Affinity Essentials Plan (EP)

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1 Affinity Essentials Plan (EP) 2018 List of Covered Drugs PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Members must use network pharmacies to get their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change. 1

2 What is the Affinity Essentials Plan (EP) Drug List? A drug list is a list of covered drugs. Affinity Essentials Plan (EP) works with a team of health care providers to choose drugs that provide quality treatment. Affinity Essentials Plan (EP) covers drugs on our drug list, as long as: The drug is medically necessary The prescription is filled at an Affinity Essentials Plan (EP) network pharmacy Other plan rules are followed For more information on how to fill your prescriptions, please review your subscriber contract. Can the Drug List change? We tell affected members about changes at least 60 days before they become effective. Some examples of changes are: Removing drugs from our list of covered drugs Adding the need for prior approval or authorization (when your doctor needs to explain why you need a specific drug and provide reasons why a preferred drug will not work for you) Adding quantity limits (when you can only get a specific amount of a drug at one time) Adding step therapy restrictions (when you have to try one type of drug as a first step in treating your condition, before you try another type of drug) Moving a medicine to a higher cost-sharing tier (when you have to cover more of the drug cost) What else could result in changes to the covered drug list? We remove drugs from our drug list right away and will let members know when: The US Food and Drug Administration (FDA) decides that a drug is unsafe The drug maker removes the drug from the market The enclosed drug list is up to date as of September 1 st, To get updated information about the drugs covered by Affinity Essentials Plan (EP), please visit: or call CVS Customer Service at , 24 hours/7 days a week. TTY/TDD users, please call How do I use the Drug List? There are 2 ways to find your drug on the drug list: 1. Medical Condition The drug list starts on page 7. 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 ANTIHYPERTENSIVES. If you know what your drug is used for, look for the category name in the list that starts on page 7. Then look under the category name for your drug. 2

3 2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 124. 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. What are generic drugs? Affinity Essentials Plan (EP) covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs, but provide the same quality of treatment. Are there any restrictions on my coverage? Some covered drugs may have more requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Affinity Essentials Plan (EP) needs you (or your doctor) to get prior approval or authorization for certain drugs. This means that you need to get approval from Affinity Essentials Plan (EP) before you fill your prescriptions. If you don t get approval, Affinity Essentials Plan (EP) may not cover the drug. Quantity Limits: For certain drugs, Affinity Essentials Plan (EP) limits the amount of the drug that it will cover. For example Affinity Essentials Plan (EP) provides 15 tabs per 25 days for zolpidem. Step Therapy: Affinity Essentials Plan (EP) 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, Affinity Essentials Plan (EP) may not cover Drug B unless you try Drug a first. If Drug A does not work for you, Affinity Essentials Plan (EP) will then cover Drug B. You can find out if your drug has any special requirements or limits by looking on the drug list that starts on page 7. You can also get more information about the restrictions for specific covered drugs by visiting You can ask Affinity Essentials Plan (EP) to make an exception to these restrictions or limits. See the section, How do I ask for an exception to the Affinity Essentials Plan (EP) drug list? on page 4. What are over-the counter (OTC) drugs? OTC drugs are nonprescription drugs that are not usually covered by a prescription drug plan. Affinity Essentials Plan (EP) pays for certain OTC drugs, but your cost may differ among the covered OTC drugs. Please see the Drug List Table that starts on page 7 for more information. If your plan allows for additional covered OTC drugs you may find a list on the Pharmacy Plan page at 3

4 Does the Plan cover prescription drugs that are considered Preventive Services under the Affordable Care Act? The U.S. Department of Health and Human Services (HHS) has adopted Guidelines for Preventive Services under the Affordable Care Act (ACA). Under the ACA, some pharmacy benefit plans may provide a range of preventive services for $0 member cost share and are designated as tier 0 on this document. These items may include: Aspirin to Prevent Cardiovascular Disease Fluoride and/or Iron Supplementation in Children Folic Acid Supplementation for Women Expecting or planning to be Pregnant Tobacco Use Counseling and Cessation Intervention Immunizations Women's Health Preventive Services (i.e. birth control, emergency contraception) A list of the preventive services covered under the Plan is available on our website at or will be mailed to you upon request. You may request the list by calling (the Customer Service number on your identification card.) 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 Affinity Essentials Plan (EP) does not cover your drug, you have 2 choices: You can ask Customer Service for a list of similar drugs that are covered by Affinity Essentials Plan (EP). When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Affinity Essentials Plan (EP). You can ask Affinity Essentials Plan (EP) to make an exception and cover your drug. Read on for information about how to ask for an exception. How do I ask for an exception to the Affinity Essentials Plan (EP) Drug List? You can ask Affinity Essentials Plan (EP) to make an exception to our coverage rules. There are many types of exceptions that you can ask us to make You can ask us to cover your drug, even if it is not on our drug list. You can ask us to remove coverage restrictions or limits on your drug. For example; for certain drugs, Affinity Essentials Plan (EP) 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 How likely is it that I will get an exception? Generally, Affinity Essentials Plan (EP) will only approve your request for an exception if the preferred drugs included on the plan s drug list would: Not be as effective in treating your condition Cause you to have adverse medical effects 4

