formulary list of covered drugs

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1 0 7 formulary list of covered drugs Johns Hopkins Advantage MD Plus and Johns Johns Hopkins Hopkins Advantage MD PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 0007, Version 6 This formulary was updated on /0/07. For more recent information or other questions, please contact Johns Hopkins Advantage MD Customer Service at or, for TTY users, 7, 4 hours a day, 7 days a week, or visit H3890_Formulary_086 Approved 086

2 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 Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO). When it refers to plan or our plan, it means Johns Hopkins Advantage MD and Johns Hopkins Advantage MD Plus This document includes a list of the drugs (formulary) for our plan which is current as of November, 07. 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, 08, and from time to time during the year. What is the Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. 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 07 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 07 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 we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November, 07. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (i.e. 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 information may be obtained from our website or by calling us at the number provided on the front and back cover pages.

3 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. 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 7. 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? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per prescription for Januvia tablets. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our 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, our plan 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 Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

4 You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Johns Hopkins Advantage MD and Johns Hopkins Advantage MD Plus 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 Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by us. 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 our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Johns Hopkins Advantage MD and Johns Hopkins Advantage MD Plus Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, 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, we 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 4 hours after we get a supporting statement from your doctor or other prescriber. 3

5 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 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 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. 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 while you pursue a formulary exception. If you experience a change in your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary (or if your ability to get your drugs is limited), we will cover a one-time temporary supply for up to 30-days (or 3-days if you are a long-term care resident) from a network pharmacy. During this period 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 Johns Hopkins Advantage MD and Johns Hopkins Advantage MD Plus 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 ( ) 4 hours a day/7 days a week. TTY users should call Or, visit Johns Hopkins Advantage MD and Johns Hopkins Advantage MD Plus Formulary The formulary below 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 7. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4

6 PA Prior authorization QL Drug has quantity limit ST Step therapy required NM Not available at mail-order pharmacies LA Limited Access. This prescription may be available only at certain pharmacies. For more information call Customer Service B/D This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Not available as. Johns Hopkins Advantage MD Cost Sharing Tier Cost-Sharing Tier (Preferred Generic) Cost-Sharing Tier (Generic) Cost-Sharing Tier 3 (Preferred Brand) Cost-Sharing Tier 4 (Non-Preferred Drug) Standard Retail Cost-Sharing (in-network) $7 copay for a 30-day supply $4 copay for a 60-day supply $ copay for a 90-day supply $ copay for a 30-day supply $30 copay for a 60-day supply $4 copay for a 90-day supply $4 copay for a 30-day supply $90 copay for a 60-day supply $3 copay for a 90-day supply $9 copay for a 30-day supply $90 copay for a 60-day supply $8 copay for a 90-day supply Standard Mail Order Cost-Sharing (in-network) $7 copay for a 30-day supply $4 copay for a 60-day supply $7.0 copay for a 90-day supply $ copay for a 30-day supply $30 copay for a 60-day supply $37.0 copay for a 90-day supply $4 copay for a 30-day supply $90 copay for a 60-day supply $.0 copay for a 90-day supply $9 copay for a 30-day supply $90 copay for a 60-day supply $37.0 copay for a 90-day supply Cost-Sharing Tier (Specialty Tier) 33% coinsurance for a 30-day supply (only) NOTE: -Drugs are provided in a Long-Term Care Facility up to a 3-day supply -Drugs in Tier are only available for a 30-day supply -You can find complete cost-sharing information in your Evidence of Coverage

7 Johns Hopkins Advantage MD Plus Cost Sharing Tier Cost-Sharing Tier (Preferred Generic) Cost-Sharing Tier (Generic) Cost-Sharing Tier 3 (Preferred Brand) Cost-Sharing Tier 4 (Non-Preferred Drug) Standard Retail Cost-Sharing (in-network) $4 copay for a 30-day supply $8 copay for a 60-day supply $ copay for a 90-day supply $ copay for a 30-day supply $4 copay for a 60-day supply $36 copay for a 90-day supply $4 copay for a 30-day supply $84 copay for a 60-day supply $6 copay for a 90-day supply $9 copay for a 30-day supply $84 copay for a 60-day supply $76 copay for a 90-day supply Standard Mail Order Cost-Sharing (in-network) $4 copay for a 30-day supply $8 copay for a 60-day supply $0 copay for a 90-day supply $ copay for a 30-day supply $4 copay for a 60-day supply $30 copay for a 90-day supply $4 copay for a 30-day supply $84 copay for a 60-day supply $0 copay for a 90-day supply $9 copay for a 30-day supply $84 copay for a 60-day supply $30 copay for a 90-day supply Cost-Sharing Tier (Specialty Tier) 33% coinsurance for a 30-day supply (only) NOTE: -Drugs are provided in a Long-Term Care Facility up to a 3-day supply -Drugs in Tier are only available for a 30-day supply -You can find complete cost-sharing information in your Evidence of Coverage 6

