Ventura County Medi-Cal Managed Care Commission (VCMMCC) … · 2012. 5. 21. · Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan Commission Meeting

Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba

Gold Coast Health Plan Commission Meeting

DATE: Monday, June 27, 2011 TIME: 3:00-5:00 pm PLACE: 2240 E. Gonzales Road, Suite 200, Oxnard CA 93036

AGENDA

Call to Order, Welcome and Roll Call

Public Comment / Correspondence

1. Approve Minutes – May 23, 2011 Meeting Action Required

2.

Accept and File Management Update

For Information

3.

Accept and File Financial Report a. Cash Flow

For Information b. Reinsurance Action Required

4.

Management Recommendations

a. Auto Assignment Action Required

b. Pharmacy &Therapeutics Committee Appointment Action Required c. Credentials Committee Appointment Action Required d. Quality Committee Appointment Action Required e. Provider Advisory Committee Appointment Action Required f. Formulary Action Required g. Response from ScriptCare For Information

Comments from Commissioners

Meeting agenda available at http://www.goldcoasthealthplan.org

IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT, IF YOU NEED SPECIAL ASSISTANCE TO PARTICIPATE IN THIS MEETING, PLEASE CONTACT TRACI AT 805/981-5320. REASONABLE ADVANCE NOTIFICATION OF THE NEED FOR ACCOMMODATION PRIOR TO THE MEETING (48 HOURS ADVANCE NOTICE IS PREFERABLE) WILL ENABLE US TO MAKE REASONABLE ARRANGEMENTS TO ENSURE ACCESSIBILITY TO THIS MEETING

http://www.goldcoasthealthplan.org/

Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)

Commission Meeting Minutes May 23, 2011

(Not official until approved)

CALL TO ORDER Chair Dial called the meeting to order at 3:05 p.m. in Suite 200 at the Ventura County Public Health Building located at 2240 E. Gonzales Road, Oxnard, CA 93036.

ROLL CALL COMMISSION MEMBERS IN ATTENDANCE David Araujo, MD, Ventura County Medical Center Family Medicine Residency Program Maylee Berry, Medi-Cal Beneficiary Advocate Lanyard Dial, MD, Ventura County Medical Association Robert Gonzalez, MD, Ventura County Health Care Agency Rick Jarvis, Private Hospitals / Healthcare System Roberto S. Juarez, Clinicas del Camino Real, Inc. Kathy Long, Ventura County Board of Supervisors Catherine Rodriguez, Ventura County Medical Health System

EXCUSED / ABSENT COMMISSIONERS Anil Chawla, MD, Clinicas del Camino Real, Inc. Laurie Eberst, RN, Private Hospitals / Healthcare System John Fankhauser, MD, Ventura County Medical Center Executive Committee

STAFF IN ATTENDANCE Earl Greenia, CEO Tin Kin Lee, Legal Counsel Traci R. McGinley, Clerk of the Board Charlie Cho, MD, Chief Medical Officer Andre Galvan, Project Management Specialist Guillermo Gonzalez, Government Affairs Director Darlane Johnsen, Chief Financial Officer Pamela Kapustay, RN, Health Services Director Steven Lalich, Communications Director Candice Limousin, Human Resources Director Audra Lucas, Administrative Assistant

Language Interpreting and Translating services provided by GCHP from Lourdes

González Campbell of Lourdes González Campbell and Associates. The Pledge of Allegiance was recited.

GCHP Commission Meeting Minutes May 23, 2011 - Page 1 of 4

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PUBLIC COMMENT / CORRESPONDENCE The following representatives were present regarding Agenda Item 4.b. Managed Care Medi-Cal Pharmacy Costs and Reimbursement (contract with ScriptCare), and expressed their concerns about the Contract with ScriptCare:

Robert Andonian, Pharmacy & Famrmacia Estrella. Ali Karandish, Stan’s Drugs Pharmacy. April Valusek, OMAC Pharmacy. Joe Hoffman, Oxnard Drug. John Skormand, Seeber’s Pharmacy. Pamela Miles, Home Care Pharmacy, Inc. James Lektwich, Rogers Pharmacy. Chris Platt, Medical Arts Pharmacy.

Kevin Brown, ScriptCare, Ltd, advised the Commission that the pharmacy contract originally had two network options, after discussing the contract with a number of pharmacists, they amended it and made it a single network contract. He announced that ScriptCare would be at the Hilton Garden Inn at 6:30 p.m. to discuss these issues and provide clarification to local pharmacies. Mr. Brown also announced that ScriptCare has opened a local office at 1701 Solar Street in Oxnard which will house approximately 20 employees.

The ScriptCare / Pharmacy contract was further discussed and that ScriptCare’s rates are within the range of other managed Medi-Cal Plans within the State.

David Cruz, Health Education League of America, expressed his belief and concern that the Plan was not ready to go “live” on July 1, 2011.

Christina Velasco, Clinicas del Camino Real, Inc., voiced her concerns regarding a recent Auto-Assignment Study Group meeting she attended and requested the Commission review the open meeting laws.

Pablo Ortiz, Gold Coast Broadcasting, introduced himself as his company is launching the Gold Coast Health Plan’s media campaign.

Richard Sochel, CSDS, Executive Director, thanked GCHP staff for attending a recent outreach hosted at his facility

1. APPROVAL OF MINUTES – APRIL 25, 2011 After a brief discussion, the following statement will be added to the Public Comment section of the minutes. “Tony Alatorre, Clinicas COO, Auto-Assignment Study Group Member, objected to Agenda Item 4b, Auto-Assignment Study Group Recommendations, being deferred.”


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Item 3.a. 2) is hereby amended to read as follows: “Budget assumes a subordinated loan of $3.5 million beginning in December 2011. With the loan, GCHP will phase in all Total Net Equity requirements.”

Commissioner Araujo moved to approve the April 25, 2011, minutes as amended; Commissioner Gonzalez seconded. The motion carried. Approved 8-0.

4. MANAGEMENT RECOMMENDATIONS

b. Outpatient Pharmacy Reimbursement

CEO Greenia discussed the relationship between GCHP and ScriptCare as well as ScriptCare and local pharmacies, GCHP does not have contracts with individual pharmacies. Out of 126 contracts offered by ScriptCare, 96 had been accepted.

Counsel Tin Kin Lee advised the Commission that there is a list of items that ScriptCare must meet or there are possible financial consequences.

Clarification was made between the Fee-For-Service and Managed Care.

Chief Medical Officer Cho gave a brief explanation of the formulary to the Commission and those in attendance.

2. CEO UPDATE CEO Greenia announced that on May 12, 2011 management received confirmation from the State for the “Go-Live” date of July 1, 2011 from the State.

The Provider Directory was completed last Friday.

Dr. Cho has made strides in the formulary.

Our community outreach/education efforts continue. The Plan continues to execute contracts with Primary Care Physicians and other providers.

No Commission action was required.

3. FINANCIAL REPORT

CFO Johnsen presented the Balance Sheet, Statement of Revenue and Expenses, Monthly Cash Flow Projections, Tangible Net Equity and Administrative Expense Details.

Management received confirmation that the ACS moneys should be classified as a liability.

GCHP Commission Meeting Minutes

May 23, 2011 - Page 3 of 4

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The short term loan was reduced to $300,000.

No Commission action was required.

4. MANAGEMENT RECOMMENDATIONS

a. Auto-Assignment Study Group Recommendations The Study Group recommendations were discussed, including the definitions of Safety- Net, Traditional and Non-Traditional Providers. Additional comments from members of the Study Group that were present were received.

Commissioner Juarez moved to accept Items 1-4 of the Auto Assignment Study Group recommendation, and amend Item 5 to a three-to-one ratio, Commissioner Gonzalez seconded. The motion carried. Approved 5-3, with Commissioners Jarvis, Berry and Dial voting no.

c. Resolution to Execute Contract with State

Commissioner Long moved to approve the Resolution giving the Chief Executive Officer the authority to approve and execute the contracts with the State, Commissioner Eberst seconded. The motion carried. Approved 8-0, with all Commissioners present voting aye.

COMMENTS FROM COMMISSIONERS Commissioner Juarez commented on the complexity of the contracting process with Gold Coast Health Plan.

ADJOURNMENT

The meeting adjourned at 5:37 p.m.


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Chief Executive’s Monthly Report to Commission

June 27, 2011

PEOPLE (Organizational Structure)

We have added additional talent to our team:

o Accounts Payable Coordinator: Shannon Godina

o Clinical Operations Assistant: Dawn Lambert

o Claims Auditor Consultant: Chris Wilson

o Health Services: Judy Delp, RN; Dee Johnston, RN; Diana Lewis, RN; and

Kathy Price, RN

o Summer Intern: Jasmine Wilson

Offers have been extended to fill the QI Specialist and Systems Manager positions.

Recruitment and selection continues for: Sr. Claims Auditor, Pharmacist and a

Providers Relations Representative.

Introduced employee performance appraisal process.

SERVICE (Member & Provider Satisfaction, Government Relations)

Efforts continue for our inaugural ceremony on July 19. The GCHP team has reached

out to invite elected officials at the city, county, state and federal level and to obtain

proclamations.

In June, we held numerous outreach/education sessions, attended community

sponsored events, and placed print ads promoting our events in Vida and Ventura

County Star.

o June 1st and 7th, at 6:30 pm, Gold Coast Health Plan made presentations to

more than 50 people at the Rainbow Connection in both at their Oxnard and

Simi Valley locations.

o Wednesday, June 8th, at 10:00 am, we made a presentation at the Tri-Counties

Regional Center’s Oxnard location to approximately 60 staff members.

o Thursday, June 9th, at 5:30 pm, we made a presentation to twenty Medi-Cal

beneficiaries at the County’s West Ventura Medical Clinic.

o Tuesday, June 14th, at 10:30 am, we held an information session with the

Ventura County’s Area Agency on Aging Health Insurance Counseling and

Advocacy Program (HICAP) at their Ventura headquarters to 45 staff members.

o Tuesday, June 14th, at 6:00 pm, we attended the Ventura County Medical

Association’s dinner at the Spanish Hills Country Club and provided an update

to over 100 attendees.

2220 E. Gonzales Road, Suite 200, Oxnard, CA 93036 Phone (805) 981-5320

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o Wednesday, June 15th, at 8:30 am, we held an information session with the

Department of Vocational Rehabilitation (DOR), at their Oxnard location.

o Thursday, June 16th, we conducted bilingual outreach to approximately 12

families at Harrington Elementary School in Oxnard.

o Friday, June 17th, at 12:00 pm, we met with the Mixteco Indigena Community

Organizing Project (MICOP) leadership to discuss partnership opportunities,

Our marketing and advertising efforts continue; some highlights:

o The pre-go-live advertising campaign began Monday, May 23rd and will

continue for 6 consecutive weeks on 8 radio stations (104.7 KCAQ-FM, 105.5

KFYV-FM, 103.7 KMLA-FM, 95.9 KOCP-FM, 910 KOXR-AM, 1590 KUNX-AM,

102.9 KXLM-FM, 96.7 KLJR-FM).

o Each station will run 45 60-second commercials per week for a total of 270

commercials per station and an 8 station 6 week grand total of 2,160

commercials.

o In the Metro Area or West County (Oxnard, Camarillo, Ventura, Port Hueneme,

Santa Paula, Fillmore, Ojai), 266,500 unique listeners (ages 12 and above) will

be reached. In the Total Survey Area (TSA) or East County, an additional

163,900 listeners (ages 12 and above) will be reached.

o Additionally, we will promote the Plan on “La Hora Mixteca” hosted by Fabian

Alfaro on KUNX 1590AM. This weekly independent radio show will run for 6

weeks in 1 hour segments. Coupled with his weekly show the program will

showcase Gold Coast Health Plan’s educational efforts to the Mixteco

Community by providing a unique platform to present Mixteco listeners with

information on the Plan.

o There will be 12, ¼ page color print ads placed in the Ventura County Star and

6, ¼ page color print ads placed in Vida, a weekly Spanish language

newspaper informing readers of the coming changes to Medi-Cal and

introducing them to Gold Coast Health Plan.

GCHP staff trained seven Mixteco Community Outreach Workers on the PCP

selection process. To date, the outreach workers have assisted over 3,500

beneficiaries complete their PCP selection forms.

The inaugural meeting of Consumer Advisory Committee was held on June 15.

The “Welcome” letters and packets were mailed to members on May 31. Distribution of

the Member handbook and identification cards begins today.

The Member Services Call Center (which employs 42 customer service

representatives, half of whom speak Spanish) continues to receive calls from

members and providers.

The U.S. House of Representatives budget bill calls for $800 billion in cuts to Medicaid

over a ten year period and transitions it to a “block grant” program. Representative

Lois Capps voted against the bill, while Representative Elton Gallegly voted in favor of

the bill, which was passed. Medicaid program advocates are encouraging supporters

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to contact their Congressional representatives to urge them to oppose these drastic

cuts and changes. GCHP had a conference call with Nora Connors, Senator

Feinstein’s Senior Aide on Health and Medicaid to ensure that Senator Feinstein was

aware of the transition to Medi-Cal Managed Care in Ventura County. A meeting

request has been submitted to Senator Boxer’s senior aide on health.

GCHP staff participated in an “All-Plan” conference call to discuss California’s budget

situation and its impact on Medi-Cal Managed Care Plans. DHCS has not yet

submitted the required waiver request to CMS to implement the provisions of AB 97.

This legislation, approved by the Legislature and Governor, authorizes provider rate

reductions, visitation caps, and other cuts to the Medi-Cal Program. GCHP has

submitted a meeting request to DHCS Director Toby Douglas to discuss our unique

situation as a start-up and the State’s mandate to reduce Medi-Cal funding.

ACCESS (Robust Provider Network)

Provider contracting efforts continue; the network composition is summarized below:

Provider Type Number of

Contracts

Number of Providers

Primary Care Providers

23 163 Physicians; 190

mid-level practitioners

Specialist Physicians 63 1,809

Hospitals 9 11

Long-Term Care

Facilities

15

16

Laboratories 3 13

Pharmacies 1 (ScriptCare) 96

Home Health / Hospice 16 19

Optometrists 15 29

Other Providers 63 90

To date, 17 provider orientation sessions have been conducted throughout Ventura

County to educate providers about GCHP policies and procedures.

The first meeting of the Provider Advisory Committee was re-scheduled for July 7.

QUALITY (Comprehensive Medical Management)

The inaugural meeting of the Quality Committee was held June 2. The Committee

considered important issues relating to referral and prior authorization processes.

The Department of Health Care Services conducted full-scope validation Facility Site

Reviews on May 24, 25, and 26 at 17 contracted PCP offices/clinics. Some minor

issues were identified at a few of the sites and were immediately resolved to the

reviewers’ satisfaction. The sites were prepared even while juggling other critical

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activities (i.e., VCMC had JCAHO on site at the same time). GCHP recognized the

sites with Certificates of Appreciation.

Health Services staff have scheduled meetings with the case management and

discharge planning departments at all hospitals in Ventura County to discuss

workflows and processes for continued stay review, discharge planning, coordination

of care and UM/CM needs.

Discussions have been held with long-term care facilities focused on their needs and

services and program coordination.

A small number of local independent pharmacies continue to voice concerns about

reimbursement rates. A follow-up letter from ScriptCare is included with this report.

On June 9, the Pharmacy and Therapeutics Committee reviewed the formulary and is

recommending approval by the Commission.

FINANCE (Optimize Rates, Ensure Long-Term Viability)

Our Claims Management department continues to implement the claims testing

program and remediate issues.

Procedures for Claims training and operational readiness continue to be developed.

A six week training program for ACS Claims Examiners dedicated to GCHP is in

process.

We have finalized language to accompany the Explanation of Benefits that

accompanies fee-for-service payments.

Secured a revolving line of credit in the amount of $500,000 from Rabobank.

Obtained renewal policies for Director’s and Officer’s insurance.

Secured Errors and Omissions policy.

Verified renewal of: Crime Insurance, Worker’s Compensation, and General

Commercial Liability coverage which is provided via Regional Government Services.

With the assistance of an insurance broker (Beecher Carlson), a vendor for “HMO

Specific Excess of Loss” Reinsurance has been identified. A presentation is included

in this month’s agenda for the Commission’s review and action.

GO-LIVE STATUS

As of June 24, 92% of our “deliverables” have been approved by the State.

Respectfully submitted,

Earl G. Greenia

Chief Executive Officer

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3a-1

Gold Coast Health Plan

Cash Flow Projection- Pre-operational Period

January, 2011 through June 2011

January February March April May June

Cumulative Enrollment 0 0 0 0 0 0

Total Staff 14 19 24 27 32 33

Incremental Staff Increase 5 5 5 3 5 1

Beginning Cash Balance 443,102 327,432 339,823 56,936 308,705 229,556

Cash In-Flow

Revenue from State

Other Funding

277

12,584

Short Term Loan

Subordinated Debt

ACS - LOC*

265,000

-

595,000

300,000

780,000

Total Receipts - 265,000 277 595,000 12,584 1,080,000

Total Cash 443,102 592,432 340,100 651,936 321,289 1,309,556

Cash Out-Flows

Health Care Payments

Premium Tax

Total Health Care - - - - - -

Salaries & Benefits 33,192 114,520 149,272 200,481 - 520,867

Other Benefits 1,070 - -

Consultants & Temp Labor 6,450 2,525 12,507 16,587 10,098 10,000

RGS Fees*

3,234 4,676

13,000

Occupancy Office Lease

- 43,920

14,640

Furniture & Equipment 13,385 30,372 7,740 - - -

Computers & Equipment (Capitalized)

18,575 11,188 Computers, Monitors, Printers (Non- Capitalized) 595 50,638 4,084 1,493 32,813 6,000

Telecommunications Equipment

5,965 14,066 2,473

2,125

Info Systems - License Fees & Maintenance 38,700

-

Info Systems - Software

3,333 3,333 - 3,334

Travel & Entertainment

2,940 2,730 - -

Supplies 4,461 8,604 6,421 3,239 2,700 9,600

Dues & Publications

16,850 3,000 428 500

Phone/Internet

104 406 511 197 200

Outreach & Education

370 2,280 32,169 680,500

Insurance

-

20,000

Legal fees 2,996 11,200 6,814 2,801 2,187 2,500

Actuary fees 14,600 27,527 26,828 19,302 7,518 7,500

Other fees

19,368

-

Miscellaneous Operating Expenses 1,291 1,154 8,654 5,849 3,623 2,000

Sub Total Administrative Expense 115,670 252,609 283,164 343,231 91,733 1,292,766

ENDING CASH BALANCE

327,432

339,823

56,936

308,705

229,556

16,790

Notes:

- RGS payments are made two month in arrears from the invoiced due date. At June 30th accrued payroll and fees will be ~ $890K.

- Assumes $300K additional funding is obtained.

- Capitation is paid at the beginning of the month following the month of eligibility - estimated cash outflow for month of start up is ~$475K (excluding vendor payments)

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HMO Reinsurance


June 27, 2011

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Why should Gold Coast Health Plan

buy Reinsurance?

1. Financial Protection – Reinsurance can protect GCHP’s financial position from unpredicted catastrophic claim costs.

2. Predictability - Reinsurance can create predictable financial results year over year

3. Regulatory Requirement

Risk Based Capital offset

Smoothing effect of reinsurance on a start-up plan

4. Value added services - Reinsurers bring cost reduction strategies to high-cost claim situations:

Transplant Networks

Catastrophic Claims Management

Complex Claim Review and Bill Audits

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Market Summary

Managing General Underwriter / Carrier

Best's

Rating

Quoted

Did Not Quote

Comments

OneBeacon Insurance Company

A

HCC Life

A+

BEL / American Fidelity Assurance

A+

Quoted Indication Only

RGA

A+

Star Line / Lloyds of London

A+

Not interested in Start-up

Midwest Risk / U.S. Fire

A

Risk is too large

Presidio / ACE American

A+

Not interested in Start-up

IOA Re

A

Not Interested in Risk

Munich Re

A+

Not interested in Risk

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Original Rates Proposed

Gold Coast Health Plan Premium Comparison Summary

Deductible M edi-Cal Family/Adult M edi-Cal (All Other) Totals Composite*

Rate PM PM Estimated Annual

Premium


Premium

Estimated Annual Premium

Rate PM PM

$250,000

American Fidelity Assurance $2.69 $2,248,560 $2.69 $894,963 $3,143,523 $2.69

RGA $2.29 $1,914,202 $6.87 $2,285,649 $4,199,851 $3.59

$300,000


RGA $1.82 $1,521,331 $5.47 $1,819,869 $3,341,200 $2.86

$350,000

OneBeacon $1.04 $869,332 $1.04 $346,008 $1,215,340 $1.04


$400,000

OneBeacon $0.84 $702,153 $0.84 $279,468 $981,621 $0.84


$450,000

OneBeacon $0.63 $526,614 $0.63 $209,601 $736,215 $0.63


HCC Life $2.17 $1,813,894 $2.17 $721,959 $2,535,853 $2.17

Estimated Membership

M edi-Cal (Family/Adult) 69,658

M edi-Cal (All Other) 27,725 *Composite Rate is for illustration only.

Total: 97,383

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Final Rates

Gold Coast Health Plan Premium Comparison Summary

Deductible M edi-Cal Family/Adult M edi-Cal (All Other) Totals


Premium


Premium

Estimated Annual Premium

$350,000

OneBeacon

$0.91

$760,665

$0.91

$302,757

$1,063,422

$400,000

OneBeacon

$0.73

$610,204

$0.73

$242,871

$853,075

$450,000

OneBeacon

$0.54

$451,384

$0.54

$179,658

$631,042

Estimated Membership

M edi-Cal (Family/Adult) 69,658

M edi-Cal (All Other) 27,725

Total: 97,383

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Coverage Summary

EFFECTIVE DATE: 12 months beginning July 1, 2011

DEDUCTIBLE: $350,000 per member per year

PREMIUM RATE: $0.91 per member per month

CLAIM REPORTING REQUIREMENTS: Incurred in 12 Months

Paid/Reported in 18 Months Filed in 21 Months

MAXIMUM LIMIT: $2,000,000 per member per year

COINSURANCE: 90%

CARRYOVER: 31 days (upon renewal with same carrier)

REIMBURSEMENT: Designed to mirror Gold Coast Health Plan contracted rates and exposures. Reimbursement based on GCHP contracted rates or if no contract, Medi-Cal Allowable.

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COVERED EXPENSES: EXCLUDED EXPENSES:

Hospital Inpatient Retail Rx (Over The Counter Prescription Drugs)

Hospital Outpatient Professional Services (except Transplant Case Rate)

Long Term Care Facility Insolvency

Rehabilitation Services Conversion

Home Health Care Services

Skilled Nursing Facility

Extended Care Facility

Pharmaceuticals

Durable Medical Equipment

Ambulance

For Summary Purposes Only. Refer to OneBeacon agreement for complete description of coverage.

To: Earl Greenia


Date: June 14, 2011

From: Tin Kin Lee

Re: Vote on Auto-Assignment Policy

TIN KIN LEE LAW OFFICES 55 South Lake Avenue | Suite 705 | Pasadena, CA 91101

626-229-9828 office | 626-229-9820 fax | [email protected]

M E M O R A N D U M


I.

QUESTIONS PRESENTED AND SHORT ANSWERS

Q: Can a Commissioner of Gold Coast Health Plan (“GCHP”) cast a vote to adopt or

amend an agenda item relating to procedures for “auto-assigning” GCHP members to

“safety net providers” or “traditional providers,” when such Commissioner has a

financial interest in the decision (e.g., as an investor, director, officer, employee of a

contracted safety net or traditional provider)?

A: No. If a Commissioner has a financial interest in the decision (e.g., as an investor,

director, officer, employee of a contracted safety net or traditional provider), then

that Commissioner may not cast a vote to adopt or amend the corresponding

agenda item.

Q: If one or more of the Commissioners who voted on the agenda item on auto-assignment

were disqualified due to the presence of a conflict of interest, then what procedures

should be followed?

A: Two alternatives may be considered: (1) Re-vote the item using the concept of

“legally required participation”; or (2) do not re-vote the item, but instead,

delegate the authority to accept or amend the recommendations of the study

group.

Memo re vote on auto-assignment 6-14-11 v2 -1-

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mailto:[email protected]

TIN KIN LEE

LAW OFFICES

Q: Can the Chair vote on the auto-assignment agenda item regardless of whether there is a

tie?

A: The Chair is not prohibited from voting at any time.

II.

FACTS

At GCHP‟s regular meeting of Commissioners held on May 23, 2011, Agenda

item 4.a was to approve the “Auto-Assignment Study Group Recommendations” which would

thereupon become GCHP‟s policy on auto-assignment. The study group that developed the

recommendations included health care providers from the community who are not

Commissioners.

The recommendations, as originally presented to the Commissioners, included the

following provisions:

Defined “Safety Net Provider,” “Traditional Provider” and “Non-Traditional

Provider.”

Limited assignment by GCHP of auto-assigned members to Safety Net Providers

and Traditional Providers only.

Weighted the assignment between Safety Net Providers and Traditional Providers

as follows: “Safety Net Providers will be assigned two members for every one

member assigned to Traditional Providers.”

Following discussion among the Commissioners, a motion to amend the study

group recommendations was made by Commissioner Juarez (and seconded by Commissioner

Gonzalez) to change the weighting such that “Safety Net Providers will be assigned three

[instead of two] members for every one member assigned to Traditional Providers.” Five

Commissioners (i.e., Commissioners Araujo, Gonzalez, Juarez, Long and Rodriguez) voted in

favor of the motion to amend the study group recommendations, while the remaining three


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TIN KIN LEE

LAW OFFICES

Commissioners (i.e., Chairman Dial and Commissioners Berry and Jarvis) voted against the

motion to amend.1

Although counsel indicated at the meeting that the motion to amend had carried,

upon further consideration regarding the possible financial interests which certain

Commissioners may have in GCHP‟s Auto-Assignment Policy and the impact which such

financial interests would have on their ability to vote on the Auto-Assignment Policy, the

analysis set forth in this memorandum was prepared.

III.

ANALYSIS

A. The Political Reform Act prohibits a Commissioner’s participation in a decision in

which the Commissioner has a conflict of interest.

Pursuant to Article XII of the GCHP bylaws, Commissioners are subject to the

conflict of interest rules set forth in the Political Reform Act of 1974 (Calif. Gov. Code, §87100

et seq.) (the “Political Reform Act”).2

Under the Political Reform Act, a Commissioner will be deemed to have a

conflict of interest if a decision has a “reasonably foreseeable material financial effect” on a

Commissioner‟s economic interests.3

1 Commissioners Chawla, Eberst and Fankhauser were absent from this meeting.

2 See GCHP bylaws, Art. XII:

“VCMMCC members [i.e., Commissioners] are subject to conflict of interest laws, including

Government Code section 1090 and the 1974 Political Reform Act (Government Code section

8100 et seq.), as modified by Welfare and Institutions Code section 14087.57, and must identify

and disclose any conflicts and refrain from participating in any manner in such matters in

accordance with the applicable statutes. Members of the VCMMCC agree to adhere to all

relevant standards established by state or federal law regarding ethical behavior.” (Emphasis

added.)

3 See Title 2, Calif. Code of Regulations (“CCR”), §18700.

“No public official at any level of state or local government may make, participate in making or

in any way use or attempt to use his/her official position to influence a governmental decision in


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TIN KIN LEE

LAW OFFICES

An “economic interest” includes (i) a direct or indirect investment worth $2,000

or more in a business entity; (ii) being a director, officer, partner, trustee, employee, or holding

any position of management in a business entity (or its parent or subsidiary); or (iii) any source

of income of $500 or more within 12 months prior to the time the decision is made.4

Exhibit A

sets forth some of the materiality standards that may be applicable regarding the agenda item‟s

financial effect on a Commissioner‟s economic interests.

For example, if the Auto-Assignment Policy would have a material financial

effect on a Commissioner‟s employer or source of income to the Commissioner (by increasing or

decreasing the applicable entity‟s revenues or expenses by an amount exceeding the stated

materiality threshold), then, that Commissioner may not “make, participate in making or in any

which he/she knows or has reason to know he/she has a disqualifying conflict of interest. A

public official has a conflict of interest if the decision will have a reasonably foreseeable material

financial effect on one or more of his/her economic interests, unless the public official can

establish either: (1) that the effect is indistinguishable from the effect on the public generally, or

(2) a public official's participation is legally required.” Also see Calif. Gov. Code, §87100

4 See, e.g., Calif. Gov. Code §87103:

“A public official has a financial interest in a decision within the meaning of Section 87100 if it is

reasonably foreseeable that the decision will have a material financial effect, distinguishable from

its effect on the public generally, on the official, a member of his or her immediate family, or on

any of the following:

“(a) Any business entity in which the public official has a direct or indirect investment worth two

thousand dollars ($2,000) or more.

“(b) Any real property in which the public official has a direct or indirect interest worth two

thousand dollars ($2,000) or more.

“(c) Any source of income, except gifts or loans by a commercial lending institution made in the

regular course of business on terms available to the public without regard to official status,

aggregating five hundred dollars ($500) or more in value provided or promised to, received by,

the public official within 12 months prior to the time when the decision is made.

“(d) Any business entity in which the public official is a director, officer, partner, trustee,

employee, or holds any position of management.

“(e) Any donor of, or any intermediary or agent for a donor of, a gift or gifts aggregating two

hundred fifty dollars ($250) or more in value provided to, received by, or promised to the public

official within 12 months prior to the time when the decision is made. The amount of the value of

gifts specified by this subdivision shall be adjusted biennially by the commission to equal the

same amount determined by the commission pursuant to subdivision (f) of Section 89503.”


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TIN KIN LEE

LAW OFFICES

way use or attempt to use his/her official position to influence” a decision involving the Auto-

Assignment Policy.

Thus, to the extent (i) one or more Commissioners are employed by, or hold an

economic interest or management position in, a “Safety Net Provider” or a “Traditional

Provider” (as such terms are defined in the study group recommendations), and (ii) the Auto-

Assignment Policy has a material financial effect on that “Safety Net Provider” or “Traditional

Provider,” then, pursuant to the Political Reform Act, the applicable Commissioner would be

prohibited from voting to adopt or amend the Auto-Assignment Policy

B. Alternatives in the event of disqualification of one or more Commissioners.

Although on its face, it would seem a relatively simple fix to simply throw out the

disqualified votes and count only the disinterested votes from the May 23rd

meeting, this would

not be a viable option for various reasons, including the following:

If the Commissioner who made the motion to amend the auto-assignment agenda

item was disqualified, then, it would follow that the motion itself would be invalid

because a disqualified Commissioner would be prohibited from making,

participating in making or in any way using or attempting to use his official

position to influence a decision involving the Auto-Assignment Policy.

Introducing motions that might influence the direction of a decision on auto-

assignment would arguably constitute “participation in a decision” and would be

prohibited to a disqualified Commissioner. Thus, if the motion itself was invalid,

then a vote to approve or reject the invalid motion should likewise be of no effect.

If certain Commissioners were disqualified from casting their votes on May 23rd

,

then there may not have been a quorum present for purposes of voting on that

agenda item because disqualified Commissioners are not counted for purposes of

a quorum.5

For example, if seven Commissioners are required for a quorum, but

5

See 2 CCR §18702.1(b):


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TIN KIN LEE

LAW OFFICES

there were only four disinterested Commissioners, a quorum would have been

lacking for valid action.

Even if certain disqualified Commissioners could be counted towards a quorum

using the concept of “legally required participation” discussed below, certain

procedures would need to be complied with in advance, including the prior

disclosure of any conflict applicable to each Commissioner as it relates to that

item.

consideration:

In view of these issues, the following possible alternatives are proposed for

1. Alternative 1: Re-vote the auto-assignment agenda item using the concept of

“legally required participation.”

If the May 23rd

motion to amend the Auto-Assignment Policy and its

corresponding vote were invalid for the reasons discussed above, then, the original auto-

assignment agenda item could be resubmitted for vote using the concept of “legally required

participation” as follows:

The vote may be resubmitted to the Commission at such time as all disinterested

Commissioners are present (which may include certain of those Commissioners

who were absent from the May 23rd

meeting).6

“When an official with a disqualifying conflict of interest abstains from making a governmental decision in an open session of the agency and the official remains on the dais or in his or her

designated seat during deliberations of the governmental decision in which he or she is

disqualified, his or her presence shall not be counted toward achieving a quorum.”

6 See 2 CCR §18708(c)(2):

“[a disqualified Commissioner shall not be allowed] to vote if a quorum can be convened of

other members of the agency who are not disqualified under Government Code section 87100,

whether or not such other members are actually present at the time of the disqualification.”

(Emphasis added.)


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If the disinterested Commissioners are insufficient in number to constitute a

quorum, then, the disqualified Commissioners may be permitted to participate,

but only to the extent needed to constitute a quorum, and shall not be permitted to

vote.7

For example, if there are four disinterested Commissioners, then three

disqualified Commissioners would be counted for purposes of establishing a

quorum for that item.

If the total number of disinterested Commissioners does not constitute a majority

of the quorum, then, one or more disqualified Commissioners may be permitted to

vote as needed such that the number of voting Commissioners would constitute a

majority of the quorum.8

For example, if there are only three disinterested

Commissioners (which is less than the four out of seven needed to take action),

then, one of the three disqualified Commissioners may be permitted to vote in

addition to being counted for purposes of establishing a quorum for that item.

The existence and nature of the conflict for each disqualified Commissioner

would need to be disclosed orally during open session prior to the re-vote.9

7 See 2 CCR §18708(c)(3):

“participation [shall be required] by the smallest number of officials with a conflict that are

“legally required” in order for the decision to be made. A random means of selection may be used

to select only the number of officials needed. When an official is selected, he or she is selected

for the duration of the proceedings in all related matters until his or her participation is no longer

legally required, or the need for invoking the exception no longer exists.” (Emphasis added.)

Also see 61 Ops. Cal. Atty. Gen. 243 (1978):

“Accordingly, the Fair Political Practices Commission (FPPC) ruled that where three of five

members of a city board of building review were disqualified pursuant to section 87100, only one

of the three disqualified members could participate in the hearing in order to create a quorum.

(4 FPPC Opinions 13 (No. 77-007, February 7, 1978).) [FN10] In reaching this conclusion, the

FPPC held that the concept of „legally required participation‟ is to be narrowly construed so that

the impact of the resulting bias can be minimized.” (Emphasis added.)

8 However, a disqualified Commissioner shall not be permitted to vote for the purpose of breaking a tie.

See 2 CCR §18708(c)(1).

9 See 2 CCR §18708(b).


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2. Alternative 2: Do not re-vote the auto-assignment agenda item, but instead,

delegate the authority to accept or amend the recommendations of the study

group.

A re-vote utilizing disqualified Commissioners under Alternative 1 described

above may be used only “if there exists no alternative source of decision consistent with the

purposes and terms of the statute authorizing the decision.”10

However, an “alternative source of decision” may be deemed to exist if the

decision on the Auto-Assignment Policy is delegated by the Commissioners to the CEO, for

example, which would then bypass the need to re-vote the item under the concept of “legally

required participation” of disqualified Commissioners as described above.

C. The Chair is not prohibited from voting at any time.

The GCHP bylaws are silent on the issue of when the Chair may or may not vote,

however, the bylaws permit the use of Roberts Rules of Order (current edition) to resolve

questions of procedure that are not otherwise addressed in the bylaws.11

Roberts Rules of Order (10th Ed.) generally gives the Chair the same right to vote

as other Commissioners, but states that “the chair protects his impartial position by exercising his

voting right only when his vote would affect the outcome, in which case he can either vote and

thereby change the result, or he can abstain.”12

There is an exception, however, for “small boards or committees.” A “small

board” is a board where “there are not more than about a dozen members present.”

10

See 2 CCR §18708(a):

“A public official who has a financial interest in a decision may establish that he or she is legally

required to make or to participate in the making of a governmental decision within the meaning of

Government Code section 87101 only if there exists no alternative source of decision consistent

with the purposes and terms of the statute authorizing the decision.”

11 See Bylaws, Art. X, sec. (j).

12 Roberts Rules of Order (10th Ed.), Sec. 4, pp. 50-51.


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“The rules governing such [small board] meetings are different

from the rules that hold in other assemblies, in the following

respects:…

“The chairman can speak in discussion without rising or leaving the chair; and, subject to rule or custom within the particular board (which should be uniformly followed regardless of how many members are present), he usually can make motions and usually

votes on all questions.”13

Based on the foregoing, Dr. Dial‟s vote on the auto assignment agenda item in his

capacity as Chair was appropriate and should have been counted (subject to the validity of the

motion).

13 Roberts Rules of Order (10th Ed.), Sec. 49, pp. 470-471 (emphasis added).


4a-9

Exhibit A

FINANCIAL MATERIALITY STANDARDS

2 CCR § 18705.1 (Materiality Standard: Economic Interests in Business Entities):

(c) Indirectly involved business entities. The following materiality standards

apply when a business entity in which a public official has an economic interest is indirectly

involved in a governmental decision. If more than one of the following subdivisions is applicable

to the business entity in question, apply the subdivision with the highest dollar thresholds…

(2) If the business entity is listed on the New York Stock Exchange, or if not

listed on the New York Stock Exchange, for its most recent fiscal year had net income of no less

than $2.5 million, the financial effect of a governmental decision on the business entity is

material if it is reasonably foreseeable that:

(A) The governmental decision will result in an increase or decrease to the

business entity's gross revenues for a fiscal year in the amount of $500,000 or more; or,

(B) The governmental decision will result in the business entity incurring or

avoiding additional expenses or reducing or eliminating existing expenses for a fiscal year in the

amount of $200,000 or more; or,

(C) The governmental decision will result in an increase or decrease in the value

of assets or liabilities of $500,000 or more.

(3) If the business entity is listed on either the NASDAQ or American Stock

Exchange, or if not so listed, for its most recent fiscal year had net income of no less than

$750,000, the financial effect of a governmental decision on the business entity is material if it is

reasonably foreseeable that:

(A) The governmental decision will result in an increase or decrease to the






of assets or liabilities of $300,000 or more.

(4) If the business entity is not covered by subdivisions (c)(1)-(3), the financial

effect of a governmental decision on the business entity is material if it is reasonably foreseeable

that:

(A) The governmental decision will result in an increase or decrease in the



4a-10





of the business entity's assets or liabilities of $20,000 or more.


4a-11

To: Ventura County Medi-Cal Managed Care Commission From: Earl Greenia, CEO

Date: May 23, 2011

RE: Auto-Assignment Policy BACKGROUND After establishing eligibility and upon enrollment into the plan, members are requested to select a Primary Care Provider (Physician or Clinic). In the event that a member does not timely select a PCP, the plan will assign the member to a provider. The Commission requested that a study group review issues related to the definition of “traditional provider” and the policy for auto assignment.

RECOMMENDATION The study group met on April 20, 2011 and again on May 18 to discuss the issue. It was recognized that a member has the right to change his/her Primary Care Physician whether self- selected or “auto-assigned” by notifying the plan, thus preserving the member’s freedom of choice. It was also recognized that the assignment process must give appropriate consideration to various member-specific factors, such as: zip code of Member’s residence, age, gender, and language.

The group developed the following recommendations:

1) That “Safety Net Provider” refers only to recognized disproportionate share hospitals (DSH), federally qualified health centers (FQHC), and rural health centers (RHC).

2) That “Traditional Provider” refers to those providers that have served Ventura County Medi-Cal beneficiaries for at least three years, and with a patient population / payor mix of at least 30% Medi-Cal and/or uninsured/charity care.

3) That “Non-Traditional Provider” refers to those providers that have served Ventura County Medi-Cal beneficiaries for at least one year.

4) That participation in the auto-assignment panel is limited to Safety Net Providers or Traditional Provider as defined above.

5) That assignment be weighted: Safety Net Providers will be assigned two members for every one member assigned to Traditional Providers.

