(List of Covered Drugs)

Transcription

1 SilverScript Plus (PDP) 2019 Formulary (List of Covered Drugs) Formulary File 19296, Version 7 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on October 19, For more recent information or other questions, please contact SilverScript at or, for TTY users, 711, 2 hours a day, 7 days a week, or visit 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 SilverScript Insurance Company. When it refers to plan or our plan, it means SilverScript Plus (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of January 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, 2020, and from time to time during the year. Y0080_62001_FORM_COMP_2019_C FRM-CM-PLS

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3 What is the SilverScript Formulary? A formulary is a list of covered drugs selected by SilverScript Plus (PDP) 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 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the SilverScript Formulary? Drugs removed from the market. 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, 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 0 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 0-day supply of the drug. The enclosed formulary is current as of January 1, To get updated information about the drugs covered by SilverScript Plus (PDP), please contact us. Our contact information appears on the front and back cover pages. If we have other types of mid-year non-maintenance formulary changes unrelated to the reasons stated above (e.g. 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 may be obtained from our website or by calling us. Our contact information appears on the front and back cover pages. i

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 1. 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 50. 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? SilverScript Plus (PDP) 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 () SilverScript Plus (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits (QL) For certain drugs, SilverScript Plus (PDP) limits the amount of the drug that we will cover. For example, our plan provides up to 0 tablets per prescription for rosuvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy (ST) In some cases, SilverScript Plus (PDP) 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, we 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 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line 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. You can ask us 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 SilverScript formulary? on page iii 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 Care and ask if your drug is covered. If you learn that SilverScript Plus (PDP) does not cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by our plan. 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 us to make an exception and cover your drug. See below for information about how to request an exception. ii

5 How do I request an exception to the SilverScript Formulary? You can ask us 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, SilverScript Plus (PDP) 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. 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. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. 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 and 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 while you pursue a formulary exception. If you experience a change in your level of care, such as a move from a home to a long-term care setting, and need a drug that is not on our formulary (or if your ability to get your drugs is limited), we may cover a one-time temporary supply from a network pharmacy for up to 1 days unless you have a prescription for fewer days. You should use the plan s exception process if you wish to have continued coverage of the drug after the temporary supply is finished. iii

6 For more information For more detailed information about your SilverScript Plus (PDP) 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 SilverScript Plus (PDP) s Formulary The formulary that begins on page 1 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 50. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTOID) 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. Prior authorization. QL Drug has quantity limit. ST Step therapy required. NM Not available at our mail-order pharmacies. NDS Non-extended day supply. Not available for an extended (long-term) supply. LA Limited access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at , 2 hours a day, 7 days a week. TTY users should call 711. High Risk Drug. According to medical experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available. B/D This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 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. iv

7 The Tier column of the drug list that begins on page 1 tells you which tier your drug is in. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug s cost that you will pay during the initial coverage stage) for up to a one-month supply of drugs in each tier. Initial Coverage Stage Copayment / Coinsurance Levels Preferred Retail/Mail-Order and Standard Retail/Mail-Order cost-sharing (in-network) (Up to a 0-day supply) State Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Pharmacy Type (Retail & Mail) Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier (Non-Preferred Drug) Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $1.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Tier 5 (Specialty Tier) % % % % % % % % % % % % % % % % v

8 State Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Pharmacy Type (Retail & Mail) Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier (Non-Preferred Drug) Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $2.00 0% Preferred $1.00 $10.00 $2.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $10.00 $2.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $10.00 $2.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Tier 5 (Specialty Tier) % % % % % % % % % % % % % % % % % % % % vi

9 State Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Pharmacy Type (Retail & Mail) Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier (Non-Preferred Drug) Preferred $1.00 $5.00 $.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $.00 0% Preferred $1.00 $5.00 $5.00 0% Preferred $1.00 $5.00 $.00 0% Preferred $1.00 $5.00 $5.00 0% Tier 5 (Specialty Tier) % % % % % % % % % % % % % % Tier 1 (Preferred Generic) includes low cost preferred generic drugs Tier 2 (Generic) includes preferred generic drugs Tier (Preferred Brand) includes preferred brand and non-preferred generic drugs Tier (Non-Preferred Drug) includes non-preferred brand and non-preferred generic drugs Tier 5 (Specialty Tier) includes high cost brand and generic drugs You can find complete cost-sharing information, including costs for long-term supplies, long-term care, and out-of-network pharmacy pricing, in your Evidence of Coverage. vii

