40625NYMENEBC Rev. 07/15 Effective 01/15

Three-tier formulary

1332531 40625NYMENEBC Select Drug List SH 05 15

Select Drug ListSubject to regulatory approval

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Empire BlueCross Select Drug List

Your prescription drug benefit includes coverage for medicines that you’ll find on the Select Drug List. You can often find more savings when your doctor prescribes medicine that is on our Select Drug List. Here are some commonly asked questions and answers about how the Select Drug List works with your prescription drug plan.

Q. What is a Select Drug List?A. The Drug List that identifies the prescription drugs

covered under Empire’s Individual and Small Group benefit plans is called the “Select Formulary.” It contains the prescription drugs subject to coverage if you buy 1) an Empire Individual plan on the New York State of Health Marketplace (“Marketplace”) or 2) an Individual or Small Group plan directly from Empire outside of the Marketplace. The Select Formulary has three levels, or tiers, and includes a select number of drugs in different categories and classes. The Select Formulary is available online at empireblue.com/EBCSelectdrugtier3. You can also find out if a specific drug is on the Select Formulary by calling the number on your ID card.

Q. What are Tiers?A. Drugs on the Select Drug List are grouped into tiers.

There are several factors that are used to determine under which tier a drug will be put in. This can include (but it’s not limited to):

} Cost of the drug.

} Cost of the drug in comparison to other drugs used for the same type of treatment.

} Availability of over-the-counter options.

} Other clinical and cost factors.

Q. What is a brand-name drug?A. These are drugs that are developed by a company who

holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-name drugs through advertising or because you know people who take them.

Q. What is a generic drug? A. Generics are simply copies of brand-name drugs.

Brand-name and generic drugs have the same active ingredients, strength and dose. And the FDA requires that generic drugs meet the same high standards for purity, quality, safety and strength.

Q. Is this list a complete listing of all covered drugs under the Select Drug List?

A. No, this piece lists the most commonly used drugs that are covered as part of the Select Drug List. If the drug you are looking for is not listed, you may call Customer Service for more information.

Q. What if my medication is not on the Select Drug List?A. You may want to first check with your doctor about

prescribing a drug that is on the Select Drug List. If your doctor prescribes a drug that’s not on the Select Drug List, you will have to pay the amount described in your policy for nonformulary drugs.

Q. Can I request that a drug be added to the Select Drug List?

A. You or your doctor can put in a request to add a drug to the Select Drug List. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the Select Drug List review. Please note that if a drug request is approved, it does not guarantee coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your insurance Certificate or Evidence of Coverage to know for sure.

Q. What if my medication is not covered?A. You may want to first check with your doctor about

prescribing a drug that is covered. If your doctor prescribes a drug that’s not covered, you will need to pay the out-of-pocket cost that applies to drugs not on the formulary.

Preventive care drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

Please note: In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a noncovered product. Empire has criteria that permits a member to obtain a noncovered medication in a closed drug list plan. If specific criteria are met, a member can receive a noncovered drug for a drug list copay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. An appeals process is in place for any medications that do not meet the criteria.

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Tier 1

AcarboseAcebutololAcetasol HCAcetazolamide tab, ER cap

AclometasoneActicinAcyclovir tab, cap, oral susp.

Adapalene Afeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadine Amcinonide Amiloride tabAmitriptylineAmlodipine QL DOAmlodipine/atorvastatin QL DO

Amlodipine/benazeprilAmmonium lactate cream, lotion

Amnesteem PACAmoxapine

Amoxicillin Amoxicillin/clavulanate Amoxicillin/clavulanate ER

Amphetamine/dextroamphetamine salts, ER PA QL

Androxy PAAntipyrine/benzocaine ear drop

ApraclonidineAtenololAtenolol/chlorthalidoneAtorvastatin QL DOAtovaquone/proguanilAzelastine nasal spray, drops QL

Azithromycin tab, susp., packet QL

Bacitracin/polymixin BBaclofen BalsalazideBenazepril

Benazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate

Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives)

