PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 20 18 FORMULARY EVIDENCE LIST of COVERED of COVERAGE DRUGS Johns Hopkins Johns Advantage Hopkins Advantage MD (HMO) MD PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version 10 This formulary was updated on 6/1/2018. For more recent information or other questions, please contact Johns Hopkins Advantage MD (HMO) Customer Service at or, for TTY users, 711, 2 hours a day, 7 days a week, or visit H890_EOC_0816 H1225_HMOFormulary_0917 Accepted 0917

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Johns Hopkins Advantage MD. When it refers to plan or our plan, it means Johns Hopkins Advantage MD (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of March 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year. What is the Johns Hopkins Advantage MD (HMO) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of March 1, To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (i.e. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the new information. The updated formulary information may be obtained from our website or by calling us at the number provided on the front and back cover pages. 2

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page number 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 55. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 0 tablets every 0 days per prescription for Januvia tablets. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

4 You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Johns Hopkins Advantage MD (HMO) s formulary? on page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by us. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Johns Hopkins Advantage MD (HMO) s Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 2 hours after we get a supporting statement from your doctor or other prescriber.

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you experience a change in your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary (or if your ability to get your drugs is limited), we will cover a onetime temporary supply for up to 0-days (or 1-days if you are a long-term care resident) from a network pharmacy. During this period you should use the plan s exception process if you wish to have continued coverage of the drug after the temporary supply is finished. For more information For more detailed information about your our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 2 hours a day/7 days a week. TTY users should call Or, visit 5

6 Johns Hopkins Advantage MD (HMO) s Formulary The formulary that begins on the page after next provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 55. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g.,levothyroxine). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. PA Prior authorization QL Drug has quantity limit ST Step therapy required NM Not available at mail-order pharmacies LA Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Services at , 2 hours a day, 7 days a week. TTY users should call 711. B/D This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. * Not available as extended days supply GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 6

7 Johns Hopkins Advantage MD (HMO) Cost Sharing Tier Cost-Sharing Tier 1 (Preferred Generic) Cost-Sharing Tier 2 (Generic) Cost-Sharing Tier (Preferred Brand) Cost-Sharing Tier (Non-Preferred Drug) Standard Retail Cost-Sharing (in-network) $0 copay for a 0-day supply $0 copay for a 60-day supply $0 copay for a 90-day supply $10 copay for a 0-day supply $15 copay for a 60-day supply $20 copay for a 90-day supply $7 copay for a 0-day supply $9 copay for a 60-day supply $11 copay for a 90-day supply $100 copay for a 0-day supply $200 copay for a 60-day supply $00 copay for a 90-day supply Standard Mail Order Cost-Sharing (in-network) $0 copay for a 0-day supply $0 copay for a 60-day supply $0 copay for a 90-day supply $10 copay for a 0-day supply $15 copay for a 60-day supply $20 copay for a 90-day supply $7 copay for a 0-day supply $70.50 copay for a 60-day supply $9 copay for a 90-day supply $100 copay for a 0-day supply $150 copay for a 60-day supply $200 copay for a 90-day supply Cost-Sharing Tier 5 (Specialty Tier) % coinsurance for a 0-day supply (only) NOTE: -Drugs are provided in a Long-Term Care Facility up to a 1-day supply -Drugs in Tier 5 are only available for a 0-day supply -We provide coverage of drugs in Tier 1 at $0 copay in the coverage gap. -You can find complete cost-sharing information in your Evidence of Coverage 7

8 Johns Hopkins Advantage MD (HMO) Drug Tier Requirements/ Limits ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab (generic of 2 ZYLOPRIM) colchicine w/ probenecid COLCRYS QL (120 tabs / 0 MITIGARE QL (60 caps / 0 probenecid ULORIC ST NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib (generic of CELEBREX) CAPS 50mg QL (20 caps / 0 celecoxib (generic of CELEBREX) CAPS 100mg QL (120 caps / 0 celecoxib (generic of CELEBREX) CAPS 200mg QL (60 caps / 0 celecoxib (generic of CELEBREX) CAPS 00mg QL (0 caps / 0 diclofenac potassium QL (120 tabs / 0 diclofenac sodium TB2; 2 TBEC diflunisal etodolac CAPS etodolac (generic of LODINE) TABS 00mg etodolac TABS 500mg etodolac TB2 flurbiprofen TABS ibu tabs 600mg ibu tabs 800mg ibuprofen SUSP ibuprofen TABS 00mg, 600mg, 800mg ketoprofen cap 50mg ketoprofen cap 75mg meloxicam (generic of MOBIC) TABS nabumetone TABS 2 naproxen (generic of NAPROSYN) SUSP naproxen (generic of NAPROSYN) TABS 250mg, 500mg naproxen TABS 75mg naproxen dr (generic of EC- 2 NAPROSYN) naproxen sodium TABS 275mg naproxen sodium (generic of ANAPROX DS) TABS 550mg piroxicam (generic of FELDENE) CAPS sulindac TABS 2 OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine SOLN QL (5000 ml / 0 acetaminophen w/ codeine TABS QL (00 tabs / 0 acetaminophen w/ codeine (generic of TYLENOL/CODEINE #) TABS QL (00 tabs / 0 acetaminophen w/ codeine (generic of TYLENOL/CODEINE #) TABS QL (00 tabs / 0 2 QL 2 QL 2 QL 2 QL butorphanol tartrate SOLN 1mg/ml, 2mg/ml nalbuphine hcl SOLN tramadol hcl (generic of ULTRAM) TABS 2 QL QL (20 tabs / 0 tramadol-acetaminophen (generic of ULTRACET) QL (20 tabs / 0 9

