2018 LIST OF COVERED DRUGS (FORMULARY)

Transcription

1 2018 LIST OF COVERED DRUGS (FORMULARY) Prescription drug list information UnitedHealthcare Connected (Medicare-Medicaid Plan) Toll-Free , TTY a.m. - 8 p.m. local time, Monday - Friday Formulary ID Number , Version 7 H7833_170614_101048_FINAL_01.02 Approved Last updated March 1, 2018

2 2 2 UnitedHealthcare Connected (Medicare-Medicaid Plan) 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in UnitedHealthcare Connected. v UnitedHealthcare Connected (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. v 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. v Benefits and/or copays may change on January 1 of each year. v You can always check UnitedHealthcare Connected s up-to-date List of Covered Drugs online at v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. v Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. v If you speak Spanish, language assistance services, free of charge, are available to you. Call , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. v Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al , TTY 7-1-1, de lunes a viernes, de 8 a.m. a 8 p.m., hora local. La llamada es gratuita. v You can get this document for free in other formats, such as large print, braille, or audio. Call , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. v You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

3 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. 3 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 UnitedHealthcare Connected. 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. UnitedHealthcare Connected 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 UnitedHealthcare Connected network pharmacy. UnitedHealthcare Connected 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 , TTY Does the Drug List ever change? Yes. UnitedHealthcare Connected 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 UnitedHealthcare Connected 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 pages 4 and 9.) If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

4 4 4 We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check UnitedHealthcare Connected s up-to-date Drug List online at You can also call Member Services to check the current Drug List at , TTY 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 Medicare Part D drug that is removed because 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. You will get a letter letting you know about the change. Contact your doctor or other prescriber to make sure this cheaper drug will work for you. 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. Contact your doctor or other prescriber and ask about your other options. 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 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 UnitedHealthcare Connected before you fill your prescription. If you don t get approval, UnitedHealthcare Connected may not cover the drug. Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a drug you can get. Step therapy: Sometimes UnitedHealthcare Connected 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. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

5 5 5 You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website 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 UnitedHealthcare Connected 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 ask for 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 pages has a column labeled. 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. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

6 6 6 To search alphabetically, go to the Alphabetical Listing section. You can find it after the "List of Covered Drugs" section. Find the name of your drug. The page number where you can find the drug will be next to it. To search by medical condition, find the section labeled List of drugs by medical condition on pages The drugs in this section are grouped into categories depending on the type of medical conditions they are used 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 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 , TTY and ask about it. If you learn that UnitedHealthcare Connected 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. 10 What if you are a new UnitedHealthcare Connected member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected. 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 ask for an exception. We will cover a 30-day 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 UnitedHealthcare Connected, or You are taking a drug that is part of a step therapy restriction. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

7 7 7 If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as up to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and you are prescribed a drug that s not on the Drug List or if it s difficult for you to get your drugs, you are required to use the plan s exception process. You may ask for a one-time emergency supply of at least 31 days to give you time to talk to your doctor about other treatment options or to try to get an exception. 11 Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected 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, UnitedHealthcare Connected 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 get a statement from your prescriber supporting your request for an exception. After we get 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 getting 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. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

8 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). UnitedHealthcare Connected covers both brand name drugs and generic drugs. 15 What are OTC drugs? OTC stands for over-the-counter. UnitedHealthcare Connected covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are covered. 16 Does UnitedHealthcare Connected cover OTC non-drug products? UnitedHealthcare Connected covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected Drug List to see what OTC non-drug products are covered. 17 What is your copay? You can read the UnitedHealthcare Connected Drug List to learn about the copay for each drug. UnitedHealthcare Connected 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 have the lowest copay. They are generic drugs. The copay is from $1.25 to $3.35, depending on your income. Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.70 to $8.35, depending on your income. Tier 3 drugs have a $0 copay. They are OTCs/Non-Part D drugs. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

9 19 For Track Refered Purpose List of Covered Drugs The List of Covered Drugs that begins on the next page gives you information about the drugs covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the Index that begins on page 103. 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., simvastatin). The information in the column tells you if UnitedHealthcare Connected has any rules for covering your drug. Coverage Rules and Limits PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. If you don t get approval, UnitedHealthcare Connected may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Connected limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected 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. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. LA - Limited access Drugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. MED - Morphine equivalent dose Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is calculated based on the number of opioid drugs prescribed for you over a period of time. This cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for those individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 9

10 Acephen Acetaminophen Butalbital/Acetaminophen Butalbital/Acetaminophen/Caffeine Butalbital/Aspirin/Caffeine Childrens Mapap Rapid Tabs ED-APAP GNP Arthritis Pain Relief Junior Mapap 1For 10 Track Refered Purpose 10 For Track Refered Purpose Note: The asterisk (*) 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 getting 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 Texas 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 , TTY You can also read the Member Handbook to learn how to appeal a decision. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used 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. Analgesics Analgesics acephen (suppository)* $0 (Tier 3) acetaminophen (tablet)* $0 (Tier 3) butalbital/acetaminophen (50mg-325mg tablet) QL butalbital/acetaminophen/caffeine (325mg-50mg-40mg tablet, 50mg-325mg-40mg QL capsule) butalbital/aspirin/caffeine (50mg-325mg-40mg capsule) QL childrens mapap rapid tabs (tablet dispersible)* $0 (Tier 3) ed-apap (liquid)* $0 (Tier 3) gnp arthritis pain relief (tablet extended-release)* $0 (Tier 3) junior mapap (tablet dispersible)* $0 (Tier 3) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

