Comprehensive PREFERRED DRUG LIST. California Health & Wellness

Transcription

1 Comprehensive PREFERRED DRUG LIST California Health & Wellness PAGE 1 LAST UPDATED 01/19/2018

2 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 Drug List The California Health & Wellness Preferred Drug 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 Envolve Pharmacy Solutions to process pharmacy claims for prescribed drugs. Some drugs on the California Health & Wellness PDL may require PA and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager. Specialty Drugs 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 PAGE 2 LAST UPDATED 01/19/2018

3 Dispensing Limits Drugs may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A total of 80% 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 Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions 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, Envolve Pharmacy Solutions 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 Limits 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. PAGE 3 LAST UPDATED 01/19/2018

4 Age Limits Some medications on the California Health & Wellness PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA 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. For 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, Envolve Pharmacy Solutions 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 Federal 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 ITS 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: PAGE 4 LAST UPDATED 01/19/2018

5 Drugs that are considered experimental Drug Efficacy Study and Implementation (DESI) drugs Drugs prescribed for infertility Drugs prescribed for erectile dysfunction Drugs prescribed for cosmetic purposes or hair growth Over-the-counter (OTC) cough and cold preparations Over-the-counter adult acetaminophen products Drugs carved-out of the California Health & Wellness contract with the DHCS (TARs/claims submitted to Medi-Cal Fee-For-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 Drugs 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. PAGE 5 LAST UPDATED 01/19/2018

6 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, Flecainide, L- Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin. Drug Efficacy Study and Implementation Drugs DESI products and known related drug products are defined as less than effective by the Food and Drug 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. Filling 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. Contact Information California Health & Wellness Provider Services: Envolve Pharmacy Solutions Prior Authorizations: Fax: Envolve Pharmacy Solutions Help Desk: AcariaHealth Prior Authorizations: Fax: Provider Administered Drug Prior Authorizations Fax: PAGE 6 LAST UPDATED 01/19/2018

7 TIER DESCRIPTION 1 Covered Drug is covered on the Preferred Drug List TYPE PA ST Quantity Limit Prior Authorization Step Therapy DESCRIPTION There is a limit on the amount of drug covered per prescription, or within a specific time frame. Prior Authorization required before prescription can be filled. Requires trial and failure of one or more preferred products prior to coverage. Age Limit Drug is limited to specific age. MDD Max Daily Dose A limit on the number of times the drug can be taken per day. MPL Max Package Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. MDS Max Days Supply There is a limit on the amount of this drug that is covered. C Custom This drug has unique restrictions. PAGE 7 LAST UPDATED 01/19/2018

8 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS ANGESICS NONSTEROID ANTI-INFLAMMATORY DRUGS ASPIRIN (300 MG SUPPOS, 600 MG SUPPOS) aspirin (tab 81 mg, tab 325 mg, tab delayed release 81 mg, tab delayed release 325 mg, tab delayed release 500 mg) aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg 12 / claim aspirin buffered tab 325 mg aspirin tab chew 81 mg ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100 mg/5ml) ibuprofen tab 200 mg naproxen sodium tab 220 mg MDD 2 per day ANESTHETICS LOC ANESTHETICS lidocaine hcl gel 2% MPL 1 / claim ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS nicotine (patch 24hr 14 mg/24hr, patch 24hr 21 mg/24hr, patch 24hr 7 mg/24hr) C 90 day supply NICOTINE MG/24HR KIT C 90 day supply PAGE 8 LAST UPDATED 01/19/2018

9 nicotine polacrilex (gum 2 mg, gum 4 mg, lozenge 4 mg) C 90 day supply nicotine polacrilex lozenge 2 mg C 90 day supply ANTIEMETICS ANTIEMETICS, OTHER dimenhydrinate tab 50 mg DRAMAMINE 50 MG CHEW TAB meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg) ANTIFUNGS clotrimazole (topical) (cream, soln) MPL 1 / claim clotrimazole vaginal cream 1% 45 / claim clotrimazole vaginal cream 2% MPL 1 / claim miconazole nitrate cream 2% MPL 1 / claim miconazole nitrate vaginal app 200 mg & 2% cream 9 gm kit miconazole nitrate vaginal cream 2% 45 / claim miconazole nitrate vaginal cream 4% (200 mg/5gm) miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit miconazole nitrate vaginal suppos 100 mg 45 / 30 days MPL 1 / claim 7 / claim tioconazole vaginal oint 6.5% 5 / claim PAGE 9 LAST UPDATED 01/19/2018

10 ANTIPARASITICS ANTIHELMINTHICS PIN-X MG CHEW TAB MFL 4 / claim 1 / 30 days pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) MFL 60 / claim 1 / 30 days BLOOD GLUCOSE REGULATORS GLYCEMIC AGENTS glucose chew tab 4 gm 50 / 30 days CARDIOVASCULAR AGENTS DYSLIPIDEMICS, OTHER niacin (tab cr 250 mg, tab er 250 mg) niacin er tab er 1000 mg niacin er tab er 500 mg niacin er tab er 750 mg CENTR NERVOUS SYSTEM AGENTS CENTR NERVOUS SYSTEM, OTHER acetaminophen (liquid 160 mg/5ml, soln 160 mg/5ml) Up to 20 yrs old acetaminophen soln 100 mg/ml 30 / 30 days DENT AND OR AGENTS BIOTENE DRY MOUTH MOISTURIZING SOLUTION BIOTENE MOISTURIZING MOUTH SOLUTION 900 / claim 900 / claim PAGE 10 LAST UPDATED 01/19/2018

11 CVS DRY MOUTH SOLUTION 900 / claim DRY MOUTH SPRAY SOLUTION 900 / claim MOI-STIR SOLUTION 900 / claim MOUTH KOTE SOLUTION 900 / claim OR RELIEF SPRAY SOLUTION 900 / claim RA DRY MOUTH SOLUTION 900 / claim stannous fluoride conc 0.63% DERMATOLOGIC AGENTS *lanolin cream*** *neomycin-bacitracin-polymyxin oint*** MPL 1 / claim A % GEL ACNE MEDICATION 5 5 % LOTION bacitracin oint 500 unit/gm MPL 1 / claim bacitracin zinc oint 500 unit/gm MPL 1 / claim benzoyl peroxide (gel 2.5%, gel 5%, gel 10%, liq 5%, liq 10%, lotion 10%) camphor & menthol lotion % MPL 1 / claim capsaicin (cream 0.075%, cream 0.1%) MPL 1 / claim capsaicin cream 0.025% CAPZASIN-P % CREAM MPL 1 / claim CASTIVA WARMING % LOTION MPL 1 / claim CLEAN & CLEAR ADVANTAGE 3-IN-1 5 % LOTION coal tar shampoo 0.5% dibucaine oint 1% MPL 1 / claim PAGE 11 LAST UPDATED 01/19/2018

