Johns Hopkins Advantage MD (PPO) and Johns Hopkins Johns Advantage Hopkins MD Advantage Plus (PPO) MD

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1 0 18 FORMULARY EVIDENCE LIST of COVERED of COVERAGE DRUGS Johns Hopkins Advantage MD (PPO) and Johns Hopkins Johns Advantage Hopkins MD Advantage Plus (PPO) MD PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version 6 This formulary was updated on 3/1/018. For more recent information or other questions, please contact Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO) Customer Service at or, for TTY users, 711, 4 hours a day, 7 days a week, or visit H3890_EOC_0816 H3890_PPO&PlusFormulary_0917 Accepted 0917

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. When it refers to plan or our plan, it means Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO). This document includes a list of the drugs (formulary) for our plan which is current as of March 1, 018. 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, 019, 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 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 March 1, 018. 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 8. 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 number 8. 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 53. 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 every 30 days 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 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. 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. 3

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 (PPO) and Johns Hopkins Advantage MD Plus (PPO) s formulary? on page 4 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 (PPO) and Johns Hopkins Advantage MD Plus (PPO) s 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. 4

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 a 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 31-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 onetime temporary supply for up to 30-days (or 31-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 (PPO) and Johns Hopkins Advantage MD Plus (PPO) 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 5

6 Johns Hopkins Advantage MD (PPO) and Johns Hopkins Advantage MD Plus (PPO) Formulary The formulary that begins on the page after next 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 53. 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. 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 consult your Pharmacy Directory or call Customer Services at , 4 hours a day, 7 days a week. TTY users should call 711. 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 1 (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 $10.50 copay for a 60-day supply $14 copay for a 90-day supply $15 copay for a 30-day supply $.50 copay for a 60-day supply $30 copay for a 90-day supply $45 copay for a 30-day supply $90 copay for a 60-day supply $135 copay for a 90-day supply $95 copay for a 30-day supply $190 copay for a 60-day supply $85 copay for a 90-day supply Standard Mail Order Cost-Sharing (in-network) $7 copay for a 30-day supply $10.50 copay for a 60-day supply $14 copay for a 90-day supply $15 copay for a 30-day supply $.50 copay for a 60-day supply $30 copay for a 90-day supply $45 copay for a 30-day supply $67.50 copay for a 60-day supply $90 copay for a 90-day supply $95 copay for a 30-day supply $14.50 copay for a 60-day supply $190 copay for a 90-day supply 6

7 Cost-Sharing Tier 5 (Specialty Tier) 33% coinsurance for a 30-day supply (only) NOTE: -Drugs are provided in a Long-Term Care Facility up to a 31-day supply -Drugs in Tier 5 are only available for a 30-day supply -You can find complete cost-sharing information in your Evidence of Coverage Johns Hopkins Advantage MD Plus Cost Sharing Tier Cost-Sharing Tier 1 (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 $6 copay for a 60-day supply $8 copay for a 90-day supply $1 copay for a 30-day supply $18 copay for a 60-day supply $4 copay for a 90-day supply $4 copay for a 30-day supply $84 copay for a 60-day supply $16 copay for a 90-day supply $9 copay for a 30-day supply $184 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 $6 copay for a 60-day supply $8 copay for a 90-day supply $1 copay for a 30-day supply $18 copay for a 60-day supply $4 copay for a 90-day supply $4 copay for a 30-day supply $63 copay for a 60-day supply $84 copay for a 90-day supply $9 copay for a 30-day supply $138 copay for a 60-day supply $184 copay for a 90-day supply Cost-Sharing Tier 5 (Specialty Tier) 33% coinsurance for a 30-day supply (only) NOTE: -Drugs are provided in a Long-Term Care Facility up to a 31-day supply -Drugs in Tier 5 are only available for a 30-day supply -You can find complete cost-sharing information in your Evidence of Coverage 7

8 Johns Hopkins Advantage MD (PPO) ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab (generic of 1 ZYLOPRIM) colchicine w/ probenecid COLCRYS QL (10 tabs / 30 MITIGARE QL (60 caps / 30 probenecid ULORIC 3 ST NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib (generic of CELEBREX) CAPS 50mg QL (40 caps / 30 celecoxib (generic of CELEBREX) CAPS 100mg QL (10 caps / 30 celecoxib (generic of CELEBREX) CAPS 00mg QL (60 caps / 30 celecoxib (generic of CELEBREX) CAPS 400mg QL (30 caps / 30 QL QL QL QL diclofenac potassium QL QL (10 tabs / 30 diclofenac sodium TB4; TBEC diflunisal etodolac CAPS etodolac (generic of LODINE) TABS 400mg etodolac TABS 500mg etodolac er flurbiprofen TABS ibuprofen SUSP ibuprofen TABS 400mg, 1 600mg, 800mg ketoprofen CAPS meloxicam (generic of 1 MOBIC) TABS nabumetone TABS naproxen (generic of NAPROSYN) SUSP naproxen (generic of NAPROSYN) TABS 50mg, 500mg Drug Tier naproxen TABS 375mg 1 naproxen dr (generic of EC- 1 NAPROSYN) naproxen sodium TABS 75mg naproxen sodium (generic of ANAPROX DS) TABS 550mg 1 Requirements/ Limits piroxicam (generic of FELDENE) CAPS sulindac TABS 1 OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine SOLN QL (5000 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 QL QL QL QL butorphanol tartrate SOLN 4 1mg/ml, mg/ml nalbuphine hcl SOLN 4 tramadol hcl (generic of ULTRAM) TABS QL QL (40 tabs / 30 tramadol-acetaminophen (generic of ULTRACET) QL (40 tabs / 30 QL OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet (generic of PERCOCET) QL (360 tabs / 30 QL 9

