DRUG FORMULARY QUALIFIED HEALTH PLANS EFFECTIVE JANUARY 1, 2017 LAST UPDATED NOVEMBER 1, 2017

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1 DRUG FORMULARY QUALIFIED HEALTH PLANS EFFECTIVE JANUARY 1, 2017 LAST UPDATED NOVEMBER 1, 2017 INTRODUCTION This is the Health Alliance Drug Formulary for Qualified Health Plans (also known as the health insurance exchange plans). In order to assist members and providers in choosing prescription drugs for treatment, we encourage members to show this list to their physicians and pharmacists. In addition, we encourage prescribers to use this list when considering treatment options. Final decisions regarding treatment options are made between the physician and patient. The formulary is subject to change at any time. Members can access the most up-to-date version of this list by visiting HealthAlliance.org. Members can also log in to YourHealthAlliance.org to check specific drug coverage and pricing information. The formulary does not provide information about an individual s specific coverage. Please refer to your plan documents for complete coverage details. HOW TO USE THIS LIST This drug list is organized in sections by drug class or medical condition. Within each section are subsections to help locate medications. Most drugs listed, whether generic or brand, are formulary drugs. To search within the PDF, choose the search function, enter a drug name and click search or find. You can also search using the index, which lists drugs alphabetically. Generics Like brand drugs, generic drugs go through an approval process by the Food and Drug Administration (FDA) and must meet similar standards of effectiveness and chemical make-up as branded drugs. The main difference between the reference brand drug and its generic equivalent is that the generic often costs much less. As a general rule, generic drugs have the lowest member copayment. Typically, when a generic enters the market the brand drug moves to Tier 3. Members who choose the brand name after the release of a generic version may pay the copayment plus the difference in cost between the brand and generic drug. Generic drugs can help members save on out-of-pocket medication costs. Generic Equivalent vs. Generic Alternative Generic equivalents are medications that contain the same active ingredient, with the same strength and dosage form as the brand medication. Generic equivalents are as safe and effective and produce the same results as the brand counterpart. Generic alternatives can produce the same intended effect on the body as the comparable brand. Generic alternatives are medications that work like a particular brand drug and are used to treat the same condition. However, the active ingredient in a generic alternative is different from the brand medication. Talk to Your Doctor If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. As a patient, you can tell your pharmacist you are interested in generics. In most situations, your pharmacist can substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. For more information on generics, visit AskForGenerics.org. Drugs to Treat Multiple Conditions Doctors use some drugs to treat more than one medical condition. Within this document, each drug is listed according to its first FDA-approved use. Please check the index if you do not find your medication in the therapeutic class that corresponds to your condition. ph-formularyintroqhp-1117

2 COVERAGE AND LIMITATIONS Tier Information A drug s copayment tier indicates what you will pay for the medication with each fill. The majority of generics are Tier 1. These are your least expensive prescription drugs. Preferred brand-name drugs are Tier 2, the lowest brand tier. Non-preferred brand-name drugs are Tier 3. Specialty drugs are in Tiers 4, 5, and 6. o Preferred Specialty drugs are Tier 4 o Non-Preferred Specialty drugs are Tier 5 o Non-Formulary Specialty drugs are Tier 6 Preventive drugs are Tier 7. These are covered at no charge as defined in the plan policy. Your pharmacy benefit includes coverage for the majority of prescription drugs, though some exclusions may apply. Utilization Management Some drugs on this list require utilization management (UM), i.e. preauthorization, managed dose limitations and step-therapy. If UM applies to a drug, it is indicated with one of the following symbols in the column next to the drug name. MDL- Managed Dose Limitations PA- Preauthorization ST- Step-Therapy NOTE: Effective 8/1/17, most specialty medications used during cancer treatment will require your doctor to submit for preauthorization through evicore. Please click on the link below for a list of these medications: evicore Preauthorization List These medications are also indicated in our Specialty Drug List. Medical Exception Medical exception is a process for reviewing coverage for drugs not on our formulary. Members may qualify for a medical exception if they meet one of these: A. Documented failure of all formulary drugs within the same therapeutic class B. Documented allergy to a formulary drug, with no other formulary choices C. Successfully maintained condition on a specific drug where switching to an alternative drug may cause a health risk: o Antiarrhythmics o Theophylline products o Seizure medications o Antipsychotics o Antidepressants Physicians Requesting a Medical Exception To request a Medical Exception for a medication on behalf of a member, or to request further information, please call the Health Alliance Pharmacy department at , option 4, or log in to YourHealthAlliance.org. Contraceptive Coverage Under Preventive Health Wellness Benefit A female member age years old has coverage of some FDA-approved contraceptives for no outof-pocket cost. Free contraceptives are listed below: Tier 1 oral contraceptives Limit of three units on condoms (male or female) Limit of 2.7 units of spermicidal product Only one Tier 1 prescription drug (like a generic oral contraceptive) or one over-the-counter (OTC) product (like male and female condoms or spermicides) is covered per 30-day period for no cost to the member. Brand-name contraceptives that are Tier 2 or higher are covered with the appropriate member cost share/quantity restrictions according to the member s plan. Emergency contraception is covered at Tier 1 using generic levonorgestrel/ethinyl estradiolcontaining products. Brand-name emergency contraception is covered according to the member s plan. Quantities above a 30-day supply, including vacation overrides and commercially available extended-cycle contraceptives (like Seasonale), are subject to appropriate member cost-sharing according to the member s plan.

