SilverScript 2017 Formulary (List of Covered Drugs)

Transcription

1 SilverScript 017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File 1755, Version 6 This formulary was updated on August 1, 016. For more recent information or other questions, please contact SilverScript at or, for TTY users, 711, hours a day, 7 days a week, or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means SilverScript Insurance Company. When it refers to plan or our plan, it means SilverScript Choice (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 018, and from time to time during the year. Y0080_6001_FORM_COMP_017 Accepted FRM-CM-CHC

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3 What is the SilverScript Formulary? A formulary is a list of covered drugs selected by SilverScript Choice (PDP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 017. To get updated information about the drugs covered by SilverScript Choice (PDP), please contact us. Our contact information appears on the front and back cover pages. If we have other types of mid-year non-maintenance formulary changes unrelated to the reasons stated above (e.g. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the new information. The updated formulary may be obtained from our website or by calling us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. 1

4 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 5. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? SilverScript Choice (PDP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization () SilverScript Choice (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits (QL) For certain drugs, SilverScript Choice (PDP) limits the amount of the drug that we will cover. For example, our plan provides up to 30 tablets per prescription for doxazosin. This may be in addition to a standard one-month or three-month supply. Step Therapy (ST) In some cases, SilverScript Choice (PDP) 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. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the SilverScript formulary? on page 3 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. If you learn that SilverScript Choice (PDP) does not cover your drug, you have two options: l l You can ask Customer Care for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask us to make an exception and cover your drug. See below for information about how to request an exception.

5 How do I request an exception to the SilverScript Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. l l l You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, SilverScript Choice (PDP) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 10-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. 3

6 If you experience a change in your level of care, such as a move from a home to a long-term care setting, and need a drug that is not on our formulary (or if your ability to get your drugs is limited), we may cover a one-time temporary supply from a network pharmacy for up to 3 days unless you have a prescription for fewer days. You should use the plan s exception process if you wish to have continued coverage of the drug after the temporary supply is finished. For more information For more detailed information about your SilverScript Choice (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day, 7 days a week. TTY users should call Or, visit SilverScript Choice (PDP) s Formulary The formulary that begins on page 7 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 5. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Prior authorization. QL Drug has quantity limit. ST Step therapy required. NM Not available at our mail-order pharmacies. NDS Non-extended day supply. Not available for an extended (long-term) supply. LA Limited access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at , hours a day, 7 days a week. TTY users should call 711. High Risk Drug. According to medical experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available. B/D This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTOID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).

7 The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug s cost that you will pay during the initial coverage stage) for up to a one-month supply of drugs in each tier. Initial Coverage Stage Copayment / Coinsurance Levels Standard retail cost-sharing (in-network) (Up to a 30-day supply) State Tier 1 (Preferred Generic) (includes low cost preferred generic drugs) Tier (Generic) (includes generic and some low cost preferred brand drugs) Tier 3 (Preferred Brand) (includes preferred brand and non-preferred generic drugs) Tier (Non-Preferred Drug) (includes non-preferred brand and non-preferred generic drugs) Tier 5 (Specialty Tier) (includes high cost generic and brand drugs) Alabama $3.00 $13.00 $ % 33% Alaska $1.00 $.00 15% 35% 5% Arizona $7.00 $0.00 $ % 33% Arkansas $3.00 $13.00 $ % 33% California $3.00 $17.00 $7.00 8% 33% Colorado $3.00 $0.00 $ % 33% Connecticut $3.00 $13.00 $.00 % 33% Delaware $3.00 $19.00 $ % 33% District of Columbia $3.00 $19.00 $ % 33% Florida $.00 $0.00 $ % 33% Georgia $3.00 $13.00 $ % 33% Hawaii $1.00 $.00 17% 36% 5% Idaho $3.00 $1.00 $ % 33% Illinois $3.00 $18.00 $ % 33% Indiana $3.00 $1.00 $ % 33% Iowa $3.00 $1.00 $.00 8% 33% Kansas $3.00 $1.00 $ % 33% Kentucky $3.00 $1.00 $ % 33% Louisiana $3.00 $1.00 $3.00 7% 33% Maine $3.00 $17.00 $ % 33% Maryland $3.00 $19.00 $ % 33% Massachusetts $3.00 $13.00 $.00 % 33% Michigan $3.00 $1.00 $5.00 9% 33% Minnesota $3.00 $1.00 $.00 8% 33% Mississippi $3.00 $1.00 $ % 33% Missouri $3.00 $1.00 $3.00 7% 33% Montana $3.00 $1.00 $.00 8% 33% Nebraska $3.00 $1.00 $.00 8% 33% Nevada $7.00 $0.00 $ % 33% 5

8 State Tier 1 (Preferred Generic) (includes low cost preferred generic drugs) Tier (Generic) (includes generic and some low cost preferred brand drugs) Tier 3 (Preferred Brand) (includes preferred brand and non-preferred generic drugs) Tier (Non-Preferred Drug) (includes non-preferred brand and non-preferred generic drugs) Tier 5 (Specialty Tier) (includes high cost generic and brand drugs) New Hampshire $3.00 $17.00 $ % 33% New Jersey $3.00 $15.00 $7.00 9% 33% New Mexico $3.00 $15.00 $ % 33% New York $3.00 $13.00 $6.00 8% 33% North Carolina $3.00 $1.00 $ % 33% North Dakota $3.00 $1.00 $.00 8% 33% Ohio $3.00 $17.00 $6.00 9% 33% Oklahoma $3.00 $1.00 $3.00 9% 33% Oregon $3.00 $1.00 $.00 8% 33% Pennsylvania $3.00 $13.00 $ % 33% Rhode Island $3.00 $13.00 $.00 % 33% South Carolina $3.00 $17.00 $ % 33% South Dakota $3.00 $1.00 $.00 8% 33% Tennessee $3.00 $13.00 $ % 33% Texas $3.00 $0.00 $ % 33% Utah $3.00 $1.00 $ % 33% Vermont $3.00 $13.00 $.00 % 33% Virginia $3.00 $18.00 $ % 33% Washington $3.00 $1.00 $.00 8% 33% West Virginia $3.00 $13.00 $ % 33% Wisconsin $3.00 $1.00 $3.00 6% 33% Wyoming $3.00 $1.00 $.00 8% 33% You can find complete cost-sharing information, including costs for long-term supplies and mail-order, long-term care, and out-of-network pharmacy pricing, in your Evidence of Coverage. 6

