2016 List of Covered Drugs (Formulary)

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1 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. FOR RE INFORMATION, call Member Services at 1-8 from 8 a.m. to 8 p.m., seven days a week. TTY rs call 711. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned the next business day , Version Number 10 Updated 06/01/2016 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take List of Covered Drugs (Formulary)

2 H1723_LOD16_Approved_ Absolute Total Care 2016 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Absolute Total Care Medicare-Medicaid Plan (MMP). Absolute Total Care (ATC) MMP is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to members. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check ATC s up-to-date List of Covered Drugs online at Limitations and restrictions may apply. For more information, call ATC Member Services or read the ATC Member Handbook. You can get this information for free in other formats, such as large print, braille, or audio. Call Member Services at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. You can get this information for free in other languages. Please call our Member Services number at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Por favor llame a nuestro número de Servicio al Cliente al de 8 am a 8 pm, los siete días de la semana. Los fines de semana y días festivos federales, se le puede pedir que deje un mensaje. Su llamada será devuelto dentro del siguiente día hábil. Usuarios de TTY deben llamar al 711. La llamada es gratuita.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 1

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by ATC. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. ATC will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a ATC network pharmacy. ATC may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at Does the Drug List ever change? Yes. ATC may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from ATC before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 4.)? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 2

4 We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check ATC s up to date Drug List online at You can also call Member Services to check the current Drug List at What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed beca a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will receive the notice by mail at least 60 days before we change the drug rules or remove the drug from our List of Covered Drugs. For example, if you are taking a drug, and we add prior authorization (approval), quantity limits, and/or step therapy, the notice you receive will explain the new rules. We must tell you of this change at least 60 days before it becomes effective. Or, we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60-day supply of the drug. For more information on these drug rules, see page 4. If you have questions about the notice you receive from ATC, call Member Services at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 3

5 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from ATC before you fill your prescription. If you don t get approval, ATC may not cover the drug. Quantity limits: Sometimes ATC limits the amount of a drug you can get. Step therapy: Sometimes ATC requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages 10 to 214. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new ATC member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 10 has a column labeled restrictions, or limits on.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 4

6 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the index of drugs that begins on page 215. To search by medical condition, find the section labeled List of drugs by medical condition on page 10. The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9. What if you are a current member and the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at and ask about it. If you learn that ATC will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. Throughout the plan year, you may have a change in your treatment setting (the place where you get and take your medicine) beca of the level of care you require. Such transitions may include, but are not limited to:? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 5

7 Members who are discharged from a hospital or skilled-nursing facility to a home setting Members who are admitted to a hospital or skilled-nursing facility from a home setting Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to their Part D plan benefit Members who give up Hospice Status and go back to standard Medicare Part A and B coverage Members discharged from psychiatric hospitals with highly individualized drug regimens For these changes in treatment settings, ATC will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a temporary supply of a drug, call Member Services. 10. What if you are a new ATC member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We will cover a temporary 30-day supply of your Part D drug and a 90-day supply of your Healthy Connections Medicaid drug during the first 180 days you are a member of ATC. This will give you time to talk to your doctor or other prescriber. He or she will determine if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a temporary supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by ATC, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 to 98 days for Part D drugs and 90 days for non-part D drugs. You may refill the drug multiple times during this time period. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 6

8 11. Can you ask for an exception to cover your drug? Yes. You can ask ATC to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, ATC may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). ATC covers both brand name drugs and generic drugs.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 7

9 15. What are OTC drugs? OTC stands for over-the-counter. ATC covers some OTC drugs when they are written as prescriptions by your provider. You can read the ATC Drug List to see what OTC drugs are covered. 16. What is your copay? You can read the ATC Drug List to learn about the copay for each drug. ATC members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs are generic drugs. The copay will be $0. Tier 2 drugs are brand name drugs. The copay will be $0. Tier 3 drugs are Healthy Connections Medicaid OTC drugs. The copay will be $0.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 8

10 List of Covered Drugs The list of covered drugs that begins on page 10 gives you information about the drugs covered by ATC. If you have trouble finding your drug in the list, turn to the Index that begins on page 215. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the necessary actions, column tells you if ATC has any rules for covering your drug. Abbreviations B/D LA PA QL ST Descriptions This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the and setting of the drug to make the determination. Drug is not a Part D drug. This item is covered under your Medicaid benefits. These drugs also have different rules for appeals. Limited Access. This prescription may be available only at certain pharmacies. For more information call Member Service at TTY rs call 711. Prior Authorization (or prior approval). ATC requires your doctor or you to get prior approval for certain drugs. This means that you will need to get approval from ATC before you fill your prescriptions. If you don t get approval, ATC may not cover the drug. Quantity Limit. For certain drugs, ATC limits the amount of the drug that will be covered. For example, only 30 tablets of JANUVIA per 30 days. This may be in addition to a standard one-month or three-month supply. Maintenance Drug. This prescription drug is eligible for a 90-day supply through our mail order service as well as through certain retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). Step Therapy. Sometimes ATC requires you to do step therapy. This means you might have to try one drug before we will cover another drug. Note: The next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Healthy Connections Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY rs call 711. The call is free. For more information, visit 9

