Trusted Health Plan Formulary

Transcription

1 2018 Trusted Health Plan Formulary Effective 7/1/2018

2 Introduction... 6 The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T)... 6 Notice...6 Preface...6 Product Selection Criteria... 6 Formulary Components... 6 Generic Substitution...6 Covered Medications without Authorization...6 Non-Covered Benefits...7 Prior Authorization... 7 Step Therapy... 7 Specialty Medications... 7 Quantity Limits... 7 Benefit Exception...7 Pharmacy Benefit Management...7 Prior Authorization Information... 8 Acne Therapy...16 Agents for Opioid Withdrawal Alcoholism Treatment Agents Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Analgesics - Narcotic Angina Therapy...22 Anorectal - Glucocorticoids Anorectal Combinations...23 Anterior Pituitary Hormones and Hormone Antagonists Anti-Infective - Immunologic Adjuvants...23 Antianxiety Agents Antiarrhythmics Antibacterial Agents...26 Anticoagulants Anticonvulsants...30 Antidepressants Antidiarrheals...35 Antiemetics Antifungals Antihemophilic Factor Agents Antihistamines...37 Antihyperlipidemics Antihypertensive Therapy Agents Antineoplastic - Alkylating Agents...42 Antineoplastic - Antibody/Antibody-Drug Complexes Antineoplastic - Antimetabolites...43 Antineoplastic - Hedgehog Pathway Inhibitor Antineoplastic - Hormone/Hormone Antagonist Agents...44 Antineoplastic - Immunomodulators...44 Antineoplastic - Mast Cell Stabilizers...45 Antineoplastic - Metal Complexes...45 Antineoplastic - Retinoids and Retinoid Receptor Agonists...45 Antineoplastic - Systemic Enzyme Inhibitors Antineoplastic - Topoisomerase Inhibitors Antiparasitics...46 Antiparkinson Therapy...46 Antiprotozoal-Antibacterial Agents...47 Antipsychotics (Neuroleptics)...47 Antitussives...50 Antivirals Appetite Stimulants...51 Asthma/COPD Therapy Agents Attention Deficit-Hyperact Disorder (ADHD) Therapy...53 Beta Adrenergic Blockers Bipolar Therapy Agents Blood Albumin and Plasma Proteins...56 Bradykinin B2 Receptor Antagonists Calcium and Bone Metabolism Regulators...56 Calcium Channel Blockers and Combinations...56 Cardiac Inotropes...57 Cardiovascular Sympathomimetics and Combinations

3 Chelating Agents...57 Chemotherapy Rescue-Antidote Agents...57 CNS Stimulants...58 Cognitive Disorder Therapy - Antidementia Colonic Acidifier (Ammonia Inhibitor)...59 Contraceptives Implant Contraceptives Injectable...59 Contraceptives Intravaginal Contraceptives Oral Contraceptives Transdermal...63 Corticosteroids...63 Cystic Fibrosis Therapy Agents Dental-Periodontal Products Dermatological - Anti-infectives Dermatological - Antineoplastic or Premalignant Lesions...65 Dermatological - Antiparasitics and Combinations Dermatological - Antipruritics Dermatological - Antipsoriatics Dermatological - Antiseborrheic Products and Combinations...65 Dermatological - Burn Products Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Immunomodulating Agents Dermatological - Immunosuppressive Agents Dermatological - Keratolytics-Antimitotics...68 Dermatological - NSAID s Dermatological - Rosacea Therapy Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy...68 Diagnostic Drugs - In Vivo Digestive Aids Diuretics...71 Emergency Contraceptives and Combinations...72 Erectile Dysfunction (ED) Drugs-Sel.cGMP Phosphodiesterase Type5 Inhib Estrogens and Combinations...72 Gallstone Solubilizing (Litholysis) Agents and Combinations Gastrointestinal Antispasmodics...73 Gastrointestinal Prokinetic Agents General Anesthetics...74 General Injectable Solutions and Diluents Genitourinary Irrigants Hematopoietic Agents...74 Hepatic Hormones (Hormones Secreted by the Liver) Hyperuricemia Therapy...75 Immunosuppressive - Calcineurin Inhibitors Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors Immunosuppressive - Mammalian Target of Rapamycin (mtor) Inhibitors Immunosuppressive - Purine Analogs Inflammatory Bowel Agents Interstitial Cystitis Agents...77 Irrigation Solutions Irritable Bowel Syndrome (IBS) Agents Laxatives...77 Local Anesthetics - Parenteral Medical Supplies and DME - Respiratory Therapy Metabolic Disease Enzyme Replacement, Gaucher s Disease Migraine Therapy...80 Minerals and Electrolytes...81 Mouth and Throat - Anti-infectives Mouth and Throat - Glucocorticoids...81 Mouth and Throat - Local Anesthetics Mouth and Throat - Xerostomia Therapy Mucolytics Multiple Sclerosis Agent - Interferons Multiple Sclerosis Agent - Potassium Channel Blocker Musculoskeletal Therapy Agents Narcolepsy and Cataplexy Therapy Agents

