166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 1

BlueCross BlueShield of Western New York Formulary 3Exclusive Please bring this guide with you the next time you visit your doctor

If you have questions about your prescription drug benefit visit the Pharmacy Services section of the BlueCross BlueShield web site at wwwbcbswnycom

MG45999Q (Revise Date 62015)

A Division of HealthNow New York Inc An independent licensee of the BlueCross BlueShield Association The Cross and Shield are registered trademarks of the BlueCross BlueShield Association

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 2

ii

INTRODUCTION iii

UNDERSTANDING THE SYMBOLS USED

THROUGHOUT THIS BOOK iii

USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS iv

Save Money on Your Prescription Drugs iv

Finding Medications in the Guide iv

SECTION 1 mdash THERAPEUTIC DRUG CATEGORIES 1

SECTION II mdash INDEX 7

TABLE OF CONTENTS

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 3

iii

The BlueCross BlueShield of Western New York Formulary 3Exclusive is a list of drugs to help guide physi-cians and pharmacists to select the medication that provides the appropriate treatment for the best price

INTRODUCTION

BlueCross Blue Shield of Western New York has established an independent committee of practicing physiciansand a pharmacist to help ensure that our formularies are medically sound and that they support your patientsrsquohealth This committeemdashcalled the Pharmacy and Therapeutics Committeemdashreviews and evaluates medicationson the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories

UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK

Throughout this book you will see certain symbols that indicate a management program is in place for selectedmedications The symbols are as follows

Key

= A step edit applies to this drug Step therapy means that in order to receive the medicationwith a step edit a preferred medication must be tried first

= Specific quantity limits apply Quantity limits are in place to ensure members receive theappropriate amount of medication not to exceed the maximum allowable daily dosage of medication

= Prior authorization required Prior authorization (also referred to as coverage review)means that a healthcare professional must submit clinical documentation to obtainapproval for a member to receive the medication Prior authorizations ensure medicationsare being used appropriately

= Included in tablet-splitting program The medication can be cut in half to obtain the dailydose of medication (ie 20mg daily of simvastatin can be obtained by 12 tablet of simvastatin 40mg) A member will receive a 1-month supply for half their regular 1-monthcopay

+ = Access restricted to specialty pharmacy Medications must be obtained through a specialtypharmacy

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 4

iv

USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS

The formulary offers a wide range of outpatient medications

Because there are over 40000 Food and Drug Administration (FDA)-approved prescription drugs on themarket not all tier 3 drugs can be listed in this formulary guide We have included in this printed for-mulary guide the drugs that are most commonly prescribed for our members If you have any questionsregarding coverage of a drug please call the customer service number on your card

Save Money on Your Prescription Drugs

Herersquos what you can do to save money

1 Bring this member guide to your doctor and review the cost-saving information below

2 Ask your doctor whether a drug listed in this guide is right for you

The amount you pay for a drug is determined by which medication you purchase and to what tier it isassigned Some drug plans also exclude certain drugs or classes of drugs from coverage Please checkyour contract or other plan documents if you have a question about your specific drug coverage

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies Costshare may vary by plan

Finding Medications in the Guide

This guide lists medications two different ways

Section 1 Alphabetically by drug category (such as Diabetes Heart or PainArthritis)

Locate a category and drug on the guide and you will see the tier and copayment for thatdrugmdashTier 1 Tier 2 or Tier 3mdashwhich determines your copayment To determine if a drug is ageneric or brand-name medication look at the name of the drug Generic medications arelower case (eg amoxicillin) and brand-name medications are capitalized (eg Advair)

Section 2 Alphabetically by drug name Use this list to find your drug

Questions Please call Pharmacy Services at 1 866 237-0333 if you have any questions about theBlueCross BlueShield of Western New York Formulary 3Exclusive For the most up-to-date version of theGuide visit the Pharmacy Services section of our web site at wwwbcbswnycom

Some plan designs require that you use a Tier 1 generic drug if a generic is available

Disclaimer The BlueCross BlueShield of Western New York Medication Guide is subject to change as we regularly reviewmedications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 3ExclusiveThe tier that a medication is currently in may change during the effective dates of the guides due to generic availability

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 5

1

AllergyCough amp ColdAntihistamines amp Decongestants

brompheniramine phenylephrine 1brompheniramine pseudoephedrine 1cetirizine 1clemastine 1cyproheptadine 1dexchlorpheniramine 1diphenhydramine 1

fexofenadine 1 fexofenadine-D 1

hydroxyzine HCl 1hydroxyzine pamoate 1

levocetirizine 1loratadine 1loratadine-D 1promethazine 1pseudoephedrine 1Semprex-D 2

Clarinex-D 3 desloratadine 3 Grastek 3+ Oralair 3

Phenergan 3 Ragwitek 3Expectorant amp Cough Products

benzonatate 1guaifenesincodeine 1hydrocodonechlorpheniramine 1hydrocodonehomatropine 1promethazinecodeine 1promethazineDM 1promethazinephenylephrine codeine 1pseudoephedrinecodeine 1CardecDM 3Guaifenesin DM 3Hycodan 3Rondec DMTR 3Vituz 3

Mucolytic Agentsacetylcysteine inh soln 1

Nasal Medicationsazelastine nasal spray 1

fluticasone nasal spray 1ipratropium nasal spray 1

Nasacort OTC 1Atrovent Nasal Spray 3

Beconase AQ 3 Flonase 3 flunisolide nasal spray 3 Nasacort AQ 3 Nasonex 3 Omnaris 3 Qnasl 3 Rhinocort Aqua 3 triamcinolone acetonide nasal spray 3 Veramyst 3 Zetonna 3Alzheimer Agents donepezil 1

ergoloid mesylates 1 galantamine 1 galantamine ER 1 rivastigmine 1 Exelon Patch 2 Namenda 2 Namenda XR 2 Namzaric 3BladderKidneyAcidifiers

K-Phos 3Alkalinizers

citric acidsod citrate 1potassium citrate 1Oracit 3

Analgesicsphenazopyridine 1

Anticholinergicsoxybutynin 1

oxybutynin ER 1 tolterodine 1 tolterodine ER 1 trospium 1 trospium ER 1 Detrol 3 Detrol LA 3 Ditropan XL 3 Enablex 3 Gelnique 3 Myrbetriq 3 Oxytrol 3 Sanctura 3 Sanctura XR 3 Toviaz 3 Vesicare 3BPH alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3

Jalyn 3 Rapaflo 3 Uroxatral 3Cholinergic Agents

Urecholine 3BloodAnticoagulantsAntithrombotics

anagrelide 1clopidogrel 1dipyridamole 1enoxaparin 1fondaparinux sodium 1heparin 1jantoven 1ticlopidine 1warfarin 1Aggrenox 2Coumadin 2Fragmin 2

Brilinta 3 Effient 3

Eliquis 3Innohep 3

Plavix 3 Pradaxa 3 Savaysa 3

Xarelto 3 Zontivity 3Other Blood Modifiers

cilostazol 1pentoxifylline 1

+ Actimmune 2+ Aranesp 2+ Exjade 2+ Leukine 2

Miacalcin inj 2 Neulasta 2+ Neupogen 2+ Promacta 2+ Procrit 2+ Revlimid 2+ Alprolix 3+ Eloctate 3+ Epogen 3 Ferriprox 3+ Granix 3+ Jadenu 3 Mircera 3+ Neumega 3 Omontys 3Cancer DrugsAlkylating Agents

cyclophosphamide 1Alkeran 2CeeNu 2

Emcyt 2Hexalen 2Leukeran 2Myleran 2

Antimetabolitescapecitabine 1mercaptopurine 1methotrexate 1Purixan 2Trexall 3

Hormonesbicalutamide 1exemastine 1flutamide 1letrozole 1

leuprolide 1megestrol 1tamoxifen 1anastrozole 1Fareston 2

Miscellaneousetoposide 1hydroxyurea 1

+ temozolamide 1+ Afinitor 2 Arcalyst 2+ Bosulif 2 Caprelsa 2 Cometriq 2+ Erivedge 2+ Farydak 2 Gilotrif 2+ Gleevec 2+ Hycamtin 2+ Ibrance 2 Iclusig 2 Imbruvica 2+ Inlyta 2+ Intron A 2 Iressa 2+ Jakafi 2 Lenvima 2 Lynparza 2

Lysodren 2Matulane 2

+ Mekinist 2Mesnex 2

+ Nexavar 2Nilandron 2

+ Pomalyst 2+ Sprycel 2+ Stivarga 2+ Sutent 2+ Sylatron 2+ Synribo 2+ Tafinlar 2+ Tarceva 2+ Tasigna 2+ Thalomid 2+ Tykerb 2 Valchlor 2+ Votrient 2+ Xalkori 2+ Xtandi 2+ Zelboraf 2+ Zolinza 2 Zydelig 2+ Zykadia 2+ Zytiga 2+ Temodar 3Rexinoids

Targretin 2

DiabetesPlease refer to your plan documents to confirm yourcost share for diabetic drugs Cost share may vary by plan

Antidiabetic Agents Injectable Byetta 2

Humalog insulin 2Humulin (all types) 2Lantus 2

Symlin 2 Victoza 2 Apidra 3 Bydureon 3 Levemir 3 Novolin 3 Novolog 3 Tanzeum 3

Toujeo 3 Trulicity 3Antidiabetic Agents Glucose Elevating Agents

acarbose 1chlorpropamide 1

glimepiride 1glipizide 1

glipizide ER 1 glipizidemetformin 1

glyburide 1glyburide micronized 1metformin 1

metformin ER 1 metforminglyburide 1 nateglinide 1 pioglitazonemetformin 1 repaglinide 1

tolazamide 1tolbutamide 1

Avandamet 2 Avandaryl 2 Avandia 2 Duetact 2

Glucagon 2 Janumet 2 Janumet XR 2 Januvia 2

Juvisync 2Kombiglyze XR 2Onglyza 2

Afrezza 3 Farxiga 3 Glumetza 3 Glyset 3 Glyxambi 3 Invokamet 3 Invokana 3 Jardiance 3 Jentadueto 3 Kazano 3 Nesina 3 Oseni 3

Riomet solution 3 Tradjenta 3 Xigduo XR 3Diabetic Test StripsPlease refer to your plan documents to confirm yourcost share for diabetic supplies Cost share may varyby plan Test strips other than OneTouch requireprior authorization

OneTouch Accu-Chek Ascensia Breeze Contour Freestyle Precision TRUEtest TRUEtrack

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 6

2

EarAnti-infective Agents

acetic acid otic 1acetic acidaluminum acetate 1ofloxacin otic 1Domeboro 3Xtoro 3

Anti-infectiveAnti-inflammatory combinationsacetic acid HC otic 1neomycinpolymyxinHC otic 1Ciprodex 2Cipro HC 3

EyeAntiallergy Agents (Eye)

azelastine ophth 1cromolyn ophth 1Alomide 3Bepreve 3ketotifen opthalmic solution 3Pataday 3Patanol 3Pazeo 3Zaditor 3

Anti-infective Agentsbacitracin ophth 1bacitracinpolymyxin 1ciprofloxacin ophth 1erythromycin ophth 1gatifloxacin 1gentamicin ophth 1neomycinbacitracinpoly B 1ofloxacin ophth 1polymyxin BTMP 1sulfacetamide 10 1tobramycin soln 1Tobrex ointment 2Vigamox 2Azasite 3Besivance 3Ciloxan 3Tobrex solution 3

Anti-inflammatoryfluorometholone ophth 1prednisolone acetate 1prednisolone sod phosphate 1FML Forte 2FML SOP 2Lotemax 2Pred Mild 2Flarex 3Maxidex 3

Anti-inflammatoryAnti-infective combinationsdexamethneomycinpoly B 1neomycinbacitracinpoly BHC 1sulfacetamideprednisolone ophth 1tobramycindexameth 1Tobradex ointment 2Maxitrol ophth 3Pred-G 3Zylet 3

Antiviral famciclovir 1

trifluridine 1Beta-Blockers (Eye)

betaxolol HCl 1carteolol 1levobunolol 1metipranolol 1timolol 1Betoptic-S 2Istalol 3

Carbonic Anhydrase Inhibitorsdorzolamide 2 eye drops 1dorzolamidetimolol eye drops 1Azopt 2

Mioticspilocarpine 1Isopto Carbachol 15 2

Phospholine Iodide 2Isopto Carbachol 3 3

Miscellaneous+ Cystaran 2

Restasis 3Mydriatics

atropine sulfate ophth 1homatropine 1tropicamide 1

NSAIDsbromfenac 1diclofenac 1flurbiprofen ophth 1ketorolac tromethamine 1Nevanac 2Acular PF 3Prolensa 3

Prostaglandin AnaloguesProstamineslatanoprost 1travoprost 1

Izba 3 Lumigan 3 Rescula 3 Travatan Z 3 Xalatan 3 Zioptan 3Sympathomimetics

brimonidine 1Alphagan P 2

Vasoconstrictorsnaphazoline 1phenylephrine ophth 1

Goutallopurinol 1colchicine 1colchicineprobenecid 1indomethacin 1probenecid 1Colcrys 2Indocin 3

Mitigare 3 Uloric 3HeartAngiotensin Converting Enzyme Inhibitors

benazepril 1captopril 1enalapril 1fosinopril 1lisinopril 1moexipril 1perindopril 1quinapril 1ramipril 1trandolapril 1Epaned 3

Angiotensin II Antagonists candesartan 1 eprosartan 600mg 1 irbesartan 1 losartan 1 telmisartan 1 valsartan 1 Atacand 3 Avapro 3 Benicar 3 Cozaar 3 Diovan 3 Edarbi 3 Micardis 3 Teveten 3Anti-Adrenergic Blockers Centrally acting

clonidine oral patch 1guanabenz 1guanfacine 1methyldopa 1midodrine 1Dibenzyline 2

+ Northera 3

Anti-Adrenergic Blockers Peripheraldoxazosin 1prazosin 1terazosin 1Cardura XL 3

Antiarrhythmicsamiodarone 1digoxin 1disopyramide 1flecainide 1mexiletine 1procainamide 1propafenone 1propafenone SR 1quinidine gluconate 1quinidine sulfate SR 1sotalol 1Lanoxin 2NorpaceCR 2Multaq 3Tikosyn 3

Antilipidemics atorvastatin calcium 1

cholestyramine 1colestipol 1fenofibrate 1fenofibric acid tab 1gemfibrozil 1

lovastatin 1niacin ER 1

niacinsimvastatin 1 pravastatin 1 simvastatin 1

Advicor 2Colestid 2

+ Kynamro 2 Altoprev 3 Antara 3 Crestor 3 Epanova 3 Fenoglide 3 Fibricor 3 fenofibric acid capsule delayed 3

release fluvastatin 3 Juxtapid 3 Lescol 3 Lescol XL 3 Lipitor 3 Lipofen 3

Liptruzet 3 Livalo 3 Lofibra 3 Mevacor 3 omega-3 acid ethyl esters 3 Omtryg 3 Pravachol 3 Tricor 3 Triglide 3

Vascepa 3 Vytorin 3

Welchol 3 Zetia 3 Zocor 3Beta Blockers

acebutolol 1atenolol 1betaxolol 1bisoprolol 1carvedilol 1labetalol 1metoprolol 1metoprolol ER 1metoprololHCTZ 1nadolol 1pindolol 1propranolol 1timolol 1Coreg CR 2

Innopran XL 2Bystolic 3Corgard 3Hemangeol 3

Calcium Channel Blockersamlodipine 1cartia XT 1diltia XT 1diltiazem 1diltiazem CDSRERXR 1felodipine ER 1isradipine 1nicardipine 1nifediac CC 1nifedical XL 1nifedipine 1nifedipine SR 1nimodipine 1nisoldipine 1verapamil 1verapamil SR 1Covera HS 3DynacircCR 3

Nymalize 3Combination Anti-Hypertensive amlodipineatorvastatin 1

amlodipinebenazepril 1atenololchlorthalidone 1benazeprilHCTZ 1bisoprololHCTZ 1

candesartanHCTZ 1captoprilHCTZ 1enalaprilHCTZ 1fosinoprilHCTZ 1

irbesartanHCTZ 1lisinoprilHCTZ 1

losartanHCTZ 1methyldopaHCTZ 1metoprololHCTZ 1propranololHCTZ 1quinaprilHCTZ 1

telmisartanHCTZ 1 valsartanHCTZ 1 Tekamlo 2 Tekturna HCT 2 amlodipinevalsartan 3 Amturnide 3 Atacand HCT 3 Avalide 3 Azor 3 Benicar HCT 3 Diovan HCT 3 Edarbyclor 3 Exforge HCT 3 Hyzaar 3 Micardis HCT 3 Prestalia 3 telmisartanamlodipine 3 Teveten HCT 3

trandolaprilverapamil 3 Tribenzor 3 Valturna 3Diuretics

acetazolamide 1acetazolamide ER 1amiloride 1amilorideHCTZ 1bumetanide 1chlorothiazide 1chlorthalidone 1furosemide 1hydrochlorothiazide 1indapamide 1methazolamide 1methyclothiazide 1metolazone 1spironolactone 1spironolactoneHCTZ 1torsemide 1triamtereneHCTZ 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 7

3

Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 14

10

Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 15

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 16

ii

INTRODUCTION iii

UNDERSTANDING THE SYMBOLS USED

THROUGHOUT THIS BOOK iii

USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS iv

Save Money on Your Prescription Drugs iv

Finding Medications in the Guide iv

SECTION 1 mdash THERAPEUTIC DRUG CATEGORIES 1

SECTION II mdash INDEX 7

TABLE OF CONTENTS

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 3

iii

The BlueCross BlueShield of Western New York Formulary 3Exclusive is a list of drugs to help guide physi-cians and pharmacists to select the medication that provides the appropriate treatment for the best price

INTRODUCTION

BlueCross Blue Shield of Western New York has established an independent committee of practicing physiciansand a pharmacist to help ensure that our formularies are medically sound and that they support your patientsrsquohealth This committeemdashcalled the Pharmacy and Therapeutics Committeemdashreviews and evaluates medicationson the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories

UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK

Throughout this book you will see certain symbols that indicate a management program is in place for selectedmedications The symbols are as follows

Key

= A step edit applies to this drug Step therapy means that in order to receive the medicationwith a step edit a preferred medication must be tried first

= Specific quantity limits apply Quantity limits are in place to ensure members receive theappropriate amount of medication not to exceed the maximum allowable daily dosage of medication

= Prior authorization required Prior authorization (also referred to as coverage review)means that a healthcare professional must submit clinical documentation to obtainapproval for a member to receive the medication Prior authorizations ensure medicationsare being used appropriately

= Included in tablet-splitting program The medication can be cut in half to obtain the dailydose of medication (ie 20mg daily of simvastatin can be obtained by 12 tablet of simvastatin 40mg) A member will receive a 1-month supply for half their regular 1-monthcopay

+ = Access restricted to specialty pharmacy Medications must be obtained through a specialtypharmacy

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 4

iv

USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS

The formulary offers a wide range of outpatient medications

Because there are over 40000 Food and Drug Administration (FDA)-approved prescription drugs on themarket not all tier 3 drugs can be listed in this formulary guide We have included in this printed for-mulary guide the drugs that are most commonly prescribed for our members If you have any questionsregarding coverage of a drug please call the customer service number on your card

