIPID 1.7%/30%                    2         PA
 IONOSOL-B/DEXTROSE 5%                  2         PA
 IONOSOL-MB/DEXTROSE 5%                 2         PA
 IONOSOL-T/DEXTROSE 5%                  2         PA
 ISOLYTE-H/DEXTROSE 5%                  2         PA
 ISOLYTE-M/DEXTROSE 5%                  3         PA
 ISOLYTE-P/DEXTROSE 5%                  2         PA
 ISOLYTE-S                              2         PA
 ISOLYTE-S/DEXTROSE 5%                  2         PA
 KCL 0.15%/D10W/NACL 0.2%               2         PA
 LIPOSYN II                             2         PA
 LIPOSYN III                            2         PA
 NEPHRAMINE                             2         PA
 NORMOSOL-M IN D5W                      3         PA
 NORMOSOL-R                             2         PA
 PLASMA-LYTE 56                         2         PA
 PLASMA-LYTE A                          2         PA
 PLASMA-LYTE-148                        2         PA
 PLASMA-LYTE-148/D5W                    2         PA
 PLASMA-LYTE-56/D5W                     2         PA
 PREMASOL 6%                            2         PA
 PROCALAMINE                            2         PA
 PROSOL                                 2         PA
 RENAMIN                                2         PA

 VITAMINS / HEMATINICS
 Generics
 prenatabs obn                          1
 sodium fluoride                        1




52  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
                                                                acyclovir                                           15 
                             8                                  ACZONE                                              34 
                                                                ADACEL                                              43 
   8-MOP                                              33 
                                                                ADAGEN                                              36 
                                                                ADALAT                                              30 
                             A 
                                                                ADCIRCA                                             49 
   ABELCET                                         15           ADDERALL                                            27 
   ABILIFY                                         27           ADOXA                                               19 
   ABRAXANE                                        20           adriamycin                                          20 
   ABSTRAL                                         25           ADVAIR DISKUS                                       49 
   ACANYA                                          34           ADVAIR HFA                                          49 
   acarbose                                        38           ADVICOR                                             32 
   ACCOLATE                                        49           AEROBID-M                                           49 
   ACCUNEB                                         49           afeditab cr                                         29 
   ACCUPRIL                                        30           AFINITOR                                            20 
   ACCURETIC                                       30           AGGRENOX                                            32 
   acebutolol hcl                                  29           AGRYLIN                                             36 
   ACEON                                           30           a-hydrocort                                         37 
   acetaminophen/caffeine/dihydrocodeine bitartrate  4 
                                                   2            ak-con                                              48 
   acetaminophen/codeine                           24           AKNE-MYCIN                                          34 
   acetasol hc                                     37           ak-tob                                              46 
   acetazolamide                                   47           ala cort cre                                        35 
   acetic acid otic                                37           ALA SCALP                                           35 
   acetic acid/ hydrocortisone                     37           ala-cort lot                                        35 
   acetylcysteine                                  49           ALAMAST                                             47 
   ACIPHEX                                         41           ALBENZA                                             17 
   ACLOVATE                                        35           albuterol sulfate                                   49 
   ACTEMRA                                         44           alclometasone dipropionate                          35 
   ACTHIB                                          43           alcohol 5%/dextrose 5%                              36 
   acticin                                         35           ALCOHOL PREPS                                       38 
   ACTIGALL                                        40           ALDACTAZIDE                                         30 
   ACTIMMUNE                                       42           ALDACTONE                                           30 
   ACTIQ                                           25           ALDARA                                              33 
   ACTIVELLA                                       44           ALDURAZYME                                          39 
   ACTONEL                                     36, 44           alendronate sodium                              36, 43 
   ACTOPLUS MET                                    38           ALIMTA                                              20 
   ACTOS                                           38           ALINIA                                              17 
   ACULAR                                          47           ALKERAN                                             20 
   ACUVAIL                                         47           allopurinol                                         43 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         53 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   ALLOPURINOL SODIUM INJ                             43         ampicillin                                         18 
   ALOCRIL                                            47         ampicillin sodium                                  18 
   ALOMIDE                                            47         AMPICILLIN SODIUM                                  18 
   ALOPRIM                                            43         AMPYRA                                             23 
   ALORA                                              44         AMRIX                                              24 
   ALOXI                                              40         AMTURNIDE                                          30 
   ALPHAGAN                                           48         ANADROL                                            39 
   ALREX                                              48         ANAFRANIL                                          27 
   ALTABAX                                            34         anagrelide hydrochloride                           36 
   ALTACE                                             30         ANAPROX                                            26 
   ALTOPREV                                           32         anastrozole                                        20 
   ALVESCO                                            49         ANCOBON                                            15 
   amantadine                                         15         ANDRODERM                                          39 
   AMARYL                                             38         ANDROGEL                                           39 
   AMBIEN                                             27         ANDROID                                            39 
   AMBISOME                                           15         androxy                                            39 
   amcinonide                                         35         anestacon                                          34 
   AMERGE                                             23         ANGELIQ                                            44 
   a-methapred                                        37         ANTABUSE                                           36 
   AMEVIVE                                            33         ANTARA                                             32 
   AMIFOSTINE                                         20         ANTIVERT                                           40 
   amikacin sulfate                                   17         ANTIZOL                                            43 
   amiloride /hydrochlorothiazide                     29         ANUSOL-HC                                          40 
   amiloride hcl                                      29         ANZEMET                                            40 
   aminophylline                                      49         APHTHASOL                                          37 
   AMINOSYN                                           51         APIDRA                                             38 
   aminosyn ii                                        51         APLENZIN                                           27 
   amiodarone hcl                                     28         APOKYN                                             23 
   AMITIZA                                            40         apraclonidine                                      48 
   amitriptyline hcl                                  26         apri                                               45 
   amlodipine besylate                                29         APRISO                                             40 
   AMMONIUM CHLORIDE INJ                              50         APTIVUS                                            15 
   ammonium lactate                                   33         ARALAST                                            36 
   amnesteem                                          33         ARALEN                                             17 
   amoxapine                                          26         aranelle                                           45 
   amoxicillin                                        18         ARANESP ALBUMIN FREE                               42 
   amoxicillin/clavulanate potassium                  18         ARAVA                                              44 
   amphetamine /dextroamphetamine                     26         ARCALYST                                           42 
   AMPHOTEC                                           15         AREDIA                                             39 
   amphotericin b                                     15         ARICEPT                                            23 
54  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   ARIMIDEX                                           20        AZACTAM                                            17 
   ARIXTRA                                            32        AZASAN                                             21 
   AROMASIN                                           20        AZASITE                                            46 
   ARRANON                                            20        azathioprine                                       20 
   ARTHROTEC                                          26        azathioprine sodium                                20 
   ARZERRA                                            21        azelastine hcl nasal                               37 
   ASACOL                                         40, 41        azelastine hcl oph drops                           47 
   ascomp/codeine                                     24        AZELEX                                             34 
   ASMANEX                                            49        AZILECT                                            23 
   ASTELIN                                            37        azithromycin                                       17 
   ASTEPRO                                            37        AZOPT                                              47 
   ASTRAMORPH                                         25        AZOR                                               30 
   ATACAND                                            30        aztreonam                                          17 
   ATELVIA                                            44        AZULFIDINE                                         41 
   atenolol                                           29        AZULFIDINE EN                                      41 
   ATGAM                                              43 
   ATRALIN                                            34                                    B 
   ATRIPLA                                            15 
                                                                baciim                                              17 
   ATROPINE SULFATE                                   40 
                                                                bacitracin                                  17, 46, 47 
   atropine sulfate inj                               40 
                                                                baclofen                                            24 
   ATROVENT                                       37, 49 
                                                                BACTOCILL                                           18 
   ATTENUVAX                                          43 
                                                                BACTRIM                                             19 
   augmented betamethasone dipropionate               35 
                                                                BACTROBAN                                       34, 37 
   AUGMENTIN                                          18 
                                                                balsalazide disodium                                40 
   AVALIDE                                            30 
                                                                balziva                                             45 
   AVANDAMET                                          38 
                                                                BANZEL                                              22 
   AVANDARYL                                          38 
                                                                BARACLUDE                                           15 
   AVANDIA                                            38 
                                                                BD INSULIN SYRINGE                                  38 
   AVAPRO                                             30 
                                                                BD PEN NEEDLE                                       38 
   AVASTIN                                            21 
                                                                BECONASE AQ                                         49 
   AVELOX                                             19 
                                                                benazepril hcl                                      29 
   aviane                                             45 
                                                                BENICAR                                             30 
   AVINZA                                             25 
                                                                BENTYL                                              40 
   avita cre                                          33 
                                                                BENZAMYCIN                                          34 
   AVITA GEL                                          34 
                                                                benztropine mesylate                                23 
   AVODART                                            50 
                                                                BEPREVE                                             47 
   AVONEX                                             42 
                                                                BESIVANCE                                           46 
   AXERT                                              23 
                                                                BETAGAN                                             46 
   AXID                                               41 
                                                                betamethasone dipropionate                          35 
   AYGESTIN                                           44 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         55 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   betamethasone valerate                               35       butorphanol tartrate nasal soln                    25 
   BETAPACE                                             29       BYETTA                                             38 
   BETASERON                                            42       BYSTOLIC                                           30 
   beta-val                                             35 
   betaxolol hcl                                    29, 46                                  C 
   bethanechol chloride                                 50 
                                                                 cabergoline                                        39 
   BETIMOL                                              46 
                                                                 CADUET                                             32 