5 How do I find out if my exception is granted? When you ask for a drug list exception, please send a statement from your doctor that supports your request. Then: We will make our decision within 3 business days of receipt of the information necessary to make a decision. You can ask for an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 3 business days for a decision. If your expedited (fast) request is granted, we will give you a decision no later than 24 hours after we get your doctor s supporting statement. For more information For more information about your Affinity Essentials Plan (EP) prescription drug coverage, please look at your subscriber contract and other plan materials. If you have questions about Affinity Essentials Plan (EP), please call Customer Service at , 8 am to 6 pm, Monday through Friday. TTY/TDD users, please call Or visit Affinity Essentials Plan (EP) Drug List The drug list that starts on page 7 gives coverage information about some of the drugs covered by Affinity Essentials Plan (EP). If you have trouble finding your drug on the list, turn to the Index that starts on page 124. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. JANUVIA). Generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if Affinity Essentials Plan (EP) has any special requirements for coverage of your drug. 5

6 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. This is NY State specific for 3-Tier structure Cost-Sharing Tier 1 (Generic Drugs) Preferred Retail Network pharmacy (Up to a 30-day supply) Specialty and Mail pharmacy (Up to a 90-day supply) $0-$6 $0-$15 Cost-Sharing Tier 2 (Preferred Brand Drugs) $0-$15 $0-$37.50 Cost-Sharing Tier 3 (Non-preferred Brand Drugs and Specialty Tier Drugs) $0-$30 $0-$75 *Copays will vary by plan design; you can contact Customer Service at CVS Customer Service at , 24 hours/7 days a week. TTY/TDD users, please call for more detailed copayment information. 6

7 EXCH_CVSC 3T NY2 STND eff 09/01/2018 Drug Name Drug Tier Requirements/Limits ANALGESICS COX-2 INHIBITORS celecoxib cap 50 1 celecoxib cap celecoxib cap celecoxib cap GOUT allopurinol tab allopurinol tab colchicine tab colchicine w/ probenecid tab probenecid tab ULORIC TAB 40MG 3 ST; ** ULORIC TAB 80MG 3 ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 1 QL (48 tabs / 25 days) butalbital-aspirin-caffeine cap QL (48 caps / 25 days) margesic cap 1 QL (48 caps / 25 days) tencon tab QL (48 tabs / 25 days) NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 1 release diclofenac w/ misoprostol tab delayed 1 release NSAIDS diclofenac potassium tab 50 1 diclofenac sodium tab delayed release 25 1 diclofenac sodium tab delayed release 50 1 diclofenac sodium tab delayed release 75 1 diclofenac sodium tab er 24hr etodolac cap etodolac cap etodolac tab etodolac tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 7

8 etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr fenoprofen calcium cap fenoprofen calcium tab flurbiprofen tab 50 1 flurbiprofen tab ibuprofen susp 100 /5ml 1 ibuprofen tab ibuprofen tab ibuprofen tab ketoprofen cap 50 1 ketoprofen cap 75 1 ketoprofen cap er 24hr ketorolac tromethamine im inj 60 /2ml 1 (30 /ml) ketorolac tromethamine inj 15 /ml 1 ketorolac tromethamine inj 30 /ml 1 ketorolac tromethamine tab 10 1 QL (20 tabs / 25 days) meclofenamate sodium cap 50 1 meclofenamate sodium cap mefenamic acid cap meloxicam susp 7.5 /5ml 1 meloxicam tab meloxicam tab 15 1 nabumetone tab nabumetone tab naproxen dr tab naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 1 naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 1 piroxicam cap 20 1 sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab (base equiv) 1 QL (90 tabs / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 8

9 buprenorphine hcl-naloxone hcl sl tab QL (90 tabs / 25 days) (base equiv) SUBOXONE MIS 2-0.5MG 2 QL (90 units / 25 days) SUBOXONE MIS 4-1MG 2 QL (90 units / 25 days) SUBOXONE MIS 8-2MG 2 QL (90 units / 25 days) SUBOXONE MIS 12-3MG 2 QL (60 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (60 units / 25 days) ZUBSOLV SUB QL (30 units / 25 days) OPIOID ANALGESICS acetaminophen w/ codeine soln /5ml acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab QL (2700 ml / 25 days), ST; Subject to initial 7-day limit QL (400 tabs / 25 days), ST; Subject to initial 7-day limit QL (360 tabs / 25 days), ST; Subject to initial 7-day limit QL (180 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (48 caps / 25 days) butalbital-acetaminophen-caff w/ cod cap butorphanol tartrate nasal soln 10 /ml 1 QL (2 bottles / 25 days) CAPITAL/COD SUS /5 3 QL (2700 ml / 25 days), ST; Subject to initial 7-day limit codeine sulfate tab 15 1 QL (42 tabs / 25 days), ST; Subject to initial 7-day limit codeine sulfate tab 30 1 QL (42 tabs / 25 days), ST; Subject to initial 7-day limit codeine sulfate tab 60 1 QL (42 tabs / 25 days), ST; Subject to initial 7-day limit EMBEDA CAP MG 3 QL (60 caps / 25 days), ST EMBEDA CAP MG 3 QL (60 caps / 25 days), ST EMBEDA CAP 50-2MG 3 QL (30 caps / 25 days), ST EMBEDA CAP MG 3 QL (30 caps / 25 days), ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 9

10 EMBEDA CAP MG 3 QL (30 caps / 25 days), ST EMBEDA CAP 100-4MG 3, ST; High Strength Requires endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit endocet tab QL (240 tabs / 25 days), ST; Subject to initial 7-day limit endocet tab QL (180 tabs / 25 days), ST; Subject to initial 7-day limit fentanyl citrate lozenge on a handle 200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 400 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 600 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 800 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1600 mcg 1 QL (120 lozenges / 25 days), fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 50 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 75 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 100 mcg/hr 1, ST; High Strength Requires hydrocodone-acetaminophen soln /15ml hydrocodone-acetaminophen soln /15ml hydrocodone-acetaminophen tab QL (2700 ml / 25 days), ST; Subject to initial 7-day limit 1 QL (2700 ml / 25 days), ST; Subject to initial 7-day limit 1 QL (360 tabs / 25 days), ST; Subject to initial 7-day limit - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 10

