Drug Formulary. A healthier you. A healthier community.

Transcription

1 ormulary The information is up to date as of January 1, or questions regarding the PDL, please contact NLH at or To receive updates regarding the PDL, please A healthier you. A healthier community.

2 Pharmacy Program NextLevel Health Partners (NLH) wants you to receive all the services you need. We work with communities, providers, and members to improve our members health. NLH is committed to providing appropriate, high quality, and cost effective drug therapy to all NLH members. NLH works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. NLH covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. NLH does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Preferred List The NLH Preferred List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The NLH PDL is continually evaluated by the Utilization Review/Pharmacy Care Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the NLH Medical Director, Pharmacy Director, and several Illinois physicians, pharmacists, and other healthcare professionals. Pharmacy Benefit Manager NLH works with Envolve Pharmacy Solutions (EPS) to process pharmacy claims for prescribed drugs. Some drugs on the NLH PDL may require PA, and Envolve Pharmacy Solutions is responsible for administering this process. EPS is our Pharmacy Benefit Manager (PBM). Specialty s NLH contracts with a number of specialty pharmacies, such as AcariaHealth Specialty Pharmacy, to ensure members have adequate access to the specialty drugs they require. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by NLH. PA requirements are programmed specific to the drug. Dispensing s may be dispensed up to a maximum of thirty-four (34) day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for noncontrolled-substance PDL drugs except for ophthalmic drugs. Appropriate Use and Safety Edits The health and safety of the member are top priorities for NLH. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on DA recommendations and promote safe and effective medication utilization.

3 Prior Authorizations Some medications listed on the NLH PDL may require PA. The information should be submitted by the practitioner to Envolve Pharmacy Solutions on the Medication Prior Authorization orm. This form should be faxed to Envolve Pharmacy Solutions at This document can be found on the NLH website. NLH will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the NLH Utilization Review/Pharmacy Care Committee. If the request is approved, NLH notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, NLH will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the NLH PDL may require specific medications to be used before the member can receive the step therapy medication. If NLH has a record that the required medication was tried first the step therapy medications are automatically covered. If NLH does not have a record that the required medication was tried, the member s practitioner may be required to provide additional information. If authorization is not granted, NLH will notify the member and their practitioner and provide information regarding the appeal process. Quantity NLH may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If NLH does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Age Some medications on the NLH PDL may have age limits. These are set for certain drugs based on DA approved labeling and for safety concerns and quality standards of care. Age limits align with current DA alerts for the appropriate use of pharmaceuticals. Non-Preferred NLH incorporates a Preferred List. A notation of Non-ormulary corresponds to drugs identified on the NLH PDL indicating the trial and failure of preferred alternatives. The number of preferred drugs that must be tried prior to approval of non-formulary drugs varies by therapeutic drug class. To request the approval of a non-formulary drug please submit rationale via prior authorization request form to Envolve Pharmacy Solutions (fax ).

4 Maintenance Medications NLH members can receive a longer days supply of maintenance medications by mail and at certain retail pharmacies. You can receive up to 90 days of these medications at a time. These drugs are used to treat longterm conditions or illnesses. Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions. or a MN request NLH requires: - Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or - Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or - Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the NLH Utilization Review/Pharmacy Care Committee. If the request is approved, Envolve Pharmacy Solutions will notify the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, the member and their practitioner will be notified of alternatives and provide information regarding the appeal process. 72 Hour Emergency Supply Policy State and ederal law require that a pharmacy dispense a 72-hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. A provision of a 72-hour supply does not guarantee that the medication will be approved after a PA review. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call Envolve Pharmacy Solutions at for a prescription override to submit the 72-hour medication supply for payment.

5 Newly Approved Products NLH reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If NLH does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Over-the-Counter Medications NLH covers a variety of OTC medications. These medications can be found throughout the NLH PDL. NLH covers OTC products listed on the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. Efficacy Study and Implementation (DESI) s DESI products and known related drug products are defined as less than effective by the ood and Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by NLH. illing a Prescription A member can have prescriptions filled at a NLH network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by NLH Member services. At the pharmacy, the member will need to provide the pharmacist with the prescription and their NLH ID card. Glossary of terms The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column. Legend Description AL Age Limit is limited to specific age. PA QL Prior Authorization Quantity Limit Prior Authorization required before prescription can be filled. There is a limit on the amount of drug covered per prescription, or within a specific time frame. Rx/OTC Rx/OTC Product has both Rx and OTC National Codes. SP Specialty This is a Specialty drug

6 ST Step Therapy Maintenance Product Requires trial and failure of one or more preferred products prior to coverage. Products that are available at certain retail and mail order pharmacies for a 90 day supply. Definitions Legend Description ormulary Preferred drugs N Non-formulary Non-preferred drugs Copays There are no member copays for covered medications. Contact Information or more information regarding specific medication(s): Next Level Health Phone: Website: Envolve Pharmacy Solutions PA Phone: Discrepancies To reports discrepancies with the PDL, please contact NLH at or pharmacy@nlhpartners.com. Disclosure The information is up to date as of April 1, or questions regarding the PDL, please contact NLH at or pharmacy@nlhpartners.com. To receive updates regarding the PDL, please pharmacy@nlhpartners.com.

7 Name ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine- Dextroamphetamine) ADDERALL XR CP24 (Use Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp24 5mg-5mg-5mg-5mg, 2.5mg-2.5mg-2.5mg- 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- 1.25mg-1.25mg-1.25mg, 3.75mg-3.75mg-3.75mg- 3.75mg, 6.25mg-6.25mg- 6.25mg-6.25mg amphetaminedextroamphetamine tabs 5mg-5mg-5mg-5mg, 2.5mg-2.5mg-2.5mg- 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- 1.25mg-1.25mg-1.25mg, 3.75mg-3.75mg-3.75mg- 3.75mg, 1.875mg mg-1.875mg mg, 3.125mg mg-3.125mg mg DEXEDRINE CP24 10 MG, 15 MG (Use Dextroamphetamine Sulfate) DEXEDRINE CP24 5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10 mg, 15 mg dextroamphetamine sulfate cp24 5 mg dextroamphetamine sulfate tabs 5 mg, 10 mg N N N N AL; At least 3 AL; At least 6 AL; At least 6 AL; At least 3 AL; At least 6 AL; At least 6 AL; At least 6 AL; At least 6 QL(3 ea daily); AL; At least 3 Name VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Analeptics caffeine citrate soln or 20 mg/ml, 60 mg/3ml ST; QL(1 ea daily) QL(45 ml per ; AL; Up to 18 Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps ST; AL; At least 6 clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 INTUNIV TB24 (Use Guanfacine HCl (ADHD)) KAPVAY TB12 (Use Clonidine HCl (ADHD)) STRATTERA CAPS (Use Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl) CONCERTA TBCR 36 MG (Use Methylphenidate HCl) dexmethylphenidate hcl tabs 5 mg, 10 mg, 2.5 mg OCALIN TABS (Use Dexmethylphenidate HCl) METADATE CD CPCR (Use Methylphenidate HCl) methylphenidate hcl cpcr 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg METHYLPHENIDATE HCL ER TB24 18 MG, 27 MG, 54 MG N N N N N N N AL; At least 6 AL; At least 6 ST; AL; At least 6 AL; At least 6 AL; At least 6 AL; At least 6 AL; At least 6 AL; At least 6 AL; At least 6 AL; At least 6 Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 1

