Blue Cross Blue Shield of Michigan

Custom Formulary Quick Guidefor Members

To ensure the quality and cost-effectiveness

of medications, your employer, sponsor,

health plan administrator or retirement

group has selected a prescription drug

plan with a formulary. A formulary is a list

of drugs approved by the Food and Drug

Administration that your doctor refers to

when prescribing your medications.

This guide can help you be a more informed

patient. It is not intended to take the place

of your doctor's advice. Please talk to your

doctor about your drug options.

Generic drugs offer the best valuePrescription drugs can be costly, but many are nowavailable as generics. Generic drugs work the sameas brand-name drugs, but cost less. Depending onyour drug benefit, using generic drugs may loweryour copayment. The FDA requires that generic drugshave the identical active ingredients as the equivalentbrand-name drugs, but they may differ from brand-name drugs in color and shape. Since the majordifference between brand-name and generic drugs isprice, your prescription will be filled with the genericequivalent when medically appropriate.

Guide lists most commonlyprescribed drugsOur formulary lists medications available to BCBSMmembers who have a triple-tier or closed (managed)formulary benefit. The formulary represents theclinical judgment of physicians, pharmacists andother experts in the diagnosis and treatment ofdisease and promotion of health.

This guide lists drugs most commonly prescribedfor BCBSM members; it is not a complete listing ofdrugs on our formulary. It encourages you and yourdoctor to select drugs recognized as the safest andmost effective. Referring to this guide can help youunderstand how your drug copayment works andsave money on your prescriptions.

Tier 1 - GenericTier 1 drugs are generic drugs made with the sameactive ingredients, available in the same strengths anddosage forms, and administered in the same ways asequivalent brand-name drugs. Generic drugs have aproven record of effectiveness. They also require thelowest copayment, making them the most cost-effectiveoption for treatment. Look for these drugs under"Tier 1 - Generic" in this guide. Please note that thegenerics are listed according to their better-knownbrand-names. Depending on your drug benefit, selectover-the-counter products may be covered under Tier 1.

Tier 2 -- Formulary brandTier 2 drugs are brand-name drugs included in theformulary. Tier 2 drugs are also safe and effectivebut require a higher copayment than Tier 1 drugs.Look for these drugs under "Tier 2 - Formulary brand"in this guide.

The following chart shows how the copayments work within each tier:

Tier 3 - Nonformulary brandTier 3 drugs are brand-name drugs not included inthe formulary. If you have a triple-tier benefit, youwill pay the highest copayment for these drugs.If you have a closed (managed) formulary benefit,these drugs will not be covered. However, genericequivalents and similar drugs with generic equivalentsor formulary brand-name alternatives are availablefor many of these drugs. If you wish to know if it ispossible to have your prescription changed to oneof the products with a lower copayment, consultwith your physician to see if a change is appropriatefor you. Look for these drugs under "Tier 3 -Nonformulary brand" in this guide.

Triple-tier planTwo-tier

closed (managed)

Tier 1 - Generic

Tier 2 - Formulary brand

Tier 3 - Nonformulary brand

Lowest copayment

Higher copayment

Highest copayment

Lower copayment

Higher copayment

Not covered*

* Not covered without medical necessity authorization

Understanding your prescription drug benefit

BCBSM drug plans do not cover certain types ofmedications and medical supplies, including:

• Drugs used for experimental or investigationalpurposes

• Cosmetic drugs

• Vaccines given solely to resist infectious diseases

• Therapeutic devices and appliances, such asasthma devices (These may be available underyour medical coverage.)

Note: BCBSM may provide coverage for a few selectover-the-counter medications with a prescription asa first-step treatment for members who have drugplans with prior authorization and step therapy or formembers enrolled in our Pharmacy Initiative program.These OTC medications are included on the BCBSMCustom Formulary and are covered at the appropriatecopayment amount.

Your drug plan may not cover nonformulary brand-name (Tier 3) drugs, contraceptive medications andcertain health, habit and reproductive drugs. Pleaserefer to your specific plan description for details.

Authorization and clinical criteriaBCBSM monitors the use of certain medications toensure our members receive the most appropriateand cost-effective drug therapy. Prior authorization forthese drugs means that certain clinical criteria mustbe met before coverage is provided. In the case ofdrugs requiring step therapy, for example, previoustreatment with one or more formulary drugs may berequired. Drugs that must meet clinical criteria areidentified in the formulary list with (PA) or (ST).If your prescription drug plan requires priorauthorization or step therapy, your physician cancontact our pharmacy help desk to request priorauthorization for these drugs.

