Prescription Drug List Effective January 1, 2017 Oxford Connecticut Four-Tier

Transcription

1 Your 2017 Prescription Drug List Effective January 1, 2017 Oxford Connecticut Four-Tier Please read: This document contains information about commonly prescribed medications. This Prescription Drug List (PDL) is accurate as of August 1, 2016 and is subject to change after this date. The next anticipated update will be in January Your estimated coverage and copay/co-insurance may vary based on the benefit plan you choose and the effective date of the plan. For more information: Call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, , Visit oxfordhealth.com, click on the Pharmacies & Prescriptions tab and then Online Pharmacy to log in to the OptumRx 1 website and: Locate a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. 1 OptumRx is the administrator of your Oxford pharmacy benefit plan. Note: Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Specialized non-standard infant formulas and nutritional supplements may be subject to prior authorization. Please see your Summary of Benefits and Coverage (SBC) for specifics. 1

2 Your Prescription Drug List This Prescription Drug List (PDL) outlines covered medications and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to oxfordhealth.com for drug information. Since the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is the best source for accessing up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. You may access the prescription drug list by visiting oxfordhealth.com Members Tools and Resources and choosing Prescription Drug List under the Your Pharmacy Coverage section. 2

3 We want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we ve included some of the most commonly asked questions about the Prescription Drug List (PDL) below. What is a Prescription Drug List (PDL)? This document is a list of covered medications. They are placed into cost levels known as tiers. The PDL includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this PDL and your health plan documents, the health plan documents will rule. Please look at your health plan documents to see what medications are covered under your health plan. You may also log on to oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more information. How do I use my PDL? Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor should consult this guide. It will help you and your doctor choose the most cost-effective prescription drugs. This guide will also help you know if a medication has special programs that apply to it. When a Prescription Drug Product is excluded from coverage, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. 3

4 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2, 3 or 4, look to see if there is a Tier 1 option available. You should discuss these options with your doctor. Check your health plan documents to find your specific pharmacy plan costs. $ Drug Tier Includes Helpful Tips Tier 1 Lowest Cost Tier 2 Mid-range Cost Tier 3 Mid-range Cost Tier 4 Highest Cost Lower-cost drugs. Some brand names and generics are also included. Preferred brands. Preferred specialty and non-preferred brands. Higher cost brands and generics. Non-preferred specialty and non-preferred brands. Use Tier 1 drugs for the lowest out of-pocket costs. Use Tier 2 drugs instead of Tier 4 drugs to help reduce your out-of-pocket costs. Use Tier 3 drugs instead of Tier 4 drugs to help reduce your out-of-pocket costs. Many Tier 4 drugs have lower cost options in Tier 1, 2 or 3. Ask your doctor if they could work for you. Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible health plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on oxfordhealth.com, or call us at the toll-free phone number on your health plan ID card for more information about your health plan. Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. When does the PDL change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic becomes available. Medications may move to a higher tier or be excluded from coverage most often on January 1 or July 1. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call us at the toll-free phone number on your health plan ID card. 4

5 Programs and s Some medications are in one or more of our pharmacy benefit programs. Your health plan determines how these medications are covered and may differ than what is noted in the PDL. Health Care Reform (HCR) Preventive This medication is part of a Health Care Reform preventive benefit and may be available at no additional cost to you. Notification or Precertification (sometimes referred to as ) required 1 Your doctor is required to provide additional information to us to determine coverage. Amount of medication covered per copayment or in a specific time period. Trial of a lower-cost medication is required before a higher-cost medication is covered. 1 Depending on your benefit, you may have notification or precertification requirements for select medications. To learn more about a pharmacy program or to find out if it applies to you, please visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to an over-the-counter (OTC) medication. 2 There may be other medication options available. Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version. 2 This is not applicable for Connecticut Public Sector plans. For Connecticut commercial business, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered if it is determined to be medically necessary 5

6 What if my doctor writes a prescription for a brand-name medication? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some health plans, if a brand-name medication is prescribed and a generic equivalent is available, your share of the cost may be the copayment PLUS the cost difference between the brand-name medication and its generic equivalent. Visit oxfordhealth.com to make sure. Are you taking a specialty medication? Take advantage of personalized support designed to help you get the most out of your benefit plan. Visit UHCRx.com or call the toll-free phone number on your health plan ID card to learn more. If you re taking a specialty medication that is on Tier 4, call us at the toll-free phone number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more current information. For more information Call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, , Or, visit oxfordhealth.com. All branded medications are trademarks or registered trademarks of their respective owners. Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc Oxford Health Plans LLC. All rights reserved. Created August 1, January 1, 2017 Prescription Drug List Oxford Connecticut Four-Tier CT MT