8 Name METHYLPHENIDATE HCL ER TB24 36 MG METHYLPHENIDATE HCL ER TBCR 18 MG methylphenidate hcl tabs 10 mg, 20 mg methylphenidate hcl tabs 5 mg methylphenidate hcl tbcr 10 mg, 36 mg methylphenidate hcl tbcr 18 mg, 20 mg, 27 mg, 54 mg RITALIN TABS 10 MG, 20 MG (Use Methylphenidate HCl) RITALIN TABS 5 MG (Use Methylphenidate HCl) N N AL; At least 6 AL; At least 6 QL(3 ea daily); AL; At least 3 QL(6 ea daily); AL; At least 3 AL; At least 6 AL; At least 6 QL(3 ea daily); AL; At least 3 QL(6 ea daily); AL; At least 3 AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides KITABIS PAK NEBU neomycin sulfate tabs TOBI NEBU (Use Tobramycin) tobramycin nebu TOBRAMYCIN NEBU TOBRAMYCIN SULATE SOLN 10 MG/ML, 40 MG/ML tobramycin sulfate soln 40 mg/ml, 80 mg/2ml, 1.2 gm/30ml tobramycin sulfate solr 1.2 gm N PA; SP PA; SP PA; SP PA; SP Name ANALGESICS - ANTI-INLAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-TN-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE PA; SP STARTER PACK PSKT HUMIRA PEN PNKT PA; SP HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT 20 MG/0.4ML, 40 MG/0.8ML Antirheumatic Antimetabolites RHEUMATREX TABS PA; SP PA; SP PA; SP Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use N Ibuprofen) ALEVE ARTHRITIS TABS N (Use Naproxen Sodium) ALEVE TABS (Use N Naproxen Sodium) ANAPROX DS TABS (Use N Naproxen Sodium) CELEBREX CAPS (Use N PA; QL(2 ea Celecoxib) daily) celecoxib caps PA; QL(2 ea daily) CHILDRENS ADVIL SUSP N ; (Use Ibuprofen) CHILDRENS MOTRIN SUSP (Use Ibuprofen) DAYPRO TABS (Use Oxaprozin) diclofenac potassium tabs diclofenac sodium tb24 or 100 mg diclofenac sodium tbec or 25 mg, 50 mg, 75 mg EC-NAPROSYN TBEC (Use Naproxen) N N N ; Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 2

9 Name etodolac caps etodolac tabs etodolac tb24 ELDENE CAPS (Use Piroxicam) flurbiprofen tabs ibuprofen chew 100 mg ibuprofen susp 100 mg/5ml ibuprofen susp 40 mg/ml, 50 mg/1.25ml ibuprofen tabs 200 mg, 400 mg, 600 mg, 800 mg indomethacin caps indomethacin cpcr INANTS ADVIL SUSP (Use Ibuprofen) ketoprofen caps 50 mg, 75 mg KETOPROEN CAPS 50 MG, 75 MG KETOPROEN ER CP24 ketorolac tromethamine tabs or 10 mg LODINE TABS (Use Etodolac) meloxicam tabs MOBIC TABS 15 MG, 7.5 MG (Use Meloxicam) MOTRIN INANTS DROPS SUSP (Use Ibuprofen) nabumetone tabs NAPROSYN SUSP (Use Naproxen) NAPROSYN TABS (Use Naproxen) N N N N N N N ; AL; At least 17 Name naproxen sodium tabs 220 mg naproxen sodium tabs 275 mg, 550 mg naproxen susp 125 mg/5ml naproxen tabs 250 mg, 375 mg, 500 mg naproxen tbec 375 mg, 500 mg oxaprozin tabs piroxicam caps sulindac tabs tolmetin sodium caps 400 mg TOLMETIN SODIUM CAPS 400 MG TOLMETIN SODIUM TABS 200 MG TOLMETIN SODIUM TABS 600 MG Pyrimidine Synthesis Inhibitors ARAVA TABS (Use N Leflunomide) leflunomide tabs Soluble Tumor Necrosis actor Receptor Agents ENBREL SOLR PA; SP ENBREL SOSY ENBREL SURECLICK SOAJ PA; SP PA; SP ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen tabs 325mg-50mg butalbital-acetaminophencaffeine caps 325mg- 50mg-40mg QL(4 ea daily) Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 3

10 Name butalbital-acetaminophencaffeine tabs 325mg-50mg- 40mg butalbital-aspirin-caffeine caps ESGIC TABS (Use Butalbital-Acetaminophen- Caffeine) IORINAL CAPS (Use Butalbital-Aspirin-Caffeine) TENCON TABS Analgesics Other acetaminophen chew or 80 mg acetaminophen liqd or 160 mg/5ml acetaminophen soln or 160 mg/5ml, 650 mg/20.3ml, 325 mg/10.15ml acetaminophen supp re 120 mg, 325 mg, 650 mg acetaminophen susp or 160 mg/5ml, 80 mg/0.8ml, 80 mg/2.5ml acetaminophen tabs or 325 mg, 500 mg NORTE INANTS SUSP TYLENOL CHILDRENS SUSP (Use Acetaminophen) TYLENOL EXTRA STRENGTH TABS (Use Acetaminophen) TYLENOL INANTS PAIN+EVER SUSP (Use Acetaminophen) TYLENOL INANTS SUSP (Use Acetaminophen) TYLENOL TABS (Use Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) tabs N N N N N N N QL(4 ea daily) QL(4 ea daily) QL(4 ea daily) QL(4 ea daily) Name aspirin chew or 81 mg ASPIRIN SUPP RE 300 MG, 600 MG aspirin supp re 300 mg, 600 mg aspirin tabs or 325 mg aspirin tbec or 81 mg, 324 mg, 325 mg BUERIN TABS (Use Aspirin Buffered (Cal Carb- Mag Carb-Mag Oxide)) choline & mag salicylate liqd diflunisal tabs DISALCID TABS (Use Salsalate) ECOTRIN REGULAR STRENGTH TBEC (Use Aspirin) salsalate tabs N N N ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists codeine sulfate tabs 15 mg, 30 mg, 60 mg CODEINE SULATE TABS 15 MG, 30 MG, 60 MG (Use Codeine Sulfate) DEMEROL TABS OR 50 MG, 100 MG (Use Meperidine HCl) DILAUDID TABS OR 2 MG, 4 MG, 8 MG (Use Hydromorphone HCl) DOLOPHINE TABS 10 MG (Use Methadone HCl) DOLOPHINE TABS 5 MG (Use Methadone HCl) DURAGESIC PT72 (Use entanyl) fentanyl pt72 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr N N N N N N QL(10 ea daily) QL(4 ea daily) QL(0.34 ea daily) QL(0.34 ea daily) Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 4

