Arkansas Blue Cross and Blue Shield Metallic Formulary List of Covered Drugs

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1 Arkansas Blue Cross and Blue Shield Metallic Formulary 018 List of Covered Drugs PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Members must use network pharmacies to fill their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change.

2 What is the Arkansas Blue Cross and Blue Shield Metallic Plans Drug List? A drug list is a list of covered drugs. Arkansas Blue Cross and Blue Shield Metallic Plans works with a team of health care providers to choose drugs that provide quality treatment. Arkansas Blue Cross and Blue Shield Metallic Plans cover drugs on our drug list, as long as: The drug is medically necessary The prescription is filled at a Arkansas Blue Cross and Blue Shield Metallic Plans network pharmacy Other plan rules are followed For more information on how to fill your prescriptions, please review your plan document or other plan materials. Can the Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed drug list is the most current drug list covered by Arkansas Blue Cross and Blue Shield Metallic Plans. To get updated information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans, please or call Member Services at How do I use the Drug List? There are two ways to find your drug on the drug list: 1. Medical Condition The drug list starts on page 5. The drugs on this drug list 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 anticoagulants. If you know what your drug is used for, look for the category name in the list that starts on the next page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 60. 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 Arkansas Blue Cross and Blue Shield Metallic Plans prescription drug coverage, please look at your plan document and other plan materials. If - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

3 you have questions about Arkansas Blue Cross and Blue Shield Metallic Plans, or this drug list please call Member Services at or visit Arkansas Blue Cross and Blue Shield Metallic Plans Drug List The drug list set forth below gives information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans. 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 information in the Requirements/Limits column tells you if Arkansas Blue Cross and Blue Shield Metallic Plans have any special requirements for coverage of your drug. These requirements and limits may include: Prior Approval: Arkansas Blue Cross and Blue Shield needs you (or your doctor) to get prior approval or authorization for certain drugs. This means that you need to get approval from Arkansas Blue Cross and Blue Shield before you fill your prescriptions. If you don t get approval, Arkansas Blue Cross and Blue Shield may not cover the drug Quantity Limits: For certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that it will cover. For example, Arkansas Blue Cross and Blue Shield provides 8 caplets per 90 day prescription for Tamiflu. This may be in addition to a standard one-month or three-month supply Step Therapy: Arkansas Blue Cross and Blue Shield needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Arkansas Blue Cross and Blue Shield may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Arkansas Blue Cross and Blue Shield will then cover Drug B Specialty Medications: Arkansas Blue Cross and Blue Shield requires that specialty medications be filled at a network specialty pharmacy. What if my drug is not on the Drug List? If your drug is not on this drug list, call Member Services and make sure that your drug is not covered. If you learn that Arkansas Blue Cross and Blue Shield does not cover your drug, you have two choices: - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 3

4 April 1, 018 Ask Member Services for a list of similar drugs that are covered by Arkansas Blue Cross and Blue Shield Metallic Plans. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Arkansas Blue Cross and Blue Shield Metallic Plans. Similar drugs that are preferred and covered by your plan s formulary may be easier to obtain and lower cost to you than non-preferred drugs. Ask Arkansas Blue Cross and Blue Shield to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more. Generally, Arkansas Blue Cross and Blue Shield will only approve your request for an exception if the preferred drugs included on the plan s drug list are not as effective in treating your condition or cause you to have adverse medical effects. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug s cost that you will pay) for drugs in each tier. Drug Tier column instructions: Plans that provide different levels of cost sharing for drugs depending on their tier must include a column indicating the drug s tier placement. Plans may choose from several methods to indicate the tier placement, including tier numbers from your plan benefit package (e.g., 0/1//3), standard tier names from your plan benefit package (e.g., ACA preventive/generic/preferred brand/other brand), copayment amounts (e.g.,$0/$10/$0/$35), or coinsurance percentages (e.g., 0%/10%/5%). The latter two methods are preferred because they are generally easier for members to understand. If one of the two former methods is used, plans must provide an explanation before the table explaining the copayment amount or coinsurance percentage associated with each tier number or tier name. Plans that have different copayment amounts or coinsurance percentages for retail and mail-service prescriptions may include both retail and mail service amounts within the same column or include separate columns for retail and mail service prescriptions. - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 4

5 ANALGESICS COX- INHIBITORS celecoxib cap 50 mg celecoxib cap 100 mg celecoxib cap 00 mg celecoxib cap 400 mg GOUT allopurinol sodium for inj 500 mg allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg colchicine w/ probenecid tab mg probenecid tab 500 mg ULORIC TAB 40MG 4 ST; ** ULORIC TAB 80MG 4 ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap QL (48 caps / 5 days) mg butalbital-acetaminophen-caffeine cap QL (48 caps / 5 days) mg butalbital-acetaminophen-caffeine tab QL (48 tabs / 5 days) mg butalbital-aspirin-caffeine cap QL (48 caps / 5 days) mg tencon tab 50-35mg QL (48 tabs / 5 days) NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed release mg diclofenac w/ misoprostol tab delayed release mg NSAIDS diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er 4hr 100 mg etodolac cap 00 mg etodolac cap 300 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 5

