2019 LIST OF COVERED DRUGS (FORMULARY)

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1 2019 LIST OF COVERED DRUGS (FORMULARY) Prescription drug list information UnitedHealthcare Connected (Medicare-Medicaid Plan) Toll-free , TTY a.m. - 8 p.m. local time, Monday - Friday Formulary ID Number , Version 5 H7833_180629_022455_v01.01 Approved Last updated September 1, 2018

2 2 UnitedHealthcare Connected (Medicare-Medicaid Plan) 2019 List of Covered Drugs (Formulary) 2 Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Connected. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Connected. Key terms and their definitions appear in the last chapter of the Member Handbook. Table of Contents A. Disclaimers...3 B. Frequently Asked Questions (FAQ)... 4 B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.)... 4 B2. Does the Drug List ever change?...4 B3. What happens when there is a change to the Drug List?...5 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?...6 B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?... 7 B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?...7 B7. How can you find a drug on the Drug List?... 7 B8. What if the drug you want to take is not on the Drug List?...8 B9. What if you are a new UnitedHealthcare Connected member and can t find your drug on the Drug List or have a problem getting your drug?...8 B10. Can you ask for an exception to cover your drug?... 9 B11. How can you ask for an exception?...9 B12. How long does it take to get an exception?...9 B13. What are generic drugs? B14. What are OTC drugs?...10 B15. What is your copay? C. List of Covered Drugs D. List of Drugs by Medical Condition E. Index of Covered Drugs

3 A. Disclaimers This is a list of drugs that members can get in UnitedHealthcare Connected. 3 v UnitedHealthcare Connected (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. v Benefits and/or copays may change on January 1 of each year. v You can always check UnitedHealthcare Connected s up-to-date List of Covered Drugs online at v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. v Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al , TTY 7-1-1, de 8 a.m. a 8 p.m., hora local, de lunes a viernes. La llamada es gratuita. v You can get this document for free in other formats, such as large print, braille, or audio. Call , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. v You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future. 3 If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

4 4 4 B. Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 13 are the drugs covered by UnitedHealthcare Connected. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. UnitedHealthcare Connected will cover all medically necessary drugs on the Drug List if: o o Your doctor or other prescriber says you need them to get better or stay healthy, and You fill the prescription at a UnitedHealthcare Connected network pharmacy. UnitedHealthcare Connected may have additional steps to access certain drugs (see question B4 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at , TTY B2. Does the Drug List ever change? Yes. UnitedHealthcare Connected may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see question B4. This section is continued on the next page. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

5 5 5 If you are taking a Medicare Part D drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless: A new, cheaper drug comes along that works as well as a drug on the Drug List now, or We learn that a drug is not safe, or A drug is removed from the market. Questions B3 and B6 below have more information on what happens when the Drug List changes. You can always check UnitedHealthcare Connected s up-to-date Drug List online at You can also call Member Services to check the current Drug List at , TTY B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example: A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. o o We may not tell you before we make this change, but we will send you information about the specific change or changes we made. You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions. A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options. This section is continued on the next page. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

6 6 6 We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: The FDA provides new guidance or there are new clinical guidelines about a drug. We add a generic drug that is not new to the market and Replace a brand name drug currently on the Drug List or Change the coverage rules or limits for the brand name drug. When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can: Get at least a 30-day supply of the drug before the change to the Drug List is made, or Ask for an exception from these changes. Please see questions B10 - B12 for more information about exceptions. B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. UnitedHealthcare Connected may not cover the drug if you do not get approval. Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a drug you can get. Step therapy: Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. This section is continued on the next page. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

7 7 7 You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions. B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on pages has a column labeled. B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/ or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change. B7. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Index of Covered Drugs section that begins on page 143. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. To search by medical condition, find the section labeled List of drugs by medical condition on pages The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

8 8 8 B8. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at , TTY and ask about it. If you learn that UnitedHealthcare Connected will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions B10 B12 for more information about exceptions. B9. What if you are a new UnitedHealthcare Connected member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. We will cover a 30-day supply of your drug if: You are taking a drug that is not on our Drug List, or Health plan rules do not let you get the amount ordered by your prescriber, or The drug requires prior approval by UnitedHealthcare Connected, or You are taking a drug that is part of a step therapy restriction. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away: We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected member. This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Connected. This section is continued on the next page. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

9 9 If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a 31-day temporary supply of the Part D drug you need. This will give you time to talk to your doctor about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions. We will not pay for more of your drug after you get a temporary or emergency supply unless you receive authorization from UnitedHealthcare Connected. 9 B10. Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UnitedHealthcare Connected may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. B11. How can you ask for an exception? To ask for an exception, call Member Services at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions. B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

