PREFERRED DRUG LIST. Comprehensive. Updated September, 2017

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1 Comprehensive PREFERRED DRUG LIST Updated September, 2017 This Formulary is up to date through its date of publication, September, Please notify IlliniCare Health at or (866) with any mistakes in the formulary.

2 Pharmacy Program IlliniCare Health is committed to providing the right drug coverage to our members. We work with providers and pharmacists to make sure we cover drugs used to treat many conditions and diseases. IlliniCare Health covers prescription and certain over-the-counter (OTC) medications when ordered by a network provider. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. The IlliniCare Health pharmacy program covers members in the Integrated Care Program (ICP) and Family Health Plan (FHP). Filling a Prescription You can have your prescriptions filled at a network pharmacy. At the pharmacy, you will need to give the pharmacist your prescription and your ID card. You can find a pharmacy that is in the IlliniCare Health network by using the Find a Provider tool on If you need help finding a pharmacy near you, call us at (toll-free) / (TDD/TTY). There is no cost for covered drugs. If your medication is not on the preferred drug list or is on the preferred drug list but has limitations, you can: 1. Speak with your doctor about switching to a similar medication that is on the preferred drug list. 2. Request a prior authorization, or speak to your doctor about submitting a prior authorization for you. You or your doctor may do this by submitting the medication prior authorization form, found on Generic Drugs Generic drugs have the same active ingredient and work the same as brand name drugs. When drugs are available, the brand name drug will not be covered without prior authorization. Specialty Drugs Specialty drugs are usually not available at retail pharmacies, and require additional review and monitoring. These drugs are only covered when supplied by an IlliniCare Health network specialty pharmacy. We work with Envolve Pharmacy Solutions and AcariaHealth to help oversee these drugs. Prior authorization request forms for specialty drugs are located on the IlliniCare Health website at

3 Pharmacy Benefit Exclusions The following drug categories are not part of the IlliniCare Health pharmacy benefit: - Fertility enhancing drugs - Anorexia, weight loss, or weight gain drugs - Durable Medical Equipment (DME) products and medical supplies (unless listed on the PDL) - Drugs and other agents used for cosmetic purposes or for hair growth - Erectile dysfunction drugs prescribed to treat impotence - Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective - OTC products (unless listed on the PDL) - Drugs not included in the Medicaid Drug Rebate Program, drug product data file (unless listed on the PDL)

4 LEGEND TYPE Quantity Limit DESCRIPTION There is a limit on the amount of drug covered per prescription, or within a specific time frame. PA Prior Authorization Prior Authorization required before prescription can be filled. ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage. Age Limit Drug is limited to specific age. 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 2 LAST UPDATED 09/01/2017

5 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANGESICS NONSTEROID ANTI-INFLAMMATORY DRUGS aspirin (suppos 300 mg, suppos 600 mg) 12 / 31 days aspirin (tab 325 mg, tab delayed release 81 mg, tab delayed release 325 mg) aspirin buffered (ca carb-mg carb-mg ox) 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 62 / 31 days 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) MDS 1 per day 180 / 365 DAYS NICOTINE MG/24HR KIT MDS 2 / 365 days 180 / 365 DAYS nicotine polacrilex (gum 2 mg, gum 4 mg) MDS 24 per day 180 / 365 DAYS nicotine polacrilex (lozenge 2 mg, lozenge 4 mg) MDS 20 per day 180 / 365 DAYS ANTIEMETICS ANTIEMETICS, OTHER dimenhydrinate tab 50 mg 24 / claim meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg) PAGE 3 LAST UPDATED 09/01/2017

6 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIFUNGS clotrimazole cream 1% MPL 1 / claim(s) clotrimazole soln 1% MPL 1 / claim clotrimazole vaginal (cream 1%, cream 2%) miconazole nitrate cream 2% MPL 1 / claim miconazole nitrate vaginal (cream 2%, cream 4% (200 mg/5gm), suppos 100 mg) miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit tioconazole vaginal oint 6.5% MPL 1 / claim BLOOD GLUCOSE REGULATORS GLYCEMIC AGENTS BD GLUCOSE 5 GM CHEW TAB 50 / 30 days glucose chew tab 4 gm 50 / 30 days CENTR NERVOUS SYSTEM AGENTS CENTR NERVOUS SYSTEM, OTHER acetaminophen soln 100 mg/ml 30 / 30 days acetaminophen soln 160 mg/5ml DERMATOLOGIC AGENTS *neomycin-bacitracin-polymyxin oint*** MPL 1 / claim ACNE MEDICATION 10 % LOTION ACNE MEDICATION % LOTION ACNE MEDICATION 5 5 % LOTION bacitracin oint 500 unit/gm C Pkg Size 30: Package Limit=1/claim; Pkg Size 15: Package Limit=2/claim; Pkg Size 28: Package Limit=1/claim PAGE 4 LAST UPDATED 09/01/2017

7 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS bacitracin zinc oint 500 unit/gm C benzoyl peroxide (gel 2.5%, gel 5%, gel 10%, liq 5%, liq 10%) Pkg Size 30: Package Limit=1/claim; Pkg Size 15: Package Limit=2/claim; Pkg Size 28: Package Limit=1/claim camphor & menthol lotion % MPL 1 / claim capsaicin (cream 0.075%, cream 0.1%) MPL 1 / claim capsaicin cream 0.025% coal tar shampoo 0.5% dibucaine oint 1% 30 / claim 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% 30 / claim lactic acid (ammonium lactate) cream 12% MPL 1 / claim lactic acid (ammonium lactate) lotion 12% MPL 1 / 31 days 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 phenyleph-shark liver oil-cocoa butter suppos % phenylephrine-cocoa butter suppos % 12 / 31 days phenylephrine-mineral oil-petrolatum oint % 31 / 31 days phenylephrine-shark liver oil-mo-pet oint % 31 / 31 days PAGE 5 LAST UPDATED 09/01/2017

8 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS 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 % MPL 1 / claim pyrethrins-piperonyl butoxide shampoo % selenium sulfide lotion 1% 240 / claim terbinafine hcl cream 1% MPL 1 / claim tolnaftate cream 1% 30 / claim XOLIDO XP 4 % CREAM MPL 1 / claim(s) zinc oxide oint 20% MPL 1 / claim 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 525 mg/15ml) calcium carbonate (antacid) chew tab 500 mg loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml)) 496 / 31 days loperamide hcl tab 2 mg 2 per day magnesium oxide tab 400 mg simethicone (chew tab 80 mg, susp 40 mg/0.6ml) sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg) 496 / 31 days HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine tab 200 mg famotidine (tab 10 mg, tab 20 mg) PAGE 6 LAST UPDATED 09/01/2017