3 General Exclusions A. Over-the-counter (OTC) medications and their equivalents are not covered, unless otherwise specified within the Formulary. Nicotine smoking-cessation products (e.g., transdermal nicotine, nicotine gum, nicotine inhaler) coverage is based on specific member benefits. B. Any drugs used for cosmetic purposes are not covered. C. Experimental drugs, or any drug product used in an experimental manner, are not covered. D. Replacement of lost or stolen medication is not covered. E. Non-self-administered injectable drugs, unless otherwise noted, are not covered through the pharmacy benefit. Refer to your description of coverage materials for details. F. Foreign drugs and drugs not approved by the FDA are not covered. G. Drugs used to treat erectile dysfunction. PHARMACY SAVINGS PROGRAMS Health Alliance offers members several programs to lower the drug costs and to help members take their medications safely and correctly. Rxtra Health Alliance members with prescription coverage can save money based on where they have their 30-day-supply of prescriptions filled. The Rxtra program is simple. Preferred At Preferred pharmacies, members can get hundreds of common prescriptions FREE. Preferred Plus At Preferred Plus pharmacies, members have the same benefits as the Preferred pharmacies mentioned above. In addition, simvastatin, pravastatin, ProAir and Ventolin HFA are FREE. Blood Glucose Monitors FREE By Mail Members with diabetes are eligible to receive a FREE blood glucose meter if they choose one of the preferred meters listed below and obtain the meter by mail. If a member picks up a blood glucose meter at their local pharmacy, the member s Tier 2 copayment will apply when obtained with a prescription. Free meters are limited to one meter per member per year. The FreeStyle InsuLinx System is limited to one meter every three years. Freestyle Lite and Freestyle InsuLinx FreeStyle Lite System FreeStyle Freedom Lite System FreeStyle InsuLinx System To get an Abbott product, call and use Offer Code ZD218BKX. Or visit and enter Offer Code ZD218BKX. InsuLinx systems are limited to one free product per member every three years. Not all benefit plans include each of the programs listed above. Please refer to your description of coverage documents for more detail or contact the Pharmacy department at , option 4. CONTACT US Health Alliance Pharmacy Department 301 S. Vine St. Urbana, IL , option 4 For a list of participating pharmacies and available drugs in the Rxtra program, visit the pharmacy section of HealthAlliance.org. Retail 90 The Retail 90 program allows members to purchase a 90-day supply of maintenance medication at a discounted copayment from participating retail pharmacies. Because this is a voluntary program designed to increase flexibility, members who prefer may continue purchasing the traditional 30-day supply from their pharmacy with their regular copayment.

4 Table of Contents ANTI-INFECTIVES PENICILLINS CEPHALOSPORIN FIRST GENERATION SECOND GENERATION THIRD GENERATION FOURTH GENERATION MACROLIDES TETRACYCLINES QUINOLONES AMINOGLYCOSIDES SULFONAMIDES ANTIMYCOBACTERIAL AGENTS ANTIFUNGALS ANTIVIRALS ANTIMALARIALS ANTHELMINTICS MISC. ANTI-INFECTIVES ANTINEOPLASTICS, ETC ALKYLATING AGENTS ANTIBIOTICS ANTINEOPLASTIC ENZYMES ANTIMETABOLITES ANGIOGENESIS INHIBITORS ANTIBODIES HORMONAL AGENTS IMMUNOMODULATORS MITOTIC INHIBITORS ENZYME INHIBITORS TOPOISOMERASE I INHIBITOR RADIOPHARMACEUTICALS CELLULAR IMMUNOTHERAPY ANTINEOPLASTICS MISC CHEMOTHERAPY RESCUE CHEMOTHERAPY ADJUNCTS ANTINEOPLASTIC COMBO CARDIOVASCULAR DRUGS

5 PHOSPHODIESTERASE INHBTR CARDIAC GLYCOSIDES ANTIANGINAL AGENTS BETA BLOCKERS CALCIUM CHANNEL BLOCKERS ANTIARRHYTHMICS ACE INHIBITORS ANGIOTENSIN RCPTR BLOCKER DIRECT RENIN INHIBITORS ANTIHYPERTENSIVES MISC ANTIHYPERTENSIVE COMBO DIURETICS VASOPRESSORS ANTIHYPERLIPIDEMICS CARDIOVASCULAR - MISC DERMATOLOGICALS ACNE PRODUCTS ROSACEA AGENTS ANTIBIOTICS - TOPICAL ANTIFUNGALS - TOPICAL ANTIVIRALS - TOPICAL ANTI-INFLAMMATORY AGENTS ANTIPRURITICS ANTIPSORIATICS ANTISEBORRHEIC AGENTS ANTINEOPLASTIC-TOPICAL CORTICOSTEROIDS - TOPICAL IMMUNOMODULATING AGENTS DERMATOLOGICALS - MISC ENDOCRINE AND METABOLIC CORTICOSTEROIDS ANDROGENS-ANABOLIC ESTROGENS CONTRACEPTIVES PROGESTINS ANTIDIABETIC AGENTS INSULIN AMYLIN ANALOGS INCRETIN MIMETIC AGENTS

6 SULFONYLUREAS BIGUANIDES MEGLITINIDE ANALOGUES DIABETIC OTHER ALPHA-GLUCOSIDASE INHIBIT DPP-4 INHIBITORS INSULIN SENSITIZING AGENT ANTIDIABETIC COMBINATIONS BISPHOSPHONATES CALCITONINS PARATHYROID HORMONE RANK LIGAND INHIBITORS HORMONE RECEPTOR MDLTR FERTILITY REGULATORS LHRH/GNRH AGONIST GNRH/LHRH ANTAGONISTS GROWTH HORMONES GHRH SOMATOMEDINS SOMATOSTATIC AGENTS GH RECEPTOR ANTAGONISTS POSTERIOR PITUITARY CORTICOTROPIN PROLACTIN INHIBITORS VASOPRESSIN ANTAGONISTS PROGESTERONE ANTAGONISTS METABOLIC MODIFIERS THYROID AGENTS GASTROINTESTINAL LAXATIVES ANTIDIARRHEALS ANTACIDS ULCER DRUGS ANTIEMETICS DIGESTIVE AIDS GASTROINTESTINAL - MISC GENITOURINARY URINARY ANTI-INFECTIVES

