Harbor Health Plan Formulary

Transcription

1 2018 Harbor Health Plan Formulary Version 13; Effective: 7/1/2018

2 Introduction... 5 The SentinelRx Pharmacy and Therapeutics Committee (P&T)... 5 Notice... 5 Preface... 5 Product Selection Criteria... 5 Formulary Components... 5 Generic Substitution... 5 Covered Medications without Authorization... 5 Non-Covered Benefits... 6 Prior Authorization... 6 Step Therapy... 6 Specialty Medications... 6 Quantity Limits... 6 Benefit Exception... 6 Pharmacy Benefit Management... 6 Step Therapy Information... 7 Prior Authorization Information Acne Therapy Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Analgesics - Narcotic Androgen-Anabolic Angina Therapy Anorectal - Glucocorticoids Anterior Pituitary Hormones and Hormone Antagonists Antianxiety Agents Antiarrhythmics Antibacterial Agents Anticoagulants Antidepressants Antidiarrheals Antiemetics Antifungals Antihistamines Antihyperlipidemics Antihypertensive Therapy Agents Antineoplastic - Alkylating Agents Antineoplastic - Antimetabolites Antineoplastic - Hedgehog Pathway Inhibitor Antineoplastic - Hormone/Hormone Antagonist Agents Antineoplastic - Immunomodulators Antineoplastic - Retinoids and Retinoid Receptor Agonists Antineoplastic - Systemic Enzyme Inhibitors Antineoplastic - Topoisomerase Inhibitors Antiparasitics Antiparkinson Therapy Antiprotozoal-Antibacterial Agents Antipsychotics (Neuroleptics) Antivirals Appetite Stimulants Asthma/COPD Therapy Agents Beta Adrenergic Blockers Calcium and Bone Metabolism Regulators Calcium Channel Blockers and Combinations Cardiac Inotropes Cardiovascular Sympathomimetics and Combinations Chelating Agents Chemotherapy Rescue-Antidote Agents CNS Stimulants Cognitive Disorder Therapy - Antidementia Colonic Acidifier (Ammonia Inhibitor) Contraceptives Injectable Contraceptives Intravaginal Contraceptives Oral Contraceptives Transdermal Corticosteroids Cystic Fibrosis Therapy Agents

3 Dental-Periodontal Products Dermatological - Anti-infectives Dermatological - Antineoplastic or Premalignant Lesions Dermatological - Antiparasitics and Combinations Dermatological - Antiperspirants and Deodorants Dermatological - Antipsoriatics Dermatological - Antiseborrheic Products and Combinations Dermatological - Burn Products Dermatological - Emollients and Combinations Dermatological - Enzymes and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Immunomodulating Agents Dermatological - Immunosuppressive Agents Dermatological - Keratolytics-Antimitotics Dermatological - NSAID s Dermatological - Rosacea Therapy Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy Digestive Aids Diuretics Electrolyte Depleters - Ion Exchange Resin Emergency Contraceptives and Combinations Estrogens and Combinations Gallstone Solubilizing (Litholysis) Agents and Combinations Gastrointestinal Antispasmodics Gastrointestinal Prokinetic Agents General Anesthetics Gout - Acute Therapy Gout and Hyperuricemia Combination Drugs Hematopoietic Agents Hematorheologic Agents Hepatic Hormones (Hormones Secreted by the Liver) Hyperuricemia Therapy Immunosuppressive - Calcineurin Inhibitors Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors Immunosuppressive - Mammalian Target of Rapamycin (mtor) Inhibitors Immunosuppressive - Purine Analogs Inflammatory Bowel Agents Interstitial Cystitis Agents Laxatives Medical Supplies and DME - Contraceptives Medical Supplies and DME - Diabetic Supplies Medical Supplies and DME - Respiratory Therapy Migraine Therapy Minerals and Electrolytes Misc Anti-Infectives and Combinations Mouth and Throat - Anti-infectives Mouth and Throat - Glucocorticoids Mouth and Throat - Local Anesthetics Mouth and Throat - Xerostomia Therapy Mucolytics Multiple Sclerosis Agent - Interferons Multiple Sclerosis Agent - Others Multiple Sclerosis Agent - Potassium Channel Blocker Multiple Sclerosis Agent - Sphingosine 1-phosphate receptor modulator Musculoskeletal Therapy Agents Nasal Preparations Neuromuscular Therapy Agents Ophthalmic - Anti-allergy Ophthalmic - Anti-infectives Ophthalmic - Anti-inflammatory Ophthalmic - Decongestants and Combinations Ophthalmic - Intraocular Pressure Reducing Agents Ophthalmic - Local Anesthetics and Combinations Ophthalmic - Mydriatics and Cycloplegics Ophthalmic Combinations Opiate/Narcotic Reversal Agents - Opiate Antagonists

4 Otic - Anti-infectives Otic - Glucocorticoids Otic Combinations Oxytocics Passive Immunizing Agents Peptic Ulcer Therapy Pharmaceutical Adjuvants Phosphate Binders Platelet Aggregation Inhibitors and Combinations Posterior Pituitary Hormones Progestins Prolactin Inhibitors Prostatic Hypertrophy Agents Sickle Cell Anemia Agents Smoking Deterrents and Combinations Thyroid Therapy Urinary Analgesics Urinary Anti-infectives Urinary Antispasmodics Urinary ph Modifiers Urinary Retention Therapy Vaccines Vaginal Anti-infectives Vaginal Estrogens Vitamin Combinations Vitamins Acne Therapy Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Antacids and Combinations Antidiarrheals Antiemetics Antihistamines Antihyperlipidemics Antiparasitics Artificial Tears and Lubricants Bulk Chemicals Contraceptives Intravaginal Dental-Periodontal Products Dermatological - Anti-infectives Dermatological - Antiparasitics and Combinations Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Irritants-Counter-Irritants Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy Dietary Products Emergency Contraceptives and Combinations Gastrointestinal Antiflatulents and Combinations Laxatives Medical Supplies and DME - Contraceptives Medical Supplies and DME - Diabetic Supplies Medical Supplies and DME - Respiratory Therapy Medical Supply, FDB Superset Minerals and Electrolytes Nasal Preparations Ophthalmic - Anti-allergy Ophthalmic - Decongestants and Combinations Ophthalmic - Hyperosmolar Agents Peptic Ulcer Therapy Sedative-Hypnotics Smoking Deterrents and Combinations Urinary Antispasmodics Urinary ph Modifiers Vaginal Anti-infectives Vitamin Combinations Vitamins