11 Mapap Acetaminophen Extra Strength Mapap Arthritis Pain Mapap Childrens Pain & Fever Pain & Fever Childrens Pain & Fever Extra Strength Pain & Fever Infants QC Arthritis Pain Relief Q-PAP Q-PAP Childrens Q-PAP Extra Strength Tencon Zebutal All Day Pain Relief All Day Relief Aspirin Aspirin EC Aspirin EC Low Dose Aspirin Low Dose Aspirin Low Strength Aspir-Low Childrens Aspirin Childrens Ibuprofen Childs Ibuprofen Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium DR Diclofenac Sodium ER Diflunisal 2For 11 Track Refered Purpose Mapap mapap (160mg/5ml liquid, 325mg tablet, 500mg tablet, 500mg capsule, 80mg tablet chewable)* $0 (Tier 3) mapap acetaminophen extra strength (liquid)* $0 (Tier 3) mapap arthritis pain (tablet extended-release)* $0 (Tier 3) mapap childrens (160mg/5ml suspension, 80mg tablet dispersible)* $0 (Tier 3) pain & fever (tablet)* $0 (Tier 3) pain & fever childrens (160mg/5ml oral solution, 160mg/5ml suspension, 80mg tablet chewable)* $0 (Tier 3) pain & fever extra strength (tablet)* $0 (Tier 3) pain & fever infants (suspension)* $0 (Tier 3) qc arthritis pain relief (tablet extended-release)* $0 (Tier 3) q-pap (tablet)* $0 (Tier 3) q-pap childrens (suspension)* $0 (Tier 3) q-pap extra strength (tablet)* $0 (Tier 3) tencon (tablet) QL zebutal (capsule) QL Nonsteroidal Anti-inflammatory Drugs all day pain relief (otc only) (tablet)* $0 (Tier 3) all day relief (tablet)* $0 (Tier 3) aspirin (325mg tablet, 325mg tablet delayed-release, 81mg tablet delayed-release, 81mg tablet $0 (Tier 3) chewable)* aspirin ec (tablet delayed-release)* $0 (Tier 3) aspirin ec low dose (tablet delayed-release)* $0 (Tier 3) aspirin low dose (tablet chewable)* $0 (Tier 3) aspirin low strength (tablet chewable)* $0 (Tier 3) aspir-low (tablet delayed-release)* $0 (Tier 3) childrens aspirin (tablet chewable)* $0 (Tier 3) childrens ibuprofen (otc only) (suspension)* $0 (Tier 3) childs ibuprofen (otc only) (suspension)* $0 (Tier 3) diclofenac potassium (tablet) diclofenac sodium (1% gel) PA diclofenac sodium dr (tablet delayed-release) diclofenac sodium er (tablet extended-release 24 hour) diflunisal (tablet) 11

12 Enteric Coated Aspirin Etodolac Flector Flurbiprofen GNP Ibuprofen GNP Ibuprofen Junior Strength Goodsense Ibuprofen Goodsense Ibuprofen Childrens Goodsense Ibuprofen Infants Ibu-200 Ibu-Drops Ibu-Drops Infants Ibuprofen Ibuprofen Ibuprofen Childrens Ibuprofen Junior Strength Indomethacin Infants Ibuprofen Ketoprofen Ketorolac Tromethamine 3For 12 Track Refered Purpose 12 enteric coated aspirin (tablet delayed-release)* $0 (Tier 3) etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediaterelease) FLECTOR (PATCH) $3.70-$8.35 (Tier 2) PA, QL flurbiprofen (tablet) gnp ibuprofen (otc only) (tablet)* $0 (Tier 3) gnp ibuprofen junior strength (otc only) (tablet chewable)* $0 (Tier 3) goodsense ibuprofen (tablet)* $0 (Tier 3) goodsense ibuprofen childrens (suspension)* $0 (Tier 3) goodsense ibuprofen infants (suspension)* $0 (Tier 3) ibu-200 (tablet)* $0 (Tier 3) ibu-drops (suspension)* $0 (Tier 3) ibu-drops infants (suspension)* $0 (Tier 3) ibuprofen (otc only) (100mg/5ml suspension, 200mg capsule, 200mg tablet)* $0 (Tier 3) ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) ibuprofen childrens (otc only) (suspension)* $0 (Tier 3) ibuprofen junior strength (otc only) (tablet chewable)* $0 (Tier 3) indomethacin (25mg capsule, 50mg capsule) infants ibuprofen (otc only) (suspension)* $0 (Tier 3) ketoprofen (capsule immediate-release) ketorolac tromethamine (15mg/ml injection, 30mg/ ml injection, 60mg/2ml injection) Meloxicameloxicam (tablet) Migraine Formula migraine formula (tablet)* $0 (Tier 3) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