   BETOPTIC                                             46 
                                                                 CAFERGOT                                           23 
   BEYAZ                                                45 
                                                                 CALAN                                              30 
   BIAXIN                                               17 
                                                                 CALCIJEX                                           39 
   bicalutamide                                         20 
                                                                 calcipotriene                                      33 
   BICILLIN                                             18 
                                                                 calcitonin-salmon nasal                            39 
   BICNU                                                21 
                                                                 calcitriol                                         39 
   BIDIL                                                30 
                                                                 CALCITRIOL                                         39 
   BILTRICIDE                                           17 
                                                                 calcium acetate cap                                50 
   bisoprolol fumarate/hydrochlorothiazide              29 
                                                                 camila                                             44 
   bleomycin sulfate                                    20 
                                                                 CAMPATH                                            21 
   BLEPH-10                                             48 
                                                                 CAMPRAL                                            36 
   BLEPHAMIDE                                           48 
                                                                 CAMPTOSAR                                          21 
   BONIVA                                               44 
                                                                 CANASA                                             41 
   BOOSTRIX                                             43 
                                                                 CANCIDAS                                           15 
   borofair                                             37 
                                                                 CANTIL                                             40 
   BREVICON                                             45 
                                                                 CAPASTAT SULFATE                                   17 
   brimonidine tartrate                                 48 
                                                                 CAPEX                                              35 
   bromocriptine mesylate                               23 
                                                                 CAPITAL/CODEINE                                    25 
   BROVANA                                              49 
                                                                 captopril                                          29 
   budeprion                                            26 
                                                                 captopril/hydrochlorothiazide                      29 
   budeprion sr                                         26 
                                                                 CARAC                                              33 
   budesonide nebu                                      49 
                                                                 CARAFATE                                           41 
   bumetanide                                           29 
                                                                 carbamazepine                                      22 
   BUPHENYL                                             36 
                                                                 CARBATROL                                          22 
   BUPRENEX                                             25 
                                                                 carbidopa/levodopa                                 23 
   buprenorphine hcl                                    24 
                                                                 carbidopa/levodopa cr                              23 
   buproban                                             36 
                                                                 carbidopa/levodopa odt                             23 
   bupropion                                            26 
                                                                 carbidopa/levodopa sr                              23 
   BUSPAR                                               27 
                                                                 carbinoxamine maleate                              48 
   buspirone                                            26 
                                                                 carboplatin                                        20 
   BUSULFEX                                             21 
                                                                 CARDIZEM                                           30 
   butalbital /apap /caffeine /codeine                  24 
                                                                 CARDURA                                            30 
   butorphanol tartrate inj                             25 
56  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   CARIMUNE NANOFILTERED                              43        CEREDASE                                            39 
   carisoprodol                                       24        CEREZYME                                            39 
   CARMOL-HC                                          33        CERUBIDINE                                          21 
   CARNITOR                                           36        CERVARIX                                            43 
   CARNITOR SOLN                                      36        CESAMET                                             41 
   CARNITOR TAB                                       36        cesia                                               45 
   carteolol hcl oph drops                            46        CHANTIX                                             36 
   cartia                                             29        CHEMET                                              36 
   carvedilol                                         29        CHLORAMPHENICOL                                     17 
   CASODEX                                            21        chlordiazepoxide /amitriptyline                     26 
   CATAFLAM                                           26        chlorhexidine gluconate oral rinse                  37 
   CATAPRES                                           30        chloroquine phosphate                               17 
   CAYSTON                                            17        chlorothiazide sodium inj                           29 
   CEDAX                                              16        chlorothiazide tab                                  29 
   CEENU                                              21        chlorpromazine hcl                                  26 
   cefaclor                                           16        chlorpropamide                                      38 
   cefadroxil                                         16        chlorthalidone                                      29 
   cefazolin sodium                                   16        chlorzoxazone                                       24 
   CEFAZOLIN SODIUM                                   16        cholestyramine light                                32 
   cefdinir                                           16        ciclopirox                                          34 
   cefepime                                           16        cilostazol                                          31 
   cefotaxime sodium                                  16        CILOXAN                                             46 
   CEFOTETAN                                          16        cimetidine                                          41 
   cefoxitin                                          16        CIMZIA                                              41 
   CEFOXITIN                                          16        CIPRO                                           19, 37 
   cefpodoxime proxetil                               16        CIPRODEX                                            37 
   cefprozil                                          16        ciprofloxacin                               18, 19, 46 
   ceftazidime                                        16        cisplatin                                           20 
   CEFTIN                                             16        citalopram hydrobromide                             26 
   ceftriaxone                                        16        CLADRIBINE                                          21 
   CEFTRIAXONE/DEXTROSE                               16        CLAFORAN                                            16 
   cefuroxime                                         16        claravis                                            33 
   CEFUROXIME/DEXTROSE                                16        CLARINEX                                            48 
   CELEBREX                                           26        CLARINEX-D                                          48 
   CELESTONE                                          37        clarithromycin                                      17 
   CELEXA                                             27        clemastine fumarate                                 48 
   CELLCEPT                                           21        CLEOCIN                                     17, 34, 45 
   CELONTIN                                           22        CLIMARA                                             44 
   cephalexin                                         16        CLINDAGEL                                           34 
   CEREBYX                                            22        clindamycin hcl                                     17 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         57 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   clindamycin phosphate                        17, 33, 45       constulose                                         40 
   clindamycin/benzoyl peroxide                         33       COPAXONE                                           23 
   CLINDESSE                                            45       COPEGUS                                            15 
   CLINORIL                                             26       CORDARONE                                          29 
   clobetasol propionate                                35       CORDRAN                                            35 
   CLOBEX                                               35       COREG                                              30 
   CLODERM                                              35       CORGARD                                            30 
   CLOLAR                                               21       CORTEF                                         37, 38 
   clomipramine hcl                                     26       CORTENEMA                                          41 
   clonidine hcl                                        29       CORTIFOAM                                          41 
   CLORPRES                                             30       cortisone acetate                                  37 
   clotrimazole troche                                  15       CORTISPORIN                                    34, 37 
   clotrimazole/betamethasone dipropionate              34       cortomycin                                         37 
   clozapine                                            27       CORZIDE                                            30 
   CLOZAPINE                                            27       COSMEGEN                                           21 
   CLOZARIL                                             27       COSOPT                                             47 
   COARTEM                                              17       COUMADIN                                           32 
   codeine sulfate                                      24       COVERA                                             30 
   COGENTIN                                             23       COZAAR                                             30 
   CO-GESIC                                             25       CREON                                              41 
   COGNEX                                               23       CRESTOR                                            32 
   COLAZAL                                              41       CRINONE                                            44 
   COLCRYS                                              43       CRIXIVAN                                           15 
   COLESTID                                             32       cromolyn sodium nebu                               49 
   colestipol hcl                                       32       cromolyn sodium oph drops                          47 
   COLISTIMETHATE                                       17       cryselle                                           45 
   COLOCORT                                             41       CUBICIN                                            17 
   COLY-MYCIN M INJ                                     17       CUPRIMINE                                          44 
   COLY-MYCIN S                                         37       CURITY GAUZE PADS                                  38 
   COLYTE-FLAVOR PACKS                                  41       CUTIVATE                                           35 
   COMBIGAN                                             47       cyclafem                                           45 
   COMBIPATCH                                           44       CYCLESSA                                           45 
   COMBIVENT                                            49       cyclobenzaprine hcl                                24 
   COMBIVIR                                             15       cyclophosphamide                                   20 
   COMBUNOX                                             25       CYCLOSET                                           38 
   compro                                               40       cyclosporine                                       20 
   COMTAN                                               23       CYCLOSPORINE                                       21 
   COMVAX                                               43       CYKLOKAPRON                                        32 
   CONCERTA                                             27       CYMBALTA                                           27 
   CONDYLOX                                             33       CYSTADANE                                          41 
58  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   CYSTAGON                                           50        DERMA-SMOOTHE                                     35 
   cytarabine                                         20        DERMATOP                                          35 
   CYTARABINE AQUEOUS                                 21        DERMOTIC                                          37 
   CYTOMEL                                            40        desipramine hcl                                   27 
   CYTOTEC                                            41        desmopressin acetate                              39 
   CYTOVENE                                           15        DESOGEN                                           45 
                                                                DESONATE                                          35 
                             D                                  desonide                                          35 
                                                                DESOWEN                                           35 
   D.H.E. 45                                          23 
                                                                DESOWEN OINTMENT                                  35 
   dacarbazine                                        20 
                                                                desoximetasone                                    35 
   DACOGEN                                            21 
                                                                DESOXYN                                           27 
   DANTRIUM                                           24 
                                                                DETROL                                            49 
   dantrolene sodium                                  24 
                                                                DETROL LA                                         49 
   DAPSONE                                            17 
                                                                dexamethasone                             37, 47, 48 
   DAPTACEL                                           43 
                                                                DEXAMETHASONE                                     37 
   DARAPRIM                                           17 
                                                                dexamethasone elixir                              37 
   DAUNORUBICIN                                       21 