9 017 SSI Choice 1755 v6 eff 01/01/017 ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM) colchicine w/ probenecid 3 COLCRYS QL (10 tabs / 30 days) probenecid 3 ULORIC 3 ST NSAIDS celecoxib (generic of CELEBREX) CAPS 50mg QL (0 caps / 30 days) celecoxib (generic of CELEBREX) CAPS 100mg QL (10 caps / 30 days) celecoxib (generic of CELEBREX) CAPS 00mg QL (60 caps / 30 days) celecoxib (generic of CELEBREX) CAPS 00mg QL (30 caps / 30 days) diclofenac potassium QL (10 tabs / 30 days) diclofenac sodium TB diclofenac sodium TBEC diflunisal etodolac CAPS; TABS flurbiprofen TABS 3 ibuprofen SUSP 3 ibuprofen TABS 00mg, 600mg, 800mg ketoprofen CAPS 3 MELOXICAM SUSP meloxicam (generic of 1 MOBIC) TABS nabumetone TABS naproxen (generic of 3 NAPROSYN) SUSP naproxen (generic of 1 NAPROSYN) TABS 50mg, 500mg naproxen TABS 375mg 1 naproxen (generic of EC-NAPROSYN) TBEC QL QL QL QL naproxen sodium TABS 75mg naproxen sodium (generic of ANAPROX DS) TABS 550mg Drug Tier sulindac TABS OPIOID ANALGESICS acetaminophen w/ codeine SOLN QL (5000 ml / 30 days) acetaminophen w/ codeine TABS QL (00 tabs / 30 days) acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS QL (00 tabs / 30 days) acetaminophen w/ codeine (generic of TYLENOL/CODEINE #) TABS QL (00 tabs / 30 days) butorphanol tartrate SOLN 1mg/ml, mg/ml BUTRANS 5mcg/hr QL (16 patches / 8 days) BUTRANS 10mcg/hr QL (8 patches / 8 days) BUTRANS 15mcg/hr, 0mcg/hr QL ( patches / 8 days) BUTRANS 7.5MCG/ QL (8 patches / 8 days) nalbuphine hcl (generic of NUBAIN) SOLN 10mg/ml nalbuphine hcl SOLN 0mg/ml tramadol hcl (generic of ULTRAM) TABS QL (0 tabs / 30 days) tramadol-acetaminophen (generic of ULTRACET) QL (0 tabs / 30 days) Requirements/ Limits QL QL QL QL QL OPIOID ANALGESICS, CII DURAMORPH B/D 7

10 017 SSI Choice 1755 v6 eff 01/01/017 EMBEDA QL (60 caps / 30 days) endocet (generic of PERCOCET) QL (360 tabs / 30 days) fentanyl citrate (generic of 5 NDS QL ACTIQ) LPOP QL (10 lozenges / 30 days) fentanyl patch 1 mcg/hr QL (generic of DURAGESIC) QL (10 patches / 30 days) fentanyl patch 5 mcg/hr QL (generic of DURAGESIC) QL (10 patches / 30 days) fentanyl patch 50 mcg/hr QL (generic of DURAGESIC) QL (10 patches / 30 days) fentanyl patch 75 mcg/hr QL (generic of DURAGESIC) QL (10 patches / 30 days) fentanyl patch 100 mcg/hr (generic of DURAGESIC) QL (10 patches / 30 days) QL FENTORA 5 NDS QL QL (10 tabs / 30 days) hydroco/apap tab 5-35mg QL (generic of NORCO) QL (360 tabs / 30 days) hydroco/apap tab mg QL (generic of NORCO) QL (360 tabs / 30 days) hydroco/apap tab 10-35mg QL (generic of NORCO) QL (360 tabs / 30 days) hydrocodone-acetaminophen QL mg/15ml (generic of HYCET) QL (500 ml / 30 days) hydrocodone-ibuprofen mg (generic of VICOPROFEN) QL (150 tabs / 30 days) hydromorphone hcl (generic 3 of DILAUDID) LIQD hydromorphone hcl (generic B/D of DILAUDID-HP) SOLN 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl (generic of DILAUDID) TABS QL (70 tabs / 30 days) HYSINGLA ER 0mg, 30mg, 0mg, 60mg QL (60 tabs / 30 days) HYSINGLA ER 80mg, 100mg, 10mg QL (30 tabs / 30 days) lorcet plus tab QL (generic of NORCO) QL (360 tabs / 30 days) lorcet tab 5-35mg (generic of QL NORCO) QL (360 tabs / 30 days) lortab tab 5-35mg (generic of QL NORCO) QL (360 tabs / 30 days) lortab tab (generic of QL NORCO) QL (360 tabs / 30 days) lortab tab 10-35mg (generic QL of NORCO) QL (360 tabs / 30 days) methadone hcl (generic of METHADOSE) CONC QL (10 ml / 30 days) methadone hcl SOLN 5mg/5ml, 10mg/5ml QL (600 ml / 30 days) methadone hcl 5mg (generic of DOLOPHINE) QL (0 tabs / 30 days) methadone hcl 10mg (generic of DOLOPHINE) QL (0 tabs / 30 days) morphine ext-rel tab (generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg QL (90 tabs / 30 days) QL 8

