2015 Formulary. List of Covered Drugs. HMSA Akamai Advantage Enhanced and Prime Group Drug Plans. Formulary ID , version 17

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1 HMSA Akamai Advantage Enhanced and Prime Group Drug Plans 2015 Formulary PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. List of Covered Drugs Formulary ID , version 17 An Independent Licensee of the Blue Cross and Blue Shield Association This formulary was updated on 11/01/2015. For more recent information or other questions, please contact HMSA at on Oahu, or 1 (800) toll-free. TTY users, call 711. Telephone hours are 8 a.m. to 8 p.m., seven days a week or visit

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3 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means HMSA. When it refers to plan or our plan, it means HMSAAkamai Advantage Enhanced and Prime Group Drug Plan. This document includes a list of the drugs (formulary) for our plan which is current as of November 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/ coinsurance may change on January 1, 2016 and from time to time during the year. What is the HMSA Akamai Advantage Enhanced and Prime Group Drug Plan Formulary? A formulary is a list of covered drugs selected by HMSA Akamai Advantage Enhanced and Prime Group Drug Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. HMSA Akamai Advantage Enhanced and Prime Group Drug Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an HMSA Akamai Advantage Enhanced and Prime Group Drug Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not i affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November To get updated information about the drugs covered by HMSA Akamai Advantage Enhanced and Prime Group Drug Plan, please contact us. Our contact information appears on the front and back cover pages. We will inform members of any formulary changes to this comprehensive formulary by mail. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 92. The Index provides an alphabetical list of all of the drugs included in this

4 document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? HMSA Akamai Advantage Enhanced and Prime Group Drug Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. 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: HMSA Akamai Advantage Enhanced and Prime Group Drug Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HMSA Akamai Advantage Enhanced and Prime Group Drug Plan before you fill your prescriptions. If you don t get approval, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan may not cover the drug. Quantity Limits: For certain drugs, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan limits the amount of the drug that HMSA Akamai Advantage Enhanced and Prime Group Drug Plan will cover. For example, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan provides 12 tablets per prescription for REPLAX. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan 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, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Akamai Advantage Enhanced and ii Prime Group Drug Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask HMSA Akamai Advantage Enhanced and Prime Group Drug Plan to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition. See the section, How do I request an exception to the HMSA Akamai Advantage Enhanced and Prime Group Drug Plan formulary? on this page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact our Customer Relations and ask if your drug is covered. If you learn that HMSA Akamai Advantage Enhanced and Prime Group Drug Plan does not cover your drug, you have two options: You can ask Customer Relations for a list of similar drugs that are covered by HMSA Akamai Advantage Enhanced and Prime Group Drug Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HMSA Akamai Advantage Enhanced and Prime Group Drug Plan. You can ask HMSA Akamai Advantage Enhanced and Prime Group Drug Plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the HMSA Akamai Advantage Enhanced and Prime Group Drug Plan Formulary? You can ask HMSA Akamai Advantage Enhanced and Prime Group Drug Plan to make an exception to our coverage rules. There are several types of

5 exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, HMSA Akamai Advantage Enhanced and Prime Group Drug Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30- day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care (LTC) facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Transition policy New members in our Plan may be taking drugs that aren t on our formulary or that are subject to certain restrictions, such as prior authorization. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See the section, How do I request an exception to HMSA Akamai Advantage Enhanced and Prime Group Drug Plan formulary? to learn more about how to request an exception. Please contact Customer Relations if your drug is not on our formulary, is subject to certain restrictions such as prior authorization, and you need to switch to a different drug that we cover or request iii

6 a formulary exception. During the period of time members are talking to their doctors to determine a course of action, we may provide a temporary supply of a non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year. When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. If a new member is a resident of a long-term care facility (like a nursing home), we will also cover a temporary 34-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn t on our formulary or is subject to other restrictions, such as dosage limits, we will cover a temporary 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. iv Current members are also eligible to receive a transition fill under certain conditions. If a current member enters a long-term care (LTC) facility, or is in an LTC facility and requires an emergency supply of non-formulary drugs, we will cover a temporary 34-day transition supply (unless the prescription is written for fewer days). We will cover more than one refill of these drugs for these members for the first 90 days. A member may experience a change in their level of care at an inpatient hospital facility or skilled nursing facility which results in non-coverage of drugs previously covered by Medicare Part D. For current members experiencing a level of care change, we will also cover a temporary 34-day transition supply as outlined above. Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can t be used to buy a non-part D drug or a drug outof-network, unless you qualify for out-of-network access. For more information For more detailed information about your HMSA Akamai Advantage Enhanced and Prime Group Drug Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about HMSA Akamai Advantage Enhanced and Prime Group Drug Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1 (800) MEDICARE [1 (800) ] 24 hours a day/seven days a week. TTY users should call 1 (877) Or visit HMSA Akamai Advantage Enhanced and Prime Group Drug Plan Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by HMSA Akamai Advantage Enhanced and Prime Group Drug Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 92. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., REPLAX) and generic drugs are listed in lower-case italics (e.g., ibuprofen). The information in the requirements/limits column tells you if HMSA Akamai Advantage Enhanced and Prime Group Drug Plan has any special requirements for coverage of your drug. Drug tier index: Tier 1 - Preferred Generic Tier 2 - Non-Preferred Generic

7 Tier 3 - Preferred Brand Tier 4 - Non-Preferred Brand Tier 5 - Specialty Tier Please refer to the Summary of Benefits or Evidence of Coverage for the specific copayment or coinsurance amount associated with each tier. Abbreviations used in this Formulary PA Prior Authorization: Requires that you or your physician receive approval from HMSA Akamai Advantage Enhanced and Prime Group Drug Plan before we will cover your prescription. QL Quantity Limits: A limit on the amount of the drug that HMSA Akamai Advantage Enhanced and Prime Group Drug Plan will cover. ST Step Therapy: Requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. M Mail Order: These drugs are available through HMSA s mail order pharmacy, CVS Caremark. B/D B or D: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. For more information, please call Customer Relations. LA Limited Availability: This prescription may be available only at certain pharmacies. For more information, please call Customer Relations. Prescription drugs can be shipped to your home from the HMSA Akamai Advantage Enhanced and Prime Group Drug Plan Mail Order pharmacy. Usually a mail-order pharmacy order will get to you in no more than 14 days after the pharmacy receives the order. If your drugs do not arrive within this timeframe, please call 1 (855) toll-free, 24 hours a day, seven days a week; TTY users, call 1 (866) You can also choose to sign up for our optional automatic delivery program by calling these numbers. v