7 URINARY ANTISPASMODICS VAGINAL PRODUCTS GENITOURINARY - MISC HEMATOLOGICAL HEMATOPOIETIC AGENTS ANTICOAGULANTS HEMOSTATICS HEMATOLOGICAL - MISC MOUTH/THROAT/DENTAL AGENT NEUROLOGY, CNS, PSYCH ANTIANXIETY AGENTS ANTIDEPRESSANTS ANTIPSYCHOTICS HYPNOTICS ADHD, NARCOLEPSY, ETC ANTICONVULSANTS ANTIPARKINSON AGENTS NEUROLOGY, PSYCH - MISC NEUROMUSCULAR AGENTS MUSCULOSKELETAL AGENTS ANTIMYASTHENIC AGENTS OPHTHALMOLOGY AND OTIC ANTI-INFECTIVES ARTIFICIAL TEAR/LUBRICANT BETA-BLOCKERS OPHTHALMIC STEROIDS PROSTAGLANDINS CYCLOPLEGIC MYDRIATICS DECONGESTANTS MIOTICS ADRENERGIC AGENTS IMMUNOMODULATORS LOCAL ANESTHETICS OPHTHALMICS - MISC OTIC AGENTS OXYTOCICS PAIN MANAGEMENT ANALGESICS - NONNARCOTIC

8 ANALGESICS - OPIOID ANTI-INFLAMMATORY MIGRAINE PRODUCTS GOUT AGENTS LOCAL ANESTHETICS-INJ GENERAL ANESTHETICS RESPIRATORY, ALLERGY, ETC ANTIHISTAMINES NASAL AGENTS COUGH/COLD/ALLERGY ANTIASTHMATIC/COPD AGENTS RESPIRATORY AGENTS - MISC TOXOIDS VACCINES VITAMINS VITAMINS MULTIVITAMINS MEDICAL DEVICES DIABETIC SUPPLIES MISCELLANEOUS

9 PENICILLINS TIER 01 TIER 03 MEDICAL November 2017 ANTI-INFECTIVES GENERIC amoxicillin amoxicillin/clavulanate potassium amoxicillin/clavulanate potassium ER ampicillin dicloxacillin sodium penicillin v potassium Amoxicillin Amoxicillin/Clavulanate Potassium Ampicillin Penicillin V Potassium NON PREFERRED Amoxicillin ER Augmentin Augmentin ES-600 Augmentin XR Moxatag GENERAL MEDICAL ampicillin sodium ampicillin-sulbactam nafcillin sodium oxacillin sodium penicillin G potassium piperacillin sodium/ tazobactam sodium piperacillin sodium/tazobactam sodium piperacillin/tazobactam Ampicillin Sodium Bactocill IN Dextrose Bicillin C-R Bicillin L-a Nafcillin Nafcillin Sodium Penicillin G Potassium IN Iso-osmotic Dextrose Penicillin G Procaine Penicillin G Sodium Pfizerpen-G Piperacillin/Tazobactam Unasyn Unasyn Bulk Pack Zosyn GENERIC cefaclor cefprozil cefuroxime axetil Cefaclor ER TIER 03 NON PREFERRED Cefaclor Ceftin MEDICAL GENERAL MEDICAL cefotetan cefoxitin sodium cefuroxime sodium Cefotan Cefotetan Cefotetan/Dextrose Cefoxitin Sodium Cefuroxime Sodium Zinacef THIRD GENERATION cefdinir cefixime cefpodoxime proxetil Ceftibuten TIER 03 NON PREFERRED Cedax Cefditoren Pivoxil Spectracef Suprax MEDICAL GENERAL MEDICAL ceftazidime ceftriaxone sodium tazicef Cefotaxime Sodium Ceftazidime/Dextrose Ceftriaxone IN Iso-osmotic Dextrose Ceftriaxone Sodium Ceftriaxone/Dextrose Claforan Claforan/D5W Fortaz Tazicef FOURTH GENERATION MEDICAL GENERAL MEDICAL cefepime Cefepime Cefepime/Dextrose Maxipime CEPHALOSPORIN FIRST GENERATION cefadroxil cephalexin Cephalexin TIER 03 NON PREFERRED Keflex MEDICAL GENERAL MEDICAL cefazolin sodium Cefazolin Cefazolin Sodium Cefazolin Sodium/Dextrose Cefazolin Sodium/Sodium Chloride Cefazolin/Dextrose Cefazolin/D5W Cefazolin/Sodium Chloride SECOND GENERATION TIER 01 MACROLIDES azithromycin clarithromycin clarithromycin ER erythromycin erythromycin ethylsuccinate Azithromycin Clarithromycin E.e.s. 400 Erythromycin Base Erythromycin Ethylsuccinate TIER 02 PREFERRED BRAND E.e.s. Granules Eryped 200 Eryped 400 TIER 03 NON PREFERRED Biaxin Dificid ST Ery-TAB Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 1

10 Erythrocin Stearate Moxifloxacin HCL PCE Zithromax Tri-PAK AMINOGLYCOSIDES Zithromax Z-PAK MEDICAL Zmax amikacin sulfate GENERAL MEDICAL neomycin sulfate Erythrocin Lactobionate paromomycin sulfate Zithromax TIER 04 PREFERRED SPECIALTY tobramycin PA TETRACYCLINES tobramycin inhalation solution PAK PA TIER 05 NON PREFERRED SPECIALTY avidoxy Bethkis PA demeclocycline hydrochloride Tobi Podhaler PA demeclocycline HCL TIER 06 NON FORMULARY SPECIALTY doxycycline Kitabis PAK PA doxycycline hyclate Tobi PA doxycycline hyclate DR Tobramycin PA doxycycline monohydrate MEDICAL GENERAL MEDICAL minocycline hydrochloride gentamicin sulfate minocycline HCL gentamicin sulfate pediatric mondoxyne nl gentamicin sulfate/0.9% sodium chloride morgidox 1X100MG tobramycin sulfate morgidox 1X50MG Gentamicin Sulfate/0.9% Sodium Chloride morgidox 2X100MG Isotonic Gentamicin okebo Streptomycin Sulfate tetracycline hydrochloride Tobramycin Sulfate tetracycline HCL TIER 03 Tetracycline HCL SULFONAMIDES NON PREFERRED Adoxa Sulfadiazine Adoxa PAK 1/100 Adoxa PAK 1/150 ANTIMYCOBACTERIAL AGENTS Adoxa PAK 2/100 Minocin ethambutol HCL Monodox isoniazid Nutridox pyrazinamide Targadox rifabutin MEDICAL Vibramycin TIER 02 PREFERRED BRAND Ximino Mycobutin GENERAL MEDICAL TIER 03 NON PREFERRED doxy 100 Cycloserine Myambutol QUINOLONES Paser Priftin ciprofloxacin Rifadin ciprofloxacin ER Rifamate ciprofloxacin HCL Rifater levofloxacin Trecator moxifloxacin HCL TIER 05 NON PREFERRED SPECIALTY ofloxacin Sirturo PA Ciprofloxacin HCL MEDICAL GENERAL MEDICAL Levofloxacin rifampin TIER 03 Ofloxacin Capastat Sulfate NON PREFERRED Isoniazid Avelox Avelox Abc Pack ANTIFUNGALS Cipro Cipro XR bio-statin Factive fluconazole Levaquin flucytosine TIER 04 PREFERRED SPECIALTY griseofulvin microsize Baxdela PA griseofulvin ultramicrosize MEDICAL GENERAL MEDICAL itraconazole ciprofloxacin I.V.-IN D5W ketoconazole levofloxacin IN D5W nystatin levofloxacin IN 5% dextrose terbinafine HCL moxifloxacin hydrochloride/sodium hydrochloride TIER 02 PREFERRED BRAND Cipro I.V.-IN D5W Grifulvin V Ciprofloxacin Gris-peg Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 2

