Health Partners Plans CHIP Formulary Updated 12/6/ Formulary

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1 Health Partners Plans HIP Formulary Updated /6/06 07 Formulary Introduction Health Partners Plans, Inc. is pleased to provide the 07 KidzPartners Formulary. This formulary covers members under the KidzPartners (hildren s Health Insurance Program) plan. The drugs listed in the KidzPartners Formulary are intended to provide sufficient options to treat the majority of patients who require drug therapy in an ambulatory setting. Excluded from coverage are drugs from specific manufacturers who have not contracted with the rebate program of the Federal government. The drugs listed in the KidzPartners Formulary have been reviewed and approved by the Health Partners Plans Pharmacy and Therapeutics ommittee. These drug products have been selected to provide the most clinically appropriate and cost-effective medications for KidzPartners members. There may be occasions when an unlisted drug is desired for medical management of a specific patient. In those instances, the unlisted medication may be requested through Prior Authorization/ Medical Exception. Preface The KidzPartners Formulary is organized by sections, which refer to either a drug/ pharmacologic class or disease state. Each section contains a list of drugs selected to be on this formulary. Prescribing a drug product that is available generically is encouraged when appropriate. Unless exceptions are noted, all applicable dosage forms and strengths of the referenced product generally are covered. Pharmacy and Therapeutics (P&T) ommittee The actions of the Health Partners Plans P&T ommittee are communicated through the Provider Newsletter to all physicians and posted on our website. Pharmacy providers in the KidzPartners network will be notified through correspondence from the Health Partners Plans Pharmacy department when applicable. Product Selection riteria The Health Partners Plans P&T ommittee will consider all FDA approved drugs for inclusion in the formulary. The evaluation process includes a literature review, and expert opinion by respected medical professionals. Formal reviews are prepared which typically address the following information:. Safety. Effectiveness 3. omparison studies 4. Approved indications 5. Adverse effects 6. ontraindications 7. Pharmacokinetics 8. Patient compliance considerations 9. Medical outcome and pharmacoeconomic studies When a new drug is considered for formulary inclusion an attempt will be made to examine the drug relative to similar drugs currently on formulary. In addition, entire therapeutic classes are periodically reviewed. This review process may result in deletion of a drug(s) in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. Plan Limits A maximum of up to a 30-day supply of medication is eligible for coverage. The prescriber is urged to prescribe in amounts that adhere to accepted standards of care. The days supply must be accurately determined by the dispensing pharmacist to assure compliance with plan parameters. Specific limits based on FDA guidelines, medication package inserts and accepted standards of care may apply to medication treatments under clinical review. Prescription quantities cannot be altered unless approved by the physician, and must be within the limits of the plan s days supply. Prescribed medications or regimens that are non-formulary require prior authorization. Immediate Need (5/5-day Emergency Supply) If a member presents at a pharmacy with a prescription which requires prior authorization, whether for a non-formulary drug or otherwise, and if the prior authorization cannot be processed immediately, Health Partners Plans will allow the pharmacy to dispense an interim supply of the prescription under the following circumstances: If the recipient is in immediate need of the medication in the professional judgment of the pharmacist and if the prescription is for a new medication (one that the recipient has not taken before or that is taken for an acute condition), Health Partners Plans will allow the pharmacy to dispense a 5-day supply of the medication to afford the recipient or pharmacy the opportunity to initiate the request for prior authorization. If the prescription is for an ongoing medication (one that is continuously prescribed for the treatment of an illness or condition that is chronic in nature in which there has not been a break in treatment for greater than 30 Days), Health Partners Plans will allow the pharmacy to dispense a 5-day supply of the medication automatically, unless Health Partners Plans mailed to the member, with a copy to the prescriber, an advance written notice of the reduction or termination of the medication at least 0 days prior to the end of the period for which the medication was previously authorized. Health Partners Plans will respond to the request for prior authorization within 4 hours from when the request was received. If the prior authorization is denied, the member is entitled to appeal the decision through several avenues. The 5-day or 5-day requirement does not apply when the pharmacist

2 Health Partners Plans HIP Formulary Updated /6/06 determines that taking the medication, either alone or along with other medication that the recipient may be taking, would jeopardize the health and safety of the recipient. Formulary Product Descriptions This formulary lists all specific strengths and dosage forms that are covered. When a strength or dosage form is specified, only the product identified will be covered. Other strengths/ dosage forms of the referenced product are not covered. For specific questions please contact the Health Partners Plans Pharmacy department at Generic Substitution Generic substitution is the process by which a generic equivalent is dispensed rather than the brand name product. The appropriate use of generic drugs is one method of providing cost conscious drug therapy. Health Partners Plans will not cover any drugs by companies that do not participate in the Federal Rebate Program or are DESI drugs. Generic drugs must be prescribed and dispensed when an A-rated generic drug is available. Brand necessary prescriptions for drugs with A-rated generics require prior authorization. The MA list sets a ceiling price for the reimbursement of certain multisource prescription drugs. This price will typically cover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MA list are commonly prescribed and dispensed and have usually gone through the FDA s review and approval process. This process assures the following requirements have been met: The generic drug will contain the same active ingredient(s) and be the same strength and dosage form as the brand name counterpart. The FDA has given the generic an A rating compared to the branded counterpart indicating bioequivalence and has determined the generic is therapeutically equivalent to the referenced brand. The ratings of generic drugs are available by referring to the FDA reference Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the brand name product. State laws or regulation may indicate the ability to practice generic substitution for selected products or categories of drugs. There are now many brand name products that are repackaged or distributed under a generic label. These generic versions should always be considered therapeutically equivalent and substitutable for the source branded product irrespective of rating. Drugs Efficacy Study Implementation (DESI) Drugs Health Partners Plans does not reimburse for DESI drugs. DESI drugs are those drugs first marketed between 938 and 96 which were approved as safe, but not required to show effectiveness for FDA product approval. The DESI program subsequently made a determination of fully effective for most of these products and they remain in the marketplace. A few DESI products remain classified as less than fully effective while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products. Examples of DESI Drugs include: Midrin Vytone Anusol H suppositories Donnatal Tigan Naldecon Prior Authorization () To ensure that select medications are utilized appropriately, Prior Authorization may be required for the dispensing of specific products. These medications may require Prior Authorization for the following reasons: Non-formulary medications, or benefit exceptions required by medical necessity All brand name medications when there is an A-rated generic equivalent available Medications and/or treatments under clinical investigation Medications used for non-fda approved indications Prescription costs that exceed $000 per claim Prescriptions that exceed set plan limits (days supply, quantity, cost) Prescriptions processed by non-network pharmacies New-to-market products High-end oral and self-administered injectable medications Medications with Health Partners Plans P&T ommittee approved treatment guidelines To request a prior authorization the physician or a member of his/her staff should contact Health Partners Plans either by fax at , or phone at All non-emergency requests can be faxed 4 hours per day; calls should be placed from 9:00 A.M. to 5:00 P.M., Monday through Friday. In the event of an immediate need after business hours, the call should be made to KidzPartners Member Relations at The call will be evaluated and routed to a pharmacist-on-call. The physician may use the Health Partners Plans Prior Authorization/Medical Exception form or a letter of request, but must include the following information for quick and appropriate review to take place: Name and recipient number of member Date of birth of member Physician s name, license number, and specialty Physician s phone and fax numbers Name of primary care physician if different Drug name, strength, and quantity of medication Days supply (duration of therapy) and number of refills Route of administration Diagnosis Medical rationale for request Formulary medications used, duration and therapy result Additional clinical information that may contribute to the review decision (e.g., labs) Upon receiving the Prior Authorization/ Medical Exception Request from the prescriber, Health