9 Drug Tier Requirements/ Limits OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet (generic of PERCOCET) QL (60 tabs / 0 fentanyl citrate (generic of ACTIQ) LPOP QL (120 lozenges / 0 fentanyl patch 12 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 25 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 50 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 75 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 fentanyl patch 100 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 FENTORA QL (120 tabs / 0 hydroco/apap tab 5-25mg (generic of NORCO) QL (60 tabs / 0 hydroco/apap tab (generic of NORCO) QL (60 tabs / 0 hydroco/apap tab 10-25mg (generic of NORCO) QL (60 tabs / 0 hydrocodone-acetaminophen mg/15ml QL (500 ml / 0 hydrocodone-ibuprofen tab mg QL (150 tabs / 0 hydromorphone hcl (generic of DILAUDID) LIQD 5 * QL NM PA PA PA PA 5 * QL NM PA 2 QL 2 QL 2 QL hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl (generic of DILAUDID) TABS QL (270 tabs / 0 HYSINGLA ER 20mg, 0mg, 0mg, 60mg QL (60 tabs / 0 HYSINGLA ER 80mg, 100mg, 120mg QL (0 tabs / 0 lorcet hd tab 10-25mg (generic of NORCO) QL (60 tabs / 0 lorcet plus tab (generic of NORCO) QL (60 tabs / 0 B/D 2 QL 2 QL methadone hcl SOLN 5mg/5ml, 10mg/5ml QL (50 ml / 0 methadone hcl 5mg (generic of DOLOPHINE) QL (180 tabs / 0 methadone hcl 10mg (generic of DOLOPHINE) QL (180 tabs / 0 methadone hcl intensol (generic of METHADOSE) QL (120 ml / 0 morphine ext-rel tab (generic of MS CONTIN) 15mg, 0mg, 60mg, 100mg QL (90 tabs / 0 morphine ext-rel tab (generic of MS CONTIN) 200mg QL (60 tabs / 0 morphine sul inj 1mg/ml B/D MORPHINE SUL INJ B/D MG/ML morphine sul inj 10mg/ml B/D (generic of MORPHINE SULFATE) MORPHINE SULFATE SOLN 2mg/ml, mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/0ml B/D 10

10 morphine sulfate (generic of MORPHINE SULFATE) SOLN mg/ml, 8mg/ml morphine sulfate SOLN 8mg/ml, 10mg/ml morphine sulfate TABS B/D B/D QL (180 tabs / 0 morphine sulfate oral sol NUCYNTA ER 50mg, 100mg QL (120 tabs / 0 NUCYNTA ER 150mg, 200mg, 250mg QL (60 tabs / 0 oxycodone hcl CAPS QL (180 caps / 0 oxycodone hcl CONC oxycodone hcl SOLN oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 0mg QL (180 tabs / 0 oxycodone hcl TABS 10mg, 20mg QL (180 tabs / 0 oxycodone w/ acetaminophen mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen 5-25mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen 10-25mg (generic of PERCOCET) QL (60 tabs / 0 ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine inj 0.5% (generic of XYLOCAINE) 2 B/D lidocaine inj 0.5% preservative free (pf) (generic of XYLOCAINE-MPF) 2 B/D lidocaine inj 1% (generic of 2 B/D XYLOCAINE) lidocaine inj 1% preservative 2 B/D free (pf) (generic of XYLOCAINE-MPF) lidocaine inj 1.5% 2 B/D preservative free (pf) (generic of XYLOCAINE-MPF) lidocaine inj 2% (generic of XYLOCAINE) 2 B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline 2 gentamicin sulfate SOLN 2 neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR SULFADIAZINE TABS tobramycin (generic of 5 * NM PA KITABIS PAK) NEBU tobramycin inj 1.2 gm/0ml tobramycin inj 1.2gm 5 * NM tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/2ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 * NM ALINIA 5 * NM atovaquone (generic of 5 * NM MEPRON) SUSP AZACTAM IN ISO-OSMOTIC DE AZACTAM/DEX INJ aztreonam (generic of AZACTAM) BILTRICIDE CAYSTON clindamycin cap 75mg (generic of CLEOCIN) clindamycin cap 00 mg (generic of CLEOCIN) clindamycin hcl cap 150 mg (generic of CLEOCIN) 11

11 clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) CLINDAMYCIN PHOSPHATE IN NACL clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY-MYCIN M) SOLR dapsone TABS daptomycin (generic of 5 * NM CUBICIN) EMVERM 5 * NM imipenem-cilastatin imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) 5 * NM linezolid in sodium chloride 5 * NM meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of 2 FLAGYL) TABS metronidazole in nacl 2 NEBUPENT B/D nitrofurantoin macrocrystal PA (generic of MACRODANTIN) 50mg, 100mg PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro PA (generic of MACROBID) PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM 00 SIVEXTRO 5 * NM sulfamethoxazole-trimethop ds (generic of BACTRIM DS) sulfamethoxazoletrimethoprim SUSP sulfamethoxazoletrimethoprim (generic of BACTRIM) TABS sulfamethoxazoletrimethoprim inj SYNERCID 5 * NM TIGECYCLINE 50mg 5 * NM tigecycline (generic of 5 * NM TYGACIL) 50mg trimethoprim TABS 2 vancomycin hcl (generic of VANCOCIN HCL) CAPS 5 * NM vancomycin hcl SOLR 10gm, 500mg, 750mg, 1000mg, 5000mg VANCOMYCIN IN NACL ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET 5 * B/D NM AMBISOME 5 * B/D NM amphotericin b SOLR B/D CANCIDAS 5 * NM caspofungin acetate 50mg, 5 * NM 70mg CASPOFUNGIN ACETATE 5 * NM 50mg, 70mg fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of 2 DIFLUCAN) TABS fluconazole in dextrose FLUCONAZOLE INJ NACL 100 fluconazole inj nacl 200 fluconazole inj nacl 00 flucytosine (generic of 5 * NM ANCOBON) CAPS griseofulvin microsize SUSP griseofulvin microsize TABS griseofulvin ultramicrosize (generic of GRIS-PEG) 12