11 TIER 03 NON PREFERRED NON PREFERRED Ancobon Baraclude PA Bio-statin Combivir Diflucan Edurant Lamisil Epivir Onmel PA Epivir HBV Sporanox Epzicom Sporanox Pulsepak Famvir TIER 04 PREFERRED SPECIALTY Flumadine voriconazole PA Hepsera PA SPECIALTY MEDICAL Intelence Vfend IV PA Lexiva TIER 05 NON PREFERRED SPECIALTY Prezista Cresemba PA Relenza Diskhaler QL Noxafil PA Retrovir Vfend PA Sitavig MEDICAL GENERAL MEDICAL Tamiflu QL caspofungin acetate Trizivir fluconazole IN dextrose Tybost ST fluconazole IN NACL Tyzeka PA Abelcet Valcyte Ambisome Valtrex Amphotec Videx EC Amphotericin B Viracept Cancidas Viramune Caspofungin Acetate Viramune XR Eraxis Zerit Fluconazole IN NACL Ziagen Mycamine Zovirax TIER 04 PREFERRED SPECIALTY ANTIVIRALS moderiba ribasphere abacavir ribavirin abacavir sulfate/lamivudine/zidovudine Copegus abacavir/lamivudine Epclusa PA acyclovir Harvoni PA adefovir dipivoxil PA Mavyret PA didanosine Peg-intron PA entecavir PA Peg-intron Redipen PA famciclovir Peg-intron Redipen PAK 4 PA fosamprenavir calcium Pegasys PA lamivudine Pegasys Proclick PA lamivudine/zidovudine Pegintron PA lopinavir/ritonavir Rebetol nevirapine Vemlidy PA nevirapine ER TIER 05 NON PREFERRED SPECIALTY oseltamivir phosphate QL Atripla rimantadine HCL Complera stavudine Descovy valacyclovir HCL Evotaz valganciclovir Fuzeon valganciclovir hydrochlorde Genvoya zidovudine Moderiba Nevirapine Moderiba 1200 Dose Pack TIER 02 PREFERRED BRAND Moderiba 800 Dose Pack Aptivus Odefsey Crixivan Prezcobix Emtriva Ribasphere Invirase Ribasphere Ribapak Isentress Ribatab Isentress HD Selzentry PA Kaletra Stribild Norvir Technivie PA Rescriptor Tivicay Reyataz Triumeq Sustiva Truvada Videx Pediatric Viekira PAK PA Viread Viekira XR PA TIER 03 Vitekta Zepatier PA Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 3

12 SPECIALTY MEDICAL Flagyl Virazole PA Impavido TIER 06 NON FORMULARY SPECIALTY Invanz Daklinza PA Ketek Olysio PA Nebupent Sovaldi PA Primsol Victrelis QL,PA Trimpex Vosevi PA Vancocin HCL MEDICAL GENERAL MEDICAL TIER 04 PREFERRED SPECIALTY acyclovir sodium linezolid QL cidofovir Xifaxan PA ganciclovir SPECIALTY MEDICAL Acyclovir Sodium Linezolid Cytovene Orbactiv Foscavir Zyvox Ganciclovir TIER 05 NON PREFERRED SPECIALTY Rapivab Cayston PA Retrovir IV Infusion SPECIALTY MEDICAL Dalvance ANTIMALARIALS Sivextro MEDICAL GENERAL MEDICAL atovaquone/proguanil HCL aztreonam chloroquine phosphate baciim hydroxychloroquine sulfate bacitracin mefloquine HCL clindamycin quinine sulfate clindamycin phosphate Chloroquine Phosphate clindamycin phosphate add-vantage Primaquine Phosphate clindamycin phosphate pharmacy bulk package TIER 02 PREFERRED BRAND clindamycin phosphate IN D5W Coartem colistimethate sodium TIER 03 NON PREFERRED daptomycin Daraprim imipenem/cilastatin Malarone lincomycin HCL Plaquenil meropenem Qualaquin metronidazole metronidazole IN NACL 0.79% ANTHELMINTICS polymyxin b sulfate vancomycin HCL ivermectin Avycaz TIER 03 NON PREFERRED Azactam Albenza Azactam IN Iso-osmotic Dextrose Benznidazole Chloramphenicol Sodium Succinate Biltricide Cleocin IN D5W Emverm Cleocin Phosphate Mebendazole Clindamycin Phosphate Stromectol Coly-mycin M Cubicin MISC. ANTI-INFECTIVES Cubicin RF Doribax atovaquone Doripenem clindamycin palmitate HCL Lincocin clindamycin HCL Meropenem/Sodium Chloride dapsone Merrem sulfamethoxazole/trimethoprim Metro IV sulfamethoxazole/trimethoprim DS Pentam 300 sulfatrim pediatric Primaxin IV tinidazole Primaxin IV Add-vantage trimethoprim Synercid Tigecycline TIER 02 PREFERRED BRAND Mepron Tygacil Tindamax Vabomere Vancomycin TIER 03 NON PREFERRED Alinia Vancomycin Hydrochloride/Dextrose Bactrim Vancomycin Hydrochloride/Sodium Chloride Bactrim DS Vancomycin HCL Cleocin Vancomycin HCL IN Dextrose Cleocin Pediatric Granules Vancomycin HCL/Sodium Chloride First-vancomycin 25 Vibativ First-vancomycin 50 Zerbaxa Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 4

