2019 FORMULARY GUIDE (Employee groups)

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1 2019 FORMULARY GUIDE (Employee groups)

2 Pharmacy Benefits Management Table of Contents Overview... iii Important Phone Numbers... iii Understanding Coverage and Cost Sharing... iii Formulary... iii Understanding Our Symbols... iv Prior Authorization... iv Step Therapy... iv Quantity Limits... iv About Generic Drugs... iv How to Fill Your Prescription Medications... v Medication Supplies Not Covered by Premier Health Plans... vi Formulary Listing... 1 ii

3 Pharmacy Benefits Management Overview This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. Important Phone Numbers Pharmacy Services Understanding Coverage and Cost Sharing Formulary The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under your plan. The inclusion of specific medications on the Premier Health Plan formulary is based on the medication's effectiveness, safety, and value. The formulary offers a wide selection of generic and brand name prescription drugs suggested by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who researches and evaluates medications. The formulary is periodically reviewed and updated throughout the year in order to ensure that our benefits package consistently and adequately meets your needs. When you need a prescription medication, you and your doctor can choose from five different levels of the formulary. These are Preferred Generics Tier 1, Generics Tier 2, Preferred Brands Tier 3, Non Preferred Brands Tier 4 and Specialty Tier 5. Each level has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. Preferred Generic Medications Tier 1 have the lowest copayment/co insurance. Generic drugs offer the same level of safety and quality as their brand name equivalents. They have the same amount of active ingredients as brand name medications. You are required to use a generic version of the drug if one is available. Generic Medications Tier 2 have low copayment/co insurance. Generic drugs offer the same level of safety and quality as their brand name equivalents. They have the same amount of active ingredients as brand name medications. You are required to use a generic version of the drug if one is available. Preferred Brand medications Tier 3 have the middle level copayment/co insurance. These drugs are brand medications and preferred because of their value and effectiveness. Non Preferred Brand and Generic medications Tier 4 have a higher copayment/co insurance level. These medications are brand and generic drugs that are more expensive and have similar effectiveness as tier 3 medications. Specialty and High cost medications Tier 5 have the highest copayment/co insurance level. These also include Specialty medications which usually treat complex and rare conditions. These drugs can be iii

4 Pharmacy Benefits Management high cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Non Formulary medications may be covered if the formulary medications do not work for you. If you require a Non Formulary medication, your doctor may request coverage for the Tier 4 or Tier 5 copayment by making a request for an exception. Understanding Our Symbols Prior Authorization You will see the symbol PA next to certain drugs on our formulary tables. This is called prior authorization. Prior authorization helps ensure that you re using the best drugs in the safest way. If you are currently taking or recently prescribed one of these drugs, please discuss possible alternatives or have your doctor request authorization by calling Drugs that require prior authorization are often: Newer drugs for which the Health Plan wants to track usage. Non formulary drugs which require the use of formulary drugs prior to coverage. These drugs are not used as a standard first option in treating a medical condition. Drugs with potential side effects that the Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications. Step Therapy You will see the symbol ST (Step Therapy) next to certain drugs on the formulary tables in this booklet. Step therapy ensures you are taking the most effective medication at the best cost. This means trying the least expensive medications usually generic medications or drugs that are considered as the standard first line treatment. How step therapy works Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or first line treatment drugs. The drug recommended will be approved by the Food and Drug Administration (FDA) as providing the same health benefit at a much lower cost. Step 2: If the generic drug in step 1 does not work for you, then you will have coverage for a brand name drug. For more information on step therapy call Quantity Limits The symbol QL next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are getting the most cost effective dose for your medication, a quantity limit or dose duration may be placed on certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. iv

5 Pharmacy Benefits Management For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Prescriptions for specialty medications are limited to a 30 day supply. For more information on quantity limits or dose durations call About Generic Drugs Generic drugs have the same active ingredients as their brand name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. Generic drugs have the same active ingredients as brand name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand name drug. How to Fill Your Prescription Medications Short term medications These are drugs you need immediately. This includes medications used to treat short term infections, or to relieve pain temporarily. You can fill these prescriptions at network pharmacies accepting CVS prescriptions. Locate the nearest retail network pharmacy by calling To fill your prescription, present your member ID card and written prescription and pay your copayment/coinsurance as described above. Long term medications These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure, diabetes, etc. These medications can be mailed to your home for up to a 90 day supply. Specialty medications Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can fill these prescriptions: Through CVS Specialty Pharmacy v

6 Pharmacy Benefits Management o CVS Specialty Pharmacy is a pharmacy that provides specialty medications. Please call to learn more about filling your specialty medication Through any Premier Health Pharmacy. o Please call member services for help finding the closest Premier Health Pharmacy at Filling Your Prescription When Traveling When you travel outside of your local area, thousands of pharmacies across the country will honor your Premier Health Plans member ID card. To locate a participating pharmacy, contact your member services team at the phone number listed on the back of your member ID card or on 1 page of this booklet. To fill a prescription at a participating out of area pharmacy, present your Premier Health Plan member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens: Submit a Direct Reimbursement Claim form to Premier Health Plan at: CVS Caremark - RxClaim P.O Box Phoenix, AZ Or you may call your member services team for assistance If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment. If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail order service so that you receive a 90 day supply before you leave home. Medication Supplies Not Covered by Premier Health Plan No authorizations will be provided for medications that are reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged. Medications received at no charge to the member (workers compensation, medications purchased with a manufacturer s coupon, etc.) will not be covered. Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription. vi

7 Pharmacy Benefits Management List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. vii

8 Formulary Listing Effective 01/01/2019 Drug Name ANALGESICS COX-II INHIBITORS celecoxib cap 50 2 ST celecoxib cap ST; QL celecoxib cap ST; QL celecoxib cap ST; QL GOUT allopurinol tab allopurinol tab COLCRYS TAB 0.6MG 3 ULORIC TAB 40MG 3 ST; QL ULORIC TAB 80MG 3 ST MISCELLANEOUS PRIALT INJ 25MCG/ML 5 PRIALT INJ 100MCG 5 PRIALT INJ 500MCG 5 NON-OPIOID ANALGESICS butalbital-acetaminophen tab butalbital-acetaminophen-caffeine cap butalbital-acetaminophen-caffeine tab butalbital-aspirin-caffeine cap NSAIDS choline & magnesium salicylates liq /5ml diclofenac potassium tab 50 2 diclofenac sodium tab delayed release 25 2 diclofenac sodium tab delayed release 50 2 diclofenac sodium tab delayed release 75 2 diclofenac sodium tab er 24hr diflunisal tab etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 1