11 017 SSI Choice 1755 v6 eff 01/01/017 morphine ext-rel tab (generic QL of MS CONTIN) 00mg QL (60 tabs / 30 days) MORPHINE SUL INJ B/D 1MG/ML MORPHINE SUL INJ B/D MG/ML MORPHINE SUL INJ B/D MG/ML MORPHINE SUL INJ B/D 10MG/ML MORPHINE SUL INJ B/D 15MG/ML morphine sulfate (generic of B/D MORPHINE SULFATE) SOLN mg/ml, 8mg/ml MORPHINE SULFATE B/D SOLN 8mg/ml, 150mg/30ml morphine sulfate SOLN B/D.5mg/ml, 1mg/ml MORPHINE SULFATE TABS QL (180 tabs / 30 days) MORPHINE SULFATE ORAL 3 SOL ONA ER (CRUSH RESISTANT) QL (10 tabs / 30 days) oxycodone hcl CAPS QL QL (180 caps / 30 days) oxycodone hcl CONC OXYCODONE HCL SOLN oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg QL (180 tabs / 30 days) oxycodone hcl TABS 10mg, 0mg QL (180 tabs / 30 days) oxycodone w/ acetaminophen.5-35mg (generic of PERCOCET) QL (360 tabs / 30 days) oxycodone w/ acetaminophen 5-35mg (generic of PERCOCET) QL (360 tabs / 30 days) oxycodone w/ acetaminophen mg (generic of PERCOCET) QL (360 tabs / 30 days) oxycodone w/ acetaminophen 10-35mg (generic of PERCOCET) QL (360 tabs / 30 days) oxycodone w/ acetaminophen soln (generic of ROXICET) QL (1800 ml / 30 days) OXYCONTIN QL (10 tabs / 30 days) roxicet soln QL (1800 ml / 30 days) roxicet tab 5-35mg (generic of PERCOCET) QL (360 tabs / 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE-MPF) 1% lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE).5% lidocaine inj 0.5% (generic of B/D XYLOCAINE-MPF) lidocaine inj 1% (generic of B/D XYLOCAINE) lidocaine inj 1.5% (generic of B/D XYLOCAINE-MPF) lidocaine inj % (generic of B/D XYLOCAINE) ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN gentamicin sulfate/0.9% s neomycin sulfate TABS 3 paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS tobramycin (generic of TOBI) 5 NDS NM NEBU 9

12 017 SSI Choice 1755 v6 eff 01/01/017 Drug Tier Requirements/ Limits tobramycin inj 1. gm/30ml tobramycin inj 1.gm 5 NDS tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 NDS ALINIA atovaquone (generic of 5 NDS MEPRON) SUSP AZACTAM IN ISO-OSMOTIC DE AZACTAM/DEX INJ GM aztreonam (generic of 3 AZACTAM) BILTRICIDE 3 CAYSTON clindamycin cap 75mg (generic of CLEOCIN) clindamycin cap 300mg (generic of CLEOCIN) clindamycin hcl cap 150 mg (generic of CLEOCIN) clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) clindamycin sol 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY-MYCIN M) SOLR CUBICIN 5 NDS dapsone TABS 3 emverm imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of 3 STROMECTOL) TABS linezolid (generic of ZYVOX) 5 NDS SOLN LINEZOLID SUSR; TABS 5 NDS LINEZOLID IN SODIUM 5 NDS CHLORIDE meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of FLAGYL) TABS metronidazole in nacl NEBUPENT B/D nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg applies if 70 years and older after a 90 day supply in a calendar year; nitrofurantoin monohyd macro (generic of MACROBID) applies if 70 years and older after a 90 day supply in a calendar year; PENTAM 300 SIVEXTRO 5 NDS sulfamethoxazole-trimethop ds (generic of BACTRIM DS) sulfamethoxazole-trimethopri m inj sulfamethoxazole-trimethopri m susp sulfamethoxazole-trimethopri m tab (generic of BACTRIM) SYNERCID 5 NDS trimethoprim TABS TYGACIL 5 NDS vancomycin hcl (generic of 5 NDS VANCOCIN HCL) CAPS vancomycin hcl SOLR VANCOMYCIN IN NACL ANTIFUNGALS ABELCET 5 NDS B/D AMBISOME B/D 10

13 017 SSI Choice 1755 v6 eff 01/01/017 amphotericin b SOLR B/D CANCIDAS 5 NDS fluconazole (generic of 3 DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS fluconazole in dextrose fluconazole inj nacl 100 fluconazole inj nacl 00 fluconazole inj nacl 00 flucytosine (generic of ANCOBON) CAPS 5 NDS griseofulvin microsize SUSP 3 griseofulvin microsize TABS griseofulvin ultramicrosize (generic of GRIS-PEG) itraconazole (generic of SPORANOX) CAPS ketoconazole TABS MYCAMINE 5 NDS NOXAFIL SUSP; TBEC 5 NDS nystatin TABS 3 terbinafine hcl (generic of LAMISIL) TABS voriconazole (generic of VFEND IV) SOLR voriconazole (generic of 5 NDS VFEND) SUSR; TABS ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate 3 TABS 50mg chloroquine phosphate 3 (generic of ARALEN) TABS 500mg COARTEM mefloquine hcl 3 PRIMAQUINE PHOSPHATE 3 quinine sulfate (generic of QUALAQUIN) CAPS ANTIRETROVIRAL AGENTS abacavir sulfate (generic of 3 ZIAGEN) APTIVUS 5 NDS CRIXIVAN didanosine (generic of VIDEX EC) EDURANT 5 NDS EMTRIVA 3 FUZEON 5 NDS NM INTELENCE 5mg INTELENCE 100mg, 00mg 5 NDS INVIRASE 5 NDS ISENTRESS CHEW 5mg 3 ISENTRESS CHEW 100mg 5 NDS ISENTRESS CK 5 NDS ISENTRESS TABS 5 NDS lamivudine (generic of 3 EPIVIR) LEXIVA SUSP LEXIVA TABS 5 NDS NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 100mg (generic of VIRAMUNE XR) nevirapine tab 00mg 3 (generic of VIRAMUNE) nevirapine tb (generic of VIRAMUNE XR) NORVIR 3 PREZISTA SUSP 5 NDS PREZISTA TABS 75mg, 3 150mg PREZISTA TABS 600mg, 5 NDS 800mg RESCRIPTOR RETROVIR IV INFUSION REYATAZ 5 NDS SELZENTRY 5 NDS stavudine (generic of ZERIT) SUSTIVA CAPS 50mg 3 SUSTIVA CAPS 00mg 5 NDS SUSTIVA TABS 5 NDS TIVICAY 10mg 3 TIVICAY 5mg, 50mg 5 NDS TYBOST 3 VIDEX PEDIATRIC VIRACEPT 5 NDS VIREAD 5 NDS 11