Save Money on Your Prescription Drugs

Herersquos what you can do to save money

1 Bring this member guide to your doctor and review the cost-saving information below

2 Ask your doctor whether a drug listed in this guide is right for you

The amount you pay for a drug is determined by which medication you purchase and to what tier it isassigned Some drug plans also exclude certain drugs or classes of drugs from coverage Please checkyour contract or other plan documents if you have a question about your specific drug coverage

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies Costshare may vary by plan

Finding Medications in the Guide

This guide lists medications two different ways

Section 1 Alphabetically by drug category (such as Diabetes Heart or PainArthritis)

Locate a category and drug on the guide and you will see the tier and copayment for thatdrugmdashTier 1 Tier 2 or Tier 3mdashwhich determines your copayment To determine if a drug is ageneric or brand-name medication look at the name of the drug Generic medications arelower case (eg amoxicillin) and brand-name medications are capitalized (eg Advair)

Section 2 Alphabetically by drug name Use this list to find your drug

Questions Please call Pharmacy Services at 1 866 237-0333 if you have any questions about theBlueCross BlueShield of Western New York Formulary 3Exclusive For the most up-to-date version of theGuide visit the Pharmacy Services section of our web site at wwwbcbswnycom

Some plan designs require that you use a Tier 1 generic drug if a generic is available

Disclaimer The BlueCross BlueShield of Western New York Medication Guide is subject to change as we regularly reviewmedications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 3ExclusiveThe tier that a medication is currently in may change during the effective dates of the guides due to generic availability

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 5

1

AllergyCough amp ColdAntihistamines amp Decongestants

brompheniramine phenylephrine 1brompheniramine pseudoephedrine 1cetirizine 1clemastine 1cyproheptadine 1dexchlorpheniramine 1diphenhydramine 1

fexofenadine 1 fexofenadine-D 1

hydroxyzine HCl 1hydroxyzine pamoate 1

levocetirizine 1loratadine 1loratadine-D 1promethazine 1pseudoephedrine 1Semprex-D 2

Clarinex-D 3 desloratadine 3 Grastek 3+ Oralair 3

Phenergan 3 Ragwitek 3Expectorant amp Cough Products

benzonatate 1guaifenesincodeine 1hydrocodonechlorpheniramine 1hydrocodonehomatropine 1promethazinecodeine 1promethazineDM 1promethazinephenylephrine codeine 1pseudoephedrinecodeine 1CardecDM 3Guaifenesin DM 3Hycodan 3Rondec DMTR 3Vituz 3

Mucolytic Agentsacetylcysteine inh soln 1

Nasal Medicationsazelastine nasal spray 1

fluticasone nasal spray 1ipratropium nasal spray 1

Nasacort OTC 1Atrovent Nasal Spray 3

Beconase AQ 3 Flonase 3 flunisolide nasal spray 3 Nasacort AQ 3 Nasonex 3 Omnaris 3 Qnasl 3 Rhinocort Aqua 3 triamcinolone acetonide nasal spray 3 Veramyst 3 Zetonna 3Alzheimer Agents donepezil 1

ergoloid mesylates 1 galantamine 1 galantamine ER 1 rivastigmine 1 Exelon Patch 2 Namenda 2 Namenda XR 2 Namzaric 3BladderKidneyAcidifiers

K-Phos 3Alkalinizers

citric acidsod citrate 1potassium citrate 1Oracit 3

Analgesicsphenazopyridine 1

Anticholinergicsoxybutynin 1

oxybutynin ER 1 tolterodine 1 tolterodine ER 1 trospium 1 trospium ER 1 Detrol 3 Detrol LA 3 Ditropan XL 3 Enablex 3 Gelnique 3 Myrbetriq 3 Oxytrol 3 Sanctura 3 Sanctura XR 3 Toviaz 3 Vesicare 3BPH alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3

Jalyn 3 Rapaflo 3 Uroxatral 3Cholinergic Agents

Urecholine 3BloodAnticoagulantsAntithrombotics

anagrelide 1clopidogrel 1dipyridamole 1enoxaparin 1fondaparinux sodium 1heparin 1jantoven 1ticlopidine 1warfarin 1Aggrenox 2Coumadin 2Fragmin 2

Brilinta 3 Effient 3

Eliquis 3Innohep 3

Plavix 3 Pradaxa 3 Savaysa 3

Xarelto 3 Zontivity 3Other Blood Modifiers

cilostazol 1pentoxifylline 1

+ Actimmune 2+ Aranesp 2+ Exjade 2+ Leukine 2

Miacalcin inj 2 Neulasta 2+ Neupogen 2+ Promacta 2+ Procrit 2+ Revlimid 2+ Alprolix 3+ Eloctate 3+ Epogen 3 Ferriprox 3+ Granix 3+ Jadenu 3 Mircera 3+ Neumega 3 Omontys 3Cancer DrugsAlkylating Agents

cyclophosphamide 1Alkeran 2CeeNu 2

Emcyt 2Hexalen 2Leukeran 2Myleran 2

Antimetabolitescapecitabine 1mercaptopurine 1methotrexate 1Purixan 2Trexall 3

Hormonesbicalutamide 1exemastine 1flutamide 1letrozole 1

leuprolide 1megestrol 1tamoxifen 1anastrozole 1Fareston 2

Miscellaneousetoposide 1hydroxyurea 1

+ temozolamide 1+ Afinitor 2 Arcalyst 2+ Bosulif 2 Caprelsa 2 Cometriq 2+ Erivedge 2+ Farydak 2 Gilotrif 2+ Gleevec 2+ Hycamtin 2+ Ibrance 2 Iclusig 2 Imbruvica 2+ Inlyta 2+ Intron A 2 Iressa 2+ Jakafi 2 Lenvima 2 Lynparza 2

Lysodren 2Matulane 2

+ Mekinist 2Mesnex 2

+ Nexavar 2Nilandron 2

+ Pomalyst 2+ Sprycel 2+ Stivarga 2+ Sutent 2+ Sylatron 2+ Synribo 2+ Tafinlar 2+ Tarceva 2+ Tasigna 2+ Thalomid 2+ Tykerb 2 Valchlor 2+ Votrient 2+ Xalkori 2+ Xtandi 2+ Zelboraf 2+ Zolinza 2 Zydelig 2+ Zykadia 2+ Zytiga 2+ Temodar 3Rexinoids

Targretin 2

DiabetesPlease refer to your plan documents to confirm yourcost share for diabetic drugs Cost share may vary by plan

Antidiabetic Agents Injectable Byetta 2

Humalog insulin 2Humulin (all types) 2Lantus 2

Symlin 2 Victoza 2 Apidra 3 Bydureon 3 Levemir 3 Novolin 3 Novolog 3 Tanzeum 3

Toujeo 3 Trulicity 3Antidiabetic Agents Glucose Elevating Agents

acarbose 1chlorpropamide 1

glimepiride 1glipizide 1

glipizide ER 1 glipizidemetformin 1

glyburide 1glyburide micronized 1metformin 1

metformin ER 1 metforminglyburide 1 nateglinide 1 pioglitazonemetformin 1 repaglinide 1

tolazamide 1tolbutamide 1

Avandamet 2 Avandaryl 2 Avandia 2 Duetact 2

Glucagon 2 Janumet 2 Janumet XR 2 Januvia 2

Juvisync 2Kombiglyze XR 2Onglyza 2

Afrezza 3 Farxiga 3 Glumetza 3 Glyset 3 Glyxambi 3 Invokamet 3 Invokana 3 Jardiance 3 Jentadueto 3 Kazano 3 Nesina 3 Oseni 3

Riomet solution 3 Tradjenta 3 Xigduo XR 3Diabetic Test StripsPlease refer to your plan documents to confirm yourcost share for diabetic supplies Cost share may varyby plan Test strips other than OneTouch requireprior authorization

OneTouch Accu-Chek Ascensia Breeze Contour Freestyle Precision TRUEtest TRUEtrack

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 6

2

EarAnti-infective Agents

acetic acid otic 1acetic acidaluminum acetate 1ofloxacin otic 1Domeboro 3Xtoro 3

Anti-infectiveAnti-inflammatory combinationsacetic acid HC otic 1neomycinpolymyxinHC otic 1Ciprodex 2Cipro HC 3

EyeAntiallergy Agents (Eye)

azelastine ophth 1cromolyn ophth 1Alomide 3Bepreve 3ketotifen opthalmic solution 3Pataday 3Patanol 3Pazeo 3Zaditor 3

Anti-infective Agentsbacitracin ophth 1bacitracinpolymyxin 1ciprofloxacin ophth 1erythromycin ophth 1gatifloxacin 1gentamicin ophth 1neomycinbacitracinpoly B 1ofloxacin ophth 1polymyxin BTMP 1sulfacetamide 10 1tobramycin soln 1Tobrex ointment 2Vigamox 2Azasite 3Besivance 3Ciloxan 3Tobrex solution 3

Anti-inflammatoryfluorometholone ophth 1prednisolone acetate 1prednisolone sod phosphate 1FML Forte 2FML SOP 2Lotemax 2Pred Mild 2Flarex 3Maxidex 3

Anti-inflammatoryAnti-infective combinationsdexamethneomycinpoly B 1neomycinbacitracinpoly BHC 1sulfacetamideprednisolone ophth 1tobramycindexameth 1Tobradex ointment 2Maxitrol ophth 3Pred-G 3Zylet 3

Antiviral famciclovir 1

trifluridine 1Beta-Blockers (Eye)

betaxolol HCl 1carteolol 1levobunolol 1metipranolol 1timolol 1Betoptic-S 2Istalol 3

Carbonic Anhydrase Inhibitorsdorzolamide 2 eye drops 1dorzolamidetimolol eye drops 1Azopt 2

Mioticspilocarpine 1Isopto Carbachol 15 2

Phospholine Iodide 2Isopto Carbachol 3 3

Miscellaneous+ Cystaran 2

Restasis 3Mydriatics

atropine sulfate ophth 1homatropine 1tropicamide 1

NSAIDsbromfenac 1diclofenac 1flurbiprofen ophth 1ketorolac tromethamine 1Nevanac 2Acular PF 3Prolensa 3

Prostaglandin AnaloguesProstamineslatanoprost 1travoprost 1

Izba 3 Lumigan 3 Rescula 3 Travatan Z 3 Xalatan 3 Zioptan 3Sympathomimetics

brimonidine 1Alphagan P 2

Vasoconstrictorsnaphazoline 1phenylephrine ophth 1

Goutallopurinol 1colchicine 1colchicineprobenecid 1indomethacin 1probenecid 1Colcrys 2Indocin 3

Mitigare 3 Uloric 3HeartAngiotensin Converting Enzyme Inhibitors

benazepril 1captopril 1enalapril 1fosinopril 1lisinopril 1moexipril 1perindopril 1quinapril 1ramipril 1trandolapril 1Epaned 3

Angiotensin II Antagonists candesartan 1 eprosartan 600mg 1 irbesartan 1 losartan 1 telmisartan 1 valsartan 1 Atacand 3 Avapro 3 Benicar 3 Cozaar 3 Diovan 3 Edarbi 3 Micardis 3 Teveten 3Anti-Adrenergic Blockers Centrally acting

clonidine oral patch 1guanabenz 1guanfacine 1methyldopa 1midodrine 1Dibenzyline 2

+ Northera 3

Anti-Adrenergic Blockers Peripheraldoxazosin 1prazosin 1terazosin 1Cardura XL 3

Antiarrhythmicsamiodarone 1digoxin 1disopyramide 1flecainide 1mexiletine 1procainamide 1propafenone 1propafenone SR 1quinidine gluconate 1quinidine sulfate SR 1sotalol 1Lanoxin 2NorpaceCR 2Multaq 3Tikosyn 3

Antilipidemics atorvastatin calcium 1

cholestyramine 1colestipol 1fenofibrate 1fenofibric acid tab 1gemfibrozil 1

lovastatin 1niacin ER 1

niacinsimvastatin 1 pravastatin 1 simvastatin 1

Advicor 2Colestid 2

+ Kynamro 2 Altoprev 3 Antara 3 Crestor 3 Epanova 3 Fenoglide 3 Fibricor 3 fenofibric acid capsule delayed 3

release fluvastatin 3 Juxtapid 3 Lescol 3 Lescol XL 3 Lipitor 3 Lipofen 3

Liptruzet 3 Livalo 3 Lofibra 3 Mevacor 3 omega-3 acid ethyl esters 3 Omtryg 3 Pravachol 3 Tricor 3 Triglide 3

Vascepa 3 Vytorin 3

Welchol 3 Zetia 3 Zocor 3Beta Blockers

acebutolol 1atenolol 1betaxolol 1bisoprolol 1carvedilol 1labetalol 1metoprolol 1metoprolol ER 1metoprololHCTZ 1nadolol 1pindolol 1propranolol 1timolol 1Coreg CR 2

Innopran XL 2Bystolic 3Corgard 3Hemangeol 3

Calcium Channel Blockersamlodipine 1cartia XT 1diltia XT 1diltiazem 1diltiazem CDSRERXR 1felodipine ER 1isradipine 1nicardipine 1nifediac CC 1nifedical XL 1nifedipine 1nifedipine SR 1nimodipine 1nisoldipine 1verapamil 1verapamil SR 1Covera HS 3DynacircCR 3

Nymalize 3Combination Anti-Hypertensive amlodipineatorvastatin 1

amlodipinebenazepril 1atenololchlorthalidone 1benazeprilHCTZ 1bisoprololHCTZ 1

candesartanHCTZ 1captoprilHCTZ 1enalaprilHCTZ 1fosinoprilHCTZ 1

irbesartanHCTZ 1lisinoprilHCTZ 1

losartanHCTZ 1methyldopaHCTZ 1metoprololHCTZ 1propranololHCTZ 1quinaprilHCTZ 1

telmisartanHCTZ 1 valsartanHCTZ 1 Tekamlo 2 Tekturna HCT 2 amlodipinevalsartan 3 Amturnide 3 Atacand HCT 3 Avalide 3 Azor 3 Benicar HCT 3 Diovan HCT 3 Edarbyclor 3 Exforge HCT 3 Hyzaar 3 Micardis HCT 3 Prestalia 3 telmisartanamlodipine 3 Teveten HCT 3

trandolaprilverapamil 3 Tribenzor 3 Valturna 3Diuretics

acetazolamide 1acetazolamide ER 1amiloride 1amilorideHCTZ 1bumetanide 1chlorothiazide 1chlorthalidone 1furosemide 1hydrochlorothiazide 1indapamide 1methazolamide 1methyclothiazide 1metolazone 1spironolactone 1spironolactoneHCTZ 1torsemide 1triamtereneHCTZ 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 7

3

Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 9

5

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

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Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

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Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 14

10

Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 15

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 16

iii

The BlueCross BlueShield of Western New York Formulary 3Exclusive is a list of drugs to help guide physi-cians and pharmacists to select the medication that provides the appropriate treatment for the best price

INTRODUCTION

BlueCross Blue Shield of Western New York has established an independent committee of practicing physiciansand a pharmacist to help ensure that our formularies are medically sound and that they support your patientsrsquohealth This committeemdashcalled the Pharmacy and Therapeutics Committeemdashreviews and evaluates medicationson the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories

UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK

Throughout this book you will see certain symbols that indicate a management program is in place for selectedmedications The symbols are as follows

Key

= A step edit applies to this drug Step therapy means that in order to receive the medicationwith a step edit a preferred medication must be tried first

= Specific quantity limits apply Quantity limits are in place to ensure members receive theappropriate amount of medication not to exceed the maximum allowable daily dosage of medication

= Prior authorization required Prior authorization (also referred to as coverage review)means that a healthcare professional must submit clinical documentation to obtainapproval for a member to receive the medication Prior authorizations ensure medicationsare being used appropriately

= Included in tablet-splitting program The medication can be cut in half to obtain the dailydose of medication (ie 20mg daily of simvastatin can be obtained by 12 tablet of simvastatin 40mg) A member will receive a 1-month supply for half their regular 1-monthcopay

+ = Access restricted to specialty pharmacy Medications must be obtained through a specialtypharmacy

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 4

iv

USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS

The formulary offers a wide range of outpatient medications

Because there are over 40000 Food and Drug Administration (FDA)-approved prescription drugs on themarket not all tier 3 drugs can be listed in this formulary guide We have included in this printed for-mulary guide the drugs that are most commonly prescribed for our members If you have any questionsregarding coverage of a drug please call the customer service number on your card

Save Money on Your Prescription Drugs

Herersquos what you can do to save money

1 Bring this member guide to your doctor and review the cost-saving information below

2 Ask your doctor whether a drug listed in this guide is right for you

The amount you pay for a drug is determined by which medication you purchase and to what tier it isassigned Some drug plans also exclude certain drugs or classes of drugs from coverage Please checkyour contract or other plan documents if you have a question about your specific drug coverage

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies Costshare may vary by plan

Finding Medications in the Guide

This guide lists medications two different ways

Section 1 Alphabetically by drug category (such as Diabetes Heart or PainArthritis)

Locate a category and drug on the guide and you will see the tier and copayment for thatdrugmdashTier 1 Tier 2 or Tier 3mdashwhich determines your copayment To determine if a drug is ageneric or brand-name medication look at the name of the drug Generic medications arelower case (eg amoxicillin) and brand-name medications are capitalized (eg Advair)

Section 2 Alphabetically by drug name Use this list to find your drug

Questions Please call Pharmacy Services at 1 866 237-0333 if you have any questions about theBlueCross BlueShield of Western New York Formulary 3Exclusive For the most up-to-date version of theGuide visit the Pharmacy Services section of our web site at wwwbcbswnycom

Some plan designs require that you use a Tier 1 generic drug if a generic is available

Disclaimer The BlueCross BlueShield of Western New York Medication Guide is subject to change as we regularly reviewmedications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 3ExclusiveThe tier that a medication is currently in may change during the effective dates of the guides due to generic availability

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 5

1

AllergyCough amp ColdAntihistamines amp Decongestants

brompheniramine phenylephrine 1brompheniramine pseudoephedrine 1cetirizine 1clemastine 1cyproheptadine 1dexchlorpheniramine 1diphenhydramine 1

fexofenadine 1 fexofenadine-D 1

hydroxyzine HCl 1hydroxyzine pamoate 1

levocetirizine 1loratadine 1loratadine-D 1promethazine 1pseudoephedrine 1Semprex-D 2

Clarinex-D 3 desloratadine 3 Grastek 3+ Oralair 3

Phenergan 3 Ragwitek 3Expectorant amp Cough Products

benzonatate 1guaifenesincodeine 1hydrocodonechlorpheniramine 1hydrocodonehomatropine 1promethazinecodeine 1promethazineDM 1promethazinephenylephrine codeine 1pseudoephedrinecodeine 1CardecDM 3Guaifenesin DM 3Hycodan 3Rondec DMTR 3Vituz 3