6 etodolac tab 400 mg etodolac tab 500 mg etodolac tab er 4hr 400 mg etodolac tab er 4hr 500 mg etodolac tab er 4hr 600 mg fenoprofen calcium cap 400 mg fenoprofen calcium tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibu tab 600mg ibu tab 800mg ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg ibuprofen tab 600 mg indomethacin cap 5 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap er 4hr 00 mg ketorolac tromethamine im inj 60 mg/ml (30 mg/ml) ketorolac tromethamine inj 15 mg/ml ketorolac tromethamine inj 30 mg/ml ketorolac tromethamine inj 60 mg/ml (30 mg/ml) ketorolac tromethamine tab 10 mg QL (0 tabs / 5 days) meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg mefenamic acid cap 50 mg meloxicam susp 7.5 mg/5ml meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 75 mg naproxen sodium tab 550 mg naproxen susp 15 mg/5ml naproxen tab 50 mg naproxen tab 375 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 6

7 naproxen tab 500 mg oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 0 mg sulindac tab 150 mg sulindac tab 00 mg tolmetin sodium cap 400 mg tolmetin sodium tab 00 mg tolmetin sodium tab 600 mg OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab -0.5 QL (90 tabs / 5 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8- QL (90 tabs / 5 days) mg (base equiv) SUBOXONE MIS -0.5MG 3 QL (90 units / 5 days) SUBOXONE MIS 4-1MG 3 QL (90 units / 5 days) SUBOXONE MIS 8-MG 3 QL (90 units / 5 days) SUBOXONE MIS 1-3MG 3 QL (60 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB QL (90 units / 5 days) ZUBSOLV SUB QL (60 units / 5 days) ZUBSOLV SUB QL (30 units / 5 days) OPIOID ANALGESICS acetaminophen w/ codeine soln 10-1 QL (700 ml / 5 days), mg/5ml ST; Subject to initial 7-day limit acetaminophen w/ codeine tab mg QL (400 tabs / 5 days), ST; Subject to initial 7-day limit acetaminophen w/ codeine tab mg QL (360 tabs / 5 days), ST; Subject to initial 7-day limit acetaminophen w/ codeine tab mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit butalbital-acetaminophen-caff w/ cod cap QL (48 caps / 5 days) mg butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj mg/ml - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 7

8 butorphanol tartrate nasal soln 10 mg/ml QL ( bottles / 5 days) CAPITAL/COD SUS 10-1/5 4 QL (700 ml / 5 days), ST; Subject to initial 7-day limit codeine sulfate tab 15 mg QL (4 tabs / 5 days), ST; Subject to initial 7-day limit codeine sulfate tab 30 mg QL (4 tabs / 5 days), ST; Subject to initial 7-day limit codeine sulfate tab 60 mg QL (4 tabs / 5 days), ST; Subject to initial 7-day limit EMBEDA CAP 0-0.8MG 4 QL (60 caps / 5 days), ST EMBEDA CAP 30-1.MG 4 QL (60 caps / 5 days), ST EMBEDA CAP 50-MG 4 QL (30 caps / 5 days), ST EMBEDA CAP 60-.4MG 4 QL (30 caps / 5 days), ST EMBEDA CAP 80-3.MG 4 QL (30 caps / 5 days), ST EMBEDA CAP 100-4MG 4, ST; High Strength Requires endocet tab.5-35 QL (360 tabs / 5 days), ST; Subject to initial 7-day limit endocet tab 5-35mg QL (360 tabs / 5 days), ST; Subject to initial 7-day limit endocet tab QL (40 tabs / 5 days), ST; Subject to initial 7-day limit endocet tab 10-35mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit fentanyl citrate lozenge on a handle 00 QL (10 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 400 QL (10 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 600 QL (10 lozenges / 5 mcg days), - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 8

9 fentanyl citrate lozenge on a handle 800 QL (10 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 100 QL (10 lozenges / 5 mcg days), fentanyl citrate lozenge on a handle 1600 QL (10 lozenges / 5 mcg days), fentanyl td patch 7hr 1 mcg/hr QL (10 patches / 5 days), ST fentanyl td patch 7hr 5 mcg/hr QL (10 patches / 5 days), ST fentanyl td patch 7hr 50 mcg/hr, ST; High Strength Requires fentanyl td patch 7hr 75 mcg/hr, ST; High Strength Requires fentanyl td patch 7hr 100 mcg/hr, ST; High Strength Requires hydrocodone-acetaminophen soln QL (700 ml / 5 days), mg/15ml ST; Subject to initial 7-day limit hydrocodone-acetaminophen soln QL (700 ml / 5 days), mg/15ml ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab.5-35 QL (360 tabs / 5 days), mg ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab 5-35 mg QL (40 tabs / 5 days), ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab QL (180 tabs / 5 days), mg ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab QL (180 tabs / 5 days), mg ST; Subject to initial 7-day limit HYDROMORPHON SUP 3MG 4 QL (10 suppositories / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl inj 1 mg/ml hydromorphone hcl inj mg/ml hydromorphone hcl inj 4 mg/ml hydromorphone hcl liqd 1 mg/ml QL (600 ml / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 9