The criteria for authorization are based on currentmedical information and the recommendations of theBlues' Pharmacy and Therapeutics Committee, agroup of physicians, pharmacists and other experts.You may be required to pay the full cost of the drug ifyour physician does not obtain prior authorization.

When your doctor prescribes a brand-name drugthat's nonformulary, requires prior authorization, oris not covered under your drug rider, it may not be acovered benefit. BCBSM reviews all physician andmember requests to determine if the drug is medicallynecessary and that there aren't equally effectivealternative drugs on the formulary.

Please call the Customer Service number on the back ofyour BCBSM ID card if you have questions about yourdrug coverage, a drug daim or filing a benefit exception.

Filling your prescriptionThere are two ways to fill your prescription:

• At a retail pharmacyMore than 2,300 retail pharmacies in Michiganand 59,000 retail pharmacies outside of Michiganparticipate with BCBSM. You may fill prescriptionsat any participating pharmacy.

• Mail order (home delivery)If you are enrolled in a mail order program, youcan receive your prescriptions through one of ourmail order vendors. The type of medication youtake determines which mail order vendor you use:

— Specialty drugs should be ordered throughWalgreens Specialty Pharmacy. Specialtydrugs are prescription medications used totreat complex conditions and require specialhandling, administration or monitoring.

— All other drugs should be ordered throughMedco.

If you have questions about which mail order vendoryou should use to order your drug, or if you wouldlike to request a mail order kit, please contact theCustomer Service phone number on the back of yourBCBSM ID card.

Formulary listsThe BCBSM Custom Formulary Quick Guide forMembers includes commonly prescribed drugs. For acomplete list of drugs included in BCBSM's CustomFormulary, visit our Web site at bcbsm.com. Clickon I am a Member, then click on Prescription Drugson the left navigation menu. From there, click onApproved Drug Lists (Formularies).

Call if you need more information

If you have questions about your prescription drug benefit,

se call the Blue Cross Blue Shield of Michigan Customer

"' imber on the back of your BCBSM ID card.

BCBSM Custom Formulary Quick Guide

•Allergy, Asthma, andRespiratory

Tier 1 — GenericAccuneb (g)Alupent (q)Atrovent Nasal, Solution (g)Brethine (g)DuoNeb (g)Flonase (g)Nasalide (g)Nasarel (g)Intal Solution (g)Mucomyst (g)Proventil/Ventolin Solution, Tab (g)Pulmicort Respules (g)Uniphyl (g)Vospire ER (g)

Tier 2 — Formulary BrandAccolate (QL)Advair Diskus, HFAAlvescoAsmanexAtrovent InhalerAzmacortCombivsntFlovent InhalerForadilIntal InhalerMaxair AutohalerNasacort AQ (PA)Proair HFAPulmicortQVARSerevent DiskusSingulair (QL)SpirivaSymbicortTheo-24Ventolin HFA

Tier 3 — Non-formulary BrandAerobid, MBeconase AQ (PA)BrovanaNasonex (PA)Omnaris (PA)PerforomistProventil HFARhinocort Aqua (PA)Veramyst (PA)Xopenex, HFAZyflo CR (QL)

Tier 1 — GenericAmoxapine(g)Anafranil (g)Celexa (g)Desyrel (g)Effexor (g)Elavil (g)Etrafon (g)Limbitrol, DS (g)Luvox (g)Maprotiline (g)Norpramin (g)Pamelor/Aventyl (g)Parnate (g)Paxil, CR (g)Prozac (g)Remeron, Soltab (g)

Sarafem Pulvule (g)Sinequan/Adapin (g)Surmontil (g)Tofranil, PM (g)Vivactil (g)Wellbutrin, SR, XL (g)Zoloft (g)

Tier 2 — Formulary BrandEffexor XR (PA)Lexapro (PA)NardilSurmontil 1 0OmgVenlafaxine ER (PA)

Tier 3 — Non-formulary BrandAplenzin (PA)Cymbalta (PA)EmsamLuvox CR (PA)MarplanPexeva (PA)Pristiq (PA)Prozac Weekly (PA) (QL)Sarafem tablet

