ASEBP and ARTA TARP Drugs and Reference Price by Categories

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1 ASEBP Pantoprazole Sodium 40 mg (generic) $ ASEBP Dexlansoprazole 30 mg Dexlansoprazole 60 mg Esomeprazole 10 mg Esomeprazole 20 mg Esomeprazole 40 mg Lansoprazole 15 mg Lansoprazole 30 mg Omeprazole 10 mg Omeprazole 20 mg Pantoprazole Sodium 20 mg Pantoprazole Sodium/ Magnesium 40 mg Rabeprazole Sodium 10 mg Rabeprazole Sodium 20 mg ARTA Effective February 1, 2017 Lower Strengths Rabeprazole Sodium 10 mg (generic) $ ARTA Lower Strengths Dexlansoprazole 30 mg Esomeprazole 10 mg Esomeprazole 20 mg Lansoprazole 15 mg Omeprazole 10 mg Pantoprazole Sodium 20 mg Rabeprazole Sodium 10 mg ARTA Effective February 1, 2017 High Strengths Pantoprazole Magnesium 40 mg (generic) $ ARTA High Strengths Dexlansoprazole 60 mg Esomeprazole 40 mg Lansoprazole 30 mg Omeprazole 20 mg Pantoprazole Sodium 40 mg Rabeprazole Sodium 20 mg Pantoprazole Magnesium 40 mg 1

2 Anti-Hypertensives - Combination: ACEI Combination Lisinopril/HCTZ Type Z 20 mg/ 25 mg (generic) $ Anti-Hypertensives Combination: ACEI Combination Cilazapril/ HCTZ 5 mg / 12.5 mg Enalapril/ HCTZ 5 mg / 12.5 mg Enalapril/ HCTZ 10 mg/ 25 mg Lisinopril/ HCTZ Type P 10 mg / 12.5 mg Lisinopril/ HCTZ Type P 20 mg / 25 mg Perindopril Erbumine/ Indapamide Hemihydrate 2 mg / mg Perindopril Erbumine/ Indapamide Hemihydrate 4 mg / 1.25 mg Perindopril Erbumine/ Indapamide Hemihydrate 8 mg / 2.5 mg Quinapril/ HCTZ 10 mg / 12.5 mg Quinapril/ HCTZ 20 mg / 12.5 mg Quinapril/ HCTZ 20 mg / 25 mg Trandolapril/ Verapamil HCl 2 mg / 240 mg Trandolapril/ Verapamil HCl 4 mg / 240 mg Lisinopril/ HCTZ Type Z 10 mg / 12.5 mg Lisinopril/ HCTZ Type Z 20 mg / 12.5 mg Lisinopril/ HCTZ Type Z 20 mg / 25 mg Ramipril/ HCTZ 2.5 mg / 12.5 mg Ramipril/ HCTZ 5 mg / 12.5 mg Ramipril/ HCTZ 5 mg / 25 mg Ramipril/ HCTZ 10 mg / 12.5 mg Ramipril/ HCTZ 10 mg / 25 mg Anti-Hypertensives Angiotensin II Receptor Antagonists (ARB)/ Renin Inhibitor Olmesartan 40 mg (generic) $ Anti-Hypertensives ARB/ Renin Inhibitor Aliskiren Fumarate 150 mg Aliskiren Fumarate 300 mg Azilsartan Medoxomil Potassium 40 mg Azilsartan Medoxomil Potassium 80 mg Candesartan Cilexetil 4 mg Eprosartan Mesylate 400 mg Eprosartan Mesylate 600 mg Valsartan 40 mg Candesartan Cilexetil 8 mg Candesartan Cilexetil 16 mg Candesartan Cilexetil 32 mg Irbesartan 75 mg Irbesartan 150 mg Irbesartan 300 mg Losartan Potassium 25 mg Losartan Potassium 50 mg Losartan Potassium 100 mg Olmesartan Medoxomil 20 mg Olmesartan Medoxomil 40 mg Telmisartan 40 mg Telmisartan 80 mg Valsartan 80 mg Valsartan 160 mg Valsartan 320 mg 2

