6-Tier Drug Formulary

Transcription

1 6-Tier Drug Formulary 2018

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3 Avera Health Plans Tier Drug Formulary Effective April 1, 2018 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs. 1

4 What is the Avera Health Plans Drug Formulary? The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. Avera Health Plans works with a team of health care providers to choose drugs that provide quality treatment. Avera Health Plans covers drugs on the Drug Formulary that are: Medically necessary Approved by the United States Food and Drug Administration (FDA) Filled at a participating pharmacy For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials. Can the Drug Formulary change? The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by Avera Health Plans. To get updated information about the drugs covered by Avera Health Plans, please visit us online at AveraHealthPlans.com or call our Service Center at or tollfree at , 8 a.m. to 5 p.m. CT, Monday through Friday. How do I use the Drug Formulary? There are two ways to find your drug on the drug list: 1. Medical Condition The Drug Formulary starts on page 5. The drugs on this Drug Formulary are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under CARDIOVASCULAR. If you know what your drug is used for, look for the category name in the list that starts on page 5. Then look under the category name for your drug 2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 190. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index. Look in the Index and find your drug Next to your drug, see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list For more information about your Avera Health Plans prescription drug coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call our Service Center at or toll-free at , 8 a.m. to 5 p.m. CT, Monday through Friday. You may also visit us online at AveraHealthPlans.com. Avera Health Plans Drug Formulary The Drug Formulary that starts on the page 5, gives you information about the drugs covered by Avera Health Plans. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary. 2

5 The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The second column (labeled Drug Tier) will list what tier the drug is placed on in the Drug Formulary. Refer to your Summary of Benefits and Coverage to find the associated co-pay for that drug tier. The information in the Requirements/Limits column tells you if Avera Health Plans has any special requirements for coverage of your drug. These requirements and limits may include: Preauthorization: Avera Health Plans needs your healthcare provider to get preauthorization for certain drugs. This means that approval from Avera Health Plans must be obtained before you fill your prescription. If you don't get approval, Avera Health Plans will not cover the cost of the drug. Additional information can be found online at AveraHealthPlans.com. Quantity Limits: For certain drugs, Avera Health Plans limits the amount of the drug that it will cover. For example, Avera Health Plans covers 18 tablets of sumatriptan 50 mg per 30 days. Avera Health Plans also limits the amount of drugs you may receive within a class of drugs. These classes have an " " next to them on the drug list. For these classes, one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply. Step Therapy: Avera Health Plans utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, Avera Health Plans will cover the step-two drugs. Visit us online at AveraHealthPlans.com to review a list of Step Therapy Programs. Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age. Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on gender. What if my drug is not on the Drug Formulary? If your drug is not on this Drug Formulary, you have two choices: Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you. You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following: Why no other prescription on the Drug Formulary will work as well as the requested drug A list of other drugs that have been tried and how you responded to these drugs Medical documentation to support the medical necessity How likely is it that I will get the formulary exception? We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non-preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescriptions co-pays. 3

6 What do the tiers mean on the Drug Formulary? Tier Type of Drugs Included Tier 1 Preventive drugs (covered at no cost to you) Tier 2 Preferred generic drugs Tier 3 Non-preferred generic drugs Tier 4 Preferred brand drugs Tier 5 Non-preferred brand drugs Tier 6 Specialty drugs (brand and generic) 4

7 ANALGESICS COX-II INHIBITORS CELEBREX CAP 50MG 5 QL CELEBREX CAP 100MG 5 QL CELEBREX CAP 200MG 5 QL CELEBREX CAP 400MG 5 QL celecoxib cap 50 mg 2 QL celecoxib cap 100 mg 2 QL celecoxib cap 200 mg 2 QL celecoxib cap 400 mg 2 QL GOUT allopurinol tab 100 mg 2 allopurinol tab 300 mg 2 colchicine cap 0.6 mg 3 colchicine tab 0.6 mg 3 QL colchicine w/ probenecid tab mg 2 COLCRYS TAB 0.6MG 5 QL MITIGARE CAP 0.6MG 5 probenecid tab 500 mg 2 ULORIC TAB 40MG 4 QL ULORIC TAB 80MG 4 QL ZURAMPIC TAB 200MG 5 QL, ST NON-OPIOID ANALGESICS bupap tab mg 2 QL butalbital-acetaminophen tab mg 2 QL butalbital-acetaminophen tab mg 2 QL butalbital-acetaminophen-caffeine cap mg butalbital-acetaminophen-caffeine cap 50-2 QL mg butalbital-acetaminophen-caffeine tab 50-2 QL mg butalbital-aspirin-caffeine cap mg esgic cap 2 QL FIORICET CAP 2 phrenilin cap forte 2 tencon tab mg 2 QL zebutal cap 2 QL NSAIDS 5

8 ANAPROX DS TAB 550MG 5 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 2 mg diclofenac sodium tab delayed release 50 2 mg diclofenac sodium tab delayed release 75 2 mg diclofenac sodium tab er 24hr 100 mg 2 diflunisal tab 500 mg 2 EC-NAPROSYN TAB 375MG 2 EC-NAPROSYN TAB 500MG 5 etodolac cap 200 mg 2 etodolac cap 300 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 etodolac tab er 24hr 400 mg 2 etodolac tab er 24hr 500 mg 2 etodolac tab er 24hr 600 mg 2 FELDENE CAP 10MG 5 FELDENE CAP 20MG 5 fenoprofen calcium cap 200 mg 3 fenoprofen calcium cap 400 mg 3 fenoprofen calcium tab 600 mg 3 FENOPROFEN CAP 200MG 5 FENORTHO CAP 200MG 5 FENORTHO CAP 400MG 5 flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 ibu tab 400mg 2 ibu tab 600mg 2 ibu tab 800mg 2 ibuprofen tab 400 mg 2 ibuprofen tab 600 mg 2 ibuprofen tab 800 mg 2 INDOCIN SUP 50MG 4 INDOCIN SUS 25MG/5ML 4 indomethacin cap 25 mg 2 QL indomethacin cap 50 mg 2 QL indomethacin cap er 75 mg 2 ketoprofen cap 75 mg 2 ketoprofen cap er 24hr 200 mg 2 6

9 ketorolac tromethamine tab 10 mg 2 QL meclofenamate sodium cap 50 mg 2 meclofenamate sodium cap 100 mg 2 mefenamic acid cap 250 mg 2 meloxicam tab 7.5 mg 2 meloxicam tab 15 mg 2 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 NALFON CAP 400MG 5 NAPRELAN TAB 375MG CR 5 NAPRELAN TAB 500MG CR 5 NAPRELAN TAB 750MG CR 5 NAPROSYN SUS 125/5ML 5 NAPROSYN TAB 500MG 5 naproxen dr tab 375mg 2 naproxen dr tab 500mg 2 naproxen sodium tab 275 mg 2 naproxen sodium tab 550 mg 2 naproxen sodium tab er 24hr 375 mg 3 (base equiv) naproxen sodium tab er 24hr 500 mg 3 (base equiv) naproxen susp 125 mg/5ml 2 naproxen tab 250 mg ze naproxen tab 375 mg 2 naproxen tab 500 mg 2 oxaprozin tab 600 mg 2 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 profeno tab 600mg 3 salsalate tab 500 mg 2 salsalate tab 750 mg 2 SPRIX SPR 15.75MG 5 QL sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sodium cap 400 mg 2 tolmetin sodium tab 200 mg 2 tolmetin sodium tab 600 mg 2 ZIPSOR CAP 25MG 5 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed release mg 3 7

