Medication Name ZD PD NPD SP PA ST EX LD BENAZAPRIL

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LVHN Health Plan (Choice Plus) Zero Dollar Generics, Preferred, Non-Preferred, Specialty, Step Therapy, Prior Authorization, Exclusion and Limited Distribution Medication List This list contains the

1 LVHN Health Plan (Choice Plus) Zero Dollar Generics, Preferred, Non-Preferred, Specialty, Step Therapy, Prior Authorization, Exclusion and Limited Distribution Medication List This list contains the names of medications, in alphabetical order, that are subject to one or more of the categories defined below. Definitions: Zero Dollar Generics (ZD)- Generic medications that are covered 100% by the health plan (effective 1/1/2018). Preferred (PD)- A medication that will have a lesser copay or co-insurance than other medications used for the same condition Non-Preferred (NPD)- A medication that will have a higher copay or co-insurance than other medications used for the same condition (effective 1/1/2018). Specialty (SP)- A medication that treats a rare, chronic, or complex condition. Because of their high cost, they are subject to a higher copay. Prior Authorization (PA)- A medication that needs additional clinical documentation submitted to Populytics Care Management from your physician for it to be covered. Step Therapy (ST)- Trying other medications in the same drug class first before the more expensive medication will be covered by the health plan (Click the hyperlink to see requirements and additional information). Excluded (E)- Medications that are not covered by the health plan because other lower-cost, clinically equivalent alternatives are available (Click the hyperlink to see additional information). Limited Distribution (LD)- Medications that are not available at Health Spectrum Pharmacy. If your physician has prescribed one of these medications, contact Populytics Care Management at (484) for details about how to obtain them. This list is updated quarterly, but is subject to change without notice to accommodate the introduction, removal and availability of new drugs and clinical information. (Last Update: 11/1/2018; items in red effective 1/1/2019) ABRAANE ACANYA ACTEMRA ACTHAR HP ACTIMMUNE ACTIVASE ADAGEN ADCETRIS ADCIRCA ADDYI ADEMPAS ADRIAMYCIN ADVATE AFINITOR AFINITOR DIS AFSTYLA ALDURAZYME ALECENSA ALFERON N Page 1 of 17

2 ALIQOPA ALOQUIN ALPHANATE ALPHANINE SD ALTOPREV ALUNBRIG ALVESCO AMLODIPINE AMMONUL AMPYRA ANDROGEL ANGIOMA APOKYN APTIVUS ARALAST NP ARANESP ARCALYST AREDIA ARISTADA ARITRA ARNUITY ELLIPTA ARRANON ARZERRA ATENOLOL ATGAM ATORVASTATIN ATRALIN ATRIPLA AUBAGIO AUSTEDO AUVI-Q 0.15mg & 0.3mg AVASTIN AVEED AVODART AVONE AERT AZASAN AZEDRA BARACLUDE BAVENCIO BEBULIN BEBULIN VH BECONASE BELEODAQ BELVIQ BELSOMRA Page 2 of 17

3 BENAZAPRIL BENEFI BENLYSTA BENZACLIN BERINERT BETASERON BETHKIS BESPONSA BEVESPI BEVYA BEAR BICNU BIKTARVY BIVIGAM BLINCYTO BONIVA INJ. BOSULIF BOTO BRAFTOVI BRAVELLE BREO ELLIPTA BRINEURA BUPHENYL BUSULFE CABOMETY CALQUENCE CAMPTOSAR CAPRELSA CARBAGLU CARIMUNE NF CARVEDILOL CATHFLO ACTI CAYSTON CEENU CELEBRE CELLCEPT CEPROTIN CERDELGA CEREZYME CERUBIDINE CETROTIDE CHENOBAL CHOLBAM CIALIS CIMDUO CIMZIA Page 3 of 17

4 CINRYZE CINQAIR CITALOPRAM CLARINE D CLOLAR COAGADE COLY-MYCIN M COMBIVIR COMETRIQ COMPLERA CONTRAVE COPAONE COPEGUS CORIFACT COSENTY COSMEGEN COTELLIC CRESEMBA CRESTOR CRINONE CRIIVAN CRYSVITA CYRAMZA CYSTADANE CYSTARAN CYTOGAM CYTOVENE DACOGEN DAKLINZA DARZALE DAUNOOME DELSTRIGO DEPOCYT DESFERAL DEILANT DIETHYLPROPION DOCEFREZ DOPTELET DOIL DUETACT DUEIS DULERA DUOPA DUPIENT DYMISTA DYSPORT Page 4 of 17