10 hydromorphone hcl preservative free (pf) inj 10 mg/ml hydromorphone hcl tab mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 4 mg QL (150 tabs / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 8 mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit hydromorphone hcl tab er 4hr deter 8 mg QL (30 tabs / 5 days), ST hydromorphone hcl tab er 4hr deter 1 mg QL (30 tabs / 5 days), ST hydromorphone hcl tab er 4hr deter 16 mg QL (30 tabs / 5 days), ST hydromorphone hcl tab er 4hr deter 3 mg, ST; High Strength Requires HYSINGLA ER TAB 0 MG 3 QL (30 tabs / 5 days), ST HYSINGLA ER TAB 30 MG 3 QL (30 tabs / 5 days), ST HYSINGLA ER TAB 40 MG 3 QL (30 tabs / 5 days), ST HYSINGLA ER TAB 60 MG 3 QL (30 tabs / 5 days), ST HYSINGLA ER TAB 80 MG 3 QL (30 tabs / 5 days), ST HYSINGLA ER TAB 100 MG 3, ST; High Strength Requires HYSINGLA ER TAB 10 MG 3, ST; High Strength Requires levorphanol tartrate tab mg QL (10 tabs / 5 days), ST; Subject to initial 7-day limit lortab tab 10-35mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit methadone con 10mg/ml QL (60 ml / 5 days), ST; (generic of Methadone Intensol, indicated for pain) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 10

11 methadone hcl conc 10 mg/ml QL (30 ml / 5 days); (indicated for opioid addiction) methadone hcl inj 10 mg/ml QL (0 ml / 5 days), ST methadone hcl soln 5 mg/5ml QL (450 ml / 5 days), ST methadone hcl soln 10 mg/5ml QL (300 ml / 5 days), ST methadone hcl tab 5 mg QL (90 tabs / 5 days), ST methadone hcl tab 10 mg QL (60 tabs / 5 days), ST methadone hcl tab for oral susp 40 mg QL (9 tabs / 5 days) METHADONE INJ 10MG/ML 4 QL (0 ml / 5 days), ST methadose tab 40mg QL (9 tabs / 5 days) MORPHINE SUL INJ MG/ML 4 MORPHINE SUL INJ 4MG/ML 4 MORPHINE SUL INJ 5MG/ML 4 MORPHINE SUL INJ 150/30ML 4 MORPHINE SUL SUP 30MG 3 QL (90 supp / 5 days), ST; Subject to initial 7-day limit morphine sulfate beads cap er 4hr 30 mg QL (30 caps / 5 days), ST morphine sulfate beads cap er 4hr 45 mg QL (30 caps / 5 days), ST morphine sulfate beads cap er 4hr 60 mg QL (30 caps / 5 days), ST morphine sulfate beads cap er 4hr 75 mg QL (30 caps / 5 days), ST morphine sulfate beads cap er 4hr 90 mg QL (30 caps / 5 days), ST morphine sulfate beads cap er 4hr 10 mg, ST; High Strength Requires morphine sulfate cap er 4hr 10 mg QL (60 caps / 5 days), ST morphine sulfate cap er 4hr 0 mg QL (60 caps / 5 days), ST morphine sulfate cap er 4hr 30 mg QL (60 caps / 5 days), ST morphine sulfate cap er 4hr 50 mg QL (30 caps / 5 days), ST - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 11

12 morphine sulfate cap er 4hr 60 mg QL (30 caps / 5 days), ST morphine sulfate cap er 4hr 80 mg QL (30 caps / 5 days), ST morphine sulfate cap er 4hr 100 mg, ST; High Strength Requires morphine sulfate inj 8 mg/ml morphine sulfate inj 10 mg/ml morphine sulfate inj pf 0.5 mg/ml morphine sulfate inj pf 1 mg/ml morphine sulfate iv soln 1 mg/ml morphine sulfate iv soln pf 4 mg/ml morphine sulfate iv soln pf 8 mg/ml morphine sulfate iv soln pf 10 mg/ml morphine sulfate iv soln pf 15 mg/ml morphine sulfate oral soln 10 mg/5ml QL (900 ml / 5 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 0 mg/5ml QL (675 ml / 5 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 100 mg/5ml (0 QL (135 ml / 5 days), mg/ml) ST; Subject to initial 7-day limit morphine sulfate suppos 5 mg QL (180 suppositories / 5 days), ST; Subject to initial 7-day limit morphine sulfate suppos 10 mg QL (180 suppositories / 5 days), ST; Subject to initial 7-day limit morphine sulfate suppos 0 mg QL (10 supp / 5 days), ST; Subject to initial 7-day limit morphine sulfate tab 15 mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit morphine sulfate tab 30 mg QL (90 tabs / 5 days), ST; Subject to initial 7-day limit morphine sulfate tab er 15 mg QL (90 tabs / 5 days), ST morphine sulfate tab er 30 mg QL (90 tabs / 5 days), ST - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 1