11 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. Name of drug What the drug Analgesics Analgesics allzital tablet 325mg; 25mg $0(Tier 1) butalbital/acetaminophen/caffeine/codeine capsule 325mg; $0(Tier 1) 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine capsule 325mg; 50mg; 40mg $0(Tier 1) butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg $0(Tier 1) butalbital/acetaminophen tablet 325mg; 50mg $0(Tier 1) butalbital/aspirin/caffeine capsule 325mg; 50mg; 40mg $0(Tier 1) GRALISE STARTER MISCELLANEOUS 0 $0(Tier 2) GRALISE TABLET 300MG $0(Tier 2) GRALISE TABLET 600MG $0(Tier 2) Nonsteroidal Anti-inflammatory Drugs diclofenac potassium tablet 50mg $0(Tier 1) diclofenac sodium dr tablet delayed release 25mg $0(Tier 1) diclofenac sodium dr tablet delayed release 50mg $0(Tier 1) diclofenac sodium dr tablet delayed release 75mg $0(Tier 1) diclofenac sodium er tablet extended release 24 hour 100mg $0(Tier 1) diflunisal tablet 500mg $0(Tier 1) etodolac er tablet extended release 24 hour 400mg $0(Tier 1) etodolac er tablet extended release 24 hour 500mg $0(Tier 1) etodolac er tablet extended release 24 hour 600mg $0(Tier 1) etodolac capsule 200mg $0(Tier 1) etodolac capsule 300mg $0(Tier 1) etodolac tablet 400mg $0(Tier 1) etodolac tablet 500mg $0(Tier 1) fenoprofen calcium tablet 600mg $0(Tier 1) flogen tablet 650mg; 250mg flurbiprofen tablet 100mg $0(Tier 1) flurbiprofen tablet 50mg $0(Tier 1) ibuprofen suspension 100mg/5ml $0(Tier 1) ibuprofen tablet 400mg $0(Tier 1) ibuprofen tablet 600mg $0(Tier 1) ibuprofen tablet 800mg $0(Tier 1) indomethacin er capsule extended release 75mg $0(Tier 1) PA (Anti-inflammatory Agents) indomethacin capsule 25mg $0(Tier 1) PA (Anti-inflammatory Agents) indomethacin capsule 50mg $0(Tier 1) PA (Anti-inflammatory Agents) 10

12 Name of drug What the drug ketoprofen er capsule extended release 24 hour 200mg $0(Tier 1) QL (30 EA per 30 days) ketoprofen capsule 50mg $0(Tier 1) ketoprofen capsule 75mg $0(Tier 1) ketorolac tromethamine injection 15mg/ml $0(Tier 1) ketorolac tromethamine injection 30mg/ml $0(Tier 1) meclofenamate sodium capsule 100mg $0(Tier 1) meclofenamate sodium capsule 50mg $0(Tier 1) meloxicam suspension 7.5mg/5ml $0(Tier 1) meloxicam tablet 15mg $0(Tier 1) QL (30 EA per 30 days) meloxicam tablet 7.5mg $0(Tier 1) QL (30 EA per 30 days) nabumetone tablet 500mg $0(Tier 1) nabumetone tablet 750mg $0(Tier 1) naproxen dr tablet delayed release 375mg $0(Tier 1) naproxen dr tablet delayed release 500mg $0(Tier 1) naproxen sodium tablet 275mg $0(Tier 1) naproxen sodium tablet 550mg $0(Tier 1) naproxen suspension 125mg/5ml $0(Tier 1) naproxen tablet 250mg $0(Tier 1) naproxen tablet 375mg $0(Tier 1) naproxen tablet 500mg $0(Tier 1) oxaprozin tablet 600mg $0(Tier 1) piroxicam capsule 10mg $0(Tier 1) piroxicam capsule 20mg $0(Tier 1) sulindac tablet 150mg $0(Tier 1) sulindac tablet 200mg $0(Tier 1) tolmetin sodium capsule 400mg $0(Tier 1) tolmetin sodium tablet 600mg $0(Tier 1) Opioid Analgesics, Long-acting fentanyl patch 72 hour 100mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 12mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 25mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 37.5mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 50mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 62.5mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 75mcg/hr $0(Tier 1) QL (10 EA per 30 days) fentanyl patch 72 hour 87.5mcg/hr $0(Tier 1) QL (10 EA per 30 days) levorphanol tartrate tablet 2mg $0(Tier 1) QL (240 EA per 30 days) METHADONE HCL INJECTION 10MG/ML $0(Tier 2) methadone hcl solution 10mg/5ml $0(Tier 1) methadone hcl solution 5mg/5ml $0(Tier 1) methadone hcl tablet 10mg $0(Tier 1) methadone hcl tablet 5mg $0(Tier 1) morphine sulfate er tablet extended release 100mg $0(Tier 1) QL (180 EA per 30 days) morphine sulfate er tablet extended release 15mg $0(Tier 1) QL (120 EA per 30 days) 11