4 Nasal Preparations Neuromuscular Therapy Agents Ophthalmic - Anti-allergy...83 Ophthalmic - Anti-infectives Ophthalmic - Anti-inflammatory...84 Ophthalmic - Intraocular Pressure Reducing Agents...84 Ophthalmic - Mydriatics and Cycloplegics Ophthalmic Combinations...85 Opiate/Narcotic Reversal Agents - Opiate Antagonists Otic - Anti-infectives Otic Combinations...85 Oxytocics Passive Immunizing Agents...85 Peptic Ulcer Therapy Pharmaceutical Adjuvants Phosphate Binders...86 Platelet Aggregation Inhibitors and Combinations Posterior Pituitary Hormones Progestins...87 Prostatic Hypertrophy Agents Pseudobulbar Affect (PBA) Agents...87 Respiratory Combinations...88 Sedative-Hypnotics...88 Sickle Cell Anemia Agents...88 Smoking Deterrents and Combinations Thyroid Therapy...89 Urinary Analgesics Urinary Anti-infectives Urinary Antispasmodics Urinary ph Modifiers Urinary Retention Therapy...92 Vaginal Anti-infectives...92 Vaginal Estrogens...92 Vitamin Combinations Vitamins Wound Care Therapy...93 Acne Therapy...94 Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Anorectal - Hemorrhoidal Single Agents Other Anorectal Combinations Antacids and Combinations Antidiarrheals Antiemetics Antihistamines Antiseptic - Biguanides Antitussives Artificial Tears and Lubricants Chemicals - Solvents Dermatological - Anti-infectives Dermatological - Antiparasitics and Combinations Dermatological - Antipruritics Dermatological - Astringents and Combinations Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Irritants-Counter-Irritants Dermatological - Keratolytics-Antimitotics Diabetic Therapy Dietary Products Digestive Aids Emergency Contraceptives and Combinations Expectorants Gastrointestinal Antiflatulents and Combinations Irrigation Solutions Laxatives Medical Supplies and DME - Diabetic Supplies Medical Supplies and DME - GI-GU Ostomy and Irrigation Supplies Medical Supplies and DME - Thermometers

5 Minerals and Electrolytes Mouth and Throat - Non-Narcotic Antitussive - Local Anesthetic Combos Nasal Preparations Nutritional Product - Nutritional Therapy Ophthalmic - Anti-allergy Ophthalmic - Hyperosmolar Agents Peptic Ulcer Therapy Respiratory Combinations Sedative-Hypnotics Smoking Deterrents and Combinations Urinary Analgesics Vaginal Anti-infectives Vitamin Combinations Vitamins

6 Introduction Trusted Health Plan is pleased to provide an updated 2018 Medicaid Formulary as a reference and informational tool for physicians, pharmacists and patients. The Trusted Health Plan Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T) The medications on this formulary have been reviewed by the Trusted Health Plan Pharmacy 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 Trusted Health Plan, 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. Trusted 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 Trusted Health Plan 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. Trusted Health Plan will not cover prescription drugs that are prescribed for experimental, investigational or non FDA approved indications, dosages, or routes of administration. Trusted Health Plan does not cover any medication excluded by District of Columbia Medicaid ( downloads/providers/dcrx_pdl_listing.pdf). Product Selection Criteria The MeridianRx 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 MeridianRx P&T Committee is to preserve and evaluate the Trusted Health Plan 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 Trusted Health Plan Formulary. Formulary decisions are communicated quarterly on the Trusted Health Plan website. Therapeutic substitution occurs when a preferred drug is approved for use because it has similar treatment effects but is not identical to a nonpreferred drug. Formulary Components The Trusted Health Plan 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 Trusted Health Plan covers a medication. Generic Substitution Trusted Health Plan 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 Trusted Health Plan covers many medications without any authorization required. These medications include many prescription and over-the-counter medications (when ordered by a physician). 6

7 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 MeridianRx Help Desk at or fax a completed Prior Authorization form to All 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. Step Therapy ensures clinically appropriate and cost-effective drugs are used before other alternatives. Specialty Medications All specialty medications noted as "SP" are handled by MeridianRx. To order a specialty medication by fax, send the prescription and a completed prior authorization form to or call MeridianRx s Help Desk at Quantity Limits Drugs indicated with a "QL" 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 MeridianRx Help Desk at or fax a completed Formulary Exception form to Pharmacy Benefit Management Trusted Health Plan utilizes MeridianRx to manage each member s pharmacy benefit. MeridianRx provides Trusted Health Plan with a pharmacy network, pharmacy claims management services, and claims adjudication. MeridianRx s Help Desk can be contacted at