13 morphine sulfate tab er 60 mg, ST; High Strength Requires morphine sulfate tab er 100 mg, ST; High Strength Requires morphine sulfate tab er 00 mg, ST; High Strength Requires nalbuphine hcl inj 10 mg/ml nalbuphine hcl inj 0 mg/ml NUCYNTA ER TAB 50MG 3 QL (60 tabs / 5 days), ST NUCYNTA ER TAB 100MG 3 QL (60 tabs / 5 days), ST NUCYNTA ER TAB 150MG 3, ST; High Strength Requires NUCYNTA ER TAB 00MG 3, ST; High Strength Requires NUCYNTA ER TAB 50MG 3, ST; High Strength Requires NUCYNTA TAB 50MG 3 QL (10 tabs / 5 days), ST; Subject to initial 7-day limit NUCYNTA TAB 75MG 3 QL (90 tabs / 5 days), ST; Subject to initial 7-day limit NUCYNTA TAB 100MG 3 QL (60 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl cap 5 mg QL (180 caps / 5 days), ST; Subject to initial 7-day limit oxycodone hcl conc 100 mg/5ml (0 mg/ml) QL (90 ml / 5 days), ST; Subject to initial 7-day limit oxycodone hcl soln 5 mg/5ml QL (900 ml / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 5 mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 10 mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 13

14 oxycodone hcl tab 15 mg QL (10 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 0 mg QL (90 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab 30 mg QL (60 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone hcl tab er 1hr deter 10 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er 1hr deter 15 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er 1hr deter 0 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er 1hr deter 30 mg QL (60 tabs / 5 days), ST oxycodone hcl tab er 1hr deter 40 mg, ST; High Strength Requires oxycodone hcl tab er 1hr deter 60 mg, ST; High Strength Requires oxycodone hcl tab er 1hr deter 80 mg, ST; High Strength Requires oxycodone w/ acetaminophen soln 5-35 QL (1800 ml / 5 days), mg/5ml ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab.5-35 QL (360 tabs / 5 days), mg ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab 5-35 mg QL (360 tabs / 5 days), ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab QL (40 tabs / 5 days), mg ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab QL (180 tabs / 5 days), mg ST; Subject to initial 7-day limit oxycodone-aspirin tab mg QL (360 tabs / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 14

15 oxycodone-ibuprofen tab mg QL (8 tabs / 5 days), ST; Subject to initial 7-day limit OXYCONTIN TAB 10MG CR 3 QL (60 tabs / 5 days), ST OXYCONTIN TAB 15MG CR 3 QL (60 tabs / 5 days), ST OXYCONTIN TAB 0MG CR 3 QL (60 tabs / 5 days), ST OXYCONTIN TAB 30MG CR 3 QL (60 tabs / 5 days), ST OXYCONTIN TAB 40MG CR 3, ST; High Strength Requires OXYCONTIN TAB 60MG CR 3, ST; High Strength Requires OXYCONTIN TAB 80MG CR 3, ST; High Strength Requires oxymorphone hcl tab 5 mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit oxymorphone hcl tab 10 mg QL (90 tabs / 5 days), ST; Subject to initial 7-day limit oxymorphone hcl tab er 1hr 5 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er 1hr 7.5 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er 1hr 10 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er 1hr 15 mg QL (60 tabs / 5 days), ST oxymorphone hcl tab er 1hr 0 mg, ST; High Strength Requires oxymorphone hcl tab er 1hr 30 mg, ST; High Strength Requires oxymorphone hcl tab er 1hr 40 mg, ST; High Strength Requires PRIMLEV TAB 5-300MG 4 QL (360 tabs / 5 days), ST; Subject to initial 7-day limit PRIMLEV TAB QL (40 tabs / 5 days), ST; Subject to initial 7-day limit - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 15

16 PRIMLEV TAB MG 4 QL (180 tabs / 5 days), ST; Subject to initial 7-day limit tramadol hcl tab 50 mg QL (180 tabs / 5 days), ST; Subject to initial 7-day limit tramadol hcl tab er 4hr 100 mg QL (30 tabs / 5 days), ST tramadol hcl tab er 4hr 00 mg, ST; High Strength Requires tramadol hcl tab er 4hr 300 mg, ST; High Strength Requires XARTEMIS XR TAB QL (10 tabs / 5 days) xylon tab 10-00mg QL (50 tabs / 5 days), ST; Subject to initial 7-day limit OPIOID RTIAL AGONISTS BELBUCA MIS 75MCG 3 QL (60 films / 5 days), ST BELBUCA MIS 150MCG 3 QL (60 films / 5 days), ST BELBUCA MIS 300MCG 3 QL (60 films / 5 days), ST BELBUCA MIS 450MCG 3 QL (60 films / 5 days), ST BELBUCA MIS 600MCG 3, ST; High Strength Requires Prior Auth BELBUCA MIS 750MCG 3, ST; High Strength Requires Prior Auth BELBUCA MIS 900MCG 3, ST; High Strength Requires Prior Auth buprenorphine hcl inj 0.3 mg/ml (base equiv) buprenorphine hcl sl tab mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) QL (90 tabs / 5 days); Must obtain approval after the initial fill QL (90 tabs / 5 days); Must obtain approval after the initial fill SALICYLATES aspirin chw 81mg 1 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 16