5 Introduction Harbor Health Plan is pleased to provide an updated 2018 Medicaid Formulary as a reference and informational tool for physicians, pharmacists and patients. The Harbor Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The SentinelRx Pharmacy and Therapeutics Committee (P&T) The medications on this formulary have been reviewed by the SentinelRx P&T Committee. The Committee includes physicians, pharmacists and health professionals. The clinical information within the formulary is primarily derived from medical literature and is reviewed and approved by the P&T Committee. Notice The information contained in this formulary is provided by Harbor, solely for the convenience of medical providers. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. Harbor Health Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. Preface The Harbor formulary is organized by sections. Each section includes therapeutic groups identified by either drug class or disease state. Products are listed by generic name. Brand and common names are included as a reference to assist in product recognition. Harbor will not cover prescription drugs that are prescribed for experimental, investigational or non FDA approved indications, dosages, or routes of administration. Harbor does not cover any medication excluded by Michigan Medicaid. Product Selection Criteria The SentinelRx P&T Committee considers clinical information on new to market drugs that are typically included in an outpatient pharmacy benefit. The primary goal of the SentinelRx P&T Committee is to preserve and evaluate the Harbor formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently included in the Harbor Formulary. Formulary decisions are communicated quarterly on the Harbor Health Plan website. Formulary Components The Harbor Formulary contains the following components: Covered medications without authorization, medications that must meet Step Therapy Protocol, medications that require Prior Authorization, Specialty medications and medications that are subject to Quantity Limits. Members will not be charged a co-pay when Harbor covers a medication. Generic Substitution Harbor is a mandatory generic plan. The brand and common names listed in the formulary are for reference only. Generic medication will be dispensed where available. Covered Medications without Authorization Harbor covers many medications without any authorization required. These medications include many prescription and over-the-counter medications(when ordered by a physician). 5

6 Non-Covered Benefits The following categories are not covered benefits: Medications used for cosmetic purposes, to promote fertility, for sexual dysfunction, for experimental or investigational purposes, or medications that are not licensed for use in the United States. Prior Authorization Drugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria are listed next to the drug name. Please call the SentinelRx Help Desk at or fax a completed Prior Authorization form to Non-Urgent requests are reviewed within 14 days. Urgent requests must be accompanied by pertinent clinical information and are reviewed within 72 hours. Step Therapy Drugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next to the drug name. Specialty Medications All specialty medications noted as "SP" are handled by SentinelRx. To order a specialty medication by fax, send the prescription and a completed prior authorization form to or call SentinelRx s Help Desk at Quantity Limits Drugs indicated with a "" have a set quantity limit imposed. These limits are based on FDA recommended dosing guidelines. The quantity limit is listed next to the drug name. All medications are subject to a maximum of 30 days per prescription. Benefit Exception The process for requesting non formulary medication(s) requires faxing of a completed Formulary Exception form indicating the request for an exception to the formulary. This request will need to include pertinent clinical documentation showing trial and failure of all formulary agents. It should also contain information showing the medication is the standard of care for the indication provided (Peer reviewed journal articles may be required). Please call the SentinelRx Help Desk at or fax a completed Formulary Exception form to Pharmacy Benefit Management Harbor Health Plan utilizes SentinelRx to manage each member s pharmacy benefit. SentinelRx provides Harbor with a pharmacy network, pharmacy claims management services, and claims adjudication. SentinelRx s Help Desk can be contacted at

7 Step Therapy Information Angina Therapy NITROGLYCERIN LINGUAL 0.4 MG NITROGLYCERIN ST Requires trial and failure of Nitroglycerin sublingual tablets;must show trial and failure of Nitroglycerin tablets Antiemetics GRANISETRON HCL 1 MG TABLET GRANISETRON HCL,ST Requires trial and failure of one of the following step 1 agents, Ondansetron HCL or Ondansetron ODT, within the last 180 days. Dermatological - Antiparasitics and Combinations MALATHION 0.5% LOTION MALATHION,ST Requires trial and failure of OTC Permethrin 1% products within the last 180 days. Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors MYCOPHENOLIC ACID DR 180 MG TB MYCOPHENOLIC ACID ST Requires trial and failure Mycophenolate within the last 180 days. MYCOPHENOLIC ACID DR 360 MG TB MYCOPHENOLIC ACID ST Requires trial and failure Mycophenolate within the last 180 days. Inflammatory Bowel Agents APRISO ER GRAM CAPSULE APRISO ST Requires trial and failure of one of the following step 1 agents, Balsalazide Disodium or Sulfasalazine, within the last 180 days. DELZICOL DR 400 MG CAPSULE DELZICOL ST Requires trial and failure of one of the following step 1 agents, Balsalazide Disodium or Sulfasalazine, within the last 180 days. MESALAMINE 800 MG DR TABLET MESALAMINE,ST Requires trial and failure of one of the following step 2 agents, Apriso and Delzicol, within the last 180 days. PENTASA 250 MG CAPSULE PENTASA,ST Requires trial and failure of one of the following step 2 agents, Apriso and Delzicol, within the last 180 days. PENTASA 500 MG CAPSULE PENTASA,ST Requires trial and failure of one of the following step 2 agents, Apriso and Delzicol, within the last 180 days. Migraine Therapy ZOLMITRIPTAN 2.5 MG ODT ZOLMITRIPTAN ODT,ST Requires trial and failure of two of the following step 1 agents, Naratriptan, Rizatriptan, or Sumatriptan, within the last 180 days. 7

8 Step Therapy Information Migraine Therapy ZOLMITRIPTAN 2.5 MG TABLET ZOLMITRIPTAN,ST Requires trial and failure of OTC Permethrin 1% products within the last 180 days.;requires trial and failure of two of the following step 1 agents, Naratriptan, Rizatriptan, or Sumatriptan, within the last 180 days. ZOLMITRIPTAN 5 MG ODT ZOLMITRIPTAN ODT,ST Requires trial and failure of two of the following step 1 agents, Naratriptan, Rizatriptan, or Sumatriptan, within the last 180 days. ZOLMITRIPTAN 5 MG TABLET ZOLMITRIPTAN,ST Requires trial and failure of two of the following step 1 agents, Naratriptan, Rizatriptan, or Sumatriptan, within the last 180 days. Peptic Ulcer Therapy LANSOPRAZOLE DR 15 MG CAPSULE LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. LANSOPRAZOLE DR 30 MG CAPSULE LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. Urinary Antispasmodics TOLTERODINE TART ER 2 MG CAP TOLTERODINE TARTRATE ER,ST Requires trial and failure of Oxybutynin within the last 180 days. TOLTERODINE TART ER 4 MG CAP TOLTERODINE TARTRATE ER,ST Requires trial and failure of Oxybutynin within the last 180 days. TOLTERODINE TARTRATE 1 MG TAB TOLTERODINE TARTRATE,ST Requires trial and failure of Oxybutynin within the last 180 days. TOLTERODINE TARTRATE 2 MG TAB TOLTERODINE TARTRATE,ST Requires trial and failure of Oxybutynin within the last 180 days. TROSPIUM CHLORIDE 20 MG TABLET TROSPIUM CHLORIDE,ST Requires trial and failure of Oxybutynin within the last 180 days. Peptic Ulcer Therapy CVS LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. EQ LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. HM LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. LANSOPRAZOLE DR 15 MG CAPSULE LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. 8

9 Step Therapy Information Peptic Ulcer Therapy NEXIUM 24HR 20 MG CAPSULE NEXIUM 24HR,ST Trial and Failure of omeprazole; limited to 60 tablets per 30 days.;requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. RA LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. SM LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE,ST Requires trial and failure of two of the following step 1 agents, Omeprazole and Pantoprazole, within the last 180 days. 9