8 Prior Authorization Information Agents for Opioid Withdrawal SUBOXONE 12 MG-3 MG SL FILM SUBOXONE PA Prior Authorization required SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE PA Prior Authorization required SUBOXONE 4 MG-1 MG SL FILM SUBOXONE PA Prior Authorization required SUBOXONE 8 MG-2 MG SL FILM SUBOXONE PA Prior Authorization required Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic BENLYSTA 120 MG VIAL BENLYSTA PA Prior Authorization required BENLYSTA 400 MG VIAL BENLYSTA PA Prior Authorization required ENBREL 25 MG KIT ENBREL PA Prior Authorization required ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA Prior Authorization required ENBREL 50 MG/ML SURECLICK SYR ENBREL SURECLICK PA Prior Authorization required ENBREL 50 MG/ML SYRINGE ENBREL PA Prior Authorization required KINERET 100 MG/0.67 ML SYRINGE KINERET PA Prior Authorization required Anterior Pituitary Hormones and Hormone Antagonists LUPRON DEPOT MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA Prior Authorization Required LUPRON DEPOT MG 3MO KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA Prior Authorization Required LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT-PED MG 3MO KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED MG KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA Prior Authorization required Anti-Infective - Immunologic Adjuvants ACTIMMUNE 100 MCG/0.5 ML VIAL ACTIMMUNE PA,SP Prior Authorization required Antibacterial Agents THALOMID 100 MG CAPSULE THALOMID PA Prior Authorization Required THALOMID 150 MG CAPSULE THALOMID PA Prior Authorization Required THALOMID 200 MG CAPSULE THALOMID PA Prior Authorization Required THALOMID 50 MG CAPSULE THALOMID PA Prior Authorization Required Anticonvulsants ONFI 10 MG TABLET ONFI PA Prior Authorization Required ONFI 20 MG TABLET ONFI PA Prior Authorization Required Antidepressants CYMBALTA 20 MG CAPSULE CYMBALTA PA,QL Prior Authorization required; limited to 60 capsules per 30 days 8

9 Prior Authorization Information Antidepressants CYMBALTA 30 MG CAPSULE CYMBALTA PA,QL Prior Authorization required; limited to 30 capsules per 30 days CYMBALTA 60 MG CAPSULE CYMBALTA PA,QL Prior Authorization required; limited to 60 capsules per 30 days Antihemophilic Factor Agents ADVATE 2,401-3,600 UNIT VIAL ADVATE PA Prior Authorization required ALPHANATE 1, UNIT VIAL ALPHANATE PA Prior Authorization required ALPHANATE 1, UNIT VIAL ALPHANATE PA Prior Authorization required ALPHANATE UNIT VIAL ALPHANATE PA Prior Authorization required ALPHANATE UNIT VIAL ALPHANATE PA Prior Authorization required ALPHANINE SD 1,000 UNIT VIAL ALPHANINE SD PA Prior Authorization required ALPHANINE SD 1,500 UNIT VIAL ALPHANINE SD PA Prior Authorization required ALPHANINE SD 500 UNIT VIAL ALPHANINE SD PA Prior Authorization required BENEFIX 1,000 UNIT RANGE BENEFIX PA Prior Authorization required BENEFIX 2,000 UNIT RANGE BENEFIX PA Prior Authorization required BENEFIX 250 UNIT RANGE BENEFIX PA Prior Authorization required BENEFIX 3,000 UNIT RANGE BENEFIX PA Prior Authorization required BENEFIX 500 UNIT RANGE BENEFIX PA Prior Authorization required FEIBA NF 1,000 UNIT (NOMINAL) FEIBA NF PA Prior Authorization required FEIBA NF 2,500 UNIT (NOMINAL) FEIBA NF PA Prior Authorization required FEIBA NF 500 UNIT (NOMINAL) FEIBA NF PA Prior Authorization required HELIXATE FS 3,000 UNITS VIAL HELIXATE FS PA Prior Authorization required HEMOFIL M 1,000 UNIT NOMINAL HEMOFIL M PA Prior Authorization required HEMOFIL M 1,700 UNIT NOMINAL HEMOFIL M PA Prior Authorization required HEMOFIL M 250 UNIT NOMINAL HEMOFIL M PA Prior Authorization required HEMOFIL M 500 UNIT NOMINAL HEMOFIL M PA Prior Authorization required KOGENATE FS 3,000 UNIT-BIOSET KOGENATE FS PA Prior Authorization required KOGENATE FS 3,000 UNITS VIAL KOGENATE FS PA Prior Authorization required KOVALTRY 3,000 UNIT KIT KOVALTRY PA Prior Authorization required KOVALTRY 3,000 UNIT VIAL KOVALTRY PA Prior Authorization required MONONINE 1,000 UNIT VIAL MONONINE PA Prior Authorization required NOVOSEVEN RT 1 MG VIAL NOVOSEVEN RT PA Prior Authorization required NOVOSEVEN RT 2 MG VIAL NOVOSEVEN RT PA Prior Authorization required NOVOSEVEN RT 5 MG VIAL NOVOSEVEN RT PA Prior Authorization required NOVOSEVEN RT 8 MG VIAL NOVOSEVEN RT PA Prior Authorization required RECOMBINATE 1,241-1,800 UNIT V RECOMBINATE PA Prior Authorization required RECOMBINATE 1,801-2,400 UNIT V RECOMBINATE PA Prior Authorization required RECOMBINATE UNIT VIAL RECOMBINATE PA Prior Authorization required RECOMBINATE UNIT VIAL RECOMBINATE PA Prior Authorization required RECOMBINATE 801-1,240 UNIT VL RECOMBINATE PA Prior Authorization required RIXUBIS 1,000 UNIT NOMINAL RIXUBIS PA Prior Authorization required 9

