Arkansas Blue Cross and Blue Shield Metallic Formulary List of Covered Drugs

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1 October, 08 Arkansas Blue Cross and Blue Shield Metallic Formulary 08 List of Covered Drugs PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Members must use network pharmacies to fill their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change. - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

2 October, 08 What is the Arkansas Blue Cross and Blue Shield Metallic Plans Drug List? A drug list is a list of covered drugs. Arkansas Blue Cross and Blue Shield Metallic Plans works with a team of health care providers to choose drugs that provide quality treatment. Arkansas Blue Cross and Blue Shield Metallic Plans cover drugs on our drug list, as long as: The drug is medically necessary The prescription is filled at a Arkansas Blue Cross and Blue Shield Metallic Plans network pharmacy Other plan rules are followed For more information on how to fill your prescriptions, please review your plan document or other plan materials. Can the Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed drug list is the most current drug list covered by Arkansas Blue Cross and Blue Shield Metallic Plans. To get updated information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans, please or call Member Services at How do I use the Drug List? There are two ways to find your drug on the drug list:. Medical Condition The drug list starts on page 5. The drugs on this drug list are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under anticoagulants. If you know what your drug is used for, look for the category name in the list that starts on the next page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 60. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index. Look in the Index and find your drug Next to your drug, 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 For more information about your Arkansas Blue Cross and Blue Shield Metallic Plans prescription drug coverage, please look at your plan document and other plan materials. If you have questions about Arkansas Blue Cross and Blue Shield Metallic Plans, or this drug - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

3 October, 08 list please call Member Services at or visit Arkansas Blue Cross and Blue Shield Metallic Plans Drug List The drug list set forth below gives information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Arkansas Blue Cross and Blue Shield Metallic Plans have any special requirements for coverage of your drug. These requirements and limits may include: Prior Approval: Arkansas Blue Cross and Blue Shield needs you (or your doctor) to get prior approval or authorization for certain drugs. This means that you need to get approval from Arkansas Blue Cross and Blue Shield before you fill your prescriptions. If you don t get approval, Arkansas Blue Cross and Blue Shield may not cover the drug Quantity Limits: For certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that it will cover. For example, Arkansas Blue Cross and Blue Shield provides 8 caplets per 90 day prescription for Tamiflu. This may be in addition to a standard one-month or three-month supply Step Therapy: Arkansas Blue Cross and Blue Shield needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Arkansas Blue Cross and Blue Shield may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Arkansas Blue Cross and Blue Shield will then cover Drug B Specialty Medications: Arkansas Blue Cross and Blue Shield requires that specialty medications be filled at a network specialty pharmacy. What if my drug is not on the Drug List? If your drug is not on this drug list, call Member Services and make sure that your drug is not covered. If you learn that Arkansas Blue Cross and Blue Shield does not cover your drug, you have two choices: Ask Member Services for a list of similar drugs that are covered by Arkansas Blue Cross and Blue Shield Metallic Plans. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Arkansas Blue Cross and Blue Shield Metallic Plans. Similar drugs that are preferred and covered - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

4 October, 08 by your plan s formulary may be easier to obtain and lower cost to you than non-preferred drugs. Ask Arkansas Blue Cross and Blue Shield to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more. Generally, Arkansas Blue Cross and Blue Shield will only approve your request for an exception if the preferred drugs included on the plan s drug list are not as effective in treating your condition or cause you to have adverse medical effects. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug s cost that you will pay) for drugs in each tier. Drug Tier column instructions: Plans that provide different levels of cost sharing for drugs depending on their tier must include a column indicating the drug s tier placement. Plans may choose from several methods to indicate the tier placement, including tier numbers from your plan benefit package (e.g., 0///), standard tier names from your plan benefit package (e.g., ACA preventive/generic/preferred brand/other brand), copayment amounts (e.g.,$0/$0/$0/$5), or coinsurance percentages (e.g., 0%/0%/5%). The latter two methods are preferred because they are generally easier for members to understand. If one of the two former methods is used, plans must provide an explanation before the table explaining the copayment amount or coinsurance percentage associated with each tier number or tier name. Plans that have different copayment amounts or coinsurance percentages for retail and mail-service prescriptions may include both retail and mail service amounts within the same column or include separate columns for retail and mail service prescriptions. - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

5 October, 08 ANALGESICS COX- INHIBITORS celecoxib cap 50 mg celecoxib cap 00 mg celecoxib cap 00 mg celecoxib cap 00 mg GOUT allopurinol sodium for inj 500 mg allopurinol tab 00 mg allopurinol tab 00 mg colchicine tab 0.6 mg colchicine w/ probenecid tab mg probenecid tab 500 mg ULORIC TAB 0MG ST; ** ULORIC TAB 80MG ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap QL (8 caps / 5 days) mg butalbital-acetaminophen-caffeine cap QL (8 caps / 5 days) mg butalbital-acetaminophen-caffeine tab QL (8 tabs / 5 days) mg butalbital-aspirin-caffeine cap QL (8 caps / 5 days) mg tencon tab 50-5mg QL (8 tabs / 5 days) NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed release mg diclofenac w/ misoprostol tab delayed release mg NSAIDS diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er hr 00 mg etodolac cap 00 mg etodolac cap 00 mg etodolac tab 00 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 5