13 ANTINEOPLASTICS, ETC ALKYLATING AGENTS TIER 01 TIER 02 TIER 03 TIER 04 TIER 05 TIER 06 MEDICAL GENERIC melphalan PA PREFERRED BRAND Alkeran PA Hexalen PA Leukeran PA Myleran NON PREFERRED Cyclophosphamide PA PREFERRED SPECIALTY temozolomide PA NON PREFERRED SPECIALTY Gleostine PA Lomustine PA Temodar PA SPECIALTY MEDICAL busulfan PA cyclophosphamide PA ifosfamide PA melphalan hydrochloride PA thiotepa PA Bendeka PA Bicnu PA Busulfex PA Ifex PA Ifosfamide PA Mustargen PA Tepadina PA Treanda PA Yondelis PA Zanosar PA NON FORMULARY SPECIALTY Valchlor PA GENERAL MEDICAL carboplatin PA cisplatin PA oxaliplatin PA Cisplatin PA Evomela Gliadel Wafer ANTIBIOTICS TIER 05 SPECIALTY MEDICAL bleomycin sulfate PA MEDICAL daunorubicin HCL PA doxorubicin HCL liposome PA epirubicin HCL PA idarubicin HCL PA lipodox PA lipodox 50 PA mitoxantrone HCL Bleo 15k PA Cosmegen PA Daunoxome PA Doxil PA Ellence PA Idamycin PFS PA Valstar PA GENERAL MEDICAL adriamycin PA doxorubicin HCL PA mitomycin PA Doxorubicin HCL PA Mitomycin PA ANTINEOPLASTIC ENZYMES TIER 05 SPECIALTY MEDICAL Erwinaze PA Oncaspar PA ANTIMETABOLITES mercaptopurine methotrexate methotrexate sodium Methotrexate Sodium TIER 02 PREFERRED BRAND Tabloid Trexall TIER 03 NON PREFERRED capecitabine PA Purixan TIER 05 SPECIALTY MEDICAL azacitidine PA cladribine PA clofarabine PA cytarabine PA cytarabine aqueous PA decitabine PA fludarabine phosphate PA Alimta PA Arranon PA Clolar PA Cytarabine Aqueous PA Dacogen PA Depocyt PA Floxuridine PA Folotyn PA Vidaza PA TIER 06 NON FORMULARY SPECIALTY Xeloda PA MEDICAL GENERAL MEDICAL adrucil PA fluorouracil PA gemcitabine PA gemcitabine HCL PA Gemzar PA ANGIOGENESIS INHIBITORS TIER 05 SPECIALTY MEDICAL Avastin PA Cyramza PA Zaltrap PA ANTIBODIES TIER 05 SPECIALTY MEDICAL Adcetris PA Arzerra PA Besponsa PA Blincyto PA Campath PA Darzalex PA Empliciti PA Erbitux PA Gazyva PA Herceptin PA Kadcyla PA Keytruda PA Lartruvo PA Mylotarg PA Opdivo PA Perjeta PA Portrazza PA Rituxan PA Tecentriq PA Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 5

14 Unituxin PA Imuran Vectibix PA Myfortic Yervoy PA TIER 05 NON PREFERRED SPECIALTY Zevalin Y-90 Pomalyst PA MEDICAL GENERAL MEDICAL Revlimid PA Bavencio Thalomid PA HORMONAL AGENTS anastrozole bicalutamide exemestane flutamide PA MEDICAL Zortress SPECIALTY MEDICAL Atgam PA GENERAL MEDICAL cyclosporine Azathioprine Cellcept Intravenous Nulojix Sandimmune Simulect Thymoglobulin letrozole megestrol acetate nilutamide tamoxifen citrate TIER 02 PREFERRED BRAND Emcyt PA MITOTIC INHIBITORS Fareston PA TIER 03 NON PREFERRED Lysodren PA Etoposide PA Nilandron TIER 05 SPECIALTY MEDICAL TIER 03 NON PREFERRED docetaxel PA Arimidex paclitaxel PA Aromasin vinorelbine tartrate PA Casodex Abraxane PA Femara Docetaxel PA Megace Oral Docetaxel (non-alcohol Formula) PA Soltamox Etopophos PA TIER 04 PREFERRED SPECIALTY Halaven PA Hydroxyprogesterone Caproate PA Ixempra Kit PA TIER 05 NON PREFERRED SPECIALTY Jevtana PA leuprolide acetate PA Marqibo PA Xtandi PA Navelbine PA Zytiga PA Paclitaxel PA SPECIALTY MEDICAL Taxotere PA Eligard PA Teniposide PA Faslodex PA Vinblastine Sulfate PA Firmagon PA MEDICAL GENERAL MEDICAL Lupron Depot (1-month) PA etoposide PA Lupron Depot (3-month) PA toposar PA Lupron Depot (4-month) PA vincasar PFS PA Lupron Depot (6-month) PA vincristine sulfate PA Trelstar PA Docefrez Trelstar Mixject PA Vantas PA ENZYME INHIBITORS Zoladex PA TIER 03 NON PREFERRED MEDICAL GENERAL MEDICAL Calquence Depo-provera Verzenio TIER 04 PREFERRED SPECIALTY IMMUNOMODULATORS imatinib mesylate QL,PA Tasigna PA azathioprine TIER 05 NON PREFERRED SPECIALTY cyclosporine modified Afinitor PA gengraf Afinitor Disperz PA mycophenolate mofetil Alecensa PA mycophenolic acid DR Alunbrig PA sirolimus Bosulif QL,PA tacrolimus Cabometyx PA Cyclosporine Modified Caprelsa PA TIER 02 PREFERRED BRAND Cometriq PA Neoral Cotellic PA Prograf Gilotrif PA Rapamune Ibrance PA TIER 03 NON PREFERRED Iclusig QL,PA Astagraf XL Idhifa PA Azasan Imbruvica PA Cellcept Inlyta PA Envarsus XR Iressa PA Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 6

