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Cleveland Clinic

Cleveland ClinicRetiree Health PlanPrescription Drug Benefitand Formulary Handbook

Calendar Year 2016

Your Guide toQuality Healthcare Services

and Healthier LivingWelcome to the Cleveland Clinic Retiree Health Plan, hereafter referred to asthe “Health Benefit Program” (HBP) Prescription Drug Benefit Program. As aCleveland Clinic or Regional hospital retiree, you have access to a comprehensiveprescription drug benefit. To help you understand the benefits available to youunder this program, the HBP has developed this Prescription Drug Benefit andFormulary Handbook (hereafter referred to as the Handbook). This Handbook isupdated as needed.

This Handbook defines your prescription drug coverage. We encourage you to takethe time to read this information carefully. You may wish to consider taking thisHandbook with you when you visit your healthcare provider(s) to aid in the selectionof effective, safe, and value-based prescription drug therapy. This information is alsoavailable on the Cleveland Clinic website at www.clevelandclinic.org/healthplan.

You will find helpful information about:

• Where you can get your prescriptions filled;

• The HBP Prescription Drug Formulary;

• Prior Authorization and Formulary Exception Program;

• Quantity Limit and Step Therapy Programs; and

• The Specialty Drug Program

Adherence to your prescribed drug therapy plan is critical to improving yourquality of life and decreasing your out-of-pocket expenses in the long run. TheHBP looks forward to assisting you with your prescription drug benefit needs.

Note to SilverScript Members: This Handbook is for both Medicare eligible andapproved and non-Medicare retirees. The section for SilverScript members(retirees who are Medicare eligible) includes abbreviated administrativeinformation specifically for SilverScript. More detailed information can befound in your “Evidence of Coverage” sent to you by SilverScript.

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Table of ContentsCLEVELAND CLINIC HBP PRESCRIPTION DRUG BENEFITPrescription Drug Benefit Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Prescription Drug Benefit Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Non-Medicare HBP Prescription Drug Benefit Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Medicare Eligible and Approved HBP Prescription Drug Benefit Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Prescription Drug Benefit Program Overview (continued)

Understanding the Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Filling Your Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Cleveland Clinic Pharmacies and Specialty/Home Delivery Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Cleveland Clinic Pharmacies — Locations and Hours of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Cleveland Clinic Home Delivery Pharmacy Ordering Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Processing Form Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Advantages of Utilizing the Cleveland Clinic Pharmacies and Home Delivery Pharmacy . . . . . . . . . . . . . . . . . . . . . . 8

CVS/caremark or SilverScript Retail Pharmacy Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CVS/caremark or SilverScript Mail Service Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8New Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Mail Service Refills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Prescription Drug Benefit Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Prescription Drug Benefit — Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

HEALTH BENEFIT PROGRAM PRESCRIPTION DRUG BENEFIT FORNON-MEDICARE ELIGIBLE RETIREES (Administered by CVS/caremark)Generic Medication Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Pharmaceuticals Requiring Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Formulary Failure Review Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Instructions for a Physician on How to Complete thePrior Authorization, Formulary Exception and Appeal Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Prior Authorization, Formulary Exception and Appeal Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Benefits and Coverage Clarification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Breast Cancer Prevention Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Contraceptive Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Oral Medications for Onychomycosis (Nail Fungus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Over-The-Counter (OTC) Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Non-Covered Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Brand Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Brand and Generic Versions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Sharps Container Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Pharmacy Coordination Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Mandatory Maintenance Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Medications Limited by Provider Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Quantity Level Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Split Fill Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Mandatory Statin Cost Reduction Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Tablet Splitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Generic Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Step Therapy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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HEALTH BENEFIT PROGRAM PRESCRIPTION DRUG BENEFIT FORNON-MEDICARE ELIGIBLE RETIREES (Administered by CVS/caremark) (continued)

Specialty Drug Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Prescription Drug Benefit Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

HEALTH BENEFIT PROGRAMDRUG FORMULARY FOR NON-MEDICARE ELIGIBLEPrescription Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Important Points About the Cleveland Clinic HBP Drug Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Drug Formulary Medications by Category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Drug Formulary Medications Alphabetically . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

HEALTH BENEFIT PROGRAM PRESCRIPTION DRUG BENEFIT FORMEDICARE ELIGIBLE RETIREES AND APPROVED RETIREES(Administered by SilverScript Insurance Company)Generic Medication Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Prior Authorizations/CoverageDecisions/Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Appointing a Representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Coverage Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Initial Coverage Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Coverage Gap Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Castrophic Coverage Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Request for Redetermination of Medicare Prescription Drug Denial (Appeal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Redetermination of Medicare Prescription Drug Denial Form Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Benefits and Coverage Clarification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Contraceptive Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Sharps Container Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Quantity Level Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Prescription Drug Benefit Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

FORMSPrior Authorization, Formulary Exception and Appeal Form (Non-Medicare) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Medicare Part D Coverage Determination Request Form (Medicare Eligible and Approved) . . . . . . . . . . . . . . . . . . . . . 49

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Cleveland Clinic Health Benefit ProgramPrescription Drug Benefit

Prescription Drug Benefit AdministrationThe HBP Prescription Drug Benefit is administered through CVS/caremark™ under the guidance of thePharmacy Coordination Department and is divided into two groups: Non-Medicare eligible and Medicareeligible and approved retirees.

Both CVS/caremark and SilverScript have dedicated toll-free Customer Service phone numbers, e-mail,or website addresses available 24 hours a day, seven days a week:

CVS/caremark SilverScript® Insurance Company866.804.5876 866.693.4617

E-mail: [email protected] Website: https://clevelandclinic.silverscript.com

If your CVS/caremark/SilverScript Prescription card is lost or stolen, contact CVS/caremark/SilverScriptat the phone number or e-mail address listed above for a replacement card.

Members can also go to both the applicable websites for the following:• Prescription Refills for CVS/caremark Mail Service• Order Status• Pharmacy Locations• Benefit Coverage• Request Forms• Frequently Asked Questions• 13 Month Drug History• Additional Health Information

When you call CVS/caremark or visit their website, please have the following information available:• Member’s ID Number• Member’s Date of Birth• Payment Method

Prescription Drug Benefit Program OverviewThe HBP Prescription Drug Benefit charts on pages 2 and 3 of this Handbook summarize drug categoriessuch as generic, preferred, non-preferred, and specialty drugs, as well as deductible and out-of- pocketmaximum information. Use this Handbook as a resource for information regarding:• Options for filling your prescription medications;• The HBP Prescription Drug Benefit guidelines;• Benefits coverage and clarification;• Pharmacy Coordination programs; and• The HBP Prescription Formulary (non-Medicare members). SilverScript members have a different formulary

which is mailed under separate cover by SilverScript. Both formularies are also available on our websiteat www.clevelandclinic.org/healthplan.

Note: In addition to this Handbook, SilverScript members receive an “Evidence of Coverage” handbook whichincludes more detailed information relative to SilverScript’s coverage.

1

CVS/caremark is a trademark of CVS Health Corp.SilverScript is a registered trademake of SliverScript Insurance Company.

2

Non-Medicare HBP Prescription Drug BenefitAdministered Through CVS/caremarkThe Following Is a Summary Overview of the Prescription Drug Benefit for 2016

Tier 1 Tier 2 Tier 3 Tier 4Non-Preferred Specialty Drugs & Items Non-

Preferred Brands Drugs at Discounted Covered DrugsCategories Generic Rx Brands (Non-Formulary) (Hi-Tech) Rate & ItemsAnnual Deductible $100 Individual No No$300 FamilyEmployee % Co-ins. 15% 25% 45% 20% Employee Pays Not AvailableCleveland Clinic 100% of the throughPharmacies : Discounted Price Rx Planup to 90-Day Supply

Employee % Co-ins. 20% 30% 50% 20% Employee Pays Not AvailableCVS/caremark Retail — 100% of the through30-Day Supply Discounted Price Rx Plan

Mail Service Program —90-Day Supply

Cleveland Clinic Yes Yes No Yes No NoPharmacies including $3 Minimum/ $3 Minimum/ No Minimum/Specialty & Home Delivery: $50 Maximum $50 Maximum $50 MaximumIs there a Min. or Max. per Month Supply per Month Supply per Month Supplyto the Rx % Co-ins.?Retail Pharmacies: Yes Yes No NA No NoIs there a Minimum or $5 Minimum/ $5 Minimum/Maximum to the Rx % $50 Maximum $50 MaximumCo-insurance? per Month Supply per Month SupplyCVS/caremark Mail Yes Yes No Yes No No Service Program: $15 Minimum/ $15 Minimum/ No Minimum/Is there a Minimum or $150 Maximum $150 Maximum $100 MaximumMaximum to the Rx % 90-Day Supply 90-Day Supply per Month SupplyCo-insurance?Is there an Annual No No No No No NoOut-of-pocket Maximum?Components of Generic Drugs Brand Name DrugsEach Category See page 14

Prior Authorization See page 10 for List of No NARequired Pharmaceuticals Requiring Prior AuthorizationDiabetic Supplies2, Co-insurance 20% No No NAAsthma Delivery Devices2

and Prescription Vitamins3

Major Chains4 ACME, Cleveland Clinic Pharmacies, Costco, CVS, Discount Drug Mart, Giant Eagle,in the Retail Network K-Mart, Marc’s, Medicine Shoppe, Rite Aid, Target, Walgreens, Wal-Mart,

plus other chains and independent pharmacies.Note: Benefit Program Includes: generic oral contraceptives — covered for Marymount HBP participants for clinical appropriateness only under the HBP.1There are 3 options for obtaining medications in the category listed above. The options are: 1. Cleveland Clinic Pharmacies in Cleveland and Cleveland Clinic Weston Pharmacy,2. Cleveland Clinic Specialty Pharmacy, and 3. CVS/caremark Specialty Drug Program. Specialty Drug prescription orders (first fill and refills) are limited to a one month supply.

2Diabetic Supplies — Insulin and all diabetic supplies covered. Includes: needles purchased separately, test strips, lancets, glucose meters, syringes, lancing devices, and injection pens.Asthma Delivery Devices — Includes spacers used with asthma inhalers.

3Refers to vitamins that require a prescription from your healthcare provider. 4Members can utilize the CVS/caremark Retail Pharmacy Network for obtaining acute care prescriptions (e.g., single course of antibiotic therapy) and for the first fill of maintenance medications butmust use a Cleveland Clinic Pharmacy or CVS/caremark Mail Service Program for all maintenance medications.

*Specialty Drugs1

See complete list ofSpecialty Drugs

on pages20 and 21.

Life Style DrugsActiclateBenzoyl Peroxide Only AgentsCaverjectCialisCosmetic AgentsDenavir CreamDoryxEdexEvzioFertility AgentsHysinglaJubliaLevitraMuseNon-controlled Cough andCold Agents

Oral Allergy MedicationPenlacPropeciaRelenzaSaxendaStendraTamifluTestosterone CypionateTestosterone EnanthateTopical Androgen ProductsViagraWeight Control ProductsXartemus XRXereseZipsorZorvolexZovirax CreamZovirax Ointment

Over-the-Counter DrugsAlcohol SwabsDME (DurableMedical Equipment)

Medical DevicesMedical Supplies

Prescription DrugsBrand and Generic Brandversions of:Adoxa, Binosto, Beleodaq,Belsomra, Cyramza,Diclegis, Keytruda,Liptruzet, Monodox, Onmel,Opdivo, Oracea, Oxytrol,Solodyn, Xopenex (notcovered for member over18 years of age.)

Contraceptive CoverageSee page 13.

Proton Pump Inhibitors(Brand Name Products)

Certain OTCMedicationsare covered.See page 14.

Waived for generic prescriptions if obtained)(from a Cleveland Clinic Pharmacy

The current RHP SPDand Drug Formulary

can be found atwww.clevelandclinic.org

and click onPlan Offerings.

3

Medicare Eligible and Approved HBP Prescription Drug BenefitAdministered Through SilverScript®

The Following Is a Summary Overview of the Prescription Drug Benefit for 2016

Tier 1 Tier 2 Tier 3 Tier 4Preferred Non-Preferred SpecialtyBrands Brands Drugs

Categories Generic Rx (Formulary) (Non-Formulary) (Hi-Tech)

Annual Deductible $100 Individual (Waived for generic prescriptions if obtained from a Cleveland Clinic Pharmacy)Member % Co-insurance 15% 25% 45% 20%Cleveland Clinic Pharmacies :Outpatient — up to 90-Day Supply

Specialty & Home Delivery —up to 90-Day Supply

Member % Co-insurance 20% 30% 50% 20%CVS/caremark Retail —up to 90-Day Supply

Mail Service Program —up to 90-Day Supply

Cleveland Clinic Pharmacies Yes Yes No Yesincluding Specialty & Home Delivery: $3 Minimum/ $3 Minimum/ No Minimum/Is there a Minimum or Maximum $50 Maximum $50 Maximum $50 Maximumto the Rx % Co-insurance? per 30-Day Supply per 30-Day Supply per Month SupplyCVS/caremark Yes Yes No N/ARetail up to 90-Day Supply: $5 Minimum/ $5 Minimum/Is there a Minimum or Maximum $75 Maximum $75 Maximumto the Rx % Co-insurance? per 30-Day Supply per 30-Day SupplyCVS/caremark Yes Yes No YesMail Service Program: $15 Minimum/ $15 Minimum/ No Minimum/Is there a Minimum or Maximum $225 Maximum $225 Maximum $100 Maximumto the Rx % Co-insurance? 90-Day Supply 90-Day Supply per Month SupplyIs there an Annual No No No NoOut-of-Pocket Maximum?Components of Each Category Generic Drugs Brand Drugs Specialty Drugs

Major Chains ACME, Cleveland Clinic Pharmacies, Costco, CVS, Discount Drug Mart,in the Retail Network Giant Eagle, K-Mart, Marc’s, Medicine Shoppe, Rite Aid, Target, Walgreens, Wal-Mart,

plus other chains and independent pharmacies.Note: Diabetic Supplies — Insulin and all diabetic supplies covered. Includes: needles purchased separately, test strips, lancets, glucose me-

ters, syringes and injection pens.Asthma Delivery Devices — Includes spacers used with asthma inhalers.

See pages 49 to 51 for SilverScript’s Request for Medicare Prescription Drug Coverage Determinaton for Prior Authorization

You will be sent a copy of the SilverScript’s Preferred Drug List.You may also contact SilverScript to request a copy of the Preferred Drug List

by calling the toll-free number on your SilverScript card.Medicare Part B vs. Medicare Part D

Please note: Most medications are covered under Medicare Part D, but there are some medicationsthat can be covered under both Medicare Part B (i.e., the Medicare outpatient benefit) or MedicarePart D (i.e., the Medicare prescription drug benefit) depending on what the drug is used for andhow it is administered. Please consult the SilverScript Prescription Drug Formulary or contactSilverScript using the toll-free phone number on the back of your SilverScript card for moreinformation regarding Medicare Part B vs. Medicare Part D medications.

Understanding the FormularyThe medications included in this Handbook5 are chosen by a group of healthcare professionals knownas the Pharmacy and Therapeutics (P&T) Committee. This Committee reviews and selects FDA-approvedprescription medications for inclusion in the Formulary based on the drug’s safety, effectiveness, qualityand cost to the benefit program. All medications that have been reviewed but not added to the Formularyor that have not yet been reviewed by the P&T Committee are considered Non-Formulary.5 The Formulary included in this Handbook does not pertain to SilverScript members. SilverScript sends

a formulary separately to their subscribers. The SilverScript Formulary is also available on the EHPwebsite at www.clevelandclinic.org/healthplan. Click on the “Retirees” tab.

Take your respective formulary with you to all doctor appointments. You are encouraged to share this withyour physician when he or she is prescribing your medication to help ensure the most appropriate prescriptiondrug therapy for your needs. Appropriate and cost-effective use of pharmaceutical therapies can be key to asuccessful strategy for improving individual patient outcomes and containing healthcare costs. The Handbookwill assist with both of these goals — maintaining the quality of patient care while helping to keep the costof prescription medications affordable.

The P&T Committee reviews and updates the Formulary throughout the year. Medications may be added to orremoved from the Formulary during the year. Cleveland Clinic Health Benefit Program may add medicationsto the Formulary four times a year. Medications may be removed from the Formulary twice a year, once atthe start of the benefit year in January and again at mid-year in July.

Two resources are available to assist you with determining if the drug prescribed for you is covered under yourprogram (another reason why you should take the Handbook with you each time you visit your doctor).The two resources are: this Cleveland Clinic Health Benefit Program Prescription Drug Benefit and FormularyHandbook and our website. The website version of the Formulary is updated on a regular basis and containsthe most current information regarding the Formulary. You can access this website by logging intowww.clevelandclinic.org/healthplan. The listing of a drug in the Formulary does not guarantee coverageif your contract does not cover that category of drugs (e.g., oral contraceptives, infertility agents).

Filling Your PrescriptionsThrough your Prescription Drug Benefit you have five options for filling your prescription medications.The five options described on the following pages include the Cleveland Clinic Pharmacies; ClevelandClinic Specialty Pharmacy; Cleveland Clinic Home Delivery Pharmacy; the CVS/caremark Retail PharmacyNetwork; and the CVS/caremark Mail Service Program.

Cleveland Clinic Pharmacies and Home Delivery PharmacyHBP members receive a lower percentage co-insurance for their prescriptions by using Cleveland ClinicPharmacies in Cleveland and Weston (Option 1), or the Specialty/Home Delivery Pharmacy (Option 2).In addition, a deductible will not be charged for prescriptions filled at these pharmacies with a genericmedication. Call the pharmacy hotline at 216.445.MEDS (6337) for answers to your questions and to obtainpharmacist consultation services. You may receive up to a 90-day supply of medication at any of the ClevelandClinic Pharmacies.

Note: By law, the Cleveland Clinic Pharmacies must fill your prescription for the exact quantity of medicationprescribed by your doctor, per the 90-day benefit program limit. For example, a prescription writtenfor a 30-day supply plus two refills does not equal one prescription written for a 90-day supply.

You may pick up your prescriptions at any of the locations listed below or you can have your prescription(s)mailed to your home by using the Cleveland Clinic Specialty or Home Delivery Pharmacy. There is a turn-around time of up to ten business days for all home delivery pharmacy orders. Please Note: You cannotdrop off or pick up prescription orders at the Cleveland Clinic Specialty or Home Delivery Pharmacy. Seepage 6 for details.

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Cleveland Clinic Pharmacies — Locations and Hours of Operation• Cleveland Clinic Pharmacies On Main Campus:

– Euclid Avenue Pharmacy (Parking Garage) . . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.445.6015Toll-free: 866.650.MEDS (6337)Direct Dial: 216.636.0760Monday–Friday, 8 a.m.–8 p.m., Saturday, Sunday and all Cleveland ClinicHolidays, 9 a.m.–5 p.m.

– Crile Pharmacy (A Building) . . . . . . . . . . . . . . . . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.445.7403Toll-free: 866.650.MEDS (6337)Direct Dial: 216.636.0761Monday–Friday, 8 a.m.–6 p.m.

– Childrens Hospital and Surgical Pharmacy (P Building) . . 216.445.MEDS (6337), Fax: 216.444.9514– . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)

Direct Dial: 216.636.0762Monday–Friday, 9 a.m.–5 p.m.

– Taussig Cancer Center (R Building) . . . . . . . . . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.445.2172Toll-free: 866.650.MEDS (6337)Direct Dial: 216.636.0763Monday–Friday, 8 a.m.–6 p.m.

• Cleveland Clinic Family Health Centers:– Beachwood Family Health Center Pharmacy . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.839.3271– 26900 Cedar Road, Beachwood, OH 44122 . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)


– Independence Ambulatory Pharmacy . . . . . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)– 5001 Rockside Road, Independence, OH 44131 . . . . . . . Direct Dial: 216.986.4610

Monday–Friday, 9 a.m.–5 p.m.

– North Coast Cancer Care Ambulatory Pharmacy . . . . . . Toll-free: 866.650.MEDS (6337)– 417 Quarry Lakes Drive, Sandusky, OH 44870 . . . . . . . . . Fax: 419.609.2869


– Richard E. Jacobs Family Health Center Pharmacy . . . . 216.445.MEDS (6337), Fax: 440.965.4109– 33100 Cleveland Clinic Boulevard, Avon, OH 44011 . . . Toll-free: 866.650.MEDS (6337)


– Stephanie Tubbs Jones Health Center Pharmacy . . . . . . . 216.445.MEDS (6337), Fax: 216.767.4128– 13944 Euclid Avenue, East Cleveland, OH 44112 . . . . . . Toll-free: 866.650.MEDS (6337)


– Strongsville Family Health Center Pharmacy . . . . . . . . . 216.445.MEDS (6337), Fax: 440.878.3148– 16761 Southpark Center, Strongsville, OH 44136 . . . . . . Toll-free: 866.650.MEDS (6337)


– Twinsburg Family Health Center Pharmacy . . . . . . . . . . 216.445.MEDS (6337), Fax: 330.888.4105– 8701 Darrow Road, Twinsburg, OH 44087 . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)


– Willoughby Hills Family Health Center Pharmacy . . . . . 216.445.MEDS (6337), Fax: 440.516.8629– 2570 SOM Center Road, Willoughby, OH 44094 . . . . . . . Toll-free: 866.650.MEDS (6337)


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• Cleveland Clinic Regional Hospital Locations:– Lutheran Hospital Ambulatory Pharmacy . . . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.696.7490– 1730 West 25th Street, Cleveland, OH 44113 . . . . . . . . . . Toll-free: 866.650.MEDS (6337)


– Mansfield Cancer Center Ambulatory Pharmacy . . . . . . 216.445.MEDS (6337), Fax: 419.774.3140– 1125 Aspira Court, Mansfield, OH 44906 . . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)


– Medina Hospital Ambulatory Pharmacy . . . . . . . . . . . . . 216.445.MEDS (6337), Fax: 330.721.5495– 1000 East Washington Street, Medina, OH 44256 . . . . . Toll-free: 866.650.MEDS (6337)


– Fairview Hospital Health Center Pharmacy . . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.476.9905– 18099 Lorain Road, Cleveland, OH 44111 . . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)


– Marymount Family Pharmacy . . . . . . . . . . . . . . . . . . . . . . . 216.445.MEDS (6337), Fax: 216.587.8844– 12000 McCracken Road, Suite 151 . . . . . . . . . . . . . . . . . . . Toll-free: 866.650.MEDS (6337)– Garfield Heights, OH 44125 . . . . . . . . . . . . . . . . . . . . . . . . . Direct Dial: 216.587.8822 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Monday–Friday, 8 a.m.–6 p.m.