3 Health Partners Plans HIP Formulary Updated /6/06 Partners Plans will render a decision within 4 hours. The Medical Director will review each prior authorization request and make the final decision. After Medical Director review, the clinical pharmacist will prepare the request for the denial/approval letter. A denial letter will be mailed to the member or parent/guardian. A copy of the member denial letter is also faxed to the prescribing physician. If the Prior Authorization/Medical Exception Request is denied, the prescriber can submit a written appeal to Health Partners Plans omplaint & Grievance Unit explaining the medical necessity of the medical treatment in question. At any time during normal business hours, the prescribing physician can discuss the denial with a clinical pharmacist or can have a peer to peer discussion with the medical director. Health Partners Plans Specialty and Injectable Medication Program Health Partners Plans supports appropriate use of injectables and has established procedures for prescribing and suppliers. Under the direction of the Health Partners Plans Pharmacy department, the physician provider has the primary responsibility for obtaining Prior Authorization for medications included in this program. all the Health Partners Plans Pharmacy department at for authorization on specialty medications. The following specialty and injectable medications, although not limited to, can be obtained through the retail pharmacy benefit without prior authorization. GENERI NAME BRAND NAME ceftriaxone Rocephin cyanocobalamin Vitamin B- epinephrine Epipen, Epipen Jr. fluphenazine decanoate Prolixin Decanoate glucagon Glucagon haloperidol decanoate Haldol Decanoate heparin sodium Heparin Insulin medroxyprogesterone Depo-Provera acetate 50 mg only methylprednisolone Depo-Medrol acetate methylprednisolone Solu-Medrol sod. succ. penicillin g benzathine Bicillin L.A. penicillin g potassium Pfizerpen sumatriptan triamcinolone acetonide fondaparinux sodium enoxaparin sodium Imitrex Kenalog-40 Arixtra Lovenox Managed Drug Limitations (MDL) The United States Food and Drug Administration (FDA) publishes guidelines on the safest and most efficient ways to use certain drugs. Many drug products on the KidzPartners Formulary have quantity limits based upon the dosage described in product labeling. Drugs subject to quantity limits may change. ontact Health Partners Plans Pharmacy department at for more information. Step Therapy Step therapy is a process that encourages the use of medications preferred by Health Partners Plans as the first course of treatment. If the preferred medication is not clinically effective or if the member suffers side effects, another medication may be approved as the second course of treatment. Editor Your comments and suggestions regarding the KidzPartners 07 Formulary are encouraged. Your input is vital to this formulary s continued success. All responses will be reviewed and considered. Please send your comments to: Attn: Pharmacy Director Health Partners Plans 90 Market Street, Suite 500 Philadelphia, 907 Phone: Internet: Notice The information contained in the KidzPartners Formulary and its appendices is provided by Health Partners Plans solely for the convenience of medical providers. Health Partners Plans neither warrants nor assures accuracy of such information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his/her choice of prescription drugs. Health Partners Plans does not assume responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer product literature or standard references for more detailed information. The information contained in this document is proprietary information subject to a licensing agreement. The information may not be copied in whole or in part without the written permission of Health Partners Plans. All rights reserved. Trade names are the intellectual property of the respective product owners. Legend Y Yes Drug is covered GP Generic Preferred Brand name drug with AB-rated generic available; use generic Prior Authorization required Quantity Limits apply OT Over the ounter (not all covered OT products are listed)

4 LEGEND TIER DESRIPTION Generics Brands 3 Specialty TYPE ST Quantity Limit Prior Authorization Step Therapy DESRIPTION There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. GL Gender Limit This prescription drug may only be covered for a single gender. Age Limit This prescription drug may only be covered if you meet the minimum or maximum age limit. ustom This drug has unique restrictions. GE 4 LAST UPDATED 0/07

5 LIST OF OVERED PRESRIPTION MEDIATIONS DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ANTI-INFETIVE AGENTS ANTHELMINTIS ivermectin 3 mg tablet ANTIBATERIALS amoxicillin 5 mg tab chew 4 / days amoxicillin 5 mg/5ml susp recon 5 / days amoxicillin 00 mg/5ml susp recon 5 / days amoxicillin 50 mg capsule 4 / days amoxicillin 50 mg tab chew 4 / days amoxicillin 50 mg/5ml susp recon 0 / days amoxicillin 400 mg/5ml susp recon.5 / days amoxicillin 500 mg capsule 4 / days amoxicillin 500 mg tablet 8 / days amoxicillin 875 mg tablet 4 / days amoxicillin/potassium clav /5 susp recon amoxicillin/potassium clav mg tab chew amoxicillin/potassium clav 50-5 mg tablet amoxicillin/potassium clav /5 susp recon amoxicillin/potassium clav mg tab chew 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill GE 5 LAST UPDATED 0/07

6 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS amoxicillin/potassium clav mg/5 susp recon amoxicillin/potassium clav mg tablet amoxicillin/potassium clav /5 susp recon amoxicillin/potassium clav mg tablet ampicillin trihydrate 5 mg/5ml susp recon ampicillin trihydrate 50 mg capsule ampicillin trihydrate 50 mg/5ml susp recon ampicillin trihydrate 500 mg capsule azithromycin g packet azithromycin 00 mg/5ml susp recon azithromycin 00 mg/5ml susp recon azithromycin 50 mg tablet 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 30 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 5 per fill Maximum day supply of 5 per fill 5 / days Maximum day supply of 5 per fill Maximum day supply of 5 per fill 5 / days Maximum day supply of 5 per fill Maximum day supply of 5 per fill 4 / days Maximum day supply of 5 per fill Maximum day supply of 5 per fill azithromycin 500 mg tablet 0 / 3 days azithromycin 600 mg tablet / days BIILLIN L-A,00,000 UNITS penicillin g benzathine 4 / 365 days GE 6 LAST UPDATED 0/07