Mucolytic Agentsacetylcysteine inh soln 1

Nasal Medicationsazelastine nasal spray 1

fluticasone nasal spray 1ipratropium nasal spray 1

Nasacort OTC 1Atrovent Nasal Spray 3

Beconase AQ 3 Flonase 3 flunisolide nasal spray 3 Nasacort AQ 3 Nasonex 3 Omnaris 3 Qnasl 3 Rhinocort Aqua 3 triamcinolone acetonide nasal spray 3 Veramyst 3 Zetonna 3Alzheimer Agents donepezil 1

ergoloid mesylates 1 galantamine 1 galantamine ER 1 rivastigmine 1 Exelon Patch 2 Namenda 2 Namenda XR 2 Namzaric 3BladderKidneyAcidifiers

K-Phos 3Alkalinizers

citric acidsod citrate 1potassium citrate 1Oracit 3

Analgesicsphenazopyridine 1

Anticholinergicsoxybutynin 1

oxybutynin ER 1 tolterodine 1 tolterodine ER 1 trospium 1 trospium ER 1 Detrol 3 Detrol LA 3 Ditropan XL 3 Enablex 3 Gelnique 3 Myrbetriq 3 Oxytrol 3 Sanctura 3 Sanctura XR 3 Toviaz 3 Vesicare 3BPH alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3

Jalyn 3 Rapaflo 3 Uroxatral 3Cholinergic Agents

Urecholine 3BloodAnticoagulantsAntithrombotics

anagrelide 1clopidogrel 1dipyridamole 1enoxaparin 1fondaparinux sodium 1heparin 1jantoven 1ticlopidine 1warfarin 1Aggrenox 2Coumadin 2Fragmin 2

Brilinta 3 Effient 3

Eliquis 3Innohep 3

Plavix 3 Pradaxa 3 Savaysa 3

Xarelto 3 Zontivity 3Other Blood Modifiers

cilostazol 1pentoxifylline 1

+ Actimmune 2+ Aranesp 2+ Exjade 2+ Leukine 2

Miacalcin inj 2 Neulasta 2+ Neupogen 2+ Promacta 2+ Procrit 2+ Revlimid 2+ Alprolix 3+ Eloctate 3+ Epogen 3 Ferriprox 3+ Granix 3+ Jadenu 3 Mircera 3+ Neumega 3 Omontys 3Cancer DrugsAlkylating Agents

cyclophosphamide 1Alkeran 2CeeNu 2

Emcyt 2Hexalen 2Leukeran 2Myleran 2

Antimetabolitescapecitabine 1mercaptopurine 1methotrexate 1Purixan 2Trexall 3

Hormonesbicalutamide 1exemastine 1flutamide 1letrozole 1

leuprolide 1megestrol 1tamoxifen 1anastrozole 1Fareston 2

Miscellaneousetoposide 1hydroxyurea 1

+ temozolamide 1+ Afinitor 2 Arcalyst 2+ Bosulif 2 Caprelsa 2 Cometriq 2+ Erivedge 2+ Farydak 2 Gilotrif 2+ Gleevec 2+ Hycamtin 2+ Ibrance 2 Iclusig 2 Imbruvica 2+ Inlyta 2+ Intron A 2 Iressa 2+ Jakafi 2 Lenvima 2 Lynparza 2

Lysodren 2Matulane 2

+ Mekinist 2Mesnex 2

+ Nexavar 2Nilandron 2

+ Pomalyst 2+ Sprycel 2+ Stivarga 2+ Sutent 2+ Sylatron 2+ Synribo 2+ Tafinlar 2+ Tarceva 2+ Tasigna 2+ Thalomid 2+ Tykerb 2 Valchlor 2+ Votrient 2+ Xalkori 2+ Xtandi 2+ Zelboraf 2+ Zolinza 2 Zydelig 2+ Zykadia 2+ Zytiga 2+ Temodar 3Rexinoids

Targretin 2

DiabetesPlease refer to your plan documents to confirm yourcost share for diabetic drugs Cost share may vary by plan

Antidiabetic Agents Injectable Byetta 2

Humalog insulin 2Humulin (all types) 2Lantus 2

Symlin 2 Victoza 2 Apidra 3 Bydureon 3 Levemir 3 Novolin 3 Novolog 3 Tanzeum 3

Toujeo 3 Trulicity 3Antidiabetic Agents Glucose Elevating Agents

acarbose 1chlorpropamide 1

glimepiride 1glipizide 1

glipizide ER 1 glipizidemetformin 1

glyburide 1glyburide micronized 1metformin 1

metformin ER 1 metforminglyburide 1 nateglinide 1 pioglitazonemetformin 1 repaglinide 1

tolazamide 1tolbutamide 1

Avandamet 2 Avandaryl 2 Avandia 2 Duetact 2

Glucagon 2 Janumet 2 Janumet XR 2 Januvia 2

Juvisync 2Kombiglyze XR 2Onglyza 2

Afrezza 3 Farxiga 3 Glumetza 3 Glyset 3 Glyxambi 3 Invokamet 3 Invokana 3 Jardiance 3 Jentadueto 3 Kazano 3 Nesina 3 Oseni 3

Riomet solution 3 Tradjenta 3 Xigduo XR 3Diabetic Test StripsPlease refer to your plan documents to confirm yourcost share for diabetic supplies Cost share may varyby plan Test strips other than OneTouch requireprior authorization

OneTouch Accu-Chek Ascensia Breeze Contour Freestyle Precision TRUEtest TRUEtrack

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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2

EarAnti-infective Agents

acetic acid otic 1acetic acidaluminum acetate 1ofloxacin otic 1Domeboro 3Xtoro 3

Anti-infectiveAnti-inflammatory combinationsacetic acid HC otic 1neomycinpolymyxinHC otic 1Ciprodex 2Cipro HC 3

EyeAntiallergy Agents (Eye)

azelastine ophth 1cromolyn ophth 1Alomide 3Bepreve 3ketotifen opthalmic solution 3Pataday 3Patanol 3Pazeo 3Zaditor 3

Anti-infective Agentsbacitracin ophth 1bacitracinpolymyxin 1ciprofloxacin ophth 1erythromycin ophth 1gatifloxacin 1gentamicin ophth 1neomycinbacitracinpoly B 1ofloxacin ophth 1polymyxin BTMP 1sulfacetamide 10 1tobramycin soln 1Tobrex ointment 2Vigamox 2Azasite 3Besivance 3Ciloxan 3Tobrex solution 3

Anti-inflammatoryfluorometholone ophth 1prednisolone acetate 1prednisolone sod phosphate 1FML Forte 2FML SOP 2Lotemax 2Pred Mild 2Flarex 3Maxidex 3

Anti-inflammatoryAnti-infective combinationsdexamethneomycinpoly B 1neomycinbacitracinpoly BHC 1sulfacetamideprednisolone ophth 1tobramycindexameth 1Tobradex ointment 2Maxitrol ophth 3Pred-G 3Zylet 3

Antiviral famciclovir 1

trifluridine 1Beta-Blockers (Eye)

betaxolol HCl 1carteolol 1levobunolol 1metipranolol 1timolol 1Betoptic-S 2Istalol 3

Carbonic Anhydrase Inhibitorsdorzolamide 2 eye drops 1dorzolamidetimolol eye drops 1Azopt 2

Mioticspilocarpine 1Isopto Carbachol 15 2

Phospholine Iodide 2Isopto Carbachol 3 3

Miscellaneous+ Cystaran 2

Restasis 3Mydriatics

atropine sulfate ophth 1homatropine 1tropicamide 1

NSAIDsbromfenac 1diclofenac 1flurbiprofen ophth 1ketorolac tromethamine 1Nevanac 2Acular PF 3Prolensa 3

Prostaglandin AnaloguesProstamineslatanoprost 1travoprost 1

Izba 3 Lumigan 3 Rescula 3 Travatan Z 3 Xalatan 3 Zioptan 3Sympathomimetics

brimonidine 1Alphagan P 2

Vasoconstrictorsnaphazoline 1phenylephrine ophth 1

Goutallopurinol 1colchicine 1colchicineprobenecid 1indomethacin 1probenecid 1Colcrys 2Indocin 3

Mitigare 3 Uloric 3HeartAngiotensin Converting Enzyme Inhibitors

benazepril 1captopril 1enalapril 1fosinopril 1lisinopril 1moexipril 1perindopril 1quinapril 1ramipril 1trandolapril 1Epaned 3

Angiotensin II Antagonists candesartan 1 eprosartan 600mg 1 irbesartan 1 losartan 1 telmisartan 1 valsartan 1 Atacand 3 Avapro 3 Benicar 3 Cozaar 3 Diovan 3 Edarbi 3 Micardis 3 Teveten 3Anti-Adrenergic Blockers Centrally acting

clonidine oral patch 1guanabenz 1guanfacine 1methyldopa 1midodrine 1Dibenzyline 2

+ Northera 3

Anti-Adrenergic Blockers Peripheraldoxazosin 1prazosin 1terazosin 1Cardura XL 3

Antiarrhythmicsamiodarone 1digoxin 1disopyramide 1flecainide 1mexiletine 1procainamide 1propafenone 1propafenone SR 1quinidine gluconate 1quinidine sulfate SR 1sotalol 1Lanoxin 2NorpaceCR 2Multaq 3Tikosyn 3

Antilipidemics atorvastatin calcium 1

cholestyramine 1colestipol 1fenofibrate 1fenofibric acid tab 1gemfibrozil 1

lovastatin 1niacin ER 1

niacinsimvastatin 1 pravastatin 1 simvastatin 1

Advicor 2Colestid 2

+ Kynamro 2 Altoprev 3 Antara 3 Crestor 3 Epanova 3 Fenoglide 3 Fibricor 3 fenofibric acid capsule delayed 3

release fluvastatin 3 Juxtapid 3 Lescol 3 Lescol XL 3 Lipitor 3 Lipofen 3

Liptruzet 3 Livalo 3 Lofibra 3 Mevacor 3 omega-3 acid ethyl esters 3 Omtryg 3 Pravachol 3 Tricor 3 Triglide 3

Vascepa 3 Vytorin 3

Welchol 3 Zetia 3 Zocor 3Beta Blockers

acebutolol 1atenolol 1betaxolol 1bisoprolol 1carvedilol 1labetalol 1metoprolol 1metoprolol ER 1metoprololHCTZ 1nadolol 1pindolol 1propranolol 1timolol 1Coreg CR 2

Innopran XL 2Bystolic 3Corgard 3Hemangeol 3

Calcium Channel Blockersamlodipine 1cartia XT 1diltia XT 1diltiazem 1diltiazem CDSRERXR 1felodipine ER 1isradipine 1nicardipine 1nifediac CC 1nifedical XL 1nifedipine 1nifedipine SR 1nimodipine 1nisoldipine 1verapamil 1verapamil SR 1Covera HS 3DynacircCR 3

Nymalize 3Combination Anti-Hypertensive amlodipineatorvastatin 1

amlodipinebenazepril 1atenololchlorthalidone 1benazeprilHCTZ 1bisoprololHCTZ 1

candesartanHCTZ 1captoprilHCTZ 1enalaprilHCTZ 1fosinoprilHCTZ 1

irbesartanHCTZ 1lisinoprilHCTZ 1

losartanHCTZ 1methyldopaHCTZ 1metoprololHCTZ 1propranololHCTZ 1quinaprilHCTZ 1

telmisartanHCTZ 1 valsartanHCTZ 1 Tekamlo 2 Tekturna HCT 2 amlodipinevalsartan 3 Amturnide 3 Atacand HCT 3 Avalide 3 Azor 3 Benicar HCT 3 Diovan HCT 3 Edarbyclor 3 Exforge HCT 3 Hyzaar 3 Micardis HCT 3 Prestalia 3 telmisartanamlodipine 3 Teveten HCT 3

trandolaprilverapamil 3 Tribenzor 3 Valturna 3Diuretics

acetazolamide 1acetazolamide ER 1amiloride 1amilorideHCTZ 1bumetanide 1chlorothiazide 1chlorthalidone 1furosemide 1hydrochlorothiazide 1indapamide 1methazolamide 1methyclothiazide 1metolazone 1spironolactone 1spironolactoneHCTZ 1torsemide 1triamtereneHCTZ 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 7

3

Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 9

5

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

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Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 14

10

Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 15

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 16

iv

USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS

The formulary offers a wide range of outpatient medications

Because there are over 40000 Food and Drug Administration (FDA)-approved prescription drugs on themarket not all tier 3 drugs can be listed in this formulary guide We have included in this printed for-mulary guide the drugs that are most commonly prescribed for our members If you have any questionsregarding coverage of a drug please call the customer service number on your card

Save Money on Your Prescription Drugs

Herersquos what you can do to save money

1 Bring this member guide to your doctor and review the cost-saving information below

2 Ask your doctor whether a drug listed in this guide is right for you

The amount you pay for a drug is determined by which medication you purchase and to what tier it isassigned Some drug plans also exclude certain drugs or classes of drugs from coverage Please checkyour contract or other plan documents if you have a question about your specific drug coverage

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies Costshare may vary by plan

Finding Medications in the Guide

This guide lists medications two different ways

Section 1 Alphabetically by drug category (such as Diabetes Heart or PainArthritis)

Locate a category and drug on the guide and you will see the tier and copayment for thatdrugmdashTier 1 Tier 2 or Tier 3mdashwhich determines your copayment To determine if a drug is ageneric or brand-name medication look at the name of the drug Generic medications arelower case (eg amoxicillin) and brand-name medications are capitalized (eg Advair)

Section 2 Alphabetically by drug name Use this list to find your drug

Questions Please call Pharmacy Services at 1 866 237-0333 if you have any questions about theBlueCross BlueShield of Western New York Formulary 3Exclusive For the most up-to-date version of theGuide visit the Pharmacy Services section of our web site at wwwbcbswnycom

Some plan designs require that you use a Tier 1 generic drug if a generic is available

Disclaimer The BlueCross BlueShield of Western New York Medication Guide is subject to change as we regularly reviewmedications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 3ExclusiveThe tier that a medication is currently in may change during the effective dates of the guides due to generic availability

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 5

1

AllergyCough amp ColdAntihistamines amp Decongestants

brompheniramine phenylephrine 1brompheniramine pseudoephedrine 1cetirizine 1clemastine 1cyproheptadine 1dexchlorpheniramine 1diphenhydramine 1

fexofenadine 1 fexofenadine-D 1

hydroxyzine HCl 1hydroxyzine pamoate 1

levocetirizine 1loratadine 1loratadine-D 1promethazine 1pseudoephedrine 1Semprex-D 2

Clarinex-D 3 desloratadine 3 Grastek 3+ Oralair 3

Phenergan 3 Ragwitek 3Expectorant amp Cough Products

benzonatate 1guaifenesincodeine 1hydrocodonechlorpheniramine 1hydrocodonehomatropine 1promethazinecodeine 1promethazineDM 1promethazinephenylephrine codeine 1pseudoephedrinecodeine 1CardecDM 3Guaifenesin DM 3Hycodan 3Rondec DMTR 3Vituz 3

Mucolytic Agentsacetylcysteine inh soln 1

Nasal Medicationsazelastine nasal spray 1

fluticasone nasal spray 1ipratropium nasal spray 1

Nasacort OTC 1Atrovent Nasal Spray 3

Beconase AQ 3 Flonase 3 flunisolide nasal spray 3 Nasacort AQ 3 Nasonex 3 Omnaris 3 Qnasl 3 Rhinocort Aqua 3 triamcinolone acetonide nasal spray 3 Veramyst 3 Zetonna 3Alzheimer Agents donepezil 1

ergoloid mesylates 1 galantamine 1 galantamine ER 1 rivastigmine 1 Exelon Patch 2 Namenda 2 Namenda XR 2 Namzaric 3BladderKidneyAcidifiers

K-Phos 3Alkalinizers

citric acidsod citrate 1potassium citrate 1Oracit 3

Analgesicsphenazopyridine 1

Anticholinergicsoxybutynin 1

oxybutynin ER 1 tolterodine 1 tolterodine ER 1 trospium 1 trospium ER 1 Detrol 3 Detrol LA 3 Ditropan XL 3 Enablex 3 Gelnique 3 Myrbetriq 3 Oxytrol 3 Sanctura 3 Sanctura XR 3 Toviaz 3 Vesicare 3BPH alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3

Jalyn 3 Rapaflo 3 Uroxatral 3Cholinergic Agents

Urecholine 3BloodAnticoagulantsAntithrombotics

anagrelide 1clopidogrel 1dipyridamole 1enoxaparin 1fondaparinux sodium 1heparin 1jantoven 1ticlopidine 1warfarin 1Aggrenox 2Coumadin 2Fragmin 2

Brilinta 3 Effient 3

Eliquis 3Innohep 3

Plavix 3 Pradaxa 3 Savaysa 3

Xarelto 3 Zontivity 3Other Blood Modifiers

cilostazol 1pentoxifylline 1

+ Actimmune 2+ Aranesp 2+ Exjade 2+ Leukine 2

Miacalcin inj 2 Neulasta 2+ Neupogen 2+ Promacta 2+ Procrit 2+ Revlimid 2+ Alprolix 3+ Eloctate 3+ Epogen 3 Ferriprox 3+ Granix 3+ Jadenu 3 Mircera 3+ Neumega 3 Omontys 3Cancer DrugsAlkylating Agents

cyclophosphamide 1Alkeran 2CeeNu 2

Emcyt 2Hexalen 2Leukeran 2Myleran 2

Antimetabolitescapecitabine 1mercaptopurine 1methotrexate 1Purixan 2Trexall 3

Hormonesbicalutamide 1exemastine 1flutamide 1letrozole 1

leuprolide 1megestrol 1tamoxifen 1anastrozole 1Fareston 2

Miscellaneousetoposide 1hydroxyurea 1

+ temozolamide 1+ Afinitor 2 Arcalyst 2+ Bosulif 2 Caprelsa 2 Cometriq 2+ Erivedge 2+ Farydak 2 Gilotrif 2+ Gleevec 2+ Hycamtin 2+ Ibrance 2 Iclusig 2 Imbruvica 2+ Inlyta 2+ Intron A 2 Iressa 2+ Jakafi 2 Lenvima 2 Lynparza 2

Lysodren 2Matulane 2

+ Mekinist 2Mesnex 2

+ Nexavar 2Nilandron 2

+ Pomalyst 2+ Sprycel 2+ Stivarga 2+ Sutent 2+ Sylatron 2+ Synribo 2+ Tafinlar 2+ Tarceva 2+ Tasigna 2+ Thalomid 2+ Tykerb 2 Valchlor 2+ Votrient 2+ Xalkori 2+ Xtandi 2+ Zelboraf 2+ Zolinza 2 Zydelig 2+ Zykadia 2+ Zytiga 2+ Temodar 3Rexinoids

Targretin 2

DiabetesPlease refer to your plan documents to confirm yourcost share for diabetic drugs Cost share may vary by plan

Antidiabetic Agents Injectable Byetta 2

Humalog insulin 2Humulin (all types) 2Lantus 2

Symlin 2 Victoza 2 Apidra 3 Bydureon 3 Levemir 3 Novolin 3 Novolog 3 Tanzeum 3

Toujeo 3 Trulicity 3Antidiabetic Agents Glucose Elevating Agents

acarbose 1chlorpropamide 1

glimepiride 1glipizide 1

glipizide ER 1 glipizidemetformin 1

glyburide 1glyburide micronized 1metformin 1

metformin ER 1 metforminglyburide 1 nateglinide 1 pioglitazonemetformin 1 repaglinide 1

tolazamide 1tolbutamide 1

Avandamet 2 Avandaryl 2 Avandia 2 Duetact 2

Glucagon 2 Janumet 2 Janumet XR 2 Januvia 2

Juvisync 2Kombiglyze XR 2Onglyza 2

Afrezza 3 Farxiga 3 Glumetza 3 Glyset 3 Glyxambi 3 Invokamet 3 Invokana 3 Jardiance 3 Jentadueto 3 Kazano 3 Nesina 3 Oseni 3