8 ANALGESICS GOUT allopurinol tab 100 allopurinol tab 300 ALOPRIM INJ 500MG 4 M colchicine w/ probenecid tab COLCRYS TAB 0.6MG 3 QL M QL (120 tabs / 30 days) probenecid tab 500 ULORIC TAB 40MG 3 M ST ULORIC TAB 80MG 3 M ST ZYLOPRIM TAB 100MG 4 M ZYLOPRIM TAB 300MG 4 M MISCELLANEOUS ARTHROTEC 50 TAB 4 M ARTHROTEC 75 TAB 4 M diclofenac w/ misoprostol tab delayed release diclofenac w/ misoprostol tab delayed release DUEXIS TAB M VIMOVO TAB MG 4 M VIMOVO TAB MG 4 M NSAIDS ANAPROX DS TAB 550MG 4 M ANAPROX TAB 275MG 4 M CELEBREX CAP 50MG 4 M CELEBREX CAP 100MG 4 M CELEBREX CAP 200MG 4 M CELEBREX CAP 400MG 4 M celecoxib cap 50 celecoxib cap 100 celecoxib cap 200 celecoxib cap 400 DAYPRO TAB 600MG 4 M diclofenac potassium tab 50 diclofenac sodium tab delayed release 25 diclofenac sodium tab delayed release 50 diclofenac sodium tab delayed release 75 diclofenac sodium tab sr 24hr 100 diflunisal tab 500 EC-NAPROSYN TAB 375MG 4 M EC-NAPROSYN TAB 500MG 4 M etodolac cap 200 etodolac cap 300 etodolac tab 400 etodolac tab 500 etodolac tab sr 24hr 400 etodolac tab sr 24hr 500 etodolac tab sr 24hr 600 FELDENE CAP 10MG 4 M FELDENE CAP 20MG 4 M fenoprofen calcium tab 600 flurbiprofen tab 50 flurbiprofen tab 100 ibuprofen susp 100 /5ml ibuprofen tab 400 ibuprofen tab 600 ibuprofen tab 800 ketoprofen cap 50 ketoprofen cap 75 ketoprofen cap sr 24hr 200 mefenamic acid cap 250 MELOXICAM SUSP 7.5 MG/5ML meloxicam tab 7.5 meloxicam tab 15 MOBIC SUS 7.5/5ML 4 M MOBIC TAB 7.5MG 4 M MOBIC TAB 15MG 4 M nabumetone tab 500 nabumetone tab 750 NAPRELAN TAB 375MG CR 4 M NAPRELAN TAB 500MG CR 4 M NAPRELAN TAB 750MG CR 4 M NAPROSYN TAB 250MG 4 M NAPROSYN TAB 375MG 4 M NAPROSYN TAB 500MG 4 M naproxen dr tab 375 naproxen dr tab 500 naproxen sodium tab 275 naproxen sodium tab 550 NAPROXEN SODIUM TAB SR 24HR 375 MG (BASE EQUIV) 1

9 NAPROXEN SODIUM TAB SR 24HR 500 MG (BASE EQUIV) naproxen susp 125 /5ml naproxen tab 250 naproxen tab 375 naproxen tab 500 oxaprozin tab 600 piroxicam cap 10 piroxicam cap 20 PONSTEL CAP 250MG 5 M sulindac tab 150 sulindac tab 200 tolmetin sodium cap 400 tolmetin sodium tab 200 tolmetin sodium tab 600 VOLTAREN-XR TAB 100MG 4 M ZIPSOR CAP 25MG 4 M ZORVOLEX CAP 18MG 4 M ZORVOLEX CAP 35MG 4 M OPIOID ANALGESICS acetaminophen w/ codeine soln /5ml QL (5000 ml / 30 days) acetaminophen w/ codeine tab QL (400 tabs / 30 days) acetaminophen w/ codeine tab QL (400 tabs / 30 days) acetaminophen w/ codeine tab QL (400 tabs / 30 days) acetaminophen-caffeinedihydrocodeine cap QL (360 caps / 30 days) ASPIRIN-CAFFEINE- DIHYDROCODEINE CAP MG QL (360 caps / 30 days) butorphanol tartrate inj 1 /ml butorphanol tartrate inj 2 /ml butorphanol tartrate nasal soln 10 /ml QL (10 ml / 30 days) BUTRANS DIS 5MCG/HR QL (16 patches / 28 days) BUTRANS DIS 7.5/HR QL (8 patches / 28 days) BUTRANS DIS 10MCG/HR QL (8 patches / 28 days) BUTRANS DIS 15MCG/HR QL (4 patches / 28 days) BUTRANS DIS 20MCG/HR QL (4 patches / 28 days) capital/cod sus /5 QL (5000 ml / 30 days) CONZIP CAP 100MG QL (90 caps / 30 days) CONZIP CAP 200MG QL (60 caps / 30 days) CONZIP CAP 300MG QL (30 caps / 30 days) hycet sol QL (5400 ml / 30 days) hydrocodone-acetaminophen soln /15ml QL (5400 ml / 30 days) hydrocodone-acetaminophen tab QL (360 tabs / 30 days) hydrocodone-acetaminophen tab QL (400 tabs / 30 days) hydrocodone-acetaminophen tab QL (360 tabs / 30 days) hydrocodone-acetaminophen tab QL (400 tabs / 30 days) hydrocodone-acetaminophen tab QL (360 tabs / 30 days) hydrocodone-acetaminophen tab QL (400 tabs / 30 days) hydrocodone-acetaminophen tab QL (360 tabs / 30 days) hydrocodone-ibuprofen tab QL (150 tabs / 30 days) 3 QL M 3 QL M 3 QL M 3 QL M 3 QL M 2