4a-12

AGENDA ITEM 4-B

To: Ventura County Medi-Cal Managed Care Commission

From: Earl Greenia, CEO

Date: June 27, 2011

Re: Pharmacy & Therapeutics Committee Appointments Recommendation: Management requests that the Commission formally appoint additional members to the Pharmacy & Therapeutics Committee as recommended below.

Background: On April 26, 2010, the Commission established parameters for the Pharmacy & Therapeutics. No committee size was established. Each member serves a two-year term and may reapply for additional terms. Chaired by the Chief Medical Officer, the committee includes physicians from major disciplines, including primary care and specialty practices. Participants are bound by confidentiality and conflict of interest rules. In March, the Committee appointed eight members.

Discussion: As we started working on the formulary, the need for additional expertise arose and five additional members were recruited:

Ravi Bajwa, M.P.H., M.D., (Pulmonary Medicine), On staff at VCMC.

Daniel Clark, M.D. (Cardiology), Director of Medicine and Cardiology, VCMC since 1993. Clinical Professor of Family Medicine, UCLA.

Robert Fuladi, Pharm. D., Vice President, Clinical Pharmacist for Coastal Pharmaceutical Services Corporation since 2006. Vice President, Pharmacy Manager for Mission Health Care Pharmacy Corporation since 2000. Received a Bachelor of Science from Massachusetts College of Pharmacy in 1993 and a Doctor of Pharmacy from the University of Kansas in 2006.

Gary Nishida, M.D. (OB/Gyn), In private practice in Oxnard since 1984.

Pari Young, M.A., M.D. (Neurology), Las Posas Family Medicine Group.

AGENDA ITEM 4-C



Date: June 27, 2011

Re: Credentialing Committee Appointments Recommendation: Management requests that the Commission appoint additional members to the Credentialing Committee as recommended below.

Background: On April 26, 2010, the Commission established parameters for the Credentialing Committee. The committee will consist of a minimum of 8 voting members, appointed by the Commission and representative of the composition of the contracted provider network. Each of the appointed members serves a two-year term and may reapply for additional terms, as there are no term limits. Chaired by the Chief Medical Officer, the committee includes physicians from major disciplines, including primary care and specialty practices. The committee has the option of inviting additional specialists, if necessary, to review case records, either in writing or in person. Participants are bound by confidentiality and conflict of interest rules. In February, the Committee appointed seven members.

Discussion: Dr. Cho has identified two additional candidates for our Credentialing Committee:

Gary J. Proffett, M.D. has been the Medical Director of Sea View IPA since 2000. He is a graduate of Universidad Autonoma de Guadalajara and completed his post-graduate training at State University of New York in Buffalo and St. Agnes Hospital in Baltimore, Maryland. He was in private practice (General/Family Medicine) from 1978 to 2000 in Granada Hills. During that time he held numerous Medical Directorships and Utilization Review Committee appointments at various hospitals and organizations including Granada Hills Community Hospital, Southern California IPA, Prudential Health Care, Astoria Convalescent hospital, and the Huntington Provider Group IPA. Dr. Proffett serves as Medical Director at several long-term care facilities in the county, such as Maywood Healthcare and Country Villa both of Oxnard and Vitas Hospice, Roze Room Hospice, Victoria Care Convalescent and Braewood Home Health Inc.

Lee Wan, M.D., is the Medical Director of the Coastal Eye Specialists Medical Group and has been in private practice in Oxnard since 1988. He is a graduate of Loma Linda University School of Medicine with his specialty training at USC. He was a Past President of the St. John’s Regional Medical Center Medical Staff where he served on numerous committees, including: Credentials, Quality Management and Quality Improvement. Currently, he serves on the Bylaws Committee and the Physician Support Committee. He is a delegate to the Organized Medical Staff Section of both CMA and AMA, while serving on the Board of Governors of Ventura County Medical Association. In addition, Dr. Wan has been serving as the Executive Vice

President of the Ventura County Ophthalmology Society since 2006.

4c-1

AGENDA ITEM 4-D



Date: June 27, 2011

Re: Quality Assurance / Utilization Review / Peer Review Committee Appointments Recommendation: Management requests that the Commission appoint two additional members to the Committee as recommended below.

Background: On April 26, 2010, the Commission established broad parameters for this Committee. Each of the appointed members serves a two-year term and may reapply for additional terms, as there are no term limits. Chaired by the Chief Medical Officer, the committee includes physicians from major disciplines, including primary care and specialty practices. Participants are bound by confidentiality and conflict of interest rules. In March the Commission appointed 11 members.

Discussion: Dr. Cho identified two additional candidates who bring additional needed expertise:

Gary Proffett, M.D. (Family Medicine) - Sea View IPA Medical Director since 2000 and Medical Director for several Long Term Facilities

Victor Pulido, D.O. (Family Medicine) - Center for Family Health – CMH since 1998. Family Practice Residency, Riverside General Hospital, 1992.

4d-1

AGENDA ITEM 4-E



Date: June 27, 2011

RE: Advisory Committee Appointment Recommendation: Management recommends that the Commission fill a vacancy on the Provider Advisory Committee created by a recent resignation.

Background: On January 24, 2011, the Commission appointed the initial Committee membership with Dr. Gary Jacobs (Optometrist) as the “Non-Physician Practitioner” representative. Unfortunately, Dr. Jacobs has resigned.

Discussion: Management recommends the appointment of Dr. Clive Salmon (podiatrist) to fill the vacancy. His brief biography follows:

Dr. Salmon earned a Bachelor’s degree in Biology from Long Beach State University and graduated from the California College of Podiatric Medicine in 1979. He has been in private practice in Oxnard since 1980 and served as the staff podiatrist for Camarillo State Hospital from 1984 to its closure in 1996.

4e-1

List of Covered Drugs

Effective

July 1, 2011

4f-1

INTRODUCTION We are pleased to provide the 2011 Gold Coast Health Plan List of Covered Drugs as a useful reference and informational tool. The GCHP List of Covered Drugs can assist practitioners in selecting clinically appropriate and cost effective products for their patients.

The information contained in the GCHP List of Covered Drugs is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This List of Covered Drugs is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in this List of Covered Drugs is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov

PREFACE The GCHP List of Covered Drugs is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the GCHP List of Covered Drugs. Generics should be considered the first line of prescribing.

Drugs represented in the GCHP List of Covered Drugs may have varying cost to the plan member based on the plans benefit structure. Generic medications typically are available at the lowest cost, brand-name medications on the GCHP List of Covered Drugs will generally cost more than generics, and brand-name medications not on the list will generally cost the most.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the GCHP Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts. The P&T Committee's voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. However, not all strengths or dosage forms of the generic name in may be generically available. The GCHP List of Covered Drugs is a mandatory generic drug list. So whenever a generic to a covered agent becomes available, it is added. And if the branded agent was part of the cover drug list, the branded agent will be removed from the covered drug list.

Generic drugs are usually priced lower than their brand-name equivalents. Generic drugs are:

• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the

same strict standards that apply to brand-name drugs.

• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

• Manufactured in the same strength and dosage form as the brand-name drugs.

• When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence).

i

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http://www.guideline.gov/

SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM)

SGM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. The utilization management program is available for all therapeutic areas dispensed by our specialty pharmacies. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the GCHP List of Covered Drugs under the heading of “Specialty Medications” for your reference. SGM may also be combined with Inventory Management/ Dose Optimization and Optimal Drug Mix through High Performance Specialty Design to appropriately manage specialty medications.

PLAN DESIGN The GCHP List of Covered Drugs is a closed drug list plan design. The medications listed on the drug list are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Step Therapy, LMN, CPA, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity.

Should it become necessary to write a prescription for a drug, which is not on the GCHP List of Covered Drugs, one must obtain clinical prior authorization.

LEGEND CPA Clinical Prior Authorization LMN Letter of Medical Necessity QL Quantity Limit STEP Step Therapy

OTC Over the Counter

The GCHP List of Covered Drugs allows members to receive up to 10 prescriptions per month. The items below are exempt from the monthly limitation:

1. Nursing home patients

2. Newborns using their mother's ID

3. Antibiotics

4. Contraceptives

5. Meds for cancer treatment

6. Meds for diabetes

7. Meds for transplant patients

8. Individual medications or medication classes as determined by GCHP 9. Individual members with multiple chronic illnesses as determined by GCHP on a case-by-case basis

DRUG COST KEY

$ $1 to $10 $$ $11 to $50 $$$ $51 to $100 $$$$ $101 to $500 $$$$$ $501 to $1,000 $$$$$$ $1,001 to $5,000

$$$$$$$ $5,001 to $10,000

ii

4f-3

EXCLUDED THERAPEUTIC CLASSES AND DRUGS FROM GCHP LIST OF COVERED DRUGS These therapeutic classes of drugs are carved out from the GCHP List of Covered Drugs. This means that when one of these medications is prescribed, it will be filled by the pharmacist, who in turn will bill the State of California for reimbursement.

DEPENDENCTY TREATMENT Buprenorphine HCl

Acamprosate Calcium Naltrexone HCl

Buprenorphine HCl-Naloxone HCl Naltrexone

HIV Amprenavir Tipranavir Efavirenz-Emtricitabine-Tenofovir DF Lamivudine-Zidovudine Indinavir Sulfate Emtricitabine Lamivudine Abacavir Sulfate-Lamivudine Saquinavir

Enfuvirtide

Etravirine Saquinavir Mesylate Raltegravir Potassium Lopinavir-Ritonavir Fosamprenavir Calcium Ritonavir Darunavir Ethanolate Delavirdine Mesylate Zidovudine Atazanavir Sulfate Maraviroc

Efavirenz Abacavir Sulfate-Lamivudine- Zidovudine Emtricitabine-Tenofovir Disoproxil Fumarate Nevirapine Tenofovir Disoproxil Fumarate Stavudine Abacavir Sulfate

ERECTILE DYSFUNCTION

PSYCHIATRIC Amantadine HCl Aripiprazole Asenapine Maleate Benztropine Mesylate Biperiden HCl Chlorpromazine HCl Chlorprothixene Clozapine Fluphenazine Decanoate

Fluphenazine Enanthate Fluphenazine HCl Haloperidol Haloperidol Decanoate

Haloperidol Lactate

Iloperidone Isocarboxazid Lithium Carbonate Lithium Citrate Loxapine HCl Loxapine Succinate

Mesoridazine Besylate Molindone HCl Olanzapine Olanzapine-Fluoxetine HCl Olanzapine Pamoate Paliperidone Paliperidone Palmitate

Perphenazine

Phenelzine Sulfate Pimozide Procyclidine HCl Promazine HCl Quetiapine Risperidone Selegiline TD Patch Thioridazine HCl Thiothixene Thiothixene HCl

Tranylcypromine Sulfate Trifluoperazine HCl Ziprasidone HCl

Ziprasidone Mesylate

NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Gold Coast Health Plan.

When viewing the GCHP List of Covered Drugs via the Internet, please be advised that the GCHP List of Covered Drugs

is updated periodically and changes may appear prior to their effective date to allow for client notification.

iii

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GCHP List of Covered Drugs

Therapeutic Category

Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA

ANESTHETICS TOPICAL ANESTHETICS LIDODERM Lidocaine Patch 5% Generic $$$$$ XYLOCAINE Lidocaine HCl 2% gel, 5% onit Generic $$ XYLOCAINE Lidocaine HCl Viscous 2% Generic $$ ANTIINFECTIVES ALLYLAMINE CLOTRIMAZOLE

Clotrimazole Vaginal, Topical, Troches Generic $ to $$$$

LAMISIL Terbinafine Oral 250mg Generic $$$$ NIZORAL Ketoconazole Topical Generic $$ NYSTATIN Nystatin Swish and Swallow Generic $$ TERCONAZOLE Terconazole Vaginal Generic $$ AMINOGLYCOSIDES AMIKIN Amikacin IV Generic $$$$ QL= 14 days

GARAMYCIN Gentamicin IM or IV Generic $$ QL= 14 days

NEOMYCIN Neomycin Sulfate ‐Oral 500mg Generic $$$$ QL= 2 tabs/30 days

TOBREX Tobramycin IV Generic $$$ QL= 14 days

VANCOCIN Vancomycin Oral, IV Generic $$$ AMINOPENICILLINS AMOXIL Amoxacillin‐Oral Generic $$ AMPICILLIN Ampicillin IV

125mg, 250mg, 500mg, 1g, 2g 10g

, Generic $$$ LMN

AUGMENTIN Amoxacillin/Clavulanate‐Tabs,

Susp Generic $$$

UNASYN Ampicillin/Sulbactam IV Generic $$$ LMN

ANTIBIOTICS BACTROBAN Mupirocin Generic $$ NEOSPORIN Neomycin/Polymyxin Gramicidin Generic $$ ANTIFUNGALS GRIS‐PEG Griseofulvin Oral 125mg, 250mg Generic $$ NYSTOP Nystatin Topical Powder Generic $$ ANCOBON Flucytosine Oral 250mg, 500mg Brand $ LMN

ANTI‐MYCOBACTERIAL ISONIAZID Isoniazid Oral Generic $$ MYAMBUTOL Ethambutol Oral 100mg, 400mg Generic $$$ PYRAZINAMIDE Pyrazinamide Oral 500mg Generic $$$ RIFADIN Rifampin Oral 150mg, 300mg Generic $$$ ANTIPARASITICS ACTICIN Permethrin Lotion 1% Generic $$ ARALEN Chloroquin Phosphate Oral 250mg Generic $$$ DAPSONE Dapsone Oral 25mg, 100mg Generic $$ MEBENDAZOLE Mebendazole Oral 100mg Generic $$$ OVIDE Malathion Lotion 0.50% Generic $$$$ PLAQUENIL Hydroxychloroquine Sulfate 200mg Generic $$$ PRIMAQUINE Primaquine Oral 26.3mg Generic $$$$ ALBENZA Albendazole Oral 200mg Brand $$$$ ALINIA Nitazoxanide Oral 500mg Brand $$$$$ BILTRICIDE Praziquantal Oral 600mg Brand $$$ STROMECTOL Ivermectin Oral 3mg Brand $$$$ YODOXIN Iodoquinol Oral 210mg, 650mg Brand $$$$ ANTI‐PSEUDOMONAL PCN ZOSYN Pipercillin/Tazobactam IV Generic $$$$ LMN

ANTI‐VIRAL CYTOVENE Gancyclovir IV 500mg Generic $ LMN

FAMVIR Famcyclovir Oral 125mg, 250mg, 500mg Generic $$$$ RIBAPAK Ribavirin Oral 400mg, 600mg Generic $$$$ Specialty

SYMMETREL Amantadine Oral Generic $$$ VALTREX Valacyclovir HCl 500mg, 1g Generic $$$$ CPA

ZOVIRAX Acyclovir Oral, IV Generic $$$$ LMN; IV only

RELENZA Zanamivir Oral 5mg Brand $$$ QL= 20 tabs/30 days

TAMIFLU Oseltamir Oral 30mg, 45mg, 70mg Brand $$$$ QL= 10 caps (45mg, 75mg) 20 caps

(30mg) 100ml/30 days (oral susp)

BURN PRODUCTS SILVADENE Silver Sulfadiazine Generic $$$ CARBAPENAM INVANZ Ertapenem IV Generic $$$$$ LMN

MERREM Meropenem IV Generic $$$$ LMN

PRIMAXIN Imipenem/Cilastin IV Generic $$$$$ LMN

CEPHALOSPORINS 1ST GENERATION

ANCEF Cefazolin Generic $$$ KEFLIN Cephalothin‐Oral Generic $$$

CEPHALOSPORINS 2ND GENERATION

CEFOTAN Cefotetan‐IV Generic $$$ LMN

CEFTIN Cefuroxime IV, Oral Generic $$$ LMN

MEFOXIN Cefoxitin‐IV Generic $$ LMN

CEPHALOSPORINS 3RD GENERATION

CLAFORAN Cefotaxime IV Generic $$$ LMN

FORTAZ Ceftazidime IV Generic $$$ LMN; Specialty

ROCEPHIN Ceftriaxone IV Generic $$$ VANTIN Cefpodoxime proxetil‐Oral Generic $$$ LMN

CEPHALOSPORINS 4TH GENERATION

MAXIPIME Cefapime IV Generic $$ LMN

CLINDAMYIN CLEOCIN Clindamycin Oral, IV Generic $$$ LMN

ECHINOCANDINS CANCIDAS Caspofungin Acetate 50mg, 70mg Brand $$ LMN; Specialty

MYCAMINE Micafungin IV 50mg, 100mg Brand $$$ LMN

ERYTHROMYCIN EES Erythromycin Esthylsuccinate 400mg Generic $$$

ERYTHROCIN Erythromycin Stearate 25mg, 500mg Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-5

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FLUORDQUINOLONE BACTRIM DS Sulfamethoxazole/Trimethoprim Generic $$

CIPRO Ciprofloxacin Oral Generic $$$

FLAGYL Metronidazole Oral, IV Generic $$ to $$$$

LEVAQUIN Levofloxacin Oral Generic $$

MACRODANTIN Nitrofurantoin Macorcrystal Oral Generic $$

AVELOX Moxifloxacin Oral Brand $$$ LMN

CUBICIN Daptomycin IV 500mg Brand $$$$ LMN

VIBATIV Televancin IV 250mg, 750mg Brand $$$ LMN

ZYVOX Linezolid Oral, IV Brand $$$$$$ LMN; Specialty

HEP B & HEP C RIBAVIRIN Ribavirin Oral 200mg, 400mg, 600mg Generic $$$$ Specialty

EMTRIVA Emtricitabine Oral 200mg Brand $$$$$

EPIVIR Lamivudine Oral 150mg, 300mg Brand $$$$

INFERGEN Interferon Brand $$$$$$ Specialty

TYZEKA Telbivudine Oral 600mg Brand $$$$$

IMIDAZOLE ANTIFUNGALS NIZORAL Ketoconazole Oral 200mg Generic $$$

MACROLIDES BIAXIN Clarithromycin Oral Generic $$$

ZITHROMAX Azithromycin Oral Generic $$

QL= 28 tabs/14 days, Max 2

fills/30 days (250mg & 500mg);

280ml/14 days, Max 2 fills of

280ml/30 days (125mg/5ml &

250mg/5ml) CPA (600mg); QL= 8

tabs/10 days, Max 2 fills/30 days

(250mg); 4 tabs/10 days,Max 2

fills/30 days (500mg)

MONOBACTAM AZACTAM Aztreonam IV Generic $$$$$ LMN

PENICILLIN BICILLIN L‐A Benzathine IM Generic $$$$ LMN

PENICILLN GK Penicillin G IV Generic $$$ LMN

PENICILLN VK Penicillin VK‐oral Generic $$$

PENICILLINASE RESISTANT PCN DYCILL Dicloxacillin‐Oral Generic $$

NAFCILLIN Nafcillin IV Generic $$$$ LMN POLYENE

ANITFUNGALS AMBISOME Amphotericin B Liposome 510mg Brand $$$$ LMN; Specialty

TETRACYCLINE DOXYCYCLINE Doxycycline Oral Generic $$

TETRACYCLINE Tetracycline Oral Generic $$

TYGACIL Tigecycline IV 50mg Brand $$$$$ LMN

TRIAZOLE ANTIFUNGALS DIFLUCAN Fluconazole Oral 50mg, 100mg, 150mg, 200mg Generic $$$$ LMN

ANTINEOPLASTIC/

IMMUNOSUPRESSANT

ANTINEOPLASTIC/

IMMUNOSUPRESSANT

NOXAFIL Posaconazole Oral 40mg/ml Brand $$$$$ LMN

SPORANOX Itraconazole Oral 100mg Brand $$$$ LMN

ADRIAMYCIN Doxorubicin HCl 2mg/ml Generic $$$$

2.5g/50ml, 5g/100ml, ADRUCIL Fluorouracil

500mg/10ml Generic $$

ARIMIDEX Anastrozole 1mg Generic $$$$

AROMASIN Exemestane 25mg Generic $$$$ Step: anastrozole

CASODEX Bicalutamide 50mg Generic $$$$

CELLCEPT Mycophenolate Mofetil 250mg, 500mg Generic $$$$

50mg/50ml, 100mg/100ml, CISPLATIN Cisplatin

200mg/200ml Generic $$$

FASLODEX Fulvestrant 250mg/5ml Generic $$$$$$

FEMARA Letrozole 2.5mg Generic $$$$$

HALAVEN Eribulin Mesylate 1mg/2ml Generic $$$$$$

HYCAMTIN Topotecan HCl 4mg Generic $$$$$

HYDREA Hydroxyurea 500mg Generic $$$$

IFEX Ifosfamide 1 gm, 3 gm Generic $$$$$$

IMURAN Azathioprine 50mg Generic $$$$$

IXEMPRA Ixabepilone 15mg, 45mg Generic $$$$$$

JEVTANA Cabazitaxel 60mg/1.5ml Generic $$$$$$$

MATULANE Procarbazine HCl 50mg Generic $$$$$$$

MEGACE Megestrol Acetate 20mg, 40mg Generic $$$$$

1g, 1g/40ml, 25mg/ml, 50mg/2ml, MEXATE Methotrexate Sodium

250mg/10ml Generic $$$$$$

MITOMYCIN Mitomycin 5mg, 20mg, 40mg Generic $$$$$$

NEORAL Cyclosporine 25mg, 100mg Generic $$$$$$

NOLVADEX Tamoxifen Citrate 10mg, 20mg Generic $$$$

NPLATE Romiplostim 250mcg, 500mcg Generic $$$$$$

30mg/5ml, 100mg/16.7ml, ONXOL Paclitaxel

150mg/25ml, 300mg/50ml Generic $$$$$

PURINETHOL Mercaptopurine 50mg Generic $$$$

RHEUMATREX Methotrexate Sodium 2.5mg Generic $$$$

SANDIMMUNE Cyclosporine 50mg/ml Generic $$$$$$

TOPOSAR Etoposide 20mg/ml Generic $$$$$

TRISENOX Arsenic Trioxide 10mg/10ml Generic $$$$$

VELCADE Bortezomib 3.5mg Generic $$$$$$

VINBLASTINE Vinblastine Sulfate 1mg/ml Generic $$$$

VINCRISTINE Vincristine Sulfate 1mg/ml Generic $$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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TREANDA Bendamustine HCl 25mg, 100mg Brand $$$$ AUTONOMIC & CNS ANALGESICS BUTALBITAL Butalbital Generic $$

10mg/ml, 25mg/ml, 50mg/ml, DEMEROL Meperidine HCl

Generic $$$ CPA; QL= 120ml/30 days

DILAUDID Hydromorphone HCl 1mg, 2mg, 4mg, 8mg Generic $$$ QL= 120 tabs/30 days

12mcg, 25mcg, 50mcg, 75mcg,

DURAGESIC Fentanyl TD Patch

100mcg Generic $$$$ CPA; QL= 15/30days

FIORICET Butalbital‐Acetaminophen‐

Caffeine 50‐325‐40mg Generic $$

METHADONE Methadone HCl 5mg, 10mg, 40mg Generic $$$ CPA; QL= 120 tabs/30 days

MS CONTIN Morphine Sulfate 15mg, 30mg, 60mg, 10mg, 200mg Generic $$$ QL= 120 tabs/30 days

REPREXAIN Hydrocodone‐Ibuprofen 2.5‐200mg, 5‐200mg, 7.5‐200mg,

10‐200mg Generic $$$$ QL= 120 tabs/30 days

ROXICODONE Oxycodone HCl 5mg, 10mg, 15mg, 20mg, 30mg,

40mg, 80mg Generic $$$ QL= 120 tabs/30 days

TYLENOL/COD Acetaminophen w/ Codeine 300‐15mg, 300‐30mg, 300‐60mg Generic $$$ QL= 120 tabs/30 days

ULTRAM Tramadol HCl 50mg, 100mg, 200mg, 300mg Generic $$$$ QL= 120 tabs/30 days

2.5‐500mg, 5‐325mg, 5‐500mg, 7.5‐325mg, 7.5‐650mg, 7.5‐ VICODIN Hydrocodone‐Acetaminophen 650mg, 7.5‐750mg, 10‐300mg, 10‐ Generic $$$ QL= 120 tabs/30 days

325mg, 10‐500mg, 10‐650mg, 10‐ 660mg FENTORA Fentanyl Citrate

100mcg, 200mcg, 300mcg,

400mcg, 600mcg, 800mcg Brand $$$$$ CPA

OPANA ER Oxymorphone HCl 5mg, 7.5mg, 10mg, 15mg, 20mg,

30mg, 40mg Brand $$$$ QL= 120 tabs/30 days

OXYCONTIN Oxycodone HCl 10mg, 15mg, 20mg, 30mg, 40mg,

60mg, 80mg, 160mg Brand $$$$ CPA; QL= 120 tabs/30 days

ANTIANXIETY ATIVAN Lorazepam 0.5mg, 1mg, 2mg, Generic $$$ QL= 120tabs/30days

BUSPAR Buspirone HCl 5mg, 7.5mg, 10mg, 15mg, 30mg Generic $$$ QL= 120tabs/30days

LIBRIUM Chlordiazepoxide HCl 5mg, 10mg, 25mg Generic $$ QL= 120tabs/30days

TRANXENE‐T Clorazepate Dipotassium 3.75mg, 7.5mg, 15mg Generic $$ QL= 120tabs/30days

VALIUM Diazepam 2mg, 5mg, 10mg Generic $$ QL= 120tabs/30days

XANAX Alprazolam 0.25mg, 0.5mg, 1mg, 2mg Generic $$ QL= 120tabs/30days

ANTICONVULSANTS DEPAKOTE SPR Divalproex Sodium Sprinkle 125mg, 250mg, 500mg Generic $$$ DEPAKOTE, DEPAKOTE ER Divalproex Sodium 125mg, 250mg, 500mg Generic $$$ DILANTIN Phenytoin Sodium 100mg Generic $$ KEPPRA Levetiracetam

100mg/ml, 250mg, 500mg, 750mg, 1000mg

Generic $$$

KLONOPIN Clonazepam 0.125mg, 0.25mg, 0.5mg, 1mg,

2mg Generic $$

LAMICTAL Lamotrigine 25mg, 50mg, 100mg, 150mg,

200mg, 250mg Generic $$

MYSOLINE Primidone 50mg, 250mg Generic $$$ NEURONTIN Gabapentin

100mg, 300mg, 400mg, 600mg, 800mg

Generic $$$$

PHENOBARB Phenobarbital 15mg, 30mg, 32.4mg, 60mg,

100mg Generic $$

PHENYTEK Phenytoin Sodium 200mg, 300mg Generic $$ TEGRETOL Carbamazepine 200mg, 400mg Generic $$$ TOPAMAX Topiramate 25mg, 50mg, 100mg, 200mg Generic $$ TOPAMAX SPRINKLE Topiramate Sprinkle 15mg, 25mg Generic $$ TRILEPTAL Oxcarbazepine Suspension 300mg/5ml Generic $$$ ZONEGRAN Zonisamide 25MG,50mg, 100mg Generic $$ CARBATROL Carbamazepine 100mg, 200mg, 300mg Brand $$$$ KEPPRA XR Levetiracetam SR 500mg, 750mg Brand $$$ LAMICTAL XR Lamotrigine SR

25mg, 100mg, 150mg, 200mg, 300mg

Brand $$$$

LYRICA

Pregabalin

25mg, 50mg, 75mg, 100mg,

150mg, 200mg, 225mg, 300mg

Brand

$$$$

Step: gabapentin

VIMPAT

Lacosamide 50mg, 100mg, 150mg, 200mg,

10mg/ml

Brand

$$$$

ANTIDEMENTIA ARICEPT, ARICEPT ODT Donepezil Hydrochloride 5mg, 10mg, 23mg Generic $$$$ EXELON Rivastigmine Tartrate 1.5mg, 3mg, 4.5mg, 6mg Generic $$$$ EXELON PATCH Rivastigmine TD Patch 4.6mg/24HR, 9.5mg/24HR Brand $$$$ NAMENDA Memantine HCl 5mg, 5‐10mg, 10mg Brand $$$$ ANTIDEPRESSANTS ANAFRANIL Clomipramine HCl 25mg, 50mg, 75mg Generic $ CELEXA Citalopram Hydrobromide 10mg, 20mg, 40mg Generic $$ DESYREL Trazodone HCl 50mg, 100mg, 150mg, 300mg Generic $$

75mg/ml, 100mg/ml

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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EFFEXOR Venlafaxine HCl 25mg, 37.5mg, 50mg, 75mg,

100mg Generic $$

EFFEXOR ER Venlafaxine HCl SR 37.5mg, 75mg, 150mg, 225mg Generic $$$

ELAVIL Amitriptyline HCl

10mg, 25mg, 50mg, 75mg, 100mg,

150mg

Generic $$

LEXAPRO Escitalopram Oxalate 5mg, 10mg, 20mg Generic $$$$

Step: Failure of two: citalopram,

fluoxetine, fluvoxamine,

paroxetine, sertraline

LUVOX Fluvoxamine Maleate 25mg, 50mg, 100mg Generic $$$

MIRTAZAPINE Mirtazapine 7.5mg, 15mg, 30mg, 45mg Generic $$$

10mg, 25mg, 50mg, 75mg, 100mg, NORPRAMIN Desipramine HCl

150mg Generic $$

PAMELOR Nortriptyline HCl 10mg, 25mg, 50mg, 75mg Generic $$$

PAXIL Paroxetine HCl 10mg, 12.5mg, 20mg, 30mg, 40mg Generic $$

PROZAC Fluoxetine HCl 10mg, 20mg, 40mg, 90mg Generic $$

PROZAC WEEKLY Fluoxetine HCl 90mg Generic $$


fluoxetine, fluvoxamine,

paroxetine, sertraline

SERZONE Nefazodone HCl

SINEQUAN Doxepin HCl

50mg, 100mg, 150mg, 200mg,

250mg

10mg, 25mg, 50mg, 75mg, 100mg,

150mg

Generic $$$

Generic $$

TOFRANIL Imipramine HCl 10mg, 25mg, 50mg Generic $$

75mg, 100mg, 150mg, 200mg, WELLBUTRIN, WELLBUTRIN XL Bupropion HCl, Bupropion HCl SR

300mg Generic $$$

ZOLOFT Sertraline HCl 25mg, 50mg, 100mg Generic $$

APLENZIN Bupropion HBr 174mg, 348mg, 522mg Brand $$

CYMBALTA Duloxetine HCl 20mg, 30mg, 60mg Brand $$$$ Step: venlafaxine ER HCL

PRISTIQ Desvenlafaxine Succinate 50mg, 100mg Brand $$$ Step: venlafaxine ER HCL

SAVELLA Milnacipran HCl 12.5mg, 25mg, 50mg, 100mg Brand $$$$ LMN

ANTIEMETIC COMPAZINE Prochlorperazine Maleate 5mg, 10mg Generic $$

PHEREGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$

TIGAN Trimethobenzamide HCl 300mg/5ml Generic $$$

ZOFRAN Ondansetron HCl 4mg, 8mg, 24mg Generic $$$ QL= 30 tabs (4mg & 8mg); 1 tab

(24mg); per 30 days

EMEND Aprepitant 80mg, 115mg, 125mg, 150mg Brand $$$$ LMN: Specialty

KYTRIL Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml Brand $$$$ LMN: Specialty

CPA; QL= 3 bottles (sol); per 30 ZOFRAN Ondansetron HCl and Dextrose 32mg/50ml Brand $$$

ANTIPARKINSON COGENTIN Benztropine Mesylate 0.5mg, 1mg, 2mg Generic $$

0.125mg, 0.25mg, 0.5mg, 0.75mg,

days

MIRAPEX Pramipexole Dihydrochloride

REQUIP Ropinirole Hydrochloride

SINEMET Carbidopa & Levodopa

1mg

0.25mg, 0.5mg, 1mg, 2mg, 3mg,

4mg, 5mg

10‐100mg, 25‐100mg, 25‐250mg,

50‐200mg

Generic $$$

Generic $$

Generic $$$

AZILECT Rasagiline Mesylate 0.5mg, 1mg Brand $$$

COMTAN Entacapone 200mg Brand $$$$

LODOSYN Carbidopa 25mg Brand $$$

0.375mg, 0.75mg, 1.5mg, 3mg,

Step: Pramipexole

MIRAPEX ER Pramipexole Dihydrochloride SR 4.5mg

Brand $$$$ Dihydrochloride

REQUIP XL Ropinirole Hydrochloride SR 2mg, 4mg, 6mg, 8mg, 12mg Brand $$$$ Step: Ropinirole Hydrochloride

DRUGS TO TREAT HEADACHES AMERGE Naratriptan HCl 1mg, 2.5mg Generic $$$$ Step: Sumatriptan Succinate; QL=

9 tabs/30 days (1mg & 2.5mg)

IMITREX Sumatriptan Succinate 25mg, 50mg, 100mg Generic $$$

IMITREX Sumatriptan Succinate Injection 4mg/0.5ml, 6mg/0.5ml Generic $$$

AXERT Almotriptan Malate 6.25mg, 12.5mg Brand $$$

FROVA Frovatriptan Succinate 2.5mg Brand $$$$

MAXALT, MAXALT‐MLT Rizatriptan Benzoate 5mg, 10mg Brand $$$$

RELPAX Eletriptan Hydrobromide 20mg, 40mg Brand $$$$

SUMATRIPTAN Sumatriptan Nasal Spray 5mg/ACT, 20mg/ACT Brand $$$

ZOMIG NASAL SPRAY Zolmitriptan Nasal Spray 5mg Brand $$$$

QL= 9 tabs/30 days (25mg, 50mg,

& 100mg) QL= 1 kit/30 days (2

syringes); 2 vials/30 days Step:

Sumatriptan Succinate; QL=

9 tabs/30 days (6.25mg); 9

tabs/30 days (12.5 mg) Step:

Sumatriptan Succinate; QL=

9 tabs/30 days

Step: Sumatriptan Succinate; QL=

9 tabs/30 days


9 tabs/30 days

QL= 6 devices/30 days (5mg &

20mg spray) Step: Sumatriptan

Succinate; QL=

9 devices/30 days

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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ZOMIG, ZOMIG ZMT Zolmitriptan 2.5mg, 5mg Brand $$$$

NEUROMUSCULAR MESTINON Pyridostigmine Bromide 60mg, 60mg/5ml Brand $$$$


9 tabs/30 days

SEDATIVE/ HYPNOTIC AMBIEN Zolpidem Tartrate 5mg, 10mg, 6.25mg, 12.5mg Generic $$ QL= 30 tabs/30 days

RESTORIL Temazepam 7.5mg, 15mg, 30mg Generic $$ QL= 30 caps/30 days

SONATA Zaleplon 5mg, 10mg Generic $$ QL= 30 caps/30 days

STIMULANTS ADDERALL Amphetamine‐

Dextroamphetamine

5mg, 7.5mg, 10mg, 15mg, 20mg,

30mg Generic $$$ CPA; Age > 23

DESOXYN Methamphetamine HCl 5mg Generic $$$$ CPA; Age > 23

5mg, 10mg, 18mg, 20mg, 27mg, RITALIN Methylphenidate HCl

Amphetamine‐ 36mg, 54mg

Generic $$$$ CPA; Age > 23

ADDERALL XR Dextroamphetamine SR

5mg, 10mg, 15mg, 20mg, 30mg Brand $$$$$ CPA; Age > 23

CONCERTA Methylphenidate HCl 18mg, 27mg, 36mg, 54mg Brand $$$$$ CPA; Age > 23

2.5mg, 5mg, 10mg, 15mg, 20mg, FOCALIN, FOCALIN XR Dexmethylphenidate HCl

METADATE CD Methylphenidate HCl

30mg, 40mg

10mg, 20mg, 30mg, 40mg, 50mg,

60mg

Brand $$$$ CPA; Age > 23

Brand $$$$$ CPA; Age > 23

NUVIGIL Armodafinil 50mg, 150mg, 250mg Brand $$$$$ CPA; Age > 23

PROVIGIL Modafinil 100mg, 200mg, 300mg Brand $$$$$ CPA; Age > 23

RITALIN LA Methylphenidate HCl 10mg, 20mg, 30mg, 40mg Brand $$$$ CPA; Age > 23

10mg, 18mg, 25mg, 40mg, 60mg,

ANGIOTENSIN CONVERTING

STRATTERA Atomoxetine HCl

VYVANSE Lisdexamfetamine Dimesylate

80mg, 100mg

20mg, 30mg, 40mg, 50mg, 60mg,

70mg


Brand $$$$$ CPA; Age > 23

CARDIOVASCULAR ENZYME INHIBITORS

ACCUPRIL Quinapril HCl 5mg, 10mg, 20mg, 40mg Generic $$$

ALTACE Ramipril 1.25mg, 2.5mg, 5mg, 10mg Generic $$$

CAPOTEN Captopril 12.5mg, 25mg, 50mg, 100mg Generic $$$

LOTENSIN Benazepril HCl 5mg, 10mg, 20mg, 40mg Generic $$$

MONOPRIL Fosinopril Sodium 10mg, 20mg, 40mg Generic $$

VASOTEC Enalapril Maleate 2.5mg, 5mg, 10mg, 20mg Generic $$

ZESTRIL lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg Generic $$

ANGIOTENSIN II RECEPTOR

ANTAGONISTS

COZAAR Losartan Potassium 25mg, 50mg, 100mg Generic $$$$

AVAPRO Irbesartan 75mg, 150mg, 300mg Brand $$$$ Step: losartan potassium

BENICAR Olmesartan Medoxomil 5mg, 20mg, 40mg Brand $$$ Step: losartan potassium

DIOVAN Valsartan 40mg, 80mg, 160mg, 320mg Brand $$$ Step: losartan potassium

MICARDIS Telmisartan 20mg, 40mg, 80mg Brand $$$$ Step: losartan potassium

ANTIARRHYTHMICS BETAPACE Sotalol HCl 80mg, 120mg, 160mg, 240mg Generic $$$$

PACERONE Amiodarone HCl 200mg Generic $$$

RYTHMOL Propafenone HCl 150mg, 225mg, 325mg, 425mg Generic $$$$

TAMBOCOR Flecainide Acetate 50mg, 100mg, 150mg, 200mg Generic $$$$$

BETA‐ADRENERGIC ANTAGONISTS COREG Carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg Generic $$$$

CORGARD Nadolol 20mg, 40mg, 80mg Generic $$

20mg, 60mg, 80mg, 120mg, INDERAL Propranolol HCl

160mg Generic $$$

LOPRESSOR Metoprolol Tartrate 25mg, 50mg, 100mg Generic $$$

NORMODYNE Labetalol HCl 100mg, 200mg, 300mg Generic $$$

TENORMIN Atenolol 25mg, 50mg, 100mg Generic $$$

TOPROL XL Metoprolol Succinate 25mg, 50mg, 100mg, 200mg Generic $$$$

ZEBETA Bisoprolol Fumarate 5mg, 10mg Generic $$$$

CALCIUM ANTAGONISTS CARDENE Nicardipine HCl 20mg, 30mg Generic $$

CARDIZEM Diltiazem HCl

30mg, 60mg, 90mg, 180mg,

240mg, 120mg/24, 180mg/24,

240mg/24, 300mg/24, 360mg/24

Generic $$$$

ISOPTIN Verapamil HCl 40mg, 80mg, 180mg, 240mg Generic $$$

NORVASC Amlodipine Besylate 2.5mg, 5mg, 10mg Generic $$$

PROCARDIA Nifedipine 10mg, 20mg Generic $$

PROCARDIA XL Nifedipine SR 30mg, 60mg, 90mg Generic $$$$

SULAR Nisoldipine 8.5mg, 17mg, 25.5mg, 34mg, Generic $$$$

CARDIAC GLYCOSIDES LANOXIN Digoxin 0.125mg, 0.25mg Generic $$$

CENTRALLY ACTING

ANTIHYPERTENSIVES

COMBINATION

ALDOMET Methyldopa 250mg, 500mg Generic $$$$

CATAPRES Clonidine HCl 0.1mg, 0.2mg, 0.3mg Generic $$$

TENEX Guanfacine HCl 1mg, 2mg Generic $$$$

25‐15mg, 25‐25mg, 50‐15mg, 50‐

ANTIHYPERTENSIVES CAPOZIDE Captopril & Hydrochlorothiazide

Losartan Potassium & HYZAAR

Hydrochlorothiazide

LOTENSIN HCT Benazepril & Hydrochlorothiazide

25mg

50‐12.5mg, 100‐12.5mg, 100‐

25mg

5‐6.5mg, 10‐12.5mg, 20‐12.5mg,

20‐25mg

Generic $$$

Generic $$$

Generic $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-9

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LOTREL Amlodipine Besylate‐Benazepril