9 fenoprofen calcium tab flurbiprofen tab 50 2 flurbiprofen tab ibuprofen susp 100 /5ml 1 ibuprofen tab ibuprofen tab ibuprofen tab indomethacin cap 25 2 indomethacin cap 50 2 indomethacin cap er 75 2 ketoprofen cap er 24hr ketorolac tromethamine tab 10 2 QL meclofenamate sodium cap 50 2 meclofenamate sodium cap mefenamic acid cap meloxicam tab meloxicam tab 15 1 nabumetone tab nabumetone tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 2 PA naproxen tab naproxen tab naproxen tab naproxen tab ec naproxen tab ec oxaprozin tab piroxicam cap 10 2 piroxicam cap 20 2 salsalate tab salsalate tab sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 2 release diclofenac w/ misoprostol tab delayed 2 release NSAIDS, TOPICAL diclofenac sodium gel 1% 2 QL VOLTAREN GEL 1% 4 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 2

10 OPIOID ANALGESICS ABSTRAL SUB 100MCG 4 PA; QL ABSTRAL SUB 200MCG 4 PA; QL ABSTRAL SUB 300MCG 4 PA; QL ABSTRAL SUB 400MCG 4 PA; QL ABSTRAL SUB 600MCG 4 PA; QL ABSTRAL SUB 800MCG 4 PA; QL acetaminophen w/ codeine soln /5ml 2 PA acetaminophen w/ codeine tab PA acetaminophen w/ codeine tab PA acetaminophen w/ codeine tab PA butalbital-acetaminophen-caff w/ cod cap 2 PA butalbital-aspirin-caff w/ codeine cap PA butorphanol tartrate nasal soln 10 /ml 2 PA; QL BUTRANS DIS 5MCG/HR 4 PA, ST BUTRANS DIS 7.5/HR 4 PA, ST BUTRANS DIS 10MCG/HR 4 PA, ST BUTRANS DIS 15MCG/HR 4 PA, ST BUTRANS DIS 20MCG/HR 4 PA, ST codeine sulfate tab 15 2 PA codeine sulfate tab 30 2 PA codeine sulfate tab 60 2 PA endocet tab PA fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl td patch 72hr 12 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 25 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 50 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 75 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 100 mcg/hr 2 PA, ST; QL FENTORA TAB 100MCG 4 PA; QL FENTORA TAB 200MCG 4 PA; QL FENTORA TAB 400MCG 4 PA; QL FENTORA TAB 600MCG 4 PA; QL FENTORA TAB 800MCG 4 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 3

11 hydrocodone-acetaminophen soln PA /15ml hydrocodone-acetaminophen soln PA /15ml hydrocodone-acetaminophen tab PA hydrocodone-acetaminophen tab PA hydrocodone-acetaminophen tab PA hydrocodone-acetaminophen tab PA hydrocodone-ibuprofen tab PA; QL hydrocodone-ibuprofen tab PA; QL hydrocodone-ibuprofen tab PA; QL HYDROMORPHON SUP 3MG 2 PA hydromorphone hcl tab 2 2 PA hydromorphone hcl tab 4 2 PA hydromorphone hcl tab 8 2 PA LAZANDA SPR 100MCG 4 PA; QL LAZANDA SPR 300MCG 4 PA; QL LAZANDA SPR 400MCG 4 PA; QL meperidine hcl oral soln 50 /5ml 2 PA meperidine hcl tab 50 2 PA meperidine hcl tab PA methadone hcl soln 5 /5ml 2 PA, ST methadone hcl soln 10 /5ml 2 PA, ST methadone hcl tab 5 2 PA, ST methadone hcl tab 10 2 PA, ST methadone hcl tab for oral susp 40 2 PA, ST MORPHINE SUL SUP 30MG 2 morphine sulfate oral soln 10 /5ml 2 PA morphine sulfate oral soln 20 /5ml 2 PA morphine sulfate oral soln 100 /5ml (20 2 PA /ml) morphine sulfate suppos 5 2 morphine sulfate suppos 10 2 morphine sulfate suppos 20 2 morphine sulfate tab 15 2 PA; QL morphine sulfate tab 30 2 PA; QL morphine sulfate tab er 15 2 PA, ST; QL morphine sulfate tab er 30 2 PA, ST; QL morphine sulfate tab er 60 2 PA, ST; QL morphine sulfate tab er PA, ST; QL morphine sulfate tab er PA, ST; QL oxycodone hcl cap 5 2 PA oxycodone hcl conc 100 /5ml (20 /ml) 2 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 4

12 oxycodone hcl soln 5 /5ml 2 PA oxycodone hcl tab 5 2 PA oxycodone hcl tab 10 2 PA oxycodone hcl tab 15 2 PA oxycodone hcl tab 20 2 PA oxycodone hcl tab 30 2 PA oxycodone hcl tab er 12hr deter 10 4 PA, ST; QL oxycodone hcl tab er 12hr deter 15 4 PA, ST; QL oxycodone hcl tab er 12hr deter 20 4 PA, ST; QL oxycodone hcl tab er 12hr deter 30 4 PA, ST; QL oxycodone hcl tab er 12hr deter 40 4 PA, ST; QL oxycodone hcl tab er 12hr deter 60 4 PA, ST; QL oxycodone hcl tab er 12hr deter 80 4 PA, ST; QL oxycodone w/ acetaminophen tab PA oxycodone w/ acetaminophen tab PA oxycodone w/ acetaminophen tab PA oxycodone w/ acetaminophen tab PA oxycodone-aspirin tab PA oxycodone-ibuprofen tab PA; QL OXYCONTIN TAB 10MG CR 5 PA, ST; QL OXYCONTIN TAB 15MG CR 5 PA, ST; QL OXYCONTIN TAB 20MG CR 5 PA, ST; QL OXYCONTIN TAB 30MG CR 5 PA, ST; QL OXYCONTIN TAB 40MG CR 5 PA, ST; QL OXYCONTIN TAB 60MG CR 5 PA, ST; QL OXYCONTIN TAB 80MG CR 5 PA, ST; QL oxymorphone hcl tab 5 4 PA oxymorphone hcl tab 10 4 PA oxymorphone hcl tab er 12hr 5 4 PA, ST; QL oxymorphone hcl tab er 12hr PA, ST; QL oxymorphone hcl tab er 12hr 10 4 PA, ST; QL oxymorphone hcl tab er 12hr 15 4 PA, ST; QL oxymorphone hcl tab er 12hr 20 4 PA, ST; QL oxymorphone hcl tab er 12hr 30 4 PA, ST; QL oxymorphone hcl tab er 12hr 40 4 PA, ST; QL pentazocine w/ naloxone tab PA SUBSYS SPR 100MCG 5 PA; QL SUBSYS SPR 200MCG 5 PA; QL SUBSYS SPR 400MCG 5 PA; QL SUBSYS SPR 600MCG 5 PA; QL SUBSYS SPR 800MCG 5 PA; QL SUBSYS SPR 1200MCG 5 PA; QL SUBSYS SPR 1600MCG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 5