6 October, 08 etodolac tab 500 mg etodolac tab er hr 00 mg etodolac tab er hr 500 mg etodolac tab er hr 600 mg fenoprofen calcium cap 00 mg fenoprofen calcium tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 00 mg ibuprofen susp 00 mg/5ml ibuprofen tab 00 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 5 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap er hr 00 mg ketorolac tromethamine im inj 60 mg/ml (0 mg/ml) ketorolac tromethamine inj 5 mg/ml ketorolac tromethamine inj 0 mg/ml ketorolac tromethamine tab 0 mg QL (0 tabs / 5 days) meclofenamate sodium cap 50 mg meclofenamate sodium cap 00 mg mefenamic acid cap 50 mg meloxicam susp 7.5 mg/5ml meloxicam tab 7.5 mg meloxicam tab 5 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 75mg naproxen dr tab 500mg naproxen sodium tab 75 mg naproxen sodium tab 550 mg naproxen susp 5 mg/5ml naproxen tab 50 mg naproxen tab 75 mg naproxen tab 500 mg oxaprozin tab 600 mg piroxicam cap 0 mg piroxicam cap 0 mg sulindac tab 50 mg sulindac tab 00 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 6

7 October, 08 tolmetin sodium cap 00 mg tolmetin sodium tab 00 mg tolmetin sodium tab 600 mg OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab -0.5 QL (90 tabs / 5 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8- QL (90 tabs / 5 days) mg (base equiv) SUBOXONE MIS -0.5MG QL (90 units / 5 days) SUBOXONE MIS -MG QL (90 units / 5 days) SUBOXONE MIS 8-MG QL (90 units / 5 days) SUBOXONE MIS -MG QL (60 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB.-0.6 QL (90 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB QL (60 units / 5 days) ZUBSOLV SUB.-.9 QL (0 units / 5 days) OPIOID ANALGESICS acetaminophen w/ codeine soln 0- mg/5ml acetaminophen w/ codeine tab 00-5 mg acetaminophen w/ codeine tab 00-0 mg acetaminophen w/ codeine tab mg butalbital-acetaminophen-caff w/ cod cap mg butorphanol tartrate inj mg/ml butorphanol tartrate inj mg/ml butorphanol tartrate nasal soln 0 mg/ml QL (700 ml / 5 days), ST; Subject to initial 7-day limit QL (00 tabs / 5 days), ST; Subject to initial 7-day limit QL (60 tabs / 5 days), ST; Subject to initial 7-day limit QL (80 tabs / 5 days), ST; Subject to initial 7-day limit QL (8 caps / 5 days) QL ( bottles / 5 days) CAPITAL/COD SUS 0-/5 QL (700 ml / 5 days), ST; Subject to initial 7-day limit codeine sulfate tab 5 mg QL ( tabs / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 7

8 October, 08 codeine sulfate tab 0 mg QL ( tabs / 5 days), ST; Subject to initial 7-day limit codeine sulfate tab 60 mg QL ( tabs / 5 days), ST; Subject to initial 7-day limit EMBEDA CAP 0-0.8MG QL (60 caps / 5 days), ST EMBEDA CAP 0-.MG QL (60 caps / 5 days), ST EMBEDA CAP 50-MG QL (0 caps / 5 days), ST EMBEDA CAP 60-.MG QL (0 caps / 5 days), ST EMBEDA CAP 80-.MG QL (0 caps / 5 days), ST EMBEDA CAP 00-MG, ST; High Strength Requires endocet tab.5-5 QL (60 tabs / 5 days), ST; Subject to initial 7-day limit endocet tab 5-5mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit endocet tab QL (0 tabs / 5 days), ST; Subject to initial 7-day limit endocet tab 0-5mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit fentanyl citrate lozenge on a handle 00 QL (0 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 00 QL (0 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 600 QL (0 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 800 QL (0 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 00 QL (0 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 600 QL (0 lozenges / 5 mcg days), fentanyl td patch 7hr mcg/hr QL (0 patches / 5 days), ST fentanyl td patch 7hr 5 mcg/hr QL (0 patches / 5 days), ST - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 8

9 October, 08 fentanyl td patch 7hr 50 mcg/hr, ST; High Strength Requires fentanyl td patch 7hr 75 mcg/hr, ST; High Strength Requires fentanyl td patch 7hr 00 mcg/hr, ST; High Strength Requires hydrocodone-acetaminophen soln QL (700 ml / 5 days), mg/5ml ST; Subject to initial 7-day limit hydrocodone-acetaminophen soln 0-5 QL (700 ml / 5 days), mg/5ml ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab.5-5 QL (60 tabs / 5 days), mg ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab 5-5 mg QL (0 tabs / 5 days), ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab QL (80 tabs / 5 days), mg ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab 0-5 QL (80 tabs / 5 days), mg ST; Subject to initial 7-day limit HYDROMORPHON SUP MG QL (0 suppositories / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl inj mg/ml hydromorphone hcl inj mg/ml hydromorphone hcl inj mg/ml hydromorphone hcl liqd mg/ml QL (600 ml / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl preservative free (pf) inj 0 mg/ml hydromorphone hcl tab mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl tab mg QL (50 tabs / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 8 mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl tab er hr deter 8 mg QL (0 tabs / 5 days), ST - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 9

10 October, 08 hydromorphone hcl tab er hr deter mg QL (0 tabs / 5 days), ST hydromorphone hcl tab er hr deter 6 mg QL (0 tabs / 5 days), ST hydromorphone hcl tab er hr deter mg, ST; High Strength Requires HYSINGLA ER TAB 0 MG QL (0 tabs / 5 days), ST HYSINGLA ER TAB 0 MG QL (0 tabs / 5 days), ST HYSINGLA ER TAB 0 MG QL (0 tabs / 5 days), ST HYSINGLA ER TAB 60 MG QL (0 tabs / 5 days), ST HYSINGLA ER TAB 80 MG QL (0 tabs / 5 days), ST HYSINGLA ER TAB 00 MG, ST; High Strength Requires HYSINGLA ER TAB 0 MG, ST; High Strength Requires levorphanol tartrate tab mg QL (0 tabs / 5 days), ST; Subject to initial 7-day limit lortab tab 0-5mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit methadone con 0mg/ml QL (60 ml / 5 days), ST; (generic of Methadone Intensol, indicated for pain) methadone hcl conc 0 mg/ml QL (0 ml / 5 days); (indicated for opioid addiction) methadone hcl inj 0 mg/ml QL (0 ml / 5 days), ST methadone hcl soln 5 mg/5ml QL (50 ml / 5 days), ST methadone hcl soln 0 mg/5ml QL (00 ml / 5 days), ST methadone hcl tab 5 mg QL (90 tabs / 5 days), ST methadone hcl tab 0 mg QL (60 tabs / 5 days), ST methadone hcl tab for oral susp 0 mg QL (9 tabs / 5 days) methadose tab 0mg QL (9 tabs / 5 days) MORPHINE SUL INJ MG/ML MORPHINE SUL INJ MG/ML - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 0