                                                                dexamethasone sodium phosphate inj                37 
   DAUNOXOME                                          21 
                                                                dexasporin                                        47 
   DAYPRO                                             26 
                                                                dexchlorpheniramine maleate syrup                 48 
   DAYTRANA                                           27 
                                                                DEXEDRINE                                         27 
   DDAVP                                              39 
                                                                DEXILANT                                          41 
   DECAVAC                                            43 
                                                                dexmethylphenidate hcl                            27 
   DELATESTRYL                                        39 
                                                                DEXPAK                                            37 
   DELESTROGEN                                        44 
                                                                DEXRAZOXANE                                       20 
   DEMADEX                                            30 
                                                                dextroamphetamine sulfate                         27 
   demeclocycline                                     19 
                                                                DEXTROSE                      17, 18, 19, 36, 51, 52 
   DEMEROL                                            25 
                                                                dextrose 10% flex                                 36 
   DEMSER                                             30 
                                                                dextrose 2.5%/sodium chloride 0.45%               36 
   DENAVIR                                            34 
                                                                dextrose 5%                                       36 
   DEPACON                                            22 
                                                                DEXTROSE 5%/POTASSIUM CHLORIDE                    50 
   depade                                             26 
                                                                DIABETA                                           38 
   DEPAKENE                                           22 
                                                                DIAMOX                                            47 
   DEPAKOTE                                           22 
                                                                DIBENZYLINE                                       30 
   DEPEN TITRATABS                                    44 
                                                                diclofenac potassium                              26 
   DEPO-ESTRADIOL                                     44 
                                                                diclofenac sodium ec                              26 
   DEPO-MEDROL                                        37 
                                                                diclofenac sodium oph drops                       47 
   DEPO-PROVERA                                       44 
                                                                diclofenac sodium xr                              26 
   DEPO-SUBQ PROVERA                                  44 
                                                                dicloxacillin sodium                              18 
   DEPO-TESTOSTERONE                                  39 
                                                                dicyclomine hcl                                   40 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         59 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   didanosine                                         15         doxorubicin                                        20 
   DIDRONEL                                           36         doxycycline                                        19 
   DIFFERIN                                           34         doxycycline hyclate                                19 
   diflorasone diacetate                              35         DOXYCYCLINE HYCLATE                                19 
   DIFLUCAN                                           15         doxycycline monohydrate                            19 
   diflunisal                                         26         dronabinol                                         40 
   digoxin                                            31         DROXIA                                             21 
   digoxin inj                                        31         DUETACT                                            38 
   dihydroergotamine mesylate                         23         DULERA                                             49 
   DILACOR                                            30         DUONEB                                             49 
   DILANTIN                                           22         DURAGESIC                                          25 
   DILATRATE                                          33         duramorph                                          24 
   DILAUDID                                           25         DUREZOL                                            48 
   dilt-cd                                            29         DYAZIDE                                            30 
   DILTIAZEM                                          30         DYNACIN                                            19 
   diltiazem cd cap24                                 29         DYNACIRC                                           30 
   diltiazem hcl                                      29         DYRENIUM                                           30 
   dilt-xr                                            29 
   diltzac                                            29                                    E 
   DIOVAN                                             30 
                                                                 e.e.s. 400                                         17 
   DIPENTUM                                           41 
                                                                 E.E.S. GRANULES                                    17 
   diphenhydramine hcl                                48 
                                                                 EC-NAPROSYN                                        26 
   diphenoxylate/atropine                             40 
                                                                 econazole nitrate                                  34 
   DIPHTHERIA/TETANUS TOXOID                          43 
                                                                 EDARBI                                             31 
   DIPROLENE                                          35 
                                                                 EDECRIN                                            31 
   dipyridamole                                       31 
                                                                 EDLUAR                                             27 
   disopyramide phosphate                             28 
                                                                 EFFEXOR                                            27 
   DITROPAN XL                                        50 
                                                                 EFFIENT                                            32 
   DIURIL                                             30 
                                                                 EFUDEX                                             33 
   divalproex sodium                                  22 
                                                                 EGRIFTA                                            42 
   DIVIGEL                                            44 
                                                                 ELAPRASE                                           39 
   DOLOPHINE                                          25 
                                                                 ELDEPRYL                                           23 
   donepezil hcl                                      23 
                                                                 ELESTAT                                            47 
   DORIBAX                                            17 
                                                                 ELESTRIN                                           44 
   DORYX                                              19 
                                                                 ELIDEL                                             33 
   dorzolamide hcl                                    47 
                                                                 ELIGARD                                            21 
   DOVONEX                                            33 
                                                                 eliphos                                            50 
   doxazosin mesylate tab                             29 
                                                                 ELITEK                                             20 
   doxepin hcl                                        27 
                                                                 ELIXOPHYLLIN                                       49 
   DOXIL                                              21 
60  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   ELLA                                               45        ERTACZO                                             34 
   ELLENCE                                            21        ery pads                                            33 
   ELMIRON                                            50        ERYPED                                              17 
   ELOCON                                             35        ery-tab                                             17 
   ELOXATIN                                           21        ERY-TAB                                             17 
   ELSPAR                                             21        ERYTHROCIN LACTOBIONATE                             17 
   EMADINE                                            47        erythrocin stearate                                 17 
   EMBEDA                                             25        erythromycin                                    17, 33 
   EMCYT                                              21        ERYTHROMYCIN                                        17 
   EMEND                                              41        erythromycin oph oint                               46 
   EMLA                                               34        ESTRACE                                             44 
   EMSAM                                              27        ESTRADERM                                           44 
   EMTRIVA                                            15        estradiol                                           44 
   ENABLEX                                            50        estradiol/norethindrone acetate                     44 
   enalapril maleate                                  29        ESTRING                                             44 
   ENBREL                                             44        estropipate tab                                     44 
   endocet                                            24        ESTROSTEP FE                                        45 
   endodan                                            24        ethambutol                                          17 
   ENGERIX                                            43        ethosuximide                                        22 
   ENJUVIA                                            44        ETHYOL                                              20 
   enoxaparin sodium                                  31        etidronate disodium                                 36 
   enpresse                                           45        etodolac                                            26 
   ENTOCORT EC                                        41        ETOPOPHOS                                           21 
   enulose                                            40        etoposide                                           20 
   EPIDUO                                             34        EURAX                                               35 
   epinephrine hcl inj                                48        EVAMIST                                             44 
   EPIPEN                                             48        EVISTA                                              44 
   epirubicin                                         20        EVOCLIN                                             34 
   epitol                                             22        EVOXAC                                              36 
   EPIVIR                                             15        EXALGO                                              25 
   eplerenone                                         29        EXELDERM                                            34 
   EPOGEN                                             42        EXELON                                              24 
   EPZICOM                                            15        EXFORGE                                             31 
   EQUETRO                                            22        EXJADE                                              36 
   ERAXIS                                             15        EXTAVIA                                             42 
   ERBITUX                                            21        EXTINA                                              34 
   ergoloid mesylates                                 27 
   ERGOMAR                                            23                                  F 
   ergotamine tartrate/caffeine                       23 
                                                                FABRAZYME                                          39 
   errin                                              44 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         61 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   FACTIVE                                              19       FLUMADINE                                          15 
   famciclovir                                          15       flunisolide nasal                                  49 
   famotidine                                           41       fluocinolone acetonide                             35 
   FAMVIR                                               15       fluocinonide                                       35 
   FANAPT                                               27       fluocinonide emollient base                        35 
   FARESTON                                             21       fluorometholone                                    48 
   FASLODEX                                             21       FLUOROPLEX                                         33 
   FAZACLO                                              27       fluorouracil                                   20, 33 
   FELBATOL                                             22       fluoxetine                                         27 
   FELDENE                                              26       fluphenazine                                       27 
   felodipine er                                        29       fluphenazine decanoate                             27 
   FEMARA                                               21       flurbiprofen sodium oph drops                      47 
   FEMHRT                                               44       flurbiprofen tab                                   26 
   FEMRING                                              44       flutamide                                          20 
   FEMTRACE                                             44       fluticasone propionate                         35, 49 
   fenofibrate                                          32       fluvoxamine maleate                                27 
   fenofibrate micronized                               32       FML                                                48 
   FENOGLIDE                                            32       FOCALIN                                            27 
   fenoprofen calcium                                   26       fomepizole                                         43 
   fentanyl citrate                                     24       FORADIL AEROLIZER                                  49 
   fentanyl patch                                       24       FORTAMET                                           38 
   FENTORA                                              25       FORTAZ                                             16 
   FEXMID                                               24       FORTEO                                             44 
   fexofenadine hcl                                     48       FORTESTA                                           39 
   FINACEA                                              34       fortical                                           39 
   finasteride                                          50       FOSAMAX                                        36, 44 
   FIORINAL/CODEINE                                     25       foscarnet sodium                                   15 
   FIRMAGON                                             21       fosinopril sodium                                  29 