10 10 10 B13. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Connected covers both brand name drugs and generic drugs. B14. What are OTC drugs? OTC stands for over-the-counter. UnitedHealthcare Connected covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are covered. B15. What is your copay? You can read the UnitedHealthcare Connected Drug List to learn about the copay for each drug. UnitedHealthcare Connected members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.25 to $3.40, depending on your income. Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.80 to $8.50, depending on your income. Tier 3 drugs have $0 copay. They are OTC drugs. If you have questions, please call UnitedHealthcare Connected at , TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

11 For Track Refered Purpose C. List of Covered Drugs The following list of covered drugs gives you information about the drugs covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 143. The index alphabetically lists all drugs covered by UnitedHealthcare Connected. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the column tells you if UnitedHealthcare Connected has any rules for covering your drug. Coverage Rules and Limits PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected before you fill your prescription. UnitedHealthcare Connected may not cover the drug if you do not get approval. QL - Quantity limits Sometimes UnitedHealthcare Connected limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. Other Special Coverage Rules 11 B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. LA - Limited access Drugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. MME - Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. 11 This section is continued on the next page.

12 12 For 212Track Refered Purpose 7D - 7-Day Limit An opioid drug used for the treatment of acute pain may be limited to a 7 day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan. DL - Dispensing limit Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at , TTY You can also read Chapter 9, of the Member Handbook to learn how to appeal a decision. Extra Help Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the Low-Income Subsidy, or LIS.

13 For Track Refered Purpose Acephen Acetaminophen Acetaminophen/Diphenhydramine Butalbital/Acetaminophen Butalbital/Acetaminophen/Caffeine 50mg-325mg-40mg Tablet, 50mg-325mg-40mg Capsule) Butalbital/Aspirin/Caffeine ED-APAP GNP Arthritis Pain Relief Mapap Mapap Acetaminophen Extra Strength Mapap Arthritis Pain Mapap Childrens Mapap PM Migraine Formula Pain & Fever Pain & Fever Childrens 1For 13 Track Refered Purpose 13 D. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. Analgesics Analgesics acephen (suppository)* acetaminophen (tablet)* acetaminophen/diphenhydramine (tablet)* butalbital/acetaminophen (50mg-325mg tablet) QL butalbital/acetaminophen/caffeine 50mg-325mg-40mg tablet, 50mg-325mg-40mg QL capsule) butalbital/aspirin/caffeine (50mg-325mg-40mg capsule) QL ed-apap (liquid)* gnp arthritis pain relief (tablet extended-release)* mapap (160mg/5ml liquid, 325mg tablet, 500mg tablet, 500mg capsule, 80mg tablet chewable)* mapap acetaminophen extra strength (liquid)* mapap arthritis pain (tablet extended-release)* mapap childrens (160mg/5ml suspension, 80mg tablet dispersible)* mapap pm (tablet)* migraine formula (tablet)* pain & fever (tablet)* pain & fever childrens (160mg/5ml oral solution, 80mg tablet chewable)* You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

14 Pain & Fever Extra Strength Pain & Fever Infants Pain Reliever PM Extra Strength QC Arthritis Pain Relief Tencon Zebutal All Day Relief Aspir-Low Aspirin Aspirin EC Aspirin Low Dose Childrens Aspirin Childrens Ibuprofen Childs Ibuprofen Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium DR Diclofenac Sodium ER Diflunisal Etodolac Flector Flurbiprofen GNP Ibuprofen GNP Ibuprofen Junior Strength Goodsense Ibuprofen Goodsense Ibuprofen Childrens Goodsense Ibuprofen Infants Goodsense Ibuprofen Junior Strength Ibu 14 2For 14 Track Refered Purpose pain & fever extra strength (tablet)* pain & fever infants (suspension)* pain reliever pm extra strength (tablet)* qc arthritis pain relief (tablet extended-release)* tencon (tablet) QL zebutal (capsule) QL Nonsteroidal Anti-inflammatory Drugs all day relief (tablet)* aspir-low (tablet delayed-release)* aspirin (325mg tablet, 325mg tablet delayed-release, 81mg tablet delayed-release, 81mg tablet chewable)* aspirin ec (tablet delayed-release)* aspirin low dose (tablet chewable)* childrens aspirin (tablet chewable)* childrens ibuprofen (otc only) (suspension)* childs ibuprofen (otc only) (suspension)* diclofenac potassium (tablet) diclofenac sodium (1% gel) PA diclofenac sodium dr (tablet delayed-release) diclofenac sodium er (tablet extended-release 24 hour) diflunisal (tablet) etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediaterelease) FLECTOR (PATCH) $3.80-$8.50 (Tier 2) PA, QL flurbiprofen (tablet) gnp ibuprofen (otc only) (tablet)* gnp ibuprofen junior strength (otc only) (tablet chewable)* goodsense ibuprofen (tablet)* goodsense ibuprofen childrens (suspension)* goodsense ibuprofen infants (suspension)* goodsense ibuprofen junior strength (otc only) (tablet chewable)* ibu (rx only) (tablet)

