Pharmacy Program Preferred Drug List Pharmacy Benefit Manager Specialty Drugs

Transcription

1 Pharmacy Program California Health & Wellness is committed to providing appropriate, high quality, and cost effective drug therapy to all California Health & Wellness members. California Health & Wellness works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. California Health & Wellness covers prescription medications and certain over-the-counter (OTC) medications when ordered by a licensed practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Preferred List The California Health & Wellness Preferred List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The California Health & Wellness PDL is continually evaluated by the California Health & Wellness Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the California Health & Wellness Medical Director, California Health & Wellness Pharmacy Director, and several California physicians, pharmacists, and other healthcare professionals. Pharmacy Benefit Manager California Health & Wellness works with US Script to process pharmacy claims for prescribed drugs. Some drugs on the California Health & Wellness PDL may require PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager. Specialty s Certain medications are only covered when supplied by California Health & Wellness specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of California Health & Wellness. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by California Health & Wellness. The California Health & Wellness Medical Director and California Health & Wellness Pharmacy Director oversee the clinical review of these PA request. AcariaHealth provides the following services: A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient Disease-specific product education and training Customized treatment programs and compliance monitoring Prior authorization support Timely delivery to your office or the patient s home, as requested

2 Dispensing s may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A total of 85% of the days supply must have elapsed before the prescription can be refilled for all drugs. Prior Authorizations Some medications listed on the California Health & Wellness PDL may require PA. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization orm. This form should be faxed to US Script at This document can be found on the California Health & Wellness website. California Health & Wellness will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the California Health & Wellness PDL may require specific medications to be used before the member can receive the step therapy medication. If California Health & Wellness has a record that the required medication was tried first the step therapy medications are automatically covered. If California Health & Wellness does not have a record that the required medication was tried, the member s practitioner may be required to provide additional information. If authorization is not granted, California Health & Wellness will notify the member and their practitioner and provide information regarding the appeal process. Quantity California Health & Wellness may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

3 Age Some medications on the California Health & Wellness PDL may have age limits. These are set for certain drugs based on DA approved labeling and for safety concerns and quality standards of care. Age limits align with current DA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions. or a MN request California Health & Wellness requires: Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process. 72 Hour Emergency Supply Policy State and ederal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call US Script at for a prescription override to submit the 72 hour medication supply for payment. Exclusions The following drug categories are not part of the California Health & Wellness PDL and are not covered by the 72 hour emergency supply policy: s that are considered experimental Efficacy Study and Implementation (DESI) drugs

4 - s prescribed for infertility - s prescribed for erectile dysfunction - s prescribed for cosmetic purposes or hair growth - Over-the-counter (OTC) cough and cold preparations - Over-the-counter adult acetaminophen products - s carved-out of the California Health & Wellness contract with the DHCS (TARs/claims submitted to Medi-Cal ee-or-service directly) o Select HIV AIDS treatment drugs o Select alcohol and heroin detoxification and dependency treatment o Select psychiatric drugs Newly Approved Products California Health & Wellness reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Over-the-Counter Medications California Health & Wellness covers a variety of OTC medications. These medications can be found throughout the California Health & Wellness PDL. California Health & Wellness covers OTC products listed in the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. Generic s When generic drugs are available, the brand name drug will not be covered without California Health & Wellness authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner requests the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If California Health & Wellness does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, lecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.

5 Efficacy Study and Implementation s DESI products and known related drug products are defined as less than effective by the ood and Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by California Health & Wellness. illing a Prescription A member can have prescriptions filled at a California Health & Wellness network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting California Health & Wellness Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their California Health & Wellness ID card. Copayments Copayments are not required for California Health & Wellness Medi-Cal members. Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column. DS/DU: Days Supply per Dosage Unit Max Days Sply: Maximum Days Supply Max ills: Maximum ills (per a designated time period) Max Qty: Maximum Quantity (per claim or designated time period) Min DS: Minimum Days Supply PA: Prior Authorization Pkg Size: Package Size Contact Information California Health & Wellness Provider Services: US Script Prior Authorizations: ax: US Script Help Desk: AcariaHealth Prior Authorizations: ax: Provider Administered Prior Authorizations ax:

6 N Description Preferred s Non-formulary Carve Out s Legend Description AL Age Limit is limited to specific age. PA QL Prior Authorization Quantity Limit Prior Authorization required before prescription can be filled. There is a limit on the amount of drug covered per prescription, or within a specific time frame. Rx/OTC Rx/OTC Product has both Rx and OTC National Codes. SP ST Specialty Step Therapy Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific pharmacy. Requires trial and failure of one or more preferred products prior to coverage.

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8 Name ADHD/ANTI-NARLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine- Dextroamphetamine) ADDERALL XR CP24 (Use Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp , , , , , amphetaminedextroamphetamine tabs , , , , , , DEXEDRINE CP24 10 MG, 15 MG (Use Dextroamphetamine Sulfate) DEXEDRINE CP24 5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10, 15 dextroamphetamine sulfate cp24 5 dextroamphetamine sulfate tabs 5, 10 N N N N ; AL(At least 3 AL(At least 6 AL(At least 6 ; AL(At least 3 ; AL(At least 6 AL(At least 6 ; AL(At least 6 AL(At least 6 QL(3 ea daily); AL(At least 3 Name VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Analeptics caffeine citrate soln or 20 /ml, 60 /3ml PA; QL(1 ea daily) QL(45 ml per Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps ST; AL(At least 6 clonidine hcl (adhd) tb guanfacine hcl (adhd) tb24 INTUNIV TB24 (Use Guanfacine HCl (ADHD)) KAPVAY TB12 (Use Clonidine HCl (ADHD)) STRATTERA CAPS (Use Atomoxetine HCl) Stimulants - Misc. NCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl) NCERTA TBCR 36 MG (Use Methylphenidate HCl) dexmethylphenidate hcl tabs 5, 10, 2.5 OCALIN TABS (Use Dexmethylphenidate HCl) METADATE CD CPCR (Use Methylphenidate HCl) methylphenidate hcl cpcr or 10, 20, 30, 40, 50, 60 methylphenidate hcl tabs or 10, 20 methylphenidate hcl tabs or 5 CA Health & Wellness Preferred List Updated January 1, 2019 N N N N N N N AL(At least 6 AL(At least 6 ST; AL(At least 6 AL(At least 6 ; AL(At least 6 ; AL(At least 6 ; AL(At least 6 AL(At least 6 AL(At least 6 QL(3 ea daily); AL(At least 3 QL(6 ea daily); AL(At least 3 1