   FLAGYL                                           17, 18       fosphenytoin sodium                                22 
   FLAREX                                               48       FOSRENOL                                           36 
   flavoxate hcl                                        49       FRAGMIN                                            32 
   flecainide acetate                                   28       FREAMINE                                           52 
   FLECTOR                                              26       FROVA                                              23 
   FLEXERIL                                             24       FURADANTIN                                         19 
   FLOMAX                                               50       furosemide                                         29 
   FLONASE                                              49       FUROSEMIDE                                         31 
   FLOVENT                                              49       furosemide inj                                     29 
   fluconazole                                          15       furosemide soln                                    29 
   FLUDARA                                              21 
   fludarabine phosphate                                20 
62  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
                             G                                  GLUCOVANCE                                         38 
                                                                GLUMETZA                                           38 
   gabapentin                                         22        glyburide                                          38 
   GABITRIL                                           22        glyburide micronized                               38 
   galantamine hydrobromide                           23        glyburide/metformin hcl                            38 
   GAMASTAN                                           43        glycopyrrolate                                     40 
   GAMMAGARD                                          43        glycron                                            38 
   GAMMAPLEX                                          43        GLYCRON                                            38 
   GAMUNEX                                            43        GLYNASE                                            38 
   ganciclovir                                        15        GLYSET                                             38 
   ganciclovir sodium inj                             15        GOLYTELY                                           41 
   GARDASIL                                           43        granisetron hcl                                    40 
   GASTROCROM                                         41        GRANISOL                                           41 
   gavilyte-c                                         40        GRIFULVIN                                          15 
   gavilyte-g                                         40        griseofulvin                                       15 
   gavilyte-n/flavor pack                             40        GRIS-PEG                                           15 
   GELNIQUE                                           50        guanabenz acetate                                  29 
   GEMCITABINE HCL                                    21        guanfacine hcl                                     29 
   gemfibrozil                                        32        GUANIDINE HCL                                      27 
   GEMZAR                                             21        GYNAZOLE-1                                         45 
   generlac                                           40        GYNODIOL                                           44 
   gengraf                                            20 
   GENOTROPIN                                         42                                   H 
   GENOTROPIN MINIQUICK                               42 
   gentak                                             46        HALAVEN                                            21 
   gentamicin sulfate                         17, 34, 46        HALDOL                                             27 
   GENTAMICIN SULFATE                                 18        HALDOL DECANOATE                                   27 
   gentasol                                           46        HALFLYTELY                                         41 
   GEODON                                             27        HALOG                                              35 
   gianvi                                             45        haloperidol                                        27 
   GILENYA                                            24        HAVRIX                                             43 
   GLASSIA                                            36        HECTOROL                                           39 
   GLEEVEC                                            21        HECTOROL INJ                                       39 
   glimepiride                                        38        HELIDAC                                            41 
   glipizide                                          38        heparin sodium                                     31 
   glipizide/metformin hcl                            38        HEPARIN SODIUM                                     32 
   GLUCAGEN                                           38        HEPATAMINE                                         52 
   GLUCAGON                                           38        HEPATASOL                                          52 
   GLUCOPHAGE                                         38        HEPSERA                                            15 
   GLUCOTROL                                          38        HERCEPTIN                                          21 

Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         63 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
  HEXALEN                                         21             IMITREX                                            23 
  HIPREX                                          19             IMOVAX RABIES                                      43 
  HIZENTRA                                        43             IMURAN                                             21 
  HUMALOG                                         38             INCRELEX                                           36 
  HUMATROPE                                       42             indapamide                                         29 
  HUMIRA                                          44             INDERAL                                            31 
  HUMIRA PEN-CROHNS DISEASESTARTER  44                           INDOCIN                                            26 
  HUMULIN                                     38, 39             indomethacin                                       26 
  HUMULIN N                                       39             INFANRIX                                           43 
  HUMULIN R                                       39             INFERGEN                                           42 
  HYCAMTIN                                        21             INFUMORPH                                          25 
  HYCET                                           25             INNOHEP                                            32 
  hydralazine hcl                                 29             INNOPRAN                                           31 
  HYDREA                                          21             INSPRA                                             31 
  hydrochlorothiazide                         29, 30             INTELENCE                                          15 
  hydrocodone /acetaminophen                      24             intralipid                                         51 
  hydrocodone /ibuprofen                          24             INTRALIPID                                         52 
  hydrocodone bitartrate/ acetaminophen           24             INTRON-A                                           42 
  hydrocortisone                      35, 37, 40, 47             INTUNIV                                            28 
  hydrocortisone butyrate                         35             INVANZ                                             18 
  hydrocortisone valerate                         35             INVEGA                                             28 
  hydromorphone hcl                               24             INVEGA SUSTENNA                                    28 
  hydroxychloroquine                              17             INVIRASE                                           15 
  hydroxyurea                                     20             IONOSOL                                            52 
  hydroxyzine hcl                                 48             IOPIDINE                                           48 
  hydroxyzine pamoate                             48             IPOL INACTIVATED IPV                               43 
  HYZAAR                                          31             ipratropium bromide nasal                          37 
                                                                 ipratropium bromide nebu                           49 
                             I                                   IQUIX                                              46 
                                                                 IRESSA                                             21 
   ibuprofen                                          26 
                                                                 irinotecan                                         20 
   IDAMYCIN                                           21 
                                                                 ISENTRESS                                          15 
   IDARUBICIN                                         21 
                                                                 ISMO                                               33 
   IFEX                                               21 
                                                                 ISOCHRON                                           33 
   ifosfamide                                         20 
                                                                 isonarif                                           17 
   IFOSFAMIDE                                         21 
                                                                 isoniazid                                          17 
   IMDUR                                              33 
                                                                 ISONIAZID SYRUP                                    18 
   imipramine hcl                                     27 
                                                                 ISO-OSMOTIC DEXTROSE                               16 
   imipramine pamoate                                 27 
                                                                 ISOPTIN                                            31 
   imiquimod                                          33 
                                                                 ISORDIL TITRADOSE                                  33 
64  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   isosorbide dinitrate                               33        ketorolac tromethamine                          26, 47 
   isosorbide mononitrate                             33        KINERET                                             44 
   isotonic gentamicin                                17        kionex                                              36 
   isradipine                                         29        KLARON                                              34 
   ISTALOL                                            46        klor-con                                            50 
   ISTODAX                                            21        KOMBIGLYZE XR                                       39 
   itraconazole                                       15        KRISTALOSE                                          41 
   IXEMPRA                                            21        kuric                                               34 
   IXIARO                                             43        KUVAN                                               39 
                                                                KYTRIL                                              41 
                             J 
                                                                                          L 
   JALYN                                              50 
   jantoven                                           31        labetalol hcl                                      29 
   JANUMET                                            39        LAC-HYDRIN                                         33 
   JANUVIA                                            39        laclotion                                          33 
   JE-VAX                                             43        LACRISERT                                          47 
   JEVTANA                                            21        lactated ringers irrigation                        36 
   jolivette                                          44        lactulose                                          40 
   junel                                              45        LAMICTAL                                           22 
                                                                LAMISIL                                            15 
                             K                                  lamotrigine                                        22 
                                                                LANOXIN                                            31 
   KADIAN                                             25 
                                                                lansoprazole                                       41 
   KALETRA                                            15 
                                                                LANTUS                                             39 
   kanamycin sulfate                                  17 
                                                                LASIX                                              31 
   KAON-CL                                            50 
                                                                LASTACAFT                                          47 
   kariva                                             45 
                                                                LATUDA                                             28 
   KAYEXALATE                                         36 
                                                                leena                                              45 
   kcl                                                50 
                                                                leflunomide                                        44 
   KCL 0.15%/D5W/NACL                                 50 
                                                                LESCOL                                             32 
   KEFLEX                                             16 
                                                                lessina                                            45 
   kelnor                                             45 
                                                                LETAIRIS                                           49 
   KENALOG                                            35 
                                                                leucovorin calcium                                 20 
   KEPIVANCE                                          20 
                                                                LEUCOVORIN CALCIUM                                 20 
   KEPPRA                                             22 
                                                                LEUKERAN                                           21 
   KERLONE                                            31 
                                                                LEUKINE                                            42 
   KETEK                                              18 
                                                                leuprolide acetate                                 20 
   ketoconazole                                   15, 34 
                                                                LEUSTATIN                                          21 
   ketoconazole cre                                   34 
                                                                levalbuterol nebu                                  49 
   ketoprofen                                         26 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         65 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   LEVAQUIN                                             19       LOKARA                                             35 
   LEVATOL                                              31       LOMOTIL                                            40 
   LEVEMIR                                              39       loperamide hcl                                     40 
   levetiracetam                                        22       LOPID                                              32 
   levobunolol hcl                                      46       LOPRESSOR                                          31 
   levocarnitine                                        36       LOPROX                                             34 
   LEVOCARNITINE                                        36       LORCET                                             25 