12 itraconazole (generic of PA SPORANOX) CAPS ketoconazole TABS PA MYCAMINE 5 * NM NOXAFIL SUSP 5 * QL NM QL (60 ml / 0 NOXAFIL TBEC 5 * QL NM QL (9 tabs / 0 nystatin TABS terbinafine hcl (generic of 2 QL LAMISIL) TABS QL (90 tabs / 65 voriconazole (generic of VFEND IV) SOLR voriconazole (generic of VFEND) SUSR; TABS 5 * NM ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate (generic of QUALAQUIN) CAPS PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate (generic of ZIAGEN) APTIVUS 5 * NM atazanavir sulfate (generic of 5 * NM REYATAZ) CRIXIVAN didanosine (generic of VIDEX EC) EDURANT 5 * NM efavirenz (generic of SUSTIVA) CAPS 50mg efavirenz (generic of 5 * NM SUSTIVA) CAPS 200mg efavirenz (generic of 5 * NM SUSTIVA) TABS EMTRIVA fosamprenavir tab 700 mg (generic of LEXIVA) 5 * NM FUZEON 5 * NM INTELENCE 25mg INTELENCE 100mg, 200mg 5 * NM INVIRASE 5 * NM ISENTRESS CHEW 25mg ISENTRESS CHEW 100mg 5 * NM ISENTRESS PACK 5 * NM ISENTRESS TABS 5 * NM ISENTRESS HD 5 * NM lamivudine (generic of EPIVIR) LEXIVA SUSP LEXIVA TABS 5 * NM nevirapine tab 200mg (generic of VIRAMUNE) nevirapine tb2 (generic of VIRAMUNE XR) NORVIR PREZISTA SUSP 5 * QL NM QL (00 ml / 0 PREZISTA TABS 75mg QL (80 tabs / 0 PREZISTA TABS 150mg 5 * QL NM QL (20 tabs / 0 PREZISTA TABS 600mg 5 * QL NM QL (60 tabs / 0 PREZISTA TABS 800mg 5 * QL NM QL (0 tabs / 0 RESCRIPTOR RETROVIR IV INFUSION REYATAZ PACK 5 * NM ritonavir (generic of NORVIR) SELZENTRY SOLN 5 * NM SELZENTRY TABS 25mg SELZENTRY TABS 75mg, 5 * NM 150mg, 00mg stavudine (generic of ZERIT) SUSTIVA TABS 5 * NM tenofovir disoproxil fumarate 5 * NM (generic of VIREAD) TIVICAY 10mg TIVICAY 25mg, 50mg 5 * NM TYBOST VIDEX EC 125mg VIDEX PEDIATRIC 1

13 VIRACEPT 5 * NM VIRAMUNE SUSP VIREAD 5 * NM ZERIT SOLR 5 * NM zidovudine cap 100mg (generic of RETROVIR) zidovudine syp 50mg/5ml (generic of RETROVIR) zidovudine tab 00mg ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine (generic of EPZICOM) abacavir sulfate-lamivudinezidovudine (generic of TRIZIVIR) 5 * NM 5 * NM ATRIPLA 5 * NM BIKTARVY 5 * NM COMPLERA 5 * NM DESCOVY 5 * NM EVOTAZ 5 * NM GENVOYA 5 * NM JULUCA 5 * NM KALETRA TAB MG KALETRA TAB MG 5 * NM lamivudine-zidovudine (generic of COMBIVIR) lopinavir-ritonavir (generic of 5 * NM KALETRA) ODEFSEY 5 * NM PREZCOBIX 5 * NM STRIBILD 5 * NM SYMFI LO 5 * NM TRIUMEQ 5 * NM TRUVADA TAB * QL NM QL (60 tabs / 0 TRUVADA TAB * QL NM QL (0 tabs / 0 TRUVADA TAB * QL NM QL (0 tabs / 0 TRUVADA TAB QL (0 tabs / 0 5 * QL NM ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SULFATE cycloserine CAPS 5 * NM ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml PASER D/R PRIFTIN pyrazinamide TABS rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO TRECATOR ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir (generic of ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium B/D adefovir dipivoxil (generic of 5 * NM HEPSERA) BARACLUDE SOLN 5 * NM DAKLINZA 5 * NM PA entecavir (generic of 5 * NM BARACLUDE) EPCLUSA 5 * NM PA EPIVIR HBV SOLN famciclovir TABS ganciclovir inj 500mg (generic B/D of CYTOVENE) GANCICLOVIR INJ B/D 500MG/10ML HARVONI 5 * NM PA lamivudine (hbv) (generic of EPIVIR HBV) MAVYRET 5 * NM PA moderiba tab 200mg NM 2 1

14 oseltamivir phosphate (generic of TAMIFLU) CAPS 0mg QL (168 caps / year) oseltamivir phosphate (generic of TAMIFLU) CAPS 5mg, 75mg QL (8 caps / year) oseltamivir phosphate (generic of TAMIFLU) SUSR QL (1080 ml / year) PEGASYS 5 * NM PA PEGASYS PROCLICK 5 * NM PA REBETOL SOLN 5 * NM RELENZA DISKHALER QL (6 inhalers / year) ribasphere (generic of NM REBETOL) CAPS ribasphere TABS 200mg NM ribasphere TABS 00mg, 5 * NM 600mg ribavirin cap 200mg (generic NM of REBETOL) ribavirin tab 200mg NM rimantadine hydrochloride (generic of FLUMADINE) SOVALDI 5 * NM PA valacyclovir hcl (generic of VALTREX) TABS valganciclovir hcl (generic of VALCYTE) 5 * NM VEMLIDY 5 * NM VOSEVI 5 * NM PA ZEPATIER 5 * NM PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor CAPS cefaclor SUSR CEFACLOR ER TAB 500MG cefadroxil CAPS 2 cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE 2GM/100ML-% cefazolin inj cefazolin sodium SOLR 1gm, 20gm CEFAZOLIN SODIUM 1 GM/50ML cefdinir CAPS cefdinir SUSR cefepime for inj (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium 1gm, 2gm, 500mg cefoxitin for inj cefpodoxime proxetil cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg cefuroxime axetil cefuroxime sodium cephalexin (generic of KEFLEX) CAPS 250mg, 500mg cephalexin SUSR SUPRAX CAPS SUPRAX CHEW SUPRAX SUSR 500mg/5ml tazicef SOLR TEFLARO 5 * NM ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin PACK azithromycin (generic of ZITHROMAX) SOLR; SUSR azithromycin (generic of ZITHROMAX) TABS clarithromycin TABS 250mg clarithromycin (generic of BIAXIN) TABS 500mg clarithromycin er (generic of BIAXIN XL) clarithromycin for susp DIFICID 5 * NM e.e.s