9 Name methylphenidate hcl tbcr or 10, 36 methylphenidate hcl tbcr or 18, 27, 54 methylphenidate hcl tbcr or 20 METHYLPHENIDATE HYDROCHLORIDE ER TB24 18 MG, 27 MG METHYLPHENIDATE HYDROCHLORIDE ER TB24 36 MG, 54 MG RITALIN TABS 10 MG, 20 MG (Use Methylphenidate HCl) RITALIN TABS 5 MG (Use Methylphenidate HCl) N N ; AL(At least 6 AL(At least 6 AL(At least 6 AL(At least 6 AL(At least 6 QL(3 ea daily); AL(At least 3 QL(6 ea daily); AL(At least 3 AMINOGLYSIDES - s to Treat Bacterial Infections Aminoglycosides KITABIS PAK NEBU 300 MG/5ML neomycin sulfate tabs or paromomycin sulfate caps PA or TOBI NEBU (Use Tobramycin) N tobramycin nebu in 300 /5ml TOBRAMYCIN NEBU IN 300 MG/5ML TOBRAMYCIN SULATE SOLN IJ 10 MG/ML, 40 MG/ML PA tobramycin sulfate soln ij PA 40 /ml, 80 /2ml, 1.2 gm/30ml tobramycin sulfate solr ij PA 1.2 gm ANALGESICS - ANTI-INLAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Name Anti-TN-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT 40 MG/0.8ML HUMIRA PEN PNKT 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER PNKT 40 MG/0.8ML HUMIRA PEN-PS/UV STARTER PNKT HUMIRA PSKT 20 MG/0.4ML, 40 MG/0.8ML Gold Compounds RIDAURA CAPS Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) N ALEVE ARTHRITIS TABS (Use Naproxen Sodium) N ALEVE TABS (Use Naproxen Sodium) N ANAPROX DS TABS (Use Naproxen Sodium) N CELEBREX CAPS (Use Celecoxib) N PA; QL(2 ea daily) celecoxib caps or 50, PA; QL(2 ea 100, 200, 400 daily) CHILDRENS ADVIL SUSP N (Use Ibuprofen) CHILDRENS MOTRIN N SUSP (Use Ibuprofen) DAYPRO TABS (Use Oxaprozin) N diclofenac potassium tabs 50 diclofenac sodium tb24 or 100 diclofenac sodium tbec or 25, 50, 75 EC-NAPROSYN TBEC (Use Naproxen) N CA Health & Wellness Preferred List Updated January 1,

10 Name etodolac caps etodolac tabs etodolac tb24 ELDENE CAPS (Use Piroxicam) flurbiprofen tabs or 50, 100 ibuprofen chew or 100 ibuprofen susp or 100 /5ml ibuprofen susp or 40 /ml, 50 /1.25ml ibuprofen tabs or 200, 400, 600, 800 indomethacin caps or 25, 50 indomethacin cpcr or 75 INANTS ADVIL SUSP (Use Ibuprofen) ketoprofen caps or 50, 75 KETOPROEN CAPS OR 50 MG, 75 MG KETOPROEN ER CP24 ketorolac tromethamine tabs or 10 LODINE TABS (Use Etodolac) meloxicam tabs or 15, 7.5 MOBIC TABS (Use Meloxicam) MOTRIN INANTS DROPS SUSP (Use Ibuprofen) nabumetone tabs or 500, 750 NAPROSYN SUSP (Use Naproxen) NAPROSYN TABS (Use Naproxen) N N N N N N N AL(At least 17 Name naproxen sodium tabs or 220, 275, 550 naproxen susp or 125 /5ml naproxen tabs or 250, 375, 500 naproxen tbec or 375, 500 oxaprozin tabs 600 piroxicam caps or 10, 20 sulindac tabs or 150, 200 TOLMETIN SODIUM CAPS TOLMETIN SODIUM TABS CA Health & Wellness Preferred List Updated January 1, 2019 Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) N leflunomide tabs or 10, 20 Soluble Tumor Necrosis actor Receptor Agents ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen tabs butalbital-acetaminophencaffeine caps 325- QL(4 ea daily) butalbital-acetaminophencaffeine tabs QL(4 ea daily) 40 butalbital-aspirin-caffeine QL(4 ea daily) caps ESGIC TABS (Use Butalbital-Acetaminophen- Caffeine) N QL(4 ea daily) 3

11 Name IORINAL CAPS (Use Butalbital-Aspirin-Caffeine) TENN TABS 325MG- 50MG Analgesics Other acetaminophen elix or 160 /5ml, 80 /2.5ml acetaminophen liqd or 160 /5ml acetaminophen soln or 160 /5ml, 650 /20.3ml, 325 /10.15ml acetaminophen supp re 120 acetaminophen susp or 160 /5ml, 80 /0.8ml, 80 /2.5ml NORTEMP INANTS SUSP TYLENOL CHILDRENS SUSP (Use Acetaminophen) TYLENOL INANTS PAIN+EVER SUSP (Use Acetaminophen) TYLENOL INANTS SUSP (Use Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) tabs aspirin chew or 81 ASPIRIN SUPP RE 300 MG, 600 MG aspirin supp re 300, 600 aspirin tabs or 325 aspirin tbec or 81, 324, 325, 500 BUERIN TABS (Use Aspirin Buffered (Cal Carb- Mag Carb-Mag Oxide)) choline & mag salicylate liqd N N N N N QL(4 ea daily) Name diflunisal tabs DISALCID TABS (Use N Salsalate) ETRIN MAXIMUM STRENGTH TBEC (Use N Aspirin) ETRIN REGULAR STRENGTH TBEC (Use N Aspirin) salsalate tabs or 500, 750 ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists codeine sulfate tabs 15, QL (2 ea daily) 30, 60 DEMEROL TABS OR 100 N QL(6 ea daily) MG (Use Meperidine HCl) DILAUDID TABS OR 2 QL(8 ea daily) MG, 4 MG, 8 MG (Use N Hydromorphone HCl) DOLOPHINE TABS 10 MG N PA; QL(10 ea (Use Methadone HCl) daily) DOLOPHINE TABS 5 MG N PA; QL(4 ea (Use Methadone HCl) daily) DURAGESIC PT72 (Use N QL(0.34 ea entanyl) daily) fentanyl pt72 12 mcg/hr, 25 QL(0.34 ea mcg/hr, 50 mcg/hr, 75 daily) mcg/hr, 100 mcg/hr HYDROMORPHONE HCL QL(12 ea per SUPP RE 3 MG hydromorphone hcl tabs or QL(8 ea daily) 2, 4, 8 MEPERIDINE HCL SOLN QL(500 ml per OR 50 MG/5ML meperidine hcl tabs or 50 QL(6 ea daily), 100 methadone hcl tabs or 10 PA; QL(10 ea daily) methadone hcl tabs or 5 PA; QL(4 ea morphine sulfate soln or 10 /5ml, 20 /5ml daily) QL(500 ml per CA Health & Wellness Preferred List Updated January 1,