HCl

Fosinopril Sodium &

2.5‐10mg, 5‐10mg, 5‐20mg, 10‐

20mg Generic $$$

MONOPRIL HCT Hydrochlorothiazide

10‐12.5mg, 20‐12.5mg Generic $$$$

UNIRETIC Moexipril‐Hydrochlorothiazide 7.5‐12.5mg, 15‐12.5mg, 15‐25mg Generic $$$

VASERETIC

Enalapril Maleate &

Hydrochlorothiazide

5‐12.5mg, 10‐25mg Generic $$$$

ZESTORETIC Lisinopril & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$

AVALIDE Irbesartan‐Hydrochlorothiazide

Amlodipine Besylate‐Olmesartan AZOR

Medoxomil

Olmesartan Medoxomil‐

150‐12.5mg, 300‐12.5mg, 300‐

25mg

5‐20mg, 5‐40mg, 10‐20mg, 10‐

40mg

Brand $$$$ Step: losartan potassium HCT

Brand $$$$ Step: amlodipine

BENICAR HCT Hydrochlorothiazide

20‐12.5mg, 40‐12.5mg, 40‐25mg Brand $$$$ Step: losartan potassium HCT

DIOVAN HCT Valsartan‐Hydrochlorothiazide

80‐12.5mg, 160‐12.5mg, 160‐

25mg, 320‐12.5mg, 320‐25mg

Brand $$$$ Step: losartan potassium HCT

TRIBENZOR

Olmesartan‐Amlodipine‐

Hydrochlorothiazide

Brand $$$$ LMN

DIURETICS, LOOP BUMEX Bumetanide 0.5mg, 1mg, 2mg, Generic $$$

LASIX Furosemide 20mg, 40mg, 80mg Generic $$

EDECRIN Ethacrynic Acid 25mg Brand $$$ CPA

Spironolactone & DIURETICS, POTASSIUM SPARING ALDACTAZIDE

Hydrochlorothiazide 25/25mg Generic $$$

ALDACTONE Spironolactone 25mg, 50mg, 100mg Generic $$$

INSPRA Eplerenone 25mg, 50mg Generic $$$$

Triamterene & MAXZIDE

Hydrochlorothiazide 37.5‐25mg, 50‐25mg, 75‐50mg Generic $$$

DIURETICS, THIAZIDE & RELATED

DRUGS

HEPARIN & HEPARIN

MIDAMOR Amiloride HCl 5mg Generic $$$$ Step: spironolactone

HYDRODIURIL Hydrochlorothiazide 12.5mg, 25mg, 50mg Generic $$$

HYGROTON Chlorthalidone 25mg, 50mg, 100mg Generic $$$$

LOZOL Indapamide 1.25mg, 2.5mg Generic $$$

ZAROXOLYN Metolazone 2.5mg, 5mg, 10mg Generic $$$$

30mg/0.3ml, 40mg/0.4ml,

60mg/0.6ml, 80mg/0.8ml,

ANTAGONISTS

HMG‐COA REDUCTASE

LOVENOX Enoxaparin Sodium 100mg/ml, 150mg/ml,

120mg/0.8ml

Brand $$$$$$ LMN: Available at Retail

INHIBITORS MEVACOR Lovastatin 20mg, 40mg Generic $$$$

PRAVACHOL Pravastatin Sodium 10mg, 20mg, 40mg, 80mg Generic $$$$

ZOCOR Simvastatin 5mg, 10mg, 20mg, 40mg, 80mg Generic $$$

LIPITOR Atorvastatin Calcium 10mg, 20mg, 40mg, 80mg Brand $$$$ Step: simvastatin 80mg

HYPOLIPOPROTEINEMICS COLESTID Colestipol HCl 1g, 5g Generic $$$$

54mg, 67mg, 134mg, 160mg, LOFIBRA Fenofibrate

200mg Generic $$$

LOPID Gemfibrozil 600mg Generic $$$

QUESTRAN Cholestyramine 4g Generic $$$

LOVAZA Omega‐3‐acid Ethyl Esters 1g Brand $$$$

NIASPAN Niacin 500mg, 750mg, 1000mg Brand $$$$

WELCHOL Colesevelam HCl 625mg, 3.75g Brand $$$$

ZETIA Ezetimibe 10mg Brand $$$$ Step: simvastatin 40mg

NITRATES IMDUR Isosorbide Mononitrate 10mg, 20mg, 30mg, 60mg, 120mg Generic $$$$

ISORDIL Isosorbide Dinitrate 5mg, 10mg, 20mg, 30mg, 40mg Generic $$$$

NITRO‐DUR Nitroglycerin 2.5mg, 6.5mg, 0.1mg/HR,

0.2mg/HR, 0.4mg/HR, 0.6mg/HR

Generic $$$$

ORAL ANTICOAGULANTS,

NITROSTAT Nitroglycerin 0.4mg, 0.6mg Generic $$$$

1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg,

VITAMIN K COUMADIN Warfarin Sodium

6mg, 7.5mg, 10mg Generic $$$

PERIPHERAL VASCULAR DISEASE PLETAL Cilostazol 50mg, 100mg Generic $$$

TRENTAL Pentoxifylline 400mg Generic $$$$

AGGRENOX Aspirin‐Dipyridamole 25‐200mg Brand $$$

EFFIENT Prasugrel HCl 5mg, 10mg Brand $$$$ Step: Plavix

PLAVIX Clopidogrel Bisulfate 75mg, 300mg Brand $$$$ CPA

POTASSIUM SUPPLEMENTS MICRO‐K Potassium Chloride 8mEq, 10mEq, 20mEq Generic $$

PULMONARY HYPERTENSION ADCIRCA Tadalafil 20mg Brand $$$$$$

LETAIRISLD Ambrisentan 5mg, 10mg Brand $$$$$$ LMN; Specialty

REMODULINLD Treprostinil Sodium 1mg/ml, 2.5mg/ml, 5mg/ml, 10mg/ml

Brand $$$$$$ LMN; Specialty

REVATIO Sildenafil Citrate 20mg, 10mg/12.5ml Brand $$$$$$ LMN; Specialty

TRACLEERLD Bosentan 62.5mg, 125mg Brand $$$$$$ LMN; Specialty

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-10

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 6 of 17




VENTAVISLD Iloprost 10mcg/ml, 20mcg/ml Brand $$$$$$ LMN; Specialty

REFRACTORY ANGINA RANEXA Ranolazine 500mg, 1000mg Brand $$$$ LMN

THERAPEUTIC VITAMINS &

MINERALS FOLTX Folic Acid 400mcg, 800mcg, 1000mcg, 1g Generic $$

ROCALTROL Calcitriol 0.25mcg, 0.5mcg Generic $$$$ HECTOROL Doxercalciferol

0.5mcg, 1mcg, 2.5mcg, 2mcg/ml,

4mcg/2ml Brand $$$$$

VASODILATOR APRESOLINE

ANTIHYPERTENSIVES Hydralazine HCl 10mg, 25mg, 50mg, 100mg Generic $$$$

CARDURA Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg Generic $$$$ HYTRIN Terazosin HCl 1mg, 2mg, 5mg, 10mg Generic $$$ MINIPRESS Prazosin HCl 1mg, 2mg, 5mg Generic $$$

VASOPRESSORS PROAMATINE Midodrine HCl 2.5mg, 5mg, 10mg Generic $$$ VITAMINS & MINERALS &

CEREFOLIN L‐Methylfolate w/ Vit B12‐V it B6‐

Brand $$$$

DIPROSONE

ELOCON

FLORONE

KENALOG

LIDEX

TEMOVATE

TOPICORT

RELATED PRODUCTS Vit B2

METANX L‐Methylfolate w/ Vit B6‐Vit B12 Brand $$$$

DERMATOLOGICAL ANTIACNE BENZACLIN

Clindamycin Phosphate‐Benzoyl

Peroxide

1‐5% Generic $$$$

BENZAMYCIN Benzoyl Peroxide‐Erythromycin 5‐3% Generic $$$$

CLEOCIN‐T Clindamycin Phosphate 1%, 2% Generic $$$$

DIFFERIN Adapalene 0.1%, 0.3% Generic $$$$ CPA

ERYTHROMYCIN BASE Erythromycin Generic $$$

METROGEL Metronidazole Gel 0.75% Generic $$$

METROLOTION Metronidazole 0.75% Generic $$$

RETIN‐A Tretinoin 0.25%, 0.375%, 0.05%, 0.1% Generic $$$$ Age >34

SUMAXIN Sulfacetamide Sodium w/ Sulfur 10‐1%, 10‐4%, 10‐5% Generic $$$$

FINACEA, FINACEA PLUS KIT Azelaic Acid 15%, Kit Brand $$$$

RETIN‐A MICRO Tretinoin Microsphere 0.04%, 0.1% Brand $$$$ Age >34

ANTIPRURITIC ATARAX Hydroxyzine HCl 10mg, 25mg, 50mg Generic $$

VISTARIL Hydroxyzine Pamoate 25mg, 50mg, 100mg Generic $$

ANTIPSORIASIS & ANTIECZEMA DOVONEX Calcipotriene 0.005% Generic $$$$$

KLARON Sulfacetamide Sodium 10% Generic $$$$

SELSUN BLUE Selenium Sulfide 1%, 2.25%, 2.5% Generic $

TAZORAC Tazarotene 0.05%, 0.1% Brand $$$$

VECTICAL Calcitriol 3mcg/gm Brand $$$$$ Step: calcipotriene

SCABICIDES ELIMITE Permethrin 5% Generic $$$$

LINDANE Lindane 1% Generic $$$

EURAX Crotamiton 10% Brand $$$$

TOPICAL CORTICOSTEROID DESOWEN Desonide 5% Generic $$$$

Betamethasone Dipropionate DIPROLENE

Augmented 5% Generic $$$

Betamethasone Dipropionate

Mometasone Furoate

Diflorasone Diacetate

Triamcinolone Acetonide

Fluocinonide Clobetasol

Propionate

5% Generic $$$ 0.1% Generic $$$

0.05% Generic $$$

0.025%, 0.1%, 0.5% Generic $$

0.05% Generic $$

5% Generic $$

TOPICAL DERMATOLOGICAL

ALDARA

Desoximetasone

Imiquimod

0.05%, 0.25%

5%

Generic

Generic

$$

$$$

CPA

CARAC

ELIDEL

PROTOPIC

Fluorouracil

Pimecrolimus

Tacrolimus

0.5%

1%

0.03%, 0.1%

Brand

Brand

Brand

$$$$

$$$$

$$$$

CPA

CPA

EAR, NOSE, THROAT DRUGS AFFECTING THE EAR AURALGAN Benzocaine‐Antipyrine Generic $$$ CORTISPORIN

Neomycin‐Colistin‐HC‐ Thonzonium Generic $$

OCUFLOX Ofloxacin 0.3% Generic $$$ CERUMENEX Triethanolamine Oleate Brand $$$ CIPRODEX Ciprofloxacin‐Dexamethasone 0.3‐0.1% Brand $$$$ DRUGS AFFECTING THE NOSE ASTELIN Azelastine HCl 0.1% Generic $$$$ QL= 2 bottles/30 days

FLONASE Fluticasone Propionate 50mcg Generic $$$ QL= 2 inhrs/30 days

NASALIDE Flunisolide 0.025% Generic $$$ QL= 3 inhrs/bottles/30 days

ASTEPRO Azelastine HCl 137mcg, 0.15% Brand $$$$ QL= 2 bottles/30 days

BECONASE AQ Beclomethasone Dipropionate Monohyd

0.042% Brand $$$$ Step: Fail one: flunisolide, fluticasone, OMNARIS

NASACORT AQ Triamcinolone Acetonide 55mcg/ACT Brand $$$$ Step: Fail one: flunisolide,

fluticasone, OMNARIS

NASONEX Mometasone Furoate 50mcg/ACT Brand $$$$ Step: Fail one: flunisolide,


OMNARIS Ciclesonide 50mcg/ACT Brand $$$$ Step: Fail one: flunisolide,

fluticasone

PATANASE Olopatadine HCl 0.6% Brand $$$$ RHINOCORT AQUA Budesonide 32mcg/ACT Brand $$$$ Step: Fail one

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-11

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DRUGS AFFECTING THE THROAT

AND MOUTH

VERAMYST Fluticasone Furoate 27.5mcg Brand $$$$

PERIDEX Chlorhexidine Gluconate 0.12% Generic $$$

Step: Fail one: flunisolide,


ENDOCRINE AMYLIN ANALOGUES SYMLIN/SYMLINPEN Pramlintide Acetate 600mcg, 1000mcg Brand $$$$ CPA; QL= 7 vials; 8 pens/30 days

ANTITHYROID DRUGS PROPYLTHIOURACIL Propylthiouracil 50mg, 100mg, 200mg, 400mg Generic $$

TAPAZOLE Methimazole 5mg, 10mg Generic $$

DIPEPTIDYL PEPTIDASE ‐ IV INHIB JANUMET Sitagliptin‐Metformin HCl 50‐500mg, 50‐1000mg Brand $$$$$

JANUVIA Sitagliptin Phosphate 25mg, 50mg, 100mg Brand $$$$

ONGLYZA Saxagliptin HCl 2.5mg, 5mg Brand $$$$

ENDOCRINE CORTROSYN Cosyntropin 0.25mg Generic $$$$

MEDROL Methylprednisolone 2mg, 4mg, 8mg, 16mg, 32mg Generic $$$

GLUCOCORTICOID AMARYL Glimepiride 1mg, 2mg, 4mg Generic $$$

DECADRON Dexamethasone 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg Generic $$$

DEPO‐MEDROL Methylprednisolone Acetate 40mg/ml, 80mg/ml Generic $$$$

HYTONE Hydrocortisone 0.5%, 1%, 2.5% Generic $$$

STERAPRED Prednisone 5mg, 10mg, 20mg Generic $$$$

VERIPRED 20 Prednisolone Sod Phosphate 20mg/5ml Brand $$$$

GLUCOSE ELEVATING GLUCAGEN Glucagon HCl 1mg Brand $$$$$

Antihemophilic Factor HEMOSTATICS XYNTHA

Recombinant PAF 250u, 500u, 1000u, 2000u, 3000u Brand $$$$ LMN

INCRETIN MIMETICS BYETTA Exenatide 5mcg, 10mcg Brand $$$$ CPA; QL= 2 syringes/30 days

VICTOZA Liraglutide 18mg/3ml Brand $$$$ CPA; QL= 3 syringes/30 days

INSULIN APIDRA Insulin Glulisine 100u/ml Brand $$$$ Step: Humalog

HUMALOG Insulin Lispro 50/50, 75/25, 100u/ml Brand $$$$

HUMULIN Insulin Isophane & Regular 50/50, 70/30 Brand $$$

HUMULIN N Insulin Isophane 100u/ml Brand $$$

HUMULIN R Insulin Isophane 100u/ml, 500u/ml Brand $$$

LANTUS Insulin Glargine 100u/ml, 500u/ml Brand $$$$

LEVEMIR, FLEXPEN Insulin Detemir 100u/ml Brand $$$$

NOVOLIN Insulin Isophane & Regular 70/30 Brand $$$

NOVOLIN N Insulin Isophane 100u/ml Brand $$$

NOVOLIN R Insulin Isophane 100u/ml Brand $$$

NOVOLOG Insulin Aspart 70/30, 100u/ml Brand $$$$

INSULIN SENSITIZERS ACTOPLUS MET Pioglitazone HCl‐Metformin HCl 15/850mg, 30/1000mg Brand $$$$

ACTOS Pioglitazone HCl 15mg, 30mg, 45mg Brand $$$$

Rosiglitazone Maleate‐Metformin 2‐500mg, 2‐1000mg, 4‐500mg, 4‐ AVANDAMET

HCl 1000mg

4‐1mg, 4‐2mg, 4‐4mg, 8‐2mg, 8‐

Brand $$$$ LMN

AVANDARYL Rosiglitazone Maleate‐Glimepiride 4mg

Brand $$$$ LMN

DUETACT Pioglitazone HCl‐Glimepiride 30‐2mg, 30‐4mg Brand $$$$

MINERALOCORTICOID FLORINEF Fludrocortisone Acetate 0.1mg Generic $$$

ORAL HYPOGLYCEMIC GLUCOPHAGE Metformin HCl 500mg, 750mg, 850mg, 1000mg Generic $$$

GLUCOPHAGE XR Metformin HCl SR 500mg, 750mg Generic $$$

GLUCOTROL Glipizide 5mg, 10mg Generic $$$

GLUCOTROL XL Glipizide SR 2.5mg, 5mg, 10mg Generic $$$

GLUCOVANCE Glyburide‐Metformin 1.25‐250mg, 2.5‐500mg, 5‐500mg Generic $$$$

MICRONASE Glyburide 1.25mg,. 2.5mg, 5mg Generic $$$

PRECOSE Acarbose 25mg, 50mg, 100mg Generic $$$

STARLIX Nateglinide 60mg, 120mg Generic $$$$

PRANDIMET Repaglinide‐Metformin HCl 1‐500mg, 2‐500mg Brand $$$$

RIOMET Metformin HCl 500mg/5ml Brand $$$$

OSTEOPOROSIS FOSAMAX Alendronate Sodium 5mg, 10mg, 35mg, 70mg Generic $$$

MIACALCIN Calcitonin 200u/ACT Generic $$$$

MIACALCIN Injection Calcitonin 200u/ml Generic $$$$ LMN

ACTONEL, ACTONEL WITH

CALCIUM

Risedronate Sodium, Risedronate

Sod with Calcium Carbonate

5mg, 30mg, 35mg, 75mg, 150mg Brand $$$$ Step: alendronate

BONIVA Ibandronate Sodium 3mg/3ml Brand $$$$ LMN

BONIVA Ibandronate Sodium 2.5mg, 150mg Brand $$$$

FORTEO Teriparatide 600mcg/2.4ml Brand $$$$$ LMN; Specialty

PROLIA Denosumab 60mg/ml Brand $$$$$$ Step: Failure on Bisphosphonate

ZOMETA Zoledronic Acid 4mg/5ml Brand $$$$$$ LMN; Specialty

THYROID SUPPLEMENTS ARMOUR THYRO Thyroid 32.5mg, 65mg, 130mg, 195mg Generic $$

LEVOTHROID Levothyroxine Sodium


100mcg, 112mcg, 125mcg,

137mcg, 150mcg, 175mcg,

200mcg, 300mcg, 500mcg

Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-12

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 8 of 17




SYNTHROID Levothyroxine Sodium

137mcg, 150mcg, 175mcg,

200mcg, 300mcg

Brand $$$

GASTROINTESTINAL ANTIDIARRHEAL IMODIUM Loperamide HCl 2mg Generic $$

LOMOTIL Diphenoxylate w/ Atropine 2.5mg Generic $$

ANTISPASMODICS/ DRUGS AFFEC GI MOTILITY

T BENTYL Dicyclomine HCl 10mg, 20mg Generic $$$

LEVBID Hyoscyamine Sulfate 0.0125mg, 0375mg Generic $$

REGLAN Metoclopramide HCl 5mg, 10mg Generic $$

ANTIULCER CARAFATE Sucralfate 1g Generic $$$$

CYTOTEC Misoprostol 100mcg, 200mcg Generic $$$$

PEPCID Famotidine 40mg Generic $$$

ZANTAC Ranitidine HCl 300mg Generic $$$

APPETITE STIMULANT MEGACE Megestrol Acetate 40mg/ml Generic $$$$

GI DRUGS ANALPRAM‐HC Hydrocortisone Acetate w/ Pramoxine

1‐1%, 1‐2.5%, 2.5%, 2.5‐1% Generic $$$$

AZULFIDINE Sulfasalazine 500mg Generic $$$

COLAZAL Balsalazide Disodium 750mg Generic $$$$

GOLYTELY PEG 3350‐KCl‐Na Bicarb‐NaCl‐Na Sulfate Generic $$$$

NULYTELY PEG 3350‐KCl‐Sod Bicarb‐NaCl Generic $$$$

URSO, URSO FORTE Ursodiol 250mg, 500mg Generic $$$$

ASACOL, ASACOL HD Mesalamine 400mg, 800mg Brand $$$ LMN

CANASA Mesalamine 1000mg Brand $$$$ LMN

CREON Amy‐Lip‐Prot 5, 10, 20, 6000u, 12000u, 24000u Brand $$$$ DIPENTUM Olsalazine Sodium 250mg Brand $$$$ LIALDA Mesalamine 1.2g Brand $$$$ LMN

PENTASA Mesalamine 250mg, 500mg Brand $$$$ LMN

HELICOBACTER PYLORI HELIDAC Metronidaz‐Tetracyc‐Bis Brand $$$$ PREVPAC Amoxicillin‐Clarithro‐Lansopraz Brand $$$$ IRRITABLE BOWEL AMITIZA Lubiprostone 8mcg, 24mcg Brand $$$$ MISCELLANEOUS GI DRUGS CEPHULAC Lactulose 10g/15ml, 20g/30ml Generic $$$$ FOSRENOL Lanthanum Carbonate 250mg, 500mg, 750mg, 1000mg Brand $$$$$

RENAGEL Sevelamer 400mg, 800mg Brand $$$$$ RENVELA Sevelamer Carbonate 800mg, 0.8g, 2.4g Brand $$$$$ PROTON PUMP INHIBITORS PREVACID Lansoprazole 15mg, 30mg Generic $$$$ PRILOSEC Omeprazole 10mg, 40mg Generic $$ PROTONIX Pantoprazole 20mg, 40mg Generic $$$ Step: Failure of two: omeprazole,

ACIPHEX Rabeprazole Sodium EC 20mg Brand $$$$ pantoprazole, lansoprazole; QL=

34 caps/packets/30 days

Step: Failure of two: omeprazole,

DEXILANT (formerly KAPIDEX) Dexlansoprazole 30mg, 60mg Brand $$$$ pantoprazole, lansoprazole; QL=



NEXIUM Esomeprazole Magnesium 20mg, 40mg Brand $$$$ pantoprazole, lansoprazole; QL=


IMMUNOLOGICALS &

VACCINES IMMUNOLOGICALS & VACCINES MICRHOGAM PL Rho D Immune Globulin 50mcg Brand $$$$$$

PRIVIGEN Immune Globulin 5g, 10g, 20g Brand $$$$$$ LMN

RHOGAM PLUS Rho D Immune Globulin 300mcg Brand $$$$$$ MEDICAL (MISCELLANEOU SUPPLIES

S) DIABETIC SUPPLIES

ACCU‐CHEK ‐ kits, strips and supplies Brand $$$$ QL= 100 strips/30 days

ONE TOUCH ‐ kits, strips and Brand $$$$ QL= 100 strips/30 days supplies

TRUE ‐ kits, strips and supplies Brand $$$ QL= 100 strips/30 days

MUSCULOSKELETAL CNS MUSCLE RELAXANTS FLEXERIL Cyclobenzaprine HCl 5mg, 10mg Generic $$$ QL= 90 tabs/30 days

DIRECT MUSCLE RELAXANTS LIORESAL Baclofen 10mg, 20mg Generic $$$$

DRUGS TO PREVENT & TREAT GOUT

BENEMID Probenecid 500mg Generic $$$$

ZYLOPRIM Allopurinol 100mg, 300mg Generic $$$

LEVOXYL Levothyroxine Sodium

UNITHROID Levothyroxine Sodium


100mcg, 112mcg, 125mcg,

137mcg, 150mcg, 175mcg,

200mcg, 300mcg


100mcg, 112mcg, 125mcg,

137mcg, 150mcg, 175mcg,

200mcg, 300mcg


100mcg, 112mcg, 125mcg,

Generic $$

Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-13

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 9 of 17




LESSINA‐28 Generic $$

Levonorgestrel & Ethinyl Estradiol

LEVORA‐28 Tab 0.15 MG‐30 MCG

Generic $$

Norgestrel & Ethinyl Estr LO/OVRAL

0.3 MG‐30 MCG

adiol Tab Generic

$$

Norethindrone Ace & Eth LOESTRIN FE Estradiol‐FE Tab 1 MG‐20

inyl MCG, Generic

$$

1.5 MG‐30 MCG

COLCRYS Colchicine 0.6mg Brand $$$$ Step: NSAIDS

ULORIC Febuxostat 40mg, 80mg Brand $$$$ Step: allopurinol

GOUT PROBEN/COLCH Colchicine w/ Probenecid 500‐0.5 Generic $$$

NON‐STEROIDAL

ANTIINFLAMMATORY AGENTS CLINORIL Sulindac 150mg, 200mg Generic $$$

DAYPRO Oxaprozin 600mg Generic $$$$

FELDENE Piroxicam 10mg, 20mg Generic $$$$

INDOCIN Indomethacin 25mg, 50mg, 75mg Generic $$

MOBIC Meloxicam 7.5mg, 15mg Generic $$$$

MOTRIN Ibuprofen 800mg Generic $$

220mg, 250mg, 275mg, 375m g, NAPROSYN Naproxen

500mg, 550mg Generic $$$

ORUDIS Ketoprofen 50mg, 75mg, 200mg Generic $$$

RELAFEN Nabumetone 500mg, 750mg Generic $$$

VOLTAREN Diclofenac Sodium 50mg, 75mg, 100mg Generic $$$

CELEBREX Celecoxib 50mg, 100mg, 200mg, 400mg Brand $$$$ Step: Fail Any 2 NSAIDs

SALICYLATES & RELATED DRUGS DISALCID Salsalate 500mg, 750mg Generic $$

OBSTETRICAL &

GYNECOLOGICAL ANDROGEN ANDRODERM Testosterone 2.5mg/24HR, 5mg/24HR Brand $

ANDROGEL Testosterone 1% Brand $

TESTIM Testosterone 1% Brand $

Medroxyprogesterone Acetate IM CONTRACEPTIVES, NON ORAL DEPO‐PROVERA

DEPO‐PROVERA

Susp 150 MG/ML

Medroxyprogesterone Acetate IM

Susp 400 MG/ML

Generic $$$

Brand $$$$

NUVARING

Etonogestrel‐Ethinyl Estradiol VA

Ring 0.120‐0.015 MG/24HR

Brand $$$

ORTHO EVRA

Norelgestromin‐Ethinyl Estradiol

TD PTWK 150‐20 MCG/24HR

Brand $$$

CONTRACEPTIVES, ORAL APRI Desogestrel & Ethinyl Estradiol

Tab 0.15 MG‐30 MCG

Generic $$$

ARANELLE Norethindrone‐Eth Estradiol Tab

0.5‐35/1‐35/0.5‐35 MG‐MCG

Generic $$

AVIANE

CESIA

CRYSELLE‐28

CYCLESSA


Tab 0.1 MG‐20 MCG

Desogest‐Ethin Est Tab 0.1‐

0.025/0.125‐0.025/0.15‐0.025MG‐

MG Norgestrel & Ethinyl Estradiol

Tab

0.3 MG‐30 MCG


0.025/0.125‐0.025/0.15‐0.025MG‐

MG

Generic $$

Generic $$

Generic $$

Generic $$

DESOGEN‐28

Desogestrel & Ethinyl Estradiol


Generic $$$

ENPRESSE‐28 Levonorgestrel‐Eth Estra Tab 0.05‐

30/0.075‐40/0.125‐30MG‐MCG

Generic $$

ESTROSTEP FE Norethindrone Ac‐Ethinyl Estrad‐

Fe Tab 1‐20/1‐30/1‐35 MG‐MCG

Generic $$$

JUNEL FE

Norethindrone Ace & Ethinyl

Estradiol‐FE Tab 1 MG‐20MCG, 1.5

MG‐30 MCG

Generic $$

KARIVA

Desogest‐Eth Estrad & Eth Estrad

Tab 0.15‐0.02/0.01 MG(21/5)

Generic $$$

KELNOR Ethynodiol Diacetate & Ethinyl

Estradiol Tab 1 MG‐35 MCG

Generic $$


Tab 0.1 MG‐20 MCG

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-14

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 10 of 17




LOW‐OGESTREL

LUTERA

MICROGESTIN

MICROGESTIN FE

Norgestrel & Ethinyl Estradiol Tab

0.3 MG‐30 MCG Levonorgestrel &

Ethinyl Estradiol Tab 0.1 MG‐20

MCG Norethindrone Ace & Ethinyl

Estradiol Tab 1 MG‐20 MCG, 1.5

MG‐30 MCG

Norethindrone Ace & Ethinyl

Estradiol‐FE Tab 1 MG‐20 MCG,

1.5 MG‐30 MCG

Generic $$

Generic $$

Generic $$

Generic $$

MIRCETTE

Desogest‐Eth Estrad & Eth Estrad

Tab 0.15‐0.02/0.01 MG(21/5)

Generic $$$

MODICON

Norethindrone & Ethinyl Estradiol

Tab 0.5 MG‐35MCG

Generic $$$

MONONESSA

Norgestimate & Ethinyl Estradiol


Generic $$

NECON


Tab 0.5 MG‐35 MCG, 1 MG‐35

MCG, 0.5‐35/0.75‐35/1‐35 MG‐

MCG

Generic $$

NORDETTE



Generic $$$

NORINYL Norethindrone & Mestranol Tab 1

MG‐35MCG, 1 MG‐50 MCG

Generic $$

NORTREL

OCELLA


Tab 0.5 MG‐35 MCG, 1 MG‐35

MCG, 0.5‐35/0.75‐35/1‐35 MG‐

MCG Drospirenone‐Ethinyl

Estradiol Tab 3‐0.03 MG

Generic $$

Generic $$$

ORTHO TRI‐CYCLEN

Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG

Generic $$

ORTHO‐CEPT Desogestrel & Ethinyl Estradiol


Generic $$

ORTHO‐CYCLEN Norgestimate & Ethinyl Estradiol


Generic $$$

ORTHO‐NOVUM


Tab 1 MG‐35 MCG, 1 MG‐50MCG,

0.5‐35/0.75‐35/1‐35 MG‐M

Generic $$$

OVCON 35


Tab 0.4 MG

Generic $$$

PREVIFEM

Norgestimate & Ethinyl Estradiol


Generic $$

SEASONALE Levonorgestrel & Ethinyl Estradiol

(91‐Day) Tab 0.15‐0.03 MG

Generic $$$$

SOLIA Desogestrel & Ethinyl Estradiol


Generic $$

SPRINTEC 28 Norgestimate & Ethinyl Estradiol


Generic $$

TRINESSA Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG

Generic $$

TRI‐NORINYL Norethindrone‐Eth Estradiol Tab

0.5‐35/1‐35/0.5‐35 MG‐MCG

Generic $$$

TRI‐PREVIFEM Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG

Generic $$

TRI‐SPRINTEC Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG

Generic $$

TRIVORA‐28 Levonorgestrel‐Eth Estra Tab 0.05‐

30/0.075‐40/0.125‐30MG‐MCG

Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-15

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VELIVET


0.025/0.125‐0.025/0.15‐0.025MG‐

Generic

$$

MG YASMIN

Drospirenone‐Ethinyl Estradiol Tab 3‐0.03 MG Generic $$$

YAZ Drospirenone‐Ethinyl Estradiol

Tab 3‐0.02 MG Generic $$$$

ZOVIA

Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG‐35 MCG, 1 MG‐

50 MCG

Generic

$$

ORTHO TRI‐CYCLEN LO


25/0.215‐25/0.25‐25 MG‐MCG

Brand

$$

CPA

ESTROGEN CLIMARA Estradiol TD 0.025mg, 0.0375mg, 0.05mg,

0.06mg, 0.075mg, 0.1mg Generic $$$$ QL= 5 patches/30 days

ESTRACE Estradiol 0.5mg, 1mg, 2mg Generic $$ OGEN Estropipate 0.75mg, 1.5mg, 3mg Generic $$ ALORA Estradiol 0.025mg, 0.05mg, 0.075mg, 0.1 mg Brand $$$ QL= 68 packets/30 days

ESTRACE VAG Estradiol Vaginal Cream Brand $$$ ESTRASORB Estradiol Brand $$$ QL= 68 packets/30 days

ESTROGEL Estradiol Brand $$$$ QL= 2 pump bottles/30 days

PREMARIN Estrogens, Conjugated 0.3mg, 0.45mg, 0.625mg, 0.9mg 1.25mg

, Brand $$$

PREMARIN VAG Estrogens, Conjugated Vaginal

Cream 0.625mg Brand $$

VIVELLE‐DOT Estradiol 0.0375, 0.025mg, 0.05mg,

0.075mg, 0.1mg Brand $$$$ QL= 10 patches/30 days

ESTROGEN/ PROGESTIN

COMBINATIONS ACTIVELLA

Estradiol & Norethindrone

Acetate 1‐0.5mg Generic $$$$

FEMHRT Norethindrone Acetate‐Ethinyl

Estradiol 0.5mg‐2.5mcg, 1mg‐5mcg Generic $$$$

ANGELIQ Drospirenone‐Estradiol 0.5‐1mg Brand $$$$ CLIMARA PRO Estradiol‐Levonorgestrel Brand $$$ QL= 5 patches/30 days

COMBIPATCH Estradiol‐Norethindrone Ace 0.05/0.14mg, 0.05/0.25mg Brand $$$ PREFEST Estradiol/Estrad‐Norgestimate Brand $$$$

PREMPHASE Conj Est/Conj Est‐Medroxypro Ac Brand $$$

PREMPRO Conjugated Estrogen‐

Medroxyprogest Acetate

0.3‐1.5mg, 0.45‐1.5mg, 0.625‐

2.5mg, 0.625‐5mg Brand $$$

PRENATAL VITAMINS NATALCARE PLUS Prenatal Vit w/ Fe Fumarate‐FA Generic $$ Step: Prenatal OTC

PRENATAL Prenatal Rx Generic $$ Step: Prenatal OTC

PRENATE ELITE Prenatal Vit w/ Fe Fum‐

Methylfolate‐FA Brand $$$$ Step: Prenatal OTC

PROGESTIN AYGESTIN Norethindrone Acetate 5mg Generic $$$$ NOR‐QD Norethindrone 0.35mg Generic $$$ PROVERA Medroxyprogesterone Acetate 2.5mg, 5mg, 10mg Generic $$$ SELECTIVE ESTROGEN RECEPTOR

MODULATOR EVISTA Raloxifene HCl 60mg Brand $$$$

OPHTHALMIC ANTIGLAUCOMA ALPHAGAN P Brimonidine Tartrate 0.1%, 0.15% Generic $$$ BETAGAN Levobunolol HCl 0.25%, 0.5% Generic $$ LUMIGAN Bimatoprost 0.01%, 0.03% Generic $$$ PILOCARPINE Pilocarpine HCl 1%, 2%, 3%, 4%, 6% Generic $$ TIMOPTIC Timolol Maleate 0.25%, 0.5% Generic $$$ TIMOPTIC‐XE Timolol Maleate 0.25%, 0.5% Generic $$$ XALATAN Latanoprost 0.005% Generic $$$ OPHTHALMIC ACULAR, LS Ketorolac Tromethamine 0.5%, 0.4% Generic $$$$ BROMDAY Bromfenac Sodium 0.09% Generic $$$$ CROLOM Cromolyn Sodium 4% Generic $$ OMNIPRED Prednisolone Acetate 1% Generic $$$$ OPTIVAR Azelastine HCl 0.05% Generic $$$$ VOLTAREN Diclofenac Sodium 0.1% Generic $$ ACUVAIL Ketorolac Tromethamine 0.45% Brand $$$ LMN

PATANOL Olopatadine HCl 0.1% Brand $$$$ RESTASIS Cyclosporine 0.05% Brand $$$$ QL= 60 vials/30 days

OPHTHALMIC ANTIINFECTIVE/

CORTICOSTEROIDS MAXITROL

Neomycin‐Polymyxin‐

Dexamethasone 0.1% Generic $$

TOBRADEX Neomycin‐Polymyxin‐

Dexamethasone Generic $$$

OPHTHALMIC CORTICOSTEROID PRED FORTE Prednisolone Acetate 1% Generic $$

ALREX Loteprednol Etabonate 0.2% Brand $$$$ FML FORTE Fluorometholone 0.25% Brand $$ LOTEMAX Loteprednol Etabonate 0.5% Brand $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-16

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OPHTHALMIC TOPICAL

ANTIBACTERIAL BLEPH‐10 Sulfacetamide Sodium 10% Generic $$

CILOXAN Ciprofloxacin HCl 3% Generic $$$

ILOTYCIN Erythromycin Generic $$

POLYTRIM Polymyxin B‐Trimethoprim Generic $

AZASITE Azithromycin 1% Brand $$

ZYMAR Gatifloxacin 0.3% Brand $$$

OVER THE COUNTER ANALGESICS ADVIL Ibuprofen 200mg OTC $ QL= 100 tabs/30 days

ALEVE Naproxen Sodium 220mg OTC $ QL= 100 tabs/30 days

ASA Aspirin 81mg, 325mg OTC $ QL= 120 tabs/30 days

ANTIACNE BENZOYL Benzoyl Peroxide 5% OTC $$ QL= 85g/ 30days

ANTIHISTAMINE ALLEGRA Fexofenadine 30mg, 60mg, 180mg OTC $$ Step: Claritin; QL= 30 tabs/30 days

ALLEGRA‐D Fexofenadine‐Pseudoephedrine 12 hour, 24 hour OTC $$ QL= 30 tabs/30 days

BENADRYL Diphenhydramine HCl 25mg, 50mg OTC $ QL= 100 caps/30 days

CLARITIN Loratadine 5mg, 10mg OTC $$ QL= 30caps/30 days

ZYRTEC Cetirizine HCl 5mg, 10mg OTC $$ QL= 30 tabs/30 days

ZYRTEC‐D Cetirizine ‐Pseudoephedrine 5mg/120mg OTC $$ QL= 30 tabs/30 days

BIRTH CONTROL CONDOMS Condoms OTC $$ QL= 12/30 days

SPERMACIDAL PRODUCTS Spermacidal Products Sponge, Foam, Cream, Gel OTC $$

COUGH SUPPRESSANT DELSYM Dextromethorphan Polistirex 30mg/5ml OTC $$ QL= 148 ml/30 days