10 ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM) colchicine w/ probenecid COLCRYS QL QL (120 tabs / 0 MITIGARE QL QL (60 caps / 0 probenecid ULORIC ST NSAIDS 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 QL QL QL QL diclofenac potassium QL QL (120 tabs / 0 diclofenac sodium TB2; TBEC diflunisal flurbiprofen TABS ibu tab 600mg ibu tab 800mg ibuprofen SUSP ibuprofen TABS 00mg, 600mg, 800mg meloxicam (generic of 1 GC MOBIC) TABS nabumetone TABS naproxen (generic of 1 GC NAPROSYN) TABS 250mg, 500mg naproxen TABS 75mg 1 GC naproxen dr (generic of EC-NAPROSYN) sulindac TABS OPIOID ANALGESICS acetaminophen w/ codeine QL 00-15mg QL (00 tabs / 0 acetaminophen w/ codeine QL 00-0mg (generic of TYLENOL/CODEINE #) QL (60 tabs / 0 acetaminophen w/ codeine QL 00-60mg (generic of TYLENOL/CODEINE #) QL (180 tabs / 0 acetaminophen w/ codeine soln QL QL (2700 ml / 0 butorphanol tartrate SOLN 1mg/ml, 2mg/ml BUTRANS QL QL ( patches / 28 nalbuphine hcl SOLN tramadol hcl tab 50 mg QL (generic of ULTRAM) QL (20 tabs / 0 tramadol-acetaminophen QL (generic of ULTRACET) QL (20 tabs / 0 OPIOID ANALGESICS, CII EMBEDA CAP MG QL QL (60 caps / 0 EMBEDA CAP 0-1.2MG QL QL (60 caps / 0 EMBEDA CAP 50-2MG QL QL (60 caps / 0 EMBEDA CAP 60-2.MG QL QL (60 caps / 0 EMBEDA CAP 80-.2MG QL QL (60 caps / 0 EMBEDA CAP 100-MG QL QL (60 caps / 0 endocet mg (generic of PERCOCET) QL (60 tabs / 0 QL - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 1

11 endocet 5-25mg (generic of QL PERCOCET) QL (60 tabs / 0 endocet mg (generic of PERCOCET) QL (20 tabs / 0 QL endocet 10-25mg (generic of PERCOCET) QL (180 tabs / 0 QL fentanyl citrate (generic of 5 NDS QL 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 5 NDS QL QL (120 tabs / 0 hydroco/apap tab 5-25mg QL (generic of NORCO) QL (20 tabs / 0 hydroco/apap tab mg QL (generic of NORCO) QL (180 tabs / 0 hydroco/apap tab 10-25mg (generic of NORCO) QL (180 tabs / 0 QL hydrocodone-acetaminophen mg/15ml QL (2700 ml / 0 hydrocodone-ibuprofen QL mg QL (150 tabs / 0 hydromorphone hcl (generic of DILAUDID) LIQD QL (600 ml / 0 hydromorphone hcl (generic B/D of HYDROMORPHONE HYDROCHLORI) SOLN 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl (generic QL of DILAUDID) TABS QL (180 tabs / 0 HYSINGLA ER QL QL (0 tabs / 0 lorcet hd tab 10-25mg QL (generic of NORCO) QL (180 tabs / 0 lorcet plus tab QL (generic of NORCO) QL (180 tabs / 0 lorcet tab 5-25mg (generic of QL NORCO) QL (20 tabs / 0 methadone hcl SOLN QL 5mg/5ml QL (50 ml / 0 methadone hcl 5mg (generic QL of DOLOPHINE) QL (90 tabs / 0 methadone hcl 10mg (generic QL of DOLOPHINE) QL (90 tabs / 0 methadone hcl intensol QL (generic of METHADOSE) QL (90 ml / 0 methadone hcl soln 10 mg/5ml QL (50 ml / 0 QL - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 2