10 Prior Authorization Information Antihemophilic Factor Agents RIXUBIS 2,000 UNIT NOMINAL RIXUBIS PA Prior Authorization required RIXUBIS 250 UNIT NOMINAL RIXUBIS PA Prior Authorization required RIXUBIS 3,000 UNIT NOMINAL RIXUBIS PA Prior Authorization required RIXUBIS 500 UNIT NOMINAL RIXUBIS PA Prior Authorization required Antihyperlipidemics JUXTAPID 10 MG CAPSULE JUXTAPID PA Prior Authorization required JUXTAPID 20 MG CAPSULE JUXTAPID PA Prior Authorization required JUXTAPID 5 MG CAPSULE JUXTAPID PA Prior Authorization required Antihypertensive Therapy Agents LETAIRIS 10 MG TABLET LETAIRIS PA Prior Authorization required LETAIRIS 5 MG TABLET LETAIRIS PA Prior Authorization required Antineoplastic - Alkylating Agents TEMODAR 100 MG CAPSULE TEMODAR PA Prior Authorization Required TEMODAR 140 MG CAPSULE TEMODAR PA,QL Prior Auhtorization required; Limited to 90 capsules per 30 days TEMODAR 180 MG CAPSULE TEMODAR PA,QL Prior Authorization required; limited to 60 capsules per 30 days TEMODAR 20 MG CAPSULE TEMODAR PA,QL Prior Authorization Required; limited to 120 capsules per 30 days TEMODAR 250 MG CAPSULE TEMODAR PA,QL Prior Authorization required; limited to 60 capsules per 30 days TEMODAR 5 MG CAPSULE TEMODAR PA,QL Prior Authorization required; Limited to 90 capsules per 30 days TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE PA Prior Authorization required TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE PA Prior Authorization required TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE PA Prior Authorization required TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE PA Prior Authorization required TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE PA Prior Authorization required TEMOZOLOMIDE 5 MG CAPSULE TEMOZOLOMIDE PA Prior Authorization required Antineoplastic - Antibody/Antibody-Drug Complexes PERJETA 420 MG/14 ML VIAL PERJETA PA Prior Authorization required Antineoplastic - Antimetabolites CAPECITABINE 150 MG TABLET CAPECITABINE PA Prior Authorization required CAPECITABINE 500 MG TABLET CAPECITABINE PA Prior Authorization required XELODA 150 MG TABLET XELODA PA Prior Authorization required XELODA 500 MG TABLET XELODA PA Prior Authorization required 10