11 October, 08 MORPHINE SUL INJ 5MG/ML MORPHINE SUL INJ 50/0ML MORPHINE SUL SUP 0MG QL (90 supp / 5 days), ST; Subject to initial 7-day limit morphine sulfate beads cap er hr 0 mg QL (0 caps / 5 days), ST morphine sulfate beads cap er hr 5 mg QL (0 caps / 5 days), ST morphine sulfate beads cap er hr 60 mg QL (0 caps / 5 days), ST morphine sulfate beads cap er hr 75 mg QL (0 caps / 5 days), ST morphine sulfate beads cap er hr 90 mg QL (0 caps / 5 days), ST morphine sulfate beads cap er hr 0 mg, ST; High Strength Requires morphine sulfate cap er hr 0 mg QL (60 caps / 5 days), ST morphine sulfate cap er hr 0 mg QL (60 caps / 5 days), ST morphine sulfate cap er hr 0 mg QL (60 caps / 5 days), ST morphine sulfate cap er hr 50 mg QL (0 caps / 5 days), ST morphine sulfate cap er hr 60 mg QL (0 caps / 5 days), ST morphine sulfate cap er hr 80 mg QL (0 caps / 5 days), ST morphine sulfate cap er hr 00 mg, ST; High Strength Requires morphine sulfate inj 8 mg/ml morphine sulfate inj 0 mg/ml morphine sulfate inj pf 0.5 mg/ml morphine sulfate inj pf mg/ml morphine sulfate iv soln mg/ml morphine sulfate iv soln pf mg/ml morphine sulfate iv soln pf 8 mg/ml morphine sulfate iv soln pf 0 mg/ml morphine sulfate iv soln pf 5 mg/ml morphine sulfate oral soln 0 mg/5ml QL (900 ml / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

12 October, 08 morphine sulfate oral soln 0 mg/5ml QL (675 ml / 5 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 00 mg/5ml (0 QL (5 ml / 5 days), mg/ml) ST; Subject to initial 7-day limit morphine sulfate suppos 5 mg QL (80 suppositories / 5 days), ST; Subject to initial 7-day limit morphine sulfate suppos 0 mg QL (80 suppositories / 5 days), ST; Subject to initial 7-day limit morphine sulfate suppos 0 mg QL (0 supp / 5 days), ST; Subject to initial 7-day limit morphine sulfate tab 5 mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit morphine sulfate tab 0 mg QL (90 tabs / 5 days), ST; Subject to initial 7-day limit morphine sulfate tab er 5 mg QL (90 tabs / 5 days), ST morphine sulfate tab er 0 mg QL (90 tabs / 5 days), ST morphine sulfate tab er 60 mg, ST; High Strength Requires morphine sulfate tab er 00 mg, ST; High Strength Requires morphine sulfate tab er 00 mg, ST; High Strength Requires nalbuphine hcl inj 0 mg/ml nalbuphine hcl inj 0 mg/ml NUCYNTA ER TAB 50MG QL (60 tabs / 5 days), ST NUCYNTA ER TAB 00MG QL (60 tabs / 5 days), ST NUCYNTA ER TAB 50MG, ST; High Strength Requires NUCYNTA ER TAB 00MG, ST; High Strength Requires NUCYNTA ER TAB 50MG, ST; High Strength Requires NUCYNTA TAB 50MG QL (0 tabs / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

13 October, 08 NUCYNTA TAB 75MG QL (90 tabs / 5 days), ST; Subject to initial 7-day limit NUCYNTA TAB 00MG QL (60 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl cap 5 mg QL (80 caps / 5 days), ST; Subject to initial 7-day limit oxycodone hcl conc 00 mg/5ml (0 mg/ml) QL (90 ml / 5 days), ST; Subject to initial 7-day limit oxycodone hcl soln 5 mg/5ml QL (900 ml / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 5 mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 0 mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 5 mg QL (0 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 0 mg QL (90 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 0 mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab er hr deter 0 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er hr deter 5 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er hr deter 0 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er hr deter 0 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er hr deter 0 mg, ST; High Strength Requires oxycodone hcl tab er hr deter 60 mg, ST; High Strength Requires oxycodone hcl tab er hr deter 80 mg, ST; High Strength Requires - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

14 October, 08 oxycodone w/ acetaminophen soln 5-5 QL (800 ml / 5 days), mg/5ml ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab.5-5 QL (60 tabs / 5 days), mg ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab 5-5 mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab QL (0 tabs / 5 days), mg ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab 0-5 QL (80 tabs / 5 days), mg ST; Subject to initial 7-day limit oxycodone-aspirin tab mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone-ibuprofen tab 5-00 mg QL (8 tabs / 5 days), ST; Subject to initial 7-day limit OXYCONTIN TAB 0MG CR QL (60 tabs / 5 days), ST OXYCONTIN TAB 5MG CR QL (60 tabs / 5 days), ST OXYCONTIN TAB 0MG CR QL (60 tabs / 5 days), ST OXYCONTIN TAB 0MG CR QL (60 tabs / 5 days), ST OXYCONTIN TAB 0MG CR, ST; High Strength Requires OXYCONTIN TAB 60MG CR, ST; High Strength Requires OXYCONTIN TAB 80MG CR, ST; High Strength Requires oxymorphone hcl tab 5 mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit oxymorphone hcl tab 0 mg QL (90 tabs / 5 days), ST; Subject to initial 7-day limit oxymorphone hcl tab er hr 5 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er hr 7.5 mg QL (60 tabs / 5 days), ST - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