– Cleveland Clinic Florida Ambulatory Pharmacy . . . . . . . 954.659.MEDS (6337), Fax: 954.659.6338– 2950 Cleveland Clinic Blvd., Weston, FL 33331 . . . . . . . . Toll-free: 866.2WESTON (293.7866)

Direct Dial: 954.659.6337Monday-Friday, 8 a.m.–7 p.m.

• Cleveland Clinic Specialty Pharmacy:– Cleveland Clinic Specialty Pharmacy . . . . . . . . . . . . . . . . Direct Dial: 216.448.7732, Fax: 216.448.5601

Toll-free: 844.216.7732, Fax: 844.337.3209• Free Shipping Mail Order by Cleveland Clinic:

– Cleveland Clinic Home Delivery Pharmacy . . . . . . . . . . . Direct Dial: 216.448.4200, Fax: 216.448.5603Toll-free: 855.276.0885

Cleveland Clinic Home Delivery Pharmacy Ordering InstructionsThe Home Delivery Pharmacy is designed to ship medication directly to your home with no shipping charge.By using the Home Delivery Pharmacy, members receive a lower percentage co-insurance for their medicationscompared to the CVS/caremark Retail Pharmacy Network and can enjoy the convenience of having 90-daysupplies of their maintenance medications delivered directly to their home. Here’s how you can get started:

1. Go to the MyRefills website at https://myrefills.clevelandclinic.net to set up your account, change your billinginformation and shipping address, or to check on the status of your order.

You may also set up your account by completing a Home Delivery Service Processing Form. You can call theHome Delivery Pharmacy at 216.448.4200 or toll-free at 855.276.0855 to have this form mailed or faxedto you. The form is also available on the EHP website at www.clevelandclinic.org/healthplan. Click on the“forms” tab. Fill out a Home Delivery Service Processing Form to indicate payment and shipping informationfor you and your dependents. This information will be kept on file to avoid filling out a form every timeyou place a prescription order.

Note: You will have to set up your Home Delivery account before the Home Delivery Pharmacy can processand ship your order. In addition, each member that wishes to use the Home Delivery Pharmacy needsa separate account.

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2. The Home Delivery Pharmacy receives prescription orders in the following ways:• Called in by your physician to 855.276.0885• Faxed in by your physician to 216.448.5603• e-Scripted by your physician via EPIC (CCF Home Delivery Pharmacy)• Requested online through https://myrefills.clevelandclinic.net• If you have a hard copy of a new prescription, by law, you cannot fax the prescription to the Home

Delivery Pharmacy. Please mail the prescription to:Cleveland Clinic Home Delivery Pharmacy9500 Euclid Ave AC5b-137Cleveland, OH 44195Phone: 216.448.4200Fax: 216.448.5603

• If you are transferring a prescription from a pharmacy other than a Cleveland Clinic Pharmacy, pleasecontact the Home Delivery Pharmacy at 216.448.4200 for assistance.Please note: Members cannot drop off or pick up their orders at the Home Delivery Pharmacy. Orderswill be shipped free of charge to the address you designate.

The Cleveland Clinic Home Delivery Pharmacy is available Monday–Friday from 7:00 a.m. to 6:00 p.m.Please allow ten business days from the time they receive your prescription order(s) for delivery.

Please note: Eligibility is based upon the date the Home Delivery Pharmacy processes your prescriptionorder and not on the day your order was received.

Please call 216.448.4200 for questions or additional information on the Cleveland Clinic Home Delivery Service.

Processing Form

Cleveland Clinic Pharmacies / Home Delivery Service:Processing Form

Date: ___________________ /______ /______ E-mail: _________________________________________________

Patient Name: ___________________________________________ Patient Medical Record No.: _______________________________

Patient Date of Birth: ______ /______ /______ Prescription Insurance: ___________________________________

Contact Phone No.:________________________________ _______________________________________________________

Alternate Phone No.: ________________________________ _______________________________________________________

Primary Shipping Address: Patient Address:

Street: __________________________________________________ Street: __________________________________________________

City/State/Zip: ____________________________________________ City/State/Zip: ____________________________________________

List prescriptions being filled (name or Rx number): *If these are prescriptions from another pharmacy, please indicatethe following:

1. ___________________________________________________Name and Phone No. of Pharmacy:

2. ___________________________________________________ _______________________________________________________

3. ___________________________________________________ ______________________________________________________

4. ___________________________________________________ Rx Number(s) or Name(s) of Medications:

5. ___________________________________________________ _____________________________________________________

6. ___________________________________________________ _____________________________________________________

Is Generic OK? ❑ Yes ❑ No, Brand Name is requested. ______________________________________________________

Drug Allergies (Please list): _______________________________________________________________________________________

Payment Method: At what amount would you like us to contact you before processing your order? $________________

Employee Only:Employee Name: ______________________________________ Prescription Insurane ID No.: _________________________

Employee ID Badge No. (Required): ______________________ Badge Encoded No.: _______ (6-digit number on back of ID badge)❏ Payroll Deduction — I understand that my badge is the property of the Cleveland Clinic Foundation and must be returned to the

ID Badge Department upon termination of employment or upon request by the Cleveland Clinic Foundation. I further understandthat I will be responsible for all charges made with this badge and I hereby authorize those charges to be deducted from mypaycheck. Charges made during a payroll period will be reflected as “Pharmacy” on the corresponding paycheck stub. Furthermore,I agree to protect this badge from unauthorized use and to pay Cleveland Clinic Pharmacies any outstanding balance upontermination of my employment or withdrawal from this program. I recognize that any unauthorized and/or illegal use of any badgeis classified as a major infraction and will be grounds for disciplinary action in accordance with CCF Policy 121.

I have read the above information and agree to all of the above and authorize use of payroll deduction for the entire amount due.

Employee Signature: _________________________________________ Date: _____ /_____ /_____

Note: Any amount of $0-$49.99 will be deducted in one-pay cycle. Any amount of $50 or more will be deducted over six-pay cycles.

At what amount would you like us to contact you before processing your order? $ _____________

Phone: 216.448.4200 • Fax: 216-448-5603 Mail to: Cleveland Clinic Home Delivery PharmacyToll-free: 855.276.0885 9500 Euclid Avenue AC5b-137Website: www.clevelandclinic.org/pharmacy Cleveland, OH 44195MyRefills: myrefills.clevelandclinic.net

All hard copy prescriptions must be mailed with this formHome Delivery turnaround time is ten business days from receipt of this form and your prescription(s)

For faster service of your refills, please call 216.445.MEDS (6337) or 866.650.6337 to use our automated refill system.*Note: Prescriptions transferred from a retail pharmacy can only be filled for a 30-day supply.*Note: If you would like to order a 90-day supply, have your physician call in or write a new prescription to be filled for a 90-day supply.

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❏ FSA Card (PayFlex): Please also indicate an alternate form ofpayment should there be an insufficient balance. If PayFlex isyour primary choice for payment, we will need a credit card toprocess any balance in excess of the PayFlex card.

FSA Card No.: __________________________________________

Expiration Date: ___________________________

Signature: _____________________________________________

❏ Credit Card (Visa/Mastercard/Discover/AMEX)

Credit Card No.: ________________________________________

Expiration Date: ___________________________

Signature: _____________________________________________

Cleveland ClinicPharmacy

SAMPLE

Advantages of Utilizing theCleveland Clinic Pharmacies and Home Delivery Pharmacy• Lower cost: You will pay less for prescription co-insurance. In addition, your deductible will be waived

for prescriptions filled with a generic medication at these pharmacies.

• Convenience: You may request a 90-day supply of medications at any Cleveland Clinic Pharmacy or theHome Delivery Pharmacy.

Note: The prescription must be written for a 90-day supply.

• Peace of mind: You will have access to a toll-free hotline number for questions and pharmacist consultationservices during regular business hours.

CVS/caremark or SilverScript Retail Pharmacy NetworkRetiree members have the option of obtaining their prescriptions at a neighbor hood pharmacy. Please see thePrescription Drug Benefit charts on pages 2 and 3 for major pharmacy chains included in both pharmacy networks.Both networks include over 67,000 participating pharmacies nationwide. A complete list of these pharmaciescan be found on the CVS/caremark website at www.caremark.com or https://cleveland clinic.silverscript.com(for Medicare eligible and approved members).

Note: If you choose to use a pharmacy within the CVS/caremark/SilverScript Retail Pharmacy Networks, yourco-insurance is higher as compared to obtaining your prescription(s) from a Cleveland Clinic Pharmacy.

CVS/caremark or SilverScript Mail Service ProgramNew PrescriptionsCVS/caremark’s Mail Service Program provides a way for you to order up to a 90-day supply of maintenanceor long-term medication for direct delivery to your home. Follow this easy step-by-step ordering procedure:

1. For new maintenance medications, ask your doctor to write two prescriptions:• One, for up to a 90-day5 supply plus refills, to be ordered through the Mail Service Program; and• A second, to be filled immediately at any Cleveland Clinic Pharmacy or CVS/caremark/SilverScript par-

ticipating retail pharmacy for use until you receive your prescription from the Mail Service Program.

2. Complete a Mail Service Order Form and send it to CVS/caremark, along with your original prescription(s)and the appropriate payment for each prescription. Be sure to include your original prescription, not aphotocopy. Forms are available on CVS/caremark’s website at www.caremark.com or SilverScript’s websiteat https://cleveland clinic.silverscript.com.• You can expect to receive your prescription approximately 14 calendar days after CVS/caremark receives

your order.• You will receive a new Mail Service Order Form and pre-addressed envelope with each shipment.

Mail Service RefillsOnce you have processed a prescription through CVS/caremark, you can obtain refills using the Internet,phone or mail. Please order your prescription three weeks in advance of your current prescription runningout. Suggested refill dates will be included on the prescription label you receive from CVS/caremark. Youwill receive specific instructions related to refills from CVS/caremark.

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5 By law, CVS Caremark must fill your prescription for the exact quantity of medication prescribed by your doctor,up to the 90-day benefit program limit. For example, a prescription written for a 30-day supply plus two refillsdoes not equal one prescription written for a 90-day supply.

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Prescription Drug Benefit GuidelinesPrescription Drug Benefit — Deductible The Prescription Drug Benefit has an annual deductible of $100 per individual.Note: Prescriptions filled through the Cleveland Clinic Pharmacies and Home Delivery Pharmacy with

generic medications are not subject to the deductible. Members will still pay the deductible whenthey purchase all brand name and generic medications at other pharmacies.

The amount you have contributed to your annual deductible resets to $0 at midnight on December 31 eachyear. It is not based on a rolling 365 days.

DeductibleNot all pharmacy charges apply toward the deductible. The total charges for medications not covered by thebenefit program (e.g., Viagra, Levitra, weight control products, cosmetic agents) does not apply to the deductible.

In addition, if a generic version of the prescribed brand medication exists, the Prescription Drug Benefit willcover only up to the price of the generic version. If you receive the brand name medication, you are requiredto pay the price difference between the generic and the brand medication. That difference does not applyto the deductible (see Generic Medication Policy on page 10 for non-Medicare and page 40 for Medicareeligible and approved members).

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Generic Medication PolicyCleveland Clinic HBP supports and encourages the use of FDA-approved generic medications that are bothchemically and therapeutically equivalent to manufacturers’ brand name products. Generically equivalentproducts are safe and effective treatments that offer savings as alternatives to brand name products.

Drugs that are available as generics are designated in this Handbook with an asterisk (*). When an asterisk (*)appears next to a drug, this indicates that the generic drug is a preferred drug (Tier 1), but the brand nameproduct is not. All other drugs listed are the Preferred Brands (Tier 2) or Specialty (SP) drugs (Tier 4).

If a member or physician requests the brand name drug be dispensed when a generic is available, theparticipant will be required to pay their generic co-insurance AND the cost difference between the brandname drug price and the generic drug price.

Prior AuthorizationPrior authorization is required for coverage of certain medications. These medications are listed below and in thecomplete drug listing that begins on page 25 of the Formulary in this Handbook. This list may change duringthe year due to new drugs being approved by the FDA or as new indications are established for previouslyapproved drugs. A Prior Authorization, Formulary Exception and Appeal Form (see page 47) must be completed orsufficient documentation must be submitted before a case will be reviewed. Please refer to the FormularyFailure Review Process on page 12 for information about obtaining a form. Completed forms can be faxedto 216.442.5790.

All prior authorization requests must meet the clinical criteria approved by the Pharmacy and Therapeutics(P&T) Committee before approval is granted. In some cases, approvals will be given a limited authorizationdate. If a limited authorization is given, both the member and the physician will receive documentation onwhen this authorization will expire. Most requests will be processed within one to two business days fromthe time of receipt. A response will be faxed to the requesting physician, and the member will be informedof the request and the decision via mail.

Pharmaceuticals Requiring Prior Authorization• Abilify• Acne Treatments > 21 Years Old• Actemra• Adcetris• Adcirca• Adempas• Akynzeo• Aspirin• Astagraf• Banzel• Benlysta• Berinert• Bethkis• Boniva IV6

6 Member is responsible for 20% co-insurance.

• Botox• Brintellix• Brisdelle• Butrans• Caprelsa• Celebrex• Cerezyme• Cimzia• Cinryze• Cosentyx• Crestor• Cuvposa• Daklinza• Daliresp

• Daraprim• Emend• Enbrel• Entresto• Entyvio• Envarsus XR• Epanova• Erivedge• Exjade• Farxiga• Farydak• Ferriprox• Fetzima• Firazyr

Cleveland Clinic Health Benefit ProgramPrescription Drug Benefit for Non-Medicare Retirees

(Administered by CVS/caremark)

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• Forteo• Gattex• Gilotrif• Grastek• Growth Hormone• H.P. Acthar• Harvoni• Hizentra• Humira• Ibrance• Ilaris• Imbruvica• Inlyta• Invokana• Iressa• Jakafi• Jardiance• Kalbitor• Kalydeco• Kineret• Korlym• Krystexxa• Lenvima• Letairis• Lidoderm• Linzess• Linzess• Lonsurf• Lumizyme• Lupron• Luzu• Lynparza• Makena• Marinol• Mekinist

• Movantik• Myobloc• Myozyme• Namenda XR• Nuedexta• Nulojix• Nuvigil• Odomzo• Onfi• Orencia• Oralair• Otezla• Otrexup• Pomalyst• Praluent• Pristiq• Prolia• Promacta• Provenge• Psoriasis Therapies• Qutenza• Ragwitek• Rasuvo• Reclast6

• Remicade• Repatha• Revatio• Revlimid• Rexulti• Rheumatoid Arthritis Therapies • Rituxan• Ruconest• Seroquel XR• Simponi• Soolantra

• Stivarga• Suboxone• Synagis

(up to five injections per season)• Synribo• Syprine• Tafinlar• Technivie• Testopel• Tracleer• Truvada• Tyvaso• Uceris• Venlafaxine ER Tablets• Viibryd• Vimovo• VPRIV• Xalkori• Xeljanz• Xeomin• Xgeva• Xiaflex• Xifaxan• Xofigo• Xolair• Xtandi• Xyrem• Zelboraf• Zemplar• Zohydro ER• Zomacton• Zorvolex• Zubsolv• Zuplenz• Zytiga

Pharmaceuticals Requiring Prior Authorization (continued)

6 Member is responsible for 20% co-insurance.

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Formulary Failure Review ProcessThe Formulary is designed to meet the needs of the majority of HBP members. However, if it is determinedthat you require treatment with a medication not included in the Formulary, your physician may request areview for preferred coverage of a Non-Formulary medication. To start the review process, your physicianshould call the Pharmacy Management Department at 216.986.1050, option 4 or toll-free at 888.246.6648,option 4 and request a Prior Authorization, Formulary Exception and Appeal Form. See sample on page 47. Youcan also obtain a form online at www.clevelandclinic.org/healthplan/usefulforms.htm.

Physicians should complete the form using specific laboratory data, physical exam findings, and othersupporting documentation whenever possible in order to document the medical necessity of using aNon-Formulary Medication. Approvals will be granted only if the physician can document ineffectivenessof Formulary alternatives or the reasonable expectation of harm from the use of Formulary medications.A separate form should be submitted for each patient for each Non-Formulary drug.

All requests must be in writing and signed by the prescribing physician. If a Non-Formulary drug is approved,the member will be responsible for a 30% co-insurance7 with no monthly maximum out-of-pocket. Theco-insurance amount will be applied to the yearly maximum out-of-pocket. In most cases, approvals will begiven an unlimited authorization date, so that you will not be required to resubmit a request every year. Mostrequests will be processed within one to two business days from the time of receipt. A response will be faxedto the requesting physician, and we will also inform the member of the request and the decision via mail.

Instructions for a Physician on How to Complete thePrior Authorization, Formulary Exception and Appeal Form:1. Complete all information requested.

2. Submit a separate form for each patient and for each drug you wish to have reviewed.

3. Keep a copy for your records.

4. Fax the form to: Cleveland Clinic Employee Health PlanPharmacy Management Department216.442.5790

OR

Mail the form to: Cleveland Clinic Employee Health PlanPharmacy Management Department6000 West Creek Road, Suite 20Independence, Ohio 44131

Exception Process — Once received, the normal turnaround time is 1-2 business days on most standardFormulary exception or prior authorization requests. Expedited requests may be made by calling the PharmacyCoordination line at 216.986.1050, option 4, or toll-free at 888.246.6648, option 4. In most cases, theserequests will be reviewed and processed on the same working day; however, calls received after 4 p.m. orduring the weekend will be handled the next business day. The expedited process can take up to 72 hours.One of the following criteria must be met to file an expedited request:• The drug is necessary to complete a specific course of therapy after discharge from an acute care facility

(e.g., hospital, skilled nursing facility).• The timeframe required for a standard review would compromise the member’s life, health or functional

status.• The drug requires administration in a timeframe that will not be met using the standard process.

7 Lower co-insurance will be assessed from the date of authorization. No refunds or adjustments will be made forpreviously purchased prescriptions.

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Prior Authorization, Formulary Exception and Appeal FormSee page 47 in the back of this Handbook for full size usable form.

Benefits and Coverage ClarificationDetailed benefit coverage clarification information about the HBP Prescription Drug Benefit is includedin the following pages. This information complements and further explains the Prescription Drug Benefitchart on page 2 in this Handbook and in the SPD, Section One: “Getting Started.”

Breast Cancer Prevention CoverageUnder the provisions of the Affordable Care Act mandate regarding breast cancer preventative health services,generic raloxifene and tamoxifen will be covered under the HBP Prescription Drug Benefit at no out-of-pocketexpense only for female members 35 years of age or older when accompanied by a valid prescription fromthe member’s healthcare provider.

Contraceptive CoverageUnder the provisions of the Affordable Care Act mandate regarding women’s preventative health services,contraceptives will be covered under the HBP Prescription Drug Benefit within the following guidelines:

• Diaphragms, emergency contraceptives, generic oral contraceptives, generic injectables (medroxypro-gesterone) will be covered with no out-of-pocket expense for the member. However, a prescription fromyour health care provider is required.

• Brand name oral contraceptives that are not available generically require prior authorization. If theprior authorization request is approved, the member will not have any out-of-pocket expense. If theprior authorization request is denied, the brand name contraceptive will not be covered.

• Members who receive a brand name formulation of a contraceptive that is available generically will notpay any co-insurance but will be charged the difference in cost between the brand name contraceptiveproduct and the generic alternative.

• Contraceptive products that do not require a prescription to be purchased are not covered under the HBPPrescription Drug Benefit.

• Members who are employed at Marymount Hospital are excluded from this coverage.

• Mirena and other intrauterine devices (IUDs) are not covered under the HBP Prescription Drug Benefit.Rather, they are covered under the medical benefit and no co-payment will be charged.