10 diclofenac w/ misoprostol tab delayed 3 release mg DUEXIS TAB VIMOVO TAB MG 5 QL VIMOVO TAB MG 5 QL NSAIDS, TOPICAL diclofenac sodium gel 1% 3 QL diclofenac sodium soln 1.5% 3 QL FLECTOR DIS 1.3% 5 QL klofensaid sol ii 3 QL PENNSAID SOL 2% 5 QL VOLTAREN GEL 1% 5 QL OPIOID ANALGESICS ABSTRAL SUB 100MCG 5 QL ABSTRAL SUB 200MCG 5 QL ABSTRAL SUB 300MCG 5 QL ABSTRAL SUB 400MCG 5 QL ABSTRAL SUB 600MCG 5 QL ABSTRAL SUB 800MCG 5 QL acetaminophen w/ codeine soln mg/5ml 2 acetaminophen w/ codeine tab mg 2 QL; Covered for ages 12 acetaminophen w/ codeine tab mg 2 QL; Covered for ages 12 acetaminophen w/ codeine tab mg 2 QL; Covered for ages 12 acetaminophen-caffeine-dihydrocodeine 3 tab mg ACTIQ LOZ 200MCG 5 QL ACTIQ LOZ 400MCG 5 QL ACTIQ LOZ 600MCG 5 QL ACTIQ LOZ 800MCG 5 QL ACTIQ LOZ 1200MCG 5 QL ACTIQ LOZ 1600MCG 5 QL ascomp/cod cap 30mg 2 QL; Covered for ages 12 BELBUCA MIS 75MCG 5 PA, QL BELBUCA MIS 150MCG 5 PA, QL BELBUCA MIS 300MCG 5 PA, QL BELBUCA MIS 450MCG 5 PA, QL BELBUCA MIS 600MCG 5 PA, QL 8

11 BELBUCA MIS 750MCG 5 PA, QL BELBUCA MIS 900MCG 5 PA, QL buprenorphine td patch weekly 5 mcg/hr 3 QL buprenorphine td patch weekly 7.5 mcg/hr 3 QL buprenorphine td patch weekly 10 mcg/hr 3 QL buprenorphine td patch weekly 15 mcg/hr 3 QL buprenorphine td patch weekly 20 mcg/hr 3 QL butalbital-acetaminophen-caff w/ cod cap mg 2 QL; Covered for ages 12 butalbital-acetaminophen-caff w/ cod cap mg 2 QL; Covered for ages 12 butalbital-aspirin-caff w/ codeine cap mg 2 QL; Covered for ages 12 butorphanol tartrate nasal soln 10 mg/ml 3 QL BUTRANS DIS 5MCG/HR 5 QL, ST BUTRANS DIS 10MCG/HR 5 QL, ST BUTRANS DIS 15MCG/HR 5 QL, ST BUTRANS DIS 20MCG/HR 5 QL, ST codeine sulfate tab 15 mg 2 QL; Covered for ages 12 codeine sulfate tab 30 mg 2 QL; Covered for ages 12 codeine sulfate tab 60 mg 2 QL; Covered for ages 12 CONZIP CAP 100MG 5 QL; Covered for ages 12 CONZIP CAP 200MG 5 QL; Covered for ages 12 CONZIP CAP 300MG 5 QL; Covered for ages 12 DILAUDID LIQ 1MG/ML 5 QL DILAUDID TAB 2MG 5 QL DILAUDID TAB 4MG 5 QL DILAUDID TAB 8MG 5 QL DURAGESIC DIS 12MCG/HR 5 QL DURAGESIC DIS 25MCG/HR 5 QL DURAGESIC DIS 50MCG/HR 5 QL DURAGESIC DIS 75MCG/HR 5 QL DURAGESIC DIS 100MCG/H 5 QL EMBEDA CAP MG 5 QL, ST EMBEDA CAP MG 5 QL, ST EMBEDA CAP 50-2MG 5 QL, ST EMBEDA CAP MG 5 QL, ST 9

12 EMBEDA CAP MG 5 QL, ST EMBEDA CAP 100-4MG 5 QL, ST endocet tab QL endocet tab 5-325mg 2 QL endocet tab QL endocet tab mg 2 QL EXALGO TAB 8MG 5 QL, ST EXALGO TAB 12MG 5 QL, ST EXALGO TAB 16MG 5 QL, ST EXALGO TAB 32MG 5 QL, ST fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl dis 37.5mcg 3 QL fentanyl dis 62.5mcg 3 QL fentanyl dis 87.5mcg 3 QL fentanyl td patch 72hr 12 mcg/hr 3 QL fentanyl td patch 72hr 25 mcg/hr 3 QL fentanyl td patch 72hr 50 mcg/hr 3 QL fentanyl td patch 72hr 75 mcg/hr 3 QL fentanyl td patch 72hr 100 mcg/hr 3 QL FENTORA TAB 100MCG 5 QL FENTORA TAB 200MCG 5 QL FENTORA TAB 400MCG 5 QL FENTORA TAB 600MCG 5 QL FENTORA TAB 800MCG 5 QL hydrocodone-acetaminophen soln QL mg/15ml hydrocodone-acetaminophen tab mg 2 QL hydrocodone-acetaminophen tab mg2 QL hydrocodone-acetaminophen tab mg2 QL hydrocodone-acetaminophen tab mg 2 QL 10

13 hydrocodone-acetaminophen tab QL mg hydrocodone-acetaminophen tab QL mg hydrocodone-acetaminophen tab QL mg hydrocodone-ibuprofen tab mg 3 QL hydrocodone-ibuprofen tab mg 2 QL hydrocodone-ibuprofen tab mg 3 QL HYDROMORPHON SUP 3MG 3 QL hydromorphone hcl liqd 1 mg/ml 3 QL hydromorphone hcl tab 2 mg 3 QL hydromorphone hcl tab 4 mg 3 QL hydromorphone hcl tab 8 mg 3 QL hydromorphone hcl tab er 24hr deter 8 mg 3 QL hydromorphone hcl tab er 24hr deter 12 3 QL mg hydromorphone hcl tab er 24hr deter 16 3 QL mg hydromorphone hcl tab er 24hr deter 32 3 QL mg HYSINGLA ER TAB 20 MG 5 QL, ST HYSINGLA ER TAB 30 MG 5 QL, ST HYSINGLA ER TAB 40 MG 5 QL, ST HYSINGLA ER TAB 60 MG 5 QL, ST HYSINGLA ER TAB 80 MG 5 QL, ST HYSINGLA ER TAB 100 MG 5 QL, ST HYSINGLA ER TAB 120 MG 5 QL, ST ibudone tab 5-200mg 3 QL ibudone tab mg 3 QL KADIAN CAP 10MG ER 5 QL, ST KADIAN CAP 20MG ER 5 QL, ST KADIAN CAP 30MG ER 5 QL, ST KADIAN CAP 40MG ER 5 QL, ST KADIAN CAP 50MG ER 5 QL, ST KADIAN CAP 60MG ER 5 QL, ST KADIAN CAP 80MG ER 5 QL, ST KADIAN CAP 100MG ER 5 QL, ST KADIAN CAP 200MG ER 5 QL, ST LAZANDA SPR 100MCG 5 QL LAZANDA SPR 300MCG 5 QL LAZANDA SPR 400MCG 5 QL 11