7 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS BIILLIN L-A,400,000 UNITS penicillin g benzathine BIILLIN L-A 600,000 UNIT/ML penicillin g benzathine / 365 days cefaclor 50 mg capsule 4 / days cefaclor 500 mg capsule 4 / days cefaclor 500 mg tab er h 8 / 4 days cefadroxil g tablet / days cefadroxil 50 mg/5ml susp recon 00 / 0 days Maximum day supply of 4 per fill Maximum day supply of 4 per fill cefadroxil 500 mg capsule 8 / days cefadroxil 500 mg/5ml susp recon 75 / 7 days Maximum day supply of 4 per fill Maximum day supply of 4 per fill cefdinir 5 mg/5ml susp recon / days cefdinir 50 mg/5ml susp recon / days cefdinir 300 mg capsule / days cefpodoxime proxetil 00 mg tablet 3 / days cefpodoxime proxetil 00 mg/5ml susp recon 40 / days cefpodoxime proxetil 00 mg tablet 4 / days cefpodoxime proxetil 50 mg/5 ml susp recon 40 / days cefprozil 5 mg/5ml susp recon 00 / 8 days cefprozil 50 mg tablet 0 / 8 days cefprozil 50 mg/5ml susp recon 00 / 8 days cefprozil 500 mg tablet 0 / 8 days ceftriaxone sodium g vial / days ceftriaxone sodium g vial port / days GE 7 LAST UPDATED 0/07

8 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ceftriaxone sodium 0 g vial ceftriaxone sodium g vial / days ceftriaxone sodium g vial port / days ceftriaxone sodium 50 mg vial / days ceftriaxone sodium 500 mg vial / days ceftriaxone na/dextrose,iso g/50 ml froz.piggy ceftriaxone na/dextrose,iso g/50 ml piggyback ceftriaxone na/dextrose,iso g/50 ml froz.piggy ceftriaxone na/dextrose,iso g/50 ml piggyback cefuroxime axetil 50 mg tablet / days cefuroxime axetil 500 mg tablet / days cephalexin 5 mg/5ml susp recon cephalexin 50 mg capsule cephalexin 50 mg/5ml susp recon cephalexin 500 mg capsule 80 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 8 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 80 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 8 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill IPRO 0% SUSPENSION ciprofloxacin 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill IPRO 5% SUSPENSION ciprofloxacin 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill ciprofloxacin hcl 00 mg tablet / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill GE 8 LAST UPDATED 0/07

9 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ciprofloxacin hcl 50 mg tablet ciprofloxacin hcl 500 mg tablet ciprofloxacin hcl 750 mg tablet clarithromycin 5 mg/5ml susp recon / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 0 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill clarithromycin 50 mg tablet / days clarithromycin 50 mg/5ml susp recon clarithromycin 500 mg tab er 4h 0 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill clarithromycin 500 mg tablet 3 / days clindamycin hcl 50 mg capsule 6 / days clindamycin hcl 300 mg capsule 6 / days clindamycin hcl 75 mg capsule clindamycin palmitate hcl 75 mg/5 ml soln recon 0 / days dicloxacillin sodium 50 mg capsule 8 / days dicloxacillin sodium 500 mg capsule 8 / days doxycycline hyclate 00 mg capsule doxycycline hyclate 00 mg tablet doxycycline hyclate 50 mg capsule doxycycline monohydrate 00 mg tablet / days doxycycline monohydrate 50 mg tablet / days GE 9 LAST UPDATED 0/07

10 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS doxycycline monohydrate 50 mg tablet / days doxycycline monohydrate 75 mg tablet / days E.E.S. 00 MG/5 ML GRANULES erythromycin ethylsuccinate ERY-TAB E 50 MG TABLET erythromycin base ERY-TAB E 333 MG TABLET erythromycin base ERY-TAB E 500 MG TABLET erythromycin base ERYPED 00 MG/5 ML SUSPENSION erythromycin ethylsuccinate ERYTHROIN 50 MG FILMTAB erythromycin stearate Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred Generic Preferred erythromycin base 50 mg capsule dr 8 / days erythromycin base 50 mg capsule dr 8 / days erythromycin base 50 mg tablet 8 / days erythromycin base 500 mg tablet 8 / days erythromycin ethylsuccinate 400 mg tablet 0 / days levofloxacin 50 mg tablet / days levofloxacin 50mg/0ml solution levofloxacin 50mg/0ml solution levofloxacin 500 mg tablet / days levofloxacin 500mg/0ml solution levofloxacin 750 mg tablet / days minocycline hcl 00 mg capsule / days minocycline hcl 50 mg capsule / days minocycline hcl 75 mg capsule 30 / 3 days moxifloxacin hcl 400 mg tablet 4 / 30 days neomycin sulfate 500 mg tablet ofloxacin 00 mg tablet 8 / 6 days GE 0 LAST UPDATED 0/07

11 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ofloxacin 300 mg tablet 8 / 6 days ofloxacin 400 mg tablet 8 / 6 days paromomycin sulfate 50 mg capsule 4 / 90 days penicillin v potassium 5 mg/5ml soln recon 40 / days penicillin v potassium 50 mg tablet 4 / days penicillin v potassium 50 mg/5ml soln recon 40 / days penicillin v potassium 500 mg tablet 4 / days rifabutin 50 mg capsule / days rifampin 50 mg capsule rifampin 300 mg capsule sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim 00-40mg/5 oral susp sulfamethoxazole/trimethoprim 400mg-80mg tablet sulfamethoxazole/trimethoprim mg tablet sulfamethoxazole/trimethoprim /0 oral susp sulfasalazine 500 mg tablet sulfasalazine 500 mg tablet dr SUPRAX 400 MG APSULE cefixime SUPRAX 400 MG TABLET cefixime 0 / 0 days 0 / 0 days tetracycline hcl 50 mg capsule tetracycline hcl 500 mg capsule vancomycin hcl 5 mg capsule vancomycin hcl 50 mg capsule 4 / days Max of 0 day supply per every 3 months Max of 0 day supply per every 3 months 8 / days Max of 0 day supply per every 3 months Max of 0 day supply per every 3 months GE LAST UPDATED 0/07