13 Name of drug What the drug morphine sulfate er tablet extended release 200mg $0(Tier 1) QL (120 EA per 30 days) morphine sulfate er tablet extended release 30mg $0(Tier 1) QL (120 EA per 30 days) morphine sulfate er tablet extended release 60mg $0(Tier 1) QL (120 EA per 30 days) Opioid Analgesics, Short-acting acetaminophen/codeine #3 tablet 300mg; 30mg $0(Tier 1) QL (390 EA per 30 days) acetaminophen/codeine tablet 300mg; 15mg $0(Tier 1) QL (390 EA per 30 days) acetaminophen/codeine tablet 300mg; 60mg $0(Tier 1) QL (390 EA per 30 days) ascomp/codeine capsule 325mg; 50mg; 40mg; 30mg $0(Tier 1) QL (180 EA per 30 days) butorphanol tartrate injection 1mg/ml $0(Tier 1) butorphanol tartrate injection 2mg/ml $0(Tier 1) butorphanol tartrate solution 10mg/ml $0(Tier 1) duramorph injection 0.5mg/ml $0(Tier 1) duramorph injection 1mg/ml $0(Tier 1) endocet tablet 325mg; 10mg $0(Tier 1) QL (360 EA per 30 days) endocet tablet 325mg; 5mg $0(Tier 1) QL (360 EA per 30 days) endocet tablet 325mg; 7.5mg $0(Tier 1) QL (360 EA per 30 days) fentanyl citrate oral transmucosal lozenge on a handle 1200mcg fentanyl citrate oral transmucosal lozenge on a handle 1600mcg fentanyl citrate oral transmucosal lozenge on a handle 200mcg fentanyl citrate oral transmucosal lozenge on a handle 400mcg fentanyl citrate oral transmucosal lozenge on a handle 600mcg fentanyl citrate oral transmucosal lozenge on a handle 800mcg hydrocodone bitartrate/acetaminophen solution 325mg/15ml; $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) $0(Tier 1) QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) 7.5mg/15ml hydrocodone bitartrate/acetaminophen tablet 300mg; 7.5mg $0(Tier 1) hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg $0(Tier 1) QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 10mg $0(Tier 1) QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 5mg $0(Tier 1) QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 7.5mg $0(Tier 1) QL (360 EA per 30 days) hydrocodone/ibuprofen tablet 10mg; 200mg $0(Tier 1) QL (360 EA per 30 days) hydrocodone/ibuprofen tablet 5mg; 200mg $0(Tier 1) QL (360 EA per 30 days) hydromorphone hcl injection 500mg/50ml $0(Tier 1) hydromorphone hcl tablet 2mg $0(Tier 1) QL (480 EA per 30 days) hydromorphone hcl tablet 4mg $0(Tier 1) QL (240 EA per 30 days) hydromorphone hcl tablet 8mg $0(Tier 1) QL (240 EA per 30 days) 12

14 Name of drug What the drug LAZANDA SOLUTION 100MCG/ACT $0(Tier 2) QL (600 EA per 30 days) PA (Lazanda) LAZANDA SOLUTION 400MCG/ACT $0(Tier 2) QL (150 EA per 30 days) PA (Lazanda) morphine sulfate solution 100mg/5ml $0(Tier 1) morphine sulfate solution 10mg/5ml $0(Tier 1) morphine sulfate solution 20mg/5ml $0(Tier 1) morphine sulfate tablet 15mg $0(Tier 1) morphine sulfate tablet 30mg $0(Tier 1) nalbuphine hcl injection 10mg/ml $0(Tier 1) nalbuphine hcl injection 20mg/ml $0(Tier 1) oxycodone hcl tablet 10mg $0(Tier 1) QL (180 EA per 30 days) oxycodone hcl tablet 15mg $0(Tier 1) QL (180 EA per 30 days) oxycodone hcl tablet 20mg $0(Tier 1) QL (180 EA per 30 days) oxycodone hcl tablet 30mg $0(Tier 1) QL (180 EA per 30 days) oxycodone hcl tablet 5mg $0(Tier 1) QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 10mg $0(Tier 1) QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 5mg $0(Tier 1) QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 7.5mg $0(Tier 1) QL (360 EA per 30 days) TALWIN INJECTION 30MG/ML $0(Tier 2) PA (High Risk Medications) tramadol hcl tablet 50mg $0(Tier 1) QL (240 EA per 30 days) tramadol hydrochloride/acetaminophen tablet 325mg; 37.5mg $0(Tier 1) QL (240 EA per 30 days) Anesthetics Local Anesthetics lidocaine hcl jelly gel 2% $0(Tier 1) lidocaine hcl jelly gel 2% $0(Tier 1) lidocaine hcl injection 0.5% $0(Tier 1) lidocaine hcl injection 2% $0(Tier 1) lidocaine hcl solution 4% $0(Tier 1) lidocaine viscous solution 2% $0(Tier 1) lidocaine/prilocaine cream 2.5%; 2.5% $0(Tier 1) lidocaine ointment 5% $0(Tier 1) lidocaine patch 5% $0(Tier 1) QL (90 EA per 30 days) PA (Anesthetics) Anti-Addiction/Substance Ab Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr tablet delayed release 333mg $0(Tier 1) disulfiram tablet 250mg $0(Tier 1) disulfiram tablet 500mg $0(Tier 1) Opioid Dependence Treatments buprenorphine hcl injection 0.3mg/ml $0(Tier 1) buprenorphine hcl tablet sublingual 2mg $0(Tier 1) QL (90 EA per 30 days) buprenorphine hcl tablet sublingual 8mg $0(Tier 1) QL (90 EA per 30 days) naltrexone hcl tablet 50mg $0(Tier 1) SUBOXONE FILM 12MG; 3MG $0(Tier 2) QL (60 EA per 30 days) SUBOXONE FILM 2MG; 0.5MG $0(Tier 2) QL (90 EA per 30 days) 13

