List of Covered Drugs

Transcription

1 List of Covered Drugs Effective January 1, 2018

2 INTRODUCTION We are pleased to provide the Gold Coast Health Plan List of Covered Drugs as a useful reference and informational tool. The GCHP List of Covered Drugs can assist practitioners in selecting clinically appropriate and cost effective products for their patients. The information contained in the GCHP List of Covered Drugs is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This List of Covered Drugs is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in this List of Covered Drugs is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. We assume no 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's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at PREFACE The GCHP List of Covered Drugs is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the GCHP List of Covered Drugs. Generics should be considered the first line of prescribing. Drugs represented in the GCHP List of Covered Drugs may have varying cost to the plan member based on the plans benefit structure. Generic medications typically are available at the lowest cost, brand-name medications on the GCHP List of Covered Drugs will generally cost more than generics, and brand-name medications not on the list will generally cost the most. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the GCHP Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts. The P&T Committee's voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. However, not all strengths or dosage forms of the generic name in may be generically available. The GCHP List of Covered Drugs is a mandatory generic drug list. So whenever a generic to a covered agent becomes available, it is added. And if the branded agent was part of the cover drug list, the branded agent will be removed from the covered drug list. Generic drugs are usually priced lower than their brand-name equivalents. Generic drugs are: Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. Manufactured in the same strength and dosage form as the brand-name drugs. When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). i

3 SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM) SGM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. The utilization management program is available for all therapeutic areas dispensed by our specialty pharmacies. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the GCHP List of Covered Drugs under the heading of Specialty Medications for your reference. SGM may also be combined with Inventory Management/ Dose Optimization and Optimal Drug Mix through High Performance Specialty Design to appropriately manage specialty medications. PLAN DESIGN The GCHP List of Covered Drugs is a closed drug list plan design. The medications listed on the drug list are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Step Therapy, LMN, CPA, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. Should it become necessary to write a prescription for a drug, which is not on the GCHP List of Covered Drugs, one must obtain clinical prior authorization. LEGEND CPA Clinical Prior Authorization QL Quantity Limit STEP Step Therapy OTC Over the Counter DRUG COST KEY $ $1 to $10 $$ $11 to $50 $$$ $51 to $100 $$$$ $101 to $500 $$$$$ $501 to $1,000 $$$$$$ $1,001 to $5,000 $$$$$$$ $5,001 to $10,000 ii

4 EXCLUDED THERAPEUTIC CLASSES AND DRUGS FROM GCHP LIST OF DRUGS These therapeutic classes of drugs are carved out from the GCHP List of Covered Drugs. This means that when one of these medications is prescribed, it will be filled by the pharmacist, who in turn will bill the State of California for reimbursement. Acamprosate Calcium Buprenorphine HCl Buprenorphine HCl-Naloxone HCl DEPENDENCTY TREATMENT Buprenorphine Transdermal Patch Naltrexone Naltrexone HCl Naltrexone Microsphere Injectable Suspension Naloxone HCL HIV Abacavir Sulfate Elvitegravir-Cobicistat-Emtricitabine- Lopinavir-Ritonavir Abacavir Sulfate-Lamivudine Tenofovir DF Maraviroc Abacavir Sulfate-Lamivudine-Zidovudine Elvitegravir-Cobicistat-Emtricitabine- Nevirapine Abacavir Sulfate-Dolutegravir-Lamivudine Tenofovir Alafenamide Nelfinavir Mesylate Atazanavir Sulfate Emtricitabine Raltegravir Potassium Atazanavir-Cobisitat Emtricitabine-Rilpivirine-Tenofovir DF Rilpirvirine Hydrochloride Cobicistat Emtricitabine-Rilpivirine-Tenofovir Alafen. Ritonavir Darunavir Ethanolate Emtricitabine-Tenofovir DF Saquinavir Darunavir-Cobicistat Enfuvirtide Saquinavir Mesylate Delavirdine Mesylate Etravirine Stavudine Dolutegravir Fosamprenavir Calcium Tenofovir Disoproxil Fumarate Efavirenz Indinavir Sulfate Tipranavir Efavirenz-Emtricitabine-Tenofovir DF Elvitegravir Lamivudine Lamivudine-Zidovudine ERECTILE DYSFUNCTION COAGULATION FACTORS Antihemophilic Factor(Factor VIII) Factor VIIa Factor IX Factor IX Complex Factor XIIIa Factor XIII Antihemophilic Factor/Von Willebrand Complex Anti-inhibitor Coagulant Complex Von Willebrand Factor Complex PSYCHIATRIC Amantadine HCl Iloperidone Phenelzine Sulfate Aripiprazole Isocarboxazid Pimozide Asenapine Maleate Lithium Carbonate Quetiapine Benztropine Mesylate Lithium Citrate Risperidone Brexpiprazole Loxapine Succinate Selegiline TD Patch Cariprazine (pending) Lurasidone Hydrochloride Thioridazine HCl Chlorpromazine HCl Molindone HCl Thiothixene Clozapine Olanzapine Thiothixene HCl Fluphenazine Decanoate Olanzapine-Fluoxetine HCl Tranylcypromine Sulfate Fluphenazine HCl Olanzapine Pamoate Trifluoperazine HCl Haloperidol Paliperidone Trihexyphenidyl Haloperidol Decanoate Paliperidone Palmitate Ziprasidone HCl Haloperidol Lactate Perphenazine Ziprasidone Mesylate NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Gold Coast Health Plan. When viewing the GCHP List of Covered Drugs via the Internet, please be advised that the GCHP List of Covered Drugs is updated periodically and changes may appear prior to their effective date to allow for client notification. iii