12 morphine ext-rel tab (generic QL of MS CONTIN) 15mg, 0mg, 60mg, 100mg QL (90 tabs / 0 morphine ext-rel tab (generic QL of MS CONTIN) 200mg QL (60 tabs / 0 morphine sul inj 1mg/ml B/D MORPHINE SUL INJ B/D 2MG/ML MORPHINE SUL INJ B/D MG/ML morphine sul inj 10mg/ml B/D MORPHINE SULFATE B/D SOLN 2mg/ml, mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/0ml morphine sulfate (generic of B/D MORPHINE SULFATE) SOLN mg/ml, 8mg/ml, 10mg/ml morphine sulfate SOLN B/D 8mg/ml morphine sulfate TABS QL 15mg QL (180 tabs / 0 morphine sulfate TABS QL 0mg QL (90 tabs / 0 morphine sulfate oral soln QL 10mg/5ml QL (900 ml / 0 morphine sulfate oral soln QL 20mg/5ml QL (750 ml / 0 morphine sulfate oral soln QL 100mg/5ml QL (180 ml / 0 NUCYNTA ER 50mg, QL 100mg, 200mg, 250mg QL (60 tabs / 0 NUCYNTA ER 150mg QL QL (90 tabs / 0 oxycodone hcl SOLN QL (900 ml / 0 oxycodone hcl (generic of QL ROXICODONE) TABS 5mg, 15mg, 0mg QL (180 tabs / 0 oxycodone hcl TABS 10mg, QL 20mg QL (180 tabs / 0 oxycodone w/ acetaminophen QL mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen QL 5-25mg (generic of PERCOCET) QL (60 tabs / 0 oxycodone w/ acetaminophen QL mg (generic of PERCOCET) QL (20 tabs / 0 oxycodone w/ acetaminophen QL 10-25mg (generic of PERCOCET) QL (180 tabs / 0 OXYCONTIN QL QL (60 tabs / 0 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE) 2% lidocaine hcl (local anesth.) B/D (generic of XYLOCAINE-MPF).5%, 1% lidocaine inj 0.5% (generic of B/D XYLOCAINE) lidocaine inj 1% (generic of B/D XYLOCAINE) lidocaine inj 1.5% B/D preservative free (pf) (generic of XYLOCAINE-MPF) ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk

13 paromomycin sulfate CAPS streptomycin sulfate SOLR 5 NDS SULFADIAZINE TABS tobramycin (generic of 5 NDS NM KITABIS K) NEBU tobramycin inj 1.2 gm/0ml tobramycin inj 1.2gm 5 NDS tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/2ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 NDS ALINIA 5 NDS atovaquone (generic of 5 NDS MEPRON) SUSP AZACTAM IN ISO-OSMOTIC DE AZACTAM/DEX INJ aztreonam (generic of AZACTAM) BILTRICIDE CAYSTON clindamycin cap 75mg (generic of CLEOCIN) clindamycin cap 00mg (generic of CLEOCIN) clindamycin hcl cap 150 mg (generic of CLEOCIN) clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) clindamycin phosphate in d5w (generic of CLEOCIN PHOSPHATE) 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 NDS CUBICIN) 500mg EMVERM 5 NDS ertapenem sodium imipenem-cilastatin imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) SOLN; TABS linezolid (generic of ZYVOX) 5 NDS SUSR linezolid in sodium chloride meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of FLAGYL) TABS metronidazole in nacl NEBUPENT B/D nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg applies if 70 years and older after a 90 day supply in a calendar year; nitrofurantoin monohyd macro (generic of MACROBID) applies if 70 years and older after a 90 day supply in a calendar year; PENTAM 00 praziquantel (generic of BILTRICIDE) TABS SIVEXTRO 5 NDS sulfamethoxazole-trimethop ds (generic of BACTRIM DS) - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk

14 sulfamethoxazole-trimethopri m inj sulfamethoxazole-trimethopri m susp sulfamethoxazole-trimethopri m tab 00-80mg (generic of BACTRIM) SYNERCID 5 NDS tigecycline (generic of 5 NDS TYGACIL) trimethoprim TABS vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg vancomycin hcl (generic of 5 NDS VANCOCIN HCL) CAPS 250mg vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg VANCOMYCIN IN NACL ANTIFUNGALS ABELCET 5 NDS B/D AMBISOME 5 NDS B/D amphotericin b SOLR B/D caspofungin acetate (generic of CANCIDAS) fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS fluconazole in dextrose fluconazole inj nacl 200 fluconazole inj nacl 00 5 NDS flucytosine (generic of 5 NDS ANCOBON) CAPS griseofulvin microsize SUSP griseofulvin microsize TABS griseofulvin ultramicrosize itraconazole (generic of SPORANOX) CAPS ketoconazole TABS MYCAMINE 5 NDS NOXAFIL SUSP QL (60 ml / 0 5 NDS QL NOXAFIL TBEC 5 NDS QL QL (9 tabs / 0 nystatin TABS terbinafine hcl (generic of LAMISIL) TABS voriconazole (generic of VFEND IV) SOLR voriconazole (generic of 5 NDS VFEND) SUSR; TABS ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate (generic of QUALAQUIN) CAPS ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) SOLN abacavir sulfate (generic of ZIAGEN) TABS APTIVUS 5 NDS atazanavir sulfate (generic of 5 NDS REYATAZ) CRIXIVAN didanosine (generic of VIDEX EC) EDURANT 5 NDS efavirenz (generic of SUSTIVA) CAPS 50mg efavirenz (generic of 5 NDS SUSTIVA) CAPS 200mg efavirenz (generic of 5 NDS SUSTIVA) TABS EMTRIVA fosamprenavir tab 700 mg 5 NDS (generic of LEXIVA) FUZEON 5 NDS NM INTELENCE 25mg INTELENCE 100mg, 200mg 5 NDS INVIRASE 5 NDS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 5