15 What the drug Name of drug SUBOXONE FILM 4MG; 1MG $0(Tier 2) QL (90 EA per 30 days) SUBOXONE FILM 8MG; 2MG $0(Tier 2) QL (90 EA per 30 days) ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG $0(Tier 2) ZUBSOLV TABLET SUBLINGUAL 11.4MG; 2.9MG $0(Tier 2) ZUBSOLV TABLET SUBLINGUAL 2.9MG; 0.71MG $0(Tier 2) ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG $0(Tier 2) ZUBSOLV TABLET SUBLINGUAL 8.6MG; 2.1MG $0(Tier 2) Opioid Reversal Agents naloxone hcl injection 1mg/ml $0(Tier 1) Smoking Cessation Agents buproban tablet extended release 12 hour 150mg $0(Tier 1) CHANTIX CONTINUING NTH PAK TABLET 1MG $0(Tier 2) QL (56 EA per 28 days) CHANTIX STARTING NTH PAK TABLET 0 $0(Tier 2) CHANTIX TABLET 0.5MG $0(Tier 2) QL (56 EA per 28 days) CHANTIX TABLET 1MG $0(Tier 2) QL (56 EA per 28 days) NICOTROL NS SOLUTION 10MG/ML $0(Tier 2) Antibacterials Aminoglycosides amikacin sulfate injection 500mg/2ml $0(Tier 1) gentak ointment 0.3% $0(Tier 1) GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE $0(Tier 2) INJECTION 0.9MG/ML; 0.9% GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE $0(Tier 2) INJECTION 1.4MG/ML; 0.9% gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml; $0(Tier 1) 0.9% gentamicin sulfate/0.9% sodium chloride injection 1mg/ml; $0(Tier 1) 0.9% gentamicin sulfate cream 0.1% $0(Tier 1) gentamicin sulfate injection 10mg/ml $0(Tier 1) gentamicin sulfate injection 40mg/ml $0(Tier 1) gentamicin sulfate ointment 0.1% $0(Tier 1) gentamicin sulfate ointment 0.3% $0(Tier 1) gentamicin sulfate solution 0.3% $0(Tier 1) isotonic gentamicin injection 0.8mg/ml; 0.9% $0(Tier 1) isotonic gentamicin injection 1.2mg/ml; 0.9% $0(Tier 1) neomycin sulfate tablet 500mg $0(Tier 1) neomycin/polymyxin b sulfates solution 40mg/ml; $0(Tier 1) unit/ml paromomycin sulfate capsule 250mg $0(Tier 1) streptomycin sulfate injection 1gm $0(Tier 1) tobramycin sulfate injection 10mg/ml $0(Tier 1) tobramycin sulfate injection 80mg/2ml $0(Tier 1) tobramycin sulfate solution 0.3% $0(Tier 1) Antibacterials, Other alcohol prep pads pad 70% $0(Tier 1) baciim injection 50000unit $0(Tier 1) 14

16 Name of drug What the drug BACITRACIN INJECTION 50000UNIT $0(Tier 2) CHLORAMPHENICOL SODIUM SUCCINATE $0(Tier 2) INJECTION 1GM CLEOCIN IN D5W INJECTION 300MG/50ML; 5% $0(Tier 2) CLEOCIN IN D5W INJECTION 600MG/50ML; 5% $0(Tier 2) CLEOCIN IN D5W INJECTION 900MG/50ML; 5% $0(Tier 2) CLEOCIN PEDIATRIC GRANULES SOLUTION $0(Tier 2) RECONSTITUTED 75MG/5ML clindamax gel 1% $0(Tier 1) clindamycin hcl capsule 150mg $0(Tier 1) clindamycin hcl capsule 300mg $0(Tier 1) clindamycin hcl capsule 75mg $0(Tier 1) clindamycin palmitate hcl solution reconstituted 75mg/5ml $0(Tier 1) clindamycin phosphate in d5w injection 300mg/50ml; 5% $0(Tier 1) clindamycin phosphate in d5w injection 600mg/50ml; 5% $0(Tier 1) clindamycin phosphate in d5w injection 900mg/50ml; 5% $0(Tier 1) clindamycin phosphate cream 2% $0(Tier 1) clindamycin phosphate gel 1% $0(Tier 1) clindamycin phosphate injection 600mg/4ml $0(Tier 1) clindamycin phosphate lotion 1% $0(Tier 1) clindamycin phosphate solution 1% $0(Tier 1) clindamycin phosphate swab 1% $0(Tier 1) colistimethate sodium injection 150mg $0(Tier 1) B/D CUBICIN INJECTION 500MG $0(Tier 2) LINCOCIN INJECTION 300MG/ML $0(Tier 2) lincomycin hcl injection 300mg/ml $0(Tier 1) linezolid injection 600mg/300ml $0(Tier 1) linezolid suspension reconstituted 100mg/5ml $0(Tier 1) QL (600 ML per 10 days) linezolid tablet 600mg $0(Tier 1) QL (20 EA per 10 days) methenamine hippurate tablet 1gm $0(Tier 1) metronidazole in nacl 0.79% injection 500mg/100ml; 0.79% $0(Tier 1) metronidazole vaginal gel 0.75% $0(Tier 1) metronidazole cream 0.75% $0(Tier 1) metronidazole gel 0.75% $0(Tier 1) metronidazole lotion 0.75% $0(Tier 1) metronidazole tablet 250mg $0(Tier 1) metronidazole tablet 500mg $0(Tier 1) mupirocin ointment 2% $0(Tier 1) neomycin/polymyxin/bacitracin/hydrocortisone ointment $0(Tier 1) 400unit/gm; 1%; 0.5%; 10000unit/gm neomycin/polymyxin/hydrocortisone suspension 1%; $0(Tier 1) 3.5mg/ml; 10000unit/ml nitrofurantoin macrocrystals capsule 100mg $0(Tier 1) PA (High Risk Medication - Nitrofurantoin) nitrofurantoin macrocrystals capsule 25mg $0(Tier 1) PA (High Risk Medication - Nitrofurantoin) 15