Riomet solution 3 Tradjenta 3 Xigduo XR 3Diabetic Test StripsPlease refer to your plan documents to confirm yourcost share for diabetic supplies Cost share may varyby plan Test strips other than OneTouch requireprior authorization

OneTouch Accu-Chek Ascensia Breeze Contour Freestyle Precision TRUEtest TRUEtrack

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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2

EarAnti-infective Agents

acetic acid otic 1acetic acidaluminum acetate 1ofloxacin otic 1Domeboro 3Xtoro 3

Anti-infectiveAnti-inflammatory combinationsacetic acid HC otic 1neomycinpolymyxinHC otic 1Ciprodex 2Cipro HC 3

EyeAntiallergy Agents (Eye)

azelastine ophth 1cromolyn ophth 1Alomide 3Bepreve 3ketotifen opthalmic solution 3Pataday 3Patanol 3Pazeo 3Zaditor 3

Anti-infective Agentsbacitracin ophth 1bacitracinpolymyxin 1ciprofloxacin ophth 1erythromycin ophth 1gatifloxacin 1gentamicin ophth 1neomycinbacitracinpoly B 1ofloxacin ophth 1polymyxin BTMP 1sulfacetamide 10 1tobramycin soln 1Tobrex ointment 2Vigamox 2Azasite 3Besivance 3Ciloxan 3Tobrex solution 3

Anti-inflammatoryfluorometholone ophth 1prednisolone acetate 1prednisolone sod phosphate 1FML Forte 2FML SOP 2Lotemax 2Pred Mild 2Flarex 3Maxidex 3

Anti-inflammatoryAnti-infective combinationsdexamethneomycinpoly B 1neomycinbacitracinpoly BHC 1sulfacetamideprednisolone ophth 1tobramycindexameth 1Tobradex ointment 2Maxitrol ophth 3Pred-G 3Zylet 3

Antiviral famciclovir 1

trifluridine 1Beta-Blockers (Eye)

betaxolol HCl 1carteolol 1levobunolol 1metipranolol 1timolol 1Betoptic-S 2Istalol 3

Carbonic Anhydrase Inhibitorsdorzolamide 2 eye drops 1dorzolamidetimolol eye drops 1Azopt 2

Mioticspilocarpine 1Isopto Carbachol 15 2

Phospholine Iodide 2Isopto Carbachol 3 3

Miscellaneous+ Cystaran 2

Restasis 3Mydriatics

atropine sulfate ophth 1homatropine 1tropicamide 1

NSAIDsbromfenac 1diclofenac 1flurbiprofen ophth 1ketorolac tromethamine 1Nevanac 2Acular PF 3Prolensa 3

Prostaglandin AnaloguesProstamineslatanoprost 1travoprost 1

Izba 3 Lumigan 3 Rescula 3 Travatan Z 3 Xalatan 3 Zioptan 3Sympathomimetics

brimonidine 1Alphagan P 2

Vasoconstrictorsnaphazoline 1phenylephrine ophth 1

Goutallopurinol 1colchicine 1colchicineprobenecid 1indomethacin 1probenecid 1Colcrys 2Indocin 3

Mitigare 3 Uloric 3HeartAngiotensin Converting Enzyme Inhibitors

benazepril 1captopril 1enalapril 1fosinopril 1lisinopril 1moexipril 1perindopril 1quinapril 1ramipril 1trandolapril 1Epaned 3

Angiotensin II Antagonists candesartan 1 eprosartan 600mg 1 irbesartan 1 losartan 1 telmisartan 1 valsartan 1 Atacand 3 Avapro 3 Benicar 3 Cozaar 3 Diovan 3 Edarbi 3 Micardis 3 Teveten 3Anti-Adrenergic Blockers Centrally acting

clonidine oral patch 1guanabenz 1guanfacine 1methyldopa 1midodrine 1Dibenzyline 2

+ Northera 3

Anti-Adrenergic Blockers Peripheraldoxazosin 1prazosin 1terazosin 1Cardura XL 3

Antiarrhythmicsamiodarone 1digoxin 1disopyramide 1flecainide 1mexiletine 1procainamide 1propafenone 1propafenone SR 1quinidine gluconate 1quinidine sulfate SR 1sotalol 1Lanoxin 2NorpaceCR 2Multaq 3Tikosyn 3

Antilipidemics atorvastatin calcium 1

cholestyramine 1colestipol 1fenofibrate 1fenofibric acid tab 1gemfibrozil 1

lovastatin 1niacin ER 1

niacinsimvastatin 1 pravastatin 1 simvastatin 1

Advicor 2Colestid 2

+ Kynamro 2 Altoprev 3 Antara 3 Crestor 3 Epanova 3 Fenoglide 3 Fibricor 3 fenofibric acid capsule delayed 3

release fluvastatin 3 Juxtapid 3 Lescol 3 Lescol XL 3 Lipitor 3 Lipofen 3

Liptruzet 3 Livalo 3 Lofibra 3 Mevacor 3 omega-3 acid ethyl esters 3 Omtryg 3 Pravachol 3 Tricor 3 Triglide 3

Vascepa 3 Vytorin 3

Welchol 3 Zetia 3 Zocor 3Beta Blockers

acebutolol 1atenolol 1betaxolol 1bisoprolol 1carvedilol 1labetalol 1metoprolol 1metoprolol ER 1metoprololHCTZ 1nadolol 1pindolol 1propranolol 1timolol 1Coreg CR 2

Innopran XL 2Bystolic 3Corgard 3Hemangeol 3

Calcium Channel Blockersamlodipine 1cartia XT 1diltia XT 1diltiazem 1diltiazem CDSRERXR 1felodipine ER 1isradipine 1nicardipine 1nifediac CC 1nifedical XL 1nifedipine 1nifedipine SR 1nimodipine 1nisoldipine 1verapamil 1verapamil SR 1Covera HS 3DynacircCR 3

Nymalize 3Combination Anti-Hypertensive amlodipineatorvastatin 1

amlodipinebenazepril 1atenololchlorthalidone 1benazeprilHCTZ 1bisoprololHCTZ 1

candesartanHCTZ 1captoprilHCTZ 1enalaprilHCTZ 1fosinoprilHCTZ 1

irbesartanHCTZ 1lisinoprilHCTZ 1

losartanHCTZ 1methyldopaHCTZ 1metoprololHCTZ 1propranololHCTZ 1quinaprilHCTZ 1

telmisartanHCTZ 1 valsartanHCTZ 1 Tekamlo 2 Tekturna HCT 2 amlodipinevalsartan 3 Amturnide 3 Atacand HCT 3 Avalide 3 Azor 3 Benicar HCT 3 Diovan HCT 3 Edarbyclor 3 Exforge HCT 3 Hyzaar 3 Micardis HCT 3 Prestalia 3 telmisartanamlodipine 3 Teveten HCT 3

trandolaprilverapamil 3 Tribenzor 3 Valturna 3Diuretics

acetazolamide 1acetazolamide ER 1amiloride 1amilorideHCTZ 1bumetanide 1chlorothiazide 1chlorthalidone 1furosemide 1hydrochlorothiazide 1indapamide 1methazolamide 1methyclothiazide 1metolazone 1spironolactone 1spironolactoneHCTZ 1torsemide 1triamtereneHCTZ 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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3

Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 9

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 10

6

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 14

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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1

AllergyCough amp ColdAntihistamines amp Decongestants

brompheniramine phenylephrine 1brompheniramine pseudoephedrine 1cetirizine 1clemastine 1cyproheptadine 1dexchlorpheniramine 1diphenhydramine 1

fexofenadine 1 fexofenadine-D 1

hydroxyzine HCl 1hydroxyzine pamoate 1

levocetirizine 1loratadine 1loratadine-D 1promethazine 1pseudoephedrine 1Semprex-D 2

Clarinex-D 3 desloratadine 3 Grastek 3+ Oralair 3

Phenergan 3 Ragwitek 3Expectorant amp Cough Products

benzonatate 1guaifenesincodeine 1hydrocodonechlorpheniramine 1hydrocodonehomatropine 1promethazinecodeine 1promethazineDM 1promethazinephenylephrine codeine 1pseudoephedrinecodeine 1CardecDM 3Guaifenesin DM 3Hycodan 3Rondec DMTR 3Vituz 3

Mucolytic Agentsacetylcysteine inh soln 1

Nasal Medicationsazelastine nasal spray 1

fluticasone nasal spray 1ipratropium nasal spray 1

Nasacort OTC 1Atrovent Nasal Spray 3

Beconase AQ 3 Flonase 3 flunisolide nasal spray 3 Nasacort AQ 3 Nasonex 3 Omnaris 3 Qnasl 3 Rhinocort Aqua 3 triamcinolone acetonide nasal spray 3 Veramyst 3 Zetonna 3Alzheimer Agents donepezil 1

ergoloid mesylates 1 galantamine 1 galantamine ER 1 rivastigmine 1 Exelon Patch 2 Namenda 2 Namenda XR 2 Namzaric 3BladderKidneyAcidifiers

K-Phos 3Alkalinizers

citric acidsod citrate 1potassium citrate 1Oracit 3

Analgesicsphenazopyridine 1

Anticholinergicsoxybutynin 1

oxybutynin ER 1 tolterodine 1 tolterodine ER 1 trospium 1 trospium ER 1 Detrol 3 Detrol LA 3 Ditropan XL 3 Enablex 3 Gelnique 3 Myrbetriq 3 Oxytrol 3 Sanctura 3 Sanctura XR 3 Toviaz 3 Vesicare 3BPH alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3

Jalyn 3 Rapaflo 3 Uroxatral 3Cholinergic Agents

Urecholine 3BloodAnticoagulantsAntithrombotics

anagrelide 1clopidogrel 1dipyridamole 1enoxaparin 1fondaparinux sodium 1heparin 1jantoven 1ticlopidine 1warfarin 1Aggrenox 2Coumadin 2Fragmin 2

Brilinta 3 Effient 3

Eliquis 3Innohep 3

Plavix 3 Pradaxa 3 Savaysa 3

Xarelto 3 Zontivity 3Other Blood Modifiers

cilostazol 1pentoxifylline 1

+ Actimmune 2+ Aranesp 2+ Exjade 2+ Leukine 2

Miacalcin inj 2 Neulasta 2+ Neupogen 2+ Promacta 2+ Procrit 2+ Revlimid 2+ Alprolix 3+ Eloctate 3+ Epogen 3 Ferriprox 3+ Granix 3+ Jadenu 3 Mircera 3+ Neumega 3 Omontys 3Cancer DrugsAlkylating Agents

cyclophosphamide 1Alkeran 2CeeNu 2

Emcyt 2Hexalen 2Leukeran 2Myleran 2

Antimetabolitescapecitabine 1mercaptopurine 1methotrexate 1Purixan 2Trexall 3

Hormonesbicalutamide 1exemastine 1flutamide 1letrozole 1

leuprolide 1megestrol 1tamoxifen 1anastrozole 1Fareston 2

Miscellaneousetoposide 1hydroxyurea 1

+ temozolamide 1+ Afinitor 2 Arcalyst 2+ Bosulif 2 Caprelsa 2 Cometriq 2+ Erivedge 2+ Farydak 2 Gilotrif 2+ Gleevec 2+ Hycamtin 2+ Ibrance 2 Iclusig 2 Imbruvica 2+ Inlyta 2+ Intron A 2 Iressa 2+ Jakafi 2 Lenvima 2 Lynparza 2

Lysodren 2Matulane 2

+ Mekinist 2Mesnex 2

+ Nexavar 2Nilandron 2

+ Pomalyst 2+ Sprycel 2+ Stivarga 2+ Sutent 2+ Sylatron 2+ Synribo 2+ Tafinlar 2+ Tarceva 2+ Tasigna 2+ Thalomid 2+ Tykerb 2 Valchlor 2+ Votrient 2+ Xalkori 2+ Xtandi 2+ Zelboraf 2+ Zolinza 2 Zydelig 2+ Zykadia 2+ Zytiga 2+ Temodar 3Rexinoids

Targretin 2

DiabetesPlease refer to your plan documents to confirm yourcost share for diabetic drugs Cost share may vary by plan

Antidiabetic Agents Injectable Byetta 2

Humalog insulin 2Humulin (all types) 2Lantus 2

Symlin 2 Victoza 2 Apidra 3 Bydureon 3 Levemir 3 Novolin 3 Novolog 3 Tanzeum 3

Toujeo 3 Trulicity 3Antidiabetic Agents Glucose Elevating Agents

acarbose 1chlorpropamide 1

glimepiride 1glipizide 1

glipizide ER 1 glipizidemetformin 1

glyburide 1glyburide micronized 1metformin 1

metformin ER 1 metforminglyburide 1 nateglinide 1 pioglitazonemetformin 1 repaglinide 1

tolazamide 1tolbutamide 1

Avandamet 2 Avandaryl 2 Avandia 2 Duetact 2

Glucagon 2 Janumet 2 Janumet XR 2 Januvia 2

Juvisync 2Kombiglyze XR 2Onglyza 2

Afrezza 3 Farxiga 3 Glumetza 3 Glyset 3 Glyxambi 3 Invokamet 3 Invokana 3 Jardiance 3 Jentadueto 3 Kazano 3 Nesina 3 Oseni 3

Riomet solution 3 Tradjenta 3 Xigduo XR 3Diabetic Test StripsPlease refer to your plan documents to confirm yourcost share for diabetic supplies Cost share may varyby plan Test strips other than OneTouch requireprior authorization

OneTouch Accu-Chek Ascensia Breeze Contour Freestyle Precision TRUEtest TRUEtrack

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Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 6

2

EarAnti-infective Agents

acetic acid otic 1acetic acidaluminum acetate 1ofloxacin otic 1Domeboro 3Xtoro 3

Anti-infectiveAnti-inflammatory combinationsacetic acid HC otic 1neomycinpolymyxinHC otic 1Ciprodex 2Cipro HC 3

EyeAntiallergy Agents (Eye)

azelastine ophth 1cromolyn ophth 1Alomide 3Bepreve 3ketotifen opthalmic solution 3Pataday 3Patanol 3Pazeo 3Zaditor 3

Anti-infective Agentsbacitracin ophth 1bacitracinpolymyxin 1ciprofloxacin ophth 1erythromycin ophth 1gatifloxacin 1gentamicin ophth 1neomycinbacitracinpoly B 1ofloxacin ophth 1polymyxin BTMP 1sulfacetamide 10 1tobramycin soln 1Tobrex ointment 2Vigamox 2Azasite 3Besivance 3Ciloxan 3Tobrex solution 3

Anti-inflammatoryfluorometholone ophth 1prednisolone acetate 1prednisolone sod phosphate 1FML Forte 2FML SOP 2Lotemax 2Pred Mild 2Flarex 3Maxidex 3

Anti-inflammatoryAnti-infective combinationsdexamethneomycinpoly B 1neomycinbacitracinpoly BHC 1sulfacetamideprednisolone ophth 1tobramycindexameth 1Tobradex ointment 2Maxitrol ophth 3Pred-G 3Zylet 3

Antiviral famciclovir 1

trifluridine 1Beta-Blockers (Eye)

betaxolol HCl 1carteolol 1levobunolol 1metipranolol 1timolol 1Betoptic-S 2Istalol 3

Carbonic Anhydrase Inhibitorsdorzolamide 2 eye drops 1dorzolamidetimolol eye drops 1Azopt 2

Mioticspilocarpine 1Isopto Carbachol 15 2

Phospholine Iodide 2Isopto Carbachol 3 3

Miscellaneous+ Cystaran 2

Restasis 3Mydriatics

atropine sulfate ophth 1homatropine 1tropicamide 1

NSAIDsbromfenac 1diclofenac 1flurbiprofen ophth 1ketorolac tromethamine 1Nevanac 2Acular PF 3Prolensa 3

Prostaglandin AnaloguesProstamineslatanoprost 1travoprost 1

Izba 3 Lumigan 3 Rescula 3 Travatan Z 3 Xalatan 3 Zioptan 3Sympathomimetics

brimonidine 1Alphagan P 2

Vasoconstrictorsnaphazoline 1phenylephrine ophth 1

Goutallopurinol 1colchicine 1colchicineprobenecid 1indomethacin 1probenecid 1Colcrys 2Indocin 3

Mitigare 3 Uloric 3HeartAngiotensin Converting Enzyme Inhibitors

benazepril 1captopril 1enalapril 1fosinopril 1lisinopril 1moexipril 1perindopril 1quinapril 1ramipril 1trandolapril 1Epaned 3

Angiotensin II Antagonists candesartan 1 eprosartan 600mg 1 irbesartan 1 losartan 1 telmisartan 1 valsartan 1 Atacand 3 Avapro 3 Benicar 3 Cozaar 3 Diovan 3 Edarbi 3 Micardis 3 Teveten 3Anti-Adrenergic Blockers Centrally acting

clonidine oral patch 1guanabenz 1guanfacine 1methyldopa 1midodrine 1Dibenzyline 2

+ Northera 3

Anti-Adrenergic Blockers Peripheraldoxazosin 1prazosin 1terazosin 1Cardura XL 3

Antiarrhythmicsamiodarone 1digoxin 1disopyramide 1flecainide 1mexiletine 1procainamide 1propafenone 1propafenone SR 1quinidine gluconate 1quinidine sulfate SR 1sotalol 1Lanoxin 2NorpaceCR 2Multaq 3Tikosyn 3

Antilipidemics atorvastatin calcium 1

cholestyramine 1colestipol 1fenofibrate 1fenofibric acid tab 1gemfibrozil 1

lovastatin 1niacin ER 1

niacinsimvastatin 1 pravastatin 1 simvastatin 1

Advicor 2Colestid 2

+ Kynamro 2 Altoprev 3 Antara 3 Crestor 3 Epanova 3 Fenoglide 3 Fibricor 3 fenofibric acid capsule delayed 3

release fluvastatin 3 Juxtapid 3 Lescol 3 Lescol XL 3 Lipitor 3 Lipofen 3

Liptruzet 3 Livalo 3 Lofibra 3 Mevacor 3 omega-3 acid ethyl esters 3 Omtryg 3 Pravachol 3 Tricor 3 Triglide 3

Vascepa 3 Vytorin 3

Welchol 3 Zetia 3 Zocor 3Beta Blockers

acebutolol 1atenolol 1betaxolol 1bisoprolol 1carvedilol 1labetalol 1metoprolol 1metoprolol ER 1metoprololHCTZ 1nadolol 1pindolol 1propranolol 1timolol 1Coreg CR 2

Innopran XL 2Bystolic 3Corgard 3Hemangeol 3

Calcium Channel Blockersamlodipine 1cartia XT 1diltia XT 1diltiazem 1diltiazem CDSRERXR 1felodipine ER 1isradipine 1nicardipine 1nifediac CC 1nifedical XL 1nifedipine 1nifedipine SR 1nimodipine 1nisoldipine 1verapamil 1verapamil SR 1Covera HS 3DynacircCR 3