15 Drug Tier ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 250mg ec Requirements/ Limits erythromycin ethylsuccinate TABS FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR 250mg/5ml ciprofloxacin (generic of CIPRO) SUSR 500mg/5ml ciprofloxacin hcl tab 100mg ciprofloxacin hcl tab (generic of CIPRO) 250mg, 500mg ciprofloxacin hcl tab 750mg ciprofloxacin in d5w ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W) ciprofloxacin inj levofloxacin (generic of LEVAQUIN) TABS levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin CAPS; SUSR; TABS amoxicillin CHEW 2 amoxicillin & pot clavulanate CHEW amoxicillin & pot clavulanate SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN ES- 600) SUSR amoxicillin & pot clavulanate TABS 2 amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12 Drug Tier 2 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK PACK) Requirements/ Limits ampicillin cap 250mg ampicillin cap 500mg ampicillin inj ampicillin sodium ampicillin susp BICILLIN L-A dicloxacillin sodium nafcillin sodium for inj 1gm, 2gm nafcillin sodium for inj 10gm 5 * NM oxacillin sodium 1gm, 2gm oxacillin sodium 10gm 5 * NM PENICILLIN G POT IN DEXTROSE 2MU PENICILLIN G POT IN DEXTROSE MU PENICILLIN G PROCAINE penicillin g sodium penicillin v potassium SOLR 2 penicillin v potassium TABS penicilln gk inj 5mu penicilln gk inj 20mu pfizerpen-g inj 5mu pfizerpen-g inj 20mu piper/tazoba inj gm (generic of ZOSYN) piper/tazoba inj -0.75gm (generic of ZOSYN) piper/tazoba inj -0.5gm (generic of ZOSYN) PIPER/TAZOBA INJ GM 16

16 Drug Tier Requirements/ Limits piper/tazoba inj 6-.5gm (generic of ZOSYN) TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 doxycycline (monohydrate) 2 CAPS 50mg, 100mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 50mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate 20 mg doxycycline hyclate 100 mg minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg minocycline hcl CAPS 75mg morgidox cap 1x50mg ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA 5 * B/D NM busulfan (generic of 5 * B/D NM BUSULFEX) CYCLOPHOSPHAMIDE B/D CAPS cyclophosphamide SOLR 5 * B/D NM dacarbazine B/D EMCYT GLEOSTINE HEXALEN 5 * NM IFEX INJ GM B/D ifosfamide inj 1gm (generic of B/D IFEX) ifosfamide inj 1gm/20ml B/D IFOSFAMIDE INJ GM B/D ifosfamide inj gm/60ml B/D LEUKERAN melphalan hcl (generic of 5 * B/D NM ALKERAN) MUSTARGEN 5 * B/D NM ANTHRACYCLINES adriamycin B/D doxorubicin hcl B/D doxorubicin hcl liposomal inj 5 * B/D NM 2mg/ml (generic of DOXIL) doxorubicin hcl soln 2mg/ml B/D epirubicin hcl (generic of B/D ELLENCE) ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR 5 * B/D NM ANTIMETABOLITES adrucil B/D adrucil inj B/D ALIMTA 5 * B/D NM azacitidine (generic of 5 * B/D NM VIDAZA) cladribine 5 * B/D NM cytarabine 20mg/ml B/D fludarabine phosphate B/D fluorouracil SOLN B/D gemcitabine inj soln B/D gemcitabine inj solr (generic 5 * B/D NM of GEMZAR) 1gm, 200mg gemcitabine inj solr 2gm 5 * B/D NM mercaptopurine TABS methotrexate sodium inj 2 B/D NIPENT 5 * B/D NM PURIXAN 5 * NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE 5 * B/D NM docetaxel (generic of 5 * B/D NM TAXOTERE) CONC 20mg/ml, 80mg/ml DOCETAXEL CONC 5 * B/D NM 80mg/ml, 160mg/8ml, 200mg/10ml DOCETAXEL SOLN 5 * B/D NM paclitaxel B/D TAXOTERE 80mg/ml 5 * B/D NM ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 B/D vincasar pfs 2 B/D vincristine sulfate 2 B/D 17