17 Name of drug What the drug nitrofurantoin macrocrystals capsule 50mg $0(Tier 1) PA (High Risk Medication - Nitrofurantoin) nitrofurantoin monohydrate/macrocrystals capsule 100mg $0(Tier 1) PA (High Risk Medication - Nitrofurantoin) nitrofurantoin monohydrate capsule 100mg $0(Tier 1) PA (High Risk Medication - Nitrofurantoin) polymyxin b sulfate injection unit $0(Tier 1) PRIMSOL SOLUTION 50MG/5ML $0(Tier 2) silver sulfadiazine cream 1% $0(Tier 1) ssd cream 1% $0(Tier 1) SYNERCID INJECTION 350MG; 150MG $0(Tier 2) trimethoprim tablet 100mg $0(Tier 1) TYGACIL INJECTION 50MG $0(Tier 2) vancomycin hcl capsule 125mg $0(Tier 1) vancomycin hcl capsule 250mg $0(Tier 1) vancomycin hcl injection 1000mg $0(Tier 1) vancomycin hcl injection 10gm $0(Tier 1) vancomycin hcl injection 500mg $0(Tier 1) vandazole gel 0.75% $0(Tier 1) XIFAXAN TABLET 200MG $0(Tier 2) ZYVOX INJECTION 600MG/300ML $0(Tier 2) ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML $0(Tier 2) QL (600 ML per 10 days) Beta-lactam, Cephalosporins cefaclor er tablet extended release 12 hour 500mg $0(Tier 1) cefaclor capsule 250mg $0(Tier 1) cefaclor capsule 500mg $0(Tier 1) cefadroxil capsule 500mg $0(Tier 1) cefadroxil suspension reconstituted 250mg/5ml $0(Tier 1) cefadroxil suspension reconstituted 500mg/5ml $0(Tier 1) cefadroxil tablet 1gm $0(Tier 1) cefazolin sodium injection 10gm $0(Tier 1) cefazolin sodium injection 1gm $0(Tier 1) CEFAZOLIN SODIUM INJECTION 1GM; 5% $0(Tier 2) cefazolin sodium injection 500mg $0(Tier 1) cefdinir capsule 300mg $0(Tier 1) cefdinir suspension reconstituted 125mg/5ml $0(Tier 1) cefdinir suspension reconstituted 250mg/5ml $0(Tier 1) cefepime injection 1gm $0(Tier 1) cefepime injection 2gm $0(Tier 1) cefotaxime sodium injection 1gm $0(Tier 1) cefotaxime sodium injection 2gm $0(Tier 1) cefotaxime sodium injection 500mg $0(Tier 1) cefoxitin sodium injection 10gm $0(Tier 1) cefoxitin sodium injection 1gm $0(Tier 1) cefoxitin sodium injection 2gm $0(Tier 1) cefpodoxime proxetil tablet 100mg $0(Tier 1) cefpodoxime proxetil tablet 200mg $0(Tier 1) 16

18 Name of drug What the drug cefprozil suspension reconstituted 125mg/5ml $0(Tier 1) cefprozil suspension reconstituted 250mg/5ml $0(Tier 1) cefprozil tablet 250mg $0(Tier 1) cefprozil tablet 500mg $0(Tier 1) ceftazidime injection 1gm $0(Tier 1) ceftazidime injection 2gm $0(Tier 1) ceftazidime injection 6gm $0(Tier 1) ceftriaxone sodium injection 10gm $0(Tier 1) ceftriaxone sodium injection 1gm $0(Tier 1) ceftriaxone sodium injection 250mg $0(Tier 1) ceftriaxone sodium injection 2gm $0(Tier 1) ceftriaxone sodium injection 500mg $0(Tier 1) cefuroxime axetil tablet 250mg $0(Tier 1) cefuroxime axetil tablet 500mg $0(Tier 1) cefuroxime sodium injection 1.5gm $0(Tier 1) cefuroxime sodium injection 7.5gm $0(Tier 1) cefuroxime sodium injection 750mg $0(Tier 1) cephalexin capsule 250mg $0(Tier 1) cephalexin capsule 500mg $0(Tier 1) cephalexin suspension reconstituted 125mg/5ml $0(Tier 1) cephalexin suspension reconstituted 250mg/5ml $0(Tier 1) cephalexin tablet 250mg $0(Tier 1) cephalexin tablet 500mg $0(Tier 1) CLAFORAN INJECTION 10GM $0(Tier 2) CLAFORAN INJECTION 1GM $0(Tier 2) CLAFORAN INJECTION 2GM $0(Tier 2) CLAFORAN INJECTION 500MG $0(Tier 2) FORTAZ INJECTION 1GM $0(Tier 2) FORTAZ INJECTION 2GM $0(Tier 2) SUPRAX CAPSULE 400MG $0(Tier 2) SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML $0(Tier 2) SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML $0(Tier 2) SUPRAX SUSPENSION RECONSTITUTED 500MG/5ML $0(Tier 2) SUPRAX TABLET CHEWABLE 100MG $0(Tier 2) SUPRAX TABLET CHEWABLE 200MG $0(Tier 2) TEFLARO INJECTION 400MG $0(Tier 2) TEFLARO INJECTION 600MG $0(Tier 2) Beta-lactam, Other AZACTAM IN ISO-OSTIC DEXTROSE INJECTION 1GM; 0 $0(Tier 2) AZACTAM IN ISO-OSTIC DEXTROSE INJECTION $0(Tier 2) 2GM; 0 AZACTAM INJECTION 1GM $0(Tier 2) aztreonam injection 1gm $0(Tier 1) imipenem/cilastatin injection 250mg; 250mg $0(Tier 1) imipenem/cilastatin injection 500mg; 500mg $0(Tier 1) INVANZ INJECTION 1GM $0(Tier 2) 17