9 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ranitidine hcl (tab 75 mg, tab 150 mg) 2 per day LAXATIVES bisacodyl ec tab dr 5 mg 1 per day bisacodyl laxative suppos 10 mg 12 / claim calcium polycarbophil tab 625 mg 10 per day complete ready-to-use enema enema 7-19 gm/118ml docusate sodium (cap 250 mg, tab 100 mg) 3 per day docusate sodium (liquid 150 mg/15ml, syrup 60 mg/15ml) docusate sodium cap 100 mg 3 per day fiber cap 0.52 gm glycerin suppos 2 gm magnesium citrate solution gm/30ml milk of magnesia suspension 400 mg/5ml 992 / 31 days polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder 34 per day psyllium (powder 28.3%, powder 30.9%, powder 48.57%, powder 58.6%) senna tab 8.6 mg senna-docusate sodium tab mg 4 per day PROTON PUMP INHIBITORS lansoprazole cap delayed release 15 mg 4 per day NEXIUM 24HR 20 MG CAP DR 2 per day omeprazole delayed release tab 20 mg 1 Per Day PRILOSEC OTC 20 MG TAB DR 1 Per Day PAGE 7 LAST UPDATED 09/01/2017

10 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS GENITOURINARY AGENTS GENITOURINARY AGENTS, OTHER sodium citrate & citric acid soln mg/5ml 500 / 30 day(s) HORMON AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) PROGESTINS levonorgestrel tab 1.5 mg MFL 1 / 21 Days 4 / 365 days MISCELLANEOUS THERAPEUTIC AGENTS *alcohol swabs*** 400 / claim *respiratory therapy supplies - misc** 1 / 360 Days acetaminophen (chew tab 80 mg, liquid 160 mg/5ml, susp 80 mg/0.8ml, susp 160 mg/5ml, tab 325 mg, tab 500 mg) acetaminophen (suppos 120 mg, suppos 325 mg, suppos 650 mg) 12 / 31 days AIMSCO LUBRICATED MISC 36 / claim ARI CHAMBER DEVICE 2 / 360 days ATLAS COLOR CONDOM/SPERMICIDE DEVICE 36 / claim ATLAS COLOR LUBRICATED CONDOM DEVICE 36 / claim ATLAS LUB CONDOM/SPERMICIDE DEVICE 36 / claim ATLAS LUBRICATED CONDOM DEVICE 36 / claim chlorhexidine gluconate liquid 4% CLASS ACT LUBRICATED MISC 36 / claim cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) 26 / claim DUREX EXTRA SENSITIVE DEVICE 36 / claim ELEXA NATUR FEEL MISC 36 / claim PAGE 8 LAST UPDATED 09/01/2017

11 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ELEXA STIMULATING MISC 36 / claim ELEXA ULTRA SENSITIVE MISC 36 / claim EXTRA SENSITIVE SPERMICID DEVICE 36 / claim FANTASY LUBRICATED MISC 36 / claim FANTASY LUBRICATED/SPERMICIDE MISC 36 / claim gauze pads & dressings (pads pads 2" 2"***, pads pads 3" 3"***, pads pads 4" 4"***) HIGH SENSATION SPERMICID DEVICE 36 / claim INTENSE SENSATION DEVICE 36 / claim KAMELEON LUBRICATED MISC 36 / claim KIMONO COLORS DEVICE 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 KIMONO SPECI DEVICE 36 / claim MAXX MISC 36 / claim MAXX PLUS MISC 36 / claim NAS DECONGESTANT (30 MG/5ML LIQUID, 30 MG/5ML SYRUP) nasal moisturizing spray solution 0.65 % MPL Up to 4 yrs old 1 / claim PAGE 9 LAST UPDATED 09/01/2017

12 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS NESSI SPACER WITH MASK LARGE DEVICE 2 / 360 days NESSI SPACER WITH MASK SM/MED DEVICE 2 / 360 days NESSI SPACER WITH MOUTHPIECE DEVICE 2 / 360 days NOVA MAX PLUS KETONE TEST STRIP 30 / 30 days OPTICHAMBER FACE MASK-LARGE MISC 2 / 360 days OPTICHAMBER FACE MASK-MEDIUM MISC 2 / 360 days OPTICHAMBER FACE MASK-SML MISC 2 / 360 days permethrin creme rinse 1% phenylephrine hcl tab 10 mg 24 / claim PRECISION XTRA KETONE STRIP 30 / 30 days PREMIUM CONDOMS LUBRICATED MISC 36 / claim pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg) pseudoephedrine hcl er tab er 12h 120 mg 62 / 31 days pseudoephedrine hcl tab 30 mg PTS PANELS KETONE TEST STRIP 30 / 30 days REITY LATEX CONDOMS MISC 36 / claim REITY LATEX/ULTRA TEXTURED DEVICE 36 / claim REITY LATEX/ULTRA THIN DEVICE 36 / claim SAFE-LUV CONDOMS MISC 36 / claim simethicone liquid 40 mg/0.6ml Up to 1 yrs old TROJAN ASSORTMENT PACK MISC 36 / claim TROJAN EXTENDED PLEASURE/LUBE DEVICE 36 / claim TROJAN EXTRA STRENGTH MISC 36 / claim TROJAN MAGNUM MISC 36 / claim TROJAN MAGNUM WARM SENSATIONS DEVICE 36 / claim PAGE 10 LAST UPDATED 09/01/2017