5 EDULAR EDURANT EGRIFTA ELAPRASE ELELYSO ELIGARD ELITEK ELLENCE ELOCTATE ELOATIN EMCYT EMFLAZA EMPLICITI EMTRIVA ENBREL ENTYVIO ENVARSUS EPCLUSA EPIDUO EPIDUO FORTE EPIVIR EPIVIR HBV EPOGEN EPZICOM ERBITU ERWINAZE ERIVEDGE ERLEADA ESBRIET ESCITALOPRAM ESKATA ETOPOPHOS ETOPOSIDE EUCRISA EUFLEA EVOMELA EVOTAZ EJADE EONDYS ETAVIA EYLEA FABRAZYME FARIGA FARYDAK FASENRA FASLODE Page 5 of 17

6 FEIBA NF FEIBA VH FERRLECIT FIRAZYR FIRMAGON FLEBOGAMMA FLOLAN FLOVENT INHALER FLUDARA FLUOETINE FOLLISTIM AQ FOLOTYN FORTEO FOSCAVIR FRAGMIN FROVA FULPHILA FUROSEMIDE FUZEON GABAPENTIN CAPSULES GALAFOLD GAMASTAN S/D GAMMAGARD GAMMAGARD SD GAMMAKED GAMMAPLE GAMMAR-P GAMUNE-C GANIRELI AC GANITE GAZYVA GEL-ONE GEMZAR GENOTROPIN GENVOYA GIAPREZA GILENYA GILOTRIF GLASSIA GLATOPA GLEEVEC GLIADEL GLIMEPERIDE GLIPIZIDE GLUMETZA GLYBURIDE Page 6 of 17

7 GLYBURIDE/METFORMIN GLYAMBI GOCOVRI GONAL-F GRANI HAEGARDA HALAVEN HARVONI HECTOROL HELIATE FS HEMLIBRA HEMOFIL M HEPAGAM B HEPSERA HERCEPTIN HETLIOZ HEALEN HIZENTRA HORIZANT HUMALOG INSULIN HUMATE-P HUMATROPE HUMIRA HUMULIN INSULIN HYALGAN HYCAMTIN HCTZ HYPERHEP B HYPERRAB S/D HYPERRHO S/D HYPERTET S/D HYQVIA IBRANCE ICLUSIG IDAMYCIN PFS IDELVION IDHFA IFE ILARIS ILUMYA ILUVIEN IMBRUVICA IMFINZI IMLYGIC IMOGAM RABIE IMURAN Page 7 of 17

8 INCRELE INFERGEN INFLECTRA INGREZZA INLYTA INNOHEP INTELENCE INTERMEZZO INTRON-A INVIRASE INVOKANA IPRIVASK IRBESARTAN IRBESARTAN/HCTZ IRESSA ISENTRESS ISTODA IVEEGAM IEMPRA KIT JAKAFI JALYN JANUVIA JARDIANCE JETREA JEVTANA JIVI JUBLIA JULUCA JUTAPID JYNARQUE KADCYLA KALBITOR KALETRA KALYDECO KANUMA KEPIVANCE KEVEYIS KEVZARA KEYTRUDA KINERET KISQALI KITABIS KOATE KOGENATE FS KORLYM KRYSTEA Page 8 of 17

9 KUVAN KYMRIAH KYNAMRO KYPROLIS LARTRUVO LASTACAFT LEMTRADA LENVIMA LESCOL L LETAIRIS LEUKINE LEVITRA LEIVA LIPITOR LIPTRUZET LISINOPRIL LISINOPRIL/HCTZ LIVALO LONHALA MAGNAIR LONSURF LOSARTAN LOSARTAN/HCTZ LOVENO LUCENTIS LUCEMYRA LUMIZYME LUNESTA LUPANETA LUPRON LUTATHERA LUTURNA LYNPARZA LYSODREN MACRILEN MACUGEN MAKENA MARQIBO MATULANE MAVYRET MEKINIST MEKTOVI MELOICAM MENOPUR MEPSEVII MESNE METFORMIN Page 9 of 17

10 METFORMIN R MICRHOGAM PL MODERIBA MONARC-M MONOCLATE-P MONONINE MOZOBIL MULPLETA MUSTARGEN MYALEPT MYFORTIC MYLERAN MYLOTARG MYOBLOC MYOZYME MYRBETRIQ NABI-HB NAGLAZYME NASONE NATPARA NAVELBINE NEORAL NERLYN NESINA NEULASTA NEUMEGA NEUPOGEN NEAVAR NEIUM NILANDRON NINLARO NIVESTIM NOVOLOG INSULIN NORDITROPIN NORTHERA NORVIR NOVANTRONE NOVAREL NOVOSEVEN RT NPLATE NUCALA NULOJI NUPLAZID NUTROPIN AQ NUVIGIL NUWIQ Page 10 of 17

11 OBIZUR OCREVUS OCTAGAM ODEFSEY ODOMZO OFEV OLUMIANT OLYSIO OMNARIS OMNITROPE OMONTYS ONETON ONGLYZA ONPATTRO ONZETRA OPDIVO OPSUMIT ORENCIA ORENITRAM ORFADIN ORKAMBI ORTHOVISC OTEZLA OVIDREL OYTROL OZURDE PANGLOBULIN PANHEMATIN PARSABIV PAZEO PEGASYS PEG-INTRON PERJETA PERSERIS PHENTERMINE PHOTREA PIFELTRO PLEGRIDY POLYGAM S/D POMALYST POTELIGEO PRALUENT PRAVASTATIN PREGNYL PREPOPIK PREVYMIS Page 11 of 17