17 vinorelbine tartrate (generic of NAVELBINE) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN BELEODAQ 5 * NM PA BORTEZOMIB 5 * NM PA ERIVEDGE FARYDAK HERCEPTIN 5 * NM PA IBRANCE IDHIFA KADCYLA 5 * B/D NM KEYTRUDA 5 * NM PA KISQALI 5 * NM PA KISQALI FEMARA 200 DOSE 5 * NM PA KISQALI FEMARA 00 DOSE 5 * NM PA KISQALI FEMARA 600 DOSE 5 * NM PA LYNPARZA MYLOTARG NINLARO 5 * NM PA ODOMZO RITUXAN RITUXAN HYCELA RUBRACA TECENTRIQ VELCADE 5 * NM PA VENCLEXTA 10mg, 50mg NM LA PA VENCLEXTA 100mg VENCLEXTA STARTING PACK VERZENIO YERVOY 5 * NM PA ZEJULA ZOLINZA 5 * NM PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of 2 ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 00/ML B/D ERLEADA exemestane (generic of AROMASIN) FARESTON 5 * NM FASLODEX 5 * B/D NM flutamide hydroxyprogesterone 5 * B/D NM caproate (antineoplastic) letrozole (generic of 2 FEMARA) TABS leuprolide inj 1mg/0.2 NM PA LUPRON DEPOT (1-MONTH) 5 * NM PA.75mg LUPRON DEPOT INJ 5 * NM PA 11.25MG (-MONTH) LYSODREN megestrol ac sus 0mg/ml PA megestrol ac tab 20mg PA megestrol ac tab 0mg PA megestrol sus 625mg/5ml PA (generic of MEGACE ES) nilutamide (generic of 5 * NM NILANDRON) SOLTAMOX tamoxifen citrate TABS TRELSTAR DEP INJ.75MG 5 * NM PA TRELSTAR LA INJ 11.25MG 5 * NM PA XTANDI ZYTIGA IMMUNOMODULATORS POMALYST REVLIMID QL (28 caps / 28 5 * QL NM LA PA THALOMID 50mg, 100mg 5 * QL NM PA QL (0 caps / 0 THALOMID 150mg, 200mg 5 * QL NM PA QL (60 caps / 0 KINASE INHIBITORS AFINITOR 5 * QL NM PA QL (0 tabs / 0 AFINITOR DISPERZ 2mg 5 * QL NM PA QL (150 tabs / 0 AFINITOR DISPERZ mg 5 * QL NM PA QL (90 tabs / 0 AFINITOR DISPERZ 5mg 5 * QL NM PA QL (60 tabs / 0 ALECENSA ALUNBRIG BOSULIF 5 * NM PA 18

18 CABOMETYX QL (0 tabs / 0 5 * QL NM LA PA CALQUENCE CAPRELSA COMETRIQ COTELLIC GILOTRIF TAB 20MG GILOTRIF TAB 0MG GILOTRIF TAB 0MG ICLUSIG imatinib mesylate (generic of 5 * QL NM PA GLEEVEC) 100mg QL (90 tabs / 0 imatinib mesylate (generic of 5 * QL NM PA GLEEVEC) 00mg QL (60 tabs / 0 IMBRUVICA INLYTA 1mg QL (180 tabs / 0 5 * QL NM LA PA INLYTA 5mg QL (120 tabs / 0 5 * QL NM LA PA IRESSA JAKAFI QL (60 tabs / 0 5 * QL NM LA PA LENVIMA 8 MG DAILY DOSE LENVIMA 10 MG DAILY DOSE LENVIMA 1 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 2 MG DAILY DOSE MEKINIST NERLYNX NEXAVAR RYDAPT 5 * NM PA SPRYCEL 5 * NM PA STIVARGA SUTENT 5 * NM PA TAFINLAR TAGRISSO TARCEVA 25mg QL (90 tabs / 0 5 * QL NM LA PA TARCEVA 100mg, 150mg QL (0 tabs / 0 5 * QL NM LA PA TASIGNA 5 * NM PA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA MISCELLANEOUS bexarotene (generic of 5 * NM PA TARGRETIN) DROXIA hydroxyurea (generic of HYDREA) CAPS LONSURF 5 * NM PA MATULANE 5 * NM LA mitoxantrone hcl B/D NM SYLATRON KIT 200MCG 5 * NM PA SYLATRON KIT 00MCG 5 * NM PA SYLATRON KIT 600MCG 5 * NM PA SYNRIBO 5 * NM PA tretinoin (chemotherapy) 5 * NM TRISENOX 5 * B/D NM PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin inj 50mg 5 * B/D NM oxaliplatin inj 50mg/10ml B/D oxaliplatin inj 100mg 5 * B/D NM oxaliplatin inj 100mg/20ml B/D PROTECTIVE AGENTS dexrazoxane (generic of ZINECARD) 5 * B/D NM ELITEK 5 * B/D NM leucovorin calcium SOLR B/D leucovorin calcium TABS levoleucovorin calcium 5 * B/D NM 175mg/17.5ml LEVOLEUCOVORIN 5 * B/D NM CALCIUM 250mg/25ml levoleucovorin calcium 50mg 5 * B/D NM (generic of FUSILEV) LEVOLEUCOVORIN 5 * B/D NM CALCIUM 175MG mesna (generic of MESNEX) B/D 19

19 Drug Tier Requirements/ Limits MESNEX TABS 5 * NM TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan hcl (generic of CAMPTOSAR) 0mg/2ml, 100mg/5ml B/D irinotecan hcl 500mg/25ml B/D toposar B/D topotecan inj mg (generic of 5 * B/D NM HYCAMTIN) TOPOTECAN INJ MG/ML 5 * B/D NM CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylatebenazepril hcl cap mg amlodipine besylatebenazepril hcl cap 5-10 mg (generic of LOTREL) amlodipine besylatebenazepril hcl cap 5-20 mg (generic of LOTREL) amlodipine besylatebenazepril hcl cap 5-0 mg amlodipine besylatebenazepril hcl cap mg (generic of LOTREL) amlodipine besylatebenazepril hcl cap 10-0 mg (generic of LOTREL) benazepril & hydrochlorothiazide benazepril & hydrochlorothiazide (generic of LOTENSIN HCT) captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide enalapril maleate & hydrochlorothiazide (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide (generic of ZESTORETIC) moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide (generic of ACCURETIC) ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 5mg benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 0mg captopril TABS enalapril maleate (generic of VASOTEC) TABS fosinopril sodium lisinopril (generic of ZESTRIL) TABS 2.5mg, 0mg, 0mg lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg moexipril hcl perindopril erbumine quinapril hcl (generic of ACCUPRIL) ramipril (generic of ALTACE) trandolapril 1mg, 2mg trandolapril (generic of MAVIK) mg ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone (generic of INSPRA) spironolactone (generic of ALDACTONE) TABS ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate (generic of CARDURA) TABS 1mg, 2mg, mg QL (0 tabs / 0 doxazosin mesylate (generic of CARDURA) TABS 8mg prazosin hcl (generic of MINIPRESS) terazosin hcl 20