11 hydrocodone-acetaminophen tab QL (240 tabs / 25 days), ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab QL (180 tabs / 25 days), ST; Subject to initial 7-day limit hydrocodone-acetaminophen tab QL (180 tabs / 25 days), ST; Subject to initial 7-day limit HYDROMORPHON SUP 3MG 3 QL (120 suppositories / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl liqd 1 /ml 1 QL (600 ml / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 2 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 4 1 QL (150 tabs / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 8 1 QL (60 tabs / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl tab er 24hr deter 8 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 12 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 16 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 32 1, ST; High Strength Requires HYSINGLA ER TAB 20 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 30 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 40 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 60 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 80 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 100 MG 2, ST; High Strength Requires HYSINGLA ER TAB 120 MG 2, ST; High Strength Requires - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 11

12 levorphanol tartrate tab 2 1 QL (120 tabs / 25 days), ST; Subject to initial 7-day limit lortab tab QL (180 tabs / 25 days), ST; Subject to initial 7-day limit methadone con 10/ml 1 QL (60 ml / 25 days), ST; (generic of Methadone Intensol, indicated for pain) methadone hcl conc 10 /ml 1 QL (30 ml / 25 days); (indicated for opioid addiction) methadone hcl soln 5 /5ml 1 QL (450 ml / 25 days), ST methadone hcl soln 10 /5ml 1 QL (300 ml / 25 days), ST methadone hcl tab 5 1 QL (90 tabs / 25 days), ST methadone hcl tab 10 1 QL (60 tabs / 25 days), ST methadone hcl tab for oral susp 40 1 QL (9 tabs / 25 days) methadose tab 40 1 QL (9 tabs / 25 days) MORPHINE SUL SUP 30MG 2 QL (90 supp / 25 days), ST; Subject to initial 7-day limit morphine sulfate beads cap er 24hr 30 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 45 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 60 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 75 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 90 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 120 1, ST; High Strength Requires morphine sulfate cap er 24hr 10 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 20 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 30 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 50 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 60 1 QL (30 caps / 25 days), ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 12

13 morphine sulfate cap er 24hr 80 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 100 1, ST; High Strength Requires morphine sulfate oral soln 10 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 20 /5ml 1 QL (675 ml / 25 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 100 /5ml (20 /ml) 1 QL (135 ml / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 5 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 10 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 20 1 QL (120 supp / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 15 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 30 1 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab er 15 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 30 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 60 1, ST; High Strength Requires morphine sulfate tab er 100 1, ST; High Strength Requires morphine sulfate tab er 200 1, ST; High Strength Requires nalbuphine hcl inj 10 /ml 1 nalbuphine hcl inj 20 /ml 1 NUCYNTA ER TAB 50MG 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 100MG 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 150MG 2, ST; High Strength Requires NUCYNTA ER TAB 200MG 2, ST; High Strength Requires - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 13

14 NUCYNTA ER TAB 250MG 2, ST; High Strength Requires NUCYNTA TAB 50MG 2 QL (120 tabs / 25 days), ST; Subject to initial 7-day limit NUCYNTA TAB 75MG 2 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit NUCYNTA TAB 100MG 2 QL (60 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl cap 5 1 QL (180 caps / 25 days), ST; Subject to initial 7-day limit oxycodone hcl conc 100 /5ml (20 /ml) 1 QL (90 ml / 25 days), ST; Subject to initial 7-day limit oxycodone hcl soln 5 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 10 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 15 1 QL (120 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 20 1 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 30 1 QL (60 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab er 12hr deter 10 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 15 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 20 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 30 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 40 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 60 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 80 1, ST; High Strength Requires - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 14

15 oxycodone w/ acetaminophen soln /5ml 1 QL (1800 ml / 25 days), ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (360 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (240 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone-aspirin tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone-ibuprofen tab QL (28 tabs / 25 days), ST; Subject to initial 7-day limit OXYCONTIN TAB 10MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 15MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 20MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 30MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 40MG CR 2, ST; High Strength Requires OXYCONTIN TAB 60MG CR 2, ST; High Strength Requires OXYCONTIN TAB 80MG CR 2, ST; High Strength Requires oxymorphone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxymorphone hcl tab 10 1 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit oxymorphone hcl tab er 12hr 5 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 10 1 QL (60 tabs / 25 days), ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 15

16 oxymorphone hcl tab er 12hr 15 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 20 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 30 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 40 1, ST; High Strength Requires PRIMLEV TAB 5-300MG 3 QL (360 tabs / 25 days), ST; Subject to initial 7-day limit PRIMLEV TAB QL (240 tabs / 25 days), ST; Subject to initial 7-day limit PRIMLEV TAB MG 3 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit tramadol hcl tab 50 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit tramadol hcl tab er 24hr QL (30 tabs / 25 days), ST tramadol hcl tab er 24hr 200 1, ST; High Strength Requires tramadol hcl tab er 24hr 300 1, ST; High Strength Requires xylon tab QL (50 tabs / 25 days), ST; Subject to initial 7-day limit OPIOID RTIAL AGONISTS BELBUCA MIS 75MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 150MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 300MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 450MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 600MCG 2, ST; High Strength Requires Prior Auth BELBUCA MIS 750MCG 2, ST; High Strength Requires Prior Auth BELBUCA MIS 900MCG 2, ST; High Strength Requires Prior Auth buprenorphine hcl sl tab 2 (base equiv) 1 QL (90 tabs / 25 days); Must obtain approval after the initial fill - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 16