13 tramadol hcl tab 50 2 PA; QL tramadol hcl tab er 24hr PA, ST; QL tramadol hcl tab er 24hr PA, ST; QL tramadol hcl tab er 24hr PA, ST; QL tramadol-acetaminophen tab PA VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 5 PA; QL ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab paromomycin sulfate cap ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap cefadroxil for susp 250 /5ml 2 cefadroxil for susp 500 /5ml 2 cefadroxil tab 1 gm 2 cephalexin cap cephalexin cap cephalexin cap cephalexin for susp 125 /5ml 2 cephalexin for susp 250 /5ml 2 cephalexin tab cephalexin tab ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap cefaclor cap CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 /5ml 2 cefaclor for susp 250 /5ml 2 cefaclor for susp 375 /5ml 2 cefprozil for susp 125 /5ml 2 cefprozil for susp 250 /5ml 2 cefprozil tab cefprozil tab cefuroxime axetil tab ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir cap cefdinir for susp 125 /5ml 2 cefdinir for susp 250 /5ml 2 cefixime for susp 100 /5ml 2 cefixime for susp 200 /5ml 2 cefpodoxime proxetil for susp 50 /5ml 2 cefpodoxime proxetil for susp 100 /5ml 2 cefpodoxime proxetil tab cefpodoxime proxetil tab SUPRAX CAP 400MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 6

14 SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 SUPRAX SUS 500/5ML 4 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 2 azithromycin for susp 200 /5ml 2 azithromycin tab azithromycin tab azithromycin tab clarithromycin for susp 125 /5ml 2 clarithromycin for susp 250 /5ml 2 clarithromycin tab clarithromycin tab clarithromycin tab er 24hr DIFICID TAB 200MG 5 ST; QL E.E.S. GRAN SUS 200/5ML 4 ERYPED SUS 400/5ML 5 erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin stearate tab erythromycin tab erythromycin tab erythromycin tab delayed release erythromycin tab delayed release erythromycin tab delayed release erythromycin w/ delayed release particles 2 cap 250 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX TAB 400MG 4 CIPRO (5%) SUS 250MG/5 4 CIPRO (10%) SUS 500MG/5 4 ciprofloxacin for oral susp 500 /5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 (base equiv) 2 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 500 (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 1000 (base eq) levofloxacin oral soln 25 /ml 2 moxifloxacin hcl tab 400 (base equiv) 2 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 7 2

15 amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin cap dicloxacillin sodium cap dicloxacillin sodium cap penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab penicillin v potassium tab ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 2 sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab demeclocycline hcl tab doxycycline hyclate cap 50 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 8

16 doxycycline hyclate cap doxycycline hyclate tab 20 2 doxycycline hyclate tab doxycycline hyclate tab delayed release 50 2 ST doxycycline hyclate tab delayed release 75 2 ST doxycycline hyclate tab delayed release 2 ST 100 doxycycline hyclate tab delayed release 2 ST 150 doxycycline hyclate tab delayed release 2 ST 200 doxycycline monohydrate cap 50 2 doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 2 /5ml doxycycline monohydrate tab 50 2 doxycycline monohydrate tab 75 2 doxycycline monohydrate tab MINOCIN CAP 50MG 4 minocycline hcl cap 50 2 minocycline hcl cap 75 2 minocycline hcl cap minocycline hcl tab 50 2 minocycline hcl tab 75 2 minocycline hcl tab mondoxyne nl cap 50 2 morgidox cap 1x50 2 morgidox cap 1x100 2 morgidox cap 2x100 2 tetracycline hcl cap tetracycline hcl cap VIBRAMYCIN SYP 50MG/5ML 4 ANTIFUNGALS clotrimazole troche 10 2 CRESEMBA CAP 186 MG 4 QL fluconazole for susp 10 /ml 2 fluconazole for susp 40 /ml 2 fluconazole tab 50 2 QL fluconazole tab QL fluconazole tab QL fluconazole tab QL flucytosine cap PA flucytosine cap PA griseofulvin microsize susp 125 /5ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 9

17 griseofulvin microsize tab itraconazole cap PA; QL NOXAFIL SUS 40MG/ML 5 PA NOXAFIL TAB 100MG 5 PA; QL nystatin susp unit/ml 2 nystatin tab unit 2 SPORANOX SOL 10MG/ML 4 PA; QL terbinafine hcl tab QL voriconazole for susp 40 /ml 2 QL voriconazole tab 50 2 QL voriconazole tab QL ANTIMALARIALS COARTEM TAB MG 3 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab abacavir sulfate-lamivudine-zidovudine tab 2 QL ATRIPLA TAB 3 QL BIKTARVY TAB 3 QL COMPLERA TAB 3 QL DESCOVY TAB 200/25 3 QL EPZICOM TAB QL EVOTAZ TAB QL GENVOYA TAB 3 QL lamivudine-zidovudine tab QL PREZCOBIX TAB QL STRIBILD TAB 3 QL TRIUMEQ TAB 3 QL TRIZIVIR TAB 4 QL TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 3 PA; QL SELZENTRY TAB 150MG 3 PA; QL SELZENTRY TAB 300MG 3 PA; QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 5 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 3 QL ISENTRESS CHW 100MG 3 QL ISENTRESS HD TAB 600MG 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 10

