ACA 5-Tier Drug List For Individual PPO and Small Group HMO, POS, and PPO plans (including Marketplace/QHP plans) with ACA-compliant coverage becoming effective on or after January 1, 2014 Effective January 1, 2014 What is the Drug List? Also called a “formulary” by doctors and pharmacists, the Drug List is an extensive list of safe and effective, FDA-approved, brand name and generic prescription drugs used to treat the most common medical conditions. The Health First Pharmacy and Therapeutics Committee (P&T), a panel of physicians and pharmacists, developed our Drug List and updates it regularly. The list includes quality drugs available to you at reasonable cost. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included. The Pharmacy and Therapeutics Committee reviews and evaluates all available literature about a drug when updating the list. About tiers Most covered prescription drugs will be categorized into one of five tiers. The cost of drugs varies widely, even though several different medications may be used to treat the same condition. What you pay for the prescription depends upon what tier the drug is listed in. Health First offers many benefit plans that can vary in coverage for each tier. Details about your specific benefit for each tier are included in the Health First Summary of Benefits. • Tier 1 — Preferred Generic Drugs • Tier 2 — Non-Preferred Generic Drugs • Tier 3 — Preferred Brand Name Drugs and some generics • Tier 4 — Non-Preferred Brand Name Drugs and some generics (limited to a 30-day supply) • Tier 5 — Specialty Drugs (limited to a 30-day supply, must obtain from Health First Family Pharmacy) Generic drugs are prescription drugs that are identified by their chemical name. When the patent has expired on a brand name drug, the FDA permits new manufacturers to create an equivalent of the brand name drug and make it available to the public. Updated January 1, 2014 Generally, more than one manufacturer will create generic versions, although often the same pharmaceutical firm that produces the brand name drug also makes the generic version. This prompts competitive pricing of the generic version and usually results in a less expensive drug. The Drug List is subject to change In order to continue to offer a safe and cost effective selection of prescription drugs, Health First periodically makes changes to the Drug List. These changes may include removing medications, adding restrictions, and/or covering a drug at a higher tier. The following list represents some of the most common scenarios in which changes to drug coverage will occur: • Throughout the year, new medications are approved by the FDA. It is the policy of Health First that new drugs will be excluded for 6 months from the date of FDA approval, during which time the Health First Pharmacy and Therapeutics Committee can review the drug for safety and efficacy. • The Drug List may change when a medication is withdrawn from the market due to safety reasons or if it becomes available over-the-counter (OTC). At the time that a medication on the Health First Drug List becomes available OTC, it may be excluded from coverage from that point forward. • When a brand-name prescription drug loses its patent and the equivalent generic form is added to the Drug List, the brand-name drug may be moved to the highest non-specialty drug tier, which is generally Tier 4 or removed from the formulary. This formulary is current as of January 1, 2014. To get updated information about covered drugs, please visit our Web site at HealthFirstHealthPlans.org or call Customer Service toll-free Monday through Friday, 8am–8pm, and Saturday, 8am–Noon: • For HMO and POS members: 1-800-716-7737 • For PPO members: 1-855-443-4735 Health First—ACA 5-Tier Drug List • TTY/TDD relay 1-800-955-8771 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: Health First requires you and/or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. In order for the plan to pay for these drugs, the physician ordering the prescription is required to submit all medical information to Health First documenting the medical necessity. These drugs are identified in the Drug List. • Step Therapy: In some cases, Health First requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Please see the reference table on page 9 for a complete listing of the drugs which currently require step therapy. • Quantity Limits: For certain drugs, Health First limits the amount of the drug that Health First will cover. For example, Health First provides 30 tablets per prescription for Pradaxa. This may be in addition to a standard one month or three month supply. How can I make the most of my prescription drug benefit? Prescription drug costs continue to rise every year and can represent a significant part of your healthcare expenses. Health First can help you pay for your medications by sharing the cost with you and providing substantial discounts for medications you purchase. To help you manage your drug costs, here are some money-saving tips to consider: • Use Tier 1 generic medications whenever possible. Generic drugs are the chemical equivalent of brand-name drugs, and are just as effective in most cases. If you take generic drugs you will generally pay less, so talk to your doctor about switching to a generic equivalent of any brandname you are taking if it is appropriate. In addition, Page 2 many of our prescription drug riders include a $2 copayment for Tier 1 generic drugs ensuring affordable access to many commonly prescribed medications. Please see the list of drugs below to determine which drugs are included in Tier 1. • See if your prescription pills can be split in half For some medications, pills may be available in different strengths but still have the same price. If you need one of these select medications, your doctor may be able to write your prescription so that you can get your pills at double strength, but half of the number of pills you’d normally need, and you’d only pay half of the regular price. Then you’d split them in half, so you’d get the proper dose—saving up to 50 percent of the cost! The drugs that may be eligible for the Pill-Splitting program are marked with the symbol (1/2) on the drug list, so review this information with your doctor if your drug qualifies. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that Health First does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by Health First. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Health First. • You can ask Health First to make an exception and cover your drug. See below for information about how to request an exception. • If Health First approves you or your physician’s request for an exception to the Health First formulary the approved drug will be covered at the Tier 4 cost share. If the cost of the medication is greater than $500 per month it will be covered at the T5 or Specialty Tier. Excluded drugs Health First does not provide coverage for all drugs. In addition to the drugs marked “excluded” in this drug list, newly FDA approved drugs are not covered unless the P & T Committee in its sole discretion approves these drugs for coverage. Health First will automatically exclude a particular drug if a generic version becomes available and an entire class of drugs if a particular drug within that class becomes available over the counter. Health First—ACA 5-Tier Drug List Page 3 Health First Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by Health First. If you have trouble finding your drug in the list, turn to the Index that begins on page 65. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if Health First has any special requirements for coverage of your drug. SP: Specialty Pharmacy. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at the numbers listed above. PA: Prior Authorization. Health First requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health First before you fill your prescriptions. If you don't get approval, Health First may not cover the drug. QL: Quantity Limit may also be listed. (For example, “30/30 days” would mean your coverage of this drug is limited to 30 pills every 30 days.) Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount. ST: Step Therapy. In some cases, Health First requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Health First may not cover drug B unless you try Drug A first. If Drug A does not work for you, Health First will then cover Drug B. 1/2: You may be able to split these pills in half. Begin by asking your doctor if pill-splitting is right for you. If so, ask your doctor to write your prescription for half the number of pills and double the strength you normally need. For example, instead of 30 pills of 20 mg, you’d get a prescription for 15 pills of 40 mg. Then you (or the pharmacy) can split them in half for the correct dose. This way, you save 50 percent of the cost. Call our Customer Service Department for details. MD: Maintenance Drug. You may be taking these drugs on a long-term basis. Maintenance medications are generally those used to treat chronic conditions and long-term conditions. For information about a specific drug not listed, please contact Customer Service. Health First Customer Service is available Monday–Friday, 8am–8pm, and Saturday, 8am–Noon. TTY is available during the same hours. For HMO and POS members — (800) 716-7737 For PPO members — (855) 443-4735 TDD/TTY relay — (800) 955-8771 E-mail — [email protected] PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List Page 4 Contraceptive coverage Beginning August 1, 2012, members are eligible to receive the following prescription contraceptives with no cost share due to the preventive care provisions of the Affordable Care Act. NECON 0.5/35-28 NECON 1/35-28 NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) CYCLAFEM 1/35 ALYACEN 1/35 LOW-OGESTREL CRYSELLE-28 NORGESTREL/ETHINYL ESTRADIOL NECON 7/7/7 NORTREL 7/7/7 CYCLAFEM 7/7/7 ALYACEN 7/7/7 TRI-SPRINTEC TRINESSA TRI-PREVIFEM NORGESTIMATE/ETHINYL ESTRADIOL If you have any questions regarding your eligibility for preventive contraceptive coverage, please contact your employer or Health First’s Customer Service Department Monday–Friday, 8am–8pm, and Saturday, 8am– Noon. For HMO and POS members — (800) 716-7737 For PPO members — (855) 443-4735 TDD/TTY relay — (800) 955-8771 E-mail — [email protected] PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants Amphetamines Amphetamine Mixtures amphetamine-dextroamphetamine Amphetamines dextroamphetamine sulfate oral tablet 10 MG, 5 MG methamphetamine hcl VYVANSE Attention-Deficit/Hyperactivity Disorder (ADHD) Agents ADHD Agent - Selective Alpha Adrenergic Agonists INTUNIV ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG ADHD Agent - Selective Norepinephrine Reuptake Inhibitor STRATTERA Stimulants - Misc. Stimulants - Misc. CONCERTA ORAL TABLET EXTENDEDRELEASE 18 MG, 27 MG, 36 MG dexmethylphenidate hcl FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG METHYLIN ORAL TABLET CHEWABLE methylphenidate hcl oral solution methylphenidate hcl oral tablet NUVIGIL PROVIGIL Aminoglycosides Aminoglycosides Aminoglycosides neomycin sulfate oral tablet paromomycin sulfate oral Analgesics - Anti-Inflammatory Gold Compounds Gold Compounds RIDAURA Interleukin-1 Blockers Page 5 TIER NOTES T2 T2 T3 T4 ST T4 PA T4 PA T3 ST T3 T4 ST T2 T2 T2 T4 T4 PA PA T4 T4 T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Interleukin-1 Blockers ARCALYST Interleukin-6 Receptor Inhibitors Interleukin-6 Receptor Inhibitors ACTEMRA INTRAVENOUS SOLUTION 80 MG/4ML Nonsteroidal Anti-Inflammatory Agents (NSAIDS) Cyclooxygenase 2 (Cox-2) Inhibitors CELEBREX Nonsteroidal Anti-Inflammatory Agents (NSAIDS) diclofenac potassium oral tablet diclofenac sodium oral tablet delayed release 50 MG, 75 MG etodolac oral tablet fenoprofen calcium oral tablet flurbiprofen oral ibuprofen oral tablet 400 MG indomethacin oral capsule ketoprofen oral ketorolac tromethamine oral meclofenamate sodium oral mefenamic acid oral meloxicam oral tablet meloxicam oral suspension nabumetone oral naproxen oral tablet naproxen sodium oral tablet 275 MG, 550 MG oxaprozin piroxicam oral capsule 20 MG PONSTEL sulindac oral tolmetin sodium Pyrimidine Synthesis Inhibitors Pyrimidine Synthesis Inhibitors leflunomide oral Soluble Tumor Necrosis Factor Receptor Agents Soluble Tumor Necrosis Factor Receptor Agents ENBREL SUBCUTANEOUS KIT Page 6 TIER NOTES T5 PA T5 PA T4 ST T2 T3 T2 T4 T2 T1 T2 T2 T3 T4 T5 T1 T2 T3 T1 T2 T3 T3 T3 T2 T3 T3 T5 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Analgesics - Nonnarcotic Salicylates Salicylates diflunisal oral Analgesics - Opioid Opioid Agonists Opioid Agonists fentanyl transdermal fentanyl citrate buccal lollipop hydromorphone hcl oral tablet levorphanol tartrate oral meperidine hcl oral tablet 50 MG methadone hcl oral tablet morphine sulfate oral tablet morphine sulfate er oral tablet extendedrelease morphine sulfate er beads oral capsule extended release 24 hour 30 MG, 60 MG NUCYNTA NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG oxycodone hcl oral tablet 15 MG, 30 MG, 5 MG oxymorphone hcl oral oxymorphone hcl er oral tablet extended release 12 hr 15 MG, 7.5 MG tramadol hcl oral tablet tramadol hcl er oral tablet extended release 24 hr 100 MG, 200 MG tramadol hcl er oral tablet extended release 24 hr 300 MG Opioid Combinations Opioid Combinations oxycodone-ibuprofen Opioid Partial Agonists Opioid Partial Agonists buprenorphine hcl sublingual tablet sublingual 8 MG butorphanol tartrate injection solution 2 MG/ML Androgens-Anabolic Anabolic Steroids Anabolic Steroids Page 7 TIER NOTES T4 T4 T5 T2 T4 T2 T2 T2 T3 T5 PA T4 T5 PA PA T2 T3 T3 T2 T3 T3 ST T3 T4 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME oxandrolone oral Androgens Androgens ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%) ANDROXY danazol oral DEPO-TESTOSTERONE INTRAMUSCULAR OIL 200 MG/ML testosterone cypionate intramuscular testosterone enanthate intramuscular Anorectal Agents Intrarectal Steroids Intrarectal Steroids COLOCORT hydrocortisone re enema Vasodilating Agents Nitrate Vasodilating Agents RECTIV Anthelmintics Anthelmintics Anthelmintics ALBENZA BILTRICIDE STROMECTOL Antianginal Agents Antianginals-Other Antianginals-Other RANEXA Nitrates Nitrates DILATRATE-SR isosorbide dinitrate oral tablet 10 MG, 20 MG, 30 MG, 5 MG isosorbide dinitrate sublingual tablet sublingual 2.5 MG isosorbide dinitrate er oral tablet extendedrelease isosorbide mononitrate oral tablet 20 MG NITROSTAT Page 8 TIER NOTES T2 T3 T3 T2 T3 T2 T2 ST ST T2 T2 T4 T3 T4 T3 T4 ST T2 T2 T2 T2 T2 T3 Antianxiety Agents PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Antianxiety Agents - Misc. Antianxiety Agents - Misc. buspirone hcl oral tablet 10 MG, 5 MG, 7.5 MG hydroxyzine hcl oral solution hydroxyzine hcl oral tablet hydroxyzine pamoate oral meprobamate Antiarrhythmics Antiarrhythmics Type I-A Antiarrhythmics Type I-A disopyramide phosphate oral NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 150 MG procainamide hcl injection quinidine gluconate er quinidine sulfate oral quinidine sulfate er Antiarrhythmics Type I-C Antiarrhythmics Type I-C flecainide acetate propafenone hcl Antiarrhythmics Type III Antiarrhythmics Type III amiodarone hcl oral tablet 200 MG, 400 MG MULTAQ TIKOSYN Antiasthmatic And Bronchodilator Agents Anti-Inflammatory Agents Anti-Inflammatory Agents cromolyn sodium inhalation Bronchodilators - Anticholinergics Bronchodilators - Anticholinergics ipratropium bromide inhalation SPIRIVA HANDIHALER Leukotriene Modulators 5-Lipoxygenase Inhibitors ZYFLO CR Page 9 TIER NOTES T2 T2 T2 T2 T2 T2 T5 T3 T2 T2 T3 PA T2 T2 T2 T4 T5 PA T2 T2 T3 T4 ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Leukotriene Receptor Antagonists zafirlukast Steroid Inhalants Steroid Inhalants ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES budesonide inhalation suspension 0.25 MG/2ML, 0.5 MG/2ML FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER Sympathomimetics Adrenergic Combinations ADVAIR DISKUS ADVAIR HFA DULERA Beta Adrenergics albuterol sulfate inhalation nebulization solution (2.5 MG/3ML) 