10 Prior Authorization Information ZARXIO 300 MCG/0.5 ML SYRINGE ZARXIO PA,SP Prior Authorization Required ZARXIO 480 MCG/0.8 ML SYRINGE ZARXIO PA,SP Prior Authorization Required Acne Therapy CLARAVIS 10 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLARAVIS 20 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLARAVIS 30 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLARAVIS 40 MG CAPSULE CLARAVIS PA, Prior Authorization Required Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic ENBREL 25 MG KIT ENBREL PA,,SP ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA,,SP ENBREL 50 MG/ML SURECLICK SYR ENBREL SURECLICK PA, ENBREL 50 MG/ML SYRINGE ENBREL PA,,SP HUMIRA 10 MG/0.2 ML SYRINGE HUMIRA PA,,SP OTEZLA 28 DAY STARTER PACK OTEZLA PA,SP Prior Authorization Required OTEZLA 30 MG TABLET OTEZLA PA,SP Prior Authorization Required OTEZLA STARTER PACK OTEZLA PA,SP Prior Authorization Required XATMEP 2.5 MG/ML ORAL SOLUTION XATMEP PA Prior Authorization Required Analgesics - Narcotic FENTANYL 100 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 12 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 25 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 50 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 75 MCG/HR PATCH FENTANYL PA, Prior Authorization Required Angina Therapy RANEXA ER 1,000 MG TABLET RANEXA PA Prior Authorization Required RANEXA ER 500 MG TABLET RANEXA PA Prior Authorization Required Anterior Pituitary Hormones and Hormone Antagonists NORDITROPIN FLEXPRO 10 MG/1.5 NORDITROPIN FLEXPRO PA,SP Prior Authorization Required NORDITROPIN FLEXPRO 15 MG/1.5 NORDITROPIN FLEXPRO PA,SP Prior Authorization Required NORDITROPIN FLEXPRO 30 MG/3 ML NORDITROPIN FLEXPRO PA,SP Prior Authorization Required NORDITROPIN FLEXPRO 5 MG/1.5 NORDITROPIN FLEXPRO PA,SP Prior Authorization Required OCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE ACETATE PA,SP Prior Authorization Required OCTREOTIDE ACET 100 MCG/ML VL OCTREOTIDE ACETATE PA,SP Prior Authorization Required OCTREOTIDE ACET 200 MCG/ML VL OCTREOTIDE ACETATE PA,SP Prior Authorization Required OCTREOTIDE ACET 50 MCG/ML VIAL OCTREOTIDE ACETATE PA,SP Prior Authorization Required 10

11 Prior Authorization Information Antibacterial Agents LINEZOLID 100 MG/5 ML SUSP LINEZOLID PA Prior Authorization Required LINEZOLID 600 MG TABLET LINEZOLID PA Prior Authorization Required THALOMID 100 MG CAPSULE THALOMID PA,SP Prior Authorization Required THALOMID 150 MG CAPSULE THALOMID PA,SP Prior Authorization Required THALOMID 200 MG CAPSULE THALOMID PA,SP Prior Authorization Required THALOMID 50 MG CAPSULE THALOMID PA,SP Prior Authorization Required Anticoagulants ELIQUIS 2.5 MG TABLET ELIQUIS PA Prior Authorization Required ELIQUIS 5 MG TABLET ELIQUIS PA Prior Authorization Required ENOXAPARIN 100 MG/ML SYRINGE ENOXAPARIN SODIUM PA Prior Authorization Required ENOXAPARIN 120 MG/0.8 ML SYR ENOXAPARIN SODIUM PA Prior Authorization Required ENOXAPARIN 150 MG/ML SYRINGE ENOXAPARIN SODIUM PA Prior Authorization Required ENOXAPARIN 30 MG/0.3 ML SYR ENOXAPARIN SODIUM PA Prior Authorization Required ENOXAPARIN 40 MG/0.4 ML SYR ENOXAPARIN SODIUM PA Prior Authorization Required ENOXAPARIN 60 MG/0.6 ML SYR ENOXAPARIN SODIUM PA Prior Authorization Required ENOXAPARIN 80 MG/0.8 ML SYR ENOXAPARIN SODIUM PA Prior Authorization Required XARELTO 10 MG TABLET XARELTO PA, XARELTO 15 MG TABLET XARELTO PA, XARELTO 20 MG TABLET XARELTO PA, Antiemetics DRONABINOL 10 MG CAPSULE DRONABINOL PA Prior Authorization Required DRONABINOL 2.5 MG CAPSULE DRONABINOL PA Prior Authorization Required DRONABINOL 5 MG CAPSULE DRONABINOL PA Prior Authorization Required Antihyperlipidemics EZETIMIBE 10 MG TABLET EZETIMIBE PA, Prior Authorization Required OMEGA-3 ETHYL ESTERS 1 GM CAP OMEGA-3 ACID ETHYL ESTERS PA, Prior Authorization Required Antihypertensive Therapy Agents ADCIRCA 20 MG TABLET ADCIRCA PA,SP, Prior Authorization required;must meet Pharmacy Approval Criteria ADEMPAS 0.5 MG TABLET ADEMPAS PA,,SP ADEMPAS 1 MG TABLET ADEMPAS PA,,SP ADEMPAS 1.5 MG TABLET ADEMPAS PA,,SP ADEMPAS 2 MG TABLET ADEMPAS PA,,SP ADEMPAS 2.5 MG TABLET ADEMPAS PA,,SP ENTRESTO 24 MG-26 MG TABLET ENTRESTO PA, ENTRESTO 49 MG-51 MG TABLET ENTRESTO PA, ENTRESTO 97 MG-103 MG TABLET ENTRESTO PA, LETAIRIS 10 MG TABLET LETAIRIS PA,,SP LETAIRIS 5 MG TABLET LETAIRIS PA,,SP 11