10 hydrocodone-ibuprofen tab QL (150 tabs / 30 days) hydrocodone-ibuprofen tab QL (150 tabs / 30 days) ibudone tab QL (150 tabs / 30 days) lortab elx QL (6000 ml / 30 days) norco tab QL (360 tabs / 30 days) norco tab QL (360 tabs / 30 days) norco tab QL (360 tabs / 30 days) reprexain tab QL (150 tabs / 30 days) reprexain tab QL (150 tabs / 30 days) SYNALGOS-DC CAP QL (360 caps / 30 days) TRAMADOL HCL CAP SR 24HR BIPHASIC RELEASE 100 MG QL (90 caps / 30 days) TRAMADOL HCL CAP SR 24HR BIPHASIC RELEASE 200 MG QL (60 caps / 30 days) TRAMADOL HCL CAP SR 24HR BIPHASIC RELEASE 300 MG QL (30 caps / 30 days) tramadol hcl tab 50 QL (240 tabs / 30 days) tramadol hcl tab sr 24hr 100 QL (90 tabs / 30 days) tramadol hcl tab sr 24hr 200 TRAMADOL HCL TAB SR 24HR 300 MG tramadol hcl tab sr 24hr biphasic release 100 QL (90 tabs / 30 days) tramadol hcl tab sr 24hr biphasic release 200 tramadol hcl tab sr 24hr biphasic release 300 tramadol-acetaminophen tab QL (240 tabs / 30 days) trezix cap QL (360 caps / 30 days) tylenol/cod tab #3 QL (400 tabs / 30 days) tylenol/cod tab #4 QL (400 tabs / 30 days) ULTRACET TAB QL (240 tabs / 30 days) ULTRAM ER TAB 100MG QL (90 tabs / 30 days) ULTRAM ER TAB 200MG ULTRAM ER TAB 300MG ULTRAM TAB 50MG QL (240 tabs / 30 days) VICOPROFEN TAB QL (150 tabs / 30 days) xodol tab QL (400 tabs / 30 days) xodol tab QL (400 tabs / 30 days) xodol tab QL (400 tabs / 30 days) zamicet sol QL (5400 ml / 30 days) OPIOID ANALGESICS, CII ABSTRAL SUB 100MCG QL (120 tabs / 30 days) ABSTRAL SUB 200MCG QL (120 tabs / 30 days) ABSTRAL SUB 300MCG QL (120 tabs / 30 days) ABSTRAL SUB 400MCG QL (120 tabs / 30 days) ABSTRAL SUB 600MCG QL (120 tabs / 30 days) ABSTRAL SUB 800MCG QL (120 tabs / 30 days) 5 QL M 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 3

11 ACTIQ LOZ 200MCG QL (120 lozenges / 30 days) ACTIQ LOZ 400MCG QL (120 lozenges / 30 days) ACTIQ LOZ 600MCG QL (120 lozenges / 30 days) ACTIQ LOZ 800MCG QL (120 lozenges / 30 days) ACTIQ LOZ 1200MCG QL (120 lozenges / 30 days) ACTIQ LOZ 1600MCG QL (120 lozenges / 30 days) AVINZA CAP 30MG QL (60 caps / 30 days) AVINZA CAP 45MG QL (60 caps / 30 days) AVINZA CAP 60MG QL (60 caps / 30 days) AVINZA CAP 75MG QL (60 caps / 30 days) AVINZA CAP 90MG QL (60 caps / 30 days) AVINZA CAP 120MG QL (60 caps / 30 days) CODEINE SULFATE TAB 15 MG QL (720 tabs / 30 days) CODEINE SULFATE TAB 30 MG QL (360 tabs / 30 days) CODEINE SULFATE TAB 60 MG QL (180 tabs / 30 days) 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA DILAUDID INJ 1MG/ML 4 B/D M DILAUDID INJ 2MG/ML 4 B/D M DILAUDID INJ 4MG/ML 4 B/D M DILAUDID LIQ 1MG/ML 4 M DILAUDID TAB 2MG QL (270 tabs / 30 days) DILAUDID TAB 4MG QL (270 tabs / 30 days) DILAUDID TAB 8MG QL (270 tabs / 30 days) DILAUDID-HP INJ 10MG/ML 4 B/D M DILAUDID-HP INJ 250MG 4 B/D M DOLOPHINE TAB 5MG QL (240 tabs / 30 days) DOLOPHINE TAB 10MG QL (240 tabs / 30 days) DURAGESIC DIS 12MCG/HR QL (10 patches / 30 days) DURAGESIC DIS 25MCG/HR QL (10 patches / 30 days) DURAGESIC DIS 50MCG/HR PA QL (10 patches / 30 days) DURAGESIC DIS 75MCG/HR 5 QL M PA QL (10 patches / 30 days) DURAGESIC DIS 100MCG/H 5 QL M PA QL (10 patches / 30 days) DURAMORPH INJ 0.5MG/ML 2 B/D M DURAMORPH INJ 1MG/ML 2 B/D M EMBEDA CAP MG QL (60 caps / 30 days) EMBEDA CAP MG QL (60 caps / 30 days) EMBEDA CAP 50-2MG QL (60 caps / 30 days) EMBEDA CAP MG QL (30 caps / 30 days) EMBEDA CAP MG QL (30 caps / 30 days) EMBEDA CAP 100-4MG QL (30 caps / 30 days) endocet tab QL (360 tabs / 30 days) endocet tab QL (360 tabs / 30 days) endocet tab QL (360 tabs / 30 days) EXALGO TAB 8MG EXALGO TAB 12MG 4

12 EXALGO TAB 16MG EXALGO TAB 32MG fentanyl citrate lozenge on a handle 200 mcg QL (120 lozenges / 30 days) fentanyl citrate lozenge on a handle 400 mcg QL (120 lozenges / 30 days) fentanyl citrate lozenge on a handle 600 mcg QL (120 lozenges / 30 days) fentanyl citrate lozenge on a handle 800 mcg QL (120 lozenges / 30 days) fentanyl citrate lozenge on a handle 1200 mcg QL (120 lozenges / 30 days) fentanyl citrate lozenge on a handle 1600 mcg QL (120 lozenges / 30 days) fentanyl td patch 72hr 12 mcg/hr QL (10 patches / 30 days) fentanyl td patch 72hr 25 mcg/hr QL (10 patches / 30 days) fentanyl td patch 72hr 50 mcg/hr QL (10 patches / 30 days) fentanyl td patch 72hr 75 mcg/hr QL (10 patches / 30 days) fentanyl td patch 72hr 100 mcg/hr QL (10 patches / 30 days) 5 QL M 5 QL M 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA 5 QL M PA PA PA PA FENTORA TAB 100MCG 5 QL M PA QL (120 tabs / 30 days) FENTORA TAB 200MCG 5 QL M PA QL (120 tabs / 30 days) FENTORA TAB 400MCG 5 QL M PA QL (120 tabs / 30 days) FENTORA TAB 600MCG 5 QL M PA QL (120 tabs / 30 days) FENTORA TAB 800MCG 5 QL M PA QL (120 tabs / 30 days) HYDROMORPHONE HCL 2 B/D M INJ G/ML HYDROMORPHONE HCL 2 B/D M INJ G/ML HYDROMORPHONE HCL 2 B/D M INJ 4 MG/ML hydromorphone hcl liqd 1 /ml hydromorphone hcl 2 B/D M preservative free (pf) inj 10 /ml hydromorphone hcl tab 2 QL (270 tabs / 30 days) hydromorphone hcl tab 4 QL (270 tabs / 30 days) hydromorphone hcl tab 8 QL (270 tabs / 30 days) hydromorphone hcl tab er 24hr deter 8 hydromorphone hcl tab er 24hr deter 12 hydromorphone hcl tab er 24hr deter 16 HYDROMORPHONE HCL 5 QL M TAB ER 24HR DETER 3G HYSINGLA ER TAB 20 MG HYSINGLA ER TAB 30 MG HYSINGLA ER TAB 40 MG HYSINGLA ER TAB 60 MG 5