3 Anti-Hypertensives ARB Combination / Renin Inhibitor Combination Losartan/HCTZ $ Anti-Hypertensives ARB Combination / Renin Inhibitor Combination Aliskiren Fumarate/ HCTZ 150 mg / 12.5 mg Aliskiren Fumarate/ HCTZ 150 mg / 25 mg Aliskiren Fumarate/ HCTZ 300 mg / 12.5 mg Aliskiren Fumarate/ HCTZ 300 mg / 25 mg Azilsartan Medoxomil Potassium/ Chlorthalidone 40 mg / 12.5 mg Azilsartan Medoxomil Potassium/ Chlorthalidone 40 mg / 25 mg Azilsartan Medoxomil Potassium/ Chlorthalidone 80 mg / 12.5 mg Eprosartan Mesylate/ HCTZ 600 mg / 12.5 mg Olmesartan/ HCTZ 20 mg / 12.5 mg Olmesartan/ HCTZ 40 mg / 12.5 mg Olmesartan/ HCTZ 40 mg / 25 mg Candesartan Cilexetil/ HCTZ 16 mg / 12.5 mg Candesartan Cilexetil/ HCTZ 32 mg / 12.5 mg Candesartan Cilexetil/ HCTZ 32 mg / 25 mg Losartan Potassium/ HCTZ 50 mg / 12.5 mg Losartan Potassium/ HCTZ 100 mg / 12.5 mg Losartan Potassium/ HCTZ 100 mg / 25 mg Irbesartan/ HCTZ 150 mg / 12.5 mg Irbesartan/ HCTZ 300 mg / 12.5 mg Irbesartan/ HCTZ 300 mg / 25 mg Telmisartan/ HCTZ 80 mg / 12.5mg Telmisartan/ HCTZ 80 mg / 25 mg Valsartan/ HCTZ 80 mg / 12.5 mg Valsartan/ HCTZ 160 mg / 12.5 mg Valsartan/ HCTZ 160 mg / 25 mg Valsartan/ HCTZ 320 mg / 12.5 mg Valsartan/ HCTZ 320 mg / 25 mg Anti-Hypertensives Calcium Channel Blockers (Dihydropyridine) Amlodipine 10 mg (generic) $ Anti-Hypertensives Calcium Channel Blockers (Dihydropyridine) Felodipine 2.5 mg Felodipine 5 mg Felodipine 10 mg Nifedipine 5 mg Nifedipine 10 mg Nifedipine 20 mg Nifedipine 30 mg Nifedipine 60 mg Amlodipine Besylate 2.5 mg Amlodipine Besylate 5 mg Amlodipine Besylate 10 mg 3

4 Anti-Hypertensives Beta Blockers Partial Coverage up to Propranolol HCl 80 mg tablet (generic) $ Anti-Hypertensives Beta Blockers Acebutolol HCl 400 mg Atenolol 100 mg Atenolol/ Chlorthalidone 50 mg / 25 mg Atenolol/ Chlorthalidone 100 mg / 25 mg Labetalol HCl 100 mg Labetalol HCl 200 mg Metoprolol Tartrate SR 100 mg Metoprolol Tartrate SR 200 mg Nadolol 40 mg Nadolol 80 mg Nadolol 160 mg Nebivolol HCl 2.5 mg Nebivolol HCl 5 mg Nebivolol HCl 10 mg Nebivolol HCl 20 mg Pindolol 10 mg Pindolol 15 mg Pindolol/ HCTZ 10 mg / 25 mg Pindolol/ HCTZ 10 mg / 50 mg Propranolol HCl LA 60 mg Propranolol HCl LA 80 mg Propranolol HCl LA 120 mg Propranolol HCl LA 160 mg Timolol Maleate 5 mg Timolol Maleate 10 mg Timolol Maleate 20 mg Acebutolol HCl 100 mg Acebutolol HCl 200 mg Atenolol 25 mg Atenolol 50 mg Bisoprolol Fumarate 5 mg Bisoprolol Fumarate 10 mg Metoprolol Tartrate 25 mg Metoprolol Tartarate 50 mg Metoprolol Tartrate 100 mg Pindolol 5 mg Propranolol HCl 10 mg Propranolol HCl 20 mg Propranolol HCl 40 mg Propranolol HCl 80 mg 4

5 Anti-Hypertensives Diuretics and Combinations Chlorthalidone 50 mg (generic) $ Anti-Hypertensives Diuretics and Combinations Amiloride HCl 5 mg Bumetanide 1 mg Bumetanide 5 mg Eplerenone 25 mg Eplerenone 50 mg Metolazone 2.5 mg Spironolactone 25 mg Spironolactone 100 mg Spironolactone/ HCTZ 25 mg / 25 mg Spironolactone/ HCTZ 50 mg / 50 mg Chlorthalidone 50 mg Furosemide 20 mg Furosemide 40 mg Furosemide 80 mg HCTZ 12.5 mg HCTZ 25 mg HCTZ 50 mg HCTZ 100 mg Indapamide Hemihydrate 1.25 mg Indapamide Hemihydrate 2.5 mg Amiloride HCl/ HCTZ 5 mg / 50 mg Triamterene/ HCTZ 50 mg / 25 mg Anti-Hypertensives Calcium Channel Blockers (Non-Dihydropyridine) Diltiazem HCl 300 mg controlled-delivery capsule (generic) $ Anti-Hypertensives Calcium Channel Blockers (Non-Dihydropyridine) Diltiazem HCl 120 mg extended-release tablet Diltiazem HCl 180 mg extended-release tablet Diltiazem HCl 240 mg extended-release tablet Diltiazem HCl 300 mg extended-release tablet Diltiazem HCl 360 mg extended-release tablet Diltiazem HCl 30 mg Diltiazem HCl 60 mg Diltiazem HCl 120 mg controlled-delivery capsule Diltiazem HCl 180 mg controlled-delivery capsule Diltiazem HCl 240 mg controlled-delivery capsule Diltiazem HCl 300 mg controlled-delivery capsule Diltiazem HCl 120 mg extended-release capsule Diltiazem HCl 180 mg extended-release capsule Diltiazem HCl 240 mg extended-release capsule Diltiazem HCl 300 mg extended-release capsule Diltiazem HCl 360 mg extended-release capsule Verapamil HCl 80 mg Verapamil HCl 120 mg Verapamil HCl SR 120 mg Verapamil HCl SR 180 mg Verapamil HCl SR 240 mg 5