8 Johns Hopkins Advantage MD_CY7_TS ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM) colchicine w/ probenecid COLCRYS 3 QL QL (0 tabs / 30 probenecid ULORIC 3 ST NSAIDS celecoxib (generic of CELEBREX) CAPS 0mg QL (40 caps / 30 celecoxib (generic of CELEBREX) CAPS 00mg QL (0 caps / 30 celecoxib (generic of CELEBREX) CAPS 00mg QL (60 caps / 30 celecoxib (generic of CELEBREX) CAPS 400mg QL (30 caps / 30 diclofenac potassium QL (0 tabs / 30 diclofenac sodium TB4 diclofenac sodium TBEC diflunisal etodolac CAPS etodolac (generic of LODINE) TABS 400mg etodolac TABS 00mg etodolac er flurbiprofen TABS ibuprofen SUSP ibuprofen TABS 400mg, 600mg, 800mg ketoprofen CAPS MELOXICAM SUSP meloxicam (generic of MOBIC) TABS nabumetone TABS NAPRELAN 37mg, 00mg NAPRELAN 70mg 4 QL QL QL QL QL naproxen (generic of NAPROSYN) SUSP naproxen (generic of NAPROSYN) TABS 0mg, 00mg Drug Tier naproxen TABS 37mg naproxen (generic of EC-NAPROSYN) TBEC naproxen sodium TABS 7mg naproxen sodium (generic of ANAPROX DS) TABS 0mg NAPROXEN SODIUM TB4 piroxicam (generic of FELDENE) CAPS sulindac TABS OPIOID ANALGESICS acetaminophen w/ codeine SOLN QL (000 ml / 30 acetaminophen w/ codeine TABS QL (400 tabs / 30 acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS QL (400 tabs / 30 acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS QL (400 tabs / 30 Requirements/ Limits QL QL QL QL butorphanol tartrate SOLN mg/ml, mg/ml nalbuphine hcl SOLN tramadol hcl (generic of ULTRAM) TABS QL QL (40 tabs / 30 tramadol-acetaminophen (generic of ULTRACET) QL (40 tabs / 30 QL OPIOID ANALGESICS, CII DURAMORPH B/D endocet (generic of PERCOCET) QL (360 tabs / 30 QL mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 7

9 fentanyl citrate (generic of ACTIQ) LPOP QL (0 lozenges / 30 fentanyl patch mcg/hr (generic of DURAGESIC) QL (0 patches / 30 fentanyl patch mcg/hr (generic of DURAGESIC) QL (0 patches / 30 fentanyl patch 0 mcg/hr (generic of DURAGESIC) QL (0 patches / 30 fentanyl patch 7 mcg/hr (generic of DURAGESIC) QL (0 patches / 30 fentanyl patch 00 mcg/hr (generic of DURAGESIC) QL (0 patches / 30 FENTORA QL (0 tabs / 30 hydroco/apap tab -3mg (generic of NORCO) QL (360 tabs / 30 hydroco/apap tab 7.-3 (generic of NORCO) QL (360 tabs / 30 hydroco/apap tab 0-3mg (generic of NORCO) QL (360 tabs / 30 hydrocodone-acetaminophen 7.-3 mg/ml (generic of HYCET) QL (400 ml / 30 hydrocodone-ibuprofen tab mg QL (0 tabs / 30 hydromorphone hcl (generic of DILAUDID) LIQD hydromorphone hcl SOLN 0mg/ml, 0mg/ml, 00mg/0ml QL PA QL QL QL PA QL PA QL PA QL PA QL QL QL QL QL B/D hydromorphone hcl (generic of QL DILAUDID) TABS QL (70 tabs / 30 HYSINGLA ER 0mg, 30mg, 3 QL 40mg, 60mg HYSINGLA ER 80mg, 3 QL 00mg, 0mg lorcet hd tab 0-3mg QL (generic of NORCO) QL (360 tabs / 30 lorcet plus tab 7.-3 QL (generic of NORCO) QL (360 tabs / 30 lorcet tab -3mg (generic of QL NORCO) QL (360 tabs / 30 methadone hcl (generic of QL METHADOSE) CONC QL (0 ml / 30 methadone hcl SOLN QL mg/ml, 0mg/ml QL (600 ml / 30 methadone hcl mg (generic QL of DOLOPHINE) QL (40 tabs / 30 methadone hcl 0mg (generic QL of DOLOPHINE) QL (40 tabs / 30 morphine ext-rel tab (generic QL of MS CONTIN) mg, 30mg, 60mg, 00mg QL (90 tabs / 30 morphine ext-rel tab (generic of MS CONTIN) 00mg QL MORPHINE SUL INJ MG/ML B/D MORPHINE SUL INJ 4MG/ML B/D MORPHINE SUL INJ B/D 0MG/ML MORPHINE SUL INJ B/D MG/ML MORPHINE SULFATE B/D SOLN mg/ml, 8mg/ml, 0mg/30ml morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml B/D mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 8

10 morphine sulfate SOLN B/D.mg/ml, mg/ml MORPHINE SULFATE TABS QL (80 tabs / 30 QL MORPHINE SULFATE ORAL SOL oxycodone hcl CAPS QL QL (80 caps / 30 oxycodone hcl CONC OXYCODONE HCL SOLN oxycodone hcl (generic of QL ROXICODONE) TABS mg, mg, 30mg QL (80 tabs / 30 oxycodone hcl TABS 0mg, QL 0mg QL (80 tabs / 30 oxycodone w/ acetaminophen QL.-3mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen QL -3mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen QL 7.-3mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen QL 0-3mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen QL soln QL (800 ml / 30 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE-MPF) % lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE).% lidocaine inj 0.% (generic of B/D XYLOCAINE-MPF) lidocaine inj % (generic of XYLOCAINE) B/D lidocaine inj.% (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 neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS 4 tobramycin (generic of NM PA KITABIS PAK) NEBU tobramycin inj. gm/30ml tobramycin inj.gm tobramycin inj 0mg/ml tobramycin inj 40mg/ml tobramycin inj 80mg/ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ALINIA 4 atovaquone (generic of MEPRON) SUSP AZACTAM IN ISO-OSMOTIC 4 DE AZACTAM/DEX INJ GM 4 aztreonam (generic of AZACTAM) BILTRICIDE 3 CAYSTON clindamycin cap 7mg (generic of CLEOCIN) clindamycin cap 300mg (generic of CLEOCIN) clindamycin hcl cap 0 mg (generic of CLEOCIN) clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 9