13 Naproxen DR QC Naproxen Sodium SM Ibuprofen Sulindac Embeda Fentanyl Hydromorphone HCl ER Hysingla ER Levorphanol Tartrate Methadone HCl Methadone HCl Morphine Sulfate ER Nucynta ER Tramadol HCl ER Xtampza ER Abstral Acetaminophen/Codeine Butorphanol Tartrate 4For 13 Track Refered Purpose Naproxenaproxen (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediate-release, 500mg tablet immediate-release) naproxen dr (tablet delayed-release) (generic ecnaprosyn) qc naproxen sodium (otc only) (tablet)* $0 (Tier 3) sm ibuprofen (otc only) (tablet)* $0 (Tier 3) sulindac (tablet) Opioid Analgesics, Long-acting EMBEDA (CAPSULE EXTENDED-RELEASE) $3.70-$8.35 (Tier 2) QL, MED fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch QL, MED 72 hour, 75mcg/hr patch 72 hour) hydromorphone hcl er (tablet extended-release 24 hour abuse-deterrent) QL, MED HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR ABUSE-DETERRENT) $3.70-$8.35 (Tier 2) QL, MED levorphanol tartrate (tablet) QL, MED methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution) QL, MED METHADONE HCL (10MG/ML INJECTION) $3.70-$8.35 (Tier 2) morphine sulfate er (100mg tablet extended-release, 15mg tablet extended-release, 200mg tablet extended-release, 30mg tablet extended-release, QL, MED 60mg tablet extended-release) (generic ms contin) NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.70-$8.35 (Tier 2) QL, MED tramadol hcl er (100mg tablet extended-release 24 hour, 200mg tablet extended-release 24 hour, QL, MED 300mg tablet extended-release 24 hour) XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12 HOUR ABUSE-DETERRENT) $3.70-$8.35 (Tier 2) QL, MED Opioid Analgesics, Short-acting ABSTRAL (TABLET SUBLINGUAL) $3.70-$8.35 (Tier 2) PA, QL acetaminophen/codeine (120mg-12mg/5ml oral solution, 300mg-15mg tablet, 300mg-30mg tablet, QL, MED 300mg-60mg tablet) butorphanol tartrate (10mg/ml nasal solution) QL, MED 13

14 Codeine Sulfate Duramorph Endocet Fentanyl Citrate Oral Transmucosal Hydrocodone/Acetaminophen Hydrocodone/Ibuprofen Hydromorphone HCl Hydromorphone HCl Hydromorphone HCl Lorcet Lorcet HD Lorcet Plus Morphine Sulfate Morphine Sulfate Morphine Sulfate Morphine Sulfate Nalbuphine HCl 5For 14 Track Refered Purpose 14 Butorphanol Tartrate butorphanol tartrate (1mg/ml injection, 2mg/ml injection) codeine sulfate (tablet) QL, MED DURAMORPH (INJECTION) $3.70-$8.35 (Tier 2) endocet (tablet) QL, MED fentanyl citrate oral transmucosal (lozenge on a handle) PA, QL hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet, 7.5mg-325mg/15ml oral QL, MED solution) hydrocodone/ibuprofen (7.5mg-200mg tablet) QL, MED hydromorphone hcl (10mg/ml injection, 50mg/5ml injection) hydromorphone hcl (1mg/ml liquid, 2mg tablet immediate-release, 4mg tablet immediate-release, QL, MED 8mg tablet immediate-release) HYDROMORPHONE HCL (2MG/ML INJECTION) $3.70-$8.35 (Tier 2) lorcet (tablet) QL, MED lorcet hd (tablet) QL, MED lorcet plus (tablet) QL, MED morphine sulfate (100mg/5ml oral solution, 10mg/ 5ml oral solution, 20mg/5ml oral solution) QL, MED morphine sulfate (10mg/ml injection, 4mg/ml injection, 8mg/ml injection) MORPHINE SULFATE (15MG TABLET IMMEDIATE- RELEASE, 30MG TABLET IMMEDIATE-RELEASE) $3.70-$8.35 (Tier 2) QL, MED MORPHINE SULFATE (2MG/ML INJECTION, 5MG/ML INJECTION) $3.70-$8.35 (Tier 2) nalbuphine hcl (injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

15 Oxycodone/Acetaminophen Oxycodone/Aspirin Oxycodone/Ibuprofen Tramadol HCl Tramadol HCl/Acetaminophen Trezix Lidocaine Lidocaine Lidocaine HCl Lidocaine HCl Lidocaine HCl Lidocaine Viscous Lidocaine/Prilocaine Acamprosate Calcium DR Disulfiram Naltrexone HCl Vivitrol Buprenorphine HCl Buprenorphine HCl Buprenorphine HCl/Naloxone HCl Suboxone 6For 15 Track Refered Purpose Oxycodone HCl oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediaterelease, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) QL, MED oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, QL, MED 7.5mg-325mg tablet) oxycodone/aspirin (tablet) QL, MED oxycodone/ibuprofen (tablet) QL, MED tramadol hcl (tablet immediate-release) QL, MED tramadol hcl/acetaminophen (tablet) QL, MED trezix (capsule) QL, MED Anesthetics Local Anesthetics lidocaine (rx only) (5% ointment) lidocaine (rx only) (5% patch) PA, QL lidocaine hcl (0.5% injection, 1% injection, 2% injection) B/D, PA lidocaine hcl (4% external solution) lidocaine hcl (gel) lidocaine viscous (solution) lidocaine/prilocaine (cream) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr (tablet delayed-release) disulfiram (tablet) naltrexone hcl (tablet) VIVITROL (INJECTION) $3.70-$8.35 (Tier 2) Opioid Dependence Treatments buprenorphine hcl (0.3mg/ml injection) buprenorphine hcl (2mg tablet sublingual, 8mg tablet sublingual) QL buprenorphine hcl/naloxone hcl (tablet sublingual) QL SUBOXONE (FILM) $3.70-$8.35 (Tier 2) QL 15

