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Massachusetts Commercial FormularyPrescription Drug List By TierLast Updated: 12/22/2014

Last Updated: 12/22/2014Key TermsMassachusetts Commercial Tier 3 FormularyTufts Health Plan Drug ListFormularyA formulary is a list of prescription medications developed by a committee of practicing physicians andpracticing pharmacists who represent a variety of specialty areas and who are knowledgeable in thediagnosis and treatment of disease.Brand-Name DrugsBrand-name drugs are typically the first products to gain U.S. Food and Drug Administration (FDA)approval.Generic DrugsGeneric drugs have the same active ingredients and come in the same strengths and dosage forms asthe equivalent brand-name drug. Multiple manufacturers may produce the same generic drug and theproduct may differ from its brand name counterpart in color, size or shape, but the differences do notalter the effectiveness. Generic versions of brand-name drugs are reviewed and approved by the FDA.The FDA works closely with all pharmaceutical companies to make sure that all drugs sold in the U.S.meet appropriate standards for strength, quality, and purity.3-Tier Pharmacy Copayment Program (3-Tier Program)To help maintain affordability in the pharmacy benefit, we encourage the use of cost-effective drugs andpreferred brand names through the three-tier program. This program gives you and your doctor theopportunity to work together to find a prescription medication that's affordable and appropriate for you.All covered drugs are placed into one of three tiers. Your physician may have the option to write you aprescription for a Tier 1, Tier 2, or Tier 3 drug (as defined below); however, there may be instances whenonly a Tier 3 drug is appropriate, which will require a higher copayment. Tier 1: Medications on this tier have the lowest copayment. This tier includes many generic drugs.Tier 2: Medications on this tier are subject to the middle copayment. This tier includes some genericsand brand-name drugs.Tier 3: This is the highest copayment tier and includes some generics and brand-name covereddrugs not selected for Tier 2.Please note that tier placement is subject to change throughout the year.CopaymentA copayment is the fee a member pays for certain covered drugs. A member pays the copayment directlyto the provider when he/she receives a covered drug, unless the provider arranges otherwise.CoinsuranceCoinsurance requires the member to pay a percentage of the total cost for certain covered drugs.Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance1

Last Updated: 12/22/2014Medical Review ProcessTufts Health Plan has pharmacy programs in place to help manage the pharmacy benefit. Requests formedically necessary review for coverage of drugs included in the New-to-Market Drug Evaluation Process(NTM), Prior Authorization Program (PA), Step Therapy Prior Authorization Program (STPA), QuantityLimitations Program (QL), Non-Covered Drugs (NC) With Suggested Alternatives Program should becompleted by the physician and sent to Tufts Health Plan. Drugs excluded under your pharmacy benefitwill not be covered through this process. The request must include clinical information that supports whythe drug is medically necessary for you. Tufts Health Plan will approve the request if it meets coverageguidelines. If Tufts Health Plan does not approve the request, you have the right to appeal. The appealprocess is described in your benefit document.Note: Drugs approved through the Medical Review Process will be subject to a Tier 3 copayment.Quantity Limitation (QL) ProgramBecause of potential safety and utilization concerns, Tufts Health Plan has placed quantity limitations onsome prescription drugs. You are covered for up to the amount posted in our list of covered drugs. Thesequantities are based on recognized standards of care as well as from FDA-approved dosing guidelines. Ifyour provider believes it is necessary for you to take more than the QL amount posted on the list, he or shemay submit a request for coverage under the Medical Review Process.New-To-Market Drug Evaluation Process (NTM)In an effort to make sure the new-to-market prescription drugs we cover are safe, effective and affordable,we delay coverage of many new drug products until the Plan's Pharmacy and Therapeutics Committee andphysician specialists have reviewed them. This review process is usually completed within six months aftera drug becomes available.The review process enables us to learn a great deal about these new drugs, including how a physician cansafely prescribe these new drugs and how physicians can choose the most appropriate patients for thenew therapy. During the review process, if your physician believes you have a medical need for the NewTo-Market drug, your doctor can submit a request for coverage to Tufts Health Plan under the MedicalReview Process.If your plan includes the 3-Tier Copayment Program, then you will pay the Tier-3 (highest) copayment if themedication is approved for coverage.Non-Covered Drugs (NC)There are thousands of drugs listed on the Tufts Health Plan covered drug list. In fact, most drugs arecovered. There is, however, a list of drugs that Tufts Health Plan currently does not cover.In many cases, these drugs are not covered by Tufts Health Plan because there are safe, comparablyeffective, and cost effective alternatives available. Our goal is to keep pharmacy benefits as affordable aspossible.If your doctor feels that one of the non-covered drugs is needed, your doctor can submit a request forcoverage to Tufts Health Plan under the Medical Review Process.Prior Authorization (PA) ProgramIn order to ensure safety and affordability for everyone, some medications require prior authorization. Thishelps us work with your doctor to ensure that medications are prescribed appropriately.If your doctor feels it is medically necessary for you to take one of the drugs listed below, he/she cansubmit a request for coverage to Tufts Health Plan under the Medical Review Process.Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance2