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

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

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

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

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

10 January 2018 ANTI-INFECTIVES PENICILLINS amox-pot cla TAB ER amox/k clav sus 200/5ML amox/k clav sus 250/5ML amox/k clav sus 400/5ML amox/k clav sus 600/5ML amox/k clav TAB amox/k clav TAB amox/k clav TAB amoxicillin sus 125/5ML amoxicillin sus 200/5ML amoxicillin sus 250/5ML amoxicillin sus 250MG/5m amoxicillin sus 400/5ML amoxicillin CAP 250MG amoxicillin CAP 500MG amoxicillin TAB 500MG amoxicillin TAB 875MG amp-sulbacta inj 1.5gm PA amp-sulbacta inj 1-0.5gm PA amp-sulbacta inj 10-5gm PA amp-sulbacta inj 15gm PA amp-sulbacta inj 2-1gm PA amp-sulbacta inj 3gm PA ampicillin inj 1gm ampicillin inj 10gm ampicillin inj 2gm ampicillin inj 250MG ampicillin inj 500MG ampicillin CAP 250MG PA ampicillin CAP 500MG PA dicloxacill CAP 250MG dicloxacill CAP 500MG nafcillin inj 1gm PA nafcillin inj 10gm PA nafcillin inj 2gm PA oxacillin inj 1gm oxacillin inj 10gm oxacillin inj 2gm penicilln vk sol 125/5ML penicilln vk sol 250/5ML penicilln vk TAB 250MG penicilln vk TAB 500MG penicilln GK inj 20mu PA penicilln GK inj 5mu PA piper/tazoba inj gm PA piper/tazoba inj G PA piper/tazoba inj gm PA piper/tazoba inj 4-0.5gm PA Amox/K Clav Chw 200MG Amox/K Clav Chw 400MG Amoxicillin Chw 125MG Amoxicillin Chw 250MG Amoxicillin Pow Trihydra Amoxicillin TAB 775MG Amp-sulbacta Inj 1.5gm PA Ampicillin CAP 500MG PA Ampicillin Inj 1gm Ampicillin Inj 125MG Ampicillin Sus 125/5ML PA Ampicillin Sus 250/5ML PA Bicillin L-a Inj PA Bicillin L-a Inj PA Bicillin L-a Inj PA Nafcillin Inj 1gm PA Nafcillin Inj 1gm/50ML Nafcillin Inj 2gm PA Nafcillin Inj 2gm/100 Pen G Proc Inj Pen G Sod Inj Penicill GK/ Inj Dex 1mu Penicill GK/ Inj Dex 2mu Penicill GK/ Inj Dex 3mu Penicilln Vk Sol 125/5ML Penicilln Vk Sol 250/5ML Pfizerpen-G Inj 5mu PA Piper/Tazoba Inj gm PA Unasyn Inj 1.5gm PA Unasyn Inj 15gm PA Unasyn Inj 3gm PA PA CEPHALOSPORIN FIRST GENERATION cefadroxil sus 250/5ML cefadroxil sus 500/5ML cefadroxil CAP 500MG cefadroxil TAB 1gm cefazolin inj 1gm cefazolin inj 10gm cefazolin inj 500MG cephalexin sus 125/5ML cephalexin sus 250/5ML cephalexin CAP 250MG cephalexin CAP 500MG cephalexin CAP 750MG Cefazol/Dex Sol 1gm Cefazol/Dex Sol 2gm PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1

11 Cefazol/D5W Inj 2/100ML Cefazol/D5W Inj 2gm/50ML Cefazol/NACL Sol 2gm/100 Cefazol/NACL Sol 2gm/50ML Cefazolin Inj 1gm Cefazolin Inj 1gm/50ML Cefazolin Inj 100gm Cefazolin Inj 2gm/50ML Cefazolin Inj 20gm Cefazolin Inj 300gm Cefazolin Sol Cefazoln/D5W Inj 3G/100ML Cephalexin TAB 250MG Cephalexin TAB 500MG SECOND GENERATION cefaclor CAP 250MG cefaclor CAP 500MG cefotetan inj 1gm/10ML PA cefotetan inj 2gm/20ML PA cefoxitin inj 1gm PA cefoxitin inj 10gm PA cefoxitin inj 2gm PA cefprozil sus 125/5ML cefprozil sus 250/5ML cefprozil TAB 250MG cefprozil TAB 500MG cefuroxime inj 1.5gm cefuroxime inj 7.5gm cefuroxime inj 750MG cefuroxime TAB 250MG QL cefuroxime TAB 500MG QL Cefaclor ER TAB 500MG Cefaclor Sus 125/5ML Cefaclor Sus 250/5ML Cefaclor Sus 375/5ML Cefotan Inj 1gm/10ML PA Cefotan Inj 2gm PA Cefotet/Dex Inj % Cefotet/Dex Inj % Cefotetan Inj 10G PA Cefoxitin Inj 1gm Cefoxitin Inj 2gm Cefuroxime Inj 1.5gm PA THIRD GENERATION cefdinir sus 125/5ML cefdinir sus 250/5ML cefdinir CAP 300MG cefixime sus 100/5ML QL,PA cefixime sus 200/5ML PA cefpodo prox sus 100/5ML cefpodo prox sus 50MG/5ML cefpodoxime TAB 100MG cefpodoxime TAB 200MG ceftazidime inj 1gm PA ceftazidime inj 2gm PA ceftazidime inj 6gm PA ceftriaxone inj 1gm ceftriaxone inj 10gm ceftriaxone inj 2gm ceftriaxone inj 250MG ceftriaxone inj 500MG tazicef inj 1gm PA tazicef inj 2gm PA tazicef inj 6gm PA Cefditoren TAB 200MG Cefditoren TAB 400MG Cefotaxime Inj 1gm PA Cefotaxime Inj 10gm PA Cefotaxime Inj 2gm PA Cefotaxime Inj 500MG PA Ceftazidime/ Sol D5W 1gm Ceftazidime/ Sol D5W 2gm Ceftibuten CAP 400MG Ceftibuten Sus 180/5ML Ceftriax/Dex Inj 1gm Ceftriax/Dex Inj 2gm Ceftriaxone Inj 100gm Ceftriaxone/ Inj Dex 1gm Ceftriaxone/ Inj Dex 2gm Claforan Inj 1gm PA Claforan Inj 10gm PA Claforan Inj 2gm PA Claforan Inj 500MG PA Suprax CAP 400MG QL,PA Suprax Sus 100/5ML QL,PA Tazicef Inj 1gm PA Tazicef Inj 2gm PA FOURTH GENERATION cefepime inj 1gm PA cefepime inj 2gm PA Cefepime Inj 1gm Cefepime Inj 2gm Cefepime/Dex Inj 1gm Cefepime/Dex Inj 2gm MACROLIDES azithromycin inj 500MG QL azithromycin sus 100/5ML QL azithromycin sus 200/5ML QL azithromycin TAB 250MG QL azithromycin TAB 500MG QL azithromycin TAB 600MG QL PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 2