DIETARY PRENATAL VITAMINS Prenatal Vitamins OTC $$ QL= 100 tabs/30 days

25mg, 50mg, 100mg, 200MG, PYRIDOXINE Pyridoxine HCl

250MG, 500MG OTC $$ QL= 60 tabs/30 days

VITAMIN K Phytonadione 100mcg OTC $$ QL= 60 tabs/30 days

H2 ANTAGONIST PEPCID Famotidine 10mg, 20mg OTC $$ QL= 90 tabs/30 days

ZANTAC Ranitidine HCl 75mg, 150mg OTC $$ QL= 90 tabs/30 days

LAXATIVES & CATHARTICS COLACE Docusate Sodium 100mg OTC $ QL= 60 caps/30 days

Fructose‐Dextrose‐Phosphoric EMETROL

Acid OTC $ QL= 240ml/ 30 days

GLYCOLAX Polyethylene Glycol OTC $$ PROTON PUMP

INHIBITORS PRILOSEC Omeprazole 20mg OTC $$ QL= 42 tabs/30 days

ZEGERID Omeprazole‐Sodium Bicarbonate 20‐1100 OTC $$ QL= 42 tabs/30 days

RESPIRATORY ANTIHISTAMINE/ DECONGESTANT

COMBINATIONS

ALLEGRA‐D Fexofenadine‐Pseudoephedrine 60mg/120mg, 180mg/240mg Generic $$

PHENERGAN/CODEINE Promethazine w/ Codeine 6.25‐10mg Generic $$

ZYRTEC‐D Cetirizine‐Pseudoephedrine 5mg/120mg Generic $$$

ANTIHISTAMINES PERIACTIN Cyproheptadine HCl 4mg Generic $$

PHENERGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$

ANTITUSSIVE & EXPECTORANT CONGESTAC Pseudoephedrine‐Guaifenesin Generic $$$

PHENERGAN DM Promethazine‐DM Generic $$

PHENERGAN/CODEINE Promethazine w/ Codeine Generic $$

PRO‐CLEAR Guaifenesin‐Codeine 300‐10mg Generic $$

Dextromethorphan‐Pot PROLEX DM

Guaiacolsulfon Generic $$

TESSALON Benzonatate 100mg, 200mg Generic $$

TUSSIONEX Hydrocod Polst‐Chlorphen Polst Generic $$$

BETA‐2 ADRENERGIC PROVENTIL Albuterol Sulfate 2mg, 4mg Generic $$

VENTOLIN Albuterol 90mcg Generic $$$$ QL= 3 inhrs/30 days

BROVANA Arformoterol Tartrate 15mcg Brand $$$$ Step: Foradil

CPA; QL= 12 caps/12pk; 120 FORADIL Formoterol Fumarate Brand $$$$

caps/60pk; per 30 days

PERFOROMIST Formoterol Fumarate 20mcg Brand $$$$ CPA; QL= 120 vials/30 days

PROAIR HFA Albuterol Sulfate Brand $$$$ QL= 3 inhrs/30 days

SEREVENT DISKUS Salmeterol Xinafoate 50mcg Brand $$$$ Step: Foradil

XOPENEX Levalbuterol HCl 0.31mg, 0.63mg, 1.25mg/3ml Brand $$$$ Step: albuterol

XOPENEX HFA Levalbuterol Tartrate Brand $$$$

DRUGS FOR ASTHMA ATROVENT Ipratropium Bromide 0.02% Generic $$$$

ADVAIR DISKUS Fluticasone‐Salmeterol 100/50, 250/50, 500/50 Brand $$$$

Step: albuterol; QL= 3 inhrs/30

days

QL= 120 inhs/60pk; 28 inhs/28pk;

14 inhs/14pk; per 30 days

ADVAIR HFA Fluticasone‐Salmeterol 45/21, 115/21, 230/21 Brand $$$$ QL= 2 inhrs/30 days

ASMANEX Mometasone Furoate 110mcg, 220mcg Brand $$$$

QL= 1 inh (#14 inhalation units); 2

inhs (#30, #60, #120 inhalation

units); per 30 days

ATROVENT HFA Ipratropium Bromide HFA 17mcg Brand $$$$ QL= 2 inhrs HFA/30 days

COMBIVENT Ipratropium‐Albuterol 18‐103mcg/ACT Brand $$$$ QL= 3 inhrs/30 days

CPA; QL= 3 units/pkg size 1; 4 EPIPEN, EPIPEN‐JR Epinephrine 0.15mg, 0.3mg Brand $$$$

units/pkg size 2; per 30 days

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-17

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FLOVENT HFA

Fluticasone Propionate HFA


Brand

$$$$

QL= 44mcg ‐ 2 inhrs; 110mcg ‐ 1

inhr; 220mcg ‐ 3 inhrs; per 30

days

PULMICORT

Budesonide

0.25mg/2ml, 0.5mg/2ml, 1mg/ml

Brand

$$$$

QL= 70 amps (0.25mg/2ml or

0.5mg/2ml); 35 amps (1mg/2ml);

2 inhrs; per 30 days

PULMICORT FLEXHALER Budesonide 90mcg, 180mcg Brand $$$$ QL= 2 inhs (90 mcg); 3 inhs (180

mcg); per 30 days

SPIRIVA Tiotropium Bromide Monohydr ate 18mcg Brand $$$$ QL= 1 pkg (6 caps or 90 caps); 2

pkgs (30 caps); per 30 days

SYMBICORT Budesonide‐Formoterol Fumarate 80‐4.5mcg/ACT, 160‐4.5mcg/ACT Brand $$$$ QL= 2 inhrs/30 days

TWINJECT Epinephrine 0.15mg, 0.3mg Brand $$$$

CPA; QL= 3 units/pkg size 1; 4

units/pkg size 2; per 30 days

LEUKOTRIENE MODIFIERS ACCOLATE Zafirlukast 10mg, 20mg Brand $$$$ Step: Singulair

SINGULAIR Montelukast Sodium 10mg Brand $$$$

METHYL XANTHINE THEO‐DUR Theophylline 100mg, 200mg, 300mg Generic $$$

THEOPHYLLINE ANHYDROUS Theophylline Brand $$

UROLOGICAL ANTICHOLINERGIC

ANTISPASMODICS DITROPAN XL Oxybutynin Chloride 5mg, 10mg Generic $$

SANCTURA, SANCTURA XR Trospium Chloride 20mg, 60mg Generic $$$

ENABLEX Darifenacin Hydrobromide 7.5mg, 15mg Brand $$$

GELNIQUE Oxybutynin Chloride 10% Brand $$$

OXYTROL Oxybutynin 3.9mg/24HR Brand $$$

TOVIAZ Fesoterodine Fumarate 4mg, 8mg Brand $$$$

VESICARE Solifenacin Succinate 5mg, 10mg Brand $$$

GENITOURINARY PRODUCTS FLOMAX Tamsulosin HCl 0.4mg Generic $$$$

PROSCAR Finasteride 5mg Generic $$$$

AVODART Dutasteride 0.5mg Brand $$$$

RAPAFLO Silodosin 4mg, 8mg Brand $$$$

UROXATRAL Alfuzosin HCl 10mg Brand $$$

URINARY ANESTHETICS PYRIDIUM Phenazopyridine HCl 100mg, 200mg Generic $$

SPECIALTY SPECIALTY MEDICATIONS AMINOCAPROIC ACID Aminocaproic Acid 250mg/ml, 500mg Generic $$$$$$ LMN

BLEOMYCIN Bleomycin Sulfate 15u, 30u Generic $$$$$$

CABERGOLINE Cabergoline 0.5mg Generic $$$$$$ LMN

50mg/5ml, 150mg/15ml,

CARBOPLATIN Carboplatin 450mg/45ml, 600mg/60ml, 50mg,

150mg, 450mg

Generic $$$$$$

CLADRIBINE Cladribine 1mg/ml Generic $$$$$$

DACARBAZINE Dacarbazine 100mg, 200mg Generic $$$$$$

DAUNORUBINCIN Daunorubicin HCl 20mg, 5mg/ml Generic $$$$$$

DEFEROXAMINE Deferoxamine Mesylate 500mg, 2g Generic $$$$$$

DESMOPRESSIN Desmopressin Acetate 0.1mg, 0.2mg, 4mcg/ml, 0.1% Generic $$$$$ LMN

EPOPROSTENOLLD Epoprostenol Sodium 0.5mg, 1.5mg Generic $$$$$$ LMN

FLUDARABINE Fludarabine Phosphate 50mg, 50mg/2ml Generic $$$$$$

1mg, 0.1mg/ml, 1mg/ml, GRANISETRON Granisetron HCl

4mg/4ml, Generic $$$$$$ LMN

LEUPROLIDE Leuprolide Acetate 1mg/0.2ml, 5mg/ml Generic $$$$$$

MYCOPHENOLATE Mycophenolate Mofetil 250mg, 500mg Generic $$$$$$ LMN

NOVAREL Chorionic Gonadotropin 10000u Generic $$$$$$ LMN

100mcg, 200mcg, 500mcg, OCTREOTIDE Octreotide Acetate

PACLITAXEL Paclitaxel

PAMIDRONATE Pamidronate Disodium

1000mcg, 1mg/ml, 50mcg/ml

100mg, 6mg/ml, 30mg/5ml,

150mg/25ml, 300mg/50ml

30mg, 90mg, 30mg/10ml,

90mg/10ml

Generic $$$$$$ LMN

Generic $$$$$$

Generic $$$$$$

PREGNYLM

TACROLIMUS

VITAMIN K1

ABELCET

Chorionic Gonadotropin 10000u

Tacrolimus 0.5mg, 1mg, 5mg

Phytonadione 1mg/0.5ml, 2mg/

Amphotericin B Lipid 5mg/ml

Generic $$$$$$ LMN

Generic $$$$$$ LMN

ml Generic $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ LMN

ACTHARLD Corticotropin 80u

ACTHREL

ACTIMMUNELD

Corticorelin Ovine Triflutate 100mcg

Interferon Gamma‐1B 2000000u/0.5ml

ADVATE 250u, 500u, 1000

Antihemophilic Factor rAHF‐PFM 3000u

u, 1500u, 2000u, Brand $$$$$$ LMN

AFINITOR Everolimus 2.5mg, 5mg, 10m g Brand $$$$$$ ALDURAZYMELD

Laronidase 2.9mg/5ml Brand $$$$$$ LMN

ALFERON NM Interferon Alfa‐n3 5000000u/ml Brand $$$$$$ LMN

ALIMTA Pemetrexed Disodium 100mg, 500mg Brand $$$$$$ ALKERAN Melphalan 2mg, 50mg Brand $$$$$$ ALOXI Palonosetron HCl 0.25mg Brand $$$$$$ ALPHANATE Antihemophilic Factor/VWF 250‐500u, 1000‐1 500u, 1500u Brand $$$$$$$ LMN

ALPHANINE Coagulation Factor IX 500u, 1000u, 150 0u Brand $$$$$$$ LMN

AMEVIVE Alefacept 15mg Brand $$$$$$ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-18

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AMPYRALD Dalfampridine 10mg Brand $$$$$$ LMN

APOKYNLD Apomorphine Hydrochloride 50mg, 100mg, 20mg/ml Brand $$$$$$ LMN

ARALASTLD Proteinase Inhibitor 400mg, 500mg, 800mg, 1000mg Brand $$$$$$ LMN


ARANESP Darbepoetin Alfa‐Polysorbate 150mcg, 200mcg, 300mcg,

500mcg

Brand $$$$$$ CPA; QL= 2 inj/30 days; Available

at Retail

ARCALYST Rilonacept 220mg Brand $$$$$$ LMN

AREDIA Pamidronate Disodium 30mg, 90mg Brand $$$$$$ LMN

ARIXTRA Fondaparinux Sodium 2.5mg/0.5ml, 5mg/0.4ml,

7.5mg/0.6ml, 10mg/0.8ml Brand $$$$$$

CPA; QL= 28 inj/14 days; Available

at Retail

AVASTIN Bevacizumab Brand $$$$$$

AVONEX Interferon Beta‐1a 30mcg Brand $$$$$$ LMN

BARACLUDE Entecavir 0.5mg, 1mg, 0.05mg/ml Brand $$$$$$ LMN

BEBULIN VH Factor IX Complex 200‐1200u Brand $$$$$$$ LMN

BENEFIX Coagulation Factor IX 250u, 500u, 1000u, 2000u Brand $$$$$$$ LMN

BETASERON Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN

BICNU Carmustine 100mg Brand $$$$$$

BOTOX OnabotulinumtoxinA 50u, 100u, 200u Brand $$$$$$ LMN

BRAVELLE Urofollitropin 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN

CAMPATH Alemtuzumab 30mg/ml Brand $$$$$$ LMN

CAMPTOSAR Irinotecan HCl 20mg/ml Brand $$$$$$

CARIMUNE Immune Globulin 3g, 6g, 12g Brand $$$$$$ LMN

CELLCEPT Mycophenolate Mofetil 250mg, 500mg, 250mg/ml Brand $$$$$$ LMN

CEREDASE Alglucerase 80u/ml Brand $$$$$$ LMN

CEREZYMELD Imiglucerase 200u, 400u Brand $$$$$$ LMN

CETROTIDE Cetrorelix Acetate 0.25mg, 3mg Brand $$$$$$ LMN

CIMZIA Certolizumab Pegol 200mg/ml Brand $$$$$$ Step: Fail 2 DMARD

CINRYZELD C1 Inhibitor 500u Brand $$$$$$ LMN COLY‐MYCIN

M Colistimethate Sodium 150mg Brand $$$$$$ LMN

COPAXONE Glatiramer Acetate 20mg/ml Brand $$$$$$ LMN

COPEGUS Ribavirin 200mg Brand $$$$$$ LMN

CYCLOPHOSPHAMIDE Cyclophosphamide 25mg, 50mg, 500mg, 1g, 2g Brand $$$$$$

CYTOGAM Cytomegalovirus Immune Globulin Brand $$$$$$ LMN

CYTOXAN Cyclophosphamide 2g Brand $$$$$$ LMN

0.1mg, 0.2mg, 4mcg/ml, DDAVP Desmopressin Acetate

15mcg/ml, 0.1% Brand $$$$$$ LMN

DESFERAL Deferoxamine Mesylate 500mg, 2g Brand $$$$$$ LMN

DOXIL Doxorubicin HCl Liposomal 2mg/ml Brand $$$$$$

ELAPRASELD Idursulfase 6mg/3ml Brand $$$$$$ LMN

ELIGARD Leuprolide Acetate 7.5mg, 22.5mg, 30mg, 45mg Brand $$$$$$

ELLENCE Epirubicin HCl 2mg/ml Brand $$$$$$ LMN

ELOXATIN Oxaliplatin 50mg, 100mg, 200mg Brand $$$$$$

ELSPAR Asparaginase 10000u Brand $$$$$$

ENBREL Etanercept 25mg, 25mg/0.5ml, 50mg/ml Brand $$$$$$ Step: Fail 2 DMARD

ENGERIX Hepatitis B Vaccine 10mcg/0.5ml, 20mcg/ml Brand $$$$$$ LMN

2000u/ml, 3000u/ml, 4000u/ml,

EPOGEN Epoetin Alfa 10000u/ml, 20000u/ml,

40000u/ml

Brand $$$$$$ CPA; QL= 2 inj/30 days; Available

at Retail

ERBITUX Cetuximab 100mg, 200mg Brand $$$$$$

ETHYOLM Amifostine Crystalline 500mg Brand $$$$$$ LMN

EUFLEXXA Sodium Hyaluronate 10mg/ml Brand $$$$$$ LMN

EVOXAC Cevimeline HCl 30mg Brand $$$$$$ LMN

EXJADELD Deferasirox 125mg, 250mg, 500mg Brand $$$$$$

EXTAVIA Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN

FABRAZYMELD Agalsidase beta 5mg, 35mg Brand $$$$$$ LMN

FEIBA VH Antiinhibitor Coagulant Complex Brand $$$$$$ LMN

FERRLECIT Sod Ferric Gluc Cmplx 12.5mg Brand $$$$$$ LMN

FLEBOGAMMALD Immune Globulin 5%, 10% Brand $$$$$$ LMN

FLOLANLD Epoprostenol Sodium 0.5mg, 1.5mg Brand $$$$$$ LMN

FLUDARA Fludarabine Phosphate 50mg Brand $$$$$$

FOLLISTIM Follitropin Beta 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN

2500u/0.2ml, 5000u/0.2ml,

FRAGMIN Dalteparin Sodium 7500u/0.3ml, 10000u/ml,

25000u/ml, 9500u, 12500u,

15000u, 18000u

Brand $$$$$$ CPA; QL=2 inj/30 days; Available

at Retail

GAMASTANLD Immune Globulin Brand $$$$$$ LMN

GAMMAGARD SD Immune Globulin

1g/10ml, 2.5g/25ml, 5g/50ml,

10g/100ml, 20g/200ml,

30g/300ml, 0.5g, 2.5g, 5g, 10g

Brand $$$$$$ LMN

GAMUNEX Immune Globulin 10%, 1g/10ml, 2.5g/25ml, 5g/5ml,

10g/100ml, 20g/200ml

Brand $$$$$$ LMN

GANIRELIX Ganirelix Acetate Brand $$$$$$ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-19

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NOVOSEVEN Coagulation Factor VIIa

Brand $$$$$$$ LMN

NUTROPINLD

Somatropin 5mg, 10mg, 5mg/2ml, 20mg/2ml Brand $$$$$$ CPA

OCTAGAMLD Immune Globulin 2.5g, 5g, 10g, 25g Brand $$$$$$ LMN

OMNITROPELD Somatropin 5.8mg, 5mg/1.5ml, 10mg/1.5ml Brand $$$$$$ CPA

ONTAK Denileukin Diftitox 150mcg/ml Brand $$$$$$ ORENCIA Abatacept 250mg Brand $$$$$$ CPA

ORTHOVISC Hyaluronan 15mg/ml Brand $$$$$$ LMN

PEGASYS Peginterferon alfa‐2a 180mcg/0.5ml, 180mcg/ml Brand $$$$$$ LMN

PEG‐INTRON Peginterferon alfa‐2b 50mcg, 80mcg, 120mcg, 150mcg Brand $$$$$$ LMN

PHENTOLAMINE Phentolamine Mesylate Brand $$$$$$ LMN

POLYGAM S/DM Immune Globulin 0.5g, 2.5g, 5g, 10g Brand $$$$$$ LMN

2000u/ml, 3000u/ml, 4000u/ml, PROCRIT Epoetin Alfa 10000u/ml, 20000u/ml, Brand $$$$$$ LMN; Available at Retail

30000u/ml, 40000u/ml PROFILNINELD

Factor IX Complex 500u, 1500u, 1500u Brand $$$$$$$ LMN

PROGRAF Tacrolimus 0.5mg, 1mg, 5mg, 5mg/ml Brand $$$$$$ LMN

PULMOZYME Dornase Alfa 1mg/ml Brand $$$$$$ LMN

RAPAMUNE Sirolimus 0.5mg, 1mg, 2mg, 1mg/ml Brand $$$$$$ LMN

REBETOL Ribavirin 200mg, 4mg/ml Brand $$$$$$ LMN

GEMZAR Gemcitabine HCl 200mg, 1g Brand $$$$$$

0.2mg, 0.4mg, 0.6mg, 0.8mg, 1mg,

GENOTROPIN Somatropin 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg,

5mg, 12mg

Brand $$$$$$ CPA

GILENYA Fingolimod HCl 0.5mg Brand $$$$$$ LMN

GLEEVEC Imatinib Mesylate 100mg, 400mg Brand $$$$$$

GONAL‐F Follitropin Alfa 300, 450, 900, 75u, 450u, 1050u Brand $$$$$$ LMN

HAVRIX Hepatitis A Vaccine 720u, 1440u Brand $$$$$$ LMN

HEALON Sodium Hyaluronate 10mg/ml, 14mg/ml, 23mg/ml Brand $$$$$$ LMN

HELIXATE FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u Brand $$$$$$ LMN

HEMOFIL M Antihemophilic Factor

220‐400u, 401‐800u, 801‐1700u,

1701u+

Brand $$$$$$ LMN

HEPSERA Adefovir Dipivoxil 10mg Brand $$$$$$ LMN

HERCEPTIN Trastuzumab 440mg Brand $$$$$$

500u, 600u, 1000u, 1200u, 2000u, HUMATE‐P Antihemophilic Factor/VWF

2400u Brand $$$$$$

HUMATROPE Somatropin 5mg, 6mg, 12mg, 24mg Brand $$$$$$ CPA

HUMIRA Adalimumab 20mg/0.4ml, 40mg/0.8ml, Brand $$$$$$ Step: Fail 2 DMARD

HYALGAN Sodium Hyaluronate 20mg/2ml Brand $$$$$$ LMN

HYPERHEP Hepatitis B Immune Globulin Brand $$$$$$ LMN

HYPERRHO Rho D Immune Globulin 50mcg, 300mcg Brand $$$$$$ LMN

INCRELEX Mecasermin 40mg/4ml Brand $$$$$$ CPA

INNOHEP Tinzaparin Sodium 20000u/ml Brand $$$$$$ LMN; Available at Retail

INTRON‐A Interferon Alfa‐2B 3u, 5u, 10u, 18u, 25u, 50u Brand $$$$$$ QL= 2 inj/30 days

KINERET Anakinra Brand $$$$$$ LMN

KOATE‐DVI Antihemophilic Factor 250u, 500u, 1000u Brand $$$$$$

250u, 500u, 1000u, 2000u, 3000u,

KOGENATE FS Antihemophilic Factor 250/BS, 500/BS, 1000/BS,

2000/BS, 3000/BS

Brand $$$$$$ LMN

KUVANLD Sapropterin Dihydrochloride 100mg Brand $$$$$$ LMN

LEUKERAN Chlorambucil 2mg Brand $$$$$$

LEUSTATIN Cladribine 1mg/ml Brand $$$$$$ LMN

LUCENTISLD Ranibizumab Brand $$$$$$ LMN

3.75mg, 7.5mg, 11.25mg, 22.5mg, LUPRON Leuprolide Acetate

30mg Brand $$$$$$

MACUGENLD Pegaptanib Sodium Brand $$$$$$ LMN

220‐400u, 401‐800u, 801‐1700u, MONARC‐M Antihemophilic Factor

1701u+ Brand $$$$$$ LMN

MONOCLATE‐P Antihemophilic Factor 250u, 500u, 1000u, 1500u Brand $$$$$$ LMN

MONONINE Coagulation Factor IX 250u, 500u, 1000u Brand $$$$$$$ LMN

MYOZYMELD Alglucosidase Alfa 50mg Brand $$$$$$ LMN

NAGLAZYMELD Galsulfase 1mg/ml Brand $$$$$$ LMN

NAVELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$

NEULASTA Pegfilgrastim 6mg/0.6ml Brand $$$$$$ CPA; QL= 2 inj/30 days

NEUPOGEN Filgrastim

300mcg, 480mcg, 300mcg/0.5ml,

480mcg/0.8ml

Brand $$$$$$ LMN; Available at Retail

NEXAVARLD Sorafenib Tosylate 200mg Brand $$$$$$

5mg/1.5ml, 10mg/1.5ml, NORDITROPIN Somatropin

15mg/1.5ml, 30mg/3ml Brand $$$$$$ CPA

1200mcg, 2400mcg, 4800mcg,

1mg, 2mg, 5mg, 8mg

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-20

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 16 of 17




SUPPRELINLD

SUTENT

Histrelin Acetate

Sunitinib Malate

50mg Brand $$$$$$

12.5mg, 25mg, 50mg Brand $$$$$$

50mg, 100mg/ml Brand $$$$$$ LMN

2mg/ml Brand $$$$$$ LMN

8mg/ml Brand $$$$$$ LMN

25mg, 100mg, 150mg Brand $$$$$$

75mg, 1% Brand $$$$$$

150mg, 200mg Brand $$$$$$

20mg/0.5ml, 20mg/ml, 80mg/2ml, Brand $$$$$$

80mg/4ml 5mg, 20mg, 100mg, 140mg,

Brand $$$$$$$ 180mg, 250mg

5mg Brand $$$$$$ CPA

50mg, 150mg, 200mg100mg, Brand $$$$$$

500u, 1000u Brand $$$$$$ LMN

25mg Brand $$$$$$ LMN

1.1mg Brand $$$$$$ LMN

50mg Brand $$$$$$ LMN

300mg/5ml Brand $$$$$$ LMN

25mg/ml Brand $$$$$$

3.75mg, 11.25mg, 22.5mg Brand $$$$$$

SYNAGISLD

SYNARELM

Palivizumab IM

Nafarelin Acetate

SYNVISC Hylan Intra‐articular

TARCEVA Erlotinib

TARGRETIN Bexarotene

TASIGNA Nilotinib

TAXOTERE Docetaxel

TEMODAR Temozolomide

TEV‐TROPINLD Somatropin

THALOMID Thalidomide

THROMBAT III Antithrombin III

THYMOGLOBULIN

THYROGENLD

Anti‐Thymocyte Globulin

Thyrotropin Alfa

TICE BCG Live Intravesical

TOBI Tobramycin

TORISEL

TRELSTARLD

Temsirolimus

Triptorelin Pamoate

TWINRIX Hepatitis A (Inact)‐Hep B (Recomb) Vac Brand $$$$$$ LMN

TYKERBLD Lapatinib Ditosylate 250mg Brand $$$$$$

TYSABRILD Natalizumab 300mg/15ml Brand $$$$$$ LMN

VALCYTE Valganciclovir HCl 450mg, 50mg/ml Brand $$$$$$ LMN

VANTASLD Histrelin Acetate 50mg Brand $$$$$$

VFEND Voriconazole 50mg, 200mg, 40mg/ l Brand $$$$$$ LMN

VIDAZALD Azacitidine 100mg Brand $$$$$$

VINORELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$ VIREAD Tenofovir Disoproxil Fumarate 300mg Brand $$$$$$ CPA

VISUDYNELD Verteporfin 15mg Brand $$$$$$ LMN

VIVAGLOBINLD Immune Globulin 160mg/ml Brand $$$$$$ LMN

VOTRIENTLD Pazopanib HCl 200mg Brand $$$$$$

WINRHO SDF Rho D Immune Globulin 600u, 1500u, 2500u, 5 15000u

000u, Brand $$$$$$ LMN

XELODA Capecitabine 150mg, 500mg Brand $$$$$$ XENAZINELD

Tetrabenazine 12.5mg, 25mg Brand $$$$$$ LMN

XIAFLEXLD

Collagenase Clostridium Histolyticum

0.9mg Brand $$$$$$ LMN

REBIF Interferon Beta‐1a 22mcg/0.5ml, 44mcg/0.5ml Brand $$$$$$ LMN

RECLAST Zoledronic Acid 5mg/100ml Brand $$$$$$ LMN

RECOMBINATE Antihemophilic Factor 220‐400u, 401‐800u, 801‐1240u, 1241‐1800u

Brand $$$$$$ LMN

REFACTOLD Antihemophilic Factor 250u, 500u, 1000u, 2000u

REFLUDAN Lepirudin 50mg

REMICADE Infliximab 100mg

REPRONEX Menotropins 75u

REVLIMIDLD Lenalidomide 5mg, 10mg, 15mg, 25mg

RHOPHYLACLD Rho D Immune Globulin 1500u/2ml

RIBASPHERE Ribavirin 200mg, 400mg, 600mg

RIMSO‐50 Dimethyl Sulfoxide 50%

RITUXAN Rituximab 100mg, 500mg

SAIZEN Somatropin 5mg, 8.8mg

10mg, 20mg, 30mg, 50mcg/ml,

SANDOSTATIN Octreotide Acetate 100mcg, 200mcg, 500mcg,

1000mcg

SENSIPAR Cinacalcet HCl 30mg, 60mg, 90mg

SEROSTIMLD Somatropin 4mg, 5mg, 6mg, 8.8mg

SIMPONI Golimumab 50mg

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ Step: Fail 2 DMARD

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ Brand $$$$$$ CPA

Brand $$$$$$

Brand $$$$$$ LMN

Brand $$$$$$ LMN

Brand $$$$$$ Step: Fail 2 DMARD

SOLU‐CORTEF Hydrocortisone Sodium Succinate 100mg, 250mg, 500mg, 1000mg Brand $$$$$$ LMN

SOMAVERTLD Pegvisomant 10mg, 15mg, 20mg Brand $$$$$$ LMN

20mg, 50mg, 70mg, 80mg, 100mg, SPRYCEL Dasatinib

140mg Brand $$$$$$

STIMATE Desmopressin Acetate 1.5mg/ml Brand $$$$$$ LMN

Sodium Hyaluronate Intra‐ SUPARTZ

articular 25mg/2.5ml Brand $$$$$$ LMN

m

XOLAIRLD Omalizumab 150mg Brand $$$$$$ LMN

1mcg, 2mcg, 4mcg, 2mcg/ml, ZEMPLAR Paricalcitol

5mcg/ml Brand $$$$$$ LMN

ZINECARD Dexrazoxane 250mg, 500mg Brand $$$$$$ LMN

ZOLADEX Goserelin Acetate 3.6mg, 10.8mg Brand $$$$$$

ZORBTIVE Somatropin 8.8mg Brand $$$$$$ CPA

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-21

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 17 of 17


Brand Name

Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA ABELCET Amphotericin B Lipid 5mg/ml Brand $$$$$$ LMN ACCOLATE Zafirlukast 10mg, 20mg Brand $$$$ Step: Singulair ACCU‐CHEK ‐ kits, strips and

supplies Brand $$$$ QL= 100 strips/30 days ACCUPRIL Quinapril HCl 5mg, 10mg, 20mg, 40mg Generic $$$

Step: Failure of two: omeprazole, ACIPHEX Rabeprazole Sodium EC 20mg Brand $$$$ pantoprazole, lansoprazole; QL= 34

caps/packets/30 days ACTHARLD

Corticotropin 80u Brand $$$$$$ LMN ACTHREL Corticorelin Ovine Triflutate 100mcg Brand $$$$$$ LMN ACTICIN Permethrin Lotion 1% Generic $$ ACTIMMUNELD

Interferon Gamma‐1B 2000000u/0.5ml Brand $$$$$$ LMN ACTIVELLA Estradiol & Norethindrone Acetate 1‐0.5mg Generic $$$$ ACTONEL, ACTONEL WITH

CALCIUM

Risedronate Sodium, Risedronate Sod wit

Calcium Carbonate h

5mg, 30mg, 35mg, 75mg, 150mg

Brand

$$$$

Step: alendronate

ACTOPLUS MET Pioglitazone HCl‐Metformin HCl 15/850mg, 30/1000mg Brand $$$$ ACTOS Pioglitazone HCl 15mg, 30mg, 45mg Brand $$$$ ACULAR, LS Ketorolac Tromethamine 0.5%, 0.4% Generic $$$$ ACUVAIL Ketorolac Tromethamine 0.45% Brand $$$ LMN ADCIRCA Tadalafil 20mg Brand $$$$$$

ADDERALL

Amphetamine‐Dextroamphetamine

5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg

Generic

$$$

CPA; Age > 23

ADDERALL XR

Amphetamine‐Dextroamphetamine SR

5mg, 10mg, 15mg, 20mg, 30mg

Brand

$$$$$

CPA; Age > 23

ADRIAMYCIN Doxorubicin HCl 2mg/ml Generic $$$$ ADRUCIL Fluorouracil 2.5g/50ml, 5g/100ml, 500mg/10ml Generic $$

ADVAIR DISKUS

Fluticasone‐Salmeterol

100/50, 250/50, 500/50

Brand

$$$$ QL= 120 inhs/60pk; 28 inhs/28pk; 14

inhs/14pk; per 30 days


ADVATE

Antihemophilic Factor rAHF‐PFM

250u, 500u, 1000u, 1500u, 2000u, 3000u

Brand

$$$$$$

LMN

ADVIL Ibuprofen 200mg OTC $ QL= 100 tabs/30 days AFINITOR Everolimus 2.5mg, 5mg, 10mg Brand $$$$$$ AGGRENOX Aspirin‐Dipyridamole 25‐200mg Brand $$$ ALBENZA Albendazole Oral 200mg Brand $$$$

ALDACTAZIDE

Spironolactone & Hydrochlorothiazide

25/25mg

Generic

$$$

ALDACTONE Spironolactone 25mg, 50mg, 100mg Generic $$$ ALDARA Imiquimod 5% Generic $$$ CPA ALDOMET Methyldopa 250mg, 500mg Generic $$$$ ALDURAZYMELD

Laronidase 2.9mg/5ml Brand $$$$$$ LMN ALEVE Naproxen Sodium 220mg OTC $ QL= 100 tabs/30 days ALFERON NM

Interferon Alfa‐n3 5000000u/ml Brand $$$$$$ LMN ALIMTA Pemetrexed Disodium 100mg, 500mg Brand $$$$$$ ALINIA Nitazoxanide Oral 500mg Brand $$$$$ ALKERAN Melphalan 2mg, 50mg Brand $$$$$$ ALLEGRA Fexofenadine 30mg, 60mg, 180mg OTC $$ Step: Claritin; QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 12 hour, 24 hour OTC $$ QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 60mg/120mg, 180mg/240mg Generic $$ ALORA Estradiol 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$ QL= 68 packets/30 days ALOXI Palonosetron HCl 0.25mg Brand $$$$$$ ALPHAGAN P Brimonidine Tartrate 0.1%, 0.15% Generic $$$ ALPHANATE Antihemophilic Factor/VWF 250‐500u, 1000‐1500u, 1500u Brand $$$$$$$ LMN ALPHANINE Coagulation Factor IX 500u, 1000u, 1500u Brand $$$$$$$ LMN ALREX Loteprednol Etabonate 0.2% Brand $$$$ ALTACE Ramipril 1.25mg, 2.5mg, 5mg, 10mg Generic $$$ AMARYL Glimepiride 1mg, 2mg, 4mg Generic $$$ AMBIEN Zolpidem Tartrate 5mg, 10mg, 6.25mg, 12.5mg Generic $$ QL= 30 tabs/30 days AMBISOME Amphotericin B Liposome 510mg Brand $$$$ LMN; Specialty

AMERGE

Naratriptan HCl

1mg, 2.5mg

Generic

$$$$ Step: Sumatriptan Succinate; QL= 9 tabs/

days (1mg & 2.5mg)

30

AMEVIVE Alefacept 15mg Brand $$$$$$ LMN AMIKIN Amikacin IV Generic $$$$ QL= 14 days AMINOCAPROIC ACID Aminocaproic Acid 250mg/ml, 500mg Generic $$$$$$ LMN AMITIZA Lubiprostone 8mcg, 24mcg Brand $$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10 $$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-22 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 1 of 18


Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA

AMOXIL Amoxacillin‐Oral Generic $$ AMPICILLIN Ampicillin IV 125mg, 250mg, 500mg, 1g, 2g, 10g Generic $$$ LMN

AMPYRALD

Dalfampridine 10mg Brand $$$$$$ LMN

ANAFRANIL Clomipramine HCl 25mg, 50mg, 75mg Generic $ ANALPRAM‐HC Hydrocortisone Acetate w/ Pramoxine 1‐1%, 1‐2.5%, 2.5%, 2.5‐1% Generic $$$$ ANCEF Cefazolin Generic $$$ ANCOBON

ANDRODERM

ANDROGEL

ANGELIQ

Flucytosine Oral

Testosterone

Testosterone

Drospirenone‐Estradiol

250mg, 500mg

2.5mg/24HR, 5mg/24HR

1%

0.5‐1mg

Brand

Brand

Brand

Brand

$

$

$

$$$$

LMN

APIDRA Insulin Glulisine 100u/ml Brand $$$$ Step: Humalog

APLENZIN Bupropion HBr 174mg, 348mg, 522mg Brand $$ APOKYNLD

Apomorphine Hydrochloride 50mg, 100mg, 20mg/ml Brand $$$$$$ LMN

APRESOLINE Hydralazine HCl 10mg, 25mg, 50mg, 100mg Generic $$$$ APRI

Desogestrel & Ethinyl Estradiol Tab 0.15

MG‐30 MCG Generic $$$

ARALASTLD Proteinase Inhibitor 400mg, 500mg, 800mg, 1000mg Brand $$$$$$ LMN

ARALEN Chloroquin Phosphate Oral 250mg Generic $$$

Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐ ARANELLE

35/0.5‐35 MG‐MCG 25mcg, 40mcg, 60mcg, 100mcg, 150mcg,

Generic $$

ARANESP Darbepoetin Alfa‐Polysorbate 200mcg, 300mcg, 500mcg

Brand $$$$$$ CPA; QL= 2 inj/30 days; Available at Retail


AREDIA Pamidronate Disodium 30mg, 90mg Brand $$$$$$ LMN

ARICEPT, ARICEPT ODT Donepezil Hydrochloride 5mg, 10mg, 23mg Generic $$$$

ARIMIDEX Anastrozole 1mg Generic $$$$

2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml, ARIXTRA Fondaparinux Sodium

10mg/0.8ml Brand $$$$$$ CPA; QL= 28 inj/14 days; Available at Retail

ARMOUR THYRO Thyroid 32.5mg, 65mg, 130mg, 195mg Generic $$

AROMASIN Exemestane 25mg Generic $$$$ Step: anastrozole

ASA Aspirin 81mg, 325mg OTC $ QL= 120 tabs/30 days

ASACOL, ASACOL HD Mesalamine 400mg, 800mg Brand $$$ LMN QL= 1 inh (#14 inhalation units); 2

inhs

ASMANEX Mometasone Furoate 110mcg, 220mcg Brand $$$$ (#30, #60, #120 inhalation units); per 30

days

ASTELIN Azelastine HCl 0.1% Generic $$$$ QL= 2 bottles/30 days

ASTEPRO Azelastine HCl 137mcg, 0.15% Brand $$$$ QL= 2 bottles/30 days

ATARAX Hydroxyzine HCl 10mg, 25mg, 50mg Generic $$

ATIVAN Lorazepam 0.5mg, 1mg, 2mg, Generic $$$ QL= 120tabs/30days

ATROVENT Ipratropium Bromide 0.02% Generic $$$$


AUGMENTIN Amoxacillin/Clavulanate‐Tabs, Susp Generic $$$

AURALGAN Benzocaine‐Antipyrine Generic $$$

AVALIDE Irbesartan‐Hydrochlorothiazide 150‐12.5mg, 300‐12.5mg, 300‐25mg Brand $$$$ Step: losartan potassium HCT

AVANDAMET Rosiglitazone Maleate‐Metformin HCl 2‐500mg, 2‐1000mg, 4‐500mg, 4‐1000mg Brand $$$$ LMN

AVANDARYL Rosiglitazone Maleate‐Glimepiride 4‐1mg, 4‐2mg, 4‐4mg, 8‐2mg, 8‐4mg Brand $$$$ LMN


AVASTIN Bevacizumab Brand $$$$$$


Levonorgestrel & Ethinyl Estradiol Tab 0.1 AVIANE

MG‐20 MCG Generic $$




Step: Sumatriptan Succinate; QL= 9 tabs/30

days (6.25mg); 9 tabs/30 days (12.5 mg)

AYGESTIN Norethindrone Acetate 5mg Generic $$$$

AZACTAM Aztreonam IV Generic $$$$$ LMN

AZASITE Azithromycin 1% Brand $$

AZILECT Rasagiline Mesylate 0.5mg, 1mg Brand $$$

Amlodipine Besylate‐Olmesartan AZOR

Medoxomil 5‐20mg, 5‐40mg, 10‐20mg, 10‐40mg Brand $$$$ Step: amlodipine


$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-23

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 2 of 18



BACTRIM DS Sulfamethoxazole/Trimethoprim Generic $$ BACTROBAN Mupirocin Generic $$ BARACLUDE Entecavir 0.5mg, 1mg, 0.05mg/ml Brand $$$$$$ LMN

BEBULIN VH Factor IX Complex 200‐1200u Brand $$$$$$$ LMN

BECONASE AQ

Beclomethasone Dipropionate Monohyd

0.042%

Brand

$$$$ Step: Fail one: flunisolide, fluticasone,

OMNARIS

BENADRYL Diphenhydramine HCl 25mg, 50mg OTC $ QL= 100 caps/30 days BENEFIX Coagulation Factor IX 250u, 500u, 1000u, 2000u Brand $$$$$$$ LMN BENEMID Probenecid 500mg Generic $$$$ BENICAR Olmesartan Medoxomil 5mg, 20mg, 40mg Brand $$$ Step: losartan potassium BENICAR HCT

Olmesartan Medoxomil‐

Hydrochlorothiazide 20‐12.5mg, 40‐12.5mg, 40‐25mg Brand $$$$ Step: losartan potassium HCT

BENTYL Dicyclomine HCl 10mg, 20mg Generic $$$ BENZACLIN Clindamycin Phosphate‐Benzoyl Peroxide 1‐5% Generic $$$$ BENZAMYCIN Benzoyl Peroxide‐Erythromycin 5‐3% Generic $$$$ BENZOYL Benzoyl Peroxide 5% OTC $$ QL= 85g/ 30days BETAGAN Levobunolol HCl 0.25%, 0.5% Generic $$ BETAPACE Sotalol HCl 80mg, 120mg, 160mg, 240mg Generic $$$$ BETASERON Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN

QL= 28 tabs/14 days, Max 2 fills/30 days BIAXIN Clarithromycin Oral Generic $$$

(250mg & 500mg); 280ml/14 days, Max 2

fills of 280ml/30 days (125mg/5ml &

BICILLIN L‐A

Benzathine IM

Generic

$$$$

250mg/5ml)

LMN BICNU Carmustine 100mg Brand $$$$$$ BILTRICIDE Praziquantal Oral 600mg Brand $$$ BLEOMYCIN Bleomycin Sulfate 15u, 30u Generic $$$$$$ BLEPH‐10 Sulfacetamide Sodium 10% Generic $$ BONIVA Ibandronate Sodium 3mg/3ml Brand $$$$ LMN BONIVA Ibandronate Sodium 2.5mg, 150mg Brand $$$$ BOTOX OnabotulinumtoxinA 50u, 100u, 200u Brand $$$$$$ LMN BRAVELLE Urofollitropin 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN BROMDAY Bromfenac Sodium 0.09% Generic $$$$ BROVANA Arformoterol Tartrate 15mcg Brand $$$$ Step: Foradil BUMEX Bumetanide 0.5mg, 1mg, 2mg, Generic $$$ BUSPAR Buspirone HCl 5mg, 7.5mg, 10mg, 15mg, 30mg Generic $$$ QL= 120tabs/30days BUTALBITAL Butalbital Generic $$ BYETTA Exenatide 5mcg, 10mcg Brand $$$$ CPA; QL= 2 syringes/30 days CABERGOLINE Cabergoline 0.5mg Generic $$$$$$ LMN CAMPATH Alemtuzumab 30mg/ml Brand $$$$$$ LMN CAMPTOSAR Irinotecan HCl 20mg/ml Brand $$$$$$ CANASA Mesalamine 1000mg Brand $$$$ LMN CANCIDAS Caspofungin Acetate 50mg, 70mg Brand $$ LMN; Specialty CAPOTEN Captopril 12.5mg, 25mg, 50mg, 100mg Generic $$$ CAPOZIDE Captopril & Hydrochlorothiazide 25‐15mg, 25‐25mg, 50‐15mg, 50‐25mg Generic $$$ CARAC Fluorouracil 0.5% Brand $$$$ CARAFATE Sucralfate 1g Generic $$$$ CARBATROL Carbamazepine 100mg, 200mg, 300mg Brand $$$$

CARBOPLATIN

Carboplatin

50mg/5ml, 150mg/15ml, 450mg/45ml,

600mg/60ml, 50mg, 150mg, 450mg

Generic

$$$$$$

CARDENE Nicardipine HCl 20mg, 30mg Generic $$

CARDIZEM Diltiazem HCl 120mg/24, 180mg/24, 240mg/24, Generic $$$$

CARDURA Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg Generic $$$$ CARIMUNE Immune Globulin 3g, 6g, 12g Brand $$$$$$ LMN CASODEX Bicalutamide 50mg Generic $$$$ CATAPRES Clonidine HCl 0.1mg, 0.2mg, 0.3mg Generic $$$ CEFOTAN Cefotetan‐IV Generic $$$ LMN CEFTIN Cefuroxime IV, Oral Generic $$$ LMN CELEBREX Celecoxib 50mg, 100mg, 200mg, 400mg Brand $$$$ Step: Fail Any 2 NSAIDs CELEXA Citalopram Hydrobromide 10mg, 20mg, 40mg Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-24 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 3 of 18

30mg, 60mg, 90mg, 180mg, 240mg,

300mg/24, 360mg/24



CELLCEPT Mycophenolate Mofetil 250mg, 500mg Generic $$$$ CELLCEPT Mycophenolate Mofetil 250mg, 500mg, 250mg/ml Brand $$$$$$ LMN CEPHULAC Lactulose 10g/15ml, 20g/30ml Generic $$$$ CEREDASE Alglucerase 80u/ml Brand $$$$$$ LMN

CEREFOLIN

L‐Methylfolate w/ Vit B12‐Vit B6‐Vit B2

Brand

$$$$


CERUMENEX Triethanolamine Oleate Brand $$$

CESIA

Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐

0.025/0.15‐0.025MG‐MG

Generic

$$

CETROTIDE Cetrorelix Acetate 0.25mg, 3mg Brand $$$$$$ LMN CILOXAN Ciprofloxacin HCl 3% Generic $$$ CIMZIA Certolizumab Pegol 200mg/ml Brand $$$$$$ Step: Fail 2 DMARD CINRYZE

LD

CIPRO

C1 Inhibitor 500u Brand $$$$$$ LMN

CIPRODEX Ciprofloxacin Oral

Ciprofloxacin‐Dexamethasone

0.3‐0.1%

Generic

Brand

$$$

$$$$

CISPLATIN

Cisplatin

50mg/50ml, 100mg/100ml, 200mg/200ml

Generic

$$$

CLADRIBINE Cladribine 1mg/ml Generic $$$$$$ CLAFORAN Cefotaxime IV Generic $$$ LMN CLARITIN Loratadine 5mg, 10mg OTC $$ QL= 30caps/30 days CLEOCIN Clindamycin Oral, IV Generic $$$ LMN CLEOCIN‐T Clindamycin Phosphate 1%, 2% Generic $$$$ CLIMARA Estradiol TD

0.025mg, 0.0375mg, 0.05mg, 0.06mg,

0.075mg, 0.1mg Generic $$$$ QL= 5 patches/30 days

CLIMARA PRO Estradiol‐Levonorgestrel Brand $$$ QL= 5 patches/30 days CLINORIL Sulindac 150mg, 200mg Generic $$$ CLOTRIMAZOLE Clotrimazole Vaginal, Topical, Troches Generic $ to $$$$ COGENTIN Benztropine Mesylate 0.5mg, 1mg, 2mg Generic $$ COLACE Docusate Sodium 100mg OTC $ QL= 60 caps/30 days COLAZAL Balsalazide Disodium 750mg Generic $$$$ COLCRYS Colchicine 0.6mg Brand $$$$ Step: NSAIDS COLESTID Colestipol HCl 1g, 5g Generic $$$$ COLY‐MYCIN M Colistimethate Sodium 150mg Brand $$$$$$ LMN COMBIPATCH Estradiol‐Norethindrone Ace 0.05/0.14mg, 0.05/0.25mg Brand $$$ COMBIVENT Ipratropium‐Albuterol 18‐103mcg/ACT Brand $$$$ QL= 3 inhrs/30 days COMPAZINE Prochlorperazine Maleate 5mg, 10mg Generic $$ COMTAN Entacapone 200mg Brand $$$$ CONCERTA Methylphenidate HCl 18mg, 27mg, 36mg, 54mg Brand $$$$$ CPA; Age > 23 CONDOMS Condoms OTC $$ QL= 12/30 days CONGESTAC Pseudoephedrine‐Guaifenesin Generic $$$ COPAXONE Glatiramer Acetate 20mg/ml Brand $$$$$$ LMN COPEGUS Ribavirin 200mg Brand $$$$$$ LMN COREG Carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg Generic $$$$ CORGARD Nadolol 20mg, 40mg, 80mg Generic $$ CORTISPORIN Neomycin‐Colistin‐HC‐Thonzonium Generic $$ CORTROSYN Cosyntropin 0.25mg Generic $$$$ COUMADIN Warfarin Sodium

1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg,

7.5mg, 10mg Generic $$$

COZAAR Losartan Potassium 25mg, 50mg, 100mg Generic $$$$ CREON Amy‐Lip‐Prot 5, 10, 20, 6000u, 12000u, 24000u Brand $$$$ CROLOM Cromolyn Sodium 4% Generic $$ CRYSELLE‐28

Norgestrel & Ethinyl Estradiol Tab 0.3 MG

30 MCG

‐ Generic $$


CYCLESSA


0.025/0.15‐0.025MG‐MG

Generic

$$

CYCLOPHOSPHAMIDE Cyclophosphamide 25mg, 50mg, 500mg, 1g, 2g Brand $$$$$$ CYMBALTA Duloxetine HCl 20mg, 30mg, 60mg Brand $$$$ Step: venlafaxine ER HCL CYTOGAM Cytomegalovirus Immune Globulin Brand $$$$$$ LMN CYTOTEC Misoprostol 100mcg, 200mcg Generic $$$$ CYTOVENE Gancyclovir IV 500mg Generic $ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10




CYTOXAN Cyclophosphamide 2g Brand $$$$$$ LMN DACARBAZINE Dacarbazine 100mg, 200mg Generic $$$$$$ DAPSONE Dapsone Oral 25mg, 100mg Generic $$ DAUNORUBINCIN Daunorubicin HCl 20mg, 5mg/ml Generic $$$$$$ DAYPRO Oxaprozin 600mg Generic $$$$

DDAVP

Desmopressin Acetate

0.1mg, 0.2mg, 4mcg/ml, 15mcg/ml, 0.1%

Brand

$$$$$$

LMN

DECADRON Dexamethasone 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg Generic $$$ DEFEROXAMINE Deferoxamine Mesylate 500mg, 2g Generic $$$$$$ DELSYM Dextromethorphan Polistirex 30mg/5ml OTC $$ QL= 148 ml/30 days

DEMEROL

Meperidine HCl 10mg/ml, 25mg/ml, 50mg/ml, 75mg/ml,

100mg/ml

Generic

$$$

CPA; QL= 120ml/30 days

DEPAKOTE SPR Divalproex Sodium Sprinkle 125mg, 250mg, 500mg Generic $$$ DEPAKOTE, DEPAKOTE ER Divalproex Sodium 125mg, 250mg, 500mg Generic $$$ DEPO‐MEDROL Methylprednisolone Acetate 40mg/ml, 80mg/ml Generic $$$$ DEPO‐PROVERA

Medroxyprogesterone Acetate IM Susp

150 MG/ML Generic $$$

DEPO‐PROVERA Medroxyprogesterone Acetate IM Susp

400 MG/ML

Brand

$$$$

DESFERAL Deferoxamine Mesylate 500mg, 2g Brand $$$$$$ LMN DESMOPRESSIN Desmopressin Acetate 0.1mg, 0.2mg, 4mcg/ml, 0.1% Generic $$$$$ LMN

DESOGEN‐28 Desogestrel & Ethinyl Estradiol Tab 0.15

MG‐30 MCG

Generic

$$$

DESOWEN Desonide 5% Generic $$$$ DESOXYN Methamphetamine HCl 5mg Generic $$$$ CPA; Age > 23 DESYREL Trazodone HCl 50mg, 100mg, 150mg, 300mg Generic $$

Step: Failure of two: omeprazole, DEXILANT (formerly KAPIDEX) Dexlansoprazole 30mg, 60mg Brand $$$$ pantoprazole, lansoprazole; QL= 34

caps/packets/30 days DIFFERIN Adapalene 0.1%, 0.3% Generic $$$$ CPA DIFLUCAN Fluconazole Oral 50mg, 100mg, 150mg, 200mg Generic $$$$ LMN DILANTIN Phenytoin Sodium 100mg Generic $$ DILAUDID Hydromorphone HCl 1mg, 2mg, 4mg, 8mg Generic $$$ QL= 120 tabs/30 days DIOVAN Valsartan 40mg, 80mg, 160mg, 320mg Brand $$$ Step: losartan potassium DIOVAN HCT Valsartan‐Hydrochlorothiazide

80‐12.5mg, 160‐12.5mg, 160‐25mg, 320‐

12.5mg, 320‐25mg Brand $$$$ Step: losartan potassium HCT

DIPENTUM Olsalazine Sodium 250mg Brand $$$$

DIPROLENE

Betamethasone Dipropionate Augmented

5%

Generic

$$$

DIPROSONE Betamethasone Dipropionate 5% Generic $$$ DISALCID Salsalate 500mg, 750mg Generic $$ DITROPAN XL Oxybutynin Chloride 5mg, 10mg Generic $$ DOVONEX Calcipotriene 0.005% Generic $$$$$ DOXIL Doxorubicin HCl Liposomal 2mg/ml Brand $$$$$$ DOXYCYCLINE Doxycycline Oral Generic $$ DUETACT Pioglitazone HCl‐Glimepiride 30‐2mg, 30‐4mg Brand $$$$

DURAGESIC

Fentanyl TD Patch

12mcg, 25mcg, 50mcg, 75mcg, 100mcg

Generic

$$$$

CPA; QL= 15/30days

DYCILL Dicloxacillin‐Oral Generic $$ EDECRIN Ethacrynic Acid 25mg Brand $$$ CPA EES Erythromycin Esthylsuccinate 400mg Generic $$$ EFFEXOR Venlafaxine HCl 25mg, 37.5mg, 50mg, 75mg, 100mg Generic $$ EFFEXOR ER Venlafaxine HCl SR 37.5mg, 75mg, 150mg, 225mg Generic $$$ EFFIENT Prasugrel HCl 5mg, 10mg Brand $$$$ Step: Plavix ELAPRASELD

Idursulfase 6mg/3ml Brand $$$$$$ LMN

ELAVIL

Amitriptyline HCl

10mg, 25mg, 50mg, 75mg, 100mg, 150mg

Generic

$$

ELIDEL Pimecrolimus 1% Brand $$$$ CPA ELIGARD Leuprolide Acetate 7.5mg, 22.5mg, 30mg, 45mg Brand $$$$$$ ELIMITE Permethrin 5% Generic $$$$ ELLENCE Epirubicin HCl 2mg/ml Brand $$$$$$ LMN ELOCON Mometasone Furoate 0.1% Generic $$$ ELOXATIN Oxaliplatin 50mg, 100mg, 200mg Brand $$$$$$ ELSPAR Asparaginase 10000u Brand $$$$$$ EMEND Aprepitant 80mg, 115mg, 125mg, 150mg Brand $$$$ LMN: Specialty

$ ‐‐‐‐‐‐‐‐‐ $1 to $10




ESTROSTEP FE Norethindrone Ac‐Ethinyl Estrad‐Fe Tab

20/1‐30/1‐35 MG‐MCG

1‐

Generic

$$$


EUFLEXXA Sodium Hyaluronate 10mg/ml Brand $$$$$$ LMN EURAX Crotamiton 10% Brand $$$$ EVISTA Raloxifene HCl 60mg Brand $$$$ EVOXAC Cevimeline HCl 30mg Brand $$$$$$ LMN EXELON Rivastigmine Tartrate 1.5mg, 3mg, 4.5mg, 6mg Generic $$$$ EXELON PATCH Rivastigmine TD Patch 4.6mg/24HR, 9.5mg/24HR Brand $$$$ EXJADELD

Deferasirox 125mg, 250mg, 500mg Brand $$$$$$ EXTAVIA Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN FABRAZYMELD

Agalsidase beta 5mg, 35mg Brand $$$$$$ LMN FAMVIR Famcyclovir Oral 125mg, 250mg, 500mg Generic $$$$ FASLODEX Fulvestrant 250mg/5ml Generic $$$$$$ FEIBA VH Antiinhibitor Coagulant Complex Brand $$$$$$ LMN FELDENE Piroxicam 10mg, 20mg Generic $$$$ FEMARA Letrozole 2.5mg Generic $$$$$ FEMHRT Norethindrone Acetate‐Ethinyl Estradiol 0.5mg‐2.5mcg, 1mg‐5mcg Generic $$$$

FENTORA

Fentanyl Citrate 100mcg, 200mcg, 300mcg, 400mcg,

600mcg, 800mcg

Brand

$$$$$

CPA

FERRLECIT Sod Ferric Gluc Cmplx 12.5mg Brand $$$$$$ LMN FINACEA, FINACEA PLUS KIT Azelaic Acid 15%, Kit Brand $$$$ FIORICET Butalbital‐Acetaminophen‐Caffeine 50‐325‐40mg Generic $$ FLAGYL Metronidazole Oral, IV Generic $$ to $$$$ FLEBOGAMMALD

Immune Globulin 5%, 10% Brand $$$$$$ LMN FLEXERIL Cyclobenzaprine HCl 5mg, 10mg Generic $$$ QL= 90 tabs/30 days FLOLANLD

Epoprostenol Sodium 0.5mg, 1.5mg Brand $$$$$$ LMN FLOMAX Tamsulosin HCl 0.4mg Generic $$$$ FLONASE Fluticasone Propionate 50mcg Generic $$$ QL= 2 inhrs/30 days FLORINEF Fludrocortisone Acetate 0.1mg Generic $$$ FLORONE Diflorasone Diacetate 0.05% Generic $$$

FLOVENT HFA



Brand

$$$$ QL= 44mcg ‐ 2 inhrs; 110m

220mcg ‐ 3 inhrs; per 30 d

cg ‐ 1 inhr;

ays

FLUDARA Fludarabine Phosphate 50mg Brand $$$$$$ FLUDARABINE Fludarabine Phosphate 50mg, 50mg/2ml Generic $$$$$$ FML FORTE Fluorometholone 0.25% Brand $$ FOCALIN, FOCALIN XR Dexmethylphenidate HCl

2.5mg, 5mg, 10mg, 15mg, 20mg, 30mg,

40mg Brand $$$$ CPA; Age > 23

FOLLISTIM Follitropin Beta 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN FOLTX Folic Acid 400mcg, 800mcg, 1000mcg, 1g Generic $$

FORADIL

Formoterol Fumarate

Brand

$$$$ CPA; QL= 12 caps/12pk; 12

per 30 days

0 caps/60pk;

FORTAZ Ceftazidime IV Generic $$$ LMN; Specialty

$ ‐‐‐‐‐‐‐‐‐ $1 to $10


EMETROL Fructose‐Dextrose‐Phosphoric Acid OTC $ QL= 240ml/ 30 days

EMTRIVA Emtricitabine Oral 200mg Brand $$$$$ ENABLEX Darifenacin Hydrobromide 7.5mg, 15mg Brand $$$ ENBREL Etanercept 25mg, 25mg/0.5ml, 50mg/ml Brand $$$$$$ Step: Fail 2 DMARD



30/0.075‐40/0.125‐30MG‐MCG

Generic

$$

EPIPEN, EPIPEN‐JR

Epinephrine

0.15mg, 0.3mg

Brand

$$$$ CPA; QL= 3 units/pkg size 1; 4 units/pkg

size 2; per 30 days

EPIVIR Lamivudine Oral 150mg, 300mg Brand $$$$

EPOGEN

Epoetin Alfa 2000u/ml, 3000u/ml, 4000u/ml,

10000u/ml, 20000u/ml, 40000u/ml

Brand

$$$$$$

CPA; QL= 2 inj/30 days; Available at Retail


ERBITUX Cetuximab 100mg, 200mg Brand $$$$$$



ESTRACE Estradiol 0.5mg, 1mg, 2mg Generic $$

ESTRACE VAG Estradiol Vaginal Cream Brand $$$

ESTRASORB Estradiol Brand $$$ QL= 68 packets/30 days





FOSAMAX Alendronate Sodium 5mg, 10mg, 35mg, 70mg Generic $$$ FOSRENOL Lanthanum Carbonate 250mg, 500mg, 750mg, 1000mg Brand $$$$$

FRAGMIN

Dalteparin Sodium

2500u/0.2ml, 5000u/0.2ml, 7500u/0.3ml,

10000u/ml, 25000u/ml, 9500u, 12500u,

Brand

$$$$$$

CPA; QL=2 inj/30 days; Available at Retail

15000u, 18000u

FROVA

Frovatriptan Succinate

2.5mg

Brand

$$$$ Step: Sumatriptan Succinate; QL= 9 tabs/30

days



1g/10ml, 2.5g/25ml, 5g/50ml, 10g/100ml,

20g/200ml, 30g/300ml, 0.5g, 2.5g, 5g, 10g

Brand $$$$$$ LMN

GAMUNEX Immune Globulin

10%, 1g/10ml, 2.5g/25ml, 5g/5ml,

10g/100ml, 20g/200ml

Brand $$$$$$ LMN



GELNIQUE Oxybutynin Chloride 10% Brand $$$


GENOTROPIN Somatropin

0.2mg, 0.4mg, 0.6mg, 0.8mg, 1mg, 1.2mg,

1.4mg, 1.6mg, 1.8mg, 2mg, 5mg, 12mg

Brand $$$$$$ CPA

GILENYA Fingolimod HCl 0.5mg Brand $$$$$$ LMN


GLUCAGEN Glucagon HCl 1mg Brand $$$$$

GLUCOPHAGE Metformin HCl 500mg, 750mg, 850mg, 1000mg Generic $$$

GLUCOPHAGE XR Metformin HCl SR 500mg, 750mg Generic $$$




GLYCOLAX Polyethylene Glycol OTC $$

GOLYTELY PEG 3350‐KCl‐Na Bicarb‐NaCl‐Na Sulfate Generic $$$$


GRANISETRON Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml, 4mg/4ml, Generic $$$$$$ LMN

GRIS‐PEG Griseofulvin Oral 125mg, 250mg Generic $$




0.5mcg, 1mcg, 2.5mcg, 2mcg/ml, HECTOROL Doxercalciferol

4mcg/2ml Brand $$$$$

HELIDAC Metronidaz‐Tetracyc‐Bis Brand $$$$ HELIXATE

FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u Brand $$$$$$ LMN

HEMOFIL M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN




HUMATE‐P Antihemophilic Factor/VWF 500u, 600u, 1000u, 1200u, 2000u, 2400u Brand $$$$$$










HYGROTON Chlorthalidone 25mg, 50mg, 100mg Generic $$$$


HYPERRHO Rho D Immune Globulin 50mcg, 300mcg Brand $$$$$$ LMN


HYTRIN Terazosin HCl 1mg, 2mg, 5mg, 10mg Generic $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-28

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 7 of 18



HYZAAR Losartan Potassium & Hydrochlorothiazide 50‐12.5mg, 100‐12.5mg, 100‐25mg

Generic

$$$



IMDUR Isosorbide Mononitrate 10mg, 20mg, 30mg, 60mg, 120mg Generic $$$$

IMITREX Sumatriptan Succinate 25mg, 50mg, 100mg Generic $$$ QL= 9 tabs/30 days (25

100mg)

g, 50mg, &

IMITREX Sumatriptan Succinate Injection 4mg/0.5ml, 6mg/0.5ml Generic $$$ QL= 1 kit/30 days (2 syri

days

nges); 2 vials/30

IMODIUM Loperamide HCl 2mg Generic $$ IMURAN Azathioprine 50mg Generic $$$$$ INCRELEX Mecasermin 40mg/4ml Brand $$$$$$ CPA INDERAL Propranolol HCl 20mg, 60mg, 80mg, 120mg, 160mg Generic $$$ INDOCIN Indomethacin 25mg, 50mg, 75mg Generic $$ INFERGEN Interferon Brand $$$$$$ Specialty INNOHEP Tinzaparin Sodium 20000u/ml Brand $$$$$$ LMN; Available at Retail INSPRA Eplerenone 25mg, 50mg Generic $$$$ INTRON‐A Interferon Alfa‐2B 3u, 5u, 10u, 18u, 25u, 50u Brand $$$$$$ QL= 2 inj/30 days INVANZ Ertapenem IV Generic $$$$$ LMN ISONIAZID Isoniazid Oral Generic $$ ISOPTIN Verapamil HCl 40mg, 80mg, 180mg, 240mg Generic $$$ ISORDIL Isosorbide Dinitrate 5mg, 10mg, 20mg, 30mg, 40mg Generic $$$$ IXEMPRA Ixabepilone 15mg, 45mg Generic $$$$$$ JANUMET Sitagliptin‐Metformin HCl 50‐500mg, 50‐1000mg Brand $$$$$ JANUVIA Sitagliptin Phosphate 25mg, 50mg, 100mg Brand $$$$ JEVTANA Cabazitaxel 60mg/1.5ml Generic $$$$$$$

JUNEL FE Norethindrone Ace & Ethinyl Estradiol

Tab 1 MG‐20MCG, 1.5 MG‐30 MCG

‐FE Generic $$

KARIVA

Desogest‐Eth Estrad & Eth Estrad Tab 0

0.02/0.01 MG(21/5)

.15‐ Generic

$$$

KEFLIN Cephalothin‐Oral Generic $$$ KELNOR

Ethynodiol Diacetate & Ethinyl Estradi

Tab 1 MG‐35 MCG ol

Generic $$ KENALOG Triamcinolone Acetonide 0.025%, 0.1%, 0.5% Generic $$ KEPPRA Levetiracetam

100mg/ml, 250mg, 500mg, 750mg,

1000mg Generic $$$

KEPPRA XR Levetiracetam SR 500mg, 750mg Brand $$$ KINERET Anakinra Brand $$$$$$ LMN KLARON Sulfacetamide Sodium 10% Generic $$$$ KLONOPIN Clonazepam 0.125mg, 0.25mg, 0.5mg, 1mg, 2mg Generic $$ KOATE‐DVI Antihemophilic Factor 250u, 500u, 1000u Brand $$$$$$

KOGENATE FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u, 250/BS,

500/BS, 1000/BS, 2000/BS, 3000/BS Brand $$$$$$ LMN

KUVANLD

Sapropterin Dihydrochloride

100mg

Brand

$$$$$$

LMN KYTRIL Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml Brand $$$$ LMN: Specialty

LAMICTAL

Lamotrigine 25mg, 50mg, 100mg, 150mg, 200mg,

250mg

Generic

$$

LAMICTAL XR

Lamotrigine SR

25mg, 100mg, 150mg, 200mg, 300mg

Brand

$$$$

LAMISIL Terbinafine Oral 250mg Generic $$$$ LANOXIN Digoxin 0.125mg, 0.25mg Generic $$$ LANTUS Insulin Glargine 100u/ml, 500u/ml Brand $$$$ LASIX Furosemide 20mg, 40mg, 80mg Generic $$ LESSINA‐28

Levonorgestrel & Ethinyl Estradiol Tab

MG‐20 MCG

0.1 Generic $$

LETAIRISLD

Ambrisentan 5mg, 10mg Brand $$$$$$ LMN; Specialty LEUKERAN Chlorambucil 2mg Brand $$$$$$ LEUPROLIDE Leuprolide Acetate 1mg/0.2ml, 5mg/ml Generic $$$$$$ LEUSTATIN Cladribine 1mg/ml Brand $$$$$$ LMN LEVAQUIN

LEVBID

Levofloxacin Oral

Hyoscyamine Sulfate

0.0125mg, 0375mg

Generic

Generic

$$

$$


$ ‐‐‐‐‐‐‐‐‐ $1 to $10


m



LEVORA‐28 Levonorgestrel & Ethinyl Estradiol Tab 0.

MG‐30 MCG

5

25mcg, 50mcg, 75mcg, 88mcg, 100mcg,

Generic

$$

LEVOTHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg, 500mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,

LEVOXYL Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg Step: Failure of two: citalopram,

LEXAPRO Escitalopram Oxalate 5mg, 10mg, 20mg Generic $$$$ fluoxetine, fluvoxamine, paroxetine, sertraline

LIALDA Mesalamine 1.2g Brand $$$$ LMN LIBRIUM Chlordiazepoxide HCl 5mg, 10mg, 25mg Generic $$ QL= 120tabs/30days LIDEX Fluocinonide 0.05% Generic $$ LIDODERM Lidocaine Patch 5% Generic $$$$$ LINDANE Lindane 1% Generic $$$ LIORESAL Baclofen 10mg, 20mg Generic $$$$ LIPITOR Atorvastatin Calcium 10mg, 20mg, 40mg, 80mg Brand $$$$ Step: simvastatin 80mg

LO/OVRAL Norgestrel & Ethinyl Estradiol Tab 0.3 MG

30 MCG

‐

Generic

$$

LODOSYN Carbidopa 25mg Brand $$$

LOESTRIN FE

Norethindrone Ace & Ethinyl Estradiol‐FE

Tab 1 MG‐20 MCG, 1.5 MG‐30 MCG

Generic

$$

LOFIBRA Fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg Generic $$$ LOMOTIL Diphenoxylate w/ Atropine 2.5mg Generic $$ LOPID Gemfibrozil 600mg Generic $$$ LOPRESSOR Metoprolol Tartrate 25mg, 50mg, 100mg Generic $$$ LOTEMAX Loteprednol Etabonate 0.5% Brand $$$ LOTENSIN Benazepril HCl 5mg, 10mg, 20mg, 40mg Generic $$$ LOTENSIN HCT Benazepril & Hydrochlorothiazide 5‐6.5mg, 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$

LOTREL Amlodipine Besylate‐Benazepril HCl 2.5‐10mg, 5‐10mg, 5‐20mg, 10‐20mg Generic $$$

LOVAZA Omega‐3‐acid Ethyl Esters 1g Brand $$$$ 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml,

LOVENOX Enoxaparin Sodium 80mg/0.8ml, 100mg/ml, 150mg/ml, Brand $$$$$$ LMN: Available at Retail 120mg/0.8ml

LOW‐OGESTREL Norgestrel & Ethinyl Estradiol Tab 0.3 MG

30 MCG

‐

Generic

$$

LOZOL Indapamide 1.25mg, 2.5mg Generic $$$ LUCENTISLD

Ranibizumab Brand $$$$$$ LMN LUMIGAN Bimatoprost 0.01%, 0.03% Generic $$$

LUPRON

Leuprolide Acetate

3.75mg, 7.5mg, 11.25mg, 22.5mg, 30mg

Brand

$$$$$$

LUTERA Levonorgestrel & Ethinyl Estradiol Tab 0.

MG‐20 MCG

1

Generic

$$

LUVOX Fluvoxamine Maleate 25mg, 50mg, 100mg Generic $$$

LYRICA

Pregabalin 25mg, 50mg, 75mg, 100mg, 150mg,

200mg, 225mg, 300mg

Brand

$$$$

Step: gabapentin

MACRODANTIN Nitrofurantoin Macorcrystal Oral Generic $$ MACUGENLD

Pegaptanib Sodium Brand $$$$$$ LMN MATULANE Procarbazine HCl 50mg Generic $$$$$$$

MAXALT, MAXALT‐MLT

Rizatriptan Benzoate

5mg, 10mg

Brand

$$$$ Step: Sumatriptan Succinate; QL= 9 tabs/

days

30

MAXIPIME Cefapime IV Generic $$ LMN MAXITROL Neomycin‐Polymyxin‐Dexamethasone 0.1% Generic $$ MAXZIDE Triamterene & Hydrochlorothiazide 37.5‐25mg, 50‐25mg, 75‐50mg Generic $$$ MEBENDAZOLE Mebendazole Oral 100mg Generic $$$ MEDROL Methylprednisolone 2mg, 4mg, 8mg, 16mg, 32mg Generic $$$ MEFOXIN Cefoxitin‐IV Generic $$ LMN MEGACE Megestrol Acetate 20mg, 40mg Generic $$$$$ MEGACE Megestrol Acetate 40mg/ml Generic $$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10


1



MONONESSA Norgestimate & Ethinyl Estradiol Tab 0

MG‐35 MCG

.25

Generic

$$

MONONINE Coagulation Factor IX 250u, 500u, 1000u Brand $$$$$$$ LMN MONOPRIL Fosinopril Sodium 10mg, 20mg, 40mg Generic $$ MONOPRIL HCT Fosinopril Sodium & Hydrochlorothiaz ide 10‐12.5mg, 20‐12.5mg Generic $$$$ MOTRIN Ibuprofen 800mg Generic $$ MS CONTIN Morphine Sulfate 15mg, 30mg, 60mg, 10mg, 200mg Generic $$$ QL= 120 tabs/30 days MYAMBUTOL Ethambutol Oral 100mg, 400mg Generic $$$ MYCAMINE Micafungin IV 50mg, 100mg Brand $$$ LMN MYCOPHENOLATE Mycophenolate Mofetil 250mg, 500mg Generic $$$$$$ LMN MYOZYME

LD Alglucosidase Alfa 50mg Brand $$$$$$ LMN

MYSOLINE Primidone 50mg, 250mg Generic $$$ NAFCILLIN Nafcillin IV Generic $$$$ LMN NAGLAZYMELD

Galsulfase 1mg/ml Brand $$$$$$ LMN NAMENDA Memantine HCl 5mg, 5‐10mg, 10mg Brand $$$$

NAPROSYN

Naproxen 220mg, 250mg, 275mg, 375m g, 500mg,

550mg

Generic

$$$

NASACORT AQ

Triamcinolone Acetonide

55mcg/ACT

Brand

$$$$ Step: Fail one: flunisolide, f

OMNARIS

luticasone,

NASALIDE Flunisolide 0.025% Generic $$$ QL= 3 inhrs/bottles/30 day s

NASONEX

Mometasone Furoate

50mcg/ACT

Brand

$$$$ Step: Fail one: flunisolide, f

OMNARIS

luticasone,

NATALCARE PLUS Prenatal Vit w/ Fe Fumarate‐FA Generic $$ Step: Prenatal OTC NAVELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10


MERREM Meropenem IV Generic $$$$ LMN

MESTINON Pyridostigmine Bromide 60mg, 60mg/5ml Brand $$$$ METADATE CD Methylphenidate HCl 10mg, 20mg, 30mg, 40mg, 50mg, 60mg Brand $$$$$ CPA; Age > 23

METANX L‐Methylfolate w/ Vit B6‐Vit B12 Brand $$$$ METHADONE Methadone HCl 5mg, 10mg, 40mg Generic $$$ CPA; QL= 120 tabs/30 days

METROGEL Metronidazole Gel 0.75% Generic $$$ METROLOTION Metronidazole 0.75% Generic $$$ MEVACOR Lovastatin 20mg, 40mg Generic $$$$ MEXATE Methotrexate Sodium

1g, 1g/40ml, 25mg/ml, 50mg/2ml,


MIACALCIN Calcitonin 200u/ACT Generic $$$$ MIACALCIN Injection Calcitonin 200u/ml Generic $$$$ LMN


MICRHOGAM PL Rho D Immune Globulin 50mcg Brand $$$$$$

MICROGESTIN

Norethindrone Ace & Ethinyl Estradiol Tab

1 MG‐20 MCG, 1.5 MG‐30 MCG

Generic $$

MICROGESTIN FE Norethindrone Ace & Ethinyl Estradiol‐FE


Generic $$

MICRO‐K Potassium Chloride 8mEq, 10mEq, 20mEq Generic $$ MICRONASE Glyburide 1.25mg,. 2.5mg, 5mg Generic $$$


MINIPRESS Prazosin HCl 1mg, 2mg, 5mg Generic $$$ MIRAPEX Pramipexole Dihydrochloride 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg Generic $$$

MIRAPEX ER

Pramipexole Dihydrochloride SR

0.375mg, 0.75mg, 1.5mg, 3mg, 4.5mg

Brand

$$$$

Step: Pramipexole Dihydrochloride

MIRCETTE Desogest‐Eth Estrad & Eth Estrad Tab 0

0.02/0.01 MG(21/5)

.15‐

Generic

$$$

MIRTAZAPINE Mirtazapine 7.5mg, 15mg, 30mg, 45mg Generic $$$ MITOMYCIN Mitomycin 5mg, 20mg, 40mg Generic $$$$$$ MOBIC Meloxicam 7.5mg, 15mg Generic $$$$ MODICON

Norethindrone & Ethinyl Estradiol Tab

MG‐35MCG

0.5 Generic $$$

MONARC‐M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN




Norethindrone & Ethinyl Estradiol Tab 0.5 Generic $$

500mg Generic $$$$ QL= 2 tabs/30 days

25mg, 100mg Generic $$$$$$

Generic $$

6mg/0.6ml Brand $$$$$$ CPA; QL= 2 inj/30 days

NECON MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐

35/1‐35 MG‐MCG

NEOMYCIN Neomycin Sulfate ‐Oral

NEORAL Cyclosporine

NEOSPORIN Neomycin/Polymyxin Gramicidin

NEULASTA Pegfilgrastim

NEUPOGEN Filgrastim 300mcg, 480mcg, 300mcg/0.5ml,

480mcg/0.8ml Brand $$$$$$ LMN; Available at Retail

NEURONTIN

Gabapentin

100mg, 300mg, 400mg, 600mg, 800mg

Generic

$$$$


Step: Failure of two: omeprazole, NEXIUM Esomeprazole Magnesium 20mg, 40mg Brand $$$$ pantoprazole, lansoprazole; QL= 34

caps/packets/30 days NIASPAN Niacin 500mg, 750mg, 1000mg Brand $$$$

NITRO‐DUR

Nitroglycerin 2.5mg, 6.5mg, 0.1mg/HR, 0.2mg/HR,

0.4mg/HR, 0.6mg/HR

Generic

$$$$

NITROSTAT Nitroglycerin 0.4mg, 0.6mg Generic $$$$ NIZORAL Ketoconazole Topical Generic $$ NIZORAL Ketoconazole Oral 200mg Generic $$$ NOLVADEX Tamoxifen Citrate 10mg, 20mg Generic $$$$ NORDETTE

Levonorgestrel & Ethinyl Estradiol Tab 0.15


NORDITROPIN

Somatropin 5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml,

30mg/3ml

Brand

$$$$$$

CPA

NORINYL Norethindrone & Mestranol Tab 1 MG‐

35MCG, 1 MG‐50 MCG

Generic

$$

NORMODYNE Labetalol HCl 100mg, 200mg, 300mg Generic $$$ NORPRAMIN Desipramine HCl 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Generic $$ NOR‐QD Norethindrone 0.35mg Generic $$$

NORTREL MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐ Generic $$

NORVASC Amlodipine Besylate 2.5mg, 5mg, 10mg Generic $$$ NOVAREL Chorionic Gonadotropin 10000u Generic $$$$$$ LMN NOVOLIN Insulin Isophane & Regular 70/30 Brand $$$ NOVOLIN N Insulin Isophane 100u/ml Brand $$$ NOVOLIN R Insulin Isophane 100u/ml Brand $$$ NOVOLOG Insulin Aspart 70/30, 100u/ml Brand $$$$

NOVOSEVEN

Coagulation Factor VIIa 1200mcg, 2400mcg, 4800mcg, 1mg, 2mg,

5mg, 8mg

Brand

$$$$$$$

LMN

NOXAFIL Posaconazole Oral 40mg/ml Brand $$$$$ LMN NPLATE Romiplostim 250mcg, 500mcg Generic $$$$$$ NULYTELY PEG 3350‐KCl‐Sod Bicarb‐NaCl Generic $$$$ NUTROPINLD

Somatropin 5mg, 10mg, 5mg/2ml, 20mg/2ml Brand $$$$$$ CPA

NUVARING Etonogestrel‐Ethinyl Estradiol VA Ring

0.120‐0.015 MG/24HR

Brand

$$$

NUVIGIL Armodafinil 50mg, 150mg, 250mg Brand $$$$$ CPA; Age > 23 NYSTATIN Nystatin Swish and Swallow Generic $$ NYSTOP Nystatin Topical Powder Generic $$ OCELLA

Drospirenone‐Ethinyl Estradiol Tab 3‐0.03

MG Generic $$$

OCTAGAMLD

Immune Globulin 2.5g, 5g, 10g, 25g Brand $$$$$$ LMN OCTREOTIDE Octreotide Acetate

100mcg, 200mcg, 500mcg, 1000mcg,

1mg/ml, 50mcg/ml Generic $$$$$$ LMN

OCUFLOX Ofloxacin 0.3% Generic $$$ OGEN Estropipate 0.75mg, 1.5mg, 3mg Generic $$