14 017 SSI Choice 1755 v6 eff 01/01/017 VITEKTA 5 NDS ZIAGEN SOLN 3 zidovudine (generic of RETROVIR) CAPS; SYRP zidovudine TABS 3 ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR) 5 NDS ATRIPLA 5 NDS COMPLERA 5 NDS DESCOVY 5 NDS EPZICOM 5 NDS EVOTAZ 5 NDS GENVOYA 5 NDS KALETRA SOL 5 NDS KALETRA TAB 100-5MG 3 KALETRA TAB 00-50MG 5 NDS lamivudine-zidovudine (generic of COMBIVIR) ODEFSEY 5 NDS PREZCOBIX 5 NDS STRIBILD 5 NDS TRIUMEQ 5 NDS TRUVADA TAB NDS QL QL (60 tabs / 30 days) TRUVADA TAB NDS QL QL (30 tabs / 30 days) TRUVADA TAB NDS QL QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) 5 NDS QL ANTITUBERCULAR AGENTS CASTAT SULFATE cycloserine CAPS 5 NDS ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml paser d/r 3 PRIFTIN pyrazinamide TABS rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) 3 CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO 5 NDS LA TRECATOR ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS acyclovir (generic of ZOVIRAX) SUSP acyclovir (generic of ZOVIRAX) TABS acyclovir sodium SOLN B/D acyclovir sodium SOLR B/D 500mg adefovir dipivoxil (generic of 5 NDS HEPSERA) BARACLUDE SOLN 5 NDS DAKLINZA 5 NDS NM entecavir (generic of 5 NDS BARACLUDE) EPIVIR HBV SOLN famciclovir (generic of 3 FAMVIR) TABS ganciclovir inj 500mg (generic 3 B/D of CYTOVENE) lamivudine (hbv) (generic of EPIVIR HBV) moderiba tab 00mg (generic of COPEGUS) NM PEGASYS 5 NDS NM PEGASYS PROCLICK 5 NDS NM REBETOL SOL 0MG/ML 5 NDS NM RELENZA DISKHALER 3 ribasphere (generic of 3 NM REBETOL) CAPS ribasphere (generic of NM COPEGUS) TABS 00mg ribasphere TABS 00mg, 5 NDS NM 600mg ribavirin cap 00mg (generic of REBETOL) 3 NM 1

15 017 SSI Choice 1755 v6 eff 01/01/017 ribavirin tab 00mg (generic NM of COPEGUS) rimantadine hydrochloride (generic of FLUMADINE) SOVALDI 5 NDS NM TAMIFLU 3 TYZEKA 5 NDS valacyclovir hcl (generic of 3 VALTREX) TABS VALCYTE SOLR 5 NDS valganciclovir hcl (generic of 5 NDS VALCYTE) CEPHALOSPORINS cefaclor CAPS 3 cefaclor SUSR cefaclor er tab 500mg cefadroxil CAPS cefadroxil SUSR 3 cefadroxil TABS CEFAZOLIN IN DEXTROSE GM/100ML-% cefazolin inj cefazolin sodium 1gm, 0gm cefazolin sodium 1 gm/50ml cefdinir CAPS 3 cefdinir SUSR cefepime hcl (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium (generic of CLAFORAN) 1gm, gm, 500mg cefoxitin sodium cefpodoxime proxetil cefprozil SUSR cefprozil TABS 3 ceftazidime (generic of FORTAZ) CEFTAZIDIME/DEXTROSE ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm ceftriaxone sodium SOLR 1gm, gm, 10gm, 50mg, 500mg Drug Tier cefuroxime axetil (generic of 3 CEFTIN) cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg cephalexin (generic of KEFLEX) CAPS 50mg, 500mg cephalexin SUSR 3 SUPRAX CAPS 3 suprax CHEW SUPRAX SUSR 500mg/5ml 3 Requirements/ Limits tazicef (generic of FORTAZ) SOLR tazicef vial (generic of FORTAZ) TEFLARO 5 NDS ERYTOMYCINS/MACROLIDES AZITOMYCIN CK 3 azithromycin (generic of ZITOMAX) SOLR azithromycin (generic of 3 ZITOMAX) SUSR azithromycin (generic of ZITOMAX) TABS clarithromycin (generic of 3 BIAXIN) TABS clarithromycin er (generic of BIAXIN XL) clarithromycin for susp 15mg/5ml clarithromycin for susp (generic of BIAXIN) 50mg/5ml DIFICID 5 NDS e.e.s. 00mg tab ery-tab erythrocin lactobionate erythrocin stearate erythromycin base erythromycin cap 50mg ec erythromycin ethylsuccinate FLUOROQUINOLONES ciprofloxacin (generic of CIPRO) SUSR 13

16 017 SSI Choice 1755 v6 eff 01/01/017 ciprofloxacin er (generic of CIPRO XR) ciprofloxacin hcl tab 100mg, 750mg ciprofloxacin hcl tab (generic of CIPRO) 50mg, 500mg ciprofloxacin in d5w ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W) ciprofloxacin inj levofloxacin (generic of LEVAQUIN) TABS levofloxacin in d5w levofloxacin inj 5mg/ml levofloxacin oral soln 5 mg/ml PENICILLINS amoxicillin amoxicillin & pot clavulanate 3 CHEW amoxicillin & pot clavulanate 3 SUSR amoxicillin & pot clavulanate 3 (generic of AUGMENTIN) SUSR amoxicillin & pot clavulanate 3 (generic of AUGMENTIN ES-600) SUSR amoxicillin & pot clavulanate TABS amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB1 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK CK) ampicillin cap ampicillin inj ampicillin sodium ampicillin susp 3 BICILLIN L-A dicloxacillin sodium nafcillin sodium oxacillin sodium 1gm, gm oxacillin sodium 10gm 5 NDS PENICILLIN G POT IN DEXTROSE penicillin g procaine penicillin g sodium penicillin v potassium penicilln gk inj 5mu penicilln gk inj 0mu pfizerpen-g piperacillin sodium-tazobactam sodium (generic of ZOSYN) TETRACYCLINES doxy doxycycline (monohydrate) CAPS 50mg doxycycline (monohydrate) (generic of MONODOX) CAPS 100mg doxycycline (monohydrate) 3 (generic of ADOXA) TABS 50mg, 75mg, 100mg doxycycline (monohydrate) 3 (generic of ADOXA K 1/150) TABS 150mg doxycycline hyclate CAPS 3 50mg doxycycline hyclate (generic 3 of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate TABS minocycline hcl (generic of MINOCIN) CAPS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 NDS B/D NM BICNU 5 NDS B/D BUSULFEX 5 NDS B/D CYCLOPHOSPHAMIDE CAPS B/D 1