0.083%, 1.25 MG/3ML albuterol sulfate oral ARCAPTA NEOHALER BROVANA FORADIL AEROLIZER levalbuterol hcl inhalation nebulization solution 1.25 MG/0.5ML MAXAIR AUTOHALER metaproterenol sulfate oral syrup metaproterenol sulfate oral tablet PROVENTIL HFA terbutaline sulfate oral Mixed Adrenergics epinephrine hcl injection solution 0.1 MG/ML Xanthines Xanthines LUFYLLIN theophylline er oral tablet extended release 12 hr Page 10 TIER NOTES T2 T4 T4 T4 T4 T3 T4 T4 T4 T4 T4 T4 T2 T2 T4 T5 T4 T4 T4 T2 T3 T3 T3 PA PA PA T3 T4 T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME theophylline er oral tablet extended release 24 hr Anticoagulants Coumarin Anticoagulants Coumarin Anticoagulants warfarin sodium oral Direct Factor Xa Inhibitors Direct Factor Xa Inhibitors XARELTO Heparins And Heparinoid-Like Agents Heparins And Heparinoid-Like Agents heparin sodium (porcine) injection solution 20000 UNIT/ML Low Molecular Weight Heparins enoxaparin sodium subcutaneous Synthetic Heparinoid-Like Agents fondaparinux sodium Thrombin Inhibitors Thrombin Inhibitors - Selective Direct & Reversible PRADAXA Anticonvulsants Anticonvulsants - Misc. Anticonvulsants - Misc. BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG carbamazepine oral tablet carbamazepine oral tablet chewable gabapentin oral capsule gabapentin oral tablet 800 MG lamotrigine oral tablet 25 MG lamotrigine oral tablet 100 MG, 150 MG, 200 MG lamotrigine oral tablet chewable 25 MG, 5 MG levetiracetam oral tablet levetiracetam er oral tablet extended release 24 hr 750 MG LYRICA ORAL CAPSULE oxcarbazepine oral tablet POTIGA Page 11 TIER NOTES T3 T2 T4 PA T3 T5 PA T5 PA T3 PA T4 T4 T5 T3 T3 T2 T2 T1 T2 T2 T2 T3 T4 T3 T5 PA PA PA PA PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME primidone oral topiramate oral VIMPAT ORAL zonisamide Carbamates Carbamates felbamate GABA Modulators GABA Modulators GABITRIL ORAL TABLET 4 MG SABRIL ORAL TABLET Hydantoins Hydantoins DILANTIN ORAL SUSPENSION PEGANONE phenytoin sodium extended oral capsule 100 MG, 200 MG, 300 MG Succinimides Succinimides CELONTIN ethosuximide oral Valproic Acid Valproic Acid DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG divalproex sodium valproic acid oral capsule Antidepressants Alpha-2 Receptor Antagonists (Tetracyclics) Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine oral Antidepressants - Misc. Antidepressants - Misc. APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG BUDEPRION SR bupropion hcl oral maprotiline hcl Page 12 TIER T2 T2 T4 T2 NOTES ST T5 ST T5 T5 PA PA T3 T4 T2 T4 T3 T2 T2 T2 T2 T4 ST T2 T2 T4 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Modified Cyclics Modified Cyclics nefazodone hcl trazodone hcl oral VIIBRYD Monoamine Oxidase Inhibitors (MAOIs) Monoamine Oxidase Inhibitors (MAOIs) EMSAM MARPLAN phenelzine sulfate oral tranylcypromine sulfate Selective Serotonin Reuptake Inhibitors (SSRIs) Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide escitalopram oxalate fluoxetine hcl oral solution fluvoxamine maleate paroxetine hcl er PAXIL ORAL SUSPENSION sertraline hcl oral Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) CYMBALTA venlafaxine hcl venlafaxine hcl er oral capsule extended release 24 hour 150 MG, 75 MG venlafaxine hcl er oral tablet extended release 24 hr 150 MG, 225 MG, 75 MG Tricyclic Agents Tricyclic Agents amitriptyline hcl oral tablet 10 MG, 100 MG, 25 MG, 50 MG, 75 MG amoxapine clomipramine hcl oral desipramine hcl oral doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral nortriptyline hcl oral capsule Page 13 TIER T2 T1 T4 T5 T4 T2 T3 NOTES ST PA T1 T2 T2 T2 T2 T4 T1 T4 T2 T2 T2 ST T1 T2 T2 T3 T2 T2 T3 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME protriptyline hcl Antidiabetics Alpha-Glucosidase Inhibitors Alpha-Glucosidase Inhibitors acarbose GLYSET Antidiabetic Combinations Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations JENTADUETO Biguanides Biguanides metformin hcl oral tablet Diabetic Other Diabetic Other GLUCAGEN HYPOKIT PROGLYCEM Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA ONGLYZA TRADJENTA Dopamine Receptor Agonists - Antidiabetic Dopamine Receptor Agonists - Ergot Derivatives CYCLOSET Incretin Mimetic Agents (GLP-1 Receptor Agonists) Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN Insulin Sensitizing Agents Thiazolidinediones ACTOS AVANDIA Insulin Human Insulin HUMALOG MIX 50/50 Page 14 TIER NOTES T3 T2 T4 ST T3 T1 T3 T3 T4 T4 T3 ST ST T4 ST T3 T3 T3 T4 T4 ST T5 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME HUMULIN R U-500 (CONCENTRATED) LEVEMIR NOVOLOG NOVOLOG MIX 70/30 Meglitinide Analogues Meglitinide Analogues nateglinide PRANDIN Sulfonylureas Sulfonylureas chlorpropamide glimepiride glipizide oral glipizide er GLIPIZIDE XL glyburide oral glyburide micronized oral tablet 1.5 MG, 3 MG, 6 MG tolazamide tolbutamide Antidiarrheals Antiperistaltic Agents Antiperistaltic Agents diphenoxylate-atropine loperamide hcl oral capsule MOTOFEN Antidotes Antidotes - Chelating Agents Antidotes - Chelating Agents CHEMET EXJADE Opioid Antagonists Opioid Antagonists naltrexone hcl oral Antiemetics 5-HT3 Receptor Antagonists 5-HT3 Receptor Antagonists Page 15 TIER T4 T3 T3 T3 NOTES PA T3 T4 ST T2 T2 T1 T2 T2 T2 T1 T4 T4 ST ST T2 T2 T4 T4 T5 PA T4 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME ANZEMET ORAL TABLET 50 MG granisetron hcl oral tablet GRANISOL ondansetron oral tablet dispersible ondansetron hcl oral Antiemetics - Anticholinergic Antiemetics - Anticholinergic meclizine hcl oral tablet 25 MG TIGAN INTRAMUSCULAR Antiemetics - Miscellaneous Antiemetics - Miscellaneous CESAMET dronabinol Substance P/Neurokinin 1 (NK1) Receptor Antagonists Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG Antifungals Antifungals Antifungals flucytosine oral griseofulvin microsize oral suspension nystatin oral tablet terbinafine hcl oral tablet Imidazole-Related Antifungals Imidazoles ketoconazole oral Triazoles fluconazole oral NOXAFIL ORAL SUSPENSION VFEND ORAL SUSPENSION RECONSTITUTED voriconazole oral tablet Antihistamines Antihistamines - Ethanolamines Antihistamines - Ethanolamines carbinoxamine maleate oral tablet clemastine fumarate oral syrup Page 16 TIER T5 T2 T2 T2 T2 NOTES PA T2 T4 PA T5 T5 PA PA T4 ST T5 T3 T2 T2 T2 T2 T5 T5 T5 PA PA PA T3 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME clemastine fumarate oral tablet 2.68 MG Antihistamines - Non-Sedating Antihistamines - Non-Sedating levocetirizine dihydrochloride oral Antihistamines - Phenothiazines Antihistamines - Phenothiazines promethazine hcl oral tablet promethazine hcl oral syrup promethazine hcl re suppository 12.5 MG, 25 MG Antihistamines - Piperidines Antihistamines - Piperidines cyproheptadine hcl oral Antihyperlipidemics Antihyperlipidemics - Misc. Antihyperlipidemics - Misc. LOVAZA Bile Acid Sequestrants Bile Acid Sequestrants colestipol hcl oral packet colestipol hcl oral tablet PREVALITE ORAL POWDER WELCHOL ORAL TABLET Fibric Acid Derivatives Fibric Acid Derivatives fenofibrate oral tablet 160 MG, 54 MG fenofibrate micronized oral capsule 134 MG, 200 MG, 67 MG gemfibrozil oral HMG COA Reductase Inhibitors HMG COA Reductase Inhibitors atorvastatin calcium CRESTOR ORAL TABLET 40 MG fluvastatin sodium LIVALO lovastatin pravastatin sodium oral tablet 20 MG, 40 MG, 80 MG pravastatin sodium oral tablet 10 MG Page 17 TIER NOTES T2 T2 T1 T2 T2 T3 T4 T2 T2 T2 T4 ST T2 T2 T2 T2 T4 T4 T4 T2 T1 T2 PA PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME simvastatin oral Intestinal Cholesterol Absorption Inhibitors Intestinal Cholesterol Absorption Inhibitors ZETIA Nicotinic Acid Derivatives Nicotinic Acid Derivatives NIACOR Antihypertensives ACE Inhibitors ACE Inhibitors benazepril hcl oral captopril oral enalapril maleate oral tablet fosinopril sodium lisinopril oral moexipril hcl perindopril erbumine quinapril hcl ramipril oral capsule trandolapril Agents For Pheochromocytoma Agents For Pheochromocytoma DIBENZYLINE Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists ATACAND BENICAR DIOVAN EDARBI eprosartan mesylate oral tablet 600 MG irbesartan losartan potassium MICARDIS Antiadrenergic Antihypertensives Antiadrenergics - Centrally Acting clonidine hcl oral Page 18 TIER NOTES T1 T4 T2 T2 T1 T1 T2 T1 T3 T3 T2 T2 T3 T4 T4 T4 T4 T4 T3 T3 T2 T4 ST ST ST ST ST T1 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME guanfacine hcl oral methyldopa oral Antiadrenergics - Peripherally Acting doxazosin mesylate prazosin hcl oral capsule 1 MG, 2 MG terazosin hcl oral Direct Renin Inhibitors Direct Renin Inhibitors TEKTURNA Selective Aldosterone Receptor Antagonists (SARAs) Selective Aldosterone Receptor Antagonists (SARAs) eplerenone Vasodilators Vasodilators hydralazine hcl oral minoxidil oral Anti-Infective Agents - Misc. Anti-Infective Agents - Misc. Anti-Infective Agents - Misc. metronidazole oral tablet PENTAM trimethoprim oral vancomycin hcl oral XIFAXAN ORAL TABLET 200 MG Anti-Infective Misc. - Combinations Anti-Infective Misc. - Combinations sulfamethoxazole-trimethoprim oral tablet 400-80 MG Antiprotozoal Agents Antiprotozoal Agents ALINIA MEPRON Carbapenems Carbapenems meropenem intravenous solution reconstituted 1 GM Ketolides Ketolides Page 19 TIER NOTES T2 T2 T2 T2 T2 T4 ST T4 T2 T2 T1 T5 T2 T5 T5 PA PA PA T1 T4 T4 PA T5 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME KETEK ORAL TABLET 300 MG Leprostatics Leprostatics dapsone oral Lincosamides Lincosamides clindamycin hcl oral capsule 150 MG, 300 MG Oxazolidinones Oxazolidinones ZYVOX ORAL Antimalarials Antimalarial Combinations Antimalarial Combinations atovaquone-proguanil hcl oral tablet 250-100 MG COARTEM MALARONE ORAL TABLET 62.5-25 MG Antimalarials Antimalarials chloroquine phosphate oral tablet 500 MG DARAPRIM hydroxychloroquine sulfate oral mefloquine hcl primaquine phosphate oral QUALAQUIN Antimyasthenic/Cholinergic Agents Antimyasthenic/Cholinergic Agents Antimyasthenic/Cholinergic Agents MESTINON ORAL TABLET MESTINON ORAL TABLET EXTENDEDRELEASE MYTELASE pyridostigmine bromide oral tablet REGONOL Antimycobacterial Agents Anti TB Combinations Anti TB Combinations RIFATER Page 20 TIER T4 NOTES PA T3 T2 T5 PA T3 T4 T3 T2 T3 T2 T2 T3 T4 T4 T4 T3 T2 T4 T4 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Antimycobacterial Agents Antimycobacterial Agents CAPASTAT SULFATE ethambutol hcl oral isoniazid oral MYCOBUTIN PASER PRIFTIN rifampin oral SEROMYCIN TRECATOR Antineoplastics And Adjunctive Therapies Alkylating Agents Alkylating Agents HEXALEN Nitrogen Mustards cyclophosphamide oral LEUKERAN melphalan hcl Antimetabolites Antimetabolites fludarabine phosphate intravenous solution 25 MG/ML fluorouracil intravenous solution 5 GM/100ML mercaptopurine oral methotrexate sodium injection solution reconstituted methotrexate sodium (pf) injection solution 200 MG/8ML TABLOID TREXALL Antineoplastic - Antibodies Antineoplastic - Monoclonal Antibodies RITUXAN Antineoplastic - Hormonal And Related Agents Androgen Biosynthesis Inhibitors ZYTIGA Antiadrenals LYSODREN Page 21 TIER NOTES T4 T2 T2 T4 T4 T4 T2 T4 T4 T5 PA T3 T3 T5 T5 T3 T2 T2 T2 T4 T4 PA T5 PA T5 PA T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Antiandrogens bicalutamide flutamide NILANDRON Antiestrogens FARESTON tamoxifen citrate oral tablet Aromatase Inhibitors anastrozole oral exemestane letrozole oral Estrogens-Antineoplastic EMCYT LHRH Analogs leuprolide acetate injection kit 1 MG/0.2ML Progestins-Antineoplastic megestrol acetate oral tablet Antineoplastic Enzyme Inhibitors Antineoplastic - Histone Deacetylase Inhibitors ZOLINZA Antineoplastic - mTOR Kinase Inhibitors AFINITOR Antineoplastic - Multikinase Inhibitors NEXAVAR SUTENT Antineoplastic - Tyrosine Kinase Inhibitors CAPRELSA GLEEVEC SPRYCEL TARCEVA TASIGNA TYKERB VOTRIENT XALKORI Janus Associated Kinase (JAK) Inhibitors JAKAFI Page 22 TIER NOTES T2 T2 T3 T5 T2 T2 T4 T4 ST ST T4 PA T5 PA T2 T5 PA T5 PA T5 T5 PA PA T5 T5 T5 T5 T5 T5 T5 T5 PA PA PA PA PA PA PA PA T5 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Antineoplastics Misc. Antineoplastics Misc. ACTIMMUNE hydroxyurea oral capsule 500 MG INTRON-A INJECTION SOLUTION 10000000 UNIT/ML MATULANE Retinoids tretinoin oral Selective Retinoid X Receptor Agonists TARGRETIN Chemotherapy Adjuncts Chemotherapy Adjuncts - Keratinocyte Growth Factors KEPIVANCE Chemotherapy Rescue/Antidote Agents Folic Acid Antagonists Rescue Agents leucovorin calcium oral tablet 25 MG, 5 MG leucovorin calcium oral tablet 10 MG, 15 MG Antiparkinson Agents Antiparkinson Adjuvants Decarboxylase Inhibitors LODOSYN Antiparkinson Anticholinergics Antiparkinson Anticholinergics benztropine mesylate oral trihexyphenidyl hcl Antiparkinson COMT Inhibitors Central/Peripheral COMT Inhibitors TASMAR Peripheral COMT Inhibitors COMTAN Antiparkinson Dopaminergics Antiparkinson Dopaminergics amantadine hcl oral bromocriptine mesylate oral capsule bromocriptine mesylate oral tablet 2.5 MG Page 23 TIER NOTES T5 T2 T5 T5 PA T5 PA T5 PA PA T5 T2 T3 T4 T2 T2 T5 T4 T2 T2 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Levodopa Combinations carbidopa-levodopa oral tablet carbidopa-levodopa er Nonergoline Dopamine Receptor Agonists MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 3 MG pramipexole dihydrochloride oral tablet 0.125 MG, 0.25 MG, 0.5 MG, 1 MG, 1.5 MG ropinirole hcl Antiparkinson Monoamine Oxidase Inhibitors Antiparkinson Monoamine Oxidase Inhibitors AZILECT selegiline hcl oral capsule selegiline hcl oral tablet Antipsychotics/Antimanic Agents Antimanic Agents Antimanic Agents lithium carbonate oral capsule 150 MG, 300 MG lithium carbonate oral capsule 600 MG lithium carbonate oral tablet lithium carbonate er Antipsychotics - Misc. Antipsychotics - Misc. LATUDA ORAL TABLET 20 MG, 40 MG, 80 MG ziprasidone hcl Benzisoxazoles Benzisoxazoles FANAPT FANAPT TITRATION PACK INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML RISPERDAL CONSTA risperidone oral solution risperidone oral tablet dispersible 0.25 MG risperidone oral tablet RISPERIDONE M-TAB Butyrophenones Page 24 TIER NOTES T2 T2 T5 T2 PA T2 T4 T2 T2 T2 T3 T3 T2 T4 T4 PA T4 T4 T4 PA PA PA T4 T2 T2 T2 T2 PA ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Butyrophenones haloperidol oral haloperidol decanoate intramuscular haloperidol lactate Dibenzapines Dibenzodiazepines clozapine oral tablet FAZACLO Dibenzo-Oxepino Pyrroles SAPHRIS Dibenzothiazepines quetiapine fumarate SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 50 MG Dibenzoxazepines loxapine succinate oral Thienbenzodiazepines olanzapine oral Phenothiazines Phenothiazines chlorpromazine hcl oral fluphenazine hcl oral tablet fluphenazine hcl oral concentrate fluphenazine hcl oral elixir perphenazine oral prochlorperazine prochlorperazine maleate oral thioridazine hcl oral trifluoperazine hcl oral Quinolinone Derivatives Quinolinone Derivatives ABILIFY ORAL SOLUTION ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG ABILIFY ORAL TABLET 20 MG, 30 MG ABILIFY DISCMELT Thioxanthenes Page 25 TIER NOTES T2 T2 T2 T2 T4 PA T4 PA T2 T4 PA T2 T3 T2 T2 T3 T3 T2 T2 T2 T3 T2 T4 T4 T5 T5 PA PA PA PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Thioxanthenes thiothixene oral capsule 1 MG, 10 MG, 2 MG, 5 MG Antivirals Antiretrovirals Antiretroviral Combinations EPZICOM KALETRA lamivudine-zidovudine TRIZIVIR TRUVADA Antiretrovirals - CCR5 Antagonists (Entry Inhibitor) SELZENTRY Antiretrovirals - Fusion Inhibitors FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Antiretrovirals - Integrase Inhibitors ISENTRESS ORAL TABLET Antiretrovirals - Protease Inhibitors APTIVUS CRIXIVAN ORAL CAPSULE 200 MG, 400 MG INVIRASE LEXIVA NORVIR PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG VIRACEPT ORAL TABLET Antiretrovirals - RTI-Non-Nucleoside Analogues EDURANT INTELENCE ORAL TABLET 100 MG, 200 MG nevirapine oral tablet RESCRIPTOR SUSTIVA Antiretrovirals - RTI-Nucleoside Analogues-Purines didanosine oral capsule delayed release VIDEX ORAL SOLUTION RECONSTITUTED 4 GM ZIAGEN ORAL SOLUTION Page 26 TIER NOTES T2 T5 T5 T3 T5 T5 PA PA PA PA PA T5 PA T5 PA T5 PA T5 T5 T5 T5 T5 T5 T5 T5 PA PA PA PA PA PA PA PA T5 T5 T3 T5 T5 PA PA PA PA PA T3 T5 T5 PA PA PA