15 Jakafi PA tretinoin PA Kisqali PA TIER 03 NON PREFERRED Lenvima 10 MG Daily Dose PA Hydrea Lenvima 14 MG Daily Dose PA TIER 05 NON PREFERRED SPECIALTY Lenvima 18 MG Daily Dose PA bexarotene PA Lenvima 20 MG Daily Dose PA Actimmune PA Lenvima 24 MG Daily Dose PA Matulane PA Lenvima 8 MG Daily Dose PA Synribo PA Lynparza PA Targretin PA Mekinist PA SPECIALTY MEDICAL Nerlynx PA dacarbazine PA Nexavar PA Alferon N PA Ninlaro PA Dacarbazine PA Rubraca PA Intron A PA Rydapt PA Intron A W/Diluent PA Sprycel PA Nipent PA Stivarga PA Photofrin PA Sutent PA Proleukin PA Tafinlar PA Sylatron PA Tagrisso PA Trisenox PA Tarceva PA MEDICAL GENERAL MEDICAL Tykerb PA Theracys PA Votrient PA Tice Bcg PA Xalkori PA Uvadex Zejula PA Zelboraf PA CHEMOTHERAPY RESCUE Zolinza PA Zykadia PA leucovorin calcium SPECIALTY MEDICAL Leucovorin Calcium Aliqopa PA TIER 05 SPECIALTY MEDICAL Beleodaq PA levoleucovorin PA Istodax PA levoleucovorin calcium PA Istodax (overfill) PA mesna Kyprolis PA Fusilev PA Torisel PA Levoleucovorin PA Velcade PA Mesnex TIER 06 NON FORMULARY SPECIALTY MEDICAL GENERAL MEDICAL Farydak PA dexrazoxane Gleevec QL,PA Totect Zydelig PA Voraxaze Zinecard TOPOISOMERASE I INHIBITOR TIER 05 SPECIALTY MEDICAL CHEMOTHERAPY ADJUNCTS Onivyde PA TIER 05 SPECIALTY MEDICAL MEDICAL GENERAL MEDICAL Elitek irinotecan PA Kepivance PA irinotecan hydrochloride PA irinotecan HCL PA ANTINEOPLASTIC COMBO topotecan HCL PA TIER 05 NON PREFERRED SPECIALTY Camptosar PA Lonsurf PA Hycamtin PA SPECIALTY MEDICAL Irinotecan PA Rituxan Hycela PA Topotecan HCL PA Vyxeos PA RADIOPHARMACEUTICALS CARDIOVASCULAR DRUGS TIER 05 SPECIALTY MEDICAL PHOSPHODIESTERASE INHBTR Quadramet MEDICAL GENERAL MEDICAL Xofigo PA milrinone lactate MEDICAL GENERAL MEDICAL milrinone IN dextrose Metastron CARDIAC GLYCOSIDES CELLULAR IMMUNOTHERAPY TIER 06 SPECIALTY MEDICAL digitek Kymriah digox Provenge PA digoxin Digoxin ANTINEOPLASTICS MISC. TIER 03 NON PREFERRED Lanoxin hydroxyurea MEDICAL Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 7

16 GENERAL MEDICAL Toprol XL Lanoxin Pediatric Zebeta MEDICAL GENERAL MEDICAL ANTIANGINAL AGENTS esmolol HCL labetalol HCL isosorbide dinitrate Brevibloc isosorbide mononitrate isosorbide mononitrate ER Sotalol Hydrochloride minitran CALCIUM CHANNEL BLOCKERS nitro-time nitroglycerin afeditab CR nitroglycerin lingual amlodipine besylate nitroglycerin transdermal cartia XT nitroglycerin ER dilt-xr Isosorbide Dinitrate ER diltiazem CD Nitroglycerin Lingual diltiazem HCL TIER 02 PREFERRED BRAND diltiazem HCL CD Dilatrate SR diltiazem HCL ER Nitro-bid felodipine ER Nitro-dur isradipine Nitromist matzim LA Nitrostat nifedical XL TIER 03 NON PREFERRED nifedipine Isordil Titradose nifedipine ER Nitrolingual Pumpspray nimodipine Ranexa nisoldipine ER MEDICAL GENERAL MEDICAL taztia XT nitroglycerin IN dextrose 5% verapamil HCL nitroglycerin IN 5% dextrose verapamil HCL ER Nitroglycerin verapamil HCL SR Nitroglycerin IN Dextrose 5% Nisoldipine ER TIER 03 NON PREFERRED BETA BLOCKERS Adalat CC Calan acebutolol hydrochloride Calan SR acebutolol HCL Cardizem atenolol Cardizem CD betaxolol HCL Cardizem LA bisoprolol fumarate Norvasc carvedilol Nymalize metoprolol succinate ER Procardia metoprolol tartrate Procardia XL nadolol Sular pindolol Tiazac propranolol hydrochloride Verelan propranolol HCL Verelan PM propranolol HCL ER MEDICAL GENERAL MEDICAL sorine nicardipine HCL sotalol hydrochloride (AF) Cardene IV sotalol HCL Cleviprex sotalol HCL (AF) Diltiazem Hydrochloride/Dextrose Metoprolol Tartrate Diltiazem Hydrochloride/Sodium Chloride Propranolol HCL Diltiazem HCL Timolol Maleate Nicardipine Hydrochloride/Sodium Chloride TIER 02 PREFERRED BRAND Bystolic ANTIARRHYTHMICS TIER 03 NON PREFERRED Betapace amiodarone HCL Betapace AF disopyramide phosphate Coreg dofetilide Coreg CR flecainide acetate Corgard mexiletine HCL Inderal LA pacerone Inderal XL propafenone hydrochloride ER Innopran XL propafenone hydrochlorideer Lopressor propafenone HCL Sectral propafenone HCL ER Sotylize quinidine gluconate CR Tenormin quinidine gluconate ER Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 8