17 017 SSI Choice 1755 v6 eff 01/01/017 cyclophosphamide SOLR 5 NDS B/D dacarbazine 3 B/D EMCYT GLEOSTINE HEXALEN 5 NDS IFEX 3gm B/D ifosfamide inj 1gm (generic of B/D IFEX) ifosfamide inj 1gm/0ml B/D IFOSFAMIDE INJ 3GM B/D ifosfamide inj 3gm/60ml B/D LEUKERAN melphalan hcl (generic of 5 NDS B/D ALKERAN) MUSTARGEN 5 NDS B/D TREANDA 5 NDS B/D NM ANTACYCLINES daunorubicin hcl B/D doxorubicin hcl 50mg B/D doxorubicin hcl inj mg/ml B/D doxorubicin hcl liposomal 5 NDS B/D (generic of DOXIL) epirubicin hcl (generic of B/D ELLENCE) idarubicin hcl (generic of 5 NDS B/D IDAMYCIN PFS) ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR 5 NDS B/D ANTIMETABOLITES adrucil B/D ALIMTA 5 NDS B/D azacitidine (generic of 5 NDS B/D NM VIDAZA) cladribine 5 NDS B/D cytarabine 0mg/ml B/D fludarabine phosphate B/D SOLN fludarabine phosphate B/D (generic of FLUDARA) SOLR fluorouracil SOLN B/D GEMCITABINE HCL SOLN 5 NDS B/D gemcitabine hcl (generic of GEMZAR) SOLR 1gm, 00mg 5 NDS B/D gemcitabine hcl SOLR gm 5 NDS B/D mercaptopurine TABS METHOTREXATE SODIUM B/D 50mg/ml methotrexate sodium 50mg/ml, 100mg/ml, 00mg/8ml, 50mg/10ml B/D methotrexate sodium inj B/D NIPENT 5 NDS B/D PURIXAN 5 NDS NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE 5 NDS B/D DOCEFREZ 0mg 5 NDS B/D DOCETAXEL CONC 5 NDS B/D 0mg/ml DOCETAXEL CONC 5 NDS B/D 80mg/ml, 160mg/8ml docetaxel CONC 10mg/7ml 5 NDS B/D DOCETAXEL SOLN 5 NDS B/D DOCETAXEL SOLN 5 NDS B/D 80MG/8ML paclitaxel B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar B/D vincristine sulfate B/D vinorelbine tartrate (generic of NAVELBINE) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN BELEODAQ 5 NDS NM ERIVEDGE FARYDAK HERCEPTIN 5 NDS NM IBRANCE ISTODAX 5 NDS B/D NM KADCYLA 5 NDS B/D NM KEYTRUDA 5 NDS NM LYNRZA NINLARO 5 NDS NM 15

18 017 SSI Choice 1755 v6 eff 01/01/017 PROLEUKIN 5 NDS B/D NM RITUXAN TECENTRIQ VELCADE 5 NDS NM VENCLEXTA 10mg, 50mg NM LA VENCLEXTA 100mg VENCLEXTA STARTING CK YERVOY 5 NDS NM ZOLINZA 5 NDS NM HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of 3 CASODEX) DEPO-PROVERA INJ 00/ML B/D exemestane (generic of AROMASIN) FARESTON 5 NDS FASLODEX 5 NDS B/D flutamide hydroxyprogesterone B/D caproate (antineoplastic) letrozole (generic of 3 FEMARA) TABS leuprolide inj 1mg/0. 3 NM LUPRON DEPOT 3.75mg 5 NDS NM LUPRON DEPOT INJ 5 NDS NM 11.5MG (3-MONTH) LYSODREN 3 megestrol ac sus 0mg/ml (generic of MEGACE ORAL) megestrol ac tab 0mg megestrol ac tab 0mg MEGESTROL SUS 65MG/5ML NILANDRON 5 NDS nilutamide 5 NDS SOLTAMOX tamoxifen citrate TABS 1 TRELSTAR DEP INJ 3.75MG 5 NDS NM TRELSTAR LA INJ 11.5MG 5 NDS NM XTANDI ZYTIGA KINASE INHIBITORS AFINITOR AFINITOR DISPERZ ALECENSA BOSULIF CABOMETYX CAPRELSA COMETRIQ COTELLIC GILOTRIF TAB 0MG GILOTRIF TAB 30MG GILOTRIF TAB 0MG ICLUSIG imatinib mesylate (generic of GLEEVEC) 100mg QL (90 tabs / 30 days) imatinib mesylate (generic of GLEEVEC) 00mg QL (60 tabs / 30 days) IMBRUVICA CAP 10MG 5 NDS NM 5 NDS NM 5 NDS NM 5 NDS QL NM 5 NDS QL NM INLYTA IRESSA JAKAFI LENVIMA 8 MG DAILY DOSE LENVIMA 10 MG DAILY DOSE 16

19 017 SSI Choice 1755 v6 eff 01/01/017 LENVIMA 1 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 0 MG DAILY DOSE LENVIMA MG DAILY DOSE MEKINIST NEXAVAR SPRYCEL STIVARGA SUTENT TAFINLAR TAGRISSO TARCEVA TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA MISCELLANEOUS bexarotene (generic of TARGRETIN) 5 NDS NM 5 NDS NM 5 NDS NM 5 NDS NM DROXIA 3 hydroxyurea (generic of 3 HYDREA) CAPS LONSURF 5 NDS NM MATULANE 5 NDS LA mitoxantrone hcl 3 B/D NM ODOMZO SYLATRON KIT 00MCG 5 NDS NM 5 NDS NM 5 NDS NM 5 NDS NM SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYNRIBO tretinoin (chemotherapy) 5 NDS TRISENOX 5 NDS B/D PLATINUM-BASED AGENTS carboplatin B/D cisplatin 3 B/D oxaliplatin B/D PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL) 5 NDS B/D dexrazoxane (generic of 5 NDS B/D ZINECARD) ELITEK 5 NDS B/D FUSILEV 5 NDS B/D NM leucovorin calcium SOLR B/D leucovorin calcium TABS 3 leucovorin calcium for inj 500 mg B/D levoleucovorin calcium 5 NDS B/D NM mesna (generic of MESNEX) B/D MESNEX TABS 5 NDS TOPOISOMERASE INHIBITORS etoposide SOLN 3 B/D irinotecan hcl (generic of CAMPTOSAR) 0mg/ml, 100mg/5ml B/D irinotecan hcl 500mg/5ml B/D toposar 3 B/D TOPOTECAN HCL SOLN 5 NDS B/D topotecan hcl (generic of 5 NDS B/D HYCAMTIN) SOLR CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap.5-10 mg amlodipine besylate-benazepril hcl cap 5-10 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5-0 mg (generic of LOTREL) 17