12 clarithromyc sus 125/5ML QL minocycline TAB 45MG ER clarithromyc sus 250/5ML QL minocycline TAB 50MG clarithromyc TAB 250MG QL minocycline TAB 75MG clarithromyc TAB 500MG QL minocycline TAB 90MG ER clarithromyc TAB 500MG ER QL mondoxyne nl CAP 100MG erythrom ETH sus 200/5ML mondoxyne nl CAP 50MG erythromycin pow mondoxyne nl CAP 75MG erythromycin CAP 250MG EC morgidox CAP 1X100MG Azithromycin Pow 1gm PAK QL morgidox CAP 1X50MG Clarithromyc Sus 125/5ML QL morgidox CAP 2X100MG Clarithromyc Sus 250/5ML QL okebo CAP 100MG E.e.s. 400 TAB 400MG okebo CAP 75MG Erythrocin Inj 500MG tetracycline CAP 250MG Erythrom ETH TAB 400MG tetracycline CAP 500MG Erythromycin Pow Doxycycline Pow Hyclate Erythromycin Pow Ethylsuc Minocycline Pow Erythromycin TAB 250MG Bs Minocycline TAB 45MG ER Erythromycin TAB 500MG Bs Oxytetracyc Pow HCL Tetracycline CAP 250MG TETRACYCLINES Tetracycline CAP 500MG avidoxy TAB 100MG QUINOLONES demeclocycl pow demeclocycl TAB 150MG ciprofloxacn inj 200MG demeclocycl TAB 300MG ciprofloxacn inj 400MG doxy 100 inj 100MG ciprofloxacn sus 250MG/5 doxycyc mono CAP 100MG ciprofloxacn sus 500MG/5 doxycyc mono CAP 150MG ciprofloxacn TAB 1000MG doxycyc mono CAP 50MG ciprofloxacn TAB 250MG doxycyc mono CAP 75MG ciprofloxacn TAB 500MG doxycyc mono TAB 100MG ciprofloxacn TAB 500MG ER doxycyc mono TAB 150MG ciprofloxacn TAB 750MG doxycyc mono TAB 50MG levoflox/d5w inj 250/50ML doxycyc mono TAB 75MG levoflox/d5w inj 500/100m doxycycl HYC inj 100MG levoflox/d5w inj 750/150 doxycycl HYC CAP 100MG levofloxacin inj 25MG/ML doxycycl HYC CAP 50MG levofloxacin sol 25MG/ML doxycycl HYC TAB 100MG levofloxacin TAB 250MG doxycycl HYC TAB 100MG DR levofloxacin TAB 500MG doxycycl HYC TAB 150MG DR levofloxacin TAB 750MG doxycycl HYC TAB 200MG DR moxifloxacin inj 400/250 doxycycl HYC TAB 50MG DR moxifloxacin TAB 400MG PA doxycycl HYC TAB 75MG DR ofloxacin TAB 400MG doxycycline pow hyclate Cipro (5%) Sus 250MG/5 doxycycline sus 25MG/5ML Ciprofloxacn Inj 200MG doxycycline TAB 150MG Ciprofloxacn Inj 400MG doxycycline TAB 20MG Ciprofloxacn TAB 100MG doxycycline TAB 75MG Levofloxacin Sol 25MG/ML minocycline CAP 100MG Moxifloxacin Inj PA minocycline CAP 50MG Ofloxacin TAB 300MG minocycline CAP 75MG minocycline TAB 100MG AMINOGLYCOSIDES minocycline TAB 135MG ER amikacin inj 1gm/4ML PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 3

13 amikacin inj 500/2ML Aminosal Acd Pow -4 gentam/nacl inj 100MG QL Cycloserine CAP 250MG gentam/nacl inj 120MG QL Ethambutol Pow HCL gentam/nacl inj 60MG QL Isoniazid Inj 100MG/ML gentam/nacl inj 80MG QL Isoniazid Pow gentam/nacl inj 80MG PB QL Isoniazid Syp 50MG/5ML gentamicin inj 10MG/ML QL Rifampin Pow gentamicin inj 40MG/ML QL neomycin TAB 500MG QL ANTIFUNGALS paromomycin CAP 250MG tobramycin inj 1.2/30ML QL bio-statin pow tobramycin inj 1.2gm QL caspofungin inj 50MG PA tobramycin inj 10MG/ML QL caspofungin inj 70MG PA tobramycin inj 40MG/ML QL fluconazole sus 10MG/ML tobramycin inj 80MG/2ML QL fluconazole sus 40MG/ML tobramycin neb 300/5ML QL fluconazole TAB 100MG Amikacin Pow Sulfate fluconazole TAB 150MG QL Gentam/NACL Inj 0.9MG/ML QL fluconazole TAB 200MG Gentam/NACL Inj 1.4MG/ML QL fluconazole TAB 50MG Gentam/NACL Inj 100MG QL fluconazole/ inj dex 200 Gentam/NACL Inj 80MG QL fluconazole/ inj dex 400 Kitabis PAK Neb 300/5ML QL fluconazole/ inj NACL 200 Streptomycin Inj 1gm fluconazole/ inj NACL 400 Streptomycin Pow Sulfate flucytosine CAP 250MG PA Tobi Neb 300/5ML QL,ST flucytosine CAP 500MG PA Tobi Podhalr CAP 28MG QL,PA griseofulvin sus 125/5ML Tobramycin Inj 10MG/ML QL griseofulvin TAB micr 500 Tobramycin Inj 40MG/ML QL griseofulvin TAB ultr 125 Tobramycin Pow Sulfate QL griseofulvin TAB ultr 250 itraconazole CAP 100MG PA SULFONAMIDES ketoconazole TAB 200MG nystatin pow sulfadiazine pow nystatin TAB sulfadiazine pow sodium terbinafine TAB 250MG Sulfadiazine Pow voriconazole inj 200MG ST Sulfadiazine Pow Sodium voriconazole sus 40MG/ML ST Sulfadiazine TAB 500MG voriconazole TAB 200MG ST Sulfamethox Pow voriconazole TAB 50MG ST Sulfamethox Pow Micro Abelcet Inj 5MG/ML PA Sulfapyridin Pow Ambisome Inj 50MG PA Sulfathiazol Pow Amphotericin Inj 50MG Sulfisoxizol Cry Cancidas Inj 50MG PA Cancidas Inj 70MG PA ANTIMYCOBACTERIAL AGENTS Caspofungin Inj 50MG PA Caspofungin Inj 70MG PA ethambutol TAB 100MG Cresemba CAP 186 MG PA ethambutol TAB 400MG Cresemba Inj 372MG PA isoniazid TAB 100MG Fluconazole/ Inj NACL 100 isoniazid TAB 300MG Gris-peg TAB 125MG pyrazinamide TAB 500MG Gris-peg TAB 250MG rifabutin CAP 150MG Miconazole Pow rifampin inj 600 MG Mycamine Inj 100MG PA rifampin CAP 150MG Mycamine Inj 50MG PA rifampin CAP 300MG PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 4