Oral Medications for Onychomycosis (Nail Fungus)All oral prescriptions for the treatment of nail fungus are covered at the Non-Preferred rate (see the PrescriptionDrug Benefit chart on page 2), which is 45% at Cleveland Clinic Pharmacies and Home Delivery Service or50% at all other locations. This Non-Preferred rate is in effect for brand name and generic medicationsappropriate for treating this condition. Formulary overrides to reimburse 25% at Cleveland Clinic Pharmaciesor 30% at all other locations are given to members who have this condition and diabetes or some form ofperipheral vascular disease (poor blood flow). Overrides are also given to any member who has the fingernailform of this condition; however, only one course of treatment will be covered at the Formulary rate in a lifetime.To obtain an override, please have your healthcare provider complete and submit a Prior Authorization,Formulary Exception and Appeal Form.

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Over-The-Counter (OTC) MedicationsCertain over-the-counter (OTC) medications that are available without a prescription are covered underthe Prescription Drug Benefit.

The member must have a prescription from his or her provider and fill the prescription at a ClevelandClinic or CVS/caremark Retail Network Pharmacy. The list includes:

• Aspirin: Prior authorization required

• Iron Supplements: Covered at 100% for members age 0-12 months

• Oral Fluoride Products: Covered at 100% for members age 0-6 years

• Folic Acid: Covered at 100% for female members age 40 and under

• Tobacco Cessation Medications:– Must be prescribed by Tobacco Treatment Center practitioners– Coverage includes bupropion, Chantix, gum, lozenges, and patches– Prescriptions must be filled at any Cleveland Clinic Pharmacy

• Vitamin D: Covered at 100% for members age 65 and over. Covered products include:– Ergocalciferol tab 400 unit– Cholecalciferol cap 400 unit– Cholecalciferol tab 400 unit– Cholecalciferol chewable tab 400 unit

All other OTC medications are not covered. When an OTC drug is available in the identical strength anddosage form as the prescription medication, and is approved for the same indications, the prescriptiondrug is usually not covered by the HBP. Providers should recommend the equivalent OTC product to thepatient.

Non-Covered MedicationsDue to the availability of generically available alternatives, medications in the following drug classes arenot covered by the HBP Prescription Drug Benefit:

Brand Name• CiproDex• Cipro HC• Durlaza• glycopyrrolate injectable sol• Karbinal ER

Brand and Generic Versions• Adoxa • Beleodaq• Belsomra• Binosto• CiproDex• Cipro HC• Cyramza

8 If approved under the Formulary Exception policy, members are charged the non-preferred co-insurance rate.9 Not covered for members over age 18.

– Cholecalciferol oral liquid 1200 unit/15ml– Cholecalciferol oral liquid 1000 unit/10ml– Cholecalciferol oral liquid 400 unit/ml– Cholecalciferol drops 400 unit/0.03ml (per drop)

• Kybella• Lemtrada• Liptruzet• Monodox • Nasacort AQ• Onmel• Opdivo

• Diclegis• Doryx• Durlaza• glycopyrrolate

injectable sol• Karbinal ER• Keytruda

• Oracea• Oxytrol• Solodyn• Xopenex9

• Kybella• Lemtrada• Oral Contraceptives (See Contraceptive Coverage

information on page 13.) • Proton Pump Inhibitors8

15

Sharps Container ProgramMembers who obtain their self-administered injection medications from the Cleveland Clinic Pharmaciesare eligible to receive one Sharps Container (1.5 quart size) every six months at no cost.

Please note that the Cleveland Clinic Pharmacies in Cleveland and the Cleveland Clinic Weston Pharmacycannot take back full containers. Each container should be disposed of properly. Should you have additionalquestions, please contact your Cleveland Clinic pharmacist.

Pharmacy Coordination ProgramsMandatory Maintenance Drug ProgramMembers may use any of the Cleveland Clinic Pharmacies or any pharmacy in the CVS/caremark RetailPharmacy Network for obtaining prescription medications for an immediate need, a one-time prescriptionmedication (example: antibiotics), or the first fill of a maintenance medication. Maintenance medicationsinclude drugs taken regularly to treat chronic medical conditions such as asthma, diabetes, or high bloodpressure, as well as drugs taken on a long-term basis, such as contraceptives.

Refills of all maintenance drugs must be obtained through one of the following three options:

• Cleveland Clinic Pharmacy Home Delivery Service — Home delivery enables you to order up to a 90-daysupply of your maintenance medication refill prescriptions, which are delivered to your home, saving youa trip to the pharmacy. There is no extra charge for home delivery and you will save 5% on your co-insurancecompared to using the CVS/caremark Mail Service Program (see page 8 for details).

• Cleveland Clinic Pharmacies — Drop off your maintenance prescriptions for refill at any of the 13 ClevelandClinic Pharmacy locations in northeast Ohio or the Weston Pharmacy in Florida. You can obtain up to a90-day supply of medication and you will save 5% on your co-insurance (see page 4 for details).

• CVS/caremark Mail Service Program — You can order up to a 90-day supply of your maintenance medicationprescription to be delivered to your home, but will not get the same 5% discount available when you orderyour prescription from a Cleveland Clinic Pharmacy or the Home Delivery Pharmacy.

In addition, some maintenance medications must be refilled for three month supplies at a ClevelandClinic Pharmacy, through the Cleveland Clinic Home Delivery Pharmacy, or through the CVS/caremarkMail Service in order to be covered. A complete list of these maintenance medications can be found atwww.clevelandclinic.org/healthplan.

Medications Limited by Provider SpecialtyThe co pment of complex drug therapy options requires that certain medications be prescribed by an appro-priate specialist (e.g., cardiologist, neurologist, oncologist) to ensure appropriate use. If these medicationsare not prescribed by an approved specialist, prior authorization (see page10) must be obtained for coverageunder the HBP Prescription Drug Benefit. The first medication included in this category is Multaq, whichmust be prescribed by a cardiologist. Additional medications limited by provider specialty (prescriptionwritten by a specialist) may be added to the Formulary in the future. Prescriptions written by non-specialistswill need prior authorization.

Quantity Level LimitsQuantity level limits are applied to medications for various reasons. For example, to prevent medicationmisuse or abuse, to promote adherence to an appropriate course of therapy for reasons of efficacy and safety,and to prevent the stockpiling of medication. Cleveland Clinic Health Benefit Program will continue tomonitor drug utilization to possibly expand quantity level limits for other medications.• Actonel 35mg — 4 tablets per 28 days• Adempas — 90 tablets per 30 days• Afinitor — 30-day supply;

limit based on instructions for use• Actos 15mg — 1 tablet per day

• Akynzeo — 1 capsule per day• Ambien 5mg — 1 tablet per day• Amerge tablets — 9 tablets per 30 days• Anzemet — 6 tablets per 30 days• Axert tablets — 12 tablets per 30 days

• Boniva 150mg — 1 tablet per 30 days• Bosulif — 30-day supply;

limit based on instructions for use• Brintellix — 30 tablets per 30 days• Brisdelle — 1 tablet per day• Butrans — 4 patches per day• Cosentyx — 30-day supply; limit based on

instructions for use• Cymbalta 30mg — 1 capsule per day• Detrol LA 2mg — 1 capsule per day• Effexor XR 37.5mg — 1 capsule per day• Effexor XR 75mg — 1 capsule per day• Emcyt — 30-day supply;

limit based on instructions for use• Emend — limit based on instructions for use• Entresto — 2 tablets per day• Envarsus XR — 1 tablet per day• Famvir — 30 tablets per 365 days• Farxiga — 1 tablet per day• Farydak — 6 capsules per 21 days• Fetzima — 30 capsules per 30 days• Fosamax 35mg — 4 tablets per 28 days• Fosamax 70mg — 4 tablets per 28 days• Frova tablets — 9 tablets per 30 days• Gattex — 30 vials per 30 days• Gleevec — 30-day supply;

limit based on instructions for use• Hexalen — 30-day supply;

limit based on instructions for use• Hycamtin — 30-day supply;

limit based on instructions for use• Imbruvica — 4 capsules per day• Imitrex tablets — 9 tablets per 30 days• Imitrex nasal spray — 9 sprays per 30 days• Imitrex injection — 4 kits per 30 days• Invokana — 1 tablet per day• Iressa — 1 tablet per day• Iressa — 30-day supply;

limit based on instructions for use• Januvia — 1 tablet per day• Kytril — 12 tablets per 30 days• Lenvima — 30-day supply; limit based on

instructions for use• Lynparza — 16 capsules per day• Maxalt tablets — 9 tablets per 30 days• Mekinist — 1 tablet per day• Movantik — 1 tablet per day

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Quantity Level Limits (continued)

• Namenda XR — 1 capsule per day• Nexavar — 30-day supply;

limit based on instructions for use• Odomzo — 1 capsule per day• Olysio — 1 capsule per day• Otezla — 2 tablets per day• Otrexup — 4 auto-injector pens per 30 days• Pomalyst — 1 capsule per day• Praluent — 2 syringes/pens per 28 days• Rasuvo — 4 auto-injector pens per 30 days• Relpax tablets — 12 tablets per 30 days• Repatha — 2 syringes/pens per 28 days• Revlimid — 30-day supply;

limit based on instructions for use• Rexulti — 1 tablet per day• Sovaldi — 30 tablets per 30 days• Sprycel — 30-day supply;

limit based on instructions for use• Sutent — 30-day supply;

limit based on instructions for use• Tabloid — 30-day supply;

limit based on instructions for use• Tafinlar — 4 capsules per day• Tarceva — 30-day supply;

limit based on instructions for use• Targretin — 30-day supply;

limit based on instructions for use• Tasigna — 30-day supply;

limit based on instructions for use• Teslac — 30-day supply;

limit based on instructions for use• Toradol 10mg — 20 tablets per 30 days• Treximet 85-500 — 12 tablets per 30 days• Tykerb — 30-day supply;

limit based on instructions for use• Uceris — 1 tablet per day• Valtrex 500mg — 10 tablets per 30 days• Valtrex 1000mg — 30 tablets per 365 days• Various acetaminophen containing

products — 4 grams a day• Votrient — 800mg per day • Wellbutrin XL 150mg — 1 tablet per day • Xyrem — 540ml per 30 days• Zofran — 30 tablets per 30 days• Zolinza — 30-day supply;

limit based on instructions for use• Zomig nasal spray — 12 sprays per 30 days• Zomig tablets — 12 tablets per 30 days

Split Fill ProgramHBP members beginning therapy with any of the medications listed below will be limited to a 15-day supplyfor the initial two months of therapy to ensure the member tolerates the medication:• Afinitor• Bosulif• Erivedge• Gleevec• Imbruvica

Mandatory Statin Cost Reduction ProgramCholesterol medications in the statin class are among the most commonly prescribed medications to HBPmembers. Refills for these statin medications must be obtained from any Cleveland Clinic Pharmacy to beincluded in the Statin Cost Reduction Program.

Tablet splitting Crestor, Lipitor, generic Lipitor, or using one of the generic statins such as lovastatin,pravastatin, or simvastatin will help HBP members save money.

The annual deductible must be satisfied before members receive the reduced co-insurance associated withthis program.

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Brand Generic Is this Medication Do I Have to Member Cost AmountName Name Available Generically? Split Tablets? Per 90-Day Supply

Crestor rosuvastatin No Yes (but not if $30your dose is40mg/day)

Lescol fluvastatin Yes No Generic Lescolimmediate immediate release

release – $6.0010

Lipitor atorvastatin Yes Yes (but not if Generic Lipitor – $6your dose is Brand Lipitor – $30 plus the80mg/day) difference in cost between

brand name Lipitorand generic Lipitor

Mevacor lovastatin Yes No Generic Mevacor – $6.0010

Pravachol pravastatin Yes No Generic Pravachol – $6.0010

Zocor simvastatin Yes No Generic Zocor – $6.0010

10 Under this program, the standard generic medication policy applies if the member receives the brand name versionsof Lescol, Lipitor, Mevacor, Pravachol, or Zocor.

• Tarceva• Targretin• Tasigna• Votrient• Xtandi

• Inlyta• Jakafi• Nexavar• Sprycel• Sutent

• Zelboraf• Zolinza• Zytiga

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Tablet SplittingThe Cleveland Clinic’s purchase prices for each of these medications are similar for different strengthtablets. For example, an equal quantity of Lipitor 20mg tablets and Lipitor 40mg tablets cost the same.Therefore, members who split larger dose tablets in half to obtain their prescribed dose reduce the totalamount of tablets purchased. This reduces medication costs and allows HBP to pass on significant savingsto members (For additional savings, see Generic Statins below).

If your provider prescribes a dose appropriate for tablet splitting, the prescription should be written that way.For example, if your daily dose is Crestor 20mg, your prescription should be written as follows:

Crestor 40mg #45 — Take one-half tablet daily

This will provide you with 90 20mg doses. Free tablet splitters are provided.

Members on maximum doses (e.g., Lipitor 80mg per day, Crestor 40mg per day) of any statin products cannotsplit their tablets. However, they still receive the reduced co-insurance as long as their prescription is writtenfor a 90-day supply and is filled by any Cleveland Clinic Pharmacy.

Generic StatinsUsing the generic alternatives listed above delivers significant cost savings to members. For example, a90-day supply of the generic medications atorvastatin, fluvastatin immediate release, lovastatin, pravastatin,or simvastatin obtained through the Cleveland Clinic Home Delivery Pharmacy costs $6, while a 90-day supplyof Crestor will cost $30. Members who receive brand name statins Lescol, Lipitor, Mevacor, Pravachol, orZocor will pay the price difference between brand name and generic costs (see Generic Medication Policyon page 10). In addition, members who use generic fluvastatin immediate release, lovastatin, pravastatin,or simvastatin do not need to split tablets to receive their reduced co-insurance.

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Step Therapy ProgramThe Step Therapy Program promotes the first-line use of effective, value-based medications over higher costalternatives. Prescriptions for equally effective — but less expensive — generic medications for coveredconditions will be approved with preferred rates. The Step Therapy Program stops payment of prescriptionclaims for higher cost alternative medications that have not received prior authorization. The followingmedications are included in the Step Therapy Program:

10Medication(s) Requiring Step Therapy11 Formulary Alternatives(s)

AcneAbsorica Myorisan Zenatane Claravis and Amnesteem

Allergies/AsthmaBeconase AQ Omnaris Veramyst Flunisolide and fluticasone nasal spraysDymista Qnasl ZetonnaNasonex Rhinocort Aqua

AntidepressantsPristiq Khedezla Venlafaxine, venlafaxine ER

Blood Pressure MedicationAtacand Benicar HCT Tekturna LisinoprilAtacand HCT Diovan Tekturna HCT Lisinopril/HCTZAvalide Diovan HCT Teveten LosartanAvapro Micardis Teveten HCT Losartan HCTBenicar Micardis HCT Valturna

Cholesterol Lowering MedicationsCrestor Livalo Atorvastatin (up to 40mg/day), generic fluvastatin

immedicate release, lovastatin, pravastatin,simvastatin

Diabetes12

Januvia Onglyza MetforminNesina Tradjenta

Gastrointestinal MedicationsAsacol HD Delzicol Balsalasizde or AprisoLialda Pentasa

Growth HormoneGenotropin Nutropin AQ Saizen Humatrope, NorditropinNutropin Omnitrope Tev-TropinZomacton

Immune ModulatorsCimzia Orencia subcutaneous HumiraEnbrel Simponi (subcutaneous)Kineret Stelara Xeljanz

StimulantsNuvigil Modafinil

11 During the benefit year, new medications may be added to this list. Members will be notified before these changes take effect.12 Januvia is the preferred DPP-IV inhibitor under the EHP prescription drug benefit.

2020

• Actemra• Acthar• Actimmune• Adempas• Adcirca• Afinitor• Alkeran• Ampyra• Apokyn• Aptivus• Aranesp• Arava• Arcalyst• Arimidex• Aromasin• Astagraf • Atripla• Aubagio• Avonex• Banzel• Baraclude• Benlysta• Berinert• Betaseron• Bethkis• Bethkis• Bosulif• Buphenyl• Caprelsa• CeeNU

• Cellcept• Cimzia13

• Cinryze• Combivir • Complera • Copaxone• Copegus• Costenyx• Crixivan • Cuprimine• Cystagon• Cytovene• Daklinza• Desferal• Edurant• Egrifta• Eligard• Emcyt• Emtriva• Enbrel13

• Entyvio• Epivir • Epivir HBV • Epogen• Epoprostenol• Epzicom• Ergamisol• Erivedge• Exjade• Extavia

• Fareston • Farydak• Femara• Ferriprox• Firazyr• Firmagon• Flolan• Forteo• Fuzeon• Gattex• Gengraf• Genotropin14

• Gilenya• Gilotrif• Gleevec• Hecoria • Hepsera • Hexalen• Humatrope• Humira• Hycamtin• Ibrance• Ilaris• Imbruvica• Incivek• Increlex• Infergen• Inlyta• Intelence• Intron-A

• Invirase • Iressa • Isentress• Jakafi• Juxtapid• Kalbitor• Kaletra • Kalydeco• Kineret• Korlym• Kuvan• Kynamro• Lenvima• Letairis• Leukeran • Leukine• Leuprolide• Lexiva• Lonsurf• Lupron• Lynparza• Lysodren• Makena• Matulane• Mekinist• Mozobil• Myfortic• Myleran• Neoral • Neulasta

13 Not covered as first line therapy. Use Humira.14 Not covered as first line therapy. Use Humatrope or Norditropin.

Specialty Drug BenefitSpecialty drugs can be obtained from any Cleveland Clinic Pharmacy including the Home Delivery Pharmacy,the Cleveland Clinic Home Infusion Pharmacy (injectables only) or from the CVS Caremark Specialty DrugProgram. Members enjoy lower out-of-pocket expenses by using a Cleveland Clinic Pharmacy to obtain theirspecialty drugs. Members with certain chronic conditions may wish to participate in the Accordant RareDisease Management Program. Please refer to your Summary Plan Description for more details.

Members will be responsible for their co-insurance for all drugs that are determined to be self-administrableby the patient. Self-administrable medications are defined as medications that are typically administeredsubcutaneously (SC) and have patient instruction for use in the package insert (PI). Some intramuscularinjections are also considered self-administrable due to frequency of injection and PI instructions for thepatient on how to self-administer the drug. A co-insurance applies at all locations where the drug can beobtained. If a self-administrable drug is administered in a doctor’s office, the member will be responsiblefor the office co-payment as well as the drug co-insurance. If administered in the physician’s office, theco-insurance is not applied to the pharmacy deductible or out-of-pocket maximum. Medications that arenot self-administered are covered under the medical benefit.

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• Neumega• Neupogen• Nexavar• Norditropin• Norvir• Noxafil• Nplate• Nuedexta• Nutropin14

• Nutropin AQ14

• Octreotide• Odomzo• Olysio• Omnitrope14

• Omontys• Onfi• Opsumit• Orencia13

• Orfadin• Otezla• Oxsoralen • Panretin• Peg Intron• Pegasys• Plegridy• Pomalyst• Praluent• Prezista • Procrit• Prograf • Prolia• Promacta

13 Not covered as first line therapy. Use Humira.14 Not covered as first line therapy. Use Humatrope or Norditropin.

• Pulmozyme• Purinethol • Rapamune • Rasuvo• Ravicti• Rebetol• Rebif• Regranex• Remicade• Remodulin• Repatha• Rescriptor • Restasis• Retrovir • Revatio• Revlimid• Reyataz • Ribapak/Ribavirin/

Ribasphere• Rilutek• Rituxan• Ruconest• Sabril• Saizen14

• Sandimmune • Sandostatin• Selzentry• Sensipar• Serostim14

• Simponi13

• Somavert• Soriatane

• Sprycel• Stelara• Stimate• Stivarga• Stribild• Sucraid• Sulfamylon• Sustiva • Sutent• Sylatron• Synarel• Syprine• Tabloid• Tafinlar• Tarceva • Targretin • Tasigna• Tecfidera• Technivie• Temodar• Tev-Tropin14

• Thalomid• Thioguanine• Tivicay• TOBI• Tracleer• Trelstar• Triumeq • Trizivir • Truvada• Tykerb• Tyvaso

• Tyzeka• Valcyte • Veletri• Ventavis• VePesid • Vesanoid• Victrelis• Videx • Videx EC • Viracept• Viramune• Viread• Votrient• Xalkori• Xeljanz• Xeloda• Xenazine• Xgeva• Xolair• Xtandi• Xyrem• Zavesca• Zelboraf• Zerit • Ziagen• Zoladex• Zolinza• Zomacton14

• Zorbtive14

• Zortress• Zytiga• Zyvox

Specialty drugs CANNOT be obtained through the CVS/caremark Retail Pharmacy Network. There are twooptions for obtaining these medications:

1. Cleveland Clinic Pharmacies in Cleveland and Weston or Cleveland Clinic Specialty Pharmacy

2. CVS Caremark Specialty Drug Program — toll-free at 800.237.2767

Specialty Drug Benefit (continued)

15 Members may contact Pharmacy Coordination at 216.986.1050, option 4 or toll-free at 888.246.6648, option 4between the hours of 8 a.m. and 4:30 p.m., Monday through Friday to request an override so that they are able topurchase a replacement supply at their expense. The member will be responsible for 100% of the discounted price.

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Prescription Drug Benefit Exclusions11. The replacement of lost or damaged prescriptions.16 Stolen medications will be covered at the benefit

program rate when accompanied by a police report.

12. Drugs prescribed for the treatment of sexual dysfunction.

13. Drugs to enhance libido function.

14. Enteral feedings, food supplements, lactose-free foods, specialized formulas, vitamins and/or mineralsthat do not require a prescription are not covered, even if they are required to maintain weight or strengthand regardless of whether these are prescribed by a physician.