20 017 SSI Choice 1755 v6 eff 01/01/017 amlodipine besylate-benazepril hcl cap 5-0 mg amlodipine besylate-benazepril hcl cap 10-0 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 10-0 mg (generic of LOTREL) benazepril & hydrochlorothiazide benazepril & hydrochlorothiazide (generic of LOTENSIN HCT) captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide enalapril maleate & hydrochlorothiazide (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide (generic of ZESTORETIC) Drug Tier moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide (generic of ACCURETIC) ACE INHIBITORS benazepril hcl TABS 5mg 1 benazepril hcl (generic of 1 LOTENSIN) TABS 10mg, 0mg, 0mg captopril TABS enalapril maleate (generic of VASOTEC) TABS fosinopril sodium lisinopril (generic of ZESTRIL) 1 TABS.5mg, 30mg, 0mg lisinopril (generic of PRINIVIL) 1 TABS 5mg, 10mg, 0mg moexipril hcl perindopril erbumine mg 1 Requirements/ Limits perindopril erbumine (generic of ACEON) mg, 8mg quinapril hcl (generic of ACCUPRIL) ramipril (generic of ALTACE) trandolapril (generic of MAVIK) ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA) spironolactone (generic of 1 ALDACTONE) TABS ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) 1mg, mg, mg QL (30 tabs / 30 days) doxazosin mesylate (generic 3 of CARDURA) 8mg prazosin hcl (generic of 3 MINIPRESS) terazosin hcl ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab mg (generic of EXFORGE) amlodipine besylate-valsartan tab 5-30 mg (generic of EXFORGE) amlodipine besylate-valsartan tab mg (generic of EXFORGE) amlodipine besylate-valsartan tab mg (generic of EXFORGE) amlodipine-valsartan-hctz tab mg (generic of EXFORGE HCT) amlodipine-valsartan-hctz tab mg (generic of EXFORGE HCT) amlodipine-valsartan-hctz tab mg (generic of EXFORGE HCT) 18

21 017 SSI Choice 1755 v6 eff 01/01/017 amlodipine-valsartan-hctz tab mg (generic of EXFORGE HCT) amlodipine-valsartan-hctz tab mg (generic of EXFORGE HCT) ENTRESTO irbesartan-hydrochlorothiazide (generic of AVALIDE) losartan potassium & hctz tab mg (generic of HYZAAR) losartan potassium & hctz tab mg (generic of HYZAAR) losartan potassium & hctz tab mg (generic of HYZAAR) valsartan & hctz tab mg (generic of DIOVAN HCT) valsartan & hctz tab mg (generic of DIOVAN HCT) valsartan & hctz tab 160-5mg (generic of DIOVAN HCT) valsartan & hctz tab mg (generic of DIOVAN HCT) valsartan & hctz tab 30-5mg (generic of DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan (generic of AVAPRO) losartan potassium (generic of 1 COZAAR) valsartan (generic of DIOVAN) ANTIARRHYTHMICS amiodarone hcl soln amiodarone tab 100mg amiodarone tab 00mg (generic of CORDARONE) amiodarone tab 00mg disopyramide phosphate (generic of NORCE) Drug Tier Requirements/ Limits DOFETILIDE NM flecainide acetate 3 mexiletine hcl MULTAQ NORCE CR pacerone 100mg, 00mg pacerone (generic of CORDARONE) 00mg propafenone hcl 150mg, 3 300mg propafenone hcl (generic of 3 RYTHMOL) 5mg propafenone hcl 1hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS sorine (generic of BETACE) 80mg, 10mg, 160mg sorine 0mg sotalol hcl (generic of BETACE) 80mg, 10mg, 160mg sotalol hcl 0mg sotalol hcl (afib/afl) (generic of 3 BETACE AF) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic 1 of LIPITOR) TABS CRESTOR QL QL (30 tabs / 30 days) lovastatin 10mg, 0mg lovastatin (generic of MEVACOR) 0mg pravastatin sodium 10mg pravastatin sodium (generic of PRAVACHOL) 0mg, 0mg, 80mg simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 0mg, 0mg 1 19

22 017 SSI Choice 1755 v6 eff 01/01/017 simvastatin (generic of ZOCOR) TABS 80mg QL (30 tabs / 30 days) 1 QL ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light colestipol hcl (generic of COLESTID) fenofibrate (generic of TRICOR) TABS 8mg, 15mg fenofibrate (generic of LOFIBRA) TABS 5mg, 160mg fenofibrate micronized (generic of LOFIBRA) 67mg, 13mg, 00mg gemfibrozil (generic of LOPID) TABS JUXTAPID KYNAMRO 5 NDS NM niacin er (antihyperlipidemic) (generic of NIASN) niacor 3 omega-3-acid ethyl esters (generic of LOVAZA) PRALUENT 5 NDS NM prevalite (generic of QUESTRAN LIGHT) VASCE WELCHOL 3 ZETIA BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50) atenolol & chlorthalidone (generic of TENORETIC 100) bisoprolol & hydrochlorothiazide (generic of ZIAC) metoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT) BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS Drug Tier 3 atenolol (generic of 1 TENORMIN) TABS bisoprolol fumarate (generic of ZEBETA) BYSTOLIC carvedilol (generic of COREG) labetalol hcl TABS 3 metoprolol succinate (generic of TOPROL XL) metoprolol tartrate SOLN metoprolol tartrate TABS 1 5mg metoprolol tartrate (generic of 1 LOPRESSOR) TABS 50mg, 100mg pindolol propranolol cap er 60mg, 80mg propranolol cap er (generic of INDERAL LA) 10mg, 160mg propranolol hcl SOLN propranolol hcl TABS 3 propranolol oral sol 3 timolol maleate TABS CALCIUM CHANNEL BLOCKERS afeditab cr (generic of 3 ADALAT CC) amlodipine besylate (generic 1 of NORVASC) TABS cartia xt (generic of 3 CARDIZEM CD) dilt-xr cap 3 diltiazem cap (generic of 3 TIAZAC) diltiazem cap 10mg/hr 3 diltiazem cap 0mg/hr 3 diltiazem cap er/1hr Requirements/ Limits 0

