REQUIRES PRIOR AUTHORIZATION by PHARMACY
Drug	Generic Name	Place of Service	Commercial/ ASO(Xerox)/ GM retiree	Gold w/Part D	Gold without Part D /Option/Kodak Gold	Kodak EPO/PPO/ Indemnity**	USDirect PPO	Policy
Abraxane	paciltaxel	office, outpatient	YES	YES	YES	NO	NO	Abraxane
Accolate	zafirlukast	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	Leukotriene Modifiers
acetylcysteine for inhalation	acetylcysteine	Pharmacy	No	YES	YES, if covered	Not Covered	NO	Medicare BvsD Policy
Aciphex	rabeprazole	Pharmacy	YES/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	YES/QTY LIMIT	PPI's
Actimmune	interferon gamma	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Actimmune
Alimta	pemetrexed	office, outpatient	YES	YES	YES	NO	NO	Select Biologic Chemotherapy Agents
Alkeran	melphalan	Pharmacy	No	YES	YES, if covered	Not Covered	NO	Medicare BvsD Policy
Altabax	retapamulin	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Ambien/CR	zolpidem tartrate	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Select Hypnotics
Amerge	naratriptan	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Amevive	alefacept	office, outpatient	YES	YES	YES	NO	NO	Psoriasis Drug Therapy
Amevive*	alefacept	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Psoriasis Drug Therapy
Amitiza	lubiprostone	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Constipation/IBS Medications
Anzemet	dolasetron	Pharmacy	NO/QTY LIMIT	YES/QTY LIMIT	YES/QTY, if covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Actiq	fentanyl citrate	Pharmacy	NO/QTY LIMIT/ STEP EDIT	YES/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Aralast	alpha1 proteinase inhibitor	office, outpatient	YES	YES	YES	NO	NO	Alpha-1 Antitrypsin Inhibitor Therapy
Aranesp	darbepoetin	office, outpatient	YES	YES	YES	NO	NO	Erythropoietic Agents
		Pharmacy	YES	YES	Not Covered	Not Covered	YES
Atacand	candesartan cilexetil	Pharmacy	YES	NO/STEP EDIT	Not Covered	Not Covered	YES	ACE/ARB Policy
Avalide	hydrochlorothiazide; irbesartan	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	ACE/ARB Policy
Avapro	irbesartan	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	ACE/ARB Policy
Avastin	bevacizumab	office, outpatient	YES	YES	YES	NO	NO	Select Biologic Chemotherapy Agents
Avinza	morphine sulfate	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Axert	almotriptan	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Azasan	azathioprine	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare BvsD Policy
Azasite	azithromycin opthalmic	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Baraclude*	entecavir	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Hepatitis B Oral Agents
Benicar/HCT	hydrochlorothiazide; olmesartan medoxomil	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	ACE/ARB Policy
Boniva IV	ibandronate sodium	office, outpatient	YES	YES	YES	NO	NO	Osteoporosis Medications
Botox	botulinum toxin type a	office, outpatient	YES	YES	YES	NO	NO	botulinum toxin policy
Brovana	arformoterol	Pharmacy	NO	YES	YES, if covered	Not Covered	YES	Medicare BvsD Policy
Caverject	alprostadil	Pharmacy	NO/QTY LIMIT	Not Covered	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Celebrex	celecoxib	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	COX-2 Inhibitors
Cellcept	mycophenolate mofetil	Pharmacy	NO	YES	YES, if covered	Not Covered	YES	Medicare BvsD Policy
Ceprotin*	human protein C	office, outpatient	YES	YES	YES	NO	NO	Orphan Drug(s) and Biologicals
Cialis	tadalafil	Pharmacy	NO/QTY LIMIT	Not Covered	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Clolar	clofarabine	office, outpatient	YES	YES	YES	NO	NO	Orphan Drug(s) and Biologicals
Copegus*	ribavirin*	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Chronic Hepatitis C Treatment
Cozaar	losartan potassium	Pharmacy	YES	NO/STEP EDIT	Not Covered	Not Covered	YES	ACE/ARB Policy
Cytoxan	cyclophosphamide	Pharmacy	NO	YES	YES, if covered	Not Covered	YES	Medicare BvsD Policy
Dacogen	decitabine	office, outpatient	YES	YES	YES	NO	NO	Myelodysplastic Syndrome Selected Agents
Diovan/HCT	hydrochlorothiazide; valsartan	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	ACE/ARB Policy
Duragesic	fentanyl	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Edex	alprostadil	Pharmacy	NO/QTY LIMIT	Not Covered	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Elaprase	idursuifase	office, outpatient	YES	YES	YES	NO	NO	Orphan Drug(s) and Biologicals
Elidel	pimecrolimus	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	Dermatologicals for Imflammation
Eloxatin	oxaliplatin	office, outpatient	YES	YES	YES	NO	NO	Select Biologic Chemotherapy Agents
Emend	aprepitant	Pharmacy	NO/QTY LIMIT	YES/QTY LIMIT	YES/QTY LIMIT	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Enbrel*	etanercept	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Psoriasis Drug Therapy/ Arthropathy Drug Therapy