15 Ibu-200 Ibu-Drops Infants Ibuprofen Ibuprofen Ibuprofen Childrens Indomethacin Infants Ibuprofen Ketoprofen Naproxen DR QC Naproxen Sodium SM Ibuprofen Sulindac Hydromorphone HCl ER 3For 15 Track Refered Purpose ibu-200 (tablet)* ibu-drops infants (suspension)* ibuprofen (otc only) (100mg/5ml suspension, 200mg capsule, 200mg tablet)* ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) ibuprofen childrens (suspension)* indomethacin (25mg capsule, 50mg capsule) infants ibuprofen (otc only) (suspension)* ketoprofen (capsule immediate-release) Meloxicameloxicam (tablet) Naproxenaproxen (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediate-release, 500mg tablet immediate-release) naproxen dr (tablet delayed-release) (generic ecnaprosyn) qc naproxen sodium (otc only) (tablet)* sm ibuprofen (otc only) (tablet)* sulindac (tablet) Opioid Analgesics, Long-acting Embeda EMBEDA (CAPSULE EXTENDED-RELEASE) $3.80-$8.50 (Tier 2) Fentanyl fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch 72 hour, 75mcg/hr patch 72 hour) hydromorphone hcl er (tablet extended-release 24 hour abuse-deterrent) Hysingla ER HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR ABUSE-DETERRENT) $3.80-$8.50 (Tier 2) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 15 You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

16 Morphine Sulfate ER Abstral Acetaminophen/Codeine Duramorph Hydrocodone Bitartrate/Acetaminophen Hydrocodone/Acetaminophen 16 4For 16 Track Refered Purpose Levorphanol Tartrate levorphanol tartrate (tablet) Methadone HCl methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution) morphine sulfate er (100mg tablet extended-release, 15mg tablet extended-release, 200mg tablet extended-release, 30mg tablet extended-release, 60mg tablet extended-release) (generic ms contin) Nucynta ER NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.80-$8.50 (Tier 2) Tramadol HCl ER tramadol hcl er (100mg tablet extended-release 24 hour, 200mg tablet extended-release 24 hour, 300mg tablet extended-release 24 hour) Xtampza ER XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12 HOUR ABUSE-DETERRENT) Opioid Analgesics, Short-acting $3.80-$8.50 (Tier 2) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME ABSTRAL (TABLET SUBLINGUAL) $3.80-$8.50 (Tier 2) DL, PA, QL acetaminophen/codeine (120mg-12mg/5ml oral 7D, DL, QL, solution, 300mg-15mg tablet, 300mg-30mg tablet, MME 300mg-60mg tablet) Butorphanol Tartrate butorphanol tartrate (nasal solution) 7D, DL, QL, MME Codeine Sulfate codeine sulfate (tablet) 7D, DL, QL, MME DURAMORPH (INJECTION) $3.80-$8.50 (Tier 2) 7D, DL Endocet endocet (tablet) 7D, DL, QL, MME Fentanyl Citrate Oral Transmucosal fentanyl citrate oral transmucosal (lozenge on a handle) DL, PA, QL hydrocodone bitartrate/acetaminophen 7D, DL, QL, (7.5mg-325mg/15ml oral solution) MME hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) Hydrocodone/Ibuprofen hydrocodone/ibuprofen (7.5mg-200mg tablet) Hydromorphone HCl hydromorphone hcl (10mg/ml injection, 50mg/5ml injection) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL

17 Hydromorphone HCl Morphine Sulfate Oxycodone HCl Oxycodone/Acetaminophen 5For 17 Track Refered Purpose 17 Hydromorphone HCl hydromorphone hcl (1mg/ml liquid, 2mg tablet immediate-release, 4mg tablet immediate-release, 8mg tablet immediate-release) 7D, DL, QL, MME HYDROMORPHONE HCL (2MG/ML INJECTION) $3.80-$8.50 (Tier 2) 7D, DL Lorcet lorcet (tablet) 7D, DL, QL, MME Lorcet HD lorcet hd (tablet) 7D, DL, QL, MME Lorcet Plus lorcet plus (tablet) 7D, DL, QL, MME Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/ 7D, DL, QL, 5ml oral solution, 20mg/5ml oral solution) MME morphine sulfate (10mg/ml injection, 4mg/ml injection, 8mg/ml injection) 7D, DL Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE- RELEASE, 30MG TABLET IMMEDIATE-RELEASE) Morphine Sulfate MORPHINE SULFATE (2MG/ML INJECTION, 5MG/ML INJECTION) oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediaterelease, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) $3.80-$8.50 (Tier 2) 7D, DL, QL, MME $3.80-$8.50 (Tier 2) 7D, DL Oxycodone/Aspirin oxycodone/aspirin (tablet) Oxycodone/Ibuprofen oxycodone/ibuprofen (tablet) 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

18 Lidocaine Lidocaine Lidocaine HCl Lidocaine HCl Lidocaine Viscous Lidocaine/Prilocaine Acamprosate Calcium DR Disulfiram Naltrexone HCl Vivitrol Buprenorphine HCl Buprenorphine HCl/Naloxone HCl Suboxone Naloxone HCl Narcan Chantix Chantix Continuing Month Pak Chantix Starting Month Pak 18 6For 18 Track Refered Purpose Tramadol HCl tramadol hcl (tablet immediate-release) Tramadol HCl/Acetaminophen tramadol hcl/acetaminophen (tablet) Trezix trezix (capsule) Anesthetics 7D, DL, QL, MME 7D, DL, QL, MME 7D, DL, QL, MME Local Anesthetics lidocaine (rx only) (5% ointment) QL lidocaine (rx only) (5% patch) PA, QL lidocaine hcl (rx only) (external solution) lidocaine hcl (gel) lidocaine viscous (solution) lidocaine/prilocaine (cream) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr (tablet delayed-release) disulfiram (tablet) naltrexone hcl (tablet) VIVITROL (INJECTION) $3.80-$8.50 (Tier 2) Opioid Dependence Treatments buprenorphine hcl (tablet sublingual) QL buprenorphine hcl/naloxone hcl (tablet sublingual) QL SUBOXONE (FILM) $3.80-$8.50 (Tier 2) QL Opioid Reversal Agents naloxone hcl (injection) NARCAN (LIQUID) $3.80-$8.50 (Tier 2) Smoking Cessation Agents Bupropion HCl SR bupropion hcl sr (150mg tablet extended-release 12 hour smoking-deterrent) CHANTIX (TABLET) $3.80-$8.50 (Tier 2) CHANTIX CONTINUING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2) CHANTIX STARTING MONTH PAK (TABLET) $3.80-$8.50 (Tier 2)

19 NicoDerm CQ NICOrelief Nicorette Nicorette Mini Nicorette Starter Kit Nicotine Polacrilex Nicotine Transdermal System Nicotine Transdermal System Step 1 Nicotine Transdermal System Step 2 Nicotine Transdermal System Step 3 Nicotrol Amikacin Sulfate Gentak Gentamicin Sulfate Gentamicin Sulfate/0.9% Sodium Chloride Isotonic Gentamicin Neomycin Sulfate Paromomycin Sulfate Streptomycin Sulfate Tobramycin Sulfate Tobrex 7For 19 Track Refered Purpose nicoderm cq (patch 24 hour)* nicorelief (gum)* nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* nicorette mini (lozenge)* nicorette starter kit (gum)* nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* nicotine transdermal system (kit, 14mg/24hr patch 24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24 hour)* nicotine transdermal system step 1 (patch 24 hour)* nicotine transdermal system step 2 (patch 24 hour)* nicotine transdermal system step 3 (patch 24 hour)* NICOTROL (INHALER) $3.80-$8.50 (Tier 2) Antibacterials 19 Aminoglycosides amikacin sulfate (injection) gentak (ophthalmic ointment) gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% ophthalmic solution, 40mg/ml injection) gentamicin sulfate/0.9% sodium chloride (injection) isotonic gentamicin (injection) neomycin sulfate (tablet) paromomycin sulfate (capsule) streptomycin sulfate (injection) tobramycin sulfate (0.3% ophthalmic solution, 10mg/ ml injection, 80mg/2ml injection) TOBREX (0.3% OPHTHALMIC OINTMENT) $3.80-$8.50 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