11 Prior Authorization Information Antineoplastic - Hedgehog Pathway Inhibitor ERIVEDGE 150 MG CAPSULE ERIVEDGE PA Prior Authorization required Antineoplastic - Hormone/Hormone Antagonist Agents ELIGARD 22.5 MG SYRINGE B ELIGARD PA Prior Authorization Required ELIGARD 22.5 MG SYRINGE KIT ELIGARD PA Prior Authorization Required ELIGARD 30 MG SYRINGE B ELIGARD PA Prior Authorization Required ELIGARD 30 MG SYRINGE KIT ELIGARD PA Prior Authorization Required ELIGARD 45 MG SYRINGE B ELIGARD PA Prior Authorization Required ELIGARD 45 MG SYRINGE KIT ELIGARD PA Prior Authorization Required ELIGARD 7.5 MG SYRINGE B ELIGARD PA Prior Authorization Required ELIGARD 7.5 MG SYRINGE KIT ELIGARD PA Prior Authorization Required LEUPROLIDE 2WK 1 MG/0.2 ML KIT LEUPROLIDE ACETATE PA Prior Authorization Required LEUPROLIDE 2WK 14 MG/2.8 ML KT LEUPROLIDE ACETATE PA Prior Authorization Required LEUPROLIDE 2WK 14 MG/2.8 ML VL LEUPROLIDE ACETATE PA Prior Authorization Required LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT PA Prior Authorization Required TRELSTAR MG SYRINGE TRELSTAR PA Prior Authorization Required TRELSTAR MG VIAL TRELSTAR PA Prior Authorization Required TRELSTAR 22.5 MG SYRINGE TRELSTAR PA Prior Authorization Required TRELSTAR 22.5 MG VIAL TRELSTAR PA Prior Authorization Required TRELSTAR 3.75 MG SYRINGE TRELSTAR PA Prior Authorization Required TRELSTAR 3.75 MG VIAL TRELSTAR PA Prior Authorization Required XTANDI 40 MG CAPSULE XTANDI PA Prior Authorization Required ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX PA Prior Authorization Required ZOLADEX 3.6 MG IMPLANT SYRN ZOLADEX PA Prior Authorization Required Antineoplastic - Systemic Enzyme Inhibitors BOSULIF 100 MG TABLET BOSULIF PA Prior Authorization required BOSULIF 500 MG TABLET BOSULIF PA Prior Authorization required COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ PA Prior Authorization required COMETRIQ 140 MG DAILY-DOSE PK COMETRIQ PA Prior Authorization required COMETRIQ 60 MG DAILY-DOSE PACK COMETRIQ PA Prior Authorization required GLEEVEC 100 MG TABLET GLEEVEC PA,QL Prior Authorization required; Limited to 120 tablets per 30 days GLEEVEC 400 MG TABLET GLEEVEC PA,QL Prior Authorization required; Limited to 60 tablets per 30 days ICLUSIG 15 MG TABLET ICLUSIG PA Prior Authorization required ICLUSIG 45 MG TABLET ICLUSIG PA Prior Authorization required IMATINIB MESYLATE 100 MG TAB IMATINIB MESYLATE PA,QL Prior Authorization required; Limited to 120 tablets per 30 days 11

12 Prior Authorization Information Antineoplastic - Systemic Enzyme Inhibitors IMATINIB MESYLATE 400 MG TAB IMATINIB MESYLATE PA,QL Prior Authorization required; Limited to 60 tablets per 30 days JAKAFI 10 MG TABLET JAKAFI PA Prior Authorization required JAKAFI 15 MG TABLET JAKAFI PA Prior Authorization required JAKAFI 20 MG TABLET JAKAFI PA Prior Authorization required JAKAFI 25 MG TABLET JAKAFI PA Prior Authorization required JAKAFI 5 MG TABLET JAKAFI PA Prior Authorization required TARCEVA 100 MG TABLET TARCEVA QL,SP Prior Authorization required; Limited to 30 tablets per 30 days TARCEVA 150 MG TABLET TARCEVA QL,SP Prior Authorization required; Limited to 30 tablets per 30 days TARCEVA 25 MG TABLET TARCEVA QL,SP Prior Authorization required; Limited to 90 tablets per 30 days XALKORI 200 MG CAPSULE XALKORI PA Prior Authorization required XALKORI 250 MG CAPSULE XALKORI PA Prior Authorization required ZELBORAF 240 MG TABLET ZELBORAF PA Prior Authorization required Antineoplastic - Topoisomerase Inhibitors HYCAMTIN 0.25 MG CAPSULE HYCAMTIN PA Prior Authorization Required HYCAMTIN 1 MG CAPSULE HYCAMTIN PA Prior Authorization Required Antivirals APTIVUS 100 MG/ML SOLUTION APTIVUS PA Prior Authorization required APTIVUS 250 MG CAPSULE APTIVUS PA Prior Authorization required EPCLUSA 400 MG-100 MG TABLET EPCLUSA PA,SP Prior Authorization required HEPSERA 10 MG TABLET HEPSERA PA Prior Authorization required MAVYRET MG TABLET MAVYRET PA,SP Prior Authorization required PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS PA Prior Authorization Required PEGASYS 180 MCG/ML VIAL PEGASYS PA Prior Authorization Required PEGASYS PROCLICK 135 MCG/0.5 ML PEGASYS PROCLICK PA Prior Authorization Required PEGASYS PROCLICK 180 MCG/0.5 PEGASYS PROCLICK PA Prior Authorization Required PEGINTRON 50 MCG KIT PEGINTRON REDIPEN PA Prior Authorization Required REBETOL 40 MG/ML SOLUTION REBETOL PA Prior Authorization required RIBAVIRIN 200 MG CAPSULE RIBAVIRIN PA Prior Authorization required RIBAVIRIN 200 MG TABLET RIBAVIRIN PA Prior Authorization required RIBAVIRIN 6 GM INHALATION VIAL RIBAVIRIN PA Prior Authorization required TRUVADA 100 MG-150 MG TABLET TRUVADA PA,SP Prior Authorization required TRUVADA 133 MG-200 MG TABLET TRUVADA PA,SP Prior Authorization required TRUVADA 167 MG-250 MG TABLET TRUVADA PA,SP Prior Authorization required TRUVADA 200 MG-300 MG TABLET TRUVADA PA,SP Prior Authorization required Asthma/COPD Therapy Agents XOLAIR 150 MG VIAL XOLAIR PA Prior Authorization required 12