15 ISENTRESS CHEW 25mg ISENTRESS CHEW 100mg 5 NDS ISENTRESS CK ISENTRESS TABS 5 NDS ISENTRESS HD 5 NDS lamivudine (generic of EPIVIR) LEXIVA SUSP nevirapine susp 50 mg/5ml (generic of VIRAMUNE) nevirapine tab 100mg (generic of VIRAMUNE XR) nevirapine tab 200mg (generic of VIRAMUNE) nevirapine tab 00mg er (generic of VIRAMUNE XR) NORVIR CAPS NORVIR CK; SOLN PREZISTA SUSP 5 NDS QL QL (00 ml / 0 PREZISTA TABS 75mg QL QL (80 tabs / 0 PREZISTA TABS 150mg 5 NDS QL QL (20 tabs / 0 PREZISTA TABS 600mg 5 NDS QL QL (60 tabs / 0 PREZISTA TABS 800mg 5 NDS QL QL (0 tabs / 0 RESCRIPTOR REYATAZ CK 5 NDS ritonavir (generic of NORVIR) SELZENTRY SOLN 5 NDS SELZENTRY TABS 25mg SELZENTRY TABS 75mg, 5 NDS 150mg, 00mg stavudine (generic of ZERIT) tenofovir disoproxil fumarate 5 NDS (generic of VIREAD) TIVICAY 10mg TIVICAY 25mg, 50mg 5 NDS TROGARZO TYBOST VIDEX EC 125mg VIDEX PEDIATRIC VIRACEPT 5 NDS VIRAMUNE SUSP VIREAD POWD 5 NDS VIREAD TABS 150mg, 5 NDS 200mg, 250mg ZERIT SOLR 5 NDS zidovudine cap 100mg (generic of RETROVIR) zidovudine syp 50mg/5ml (generic of RETROVIR) zidovudine tab 00mg ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of EPZICOM) abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR) 5 NDS ATRIPLA 5 NDS BIKTARVY 5 NDS CIMDUO 5 NDS COMPLERA 5 NDS DESCOVY 5 NDS EVOTAZ 5 NDS GENVOYA 5 NDS JULUCA 5 NDS KALETRA TAB MG KALETRA TAB MG 5 NDS lamivudine-zidovudine (generic of COMBIVIR) lopinavir-ritonavir (generic of KALETRA) ODEFSEY 5 NDS PREZCOBIX 5 NDS STRIBILD 5 NDS SYMFI 5 NDS SYMFI LO 5 NDS SYMTUZA 5 NDS TRIUMEQ 5 NDS TRUVADA TAB QL (60 tabs / 0 TRUVADA TAB QL (0 tabs / 0 5 NDS QL 5 NDS QL - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 6

16 TRUVADA TAB NDS QL QL (0 tabs / 0 TRUVADA TAB QL (0 tabs / 0 5 NDS QL ANTITUBERCULAR AGENTS cycloserine CAPS 5 NDS ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS isoniazid syp 50mg/5ml SER D/R PRIFTIN pyrazinamide TABS rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO 5 NDS LA TRECATOR ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium B/D adefovir dipivoxil (generic of 5 NDS HEPSERA) BARACLUDE SOLN 5 NDS entecavir (generic of BARACLUDE) EPCLUSA 5 NDS NM EPIVIR HBV SOLN famciclovir TABS ganciclovir sodium (generic of CYTOVENE) B/D HARVONI 5 NDS NM lamivudine (hbv) (generic of EPIVIR HBV) MAVYRET 5 NDS NM moderiba tab 200mg NM oseltamivir phosphate QL (generic of TAMIFLU) CAPS 0mg QL (168 caps / year) oseltamivir phosphate QL (generic of TAMIFLU) CAPS 5mg, 75mg QL (8 caps / year) oseltamivir phosphate (generic of TAMIFLU) SUSR QL (1080 ml / year) QL PEGASYS 5 NDS NM PEGASYS PROCLICK 5 NDS NM 180mcg/0.5ml REBETOL SOL 0MG/ML 5 NDS NM RELENZA DISKHALER QL QL (6 inhalers / year) ribasphere (generic of NM REBETOL) CAPS ribasphere TABS 200mg NM ribasphere TABS 00mg, 5 NDS NM 600mg ribavirin cap 200mg (generic NM of REBETOL) ribavirin tab 200mg NM rimantadine hydrochloride (generic of FLUMADINE) valacyclovir hcl (generic of VALTREX) TABS valganciclovir hcl (generic of 5 NDS VALCYTE) VEMLIDY 5 NDS VOSEVI 5 NDS NM ZETIER 5 NDS NM CEPHALOSPORINS cefaclor CAPS cefaclor SUSR CEFACLOR ER TAB 500MG cefadroxil CAPS cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE 2GM/100ML-% cefazolin inj - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 7