17 buprenorphine hcl sl tab 8 (base equiv) 1 QL (90 tabs / 25 days); Must obtain approval after the initial fill SALICYLATES aspirin chw 81 0 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply aspirin low tab 81 ec 0 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply diflunisal tab ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS KETEK TAB 300MG 3 KETEK TAB 400MG 3 MONUROL K GRANULES 3 neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 gm 1 SULFADIAZINE TAB 500MG 3 tinidazole tab tinidazole tab tobramycin nebu soln 300 /5ml 1 QL (280 ml / 28 days), ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 2 ALINIA SUS 100/5ML 2 ALINIA TAB 500MG 2 atovaquone susp 750 /5ml 1 aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 BILTRICIDE TAB 600MG 3 CAYSTON INH 75MG 3 QL (84 vials / 28 days), clindamycin hcl cap 75 1 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 1 /5ml (base equiv) dapsone tab 25 1 dapsone tab daptomycin for iv soln DARAPRIM TAB 25MG 3 doripenem for iv infusion doripenem for iv infusion ivermectin tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 17

18 linezolid for susp 100 /5ml 1 linezolid tab methenamine hippurate tab 1 gm 1 metronidazole cap metronidazole tab metronidazole tab NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 25 1 nitrofurantoin macrocrystalline cap 50 1 nitrofurantoin macrocrystalline cap nitrofurantoin monohydrate macrocrystalline cap 100 ; High Risk Medications require for members age 70 and older ; High Risk Medications require for members age 70 and older ; High Risk Medications require for members age 70 and older 1 ; High Risk Medications require for members age 70 and older PENTAM 300 INJ 300MG 3 praziquantel tab PRIMSOL SOL 50MG/5ML 2 SIVEXTRO INJ 200MG 3 SIVEXTRO TAB 200MG 3 sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab trimethoprim tab vancomycin hcl cap QL (80 caps / 10 days) vancomycin hcl cap QL (80 caps / 10 days) XIFAXAN TAB 200MG 2 XIFAXAN TAB 550MG 2 ANTIFUNGALS amphotericin b for inj 50 1 BIO-STATIN CAP BIO-STATIN CAP CRESEMBA CAP 186 MG 3 fluconazole for susp 10 /ml 1 fluconazole for susp 40 /ml 1 fluconazole tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 18

19 fluconazole tab fluconazole tab fluconazole tab griseofulvin microsize susp 125 /5ml 1 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab itraconazole cap NOXAFIL SUS 40MG/ML 2 NOXAFIL TAB 100MG 2 nystatin oral powder 1 nystatin tab unit 1 SPORANOX SOL 10MG/ML 2 terbinafine hcl tab voriconazole for susp 40 /ml 1 voriconazole tab 50 1 voriconazole tab ANTIMALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTEM TAB MG 3 mefloquine hcl tab PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 /ml (base 1 QL (900 ml / 30 days) equiv) abacavir sulfate tab 300 (base equiv) 1 QL (60 tabs / 30 days) APTIVUS CAP 250MG 2 QL (120 caps / 30 days) APTIVUS SOL 2 QL (300 ml / 30 days) atazanavir sulfate cap 150 (base equiv) 1 QL (30 caps / 30 days) atazanavir sulfate cap 200 (base equiv) 1 QL (60 caps / 30 days) atazanavir sulfate cap 300 (base equiv) 1 QL (30 caps / 30 days) CRIXIVAN CAP 200MG 2 QL (450 caps / 30 days) CRIXIVAN CAP 400MG 2 QL (180 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) EDURANT TAB 25MG 2 QL (60 tabs / 30 days) efavirenz cap 50 1 QL (90 caps / 30 days) efavirenz cap QL (90 caps / 30 days) efavirenz tab QL (30 tabs / 30 days) EMTRIVA CAP 200MG 2 QL (30 caps / 30 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 19