13 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS TROJAN MAGNUM XL LUBRICATED DEVICE 36 / claim TROJAN MISC 36 / claim TROJAN PLEASURE MESH/SPERMICID DEVICE 36 / claim TROJAN PLUS MISC 36 / claim TROJAN REGULAR MISC 36 / claim TROJAN RIBBED MISC 36 / claim TROJAN RIBBED/SPERMICID MISC 36 / claim TROJAN SHARED SENSATION/LUBE DEVICE 36 / claim TROJAN SUPRAS SPERMICID DEVICE 36 / claim TROJAN TWISTED PLEASURE DEVICE 36 / claim TROJAN ULTRA PLEASURE LUBRICAT DEVICE 36 / claim TROJAN VERY SENSITIVE LUBRICAT MISC 36 / claim TROJAN VERY SENSITIVE SPERMICI MISC 36 / claim TROJAN VERY THIN LUBRICATED MISC 36 / claim TROJAN VERY THIN SPERMICIDE MISC 36 / claim TROJAN-ENZ LUBRICATED MISC 36 / claim TROJAN-ENZ/SPERMICID MISC 36 / claim TRUSTEX COLOR CONDOMS + LUBE MISC 36 / claim TRUSTEX LUB/RIBBED/STUDDED MISC 36 / claim TRUSTEX LUB/SPERMICIDE EX ST MISC 36 / claim TRUSTEX LUB/SPERMICIDE XL MISC 36 / claim TRUSTEX LUBRICATED EX LARGE MISC 36 / claim TRUSTEX LUBRICATED EXTRA ST MISC 36 / claim TRUSTEX LUBRICATED MISC 36 / claim PAGE 11 LAST UPDATED 09/01/2017

14 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS TRUSTEX LUBRICATED/SPERMICIDE MISC 36 / claim TRUSTEX NATUR CONDOMS + LUBE MISC 36 / claim TRUSTEX NON-LUBRICATED MISC 36 / claim TRUSTEX RIA LUB/SPERMICIDE MISC 36 / claim TRUSTEX RIA LUBRICATED MISC 36 / claim TRUSTEX RIA NON-LUBRICATED MISC 36 / claim TRUSTEX-NONOXYNOL-9/RIB/STUD MISC 36 / claim ULTIMATE FEELING DEVICE 36 / claim OPHTHMIC AGENTS OPHTHMIC AGENTS, OTHER *artificial tear ophth ointment*** 4 / claim *white petrolatum-mineral oil ophth ointment*** MPL 1 / claim HYPOTEARS 1-1 % SOLUTION hypromellose ophth soln 0.4% 15 / claim ketotifen fumarate ophth soln 0.025% (base equiv) MPL 1 / claim polyvinyl alcohol ophth soln 1.4% 15 / claim tetrahydrozoline hcl ophth soln 0.05% MPL 1 / 30 days OTIC AGENTS carbamide peroxide 6.5% otic soln 15 / 31 days RESPIRATORY TRACT/PULMONARY AGENTS ANTIHISTAMINES cetirizine hcl allergy child solution 5 mg/5ml 240 / claim cetirizine hcl chew tab 10 mg 1 per day cetirizine hcl chew tab 5 mg 1 per day PAGE 12 LAST UPDATED 09/01/2017

15 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS cetirizine hcl tab 10 mg 1 per day cetirizine hcl tab 5 mg 1 per day childrens loratadine syrup 5 mg/5ml 240 / claim chlorpheniramine maleate syrup 2 mg/5ml 60 per day chlorpheniramine maleate tab 4 mg 120 / claim clemastine fumarate tab 1.34 mg 2 per day diphenhydramine hcl cap 25 mg 4 per day diphenhydramine hcl cap 50 mg 4 per day diphenhydramine hcl liquid 12.5 mg/5ml 240 / claim diphenhydramine hcl syrup 12.5 mg/5ml 240 / claim diphenhydramine hcl tab 25 mg 4 per day fexofenadine hcl tab 180 mg 1 per day fexofenadine hcl tab 60 mg 2 per day loratadine allergy relief tab disp 10 mg loratadine tab 10 mg 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) 2 per day dextromethorphan polistirex er liquid er 30 mg/5ml dextromethorphan polistirex extended release susp 30 mg/5ml dextromethorphan-doxylamine-apap liquid mg/30ml PAGE 13 LAST UPDATED 09/01/2017

16 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS dextromethorphan-guaifenesin (liquid mg/5ml, liquid mg/5ml, syrup mg/5ml) 240 / claim dextromethorphan-guaifenesin liquid mg/5ml dextromethorphan-phenylephrine-apap cap mg DIMETAPP LONG ACT COUGH/COLD MG/5ML SYRUP ED BRON GP MG/5ML LIQUID 240 / claim guaifenesin liquid 100 mg/5ml MFL 240 / claim 1 / 30 days guaifenesin syrup 100 mg/5ml 240 / 6 days guaifenesin tab sr 12hr 600 mg MFL 40 / claim 1 / 30 days guaifenesin-codeine soln mg/5ml LOHIST-D 2-30 MG/5ML LIQUID 240 / claim loratadine & pseudoephedrine tab sr 12hr mg 62 / 31 days 2 per day loratadine & pseudoephedrine tab sr 24hr mg 1 per day phenylephrine-dm soln mg/5ml 240 / claim pseudoephed-bromphen-dm elixir mg/5ml 240 / claim pseudoephed-chlorphen-dm liq mg/5ml 240 / claim pseudoephedrine w/ cod-gg soln mg/5ml 240 / 6 days pseudoephedrine-ibuprofen tab mg TRIAMINIC COLD/COUGH DAY TIME MG/5ML SYRUP 240 / claim SLEEP DISORDER AGENTS SLEEP DISORDERS, OTHER diphenhydramine hcl (sleep) (cap 50 mg, tab 50 mg) diphenhydramine hcl (sleep) tab 25 mg 1 per day PAGE 14 LAST UPDATED 09/01/2017

17 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS doxylamine succinate (sleep) tab 25 mg THERAPEUTIC NUTRIENTS/MINERS/ELECTROLYTES ELECTROLYTE/MINER REPLACEMENT *oral electrolyte solution*** Up to 12 yrs old calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca) FERRETTS 325 (106 FE) MG TAB ferrous fumarate tab 324 mg (106 mg elemental fe) 500 / 30 days ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) 16 per day ferrous sulfate tab 325 mg (65 mg elemental fe) magnesium oxide tab 400 mg (241.3 mg elemental mg) *pediatric multiple vitamin w/ c & fa chew tab** 1 per day *pediatric multiple vitamin w/ c soln 35 mg/ml** 50 / claim *pediatric multiple vitamins w/ iron drops 10 mg/ml** 60 / claim *pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml*** 50 / claim *prenatal multivitamins & minerals w/iron & fa tab 0.8 mg*** 1 per day folic acid (tab 400 mcg, tab 800 mcg) 1 per day KPN PRENAT 0.1 MG TAB 1 per day MISSION PRENAT TAB 1 per day MISSION PRENAT FA MG TAB Up to 45 yrs old 1 per day MISSION PRENAT HP TAB Up to 45 yrs old 1 per day niacin (cap 250 mg, cap 500 mg) NUTRICION PORVIDA 0.25 MG TAB 1 per day PERRY PRENAT MG CAP 1 per day PAGE 15 LAST UPDATED 09/01/2017