14 levorphanol tartrate tab 2 mg 3 QL lorcet hd tab mg 2 QL lorcet plus tab QL lorcet tab 5-325mg 2 QL LORTAB ELX MG 3 QL meperidine hcl oral soln 50 mg/5ml 3 QL meperidine hcl tab 50 mg 3 QL meperidine hcl tab 100 mg 3 QL methadone con 10mg/ml 3 QL methadone hcl conc 10 mg/ml 3 QL methadone hcl soln 5 mg/5ml 3 QL methadone hcl soln 10 mg/5ml 3 QL methadone hcl tab 5 mg 3 QL methadone hcl tab 10 mg 3 QL methadone hcl tab for oral susp 40 mg 3 QL methadose tab 40mg 2 QL MORPHINE SUL SUP 30MG 3 QL, ST morphine sulfate beads cap er 24hr 30 mg 3 morphine sulfate beads cap er 24hr 45 mg 3 morphine sulfate beads cap er 24hr 60 mg 3 morphine sulfate beads cap er 24hr 75 mg 3 morphine sulfate beads cap er 24hr 90 mg 3 morphine sulfate beads cap er 24hr mg morphine sulfate cap er 24hr 10 mg 3 QL morphine sulfate cap er 24hr 20 mg 3 QL morphine sulfate cap er 24hr 30 mg 3 QL morphine sulfate cap er 24hr 50 mg 3 QL morphine sulfate cap er 24hr 60 mg 3 QL morphine sulfate cap er 24hr 80 mg 3 QL morphine sulfate cap er 24hr 100 mg 3 QL morphine sulfate oral soln 10 mg/5ml 3 QL morphine sulfate oral soln 20 mg/5ml 3 QL morphine sulfate oral soln 100 mg/5ml (20 3 QL mg/ml) morphine sulfate suppos 5 mg 3 QL morphine sulfate suppos 10 mg 3 QL morphine sulfate suppos 20 mg 3 QL morphine sulfate tab 15 mg 3 QL morphine sulfate tab 30 mg 3 QL morphine sulfate tab er 15 mg 3 QL morphine sulfate tab er 30 mg 3 QL 12

15 morphine sulfate tab er 60 mg 3 QL morphine sulfate tab er 100 mg 3 QL morphine sulfate tab er 200 mg 3 QL MS CONTIN TAB 15MG ER 5 QL, ST MS CONTIN TAB 30MG ER 5 QL, ST MS CONTIN TAB 60MG ER 5 QL, ST MS CONTIN TAB 100MG ER 5 QL, ST MS CONTIN TAB 200MG ER 5 QL, ST NORCO TAB 5-325MG 2 QL NORCO TAB QL NORCO TAB MG 2 QL NUCYNTA ER TAB 50MG 5 QL, ST NUCYNTA ER TAB 100MG 5 QL, ST NUCYNTA ER TAB 150MG 5 QL, ST NUCYNTA ER TAB 200MG 5 QL, ST NUCYNTA ER TAB 250MG 5 QL, ST NUCYNTA TAB 50MG 5 QL NUCYNTA TAB 75MG 5 QL NUCYNTA TAB 100MG 5 QL OPANA TAB 5MG 5 QL OPANA TAB 10MG 5 QL oxycodone hcl cap 5 mg 3 QL oxycodone hcl conc 100 mg/5ml (20 3 QL mg/ml) oxycodone hcl soln 5 mg/5ml 3 QL oxycodone hcl tab 5 mg 3 QL oxycodone hcl tab 10 mg 3 QL oxycodone hcl tab 15 mg 3 QL oxycodone hcl tab 20 mg 3 QL oxycodone hcl tab 30 mg 3 QL oxycodone hcl tab er 12hr deter 10 mg 3 QL oxycodone hcl tab er 12hr deter 15 mg 3 QL oxycodone hcl tab er 12hr deter 20 mg 3 QL oxycodone hcl tab er 12hr deter 30 mg 3 QL oxycodone hcl tab er 12hr deter 40 mg 3 QL oxycodone hcl tab er 12hr deter 60 mg 3 QL oxycodone hcl tab er 12hr deter 80 mg 3 QL oxycodone w/ acetaminophen soln mg/5ml 2 QL oxycodone w/ acetaminophen tab QL mg 13

16 oxycodone w/ acetaminophen tab mg 2 QL oxycodone w/ acetaminophen tab QL mg oxycodone w/ acetaminophen tab QL mg oxycodone-aspirin tab mg 2 QL oxycodone-ibuprofen tab mg 2 QL OXYCONTIN TAB 10MG CR 4 QL, ST OXYCONTIN TAB 15MG CR 4 QL, ST OXYCONTIN TAB 20MG CR 4 QL, ST OXYCONTIN TAB 30MG CR 4 QL, ST OXYCONTIN TAB 40MG CR 4 QL, ST OXYCONTIN TAB 60MG CR 4 QL, ST OXYCONTIN TAB 80MG CR 4 QL, ST oxymorphone hcl tab 5 mg 3 QL oxymorphone hcl tab 10 mg 3 QL oxymorphone hcl tab er 12hr 5 mg 3 QL oxymorphone hcl tab er 12hr 7.5 mg 3 QL oxymorphone hcl tab er 12hr 10 mg 3 QL oxymorphone hcl tab er 12hr 15 mg 3 QL oxymorphone hcl tab er 12hr 20 mg 3 QL oxymorphone hcl tab er 12hr 30 mg 3 QL oxymorphone hcl tab er 12hr 40 mg 3 QL pentazocine w/ naloxone tab mg 3 QL PERCOCET TAB QL PERCOCET TAB 5-325MG 5 QL PERCOCET TAB QL PERCOCET TAB MG 5 QL ROXICODONE TAB 5MG 5 QL ROXICODONE TAB 15MG 5 QL ROXICODONE TAB 30MG 5 QL SUBSYS SPR 100MCG 5 SUBSYS SPR 200MCG 5 SUBSYS SPR 400MCG 5 SUBSYS SPR 600MCG 5 SUBSYS SPR 800MCG 5 SUBSYS SPR 1200MCG 5 SUBSYS SPR 1600MCG 5 TRAMADOL HCL CAP 150MG ER 5 QL; Covered for ages 12 14

17 tramadol hcl cap er 24hr biphasic release 100 mg 5 QL; Covered for ages 12 tramadol hcl cap er 24hr biphasic release 200 mg 5 QL; Covered for ages 12 tramadol hcl cap er 24hr biphasic release 300 mg 5 QL; Covered for ages 12 tramadol hcl tab 50 mg 2 QL; Covered for ages 12 tramadol hcl tab er 24hr 100 mg 3 QL; Covered for ages 12 tramadol hcl tab er 24hr 200 mg 3 QL; Covered for ages 12 tramadol hcl tab er 24hr 300 mg 3 QL; Covered for ages 12 tramadol hcl tab er 24hr biphasic release 100 mg 3 QL; Covered for ages 12 tramadol hcl tab er 24hr biphasic release 200 mg 3 QL; Covered for ages 12 tramadol hcl tab er 24hr biphasic release 300 mg 3 QL; Covered for ages 12 tramadol-acetaminophen tab mg 3 QL; Covered for ages 12 TYLENOL/COD TAB #3 5 QL; Covered for ages 12 TYLENOL/COD TAB #4 5 QL; Covered for ages 12 ULTRAM TAB 50MG 5 QL; Covered for ages 12 verdrocet tab QL vicodin es tab QL vicodin hp tab mg 2 QL vicodin tab 5-300mg 2 QL ZOHYDRO ER CAP 10MG 5 QL, ST ZOHYDRO ER CAP 15MG 5 QL, ST ZOHYDRO ER CAP 20MG 5 QL, ST ZOHYDRO ER CAP 30MG 5 QL, ST ZOHYDRO ER CAP 40MG 5 QL, ST ZOHYDRO ER CAP 50MG 5 QL, ST ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg 3 paromomycin sulfate cap 250 mg 3 ANTIBACTERIALS, CEPHALOSPORINS, First Generation 15