16 Naloxone HCl Narcan Chantix Chantix Continuing Month Pak Chantix Starting Month Pak NicoDerm CQ NICOrelief Nicorette Nicorette Mini Nicorette Starter Kit Nicotine Polacrilex Nicotine Transdermal System Nicotine Transdermal System Step 1 Nicotine Transdermal System Step 2 Nicotine Transdermal System Step 3 Nicotrol Inhaler 7For 16 Track Refered Purpose 16 Opioid Reversal Agents naloxone hcl (injection) NARCAN (LIQUID) $3.70-$8.35 (Tier 2) Smoking Cessation Agents Bupropion HCl SR bupropion hcl sr (150mg tablet extended-release 12 hour) CHANTIX (TABLET) $3.70-$8.35 (Tier 2) CHANTIX CONTINUING MONTH PAK (TABLET) $3.70-$8.35 (Tier 2) CHANTIX STARTING MONTH PAK (TABLET) $3.70-$8.35 (Tier 2) nicoderm cq (patch 24 hour)* $0 (Tier 3) nicorelief (gum)* $0 (Tier 3) nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* $0 (Tier 3) nicorette mini (lozenge)* $0 (Tier 3) nicorette starter kit (gum)* $0 (Tier 3) nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* $0 (Tier 3) nicotine transdermal system (14mg/24hr patch 24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24 $0 (Tier 3) hour)* nicotine transdermal system step 1 (patch 24 hour)* $0 (Tier 3) nicotine transdermal system step 2 (patch 24 hour)* $0 (Tier 3) nicotine transdermal system step 3 (patch 24 hour)* $0 (Tier 3) NICOTROL INHALER (INHALER) $3.70-$8.35 (Tier 2) Antibacterials Aminoglycosides Amikacin Sulfate amikacin sulfate (injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

17 Gentak Gentamicin Sulfate Gentamicin Sulfate/0.9% Sodium Chloride Isotonic Gentamicin Neomycin Sulfate Paromomycin Sulfate Streptomycin Sulfate Tobramycin Sulfate Tobrex BACiiM Bacitracin Bacitracin Bacitracin Zinc Bacitracin/Neomycin/Polymyxin Bactroban Nasal Chloramphenicol Sodium Succinate Clindamycin HCl Clindamycin Palmitate HCl Clindamycin Phosphate Clindamycin Phosphate in D5W Colistimethate Sodium Cubicin Dalvance Daptomycin Lincomycin HCl Linezolid Linezolid Methenamine Hippurate 8For 17 Track Refered Purpose gentak (ophthalmic ointment) gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% ophthalmic solution, 10mg/ml injection, 40mg/ ml injection) gentamicin sulfate/0.9% sodium chloride (injection) isotonic gentamicin (injection) neomycin sulfate (tablet) paromomycin sulfate (capsule) streptomycin sulfate (injection) tobramycin sulfate (0.3% ophthalmic solution, 10mg/ ml injection, 80mg/2ml injection) TOBREX (0.3% OPHTHALMIC OINTMENT) $3.70-$8.35 (Tier 2) Antibacterials, Other baciim (injection) bacitracin (otc only) (ointment)* $0 (Tier 3) bacitracin (rx only) (50000unit injection, 500unit/gm ophthalmic ointment) bacitracin zinc (ointment)* $0 (Tier 3) bacitracin/neomycin/polymyxin (otc only) (ointment)* $0 (Tier 3) BACTROBAN NASAL (OINTMENT) $3.70-$8.35 (Tier 2) PA chloramphenicol sodium succinate (injection) clindamycin hcl (capsule immediate-release) clindamycin palmitate hcl (oral solution) clindamycin phosphate (2% cream, 300mg/2ml injection, 600mg/4ml injection, 900mg/6ml injection) clindamycin phosphate in d5w (injection) colistimethate sodium (injection) CUBICIN (INJECTION) $3.70-$8.35 (Tier 2) DALVANCE (INJECTION) $3.70-$8.35 (Tier 2) PA daptomycin (injection) lincomycin hcl (injection) linezolid (100mg/5ml suspension, 600mg/300ml injection) PA linezolid (600mg tablet) PA, QL methenamine hippurate (tablet) 17