12 dibucaine rectal ointment 1% MPL 1 / claim diphenhydramine hcl cream 2% GOLD BOND MULTI-SYMPTOM 4 % CREAM MPL 1 / claim(s) hydrocortisone (topical) (cream, lotion) MPL 1 / claim hydrocortisone cream 0.5% 30 / claim hydrocortisone oint 1% MPL 60 / 30 days 1 / 30 days hydrocortisone-aloe vera cream 1% MPL 1 / claim lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 12% MPL 1 / claim MPL 1 / 30 days LICIDE TREATMENT KIT lidocaine cream 4% MPL 1 / claim(s) neomycin-polymyxin w/ pramoxine cream 1% MPL 1 / claim NEUROMED7 4 % CREAM MPL 1 / claim(s) permethrin lotion 1% MPL 1 / claim permethrin spray & pyrethins-piperonyl butoxide shamp kit phenyleph-shark liver oil-cocoa butter suppos % phenylephrine-cocoa butter suppos % phenylephrine-mineral oil-petrolatum oint % phenylephrine-shark liver oil-mo-pet oint % 12 / claim 12 / claim MPL 1 / claim MPL 1 / claim PAGE 12 LAST UPDATED 01/19/2018

13 pramoxine hcl rectal foam 1% 15 / claim PREDATOR 4 % CREAM MPL 1 / claim(s) pyreth-piperonyl butox sham-permeth aero-nit remover gel kit pyrethrins-piperonyl butoxide liq % pyrethrins-piperonyl butoxide shampoo % MPL 1 / claim RA PAIN RELIEF 4 % CREAM MPL 1 / claim(s) SCHOOLTIME SHAMPOO SHAMPOO selenium sulfide lotion 1% 240 / claim terbinafine hcl cream 1% MPL 1 / claim tolnaftate cream 1% MPL 1 / claim XOLIDO XP 4 % CREAM MPL 1 / claim(s) GASTROINTESTIN AGENTS GASTROINTESTIN AGENTS, OTHER alum & mag hydroxide-simethicone susp mg/5ml aluminum hydroxide gel susp 320 mg/5ml bismuth subsalicylate (chew tab 262 mg, susp 262 mg/15ml, susp 525 mg/15ml) calcium carbonate (antacid) chew tab 500 mg loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml)) 496 / 30 days loperamide hcl tab 2 mg MDD 2 per day PAGE 13 LAST UPDATED 01/19/2018

14 magnesium oxide tab 400 mg simethicone chew tab 80 mg simethicone susp 40 mg/0.6ml MPL 1 / claim sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg) 496 / 30 days HISTAMINE2 (H2) RECEPTOR ANTAGONISTS AXID AR 75 MG TAB cimetidine tab 200 mg famotidine (tab 10 mg, tab 20 mg) ranitidine hcl (tab 75 mg, tab 150 mg) MDD 2 per day LAXATIVES bisacodyl ec tab dr 5 mg MDD 1 per day bisacodyl laxative suppos 10 mg 12 / claim calcium polycarbophil tab 625 mg MDD 10 per day complete ready-to-use enema enema 7-19 gm/118ml docusate sodium (cap 50 mg, liquid 150 mg/15ml, syrup 60 mg/15ml, tab 100 mg) docusate sodium cap 100 mg MDD 3 per day docusate sodium cap 250 mg MDD 3 per day fiber cap 0.52 gm glycerin suppos 2 gm magnesium citrate solution gm/30ml milk of magnesia suspension 400 mg/5ml 990 / 30 days PAGE 14 LAST UPDATED 01/19/2018

15 polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder MDD 34 per day psyllium (powder 28.3%, powder 30%, powder 30.9%, powder 33%, powder 48.57%, powder 50%, powder 58.6%, powder 68%, powder 100%) senna tab 8.6 mg senna-docusate sodium tab mg MDD 4 per day SENNA-DOCUSATE SODIUM TAB MG sorbitol (laxative) (oral solution, rectal solution) MDD 4 per day PROTON PUMP INHIBITORS lansoprazole cap delayed release 15 mg MDD C 4 per day OTC Covered Only NEXIUM 24HR 20 MG CAP DR omeprazole delayed release tab 20 mg PRILOSEC OTC 20 MG TAB DR GENITOURINARY AGENTS MDD C MDD C MDD C 2 per day OTC Covered Only 4 per day OTC Covered Only 4 per day OTC Covered Only GENITOURINARY AGENTS, OTHER ENCARE 100 MG SUPPOS MPL 1 / claim GYNOL II 2 % GEL MPL 1 / claim OPTIONS GYNOL II CONTRACEPTIVE 3 % GEL 86 / claim PAGE 15 LAST UPDATED 01/19/2018

16 sodium citrate & citric acid soln mg/5ml VCF VAGIN CONTRACEPTIVE 28 % FILM 500 / 30 days MPL 1 / claim HORMON AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) PROGESTINS levonorgestrel tab 1.5 mg METABOLIC BONE DISEASE AGENTS MFL 1 / 21 days 4 / 365 days cholecalciferol cap unit 8 / 30 days MISCELLANEOUS THERAPEUTIC AGENTS *GAUZE PADS & DRESSINGS - PADS 3" X 3"*** *GAUZE PADS & DRESSINGS - PADS 4" X 4"*** *respiratory therapy supplies - misc** 1 / 360 days acetaminophen (elixir 160 mg/5ml, liquid 160 mg/5ml, susp 80 mg/0.8ml, susp 160 mg/5ml) Up to 20 yrs old acetaminophen suppos 120 mg 12 / claim Up to 20 yrs old AIMSCO LUBRICATED MISC 36 / claim ARI CHAMBER DEVICE 2 / 360 days cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) 26 / claim ELEXA NATUR FEEL MISC 36 / claim PAGE 16 LAST UPDATED 01/19/2018