15. Drugs used for experimental or investigational purposes.

16. Drugs that can be purchased without a prescription.

17. Drugs used for cosmetic purposes.

18. Drugs used for the treatment of infertility.

19. Drugs not included in the Patient Protection and Affordable Care Act that can be purchased withouta prescription.

10. Medicinal foods (regardless of whether they require a prescription or not).

Refer to the Prescription Drug Benefit chart on page 2 to see the Drugs & Items at Discounted Rate andNon-covered Drugs & Items for additional exclusions.

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Health Benefit ProgramDrug Formulary for Non-Medicare Retirees

January 2016

Prescription Drug CoverageThe listing of a drug in the Formulary does not guarantee coverage if your contract does not cover that categoryof drugs (e.g., oral contraceptives, infertility agents). Refer to the Benefits and Coverage Clarification section(page 13) in this Handbook to determine specific coverage.

Approved Medications — Only FDA-approved medications are eligible for coverage.

Non-Covered Medications — These drugs are determined by the terms of the member’s group health plan.The following are examples of, but not limited to, drug categories that plans exclude from coverage: drugsused for cosmetic purposes, weight control, promotion of fertility, and sexual dysfunction.

Generic Medications (Tier 1) — Cleveland Clinic Health Benefit Program supports and encourages the useof FDA-approved generic drugs that are both chemically and therapeutically equivalent to manufacturers’brand name products. Generically equivalent products are safe and effective treatments that offer savingsas alternatives to brand name products. This Formulary lists both generic and brand names for drugrecognition.

This Handbook lists both a generic and a brand name for the purpose of drug recognition.

Preferred Brands (Tier 2) — An FDA-approved drug of proven therapeutic efficacy and safety and approvedby the P&T Committee for inclusion in the Formulary.

Non-Preferred Brands (Tier 3) — Any FDA-approved medi cation which has been reviewed by the P&TCommittee and not added to the Formulary or is new and has not yet been reviewed by the P&T Committeeis considered a Non-Preferred drug. A higher co-insurance is charged for Non-Preferred medications.

Compounded Prescriptions — A customized medication prepared by a pharmacist according to a doctor’sspecifications. Compounded prescriptions are considered Non-Preferred and have a charge of 45% at anyCleveland Clinic Pharmacy or 50% at all other locations.

Investigational/Experimental Drug Use — A medication pending FDA approval or a FDA-approved medicationnot generally recognized by the medical community as effective or appropriate for a particular diagnosis.Charges for experimental or investigational drugs are not a covered benefit.

Important Points About theCleveland Clinic HBP Drug Formulary• The Formulary lists medications that are included in Tier 1, Tier 2 and Tier 4 of the HBP Prescription Drug

Benefit (Tier 3 are Non-Preferred/Non-Formulary drugs). All of the medications listed in this Formularyare considered formulary medications. This Formulary is designed to assist members and physiciansto enhance cost savings by using Generic (Tier 1), Preferred Brand (Tier 2) and Specialty Drugs (Tier 4),thereby making all drugs in these Tiers the preferred drug(s) of choice. Take this Handbook with you toall physician appointments.

• Coverage of certain Formulary medications may also be subject to restrictions established by thePharmacy and Therapeutics (P&T) Committee. Example: Singulair is considered a Preferred medicationwhen a member receives an inhaled steroid for asthma and Non-Preferred when a member takes themedication for allergic rhinitis. If a member has asthma and does not receive an inhaled steroid, thephysician must complete a Prior Authorization, Formulary Exception and Appeal Form for the memberto receive Singulair at the Preferred rate.

• Brand names are listed in the Drug Formulary only as a reference to help you identify the Preferred drugand do not indicate coverage of a particular brand. Brand names are capitalized (e.g., Amoxil) and genericnames are in lower case (e.g., amoxicillin).

• The inclusion of a drug on this list does not mean that all strengths or dosage forms for a given drug arecovered under your prescription drug benefit. The Formulary lists the excluded strengths or dosage formnext to the drug name.

• Designated symbols/letters follow certain drugs listed in the Formulary and indicate criteria related to thedrugs as follows: (*) indicates availability of a generic equivalent; (**) indicates availability of a genericequivalent but the brand product is still covered as a Preferred Brand (Tier 2); (PA) indicates that priorauthorization is required for use (physician must submit a Prior Authorization/Formulary Exception Form);(SP) indicates a specialty drug (a higher co-insurance may be charged and medications only availablethrough Cleveland Clinic Pharmacy or the CVS Caremark Specialty Pharmacy); (QL) indicates the drughas a quantity limit. (ST) indicates the drug is part of the Step Therapy Program.

NoticeThe information contained in this document is proprietary. The information may not be copied in wholeor in part without written permission. ©2015. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registeredtrademarks of pharmaceutical manufacturers not affiliated with Cleveland Clinic or CVS/caremark.

When viewing the Formulary via the Internet, please be advised that the Formulary is updated periodicallyand changes may appear prior to their effective date to allow for client notification.

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25

ALLERGY/COUGH & COLD/RESPIRATORYAnticholinergic, Inhaled NasalAtrovent (ipratropium)*

Anticholinergic, Inhaled OralAtrovent (ipratropium) inhalation solution*Atrovent HFA (ipratropium) inhalerSpiriva (tiotropium)Tudorza Pressair (aclidinium)

Anticholinergic/Beta Agonist, Inhaled OralCombivent Respimat (ipratropium/albuterol)

inhaler

Antihistamines, Inhaled NasalAstepro (azelastine)*

Antihistamines, OralAtarax (hydroxyzine HCl)*Phenergan (promethazine)*Vistaril (hydroxyzine pamoate)*

Anti-Inflammatory, Inhaled NasalFlonase (fluticasone)*Nasarel (flunisolide)*Nasonex (mometasone) (ST)Rhinocort Aqua (budesonide)* (ST)

Anti-Inflammatory, Inhaled OralAsmanex (mometasone) inhalerFlovent HFA (fluticasone) inhalerPulmicort (budesonide) inhalerPulmicort Respules (budesonide)*Qvar (beclomethasone) inhaler

Anti-Inflammatory, Inhaled Oral/LongActing Beta Agonist CombinationAdvair Diskus (fluticasone/salmeterol)Dulera (mometasone/formoterol)Symbicort (budesonide/formoterol)

Beta Agonists, Inhaled OralAccuneb (albuterol) inhalation solution*Arcapta (indacaterol ) NeohalerForadil (formoterol)Proventil (albuterol) inhalation solution*Proventil HFA (albuterol) inhalerProAir HFA (albuterol) inhalerProAir Respiclick (albuterol) inhalerSerevent Diskus (salmeterol)Ventolin HFA (albuterol) inhalerXopenex (levalbuterol)*

Beta Agonists, OralAlupent (metaproterenol) syrup*, tablet*Brethine (terbutaline) tablet*Proventil (albuterol) tablet*, syrup*Vospire ER (albuterol extended release) tablet*

Cough/ColdTessalon (benzonatate)*

Leukotriene ModulatorSingulair (montelukast)*

Miscellaneous AgentsBerinert (C1 inhibitor) (PA) (SP)Bethkis (tobramycin for inhalation) (PA) (SP)Cayston (aztreonam) inhalation solution (SP)Cinryze (C1 inhibitor) (PA) (SP)Cuvposa (glycopyrrolate) (PA)Daliresp (roflumilast) (PA)Elixophyllin (theophylline) elixirEpipen (epinephrine)Epipen Jr (epinephrine)Firazyr (icatibant) (PA) (SP)Grastek (timothy grass pollen allergenextract) (PA) (QL)

Intal (cromolyn sodium) inhalation solution*Kalydeco (ivacaftor) (PA) (SP)Oralair (grass mixed pollen allergen

extract) (PA) (QL)Pulmozyme (dornase alfa) inhalation

solution (SP)Ragwitek (ragweed pollen allergen

extract) (PA) (QL) Ruconest (recombinant C1 inhibitor) (PA) (SP)Theo-Dur (theophylline)*TOBI (tobramycin) inhalation solution* (SP)

ANALGESICSArthritisActemra (tocilizumab) (PA) (SP)Arava (leflunomide)* (SP)Astagraf XL (tacrolimus ext-rel) (PA) (SP)Azulfidine (sulfasalazine)*Cimzia (certolizumab) (PA) (SP)Enbrel (etanercept) (PA) (SP)Entyvio (vedolizumab) (PA) (SP)Gengraf (cyclosporine)* (SP)Humira (adalimumab) (PA) (SP)Imuran (azathioprine)*Kineret (anakinra) (PA) (SP)Neoral (cyclosporine) capsules*,

oral solution* (SP)Orencia (abatacept) (PA) (SP)Otezla (apremilast) (PA) (QL) (SP)Otrexup (methotrexate injection) (PA) (QL) (SP)Plaquenil (hydroxychloroquine)*Rasuvo (methotrexate injection) (PA) (QL) (SP)Rheumatrex (methotrexate)*Sandimmune (cyclosporine) capsules*,

solution (SP)Simponi (golimumab) (PA) (SP)Xeljanz (tofacitinib) (PA) (SP)

GoutBenemid (probenecid)*Colcrys (colchicine)Zyloprim (allopurinol)*Cafergot (ergotamine/caffeine)D.H.E. (dihydroergotamine)*Esgic (butalbital/acetaminophen/caffeine)*

MigraineAmerge (naratriptan)* (QL)Fioricet (butalbital/acetaminophen/

caffeine)* (QL)Fioricet with Codeine (butalbital/

acetaminophen/caffeine/codeine)* (QL)Fiorinal (butalbital/aspirin/caffeine)*Fiorinal with Codeine (butalbital/aspirin/

caffeine/codeine)*Imitrex (sumatriptan) injection*, nasal spray*,

tablet* (QL)Maxalt/Maxalt-MLT (rizatriptan)* (QL)Midrin (isometheptene/dichloralphenazone/

acetaminophen)* (QL)Migranal (dihydroergotamine)* Relpax (eletriptan) (QL)Zomig (zolmitriptan)* (QL)

Muscle RelaxantsEquanil (meprobamate)*Flexeril (cyclobenzaprine)*Lioresal (baclofen)*Norflex (orphenadrine)*Norgesic (orphenadrine/aspirin/caffeine)*Norgesic Forte (orphenadrine/aspirin/

caffeine)*Parafon Forte DSC (chlorzoxazone)*Robaxin (methocarbamol)*Skelaxin (metaxalone)*Soma (carisoprodol)*Zanaflex (tizanidine)*

Nonsteroidal Anti-Inflammatory Drugs(NSAIDs)Anaprox (naproxen)*Ansaid (flurbiprofen)*Arthrotec (diclofenac sodium delayed release/

misoprostol)*Cataflam (diclofenac)*Clinoril (sulindac)*Daypro (oxaprozin)*Feldene (piroxicam)*Indocin (indomethacin)*Lodine (etodolac)* Mobic (meloxicam)*Motrin (ibuprofen) tablets*, suspension*Naprosyn (naproxen)* Orudis (ketoprofen)*Pennsaid (diclofenac sodium solution)

Brand names are listed only as a reference and do not indicate coverage of a particular brand. **Indicates that a generic is available. The brand name form will be covered only when the generic form is not available on the Formulary.**Indicates both the brand and generic product are on the Formulary.(PA)—Indicates the drug requires prior authorization. (SP)—Indicates the drug is a specialty product.(QL)—Indicates the drug is a quantity limit product. (ST)—Indicates the drug is part of the step therapy program.

Drug Formulary Medications by Category

Drug Formulary Medications by Category (continued)


ANALGESICS (cont.)Nonsteroidal Anti-Inflammatory Drugs(NSAIDs) (cont.)Relafen (nabumetone)*Tolectin (tolmetin)*Toradol (ketorolac)* (QL)Voltaren (diclofenac)*

Opioid AnalgesicsAvinza (morphine extended release)Codeine (codeine) tablet*Demerol (meperidine)*Dilaudid (hydromorphone)*Dolophine (methadone)*Duragesic (fentanyl)*Lortab (hydrocodone/acetaminophen) elixir*,

tablets* (QL)MS Contin (morphine extended release)*MS IR (morphine) tablets*, solution*Norco (hydrocodone/acetaminophen)* (QL)Oxycontin (oxycodone extended release)Percocet (oxycodone/acetaminophen)* (QL)Percodan (oxycodone/aspirin)*Tylenol with Codeine (acetaminophen/

codeine)* (QL)Ultracet (tramadol/acetaminophen)* (QL)Ultram (tramadol)*Ultram ER (tramadol extended release)*Vicodin (hydrocodone/acetaminophen)* (QL)Vicodin ES (hydrocodone/acetaminophen)* (QL)

Opioid AntagonistReVia (naltrexone)*

SalicylatesDisalcid (salsalate)*Dolobid (diflunisal)*Easprin (aspirin)*Trilisate (choline magnesium trisalicylate)*

Systemic Lupus ErythematosusBenlysta (belimumab) (SP) (PA)

Miscellaneous AnalgesicsLidoderm (lidocaine) patch* (PA)Stadol NS (butorphanol)*Talwin NX (pentazocine/naloxone)*

ANTI-INFECTIVES(Antibiotics/Antifungals/Antivirals)Antifungals, OralDiflucan (fluconazole) tablet*, suspension*Mycelex Troche (clotrimazole)*Mycostatin (nystatin) tablet*, suspension*Nizoral (ketoconazole)*Noxafil (posaconazole) (SP)Vfend (voriconazole)* (SP)

Antifungals, TopicalLotrisone (clotrimazole/betamethasone)

cream*Mycolog II (nystatin/triamcinolone)*Mycostatin (nystatin) cream*, ointment*,

powder*Nizoral (ketoconazole) cream*Selsun Rx (selenium sulfide)*

Antivirals, InjectableFuzeon (enfuvirtide) (SP)Intron A (interferon alfa-2b) (SP)Pegasys (peginterferon alfa-2a) (SP)PEGIntron (peginterferon alfa-2b) (SP)Sylatron (peginterferon alfa-2b) (SP)

Antivirals, OralAptivus (tipranavir) (SP)Atripla (efavirenz/emtricitabine/tenofovir) (SP)Baraclude (entecavir) (SP)Combivir (zidovudine/lamivudine)* (SP)Complera (emtricitabine/rilpivirine/

tenofovir) (SP)Copegus (ribavirin)* (SP)Crixivan (indinavir) (SP)Cytovene (ganciclovir) (SP)Edurant (rilpivirine) (SP)Emtriva (emtricitabine) (SP)Epivir (lamivudine)* (SP)Epivir HBV (lamivudine)* (SP)Epzicom (abacavir/lamivudine) (SP)Famvir (famciclovir)* (QL)Hepsera (adefovir)* (SP)Incivek (telaprevir) (SP)Intelence (etravirine) (SP)Invirase (saquinavir) (SP)Isentress (raltegravir) (SP)Kaletra (lopinavir/ritonavir) (SP)Lexiva (fosamprenavir) (SP)Norvir (ritonavir) (SP)Olysio (simeprevir) (PA) (QL) (SP)Prezista (darunavir) (SP)Rebetol (ribavirin)* (SP)Rescriptor (delavirdine) (SP)Retrovir (zidovudine)* (SP)Reyataz (atazanavir) (SP)Selzentry (maraviroc) (SP)Stribild (elvitegravir, cobicistat, emtricitabine,

tenofovir) (SP)Sustiva (efavirenz) (SP)Symmetrel (amantadine)*Tivicay (Dolutegravir) (SP)Trizivir (abacavir/lamivudine/zidovudine)* (SP)Truvada (emtricitabine/tenofovir) (PA) (SP)Tyzeka (telbivudine) (SP)

Antivirals, Oral (cont.)Valcyte (valganciclovir) (SP)Valtrex (valacyclovir)* (QL)Victrelis (boceprevir) (PA) (SP)Videx (didanosine) (SP)Videx EC (didanosine)* (SP)Viracept (nelfinavir) (SP)Viramune (nevirapine)* (SP)Viread (tenofovir) (SP)Zerit (stavudine)* (SP)Ziagen (abacavir)* (SP)Zovirax (acyclovir) capsule*, suspension*, tablet*

Antivirals, TopicalAldara (imiquimod)* Condylox (podofilox) topical gelCondylox (podofilox) topical solution*

Antibiotics, OralCephalosporinsCeclor (cefaclor)* Ceftin (cefuroxime)* Duricef (cefadroxil) capsule*Keflex (cephalexin)*Omnicef (cefdinir)*Erythromycins/MacrolidesBiaxin (clarithromycin)*Dificid (fidaxomicin) (ST)E.E.S. (erythromycin ethylsuccinate)*EryPed (erythromycin ethylsuccinate)*Ery-Tab (erythromycin)*Zithromax (azithromycin)*PenicillinsAmoxil (amoxicillin)* Augmentin (amoxicillin/clavulanate)*Augmentin XR (amoxicillin/clavulanate XR)*Dynapen (dicloxacillin)*Pen-Vee K (penicillin VK)*Principen (ampicillin)*QuinolonesAvelox (moxifloxacin)*Cipro (ciprofloxacin)*Cipro XR (ciprofloxacin extended release)*Levaquin (levofloxacin)*SulfasBactrim (sulfamethoxazole/trimethoprim)*Bactrim DS (sulfamethoxazole/trimethoprim)*TetracyclinesMinocin (minocycline) capsule*Monodox (doxycycline)*Sumycin (tetracycline)*Miscellaneous Campral (acamprosate calcium)*Cleocin (clindamycin)*Dapsone (dapsone)*

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ANTI-INFECTIVES (cont.)(Antibiotics/Antifungals/Antivi-rals)Miscellaneous (cont.)Flagyl (metronidazole)*Humatin (paromomycin)*Neomycin (neomycin)*Tindamax (tinidazole)*Vancocin (vancomycin)*Xifaxan (rifaximin) (PA) (SP)Zyvox (linezolid) (SP)

Antibiotics, TopicalBactroban (mupirocin)*Garamycin (gentamicin)*Peridex (chlorhexidine gluconate)*Silvadene (silver sulfadiazine)*

AntimalarialsAralen (chloroquine phosphate)*Lariam (mefloquine)*Plaquenil (hydroxychloroquine)*

AntimycobacterialsNydrazid (isoniazid)*Priftin (rifapentine)Pyrazinamide (pyrazinamide)*Rifadin (rifampin)*

Urinary Tract AgentsMacrobid (nitrofurantoin)*Macrodantin (nitrofurantoin)* Proloprim (trimethoprim)*

Vaginal AgentsMetroGel Vaginal (metronidazole)*

CARDIOVASCULAR(Blood Pressure/Heart/Cholesterol)ACE InhibitorsAccupril (quinapril)*Accuretic (quinapril/HCTZ)*Altace (ramipril)*Capoten (captopril)*Capozide (captopril/HCTZ)*Lotensin (benazepril)*Lotensin HCT (benazepril/HCTZ)*Mavik (trandolapril)*Monopril (fosinopril)*Monopril-HCT (fosinopril/HCTZ)*Prinivil (lisinopril)*Prinzide (lisinopril/HCTZ)*Univasc (moexipril)*Vaseretic (enalapril/HCTZ)* Vasotec (enalapril)*Zestoretic (lisinopril/HCTZ)*Zestril (lisinopril)*

Angiotensin II Receptor BlockersAtacand (candesartan)* (ST)Atacand HCT (candesartan/HCTZ)* (ST)Avalide (irbesartan/HCTZ)* (ST)Avapro (irbesartan)* (ST)Cozaar (losartan)*Diovan (valsartan)* (ST)Diovan HCT (valsartan/hydrochlorothiazide)* (ST)Entresto (sacubitril/valsartan) (PA) (QL)Exforge (amlodipine/valsartan)*Hyzaar (losartan/HCTZ)*Micardis (telmisartan)* (ST)Micardis HCT (telmisartan/HCTZ)* (ST)Twynsta (amlodipine/telmisartan)*

Antiarrhythmic AgentsBetapace (sotalol)* Cordarone (amiodarone)*Mexitil (mexiletine)*Multaq (dronedarone) (restricted to Cardiology)Norpace (disopyramide)*Norpace CR (disopyramide)Rythmol (propafenone)*Rythmol SR (propafenone extended release)*Tambocor (flecainide)*Tikosyn (dofetilide)

Beta BlockersBlocadren (timolol)*Bystolic (nebivolol)Coreg (carvedilol)* Corgard (nadolol)*Inderal (propranolol)*Inderal LA (propranolol extended release)*Inderide (propranolol/HCTZ)*Lopressor (metoprolol)*Lopressor HCT (metoprolol/HCTZ)*Sectral (acebutolol)*Tenoretic (atenolol/chlorthalidone)*Tenormin (atenolol)*Toprol-XL (metoprolol extended release)*Trandate (labetalol)*Visken (pindolol)*Zebeta (bisoprolol)*Ziac (bisoprolol/HCTZ)*

Calcium Channel BlockersAdalat CC (nifedipine extended release)*Caduet (amlodipine/atorvastatin)*Calan (verapamil)*Calan SR (verapamil extended release)*Cardizem (diltiazem)*Cardizem CD (diltiazem extended release)*Cardizem SR (diltiazem extended release)*