12 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ANTIFUNGAL (SYSTEMI) fluconazole 0 mg/ml susp recon 40 / days fluconazole 00 mg tablet / days fluconazole 50 mg tablet / days fluconazole 00 mg tablet / days fluconazole 40 mg/ml susp recon 0 / days fluconazole 50 mg tablet / days griseofulvin ultramicrosize 5 mg tablet 3 / days griseofulvin ultramicrosize 50 mg tablet 3 / days griseofulvin, microsize 5 mg/5ml oral susp 40 / days griseofulvin, microsize 500 mg tablet / days ketoconazole 00 mg tablet / days nystatin 50mm unit powder(ea) nystatin 500k unit tablet 6 / days nystatin 500mm unit powder(ea) nystatin 50mm unit powder(ea) SSKI GM/ML SOLUTION potassium iodide terbinafine hcl 50 mg tablet / days ANTIMYOBATERIALS IPRO 0% SUSPENSION ciprofloxacin 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill IPRO 5% SUSPENSION ciprofloxacin 5 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill ciprofloxacin hcl 00 mg tablet / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill GE LAST UPDATED 0/07

13 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ciprofloxacin hcl 50 mg tablet ciprofloxacin hcl 500 mg tablet ciprofloxacin hcl 750 mg tablet clarithromycin 5 mg/5ml susp recon / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill 0 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill clarithromycin 50 mg tablet / days clarithromycin 50 mg/5ml susp recon clarithromycin 500 mg tab er 4h 0 / days Maximum day supply of 4 per fill Maximum day supply of 4 per fill / days Maximum day supply of 4 per fill clarithromycin 500 mg tablet 3 / days dapsone 00 mg tablet / days dapsone 5 mg tablet 3 / days ethambutol hcl 00 mg tablet ethambutol hcl 400 mg tablet isoniazid 00 mg tablet isoniazid 300 mg tablet isoniazid 50 mg/5 ml solution levofloxacin 50 mg tablet / days levofloxacin 50mg/0ml solution levofloxacin 50mg/0ml solution levofloxacin 500 mg tablet / days GE 3 LAST UPDATED 0/07

14 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS levofloxacin 500mg/0ml solution levofloxacin 750 mg tablet / days moxifloxacin hcl 400 mg tablet 4 / 30 days pyrazinamide 500 mg tablet rifabutin 50 mg capsule / days rifampin 50 mg capsule rifampin 300 mg capsule ANTIPROTOZOALS chloroquine phosphate 50 mg tablet / days chloroquine phosphate 500 mg tablet / days dapsone 00 mg tablet / days dapsone 5 mg tablet 3 / days hydroxychloroquine sulfate 00 mg tablet 4 / days mefloquine hcl 50 mg tablet 5 / 6 days metronidazole 50 mg tablet 3 / days metronidazole 500 mg tablet 3 / days paromomycin sulfate 50 mg capsule 4 / 90 days primaquine phosphate 6.3 mg tablet / days quinidine gluconate 34 mg tablet er 3 / days quinidine sulfate 00 mg tablet 6 / days quinidine sulfate 300 mg tablet 6 / days quinidine sulfate 300 mg tablet er 3 / days tinidazole 50 mg tablet tinidazole 500 mg tablet 4 / days At least 3 yrs old 4 / days At least 3 yrs old GE 4 LAST UPDATED 0/07

15 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ANTIVIRALS (SYSTEMI) abacavir sulfate 300 mg tablet 60 / 30 days abacavir/lamivudine/zidovudine mg tablet 60 / 30 days acyclovir 00 mg capsule 5 / days acyclovir 00 mg/5ml oral susp 50 / days acyclovir 400 mg tablet 5 / days acyclovir 800 mg tablet 5 / days APTIVUS 50 MG APSULE tipranavir 0 / 30 days At least yrs old ATRIPLA TABLET efavirenz/emtricitabine/tenofovir disoproxil fumarate 30 / 30 days At least yrs old BARALUDE 0.05 MG/ML SOLUTION entecavir OMPLERA TABLET emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate / days At least 8 yrs old RIXIVAN 00 MG APSULE indinavir sulfate 360 / 30 days At least 6 yrs old RIXIVAN 400 MG APSULE indinavir sulfate 80 / 30 days At least 6 yrs old DESOVY 00-5 MG TABLET emtricitabine/tenofovir alafenamide fumarate / days At least yrs old didanosine 5 mg capsule dr didanosine 00 mg capsule dr didanosine 50 mg capsule dr didanosine 400 mg capsule dr 60 / 30 days At least 6 yrs old 60 / 30 days At least 6 yrs old 30 / 30 days At least 6 yrs old 30 / 30 days At least 6 yrs old GE 5 LAST UPDATED 0/07

16 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS EDURANT 5 MG TABLET rilpivirine hcl 30 / 30 days At least 8 yrs old EMTRIVA 00 MG APSULE emtricitabine 30 / 30 days entecavir 0.5 mg tablet entecavir mg tablet EPZIOM TABLET abacavir sulfate/lamivudine 30 / 30 days At least 8 yrs old EVOTAZ 300 MG-50 MG TABLET atazanavir sulfate/cobicistat / days At least 8 yrs old famciclovir 5 mg tablet 3 / days famciclovir 50 mg tablet 3 / days famciclovir 500 mg tablet 3 / days GENVOYA TABLET elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide / days At least yrs old INTELENE 00 MG TABLET etravirine 0 / 30 days At least 6 yrs old INTELENE 00 MG TABLET etravirine 60 / 30 days At least 6 yrs old INVIRASE 00 MG APSULE saquinavir mesylate 300 / 30 days At least 6 yrs old INVIRASE 500 MG TABLET saquinavir mesylate 0 / 30 days At least 6 yrs old 8 / days ISENTRESS 00 MG TABLET HEW raltegravir potassium to yrs old Age of and over requires prior authorization. 6 / days ISENTRESS 5 MG TABLET HEW raltegravir potassium to yrs old Age of and over requires prior authorization. GE 6 LAST UPDATED 0/07

17 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS ISENTRESS 400 MG TABLET raltegravir potassium KALETRA 00-5 MG TABLET lopinavir/ritonavir KALETRA MG TABLET lopinavir/ritonavir KALETRA /5 ML ORAL SOLU lopinavir/ritonavir / days 300 / 30 days 50 / 30 days 400 / 30 days lamivudine 0 mg/ml solution 900 / 30 days lamivudine 50 mg tablet 60 / 30 days lamivudine 300 mg tablet 30 / 30 days lamivudine/zidovudine mg tablet 60 / 30 days LEXIVA 700 MG TABLET fosamprenavir calcium NORVIR 00 MG SOFTGEL AP ritonavir NORVIR 00 MG TABLET ritonavir NORVIR 80 MG/ML SOLUTION ritonavir 0 / 30 days 360 / 30 days 360 / 30 days 480 / 30 days ODEFSEY TABLET emtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate / days At least yrs old PREZOBIX 800 MG-50 MG TABLET darunavir ethanolate/cobicistat / days At least 8 yrs old PREZISTA 00 MG/ML SUSPENSION darunavir ethanolate PREZISTA 50 MG TABLET darunavir ethanolate PREZISTA 400 MG TABLET darunavir ethanolate PREZISTA 600 MG TABLET darunavir ethanolate PREZISTA 800 MG TABLET darunavir ethanolate / days 0 / 30 days 60 / 30 days 60 / 30 days / days RESRIPTOR 00 MG TABLET delavirdine mesylate 360 / 30 days At least 6 yrs old GE 7 LAST UPDATED 0/07