11 Name HYDROMORPHONE HCL SUPP RE 3 MG hydromorphone hcl tabs or 2 mg, 4 mg, 8 mg KADIAN CP24 10 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG, 100 MG (Use Morphine Sulfate) KADIAN CP MG MEPERIDINE HCL SOLN OR 50 MG/5ML meperidine hcl tabs or 50 mg, 100 mg methadone hcl tabs or 10 mg methadone hcl tabs or 5 mg morphine sulfate cp24 or 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg morphine sulfate soln or 10 mg/5ml, 20 mg/5ml morphine sulfate soln or 20 mg/ml, 100 mg/5ml MORPHINE SULATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG MORPHINE SULATE TABS OR 15 MG, 30 MG morphine sulfate tbcr or 15 mg, 30 mg, 60 mg, 100 mg, 200 mg MS CONTIN TBCR (Use Morphine Sulfate) oxycodone hcl caps 5 mg oxycodone hcl conc 100 mg/5ml OXYCODONE HCL ER T12A oxycodone hcl soln 5 mg/5ml oxycodone hcl tabs 5 mg, 10 mg, 15 mg, 20 mg, 30 mg N N QL(12 ea per QL(500 ml per QL(10 ea daily) QL(4 ea daily) QL(240 ml per QL(24 ea per QL(3 ea daily) QL(3 ea daily) QL(6 ml daily) Name OXYCONTIN T12A oxymorphone hcl tb12 5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 7.5 mg OXYMORPHONE HYDROCHLORIDE ER TB12 ROXICODONE TABS (Use Oxycodone HCl) tramadol hcl tabs 50 mg ULTRAM TABS (Use Tramadol HCl) Opioid Combinations acetaminophen w/ codeine soln 120mg/5ml-12mg/5ml acetaminophen w/ codeine tabs 300mg-15mg, 300mg- 30mg, 300mg-60mg butalbital-acetaminophencaffeine w/ codeine caps 325mg-50mg-40mg-30mg butalbital-aspirin-caffeine w/cod caps IORINAL/CODEINE #3 CAPS (Use Butalbital- Aspirin-Caffeine w/cod) HYCET SOLN (Use Hydrocodone- Acetaminophen) hydrocodoneacetaminophen soln 2.5mg/5ml-108mg/5ml, 5mg/10ml-217mg/10ml, 7.5mg/15ml-325mg/15ml hydrocodoneacetaminophen tabs 5mg- 325mg, 10mg-325mg, 7.5mg-325mg NORCO TABS (Use Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 5mg- 325mg, 10mg-325mg, 7.5mg-325mg N N N N N QL(8 ea daily) QL(8 ea daily) QL(30 ml daily) QL(4 ea daily) QL(4 ea daily) QL(4 ea daily) QL(180 ml daily) QL(180 ml daily) Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 5

12 Name oxycodone-aspirin tabs OXYCODONE/ACETAMIN OPHEN SOLN PERCOCET TABS 5MG- 325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/ Acetaminophen) tramadol-acetaminophen tabs TYLENOL/CODEINE #3 TABS (Use Acetaminophen w/ Codeine) TYLENOL/CODEINE #4 TABS (Use Acetaminophen w/ Codeine) ULTRACET TABS (Use Tramadol-Acetaminophen) Opioid Partial Agonists BUNAVAIL ILM buprenorphine hcl subl sl 2 mg, 8 mg buprenorphine hclnaloxone hcl dihydrate subl SUBOXONE ILM ZUBSOLV SUBL N N N N QL(6 ea daily) QL(30 ml daily) QL(4 ea daily) QL(4 ea daily) ANDROGENS-ANABOLIC - s to Regulate Hormones Androgens ANDRODERM PT24 ANDROXY TABS DEPO-TESTOSTERONE SOLN 200 MG/ML (Use Testosterone Cypionate) METHITEST TABS testosterone cypionate soln 200 mg/ml N ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Name Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem Rectal Combinations ANALPRAM-HC LOTN 1%- 2.5% phenylephrine-cocoa butter supp 88.44%-0.25% phenylephrine-shark liver oil-cocoa butter supp phenylephrine-shark liver oil-mineral oil-petrolatum oint Rectal Local Anesthetics pramoxine hcl (rectal) foam PROCTOOAM OAM (Use Pramoxine HCl (Rectal)) Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) hydrocortisone (rectal) crea 2.5 % ANTACIDS Antacid Combinations alum & mag hydroxsimethicone liqd 200mg/5ml-20mg/5ml- 200mg/5ml alum & mag hydroxsimethicone susp 200mg/5ml-20mg/5ml- 200mg/5ml, 200mg/5ml- 200mg/5ml-20mg/5ml- 20mg/5ml-200mg/5ml- 200mg/5ml Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate N N N QL(420 ml per QL(420 ml per QL(60 ml per QL(15 gm per QL(15 gm per QL(30 gm per QL(30 gm per Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 6

13 Name sodium bicarbonate (antacid) tabs Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg calcium carbonate (antacid) susp 1250 mg/5ml TUMS CHEW (Use Calcium Carbonate (Antacid)) TUMS LASTING EECTS CHEW (Use Calcium Carbonate (Antacid)) Antacids - Magnesium Salts magnesium oxide tabs 400 mg N N ANTHELMINTICS - s to Treat Worm Infections Anthelmintics EMVERM CHEW ANTI-INECTIVE AGENTS -. - s to Treat Bacterial Infections Anti-infective Agents - Misc. IRST-VANCOMYCIN 25 SOLN IRST-VANCOMYCIN 50 SOLN LAGYL TABS 250 MG, 500 MG (Use Metronidazole) metronidazole tabs or 250 mg, 500 mg trimethoprim tabs VANCOCIN HCL CAPS 125 MG (Use Vancomycin HCl) VANCOCIN HCL CAPS 250 MG (Use Vancomycin HCl) vancomycin hcl caps or 125 mg N N N QL(4 ea daily) QL(8 ea daily) QL(4 ea daily) Name vancomycin hcl caps or 250 mg vancomycin hcl solr iv 1000 mg vancomycin hcl solr iv 500 mg Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- N Trimethoprim) BACTRIM TABS (Use Sulfamethoxazole- N Trimethoprim) sulfamethoxazoletrimethoprim susp or 40mg/5ml-200mg/5ml sulfamethoxazoletrimethoprim tabs or 80mg- 400mg, 160mg-800mg Leprostatics dapsone tabs Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use Clindamycin HCl) CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin Palmitate Hydrochloride) clindamycin hcl caps 150 mg, 300 mg clindamycin palmitate hydrochloride solr Oxazolidinones SIVEXTRO TABS OR N N QL(8 ea daily) QL(14 ea per QL(300 ml per QL(300 ml per PA; QL(6 ea per ANTIANGINAL AGENTS - s to Treat Chest Pain Nitrates ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate) ISOSORBIDE DINITRATE ER TBCR N Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 7