18 ISENTRESS POW 100MG 3 QL ISENTRESS TAB 400MG 3 QL TIVICAY TAB 10MG 3 QL TIVICAY TAB 25MG 3 QL TIVICAY TAB 50MG 3 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 3 QL APTIVUS SOL 3 QL atazanavir sulfate cap 150 (base equiv) 2 QL atazanavir sulfate cap 200 (base equiv) 2 QL atazanavir sulfate cap 300 (base equiv) 2 QL CRIXIVAN CAP 200MG 3 QL CRIXIVAN CAP 400MG 3 QL fosamprenavir calcium tab 700 (base 2 QL equiv) INVIRASE CAP 200MG 3 QL INVIRASE TAB 500MG 3 QL KALETRA TAB MG 3 QL KALETRA TAB MG 3 QL LEXIVA SUS 50MG/ML 3 QL LEXIVA TAB 700MG 4 QL lopinavir-ritonavir soln /5ml 2 QL (80-20 /ml) NORVIR CAP 100MG 3 QL NORVIR SOL 80MG/ML 3 QL NORVIR TAB 100MG 3 QL PREZISTA SUS 100MG/ML 3 QL PREZISTA TAB 75MG 3 QL PREZISTA TAB 150MG 3 QL PREZISTA TAB 600MG 3 QL PREZISTA TAB 800MG 3 QL REYATAZ CAP 150MG 4 QL REYATAZ CAP 200MG 4 QL REYATAZ CAP 300MG 4 QL REYATAZ POW 50MG 3 QL ritonavir tab QL VIRACEPT TAB 250MG 3 QL VIRACEPT TAB 625MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-NUCLEOSIDE EDURANT TAB 25MG 3 QL efavirenz cap 50 2 QL efavirenz cap QL efavirenz tab QL INTELENCE TAB 25MG 3 PA; QL INTELENCE TAB 100MG 3 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 11

19 INTELENCE TAB 200MG 3 PA; QL nevirapine tab QL nevirapine tab er 24hr QL nevirapine tab er 24hr QL RESCRIPTOR TAB 100 MG 3 QL RESCRIPTOR TAB 200MG 3 QL SUSTIVA CAP 50MG 4 QL SUSTIVA CAP 200MG 4 QL SUSTIVA TAB 600MG 4 QL VIRAMUNE SUS 50MG/5ML 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOSIDE abacavir sulfate tab 300 (base equiv) 2 QL didanosine delayed release capsule QL didanosine delayed release capsule QL didanosine delayed release capsule QL EMTRIVA CAP 200MG 3 QL EMTRIVA SOL 10MG/ML 3 QL EPIVIR SOL 10MG/ML 4 lamivudine oral soln 10 /ml 2 lamivudine tab lamivudine tab RETROVIR INJ 10MG/ML 5 stavudine cap 15 2 QL stavudine cap 20 2 QL stavudine cap 30 2 QL stavudine cap 40 2 QL VIDEX SOL 2GM 3 QL VIDEX SOL 4GM 3 QL zidovudine cap QL zidovudine syrup 10 /ml 2 QL zidovudine tab QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOTIDE tenofovir disoproxil fumarate tab QL VIREAD POW 40MG/GM 3 VIREAD TAB 150MG 3 QL VIREAD TAB 200MG 3 QL VIREAD TAB 250MG 3 QL VIREAD TAB 300MG 4 QL ANTITUBERCULAR AGENTS cycloserine cap ethambutol hcl tab ethambutol hcl tab isoniazid syrup 50 /5ml 2 isoniazid tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 12

20 isoniazid tab PASER GRA 4GM 3 PRIFTIN TAB 150MG 3 pyrazinamide tab RIFAMATE CAP 4 rifampin cap rifampin cap RIFATER TAB 3 SIRTURO TAB 100MG 4 PA TRECATOR TAB 250MG 3 ANTIVIRALS, CMV AGENTS VALCYTE SOL 50MG/ML 5 QL VALCYTE TAB 450MG 5 valganciclovir hcl tab 450 (base equivalent) 4 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B BARACLUDE SOL.05MG/ML 5 PA BARACLUDE TAB 0.5MG 5 PA BARACLUDE TAB 1MG 5 PA entecavir tab PA entecavir tab 1 5 PA EPIVIR HBV SOL 5MG/ML 3 PA EPIVIR HBV TAB 100MG 4 PA lamivudine tab 100 (hbv) 2 PA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA TAB PA; QL HARVONI TAB MG 5 PA; QL MAVYRET TAB MG 5 PA; QL REBETOL SOL 40MG/ML 5 QL ribavirin cap QL ribavirin tab QL ribavirin tab QL ribavirin tab QL VOSEVI TAB 5 PA; QL ANTIVIRALS, HERPES AGENTS acyclovir cap acyclovir susp 200 /5ml 2 acyclovir tab acyclovir tab famciclovir tab QL famciclovir tab QL famciclovir tab QL valacyclovir hcl tab 1 gm 2 QL valacyclovir hcl tab QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 13

21 ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 (base 2 QL equiv) oseltamivir phosphate cap 45 (base 2 QL equiv) oseltamivir phosphate cap 75 (base 2 QL equiv) oseltamivir phosphate for susp 6 /ml 2 QL (base equiv) RELENZA MIS DISKHALE 4 QL rimantadine hydrochloride tab TAMIFLU CAP 30MG 4 QL TAMIFLU CAP 45MG 4 QL TAMIFLU CAP 75MG 4 QL TAMIFLU SUS 6MG/ML 4 QL MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 /5ml 2 BILTRICIDE TAB 600MG 3 CLEOCIN CAP 75MG 4 clindamycin hcl cap 75 2 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 2 /5ml (base equiv) dapsone tab 25 3 dapsone tab ivermectin tab 3 2 linezolid for susp 100 /5ml 4 QL linezolid tab QL MEPRON SUS 4 metronidazole cap metronidazole tab metronidazole tab NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 50 2 nitrofurantoin macrocrystalline cap nitrofurantoin monohydrate 2 macrocrystalline cap 100 PRIMSOL SOL 50MG/5ML 3 rifabutin cap SIVEXTRO INJ 200MG 5 SIVEXTRO TAB 200MG 5 QL STROMECTOL TAB 3MG 4 trimethoprim tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 14