18 cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cephalexin cap 250 mg 2 cephalexin cap 500 mg 2 cephalexin cap 750 mg 3 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 cefaclor for susp 125 mg/5ml 3 cefaclor for susp 250 mg/5ml 3 cefaclor for susp 375 mg/5ml 3 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIN SUS 125/5ML 5 CEFTIN SUS 250/5ML 5 cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefditoren pivoxil tab 200 mg (base 3 equivalent) cefditoren pivoxil tab 400 mg (base 3 equivalent) cefixime for susp 100 mg/5ml 3 cefixime for susp 200 mg/5ml 3 cefpodoxime proxetil for susp 50 mg/5ml 3 cefpodoxime proxetil for susp 100 mg/5ml 3 cefpodoxime proxetil tab 100 mg 3 cefpodoxime proxetil tab 200 mg 3 SPECTRACEF TAB 400MG 5 SUPRAX CAP 400MG 5 SUPRAX CHW 100MG 5 16

19 SUPRAX CHW 200MG 5 SUPRAX SUS 100/5ML 5 SUPRAX SUS 200/5ML 5 SUPRAX SUS 500/5ML 5 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 3 clarithromycin for susp 250 mg/5ml 3 clarithromycin tab 250 mg 3 clarithromycin tab 500 mg 3 clarithromycin tab er 24hr 500 mg 3 DIFICID TAB 200MG 4 QL e.e.s. 400 tab 400mg 3 E.E.S. GRAN SUS 200/5ML 5 ery-tab tab 250mg ec 2 ery-tab tab 333mg ec 2 ery-tab tab 500mg ec 2 ERYPED SUS 200/5ML 5 ERYPED SUS 400/5ML 5 erythrocin tab 250mg 2 erythromycin ethylsuccinate for susp mg/5ml erythromycin ethylsuccinate tab 400 mg 3 erythromycin tab 250 mg 2 erythromycin tab 500 mg 2 erythromycin w/ delayed release particles 2 cap 250 mg PCE TAB 333MG EC 5 PCE TAB 500MG EC 5 ZITHROMAX POW 1GM PAK 5 ZITHROMAX SUS 100/5ML 5 ZITHROMAX SUS 200/5ML 5 ZITHROMAX TAB 250MG 5 ZITHROMAX TAB 500MG 5 ZITHROMAX TAB 600MG 5 ZITHROMAX TAB TRI-PAK 5 ZITHROMAX TAB Z-PAK 5 17

20 ZMAX SUS 2GM 5 ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin for oral susp 500 mg/5ml 3 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr mg(base eq) levofloxacin oral soln 25 mg/ml 3 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl tab 400 mg (base equiv) 3 ofloxacin tab 300 mg 3 ofloxacin tab 400 mg 3 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab er 12hr mg amoxicillin (trihydrate) cap 250 mg 2 amoxicillin (trihydrate) cap 500 mg 2 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp mg/5ml 18

21 amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin cap 500 mg 2 AUGMENTIN SUS 125/5ML 5 AUGMENTIN SUS 250/5ML 5 AUGMENTIN SUS ES AUGMENTIN TAB 500MG 5 AUGMENTIN TAB 875MG 5 AUGMENTIN XR TAB 12HR 5 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 MOXATAG TAB 775MG 5 penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2 penicillin v potassium tab 250 mg 2 penicillin v potassium tab 500 mg 2 ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 3 sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg sulfatrim pd sus /5 2 ANTIBACTERIALS, TETRACYCLINES avidoxy tab 100mg 3 demeclocycline hcl tab 150 mg 3 demeclocycline hcl tab 300 mg 3 doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg 2 doxycycline hyclate tab 20 mg 3 doxycycline hyclate tab 75 mg 3 doxycycline hyclate tab 100 mg 3 doxycycline hyclate tab 150 mg 3 19

22 doxycycline hyclate tab delayed release 50 3 mg doxycycline hyclate tab delayed release 75 3 mg doxycycline hyclate tab delayed release mg doxycycline hyclate tab delayed release mg doxycycline hyclate tab delayed release mg doxycycline monohydrate cap 50 mg 3 doxycycline monohydrate cap 75 mg 3 doxycycline monohydrate cap 100 mg 3 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25 3 mg/5ml doxycycline monohydrate tab 50 mg 3 doxycycline monohydrate tab 75 mg 3 doxycycline monohydrate tab 100 mg 3 doxycycline monohydrate tab 150 mg 3 MINOCIN CAP 50MG 5 MINOCIN CAP 100MG 5 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 minocycline hcl tab er 24hr 65 mg 3 minocycline hcl tab er 24hr 115 mg 3 mondoxyne nl cap 50mg 3 mondoxyne nl cap 75mg 3 mondoxyne nl cap 100mg 3 morgidox cap 1x50mg 2 morgidox cap 1x100mg 2 morgidox cap 2x100mg 2 okebo cap 75mg 3 SOLODYN TAB 55MG 5 SOLODYN TAB 65MG 5 SOLODYN TAB 80MG 5 SOLODYN TAB 105MG 5 SOLODYN TAB 115MG 5 20

23 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 VIBRAMYCIN SYP 50MG/5ML 5 ANTIFUNGALS clotrimazole troche 10 mg 3 CRESEMBA CAP 186 MG 5 QL; Restricted to infectious disease specialists fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole tab 50 mg 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 flucytosine cap 250 mg 3 flucytosine cap 500 mg 3 GRIS-PEG TAB 125MG 5 GRIS-PEG TAB 250MG 5 griseofulvin microsize susp 125 mg/5ml 3 griseofulvin microsize tab 500 mg 3 griseofulvin ultramicrosize tab 125 mg 3 griseofulvin ultramicrosize tab 250 mg 3 itraconazole cap 100 mg 3 QL; Restricted to infectious disease specialists ketoconazole tab 200 mg 2 NOXAFIL SUS 40MG/ML 4 QL; Restricted to infectious disease specialists NOXAFIL TAB 100MG 4 QL; Restricted to infectious disease specialists nystatin susp unit/ml 4 nystatin tab unit 2 ONMEL TAB 200MG 5 ORAVIG TAB 50MG 5 SPORANOX CAP 100MG 5 QL; Restricted to infectious disease specialists SPORANOX CAP PULSEPAK 5 QL; Restricted to infectious disease specialists 21