6 Anti-Hypertensives - Angiotensin Converting Enzyme Inhibitors (ACEI) Cilazapril 5 mg (generic) $ Anti-Hypertensives - ACEI Benazepril HCl 5 mg Benazepril HCl 10 mg Benazepril HCl 20 mg Captopril 25 mg Captopril 50 mg Captopril 100 mg Enalapril Maleate 5 mg Enalapril Maleate 10 mg Enalapril Maleate 20 mg Fosinopril Sodium 10 mg Fosinopril Sodium 20 mg Perindopril Erbumine 8 mg Quinapril 5 mg Quinapril 10 mg Quinapril 20 mg Quinapril 40 mg Ramipril 15 mg Trandolapril 4 mg Captopril 6.25 mg Captopril 12.5 mg Cilazapril 1 mg Cilazapril 2.5 mg Cilazapril 5 mg Enalapril Maleate 2.5 mg Lisinopril 5 mg Lisinopril 10 mg Lisinopril 20 mg Perindopril Erbumine 2 mg Perindopril Erbumine 4 mg Ramipril 1.25 mg Ramipril 2.5 mg Ramipril 5 mg Ramipril 10mg Trandolapril 0.5 mg Trandolapril 1 mg Trandolapril 2 mg 6

7 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Diclofenac Sodium 75 mg (generic) $ NSAIDs Diclofenac Potassium 50 mg Diclofenac Sodium 100 mg Etodolac 200 mg Etodolac 300 mg Floctafenine 200 mg Floctafenine 400 mg Flurbiprofen 100 mg Indomethacin 50 mg Ketoprofen 50 mg Ketoprofen 100 mg Ketoprofen 200 mg Ketorolac 10 mg Mefenamic Acid 250 mg Nabumetone 500 mg Nabumetone 750 mg Naproxen 750 mg Naproxen Sodium 275 mg Naproxen Sodium 550 mg Oxaprozin 600 mg Piroxicam 10 mg Piroxicam 20 mg Sulindac 150 mg Sulindac 200 mg Tenoxicam 20 mg Tiaprofenic Acid 200 mg Tiaprofenic Acid 300 mg Diclofenac Sodium 25 mg Diclofenac Sodium 50 mg Diclofenac Sodium 75 mg Flurbiprofen 50 mg Ibuprofen 600 mg Indomethacin 25 mg Naproxen 125 mg Naproxen 250 mg Naproxen 375 mg Naproxen 500 mg Anti-Inflammatories Cyclooxygenase-2 (COX-2) Inhibitors and Combo NSAIDs Diclofenac Sodium/ Misoprostol 75 mg / 200 mcg (generic) $ Anti-Inflammatory COX-2 Inhibitors And Combo NSAIDs Meloxicam 7.5 mg Meloxicam 15 mg Naproxen/ Esomeprazole 375 mg / 20 mg Naproxen/ Esomeprazole 500 mg / 20 mg Diclofenac Sodium/ Misoprostol 50 mg / 200 mcg Diclofenac Sodium/ Misoprostol 75 mg / 200 mcg Celecoxib 100 mg Celecoxib 200 mg 7

8 Triptans Rizatriptan 10 mg orally disintegrating tablet (generic) $ Triptans Almotriptan Malate 6.25 mg Eletriptan Hydrobromide 20 mg Eletriptan Hydrobromide 40 mg Frovatriptan Succinate 2.5 mg Naratriptan HCl 1 mg Naratriptan HCl 2.5 mg Sumatriptan Succinate 25 mg Almotriptan Malate 12.5 mg Rizatriptan Benzoate 5 mg oral disintegrating tablet Rizatriptan Benzoate 10 mg oral disintegrating tablet Rizatriptan Benzoate 5 mg Rizatriptan Benzoate 10mg Sumatriptan Succinate 50 mg Sumatriptan Succinate 100 mg Zolmitriptan 2.5mg Zolmitriptan 2.5 mg oral dispersible tablet 8

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