BisoprololBisoprolol/HCTZBrimonidineBromocriptine Budesonide 0.25mg/2mL, 0.5mg/2mL QL

Bumetanide tabBuprenorphine tab PA QLBupropion QLBupropion SR, XL QL DOBuspirone Butalbital/acetaminophen

Butalbital/acetaminophen/caffeine

Butalbital/acetaminophen/caffeine/codeine QL

Butalbital/aspirin/caffeine

Butalbital/aspirin/caffeine/codeine

Butorphanol nasal spray PA QL

CabergolineCalcipotriene Calcitriol cap, soln, ointCandesartan QL DOCandesartan/HCTZ QL DOCaptopril Carbamazepine, ER, XRCarbidopa/Levodopa, ER, ODT

CarbinoxamineCarisoprodolCarteololCartia XT QL DOCarvedilolCefaclor, ERCefadroxilCefdinirCefditoren Pivoxil

CefprozilCefuroxime AxetilCephalexinCetirizine syrup QLChlorhexidine gluconateChlorhexidine RinseChloroquineChlorothiazide tabChlorpromazine tab PAChlorpropamideChlorthalidoneChlorzoxazoneCholestyramineCiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops

Ciprofloxacin tab QLCitalopram QL DOClaravis PAClarithromycin, ERClemastine 2.68mgClemastine syrupClindamycin cap, oral soln, topical preparations

Clindamycin/Benzoyl Peroxide Gel

ClobetasolClomipramineClonazepam, ODTClonidine ER PA Clonidine tabClopidogrel QLClotrimazole 1% cream, troche

Clotrimazole/betamethasone

Codeine sulfate tabs QLCodeine/acetaminophen QL

Codeine/butalbital/aspirin/caffeine

ColestipolCortisone tabCovaryx, H.S.Cromolyn eye drops QLCromolyn neb soln.Cyclobenzaprine tabCyproheptadine DepadeDermazene

Desloratadine, ODT QLDesmopressin nasal spray, tab PA

DesonideDesoximetasoneDexamethasone eye dropDexamethasone tab, oral soln.

DexchlorpheneramineDexmethylphenidate, ER PA QL

Dextroamphetamine, ER PA QL

Diazepam tab, oral soln.Diclofenac eye dropDiclofenac, ERDicloxacillinDicylomine cap, tab, syrup

DiflorasoneDiflunisalDigoxin tab, oral soln.DiltiazemDiltiazem ER, XR, CD QL DO

Diphenhydramine 50mg cap

Diphenoxylate/atropineDipyridamole tabDisopyramideDisulfiramDivalproex, ER, DRDonepezil 5mg, 10mg, ODT QL

Dorzolamide eye dropsDorzolamide/timolol eye drops

DoxazosinDoxepin Doxycycline hyclate tab, cap

Doxycycline hyclate, delayed release PA

Doxycycline monohydrate tab, cap

EconazoleEnalaprilEnalapril/HCTZEndocet QLEndodan QLEpidrinEpinastine eye drops QLEpitol

For more information about your drug plan, you can do the following:} Go to empireblue.com.

} Call Customer Service at the number on your ID card.

} Speech and hearing impaired users (TDD/TTY) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET.

Tier Definitions

Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions.

Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.

Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

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Eprosartan QLErgocalciferol (Vit D2) caps

Ery-Tab 250mg, 333mg tab

Erythromcyin eye oint.Erythromycin 2% gel, topical solution

Erythromycin ethylsuccinate 400mg Filmtab

Erythromycin Filmtab, 250mg cap

Erythromycin stearateErythromycin/benzoyl peroxide gel

Erythromycin/sulfisoxazole

Escitalopram QL DOEstradiol patch QLEstradiol tabEstrogen/methyltestosterone

EstropipateEszopiclone PA QLEthambutolEthosuximideEtodolac, ERFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QLFenofibrateFenofibric acid, DRFenoprofenFinasteride 5mg tab PAFlavoxateFluconazole tab, oral soln.