20 Drug Tier Requirements/ Limits ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylateolmesartan medoxomil (generic of AZOR) amlodipine besylate-valsartan tab (generic of EXFORGE) amlodipine-valsartanhydrochlorothiazide tab (generic of EXFORGE HCT) ENTRESTO irbesartan-hydrochlorothiazide (generic of AVALIDE) losartan-hydrochlorothiazide (generic of HYZAAR) olmesartan medoxomilamlodipinehydrochlorothiazide (generic of TRIBENZOR) olmesartan medoxomilhydrochlorothiazide (generic of BENICAR HCT) valsartan-hydrochlorothiazide (generic of DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE irbesartan (generic of AVAPRO) losartan potassium (generic of COZAAR) olmesartan medoxomil (generic of BENICAR) TABS valsartan (generic of DIOVAN) ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl SOLN 2 amiodarone hcl TABS 100mg, 00mg amiodarone hcl TABS 200mg disopyramide phosphate (generic of NORPACE) PA dofetilide (generic of NM TIKOSYN) flecainide acetate mexiletine hcl MULTAQ NORPACE CR PA pacerone 100mg, 00mg pacerone 200mg propafenone hcl propafenone hcl 12hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS 2 sorine (generic of 2 BETAPACE) 80mg, 120mg, 160mg sorine 20mg 2 sotalol hcl (generic of 2 BETAPACE) 80mg, 120mg, 160mg sotalol hcl 20mg 2 sotalol hcl (afib/afl) (generic of BETAPACE AF) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium (generic of LIPITOR) TABS lovastatin 10mg, 20mg lovastatin (generic of MEVACOR) 0mg pravastatin sodium 10mg pravastatin sodium (generic of PRAVACHOL) 20mg, 0mg, 80mg rosuvastatin calcium (generic of CRESTOR) QL (0 tabs / 0 simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 0mg simvastatin (generic of ZOCOR) TABS 80mg QL (0 tabs / 0 QL QL 21

21 Drug Tier Requirements/ Limits ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine (generic of QUESTRAN) cholestyramine light PACK cholestyramine light (generic of QUESTRAN LIGHT) POWD colestipol hcl gran (generic of COLESTID) colestipol hcl pack (generic of COLESTID) colestipol hcl tabs (generic of COLESTID) ezetimibe (generic of ZETIA) fenofibrate (generic of TRICOR) TABS 8mg, 15mg fenofibrate TABS 5mg, 160mg fenofibrate micronized 67mg, 1mg, 200mg gemfibrozil (generic of LOPID) 2 TABS JUXTAPID KYNAMRO 5 * NM PA niacin er (antihyperlipidemic) (generic of NIASPAN) 500mg QL (90 tabs / 0 niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg niacor omega--acid ethyl esters (generic of LOVAZA) PRALUENT 5 * NM PA prevalite PACK prevalite (generic of QUESTRAN LIGHT) POWD VASCEPA WELCHOL BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide (generic of ZIAC) metoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT) propranolol & hydrochlorothiazide BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 2 atenolol (generic of TENORMIN) TABS 25mg atenolol TABS 50mg, 100mg bisoprolol fumarate 2 BYSTOLIC 2.5mg, 5mg, 10mg QL (0 tabs / 0 BYSTOLIC 20mg QL (60 tabs / 0 carvedilol (generic of COREG) labetalol hcl TABS metoprolol succinate (generic of TOPROL XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS 25mg metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg nadolol (generic of CORGARD) TABS pindolol propranolol cap er (generic of INDERAL LA) propranolol hcl SOLN; TABS propranolol oral sol timolol maleate TABS CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS 22

22 afeditab cr (generic of ADALAT CC) amlodipine besylate (generic of NORVASC) TABS cartia xt (generic of CARDIZEM CD) 120mg, 180mg, 20mg cartia xt 00mg dilt-xr cap diltiazem cap 120mg cd (generic of CARDIZEM CD) diltiazem cap 180mg cd (generic of CARDIZEM CD) diltiazem cap 20mg cd (generic of CARDIZEM CD) diltiazem cap 00mg cd diltiazem cap 60mg cd (generic of CARDIZEM CD) diltiazem cap er/12hr diltiazem hcl (generic of 2 CARDIZEM) TABS 0mg, 60mg, 120mg diltiazem hcl TABS 90mg 2 diltiazem hcl cap sr 2hr diltiazem hcl coated beads cap sr 2hr (generic of CARDIZEM CD) 120mg, 60mg diltiazem hcl coated beads cap sr 2hr 00mg diltiazem hcl extended release beads cap sr (generic of TIAZAC) 120mg, 180mg, 20mg, 00mg, 60mg, 20mg diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg diltiazem inj 2 felodipine isradipine nicardipine hcl CAPS nifedical xl (generic of PROCARDIA XL) nifedipine (generic of PROCARDIA XL) TB2 Drug Tier Requirements/ Limits nifedipine er (generic of ADALAT CC) nimodipine CAPS 5 * NM NYMALIZE 5 * NM taztia xt (generic of TIAZAC) verapamil cap er (generic of VERELAN PM) 100mg, 200mg, 00mg verapamil cap er (generic of VERELAN) 120mg, 180mg, 20mg verapamil cap er 60mg verapamil hcl SOLN verapamil hcl TABS 0mg verapamil hcl (generic of CALAN) TABS 80mg, 120mg verapamil hcl (generic of 2 CALAN SR) TBCR verapamil tab er (generic of CALAN SR) 2 DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek (generic of LANOXIN) PA.25mg digitek (generic of LANOXIN).125mg QL (0 tabs / 0 digox (generic of LANOXIN) 125mcg QL (0 tabs / 0 digox (generic of LANOXIN) PA 250mcg digoxin (generic of LANOXIN) TABS 125mcg QL (0 tabs / 0 digoxin (generic of LANOXIN) PA TABS 250mcg digoxin inj (generic of LANOXIN) digoxin sol 50mcg/ml PA DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS 2