18 Metronidazole in NaCl 0.79% Metronidazole Vaginal Mupirocin Neomycin/Polymyxin B Sulfates Nitrofurantoin Monohydrate Polymyxin B Sulfate Povidone-Iodine Synercid Tigecycline Tinidazole Trimethoprim Triple Antibiotic Triple Antibiotic Plus Tygacil Vancomycin HCl Vandazole 9For 18 Track Refered Purpose 18 Metronidazole metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75% lotion, 250mg tablet immediate-release, 500mg tablet immediate-release) metronidazole in nacl 0.79% (injection) metronidazole vaginal (gel) mupirocin (2% ointment) neomycin/polymyxin b sulfates (irrigation solution) Nitrofurantoinitrofurantoin (suspension) Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg capsule) (generic macrodantin) nitrofurantoin monohydrate (100mg capsule) (generic macrobid) polymyxin b sulfate (injection) povidone-iodine (10% external solution, 10% ointment)* $0 (Tier 3) SYNERCID (INJECTION) $3.70-$8.35 (Tier 2) TIGECYCLINE (INJECTION) $3.70-$8.35 (Tier 2) tinidazole (tablet) trimethoprim (tablet) triple antibiotic (ointment)* $0 (Tier 3) triple antibiotic plus (ointment)* $0 (Tier 3) TYGACIL (INJECTION) $3.70-$8.35 (Tier 2) vancomycin hcl (1000mg injection, 10gm injection, 500mg injection, 125mg capsule, 250mg capsule) VANDAZOLE (GEL) $3.70-$8.35 (Tier 2) Beta-lactam, Cephalosporins Cefaclor cefaclor (250mg capsule immediate-release, 500mg capsule immediate-release) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

19 Cefazolin Sodium Cefdinir Cefepime Cefixime Cefotaxime Sodium Cefotetan Cefoxitin Sodium Cefpodoxime Proxetil Cefprozil Ceftazidime Ceftriaxone Sodium Cefuroxime Axetil Cefuroxime Sodium Cephalexin Suprax Suprax Tazicef Zerbaxa Aztreonam Imipenem/Cilastatin Invanz For Track Refered Purpose Cefadroxil cefadroxil (250mg/5ml suspension, 500mg/5ml suspension, 500mg capsule) cefazolin sodium (injection) cefdinir (125mg/5ml suspension, 250mg/5ml suspension, 300mg capsule) cefepime (injection) cefixime (suspension) cefotaxime sodium (injection) cefotetan (injection) cefoxitin sodium (10gm injection, 1gm injection, 2gm injection) cefpodoxime proxetil (100mg tablet, 200mg tablet, 100mg/5ml suspension, 50mg/5ml suspension) cefprozil (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) ceftazidime (injection) ceftriaxone sodium (10gm injection, 1gm injection, 250mg injection, 2gm injection, 500mg injection) cefuroxime axetil (tablet) cefuroxime sodium (injection) cephalexin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule, 750mg capsule) suprax (100mg tablet chewable, 200mg tablet chewable) SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.70-$8.35 (Tier 2) tazicef (injection) ZERBAXA (INJECTION) $3.70-$8.35 (Tier 2) PA Beta-lactam, Other Azactam AZACTAM (INJECTION) $3.70-$8.35 (Tier 2) aztreonam (injection) imipenem/cilastatin (injection) INVANZ (INJECTION) $3.70-$8.35 (Tier 2) Meropenemeropenem (injection) Beta-lactam, Penicillins 19

20 Amoxicillin/Clavulanate Potassium Amoxicillin/Clavulanate Potassium ER Ampicillin Ampicillin Sodium Ampicillin-Sulbactam Bactocill in Dextrose Bicillin C-R Bicillin L-A Dicloxacillin Sodium Nafcillin Sodium Oxacillin Sodium Penicillin G Potassium Penicillin G Procaine Penicillin G Sodium For Track Refered Purpose 20 Amoxicillin amoxicillin (125mg tablet chewable, 250mg tablet chewable, 125mg/5ml suspension, 200mg/5ml suspension, 250mg/5ml suspension, 400mg/5ml suspension, 250mg capsule, 500mg capsule, 500mg tablet, 875mg tablet) amoxicillin/clavulanate potassium (200mg-28.5mg tablet chewable, 400mg-57mg tablet chewable, 200mg/5ml-28.5mg/5ml suspension, 250mg/ 5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml suspension, 600mg/5ml-42.9mg/5ml suspension, 250mg-125mg tablet immediate-release, 500mg-125mg tablet immediate-release, 875mg-125mg tablet immediate-release) (generic augmentin) amoxicillin/clavulanate potassium er (tablet extended-release 12 hour) ampicillin (capsule) ampicillin sodium (10gm injection, 125mg injection, 1gm injection) ampicillin-sulbactam (injection) BACTOCILL IN DEXTROSE (INJECTION) $3.70-$8.35 (Tier 2) BICILLIN C-R (INJECTION) $3.70-$8.35 (Tier 2) BICILLIN L-A (INJECTION) $3.70-$8.35 (Tier 2) dicloxacillin sodium (capsule) nafcillin sodium (injection) oxacillin sodium (injection) penicillin g potassium (injection) penicillin g procaine (injection) penicillin g sodium (injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