17 Quinidine Sulfate Cozaar Quinidine Sulfate ER Diovan TIER 02 PREFERRED BRAND Edarbi Multaq Micardis Norpace CR TIER 03 NON PREFERRED DIRECT RENIN INHIBITORS Cordarone TIER 02 PREFERRED BRAND Norpace Tekturna Rythmol Rythmol SR ANTIHYPERTENSIVES MISC. Tikosyn MEDICAL GENERAL MEDICAL clonidine HCL adenosine doxazosin ibutilide fumarate doxazosin mesylate lidocaine HCL eplerenone lidocaine HCL IN D5W guanfacine HCL lidocaine HCL/dextrose hydralazine HCL procainamide hydrochloride methyldopa procainamide HCL minoxidil Adenocard phenoxybenzamine hydrochloride QL,PA Adenosine prazosin HCL Amiodarone Hydrochloride/Dextrose terazosin HCL Amiodarone HCL Reserpine Corvert TIER 03 NON PREFERRED Lidocaine HCL Cardura Nexterone Catapres Quinidine Gluconate Catapres-tts-1 Xylocaine Catapres-tts-2 Catapres-tts-3 ACE INHIBITORS Demser Dibenzyline QL,PA benazepril HCL Inspra captopril Minipress enalapril maleate Tenex fosinopril sodium Vecamyl lisinopril MEDICAL GENERAL MEDICAL moexipril HCL sodium nitroprusside perindopril erbumine Corlopam quinapril HCL Methyldopate HCL ramipril Nipride RTU TIER 03 trandolapril Nitropress NON PREFERRED Phentolamine Mesylate Accupril Aceon ANTIHYPERTENSIVE COMBO Altace Epaned amlodipine besylate/benazepril hydrochloride Lotensin amlodipine besylate/benazepril HCL Mavik amlodipine besylate/valsartan Prinivil amlodipine/olmesartan medoxomil Qbrelis amlodipine/valsartan/hctz Vasotec atenolol/chlorthalidone MEDICAL Zestril benazepril HCL/hydrochlorothiazide GENERAL MEDICAL bisoprolol fumarate/hydrochlorothiazide enalaprilat candesartan cilexetil/hydrochlorothiazide enalapril maleate/hydrochlorothiazide ANGIOTENSIN RCPTR BLOCKER fosinopril sodium/hydrochlorothiazide irbesartan/hydrochlorothiazide candesartan cilexetil lisinopril/hydrochlorothiazide irbesartan losartan potassium/hydrochlorothiazide losartan potassium metoprolol/hydrochlorothiazide olmesartan medoxomil moexipril/hydrochlorothiazide telmisartan nadolol/bendroflumethiazide valsartan olmesartan medoxomil/amlodipine/hydrochlorothiazide TIER 02 Eprosartan Mesylate olmesartan medoxomil/hydrochlorothiazide PREFERRED BRAND quinapril/hydrochlorothiazide TIER 03 Benicar telmisartan/amlodipine NON PREFERRED telmisartan/hydrochlorothiazide Atacand trandolapril/verapamil HCL ER Avapro valsartan/hydrochlorothiazide Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 9

18 Captopril/Hydrochlorothiazide Edecrin Methyldopa/Hydrochlorothiazide Lasix Metoprolol/Hydrochlorothiazide Maxzide Propranolol/Hydrochlorothiazide Maxzide-25 TIER 02 PREFERRED BRAND Microzide Azor Neptazane Benicar HCT TIER 06 NON FORMULARY SPECIALTY Tekturna HCT Keveyis PA Tribenzor MEDICAL GENERAL MEDICAL TIER 03 NON PREFERRED acetazolamide sodium Accuretic chlorothiazide sodium Atacand HCT ethacrynate sodium Avalide mannitol Byvalson osmitrol viaflex Clorpres Osmitrol Viaflex Corzide Sodium Diuril Diovan HCT Sodium Edecrin Dutoprol Edarbyclor VASOPRESSORS Exforge Exforge HCT midodrine HCL Hyzaar Epinephrine QL Lopressor HCT TIER 02 PREFERRED BRAND Lotensin HCT Adrenaclick QL Lotrel TIER 03 NON PREFERRED Metoprolol Succinate ER/Hydrochlorothiazide Epipen 2-PAK QL Micardis HCT Epipen-JR 2-PAK QL Prestalia TIER 05 NON PREFERRED SPECIALTY Tarka Northera PA Tenoretic 100 MEDICAL GENERAL MEDICAL Tenoretic 50 dobutamine hydrochloride/dextrose Twynsta dobutamine HCL Vaseretic dobutamine HCL/D5W Zestoretic dobutamine/dextrose 5% Ziac dopamine hydrochloride/dextrose dopamine HCL DIURETICS dopamine/d5w ephedrine sulfate acetazolamide epinephrine HCL acetazolamide ER norepinephrine bitartrate amiloride HCL phenylephrine HCL amiloride/hydrochlorothiazide Adrenalin QL bumetanide Akovaz chlorothiazide Dopamine HCL chlorthalidone Ephedrine Sulfate/Sodium Chloride ethacrynic acid Epinephrine Hydrochloride/Sodium Chloride furosemide Epinephrine HCL hydrochlorothiazide Levophed indapamide Norepinephrine Bitartrate/Sodium Chloride methazolamide Norepinephrine/Dextrose metolazone Phenylephrine Hydrochloride/Dextrose spironolactone Phenylephrine Hydrochloride/Sodium Chloride spironolactone/hydrochlorothiazide Phenylephrine HCL torsemide Phenylephrine/Sodium Chloride triamterene/hydrochlorothiazide Vazculep Chlorothiazide Furosemide ANTIHYPERLIPIDEMICS Methyclothiazide TIER 03 Triamterene/Hydrochlorothiazide atorvastatin calcium NON PREFERRED cholestyramine Aldactazide cholestyramine light Aldactone colestipol HCL Bumex ezetimibe Carospir ezetimibe/simvastatin Demadex fenofibrate Diamox fenofibrate micronized Diuril fenofibric acid DR Dyazide fluvastatin Dyrenium fluvastatin sodium ER PA Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 10