7 1st Generation/Typical - Mood Disorder ADASUVE INH 10MG Tier 3 1st Generation/Typical - Mood Disorder CHLORPROMAZ POW HCL Tier 3 1st Generation/Typical - Mood Disorder CHLORPROMAZ TAB 100MG Tier 1 1st Generation/Typical - Mood Disorder CHLORPROMAZ TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder CHLORPROMAZ TAB 200MG Tier 1 1st Generation/Typical - Mood Disorder CHLORPROMAZ TAB 25MG Tier 1 1st Generation/Typical - Mood Disorder CHLORPROMAZ TAB 50MG Tier 1 1st Generation/Typical - Mood Disorder COMPRO SUP 25MG Tier 1 1st Generation/Typical - Mood Disorder FLUPHENAZINE CON 5MG/ML Tier 1 1st Generation/Typical - Mood Disorder FLUPHENAZINE ELX 2.5/5ML Tier 1 1st Generation/Typical - Mood Disorder FLUPHENAZINE TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder FLUPHENAZINE TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder FLUPHENAZINE TAB 2.5MG Tier 1 1st Generation/Typical - Mood Disorder FLUPHENAZINE TAB 5MG Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL CON 2MG/ML Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL TAB 0.5MG Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL TAB 20MG Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder HALOPERIDOL TAB 5MG Tier 1 1st Generation/Typical - Mood Disorder LOXAPINE CAP 10MG Tier 1 1st Generation/Typical - Mood Disorder LOXAPINE CAP 25MG Tier 1 1st Generation/Typical - Mood Disorder LOXAPINE CAP 50MG Tier 1 1st Generation/Typical - Mood Disorder LOXAPINE CAP 5MG Tier 1 1st Generation/Typical - Mood Disorder ORAP TAB 1MG Tier 4 1st Generation/Typical - Mood Disorder ORAP TAB 2MG Tier 4 1st Generation/Typical - Mood Disorder PERPHENAZINE TAB 16MG Tier 1 1st Generation/Typical - Mood Disorder PERPHENAZINE TAB 2MG Tier 1 Page 1 of 279

8 1st Generation/Typical - Mood Disorder PERPHENAZINE TAB 4MG Tier 1 1st Generation/Typical - Mood Disorder PERPHENAZINE TAB 8MG Tier 1 1st Generation/Typical - Mood Disorder PIMOZIDE TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder PIMOZIDE TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder PROCHLORPER SUP 25MG Tier 1 1st Generation/Typical - Mood Disorder PROCHLORPER TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder PROCHLORPER TAB 5MG Tier 1 1st Generation/Typical - Mood Disorder THIORIDAZINE TAB 100MG Tier 1 1st Generation/Typical - Mood Disorder THIORIDAZINE TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder THIORIDAZINE TAB 25MG Tier 1 1st Generation/Typical - Mood Disorder THIORIDAZINE TAB 50MG Tier 1 1st Generation/Typical - Mood Disorder THIOTHIXENE CAP 10MG Tier 1 1st Generation/Typical - Mood Disorder THIOTHIXENE CAP 1MG Tier 1 1st Generation/Typical - Mood Disorder THIOTHIXENE CAP 2MG Tier 1 1st Generation/Typical - Mood Disorder THIOTHIXENE CAP 5MG Tier 1 1st Generation/Typical - Mood Disorder TRIFLUOPERAZ TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder TRIFLUOPERAZ TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder TRIFLUOPERAZ TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder TRIFLUOPERAZ TAB 5MG Tier 1 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder 2nd Generation/Atypical - Mood Disorder ABILIFY SOL 1MG/ML Tier 4 ABILIFY TAB 10MG Tier 4 X X X ABILIFY TAB 15MG Tier 4 X X X ABILIFY TAB 20MG Tier 4 X X X ABILIFY TAB 2MG Tier 4 X X X ABILIFY TAB 30MG Tier 4 X X X ABILIFY TAB 5MG Tier 4 X X X ABILIFY DISC TAB 10MG Tier 4 X ABILIFY DISC TAB 15MG Tier 4 X ARIPIPRAZOLE SOL 1MG/ML Tier 1 Page 2 of 279

9 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 10MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 10MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 15MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 15MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 20MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 2MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 30MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ARIPIPRAZOLE TAB 5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder FANAPT PAK Tier 3 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 10MG Tier 4 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 12MG Tier 4 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 1MG Tier 4 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 2MG Tier 4 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 4MG Tier 4 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 6MG Tier 4 X 2nd Generation/Atypical - Mood Disorder FANAPT TAB 8MG Tier 4 X 2nd Generation/Atypical - Mood Disorder GEODON CAP 20MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder GEODON CAP 40MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder GEODON CAP 60MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder GEODON CAP 80MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder INVEGA TAB 1.5MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder INVEGA TAB 3MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder INVEGA TAB 6MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder INVEGA TAB 9MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder LATUDA TAB 120MG Tier 4 X 2nd Generation/Atypical - Mood Disorder LATUDA TAB 20MG Tier 4 X 2nd Generation/Atypical - Mood Disorder LATUDA TAB 40MG Tier 4 X 2nd Generation/Atypical - Mood Disorder LATUDA TAB 60MG Tier 4 X 2nd Generation/Atypical - Mood Disorder LATUDA TAB 80MG Tier 4 X Page 3 of 279