21 Piperacillin/Tazobactam Clarithromycin Clarithromycin ER Dificid E.E.S. Granules Ery-Tab EryPed 200 EryPed 400 Erythrocin Lactobionate Erythromycin Erythromycin Base Erythromycin Ethylsuccinate Zmax Avelox Ciprofloxacin Ciprofloxacin ER Ciprofloxacin HCl Ciprofloxacin I.V. in D5W Levofloxacin Levofloxacin in D5W For Track Refered Purpose 21 Penicillin V Potassium penicillin v potassium (125mg/5ml oral solution, 250mg/5ml oral solution, 250mg tablet, 500mg tablet) piperacillin/tazobactam (injection) Macrolides Azithromycin azithromycin (100mg/5ml suspension, 200mg/5ml suspension, 250mg tablet, 500mg tablet, 500mg injection, 600mg tablet) clarithromycin (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) clarithromycin er (tablet extended-release 24 hour) DIFICID (TABLET) $3.70-$8.35 (Tier 2) E.E.S. GRANULES (SUSPENSION) $3.70-$8.35 (Tier 2) ery-tab (tablet delayed-release) ERYPED 200 (SUSPENSION) $3.70-$8.35 (Tier 2) ERYPED 400 (SUSPENSION) $3.70-$8.35 (Tier 2) erythrocin lactobionate (injection) erythromycin (250mg capsule delayed-release, 5mg/ gm ophthalmic ointment) erythromycin base (tablet) erythromycin ethylsuccinate (200mg/5ml suspension, 400mg tablet) ZMAX (SUSPENSION) $3.70-$8.35 (Tier 2) Quinolones AVELOX (400MG/250ML-0.8% INJECTION) $3.70-$8.35 (Tier 2) ciprofloxacin (250mg/5ml suspension, 500mg/5ml suspension, 400mg/40ml injection) ciprofloxacin er (tablet extended-release 24 hour) ciprofloxacin hcl (0.3% ophthalmic solution, 100mg tablet immediate-release, 250mg tablet immediaterelease, 500mg tablet immediate-release, 750mg tablet immediate-release) ciprofloxacin i.v. in d5w (injection) levofloxacin (0.5% ophthalmic solution, 250mg tablet, 500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/ml oral solution) levofloxacin in d5w (injection)

22 Moxeza Moxifloxacin HCl Moxifloxacin HCl Ofloxacin Vigamox Sodium Sulfacetamide SSD Sulfacetamide Sodium Sulfadiazine Sulfamethoxazole/Trimethoprim Sulfamethoxazole/Trimethoprim DS Demeclocycline HCl Doxy 100 Doxycycline Doxycycline Hyclate Doxycycline Monohydrate Minocycline HCl Tetracycline HCl For Track Refered Purpose 22 MOXEZA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2) moxifloxacin hcl (0.5% ophthalmic solution, 400mg tablet) MOXIFLOXACIN HCL (400MG/250ML INJECTION) ofloxacin (0.3% ophthalmic solution, 0.3% otic solution, 300mg tablet, 400mg tablet) VIGAMOX (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2) Sulfonamides Silver Sulfadiazine SILVER SULFADIAZINE (CREAM) $3.70-$8.35 (Tier 2) sodium sulfacetamide (ophthalmic solution) SSD (CREAM) $3.70-$8.35 (Tier 2) sulfacetamide sodium (ophthalmic ointment) sulfadiazine (tablet) sulfamethoxazole/trimethoprim (200mg-40mg/5ml suspension, 400mg-80mg tablet, 400mg-80mg/5ml injection) sulfamethoxazole/trimethoprim ds (tablet) Tetracyclines demeclocycline hcl (tablet) doxy 100 (injection) doxycycline (25mg/5ml suspension) doxycycline hyclate (100mg capsule, 50mg capsule, 100mg tablet immediate-release, 150mg tablet immediate-release, 75mg tablet immediate-release, 20mg tablet immediate-release) doxycycline monohydrate (100mg capsule, 50mg capsule, 100mg tablet, 50mg tablet, 75mg tablet) minocycline hcl (capsule) tetracycline hcl (capsule) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

23 Levetiracetam Levetiracetam ER Roweepra Spritam Zonisamide Diastat AcuDial Diastat Pediatric Gabapentin Gabitril Onfi Onfi Phenobarbital Primidone Sabril Tiagabine HCl Valproate Sodium For Track Refered Purpose 23 Vibramycin VIBRAMYCIN (50MG/5ML SYRUP) $3.70-$8.35 (Tier 2) Anticonvulsants Anticonvulsants, Other BRIVIACT (100MG TABLET, 10MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET, 10MG/ML ORAL SOLUTION, 50MG/5ML INJECTION) $3.70-$8.35 (Tier 2) QL levetiracetam (1000mg tablet immediate-release, 250mg tablet immediate-release, 500mg tablet immediate-release, 750mg tablet immediate-release, 1000mg/100ml injection, 1500mg/100ml injection, 500mg/100ml injection, 500mg/5ml injection, 100mg/ml oral solution) levetiracetam er (tablet extended-release 24 hour) roweepra (tablet) SPRITAM (TABLET DISINTEGRATING SOLUBLE) $3.70-$8.35 (Tier 2) Calcium Channel Modifying Agents Celontin CELONTIN (CAPSULE) $3.70-$8.35 (Tier 2) Ethosuximidethosuximide (250mg capsule, 250mg/5ml oral solution) zonisamide (capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT ACUDIAL (GEL) $3.70-$8.35 (Tier 2) DIASTAT PEDIATRIC (GEL) $3.70-$8.35 (Tier 2) gabapentin (100mg capsule, 300mg capsule, 400mg capsule, 250mg/5ml oral solution, 600mg tablet, 800mg tablet) GABITRIL (12MG TABLET, 16MG TABLET) $3.70-$8.35 (Tier 2) QL ONFI (10MG TABLET, 20MG TABLET) $3.70-$8.35 (Tier 2) QL ONFI (2.5MG/ML SUSPENSION) $3.70-$8.35 (Tier 2) phenobarbital (100mg tablet, 15mg tablet, 16.2mg tablet, 30mg tablet, 32.4mg tablet, 60mg tablet, 64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir) primidone (tablet) SABRIL (500MG PACKET, 500MG TABLET) $3.70-$8.35 (Tier 2) PA, QL, LA tiagabine hcl (tablet) valproate sodium (100mg/ml injection)