14 Noxafil Sus 40MG/ML ST Pegasys Inj PA Noxafil TAB 100MG ST Pegasys Inj Proclick PA Vfend IV Inj 200MG ST Pegasys Inj 180mcg/M PA Vfend Sus 40MG/ML ST Pegintron Kit 120mcg PA Vfend TAB 200MG ST Relenza Mis Diskhale QL Vfend TAB 50MG ST Retrovir CAP 100MG PA Retrovir Inj 10MG/ML ANTIVIRALS Ribapak PAK 1200/Day Ribapak PAK 800/Day acyclovir sus 200/5ML Ribasphere TAB 400MG acyclovir CAP 200MG Ribasphere TAB 600MG acyclovir NA inj 50MG/ML Ribatab TAB 1000/Day acyclovir TAB 400MG Ribatab TAB 1200/Day acyclovir TAB 800MG Ribatab TAB 800/Day adefov dipiv TAB 10MG PA Sovaldi TAB 400MG PA cidofovir inj 75MG/ML Tamiflu CAP 30MG QL entecavir TAB 0.5MG PA Tamiflu CAP 45MG QL entecavir TAB 1MG PA Tamiflu CAP 75MG QL famciclovir TAB 125MG Technivie TAB PA famciclovir TAB 250MG Tyzeka TAB 600MG PA famciclovir TAB 500MG Viekira PAK TAB PA ganciclovir inj 500MG PA Zepatier TAB MG PA lamivudine TAB 100MG moderiba TAB 200MG ANTIMALARIALS oseltamivir sus 6MG/ML QL oseltamivir CAP 30MG QL atovaq/progu TAB oseltamivir CAP 45MG QL atovaq/progu TAB oseltamivir CAP 75MG QL chloroquine TAB 250MG ribasphere CAP 200MG chloroquine TAB 500MG ribasphere TAB 200MG hydroxychlor TAB 200MG ribavirin inh 6gm mefloquine TAB 250MG ribavirin CAP 200MG quinine sulf CAP 324MG ribavirin TAB 200MG Chloroquine Pow Phosphat rimantadine TAB 100MG Chloroquine TAB 250MG valacyclovir TAB 1gm Mefloquine TAB 250MG valacyclovir TAB 500MG Primaquine TAB 26.3MG valganciclov sol 50MG/ML PA Quinacrine Pow valganciclov TAB 450MG PA Quinine Pow Sulfate zidovudine syp 50MG/5ML Quinine Sulf Pow Dihydrat zidovudine CAP 100MG PA zidovudine TAB 300MG AMEBICIDES Acyclovir NA Inj 500MG PA Baraclude Sol.05MG/ML PA Iodoquinol Pow Daklinza TAB 30MG PA Daklinza TAB 60MG PA ANTHELMINTICS Daklinza TAB 90MG PA Epclusa TAB PA ivermectin TAB 3MG Harvoni TAB MG PA Albenza TAB 200MG Mavyret TAB MG PA Benznidazole TAB 100MG Moderiba PAK 1200/Day Benznidazole TAB 12.5MG Biltricide TAB 600MG Moderiba PAK 800/Day Olysio CAP 150MG PA Emverm Chw 100MG Peg-intron Kit 120 Rp PA Mebendazole Pow Piperazine Pow PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5

15 Thiabendazol Pow vancomycin inj 750MG PA vancomycin CAP 125MG PA MISC. ANTI-INFECTIVES vancomycin CAP 250MG PA vancomycin 250/5ML PA atovaquone sus 750/5ML Alinia TAB 500MG aztreonam inj 1gm PA Chloramphen Inj 1gm aztreonam inj 2gm PA Chloramphen Pow baciim inj 50000unt Coly-mycin M Inj 150MG PA bacitracin inj 50000unt Cubicin RF Sol 500MG PA clindamycin inj 300/2ML PA Cubicin Sol 500MG PA clindamycin inj 300MG Dalvance Sol 500MG PA clindamycin inj 600/4ML PA Impavido CAP 50MG PA clindamycin inj 600MG Invanz Inj 1gm PA clindamycin inj 9gm/60ML PA Linezolid Inj 2MG/ML clindamycin inj 900/6ML PA Merop/NACL Inj 1gm/50ML clindamycin inj 900MG Merop/NACL Inj 500/50ML clindamycin sol 75MG/5ML Polymyxin B Pow Sulfate clindamycin CAP 150MG Tigecycline Inj 50MG PA clindamycin CAP 300MG Trimethoprim Pow clindamycin CAP 75MG Tygacil Inj 50MG PA colistimeth inj 150MG PA Vancocin HCL CAP 125MG PA dapsone TAB 100MG Vancocin HCL CAP 250MG PA dapsone TAB 25MG Vancomy/HCL Inj 2/250ML daptomycin inj 500MG PA Vancomy/NACL Inj 1.25/250 imipenem/cil inj 250MG PA Vancomy/NACL Inj 1.5/150 imipenem/cil inj 500MG PA Vancomy/NACL Inj 1.5/500 lincomycin inj 300MG/ML Vancomy/NACL Inj 1.75/250 linezolid inj 2MG/ML PA Vancomy/NACL Inj 1.75/300 linezolid sus 100/5ML PA Vancomy/NACL Inj 1/250ML linezolid TAB 600MG PA Vancomy/NACL Inj 1G/150ML meropenem inj 1gm PA Vancomy/NACL Inj 1G/250ML meropenem inj 500MG PA Vancomy/NACL Inj 2/250ML metron/nacl inj 500MG Vancomy/NACL Inj 750/150 metronidazol CAP 375MG Vancomy/NACL Sol 1.5/250 metronidazol TAB 250MG Vancomyc/Dex Inj 1gm metronidazol TAB 500MG Vancomyc/Dex Inj 500MG polymyxin b inj Vancomyc/Dex Inj 750MG smz-tmp inj /5 Vancomyc/D5W Inj 1/100ML smz-tmp sus /5 Vancomyc/D5W Inj 1G/250ML smz-tmp DS TAB Vancomyc/D5W Inj 750/150 smz-tmp TAB MG Vancomyc/D5W Sol 1.5/250 smz/tmp DS TAB Vancomyc/D5W Sol 2G/500ML sulfatrim PD sus /5 Vancomycin Inj 1 Gm tigecycline inj 50MG PA Vancomycin Inj 100gm PA tinidazole TAB 250MG Vancomycin Inj 500MG tinidazole TAB 500MG Vancomycin Inj 750MG trimethoprim pow Vancomycin Pow PA trimethoprim TAB 100MG Vancomycin Sus +syrspen PA vancomycin inj 1 gm PA Vancomycn 25 Sol 25MG/ML PA vancomycin inj 10gm PA Vancomycn 50 Sol 50MG/ML PA vancomycin inj 1000MG PA Vibativ Inj 250MG ST vancomycin inj 5gm PA Vibativ Inj 750MG ST vancomycin inj 500MG PA PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 6