9 fentanyl citrate (generic of ACTIQ) LPOP QL (10 lozenges / 30 fentanyl patch 1 mcg/hr (generic of DURAGESIC) QL (10 patches / 30 fentanyl patch 5 mcg/hr (generic of DURAGESIC) QL (10 patches / 30 fentanyl patch 50 mcg/hr (generic of DURAGESIC) QL (10 patches / 30 fentanyl patch 75 mcg/hr (generic of DURAGESIC) QL (10 patches / 30 fentanyl patch 100 mcg/hr (generic of DURAGESIC) QL (10 patches / 30 FENTORA QL (10 tabs / 30 hydroco/apap tab 5-35mg (generic of NORCO) QL (360 tabs / 30 hydroco/apap tab (generic of NORCO) QL (360 tabs / 30 hydroco/apap tab 10-35mg (generic of NORCO) QL (360 tabs / 30 hydrocodone-acetaminophen mg/15ml (generic of HYCET) QL (5400 ml / 30 hydrocodone-ibuprofen tab mg QL (150 tabs / 30 hydromorphone hcl (generic of DILAUDID) LIQD hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl (generic of DILAUDID) TABS QL (70 tabs / 30 5 * QL NM PA QL QL QL PA QL PA QL PA 5 * QL NM PA QL QL QL QL QL 4 B/D QL HYSINGLA ER 0mg, 30mg, 40mg, 60mg QL (60 tabs / 30 HYSINGLA ER 80mg, 100mg, 10mg QL (30 tabs / 30 lorcet hd tab 10-35mg QL (generic of NORCO) QL (360 tabs / 30 lorcet plus tab QL (generic of NORCO) QL (360 tabs / 30 methadone hcl SOLN QL 5mg/5ml, 10mg/5ml QL (450 ml / 30 methadone hcl 5mg (generic QL of DOLOPHINE) QL (180 tabs / 30 methadone hcl 10mg (generic QL of DOLOPHINE) QL (180 tabs / 30 methadone hcl intensol QL (generic of METHADOSE) QL (10 ml / 30 morphine ext-rel tab (generic QL of MS CONTIN) 15mg, 30mg, 60mg, 100mg QL (90 tabs / 30 morphine ext-rel tab (generic QL of MS CONTIN) 00mg QL (60 tabs / 30 morphine sul inj 1mg/ml 4 B/D MORPHINE SUL INJ 4 B/D 4MG/ML morphine sul inj 10mg/ml 4 B/D (generic of MORPHINE SULFATE) MORPHINE SULFATE 4 B/D SOLN mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml morphine sulfate (generic of 4 B/D MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml morphine sulfate TABS QL QL (180 tabs / 30 morphine sulfate oral sol NUCYNTA ER 50mg, 100mg QL (10 tabs / 30 10

10 NUCYNTA ER 150mg, 00mg, 50mg QL (60 tabs / 30 oxycodone hcl CAPS QL QL (180 caps / 30 oxycodone hcl CONC oxycodone hcl SOLN oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg QL (180 tabs / 30 QL oxycodone hcl TABS 10mg, 0mg QL (180 tabs / 30 oxycodone w/ acetaminophen.5-35mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen 5-35mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen 10-35mg (generic of PERCOCET) QL (360 tabs / 30 oxycodone w/ acetaminophen soln QL (1800 ml / 30 QL QL QL QL QL QL ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine inj 0.5% (generic of XYLOCAINE) B/D lidocaine inj 0.5% preservative free (pf) (generic of XYLOCAINE-MPF) lidocaine inj 1% (generic of XYLOCAINE) lidocaine inj 1% preservative free (pf) (generic of XYLOCAINE-MPF) lidocaine inj 1.5% preservative free (pf) (generic of XYLOCAINE-MPF) B/D B/D B/D B/D lidocaine inj % (generic of XYLOCAINE) B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS 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 5 * NM PA KITABIS PAK) NEBU tobramycin inj 1. gm/30ml tobramycin inj 1.gm 5 * NM tobramycin inj 10mg/ml tobramycin inj 40mg/ml tobramycin inj 80mg/ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 * NM ALINIA 5 * NM atovaquone (generic of 5 * NM MEPRON) SUSP AZACTAM IN ISO-OSMOTIC 4 DE AZACTAM/DEX INJ 4 aztreonam (generic of AZACTAM) BILTRICIDE 3 CAYSTON clindamycin cap 75mg 1 (generic of CLEOCIN) clindamycin cap 300mg 1 (generic of CLEOCIN) clindamycin hcl cap 150 mg 1 (generic of CLEOCIN) clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) CLINDAMYCIN PHOSPHATE 4 IN NACL clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) 11