10 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 10MG Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 10MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 15MG Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 15MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 2.5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 20MG Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 20MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 5MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder OLANZAPINE TAB 7.5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder PALIPERIDONE TAB ER 1.5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder PALIPERIDONE TAB ER 3MG Tier 1 X 2nd Generation/Atypical - Mood Disorder PALIPERIDONE TAB ER 6MG Tier 1 X 2nd Generation/Atypical - Mood Disorder PALIPERIDONE TAB ER 9MG Tier 1 X 2nd Generation/Atypical - Mood Disorder QUETIAPINE TAB 100MG Tier 1 2nd Generation/Atypical - Mood Disorder QUETIAPINE TAB 200MG Tier 1 2nd Generation/Atypical - Mood Disorder QUETIAPINE TAB 25MG Tier 1 2nd Generation/Atypical - Mood Disorder QUETIAPINE TAB 300MG Tier 1 2nd Generation/Atypical - Mood Disorder QUETIAPINE TAB 400MG Tier 1 2nd Generation/Atypical - Mood Disorder QUETIAPINE TAB 50MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERDAL SOL 1MG/ML Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL TAB 0.25MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL TAB 0.5MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL TAB 1MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL TAB 2MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL TAB 3MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL TAB 4MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL M TAB 0.5MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL M TAB 1MG Tier 4 X Page 4 of 279

11 2nd Generation/Atypical - Mood Disorder RISPERDAL M TAB 2MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL M TAB 3MG Tier 4 X 2nd Generation/Atypical - Mood Disorder RISPERDAL M TAB 4MG Tier 3 X 2nd Generation/Atypical - Mood Disorder RISPERIDONE SOL 1MG/ML Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 0.25 ODT Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 0.25MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 0.5MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 0.5MG OD Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 1MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 1MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 2MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 2MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 3MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 3MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 4MG Tier 1 2nd Generation/Atypical - Mood Disorder RISPERIDONE TAB 4MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder SAPHRIS SUB 10MG Tier 3 X 2nd Generation/Atypical - Mood Disorder SAPHRIS SUB 2.5MG Tier 3 2nd Generation/Atypical - Mood Disorder SAPHRIS SUB 5MG Tier 3 X 2nd Generation/Atypical - Mood Disorder SEROQUEL TAB 100MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL TAB 200MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL TAB 25MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL TAB 300MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL TAB 400MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL TAB 50MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL XR TAB 150MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL XR TAB 200MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL XR TAB 300MG Tier 4 X 2nd Generation/Atypical - Mood Disorder SEROQUEL XR TAB 400MG Tier 4 X Page 5 of 279

12 2nd Generation/Atypical - Mood Disorder SEROQUEL XR TAB 50MG Tier 4 X 2nd Generation/Atypical - Mood Disorder ZIPRASIDONE CAP 20MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ZIPRASIDONE CAP 40MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ZIPRASIDONE CAP 60MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ZIPRASIDONE CAP 80MG Tier 1 X 2nd Generation/Atypical - Mood Disorder ZYPREXA TAB 10MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA TAB 15MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA TAB 2.5MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA TAB 20MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA TAB 5MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA TAB 7.5MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA ZYDI TAB 10MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA ZYDI TAB 15MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA ZYDI TAB 20MG Tier 4 X X 2nd Generation/Atypical - Mood Disorder ZYPREXA ZYDI TAB 5MG Tier 4 X X Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants ACAMPRO CAL TAB 333MG Tier 1 Alcohol Deterrents/Anti-craving - ANTABUSE TAB 250MG Tier 4 Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants ANTABUSE TAB 500MG Tier 4 Alcohol Deterrents/Anti-craving - DISULFIRAM TAB 250MG Tier 1 Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving - DISULFIRAM TAB 500MG Tier 1 Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants NALTREXONE TAB 50MG Tier 1 Alcohol Deterrents/Anti-craving - REVIA TAB 50MG Tier 4 Antidotes/Deterrents/Protectants Alkylating Agents - Chemotherapy Agents ALKERAN TAB 2MG Tier 3 X Alkylating Agents - Chemotherapy Agents CYCLOPHOSPH CAP 25MG Tier 3 X Alkylating Agents - Chemotherapy Agents CYCLOPHOSPH CAP 50MG Tier 3 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 100MG Tier 4 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 10MG Tier 4 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 40MG Tier 4 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 5MG Tier 4 X Page 6 of 279