18 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS RESRIPTOR 00 MG TABLET delavirdine mesylate 80 / 30 days At least 6 yrs old REYATAZ 50 MG APSULE atazanavir sulfate 60 / 30 days At least 6 yrs old REYATAZ 00 MG APSULE atazanavir sulfate 60 / 30 days At least 6 yrs old REYATAZ 300 MG APSULE atazanavir sulfate 30 / 30 days At least 6 yrs old ribavirin 00 mg capsule 3 ribavirin 00 mg tablet 3 7 / days 7 / days SELZENTRY 50 MG TABLET maraviroc 0 / 30 days At least 8 yrs old SELZENTRY 300 MG TABLET maraviroc 0 / 30 days At least 8 yrs old stavudine mg/ml soln recon 400 / 30 days stavudine 5 mg capsule 0 / 30 days stavudine 0 mg capsule 0 / 30 days stavudine 30 mg capsule 60 / 30 days stavudine 40 mg capsule 60 / 30 days STRIBILD TABLET elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil / days At least 8 yrs old SUSTIVA 00 MG APSULE efavirenz SUSTIVA 50 MG APSULE efavirenz SUSTIVA 600 MG TABLET efavirenz SYNAGIS 00 MG/ ML VIAL palivizumab 90 / 30 days 40 / 30 days 30 / 30 days 3 GE 8 LAST UPDATED 0/07

19 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS SYNAGIS 50 MG/0.5 ML VIAL palivizumab 3 TAMIFLU 30 MG APSULE oseltamivir phosphate TAMIFLU 45 MG APSULE oseltamivir phosphate 0 / 365 days At least yrs old 0 day supply per 365 days 0 / 365 days At least yrs old 0 day supply per 365 days TAMIFLU 6 MG/ML SUSPENSION oseltamivir phosphate 5 / 365 days At least yrs old 50 ml per 0 day supply per 365 days 0 / 365 days TAMIFLU 75 MG APSULE oseltamivir phosphate At least yrs old 0 day supply per 365 days 0 day supply per 365 days TIVIAY 50 MG TABLET dolutegravir sodium / days At least yrs old TRIUMEQ TABLET abacavir sulfate/dolutegravir sodium/lamivudine / days At least 8 yrs old TRUVADA 00 MG-300 MG TABLET emtricitabine/tenofovir disoproxil fumarate 30 / 30 days At least yrs old valacyclovir hcl 000 mg tablet 4 / days valacyclovir hcl 500 mg tablet 4 / days VITRELIS 00 MG APSULE boceprevir 3 / days VIDEX GM PEDIATRI SOLN didanosine VIDEX 4 GM PEDIATRI SOLN didanosine 00 / 30 days 00 / 30 days VIRAEPT 50 MG TABLET nelfinavir mesylate 70 / 30 days At least yrs old GE 9 LAST UPDATED 0/07

20 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS VIRAEPT 65 MG TABLET nelfinavir mesylate 0 / 30 days At least yrs old VIREAD 50 MG TABLET tenofovir disoproxil fumarate VIREAD 00 MG TABLET tenofovir disoproxil fumarate VIREAD 50 MG TABLET tenofovir disoproxil fumarate At least yrs old At least yrs old At least yrs old VIREAD 300 MG TABLET tenofovir disoproxil fumarate 30 / 30 days At least yrs old VITEKTA 50 MG TABLET elvitegravir / days At least 8 yrs old VITEKTA 85 MG TABLET elvitegravir / days At least 8 yrs old ZETIER MG TABLET elbasvir/grazoprevir ZIAGEN 0 MG/ML SOLUTION abacavir sulfate / 30 days zidovudine 0 mg/ml syrup 800 / 30 days zidovudine 00 mg capsule 80 / 30 days zidovudine 300 mg tablet 60 / 30 days URINARY ANTI-INFETIVES nitrofurantoin 5 mg/5 ml oral susp nitrofurantoin macrocrystal 00 mg capsule nitrofurantoin macrocrystal 5 mg capsule nitrofurantoin macrocrystal 50 mg capsule trimethoprim 00 mg tablet ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES cyproheptadine hcl mg/5 ml syrup 30 / days cyproheptadine hcl 4 mg tablet 8 / days GE 0 LAST UPDATED 0/07

21 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS cyproheptadine hcl 4 mg/0 ml syrup 30 / days diphenhydramine.5 mg/5 ml 40 / 5 days diphenhydramine hcl.5mg/5ml elixir 40 / 5 days diphenhydramine.5 mg/5 ml 40 / 5 days diphenhydramine cough syrup 40 / 5 days diphenhydramine 5 mg capsule 00 / 6 days diphenhydramine 5 mg caplet 00 / 6 days diphenhydramine 50 mg capsule 00 / 6 days diphenhydramine 50 mg tablet 00 / 6 days diphenhydramine hcl 50 mg/ml vial hydroxyzine hcl 0 mg tablet 6 / days hydroxyzine hcl 0 mg/5 ml solution 30 / days hydroxyzine hcl 0 mg/5 ml solution 30 / days hydroxyzine hcl 5 mg tablet 6 / days hydroxyzine hcl 50 mg tablet 6 / days hydroxyzine pamoate 00 mg capsule 6 / days hydroxyzine pamoate 5 mg capsule 6 / days hydroxyzine pamoate 50 mg capsule 6 / days meclizine.5 mg caplet 4 / days meclizine.5 mg tablet 4 / days meclizine 5 mg tablet chew 4 / days meclizine 5 mg tablet 4 / days PHENADOZ.5 MG SUPPOSITORY promethazine hcl / days At least 6 yrs old PHENADOZ 5 MG SUPPOSITORY promethazine hcl / days At least 6 yrs old phenylephrine hcl/prometh hcl 5-6.5mg/5 syrup 80 / 30 days At least 6 yrs old GE LAST UPDATED 0/07