19 What the drug Name of drug meropenem injection 500mg $0(Tier 1) Beta-lactam, Penicillins amoxicillin/clavulanate potassium er tablet extended release $0(Tier 1) 12 hour 1000mg; 62.5mg amoxicillin/clavulanate potassium suspension reconstituted $0(Tier 1) 200mg/5ml; 28.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted $0(Tier 1) 250mg/5ml; 62.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted $0(Tier 1) 400mg/5ml; 57mg/5ml amoxicillin/clavulanate potassium suspension reconstituted $0(Tier 1) 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium tablet chewable 200mg; $0(Tier 1) 28.5mg amoxicillin/clavulanate potassium tablet chewable 400mg; $0(Tier 1) 57mg amoxicillin/clavulanate potassium tablet 250mg; 125mg $0(Tier 1) amoxicillin/clavulanate potassium tablet 500mg; 125mg $0(Tier 1) amoxicillin/clavulanate potassium tablet 875mg; 125mg $0(Tier 1) amoxicillin capsule 250mg $0(Tier 1) amoxicillin capsule 500mg $0(Tier 1) amoxicillin suspension reconstituted 125mg/5ml $0(Tier 1) amoxicillin suspension reconstituted 200mg/5ml $0(Tier 1) amoxicillin suspension reconstituted 250mg/5ml $0(Tier 1) amoxicillin suspension reconstituted 400mg/5ml $0(Tier 1) amoxicillin tablet chewable 125mg $0(Tier 1) amoxicillin tablet chewable 250mg $0(Tier 1) amoxicillin tablet 500mg $0(Tier 1) amoxicillin tablet 875mg $0(Tier 1) ampicillin sodium injection 10gm $0(Tier 1) ampicillin sodium injection 125mg $0(Tier 1) ampicillin sodium injection 1gm $0(Tier 1) ampicillin-sulbactam injection 10gm; 5gm $0(Tier 1) ampicillin-sulbactam injection 1gm; 0.5gm $0(Tier 1) ampicillin-sulbactam injection 2gm; 1gm $0(Tier 1) ampicillin capsule 250mg $0(Tier 1) ampicillin capsule 500mg $0(Tier 1) ampicillin suspension reconstituted 125mg/5ml $0(Tier 1) ampicillin suspension reconstituted 250mg/5ml $0(Tier 1) BACTOCILL IN DEXTROSE INJECTION 0; 1GM/50ML $0(Tier 2) BACTOCILL IN DEXTROSE INJECTION 0; 2GM/50ML $0(Tier 2) BICILLIN C-R INJECTION UNIT/ML; $0(Tier 2) UNIT/ML BICILLIN C-R INJECTION UNIT/2ML; $0(Tier 2) UNIT/2ML BICILLIN L-A INJECTION UNIT/2ML $0(Tier 2) BICILLIN L-A INJECTION UNIT/4ML $0(Tier 2) 18

20 What the drug Name of drug BICILLIN L-A INJECTION UNIT/ML $0(Tier 2) dicloxacillin sodium capsule 250mg $0(Tier 1) dicloxacillin sodium capsule 500mg $0(Tier 1) nafcillin sodium injection 10gm $0(Tier 1) nafcillin sodium injection 1gm $0(Tier 1) NALLPEN/DEXTROSE INJECTION 0; 1GM/50ML $0(Tier 2) oxacillin sodium injection 10gm $0(Tier 1) oxacillin sodium injection 2gm $0(Tier 1) PENICILLIN G POTASSIUM IN ISO-OSTIC $0(Tier 2) DEXTROSE INJECTION 0; 40000UNIT/ML PENICILLIN G POTASSIUM IN ISO-OSTIC $0(Tier 2) DEXTROSE INJECTION 0; 60000UNIT/ML penicillin g potassium injection unit $0(Tier 1) penicillin g procaine injection unit/ml $0(Tier 1) PENICILLIN G SODIUM INJECTION UNIT $0(Tier 2) penicillin v potassium solution reconstituted 125mg/5ml $0(Tier 1) penicillin v potassium solution reconstituted 250mg/5ml $0(Tier 1) penicillin v potassium tablet 250mg $0(Tier 1) penicillin v potassium tablet 500mg $0(Tier 1) piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm $0(Tier 1) ZOSYN INJECTION 3GM; 0.375GM $0(Tier 2) ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML $0(Tier 2) ZOSYN INJECTION 5%; 3GM/50ML; 0.375GM/50ML $0(Tier 2) Macrolides azithromycin injection 500mg $0(Tier 1) azithromycin suspension reconstituted 100mg/5ml $0(Tier 1) QL (15 ML per 5 days) azithromycin suspension reconstituted 200mg/5ml $0(Tier 1) QL (22.5 ML per 5 days) azithromycin tablet 250mg $0(Tier 1) QL (6 EA per 5 days) azithromycin tablet 250mg $0(Tier 1) QL (6 EA per 5 days) azithromycin tablet 500mg $0(Tier 1) QL (3 EA per 3 days) azithromycin tablet 600mg $0(Tier 1) QL (8 EA per 28 days) clarithromycin er tablet extended release 24 hour 500mg $0(Tier 1) clarithromycin suspension reconstituted 125mg/5ml $0(Tier 1) clarithromycin suspension reconstituted 250mg/5ml $0(Tier 1) clarithromycin tablet 250mg $0(Tier 1) QL (28 EA per 14 days) clarithromycin tablet 500mg $0(Tier 1) QL (42 EA per 21 days) e.e.s. 400 tablet 400mg $0(Tier 1) e.e.s. granules suspension reconstituted 200mg/5ml $0(Tier 1) ERY-TAB TABLET DELAYED RELEASE 250MG $0(Tier 2) ERY-TAB TABLET DELAYED RELEASE 333MG $0(Tier 2) ERY-TAB TABLET DELAYED RELEASE 500MG $0(Tier 2) ERYPED 400 SUSPENSION RECONSTITUTED $0(Tier 2) 400MG/5ML ERYTHROCIN LACTOBIONATE INJECTION 500MG $0(Tier 2) erythrocin stearate tablet 250mg $0(Tier 1) erythromycin base tablet 250mg $0(Tier 1) erythromycin base tablet 500mg $0(Tier 1) 19