1 AntifungalsTier 1 — GenericDiflucan (g)Grifulvin V Susp (g)Lamisil Tabs (g)Loprox Cr, Lotion, GelLotrimin (g)Lotrisone Cr, Lotion (g)Monistat-Derm (g)Mycelex Troche (g)Mycostatin (g)Nizoral, Tabs, Cr, Shampoo (g)Nystatin (g)Penlac (g)Spectazole (g)Sporanox Caps (g)Tier 2 — Formulary BrandAncobonGrifulvin V SOOmgGris-Peg

Sporanox SolutionVfend

Tier 3 — Nonformulary BrandErtaczoExelderm Soln, CrExtinaLamisil GranulesLoprox ShampooMentaxNaftinOxistatVusionXolegel

1 Antihistamines and

Tier 1 — GenericAllegra, D-12h(g)(QL)AtaraxA/istaril (g)Benadryl (g)Bromfed, PD (g)Claritin, D, Alavert (OTC) (g)Deconamine, SR, Syrup (g)Periactin (g)Phenergan, VC (g)

Polaramine (g)Rondec (g)Rynatan, Suspension (g)Tavist-RX (g)Zyrtec, D (OTC) (g)

Tier 2 — Formulary BrandAllegra D 24h (QL)Astelin, Astepro Nasal Spray

Tier 3 — Nonformulary BrandAllegra Susp (PA)Clarinex, Reditabs, D (PA) (QL)PatanaseSemprex-DXyzal (PA) (QL)Allegra ODT (PA)

1 Anti-infectivesTier 1 — GenericAdoxa (g)Amoxil (g)Ampicillin (g)Augmentin, ES (g)Bactrim, DS/Septra, DS (g)Diaxin, AL \g/Ceclor, ER (g)Ceftin (g)Cefzil (g)Cipro, XR (g)Cleocin (g)Dicloxacillin (g)Duricef (Q)Erythromycin (g)Floxin (g)Hiprex/Urex (g)Keflex (g)Macrobid (g)Macrodantin (g)MandeJamine (g)Minocin/Dynacin (g)Monodox (g)Neomycin (g)Omnicef (g)Pediazole (g)Penicillin VK (g)Periostat (g)Pyridium (g)Sulfadiazine (g)Tetracyoline (g)Trimethoprim (g)Vantin (g)Vibramycin/Vibratabs (g)Zithromax (g)Tier 2 — Formulary BrandAvelox, ABCTOBI (s)VancocinZyvoxTier 3 — Nonformulary BrandAdoxa 150mg, CK, TTAugmentin XRCedaxDoryxFactiveKeflex 750mgKetekLevaquinMaxaquinMonurolMoxatagNoroxin

OraceaOraxylPCEProquin XRRaniclorSolodynSpectracefSupraxXifaxanZmax

1 Bladder Control ^MTier 1 — GenericRpntvl (n\f ii.yt \\j)Ditropan, XL (g)Pro-Banthine (g)Levsin, SL (g)Levsinex (g)Urispas (g)

Tier 2 — Formulary BrandDetrol, LA

Tier 3 — Nonformulary BrandEnablexueinique (ULJOxytrol (QL)Sanctura, XRToviaz (QL)Vesicare

•\JO* VI W VUOWMIUI \l I UI I Ul IVi ^^^^H

High Blood Pressure) ^H

Tier 1 — GenericAccupril/Accuretic (g)Aceon (g)Agrylin (g)Aldactone/Aldactazide (g)Aldomet/Aldoril (g)Altace capsules (g)Betapace, AF (g)Blocadren (g)Bumex (g)Calan/lsoptin, SR (g)Capoten/Capozide (g)Cardene (g)Cardizem, SR, CD (g)Cardura (g)Catapres (g)Cordarone (g)Coreg (g)Corgard (g)Corzide (g)Coumadin (g)Demadex (g)Diamox, Sequels (g)Digoxin Tabs (g)Diuril (q)Dynacirc (Q)Hygroton, Thalitone (g)Hytrin (g)Inderal, LA/lnderide (g)Inspra (g)Ismo/lmdur (g)JSQf"Hj| ^Q^

Ksrlone (g)

Lopressor, HCT (g)Lotensin, HGT(g)I ntrpl (n\i \yj

Lozol (Q)Mavik (g)

(PA) — Prior authorization may be required; clinical criteria must be met(ST) — Step therapy may be required