18 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS POLYCOSE (380/100 G LIQUID, 380/100 G POWDER, LIQUID, POWDER) MPL 1 / 30 days polysaccharide iron complex cap 150 mg (iron equivalent) 1 per day prenatal vit w/ ferrous fumarate-folic acid (w/ tab , w/ tab ) 1 per day TRI-VI-SOL/IRON 10 MG/ML SOLUTION 50 / claim PAGE 16 LAST UPDATED 09/01/2017

19 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANGESICS NONSTEROID ANTI-INFLAMMATORY DRUGS butalbital-aspirin-caffeine tab mg 4 per day 62 / 31 days celecoxib (cap 100 mg, cap 200 mg) PA 2 per day celecoxib cap 400 mg PA 62 / 31 days 62 / 31 days celecoxib cap 50 mg PA 1 per day 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 sr 24hr 100 mg) diflunisal tab 500 mg etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg, tab sr 24hr 400 mg, tab sr 24hr 500 mg, tab sr 24hr 600 mg) flurbiprofen (tab 50 mg, tab 100 mg) ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab 800 mg) indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg) ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg) ketorolac tromethamine tab 10 mg 20 / 30 days At least 17 yrs old meloxicam (tab 7.5 mg, tab 15 mg) PAGE 17 LAST UPDATED 09/01/2017

20 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS nabumetone tab 500 mg 2 per day nabumetone tab 750 mg naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab 500 mg, tab ec 375 mg, tab ec 500 mg) naproxen sodium (tab 275 mg, tab 550 mg) 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) 0.33 per day methadone hcl tab 10 mg PA 10 per day methadone hcl tab 5 mg PA 4 per day morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) 3 per day oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab er deter 40 mg, tab er deter 80 mg) PA 2 per day OXYCONTIN (15 MG TB12 DETER, 30 MG TB12 DETER, 60 MG TB12 DETER) PA 2 per day OPIOID ANGESICS, SHORT-ACTING acetaminophen w/ codeine (w/ tab mg, w/ tab mg, w/ tab mg) 6 per day acetaminophen w/ codeine soln mg/5ml 30 per day butalbital-acetaminophen-caff w/ cod cap mg 4 per day PAGE 18 LAST UPDATED 09/01/2017

21 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS butalbital-aspirin-caff w/ codeine cap mg 4 per day codeine sulfate (tab 15 mg, tab 60 mg) 2 per day codeine sulfate tab 30 mg hydrocodone-acetaminophen soln mg/15ml 180 per day hydrocodone-acetaminophen tab mg 6 per day hydrocodone-acetaminophen tab mg 12 per day hydrocodone-acetaminophen tab mg 8 per day hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg) 8 per day hydromorphone hcl suppos 3 mg 12 / claim meperidine hcl (tab 50 mg, tab 100 mg) 6 per day meperidine hcl oral soln 50 mg/5ml 500 / claim morphine sulfate (soln 10 mg/5ml, soln 20 mg/5ml) 500 / 30 days morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20 mg, suppos 30 mg, tab 30 mg) 24 / claim morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 240 / claim morphine sulfate tab 15 mg 6 per day oxycodone hcl (cap 5 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) 6 per day oxycodone hcl conc 100 mg/5ml (20 mg/ml) 2 per day oxycodone hcl soln 5 mg/5ml oxycodone w/ acetaminophen (w/ tab mg, w/ tab mg, w/ tab mg) 6 per day oxycodone-aspirin tab mg 6 per day ROXICET MG/5ML SOLUTION tramadol hcl tab 50 mg 8 per day tramadol-acetaminophen tab mg 4 per day PAGE 19 LAST UPDATED 09/01/2017

22 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANESTHETICS LOC ANESTHETICS lidocaine hcl gel 2% 30 / claim lidocaine hcl viscous soln 2% 100 / claim lidocaine-prilocaine cream % MPL 1 / claim ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS COHOL DETERRENTS/ANTI-CRAVING acamprosate calcium tab delayed release 333 mg disulfiram (tab 250 mg, tab 500 mg) naltrexone hcl tab 50 mg VIVITROL 380 MG RECON SUSP OPIOID DEPENDENCE TREATMENTS BUNAVAIL ( MG FILM, MG FILM, MG FILM) buprenorphine hcl (sl tab 2 mg, sl tab 8 mg) buprenorphine hcl-naloxone hcl dihydrate (-naloxone sl tab mg, -naloxone sl tab 8-2 mg) SUBOXONE (2-0.5 MG FILM, 4-1 MG FILM) 1 per day SUBOXONE (8-2 MG FILM, 12-3 MG FILM) 2 per day ZUBSOLV ( MG SL TAB, MG SL TAB, MG SL TAB, MG SL TAB, MG SL TAB) OPIOID REVERS AGENTS EVZIO 0.4 MG/0.4ML SOLN A-INJ naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml) NARCAN 4 MG/0.1ML LIQUID PAGE 20 LAST UPDATED 09/01/2017

23 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS SMOKING CESSATION AGENTS bupropion hcl (smoking deterrent) tab sr 12hr 150 mg MDS 2 per day 180 / 365 DAYS CHANTIX (0.5 MG TAB, 1 MG TAB) MDS 2 per day 180 / 365 DAYS CHANTIX CONTINUING MONTH PAK 1 MG TAB MDS 2 per day 180 / 365 DAYS CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 MG X 42 TAB MFL MDS 2 / 365 days 180 / 365 DAYS NICOTROL 10 MG INHER MDS 504 / 30 days 180 / 365 DAYS NICOTROL NS 10 MG/ML SOLUTION MDS 120 / 30 days 180 ML / 365 DAYS 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 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) (base equiv)) PA TOBREX 0.3 % OINTMENT 4 / claim PAGE 21 LAST UPDATED 09/01/2017