12 Name morphine sulfate soln or 20 /ml, 100 /5ml MORPHINE SULATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG MORPHINE SULATE TABS OR 15 MG, 30 MG morphine sulfate tbcr or 15, 30, 60, 100, 200 MS NTIN TBCR (Use Morphine Sulfate) oxycodone hcl caps or 5 oxycodone hcl conc or 100 /5ml oxycodone hcl soln or 5 /5ml oxycodone hcl t12a or 10, 15, 20, 30, 40, 60, 80 oxycodone hcl tabs or 5, 10, 15, 20, 30 OXYNTIN T12A (Use Oxycodone HCl) ROXIDONE TABS (Use Oxycodone HCl) tramadol hcl tabs or 50 ULTRAM TABS (Use Tramadol HCl) Opioid Combinations acetaminophen w/ codeine soln 120/5ml-12/5ml acetaminophen w/ codeine tabs , , butalbital-acetaminophencaffeine w/ codeine caps N N N N QL(240 ml per QL(24 ea per QL(6 ea daily) QL(3 ea daily) QL(3 ea daily) QL(6 ea daily) QL(6 ml daily) PA; QL(2 ea daily) QL(6 ea daily) QL(6 ea daily) QL(8 ea daily); AL(At least 18 QL(8 ea daily); AL(At least 18 QL(30 ml daily); AL(At least 12 yrs old) QL(6 ea daily); AL(At least 12 QL(4 ea daily); AL(At least 12 Name butalbital-aspirin-caffeine w/cod caps IORINAL/DEINE #3 CAPS (Use Butalbital- Aspirin-Caffeine w/cod) hydrocodoneacetaminophen soln 2.5/5ml-108/5ml, 5/10ml-217/10ml, 7.5/15ml-325/15ml hydrocodoneacetaminophen tabs hydrocodoneacetaminophen tabs hydrocodoneacetaminophen tabs NOR TABS 10MG- 325MG (Use Hydrocodone- Acetaminophen) NOR TABS 5MG- 325MG (Use Hydrocodone- Acetaminophen) NOR TABS 7.5MG- 325MG (Use Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 5-325, , oxycodone-aspirin tabs OXYDONE/ACETAMIN OPHEN SOLN PERCET TABS 5MG- 325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/ Acetaminophen) tramadol-acetaminophen tabs TYLENOL/DEINE #3 TABS (Use Acetaminophen w/ Codeine) N N N N N N QL(4 ea daily); AL(At least 12 QL(4 ea daily); AL(At least 12 QL(180 ml daily) QL(6 ea daily) QL(12 ea daily) QL(8 ea daily) QL(6 ea daily) QL(12 ea daily) QL(8 ea daily) QL(6 ea daily) QL(6 ea daily) QL(30 ml daily) QL(6 ea daily) QL(4 ea daily); AL(At least 18 QL(6 ea daily); AL(At least 12 CA Health & Wellness Preferred List Updated January 1,

13 Name TYLENOL/DEINE #4 TABS (Use Acetaminophen w/ Codeine) ULTRACET TABS (Use Tramadol-Acetaminophen) Opioid Partial Agonists BELBUCA ILM BUNAVAIL ILM BUPRENEX SOLN (Use Buprenorphine HCl) buprenorphine hcl soln ij 0.3 /ml buprenorphine hcl subl sl 2, 8 buprenorphine hclnaloxone hcl dihydrate film buprenorphine hclnaloxone hcl dihydrate subl buprenorphine ptwk 5 mcg/hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr BUPRENORPHINE PTWK 5 MCG/HR, 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 7.5 MCG/HR BUTRANS PTWK 5 MCG/HR, 10 MCG/HR, 15 MCG/HR, 20 MCG/HR (Use Buprenorphine) BUTRANS PTWK 7.5 MCG/HR PROBUPHINE IMPLANT KIT IMPL SUBLOCADE SOSY SUBOXONE ILM ZUBSOLV SUBL N N QL(6 ea daily); AL(At least 12 QL(4 ea daily); AL(At least 18 ANDROGENS-ANABOLIC - s to Regulate Hormones Androgens ANDRODERM PT24 Name ANDROXY TABS DEPO-TESTOSTERONE SOLN 200 MG/ML (Use Testosterone Cypionate) METHITEST TABS 10 MG testosterone cypionate soln im 200 /ml TESTOSTERONE CYPIONATE SOLN IM 200 MG/ML N QL(0.134 ml daily) QL(0.134 ml daily) QL(0.134 ml daily) ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids RTENEMA ENEM (Use Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem 100 /60ml Rectal Combinations phenylephrine-shark liver oil-cocoa butter supp phenylephrine-shark liver oil-mineral oil-petrolatum oint Rectal Local Anesthetics pramoxine hcl (rectal) foam 1 % PROCTOOAM OAM (Use Pramoxine HCl (Rectal)) Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) hydrocortisone (rectal) crea 2.5 % ANTACIDS Antacid Combinations alum & mag hydroxsimethicone liqd 200/5ml-20/5ml- 200/5ml N N N QL(420 ml per QL(420 ml per QL(60 gm per QL(30 gm per QL(30 gm per CA Health & Wellness Preferred List Updated January 1,

14 Name alum & mag hydroxsimethicone susp 200/5ml-20/5ml- 200/5ml, 200/5ml- 200/5ml-20/5ml- 20/5ml-200/5ml- 200/5ml Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs Antacids - Calcium Salts calcium carbonate (antacid) chew 500 calcium carbonate (antacid) susp 1250 /5ml TUMS CHEW (Use Calcium Carbonate (Antacid)) TUMS LASTING EECTS CHEW (Use Calcium Carbonate (Antacid)) N N Antacids - Magnesium Salts magnesium oxide tabs 400 ANTHELMINTICS - s to Treat Worm Infections Anthelmintics EMVERM CHEW 100 MG pyrantel pamoate susp or 144 /ml ANTI-INECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. LAGYL TABS 250 MG, 500 MG (Use N Metronidazole) metronidazole tabs or 250, 500 trimethoprim tabs or 100 Name Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- N Trimethoprim) BACTRIM TABS (Use Sulfamethoxazole- N Trimethoprim) sulfamethoxazoletrimethoprim susp or 40/5ml-200/5ml sulfamethoxazoletrimethoprim tabs or , Antiprotozoal Agents atovaquone susp or 750 QL(10 ml daily) /5ml MEPRON SUSP (Use N QL(10 ml daily) Atovaquone) Glycopeptides IRVANQ SOLR QL(300 ml per VANCIN HCL CAPS QL(4 ea daily) 125 MG (Use Vancomycin N HCl) VANCIN HCL CAPS QL(8 ea daily) 250 MG (Use Vancomycin N HCl) vancomycin hcl caps or QL(4 ea daily) 125 vancomycin hcl caps or QL(8 ea daily) 250 vancomycin hcl solr iv 1 QL(14 ea per gm, 500, 1000 Leprostatics dapsone tabs or 25, 100 Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use N Clindamycin HCl) CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin Palmitate Hydrochloride) CA Health & Wellness Preferred List Updated January 1, 2019 N QL(100 ml per 7