12 Prior Authorization Information Antihypertensive Therapy Agents SILDENAFIL 20 MG TABLET SILDENAFIL PA,SP Prior Authorization Required TEKTURNA 150 MG TABLET TEKTURNA PA, TEKTURNA 300 MG TABLET TEKTURNA PA, TEKTURNA HCT MG TAB TEKTURNA HCT PA, TEKTURNA HCT MG TABLET TEKTURNA HCT PA, TEKTURNA HCT MG TAB TEKTURNA HCT PA, TEKTURNA HCT MG TABLET TEKTURNA HCT PA, TRACLEER 125 MG TABLET TRACLEER PA,,SP TRACLEER 32 MG TABLET FOR SUSP TRACLEER PA,SP Prior Authorization Required; Limited to members at or between ages 3 through 12. TRACLEER 62.5 MG TABLET TRACLEER PA,,SP Antineoplastic - Alkylating Agents ALKERAN 2 MG TABLET ALKERAN PA,SP Prior Authorization Required CYCLOPHOSPHAMIDE 25 MG CAPSULE CYCLOPHOSPHAMIDE 50 MG CAPSULE CYCLOPHOSPHAMIDE PA,SP Prior Authorization Required CYCLOPHOSPHAMIDE PA,SP Prior Authorization Required HEXALEN 50 MG CAPSULE HEXALEN PA,SP Prior Authorization Required LEUKERAN 2 MG TABLET LEUKERAN PA,SP Prior Authorization Required MATULANE 50 MG CAPSULE MATULANE PA,SP Prior Authorization Required MYLERAN 2 MG TABLET MYLERAN PA,SP Prior Authorization Required TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 5 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required Antineoplastic - Antimetabolites CAPECITABINE 150 MG TABLET CAPECITABINE PA,SP Prior Authorization Required CAPECITABINE 500 MG TABLET CAPECITABINE PA,SP Prior Authorization Required LONSURF 15 MG-6.14 MG TABLET LONSURF PA,SP Prior Authorization Required LONSURF 20 MG-8.19 MG TABLET LONSURF PA,SP Prior Authorization Required TABLOID 40 MG TABLET TABLOID PA,SP Prior Authorization Required Antineoplastic - Hedgehog Pathway Inhibitor ERIVEDGE 150 MG CAPSULE ERIVEDGE PA,,SP ODOMZO 200 MG CAPSULE ODOMZO PA Prior Authorization Required Antineoplastic - Hormone/Hormone Antagonist Agents BICALUTAMIDE 50 MG TABLET BICALUTAMIDE PA Prior Authorization Required 12

13 Prior Authorization Information Antineoplastic - Hormone/Hormone Antagonist Agents EMCYT 140 MG CAPSULE EMCYT PA,SP Restricted to Males Only; Prior Authorization Required EXEMESTANE 25 MG TABLET EXEMESTANE SP FARESTON 60 MG TABLET FARESTON PA,SP Prior Authorization Required FLUTAMIDE 125 MG CAPSULE FLUTAMIDE PA,SP Restricted to Males Only; Prior Authorization Required LEUPROLIDE 2WK 1 MG/0.2 ML KIT LEUPROLIDE ACETATE PA,SP LEUPROLIDE 2WK 14 MG/2.8 ML KT LEUPROLIDE ACETATE PA,SP LYSODREN 500 MG TABLET LYSODREN PA,SP Prior Authorization Required NILUTAMIDE 150 MG TABLET NILUTAMIDE PA,SP Prior Authorization Required XTANDI 40 MG CAPSULE XTANDI PA,,SP ZYTIGA 250 MG TABLET ZYTIGA PA,,SP Antineoplastic - Immunomodulators INTRON A 10 MILLION UNITS VIAL INTRON A PA,SP Prior Authorization Required INTRON A 18 MILLION UNIT/3 ML INTRON A PA,SP Prior Authorization Required INTRON A 18 MILLION UNITS VIAL INTRON A PA,SP Prior Authorization Required INTRON A 25 MILLION UNIT/2.5 ML INTRON A PA,SP Prior Authorization Required INTRON A 50 MILLION UNITS VIAL INTRON A PA,SP Prior Authorization Required POMALYST 1 MG CAPSULE POMALYST PA,SP Prior Authorization Required POMALYST 2 MG CAPSULE POMALYST PA,SP Prior Authorization Required POMALYST 3 MG CAPSULE POMALYST PA,SP Prior Authorization Required POMALYST 4 MG CAPSULE POMALYST PA,SP Prior Authorization Required REVLIMID 10 MG CAPSULE REVLIMID PA,,SP REVLIMID 15 MG CAPSULE REVLIMID PA,,SP REVLIMID 2.5 MG CAPSULE REVLIMID PA,SP Prior Authorization Required REVLIMID 20 MG CAPSULE REVLIMID PA,SP Prior Authorization Required REVLIMID 25 MG CAPSULE REVLIMID PA,,SP REVLIMID 5 MG CAPSULE REVLIMID PA,,SP Antineoplastic - Retinoids and Retinoid Receptor Agonists TARGRETIN 75 MG CAPSULE TARGRETIN PA,SP Prior Authorization Required TRETINOIN 10 MG CAPSULE TRETINOIN PA Prior Authorization Required Antineoplastic - Systemic Enzyme Inhibitors AFINITOR 10 MG TABLET AFINITOR PA,,SP AFINITOR 2.5 MG TABLET AFINITOR PA,,SP AFINITOR 5 MG TABLET AFINITOR PA,,SP AFINITOR 7.5 MG TABLET AFINITOR PA,SP Prior Authorization Required AFINITOR DISPERZ 2 MG TABLET AFINITOR DISPERZ PA,,SP AFINITOR DISPERZ 3 MG TABLET AFINITOR DISPERZ PA,,SP AFINITOR DISPERZ 5 MG TABLET AFINITOR DISPERZ PA,,SP 13

14 Prior Authorization Information Antineoplastic - Systemic Enzyme Inhibitors FARYDAK 10 MG CAPSULE FARYDAK PA,SP Prior Authorization Required FARYDAK 15 MG CAPSULE FARYDAK PA,SP Prior Authorization Required FARYDAK 20 MG CAPSULE FARYDAK PA,SP Prior Authorization Required IDHIFA 100 MG TABLET IDHIFA PA Prior Authorization Required IDHIFA 50 MG TABLET IDHIFA PA Prior Authorization Required JAKAFI 10 MG TABLET JAKAFI PA,,SP JAKAFI 15 MG TABLET JAKAFI PA,,SP JAKAFI 20 MG TABLET JAKAFI PA,,SP JAKAFI 25 MG TABLET JAKAFI PA,,SP JAKAFI 5 MG TABLET JAKAFI PA,,SP ZOLINZA 100 MG CAPSULE ZOLINZA PA,SP Prior Authorization Required Antineoplastic - Topoisomerase Inhibitors ETOPOSIDE 50 MG CAPSULE ETOPOSIDE PA,SP Prior Authorization Required HYCAMTIN 0.25 MG CAPSULE HYCAMTIN PA,SP Prior Authorization Required HYCAMTIN 1 MG CAPSULE HYCAMTIN PA,SP Prior Authorization Required Antiparasitics ATOVAQUONE 750 MG/5 ML SUSP ATOVAQUONE PA,SP Prior Authorization Required BENZNIDAZOLE 100 MG TABLET BENZNIDAZOLE PA Prior Authorization required BENZNIDAZOLE 12.5 MG TABLET BENZNIDAZOLE PA Prior Authorization required DARAPRIM 25 MG TABLET DARAPRIM PA,,SP MEFLOQUINE HCL 250 MG TABLET MEFLOQUINE HCL PA, Antivirals ADEFOVIR DIPIVOXIL 10 MG TAB ADEFOVIR DIPIVOXIL SP ENTECAVIR 0.5 MG TABLET ENTECAVIR SP ENTECAVIR 1 MG TABLET ENTECAVIR SP LAMIVUDINE 100 MG TABLET LAMIVUDINE SP LAMIVUDINE HBV 100 MG TABLET LAMIVUDINE HBV SP VALGANCICLOVIR 450 MG TABLET VALGANCICLOVIR HCL PA,,SP Prior Authorization Required VEMLIDY 25 MG TABLET VEMLIDY SP Calcium and Bone Metabolism Regulators FORTEO 600 MCG/2.4 ML PEN INJ FORTEO PA,,SP SENSIPAR 30 MG TABLET SENSIPAR PA,,SP SENSIPAR 60 MG TABLET SENSIPAR PA,,SP SENSIPAR 90 MG TABLET SENSIPAR PA,,SP TYMLOS 80 MCG DOSE PEN INJECTR TYMLOS PA,SP Chelating Agents CHEMET 100 MG CAPSULE CHEMET SP 14