Antiretrovirals - RTI-Nucleoside Analogues-Pyrimidines PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME EMTRIVA EPIVIR ORAL SOLUTION EPIVIR HBV lamivudine oral tablet 150 MG, 300 MG Antiretrovirals - RTI-Nucleoside Analogues-Thymidines RETROVIR INTRAVENOUS stavudine oral capsule zidovudine oral capsule zidovudine oral syrup 50 MG/5ML zidovudine oral tablet Antiretrovirals - RTI-Nucleotide Analogues VIREAD CMV Agents CMV Agents VALCYTE Hepatitis Agents Hepatitis B Agents BARACLUDE HEPSERA TYZEKA Hepatitis C Agents INCIVEK INFERGEN PEGASYS PEGASYS PROCLICK PEG-INTRON SUBCUTANEOUS KIT 50 MCG/0.5ML PEG-INTRON REDIPEN PEG-INTRON REDIPEN PAK 4 ribavirin oral capsule ribavirin oral tablet 200 MG VICTRELIS Herpes Agents Herpes Agents - Purine Analogues acyclovir oral valacyclovir hcl oral Herpes Agents - Thymidine Analogues Page 27 TIER NOTES T5 T5 T4 T3 PA PA PA PA T5 T3 T3 T3 T3 PA PA PA PA PA T5 PA T5 T5 T5 T5 PA PA PA T5 T5 T5 T5 T5 T5 T5 T3 T3 T5 PA PA PA PA PA PA PA PA PA PA T2 T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME famciclovir Influenza Agents Influenza Agents rimantadine hcl Neuraminidase Inhibitors RELENZA DISKHALER TAMIFLU ORAL CAPSULE 75 MG Assorted Classes Chelating Agents Chelating Agents DEPEN TITRATABS SYPRINE Immunomodulators Antileprotics THALOMID Immunomodulators For Myelodysplastic Syndromes REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG Immunosuppressive Agents Cyclosporine Analogs cyclosporine oral capsule 25 MG cyclosporine modified oral capsule 100 MG cyclosporine modified oral solution cyclosporine modified oral capsule 50 MG GENGRAF Immune Globulin Immunosuppressants THYMOGLOBULIN Inosine Monophosphate Dehydrogenase Inhibitors CELLCEPT mycophenolate mofetil oral capsule MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG MYFORTIC ORAL TABLET DELAYED RELEASE 360 MG Macrolide Immunosuppressants PROGRAF ORAL RAPAMUNE tacrolimus oral capsule ZORTRESS Page 28 TIER NOTES T3 T2 PA T5 T4 PA T4 T4 T5 PA T5 PA T2 T2 T2 T3 T2 T5 PA T4 T3 T4 T5 T4 T3 T3 T3 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Purine Analogs AZASAN azathioprine oral tablet 50 MG Selective T-Cell Costimulation Blockers NULOJIX Irrigation Solutions Irrigation Solutions PHYSIOLYTE Potassium Removing Resins Potassium Removing Resins KAYEXALATE Beta Blockers Alpha-Beta Blockers Alpha-Beta Blockers carvedilol COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG labetalol hcl oral Beta Blockers Cardio-Selective Beta Blockers Cardio-Selective acebutolol hcl oral atenolol oral betaxolol hcl oral tablet 20 MG bisoprolol fumarate BYSTOLIC metoprolol tartrate oral Beta Blockers Non-Selective Beta Blockers Non-Selective INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG LEVATOL nadolol oral pindolol oral tablet 5 MG propranolol hcl oral tablet propranolol hcl oral solution sotalol hcl oral tablet 240 MG Page 29 TIER NOTES T3 T2 T5 PA T2 T4 T1 T4 ST T2 T2 T1 T2 T2 T4 T1 ST T4 T4 T3 T3 T1 T3 T2 ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME timolol maleate oral Biologicals Misc Biologicals Misc Biologicals Misc ADAGEN Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers amlodipine besylate oral tablet 10 MG, 5 MG amlodipine besylate oral tablet 2.5 MG CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG diltiazem hcl oral felodipine er oral tablet extended release 24 hr 2.5 MG, 5 MG isradipine nicardipine hcl oral nifedipine oral capsule 10 MG nifedipine oral capsule 20 MG nimodipine oral capsule nisoldipine er oral tablet extended release 24 hr 40 MG, 8.5 MG verapamil hcl oral verapamil hcl er oral capsule extended release 24 hour 100 MG, 120 MG, 180 MG, 200 MG, 240 MG, 300 MG verapamil hcl er oral tablet extendedrelease 120 MG verapamil hcl er (co) Cardiotonics Cardiac Glycosides Cardiac Glycosides digoxin oral tablet digoxin oral solution Cardiovascular Agents - Misc. Prostaglandin Vasodilators Prostaglandin Vasodilators REMODULIN INJECTION SOLUTION 1 MG/ML Page 30 TIER NOTES T2 T5 PA T1 T2 T2 T2 T2 T3 T3 T3 T2 T3 T4 T3 T2 T3 T3 T3 T1 T3 T5 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME VENTAVIS INHALATION SOLUTION 10 MCG/ML Pulmonary Hypertension - Endothelin Receptor Antagonists Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS TRACLEER Pulmonary Hypertension - Phosphodiesterase Inhibitors Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA Cephalosporins Cephalosporins – 1st Generation Cephalosporins – 1st Generation cefadroxil oral cefazolin sodium injection solution reconstituted 300 GM cephalexin oral capsule 250 MG, 500 MG Cephalosporins – 2nd Generation Cephalosporins – 2nd Generation cefaclor oral capsule cefuroxime axetil oral tablet Cephalosporins – 3rd Generation Cephalosporins – 3rd Generation CEDAX ORAL CAPSULE cefdinir oral suspension reconstituted cefpodoxime proxetil oral suspension reconstituted 50 MG/5ML cefpodoxime proxetil oral tablet ceftriaxone sodium injection solution reconstituted 250 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML SUPRAX ORAL TABLET Contraceptives Emergency Contraceptives Emergency Contraceptives ELLA Progestin Contraceptives - Oral Progestin Contraceptives - Oral ERRIN Corticosteroids Page 31 TIER NOTES T5 PA T5 T5 PA PA T5 PA T2 T2 T1 T2 T2 T4 T3 T3 T3 T2 T4 T4 T4 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Glucocorticosteroids Glucocorticosteroids cortisone acetate oral dexamethasone oral solution dexamethasone oral tablet hydrocortisone oral methylprednisolone oral tablet 4 MG, 8 MG methylprednisolone (pak) prednisolone oral solution prednisone oral tablet 2.5 MG, 20 MG, 5 MG prednisone oral tablet 1 MG, 50 MG Mineralocorticoids Mineralocorticoids fludrocortisone acetate oral Cough/Cold/Allergy Mucolytics Mucolytics acetylcysteine inhalation solution 10 % Dermatologicals Acne Products Acne Antibiotics clindamycin phosphate external gel clindamycin phosphate external lotion clindamycin phosphate external solution ery erythromycin external gel erythromycin external solution Acne Combinations ACANYA BENZAMYCINPAK EPIDUO ZIANA Acne Products adapalene external cream AMNESTEEM CLARAVIS Page 32 TIER NOTES T2 T2 T2 T2 T2 T2 T2 T1 T2 T2 T2 T2 T2 T2 T2 T2 T2 T4 T5 T4 T4 T4 T5 T5 PA PA PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME tretinoin external cream 0.025 %, 0.1 % tretinoin external gel 0.01 % Agents For External Genital And Perianal Warts Agents For External Genital And Perianal Warts VEREGEN Antibiotics - Topical Antibiotic Steroid Combinations - Topical CORTISPORIN EXTERNAL Antibiotics - Topical ALTABAX gentamicin sulfate external Antifungals - Topical Antifungals - Topical Combinations clotrimazole-betamethasone nystatin-triamcinolone Antifungals - Topical ciclopirox external gel ciclopirox external shampoo ciclopirox olamine external suspension MENTAX NAFTIN EXTERNAL GEL 1 % nystatin external cream nystatin external ointment nystatin external powder 100000 UNIT/GM NYSTOP Page 33 TIER NOTES T2 T2 T4 T4 T4 T2 T2 T1 T3 T3 T3 T4 T4 T2 T2 T2 T2 Imidazole-Related Antifungals - Topical econazole nitrate external ERTACZO EXELDERM ketoconazole external cream ketoconazole external shampoo 2 % OXISTAT EXTERNAL CREAM T2 T5 T4 T2 T2 T4 Anti-Inflammatory Agents - Topical Anti-Inflammatory Agents - Topical VOLTAREN TRANSDERMAL T3 ST ST PA ST ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Antineoplastic Or Premalignant Lesion Agents - Topical Antineoplastic Or Premalignant Lesions - Topical Misc. PICATO Antineoplastic Or Premalignant Lesions - Topical NSAIDs SOLARAZE Antineoplastic Retinoids - Topical PANRETIN Topical Selective Retinoid X Receptor Agonists TARGRETIN Page 34 TIER NOTES T5 PA T5 PA T5 PA T5 PA Antipruritics - Topical Antipruritics - Topical ZONALON T4 Antipsoriatics Antipsoriatics - Systemic 8-MOP SORIATANE ORAL CAPSULE 17.5 MG T5 T5 PA T4 T4 T5 PA Antipsoriatics calcipotriene external solution TAZORAC VECTICAL Antiseborrheic Products Antiseborrheic Products selenium sulfide external lotion 2.5 % Antivirals - Topical Antivirals - Topical DENAVIR ZOVIRAX EXTERNAL Burn Products Burn Products SILVADENE silver sulfadiazine external SSD SULFAMYLON EXTERNAL CREAM Corticosteroids - Topical Corticosteroids - Topical alclometasone dipropionate T2 T4 T4 T2 T2 T2 T4 T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME amcinonide external cream betamethasone dipropionate aug external lotion clobetasol propionate external gel clobetasol propionate external ointment clobetasol propionate external solution CLODERM PUMP CUTIVATE EXTERNAL LOTION DERMA-SMOOTHE/FS SCALP desoximetasone external cream 0.25 % desoximetasone external gel desoximetasone external ointment 0.25 % fluocinolone acetonide external cream 0.01 % fluocinonide external gel fluocinonide external ointment fluocinonide external solution fluticasone propionate external cream fluticasone propionate external ointment halobetasol propionate HALOG EXTERNAL OINTMENT hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 2.5 % hydrocortisone valerate mometasone furoate external cream mometasone furoate external ointment OLUX-E prednicarbate triamcinolone acetonide external cream 0.025 %, 0.5 % triamcinolone acetonide external lotion triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % Topical Steroid Combinations TACLONEX EXTERNAL OINTMENT Emollients Emollients ammonium lactate external cream 12 % Enzymes - Topical Page 35 TIER T2 T2 T2 T2 T2 T2 T3 T3 T2 T2 T2 T1 T2 T2 T2 T2 T2 T2 T4 T2 T2 T2 T2 T2 T2 T5 T3 T2 T2 T2 T5 NOTES PA PA T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Enzymes - Topical SANTYL Immunomodulating Agents - Topical Immunomodulators Imidazoquinolinamines - Topical ALDARA Immunosuppressive Agents - Topical Macrolide Immunosuppressants - Topical ELIDEL PROTOPIC Keratolytic/Antimitotic Agents Keratolytic/Antimitotic Agents CONDYLOX EXTERNAL GEL podofilox external solution Local Anesthetics - Topical Local Anesthetics - Topical lidocaine hcl external gel 2 % Topical Anesthetic Combinations lidocaine-prilocaine external kit SYNERA Rosacea Agents Rosacea Agents FINACEA Scabicides & Pediculicides Scabicides & Pediculicides EURAX lindane external malathion external permethrin external cream ULESFIA Wound Care Products Wound Care - Growth Factor Agents REGRANEX Page 36 TIER T4 NOTES PA T4 T4 T5 PA T4 T3 T2 T2 T4 PA T4 T4 T2 T2 T2 T4 ST T4 PA Digestive Aids Digestive Enzymes Digestive Enzymes PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 6000 UNIT Diuretics Carbonic Anhydrase Inhibitors Carbonic Anhydrase Inhibitors acetazolamide oral acetazolamide sodium methazolamide oral Loop Diuretics Loop Diuretics bumetanide oral EDECRIN furosemide oral tablet furosemide oral solution 8 MG/ML torsemide oral Potassium Sparing Diuretics Potassium Sparing Diuretics amiloride hcl oral DYRENIUM spironolactone oral Thiazides and Thiazide-Like Diuretics Thiazides and Thiazide-Like Diuretics chlorothiazide oral tablet chlorthalidone oral tablet 25 MG, 50 MG DIURIL hydrochlorothiazide oral tablet 25 MG, 50 MG hydrochlorothiazide oral capsule indapamide oral methyclothiazide oral metolazone Endocrine And Metabolic Agents - Misc. Bone Density Regulators Bisphosphonates ACTONEL ORAL TABLET 150 MG, 30 MG, 5 MG alendronate sodium oral tablet etidronate disodium Page 37 TIER NOTES T5 T3 T3 T2 T2 T4 T1 T3 T2 T3 T4 T2 ST T2 T2 T3 T1 T2 T2 T3 T2 T4 T2 T3 ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME ibandronate sodium oral pamidronate disodium intravenous solution 6 MG/ML RECLAST Calcitonins MIACALCIN Parathyroid Hormone And Derivatives FORTEO RANK Ligand (RANKL) Inhibitors PROLIA Growth Hormone Receptor Antagonists Growth Hormone Receptor Antagonists SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG Growth Hormones Growth Hormones SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 6 MG Hormone Receptor Modulators Selective Estrogen Receptor Modulators (SERMs) EVISTA Insulin-Like Growth Factors (Somatomedins) Insulin-Like Growth Factors (Somatomedins) INCRELEX LHRH/GNRH Agonist Analog Pituitary Suppressants LHRH/GNRH Agonist Analog Pituitary Suppressants SYNAREL Metabolic Modifiers Calcimimetic Agents SENSIPAR GAA Deficiency Treatment - Agents LUMIZYME Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents ORFADIN Hyperparathyroid Treatment - Vitamin D Analogs calcitriol oral HECTOROL ORAL ZEMPLAR ORAL Page 38 TIER NOTES T3 T5 T5 PA PA T4 PA T5 PA T5 PA T5 PA T5 PA T3 T5 PA T5 T5 PA T5 PA T5 PA T2 T4 T4 PA PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Mucopolysaccharidosis VI (MPS VI) - Agents NAGLAZYME Phenylketonuria Treatment - Agents KUVAN Urea Cycle Disorder - Agents BUPHENYL ORAL TABLET Posterior Pituitary Hormones Vasopressin desmopressin acetate oral Prolactin Inhibitors Dopamine Receptor Agonists cabergoline Somatostatic Agents Somatostatic Agents octreotide acetate injection solution 1000 MCG/5ML, 1000 MCG/ML SANDOSTATIN LAR DEPOT Vasopressin Receptor Antagonists Selective Vasopressin V2-Receptor Antagonists SAMSCA Estrogens Estrogens Estrogens CENESTIN ENJUVIA estradiol transdermal patch weekly 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR estradiol oral estropipate oral MENEST PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.9 MG, 1.25 MG PREMARIN ORAL TABLET 0.625 MG Fluoroquinolones Fluoroquinolones Fluoroquinolones AVELOX INTRAVENOUS ciprofloxacin hcl oral tablet 250 MG, 500 MG, 750 MG Page 39 TIER NOTES T5 PA T5 PA T5 PA T2 T2 T5 T5 PA PA T5 PA T3 T3 T2 T2 T3 T4 T3 T3 PA PA PA T3 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME FACTIVE levofloxacin oral solution levofloxacin oral tablet 250 MG, 500 MG NOROXIN ofloxacin Gastrointestinal Agents - Misc. Gallstone Solubilizing Agents Gallstone Solubilizing Agents ursodiol oral capsule Gastrointestinal Antiallergy Agents Gastrointestinal Antiallergy Agents cromolyn sodium oral Gastrointestinal Chloride Channel Activators Gastrointestinal Chloride Channel Activators AMITIZA ORAL CAPSULE 24 MCG AMITIZA ORAL CAPSULE 8 MCG Gastrointestinal Stimulants Gastrointestinal Stimulants metoclopramide hcl oral tablet Inflammatory Bowel Agents Inflammatory Bowel Agents balsalazide disodium oral capsule DIPENTUM LIALDA sulfasalazine oral tablet Tumor Necrosis Factor Alpha Blockers REMICADE Irritable Bowel Syndrome (IBS) Agents IBS Agent - Selective 5-Ht3 Receptor Antagonists LOTRONEX Phosphate Binder Agents Phosphate Binder Agents calcium acetate oral capsule FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG RENAGEL ORAL TABLET 800 MG RENVELA ORAL TABLET Page 40 TIER NOTES T4 T2 T2 T4 T2 T2 T2 T3 T4 ST PA; ST T2 T2 T4 T4 T2 PA T5 PA T5 PA T2 T3 T4 T3 ST ST ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Genitourinary Agents - Miscellaneous Cystinosis Agents Cystinosis Agents CYSTAGON Interstitial Cystitis Agents Interstitial Cystitis Agents ELMIRON Prostatic Hypertrophy Agents 5-Alpha Reductase Inhibitors AVODART finasteride oral tablet 5 MG Alpha 1-Adrenoceptor Antagonists alfuzosin hcl er RAPAFLO tamsulosin hcl Gout Agents Gout Agent Combinations Gout Agent Combinations colchicine-probenecid Gout Agents Gout Agents allopurinol oral COLCRYS ULORIC Uricosurics Uricosurics probenecid oral Hematological Agents - Misc. Hematorheologic Agents Hematorheologic Agents pentoxifylline er Platelet Aggregation Inhibitors Cyclopentyltriazolopyrimidine (CPTP) Derivatives BRILINTA Phosphodiesterase III Inhibitors cilostazol Page 41 TIER T4 NOTES PA T4 T3 T2 T3 T4 T2 ST T2 T1 T3 T4 ST T2 T2 T4 PA T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Platelet Aggregation Inhibitor Combinations AGGRENOX Platelet Aggregation Inhibitors dipyridamole oral Quinazoline Agents anagrelide hcl oral capsule 1 MG anagrelide hcl oral capsule 0.5 MG Thienopyridine Derivatives clopidogrel bisulfate oral tablet 75 MG EFFIENT ticlopidine hcl Hematopoietic Agents Agents For Gaucher Disease Agents For Gaucher Disease ZAVESCA Agents For Sickle Cell Anemia Cytotoxic Agents DROXIA Hematopoietic Growth Factors Erythropoiesis-Stimulating Agents (ESAs) ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25 MCG/ML, 300 MCG/ML, 40 MCG/ML PROCRIT INJECTION SOLUTION 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML Granulocyte Colony-Stimulating Factors (G-CSF) NEULASTA NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML Granulocyte/Macrophage Colony-Stimulating Factor (GM-CSF) LEUKINE INJECTION Thrombopoietin (TPO) Receptor Agonists PROMACTA Hemostatics Hemostatics - Systemic Hemostatics - Systemic CYKLOKAPRON Hypnotics Page 42 TIER T4 NOTES PA T2 T2 T3 T2 T4 T2 PA T5 PA T4 T5 PA T5 PA T5 T5 PA PA T5 PA T5 PA T4 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Hypnotics - Tricyclic Agents Hypnotics - Tricyclic Agents SILENOR ORAL TABLET 6 MG Non-Barbiturate Hypnotics Benzodiazepine Hypnotics flurazepam hcl oral capsule 30 MG Non-Benzodiazepine - GABA-Receptor Modulators LUNESTA zaleplon zolpidem tartrate oral tablet Selective Melatonin Receptor Agonists Selective Melatonin Receptor Agonists ROZEREM Laxatives Laxative Combinations Bowel Evacuant Combinations MOVIPREP SUPREP BOWEL PREP Laxatives - Miscellaneous Laxatives - Miscellaneous lactulose oral solution 20 GM/30ML polyethylene glycol 3350 oral Saline Laxatives Saline Laxative Mixtures OSMOPREP Macrolides Azithromycin Azithromycin azithromycin oral suspension reconstituted 100 MG/5ML, 200 MG/5ML azithromycin oral tablet 500 MG, 600 MG Clarithromycin Clarithromycin clarithromycin oral Erythromycins Erythromycins E.E.S. 400 Page 43 TIER NOTES T4 T2 T4 T2 T2 PA T4 T4 T4 T2 T2 T4 T2 T2 T2 T4 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME erythromycin base oral tablet 250 MG Fidaxomicin Fidaxomicin DIFICID Migraine Products Migraine Combinations Ergot Combinations MIGERGOT Migraine Products Migraine Products dihydroergotamine mesylate injection Serotonin Agonists Selective Serotonin Agonists 5-HT(1) AXERT FROVA MAXALT naratriptan hcl RELPAX sumatriptan succinate oral ZOMIG ORAL ZOMIG ZMT Minerals & Electrolytes Chloride Chloride ammonium chloride intravenous Electrolyte Mixtures Electrolytes Parenteral ISOLYTE-S PH 7.4 Potassium Potassium KLOR-CON ORAL TABLET EXTENDEDRELEASE KLOR-CON M10 KLOR-CON M15 K-TABS potassium chloride crys er oral tablet extendedrelease 10 MEQ potassium chloride er oral capsule extended release 10 MEQ Page 44 TIER NOTES T2 T5 PA T4 T3 T4 T4 T4 T3 T4 T2 T4 T4 ST ST ST ST ST ST T2 T2 T2 T2 T2 T2 T2 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Mouth/Throat/Dental Agents Anti-Infectives - Throat Anti-Infectives - Throat clotrimazole mouth/throat lozenge Antiseptics - Mouth/Throat Antiseptics - Mouth/Throat chlorhexidine gluconate mouth/throat Steroids - Mouth/Throat Steroids - Mouth/Throat triamcinolone acetonide mouth/throat Throat Products - Misc. Saliva Stimulants pilocarpine hcl oral Musculoskeletal Therapy Agents Central Muscle Relaxants Central Muscle Relaxants baclofen oral carisoprodol oral tablet 350 MG chlorzoxazone oral tablet 500 MG cyclobenzaprine hcl oral tablet 10 MG methocarbamol oral SKELAXIN tizanidine hcl oral tablet tizanidine hcl oral capsule 2 MG, 4 MG Direct Muscle Relaxants Direct Muscle Relaxants dantrolene sodium oral Nasal Agents - Systemic And Topical Nasal Antiallergy Nasal Antihistamines azelastine hcl nasal solution 137 MCG/SPRAY PATANASE Nasal Steroids Nasal Steroids fluticasone propionate nasal NASONEX Page 45 TIER NOTES T2 T2 T2 T2 T2 T2 T2 T2 T2 T4 T2 T3 ST T3 T3 T4 ST T2 T4 ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Page 46 TIER OMNARIS triamcinolone acetonide nasal VERAMYST T4 T2 T4 Sympathomimetic Decongestants Topical Decongestants TYZINE NASAL SOLUTION 0.05 % T3 Neuromuscular Agents Als Agents Benzathiazoles RILUTEK Ophthalmic Agents Beta-Blockers - Ophthalmic Beta-Blockers - Ophthalmic Combinations COMBIGAN dorzolamide hcl-timolol mal dorzolamide hcl-timolol mal pf Beta-Blockers - Ophthalmic betaxolol hcl ophthalmic solution BETOPTIC-S carteolol hcl levobunolol hcl ophthalmic solution 0.5 % metipranolol timolol hemihydrate timolol maleate ophthalmic gel forming solution 0.25 % timolol maleate ophthalmic solution 0.25 %, 0.5 % Miotics Miotics - Cholinesterase Inhibitors PHOSPHOLINE IODIDE Miotics - Direct Acting PILOPINE HS Ophthalmic Adrenergic Agents Ophthalmic Selective Alpha Adrenergic Agonists ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % apraclonidine hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % Ophthalmic Anti-Infectives T5 NOTES ST ST PA T4 T3 T3 T3 T3 T2 T2 T2 T3 T2 T2 T4 T3 T4 T4 T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Ophthalmic Antibiotics bacitracin ophthalmic BESIVANCE ciprofloxacin hcl ophthalmic solution erythromycin ophthalmic gentamicin sulfate ophthalmic solution levofloxacin ophthalmic solution 0.5 % MOXEZA ofloxacin tobramycin sulfate ophthalmic solution VIGAMOX ZYMAXID Ophthalmic Antifungal NATACYN Ophthalmic Antivirals trifluridine ophthalmic ZIRGAN Ophthalmic Sulfonamides sulfacetamide sodium ophthalmic Ophthalmic Immunomodulators Ophthalmic Immunomodulators RESTASIS Ophthalmic Local Anesthetics Ophthalmic Local Anesthetics proparacaine hcl ophthalmic Ophthalmic Steroids Ophthalmic Steroid Combinations TOBRADEX OPHTHALMIC OINTMENT Ophthalmic Steroids dexamethasone sodium phosphate ophthalmic DUREZOL FML LIQUIFILM LOTEMAX OPHTHALMIC OINTMENT LOTEMAX OPHTHALMIC SUSPENSION OMNIPRED prednisolone acetate ophthalmic suspension 1 % Page 47 TIER NOTES T2 T4 T2 T2 T2 T2 T3 T2 T2 T3 T4 T4 T3 T4 T2 T4 T3 T4 T2 T4 T3 T4 T4 T5 T2 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME prednisolone sodium phosphate ophthalmic VEXOL Ophthalmics - Misc. Ophthalmic Antiallergic ALOCRIL ALOMIDE azelastine hcl ophthalmic BEPREVE cromolyn sodium ophthalmic EMADINE epinastine hcl LASTACAFT PATADAY PATANOL Ophthalmic Carbonic Anhydrase Inhibitors AZOPT dorzolamide hcl Ophthalmic Nonsteroidal Anti-Inflammatory Agents diclofenac sodium ophthalmic flurbiprofen sodium ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % NEVANAC Prostaglandins - Ophthalmic Prostaglandins - Ophthalmic latanoprost LUMIGAN OPHTHALMIC SOLUTION 0.01 % TRAVATAN Z ZIOPTAN Otic Agents Otic Agents - Miscellaneous Otic Agents - Miscellaneous acetic acid otic Otic Anti-Infectives Otic Anti-Infectives ofloxacin Otic Combinations Page 48 TIER NOTES T3 T4 T4 T4 T3 T4 T2 T4 T3 T4 T4 T4 T4 T2 T3 T2 T2 T4 T2 T4 T4 T4 ST ST T2 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Otic Steroid-Anti-Infective Combinations CIPRO HC CIPRODEX COLY-MYCIN S neomycin-polymyxin-hc otic solution 3.5-10000-1 neomycin-polymyxin-hc otic suspension Otic Steroids Otic Steroids DERMOTIC hydrocortisone-acetic acid Passive Immunizing Agents Immune Serums Immune Serums CARIMUNE NF GAMMAGARD INJECTION SOLUTION 30 GM/300ML Penicillins Aminopenicillins Aminopenicillins amoxicillin oral capsule amoxicillin oral suspension reconstituted 125 MG/5ML, 400 MG/5ML amoxicillin oral tablet chewable 125 MG amoxicillin oral tablet amoxicillin oral tablet chewable 250 MG ampicillin oral capsule ampicillin oral suspension reconstituted ampicillin sodium intravenous solution reconstituted 10 GM Natural Penicillins Natural Penicillins penicillin v potassium oral solution reconstituted 125 MG/5ML penicillin v potassium oral tablet Penicillin Combinations Penicillin Combinations amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 MG/5ML, 250-62.5 MG/5ML, 400-57 MG/5ML, 600-42.9 MG/5ML amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet chewable Page 49 TIER NOTES T4 T3 T4 T2 T2 T3 T2 T5 T5 PA PA T1 T1 T1 T2 T2 T2 T3 T5 PA T1 T1 T2 T2 T2 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Penicillinase-Resistant Penicillins Penicillinase-Resistant Penicillins dicloxacillin sodium Progestins Progestins Progestins medroxyprogesterone acetate oral norethindrone acetate oral progesterone micronized oral capsule 100 MG PROVERA ORAL TABLET 10 MG Psychotherapeutic And Neurological Agents - Misc. Agents For Chemical Dependency Alcohol Deterrents CAMPRAL disulfiram oral Anti-Cataplectic Agents Anti-Cataplectic Agents XYREM Antidementia Agents Cholinomimetics - AChE Inhibitors donepezil hcl oral tablet 10 MG, 5 MG donepezil hcl oral tablet dispersible galantamine hydrobromide RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 24 MG rivastigmine tartrate oral capsule N-Methyl-D-Aspartate (NMDA) Receptor Antagonists NAMENDA NAMENDA TITRATION PAK Page 50 TIER NOTES T2 T2 T3 T3 T2 T4 T4 T4 PA T2 T2 T3 T3 T3 T3 T3 Fibromyalgia Agents Fibromyalgia Agent - SNRIs SAVELLA SAVELLA TITRATION PACK T4 T4 Movement Disorder Drug Therapy Movement Disorder Drug Therapy XENAZINE T5 PA PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Multiple Sclerosis Agents Multiple Sclerosis Agents - Interferons AVONEX REBIF TITRATION PACK Multiple Sclerosis Agents - Monoclonal Antibodies TYSABRI Multiple Sclerosis Agents - Potassium Channel Blockers AMPYRA Multiple Sclerosis Agents COPAXONE Sphingosine 1-Phosphate (S1P) Receptor Modulators GILENYA Postherpetic Neuralgia (PHN) Agents Postherpetic Neuralgia (PHN) Agents GRALISE STARTER Premenstrual Dysphoric Disorder (PMDD) Agents Premenstrual Dysphoric Disorder (PMDD) Agents - SSRIs fluoxetine hcl (pmdd) oral capsule 20 MG fluoxetine hcl (pmdd) oral capsule 10 MG Pseudobulbar Affect (PBA) Agents Pseudobulbar Affect Agent Combinations NUEDEXTA Psychotherapeutic And Neurological Agents - Misc. Psychotherapeutic And Neurological Agents - Misc. ergoloid mesylates oral ORAP Respiratory Agents - Misc. Alpha-Proteinase Inhibitor (Human) Alpha-Proteinase Inhibitor (Human) ZEMAIRA Sulfonamides Sulfonamides Sulfonamides sulfadiazine oral Tetracyclines Tetracyclines Page 51 TIER NOTES T5 T5 PA PA T5 PA T5 PA T5 PA T5 PA T5 PA T1 T2 T5 PA T2 T3 T5 PA T4 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Tetracyclines demeclocycline hcl oral doxycycline hyclate oral tablet 100 MG doxycycline monohydrate oral tablet 50 MG minocycline hcl oral capsule 75 MG minocycline hcl oral tablet tetracycline hcl oral Thyroid Agents Antithyroid Agents Antithyroid Agents methimazole oral propylthiouracil oral Thyroid Hormones Thyroid Hormones levothyroxine sodium oral tablet liothyronine sodium oral SYNTHROID Ulcer Drugs Antispasmodics Antispasmodics dicyclomine hcl oral Belladonna Alkaloids atropine sulfate injection solution 0.05 MG/ML Quaternary Anticholinergics CANTIL glycopyrrolate oral tablet 1 MG, 2 MG methscopolamine bromide oral tablet 2.5 MG propantheline bromide oral H-2 Antagonists H-2 Antagonists cimetidine oral tablet 800 MG cimetidine hcl oral famotidine oral tablet 20 MG, 40 MG nizatidine oral capsule ranitidine hcl oral capsule ranitidine hcl oral tablet 300 MG Page 52 TIER NOTES T3 T2 T2 T2 T2 T1 T2 T2 T2 T2 T3 T2 T4 T4 T3 T3 T4 T3 T2 T2 T3 T1 T1 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Misc. Anti-Ulcer Misc. Anti-Ulcer sucralfate oral tablet Proton Pump Inhibitors Proton Pump Inhibitors DEXILANT lansoprazole oral capsule delayed release 30 MG omeprazole oral capsule delayed release 10 MG, 40 MG pantoprazole sodium oral tablet delayed release 20 MG Ulcer Drugs - Prostaglandins Ulcer Drugs - Prostaglandins misoprostol oral tablet 200 MCG Urinary Anti-Infectives Urinary Anti-Infectives Urinary Anti-Infectives methenamine hippurate MONUROL nitrofurantoin macrocrystal oral capsule 50 MG nitrofurantoin monohyd macro Urinary Antispasmodics Urinary Antispasmodic - Antimuscarinics (Anticholinergic) Urinary Antispasmodic - Antimuscarinic (Anticholinergic) DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 MG Urinary Antispasmodics - Cholinergic Agonists Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride oral Urinary Antispasmodics Urinary Antispasmodics bethanechol chloride oral DETROL ORAL TABLET 1 MG ENABLEX flavoxate hcl oxybutynin chloride oral tablet trospium chloride VESICARE Page 53 TIER NOTES T2 T3 T3 T2 T2 ST T2 T2 T4 T2 T2 T4 ST T2 T2 T4 T4 T3 T1 T4 T4 ST ST ST ST PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List DRUG NAME Vaginal Products Vaginal Anti-Infectives Imidazole-Related Antifungals terconazole vaginal cream 0.4 % ZAZOLE VAGINAL CREAM Vaginal Anti-Infectives clindamycin phosphate vaginal cream metronidazole vaginal Vaginal Estrogens Vaginal Estrogens PREMARIN VAGINAL VAGIFEM VAGINAL TABLET 10 MCG Vasopressors Anaphylaxis Therapy Agents Anaphylaxis Therapy Agents EPIPEN EPIPEN JR Vasopressors Vasopressors midodrine hcl Page 54 TIER NOTES T2 T3 T2 T2 T3 T3 T3 T3 T3 PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication (1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details. Health First—ACA 5-Tier Drug List Page 55 Index 8-Mop .....................................................................34 Abilify.....................................................................25 Abilify Discmelt .....................................................25 Acanya ....................................................................32 Acarbose .................................................................14 Acebutolol HCl .......................................................29 AcetaZOLAMIDE ..................................................37 AcetaZOLAMIDE Sodium.....................................37 Acetic Acid .............................................................48 Acetylcysteine ........................................................32 Actemra ....................................................................6 Actimmune .............................................................23 Actonel ...................................................................37 Actos .......................................................................14 Acyclovir ................................................................27 Adagen ....................................................................30 Adapalene ...............................................................32 Adcirca ...................................................................31 Advair Diskus .........................................................10 Advair HFA ............................................................10 Afinitor ...................................................................22 Aggrenox ................................................................42 Albenza .....................................................................8 Albuterol Sulfate.....................................................10 Alclometasone Dipropionate ..................................34 Aldara .....................................................................36 Alendronate Sodium ...............................................37 Alfuzosin HCl ER ...................................................41 Alinia ......................................................................19 Allopurinol..............................................................41 Alocril .....................................................................48 Alomide ..................................................................48 Alphagan P .............................................................46 Altabax ...................................................................33 Amantadine HCl .....................................................23 Amcinonide ............................................................35 AMILoride HCl ......................................................37 Amiodarone HCl.......................................................9 Amitiza ...................................................................40 Amitriptyline HCl ...................................................13 AmLODIPine Besylate ...........................................30 Ammonium Chloride ..............................................44 Ammonium Lactate ................................................35 Amnesteem .............................................................32 Amoxapine..............................................................13 Amoxicillin .............................................................49 Amoxicillin-Pot Clavulanate ..................................49 Amphetamine-Dextroamphetamine ..........................5 Ampicillin ...............................................................49 Ampicillin Sodium .................................................49 Ampyra ...................................................................51 Anagrelide HCl .......................................................42 Anastrozole .............................................................22 AndroGel .................................................................. 