Calcium Channel Blockers (cont.)Lotrel (amlodipine/benazepril)*Norvasc (amlodipine)*Plendil (felodipine extended release)*Procardia XL (nifedipine extended release)*Sular (nisoldipine extended release)*Tarka (trandolapril/verapamil extended release)*Verelan PM (verapamil extended release)*

Cholesterol-Lowering AgentsAntara (fenofibrate capsules)Colestid (colestipol)*Crestor (rosuvastatin)

(mandatory tablet splitting) (ST)Epanova (omega-3 carboxylic acids)

(restricted to Cardiology) (PA) (QL)Lescol (fluvastatin immediate release)*Lipitor (atorvastatin)*

(mandatory tablet splitting)Lopid (gemfibrozil)*Lipofen (fenofibrate)*Lovaza (omega-3-acid ethyl esters)*

(restricted to Cardiology)Mevacor (lovastatin)*Niaspan (niacin extended release)*Praluent (alirocumab) (PA) (QL) (SP)Pravachol (pravastatin)*Questran (cholestyramine)*Questran Light (cholestyramine)*Repatha (evolocumab) (PA) (QL) (SP)Tricor (fenofibrate)*Trilipix (fenofibric acid delayed release)*Vascepa (icosapent ethyl)

(restricted to Cardiology)Welchol (colesevelam)Zocor (simvastatin)*

Coagulation TherapyAggrenox (dipyridamole extended release/

aspirin) Agrylin (anagrelide)*Arixtra (fondaparinux)*Coumadin (warfarin)**Eliquis (apixaban)Lovenox (enoxaparin)*Persantine (dipyridamole)*Plavix (clopidogrel)*Pletal (cilostazol)*Pradaxa (dabigatran etexilate)Ticlid (ticlopidine)*Trental (pentoxifylline)*Xarelto (rivaroxaban)



CARDIOVASCULAR (cont.)(Blood Pressure/Heart/Cholesterol)DiureticsAldactazide (spironolactone/HCTZ)*Aldactone (spironolactone)*Bumex (bumetanide)*Demadex (torsemide)*Diuril (chlorothiazide)*Dyazide (triamterene/HCTZ)*HydroDIURIL (hydrochlorothiazide)*Hygroton (chlorthalidone)*Inspra (eplerenone)*Lasix (furosemide)*Lozol (indapamide)*Maxzide (triamterene/HCTZ)*Midamor (amiloride)*Moduretic (amiloride/HCTZ)*Zaroxolyn (metolazone)*

NitratesImdur (isosorbide mononitrate)*Isordil (isosorbide dinitrate)*Minitran (nitroglycerin) patches*Nitro-Bid (nitroglycerin) ointmentNitro-Dur (nitroglycerin) patches*Nitrolingual (nitroglycerin) spray*Nitrostat (nitroglycerin) SL tablets

Orthostatic HypotensionFlorinef (fludrocortisone)*Proamatine (midodrine)*

Pulmonary Arterial HypertensionAdcirca (tadalafil) (PA) (SP)Adempas (riociguat) (PA) (QL) (SP)Letairis (ambrisentan) (PA) (SP)Revatio (sildenafil)* (PA) (SP)Tracleer (bosentan) (PA) (SP)Tyvaso (treprostinil) (PA) (SP)Ventavis (iloprost) (SP)

Miscellaneous AgentsAldomet (methyldopa)*Aldoril (methyldopa/HCTZ)*Apresoline (hydralazine)*Cardura (doxazosin)*Catapres (clonidine) tablet*Catapres-TTS (clonidine) patch*Corzide (nadolol/bendroflumethiazide)*Hytrin (terazosin)*Lanoxin (digoxin) tablet**Loniten (minoxidil) tablet*Minipress (prazosin)*Ranexa (ranolazine) (PA)Serpasil (reserpine)*Tenex (guanfacine)*

CENTRAL NERVOUS SYSTEMAlzheimer’sAricept (donepezil)*Exelon (rivastigmine)*Namenda (memantine)Namenda XR (memantine) (PA)Razadyne (galantamine)*

AnticonvulsantsBanzel (rufinamide) (PA) (SP)Carbatrol (carbamazepine extended release)*Celontin (methsuximide)Depakene (valproic acid)*Depakote (divalproex)*Diastat (diazepam rectal gel)* Dilantin (phenytoin)**Gabitril (tiagabine)* Keppra (levetiracetam)* Keppra XR (levetiracetam)* Klonopin (clonazepam)*Lamictal (lamotrigine)*Lamictal ODT (lamotrigine orally disintegrating

tablets)*Lamictal XR (lamotrigine extended release)*Lyrica (pregabalin)Mysoline (primidone)*Neurontin (gabapentin)*Onfi (clobazam) (PA) (SP)Phenobarbital (phenobarbital)*Sabril (vigabatrin) (PA) (SP)Tegretol (carbamazepine)*Tegretol-XR (carbamazepine extended release)*Topamax (topiramate)*Trileptal (oxcarbazepine) tablets*, suspension*Valium (diazepam)*Vimpat (lacosamide)Zarontin (ethosuximide)*Zonegran (zonisamide)*

AntidepressantsSelective Serotonin Reuptake InhibitorsCelexa (citalopram)*Lexapro (escitalopram)* (QL)Luvox (fluvoxamine)*Paxil (paroxetine)*Prozac (fluoxetine)*Zoloft (sertraline)*TricyclicsAnafranil (clomipramine)*Elavil (amitriptyline)*Norpramin (desipramine)*Pamelor (nortriptyline)*Sinequan (doxepin)*Tofranil (imipramine)* Tofranil-PM (imipramine pamoate)*

Miscellaneous AntidepressantsCymbalta (duloxetine)* (QL)Desyrel (trazodone)*Effexor (venlafaxine)*Effexor XR (venlafaxine extended release)* (QL)Emsam (selegiline transdermal)Ludiomil (maprotiline)*Parnate (tranylcypromine)*Remeron (mirtazapine)*Wellbutrin (bupropion)* Wellbutrin SR (bupropion extended release)*Wellbutrin XL (bupropion extended

release)* (QL)

Antiparkinson’s Artane (trihexyphenidyl)* Benadryl (diphenhydramine)* (50mg only)Cogentin (benztropine)*Comtan (entacapone)*Eldepryl (selegiline)*Mirapex (pramipexole)*Mirapex ER (pramipexole extended release)*Parcopa (carbidopa/levodopa orally

disintegrating tablets)*Parlodel (bromocriptine)*Requip (ropinirole)*Requip XL (ropinirole extended release)*Sinemet (carbidopa/levodopa)*Sinemet CR (carbidopa/levodopa extended

release)*Stalevo (carbidopa/entacapone/levodopa)*Symmetrel (amantadine)*

Anxiolytics/Sedatives/HypnoticsAmbien (zolpidem)* (QL)Ambien CR (zolpidem extended release)*Ativan (lorazepam)*Buspar (buspirone)*Halcion (triazolam)*Klonopin (clonazepam)*Librium (chlordiazepoxide)*Lunesta (eszopiclone)*Restoril (temazepam)*Serax (oxazepam)*Sonata (zaleplon)*Tranxene (clorazepate)*Valium (diazepam)*Versed (midazolam)*Xanax (alprazolam)*

Attention Deficit Disorder/NarcolepsyAdderall (dextroamphetamine racemic salts)* Adderall XR (dextroamphetamine racemic

salts extended release)* Concerta (methylphenidate extended release)*Dexedrine (dextroamphetamine)*Focalin (dexmethylphenidate)*

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CENTRAL NERVOUS SYSTEM (cont.)Attention DeficitDisorder/Narcolepsy (cont.)Focalin XR (dexmethylphenidate

extended release)*Intuniv (guanfacine extended release)Metadate CD (methylphenidate

extended release)*Nuvigil (armodafinil) (ST)Provigil (modafinil)*Ritalin (methylphenidate)*Ritalin LA (methylphenidate extended release)*Ritalin-SR (methylphenidate extended release)*Strattera (atomoxetine)Vyvanse (lisdexamfetamine)

Mood StabilizersAbilify (aripiprazole)* (PA)Clozaril (clozapine)* Eskalith (lithium carbonate)*Geodon (ziprasidone)*Haldol (haloperidol)*Invega (paliperidone extended release)Latuda (lurasidone)Lithobid (lithium carbonate extended release)*Lithotabs (lithium carbonate)*Loxitane (loxapine)*Mellaril (thioridazine)*Navane (thiothixene)*Prolixin (fluphenazine)*Risperdal (risperidone)*Seroquel (quetiapine)*Stelazine (trifluoperazine)*Thorazine (chlorpromazine)*Trilafon (perphenazine)*Zyprexa (olanzapine)*

Multiple Sclerosis AgentsAubagio (teriflunomide) (SP)Avonex (interferon beta-1a) (SP)Betaseron (interferon beta-1b) (SP)Copaxone (glatiramer acetate) (SP)Gilenya (fingolimod) (SP)Plegridy (peginterferon beta-1a) (SP)Rebif (interferon beta-1a) (SP)Tecfidera (dimethyl fumarate) (SP)

MiscellaneousAntabuse (disulfiram)*Nimotop (nimodipine)*Nuedexta (dextromethorphan/quinidine) (SP)ReVia (naltrexone)*Rilutek (riluzole)* (SP)Suboxone (buprenorphine/naloxone sublingual

tablets)* (PA)Subutex (buprenorphine)* (PA)Xyrem (sodium oxybate) (PA) (QL) (SP)

DERMATOLOGICAL Acne Therapy (PA over Age 21)Accutane (isotretinoin)*Amnesteem (isotretinoin)*Avita (tretinoin) cream*Benzaclin (clindamycin/benzoyl peroxide)*Benzamycin (erythromycin/benzoyl peroxide)*Claravis (isotretinoin)*Cleocin T (clindamycin) lotion*, pads*, solution*Differin (adapalene) cream*, gel*Erycette (erythromycin) pads*Eryderm (erythromycin) topical solution*Erygel (erythromycin) topical gel*Klaron (sulfacetamide)*Plexion (sulfacetamide/sulfur)*Retin-A (tretinoin) cream*, gel*Retin-A Micro (tretinoin)*Sulfacet-R (sulfur/sodium sulfacetamide)*

Antipsoriatic/AntiseborrheicCosentyx (secukinumab) (PA) (QL) (SP)Dovonex (calcipotriene)*Oxsoralen (methoxsalen) (PA) (SP)Oxsoralen-Ultra (methoxsalen) (PA) (SP)Soriatane (acitretin)* (SP)Stelara (ustekinumab) (PA) (SP)

ImmunomodulatorElidel (pimecrolimus)Protopic (tacrolimus)

RosaceaMetrocream (metronidazole)*MetroGel (metronidazole)*Metrolotion (metronidazole)*

Topical CorticosteroidsAristocort (triamcinolone) cream*, ointment*Cloderm (clocortolone) cream*Cordran Tape (flurandrenolide)Cutivate (fluticasone) cream*, lotion*, ointment*DesOwen (desonide) cream*, lotion*, ointment*Diprolene (augmented betamethasone

dipropionate) cream*, gel*, ointment*Diprolene AF (augmented betamethasone

dipropionate) cream*Diprosone (betamethasone dipropionate)

cream*Elocon (mometasone) cream*, lotion*,

ointment*Hytone (hydrocortisone) cream*, lotion*,

ointment*Kenalog (triamcinolone) lotion*Lidex (fluocinonide) cream*, gel*, ointment*,

solution*Lidex-E (fluocinonide emollient) cream*

Topical Corticosteroids (cont.)Temovate (clobetasol) cream*, lotion*, gel*,

ointment*Temovate-E (clobetasol emollient) cream*Topicort (desoximetasone) cream*, gel*,

ointment*Topicort LP (desoximetasone) cream*Ultravate (halobetasol) cream*, ointment*Westcort (hydrocortisone valerate) cream*,

ointment*

MiscellaneousCarac (fluorouracil)*Drysol (aluminum chloride hexahydrate)*Drysol Dab-O (aluminum chloride hexahydrate)*Elimite (permethrin) cream*EMLA (lidocaine/prilocaine) cream*Kwell (lindane) lotion*, shampoo*Panretin (alitretinoin) (SP)Sulfamylon (mafenide) cream, lotion (SP)Xylocaine (lidocaine) gel*, ointment*

ENDOCRINE/DIABETESAdrenal HormonesCortef (hydrocortisone)*Cortone Acetate (cortisone)*Decadron (dexamethasone)*Deltasone (prednisone)*Florinef (fludrocortisone)*Medrol (methylprednisolone)*Orapred (prednisolone)*Orapred ODT (prednisolone sodium phosphate

orally disintegrating tablets)Prelone (prednisolone) syrup*

AntiandrogensCasodex (bicalutamide)*Eulexin (flutamide)*Nilandron (nilutamide)

AntithyroidPropylthiouracil (propylthiouracil)*SSKI (potassium iodide)Tapazole (methimazole)*

Blood Glucose Monitoring Devicesand SuppliesAll covered under DME Benefit

CarnitineCarnitor (levocarnitine)*

Glucose Elevating AgentsGlucaGen (glucagon)Glucagon Emergency Kit (glucagon)

Growth Hormone Releasing FactorEgrifta (tesamorelin) (PA) (SP)



ENDOCRINE/DIABETES (cont.)Human Growth HormoneReceptor AntagonistSomavert (pegvisomant) injection (PA) (SP)

Human Growth HormoneGenotropin (somatropin) (PA) (SP)Humatrope (somatropin) (PA) (SP)Increlex (mecasermin) (PA) (SP)Nutropin AQ (somatropin) (PA) (SP)Saizen (somatropin) (PA) (SP)Serostim (somatropin) (PA) (SP)Tev-Tropin (somatropin) (PA) (SP)Zomacton (somatropin) (PA) (SP) (ST)Zorbtive (somatropin) (PA) (SP)

Hypoglycemic AgentsActos (pioglitazone)* (QL)Actoplus Met (pioglitazone/metformin)

tablets*Amaryl (glimepiride)*Bydureon (exenatide)Byetta (exenatide)Diabeta (glyburide)*Duetact (pioglitazone/glimepiride) tablets*Farxiga (dapagliflozin) (PA) (QL)Glucophage (metformin)*Glucophage XR (metformin extended release)*Glucotrol (glipizide)*Glucotrol XL (glipizide extended release)*Glucovance (glyburide/metformin)*Glynase (glyburide)*Invokana (canagliflozin) (PA) (QL)Januvia (sitagliptin) (QL) (ST)Jardiance (empagliflozin) (PA) (QL)Micronase (glyburide)*Onglyza (saxagliptin) (Januvia first) (ST)Prandin (repaglinide)*Precose (acarbose)*SymlinPen (pramlintide)Tradjenta (linagliptin) (Januvia first) (ST)Trulicity (dulaglutide)Victoza (liraglutide)

Insulin TherapyApidra (insulin glulisine)Humalog (insulin human lispro)Humalog Mix 50/50

(insulin human lispro NPL/lispro) Humalog Mix 75/25

(insulin human lispro NPL/lispro)Humulin 70/30 (insulin human NPH/R)Humulin N (insulin human NPH)Humulin R (insulin human regular)Lantus (insulin human glargine)

Insulin Therapy (cont.)Levemir (insulin detemir)Novolin 70/30 (insulin human NPH/R)Novolin N (insulin human NPH)Novolin R (insulin human regular)NovoLog (insulin aspart)NovoLog Mix 70/30

(insulin human aspart NPL/aspart)Toujeo (insulin human glargine)

Metabolic Bone DisordersActonel (risedronate) (QL)Boniva (ibandronate) tablets*Didronel (etidronate)*Forteo (teriparatide) (PA) (SP)Fosamax (alendronate)* (QL)

Thyroid SupplementLevothroid (levothyroxine)**Synthroid (levothyroxine)**Unithroid (levothyroxine)**

MiscellaneousArcalyst (rilonacept) (PA) (SP)Buphenyl (sodium phenylbutyrate)* (SP)Danocrine (danazol)*DDAVP (desmopressin acetate)*Dibenzyline (phenoxybenzamine)Dostinex (cabergoline)*Orfadin (nitisinone) (SP)Regranex (becaplermin) (SP)Renvela (sevelamer) tablets*, powderSensipar (cinacalcet) (SP)Stimate (desmopressin) (SP)Sucraid (sacrosidase) (SP)Zavesca (miglustat) (SP)

GASTROINTESTINALAntidiarrhealsImodium (loperamide)*Lomotil (diphenoxylate/atropine)*Paregoric (paregoric)*

Antiemetic/AntivertigoAkynzeo (netupitant/palonosetron) (PA) (QL)Antivert (meclizine)*Anzemet (dolasetron) (QL)Cesamet (nabilone) capsules (PA) (SP)Compazine (prochlorperazine) suppository*,

tablet*Emend (aprepitant) (PA) (QL)Kytril (granisetron)* (QL)Marinol (dronabinol)* (PA)Phenergan (promethazine)*Reglan (metoclopramide)*Tigan (trimethobenzamide)*Zofran (ondansetron)* (QL)

Anti-Spasmodic AgentsBentyl (dicyclomine) capsule*, tablet*Levbid (hyoscyamine)*Levsin (hyoscyamine)*Librax (clidinium/chlordiazepoxide)*Pro-Banthine (propantheline)*

Heartburn/Ulcer TherapiesCarafate (sucralfate) tablet*Cytotec (misoprostol)*Pamine (methscopolamine)*Pepcid (famotidine) tablet*Prevacid (lansoprazole)*Prevpac (lansoprazole, amoxicillin, and

clarithromycin)*Prilosec (omeprazole)*Protonix (pantoprazole)*Tagamet (cimetidine) tablet*, solution*Zantac (ranitidine) tablet*

Pancreatic EnzymeCreon (amylase/lipase/protease)Pertzye (amylase/lipase/protease)

Saliva StimulantEvoxac (cevimeline)*

MiscellaneousActigall (ursodiol)*Anusol HC (hydrocortisone)*Apriso (mesalamine)Azulfidine (sulfasalazine)*Chronulac (lactulose)*Colazal (balsalazide)∗Colyte (polyethylene

glycol/potassium/sodium)*Cortenema (hydrocortisone)*Cortifoam (hydrocortisone)Gattex (teduglutide) (PA) (QL) (SP)GoLYTELY (polyethylene glycol-electrolyte

solution)*Lotronex (alosetron)*Miralax (polyethylene glycol)*MoviPrep (polyethylene glycol)Proctofoam-HC (pramoxine/hydrocortisone)Rowasa (mesalamine)*Syprine (trientine) (SP)Uceris (budesonide extended release) (PA) (QL)

GENITOURINARYBPHCardura (doxazosin)*Flomax (tamsulosin)*Hytrin (terazosin)*Proscar (finasteride)*Uroxatral (alfuzosin)*

30

31

GENITOURINARY (cont.)Urinary AnestheticPyridium (phenazopyridine)*

Urinary AntispasmodicsDetrol (tolterodine)*Detrol LA (tolterodine extended release)* (QL)Ditropan (oxybutynin)*Ditropan XL (oxybutynin extended release)*Enablex (darifenacin)Sanctura (trospium)*Sanctura XR (trospium extended release)*

HEMATOLOGICIron ChelatorExjade (deferasirox) (PA) (SP)Ferriprox (deferiprone) (PA) (SP)

MiscellenousCuprimine (penicillamine) (SP)

IMMUNOSUPPRESSANT/ANTINEOPLASTICAdjunctive AgentsActimmune (interferon gamma-1b) (SP)Aranesp (darbepoetin alfa) (SP)Epogen (epoetin alfa) (SP)Leucovorin (leucovorin)*Leukine (sargramostim) (SP)Neulasta (pegfilgrastim) (SP)Neumega (oprelvekin) (SP)Neupogen (filgrastim) (SP)Procrit (epoetin alfa) (SP)Promacta (eltrombopag) (PA) (SP)

Alkylating AgentsAlkeran (melphalan) (SP)CeeNU (lomustine)* (SP)Cytoxan (cyclophosphamide)*Leukeran (chlorambucil) (SP)Matulane (procarbazine) (SP)Myleran (busulfan) (SP)Temodar (temozolomide)* (SP)

AntiandrogensZytiga (abiraterone acetate) (PA) (SP)

AntiestrogensFareston (toremifene) (SP)Nolvadex (tamoxifen)*

AntimetabolitesHydrea (hydroxyurea)*Purinethol (mercaptopurine)** (SP)Rheumatrex (methotrexate)*Tabloid (thioguanine) (QL) (SP)Xeloda (capecitabine)* (SP)

Immunosuppressant TherapiesCellcept (mycophenolate)* (SP)Gengraf (cyclosporine)* (SP)Imuran (azathioprine)*Myfortic (mycophenolic acid)* (SP)Neoral (cyclosporine) capsules*,

oral solution* (SP)Prograf (tacrolimus)* (SP)Rapamune (sirolimus)* (SP)Sandimmune (cyclosporine) capsules*,

solution (SP)Zortress (everolimus) (SP)