13 Alkylating Agents - Chemotherapy Agents HEXALEN CAP 50MG Tier 3 X Alkylating Agents - Chemotherapy Agents LEUKERAN TAB 2MG Tier 3 X Alkylating Agents - Chemotherapy Agents LOMUSTINE CAP 100MG Tier 1 X Alkylating Agents - Chemotherapy Agents LOMUSTINE CAP 10MG Tier 1 X Alkylating Agents - Chemotherapy Agents LOMUSTINE CAP 40MG Tier 1 X Alkylating Agents - Chemotherapy Agents MATULANE CAP 50MG Tier 3 X Alkylating Agents - Chemotherapy Agents MYLERAN TAB 2MG Tier 3 X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 100MG Tier 4 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 140MG Tier 4 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 180MG Tier 4 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 20MG Tier 4 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 250MG Tier 4 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 5MG Tier 4 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 100MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 140MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 180MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 20MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 250MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 5MG Tier 1 X X Alkylating Agents - Chemotherapy Agents VALCHLOR GEL 0.016% Tier 3 X X X Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure Alpha-Adrenergic Agonists - Blood Pressure CATAPRES TAB 0.1MG Tier 4 CATAPRES TAB 0.2MG Tier 4 CATAPRES TAB 0.3MG Tier 4 CATAPRES-TTS DIS 0.1/24HR Tier 4 CATAPRES-TTS DIS 0.2/24HR Tier 4 CATAPRES-TTS DIS 0.3/24HR Tier 4 CLONIDINE DIS 0.1/24HR Tier 1 CLONIDINE DIS 0.2/24HR Tier 1 CLONIDINE DIS 0.3/24HR Tier 1 Page 7 of 279

14 Alpha-Adrenergic Agonists - Blood Pressure CLONIDINE TAB 0.1MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure CLONIDINE TAB 0.2MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure CLONIDINE TAB 0.3MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure CLORPRES TAB MG Tier 2 Alpha-Adrenergic Agonists - Blood Pressure CLORPRES TAB MG Tier 2 Alpha-Adrenergic Agonists - Blood Pressure CLORPRES TAB MG Tier 2 Alpha-Adrenergic Agonists - Blood Pressure GUANFACINE TAB 1MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure GUANFACINE TAB 2MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure METHYLD/HCTZ TAB 250/15 Tier 1 Alpha-Adrenergic Agonists - Blood Pressure METHYLD/HCTZ TAB 250/25 Tier 1 Alpha-Adrenergic Agonists - Blood Pressure METHYLDOPA TAB 250MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure METHYLDOPA TAB 500MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure MIDODRINE TAB 10MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure MIDODRINE TAB 2.5MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure MIDODRINE TAB 5MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure TENEX TAB 1MG Tier 3 Alpha-Adrenergic Agonists - Blood Pressure TENEX TAB 2MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood CARDURA XL TAB 4MG Tier 3 Pressure Alpha-Adrenergic Blocking Agents - Blood CARDURA XL TAB 8MG Tier 3 Pressure Alpha-Adrenergic Blocking Agents - Blood DIBENZYLINE CAP 10MG Tier 4 X Pressure Alpha-Adrenergic Blocking Agents - Blood MINIPRESS CAP 1MG Tier 4 Pressure Alpha-Adrenergic Blocking Agents - Blood MINIPRESS CAP 2MG Tier 4 Pressure Alpha-Adrenergic Blocking Agents - Blood MINIPRESS CAP 5MG Tier 4 Pressure Alpha-Adrenergic Blocking Agents - Blood PHENOXYBENZA CAP 10MG Tier 1 Pressure Alpha-Adrenergic Blocking Agents - Blood PRAZOSIN HCL CAP 1MG Tier 1 Pressure Alpha-Adrenergic Blocking Agents - Blood PRAZOSIN HCL CAP 2MG Tier 1 Pressure Alpha-Adrenergic Blocking Agents - Blood PRAZOSIN HCL CAP 5MG Tier 1 Pressure Alpha-Adrenergic Blocking Agents - Blood RESERPINE TAB 0.1MG Tier 1 Pressure RESERPINE TAB 0.25MG Tier 1 Alpha-Adrenergic Blocking Agents - Blood Pressure Page 8 of 279