15 Prior Authorization Information Chemotherapy Rescue-Antidote Agents LEUCOVORIN CALCIUM 10 MG TAB LEUCOVORIN CALCIUM SP LEUCOVORIN CALCIUM 15 MG TAB LEUCOVORIN CALCIUM SP LEUCOVORIN CALCIUM 25 MG TAB LEUCOVORIN CALCIUM SP LEUCOVORIN CALCIUM 5 MG TAB LEUCOVORIN CALCIUM SP MESNEX 400 MG TABLET MESNEX PA,SP Prior Authorization Required Contraceptives Oral LAYOLIS FE CHEWABLE TABLET LAYOLIS FE PA Restricted to Females Only WYMZYA FE CHEWABLE TABLET WYMZYA FE PA Restricted to Females Only ZENCHENT FE TABLET CHEWABLE ZENCHENT FE PA Restricted to Females Only Cystic Fibrosis Therapy Agents BETHKIS 300 MG/4 ML AMPULE BETHKIS PA,SP Prior Authorization Required CAYSTON 75 MG INHAL SOLUTION CAYSTON PA,SP Prior Authorization Required KITABIS PAK 300 MG/5 ML KITABIS PAK PA,SP Prior Authorization Required TOBI PODHALER 28 MG INHALE CAP TOBI PODHALER PA,SP Prior Authorization Required TOBRAMYCIN 300 MG/5 ML AMPULE TOBRAMYCIN PA,SP Prior Authorization Required Dermatological - Antineoplastic or Premalignant Lesions DICLOFENAC SODIUM 3% GEL DICLOFENAC SODIUM PA Prior Authorization Required FLUOROURACIL 0.5% CREAM FLUOROURACIL PA Prior Authorization Required FLUOROURACIL 5% CREAM FLUOROURACIL PA Prior Authorization Required Dermatological - Antipsoriatics ACITRETIN 10 MG CAPSULE ACITRETIN PA, Prior Authorization Required ACITRETIN 17.5 MG CAPSULE ACITRETIN PA, Prior Authorization Required ACITRETIN 25 MG CAPSULE ACITRETIN PA, Prior Authorization Required CALCIPOTRIENE 0.005% OINTMENT CALCIPOTRIENE PA, Prior Authorization Required CALCIPOTRIENE 0.005% SOLUTION CALCIPOTRIENE PA, Dermatological - Glucocorticoids and Combinations CLOBETASOL 0.05% CREAM CLOBETASOL PROPIONATE PA, Prior Authorization Required CLOBETASOL 0.05% OINTMENT CLOBETASOL PROPIONATE PA, Prior Authorization Required CLOBETASOL 0.05% SOLUTION CLOBETASOL PROPIONATE PA, Prior Authorization Required Dermatological - Immunomodulating Agents IMIQUIMOD 5% CREAM PACKET IMIQUIMOD PA, Prior Authorization Required Dermatological - Immunosuppressive Agents ELIDEL 1% CREAM ELIDEL PA, TACROLIMUS 0.03% OINTMENT TACROLIMUS PA, Prior Authorization Required TACROLIMUS 0.1% OINTMENT TACROLIMUS PA, Prior Authorization Required 15

16 Prior Authorization Information Diabetic Therapy ALOGLIPTIN 12.5 MG TABLET ALOGLIPTIN PA Prior Authorization Required ALOGLIPTIN 25 MG TABLET ALOGLIPTIN PA Prior Authorization Required ALOGLIPTIN 6.25 MG TABLET ALOGLIPTIN PA Prior Authorization Required ALOGLIPTIN-METFORMIN ALOGLIPTIN-METFORMIN PA Prior Authorization Required ALOGLIPTIN-METFORMIN ALOGLIPTIN-METFORMIN PA Prior Authorization Required ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLITAZONE PA, Prior Authorization Required ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLITAZONE PA, Prior Authorization Required ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLITAZONE PA, Prior Authorization Required ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLITAZONE PA, Prior Authorization Required ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLITAZONE PA, Prior Authorization Required ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLITAZONE PA, Prior Authorization Required HUMULIN R 500 UNITS/ML VIAL HUMULIN R U-500 PA Prior Authorization Required INVOKAMET 150-1,000 MG TABLET INVOKAMET PA, INVOKAMET MG TABLET INVOKAMET PA, INVOKAMET 50-1,000 MG TABLET INVOKAMET PA, INVOKAMET MG TABLET INVOKAMET PA, INVOKAMET XR 150-1,000 MG TAB INVOKAMET XR PA, Prior Authorization Required; Limit 60 tablets per 30 days INVOKAMET XR MG TABLET INVOKAMET XR PA, Prior Authorization Required; Limit 60 tablets per 30 days INVOKAMET XR 50-1,000 MG TAB INVOKAMET XR PA, Prior Authorization Required; Limit 60 tablets per 30 days INVOKAMET XR MG TABLET INVOKAMET XR PA, Prior Authorization Required; Limit 60 tablets per 30 days INVOKANA 100 MG TABLET INVOKANA PA, INVOKANA 300 MG TABLET INVOKANA PA, JANUMET 50-1,000 MG TABLET JANUMET PA, JANUMET MG TABLET JANUMET PA, JANUMET XR 100-1,000 MG TABLET JANUMET XR PA, JANUMET XR 50-1,000 MG TABLET JANUMET XR PA, JANUMET XR MG TABLET JANUMET XR PA, JANUVIA 100 MG TABLET JANUVIA PA, JANUVIA 25 MG TABLET JANUVIA PA, JANUVIA 50 MG TABLET JANUVIA PA, JARDIANCE 10 MG TABLET JARDIANCE PA, Prior Authorization required; limited to 1 tablet per day. JARDIANCE 25 MG TABLET JARDIANCE PA, Prior Authorization required; limited to 1 tablet per day. JENTADUETO 2.5 MG-1,000 MG TAB JENTADUETO PA, JENTADUETO 2.5 MG-500 MG TAB JENTADUETO PA, JENTADUETO 2.5 MG-850 MG TAB JENTADUETO PA, SYNJARDY ,000 MG TABLET SYNJARDY PA, Prior Authorization required; limit 2 tablets per day 16