14 Name isosorbide dinitrate tabs isosorbide mononitrate tabs 10 mg, 20 mg isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg NITRO-BID OINT NITRO-DUR PT MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) nitroglycerin cpcr or 2.5 mg, 6.5 mg nitroglycerin cpcr or 9 mg nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin subl sl 0.3 mg, 0.4 mg, 0.6 mg NITROSTAT SUBL (Use Nitroglycerin) N N ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs 15 mg buspirone hcl tabs 30 mg, 7.5 mg buspirone hcl tabs 5 mg, 10 mg hydroxyzine hcl syrp or 10 mg/5ml hydroxyzine hcl tabs or 10 mg, 25 mg, 50 mg HYDROXYZINE PAMOATE CAPS 100 MG hydroxyzine pamoate caps 25 mg hydroxyzine pamoate caps 50 mg meprobamate tabs VISTARIL CAPS 25 MG (Use Hydroxyzine Pamoate) N QL(4 ea daily); QL(3 ea daily); QL(6 ea daily); Name VISTARIL CAPS 50 MG (Use Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg ATIVAN SOLN IJ 2 MG/ML (Use Lorazepam) ATIVAN TABS OR 0.5 MG, 2 MG (Use Lorazepam) ATIVAN TABS OR 1 MG (Use Lorazepam) chlordiazepoxide hcl caps clorazepate dipotassium tabs DIAZEPAM SOLN OR 1 MG/ML diazepam tabs or 2 mg, 5 mg, 10 mg lorazepam soln ij 2 mg/ml, 20 mg/10ml lorazepam tabs or 0.5 mg, 2 mg lorazepam tabs or 1 mg oxazepam caps 10 mg, 15 mg, 30 mg OXAZEPAM CAPS 30 MG TRANXENE T TABS (Use Clorazepate Dipotassium) VALIUM TABS (Use Diazepam) XANAX TABS (Use Alprazolam) N N N N N N N QL(4 ea daily) QL(3 ml daily) QL(3 ea daily) QL(4 ea daily) QL(4 ea daily) QL(3 ea daily) QL(500 ml per QL(4 ea daily) QL(3 ml daily) QL(3 ea daily) QL(4 ea daily) QL(4 ea daily) QL(4 ea daily) QL(3 ea daily) QL(4 ea daily) QL(4 ea daily) ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Use Disopyramide Phosphate) NORPACE CR CP MG Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 8

15 Name quinidine gluconate tbcr or 324 mg QUINIDINE SULATE TABS Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs propafenone hcl cp12 propafenone hcl tabs RYTHMOL SR CP12 (Use Propafenone HCl) RYTHMOL TABS (Use Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 200 mg dofetilide caps TIKOSYN CAPS (Use Dofetilide) N N N ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu Bronchodilators - Anticholinergics ATROVENT HA AERS INCRUSE ELLIPTA AEPB ipratropium bromide soln TUDORZA PRESSAIR AEPB Leukotriene Modulators montelukast sodium chew 4 mg, 5 mg montelukast sodium pack 4 mg QL(30 ea per Name montelukast sodium tabs 10 mg SINGULAIR CHEW 4 MG, 5 MG (Use Montelukast Sodium) SINGULAIR PACK 4 MG (Use Montelukast Sodium) SINGULAIR TABS 10 MG (Use Montelukast Sodium) Steroid Inhalants AEROSPAN AERS budesonide (inhalation) susp LOVENT DISKUS AEPB 100 MCG/BLIST, 250 MCG/BLIST LOVENT DISKUS AEPB 50 MCG/BLIST LOVENT HA AERO 110 MCG/ACT, 220 MCG/ACT LOVENT HA AERO 44 MCG/ACT PULMICORT LEXHALER AEPB PULMICORT SUSP (Use Budesonide (Inhalation)) Sympathomimetics ALBUTEROL SULATE ER TB12 albuterol sulfate nebu in 0.5 % albuterol sulfate nebu in 0.63 mg/3ml, %, 1.25 mg/3ml albuterol sulfate syrp or 2 mg/5ml albuterol sulfate tabs or 2 mg, 4 mg albuterol sulfate tb12 or 4 mg, 8 mg COMBIVENT RESPIMAT AERS N N N N QL(0.3 gm daily,8.9 gm per AL; At least 1 - Up to 8 QL(60 ea per QL(12 gm per QL(11 gm per AL; At least 1 - Up to 8 QL(2 ml daily) Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 9

16 Name DULERA AERO ipratropium-albuterol soln METAPROTERENOL SULATE SYRP 10 MG/5ML METAPROTERENOL SULATE TABS 10 MG, 20 MG SEREVENT DISKUS AEPB SYMBICORT AERO terbutaline sulfate tabs or 5 mg, 2.5 mg VENTOLIN HA AERS VENTOLIN HA AERS VOSPIRE ER TB12 (Use Albuterol Sulfate) Xanthines ELIXOPHYLLIN ELIX THEO-24 CP24 theophylline soln 80 mg/15ml theophylline tb mg, 200 mg, 300 mg theophylline tb mg theophylline tb mg, 600 mg N QL(13 gm per QL(12 ml daily) QL(30 ml daily) QL(11 gm per QL(16 gm per fill retail,16 gm per 30 days retail) QL(36 gm per fill retail,36 gm per 30 days retail) QL(475 ml per ; ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) warfarin sodium tabs Name Direct actor Xa Inhibitors ELIQUIS STARTER PACK TABS ELIQUIS TABS XARELTO TABS 10 MG XARELTO TABS 15 MG XARELTO TABS 20 MG Heparins And Heparinoid-Like Agents enoxaparin sodium soln ij 300 mg/3ml enoxaparin sodium soln sc 100 mg/ml, 150 mg/ml enoxaparin sodium soln sc 30 mg/0.3ml enoxaparin sodium soln sc 40 mg/0.4ml enoxaparin sodium soln sc 60 mg/0.6ml enoxaparin sodium soln sc 80 mg/0.8ml, 120 mg/0.8ml heparin sodium (porcine) soln LOVENOX SOLN IJ 300 MG/3ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 100 MG/ML, 150 MG/ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 30 MG/0.3ML (Use Enoxaparin Sodium) N N N QL(4 ea daily) QL(4 ea daily) QL(1 ea daily,35 ea per 180 days retail) QL(42 ml per fill retail,42 ml per 7 days retail); SP QL(14 ml per fill retail,14 ml per 7 days retail); SP QL(5 ml per fill retail,5 ml per 7 days retail); SP QL(6 ml per fill retail,6 ml per 7 days retail); SP QL(9 ml per fill retail,9 ml per 7 days retail); SP QL(12 ml per fill retail,12 ml per 7 days retail); SP QL(42 ml per fill retail,42 ml per 7 days retail); SP QL(14 ml per fill retail,14 ml per 7 days retail); SP QL(5 ml per fill retail,5 ml per 7 days retail); SP Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 10