23 Drug Tier Requirements/ Limits TEKTURNA TEKTURNA HCT DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12 acetazolamide TABS amiloride & 2 hydrochlorothiazide amiloride hcl TABS bumetanide inj 0.25/ml bumetanide tab (generic of BUMEX) chlorothiazide tabs chlorthalidone furosemide SOLN 2 furosemide (generic of LASIX) TABS furosemide inj 2 hydrochlorothiazide (generic of MICROZIDE) CAPS hydrochlorothiazide TABS indapamide 2 methazolamide (generic of NEPTAZANE) TABS 25mg methazolamide TABS 50mg methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs 5mg, 100mg 2 torsemide tabs (generic of 2 DEMADEX) 10mg, 20mg triamterene & hydrochlorothiazide cap mg (generic of DYAZIDE) triamterene & hydrochlorothiazide tabs (generic of MAXZIDE) triamterene & hydrochlorothiazide tabs (generic of MAXZIDE-25) MISCELLANEOUS clonidine hcl (generic of CATAPRES-TTS-1) PTWK.1mg/2hr clonidine hcl (generic of CATAPRES-TTS-2) PTWK.2mg/2hr clonidine hcl (generic of CATAPRES-TTS-) PTWK.mg/2hr Drug Tier Requirements/ Limits clonidine hcl (generic of CATAPRES) TABS CORLANOR DEMSER 5 * NM hydralazine hcl SOLN hydralazine hcl TABS 2 midodrine hcl minoxidil TABS 2 NORTHERA RANEXA NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab 2 isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg isosorbide dinitrate 10mg, 20mg, 0mg isosorbide dinitrate er isosorbide mononitrate er 2 minitran (generic of NITRO- DUR) NITRO-BID NITRO-DUR DIS 0.MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin (generic of NITROSTAT) SUBL nitroglycerin td patch.1mg/hr nitroglycerin td patch (generic of NITRO-DUR).2mg/hr,.mg/hr,.6mg/hr PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA 5 * QL NM PA QL (60 tabs / 0 2

24 ADEMPAS QL (90 tabs / 0 5 * QL NM LA PA LETAIRIS QL (0 tabs / 0 5 * QL NM LA PA OPSUMIT QL (0 tabs / 0 5 * QL NM LA PA REMODULIN sildenafil citrate (pulmonary NM PA hypertension) (generic of REVATIO) TABS QL (90 tabs / 0 TRACLEER TABS 62.5mg QL (120 tabs / 0 5 * QL NM LA PA TRACLEER TABS 125mg QL (60 tabs / 0 5 * QL NM LA PA VENTAVIS 5 * NM PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg (generic of XANAX) QL QL (20 tabs / 0 alprazolam tab 0.25mg QL (generic of XANAX) QL (80 tabs / 0 alprazolam tab 1mg (generic QL of XANAX) QL (120 tabs / 0 alprazolam tab 2 mg (generic QL of XANAX) QL (150 tabs / 0 buspirone hcl TABS 5mg, 2 7.5mg, 10mg, 15mg buspirone hcl TABS 0mg fluvoxamine maleate TABS 2 QL 25mg, 50mg QL (5 tabs / 0 fluvoxamine maleate TABS 2 100mg lorazepam (generic of 2 ATIVAN) SOLN lorazepam (generic of ATIVAN) TABS QL (150 tabs / 0 QL lorazepam intensol QL (150 ml / 0 ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 200mg 5 * QL NM QL (180 tabs / 0 APTIOM 00mg 5 * QL NM QL (90 tabs / 0 APTIOM 600mg, 800mg 5 * QL NM QL (60 tabs / 0 BANZEL SUS 0MG/ML 5 * NM PA BANZEL TAB 200MG 5 * NM PA BANZEL TAB 00MG 5 * NM PA BRIVIACT SOLN 10mg/ml 5 * NM PA BRIVIACT SOLN 50mg/5ml PA BRIVIACT TABS 5 * NM PA carbamazepine CHEW carbamazepine (generic of CARBATROL) CP12 carbamazepine (generic of TEGRETOL) SUSP carbamazepine (generic of TEGRETOL) TABS carbamazepine (generic of TEGRETOL-XR) TB12 CELONTIN clonazepam (generic of QL KLONOPIN) TABS 1mg QL (120 tabs / 0 clonazepam (generic of QL KLONOPIN) TABS 2mg QL (00 tabs / 0 clonazepam (generic of QL KLONOPIN) TABS.5mg QL (20 tabs / 0 clonazepam TBDP 1mg QL (120 tabs / 0 clonazepam TBDP 2mg QL (00 tabs / 0 clonazepam TBDP.5mg QL (20 tabs / 0 clonazepam TBDP.25mg QL (80 tabs / 0 clonazepam TBDP.125mg QL (960 tabs / 0 25