Nymalize 3Combination Anti-Hypertensive amlodipineatorvastatin 1

amlodipinebenazepril 1atenololchlorthalidone 1benazeprilHCTZ 1bisoprololHCTZ 1

candesartanHCTZ 1captoprilHCTZ 1enalaprilHCTZ 1fosinoprilHCTZ 1

irbesartanHCTZ 1lisinoprilHCTZ 1

losartanHCTZ 1methyldopaHCTZ 1metoprololHCTZ 1propranololHCTZ 1quinaprilHCTZ 1

telmisartanHCTZ 1 valsartanHCTZ 1 Tekamlo 2 Tekturna HCT 2 amlodipinevalsartan 3 Amturnide 3 Atacand HCT 3 Avalide 3 Azor 3 Benicar HCT 3 Diovan HCT 3 Edarbyclor 3 Exforge HCT 3 Hyzaar 3 Micardis HCT 3 Prestalia 3 telmisartanamlodipine 3 Teveten HCT 3

trandolaprilverapamil 3 Tribenzor 3 Valturna 3Diuretics

acetazolamide 1acetazolamide ER 1amiloride 1amilorideHCTZ 1bumetanide 1chlorothiazide 1chlorthalidone 1furosemide 1hydrochlorothiazide 1indapamide 1methazolamide 1methyclothiazide 1metolazone 1spironolactone 1spironolactoneHCTZ 1torsemide 1triamtereneHCTZ 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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3

Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 10

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 14

10

Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 15

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 16

2

EarAnti-infective Agents

acetic acid otic 1acetic acidaluminum acetate 1ofloxacin otic 1Domeboro 3Xtoro 3

Anti-infectiveAnti-inflammatory combinationsacetic acid HC otic 1neomycinpolymyxinHC otic 1Ciprodex 2Cipro HC 3

EyeAntiallergy Agents (Eye)

azelastine ophth 1cromolyn ophth 1Alomide 3Bepreve 3ketotifen opthalmic solution 3Pataday 3Patanol 3Pazeo 3Zaditor 3

Anti-infective Agentsbacitracin ophth 1bacitracinpolymyxin 1ciprofloxacin ophth 1erythromycin ophth 1gatifloxacin 1gentamicin ophth 1neomycinbacitracinpoly B 1ofloxacin ophth 1polymyxin BTMP 1sulfacetamide 10 1tobramycin soln 1Tobrex ointment 2Vigamox 2Azasite 3Besivance 3Ciloxan 3Tobrex solution 3

Anti-inflammatoryfluorometholone ophth 1prednisolone acetate 1prednisolone sod phosphate 1FML Forte 2FML SOP 2Lotemax 2Pred Mild 2Flarex 3Maxidex 3

Anti-inflammatoryAnti-infective combinationsdexamethneomycinpoly B 1neomycinbacitracinpoly BHC 1sulfacetamideprednisolone ophth 1tobramycindexameth 1Tobradex ointment 2Maxitrol ophth 3Pred-G 3Zylet 3

Antiviral famciclovir 1

trifluridine 1Beta-Blockers (Eye)

betaxolol HCl 1carteolol 1levobunolol 1metipranolol 1timolol 1Betoptic-S 2Istalol 3

Carbonic Anhydrase Inhibitorsdorzolamide 2 eye drops 1dorzolamidetimolol eye drops 1Azopt 2

Mioticspilocarpine 1Isopto Carbachol 15 2

Phospholine Iodide 2Isopto Carbachol 3 3

Miscellaneous+ Cystaran 2

Restasis 3Mydriatics

atropine sulfate ophth 1homatropine 1tropicamide 1

NSAIDsbromfenac 1diclofenac 1flurbiprofen ophth 1ketorolac tromethamine 1Nevanac 2Acular PF 3Prolensa 3

Prostaglandin AnaloguesProstamineslatanoprost 1travoprost 1

Izba 3 Lumigan 3 Rescula 3 Travatan Z 3 Xalatan 3 Zioptan 3Sympathomimetics

brimonidine 1Alphagan P 2

Vasoconstrictorsnaphazoline 1phenylephrine ophth 1

Goutallopurinol 1colchicine 1colchicineprobenecid 1indomethacin 1probenecid 1Colcrys 2Indocin 3

Mitigare 3 Uloric 3HeartAngiotensin Converting Enzyme Inhibitors

benazepril 1captopril 1enalapril 1fosinopril 1lisinopril 1moexipril 1perindopril 1quinapril 1ramipril 1trandolapril 1Epaned 3

Angiotensin II Antagonists candesartan 1 eprosartan 600mg 1 irbesartan 1 losartan 1 telmisartan 1 valsartan 1 Atacand 3 Avapro 3 Benicar 3 Cozaar 3 Diovan 3 Edarbi 3 Micardis 3 Teveten 3Anti-Adrenergic Blockers Centrally acting

clonidine oral patch 1guanabenz 1guanfacine 1methyldopa 1midodrine 1Dibenzyline 2

+ Northera 3

Anti-Adrenergic Blockers Peripheraldoxazosin 1prazosin 1terazosin 1Cardura XL 3

Antiarrhythmicsamiodarone 1digoxin 1disopyramide 1flecainide 1mexiletine 1procainamide 1propafenone 1propafenone SR 1quinidine gluconate 1quinidine sulfate SR 1sotalol 1Lanoxin 2NorpaceCR 2Multaq 3Tikosyn 3

Antilipidemics atorvastatin calcium 1

cholestyramine 1colestipol 1fenofibrate 1fenofibric acid tab 1gemfibrozil 1

lovastatin 1niacin ER 1

niacinsimvastatin 1 pravastatin 1 simvastatin 1

Advicor 2Colestid 2

+ Kynamro 2 Altoprev 3 Antara 3 Crestor 3 Epanova 3 Fenoglide 3 Fibricor 3 fenofibric acid capsule delayed 3

release fluvastatin 3 Juxtapid 3 Lescol 3 Lescol XL 3 Lipitor 3 Lipofen 3

Liptruzet 3 Livalo 3 Lofibra 3 Mevacor 3 omega-3 acid ethyl esters 3 Omtryg 3 Pravachol 3 Tricor 3 Triglide 3

Vascepa 3 Vytorin 3

Welchol 3 Zetia 3 Zocor 3Beta Blockers

acebutolol 1atenolol 1betaxolol 1bisoprolol 1carvedilol 1labetalol 1metoprolol 1metoprolol ER 1metoprololHCTZ 1nadolol 1pindolol 1propranolol 1timolol 1Coreg CR 2

Innopran XL 2Bystolic 3Corgard 3Hemangeol 3

Calcium Channel Blockersamlodipine 1cartia XT 1diltia XT 1diltiazem 1diltiazem CDSRERXR 1felodipine ER 1isradipine 1nicardipine 1nifediac CC 1nifedical XL 1nifedipine 1nifedipine SR 1nimodipine 1nisoldipine 1verapamil 1verapamil SR 1Covera HS 3DynacircCR 3

Nymalize 3Combination Anti-Hypertensive amlodipineatorvastatin 1

amlodipinebenazepril 1atenololchlorthalidone 1benazeprilHCTZ 1bisoprololHCTZ 1

candesartanHCTZ 1captoprilHCTZ 1enalaprilHCTZ 1fosinoprilHCTZ 1

irbesartanHCTZ 1lisinoprilHCTZ 1

losartanHCTZ 1methyldopaHCTZ 1metoprololHCTZ 1propranololHCTZ 1quinaprilHCTZ 1

telmisartanHCTZ 1 valsartanHCTZ 1 Tekamlo 2 Tekturna HCT 2 amlodipinevalsartan 3 Amturnide 3 Atacand HCT 3 Avalide 3 Azor 3 Benicar HCT 3 Diovan HCT 3 Edarbyclor 3 Exforge HCT 3 Hyzaar 3 Micardis HCT 3 Prestalia 3 telmisartanamlodipine 3 Teveten HCT 3

trandolaprilverapamil 3 Tribenzor 3 Valturna 3Diuretics

acetazolamide 1acetazolamide ER 1amiloride 1amilorideHCTZ 1bumetanide 1chlorothiazide 1chlorthalidone 1furosemide 1hydrochlorothiazide 1indapamide 1methazolamide 1methyclothiazide 1metolazone 1spironolactone 1spironolactoneHCTZ 1torsemide 1triamtereneHCTZ 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 7

3

Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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KEY Note 1

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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Miscellaneous Cardiovascular Agents eplerenone 1

midodrine 1+ Berinert 2 Cinryze 2+ Firazyr 2

Ranexa 2+ Ruconest 2 Samsca 2 Tekturna 2 Corlanor 3Pulmonary Arterial Hypertension+ sildenafil citrate 1+ Adcirca 2+ Letairis 2+ Tracleer 2 Adempas 3 Flolan 3+ Opsumit 3 Orenitram 3+ Revatio 3 Tyvaso 3 Veletri 3 Ventavis 3Vasodilators

hydralazine 1isosorbide dinitrate 1isosorbide mononitrate 1isosorbide mononitrate SA 1isoxsuprine 1minoxidil oral 1nitroglycerin pumpspray 1nitroglycerin SR 1nitroglycerin transdermal patch 1Dilatrate SR 2Nitrostat SL tabs 2Minitran 3NitroDur patches 3

HIV - AntiviralsNon-Nucleoside Reverse Transcriptase Inhibitor

Atripla 2Edurant 2Intelence 2Rescriptor 2Sustiva 2Viramune XR 2

Nucleoside Analog Reverse Transcriptase InhibitorCombination

abacavirlamivudinezidovudine 1lamivudinezidovudine 1Complera 2Dutrebis 2Stribild 2Triumeq 2Truvada 2Viread 2

Nucleoside Reverse Transcriptase Inhibitorsdidanosine 1lamivudine tabs 1stavudine 1zidovudine 1Emtriva 2Epivir solution 2Epzicom 2Videx 2Ziagen 2

Other+ Fuzeon 2

Isentress 2Selzentry 2Tivicay 2Tybost 2Vitekta 2

Protease InhibitorsAptivus 2Crixivan 2Evotaz 2Invirase 2Lexiva 2

Norvir 2Prezcobix 2Prezista 2Reyataz 2Viracept 2

Protease Inhibitors CombinationsKaletra 2

Huntingtonrsquos Disease+ Xenazine 3Immunosuppressants

azathioprine 1cyclosporine 1gengraf 1mycophenolate mofetil 1mycophenolic acid 1sirolimus 1tacrolimus 1Neoral 2Sandimmune 2Astagraf XL 3Cellcept 3Prograf 3

InfectionAntibacterial AgentsAntibiotics

amoxicillin 1amoxicillin-clavulanate ER 1ampicillin 1azithromycin suspension 1azithromycin tablets 1cefaclor 1cefadroxil 1cefdinir 1cefpodoxime 1cefprozil 1cefuroxime 1cephalexin 1ciprofloxacin 1clarithromycin susp 1clarithromycin tabs 1clindamycin HCl 1dicloxacillin 1doxycycline 1erythromycin base 1erythromycin ethylsuccinate (EES) 1erythromycin stearate 1erythromycinsulfisoxazole 1levofloxacin 1minocycline 1nitrofurantoin 1ofloxacin 1penicillin VK 1sulfamethoxazoletrimethoprim 1tetracycline 1Ery-Tab 2Ketek 2Zmax 2

Acticlate 3Biaxin XL 3Ceftin 3Cleocin 3erythromycin estolate 3Factive 3Minocin 3moxifloxacin 3Noroxin 3PCE 3Spectracef 3Suprax 3Vibramycin 3

Antifungalsclotrimazole lozenge 1fluconazole 1flucytosine 1griseofulvin 1

itraconazole 1ketoconazole 1nystatin 1

terbinafine 1 voriconazole 1 Sporanox suspension 2

Ecoza 3 Lamisil Oral 3

Luzu 3 Noxafil 3

Oravig 3Antimalarials

atovaquoneproguanil HCl 1chloroquine phosphate 1hydroxychloroquine 1mefloquine 1Daraprim 2Primaquine 2quinine sulfate 3

Antituberculosisethambutol 1isoniazid 1pyrazinamide 1rifabutin 1rifampin 1Coartem 2Rifater 2Myambutol 3Rifadin 3Rifamate 3Sirturo 3

Antivirals acyclovir oral 1

amantadine 1 famciclovir 1

ganciclovir 1lamivudine tablets 1valganciclovir tablets 1

+ moderiba 1+ ribapak 1+ ribasphere 1+ ribavirin 1

rimantadine 1 valacyclovir 1

Epivir-HBV solution 2+ Harvoni 2 Hepsera 2+ Olysio 2+ Pegasys 2 Relenza 2+ Sovaldi 2 Tamiflu 2+ Victrelis 2+ Viekira 2

Baraclude solution 3+ Copegus 3

entecavir tablets 3+ Infergen 3+ Peg-Intron 3+ Rebetol 3+ Ribatab 3 Sitavig 3 Tyzeka 3

Valcyte 3 Valtrex 3Other Anti-Infectives

atovaquone 1methenamine combination 1metronidazole 1neomycin 1nitrofurantoin 1paromomycin 1tinidazole 1

+ tobramycin ampuleneb 1trimethoprim 1vancomycin caps 1Dapsone 2Nebupent 2

Sivextro 2 Zyvox 2+ Bethkis 3+ Cayston 3

Dificid 3FlagylER 3

Impavido 3+ Kitabis Pak 3

Macrodantin 3+ Tobi 3

Vancocin 3 Xifaxan 3Menrsquos HealthImpotence - possible contract exclusion refer toindividual contract

yohimbine 1 Caverject 3 Cialis 3 Edex 3 Levitra 3 MUSE 3 Staxyn 3 Stendra 3 Viagra 3Male Hormones testosterone cypionate 1 testosterone enanthionate 1 Androgel 2 Androderm patch 3

Android 3fluoxymesterone 3

Axiron 3 Fortesta 3 Natesto 3 Striant 3 Testim 3 Testosterone gel 3 Vogelxo 3Prostate Health alfuzosin HCl 1 finasteride 1

tamsulosin 1 Avodart 3 Flomax 3

Jalyn 3 Proscar 3 Rapaflo 3 Uroxatral 3Mental HealthAntidepressants

amitriptyline 1amitriptyline chlordiazepoxide 1amitriptylineperphenazine 1amoxapine 1bupropion 1bupropion ER 1bupropion XL 1

citalopram 1clomipramine 1desipramine 1doxepin 1

escitalopram 1 fluoxetine 10mg and 20mg tablet 1

fluoxetine capsule 1 fluvoxamine tablet 1

imipramine 1maprotiline 1

mirtazapine 1nefazodone 1nortriptyline 1

paroxetine HCl 1phenelzine 1protriptyline 1

sertraline 1tranylcypromine 1trazodone 1

venlafaxine 1venlafaxine ER 1Brintellix 3

Celexa 3 Desvenlafaxine ER 3 Desvenlafaxine fumarate ER 3

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1129 AM Page 8

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 10

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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10

Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 16

duloxetine 3Fetzima 3

fluoxetine 60mg tablet 3 fluvoxamine ER capsule 3

Forfivo 3 Khedezla 3 Lexapro 3 Luvox CR 3 Oleptro ER 3 PaxilCR 3 Pexeva 3 Pristiq ER 3 Prozac 3 Sarafem 3

Viibryd 3 Zoloft 3Antimanic Agents

lithium carbonate 1Antipsychotic Agents

chlorpromazine 1clozapine 1fluphenazine 1haloperidol 1loxapine 1

olanzapine 1perphenazine 1

quetiapine 1 risperidone 1 risperidone m-tab 1

thioridazine 1thiothixene 1trifluoperazine 1

ziprasidone caps 1 Abilify 3

aripiprazole 3 Fanapt 3

Fazaclo 3 Geodon 3 Invega 3 Latuda 3 olanzapinefluoxetine 3 Risperdal 3 Saphris 3 Seroquel 3 Seroquel XR 3 Symbyax 3 Versacloz 3 Zyprexa 3 Zyprexa Zydis 3Anxiolytics Sedatives and Hypnotics

alprazolamER 1buspirone 1chloral hydrate 1chlordiazepoxide 1clorazepate 1diazepam 1estazolam 1flurazepam 1lorazepam 1meprobamate 1oxazepam 1temazepam 1triazolam 1

zaleplon 1 zolpidem 1 zolpidem ER 1

Somnote 3 Ambien 3 Ambien CR 3

Ativan 3 Belsomra 3 Edluar 3 eszopiclone 3+ Hetlioz 3 Intermezzo 3

Librium 3 Lunesta 3 Rozerem 3 Silenor 3

Sonata 3 Zolpimist 3Cerebral Stimulants

dexmethylphenidate 1dexmethylphenidate XR 1dextroamphetamine tabs 1generic Adderall 1generic Adderall XR 1generic Concerta 1generic Dexedrine spansules 1metadate ER 1methylphenidate CD 1methylphenidateSR 1

modafinil 1procentra 1

Focalin XR 3Intuniv 3

Nuvigil 3Quillivant XR 3Strattera 3

Vyvanse 3MiscellaneousAntidiuretic Agents

desmopressin solution 1desmopressin tabs 1Stimate 2DDAVP nasal spray 3DDAVP sol tab 3

Other CNSacamprosate calcium tablet EC 1buprenorphine HCl 1disulfiram 1naltrexone 1

Evzio 2Rilutek 2Suboxone film 2

Bunavail 3 buprenorphine-naloxone 3

Campral dosepack 3 Gralise 3 Horizant 3

Savella 3 Suboxone tablet 3 Zubsolv 3Other Endocrine

danazol 1fludrocortisone 1

+ octreotide 1+ Egrifta 2+ HP Acthar Gel 2+ Norditropin 2+ Sensipar 2

Synarel 2Zavesca 2

+ Genotropin 3+ Humatrope 3+ Increlex 3 Myalept 3+ Natpara 3+ NutropinAQ 3+ Omnitrope 3+ Saizen 3+ Sandostatin 3+ Sandostatin LAR 3+ Serostim 3+ Somatuline Depot 3+ Somavert 3+ Tev-Tropin 3+ Zorbtive 3Other Miscellaneous Signifor 2 Carbaglu 3

Cystadane 3 Korlym 3 Procysbi 3 Ravicti 3Miscellaneous Immunologicals+ Gammagard Liquid 3

+ Gammaked 3+ Gamunex-C 3+ Hizentra 3+ HyQvia 3 Vivaglobin 3Multiple Sclerosis Agents+ Avonex 2+ Rebif 2+ Copaxone 20mg 2+ Gilenya 2+ Tecfidera 2+ Ampyra 3+ Betaseron 3+ Aubagio 3+ Copaxone 40mg 3+ Extavia 3+ Plegridy 3Muscle Relaxants

baclofen 1carisoprodol 1carisoprodolASA 1chlorzoxazone 1cyclobenzaprine 1dantrolene sodium 1diazepam 1metaxalone 1methocarbamol 1orphenadrine 1tizanidine 1