(g) — Drug is available as generic equivalent but is listed by its brand-name(QL) — Quantity limits may apply

(s) — Specialty drug(OTC) — Over-the-counter product may be covered as Tier 1 (generic) copayment

Should a Tier 2 formulary brand-name drug lose its patent and generic versionsbecome available, the generic versions are added to Tier 1 and the brand versionmay become a Tier 3 nonformulary brand

BCBSM Custom Formulary Quick GuideMaxzide/Dyazide (g)Microzide (g)Midamor (g)Minipress (g)Moduretic (g)Monopril, HCT (g)Nitroglycerin Oral, Patch (g)Normodyne (g)Norvasc (g)Persantine (g)PinHnlnl (n\I lul

Plendil (g)Pletal (g)Prinivil/Zestril (g)Prinzide/Zestoretic (g)Procardia, XL/Adalat CC (g)Rythmol (g)Sectral (g)Sular 20, 30, 40mg (g)Tenormin/Tenoretic (g)Tenex (g)Tiazac (g)Ticlid (g)Toprol XL (g)Univasc/Uniretic (g)Vasotec/Vaseretic (g)Verelan, PM (g)Zaroxolyn (g)Zebeta (g)Ziac (g)

Tier 2 — Formulary BrandBenicar, HCT (PA)BidilCatapres-TTSCovera-HSCozaar/Hyzaar (PA)EdecrinEffientDilatrate-SRDyreniumDigoxin ElixirLotrel 5/40, 1 0/40Lovenox (s)Multaq (QL)Nitro-BidNitrolingual sprayNitrostatNorpace CRPlavixTikosynTrental

Tier 3 — Nonf ormulary BrandAggrenoxAltace tabletsArixtra (s)Atacand, HCT (PA)Avapro/Avalide (PA)AzorSystolic (PA)Caduet (QL)Gardens SRCardizem LACoreg CRDiovan, HCT (PA)Dynacirc CR^vfrtrrto k-t/~*Tcxrorgs, nu iFragmin (s)Innohep (s)Innopran XLLevatolMicardis, HCT (PA)

Naturetin-5RanexaRythmol SRSular 8.5, 17, 25.5, 34mgTarkaTekturna, HCT (PA)Teveten, HCT (PA)TwynstaValturna PA)

1 Central Nervous SystemTier 1 — GenericAdderall, XR (g)Chlorpromazine (g)Clozaril (g)Dexedrine (g)Eskalith, CR/Lithobid (g)Focalin (g)Haldol, Decanoate (g)Lithium Citrate (g)Loxitane (g)Mellaril (g)Navane (g)Nimotop (g)Perphenazine (g)Prolixin, Decanoate (g)Razadyne, ER, Solution (g)Requip (g)Risperdal, M-tab (g)Ritalin, SR/Methylin, ER (g)Stelazine (g)Thorazine (g)

Tier 2 — Formulary BrandAbility, Discmelt, SolutionAricept, ODTConcertaDesoxynExelonGeodonMetadata CDMobanNamendaOrapProvigil (QL)SeraquelZyprexa, ZydisTier 3 — Nonf ormulary BrandCognexDaytranaFazaoloFocalin XRIntuniv (PA) (QL)Invega (QL)Methylin Chew, SolutionNuvigil (QL)ProcentraRequip XLPitalin I ArWdml LJ\s (QL)

Savella (PA) (QL)Seroquel XR (QL)Strattera (PA)SymbyaxVwanse (PA)

• Cholesterol — LoweringTier 1 — GenericsColestid (g)Fibricor (g)Lofibra (g)Lopid (g)Mevacor (g) (QL)

Pravachol (g) (QL)Questran, Light (g)Zocor (g) (QL)

Tier 2 — Formulary BrandCreator (PA) (QL)NiaspanTricorWelcholZetia (PA) (QL)

Tier 3 — NonformularyAdvicor PA)Altoprev (PA) (QL)AntaraCaduet (QL)Colestid FlavoredFenoglideLescol, XL (PA) (QL)Lipitor (PA) (QL)LipofenLivalo (PA)LovazsSimcor (PA)TriglideTrilipix (PA)vylorin (PA) (QL)

1 Diabetes TreatmentTier 1 — GenericAmaryl (g)Diabinese (g)Glucophage, XR (g)Glucotrol, XL (g)Glucovance (g)Glynase (g)Metaglip (g)Micronase/Diabeta (g)Orinase (g)Precose (g)Tolinase (g)