17 ELEXA STIMULATING MISC 36 / claim ELEXA ULTRA SENSITIVE MISC 36 / claim FANTASY LUBRICATED MISC 36 / claim FANTASY LUBRICATED/SPERMICIDE MISC 36 / claim KAMELEON LUBRICATED MISC 36 / claim KIMONO MICRO THIN MISC 36 / claim KIMONO MICRO THIN PLUS MISC 36 / claim KIMONO MISC 36 / claim KIMONO PLUS MISC 36 / claim KIMONO PS MISC 36 / claim KIMONO PS PLUS MISC 36 / claim KIMONO SENSATION MISC 36 / claim KIMONO SENSATION PLUS MISC 36 / claim MAXX MISC 36 / claim MAXX PLUS MISC 36 / claim nasal moisturizing spray solution 0.65 % NESSI SPACER WITH MASK LARGE DEVICE NESSI SPACER WITH MASK SM/MED DEVICE NESSI SPACER WITH MOUTHPIECE DEVICE NOVA MAX PLUS KETONE TEST STRIP MPL 1 / claim 2 / 360 days 2 / 360 days 2 / 360 days 30 / 30 days OFF ACTIVE 15 % AEROSOL PAGE 17 LAST UPDATED 01/19/2018

18 OFF DEEP WOODS DRY AEROSOL OFF DEEP WOODS SPORTSMEN 30 % AEROSOL OFF SMOOTH & DRY 15 % AEROSOL OPTICHAMBER FACE MASK-LARGE MISC OPTICHAMBER FACE MASK- MEDIUM MISC OPTICHAMBER FACE MASK-SML MISC permethrin (aerosol 0.5%, creme rinse 1%) 2 / 360 days 2 / 360 days 2 / 360 days phenylephrine hcl tab 10 mg 24 / claim polyethylene glycol 3350 powder MDD 34 per day PRECISION XTRA KETONE STRIP 30 / 30 days PREMIUM CONDOMS LUBRICATED MISC pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg) pseudoephedrine hcl er tab er 12h 120 mg 36 / claim MDD 2 per day pseudoephedrine hcl tab 30 mg PTS PANELS KETONE TEST STRIP 30 / 30 days REITY LATEX/ULTRA TEXTURED DEVICE REITY LATEX/ULTRA THIN DEVICE 36 / claim 36 / claim simethicone liquid 40 mg/0.6ml MPL 1 / claim PAGE 18 LAST UPDATED 01/19/2018

19 SIMPLYTHICK (15 G GEL, 30G GEL, 120G GEL, 240 G GEL) 1816 / claim At least 1 yrs old sorbitol solution (bulk) TROJAN MAGNUM WARM SENSATIONS DEVICE TROJAN SUPRAS SPERMICID DEVICE TROJAN TWISTED PLEASURE DEVICE TRUSTEX COLOR CONDOMS + LUBE MISC TRUSTEX LUB/RIBBED/STUDDED MISC TRUSTEX LUB/SPERMICIDE EX ST MISC TRUSTEX LUB/SPERMICIDE XL MISC TRUSTEX LUBRICATED EX LARGE MISC TRUSTEX LUBRICATED EXTRA ST MISC 36 / claim 36 / claim 36 / claim 36 / claim 36 / claim 36 / claim 36 / claim 36 / claim 36 / claim TRUSTEX LUBRICATED MISC 36 / claim TRUSTEX LUBRICATED/SPERMICIDE MISC TRUSTEX NATUR CONDOMS + LUBE MISC 36 / claim 36 / claim TRUSTEX NON-LUBRICATED MISC 36 / claim TRUSTEX RIA LUB/SPERMICIDE MISC 36 / claim TRUSTEX RIA LUBRICATED MISC 36 / claim PAGE 19 LAST UPDATED 01/19/2018

20 TRUSTEX RIA NON-LUBRICATED MISC TRUSTEX-NONOXYNOL-9/RIB/STUD MISC ULTRATHON INSECT REPELLENT 8 HR 25% 36 / claim 36 / claim OPHTHMIC AGENTS OPHTHMIC AGENTS, OTHER *artificial tear ophth ointment*** 4 / claim *white petrolatum-mineral oil ophth ointment*** MPL 1 / claim hypromellose ophth soln 0.4% 15 / claim ketotifen fumarate ophth soln 0.025% (base equiv) naphazoline w/ pheniramine ophth soln % naphazoline w/ pheniramine ophth soln % MPL 1 / claim MFL 1 / 30 days 15 / 30 days polyvinyl alcohol ophth soln 1.4% 15 / claim sodium chloride hypertonic (oint, soln) 3.5 / 30 days tetrahydrozoline hcl ophth soln 0.05% MPL 1 / 30 days OTIC AGENTS carbamide peroxide 6.5% otic soln 15 / 30 days RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHED CORTICOSTEROIDS triamcinolone acetonide nasal aerosol suspension 55 mcg/act C 17 / 30 days At least 2 yrs old OTC Covered Only PAGE 20 LAST UPDATED 01/19/2018

21 ANTIHISTAMINES ER-DRYL 50 MG TAB MDD 4 per day cetirizine hcl allergy child solution 5 mg/5ml 240 / claim cetirizine hcl chew tab 10 mg MDD 1 per day cetirizine hcl chew tab 5 mg MDD 1 per day cetirizine hcl tab 10 mg MDD 1 per day cetirizine hcl tab 5 mg MDD 1 per day childrens loratadine syrup 5 mg/5ml 240 / claim chlorpheniramine maleate syrup 2 mg/5ml MDD 60 per day chlorpheniramine maleate tab 4 mg 120 / claim clemastine fumarate tab 1.34 mg MDD 2 per day diphenhydramine hcl cap 25 mg MDD 4 per day diphenhydramine hcl cap 50 mg MDD 4 per day diphenhydramine hcl elixir 12.5 mg/5ml 240 / claim diphenhydramine hcl liquid 12.5 mg/5ml 240 / claim diphenhydramine hcl syrup 12.5 mg/5ml 240 / claim diphenhydramine hcl tab 25 mg MDD 4 per day fexofenadine hcl tab 180 mg MDD 1 per day fexofenadine hcl tab 60 mg MDD 2 per day loratadine allergy relief tab disp 10 mg loratadine tab 10 mg PAGE 21 LAST UPDATED 01/19/2018

22 RESPIRATORY TRACT AGENTS, OTHER brompheniramine & phenylephrine elixir mg/5ml MFL 120 / claim 1 / 30 days brompheniramine & pseudoephedrine elixir 1-15 mg/5ml MFL 120 / claim 1 / 30 days cetirizine-pseudoephedrine (tab er mg, tab sr mg) MDD 2 per day DECON-A 2-5 MG/ML LIQUID guaifenesin-codeine soln mg/5ml MFL 240 / claim 1 / 30 days loratadine & pseudoephedrine (tab er 24hr mg, tab sr 24hr mg) loratadine & pseudoephedrine (tab er mg, tab sr mg) MDD 1 per day MDD 2 per day pseudoephedrine w/ cod-gg soln mg/5ml MFL 240 / claim 1 / 30 days pseudoephedrine-ibuprofen (susp mg/5ml, tab mg) sodium chloride aero soln 0.9% 240 / claim SLEEP DISORDER AGENTS SLEEP DISORDERS, OTHER diphenhydramine hcl (sleep) (cap 50 mg, tab 50 mg) diphenhydramine hcl (sleep) tab 25 mg MDD 1 per day doxylamine succinate (sleep) tab 25 mg PAGE 22 LAST UPDATED 01/19/2018