Osteoporosis alendronate 1 calcitonin-salmon 1 fortical NS 1 ibandronate tabs 1 raloxifene 1+ Forteo 2 Actonel 3 Atelvia 3 Binosto 3 Boniva 3 Fosamax 3 Fosamax D 3 risedronate 150mg 3PainArthritisAnalgesics Narcotic

acetaminophen wcodeine 1belladonna amp opium supp 1butalbitalAPAPcodeine 1butalbitalaspirincodeine 1butorphanol NS 1codeine sulfate 1endocet 1

fentanyl lozenge 1fentanyl patch 1hydrocodoneAPAP 1hydrocodoneibuprofen 1hydromorphone 1meperidine 1methadone 1morphine SR 1

morphine sulfate ER 1morphine tab soln supp 1oxycodone 1oxycodoneacetaminophen 1oxycodoneaspirin 1oxycodoneibuprofen 1oxymorphoneER 1pentazocinenaloxone 1

Abstral 3 Actiq 3 Avinza 3

Demerol 3Embeda 3

Exalgo 3 Fentora 3

Fioricetcodeine 3Fiorinalcodeine 3

hydromorphone ER 3 Hysingla ER 3 Kadian 3 Lazanda 3 MS Contin 3

NucyntaER 3 Onsolis 3 Opana ER 3 Oramorph SR 3 Oxycodone ER 3 Oxycontin 3

Roxicet solution 3 Subsys 3 Targiniq ER 3

Tylenolcodeine 3VicodinES 3

Xartemis XR 3 Zohydro ER 3Analgesics Salicylates

choline mag trisalicylate 1diflunisal 1salsalate 1Easprin 3

Anti-Rheumatichydroxychloroquine 1leflunomide 1methotrexate 1Cuprimine 2

+ Enbrel 2+ Humira 2

Ridaura 2+ Actemra 3+ Cimzia 3

Depen 3+ Kineret 3+ Orencia SC 3+ Otezla 3

Otrexup 3Rasuvo 3

+ Simponi 3+ Xeljanz 3Cox-2s celecoxib 3Migraine (Analgesics Non-narcotic)

butalbitalAPAP 1butalbitalAPAPcaffeine 1butalbitalaspirincaffeine 1

dihydroergotamine mesylate 1ergotaminecaffeine 1isomethdichloralphenAPAP 1

naratriptan 1 rizatriptan 1 sumatriptan 1

tramadol 1tramadolacetaminopen 1

zolmitriptan 1Ergomar 2

Amerge 3 Axert 3

Cafergot 3 Cambia 3 Frova 3 Imitrex 3 Maxalt 3 Maxalt MLT 3 Relpax 3 Sumavel 3 Treximet 3

UltramER 3 Zecuity 3 Zomig 3 Zomig Nasal 3 Zomig ZMT 3Nonsteroidal Anti-InflammatoryCombinationProducts

diclofenac potassium 1diclofenac sodium 1etodolac 1etodolac SA 1fenoprofen 1

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

4

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 10

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

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5

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

flurbiprofen 1ibuprofen 1indomethacin 1ketoprofen 1ketorolac inj 1

ketorolac tab 1meclofenamate 1meloxicam 1nabumetone 1naproxen 1naproxen EC 1oxaprozin 1piroxicam 1sulindac 1tolmetin 1

Voltaren Gel 2diclofenac sodium gel 3diclofenac sodiummisoprostol 3

diclofenac sodium topical solution 3Duexis 3

Flector 3Indocin 3mefenamic acid 3Naprosyn 3

Pennsaid 3 Sprix 3

Tivorbex 3 Vimovo 3

Zorvolex 3Parkinsonrsquos Disease

amantadine 1benztropine 1bromocriptine 1carbidopalevodopa 1carbidopalevodopa SA 1entacapone 1pramipexole 1ropinirole 1

selegiline 1trihexyphenidyl 1

+ Apokyn 3carbidopa 3

Duopa 3pergolide 3ropinirole ER 3Rytary 3Tasmar 3

PotassiumPotassium agents

potassium bicarbpotassium chloride 1potassium bicarbonate 1potassium chloride 1Micro-K 3

Potassium Removing agentsod polystyrene sulfonate 1Kayexalate 3

RespiratoryAsthmaAdrenergic

epinephrine inj 1EpipenJr 2Twinject 2

Adrenaclick 3 Auvi-Q 3Corticosteroids

budesonide inh 1(025mg2ml 05mg2ml)

Asmanex 2 Pulmicort flexhalerpowder 2

Pulmicort respules (1mg2ml) 2 Qvar 2 AerobidM 3 Alvesco 3 Arnuity Ellipta 3 Flovent HFADiskus 3Leukotrienes

montelukast 1zafirlukast 1

ZyfloCR 3

Other Agentscromolyn inh soln 1ipratropium inh soln 1ipratropiumalbuterol 1

Atrovent HFA 2 Combivent Respimat 2 Dulera 2+ Esbriet 2+ Kalydeco 2+ Ofev 2+ Pulmozyme 2 Spiriva 2 Spiriva Respimat 2 Symbicort 2 Advair diskus 3 Advair HFA 3

Anoro Ellipta 3 Breo Ellipta 3

Daliresp 3 Incruse Ellipta 3

Tudorza 3Sympathomimetics

albuterol sulfate ER 1albuterol tab syr 1metaproterenol syr 1terbutaline tab 1

Foradil 2 Maxair Autohaler 2 ProAir HFA 2 Serevent Diskus 2

Arcapta 3 Proventil HFA 3 Striverdi Respimat 3 Ventolin HFA 3 Xopenex HFA 3Xanthine Derivatives

aminophylline 1theochron 1theophyllineSR tabs liquid 1Theo-24 2Elixophyllin 3

SeizuresBarbiturates

mephobarbital 1phenobarbital 1

Hydantoinsphenytoin 1Dilantin 3Peganone 3

Miscellaneouscarbamazepine 1carbamazepine XR 200mg 400mg 1clonazepam 1divalproex sodiumER 1felbamate 1gabapentin 1lamotrigine 1levetiracetam 1oxcarbazepine 1primidone 1topiramate 1valproic acid 1zonisamide 1Tegretol 2Aptiom 3Banzel 3Fycompa 3Gabitril 3lamotrigine ER 3Lyrica 3Oxtellar XR 3Potiga 3Qudexy XR 3Sabril 3Tegretol XR 100mg 3Trokendi XR 3Vimpat 3

Succinimidesethosuximide 1Celontin 3

SkinAcneRosacea

adapalene 1amnesteem 1avita cream 1benzoyl peroxide 1claravis 1clindamycinbenzoyl peroxide 1clindamycin phospate 1erythromycinbenz peroxide 1minocycline HCl 1prascion RA 1sodium sulfacetamide 1sod sulfacetamidesulfur emulsion 1cleanser

sod sulfacetamidesulfur lot 1sotret 1

tretinoin crgel 1 Absorica 3 Avita gel 3 Doryx 3 doxycycline hyclate DR 3 Duac CS 3 Fabior 3 minocycline HCl ER 3 Mirvaso 3 Oracea 3 Solodyn 3 Soolantra 3 Tazorac cream 3 tretinoin microsphere gel 3 Veltin gel 3 Ziana gel 3Antibiotics (Topical)

clindamycin solswabsgellotion 1erythromycin solswabsgel 1gentamicin croint 1metronidazole creamlotion 075 gel 1mupirocin 1Bactroban cream 3Centany 3

Finacea 3 Metrogel topical 1 3 Noritate 3Antipsoriatics

acitretin 1calcipotriene 1Dritho-Scalp 2

Elidel 2 Protopic 2

Soriatane CK 2Tazorac gel 2

calcipotriene-betamethasone ointment 3calcitriol ointment 3

+ Cosentyx 3+ Stelara 3 Taclonex 3Burn preparation

silver sulfadiazine 1Fungicides

betamethasoneclotrimazole 1ciclopirox cream 1ciclopirox soln 1econazole 1ketoconazole 1nystatin 1nystatintriamcinolone 1nystop 1Exelderm 2Oxistat 2

Jublia 3 Kerydin 3

Naftin 3

Other Topicalsaluminum chloride 20 1fluorouracil 1imiquimod 5 cream 1podofilox 1sodium chloride irrigating soln 1Panretin 2Phisohex 2Picato 2Regranex 2Carac 3Fluoroplex 3Regenecare 3

Psoralens8-MOP 2Oxsoralen Ultra 2

Scabicides amp Pediculicidesacticin 1permethrin 1spinosad 1Lindane 2Ulesfia 2Eurax 3Sklice 3

Topical Anti-Inflammatory Agentsalclometasone 1amcinonide 1aug betamethasone diprop 1betamethasone dipropionate 1betamethasone valerate 1clobetasol propionate 1desonide 1desoximetasone 1diflorasone 1fluocinolone acetonide 1fluocinonide 1fluticasone propionate 1halobetasol 1halobetasol propionate 1hydrocortisone 25 1hydrocortisone valerate 1hydrocortisoneiodoquinol 1mometasone croint 1prednicarbate 1triamcinolone acetonide 1Cordran tape 2betamethasone valerate foam 3Capex Shampoo 3clobetasol propionate shampoo 3Cordran SP 3Halog 3hydrocortisone butyrateemoll cream 3Kenalogaerosol 3

Topical AntipruriticsAnestheticslidocaine 1

lidocaine patch 1selenium sulf 25 suspension 1Rectiv 3

Topical Antiviralsacyclovir ointment 1Zovirax Cream 2Denavir 3

Smoking CessationMembers coverage varies by plan Patient should bein a smoking cessation program bupropion 1 Nicorelief gum 1 Nicorelief lozenge 1 Nicotine Gum 1 Nicotine lozenges 1 Nicotine patches various 1 Chantix 2 Commit 2 Nicotrol Inhaler 2 Nicotrol NS 2 Zyban 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 10

6

SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

7

Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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SEcTIoN I mdash ThERapEuTIc dRug caTEgoRIES (coNTrsquod)

TIER TIER TIER TIER

Steroidscortisone acetate 1dexamethasone oral 1hydrocortisone oral 1methylprednisolone 4mg 8mg 16mg 132mg

prednisolone oral 1prednisone oral 1Medrol 2mg 2

Rayos 3StomachUlcerAnorectal

hydrocortisone rectal cr amp supp 1hydrocortisone rectal enema 1pramoxineHC acetate 25 1Analpram-HC 1-1 3Analpram-HC 25 crlot 3Cortifoam 3Proctofoam-HC 3

AnticholinergicsAntispasmodicGI Motilitybelladonnaphenobarbital 1chlordiazepoxideclindinium 1dicyclomine 1glycopyrrolate 1hyoscyamineCR 1metoclopramide 1Donnatal 2

Antidiarrhealdiphenoxylateatropine 1paregoric 1

Alinia 2Fulyzaq 2

AntiemeticAntivertigo granisetron 1

meclizine 1 ondansetron 1

prochlorperazine 1promethazine 1trimethobenzamide 1Antivert 50mg 2

Anzemet 2 Emend 2

Transderm Scop 2+ Akynzeo 3 Diclegis 3 Granisol 3 Sancuso 3 Zuplenz 3Bowel Evacuants

peg 3350electrolyte 1Trilyte 1Halflytely 2Nulytely 3Prepopik 3Suclear 3

DigestantsZenpep 2

Creon 3 Pancreaze 3 Pertzye 3 Ultresa 3

Viokace 3Gallstone Solubilizing Agents

ursodiol 1H2 Antagonists

cimetidine 1famotidine 1nizatidine 1ranitidine (all) 1

Other Antiulcermisoprostol 1propantheline bromide 1sucralfate 1Helidac 3lansoprazoleamoxclarith 3

Other GI Productsbalsalazide 1budesonide EC 1cromolyn sodium 1enulose 1lactulose 1mesalamine enema 1sulfasalazine 1sulfasalazine EC 1

+ Kuvan 2 Amitiza 3

Apriso 3Asacol HD 3Azulfidine 3Canasa supp 3

+ Cimzia 3Delzicol 3Dipentum 3

+ Gattex 3Giazo 3Linzess 3Lotronex 3

Movantik 3Pentasa 3

Relistor 3Uceris 3

Proton Pump Inhibitors Nexium 24HR 1 omeprazole 1 omeprazolesodium bicarbonate 1 pantoprazole 1 Prevacid 24HR 1 Prilosec-OTC 1 Aciphex 3 Dexilant 3 esomeprazole magnesium 3 lansoprazole 3 Nexiumsusp 3 Prevacidsusp 3 Prilosec 3 Protonix 3 rabeprazole 3 Zegerid 3ThyroidAntithyroid

methimazole 1propylthiouracil 1

Thyroidlevothroid 1levothyroxine 1levoxyl 1liothyronine 1thyroid 1unithroid 1Synthroid 2Thyroid (Armour) 2Thyrolar 2

Vitaminscalcitriol 1calcitriol inj 1calcium acetate 1cholecalciferol 1cyanocobalamin inj 1ergocalciferol 1etidronate 1folic acid Rx 1mg tab 1leucovorin 1levocarnitine 1multivitamin + fluoride 1potassium aminobenzoate 1pre-natal vitamins 1sevelamer 1sodium fluoride chewable tab amp drops 1vit ADC + fluoride 1

vit ADC + fluoride and iron 1Galzin 2Mephyton 2Nascobal 2Orfadin 2phytonadione 2Prenate Elite 2Renagel 2Renvela 2Auryxia 3Fosrenol 3paricalcitol 3Poly-Vi-Flor + Iron 3Tri-Vi-Flor 3Velphoro 3

Weight Loss - possible contract exclusion refer to individual contract benzphetamine 1 diethylpropion 1 phendimetrazine 1 phentermine 1 Belviq 3 Contrave 3 Qsymia 3 Saxenda 3 Suprenza ODT 3 Xenical 3Womenrsquos HealthContraceptives - Other

xulane 1Mirena 2NuvaRing 2Depo-SubQ Provera 3Liletta 3Paragard 3Skyla 3

Fertility Induction Agents - possible contractexclusion refer to individual contract

clomiphene 1serophene 1

Bravelle 2 Cetrotide 2 Follistim AQ 2 Novarel 2 Ovidrel 2 Repronex 2 chorionic gonadotropin 3 Ganirelix 3 Gonal F 3 Luveris 3 Pregnyl 3Hormones estradiolnoreth ac 1 estradiol oral 1 estradiol patches 1 estropipate 1 estrogenmethyltesterone 1 jinteli 1

medroxyprogesterone 1norethindrone 1

Combipatch 2Premphase 2Prempro 2Progesterone Powder 2

Alora 3Cenestin 3

Climara Pro 3Crinone 8 3Duavee 3Enjuvia 3Estrace Vag Cream 3

Estraderm 3 Estrasorb packet 3 Estring 3

Estrogel 3Evamist 3

Femring 3Menest 3

Menostar 3Ortho-Est 3Osphena 3

Prefest 3Premarin 3Premarin vag cream 3progesterone micronized 3Vagifem 3

Vivelle-DOT 3Miscellaneous

Brisdelle 3Oral Contraceptives

amethia 1amethyst 1apri 1aranelle 1aviane 1balziva 1camila 1camrese 1cesia 1cryselle 1enpresse 1errin 1jolessa 1jolivette 1junelFE 1kariva 1lessina 1levora 1low-ogestrel 1lutera 1microgestinFE 1mononessa 1necon 1nora-BE 1norethindrone a-e estradiol ferrous 1fumarate

nortrel 1ocella 1ogestrel 1portia 1previfem 1quasense 1solia 1sprintec 1tri-sprintec 1trinessa 1triprevifem 1trivora 1velivet 1zarah 1zenchent 1zovia 1Beyaz 3Ortho Tri-Cyclen Lo 3Ovcon-50 3Quartette 3

Oxytocic Agentsmethylergonovine maleate 1Methergine 3

Vaginal Preparationsmiconazole vag supp 1nystatin vag tab 1terconazole 1vandazole vag 1Cleocin VagOvules 3Clindesse 3Gynazole-1 3

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 11

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Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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KEY Note 1

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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KEY Note 1

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Aabacavirlamivudine 1 3zidovudine

Abilify 3 4Absorica 3 5Abstral 3 4acamprosate calcium 1 4tablet ECacarbose 1 1Accu-Chek 1acebutolol 1 2acetaminophen w 1 4codeineacetazolamide 1 2acetazolamide ER 1 2acetic acid HC otic 1 1acetic acid otic 1 1acetic acidaluminum 1 1acetateacetylcysteine inh 1 1soln

Aciphex 3 6acitretin 1 5+Actemra 3 4acticin 1 5Acticlate 3 3+Actimmune 2 1Actiq 3 4Actonel 3 4Acular PF 3 2acyclovir ointment 1 5acyclovir oral 1 3adapalene 1 5+Adcirca 2 3Adempas 3 3Adrenaclick 3 5Advair diskus 3 5Advair HFA 3 5Advicor 2 2AerobidM 3 5+Afinitor 2 1Afrezza 3 1Aggrenox 2 1+Akynzeo 3 6albuterol sulfate ER 1 5albuterol tab syr 1 5alclometasone 1 5alendronate 1 4alfuzosin HCl 1 13Alinia 2 6Alkeran 2 1allopurinol 1 2Alomide 3 2Alora 3 6Alphagan P 2 2alprazolamER 1 4+Alprolix 3 1Altoprev 3 2aluminum chloride 1 520

Alvesco 3 5amantadine 1 35Ambien 3 4Ambien CR 3 4amcinonide 1 5Amerge 3 4amethia 1 6amethyst 1 6amiloride 1 2amilorideHCTZ 1 2aminophylline 1 5amiodarone 1 2Amitiza 3 6amitriptyline 1 3amitriptyline 1 3chlordiazepoxideamitriptyline 1 3perphenazineamlodipine 1 2amlodipine 1 2atorvastatinamlodipine 1 2benazepril

amlodipinevalsartan 3 2amnesteem 1 5amoxapine 1 3amoxicillin 1 3amoxicillin- 1 3clavulanate ERampicillin 1 3+Ampyra 3 4

Amturnide 3 2anagrelide 1 1Analpram-HC 1-1 3 6Analpram-HC 25 cr 3 6lotanastrozole 1 1Androderm patch 3 3Androgel 2 3Android 3 3Anoro Ellipta 3 5Antara 3 2Antivert 50mg 2 6Anzemet 2 6Apidra 3 1+Apokyn 3 5apri 1 6Apriso 3 6Aptiom 3 5Aptivus 2 3aranelle 1 6+Aranesp 2 1Arcalyst 2 1Arcapta 3 5aripiprazole 1 4Arnuity Ellipta 3 5Asacol HD 3 6Ascensia Breeze 1Asmanex 2 5Astagraf XL 3 3Atacand 3 2Atacand HCT 3 2Atelvia 3 4atenolol 1 2atenolol 1 2chlorthalidoneAtivan 3 4atorvastatin calcium 1 2atovaquone 1 3atovaquoneproguanil 1 3HClAtripla 2 3atropine sulfate 1 2ophth

Atrovent HFA 2 5Atrovent Nasal Spray 3 1+Aubagio 3 4aug betamethasone 1 5dipropAuryxia 3 6Auvi-Q 3 5Avalide 3 2Avandamet 2 1Avandaryl 2 1Avandia 2 1Avapro 3 2aviane 1 6Avinza 3 4avita cream 1 5Avita gel 3 5Avodart 3 13+Avonex 2 4Axert 3 4Axiron 3 3Azasite 3 2azathioprine 1 3azelastine nasal 1 1sprayazelastine ophth 1 2azithromycin 1 3suspensionazithromycin tablets 1 3Azopt 2 2Azor 3 2Azulfidine 3 6