24 SPORANOX SOL 10MG/ML 5 QL; Restricted to infectious disease specialists terbinafine hcl tab 250 mg 2 QL voriconazole for susp 40 mg/ml 3 QL; Restricted to infectious disease specialists voriconazole tab 50 mg 3 QL; Restricted to infectious disease specialists voriconazole tab 200 mg 3 QL; Restricted to infectious disease specialists ANTIMALARIALS atovaquone-proguanil hcl tab mg 3 atovaquone-proguanil hcl tab mg 3 chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 COARTEM TAB MG 4 QL DARAPRIM TAB 25MG 5 mefloquine hcl tab 250 mg 3 PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 mg 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 5 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab mg 6 QL abacavir sulfate-lamivudine-zidovudine tab 6 QL mg ATRIPLA TAB 6 QL BIKTARVY TAB 6 COMBIVIR TAB QL COMPLERA TAB 6 QL DESCOVY TAB 200/25 6 QL EPZICOM TAB QL EVOTAZ TAB QL GENVOYA TAB 6 QL JULUCA TAB 50-25MG 6 QL lamivudine-zidovudine tab mg 6 QL PREZCOBIX TAB QL STRIBILD TAB 6 QL 22

25 TRIUMEQ TAB 6 QL TRIZIVIR TAB 6 QL TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 6 QL SELZENTRY TAB 25MG 6 QL SELZENTRY TAB 75MG 6 QL SELZENTRY TAB 150MG 6 QL SELZENTRY TAB 300MG 6 QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 6 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 6 QL ISENTRESS CHW 100MG 6 QL ISENTRESS HD TAB 600MG 6 QL ISENTRESS POW 100MG 6 QL ISENTRESS TAB 400MG 6 QL TIVICAY TAB 10MG 6 QL TIVICAY TAB 25MG 6 QL TIVICAY TAB 50MG 6 QL ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS EDURANT TAB 25MG 6 QL efavirenz cap 50 mg 6 QL efavirenz cap 200 mg 6 QL efavirenz tab 600 mg 6 QL INTELENCE TAB 25MG 6 QL INTELENCE TAB 100MG 6 QL INTELENCE TAB 200MG 6 QL nevirapine tab 200 mg 6 QL nevirapine tab er 24hr 100 mg 6 QL nevirapine tab er 24hr 400 mg 6 QL RESCRIPTOR TAB 100 MG 6 QL RESCRIPTOR TAB 200MG 6 QL SUSTIVA CAP 50MG 6 QL SUSTIVA CAP 200MG 6 QL SUSTIVA TAB 600MG 6 QL VIRAMUNE SUS 50MG/5ML 6 QL 23

26 VIRAMUNE TAB 200MG 6 QL VIRAMUNE XR TAB 100MG 6 QL VIRAMUNE XR TAB 400MG 6 QL ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate soln 20 mg/ml (base 6 QL equiv) abacavir sulfate tab 300 mg (base equiv) 6 QL didanosine delayed release capsule 200 mg6 QL didanosine delayed release capsule 250 mg6 QL didanosine delayed release capsule 400 mg6 QL EMTRIVA CAP 200MG 6 QL EMTRIVA SOL 10MG/ML 6 QL EPIVIR SOL 10MG/ML 6 QL EPIVIR TAB 150MG 6 QL EPIVIR TAB 300MG 6 QL lamivudine oral soln 10 mg/ml 6 QL lamivudine tab 150 mg 6 QL lamivudine tab 300 mg 6 QL RETROVIR CAP 100MG 6 QL RETROVIR SYP 50MG/5ML 6 QL stavudine cap 15 mg 6 QL stavudine cap 20 mg 6 QL stavudine cap 30 mg 6 QL stavudine cap 40 mg 6 QL VIDEX EC CAP 125MG 6 QL VIDEX EC CAP 200MG 6 QL VIDEX EC CAP 250MG 6 QL VIDEX EC CAP 400MG 6 QL VIDEX SOL 2GM 6 QL VIDEX SOL 4GM 6 QL ZERIT CAP 15MG 6 QL ZERIT CAP 20MG 6 QL ZERIT CAP 30MG 6 QL ZERIT CAP 40MG 6 QL ZERIT SOL 1MG/ML 6 QL ZIAGEN SOL 20MG/ML 6 QL ZIAGEN TAB 300MG 6 QL zidovudine cap 100 mg 6 QL zidovudine syrup 10 mg/ml 6 QL zidovudine tab 300 mg 6 QL 24

27 ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS tenofovir disoproxil fumarate tab 300 mg 6 QL VIREAD POW 40MG/GM 6 QL VIREAD TAB 150MG 6 QL VIREAD TAB 200MG 6 QL VIREAD TAB 250MG 6 QL VIREAD TAB 300MG 6 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 6 QL APTIVUS SOL 6 QL atazanavir sulfate cap 150 mg (base equiv)6 QL atazanavir sulfate cap 200 mg (base equiv)6 QL atazanavir sulfate cap 300 mg (base equiv)6 QL CRIXIVAN CAP 200MG 6 QL CRIXIVAN CAP 400MG 6 QL fosamprenavir calcium tab 700 mg (base 6 QL equiv) INVIRASE CAP 200MG 6 QL INVIRASE TAB 500MG 6 QL KALETRA SOL 6 QL KALETRA TAB MG 6 QL KALETRA TAB MG 6 QL LEXIVA SUS 50MG/ML 6 QL LEXIVA TAB 700MG 6 QL lopinavir-ritonavir soln mg/5ml 6 QL (80-20 mg/ml) NORVIR CAP 100MG 6 QL NORVIR SOL 80MG/ML 6 QL NORVIR TAB 100MG 6 QL PREZISTA SUS 100MG/ML 6 QL PREZISTA TAB 75MG 6 QL PREZISTA TAB 150MG 6 QL PREZISTA TAB 600MG 6 QL PREZISTA TAB 800MG 6 QL REYATAZ CAP 150MG 6 QL REYATAZ CAP 200MG 6 QL REYATAZ CAP 300MG 6 QL REYATAZ POW 50MG 6 QL VIRACEPT TAB 250MG 6 QL VIRACEPT TAB 625MG 6 QL ANTITUBERCULAR AGENTS 25

28 cycloserine cap 250 mg 3 ethambutol hcl tab 100 mg 3 ethambutol hcl tab 400 mg 3 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 MYAMBUTOL TAB 100MG 5 MYAMBUTOL TAB 400MG 5 PASER GRA 4GM 3 PRIFTIN TAB 150MG 5 pyrazinamide tab 500 mg 3 RIFADIN CAP 150MG 5 RIFAMATE CAP 5 rifampin cap 150 mg 3 rifampin cap 300 mg 3 RIFATER TAB 5 SIRTURO TAB 100MG 6 QL TRECATOR TAB 250MG 5 ANTIVIRALS, CYTOMEGALOVIRUS AGENTS PREVYMIS TAB 240MG 6 QL PREVYMIS TAB 480MG 6 QL VALCYTE SOL 50MG/ML 6 QL VALCYTE TAB 450MG 6 QL valganciclovir hcl for soln 50 mg/ml (base 6 QL equiv) valganciclovir hcl tab 450 mg (base 6 QL equivalent) ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg 6 QL BARACLUDE SOL.05MG/ML 6 QL BARACLUDE TAB 0.5MG 6 QL BARACLUDE TAB 1MG 6 QL entecavir tab 0.5 mg 6 QL entecavir tab 1 mg 6 QL EPIVIR HBV SOL 5MG/ML 6 QL EPIVIR HBV TAB 100MG 6 QL HEPSERA TAB 10MG 6 QL lamivudine tab 100 mg (hbv) 6 QL ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C EPCLUSA TAB PA, QL HARVONI TAB MG 6 PA, QL MAVYRET TAB MG 6 PA, QL 26