11 clindamycin phosphate in dw (generic of CLEOCIN IN DW) CLINDAMYCIN PHOSPHATE 4 IN NACL clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) clindamycin sol 7mg/ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY-MYCIN M) SOLR CUBICIN dapsone TABS daptomycin (generic of CUBICIN) emverm 4 imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ 4 ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) SOLN LINEZOLID SUSR; TABS LINEZOLID IN SODIUM CHLORIDE meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of FLAGYL) TABS metronidazole in nacl NEBUPENT 4 B/D nitrofurantoin macrocrystal (generic of MACRODANTIN) 0mg, 00mg PA applies if 6 years and older after a 90 day supply in a calendar year 4 PA nitrofurantoin monohyd macro 4 PA (generic of MACROBID) PA applies if 6 years and older after a 90 day supply in a calendar year PENTAM SIVEXTRO sulfamethoxazole-trimethop ds (generic of BACTRIM DS) sulfamethoxazole-trimethopri m SUSP sulfamethoxazole-trimethopri m (generic of BACTRIM) TABS sulfamethoxazole-trimethopri m inj SYNERCID TIGECYCLINE trimethoprim TABS TYGACIL vancomycin hcl (generic of VANCOCIN HCL) CAPS vancomycin hcl SOLR 0gm, 00mg, 70mg, 000mg, 000mg VANCOMYCIN IN NACL 4 ANTIFUNGALS ABELCET B/D AMBISOME 4 B/D amphotericin b SOLR B/D CANCIDAS CASPOFUNGIN ACETATE fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS fluconazole in dextrose fluconazole inj nacl 00 fluconazole inj nacl 00 fluconazole inj nacl 400 mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 0

12 flucytosine (generic of ANCOBON) CAPS Drug Tier Requirements/ Limits griseofulvin microsize griseofulvin ultramicrosize (generic of GRIS-PEG) itraconazole (generic of PA SPORANOX) CAPS ketoconazole TABS PA MYCAMINE NOXAFIL SUSP; TBEC nystatin TABS terbinafine hcl (generic of LAMISIL) TABS QL (90 tabs / 36 QL voriconazole (generic of VFEND IV) SOLR voriconazole (generic of VFEND) SUSR; TABS ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate TABS COARTEM 4 mefloquine hcl PRIMAQUINE PHOSPHATE 3 quinine sulfate (generic of QUALAQUIN) CAPS PA ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) APTIVUS CRIXIVAN 4 didanosine (generic of VIDEX EC) EDURANT EMTRIVA 3 FUZEON NM INTELENCE mg 4 INTELENCE 00mg, 00mg INVIRASE ISENTRESS CHEW mg 3 ISENTRESS CHEW 00mg ISENTRESS PACK ISENTRESS TABS ISENTRESS HD lamivudine (generic of EPIVIR) LEXIVA SUSP 4 LEXIVA TABS NEVIRAPINE SUSP nevirapine (generic of VIRAMUNE) TABS nevirapine (generic of VIRAMUNE XR) TB4 NORVIR 3 PREZISTA SUSP PREZISTA TABS 7mg, 3 0mg PREZISTA TABS 600mg, 800mg RESCRIPTOR 4 RETROVIR IV INFUSION 3 REYATAZ SELZENTRY SOLN SELZENTRY TABS mg 4 SELZENTRY TABS 7mg, 0mg, 300mg stavudine (generic of ZERIT) SUSTIVA CAPS 0mg 3 SUSTIVA CAPS 00mg SUSTIVA TABS TIVICAY 0mg 3 TIVICAY mg, 0mg mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as

13 Drug Tier TYBOST 3 VIDEX PEDIATRIC 4 VIRACEPT VIRAMUNE SUSP 4 VIREAD ZERIT SOLR ZIAGEN SOLN 3 zidovudine (generic of RETROVIR) CAPS; SYRP zidovudine TABS ANTIRETROVIRAL COMBINATION AGENTS ABACAVIR SULFATE-LAMIVUDINE abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR) ATRIPLA COMPLERA DESCOVY EVOTAZ GENVOYA KALETRA SOL KALETRA TAB 00-MG 3 KALETRA TAB 00-0MG lamivudine-zidovudine (generic of COMBIVIR) lopinavir-ritonavir (generic of KALETRA) ODEFSEY PREZCOBIX STRIBILD Requirements/ Limits TRIUMEQ TRUVADA TAB 00-0 TRUVADA TAB TRUVADA TAB 67-0 TRUVADA TAB Drug Tier ANTITUBERCULAR AGENTS CAPASTAT SULFATE 4 cycloserine CAPS ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS isoniazid inj 00 mg/ml isoniazid syp 0mg/ml paser d/r 3 PRIFTIN 4 pyrazinamide TABS Requirements/ Limits QL QL QL QL rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS; SOLR RIFATER 4 SIRTURO LA PA TRECATOR 4 ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS acyclovir (generic of ZOVIRAX) SUSP acyclovir (generic of ZOVIRAX) TABS acyclovir sodium B/D adefovir dipivoxil (generic of HEPSERA) BARACLUDE SOLN mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as

14 DAKLINZA NM PA entecavir (generic of BARACLUDE) EPCLUSA NM PA EPIVIR HBV SOLN 4 famciclovir TABS mg, 0mg famciclovir (generic of FAMVIR) TABS 00mg ganciclovir inj 00mg (generic B/D of CYTOVENE) HARVONI NM PA lamivudine (hbv) (generic of EPIVIR HBV) MAVYRET NM PA moderiba tab 00mg (generic NM of COPEGUS) oseltamivir phosphate (generic of TAMIFLU) PEGASYS NM PA PEGASYS PROCLICK NM PA REBETOL SOLN NM RELENZA DISKHALER 3 ribasphere (generic of NM REBETOL) CAPS ribasphere (generic of NM COPEGUS) TABS 00mg ribasphere TABS 400mg, NM 600mg ribavirin 00mg (generic of NM REBETOL) CAPS ribavirin 00mg (generic of NM COPEGUS) TABS rimantadine hydrochloride (generic of FLUMADINE) SOVALDI NM PA TAMIFLU SUSR 3 TYZEKA valacyclovir hcl (generic of VALTREX) TABS VALCYTE SOLR valganciclovir hcl (generic of VALCYTE) Drug Tier VEMLIDY VOSEVI ZEPATIER CEPHALOSPORINS cefaclor cefaclor monohydrate er 3 cefadroxil CAPS cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE 3 GM/00ML-4% cefazolin inj cefazolin sodium SOLR gm, 0gm cefazolin sodium gm/0ml 3 cefdinir cefepime hcl (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium gm, gm, 00mg cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE 4 ceftriaxone sodium (generic of ROCEPHIN) SOLR gm ceftriaxone sodium SOLR gm, gm, 0gm, 0mg, 00mg cefuroxime axetil (generic of CEFTIN) cefuroxime sodium cephalexin (generic of KEFLEX) CAPS 0mg, 00mg cephalexin SUSR Requirements/ Limits NM PA NM PA mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 3