20 Bacitracin Bacitracin Bacitracin Zinc Bacitracin/Neomycin/Polymyxin Bactroban Nasal Clindamycin HCl Clindamycin Palmitate HCl Clindamycin Phosphate Clindamycin Phosphate in D5W Colistimethate Sodium Dalvance Daptomycin Linezolid Linezolid Methenamine Hippurate Metronidazole Metronidazole in NaCl 0.79% Metronidazole Vaginal Mupirocin Nitrofurantoin Monohydrate Polymyxin B Sulfate Povidone-Iodine Tigecycline Tinidazole Trimethoprim Triple Antibiotic 20 8For 20 Track Refered Purpose Antibacterials, Other bacitracin (otc only) (ointment)* bacitracin (rx only) (ophthalmic ointment) bacitracin zinc (ointment)* bacitracin/neomycin/polymyxin (otc only) (ointment)* BACTROBAN NASAL (OINTMENT) $3.80-$8.50 (Tier 2) PA clindamycin hcl (capsule immediate-release) clindamycin palmitate hcl (oral solution) clindamycin phosphate (2% cream, 300mg/2ml injection, 600mg/4ml injection, 900mg/6ml injection) clindamycin phosphate in d5w (injection) colistimethate sodium (injection) DALVANCE (INJECTION) $3.80-$8.50 (Tier 2) PA daptomycin (injection) linezolid (100mg/5ml suspension, 600mg/300ml injection) PA linezolid (600mg tablet) PA, QL methenamine hippurate (tablet) metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75% lotion, 250mg tablet immediate-release, 500mg tablet immediate-release) metronidazole in nacl 0.79% (injection) metronidazole vaginal (gel) mupirocin (2% ointment) Nitrofurantoinitrofurantoin (suspension) Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg capsule) (generic macrodantin) nitrofurantoin monohydrate (100mg capsule) (generic macrobid) polymyxin b sulfate (injection) povidone-iodine (10% external solution, 10% ointment)* tigecycline (injection) tinidazole (tablet) trimethoprim (tablet) triple antibiotic (ointment)*

21 Triple Antibiotic Plus Vancomycin HCl Vandazole Cefadroxil Cefazolin Sodium Cefdinir Cefepime Cefixime Cefotaxime Sodium Cefotetan Cefoxitin Sodium Cefpodoxime Proxetil Cefprozil Ceftazidime Ceftriaxone Sodium Cefuroxime Axetil Cefuroxime Sodium 9For 21 Track Refered Purpose triple antibiotic plus (ointment)* vancomycin hcl (1000mg injection, 10gm injection, 500mg injection, 125mg capsule, 250mg capsule) VANDAZOLE (GEL) $3.80-$8.50 (Tier 2) Beta-lactam, Cephalosporins Cefaclor cefaclor (250mg capsule immediate-release, 500mg capsule immediate-release) cefadroxil (250mg/5ml suspension, 500mg/5ml suspension, 500mg capsule) cefazolin sodium (injection) cefdinir (125mg/5ml suspension, 250mg/5ml suspension, 300mg capsule) cefepime (injection) cefixime (suspension) cefotaxime sodium (injection) cefotetan (injection) cefoxitin sodium (10gm injection, 1gm injection, 2gm injection) cefpodoxime proxetil (100mg tablet, 200mg tablet, 100mg/5ml suspension, 50mg/5ml suspension) cefprozil (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) ceftazidime (injection) ceftriaxone sodium (10gm injection, 1gm injection, 250mg injection, 2gm injection, 500mg injection) cefuroxime axetil (tablet) cefuroxime sodium (1.5gm injection, 7.5gm injection, 750mg injection) 21 You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