Last Updated: 12/22/2014Step Therapy Prior Authorization (STPA )Step Therapy is an automated form of Prior Authorization. It encourages the use of therapies that shouldbe tried first, before other treatments are covered, based on clinical practice guidelines and costeffectiveness. Some types of Step Therapy include requiring the use of generics before brand name drugs,preferred before non-preferred brand name drugs, and first-line before second-line therapies.Medications included on step 1- the lowest step-are usually covered without authorization. We have notedthe few exceptions, which may require your physician to submit a request to Tufts Health Plan for coverage.Medications on Step 2 or higher are automatically authorized at the point-of-sale if you have taken therequired prerequisite drugs. However, if your physician prescribes a medication on a higher step, and youhave not yet taken the required medication(s) on a lower step, or if you are a new Tufts Health Plan memberand do not have any prescription drug claims history, the prescription will deny at the point-of-sale with amessage indicating that a Prior Authorization (PA) is required. Physicians may submit requests for coverageto Tufts Health Plan for members who do not meet the Step Therapy criteria at the point of sale under theMedical Review process.Designated Specialty Pharmacy Program (SP)Tufts Health Plan's goal is to offer you the most clinically appropriate and cost-effective services.As a result, we have designated special pharmacies to supply a select number of medications used in thetreatment of complex diseases. These pharmacies are specialized in providing these medications and arestaffed with nurses, coordinators and pharmacists to provide support services for members.Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis,hemophilia, hepatitis C and growth hormone deficiency. You can obtain up to a 30-day supply of thesemedications at a time.Other special designated pharmacies and medications may be identified and added to this program fromtime to time.Benefits vary; some members may not participate in this program. Please see your benefit document forcomplete information.Physicians may obtain a select number of specialty medications through a designated SP foradministration in the office as an alternative to direct purchase. These medications are covered under themedical benefit, and will be shipped directly to and administered in the office by the member’s provider.The designated pharmacy will bill Tufts Health Plan directly for the medication.For the most current listing of special designated pharmacies or to find out if your plan includes thisprogram, please call us at the number listed on the back of your member identification card.Designated Specialty Infusion Program for Drugs Covered Under the Medical Benefit (SI)Tufts Health Plan has designated home infusion providers for a select number of specialized pharmacyproducts and drug administration services.Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance3

Last Updated: 12/22/2014The designated specialty infusion provider offers clinical management of drug therapies, nursing support,and care coordination to members with acute and chronic conditions. Place of service may be in the homeor alternate infusion site based on availability of infusion centers and determination of the most clinicallyappropriate site for treatment. These medications are covered under the medical benefit (not the pharmacybenefit) and generally require support services, medication dose management, and special handling inaddition to the drug administration services. Medications include, but are not limited to, medications usedin the treatment of hemophilia, pulmonary arterial hypertension, and immune deficiency. Other specialtyinfusion providers and medications may be identified and added to this program from time to time.Generic Focused FormularyThe Generic Focused Formulary, which is the formulary used in our Select Network and/or ConnectorPlans differs from other Tufts Health Plan formularies. Most generic drugs are covered, and only selectbrand name drugs that have no generic drug equivalent are covered. Brand name drugs with genericequivalents are not covered under this formulary. If the patent of a brand name drug listed expires and ageneric version becomes available, the brand will no longer be covered. This change will happenautomatically and without notification to members or providers.GFF FormularyManaged Mail (MM) ProgramOur Managed Mail (MM) Program applies to certain plans. It requires that in order to be covered,prescriptions for most maintenance medications must be filled by our mail order pharmacy. Maintenancemedications are those you refill monthly for chronic conditions like asthma, high blood pressure, ordiabetes. Under this program, you are allowed an initial fill at a retail pharmacy and a limited number ofrefills. After that, in order to be covered, you must fill your maintenance prescription through the mail orderprogram offered by CVS Caremark, our pharmacy benefits manager. You may obtain up to a 90-daysupply for these maintenance medications at mail order. Please note that some medications may not beappropriate for mail order. These include medications with quantity limitations (QL) of less than 84 or 90days.If you have questions about this program, please contact us at the number listed on the back of yourmember identification card.Over-The-Counter Drugs (OTC)When a medication with the same active ingredient or a modified version of an active ingredient that istherapeutically equivalent, becomes available over-the-counter, Tufts Health Plan may exclude coverageof the specific medication or all of the prescription drugs in the class. For more information, please call ourMember Services Department at the number listed on the back of your member identification card.Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance4