23 017 SSI Choice 1755 v6 eff 01/01/017 Drug Tier diltiazem hcl SOLN diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 10mg diltiazem hcl TABS 90mg diltiazem hcl coated beads 3 (generic of CARDIZEM CD) CP felodipine 3 isradipine nicardipine hcl CAPS Requirements/ Limits nifedical (generic of 3 PROCARDIA XL) nifedipine (generic of ADALAT 3 CC) TB nifedipine er (generic of 3 PROCARDIA XL) nimodipine CAPS 5 NDS NYMALIZE 5 NDS taztia (generic of TIAZAC) 3 verapamil cap er (generic of VERELAN PM) 100mg, 00mg, 300mg verapamil cap er (generic of VERELAN) 10mg, 180mg, 0mg VERAMIL CAP ER 360mg verapamil hcl SOLN verapamil hcl TABS 0mg verapamil hcl (generic of CALAN) TABS 80mg, 10mg verapamil hcl (generic of CALAN SR) TBCR verapamil tab er (generic of CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) 3.5mg if 70 years and older; digitek (generic of LANOXIN).15mg QL (30 tabs / 30 days) (doses > 0.15 mg/day) digox (generic of LANOXIN) 15mcg QL (30 tabs / 30 days) (doses > 0.15 mg/day) digox (generic of LANOXIN) 50mcg if 70 years and older; digoxin (generic of LANOXIN) TABS 15mcg QL (30 tabs / 30 days) (doses > 0.15 mg/day) digoxin (generic of LANOXIN) TABS 50mcg if 70 years and older; digoxin inj (generic of LANOXIN) (doses > 0.15 mg/day) DIGOXIN SOL 50MCG/ML if 70 years and older; DIURETICS acetazolamide (generic of DIAMOX) CP1 acetazolamide TABS 3 amiloride & hydrochlorothiazide amiloride hcl TABS 3 bumetanide SOLN bumetanide (generic of 3 BUMEX) TABS chlorothiazide tabs 3 chlorthalidone 5mg, 50mg 3 furosemide SOLN furosemide (generic of LASIX) 1 TABS furosemide inj 10mg/ml FUROSEMIDE INJ 10mg/ml hydrochlorothiazide (generic 1 of MICROZIDE) CAPS hydrochlorothiazide TABS 1 indapamide methazolamide (generic of NEPTAZANE) TABS methyclothiazide

24 017 SSI Choice 1755 v6 eff 01/01/017 metolazone 3 spironolactone & 3 hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs (generic of DEMADEX) 5mg, 10mg, 0mg torsemide tabs 100mg triamterene & 1 hydrochlorothiazide (generic of MAXZIDE) TABS triamterene & 1 hydrochlorothiazide (generic of MAXZIDE-5) TABS triamterene & hydrochlorothiazide cap mg (generic of DYAZIDE) MISCELLANEOUS clonidine hcl (generic of CATAPRES-TTS-1) PTWK.1mg/hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/hr clonidine hcl (generic of CATAPRES-TTS-3) PTWK.3mg/hr clonidine hcl (generic of CATAPRES) TABS DEMSER 5 NDS hydralazine hcl SOLN hydralazine hcl TABS midodrine hcl minoxidil TABS NORTHERA RANEXA NITRATES isosorb mononitrate tab isosorbide dinitrate (generic of 3 ISORDIL TITRADOSE) 5mg isosorbide dinitrate 10mg, 3 0mg, 30mg isosorbide dinitrate er isosorbide mononitrate er Drug Tier 3 minitran (generic of NITRO-DUR) nitro-bid 3 NITRO-DUR DIS 0.3MG/ NITRO-DUR DIS 0.8MG/ nitroglycerin td patch 3 NITROSTAT 3 PULMONARY ARTERIAL HYPERTENSION Requirements/ Limits ADCIRCA 5 NDS NM ADEMS QL (90 tabs / 30 days) 5 NDS QL NM LA LETAIRIS QL (30 tabs / 30 days) 5 NDS QL NM LA OPSUMIT REMODULIN REVATIO SUSR QL ( ml / 30 days) 5 NDS QL NM sildenafil citrate (pulmonary NM hypertension) (generic of REVATIO) TABS QL (90 tabs / 30 days) UPTRAVI TABS 00mcg QL (80 tabs / 30 days) 5 NDS QL NM LA UPTRAVI TABS 00mcg QL (0 tabs / 30 days) 5 NDS QL NM LA UPTRAVI TABS 600mcg QL (150 tabs / 30 days) 5 NDS QL NM LA UPTRAVI TABS 800mcg QL (10 tabs / 30 days) 5 NDS QL NM LA UPTRAVI TABS 1000mcg QL (90 tabs / 30 days) 5 NDS QL NM LA UPTRAVI TABS 100mcg, 100mcg, 1600mcg 5 NDS QL NM LA QL (60 tabs / 30 days) UPTRAVI TBPK VENTAVIS 5 NDS NM CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg (generic of XANAX) QL (0 tabs / 30 days) QL

25 017 SSI Choice 1755 v6 eff 01/01/017 alprazolam tab 0.5mg (generic of XANAX) QL (80 tabs / 30 days) alprazolam tab 1mg (generic of XANAX) QL (10 tabs / 30 days) alprazolam tab mg (generic of XANAX) QL (150 tabs / 30 days) QL QL QL buspirone hcl TABS fluvoxamine maleate TABS 5mg, 50mg QL (5 tabs / 30 days) fluvoxamine maleate TABS 100mg lorazepam CONC QL (150 ml / 30 days) lorazepam (generic of ATIVAN) SOLN lorazepam (generic of ATIVAN) TABS QL (150 tabs / 30 days) ANTICONVULSANTS APTIOM 00mg QL (180 tabs / 30 days) 3 QL QL APTIOM 00mg QL QL (90 tabs / 30 days) APTIOM 600mg QL QL (60 tabs / 30 days) APTIOM 800mg QL QL (30 tabs / 30 days) BANZEL SUS 0MG/ML 5 NDS BANZEL TAB 00MG 5 NDS BANZEL TAB 00MG 5 NDS BRIVIACT SOLN 10mg/ml 5 NDS BRIVIACT SOLN 50mg/5ml BRIVIACT TABS 5 NDS carbamazepine CHEW 3 carbamazepine (generic of CARBATROL) CP1 carbamazepine (generic of TEGRETOL) SUSP; TABS carbamazepine (generic of TEGRETOL-XR) TB1 CELONTIN clonazepam (generic of KLONOPIN) TABS 1mg QL (10 tabs / 30 days) clonazepam (generic of KLONOPIN) TABS mg QL (300 tabs / 30 days) clonazepam (generic of KLONOPIN) TABS.5mg QL (0 tabs / 30 days) clonazepam TBDP 1mg QL (10 tabs / 30 days) clonazepam TBDP mg QL (300 tabs / 30 days) clonazepam TBDP.5mg QL (0 tabs / 30 days) clonazepam TBDP.5mg QL (80 tabs / 30 days) clonazepam TBDP.15mg QL (960 tabs / 30 days) clorazepate dipotassium 3.75mg QL (10 tabs / 30 days) clorazepate dipotassium (generic of TRANXENE T) 7.5mg QL (10 tabs / 30 days) clorazepate dipotassium 15mg QL (180 tabs / 30 days) QL QL QL diazepam CONC QL (0 ml / 30 days) diazepam SOLN 1mg/ml QL (100 ml / 30 days) diazepam SOLN 5mg/ml diazepam (generic of VALIUM) TABS QL QL (10 tabs / 30 days) DIAZEM GEL (ANTICONVULSANT) dilantin DILANTIN-15 SUS 15/5ML divalproex sodium (generic of DEKOTE SPRINKLES) CSDR divalproex sodium (generic of DEKOTE ER) TB 3