17 Name LOVENOX SOLN SC 40 MG/0.4ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 60 MG/0.6ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML (Use Enoxaparin Sodium) N N N QL(6 ml per fill retail,6 ml per 7 days retail); SP QL(9 ml per fill retail,9 ml per 7 days retail); SP QL(12 ml per fill retail,12 ml per 7 days retail); SP ANTICONVULSANTS - s to Treat Seizures Anticonvulsants - Benzodiazepines clonazepam tabs 0.5 mg, 1 mg, 2 mg QL(4 ea daily) DIASTAT ACUDIAL GEL QL(1 ea per fill retail); AL; At least 2 DIASTAT PEDIATRIC GEL QL(1 ea per fill retail); AL; At least 2 DIAZEPAM GEL RE 10 MG, 20 MG, 2.5 MG DIAZEPAM RECTAL GEL GEL KLONOPIN TABS (Use Clonazepam) Anticonvulsants - Misc. carbamazepine chew carbamazepine cp12 carbamazepine susp carbamazepine tabs carbamazepine tb12 CARBATROL CP12 (Use Carbamazepine) gabapentin caps 100 mg, 300 mg, 400 mg gabapentin soln 250 mg/5ml, 300 mg/6ml N QL(1 ea per fill retail); AL; At least 2 QL(1 ea per fill retail); AL; At least 2 QL(4 ea daily) QL(9 ea daily); Name gabapentin tabs 600 mg gabapentin tabs 800 mg KEPPRA SOLN OR 100 MG/ML (Use Levetiracetam) KEPPRA TABS OR 250 MG, 750 MG (Use Levetiracetam) KEPPRA TABS OR 500 MG (Use Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine) LAMICTAL TABS (Use Lamotrigine) lamotrigine chew 5 mg, 25 mg lamotrigine tabs 25 mg, 100 mg, 150 mg, 200 mg levetiracetam soln or 100 mg/ml, 500 mg/5ml levetiracetam tabs or 250 mg, 750 mg levetiracetam tabs or 500 mg MYSOLINE TABS (Use Primidone) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin) NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NEURONTIN TABS 600 MG (Use Gabapentin) NEURONTIN TABS 800 MG (Use Gabapentin) oxcarbazepine susp oxcarbazepine tabs primidone tabs TEGRETOL SUSP (Use Carbamazepine) N N N N N N N N N N QL(6 ea daily); QL(4 ea daily); QL(30 ml daily); QL(4 ea daily); QL(6 ea daily); QL(30 ml daily); QL(4 ea daily); QL(6 ea daily); QL(9 ea daily); QL(6 ea daily); QL(4 ea daily); Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 11

18 Name TEGRETOL TABS (Use Carbamazepine) TEGRETOL-XR TB12 (Use Carbamazepine) TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate) TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate) TOPAMAX TABS 100 MG (Use Topiramate) TOPAMAX TABS 200 MG (Use Topiramate) TOPAMAX TABS 25 MG, 50 MG (Use Topiramate) topiramate cpsp 15 mg topiramate cpsp 25 mg topiramate tabs 100 mg topiramate tabs 200 mg topiramate tabs 25 mg, 50 mg TRILEPTAL SUSP (Use Oxcarbazepine) TRILEPTAL TABS (Use Oxcarbazepine) ZONEGRAN CAPS (Use Zonisamide) zonisamide caps Carbamates felbamate susp felbamate tabs ELBATOL SUSP (Use elbamate) ELBATOL TABS (Use elbamate) GABA Modulators N N N N N N N N N N QL(6 ea daily); QL(8 ea daily); QL(4 ea daily); QL(6 ea daily); QL(6 ea daily); QL(8 ea daily); QL(4 ea daily); QL(6 ea daily); Name GABITRIL TABS 12 MG, 16 MG (Use Tiagabine HCl) GABITRIL TABS 2 MG, 4 MG (Use Tiagabine HCl) tiagabine hcl tabs 12 mg, 16 mg tiagabine hcl tabs 2 mg, 4 mg Hydantoins CEREBYX SOLN (Use osphenytoin Sodium) DILANTIN CAPS 100 MG (Use Phenytoin Sodium Extended) DILANTIN CAPS 30 MG DILANTIN INATABS CHEW (Use Phenytoin) DILANTIN-125 SUSP (Use Phenytoin) fosphenytoin sodium soln PHENYTEK CAPS (Use Phenytoin Sodium Extended) phenytoin chew phenytoin sodium extended caps phenytoin susp Succinimides ethosuximide caps ethosuximide soln ZARONTIN CAPS (Use Ethosuximide) ZARONTIN SOLN (Use Ethosuximide) Valproic Acid DEPACON SOLN (Use Valproate Sodium) DEPAKENE CAPS 250 MG (Use Valproic Acid) N N N N Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 12

19 Name DEPAKENE SOLN 250 MG/5ML (Use Valproate Sodium) DEPAKOTE ER TB24 (Use Divalproex Sodium) DEPAKOTE SPRINKLES CSDR (Use Divalproex Sodium) DEPAKOTE TBEC (Use Divalproex Sodium) divalproex sodium csdr or 125 mg divalproex sodium tb24 or 250 mg, 500 mg divalproex sodium tbec or 125 mg, 250 mg, 500 mg valproate sodium soln valproic acid caps N N N ANTIDEPRESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg QL(3 ea daily); mirtazapine tabs 30 mg QL(1.5 ea daily); mirtazapine tabs 45 mg mirtazapine tabs 7.5 mg mirtazapine tbdp 15 mg mirtazapine tbdp 30 mg mirtazapine tbdp 45 mg REMERON SOLTAB TBDP 15 MG (Use Mirtazapine) REMERON SOLTAB TBDP 30 MG (Use Mirtazapine) REMERON SOLTAB TBDP 45 MG (Use Mirtazapine) REMERON TABS 15 MG (Use Mirtazapine) N N N N QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily); Name REMERON TABS 30 MG (Use Mirtazapine) REMERON TABS 45 MG (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs 75 mg, 100 mg bupropion hcl tb mg bupropion hcl tb mg bupropion hcl tb mg bupropion hcl tb mg bupropion hcl tb mg MAPROTILINE HCL TABS WELLBUTRIN SR TB MG (Use Bupropion HCl) WELLBUTRIN SR TB MG (Use Bupropion HCl) WELLBUTRIN SR TB MG (Use Bupropion HCl) WELLBUTRIN TABS (Use Bupropion HCl) WELLBUTRIN XL TB MG (Use Bupropion HCl) WELLBUTRIN XL TB MG (Use Bupropion HCl) N N N N N N N N QL(1.5 ea daily); Monoamine Oxidase Inhibitors (MAOIs) NARDIL TABS (Use Phenelzine Sulfate) N PARNATE TABS (Use Tranylcypromine Sulfate) N phenelzine sulfate tabs tranylcypromine sulfate tabs QL(3 ea daily); QL(4 ea daily); QL(3 ea daily); QL(3 ea daily); QL(4 ea daily); QL(3 ea daily); QL(3 ea daily); QL(3 ea daily); Selective Serotonin Reuptake Inhibitors (SSRIs) Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 13