17 Prior Authorization Information Diabetic Therapy SYNJARDY MG TABLET SYNJARDY PA, Prior Authorization required; limit 2 tablets per day SYNJARDY 5-1,000 MG TABLET SYNJARDY PA, Prior Authorization required; limit 2 tablets per day SYNJARDY MG TABLET SYNJARDY PA, Prior Authorization required; limit 2 tablets per day SYNJARDY XR 10-1,000 MG TABLET SYNJARDY XR PA, Prior Authorization required; limit 1 tablet per day SYNJARDY XR ,000 MG TAB SYNJARDY XR PA, Prior Authorization required; limit 2 tablets per day SYNJARDY XR 25-1,000 MG TABLET SYNJARDY XR PA, Prior Authorization required; limit 1 tablet per day SYNJARDY XR 5-1,000 MG TABLET SYNJARDY XR PA, Prior Authorization required; limit 2 tablets per day TANZEUM 30 MG PEN INJECT TANZEUM PA, TANZEUM 50 MG PEN INJECT TANZEUM PA, TRADJENTA 5 MG TABLET TRADJENTA PA, VICTOZA 2-PAK 18 MG/3 ML PEN VICTOZA 2-PAK PA, VICTOZA 3-PAK 18 MG/3 ML PEN VICTOZA 3-PAK PA, Prior Authorization Required Hematopoietic Agents ARANESP 10 MCG/0.4 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 100 MCG/0.5 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 100 MCG/ML VIAL ARANESP PA,SP Prior Authorization Required ARANESP 150 MCG/0.3 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 150 MCG/0.75 ML VIAL ARANESP PA,SP Prior Authorization Required ARANESP 200 MCG/0.4 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 200 MCG/ML VIAL ARANESP PA,SP Prior Authorization Required ARANESP 25 MCG/0.42 ML SYRING ARANESP PA,SP Prior Authorization Required ARANESP 25 MCG/ML VIAL ARANESP PA,SP Prior Authorization Required ARANESP 300 MCG/0.6 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 300 MCG/ML VIAL ARANESP PA,SP Prior Authorization Required ARANESP 40 MCG/0.4 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 40 MCG/ML VIAL ARANESP PA,SP Prior Authorization Required ARANESP 500 MCG/1 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 60 MCG/0.3 ML SYRINGE ARANESP PA,SP Prior Authorization Required ARANESP 60 MCG/ML VIAL ARANESP PA,SP Prior Authorization Required EPOGEN 10,000 UNITS/ML VIAL EPOGEN PA,SP Prior Authorization Required EPOGEN 2,000 UNITS/ML VIAL EPOGEN PA,SP Prior Authorization Required EPOGEN 20,000 UNITS/2 ML VIAL EPOGEN PA,SP Prior Authorization Required EPOGEN 20,000 UNITS/ML VIAL EPOGEN PA,SP Prior Authorization Required EPOGEN 3,000 UNITS/ML VIAL EPOGEN PA,SP Prior Authorization Required EPOGEN 4,000 UNITS/ML VIAL EPOGEN PA,SP Prior Authorization Required GRANIX 300 MCG/0.5 ML SAFE SYR GRANIX PA,SP Prior Authorization Required 17

18 Prior Authorization Information Hematopoietic Agents GRANIX 300 MCG/0.5 ML SYRINGE GRANIX PA,SP Prior Authorization Required GRANIX 480 MCG/0.8 ML SAFE SYR GRANIX PA,SP Prior Authorization Required GRANIX 480 MCG/0.8 ML SYRINGE GRANIX PA,SP Prior Authorization Required NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN PA,SP Prior Authorization Required NEUPOGEN 300 MCG/ML VIAL NEUPOGEN PA,SP Prior Authorization Required NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN PA,SP Prior Authorization Required NEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN PA,SP Prior Authorization Required PROCRIT 10,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required PROCRIT 2,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required PROCRIT 20,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required PROCRIT 3,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required PROCRIT 4,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required PROCRIT 40,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required Hepatic Hormones (Hormones Secreted by the Liver) INCRELEX 40 MG/4 ML VIAL INCRELEX PA,SP Prior Authorization Required Hyperuricemia Therapy ULORIC 40 MG TABLET ULORIC PA, ULORIC 80 MG TABLET ULORIC PA, Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors MYCOPHENOLATE 200 MG/ML SUSP MYCOPHENOLATE MOFETIL SP Immunosuppressive - Mammalian Target of Rapamycin (mtor) Inhibitors SIROLIMUS 0.5 MG TABLET SIROLIMUS SP SIROLIMUS 1 MG TABLET SIROLIMUS SP SIROLIMUS 2 MG TABLET SIROLIMUS SP Inflammatory Bowel Agents HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA PA,,SP HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA,,SP HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PA,,SP HUMIRA PED CROHNS 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN S PA,,SP Prior Authorization Required HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS-UVEITIS STARTER HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS- UVEITIS Interstitial Cystitis Agents PA,,SP PA,,SP Prior Authorization Required Prior Authorization Required; Limited to 4 pens per 28 days ELMIRON 100 MG CAPSULE ELMIRON PA, 18

19 Prior Authorization Information Migraine Therapy SUMATRIPTAN 20 MG NASAL SPRAY SUMATRIPTAN PA, Prior Authorization required; Limited to 1 fill of 1 unit per 30 days SUMATRIPTAN 4 MG/0.5 ML CART SUMATRIPTAN SUCCINATE PA, Prior Authorization Required SUMATRIPTAN 4 MG/0.5 ML INJECT SUMATRIPTAN SUCCINATE PA, Prior Authorization Required SUMATRIPTAN 5 MG NASAL SPRAY SUMATRIPTAN PA, Prior Authorization required; Limited to 1 fill of 1 unit per 30 days SUMATRIPTAN 6 MG/0.5 ML INJECT SUMATRIPTAN SUCCINATE PA, Prior Authorization Required SUMATRIPTAN 6 MG/0.5 ML REFILL SUMATRIPTAN SUCCINATE PA, Prior Authorization Required SUMATRIPTAN 6 MG/0.5 ML VIAL SUMATRIPTAN SUCCINATE PA, Prior Authorization Required Mucolytics PULMOZYME 1 MG/ML AMPUL PULMOZYME PA,,SP Multiple Sclerosis Agent - Interferons AVONEX 30 MCG VIAL KIT AVONEX PA,,SP Prior Authorization Required AVONEX PEN 30 MCG/0.5 ML KIT AVONEX PEN PA,,SP AVONEX PREFILLED SYR 30 MCG KIT AVONEX PA,,SP Multiple Sclerosis Agent - Others GLATIRAMER 20 MG/ML SYRINGE GLATIRAMER ACETATE PA,,SP GLATIRAMER 40 MG/ML SYRINGE GLATIRAMER ACETATE PA,,SP Prior Authorization required; limit 12 syringes per 28 days GLATOPA 20 MG/ML SYRINGE GLATOPA PA,,SP Prior Authorization Required TECFIDERA DR 120 MG CAPSULE TECFIDERA PA,,SP TECFIDERA DR 240 MG CAPSULE TECFIDERA PA,,SP TECFIDERA STARTER PACK TECFIDERA PA,,SP Multiple Sclerosis Agent - Potassium Channel Blocker AMPYRA ER 10 MG TABLET AMPYRA PA,SP Prior Authorization Required Multiple Sclerosis Agent - Sphingosine 1-phosphate receptor modulator GILENYA 0.5 MG CAPSULE GILENYA PA,,SP Passive Immunizing Agents SYNAGIS 100 MG/1 ML VIAL SYNAGIS PA,SP Prior Authorization Required SYNAGIS 50 MG/0.5 ML VIAL SYNAGIS PA,SP Prior Authorization Required Phosphate Binders FOSRENOL 1,000 MG TABLET CHEW FOSRENOL PA Prior Authorization Required FOSRENOL 500 MG TABLET CHEW FOSRENOL PA Prior Authorization Required FOSRENOL 750 MG TABLET CHEW FOSRENOL PA Prior Authorization Required LANTHANUM CARB 1,000 MG TB CHW LANTHANUM CARBONATE PA Prior Authorization required;must meet Pharmacy Approval Criteria 19