24 Vigabatrin Fycompa Lamotrigine Topiramate Aptiom Carbamazepine Carbamazepine ER Dilantin For Track Refered Purpose 24 Valproic Acid valproic acid (250mg capsule, 250mg/5ml oral solution) vigabatrin (packet) PA, QL Glutamate Reducing Agents Felbamate felbamate (400mg tablet, 600mg tablet, 600mg/5ml suspension) FYCOMPA (0.5MG/ML SUSPENSION, 10MG TABLET, 12MG TABLET, 2MG TABLET, 4MG TABLET, 6MG TABLET, 8MG TABLET) lamotrigine (100mg tablet immediate-release, 150mg tablet immediate-release, 200mg tablet immediaterelease, 25mg tablet immediate-release, 25mg tablet chewable, 5mg tablet chewable) topiramate (100mg tablet immediate-release, 200mg tablet immediate-release, 25mg tablet immediaterelease, 50mg tablet immediate-release, 15mg capsule sprinkle immediate-release, 25mg capsule sprinkle immediate-release) Sodium Channel Agents $3.70-$8.35 (Tier 2) APTIOM (TABLET) $3.70-$8.35 (Tier 2) QL Banzel BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION) $3.70-$8.35 (Tier 2) carbamazepine (100mg tablet chewable, 100mg/5ml suspension, 200mg tablet immediate-release) carbamazepine er (100mg capsule extended-release 12 hour, 200mg capsule extended-release 12 hour, 300mg capsule extended-release 12 hour, 100mg tablet extended-release 12 hour, 200mg tablet extended-release 12 hour, 400mg tablet extendedrelease 12 hour) dilantin (capsule) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

25 Dilantin INFATABS Epitol Fosphenytoin Sodium Oxcarbazepine Peganone Phenytek Phenytoin Phenytoin Sodium Phenytoin Sodium Extended Vimpat Vimpat Donepezil HCl Donepezil HCl ODT Rivastigmine Tartrate Rivastigmine Transdermal System Memantine HCl Titration Pak Namenda XR Titration Pack Bupropion HCl Bupropion HCl SR Bupropion HCl XL For Track Refered Purpose dilantin infatabs (tablet chewable) epitol (tablet) fosphenytoin sodium (injection) oxcarbazepine (150mg tablet, 300mg tablet, 600mg tablet, 300mg/5ml suspension) PEGANONE (TABLET) $3.70-$8.35 (Tier 2) phenytek (capsule) phenytoin (125mg/5ml suspension, 50mg tablet chewable) phenytoin sodium (injection) phenytoin sodium extended (capsule) VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2) QL VIMPAT (200MG/20ML INJECTION) $3.70-$8.35 (Tier 2) Antidementia Agents Cholinesterase Inhibitors donepezil hcl (10mg tablet, 5mg tablet) QL donepezil hcl odt (tablet dispersible) QL rivastigmine tartrate (capsule) QL rivastigmine transdermal system (patch 24 hour) QL, ST N-methyl-D-aspartate (NMDA) Receptor Antagonist Memantine HCl memantine hcl (10mg tablet, 5mg tablet, 2mg/ml oral solution) PA, QL MEMANTINE HCL TITRATION PAK (TABLET) $3.70-$8.35 (Tier 2) PA Namenda XR NAMENDA XR (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) PA, QL NAMENDA XR TITRATION PACK (CAPSULE EXTENDED- RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) PA, QL Antidepressants Antidepressants, Other bupropion hcl (tablet immediate-release) bupropion hcl sr (100mg tablet extended-release 12 hour, 150mg tablet extended-release 12 hour, 200mg tablet extended-release 12 hour) bupropion hcl xl (tablet extended-release 24 hour) 25