17 cefazolin sodium SOLR 1gm, 20gm CEFAZOLIN SODIUM 1 GM/50ML cefdinir CAPS cefdinir SUSR cefepime hcl (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium cefoxitin sodium cefpodoxime proxetil SUSR cefpodoxime proxetil TABS cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE 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 NDS ERYTOMYCINS/MACROLIDES azithromycin CK azithromycin (generic of ZITOMAX) SOLR azithromycin (generic of ZITOMAX) SUSR azithromycin (generic of ZITOMAX) TABS clarithromycin TABS 250mg clarithromycin (generic of BIAXIN) TABS 500mg clarithromycin er (generic of BIAXIN XL) clarithromycin for susp DIFICID 5 NDS e.e.s. 00mg tab ery-tab ERYTOCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate TABS FLUOROQUINOLONES 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) levofloxacin (generic of LEVAQUIN) TABS levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml PENICILLINS amoxicillin 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 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 8

18 amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK CK) ampicillin cap 500mg ampicillin inj ampicillin sodium BICILLIN L-A dicloxacillin sodium nafcillin sodium 1gm, 2gm nafcillin sodium 10gm 5 NDS oxacillin sodium 1gm, 2gm oxacillin sodium 10gm 5 NDS PENICILLIN G POT IN DEXTROSE 2MU PENICILLIN G POT IN DEXTROSE MU PENICILLIN G PROCAINE penicillin g sodium penicillin v potassium 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 piper/tazoba inj 6-.5gm (generic of ZOSYN) TETRACYCLINES doxy 100 doxycycline (monohydrate) CAPS 50mg, 100mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 50mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate TABS 20mg, 100mg minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg minocycline hcl CAPS 75mg morgidox cap 1x50mg tetracycline hcl CAPS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA cyclophosphamide (generic of CYCLOPHOSPHAMIDE) CAPS 5 NDS B/D NM B/D cyclophosphamide SOLR 5 NDS B/D dacarbazine 100mg B/D EMCYT GLEOSTINE HEXALEN 5 NDS IFEX gm B/D ifosfamide inj 1gm/20ml B/D IFOSFAMIDE INJ GM B/D ifosfamide inj gm/60ml B/D LEUKERAN 5 NDS ANTACYCLINES adriamycin B/D doxorubicin hcl B/D doxorubicin hcl liposomal 5 NDS B/D (generic of DOXIL) epirubicin hcl (generic of B/D ELLENCE) ANTIBIOTICS bleomycin sulfate B/D - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 9

19 Drug Tier Requirements/ Limits mitomycin SOLR 5 NDS B/D ANTIMETABOLITES adrucil B/D ALIMTA 5 NDS B/D azacitidine (generic of VIDAZA) cytarabine 20mg/ml B/D fluorouracil SOLN B/D gemcitabine inj soln B/D 5 NDS B/D NM gemcitabine inj solr (generic B/D of GEMZAR) 1gm, 200mg gemcitabine inj solr 2gm B/D mercaptopurine TABS methotrexate sodium inj B/D PURIXAN 5 NDS NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE 5 NDS B/D docetaxel (generic of TAXOTERE) CONC 20mg/ml, 80mg/ml DOCETAXEL CONC 80mg/ml, 160mg/8ml, 200mg/10ml DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml docetaxel (generic of DOCETAXEL) SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml 5 NDS B/D 5 NDS B/D 5 NDS B/D 5 NDS B/D paclitaxel B/D TAXOTERE 80mg/ml 5 NDS B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar pfs B/D vincristine sulfate B/D vinorelbine tartrate (generic of NAVELBINE) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN BORTEZOMIB 5 NDS NM ERIVEDGE FARYDAK HERCEPTIN 5 NDS NM IBRANCE IDHIFA KADCYLA 5 NDS B/D NM KEYTRUDA 5 NDS NM KISQALI 5 NDS NM KISQALI FEMARA 200 DOSE 5 NDS NM KISQALI FEMARA 00 DOSE 5 NDS NM KISQALI FEMARA 600 DOSE 5 NDS NM LYNRZA MYLOTARG NINLARO 5 NDS NM ODOMZO RITUXAN RITUXAN HYCELA RUBRACA TECENTRIQ TIBSOVO VELCADE 5 NDS NM VENCLEXTA 10mg, 50mg NM LA VENCLEXTA 100mg VENCLEXTA STARTING CK VERZENIO ZEJULA ZOLINZA 5 NDS NM HORMONAL ANTINEOPLASTIC AGENTS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 10