OMNARIS

Ciclesonide

50mcg/ACT

Brand

$$$$

Step: Fail one: flunisolide, fluticasone

OMNIPRED Prednisolone Acetate 1% Generic $$$$ OMNITROPELD

Somatropin 5.8mg, 5mg/1.5ml, 10mg/1.5ml Brand $$$$$$ CPA ONE TOUCH ‐ kits, strips a

supplies

nd

Brand

$$$$

QL= 100 strips/30 days

$ ‐‐‐‐‐‐‐‐‐ $1 to $10


Norethindrone & Ethinyl Estradiol Tab 0.5

35/1‐35 MG‐MCG



ONGLYZA Saxagliptin HCl 2.5mg, 5mg Brand $$$$

ONTAK Denileukin Diftitox 150mcg/ml Brand $$$$$$

30mg/5ml, 100mg/16.7ml, 150mg/25ml, ONXOL Paclitaxel

OPANA ER Oxymorphone HCl

300mg/50ml

5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg,

40mg

Generic $$$$$

Brand $$$$ QL= 120 tabs/30 days

OPTIVAR Azelastine HCl 0.05% Generic $$$$

ORENCIA Abatacept 250mg Brand $$$$$$ CPA

Norelgestromin‐Ethinyl Estradiol TD PTWK ORTHO EVRA

ORTHO TRI‐CYCLEN

ORTHO TRI‐CYCLEN LO

ORTHO‐CEPT

ORTHO‐CYCLEN

ORTHO‐NOVUM

150‐20 MCG/24HR


35/0.215‐35/0.25‐35 MG‐MCG


25/0.215‐25/0.25‐25 MG‐MCG


MG‐30 MCG

Norgestimate & Ethinyl Estradiol Tab 0.25

MG‐35 MCG Norethindrone & Ethinyl

Estradiol Tab 1

MG‐35 MCG, 1 MG‐50MCG, 0.5‐35/0.75‐

35/1‐35 MG‐M

Brand $$$

Generic $$

Brand $$ CPA

Generic $$

Generic $$$

Generic $$$


ORUDIS Ketoprofen 50mg, 75mg, 200mg Generic $$$

Norethindrone & Ethinyl Estradiol Tab 0.4 OVCON 35

MG Generic $$$

OVIDE Malathion Lotion 0.50% Generic $$$$

10mg, 15mg, 20mg, 30mg, 40mg, 60mg, OXYCONTIN Oxycodone HCl

80mg, 160mg Brand $$$$ CPA; QL= 120 tabs/30 days

OXYTROL Oxybutynin 3.9mg/24HR Brand $$$


100mg, 6mg/ml, 30mg/5ml, 150mg/25ml, PACLITAXEL Paclitaxel


PAMELOR Nortriptyline HCl 10mg, 25mg, 50mg, 75mg Generic $$$

PAMIDRONATE Pamidronate Disodium 30mg, 90mg, 30mg/10ml, 90mg/10ml Generic $$$$$$

PATANASE Olopatadine HCl 0.6% Brand $$$$

PATANOL Olopatadine HCl 0.1% Brand $$$$

PAXIL Paroxetine HCl 10mg, 12.5mg, 20mg, 30mg, 40mg Generic $$

PEGASYS Peginterferon alfa‐2a 180mcg/0.5ml, 180mcg/ml Brand $$$$$$ LMN

PEG‐INTRON Peginterferon alfa‐2b 50mcg, 80mcg, 120mcg, 150mcg Brand $$$$$$ LMN

PENICILLN GK Penicillin G IV Generic $$$ LMN

PENICILLN VK Penicillin VK‐oral Generic $$$


PEPCID Famotidine 40mg Generic $$$

PEPCID Famotidine 10mg, 20mg OTC $$ QL= 90 tabs/30 days


PERIACTIN Cyproheptadine HCl 4mg Generic $$

PERIDEX Chlorhexidine Gluconate 0.12% Generic $$$

PHENERGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$

PHENERGAN DM Promethazine‐DM Generic $$

PHENERGAN/CODEINE Promethazine w/ Codeine 6.25‐10mg Generic $$

PHENERGAN/CODEINE Promethazine w/ Codeine Generic $$

PHENOBARB Phenobarbital 15mg, 30mg, 32.4mg, 60mg, 100mg Generic $$

PHENTOLAMINE Phentolamine Mesylate Brand $$$$$$ LMN

PHENYTEK Phenytoin Sodium 200mg, 300mg Generic $$

PHEREGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$

PILOCARPINE Pilocarpine HCl 1%, 2%, 3%, 4%, 6% Generic $$

PLAQUENIL Hydroxychloroquine Sulfate 200mg Generic $$$


PLETAL Cilostazol 50mg, 100mg Generic $$$ POLYGAM

S/DM Immune Globulin 0.5g, 2.5g, 5g, 10g Brand $$$$$$ LMN

POLYTRIM Polymyxin B‐Trimethoprim Generic $

PRANDIMET Repaglinide‐Metformin HCl 1‐500mg, 2‐500mg Brand $$$$

PRAVACHOL Pravastatin Sodium 10mg, 20mg, 40mg, 80mg Generic $$$$


$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-33

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 12 of 18



PRED FORTE Prednisolone Acetate 1% Generic $$ PREFEST Estradiol/Estrad‐Norgestimate Brand $$$$ PREGNYLM

Chorionic Gonadotropin 10000u Generic $$$$$$ LMN

PREMARIN

Estrogens, Conjugated

0.3mg, 0.45mg, 0.625mg, 0.9mg, 1.25mg

Brand

$$$

PREMARIN VAG Estrogens, Conjugated Vaginal Cream 0.625mg Brand $$

PREMPHASE Conj Est/Conj Est‐Medroxypro Ac Brand $$$ PREMPRO

Conjugated Estrogen‐Medroxyprogest

Acetate

0.3‐1.5mg, 0.45‐1.5mg, 0.625‐2.5mg, 0.625

5mg

‐ Brand $$$

PRENATAL Prenatal Rx Generic $$ Step: Prenatal OTC PRENATAL VITAMINS Prenatal Vitamins OTC $$ QL= 100 tabs/30 days

PRENATE ELITE

Prenatal Vit w/ Fe Fum‐Methylfolate‐FA

Brand

$$$$

Step: Prenatal OTC

PREVACID Lansoprazole 15mg, 30mg Generic $$$$ PREVIFEM

Norgestimate & Ethinyl Estradiol Tab 0.2

MG‐35 MCG

5 Generic $$

PREVPAC Amoxicillin‐Clarithro‐Lansopraz Brand $$$$ PRILOSEC Omeprazole 10mg, 40mg Generic $$ PRILOSEC Omeprazole 20mg OTC $$ QL= 42 tabs/30 days PRIMAQUINE Primaquine Oral 26.3mg Generic $$$$ PRIMAXIN Imipenem/Cilastin IV Generic $$$$$ LMN PRISTIQ Desvenlafaxine Succinate 50mg, 100mg Brand $$$ Step: venlafaxine ER HCL PRIVIGEN Immune Globulin 5g, 10g, 20g Brand $$$$$$ LMN PROAIR HFA Albuterol Sulfate Brand $$$$ QL= 3 inhrs/30 days PROAMATINE Midodrine HCl 2.5mg, 5mg, 10mg Generic $$$ PROBEN/COLCH Colchicine w/ Probenecid 500‐0.5 Generic $$$ PROCARDIA Nifedipine 10mg, 20mg Generic $$ PROCARDIA XL Nifedipine SR 30mg, 60mg, 90mg Generic $$$$ PRO‐CLEAR Guaifenesin‐Codeine 300‐10mg Generic $$

2000u/ml, 3000u/ml, 4000u/ml, PROCRIT Epoetin Alfa 10000u/ml, 20000u/ml, 30000u/ml, Brand $$$$$$ LMN; Available at Retail

40000u/ml PROFILNINELD

Factor IX Complex 500u, 1500u, 1500u Brand $$$$$$$ LMN PROGRAF Tacrolimus 0.5mg, 1mg, 5mg, 5mg/ml Brand $$$$$$ LMN

PROLEX DM

Dextromethorphan‐Pot Guaiacolsulfon

Generic

$$

PROLIA Denosumab 60mg/ml Brand $$$$$$ Step: Failure on Bisphosphonate PROPYLTHIOURACIL Propylthiouracil 50mg, 100mg, 200mg, 400mg Generic $$ PROSCAR Finasteride 5mg Generic $$$$ PROTONIX Pantoprazole 20mg, 40mg Generic $$$ PROTOPIC Tacrolimus 0.03%, 0.1% Brand $$$$ CPA PROVENTIL Albuterol Sulfate 2mg, 4mg Generic $$ PROVERA Medroxyprogesterone Acetate 2.5mg, 5mg, 10mg Generic $$$ PROVIGIL Modafinil 100mg, 200mg, 300mg Brand $$$$$ CPA; Age > 23 PROZAC Fluoxetine HCl 10mg, 20mg, 40mg, 90mg Generic $$

Step: Failure of two: citalopram, PROZAC WEEKLY Fluoxetine HCl 90mg Generic $$ fluoxetine, fluvoxamine, paroxetine,

sertraline

PULMICORT

Budesonide


Brand

$$$$

QL= 70 amps (0.25mg/2ml or 0.5mg/2ml

35 amps (1mg/2ml); 2 inhrs; per 30 days

);

PULMICORT FLEXHALER

Budesonide

90mcg, 180mcg

Brand

$$$$

QL= 2 inhs (90 mcg); 3 inhs (180 mcg); pe

30 days

r

PULMOZYME Dornase Alfa 1mg/ml Brand $$$$$$ LMN PURINETHOL Mercaptopurine 50mg Generic $$$$ PYRAZINAMIDE Pyrazinamide Oral 500mg Generic $$$ PYRIDIUM Phenazopyridine HCl 100mg, 200mg Generic $$

PYRIDOXINE

Pyridoxine HCl 25mg, 50mg, 100mg, 200MG, 250MG,

500MG

OTC

$$

QL= 60 tabs/30 days

QUESTRAN Cholestyramine 4g Generic $$$ RANEXA Ranolazine 500mg, 1000mg Brand $$$$ LMN RAPAFLO Silodosin 4mg, 8mg Brand $$$$ RAPAMUNE Sirolimus 0.5mg, 1mg, 2mg, 1mg/ml Brand $$$$$$ LMN REBETOL Ribavirin 200mg, 4mg/ml Brand $$$$$$ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10






220‐400u, 401‐800u, 801‐1240u, 1241‐ RECOMBINATE Antihemophilic Factor Brand $$$$$$ LMN

1800u

REFACTOLD

Antihemophilic Factor 250u, 500u, 1000u, 2000u Brand $$$$$$ LMN

REFLUDAN Lepirudin 50mg Brand $$$$$$ LMN

REGLAN Metoclopramide HCl 5mg, 10mg Generic $$ RELAFEN Nabumetone 500mg, 750mg Generic $$$ RELENZA Zanamivir Oral 5mg Brand $$$ QL= 20 tabs/30 days

RELPAX Eletriptan Hydrobromide 20mg, 40mg Brand $$$$ Step: Sumatriptan Succinate; QL= 9 tabs/30

days

REMICADE Infliximab 100mg Brand $$$$$$ Step: Fail 2 DMARD

REMODULINLD Treprostinil Sodium 1mg/ml, 2.5mg/ml, 5mg/ml, 10mg/ml Brand $$$$$$ LMN; Specialty

RENAGEL Sevelamer 400mg, 800mg Brand $$$$$ RENVELA Sevelamer Carbonate 800mg, 0.8g, 2.4g Brand $$$$$

REPREXAIN

Hydrocodone‐Ibuprofen 2.5‐200mg, 5‐200mg, 7.5‐200mg, 10‐

200mg

Generic

$$$$

QL= 120 tabs/30 days

REPRONEX Menotropins 75u Brand $$$$$$ LMN

REQUIP

Ropinirole Hydrochloride

0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg

Generic

$$


RESTASIS Cyclosporine 0.05% Brand $$$$ QL= 60 vials/30 days





REVLIMIDLD Lenalidomide 5mg, 10mg, 15mg, 25mg Brand $$$$$$ LMN

RHEUMATREX Methotrexate Sodium 2.5mg Generic $$$$ RHINOCORT AQUA Budesonide 32mcg/ACT Brand $$$$ Step: Fail one

RHOGAM PLUS Rho D Immune Globulin 300mcg Brand $$$$$$ RHOPHYLACLD

Rho D Immune Globulin 1500u/2ml Brand $$$$$$ LMN

RIBAPAK Ribavirin Oral 400mg, 600mg Generic $$$$ Specialty

RIBASPHERE Ribavirin 200mg, 400mg, 600mg Brand $$$$$$ LMN

RIBAVIRIN Ribavirin Oral 200mg, 400mg, 600mg Generic $$$$ Specialty

RIFADIN Rifampin Oral 150mg, 300mg Generic $$$ RIMSO‐50 Dimethyl Sulfoxide 50% Brand $$$$$$ LMN

RIOMET Metformin HCl 500mg/5ml Brand $$$$

RITALIN

Methylphenidate HCl 5mg, 10mg, 18mg, 20mg, 27mg, 36mg,

54mg

Generic

$$$$

CPA; Age > 23


RITUXAN Rituximab 100mg, 500mg Brand $$$$$$ ROCALTROL Calcitriol 0.25mcg, 0.5mcg Generic $$$$ ROCEPHIN Ceftriaxone IV Generic $$$ ROXICODONE Oxycodone HCl

5mg, 10mg, 15mg, 20mg, 30mg, 40mg,

80mg Generic $$$ QL= 120 tabs/30 days

RYTHMOL Propafenone HCl 150mg, 225mg, 325mg, 425mg Generic $$$$ SAIZEN Somatropin 5mg, 8.8mg Brand $$$$$$ CPA

SANCTURA, SANCTURA XR Trospium Chloride 20mg, 60mg Generic $$$ SANDIMMUNE Cyclosporine 50mg/ml Generic $$$$$$

SANDOSTATIN

Octreotide Acetate 10mg, 20mg, 30mg, 50mcg/ml, 100mcg,

200mcg, 500mcg, 1000mcg

Brand

$$$$$$


SEASONALE Levonorgestrel & Ethinyl Estradiol (9

Tab 0.15‐0.03 MG

1‐Day)

Generic

$$$$

SELSUN BLUE Selenium Sulfide 1%, 2.25%, 2.5% Generic $ SENSIPAR Cinacalcet HCl 30mg, 60mg, 90mg Brand $$$$$$ LMN


SEROSTIMLD

Somatropin 4mg, 5mg, 6mg, 8.8mg Brand $$$$$$ LMN

SERZONE

Nefazodone HCl

50mg, 100mg, 150mg, 200mg, 250mg

Generic

$$$

SILVADENE Silver Sulfadiazine Generic $$$ SIMPONI Golimumab 50mg Brand $$$$$$ Step: Fail 2 DMARD

SINEMET

Carbidopa & Levodopa 10‐100mg, 25‐100mg, 25‐250mg, 50‐

200mg

Generic

$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-35

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 14 of 18



SINEQUAN

Doxepin HCl

10mg, 25mg, 50mg, 75mg, 100mg, 150mg

Generic

$$


SOLIA Desogestrel & Ethinyl Estradiol Tab 0.15

MG‐30 MCG

Generic

$$


SOMAVERTLD

Pegvisomant 10mg, 15mg, 20mg Brand $$$$$$ LMN



SPIRIVA

Tiotropium Bromide Monohydrate

18mcg

Brand

$$$$ QL= 1 pkg (6 caps or 90 caps); 2 pkgs (30

caps); per 30 days


SPRINTEC 28 Norgestimate & Ethinyl Estradiol Tab 0.

MG‐35 MCG

25

Generic

$$

SPRYCEL

Dasatinib

20mg, 50mg, 70mg, 80mg, 100mg, 140mg

Brand

$$$$$$

STARLIX Nateglinide 60mg, 120mg Generic $$$$ STERAPRED Prednisone 5mg, 10mg, 20mg Generic $$$$ STIMATE Desmopressin Acetate 1.5mg/ml Brand $$$$$$ LMN

STRATTERA

Atomoxetine HCl 10mg, 18mg, 25mg, 40mg, 60mg, 80mg,

100mg

Brand

$$$$

CPA; Age > 23

STROMECTOL Ivermectin Oral 3mg Brand $$$$ SULAR Nisoldipine 8.5mg, 17mg, 25.5mg, 34mg, Generic $$$$

SUMATRIPTAN

Sumatriptan Nasal Spray

5mg/ACT, 20mg/ACT

Brand

$$$

QL= 6 devices/30 days (5mg & 20mg spray)

SUMAXIN Sulfacetamide Sodium w/ Sulfur 10‐1%, 10‐4%, 10‐5% Generic $$$$ SUPARTZ Sodium Hyaluronate Intra‐articular 25mg/2.5ml Brand $$$$$$ LMN

SUPPRELINLD Histrelin Acetate 50mg Brand $$$$$$

SUTENT Sunitinib Malate 12.5mg, 25mg, 50mg Brand $$$$$$ SYMBICORT Budesonide‐Formoterol Fumarate 80‐4.5mcg/ACT, 160‐4.5mcg/ACT Brand $$$$ QL= 2 inhrs/30 days

SYMLIN/SYMLINPEN Pramlintide Acetate 600mcg, 1000mcg Brand $$$$ CPA; QL= 7 vials; 8 pens/30 days

SYMMETREL Amantadine Oral Generic $$$ SYNAGISLD

Palivizumab IM 50mg, 100mg/ml Brand $$$$$$ LMN

SYNARELM Nafarelin Acetate 2mg/ml Brand $$$$$$ LMN

SYNTHROID

Levothyroxine Sodium

25mcg, 50mcg, 75mcg, 88mcg, 100mcg,

112mcg, 125mcg, 137mcg, 150mcg,


Brand

$$$

SYNVISC Hylan Intra‐articular 8mg/ml Brand $$$$$$ LMN

TACROLIMUS Tacrolimus 0.5mg, 1mg, 5mg Generic $$$$$$ LMN

TAMBOCOR Flecainide Acetate 50mg, 100mg, 150mg, 200mg Generic $$$$$

TAMIFLU

Oseltamir Oral

30mg, 45mg, 70mg

Brand

$$$$ QL= 10 caps (45mg, 75mg) 20 caps (30mg)

100ml/30 days (oral susp)

TAPAZOLE Methimazole 5mg, 10mg Generic $$ TARCEVA Erlotinib 25mg, 100mg, 150mg Brand $$$$$$ TARGRETIN Bexarotene 75mg, 1% Brand $$$$$$ TASIGNA Nilotinib 150mg, 200mg Brand $$$$$$ TAXOTERE Docetaxel

20mg/0.5ml, 20mg/ml, 80mg/2ml,

80mg/4ml Brand $$$$$$

TAZORAC Tazarotene 0.05%, 0.1% Brand $$$$ TEGRETOL Carbamazepine 200mg, 400mg Generic $$$

TEMODAR

Temozolomide

5mg, 20mg, 100mg, 140mg, 180mg, 250mg

Brand

$$$$$$$

TEMOVATE Clobetasol Propionate 5% Generic $$ TENEX Guanfacine HCl 1mg, 2mg Generic $$$$ TENORMIN Atenolol 25mg, 50mg, 100mg Generic $$$ TERCONAZOLE Terconazole Vaginal Generic $$ TESSALON Benzonatate 100mg, 200mg Generic $$ TESTIM Testosterone 1% Brand $ TETRACYCLINE Tetracycline Oral Generic $$ TEV‐TROPINLD

Somatropin 5mg Brand $$$$$$ CPA

THALOMID Thalidomide 50mg, 150mg, 200mg100mg, Brand $$$$$$ THEO‐DUR Theophylline 100mg, 200mg, 300mg Generic $$$ THEOPHYLLINE ANHYDROUS Theophylline Brand $$ THROMBAT III Antithrombin III 500u, 1000u Brand $$$$$$ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-36

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 15 of 18



THYMOGLOBULIN Anti‐Thymocyte Globulin 25mg Brand $$$$$$ LMN THYROGENLD

Thyrotropin Alfa 1.1mg Brand $$$$$$ LMN TICE BCG Live Intravesical 50mg Brand $$$$$$ LMN TIGAN Trimethobenzamide HCl 300mg/5ml Generic $$$ TIMOPTIC Timolol Maleate 0.25%, 0.5% Generic $$$ TIMOPTIC‐XE Timolol Maleate 0.25%, 0.5% Generic $$$ TOBI Tobramycin 300mg/5ml Brand $$$$$$ LMN

TOBRADEX

Neomycin‐Polymyxin‐Dexamethasone

Generic

$$$

TOBREX Tobramycin IV Generic $$$ QL= 14 days TOFRANIL Imipramine HCl 10mg, 25mg, 50mg Generic $$ TOPAMAX Topiramate 25mg, 50mg, 100mg, 200mg Generic $$ TOPAMAX SPRINKLE Topiramate Sprinkle 15mg, 25mg Generic $$ TOPICORT Desoximetasone 0.05%, 0.25% Generic $$ TOPOSAR Etoposide 20mg/ml Generic $$$$$ TOPROL XL Metoprolol Succinate 25mg, 50mg, 100mg, 200mg Generic $$$$ TORISEL Temsirolimus 25mg/ml Brand $$$$$$ TOVIAZ Fesoterodine Fumarate 4mg, 8mg Brand $$$$ TRACLEERLD

Bosentan 62.5mg, 125mg Brand $$$$$$ LMN; Specialty TRANXENE‐T Clorazepate Dipotassium 3.75mg, 7.5mg, 15mg Generic $$ QL= 120tabs/30days TREANDA Bendamustine HCl 25mg, 100mg Brand $$$$ TRELSTAR

LD Triptorelin Pamoate 3.75mg, 11.25mg, 22.5mg Brand $$$$$$

TRENTAL Pentoxifylline 400mg Generic $$$$

TRIBENZOR Olmesartan‐Amlodipine‐

Hydrochlorothiazide

Brand

$$$$

LMN

TRILEPTAL Oxcarbazepine Suspension 300mg/5ml Generic $$$ TRINESSA

Norgestimate‐Eth Estrad Tab 0.18‐ Generic $$ 35/0.215‐35/0.25‐35 MG‐MCG

Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐ TRI‐NORINYL

35/0.5‐35 MG‐MCG Generic $$$

TRI‐PREVIFEM


35/0.215‐35/0.25‐35 MG‐MCG Generic $$

TRISENOX Arsenic Trioxide 10mg/10ml Generic $$$$$ TRI‐SPRINTEC


35/0.215‐35/0.25‐35 MG‐MCG Generic $$


30/0.075‐40/0.125‐30MG‐MCG Generic $$

TRUE ‐ kits, strips and supplies

Brand

$$$

QL= 100 strips/30 days


TWINJECT

Epinephrine

0.15mg, 0.3mg

Brand

$$$$ CPA; QL= 3 units/pkg size 1

size 2; per 30 days

; 4 units/pkg

TWINRIX

Hepatitis A (Inact)‐Hep B (Recomb) Vac

Brand

$$$$$$

LMN

TYGACIL Tigecycline IV 50mg Brand $$$$$ LMN TYKERB

LD Lapatinib Ditosylate 250mg Brand $$$$$$

TYLENOL/COD Acetaminophen w/ Codeine 300‐15mg, 300‐30mg, 300‐60mg Generic $$$ QL= 120 tabs/30 days TYSABRILD

Natalizumab 300mg/15ml Brand $$$$$$ LMN TYZEKA Telbivudine Oral 600mg Brand $$$$$ ULORIC Febuxostat 40mg, 80mg Brand $$$$ Step: allopurinol ULTRAM Tramadol HCl 50mg, 100mg, 200mg, 300mg Generic $$$$ QL= 120 tabs/30 days UNASYN Ampicillin/Sulbactam IV Generic $$$ LMN UNIRETIC Moexipril‐Hydrochlorothiazide 7.5‐12.5mg, 15‐12.5mg, 15‐25mg Generic $$$

25mcg, 50mcg, 75mcg, 88mcg, 100mcg, UNITHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$

175mcg, 200mcg, 300mcg UROXATRAL Alfuzosin HCl 10mg Brand $$$ URSO, URSO FORTE Ursodiol 250mg, 500mg Generic $$$$ VALCYTE Valganciclovir HCl 450mg, 50mg/ml Brand $$$$$$ LMN VALIUM Diazepam 2mg, 5mg, 10mg Generic $$ QL= 120tabs/30days VALTREX Valacyclovir HCl 500mg, 1g Generic $$$$ CPA VANCOCIN Vancomycin Oral, IV Generic $$$ VANTAS

LD Histrelin Acetate 50mg Brand $$$$$$

VANTIN Cefpodoxime proxetil‐Oral Generic $$$ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10




VASERETIC

Enalapril Maleate & Hydrochlorothiazide

5‐12.5mg, 10‐25mg

Generic

$$$$



VELCADE Bortezomib 3.5mg Generic $$$$$$

VELIVET Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐

0.025/0.15‐0.025MG‐MG

Generic $$



Step: Fail one: flunisolide, fluticasone, VERAMYST Fluticasone Furoate 27.5mcg Brand $$$$

VERIPRED 20 Prednisolone Sod Phosphate 20mg/5ml Brand $$$$


OMNARIS

VFEND Voriconazole 50mg, 200mg, 40mg/ml Brand $$$$$$ LMN


2.5‐500mg, 5‐325mg, 5‐500mg, 7.5‐325mg,

VICODIN Hydrocodone‐Acetaminophen 7.5‐650mg, 7.5‐650mg, 7.5‐750mg, 10‐

300mg, 10‐325mg, 10‐500mg, 10‐650mg,

10‐660mg

Generic $$$ QL= 120 tabs/30 days


VIDAZALD Azacitidine 100mg Brand $$$$$$

VIMPAT Lacosamide 50mg, 100mg, 150mg, 200mg, 10mg/ml Brand $$$$



VINORELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$

VIREAD Tenofovir Disoproxil Fumarate 300mg Brand $$$$$$ CPA



VITAMIN K Phytonadione 100mcg OTC $$ QL= 60 tabs/30 days

VITAMIN K1 Phytonadione 1mg/0.5ml, 2mg/ml Generic $$$$$$ LMN


VIVELLE‐DOT Estradiol 0.0375, 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$$ QL= 10 patches/30 days


VOLTAREN Diclofenac Sodium 0.1% Generic $$

VOTRIENTLD Pazopanib HCl 200mg Brand $$$$$$

VYVANSE Lisdexamfetamine Dimesylate 20mg, 30mg, 40mg, 50mg, 60mg, 70mg Brand $$$$$ CPA; Age > 23


WELLBUTRIN, WELLBUTRIN XL Bupropion HCl, Bupropion HCl SR 75mg, 100mg, 150mg, 200mg, 300mg Generic $$$

WINRHO SDF Rho D Immune Globulin 600u, 1500u, 2500u, 5000u, 15000u Brand $$$$$$ LMN

XALATAN Latanoprost 0.005% Generic $$$


XELODA Capecitabine 150mg, 500mg Brand $$$$$$

XENAZINELD Tetrabenazine 12.5mg, 25mg Brand $$$$$$ LMN

XIAFLEXLD Collagenase Clostridium Histolyticum 0.9mg Brand $$$$$$ LMN

XOLAIRLD Omalizumab 150mg Brand $$$$$$ LMN

XOPENEX Levalbuterol HCl 0.31mg, 0.63mg, 1.25mg/3ml Brand $$$$ Step: albuterol

XOPENEX HFA Levalbuterol Tartrate Brand $$$$ Step: albuterol; QL= 3 inhrs/30 days

XYLOCAINE Lidocaine HCl 2% gel, 5% onit Generic $$

XYLOCAINE Lidocaine HCl Viscous 2% Generic $$

XYNTHA Antihemophilic Factor Recombinant PAF 250u, 500u, 1000u, 2000u, 3000u Brand $$$$ LMN

YASMIN

YAZ


MG Drospirenone‐Ethinyl Estradiol Tab

3‐0.02

MG

Generic $$$

Generic $$$$

YODOXIN Iodoquinol Oral 210mg, 650mg Brand $$$$

ZANTAC Ranitidine HCl 300mg Generic $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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ZANTAC Ranitidine HCl 75mg, 150mg OTC $$ QL= 90 tabs/30 days

ZAROXOLYN Metolazone 2.5mg, 5mg, 10mg Generic $$$$ ZEBETA Bisoprolol Fumarate 5mg, 10mg Generic $$$$ ZEGERID Omeprazole‐Sodium Bicarbonate 20‐1100 OTC $$ QL= 42 tabs/30 days

ZEMPLAR

Paricalcitol

1mcg, 2mcg, 4mcg, 2mcg/ml, 5mcg/ml

Brand

$$$$$$

LMN

ZESTORETIC Lisinopril & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$ ZESTRIL lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg Generic $$ ZETIA Ezetimibe 10mg Brand $$$$ Step: simvastatin 40mg


CPA (600mg); QL= 8 tabs/10 days, Max 2

ZITHROMAX Azithromycin Oral Generic $$ fills/30 days (250mg); 4 tabs/10 days,Max

2 fills/30 days (500mg)

ZOCOR Simvastatin 5mg, 10mg, 20mg, 40mg, 80mg Generic $$$ ZOFRAN Ondansetron HCl 4mg, 8mg, 24mg Generic $$$

QL= 30 tabs (4mg & 8mg); 1 tab (24mg);

per 30 days

ZOFRAN Ondansetron HCl and Dextrose 32mg/50ml Brand $$$ CPA; QL= 3 bottles (sol); per 30 days

ZOLADEX Goserelin Acetate 3.6mg, 10.8mg Brand $$$$$$ ZOLOFT Sertraline HCl 25mg, 50mg, 100mg Generic $$ ZOMETA Zoledronic Acid 4mg/5ml Brand $$$$$$ LMN; Specialty

ZOMIG NASAL SPRAY

Zolmitriptan Nasal Spray

5mg

Brand

$$$$ Step: Sumatriptan Succinate; QL= 9

devices/30 days

ZOMIG, ZOMIG ZMT Zolmitriptan 2.5mg, 5mg Brand $$$$ Step: Sumatriptan Succinate; QL= 9 tabs/30

days

ZONEGRAN Zonisamide 25MG,50mg, 100mg Generic $$ ZORBTIVE Somatropin 8.8mg Brand $$$$$$ CPA

ZOSYN Pipercillin/Tazobactam IV Generic $$$$ LMN

Ethynodiol Diacetate & Ethinyl Estradiol ZOVIA

Generic $$

Tab 1 MG‐35 MCG, 1 MG‐50 MCG


ZYLOPRIM Allopurinol 100mg, 300mg Generic $$$ ZYMAR Gatifloxacin 0.3% Brand $$$ ZYRTEC Cetirizine HCl 5mg, 10mg OTC $$ QL= 30 tabs/30 days

ZYRTEC‐D Cetirizine ‐Pseudoephedrine 5mg/120mg OTC $$ QL= 30 tabs/30 days

ZYRTEC‐D Cetirizine‐Pseudoephedrine 5mg/120mg Generic $$$ ZYVOX Linezolid Oral, IV Brand $$$$$$ LMN; Specialty

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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Generic Name

Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA

ORENCIA Abatacept 250mg Brand $$$$$$ CPA


TYLENOL/COD Acetaminophen w/ Codeine 300‐15mg, 300‐30mg, 300‐60mg Generic $$$ QL= 120 tabs/30 days



DIFFERIN Adapalene 0.1%, 0.3% Generic $$$$ CPA


FABRAZYMELD Agalsidase beta 5mg, 35mg Brand $$$$$$ LMN

ALBENZA Albendazole Oral 200mg Brand $$$$


PROAIR HFA Albuterol Sulfate Brand $$$$ QL= 3 inhrs/30 days

PROVENTIL Albuterol Sulfate 2mg, 4mg Generic $$

AMEVIVE Alefacept 15mg Brand $$$$$$ LMN

CAMPATH Alemtuzumab 30mg/ml Brand $$$$$$ LMN

FOSAMAX Alendronate Sodium 5mg, 10mg, 35mg, 70mg Generic $$$

UROXATRAL Alfuzosin HCl 10mg Brand $$$

CEREDASE Alglucerase 80u/ml Brand $$$$$$ LMN

MYOZYMELD Alglucosidase Alfa 50mg Brand $$$$$$ LMN

ZYLOPRIM Allopurinol 100mg, 300mg Generic $$$



days (6.25mg); 9 tabs/30 days (12.5 mg)


SYMMETREL Amantadine Oral Generic $$$

LETAIRISLD Ambrisentan 5mg, 10mg Brand $$$$$$ LMN; Specialty


AMIKIN Amikacin IV Generic $$$$ QL= 14 days


AMINOCAPROIC ACID Aminocaproic Acid 250mg/ml, 500mg Generic $$$$$$ LMN


ELAVIL Amitriptyline HCl 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Generic $$

NORVASC Amlodipine Besylate 2.5mg, 5mg, 10mg Generic $$$

LOTREL Amlodipine Besylate‐Benazepril HCl 2.5‐10mg, 5‐10mg, 5‐20mg, 10‐20mg Generic $$$

AZOR

Amlodipine Besylate‐Olmesartan

Medoxomil

5‐20mg, 5‐40mg, 10‐20mg, 10‐40mg Brand $$$$ Step: amlodipine

AUGMENTIN Amoxacillin/Clavulanate‐Tabs, Susp Generic $$$

AMOXIL Amoxacillin‐Oral Generic $$

PREVPAC Amoxicillin‐Clarithro‐Lansopraz Brand $$$$

ADDERALL Amphetamine‐Dextroamphetamine 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg Generic $$$ CPA; Age > 23

ADDERALL XR Amphetamine‐Dextroamphetamine SR 5mg, 10mg, 15mg, 20mg, 30mg Brand $$$$$ CPA; Age > 23

ABELCET Amphotericin B Lipid 5mg/ml Brand $$$$$$ LMN

AMBISOME Amphotericin B Liposome 510mg Brand $$$$ LMN; Specialty

AMPICILLIN Ampicillin IV 125mg, 250mg, 500mg, 1g, 2g, 10g Generic $$$ LMN

UNASYN Ampicillin/Sulbactam IV Generic $$$ LMN

CREON Amy‐Lip‐Prot 5, 10, 20, 6000u, 12000u, 24000u Brand $$$$

KINERET Anakinra Brand $$$$$$ LMN

ARIMIDEX Anastrozole 1mg Generic $$$$ HELIXATE

FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u Brand $$$$$$ LMN

HEMOFIL M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN

KOATE‐DVI Antihemophilic Factor 250u, 500u, 1000u Brand $$$$$$

KOGENATE FS Antihemophilic Factor

250u, 500u, 1000u, 2000u, 3000u, 250/BS,

500/BS, 1000/BS, 2000/BS, 3000/BS

Brand $$$$$$ LMN

MONARC‐M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN


220‐400u, 401‐800u, 801‐1240u, 1241‐ RECOMBINATE Antihemophilic Factor

1800u Brand $$$$$$ LMN

REFACTOLD Antihemophilic Factor 250u, 500u, 1000u, 2000u Brand $$$$$$ LMN

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA

ADVATE

Antihemophilic Factor rAHF‐PFM

250u, 500u, 1000u, 1500u, 2000u, 3000u

Brand

$$$$$$

LMN

XYNTHA

Antihemophilic Factor Recombinant PAF

250u, 500u, 1000u, 2000u, 3000u

Brand

$$$$

LMN

ALPHANATE Antihemophilic Factor/VWF 250‐500u, 1000‐1500u, 1500u Brand $$$$$$$ LMN HUMATE‐P Antihemophilic Factor/VWF 500u, 600u, 1000u, 1200u, 2000u, 2400u Brand $$$$$$ FEIBA VH Antiinhibitor Coagulant Complex Brand $$$$$$ LMN THROMBAT III Antithrombin III 500u, 1000u Brand $$$$$$ LMN THYMOGLOBULIN Anti‐Thymocyte Globulin 25mg Brand $$$$$$ LMN APOKYNLD

Apomorphine Hydrochloride 50mg, 100mg, 20mg/ml Brand $$$$$$ LMN EMEND Aprepitant 80mg, 115mg, 125mg, 150mg Brand $$$$ LMN: Specialty BROVANA Arformoterol Tartrate 15mcg Brand $$$$ Step: Foradil NUVIGIL Armodafinil 50mg, 150mg, 250mg Brand $$$$$ CPA; Age > 23 TRISENOX Arsenic Trioxide 10mg/10ml Generic $$$$$ ELSPAR Asparaginase 10000u Brand $$$$$$ ASA Aspirin 81mg, 325mg OTC $ QL= 120 tabs/30 days AGGRENOX Aspirin‐Dipyridamole 25‐200mg Brand $$$ TENORMIN Atenolol 25mg, 50mg, 100mg Generic $$$

STRATTERA

Atomoxetine HCl 10mg, 18mg, 25mg, 40mg, 60mg, 80mg,

100mg

Brand

$$$$

CPA; Age > 23

LIPITOR Atorvastatin Calcium 10mg, 20mg, 40mg, 80mg Brand $$$$ Step: simvastatin 80mg VIDAZALD

Azacitidine 100mg Brand $$$$$$ IMURAN Azathioprine 50mg Generic $$$$$ FINACEA, FINACEA PLUS KIT Azelaic Acid 15%, Kit Brand $$$$ ASTELIN Azelastine HCl 0.1% Generic $$$$ QL= 2 bottles/30 days ASTEPRO Azelastine HCl 137mcg, 0.15% Brand $$$$ QL= 2 bottles/30 days OPTIVAR Azelastine HCl 0.05% Generic $$$$ AZASITE Azithromycin 1% Brand $$

ZITHROMAX

Azithromycin Oral

Generic

$$

CPA (600mg); QL= 8 tabs/1

fills/30 days (250mg); 4 tab

2 fills/30 days (500mg)

0 days, Max 2

s/10 days,Max

AZACTAM

Aztreonam IV

Generic

$$$$$

LMN LIORESAL Baclofen 10mg, 20mg Generic $$$$ COLAZAL Balsalazide Disodium 750mg Generic $$$$ TICE BCG Live Intravesical 50mg Brand $$$$$$ LMN

BECONASE AQ

Beclomethasone Dipropionate Monohyd

0.042%

Brand

$$$$ Step: Fail one: flunisolide, fl

OMNARIS

uticasone,

LOTENSIN HCT

Benazepril & Hydrochlorothiazide

5‐6.5mg, 10‐12.5mg, 20‐12.5mg, 20‐25mg

Generic

$$$

LOTENSIN Benazepril HCl 5mg, 10mg, 20mg, 40mg Generic $$$ TREANDA Bendamustine HCl 25mg, 100mg Brand $$$$ BICILLIN L‐A Benzathine IM Generic $$$$ LMN AURALGAN Benzocaine‐Antipyrine Generic $$$ TESSALON Benzonatate 100mg, 200mg Generic $$ BENZOYL Benzoyl Peroxide 5% OTC $$ QL= 85g/ 30days BENZAMYCIN Benzoyl Peroxide‐Erythromycin 5‐3% Generic $$$$ COGENTIN Benztropine Mesylate 0.5mg, 1mg, 2mg Generic $$ DIPROSONE Betamethasone Dipropionate 5% Generic $$$ DIPROLENE Betamethasone Dipropionate Augmented 5% Generic $$$ AVASTIN Bevacizumab Brand $$$$$$ TARGRETIN Bexarotene 75mg, 1% Brand $$$$$$ CASODEX Bicalutamide 50mg Generic $$$$ LUMIGAN Bimatoprost 0.01%, 0.03% Generic $$$ ZEBETA Bisoprolol Fumarate 5mg, 10mg Generic $$$$ BLEOMYCIN Bleomycin Sulfate 15u, 30u Generic $$$$$$ VELCADE Bortezomib 3.5mg Generic $$$$$$ TRACLEER

LD Bosentan 62.5mg, 125mg Brand $$$$$$ LMN; Specialty

ALPHAGAN P Brimonidine Tartrate 0.1%, 0.15% Generic $$$ BROMDAY Bromfenac Sodium 0.09% Generic $$$$

PULMICORT

Budesonide


Brand

$$$$

QL= 70 amps (0.25mg/2ml o

35 amps (1mg/2ml); 2 inhrs

r 0.5mg/2ml);

; per 30 days

$ ‐‐‐‐‐‐‐‐‐ $1 to $10




PULMICORT FLEXHALER Budesonide 90mcg, 180mcg Brand $$$$ QL= 2 inhs (90 mcg); 3 inhs (180 mcg); per

30 days

RHINOCORT AQUA Budesonide 32mcg/ACT Brand $$$$ Step: Fail one

SYMBICORT Budesonide‐Formoterol Fumarate 80‐4.5mcg/ACT, 160‐4.5mcg/ACT Brand $$$$ QL= 2 inhrs/30 days