8 Androxy .................................................................... 8 Anzemet.................................................................. 16 Aplenzin ................................................................. 12 Apraclonidine HCl ................................................. 46 Aptivus ................................................................... 26 Aranesp (Albumin Free) ......................................... 42 Arcalyst .................................................................... 6 Arcapta Neohaler .................................................... 10 Asmanex 120 Metered Doses ................................. 10 Asmanex 14 Metered Doses ................................... 10 Asmanex 30 Metered Doses ................................... 10 Asmanex 60 Metered Doses ................................... 10 Atacand ................................................................... 18 Atenolol .................................................................. 29 Atorvastatin Calcium .............................................. 17 Atovaquone-Proguanil HCl .................................... 20 Atropine Sulfate ..................................................... 52 Avandia .................................................................. 14 Avelox .................................................................... 39 Avodart ................................................................... 41 Avonex ................................................................... 51 Axert ....................................................................... 44 Azasan .................................................................... 29 AzaTHIOprine ........................................................ 29 Azelastine HCl ................................................. 45, 48 Azilect .................................................................... 24 Azithromycin .......................................................... 43 Azopt ...................................................................... 48 Bacitracin................................................................ 47 Baclofen.................................................................. 45 Balsalazide Disodium ............................................. 40 Banzel ..................................................................... 11 Baraclude ................................................................ 27 Benazepril HCl ....................................................... 18 Benicar.................................................................... 18 BenzamycinPak ...................................................... 32 Benztropine Mesylate ............................................. 23 Bepreve ................................................................... 48 Besivance................................................................ 47 Betamethasone Dipropionate Aug .......................... 35 Betaxolol HCl ................................................... 29, 46 Bethanechol Chloride ............................................. 53 Betoptic-S ............................................................... 46 Bicalutamide ........................................................... 22 Biltricide ................................................................... 8 Bisoprolol Fumarate ............................................... 29 Brilinta .................................................................... 41 Brimonidine Tartrate .............................................. 46 Bromocriptine Mesylate ......................................... 23 Brovana .................................................................. 10 Budeprion SR ......................................................... 12 Budesonide ............................................................. 10 Health First—ACA 5-Tier Drug List Bumetanide .............................................................37 Buphenyl.................................................................39 Buprenorphine HCl...................................................7 BuPROPion HCl .....................................................12 BusPIRone HCl ........................................................9 Butorphanol Tartrate.................................................7 Bydureon ................................................................14 Byetta 10 MCG Pen ................................................14 Byetta 5 MCG Pen ..................................................14 Bystolic ...................................................................29 Cabergoline.............................................................39 Calcipotriene...........................................................34 Calcitriol .................................................................38 Calcium Acetate .....................................................40 Campral ..................................................................50 Cantil ......................................................................52 Capastat Sulfate ......................................................21 Caprelsa ..................................................................22 Captopril .................................................................18 CarBAMazepine .....................................................11 Carbidopa-Levodopa ..............................................24 Carbidopa-Levodopa ER ........................................24 Carbinoxamine Maleate ..........................................16 Cardizem CD ..........................................................30 Carimune NF ..........................................................49 Carisoprodol ...........................................................45 Carteolol HCl..........................................................46 Cartia XT ................................................................30 Carvedilol ...............................................................29 Cedax ......................................................................31 Cefaclor ..................................................................31 Cefadroxil ...............................................................31 CeFAZolin Sodium.................................................31 Cefdinir ...................................................................31 Cefpodoxime Proxetil .............................................31 CefTRIAXone Sodium ...........................................31 Cefuroxime Axetil ..................................................31 CeleBREX ................................................................6 CellCept ..................................................................28 Celontin ..................................................................12 Cenestin ..................................................................39 Cephalexin ..............................................................31 Cesamet ..................................................................16 Chemet ....................................................................15 Chlorhexidine Gluconate ........................................45 Chloroquine Phosphate ...........................................20 Chlorothiazide ........................................................37 ChlorproMAZINE HCl...........................................25 ChlorproPAMIDE ..................................................15 Chlorthalidone ........................................................37 Chlorzoxazone ........................................................45 Ciclopirox ...............................................................33 Ciclopirox Olamine ................................................33 Cilostazol ................................................................41 Cimetidine ..............................................................52 Cimetidine HCl .......................................................52 Page 56 Cipro HC ................................................................ 49 Ciprodex ................................................................. 49 Ciprofloxacin HCl ............................................ 39, 47 Citalopram Hydrobromide...................................... 13 Claravis ................................................................... 32 Clarithromycin........................................................ 43 Clemastine Fumarate ........................................ 16, 17 Clindamycin HCl .................................................... 20 Clindamycin Phosphate .................................... 32, 54 Clobetasol Propionate............................................. 35 Cloderm Pump ........................................................ 35 ClomiPRAMINE HCl ............................................ 13 CloNIDine HCl....................................................... 18 Clopidogrel Bisulfate ............................................. 42 Clotrimazole ........................................................... 45 Clotrimazole-Betamethasone ................................. 33 CloZAPine .............................................................. 25 Coartem .................................................................. 20 Colchicine-Probenecid ........................................... 41 Colcrys.................................................................... 41 Colestipol HCl ........................................................ 17 Colocort .................................................................... 8 Coly-Mycin S ......................................................... 49 Combigan ............................................................... 46 Comtan ................................................................... 23 Concerta.................................................................... 5 Condylox ................................................................ 36 Copaxone ................................................................ 51 Coreg CR ................................................................ 29 Cortisone Acetate ................................................... 32 Cortisporin .............................................................. 33 Creon ...................................................................... 37 Crestor .................................................................... 17 Crixivan .................................................................. 26 Cromolyn Sodium ........................................ 9, 40, 48 Cutivate .................................................................. 35 Cyclobenzaprine HCl ............................................. 45 Cyclophosphamide ................................................. 21 Cycloset .................................................................. 14 CycloSPORINE ...................................................... 28 CycloSPORINE Modified ...................................... 28 Cyklokapron ........................................................... 42 Cymbalta ................................................................ 13 Cyproheptadine HCl ............................................... 17 Cystagon ................................................................. 41 Danazol ..................................................................... 8 Dantrolene Sodium ................................................. 45 Dapsone .................................................................. 20 Daraprim ................................................................. 20 Demeclocycline HCl .............................................. 52 Denavir ................................................................... 34 Depakote ER........................................................... 12 Depen Titratabs ...................................................... 28 Depo-Testosterone.................................................... 8 Derma-Smoothe/FS Scalp ...................................... 35 DermOtic ................................................................ 49 Health First—ACA 5-Tier Drug List Desipramine HCl ....................................................13 Desmopressin Acetate ............................................39 Desoximetasone ......................................................35 Detrol ......................................................................53 Detrol LA................................................................53 Dexamethasone .......................................................32 Dexamethasone Sodium Phosphate ........................47 Dexilant ..................................................................53 Dexmethylphenidate HCl .........................................5 Dextroamphetamine Sulfate .....................................5 Dibenzyline.............................................................18 Diclofenac Potassium ...............................................6 Diclofenac Sodium .............................................6, 48 Dicloxacillin Sodium ..............................................50 Dicyclomine HCl ....................................................52 Didanosine ..............................................................26 Dificid .....................................................................44 Diflunisal ..................................................................7 Digoxin ...................................................................30 Dihydroergotamine Mesylate .................................44 Dilantin ...................................................................12 Dilatrate-SR ..............................................................8 Diltiazem HCl .........................................................30 Diovan ....................................................................18 Dipentum ................................................................40 Diphenoxylate-Atropine .........................................15 Dipyridamole ..........................................................42 Disopyramide Phosphate ..........................................9 Disulfiram ...............................................................50 Diuril.......................................................................37 Divalproex Sodium .................................................12 Donepezil HCl ........................................................50 Dorzolamide HCl ....................................................48 Dorzolamide HCl-Timolol Mal ..............................46 Dorzolamide HCl-Timolol Mal PF .........................46 Doxazosin Mesylate ...............................................19 Doxepin HCl ...........................................................13 Doxycycline Hyclate ..............................................52 Doxycycline Monohydrate .....................................52 Dronabinol ..............................................................16 Droxia .....................................................................42 Dulera .....................................................................10 Durezol ...................................................................47 Dyrenium ................................................................37 E.E.S. 400 ...............................................................43 Econazole Nitrate ...................................................33 Edarbi .....................................................................18 Edecrin ....................................................................37 Edurant ...................................................................26 Effient .....................................................................42 Elidel.......................................................................36 Ella ..........................................................................31 Elmiron ...................................................................41 Emadine ..................................................................48 Emcyt ......................................................................22 Emend .....................................................................16 Page 57 Emsam .................................................................... 