   levocarnitine soln                                   36       LORTAB                                             25 
   levocetirizine                                       48       losartan potassium                                 29 
   levora                                               45       LOSEASONIQUE                                       46 
   levorphanol tartrate                                 24       LOTEMAX                                            48 
   LEVOTHROID                                           40       LOTENSIN                                           31 
   levothyroxine sodium                                 40       LOTREL                                             31 
   levoxyl                                              40       LOTRISONE                                          34 
   LEXAPRO                                              28       LOTRONEX                                           41 
   LEXIVA                                               15       lovastatin                                         32 
   LIALDA                                               41       LOVAZA                                             32 
   lidocaine hcl                                        34       LOVENOX                                            32 
   lidocaine viscous                                    34       loxapine succinate                                 27 
   lidocaine/prilocaine                                 34       LOXITANE                                           28 
   LIDODERM                                             34       LUFYLLIN                                           49 
   LINCOCIN                                             18       LUMIGAN                                            47 
   LINDANE                                              35       LUNESTA                                            28 
   liothyronine sodium                                  40       LUPRON DEPOT                                       21 
   LIPITOR                                              32       lutera                                             45 
   LIPOFEN                                              32       LUVOX                                              28 
   LIPOSYN III                                          52       LUXIQ                                              35 
   lisinopril                                           29       LYBREL                                             46 
   lithium carbonate                                    27       LYRICA                                             22 
   LITHIUM CARBONATE                                    28       LYSODREN                                           21 
   lithium citrate                                      27       LYSTEDA                                            19 
   LITHOBID                                             28 
   LIVALO                                               32                                 M 
   LO/OVRAL                                             45 
                                                                 MACROBID                                           19 
   LOCOID                                               35 
                                                                 MACRODANTIN                                        19 
   LOCOID LIPOCREAM                                     35 
                                                                 MAGNACET                                           25 
   LODOSYN                                              23 
                                                                 MAGNESIUM SULFATE                                  51 
   LOESTRIN                                         45, 46 
                                                                 MALARONE                                           18 
   LOESTRIN FE                                          46 
                                                                 malathion lot                                      35 
   LOFIBRA                                              32 
66  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   maprotiline hcl                                    27        MESNEX                                             20 
   margesic-h 1                                       24        MESTINON                                           24 
   MARINOL                                            41        metadate                                           27 
   MARPLAN                                            28        METADATE                                           28 
   MATULANE                                           21        METAGLIP                                           39 
   MAVIK                                              31        metaproterenol sulfate syrup                       49 
   MAXAIR AUTOHALER                                   49        metaproterenol sulfate tab                         49 
   MAXALT                                             23        metaxalone                                         24 
   MAXIDEX                                            48        metformin                                          38 
   MAXIDONE                                           25        methadone hcl                                      24 
   MAXIPIME                                           16        METHADONE HCL                                      25 
   MAXITROL                                           47        methadose                                          24 
   MAXZIDE                                            31        methamphetamine hcl                                27 
   mebendazole                                        17        methazolamide                                      47 
   meclizine hcl                                      40        methenamine hippurate                              19 
   meclofenamate sodium                               26        METHERGINE                                         46 
   MEDROL                                             37        methimazole                                        38 
   medroxyprogesterone acetate                        44        METHITEST                                          39 
   medroxyprogesterone acetate tab                    44        methocarbamol                                      24 
   mefenamic acid                                     26        methotrexate                                       20 
   mefloquine                                         17        methotrexate sodium                                20 
   MEGACE                                             21        METHOTREXATE SODIUM                                21 
   megestrol acetate                                  20        methscopolamine bromide                            40 
   meloxicam                                          26        methyclothiazide                                   29 
   MELPHALAN HYDROCHLORIDE                            21        methyldopa                                         29 
   MENACTRA                                           43        methyldopate hcl                                   29 
   MENEST                                             44        METHYLIN                                           28 
   MENOMUNE                                           43        methylin er                                        27 
   MENOSTAR                                           44        methylin tab                                       27 
   MENVEO A-C-Y-W-135-DIP                             43        methylphenidate                                    27 
   meperidine hcl                                     24        methylprednisolone                                 37 
   MEPERIDINE HCL                                     25        methylprednisolone acetate inj                     37 
   meprobamate                                        24        methylprednisolone sodium succinate                37 
   MEPRON                                             18        metipranolol                                       46 
   mercaptopurine                                     20        metoclopramide hcl                                 40 
   meropenem                                          17        metolazone                                         29 
   MERREM                                             18        metoprolol /hydrochlorothiazide                    30 
   MERUVAX II                                         43        metoprolol succinate er                            30 
   mesalamine enema                                   40        metoprolol tartrate                                30 
   mesna                                              20        METOZOLV                                           41 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         67 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   METROCREAM                                           34       morphine sulfate er                                24 
   METROGEL                                         34, 45       MOTOFEN                                            40 
   METROLOTION                                          34       MOVIPREP                                           41 
   metronidazole                                    17, 33       MOXATAG                                            18 
   Metronidazole vaginal                                45       MOZOBIL                                            42 
   MEVACOR                                              32       MS CONTIN                                          25 
   mexiletine hcl                                       28       MULTAQ                                             29 
   MIACALCIN                                            39       mupirocin oint                                     34 
   MICARDIS                                             31       MUSTARGEN                                          21 
   miconazole                                           45       MYAMBUTOL                                          18 
   microgestin                                          45       MYCAMINE                                           15 
   microgestin fe                                       45       MYCOBUTIN                                          18 
   MICROZIDE                                            31       mycophenolate mofetil                              20 
   midodrine                                            36       mydral                                             47 
   migergot                                             23       MYDRIACYL                                          47 
   MIGRANAL                                             23       MYFORTIC                                           21 
   millipred                                            37       MYOZYME                                            39 
   MILLIPRED SOLN                                       37       MYSOLINE                                           22 
   MINIPRESS                                            31       MYTELASE                                           24 
   MINITRAN                                             33 
   MINOCIN                                              19                                  N 
   minocycline                                          19 
                                                                 nabumetone                                         26 
   minoxidil tab                                        30 
                                                                 nadolol                                            30 
   MIRAPEX                                              23 
                                                                 nadolol/bendroflumethiazide 1                      30 
   mirtazapine                                          27 
                                                                 nafcillin sodium                                   18 
   misoprostol                                          41 
                                                                 NAFTIN                                             34 
   mitomycin                                            20 
                                                                 NAGLAZYME                                          39 
   mitoxantrone                                         20 
                                                                 nalbuphine hcl                                     26 
   M-M-R II                                             43 
                                                                 NALFON                                             26 
   MOBIC                                                26 
                                                                 NALLPEN/DEXTROSE                                   18 
   MODICON                                              46 
                                                                 naloxone hcl                                       26 
   moexipril /hydrochlorothiazide                       30 
                                                                 naltrexone hcl                                     26 
   moexipril hcl                                        30 
                                                                 NAMENDA                                            24 
   mometasone furoate                                   35 
                                                                 naphazoline hcl oph drops                          48 
   MONODOX                                              19 
                                                                 NAPRELAN                                           26 
   MONOKET                                              33 
                                                                 NAPROSYN                                           26 
   mononessa                                            45 
                                                                 naproxen                                           26 
   MONOPRIL                                             31 
                                                                 naratriptan hcl                                    23 
   MONUROL                                              19 
                                                                 NARDIL                                             28 
   morphine sulfate                                     24 
68  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   NASACORT AQ                                        49        NITRO-DUR                                           33 
   NASONEX                                            49        nitrofurantoin macrocrystalline                     19 
   NATACYN                                            46        nitrofurantoin monohydrate                          19 
   nateglinide                                        38        nitroglycerin                                       33 
   NAVANE                                             28        NITROLINGUAL                                        33 
   NEBUPENT                                           18        NITROMIST                                           33 
   necon                                              45        NITROSTAT                                           33 
   nefazodone                                         27        nizatidine                                          41 
   NEO-FRADIN                                         18        NIZORAL                                             34 
   neomycin /bacitracin /polymyxin oph oint           46        nora-be                                             44 
   neomycin /polymyxin /dexamethasone oph drops       47        NORCO                                               25 
   neomycin /polymyxin /gramicidin oph soln           46        NORDETTE                                            46 
   neomycin /polymyxin /hydrocortisone otic           37        NORDIFLEX PEN                                       42 
   neomycin sulfate                                   17        NORDITROPIN                                         42 
   neomycin/polymyxin b sulfates irrigation           36        NORFLEX                                             24 
   NEORAL                                             21        NORINYL                                             46 
   NEOSPORIN OPH DROPS                                46        NORITATE                                            34 
   NEULASTA                                           42        NORMOSOL                                        51, 52 
   NEUMEGA                                            42        NORMOSOL-R                                      51, 52 
   NEUPOGEN                                           42        NORMOSOL-R IN D5W                                   51 
   NEURONTIN                                          22        NOROXIN                                             19 
   NEVANAC                                            47        NORPACE                                             29 
   NEXAVAR                                            21        NORPRAMIN                                           28 
   NEXIUM                                             41        NOR-QD                                              44 
   next choice                                        45        nortrel                                             45 
   NIACOR                                             32        nortriptyline                                       27 
   NIASPAN                                            32        NORVASC                                             31 
   NICARDIPINE                                        31        NORVIR                                              15 