Bbacitracin ophth 1 2bacitracinpolymyxin 1 2baclofen 1 4Bactroban cream 3 5balsalazide 1 6balziva 1 6Banzel 3 5Baraclude solution 3 3Beconase AQ 3 1belladonna amp opium 1 4suppbelladonna 1 6phenobarbital

Belsomra 3 4Belviq 3 6benazepril 1 2

benazeprilHCTZ 1 2Benicar 3 2Benicar HCT 3 2benzonatate 1 1benzoyl peroxide 1 5benzphetamine 1 6benztropine 1 5Bepreve 3 2+Berinert 2 3Besivance 3 2betamethasone 1 5dipropionatebetamethasone 1 5valeratebetamethasone 3 5valerate foambetamethasone 1 5clotrimazole

+Betaseron 3 4betaxolol 1 2betaxolol HCl 1 2+Bethkis 3 3Betoptic-S 2 2Beyaz 3 6Biaxin XL 3 3bicalutamide 1 1Binosto 3 4bisoprolol 1 2bisoprololHCTZ 1 2Boniva 3 4+Bosulif 2 1Bravelle 2 6Breo Ellipta 3 5Brilinta 3 1brimonidine 1 2Brintellix 3 3Brisdelle 3 6bromfenac 1 2bromocriptine 1 5brompheniramine 1 1phenylephrinebrompheniramine 1 1pseudoephedrinebudesonide EC 1 6budesonide inh 1 5(025mg2ml 05mg2ml)bumetanide 1 2Bunavail 3 4buprenorphine HCl 1 4buprenorphine- 3 4naloxonebupropion 1 3bupropion 1 5bupropion ER 1 3bupropion XL 1 3buspirone 1 4butalbitalAPAP 1 4butalbitalAPAP 1 4caffeinebutalbitalAPAP 1 4codeinebutalbitalaspirin 1 4caffeinebutalbitalaspirin 1 4codeinebutorphanol NS 1 4Bydureon 3 1Byetta 2 1Bystolic 3 2

CCafergot 3 4calcipotriene 1 5calcipotriene- 3 5betamethasone ointment

calcitonin-salmon 1 4calcitriol 1 6calcitriol inj 1 6calcitriol ointment 3 5calcium acetate 1 6Cambia 3 4camila 1 6Campral dosepack 3 4camrese 1 6Canasa supp 3 6candesartan 1 2candesartanHCTZ 1 2capecitabine 1 1Capex Shampoo 3 5Caprelsa 2 1

captopril 1 2captoprilHCTZ 1 2Carac 3 5Carbaglu 3 4carbamazepine 1 5carbamazepine XR 1 5200mg 400mgcarbidopa 3 5carbidopalevodopa 1 5carbidopalevodopa 1 5SACardecDM 3 1Cardura XL 3 2carisoprodol 1 4carisoprodolASA 1 4carteolol 1 2cartia XT 1 2carvedilol 1 2Caverject 3 3+Cayston 3 3CeeNu 2 1cefaclor 1 3cefadroxil 1 3cefdinir 1 3cefpodoxime 1 3cefprozil 1 3Ceftin 3 3cefuroxime 1 3celecoxib 3 4Celexa 3 3Cellcept 3 3Celontin 3 5Cenestin 3 6Centany 3 5cephalexin 1 3cesia 1 6cetirizine 1 1Cetrotide 2 6Chantix 2 5chloral hydrate 1 4chlordiazepoxide 1 4chlordiazepoxide 1 6clindiniumchloroquine 1 3phosphatechlorothiazide 1 2chlorpromazine 1 4chlorpropamide 1 1chlorthalidone 1 2chlorzoxazone 1 4cholecalciferol 1 6cholestyramine 1 2choline mag 1 4trisalicylate

chorionic 3 6gonadotropin

Cialis 3 3ciclopirox cream 1 5ciclopirox soln 1 5cilostazol 1 1Ciloxan 3 2cimetidine 1 6+Cimzia 3 46Cinryze 2 3Cipro HC 3 1Ciprodex 2 1ciprofloxacin 1 3ciprofloxacin ophth 1 2citalopram 1 3citric acidsod 1 1citrateclaravis 1 5Clarinex-D 3 1clarithromycin susp 1 3clarithromycin tabs 1 3clemastine 1 1Cleocin 3 3Cleocin VagOvules 3 6Climara Pro 3 6clindamycin HCl 1 3clindamycin phospate 1 5clindamycin sol 1 5swabsgellotionclindamycinbenzoyl 1 5peroxideClindesse 3 6clobetasol 1 5propionateclobetasol 3 5propionate shampooclomiphene 1 6

clomipramine 1 3clonazepam 1 5clonidine oral 1 2patchclopidogrel 1 1clorazepate 1 4clotrimazole lozenge 1 3clozapine 1 4Coartem 2 3codeine sulfate 1 4colchicine 1 2colchicine 1 2probenecidColcrys 2 2Colestid 2 2colestipol 1 2Combipatch 2 6Combivent Respimat 2 5Cometriq 2 1Commit 2 5Complera 2 3Contour 1Contrave 3 6+Copaxone 20mg 2 4+Copaxone 40mg 3 4+Copegus 3 3Cordran SP 3 5Cordran tape 2 5Coreg CR 2 2Corgard 3 2Corlanor 3 3Cortifoam 3 6cortisone acetate 1 6+Cosentyx 3 5Coumadin 2 1Covera HS 3 2Cozaar 3 2Creon 3 6Crestor 3 2Crinone 8 3 6Crixivan 2 3cromolyn inh soln 1 5cromolyn ophth 1 2cromolyn sodium 1 6cryselle 1 6Cuprimine 2 4cyanocobalamin inj 1 6cyclobenzaprine 1 4cyclophosphamide 1 1cyclosporine 1 3cyproheptadine 1 1Cystadane 3 4+Cystaran 2 2

DDaliresp 3 5danazol 1 4dantrolene sodium 1 4Dapsone 2 3Daraprim 2 3DDAVP nasal spray 3 4DDAVP sol tab 3 4Delzicol 3 6Demerol 3 4Denavir 3 5Depen 3 4Depo-SubQ Provera 3 6desipramine 1 3desloratadine 3 1desmopressin 1 4solutiondesmopressin tabs 1 4desonide 1 5desoximetasone 1 5Desvenlafaxine ER 3 3Desvenlafaxine 3 3fumarate ER

Detrol 3 1Detrol LA 3 1dexamethneomycin 1 2poly Bdexamethasone oral 1 6dexchlorpheniramine 1 1Dexilant 3 6dexmethylphenidate 1 4dexmethylphenidate 1 4XRdextroamphetamine 1 4tabsdiazepam 1 4Dibenzyline 2 2Diclegis 3 6

diclofenac 1 2diclofenac potassium 1 4diclofenac sodium 1 4diclofenac sodium 3 5gel

diclofenac sodium 3 5topical solutiondiclofenac sodium 3 5misoprostoldicloxacillin 1 3dicyclomine 1 6didanosine 1 3diethylpropion 1 6Dificid 3 3diflorasone 1 5diflunisal 1 4digoxin 1 2dihydroergotamine 1 4mesylateDilantin 3 5Dilatrate SR 2 3diltia XT 1 2diltiazem 1 2diltiazem CDSRER 1 2XR

Diovan 3 2Diovan HCT 3 2Dipentum 3 6diphenhydramine 1 1diphenoxylate 1 6atropinedipyridamole 1 1disopyramide 1 2disulfiram 1 4Ditropan XL 3 1divalproex sodiumER 1 5Domeboro 3 1donepezil 1 1Donnatal 2 6Doryx 3 5dorzolamide 2 eye 1 2dropsdorzolamidetimolol 1 2eye dropsdoxazosin 1 2doxepin 1 3doxycycline 1 3doxycycline hyclate 3 5DRDritho-Scalp 2 5Duac CS 3 5Duavee 3 6Duetact 2 1Duexis 3 5Dulera 2 5duloxetine 3 4Duopa 3 5Dutrebis 2 3DynacircCR 3 2

EEasprin 3 4econazole 1 5Ecoza 3 3Edarbi 3 2Edarbyclor 3 2Edex 3 3Edluar 3 4Edurant 2 3Effient 3 1+Egrifta 2 48-MOP 2 5Elidel 2 5Eliquis 3 1Elixophyllin 3 5+Eloctate 3 1Embeda 3 4Emcyt 2 1Emend 2 6Emtriva 2 3Enablex 3 1enalapril 1 2enalaprilHCTZ 1 2+Enbrel 2 4endocet 1 4Enjuvia 3 6enoxaparin 1 1enpresse 1 6entacapone 1 5entecavir tablets 3 3enulose 1 6Epaned 3 2

SEcTIoN II mdash INdEx

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 12

8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

166128C_MG45999Q_BCBS WNY Exclusive_v2 7215 1130 AM Page 13

9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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8

Epanova 3 2epinephrine inj 1 5EpipenJr 2 5Epivir solution 2 3Epivir-HBV solution 2 3eplerenone 1 3+Epogen 3 1eprosartan 600mg 1 2Epzicom 2 3ergocalciferol 1 6ergoloid mesylates 1 1Ergomar 2 4ergotaminecaffeine 1 4+Erivedge 2 1errin 1 6Ery-Tab 2 3erythromycin base 1 3erythromycin 3 3estolateerythromycin 1 3ethylsuccinate(EES)erythromycin ophth 1 2erythromycin sol 1 5swabsgelerythromycin 1 3stearateerythromycinbenz 1 5peroxideerythromycin 1 3sulfisoxazole

+Esbriet 2 5escitalopram 1 3esomeprazole 3 6magnesiumestazolam 1 4Estrace Vag Cream 3 6Estraderm 3 6estradiol oral 1 6estradiol patches 1 6estradiolnoreth ac 1 6Estrasorb packet 3 6Estring 3 6Estrogel 3 6estrogen 1 6methyltesterone

estropipate 1 6eszopiclone 3 4ethambutol 1 3ethosuximide 1 5etidronate 1 6etodolac 1 4etodolac SA 1 4etoposide 1 1Eurax 3 5Evamist 3 6Evotaz 2 3Evzio 2 4Exalgo 3 4Exelderm 2 5Exelon Patch 2 1exemastine 1 1Exforge HCT 3 2+Exjade 2 1+Extavia 3 4

FFabior 3 5Factive 3 3famciclovir 1 23famotidine 1 6Fanapt 3 4Fareston 2 1Farxiga 3 1+Farydak 2 1Fazaclo 3 4felbamate 1 5felodipine ER 1 2Femring 3 6fenofibrate 1 2fenofibric acid 3 2capsule delayedreleasefenofibric acid tab 1 2Fenoglide 3 2fenoprofen 1 4fentanyl lozenge 1 4fentanyl patch 1 4Fentora 3 4Ferriprox 3 1Fetzima 3 4fexofenadine 1 1

fexofenadine-D 1 1Fibricor 3 2Finacea 3 5finasteride 1 13Fioricetcodeine 3 4Fiorinalcodeine 3 4+Firazyr 2 3FlagylER 3 3Flarex 3 2flecainide 1 2Flector 3 5Flolan 3 3Flomax 3 3Flonase 3 1Flovent HFADiskus 3 5fluconazole 1 3flucytosine 1 3fludrocortisone 1 4flunisolide nasal 3 1sprayfluocinolone 1 5acetonidefluocinonide 1 5fluorometholone 1 2ophthFluoroplex 3 5fluorouracil 1 5fluoxetine 10mg and 1 320mg tablet

fluoxetine 60mg 3 4tabletfluoxetine capsule 1 3fluoxymesterone 3 3fluphenazine 1 4flurazepam 1 4flurbiprofen 1 5flurbiprofen ophth 1 2flutamide 1 1fluticasone nasal 1 1sprayfluticasone 1 5propionate

fluvastatin 3 2fluvoxamine ER 3 4capsule

fluvoxamine tablet 1 3FML Forte 2 2FML SOP 2 2Focalin XR 3 4folic acid Rx 1mg 1 6tab

Follistim AQ 2 6fondaparinux sodium 1 1Foradil 2 5Forfivo 3 4+Forteo 2 4Fortesta 3 3fortical NS 1 4Fosamax 3 4Fosamax D 3 4fosinopril 1 2fosinoprilHCTZ 1 2Fosrenol 3 6Fragmin 2 1Freestyle 1Frova 3 4Fulyzaq 2 6furosemide 1 2+Fuzeon 2 3Fycompa 3 5

Ggabapentin 1 5Gabitril 3 5galantamine 1 1galantamine ER 1 1Galzin 2 6+Gammagard Liquid 3 4+Gammaked 3 4+Gamunex-C 3 4ganciclovir 1 3Ganirelix 3 6gatifloxacin 1 2+Gattex 3 6Gelnique 3 1gemfibrozil 1 2generic Adderall 1 4generic Adderall XR 1 4generic Concerta 1 4generic Dexedrine 1 4spansulesgengraf 1 3

+Genotropin 3 4gentamicin croint 1 5gentamicin ophth 1 2Geodon 3 4Giazo 3 6+Gilenya 2 4Gilotrif 2 1+Gleevec 2 1glimepiride 1 1glipizide 1 1glipizide ER 1 1glipizidemetformin 1 1Glucagon 2 1Glumetza 3 1glyburide 1 1glyburide micronized 1 1glycopyrrolate 1 6Glyset 3 1Glyxambi 3 1Gonal F 3 6Gralise 3 4granisetron 1 6Granisol 3 6+Granix 3 1Grastek 3 1griseofulvin 1 3Guaifenesin DM 3 1guaifenesincodeine 1 1guanabenz 1 2guanfacine 1 2Gynazole-1 3 6

HHalflytely 2 6halobetasol 1 5halobetasol 1 5propionateHalog 3 5haloperidol 1 4+Harvoni 2 3Helidac 3 6Hemangeol 3 2heparin 1 1Hepsera 2 3+Hetlioz 3 4Hexalen 2 1+Hizentra 3 4homatropine 1 2Horizant 3 4+HP Acthar Gel 2 4Humalog insulin 2 1+Humatrope 3 4+Humira 2 4Humulin (all types) 2 1+Hycamtin 2 1Hycodan 3 1hydralazine 1 3hydrochlorothiazide 1 2hydrocodoneAPAP 1 4hydrocodone 1 1chlorpheniraminehydrocodone 1 1homatropinehydrocodone 1 4ibuprofenhydrocortisone 25 1 5hydrocortisone 3 5butyrateemoll creamhydrocortisone oral 1 6hydrocortisone 1 6rectal cr amp supphydrocortisone 1 6rectal enemahydrocortisone 1 5valeratehydrocortisone 1 5iodoquinolhydromorphone 1 4hydromorphone ER 3 4hydroxychloroquine 1 34hydroxyurea 1 1hydroxyzine HCl 1 1hydroxyzine pamoate 1 1hyoscyamineCR 1 6+HyQvia 3 4Hysingla ER 3 4Hyzaar 3 2

Iibandronate tabs 1 4+Ibrance 2 1ibuprofen 1 5

Iclusig 2 1Imbruvica 2 1imipramine 1 3imiquimod 5 cream 1 5Imitrex 3 4Impavido 3 3+Increlex 3 4Incruse Ellipta 3 5indapamide 1 2Indocin 3 25indomethacin 1 25+Infergen 3 3+Inlyta 2 1Innohep 3 1Innopran XL 2 2Intelence 2 3Intermezzo 3 4+Intron A 2 1Intuniv 3 4Invega 3 4Invirase 2 3Invokamet 3 1Invokana 3 1ipratropium inh 1 5solnipratropium nasal 1 1sprayipratropium 1 5albuterol

irbesartan 1 2irbesartanHCTZ 1 2Iressa 2 1Isentress 2 3isometh 1 4dichloralphenAPAPisoniazid 1 3Isopto Carbachol 2 215Isopto Carbachol 3 3 2isosorbide dinitrate 1 3isosorbide 1 3mononitrateisosorbide 1 3mononitrate SAisoxsuprine 1 3isradipine 1 2Istalol 3 2itraconazole 1 3Izba 3 2

J+Jadenu 3 1+Jakafi 2 1Jalyn 3 13jantoven 1 1Janumet 2 1Janumet XR 2 1Januvia 2 1Jardiance 3 1Jentadueto 3 1jinteli 1 6jolessa 1 6jolivette 1 6Jublia 3 5junelFE 1 6Juvisync 2 1Juxtapid 3 2

KK-Phos 3 1Kadian 3 4Kaletra 2 3+Kalydeco 2 5kariva 1 6Kayexalate 3 5Kazano 3 1Kenalogaerosol 3 5Kerydin 3 5Ketek 2 3ketoconazole 1 35ketoprofen 1 5ketorolac inj 1 5ketorolac tab 1 5ketorolac 1 2tromethamineketotifen opthalmic 3 2solution

Khedezla 3 4+Kineret 3 4+Kitabis Pak 3 3Kombiglyze XR 2 1Korlym 3 4

+Kuvan 2 6+Kynamro 2 2

Llabetalol 1 2lactulose 1 6Lamisil Oral 3 3lamivudine tablets 1 3lamivudine tabs 1 3lamivudine 1 3zidovudinelamotrigine 1 5lamotrigine ER 3 5Lanoxin 2 2lansoprazole 3 6lansoprazoleamox 3 6clarithLantus 2 1latanoprost 1 2Latuda 3 4Lazanda 3 4leflunomide 1 4Lenvima 2 1Lescol 3 2Lescol XL 3 2lessina 1 6+Letairis 2 3letrozole 1 1leucovorin 1 6Leukeran 2 1+Leukine 2 1leuprolide 1 1Levemir 3 1levetiracetam 1 5Levitra 3 3levobunolol 1 2levocarnitine 1 6levocetirizine 1 1levofloxacin 1 3levora 1 6levothroid 1 6levothyroxine 1 6levoxyl 1 6Lexapro 3 4Lexiva 2 3Librium 3 4lidocaine 1 5lidocaine patch 1 5Liletta 3 6Lindane 2 5Linzess 3 6liothyronine 1 6Lipitor 3 2Lipofen 3 2Liptruzet 3 2lisinopril 1 2lisinoprilHCTZ 1 2lithium carbonate 1 4Livalo 3 2Lofibra 3 2loratadine 1 1loratadine-D 1 1lorazepam 1 4losartan 1 2losartanHCTZ 1 2Lotemax 2 2Lotronex 3 6lovastatin 1 2low-ogestrel 1 6loxapine 1 4Lumigan 3 2Lunesta 3 4lutera 1 6Luveris 3 6Luvox CR 3 4Luzu 3 3Lynparza 2 1Lyrica 3 5Lysodren 2 1