13 Emtriva ................................................................... 27 Enablex ................................................................... 53 Enalapril Maleate ................................................... 18 Enbrel ....................................................................... 6 Enjuvia.................................................................... 39 Enoxaparin Sodium ................................................ 11 Epiduo .................................................................... 32 Epinastine HCl ....................................................... 48 EPINEPHrine HCl .................................................. 10 EpiPen .................................................................... 54 EpiPen Jr................................................................. 54 Epivir ...................................................................... 27 Epivir HBV............................................................. 27 Eplerenone .............................................................. 19 Eprosartan Mesylate ............................................... 18 Epzicom .................................................................. 26 Ergoloid Mesylates ................................................. 51 Errin ........................................................................ 31 Ertaczo .................................................................... 33 Ery .......................................................................... 32 Erythromycin .................................................... 32, 47 Erythromycin Base ................................................. 44 Escitalopram Oxalate.............................................. 13 Estradiol.................................................................. 39 Estropipate .............................................................. 39 Ethambutol HCl ...................................................... 21 Ethosuximide .......................................................... 12 Etidronate Disodium............................................... 37 Etodolac .................................................................... 6 Eurax ...................................................................... 36 Evista ...................................................................... 38 Exelderm ................................................................ 33 Exemestane ............................................................. 22 Exjade ..................................................................... 15 Factive .................................................................... 40 Famciclovir ............................................................. 28 Famotidine .............................................................. 52 Fanapt ..................................................................... 24 Fanapt Titration Pack ............................................. 24 Fareston .................................................................. 22 FazaClo ................................................................... 25 Felbamate ............................................................... 12 Felodipine ER ......................................................... 30 Fenofibrate.............................................................. 17 Fenofibrate Micronized .......................................... 17 Fenoprofen Calcium ................................................. 6 FentaNYL ................................................................. 7 FentaNYL Citrate ..................................................... 7 Finacea.................................................................... 36 Finasteride .............................................................. 41 FlavoxATE HCl ..................................................... 53 Flecainide Acetate .................................................... 9 Flovent Diskus ........................................................ 10 Flovent HFA ........................................................... 10 Fluconazole ............................................................ 16 Health First—ACA 5-Tier Drug List Flucytosine..............................................................16 Fludarabine Phosphate ............................................21 Fludrocortisone Acetate ..........................................32 Fluocinolone Acetonide ..........................................35 Fluocinonide ...........................................................35 Fluorouracil ............................................................21 FLUoxetine HCl .....................................................13 FLUoxetine HCl (PMDD) ......................................51 FluPHENAZine HCl...............................................25 Flurazepam HCl ......................................................43 Flurbiprofen ..............................................................6 Flurbiprofen Sodium...............................................48 Flutamide ................................................................22 Fluticasone Propionate .....................................35, 45 Fluvastatin Sodium .................................................17 FluvoxaMINE Maleate ...........................................13 FML Liquifilm ........................................................47 Focalin XR................................................................5 Fondaparinux Sodium.............................................11 Foradil Aerolizer.....................................................10 Forteo ......................................................................38 Fosinopril Sodium ..................................................18 Fosrenol ..................................................................40 Frova .......................................................................44 Furosemide .............................................................37 Fuzeon ....................................................................26 Gabapentin ..............................................................11 Gabitril ....................................................................12 Galantamine Hydrobromide ...................................50 Gammagard ............................................................49 Gemfibrozil.............................................................17 Gengraf ...................................................................28 Gentamicin Sulfate ...........................................33, 47 Gilenya ...................................................................51 Gleevec ...................................................................22 Glimepiride .............................................................15 GlipiZIDE ...............................................................15 GlipiZIDE ER .........................................................15 GlipiZIDE XL.........................................................15 GlucaGen HypoKit .................................................14 GlyBURIDE ...........................................................15 GlyBURIDE Micronized ........................................15 Glycopyrrolate ........................................................52 Glyset ......................................................................14 Gralise Starter .........................................................51 Granisetron HCl ......................................................16 Granisol ..................................................................16 Griseofulvin Microsize ...........................................16 GuanFACINE HCl .................................................19 Halobetasol Propionate ...........................................35 Halog ......................................................................35 Haloperidol .............................................................25 Haloperidol Decanoate ...........................................25 Haloperidol Lactate ................................................25 Hectorol ..................................................................38 Heparin Sodium (Porcine) ......................................11 Page 58 Hepsera ................................................................... 27 Hexalen ................................................................... 21 HumaLOG Mix 50/50 ............................................ 14 HumuLIN R U-500 (CONCENTRATED) ............. 15 HydrALAZINE HCl ............................................... 19 Hydrochlorothiazide ............................................... 37 Hydrocortisone ............................................. 8, 32, 35 Hydrocortisone Valerate ......................................... 35 Hydrocortisone-Acetic Acid ................................... 49 HYDROmorphone HCl ............................................ 7 Hydroxychloroquine Sulfate .................................. 20 Hydroxyurea ........................................................... 23 HydrOXYzine HCl ................................................... 9 HydrOXYzine Pamoate ............................................ 9 Ibandronate Sodium ............................................... 38 Ibuprofen .................................................................. 6 Imipramine HCl ...................................................... 13 Incivek .................................................................... 27 Increlex ................................................................... 38 Indapamide ............................................................. 37 Indomethacin ............................................................ 6 Infergen .................................................................. 27 InnoPran XL ........................................................... 29 Intelence ................................................................. 26 Intron-A .................................................................. 23 Intuniv ...................................................................... 5 Invega Sustenna ...................................................... 24 Invirase ................................................................... 26 Ipratropium Bromide ................................................ 9 Irbesartan ................................................................ 18 Isentress .................................................................. 26 Isolyte-S pH 7.4 ...................................................... 44 Isoniazid ................................................................. 21 Isosorbide Dinitrate .................................................. 8 Isosorbide Dinitrate ER ............................................ 8 Isosorbide Mononitrate............................................. 8 Isradipine ................................................................ 30 Jakafi ...................................................................... 22 Januvia .................................................................... 14 Jentadueto ............................................................... 14 Kaletra .................................................................... 26 Kayexalate .............................................................. 29 Kepivance ............................................................... 23 Ketek ...................................................................... 20 Ketoconazole .................................................... 16, 33 Ketoprofen ................................................................ 6 Ketorolac Tromethamine .................................... 6, 48 Klor-Con ................................................................. 44 Klor-Con M10 ........................................................ 44 Klor-Con M15 ........................................................ 44 K-Tabs .................................................................... 44 Kuvan ..................................................................... 39 Labetalol HCl ......................................................... 29 Lactulose ................................................................ 43 LamiVUDine .......................................................... 27 Lamivudine-Zidovudine ......................................... 26 Health First—ACA 5-Tier Drug List LamoTRIgine..........................................................11 Lansoprazole ...........................................................53 Lastacaft .................................................................48 Latanoprost .............................................................48 Latuda .....................................................................24 Leflunomide..............................................................6 Letairis ....................................................................31 Letrozole .................................................................22 Leucovorin Calcium ...............................................23 Leukeran .................................................................21 Leukine ...................................................................42 Leuprolide Acetate .................................................22 Levalbuterol HCl ....................................................10 Levatol ....................................................................29 Levemir...................................................................15 LevETIRAcetam .....................................................11 LevETIRAcetam ER...............................................11 Levobunolol HCl ....................................................46 Levocetirizine Dihydrochloride ..............................17 Levofloxacin .....................................................40, 47 Levorphanol Tartrate ................................................7 Levothyroxine Sodium ...........................................52 Lexiva .....................................................................26 Lialda ......................................................................40 Lidocaine HCl.........................................................36 Lidocaine-Prilocaine ...............................................36 Lindane ...................................................................36 Liothyronine Sodium ..............................................52 Lisinopril ................................................................18 Lithium Carbonate ..................................................24 Lithium Carbonate ER ............................................24 Livalo ......................................................................17 Lodosyn ..................................................................23 Loperamide HCl .....................................................15 Losartan Potassium .................................................18 Lotemax ..................................................................47 Lotronex .................................................................40 Lovastatin ...............................................................17 Lovaza ....................................................................17 Loxapine Succinate.................................................25 Lufyllin ...................................................................10 Lumigan ..................................................................48 Lumizyme ...............................................................38 Lunesta ...................................................................43 Lyrica ......................................................................11 Lysodren .................................................................21 Malarone .................................................................20 Malathion ................................................................36 Maprotiline HCl ......................................................12 Marplan...................................................................13 Matulane .................................................................23 Maxair Autohaler ....................................................10 Maxalt .....................................................................44 Meclizine HCl.........................................................16 Meclofenamate Sodium ............................................6 MedroxyPROGESTERone Acetate ........................50 Page 59 Mefenamic Acid ....................................................... 