15 Drug Tier SUPRAX CAPS 3 suprax CHEW 4 SUPRAX SUSR 00mg/ml 3 tazicef SOLR tazicef vial TEFLARO ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK azithromycin (generic of ZITHROMAX) SOLR; SUSR azithromycin (generic of ZITHROMAX) TABS clarithromycin (generic of BIAXIN) TABS clarithromycin er (generic of BIAXIN XL) clarithromycin for susp DIFICID e.e.s. 400 ery-tab erythrocin lactobionate 4 erythrocin stearate erythromycin base erythromycin cap 0mg ec erythromycin ethylsuccinate TABS FLUOROQUINOLONES ciprofloxacin (generic of CIPRO) SUSR ciprofloxacin er (generic of CIPRO XR) ciprofloxacin hcl tab 00mg, 70mg ciprofloxacin hcl tab (generic of CIPRO) 0mg, 00mg ciprofloxacin in dw ciprofloxacin in dw (generic of CIPRO I.V.-IN DW) ciprofloxacin inj levofloxacin (generic of LEVAQUIN) TABS levofloxacin in dw levofloxacin inj mg/ml levofloxacin oral soln mg/ml PENICILLINS Requirements/ Limits Drug Tier amoxicillin amoxicillin & pot clavulanate CHEW amoxicillin & pot clavulanate SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR amoxicillin & pot clavulanate TABS amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK PACK) ampicillin cap 0 mg ampicillin cap 00 mg ampicillin inj ampicillin sodium ampicillin susp AUGMENTIN SUSR 4 BICILLIN L-A 4 dicloxacillin sodium nafcillin sodium oxacillin sodium gm, gm oxacillin sodium 0gm PENICILLIN G POT IN 4 DEXTROSE penicillin g procaine 3 penicillin g sodium penicillin v potassium penicilln gk inj mu penicilln gk inj 0mu pfizerpen-g Requirements/ Limits mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 4

16 piperacillin sodium-tazobactam sodium (generic of ZOSYN) Drug Tier piperacillin/tazobactam TETRACYCLINES doxy Requirements/ Limits doxycycline (monohydrate) CAPS 0mg doxycycline (monohydrate) (generic of MONODOX) CAPS 00mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 0mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 00mg doxycycline hyclate SOLR doxycycline hyclate TABS 0mg, 00mg minocycline hcl (generic of MINOCIN) CAPS 0mg, 00mg minocycline hcl CAPS 7mg morgidox cap x0mg ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA B/D NM BICNU B/D busulfan (generic of B/D BUSULFEX) BUSULFEX B/D CYCLOPHOSPHAMIDE 4 B/D CAPS cyclophosphamide SOLR B/D dacarbazine B/D EMCYT 4 GLEOSTINE 4 HEXALEN IFEX INJ 3GM 4 B/D ifosfamide inj gm (generic of IFEX) B/D ifosfamide inj gm/0ml B/D IFOSFAMIDE INJ 3GM 4 B/D ifosfamide inj 3gm/60ml B/D LEUKERAN 4 melphalan hcl (generic of B/D ALKERAN) MUSTARGEN B/D TREANDA B/D NM ANTHRACYCLINES adriamycin B/D daunorubicin hcl B/D doxorubicin hcl B/D doxorubicin hcl liposomal inj B/D mg/ml (generic of DOXIL) doxorubicin inj 0mg B/D epirubicin hcl (generic of B/D ELLENCE) idarubicin hcl (generic of B/D IDAMYCIN PFS) ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR B/D ANTIMETABOLITES adrucil B/D ALIMTA B/D azacitidine (generic of B/D NM VIDAZA) cladribine B/D cytarabine 0mg/ml B/D fludarabine phosphate B/D fluorouracil SOLN B/D GEMCITABINE HCL SOLN B/D gemcitabine hcl (generic of B/D GEMZAR) SOLR gm, 00mg gemcitabine hcl SOLR gm B/D mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as

17 mercaptopurine TABS METHOTREXATE SODIUM B/D 0mg/ml methotrexate sodium B/D 0mg/ml, 00mg/4ml, 00mg/8ml, 0mg/0ml methotrexate sodium inj B/D NIPENT B/D PURIXAN NM TABLOID 4 ANTIMITOTIC, TAXOIDS ABRAXANE B/D DOCEFREZ B/D DOCETAXEL 0mg/ml B/D docetaxel (generic of B/D TAXOTERE) 80mg/4ml DOCETAXEL 80mg/4ml, B/D 60mg/8ml docetaxel 00mg/0ml B/D DOCETAXEL 0MG/ML B/D DOCETAXEL 60MG/6ML B/D DOCETAXEL SOLN B/D 80MG/8ML paclitaxel B/D TAXOTERE 80mg/4ml B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 3 B/D vincasar B/D vincristine sulfate B/D vinorelbine tartrate (generic of NAVELBINE) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN BELEODAQ NM PA ERIVEDGE FARYDAK HERCEPTIN NM PA IBRANCE IDHIFA ISTODAX (OVERFILL) B/D NM KADCYLA B/D NM KEYTRUDA NM PA KISQALI NM PA KISQALI FEMARA 00 DOSE NM PA KISQALI FEMARA 400 DOSE NM PA KISQALI FEMARA 600 DOSE NM PA LYNPARZA CAPS NINLARO NM PA PROLEUKIN B/D NM RITUXAN RITUXAN HYCELA RUBRACA TECENTRIQ VELCADE NM PA VENCLEXTA 0mg, 0mg 4 NM LA PA VENCLEXTA 00mg VENCLEXTA STARTING PACK YERVOY NM PA mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 6