23 THERAPEUTIC NUTRIENTS/MINERS/ELECTROLYTES ELECTROLYTE/MINER REPLACEMENT *oral electrolyte solution*** calcium carbonate (antacid) susp 1250 mg/5ml calcium carbonate-cholecalciferol (chew tab 500 mg-100, tab 500 mg- 200) calcium carbonate-cholecalciferol (tab 600 mg-200, tab 600 mg-400, tab 600 mg-800) calcium carbonate-vitamin d (tab 250 mg-125, tab 500 mg-125, tab 500 mg- 200) calcium carbonate-vitamin d (tab 600 mg-200, tab 600 mg-400) ferrous fumarate tab 324 mg (106 mg elemental fe) ferrous fumarate tab 325 mg (106 mg elemental fe) ferrous gluconate (tab 240 mg (27 mg elemental fe), tab 324 mg (38 mg elemental iron), tab 325 mg, tab 325 mg (37.5 mg elemental fe)) FERROUS GLUCONATE 225 (27 FE) MG TAB ferrous sulfate (soln 75 mg/0.6ml mg/0.6ml, soln 75 mg/ml mg/ml) ferrous sulfate (tab 28 mg (elemental fe), tab 325 mg (65 mg elemental fe), tab ec 324 mg (65 mg fe equivalent), tab ec 325 mg (65 mg fe equivalent)) 500 / 30 days MDD 2 per day MDD 2 per day MDD 2 per day MDD 3.4 per day PAGE 23 LAST UPDATED 01/19/2018

24 ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent) ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) IRON CHEWS PEDIATRIC 15 MG CHEW TAB magnesium oxide (mg supplement) (cap 400 mg (elemental (mg supplement), tab 400 mg (240 mg elemental) MDD 16 per day oyster shell calcium tab 500 mg zinc sulfate cap 220 mg (50 mg elemental zn) *multiple vitamins w/ minerals tab** MDD 1 per day *pediatric multiple vitamin w/ c & fa chew tab** *pediatric multiple vitamin w/ c soln 35 mg/ml** *pediatric multiple vitamins w/ iron drops 10 mg/ml** *pediatric vitamins adc drops 1500 unit- 400 unit-35 mg/ml*** *prenatal multivitamins & minerals w/iron & fa tab 0.8 mg*** *prenatal vit w/ fe fumarate-fa tab mg*** MDD 1 per day 50 / claim 60 / claim 50 / claim MDD 1 per day MDD 1 per day cholecalciferol (cap 1000, cap 2000) cholecalciferol cap 5000 unit MDD 2 per day folic acid (tab 400 mcg, tab 800 mcg) MDD 1 per day folic acid tab 1 mg PAGE 24 LAST UPDATED 01/19/2018

25 KPN PRENAT 0.1 MG TAB MDD 1 per day MISSION PRENAT TAB MDD 1 per day niacin (cap cr 250 mg, cap cr 500 mg, tab 500 mg) NUTRICION PORVIDA 0.25 MG TAB MDD 1 per day PERRY PRENAT MG CAP MDD 1 per day PNV PRENAT PLUS MULTIVITAMIN 27-1 MG TAB POLYCOSE (380/100 G LIQUID, LIQUID, POWDER) polysaccharide iron complex cap 150 mg (iron equivalent) pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg) THERANAT CORE NUTRITION 27-1 MG TAB TRI-VI-SOL/IRON 10 MG/ML SOLUTION MDD 1 per day MPL 1 / 30 days MDD 1 per day MDD 1 per day 50 / claim PAGE 25 LAST UPDATED 01/19/2018

26 LIST OF COVERED PRESCRIPTION MEDICATIONS ANGESICS NONSTEROID ANTI-INFLAMMATORY DRUGS celecoxib (cap 50 mg, cap 100 mg, cap 200 mg, cap 400 mg) PA MDD 2 per day CHOLINE & MAG TRISICYLATE 1000 MG TAB choline & magnesium salicylates liq 500 mg/5ml diclofenac potassium tab 50 mg diclofenac sodium (tab delayed release 25 mg, tab delayed release 50 mg, tab delayed release 75 mg, tab er 24hr 100 mg, tab sr 24hr 100 mg) diflunisal tab 500 mg etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg, tab er 24hr 400 mg, tab sr 24hr 400 mg, tab sr 24hr 500 mg, tab sr 24hr 600 mg) flurbiprofen (tab 50 mg, tab 100 mg) ibuprofen (tab 400 mg, tab 600 mg, tab 800 mg) indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg, cap er 75 mg) ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg) ketorolac tromethamine tab 10 mg meloxicam (tab 7.5 mg, tab 15 mg) 20 / 30 days At least 17 yrs old PAGE 26 LAST UPDATED 01/19/2018

27 nabumetone (tab 500 mg, tab 750 mg) naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab 500 mg) naproxen (tab ec 375 mg, tab ec 500 mg) naproxen sodium (tab 275 mg, tab 550 mg) MDD 2 per day oxaprozin tab 600 mg piroxicam (cap 10 mg, cap 20 mg) salsalate (tab 500 mg, tab 750 mg) sulindac (tab 150 mg, tab 200 mg) tolmetin sodium (cap 400 mg, tab 200 mg, tab 600 mg) OPIOID ANGESICS, LONG-ACTING fentanyl (patch 72hr 100 mcg/hr, patch 72hr 12 mcg/hr, patch 72hr 25 mcg/hr, patch 72hr 50 mcg/hr, patch 72hr 75 mcg/hr) MDD 0.33 per day methadone hcl tab 10 mg PA MDD 10 per day methadone hcl tab 5 mg morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) oxycodone hcl (tab er deter 10 mg, tab er deter 15 mg, tab er deter 20 mg, tab er deter 30 mg, tab er deter 40 mg, tab er deter 60 mg, tab er deter 80 mg) PA MDD 4 per day MDD 3 per day PA MDD 2 per day PAGE 27 LAST UPDATED 01/19/2018