6 Mefloquine HCl ...................................................... 20 Megestrol Acetate................................................... 22 Meloxicam ................................................................ 6 Melphalan HCl ....................................................... 21 Menest .................................................................... 39 Mentax .................................................................... 33 Meperidine HCl ........................................................ 7 Meprobamate ............................................................ 9 Mepron ................................................................... 19 Mercaptopurine ...................................................... 21 Meropenem ............................................................. 19 Mestinon ................................................................. 20 Metaproterenol Sulfate ........................................... 10 MetFORMIN HCl .................................................. 14 Methadone HCl ........................................................ 7 Methamphetamine HCl ............................................ 5 Methazolamide ....................................................... 37 Methenamine Hippurate ......................................... 53 Methimazole ........................................................... 52 Methocarbamol ....................................................... 45 Methotrexate Sodium ............................................. 21 Methotrexate Sodium (PF) ..................................... 21 Methscopolamine Bromide .................................... 52 Methyclothiazide .................................................... 37 Methyldopa ............................................................. 19 Methylin ................................................................... 5 Methylphenidate HCl ............................................... 5 MethylPREDNISolone ........................................... 32 MethylPREDNISolone (Pak) ................................. 32 Metipranolol ........................................................... 46 Metoclopramide HCl .............................................. 40 Metolazone ............................................................. 37 Metoprolol Tartrate ................................................ 29 MetroNIDAZOLE ............................................ 19, 54 Miacalcin ................................................................ 38 Micardis .................................................................. 18 Midodrine HCl ....................................................... 54 Migergot ................................................................. 44 Minocycline HCl .................................................... 52 Minoxidil ................................................................ 19 Mirapex ER ............................................................ 24 Mirtazapine ............................................................. 12 Misoprostol ............................................................. 53 Moexipril HCl ........................................................ 18 Mometasone Furoate .............................................. 35 Monurol .................................................................. 53 Morphine Sulfate ...................................................... 7 Morphine Sulfate ER ................................................ 7 Morphine Sulfate ER Beads ..................................... 7 Motofen .................................................................. 15 MoviPrep ................................................................ 43 Moxeza ................................................................... 47 Multaq ...................................................................... 9 Mycobutin .............................................................. 21 Mycophenolate Mofetil .......................................... 28 Health First—ACA 5-Tier Drug List Myfortic ..................................................................28 Mytelase .................................................................20 Nabumetone ..............................................................6 Nadolol ...................................................................29 Naftin ......................................................................33 Naglazyme ..............................................................39 Naltrexone HCl .......................................................15 Namenda .................................................................50 Namenda Titration Pak ...........................................50 Naproxen ..................................................................6 Naproxen Sodium .....................................................6 Naratriptan HCl ......................................................44 Nasonex ..................................................................45 Natacyn ...................................................................47 Nateglinide..............................................................15 Nefazodone HCl .....................................................13 Neomycin Sulfate .....................................................5 Neomycin-Polymyxin-HC ......................................49 Neulasta ..................................................................42 Neupogen ................................................................42 Nevanac ..................................................................48 Nevirapine ..............................................................26 NexAVAR ..............................................................22 Niacor .....................................................................18 NiCARdipine HCl ..................................................30 NIFEdipine .............................................................30 Nilandron ................................................................22 NiMODipine ...........................................................30 Nisoldipine ER .......................................................30 Nitrofurantoin Macrocrystal ...................................53 Nitrofurantoin Monohyd Macro .............................53 Nitrostat ....................................................................8 Nizatidine ...............................................................52 Norethindrone Acetate ............................................50 Noroxin ...................................................................40 Norpace CR ..............................................................9 Nortriptyline HCl ....................................................13 Norvir .....................................................................26 NovoLOG ...............................................................15 NovoLOG Mix 70/30 .............................................15 Noxafil ....................................................................16 Nucynta.....................................................................7 Nucynta ER...............................................................7 Nuedexta .................................................................51 Nulojix ....................................................................29 Nuvigil ......................................................................5 Nystatin.............................................................16, 33 Nystatin-Triamcinolone ..........................................33 Nystop.....................................................................33 Octreotide Acetate ..................................................39 Ofloxacin ....................................................40, 47, 48 OLANZapine ..........................................................25 Olux-E ....................................................................35 Omeprazole.............................................................53 Omnaris ..................................................................46 Omnipred ................................................................47 Page 60 Ondansetron............................................................ 16 Ondansetron HCl .................................................... 16 Onglyza .................................................................. 14 Orap ........................................................................ 51 Orfadin.................................................................... 38 OsmoPrep ............................................................... 43 Oxandrolone ............................................................. 8 Oxaprozin ................................................................. 6 OXcarbazepine ....................................................... 11 Oxistat .................................................................... 33 Oxybutynin Chloride .............................................. 53 OxyCODONE HCl ................................................... 7 Oxycodone-Ibuprofen............................................... 7 Oxymorphone HCl ................................................... 7 Oxymorphone HCl ER ............................................. 7 Pamidronate Disodium ........................................... 38 Panretin ................................................................... 34 Pantoprazole Sodium .............................................. 53 Paromomycin Sulfate ............................................... 5 PARoxetine HCl ER ............................................... 13 Paser ....................................................................... 21 Pataday ................................................................... 48 Patanase .................................................................. 45 Patanol .................................................................... 48 Paxil ........................................................................ 13 Peganone ................................................................ 12 Pegasys ................................................................... 27 Pegasys ProClick .................................................... 27 Peg-Intron ............................................................... 27 Peg-Intron Redipen................................................. 27 Peg-Intron Redipen Pak 4 ....................................... 27 Penicillin V Potassium ........................................... 49 Pentam .................................................................... 19 Pentoxifylline ER ................................................... 41 Perindopril Erbumine ............................................. 18 Permethrin .............................................................. 36 Perphenazine .......................................................... 25 Phenelzine Sulfate .................................................. 13 Phenytoin Sodium Extended .................................. 12 Phospholine Iodide ................................................. 46 Physiolyte ............................................................... 29 Picato ...................................................................... 34 Pilocarpine HCl ...................................................... 45 Pilopine HS............................................................. 46 Pindolol .................................................................. 29 Piroxicam.................................................................. 6 Podofilox ................................................................ 36 Polyethylene Glycol 3350 ...................................... 43 Ponstel ...................................................................... 6 Potassium Chloride Crys ER .................................. 44 Potassium Chloride ER .......................................... 44 Potiga ...................................................................... 11 Pradaxa ................................................................... 11 Pramipexole Dihydrochloride ................................ 24 Prandin.................................................................... 15 Pravastatin Sodium ................................................. 17 Health First—ACA 5-Tier Drug List Prazosin HCl ...........................................................19 Prednicarbate ..........................................................35 PrednisoLONE........................................................32 PrednisoLONE Acetate ..........................................47 PrednisoLONE Sodium Phosphate .........................48 PredniSONE ...........................................................32 Premarin ...........................................................39, 54 Prevalite ..................................................................17 Prezista ...................................................................26 Priftin ......................................................................21 Primaquine Phosphate ............................................20 Primidone ...............................................................12 Probenecid ..............................................................41 Procainamide HCl.....................................................9 Prochlorperazine .....................................................25 Prochlorperazine Maleate .......................................25 Procrit .....................................................................42 Progesterone Micronized ........................................50 Proglycem ...............................................................14 Prograf ....................................................................28 Prolia.......................................................................38 Promacta .................................................................42 Promethazine HCl...................................................17 Propafenone HCl ......................................................9 Propantheline Bromide ...........................................52 Proparacaine HCl ....................................................47 Propranolol HCl ......................................................29 Propylthiouracil ......................................................52 Protopic...................................................................36 Protriptyline HCl ....................................................14 Proventil HFA.........................................................10 Provera ....................................................................50 Provigil .....................................................................5 Pulmicort Flexhaler ................................................10 Pyridostigmine Bromide .........................................20 Qualaquin ...............................................................20 QUEtiapine Fumarate .............................................25 Quinapril HCl .........................................................18 QuiNIDine Gluconate ER .........................................9 QuiNIDine Sulfate ....................................................9 QuiNIDine Sulfate ER ..............................................9 Ramipril ..................................................................18 Ranexa ......................................................................8 Ranitidine HCl ........................................................52 Rapaflo ...................................................................41 Rapamune ...............................................................28 Razadyne ER ..........................................................50 Rebif Titration Pack................................................51 Reclast ....................................................................38 Rectiv ........................................................................8 Regonol...................................................................20 Regranex .................................................................36 Relenza Diskhaler ...................................................28 Relpax .....................................................................44 Remicade ................................................................40 Remodulin ..............................................................30 Page 61 Renagel ................................................................... 