Last Updated: 12/22/2014Drug NameTierPharmacy ProgramDiabetic Test Strips, OtherOneTouch Test Strips, Accu-Chek Test Strips, OneTouch andAccu-Chek are the preferred, covered, test strips. Examples ofnon-covered test strips include, but are not limited to: Ascensia,BD, FreeStyle, Precision, TrueTrack test stripsesomeprazole delayed-relQLNexiumQL Prilosec OTC, omeprazole, lansoprazole, pantoprazole;Nexium Oral Packets are covered for members 12 years of ageand younger. Quantity Limitations apply., 90 capsules/90 days;90 oral packets/90 days, Nexium Packets for Oral Suspensionare covered for members 12 years of age and younger.pantoprazole delayed-relQLPrevacid SolutabQL 90 solutabs/90 days, Prilosec OTC, omeprazole,lansoprazole, pantoprazole. Prevacid Solutab and genericlansoprazole soluble tablets are covered for members 12 years ofage and younger. Quantity Limitations apply., Prevacid Solutaband generic lansoprazole soluble tablets are covered formembers 12 years of age and younger. Quantity Limitationsapply.Proscarfinasteride 5 mg, Not covered for women (no exceptions).Protonix Oral SuspensionQL 90 packets/90 days, omeprazole, lansoprazole,pantoprazole. Protonix Oral Suspension is covered for members12 years of age and younger. Quantity Limitations apply.,Protonix Packets for Oral Suspension are covered for members12 years of age and younger.test stripsMedical BenefitDrug NameTierPharmacy Programnaltrexone vered under the medical benefit. Available throughAccredo, call 1-877-238-8387.Drug NameTierPharmacy ProgramAciphex Sprinkle CapsNTMActemra prefilled syringeNTMAdempasNTMAerospanNTMAvar LSNTMDermasorb AF kitNTMDermasorb XM dface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentSP Call Accredo at 1-866-344-4874SP Call Accredo at 1-877-238-8387PA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance5

Last Updated: 12/22/2014ImbruvicaNTMMirvasoNTMNicazeldoxy KitNTMNoxafil tabletsNTMOlysioNTMSP Call Caremark at 1-800-237-2767OpsumitNTMSP Call Accredo at 1-866-344-4874OtrexupNTMSP Call Accredo at 1-877-238-8387SovaldiNTMSP Call Caremark at 1-800-237-2767ValchlorNTMVersaclozNTMZohydro ERNTMTier 1Drug NameTierabacavirTier 1acamprosate calciumTier 1acarboseTier 1acebutololTier 1acetazolamideTier 1acetazolamide ext-relTier 1acetic acid oticTier 1acetic acid/aluminum acetate oticTier 1acetic acid/hydrocortisone oticTier 1acitretinTier 1acyclovir capsules, tabletsTier 1acyclovir ointment 5%Tier 1QL 1 tube/30 daysadapalene cream/gelTier 1PA Prior Authorization required for members 26 years of age orolder.adefovir dipivoxilTier 1albuterol ext-relTier 1albuterol sulfate nebulizer solutionTier 1albuterol syrup/tabletsTier 1alclometasoneTier 1alendronateTier 1alfuzosin ext-relTier 1allopurinolTier 1alprazolamTier 1alprazolam ext-relTier 1alprazolam orally disintegrating tabletsTier 1amantadineTier 1amcinonide cream, lotionTier 1amethiaTier 1amethia loTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentPharmacy ProgramQL 360 vials/90 days or 9 dropper bottles/90 daysPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance6