13 HYSINGLA ER TAB 80 MG 5 QL M HYSINGLA ER TAB 100 MG 5 QL M HYSINGLA ER TAB 120 MG 5 QL M INFUMORPH INJ 10MG/ML 4 B/D M INFUMORPH INJ 25MG/ML 4 B/D M KADIAN CAP 10MG ER QL (60 caps / 30 days) KADIAN CAP 20MG ER QL (60 caps / 30 days) KADIAN CAP 30MG ER QL (60 caps / 30 days) KADIAN CAP 40MG ER QL (60 caps / 30 days) KADIAN CAP 50MG ER QL (60 caps / 30 days) KADIAN CAP 60MG ER 5 QL M QL (60 caps / 30 days) KADIAN CAP 80MG ER 5 QL M QL (60 caps / 30 days) KADIAN CAP 100MG ER 5 QL M QL (60 caps / 30 days) KADIAN CAP 200MG ER 5 QL M QL (60 caps / 30 days) LAZANDA SPR 100MCG 5 QL M PA QL (30 bottles / 30 days) LAZANDA SPR 400MCG 5 QL M PA QL (30 bottles / 30 days) levorphanol tartrate tab 2 QL (180 tabs / 30 days) methadone con 10/ml QL (120 ml / 30 days) methadone hcl soln 5 /5ml QL (600 ml / 30 days) methadone hcl soln 10 /5ml QL (600 ml / 30 days) methadone hcl tab 5 QL (240 tabs / 30 days) methadone hcl tab 10 QL (240 tabs / 30 days) METHADONE INJ 10MG/ML 4 M METHADOSE CON 10MG/ML QL (120 ml / 30 days) 3 QL M MORPHINE SUL INJ 2 B/D M 2MG/ML MORPHINE SUL INJ 2 B/D M 4MG/ML MORPHINE SUL INJ 8MG/ML 2 B/D M morphine sulfate beads cap sr 24hr 30 QL (60 caps / 30 days) morphine sulfate beads cap sr 24hr 45 QL (60 caps / 30 days) morphine sulfate beads cap sr 24hr 60 QL (60 caps / 30 days) morphine sulfate beads cap sr 24hr 75 QL (60 caps / 30 days) morphine sulfate beads cap sr 24hr 90 QL (60 caps / 30 days) morphine sulfate beads cap sr 24hr 120 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 10 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 20 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 30 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 50 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 60 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 5 QL M 80 QL (60 caps / 30 days) morphine sulfate cap sr 24hr 5 QL M 100 QL (60 caps / 30 days) morphine sulfate inj pf 0.5 /ml 2 B/D M 6

14 morphine sulfate inj pf 1 2 B/D M /ml MORPHINE SULFATE IV 2 B/D M SOLN G/ML MORPHINE SULFATE IV 2 B/D M SOLN PF 10 MG/ML MORPHINE SULFATE IV SOLN PF 15 MG/ML 2 B/D M MORPHINE SULFATE ORAL SOLN 10 MG/5ML MORPHINE SULFATE ORAL SOLN 20 MG/5ML MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) MORPHINE SULFATE TAB 15 MG QL (180 tabs / 30 days) MORPHINE SULFATE TAB 30 MG QL (180 tabs / 30 days) morphine sulfate tab cr 15 QL (90 tabs / 30 days) morphine sulfate tab cr 30 QL (90 tabs / 30 days) morphine sulfate tab cr 60 QL (90 tabs / 30 days) morphine sulfate tab cr 100 QL (90 tabs / 30 days) morphine sulfate tab cr 200 MS CONTIN TAB 15MG CR QL (90 tabs / 30 days) MS CONTIN TAB 30MG CR QL (90 tabs / 30 days) MS CONTIN TAB 60MG CR QL (90 tabs / 30 days) MS CONTIN TAB 100MG CR 5 QL M QL (90 tabs / 30 days) MS CONTIN TAB 200MG CR 5 QL M NUCYNTA ER TAB 50MG QL (120 tabs / 30 days) NUCYNTA ER TAB 100MG QL (120 tabs / 30 days) NUCYNTA ER TAB 150MG NUCYNTA ER TAB 200MG NUCYNTA ER TAB 250MG NUCYNTA TAB 50MG QL (360 tabs / 30 days) NUCYNTA TAB 75MG QL (240 tabs / 30 days) NUCYNTA TAB 100MG QL (180 tabs / 30 days) OPANA ER TAB 5MG QL (120 tabs / 30 days) OPANA ER TAB 7.5MG QL (120 tabs / 30 days) OPANA ER TAB 10MG QL (120 tabs / 30 days) OPANA ER TAB 15MG QL (120 tabs / 30 days) OPANA ER TAB 20MG QL (120 tabs / 30 days) OPANA ER TAB 30MG QL (120 tabs / 30 days) OPANA ER TAB 40MG 5 QL M QL (120 tabs / 30 days) OPANA TAB 5MG QL (180 tabs / 30 days) OPANA TAB 10MG QL (180 tabs / 30 days) OXECTA TAB 5MG QL (270 tabs / 30 days) OXECTA TAB 7.5MG QL (270 tabs / 30 days) OXYCODONE HCL CAP 5 MG QL (180 caps / 30 days) OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML) oxycodone hcl soln 5 /5ml oxycodone hcl tab 5 QL (180 tabs / 30 days) oxycodone hcl tab 10 QL (180 tabs / 30 days) oxycodone hcl tab 15 QL (180 tabs / 30 days) oxycodone hcl tab 20 QL (180 tabs / 30 days) 7