22 Suprax Suprax Tazicef Zerbaxa Aztreonam Doripenem Imipenem/Cilastatin Invanz Amoxicillin/Clavulanate Potassium Amoxicillin/Clavulanate Potassium ER Ampicillin Ampicillin Sodium Ampicillin-Sulbactam Bactocill in Dextrose Bicillin C-R Bicillin L-A 22 For Track Refered Purpose Cephalexin cephalexin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule, 750mg capsule) suprax (100mg tablet chewable, 200mg tablet chewable) SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2) tazicef (injection) ZERBAXA (INJECTION) $3.80-$8.50 (Tier 2) PA Beta-lactam, Other aztreonam (injection) DORIPENEM (INJECTION) $3.80-$8.50 (Tier 2) imipenem/cilastatin (injection) INVANZ (INJECTION) $3.80-$8.50 (Tier 2) Meropenemeropenem (injection) Beta-lactam, Penicillins Amoxicillin amoxicillin (125mg tablet chewable, 250mg tablet chewable, 125mg/5ml suspension, 200mg/5ml suspension, 250mg/5ml suspension, 400mg/5ml suspension, 250mg capsule, 500mg capsule, 500mg tablet, 875mg tablet) amoxicillin/clavulanate potassium (200mg-28.5mg tablet chewable, 400mg-57mg tablet chewable, 200mg/5ml-28.5mg/5ml suspension, 250mg/ 5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml suspension, 600mg/5ml-42.9mg/5ml suspension, 250mg-125mg tablet immediate-release, 500mg-125mg tablet immediate-release, 875mg-125mg tablet immediate-release) (generic augmentin) amoxicillin/clavulanate potassium er (tablet extended-release 12 hour) ampicillin (capsule) ampicillin sodium (10gm injection, 125mg injection, 1gm injection) ampicillin-sulbactam (injection) BACTOCILL IN DEXTROSE (INJECTION) $3.80-$8.50 (Tier 2) BICILLIN C-R (INJECTION) $3.80-$8.50 (Tier 2) BICILLIN L-A (INJECTION) $3.80-$8.50 (Tier 2)

23 Dicloxacillin Sodium Nafcillin Sodium Oxacillin Sodium Penicillin G Potassium Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium Piperacillin/Tazobactam Clarithromycin Clarithromycin ER Dificid E.E.S. Granules Ery-Tab EryPed 200 EryPed 400 Erythrocin Lactobionate Erythromycin Erythromycin Base Erythromycin Ethylsuccinate For Track Refered Purpose dicloxacillin sodium (capsule) nafcillin sodium (10gm injection, 1gm injection) oxacillin sodium (injection) penicillin g potassium (injection) penicillin g procaine (injection) penicillin g sodium (injection) penicillin v potassium (125mg/5ml oral solution, 250mg/5ml oral solution, 250mg tablet, 500mg tablet) piperacillin/tazobactam (injection) Macrolides Azithromycin azithromycin (100mg/5ml suspension, 200mg/5ml suspension, 250mg tablet, 500mg tablet, 600mg tablet, 500mg injection) clarithromycin (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) clarithromycin er (tablet extended-release 24 hour) DIFICID (TABLET) $3.80-$8.50 (Tier 2) E.E.S. GRANULES (SUSPENSION) $3.80-$8.50 (Tier 2) ery-tab (tablet delayed-release) ERYPED 200 (SUSPENSION) $3.80-$8.50 (Tier 2) ERYPED 400 (SUSPENSION) $3.80-$8.50 (Tier 2) erythrocin lactobionate (injection) erythromycin (250mg capsule delayed-release, 5mg/ gm ophthalmic ointment) erythromycin base (tablet) erythromycin ethylsuccinate (200mg/5ml suspension, 400mg tablet) Quinolones 23 You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

24 Ciprofloxacin Ciprofloxacin ER Ciprofloxacin HCl Ciprofloxacin I.V. in D5W Levofloxacin Levofloxacin in D5W Moxeza Moxifloxacin HCl/Sodium HCl Moxifloxacin HCl Moxifloxacin HCl Ofloxacin Silver Sulfadiazine Sodium Sulfacetamide SSD Sulfacetamide Sodium Sulfadiazine Sulfamethoxazole/Trimethoprim Sulfamethoxazole/Trimethoprim DS Demeclocycline HCl Doxy 100 Doxycycline Doxycycline Hyclate Doxycycline Monohydrate Minocycline HCl Tetracycline HCl Vibramycin 24 For Track Refered Purpose ciprofloxacin (suspension) ciprofloxacin er (tablet extended-release 24 hour) ciprofloxacin hcl (tablet immediate-release, 0.3% ophthalmic solution) ciprofloxacin i.v. in d5w (injection) levofloxacin (0.5% ophthalmic solution, 250mg tablet, 500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/ml oral solution) levofloxacin in d5w (injection) MOXEZA (OPHTHALMIC SOLUTION) $3.80-$8.50 (Tier 2) moxifloxacin hcl/sodium hcl (injection) moxifloxacin hcl (ophthalmic solution) moxifloxacin hcl (tablet) ofloxacin (0.3% ophthalmic solution, 0.3% otic solution, 300mg tablet, 400mg tablet) Sulfonamides silver sulfadiazine (cream) $3.80-$8.50 (Tier 2) sodium sulfacetamide (ophthalmic solution) SSD (CREAM) $3.80-$8.50 (Tier 2) sulfacetamide sodium (ophthalmic ointment) sulfadiazine (tablet) sulfamethoxazole/trimethoprim (200mg-40mg/5ml suspension, 400mg-80mg tablet) sulfamethoxazole/trimethoprim ds (tablet) Tetracyclines demeclocycline hcl (tablet) doxy 100 (injection) doxycycline (25mg/5ml suspension) doxycycline hyclate (100mg capsule, 50mg capsule, 100mg tablet, 20mg tablet immediate-release) doxycycline monohydrate (100mg capsule, 50mg capsule, 100mg tablet, 50mg tablet, 75mg tablet) minocycline hcl (100mg capsule, 50mg capsule, 75mg capsule) tetracycline hcl (capsule) VIBRAMYCIN (50MG/5ML SYRUP) $3.80-$8.50 (Tier 2)