11 clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY-MYCIN M) SOLR Drug Tier Requirements/ Limits dapsone TABS daptomycin (generic of 5 * NM CUBICIN) EMVERM 5 * NM imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ 4 ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) 5 * NM linezolid in sodium chloride 5 * NM meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of 1 FLAGYL) TABS metronidazole in nacl NEBUPENT 4 B/D nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg PA applies if 65 years and older after a 90 day supply in a calendar year 4 PA nitrofurantoin monohyd macro (generic of MACROBID) PA applies if 65 years and older after a 90 day supply in a calendar year 4 PA PENTAM SIVEXTRO 5 * NM sulfamethoxazole-trimethop 1 ds (generic of BACTRIM DS) sulfamethoxazoletrimethoprim SUSP sulfamethoxazoletrimethoprim (generic of BACTRIM) TABS 1 sulfamethoxazoletrimethoprim inj SYNERCID 5 * NM TIGECYCLINE 50mg 5 * NM tigecycline (generic of 5 * NM TYGACIL) 50mg trimethoprim TABS 1 vancomycin hcl (generic of 5 * NM VANCOCIN HCL) CAPS vancomycin hcl SOLR 10gm, 500mg, 750mg, 1000mg, 5000mg VANCOMYCIN IN NACL 4 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET 5 * B/D NM AMBISOME 5 * B/D NM amphotericin b SOLR B/D CANCIDAS 5 * NM caspofungin acetate 50mg 5 * NM CASPOFUNGIN ACETATE 5 * NM 50mg, 70mg fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS 50mg, 100mg, 00mg fluconazole (generic of 1 DIFLUCAN) TABS 150mg fluconazole in dextrose FLUCONAZOLE INJ NACL fluconazole inj nacl 00 fluconazole inj nacl 400 flucytosine (generic of 5 * NM ANCOBON) CAPS griseofulvin microsize griseofulvin ultramicrosize (generic of GRIS-PEG) itraconazole (generic of PA SPORANOX) CAPS ketoconazole TABS PA MYCAMINE 5 * NM NOXAFIL SUSP 5 * QL NM QL (630 ml / 30 NOXAFIL TBEC 5 * QL NM QL (93 tabs / 30 nystatin TABS terbinafine hcl (generic of LAMISIL) TABS QL (90 tabs / QL 1

12 voriconazole (generic of VFEND IV) SOLR voriconazole (generic of VFEND) SUSR; TABS 5 * NM ANTIMALARIALS - DRUGS TO TREAT MALARIA 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 - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate (generic of ZIAGEN) APTIVUS 5 * NM atazanavir sulfate (generic of 5 * NM REYATAZ) CRIXIVAN 4 didanosine 15mg didanosine (generic of VIDEX EC) 00mg, 50mg, 400mg EDURANT 5 * NM efavirenz (generic of SUSTIVA) CAPS 50mg efavirenz (generic of 5 * NM SUSTIVA) CAPS 00mg EMTRIVA 3 fosamprenavir tab 700 mg 5 * NM (generic of LEXIVA) FUZEON 5 * NM INTELENCE 5mg 4 INTELENCE 100mg, 00mg 5 * NM INVIRASE 5 * NM ISENTRESS CHEW 5mg 3 ISENTRESS CHEW 100mg 5 * NM ISENTRESS PACK 5 * NM ISENTRESS TABS 5 * NM ISENTRESS HD 5 * NM lamivudine (generic of EPIVIR) LEXIVA SUSP 4 LEXIVA TABS 5 * NM nevirapine SUSP nevirapine (generic of VIRAMUNE) TABS nevirapine (generic of VIRAMUNE XR) TB4 NORVIR 3 PREZISTA SUSP 5 * QL NM QL (400 ml / 30 PREZISTA TABS 75mg QL (480 tabs / 30 PREZISTA TABS 150mg 5 * QL NM QL (40 tabs / 30 PREZISTA TABS 600mg 5 * QL NM QL (60 tabs / 30 PREZISTA TABS 800mg 5 * QL NM QL (30 tabs / 30 RESCRIPTOR 4 RETROVIR IV INFUSION 4 REYATAZ 5 * NM SELZENTRY SOLN 5 * NM SELZENTRY TABS 5mg 4 SELZENTRY TABS 75mg, 5 * NM 150mg, 300mg stavudine (generic of ZERIT) SUSTIVA CAPS 50mg 4 SUSTIVA CAPS 00mg 5 * NM SUSTIVA TABS 5 * NM tenofovir disoproxil fumarate 5 * NM (generic of VIREAD) TIVICAY 10mg 3 TIVICAY 5mg, 50mg 5 * NM TYBOST 3 VIDEX EC 15mg 4 VIDEX PEDIATRIC 4 VIRACEPT 5 * NM VIRAMUNE SUSP 4 VIREAD 5 * NM ZERIT SOLR 5 * NM ZIAGEN SOLN 3 zidovudine cap 100mg (generic of RETROVIR) zidovudine syp 50mg/5ml (generic of RETROVIR) zidovudine tab 300mg ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION 13

13 abacavir sulfate-lamivudine (generic of EPZICOM) abacavir sulfate-lamivudinezidovudine (generic of TRIZIVIR) 5 * NM 5 * NM ATRIPLA 5 * NM COMPLERA 5 * NM DESCOVY 5 * NM EVOTAZ 5 * NM GENVOYA 5 * NM KALETRA TAB 100-5MG 4 KALETRA TAB 00-50MG 5 * NM lamivudine-zidovudine (generic of COMBIVIR) lopinavir-ritonavir (generic of 5 * NM KALETRA) ODEFSEY 5 * NM PREZCOBIX 5 * NM STRIBILD 5 * NM TRIUMEQ 5 * NM TRUVADA TAB * QL NM QL (60 tabs / 30 TRUVADA TAB * QL NM QL (30 tabs / 30 TRUVADA TAB * QL NM QL (30 tabs / 30 TRUVADA TAB QL (30 tabs / 30 5 * QL NM ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SULFATE 4 cycloserine CAPS 5 * NM ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS 1 isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml PASER D/R 4 PRIFTIN 4 pyrazinamide TABS rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS; SOLR RIFATER 4 SIRTURO TRECATOR 4 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir (generic of 1 ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium B/D adefovir dipivoxil (generic of 5 * NM HEPSERA) BARACLUDE SOLN 5 * NM DAKLINZA 5 * NM PA entecavir (generic of 5 * NM BARACLUDE) EPCLUSA 5 * NM PA EPIVIR HBV SOLN 4 famciclovir TABS ganciclovir inj 500mg (generic B/D of CYTOVENE) HARVONI 5 * NM PA lamivudine (hbv) (generic of EPIVIR HBV) MAVYRET 5 * NM PA moderiba tab 00mg NM oseltamivir phosphate QL (generic of TAMIFLU) CAPS 30mg QL (168 caps / year) oseltamivir phosphate QL (generic of TAMIFLU) CAPS 45mg, 75mg QL (84 caps / year) oseltamivir phosphate QL (generic of TAMIFLU) SUSR QL (1080 ml / year) PEGASYS 5 * NM PA PEGASYS PROCLICK 5 * NM PA REBETOL SOLN 5 * NM RELENZA DISKHALER QL (6 inhalers / year) ribasphere (generic of NM REBETOL) CAPS ribasphere TABS 00mg NM ribasphere TABS 400mg, 5 * NM 600mg ribavirin 00mg (generic of NM REBETOL) CAPS ribavirin 00mg TABS NM rimantadine hydrochloride (generic of FLUMADINE) 14