18 ZEJULA ZOLINZA NM PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 400/ML 4 B/D exemestane (generic of AROMASIN) FARESTON FASLODEX B/D flutamide hydroxyprogesterone 4 B/D caproate (antineoplastic) letrozole (generic of FEMARA) TABS leuprolide acetate KIT NM PA LUPRON DEPOT (-MONTH) NM PA 3.7mg LUPRON DEPOT INJ NM PA.MG (3-MONTH) LYSODREN 3 megestrol ac sus 40mg/ml 4 PA PA if 6 years and older megestrol ac tab 0mg 4 PA PA if 6 years and older megestrol ac tab 40mg 4 PA PA if 6 years and older MEGESTROL SUS 4 PA 6MG/ML nilutamide (generic of NILANDRON) SOLTAMOX 4 tamoxifen citrate TABS TRELSTAR DEP INJ 3.7MG NM PA TRELSTAR LA INJ.MG NM PA XTANDI ZYTIGA KINASE INHIBITORS AFINITOR AFINITOR DISPERZ ALECENSA ALUNBRIG BOSULIF CABOMETYX CAPRELSA COMETRIQ COTELLIC GILOTRIF TAB 0MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLEEVEC 00mg QL (90 tabs / 30 GLEEVEC 400mg ICLUSIG imatinib mesylate (generic of GLEEVEC) 00mg QL (90 tabs / 30 imatinib mesylate (generic of GLEEVEC) 400mg IMBRUVICA CAP 40MG INLYTA IRESSA NM PA NM PA NM PA QL NM PA QL NM PA QL NM PA QL NM PA mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 7

19 JAKAFI LENVIMA 8 MG DAILY DOSE LENVIMA 0 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LENVIMA 0 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE MEKINIST NERLYNX NEXAVAR RYDAPT NM PA SPRYCEL NM PA STIVARGA SUTENT NM PA TAFINLAR TAGRISSO TARCEVA TASIGNA NM PA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA MISCELLANEOUS bexarotene (generic of NM PA TARGRETIN) DROXIA 3 hydroxyurea (generic of HYDREA) CAPS LONSURF NM PA MATULANE LA mitoxantrone hcl B/D NM ODOMZO SYLATRON KIT 00MCG NM PA SYLATRON KIT 300MCG NM PA SYLATRON KIT 600MCG NM PA SYNRIBO NM PA tretinoin (chemotherapy) TRISENOX B/D PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin B/D PROTECTIVE AGENTS AMIFOSTINE B/D dexrazoxane (generic of B/D ZINECARD) ELITEK B/D FUSILEV B/D NM leucovorin calcium SOLR B/D leucovorin calcium TABS leucovorin calcium for inj 00 mg B/D mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 8

20 levoleucovorin calcium SOLN levoleucovorin calcium (generic of FUSILEV) SOLR 0mg LEVOLEUCOVORIN CALCIUM SOLR 7mg B/D NM B/D NM B/D NM mesna (generic of MESNEX) B/D MESNEX TABS TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan inj 40mg/ml B/D (generic of CAMPTOSAR) irinotecan inj 00/ml (generic B/D of CAMPTOSAR) irinotecan inj 00mg/ml B/D toposar B/D TOPOTECAN HCL SOLN B/D topotecan hcl (generic of HYCAMTIN) SOLR B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine--benazepril hcl cap 0-0 mg (generic of LOTREL) amlodipine-benazepril hcl cap.-0 mg amlodipine-benazepril hcl cap -0 mg (generic of LOTREL) amlodipine-benazepril hcl cap -0 mg (generic of LOTREL) amlodipine-benazepril hcl cap -40 mg amlodipine-benazepril hcl cap 0-40mg (generic of LOTREL) benazepril & hydrochlorothiazide benazepril & hydrochlorothiazide (generic of LOTENSIN HCT) captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide enalapril maleate & hydrochlorothiazide (generic of VASERETIC) Drug Tier fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide (generic of ZESTORETIC) moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide (generic of ACCURETIC) ACE INHIBITORS benazepril hcl TABS mg benazepril hcl (generic of LOTENSIN) TABS 0mg, 0mg, 40mg captopril TABS enalapril maleate (generic of VASOTEC) TABS fosinopril sodium lisinopril (generic of ZESTRIL) TABS.mg, 30mg, 40mg lisinopril (generic of PRINIVIL) TABS mg, 0mg, 0mg moexipril hcl perindopril erbumine mg perindopril erbumine (generic of ACEON) 4mg, 8mg quinapril hcl (generic of ACCUPRIL) ramipril (generic of ALTACE) trandolapril mg, mg trandolapril (generic of MAVIK) 4mg ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA) spironolactone (generic of ALDACTONE) TABS ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) mg, mg, 4mg doxazosin mesylate (generic of CARDURA) 8mg Requirements/ Limits QL mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 9