   nicardipine hcl cap                                30        novamine                                            51 
   NICOTROL INHALER                                   36        NOVANTRONE                                          21 
   NICOTROL NS                                        36        NOVOLIN                                             39 
   nifediac cc                                        30        NOVOLIN N                                           39 
   nifedical xl                                       30        NOVOLIN R                                           39 
   nifedipine cap                                     30        NOVOLOG                                             39 
   nifedipine er                                      30        NOVOLOG MIX                                         39 
   NILANDRON                                          21        NOXAFIL                                             15 
   NIMODIPINE                                         31        NUCYNTA                                             26 
   NIPENT                                             21        NUEDEXTA                                            24 
   nisoldipine                                        30        NULYTELY                                            41 
   nitro-bid oint                                     33        NUTROPIN                                            42 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         69 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
  NUTROPIN AQ NUSPIN                                  42        ORFADIN                                            36 
  NUVARING                                            45        orphenadrine /asa /caffeine                        24 
  NUVIGIL                                             28        orphenadrine citrate                               24 
  nyamyc                                              34        orphenadrine compound                              24 
  nystatin                                        15, 34        ORTHO EVRA                                         45 
  nystatin/triamcinolone                              34        ORTHO MICRONOR                                     44 
  nystop                                              34        ORTHO TRI-CYCLEN                                   46 
                                                                ORTHO-CEPT                                         46 
                            O                                   ORTHOCLONE OKT3                                    21 
                                                                ORTHO-CYCLEN                                       46 
  ocella                                              45 
                                                                ORTHO-NOVUM                                        46 
  octreotide acetate                                  20 
                                                                OSMOPREP                                           41 
  OCUFEN                                              47 
                                                                OVCON                                              46 
  OCUFLOX                                             46 
                                                                OVIDE                                              35 
  ofloxacin                                   19, 37, 46 
                                                                OXACILLIN SODIUM                                   18 
  OGEN                                                44 
                                                                OXALIPLATIN                                        21 
  ogestrel                                            45 
                                                                OXANDRIN                                           39 
  OLEPTRO                                             28 
                                                                oxandrolone                                        39 
  OLUX-E                                              35 
                                                                oxaprozin                                          26 
  omeprazole                                          41 
                                                                oxcarbazepine                                      22 
  omeprazole-sodium bicarbonate                       41 
                                                                OXISTAT                                            34 
  OMNARIS                                             49 
                                                                OXSORALEN                                          33 
  OMNICEF                                             16 
                                                                oxybutynin chloride                                49 
  OMNIPRED                                            48 
                                                                oxycodone /acetaminophen                           24 
  OMNITROPE                                           42 
                                                                oxycodone /aspirin                                 25 
  ONCASPAR                                            21 
                                                                oxycodone /ibuprofen                               25 
  ondansetron hcl                                     40 
                                                                oxycodone hcl                                      25 
  ondansetron odt                                     40 
                                                                oxycodone-apap                                     25 
  ONGLYZA                                             39 
                                                                OXYCONTIN                                          25 
  ONSOLIS                                             25 
                                                                oxymorphone hcl                                    25 
  ONTAK                                               21 
                                                                OXYTROL                                            50 
  OPANA                                               25 
  OPTIPRANOLOL                                        46 
                                                                                          P 
  OPTIVAR                                             47 
  ORACEA                                              19        pacerone                                           28 
  ORAMORPH                                            25        PACERONE                                           29 
  ORAP                                                28        paclitaxel                                         20 
  ORAPRED                                             38        PALGIC                                             48 
  ORAVIG                                              15        palgic liq                                         48 
  ORENCIA                                             44        PAMELOR                                            28 

70  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
   therapy requirements
    
   pamidronate disodium                               39        PEPCID                                              41 
   PAMIDRONATE DISODIUM                               39        PERCOCET                                            25 
   PAMINE                                             40        PERCODAN                                            25 
   PAMINE FORTE                                       40        PERFOROMIST                                         49 
   PANCREAZE                                          41        perindopril erbumine                                30 
   PANDEL                                             35        periogard                                           37 
   PANLOR                                             25        PERIOSTAT                                           19 
   PANRETIN                                           33        permethrin cre                                      35 
   pantoprazole sodium                                41        perphenazine                                        27 
   PARAFON FORTE                                      24        perphenazine /amitriptyline                         27 
   PARCOPA                                            23        PERSANTINE                                          32 
   PARLODEL                                           23        PEXEVA                                              28 
   PARNATE                                            28        pfizerpen-g                                         18 
   paromomycin sulfate                                17        phenadoz                                            48 
   paroxetine                                         27        PHENERGAN                                           48 
   PASER                                              18        PHENYTEK                                            22 
   PATADAY                                            47        phenytoin                                           22 
   PATANOL                                            47        PHENYTOIN SODIUM                                    22 
   PAXIL                                              28        PHISOHEX                                            34 
   PCE                                                17        PHOSLO                                              51 
   PEDIAPRED                                          38        PHOSPHOLINE IODIDE                                  46 
   PEDIARIX                                           43        PHOTOFRIN                                           21 
   pedi-dri                                           34        PHYSIOLYTE                                          36 
   PEDVAX HIB                                         43        PHYSIOSOL IRRIGATION                                36 
   PEGANONE                                           22        pilocarpine                                         36 
   PEGASYS                                            42        PILOPINE HS                                         47 
   PEG-INTRON                                         42        pindolol                                            30 
   PENICILLIN G                                       18        piperacillin sodium                                 18 
   penicillin g potassium                             18        PIPERACILLIN SODIUM                                 18 
   PENICILLIN G POTASSIUM                             18        piroxicam                                           26 
   penicillin v potassium                             18        PLAQUENIL                                           18 
   PENLAC NAIL LACQUER                                34        PLASMA-LYTE                                         52 
   PENNSAID                                           26        PLAVIX                                              32 
   PENTAM                                             18        PLETAL                                              32 
   PENTASA                                            41        podofilox                                           33 
   pentazocine /acetaminophen                         26        polycin b                                           46 
   pentazocine/naloxone hcl                           26        poly-dex                                            47 
   pentopak                                           31        polyethylene glycol                                 40 
   pentostatin                                        20        polymyxin b sulfate                             17, 46 
   pentoxifylline er                                  32        POLY-PRED                                           47 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         71 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   POLYTRIM                                           46         PRIMAQUINE PHOSPHATE                               18 
   PONSTEL                                            26         PRIMAXIN                                           18 
   portia                                             45         primidone                                          22 
   potassium chloride                                 50         PRIMSOL                                            19 
   POTASSIUM CHLORIDE                                 51         PRINIVIL                                           31 
   potassium citrate extended-release                 50         PRINZIDE                                           31 
   PRADAXA                                            32         PRISTIQ                                            28 
   pramipexole dihydrochloride                        23         PRIVIGEN                                           43 
   PRANDIMET                                          39         PROAIR HFA                                         49 
   PRANDIN                                            39         PROAMATINE                                         36 
   PRAVACHOL                                          32         probenecid                                         43 
   pravastatin sodium                                 32         probenecid/colchicine                              43 
   prazosin hcl                                       30         procainamide hcl                                   28 
   PRECOSE                                            39         PROCALAMINE                                        52 
   PRED FORTE                                         48         PROCARDIA                                          31 
   PRED MILD                                          48         PROCHIEVE                                          44 
   PRED-G                                             47         prochlorperazine edisylate                         40 
   PRED-G S.O.P                                       47         prochlorperazine maleate tab                       40 
   prednicarbate                                      35         prochlorperazine supp                              40 
   prednisolone acetate oph drops                     48         PROCRIT                                        42, 43 
   prednisolone sodium phosphate oph drops            48         PROCTOCORT                                         41 
   prednisolone sodium phosphate soln                 37         PROCTOCREAM                                        41 
   prednisolone syrup                                 37         procto-pak                                         40 
   prednisone                                         37         proctosol hc                                       40 
   PREDNISONE                                         38         proctozone-hc                                      40 
   PREFEST                                            44         PROGLYCEM                                          39 
   PRELONE                                            38         PROGRAF                                            21 
   PREMARIN                                           44         PROLASTIN                                          36 
   premasol                                           51         PROLEUKIN                                          43 
   PREMASOL                                           52         PROLIA                                             44 
   PREMPHASE                                          44         PROMACTA                                           32 
   PREMPRO                                            44         promethazine                                       48 
   prenatabs                                          52         promethegan                                        48 
   PREVACID                                           41         PROMETRIUM                                         45 
   prevalite                                          32         propafenone hcl                                    29 
   previfem                                           45         PROPINE                                            48 
   PREVPAC                                            41         propranolol                                        30 
   PREZISTA                                           15         propranolol /hydrochlorothiazide                   30 
   PRIFTIN                                            18         propylthiouracil                                   38 
   PRILOSEC                                           41         PROQUAD                                            43 
72  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   PROQUIN XR                                         19        REBIF                                               43 
   PROSCAR                                            50        RECLAST                                             36 
   PROSOL                                             52        reclipsen                                           45 
   PROTONIX                                           41        RECOMBIVAX                                          43 
   PROTOPIC                                           33        REGLAN                                              41 
   protriptyline hcl                                  27        regonol                                             24 
   PROVENTIL HFA                                      49        REGRANEX                                            33 