Tier 2 — Formulary BrandActosActoplus MetApidraAvandiaDuetactInsulin (all)LantusLevemirPrandin

Tier 3 — Nonformulary BrandsAvandametAvandarylByetta (PA)FortametGlumetzaGlysetJanumetJanuvia (QL)Onglyza (QL)PrandimetRiometStarlixSymlin

1 Gastrointestinal AgentsTier 1 — GenericAxid (g)Carafate Tabs (g)Cytotec (g)Pepcid (g)Prevacid (g)

Prilosec (g)Prilosec (OTC) (g)Protonix (g)Tagamet (g)Zantac (g)

Tier 2 — Formulary BrandCarafate SuspensionHelidacPrevacid SolutabPrevpac

Tier 3 — Nonformulary BrandAciphex (PA)Kapidex (PA)Nexium (PA)Prilosec SuspensionProtonix SuspensionPyleraZantac EfferdoseZegerid (PA)

1 Hormones and Birth Control ^HTier 1 - GenericActivella1/0.5mg(g)Alesse, Levlite (g)Androxy 1 0mg (g)Aygestin (g)r^timaro /n\ Notimara (gj (ULJCyclessa (g)Danocrine (g)Demulen (g)Depo Provera (1 SOmg) (g)Depo-Testosterone (g)Desogen, Ortho-Cept (g)Estrace (g)Estratest, HS (g)Estrostep Fe (g)Lo/Ovral (g)Loestrin, Fe (g)Mircette (g)Modicon (g)Necon 10/11 (g)Nordette, Levlen (g)

Nonnyl, Ortho-Novum - 1/35 1/50 fe)Ogen, Ortho-Est (g)Ortho Micronor, Nor-QD (g)Ortho Tri-Cyolen (g)Ortho-Cyclen (g)Ortho-Novum 7/7/7 (g)Ovcon-35 (g)Ovral (g)Oxandrin (g) (PA)Plan B (g)Provera (g)Seasonale (g) (QL)Tri-Norinyl (g)Triphasil, Trilevlen (g)Yasmin (g)

Tier 2 — Formulary BrandAlora (QL)Androderm (QL)CrinoneDelatestrylDepo-SubQ Provera 104EndometrinEstraderm (QL)Estring (QL)FemhrtLybrelOrtho Evra (QL)Ortho Tri-Cyclen Lo

(PA) — Prior authorization may be required; clinical criteria must be met

(ST) — Step therapy may be required

(g) — Drug is available as generic equivalent but is listed by its brand-name

(QL) — Quantity limits may apply

BCBSM Custom Formulary Quick GuidePremarin, Low DosePremphasePrempro, Low DoseProchievePrometriumVivelle-DOT (QL)YazTier 3 — Nonf ormulary BrandActivella 0.5/0.1 mgAnadrol-50 (PA)Androgel (QL)AngeliqCenestinClimara Pro (QL)Combipatch (QL)DMgelElestrinEnjuviaEstrace Vaginal CreamEstrasorb (QL)Estrogel (QL)EvamistFemcon FeFemring (QL)FemtraceLoestrin 24 FeLoseasonique (QL)MenestMenostar (QL)Methitest, Testred, AndroidNuvaring (QL)Ortho-PrefestOvcon-50, FePlan B One-StepSeasonique (QL)Striant (QL)Testim (QL)Vagifem

Suin&CflMMiiiHHiilHHTier 1 — GeneticsCafergot (g)D.H.E. 45 (g)Fioricet/Esgic, Plus (g)Fiorinal, w/ codeine (g)Imitrex Tab, Injection, Spray (g) (QL)Midrin (g)Stadol NS (g)

Tier 2 — Formulary BrandsErgomarMaxalt, MLT (PA) (QL)Migranal (QL)Phrenilin ForteTier 3 — Nonf ormulary BrandArnerge (PA) (QL)Axert (PA) (QL)Frova (PA) (QL)Rolpax (PA) (QL)Sumavel Dosepro (PA) (QL)Treximet (PA) (QL)Zomig, ZMT, Nasal Spray (PA) (QL)

Tier 1 — GeneticsDidronel (g) (QL)Estrogens (See Hormones and Birth

Control)Fosamax, Weekly (g) (QL)Miacalcin (g)