20 anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 00/ML B/D ERLEADA exemestane (generic of AROMASIN) FARESTON 5 NDS FASLODEX 5 NDS B/D flutamide letrozole (generic of FEMARA) TABS leuprolide inj 1mg/0.2 NM LUPRON DEPOT (1-MONTH) 5 NDS NM.75mg LUPRON DEPOT INJ 5 NDS NM 11.25MG (-MONTH) LYSODREN megestrol ac sus 0mg/ml megestrol ac tab 20mg megestrol ac tab 0mg megestrol sus 625mg/5ml (generic of MEGACE ES) nilutamide (generic of 5 NDS NILANDRON) SOLTAMOX 5 NDS tamoxifen citrate TABS 1 GC TRELSTAR DEP INJ.75MG 5 NDS NM TRELSTAR LA INJ 11.25MG 5 NDS NM XTANDI ZYTIGA IMMUNOMODULATORS POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP MG POMALYST CAP MG REVLIMID QL (28 caps / 28 LA THALOMID 50mg, 100mg QL (0 caps / 0 THALOMID 150mg, 200mg QL (60 caps / 0 KINASE INHIBITORS AFINITOR QL (0 tabs / 0 AFINITOR DISPERZ 2mg QL (150 tabs / 0 AFINITOR DISPERZ mg QL (90 tabs / 0 AFINITOR DISPERZ 5mg QL (60 tabs / 0 ALECENSA ALUNBRIG BOSULIF BRAFTOVI CABOMETYX QL (0 tabs / 0 CALQUENCE CAPRELSA COMETRIQ COTELLIC GILOTRIF TAB 20MG GILOTRIF TAB 0MG GILOTRIF TAB 0MG ICLUSIG 5 NDS NM LA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 11

21 imatinib mesylate (generic of GLEEVEC) 100mg QL (90 tabs / 0 imatinib mesylate (generic of GLEEVEC) 00mg QL (60 tabs / 0 IMBRUVICA INLYTA 1mg QL (180 tabs / 0 INLYTA 5mg QL (120 tabs / 0 IRESSA LA LA LA JAKAFI QL (60 tabs / 0 LENVIMA MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LENVIMA 10 MG DAILY DOSE LENVIMA 12MG DAILY DOSE LENVIMA 1 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 2 MG DAILY DOSE MEKINIST MEKTOVI NERLYNX NEXAVAR RYDAPT SPRYCEL STIVARGA SUTENT 5 NDS NM 5 NDS NM 5 NDS NM TAFINLAR TAGRISSO TARCEVA 25mg QL (90 tabs / 0 TARCEVA 100mg, 150mg QL (0 tabs / 0 TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA MISCELLANEOUS bexarotene (generic of TARGRETIN) hydroxyurea (generic of HYDREA) CAPS LONSURF LA LA 5 NDS NM 5 NDS NM 5 NDS NM MATULANE 5 NDS LA SYLATRON KIT 200MCG 5 NDS NM SYLATRON KIT 00MCG 5 NDS NM SYLATRON KIT 600MCG 5 NDS NM SYNRIBO 5 NDS NM tretinoin (chemotherapy) 5 NDS PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin inj 50mg 5 NDS B/D oxaliplatin inj 50mg/10ml B/D oxaliplatin inj 100mg 5 NDS B/D oxaliplatin inj 100mg/20ml B/D PROTECTIVE AGENTS dexrazoxane (generic of ZINECARD) 500mg 5 NDS B/D leucovorin calcium SOLR B/D - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 12