24 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIBACTERIS, OTHER *methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg*** BACTROBAN NAS 2 % OINTMENT clindamycin hcl (cap 150 mg, cap 300 mg) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 300 / claim clindamycin phosphate (topical) (gel, lotion, soln) MPL 1 / claim clindamycin phosphate vaginal cream 2% MPL 1 / claim 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) metronidazole cream 0.75 % 45 / claim metronidazole gel 0.75 % 45 / claim metronidazole lotion 0.75% metronidazole vaginal gel 0.75% 45 / claim mupirocin calcium cream 2% MPL 1 / claim mupirocin oint 2% C nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) Pkg Size 22: Package Limit=1/claim; Pkg Size.9: Package Limit=72/30 days nitrofurantoin monohydrate macrocrystalline cap 100 mg nitrofurantoin susp 25 mg/5ml 40 per day SIVEXTRO 200 MG TAB PA 6 / claim trimethoprim tab 100 mg vancomycin hcl cap 125 mg 4 per day PAGE 22 LAST UPDATED 09/01/2017

25 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS vancomycin hcl cap 250 mg 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 (tab 250 mg, tab 500 mg) 20 / claim cefprozil for susp 125 mg/5ml MPL Up to 12 yrs old 2 / claim cefprozil for susp 250 mg/5ml MPL Up to 12 yrs old 1 / claim 100 / claim(s) CEFTIN 125 MG/5ML RECON SUSP ST Up to 12 yrs old 100 / claim CEFTIN 250 MG/5ML RECON SUSP ST Up to 12 yrs old ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg) MFL 3 / claim 1 / 30 days cefuroxime axetil (tab 250 mg, tab 500 mg) 20 / claim cephalexin (cap 250 mg, cap 500 mg, for susp 125 mg/5ml, for susp 250 mg/5ml) PAGE 23 LAST UPDATED 09/01/2017

26 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS BETA-LACTAM, PENICILLINS amoxicillin & k clavulanate for susp mg/5ml C Pkg Size 50: Package Limit=1/claim; Pkg Size 75: Package Limit=2/claim; Pkg Size 100: Package Limit=2/claim amoxicillin & k clavulanate for susp mg/5ml MPL 2 / claim amoxicillin & k clavulanate tab mg 30 / claim amoxicillin & k clavulanate tab sr 12hr mg 40 / 30 days 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) AMPICILLIN (125 MG/5ML RECON SUSP, 250 MG/5ML RECON SUSP) ampicillin (cap 250 mg, cap 500 mg) 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) 20 / claim MPL 1 / claim MACROLIDES azithromycin for susp 100 mg/5ml 15 / claim azithromycin for susp 200 mg/5ml C Pkg Size 15: Package Limit=1/claim; Pkg Size 30: Package Limit=2/claim; Pkg Size 22.5: Package Limit=2/claim azithromycin powd pack for susp 1 gm 2 / claim azithromycin tab 250 mg 6 / claim azithromycin tab 500 mg 4 per day PAGE 24 LAST UPDATED 09/01/2017

27 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS 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 C Pkg Size 50: Package Limit=1/claim; Pkg Size 100: Package Limit=2/claim clarithromycin tab sr 24hr 500 mg 14 / claim E.E.S MG TAB ERY-TAB (250 MG TAB DR, 333 MG TAB DR, 500 MG TAB DR) ERYPED MG/5ML RECON SUSP 4 per day ERYTHROCIN STEARATE 250 MG TAB ERYTHROMYCIN BASE 500 MG TAB ERYTHROMYCIN ETHYLSUCCINATE 400 MG TAB erythromycin ethylsuccinate for susp 200 mg/5ml erythromycin gel 2% MPL 1 / claim erythromycin ophth oint 5 mg/gm 4 / claim erythromycin soln 2% erythromycin w/ delayed release particles cap 250 mg PCE (333 MG TAB DR, 500 MG TAB DR) QUINOLONES CILOXAN 0.3 % OINTMENT 4 / claim ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg) ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 100 mg (base equiv) 6 / claim levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg) 14 / claim 1 per day PAGE 25 LAST UPDATED 09/01/2017

28 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg) 56 / claim ofloxacin ophth soln 0.3% MPL 1 / claim ofloxacin otic soln 0.3% MPL 1 / claim VIGAMOX 0.5 % SOLUTION 3 / claim SULFONAMIDES silver sulfadiazine cream 1% MPL 1 / claim sulfacetamide sodium ophth oint 10% 4 / claim sulfacetamide sodium ophth soln 10% MPL 15 / claim 1 / 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) ANTICONVULSANTS ANTICONVULSANTS, OTHER levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg) 4 per day levetiracetam oral soln 100 mg/ml 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 At least 2 yrs old PAGE 26 LAST UPDATED 09/01/2017

29 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS 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 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) 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) valproate sodium (inj 100 mg/ml, oral soln 250 mg/5ml (base equiv), syrup 250 mg/5ml (base equiv)) valproic acid cap 250 mg 4 per day 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) 3 per day topiramate sprinkle cap 15 mg 6 per day topiramate sprinkle cap 25 mg 8 per day SODIUM CHANNEL AGENTS carbamazepine (cap sr 12hr 100 mg, cap sr 12hr 200 mg, cap sr 12hr 300 mg, chew tab 100 mg, susp 100 mg/5ml, tab 200 mg, tab sr 12hr 100 mg, tab sr 12hr 200 mg, tab sr 12hr 400 mg) DILANTIN 30 MG CAP fosphenytoin sodium (inj 100 mg/2ml, inj 500 mg/10ml) oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg, tab 300 mg, tab 600 mg) PAGE 27 LAST UPDATED 09/01/2017

30 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS phenytoin (chew tab 50 mg, susp 125 mg/5ml) phenytoin sodium extended (cap 100 mg, cap 200 mg, cap 300 mg) ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates tab 1 mg CHOLINESTERASE INHIBITORS donepezil hydrochloride (tab 5 mg, tab 10 mg) 1 per day 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) 1 per day galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg) 2 per day galantamine hydrobromide oral soln 4 mg/ml 6 per day rivastigmine (patch 24hr 4.6 mg/24hr, patch 24hr 9.5 mg/24hr) PA 1 per day rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg, cap 6 mg) PA 2 per day N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl (tab 5 mg, tab 10 mg) 2 per day memantine hcl tab 5 mg (28) & 10 mg (21) titration pak MPL 1 / 28 days ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg) 1 per day bupropion hcl (tab 75 mg, tab 100 mg) 3 per day bupropion hcl (tab er 200 mg, tab sr 200 mg) 2 per day bupropion hcl er (sr) tab er 12h 100 mg 2 per day PAGE 28 LAST UPDATED 09/01/2017