21 Drug Tier prazosin hcl (generic of MINIPRESS) terazosin hcl ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil (generic of AZOR) amlodipine besylate-valsartan tab -60 mg (generic of EXFORGE) amlodipine besylate-valsartan tab -30 mg (generic of EXFORGE) amlodipine besylate-valsartan tab 0-60 mg (generic of EXFORGE) amlodipine besylate-valsartan tab 0-30 mg (generic of EXFORGE) amlodipine-valsartan-hydrochl orothiazide -60-.mg (generic of EXFORGE HCT) amlodipine-valsartan-hydrochl orothiazide -60-mg (generic of EXFORGE HCT) amlodipine-valsartan-hydrochl orothiazide mg (generic of EXFORGE HCT) amlodipine-valsartan-hydrochl orothiazide 0-60-mg (generic of EXFORGE HCT) amlodipine-valsartan-hydrochl orothiazide 0-30-mg (generic of EXFORGE HCT) AZOR 4 BENICAR HCT 4 ENTRESTO 3 irbesartan-hydrochlorothiazide (generic of AVALIDE) losartan-hydrochlorothiazide (generic of HYZAAR) olmesartan medoxomil-amlodipine-hydroc hlorothiazide (generic of TRIBENZOR) olmesartan medoxomil-hydrochlorothiazid e (generic of BENICAR HCT) Requirements/ Limits valsartan & hctz tab 80-.mg (generic of DIOVAN HCT) valsartan & hctz tab 60-.mg (generic of DIOVAN HCT) valsartan & hctz tab 60-mg (generic of DIOVAN HCT) valsartan & hctz tab 30-.mg (generic of DIOVAN HCT) Drug Tier valsartan & hctz tab 30-mg (generic of DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 4 Requirements/ Limits irbesartan (generic of AVAPRO) losartan potassium (generic of COZAAR) olmesartan medoxomil (generic of BENICAR) TABS valsartan (generic of DIOVAN) ANTIARRHYTHMICS amiodarone hcl SOLN amiodarone hcl TABS 00mg, 400mg amiodarone hcl TABS 00mg disopyramide phosphate 4 PA (generic of NORPACE) PA if 6 years and older DOFETILIDE NM flecainide acetate mexiletine hcl MULTAQ 4 NORPACE CR 4 PA PA if 6 years and older pacerone 00mg, 400mg pacerone 00mg propafenone hcl propafenone hcl hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS sorine (generic of BETAPACE) 80mg, 0mg, 60mg mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 0

22 Drug Tier sorine 40mg sotalol hcl (generic of BETAPACE) 80mg, 0mg, 60mg sotalol hcl 40mg sotalol hcl (afib/afl) (generic of BETAPACE AF) Requirements/ Limits ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) TABS lovastatin 0mg, 0mg lovastatin (generic of MEVACOR) 40mg pravastatin sodium 0mg pravastatin sodium (generic of PRAVACHOL) 0mg, 40mg, 80mg rosuvastatin calcium (generic of CRESTOR) simvastatin (generic of ZOCOR) TABS mg, 0mg, 0mg, 40mg simvastatin (generic of ZOCOR) TABS 80mg QL QL ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light PACK cholestyramine light (generic of QUESTRAN LIGHT) POWD choline fenofibrate (generic of TRILIPIX) colestipol hcl (generic of COLESTID) ezetimibe (generic of ZETIA) ezetimibe-simvastatin (generic of VYTORIN) QL fenofibrate (generic of TRICOR) TABS 48mg, 4mg fenofibrate (generic of LOFIBRA) TABS 4mg fenofibrate TABS 60mg fenofibrate micronized (generic of LOFIBRA) 67mg, 34mg, 00mg gemfibrozil (generic of LOPID) TABS JUXTAPID KYNAMRO NM PA niacin er (antihyperlipidemic) QL (generic of NIASPAN) 00mg QL (90 tabs / 30 niacin er (antihyperlipidemic) (generic of NIASPAN) 70mg, 000mg niacor omega-3-acid ethyl esters (generic of LOVAZA) PRALUENT NM PA prevalite (generic of QUESTRAN LIGHT) triklo (generic of LOVAZA) VASCEPA 4 VYTORIN 4 QL WELCHOL 3 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide (generic of ZIAC) metoprolol & hctz tab 0-mg (generic of LOPRESSOR HCT) metoprolol & hctz tab 00-mg metoprolol & hctz tab 00-0mg propranolol & hydrochlorothiazide BETA-BLOCKERS acebutolol hcl CAPS atenolol (generic of TENORMIN) TABS mg atenolol TABS 0mg, 00mg mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as

23 Drug Tier bisoprolol fumarate BYSTOLIC 4 carvedilol (generic of COREG) labetalol hcl TABS metoprolol succinate (generic of TOPROL XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS mg metoprolol tartrate (generic of LOPRESSOR) TABS 0mg, 00mg nadolol (generic of CORGARD) TABS pindolol propranolol cap er (generic of INDERAL LA) propranolol hcl SOLN; TABS propranolol oral sol timolol maleate TABS CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC) amlodipine besylate (generic of NORVASC) TABS cartia xt cap 0/4hr (generic of CARDIZEM CD) cartia xt cap 80/4hr (generic of CARDIZEM CD) cartia xt cap 40/4hr (generic of CARDIZEM CD) cartia xt cap 300/4hr dilt-xr cap diltiazem cap 0mg cd (generic of CARDIZEM CD) diltiazem cap 80mg cd (generic of CARDIZEM CD) diltiazem cap 40mg cd (generic of CARDIZEM CD) diltiazem cap 300mg cd DILTIAZEM CAP 360MG CD diltiazem cap er/hr diltiazem hcl SOLN diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 0mg Requirements/ Limits Drug Tier diltiazem hcl TABS 90mg diltiazem hcl cap sr 4hr diltiazem hcl coated beads cap sr 4hr (generic of CARDIZEM CD) 0mg, 80mg, 360mg diltiazem hcl coated beads cap sr 4hr 300mg diltiazem hcl extended release beads cap sr (generic of TIAZAC) felodipine isradipine nicardipine hcl CAPS Requirements/ Limits nifedical xl (generic of PROCARDIA XL) nifedipine (generic of PROCARDIA XL) TB4 nifedipine er (generic of ADALAT CC) nimodipine CAPS NYMALIZE taztia (generic of TIAZAC) verapamil cap er (generic of VERELAN PM) 00mg, 00mg, 300mg verapamil cap er (generic of VERELAN) 0mg, 80mg, 40mg VERAPAMIL CAP ER 360mg verapamil hcl SOLN verapamil hcl TABS 40mg verapamil hcl (generic of CALAN) TABS 80mg, 0mg verapamil hcl (generic of CALAN SR) TBCR verapamil tab er (generic of CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) PA.mg PA if 6 years and older digitek (generic of LANOXIN).mg QL mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as