15 Aminoglycosides - Antibiotics BETHKIS NEB 300/4ML Tier 1 X X X Aminoglycosides - Antibiotics GARAMYCIN SOL 0.3% OP Tier 3 Aminoglycosides - Antibiotics GENTAK OIN 0.3% OP Tier 1 Aminoglycosides - Antibiotics GENTAMICIN CRE 0.1% Tier 1 Aminoglycosides - Antibiotics GENTAMICIN OIN 0.1% Tier 1 Aminoglycosides - Antibiotics GENTAMICIN OIN 0.3% OP Tier 1 Aminoglycosides - Antibiotics GENTAMICIN SOL 0.3% OP Tier 1 Aminoglycosides - Antibiotics KITABIS PAK NEB 300/5ML Tier 4 X X X X Aminoglycosides - Antibiotics NEOMYCIN TAB 500MG Tier 1 Aminoglycosides - Antibiotics PAROMOMYCIN CAP 250MG Tier 1 Aminoglycosides - Antibiotics TOBI NEB 300/5ML Tier 4 X X X X Aminoglycosides - Antibiotics TOBI PODHALR CAP 28MG Tier 4 X X X Aminoglycosides - Antibiotics TOBRAMYCIN NEB 300/5ML Tier 1 X X X X Aminoglycosides - Antibiotics TOBRAMYCIN SOL 0.3% OP Tier 1 Aminoglycosides - Antibiotics TOBREX OIN 0.3% OP Tier 3 Aminoglycosides - Antibiotics TOBREX SOL 0.3% OP Tier 4 Aminosalicylates - Inflammatory Bowel Disease APRISO CAP 0.375GM Tier 2 Aminosalicylates - Inflammatory Bowel Disease ASACOL HD TAB 800MG Tier 4 X Aminosalicylates - Inflammatory Bowel Disease BALSALAZIDE CAP 750MG Tier 1 Aminosalicylates - Inflammatory Bowel CANASA SUP 1000MG Tier 2 Disease Aminosalicylates - Inflammatory Bowel COLAZAL CAP 750MG Tier 4 X Disease Aminosalicylates - Inflammatory Bowel DELZICOL CAP 400MG Tier 4 X Disease Aminosalicylates - Inflammatory Bowel Disease DIPENTUM CAP 250MG Tier 3 Aminosalicylates - Inflammatory Bowel GIAZO TAB 1.1GM Tier 4 X Disease Aminosalicylates - Inflammatory Bowel Disease LIALDA TAB 1.2GM Tier 2 Aminosalicylates - Inflammatory Bowel MESALAMINE ENE 4GM Tier 1 Disease Aminosalicylates - Inflammatory Bowel Disease MESALAMINE KIT 4GM Tier 1 X Aminosalicylates - Inflammatory Bowel Disease MESALAMINE TAB 800MG DR Tier 4 X Aminosalicylates - Inflammatory Bowel PENTASA CAP 250MG CR Tier 4 X Disease Aminosalicylates - Inflammatory Bowel Disease PENTASA CAP 500MG CR Tier 4 X Aminosalicylates - Inflammatory Bowel ROWASA KIT 4GM Tier 4 X Disease Aminosalicylates - Inflammatory Bowel Disease SFROWASA ENE 4GM Tier 4 Anabolic Steroids - Hormone Replacement/Modifying ANADROL-50 TAB 50MG Tier 3 Anabolic Steroids - Hormone OXANDRIN TAB 10MG Tier 4 Replacement/Modifying Anabolic Steroids - Hormone Replacement/Modifying OXANDRIN TAB 2.5MG Tier 3 Anabolic Steroids - Hormone Replacement/Modifying OXANDROLONE TAB 10MG Tier 1 Page 9 of 279

16 Therapeutic Class Product Name Tier Value Anabolic Steroids - Hormone OXANDROLONE TAB 2.5MG Tier 1 Replacement/Modifying Analgesics - Miscellaneous Analgesics ALAGESIC LQ SOL Tier 1 X Analgesics - Miscellaneous Analgesics ALLZITAL TAB MG Tier 4 X X Analgesics - Miscellaneous Analgesics BUPAP TAB MG Tier 4 Analgesics - Miscellaneous Analgesics BUT/APAP/CAF CAP Tier 1 X Analgesics - Miscellaneous Analgesics BUT/APAP/CAF CAP Tier 1 X Analgesics - Miscellaneous Analgesics BUT/APAP/CAF TAB Tier 1 X Analgesics - Miscellaneous Analgesics BUT/ASA/CAFF CAP Tier 1 Analgesics - Miscellaneous Analgesics BUTAL/APAP TAB MG Tier 1 Analgesics - Miscellaneous Analgesics CAPACET CAP Tier 1 X Analgesics - Miscellaneous Analgesics ESGIC CAP Tier 4 X Analgesics - Miscellaneous Analgesics ESGIC TAB Tier 4 X Analgesics - Miscellaneous Analgesics FIORICET CAP Tier 4 X Analgesics - Miscellaneous Analgesics FIORINAL CAP Tier 4 Analgesics - Miscellaneous Analgesics GRALISE TAB 300MG Tier 4 X X Analgesics - Miscellaneous Analgesics GRALISE TAB 600MG Tier 4 X X Analgesics - Miscellaneous Analgesics GRALISE STAR MIS 300/600 Tier 3 X X Analgesics - Miscellaneous Analgesics MARGESIC CAP Tier 1 X Analgesics - Miscellaneous Analgesics MARTEN-TAB TAB MG Tier 1 Analgesics - Miscellaneous Analgesics TENCON TAB MG Tier 1 Analgesics - Miscellaneous Analgesics VANATOL LQ SOL Tier 1 X Analgesics - Miscellaneous Analgesics ZEBUTAL CAP Tier 1 X Androgens - Hormone ANDRODERM DIS 2MG/24HR Tier 2 X X Replacement/Modifying Androgens - Hormone Replacement/Modifying ANDRODERM DIS 4MG/24HR Tier 2 X X Androgens - Hormone ANDROGEL GEL 1%(25MG) Tier 4 X X X Replacement/Modifying Androgens - Hormone ANDROGEL GEL 1%(50MG) Tier 4 X X X Replacement/Modifying Androgens - Hormone ANDROGEL GEL 1.62% Tier 4 X X X Replacement/Modifying Androgens - Hormone ANDROGEL GEL 1.62% Tier 4 X X X Replacement/Modifying Androgens - Hormone ANDROGEL GEL 1.62% Tier 4 X X X Replacement/Modifying Androgens - Hormone ANDROGEL GEL PUMP 1% Tier 4 X X X Replacement/Modifying Androgens - Hormone ANDROID CAP 10MG Tier 4 Replacement/Modifying Androgens - Hormone Replacement/Modifying ANDROXY TAB 10MG Tier 1 Androgens - Hormone AXIRON SOL 30MG/ACT Tier 4 X X X Replacement/Modifying Androgens - Hormone DANAZOL CAP 100MG Tier 1 Replacement/Modifying Androgens - Hormone DANAZOL CAP 200MG Tier 1 Replacement/Modifying Androgens - Hormone Replacement/Modifying DANAZOL CAP 50MG Tier 1 Androgens - Hormone DEPO-TESTOST INJ 100MG/ML Tier 3 Replacement/Modifying Androgens - Hormone Replacement/Modifying DEPO-TESTOST INJ 200MG/ML Tier 4 Page 10 of 279