40 Renvela ................................................................... 40 Rescriptor ............................................................... 26 Restasis ................................................................... 47 Retrovir ................................................................... 27 Revlimid ................................................................. 28 Reyataz ................................................................... 26 Ribavirin ................................................................. 27 Ridaura ..................................................................... 5 Rifampin ................................................................. 21 Rifater ..................................................................... 20 Rilutek .................................................................... 46 Rimantadine HCl .................................................... 28 RisperDAL Consta ................................................. 24 RisperiDONE ......................................................... 24 RisperiDONE M-TAB ........................................... 24 Rituxan ................................................................... 21 Rivastigmine Tartrate ............................................. 50 ROPINIRole HCl ................................................... 24 Rozerem.................................................................. 43 Sabril ...................................................................... 12 Samsca .................................................................... 39 SandoSTATIN LAR Depot .................................... 39 Santyl ...................................................................... 36 Saphris .................................................................... 25 Savella .................................................................... 50 Savella Titration Pack............................................. 50 Selegiline HCl ........................................................ 24 Selenium Sulfide .................................................... 34 Selzentry ................................................................. 26 Sensipar .................................................................. 38 Seromycin ............................................................... 21 SEROquel XR ........................................................ 25 Serostim .................................................................. 38 Sertraline HCl ......................................................... 13 Silenor .................................................................... 43 Silvadene ................................................................ 34 Silver Sulfadiazine ................................................. 34 Simvastatin ............................................................. 18 Skelaxin .................................................................. 45 Solaraze .................................................................. 34 Somavert ................................................................. 38 Soriatane ................................................................. 34 Sotalol HCl ............................................................. 29 Spiriva HandiHaler ................................................... 9 Spironolactone ........................................................ 37 Sprycel .................................................................... 22 SSD......................................................................... 34 Stavudine ................................................................ 27 Strattera .................................................................... 5 Stromectol ................................................................ 8 Sucralfate ................................................................ 53 Sulfacetamide Sodium ............................................ 47 SulfADIAZINE ...................................................... 51 Sulfamethoxazole-Trimethoprim ........................... 19 Sulfamylon ............................................................. 34 Health First—ACA 5-Tier Drug List SulfaSALAzine .......................................................40 Sulindac ....................................................................6 SUMAtriptan Succinate ..........................................44 Suprax .....................................................................31 Suprep Bowel Prep .................................................43 Sustiva ....................................................................26 Sutent ......................................................................22 Synarel ....................................................................38 Synera .....................................................................36 Synthroid ................................................................52 Syprine ....................................................................28 Tabloid ....................................................................21 Taclonex .................................................................35 Tacrolimus ..............................................................28 Tamiflu ...................................................................28 Tamoxifen Citrate ...................................................22 Tamsulosin HCl ......................................................41 Tarceva ...................................................................22 Targretin ...........................................................23, 34 Tasigna ...................................................................22 Tasmar ....................................................................23 Tazorac ...................................................................34 Tekturna ..................................................................19 Terazosin HCl .........................................................19 Terbinafine HCl ......................................................16 Terbutaline Sulfate .................................................10 Terconazole ............................................................54 Testosterone Cypionate ............................................8 Testosterone Enanthate .............................................8 Tetracycline HCl.....................................................52 Thalomid.................................................................28 Theophylline ER ...............................................10, 11 Thioridazine HCl ....................................................25 Thiothixene .............................................................26 Thymoglobulin .......................................................28 Ticlopidine HCl ......................................................42 Tigan .......................................................................16 Tikosyn .....................................................................9 Timolol Hemihydrate .............................................46 Timolol Maleate ...............................................30, 46 TiZANidine HCl .....................................................45 TobraDex ................................................................47 Tobramycin Sulfate ................................................47 TOLAZamide .........................................................15 TOLBUTamide .......................................................15 Tolmetin Sodium ......................................................6 Topiramate ..............................................................12 Torsemide ...............................................................37 Tracleer ...................................................................31 Tradjenta .................................................................14 TraMADol HCl.........................................................7 TraMADol HCl ER ..................................................7 Trandolapril ............................................................18 Tranylcypromine Sulfate ........................................13 Travatan Z...............................................................48 TraZODone HCl .....................................................13 Page 62 Trecator .................................................................. 21 Tretinoin ........................................................... 23, 33 Trexall .................................................................... 21 Triamcinolone Acetonide ........................... 35, 45, 46 Trifluoperazine HCl................................................ 25 Trifluridine ............................................................. 47 Trihexyphenidyl HCl .............................................. 23 Trimethoprim.......................................................... 19 Trizivir .................................................................... 26 Trospium Chloride ................................................. 53 Truvada ................................................................... 26 Tykerb .................................................................... 22 Tysabri .................................................................... 51 Tyzeka .................................................................... 27 Tyzine ..................................................................... 46 Ulesfia .................................................................... 36 Uloric ...................................................................... 41 Ursodiol .................................................................. 40 Vagifem .................................................................. 54 ValACYclovir HCl ................................................. 27 Valcyte.................................................................... 27 Valproic Acid ......................................................... 12 Vancomycin HCl .................................................... 19 Vectical ................................................................... 34 Venlafaxine HCl ..................................................... 13 Venlafaxine HCl ER ............................................... 13 Ventavis .................................................................. 31 Veramyst ................................................................ 46 Verapamil HCl ....................................................... 30 Verapamil HCl ER ................................................. 30 Verapamil HCl ER (CO) ........................................ 30 Veregen .................................................................. 33 VESIcare ................................................................ 53 Vexol ...................................................................... 48 Vfend ...................................................................... 16 Victrelis .................................................................. 27 Videx ...................................................................... 26 Vigamox ................................................................. 47 Viibryd.................................................................... 13 Vimpat .................................................................... 12 Viracept .................................................................. 26 Viread ..................................................................... 27 Voltaren .................................................................. 33 Voriconazole .......................................................... 16 Votrient ................................................................... 22 Vyvanse .................................................................... 5 Warfarin Sodium .................................................... 11 Welchol .................................................................. 17 Xalkori .................................................................... 22 Xarelto .................................................................... 11 Xenazine ................................................................. 50 Xifaxan ................................................................... 19 Xyrem ..................................................................... 50 Zafirlukast .............................................................. 10 Zaleplon .................................................................. 43 Zavesca ................................................................... 42 Health First—ACA 5-Tier Drug List Zazole .....................................................................54 Zemaira ...................................................................51 Zemplar...................................................................38 Zetia ........................................................................18 Ziagen .....................................................................26 Ziana .......................................................................32 Zidovudine ..............................................................27 Zioptan ....................................................................48 Ziprasidone HCl .....................................................24 Zirgan .....................................................................47 Zolinza ....................................................................22 Page 63 Zolpidem Tartrate ................................................... 43 Zomig ..................................................................... 44 Zomig ZMT ............................................................ 44 Zonalon ................................................................... 34 Zonisamide ............................................................. 12 Zortress ................................................................... 28 Zovirax ................................................................... 34 Zyflo CR ................................................................... 9 Zymaxid.................................................................. 47 Zytiga...................................................................... 21 Zyvox...................................................................... 20 Health First offers health care coverage options through two companies. Health First Health Plans, Inc. offers Medicare Advantage and Group HMO and POS (point of service) health plans. Health First Insurance, Inc. offers Medigap/Medicare Supplement insurance, as well as Group and Individual PPO insurance, including Exchange policies.
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