   PROVERA                                        44, 45        RELENZA                                             15 
   PROVIGIL                                           28        RELION                                              39 
   PROZAC                                             28        RELISTOR                                            41 
   PULMICORT                                          49        RELPAX                                              23 
   PULMOZYME                                          49        REMERON                                             28 
   PURINETHOL                                         21        REMICADE                                            41 
   PYLERA                                             41        REMODULIN                                           31 
   pyrazinamide                                       17        RENAGEL                                             36 
   pyridostigmine bromide                             24        RENAMIN                                             52 
                                                                RENVELA                                             36 
                             Q                                  REPREXAIN                                           25 
                                                                reprexain tab                                       25 
   QUALAQUIN                                          18 
                                                                REQUIP                                              23 
   quasense                                           45 
                                                                RESCRIPTOR                                          15 
   QUESTRAN                                           32 
                                                                reserpine                                           30 
   quinapril                                          30 
                                                                RESTASIS                                            47 
   quinapril /hydrochlorothiazide                     30 
                                                                RETIN-A                                             34 
   QUINIDINE GLUCONATE                                29 
                                                                RETROVIR                                            15 
   quinidine gluconate cr                             29 
                                                                REVATIO                                             49 
   quinidine sulfate                                  29 
                                                                REVIA                                               26 
   QUIXIN                                             46 
                                                                REVLIMID                                            21 
   QVAR                                               49 
                                                                REYATAZ                                         15, 16 
                                                                RHEUMATREX                                          22 
                             R 
                                                                RHINOCORT                                           49 
   RABAVERT                                           43        RIBAPAK                                             16 
   ramipril                                           30        ribasphere                                          15 
   RANEXA                                             32        RIBASPHERE TAB                                      16 
   ranitidine hcl                                     41        ribavirin                                           15 
   RAPAFLO                                            50        RIDAURA                                             44 
   RAPAMUNE                                           21        RIFADIN                                             18 
   RAPIFLUX                                           28        RIFAMATE                                            18 
   RAZADYNE                                           24        rifampin                                            17 
   REBETOL                                            15        RIFATER                                             18 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         73 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
  RILUTEK                                             36         SARAFEM                                             28 
  rimantadine                                         15         SAVELLA                                             44 
  ringers injection                                   50         SEASONALE                                           46 
  ringers irrigation                                  36         SEASONIQUE                                          46 
  RIOMET                                              39         SECTRAL                                             31 
  RISPERDAL                                           28         selegiline hcl                                      23 
  RISPERDAL CONSTA                                    28         selenium sulfide 2.5% lot                           33 
  risperidone                                         27         selfemra                                            27 
  RISPERIDONE ODT                                     28         SELSUN SHAMPOO                                      33 
  RITALIN                                             28         SELZENTRY                                           16 
  RITUXAN                                             22         SEMPREX-D                                           49 
  rivastigmine cap                                    23         SENSIPAR                                            39 
  ROBAXIN                                             24         SEPTRA                                              19 
  ROBINUL                                             40         SEREVENT                                            49 
  ROCALTROL                                           39         SEROMYCIN                                           18 
  ROCEPHIN                                            16         SEROQUEL                                            28 
  romycin                                             46         SEROSTIM                                            43 
  ropinirole hcl                                      23         sertraline hcl                                      27 
  ROTATEQ                                             43         SILVADENE                                           33 
  ROWASA                                              41         SIMCOR                                              32 
  ROXICET                                             25         SIMPONI                                             44 
  roxicet tab                                         25         SIMULECT                                            22 
  ROXICODONE                                          25         simvastatin                                         32 
  ROZEREM                                             28         SINEMET                                             23 
  RYTHMOL                                             29         SINGULAIR                                           49 
  RYZOLT                                              26         SKELAXIN                                            24 
                                                                 SKELID                                              36 
                             S                                   sodium chloride                         17, 31, 36, 50 
                                                                 SODIUM EDECRIN                                      31 
   SABRIL                                             23 
                                                                 sodium fluoride                                     52 
   SAIZEN                                             43 
                                                                 sodium lactate                                      50 
   SALAGEN                                            36 
                                                                 sodium polystyrene sulfonate                        36 
   SAMSCA                                             39 
                                                                 sodium sulfacetamide lot                            34 
   SANCTURA                                           50 
                                                                 sodium sulfacetamide oph drops                      48 
   SANCTURA XR                                        50 
                                                                 SOLARAZE                                            33 
   SANCUSO                                            41 
                                                                 solia                                               45 
   SANDIMMUNE                                         22 
                                                                 SOLODYN                                             19 
   SANDOSTATIN                                        22 
                                                                 SOLU-MEDROL                                         38 
   SANTYL                                             35 
                                                                 solu-medrol inj 500 mg                              37 
   SAPHRIS                                            28 
                                                                 SOMA                                                24 
74  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   SOMATULINE                                         22        sulfatrim                                          19 
   SOMAVERT                                           39        sulfazine ec                                       40 
   SONATA                                             28        sulindac                                           26 
   SORIATANE                                          33        sumatriptan succinate                              23 
   sorine                                             29        SUPRAX                                             16 
   sotalol hcl                                        29        SUPREP                                             41 
   SOTALOL HCL                                        29        SURMONTIL                                          28 
   sotret                                             33        SUSTIVA                                            16 
   SPECTRACEF                                         16        SUTENT                                             22 
   SPIRIVA                                            49        SYMBICORT                                          49 
   spironolactone                                     30        SYMBYAX                                            28 
   SPORANOX                                           15        SYMLIN                                             39 
   sprintec                                           45        SYMLINPEN                                          39 
   SPRYCEL                                            22        SYNAGIS                                            16 
   sronyx                                             45        SYNALGOS                                           25 
   ssd                                                33        SYNAREL                                            39 
   STADOL                                             26        SYNERA                                             34 
   stagesic                                           25        SYNERCID                                           18 
   STALEVO                                            23        SYNTHROID                                          40 
   STARLIX                                            39        SYPRINE                                            36 
   stavudine                                          15 
   STAVZOR                                            23                                  T 
   STELARA                                            33 
                                                                TABLOID                                            22 
   sterile water irrigation                           36 
                                                                TACLONEX                                           33 
   STIMATE                                            39 
                                                                tacrolimus                                         20 
   STRATTERA                                          28 
                                                                TALACEN                                            26 
   STREPTOMYCIN SULFATE                               18 
                                                                TALWIN                                             26 
   STRIANT                                            39 
                                                                TAMBOCOR                                           29 
   STROMECTOL                                         18 
                                                                TAMIFLU                                            16 
   SUBOXONE                                           26 
                                                                tamoxifen citrate                                  20 
   SUBUTEX                                            25 
                                                                tamsulosin                                         50 
   sucralfate                                         41 
                                                                TAPAZOLE                                           38 
   SULAR                                              31 
                                                                TARCEVA                                            22 
   sulfacetamide sodium/prednisolone sodium
                                                                TARGRETIN                                          22 
      phosphate oph drops                             48 
                                                                TARKA                                              31 
   sulfadiazine                                   19, 33 
                                                                TASIGNA                                            22 
   sulfamethoxazole /trimethoprim                     19 
                                                                TASMAR                                             23 
   sulfamethoxazole/trimethoprim                      19 
                                                                TAXOTERE                                           22 
   SULFAMYLON                                         34 
                                                                TAZICEF                                            16 
   sulfasalazine                                      40 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         75 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   tazobactam sodium                                  18         TIMENTIN                                           18 
   TAZORAC                                            34         timolol maleate oph drops                          46 
   taztia xt                                          30         timolol maleate ophthalmic gel forming             46 
   TEFLARO                                            16         timolol maleate tab                                30 
   TEGRETOL                                           23         TIMOPTIC                                           46 
   TEKAMLO                                            31         TIMOPTIC-XE                                        46 
   TEKTURNA                                           31         TIS-U-SOL                                          36 
   TEMOVATE                                           35         tizanidine hcl                                     24 
   TENEX                                              31         TOBI                                               18 
   TENORETIC                                          31         TOBRADEX OPH                                       47 
   TENORMIN                                           31         TOBRADEX ST                                        47 
   TERAZOL                                            45         TOBRAMYCIN SULFATE/ SODIUM
   terazosin hcl                                      30            CHLORIDE                                        18 
   terbinafine                                        15         tobramycin sulfate                             17, 46 
   terbutaline sulfate                                49         tobrasol                                           46 
   terconazole                                        45         TOBREX                                             46 
   TESTIM                                             40         TOFRANIL                                           28 
   testosterone cypionate                             39         tolazamide                                         38 
   testosterone enanthate                             39         tolbutamide                                        38 