16 ANTINEOPLASTICS, ETC. doxorubicin inj 150/75ML ALKYLATING AGENTS doxorubicin inj 2MG/ML doxorubicin inj 20/10ML busulfan inj 6MG/ML doxorubicin inj 200/100 carboplatin inj 150/15ML PA doxorubicin inj 200MG carboplatin inj 450/45ML PA doxorubicin inj 50/25ML carboplatin inj 50MG/5ML PA doxorubicin inj 50MG carboplatin inj 600/60ML PA epirubicin inj 200MG PA cisplatin inj 100MG epirubicin inj 50/25ML PA cisplatin inj 50/50ML idarubicin inj 10/10ML cyclophosph inj 1gm idarubicin inj 20/20ML cyclophosph inj 2gm idarubicin inj 5MG/5ML cyclophosph inj 500MG lipodox inj 2MG/ML ifosfamide inj 1gm lipodox 50 inj 2MG/ML ifosfamide inj 1gm/20ML mitomycin inj 20MG ifosfamide inj 3gm/60ML mitomycin inj 40MG melphalan inj 50MG mitoxantron inj 2MG/ML melphalan TAB 2MG Doxorubicin Inj 10MG oxaliplatin inj 100MG Doxorubicin Inj 50MG oxaliplatin inj 50/10ML Mitomycin Inj 5MG oxaliplatin inj 50MG oxaliplatin sol 100MG ANTIMETABOLITES temozolomide CAP 100MG temozolomide CAP 140MG adrucil inj 2.5G/50m temozolomide CAP 180MG adrucil inj 5gm/100m temozolomide CAP 20MG adrucil inj 500/10ML temozolomide CAP 250MG azacitidine inj 100MG temozolomide CAP 5MG capecitabine TAB 150MG thiotepa inj 15MG capecitabine TAB 500MG Bicnu Inj 100MG cladribine inj 1MG/ML Cisplatin Inj 200MG clofarabine inj 20/20ML Cyclophosph CAP 25MG cytarabine inj 100MG/ML Cyclophosph CAP 50MG cytarabine inj 20MG/ML Ifosfamide Inj 3gm decitabine inj 50MG Lomustine CAP 10MG fludarabine inj 50MG Lomustine CAP 100MG fludarabine inj 50MG/2ML Lomustine CAP 40MG fluorouracil inj 1gm/20ML Treanda Inj 100MG fluorouracil inj 2.5G/50m Treanda Inj 25MG fluorouracil inj 5gm/100m Valchlor Gel 0.016% PA fluorouracil inj 500/10ML gemcitabine inj 1gm ANTIBIOTICS gemcitabine inj 2gm gemcitabine inj 200MG adriamycin inj 10MG mercaptopur TAB 50MG adriamycin inj 20MG methotrexate inj 1gm adriamycin inj 200MG methotrexate inj 1gm/40ML adriamycin inj 50MG methotrexate inj 100/4ML bleomycin inj 15unit methotrexate inj 200/8ML bleomycin inj 30unit methotrexate inj 25MG/ML daunorubicin inj 5MG/ML methotrexate inj 250/10ML doxorubicin inj 10/5ML methotrexate inj 50MG/2ML doxorubicin inj 10MG methotrexate TAB 2.5MG doxorubicin inj 10MG/5ML Alimta Inj 100MG PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 7

17 Alimta Inj 500MG Cytarabine Inj 20MG/ML Floxuridine Inj 0.5gm Methotrexate Inj 25MG/ML Methotrexate Pow ANGIOGENESIS INHIBITORS Avastin Inj Avastin Inj 400/16ML ANTIBODIES Campath Inj 30MG/ML Erbitux Inj 100MG Erbitux Inj 200MG Herceptin Inj 440MG Rituxan Inj 100MG Rituxan Inj 500MG Tecentriq Inj 1200/20 HORMONAL AGENTS anastrozole TAB 1MG bicalutamide TAB 50MG exemestane TAB 25MG flutamide CAP 125MG letrozole TAB 2.5MG leuprolide inj 1MG/0.2 PA megestrol ac sus 40MG/ML megestrol ac sus 400MG/10 megestrol ac TAB 20MG megestrol ac TAB 40MG nilutamide TAB 150MG tamoxifen TAB 10MG tamoxifen TAB 20MG Depo-provera Inj 400/ML Eligard Inj 22.5MG Eligard Inj 30MG Eligard Inj 45MG Eligard Inj 7.5MG PA Faslodex Inj 250/5ML Hydroxy Capr Inj 1.25/5ML Lupron Depot Inj 11.25MG Lupron Depot Inj 22.5MG Lupron Depot Inj 3.75MG PA Lupron Depot Inj 30MG Lupron Depot Inj 45MG Lupron Depot Inj 7.5MG PA Megestrol Pow Acetate Trelstar Inj 11.25MG Trelstar Inj 3.75MG Trelstar Mix Inj 11.25MG Trelstar Mix Inj 22.5MG Trelstar Mix Inj 3.75MG Vantas Kit 50MG Zoladex Imp 10.8MG Zoladex Imp 3.6MG IMMUNOMODULATORS azathioprine TAB 50MG cyclosporine inj 50MG/ML cyclosporine sol modified cyclosporine CAP 100MG cyclosporine CAP 100MG MD cyclosporine CAP 25MG cyclosporine CAP 25MG mod gengraf sol 100MG/ML gengraf CAP 100MG gengraf CAP 25MG gengraf CAP 50MG levamisole pow HCL mycophenolat inj 500MG mycophenolat sus 200MG/ML mycophenolat CAP 250MG mycophenolat TAB 500MG mycophenolic TAB 180MG DR mycophenolic TAB 360MG DR sirolimus TAB 0.5MG sirolimus TAB 1MG sirolimus TAB 2MG tacrolimus CAP 0.5MG tacrolimus CAP 1MG tacrolimus CAP 5MG Azathioprine Inj 100MG Azathioprine Pow Cyclosporine CAP 50MG Mod Levamisole Pow HCL Pomalyst CAP 1MG PA Pomalyst CAP 2MG PA Pomalyst CAP 3MG PA Pomalyst CAP 4MG PA Revlimid CAP 10MG PA Revlimid CAP 15MG PA Revlimid CAP 2.5MG PA Revlimid CAP 20MG PA Revlimid CAP 25MG PA Revlimid CAP 5MG PA Thalomid CAP 100MG Thalomid CAP 150MG Thalomid CAP 200MG Thalomid CAP 50MG Thymoglobuln Inj 25MG PA MITOTIC INHIBITORS docetaxel inj 20MG/ML PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 8