26 017 SSI Choice 1755 v6 eff 01/01/017 divalproex sodium (generic of 3 DEKOTE) TBEC epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of 5 NDS FELBATOL) SUSP felbamate (generic of FELBATOL) TABS FYCOM SUSP QL QL (70 ml / 30 days) FYCOM TABS mg QL QL (180 tabs / 30 days) FYCOM TABS mg QL QL (90 tabs / 30 days) FYCOM TABS 6mg QL QL (60 tabs / 30 days) FYCOM TABS 8mg, QL 10mg, 1mg QL (30 tabs / 30 days) gabapentin (generic of NEURONTIN) CAPS; TABS gabapentin (generic of NEURONTIN) SOLN GABITRIL 1mg, 16mg lamotrigine (generic of 3 LAMICTAL CHEWABLE DISPERS) CHEW lamotrigine (generic of LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB levetiracetam (generic of 3 KEPPRA) TABS levetiracetam (generic of 3 KEPPRA XR) TB levetiracetam inj (generic of KEPPRA) LEVETIRACETAM IV levetiracetam sol 100mg/ml 3 (generic of KEPPRA) LYRICA CAPS 5mg, 50mg, 75mg, 100mg, 150mg QL (10 caps / 30 days) LYRICA CAPS 00mg QL (90 caps / 30 days) LYRICA CAPS 5mg, 300mg QL (60 caps / 30 days) LYRICA SOLN QL (96 ml / 30 days) ONFI SOLN 5 NDS ONFI TAB 10mg ONFI TAB 0mg 5 NDS oxcarbazepine (generic of TRILEPTAL) SUSP oxcarbazepine (generic of 3 TRILEPTAL) TABS PEGANONE phenobarbital ELIX; TABS if 70 years and older; PHENOBARBITAL SODIUM SOLN 65mg/ml if 70 years and older; phenobarbital sodium SOLN 130mg/ml if 70 years and older; phenytek phenytoin (generic of 3 DILANTIN INFATABS) CHEW phenytoin (generic of 3 DILANTIN-15) SUSP phenytoin sodium SOLN phenytoin sodium extended 3 (generic of DILANTIN) 100mg phenytoin sodium extended (generic of PHENYTEK) 00mg, 300mg POTIGA 50mg POTIGA 00mg QL QL (180 tabs / 30 days) POTIGA 300mg, 00mg QL QL (90 tabs / 30 days) primidone (generic of MYSOLINE) TABS roweepra (generic of KEPPRA) 3 3

27 017 SSI Choice 1755 v6 eff 01/01/017 SABRIL CK QL (180 packets / 30 days) SABRIL TABS QL (180 tabs / 30 days) SPRITAM TEGRETOL TEGRETOL-XR 5 NDS QL NM LA 5 NDS QL NM LA tiagabine hcl (generic of GABITRIL) topiramate (generic of TOMAX SPRINKLE) CPSP topiramate (generic of 3 TOMAX) TABS valproate sodium (generic of DECON) SOLN valproate sodium (generic of DEKENE) SYRP valproic acid (generic of 3 DEKENE) VIMT SOLN 10mg/ml QL QL (100 ml / 30 days) VIMT SOLN 00mg/0ml VIMT TABS 50mg QL QL (180 tabs / 30 days) VIMT TABS 100mg, QL 150mg, 00mg QL (60 tabs / 30 days) zonisamide (generic of 3 ZONEGRAN) CAPS 5mg, 100mg zonisamide CAPS 50mg 3 ANTIDEMENTIA donepezil hydrochloride QL (generic of ARICEPT) TABS 5mg QL (60 tabs / 30 days) donepezil hydrochloride (generic of ARICEPT) TABS 10mg donepezil hydrochloride (generic of ARICEPT) TABS 3mg donepezil hydrochloride TBDP 5mg QL (60 tabs / 30 days) donepezil hydrochloride 3 TBDP 10mg EXELON TCHES QL (30 patches / 30 days) galantamine hydrobromide SOLN galantamine hydrobromide (generic of RAZADYNE) TABS galantamine hydrobromide er (generic of RAZADYNE ER) memantine hcl (generic of 3 NAMENDA) SOLN if < 30 yrs memantine hcl (generic of NAMENDA) TABS 5mg if < 30 yrs MEMANTINE HCL TABS 10mg if < 30 yrs NAMENDA XR if < 30 yrs NAMENDA XR TITRATION CK if < 30 yrs NAMZARIC rivastigmine tartrate (generic of EXELON) ANTIDEPRESSANTS amitriptyline hcl TABS 10mg, 50mg, 75mg, 100mg, 150mg amitriptyline hcl (generic of ELAVIL) TABS 5mg amoxapine 3 bupropion hcl TABS 3 bupropion hcl (generic of WELLBUTRIN SR) TB1 bupropion hcl (generic of 3 WELLBUTRIN XL) TB citalopram hydrobromide SOLN citalopram hydrobromide (generic of CELEXA) TABS 1 5