25 Levetiracetam Levetiracetam ER Roweepra Roweepra XR Spritam Zonisamide Diastat AcuDial Diastat Pediatric Gabapentin Onfi Onfi Phenobarbital Primidone Anticonvulsants For Track Refered Purpose 25 Anticonvulsants, Other Briviact BRIVIACT (100MG TABLET, 10MG TABLET, 25MG TABLET, 50MG TABLET, 75MG TABLET, 10MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) QL levetiracetam (tablet immediate-release, 100mg/ml oral solution) levetiracetam er (tablet extended-release 24 hour) roweepra (tablet) roweepra xr (tablet extended-release 24 hour) SPRITAM (TABLET DISINTEGRATING SOLUBLE) $3.80-$8.50 (Tier 2) Calcium Channel Modifying Agents Celontin CELONTIN (CAPSULE) $3.80-$8.50 (Tier 2) Ethosuximidethosuximide (250mg capsule, 250mg/5ml oral solution) zonisamide (capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT ACUDIAL (GEL) $3.80-$8.50 (Tier 2) DIASTAT PEDIATRIC (GEL) $3.80-$8.50 (Tier 2) gabapentin (100mg capsule, 300mg capsule, 400mg capsule, 250mg/5ml oral solution, 600mg tablet, 800mg tablet) ONFI (10MG TABLET, 20MG TABLET) $3.80-$8.50 (Tier 2) PA, QL ONFI (2.5MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) PA phenobarbital (100mg tablet, 15mg tablet, 16.2mg tablet, 30mg tablet, 32.4mg tablet, 60mg tablet, 64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir) primidone (tablet) You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

26 Sabril Tiagabine HCl Valproic Acid Vigabatrin Fycompa Lamotrigine Topiramate Aptiom Carbamazepine Carbamazepine ER Dilantin Dilantin INFATABS Epitol Oxcarbazepine Peganone 26 For Track Refered Purpose SABRIL (500MG TABLET) $3.80-$8.50 (Tier 2) PA, QL, LA tiagabine hcl (tablet) valproic acid (250mg capsule, 250mg/5ml oral solution) vigabatrin (packet) PA, QL, LA Glutamate Reducing Agents Felbamate felbamate (400mg tablet, 600mg tablet, 600mg/5ml suspension) FYCOMPA (0.5MG/ML SUSPENSION, 10MG TABLET, 12MG TABLET, 2MG TABLET, 4MG TABLET, 6MG TABLET, 8MG TABLET) lamotrigine (100mg tablet immediate-release, 150mg tablet immediate-release, 200mg tablet immediaterelease, 25mg tablet immediate-release, 25mg tablet chewable, 5mg tablet chewable) topiramate (100mg tablet, 200mg tablet, 25mg tablet, 50mg tablet, 15mg capsule sprinkle immediate-release, 25mg capsule sprinkle immediate-release) Sodium Channel Agents $3.80-$8.50 (Tier 2) APTIOM (TABLET) $3.80-$8.50 (Tier 2) QL Banzel BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION) $3.80-$8.50 (Tier 2) carbamazepine (100mg tablet chewable, 100mg/5ml suspension, 200mg tablet immediate-release) carbamazepine er (100mg capsule extended-release 12 hour, 200mg capsule extended-release 12 hour, 300mg capsule extended-release 12 hour, 100mg tablet extended-release 12 hour, 200mg tablet extended-release 12 hour, 400mg tablet extendedrelease 12 hour) dilantin (capsule) dilantin infatabs (tablet chewable) epitol (tablet) oxcarbazepine (150mg tablet, 300mg tablet, 600mg tablet, 300mg/5ml suspension) PEGANONE (TABLET) $3.80-$8.50 (Tier 2) Phenytek phenytek (capsule)