20 EMTRIVA SOL 10MG/ML 2 QL (680 ml / 28 days) fosamprenavir calcium tab 700 (base 1 QL (120 tabs / 30 days) equiv) FUZEON INJ 90MG 3 QL (60 vials / 30 days) INTELENCE TAB 25MG 2 QL (120 tabs / 30 days) INTELENCE TAB 100MG 2 QL (120 tabs / 30 days) INTELENCE TAB 200MG 2 QL (60 tabs / 30 days) INVIRASE CAP 200MG 2 QL (300 caps / 30 days) INVIRASE TAB 500MG 2 QL (120 tabs / 30 days) ISENTRESS CHW 25MG 2 QL (180 tabs / 30 days) ISENTRESS CHW 100MG 2 QL (180 tabs / 30 days) ISENTRESS HD TAB 600MG 2 QL (60 tabs / 30 days) ISENTRESS POW 100MG 2 QL (60 packets / 30 days) ISENTRESS TAB 400MG 2 QL (120 tabs / 30 days) lamivudine oral soln 10 /ml 1 QL (900 ml / 30 days) lamivudine tab QL (60 tabs / 30 days) lamivudine tab QL (30 tabs / 30 days) LEXIVA SUS 50MG/ML 2 QL (1680 ml / 30 days) nevirapine susp 50 /5ml 1 QL (1200 ml / 30 days) nevirapine tab QL (60 tabs / 30 days) nevirapine tab er 24hr QL (90 tabs / 30 days) nevirapine tab er 24hr QL (30 tabs / 30 days) NORVIR CAP 100MG 2 QL (360 caps / 30 days) NORVIR SOL 80MG/ML 2 QL (480 ml / 30 days) NORVIR TAB 100MG 2 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 2 QL (400 ml / 30 days) PREZISTA TAB 75MG 2 QL (300 tabs / 30 days) PREZISTA TAB 150MG 2 QL (180 tabs / 30 days) PREZISTA TAB 600MG 2 QL (60 tabs / 30 days) PREZISTA TAB 800MG 2 QL (30 tabs / 30 days) REYATAZ POW 50MG 2 QL (180 packets / 30 days) ritonavir tab QL (360 tabs / 30 days) SELZENTRY SOL 20MG/ML 2 QL (1840 ml / 30 days) SELZENTRY TAB 25MG 2 QL (240 tabs / 30 days) SELZENTRY TAB 75MG 2 QL (60 tabs / 30 days) SELZENTRY TAB 150MG 2 QL (60 tabs / 30 days) SELZENTRY TAB 300MG 2 QL (120 tabs / 30 days) stavudine cap 15 1 QL (60 caps / 30 days) stavudine cap 20 1 QL (60 caps / 30 days) stavudine cap 30 1 QL (60 caps / 30 days) stavudine cap 40 1 QL (60 caps / 30 days) tenofovir disoproxil fumarate tab QL (30 tabs / 30 days) TIVICAY TAB 10MG 2 QL (60 tabs / 30 days) TIVICAY TAB 25MG 2 QL (60 tabs / 30 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 20

21 TIVICAY TAB 50MG 2 QL (60 tabs / 30 days) TROGARZO INJ 150MG/ML 3 TYBOST TAB 150MG 2 QL (30 tabs / 30 days) VIDEX EC CAP 125MG 2 QL (30 caps / 30 days) VIDEX SOL 2GM 2 QL (1200 ml / 30 days) VIDEX SOL 4GM 2 QL (1200 ml / 30 days) VIRACEPT TAB 250MG 2 QL (300 tabs / 30 days) VIRACEPT TAB 625MG 2 QL (120 tabs / 30 days) VIRAMUNE SUS 50MG/5ML 2 QL (1200 ml / 30 days) VIREAD POW 40MG/GM 2 QL (240 gm / 30 days) VIREAD TAB 150MG 2 QL (30 tabs / 30 days) VIREAD TAB 200MG 2 QL (30 tabs / 30 days) VIREAD TAB 250MG 2 QL (30 tabs / 30 days) ZERIT SOL 1MG/ML 2 QL (2400 ml / 30 days) zidovudine cap QL (180 caps / 30 days) zidovudine syrup 10 /ml 1 QL (1800 ml / 30 days) zidovudine tab QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab QL (30 tabs / 30 days) abacavir sulfate-lamivudine-zidovudine tab 1 QL (60 tabs / 30 days) ATRIPLA TAB 2 QL (30 tabs / 30 days) BIKTARVY TAB 2 QL (30 tabs / 30 days) COMPLERA TAB 2 QL (30 tabs / 30 days) DESCOVY TAB 200/25 2 QL (30 tabs / 30 days) EVOTAZ TAB QL (30 tabs / 30 days) GENVOYA TAB 2 QL (30 tabs / 30 days) KALETRA TAB MG 2 QL (240 tabs / 30 days) KALETRA TAB MG 2 QL (120 tabs / 30 days) lamivudine-zidovudine tab QL (60 tabs / 30 days) lopinavir-ritonavir soln /5ml 1 QL (390 ml / 30 days) (80-20 /ml) ODEFSEY TAB 2 QL (30 tabs / 30 days) PREZCOBIX TAB QL (30 tabs / 30 days) STRIBILD TAB 2 QL (30 tabs / 30 days) TRIUMEQ TAB 2 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 ethambutol hcl tab ethambutol hcl tab isoniazid syrup 50 /5ml 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 21

22 isoniazid tab isoniazid tab SER GRA 4GM 3 PRIFTIN TAB 150MG 2 pyrazinamide tab rifabutin cap RIFAMATE CAP 2 rifampin cap rifampin cap RIFATER TAB 2 SIRTURO TAB 100MG 3 TRECATOR TAB 250MG 2 ANTIVIRALS acyclovir cap acyclovir susp 200 /5ml 1 acyclovir tab acyclovir tab adefovir dipivoxil tab 10 1 BARACLUDE SOL.05MG/ML 2 entecavir tab entecavir tab 1 1 EPCLUSA TAB QL (28 tabs / 28 days), EPIVIR HBV SOL 5MG/ML 2 famciclovir tab famciclovir tab famciclovir tab HARVONI TAB MG 3 QL (28 tabs / 28 days), lamivudine tab 100 (hbv) 1 oseltamivir phosphate cap 30 (base 1 QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate cap 75 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate for susp 6 /ml 1 QL (300 ml / 90 days) (base equiv) PEGASYS INJ 3 QL (4 injections / 28 days), PEGASYS INJ 180MCG/M 3 QL (4 injections / 28 days), PEGASYS INJ PROCLICK 3 QL (4 injections / 28 days), REBETOL SOL 40MG/ML 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 22