15 oxycodone hcl tab 30 QL (180 tabs / 30 days) oxycodone w/ acetaminophen tab QL (360 tabs / 30 days) oxycodone w/ acetaminophen tab QL (360 tabs / 30 days) oxycodone w/ acetaminophen tab QL (360 tabs / 30 days) oxycodone w/ acetaminophen tab QL (360 tabs / 30 days) oxycodone-aspirin tab QL (360 tabs / 30 days) OXYCODONE-ASPIRIN TAB MG QL (360 tabs / 30 days) oxycodone-ibuprofen tab QL (28 tabs / 30 days) OXYCONTIN TAB 10MG CR QL (120 tabs / 30 days) OXYCONTIN TAB 15MG CR QL (120 tabs / 30 days) OXYCONTIN TAB 20MG CR QL (120 tabs / 30 days) OXYCONTIN TAB 30MG CR QL (120 tabs / 30 days) OXYCONTIN TAB 40MG CR QL (120 tabs / 30 days) OXYCONTIN TAB 60MG CR 5 QL M QL (120 tabs / 30 days) OXYCONTIN TAB 80MG CR 5 QL M QL (120 tabs / 30 days) oxymorphone hcl tab 5 QL (180 tabs / 30 days) oxymorphone hcl tab 10 QL (180 tabs / 30 days) percocet tab QL (360 tabs / 30 days) percocet tab QL (360 tabs / 30 days) percocet tab QL (360 tabs / 30 days) percocet tab QL M QL (360 tabs / 30 days) PERCODAN TAB QL (360 tabs / 30 days) roxicet sol 5-325/5 3 QL M QL (1800 ml / 30 days) ROXICODONE TAB 5MG QL (180 tabs / 30 days) ROXICODONE TAB 15MG QL (180 tabs / 30 days) ROXICODONE TAB 30MG 5 QL M QL (180 tabs / 30 days) SUBSYS SPR 100MCG 5 QL M PA QL (4 boxes / 30 days) SUBSYS SPR 200MCG 5 QL M PA QL (4 boxes / 30 days) SUBSYS SPR 400MCG 5 QL M PA QL (4 boxes / 30 days) SUBSYS SPR 600MCG 5 QL M PA QL (4 boxes / 30 days) SUBSYS SPR 800MCG 5 QL M PA QL (4 boxes / 30 days) SUBSYS SPR 1200MCG 5 QL M PA QL (4 boxes / 30 days) SUBSYS SPR 1600MCG 5 QL M PA QL (4 boxes / 30 days) XARTEMIS XR TAB QL (120 tabs / 30 days) ZOHYDRO ER CAP 10MG QL (120 caps / 30 days) ZOHYDRO ER CAP 15MG QL (120 caps / 30 days) ZOHYDRO ER CAP 20MG QL (120 caps / 30 days) ZOHYDRO ER CAP 30MG QL (60 caps / 30 days) ZOHYDRO ER CAP 40MG QL (60 caps / 30 days) ZOHYDRO ER CAP 50MG QL (60 caps / 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl local inj 0.5% 2 B/D M lidocaine hcl local inj 1% 2 B/D M lidocaine hcl local inj 1.5% 2 B/D M lidocaine hcl local inj 2% 2 B/D M lidocaine hcl local inj 4% 8

16 lidocaine hcl local 2 B/D M preservative free (pf) inj 0.5% lidocaine hcl local 2 B/D M preservative free (pf) inj 1% lidocaine hcl local 2 B/D M preservative free (pf) inj 2% XYLOCAINE INJ 0.5% 4 B/D M XYLOCAINE INJ 1% 4 B/D M XYLOCAINE INJ 2% 4 B/D M XYLOCAINE INJ -MPF 1% 4 B/D M XYLOCAINE INJ -MPF 2% 4 B/D M XYLOCAINE INJ -MPF 4% 4 M XYLOCAINE INJ MPF 0.5% 4 B/D M XYLOCAINE INJ MPF 1.5% 4 B/D M ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 /ml) amikacin sulfate inj 500 /2ml (250 /ml) BETHKIS NEB 300/4ML 5 B/D gentam/nacl inj 0.9/ml gentam/nacl inj 1.4/ml gentamicin in saline inj 0.8 /ml gentamicin in saline inj 1 /ml gentamicin in saline inj 1.2 /ml gentamicin in saline inj 1.6 /ml gentamicin in saline inj 2 /ml gentamicin sulfate inj 10 /ml gentamicin sulfate inj 40 /ml gentamicin sulfate iv soln 10 /ml neomycin sulfate tab 500 paromomycin sulfate cap 250 streptomycin sulfate for inj 1 gm sulfadiazine tab M TOBI NEB 300/5ML 5 B/D TOBI PODHALR CAP 28MG 5 PA tobra/nacl inj 80/0.9 3 M tobramycin nebu soln B/D /5ml tobramycin sulfate for inj 1.2 gm tobramycin sulfate inj 1.2 gm/30ml (40 /ml) tobramycin sulfate inj 2 gm/50ml (40 /ml) tobramycin sulfate inj 10 /ml tobramycin sulfate inj 80 /2ml (40 /ml) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 4 M ALINIA SUS 100/5ML 4 M ALINIA TAB 500MG 4 M atovaquone susp 750 /5ml 5 M AZACTAM INJ 1GM 4 M AZACTAM INJ 2GM 4 M AZACTAM/DEX INJ 1GM 4 M AZACTAM/DEX INJ 2GM 5 M aztreonam for inj 1 gm aztreonam for inj 2 gm BACTRIM DS TAB M BACTRIM TAB MG 4 M BILTRICIDE TAB 600MG 3 M CAYSTON INH 75MG 5 LA PA CLEOCIN CAP 75MG 4 M CLEOCIN CAP 150MG 4 M CLEOCIN CAP 300MG 4 M cleocin ped sol 75/5ml 4 M CLEOCIN PHOS INJ 4 M 9GM/60ML CLEOCIN PHOS INJ 300MG 4 M CLEOCIN PHOS INJ 600MG 4 M CLEOCIN PHOS INJ 900MG 4 M CLEOCIN/D5W INJ 300MG 4 M CLEOCIN/D5W INJ 600MG 4 M CLEOCIN/D5W INJ 900MG 4 M clindamycin hcl cap 75 clindamycin hcl cap 150 clindamycin hcl cap 300 clindamycin palmitate hcl for soln 75 /5ml (base equiv) clindamycin phosphate in d5w iv soln 300 /50ml 9