12 PREZCOBI PREZISTA PRIVIGEN PROCRIT PROFILNINIE PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA PROPLE T PULMOZYME PURINETHOL PURIAN QNASL QSYMIA QUTENZA RADICAVA RAPAFLO RAPAMUNE RAVICTI RAYOS REBETOL REBIF REBINYN RECLAST RECOMBINATE REFLUDAN RELPA REMICADE REMODULIN RENFLEIS REPATHA REPRONE RESCRIPTOR RETACRIT RETAVASE RETISERT RETROVIR REVATIO REVIA REVLIMID REYATAZ RHINOCORT RHOGAM PLUS RHOPHYLAC Page 12 of 17

13 RIASTAP RIBAPAK RIBASPHERE RIBATAB RIBAVIRIN RILUTEK RITUAN RIUBIS ROFERON-A ROZEREM RUBRACA RUCONEST RYDAPT SABRIL SAIZEN SAMSCA SANDIMMUNE SANDOSTATIN SAENDA SELZENTRY SENSIPAR SEREVENT INHALER SEROSTIM SIGNIFOR SILIQ SIMPONI SIMULECT SIMVASTATIN SINUVA SOLIQUA SOLIRIS SOLODYN SOLTAMO SOMATULINE SOMAVERT SORIATANE SOVALDI SPINRAZA SPRYCEL STAYN STELARA STENDRA STIMATE STIVARGA STRENSIQ STRIBILD Page 13 of 17

14 SUBLOCADE SUCRAID SUMATRIPTAN TABLETS SUMAVEL SUPARTZ SUPPRELIN LA SUSTIVA SUTENT SYLATRON SYLVANT SYMDEKO SYMFI LO SYMTUZA SYNAGIS SYNAREL SYNRIBO SYNVISC SYNVISC ONE SYPRINE TABLOID TAFINLAR TAGRISSO TAKHZYRO TALTZ TARCEVA TARGRETIN TASIGNA TAVALISSE TAOTERE TECFIDERA TECHNIVIE TEMODAR TEPADINA TESTOPEL TEV-TROPIN THALOMID THROMBAT III THYMOGLOBULIN THYROGEN TIBSOVO TIVICAY TNKASE TOBI PODHALER TOPOSAR TORISEL TOTECT Page 14 of 17

15 TRACLEER TRADJENTA TREANDA TRELSTAR TRISENO TREMFYA TRETTEN TRIPTODUR TRIUMEQ TRIZIVIR TROGARZO TROKENDI R TRULICITY TRUVADA TYBOST TYKERB TYMLOS TYSABRI TYVASO TYZEKA UPTRAVI VALCHLOR VALCYTE VALSTAR VANTAS VECTIBI VELCADE VELETRI VELPHORO VEMLIDY VENCLETA VENOFER VERAMYST VERZENIO VESANOID VIAGRA VICTOZA VICTRELIS VIDAZA VIDE VIDE EC VIEKIRA VIMIZIM VIMOVO VIRACEPT VIRAMUNE Page 15 of 17

16 VIRAMUNE R VIRAZOLE VIREAD VISTIDE VISTOGARD VISUDYNE VIVITROL VORAAZE VOSEVI VOTRIENT VPRIV VRAYLAR VYTORIN VYEOS WELLBUTRIN L & SR WILATE WINRHO SDF ALKORI ATMEP ELJANZ ELODA ENAZINE EOMIN ERMELO GEVA HANCE IAFLE IIDRA OLAIR TANDI ULTOPHY URIDEN YNTHA YREM YERVOY YESCARTA YONDELIS YONSA ZALTRAP ZANOSAR ZARIO ZAVESCA ZEJULA ZELBORAF ZEMAIRA ZEMPLAR Page 16 of 17

17 ZEPATIER ZERIT ZETONNA ZEVALIN ZIAGEN ZINBRYTA ZINECARD ZOLADE ZOLINZA ZOLOFT ZOLPIMIST ZOMETA ZOMIG NASAL SPRAY ZORBTIVE ZORTRESS ZYCLARA ZYDELIG ZYKADIA ZYTIGA Page 17 of 17

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Revenue Codes in excess of $10,000 ABRAXANE J9264 & J9267. ADVATE (All Forms) AFINITOR DISPERZ J7193, J7194, J7200, J7201, AMPYRA

Unclassified Drugs in excess of $10,000 Unclassified Biologics in excess of $10,000 Revenue Codes in excess of $10,000 J3490 J3590 R250 - R259 ABRAXANE J9264 & J9267 ACTEMRA J3262 ACTHAR J0800 ACTIMMUNE