15 Name clindamycin hcl caps or 150, 300 clindamycin palmitate hydrochloride solr 75 /5ml Oxazolidinones SIVEXTRO TABS OR 200 MG QL(100 ml per PA; QL(6 ea per ANTIANGINAL AGENTS - s to Treat Chest Pain Nitrates ISORDIL TITRADOSE TABS 5 MG (Use N Isosorbide Dinitrate) ISOSORBIDE DINITRATE ER TBCR isosorbide dinitrate tabs isosorbide mononitrate tabs 10, 20 isosorbide mononitrate tb24 30, 60, 120 NITRO-BID OINT NITRO-DUR PT MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) nitroglycerin cpcr or 9, 2.5, 6.5 nitroglycerin pt24 td 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin subl sl 0.3, 0.4, 0.6 NITROSTAT SUBL (Use Nitroglycerin) N N ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 15 buspirone hcl tabs or 30, 7.5 buspirone hcl tabs or 5, 10 QL(4 ea daily) QL(3 ea daily) QL(6 ea daily) Name hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 HYDROXYZINE PAMOATE CAPS OR 100 MG hydroxyzine pamoate caps or 25, 50 meprobamate tabs VISTARIL CAPS (Use Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.25, 0.5, 1, 2 ATIVAN TABS OR 0.5 MG, 2 MG (Use Lorazepam) ATIVAN TABS OR 1 MG (Use Lorazepam) chlordiazepoxide hcl caps clorazepate dipotassium tabs DIAZEPAM SOLN OR 5 MG/5ML diazepam tabs or 2, 5, 10 lorazepam tabs or 0.5, 2 lorazepam tabs or 1 oxazepam caps 10, 15, 30 OXAZEPAM CAPS 30 MG CA Health & Wellness Preferred List Updated January 1, 2019 N N N QL(4 ea daily) QL(3 ea daily) QL(4 ea daily) QL(4 ea daily) QL(3 ea daily) QL(500 ml per QL(4 ea daily) QL(3 ea daily) QL(4 ea daily) QL(4 ea daily) QL(4 ea daily) TRANXENE T TABS (Use Clorazepate Dipotassium) N QL(3 ea daily) VALIUM TABS (Use Diazepam) N QL(4 ea daily) XANAX TABS (Use Alprazolam) N QL(4 ea daily) ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A 8

16 Name disopyramide phosphate caps NORPACE CAPS (Use Disopyramide Phosphate) NORPACE CR CP MG quinidine gluconate tbcr or 324 QUINIDINE SULATE TABS OR 200 MG, 300 MG Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs propafenone hcl tabs 150, 225, 300 Antiarrhythmics Type III amiodarone hcl tabs or 200 dofetilide caps MULTAQ TABS TIKOSYN CAPS (Use N Dofetilide) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in 20 /2ml Antiasthmatic - Monoclonal Antibodies ASENRA SOSY PA QL(240 ml per Bronchodilators - Anticholinergics ATROVENT HA AERS QL(26 gm per INCRUSE ELLIPTA AEPB QL(30 ea per ipratropium bromide soln in 0.02 % TUDORZA PRESSAIR AEPB QL(1 ea per fill retail) Name Leukotriene Modulators montelukast sodium chew or 4, 5 montelukast sodium pack or 4 montelukast sodium tabs or 10 SINGULAIR CHEW (Use Montelukast Sodium) N SINGULAIR PACK (Use Montelukast Sodium) N SINGULAIR TABS (Use Montelukast Sodium) N Steroid Inhalants AEROSPAN AERS budesonide (inhalation) susp LOVENT DISKUS AEPB 100 MCG/BLIST, 250 MCG/BLIST LOVENT DISKUS AEPB 50 MCG/BLIST LOVENT HA AERO PULMIRT LEXHALER AEPB PULMIRT SUSP (Use Budesonide (Inhalation)) Sympathomimetics ALBUTEROL SULATE ER TB12 albuterol sulfate nebu in 0.5 % albuterol sulfate nebu in 0.63 /3ml, %, 1.25 /3ml albuterol sulfate syrp or 2 /5ml albuterol sulfate tabs or 2 CA Health & Wellness Preferred List Updated January 1, 2019 N QL(8.9 gm per QL(4 ml daily); AL(At least 1 yrs old - Up to 8 QL(60 ea per 25 days retail) QL(1 ea per fill retail) QL(4 ml daily); AL(At least 1 yrs old - Up to 8 QL(2 ml daily) QL(100 ml per QL(150 ea per 9

17 Name albuterol sulfate tabs or 4 albuterol sulfate tb12 or 4, 8 BREO ELLIPTA AEPB 25MCG/INH-200MCG/INH MBIVENT RESPIMAT AERS DULERA AERO ipratropium-albuterol soln METAPROTERENOL SULATE SYRP OR 10 MG/5ML METAPROTERENOL SULATE TABS OR 10 MG, 20 MG PROAIR HA AERS SEREVENT DISKUS AEPB SYMBIRT AERO terbutaline sulfate tabs or 5, 2.5 VENTOLIN HA AERS VENTOLIN HA AERS VOSPIRE ER TB12 (Use Albuterol Sulfate) Xanthines ELIXOPHYLLIN ELIX THEO-24 CP24 theophylline soln 80 /15ml theophylline tb12 100, 200, 300, 450 theophylline tb24 400, 600 N ANTIAGULANTS - Blood Thinners Coumarin Anticoagulants QL(200 ea per QL(60 ea per QL(4 gm per fill retail) QL(13 gm per QL(12 ml daily) QL(30 ml daily) QL(17 gm per 30 days retail) QL(11 gm per QL(36 gm per 30 days retail) QL(16 gm per 30 days retail) QL(475 ml per Name UMADIN TABS (Use Warfarin Sodium) warfarin sodium tabs Direct actor Xa Inhibitors ELIQUIS STARTER PACK TABS ELIQUIS TABS XARELTO STARTER PACK TBPK XARELTO TABS 10 MG XARELTO TABS 15 MG XARELTO TABS 20 MG Heparins And Heparinoid-Like Agents enoxaparin sodium soln sc 100 /ml, 150 /ml enoxaparin sodium soln sc 30 /0.3ml enoxaparin sodium soln sc 40 /0.4ml QL(4 ea daily) QL(4 ea daily) QL(1 ea daily,35 ea per 180 days retail) SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(10 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(3 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(4 ml per 180 days retail); SP CA Health & Wellness Preferred List Updated January 1,