17 clindamycin phosphate in d5w iv soln 600 /50ml clindamycin phosphate in d5w iv soln 900 /50ml clindamycin phosphate inj 9 gm/60ml clindamycin phosphate inj 300 /2ml clindamycin phosphate inj 600 /4ml clindamycin phosphate inj 900 /6ml clindamycin phosphate iv soln 300 /2ml clindamycin phosphate iv soln 600 /4ml clindamycin phosphate iv soln 900 /6ml colistimethate sodium for inj 150 COLY-MYCIN M INJ 150MG 4 M CUBICIN SOL 500MG 5 M DALVANCE SOL 500MG 5 M dapsone tab 25 dapsone tab 100 DARAPRIM TAB 25MG 4 M DORIBAX INJ 250MG 4 M DORIBAX INJ 500MG 4 M FLAGYL CAP 375MG 4 M FLAGYL TAB 250MG 4 M FLAGYL TAB 500MG 4 M FURADANTIN SUS 5 M PA 25MG/5ML 90 day limit if >64 yr HIPREX TAB 1GM 4 M imipenem-cilastatin intravenous for soln 250 imipenem-cilastatin intravenous for soln 500 INVANZ INJ 1GM 4 M ivermectin tab 3 linezolid iv soln 2 /ml 5 M LINEZOLID TAB 600 MG 5 M MACROBID CAP 100MG 4 M PA 90 day limit if >64 yr MACRODANTIN CAP 25MG 90 day limit if >64 yr 4 M PA MACRODANTIN CAP 50MG 90 day limit if >64 yr 4 M PA MACRODANTIN CAP 100MG 4 M PA 90 day limit if >64 yr MEPRON SUS 5 M meropenem iv for soln 1 gm meropenem iv for soln 500 MERREM INJ 1GM 4 M MERREM INJ 500MG 4 M methenamine hippurate tab 1 gm METRO IV INJ 5MG/ML 3 M metronidazole cap 375 metronidazole in nacl 0.79% iv soln 500 /100ml metronidazole tab 250 metronidazole tab 500 NEBUPENT INH 300MG 4 B/D M nitrofurantoin macrocrystalline 4 M PA cap day limit if >64 yr nitrofurantoin macrocrystalline 4 M PA cap day limit if >64 yr nitrofurantoin monohydrate 4 M PA macrocrystalline cap day limit if >64 yr nitrofurantoin susp 25 /5ml PA 90 day limit if >64 yr PENTAM 300 INJ 300MG 4 M polymyxin b sulfate for inj unit PRIMAXIN IV INJ 250MG 4 M PRIMAXIN IV INJ 500MG 4 M PRIMSOL SOL 50MG/5ML 4 M SIVEXTRO INJ 200MG 5 M SIVEXTRO TAB 200MG 5 M STROMECTOL TAB 3MG 4 M sulfamethoxazoletrimethoprim iv soln /5ml sulfamethoxazoletrimethoprim susp /5ml sulfamethoxazoletrimethoprim tab

18 sulfamethoxazoletrimethoprim tab SYNERCID INJ 500MG 5 M trimethoprim tab 100 TYGACIL INJ 50MG 5 M VANCOCIN HCL CAP 125MG 5 M VANCOCIN HCL CAP 250MG 5 M vancomycin hcl cap M vancomycin hcl cap M vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 vancomycin hcl for inj 1000 vancomycin hcl for inj 5000 vancomycin inj 750 XIFAXAN TAB 200MG 5 M ZYVOX SOL 2MG/ML 5 M ZYVOX SUS 100MG/5M 5 M ZYVOX TAB 600MG 5 M ANTIFUNGALS ABELCET INJ 5MG/ML 5 B/D M AMBISOME INJ 50MG 5 B/D M AMPHOTEC INJ 50MG 4 B/D M AMPHOTEC INJ 100MG 4 B/D M amphotericin b for inj 50 2 B/D M ANCOBON CAP 250MG 5 M ANCOBON CAP 500MG 5 M CANCIDAS INJ 50MG 5 M CANCIDAS INJ 70MG 5 M CRESEMBA CAP 186 MG 5 M CRESEMBA INJ 372MG 5 M DIFLUCAN SUS 10MG/ML 4 M DIFLUCAN SUS 40MG/ML 4 M DIFLUCAN TAB 50MG 4 M DIFLUCAN TAB 100MG 4 M DIFLUCAN TAB 150MG 4 M DIFLUCAN TAB 200MG 4 M ERAXIS INJ 50MG 5 M ERAXIS INJ 100MG 5 M fluconazole for susp 10 /ml fluconazole for susp 40 /ml fluconazole in dextrose inj 200 /100ml fluconazole in dextrose inj 400 /200ml fluconazole in nacl 0.9% inj 200 /100ml fluconazole in nacl 0.9% inj 400 /200ml fluconazole tab 50 fluconazole tab 100 fluconazole tab 150 fluconazole tab 200 fluconazole/ inj nacl 100 flucytosine cap M flucytosine cap M GRIS-PEG TAB 125MG 4 M GRIS-PEG TAB 250MG 4 M griseofulvin microsize susp 125 /5ml griseofulvin microsize tab 500 griseofulvin ultramicrosize tab 125 griseofulvin ultramicrosize tab 250 itraconazole cap 100 PA ketoconazole tab 200 PA LAMISIL GRA 125MG 4 M LAMISIL GRA 187.5MG 4 M LAMISIL TAB 250MG QL (90 tabs / 365 days) MYCAMINE INJ 50MG 5 M MYCAMINE INJ 100MG 5 M NOXAFIL INJ 300/ M NOXAFIL SUS 40MG/ML 5 M NOXAFIL TAB 100MG 5 M nystatin tab unit ONMEL TAB 200MG 4 M PA SPORANOX CAP 100MG 5 M PA SPORANOX CAP 5 M PA PULSEPAK SPORANOX SOL 10MG/ML 5 M terbinafine hcl tab QL M QL (90 tabs / 365 days) VFEND IV INJ 200MG 4 M VFEND SUS 40MG/ML 5 M VFEND TAB 50MG 5 M VFEND TAB 200MG 5 M voriconazole for inj 200 voriconazole for susp 40 /ml 5 M 11