FlucytosineFludrocortisoneFlunisolide nasal spray ST QL

Fluocinolone body oil, scalp oil PA

Fluocinolone cream, topical soln., oint., ear drop

FluocinonideFluorometholone eye drops

Fluorouracil cream, topical solution

Fluoxetine, DR (except 60mg) QL DO

Fluphenazine tab, oral soln. PA

Flurbiprofen eye dropFlurbiprofen tabFluticasone nasal spray QL

Fluticasone topicalFluvastatin QL DOFluvoxamine QL DOFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGatifloxacin eye dropsGemfibrozilGentamycin eye drops, oint.

GlimepirideGlipizide, ER, XLGlipizide/metforminGlyburideGlyburide/metforminGriseofulvinGuaifenesin/codeine syrup

GuanfacineGuanidineHalacHalobetasol propionateHaloperidol tab PAHydralazine tabHydrochlorothiazideHydrocodone/acetaminophen QL

Hydrocortisone tabHydrocortisone 2.5% cream, lotion, oint.

Hydrocortisone acetate 2% gel

Hydrocortisone acetate suppository

Hydrocortisone butyrate 0.1% cream, oint., soln.

Hydrocortisone enemaHydrocortisone valerate 0.2% cream, ointment

Hydrocortisone/acetic acid ear drops

Hydrocortisone/pramoxine cream, ointment

Hydromorphone suppository

Hydromorphone tab, oral soln. QL

HydroxychloroquineHydroxyzine HCL tab, oral soln.

Hydroxyzine pamoateIbandronate ST QLIbuprofenImipramine HCL tabImiquimod PA QLIndapamideIndomethacin, ER capIpratropium bromide neb soln. QL

Irbesartan QL DOIrbesartan/HCTZ QL DOIsometheptene/acetaminophen/caffeine

Isometheptene/acetaminophen/dichloralphenazone

IsonarifIsoniazid tab, oral soln.Isosorbide dinitrate, ER tab

Isosorbide mononitrate, ER tablet

IsradipineKetoconazoleKetoprofen, ERKetorolac eye dropsKetorolac tab QLKlor-Con tabLabetolol tabLactuloseLamotrigine tab (immediate release)

Lansoprazole, DR QLLatanoprostLevobunolol eye dropsLevofloxacin tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone 3/0.5% cream

Lidocaine/prilocaine

LindaneLiothyronine tabLisinoprilLisinopril/HCTZLithium carbonate, ERLithium citrate oral soln.LonoxLosartan QL DOLosartan/HCTZ QL DOLovastatin QL DOLoxapine PAMalathionMaprotilineMatzim LA QL DOMebendazoleMeclizine tabMeclofenamate capMedroxyprogesterone tab

Mefenamic acidMefloquineMegestrolMeloxicam oral suspension

Meloxicam tab QLMeperidine tab, oral soln. QL

Meprobamate QLMetadate ER PA QLMetaproterenolMetaxaloneMetformin, ERMethadone tab, oral soln. QL

Methamphetamine PA QLMethazolamideMethimazoleMethocarbamolMethscopolamine bromide

MethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tabMethylphenidate, CD, ER, SR PA QL

Methylprednisolone tabMetipranolol eye dropsMetoclopramide tab, oral soln.

Metoprolol tab, ERMetoprolol/HCTZ

Metronidazole 0.75% gelMetronidazole tab, capsule, cream, lotion

Miconazole 200mg vaginal suppository

MinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAModafinil PA QLMoexiprilMoexipril/HCTZMometasone cream, oint, topical soln.

Montelukast QLMorphine sulfate IR tab QL

Morphine sulfate oral soln. QL

Morphine sulfate supppository

Mupirocin oint.NabumetoneNadololNadolol/bendroflumethiazide

NaltrexoneNaphazoline eye dropsNaproxen, DRNaratriptan QLNature-ThroidNefazodoneNeomycin tabNeomycin/polymixin/bacitracin eye oint.