18 Name enoxaparin sodium soln sc 60 /0.6ml enoxaparin sodium soln sc 80 /0.8ml, 120 /0.8ml heparin sodium (porcine) soln LOVENOX SOLN SC 100 MG/ML, 150 MG/ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 30 MG/0.3ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 40 MG/0.4ML (Use Enoxaparin Sodium) N N N SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(6 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(8 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(10 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(3 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(4 ml per 180 days retail); SP Name LOVENOX SOLN SC 60 MG/0.6ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML (Use Enoxaparin Sodium) N N SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(6 ml per 180 days retail); SP SP- AccariaHealth only after Quantity Limit has been exceeded ;QL(8 ml per 180 days retail); SP ANTINVULSANTS - s to Treat Seizures Anticonvulsants - Benzodiazepines clonazepam tabs or 0.5 QL(4 ea daily), 1, 2 diazepam (anticonvulsant) gel DIAZEPAM GEL RE 20 MG, 2.5 MG DIAZEPAM RECTAL GEL GEL KLONOPIN TABS (Use Clonazepam) Anticonvulsants - Misc. carbamazepine chew or 100 carbamazepine susp or 100 /5ml carbamazepine tabs or 200 carbamazepine tb12 or 100, 200, 400 gabapentin caps or 100, 300, 400 gabapentin soln or 250 /5ml, 300 /6ml N QL(1 ea per fill retail); AL(At least 2 QL(1 ea per fill retail); AL(At least 2 QL(1 ea per fill retail); AL(At least 2 QL(4 ea daily) QL(9 ea daily) CA Health & Wellness Preferred List Updated January 1,

19 Name gabapentin tabs or 600 gabapentin tabs or 800 KEPPRA SOLN OR 100 MG/ML (Use Levetiracetam) KEPPRA TABS OR 1000 MG (Use Levetiracetam) KEPPRA TABS OR 250 MG, 750 MG (Use Levetiracetam) KEPPRA TABS OR 500 MG (Use Levetiracetam) KEPPRA XR TB24 (Use Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine) LAMICTAL TABS (Use Lamotrigine) LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine) lamotrigine chew or 5, 25 lamotrigine tabs or 25, 100, 150, 200 lamotrigine tb24 or 25, 50, 100, 200, 250, 300 levetiracetam soln or 100 /ml, 500 /5ml levetiracetam tabs or 1000 levetiracetam tabs or 250, 750 levetiracetam tabs or 500 levetiracetam tb24 or 500, 750 MYSOLINE TABS (Use Primidone) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin) N N N N N N N N N N QL(6 ea daily) QL(4 ea daily) QL(30 ml daily) QL(4 ea daily) QL(6 ea daily) ST ST ST QL(30 ml daily) QL(4 ea daily) QL(6 ea daily) ST QL(9 ea daily) Name NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NEURONTIN TABS 600 MG (Use Gabapentin) NEURONTIN TABS 800 MG (Use Gabapentin) oxcarbazepine susp oxcarbazepine tabs primidone tabs or 50, 250 TEGRETOL SUSP (Use Carbamazepine) TEGRETOL TABS (Use Carbamazepine) TEGRETOL-XR TB12 (Use Carbamazepine) TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate) TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate) TOPAMAX TABS 100 MG (Use Topiramate) TOPAMAX TABS 200 MG (Use Topiramate) TOPAMAX TABS 25 MG, 50 MG (Use Topiramate) topiramate cpsp or 15 topiramate cpsp or 25 topiramate tabs or 100 topiramate tabs or 200 topiramate tabs or 25, 50 TRILEPTAL SUSP (Use Oxcarbazepine) TRILEPTAL TABS (Use Oxcarbazepine) ZONEGRAN CAPS (Use Zonisamide) N N N N N N N N N N N QL(6 ea daily) QL(4 ea daily) QL(6 ea daily) QL(8 ea daily) QL(4 ea daily) QL(6 ea daily) QL(6 ea daily) QL(8 ea daily) QL(4 ea daily) QL(6 ea daily) CA Health & Wellness Preferred List Updated January 1,

20 Name zonisamide caps or 25, 50, 100 Carbamates felbamate susp felbamate tabs ELBATOL SUSP (Use elbamate) ELBATOL TABS (Use elbamate) GABA Modulators GABITRIL TABS (Use Tiagabine HCl) tiagabine hcl tabs Hydantoins DILANTIN CAPS 100 MG (Use Phenytoin Sodium Extended) DILANTIN CAPS 30 MG DILANTIN INATABS CHEW (Use Phenytoin) DILANTIN-125 SUSP (Use Phenytoin) phenytoin chew or 50 phenytoin sodium extended caps 100 phenytoin susp or 125 /5ml Succinimides ethosuximide caps or 250 ethosuximide soln or 250 /5ml ZARONTIN CAPS (Use Ethosuximide) ZARONTIN SOLN (Use Ethosuximide) Valproic Acid DEPAKENE CAPS (Use Valproic Acid) N N N Name DEPAKENE SOLN 250 MG/5ML (Use Valproate Sodium) DEPAKOTE ER TB24 (Use Divalproex Sodium) DEPAKOTE SPRINKLES CSDR (Use Divalproex Sodium) DEPAKOTE TBEC (Use Divalproex Sodium) divalproex sodium csdr or 125 divalproex sodium tb24 or 250, 500 divalproex sodium tbec or 125, 250, 500 valproate sodium soln or 250 /5ml valproic acid caps N N N ANTIDEPRESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs or 15 QL(3 ea daily) mirtazapine tabs or 30 QL(1.5 ea mirtazapine tabs or 45, 7.5 mirtazapine tbdp or 15 mirtazapine tbdp or 30 mirtazapine tbdp or 45 REMERON SOLTAB TBDP 15 MG (Use Mirtazapine) REMERON SOLTAB TBDP 30 MG (Use Mirtazapine) REMERON SOLTAB TBDP 45 MG (Use Mirtazapine) REMERON TABS 15 MG (Use Mirtazapine) REMERON TABS 30 MG (Use Mirtazapine) N N N N N daily) QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily) QL(1.5 ea daily) CA Health & Wellness Preferred List Updated January 1,