22 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS promethazine hcl.5 mg supp.rect promethazine hcl.5 mg tablet promethazine hcl 5 mg supp.rect promethazine hcl 5 mg tablet promethazine hcl 50 mg tablet promethazine hcl 6.5mg/5ml syrup 6 / days At least 6 yrs old 3 / days At least 6 yrs old / days At least 6 yrs old / days At least 6 yrs old / days At least 6 yrs old 30 / days At least 6 yrs old promethazine/dextromethorphan 6.5-5/5 syrup At least 6 yrs old promethazine/dextromethorphan 6.5-5/5 syrup At least 6 yrs old promethazine/phenyleph/codeine syrup promethazine/phenyleph/codeine syrup 40 / 30 days At least 6 yrs old 40 / 30 days At least 6 yrs old PROMETHEGAN.5 MG SUPPOS promethazine hcl / days At least 6 yrs old PROMETHEGAN 5 MG SUPPOSITORY promethazine hcl / days At least 6 yrs old PROMETHEGAN 50 MG SUPPOSITORY promethazine hcl SIMPLY SLEEP 5 MG APLET diphenhydramine hcl / days 00 / 6 days GS SLEEP AID 5 MG TABLET doxylamine succinate 4 / days At least yrs old HM SLEEP AID 5 MG TABLET doxylamine succinate 4 / days At least yrs old GE LAST UPDATED 0/07

23 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS SLEEP AID 5 MG TABLET doxylamine succinate 4 / days At least yrs old SM SLEEP AID 5 MG TABLET doxylamine succinate 4 / days At least yrs old SEOND GENERATION ANTIHISTAMINES ALL DAY ALLERGY 0 MG HEW TAB cetirizine hcl ALL DAY ALLERGY 0 MG TABLET cetirizine hcl E ALL DAY ALLERGY 0 MG TAB cetirizine hcl GNP ALL DAY ALLERGY 0 MG TAB cetirizine hcl HM ALL DAY ALLERGY 0 MG TAB cetirizine hcl KRO ALL DAY ALLERGY 0 MG TAB cetirizine hcl Q ALL DAY ALLERGY 0 MG TAB cetirizine hcl SM ALL DAY ALLERGY MG/ML SYR cetirizine hcl SM ALL DAY ALLERGY 0 MG TAB cetirizine hcl / days / days / days / days / days / days / days 0 / days / days cetirizine hcl mg/ ml soln 0 / days cetirizine hcl mg/ml soln 0 / days cetirizine hcl mg/ml syrup 0 / days pv cetirizine hcl mg/ml soln 0 / days cetirizine hcl 0 mg chew tab / days cetirizine hcl 0 mg tablet 4 / days pv cetirizine hcl 0 mg tablet / days ra cetirizine hcl 0 mg tablet / days cetirizine hcl 5 mg chew tab / days cetirizine hcl 5 mg tablet / days GE 3 LAST UPDATED 0/07

24 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS HILD ALL DAY ALLERGY MG/ML cetirizine hcl GNP HLD ALL DAY ALLER MG/ML cetirizine hcl 0 / days 0 / days fexofenadine hcl 80 mg tablet / days hm fexofenadine hcl 80 mg tab / days pv fexofenadine hcl 80 mg tab / days sm fexofenadine hcl 80 mg tab / days fexofenadine hcl 30 mg/5 ml fexofenadine hcl 60 mg tablet 30 / days At least yrs old / days At least yrs old levocetirizine dihydrochloride 5 mg tablet / days cvs loratadine 0 mg tablet / days gnp loratadine 0 mg tablet / days loratadine 0 mg tablet / days qc loratadine 0 mg tablet / days ra loratadine 0 mg tablet / days sb loratadine 0 mg tablet / days sm loratadine 0 mg tablet / days child loratadine 5 mg/5 ml syr 0 / days eql loratadine 5 mg/5 ml syrup 0 / days gnp chld loratadine 5 mg/5 ml 0 / days gnp loratadine 5 mg/5 ml syrup 0 / days hm child loratadine 5 mg/5 ml 0 / days loratadine 5 mg/5 ml soln 0 / days loratadine 5 mg/5 ml syrup 0 / days loratadine allergy 5 mg/5 ml 0 / days GE 4 LAST UPDATED 0/07

25 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS loratadine hives 5 mg/5 ml 0 / days pv child loratadine 5 mg/5 ml 0 / days pv loratadine 5 mg/5 ml syrup 0 / days ra loratadine 5 mg/5 ml syrup 0 / days sm child loratadine 5 mg/5 ml 0 / days sm loratadine 5 mg/5 ml syrup 0 / days NON-DROWSY ALLERGY 0 MG TAB loratadine / days ANTINEOPLASTI AGENTS ALKERAN MG TABLET melphalan anastrozole mg tablet / days bicalutamide 50 mg tablet / days capecitabine 50 mg tablet capecitabine 500 mg tablet cyclophosphamide 5 mg capsule cyclophosphamide 5 mg tablet cyclophosphamide 50 mg capsule cyclophosphamide 50 mg tablet DROXIA 00 MG APSULE hydroxyurea DROXIA 300 MG APSULE hydroxyurea DROXIA 400 MG APSULE hydroxyurea EMYT 40 MG APSULE estramustine phosphate sodium etoposide 50 mg capsule exemestane 5 mg tablet / days FARESTON 60 MG TABLET toremifene citrate 4 / days flutamide 5 mg capsule 6 / days GE 5 LAST UPDATED 0/07

26 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS HEXALEN 50 MG APSULE altretamine 3 hydroxyurea 500 mg capsule letrozole.5 mg tablet LEUKERAN MG TABLET chlorambucil leuprolide acetate mg/0.ml kit 3 leuprolide acetate mg/0.ml kit 3 LYSODREN 500 MG TABLET mitotane megestrol acetate 0 mg tablet 8 / days megestrol acetate 40 mg tablet 8 / days megestrol acetate 400mg/0ml oral susp megestrol acetate 400mg/0ml oral susp mercaptopurine 50 mg tablet methotrexate sodium.5 mg tablet methotrexate sodium 5 mg/ml vial methotrexate sodium 5 mg/ml vial methotrexate sodium/pf g vial methotrexate sodium/pf 5 mg/ml vial methotrexate sodium/pf 5 mg/ml vial methotrexate sodium/pf 5 mg/ml vial methotrexate sodium/pf 5 mg/ml vial methotrexate sodium/pf 5 mg/ml vial methotrexate sodium/pf 5 mg/ml vial MYLERAN MG TABLET busulfan 4 / days nilutamide 50 mg tablet / days TABLOID 40 MG TABLET thioguanine tamoxifen citrate 0 mg tablet / days tamoxifen citrate 0 mg tablet / days GE 6 LAST UPDATED 0/07