Neomycin/polymixin/bacitracin/hydrocortisone eye oint.

Neomycin/polymixin/dexamethasone eye drops, oint.

Neomycin/polymixin/gramicidin eye drops

Neomycin/polymixin/hydrocortisone ear and eye drops

Niacin ER Nicardipine capsNifedipine capNifedipine tab ER, XL QL DO

Nisoldipine ER QL DO

Nitro-Bid oint.Nitrofurantoin Nitroglycerin, ER, SRNizatidineNorethindronenortriptylineNP ThyroidNystatin cream, oint., powder, tab

Nystatin/triamcinoloneOfloxacin ear and eye drops

Ofloxacin tab QLOmeprazole caps QLOrphenadrine EROxaprozinOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab, cap QL

Oxycodone/aspirin QLOxymorphoneOxymorphone ER QLPancrelipase, DR ParamomycinParoxetine, CR, ER QL DOPenicillin VKPentoxifylline, ERPerindoprilPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab, oral soln.

Phenytoin ext. capPilocarpine eye dropsPindololPioglitazone QLPiroxicamPodofiloxPolymixin/trimethoprim eye drops

Potassium chloride ER tab, ER cap

Potassium Citrate ER TabPramipexolePravastatin QL DOPrazosinPrednicarbate

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Prednisolone eye dropsPrednisolone oral soln.PrednisonePrenatal Vitamins (all generic covered)

PrimidoneProbenecidProbenecid/colchicineProcentra QLProchlorperazine tabProgesterone, micronized cap

Promethazine tab, suppository, syrup

Promethazine VC syrupPromethazine VC syrup with codeine

Promethazine/codeine syrup

Promethazine-DM syrupPropranolol ERPropranolol HCTZPropranolol tab, oral soln.PropylthiouracilProtriptylinePyrazinamideQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRaloxifene RamiprilRanitidine 150, 300mg tab, cap

Ranitidine oral soln.RifampinRimantadineRisperidone, ODT, oral soln. PA

Rizatriptan, ODT QLRopinirole, ERRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo

Sertraline QL DOSilver sulfadiazine creamSimvastatin 80mg PA QL DO

Simvastatin QL DO

Sodium polystyrene sulfate 30gm/120ml enema

Sodium polystyrene sulfate powder

Sodium polystyrene sulfonate

Sodium sulfacetamide/sulfur

Sodium sulfacetamide/sulfur/urea

SpinosadSpironolactoneSucralfateSulfacetamide eye drops, oint.

Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye drops

Sulfacetamide sodium/sulfur

Sulfacetamide sodium/sulfur/urea

Sulfacetamide sodium/urea

Sulfamethoxazole/trimethoprim, DS

SulfasalazineSulindacSumatriptan tab QLTamsulosinTaztia XT QL DOTelmisartan QL DOTerazosinTerbinafine tab PATerbutaline tabTerconazoleTetracycline capsTheochron ERTheophylline ER, oral soln.

Thioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasone eye drops

TolazamideTolbutamide

TolmetinTolterodineTopiramate PATorsemide tabTramadol, ER tab QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.

Triamcinolone nasal spray QL

Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrifluridine eye dropsTrihexyphenidylTrimethobenzamide capTrimethoprimTrimipramineTropicamide eye dropsUnithroidValacyclovirValproid acid cap, oral soln.