21 Name REMERON TABS 45 MG (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 75, 100 bupropion hcl tb12 or 100 bupropion hcl tb12 or 150 bupropion hcl tb12 or 200 bupropion hcl tb24 or 150 bupropion hcl tb24 or 300 MAPROTILINE HCL TABS N QL(3 ea daily) QL(4 ea daily) QL(3 ea daily) QL(3 ea daily) WELLBUTRIN SR TB12 QL(4 ea daily) 100 MG (Use Bupropion N HCl) WELLBUTRIN SR TB12 QL(3 ea daily) 150 MG (Use Bupropion N HCl) WELLBUTRIN SR TB MG (Use Bupropion N HCl) WELLBUTRIN XL TB24 QL(3 ea daily) 150 MG (Use Bupropion N HCl) WELLBUTRIN XL TB MG (Use Bupropion N HCl) Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 Name CELEXA TABS 10 MG (Use Citalopram Hydrobromide) CELEXA TABS 20 MG (Use Citalopram Hydrobromide) CELEXA TABS 40 MG (Use Citalopram Hydrobromide) citalopram hydrobromide soln 10 /5ml citalopram hydrobromide tabs 10 citalopram hydrobromide tabs 20 citalopram hydrobromide tabs 40 escitalopram oxalate tabs 10 escitalopram oxalate tabs 20 escitalopram oxalate tabs 5 fluoxetine hcl caps or 10, 20 fluoxetine hcl caps or 40 fluoxetine hcl soln or 20 /5ml fluoxetine hcl tabs or 10 fluoxetine hcl tabs or 20 N N N QL(4 ea daily) QL(8 ml daily) QL(4 ea daily) QL(4 ea daily) QL(4 ea daily) ; AL(At least 7 QL(20 ml daily); AL(At least 7 AL(At least 7 QL(4 ea daily) MARPLAN TABS NARDIL TABS (Use Phenelzine Sulfate) PARNATE TABS (Use Tranylcypromine Sulfate) phenelzine sulfate tabs or tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) fluvoxamine maleate tabs 100 fluvoxamine maleate tabs 25, 50 LEXAPRO TABS 10 MG (Use Escitalopram Oxalate) LEXAPRO TABS 20 MG (Use Escitalopram Oxalate) LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) N N N QL(3 ea daily) QL(4 ea daily) CA Health & Wellness Preferred List Updated January 1,

22 Name paroxetine hcl tabs 10 paroxetine hcl tabs 20 paroxetine hcl tabs 30, 40 paroxetine hcl tb24 25, 12.5, 37.5 PAXIL CR TB24 (Use Paroxetine HCl) PAXIL SUSP 10 MG/5ML PAXIL TABS 10 MG (Use Paroxetine HCl) PAXIL TABS 20 MG (Use Paroxetine HCl) PAXIL TABS 30 MG, 40 MG (Use Paroxetine HCl) PROZAC CAPS 10 MG, 20 MG (Use luoxetine HCl) PROZAC CAPS 40 MG (Use luoxetine HCl) sertraline hcl conc or 20 /ml sertraline hcl tabs or 100 sertraline hcl tabs or 25, 50 ZOLOT NC 20 MG/ML (Use Sertraline HCl) ZOLOT TABS 100 MG (Use Sertraline HCl) ZOLOT TABS 25 MG, 50 MG (Use Sertraline HCl) Serotonin Modulators NEAZODONE HCL TABS 100 MG, 150 MG nefazodone hcl tabs 50, 250 NEAZODONE HYDROCHLORIDE TABS trazodone hcl tabs or 300 trazodone hcl tabs or 50, 100, 150 N N N N N N N N N QL(6 ea daily) QL(3 ea daily) QL(40 ml daily) QL(6 ea daily) QL(3 ea daily) QL(4 ea daily) ; AL(At least 7 QL(10 ml daily) QL(4 ea daily) QL(10 ml daily) QL(4 ea daily) Name VIIBRYD TABS PA; QL(1 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use N Duloxetine HCl) AL(At least 7 duloxetine hcl cpep or 20, 30, 60 EEXOR XR CP MG (Use Venlafaxine HCl) EEXOR XR CP MG (Use Venlafaxine HCl) EEXOR XR CP24 75 MG (Use Venlafaxine HCl) venlafaxine hcl cp venlafaxine hcl cp venlafaxine hcl cp24 75 venlafaxine hcl tabs 25, 50, 75, 100, 37.5 venlafaxine hcl tb24 75, 150, 225, 37.5 Tricyclic Agents amitriptyline hcl tabs or 10 amitriptyline hcl tabs or 150 amitriptyline hcl tabs or 25, 100 amitriptyline hcl tabs or 50 amitriptyline hcl tabs or 75 AMOXAPINE TABS ANARANIL CAPS (Use Clomipramine HCl) clomipramine hcl caps or 25, 50, 75 desipramine hcl tabs or 10, 50, 75, 100, 150 N N N N AL(At least 7 QL(4 ea daily) QL(5 ea daily) QL(4 ea daily) QL(5 ea daily) QL(20 ea per QL(100 ea per QL(150 ea per QL(200 ea per QL(400 ea per CA Health & Wellness Preferred List Updated January 1,

23 Name desipramine hcl tabs or 25 doxepin hcl caps or 10, 25, 50, 75, 100, 150 doxepin hcl conc or 10 /ml ELAVIL TABS (Use Amitriptyline HCl) imipramine hcl tabs or 10, 25, 50 NORPRAMIN TABS 10 MG (Use Desipramine HCl) NORPRAMIN TABS 25 MG (Use Desipramine HCl) nortriptyline hcl caps or 10, 25, 50, 75 NORTRIPTYLINE HCL SOLN OR 10 MG/5ML nortriptyline hcl soln or 10 /5ml PAMELOR CAPS (Use Nortriptyline HCl) TORANIL TABS (Use Imipramine HCl) N N N N N QL(150 ea per QL(20 ml daily) QL(20 ml daily) ANTIDIABETICS - s to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose tabs PRESE TABS (Use N Acarbose) Antidiabetic - Amylin Analogs SYMLINPEN 120 SOPN SYMLINPEN 60 SOPN Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl- Metformin HCl) alogliptin-metformin hcl tabs N PA; QL(10.8 ml per 30 days retail) PA; QL(6 ml per 30 days retail) Name alogliptin-pioglitazone tabs glipizide-metformin hcl tabs GLUVANCE TABS (Use Glyburide-Metformin) glyburide-metformin tabs INVOKAMET TABS INVOKAMET XR TB24 JANUMET TABS JANUMET XR TB24 JENTADUETO TABS KOMBIGLYZE XR TB24 pioglitazone hcl-metformin hcl tabs SEGLUROMET TABS SYNJARDY TABS SYNJARDY XR TB24 Biguanides GLUPHAGE TABS 1000 MG (Use Metformin HCl) GLUPHAGE TABS 500 MG (Use Metformin HCl) GLUPHAGE TABS 850 MG (Use Metformin HCl) GLUPHAGE XR TB MG (Use Metformin HCl) GLUPHAGE XR TB MG (Use Metformin HCl) metformin hcl tabs or 1000 metformin hcl tabs or 500 CA Health & Wellness Preferred List Updated January 1, 2019 N N N N N N PA PA PA PA PA; QL(2 ea daily); AL(At least 18 yrs old) PA ST; QL(2 ea daily) PA PA QL(5 ea daily) QL(3 ea daily) QL(4 ea daily) QL(5 ea daily) 16