27 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS temozolomide 00 mg capsule temozolomide 40 mg capsule temozolomide 80 mg capsule temozolomide 0 mg capsule temozolomide 50 mg capsule temozolomide 5 mg capsule tretinoin 0 mg capsule ANTITOXINS,IMMUNE GLOB,TOXOIDS,VAINES ANTITOXINS AND IMMUNE GLOBULINS At least 0 yrs old Prior authorization required for members less than 0 years old Prior authorization required for members less than 0 years old HYPERRHO S-D 500 UNITS SYR rho(d) immune globulin RHOGAM ULTRA-FILTERED PLUS SYR rho(d) immune globulin VAINES AFLURIA SYRINGE influenza virus vaccine trivalent (5 years up)/pf AFLURIA VIAL influenza virus vaccine trivalent (5 yr and older) FLUARIX QUAD SYRINGE influenza virus vaccine quadval split 06-7(36 mos up)/pf FLUELVAX QUAD SYR flu vaccine qs 06-07(4 years and older)cell derived/pf FLULAVAL QUAD SYR influenza virus vaccine quadval split 06-7(36 mos up)/pf FLULAVAL QUAD VIAL influenza virus vaccine quadriv (36 mos and older) FLUVIRIN SYRINGE influenza virus vaccine trival (4yr and older)/pf FLUVIRIN VIAL influenza virus vaccine trivalent (4 yr and older) FLUZONE QUAD SYRINGE influenza virus vaccine quadval split 06-7(36 mos up)/pf At least 5 yrs old At least 5 yrs old At least 3 yrs old At least 4 yrs old At least 3 yrs old At least 3 yrs old At least 4 yrs old At least 4 yrs old At least 3 yrs old GE 7 LAST UPDATED 0/07

28 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS FLUZONE QUAD VIAL influenza virus vaccine quadval split 06-7(36 mos up)/pf FLUZONE QUAD VIAL influenza virus vaccine qvalsplit 06-07(6 mos and older) FLUZONE QUAD PEDI 06-7 SYR influenza virus vaccine quadrival 06-7 (6 mos-35 mos)/pf At least 3 yrs old At least 3 yrs old At least 3 yrs old PREVNAR 3 SYRINGE pneumococcal 3-valent conjugate vaccine (diphtheria crm)/pf / days At least 9 yrs old AUTONOMI DRUGS ANTIHOLINERGI AGENTS ATROVENT HFA INHALER ipratropium bromide.9 / 6 days benztropine mesylate 0.5 mg tablet 4 / days benztropine mesylate mg tablet 4 / days benztropine mesylate mg tablet 4 / days 4 / 0 days OMBIVENT RESPIMAT INHAL SPRAY ipratropium bromide/albuterol sulfate At least 8 yrs old required for initial fill or greater than 45 days since last fill dicyclomine hcl 0 mg capsule 8 / days dicyclomine hcl 0 mg tablet 8 / days diphenoxylate hcl/atropine.5-.05/5 liquid 40 / days diphenoxylate hcl/atropine.5-.05mg tablet 8 / days glycopyrrolate mg tablet 6 / days glycopyrrolate mg tablet 4 / days hydrocodone bit/homatrop me-br 5 mg-.5mg tablet hyoscyamine sulfate 0.5 mg tab rapdis hyoscyamine sulfate 0.5 mg tab subl / days hyoscyamine sulfate 0.5 mg tablet / days GE 8 LAST UPDATED 0/07

29 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS hyoscyamine sulfate 0.5mg/ml drops / days hyoscyamine sulfate mg tab er h 4 / days hyoscyamine sulfate mg tab er h 4 / days hyoscyamine sulfate 5mcg/5ml elixir 60 / days hyoscyamine sulfate 5mcg/5ml elixir 60 / days HYOSYNE 0.5 MG/ML DROP hyoscyamine sulfate HYOSYNE 5 MG/5 ML ELIXIR hyoscyamine sulfate ipratropium bromide 0. mg/ml solution 0 / days ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb propantheline bromide 5 mg tablet 5 / days / month SPIRIVA RESPIMAT.5 MG INH tiotropium bromide At least yrs old required for initial fill or greater than 45 days since last fill / month SPIRIVA RESPIMAT.5 MG INH tiotropium bromide At least 8 yrs old required for initial fill or greater than 45 days since last fill STIOLTO RESPIMAT INHAL SPRAY tiotropium bromide/olodaterol hcl / fill At least 8 yrs old AUTONOMI DRUGS, MISELLANEOUS HANTIX 0.5 MG TABLET varenicline tartrate / days At least 8 yrs old Max of 80 tablets per 365 days HANTIX MG ONT MONTH BOX varenicline tartrate / days At least 8 yrs old Max of 80 tablets per 365 days GE 9 LAST UPDATED 0/07

30 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS HANTIX MG TABLET varenicline tartrate / days At least 8 yrs old HANTIX STARTING MONTH BOX varenicline tartrate / days At least 8 yrs old Max of 80 tablets per 365 days cvs nicotine 4 mg/4 hr patch 8 / 8 days cvs nicotine 4 mg/4hr patch 8 / 8 days eq nicotine 4 mg/4hr patch 8 / 8 days hm nicotine 4 mg/4hr patch 8 / 8 days kro nicotine 4 mg/4 hr patch 8 / 8 days nicotine 4 mg/4 hr patch 8 / 8 days nicotine 4 mg/4hr patch 8 / 8 days pv nicotine 4 mg/4 hr patch 8 / 8 days ra nicotine 4 mg/4hr patch 8 / 8 days sm nicotine 4 mg/4hr patch 8 / 8 days eq nicotine mg/4hr patch 8 / 8 days hm nicotine mg/4hr patch 8 / 8 days kro nicotine mg/4hr patch 8 / 8 days nicotine mg/4 hr patch 8 / 8 days nicotine mg/4hr patch 8 / 8 days pv nicotine mg/4 hr patch 8 / 8 days ra nicotine mg/4hr patch 8 / 8 days sm nicotine mg/4hr patch 8 / 8 days nicotine transdermal system 8 / 8 days cvs nicotine 7 mg/4hr patch 8 / 8 days eq nicotine 7 mg/4hr patch 8 / 8 days GE 30 LAST UPDATED 0/07