23 RELENZA MIS DISKHALE 2 QL (2 inhalers / 90 days) ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin tab rimantadine hydrochloride tab SOVALDI TAB 400MG 3 QL (28 tabs / 28 days),, ST valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab valganciclovir hcl for soln 50 /ml (base 1 equiv) valganciclovir hcl tab 450 (base 1 equivalent) VOSEVI TAB 3 QL (28 tabs / 28 days), ZETIER TAB MG 3 QL (28 tabs / 28 days),, ST CEPHALOSPORINS cefaclor cap cefaclor cap CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 /5ml 1 cefaclor for susp 250 /5ml 1 cefaclor for susp 375 /5ml 1 cefadroxil cap cefadroxil for susp 250 /5ml 1 cefadroxil for susp 500 /5ml 1 cefadroxil tab 1 gm 1 cefdinir cap cefdinir for susp 125 /5ml 1 cefdinir for susp 250 /5ml 1 cefditoren pivoxil tab 200 (base 1 equivalent) cefditoren pivoxil tab 400 (base 1 equivalent) cefepime hcl for inj 1 gm 1 cefepime hcl for inj 2 gm 1 cefixime for susp 100 /5ml 1 cefixime for susp 200 /5ml 1 cefpodoxime proxetil for susp 50 /5ml 1 cefpodoxime proxetil for susp 100 /5ml 1 cefpodoxime proxetil tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 23

24 cefpodoxime proxetil tab cefprozil for susp 125 /5ml 1 cefprozil for susp 250 /5ml 1 cefprozil tab cefprozil tab ceftazidime for inj 2 gm 1 ceftibuten cap ceftibuten for susp 180 /5ml 1 CEFTIN SUS 125/5ML 2 CEFTIN SUS 250/5ML 2 ceftriaxone sodium for inj 1 gm 1 ceftriaxone sodium for inj 2 gm 1 ceftriaxone sodium for inj 10 gm 1 ceftriaxone sodium for inj ceftriaxone sodium for inj ceftriaxone sodium for iv soln 1 gm 1 ceftriaxone sodium for iv soln 2 gm 1 cefuroxime axetil tab cefuroxime axetil tab cephalexin cap cephalexin cap cephalexin cap cephalexin for susp 125 /5ml 1 cephalexin for susp 250 /5ml 1 cephalexin tab cephalexin tab SUPRAX CAP 400MG 2 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2 SUPRAX SUS 500/5ML 2 tazicef inj 1gm 1 tazicef inj 2gm 1 tazicef inj 6gm 1 ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 1 azithromycin for susp 200 /5ml 1 azithromycin powd pack for susp 1 gm 1 azithromycin tab azithromycin tab azithromycin tab clarithromycin for susp 125 /5ml 1 clarithromycin for susp 250 /5ml 1 clarithromycin tab clarithromycin tab clarithromycin tab er 24hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 24

25 DIFICID TAB 200MG 2 e.e.s. 400 tab ery-tab tab 250 ec 1 ery-tab tab 333 ec 1 ery-tab tab 500 ec 1 ERYPED SUS 400/5ML 2 erythrocin tab erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin tab erythromycin tab erythromycin w/ delayed release particles 1 cap 250 FLUOROQUINOLONES ciprofloxacin for oral susp 250 /5ml 1 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) 1 ciprofloxacin hcl tab 100 (base equiv) 1 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) FACTIVE TAB 320MG 3 levofloxacin oral soln 25 /ml 1 levofloxacin tab levofloxacin tab levofloxacin tab moxifloxacin hcl tab 400 (base equiv) 1 PENICILLINS amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 25

26 amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin cap ampicillin cap ampicillin for susp 125 /5ml 1 ampicillin for susp 250 /5ml 1 AUGMENTIN SUS 125/5ML 2 dicloxacillin sodium cap dicloxacillin sodium cap penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab penicillin v potassium tab TETRACYCLINES avidoxy tab demeclocycline hcl tab demeclocycline hcl tab doxycycline hyclate cap 50 1 doxycycline hyclate cap doxycycline hyclate tab 20 1 doxycycline hyclate tab doxycycline monohydrate cap 50 1 doxycycline monohydrate cap 75 1 doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 1 /5ml doxycycline monohydrate tab 50 1 doxycycline monohydrate tab 75 1 doxycycline monohydrate tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 26

27 minocycline hcl cap 50 1 minocycline hcl cap 75 1 minocycline hcl cap minocycline hcl tab 50 1 minocycline hcl tab 75 1 minocycline hcl tab morgidox cap 1x100 1 tetracycline hcl cap tetracycline hcl cap ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 100MG 2 busulfan inj 6 /ml 1 CYCLOPHOSPH CAP 25MG 2 CYCLOPHOSPH CAP 50MG 2 cyclophosphamide cap 25 1 cyclophosphamide cap 50 1 cyclophosphamide for inj 1 gm 1 cyclophosphamide for inj 2 gm 1 cyclophosphamide for inj dacarbazine for inj dacarbazine for inj EMCYT CAP 140MG 2 GLEOSTINE CAP 5MG 2 GLEOSTINE CAP 10MG 2 GLEOSTINE CAP 40MG 2 GLEOSTINE CAP 100MG 2 GLIADEL WAF 7.7MG 2 HEXALEN CAP 50MG 2 ifosfamide for inj 1 gm 1 ifosfamide iv inj 1 gm/20ml (50 /ml) 1 ifosfamide iv inj 3 gm/60ml (50 /ml) 1 LEUKERAN TAB 2MG 2 melphalan tab 2 1 TEMODAR INJ 100MG 3 temozolomide cap 5 3 temozolomide cap 20 3 temozolomide cap temozolomide cap temozolomide cap temozolomide cap ANTHRACYCLINES daunorubicin hcl inj 5 /ml (base equiv) 1 DAUNOXOME INJ 2MG/ML 2 doxorubicin hcl for inj Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 27