21 Name of drug What the drug erythromycin capsule delayed release particles 250mg $0(Tier 1) erythromycin ointment 5mg/gm $0(Tier 1) erythromycin solution 2% $0(Tier 1) KETEK TABLET 300MG $0(Tier 2) KETEK TABLET 400MG $0(Tier 2) QL (20 EA per 10 days) ZMAX SUSPENSION RECONSTITUTED 2GM $0(Tier 2) Quinolones AVELOX INJECTION 400MG/250ML; 0.8% $0(Tier 2) ciprofloxacin hcl solution 0.3% $0(Tier 1) ciprofloxacin hcl tablet 100mg $0(Tier 1) ciprofloxacin hcl tablet 250mg $0(Tier 1) ciprofloxacin hcl tablet 500mg $0(Tier 1) ciprofloxacin hcl tablet 750mg $0(Tier 1) ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5% $0(Tier 1) ciprofloxacin injection 400mg/40ml $0(Tier 1) levofloxacin in d5w injection 5%; 500mg/100ml $0(Tier 1) levofloxacin in d5w injection 5%; 750mg/150ml $0(Tier 1) levofloxacin injection 25mg/ml $0(Tier 1) levofloxacin solution 25mg/ml $0(Tier 1) levofloxacin tablet 250mg $0(Tier 1) QL (10 EA per 10 days) levofloxacin tablet 500mg $0(Tier 1) QL (14 EA per 14 days) levofloxacin tablet 750mg $0(Tier 1) QL (14 EA per 14 days) moxifloxacin hcl injection 400mg/250ml $0(Tier 1) ofloxacin solution 0.3% $0(Tier 1) ofloxacin solution 0.3% $0(Tier 1) ofloxacin tablet 400mg $0(Tier 1) Sulfonamides sodium sulfacetamide solution 10% $0(Tier 1) sulfacetamide sodium suspension 10% $0(Tier 1) sulfadiazine tablet 500mg $0(Tier 1) sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg $0(Tier 1) sulfamethoxazole/trimethoprim injection 400mg/5ml; $0(Tier 1) 80mg/5ml sulfamethoxazole/trimethoprim suspension 200mg/5ml; $0(Tier 1) 40mg/5ml sulfamethoxazole/trimethoprim tablet 400mg; 80mg $0(Tier 1) Tetracyclines demeclocycline hcl tablet 150mg $0(Tier 1) demeclocycline hcl tablet 300mg $0(Tier 1) doxy 100 injection 100mg $0(Tier 1) doxycycline hyclate capsule 100mg $0(Tier 1) doxycycline hyclate capsule 50mg $0(Tier 1) doxycycline hyclate injection 100mg $0(Tier 1) doxycycline hyclate tablet 100mg $0(Tier 1) doxycycline hyclate tablet 20mg $0(Tier 1) doxycycline monohydrate capsule 100mg $0(Tier 1) doxycycline monohydrate capsule 50mg $0(Tier 1) 20

22 What the drug Name of drug minocycline hcl capsule 100mg $0(Tier 1) minocycline hcl capsule 50mg $0(Tier 1) minocycline hcl capsule 75mg $0(Tier 1) Anticonvulsants Anticonvulsants, Other APTIOM TABLET 200MG $0(Tier 2) QL (30 EA per 30 days) APTIOM TABLET 400MG $0(Tier 2) QL (30 EA per 30 days) APTIOM TABLET 600MG $0(Tier 2) QL (60 EA per 30 days) APTIOM TABLET 800MG $0(Tier 2) QL (30 EA per 30 days) FYCOMPA TABLET 10MG $0(Tier 2) QL (30 EA per 30 days) FYCOMPA TABLET 12MG $0(Tier 2) QL (30 EA per 30 days) FYCOMPA TABLET 2MG $0(Tier 2) QL (30 EA per 30 days) FYCOMPA TABLET 4MG $0(Tier 2) QL (30 EA per 30 days) FYCOMPA TABLET 6MG $0(Tier 2) QL (30 EA per 30 days) FYCOMPA TABLET 8MG $0(Tier 2) QL (30 EA per 30 days) levetiracetam injection 1000mg/100ml; 750mg/100ml $0(Tier 1) levetiracetam injection 1500mg/100ml; 540mg/100ml $0(Tier 1) levetiracetam injection 500mg/100ml; 820mg/100ml $0(Tier 1) levetiracetam injection 500mg/5ml $0(Tier 1) levetiracetam solution 100mg/ml $0(Tier 1) levetiracetam tablet 1000mg $0(Tier 1) levetiracetam tablet 250mg $0(Tier 1) levetiracetam tablet 500mg $0(Tier 1) levetiracetam tablet 750mg $0(Tier 1) POTIGA TABLET 200MG $0(Tier 2) QL (90 EA per 30 days) POTIGA TABLET 300MG $0(Tier 2) QL (90 EA per 30 days) POTIGA TABLET 400MG $0(Tier 2) QL (90 EA per 30 days) POTIGA TABLET 50MG $0(Tier 2) QL (180 EA per 30 days) SPRITAM TABLET DISINTEGRATING SOLUBLE $0(Tier 2) 1000MG SPRITAM TABLET DISINTEGRATING SOLUBLE 250MG $0(Tier 2) SPRITAM TABLET DISINTEGRATING SOLUBLE 500MG $0(Tier 2) SPRITAM TABLET DISINTEGRATING SOLUBLE 750MG $0(Tier 2) 21