17 aspirin low tab 81mg ec 1 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply diflunisal tab 500 mg ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% 4 lidocaine hcl local inj 0.5% lidocaine hcl local inj 1% lidocaine hcl local inj % lidocaine hcl local preservative free (pf) inj 0.5% lidocaine hcl local preservative free (pf) inj 1% lidocaine hcl local preservative free (pf) inj 1.5% lidocaine hcl local preservative free (pf) inj % lidocaine hcl local preservative free (pf) inj 4% ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (50 mg/ml) amikacin sulfate inj 500 mg/ml (50 mg/ml) chloramphenicol sodium succinate for iv inj 1 gm GENTAM/NACL INJ 0.9MG/ML 4 GENTAM/NACL INJ 1.4MG/ML 4 gentamicin in saline inj 0.8 mg/ml gentamicin in saline inj 1 mg/ml gentamicin in saline inj 1. mg/ml gentamicin in saline inj 1.6 mg/ml gentamicin in saline inj mg/ml gentamicin sulfate inj 10 mg/ml gentamicin sulfate inj 40 mg/ml gentamicin sulfate iv soln 10 mg/ml KETEK TAB 300MG 4 KETEK TAB 400MG 4 MONUROL K GRANULES 4 neomycin sulfate tab 500 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 17

18 paromomycin sulfate cap 50 mg streptomycin sulfate for inj 1 gm SULFADIAZINE TAB 500MG 4 tinidazole tab 50 mg tinidazole tab 500 mg tobramycin nebu soln 300 mg/5ml QL (80 ml / 8 days), tobramycin sulfate for inj 1. gm tobramycin sulfate inj 1. gm/30ml (40 mg/ml) (base equiv) tobramycin sulfate inj gm/50ml (40 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base equivalent) tobramycin sulfate inj 80 mg/ml (40 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 00MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 mg/5ml AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ GM 4 aztreonam for inj 1 gm aztreonam for inj gm BILTRICIDE TAB 600MG 4 CAYSTON INH 75MG 5 QL (84 vials / 8 days), clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml clindamycin phosphate inj 300 mg/ml clindamycin phosphate inj 600 mg/4ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate iv soln 300 mg/ml clindamycin phosphate iv soln 900 mg/6ml dapsone tab 5 mg dapsone tab 100 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 18

19 daptomycin for iv soln 500 mg DARAPRIM TAB 5MG 4 doripenem for iv infusion 50 mg doripenem for iv infusion 500 mg EMVERM CHW 100MG 4 imipenem-cilastatin intravenous for soln 50 mg imipenem-cilastatin intravenous for soln 500 mg INVANZ INJ 1GM 4 ivermectin tab 3 mg linezolid for susp 100 mg/5ml linezolid in sodium chloride iv soln 600 mg/300ml-0.9% linezolid iv soln 600 mg/300ml ( mg/ml) linezolid tab 600 mg meropenem iv for soln 1 gm meropenem iv for soln 500 mg methenamine hippurate tab 1 gm metronidazole cap 375 mg metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 50 mg metronidazole tab 500 mg NEBUPENT INH 300MG 4 nitrofurantoin macrocrystalline cap 5 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg April 1, 018 ; High Risk Medications require for members age 65 and older ; High Risk Medications require for members age 65 and older ; High Risk Medications require for members age 65 and older nitrofurantoin monohydrate ; High Risk macrocrystalline cap 100 mg Medications require for members age 65 and older - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 19

20 nitrofurantoin susp 5 mg/5ml ; High Risk Medications require for members age 65 and older PENTAM 300 INJ 300MG 4 polymyxin b sulfate for inj unit PRIMSOL SOL 50MG/5ML 3 SIVEXTRO INJ 00MG 4 SIVEXTRO TAB 00MG 4 sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg trimethoprim tab 100 mg vancomycin hcl cap 15 mg QL (80 caps / 14 days), ST; ** vancomycin hcl cap 50 mg QL (80 caps / 14 days), ST; ** vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 mg vancomycin hcl for inj 750 mg vancomycin hcl for inj 1000 mg vancomycin hcl for inj 5000 mg XIFAXAN TAB 00MG 3 XIFAXAN TAB 550MG 3 ANTIFUNGALS amphotericin b for inj 50 mg BIO-STATIN CAP BIO-STATIN CAP CRESEMBA CAP 186 MG 4 fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole in dextrose inj 00 mg/100ml fluconazole in dextrose inj 400 mg/00ml fluconazole in nacl 0.9% inj 00 mg/100ml fluconazole in nacl 0.9% inj 400 mg/00ml fluconazole tab 50 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 0