31 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS bupropion hcl er (sr) tab er 12h 150 mg 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) perphenazine-amitriptyline tab 4-50 mg 1 per day 4 per day MONOAMINE OXIDASE INHIBITORS phenelzine sulfate tab 15 mg tranylcypromine sulfate tab 10 mg SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR ST BRINTELLIX (5 MG TAB, 10 MG TAB, 20 MG TAB) At least 18 yrs old 1 per day citalopram hydrobromide (tab 10 mg, tab 20 mg, tab 40 mg) citalopram hydrobromide oral soln 10 mg/5ml 1.5 per day escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg) 1 per day fluoxetine hcl (cap 10 mg, cap 20 mg) 4 per day fluoxetine hcl cap 40 mg At least 7 yrs old 2 per day fluoxetine hcl solution 20 mg/5ml Up to 6 yrs old 4 Per Day fluoxetine hcl tab 10 mg At least 7 yrs old 4 per day fluvoxamine maleate (tab 25 mg, tab 50 mg) 2 per day fluvoxamine maleate tab 100 mg 3 per day maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg) PAGE 29 LAST UPDATED 09/01/2017

32 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS 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) MFL 2 per day 1 / 30 days paroxetine hcl oral susp 10 mg/5ml (base equiv) MFL 40 per day 1 / 30 days sertraline hcl (tab 25 mg, tab 50 mg) MFL 1.5 per day 1 / 30 days sertraline hcl oral conc 20 mg/ml MFL 10 per day 1 / 30 days sertraline hcl tab 100 mg MFL 2 per day 1 / 30 days trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg) trazodone hcl tab 300 mg 2 per day venlafaxine hcl (cap 24hr 150 mg, cap 24hr 37.5 mg, cap 24hr 75 mg, tab 24hr 37.5 mg, tab 24hr 75 mg) venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg) 1 per day VENLAFAXINE HCL ER 225 MG TAB ER 24H 1 per day venlafaxine hcl tab sr 24hr 150 mg (base equivalent) 2 per day VIIBRYD (10 MG TAB, 20 MG TAB, 40 MG TAB) PA 1 per day VIIBRYD 10 & 20 & 40 MG KIT PA TRICYCLICS 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 50 mg, cap 75 mg) PAGE 30 LAST UPDATED 09/01/2017

33 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS desipramine hcl (tab 10 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) desipramine hcl tab 25 mg 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 20 per day ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl (tab 12.5 mg, tab 25 mg) metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5 mg, tab 10 mg) perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg) 4 per day prochlorperazine maleate (tab 5 mg, tab 10 mg) prochlorperazine suppos 25 mg EMETOGENIC THERAPY ADJUNCTS ondansetron hcl (tab 4 mg, tab 8 mg) MDS 2 per day 90 / 365 DAYS ondansetron hcl oral soln 4 mg/5ml 50 / claim(s) ondansetron orally disintegrating tab 4 mg MDS 2 per day 90 / 365 DAYS ondansetron orally disintegrating tab 8 mg MDS 2 per day 90 / 365 DAYS ondansetron orally disintegrating tab 8 mg MDS 2 per day 90 / 365 DAYS PAGE 31 LAST UPDATED 09/01/2017

34 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIFUNGS clotrimazole cream 1% MPL 1 / claim(s) clotrimazole soln 1% MPL 1 / claim econazole nitrate cream 1% 30 / claim fluconazole (susp 10 mg/ml, susp 40 mg/ml) 70 / claim fluconazole tab 100 mg 1 per day fluconazole tab 150 mg 2 / claim fluconazole tab 200 mg 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) GYNAZOLE-1 2 % CREAM itraconazole cap 100 mg PA 1 per day ketoconazole cream 2% MPL 1 / claim ketoconazole shampoo 2% 120 / claim MICONAZOLE MG SUPPOS 3 / claim nystatin (topical) (*nystatin powder**, nystatin powder unit/gm) nystatin (topical) (cream unit/gm, oint unit/gm) MPL 1 / claim nystatin susp unit/ml 120 / claim nystatin tab unit 6 per day nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%) MPL 1 / claim terbinafine hcl tab 250 mg 90 / 120 days 1 per day PAGE 32 LAST UPDATED 09/01/2017

35 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80 mg) ANTIGOUT AGENTS allopurinol (tab 100 mg, tab 300 mg) colchicine tab 0.6 mg MFL 6 / claim(s) 1 / 30 days colchicine w/ probenecid tab mg probenecid tab 500 mg ANTIMIGRAINE AGENTS ERGOT KOIDS dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4 mg/ml) ergotamine w/ caffeine tab mg SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS naratriptan hcl (tab 1 mg, tab 2.5 mg) 9 / 30 days At least 18 yrs old RELPAX (20 MG TAB, 40 MG TAB) 6 / 30 days 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 autoinjector 6 mg/0.5ml, solution cartridge 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 6 MG/0.5ML SOLN PRSYR 2 / 30 days At least 12 yrs old PAGE 33 LAST UPDATED 09/01/2017

36 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS zolmitriptan (tab 2.5 mg, tab 5 mg) 6 / 30 days zolmitriptan (tab 2.5 mg, tab 5 mg) 6 / 30 days At least 12 yrs old ZOMIG 5 MG SOLUTION 6 / 30 days At least 12 yrs old 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 pyrazinamide tab 500 mg rifampin (cap 150 mg, cap 300 mg) TRECATOR 250 MG TAB ANTINEOPLASTICS KYLATING AGENTS KERAN 2 MG TAB cyclophosphamide (tab 25 mg, tab 50 mg) LEUKERAN 2 MG TAB MYLERAN 2 MG TAB temozolomide (cap 180 mg, cap 250 mg) 2 per day PAGE 34 LAST UPDATED 09/01/2017

37 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIANDROGENS bicalutamide tab 50 mg 1 per day flutamide cap 125 mg ANTIESTROGENS/MODIFIERS FARESTON 60 MG TAB 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 HEMANGEOL 4.28 MG/ML SOLUTION PA leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25 mg) AROMATASE INHIBITORS, 3RD GENERATION anastrozole tab 1 mg exemestane tab 25 mg ST letrozole tab 2.5 mg ST MOLECULAR TARGET INHIBITORS COTELLIC 20 MG TAB PA NINLARO (2.3 MG CAP, 3 MG CAP, 4 MG CAP) PA ANTIPARASITICS ANTIHELMINTHICS mebendazole chew tab 100 mg MDS 1 / 14 DAY(S) PAGE 35 LAST UPDATED 09/01/2017