Miscellaneous AntineoplasticsAfinitor (everolimus) (QL) (SP)Arimidex (anastrozole)* (SP)Aromasin (exemestane)* (SP)Bosulif (bosutinib) (QL) (SP)Caprelsa (vandetanib) (PA) (SP)Cometriq (cabozantinib) capsules (PA) (SP)Emcyt (estramustine) (SP)Farydak (panobinostat) (PA) (QL) (SP)Femara (letrozole)* (SP)Gilotrif (afatinib) (PA) (SP)Gleevec (imatinib) (QL) (SP)Hexalen (altretamine) (SP)Hycamtin (topotecan) (QL) (SP)Ibrance (palbociclib) (PA) (SP)Iclusig (ponatinib) tablets (PA) (SP)Imbruvica (ibrutinib) (PA) (QL) (SP)Iressa (gefitinib) (PA) (QL) (SP)Lenvima (lenvatinib) (PA) (QL) (SP)Lupron (leuprolide) (PA) (SP)Lynparza (olaparib) (PA) (QL) (SP)Lysodren (mitotane) (SP)Megace (megestrol)*Mekinist (trametinib) (PA) (QL) (SP)Nexavar (sorafenib) (QL) (SP)Odomzo (sonidegib) (PA) (QL) (SP)Pomalyst (pomalidomide) (PA) (QL) (SP)Revlimid (lenalidomide) (PA) (QL) (SP)Rituxan (rituximab) (PA) (SP)Sandostatin (octreotide)* (SP)Sprycel (dasatinib) (QL) (SP)Stivarga (regorafenib) (PA) (SP)Sutent (sunitinib) (QL) (SP)Tafinlar (dabrafenib) (PA) (QL) (SP)Tarceva (erlotinib) (QL) (SP)Targretin (bexarotene) (SP)Tasigna (nilotinib) (QL) (SP)Thalomid (thalidomide) (SP)Tykerb (lapatinib) (SP)VePesid (etoposide)*Vesanoid (tretinoin)* (SP)

Miscellaneous Antineoplastics (cont.)Votrient (pazopanib) (QL) (SP)Xalkori (crizotinib) (PA) (SP)Xtandi (enzalutamide) (PA) (SP)Zelboraf (vemurafenib) (PA) (SP)Zolinza (vorinostat) (QL) (SP)

OBSTETRICS/GYNECOLOGYContraceptivesAviane (ethinyl estradiol/levonorgestrel)*Brevicon (ethinyl estradiol/norethindrone)*Cyclessa (ethinyl estradiol/desogestrel)*Depo-Provera (medroxyprogesterone)* Estrostep Fe (ethinyl estradiol/norethindrone/

ferrous fumarate)*Levora (ethinyl estradiol/levonorgestrel)*Lessina (ethinyl estradiol/levonorgestrel)*Lo/Ovral (ethinyl estradiol/norgestrel)*Loestrin (ethinyl estradiol/norethindrone)*Loestrin 24 Fe (ethinyl estradiol/norethindrone/

ferrous fumarate)*Loestrin Fe (ethinyl estradiol/norethindrone/

ferrous fumarate)*Micronor (norethindrone)*Mircette (ethinyl estradiol/desogestrel)*Modicon (ethinyl estradiol/norethindrone)*NuvaRing (ethinyl estradiol/etonogestrel) Ogestrel (ethinyl estradiol/norgestrel)*Ortho Evra (ethinyl estradiol/norelgestromin)* (QL)Ortho Tri-Cyclen (ethinyl estradiol/

norgestimate)*Ortho-Cept (ethinyl estradiol/desogestrel)*Ortho-Cyclen (ethinyl estradiol/norgestimate)*Ortho-Novum 1/35 (ethinyl estradiol/

norethindrone)*Ortho-Novum 1/50 (mestranol & norethindrone)*Ortho-Novum 7/7/7 (ethinyl estradiol/

norethindrone)*Seasonale (ethinyl estradiol/levonorgestrel)*Trivora (ethinyl estradiol/levonorgestrel)*Yasmin (ethinyl estradiol/drospirenone)*Zovia (ethinyl estradiol/ethynodiol diacetate)*

Emergency ContraceptivesPlan B One Step (levonorgestrel)*Ella (ulipristal)Next Choice (levonorgestrel)*

Estrogens/ProgestinsAygestin (norethindrone acetate)*Climara (estradiol)*Duavee (conjugated estrogens/bazedoxifene)Estrace (estradiol)*Estrace (estradiol) vaginal creamFemHRT (ethinyl estradiol/norethindrone)*Ogen (estropipate)*Prefest (estradiol/norgestimate)



32

OBSTETRICS/GYNECOLOGY (cont.)Estrogens/Progestins (cont.)Premarin (conjugated estrogens) tablets,

vaginal creamPremphase (conjugated estrogens/

medroxyprogesterone)Prempro (conjugated estrogens/

medroxyprogesterone)Prometrium (progesterone)*Provera (medroxyprogesterone)*

Infertility (Consult SPD for Coverage)Clomid (clomiphene)*

MiscellaneousEvista (raloxifene)*Methergine (methylergonovine)*

OPHTHALMICAntihistaminesPatanol (olopatadine)

Anti-InfectivesBacitracin (bacitracin)*Bleph-10 (sulfacetamide) solution*Ciloxan (ciprofloxacin)*Garamycin (gentamicin)*Ilotycin (erythromycin)*Neosporin (bacitracin/neomycin/

polymixin B) ointment*Neosporin (gramicidin/neomycin/

polymixin B) solution*Ocuflox (ofloxacin)*Polysporin (bacitracin/polymyxin B)*Polytrim (trimethoprim/polymyxin B)*Tobrex (tobramycin) solution*

Anti-Infective/Steroidal CombinationsCortisporin (bacitracin/hydrocortisone

neomycin/polymyxin B) ointment*Maxitrol (dexamethasone/neomycin/

polymixin B)*TobraDex (tobramycin/dexamethasone)

suspension*, ointmentVasocidin (sodium sulfacetamide/

prednisolone)*

Anti-Inflammatory, Non-SteroidalAcular (ketorolac)*Ocufen (flurbiprofen)*Voltaren (diclofenac) solution*

Anti-Inflammatory, SteroidalAlrex (loteprednol)Decadron (dexamethasone) solution*Lotemax (loteprednol)Pred Forte (prednisolone acetate)*

Beta-BlockersBetagan (levobunolol)*Betimol (timolol)Betoptic S (betaxolol)Ocupress (carteolol)*OptiPranolol (metipranolol)*Timoptic (timolol)*Timoptic-XE (timolol)*

Carbonic Anhydrase InhibitorsAzopt (brinzolamide)Trusopt (dorzolamide)*

Cycloplegic MydriaticsCyclogyl (cyclopentolate)*Isopto Atropine (atropine)*Isopto Homatropine (homatropine)*Mydriacyl (tropicamide)*

Prostaglandin AgonistsTravatan Z (travoprost)Travoprost*Xalatan (latanoprost)*

SympathomimeticsAlphagan P (brimonidine)*

Miscellaneous OphthalmicsCosopt (dorzolamide/timolol)*Crolom (cromolyn)*Pilocar (pilocarpine)*Restasis (cyclosporine) (SP)Viroptic (trifluridine)*

OTICOtic AgentsAuralgan (antipyrine/benzocaine)*Cortisporin Otic (hydrocortisone/neomycin/

polymixin B)*Domeboro Otic (aluminum acetate/acetic acid)*Floxin Otic (ofloxacin)*Vosol (acetic acid)*Vosol HC (acetic acid/hydrocortisone)*

VITAMINS/ELECTROLYTESElectrolytesK-Dur (potassium chloride)*Klor-Con (potassium chloride)*K-Lyte (potassium bicarbonate/citrate)*PhosLo (calcium acetate)*

Miscellaneous Vitamins Drisdol (ergocalciferol)*Folic Acid*Hectorol (doxercalciferol)*Luride (sodium fluoride) chewable tablets*Mephyton (phytonadione)Poly-Vi-FlorPoly-Vi-Flor with IronRocaltrol (calcitriol)*Tri-Vi-Flor*Zemplar (paricalcitriol)* (PA)

Prenatal VitaminsPrenatal Plus*



AAbilify (aripiprazole)* (PA)Accuneb (albuterol) inhalation solution*Accupril (quinapril)*Accuretic (quinapril/HCTZ)*Accutane (isotretinoin)*Actemra (tocilizumab) (PA) (SP)Actigall (ursodiol)*Actimmune (interferon gamma-1b) (SP)Actonel (risedronate) (QL)Actoplus Met (pioglitazone/metformin)

tablets*Actos (pioglitazone)* (QL)Acular (ketorolac)*Adalat CC (nifedipine extended release)*Adcirca (tadalafil) (PA) (SP)Adderall (dextroamphetamine racemic salts)* Adderall XR (dextroamphetamine racemic

salts extended release)* Adempas (riociguat) (PA) (QL) (SP)Advair Diskus (fluticasone/salmeterol)Afinitor (everolimus) (QL) (SP)Aggrenox (dipyridamole extended release/

aspirin) Agrylin (anagrelide)* Aldactazide (spironolactone/HCTZ)*Aldactone (spironolactone)*Aldara (imiquimod)* Aldomet (methyldopa)*Aldoril (methyldopa/HCTZ)*Alkeran (melphalan) (SP)Alphagan P (brimonidine)*Alrex (loteprednol)Altace (ramipril)*Alupent (metaproterenol) syrup*, tablet*Akynzeo (netupitant/palonosetron) (PA) (QL)Amaryl (glimepiride)*Ambien (zolpidem)* (QL)Ambien CR (zolpidem extended release)*Amerge (naratriptan)* (QL)Amnesteem (isotretinoin)*Amoxil (amoxicillin)* Anafranil (clomipramine)*Anaprox (naproxen)*Ansaid (flurbiprofen)*Antabuse (disulfiram)*Antara (fenofibrate capsules)Antivert (meclizine)*Anusol HC (hydrocortisone)*Anzemet (dolasetron) (QL)Apidra (insulin glulisine)Apresoline (hydralazine)*Apriso (mesalamine)Aptivus (tipranavir) (SP)Aralen (chloroquine phosphate)*

A (cont.)Aranesp (darbepoetin alfa) (SP)Arava (leflunomide)* (SP)Arcalyst (rilonacept) (PA) (SP)Arcapta (indacaterol ) NeohalerAricept (donepezil)*Arimidex (anastrozole)* (SP)Aristocort (triamcinolone) cream*, ointment*Arixtra (fondaparinux)*Aromasin (exemestane)* (SP)Artane (trihexyphenidyl)* Arthrotec (diclofenac sodium delayed release/

misoprostol)*Asmanex (mometasone) inhalerAstagraf XL (tacrolimus ext-rel) (PA) (SP)Astepro (azelastine)*Atacand (candesartan)* (ST)Atacand HCT (candesartan/HCTZ)* (ST)Atarax (hydroxyzine HCl)*Ativan (lorazepam)*Atripla (efavirenz/emtricitabine/tenofovir) (SP)Atrovent (ipratropium) inhalation solution*Atrovent (ipratropium)*Atrovent HFA (ipratropium) inhalerAubagio (teriflunomide) (SP)Augmentin (amoxicillin/clavulanate)*Augmentin XR (amoxicillin/clavulanate XR)*Auralgan (antipyrine/benzocaine)*Avalide (irbesartan/HCTZ)* (ST)Avapro (irbesartan)* (ST)Avelox (moxifloxacin)*Aviane (ethinyl estradiol/levonorgestrel)*Avinza (morphine extended release)Avita (tretinoin) cream*Avonex (interferon beta-1a) (SP)Aygestin (norethindrone acetate)*Azopt (brinzolamide)Azulfidine (sulfasalazine)*

BBacitracin (bacitracin)*Bactrim (sulfamethoxazole/trimethoprim)*Bactrim DS (sulfamethoxazole/trimethoprim)*Bactroban (mupirocin)*Banzel (rufinamide) (PA) (SP)Baraclude (entecavir) (SP)Benadryl (diphenhydramine)* (50mg only)Benemid (probenecid)*Benlysta (belimumab) (SP) (PA)Bentyl (dicyclomine) capsule*, tablet*Benzaclin (clindamycin/benzoyl peroxide)*Benzamycin (erythromycin/benzoyl peroxide)*Berinert (C1 inhibitor) (PA) (SP)Betagan (levobunolol)*Betapace (sotalol)*

B (cont.)Betaseron (interferon beta-1b) (SP)Bethkis (tobramycin for inhalation) (PA) (SP)Betimol (timolol)Betoptic S (betaxolol)Biaxin (clarithromycin)*Bleph-10 (sulfacetamide) solution*Blocadren (timolol)*Boniva (ibandronate) tablets*Bosulif (bosutinib) (QL) (SP)Brethine (terbutaline) tablet*Brevicon (ethinyl estradiol/norethindrone)*Bumex (bumetanide)*Buphenyl (sodium phenylbutyrate)* (SP)Buspar (buspirone)*Bydureon (exenatide)Byetta (exenatide)Bystolic (nebivolol)

CCaduet (amlodipine/atorvastatin)*Cafergot (ergotamine/caffeine)Calan (verapamil)*Calan SR (verapamil extended release)*Campral (acamprosate calcium)*Capoten (captopril)*Capozide (captopril/HCTZ)*Caprelsa (vandetanib) (PA) (SP)Carac (fluorouracil)*Carafate (sucralfate) tablet*Carbatrol (carbamazepine extended release)*Cardizem (diltiazem)*Cardizem CD (diltiazem extended release)*Cardizem SR (diltiazem extended release)*Cardura (doxazosin)*Carnitor (levocarnitine)*Casodex (bicalutamide)*Cataflam (diclofenac)*Catapres (clonidine) tablet*Catapres-TTS (clonidine) patch*Cayston (aztreonam) inhalation solution (SP)Ceclor (cefaclor)* CeeNU (lomustine)* (SP)Ceftin (cefuroxime)* Celexa (citalopram)*Cellcept (mycophenolate)* (SP)Celontin (methsuximide)Cesamet (nabilone) capsules (PA) (SP)Chronulac (lactulose)*Ciloxan (ciprofloxacin)*Cimzia (certolizumab) (PA) (SP)Cinryze (C1 inhibitor) (PA) (SP)Cipro (ciprofloxacin)*Cipro XR (ciprofloxacin extended release)*


33

Drug Formulary Medications Alphabetically

C (cont.)Claravis (isotretinoin)*Cleocin (clindamycin)*Cleocin T (clindamycin) lotion*, pads*, solution*Climara (estradiol)*Clinoril (sulindac)*Cloderm (clocortolone) cream*Clomid (clomiphene)*Clozaril (clozapine)* Codeine (codeine) tablet*Cogentin (benztropine)*Colazal (balsalazide)∗Colcrys (colchicine)Colestid (colestipol)*Colyte (polyethylene

glycol/potassium/sodium)*Combivent Respimat (ipratropium/albuterol)

inhalerCombivir (zidovudine/lamivudine)* (SP)Cometriq (cabozantinib) capsules (PA) (SP)Combivir (zidovudine/lamivudine)* (SP)Cometriq (cabozantinib) capsules (PA) (SP)Compazine (prochlorperazine) suppository*,

tablet*Complera (emtricitabine/rilpivirine/

tenofovir) (SP)Comtan (entacapone)*Concerta (methylphenidate extended release)*Condylox (podofilox) topical gelCondylox (podofilox) topical solution*Copaxone (glatiramer acetate) (SP)Copegus (ribavirin)* (SP)Cordarone (amiodarone)*Cordran Tape (flurandrenolide)Coreg (carvedilol)* Corgard (nadolol)*Cortef (hydrocortisone)*Cortenema (hydrocortisone)*Cortifoam (hydrocortisone)Cortisporin (bacitracin/hydrocortisone

neomycin/polymyxin B) ointment*Cortisporin Otic (hydrocortisone/neomycin/

polymixin B)*Cortone Acetate (cortisone)*Corzide (nadolol/bendroflumethiazide)*Cosentyx (secukinumab) (PA) (QL) (SP)Cosopt (dorzolamide/timolol)*Coumadin (warfarin)**Cozaar (losartan)*Creon (amylase/lipase/protease)Crestor (rosuvastatin)

(mandatory tablet splitting) (ST)Crixivan (indinavir) (SP)Crolom (cromolyn)*Cutivate (fluticasone) cream*, lotion*, ointment*Cuvposa (glycopyrrolate) (PA)

C (cont.)Cyclessa (ethinyl estradiol/desogestrel)*Cyclogyl (cyclopentolate)*Cymbalta (duloxetine)* (QL)Cytotec (misoprostol)*Cytovene (ganciclovir) (SP)Cytoxan (cyclophosphamide)*

DD.H.E. (dihydroergotamine)*Daliresp (roflumilast) (PA)Danocrine (danazol)*Dapsone (dapsone)*Daypro (oxaprozin)*DDAVP (desmopressin acetate)*Decadron (dexamethasone)*Decadron (dexamethasone) solution*Deltasone (prednisone)*Demadex (torsemide)*Demerol (meperidine)*Depakene (valproic acid)*Depakote (divalproex)*Depo-Provera (medroxyprogesterone)* DesOwen (desonide) cream*, lotion*, ointment*Desyrel (trazodone)*Detrol (tolterodine)*Detrol LA (tolterodine extended release)* (QL)Dexedrine (dextroamphetamine)*Diabeta (glyburide)*Diastat (diazepam rectal gel)* Dibenzyline (phenoxybenzamine)Didronel (etidronate)*Differin (adapalene) cream*, gel*Dificid (fidaxomicin) (ST)Diflucan (fluconazole) tablet*, suspension*Dilantin (phenytoin)**Dilaudid (hydromorphone)*Diovan (valsartan)* (ST)Diovan HCT (valsartan/hydrochlorothiazide)* (ST)Diprolene (augmented betamethasone

dipropionate) cream*, gel*, ointment*Diprolene AF (augmented betamethasone

dipropionate) cream*Diprosone (betamethasone dipropionate)

cream*Disalcid (salsalate)*Ditropan (oxybutynin)*Ditropan XL (oxybutynin extended release)*Diuril (chlorothiazide)*Dolobid (diflunisal)*Dolophine (methadone)*Domeboro Otic (aluminum acetate/acetic acid)*Dostinex (cabergoline)*Dovonex (calcipotriene)*Drisdol (ergocalciferol)*

D (cont.)Drysol (aluminum chloride hexahydrate)*Drysol Dab-O (aluminum chloride hexahydrate)*Duavee (conjugated estrogens/bazedoxifene)Duetact (pioglitazone/glimepiride) tablets*Dulera (mometasone/formoterol)Duragesic (fentanyl)*Duricef (cefadroxil) capsule*Dyazide (triamterene/HCTZ)*Dynapen (dicloxacillin)*

E E.E.S. (erythromycin ethylsuccinate)*Easprin (aspirin)*Edurant (rilpivirine) (SP)Effexor (venlafaxine)*Effexor XR (venlafaxine extended release)* (QL)Egrifta (tesamorelin) (PA) (SP)Elavil (amitriptyline)*Eldepryl (selegiline)*Elidel (pimecrolimus)Elimite (permethrin) cream*Eliquis (apixaban)Elixophyllin (theophylline) elixirElla (ulipristal)Elocon (mometasone) cream*, lotion*,

ointment*Emcyt (estramustine) (SP)Emend (aprepitant) (PA) (QL)EMLA (lidocaine/prilocaine) cream*Emsam (selegiline transdermal)Emtriva (emtricitabine) (SP)Enablex (darifenacin)Enbrel (etanercept) (PA) (SP)Entresto (sacubitril/valsartan) (PA) (QL)Entyvio (vedolizumab) (PA) (SP)Epipen (epinephrine)Epipen Jr (epinephrine)Epivir (lamivudine)* (SP)Epivir HBV (lamivudine)* (SP)Epanova (omega-3 carboxylic acids)

(restricted to Cardiology) (PA) (QL)Epogen (epoetin alfa) (SP)Epzicom (abacavir/lamivudine) (SP)Equanil (meprobamate)*Erycette (erythromycin) pads*Eryderm (erythromycin) topical solution*Erygel (erythromycin) topical gel*EryPed (erythromycin ethylsuccinate)*Ery-Tab (erythromycin)*Esgic (butalbital/acetaminophen/caffeine)*Eskalith (lithium carbonate)*Estrace (estradiol)*Estrace (estradiol) vaginal creamEstrostep Fe (ethinyl estradiol/norethindrone/

ferrous fumarate)*


34

Drug Formulary Medications Alphabetically (continued)

E (cont.)Eulexin (flutamide)*Evista (raloxifene)*Evoxac (cevimeline)*Exelon (rivastigmine)*Exforge (amlodipine/valsartan)*Exjade (deferasirox) (PA) (SP)

FFamvir (famciclovir)* (QL)Fareston (toremifene) (SP)Farxiga (dapagliflozin) (PA) (QL)Farydak (panobinostat) (PA) (QL) (SP)Feldene (piroxicam)*Femara (letrozole)* (SP)FemHRT (ethinyl estradiol/norethindrone)*Ferriprox (deferiprone) (PA) (SP)Fioricet (butalbital/acetaminophen/

caffeine)* (QL)Fioricet with Codeine (butalbital/

acetaminophen/caffeine/codeine)* (QL)Fiorinal (butalbital/aspirin/caffeine)*Fiorinal with Codeine (butalbital/aspirin/

caffeine/codeine)*Firazyr (icatibant) (PA) (SP)Flagyl (metronidazole)*Flexeril (cyclobenzaprine)*Flomax (tamsulosin)*Flonase (fluticasone)*Florinef (fludrocortisone)*Florinef (fludrocortisone)*Flovent HFA (fluticasone) inhalerFloxin Otic (ofloxacin)*Focalin (dexmethylphenidate)*Focalin XR (dexmethylphenidate

extended release)*Folic Acid*Foradil (formoterol)Forteo (teriparatide) (PA) (SP)Fosamax (alendronate)* (QL)Fuzeon (enfuvirtide) (SP)