21 fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 00 mg FLUCONAZOLE/ INJ NACL griseofulvin microsize susp 15 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 15 mg griseofulvin ultramicrosize tab 50 mg itraconazole cap 100 mg LAMISIL GRA 15MG 4 LAMISIL GRA 187.5MG 4 NOXAFIL SUS 40MG/ML 3 NOXAFIL TAB 100MG 3 nystatin oral powder nystatin tab unit SPORANOX SOL 10MG/ML 3 terbinafine hcl tab 50 mg voriconazole for susp 40 mg/ml voriconazole tab 50 mg voriconazole tab 00 mg ANTIMALARIALS atovaquone-proguanil hcl tab mg atovaquone-proguanil hcl tab mg chloroquine phosphate tab 50 mg chloroquine phosphate tab 500 mg COARTEM TAB 0-10MG 4 mefloquine hcl tab 50 mg PRIMAQUINE TAB 6.3MG 4 quinine sulfate cap 34 mg ANTIRETROVIRAL AGENTS abacavir sulfate soln 0 mg/ml (base equiv) QL (900 ml / 30 days) abacavir sulfate tab 300 mg (base equiv) QL (60 tabs / 30 days) APTIVUS CAP 50MG 3 QL (10 caps / 30 days) APTIVUS SOL 3 QL (300 ml / 30 days) atazanavir sulfate cap 150 mg (base equiv) QL (30 caps / 30 days) atazanavir sulfate cap 00 mg (base equiv) QL (60 caps / 30 days) atazanavir sulfate cap 300 mg (base equiv) QL (30 caps / 30 days) CRIXIVAN CAP 00MG 3 QL (450 caps / 30 days) CRIXIVAN CAP 400MG 3 QL (180 caps / 30 days) didanosine delayed release capsule 15 mg QL (30 caps / 30 days) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 1

22 didanosine delayed release capsule 00 mg QL (30 caps / 30 days) didanosine delayed release capsule 50 mg QL (30 caps / 30 days) didanosine delayed release capsule 400 mg QL (30 caps / 30 days) EDURANT TAB 5MG 3 QL (60 tabs / 30 days) efavirenz cap 50 mg QL (90 caps / 30 days) efavirenz cap 00 mg QL (90 caps / 30 days) efavirenz tab 600 mg QL (30 tabs / 30 days) EMTRIVA CAP 00MG 3 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML 3 QL (680 ml / 8 days) fosamprenavir calcium tab 700 mg (base QL (10 tabs / 30 days) equiv) FUZEON INJ 90MG 5 QL (60 vials / 30 days) INTELENCE TAB 5MG 3 QL (10 tabs / 30 days) INTELENCE TAB 100MG 3 QL (10 tabs / 30 days) INTELENCE TAB 00MG 3 QL (60 tabs / 30 days) INVIRASE CAP 00MG 3 QL (300 caps / 30 days) INVIRASE TAB 500MG 3 QL (10 tabs / 30 days) ISENTRESS CHW 5MG 3 QL (180 tabs / 30 days) ISENTRESS CHW 100MG 3 QL (180 tabs / 30 days) ISENTRESS HD TAB 600MG 3 QL (60 tabs / 30 days) ISENTRESS POW 100MG 3 QL (60 packets / 30 days) ISENTRESS TAB 400MG 3 QL (10 tabs / 30 days) lamivudine oral soln 10 mg/ml QL (900 ml / 30 days) lamivudine tab 150 mg QL (60 tabs / 30 days) lamivudine tab 300 mg QL (30 tabs / 30 days) LEXIVA SUS 50MG/ML 3 QL (1680 ml / 30 days) LEXIVA TAB 700MG 3 QL (10 tabs / 30 days) nevirapine susp 50 mg/5ml QL (100 ml / 30 days) nevirapine tab 00 mg QL (60 tabs / 30 days) nevirapine tab er 4hr 100 mg QL (90 tabs / 30 days) nevirapine tab er 4hr 400 mg QL (30 tabs / 30 days) NORVIR CAP 100MG 3 QL (360 caps / 30 days) NORVIR SOL 80MG/ML 3 QL (450 ml / 30 days) NORVIR TAB 100MG 3 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 3 QL (400 ml / 30 days) PREZISTA TAB 75MG 3 QL (300 tabs / 30 days) PREZISTA TAB 150MG 3 QL (180 tabs / 30 days) PREZISTA TAB 600MG 3 QL (60 tabs / 30 days) PREZISTA TAB 800MG 3 QL (30 tabs / 30 days) RESCRIPTOR TAB 100 MG 4 QL (900 tabs / 30 days) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)

23 RESCRIPTOR TAB 00MG 4 QL (450 tabs / 30 days) RETROVIR INJ 10MG/ML 3 REYATAZ CAP 150MG 3 QL (30 caps / 30 days) REYATAZ CAP 00MG 3 QL (60 caps / 30 days) REYATAZ CAP 300MG 3 QL (30 caps / 30 days) REYATAZ POW 50MG 3 QL (180 packets / 30 days) SELZENTRY SOL 0MG/ML 3 QL (1840 ml / 30 days) SELZENTRY TAB 5MG 3 QL (40 tabs / 30 days) SELZENTRY TAB 75MG 3 QL (60 tabs / 30 days) SELZENTRY TAB 150MG 3 QL (60 tabs / 30 days) SELZENTRY TAB 300MG 3 QL (10 tabs / 30 days) stavudine cap 15 mg QL (60 caps / 30 days) stavudine cap 0 mg QL (60 caps / 30 days) stavudine cap 30 mg QL (60 caps / 30 days) stavudine cap 40 mg QL (60 caps / 30 days) SUSTIVA CAP 50MG 3 QL (90 caps / 30 days) SUSTIVA CAP 00MG 3 QL (90 caps / 30 days) SUSTIVA TAB 600MG 3 QL (30 tabs / 30 days) tenofovir disoproxil fumarate tab 300 mg QL (30 tabs / 30 days) TIVICAY TAB 10MG 3 QL (60 tabs / 30 days) TIVICAY TAB 5MG 3 QL (60 tabs / 30 days) TIVICAY TAB 50MG 3 QL (60 tabs / 30 days) TYBOST TAB 150MG 3 QL (30 tabs / 30 days) VIDEX SOL GM 3 QL (100 ml / 30 days) VIDEX SOL 4GM 3 QL (100 ml / 30 days) VIRACEPT TAB 50MG 3 QL (300 tabs / 30 days) VIRACEPT TAB 65MG 3 QL (10 tabs / 30 days) VIRAMUNE SUS 50MG/5ML 3 QL (100 ml / 30 days) VIREAD POW 40MG/GM 3 QL (40 gm / 30 days) VIREAD TAB 150MG 3 QL (30 tabs / 30 days) VIREAD TAB 00MG 3 QL (30 tabs / 30 days) VIREAD TAB 50MG 3 QL (30 tabs / 30 days) VIREAD TAB 300MG 3 QL (30 tabs / 30 days) ZERIT SOL 1MG/ML 3 QL (400 ml / 30 days) ZIAGEN SOL 0MG/ML 3 QL (900 ml / 30 days) zidovudine cap 100 mg QL (180 caps / 30 days) zidovudine syrup 10 mg/ml QL (1800 ml / 30 days) zidovudine tab 300 mg QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 3