22 Drug Tier Requirements/ Limits leucovorin calcium TABS MESNEX TABS 5 NDS 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 hcl (generic of 5 NDS B/D TOPOTECAN HCL) SOLN topotecan hcl (generic of 5 NDS B/D HYCAMTIN) SOLR TOPOTECAN INJ MG/ML 5 NDS B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-10 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5-20 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5-0 mg amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 10-0 mg (generic of LOTREL) benazepril & hydrochlorothiazide benazepril & hydrochlorothiazide (generic of LOTENSIN HCT) enalapril maleate & hydrochlorothiazide enalapril maleate & hydrochlorothiazide (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide (generic of ZESTORETIC) 1 GC moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide (generic of ACCURETIC) ACE INHIBITORS benazepril hcl TABS 5mg 1 GC benazepril hcl (generic of 1 GC LOTENSIN) TABS 10mg, 20mg, 0mg enalapril maleate (generic of VASOTEC) TABS fosinopril sodium lisinopril (generic of ZESTRIL) 1 GC TABS 2.5mg, 0mg, 0mg lisinopril (generic of PRINIVIL) 1 GC 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 eplerenone (generic of INSPRA) spironolactone (generic of 1 GC ALDACTONE) TABS 25mg spironolactone (generic of ALDACTONE) TABS 50mg, 100mg ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) TABS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 1

23 Drug Tier Requirements/ Limits prazosin hcl (generic of MINIPRESS) terazosin hcl ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil (generic of AZOR) amlodipine besylate-valsartan tab mg (generic of EXFORGE) amlodipine besylate-valsartan tab 5-20 mg (generic of EXFORGE) amlodipine besylate-valsartan tab mg (generic of EXFORGE) amlodipine besylate-valsartan tab mg (generic of EXFORGE) ENTRESTO irbesartan-hydrochlorothiazide (generic of AVALIDE) losartan potassium & hctz tab mg (generic of HYZAAR) 1 GC losartan potassium & hctz tab mg (generic of HYZAAR) losartan potassium & hctz tab mg (generic of HYZAAR) olmesartan medoxomil-amlodipine-hydroc hlorothiazide (generic of TRIBENZOR) olmesartan medoxomil-hydrochlorothiazid e (generic of BENICAR HCT) 1 GC 1 GC valsartan-hydrochlorothiazide (generic of DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan (generic of AVAPRO) losartan potassium (generic of 1 GC COZAAR) olmesartan medoxomil (generic of BENICAR) TABS telmisartan (generic of MICARDIS) valsartan (generic of DIOVAN) ANTIARRHYTHMICS amiodarone hcl soln amiodarone tab 100mg amiodarone tab 200mg amiodarone tab 00mg disopyramide phosphate (generic of NORCE) dofetilide (generic of NM TIKOSYN) flecainide acetate mexiletine hcl MULTAQ NORCE CR pacerone 100mg, 00mg pacerone 200mg propafenone hcl propafenone hcl 12hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS sorine (generic of BETACE) 80mg, 120mg, 160mg sorine 20mg sotalol hcl (generic of BETACE) 80mg, 120mg, 160mg sotalol hcl 20mg sotalol hcl (afib/afl) (generic of BETACE AF) ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) TABS 1 GC - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 1

24 lovastatin 10mg, 20mg 1 GC lovastatin (generic of 1 GC MEVACOR) 0mg pravastatin sodium 10mg pravastatin sodium (generic of PRAVACHOL) 20mg, 0mg, 80mg rosuvastatin calcium (generic QL of CRESTOR) QL (0 tabs / 0 simvastatin (generic of 1 GC ZOCOR) TABS 5mg, 10mg, 20mg, 0mg simvastatin (generic of ZOCOR) TABS 80mg QL (0 tabs / 0 1 GC QL ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light CK 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) TABS JUXTAPID KYNAMRO 5 NDS NM niacin er (antihyperlipidemic) (generic of NIASN) niacor PRALUENT 5 NDS NM prevalite CK prevalite (generic of QUESTRAN LIGHT) POWD VASCE WELCHOL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide (generic of ZIAC) metoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT) BETA-BLOCKERS acebutolol hcl CAPS atenolol (generic of TENORMIN) TABS 25mg 1 GC atenolol TABS 50mg, 100mg 1 GC bisoprolol fumarate 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 1 GC of TOPROL XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS 1 GC 25mg metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg 1 GC pindolol propranolol cap er (generic of INDERAL LA) propranolol hcl TABS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 15