15 October, 08 oxymorphone hcl tab er hr 0 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er hr 5 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er hr 0 mg, ST; High Strength Requires oxymorphone hcl tab er hr 0 mg, ST; High Strength Requires oxymorphone hcl tab er hr 0 mg, ST; High Strength Requires PRIMLEV TAB 5-00MG QL (60 tabs / 5 days), ST; Subject to initial 7-day limit PRIMLEV TAB QL (0 tabs / 5 days), ST; Subject to initial 7-day limit PRIMLEV TAB 0-00MG QL (80 tabs / 5 days), ST; Subject to initial 7-day limit tramadol hcl tab 50 mg QL (80 tabs / 5 days), ST; Subject to initial 7-day limit tramadol hcl tab er hr 00 mg QL (0 tabs / 5 days), ST tramadol hcl tab er hr 00 mg, ST; High Strength Requires tramadol hcl tab er hr 00 mg, ST; High Strength Requires XARTEMIS XR TAB QL (0 tabs / 5 days) xylon tab 0-00mg QL (50 tabs / 5 days), ST; Subject to initial 7-day limit OPIOID RTIAL AGONISTS BELBUCA MIS 75MCG QL (60 films / 5 days), ST BELBUCA MIS 50MCG QL (60 films / 5 days), ST BELBUCA MIS 00MCG QL (60 films / 5 days), ST BELBUCA MIS 50MCG QL (60 films / 5 days), ST BELBUCA MIS 600MCG, ST; High Strength Requires Prior Auth BELBUCA MIS 750MCG, ST; High Strength Requires Prior Auth - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 5

16 October, 08 BELBUCA MIS 900MCG, ST; High Strength Requires Prior Auth buprenorphine hcl inj 0. mg/ml (base equiv) buprenorphine hcl sl tab mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) QL (90 tabs / 5 days); Must obtain approval after the initial fill QL (90 tabs / 5 days); Must obtain approval after the initial fill SALICYLATES aspirin chw 8mg QL (00 tabs / 0 days); OTC; $0 copay-age and gender restrictions apply aspirin low tab 8mg ec QL (00 tabs / 0 days); OTC; $0 copay-age and gender restrictions apply diflunisal tab 500 mg ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% lidocaine hcl local inj 0.5% lidocaine hcl local inj % lidocaine hcl local inj % lidocaine hcl local preservative free (pf) inj 0.5% lidocaine hcl local preservative free (pf) inj % lidocaine hcl local preservative free (pf) inj.5% lidocaine hcl local preservative free (pf) inj % lidocaine hcl local preservative free (pf) inj % ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj gm/ml (50 mg/ml) amikacin sulfate inj 500 mg/ml (50 mg/ml) chloramphenicol sodium succinate for iv inj gm GENTAM/NACL INJ 0.9MG/ML GENTAM/NACL INJ.MG/ML gentamicin in saline inj 0.8 mg/ml - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 6

17 October, 08 gentamicin in saline inj mg/ml gentamicin in saline inj. mg/ml gentamicin in saline inj.6 mg/ml gentamicin in saline inj mg/ml gentamicin sulfate inj 0 mg/ml gentamicin sulfate inj 0 mg/ml gentamicin sulfate iv soln 0 mg/ml KETEK TAB 00MG KETEK TAB 00MG MONUROL K GRANULES neomycin sulfate tab 500 mg paromomycin sulfate cap 50 mg streptomycin sulfate for inj gm SULFADIAZINE TAB 500MG tinidazole tab 50 mg tinidazole tab 500 mg tobramycin nebu soln 00 mg/5ml QL (80 ml / 8 days), tobramycin sulfate for inj. gm tobramycin sulfate inj. gm/0ml (0 mg/ml) (base equiv) tobramycin sulfate inj gm/50ml (0 mg/ml) (base equiv) tobramycin sulfate inj 0 mg/ml (base equivalent) tobramycin sulfate inj 80 mg/ml (0 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 00MG ALINIA SUS 00/5ML ALINIA TAB 500MG atovaquone susp 750 mg/5ml AZACTAM/DEX INJ GM AZACTAM/DEX INJ GM aztreonam for inj gm aztreonam for inj gm CAYSTON INH 75MG 5 QL (8 vials / 8 days), clindamycin hcl cap 75 mg clindamycin hcl cap 50 mg clindamycin hcl cap 00 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 7

18 October, 08 clindamycin phosphate inj 00 mg/ml clindamycin phosphate inj 600 mg/ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate iv soln 00 mg/ml clindamycin phosphate iv soln 900 mg/6ml dapsone tab 5 mg dapsone tab 00 mg daptomycin for iv soln 500 mg DARAPRIM TAB 5MG doripenem for iv infusion 50 mg doripenem for iv infusion 500 mg EMVERM CHW 00MG imipenem-cilastatin intravenous for soln 50 mg imipenem-cilastatin intravenous for soln 500 mg INVANZ INJ GM ivermectin tab mg linezolid for susp 00 mg/5ml linezolid in sodium chloride iv soln 600 mg/00ml-0.9% linezolid iv soln 600 mg/00ml ( mg/ml) linezolid tab 600 mg meropenem iv for soln gm meropenem iv for soln 500 mg methenamine hippurate tab gm metronidazole cap 75 mg metronidazole in nacl 0.79% iv soln 500 mg/00ml metronidazole tab 50 mg metronidazole tab 500 mg NEBUPENT INH 00MG nitrofurantoin macrocrystalline cap 5 mg ; High Risk Medications require for members age 70 and older nitrofurantoin macrocrystalline cap 50 mg ; High Risk Medications require for members age 70 and older nitrofurantoin macrocrystalline cap 00 mg ; High Risk Medications require for members age 70 and older - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 8