24 abacavir sulfate-lamivudine tab QL (30 tabs / 30 days) mg abacavir sulfate-lamivudine-zidovudine tab QL (60 tabs / 30 days) mg ATRIPLA TAB 3 QL (30 tabs / 30 days) COMPLERA TAB 3 QL (30 tabs / 30 days) DESCOVY TAB 00/5 3 QL (30 tabs / 30 days) EVOTAZ TAB QL (30 tabs / 30 days) GENVOYA TAB 3 QL (30 tabs / 30 days) KALETRA TAB 100-5MG 3 QL (40 tabs / 30 days) KALETRA TAB 00-50MG 3 QL (10 tabs / 30 days) lamivudine-zidovudine tab mg QL (60 tabs / 30 days) lopinavir-ritonavir soln mg/5ml QL (390 ml / 30 days) (80-0 mg/ml) ODEFSEY TAB 3 QL (30 tabs / 30 days) PREZCOBIX TAB QL (30 tabs / 30 days) STRIBILD TAB 3 QL (30 tabs / 30 days) TRIUMEQ TAB 3 QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS cycloserine cap 50 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg SER GRA 4GM 4 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 mg rifabutin cap 150 mg RIFAMATE CAP 3 rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB 3 SIRTURO TAB 100MG 4 TRECATOR TAB 50MG 3 - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 4

25 ANTIVIRALS acyclovir cap 00 mg acyclovir sodium for inj 500 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 00 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg BARACLUDE SOL.05MG/ML 3 cidofovir iv inj 75 mg/ml entecavir tab 0.5 mg entecavir tab 1 mg EPCLUSA TAB QL (8 tabs / 8 days), EPIVIR HBV SOL 5MG/ML 3 famciclovir tab 15 mg famciclovir tab 50 mg famciclovir tab 500 mg HARVONI TAB MG 5 QL (8 tabs / 8 days), lamivudine tab 100 mg (hbv) oseltamivir phosphate cap 30 mg (base QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 mg (base QL (0 caps / 90 days) equiv) oseltamivir phosphate cap 75 mg (base QL (0 caps / 90 days) equiv) oseltamivir phosphate for susp 6 mg/ml QL (300 ml / 90 days) (base equiv) PEGASYS INJ 5 QL (4 injections / 8 days), PEGASYS INJ 180MCG/M 5 QL (4 injections / 8 days), PEGASYS INJ PROCLICK 5 QL (4 injections / 8 days), REBETOL SOL 40MG/ML 5 RELENZA MIS DISKHALE 3 QL ( inhalers / 90 days) ribasphere cap 00mg ribasphere tab 00mg ribasphere tab 400mg ribasphere tab 600mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 5

26 ribavirin cap 00 mg ribavirin for inhal soln 6 gm ribavirin tab 00 mg rimantadine hydrochloride tab 100 mg SOVALDI TAB 400MG 6 QL (8 tabs / 8 days),, ST TAMIFLU SUS 6MG/ML 3 QL (300 ml / 90 days) TECHNIVIE TAB 6 QL (56 tabs / 8 days),, ST valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg valganciclovir hcl for soln 50 mg/ml (base equiv) valganciclovir hcl tab 450 mg (base equivalent) VOSEVI TAB 5 QL (8 tabs / 8 days), ZETIER TAB MG 6 QL (8 tabs / 8 days),, ST CEPHALOSPORINS cefaclor cap 50 mg cefaclor cap 500 mg CEFACLOR ER TAB 500MG 3 cefaclor for susp 15 mg/5ml cefaclor for susp 50 mg/5ml cefaclor for susp 375 mg/5ml cefadroxil cap 500 mg cefadroxil for susp 50 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 0 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln 1 gm cefdinir cap 300 mg cefdinir for susp 15 mg/5ml cefdinir for susp 50 mg/5ml cefditoren pivoxil tab 00 mg (base equivalent) - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 6