31 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS hm nicotine 7 mg/4hr patch 8 / 8 days kro nicotine 7 mg/4hr patch 8 / 8 days nicotine 7 mg/4hr patch 8 / 8 days pv nicotine 7 mg/4 hr patch 8 / 8 days ra nicotine 7 mg/4hr patch 8 / 8 days sm nicotine 7 mg/4hr patch 8 / 8 days cvs nicotine mg chewing gum 4 / days eq nicotine mg chewing gum 4 / days eql nicotine mg chewing gum 4 / days gnp nicotine mg chewing gum 4 / days hm nicotine mg chewing gum 4 / days kro nicotine mg chewing gum 4 / days ldr nicotine mg chewing gum 4 / days nicotine mg chewing gum 4 / days pc nicotine mg chewing gum 4 / days pv nicotine mg chewing gum 4 / days ra nicotine mg chewing gum 4 / days sm nicotine mg chewing gum 4 / days sw nicotine mg chewing gum 4 / days cvs nicotine mg lozenge 4 / days eq nicotine mg lozenge 4 / days eql nicotine mg lozenge 4 / days gnp nicotine mg lozenge 4 / days gnp nicotine mg mini lozenge 4 / days hm nicotine mg lozenge 4 / days kro nicotine mg lozenge 4 / days GE 3 LAST UPDATED 0/07

32 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS nicotine mg lozenge 4 / days nicotine mg mini lozenge 4 / days ra nicotine mg lozenge 4 / days ra nicotine mg mini lozenge 4 / days sm nicotine mg lozenge 4 / days sw nicotine mg lozenge 4 / days cvs nicotine 4 mg chewing gum 4 / days eq nicotine 4 mg chewing gum 4 / days eql nicotine 4 mg chewing gum 4 / days gnp nicotine 4 mg chewing gum 4 / days hm nicotine 4 mg chewing gum 4 / days kro nicotine 4 mg chewing gum 4 / days ldr nicotine 4 mg chewing gum 4 / days nicotine 4 mg chewing gum 4 / days pv nicotine 4 mg chewing gum 4 / days ra nicotine 4 mg chewing gum 4 / days sm nicotine 4 mg chewing gum 4 / days sw nicotine 4 mg chewing gum 4 / days cvs nicotine 4 mg lozenge 4 / days eq nicotine 4 mg lozenge 4 / days eql nicotine 4 mg lozenge 4 / days gnp nicotine 4 mg lozenge 4 / days gnp nicotine 4 mg mini lozenge 4 / days hm nicotine 4 mg lozenge 4 / days kro nicotine 4 mg lozenge 4 / days nicotine 4 mg lozenge 4 / days GE 3 LAST UPDATED 0/07

33 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS nicotine 4 mg mini lozenge 4 / days ra nicotine 4 mg lozenge 4 / days ra nicotine 4 mg mini lozenge 4 / days sm nicotine 4 mg lozenge 4 / days sw nicotine 4 mg lozenge 4 / days NIOTROL NS 0 MG/ML SPRAY nicotine 60 / 30 days RASYMTHOMIMETI (HOLINERGI AGENTS) bethanechol chloride 0 mg tablet 4 / days bethanechol chloride 5 mg tablet 4 / days bethanechol chloride 5 mg tablet 4 / days bethanechol chloride 50 mg tablet 4 / days donepezil hcl 0 mg tab rapdis donepezil hcl 5 mg tab rapdis / days At least 8 yrs old / days At least 8 yrs old pilocarpine hcl 5 mg tablet 4 / days pilocarpine hcl 7.5 mg tablet 4 / days SKELETAL MUSLE RELAXANTS baclofen 0 mg tablet 5 / days baclofen 0 mg tablet 4 / days carisoprodol 350 mg tablet 4 / days carisoprodol/aspirin mg tablet 3 / days carisoprodol/aspirin mg tablet 3 / days carisoprodol/aspirin/codeine tablet 3 / days carisoprodol/aspirin/codeine tablet 3 / days chlorzoxazone 500 mg tablet 6 / days GE 33 LAST UPDATED 0/07

34 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS cyclobenzaprine hcl 0 mg tablet 3 / days cyclobenzaprine hcl 5 mg tablet 6 / days dantrolene sodium 00 mg capsule 4 / days dantrolene sodium 5 mg capsule 4 / days dantrolene sodium 50 mg capsule 4 / days methocarbamol 500 mg tablet 6 / days methocarbamol 750 mg tablet 0 / days orphenadrine citrate 00 mg tablet er / days tizanidine hcl mg tablet 6 / days tizanidine hcl 4 mg tablet 6 / days SYMTHOLYTI ADRENERGI BLOKING AGENTS acebutolol hcl 00 mg capsule 3 / days acebutolol hcl 400 mg capsule 3 / days atenolol 00 mg tablet / days atenolol 5 mg tablet / days atenolol 50 mg tablet / days atenolol/chlorthalidone 00mg-5mg tablet / days atenolol/chlorthalidone 50 mg-5mg tablet / days betaxolol hcl 0 mg tablet / days betaxolol hcl 0 mg tablet / days bisoprolol fumarate 0 mg tablet / days bisoprolol fumarate 5 mg tablet 4 / days bisoprol/hydrochlorothiazide 0-6.5mg tablet / days bisoprol/hydrochlorothiazide.5-6.5mg tablet / days bisoprol/hydrochlorothiazide 5-6.5mg tablet / days carvedilol.5 mg tablet / days GE 34 LAST UPDATED 0/07

35 DRUG DESRIPTION (RX) TIER LIMITS & RESTRITIONS carvedilol 5 mg tablet 4 / days carvedilol 3.5 mg tablet / days carvedilol 6.5 mg tablet / days dihydroergotamine mesylate mg/ml ampul dihydroergotamine mesylate mg/ml vial labetalol hcl 00 mg tablet 4 / days labetalol hcl 00 mg tablet / days labetalol hcl 300 mg tablet 8 / days metoprolol succinate 00 mg tab er 4h / days metoprolol succinate 00 mg tab er 4h / days metoprolol succinate 5 mg tab er 4h / days metoprolol succinate 50 mg tab er 4h / days metoprolol tartrate 00 mg tablet 4 / days metoprolol tartrate 5 mg tablet 4 / days metoprolol tartrate 50 mg tablet 4 / days nadolol 0 mg tablet 4 / days nadolol 40 mg tablet 4 / days nadolol 80 mg tablet 4 / days pindolol 0 mg tablet 6 / days pindolol 5 mg tablet 6 / days propranolol hcl 0 mg tablet 8 / days propranolol hcl 0 mg cap sa 4h / days propranolol hcl 60 mg cap sa 4h / days propranolol hcl 0 mg tablet 8 / days propranolol hcl 0 mg/5 ml solution 80 / days propranolol hcl 40 mg tablet 8 / days GE 35 LAST UPDATED 0/07

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