24 Name metformin hcl tabs or 850 metformin hcl tb24 or 500 metformin hcl tb24 or 750 Diabetic Other BD GLUSE CHEW CVS GLUSE CHEW 4 GM DEX4 QUICK DISSOLVE GLUSE CHEW GLUCAGEN HYPOKIT SOLR GLUCAGON EMERGENCY KIT KIT GLUSE CHEW 4 GM QL(3 ea daily) QL(4 ea daily) QL(1 ea per fill retail) GNP GLUSE CHEW 4 GM GNP QUICK DISSOLVE GLUSE CHEW LEADER QUICK DISSOLVE GLUSE CHEW SM GLUSE CHEW 4 GM WALGREENS GLUSE CHEW 4 GM Dipeptidyl Peptidase-4 (DPP-4) Inhibitors alogliptin benzoate tabs JANUVIA TABS PA TRADJENTA TABS PA; QL(1 ea daily); AL(At least 18 yrs old) Incretin Mimetic Agents (GLP-1 Receptor QL(18 ml per BYDUREON BCISE AUIJ 30 days retail); AL(At least 18 Name BYDUREON PEN PEN BYDUREON SRER BYETTA SOPN 10 MCG/0.04ML BYETTA SOPN 5 MCG/0.02ML VICTOZA SOPN Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) AVANDIA TABS pioglitazone hcl tabs Insulin ADMELOG SOLN 100 UNIT/ML ADMELOG SOLOSTAR SOPN 100 UNIT/ML BASAGLAR KWIKPEN SOPN 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUPN HUMALOG MIX 50/50 SUSP HUMALOG MIX 75/25 KWIKPEN SUPN HUMALOG MIX 75/25 SUSP HUMULIN 70/30 KWIKPEN SUPN N PA; QL(4 ea per 30 days retail); AL(At least 18 yrs old) PA; QL(4 ea per 28 days retail); AL(At least 18 yrs old) PA; QL(2.4 ml per 30 days retail); AL(At least 18 yrs old) PA; QL(1.2 ml per 30 days retail); AL(At least 18 yrs old) PA; QL(1.8 ml daily) QL(40 ml per 30 days retail) QL(30 ml per 30 days retail) Limit 50mls per month;ql(1.67 ml daily) QL(30 ml per 30 days retail) QL(40 ml per 30 days retail) QL(30 ml per 30 days retail) QL(40 ml per 30 days retail) CA Health & Wellness Preferred List Updated January 1,

25 Name HUMULIN 70/30 SUSP HUMULIN N KWIKPEN SUPN HUMULIN N SUSP HUMULIN R SOLN 100 UNIT/ML NOVOLIN 70/30 LEXPEN RELION SUPN NOVOLIN 70/30 LEXPEN SUPN NOVOLIN 70/30 RELION SUSP NOVOLIN 70/30 SUSP NOVOLIN N RELION SUSP NOVOLIN N SUSP NOVOLIN R RELION SOLN 100 UNIT/ML NOVOLIN R SOLN 100 UNIT/ML NOVOLOG MIX 70/30 PREILLED LEXPEN SUPN NOVOLOG MIX 70/30 SUSP Meglitinide Analogues nateglinide tabs QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(40 ml per 30 days retail) QL(30 ml per 30 days retail) QL(40 ml per 30 days retail) QL(3 ea daily) STARLIX TABS (Use N QL(3 ea daily) Nateglinide) Sodium-Glucose Co-Transporter 2 (SGLT2) INVOKANA TABS PA JARDIANCE TABS STEGLATRO TABS Sulfonylureas AMARYL TABS 1 MG, 2 MG (Use Glimepiride) N PA; QL(1 ea daily) ST; QL(1 ea daily) QL(4 ea daily) Name AMARYL TABS 4 MG (Use Glimepiride) glimepiride tabs 1, 2 glimepiride tabs 4 glipizide tabs or 5, 10 glipizide tb24 or 5, 10, 2.5 GLUTROL TABS (Use Glipizide) GLUTROL XL TB24 (Use Glipizide) glyburide micronized tabs N N N QL(4 ea daily) glyburide tabs or 5, 2.5, 1.25 GLYNASE TABS (Use N Glyburide Micronized) ANTIDIARRHEAL/PROBIOTIC AGENTS - s to Treat Diarrhea Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew or 262 bismuth subsalicylate susp or 262 /15ml, 525 /15ml, 525 /30ml, 527 /30ml PEPTO-BISMOL CHEW (Use Bismuth N Subsalicylate) PEPTO-BISMOL INSTAOL CHEW (Use N Bismuth Subsalicylate) PEPTO-BISMOL MAX STRENGTH SUSP (Use N Bismuth Subsalicylate) PEPTO-BISMOL SUSP (Use Bismuth N Subsalicylate) PEPTO-BISMOL TO-GO CHEW (Use Bismuth N Subsalicylate) Antiperistaltic Agents CA Health & Wellness Preferred List Updated January 1,

26 Name diphenoxylate w/ atropine tabs DIPHENOXYLATE/ATROP INE LIQD IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) IMODIUM A-D TABS 2 MG (Use Loperamide HCl) LOMOTIL TABS (Use Diphenoxylate w/ Atropine) loperamide hcl caps or 2 loperamide hcl liqd or 1 /5ml loperamide hcl tabs or 2 PAREGORIC TINC N N N QL(8 ea daily); QL(8 ea daily) QL(8 ea daily); QL(40 ml daily) QL(8 ea daily) ANTIDOTES AND SPECIIC ANTAGONISTS Antidotes - Chelating Agents CHEMET CAPS JADENU SPRINKLE PACK JADENU TABS Antidotes and Specific Antagonists VISTOGARD PACK Opioid Antagonists NALOXONE HCL SOCT IJ 0.4 MG/ML naloxone hcl soln ij 0.4 /ml, 4 /10ml NALOXONE HCL SOSY IJ 2 MG/2ML naltrexone hcl tabs or NARCAN LIQD VIVITROL SUSR ANTIEMETICS - s to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists Name ondansetron hcl soln or 4 QL(50 ml per /5ml ondansetron hcl tabs or 4 QL(20 ea per, 8 30 days retail) ondansetron tbdp QL(20 ea per 30 days retail) ZORAN ODT TBDP (Use Ondansetron) N QL(20 ea per 30 days retail) ZORAN SOLN 4 MG/5ML N QL(50 ml per (Use Ondansetron HCl) ZORAN TABS 4 MG, 8 MG (Use Ondansetron N QL(20 ea per 30 days retail) HCl) Antiemetics - Anticholinergic dimenhydrinate tabs or 50 DRAMAMINE CHEW 50 MG DRAMAMINE TABS (Use Dimenhydrinate) N meclizine hcl chew or 25 meclizine hcl tabs or 25, 12.5 Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps 1 rtl pack lmt per fill, aprepitant caps 40, 125 QL(1 ea per fill retail) aprepitant caps 80 QL(2 ea per fill retail) EMEND CAPS OR 40 MG, 125 MG (Use Aprepitant) N QL(1 ea per fill retail) EMEND CAPS OR 80 MG N QL(2 ea per fill (Use Aprepitant) retail) EMEND TRIPACK CAPS (Use Aprepitant) N 1 rtl pack lmt per fill, ANTIUNGALS - s to Treat ungal Infections Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) griseofulvin microsize susp CA Health & Wellness Preferred List Updated January 1, 2019 N 19