Last Updated: 12/22/2014amethystTier 1amilorideTier 1amiloride/hydrochlorothiazideTier 1amiodaroneTier 1amitriptylineTier 1amitriptyline/perphenazineTier 1amlodipineTier 1amlodipine/benazeprilTier 1ammonium lactate 12%Tier 1AmnesteemTier 1amoxicillinTier 1amoxicillin/clavulanateTier 1amoxicillin/clavulanate ext-relTier 1amphetamine/dextroamphetamine mixed saltsTier 1amphetamine/dextroamphetamine mixed salts ext-relTier 1ampicillinTier 1anagrelideTier 1anastrozoleTier 1apraclonidine 0.5% eye dropsTier 1apriTier 1aranelleTier 1atenololTier 1atenolol/chlorthalidoneTier 1atorvastatinTier 1atropine eye drops, eye ointmentTier r 1AvianeTier 1azathioprineTier 1azelastine eye dropsTier 1azelastine sprayTier 1azithromycinTier 1b complex c/folic acidTier 1bacitracin eye ointmentTier 1bacitracin/polymyxin B eye ointmentTier 1baclofenTier 1balsalazideTier 1balzivaTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentContraceptive covered without copayment under Women'sHealth Preventive Services Initiative. Please contact your plansponsor / employer about applicability and effective date foryour group.This drug may be covered without copayment under theMassachusetts Act Relative to Oral Cancer Therapy. Pleasecontact your plan sponsor/employer about applicability andeffective date for your group.Contraceptive covered without copayment under Women'sHealth Preventive Services Initiative. Please contact your plansponsor / employer about applicability and effective date foryour group.QLPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance7

Last Updated: 12/22/2014benazeprilTier 1benazepril/hydrochlorothiazideTier 1benzocaine/antipyrine oticTier 1benzonatateTier 1benzoyl peroxideTier 1benztropineTier 1betamethasone dipropionateTier 1betamethasone dipropionate augmented creamTier 1betamethasone dipropionate augmented gel, lotion,ointmentTier 1betamethasone valerateTier 1betamethasone valerate foamTier 1betaxololTier 1bethanecholTier 1bicalutamideTier 1bisoprololTier 1bisoprolol/hydrochlorothiazideTier 1brimonidine 0.15% eye dropsTier 1brimonidine 0.2% eye dropsTier 1bromfenac sodium eye dropsTier 1bromocriptineTier 1budesonide delayed-release capsulesTier 1budesonide inhalation suspensionTier 1bumetanideTier 1buprenorphine (Subutex discontinued)Tier 1PAbuprenorphine/naloxone SL tabletsTier 1PAbupropionTier 1bupropion ext-relTier 1bupropion HCl SRTier 1buspironeTier 1butalbital/acetaminophenTier 1butalbital/acetaminophen/caffeineTier 1butalbital/aspirin/caffeineTier 1butorphanol nasal sprayTier 1calcipotrieneTier 1calcitonin-salmon sprayTier 1calcitriolTier 1calcium acetateTier 1camilaTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentSP This drug may be covered without copayment under theMassachusetts Act Relative to Oral Cancer Therapy. Pleasecontact your plan sponsor/employer about applicability andeffective date for your group., Call Accredo at 1-877-238-8387QL Step Therapy Prior Authorization required for members 18years of age and older. Step Therapy Prior Authorization appliesto both brand and generic drug., 180 vials/90 daysQL 3 bottles (9 mL total)/30 daysPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance8

Last Updated: 12/22/2014camreseTier 1captoprilTier 1captopril/hydrochlorothiazideTier 1carbamazepineTier 1carbamazepine ext-relTier 1carbamazepine ext-rel 200 mg, 400 mgTier 1carbidopa/levodopaTier 1carbidopa/levodopa ext-relTier 1carbidopa/levodopa/entacaponeTier 1carisoprodol 250 mgTier 1carisoprodol 350 mgTier 1carisoprodol/aspirinTier 1carteolol eye dropsTier 1carvedilolTier 1cefaclorTier 1cefadroxilTier 1cefdinirTier 1cefditoren pivoxilTier 1cefpodoximeTier 1cefprozilTier 1cefuroxime axetilTier 1cephalexinTier 1cevimelineTier 1chloral hydrateTier 1chlordiazepoxideTier 1chlordiazepoxide/clidiniumTier 1chlorhexidine gluconateTier 1chloroquine phosphateTier 1chlorpromazineTier 1chlorpropamideTier 1chlorthalidoneTier 1chlorzoxazoneTier 1cholestyramineTier 1chorionic gonadotropinTier 1ciclopiroxTier 1ciclopirox topical solution 8%Tier 1cilostazolTier 1cimetidineTier 1ciprofloxacinTier 1ciprofloxacin ext-relTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentContraceptive covered without copayment under Women'sHealth Preventive Services Initiative. Please contact your plansponsor / employer about applicability and effective date foryour group.SP PA Call Village Pharmacy at 1-877-344-1610 or FreedomDrug at 1-877-585-4560 or Walgreens Specialty Pharmacy, LLCat 1-866-657-0500QL 1 bottle/30 daysPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance9