20 Prior Authorization Information Phosphate Binders LANTHANUM CARB 500 MG TAB CHEW LANTHANUM CARB 750 MG TAB CHEW LANTHANUM CARBONATE PA Prior Authorization required;must meet Pharmacy Approval Criteria LANTHANUM CARBONATE PA Prior Authorization required;must meet Pharmacy Approval Criteria RENAGEL 400 MG TABLET RENAGEL PA Prior Authorization Required RENAGEL 800 MG TABLET RENAGEL PA Prior Authorization Required RENVELA 800 MG TABLET RENVELA PA Prior Authorization Required SEVELAMER CARBONATE 800 MG TAB SEVELAMER CARBONATE PA Prior Authorization required;must meet Pharmacy Approval Criteria Platelet Aggregation Inhibitors and Combinations ANAGRELIDE HCL 0.5 MG CAPSULE ANAGRELIDE HCL SP ANAGRELIDE HCL 1 MG CAPSULE ANAGRELIDE HCL SP Posterior Pituitary Hormones DESMOPRESSIN 0.01% SOLUTION DESMOPRESSIN ACETATE PA Prior Authorization Required DESMOPRESSIN 0.01% SPRAY DESMOPRESSIN ACETATE PA Prior Authorization Required DESMOPRESSIN 10 MCG/0.1 ML SPR DESMOPRESSIN ACETATE PA Prior Authorization Required STIMATE 1.5 MG/ML NASAL SPRAY STIMATE PA,SP Prior Authorization Required Sickle Cell Anemia Agents ENDARI 5 GRAM POWDER PACKET ENDARI PA Prior Authorization required 20

21 2018 Harbor Health Plan Medicaid Formulary ZARXIO 300 MCG/0.5 ML SYRINGE ZARXIO PA,SP Prior Authorization Required ZARXIO 480 MCG/0.8 ML SYRINGE ZARXIO PA,SP Prior Authorization Required Acne Therapy BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE CLARAVIS 10 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLARAVIS 20 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLARAVIS 30 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLARAVIS 40 MG CAPSULE CLARAVIS PA, Prior Authorization Required CLINDAMYCIN PH 1% SOLUTION CLINDAMYCIN PHOS 1% PLEDGET CLINDAMYCIN-BENZOYL PEROX 1-5% CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN-BENZOYL PEROXIDE DIFFERIN 0.1% GEL DIFFERIN ERYTHROMYCIN 2% SOLUTION METRONIDAZOLE 0.75% CREAM SOD SULFACET-SULFUR 10-5% CLSR SODIUM SULF-SULFUR CLEANSER ERYTHROMYCIN METRONIDAZOLE SODIUM SULFACETAMIDE- SULFUR SODIUM SULFACETAMIDE- SULFUR Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic BUTALB-ACETAMINOPHEN-CAFF TAB BUTALBIT-ACETAMINOPHEN-CAFF CP BUTALBITAL-ACETAMINOPHEN MG TAB BUTALBITAL-ASA-CAFFEINE CAP BUTALBITAL-ACETAMINOPHEN- CAFFE BUTALBITAL-ACETAMINOPHEN- CAFFE BUTALBITAL-ACETAMINOPHEN BUTALBITAL-ASPIRIN- CAFFEINE CAPACET CAPSULE CAPACET CELECOXIB 100 MG CAPSULE CELECOXIB Prior Authorization Required CELECOXIB 200 MG CAPSULE CELECOXIB Prior Authorization Required CELECOXIB 400 MG CAPSULE CELECOXIB Prior Authorization Required CELECOXIB 50 MG CAPSULE CELECOXIB Prior Authorization Required CHOLINE MAG TRISAL LIQUID DICLOFENAC SOD DR 25 MG TAB DICLOFENAC SOD DR 50 MG TAB DICLOFENAC SOD DR 75 MG TAB DICLOFENAC SOD EC 25 MG TAB DICLOFENAC SOD EC 50 MG TAB DICLOFENAC SOD EC 75 MG TAB DICLOFENAC SOD ER 100 MG TAB CHOLINE MAG TRISALICYLATE DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM ER ENBREL 25 MG KIT ENBREL PA,,SP ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA,,SP 21

22 2018 Harbor Health Plan Medicaid Formulary Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic ENBREL 50 MG/ML SURECLICK SYR ENBREL SURECLICK PA, ENBREL 50 MG/ML SYRINGE ENBREL PA,,SP ESGIC MG TABLET ESGIC ESGIC CAPSULE ESGIC ETODOLAC 200 MG CAPSULE ETODOLAC ETODOLAC 300 MG CAPSULE ETODOLAC ETODOLAC 400 MG TABLET ETODOLAC ETODOLAC 500 MG TABLET ETODOLAC FENOPROFEN 600 MG TABLET FLURBIPROFEN 100 MG TABLET FLURBIPROFEN 50 MG TABLET FENOPROFEN CALCIUM FLURBIPROFEN FLURBIPROFEN HUMIRA 10 MG/0.2 ML SYRINGE HUMIRA PA,,SP IBU 400 MG TABLET IBU 600 MG TABLET IBU 800 MG TABLET IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN IBUPROFEN 400 MG TABLET IBUPROFEN 600 MG TABLET IBUPROFEN 800 MG TABLET INDOMETHACIN 25 MG CAPSULE INDOMETHACIN 50 MG CAPSULE INDOMETHACIN ER 75 MG CAPSULE KETOROLAC 10 MG TABLET IBU IBU IBU IBUPROFEN IBUPROFEN IBUPROFEN INDOMETHACIN INDOMETHACIN INDOMETHACIN ER KETOROLAC TROMETHAMINE LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE LEFLUNOMIDE 20 MG TABLET LEFLUNOMIDE MARTEN-TAB TABLET MARTEN-TAB MELOXICAM 15 MG TABLET MELOXICAM MELOXICAM 7.5 MG TABLET MELOXICAM METHOTREXATE 2.5 MG TABLET METHOTREXATE NABUMETONE 500 MG TABLET NABUMETONE NABUMETONE 750 MG TABLET NABUMETONE NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN Limited to members age 12 and younger; Prior Authorization Required NAPROXEN 250 MG TABLET NAPROXEN 375 MG TABLET NAPROXEN 500 MG KIT NAPROXEN 500 MG TABLET NAPROXEN DR 375 MG TABLET NAPROXEN DR 500 MG TABLET NAPROXEN EC 375 MG TABLET NAPROXEN EC 500 MG TABLET NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN OTEZLA 28 DAY STARTER PACK OTEZLA PA,SP Prior Authorization Required 22