38 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIPROTOZOS chloroquine phosphate tab 250 mg 60 / 30 days chloroquine phosphate tab 500 mg 8 / 56 days COARTEM MG TAB 24 / claim hydroxychloroquine sulfate tab 200 mg mefloquine hcl tab 250 mg primaquine phosphate tab 26.3 mg (15 mg base) PEDICULICIDES/SCABICIDES EURAX 10 % CREAM 60 / claim EURAX 10 % LOTION MPL 1 / claim malathion lotion 0.5% MFL 59 / claim 2 / 30 days 120 / claim NATROBA 0.9 % SUSPENSION At least 1 yrs old MFL 2 / 30 days permethrin cream 5% MPL 1 / claim 120 / claim SPINOSAD 0.9 % SUSPENSION At least 1 yrs old MFL 2 / 30 days ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg) trihexyphenidyl hcl (tab 2 mg, tab 5 mg) trihexyphenidyl hcl elixir 0.4 mg/ml 500 / 31 days PAGE 36 LAST UPDATED 09/01/2017

39 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIPARKINSON AGENTS, OTHER amantadine hcl (cap 100 mg, syrup 50 mg/5ml) 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) At least 18 yrs old 3 per day ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg) 6 per day ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg, tab 5 mg) 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) ANTIPSYCHOTICS 1ST GENERATION/TYPIC chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml) 12 per day chlorpromazine hcl (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) 3 per day chlorpromazine hcl tab 10 mg 10 per day fluphenazine decanoate inj 25 mg/ml fluphenazine hcl (tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg) haloperidol (tab 0.5 mg, tab 1 mg, tab 10 mg) 3 per day haloperidol (tab 2 mg, tab 5 mg, tab 20 mg) haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml) PAGE 37 LAST UPDATED 09/01/2017

40 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS haloperidol lactate inj 5 mg/ml 6 per day haloperidol lactate oral conc 2 mg/ml loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap 50 mg) MOLINDONE HCL (5 MG TAB, 10 MG TAB, 25 MG TAB) thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg) 4 per day 3 per day thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg) 3 per day trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg) 3 per day 2ND GENERATION/ATYPIC aripiprazole (orally disintegrating tab 10 mg, orally disintegrating tab 15 mg, tab 2 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) PA At least 6 yrs old 1 per day 750 / 30 days aripiprazole oral solution 1 mg/ml PA At least 6 yrs old NUPLAZID 17 MG TAB PA 2 Per Day olanzapine (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg, tab 20 mg) At least 13 yrs old 1 per day At least 13 yrs old olanzapine tab 2.5 mg 1 per day MFL 1 / 30 days quetiapine fumarate (tab 100 mg, tab 200 mg, tab 300 mg, tab 400 mg) At least 10 yrs old 2 per day At least 10 yrs old quetiapine fumarate (tab 25 mg, tab 50 mg) C 2 per day From age 18 through 64: Max Fills=1/year PAGE 38 LAST UPDATED 09/01/2017

41 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg) At least 5 yrs old 2 per day risperidone odt (tab 3 mg, tab 4 mg) At least 5 yrs old 2 per day risperidone orally disintegrating tab 0.25 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 0.5 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 1 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 2 mg At least 5 yrs old 2 per day risperidone soln 1 mg/ml At least 5 yrs old 4 per day ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80 mg) At least 18 yrs old 2 per day TREATMENT-RESISTANT clozapine (tab 50 mg, tab 200 mg) At least 18 yrs old 3 per day clozapine tab 100 mg At least 18 yrs old 9 per day clozapine tab 25 mg At least 18 yrs old 3 Per Day 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)) PAGE 39 LAST UPDATED 09/01/2017

42 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS ANTIVIRS ANTI-CYTOMEGOVIRUS (CMV) AGENTS valganciclovir hcl tab 450 mg (base equivalent) 2 per day ANTI-HEPATITIS C (HCV) AGENTS EPCLUSA MG TAB PA 1 Per Day ZEPATIER MG TAB PA 1 per day ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) GENVOYA MG TAB 1 per day ISENTRESS (100 MG PACKET, 400 MG TAB) 2 per day ISENTRESS 100 MG CHEW TAB 6 per day ISENTRESS 25 MG CHEW TAB 12 per day STRIBILD MG TAB 1 per day TIVICAY 50 MG TAB ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA MG TAB 1 per day COMPLERA MG TAB 1 per day EDURANT 25 MG TAB 1 per day INTELENCE (25 MG TAB, 100 MG TAB) 4 per day INTELENCE 200 MG TAB 2 per day nevirapine susp 50 mg/5ml 40 per day nevirapine tab 200 mg 2 per day nevirapine tab sr 24hr 100 mg 3 Per Day PAGE 40 LAST UPDATED 09/01/2017

43 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS nevirapine tab sr 24hr 400 mg 1 per day ODEFSEY MG TAB 1 per day RESCRIPTOR 100 MG TAB 12 per day RESCRIPTOR 200 MG TAB 6 per day SUSTIVA (200 MG CAP, 600 MG TAB) 1 per day SUSTIVA 50 MG CAP 2 per day ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate tab 300 mg (base equiv) 2 per day abacavir sulfate-lamivudine tab mg 1 Per Day abacavir sulfate-lamivudine-zidovudine tab mg 2 per day DESCOVY MG TAB 1 per day didanosine (capsule 125 mg, capsule 200 mg, capsule 250 mg, capsule 400 mg) 1 per day EMTRIVA 10 MG/ML SOLUTION 24 per day EMTRIVA 200 MG CAP 1 per day lamivudine oral soln 10 mg/ml 30 per day lamivudine tab 150 mg 2 per day lamivudine tab 300 mg 1 per day lamivudine-zidovudine tab mg 2 per day stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg) 2 per day stavudine for oral soln 1 mg/ml 80 per day TRUVADA MG TAB 1 per day VIDEX (2 GM RECON SOLN, 4 GM RECON SOLN) 20 per day VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB, 300 MG TAB) 1 per day PAGE 41 LAST UPDATED 09/01/2017