Valsartan QL DOValsartan/HCTZ QL DOVenlafaxineVenlafaxine, ER QL DOVerapamil tab, ER PM QL DO

Verapamil tab, ER tab, cap

Vicodin, ES, HP QLWarfarinWesthroidZafirlukastZaleplon ST QLZiprasidone PAZolmitriptan QLZolpidem (immediate release) QL

Tier 2

Acamprosate Acitretin Advair Diskus, HFA QLAnaspaz ODTAsmanex Twisthaler QL

Atovaquone suspBethanechol tabBromfenac eye dropsBudesonide ECBuprenorphine syringe, vial

Calcitonin QLCalcium acetate tabCarbidopa STCefpodoximeCeftibuten CevimelineCilostazolClozapine, ODT PADanazolDantroleneDemeclocyclineDesipramineDiclofenac Gel PA QLDulera QLDuloxetine PA QL DOEliphosEntacaponeEpipen, Jr.EplerenoneErgoloidFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLGabapentinGalantamine, ER QLGlucagenGranisetron tab QLHumalogHumalog MixHumulin N, R, 70-30Hydromorphone ER STItraconazole PAKetorolac inj. QLLantusLantus SolostarLeflunomideLevalbuterol neb soln.LevemirLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.

Levorphanol tab QLMafenide Acetate Methanamine MDMethenamine hippurateMexiletineMorphine sulfate ER QLNateglinide PANimodipineNitroglycerin sprayNitrostatNovolin NNovologNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL

Oxandrolone PAPantoprazole QLPilocarpine tabsProair HFA ST QLPropafenonePrudoxinPulmicort 1mg/2mL respules QL

Pulmicort Flexhaler QLQvar QLRabeprazole QLRelenza QLRepaglinide PARifabutinRivastigmine QLSerevent Diskus QLSotalol tab, AF tabSulfadiazineSumatriptan inj QLSymbicort QLTamiflu QLTiagabine PATranexamic acid 1000mg/10mL

Trospium chloride ER STUrsodiolVancomycin caps PAZonisamide

Tier 3

AbacavirAbacavir/Lamivudine/Zidovudine

Abilify tab PAActonel ST QL

AczoneAdcirca PAAdefovir Dipivoxil Afinitor PAAggrenox QLAlamast PAAlbenzaAliniaAlkeran tabAlocril PA QLAlomide PA QLAltabaxAmevive PAAmitizaAmpyra PA QLAnadrol-50AnagrelideAnastrazole tab PAAndrogel PA QLAntivert 50mgAnzemet tablet QLApidra, Solostar STApriso ERAptivus Aranesp PAArestinAtripla Aubagio PA QLAvodartAxert ST QLAzathioprine tabAzelex PAAzilectAzoptBenicar PA QL DOBepreve PA QLBesivanceBicalutamideBiltricideBosulif PABrilinta QLBrovana QLBuphenyl tablet PABydureon ST QLBystolicCambia QLCantilCapecitabine PACaprelsa PACarbaglu PA

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CeeNUCelebrex ST QLCelontinCenestinCesamet PAChemetCialis 2.5mg, 5mg PACiclodanCimzia PA QLCipro HC ear dropsCiprodex ear drops PAClindacinClodermCoartemColcrys PA QLCombiganCometriq PACordran, SPCortisporin cream, oint.Crestor ST QL DOCresylateCrixivanCuprimineCyclophosphamide tabCyclosporine Cyclosporine cap, soln.Daliresp QLDapsoneDaraprimDexilant ST QLDibenzylineDidanosine DRDificid PADipentumDroxiaDurezol QLDyreniumEdarbi QL DOEdecrinEdurantEffient QL DOElidel PAEllaElmironEmadine PA QLEmcyt PAEmsam QLEmtrivaEnablex STEnbrel PA QL

EnjuviaEnoxaparin PAEpiduoEpivir HBV soln. PAEpzicomErivedge PAErtaczoEstringEtoposide capsEuraxExeldermExemestane Exjade PAExtavia STFactive QLFanapt PAFarestonFerriprox PAFinaceaFlector STFluoridexFluoroplexFlutamideFML S.O.PFondaparinux PAForteo PAFosamax Plus D ST QLFosrenol PAFragmin PAFrova ST QLFuzeonGengrafGleevec PAGlysetHalogHarvoni PAHexalenHorizant PAHumira PA QLHycamtin capsHydroxyureaIclusig PAIncrelex PAInfergen PAInlyta PAInnohep PAIntelenceIntron A PAIntuniv ER PAInvega tab PA