BUMEX Bumetanide 0.5mg, 1mg, 2mg, Generic $$$

APLENZIN Bupropion HBr 174mg, 348mg, 522mg Brand $$

WELLBUTRIN, WELLBUTRIN XL Bupropion HCl, Bupropion HCl SR 75mg, 100mg, 150mg, 200mg, 300mg Generic $$$

BUSPAR Buspirone HCl 5mg, 7.5mg, 10mg, 15mg, 30mg Generic $$$ QL= 120tabs/30days

BUTALBITAL Butalbital Generic $$

FIORICET Butalbital‐Acetaminophen‐Caffeine 50‐325‐40mg Generic $$

CINRYZELD C1 Inhibitor 500u Brand $$$$$$ LMN

JEVTANA Cabazitaxel 60mg/1.5ml Generic $$$$$$$

CABERGOLINE Cabergoline 0.5mg Generic $$$$$$ LMN

DOVONEX Calcipotriene 0.005% Generic $$$$$

MIACALCIN Calcitonin 200u/ACT Generic $$$$

MIACALCIN Injection Calcitonin 200u/ml Generic $$$$ LMN

ROCALTROL Calcitriol 0.25mcg, 0.5mcg Generic $$$$


XELODA Capecitabine 150mg, 500mg Brand $$$$$$

CAPOTEN Captopril 12.5mg, 25mg, 50mg, 100mg Generic $$$

CAPOZIDE Captopril & Hydrochlorothiazide 25‐15mg, 25‐25mg, 50‐15mg, 50‐25mg Generic $$$

CARBATROL

TEGRETOL

LODOSYN

Carbamazepine 100mg, 200mg, 300mg Brand $$$$

Carbamazepine 200mg, 400mg Generic $$$

Carbidopa 25mg Brand $$$

10‐100mg, 25‐100mg, 25‐250mg, 50‐ SINEMET Carbidopa & Levodopa

200mg Generic $$$

CARBOPLATIN

Carboplatin

50mg/5ml, 150mg/15ml, 450mg/45ml,

600mg/60ml, 50mg, 150mg, 450mg

Generic $$$$$$

BICNU

COREG

CANCIDAS

MAXIPIME

ANCEF

CLAFORAN

CEFOTAN

MEFOXIN

VANTIN

FORTAZ

ROCEPHIN

CEFTIN

CELEBREX

KEFLIN

CIMZIA

ZYRTEC

ZYRTEC‐D

ZYRTEC‐D

CETROTIDE

ERBITUX

EVOXAC

LEUKERAN

LIBRIUM

PERIDEX

ARALEN

HYGROTON

QUESTRAN

NOVAREL

PREGNYLM

Carmustine 100mg Brand $$$$$$ Carvedilol

3.125mg, 6.25mg, 12.5mg, 25mg Generic $$$$ Caspofungin

Acetate 50mg, 70mg Brand $$ LMN; Specialty

Cefapime IV Generic $$ LMN

Cefazolin Generic $$$ Cefotaxime IV

Generic $$$ LMN

Cefotetan‐IV Generic $$$ LMN

Cefoxitin‐IV Generic $$ LMN

Cefpodoxime proxetil‐Oral Generic $$$ LMN

Ceftazidime IV Generic $$$ LMN; Specialty

Ceftriaxone IV Generic $$$

Cefuroxime IV, Oral Generic $$$ LMN

Celecoxib 50mg, 100mg, 200mg, 400mg Brand $$$$ Step: Fail Any 2 NSAIDs

Cephalothin‐Oral Generic $$$

Certolizumab Pegol 200mg/ml Brand $$$$$$ Step: Fail 2 DMARD

Cetirizine HCl 5mg, 10mg OTC $$ QL= 30 tabs/30 days

Cetirizine ‐Pseudoephedrine 5mg/120mg OTC $$ QL= 30 tabs/30 days

Cetirizine‐Pseudoephedrine 5mg/120mg Generic $$$

Cetrorelix Acetate 0.25mg, 3mg Brand $$$$$$ LMN

Cetuximab 100mg, 200mg Brand $$$$$$

Cevimeline HCl 30mg Brand $$$$$$ LMN

Chlorambucil 2mg Brand $$$$$$

Chlordiazepoxide HCl 5mg, 10mg, 25mg Generic $$ QL= 120tabs/30days

Chlorhexidine Gluconate 0.12% Generic $$$ Chloroquin Phosphate

Oral 250mg Generic $$$

Chlorthalidone 25mg, 50mg, 100mg Generic $$$$

Cholestyramine 4g Generic $$$ Chorionic

Gonadotropin 10000u Generic $$$$$$ LMN

Chorionic Gonadotropin 10000u Generic $$$$$$ LMN

OMNARIS Ciclesonide 50mcg/ACT Brand $$$$ Step: Fail one: flunisolide, fluticasone

PLETAL

SENSIPAR

CILOXAN

Cilostazol 50mg, 100mg Generic $$$ Cinacalcet

HCl 30mg, 60mg, 90mg Brand $$$$$$ LMN

Ciprofloxacin HCl 3% Generic $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-42

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 3 of 18



CIPRO Ciprofloxacin Oral Generic $$$

CIPRODEX Ciprofloxacin‐Dexamethasone 0.3‐0.1% Brand $$$$

CISPLATIN Cisplatin 50mg/50ml, 100mg/100ml, 200mg/200ml Generic $$$

CELEXA Citalopram Hydrobromide 10mg, 20mg, 40mg Generic $$

CLADRIBINE Cladribine 1mg/ml Generic $$$$$$

LEUSTATIN Cladribine 1mg/ml Brand $$$$$$ LMN

QL= 28 tabs/14 days, Max 2 fills/30 days

BIAXIN Clarithromycin Oral Generic $$$ (250mg & 500mg); 280ml/14 days, Max 2

fills of 280ml/30 days (125mg/5ml &

250mg/5ml)

CLEOCIN Clindamycin Oral, IV Generic $$$ LMN

CLEOCIN‐T Clindamycin Phosphate 1%, 2% Generic $$$$

BENZACLIN Clindamycin Phosphate‐Benzoyl Peroxide 1‐5% Generic $$$$

TEMOVATE Clobetasol Propionate 5% Generic $$

ANAFRANIL Clomipramine HCl 25mg, 50mg, 75mg Generic $

KLONOPIN Clonazepam 0.125mg, 0.25mg, 0.5mg, 1mg, 2mg Generic $$

CATAPRES Clonidine HCl 0.1mg, 0.2mg, 0.3mg Generic $$$


TRANXENE‐T Clorazepate Dipotassium 3.75mg, 7.5mg, 15mg Generic $$ QL= 120tabs/30days

CLOTRIMAZOLE Clotrimazole Vaginal, Topical, Troches Generic $ to $$$$

ALPHANINE Coagulation Factor IX 500u, 1000u, 1500u Brand $$$$$$$ LMN

BENEFIX Coagulation Factor IX 250u, 500u, 1000u, 2000u Brand $$$$$$$ LMN

MONONINE Coagulation Factor IX 250u, 500u, 1000u Brand $$$$$$$ LMN

1200mcg, 2400mcg, 4800mcg, 1mg, 2mg, NOVOSEVEN Coagulation Factor VIIa

5mg, 8mg Brand $$$$$$$ LMN

COLCRYS Colchicine 0.6mg Brand $$$$ Step: NSAIDS

PROBEN/COLCH Colchicine w/ Probenecid 500‐0.5 Generic $$$


COLESTID Colestipol HCl 1g, 5g Generic $$$$

COLY‐MYCIN M Colistimethate Sodium 150mg Brand $$$$$$ LMN

XIAFLEXLD Collagenase Clostridium Histolyticum 0.9mg Brand $$$$$$ LMN

CONDOMS Condoms OTC $$ QL= 12/30 days

PREMPHASE Conj Est/Conj Est‐Medroxypro Ac Brand $$$

PREMPRO Conjugated Estrogen‐Medroxyprogest

Acetate

0.3‐1.5mg, 0.45‐1.5mg, 0.625‐2.5mg, 0.625‐

5mg

Brand $$$

ACTHREL Corticorelin Ovine Triflutate 100mcg Brand $$$$$$ LMN

ACTHARLD Corticotropin 80u Brand $$$$$$ LMN

CORTROSYN Cosyntropin 0.25mg Generic $$$$

CROLOM Cromolyn Sodium 4% Generic $$

EURAX Crotamiton 10% Brand $$$$

FLEXERIL Cyclobenzaprine HCl 5mg, 10mg Generic $$$ QL= 90 tabs/30 days

CYCLOPHOSPHAMIDE Cyclophosphamide 25mg, 50mg, 500mg, 1g, 2g Brand $$$$$$

CYTOXAN Cyclophosphamide 2g Brand $$$$$$ LMN

NEORAL Cyclosporine 25mg, 100mg Generic $$$$$$

RESTASIS Cyclosporine 0.05% Brand $$$$ QL= 60 vials/30 days

SANDIMMUNE Cyclosporine 50mg/ml Generic $$$$$$

PERIACTIN Cyproheptadine HCl 4mg Generic $$

CYTOGAM Cytomegalovirus Immune Globulin Brand $$$$$$ LMN

DACARBAZINE Dacarbazine 100mg, 200mg Generic $$$$$$

AMPYRALD Dalfampridine 10mg Brand $$$$$$ LMN

FRAGMIN Dalteparin Sodium

2500u/0.2ml, 5000u/0.2ml, 7500u/0.3ml,

10000u/ml, 25000u/ml, 9500u, 12500u,

15000u, 18000u

Brand $$$$$$ CPA; QL=2 inj/30 days; Available at Retail

DAPSONE Dapsone Oral 25mg, 100mg Generic $$


25mcg, 40mcg, 60mcg, 100mcg, 150mcg, ARANESP Darbepoetin Alfa‐Polysorbate

200mcg, 300mcg, 500mcg Brand $$$$$$ CPA; QL= 2 inj/30 days; Available at Retail

ENABLEX Darifenacin Hydrobromide 7.5mg, 15mg Brand $$$

SPRYCEL Dasatinib 20mg, 50mg, 70mg, 80mg, 100mg, 140mg Brand $$$$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-43

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 4 of 18



DAUNORUBINCIN Daunorubicin HCl 20mg, 5mg/ml Generic $$$$$$ EXJADE

LD Deferasirox 125mg, 250mg, 500mg Brand $$$$$$

DEFEROXAMINE Deferoxamine Mesylate 500mg, 2g Generic $$$$$$

DESFERAL Deferoxamine Mesylate 500mg, 2g Brand $$$$$$ LMN

ONTAK Denileukin Diftitox 150mcg/ml Brand $$$$$$ PROLIA Denosumab 60mg/ml Brand $$$$$$ Step: Failure on Bisphosphonate

NORPRAMIN

Desipramine HCl

10mg, 25mg, 50mg, 75mg, 100mg, 150mg

Generic

$$

DDAVP

Desmopressin Acetate

0.1mg, 0.2mg, 4mcg/ml, 15mcg/ml, 0.1%

Brand

$$$$$$

LMN

DESMOPRESSIN Desmopressin Acetate 0.1mg, 0.2mg, 4mcg/ml, 0.1% Generic $$$$$ LMN

STIMATE Desmopressin Acetate 1.5mg/ml Brand $$$$$$ LMN

KARIVA Desogest‐Eth Estrad & Eth Estrad T

0.02/0.01 MG(21/5)

ab 0.15‐

Generic

$$$

MIRCETTE Desogest‐Eth Estrad & Eth Estrad Tab 0.15‐

0.02/0.01 MG(21/5)

Generic $$$

CESIA


0.025/0.15‐0.025MG‐MG

Generic $$

CYCLESSA Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐

0.025/0.15‐0.025MG‐MG

Generic $$

VELIVET Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐

0.025/0.15‐0.025MG‐MG

Generic $$

APRI

DESOGEN‐28

ORTHO‐CEPT

SOLIA


MG‐30 MCG Desogestrel & Ethinyl

Estradiol Tab 0.15

MG‐30 MCG


MG‐30 MCG Desogestrel & Ethinyl

Estradiol Tab 0.15

MG‐30 MCG

Generic $$$

Generic $$$

Generic $$

Generic $$

DESOWEN Desonide 5% Generic $$$$

TOPICORT Desoximetasone 0.05%, 0.25% Generic $$

PRISTIQ Desvenlafaxine Succinate 50mg, 100mg Brand $$$ Step: venlafaxine ER HCL

DECADRON Dexamethasone 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg Generic $$$

DEXILANT (formerly KAPIDEX) Dexlansoprazole 30mg, 60mg Brand $$$$

2.5mg, 5mg, 10mg, 15mg, 20mg, 30mg,


pantoprazole, lansoprazole; QL= 34

caps/packets/30 days

FOCALIN, FOCALIN XR Dexmethylphenidate HCl 40mg



DELSYM Dextromethorphan Polistirex 30mg/5ml OTC $$ QL= 148 ml/30 days

PROLEX DM Dextromethorphan‐Pot Guaiacolsulfon Generic $$

VALIUM Diazepam 2mg, 5mg, 10mg Generic $$ QL= 120tabs/30days


VOLTAREN Diclofenac Sodium 0.1% Generic $$

DYCILL Dicloxacillin‐Oral Generic $$

BENTYL Dicyclomine HCl 10mg, 20mg Generic $$$

FLORONE Diflorasone Diacetate 0.05% Generic $$$

LANOXIN Digoxin 0.125mg, 0.25mg Generic $$$

30mg, 60mg, 90mg, 180mg, 240mg,

CARDIZEM Diltiazem HCl 120mg/24, 180mg/24, 240mg/24,

300mg/24, 360mg/24

Generic $$$$

RIMSO‐50 Dimethyl Sulfoxide 50% Brand $$$$$$ LMN

BENADRYL Diphenhydramine HCl 25mg, 50mg OTC $ QL= 100 caps/30 days

LOMOTIL Diphenoxylate w/ Atropine 2.5mg Generic $$

DEPAKOTE, DEPAKOTE ER Divalproex Sodium 125mg, 250mg, 500mg Generic $$$

DEPAKOTE SPR Divalproex Sodium Sprinkle 125mg, 250mg, 500mg Generic $$$

20mg/0.5ml, 20mg/ml, 80mg/2ml, TAXOTERE Docetaxel

80mg/4ml Brand $$$$$$

COLACE Docusate Sodium 100mg OTC $ QL= 60 caps/30 days

ARICEPT, ARICEPT ODT Donepezil Hydrochloride 5mg, 10mg, 23mg Generic $$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-44

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 5 of 18



PULMOZYME Dornase Alfa 1mg/ml Brand $$$$$$ LMN

CARDURA Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg Generic $$$$ SINEQUAN Doxepin HCl 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Generic $$

HECTOROL

Doxercalciferol 0.5mcg, 1mcg, 2.5mcg, 2mcg/ml,

4mcg/2ml

Brand

$$$$$

ADRIAMYCIN Doxorubicin HCl 2mg/ml Generic $$$$ DOXIL Doxorubicin HCl Liposomal 2mg/ml Brand $$$$$$ DOXYCYCLINE Doxycycline Oral Generic $$ ANGELIQ Drospirenone‐Estradiol 0.5‐1mg Brand $$$$

YAZ Drospirenone‐Ethinyl Estradiol Tab

MG

3‐0.02

Generic

$$$$

OCELLA

YASMIN


MG Drospirenone‐Ethinyl Estradiol Tab

3‐0.03

MG

Generic $$$

Generic $$$

CYMBALTA Duloxetine HCl 20mg, 30mg, 60mg Brand $$$$ Step: venlafaxine ER HCL


RELPAX Eletriptan Hydrobromide 20mg, 40mg Brand $$$$

EMTRIVA Emtricitabine Oral 200mg Brand $$$$$


VASERETIC Enalapril Maleate & Hydrochlorothiazide 5‐12.5mg, 10‐25mg Generic $$$$


days

LOVENOX Enoxaparin Sodium

30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml,

80mg/0.8ml, 100mg/ml, 150mg/ml,

120mg/0.8ml

Brand $$$$$$ LMN: Available at Retail

COMTAN Entacapone 200mg Brand $$$$

BARACLUDE Entecavir 0.5mg, 1mg, 0.05mg/ml Brand $$$$$$ LMN

CPA; QL= 3 units/pkg size 1; 4 units/pkg EPIPEN, EPIPEN‐JR Epinephrine 0.15mg, 0.3mg Brand $$$$

TWINJECT Epinephrine 0.15mg, 0.3mg Brand $$$$

size 2; per 30 days CPA; QL= 3 units/pkg

size 1; 4 units/pkg size 2; per 30 days

ELLENCE Epirubicin HCl 2mg/ml Brand $$$$$$ LMN

INSPRA Eplerenone 25mg, 50mg Generic $$$$

2000u/ml, 3000u/ml, 4000u/ml, EPOGEN Epoetin Alfa

PROCRIT Epoetin Alfa

10000u/ml, 20000u/ml, 40000u/ml

2000u/ml, 3000u/ml, 4000u/ml,

10000u/ml, 20000u/ml, 30000u/ml,

40000u/ml

Brand $$$$$$ CPA; QL= 2 inj/30 days; Available at Retail

Brand $$$$$$ LMN; Available at Retail


FLOLANLD Epoprostenol Sodium 0.5mg, 1.5mg Brand $$$$$$ LMN


TARCEVA Erlotinib 25mg, 100mg, 150mg Brand $$$$$$

INVANZ Ertapenem IV Generic $$$$$ LMN



EES Erythromycin Esthylsuccinate 400mg Generic $$$


LEXAPRO Escitalopram Oxalate 5mg, 10mg, 20mg Generic $$$$

NEXIUM Esomeprazole Magnesium 20mg, 40mg Brand $$$$

ESTRACE Estradiol 0.5mg, 1mg, 2mg Generic $$


fluoxetine, fluvoxamine, paroxetine,

sertraline Step: Failure of two:

omeprazole, pantoprazole,

lansoprazole; QL= 34

caps/packets/30 days

ESTRASORB Estradiol Brand $$$ QL= 68 packets/30 days


VIVELLE‐DOT Estradiol 0.0375, 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$$ QL= 10 patches/30 days

ALORA Estradiol 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$ QL= 68 packets/30 days

ACTIVELLA Estradiol & Norethindrone Acetate 1‐0.5mg Generic $$$$

0.025mg, 0.0375mg, 0.05mg, 0.06mg, CLIMARA Estradiol TD

0.075mg, 0.1mg Generic $$$$ QL= 5 patches/30 days

ESTRACE VAG Estradiol Vaginal Cream Brand $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-45

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 6 of 18



NUVARING Etonogestrel‐Ethinyl Estradiol VA Ri

0.120‐0.015 MG/24HR

ng

Brand

$$$

TOPOSAR Etoposide 20mg/ml Generic $$$$$ AFINITOR Everolimus 2.5mg, 5mg, 10mg Brand $$$$$$ AROMASIN Exemestane 25mg Generic $$$$ Step: anastrozole BYETTA Exenatide 5mcg, 10mcg Brand $$$$ CPA; QL= 2 syringes/30 days ZETIA Ezetimibe 10mg Brand $$$$ Step: simvastatin 40mg BEBULIN VH Factor IX Complex 200‐1200u Brand $$$$$$$ LMN PROFILNINELD

Factor IX Complex 500u, 1500u, 1500u Brand $$$$$$$ LMN FAMVIR Famcyclovir Oral 125mg, 250mg, 500mg Generic $$$$ PEPCID Famotidine 40mg Generic $$$ PEPCID Famotidine 10mg, 20mg OTC $$ QL= 90 tabs/30 days ULORIC Febuxostat 40mg, 80mg Brand $$$$ Step: allopurinol LOFIBRA Fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg Generic $$$

FENTORA

Fentanyl Citrate 100mcg, 200mcg, 300mcg, 400mcg,

600mcg, 800mcg

Brand

$$$$$

CPA

DURAGESIC Fentanyl TD Patch 12mcg, 25mcg, 50mcg, 75mcg, 100mcg Generic

$$$$ CPA; QL= 15/30days

TOVIAZ Fesoterodine Fumarate 4mg, 8mg Brand $$$$ ALLEGRA Fexofenadine 30mg, 60mg, 180mg OTC $$ Step: Claritin; QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 12 hour, 24 hour OTC $$ QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 60mg/120mg, 180mg/240mg Generic $$

NEUPOGEN

Filgrastim 300mcg, 480mcg, 300mcg/0.5ml,

480mcg/0.8ml

Brand

$$$$$$

LMN; Available at Retail

PROSCAR Finasteride 5mg Generic $$$$ GILENYA Fingolimod HCl 0.5mg Brand $$$$$$ LMN TAMBOCOR Flecainide Acetate 50mg, 100mg, 150mg, 200mg Generic $$$$$ DIFLUCAN Fluconazole Oral 50mg, 100mg, 150mg, 200mg Generic $$$$ LMN ANCOBON Flucytosine Oral 250mg, 500mg Brand $ LMN FLUDARA Fludarabine Phosphate 50mg Brand $$$$$$ FLUDARABINE Fludarabine Phosphate 50mg, 50mg/2ml Generic $$$$$$ FLORINEF Fludrocortisone Acetate 0.1mg Generic $$$ NASALIDE Flunisolide 0.025% Generic $$$ QL= 3 inhrs/bottles/30 days LIDEX Fluocinonide 0.05% Generic $$ FML FORTE Fluorometholone 0.25% Brand $$ ADRUCIL Fluorouracil 2.5g/50ml, 5g/100ml, 500mg/10ml Generic $$ CARAC Fluorouracil 0.5% Brand $$$$

Step: Failure of two: citalopram, PROZAC WEEKLY Fluoxetine HCl 90mg Generic $$ fluoxetine, fluvoxamine, paroxetine,

sertraline PROZAC Fluoxetine HCl 10mg, 20mg, 40mg, 90mg Generic $$

VERAMYST

Fluticasone Furoate

27.5mcg

Brand

$$$$ Step: Fail one: flunisolide, fluticasone,

OMNARIS

FLONASE Fluticasone Propionate 50mcg Generic $$$ QL= 2 inhrs/30 days

FLOVENT HFA



Brand

$$$$ QL= 44mcg ‐ 2 inhrs; 110mcg ‐ 1 inhr;

220mcg ‐ 3 inhrs; per 30 days

ADVAIR DISKUS Fluticasone‐Salmeterol 100/50, 250/50, 500/50 Brand $$$$ QL= 120 inhs/60pk; 28 inhs/28pk; 14

inhs/14pk; per 30 days


$ ‐‐‐‐‐‐‐‐‐ $1 to $10


PREFEST Estradiol/Estrad‐Norgestimate Brand $$$$ CLIMARA PRO Estradiol‐Levonorgestrel Brand $$$ QL= 5 patches/30 days

COMBIPATCH Estradiol‐Norethindrone Ace 0.05/0.14mg, 0.05/0.25mg Brand $$$ PREMARIN Estrogens, Conjugated 0.3mg, 0.45mg, 0.625mg, 0.9mg, 1.25mg Brand $$$

PREMARIN VAG Estrogens, Conjugated Vaginal Cream 0.625mg Brand $$

OGEN Estropipate 0.75mg, 1.5mg, 3mg Generic $$ ENBREL Etanercept 25mg, 25mg/0.5ml, 50mg/ml Brand $$$$$$ Step: Fail 2 DMARD

EDECRIN Ethacrynic Acid 25mg Brand $$$ CPA

MYAMBUTOL Ethambutol Oral 100mg, 400mg Generic $$$ KELNOR

Ethynodiol Diacetate & Ethinyl Estradiol

Tab 1 MG‐35 MCG Generic $$

ZOVIA

Ethynodiol Diacetate & Ethinyl Estradiol

Tab 1 MG‐35 MCG, 1 MG‐50 MCG

Generic $$



LUVOX Fluvoxamine Maleate 25mg, 50mg, 100mg Generic $$$ FOLTX Folic Acid 400mcg, 800mcg, 1000mcg, 1g Generic $$


FOLLISTIM Follitropin Beta 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN

ARIXTRA Fondaparinux Sodium 2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml,

10mg/0.8ml Brand $$$$$$ CPA; QL= 28 inj/14 days; Available at Retail

CPA; QL= 12 caps/12pk; 120 caps/60pk; FORADIL Formoterol Fumarate Brand $$$$

per 30 days


MONOPRIL Fosinopril Sodium 10mg, 20mg, 40mg Generic $$

MONOPRIL HCT Fosinopril Sodium & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg Generic $$$$

FROVA Frovatriptan Succinate 2.5mg Brand $$$$


days

EMETROL Fructose‐Dextrose‐Phosphoric Acid OTC $ QL= 240ml/ 30 days

FASLODEX Fulvestrant 250mg/5ml Generic $$$$$$

LASIX Furosemide 20mg, 40mg, 80mg Generic $$

NEURONTIN Gabapentin 100mg, 300mg, 400mg, 600mg, 800mg Generic $$$$

NAGLAZYMELD Galsulfase 1mg/ml Brand $$$$$$ LMN

CYTOVENE Gancyclovir IV 500mg Generic $ LMN


ZYMAR Gatifloxacin 0.3% Brand $$$


LOPID Gemfibrozil 600mg Generic $$$


COPAXONE Glatiramer Acetate 20mg/ml Brand $$$$$$ LMN

AMARYL Glimepiride 1mg, 2mg, 4mg Generic $$$



GLUCAGEN Glucagon HCl 1mg Brand $$$$$

MICRONASE Glyburide 1.25mg,. 2.5mg, 5mg Generic $$$


SIMPONI Golimumab 50mg Brand $$$$$$ Step: Fail 2 DMARD

ZOLADEX Goserelin Acetate 3.6mg, 10.8mg Brand $$$$$$

GRANISETRON Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml, 4mg/4ml, Generic $$$$$$ LMN

KYTRIL Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml Brand $$$$ LMN: Specialty

GRIS‐PEG Griseofulvin Oral 125mg, 250mg Generic $$

PRO‐CLEAR Guaifenesin‐Codeine 300‐10mg Generic $$

TENEX Guanfacine HCl 1mg, 2mg Generic $$$$

TWINRIX Hepatitis A (Inact)‐Hep B (Recomb) Vac Brand $$$$$$ LMN




SUPPRELINLD Histrelin Acetate 50mg Brand $$$$$$

VANTASLD Histrelin Acetate 50mg Brand $$$$$$


APRESOLINE Hydralazine HCl 10mg, 25mg, 50mg, 100mg Generic $$$$



2.5‐500mg, 5‐325mg, 5‐500mg, 7.5‐325mg,

VICODIN Hydrocodone‐Acetaminophen

REPREXAIN Hydrocodone‐Ibuprofen

7.5‐650mg, 7.5‐650mg, 7.5‐750mg, 10‐

300mg, 10‐325mg, 10‐500mg, 10‐650mg,

10‐660mg

2.5‐200mg, 5‐200mg, 7.5‐200mg, 10‐

200mg

Generic $$$ QL= 120 tabs/30 days

Generic $$$$ QL= 120 tabs/30 days


ANALPRAM‐HC Hydrocortisone Acetate w/ Pramoxine 1‐1%, 1‐2.5%, 2.5%, 2.5‐1% Generic $$$$


DILAUDID Hydromorphone HCl 1mg, 2mg, 4mg, 8mg Generic $$$ QL= 120 tabs/30 days

PLAQUENIL Hydroxychloroquine Sulfate 200mg Generic $$$


ATARAX Hydroxyzine HCl 10mg, 25mg, 50mg Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-47

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 8 of 18



Ketoconazole Topical Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

$$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 4f-48

9 of 18


SYNVISC Hylan Intra‐articular 8mg/ml Brand $$$$$$ LMN

LEVBID Hyoscyamine Sulfate 0.0125mg, 0375mg Generic $$

BONIVA Ibandronate Sodium 3mg/3ml Brand $$$$ LMN

BONIVA Ibandronate Sodium 2.5mg, 150mg Brand $$$$

ADVIL Ibuprofen 200mg OTC $ QL= 100 tabs/30 days

MOTRIN Ibuprofen 800mg Generic $$

ELAPRASELD Idursulfase 6mg/3ml Brand $$$$$$ LMN





PRIMAXIN Imipenem/Cilastin IV Generic $$$$$ LMN

TOFRANIL Imipramine HCl 10mg, 25mg, 50mg Generic $$

ALDARA Imiquimod 5% Generic $$$ CPA

CARIMUNE Immune Globulin 3g, 6g, 12g Brand $$$$$$ LMN

FLEBOGAMMALD Immune Globulin 5%, 10% Brand $$$$$$ LMN



1g/10ml, 2.5g/25ml, 5g/50ml, 10g/100ml,

20g/200ml, 30g/300ml, 0.5g, 2.5g, 5g, 10g

Brand $$$$$$ LMN

GAMUNEX Immune Globulin

10%, 1g/10ml, 2.5g/25ml, 5g/5ml,

10g/100ml, 20g/200ml

Brand $$$$$$ LMN

OCTAGAMLD Immune Globulin 2.5g, 5g, 10g, 25g Brand $$$$$$ LMN

POLYGAM S/DM Immune Globulin 0.5g, 2.5g, 5g, 10g Brand $$$$$$ LMN

PRIVIGEN Immune Globulin 5g, 10g, 20g Brand $$$$$$ LMN


LOZOL Indapamide 1.25mg, 2.5mg Generic $$$

INDOCIN Indomethacin 25mg, 50mg, 75mg Generic $$

REMICADE Infliximab 100mg Brand $$$$$$ Step: Fail 2 DMARD

NOVOLOG Insulin Aspart 70/30, 100u/ml Brand $$$$


LANTUS Insulin Glargine 100u/ml, 500u/ml Brand $$$$

APIDRA Insulin Glulisine 100u/ml Brand $$$$ Step: Humalog



NOVOLIN N Insulin Isophane 100u/ml Brand $$$

NOVOLIN R Insulin Isophane 100u/ml Brand $$$


NOVOLIN Insulin Isophane & Regular 70/30 Brand $$$


INFERGEN Interferon Brand $$$$$$ Specialty

INTRON‐A Interferon Alfa‐2B 3u, 5u, 10u, 18u, 25u, 50u Brand $$$$$$ QL= 2 inj/30 days

ALFERON NM Interferon Alfa‐n3 5000000u/ml Brand $$$$$$ LMN



BETASERON Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN

EXTAVIA Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN

ACTIMMUNELD Interferon Gamma‐1B 2000000u/0.5ml Brand $$$$$$ LMN

YODOXIN Iodoquinol Oral 210mg, 650mg Brand $$$$

ATROVENT Ipratropium Bromide 0.02% Generic $$$$


COMBIVENT Ipratropium‐Albuterol 18‐103mcg/ACT Brand $$$$ QL= 3 inhrs/30 days


AVALIDE Irbesartan‐Hydrochlorothiazide 150‐12.5mg, 300‐12.5mg, 300‐25mg Brand $$$$ Step: losartan potassium HCT

CAMPTOSAR Irinotecan HCl 20mg/ml Brand $$$$$$

ISONIAZID Isoniazid Oral Generic $$

ISORDIL Isosorbide Dinitrate 5mg, 10mg, 20mg, 30mg, 40mg Generic $$$$

IMDUR Isosorbide Mononitrate 10mg, 20mg, 30mg, 60mg, 120mg Generic $$$$


STROMECTOL Ivermectin Oral 3mg Brand $$$$

IXEMPRA Ixabepilone 15mg, 45mg Generic $$$$$$

NIZORAL Ketoconazole Oral 200mg Generic $$$

NIZORAL

6/23/2011



ORUDIS Ketoprofen 50mg, 75mg, 200mg Generic $$$ ACULAR, LS Ketorolac Tromethamine 0.5%, 0.4% Generic $$$$

ACUVAIL Ketorolac Tromethamine 0.45% Brand $$$ LMN

NORMODYNE Labetalol HCl 100mg, 200mg, 300mg Generic $$$

VIMPAT

Lacosamide

50mg, 100mg, 150mg, 200mg, 10mg/ml

Brand

$$$$

CEPHULAC Lactulose 10g/15ml, 20g/30ml Generic $$$$ EPIVIR Lamivudine Oral 150mg, 300mg Brand $$$$

LAMICTAL

Lamotrigine 25mg, 50mg, 100mg, 150mg, 200mg,

250mg

Generic

$$

LAMICTAL XR Lamotrigine SR 25mg, 100mg, 150mg, 200mg, 300mg Brand

$$$$

PREVACID Lansoprazole 15mg, 30mg Generic $$$$ FOSRENOL Lanthanum Carbonate 250mg, 500mg, 750mg, 1000mg Brand $$$$$ TYKERBLD Lapatinib Ditosylate 250mg Brand $$$$$$ ALDURAZYMELD Laronidase 2.9mg/5ml Brand $$$$$$ LMN

XALATAN Latanoprost 0.005% Generic $$$ REVLIMIDLD Lenalidomide 5mg, 10mg, 15mg, 25mg Brand $$$$$$ LMN

REFLUDAN Lepirudin 50mg Brand $$$$$$ LMN

FEMARA Letrozole 2.5mg Generic $$$$$ ELIGARD Leuprolide Acetate 7.5mg, 22.5mg, 30mg, 45mg Brand $$$$$$ LEUPROLIDE Leuprolide Acetate 1mg/0.2ml, 5mg/ml Generic $$$$$$ LUPRON Leuprolide Acetate 3.75mg, 7.5mg, 11.25mg, 22.5mg, 30mg Brand $$$$$$ XOPENEX Levalbuterol HCl 0.31mg, 0.63mg, 1.25mg/3ml Brand $$$$ Step: albuterol

XOPENEX HFA Levalbuterol Tartrate Brand $$$$ Step: albuterol; QL= 3 inhrs/30 days

KEPPRA

Levetiracetam 100mg/ml, 250mg, 500mg, 750mg,

1000mg

Generic

$$$

KEPPRA XR Levetiracetam SR 500mg, 750mg Brand $$$ BETAGAN Levobunolol HCl 0.25%, 0.5% Generic $$ LEVAQUIN Levofloxacin Oral Generic $$ SEASONALE


Tab 0.15‐0.03 MG

(91‐Day) Generic $$$$

AVIANE Levonorgestrel & Ethinyl Estradiol

MG‐20 MCG

Tab 0.1 Generic $$

LESSINA‐28 Levonorgestrel & Ethinyl Estradiol

MG‐20 MCG

Tab 0.1 Generic $$

LUTERA Levonorgestrel & Ethinyl Estradiol

MG‐20 MCG

Tab 0.1 Generic $$

LEVORA‐28 Levonorgestrel & Ethinyl Estradiol

MG‐30 MCG

Tab 0.15 Generic $$

NORDETTE Levonorgestrel & Ethinyl Estradiol

MG‐30 MCG

Tab 0.15 Generic $$$


30/0.075‐40/0.125‐30MG‐MCG Generic $$


30/0.075‐40/0.125‐30MG‐MCG Generic $$

25mcg, 50mcg, 75mcg, 88mcg, 100mcg, LEVOTHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$

175mcg, 200mcg, 300mcg, 500mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,

LEVOXYL Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,

SYNTHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Brand $$$ 175mcg, 200mcg, 300mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,

UNITHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg

XYLOCAINE Lidocaine HCl 2% gel, 5% onit Generic $$ XYLOCAINE Lidocaine HCl Viscous 2% Generic $$ LIDODERM Lidocaine Patch 5% Generic $$$$$ LINDANE Lindane 1% Generic $$$ ZYVOX Linezolid Oral, IV Brand $$$$$$ LMN; Specialty

$ ‐‐‐‐‐‐‐‐‐ $1 to $10





VYVANSE Lisdexamfetamine Dimesylate 20mg, 30mg, 40mg, 50mg, 60mg, 70mg Brand $$$$$ CPA; Age > 23

ZESTRIL lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg Generic $$ ZESTORETIC Lisinopril & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$

CEREFOLIN

L‐Methylfolate w/ Vit B12‐Vit B6‐Vit B2

Brand

$$$$

METANX L‐Methylfolate w/ Vit B6‐Vit B12 Brand $$$$ IMODIUM Loperamide HCl 2mg Generic $$ CLARITIN Loratadine 5mg, 10mg OTC $$ QL= 30caps/30 days

ATIVAN Lorazepam 0.5mg, 1mg, 2mg, Generic $$$ QL= 120tabs/30days

COZAAR Losartan Potassium 25mg, 50mg, 100mg Generic $$$$ HYZAAR Losartan Potassium & Hydrochlorothiazid e 50‐12.5mg, 100‐12.5mg, 100‐25mg Generic $$$ ALREX Loteprednol Etabonate 0.2% Brand $$$$ LOTEMAX Loteprednol Etabonate 0.5% Brand $$$ MEVACOR Lovastatin 20mg, 40mg Generic $$$$ AMITIZA Lubiprostone 8mcg, 24mcg Brand $$$$ OVIDE Malathion Lotion 0.50% Generic $$$$ MEBENDAZOLE Mebendazole Oral 100mg Generic $$$ INCRELEX Mecasermin 40mg/4ml Brand $$$$$$ CPA

PROVERA Medroxyprogesterone Acetate 2.5mg, 5mg, 10mg Generic $$$ DEPO‐PROVERA

Medroxyprogesterone Acetate IM Susp

150 MG/ML Generic $$$

DEPO‐PROVERA Medroxyprogesterone Acetate IM Susp

400 MG/ML

Brand

$$$$

MEGACE Megestrol Acetate 20mg, 40mg Generic $$$$$ MEGACE Megestrol Acetate 40mg/ml Generic $$$$ MOBIC Meloxicam 7.5mg, 15mg Generic $$$$ ALKERAN Melphalan 2mg, 50mg Brand $$$$$$ NAMENDA Memantine HCl 5mg, 5‐10mg, 10mg Brand $$$$ REPRONEX Menotropins 75u Brand $$$$$$ LMN

DEMEROL

Meperidine HCl 10mg/ml, 25mg/ml, 50mg/ml, 75mg/ml,

100mg/ml

Generic

$$$

CPA; QL= 120ml/30 days

PURINETHOL Mercaptopurine 50mg Generic $$$$ MERREM Meropenem IV Generic $$$$ LMN

ASACOL, ASACOL HD Mesalamine 400mg, 800mg Brand $$$ LMN

CANASA Mesalamine 1000mg Brand $$$$ LMN

LIALDA Mesalamine 1.2g Brand $$$$ LMN


GLUCOPHAGE Metformin HCl 500mg, 750mg, 850mg, 1000mg Generic $$$ RIOMET Metformin HCl 500mg/5ml Brand $$$$ GLUCOPHAGE XR Metformin HCl SR 500mg, 750mg Generic $$$ METHADONE Methadone HCl 5mg, 10mg, 40mg Generic $$$ CPA; QL= 120 tabs/30 days

DESOXYN Methamphetamine HCl 5mg Generic $$$$ CPA; Age > 23

TAPAZOLE Methimazole 5mg, 10mg Generic $$ MEXATE Methotrexate Sodium

1g, 1g/40ml, 25mg/ml, 50mg/2ml,


RHEUMATREX Methotrexate Sodium 2.5mg Generic $$$$ ALDOMET Methyldopa 250mg, 500mg Generic $$$$ CONCERTA Methylphenidate HCl 18mg, 27mg, 36mg, 54mg Brand $$$$$ CPA; Age > 23

RITALIN

Methylphenidate HCl 5mg, 10mg, 18mg, 20mg, 27mg, 36mg,

54mg

Generic

$$$$

CPA; Age > 23


METADATE CD Methylphenidate HCl 10mg, 20mg, 30mg, 40mg, 50mg, 60mg Brand $$$$$ CPA; Age > 23

MEDROL Methylprednisolone 2mg, 4mg, 8mg, 16mg, 32mg Generic $$$ DEPO‐MEDROL Methylprednisolone Acetate 40mg/ml, 80mg/ml Generic $$$$ REGLAN Metoclopramide HCl 5mg, 10mg Generic $$ ZAROXOLYN Metolazone 2.5mg, 5mg, 10mg Generic $$$$ TOPROL XL Metoprolol Succinate 25mg, 50mg, 100mg, 200mg Generic $$$$ LOPRESSOR Metoprolol Tartrate 25mg, 50mg, 100mg Generic $$$ METROLOTION Metronidazole 0.75% Generic $$$ METROGEL Metronidazole Gel 0.75% Generic $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-50