19 October, 08 nitrofurantoin monohydrate ; High Risk macrocrystalline cap 00 mg Medications require for members age 70 and older nitrofurantoin susp 5 mg/5ml ; High Risk Medications require for members age 70 and older PENTAM 00 INJ 00MG polymyxin b sulfate for inj unit praziquantel tab 600 mg PRIMSOL SOL 50MG/5ML SIVEXTRO INJ 00MG SIVEXTRO TAB 00MG sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole-trimethoprim susp 00-0 mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg trimethoprim tab 00 mg vancomycin hcl cap 5 mg QL (80 caps / 0 days) vancomycin hcl cap 50 mg QL (80 caps / 0 days) vancomycin hcl for inj 0 gm vancomycin hcl for inj 500 mg vancomycin hcl for inj 750 mg vancomycin hcl for inj 000 mg vancomycin hcl for inj 5000 mg XIFAXAN TAB 00MG XIFAXAN TAB 550MG ANTIFUNGALS amphotericin b for inj 50 mg BIO-STATIN CAP BIO-STATIN CAP CRESEMBA CAP 86 MG fluconazole for susp 0 mg/ml fluconazole for susp 0 mg/ml fluconazole in dextrose inj 00 mg/00ml fluconazole in dextrose inj 00 mg/00ml fluconazole in nacl 0.9% inj 00 mg/00ml fluconazole in nacl 0.9% inj 00 mg/00ml fluconazole tab 50 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 9

20 October, 08 fluconazole tab 00 mg fluconazole tab 50 mg fluconazole tab 00 mg FLUCONAZOLE/ INJ NACL 00 griseofulvin microsize susp 5 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 5 mg griseofulvin ultramicrosize tab 50 mg itraconazole cap 00 mg LAMISIL GRA 5MG LAMISIL GRA 87.5MG NOXAFIL SUS 0MG/ML NOXAFIL TAB 00MG nystatin oral powder nystatin tab unit SPORANOX SOL 0MG/ML terbinafine hcl tab 50 mg voriconazole for susp 0 mg/ml voriconazole tab 50 mg voriconazole tab 00 mg ANTIMALARIALS atovaquone-proguanil hcl tab mg atovaquone-proguanil hcl tab mg chloroquine phosphate tab 50 mg chloroquine phosphate tab 500 mg COARTEM TAB 0-0MG mefloquine hcl tab 50 mg PRIMAQUINE TAB 6.MG quinine sulfate cap mg ANTIRETROVIRAL AGENTS abacavir sulfate soln 0 mg/ml (base equiv) QL (900 ml / 0 days) abacavir sulfate tab 00 mg (base equiv) QL (60 tabs / 0 days) APTIVUS CAP 50MG QL (0 caps / 0 days) APTIVUS SOL QL (85 ml / 8 days) atazanavir sulfate cap 50 mg (base equiv) QL (0 caps / 0 days) atazanavir sulfate cap 00 mg (base equiv) QL (60 caps / 0 days) atazanavir sulfate cap 00 mg (base equiv) QL (0 caps / 0 days) CRIXIVAN CAP 00MG QL (50 caps / 0 days) CRIXIVAN CAP 00MG QL (80 caps / 0 days) didanosine delayed release capsule 00 mg QL (0 caps / 0 days) didanosine delayed release capsule 50 mg QL (0 caps / 0 days) didanosine delayed release capsule 00 mg QL (0 caps / 0 days) EDURANT TAB 5MG QL (60 tabs / 0 days) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 0

21 October, 08 efavirenz cap 50 mg QL (90 caps / 0 days) efavirenz cap 00 mg QL (90 caps / 0 days) efavirenz tab 600 mg QL (0 tabs / 0 days) EMTRIVA CAP 00MG QL (0 caps / 0 days) EMTRIVA SOL 0MG/ML QL (680 ml / 8 days) fosamprenavir calcium tab 700 mg (base QL (0 tabs / 0 days) equiv) FUZEON INJ 90MG 5 QL (60 vials / 0 days) INTELENCE TAB 5MG QL (0 tabs / 0 days) INTELENCE TAB 00MG QL (0 tabs / 0 days) INTELENCE TAB 00MG QL (60 tabs / 0 days) INVIRASE CAP 00MG QL (00 caps / 0 days) INVIRASE TAB 500MG QL (0 tabs / 0 days) ISENTRESS CHW 5MG QL (80 tabs / 0 days) ISENTRESS CHW 00MG QL (80 tabs / 0 days) ISENTRESS HD TAB 600MG QL (60 tabs / 0 days) ISENTRESS POW 00MG QL (60 packets / 0 days) ISENTRESS TAB 00MG QL (0 tabs / 0 days) lamivudine oral soln 0 mg/ml QL (900 ml / 0 days) lamivudine tab 50 mg QL (60 tabs / 0 days) lamivudine tab 00 mg QL (0 tabs / 0 days) LEXIVA SUS 50MG/ML QL (575 ml / 8 days) nevirapine susp 50 mg/5ml QL (00 ml / 0 days) nevirapine tab 00 mg QL (60 tabs / 0 days) nevirapine tab er hr 00 mg QL (90 tabs / 0 days) nevirapine tab er hr 00 mg QL (0 tabs / 0 days) NORVIR CAP 00MG QL (60 caps / 0 days) NORVIR POW 00MG QL (60 packets / 0 days) NORVIR SOL 80MG/ML QL (80 ml / 0 days) PREZISTA SUS 00MG/ML QL (00 ml / 0 days) PREZISTA TAB 75MG QL (00 tabs / 0 days) PREZISTA TAB 50MG QL (80 tabs / 0 days) PREZISTA TAB 600MG QL (60 tabs / 0 days) PREZISTA TAB 800MG QL (0 tabs / 0 days) RESCRIPTOR TAB 00 MG QL (900 tabs / 0 days) RESCRIPTOR TAB 00MG QL (50 tabs / 0 days) RETROVIR INJ 0MG/ML REYATAZ POW 50MG QL (80 packets / 0 days) ritonavir tab 00 mg QL (60 tabs / 0 days) SELZENTRY SOL 0MG/ML QL (80 ml / 0 days) SELZENTRY TAB 5MG QL (0 tabs / 0 days) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