19 gemfibrozil Letairis PA lovastatin Opsumit PA niacin ER Orenitram PA omega-3-acid ethyl esters PA Revatio PA pravastatin sodium Tracleer PA prevalite Tyvaso PA rosuvastatin calcium Tyvaso Refill PA simvastatin Tyvaso Starter PA triklo PA Uptravi PA Fenofibrate Ventavis PA Fenofibric Acid SPECIALTY MEDICAL TIER 02 PREFERRED BRAND Flolan PA Welchol Remodulin PA TIER 03 NON PREFERRED Veletri PA Advicor MEDICAL GENERAL MEDICAL Altoprev PA cardioplegic Antara Natrecor Colestid Plegisol Colestid Flavored Crestor DERMATOLOGICALS Equapax/Atorvastatin Calcium/Coq10 ACNE PRODUCTS Fibricor Lescol XL PA adapalene Lipitor adapalene P.M. Lipofen amnesteem QL Livalo PA avar cleanser Lofibra avar-e emollient Lopid avar-e green Lovaza PA avita Mevacor ST bp 10-1 Niacor cerisa wash Niaspan claravis QL Pravachol ST clindacin etz pledgets Questran clindacin-p Questran Light clindamycin phosphate Simcor dapsone PA Tricor ery Triglide erythromycin Trilipix myorisan QL Vascepa PA rosanil cleanser Vytorin sodium sulfacetamide Zetia sodium sulfacetamide/sulfur Zocor ST sodium sulfacetamide/sulfur cleanser TIER 05 NON PREFERRED SPECIALTY sodium sulfacetamide/sulfur green Praluent PA sodium sulfacetamide/sulfur wash Repatha PA sss 10%-5% Repatha Pushtronex System PA sulfacetamide sodium Repatha Sureclick PA sulfacetamide sodium/sulfur TIER 06 NON FORMULARY SPECIALTY sulfacetamide sodium/sulfur cleanser Juxtapid PA sulfacleanse 8/4 Kynamro PA tretinoin tretinoin microsphere CARDIOVASCULAR - MISC. tretinoin microsphere P.M. zenatane QL TIER 03 amlodipine besylate/atorvastatin calcium zencia NON PREFERRED Sodium Sulfacetamide/Sulfur IN Urea Bidil TIER 03 NON PREFERRED Caduet Absorica QL,PA Cialis QL,ST Aczone PA Corlanor ST Azelex PA Entresto PA Bp Cleansing Wash TIER 04 PREFERRED SPECIALTY Clindacin Etz sildenafil PA Clindacin PAC sildenafil citrate PA Clinoin SPECIALTY MEDICAL Inova epoprostenol sodium PA Inova 4/1 Acne Control Therapy TIER 05 NON PREFERRED SPECIALTY Inova 8/2 Acne Control Therapy Adcirca PA Sodium Sulfacetamide/Sulfur Cleanser IN Urea Adempas PA Sumadan Kit Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 11

20 Sumaxin CP Kit Vanoxide-HC Zacare 4% Kit Zacare 8% Kit Vusion Xolegel Xolegel Corepak Xolegel Duo/Head & Shoulders Xolegel Duo/Xolex ROSACEA AGENTS ANTIVIRALS - TOPICAL metronidazole rosadan acyclovir QL TIER 03 NON PREFERRED TIER 02 PREFERRED BRAND Finacea PA Zovirax QL Mirvaso PA TIER 03 NON PREFERRED Rhofade PA Denavir ST Rosadan Kit Soolantra PA ANTI-INFLAMMATORY AGENTS ANTIBIOTICS - TOPICAL diclofenac sodium TIER 03 NON PREFERRED gentamicin sulfate Active-ketoprofen Kit mupirocin Diclofenac Sodium Gentamicin Sulfate Enovarx-ibuprofen TIER 02 PREFERRED BRAND Fbl Kit Altabax Flector ST Centany AT Lidoprofen TIER 03 NON PREFERRED Triple Complex Formula 3 Kit Cortisporin Neo-synalar ANTIFUNGALS - TOPICAL ciclodan QL Voltaren Vopac Kt Vopac Mds Vp Gkl Kit ANTIPRURITICS ciclopirox ciclopirox nail lacquer QL Doxepin Hydrochloride ciclopirox olamine TIER 03 NON PREFERRED ciclopirox treatment Prudoxin clotrimazole Zonalon clotrimazole/betamethasone dipropionate econazole nitrate ANTIPSORIATICS ketoconazole ketodan acitretin naftifine hydrochloride ST calcipotriene naftifine HCL ST calcitrene nyata methoxsalen nystatin tazarotene nystatin/triamcinolone Calcitriol ST nystop TIER 02 PREFERRED BRAND oxiconazole nitrate ST Dritho-creme HP TIER 03 NON PREFERRED Oxsoralen Ultra Ciclodan Cream Kit PA Soriatane Ciclodan Solution Kit 8-mop Cnl8 Nail Kit PA TIER 03 NON PREFERRED Ertaczo ST Tazorac PA Exelderm Vectical ST Exoderm Zithranol Extina Zithranol-rr Halotin TIER 05 NON PREFERRED SPECIALTY Jublia PA Cosentyx PA Kerydin PA Cosentyx Sensoready Pen PA Loprox Siliq PA Loprox Shampoo Stelara PA Lotrisone Taltz PA Luzu ST Tremfya PA Mentax ST Naftin ST ANTISEBORRHEIC AGENTS Nizoral Oxistat ST seb-prev wash Pediaderm AF Complete Kit selenium sulfide Penlac Nail Lacquer QL sodium sulfacetamide Recura sodium sulfacetamide wash Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 12