28 doxorubicin hcl for inj 50 1 doxorubicin hcl inj 2 /ml 1 doxorubicin hcl liposomal inj (for iv 1 infusion) 2 /ml epirubicin hcl iv soln 50 /25ml (2 1 /ml) epirubicin hcl iv soln 200 /100ml (2 1 /ml) idarubicin hcl iv inj 5 /5ml (1 /ml) 1 idarubicin hcl iv inj 10 /10ml (1 /ml) 1 idarubicin hcl iv inj 20 /20ml (1 /ml) 1 ANTIBIOTICS bleomycin sulfate for inj 15 unit 1 bleomycin sulfate for inj 30 unit 1 mitomycin for iv soln 5 1 mitomycin for iv soln 20 1 mitomycin for iv soln 40 1 ANTIMETABOLITES adrucil inj 2.5g/50m 1 adrucil inj 500/10ml 1 ALIMTA INJ 100MG 2 ALIMTA INJ 500MG 2 ARRANON INJ 5MG/ML 2 azacitidine for inj capecitabine tab QL (120 tabs / 30 days), capecitabine tab QL (300 tabs / 30 days), cladribine iv soln 10 /10ml (1 /ml) 1 clofarabine iv soln 1 /ml 1 cytarabine inj 20 /ml 1 cytarabine inj pf 20 /ml 1 cytarabine inj pf 100 /ml 1 decitabine for inj 50 3 DEPOCYT INJ 50MG/5ML 2 floxuridine for inj 0.5 gm 1 fludarabine phosphate for inj 50 1 fludarabine phosphate inj 25 /ml 1 fluorouracil iv soln 1 gm/20ml (50 /ml) 1 fluorouracil iv soln 2.5 gm/50ml (50 1 /ml) fluorouracil iv soln 5 gm/100ml (50 /ml) 1 fluorouracil iv soln 500 /10ml (50 1 /ml) gemcitabine hcl for inj 1 gm 1 gemcitabine hcl for inj 2 gm 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 28

29 gemcitabine hcl for inj gemcitabine hcl inj 1 gm/26.3ml (38 1 /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 1 /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 1 /ml) (base equiv) mercaptopurine tab 50 1 methotrexate sodium for inj 1 gm 1 methotrexate sodium inj 50 /2ml (25 1 /ml) methotrexate sodium inj 250 /10ml (25 1 /ml) methotrexate sodium inj pf 50 /2ml (25 1 /ml) methotrexate sodium inj pf 100 /4ml 1 (25 /ml) methotrexate sodium inj pf 200 /8ml 1 (25 /ml) methotrexate sodium inj pf 250 /10ml 1 (25 /ml) methotrexate sodium inj pf 1000 /40ml 1 (25 /ml) NIPENT INJ 10MG 2 TABLOID TAB 40MG 2 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 2 DOCEFREZ INJ 20MG 2 docetaxel for inj conc 20 /ml 1 docetaxel for inj conc 80 /4ml (20 1 /ml) DOCETAXEL INJ 20/0.5ML 2 DOCETAXEL INJ 20MG/2ML 2 DOCETAXEL INJ 80MG/2ML 2 DOCETAXEL INJ 80MG/8ML 2 DOCETAXEL INJ 140/7ML 2 DOCETAXEL INJ 160/8ML 2 DOCETAXEL INJ 160/16ML 2 DOCETAXEL INJ 200MG/20 2 DOCETAXEL INJ NON-ALCO 2 docetaxel soln for iv infusion 20 /2ml 1 docetaxel soln for iv infusion 80 /8ml 1 docetaxel soln for iv infusion 160 /16ml 1 paclitaxel iv conc 30 /5ml (6 /ml) 1 paclitaxel iv conc 100 /16.7ml (6 1 /ml) paclitaxel iv conc 150 /25ml (6 /ml) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 29

30 paclitaxel iv conc 300 /50ml (6 /ml) 1 ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 /ml 1 vincasar pfs inj 1/ml 1 vincristine sulfate iv soln 1 /ml 1 vinorelbine tartrate inj 10 /ml (base 1 equiv) vinorelbine tartrate inj 50 /5ml (10 1 /ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS ERBITUX INJ 100MG 3 ERBITUX INJ 200MG 3 ERIVEDGE CAP 150MG 3 QL (30 caps / 30 days), FARYDAK CAP 10MG 3 FARYDAK CAP 15MG 3 FARYDAK CAP 20MG 3 GAZYVA INJ 25MG/ML 3 IBRANCE CAP 75MG 3 QL (21 caps / 28 days), IBRANCE CAP 100MG 3 QL (21 caps / 28 days), IBRANCE CAP 125MG 3 QL (21 caps / 28 days), KADCYLA INJ 100MG 3 KADCYLA INJ 160MG 3 KEYTRUDA INJ 100MG/4M 3 KEYTRUDA SOL 50MG 3 LYNRZA CAP 50MG 3 QL (480 caps / 30 days), LYNRZA TAB 100MG 3 QL (180 tabs / 30 days), LYNRZA TAB 150MG 3 QL (120 tabs / 30 days), RYDAPT CAP 25MG 3 QL (224 caps / 28 days), ZEJULA CAP 100MG 3 QL (90 caps / 30 days), ZOLINZA CAP 100MG 3 QL (120 caps / 30 days), HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 1 bicalutamide tab 50 1 exemestane tab 25 1 FARESTON TAB 60MG 2 FASLODEX INJ 250/5ML 2 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 30