13 Prior Authorization Information Bipolar Therapy Agents ABILIFY 10 MG TABLET ABILIFY PA Prior Authorization required ABILIFY 15 MG TABLET ABILIFY PA Prior Authorization required ABILIFY 2 MG TABLET ABILIFY PA Prior Authorization required ABILIFY 20 MG TABLET ABILIFY PA Prior Authorization required ABILIFY 30 MG TABLET ABILIFY PA Prior Authorization required ABILIFY 5 MG TABLET ABILIFY PA Prior Authorization required Blood Albumin and Plasma Proteins CINRYZE 500 UNIT VIAL CINRYZE PA Prior Authorization required Bradykinin B2 Receptor Antagonists FIRAZYR 30 MG/3 ML SYRINGE FIRAZYR PA Prior Authorization required Calcium and Bone Metabolism Regulators FORTEO 600 MCG/2.4 ML PEN INJ FORTEO PA Prior Authorization required Chelating Agents EXJADE 125 MG TABLET EXJADE PA Prior Authorization required EXJADE 250 MG TABLET EXJADE PA Prior Authorization required EXJADE 500 MG TABLET EXJADE PA Prior Authorization required Cystic Fibrosis Therapy Agents KALYDECO 150 MG TABLET KALYDECO PA Prior Authorization required TOBI 300 MG/5 ML SOLUTION TOBI PA Prior Authorization required TOBI PODHALER 28 MG INHALE CAP TOBI PODHALER PA Prior Authorization required Diabetic Therapy BYDUREON 2 MG VIAL BYDUREON PA Prior Authorization required Hematopoietic Agents ARANESP 100 MCG/0.5 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 100 MCG/ML VIAL ARANESP PA Prior Authorization required ARANESP 150 MCG/0.3 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 150 MCG/0.75 ML VIAL ARANESP PA Prior Authorization required ARANESP 200 MCG/0.4 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 200 MCG/ML VIAL ARANESP PA Prior Authorization required ARANESP 25 MCG/0.42 ML SYRING ARANESP PA Prior Authorization required ARANESP 25 MCG/ML VIAL ARANESP PA Prior Authorization required ARANESP 300 MCG/0.6 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 300 MCG/ML VIAL ARANESP PA Prior Authorization required ARANESP 40 MCG/0.4 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 40 MCG/ML VIAL ARANESP PA Prior Authorization required 13

14 Prior Authorization Information Hematopoietic Agents ARANESP 500 MCG/1 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 60 MCG/0.3 ML SYRINGE ARANESP PA Prior Authorization required ARANESP 60 MCG/ML VIAL ARANESP PA Prior Authorization required EPOGEN 10,000 UNITS/ML VIAL EPOGEN PA Prior Authorization required EPOGEN 2,000 UNITS/ML VIAL EPOGEN PA Prior Authorization required EPOGEN 20,000 UNITS/2 ML VIAL EPOGEN PA Prior Authorization required EPOGEN 20,000 UNITS/ML VIAL EPOGEN PA Prior Authorization required EPOGEN 3,000 UNITS/ML VIAL EPOGEN PA Prior Authorization required EPOGEN 4,000 UNITS/ML VIAL EPOGEN PA Prior Authorization required NEULASTA 6 MG/0.6 ML SYRINGE NEULASTA PA Prior Authorization required NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN PA Prior Authorization required NEUPOGEN 300 MCG/ML VIAL NEUPOGEN PA Prior Authorization required NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN PA Prior Authorization required NEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN PA Prior Authorization required NPLATE 250 MCG VIAL NPLATE PA Prior Authorization required NPLATE 500 MCG VIAL NPLATE PA Prior Authorization required PROCRIT 10,000 UNITS/ML VIAL PROCRIT PA Prior Authorization required PROCRIT 2,000 UNITS/ML VIAL PROCRIT PA Prior Authorization required PROCRIT 20,000 UNITS/ML VIAL PROCRIT PA Prior Authorization required PROCRIT 3,000 UNITS/ML VIAL PROCRIT PA Prior Authorization required PROCRIT 4,000 UNITS/ML VIAL PROCRIT PA Prior Authorization required PROCRIT 40,000 UNITS/ML VIAL PROCRIT PA Prior Authorization required Hepatic Hormones (Hormones Secreted by the Liver) INCRELEX 40 MG/4 ML VIAL INCRELEX PA Prior Authorization required Inflammatory Bowel Agents HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA PA Prior Authorization required HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA Prior Authorization required HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PA Prior Authorization required HUMIRA PED CROHNS 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN S PA Prior Authorization required HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS-UVEITIS STARTER HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS- UVEITIS PA PA Prior Authorization required Prior Authorization required REMICADE 100 MG VIAL REMICADE PA Prior Authorization required Metabolic Disease Enzyme Replacement, Gaucher s Disease CEREZYME 400 UNITS VIAL CEREZYME PA Prior Authorization required Mucolytics PULMOZYME 1 MG/ML AMPUL PULMOZYME PA Prior Authorization required 14