19 Drug Tier voriconazole tab 50 5 M voriconazole tab M ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB MG Requirements/ Limits atovaquone-proguanil hcl tab chloroquine phosphate tab 250 chloroquine phosphate tab 500 COARTEM TAB MG 3 M MALARONE TAB M MALARONE TAB M mefloquine hcl tab 250 PRIMAQUINE TAB 26.3MG 3 M QUALAQUIN CAP 324MG 4 M quinine sulfate cap 324 ANTIRETROVIRAL AGENTS abacavir sulfate tab 300 (base equiv) APTIVUS CAP 250MG 5 M APTIVUS SOL 5 M CRIXIVAN CAP 200MG 4 M CRIXIVAN CAP 400MG 4 M didanosine delayed release capsule 125 didanosine delayed release capsule 200 didanosine delayed release capsule 250 didanosine delayed release capsule 400 EDURANT TAB 25MG 5 M EMTRIVA CAP 200MG 3 M EMTRIVA SOL 10MG/ML 3 M EPIVIR SOL 10MG/ML 3 M EPIVIR TAB 150MG 4 M EPIVIR TAB 300MG 4 M FUZEON INJ 90MG 5 INTELENCE TAB 25MG 4 M INTELENCE TAB 100MG 5 M INTELENCE TAB 200MG 5 M INVIRASE CAP 200MG 4 M INVIRASE TAB 500MG 5 M ISENTRESS CHW 25MG 3 M ISENTRESS CHW 100MG 5 M ISENTRESS POW 100MG 3 M ISENTRESS TAB 400MG 5 M lamivudine oral soln 10 /ml lamivudine tab 150 lamivudine tab 300 LEXIVA SUS 50MG/ML 4 M LEXIVA TAB 700MG 5 M NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 200 nevirapine tab sr 24hr 400 NORVIR CAP 100MG 3 M NORVIR SOL 80MG/ML 3 M NORVIR TAB 100MG 3 M PREZISTA SUS 100MG/ML 5 M PREZISTA TAB 75MG 3 M PREZISTA TAB 150MG 3 M PREZISTA TAB 600MG 5 M PREZISTA TAB 800MG 5 M RESCRIPTOR TAB 100 MG 4 M RESCRIPTOR TAB 200MG 4 M RETROVIR CAP 100MG 4 M RETROVIR INJ 10MG/ML 3 M RETROVIR SYP 50MG/5ML 4 M REYATAZ CAP 150MG 5 M REYATAZ CAP 200MG 5 M REYATAZ CAP 300MG 5 M REYATAZ POW 50MG 5 M SELZENTRY TAB 150MG 5 M SELZENTRY TAB 300MG 5 M stavudine cap 15 stavudine cap 20 stavudine cap 30 stavudine cap 40 stavudine for oral soln 1 /ml SUSTIVA CAP 50MG 3 M SUSTIVA CAP 200MG 3 M SUSTIVA TAB 600MG 5 M TIVICAY TAB 50MG 5 M TYBOST TAB 150MG 4 M VIDEX EC CAP 125MG 4 M VIDEX EC CAP 200MG 4 M VIDEX EC CAP 250MG 4 M VIDEX EC CAP 400MG 4 M VIDEX SOL 2GM 4 M VIDEX SOL 4GM 4 M 12

20 Drug Tier Requirements/ Limits VIRACEPT TAB 250MG 5 M VIRACEPT TAB 625MG 5 M VIRAMUNE SUS 50MG/5ML 4 M VIRAMUNE TAB 200MG 4 M VIRAMUNE XR TAB 100MG 4 M VIRAMUNE XR TAB 400MG 4 M VIREAD POW 40MG/GM 5 M VIREAD TAB 150MG 5 M VIREAD TAB 200MG 5 M VIREAD TAB 250MG 5 M VIREAD TAB 300MG 5 M VITEKTA TAB 85MG 5 M VITEKTA TAB 150MG 5 M ZERIT CAP 15MG 4 M ZERIT CAP 20MG 4 M ZERIT CAP 30MG 4 M ZERIT CAP 40MG 4 M ZERIT SOL 1MG/ML 4 M ZIAGEN SOL 20MG/ML 4 M ZIAGEN TAB 300MG 4 M zidovudine cap 100 zidovudine syrup 10 /ml zidovudine tab 300 ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudinezidovudine tab M ATRIPLA TAB 5 M COMBIVIR TAB M COMPLERA TAB 5 M EPZICOM TAB M EVOTAZ TAB M KALETRA SOL 5 M KALETRA TAB MG 3 M KALETRA TAB MG 5 M lamivudine-zidovudine tab 5 M PREZCOBIX TAB M STRIBILD TAB 5 M TRIUMEQ TAB 5 M TRIZIVIR TAB 5 M TRUVADA TAB QL M ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM 5 M cycloserine cap 250 ethambutol hcl tab 100 ethambutol hcl tab 400 isoniazid inj 100 /ml isoniazid syrup 50 /5ml isoniazid tab 100 isoniazid tab 300 MYAMBUTOL TAB 100MG 4 M MYAMBUTOL TAB 400MG 4 M MYCOBUTIN CAP 150MG 4 M paser gra 4gm 3 M PRIFTIN TAB 150MG 4 M pyrazinamide tab 500 rifabutin cap 150 rifadin cap M RIFADIN CAP 300MG 4 M RIFADIN INJ 600 MG 4 M rifamate cap 4 M rifampin cap 150 rifampin cap 300 rifampin for inj 600 RIFATER TAB 4 M SIRTURO TAB 100MG 5 M LA PA TRECATOR TAB 250MG 4 M ANTIVIRALS acyclovir cap 200 acyclovir sodium for inj B/D M acyclovir sodium for inj B/D M acyclovir sodium iv soln 50 2 B/D M /ml acyclovir susp 200 /5ml acyclovir tab 400 acyclovir tab 800 adefovir dipivoxil tab 10 5 M BARACLUDE SOL.05MG/ML 3 M BARACLUDE TAB 0.5MG 5 M BARACLUDE TAB 1MG 5 M cidofovir iv inj 75 /ml COPEGUS TAB 200MG 5 PA CYTOVENE INJ 500MG 4 B/D M entecavir tab M entecavir tab 1 5 M EPIVIR HBV SOL 5MG/ML 4 M EPIVIR HBV TAB 100MG 4 M famciclovir tab 125 famciclovir tab