25 propranolol oral sol timolol maleate TABS CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC) amlodipine besylate (generic 1 GC of NORVASC) TABS cartia xt (generic of CARDIZEM CD) 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 (generic of CARDIZEM CD) diltiazem cap 60mg cd (generic of CARDIZEM CD) diltiazem cap er/12hr diltiazem hcl (generic of CARDIZEM) TABS 0mg, 60mg, 120mg diltiazem hcl TABS 90mg diltiazem hcl cap sr 2hr diltiazem hcl coated beads cap sr 2hr (generic of CARDIZEM CD) 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 felodipine nicardipine hcl CAPS nifedipine (generic of PROCARDIA XL) TB2 nifedipine er (generic of ADALAT CC) nimodipine CAPS 5 NDS NYMALIZE 5 NDS 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 CALAN SR) TBCR verapamil tab er (generic of CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN).25mg if 70 years and older; digitek (generic of LANOXIN).125mg QL (0 tabs / 0 QL (doses > mg/day) digox (generic of LANOXIN) QL 125mcg QL (0 tabs / 0 (doses > mg/day) digox (generic of LANOXIN) 250mcg if 70 years and older; digoxin (generic of LANOXIN) QL TABS 125mcg QL (0 tabs / 0 (doses > mg/day) digoxin (generic of LANOXIN) TABS 250mcg if 70 years and older; - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 16

26 digoxin inj (generic of LANOXIN) digoxin sol 50mcg/ml if 70 years and older; Drug Tier DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TEKTURNA HCT DIURETICS acetazolamide CP12 acetazolamide TABS Requirements/ Limits amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide SOLN bumetanide (generic of BUMEX) TABS chlorothiazide tabs chlorthalidone furosemide SOLN furosemide (generic of LASIX) 1 GC TABS furosemide inj hydrochlorothiazide (generic 1 GC of MICROZIDE) CAPS hydrochlorothiazide TABS 1 GC indapamide methazolamide TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs 5mg, 100mg torsemide tabs (generic of 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) TABS clonidine hcl ptwk (generic of CATAPRES-TTS-1).1mg/2hr clonidine hcl ptwk (generic of CATAPRES-TTS-2).2mg/2hr clonidine hcl ptwk (generic of CATAPRES-TTS-).mg/2hr 1 GC 1 GC CORLANOR DEMSER 5 NDS hydralazine hcl SOLN hydralazine hcl TABS midodrine hcl minoxidil TABS NORTHERA RANEXA NITRATES isosorb mononitrate tab isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg isosorbide dinitrate 10mg, 20mg, 0mg isosorbide dinitrate er isosorbide mononitrate er minitran (generic of NITRO-DUR) NITRO-BID NITRO-DUR DIS 0.MG/ NITRO-DUR DIS 0.8MG/ nitroglycerin (generic of NITROSTAT) SUBL nitroglycerin td patch.1mg/hr - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 17

27 Drug Tier nitroglycerin td patch (generic of NITRO-DUR).2mg/hr,.mg/hr,.6mg/hr PULMONARY ARTERIAL HYPERTENSION ADCIRCA QL (60 tabs / 0 ADEMS QL (90 tabs / 0 LETAIRIS QL (0 tabs / 0 REMODULIN sildenafil citrate tab 20 mg (pulmonary hypertension) (generic of REVATIO) QL (90 tabs / 0 tadalafil (pulmonary hypertension) (generic of ADCIRCA) QL (60 tabs / 0 TRACLEER TABS 62.5mg QL (120 tabs / 0 TRACLEER TABS 125mg QL (60 tabs / 0 VENTAVIS Requirements/ Limits LA LA QL NM LA LA 5 NDS NM CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg QL (generic of XANAX) QL (150 tabs / 0 alprazolam tab 0.25mg QL (generic of XANAX) QL (150 tabs / 0 alprazolam tab 1mg (generic QL of XANAX) QL (150 tabs / 0 alprazolam tab 2 mg (generic QL of XANAX) QL (150 tabs / 0 buspirone hcl TABS 5mg, 7.5mg, 10mg, 15mg buspirone hcl TABS 0mg fluvoxamine maleate TABS lorazepam (generic of ATIVAN) SOLN lorazepam (generic of QL ATIVAN) TABS QL (150 tabs / 0 lorazepam intensol QL QL (150 ml / 0 ANTICONVULSANTS APTIOM 200mg QL (180 tabs / 0 APTIOM 00mg QL (90 tabs / 0 APTIOM 600mg, 800mg QL (60 tabs / 0 BANZEL SUS 0MG/ML 5 NDS BANZEL TAB 200MG 5 NDS BANZEL TAB 00MG 5 NDS BRIVIACT INJ 50MG/5ML BRIVIACT SOL 10MG/ML BRIVIACT TAB 10MG BRIVIACT TAB 25MG BRIVIACT TAB 50MG BRIVIACT TAB 75MG BRIVIACT TAB 100MG 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 2mg QL (00 tabs / 0 clonazepam (generic of QL KLONOPIN) TABS.5mg, 1mg QL (90 tabs / 0 clonazepam TBDP 2mg QL (00 tabs / 0 QL - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at for more information about this coverage. NDS - Non-Extended Days Supply - High Risk 18