Energix-B		office, outpatient	NO	YES	YES	NO	NO	Medicare BvsD Policy
Epogen	erythropoietin	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Erythropoietic Agents
		office, outpatient	YES	YES	YES	NO	NO
Erbitux	cetuximab	office, outpatient	YES	YES	YES	NO	NO	Select Biologic Chemotherapy Agents
Evamist	estradiol MDTS	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Exelon Patch	rivastigmine	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Exforge	amlodipine + valspartan	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Exjade	deferasirox	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Orphan Drug(s) and Biologicals
Exubera	inhaled insulin	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Non-injectable Insulins
Fabrazyme	agalsidase beta	office, outpatient	YES	YES	YES	NO	NO	Fabry Disease (treatment of)
Fentanyl	fentanyl	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Flector	diclofenac	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Flolan	epoprostenol sodium	office, outpatient	YES	YES	YES	NO	NO	Advanced Agents for Pulmonary Hypertension
Flumist		office, outpatient	Prior authorization is not needed except for those members on a Xerox plan
Forteo*	teriparatide	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Osteoporosis Medications
Frova	frovatriptan	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limit Policy
Gengraf	cyclosporine	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare Part B vs Part D Determination
Gleevec*	imatinib	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Antineoplastic Enzyme Inhibitors
Gondatropins and Fertility Agents	various	Pharmacy	YES	Not Covered	Not Covered	Not Covered	YES	Infertility (Involuntary)
Growth Horomone*	various	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Growth Hormone Therapy
Humira*	adalimumab	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Biologic Drug Therapy for Inflammatory Arthritis
Hyalgan	sodium hyaluronate	office, outpatient	YES	YES	YES	NO	NO	Hyaluronic Acid Derivatives
Hyzaar	hydrochlorothiazide; losartan potassium	Pharmacy	YES	NO/STEP EDIT	Not Covered	Not Covered	YES	ACE/ARB Policy
IGG/IVIG	Intravenous Immunoglobulin	office, outpatient	YES	YES	YES	NO	YES	Intravenous Immunoglobulin Therapy
Imitrex	sumatriptan	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limits
Imuran	azathioprine	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare BvsD Policy
Infergen*	infergen alfacon-1	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Chronic Hepatitis C Treatment
Inspra	eplerenone	Pharmacy	NO/ STEPEDIT	NO/ STEPEDIT	Not Covered	Not Covered	NO/ STEPEDIT	Aldosterone Blocker Policy (Inspra® eplerenone)
Iressa*	gefitnib	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Antineoplastic Enzyme Inhibitors
Kadian	morphine sulfate	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Kineret*	anakinra	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Biologic Drug Therapy for Inflammatory Arthritis
Kytril	granisetron	Pharmacy	NO/QTY LIMIT	YES/QTY LIMIT	YES/QTY, if covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limit Policy
Lamisil	terbinafine	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Onychomycosis
Letairis*	ambrisentan	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Levitra	vardenafil	Pharmacy	NO/QTY LIMIT	Not Covered	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limit Policy
Lotronex	alosetron	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Constipation/IBS Medications
Lucentis*	ranibizumab	office, outpatient	YES	YES	YES	NO	NO
Lunesta	eszopiclone	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Select Hypnotics
Lupron SQ	leuprolide acetate	Pharmacy	YES	YES	Not Covered	Not Covered	YES	GnRH Agonist and Antagonist Medications
Maxalt	rizatriptan	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limit Policy
Menomune	Meningococcal Polysaccharide Vaccine	office, outpatient	YES	YES	YES	NO	NO	Immunization
Micardis/HCT	telmisartan	Pharmacy	YES	NO/STEP EDIT	Not Covered	Not Covered	YES	ACE/ARB Policy
MIGRANAL	dihydroergotamine	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limit Policy
Morphine SR	morphine sulfate	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
MS Contin	morphine sulfate	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Muse	alprostadil	Pharmacy	NO/QTY LIMIT	Not Covered	Not Covered	Not Covered	NO/QTY LIMIT	Prescription Drug Quantity Limit Policy
Mycamine	micafungin sodium	office, outpatient	YES	YES	YES	NO	NO
Myobloc	botulinum toxin type b	office, outpatient	YES	YES	YES	NO	NO	botulinum toxin policy
Myozyme	alglucosidase alfa	office, outpatient	YES	YES	YES	NO	NO	Orphan Drug(s) and Biologicals
Nebulizer solution	examples are: Duoneb, Albuterol, Xopenex, Brovana, Performomist	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare Part B vs Part D Determination