28 OPIOID ANGESICS, SHORT-ACTING acetaminophen w/ codeine (w/ tab mg, w/ tab mg, w/ tab mg) acetaminophen w/ codeine soln mg/5ml butalbital-acetaminophen-caff w/ cod cap mg butalbital-aspirin-caff w/ codeine cap mg codeine sulfate (tab 15 mg, tab 30 mg, tab 60 mg) hydrocodone-acetaminophen soln mg/15ml hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg) MDD 6 per day MDD 30 per day MDD 4 per day MDD 4 per day MDD 2 per day MDD 180 per day MDD 6 per day MDD 12 per day MDD 8 per day MDD 8 per day hydromorphone hcl suppos 3 mg 12 / claim meperidine hcl (tab 50 mg, tab 100 mg) MDD 6 per day meperidine hcl oral soln 50 mg/5ml 500 / claim morphine sulfate (soln 10 mg/5ml, soln 20 mg/5ml) morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20 mg, suppos 30 mg) morphine sulfate (tab 15 mg, tab 30 mg) 500 / 30 days 24 / claim MDD 6 per day PAGE 28 LAST UPDATED 01/19/2018

29 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) oxycodone hcl (cap 5 mg, conc 100 mg/5ml (20 mg/ml), tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) 240 / claim MDD 6 per day oxycodone hcl soln 5 mg/5ml oxycodone w/ acetaminophen (w/ tab mg, w/ tab mg, w/ tab mg) OXYCODONE-ACETAMINOPHEN MG/5ML SOLUTION MDD 6 per day MDD 30 per day oxycodone-aspirin tab mg MDD 6 per day tramadol hcl tab 50 mg MDD 8 per day tramadol-acetaminophen tab mg MDD 4 per day ANESTHETICS LOC ANESTHETICS lidocaine hcl viscous soln 2% 100 / claim lidocaine-prilocaine cream % MPL 1 / claim ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS COHOL DETERRENTS/ANTI-CRAVING disulfiram tab 250 mg SMOKING CESSATION AGENTS bupropion hcl (smoking deterrent) tab sr 12hr 150 mg C 90 day supply CHANTIX (0.5 MG TAB, 1 MG TAB) C 90 day supply CHANTIX CONTINUING MONTH PAK 1 MG TAB C 90 day supply PAGE 29 LAST UPDATED 01/19/2018

30 CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 MG X 42 TAB C 90 day supply NICOTROL 10 MG INHER C 90 day supply NICOTROL NS 10 MG/ML SOLUTION C 90 day supply ANTIBACTERIS AMINOGLYCOSIDES gentamicin sulfate (topical) (cream, oint) MPL 1 / claim gentamicin sulfate ophth oint 0.3% 4 / claim gentamicin sulfate ophth soln 0.3% MPL 1 / claim neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg PA TOBRADEX % OINTMENT 4 / claim tobramycin ophth soln 0.3% 5 / claim tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40 mg/ml) (base equiv), inj 2 gm/50ml (40 mg/ml) (base equiv), inj 10 mg/ml (base equivalent), inj 80 mg/2ml (40 mg/ml), inj 80 mg/2ml (40 mg/ml) (base equiv)) TOBRAMYCIN SULFATE IN SINE MG/ML-% SOLUTION PA PA TOBREX 0.3 % OINTMENT 4 / claim ANTIBACTERIS, OTHER *methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg*** BACTROBAN NAS 2 % OINTMENT PAGE 30 LAST UPDATED 01/19/2018

31 clindamycin hcl (cap 150 mg, cap 300 mg) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate (topical) (gel, lotion) MPL 1 / claim MPL 1 / claim clindamycin phosphate soln 1% clindamycin phosphate vaginal cream 2% erythromycin-sulfisoxazole for susp mg/5ml FIRST-VANCOMYCIN MG/ML SOLUTION FIRST-VANCOMYCIN MG/ML SOLUTION methenamine mandelate (tab 0.5 gm, tab 1 gm) metronidazole (tab 250 mg, tab 500 mg) 40 / claim metronidazole cream 0.75 % 45 / claim metronidazole gel 0.75 % 45 / claim metronidazole lotion 0.75% metronidazole vaginal gel 0.75% 70 / claim mupirocin calcium cream 2% MPL 1 / claim mupirocin oint 2% MPL 1 / claim nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) nitrofurantoin monohydrate macrocrystalline cap 100 mg PAGE 31 LAST UPDATED 01/19/2018

32 nitrofurantoin susp 25 mg/5ml MDD 40 per day SIVEXTRO 200 MG TAB trimethoprim tab 100 mg PA 6 / claim vancomycin hcl cap 125 mg MDD 4 per day vancomycin hcl cap 250 mg MDD 8 per day vancomycin hcl for inj 1000 mg 14 / claim vancomycin hcl for inj 500 mg 14 / 30 days BETA-LACTAM, CEPHOSPORINS cefaclor (cap 250 mg, cap 500 mg, for susp 125 mg/5ml, for susp 250 mg/5ml, for susp 375 mg/5ml) cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500 mg/5ml, tab 1 gm) cefdinir (susp 125 mg/5ml, susp 250 mg/5ml) MPL 1 / claim cefdinir cap 300 mg 20 / claim cefprozil (susp 125 mg/5ml, susp 250 mg/5ml) MPL Up to 12 yrs old 1 / claim cefprozil (tab 250 mg, tab 500 mg) 20 / claim CEFTIN 250 MG/5ML RECON SUSP 100 / claim Up to 12 yrs old ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg) MFL 3 / claim 1 / 30 days ceftriaxone sodium for iv soln 1 gm MFL 1 / 30 days cefuroxime axetil (tab 250 mg, tab 500 mg) 20 / claim PAGE 32 LAST UPDATED 01/19/2018

33 cefuroxime axetil for susp 125 mg/5ml 100 / claim Up to 12 yrs old cephalexin (cap 250 mg, cap 500 mg, for susp 125 mg/5ml, for susp 250 mg/5ml) BETA-LACTAM, PENICILLINS amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab sr 12hr mg amoxicillin & pot clavulanate (chew tab mg, chew tab mg, tab mg, tab mg) amoxicillin & pot clavulanate (susp mg/5ml, susp mg/5ml) amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg, chew tab 250 mg, for susp 125 mg/5ml, for susp 200 mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab 875 mg) MPL 2 / claim 30 / claim 40 / 30 days 20 / claim MPL 1 / claim ampicillin (cap 250 mg, cap 500 mg) AUGMENTIN MG/5ML RECON SUSP dicloxacillin sodium (cap 250 mg, cap 500 mg) penicillin v potassium (for soln 125 mg/5ml, for soln 250 mg/5ml, tab 250 mg, tab 500 mg) MPL 1 / claim PAGE 33 LAST UPDATED 01/19/2018