Tier 2 — Formulary BrandsActonel, Weekly, Plus Calcium (PA) (QL)Estrogens (See Hormones and Birth

Control)EvistaFortical

Tier 3 — Nonf ormulary BrandBoniva (PA) (QL)Forteo (PA) (QL) (s)Fosamax Plus D (QL)

•Pain and Arthritis 1(anti-inflammatory) 1

Tier 1 — GeneticsAnaprox, OS (g)Ansaid (g)Cataflam (g)Clinoril (g)Daypro (g)Feldene (g)Indocin, SR (g)Ketoprofen (g)Lodine, XL (g)Meclomen (g)Mobic (g)Motrin (g)Naprosyn, EC (g)Relafen (g)Tolectin, DS (g)Toradol (g) (QL)Vottaren, XR (g)

Tier 2 — Formulary BrandIndocin suppPonstel

Tier 3 — Nonf ormulary BrandArthrotecCelebrex (PA)Fleeter (PA)Naprelan, CRPrevacid NaprapacVoltaren Gel

I Sleep and Anxiety I

Tier 1 — GenericAmbien (g) (QL)Ativan (g)Buspar (g)Chloral hydrate (g)Dalmane (g) (QL)Halcion (g) (QL)Librium (g)Miltown (g)Niravam (g)ProSom (g) (QL)Restoril (g) (QL)Serax (g)Sonata (g) (QL)Tranxene (g)Valium (g)Xanax, XR (g)Tier 2 — Formulary BrandNoneTier 3 — Nonf ormulary BrandAmbien CR (PA) (QL)Butisol SodiumDoral (QL)Edluar (PA) (QL)LibritsbsLunesta (PA) (QL)Rozerem (PA) (QL)Xyrem (QL)Zolpimist (PA)

Additional Tier 3 — NonformularyAcular, LS, PFAcuvailAczoneAdcirca (PA) (s)Akne-MycinAlamastAldaraAlrexAltabaxAmitiza (PA)AmrixAnzemetApexicon E CreamAprisoArmour ThyroidAranesp (PA) (s)AvinzaAvodartAzasiteAzelexAzilectBeconase AQBenzaclinBenzashave, Brevoxyl-4,8 PackBepreveBesivanceBetaseron (s)BetimolCaracCarbatrolCardura XLCarmol HCCesametCimzia Syringe (PA) (s)Clarifoam EFClinac BPOClobexCombiganCutivate LotionDarvon-NDenavirDepenDerma-Smoothe/FSDesonateDipentumDuac CSDurezolEdex (QL)Efudex OcclusionElestatEmadineEmbeda (QL)Entocort ECEpiduoEpogen (PA) (s)EquetroEvoclin FoamFentora (PA) (QL)FexmidFinaceaFlomaxHalogHumatrope (PA) (s)Increlex (PA) (s)lopidineIquixKadianKeppra XRKineret (PA) (s)Lamictal ODT, XRLevitra (QL)

LialdaLidoderm PatchLocoid LipocreamLotemaxLotronex (PA)LuxiqLyrica (PA)MagnacetMaxidexMeridiaMetozolv ODTNasonexNeulasta (QL) (s)NevanacNicotrol, Inhaler, Nasal SprayNorditropin (PA) (s)NoritateNucynta (QL)NumorphanOlux-EOmnarisOmnitrope (PA) (s)Onsolis (PA) (QL)Opana, EROptivarOrapred ODTOxycontin (QL)PandelPatadayPatanasePeranex HCPramosone Lotion, OintmentPred-GProtopicQuixinRapaflo (QL)RegranexRequip XLRhinocort AquaRyzoltSatzen (PA) (s)Sancuso (PA)Canf\/toantyiSerostim (PA) (s)Simponi (PA) (s)Sola razeSottamoxSoma 250Taclonex, ScalpTargretin Gel (s)TasmarTev-Tropin (PA) (s)Uloric (PA) (QL)Ultram ER 300mgUltravate PACVanos CreamVecticalVeramystVerdesoVeregenXenicalXibromXodolZacareZelaparZiana GelZorbtive (PA) (s)

(s) — Specialty drug

(OTC) — Over-the-counter product may be covered as Tier 1 (generic) copayment

Should a Tier 2 formulary brand-name drug lose its patent and generic versionsbecome available, the generic versions are added to Tier 1 and the brand versionmay become a Tier 3 nonformulary brand