MMacrodantin 3 3maprotiline 1 3Matulane 2 1Maxair Autohaler 2 5Maxalt 3 4Maxalt MLT 3 4Maxidex 3 2Maxitrol ophth 3 2meclizine 1 6meclofenamate 1 5Medrol 2mg 2 6medroxyprogesterone 1 6

mefenamic acid 3 5mefloquine 1 3megestrol 1 1+Mekinist 2 1meloxicam 1 5Menest 3 6Menostar 3 6meperidine 1 4mephobarbital 1 5Mephyton 2 6meprobamate 1 4mercaptopurine 1 1mesalamine enema 1 6Mesnex 2 1metadate ER 1 4metaproterenol syr 1 5metaxalone 1 4metformin 1 1metformin ER 1 1metforminglyburide 1 1methadone 1 4methazolamide 1 2methenamine 1 3combinationMethergine 3 6methimazole 1 6methocarbamol 1 4methotrexate 1 14methyclothiazide 1 2methyldopa 1 2methyldopaHCTZ 1 2methylergonovine 1 6maleatemethylphenidate CD 1 4methylphenidateSR 1 4methylprednisolone 1 64mg 8mg 16mg 32mgmetipranolol 1 2metoclopramide 1 6metolazone 1 2metoprolol 1 2metoprolol ER 1 2metoprololHCTZ 1 2Metrogel topical 1 3 5metronidazole 1 3metronidazole cream 1 5lotion 075 gel

Mevacor 3 2mexiletine 1 2Miacalcin inj 2 1Micardis 3 2Micardis HCT 3 2miconazole vag supp 1 6Micro-K 3 5microgestinFE 1 6midodrine 1 23Minitran 3 3Minocin 3 3minocycline 1 3minocycline HCl 1 5minocycline HCl ER 3 5minoxidil oral 1 3Mircera 3 1Mirena 2 6mirtazapine 1 3Mirvaso 3 5misoprostol 1 6Mitigare 3 2modafinil 1 4+moderiba 1 3moexipril 1 2mometasone croint 1 5mononessa 1 6montelukast 1 5morphine SR 1 4morphine sulfate ER 1 4morphine tab soln 1 4supp

Movantik 3 6moxifloxacin 3 3MS Contin 3 4Multaq 3 2multivitamin + 1 6fluoridemupirocin 1 5MUSE 3 3Myalept 3 4Myambutol 3 3mycophenolate 1 3mofetilmycophenolic acid 1 3Myleran 2 1

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

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Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

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9

Myrbetriq 3 1N

nabumetone 1 5nadolol 1 2Naftin 3 5naltrexone 1 4Namenda 2 1Namenda XR 2 1Namzaric 3 1naphazoline 1 2Naprosyn 3 5naproxen 1 5naproxen EC 1 5naratriptan 1 4Nasacort AQ 3 1Nasacort OTC 1 1Nascobal 2 6Nasonex 3 1nateglinide 1 1Natesto 3 3+Natpara 3 4Nebupent 2 3necon 1 6nefazodone 1 3neomycin 1 3neomycinbacitracin 1 2poly Bneomycinbacitracin 1 2poly BHCneomycinpolymyxin 1 1HC oticNeoral 2 3Nesina 3 1Neulasta 2 1+Neumega 3 1+Neupogen 2 1Nevanac 2 2+Nexavar 2 1Nexium 24HR 1 6Nexiumsusp 3 6niacin ER 1 2niacinsimvastatin 1 2nicardipine 1 2Nicorelief gum 1 5Nicorelief lozenge 1 5Nicotine Gum 1 5Nicotine lozenges 1 5Nicotine patches 1 5various

Nicotrol Inhaler 2 5Nicotrol NS 2 5nifediac CC 1 2nifedical XL 1 2nifedipine 1 2nifedipine SR 1 2Nilandron 2 1nimodipine 1 2nisoldipine 1 2NitroDur patches 3 3nitrofurantoin 1 3nitroglycerin 1 3pumpspraynitroglycerin SR 1 3nitroglycerin 1 3transdermal patchNitrostat SL tabs 2 3nizatidine 1 6nora-BE 1 6+Norditropin 2 4norethindrone 1 6norethindrone a-e 1 6estradiol ferrousfumarate

Noritate 3 5Noroxin 3 3NorpaceCR 2 2+Northera 3 2nortrel 1 6nortriptyline 1 3Norvir 2 3Novarel 2 6Novolin 3 1Novolog 3 1Noxafil 3 3NucyntaER 3 4Nulytely 3 6+NutropinAQ 3 4NuvaRing 2 6Nuvigil 3 4Nymalize 3 2nystatin 1 35

nystatin vag tab 1 6nystatin 1 5triamcinolonenystop 1 5

Oocella 1 6+octreotide 1 4+Ofev 2 5ofloxacin 1 3ofloxacin ophth 1 2ofloxacin otic 1 1ogestrel 1 6olanzapine 1 4olanzapine 3 4fluoxetine

Oleptro ER 3 4+Olysio 2 3omega-3 acid ethyl 3 2esters

omeprazole 1 6omeprazolesodium 1 6bicarbonate

Omnaris 3 1+Omnitrope 3 4Omontys 3 1Omtryg 3 2ondansetron 1 6OneTouch 1Onglyza 2 1Onsolis 3 4Opana ER 3 4+Opsumit 3 3Oracea 3 5Oracit 3 1+Oralair 3 1Oramorph SR 3 4Oravig 3 3+Orencia SC 3 4Orenitram 3 3Orfadin 2 6orphenadrine 1 4Ortho Tri-Cyclen Lo 3 6Ortho-Est 3 6Oseni 3 1Osphena 3 6+Otezla 3 4Otrexup 3 4Ovcon-50 3 6Ovidrel 2 6oxaprozin 1 5oxazepam 1 4oxcarbazepine 1 5Oxistat 2 5Oxsoralen Ultra 2 5Oxtellar XR 3 5oxybutynin 1 1oxybutynin ER 1 1oxycodone 1 4Oxycodone ER 3 4oxycodone 1 4acetaminophenoxycodoneaspirin 1 4oxycodoneibuprofen 1 4Oxycontin 3 4oxymorphoneER 1 4Oxytrol 3 1

PPancreaze 3 6Panretin 2 5pantoprazole 1 6Paragard 3 6paregoric 1 6paricalcitol 3 6paromomycin 1 3paroxetine HCl 1 3Pataday 3 2Patanol 3 2PaxilCR 3 4Pazeo 3 2PCE 3 3peg 3350electrolyte 1 6+Peg-Intron 3 3Peganone 3 5+Pegasys 2 3penicillin VK 1 3Pennsaid 3 5Pentasa 3 6pentazocinenaloxone 1 4pentoxifylline 1 1pergolide 3 5perindopril 1 2

permethrin 1 5perphenazine 1 4Pertzye 3 6Pexeva 3 4phenazopyridine 1 1phendimetrazine 1 6phenelzine 1 3Phenergan 3 1phenobarbital 1 5phentermine 1 6phenylephrine ophth 1 2phenytoin 1 5Phisohex 2 5Phospholine Iodide 2 2phytonadione 2 6Picato 2 5pilocarpine 1 2pindolol 1 2pioglitazone 1 1metforminpiroxicam 1 5Plavix 3 1+Plegridy 3 4podofilox 1 5Poly-Vi-Flor + Iron 3 6polymyxin BTMP 1 2+Pomalyst 2 1portia 1 6potassium 1 6aminobenzoatepotassium bicarb 1 5potassium chloridepotassium 1 5bicarbonatepotassium chloride 1 5potassium citrate 1 1Potiga 3 5Pradaxa 3 1pramipexole 1 5pramoxineHC acetate 1 625prascion RA 1 5Pravachol 3 2pravastatin 1 2prazosin 1 2pre-natal vitamins 1 6Precision 1Pred Mild 2 2Pred-G 3 2prednicarbate 1 5prednisolone acetate 1 2prednisolone oral 1 6prednisolone sod 1 2phosphateprednisone oral 1 6Prefest 3 6Pregnyl 3 6Premarin 3 6Premarin vag cream 3 6Premphase 2 6Prempro 2 6Prenate Elite 2 6Prepopik 3 6Prestalia 3 2Prevacid 24HR 1 6Prevacidsusp 3 6previfem 1 6Prezcobix 2 3Prezista 2 3Prilosec 3 6Prilosec-OTC 1 6Primaquine 2 3primidone 1 5Pristiq ER 3 4ProAir HFA 2 5probenecid 1 2procainamide 1 2procentra 1 4prochlorperazine 1 6+Procrit 2 1Proctofoam-HC 3 6Procysbi 3 4Progesterone Powder 2 6progesterone 3 6micronizedPrograf 3 3Prolensa 3 2+Promacta 2 1promethazine 1 16promethazinecodeine 1 1promethazineDM 1 1

promethazine 1 1phenylephrinecodeinepropafenone 1 2propafenone SR 1 2propantheline 1 6bromidepropranolol 1 2propranololHCTZ 1 2propylthiouracil 1 6Proscar 3 3Protonix 3 6Protopic 2 5protriptyline 1 3Proventil HFA 3 5Prozac 3 4pseudoephedrine 1 1pseudoephedrine 1 1codeine

Pulmicort flexhaler 2 5powderPulmicort respules 2 5(1mg2ml)

+Pulmozyme 2 5Purixan 2 1pyrazinamide 1 3

QQnasl 3 1Qsymia 3 6Quartette 3 6quasense 1 6Qudexy XR 3 5quetiapine 1 4Quillivant XR 3 4quinapril 1 2quinaprilHCTZ 1 2quinidine gluconate 1 2quinidine sulfate SR 1 2quinine sulfate 3 3Qvar 2 5

Rrabeprazole 3 6Ragwitek 3 1raloxifene 1 4ramipril 1 2Ranexa 2 3ranitidine (all) 1 6Rapaflo 3 13Rasuvo 3 4Ravicti 3 4Rayos 3 6+Rebetol 3 3+Rebif 2 4Rectiv 3 5Regenecare 3 5Regranex 2 5Relenza 2 3Relistor 3 6Relpax 3 4Renagel 2 6Renvela 2 6repaglinide 1 1Repronex 2 6Rescriptor 2 3Rescula 3 2Restasis 3 2+Revatio 3 3+Revlimid 2 1Reyataz 2 3Rhinocort Aqua 3 1+ribapak 1 3+ribasphere 1 3+Ribatab 3 3+ribavirin 1 3Ridaura 2 4rifabutin 1 3Rifadin 3 3Rifamate 3 3rifampin 1 3Rifater 2 3Rilutek 2 4rimantadine 1 3Riomet solution 3 1risedronate 150mg 3 4Risperdal 3 4risperidone 1 4risperidone m-tab 1 4rivastigmine 1 1rizatriptan 1 4Rondec DMTR 3 1ropinirole 1 5

ropinirole ER 3 5Roxicet solution 3 4Rozerem 3 4+Ruconest 2 3Rytary 3 5

SSabril 3 5+Saizen 3 4salsalate 1 4Samsca 2 3Sanctura 3 1Sanctura XR 3 1Sancuso 3 6Sandimmune 2 3+Sandostatin 3 4+Sandostatin LAR 3 4Saphris 3 4Sarafem 3 4Savaysa 3 1Savella 3 4Saxenda 3 6selegiline 1 5selenium sulf 25 1 5suspensionSelzentry 2 3Semprex-D 2 1+Sensipar 2 4Serevent Diskus 2 5serophene 1 6Seroquel 3 4Seroquel XR 3 4+Serostim 3 4sertraline 1 3sevelamer 1 6Signifor 2 4+sildenafil citrate 1 3Silenor 3 4silver sulfadiazine 1 5+Simponi 3 4simvastatin 1 2sirolimus 1 3Sirturo 3 3Sitavig 3 3Sivextro 2 3Sklice 3 5Skyla 3 6sod polystyrene 1 5sulfonatesod sulfacetamide 1 5sulfur emulsioncleansersod sulfacetamide 1 5sulfur lotsodium chloride 1 5irrigating solnsodium fluoride 1 6chewable tab ampdropssodium sulfacetamide 1 5solia 1 6Solodyn 3 5+Somatuline Depot 3 4+Somavert 3 4Somnote 3 4Sonata 3 4Soolantra 3 5Soriatane CK 2 5sotalol 1 2sotret 1 5+Sovaldi 2 3Spectracef 3 3spinosad 1 5Spiriva 2 5Spiriva Respimat 2 5spironolactone 1 2spironolactoneHCTZ 1 2Sporanox suspension 2 3sprintec 1 6Sprix 3 5+Sprycel 2 1stavudine 1 3Staxyn 3 3+Stelara 3 5Stendra 3 3Stimate 2 4+Stivarga 2 1Strattera 3 4Striant 3 3Stribild 2 3Striverdi Respimat 3 5Suboxone film 2 4

Suboxone tablet 3 4Subsys 3 4Suclear 3 6sucralfate 1 6sulfacetamide 10 1 2sulfacetamide 1 2prednisolone ophthsulfamethoxazole 1 3trimethoprimsulfasalazine 1 6sulfasalazine EC 1 6sulindac 1 5sumatriptan 1 4Sumavel 3 4Suprax 3 3Suprenza ODT 3 6Sustiva 2 3+Sutent 2 1+Sylatron 2 1Symbicort 2 5Symbyax 3 4Symlin 2 1Synarel 2 4+Synribo 2 1Synthroid 2 6

TTaclonex 3 5tacrolimus 1 3+Tafinlar 2 1Tamiflu 2 3tamoxifen 1 1tamsulosin 1 13Tanzeum 3 1+Tarceva 2 1Targiniq ER 3 4Targretin 2 1+Tasigna 2 1Tasmar 3 5Tazorac cream 3 5Tazorac gel 2 5+Tecfidera 2 4Tegretol 2 5Tegretol XR 100mg 3 5Tekamlo 2 2Tekturna 2 3Tekturna HCT 2 2telmisartan 1 2telmisartan 3 2amlodipine

telmisartanHCTZ 1 2temazepam 1 4+Temodar 3 1+temozolamide 1 1terazosin 1 2terbinafine 1 3terbutaline tab 1 5terconazole 1 6Testim 3 3testosterone 1 3cypionate

testosterone 1 3enanthionate

Testosterone gel 3 3tetracycline 1 3+Tev-Tropin 3 4Teveten 3 2Teveten HCT 3 2+Thalomid 2 1Theo-24 2 5theochron 1 5theophyllineSR tabs 1 5liquidthioridazine 1 4thiothixene 1 4thyroid 1 6Thyroid (Armour) 2 6Thyrolar 2 6ticlopidine 1 1Tikosyn 3 2timolol 1 2tinidazole 1 3Tivicay 2 3Tivorbex 3 5tizanidine 1 4+Tobi 3 3Tobradex ointment 2 2+tobramycin ampule 1 3nebtobramycin soln 1 2tobramycindexameth 1 2Tobrex ointment 2 2

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

23

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Tobrex solution 3 2tolazamide 1 1tolbutamide 1 1tolmetin 1 5tolterodine 1 1tolterodine ER 1 1topiramate 1 5torsemide 1 2Toujeo 3 1Toviaz 3 1+Tracleer 2 3Tradjenta 3 1tramadol 1 4tramadol 1 4acetaminopentrandolapril 1 2trandolapril 3 2verapamilTransderm Scop 2 6tranylcypromine 1 3Travatan Z 3 2travoprost 1 2trazodone 1 3tretinoin crgel 1 5tretinoin 3 5microsphere gelTrexall 3 1Treximet 3 4tri-sprintec 1 6Tri-Vi-Flor 3 6triamcinolone 1 5acetonide

triamcinolone 3 1acetonide nasalspraytriamtereneHCTZ 1 2triazolam 1 4Tribenzor 3 2Tricor 3 2trifluoperazine 1 4trifluridine 1 2Triglide 3 2trihexyphenidyl 1 5Trilyte 1 6trimethobenzamide 1 6trimethoprim 1 3trinessa 1 6triprevifem 1 6Triumeq 2 3trivora 1 6Trokendi XR 3 5tropicamide 1 2trospium 1 1trospium ER 1 1TRUEtest 1TRUEtrack 1Trulicity 3 1Truvada 2 3Tudorza 3 5Twinject 2 5Tybost 2 3+Tykerb 2 1Tylenolcodeine 3 4Tyvaso 3 3Tyzeka 3 3

UUceris 3 6Ulesfia 2 5Uloric 3 2UltramER 3 4Ultresa 3 6unithroid 1 6Urecholine 3 1Uroxatral 3 13ursodiol 1 6

VVagifem 3 6valacyclovir 1 3Valchlor 2 1Valcyte 3 3valganciclovir 1 3tabletsvalproic acid 1 5valsartan 1 2valsartanHCTZ 1 2Valtrex 3 3Valturna 3 2Vancocin 3 3vancomycin caps 1 3vandazole vag 1 6Vascepa 3 2Veletri 3 3velivet 1 6Velphoro 3 6Veltin gel 3 5venlafaxine 1 3venlafaxine ER 1 3Ventavis 3 3

Ventolin HFA 3 5Veramyst 3 1verapamil 1 2verapamil SR 1 2Versacloz 3 4Vesicare 3 1Viagra 3 3Vibramycin 3 3VicodinES 3 4Victoza 2 1+Victrelis 2 3Videx 2 3+Viekira 2 3Vigamox 2 2Viibryd 3 4Vimovo 3 5Vimpat 3 5Viokace 3 6Viracept 2 3Viramune XR 2 3Viread 2 3vit ADC + fluoride 1 6vit ADC + fluoride 1 6and ironVitekta 2 3Vituz 3 1Vivaglobin 3 4Vivelle-DOT 3 6Vogelxo 3 3Voltaren Gel 2 5voriconazole 1 3+Votrient 2 1Vytorin 3 2Vyvanse 3 4

Wwarfarin 1 1Welchol 3 2

XXalatan 3 2+Xalkori 2 1Xarelto 3 1Xartemis XR 3 4+Xeljanz 3 4+Xenazine 3 3Xenical 3 6Xifaxan 3 3Xigduo XR 3 1Xopenex HFA 3 5+Xtandi 2 1Xtoro 3 1xulane 1 6

Yyohimbine 1 3

ZZaditor 3 2zafirlukast 1 5zaleplon 1 4zarah 1 6Zavesca 2 4Zecuity 3 4Zegerid 3 6+Zelboraf 2 1zenchent 1 6Zenpep 2 6Zetia 3 2Zetonna 3 1Ziagen 2 3

Ziana gel 3 5zidovudine 1 3Zioptan 3 2ziprasidone caps 1 4Zmax 2 3Zocor 3 2Zohydro ER 3 4+Zolinza 2 1zolmitriptan 1 4Zoloft 3 4zolpidem 1 4zolpidem ER 1 4Zolpimist 3 4Zomig 3 4Zomig Nasal 3 4Zomig ZMT 3 4zonisamide 1 5Zontivity 3 1+Zorbtive 3 4Zorvolex 3 5zovia 1 6Zovirax Cream 2 5Zubsolv 3 4Zuplenz 3 6Zyban 3 5Zydelig 2 1ZyfloCR 3 5+Zykadia 2 1Zylet 3 2Zyprexa 3 4Zyprexa Zydis 3 4+Zytiga 2 1Zyvox 2 3

SEcTIoN II mdash INdEx (coNTrsquod)

DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE

= A step edit applies to this drug = Specific Quantity Limits Apply = Prior Authorization Required = Included in Tablet-Splitting Program+ = Access restricted to specialty pharmacy

Please note that medications listed in the 3rd tier are considered non-formulary and are not all-inclusive

All branded self-injectables are subject to prior authorization Some drugs are limited to 1 unit of use package per dispensing

KEY Note 1

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