27 Name griseofulvin microsize tabs griseofulvin ultramicrosize tabs LAMISIL TABS (Use Terbinafine HCl) N nystatin tabs or unit terbinafine hcl tabs or 250 Imidazole-Related Antifungals DILUCAN SUSR 10 MG/ML, 40 MG/ML (Use N luconazole) DILUCAN TABS 100 MG (Use luconazole) N DILUCAN TABS 150 MG (Use luconazole) N DILUCAN TABS 200 MG (Use luconazole) N DILUCAN TABS 50 MG (Use luconazole) N fluconazole susr or 10 /ml, 40 /ml fluconazole tabs or 100 fluconazole tabs or 150 fluconazole tabs or 200 fluconazole tabs or 50 itraconazole caps or 100 ketoconazole tabs or SPORANOX CAPS 100 MG (Use Itraconazole) SPORANOX PULSEPAK CAPS (Use Itraconazole) N N QL(6 ea daily) QL(70 ml per QL(2 ea per fill retail) QL(7 ea per fill retail) QL(70 ml per QL(2 ea per fill retail) QL(7 ea per fill retail) PA; QL(1 ea daily) PA; QL(1 ea daily) PA; QL(1 ea daily) ANTIHISTAMINES - s to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON SYRP (Use Chlorpheniramine Maleate) N Name CHLOR-TRIMETON TABS (Use Chlorpheniramine Maleate) chlorpheniramine maleate syrp or 2 /5ml chlorpheniramine maleate tabs or 4 RYCLORA SYRP N Antihistamines - Ethanolamines ALER-DRYL TABS BENADRYL ALLERGY CAPS (Use Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl) BENADRYL ALLERGY TABS (Use Diphenhydramine HCl) clemastine fumarate tabs or 1.34 diphenhydramine hcl caps or 25 diphenhydramine hcl caps or 50 diphenhydramine hcl elix or 12.5 /5ml diphenhydramine hcl liqd or 25 /10ml, 50 /20ml, 12.5 /5ml diphenhydramine hcl tabs or 25 SILPHEN UGH SYRP N N N TAVIST ALLERGY TABS N (Use Clemastine umarate) Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS (Use exofenadine N HCl) cetirizine hcl chew 5, 10 QL(4 ea daily); QL(240 ml per ; CA Health & Wellness Preferred List Updated January 1,

28 Name cetirizine hcl soln 1 /ml, 5 /5ml cetirizine hcl syrp 1 /ml, 5 /5ml cetirizine hcl tabs 5, 10 CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine) CLARITIN REDITABS TBDP 10 MG (Use Loratadine) CLARITIN SYRP 5 MG/5ML (Use Loratadine) CLARITIN TABS 10 MG (Use Loratadine) fexofenadine hcl tabs or 60, 180 levocetirizine dihydrochloride tabs or 5 loratadine soln or 5 /5ml loratadine syrp or 5 /5ml loratadine tabs or 10 loratadine tbdp or 10 N N N N XYZAL ALLERGY 24HR TABS (Use Levocetirizine N Dihydrochloride) XYZAL TABS 5 MG (Use Levocetirizine N Dihydrochloride) ZYRTEC ALLERGY TABS N (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN (Use N Cetirizine HCl) Antihistamines - Phenothiazines promethazine hcl soln or 6.25 /5ml QL(240 ml per ; QL(240 ml per ; QL(240 ml per ; QL(240 ml per ; AL(At least 2 Name promethazine hcl supp re 25, 50, 12.5 promethazine hcl syrp or 6.25 /5ml promethazine hcl tabs or 25, 50, 12.5 Antihistamines - Piperidines cyproheptadine hcl syrp or 2 /5ml cyproheptadine hcl tabs or 4 QL(12 ea per ; AL(At least 2 QL(240 ml per ; AL(At least 2 AL(At least 2 ANTIHYPERLIPIDEMICS - s to Treat High Cholesterol Bile Acid Sequestrants cholestyramine light pack cholestyramine light powd cholestyramine pack or 4 gm cholestyramine powd or 4 gm/dose LESTID LAVORED GRAN 5 GM (Use Colestipol HCl) LESTID GRAN 5 GM (Use Colestipol HCl) LESTID TABS 1 GM (Use Colestipol HCl) colestipol hcl gran 5 gm colestipol hcl tabs 1 gm QUESTRAN LIGHT POWD (Use Cholestyramine Light) QUESTRAN PACK (Use Cholestyramine) QUESTRAN POWD (Use Cholestyramine) ibric Acid Derivatives fenofibrate micronized caps 134, 200 fenofibrate micronized caps 67 CA Health & Wellness Preferred List Updated January 1, 2019 N N N N N N 21

29 Name ENOIBRATE TABS OR 160 MG fenofibrate tabs or 160 fenofibrate tabs or 54 gemfibrozil tabs or 600 LOIBRA CAPS (Use enofibrate Micronized) LOPID TABS (Use Gemfibrozil) TRIGLIDE TABS N N HMG CoA Reductase Inhibitors atorvastatin calcium tabs or 10, 20, 40, 80 CRESTOR TABS (Use N Rosuvastatin Calcium) LIPITOR TABS (Use N Atorvastatin Calcium) lovastatin tabs 10, 20 lovastatin tabs 40 MEVAR TABS (Use Lovastatin) PRAVACHOL TABS (Use Pravastatin Sodium) pravastatin sodium tabs rosuvastatin calcium tabs simvastatin tabs or 5, 10, 20, 40 simvastatin tabs or 80 N N QL(3 ea daily) ST; QL(1 ea daily) ST; QL(1 ea daily) PA ZOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use N Simvastatin) ZOR TABS 80 MG (Use Simvastatin) N PA Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs 10 PA; QL(1 ea daily) Name ZETIA TABS (Use Ezetimibe) Nicotinic Acid Derivatives niacin (antihyperlipidemic) tbcr N PA; QL(1 ea daily) NIAR TABS NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) N ANTIHYPERTENSIVES - s to Treat High Blood Pressure ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) N ALTACE CAPS (Use N Ramipril) benazepril hcl tabs or 40 benazepril hcl tabs or 5, 10, 20 captopril tabs or 25, 50 QL(3 ea daily), 100, 12.5 enalapril maleate tabs or 5, 10, 20, 2.5 EPANED SOLR PA fosinopril sodium tabs lisinopril tabs or 5, 10, 20, 30, 40, 2.5 LOTENSIN TABS 10 MG, 20 MG (Use Benazepril HCl) N LOTENSIN TABS 40 MG N (Use Benazepril HCl) MAVIK TABS (Use Trandolapril) N PRINIVIL TABS (Use Lisinopril) N quinapril hcl tabs ramipril caps trandolapril tabs 1, 2 CA Health & Wellness Preferred List Updated January 1,