22 vancomycin hcl cap 125 (base 2 equivalent) vancomycin hcl cap 250 (base 2 equivalent) VANCOMYCIN INJ 500MG 4 VANCOMYCIN INJ 750MG 4 XIFAXAN TAB 200MG 4 QL XIFAXAN TAB 550MG 5 PA; QL ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN TAB 2MG 5 BICNU INJ 100MG 5 busulfan inj 6 /ml 5 BUSULFEX INJ 6MG/ML 5 carboplatin iv soln 50 /5ml 5 carboplatin iv soln 150 /15ml 5 carboplatin iv soln 450 /45ml 5 carboplatin iv soln 600 /60ml 5 cisplatin inj 50 /50ml (1 /ml) 5 cisplatin inj 100 /100ml (1 /ml) 5 cisplatin inj 200 /200ml (1 /ml) 5 CYCLOPHOSPH CAP 25MG 5 CYCLOPHOSPH CAP 50MG 5 cyclophosphamide for inj 1 gm 5 cyclophosphamide for inj 2 gm 5 cyclophosphamide for inj dacarbazine for inj dacarbazine for inj EMCYT CAP 140MG 5 PA GLEOSTINE CAP 10MG 5 PA GLEOSTINE CAP 40MG 5 PA GLEOSTINE CAP 100MG 5 PA HEXALEN CAP 50MG 5 IFEX INJ 1GM 5 ifosfamide for inj 1 gm 5 IFOSFAMIDE INJ 3GM 5 ifosfamide iv inj 1 gm/20ml (50 /ml) 5 ifosfamide iv inj 3 gm/60ml (50 /ml) 5 LEUKERAN TAB 2MG 5 MUSTARGEN INJ 10MG 5 MYLERAN TAB 2MG 5 oxaliplatin for iv inj 50 5 oxaliplatin for iv inj oxaliplatin iv soln 50 /10ml 5 oxaliplatin iv soln 100 /20ml 5 TEMODAR CAP 5MG 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 15

23 TEMODAR CAP 20MG 5 PA TEMODAR CAP 100MG 5 PA TEMODAR CAP 140MG 5 PA TEMODAR CAP 180MG 5 PA TEMODAR CAP 250MG 5 PA TEMODAR INJ 100MG 5 PA temozolomide cap 5 5 PA temozolomide cap 20 5 PA temozolomide cap PA temozolomide cap PA temozolomide cap PA temozolomide cap PA VALCHLOR GEL 0.016% 5 PA ZANOSAR INJ 1GM 5 ANTIMETABOLITES ALIMTA INJ 100MG 5 ALIMTA INJ 500MG 5 capecitabine tab PA capecitabine tab PA cladribine iv soln 10 /10ml (1 /ml) 2 cytarabine inj 20 /ml 2 cytarabine inj pf 20 /ml 4 cytarabine inj pf 100 /ml 2 floxuridine for inj 0.5 gm 5 fludarabine phosphate for inj 50 5 fludarabine phosphate inj 25 /ml 5 fluorouracil iv soln 1 gm/20ml (50 /ml) 5 fluorouracil iv soln 2.5 gm/50ml (50 5 /ml) fluorouracil iv soln 5 gm/100ml (50 /ml) 5 fluorouracil iv soln 500 /10ml (50 5 /ml) gemcitabine hcl for inj 2 gm 2 gemcitabine hcl inj 1 gm/26.3ml (38 2 /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 2 /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 2 /ml) (base equiv) mercaptopurine tab 50 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 /2ml (25 5 /ml) methotrexate sodium inj 250 /10ml (25 5 /ml) methotrexate sodium inj pf 50 /2ml (25 2 /ml) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 16

24 methotrexate sodium inj pf 250 /10ml 2 (25 /ml) methotrexate sodium inj pf 1000 /40ml 2 (25 /ml) methotrexate sodium tab 2.5 (base 2 equiv) TABLOID TAB 40MG 5 PA XELODA TAB 150MG 5 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 2 ERLEADA TAB 60MG 5 PA; QL flutamide cap NILANDRON TAB 150MG 5 PA XTANDI CAP 40MG 5 PA; QL ZYTIGA TAB 250MG 5 PA; QL ZYTIGA TAB 500MG 5 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 5 PA FASLODEX INJ 250/5ML 5 HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 2 exemestane tab 25 2 letrozole tab HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS FIRMAGON INJ 80MG 5 PA; QL FIRMAGON INJ 120MG 5 PA; QL HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG 5 PA; QL ELIGARD INJ 22.5MG 5 PA; QL ELIGARD INJ 30MG 5 PA; QL ELIGARD INJ 45MG 5 PA; QL leuprolide acetate inj kit 5 /ml 5 PA; QL LUPRON DEPOT INJ 3.75MG 5 PA; QL LUPRON DEPOT INJ 7.5MG 5 PA; QL LUPRON DEPOT INJ 11.25MG 5 PA; QL LUPRON DEPOT INJ 22.5MG 5 PA; QL LUPRON DEPOT INJ 30MG 5 PA; QL LUPRON DEPOT INJ 45MG 5 PA; QL TRELSTAR MIX INJ 3.75MG 5 PA; QL TRELSTAR MIX INJ 11.25MG 5 PA; QL TRELSTAR MIX INJ 22.5MG 5 PA; QL VANTAS KIT 50MG 5 PA; QL ZOLADEX IMP 3.6MG 5 PA; QL ZOLADEX IMP 10.8MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 17