17 Androgens - Hormone FIRST-TESTOS CRE MC 2% Tier 3 X Replacement/Modifying Androgens - Hormone FIRST-TESTOS OIN 2% Tier 3 X Replacement/Modifying Androgens - Hormone FORTESTA GEL 10MG/ACT Tier 4 X X X Replacement/Modifying Androgens - Hormone METHITEST TAB 10MG Tier 2 Replacement/Modifying Androgens - Hormone METHYLTESTOS CAP 10MG Tier 1 Replacement/Modifying Androgens - Hormone NATESTO GEL 5.5MG Tier 4 X X X Replacement/Modifying Androgens - Hormone STRIANT MIS 30MG Tier 3 X X Replacement/Modifying Androgens - Hormone TESTIM GEL 1%(50MG) Tier 2 X X Replacement/Modifying Androgens - Hormone TESTOST CYP INJ 100MG/ML Tier 1 Replacement/Modifying Androgens - Hormone TESTOST CYP INJ 200MG/ML Tier 1 Replacement/Modifying Androgens - Hormone TESTOST ENAN INJ 200MG/ML Tier 1 Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL 1%(25MG) Tier 1 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL 1%(50MG) Tier 4 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL 1%(50MG) Tier 4 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL 1%(50MG) Tier 1 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL 1%(50MG) Tier 3 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL Tier 4 X X X Replacement/Modifying 10MG/ACT Androgens - Hormone TESTOSTERONE GEL PUMP 1% Tier 4 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL PUMP 1% Tier 3 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL PUMP 1% Tier 1 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE GEL PUMP 1% Tier 4 X X X Replacement/Modifying Androgens - Hormone TESTOSTERONE INJ 250MG/ML Tier 3 Replacement/Modifying Androgens - Hormone TESTRED CAP 10MG Tier 4 Replacement/Modifying Androgens - Hormone VOGELXO GEL 1%(50MG) Tier 4 X X X Replacement/Modifying Androgens - Hormone VOGELXO GEL PUMP 1% Tier 4 X X X Replacement/Modifying Angiotensin II Receptor Antagonists - Blood ATACAND TAB 16MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood ATACAND TAB 32MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood ATACAND TAB 4MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood ATACAND TAB 8MG Tier 4 X Pressure Page 11 of 279

18 Angiotensin II Receptor Antagonists - Blood ATACAND HCT TAB Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood ATACAND HCT TAB Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood ATACAND HCT TAB 32-25MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood AVALIDE TAB Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood AVALIDE TAB Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood AVAPRO TAB 150MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood AVAPRO TAB 300MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood AVAPRO TAB 75MG Tier 4 X Pressure Angiotensin II Receptor Antagonists - Blood BENICAR TAB 20MG Tier 2 X Pressure Angiotensin II Receptor Antagonists - Blood BENICAR TAB 40MG Tier 2 X Pressure Angiotensin II Receptor Antagonists - Blood BENICAR TAB 5MG Tier 2 X Pressure Angiotensin II Receptor Antagonists - Blood BENICAR HCT TAB Tier 2 X Pressure Angiotensin II Receptor Antagonists - Blood BENICAR HCT TAB Tier 2 X Pressure Angiotensin II Receptor Antagonists - Blood BENICAR HCT TAB 40-25MG Tier 2 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESA/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESA/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESA/HCTZ TAB 32-25MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESARTAN TAB 16MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESARTAN TAB 32MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESARTAN TAB 4MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood CANDESARTAN TAB 8MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood COZAAR TAB 100MG Tier 4 Pressure Angiotensin II Receptor Antagonists - Blood COZAAR TAB 25MG Tier 4 Pressure Angiotensin II Receptor Antagonists - Blood COZAAR TAB 50MG Tier 4 Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN TAB 160MG Tier 3 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN TAB 320MG Tier 3 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN TAB 40MG Tier 3 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN TAB 80MG Tier 3 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN HCT TAB Tier 4 X X Pressure Page 12 of 279