27 Phenytoin Sodium Extended Vimpat Donepezil HCl Donepezil HCl ODT Rivastigmine Tartrate Rivastigmine Transdermal System Memantine HCl ER Memantine HCl Titration Pak Bupropion HCl Bupropion HCl SR Bupropion HCl XL Mirtazapine Mirtazapine ODT For Track Refered Purpose 27 Phenytoin phenytoin (125mg/5ml suspension, 50mg tablet chewable) phenytoin sodium extended (capsule) VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML ORAL SOLUTION) $3.80-$8.50 (Tier 2) QL Antidementia Agents Cholinesterase Inhibitors donepezil hcl (10mg tablet, 5mg tablet) QL donepezil hcl odt (tablet dispersible) QL rivastigmine tartrate (capsule) QL rivastigmine transdermal system (patch 24 hour) QL, ST N-methyl-D-aspartate (NMDA) Receptor Antagonist Memantine HCl memantine hcl (10mg tablet, 5mg tablet, 2mg/ml oral solution) PA, QL memantine hcl er (capsule extended-release 24 hour) PA, QL MEMANTINE HCL TITRATION PAK (TABLET) $3.80-$8.50 (Tier 2) PA Antidepressants Antidepressants, Other bupropion hcl (tablet immediate-release) bupropion hcl sr (100mg tablet extended-release 12 hour, 150mg tablet extended-release 12 hour, 200mg tablet extended-release 12 hour) bupropion hcl xl (tablet extended-release 24 hour) mirtazapine (tablet) mirtazapine odt (tablet dispersible) Monoamine Oxidase Inhibitors You can find information on what the symbols and abbreviations in this table mean by going to pages 11 and 12. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs drugs. These drugs require a written prescription by your provider in order to be covered by the plan.

28 Emsam Marplan Phenelzine Sulfate Tranylcypromine Sulfate Desvenlafaxine ER Escitalopram Oxalate Fetzima Fluoxetine DR Fluoxetine HCl Fluvoxamine Maleate Maprotiline HCl Nefazodone HCl Paroxetine HCl Paxil Sertraline HCl Trazodone HCl Trintellix Venlafaxine HCl Venlafaxine HCl ER Viibryd Viibryd Starter Pack 28 For Track Refered Purpose EMSAM (PATCH 24 HOUR) $3.80-$8.50 (Tier 2) QL MARPLAN (TABLET) $3.80-$8.50 (Tier 2) phenelzine sulfate (tablet) tranylcypromine sulfate (tablet) SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Citalopram HBr citalopram hbr (10mg tablet, 20mg tablet, 40mg tablet, 10mg/5ml oral solution) desvenlafaxine er (100mg tablet extended-release 24 hour, 25mg tablet extended-release 24 hour, 50mg QL tablet extended-release 24 hour) escitalopram oxalate (10mg tablet, 20mg tablet, 5mg tablet, 5mg/5ml oral solution) FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.80-$8.50 (Tier 2) QL, ST Fetzima Titration Pack FETZIMA TITRATION PACK (CAPSULE EXTENDED- RELEASE 24 HOUR THERAPY PACK) $3.80-$8.50 (Tier 2) ST fluoxetine dr (capsule delayed-release) fluoxetine hcl (10mg capsule immediate-release, 20mg capsule immediate-release, 40mg capsule immediate-release, 20mg/5ml oral solution) fluvoxamine maleate (tablet) maprotiline hcl (tablet) nefazodone hcl (tablet) paroxetine hcl (tablet immediate-release) PAXIL (10MG/5ML SUSPENSION) $3.80-$8.50 (Tier 2) sertraline hcl (100mg tablet, 25mg tablet, 50mg tablet, 20mg/ml concentrate) trazodone hcl (tablet) TRINTELLIX (TABLET) $3.80-$8.50 (Tier 2) QL venlafaxine hcl (tablet immediate-release) venlafaxine hcl er (150mg capsule extended-release 24 hour, 37.5mg capsule extended-release 24 hour, 75mg capsule extended-release 24 hour) VIIBRYD (TABLET) $3.80-$8.50 (Tier 2) QL VIIBRYD STARTER PACK (KIT) $3.80-$8.50 (Tier 2) QL Tricyclics Amitriptyline HCl amitriptyline hcl (tablet)

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