29 moderiba tab 200mg 6 QL OLYSIO CAP 150MG 6 PA, QL ribasphere cap 200mg 6 QL ribasphere tab 200mg 6 QL ribavirin cap 200 mg 6 QL ribavirin tab 200 mg 6 QL VOSEVI TAB 6 PA, QL ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 2 acyclovir susp 200 mg/5ml 2 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 famciclovir tab 125 mg 3 famciclovir tab 250 mg 3 famciclovir tab 500 mg 3 valacyclovir hcl tab 1 gm 3 valacyclovir hcl tab 500 mg 3 ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base 3 QL equiv) oseltamivir phosphate cap 45 mg (base 3 QL equiv) oseltamivir phosphate cap 75 mg (base 3 QL equiv) oseltamivir phosphate for susp 6 mg/ml 2 QL (base equiv) RELENZA MIS DISKHALE 5 QL rimantadine hydrochloride tab 100 mg 2 TAMIFLU CAP 30MG 5 QL TAMIFLU CAP 45MG 5 QL TAMIFLU CAP 75MG 5 QL TAMIFLU SUS 6MG/ML 5 QL MISCELLANEOUS ALBENZA TAB 200MG 5 ALINIA SUS 100/5ML 4 ALINIA TAB 500MG 4 atovaquone susp 750 mg/5ml 3 BENZNIDAZOLE TAB 12.5MG 5 BENZNIDAZOLE TAB 100MG 5 BILTRICIDE TAB 600MG 5 clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 27

30 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) dapsone tab 25 mg 2 dapsone tab 100 mg 2 IMPAVIDO CAP 50MG 6 QL ivermectin tab 3 mg 2 linezolid for susp 100 mg/5ml 3 Restricted to infectious disease specialists linezolid tab 600 mg 3 QL; Restricted to infectious disease specialists methenamine hippurate tab 1 gm 3 methenamine mandelate tab 0.5 gm 3 methenamine mandelate tab 1 gm 3 metronidazole cap 375 mg 2 metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 MONUROL PAK GRANULES 5 nitrofurantoin macrocrystalline cap 25 mg 3 nitrofurantoin macrocrystalline cap 50 mg 2 nitrofurantoin macrocrystalline cap 100 mg 2 nitrofurantoin monohydrate 2 macrocrystalline cap 100 mg nitrofurantoin susp 25 mg/5ml 2 PRIMSOL SOL 50MG/5ML 5 rifabutin cap 150 mg 3 SIVEXTRO TAB 200MG 4 QL tinidazole tab 250 mg 3 tinidazole tab 500 mg 3 trimethoprim tab 100 mg 2 TRIMPEX SOL 50MG/5ML 5 XIFAXAN TAB 200MG 4 XIFAXAN TAB 550MG 4 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN TAB 2MG 6 PA, QL EMCYT CAP 140MG 6 PA, QL GLEOSTINE CAP 5MG 6 PA, QL GLEOSTINE CAP 100MG 6 PA, QL HEXALEN CAP 50MG 6 PA, QL LEUKERAN TAB 2MG 4 PA 28

31 melphalan tab 2 mg 6 PA, QL MYLERAN TAB 2MG 5 TEMODAR CAP 5MG 6 PA, QL TEMODAR CAP 20MG 6 PA, QL TEMODAR CAP 100MG 6 PA, QL TEMODAR CAP 140MG 6 PA, QL TEMODAR CAP 180MG 6 PA, QL TEMODAR CAP 250MG 6 PA, QL temozolomide cap 5 mg 6 PA, QL temozolomide cap 20 mg 6 PA, QL temozolomide cap 100 mg 6 PA, QL temozolomide cap 140 mg 6 PA, QL temozolomide cap 180 mg 6 PA, QL temozolomide cap 250 mg 6 PA, QL VALCHLOR GEL 0.016% 6 QL ANTIMETABOLITES capecitabine tab 150 mg 6 PA, QL capecitabine tab 500 mg 6 PA, QL mercaptopurine tab 50 mg 2 methotrexate sodium tab 2.5 mg (base 2 equiv) PURIXAN SUS 20MG/ML 5 TABLOID TAB 40MG 5 PA TREXALL TAB 5MG 4 TREXALL TAB 7.5MG 4 TREXALL TAB 10MG 4 TREXALL TAB 15MG 4 XELODA TAB 150MG 6 PA, QL XELODA TAB 500MG 6 PA, QL HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg 2 QL ERLEADA TAB 60MG 6 PA flutamide cap 125 mg 3 NILANDRON TAB 150MG 6 PA, QL nilutamide tab 150 mg 6 PA, QL XTANDI CAP 40MG 6 PA, QL ZYTIGA TAB 250MG 6 PA, QL ZYTIGA TAB 500MG 6 PA, QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 5 PA tamoxifen citrate tab 10 mg (base 2 Covered at Tier 0 for equivalent) ages 35 and older 29

32 tamoxifen citrate tab 20 mg (base equivalent) 2 Covered at Tier 0 for ages 35 and older HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg 2 QL ARIMIDEX TAB 1MG 5 QL exemestane tab 25 mg 3 PA letrozole tab 2.5 mg 2 HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS leuprolide acetate inj kit 5 mg/ml 6 PA, QL HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 mg 3 megestrol acetate tab 40 mg 3 IMMUNOMODULATORS POMALYST CAP 1MG 6 PA, QL POMALYST CAP 2MG 6 PA, QL POMALYST CAP 3MG 6 PA, QL POMALYST CAP 4MG 6 PA, QL REVLIMID CAP 2.5MG 6 PA, QL REVLIMID CAP 5MG 6 PA, QL REVLIMID CAP 10MG 6 PA, QL REVLIMID CAP 15MG 6 PA, QL REVLIMID CAP 20MG 6 PA, QL REVLIMID CAP 25MG 6 PA, QL THALOMID CAP 50MG 6 PA, QL THALOMID CAP 100MG 6 PA, QL THALOMID CAP 150MG 6 PA, QL THALOMID CAP 200MG 6 PA, QL KINASE INHIBITORS AFINITOR DIS TAB 2MG 6 PA, QL AFINITOR DIS TAB 3MG 6 PA, QL AFINITOR DIS TAB 5MG 6 PA, QL AFINITOR TAB 2.5MG 6 PA, QL AFINITOR TAB 5MG 6 PA, QL AFINITOR TAB 7.5MG 6 PA, QL AFINITOR TAB 10MG 6 PA, QL ALECENSA CAP 150MG 6 PA, QL ALUNBRIG PAK 6 PA, QL ALUNBRIG TAB 30MG 6 PA, QL ALUNBRIG TAB 90MG 6 PA, QL ALUNBRIG TAB 180MG 6 PA, QL 30