19 Angiotensin II Receptor Antagonists - Blood DIOVAN HCT TAB MG Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN HCT TAB Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN HCT TAB MG Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood DIOVAN HCT TAB 80/12.5 Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood EDARBI TAB 40MG Tier 3 X Pressure Angiotensin II Receptor Antagonists - Blood EDARBI TAB 80MG Tier 3 X Pressure Angiotensin II Receptor Antagonists - Blood EDARBYCLOR TAB Tier 3 X Pressure Angiotensin II Receptor Antagonists - Blood EDARBYCLOR TAB 40-25MG Tier 3 X Pressure Angiotensin II Receptor Antagonists - Blood EPROSART MES TAB 600MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood HYZAAR TAB Tier 4 Pressure Angiotensin II Receptor Antagonists - Blood HYZAAR TAB Tier 4 Pressure Angiotensin II Receptor Antagonists - Blood HYZAAR TAB Tier 4 Pressure Angiotensin II Receptor Antagonists - Blood IRBESAR/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood IRBESAR/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood IRBESARTAN TAB 150MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood IRBESARTAN TAB 300MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood IRBESARTAN TAB 75MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood LOSARTAN POT TAB 100MG Tier 1 Pressure Angiotensin II Receptor Antagonists - Blood LOSARTAN POT TAB 25MG Tier 1 Pressure Angiotensin II Receptor Antagonists - Blood LOSARTAN POT TAB 50MG Tier 1 Pressure Angiotensin II Receptor Antagonists - Blood LOSARTAN/HCT TAB Tier 1 Pressure Angiotensin II Receptor Antagonists - Blood LOSARTAN/HCT TAB Tier 1 Pressure Angiotensin II Receptor Antagonists - Blood LOSARTAN/HCT TAB Tier 1 Pressure Angiotensin II Receptor Antagonists - Blood MICARDIS TAB 20MG Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood MICARDIS TAB 40MG Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood MICARDIS TAB 80MG Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood MICARDIS HCT TAB 40/12.5 Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood MICARDIS HCT TAB 80/12.5 Tier 4 X X Pressure Angiotensin II Receptor Antagonists - Blood MICARDIS HCT TAB 80-25MG Tier 4 X X Pressure Page 13 of 279

20 Angiotensin II Receptor Antagonists - Blood TELMISA/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood TELMISA/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood TELMISA/HCTZ TAB 80-25MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood TELMISARTAN TAB 20MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood TELMISARTAN TAB 40MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood TELMISARTAN TAB 80MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood TEVETEN HCT TAB MG Tier 3 X Pressure Angiotensin II Receptor Antagonists - Blood VALSART/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSART/HCTZ TAB MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSART/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSART/HCTZ TAB MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSART/HCTZ TAB Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSARTAN TAB 160MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSARTAN TAB 320MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSARTAN TAB 40MG Tier 1 X Pressure Angiotensin II Receptor Antagonists - Blood VALSARTAN TAB 80MG Tier 1 X Pressure Angiotensin-converting Enzyme (ACE) ACCUPRIL TAB 10MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACCUPRIL TAB 20MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACCUPRIL TAB 40MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACCUPRIL TAB 5MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACCURETIC TAB Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACCURETIC TAB Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACCURETIC TAB 20-25MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACEON TAB 4MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ACEON TAB 8MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ALTACE CAP 1.25MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ALTACE CAP 10MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ALTACE CAP 2.5MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ALTACE CAP 5MG Tier 4 Inhibitors - Blood Pressure Page 14 of 279

21 Angiotensin-converting Enzyme (ACE) BENAZEP/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEP/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEP/HCTZ TAB 20-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEP/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEPRIL TAB 10MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEPRIL TAB 20MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEPRIL TAB 40MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) BENAZEPRIL TAB 5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPR/HCTZ TAB 25-15MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPR/HCTZ TAB 25-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPR/HCTZ TAB 50-15MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPR/HCTZ TAB 50-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPRIL TAB 100MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPRIL TAB 12.5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPRIL TAB 25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) CAPTOPRIL TAB 50MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ENALAPR/HCTZ TAB 10-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ENALAPR/HCTZ TAB MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ENALAPRIL TAB 10MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ENALAPRIL TAB 2.5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ENALAPRIL TAB 20MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ENALAPRIL TAB 5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) EPANED SOL 1MG/ML Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) FOSINOP/HCTZ TAB 10/12.5 Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) FOSINOP/HCTZ TAB 20/12.5 Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) FOSINOPRIL TAB 10MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) FOSINOPRIL TAB 20MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) FOSINOPRIL TAB 40MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOP/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Page 15 of 279