   TESTRED                                            40         tolmetin sodium                                    26 
   tetanus toxoid adsorbed                            43         TOPAMAX                                            23 
   TETANUS/DIPHTHERIA                                 43         TOPICORT                                           35 
   tetracycline                                       19         topiramate                                         22 
   TEVETEN                                            31         toposar                                            20 
   TEV-TROPIN                                         43         topotecan                                          20 
   THALITONE                                          31         TOPROL                                             31 
   THALOMID                                           22         TORISEL                                            22 
   THEO-24                                            49         TORSEMIDE                                          31 
   theochron                                          49         torsemide tab                                      30 
   theophylline er                                    49         TOVIAZ                                             50 
   thermazene                                         33         TRACLEER                                           49 
   thioridazine hcl                                   27         tramadol                                           26 
   thiotepa                                           20         tramadol hydrochloride/ acetaminophen              26 
   thiothixene                                        27         TRANDATE                                           31 
   THYMOGLOBULIN                                      43         trandolapril                                       30 
   THYROLAR                                           40         trandolapril/verapamil hcl                         30 
   TIAZAC                                             31         TRANSDERM-SCOP                                     41 
   ticlopidine hcl                                    32         tranylcypromine sulfate                            27 
   TIGAN                                              41         travasol                                           51 
   TIKOSYN                                            29         TRAVATAN Z                                         47 
76  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   trazodone hcl                                      27        TWINJECT                                           49 
   TREANDA                                            22        TWINRIX                                            43 
   TRECATOR                                           18        TWYNSTA                                            31 
   TRELSTAR                                           22        TYGACIL                                            18 
   TRELSTAR LA                                        22        TYKERB                                             22 
   TRENTAL                                            32        TYLENOL/CODEINE                                    25 
   tretinoin                                      20, 34        TYLOX                                              25 
   TRETIN-X                                           34        TYPHIM                                             43 
   TREXALL                                            22        TYSABRI                                            24 
   TREXIMET                                           23        TYZEKA                                             16 
   TRIAMCINOLONE ACETONIDE                            35        TYZINE                                             37 
   triamcinolone acetonide                            35 
   triamcinolone in orabase                           37                                  U 
   triamterene /hydrochlorothiazide                   30 
                                                                U-CORT                                             33 
   TRIBENZOR                                          31 
                                                                ULESFIA                                            35 
   TRICOR                                             32 
                                                                ULORIC                                             43 
   triderm                                            35 
                                                                ULTRACET                                           26 
   trifluoperazine hcl                                27 
                                                                ULTRAM                                             26 
   trifluridine                                       46 
                                                                ULTRAM ER                                          26 
   TRIGLIDE                                           32 
                                                                ULTRAVATE                                          35 
   trihexyphenidyl hcl                                23 
                                                                UNASYN                                             18 
   TRIHIBIT                                           43 
                                                                UNIPHYL                                            49 
   tri-legest fe                                      45 
                                                                UNIRETIC                                           31 
   TRILEPTAL                                          23 
                                                                unithroid                                          40 
   TRILIPIX                                           32 
                                                                UNIVASC                                            31 
   trilyte                                            40 
                                                                URECHOLINE                                         50 
   trimethobenzamide hcl                              40 
                                                                UROXATRAL                                          50 
   trimethoprim                                   19, 46 
                                                                URSO                                               41 
   trinessa                                           45 
                                                                URSO FORTE                                         41 
   TRI-NORINYL                                        46 
                                                                ursodiol                                           40 
   TRIPEDIA                                           43 
                                                                UVADEX                                             33 
   tri-previfem                                       45 
   TRISENOX                                           22 
                                                                                          V 
   tri-sprintec                                       45 
   trivora                                            45        VAGIFEM                                            45 
   TRIZIVIR                                           16        valacyclovir                                       15 
   tropicamide                                        47        VALCYTE                                            16 
   trospium chloride                                  49        valproate sodium                                   22 
   TRUSOPT                                            47        valproic acid                                      22 
   TRUVADA                                            16        VALTREX                                            16 
Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         77 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
   VALTURNA                                           31         vincasar pfs                                       20 
   VANCOCIN                                           19         vincristine sulfate                                20 
   vancomycin hcl                                     19         vinorelbine tartrate                               20 
   VANCOMYCIN HCL                                     19         VIRACEPT                                           16 
   vandazole                                          45         VIRAMUNE                                           16 
   VANOS                                              35         VIRAZOLE                                           16 
   VANTIN                                             16         VIREAD                                             16 
   VAQTA                                              43         VIROPTIC                                           46 
   VARIVAX                                            43         VISICOL                                            41 
   VASERETIC                                          31         VISTARIL                                           49 
   VASOTEC                                            31         VISTIDE                                            16 
   VECTIBIX                                           22         VIVACTIL                                           28 
   VECTICAL                                           33         VIVAGLOBIN                                         43 
   VELCADE                                            22         VIVELLE-DOT                                        45 
   velivet                                            45         VIVITROL                                           26 
   VENLAFAXINE                                        28         VOLTAREN                                       26, 47 
   venlafaxine hcl er cap                             27         VOSPIRE ER                                         49 
   venlafaxine hcltab                                 27         VOTRIENT                                           22 
   VENTAVIS                                           49         VPRIV                                              40 
   VENTOLIN                                           49         VYTORIN                                            32 
   VERAMYST                                           49         VYVANSE                                            28 
   verapamil hcl                                      30 
   VERDESO                                            35                                   W 
   VEREGEN                                            33 
                                                                 warfarin sodium                                    32 
   VERELAN                                            31 
                                                                 WELCHOL                                            32 
   VERIPRED                                           38 
                                                                 WELLBUTRIN                                         28 
   VESICARE                                           50 
                                                                 WESTCORT                                           35 
   VEXOL                                              48 
   VFEND                                              15 
                                                                                            X 
   VIBATIV                                            19 
   VIBRAMYCIN                                         19         XALATAN                                            47 
   VICODIN                                            25         XENAZINE                                           24 
   VICOPROFEN                                         25         XGEVA                                              20 
   VICTOZA                                            39         XIBROM                                             47 
   VIDAZA                                             22         XIFAXAN                                            18 
   VIDEX                                              16         XODOL                                              25 
   VIGAMOX                                            46         XOLAIR                                             49 
   VIMOVO                                             26         XOLEGEL                                            34 
   VIMPAT                                             23         XOPENEX                                            49 
   vinblastine sulfate                                20         XYLOCAINE                                          34 
78  Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;
     PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step
     therapy requirements
    
   XYREM                                              28        zidovudine                                          15 
   XYZAL                                              49        ZINACEF                                             16 
                                                                ZINECARD                                            20 
                             Y                                  ZIPSOR                                              26 
                                                                ZIRGAN                                              46 
   YASMIN                                             46 
                                                                ZITHROMAX                                           17 
   YAZ                                                46 
                                                                ZMAX                                                17 
   YF-VAX                                             43 
                                                                ZOCOR                                               32 
                                                                ZOFRAN                                              41 
                             Z 
                                                                ZOLINZA                                             22 
   zafirlukast                                        49        ZOLOFT                                              28 
   zaleplon                                           27        zolpidem tartrate                                   27 
   ZAMICET                                            25        ZOLPIMIST                                           28 
   ZANOSAR                                            22        ZOMETA                                              40 
   ZANTAC                                             41        ZOMIG                                               23 
   ZARONTIN                                           23        ZONALON                                             33 
   ZAROXOLYN                                          31        ZONEGRAN                                            23 
   ZAVESCA                                            40        zonisamide                                          22 
   ZAZOLE                                             45        ZORTRESS                                            22 
   zazole vag                                         45        ZOSTAVAX                                            43 
   ZEBETA                                             31        ZOSYN                                               18 
   ZEGERID                                            41        zovia                                               45 
   ZELAPAR                                            23        ZOVIRAX                                         16, 34 
   ZEMAIRA                                            36        ZUPLENZ                                             41 
   ZEMPLAR                                            40        ZYBAN                                               36 
   ZEMPLAR INJ                                        40        ZYCLARA                                             33 
   ZENPEP                                             41        ZYDIS                                               28 
   ZERIT                                              16        ZYDONE                                              25 
   zerlor                                             25        ZYFLO CR                                            49 
   ZESTORETIC                                         31        ZYLET                                               47 
   ZESTRIL                                            31        ZYLOPRIM                                            43 
   ZETIA                                              32        ZYMAR                                               46 
   ZIAC                                               31        ZYMAXID                                             46 
   ZIAGEN                                             16        ZYPREXA                                             28 
   ZIANA                                              34        ZYVOX                                               18 




Legend: GC- Gap coverage; LA- This drug may only be available at certain pharmacies; call Customer Service;         79 
  PA- This drug may require prior authorization; QL- This drug may have quantity limits; ST- This drug may have step  
therapy requirements
 
An independent licensee of the Blue Cross and Blue Shield Association. U3348d, 4/11

				
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