21 famciclovir tab 500 FAMVIR TAB 125MG 4 M FAMVIR TAB 250MG 4 M FAMVIR TAB 500MG 4 M FLUMADINE TAB 100MG 4 M ganciclovir sodium for inj B/D M HARVONI TAB MG 5 PA HEPSERA TAB 10MG 5 M lamivudine tab 100 (hbv) moderiba pak 600/day 5 PA moderiba pak 800/day 5 PA moderiba pak 1000/day 5 PA moderiba pak 1200/day 5 PA OLYSIO CAP 150MG 5 PA REBETOL CAP 200MG 5 PA REBETOL SOL 40MG/ML 5 PA RELENZA MIS DISKHALE 3 M ribapak pak 600/day 5 PA ribapak pak 800/day 5 PA ribapak pak 1000/day 5 PA ribapak pak 1200/day 5 PA ribasphere cap PA ribasphere tab PA ribasphere tab PA ribasphere tab PA ribavirin cap PA ribavirin tab PA rimantadine hydrochloride tab 100 SOVALDI TAB 400MG 5 PA TAMIFLU CAP 30MG 3 M TAMIFLU CAP 45MG 3 M TAMIFLU CAP 75MG 3 M TAMIFLU SUS 6MG/ML 3 M TYZEKA TAB 600MG 5 M valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 VALCYTE SOL 50MG/ML 5 M VALCYTE TAB 450MG 5 M valganciclovir hcl tab M (base equivalent) VALTREX TAB 1GM 4 M VALTREX TAB 500MG 4 M VICTRELIS CAP 200MG 5 PA VISTIDE INJ 75MG/ML 4 M ZOVIRAX CAP 200MG 4 M Drug Tier Requirements/ Limits ZOVIRAX SUS 200/5ML 4 M CEPHALOSPORINS AVYCAZ INJ 2-0.5GM 5 M CEDAX CAP 400MG 4 M CEDAX SUS 90MG/5ML 4 M CEDAX SUS 180/5ML 4 M cefaclor cap 250 cefaclor cap 500 cefaclor er tab M cefaclor for susp 125 /5ml cefaclor for susp 250 /5ml cefaclor for susp 375 /5ml cefadroxil cap 500 cefadroxil for susp 250 /5ml cefadroxil for susp 500 /5ml cefadroxil tab 1 gm cefazolin inj 1gm/50ml 3 M cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 cefazolin sodium for iv soln 1 gm cefdinir cap 300 cefdinir for susp 125 /5ml cefdinir for susp 250 /5ml cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm CEFEPIME INJ 1GM 4 M CEFEPIME INJ 2GM 4 M cefixime for susp 100 /5ml cefixime for susp 200 /5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 500 cefotetan inj 1gm/10ml 4 M cefotetan inj 2gm/20ml 4 M cefotetan inj 10g 4 M CEFOXITIN INJ 1GM 4 M CEFOXITIN INJ 2GM 4 M cefoxitin sodium for inj 10 gm 14

22 cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 100 /5ml cefpodoxime proxetil tab 100 cefpodoxime proxetil tab 200 cefprozil for susp 125 /5ml cefprozil for susp 250 /5ml cefprozil tab 250 cefprozil tab 500 ceftazidime for inj 1 gm ceftazidime for inj 2 gm ceftazidime for inj 6 gm CEFTAZIDIME/ SOL D5W 4 M 1GM CEFTAZIDIME/ SOL D5W 4 M 2GM ceftibuten cap 400 ceftibuten for susp 180 /5ml CEFTIN SUS 125/5ML 4 M CEFTIN SUS 250/5ML 4 M CEFTIN TAB 250MG 4 M CEFTIN TAB 500MG 4 M ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 ceftriaxone sodium for inj 500 ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil for susp 125 /5ml cefuroxime axetil tab 250 cefuroxime axetil tab 500 cefuroxime inj 7.5gm cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 cefuroxime sodium for iv soln 1.5 gm cephalexin cap 250 cephalexin cap 500 cephalexin cap 750 cephalexin for susp 125 /5ml cephalexin for susp 250 /5ml cephalexin tab 250 cephalexin tab 500 claforan inj 1gm 4 M CLAFORAN INJ 1GM 4 M claforan inj 2gm 4 M CLAFORAN INJ 2GM 4 M CLAFORAN INJ 10GM 4 M CLAFORAN INJ 500MG 4 M FORTAZ INJ 1GM 4 M FORTAZ INJ 2GM 4 M FORTAZ INJ 6GM 4 M FORTAZ INJ 500MG 4 M KEFLEX CAP 250MG 4 M KEFLEX CAP 500MG 4 M KEFLEX CAP 750MG 4 M MAXIPIME INJ 1GM 4 M MAXIPIME INJ 2GM 4 M rocephin inj 1gm 4 M rocephin inj M SUPRAX CAP 400MG 3 M suprax chw M suprax chw M suprax sus 100/5ml 3 M suprax sus 200/5ml 3 M SUPRAX SUS 500/5ML 3 M tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TEFLARO INJ 400MG 4 M TEFLARO INJ 600MG 4 M ZERBAXA INJ GM 5 M 15

23 ZINACEF INJ 1.5GM 4 M ZINACEF INJ 7.5GM 4 M ZINACEF INJ 750MG 4 M ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml azithromycin for susp 200 /5ml azithromycin iv for soln 500 AZITHROMYCIN POWD PACK FOR SUSP 1 GM azithromycin tab 250 azithromycin tab 500 azithromycin tab 600 BIAXIN SUS 250/5ML 4 M BIAXIN TAB 250MG 4 M BIAXIN TAB 500MG 4 M clarithromycin for susp 125 /5ml clarithromycin for susp 250 /5ml clarithromycin tab 250 clarithromycin tab 500 clarithromycin tab sr 24hr 500 DIFICID TAB 200MG 5 M E.E.S. GRAN SUS 200/5ML 4 M ery-tab tab 250 ec 4 M ery-tab tab 333 ec 4 M ery-tab tab 500 ec 4 M ERYPED SUS 200/5ML 4 M ERYPED SUS 400/5ML 4 M erythrocin inj M erythrocin tab 250 erythromycin ethylsuccinate tab 400 erythromycin tab 250 erythromycin tab 500 erythromycin w/ delayed release particles cap 250 PCE TAB 333MG EC 4 M PCE TAB 500MG EC 4 M ZITHROMAX INJ 500MG 4 M ZITHROMAX POW 1GM PAK 4 M ZITHROMAX SUS 100/5ML 4 M ZITHROMAX SUS 200/5ML 4 M Drug Tier Requirements/ Limits ZITHROMAX TAB 250MG 4 M ZITHROMAX TAB 500MG 4 M ZITHROMAX TAB 600MG 4 M ZITHROMAX TAB TRI-PAK 4 M ZITHROMAX TAB Z-PAK 4 M ZMAX SUS 2GM 3 M FLUOROQUINOLONES AVELOX ABC TAB 400MG 4 M AVELOX INJ 4 M AVELOX TAB 400MG 4 M CIPRO (5%) SUS 250MG/5 4 M CIPRO (10%) SUS 500MG/5 4 M CIPRO TAB 250MG 4 M CIPRO TAB 500MG 4 M CIPRO XR TAB 500MG 4 M CIPRO XR TAB 1000MG 4 M ciprofloxacin 200 /100ml in d5w ciprofloxacin 400 /200ml in d5w ciprofloxacin for oral susp 250 /5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 (base equiv) ciprofloxacin hcl tab 250 (base equiv) ciprofloxacin hcl tab 500 (base equiv) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin iv soln 200 /20ml (1%) ciprofloxacin iv soln 400 /40ml (1%) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 (base eq) LEVAQUIN SOL 25MG/ML 4 M LEVAQUIN TAB 250MG 4 M LEVAQUIN TAB 500MG 4 M LEVAQUIN TAB 750MG 4 M LEVAQUIN/D5W INJ 250/50ML 4 M 16