Neoral	cyclosporine	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare Part B vs Part D Determination
Neulasta	pegfilgrastim	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Blood Modifiers - excluding
		office, outpatient	YES	YES	YES	NO	NO	RBC Agents
Neupro	rotigotine	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Nexavar*	sorafenib tosylate	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Antineoplastic Enzyme Inhibitors
Nexium	esomeprazole magnesium	Pharmacy	YES/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	YES/QTY LIMIT	PPI's
Nuflexxa	sodium hyaluronate	office, outpatient	YES	YES	YES	NO	NO	Hyaluronic Acid Derivatives
Nuvigil	armodafinil	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Omnaris	ciclesonide	Pharmacy	YES	YES	Not Covered	Not Covered	YES	New Drug Policy
Opana ER	oxymorphone ER	Pharmacy	STEP EDIT/ QTY LIMIT	STEP EDIT/ QTY LIMIT	Not Covered	Not Covered	STEP EDIT/ QTY LIMIT	Pain Medication
Oramorph SR	morphine sulfate	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Orencia*	abatacept	office, outpatient	YES	YES	YES	NO	NO	Biologic Drug Therapy for Inflammatory Arthritis
Orthovisc	high molecular weight hyaluronan	office, outpatient	YES	YES	YES	NO	NO	Hyaluronic Acid Derivatives
Oxycodone SR	oxycodone hydrocholoride	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Oxycontin	oxycodone hydrocholoride	Pharmacy	NO/QTY LIMIT/ STEP EDIT	NO/QTY LIMIT/ STEP EDIT	Not Covered	Not Covered	NO/QTY LIMIT/ STEP EDIT	Pain Medication
Pegasys*	peginterferon alfa 2a	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Chronic Hepatitis C Treatment
PEGIntron*	peginterferon alfa 2b	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Chronic Hepatitis C Treatment
Penlac	ciclopirox	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Onychomycosis
Prevacid	lansoprazole	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	PPI's
Prevacid/Naprapac	lansoprazole; naproxen	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	PPI's
Prevnar	pneumococcal vaccine	office, outpatient	YES	YES	YES	NO	NO	Immunization
Prialt	ziconotide	office, outpatient	YES	YES	YES	NO	NO
Prilosec (RX)	brand only	Pharmacy	YES/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	YES/QTY LIMIT	PPI's
Procrit	erythropoietin	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Erythropoietic Agents
		office, outpatient	YES	YES	YES	NO	NO	Erythropoietic Agents
Prograf	tacrolimus	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare Part B vs Part D Determination
Prolastin	alpha1 proteinase inhibitor	office, outpatient	YES	YES	YES	NO	NO	Alpha-1 Antitrypsin Inhibitor Therapy
Protonix	pantoprazole sodium	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	PPI's
Protopic	tacrolimus	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	Dermatologicals for Imflammation
Qualaquin	quinine sulfate	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Quinine
Rapamune	sirolimus	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare Part B vs Part D Determination
Raptiva*	efalizumab	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Psoriasis Drug Therapy
Rebetol*	ribavirin*	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Chronic Hepatitis C Treatment
Reclast	zoledronic acid	office, outpatient	YES	YES	YES	NO	NO	New Drug Policy
Recombivax Hb	hepatitis B vaccine	office, outpatient	NO	NO	NO	NO	NO
Recombivax Hb		Pharmacy	Not Covered	YES	Not Covered	Not Covered	Not Covered	Medicare BvsD Policy
Relenza	zanamivir	office, outpatient	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Quantity Limits
Relpax	eletriptan	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Quantity Limits
Remicade*	infliximab	office, outpatient	YES	YES	YES	NO	NO	Biologic Drug Therapy for Inflammatory Arthritis/ Remicade (for IBD)
Remodulin	tresprostinil sodium	office, outpatient	YES	YES	YES	NO	NO	Advanced Agents for Pulmonary Hypertension
Restasis	cyclosporine ophthalmic	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Restasis
Retisert	fluocinolone acetonide	office, outpatient	YES	YES	YES	NO	NO	Orphan Drug(s) and Biologicals
Revatio*	sildenafil	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Advanced Agents for Pulmonary Hypertension
Revlimid*	lenalidomide	Pharmacy	YES	YES	Not Covered	Not Covered	YES	Thalidomide and derivatives
Rozerem	ramelteon	Pharmacy	NO/QTY LIMIT	NO/QTY LIMIT	Not Covered	Not Covered	NO/QTY LIMIT	Select Hypnotics
Sandimunne	cyclosporine	Pharmacy	NO	YES	YES, if covered	Not Covered	NO	Medicare Part B vs Part D Determination
Selzentry	maraviroc	Pharmacy	YES	NO	Not Covered	Not Covered	YES	New Drug Policy
Singulair	montelukast sodium	Pharmacy	NO/STEP EDIT	NO/STEP EDIT	Not Covered	Not Covered	NO/STEP EDIT	Leukotriene Modifiers
Soliris*	eculizumab	office, outpatient	YES	YES	YES	NO	NO	New Drug Policy
Somavert*