23 2018 Harbor Health Plan Medicaid Formulary Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic OTEZLA 30 MG TABLET OTEZLA PA,SP Prior Authorization Required OTEZLA STARTER PACK OTEZLA PA,SP Prior Authorization Required PIROXICAM 10 MG CAPSULE PIROXICAM PIROXICAM 20 MG CAPSULE PIROXICAM SULINDAC 150 MG TABLET SULINDAC 200 MG TABLET SULINDAC SULINDAC TENCON MG TABLET TENCON XATMEP 2.5 MG/ML ORAL SOLUTION XATMEP PA Prior Authorization Required ZEBUTAL MG CAPSULE ZEBUTAL Analgesics - Narcotic ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-CODEINE ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-CODEINE ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE 120 MG- 12 MG/5 ML SOLUTION ACETAMINOPHEN-CODEINE MG/5 ML BUTALBITAL COMP-CODEINE #3 CAP BUTALBITAL-CAFF-ACETAMINOPHEN- COD CAP ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE BUTALBITAL COMPOUND- CODEINE BUTALB-CAFF-ACETAMINOPH- CODEIN CODEINE SULFATE 15 MG TABLET CODEINE SULFATE CODEINE SULFATE 30 MG TABLET CODEINE SULFATE CODEINE SULFATE 60 MG TABLET CODEINE SULFATE FENTANYL 100 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 12 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 25 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 50 MCG/HR PATCH FENTANYL PA, Prior Authorization Required FENTANYL 75 MCG/HR PATCH FENTANYL PA, Prior Authorization Required HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG/15 ML SOLUTION HYDROMORPHONE 1 MG/ML SOLUTION HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROMORPHONE HCL HYDROMORPHONE 2 MG TABLET HYDROMORPHONE HCL HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE HCL HYDROMORPHONE 4 MG TABLET HYDROMORPHONE HCL HYDROMORPHONE 5 MG/5 ML SOLN HYDROMORPHONE HCL MEPERIDINE 100 MG TABLET MEPERIDINE HCL 23

24 2018 Harbor Health Plan Medicaid Formulary Analgesics - Narcotic MEPERIDINE 50 MG TABLET MEPERIDINE HCL MEPERIDINE 50 MG/5 ML SOLUTION MEPERIDINE HCL METHADONE 10 MG/5 ML SOLUTION METHADONE HCL METHADONE 10 MG/ML ORAL CONC METHADONE HCL METHADONE 5 MG/5 ML SOLUTION METHADONE HCL METHADONE HCL 10 MG TABLET METHADONE HCL METHADONE HCL 5 MG TABLET METHADONE HCL MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULFATE MORPHINE SULF 100 MG/5 ML (20 MG/ ML) SOLUTION MORPHINE SULFATE MORPHINE SULF 100 MG/5 ML SOLN MORPHINE SULFATE MORPHINE SULF 20 MG/5 ML SOLN MORPHINE SULFATE MORPHINE SULF ER 100 MG TABLET MORPHINE SULFATE ER MORPHINE SULF ER 15 MG TABLET MORPHINE SULFATE ER MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE ER MORPHINE SULF ER 30 MG TABLET MORPHINE SULFATE ER MORPHINE SULF ER 60 MG TABLET MORPHINE SULFATE ER MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE MORPHINE SULFATE IR 30 MG TAB MORPHINE SULFATE OXYCODONE HCL 5 MG TABLET OXYCODONE HCL OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN PENTAZOCINE-NALOXONE TABLET PENTAZOCINE-NALOXONE HCL TRAMADOL HCL 50 MG TABLET TRAMADOL HCL Androgen-Anabolic TESTOSTERON CYP 1,000 MG/10 ML TESTOSTERON CYP 2,000 MG/10 ML TESTOSTERONE CYP 100 MG/ML TESTOSTERONE CYP 200 MG/ML TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE Angina Therapy ISOSORBIDE DINITR ER 40 MG TAB ISOSORBIDE DINITRATE 10 MG TAB ISOSORBIDE DINITRATE 20 MG TAB ISOSORBIDE DINITRATE 30 MG TAB ISOSORBIDE DINITRATE ER ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 24

25 2018 Harbor Health Plan Medicaid Formulary Angina Therapy ISOSORBIDE DINITRATE 5 MG TAB ISOSORBIDE MONONIT 10 MG TAB ISOSORBIDE MONONIT 20 MG TAB ISOSORBIDE MONONIT ER 120 MG ISOSORBIDE MONONIT ER 30 MG TB ISOSORBIDE MONONIT ER 60 MG TB NITRO-BID 2% OINTMENT ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER NITRO-BID NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN PATCH NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN PATCH NITROGLYCERIN 0.3 MG TABLET SL NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN PATCH NITROGLYCERIN 0.6 MG TABLET SL NITROGLYCERIN NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN PATCH NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN ER 6.5 MG CAP NITROGLYCERIN ER 9 MG CAPSULE NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN LINGUAL 0.4 MG NITROGLYCERIN ST Requires trial and failure of Nitroglycerin sublingual tablets;must show trial and failure of Nitroglycerin tablets NITROSTAT 0.3 MG TABLET SL NITROSTAT 0.4 MG TABLET SL NITROSTAT 0.6 MG TABLET SL NITROSTAT NITROSTAT NITROSTAT RANEXA ER 1,000 MG TABLET RANEXA PA Prior Authorization Required RANEXA ER 500 MG TABLET RANEXA PA Prior Authorization Required Anorectal - Glucocorticoids HYDROCORTISONE 1% CREAM HYDROCORTISONE 2.5% CREAM HYDROCORTISONE HYDROCORTISONE Anterior Pituitary Hormones and Hormone Antagonists DANAZOL 100 MG CAPSULE DANAZOL 200 MG CAPSULE DANAZOL 50 MG CAPSULE DANAZOL DANAZOL DANAZOL NORDITROPIN FLEXPRO 10 MG/1.5 NORDITROPIN FLEXPRO PA,SP Prior Authorization Required NORDITROPIN FLEXPRO 15 MG/1.5 NORDITROPIN FLEXPRO PA,SP Prior Authorization Required NORDITROPIN FLEXPRO 30 MG/3 ML NORDITROPIN FLEXPRO PA,SP Prior Authorization Required NORDITROPIN FLEXPRO 5 MG/1.5 NORDITROPIN FLEXPRO PA,SP Prior Authorization Required OCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE ACETATE PA,SP Prior Authorization Required OCTREOTIDE ACET 100 MCG/ML VL OCTREOTIDE ACETATE PA,SP Prior Authorization Required 25