20 Name CELEXA TABS 10 MG (Use Citalopram Hydrobromide) CELEXA TABS 20 MG (Use Citalopram Hydrobromide) CELEXA TABS 40 MG (Use Citalopram Hydrobromide) citalopram hydrobromide soln 10 mg/5ml citalopram hydrobromide tabs 10 mg citalopram hydrobromide tabs 20 mg citalopram hydrobromide tabs 40 mg escitalopram oxalate tabs 10 mg escitalopram oxalate tabs 20 mg escitalopram oxalate tabs 5 mg fluoxetine hcl caps 10 mg, 20 mg fluoxetine hcl caps 40 mg fluoxetine hcl soln 20 mg/5ml fluoxetine hcl tabs 10 mg fluvoxamine maleate tabs 100 mg fluvoxamine maleate tabs 25 mg, 50 mg LEXAPRO TABS 10 MG (Use Escitalopram Oxalate) LEXAPRO TABS 20 MG (Use Escitalopram Oxalate) LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) paroxetine hcl tabs 10 mg N N N N N N QL(4 ea daily); QL(4 ea daily); QL(4 ea daily); QL(4 ea daily); QL(4 ea daily); AL; At least 7 ; QL(20 ml daily); AL; At least 7 AL; At least 7 ; QL(3 ea daily) QL(4 ea daily); QL(6 ea daily); Name paroxetine hcl tabs 20 mg paroxetine hcl tabs 30 mg, 40 mg PAXIL SUSP 10 MG/5ML PAXIL TABS 10 MG (Use Paroxetine HCl) PAXIL TABS 20 MG (Use Paroxetine HCl) PAXIL TABS 30 MG, 40 MG (Use Paroxetine HCl) PROZAC CAPS 10 MG, 20 MG (Use luoxetine HCl) PROZAC CAPS 40 MG (Use luoxetine HCl) sertraline hcl conc 20 mg/ml sertraline hcl tabs 100 mg sertraline hcl tabs 25 mg, 50 mg ZOLOT CONC 20 MG/ML (Use Sertraline HCl) ZOLOT TABS 100 MG (Use Sertraline HCl) ZOLOT TABS 25 MG, 50 MG (Use Sertraline HCl) Serotonin Modulators NEAZODONE HCL TABS 100 MG, 150 MG, 200 MG nefazodone hcl tabs 50 mg, 250 mg trazodone hcl tabs 300 mg trazodone hcl tabs 50 mg, 100 mg, 150 mg TRINTELLIX TABS VIIBRYD TABS N N N N N N N N QL(3 ea daily); QL(40 ml daily) QL(6 ea daily); QL(3 ea daily); QL(4 ea daily); QL(4 ea daily); AL; At least 7 ; QL(10 ml daily) QL(4 ea daily); QL(10 ml daily) QL(4 ea daily); AL; At least 18 PA; QL(1 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use N Duloxetine HCl) Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 14

21 Name desvenlafaxine succinate tb mg desvenlafaxine succinate tb24 25 mg, 50 mg duloxetine hcl cpep 20 mg, 30 mg, 60 mg EEXOR XR CP MG (Use Venlafaxine HCl) EEXOR XR CP MG (Use Venlafaxine HCl) EEXOR XR CP24 75 MG (Use Venlafaxine HCl) PRISTIQ TB MG (Use Desvenlafaxine Succinate) PRISTIQ TB24 25 MG, 50 MG (Use Desvenlafaxine Succinate) venlafaxine hcl cp mg venlafaxine hcl cp mg venlafaxine hcl cp24 75 mg VENLAAXINE HCL ER TB MG (Use Venlafaxine HCl) VENLAAXINE HCL ER TB MG VENLAAXINE HCL ER TB MG (Use Venlafaxine HCl) VENLAAXINE HCL ER TB24 75 MG (Use Venlafaxine HCl) venlafaxine hcl tabs 25 mg, 50 mg, 100 mg venlafaxine hcl tabs 75 mg, 37.5 mg venlafaxine hcl tb mg venlafaxine hcl tb mg, 37.5 mg venlafaxine hcl tb24 75 mg Tricyclic Agents N N N N N N N N ST; QL(4 ea daily) ST; QL(1 ea daily) QL(4 ea daily); ST; QL(4 ea daily) ST; QL(1 ea daily) QL(4 ea daily); Name amitriptyline hcl tabs AMOXAPINE TABS ANARANIL CAPS 50 MG, 75 MG (Use Clomipramine HCl) clomipramine hcl caps 50 mg, 75 mg desipramine hcl tabs 10 mg, 50 mg, 75 mg, 100 mg, 150 mg desipramine hcl tabs 25 mg doxepin hcl caps doxepin hcl conc ELAVIL TABS (Use Amitriptyline HCl) imipramine hcl tabs NORPRAMIN TABS 10 MG, 50 MG, 75 MG, 100 MG, 150 MG (Use Desipramine HCl) NORPRAMIN TABS 25 MG (Use Desipramine HCl) nortriptyline hcl caps 10 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl soln 10 mg/5ml PAMELOR CAPS (Use Nortriptyline HCl) TORANIL TABS (Use Imipramine HCl) N N N N N N QL(20 ml daily) ANTIDIABETICS - s to Regulate Blood Sugar Antidiabetic - Amylin Analogs SYMLINPEN 120 SOPN SYMLINPEN 60 SOPN Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl- Metformin HCl) N PA PA Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 15