15 Prior Authorization Information Multiple Sclerosis Agent - Interferons BETASERON 0.3 MG KIT BETASERON PA Prior Authorization required BETASERON 0.3 MG VIAL BETASERON PA Prior Authorization required EXTAVIA 0.3 MG KIT EXTAVIA PA Prior Authorization required EXTAVIA 0.3 MG VIAL EXTAVIA PA Prior Authorization required REBIF 22 MCG/0.5 ML SYRINGE REBIF PA Prior Authorization required REBIF 44 MCG/0.5 ML SYRINGE REBIF PA Prior Authorization required REBIF REBIDOSE 22 MCG/0.5 ML REBIF REBIDOSE PA Prior Authorization required REBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE PA Prior Authorization required REBIF REBIDOSE TITRATION PACK REBIF REBIDOSE PA Prior Authorization required REBIF TITRATION PACK REBIF PA Prior Authorization required Multiple Sclerosis Agent - Potassium Channel Blocker AMPYRA ER 10 MG TABLET AMPYRA PA Prior Authorization required Musculoskeletal Therapy Agents GENVISC MG/2.5 ML SYR GENVISC 850 PA Prior Authorization required HYALGAN 20 MG/2 ML SYRINGE HYALGAN PA Prior Authorization required HYALGAN 20 MG/2 ML VIAL HYALGAN PA Prior Authorization required SUPARTZ FX 25 MG/2.5 ML SYR SUPARTZ FX PA Prior Authorization required SYNVISC SYRINGE SYNVISC PA Prior Authorization required SYNVISC-ONE SYRINGE SYNVISC-ONE PA Prior Authorization required VISCO-3 25 MG/2.5 ML SYR VISCO-3 PA Prior Authorization required Passive Immunizing Agents CYTOGAM 2.5 GM/50 ML VIAL CYTOGAM PA Prior Authorization required HYPERRHO S-D 1,500 UNIT SYRING HYPERRHO S-D PA Prior Authorization required RHOGAM ULTRA-FILTERED PLUS SYR RHOGAM ULTRA-FILTERED PLUS PA Prior Authorization required SYNAGIS 100 MG/1 ML VIAL SYNAGIS PA Prior Authorization required SYNAGIS 50 MG/0.5 ML VIAL SYNAGIS PA Prior Authorization required Pseudobulbar Affect (PBA) Agents NUEDEXTA MG CAPSULE NUEDEXTA PA Prior Authorization required 15

16 2018 Trusted Health Plan Medicaid Formulary Acne Therapy ABSORICA 10 MG CAPSULE ABSORICA 20 MG CAPSULE ABSORICA 30 MG CAPSULE ABSORICA 40 MG CAPSULE ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ADAPALENE 0.1% LOTION ADAPALENE 0.3% GEL ADAPALENE 0.3% GEL PUMP AMNESTEEM 10 MG CAPSULE AMNESTEEM 20 MG CAPSULE AMNESTEEM 40 MG CAPSULE BENZOYL PEROX 4% CREAMY WASH CLARAVIS 10 MG CAPSULE CLARAVIS 20 MG CAPSULE CLARAVIS 30 MG CAPSULE CLARAVIS 40 MG CAPSULE CLINDAMYCIN PH 1% GEL CLINDAMYCIN PH 1% SOLUTION CLINDAMYCIN PHOS 1% PLEDGET CLINDAMYCIN PHOSP 1% LOTION CLINDAMYCIN PHOSPHATE 1% FOAM DAPSONE 5% GEL ERYTHROMYCIN 2% GEL ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN 2% SOLUTION ISOTRETINOIN 10 MG CAPSULE ISOTRETINOIN 20 MG CAPSULE ISOTRETINOIN 30 MG CAPSULE ISOTRETINOIN 40 MG CAPSULE METRONIDAZOLE 0.75% CREAM METRONIDAZOLE 0.75% LOTION MYORISAN 10 MG CAPSULE MYORISAN 20 MG CAPSULE MYORISAN 30 MG CAPSULE MYORISAN 40 MG CAPSULE NORITATE 1% CREAM SODIUM SULFACETAMIDE 10% LOTN SULFACETAMIDE SOD 10% TOP SUSP SULFACETAMIDE-SULFUR 8-4% SUSP TRETINOIN 0.01% GEL ABSORICA ABSORICA ABSORICA ABSORICA ADAPALENE ADAPALENE ADAPALENE ADAPALENE ADAPALENE AMNESTEEM AMNESTEEM AMNESTEEM BENZOYL PEROXIDE CLARAVIS CLARAVIS CLARAVIS CLARAVIS CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE DAPSONE ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN METRONIDAZOLE METRONIDAZOLE MYORISAN MYORISAN MYORISAN MYORISAN NORITATE SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE- SULFUR TRETINOIN 16