33 BOSULIF TAB 100MG 6 PA, QL BOSULIF TAB 400MG 6 PA, QL BOSULIF TAB 500MG 6 PA, QL CAPRELSA TAB 100MG 6 PA, QL CAPRELSA TAB 300MG 6 PA, QL COMETRIQ KIT 60MG 6 PA, QL COMETRIQ KIT 100MG 6 PA, QL COMETRIQ KIT 140MG 6 PA, QL COTELLIC TAB 20MG 6 PA, QL GILOTRIF TAB 20MG 6 PA, QL GILOTRIF TAB 30MG 6 PA, QL GILOTRIF TAB 40MG 6 PA, QL GLEEVEC TAB 100MG 6 PA, QL GLEEVEC TAB 400MG 6 PA, QL IBRANCE CAP 75MG 6 PA, QL IBRANCE CAP 100MG 6 PA, QL IBRANCE CAP 125MG 6 PA, QL ICLUSIG TAB 15MG 6 PA, QL ICLUSIG TAB 45MG 6 PA, QL imatinib mesylate tab 100 mg (base 6 PA, QL equivalent) imatinib mesylate tab 400 mg (base 6 PA, QL equivalent) IMBRUVICA CAP 70MG 6 PA, QL IMBRUVICA CAP 140MG 6 PA, QL IMBRUVICA TAB 140MG 6 PA, QL IMBRUVICA TAB 280MG 6 PA, QL IMBRUVICA TAB 420MG 6 PA, QL IMBRUVICA TAB 560MG 6 PA, QL INLYTA TAB 1MG 6 PA, QL INLYTA TAB 5MG 6 PA, QL JAKAFI TAB 5MG 6 PA, QL JAKAFI TAB 10MG 6 PA, QL JAKAFI TAB 15MG 6 PA, QL JAKAFI TAB 20MG 6 PA, QL JAKAFI TAB 25MG 6 PA, QL LENVIMA CAP 8 MG 6 PA, QL LENVIMA CAP 10 MG 6 PA, QL LENVIMA CAP 14 MG 6 PA, QL LENVIMA CAP 18 MG 6 PA, QL LENVIMA CAP 20 MG 6 PA, QL LENVIMA CAP 24 MG 6 PA, QL 31

34 MEKINIST TAB 0.5MG 6 PA, QL MEKINIST TAB 2MG 6 PA, QL NERLYNX TAB 40MG 6 PA, QL NEXAVAR TAB 200MG 6 PA, QL RYDAPT CAP 25MG 6 PA, QL SPRYCEL TAB 20MG 6 PA, QL SPRYCEL TAB 50MG 6 PA, QL SPRYCEL TAB 70MG 6 PA, QL SPRYCEL TAB 80MG 6 PA, QL SPRYCEL TAB 100MG 6 PA, QL SPRYCEL TAB 140MG 6 PA, QL STIVARGA TAB 40MG 6 PA, QL SUTENT CAP 12.5MG 6 PA, QL SUTENT CAP 25MG 6 PA, QL SUTENT CAP 37.5MG 6 PA, QL SUTENT CAP 50MG 6 PA, QL TAFINLAR CAP 50MG 6 PA, QL TAFINLAR CAP 75MG 6 PA, QL TAGRISSO TAB 40MG 6 PA, QL TAGRISSO TAB 80MG 6 PA, QL TARCEVA TAB 25MG 6 PA, QL TARCEVA TAB 100MG 6 PA, QL TARCEVA TAB 150MG 6 PA, QL TASIGNA CAP 150MG 6 PA, QL TASIGNA CAP 200MG 6 PA, QL TYKERB TAB 250MG 6 PA, QL VERZENIO TAB 50MG 6 PA VERZENIO TAB 100MG 6 PA VERZENIO TAB 150MG 6 PA VERZENIO TAB 200MG 6 PA VOTRIENT TAB 200MG 6 PA, QL XALKORI CAP 200MG 6 PA, QL XALKORI CAP 250MG 6 PA, QL ZELBORAF TAB 240MG 6 PA, QL ZYDELIG TAB 100MG 6 PA, QL ZYDELIG TAB 150MG 6 PA, QL ZYKADIA CAP 150MG 6 PA, QL MISCELLANEOUS bexarotene cap 75 mg 6 PA, QL DROXIA CAP 200MG 5 DROXIA CAP 300MG 5 DROXIA CAP 400MG 5 32

35 ERIVEDGE CAP 150MG 6 PA, QL FARYDAK CAP 10MG 6 PA, QL FARYDAK CAP 15MG 6 PA, QL FARYDAK CAP 20MG 6 PA, QL hydroxyurea cap 500 mg 3 IDHIFA TAB 50MG 6 PA IDHIFA TAB 100MG 6 PA leucovorin calcium tab 5 mg 3 leucovorin calcium tab 10 mg 3 leucovorin calcium tab 15 mg 3 leucovorin calcium tab 25 mg 3 LONSURF TAB PA, QL LONSURF TAB PA, QL LYNPARZA CAP 50MG 6 PA, QL LYSODREN TAB 500MG 6 PA, QL MATULANE CAP 50MG 6 PA, QL MESNEX TAB 400MG 6 QL NINLARO CAP 2.3MG 6 PA, QL NINLARO CAP 3MG 6 PA, QL NINLARO CAP 4MG 6 PA, QL ODOMZO CAP 200MG 6 PA, QL RUBRACA TAB 200MG 6 PA, QL RUBRACA TAB 250MG 6 PA, QL RUBRACA TAB 300MG 6 PA, QL TARGRETIN CAP 75MG 6 PA, QL TARGRETIN GEL 1% 6 QL tretinoin cap 10 mg 6 PA, QL VENCLEXTA TAB 10MG 6 PA, QL VENCLEXTA TAB 50MG 6 PA, QL VENCLEXTA TAB 100MG 6 PA, QL VENCLEXTA TAB START PK 6 PA, QL VISTOGARD PAK 10GM 6 QL ZEJULA CAP 100MG 6 PA, QL ZOLINZA CAP 100MG 6 PA, QL TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG 6 PA, QL HYCAMTIN CAP 1MG 6 PA, QL CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap mg 33

36 amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg trandolapril-verapamil hcl tab er mg 3 trandolapril-verapamil hcl tab er mg 3 trandolapril-verapamil hcl tab er mg 3 trandolapril-verapamil hcl tab er mg 3 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg 34

37 lisinopril & hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg2 ACE INHIBITORS ACCUPRIL TAB 5MG 5 ACCUPRIL TAB 10MG 5 ACCUPRIL TAB 20MG 5 ACCUPRIL TAB 40MG 5 benazepril hcl tab 5 mg 2 benazepril hcl tab 10 mg 2 benazepril hcl tab 20 mg 2 benazepril hcl tab 40 mg 2 captopril tab 12.5 mg 2 captopril tab 25 mg 2 captopril tab 50 mg 2 captopril tab 100 mg 2 enalapril maleate tab 2.5 mg 2 enalapril maleate tab 5 mg 2 enalapril maleate tab 10 mg 2 enalapril maleate tab 20 mg 2 fosinopril sodium tab 10 mg 2 fosinopril sodium tab 20 mg 2 fosinopril sodium tab 40 mg 2 lisinopril tab 2.5 mg 2 lisinopril tab 5 mg 2 lisinopril tab 10 mg 2 lisinopril tab 20 mg 2 lisinopril tab 30 mg 2 lisinopril tab 40 mg 2 moexipril hcl tab 7.5 mg 2 moexipril hcl tab 15 mg 2 perindopril erbumine tab 2 mg 2 35