22 October, 08 SELZENTRY TAB 75MG QL (60 tabs / 0 days) SELZENTRY TAB 50MG QL (60 tabs / 0 days) SELZENTRY TAB 00MG QL (0 tabs / 0 days) stavudine cap 5 mg QL (60 caps / 0 days) stavudine cap 0 mg QL (60 caps / 0 days) stavudine cap 0 mg QL (60 caps / 0 days) stavudine cap 0 mg QL (60 caps / 0 days) tenofovir disoproxil fumarate tab 00 mg QL (0 tabs / 0 days) TIVICAY TAB 0MG QL (60 tabs / 0 days) TIVICAY TAB 5MG QL (60 tabs / 0 days) TIVICAY TAB 50MG QL (60 tabs / 0 days) TROGARZO INJ 50MG/ML 5 TYBOST TAB 50MG QL (0 tabs / 0 days) VIDEX EC CAP 5MG QL (0 caps / 0 days) VIDEX SOL GM QL (00 ml / 0 days) VIDEX SOL GM QL (00 ml / 0 days) VIRACEPT TAB 50MG QL (00 tabs / 0 days) VIRACEPT TAB 65MG QL (0 tabs / 0 days) VIRAMUNE SUS 50MG/5ML QL (00 ml / 0 days) VIREAD POW 0MG/GM QL (0 gm / 0 days) VIREAD TAB 50MG QL (0 tabs / 0 days) VIREAD TAB 00MG QL (0 tabs / 0 days) VIREAD TAB 50MG QL (0 tabs / 0 days) ZERIT SOL MG/ML QL (00 ml / 0 days) zidovudine cap 00 mg QL (80 caps / 0 days) zidovudine syrup 0 mg/ml QL (800 ml / 0 days) zidovudine tab 00 mg QL (60 tabs / 0 days) ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab mg QL (0 tabs / 0 days) abacavir sulfate-lamivudine-zidovudine tab QL (60 tabs / 0 days) mg ATRIPLA TAB QL (0 tabs / 0 days) BIKTARVY TAB QL (0 tabs / 0 days) COMPLERA TAB QL (0 tabs / 0 days) DESCOVY TAB 00/5 QL (0 tabs / 0 days) EVOTAZ TAB QL (0 tabs / 0 days) GENVOYA TAB QL (0 tabs / 0 days) KALETRA TAB 00-5MG QL (0 tabs / 0 days) KALETRA TAB 00-50MG QL (0 tabs / 0 days) lamivudine-zidovudine tab mg QL (60 tabs / 0 days) lopinavir-ritonavir soln mg/5ml (80-0 mg/ml) QL (90 ml / 0 days) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

23 October, 08 ODEFSEY TAB QL (0 tabs / 0 days) PREZCOBIX TAB QL (0 tabs / 0 days) STRIBILD TAB QL (0 tabs / 0 days) TRIUMEQ TAB QL (0 tabs / 0 days) TRUVADA TAB QL (0 tabs / 0 days) TRUVADA TAB -00 QL (0 tabs / 0 days) TRUVADA TAB QL (0 tabs / 0 days) TRUVADA TAB QL (0 tabs / 0 days) ANTITUBERCULAR AGENTS cycloserine cap 50 mg ethambutol hcl tab 00 mg ethambutol hcl tab 00 mg isoniazid inj 00 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 00 mg isoniazid tab 00 mg SER GRA GM PRIFTIN TAB 50MG pyrazinamide tab 500 mg rifabutin cap 50 mg RIFAMATE CAP rifampin cap 50 mg rifampin cap 00 mg rifampin for inj 600 mg RIFATER TAB SIRTURO TAB 00MG TRECATOR TAB 50MG ANTIVIRALS acyclovir cap 00 mg acyclovir sodium for inj 500 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 00 mg/5ml acyclovir tab 00 mg acyclovir tab 800 mg adefovir dipivoxil tab 0 mg BARACLUDE SOL.05MG/ML cidofovir iv inj 75 mg/ml entecavir tab 0.5 mg entecavir tab mg EPCLUSA TAB QL (8 tabs / 8 days), EPIVIR HBV SOL 5MG/ML famciclovir tab 5 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

24 October, 08 famciclovir tab 50 mg famciclovir tab 500 mg HARVONI TAB 90-00MG 5 QL (8 tabs / 8 days), lamivudine tab 00 mg (hbv) oseltamivir phosphate cap 0 mg (base QL (0 caps / 90 days) equiv) oseltamivir phosphate cap 5 mg (base QL (0 caps / 90 days) equiv) oseltamivir phosphate cap 75 mg (base QL (0 caps / 90 days) equiv) oseltamivir phosphate for susp 6 mg/ml QL (00 ml / 90 days) (base equiv) PEGASYS INJ 5 QL ( injections / 8 days), PEGASYS INJ 80MCG/M 5 QL ( injections / 8 days), PEGASYS INJ PROCLICK 5 QL ( injections / 8 days), REBETOL SOL 0MG/ML 5 RELENZA MIS DISKHALE QL ( inhalers / 90 days) ribasphere cap 00mg ribasphere tab 00mg ribasphere tab 00mg ribasphere tab 600mg ribavirin cap 00 mg ribavirin for inhal soln 6 gm ribavirin tab 00 mg rimantadine hydrochloride tab 00 mg SOVALDI TAB 00MG 6 QL (8 tabs / 8 days),, ST TECHNIVIE TAB 6 QL (56 tabs / 8 days),, ST valacyclovir hcl tab gm valacyclovir hcl tab 500 mg valganciclovir hcl for soln 50 mg/ml (base equiv) valganciclovir hcl tab 50 mg (base equivalent) VOSEVI TAB 5 QL (8 tabs / 8 days), ZETIER TAB 50-00MG 6 QL (8 tabs / 8 days),, ST CEPHALOSPORINS cefaclor cap 50 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