44 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS VIREAD 40 MG/GM POWDER 240 / 30 days ZIAGEN 20 MG/ML SOLUTION 30 per day zidovudine cap 100 mg 6 per day zidovudine syrup 10 mg/ml 60 per day zidovudine tab 300 mg 2 per day ANTI-HIV AGENTS, OTHER PREZCOBIX MG TAB 1 Per Day SELZENTRY 150 MG TAB 2 per day SELZENTRY 300 MG TAB 4 per day TRIUMEQ MG TAB TYBOST 150 MG TAB At least 18 yrs old 1 per day ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS 100 MG/ML SOLUTION 10 per day APTIVUS 250 MG CAP 4 per day CRIXIVAN 200 MG CAP 9 per day CRIXIVAN 400 MG CAP 6 per day EVOTAZ MG TAB 1 per day INVIRASE 200 MG CAP 10 per day INVIRASE 500 MG TAB 4 per day KETRA MG TAB 4 per day KETRA MG TAB 6 per day LEXIVA 50 MG/ML SUSPENSION 56 per day LEXIVA 700 MG TAB 4 per day PAGE 42 LAST UPDATED 09/01/2017

45 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) NORVIR (100 MG CAP, 100 MG TAB) 12 per day NORVIR 80 MG/ML SOLUTION 15 per day PREZISTA (75 MG TAB, 600 MG TAB) 2 per day PREZISTA 100 MG/ML SUSPENSION 12 per day PREZISTA 150 MG TAB 3 per day PREZISTA 800 MG TAB 1 per day REYATAZ (150 MG CAP, 200 MG CAP, 300 MG CAP) 2 per day REYATAZ 50 MG PACKET 6 per day VIRACEPT 250 MG TAB 9 per day VIRACEPT 625 MG TAB 4 per day ANTI-INFLUENZA AGENTS oseltamivir phosphate (cap 45 mg, cap 75 mg) MFL 10 / 30 day(s) 1 / 180 days oseltamivir phosphate cap 30 mg (base equiv) MFL 20 / 30 day(s) 1 / 180 days RELENZA DISKHER 5 MG/BLISTER AER POW BA MPL At least 5 yrs old 1 / 30 days TAMIFLU 6 MG/ML RECON SUSP MFL 120 / 30 days 1 / 180 days ANTIHERPETIC AGENTS acyclovir (cap 200 mg, tab 800 mg) 50 / 30 days acyclovir oint 5% 30 / 30 days acyclovir susp 200 mg/5ml 400 / 30 days acyclovir tab 400 mg 3 per day PAGE 43 LAST UPDATED 09/01/2017

46 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS trifluridine ophth soln 1% 8 / claim valacyclovir hcl tab 1 gm 21 / 21 Days valacyclovir hcl tab 500 mg 60 / 30 days ZOVIRAX 5 % CREAM MPL 1 / claim ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30 mg) meprobamate (tab 200 mg, tab 400 mg) midazolam hcl (inj 2 mg/2ml, inj 5 mg/5ml, inj 5 mg/ml, inj 10 mg/10ml, inj 10 mg/2ml, inj 25 mg/5ml, inj 50 mg/10ml) 3 per day BENZODIAZEPINES alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg) 4 per day chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg) 4 per day clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg) 4 per day clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15 mg) 3 per day diazepam (tab 2 mg, tab 5 mg, tab 10 mg) 4 per day diazepam oral soln 1 mg/ml 500 / claim(s) lorazepam (inj 2 mg/ml, tab 0.5 mg, tab 2 mg) 3 per day lorazepam tab 1 mg 4 per day oxazepam (cap 10 mg, cap 15 mg, cap 30 mg) 4 per day BIPOLAR AGENTS MOOD STABILIZERS lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg, tab 300 mg, tab cr 300 mg, tab cr 450 mg) PAGE 44 LAST UPDATED 09/01/2017

47 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS OGLIPTIN BENZOATE (6.25 MG TAB, 12.5 MG TAB, 25 MG TAB) PA 1 Per Day OGLIPTIN-METFORMIN HCL ( MG TAB, MG TAB) PA 1 Per Day OGLIPTIN-PIOGLITAZONE ( MG TAB, MG TAB, MG TAB, MG TAB, MG TAB, MG TAB) PA 1 Per Day AVANDAMET ( MG TAB, MG TAB, MG TAB, MG TAB) AVANDARYL (4-1 MG TAB, 4-2 MG TAB, 4-4 MG TAB, 8-2 MG TAB, 8-4 MG TAB) 2 per day 1 per day AVANDIA (2 MG TAB, 4 MG TAB, 8 MG TAB) 1 per day BYDUREON (2 MG PEN, 2 MG RECON SUSP, 2 MG SRER) PA 4 / 28 days At least 18 yrs old 2.4 / 30 days BYETTA 10 MCG PEN 10 MCG/0.04ML SOLN PEN PA At least 18 yrs old 1.2 / 30 days BYETTA 5 MCG PEN 5 MCG/0.02ML SOLN PEN PA At least 18 yrs old glimepiride (tab 1 mg, tab 2 mg) 1 per day glimepiride tab 4 mg 2 per day glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 10 mg, tab sr 24hr 2.5 mg, tab sr 24hr 5 mg) glipizide-metformin hcl (tab mg, tab mg, tab mg) PAGE 45 LAST UPDATED 09/01/2017

48 PRODUCT DESCRIPTION /GEN LIMITS & RESTRICTIONS glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg) glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg) glyburide-metformin (tab mg, tab mg, tab mg) JARDIANCE (10 MG TAB, 25 MG TAB) PA 1 Per Day JENTADUETO ( MG TAB, MG TAB, MG TAB) PA At least 8 yrs old 2 per day metformin hcl (tab 1000 mg, tab er 24hr 750 mg, tab sr 24hr 750 mg) 2 per day metformin hcl (tab er 24hr 500 mg, tab sr 24hr 500 mg) 4 per day metformin hcl tab 500 mg 5 per day metformin hcl tab 850 mg 3 per day nateglinide (tab 60 mg, tab 120 mg) 3 per day pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg) 1 per day pioglitazone hcl-metformin hcl (-metformin tab mg, - metformin tab mg) 2 per day SYMLINPEN MCG/2.7ML SOLN PEN PA 10.8 / 30 days SYMLINPEN MCG/1.5ML SOLN PEN PA 6 / 30 days PA TRADJENTA 5 MG TAB At least 8 yrs old 1 per day VICTOZA 18 MG/3ML SOLN PEN PA 0.3 Per Day PAGE 46 LAST UPDATED 09/01/2017