34 MACROLIDES azithromycin for susp 100 mg/5ml 15 / claim azithromycin for susp 200 mg/5ml MPL 1 / claim azithromycin powd pack for susp 1 gm 2 / claim azithromycin tab 250 mg 6 / claim azithromycin tab 500 mg MDD 4 per day azithromycin tab 600 mg 8 / 28 days clarithromycin (tab 250 mg, tab 500 mg) 28 / claim clarithromycin for susp 125 mg/5ml MPL 1 / claim clarithromycin for susp 250 mg/5ml clarithromycin tab sr 24hr 500 mg 14 / claim ERY-TAB (250 MG TAB DR, 333 MG TAB DR, 500 MG TAB DR) ERYPED MG/5ML RECON SUSP erythromycin base (tab 250 mg, tab 500 mg, w/ delayed release particles cap 250 mg) erythromycin ethylsuccinate (for susp 200 mg/5ml, tab 400 mg) erythromycin gel 2% MPL 1 / claim erythromycin ophth oint 5 mg/gm 4 / claim erythromycin soln 2% PCE (333 MG TAB DR, 500 MG TAB DR) PAGE 34 LAST UPDATED 01/19/2018

35 QUINOLONES CILOXAN 0.3 % OINTMENT 4 / claim ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg) ciprofloxacin hcl ophth soln 0.3% MPL 1 / claim ciprofloxacin hcl tab 100 mg (base equiv) 6 / claim levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg) MDD 14 / claim 1 per day moxifloxacin hcl ophth soln 0.5% (base equiv) ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg) 3 / claim(s) 56 / claim ofloxacin ophth soln 0.3% MPL 1 / claim ofloxacin otic soln 0.3% MPL 1 / claim SULFONAMIDES silver sulfadiazine cream 1% MPL 1 / claim sulfacetamide sodium ophth soln 10% 15 / claim sulfamethoxazole-trimethoprim (susp mg/5ml, tab mg, tab mg) TETRACYCLINES doxycycline hyclate (cap 50 mg, cap 100 mg, tab 100 mg) minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg) PAGE 35 LAST UPDATED 01/19/2018

36 ANTICONVULSANTS ANTICONVULSANTS, OTHER levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg) MDD 4 per day levetiracetam oral soln 100 mg/ml MDD 30 per day CCIUM CHANNEL MODIFYING AGENTS ethosuximide (cap 250 mg, soln 250 mg/5ml) zonisamide (cap 25 mg, cap 50 mg, cap 100 mg) GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20 mg) 1 / claim(s) Up to 21 yrs old divalproex sodium (cap delayed release sprinkle 125 mg, tab delayed release 125 mg, tab delayed release 250 mg, tab delayed release 500 mg, tab er 24 hr 250 mg, tab er 24 hr 500 mg, tab sr 24 hr 250 mg, tab sr 24 hr 500 mg) gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600 mg, tab 800 mg) MDD 4 per day gabapentin oral soln 250 mg/5ml GABITRIL (12 MG TAB, 16 MG TAB) phenobarbital (elixir 20 mg/5ml, tab 15 mg, tab 16.2 mg, tab 30 mg, tab 32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2 mg, tab 100 mg) primidone (tab 50 mg, tab 250 mg) tiagabine hcl (tab 2 mg, tab 4 mg) PAGE 36 LAST UPDATED 01/19/2018

37 valproate sodium (oral soln 250 mg/5ml, syrup 250 mg/5ml) valproic acid cap 250 mg GLUTAMATE REDUCING AGENTS felbamate (susp 600 mg/5ml, tab 400 mg, tab 600 mg) lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200 mg, tab chewable dispersible 5 mg, tab chewable dispersible 25 mg) topiramate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) MDD 3 per day topiramate sprinkle cap 15 mg MDD 6 per day topiramate sprinkle cap 25 mg MDD 8 per day SODIUM CHANNEL AGENTS carbamazepine (chew tab 100 mg, susp 100 mg/5ml, tab 200 mg, tab er 12hr 200 mg, tab er 12hr 400 mg, tab sr 12hr 100 mg, tab sr 12hr 200 mg, tab sr 12hr 400 mg) DILANTIN 30 MG CAP oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg, tab 300 mg, tab 600 mg) phenytoin (chew tab 50 mg, susp 125 mg/5ml) phenytoin sodium extended cap 100 mg PAGE 37 LAST UPDATED 01/19/2018

38 ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates tab 1 mg CHOLINESTERASE INHIBITORS donepezil hydrochloride (tab 5 mg, tab 10 mg) MDD 1 per day EXELON 2 MG/ML SOLUTION galantamine hydrobromide (cap er 24hr 16 mg, cap er 24hr 24 mg, cap er 24hr 8 mg, cap sr 24hr 16 mg, cap sr 24hr 24 mg, cap sr 24hr 8 mg) galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg) galantamine hydrobromide oral soln 4 mg/ml PA MDD 6 per day MDD 1 per day MDD 2 per day MDD 6 per day rivastigmine (patch 24hr 4.6 mg/24hr, patch 24hr 9.5 mg/24hr) PA MDD 1 per day rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg, cap 6 mg) PA MDD 2 per day N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl (tab 5 mg, tab 10 mg) MDD 2 per day memantine hcl oral solution 2 mg/ml memantine hcl tab 5 mg (28) & 10 mg (21) titration pak MPL 1 / 28 days PAGE 38 LAST UPDATED 01/19/2018

39 ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl (tab 75 mg, tab 100 mg) MDD 3 per day bupropion hcl (tab er 24hr 150 mg, tab er 24hr 300 mg, tab sr 24hr 150 mg, tab sr 24hr 300 mg) MDD 1 per day bupropion hcl er (sr) tab er 12h 100 mg MDD 2 per day bupropion hcl er (sr) tab er 12h 150 mg MDD 2 per day bupropion hcl tab sr 12hr 100 mg MDD 2 per day bupropion hcl tab sr 12hr 150 mg MDD 2 per day bupropion hcl tab sr 12hr 200 mg MDD 2 per day mirtazapine (orally disintegrating tab 15 mg, orally disintegrating tab 30 mg, orally disintegrating tab 45 mg, tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg) perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab 4-10 mg, tab 4-25 mg, tab 4-50 mg) MDD 1 per day MDD 4 per day SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR citalopram hydrobromide (tab 10 mg, tab 20 mg) citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 40 mg (base equiv) escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg) MDD 1.5 per day 240 / 30 days MDD 1 per day MDD 1 per day PAGE 39 LAST UPDATED 01/19/2018