14 SOVALDI 5 * NM PA TAMIFLU SUSR QL (1080 ml / year) valacyclovir hcl (generic of VALTREX) TABS valganciclovir hcl (generic of 5 * NM VALCYTE) VEMLIDY 5 * NM VOSEVI 5 * NM PA ZEPATIER 5 * NM PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor CEFACLOR 4 MONOHYDRATE ER cefadroxil CAPS 1 cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE 3 GM/100ML-4% cefazolin inj cefazolin sodium SOLR 1gm, 0gm CEFAZOLIN SODIUM 1 3 GM/50ML cefdinir cefepime hcl (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium 1gm, gm, 500mg cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE 4 ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm ceftriaxone sodium SOLR 1gm, gm, 10gm, 50mg, 500mg cefuroxime axetil (generic of CEFTIN) 50mg cefuroxime axetil 500mg cefuroxime sodium cephalexin (generic of 1 KEFLEX) CAPS 50mg, 500mg cephalexin SUSR SUPRAX CAPS 3 SUPRAX CHEW 4 SUPRAX SUSR 500mg/5ml 3 tazicef SOLR TEFLARO 5 * NM ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin PACK azithromycin (generic of ZITHROMAX) SOLR; SUSR azithromycin (generic of 1 ZITHROMAX) TABS clarithromycin (generic of BIAXIN) TABS clarithromycin er (generic of BIAXIN XL) clarithromycin for susp DIFICID 5 * NM e.e.s 400 ery-tab ERYTHROCIN 4 LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 50mg ec erythromycin ethylsuccinate TABS FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR 50mg/5ml ciprofloxacin (generic of CIPRO) SUSR 500mg/5ml ciprofloxacin hcl tab 100mg ciprofloxacin hcl tab (generic 1 of CIPRO) 50mg, 500mg ciprofloxacin hcl tab 750mg 1 ciprofloxacin in d5w ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W) ciprofloxacin inj levofloxacin (generic of 1 LEVAQUIN) TABS levofloxacin in d5w levofloxacin inj 5mg/ml 15

15 levofloxacin oral soln 5 mg/ml PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin CAPS; SUSR; 1 TABS amoxicillin CHEW 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) TB1 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK PACK) ampicillin cap 50mg 1 ampicillin cap 500mg 1 ampicillin inj ampicillin sodium ampicillin susp AUGMENTIN SUSR 4 BICILLIN L-A 4 dicloxacillin sodium nafcillin sodium 1gm, gm nafcillin sodium 10gm 5 * NM oxacillin sodium 1gm, gm oxacillin sodium 10gm 5 * NM PENICILLIN G POT IN 4 DEXTROSE MU PENICILLIN G POT IN 4 DEXTROSE 3MU PENICILLIN G PROCAINE 4 Drug Tier penicillin g sodium penicillin v potassium SOLR penicillin v potassium TABS 1 penicilln gk inj 5mu penicilln gk inj 0mu pfizerpen-g inj 5mu pfizerpen-g inj 0mu Requirements/ Limits piper/tazoba inj -0.5gm (generic of ZOSYN) piper/tazoba inj gm (generic of ZOSYN) piper/tazoba inj 4-0.5gm (generic of ZOSYN) PIPER/TAZOBA INJ GM piper/tazoba inj gm (generic of ZOSYN) TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 doxycycline (monohydrate) CAPS 50mg doxycycline (monohydrate) (generic of MONODOX) CAPS 100mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 50mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate TABS 0mg, 100mg minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg minocycline hcl CAPS 75mg morgidox cap 1x50mg ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA 5 * B/D NM busulfan (generic of 5 * B/D NM BUSULFEX) CYCLOPHOSPHAMIDE CAPS 4 B/D 16