27 cefditoren pivoxil tab 400 mg (base equivalent) cefepime hcl for inj 1 gm cefepime hcl for inj gm cefixime for susp 100 mg/5ml cefixime for susp 00 mg/5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj gm cefotaxime sodium for inj 10 gm cefotaxime sodium for inj 500 mg cefotetan disodium for inj 1 gm cefotetan disodium for inj gm cefotetan disodium for inj 10 gm cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln gm cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 00 mg cefprozil for susp 15 mg/5ml cefprozil for susp 50 mg/5ml cefprozil tab 50 mg cefprozil tab 500 mg ceftazidime for inj gm ceftibuten cap 400 mg ceftibuten for susp 180 mg/5ml CEFTIN SUS 15/5ML 3 CEFTIN SUS 50/5ML 3 ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 50 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln gm cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg CEFUROXIME INJ 75GM 4 CEFUROXIME INJ 5GM 4 cefuroxime sodium for inj 1.5 gm - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 7

28 cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 gm cephalexin cap 50 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin for susp 15 mg/5ml cephalexin for susp 50 mg/5ml cephalexin tab 50 mg cephalexin tab 500 mg SUPRAX CAP 400MG 3 SUPRAX CHW 100MG 3 SUPRAX CHW 00MG 3 SUPRAX SUS 500/5ML 3 tazicef inj 1gm tazicef inj gm tazicef inj 6gm ZINACEF INJ 750MG 4 ZINACEF/H0 INJ 1.5GM PB 4 ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml azithromycin for susp 00 mg/5ml azithromycin iv for soln 500 mg azithromycin powd pack for susp 1 gm azithromycin tab 50 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 15 mg/5ml clarithromycin for susp 50 mg/5ml clarithromycin tab 50 mg clarithromycin tab 500 mg clarithromycin tab er 4hr 500 mg DIFICID TAB 00MG 3 e.e.s. 400 tab 400mg ery-tab tab 50mg ec ery-tab tab 333mg ec ery-tab tab 500mg ec ERYPED SUS 400/5ML 3 ERYTHROCIN INJ 500MG 4 erythrocin tab 50mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 8

29 erythromycin ethylsuccinate for susp 00 mg/5ml erythromycin ethylsuccinate tab 400 mg erythromycin tab 50 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 50 mg PCE TAB 333MG EC 4 PCE TAB 500MG EC 4 ZMAX SUS GM 4 FLUOROQUINOLONES AVELOX INJ 4 ciprofloxacin 00 mg/100ml in d5w ciprofloxacin 400 mg/00ml in d5w ciprofloxacin for oral susp 50 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 50 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin iv soln 400 mg/40ml (1%) ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 4hr 1000 mg(base eq) FACTIVE TAB 30MG 4 levofloxacin in d5w iv soln 50 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 5 mg/ml levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg levofloxacin tab 500 mg levofloxacin tab 750 mg moxifloxacin hcl 400 mg/50ml in sodium chloride 0.8% inj moxifloxacin hcl tab 400 mg (base equiv) ofloxacin tab 300 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 9

30 ofloxacin tab 400 mg 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 mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab er 1hr mg amoxicillin (trihydrate) cap 50 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 15 mg amoxicillin (trihydrate) chew tab 50 mg amoxicillin (trihydrate) for susp 15 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) for susp 50 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (-1) gm ampicillin & sulbactam sodium for inj 15 (10-5) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap 50 mg ampicillin cap 500 mg ampicillin for susp 15 mg/5ml ampicillin for susp 50 mg/5ml ampicillin sodium for inj 1 gm - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 30

31 ampicillin sodium for inj gm ampicillin sodium for inj 10 gm ampicillin sodium for inj 15 mg ampicillin sodium for inj 50 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln gm ampicillin sodium for iv soln 10 gm AUGMENTIN SUS 15/5ML 3 dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg nafcillin sodium for inj 1 gm nafcillin sodium for inj gm nafcillin sodium for inj 10 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln gm oxacillin sodium for inj 1 gm (base equivalent) oxacillin sodium for inj gm (base equivalent) oxacillin sodium for inj 10 gm (base equivalent) penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 15 mg/5ml penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg pfizerpen-g inj 0mu piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj.5 gm (-0.5 gm) piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) TETRACYCLINES avidoxy tab 100mg demeclocycline hcl tab 150 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 31

32 demeclocycline hcl tab 300 mg doxy 100 inj 100mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 0 mg doxycycline hyclate tab 100 mg doxycycline hyclate tab delayed release 75 mg doxycycline hyclate tab delayed release 100 mg doxycycline hyclate tab delayed release 150 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate cap 150 mg doxycycline monohydrate for susp 5 mg/5ml doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 150 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg minocycline hcl tab 100 mg morgidox cap 1x100mg tetracycline hcl cap 50 mg tetracycline hcl cap 500 mg VIBRAMYCIN SYP 50MG/5ML 4 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 100MG 3 busulfan inj 6 mg/ml CYCLOPHOSPH CAP 5MG 3 CYCLOPHOSPH CAP 50MG 3 cyclophosphamide for inj 1 gm cyclophosphamide for inj gm cyclophosphamide for inj 500 mg - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 3

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