40 fluoxetine hcl (cap 10 mg, cap 20 mg) MDD 4 per day fluoxetine hcl cap 40 mg MDD At least 7 yrs old 2 per day fluoxetine hcl solution 20 mg/5ml 120 / 30 days fluoxetine hcl tab 10 mg MDD At least 7 yrs old 1 per day fluvoxamine maleate (tab 25 mg, tab 50 mg) MDD 2 per day fluvoxamine maleate tab 100 mg MDD 3 per day maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg) nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab 200 mg, tab 250 mg) paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40 mg) paroxetine hcl oral susp 10 mg/5ml (base equiv) MDD 2 per day MDD 40 per day sertraline hcl (tab 25 mg, tab 50 mg) MDD 1.5 per day sertraline hcl oral conc 20 mg/ml MDD 10 per day sertraline hcl tab 100 mg MDD 2 per day trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg) trazodone hcl tab 300 mg MDD 2 per day venlafaxine hcl (cap er 24hr 150 mg, cap er 24hr 37.5 mg, cap er 24hr 75 mg, cap sr 24hr 150 mg, cap sr 24hr 37.5 mg, cap sr 24hr 75 mg, tab er 24hr 150 mg, tab er 24hr 37.5 mg, tab er 24hr 75 mg, tab sr 24hr 150 mg, tab sr 24hr 75 mg) MDD 1 per day PAGE 40 LAST UPDATED 01/19/2018

41 venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab er 24hr 225 mg (base equivalent)) VIIBRYD (10 MG TAB, 20 MG TAB, 40 MG TAB) PA MDD 1 per day VIIBRYD 10 & 20 & 40 MG KIT TRICYCLICS PA 30 / 365 days amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150 mg) clomipramine hcl cap 75 mg desipramine hcl (tab 10 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) desipramine hcl tab 25 mg MDD 2 per day doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, cap 100 mg, cap 150 mg, conc 10 mg/ml) imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg) nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg) nortriptyline hcl soln 10 mg/5ml MDD 20 per day ANTIEMETICS ANTIEMETICS, OTHER metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5 mg, tab 10 mg) PAGE 41 LAST UPDATED 01/19/2018

42 prochlorperazine maleate (tab 5 mg, tab 10 mg) prochlorperazine suppos 25 mg EMETOGENIC THERAPY ADJUNCTS aprepitant capsule 125 mg 1 / claim aprepitant capsule 40 mg 1 / 30 days aprepitant capsule 80 mg 2 / claim aprepitant capsule therapy pack 80 & 125 mg MPL 1 / claim ondansetron hcl (tab 4 mg, tab 8 mg) MDD 2 per day ondansetron hcl oral soln 4 mg/5ml 50 / claim ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg MDD 2 per day MDD 2 per day ANTIFUNGS econazole nitrate cream 1% MPL 1 / claim fluconazole (susp 10 mg/ml, susp 40 mg/ml) 70 / claim fluconazole tab 100 mg MDD 1 per day fluconazole tab 150 mg 2 / claim fluconazole tab 200 mg MDD 2 per day fluconazole tab 50 mg 7 / claim griseofulvin microsize (susp 125 mg/5ml, tab 500 mg) griseofulvin ultramicrosize (tab 125 mg, tab 250 mg) PAGE 42 LAST UPDATED 01/19/2018

43 GYNAZOLE-1 2 % CREAM itraconazole cap 100 mg PA MDD 1 per day ketoconazole cream 2% MPL 1 / claim ketoconazole shampoo 2% 120 / claim ketoconazole tab 200 mg MDD 2 per day nystatin (topical) (*nystatin topical powder**, nystatin cream unit/gm, nystatin oint unit/gm) MPL 1 / claim nystatin susp unit/ml 120 / claim nystatin tab unit MDD 6 per day nystatin topical powder unit/gm nystatin-triamcinolone (cream unit/gm- %, oint unit/gm-%) MPL 1 / claim terbinafine hcl tab 250 mg MDD 90 / 120 days 1 per day terconazole vaginal cream 0.4% 45 / claim terconazole vaginal cream 0.8% 20 / claim terconazole vaginal suppos 80 mg 3 / claim ANTIGOUT AGENTS allopurinol (tab 100 mg, tab 300 mg) colchicine tab 0.6 mg MFL 6 / claim 1 / 30 days colchicine w/ probenecid tab mg probenecid tab 500 mg PAGE 43 LAST UPDATED 01/19/2018

44 ANTIMIGRAINE AGENTS ERGOT KOIDS dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4 mg/ml) At least 18 yrs old SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS eletriptan hydrobromide (tab 20 mg, tab 40 mg) 6 / 30 day(s) At least 18 yrs old naratriptan hcl (tab 1 mg, tab 2.5 mg) 9 / 30 days At least 18 yrs old rizatriptan benzoate (tab 5 mg, tab 10 mg) 12 / 30 days At least 6 yrs old sumatriptan nasal spray (5 mg/act, 20 mg/act) 6 / 30 days At least 12 yrs old sumatriptan succinate (inj 6 mg/0.5ml, solution auto-injector 6 mg/0.5ml, solution prefilled syringe 6 mg/0.5ml) 2 / 30 days At least 12 yrs old sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg) 9 / 30 days At least 12 yrs old sumatriptan succinate solution cartridge 6 mg/0.5ml At least 12 yrs old zolmitriptan (orally disintegrating tab 2.5 mg, orally disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg) 6 / 30 days At least 18 yrs old ZOMIG 5 MG SOLUTION 6 / 30 days At least 12 yrs old PAGE 44 LAST UPDATED 01/19/2018

45 ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS pyridostigmine bromide (tab 60 mg, tab cr 180 mg) ANTIMYCOBACTERIS ANTIMYCOBACTERIS, OTHER dapsone (tab 25 mg, tab 100 mg) ANTITUBERCULARS ethambutol hcl (tab 100 mg, tab 400 mg) isoniazid (tab 100 mg, tab 300 mg) ISONIAZID 50 MG/5ML SYRUP PRIFTIN 150 MG TAB 72 / 84 days pyrazinamide tab 500 mg rifampin (cap 150 mg, cap 300 mg) TRECATOR 250 MG TAB ANTINEOPLASTICS KYLATING AGENTS cyclophosphamide (tab 25 mg, tab 50 mg) LEUKERAN 2 MG TAB melphalan tab 2 mg MYLERAN 2 MG TAB PAGE 45 LAST UPDATED 01/19/2018