18 docetaxel inj 80MG/4ML etoposide inj 1gm/50ML etoposide inj 100/5ML etoposide inj 20MG/ML etoposide inj 500/25ML paclitaxel inj 100MG paclitaxel inj 30MG/5ML paclitaxel inj 300/50ML toposar inj 1gm/50ML toposar inj 100/5ML toposar inj 20MG/ML toposar inj 500/25ML vincasar PFS inj 1MG/ML vincristine inj 1MG/ML vinorelbine inj soln vinorelbine inj 10MG/ML vinorelbine inj 50MG/5ML Docetaxel Inj Non-alco Docetaxel Inj 140/7ML Docetaxel Inj 160/16ML Docetaxel Inj 160/8ML Docetaxel Inj 20/0.5ML Docetaxel Inj 20MG/ML Docetaxel Inj 20MG/2ML Docetaxel Inj 200/10 Docetaxel Inj 200MG/20 Docetaxel Inj 80MG/2ML Docetaxel Inj 80MG/4ML Docetaxel Inj 80MG/8ML Etoposide CAP 50MG Halaven Inj 1MG/2ML Ixempra Kit Inj 15MG Ixempra Kit Inj 45MG Paclitaxel Inj 150/25ML Teniposide Inj 50MG/5ML Vinblastine Inj 1MG/ML ENZYME INHIBITORS imatinib mes TAB 100MG imatinib mes TAB 400MG Afinitor Dis TAB 2MG Afinitor Dis TAB 3MG Afinitor Dis TAB 5MG Afinitor TAB 10MG Afinitor TAB 2.5MG Afinitor TAB 5MG Afinitor TAB 7.5MG Alecensa CAP 150MG PA Alunbrig TAB 30MG PA Cabometyx TAB 20MG PA Cabometyx TAB 40MG PA Cabometyx TAB 60MG PA Cotellic TAB 20MG PA Farydak CAP 10MG PA Farydak CAP 15MG PA Farydak CAP 20MG PA Gilotrif TAB 20MG PA Gilotrif TAB 30MG PA Gilotrif TAB 40MG PA Ibrance CAP 100MG PA Ibrance CAP 125MG PA Ibrance CAP 75MG PA Idhifa TAB 100MG PA Idhifa TAB 50MG PA Imbruvica CAP 140MG PA Kisqali TAB 200dose PA Kisqali TAB 400dose PA Kisqali TAB 600dose PA Lenvima CAP 10 MG PA Lenvima CAP 14 MG PA Lenvima CAP 18 MG PA Lenvima CAP 20 MG PA Lenvima CAP 24 MG PA Lenvima CAP 8 MG PA Lynparza CAP 50MG PA Lynparza TAB 100MG PA Lynparza TAB 150MG PA Mekinist TAB 0.5MG PA Mekinist TAB 2MG PA Nerlynx TAB 40MG PA Nexavar TAB 200MG PA Ninlaro CAP 2.3MG PA Ninlaro CAP 3MG PA Ninlaro CAP 4MG PA Rubraca TAB 200MG PA Rubraca TAB 250MG PA Rubraca TAB 300MG PA Rydapt CAP 25MG PA Sprycel TAB 100MG Sprycel TAB 140MG Sprycel TAB 20MG Sprycel TAB 50MG Sprycel TAB 70MG Sprycel TAB 80MG Stivarga TAB 40MG PA Sutent CAP 12.5MG Sutent CAP 25MG Sutent CAP 37.5MG Sutent CAP 50MG Tafinlar CAP 50MG PA Tafinlar CAP 75MG PA Tagrisso TAB 40MG PA Tagrisso TAB 80MG PA Tarceva TAB 100MG Tarceva TAB 150MG Tarceva TAB 25MG PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 9