Last Updated: 12/22/2014ciprofloxacin eye drops, eye ointmentTier 1citalopramTier 1ClaravisTier 1clarithromycinTier 1clarithromycin ext-relTier 1clemastine 2.68 mgTier 1clindamycinTier 1clindamycin 1%/benzoyl peroxide 5%Tier 1clindamycin palmitate oral solutionTier 1clindamycin phosphate foam 1%Tier 1clindamycin vaginal creamTier 1clindamycin/benzoyl peroxide gelTier 1clobetasol propionateTier 1clobetasol propionate 0.05%Tier 1clobetasol propionate foamTier 1clobetasol propionate/emollient foamTier 1clomipheneTier 1clomipramineTier 1clonazepamTier 1clonidineTier 1clonidine ext-relTier 1clonidine transdermalTier 1clopidogrelTier 1clorazepateTier 1clotrimazole (Rx only)Tier 1clotrimazole trochesTier 1clotrimazole/betamethasoneTier 1clozapineTier 1codeine sulfateTier 1codeine/acetaminophenTier 1codeine/chlorpheniramine/pseudoephedrineTier 1codeine/guaifenesinTier 1codeine/guaifenesin/pseudoephedrineTier 1codeine/promethazineTier 1colestipolTier 1ConstuloseTier 1cortisone acetateTier 1cromolyn sodium eye dropsTier 1cromolyn sodium nebulizer solutionTier 1QL 360 vials/90 dayscryselleTier 1Contraceptive covered without copayment under Women'sHealth Preventive Services Initiative. Please contact your plansponsor / employer about applicability and effective date foryour group.cyanocobalamin injectionTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance10

Last Updated: 12/22/2014cyclobenzaprineTier 1cyclopentolate eye dropsTier 1cyclophosphamide tabletsTier 1cyclosporineTier 1cyclosporine, modifiedTier 1cyproheptadineTier 1danazolTier 1dantroleneTier 1dapsoneTier 1desipramineTier 1desmopressinTier 1desonideTier 1desoximetasoneTier 1dexamethasoneTier 1dexamethasone sodium phosphate eye drops, eyeointmentTier 1DexferrumTier 1dexmethylphenidateTier 1dextroamphetamineTier 1dextroamphetamine ext-relTier 1dextroamphetamine solutionTier 1dextromethorphan/promethazineTier 1diazepamTier 1diazepam rectal gelTier 1diclofenac potassiumTier 1diclofenac sodium 3% gelTier 1diclofenac sodium delayed-relTier 1diclofenac sodium delayed-rel/misoprostolTier 1diclofenac sodium eye dropsTier 1dicloxacillinTier 1dicyclomineTier 1didanosine delayed-relTier 1diethylpropionTier 1diflorasone diacetateTier 1diflunisalTier 1digoxinTier 1dihydroergotamine injectionTier 1dihydroergotamine sprayTier 1diltiazemTier 1diltiazem ext-relTier 1diphenhydramine 50 mgTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentSP This drug may be covered without copayment under theMassachusetts Act Relative to Oral Cancer Therapy. Pleasecontact your plan sponsor/employer about applicability andeffective date for your group., Call Accredo at 1-877-238-8387QLPAQLPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance11

Last Updated: 12/22/2014diphenoxylate/atropineTier 1dipivefrin eye dropsTier 1dipyridamoleTier 1disopyramideTier 1disulfiramTier 1divalproex sodium delayed-relTier 1divalproex sodium ext-relTier 1divalproex sodium sprinkleTier 1donepezilTier 1dorzolamide HCl eye dropsTier 1dorzolamide HCl/timolol maleate eye dropsTier 1doxazosinTier 1doxepinTier 1doxycycline hyclateTier 1doxycycline hyclate 20 mg tabletsTier 1doxycycline monohydrateTier 1econazoleTier 1enalaprilTier 1enalapril/hydrochlorothiazideTier 1enoxaparinTier 1enpresseTier 1entacaponeTier 1EnuloseTier 1epinastine eye dropsTier 1epinephrineTier 1QL 2 injectors/each filleplerenoneTier 1Step Therapy Prior Authorization applies to both brand andgeneric drug.eprosartanTier 1ergocalciferol (D2)Tier 1errinTier 1erythromycin delayed-relTier 1erythromycin ethylsuccinate tabletsTier 1erythromycin eye ointmentTier 1erythromycin gelTier 1erythromycin solutionTier 1erythromycin stearateTier 1erythromycin/benzoyl peroxideTier 1erythromycin/sulfisoxazoleTier 1escitalopramTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentContraceptive covered without copayment under Women'sHealth Preventive Services Initiative. Please contact your plansponsor / employer about applicability and effective date foryour group.Contraceptive covered without copayment under Women'sHealth Preventive Services Initiative. Please contact your plansponsor / employer about applicability and effective date foryour group.PA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance12