16 cyclophosphamide SOLR 5 * B/D NM dacarbazine B/D EMCYT 4 GLEOSTINE 4 HEXALEN 5 * NM IFEX INJ 3GM 4 B/D ifosfamide inj 1gm (generic of B/D IFEX) ifosfamide inj 1gm/0ml B/D IFOSFAMIDE INJ 3GM 4 B/D ifosfamide inj 3gm/60ml B/D LEUKERAN 4 melphalan hcl (generic of 5 * B/D NM ALKERAN) MUSTARGEN 5 * B/D NM ANTHRACYCLINES adriamycin B/D doxorubicin hcl B/D doxorubicin hcl liposomal inj 5 * B/D NM mg/ml (generic of DOXIL) doxorubicin hcl soln mg/ml B/D epirubicin hcl (generic of B/D ELLENCE) ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR 5 * B/D NM ANTIMETABOLITES adrucil B/D ALIMTA 5 * B/D NM azacitidine (generic of 5 * B/D NM VIDAZA) cladribine 5 * B/D NM cytarabine 0mg/ml B/D fludarabine phosphate B/D fluorouracil SOLN B/D gemcitabine inj soln B/D gemcitabine inj solr (generic 5 * B/D NM of GEMZAR) 1gm, 00mg gemcitabine inj solr gm 5 * B/D NM mercaptopurine TABS methotrexate sodium inj B/D NIPENT 5 * B/D NM PURIXAN 5 * NM TABLOID 4 ANTIMITOTIC, TAXOIDS ABRAXANE 5 * B/D NM docetaxel (generic of TAXOTERE) CONC 0mg/ml, 80mg/4ml DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 5 * B/D NM 5 * B/D NM 00mg/10ml DOCETAXEL SOLN 5 * B/D NM paclitaxel B/D TAXOTERE 80mg/4ml 5 * B/D NM ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar pfs B/D vincristine sulfate B/D vinorelbine tartrate (generic of NAVELBINE) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN BELEODAQ 5 * NM PA BORTEZOMIB 5 * NM PA ERIVEDGE FARYDAK HERCEPTIN 5 * NM PA IBRANCE IDHIFA KADCYLA 5 * B/D NM KEYTRUDA 5 * NM PA KISQALI 5 * NM PA KISQALI FEMARA 00 DOSE 5 * NM PA KISQALI FEMARA 400 DOSE 5 * NM PA KISQALI FEMARA 600 DOSE 5 * NM PA LYNPARZA MYLOTARG NINLARO 5 * NM PA ODOMZO RITUXAN RITUXAN HYCELA RUBRACA TECENTRIQ VELCADE 5 * NM PA VENCLEXTA 10mg, 50mg 4 NM LA PA VENCLEXTA 100mg VENCLEXTA STARTING PACK VERZENIO YERVOY 5 * NM PA ZEJULA ZOLINZA 5 * NM PA HORMONAL ANTINEOPLASTIC AGENTS 17

17 anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 400/ML 4 B/D exemestane (generic of AROMASIN) FARESTON 5 * NM FASLODEX 5 * B/D NM flutamide hydroxyprogesterone 5 * B/D NM caproate (antineoplastic) letrozole (generic of FEMARA) TABS leuprolide inj 1mg/0. NM PA LUPRON DEPOT (1-MONTH) 5 * NM PA 3.75mg LUPRON DEPOT INJ 5 * NM PA 11.5MG (3-MONTH) LYSODREN 3 megestrol ac sus 40mg/ml 4 PA megestrol ac tab 0mg 4 PA megestrol ac tab 40mg 4 PA megestrol sus 65mg/5ml 4 PA (generic of MEGACE ES) nilutamide (generic of 5 * NM NILANDRON) SOLTAMOX 4 tamoxifen citrate TABS 1 TRELSTAR DEP INJ 3.75MG 5 * NM PA TRELSTAR LA INJ 11.5MG 5 * NM PA XTANDI ZYTIGA IMMUNOMODULATORS POMALYST CAP 1MG POMALYST CAP MG POMALYST CAP 3MG POMALYST CAP 4MG REVLIMID QL (8 caps / 8 5 * QL NM LA PA THALOMID 50mg, 100mg 5 * QL NM PA QL (30 caps / 30 THALOMID 150mg, 00mg 5 * QL NM PA QL (60 caps / 30 KINASE INHIBITORS AFINITOR 5 * QL NM PA QL (30 tabs / 30 AFINITOR DISPERZ mg 5 * QL NM PA QL (150 tabs / 30 AFINITOR DISPERZ 3mg 5 * QL NM PA QL (90 tabs / 30 AFINITOR DISPERZ 5mg 5 * QL NM PA QL (60 tabs / 30 ALECENSA ALUNBRIG BOSULIF 5 * NM PA CABOMETYX QL (30 tabs / 30 5 * QL NM LA PA CALQUENCE CAPRELSA COMETRIQ COTELLIC GILOTRIF TAB 0MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG ICLUSIG imatinib mesylate (generic of 5 * QL NM PA GLEEVEC) 100mg QL (90 tabs / 30 imatinib mesylate (generic of 5 * QL NM PA GLEEVEC) 400mg QL (60 tabs / 30 IMBRUVICA CAP 140MG INLYTA 1mg QL (180 tabs / 30 5 * QL NM LA PA INLYTA 5mg QL (10 tabs / 30 5 * QL NM LA PA IRESSA JAKAFI QL (60 tabs / 30 5 * QL NM LA PA LENVIMA 8 MG DAILY DOSE LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 0 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE MEKINIST NERLYNX NEXAVAR 18

18 RYDAPT 5 * NM PA SPRYCEL 5 * NM PA STIVARGA SUTENT 5 * NM PA TAFINLAR TAGRISSO TARCEVA 5mg QL (90 tabs / 30 5 * QL NM LA PA TARCEVA 100mg, 150mg QL (30 tabs / 30 5 * QL NM LA PA TASIGNA 5 * NM PA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA MISCELLANEOUS bexarotene (generic of 5 * NM PA TARGRETIN) DROXIA 3 hydroxyurea (generic of HYDREA) CAPS LONSURF 5 * NM PA MATULANE 5 * NM LA mitoxantrone hcl B/D NM SYLATRON KIT 00MCG 5 * NM PA SYLATRON KIT 300MCG 5 * NM PA SYLATRON KIT 600MCG 5 * NM PA SYNRIBO 5 * NM PA tretinoin (chemotherapy) 5 * NM TRISENOX 5 * B/D NM PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin inj 50mg 5 * B/D NM oxaliplatin inj 50mg/10ml B/D oxaliplatin inj 100mg 5 * B/D NM oxaliplatin inj 100mg/0ml B/D PROTECTIVE AGENTS dexrazoxane (generic of 5 * B/D NM ZINECARD) ELITEK 5 * B/D NM leucovorin calcium SOLR B/D leucovorin calcium TABS levoleucovorin calcium 175mg/17.5ml 5 * B/D NM LEVOLEUCOVORIN 5 * B/D NM CALCIUM 50mg/5ml levoleucovorin calcium 50mg 5 * B/D NM (generic of FUSILEV) LEVOLEUCOVORIN 5 * B/D NM CALCIUM 175MG mesna (generic of MESNEX) B/D MESNEX TABS 5 * NM TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan hcl (generic of B/D CAMPTOSAR) 40mg/ml, 100mg/5ml irinotecan hcl 500mg/5ml B/D toposar B/D topotecan inj 4mg (generic of 5 * B/D NM HYCAMTIN) TOPOTECAN INJ 4MG/4ML 5 * B/D NM CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine--benazepril hcl 1 cap 10-0 mg (generic of LOTREL) amlodipine-benazepril hcl cap mg amlodipine-benazepril hcl cap mg (generic of LOTREL) amlodipine-benazepril hcl cap mg (generic of LOTREL) amlodipine-benazepril hcl cap mg amlodipine-benazepril hcl cap mg (generic of LOTREL) benazepril & 1 hydrochlorothiazide benazepril & 1 hydrochlorothiazide (generic of LOTENSIN HCT) captopril & 1 hydrochlorothiazide enalapril maleate & 1 hydrochlorothiazide enalapril maleate & 1 hydrochlorothiazide (generic of VASERETIC) 19