24 digox (generic of LANOXIN) mcg digox (generic of LANOXIN) 0mcg PA if 6 years and older digoxin (generic of LANOXIN) TABS mcg digoxin (generic of LANOXIN) TABS 0mcg PA if 6 years and older digoxin inj (generic of LANOXIN) DIGOXIN SOL 0MCG/ML PA if 6 years and older DIURETICS acetazolamide (generic of DIAMOX) CP acetazolamide TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide SOLN bumetanide (generic of BUMEX) TABS chlorothiazide tabs chlorthalidone furosemide SOLN furosemide (generic of LASIX) TABS furosemide inj 0mg/ml FUROSEMIDE INJ 0mg/ml hydrochlorothiazide (generic of MICROZIDE) CAPS hydrochlorothiazide TABS indapamide methazolamide (generic of NEPTAZANE) TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs mg, 00mg torsemide tabs (generic of DEMADEX) 0mg, 0mg QL PA QL PA PA triamterene & hydrochlorothiazide (generic of MAXZIDE) TABS triamterene & hydrochlorothiazide (generic of MAXZIDE-) TABS triamterene & hydrochlorothiazide cap 37.- mg (generic of DYAZIDE) MISCELLANEOUS clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/4hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/4hr clonidine hcl (generic of CATAPRES-TTS-3) PTWK.3mg/4hr Drug Tier clonidine hcl (generic of CATAPRES) TABS DEMSER hydralazine hcl SOLN; TABS midodrine hcl minoxidil TABS Requirements/ Limits NORTHERA RANEXA 3 NITRATES isosorb mononitrate tab isosorbide dinitrate (generic of ISORDIL TITRADOSE) mg isosorbide dinitrate 0mg, 0mg, 30mg isosorbide dinitrate er isosorbide mononitrate er minitran (generic of NITRO-DUR) nitro-bid 3 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin (generic of NITROSTAT) SUBL nitroglycerin td patch PULMONARY ARTERIAL HYPERTENSION mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 3

25 ADCIRCA ADEMPAS QL (90 tabs / 30 LETAIRIS OPSUMIT REMODULIN REVATIO SUSR QL (4 ml / 30 sildenafil citrate (pulmonary hypertension) (generic of REVATIO) TABS QL (90 tabs / 30 TRACLEER UPTRAVI TABS 00mcg QL (480 tabs / 30 UPTRAVI TABS 400mcg QL (40 tabs / 30 UPTRAVI TABS 600mcg QL (0 tabs / 30 UPTRAVI TABS 800mcg QL (0 tabs / 30 UPTRAVI TABS 000mcg QL (90 tabs / 30 UPTRAVI TABS 00mcg, 400mcg, 600mcg NM PA QL NM LA PA QL NM LA PA QL NM PA QL NM PA QL NM LA PA QL NM LA PA QL NM LA PA QL NM LA PA QL NM LA PA QL NM LA PA UPTRAVI TBPK VENTAVIS NM PA CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.mg (generic of XANAX) QL (40 tabs / 30 QL alprazolam tab 0.mg (generic of XANAX) QL (480 tabs / 30 alprazolam tab mg (generic of XANAX) QL (0 tabs / 30 alprazolam tab mg (generic of XANAX) QL (0 tabs / 30 QL QL QL buspirone hcl TABS fluvoxamine maleate TABS mg, 0mg QL (4 tabs / 30 QL fluvoxamine maleate TABS 00mg lorazepam CONC QL (0 ml / 30 lorazepam (generic of ATIVAN) SOLN lorazepam (generic of ATIVAN) TABS QL (0 tabs / 30 ANTICONVULSANTS APTIOM 00mg QL (80 tabs / 30 APTIOM 400mg QL (90 tabs / 30 APTIOM 600mg, 800mg QL QL 4 QL QL QL BANZEL SUS 40MG/ML PA BANZEL TAB 00MG PA BANZEL TAB 400MG PA BRIVIACT SOLN 0mg/ml PA BRIVIACT SOLN 0mg/ml 4 PA BRIVIACT TABS PA carbamazepine CHEW carbamazepine (generic of CARBATROL) CP carbamazepine (generic of TEGRETOL) SUSP; TABS carbamazepine (generic of TEGRETOL-XR) TB mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 4

26 CELONTIN 4 clonazepam (generic of QL KLONOPIN) TABS mg QL (0 tabs / 30 clonazepam (generic of QL KLONOPIN) TABS mg QL (300 tabs / 30 clonazepam (generic of QL KLONOPIN) TABS.mg QL (40 tabs / 30 clonazepam TBDP mg QL QL (0 tabs / 30 clonazepam TBDP mg QL QL (300 tabs / 30 clonazepam TBDP.mg QL QL (40 tabs / 30 clonazepam TBDP.mg QL QL (480 tabs / 30 clonazepam TBDP.mg QL QL (960 tabs / 30 clorazepate dipotassium QL PA 3.7mg QL (0 tabs / 30 PA if 6 years and older clorazepate dipotassium QL PA (generic of TRANXENE T) 7.mg QL (0 tabs / 30 PA if 6 years and older clorazepate dipotassium QL PA mg QL (80 tabs / 30 PA if 6 years and older DIASTAT ACUDIAL 4 DIASTAT PEDIATRIC 4 diazepam CONC QL PA QL (40 ml / 30 PA if 6 years and older diazepam SOLN mg/ml QL PA QL (00 ml / 30 PA if 6 years and older diazepam SOLN mg/ml diazepam (generic of QL PA VALIUM) TABS QL (0 tabs / 30 PA if 6 years and older DIAZEPAM GEL dilantin 3 DILANTIN- SUS /ML 3 divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR divalproex sodium (generic of DEPAKOTE ER) TB4 divalproex sodium (generic of DEPAKOTE) TBEC epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of FELBATOL) SUSP felbamate (generic of FELBATOL) TABS FYCOMPA SUSP 4 QL PA QL (70 ml / 30 FYCOMPA TABS mg 4 QL PA QL (80 tabs / 30 FYCOMPA TABS 4mg 4 QL PA QL (90 tabs / 30 FYCOMPA TABS 6mg 4 QL PA FYCOMPA TABS 8mg, 4 QL PA 0mg, mg gabapentin (generic of QL NEURONTIN) CAPS 00mg QL (080 caps / 30 gabapentin (generic of QL NEURONTIN) CAPS 300mg QL (360 caps / 30 gabapentin (generic of QL NEURONTIN) CAPS 400mg QL (70 caps / 30 gabapentin (generic of QL NEURONTIN) SOLN QL (60 ml / 30 gabapentin (generic of QL NEURONTIN) TABS 600mg QL (80 tabs / 30 gabapentin (generic of QL NEURONTIN) TABS 800mg QL (0 tabs / 30 GABITRIL mg, 6mg 4 lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as