Last Updated: 12/22/2014estazolamTier 1estradiolTier 1estradiol transdermalTier 1estradiol valerateTier 1estradiol/norethindrone acetateTier 1estropipateTier 1ethambutolTier 1ethosuximideTier 1etidronateTier 1etodolacTier 1etodolac ext-relTier 1etoposide capsulesTier 1SP This drug may be covered without copayment under theMassachusetts Act Relative to Oral Cancer Therapy. Pleasecontact your plan sponsor/employer about applicability andeffective date for your group., Call Accredo at 1-877-238-8387exemestaneTier 1This drug may be covered without copayment under theMassachusetts Act Relative to Oral Cancer Therapy. Pleasecontact your plan sponsor/employer about applicability andeffective date for your group.famciclovirTier 1famotidineTier 1famotidine suspensionTier 1felbamateTier 1felodipine ext-relTier 1fenofibrate 43 mg, 130 mgTier 1fenofibrate 54 mg, 67 mg, 134 mg, 160 mg, 200 mgTier 1fenofibric acidTier 1fenofibric acid delayed-relTier 1fentanyl citrate lollipopTier 1QL 120 units (lollipops)/30 daysfentanyl transdermalTier 1QL 10 patches/30 daysfinasteride 5 mgTier 1Covered for men only, all ages. Not covered for women (noexceptions).flavoxate hydrochlorideTier 1flecainideTier 1fluconazoleTier 1fludrocortisoneTier 1flunisolide nasal sprayTier 1fluocinolone acetonideTier 1fluocinolone acetonide oilTier 1fluocinonideTier 1fluoride dropsTier 1fluoride tabletsTier 1fluorometholone eye drops, eye ointmentTier 1fluorouracilTier 1fluoxetineTier 1Boldface - indicates generic availability.SP- Designated Specialty PharmacySTPA - Step Therapy Prior AuthorizationSI- Specialty InfusionTier 1 - Lowest CopaymentQL 3 nasal spray units/90 daysPA - Prior AuthorizationQL - Quantity Limitation ProgramTier 2 - Middle Copayment/CoinsuranceNC- Non Covered DrugsNTM - New-to-MarketTier 3 - Highest Copayment/Coinsurance13

Last Updated: 12/22/2014fluoxetine delayed-relTier 1fluphenazineTier 1flurazepamTier 1flurbiprofenTier 1flutamideTier 1This drug may be covered without copayment under theMassachusetts Act Relative to Oral Cancer Therapy. Pleasecontact your plan sponsor/employer about applicability andeffective date for your group.fluticasone nasal sprayTier 1QL 3 nasal spray units/90 daysfluticasone propionate cream, lotion, ointmentTier 1fluvastatinTier 1fluvoxamineTier 1folic acidTier 1fondaparinux sodiumTier 1fosinoprilTier 1fosinopril/hydrochlorothiazideTier 1furosemideTier 1gabapentinTier 1galantamineTier 1galantamine ext-relTier 1ganciclovirTier 1gemfibrozilTier 1gentamicinTier 1gentamicin eye drops, eye ointmentTier 1gianviTier 1glimepirideTier 1glipizideTier 1glipizide ext-relTier 1glipizide/metforminTier 1glyburideTier 1glyburide, micronizedTier 1glyburide/metforminTier 1granisetron tabletsTier 1griseofulvin microsizeTier 1griseofulvin microsize suspensionTier 1griseofulvin ultramicrosizeTier 1guanfacineTier 1Guiatuss ACTier 1Guiatuss DACTier 1hal

Dec 22, 2014 · Step Therapy Prior Authorization Step Therapy is an automated form of Prior Authorization. It encourages the use of therapies that should be tried first, before other treatments are