19 fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide (generic of ZESTORETIC) Drug Tier 1 1 Requirements/ Limits moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide 1 (generic of ACCURETIC) ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 5mg 1 benazepril hcl (generic of 1 LOTENSIN) TABS 10mg, 0mg, 40mg captopril TABS 1 enalapril maleate (generic of 1 VASOTEC) TABS fosinopril sodium 1 lisinopril (generic of ZESTRIL) 1 TABS.5mg, 30mg, 40mg lisinopril (generic of PRINIVIL) 1 TABS 5mg, 10mg, 0mg moexipril hcl 1 perindopril erbumine 1 quinapril hcl (generic of 1 ACCUPRIL) ramipril (generic of ALTACE) 1 trandolapril 1mg, mg 1 trandolapril (generic of 1 MAVIK) 4mg ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone (generic of INSPRA) spironolactone (generic of 1 ALDACTONE) TABS ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate (generic of CARDURA) 1mg, mg, 4mg QL (30 tabs / 30 QL doxazosin mesylate (generic of CARDURA) 8mg prazosin hcl (generic of MINIPRESS) terazosin hcl 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylateolmesartan medoxomil 1 (generic of AZOR) amlodipine besylate-valsartan 1 tab mg (generic of EXFORGE) amlodipine besylate-valsartan 1 tab 5-30 mg (generic of EXFORGE) amlodipine besylate-valsartan 1 tab mg (generic of EXFORGE) amlodipine besylate-valsartan 1 tab mg (generic of EXFORGE) amlodipine-valsartanhydrochlorothiazide mg (generic of EXFORGE HCT) amlodipine-valsartanhydrochlorothiazide mg (generic of EXFORGE HCT) amlodipine-valsartanhydrochlorothiazide mg (generic of EXFORGE HCT) amlodipine-valsartanhydrochlorothiazide mg (generic of EXFORGE HCT) amlodipine-valsartanhydrochlorothiazide mg (generic of EXFORGE HCT) ENTRESTO 3 irbesartan-hydrochlorothiazide 1 (generic of AVALIDE) losartan-hydrochlorothiazide 1 (generic of HYZAAR) olmesartan medoxomil- 1 amlodipine- hydrochlorothiazide (generic of TRIBENZOR) 0

20 olmesartan medoxomilhydrochlorothiazide (generic of BENICAR HCT) Drug Tier 1 Requirements/ Limits valsartan-hydrochlorothiazide 1 (generic of DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE irbesartan (generic of AVAPRO) losartan potassium (generic of 1 COZAAR) olmesartan medoxomil 1 (generic of BENICAR) TABS valsartan (generic of 1 DIOVAN) ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl SOLN amiodarone hcl TABS 100mg, 400mg amiodarone hcl TABS 1 00mg disopyramide phosphate 4 PA (generic of NORPACE) dofetilide (generic of NM TIKOSYN) flecainide acetate mexiletine hcl MULTAQ 4 NORPACE CR 4 PA pacerone 100mg, 400mg pacerone 00mg 1 propafenone hcl propafenone hcl 1hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS sorine (generic of BETAPACE) 80mg, 10mg, 160mg sorine 40mg sotalol hcl (generic of BETAPACE) 80mg, 10mg, 160mg sotalol hcl 40mg 1 sotalol hcl (afib/afl) (generic of BETAPACE AF) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium (generic 1 of LIPITOR) TABS lovastatin 10mg, 0mg 1 lovastatin (generic of 1 MEVACOR) 40mg pravastatin sodium 10mg 1 pravastatin sodium (generic of 1 PRAVACHOL) 0mg, 40mg, 80mg rosuvastatin calcium (generic 1 QL of CRESTOR) QL (30 tabs / 30 simvastatin (generic of 1 ZOCOR) TABS 5mg, 10mg, 0mg, 40mg simvastatin (generic of ZOCOR) TABS 80mg QL (30 tabs / 30 1 QL ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine (generic of QUESTRAN) cholestyramine light PACK cholestyramine light (generic of QUESTRAN LIGHT) POWD colestipol hcl gran (generic of COLESTID) colestipol hcl pack (generic of COLESTID) colestipol hcl tabs (generic of COLESTID) ezetimibe (generic of ZETIA) ezetimibe-simvastatin 1 (generic of VYTORIN) fenofibrate (generic of TRICOR) TABS 48mg, 145mg fenofibrate (generic of LOFIBRA) TABS 54mg fenofibrate TABS 160mg 1