19 Tasigna CAP 150MG Tasigna CAP 200MG Torisel Sol 25MG/ML Tykerb TAB 250MG Velcade Inj 3.5MG Votrient TAB 200MG Zejula CAP 100MG PA Zydelig TAB 100MG PA Zydelig TAB 150MG PA Zykadia CAP 150MG PA TOPOISOMERASE I INHIBITOR irinotecan inj 100/5ML irinotecan inj 40MG/2ML topotecan inj 4MG Hycamtin CAP 0.25MG Hycamtin CAP 1MG Irinotecan Inj 500MG/25 Topotecan Inj 4MG/4ML ANTINEOPLASTICS MISC. bexarotene CAP 75MG dacarbazine inj 200MG hydroxyurea CAP 500MG tretinoin CAP 10MG Actimmune Inj 2mu/0.5 PA Alferon N Inj 5mu/ML Dacarbazine Inj 100MG Intron A Inj 10mu QL Intron A Inj 18mu QL Intron A Inj 25mu QL Intron A Inj 50mu QL Matulane CAP 50MG Tice Bcg Inj PA Trisenox Sol 10MG/10m CHEMOTHERAPY RESCUE amifostine inj 500MG PA dexrazoxane inj 250MG PA dexrazoxane inj 500MG PA leucovor CA inj 100MG leucovor CA inj 200MG leucovor CA inj 350MG leucovor CA inj 50MG leucovor CA TAB 25MG leucovor CA TAB 5MG levoleucovor inj 175/17.5 levoleucovor inj 50MG mesna inj 1gm Leucovor CA TAB 10MG Leucovor CA TAB 15MG Leucovorin Inj Calcium Levoleucovor Inj 175MG Levoleucovor Sol 250MG/25 ANTINEOPLASTIC COMBO Lonsurf TAB PA Lonsurf TAB PA CARDIOVASCULAR DRUGS PHOSPHODIESTERASE INHBTR milrinone inj 1MG/ML milrinone inj 10/10ML milrinone inj 20/20ML milrinone inj 50/50ML milrinone/d5 inj 20/100ML milrinone/d5 inj 40/200ML CARDIAC GLYCOSIDES digitek TAB 0.125MG digitek TAB 0.25MG digox TAB 0.125MG digox TAB 0.25MG digoxin inj 0.25MG/1 digoxin TAB 0.125MG digoxin TAB 0.25MG Digoxin Sol 50mcg/ML ANTIANGINAL AGENTS isosorb din TAB 10MG isosorb din TAB 20MG isosorb din TAB 30MG isosorb din TAB 5MG isosorb mono TAB 10MG isosorb mono TAB 120MG ER isosorb mono TAB 20MG isosorb mono TAB 30MG ER isosorb mono TAB 60MG ER minitran dis 0.1MG/HR ST minitran dis 0.2MG/HR ST minitran dis 0.4MG/HR ST minitran dis 0.6MG/HR ST nitro-time CAP 2.5MG CR nitro-time CAP 6.5MG CR nitro-time CAP 9MG CR nitrogly/d5w inj 100MG nitrogly/d5w inj 200MG nitrogly/d5w inj 25MG nitrogly/d5w inj 50MG nitroglycer dis 0.1MG/HR ST nitroglycer dis 0.2MG/HR ST PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 10

20 nitroglycer dis 0.4MG/HR ST nitroglycer dis 0.6MG/HR ST nitroglycer CAP 2.5MG ER nitroglycer CAP 6.5MG ER nitroglycer CAP 9MG ER nitroglyceri sub 0.6MG nitroglycern sub 0.3MG nitroglycern sub 0.4MG nitroglycrn spr 0.4MG Isosorb Din TAB 40MG ER Nitrogly/D5W Inj 100MG Nitrogly/D5W Inj 25MG Nitrogly/D5W Inj 50MG Nitroglycer Aer 400mcg Nitroglycer Inj 5MG/ML Nitrostat Sub 0.3MG Nitrostat Sub 0.4MG Nitrostat Sub 0.6MG Ranexa TAB 1000MG PA Ranexa TAB 500MG PA BETA BLOCKERS acebutolol CAP 200MG acebutolol CAP 400MG atenolol TAB 100MG atenolol TAB 25MG atenolol TAB 50MG betaxolol TAB 10MG betaxolol TAB 20MG bisoprol fum TAB 10MG bisoprol fum TAB 5MG carvedilol CAP 10MG ER carvedilol CAP 20MG ER carvedilol CAP 40MG ER carvedilol CAP 80MG ER carvedilol TAB 12.5MG carvedilol TAB 25MG carvedilol TAB 3.125MG carvedilol TAB 6.25MG esmolol HCL inj 10MG/ML esmolol HCL inj 100MG/10 labetalol inj 5MG/ML labetalol TAB 100MG labetalol TAB 200MG labetalol TAB 300MG metoprol suc TAB 100MG ER metoprol suc TAB 200MG ER metoprol suc TAB 25MG ER metoprol suc TAB 50MG ER metoprol TAR TAB 100MG metoprol TAR TAB 25MG metoprol TAR TAB 50MG metoprolol inj 1MG/ML metoprolol inj 5MG/5ML metoprolol pow tartrate metoprolol TAB 100MG ER metoprolol TAB 200MG ER metoprolol TAB 25MG ER metoprolol TAB 50MG ER nadolol TAB 20MG nadolol TAB 40MG nadolol TAB 80MG pindolol TAB 10MG pindolol TAB 5MG propranolol inj 1MG/ML propranolol CAP 120MG ER propranolol CAP 160MG ER propranolol CAP 60MG ER propranolol CAP 80MG ER propranolol TAB 10MG propranolol TAB 20MG propranolol TAB 40MG propranolol TAB 60MG propranolol TAB 80MG sorine TAB 120MG sorine TAB 160MG sorine TAB 240MG sorine TAB 80MG sotalol AF TAB 120MG sotalol AF TAB 160MG sotalol AF TAB 80MG sotalol HCL TAB 120MG sotalol HCL TAB 160MG sotalol HCL TAB 240MG sotalol HCL TAB 80MG timolol pow maleate Acebutolol Pow Atenolol Pow Esmolol HCL Inj 100/10ML Hemangeol Sol 4.28/ML PA Metoprolol Inj 1MG/ML Metoprolol Pow Tartrate Metoprolol TAB 37.5MG Metoprolol TAB 75MG Nadolol Pow Propranolol Pow HCL Propranolol Sol 20MG/5ML Propranolol Sol 40MG/5ML Sotalol HCL Inj 150/10ML Timolol Mal TAB 10MG Timolol Mal TAB 20MG Timolol Mal TAB 5MG Timolol Pow Maleate CALCIUM CHANNEL BLOCKERS PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 11