22 Angiotensin-converting Enzyme (ACE) LISINOP/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOP/HCTZ TAB 20-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOPRIL TAB 10MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOPRIL TAB 2.5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOPRIL TAB 20MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOPRIL TAB 30MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOPRIL TAB 40MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LISINOPRIL TAB 5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LOTENSIN TAB 10MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LOTENSIN TAB 20MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LOTENSIN TAB 40MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LOTENSIN HCT TAB Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LOTENSIN HCT TAB Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) LOTENSIN HCT TAB 20-25MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MAVIK TAB 1MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MAVIK TAB 2MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MAVIK TAB 4MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MOEXIPR/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MOEXIPR/HCTZ TAB 15-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MOEXIPR/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MOEXIPRIL TAB 15MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) MOEXIPRIL TAB 7.5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) PERINDOPRIL TAB 2MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) PERINDOPRIL TAB 4MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) PERINDOPRIL TAB 8MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) PRINIVIL TAB 10MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) PRINIVIL TAB 20MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) PRINIVIL TAB 5MG Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QBRELIS SOL 1MG/ML Tier 4 X Inhibitors - Blood Pressure Page 16 of 279

23 Angiotensin-converting Enzyme (ACE) QNAPRIL/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QNAPRIL/HCTZ TAB Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QNAPRIL/HCTZ TAB 20-25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QUINAPRIL TAB 10MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QUINAPRIL TAB 20MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QUINAPRIL TAB 40MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) QUINAPRIL TAB 5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) RAMIPRIL CAP 1.25MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) RAMIPRIL CAP 10MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) RAMIPRIL CAP 2.5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) RAMIPRIL CAP 5MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TARKA TAB CR Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TARKA TAB CR Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TARKA TAB CR Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TARKA TAB CR Tier 4 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB CR Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB ER Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB CR Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB ER Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB CR Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB ER Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB CR Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDO/VERAP TAB ER Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDOLAPRIL TAB 1MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDOLAPRIL TAB 2MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) TRANDOLAPRIL TAB 4MG Tier 1 Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) VASERETIC TAB 10-25MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) VASOTEC TAB 10MG Tier 4 X Inhibitors - Blood Pressure VASOTEC TAB 2.5MG Tier 4 X Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Page 17 of 279

24 Angiotensin-converting Enzyme (ACE) VASOTEC TAB 20MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure VASOTEC TAB 5MG Tier 4 X Angiotensin-converting Enzyme (ACE) ZESTORETIC TAB Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ZESTORETIC TAB Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure ZESTORETIC TAB 20-25MG Tier 4 X Angiotensin-converting Enzyme (ACE) ZESTRIL TAB 10MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ZESTRIL TAB 2.5MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ZESTRIL TAB 20MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ZESTRIL TAB 30MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ZESTRIL TAB 40MG Tier 4 X Inhibitors - Blood Pressure Angiotensin-converting Enzyme (ACE) ZESTRIL TAB 5MG Tier 4 X Inhibitors - Blood Pressure Anthelmintics - Worm Infection ALBENZA TAB 200MG Tier 2 Anthelmintics - Worm Infection BILTRICIDE TAB 600MG Tier 2 Anthelmintics - Worm Infection EMVERM CHW 100MG Tier 4 X Anthelmintics - Worm Infection IVERMECTIN TAB 3MG Tier 1 Antiandrogens - Hormone Suppressants BICALUTAMIDE TAB 50MG Tier 1 X Antiandrogens - Hormone Suppressants CASODEX TAB 50MG Tier 4 X Antiandrogens - Hormone Suppressants FLUTAMIDE CAP 125MG Tier 1 X Antiandrogens - Hormone Suppressants NILANDRON TAB 150MG Tier 4 X Antiandrogens - Hormone Suppressants NILUTAMIDE TAB 150MG Tier 1 X Antiandrogens - Hormone Suppressants XTANDI CAP 40MG Tier 4 X X X X Antiangiogenic Agents - Chemotherapy CAPRELSA TAB 100MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy CAPRELSA TAB 300MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy REVLIMID CAP 10MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy REVLIMID CAP 15MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy REVLIMID CAP 2.5MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy REVLIMID CAP 20MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy REVLIMID CAP 25MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 5MG Tier 3 X X X Antiangiogenic Agents - Chemotherapy THALOMID CAP 100MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy THALOMID CAP 150MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy THALOMID CAP 200MG Tier 3 X X X Agents Antiangiogenic Agents - Chemotherapy Agents THALOMID CAP 50MG Tier 3 X X X Antiarrhythmics - Heart Regulation AMIODARONE TAB 100MG Tier 1 Antiarrhythmics - Heart Regulation AMIODARONE TAB 200MG Tier 1 Page 18 of 279