25 clorazepate dipotassium PA.75mg QL (120 tabs / 0 clorazepate dipotassium PA (generic of TRANXENE T) 7.5mg QL (120 tabs / 0 clorazepate dipotassium PA 15mg QL (180 tabs / 0 DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam SOLN 1mg/ml PA QL (1200 ml / 0 diazepam SOLN 5mg/ml diazepam (generic of QL PA VALIUM) TABS QL (120 tabs / 0 diazepam gel diazepam intensol PA QL (20 ml / 0 DILANTIN DILANTIN-125 SUS 125/5ML divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR divalproex sodium (generic of DEPAKOTE ER) TB2 divalproex sodium (generic of DEPAKOTE) TBEC epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of 5 * NM FELBATOL) SUSP felbamate (generic of FELBATOL) TABS FYCOMPA SUSP 5 * QL NM PA QL (720 ml / 0 FYCOMPA TABS 2mg QL (180 tabs / 0 PA FYCOMPA TABS mg 5 * QL NM PA QL (90 tabs / 0 FYCOMPA TABS 6mg 5 * QL NM PA QL (60 tabs / 0 FYCOMPA TABS 8mg, 5 * QL NM PA 10mg, 12mg QL (0 tabs / 0 gabapentin (generic of 2 QL NEURONTIN) CAPS 100mg QL (1080 caps / 0 gabapentin (generic of 2 QL NEURONTIN) CAPS 00mg QL (60 caps / 0 gabapentin (generic of 2 QL NEURONTIN) CAPS 00mg QL (270 caps / 0 gabapentin (generic of NEURONTIN) SOLN QL (2160 ml / 0 gabapentin (generic of NEURONTIN) TABS 600mg QL (180 tabs / 0 gabapentin (generic of NEURONTIN) TABS 800mg QL (120 tabs / 0 GABITRIL 12mg, 16mg lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW lamotrigine (generic of 2 LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB2 levetiracetam (generic of KEPPRA) TABS levetiracetam (generic of KEPPRA XR) TB2 levetiracetam in sodium chloride (generic of LEVETIRACETAM) levetiracetam inj (generic of KEPPRA) levetiracetam oral soln 100 mg/ml (generic of KEPPRA) 26

26 LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg QL (120 caps / 0 LYRICA CAPS 200mg QL (90 caps / 0 LYRICA CAPS 225mg, 00mg QL (60 caps / 0 LYRICA SOLN QL (96 ml / 0 ONFI 5 * NM PA oxcarbazepine (generic of TRILEPTAL) SUSP oxcarbazepine (generic of TRILEPTAL) TABS PEGANONE phenobarbital ELIX; TABS PA PHENOBARBITAL SODIUM PA SOLN 65mg/ml phenobarbital sodium SOLN PA 10mg/ml PHENYTEK phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-125) SUSP phenytoin sodium SOLN phenytoin sodium extended (generic of DILANTIN) 100mg phenytoin sodium extended (generic of PHENYTEK) 200mg, 00mg primidone (generic of 2 MYSOLINE) TABS roweepra (generic of KEPPRA) roweepra xr (generic of KEPPRA XR) SABRIL TABS QL (180 tabs / 0 5 * QL NM LA PA SPRITAM TEGRETOL Drug Tier TEGRETOL-XR tiagabine hcl (generic of GABITRIL) topiramate (generic of TOPAMAX SPRINKLE) CPSP topiramate (generic of 2 TOPAMAX) TABS valproate sodium oral soln (generic of DEPAKENE) valproate sodium soln 100mg/ml (generic of DEPACON) valproic acid (generic of DEPAKENE) vigabatrin powd pack 500mg (generic of SABRIL) QL (180 packets / 0 Requirements/ Limits 5 * QL NM LA PA VIMPAT SOLN 10mg/ml 5 * QL NM QL (1200 ml / 0 VIMPAT SOLN 200mg/20ml 5 * NM VIMPAT TABS 50mg QL (180 tabs / 0 VIMPAT TABS 100mg, 150mg, 200mg QL (60 tabs / 0 5 * QL NM zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg zonisamide CAPS 50mg ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride (generic of ARICEPT) TABS 5mg QL (60 tabs / 0 donepezil hydrochloride (generic of ARICEPT) TABS 10mg donepezil hydrochloride (generic of ARICEPT) TABS 2mg donepezil hydrochloride TBDP 5mg QL (60 tabs / 0 2 QL 2 2 QL 27

27 donepezil hydrochloride 2 TBDP 10mg galantamine hydrobromide SOLN galantamine hydrobromide (generic of RAZADYNE) TABS mg QL (180 tabs / 0 galantamine hydrobromide (generic of RAZADYNE) TABS 8mg QL (90 tabs / 0 galantamine hydrobromide (generic of RAZADYNE) TABS 12mg galantamine hydrobromide er (generic of RAZADYNE ER) 8mg, 16mg QL (0 caps / 0 galantamine hydrobromide er (generic of RAZADYNE ER) 2mg memantine hcl SOLN PA PA if < 0 yrs memantine hcl (generic of PA NAMENDA) TABS PA if < 0 yrs memantine hcl cp2 (generic PA of NAMENDA XR) PA if < 0 yrs NAMENDA XR PA PA if < 0 yrs NAMENDA XR TITRATION PA PACK PA if < 0 yrs NAMZARIC rivastigmine tartrate rivastigmine td patch 2hr.6 mg/2hr (generic of EXELON) QL (0 patches / 0 rivastigmine td patch 2hr 9.5 mg/2hr (generic of EXELON) QL (0 patches / 0 rivastigmine td patch 2hr 1. mg/2hr (generic of EXELON) QL (0 patches / 0 ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS PA amoxapine bupropion hcl TABS bupropion hcl (generic of 2 WELLBUTRIN SR) TB12 bupropion hcl (generic of WELLBUTRIN XL) TB2 150mg QL (90 tabs / 0 bupropion hcl (generic of WELLBUTRIN XL) TB2 00mg QL (0 tabs / 0 citalopram hydrobromide SOLN citalopram hydrobromide (generic of CELEXA) TABS 10mg, 20mg QL (5 tabs / 0 citalopram hydrobromide (generic of CELEXA) TABS 0mg QL (0 tabs / 0 clomipramine hcl (generic of ANAFRANIL) CAPS desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg desipramine hcl TABS 50mg, 75mg, 100mg, 150mg desvenlafaxine succinate (generic of PRISTIQ) QL (0 tabs / 0 doxepin hcl CAPS; CONC duloxetine hcl (generic of CYMBALTA) CPEP 20mg QL (180 caps / 0 QL QL PA PA 28