25 October, 08 cefaclor cap 500 mg CEFACLOR ER TAB 500MG cefaclor for susp 5 mg/5ml cefaclor for susp 50 mg/5ml cefaclor for susp 75 mg/5ml cefadroxil cap 500 mg cefadroxil for susp 50 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab gm cefazolin sodium for inj gm cefazolin sodium for inj 0 gm cefazolin sodium for inj 0 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln gm cefdinir cap 00 mg cefdinir for susp 5 mg/5ml cefdinir for susp 50 mg/5ml cefditoren pivoxil tab 00 mg (base equivalent) cefditoren pivoxil tab 00 mg (base equivalent) cefepime hcl for inj gm cefepime hcl for inj gm cefixime for susp 00 mg/5ml cefixime for susp 00 mg/5ml cefotaxime sodium for inj gm cefotaxime sodium for inj gm cefotaxime sodium for inj 0 gm cefotaxime sodium for inj 500 mg cefotetan disodium for inj gm cefotetan disodium for inj gm cefotetan disodium for inj 0 gm cefoxitin sodium for inj 0 gm cefoxitin sodium for iv soln gm cefoxitin sodium for iv soln gm cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 00 mg/5ml cefpodoxime proxetil tab 00 mg cefpodoxime proxetil tab 00 mg cefprozil for susp 5 mg/5ml cefprozil for susp 50 mg/5ml cefprozil tab 50 mg cefprozil tab 500 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 5

26 October, 08 ceftazidime for inj gm ceftibuten cap 00 mg ceftibuten for susp 80 mg/5ml CEFTIN SUS 5/5ML CEFTIN SUS 50/5ML ceftriaxone sodium for inj gm ceftriaxone sodium for inj gm ceftriaxone sodium for inj 0 gm ceftriaxone sodium for inj 50 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln gm ceftriaxone sodium for iv soln gm cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg CEFUROXIME INJ 75GM CEFUROXIME INJ 5GM cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln.5 gm cephalexin cap 50 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin for susp 5 mg/5ml cephalexin for susp 50 mg/5ml cephalexin tab 50 mg cephalexin tab 500 mg SUPRAX CAP 00MG SUPRAX CHW 00MG SUPRAX CHW 00MG SUPRAX SUS 500/5ML tazicef inj gm tazicef inj gm tazicef inj 6gm ZINACEF INJ 750MG ZINACEF/H0 INJ.5GM PB ERYTHROMYCINS/MACROLIDES azithromycin for susp 00 mg/5ml azithromycin for susp 00 mg/5ml azithromycin iv for soln 500 mg azithromycin powd pack for susp gm azithromycin tab 50 mg azithromycin tab 500 mg azithromycin tab 600 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 6

27 October, 08 clarithromycin for susp 5 mg/5ml clarithromycin for susp 50 mg/5ml clarithromycin tab 50 mg clarithromycin tab 500 mg clarithromycin tab er hr 500 mg DIFICID TAB 00MG e.e.s. 00 tab 00mg ery-tab tab 50mg ec ery-tab tab mg ec ery-tab tab 500mg ec ERYPED SUS 00/5ML ERYTHROCIN INJ 500MG erythrocin tab 50mg erythromycin ethylsuccinate for susp 00 mg/5ml erythromycin ethylsuccinate tab 00 mg erythromycin tab 50 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 50 mg PCE TAB MG EC PCE TAB 500MG EC ZMAX SUS GM FLUOROQUINOLONES ciprofloxacin 00 mg/00ml in d5w ciprofloxacin 00 mg/00ml in d5w ciprofloxacin for oral susp 50 mg/5ml (5%) (5 gm/00ml) ciprofloxacin for oral susp 500 mg/5ml (0%) (0 gm/00ml) ciprofloxacin hcl tab 00 mg (base equiv) ciprofloxacin hcl tab 50 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin iv soln 00 mg/0ml (%) ciprofloxacin iv soln 00 mg/0ml (%) ciprofloxacin-ciprofloxacin hcl tab er hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er hr 000 mg(base eq) FACTIVE TAB 0MG levofloxacin in d5w iv soln 50 mg/50ml levofloxacin in d5w iv soln 500 mg/00ml levofloxacin in d5w iv soln 750 mg/50ml - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 7

28 October, 08 levofloxacin iv soln 5 mg/ml levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg levofloxacin tab 500 mg levofloxacin tab 750 mg moxifloxacin hcl 00 mg/50ml in sodium chloride 0.8% inj moxifloxacin hcl tab 00 mg (base equiv) ofloxacin tab 00 mg ofloxacin tab 00 mg PENICILLINS amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab 50-5 mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab er hr mg amoxicillin (trihydrate) cap 50 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 5 mg amoxicillin (trihydrate) chew tab 50 mg amoxicillin (trihydrate) for susp 5 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) for susp 50 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin & sulbactam sodium for inj.5 (-0.5) gm ampicillin & sulbactam sodium for inj (-) gm ampicillin & sulbactam sodium for inj 5 (0-5) gm - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 8