23 Name of drug What the drug Calcium Channel Modifying Agents CELONTIN CAPSULE 300MG $0(Tier 2) ethosuximide capsule 250mg $0(Tier 1) ethosuximide solution 250mg/5ml $0(Tier 1) LYRICA CAPSULE 100MG $0(Tier 2) QL (90 EA per 30 days) LYRICA CAPSULE 150MG $0(Tier 2) QL (60 EA per 30 days) LYRICA CAPSULE 200MG $0(Tier 2) QL (60 EA per 30 days) LYRICA CAPSULE 225MG $0(Tier 2) QL (60 EA per 30 days) LYRICA CAPSULE 25MG $0(Tier 2) QL (90 EA per 30 days) LYRICA CAPSULE 300MG $0(Tier 2) QL (60 EA per 30 days) LYRICA CAPSULE 50MG $0(Tier 2) QL (90 EA per 30 days) LYRICA CAPSULE 75MG $0(Tier 2) QL (90 EA per 30 days) LYRICA SOLUTION 20MG/ML $0(Tier 2) zonisamide capsule 100mg $0(Tier 1) zonisamide capsule 25mg $0(Tier 1) zonisamide capsule 50mg $0(Tier 1) Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tablet dispersible 0.125mg $0(Tier 1) QL (150 EA per 30 days) clonazepam odt tablet dispersible 0.25mg $0(Tier 1) QL (150 EA per 30 days) clonazepam odt tablet dispersible 0.5mg $0(Tier 1) QL (150 EA per 30 days) clonazepam odt tablet dispersible 1mg $0(Tier 1) QL (150 EA per 30 days) clonazepam odt tablet dispersible 2mg $0(Tier 1) QL (300 EA per 30 days) clonazepam tablet 0.5mg $0(Tier 1) QL (150 EA per 30 days) clonazepam tablet 1mg $0(Tier 1) QL (150 EA per 30 days) clonazepam tablet 2mg $0(Tier 1) QL (300 EA per 30 days) diazepam gel 10mg $0(Tier 1) QL (50 EA per 30 days) diazepam gel 2.5mg $0(Tier 1) QL (24.9 EA per 30 days) diazepam gel 20mg $0(Tier 1) QL (100 EA per 30 days) divalproex sodium dr tablet delayed release 125mg $0(Tier 1) divalproex sodium dr tablet delayed release 250mg $0(Tier 1) divalproex sodium dr tablet delayed release 500mg $0(Tier 1) divalproex sodium er tablet extended release 24 hour 250mg $0(Tier 1) divalproex sodium er tablet extended release 24 hour 500mg $0(Tier 1) divalproex sodium capsule delayed release sprinkle 125mg $0(Tier 1) gabapentin capsule 100mg $0(Tier 1) gabapentin capsule 300mg $0(Tier 1) gabapentin capsule 400mg $0(Tier 1) gabapentin solution 250mg/5ml $0(Tier 1) gabapentin tablet 600mg $0(Tier 1) 22

24 Name of drug What the drug gabapentin tablet 800mg $0(Tier 1) GABITRIL TABLET 12MG $0(Tier 2) QL (90 EA per 30 days) GABITRIL TABLET 16MG $0(Tier 2) QL (90 EA per 30 days) ONFI SUSPENSION 2.5MG/ML $0(Tier 2) ONFI TABLET 10MG $0(Tier 2) ONFI TABLET 20MG $0(Tier 2) phenobarbital elixir 20mg/5ml $0(Tier 1) phenobarbital tablet 100mg $0(Tier 1) phenobarbital tablet 15mg $0(Tier 1) phenobarbital tablet 16.2mg $0(Tier 1) phenobarbital tablet 30mg $0(Tier 1) phenobarbital tablet 32.4mg $0(Tier 1) phenobarbital tablet 60mg $0(Tier 1) phenobarbital tablet 64.8mg $0(Tier 1) phenobarbital tablet 97.2mg $0(Tier 1) primidone tablet 250mg $0(Tier 1) primidone tablet 50mg $0(Tier 1) SABRIL PACKET 500MG $0(Tier 2) QL (360 EA per 30 days) SABRIL TABLET 500MG $0(Tier 2) QL (360 EA per 30 days) tiagabine hydrochloride tablet 2mg $0(Tier 1) QL (90 EA per 30 days) tiagabine hydrochloride tablet 4mg $0(Tier 1) valproate sodium injection 500mg/5ml $0(Tier 1) valproic acid capsule 250mg $0(Tier 1) valproic acid syrup 250mg/5ml $0(Tier 1) Glutamate Reducing Agents felbamate suspension 600mg/5ml $0(Tier 1) felbamate tablet 400mg $0(Tier 1) felbamate tablet 600mg $0(Tier 1) lamotrigine odt tablet dispersible 100mg $0(Tier 1) lamotrigine odt tablet dispersible 200mg $0(Tier 1) lamotrigine odt tablet dispersible 25mg $0(Tier 1) lamotrigine odt tablet dispersible 50mg $0(Tier 1) lamotrigine tablet chewable 25mg $0(Tier 1) lamotrigine tablet chewable 5mg $0(Tier 1) lamotrigine tablet 100mg $0(Tier 1) lamotrigine tablet 150mg $0(Tier 1) lamotrigine tablet 200mg $0(Tier 1) lamotrigine tablet 25mg $0(Tier 1) QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG $0(Tier 2) QL (120 EA per 30 days) QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG $0(Tier 2) QL (60 EA per 30 days) QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 200MG $0(Tier 2) QL (60 EA per 30 days) 23

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