21 fenofibrate micronized (generic of LOFIBRA) 67mg, 134mg fenofibrate micronized 00mg gemfibrozil (generic of LOPID) 1 TABS JUXTAPID KYNAMRO 5 * NM PA niacin er (antihyperlipidemic) QL (generic of NIASPAN) 500mg QL (90 tabs / 30 niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg niacor omega-3-acid ethyl esters (generic of LOVAZA) PRALUENT 5 * NM PA prevalite PACK prevalite (generic of QUESTRAN LIGHT) POWD VASCEPA 4 WELCHOL 3 BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone bisoprolol & 1 hydrochlorothiazide (generic of ZIAC) metoprolol & hctz tab 50-5mg (generic of LOPRESSOR HCT) metoprolol & hctz tab 100-5mg metoprolol & hctz tab mg propranolol & hydrochlorothiazide BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS atenolol (generic of 1 TENORMIN) TABS 5mg atenolol TABS 50mg, 100mg 1 bisoprolol fumarate BYSTOLIC.5mg, 5mg, 4 QL 10mg QL (30 tabs / 30 BYSTOLIC 0mg 4 QL QL (60 tabs / 30 carvedilol (generic of 1 COREG) labetalol hcl TABS metoprolol succinate (generic of TOPROL XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS 1 5mg metoprolol tartrate (generic of 1 LOPRESSOR) TABS 50mg, 100mg 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 - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab cr (generic of ADALAT CC) amlodipine besylate (generic 1 of NORVASC) TABS cartia xt cap 10/4hr (generic of CARDIZEM CD) cartia xt cap 180/4hr (generic of CARDIZEM CD) cartia xt cap 40/4hr (generic of CARDIZEM CD) cartia xt cap 300/4hr dilt-xr cap diltiazem cap 10mg cd (generic of CARDIZEM CD) diltiazem cap 180mg cd (generic of CARDIZEM CD) diltiazem cap 40mg cd (generic of CARDIZEM CD)

22 Drug Tier diltiazem cap 300mg cd diltiazem cap 360mg cd (generic of CARDIZEM CD) diltiazem cap er/1hr diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 10mg diltiazem hcl TABS 90mg diltiazem hcl cap sr 4hr diltiazem hcl coated beads cap sr 4hr (generic of CARDIZEM CD) 10mg, 360mg diltiazem hcl coated beads cap sr 4hr 300mg diltiazem hcl extended release beads cap sr (generic of TIAZAC) 10mg, 180mg, 40mg, 300mg, 360mg, 40mg diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg diltiazem inj 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 5 * NM NYMALIZE 5 * NM taztia xt (generic of TIAZAC) verapamil cap er (generic of VERELAN PM) 100mg, 00mg, 300mg verapamil cap er (generic of VERELAN) 10mg, 180mg, 40mg verapamil cap er 360mg verapamil hcl SOLN verapamil hcl TABS 40mg 1 verapamil hcl (generic of CALAN) TABS 80mg, 10mg 1 verapamil hcl tab er (generic 1 of CALAN SR) DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek (generic of LANOXIN) PA.5mg digitek (generic of LANOXIN) QL.15mg QL (30 tabs / 30 digox (generic of LANOXIN) QL 15mcg QL (30 tabs / 30 digox (generic of LANOXIN) PA 50mcg digoxin (generic of LANOXIN) QL TABS 15mcg QL (30 tabs / 30 digoxin (generic of LANOXIN) PA TABS 50mcg digoxin inj (generic of LANOXIN) digoxin sol 50mcg/ml PA DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS TEKTURNA 4 TEKTURNA HCT 4 DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP1; TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide SOLN bumetanide (generic of BUMEX) TABS chlorothiazide tabs chlorthalidone furosemide SOLN 1 furosemide (generic of LASIX) 1 TABS furosemide inj hydrochlorothiazide (generic 1 of MICROZIDE) CAPS 3

23 Drug Tier hydrochlorothiazide TABS 1 indapamide methazolamide (generic of NEPTAZANE) TABS 5mg methazolamide TABS 50mg methyclothiazide metolazone Requirements/ Limits spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs 5mg, 100mg torsemide tabs (generic of DEMADEX) 10mg, 0mg triamterene & 1 hydrochlorothiazide (generic of MAXZIDE) TABS triamterene & 1 hydrochlorothiazide (generic of MAXZIDE-5) TABS triamterene & 1 hydrochlorothiazide cap mg (generic of DYAZIDE) MISCELLANEOUS clonidine hcl (generic of CATAPRES-TTS-1) PTWK.1mg/4hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/4hr clonidine hcl (generic of CATAPRES-TTS-3) PTWK.3mg/4hr clonidine hcl (generic of 1 CATAPRES) TABS CORLANOR 4 DEMSER 5 * NM hydralazine hcl SOLN; TABS midodrine hcl minoxidil TABS NORTHERA RANEXA 3 NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab 1 isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg isosorbide dinitrate 10mg, 0mg, 30mg Drug Tier 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 Requirements/ Limits nitroglycerin (generic of NITROSTAT) SUBL nitroglycerin td patch.1mg/hr nitroglycerin td patch (generic of NITRO-DUR).mg/hr,.4mg/hr,.6mg/hr PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA 5 * QL NM PA QL (60 tabs / 30 ADEMPAS QL (90 tabs / 30 5 * QL NM LA PA LETAIRIS QL (30 tabs / 30 5 * QL NM LA PA OPSUMIT QL (30 tabs / 30 5 * QL NM LA PA REMODULIN sildenafil citrate (pulmonary QL NM PA hypertension) (generic of REVATIO) TABS QL (90 tabs / 30 TRACLEER TABS 6.5mg QL (10 tabs / 30 5 * QL NM LA PA TRACLEER TABS 15mg QL (60 tabs / 30 5 * QL NM LA PA VENTAVIS 5 * NM PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg 1 QL (generic of XANAX) QL (40 tabs / 30 alprazolam tab 0.5mg (generic of XANAX) QL (480 tabs / 30 1 QL 4