31 flutamide cap letrozole tab leuprolide acetate inj kit 5 /ml 3 LUPR DEP-PED INJ 3M 30MG 3 LUPR DEP-PED INJ 7.5MG 3 LUPR DEP-PED INJ 11.25MG 3 LUPR DEP-PED INJ 15MG 3 LUPRON DEPOT INJ 3.75MG 3 LUPRON DEPOT INJ 7.5MG 3 LUPRON DEPOT INJ 11.25MG 3 LUPRON DEPOT INJ 22.5MG 3 LUPRON DEPOT INJ 30MG 3 LUPRON DEPOT INJ 45MG 3 LYSODREN TAB 500MG 2 megestrol acetate susp 40 /ml 1 megestrol acetate tab 20 1 megestrol acetate tab 40 1 nilutamide tab tamoxifen citrate tab 10 (base equivalent) tamoxifen citrate tab 20 (base equivalent) 1 $0 copay for women > 35 years for the primary prevention of breast cancer 1 $0 copay for women > 35 years for the primary prevention of breast cancer XTANDI CAP 40MG 3 QL (120 caps / 30 days), ZYTIGA TAB 250MG 3 QL (120 tabs / 30 days), ZYTIGA TAB 500MG 3 QL (60 tabs / 30 days), KINASE INHIBITORS AFINITOR DIS TAB 2MG 3 QL (60 tabs / 30 days), AFINITOR DIS TAB 3MG 3 QL (90 tabs / 30 days), AFINITOR DIS TAB 5MG 3 QL (60 tabs / 30 days), AFINITOR TAB 2.5MG 3 QL (30 tabs / 30 days), AFINITOR TAB 5MG 3 QL (30 tabs / 30 days), AFINITOR TAB 7.5MG 3 QL (30 tabs / 30 days), AFINITOR TAB 10MG 3 QL (30 tabs / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 31

32 ALECENSA CAP 150MG 3 QL (240 caps / 30 days), BOSULIF TAB 100MG 3 QL (90 tabs / 30 days), BOSULIF TAB 400MG 3 QL (30 tabs / 30 days), BOSULIF TAB 500MG 3 QL (30 tabs / 30 days), CALQUENCE CAP 100MG 3 QL (60 caps / 30 days), CAPRELSA TAB 100MG 3 QL (60 tabs / 30 days), CAPRELSA TAB 300MG 3 QL (30 tabs / 30 days), COMETRIQ KIT 60MG 3 QL (1 kit / 28 days), COMETRIQ KIT 100MG 3 QL (1 kit / 28 days), COMETRIQ KIT 140MG 3 QL (1 kit / 28 days), ICLUSIG TAB 15MG 3 QL (60 tabs / 30 days), ICLUSIG TAB 45MG 3 QL (30 tabs / 30 days), IDHIFA TAB 50MG 3 QL (30 tabs / 30 days), IDHIFA TAB 100MG 3 QL (30 tabs / 30 days), imatinib mesylate tab 100 (base equivalent) 3 QL (90 tabs / 30 days), imatinib mesylate tab 400 (base equivalent) 3 QL (60 tabs / 30 days), IMBRUVICA CAP 70MG 3 QL (30 caps / 30 days), IMBRUVICA CAP 140MG 3 QL (120 caps / 30 days), IMBRUVICA TAB 140MG 3 QL (30 tabs / 30 days), IMBRUVICA TAB 280MG 3 QL (30 tabs / 30 days), IMBRUVICA TAB 420MG 3 QL (30 tabs / 30 days), IMBRUVICA TAB 560MG 3 QL (30 tabs / 30 days), INLYTA TAB 1MG 3 QL (180 tabs / 30 days), INLYTA TAB 5MG 3 QL (120 tabs / 30 days), JAKAFI TAB 5MG 3 QL (60 tabs / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 32

33 JAKAFI TAB 10MG 3 QL (60 tabs / 30 days), JAKAFI TAB 15MG 3 QL (60 tabs / 30 days), JAKAFI TAB 20MG 3 QL (60 tabs / 30 days), JAKAFI TAB 25MG 3 QL (60 tabs / 30 days), LENVIMA CAP 8 MG 3 QL (60 caps / 30 days), LENVIMA CAP 10 MG 3 QL (30 caps / 30 days), LENVIMA CAP 14 MG 3 QL (60 caps / 30 days), LENVIMA CAP 18 MG 3 QL (90 caps / 30 days), LENVIMA CAP 20 MG 3 QL (60 caps / 30 days), LENVIMA CAP 24 MG 3 QL (90 caps / 30 days), MEKINIST TAB 0.5MG 3 QL (90 tabs / 30 days), MEKINIST TAB 2MG 3 QL (30 tabs / 30 days), NEXAVAR TAB 200MG 3 QL (120 tabs / 30 days), SPRYCEL TAB 20MG 3 QL (90 tabs / 30 days), SPRYCEL TAB 50MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 70MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 80MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 100MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 140MG 3 QL (30 tabs / 30 days), STIVARGA TAB 40MG 3 QL (84 tabs / 28 days), SUTENT CAP 12.5MG 3 QL (30 caps / 30 days), SUTENT CAP 25MG 3 QL (30 caps / 30 days), SUTENT CAP 37.5MG 3 QL (30 caps / 30 days), SUTENT CAP 50MG 3 QL (30 caps / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met ^- The cost of these drugs are the 33

Affinity Essentials Plan (EP)

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