22 Name ALOGLIPTIN/METORMIN HCL TABS ALOGLIPTIN/PIOGLITAZO NE TABS glipizide-metformin hcl tabs GLUCOVANCE TABS (Use Glyburide-Metformin) glyburide-metformin tabs JENTADUETO TABS KAZANO TABS OSENI TABS pioglitazone hcl-metformin hcl tabs Biguanides GLUCOPHAGE TABS 1000 MG (Use Metformin HCl) GLUCOPHAGE TABS 500 MG (Use Metformin HCl) GLUCOPHAGE TABS 850 MG (Use Metformin HCl) GLUCOPHAGE XR TB MG (Use Metformin HCl) GLUCOPHAGE XR TB MG (Use Metformin HCl) metformin hcl tabs 1000 mg metformin hcl tabs 500 mg metformin hcl tabs 850 mg metformin hcl tb mg metformin hcl tb mg Diabetic Other N N N N N N PA; QL(1 ea daily); PA; QL(1 ea daily); PA; QL(2 ea daily); AL; At least 18 ; PA; QL(1 ea daily); PA; QL(1 ea daily); QL(3 ea daily); QL(4 ea daily); QL(3 ea daily); QL(4 ea daily); Name BD GLUCOSE CHEW CVS GLUCOSE CHEW 4 GM DEX4 QUICK DISSOLVE GLUCOSE CHEW GLUCAGEN HYPOKIT SOLR GLUCAGON EMERGENCY KIT KIT GLUCOSE CHEW 4 GM GNP GLUCOSE CHEW 4 GM GNP QUICK DISSOLVE GLUCOSE CHEW LEADER QUICK DISSOLVE GLUCOSE CHEW SM GLUCOSE CHEW 4 GM WALGREENS GLUCOSE CHEW 4 GM QL(1 ea per fill retail) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ALOGLIPTIN TABS PA; QL(1 ea daily); NESINA TABS PA; QL(1 ea daily); TRADJENTA TABS PA; QL(1 ea daily); AL; At least 18 ; Incretin Mimetic Agents (GLP-1 Receptor BYDUREON PEN PEN PA; AL; At least 18 BYDUREON SRER PA; AL; At least 18 BYETTA SOPN PA; AL; At least 18 VICTOZA SOPN PA; QL(0.3 ml daily) Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) N Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 16

23 Name AVANDIA TABS pioglitazone hcl tabs Insulin ADMELOG SOLN ADMELOG SOLOSTAR SOPN APIDRA SOLN APIDRA SOLOSTAR SOPN BASAGLAR KWIKPEN SOPN IASP LEXTOUCH SOPN IASP SOLN HUMALOG JUNIOR KWIKPEN SOPN HUMALOG KWIKPEN SOPN 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUPN HUMALOG MIX 50/50 SUSP HUMALOG MIX 75/25 KWIKPEN SUPN HUMALOG MIX 75/25 SUSP HUMALOG SOCT HUMALOG SOLN HUMULIN 70/30 KWIKPEN SUPN HUMULIN 70/30 SUSP HUMULIN N KWIKPEN SUPN HUMULIN N SUSP HUMULIN R SOLN NOVOLIN 70/30 RELION SUSP Name NOVOLIN 70/30 SUSP NOVOLIN N RELION SUSP NOVOLIN N SUSP NOVOLIN R RELION SOLN NOVOLIN R SOLN NOVOLOG LEXPEN SOPN NOVOLOG MIX 70/30 PREILLED LEXPEN SUPN NOVOLOG MIX 70/30 SUSP NOVOLOG PENILL SOCT NOVOLOG SOLN Meglitinide Analogues nateglinide tabs STARLIX TABS (Use Nateglinide) N QL(3 ea daily); QL(3 ea daily); Sodium-Glucose Co-Transporter 2 (SGLT2) JARDIANCE TABS PA; QL(1 ea daily) Sulfonylureas AMARYL TABS 1 MG, 2 MG (Use Glimepiride) AMARYL TABS 4 MG (Use Glimepiride) glimepiride tabs 1 mg, 2 mg glimepiride tabs 4 mg glipizide tabs glipizide tb24 GLUCOTROL TABS (Use Glipizide) GLUCOTROL XL TB24 (Use Glipizide) N N N QL(4 ea daily); QL(4 ea daily); Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products N 17

24 Name glyburide micronized tabs glyburide tabs GLYNASE TABS (Use Glyburide Micronized) N ANTIDIARRHEAL/PROBIOTIC AGENTS - s to Treat Diarrhea Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew 262 mg bismuth subsalicylate susp 525 mg/15ml PEPTO-BISMOL CHEW 262 MG (Use Bismuth N Subsalicylate) PEPTO-BISMOL INSTACOOL CHEW (Use N Bismuth Subsalicylate) PEPTO-BISMOL MAX STRENGTH SUSP (Use N Bismuth Subsalicylate) PEPTO-BISMOL TO-GO CHEW (Use Bismuth N Subsalicylate) Antiperistaltic Agents diphenoxylate w/ atropine tabs DIPHENOXYLATE/ATROP INE LIQD IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) IMODIUM A-D TABS 2 MG (Use Loperamide HCl) LOMOTIL TABS (Use Diphenoxylate w/ Atropine) loperamide hcl caps 2 mg loperamide hcl liqd 1 mg/5ml loperamide hcl tabs 2 mg PAREGORIC TINC N N N ANTIDOTES AND SPECIIC ANTAGONISTS Name Antidotes - Chelating Agents CHEMET CAPS JADENU TABS Antidotes and Specific Antagonists VISTOGARD PACK Opioid Antagonists EVZIO SOAJ 0.4 MG/0.4ML naloxone hcl soln 0.4 mg/ml, 4 mg/10ml NALOXONE HCL SOSY 2 MG/2ML naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR PA; SP ANTIEMETICS - s to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists ondansetron hcl soln or 4 mg/5ml ondansetron hcl tabs or 4 mg, 8 mg ondansetron tbdp ZORAN ODT TBDP (Use Ondansetron) ZORAN SOLN 4 MG/5ML (Use Ondansetron HCl) ZORAN TABS 4 MG, 8 MG (Use Ondansetron HCl) Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg DRAMAMINE TABS (Use Dimenhydrinate) N N N N QL(50 ml per QL(2 ea daily,20 ea per 30 days retail) QL(2 ea daily,20 ea per 30 days retail) QL(2 ea daily,20 ea per 30 days retail) QL(50 ml per QL(2 ea daily,20 ea per 30 days retail) QL(24 ea per QL(24 ea per Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 18