24 alprazolam tab 1mg (generic 1 QL of XANAX) QL (10 tabs / 30 alprazolam tab mg (generic 1 QL of XANAX) QL (150 tabs / 30 buspirone hcl TABS fluvoxamine maleate TABS QL 5mg, 50mg QL (45 tabs / 30 fluvoxamine maleate TABS 100mg lorazepam (generic of ATIVAN) SOLN lorazepam (generic of 1 QL ATIVAN) TABS QL (150 tabs / 30 lorazepam intensol QL (150 ml / 30 QL ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 00mg 5 * QL NM QL (180 tabs / 30 APTIOM 400mg 5 * QL NM QL (90 tabs / 30 APTIOM 600mg, 800mg 5 * QL NM QL (60 tabs / 30 BANZEL SUS 40MG/ML 5 * NM PA BANZEL TAB 00MG 5 * NM PA BANZEL TAB 400MG 5 * NM PA BRIVIACT SOLN 10mg/ml 5 * NM PA BRIVIACT SOLN 50mg/5ml 4 PA BRIVIACT TABS 5 * NM PA carbamazepine CHEW carbamazepine (generic of CARBATROL) CP1 carbamazepine (generic of TEGRETOL) SUSP; TABS carbamazepine (generic of TEGRETOL-XR) TB1 CELONTIN 4 clonazepam (generic of 1 QL KLONOPIN) TABS 1mg QL (10 tabs / 30 clonazepam (generic of KLONOPIN) TABS mg QL (300 tabs / 30 1 QL clonazepam (generic of 1 QL KLONOPIN) TABS.5mg QL (40 tabs / 30 clonazepam TBDP 1mg QL QL (10 tabs / 30 clonazepam TBDP mg QL QL (300 tabs / 30 clonazepam TBDP.5mg QL QL (40 tabs / 30 clonazepam TBDP.5mg QL QL (480 tabs / 30 clonazepam TBDP.15mg QL QL (960 tabs / 30 clorazepate dipotassium QL PA 3.75mg QL (10 tabs / 30 clorazepate dipotassium QL PA (generic of TRANXENE T) 7.5mg QL (10 tabs / 30 clorazepate dipotassium QL PA 15mg QL (180 tabs / 30 DIASTAT ACUDIAL 4 DIASTAT PEDIATRIC 4 diazepam SOLN 1mg/ml QL PA QL (100 ml / 30 diazepam SOLN 5mg/ml diazepam (generic of 1 QL PA VALIUM) TABS QL (10 tabs / 30 diazepam gel diazepam intensol QL PA QL (40 ml / 30 DILANTIN 3 DILANTIN-15 SUS 15/5ML 4 divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR divalproex sodium (generic of DEPAKOTE ER) TB4 divalproex sodium (generic of DEPAKOTE) TBEC 5

25 epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of 5 * NM FELBATOL) SUSP felbamate (generic of FELBATOL) TABS FYCOMPA SUSP 5 * QL NM PA QL (70 ml / 30 FYCOMPA TABS mg QL (180 tabs / 30 4 QL PA FYCOMPA TABS 4mg 5 * QL NM PA QL (90 tabs / 30 FYCOMPA TABS 6mg 5 * QL NM PA QL (60 tabs / 30 FYCOMPA TABS 8mg, 5 * QL NM PA 10mg, 1mg QL (30 tabs / 30 gabapentin (generic of 1 QL NEURONTIN) CAPS 100mg QL (1080 caps / 30 gabapentin (generic of 1 QL NEURONTIN) CAPS 300mg QL (360 caps / 30 gabapentin (generic of 1 QL NEURONTIN) CAPS 400mg QL (70 caps / 30 gabapentin (generic of QL NEURONTIN) SOLN QL (160 ml / 30 gabapentin (generic of QL NEURONTIN) TABS 600mg QL (180 tabs / 30 gabapentin (generic of QL NEURONTIN) TABS 800mg QL (10 tabs / 30 GABITRIL 1mg, 16mg 4 lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW lamotrigine (generic of 1 LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB4 levetiracetam (generic of KEPPRA) SOLN; TABS levetiracetam (generic of KEPPRA XR) TB4 levetiracetam in sodium chloride (generic of LEVETIRACETAM) levetiracetam oral soln 100 mg/ml (generic of KEPPRA) LYRICA CAPS 5mg, 50mg, 75mg, 100mg, 150mg QL (10 caps / 30 LYRICA CAPS 00mg QL (90 caps / 30 LYRICA CAPS 5mg, 300mg QL (60 caps / 30 Drug Tier Requirements/ Limits LYRICA SOLN QL (946 ml / 30 ONFI 5 * NM PA oxcarbazepine (generic of TRILEPTAL) PEGANONE 4 phenobarbital ELIX; TABS 4 PA PHENOBARBITAL SODIUM SOLN 65mg/ml 4 PA phenobarbital sodium SOLN 130mg/ml PHENYTEK 3 phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-15) SUSP phenytoin sodium SOLN phenytoin sodium extended (generic of DILANTIN) 100mg phenytoin sodium extended (generic of PHENYTEK) 00mg, 300mg primidone (generic of MYSOLINE) TABS roweepra (generic of KEPPRA) SABRIL PACK QL (180 packets / 30 SABRIL TABS QL (180 tabs / 30 4 PA 5 * QL NM LA PA 5 * QL NM LA PA 6