29 October, 08 ampicillin & sulbactam sodium for iv soln 5 (0-5) gm ampicillin cap 50 mg ampicillin cap 500 mg ampicillin for susp 5 mg/5ml ampicillin for susp 50 mg/5ml ampicillin sodium for inj gm ampicillin sodium for inj gm ampicillin sodium for inj 0 gm ampicillin sodium for inj 5 mg ampicillin sodium for inj 50 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln gm ampicillin sodium for iv soln gm ampicillin sodium for iv soln 0 gm AUGMENTIN SUS 5/5ML dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg nafcillin sodium for inj gm nafcillin sodium for inj gm nafcillin sodium for iv soln gm nafcillin sodium for iv soln gm nafcillin sodium for iv soln 0 gm oxacillin sodium for inj gm (base equivalent) oxacillin sodium for inj gm (base equivalent) oxacillin sodium for inj 0 gm (base equivalent) penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 5 mg/5ml penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg pfizerpen inj 0mu piperacillin sod-tazobactam na for inj.75 gm (-0.75 gm) piperacillin sod-tazobactam sod for inj.5 gm (-0.5 gm) piperacillin sod-tazobactam sod for inj.5 gm (-0.5 gm) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 9

30 October, 08 piperacillin sod-tazobactam sod for inj 0.5 gm (6-.5 gm) TETRACYCLINES avidoxy tab 00mg demeclocycline hcl tab 50 mg demeclocycline hcl tab 00 mg doxy 00 inj 00mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 00 mg doxycycline hyclate for inj 00 mg doxycycline hyclate tab 0 mg doxycycline hyclate tab 00 mg doxycycline hyclate tab delayed release 75 mg doxycycline hyclate tab delayed release 00 mg doxycycline hyclate tab delayed release 50 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg doxycycline monohydrate cap 00 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate for susp 5 mg/5ml doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 50 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 00 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg minocycline hcl tab 00 mg morgidox cap x00mg tetracycline hcl cap 50 mg tetracycline hcl cap 500 mg VIBRAMYCIN SYP 50MG/5ML ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 00MG busulfan inj 6 mg/ml cyclophosphamide cap 5 mg cyclophosphamide cap 50 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 0

31 October, 08 cyclophosphamide for inj gm cyclophosphamide for inj gm cyclophosphamide for inj 500 mg dacarbazine for inj 00 mg dacarbazine for inj 00 mg EMCYT CAP 0MG GLEOSTINE CAP 5MG GLEOSTINE CAP 0MG GLEOSTINE CAP 0MG GLEOSTINE CAP 00MG GLIADEL WAF 7.7MG HEXALEN CAP 50MG ifosfamide for inj gm ifosfamide iv inj gm/0ml (50 mg/ml) ifosfamide iv inj gm/60ml (50 mg/ml) LEUKERAN TAB MG melphalan hcl for inj 50 mg (base equiv) melphalan tab mg TEMODAR INJ 00MG 5 temozolomide cap 5 mg 5 temozolomide cap 0 mg 5 temozolomide cap 00 mg 5 temozolomide cap 0 mg 5 temozolomide cap 80 mg 5 temozolomide cap 50 mg 5 ANTHRACYCLINES daunorubicin hcl inj 5 mg/ml (base equiv) DAUNOXOME INJ MG/ML doxorubicin hcl for inj 0 mg doxorubicin hcl for inj 50 mg doxorubicin hcl inj mg/ml doxorubicin hcl liposomal inj (for iv infusion) mg/ml epirubicin hcl iv soln 50 mg/5ml ( mg/ml) epirubicin hcl iv soln 00 mg/00ml ( mg/ml) idarubicin hcl iv inj 5 mg/5ml ( mg/ml) idarubicin hcl iv inj 0 mg/0ml ( mg/ml) idarubicin hcl iv inj 0 mg/0ml ( mg/ml) ANTIBIOTICS bleomycin sulfate for inj 5 unit bleomycin sulfate for inj 0 unit mitomycin for iv soln 5 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

32 October, 08 mitomycin for iv soln 0 mg mitomycin for iv soln 0 mg ANTIMETABOLITES adrucil inj 500/0ml ALIMTA INJ 00MG ALIMTA INJ 500MG ARRANON INJ 5MG/ML azacitidine for inj 00 mg 5 capecitabine tab 50 mg 5 QL (0 tabs / 0 days), capecitabine tab 500 mg 5 QL (00 tabs / 0 days), cladribine iv soln 0 mg/0ml ( mg/ml) clofarabine iv soln mg/ml cytarabine inj 0 mg/ml cytarabine inj pf 0 mg/ml cytarabine inj pf 00 mg/ml decitabine for inj 50 mg 5 DEPOCYT INJ 50MG/5ML floxuridine for inj 0.5 gm fludarabine phosphate for inj 50 mg fludarabine phosphate inj 5 mg/ml fluorouracil iv soln gm/0ml (50 mg/ml) fluorouracil iv soln.5 gm/50ml (50 mg/ml) fluorouracil iv soln 5 gm/00ml (50 mg/ml) fluorouracil iv soln 500 mg/0ml (50 mg/ml) gemcitabine hcl for inj gm gemcitabine hcl for inj gm gemcitabine hcl for inj 00 mg gemcitabine hcl inj gm/6.ml (8 mg/ml) (base equiv) gemcitabine hcl inj gm/5.6ml (8 mg/ml) (base equiv) gemcitabine hcl inj 00 mg/5.6ml (8 mg/ml) (base equiv) mercaptopurine tab 50 mg methotrexate sodium for inj gm methotrexate sodium inj 50 mg/ml (5 mg/ml) methotrexate sodium inj 50 mg/0ml (5 mg/ml) methotrexate sodium inj pf 50 mg/ml (5 mg/ml) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier - Preventive, Tier - Generics, Tier - Preferred Brands, Tier - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)