25 Name meclizine hcl chew 25 mg meclizine hcl tabs 25 mg, 12.5 mg ANTIUNGALS - s to Treat ungal Infections Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs LAMISIL TABS 250 MG (Use Terbinafine HCl) nystatin tabs terbinafine hcl tabs N N Imidazole-Related Antifungals DILUCAN SUSR 10 MG/ML, 40 MG/ML (Use N luconazole) DILUCAN TABS 100 MG (Use luconazole) N DILUCAN TABS 150 MG (Use luconazole) N DILUCAN TABS 200 MG (Use luconazole) N DILUCAN TABS 50 MG (Use luconazole) N fluconazole susr 10 mg/ml, 40 mg/ml fluconazole tabs 100 mg fluconazole tabs 150 mg fluconazole tabs 200 mg fluconazole tabs 50 mg itraconazole caps QL(1 ea daily,90 ea per 120 days retail) QL(6 ea daily) QL(1 ea daily,90 ea per 120 days retail) QL(70 ml per QL(2 ea per fill retail) QL(7 ea per fill retail) QL(70 ml per QL(2 ea per fill retail) QL(7 ea per fill retail) PA; QL(1 ea daily) Name SPORANOX CAPS 100 MG (Use Itraconazole) SPORANOX PULSEPAK CAPS (Use Itraconazole) N N PA; QL(1 ea daily) PA; QL(1 ea daily) ANTIHISTAMINES - s to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON SYRP 2 MG/5ML (Use Chlorpheniramine Maleate) CHLOR-TRIMETON TABS 4 MG (Use Chlorpheniramine Maleate) chlorpheniramine maleate syrp 2 mg/5ml chlorpheniramine maleate tabs 4 mg N N Antihistamines - Ethanolamines BENADRYL ALLERGY CAPS (Use N Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS LIQD 12.5 N MG/5ML (Use Diphenhydramine HCl) BENADRYL ALLERGY TABS (Use N Diphenhydramine HCl) clemastine fumarate tabs 1.34 mg diphenhydramine hcl caps or 25 mg diphenhydramine hcl caps or 50 mg diphenhydramine hcl elix or 12.5 mg/5ml diphenhydramine hcl liqd or 25 mg/10ml, 50 mg/20ml, 12.5 mg/5ml diphenhydramine hcl syrp or 12.5 mg/5ml diphenhydramine hcl tabs or 25 mg SILPHEN COUGH SYRP QL(60 ml daily) QL(120 ea per QL(60 ml daily) QL(120 ea per QL(4 ea daily) QL(240 ml per QL(4 ea daily) QL(4 ea daily) QL(4 ea daily); QL(240 ml per ; QL(240 ml per QL(240 ml per QL(4 ea daily) QL(240 ml per Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 19

26 Name TAVIST ALLERGY TABS (Use Clemastine umarate) N Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS 180 MG (Use N exofenadine HCl) ALLEGRA ALLERGY TABS 60 MG (Use N exofenadine HCl) cetirizine hcl chew 5 mg, 10 mg cetirizine hcl soln 1 mg/ml, 5 mg/5ml cetirizine hcl syrp 1 mg/ml, 5 mg/5ml cetirizine hcl tabs 5 mg, 10 mg CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine) CLARITIN REDITABS TBDP 10 MG (Use Loratadine) CLARITIN SYRP 5 MG/5ML (Use Loratadine) CLARITIN TABS 10 MG (Use Loratadine) fexofenadine hcl tabs 180 mg fexofenadine hcl tabs 60 mg loratadine soln 5 mg/5ml loratadine syrp 5 mg/5ml loratadine tabs 10 mg loratadine tbdp 10 mg ZYRTEC ALLERGY TABS (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN (Use Cetirizine HCl) N N N N N N QL(480 ml per ; QL(480 ml per ; QL(240 ml per QL(240 ml per QL(240 ml per QL(240 ml per QL(480 ml per ; Name Antihistamines - Phenothiazines promethazine hcl soln or 6.25 mg/5ml promethazine hcl supp re 25 mg, 50 mg, 12.5 mg promethazine hcl syrp or 6.25 mg/5ml promethazine hcl tabs or 25 mg, 50 mg, 12.5 mg Antihistamines - Piperidines cyproheptadine hcl syrp cyproheptadine hcl tabs QL(240 ml per ; AL; At least 2 QL(12 ea per ; AL; At least 2 QL(240 ml per ; AL; At least 2 AL; At least 2 ANTIHYPERLIPIDEMICS - s to Treat High Cholesterol Bile Acid Sequestrants cholestyramine light pack cholestyramine light powd cholestyramine pack cholestyramine powd COLESTID LAVORED GRAN 5 GM (Use Colestipol HCl) COLESTID GRAN 5 GM (Use Colestipol HCl) COLESTID TABS 1 GM (Use Colestipol HCl) colestipol hcl gran 5 gm colestipol hcl tabs 1 gm QUESTRAN LIGHT POWD (Use Cholestyramine Light) QUESTRAN PACK (Use Cholestyramine) QUESTRAN POWD (Use Cholestyramine) ibric Acid Derivatives Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products N N N N N N 20

27 Name fenofibrate micronized caps 134 mg, 200 mg fenofibrate micronized caps 67 mg fenofibrate tabs 160 mg fenofibrate tabs 54 mg gemfibrozil tabs LOIBRA CAPS 134 MG, 200 MG (Use enofibrate Micronized) LOIBRA CAPS 67 MG (Use enofibrate Micronized) LOIBRA TABS 160 MG (Use enofibrate) LOIBRA TABS 54 MG (Use enofibrate) LOPID TABS (Use Gemfibrozil) TRIGLIDE TABS N N N N N HMG CoA Reductase Inhibitors atorvastatin calcium tabs CRESTOR TABS 20 MG (Use Rosuvastatin Calcium) CRESTOR TABS 5 MG, 10 MG, 40 MG (Use Rosuvastatin Calcium) LIPITOR TABS (Use Atorvastatin Calcium) lovastatin tabs 10 mg, 20 mg lovastatin tabs 40 mg MEVACOR TABS (Use Lovastatin) PRAVACHOL TABS (Use Pravastatin Sodium) pravastatin sodium tabs N N N N N QL(3 ea daily); QL(3 ea daily); ST; ST Name rosuvastatin calcium tabs 20 mg rosuvastatin calcium tabs 5 mg, 10 mg, 40 mg simvastatin tabs ZOCOR TABS (Use Simvastatin) Nicotinic Acid Derivatives niacin (antihyperlipidemic) tbcr NIACOR TABS NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) N N ST; ST ANTIHYPERTENSIVES - s to Treat High Blood Pressure ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) ALTACE CAPS (Use Ramipril) benazepril hcl tabs 40 mg benazepril hcl tabs 5 mg, 10 mg, 20 mg captopril tabs enalapril maleate tabs EPANED SOLR fosinopril sodium tabs lisinopril tabs LOTENSIN TABS 20 MG (Use Benazepril HCl) LOTENSIN TABS 40 MG (Use Benazepril HCl) MAVIK TABS (Use Trandolapril) PRINIVIL TABS (Use Lisinopril) N N N N N N QL(3 ea daily); Updated June 1, 2018\ -Preferred drug, N-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy, -Maintenance Products 21