27 lamotrigine (generic of LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB4 levetiracetam (generic of KEPPRA) SOLN; TABS levetiracetam (generic of KEPPRA XR) TB4 LEVETIRACETAM IN 4 SODIUM CHLORIDE LEVETIRACETAM IV levetiracetam oral soln 00 mg/ml (generic of KEPPRA) LYRICA CAPS mg, 0mg, 3 QL 7mg, 00mg, 0mg QL (0 caps / 30 LYRICA CAPS 00mg 3 QL QL (90 caps / 30 LYRICA CAPS mg, 3 QL 300mg QL (60 caps / 30 LYRICA SOLN 3 QL QL (946 ml / 30 ONFI SUSP PA ONFI TABS 0mg 4 PA ONFI TABS 0mg PA oxcarbazepine (generic of TRILEPTAL) PEGANONE 4 phenobarbital ELIX; TABS 4 PA PA if 6 years and older PHENOBARBITAL SODIUM 4 PA SOLN 6mg/ml PA if 6 years and older phenobarbital sodium SOLN 4 PA 30mg/ml PA if 6 years and older phenytek 3 phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-) SUSP phenytoin sodium SOLN phenytoin sodium extended (generic of DILANTIN) 00mg phenytoin sodium extended (generic of PHENYTEK) 00mg, 300mg Drug Tier Requirements/ Limits POTIGA 0mg 4 POTIGA 00mg QL (80 tabs / 30 QL POTIGA 300mg, 400mg QL (90 tabs / 30 primidone (generic of MYSOLINE) TABS roweepra (generic of KEPPRA) SABRIL PACK QL (80 packets / 30 SABRIL TABS QL (80 tabs / 30 SPRITAM 4 TEGRETOL 4 TEGRETOL-XR 4 QL QL NM LA PA QL NM LA PA tiagabine hcl (generic of GABITRIL) topiramate (generic of TOPAMAX SPRINKLE) CPSP topiramate (generic of TOPAMAX) TABS valproate sodium (generic of DEPAKENE) SOLN 0mg/ml valproate sodium (generic of DEPACON) SOLN 00mg/ml valproic acid (generic of DEPAKENE) vigabatrin powd pack (generic QL NM LA PA of SABRIL) QL (80 packets / 30 VIMPAT SOLN 0mg/ml 4 QL QL (00 ml / 30 VIMPAT SOLN 00mg/0ml 4 VIMPAT TABS 0mg QL (80 tabs / 30 4 QL mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 6

28 VIMPAT TABS 00mg, 0mg, 00mg zonisamide (generic of ZONEGRAN) CAPS mg, 00mg zonisamide CAPS 0mg ANTIDEMENTIA donepezil hydrochloride (generic of ARICEPT) TABS mg donepezil hydrochloride (generic of ARICEPT) TABS 0mg, 3mg donepezil hydrochloride TBDP mg donepezil hydrochloride TBDP 0mg galantamine hydrobromide SOLN galantamine hydrobromide (generic of RAZADYNE) TABS 4mg QL (80 tabs / 30 galantamine hydrobromide (generic of RAZADYNE) TABS 8mg QL (90 tabs / 30 galantamine hydrobromide (generic of RAZADYNE) TABS mg galantamine hydrobromide er (generic of RAZADYNE ER) 8mg, 6mg QL (30 caps / 30 galantamine hydrobromide er (generic of RAZADYNE ER) 4mg memantine hcl SOLN PA if < 30 yrs memantine hcl (generic of NAMENDA) TABS mg PA if < 30 yrs MEMANTINE HCL TABS 0mg PA if < 30 yrs 4 QL QL QL QL QL QL PA PA PA MEMANTINE TITRATION PAK PA if < 30 yrs NAMENDA PA if < 30 yrs NAMENDA SOL 0MG/ML PA if < 30 yrs NAMENDA TITRATION PAK PA if < 30 yrs NAMENDA XR PA if < 30 yrs NAMENDA XR TITRATION PACK PA if < 30 yrs PA 4 PA 4 PA 4 PA 4 PA 4 PA NAMZARIC 4 rivastigmine tartrate rivastigmine td patch 4hr 4.6 mg/4hr (generic of EXELON) QL (30 patches / 30 QL rivastigmine td patch 4hr 9. mg/4hr (generic of EXELON) QL (30 patches / 30 rivastigmine td patch 4hr 3.3 mg/4hr (generic of EXELON) QL (30 patches / 30 ANTIDEPRESSANTS amitriptyline hcl TABS 0mg, 0mg, 7mg, 00mg, 0mg PA if 6 years and older amitriptyline hcl (generic of ELAVIL) TABS mg PA if 6 years and older amoxapine tab mg amoxapine tab 0mg amoxapine tab 00mg amoxapine tab 0mg bupropion hcl TABS bupropion hcl (generic of WELLBUTRIN SR) TB bupropion hcl (generic of WELLBUTRIN XL) TB4 0mg QL (90 tabs / 30 QL QL 4 PA 4 PA QL mail-order B/D - Covered under Medicare B or D LA - Limited Access - Not available as 7