25 HORMONAL ANTINEOPLASTICS, PROGESTINS DEPO-PROVERA INJ 400/ML 4 QL megestrol acetate susp 40 /ml 2 megestrol acetate tab 20 2 megestrol acetate tab 40 2 IMMUNOMODULATORS POMALYST CAP 1MG 5 PA; QL POMALYST CAP 2MG 5 PA; QL POMALYST CAP 3MG 5 PA; QL POMALYST CAP 4MG 5 PA; QL REVLIMID CAP 2.5MG 5 PA; QL REVLIMID CAP 5MG 5 PA; QL REVLIMID CAP 10MG 5 PA; QL REVLIMID CAP 15MG 5 PA; QL REVLIMID CAP 20MG 5 PA; QL REVLIMID CAP 25MG 5 PA; QL THALOMID CAP 50MG 5 PA; QL THALOMID CAP 100MG 5 PA; QL THALOMID CAP 150MG 5 PA; QL THALOMID CAP 200MG 5 PA; QL KINASE INHIBITORS AFINITOR DIS TAB 2MG 5 PA; QL AFINITOR DIS TAB 3MG 5 PA; QL AFINITOR DIS TAB 5MG 5 PA; QL AFINITOR TAB 2.5MG 5 PA; QL AFINITOR TAB 5MG 5 PA; QL AFINITOR TAB 7.5MG 5 PA; QL AFINITOR TAB 10MG 5 PA; QL ALECENSA CAP 150MG 5 PA; QL ALUNBRIG PAK 5 PA; QL ALUNBRIG TAB 30MG 5 PA; QL ALUNBRIG TAB 90MG 5 PA; QL ALUNBRIG TAB 180MG 5 PA; QL BOSULIF TAB 100MG 5 PA; QL BOSULIF TAB 500MG 5 PA; QL CABOMETYX TAB 20MG 5 PA; QL CABOMETYX TAB 40MG 5 PA; QL CABOMETYX TAB 60MG 5 PA; QL CALQUENCE CAP 100MG 5 PA; QL CAPRELSA TAB 100MG 5 PA; QL CAPRELSA TAB 300MG 5 PA; QL COMETRIQ KIT 60MG 5 PA; QL COMETRIQ KIT 100MG 5 PA; QL COMETRIQ KIT 140MG 5 PA; QL COTELLIC TAB 20MG 5 PA; QL GILOTRIF TAB 20MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 18

26 GILOTRIF TAB 30MG 5 PA; QL GILOTRIF TAB 40MG 5 PA; QL IBRANCE CAP 75MG 5 PA; QL IBRANCE CAP 100MG 5 PA; QL IBRANCE CAP 125MG 5 PA; QL ICLUSIG TAB 15MG 5 PA; QL ICLUSIG TAB 45MG 5 PA; QL imatinib mesylate tab 100 (base 5 PA; QL equivalent) imatinib mesylate tab 400 (base 5 PA; QL equivalent) IMBRUVICA CAP 140MG 5 PA; QL IMBRUVICA TAB 140MG 5 PA; QL IMBRUVICA TAB 280MG 5 PA; QL IMBRUVICA TAB 420MG 5 PA; QL IMBRUVICA TAB 560MG 5 PA; QL INLYTA TAB 1MG 5 PA; QL INLYTA TAB 5MG 5 PA; QL IRESSA TAB 250MG 5 PA; QL JAKAFI TAB 5MG 5 PA; QL JAKAFI TAB 10MG 5 PA; QL JAKAFI TAB 15MG 5 PA; QL JAKAFI TAB 20MG 5 PA; QL JAKAFI TAB 25MG 5 PA; QL KISQALI 200 PAK FEMARA 5 PA; QL KISQALI 400 PAK FEMARA 5 PA; QL KISQALI 600 PAK FEMARA 5 PA; QL KISQALI TAB 200DOSE 5 PA; QL KISQALI TAB 400DOSE 5 PA; QL KISQALI TAB 600DOSE 5 PA; QL LENVIMA CAP 8 MG 5 PA; QL LENVIMA CAP 10 MG 5 PA; QL LENVIMA CAP 14 MG 5 PA; QL LENVIMA CAP 18 MG 5 PA; QL LENVIMA CAP 20 MG 5 PA; QL LENVIMA CAP 24 MG 5 PA; QL MEKINIST TAB 0.5MG 5 PA; QL MEKINIST TAB 2MG 5 PA; QL NERLYNX TAB 40MG 5 PA; QL NEXAVAR TAB 200MG 5 PA; QL RYDAPT CAP 25MG 5 PA; QL SPRYCEL TAB 20MG 5 PA; QL SPRYCEL TAB 50MG 5 PA; QL SPRYCEL TAB 70MG 5 PA; QL SPRYCEL TAB 80MG 5 PA; QL SPRYCEL TAB 100MG 5 PA; QL SPRYCEL TAB 140MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 19

27 STIVARGA TAB 40MG 5 PA; QL SUTENT CAP 12.5MG 5 PA; QL SUTENT CAP 25MG 5 PA; QL SUTENT CAP 37.5MG 5 PA; QL SUTENT CAP 50MG 5 PA; QL TAFINLAR CAP 50MG 5 PA; QL TAFINLAR CAP 75MG 5 PA; QL TAGRISSO TAB 40MG 5 PA; QL TAGRISSO TAB 80MG 5 PA; QL TARCEVA TAB 25MG 5 PA TARCEVA TAB 100MG 5 PA; QL TARCEVA TAB 150MG 5 PA; QL TASIGNA CAP 50MG 5 PA; QL TASIGNA CAP 150MG 5 PA; QL TASIGNA CAP 200MG 5 PA; QL TORISEL SOL 25MG/ML 5 QL TYKERB TAB 250MG 5 PA; QL VERZENIO TAB 50MG 5 PA; QL VERZENIO TAB 100MG 5 PA; QL VERZENIO TAB 150MG 5 PA; QL VERZENIO TAB 200MG 5 PA; QL VOTRIENT TAB 200MG 5 QL XALKORI CAP 200MG 5 PA; QL XALKORI CAP 250MG 5 PA; QL ZELBORAF TAB 240MG 5 PA; QL ZYDELIG TAB 100MG 5 PA; QL ZYDELIG TAB 150MG 5 PA; QL ZYKADIA CAP 150MG 5 PA; QL MISCELLANEOUS ABRAXANE INJ 100MG 5 ARRANON INJ 5MG/ML 5 AVASTIN INJ 5 AVASTIN INJ 400/16ML 5 bexarotene cap 75 5 PA bleomycin sulfate for inj 15 unit 5 bleomycin sulfate for inj 30 unit 5 daunorubicin hcl iv soln 20 /4ml (base 5 equiv) doxorubicin hcl for inj 10 5 doxorubicin hcl for inj 50 5 doxorubicin hcl inj 2 /ml 5 ELITEK INJ 1.5MG 5 ELITEK INJ 7.5MG 5 ELLENCE INJ 2MG/ML 5 epirubicin hcl iv soln 200 /100ml (2 5 /ml) ERBITUX INJ 100MG 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 20