GGabitril (tiagabine)* Garamycin (gentamicin)*Gattex (teduglutide) (PA) (QL) (SP)Gengraf (cyclosporine)* (SP)Genotropin (somatropin) (PA) (SP)Geodon (ziprasidone)*Gilenya (fingolimod) (SP)Gilotrif (afatinib) (PA) (SP)Gleevec (imatinib) (QL) (SP)GlucaGen (glucagon)Glucagon Emergency Kit (glucagon)Glucophage (metformin)*Glucophage XR (metformin extended release)*

G (cont.)Glucotrol (glipizide)*Glucotrol XL (glipizide extended release)*Glucovance (glyburide/metformin)*Glynase (glyburide)*GoLYTELY (polyethylene glycol-electrolyte

solution)*Grastek (timothy grass pollen allergenextract) (PA) (QL)

HHalcion (triazolam)*Haldol (haloperidol)*Hectorol (doxercalciferol)*Hepsera (adefovir)* (SP)Hexalen (altretamine) (SP)Humalog (insulin human lispro)Humalog Mix 50/50

(insulin human lispro NPL/lispro) Humalog Mix 75/25

(insulin human lispro NPL/lispro)Humatin (paromomycin)*Humatrope (somatropin) (PA) (SP)Humira (adalimumab) (PA) (SP)Humulin 70/30 (insulin human NPH/R)Humulin N (insulin human NPH)Humulin R (insulin human regular)Hycamtin (topotecan) (QL) (SP)Hydrea (hydroxyurea)*HydroDIURIL (hydrochlorothiazide)*Hygroton (chlorthalidone)*Hytone (hydrocortisone) cream*, lotion*,

ointment*Hytrin (terazosin)*Hyzaar (losartan/HCTZ)*

IIbrance (palbociclib) (PA) (SP)Iclusig (ponatinib) tablets (PA) (SP)Ilotycin (erythromycin)*Imbruvica (ibrutinib) (PA) (QL) (SP)Imdur (isosorbide mononitrate)*Imitrex (sumatriptan) injection*, nasal spray*,

tablet* (QL)Imodium (loperamide)*Imuran (azathioprine)*Incivek (telaprevir) (SP)Increlex (mecasermin) (PA) (SP)Inderal (propranolol)*Inderal LA (propranolol extended release)*Inderide (propranolol/HCTZ)*Indocin (indomethacin)*Inspra (eplerenone)*Intal (cromolyn sodium) inhalation solution*Intelence (etravirine) (SP)Intron A (interferon alfa-2b) (SP)

I (cont.)Intuniv (guanfacine extended release)Invega (paliperidone extended release)Invirase (saquinavir) (SP)Invokana (canagliflozin) (PA) (QL)Iressa (gefitinib) (PA) (QL) (SP)Isentress (raltegravir) (SP)Isopto Atropine (atropine)*Isopto Homatropine (homatropine)*Isordil (isosorbide dinitrate)*

JJanuvia (sitagliptin) (QL) (ST)Jardiance (empagliflozin) (PA) (QL)

KKaletra (lopinavir/ritonavir) (SP)K-Dur (potassium chloride)*Kalydeco (ivacaftor) (PA) (SP)Keflex (cephalexin)*Kenalog (triamcinolone) lotion*Keppra (levetiracetam)* Keppra XR (levetiracetam)* Kineret (anakinra) (PA) (SP)Klaron (sulfacetamide)*Klonopin (clonazepam)*Klor-Con (potassium chloride)*K-Lyte (potassium bicarbonate/citrate)*Kwell (lindane) lotion*, shampoo*Kytril (granisetron)* (QL)

LLamictal (lamotrigine)*Lamictal ODT (lamotrigine orally disintegrating

tablets)*Lamictal XR (lamotrigine extended release)*Lanoxin (digoxin) tablet**Lantus (insulin human glargine)Lariam (mefloquine)*Lasix (furosemide)*Latuda (lurasidone)Lenvima (lenvatinib) (PA) (QL) (SP)Lescol (fluvastatin immediate release)*Lessina (ethinyl estradiol/levonorgestrel)*Letairis (ambrisentan) (PA) (SP)Leucovorin (leucovorin)*Leukeran (chlorambucil) (SP)Leukine (sargramostim) (SP)Levaquin (levofloxacin)*Levbid (hyoscyamine)*Levemir (insulin detemir)Levora (ethinyl estradiol/levonorgestrel)*Levothroid (levothyroxine)**Levsin (hyoscyamine)*Lexapro (escitalopram)* (QL)Lexiva (fosamprenavir) (SP)


35


L (cont.)Librax (clidinium/chlordiazepoxide)*Librium (chlordiazepoxide)*Lidex (fluocinonide) cream*, gel*, ointment*,

solution*Lidex-E (fluocinonide emollient) cream*Lidoderm (lidocaine) patch* (PA)Lioresal (baclofen)*Lipitor (atorvastatin)*

(mandatory tablet splitting)Lipofen (fenofibrate)*Lithobid (lithium carbonate extended release)*Lithotabs (lithium carbonate)*Lo/Ovral (ethinyl estradiol/norgestrel)*Lodine (etodolac)* Loestrin (ethinyl estradiol/norethindrone)*Loestrin 24 Fe (ethinyl estradiol/norethindrone/

ferrous fumarate)*Loestrin Fe (ethinyl estradiol/norethindrone/

ferrous fumarate)*Lomotil (diphenoxylate/atropine)*Loniten (minoxidil) tablet*Lopid (gemfibrozil)*Lopressor (metoprolol)*Lopressor HCT (metoprolol/HCTZ)*Lortab (hydrocodone/acetaminophen) elixir*,

tablets* (QL)Lotemax (loteprednol)Lotensin (benazepril)*Lotensin HCT (benazepril/HCTZ)*Lotrel (amlodipine/benazepril)*Lotrisone (clotrimazole/betamethasone) cream*Lovaza (omega-3-acid ethyl esters)*

(restricted to Cardiology)Lovenox (enoxaparin)*Loxitane (loxapine)*Lozol (indapamide)*Ludiomil (maprotiline)*Lunesta (eszopiclone)*Lupron (leuprolide) (PA) (SP)Luride (sodium fluoride) chewable tablets*Luvox (fluvoxamine)*Lynparza (olaparib) (PA) (QL) (SP)Lyrica (pregabalin)Lysodren (mitotane) (SP)

MMacrobid (nitrofurantoin)*Macrodantin (nitrofurantoin)* Marinol (dronabinol)* (PA)Matulane (procarbazine) (SP)Mavik (trandolapril)*Maxalt/Maxalt-MLT (rizatriptan)* (QL)Maxitrol (dexamethasone/neomycin/

polymixin B)*

M (cont.)Maxzide (triamterene/HCTZ)*Medrol (methylprednisolone)*Megace (megestrol)*Mekinist (trametinib) (PA) (QL) (SP)Mellaril (thioridazine)*Mephyton (phytonadione)Metadate CD (methylphenidate

extended release)*Methergine (methylergonovine)*Metrocream (metronidazole)*MetroGel (metronidazole)*MetroGel Vaginal (metronidazole)*Metrolotion (metronidazole)*Mevacor (lovastatin)*Mexitil (mexiletine)*Micardis (telmisartan)* (ST)Micardis HCT (telmisartan/HCTZ)* (ST)Micronase (glyburide)*Micronor (norethindrone)*Midamor (amiloride)*Midrin (isometheptene/dichloralphenazone/

acetaminophen)* (QL)Migranal (dihydroergotamine)* Minipress (prazosin)*Minitran (nitroglycerin) patches*Minocin (minocycline) capsule*Miralax (polyethylene glycol)*Mirapex (pramipexole)*Mirapex ER (pramipexole extended release)*Mircette (ethinyl estradiol/desogestrel)*Mobic (meloxicam)*Modicon (ethinyl estradiol/norethindrone)*Moduretic (amiloride/HCTZ)*Monodox (doxycycline)*Monopril (fosinopril)*Monopril-HCT (fosinopril/HCTZ)*Motrin (ibuprofen) tablets*, suspension*MoviPrep (polyethylene glycol)MS Contin (morphine extended release)*MS IR (morphine) tablets*, solution*Multaq (dronedarone) (restricted to Cardiology)Mycelex Troche (clotrimazole)*Mycolog II (nystatin/triamcinolone)*Mycostatin (nystatin) cream*, ointment*,

powder*Mycostatin (nystatin) tablet*, suspension*Mydriacyl (tropicamide)*Myfortic (mycophenolic acid)* (SP)Myleran (busulfan) (SP)Mysoline (primidone)*

NNamenda (memantine)Namenda XR (memantine) (PA)

N (cont.)Naprosyn (naproxen)* Nasarel (flunisolide)*Nasonex (mometasone) (ST)Navane (thiothixene)*Neomycin (neomycin)*Neoral (cyclosporine) capsules*,

oral solution* (SP)Neosporin (bacitracin/neomycin/

polymixin B) ointment*Neosporin (gramicidin/neomycin/

polymixin B) solution*Neulasta (pegfilgrastim) (SP)Neumega (oprelvekin) (SP)Neupogen (filgrastim) (SP)Neurontin (gabapentin)*Nexavar (sorafenib) (QL) (SP)Next Choice (levonorgestrel)*Niaspan (niacin extended release)*Nilandron (nilutamide)Nimotop (nimodipine)*Nitro-Bid (nitroglycerin) ointmentNitro-Dur (nitroglycerin) patches*Nitrolingual (nitroglycerin) spray*Nitrostat (nitroglycerin) SL tabletsNizoral (ketoconazole)*Nizoral (ketoconazole) cream*Nolvadex (tamoxifen)*Norco (hydrocodone/acetaminophen)* (QL)Norflex (orphenadrine)*Norgesic (orphenadrine/aspirin/caffeine)*Norgesic Forte (orphenadrine/aspirin/

caffeine)*Norpace (disopyramide)*Norpace CR (disopyramide)Norpramin (desipramine)*Norvasc (amlodipine)*Norvir (ritonavir) (SP)Novolin 70/30 (insulin human NPH/R)Novolin N (insulin human NPH)Novolin R (insulin human regular)NovoLog (insulin aspart)NovoLog Mix 70/30

(insulin human aspart NPL/aspart)Noxafil (posaconazole) (SP)Nuedexta (dextromethorphan/quinidine) (SP)Nutropin AQ (somatropin) (PA) (SP)NuvaRing (ethinyl estradiol/etonogestrel) Nuvigil (armodafinil) (ST)Nydrazid (isoniazid)*

OOcufen (flurbiprofen)*Ocuflox (ofloxacin)*Ocupress (carteolol)*Odomzo (sonidegib) (PA) (QL) (SP)


36


O (cont.)Ogen (estropipate)*Ogestrel (ethinyl estradiol/norgestrel)*Olysio (simeprevir) (PA) (QL) (SP)Omnicef (cefdinir)*Onfi (clobazam) (PA) (SP)Onglyza (saxagliptin) (Januvia first) (ST)OOptiPranolol (metipranolol)*Oralair (grass mixed pollen allergen

extract) (PA) (QL)Orapred (prednisolone)*Orapred ODT (prednisolone sodium phosphate

orally disintegrating tablets)Orencia (abatacept) (PA) (SP)Orfadin (nitisinone) (SP)Ortho Evra (ethinyl estradiol/norelgestromin)* (QL)Ortho Tri-Cyclen (ethinyl estradiol/

norgestimate)*Ortho-Cept (ethinyl estradiol/desogestrel)*Ortho-Cyclen (ethinyl estradiol/norgestimate)*Ortho-Novum 1/35 (ethinyl estradiol/

norethindrone)*Ortho-Novum 1/50 (mestranol & norethindrone)*Ortho-Novum 7/7/7 (ethinyl estradiol/

norethindrone)*Orudis (ketoprofen)*Otezla (apremilast) (PA) (QL) (SP)Otrexup (methotrexate injection) (PA) (QL) (SP)Oxsoralen (methoxsalen) (PA) (SP)Oxsoralen-Ultra (methoxsalen) (PA) (SP)Oxycontin (oxycodone extended release)

PPamelor (nortriptyline)*Pamine (methscopolamine)*Panretin (alitretinoin) (SP)Parcopa (carbidopa/levodopa orally

disintegrating tablets)*Parafon Forte DSC (chlorzoxazone)*Paregoric (paregoric)*Parlodel (bromocriptine)*Parnate (tranylcypromine)*Patanol (olopatadine)Paxil (paroxetine)*Pegasys (peginterferon alfa-2a) (SP)PEGIntron (peginterferon alfa-2b) (SP)Pen-Vee K (penicillin VK)*Pennsaid (diclofenac sodium solution)Pepcid (famotidine) tablet*Percocet (oxycodone/acetaminophen)* (QL)Percodan (oxycodone/aspirin)*Peridex (chlorhexidine gluconate)*Persantine (dipyridamole)*Pertzye (amylase/lipase/protease)Phenergan (promethazine)*

P (cont.)Phenobarbital (phenobarbital)*PhosLo (calcium acetate)*Pilocar (pilocarpine)*Plan B One Step (levonorgestrel)*Plaquenil (hydroxychloroquine)*Plavix (clopidogrel)*Plegridy (peginterferon beta-1a) (SP)Plendil (felodipine extended release)*Pletal (cilostazol)*Plexion (sulfacetamide/sulfur)*Poly-Vi-FlorPoly-Vi-Flor with IronPolysporin (bacitracin/polymyxin B)*Polytrim (trimethoprim/polymyxin B)*Pomalyst (pomalidomide) (PA) (QL) (SP)Pradaxa (dabigatran etexilate)Praluent (alirocumab) (PA) (QL) (SP)Prandin (repaglinide)*Pravachol (pravastatin)*Precose (acarbose)*Pred Forte (prednisolone acetate)*Prefest (estradiol/norgestimate)Prelone (prednisolone) syrup*Premarin (conjugated estrogens) tablets,

vaginal creamPremphase (conjugated estrogens/

medroxyprogesterone)Prempro (conjugated estrogens/

medroxyprogesterone)Prenatal Plus*Prevacid (lansoprazole)*Prevpac (lansoprazole, amoxicillin, and

clarithromycin)*Prezista (darunavir) (SP)Priftin (rifapentine)Prilosec (omeprazole)*Principen (ampicillin)*Prinivil (lisinopril)*Prinzide (lisinopril/HCTZ)*Pro-Banthine (propantheline)*ProAir HFA (albuterol) inhalerProAir Respiclick (albuterol) inhalerProamatine (midodrine)*Procardia XL (nifedipine extended release)*Procrit (epoetin alfa) (SP)Proctofoam-HC (pramoxine/hydrocortisone)Prograf (tacrolimus)* (SP)Prolixin (fluphenazine)*Proloprim (trimethoprim)* Promacta (eltrombopag) (PA) (SP)Prometrium (progesterone)*Propylthiouracil (propylthiouracil)*Proscar (finasteride)*Protonix (pantoprazole)*

P (cont.)Protopic (tacrolimus)Proventil (albuterol) inhalation solution*Proventil (albuterol) tablet*, syrup*Proventil HFA (albuterol) inhalerProvera (medroxyprogesterone)*Provigil (modafinil)*Prozac (fluoxetine)*Pulmicort (budesonide) inhalerPulmicort Respules (budesonide)*Pulmozyme (dornase alfa) inhalation

solution (SP)Purinethol (mercaptopurine)** (SP)Pyrazinamide (pyrazinamide)*Pyridium (phenazopyridine)*

QQuestran (cholestyramine)*Questran Light (cholestyramine)*Qvar (beclomethasone) inhaler

RRagwitek (ragweed pollen allergen

extract) (PA) (QL) Ranexa (ranolazine) (PA)Rapamune (sirolimus)* (SP)Rasuvo (methotrexate injection) (PA) (QL) (SP)Razadyne (galantamine)*Rebetol (ribavirin)* (SP)Rebif (interferon beta-1a) (SP)Reglan (metoclopramide)*Regranex (becaplermin) (SP)Relafen (nabumetone)*Relpax (eletriptan) (QL)Remeron (mirtazapine)*Renvela (sevelamer) tablets*, powderRepatha (evolocumab) (PA) (QL) (SP)Requip (ropinirole)*Requip XL (ropinirole extended release)*Rescriptor (delavirdine) (SP)Restasis (cyclosporine) (SP)Restoril (temazepam)*Retin-A (tretinoin) cream*, gel*Retin-A Micro (tretinoin)*Retrovir (zidovudine)* (SP)Revatio (sildenafil)* (PA) (SP)ReVia (naltrexone)*Revlimid (lenalidomide) (PA) (QL) (SP)Reyataz (atazanavir) (SP)Rheumatrex (methotrexate)Rhinocort Aqua (budesonide)* (ST)Rifadin (rifampin)*Rilutek (riluzole)* (SP)Risperdal (risperidone)*Ritalin (methylphenidate)*Ritalin LA (methylphenidate extended release)*


37


R (cont.)Ritalin-SR (methylphenidate

extended release)*Rituxan (rituximab) (PA) (SP)Robaxin (methocarbamol)*Rocaltrol (calcitriol)*Rowasa (mesalamine)*Ruconest (recombinant C1 inhibitor) (PA) (SP)Rythmol (propafenone)*Rythmol SR (propafenone extended release)*

SSabril (vigabatrin) (PA) (SP)Saizen (somatropin) (PA) (SP)Sanctura (trospium)*Sanctura XR (trospium extended release)*Sandimmune (cyclosporine) capsules*,

solution (SP)Sandostatin (octreotide)* (SP)Seasonale (ethinyl estradiol/levonorgestrel)*Sectral (acebutolol)*Selsun Rx (selenium sulfide)*Selzentry (maraviroc) (SP)Sensipar (cinacalcet) (SP)Serax (oxazepam)*Serevent Diskus (salmeterol)Seroquel (quetiapine)*Serostim (somatropin) (PA) (SP)Serpasil (reserpine)*Silvadene (silver sulfadiazine)*Simponi (golimumab) (PA) (SP)Sinemet (carbidopa/levodopa)*Sinemet CR (carbidopa/levodopa extended

release)*Sinequan (doxepin)*Singulair (montelukast)*Skelaxin (metaxalone)Soma (carisoprodol)*Somavert (pegvisomant) injection (PA) (SP)Sonata (zaleplon)*Soriatane (acitretin)* (SP)Spiriva (tiotropium)Sprycel (dasatinib) (QL) (SP)SSKI (potassium iodide)Stadol NS (butorphanol)*Stalevo (carbidopa/entacapone/levodopa)*Stelara (ustekinumab) (PA) (SP)Stelazine (trifluoperazine)*Stimate (desmopressin) (SP)Stivarga (regorafenib) (PA) (SP)Strattera (atomoxetine)Stribild (elvitegravir, cobicistat, emtricitabine,

tenofovir) (SP)Suboxone (buprenorphine/naloxone

sublingual tablets)* (PA)

S (cont.)Subutex (buprenorphine)* (PA)Sucraid (sacrosidase) (SP)Sular (nisoldipine extended release)*Sulfacet-R (sulfur/sodium sulfacetamide)*Sulfamylon (mafenide) cream, lotion (SP)Sumycin (tetracycline)*Sustiva (efavirenz) (SP)Sutent (sunitinib) (QL) (SP)Sylatron (peginterferon alfa-2b) (SP)Symbicort (budesonide/formoterol)SymlinPen (pramlintide)Symmetrel (amantadine)*Synthroid (levothyroxine)**Syprine (trientine) (SP)

TTabloid (thioguanine) (QL) (SP)Tafinlar (dabrafenib) (PA) (QL) (SP)Tagamet (cimetidine) tablet*, solution*Talwin NX (pentazocine/naloxone)*Tambocor (flecainide)*Tapazole (methimazole)*Tarceva (erlotinib) (QL) (SP)Targretin (bexarotene) (SP)Tarka (trandolapril/verapamil extended release)*Tasigna (nilotinib) (QL) (SP)Tecfidera (dimethyl fumarate) (SP)Tegretol (carbamazepine)*Tegretol-XR (carbamazepine extended release)*Temodar (temozolomide)* (SP)Temovate (clobetasol) cream*, lotion*, gel*,

ointment*Temovate-E (clobetasol emollient) cream*Tenex (guanfacine)*Tenoretic (atenolol/chlorthalidone)*Tenormin (atenolol)*Tessalon (benzonatate)*Tev-Tropin (somatropin) (PA) (SP)Thalomid (thalidomide) (SP)Theo-Dur (theophylline)*Thorazine (chlorpromazine)*Ticlid (ticlopidine)*Tigan (trimethobenzamide)*Tikosyn (dofetilide) Timoptic (timolol)*Timoptic-XE (timolol)*Tindamax (tinidazole)*Tivicay (Dolutegravir) (SP)TOBI (tobramycin) inhalation solution* (SP)TobraDex (tobramycin/dexamethasone)

suspension*, ointmentTobrex (tobramycin) solution*Tofranil (imipramine)* Tofranil-PM (imipramine pamoate)*