46 ANTIANDROGENS bicalutamide tab 50 mg MDD 1 per day flutamide cap 125 mg XTANDI 40 MG CAP PA ZYTIGA 250 MG TAB PA ANTIANGIOGENIC AGENTS POMYST (1 MG CAP, 2 MG CAP, 3 MG CAP, 4 MG CAP) REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MG CAP, 15 MG CAP, 20 MG CAP, 25 MG CAP) PA PA ANTIESTROGENS/MODIFIERS FARESTON 60 MG TAB PA tamoxifen citrate (tab 10 mg, tab 20 mg) ANTIMETABOLITES DROXIA (200 MG CAP, 300 MG CAP, 400 MG CAP) hydroxyurea cap 500 mg mercaptopurine tab 50 mg PURIXAN 2000 MG/100ML SUSPENSION ANTINEOPLASTICS, OTHER CYRAMZA (100 MG/10ML SOLUTION, 500 MG/50ML SOLUTION) PA HEMANGEOL 4.28 MG/ML SOLUTION PA PAGE 46 LAST UPDATED 01/19/2018

47 leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25 mg) SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT) PA ZOLINZA 100 MG CAP PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole tab 1 mg exemestane tab 25 mg ST letrozole tab 2.5 mg ENZYME INHIBITORS HYCAMTIN (0.25 MG CAP, 1 MG CAP) topotecan hcl (for inj 4 mg, inj 4 mg/4ml (base equiv) (for infusion)) PA PA MOLECULAR TARGET INHIBITORS AFINITOR (2.5 MG TAB, 5 MG TAB, 7.5 MG TAB, 10 MG TAB) AFINITOR DISPERZ (2 MG TAB SOL, 3 MG TAB SOL, 5 MG TAB SOL) PA PA ECENSA 150 MG CAP PA BOSULIF (100 MG TAB, 500 MG TAB) PA CABOMETYX (20 MG TAB, 40 MG TAB, 60 MG TAB) CAPRELSA (100 MG TAB, 300 MG TAB) COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 MG KIT COMETRIQ (140 MG DAILY DOSE) 1 X 80 & 3 X 20 MG KIT PA PA PA PA PAGE 47 LAST UPDATED 01/19/2018

48 COMETRIQ (60 MG DAILY DOSE) 20 MG KIT PA COTELLIC 20 MG TAB PA ERIVEDGE 150 MG CAP PA GILOTRIF (20 MG TAB, 30 MG TAB, 40 MG TAB) IBRANCE (75 MG CAP, 100 MG CAP, 125 MG CAP) PA PA ICLUSIG (15 MG TAB, 45 MG TAB) PA imatinib mesylate (tab 100 mg, tab 400 mg) PA IMBRUVICA 140 MG CAP PA INLYTA (1 MG TAB, 5 MG TAB) PA IRESSA 250 MG TAB PA MEKINIST (0.5 MG TAB, 2 MG TAB) PA NEXAVAR 200 MG TAB PA NINLARO (2.3 MG CAP, 3 MG CAP, 4 MG CAP) SPRYCEL (20 MG TAB, 50 MG TAB, 70 MG TAB, 80 MG TAB, 100 MG TAB, 140 MG TAB) PA PA STIVARGA 40 MG TAB PA SUTENT (12.5 MG CAP, 25 MG CAP, 37.5 MG CAP, 50 MG CAP) PA TAFINLAR (50 MG CAP, 75 MG CAP) PA TARCEVA (25 MG TAB, 100 MG TAB, 150 MG TAB) TASIGNA (150 MG CAP, 200 MG CAP) PA PA PAGE 48 LAST UPDATED 01/19/2018

49 VANDETANIB (100 MG TAB, 300 MG TAB) PA VOTRIENT 200 MG TAB PA XKORI (200 MG CAP, 250 MG CAP) PA ZELBORAF 240 MG TAB PA MONOCLON ANTIBODIES AVASTIN (100 MG/4ML SOLUTION, 400 MG/16ML SOLUTION) PA HERCEPTIN 440 MG RECON SOLN PA KADCYLA (100 MG RECON SOLN, 160 MG RECON SOLN) OPDIVO (40 MG/4ML SOLUTION, 100 MG/10ML SOLUTION) PA PA PERJETA 420 MG/14ML SOLUTION PA RITUXAN (100 MG/10ML SOLUTION, 500 MG/50ML SOLUTION) PA RETINOIDS bexarotene cap 75 mg PA ANTIPARASITICS ANTIHELMINTHICS mebendazole chew tab 100 mg MDS 1 / 14 DAY(S) ANTIPROTOZOS atovaquone susp 750 mg/5ml ST MDD 10 per day chloroquine phosphate tab 250 mg 60 / 30 days PAGE 49 LAST UPDATED 01/19/2018

50 chloroquine phosphate tab 500 mg 8 / 56 days COARTEM MG TAB 24 / claim hydroxychloroquine sulfate tab 200 mg mefloquine hcl tab 250 mg PEDICULICIDES/SCABICIDES EURAX 10 % CREAM 60 / claim EURAX 10 % LOTION MPL 1 / claim malathion lotion 0.5% MFL 59 / claim 2 / 30 days permethrin cream 5% MPL 1 / claim SPINOSAD 0.9 % SUSPENSION MPL MFL 120 / claim At least 4 yrs old 1 / claim 2 / month C limited to ages 6 months or older ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS, OTHER entacapone tab 200 mg DOPAMINE AGONISTS bromocriptine mesylate (cap 5 mg, tab 2.5 mg) pramipexole dihydrochloride (tab mg, tab 0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) MDD At least 18 yrs old 3 per day ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg) MDD 6 per day PAGE 50 LAST UPDATED 01/19/2018

51 ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg, tab 5 mg) MDD 3 per day DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa tab 25 mg carbidopa-levodopa (tab mg, tab mg, tab mg, tab cr mg, tab cr mg, tab er mg, tab er mg) MONOAMINE OXIDASE B (MAO-B) INHIBITORS selegiline hcl (cap 5 mg, tab 5 mg) ANTISPASTICITY AGENTS baclofen (tab 10 mg, tab 20 mg) tizanidine hcl (tab 2 mg, tab 2 mg (base equivalent), tab 4 mg, tab 4 mg (base equivalent)) ANTIVIRS ANTI-CYTOMEGOVIRUS (CMV) AGENTS valganciclovir hcl tab 450 mg (base equivalent) MDD 2 per day ANTI-HEPATITIS C (HCV) AGENTS MAVYRET MG TAB PA MDD 3 Per Day ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) zidovudine (cap 100 mg, syrup 10 mg/ml, tab 300 mg) PAGE 51 LAST UPDATED 01/19/2018