28 ERBITUX INJ 200MG 5 ERIVEDGE CAP 150MG 5 PA; QL ETOPOPHOS INJ 100MG 5 etoposide cap 50 5 PA etoposide inj 1 gm/50ml (20 /ml) 2 PA etoposide inj 100 /5ml (20 /ml) 2 PA etoposide inj 500 /25ml (20 /ml) 2 PA FARYDAK CAP 10MG 5 PA; QL FARYDAK CAP 15MG 5 PA; QL FARYDAK CAP 20MG 5 PA; QL HERCEPTIN INJ 150MG 5 HERCEPTIN INJ 440MG 5 hydroxyurea cap IDAMYCIN PFS INJ 5MG/5ML 5 IDAMYCIN PFS INJ 20/20ML 5 idarubicin hcl iv inj 5 /5ml (1 /ml) 5 idarubicin hcl iv inj 20 /20ml (1 /ml) 5 IDHIFA TAB 50MG 5 PA; QL IDHIFA TAB 100MG 5 PA; QL IXEMPRA KIT INJ 15MG 5 IXEMPRA KIT INJ 45MG 5 JEVTANA INJ 60/1.5ML 5 KYPROLIS SOL 30MG 5 KYPROLIS SOL 60MG 5 leucovorin calcium for inj leucovorin calcium tab 5 5 leucovorin calcium tab 10 2 leucovorin calcium tab 15 5 leucovorin calcium tab 25 5 LONSURF TAB PA LONSURF TAB PA LYNPARZA CAP 50MG 5 PA; QL LYSODREN TAB 500MG 5 PA MATULANE CAP 50MG 5 MESNEX TAB 400MG 5 mitomycin for iv soln 5 5 mitomycin for iv soln 20 5 mitomycin for iv soln 40 5 mitoxantrone hcl inj conc 20 /10ml (2 /ml) 5 mitoxantrone hcl inj conc 25 /12.5ml (2 5 /ml) mitoxantrone hcl inj conc 30 /15ml (2 5 /ml) NINLARO CAP 2.3MG 5 PA; QL NINLARO CAP 3MG 5 PA; QL NINLARO CAP 4MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 21

29 NIPENT INJ 10MG 5 ODOMZO CAP 200MG 5 PA; QL paclitaxel iv conc 30 /5ml (6 /ml) 2 paclitaxel iv conc 100 /16.7ml (6 /ml) 2 paclitaxel iv conc 150 /25ml (6 /ml) 2 paclitaxel iv conc 300 /50ml (6 /ml) 2 PERJETA INJ 420/14ML 5 PHOTOFRIN INJ 75MG 5 PROLEUKIN INJ 22MU 5 RITUXAN INJ 100MG 5 PA RITUXAN INJ 500MG 5 PA RUBRACA TAB 200MG 5 PA; QL RUBRACA TAB 250MG 5 PA; QL RUBRACA TAB 300MG 5 PA; QL SYNRIBO INJ 3.5MG 5 PA TARGRETIN GEL 1% 5 PA THERACYS INJ 5 TICE BCG INJ 5 tretinoin cap 10 5 VECTIBIX INJ 100MG 5 VECTIBIX INJ 400MG 5 VELCADE INJ 3.5MG 5 VENCLEXTA TAB 10MG 5 PA; QL VENCLEXTA TAB 50MG 5 PA; QL VENCLEXTA TAB 100MG 5 PA; QL VENCLEXTA TAB START PK 5 PA; QL vinblastine sulfate inj 1 /ml 2 vincristine sulfate iv soln 1 /ml 2 YERVOY INJ 50MG 5 YERVOY INJ 200MG 5 ZALTRAP INJ 100/4ML 5 ZALTRAP INJ 200/8ML 5 ZEJULA CAP 100MG 5 PA; QL ZEVALIN KIT Y-90 5 ZOLINZA CAP 100MG 5 PA; QL TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 300/15ML 5 HYCAMTIN CAP 0.25MG 5 PA HYCAMTIN CAP 1MG 5 PA irinotecan hcl inj 500 /25ml (20 /ml) 5 TOPOTECAN INJ 4MG/4ML 5 CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 22

30 amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap TARKA TAB CR 4 TARKA TAB CR 4 TARKA TAB CR 4 trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 23

31 moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab ACE INHIBITORS benazepril hcl tab 5 1 benazepril hcl tab 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab captopril tab 25 2 captopril tab 50 2 captopril tab enalapril maleate tab enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab 20 1 enalaprilat iv inj 1.25 /ml 2 fosinopril sodium tab 10 2 fosinopril sodium tab 20 2 fosinopril sodium tab 40 2 lisinopril tab lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab moexipril hcl tab 15 2 perindopril erbumine tab 2 2 perindopril erbumine tab 4 2 perindopril erbumine tab 8 2 quinapril hcl tab 5 2 quinapril hcl tab 10 2 quinapril hcl tab 20 2 quinapril hcl tab 40 2 ramipril cap ramipril cap ramipril cap 5 2 ramipril cap 10 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 24

32 trandolapril tab 1 2 trandolapril tab 2 2 trandolapril tab 4 2 ADRENOLYTICS, CENTRAL clonidine hcl tab clonidine hcl tab clonidine hcl tab clonidine td patch weekly 0.1 /24hr 2 clonidine td patch weekly 0.2 /24hr 2 clonidine td patch weekly 0.3 /24hr 2 guanfacine hcl tab 1 1 guanfacine hcl tab 2 1 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 4 PA DIBENZYLINE CAP 10MG 4 PA phenoxybenzamine hcl cap 10 4 PA ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 2 eplerenone tab 50 2 spironolactone tab 25 1 spironolactone tab 50 2 spironolactone tab ALPHA BLOCKERS doxazosin mesylate tab 1 2 doxazosin mesylate tab 2 2 doxazosin mesylate tab 4 2 doxazosin mesylate tab 8 2 prazosin hcl cap 1 2 prazosin hcl cap 2 2 prazosin hcl cap 5 2 terazosin hcl cap 1 (base equivalent) 1 terazosin hcl cap 2 (base equivalent) 1 terazosin hcl cap 5 (base equivalent) 1 terazosin hcl cap 10 (base equivalent) 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS candesartan cilexetil-hydrochlorothiazide 2 tab candesartan cilexetil-hydrochlorothiazide 2 tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 25