T (cont.)Tolectin (tolmetin)*Topamax (topiramate)*Topicort (desoximetasone) cream*, gel*,

ointment*Topicort LP (desoximetasone) cream*Toprol-XL (metoprolol extended release)*Toradol (ketorolac)* (QL)Toujeo (insulin human glargine)Tracleer (bosentan) (PA) (SP)Tradjenta (linagliptin) (Januvia first) (ST)Trandate (labetalol)*Tranxene (clorazepate)*Travatan Z (travoprost)Travoprost*Trental (pentoxifylline)*Tri-Vi-Flor*Tricor (fenofibrate)*Trilafon (perphenazine)*Trileptal (oxcarbazepine) tablets*, suspension*Trilipix (fenofibric acid delayed release)*Trilisate (choline magnesium trisalicylate)*Trivora (ethinyl estradiol/levonorgestrel)*Trizivir (abacavir/lamivudine/zidovudine)* (SP)Trulicity (dulaglutide)Trusopt (dorzolamide)*Truvada (emtricitabine/tenofovir) (PA) (SP)Tudorza Pressair (aclidinium)Tykerb (lapatinib) (SP)Tylenol with Codeine (acetaminophen/

codeine)* (QL)Tyvaso (treprostinil) (PA) (SP)Tyzeka (telbivudine) (SP)

UUceris (budesonide extended release) (PA) (QL)Ultracet (tramadol/acetaminophen)* (QL)Ultram (tramadol)*Ultram ER (tramadol extended release)*Ultravate (halobetasol) cream*, ointment*Unithroid (levothyroxine)**Univasc (moexipril)*Uroxatral (alfuzosin)*

VValcyte (valganciclovir) (SP)Valium (diazepam)*Valtrex (valacyclovir)* (QL)Vancocin (vancomycin)*Vascepa (icosapent ethyl) (restricted to

Cardiology)Vaseretic (enalapril/HCTZ)* Vasocidin (sodium sulfacetamide/

prednisolone)*Vasotec (enalapril)*


38


Drug Formulary Medications Alphabetically (continued)V (cont.)Ventavis (iloprost) (SP)Ventolin HFA (albuterol) inhalerVePesid (etoposide)*Verelan PM (verapamil extended release)*Versed (midazolam)*Vesanoid (tretinoin)* (SP)Vfend (voriconazole)* (SP)Vicodin (hydrocodone/acetaminophen)* (QL)Vicodin ES (hydrocodone/acetaminophen)* (QL)Victoza (liraglutide)Victrelis (boceprevir) (PA) (SP)Videx (didanosine) (SP)Videx EC (didanosine)* (SP)Vimpat (lacosamide)Viramune (nevirapine)* (SP)Viread (tenofovir) (SP)Viroptic (trifluridine)*Visken (pindolol)*Vistaril (hydroxyzine pamoate)*Voltaren (diclofenac)*Voltaren (diclofenac) solution*Vosol (acetic acid)*Vosol HC (acetic acid/hydrocortisone)*Vospire ER (albuterol extended release) tablet*Votrient (pazopanib) (QL) (SP)Vyvanse (lisdexamfetamine)

WWelchol (colesevelam)Wellbutrin (bupropion)* Wellbutrin SR (bupropion extended release)*Wellbutrin XL (bupropion extended

release)* (QL)Westcort (hydrocortisone valerate) cream*,

ointment*

XXalatan (latanoprost)*Xalkori (crizotinib) (PA) (SP)Xanax (alprazolam)*Xarelto (rivaroxaban)Xeljanz (tofacitinib) (PA) (SP)Xeloda (capecitabine)* (SP)Xifaxan (rifaximin) (PA) (SP)Xopenex (levalbuterol)*Xtandi (enzalutamide) (PA) (SP)Xylocaine (lidocaine) gel*, ointment*Xyrem (sodium oxybate) (PA) (QL) (SP)

YYasmin (ethinyl estradiol/drospirenone)*

ZZanaflex (tizanidine)*Zantac (ranitidine) tablet*Zarontin (ethosuximide)*Zaroxolyn (metolazone)*Zavesca (miglustat) (SP)Zebeta (bisoprolol)*Zelboraf (vemurafenib) (PA) (SP)Zemplar (paricalcitriol)* (PA)Zerit (stavudine)* (SP)Zestoretic (lisinopril/HCTZ)*Zestril (lisinopril)*Ziac (bisoprolol/HCTZ)*Ziagen (abacavir)* (SP)Zithromax (azithromycin)*Zocor (simvastatin)*Zofran (ondansetron)* (QL)Zolinza (vorinostat) (QL) (SP)Zoloft (sertraline)*Zomacton (somatropin) (PA) (SP) (ST)Zomig (zolmitriptan)* (QL)Zonegran (zonisamide)*Zorbtive (somatropin) (PA) (SP)Zortress (everolimus) (SP)Zovia (ethinyl estradiol/ethynodiol diacetate)*Zovirax (acyclovir) capsule*, suspension*, tablet*Zyloprim (allopurinol)*Zyprexa (olanzapine)*Zytiga (abiraterone acetate) (PA) (SP)Zyvox (linezolid) (SP)


39

40

Please Note: On pages 40–43 and 49–51 “we/us/our” refers to SilverScript Insurance Company.

The information listed below is brief excerpts from your Evidence of Coverage (EOC). If you wantmore detailed information, please refer to your EOC. If you want a printed copy, feel free to contact

SilverScript Customer Care 24 hours a day, 7 days a week toll-free at866.425.9732 (TTY users should call toll-free at 866.236.1069.).

Generic Medication PolicyGenerally, a “generic” drug works the same as a brand drug and usually costs less. In most cases, when ageneric version of a brand name drug is available, our network pharmacies will provide you with the genericversion. Usually, the brand name drug will not be covered when the generic version is available. However,if your provider has told us the medical reason that neither the generic drug nor other covered drugs thattreat the same condition will work for you, then we will cover the brand name drug. (Your share of the costmay be greater for the brand name drug than for the generic drug.)

Note: If a member or physician requests the brand name drug be dispensed when a generic is available, themember will be required to pay their generic co-insurance AND the cost difference between the brand namedrug price and the generic drug price.

The Cleveland Clinic HBP supports and encourages the use of FDA-approved generic medications thatare both chemically and therapeutically equivalent to manufacturers’ brand name products. Genericallyequivalent products are safe and effective treatments that offer savings as alternatives to brand name products.

Medications that are available as generics for Medicare eligible and approved retirees are listed in the SilverScriptPlatinum Formulary in lower case italics.

Prior Authorizations/Coverage Decisions/Appeals ProcessFor certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctorsand pharmacists develop these rules to help our members use drugs in the most effective ways. These specialrules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe andeffective. When a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s rulesare designed to encourage you and your provider to use that lower-cost option. We also need to complywith Medicare’s rules and regulations for drug coverage and cost.

If your drug is not covered, you or your provider will need to get approval from the plan before we will agree tocover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approvalin advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug mightnot be covered by the plan. A copy of this form is located in the back of this Handbook. Or you may find theform on our website at: http://clevelandclinic.silverscript.com under the documents tab. Click the “PriorAuthorization” link.

Health Benefit Program Prescription Drug Benefitfor Medicare Eligible and Approved Retirees(Administered by SilverScript® Insurance Company)

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You and your provider may ask the plan to make an exception for you and cover the drug in the way youwould like it to be covered. If your provider says that you have medical reasons that justify asking for anexception, your provider can help you request an exception to the rule.

A “coverage decision” is a decision we make about your benefits and coverage or about the amount we will payfor your prescription drugs. We are making a coverage decision for you whenever we decide what is coveredfor you and how much we pay. In some cases we might decide a drug is not covered or is no longer coveredby Medicare for you. If you disagree with this coverage decision, you can make an appeal.

An “appeal” is a formal way of asking us to review and change a decision we have made. When you make anappeal, we review the decision we have made to check to see if we were following the rules properly. Yourappeal is handled by different reviewers than those who made the unfavorable decision. When we havecompleted the review we give you or your provider our decision.

If we say no to all or part of your Level 1 Appeal, you can ask for a Level 2 Appeal. Level 2 Appeal is conductedby an independent organization that is not connected to us. If you are not satisfied with the decision at theLevel 2 Appeal, you may be able to continue through additional levels of appeal. Please see your Evidence ofCoverage for further details.

Appointing a RepresentativeYou can ask someone to act on your behalf. If you want to, you can name another person to act for you asyour “representative” to ask for a coverage decision or make an appeal.

Examples:

• There may be someone who is already legally authorized to act as your representative under State law.

• If you want a friend, relative, your doctor or other prescriber, or other person to be your representative,call SilverScript Customer Care 24 hours a day, 7 days a week toll-free at 866.425.9732 (TTY users shouldcall toll-free at 866.236.1069.) and ask for the “Appointment of Representative” form. (This form is alsoavailable on our website: http://clevelandclinic.silverscript.com under the documents tab. Click the“Appointment of Representative Form.”)

Coverage Stages Section 5 of your Evidence of Coverage will explain the various coverage stages that a member may reachduring the course of the year. These stages are called: Deductible, Initial Coverage, Coverage Gap, andCatastrophic Coverage.

Please note: Explanation of Benefits (EOB) provided by SilverScript each month will not factor in youradded HPB program.

DeductibleThe deductible will be $100 per individual. If you fill your generic medication at a Cleveland Clinic Pharmacy,your deductible will be waived. Brand medications or medications filled outside of a Cleveland ClinicPharmacy will be subjected to the $100 deductible.

Initial Coverage StageDuring the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs andyou pay your share. Your share of the cost will vary depending on the drug and where you fill your prescriptions.You will stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filledreaches the $2,960.00 limit for the Initial Coverage Stage.

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Coverage Gap StageThe Cleveland Clinic HBP is providing additional coverage that is keeping your co-insurances consistentthrough the Coverage Gap. Therefore, you will see no change in co-payments until you qualify for Cata-strophic Coverage. When you reach an out-of-pocket limit of $4,700.00, you leave the Coverage Gap Stage.

Catastrophic Coverage StageYou qualify for the Catastrophic Coverage Stage when your true-out-of-pocket (TrOOP) costs have reached the$4,700.00 limit for the plan year. Once you are in Catastrophic Coverage Stage, you will stay in this paymentstage until the end of the plan year.

During this stage, the plan will pay most of the cost for your drugs. During this stage, you will pay no morethan: the greater of 5% co-insurance or $2.65 for generic drugs (or drugs treated as generic) and $6.60 for allother drugs. The HBP will pay the rest.

Please refer to your Evidence of Coverage and any amendments you may receive fromSilverScript that describe the benefit program coverage. The Evidence of Coveragealso list exclusions (benefits that are not covered). Please refer to Chapter 7 foradditional information on what to do if you have a problem or a complaint (coveragedecisions, appeals, or complaints). If you would like a printed copy, feel free to contactSilverScript Customer Care 24 hours a day, 7 days a week toll-free at 866.425.9732.TTY users should call toll-free at 866.236.1069.

Request for Redetermination ofMedicare Prescription Drug Denial (Appeal)If SilverScript Insurance Company denies your request for coverage of (or payment for) a prescriptionmedication, you have the right to ask for a redetermination (appeal) of their decision. You have 60 days fromthe date of their Notice of Denial of Medicare Prescription Drug Coverage to ask for a redetermination. TheRedetermination Form (sample on page 43) is available on SilverScript’s website at www.silverscript.comor on the EHP website at www.clevelandclinic.org/healthplan. Click on the Retiree button on the left. Thecompleted form should be sent to:

Appeals DepartmentMC109P.O. Box 52000Phoenix, AZ 85072-2000

Fax number: 855.633.7373

You can also ask for an appeal via the SilverScript website at www.silverscript.com. Expedited appeal requestscan be made by phone at 866.884.9479 (TTY866.236.1069). Call the toll-free numbers 24 hours a day, 7 daysa week.

Who May Make a Request: Your prescriber may ask SilverScript for an appeal on your behalf. If you wantanother individual (such as a family member or friend) to request an appeal for you, that individual mustbe your representative. Contact SilverScript to learn how to name a representative.

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Redetermination of Medicare Prescription Drug Denial Form

SilverScript Medicare Part D Coverage Determination Request FormSee page 49 in the back of this Handbook for full size usable form.

Benefits and Coverage ClarificationDetailed benefit coverage clarification information about the HBP Prescription Drug Benefit is includedin the following pages. This information complements and further explains the Prescription Drug Benefitchart on page 3 in this Handbook and in the SPD, Section One: “Getting Started.”

Contraceptive CoverageUnder the provisions of the Affordable Care Act mandate regarding women’s preventative health services,contraceptives will be covered under the HBP Prescription Drug Benefit within the following guidelines:

• Diaphragms, emergency contraceptives, generic oral contraceptives, generic injectables (medroxyprog-esterone), Nuvaring, and Ortho Evra will be covered with no out-of-pocket expense for the member. However, a prescription from your health care provider is required.

• Brand name oral contraceptives that are not available generically require prior authorization. If theprior authorization request is approved, the member will not have any out-of-pocket expense. If the priorauthorization request is denied, the brand name contraceptive will not be covered.

• Members who receive a brand name formulation of a contraceptive that is available generically will notpay any co-insurance but will be charged the difference in cost between the brand name contraceptiveproduct and the generic alternative.

• Contraceptive products that do not require a prescription to be purchased are not covered under the HBPPrescription Drug Benefit.

• Members who are employed at Marymount Hospital are excluded from this coverage since 2014.

• Mirena and other intrauterine devices (IUDs) are not covered under the HBP Prescription Drug Benefit.Rather, they are covered under the medical benefit and no co-payment will be charged.

SAMPLE

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Sharps Container ProgramMembers who obtain their self-administered injection medications from the Cleveland Clinic Pharmaciesare eligible to receive one Sharps Container (1.5 quart size) every six months at no cost.

Please note that the Cleveland Clinic Pharmacies in Cleveland and the Cleveland Clinic Weston Pharmacycannot take back full containers. Each container should be disposed of properly. Should you have additionalquestions, please contact your Cleveland Clinic pharmacist.

Quantity Level LimitsQuantity level limits are applied to medications for several reasons, including preventing medication misuseor abuse; ensuring appropriate, effective and safe courses of therapy; and preventing the stockpiling ofmedication. The table below lists the medications included in the SilverScript Quantity Limit Program.

• Aciphex — 30 tablets per 30 days

• Actos 15mg — 90 tablets per 30 days



• Advair — 1 inhaler per 30 days

• Alinia — 12 tablets per 30 days

• Alvesco — 2 inhalers per 30 days

• Amaryl — 240 tablets per 30 days

• Ambien — 30 tablets per 30 days

• Ambien CR — 30 tablets per 30 days

• Amerge — 9 tablets per 30 days

• Asmanex — 2 inhalers per 30 days

• Atrovent — 2 inhalers per 30 days

• Avinza — 60 tablets per 30 days

• Axert — 12 tablets per 30 days

• Azelastine — 2 bottles per 30 days

• Beconase — 2 inhalers per 30 days

• Butorphanol — 3 bottles per 30 days

• Colcrys — 60 tablets per 30 days

• Combivent — 2 inhalers per 30 days

• Dexilant — 30 tablets per 30 days

• Diabeta 1.25mg — 480 tablets per 30 days

• Diabeta 2.5mg — 240 tablets per 30 days

• Diabeta 5mg — 120 tablets per 30 days

• Dolophine — 240 tablets per 30 days

• Dulera — 1 inhaler per 30 days

• Duragesic — 10 patches per 30 days

• Edluar — 30 tablets per 30 days

• Embeda — 60 tablets per 30 days

• Exalgo — 60 tablets per 30 days

• Flonase — 1 bottle per 30 days

• Flovent HFA — 2 inhalers per 30 days

• Flunisolide — 2 bottles per 30 days

• Foradil — 60 caps per 30 days

• Frova — 18 tablets per 30 days

• Glucophage 500mg — 150 tablets per 30 days



• Glucophage XR 120mg — 120 tablets per 30 days

• Glucophage XR 750mg — 90 tablets per 30 days

• Glucotrol 5mg — 240 tablets per 30 days

• Glucotrol 10mg — 120 tablets per 30 days

• Glucotrol XL 2.5mg — 240 tablets per 30 days

• Glucotrol XL 5mg — 120 tablets per 30 days

• Glucotrol XL 10mg — 60 tablets per 30 days

• Glycron — 90 tablets per 30 days

• Glynase 1.5mg — 240 tablets per 30 days

• Glynase 3mg — 120 tablets per 30 days

• Glynase 6mg — 60 tablets per 30 days

• Imitrex Injection — 20 vials per 30 days

• Imitrex Tab — 9 tablets per 30 days

• Kadian — 60 tablets per 30 days

• Lamisil — 90 tablets per 365 days

• Lumigan — 1 bottle per 30 days

• Lunesta — 30 tablets per 30 days

• Lyrica — 120 caps per 30 days

• Lyrica 300mg — 60 caps per 30 days

• Maxalt — 12 tablets per 30 days

• Maxalt-MLT — 12 tablets per 30 days

• Migranal — 8 bottles per 30 days

• MS Contin — 90 tablets per 30 days

• MS Contin 200mg — 60 tablets per 30 days

• Nasacort — 1 inhaler per 30 days

• Nasonex — 2 inhalers per 30 days

• Neurontin 300mg — 360 caps per 30 days




• Nexium — 30 tablets per 30 days

• Omnaris — 1 inhaler per 30 days

45

• Opana ER — 120 tablets per 30 days

• Oramorph SR — 90 tablets per 30 days

• Oxycontin CR — 120 tablets per 30 days

• Prevacid — 30 tablets per 30 days

• Prilosec 10mg or 40mg — 30 tablets per 365 days

• Prilosec 20mg — 60 tablets per 365 days

• ProAir — 2 inhalers per 30 days

• Protonix — 30 tablets per 30 days

• Proventil — 2 inhalers per 30 days

• Pulmicort Flexhaler 90mcg — 4 inhalers per 30 days

• Pulmicort Flexhaler 180mcg — 2 inhalers per 30 days

• QVAR — 3 inhalers per 30 days

• Relpax — 12 tablets per 30 days

• Rhinocort — 2 inhalers per 30 days

• Rozerem — 30 tablets per 30 days

• Sancuso — 4 patches per 30 days

• Serevent — 1 inhaler per 30 days

• Sonata — 30 caps per 30 days

• Spiriva — 30 caps per 30 days

• Symbicort — 1 inhaler per 30 days

• Travatan-Z — 2.5 ml per 30 days

• Treximet — 9 tablets per 30 days

• Ventolin HFA — 2 inhalers per 30 days

• Veramyst — 1 bottle per 30 days

• Victoza — 3 pens per 30 days

• Xalatan — 1 bottle per 30 days

• Xopenex HFA — 2 inhalers per 30 days

• Zegerid — 1 packet per 30 days

• Zomig 2.5mg or 5mg — 12 tablets per 30 days

• Zomig-ZMT — 12 tablets per 30 days

Prescription Drug Benefit Exclusions11. The replacement of lost or damaged prescriptions.17 Stolen medications will be covered at the benefit

program rate when accompanied by a police report.

12. Drugs prescribed for the treatment of sexual dysfunction.

13. Drugs to enhance libido function.

14. Enteral feedings, food supplements, lactose-free foods, specialized formulas, vitamins and/or mineralsthat do not require a prescription are not covered, even if they are required to maintain weight or strengthand regardless of whether these are prescribed by a physician.

15. Drugs used for experimental or investigational purposes.

16. Drugs that can be purchased without a prescription.

17. Drugs used for cosmetic purposes.

18. Drugs used for the treatment of infertility.

19. Drugs not included in the Patient Protection and Affordable Care Act that can be purchased withouta prescription.

10. Medicinal foods (regardless of whether they require a prescription or not).

Quantity Level Limits (continued)

17 Members may contact Pharmacy Coordination at 216.986.1050, option 4 or toll-free at 888.246.6648, option 4between the hours of 8 a.m. and 4:30 p.m., Monday through Friday to request an override so that they are able topurchase a replacement supply at their expense. The member will be responsible for 100% of the discounted price.

46

Notes

47

Patient Name:

Patient EHP Insurance ID Number: Patient DOB:

Requesting Physician’s Name:

Office Phone Number: Office Fax Number:

Requesting Physician’s Signature: Date:

Requesting Medication:

Strength: Quantity: Dosage Regimen:

Diagnosis:

Medical Rationale for Requested Medication:

Formulary Agents Tried and Failed by the Patient:

Dates Used Documentation ofDrug & Strength Dosing Regimen (Approximate) Treatment Failure

Please Note: Completion of this form does not guarantee approval. Requests are reviewed on all available information.Decisions are generally made within two business days, but may take longer pending clinical review.Decision letters will be sent via fax to the requesting provider and to the patient via U.S. mail.

Internal Use Only: DO NOT WRITE BELOW

EHP Pharmacy ManagementQuestions? Call 216.986.1050, option 4 or 888.246.6648, option 4.

Please complete this form and return via fax: 216.442.5790.

Cleveland Clinic✓ Appropriate Box❏ Prior Authorization❏ Formulary Exception❏ Appeal

Rev. 2/2016

Medical Pharmacy MDR OutcomeApproved Tier 1 Initial Determination Provider 1st Level Approved

Approved Tier 2 Member 1st Level Provider 2nd Level Denied

Denied Member 2nd Level External Review Peer-to-Peer

2/2016

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