InviraseIressaIsentressJakafi PAJalynJanumet, XR QLJanuvia ST QLKaletraKapvay PAKetekKineret PALacrisertLamuvidineLamuvidine/ZidovudineLanoxin tabLatuda PALetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALevatolLexivaLivalo ST QL DOLotemaxLotronex PALumiganLyrica PA QLLysodrenMarplanMatulaneMaxair QLMenestMentaxMercaptopurineMethitestMethotrexate tabMorgidox PAMotofenMoviprepMultaqMycophenolateMyleranNaftin cream, 1% gelNamenda QLNatacynNatazia STNeulasta PA QLNeupogen PANevanac

NevirapineNexavar PANexium PA QLNilandronNoroxin QLNorvirNucynta, ER QLNuedextaNuoxNuvaringNuvigil PA QLOforta PAOmnaris ST QLOnglyza ST QLOraceaOrap PAOrfadinOxistatOxsoralen-Ultra PAOxycontin ST QLPanretinPataday PA QLPatanase QLPatanol PA QLPeganonePegasys PA QLPegintron PAPerforomist QLPhisohexPhospholine iodidePomalystPradaxa QLPred-GPred-G S.O.P Premarin CreamPremarin tab STPremphasePremproPrevident 5000 Booster Plus

PrezistaPrimaquinePrimsolPristiq QL DOProcrit PAProglycemProlia PAPromacta PAProquin XRProtopic PA

Proventil HFA ST QLRanexaRapafloRebif PARectivRegranex PARelistor PARelpax ST QLRemicade PARemodulin PARenvela PARescriptorRestasisRevlimid PA QLReyatazRibavirin PARidauraRifaterRiluzole Rituxan PARosadanRozerem ST QLSabrilSafyral STSamsca PASantylSaphris PASavella QLScopaceSelzentrySensiparSeroquel XR PASildenafil 20mg tab PASilenor STSimponi PA QLSirolimus SkelidSomatulineSpiriva QLSprycel PAStavudineStelara PA QLStivarga PAStrattera PA QLStromectolSuprax tab, susp.SustivaSutent PASymlin PASynarel PA

SyneraSyprineTabloidTaclonex scalp suspension

Taclonex suspensionTacrolimusTamoxifenTarceva PATargretin PATasigna PATasmarTazorac PATekturna QL DOTemozolomide PATeveten 400mg QLTev-Tropin PAThalomid PAThyrolarTikosynToriselToviaz ER STTradjenta ST QLTransderm-Scop PATravatan ZTrelstar Depot PATrelstar PATretinoin 10mg capsuleTruvadaTykerb PATysabriTyzeka PATyzineUlesfiaUloric STVagifemVandetanib PAVentavis PAVentolin HFA ST QLVeregenVesicare STVexolVictoza ST QLVictrelis PAVigamox PAViibryd STViraceptViread PAVivelle-Dot PA QLVoltaren gel

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Votrient PAVyvanse PA QLWelcholXalkori PAXarelto PA QLXenazine PAXopenex HFA ST QLXtandi PAXyrem PAZelboraf PAZetia PA QLZiana ST

ZidovudineZinoticZioptanZipsorZirganZoledronic Acid Zolinza PAZortress PAZyflo, CR PAZytiga PAZyvox tab, oral soln. PA QL

KEY

† = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification requirements are met, this brand-name drug may no longer be covered by your prescription drug plan. Check empireblue.com to find out about changes in tier status.

PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.

QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.

ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.

DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.

Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Customer Service at the telephone number listed on your identification card.

40625NYMENEBC Rev. 07/15 Effective 01/15

For more information, please visit empireblue.com: } If you have additional questions about your prescription benefits,

please call the Customer Service number on your ID card.

} Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET.

} For the most current version of this Select Drug List, please visit empireblue.com.

Services provided by Empire HealthChoice Assurance, Inc., licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.