38 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2 PRINIVIL TAB 5MG 5 PRINIVIL TAB 10MG 5 PRINIVIL TAB 20MG 5 QBRELIS SOL 1MG/ML 5 quinapril hcl tab 5 mg 2 quinapril hcl tab 10 mg 2 quinapril hcl tab 20 mg 2 quinapril hcl tab 40 mg 2 ramipril cap 1.25 mg 2 ramipril cap 2.5 mg 2 ramipril cap 5 mg 2 ramipril cap 10 mg 2 trandolapril tab 1 mg 2 trandolapril tab 2 mg 2 trandolapril tab 4 mg 2 ZESTRIL TAB 2.5MG 5 ZESTRIL TAB 5MG 5 ZESTRIL TAB 10MG 5 ZESTRIL TAB 20MG 5 ZESTRIL TAB 30MG 5 ZESTRIL TAB 40MG 5 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 2 clonidine hcl tab 0.3 mg 2 clonidine hcl td patch weekly 0.1 mg/24hr 3 QL clonidine hcl td patch weekly 0.2 mg/24hr 3 QL clonidine hcl td patch weekly 0.3 mg/24hr 3 QL guanfacine hcl tab 1 mg 2 guanfacine hcl tab 2 mg 2 methyldopa tab 250 mg 2 methyldopa tab 500 mg 2 ADRENOLYTICS, CENTRAL/DIURETIC COMBINATIONS clorpres tab mg 2 clorpres tab mg 2 clorpres tab mg 2 methyldopa & hydrochlorothiazide tab mg methyldopa & hydrochlorothiazide tab mg 36

39 ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE TAB 25MG 5 ALDACTONE TAB 50MG 5 ALDACTONE TAB 100MG 5 CAROSPIR SUS 25MG/5ML 5 Covered for ages 12 years and under eplerenone tab 25 mg 3 QL eplerenone tab 50 mg 3 QL spironolactone tab 25 mg 2 spironolactone tab 50 mg 2 spironolactone tab 100 mg 2 ALPHA BLOCKERS doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2 prazosin hcl cap 1 mg 2 prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg (base equivalent) 2 terazosin hcl cap 2 mg (base equivalent) 2 terazosin hcl cap 5 mg (base equivalent) 2 terazosin hcl cap 10 mg (base equivalent) 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil 3 tab 5-20 mg amlodipine besylate-olmesartan medoxomil 3 tab 5-40 mg amlodipine besylate-olmesartan medoxomil 3 tab mg amlodipine besylate-olmesartan medoxomil 3 tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg AZOR TAB 5-20MG 5 37

40 AZOR TAB 5-40MG 5 AZOR TAB 10-20MG 5 AZOR TAB 10-40MG 5 telmisartan-amlodipine tab 40-5 mg 3 telmisartan-amlodipine tab mg 3 telmisartan-amlodipine tab 80-5 mg 3 telmisartan-amlodipine tab mg 3 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide 3 tab mg amlodipine-valsartan-hydrochlorothiazide 3 tab mg amlodipine-valsartan-hydrochlorothiazide 3 tab mg amlodipine-valsartan-hydrochlorothiazide 3 tab mg amlodipine-valsartan-hydrochlorothiazide 3 tab mg olmesartan-amlodipine-hydrochlorothiazide 3 tab mg olmesartan-amlodipine-hydrochlorothiazide 3 tab mg olmesartan-amlodipine-hydrochlorothiazide 3 tab mg olmesartan-amlodipine-hydrochlorothiazide 3 tab mg olmesartan-amlodipine-hydrochlorothiazide 3 tab mg ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS BENICAR HCT TAB BENICAR HCT TAB BENICAR HCT TAB 40-25MG 5 candesartan cilexetil-hydrochlorothiazide 2 tab mg candesartan cilexetil-hydrochlorothiazide 2 tab mg candesartan cilexetil-hydrochlorothiazide 2 tab mg DIOVAN HCT TAB 80/ DIOVAN HCT TAB DIOVAN HCT TAB MG 5 38

41 DIOVAN HCT TAB DIOVAN HCT TAB MG 5 EDARBYCLOR TAB EDARBYCLOR TAB 40-25MG 5 irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide 2 tab mg losartan potassium & hydrochlorothiazide 2 tab mg losartan potassium & hydrochlorothiazide 2 tab mg olmesartan medoxomil-hydrochlorothiazide 3 tab mg olmesartan medoxomil-hydrochlorothiazide 3 tab mg olmesartan medoxomil-hydrochlorothiazide 3 tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR TAB 5MG 5 BENICAR TAB 20MG 5 BENICAR TAB 40MG 5 candesartan cilexetil tab 4 mg 2 candesartan cilexetil tab 8 mg 2 candesartan cilexetil tab 16 mg 2 39

42 candesartan cilexetil tab 32 mg 2 DIOVAN TAB 40MG 5 DIOVAN TAB 80MG 5 DIOVAN TAB 160MG 5 DIOVAN TAB 320MG 5 EDARBI TAB 40MG 5 EDARBI TAB 80MG 5 eprosartan mesylate tab 600 mg 2 irbesartan tab 75 mg 2 irbesartan tab 150 mg 2 irbesartan tab 300 mg 2 losartan potassium tab 25 mg 2 losartan potassium tab 50 mg 2 losartan potassium tab 100 mg 2 olmesartan medoxomil tab 5 mg 3 olmesartan medoxomil tab 20 mg 3 olmesartan medoxomil tab 40 mg 3 telmisartan tab 20 mg 3 telmisartan tab 40 mg 3 telmisartan tab 80 mg 3 valsartan tab 40 mg 2 valsartan tab 80 mg 2 valsartan tab 160 mg 2 valsartan tab 320 mg 2 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 3 BETAPACE TAB 80MG 5 BETAPACE TAB 120MG 5 BETAPACE TAB 160MG 5 disopyramide phosphate cap 100 mg 3 disopyramide phosphate cap 150 mg 3 dofetilide cap 125 mcg (0.125 mg) 3 dofetilide cap 250 mcg (0.25 mg) 3 dofetilide cap 500 mcg (0.5 mg) 3 flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 mexiletine hcl cap 150 mg 3 mexiletine hcl cap 200 mg 3 mexiletine hcl cap 250 mg 3 40

43 MULTAQ TAB 400MG 5 QL NORPACE CAP 100MG 5 NORPACE CAP 100MG CR 5 NORPACE CAP 150MG 5 NORPACE CAP 150MG CR 5 pacerone tab 100mg 2 pacerone tab 200mg 2 pacerone tab 400mg 3 propafenone hcl cap er 12hr 225 mg 2 propafenone hcl cap er 12hr 325 mg 2 propafenone hcl cap er 12hr 425 mg 2 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 quinidine gluconate tab er 324 mg 3 quinidine sulfate tab 200 mg 3 quinidine sulfate tab 300 mg 3 sorine tab 80mg 2 sorine tab 120mg 2 sorine tab 160mg 2 sorine tab 240mg 2 sotalol hcl (afib/afl) tab 80 mg 2 sotalol hcl (afib/afl) tab 120 mg 2 sotalol hcl (afib/afl) tab 160 mg 2 sotalol hcl tab 80 mg 2 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 SOTYLIZE SOL 5MG/ML 5 TIKOSYN CAP 125MCG 5 TIKOSYN CAP 250MCG 5 TIKOSYN CAP 500MCG 5 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 colestipol hcl granule packets 5 gm 3 colestipol hcl granules 5 gm 3 colestipol hcl tab 1 gm 3 prevalite pow 4gm 2 prevalite pow 4gm pk 2 41