26 Mirtazapine Mirtazapine ODT Emsam Marplan Phenelzine Sulfate Tranylcypromine Sulfate Desvenlafaxine ER Escitalopram Oxalate Fetzima Fluoxetine DR Fluoxetine HCl Fluvoxamine Maleate Maprotiline HCl Nefazodone HCl Paroxetine HCl Paxil For Track Refered Purpose 26 mirtazapine (tablet) mirtazapine odt (tablet dispersible) Monoamine Oxidase Inhibitors EMSAM (PATCH 24 HOUR) $3.70-$8.35 (Tier 2) QL MARPLAN (TABLET) $3.70-$8.35 (Tier 2) phenelzine sulfate (tablet) tranylcypromine sulfate (tablet) SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Citalopram HBr citalopram hbr (10mg tablet, 20mg tablet, 40mg tablet, 10mg/5ml oral solution) desvenlafaxine er (100mg tablet extended-release 24 hour, 25mg tablet extended-release 24 hour, 50mg QL tablet extended-release 24 hour) escitalopram oxalate (10mg tablet, 20mg tablet, 5mg tablet, 5mg/5ml oral solution) FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) QL, ST Fetzima Titration Pack FETZIMA TITRATION PACK (CAPSULE EXTENDED- RELEASE 24 HOUR THERAPY PACK) $3.70-$8.35 (Tier 2) ST fluoxetine dr (capsule delayed-release) fluoxetine hcl (10mg capsule immediate-release, 20mg capsule immediate-release, 40mg capsule immediate-release, 20mg/5ml oral solution) fluvoxamine maleate (tablet) maprotiline hcl (tablet) nefazodone hcl (tablet) paroxetine hcl (tablet immediate-release) PAXIL (10MG/5ML SUSPENSION) $3.70-$8.35 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

27 Trazodone HCl Trintellix Venlafaxine HCl Venlafaxine HCl ER Viibryd Viibryd Starter Pack Amitriptyline HCl Amoxapine Clomipramine HCl Desipramine HCl Doxepin HCl Imipramine HCl Imipramine Pamoate Nortriptyline HCl Protriptyline HCl Trimipramine Maleate Compro Formula EM Hydroxyzine Pamoate Meclizine HCl Meclizine HCl Metoclopramide HCl Perphenazine Prochlorperazine For Track Refered Purpose Sertraline HCl sertraline hcl (100mg tablet, 25mg tablet, 50mg tablet, 20mg/ml concentrate) trazodone hcl (tablet) TRINTELLIX (TABLET) $3.70-$8.35 (Tier 2) QL venlafaxine hcl (tablet immediate-release) venlafaxine hcl er (150mg capsule extended-release 24 hour, 37.5mg capsule extended-release 24 hour, 75mg capsule extended-release 24 hour) VIIBRYD (TABLET) $3.70-$8.35 (Tier 2) QL VIIBRYD STARTER PACK (KIT) $3.70-$8.35 (Tier 2) QL Tricyclics amitriptyline hcl (tablet) amoxapine (tablet) clomipramine hcl (capsule) desipramine hcl (tablet) doxepin hcl (100mg capsule, 10mg capsule, 150mg capsule, 25mg capsule, 50mg capsule, 75mg capsule, 10mg/ml concentrate) imipramine hcl (tablet) imipramine pamoate (capsule) nortriptyline hcl (10mg capsule, 25mg capsule, 50mg capsule, 75mg capsule, 10mg/5ml oral solution) protriptyline hcl (tablet) trimipramine maleate (capsule) Antiemetics Antiemetics, Other compro (suppository) formula em (oral solution)* $0 (Tier 3) hydroxyzine pamoate (capsule) meclizine hcl (otc only) (tablet)* $0 (Tier 3) meclizine hcl (rx only) (tablet) metoclopramide hcl (10mg tablet, 5mg tablet, 5mg/ 5ml oral solution, 5mg/ml injection) perphenazine (tablet) prochlorperazine (suppository) 27

28 Prochlorperazine Edisylate Prochlorperazine Maleate Scopolamine Transderm-Scop Aloxi Anzemet Aprepitant Cesamet Dronabinol Emend Emend Granisetron HCl Granisetron HCl Ondansetron HCl Ondansetron HCl Ondansetron ODT Sancuso Abelcet AmBisome Amphotericin B Antifungal For Track Refered Purpose 28 prochlorperazine edisylate (injection) prochlorperazine maleate (tablet) scopolamine (patch 72 hour) TRANSDERM-SCOP (PATCH 72 HOUR) $3.70-$8.35 (Tier 2) Travel Sickness travel sickness (otc only) (tablet)* $0 (Tier 3) Emetogenic Therapy Adjuncts ALOXI (INJECTION) $3.70-$8.35 (Tier 2) ANZEMET (100MG TABLET, 50MG TABLET) $3.70-$8.35 (Tier 2) B/D, PA aprepitant (therapy pack, capsule) PA CESAMET (CAPSULE) $3.70-$8.35 (Tier 2) PA dronabinol (capsule) PA, QL EMEND (125MG SUSPENSION) $3.70-$8.35 (Tier 2) PA EMEND (150MG INJECTION) $3.70-$8.35 (Tier 2) granisetron hcl (0.1mg/ml injection, 1mg/ml injection, 4mg/4ml injection) granisetron hcl (1mg tablet) B/D, PA, QL ondansetron hcl (24mg tablet, 4mg tablet, 8mg tablet, 4mg/5ml oral solution) B/D, PA ondansetron hcl (4mg/2ml injection) ondansetron odt (tablet dispersible) B/D, PA SANCUSO (PATCH) $3.70-$8.35 (Tier 2) Antifungals Antifungals ABELCET (INJECTION) $3.70-$8.35 (Tier 2) B/D, PA AMBISOME (INJECTION) $3.70-$8.35 (Tier 2) B/D, PA amphotericin b (injection) B/D, PA antifungal (1% aerosol, 1% cream, 2% cream)* $0 (Tier 3) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.