33 candesartan cilexetil-hydrochlorothiazide 2 tab irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab losartan potassium & hydrochlorothiazide 2 tab losartan potassium & hydrochlorothiazide 2 tab losartan potassium & hydrochlorothiazide 2 tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 2 candesartan cilexetil tab 8 2 candesartan cilexetil tab 16 2 candesartan cilexetil tab 32 2 eprosartan mesylate tab irbesartan tab 75 2 irbesartan tab irbesartan tab losartan potassium tab 25 2 losartan potassium tab 50 2 losartan potassium tab telmisartan tab 20 2 telmisartan tab 40 2 telmisartan tab 80 2 valsartan tab 40 2 valsartan tab 80 2 valsartan tab valsartan tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 26

34 ANTIARRHYTHMICS amiodarone hcl tab amiodarone hcl tab amiodarone hcl tab disopyramide phosphate cap disopyramide phosphate cap dofetilide cap 125 mcg (0.125 ) 2 dofetilide cap 250 mcg (0.25 ) 2 dofetilide cap 500 mcg (0.5 ) 2 flecainide acetate tab 50 2 flecainide acetate tab flecainide acetate tab lidocaine hcl iv inj 10 /ml 2 lidocaine hcl iv inj 20 /ml 2 lidocaine iv infusion in d5w inj 4 /ml 2 lidocaine iv infusion in d5w inj 8 /ml 2 mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap MULTAQ TAB 400MG 3 NEXTERONE INJ 4 NORPACE CAP 100MG CR 4 NORPACE CAP 150MG CR 4 PROCAINAMIDE INJ 500MG/ML 2 propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab quinidine sulfate tab quinidine sulfate tab sotalol hcl (afib/afl) tab 80 2 sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab sotalol hcl tab 80 1 sotalol hcl tab sotalol hcl tab sotalol hcl tab TIKOSYN CAP 125MCG 3 TIKOSYN CAP 250MCG 3 TIKOSYN CAP 500MCG 3 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 27

35 cholestyramine powder packets 4 gm 2 colesevelam hcl tab COLESTID GRA 5GM 4 COLESTID POW 5GM 4 COLESTID TAB 1GM 4 colestipol hcl granule packets 5 gm 2 colestipol hcl granules 5 gm 2 colestipol hcl tab 1 gm 2 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 2 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 (fenofibric 2 PA, ST acid equiv) choline fenofibrate cap dr PA, ST (fenofibric acid equiv) fenofibrate micronized cap 43 2 fenofibrate micronized cap 67 2 fenofibrate micronized cap fenofibrate micronized cap fenofibrate tab 48 2 fenofibrate tab 54 2 fenofibrate tab fenofibrate tab fenofibric acid tab 35 2 fenofibric acid tab gemfibrozil tab LOPID TAB 600MG 4 TRILIPIX CAP 45MG 4 PA, ST TRILIPIX CAP 135MG 4 PA, ST ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 (base 2 equivalent) atorvastatin calcium tab 20 (base 2 equivalent) atorvastatin calcium tab 40 (base 2 equivalent) atorvastatin calcium tab 80 (base 2 equivalent) ezetimibe-simvastatin tab QL ezetimibe-simvastatin tab QL ezetimibe-simvastatin tab QL ezetimibe-simvastatin tab QL fluvastatin sodium cap 20 2 fluvastatin sodium cap 40 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 28

36 lovastatin tab 10 1 lovastatin tab 20 1 lovastatin tab 40 1 pravastatin sodium tab 10 2 pravastatin sodium tab 20 2 pravastatin sodium tab 40 2 pravastatin sodium tab 80 2 rosuvastatin calcium tab 5 2 rosuvastatin calcium tab 10 2 rosuvastatin calcium tab 20 2 rosuvastatin calcium tab 40 2 simvastatin tab 5 1 simvastatin tab 10 1 simvastatin tab 20 1 simvastatin tab 40 1 simvastatin tab 80 1 VYTORIN TAB 10-10MG 4 ST; QL VYTORIN TAB 10-20MG 4 ST; QL VYTORIN TAB 10-40MG 4 ST; QL VYTORIN TAB 10-80MG 4 ST; QL ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS JUXTAPID CAP 5MG 5 PA; QL JUXTAPID CAP 10MG 5 PA; QL JUXTAPID CAP 20MG 5 PA; QL JUXTAPID CAP 30MG 5 PA; QL JUXTAPID CAP 40MG 5 PA; QL JUXTAPID CAP 60MG 5 PA; QL ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 5 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 (antihyperlipidemic) 4 niacin tab er 750 (antihyperlipidemic) 4 niacin tab er 1000 (antihyperlipidemic) 4 ANTILIPEMICS, OMEGA-3 FATTY ACIDS LOVAZA CAP 1GM 4 omega-3-acid ethyl esters cap 1 gm 4 VASCEPA CAP 1GM 3 ANTILIPEMICS, PCSK9 INHIBITORS REPATHA INJ 140MG/ML 5 PA; QL REPATHA PUSH INJ 420/3.5 5 PA; QL REPATHA SURE INJ 140MG/ML 5 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab atenolol & chlorthalidone tab PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 29

37 bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab nadolol & bendroflumethiazide tab nadolol & bendroflumethiazide tab propranolol & hydrochlorothiazide tab propranolol & hydrochlorothiazide tab BETA-BLOCKERS acebutolol hcl cap acebutolol hcl cap atenolol tab 25 1 atenolol tab 50 1 atenolol tab betaxolol hcl tab 10 2 betaxolol hcl tab 20 2 bisoprolol fumarate tab 5 2 bisoprolol fumarate tab 10 2 BYSTOLIC TAB 2.5MG 4 PA, ST BYSTOLIC TAB 5MG 4 PA, ST BYSTOLIC TAB 10MG 4 PA, ST BYSTOLIC TAB 20MG 4 PA, ST carvedilol tab carvedilol tab carvedilol tab carvedilol tab 25 1 INNOPRAN XL CAP 80MG 4 ST INNOPRAN XL CAP 120MG 4 ST labetalol hcl iv soln 5 /ml 2 labetalol hcl tab labetalol hcl tab labetalol hcl tab metoprolol succinate tab er 24hr 25 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 2 (tartrate equiv) metoprolol succinate tab er 24hr 100 (tartrate equiv) 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 30

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