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 11 of 18



FLAGYL Metronidazole Oral, IV Generic $$ to $$$$

HELIDAC Metronidaz‐Tetracyc‐Bis Brand $$$$

MYCAMINE Micafungin IV 50mg, 100mg Brand $$$ LMN

PROAMATINE Midodrine HCl 2.5mg, 5mg, 10mg Generic $$$


MIRTAZAPINE Mirtazapine 7.5mg, 15mg, 30mg, 45mg Generic $$$

CYTOTEC Misoprostol 100mcg, 200mcg Generic $$$$

MITOMYCIN Mitomycin 5mg, 20mg, 40mg Generic $$$$$$

PROVIGIL Modafinil 100mg, 200mg, 300mg Brand $$$$$ CPA; Age > 23

UNIRETIC Moexipril‐Hydrochlorothiazide 7.5‐12.5mg, 15‐12.5mg, 15‐25mg Generic $$$

ASMANEX Mometasone Furoate 110mcg, 220mcg Brand $$$$

ELOCON Mometasone Furoate 0.1% Generic $$$

NASONEX Mometasone Furoate 50mcg/ACT Brand $$$$


QL= 1 inh (#14 inhalation units); 2 inhs

(#30, #60, #120 inhalation units); per 30

days

Step: Fail one: flunisolide, fluticasone,

OMNARIS

MS CONTIN Morphine Sulfate 15mg, 30mg, 60mg, 10mg, 200mg Generic $$$ QL= 120 tabs/30 days


BACTROBAN Mupirocin Generic $$

CELLCEPT Mycophenolate Mofetil 250mg, 500mg Generic $$$$ CELLCEPT

Mycophenolate Mofetil 250mg, 500mg, 250mg/ml Brand $$$$$$ LMN

MYCOPHENOLATE Mycophenolate Mofetil 250mg, 500mg Generic $$$$$$ LMN

RELAFEN Nabumetone 500mg, 750mg Generic $$$ CORGARD

Nadolol 20mg, 40mg, 80mg Generic $$

SYNARELM Nafarelin Acetate 2mg/ml Brand $$$$$$ LMN

NAFCILLIN Nafcillin IV Generic $$$$ LMN

220mg, 250mg, 275mg, 375m g, 500mg, NAPROSYN Naproxen

550mg Generic $$$

ALEVE Naproxen Sodium 220mg OTC $ QL= 100 tabs/30 days

Step: Sumatriptan Succinate; QL= 9 tabs/30 AMERGE Naratriptan HCl 1mg, 2.5mg Generic $$$$

days (1mg & 2.5mg)

TYSABRILD Natalizumab 300mg/15ml Brand $$$$$$ LMN

STARLIX Nateglinide 60mg, 120mg Generic $$$$

SERZONE Nefazodone HCl 50mg, 100mg, 150mg, 200mg, 250mg Generic $$$

NEOMYCIN Neomycin Sulfate ‐Oral 500mg Generic $$$$ QL= 2 tabs/30 days

NEOSPORIN Neomycin/Polymyxin Gramicidin Generic $$

CORTISPORIN Neomycin‐Colistin‐HC‐Thonzonium Generic $$

MAXITROL Neomycin‐Polymyxin‐Dexamethasone 0.1% Generic $$

TOBRADEX Neomycin‐Polymyxin‐Dexamethasone Generic $$$

NIASPAN Niacin 500mg, 750mg, 1000mg Brand $$$$

CARDENE Nicardipine HCl 20mg, 30mg Generic $$

PROCARDIA Nifedipine 10mg, 20mg Generic $$

PROCARDIA XL Nifedipine SR 30mg, 60mg, 90mg Generic $$$$

TASIGNA Nilotinib 150mg, 200mg Brand $$$$$$

SULAR Nisoldipine 8.5mg, 17mg, 25.5mg, 34mg, Generic $$$$

ALINIA Nitazoxanide Oral 500mg Brand $$$$$

MACRODANTIN Nitrofurantoin Macorcrystal Oral Generic $$

2.5mg, 6.5mg, 0.1mg/HR, 0.2mg/HR, NITRO‐DUR Nitroglycerin

0.4mg/HR, 0.6mg/HR Generic $$$$

NITROSTAT Nitroglycerin 0.4mg, 0.6mg Generic $$$$

Norelgestromin‐Ethinyl Estradiol TD PTWK ORTHO EVRA

150‐20 MCG/24HR Brand $$$

NOR‐QD Norethindrone 0.35mg Generic $$$

Norethindrone & Ethinyl Estradiol Tab 0.4 OVCON 35

NECON

MG Norethindrone & Ethinyl Estradiol Tab

0.5

MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐

35/1‐35 MG‐MCG

Generic $$$

Generic $$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-51

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 12 of 18



NORTREL


MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐

Generic

$$

35/1‐35 MG‐MCG MODICON


MG‐35MCG Generic $$$

ORTHO‐NOVUM

Norethindrone & Ethinyl Estradiol Tab 1

MG‐35 MCG, 1 MG‐50MCG, 0.5‐35/0.75‐

35/1‐35 MG‐M

Generic

$$$

NORINYL

Norethindrone & Mestranol Tab 1 MG‐

35MCG, 1 MG‐50 MCG

Generic

$$

MICROGESTIN

Norethindrone Ace & Ethinyl Estradiol Tab

1 MG‐20 MCG, 1.5 MG‐30 MCG

Generic

$$

LOESTRIN FE



Generic

$$

MICROGESTIN FE



Generic

$$

JUNEL FE


Tab 1 MG‐20MCG, 1.5 MG‐30 MCG

Generic

$$

AYGESTIN Norethindrone Acetate 5mg Generic $$$$

FEMHRT Norethindrone Acetate‐Ethinyl Estradiol 0.5mg‐2.5mcg, 1mg‐5mcg Generic $$$$

ESTROSTEP FE Norethindrone Ac‐Ethinyl Estrad‐Fe Tab 1‐

20/1‐30/1‐35 MG‐MCG Generic $$$

ARANELLE Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐

35/0.5‐35 MG‐MCG Generic $$

TRI‐NORINYL Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐

35/0.5‐35 MG‐MCG Generic $$$

MONONESSA Norgestimate & Ethinyl Estradiol Tab 0.25


ORTHO‐CYCLEN Norgestimate & Ethinyl Estradiol Tab 0.25


PREVIFEM Norgestimate & Ethinyl Estradiol Tab 0.25


SPRINTEC 28 Norgestimate & Ethinyl Estradiol Tab 0.25


ORTHO TRI‐CYCLEN LO Norgestimate‐Eth Estrad Tab 0.18‐

25/0.215‐25/0.25‐25 MG‐MCG

Brand

$$

CPA

ORTHO TRI‐CYCLEN Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG

Generic

$$

TRINESSA Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG Generic $$

TRI‐PREVIFEM Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG Generic $$

TRI‐SPRINTEC Norgestimate‐Eth Estrad Tab 0.18‐

35/0.215‐35/0.25‐35 MG‐MCG Generic $$

CRYSELLE‐28 Norgestrel & Ethinyl Estradiol Tab 0.3 MG‐

30 MCG Generic $$

LO/OVRAL Norgestrel & Ethinyl Estradiol Tab 0.3 MG‐

30 MCG Generic $$

LOW‐OGESTREL Norgestrel & Ethinyl Estradiol Tab 0.3 MG‐

30 MCG Generic $$

PAMELOR Nortriptyline HCl 10mg, 25mg, 50mg, 75mg Generic $$$ NYSTATIN Nystatin Swish and Swallow Generic $$ NYSTOP Nystatin Topical Powder Generic $$

OCTREOTIDE

Octreotide Acetate 100mcg, 200mcg, 500mcg, 1000mcg,

1mg/ml, 50mcg/ml

Generic

$$$$$$

LMN

SANDOSTATIN Octreotide Acetate 10mg, 20mg, 30mg, 50mcg/ml, 100mcg

200mcg, 500mcg, 1000mcg

, Brand $$$$$$

OCUFLOX Ofloxacin 0.3% Generic $$$ BENICAR Olmesartan Medoxomil 5mg, 20mg, 40mg Brand $$$ Step: losartan potassium

$ ‐‐‐‐‐‐‐‐‐ $1 to $10




BENICAR HCT Olmesartan Medoxomil‐

Hydrochlorothiazide 20‐12.5mg, 40‐12.5mg, 40‐25mg Brand $$$$ Step: losartan potassium HCT

g)

TRIBENZOR Olmesartan‐Amlodipine‐

Hydrochlorothiazide Brand $$$$ LMN

PATANASE Olopatadine HCl 0.6% Brand $$$$ PATANOL Olopatadine HCl 0.1% Brand $$$$ DIPENTUM Olsalazine Sodium 250mg Brand $$$$ XOLAIRLD

Omalizumab 150mg Brand $$$$$$ LMN LOVAZA Omega‐3‐acid Ethyl Esters 1g Brand $$$$ PRILOSEC Omeprazole 10mg, 40mg Generic $$ PRILOSEC Omeprazole 20mg OTC $$ QL= 42 tabs/30 days ZEGERID Omeprazole‐Sodium Bicarbonate 20‐1100 OTC $$ QL= 42 tabs/30 days BOTOX OnabotulinumtoxinA 50u, 100u, 200u Brand $$$$$$ LMN

ZOFRAN

Ondansetron HCl

4mg, 8mg, 24mg

Generic

$$$ QL= 30 tabs (4mg & 8mg); 1 tab

per 30 days

(24mg);

ZOFRAN Ondansetron HCl and Dextrose 32mg/50ml Brand $$$ CPA; QL= 3 bottles (sol); per 30 days

TAMIFLU Oseltamir Oral 30mg, 45mg, 70mg Brand $$$$ QL= 10 caps (45mg, 75mg) 20 c

100ml/30 days (oral susp)

aps (30m

ELOXATIN Oxaliplatin 50mg, 100mg, 200mg Brand $$$$$$ DAYPRO Oxaprozin 600mg Generic $$$$ TRILEPTAL Oxcarbazepine Suspension 300mg/5ml Generic $$$ OXYTROL Oxybutynin 3.9mg/24HR Brand $$$ DITROPAN XL Oxybutynin Chloride 5mg, 10mg Generic $$ GELNIQUE Oxybutynin Chloride 10% Brand $$$ OXYCONTIN Oxycodone HCl

10mg, 15mg, 20mg, 30mg, 40mg, 60mg

80mg, 160mg

, Brand $$$$ CPA; QL= 120 tabs/30 days

ROXICODONE

Oxycodone HCl 5mg, 10mg, 15mg, 20mg, 30mg, 40mg,

80mg

Generic

$$$


OPANA ER

Oxymorphone HCl 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg,

40mg

Brand

$$$$


ONXOL

Paclitaxel 30mg/5ml, 100mg/16.7ml, 150mg/25m

300mg/50ml

l, Generic

$$$$$

PACLITAXEL

Paclitaxel 100mg, 6mg/ml, 30mg/5ml, 150mg/25

300mg/50ml

l, Generic

$$$$$$

SYNAGISLD Palivizumab IM 50mg, 100mg/ml Brand $$$$$$ LMN

ALOXI Palonosetron HCl 0.25mg Brand $$$$$$ AREDIA Pamidronate Disodium 30mg, 90mg Brand $$$$$$ LMN PAMIDRONATE Pamidronate Disodium 30mg, 90mg, 30mg/10ml, 90mg/10ml Generic $$$$$$ PROTONIX Pantoprazole 20mg, 40mg Generic $$$

ZEMPLAR

Paricalcitol

1mcg, 2mcg, 4mcg, 2mcg/ml, 5mcg/ml

Brand

$$$$$$

LMN

PAXIL Paroxetine HCl 10mg, 12.5mg, 20mg, 30mg, 40mg Generic $$ VOTRIENTLD

Pazopanib HCl 200mg Brand $$$$$$

GOLYTELY

PEG 3350‐KCl‐Na Bicarb‐NaCl‐Na Sulf

ate

Generic

$$$$

NULYTELY PEG 3350‐KCl‐Sod Bicarb‐NaCl Generic $$$$ MACUGENLD

Pegaptanib Sodium Brand $$$$$$ LMN NEULASTA Pegfilgrastim 6mg/0.6ml Brand $$$$$$ CPA; QL= 2 inj/30 days PEGASYS Peginterferon alfa‐2a 180mcg/0.5ml, 180mcg/ml Brand $$$$$$ LMN PEG‐INTRON Peginterferon alfa‐2b 50mcg, 80mcg, 120mcg, 150mcg Brand $$$$$$ LMN SOMAVERTLD

Pegvisomant 10mg, 15mg, 20mg Brand $$$$$$ LMN ALIMTA Pemetrexed Disodium 100mg, 500mg Brand $$$$$$ PENICILLN GK Penicillin G IV Generic $$$ LMN PENICILLN VK Penicillin VK‐oral Generic $$$ TRENTAL Pentoxifylline 400mg Generic $$$$ ELIMITE Permethrin 5% Generic $$$$ ACTICIN Permethrin Lotion 1% Generic $$ PYRIDIUM Phenazopyridine HCl 100mg, 200mg Generic $$ PHENOBARB Phenobarbital 15mg, 30mg, 32.4mg, 60mg, 100mg Generic $$ PHENTOLAMINE Phentolamine Mesylate Brand $$$$$$ LMN DILANTIN Phenytoin Sodium 100mg Generic $$ PHENYTEK Phenytoin Sodium 200mg, 300mg Generic $$ VITAMIN K Phytonadione 100mcg OTC $$ QL= 60 tabs/30 days

$ ‐‐‐‐‐‐‐‐‐ $1 to $10


m



VITAMIN K1 Phytonadione 1mg/0.5ml, 2mg/ml Generic $$$$$$ LMN PILOCARPINE Pilocarpine HCl 1%, 2%, 3%, 4%, 6% Generic $$ ELIDEL Pimecrolimus 1% Brand $$$$ CPA ACTOS Pioglitazone HCl 15mg, 30mg, 45mg Brand $$$$ DUETACT Pioglitazone HCl‐Glimepiride 30‐2mg, 30‐4mg Brand $$$$ ACTOPLUS MET Pioglitazone HCl‐Metformin HCl 15/850mg, 30/1000mg Brand $$$$ ZOSYN Pipercillin/Tazobactam IV Generic $$$$ LMN FELDENE Piroxicam 10mg, 20mg Generic $$$$ GLYCOLAX Polyethylene Glycol OTC $$ POLYTRIM Polymyxin B‐Trimethoprim Generic $ NOXAFIL Posaconazole Oral 40mg/ml Brand $$$$$ LMN MICRO‐K Potassium Chloride 8mEq, 10mEq, 20mEq Generic $$ MIRAPEX Pramipexole Dihydrochloride 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg Generic $$$

MIRAPEX ER

Pramipexole Dihydrochloride SR

0.375mg, 0.75mg, 1.5mg, 3mg, 4.5mg

Brand

$$$$

Step: Pramipexole Dihydrochloride

SYMLIN/SYMLINPEN Pramlintide Acetate 600mcg, 1000mcg Brand $$$$ CPA; QL= 7 vials; 8 pens/30 days EFFIENT Prasugrel HCl 5mg, 10mg Brand $$$$ Step: Plavix PRAVACHOL Pravastatin Sodium 10mg, 20mg, 40mg, 80mg Generic $$$$ BILTRICIDE Praziquantal Oral 600mg Brand $$$ MINIPRESS Prazosin HCl 1mg, 2mg, 5mg Generic $$$ OMNIPRED Prednisolone Acetate 1% Generic $$$$ PRED FORTE Prednisolone Acetate 1% Generic $$ VERIPRED 20 Prednisolone Sod Phosphate 20mg/5ml Brand $$$$ STERAPRED Prednisone 5mg, 10mg, 20mg Generic $$$$

LYRICA

Pregabalin 25mg, 50mg, 75mg, 100mg, 150mg,

200mg, 225mg, 300mg

Brand

$$$$

Step: gabapentin

PRENATAL Prenatal Rx Generic $$ Step: Prenatal OTC NATALCARE PLUS Prenatal Vit w/ Fe Fumarate‐FA Generic $$ Step: Prenatal OTC

PRENATE ELITE

Prenatal Vit w/ Fe Fum‐Methylfolate‐FA

Brand

$$$$

Step: Prenatal OTC

PRENATAL VITAMINS Prenatal Vitamins OTC $$ QL= 100 tabs/30 days PRIMAQUINE Primaquine Oral 26.3mg Generic $$$$ MYSOLINE Primidone 50mg, 250mg Generic $$$ BENEMID Probenecid 500mg Generic $$$$ MATULANE Procarbazine HCl 50mg Generic $$$$$$$ COMPAZINE Prochlorperazine Maleate 5mg, 10mg Generic $$ PHENERGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$ PHEREGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$ PHENERGAN/CODEINE Promethazine w/ Codeine 6.25‐10mg Generic $$ PHENERGAN/CODEINE Promethazine w/ Codeine Generic $$ PHENERGAN DM Promethazine‐DM Generic $$ RYTHMOL Propafenone HCl 150mg, 225mg, 325mg, 425mg Generic $$$$ INDERAL Propranolol HCl 20mg, 60mg, 80mg, 120mg, 160mg Generic $$$ PROPYLTHIOURACIL Propylthiouracil 50mg, 100mg, 200mg, 400mg Generic $$ ARALASTLD

Proteinase Inhibitor 400mg, 500mg, 800mg, 1000mg Brand $$$$$$ LMN CONGESTAC Pseudoephedrine‐Guaifenesin Generic $$$ PYRAZINAMIDE Pyrazinamide Oral 500mg Generic $$$ MESTINON Pyridostigmine Bromide 60mg, 60mg/5ml Brand $$$$

PYRIDOXINE

Pyridoxine HCl 25mg, 50mg, 100mg, 200MG, 250MG,

500MG

OTC

$$

QL= 60 tabs/30 days

ACCUPRIL Quinapril HCl 5mg, 10mg, 20mg, 40mg Generic $$$ Step: Failure of two: omeprazole,

ACIPHEX Rabeprazole Sodium EC 20mg Brand $$$$ pantoprazole, lansoprazole; QL= 34 caps/packets/30 days

EVISTA Raloxifene HCl 60mg Brand $$$$ ALTACE Ramipril 1.25mg, 2.5mg, 5mg, 10mg Generic $$$ LUCENTIS

LD Ranibizumab Brand $$$$$$ LMN

ZANTAC Ranitidine HCl 300mg Generic $$$ ZANTAC Ranitidine HCl 75mg, 150mg OTC $$ QL= 90 tabs/30 days RANEXA Ranolazine 500mg, 1000mg Brand $$$$ LMN AZILECT Rasagiline Mesylate 0.5mg, 1mg Brand $$$ PRANDIMET Repaglinide‐Metformin HCl 1‐500mg, 2‐500mg Brand $$$$ HYPERRHO Rho D Immune Globulin 50mcg, 300mcg Brand $$$$$$ LMN MICRHOGAM PL Rho D Immune Globulin 50mcg Brand $$$$$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10 $$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-54 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 15 of 18



RHOGAM PLUS Rho D Immune Globulin 300mcg Brand $$$$$$

RHOPHYLACLD Rho D Immune Globulin 1500u/2ml Brand $$$$$$ LMN

WINRHO SDF Rho D Immune Globulin 600u, 1500u, 2500u, 5000u, 15000u Brand $$$$$$ LMN

COPEGUS Ribavirin 200mg Brand $$$$$$ LMN

REBETOL Ribavirin 200mg, 4mg/ml Brand $$$$$$ LMN

RIBASPHERE Ribavirin 200mg, 400mg, 600mg Brand $$$$$$ LMN

RIBAPAK Ribavirin Oral 400mg, 600mg Generic $$$$ Specialty

RIBAVIRIN Ribavirin Oral 200mg, 400mg, 600mg Generic $$$$ Specialty

RIFADIN Rifampin Oral 150mg, 300mg Generic $$$


ACTONEL, ACTONEL WITH

CALCIUM

Risedronate Sodium, Risedronate Sod with

Calcium Carbonate

5mg, 30mg, 35mg, 75mg, 150mg Brand $$$$ Step: alendronate

RITUXAN Rituximab 100mg, 500mg Brand $$$$$$

EXELON Rivastigmine Tartrate 1.5mg, 3mg, 4.5mg, 6mg Generic $$$$

EXELON PATCH Rivastigmine TD Patch 4.6mg/24HR, 9.5mg/24HR Brand $$$$

MAXALT, MAXALT‐MLT Rizatriptan Benzoate 5mg, 10mg Brand $$$$

NPLATE Romiplostim 250mcg, 500mcg Generic $$$$$$

REQUIP Ropinirole Hydrochloride 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg Generic $$


days


AVANDARYL Rosiglitazone Maleate‐Glimepiride 4‐1mg, 4‐2mg, 4‐4mg, 8‐2mg, 8‐4mg Brand $$$$ LMN

AVANDAMET Rosiglitazone Maleate‐Metformin HCl 2‐500mg, 2‐1000mg, 4‐500mg, 4‐1000mg Brand $$$$ LMN


DISALCID Salsalate 500mg, 750mg Generic $$

KUVANLD Sapropterin Dihydrochloride 100mg Brand $$$$$$ LMN

ONGLYZA Saxagliptin HCl 2.5mg, 5mg Brand $$$$ SELSUN

BLUE Selenium Sulfide 1%, 2.25%, 2.5% Generic $

ZOLOFT Sertraline HCl 25mg, 50mg, 100mg Generic $$

RENAGEL Sevelamer 400mg, 800mg Brand $$$$$

RENVELA Sevelamer Carbonate 800mg, 0.8g, 2.4g Brand $$$$$


RAPAFLO Silodosin 4mg, 8mg Brand $$$$

SILVADENE Silver Sulfadiazine Generic $$$

ZOCOR Simvastatin 5mg, 10mg, 20mg, 40mg, 80mg Generic $$$

RAPAMUNE Sirolimus 0.5mg, 1mg, 2mg, 1mg/ml Brand $$$$$$ LMN

JANUVIA Sitagliptin Phosphate 25mg, 50mg, 100mg Brand $$$$

JANUMET Sitagliptin‐Metformin HCl 50‐500mg, 50‐1000mg Brand $$$$$

FERRLECIT Sod Ferric Gluc Cmplx 12.5mg Brand $$$$$$ LMN

EUFLEXXA Sodium Hyaluronate 10mg/ml Brand $$$$$$ LMN



SUPARTZ Sodium Hyaluronate Intra‐articular 25mg/2.5ml Brand $$$$$$ LMN


GENOTROPIN Somatropin

0.2mg, 0.4mg, 0.6mg, 0.8mg, 1mg, 1.2mg,

1.4mg, 1.6mg, 1.8mg, 2mg, 5mg, 12mg

Brand $$$$$$ CPA


5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml, NORDITROPIN Somatropin

30mg/3ml Brand $$$$$$ CPA

NUTROPINLD Somatropin 5mg, 10mg, 5mg/2ml, 20mg/2ml Brand $$$$$$ CPA

OMNITROPELD Somatropin 5.8mg, 5mg/1.5ml, 10mg/1.5ml Brand $$$$$$ CPA

SAIZEN Somatropin 5mg, 8.8mg Brand $$$$$$ CPA

SEROSTIMLD Somatropin 4mg, 5mg, 6mg, 8.8mg Brand $$$$$$ LMN

TEV‐TROPINLD Somatropin 5mg Brand $$$$$$ CPA

ZORBTIVE Somatropin 8.8mg Brand $$$$$$ CPA


BETAPACE Sotalol HCl 80mg, 120mg, 160mg, 240mg Generic $$$$


ALDACTONE Spironolactone 25mg, 50mg, 100mg Generic $$$

ALDACTAZIDE Spironolactone & Hydrochlorothiazide 25/25mg Generic $$$

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

4f-55

6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 16 of 18



CARAFATE Sucralfate 1g Generic $$$$

BLEPH‐10 Sulfacetamide Sodium 10% Generic $$

KLARON Sulfacetamide Sodium 10% Generic $$$$

SUMAXIN Sulfacetamide Sodium w/ Sulfur 10‐1%, 10‐4%, 10‐5% Generic $$$$

BACTRIM DS Sulfamethoxazole/Trimethoprim Generic $$


CLINORIL Sulindac 150mg, 200mg Generic $$$

SUMATRIPTAN Sumatriptan Nasal Spray 5mg/ACT, 20mg/ACT Brand $$$ QL= 6 devices/30 days (5mg & 20mg spray)

IMITREX Sumatriptan Succinate 25mg, 50mg, 100mg Generic $$$

IMITREX Sumatriptan Succinate Injection 4mg/0.5ml, 6mg/0.5ml Generic $$$

SUTENT Sunitinib Malate 12.5mg, 25mg, 50mg Brand $$$$$$

QL= 9 tabs/30 days (25mg, 50mg, &

100mg) QL= 1 kit/30 days (2 syringes); 2

vials/30 days

PROGRAF Tacrolimus 0.5mg, 1mg, 5mg, 5mg/ml Brand $$$$$$ LMN

PROTOPIC Tacrolimus 0.03%, 0.1% Brand $$$$ CPA

TACROLIMUS Tacrolimus 0.5mg, 1mg, 5mg Generic $$$$$$ LMN

ADCIRCA Tadalafil 20mg Brand $$$$$$

NOLVADEX Tamoxifen Citrate 10mg, 20mg Generic $$$$

FLOMAX Tamsulosin HCl 0.4mg Generic $$$$

TAZORAC Tazarotene 0.05%, 0.1% Brand $$$$

TYZEKA Telbivudine Oral 600mg Brand $$$$$




TEMODAR Temozolomide 5mg, 20mg, 100mg, 140mg, 180mg, 250mg Brand $$$$$$$

TORISEL Temsirolimus 25mg/ml Brand $$$$$$

VIREAD Tenofovir Disoproxil Fumarate 300mg Brand $$$$$$ CPA

HYTRIN Terazosin HCl 1mg, 2mg, 5mg, 10mg Generic $$$

LAMISIL Terbinafine Oral 250mg Generic $$$$

TERCONAZOLE Terconazole Vaginal Generic $$


ANDRODERM Testosterone 2.5mg/24HR, 5mg/24HR Brand $

ANDROGEL Testosterone 1% Brand $

TESTIM Testosterone 1% Brand $

XENAZINELD Tetrabenazine 12.5mg, 25mg Brand $$$$$$ LMN

TETRACYCLINE Tetracycline Oral Generic $$

THALOMID Thalidomide 50mg, 150mg, 200mg100mg, Brand $$$$$$

THEO‐DUR Theophylline 100mg, 200mg, 300mg Generic $$$

THEOPHYLLINE ANHYDROUS Theophylline Brand $$ ARMOUR

THYRO Thyroid 32.5mg, 65mg, 130mg, 195mg Generic $$

THYROGENLD Thyrotropin Alfa 1.1mg Brand $$$$$$ LMN

TYGACIL Tigecycline IV 50mg Brand $$$$$ LMN

TIMOPTIC Timolol Maleate 0.25%, 0.5% Generic $$$

TIMOPTIC‐XE Timolol Maleate 0.25%, 0.5% Generic $$$

INNOHEP Tinzaparin Sodium 20000u/ml Brand $$$$$$ LMN; Available at Retail

QL= 1 pkg (6 caps or 90 caps); 2 pkgs (30 SPIRIVA Tiotropium Bromide Monohydrate 18mcg Brand $$$$

caps); per 30 days

TOBI Tobramycin 300mg/5ml Brand $$$$$$ LMN

TOBREX Tobramycin IV Generic $$$ QL= 14 days

TOPAMAX Topiramate 25mg, 50mg, 100mg, 200mg Generic $$ TOPAMAX

SPRINKLE Topiramate Sprinkle 15mg, 25mg Generic $$


ULTRAM Tramadol HCl 50mg, 100mg, 200mg, 300mg Generic $$$$ QL= 120 tabs/30 days


DESYREL Trazodone HCl 50mg, 100mg, 150mg, 300mg Generic $$

REMODULINLD Treprostinil Sodium 1mg/ml, 2.5mg/ml, 5mg/ml, 10mg/ml Brand $$$$$$ LMN; Specialty



KENALOG Triamcinolone Acetonide 0.025%, 0.1%, 0.5% Generic $$

NASACORT AQ Triamcinolone Acetonide 55mcg/ACT Brand $$$$

MAXZIDE Triamterene & Hydrochlorothiazide 37.5‐25mg, 50‐25mg, 75‐50mg Generic $$$

Step: Fail one: flunisolide, fluticasone,

OMNARIS

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 17 of 18



CERUMENEX Triethanolamine Oleate Brand $$$

TIGAN Trimethobenzamide HCl 300mg/5ml Generic $$$

TRELSTARLD Triptorelin Pamoate 3.75mg, 11.25mg, 22.5mg Brand $$$$$$

SANCTURA, SANCTURA XR Trospium Chloride 20mg, 60mg Generic $$$

BRAVELLE Urofollitropin 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN

URSO, URSO FORTE Ursodiol 250mg, 500mg Generic $$$$

VALTREX Valacyclovir HCl 500mg, 1g Generic $$$$ CPA

VALCYTE Valganciclovir HCl 450mg, 50mg/ml Brand $$$$$$ LMN

DIOVAN Valsartan 40mg, 80mg, 160mg, 320mg Brand $$$ Step: losartan potassium

80‐12.5mg, 160‐12.5mg, 160‐25mg, 320‐ DIOVAN HCT Valsartan‐Hydrochlorothiazide

12.5mg, 320‐25mg Brand $$$$ Step: losartan potassium HCT

VANCOCIN Vancomycin Oral, IV Generic $$$

EFFEXOR Venlafaxine HCl 25mg, 37.5mg, 50mg, 75mg, 100mg Generic $$

EFFEXOR ER Venlafaxine HCl SR 37.5mg, 75mg, 150mg, 225mg Generic $$$

ISOPTIN Verapamil HCl 40mg, 80mg, 180mg, 240mg Generic $$$




NAVELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$

VINORELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$

VFEND Voriconazole 50mg, 200mg, 40mg/ml Brand $$$$$$ LMN

1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, COUMADIN Warfarin Sodium

7.5mg, 10mg Generic $$$

ACCOLATE Zafirlukast 10mg, 20mg Brand $$$$ Step: Singulair


RELENZA Zanamivir Oral 5mg Brand $$$ QL= 20 tabs/30 days


ZOMETA Zoledronic Acid 4mg/5ml Brand $$$$$$ LMN; Specialty

Step: Sumatriptan Succinate; QL= 9 tabs/30 ZOMIG, ZOMIG ZMT Zolmitriptan 2.5mg, 5mg Brand $$$$

ZOMIG NASAL SPRAY Zolmitriptan Nasal Spray 5mg Brand $$$$

days Step: Sumatriptan Succinate;

QL= 9 devices/30 days

AMBIEN Zolpidem Tartrate 5mg, 10mg, 6.25mg, 12.5mg Generic $$ QL= 30 tabs/30 days

ZONEGRAN Zonisamide 25MG,50mg, 100mg Generic $$

ACCU‐CHEK ‐ kits, strips and

supplies

ONE TOUCH ‐ kits, strips and

supplies

Brand $$$$ QL= 100 strips/30 days

Brand $$$$ QL= 100 strips/30 days

TRUE ‐ kits, strips and supplies Brand $$$ QL= 100 strips/30 days

$ ‐‐‐‐‐‐‐‐‐ $1 to $10

$$ ‐‐‐‐‐‐‐‐‐ $11 to $50

$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100

$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500

$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000

$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000

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6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 18 of 18

June 23, 2011

Earl Greenia



2220 E. Gonzales Road, Suite 200

Oxnard, CA 93036

Dear Earl,

Thank you for the opportunity to provide this written update to you and the Commission. Script

Care and GCHP have been working diligently to ensure a successful go-live on July 1. Some

recent successes include:

- Script Care and your Pharmacy and Therapeutics Committee recently completed the

final draft of the List of Covered Drugs (formulary).

- We officially opened our local office at 1701 Solar, Oxnard, CA on June 20, 2011. The

office has begun fielding calls and inquiries regarding the Pharmacy Services program.

Our customer service department will begin providing 24 hour access on July 1, 2011.

- We are making the final adjustments on the plan design in the adjudication system to be

completed on June 27.

- Script Care has completed the Pharmacy Network development, and the network has

been loaded and activated in the system.

I understand that there has been concern voiced by a few of the local independent pharmacy

owners. Any transition from a fee-for-service to a managed care reimbursement system will

create some anxiety. Since the last commission meeting, we have continued outreach to

independent and chain providers in the community. We held two open forum meetings with 27

attendees, 4 direct provider meetings, 6 pharmacy location meetings and multiple conference

calls with chain providers. We have addressed concerns such as timing of activation, member

awareness, changes in program design, the list of covered drugs, and reimbursement rates.

We have conducted multiple meetings with these pharmacies over the past two months to hear

their concerns. We have provided information including cost analysis and the detailed MAC list.

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We also made some favorable adjustments to the original contract offer based on the concerns

expressed by these providers. These included combining the limited and restricted network to

offer more favorable reimbursement, limiting the network to provide contract pharmacies with

increased volume opportunity, and increasing the dispensing fee in the Long Term Care

population to $2.25, an increase of $1.00 per prescription.

We have provided a comparative analysis (please see attached Exhibit A) including some of the

other COHS pharmacy reimbursement rates and other local PBM reimbursement rates to

address the fairness on the contracted rates that continues to be expressed directly to Script

Care by these few providers. The comparison illustrates that the adjustments SCL made to the

original contract offering make the GCHP reimbursement rates more favorable to pharmacies

than what is found in similar programs.

Original concerns regarding the brand reimbursements rates have decreased among providers

after a cost analysis was conducted to demonstrate the manner in which brand claims were

adjudicated. Providers were able to see that little to no change is found in the reimbursement of

brand drugs. The focus moved to generic products and concerns were voiced that pharmacies

would only see gross profit margin averages of $1.25 to $2.00 per script. We understand

pharmacy reimbursements will be reduced in comparison to the Medi-Cal FFS rates although not

to the level expressed by these few providers. Exhibit B utilizes a generic reimbursement

comparison provided by the referenced local independent providers on May 24, 2011. In this

analysis we added the acquisition cost provided by a local independent pharmacy to give

reference to the average margins expected on these items.

Script Care/GCHP will be conducting a Pharmacy Benefit Outreach Program on June 29 at

7:30pm held at the Adagio Building, Hilton Garden Inn, 2000 Solar Drive. The program has

been announced (please see Exhibit C) to all providers in the network. With the expectation of

an average 3,500+ transactions a day, the focus of the meeting will be to educate pharmacies

on changes, procedures and requirements to enable a smoother transition.

Again, thank you for the opportunity to provide this response.

Sincerely,

Kevin J. Brown Executive Vice President Script Care, Ltd.

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4g-3

EXHIBIT A: PROGRAM RATE COMPARISON

CenCal

PHA

GCHP

Restat (PBM) Commercial

Contract Limited

Restat (PBM) Commercial

Contract Restricted

Retail Brand - 30

AWP - 17.65% or U&C

AWP - 17.65% or U&C

AWP - 17.65% or U&C

AWP - 18% or U&C

AWP - 20% or U&C

-Dispensing Fee

$1.25

$1.25

$1.25

$1.25

$0.95

Retail Generic-30

MAC or AWP - 27%

or U&C

MAC or AWP - 27%

or U&C

SCL MAC or AWP -

22% or U&C

MAC or AWP -25%

or U&C

MAC or AWP -25% or

U&C -Dispensing Fee

$1.25

$1.25

$1.25

$1.25

$0.95

Retail Brand -90

AWP - 22% or U&C

AWP - 22% or U&C

AWP - 21% or U&C

AWP - 23% or U&C

AWP - 25% or U&C

-Dispensing Fee

$0.00

$0.00

$0.00

$0.25

$0.00

Retail Generic - 90

MAC or AWP - 22%

or U&C

MAC or AWP -

22% or U&C

SCL MAC or AWP -

22% or U&C

MAC or AWP - 25%

or U&C

MAC or AWP -25% or

U&C -Dispensing Fee

$0.00

$0.00

$0.00

$0.25

$0.00

Retail Brand - LTC

AWP - 17.65% or U&C

AWP - 17.65% or U&C

AWP - 17.65% or U&C

N/A

N/A

-Dispensing Fee

$1.25

$1.25

$2.25

N/A

N/A

Retail Generic - LTC

MAC or AWP - 27% or U&C

MAC or AWP - 27% or U&C

SCL MAC or AWP - 22% or U&C

N/A

N/A

-Dispensing Fee

$1.25

$1.25

$2.25

N/A

N/A

4g-4

EXHIBIT B

DATE

DRUG

NDC

QTY

MEDI-CAL

REIMBURSEMENT

SCL MAC

SCRIPT CARE

REIMBURSEMENT

(SAMPLE) LOCAL INDEPENDENT

ACQUISTION COST

5/24/2011 GLIPIZIDE 5MG 00591046010 30 $9.35 0.0699 $3.35 $0.68

5/24/2011 BENAZEPRL 40MG 00185004805 30 $21.97 0.1753 $6.51 $1.88

5/24/2011 LISINOPRIL 20MG 00185010210 30 $9.64 0.114 $4.67 $2.10

5/24/2011 GLYBURIDE 5MG 64720012511 30 $15.74 0.0926 $4.03 $2.94

5/24/2011 METFORMIN 1000 68382003010 60 $17.20 0.1135 $8.06 $3.00

5/24/2011 AZITHRO 200/5 59762312001 15 $34.58 1.32 $21.05 $13.06

5/24/2011 CEPHALEXIN 500MG 61442016205 30 $15.44 0.1911 $6.98 $5.86

5/24/2011 OXYCODONE 30MG 00406853001 90 $114.49 1.309 $119.06 $29.29

5/24/2011 NAPROXEN 500 68462019001 60 $12.19 0.0858 $6.40 $3.61

5/24/2011 IBU 100/5ML 45802095226 120 $15.95 0.0373 $5.73 $2.67

5/24/2011 AMOX 250/5 00143988915 150 $11.55 0.0254 $5.06 $4.69

5/24/2011 CEPHALEXIN 250/5 68180012402 200 $33.39 0.0917 $19.59 $12.56

5/24/2011 AMOX TR-K CLD 66685101202 100 $60.72 0.3755 $38.80 $16.58

5/24/2011 HCTZ 00603385632 30 $6.90 0.018 $1.79 $0.33

5/24/2011 VICODIN GENERIC 00591034905 30 $18.48 0.4763 $15.54 $0.75

5/24/2011 RANITIDINE 150 64679090603 60 $10.85 0.0658 $5.20 $2.40

5/24/2011 IBU 800 55111068405 30 $9.16 0.0638 $3.16 $1.30

5/24/2011 ATENOLOL 50 00781150610 30 $8.75 0.0535 $2.86 $0.60

Based on local Indpendents sample claims provided 5/24/11:

Current Medi-Cal Est. Margin - $17.89/Generic Rx

GCHP Contract Est Margin -$9.64/Generic Rx

Exhibit C

Pharmacy Benefit Outreach Program

Wednesday June 29, 2011

7:30 PM

Adagio Building, Hilton Garden Inn

2000 Solar Drive

Oxnard

This program will outline the upcoming transition from the

Medi-Cal FFS Program to the GCHP Pharmacy Services

Program for the County of Ventura beginning July 1, 2011.

All GCHP contracted pharmacies should plan to attend or

send at least one representative. Pertinent procedures and

guidelines will be discussed and highlighted at this time.

GCHP Pharmacy Services Procedure Manuals and the GCHP

List of Covered Drugs will be available.

For More Information Contact:

Jade Thibodeaux

1-800-880-9902 ext. 1153

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Documents

Ventura County Medi-Cal Managed Care Commission (VCMMCC) … · 2012. 5. 21. · Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan Commission Meeting