21 nicardipine inj 25/10ML afeditab TAB 30MG CR nicardipine CAP 20MG afeditab TAB 60MG CR nicardipine CAP 30MG amlodipine TAB 10MG nifedical XL TAB 30MG amlodipine TAB 2.5MG nifedical XL TAB 60MG amlodipine TAB 5MG nifedipine CAP 10MG cartia XT CAP 120/24HR nifedipine CAP 20MG cartia XT CAP 180/24HR nifedipine TAB 30MG ER cartia XT CAP 240/24HR nifedipine TAB 60MG ER cartia XT CAP 300/24HR nifedipine TAB 90MG ER dilt-xr CAP 120MG nimodipine CAP 30MG dilt-xr CAP 180MG nisoldipine TAB 17MG ER dilt-xr CAP 240MG nisoldipine TAB 34MG ER diltiazem inj 125/25ML nisoldipine TAB 8.5MG ER diltiazem inj 25MG/5ML taztia XT CAP 120MG/24 diltiazem inj 50/10ML taztia XT CAP 180MG/24 diltiazem CAP 120MG CD taztia XT CAP 240MG/24 diltiazem CAP 120MG ER taztia XT CAP 300MG/24 diltiazem CAP 120MG/24 taztia XT CAP 360MG/24 diltiazem CAP 180MG CD verapamil inj 2.5MG/ML diltiazem CAP 180MG ER verapamil CAP 100MG ER diltiazem CAP 180MG/24 verapamil CAP 120MG ER diltiazem CAP 240MG CD verapamil CAP 120MG SR diltiazem CAP 240MG ER verapamil CAP 180MG ER diltiazem CAP 240MG/24 verapamil CAP 180MG SR diltiazem CAP 300MG CD verapamil CAP 200MG ER diltiazem CAP 300MG ER verapamil CAP 240MG ER diltiazem CAP 300MG/24 verapamil CAP 240MG SR diltiazem CAP 360MG CD verapamil CAP 300MG ER diltiazem CAP 360MG ER verapamil CAP 360MG SR diltiazem CAP 360MG/24 verapamil TAB 120MG diltiazem CAP 420MG/24 verapamil TAB 120MG ER diltiazem CAP 60MG ER verapamil TAB 180MG ER diltiazem CAP 90MG ER verapamil TAB 240MG ER diltiazem ER TAB 180MG verapamil TAB 40MG diltiazem ER TAB 240MG verapamil TAB 80MG diltiazem ER TAB 300MG Diltiaz/NACL Inj 100/100 diltiazem ER TAB 360MG Diltiaz/NACL Inj 125/125 diltiazem ER TAB 420MG Diltiazem Inj 100MG diltiazem TAB 120MG Diltiazm/D5W Inj 100/100 diltiazem TAB 30MG Diltiazm/D5W Inj 250/250 diltiazem TAB 60MG Diltiazm/D5W Sol 125/125 diltiazem TAB 90MG Nifedipine Pow felodipine TAB 10MG ER Nisoldipine TAB 20MG ER felodipine TAB 2.5MG ER Nisoldipine TAB 25.5MG felodipine TAB 5MG ER Nisoldipine TAB 30MG ER isradipine CAP 2.5MG Nisoldipine TAB 40MG ER isradipine CAP 5MG Verapamil Pow matzim LA TAB 180MG/24 matzim LA TAB 240MG/24 ANTIARRHYTHMICS matzim LA TAB 300MG/24 matzim LA TAB 360MG/24 adenosine inj 12MG/4ML matzim LA TAB 420MG/24 adenosine inj 6MG/2ML nicardipine inj 2.5MG/ML PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 12

22 amiodarone inj 150MG/3m amiodarone inj 50MG/ML amiodarone TAB 100MG amiodarone TAB 200MG amiodarone TAB 400MG disopyramide CAP 100MG disopyramide CAP 150MG dofetilide CAP 125mcg dofetilide CAP 250mcg dofetilide CAP 500mcg flecainide TAB 100MG flecainide TAB 150MG flecainide TAB 50MG ibutilide inj 1MG/10ML lidocain/d5w inj 4MG/ML lidocain/d5w inj 8MG/ML lidocaine inj 20MG/ML mexiletine CAP 150MG mexiletine CAP 200MG mexiletine CAP 250MG pacerone TAB 100MG pacerone TAB 200MG pacerone TAB 400MG procainamide inj 100MG/ML procainamide inj 500MG/ML procainamide pow propafenone CAP 225MG ER propafenone CAP 325MG ER propafenone CAP 425MG ER propafenone CAP 425MG SR propafenone TAB 150MG propafenone TAB 225MG propafenone TAB 300MG quinidine gl TAB 324MG CR quinidine gl TAB 324MG ER Adenosine Inj 3MG/ML Adenosine Inj 90/30ML Amiodaro/D5W Sol 150/100 Amiodaro/D5W Sol 900/500 Amiodarone Inj 50MG/ML Lidocaine Inj 10MG/ML Procainamide Pow Quinidine Gl Inj 80MG/ML Quinidine SU TAB 200MG Quinidine SU TAB 300MG Quinidine SU TAB 300MG ER ACE INHIBITORS benazepril TAB 10MG benazepril TAB 20MG benazepril TAB 40MG benazepril TAB 5MG captopril TAB 100MG captopril TAB 12.5MG captopril TAB 25MG captopril TAB 50MG enalapril TAB 10MG enalapril TAB 2.5MG enalapril TAB 20MG enalapril TAB 5MG enalaprilat inj 1.25/ML fosinopril TAB 10MG fosinopril TAB 20MG fosinopril TAB 40MG lisinopril TAB 10MG lisinopril TAB 2.5MG lisinopril TAB 20MG lisinopril TAB 30MG lisinopril TAB 40MG lisinopril TAB 5MG moexipril TAB 15MG moexipril TAB 7.5MG perindopril TAB 2MG perindopril TAB 4MG perindopril TAB 8MG quinapril TAB 10MG quinapril TAB 20MG quinapril TAB 40MG quinapril TAB 5MG ramipril CAP 1.25MG ramipril CAP 10MG ramipril CAP 2.5MG ramipril CAP 5MG trandolapril TAB 1MG trandolapril TAB 2MG trandolapril TAB 4MG ANGIOTENSIN RCPTR BLOCKER candesartan TAB 16MG candesartan TAB 32MG candesartan TAB 4MG candesartan TAB 8MG irbesartan TAB 150MG ST irbesartan TAB 300MG ST irbesartan TAB 75MG ST losartan pot TAB 100MG losartan pot TAB 25MG losartan pot TAB 50MG olmesa medox TAB 20MG ST olmesa medox TAB 40MG ST olmesa medox TAB 5MG ST telmisartan TAB 20MG ST telmisartan TAB 40MG ST telmisartan TAB 80MG ST PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 13