17 2018 Trusted Health Plan Medicaid Formulary Acne Therapy TRETINOIN 0.025% CREAM TRETINOIN 0.025% GEL TRETINOIN 0.05% CREAM TRETINOIN 0.05% GEL TRETINOIN 0.1% CREAM ZENATANE 10 MG CAPSULE ZENATANE 20 MG CAPSULE ZENATANE 30 MG CAPSULE ZENATANE 40 MG CAPSULE TRETINOIN TRETINOIN TRETINOIN TRETINOIN TRETINOIN ZENATANE ZENATANE ZENATANE ZENATANE Agents for Opioid Withdrawal SUBOXONE 12 MG-3 MG SL FILM SUBOXONE PA Prior Authorization required SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE PA Prior Authorization required SUBOXONE 4 MG-1 MG SL FILM SUBOXONE PA Prior Authorization required SUBOXONE 8 MG-2 MG SL FILM SUBOXONE PA Prior Authorization required Alcoholism Treatment Agents DISULFIRAM 250 MG TABLET DISULFIRAM 500 MG TABLET DISULFIRAM DISULFIRAM Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic BENLYSTA 120 MG VIAL BENLYSTA PA Prior Authorization required BENLYSTA 400 MG VIAL BENLYSTA PA Prior Authorization required BUTALB-ACETAMIN-CAFF BUTALB-ASPIRIN-CAFFE CELEBREX 100 MG CAPSULE CELEBREX 200 MG CAPSULE CELEBREX 400 MG CAPSULE CELEBREX 50 MG CAPSULE CELECOXIB 100 MG CAPSULE CELECOXIB 200 MG CAPSULE CELECOXIB 400 MG CAPSULE CELECOXIB 50 MG CAPSULE 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 DIFLUNISAL 500 MG TABLET BUTALBITAL-ACETAMINOPHEN- CAFFE BUTALBITAL-ASPIRIN- CAFFEINE CELEBREX CELEBREX CELEBREX CELEBREX CELECOXIB CELECOXIB CELECOXIB CELECOXIB DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM ER DIFLUNISAL QL QL 17

18 2018 Trusted Health Plan Medicaid Formulary Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic ENBREL 25 MG KIT ENBREL PA Prior Authorization required ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA Prior Authorization required ENBREL 50 MG/ML SURECLICK SYR ENBREL SURECLICK PA Prior Authorization required ENBREL 50 MG/ML SYRINGE ENBREL PA Prior Authorization required IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN IBUPROFEN 400 MG TABLET IBUPROFEN IBUPROFEN 600 MG TABLET IBUPROFEN IBUPROFEN 800 MG TABLET IBUPROFEN KETOPROFEN 50 MG CAPSULE KETOPROFEN KETOPROFEN 75 MG CAPSULE KETOPROFEN KETOPROFEN ER 200 MG CAPSULE KETOPROFEN KETOROLAC 10 MG TABLET KETOROLAC TROMETHAMINE KETOROLAC 15 MG/ML CARPUJECT KETOROLAC TROMETHAMINE KETOROLAC 15 MG/ML ISECURE SYR KETOROLAC TROMETHAMINE KETOROLAC 15 MG/ML SYRINGE KETOROLAC TROMETHAMINE KETOROLAC 15 MG/ML VIAL KETOROLAC TROMETHAMINE KETOROLAC 30 MG/ML CARPUJECT KETOROLAC TROMETHAMINE KETOROLAC 30 MG/ML ISECURE SYR KETOROLAC TROMETHAMINE KETOROLAC 30 MG/ML SYRINGE KETOROLAC TROMETHAMINE KETOROLAC 30 MG/ML VIAL KETOROLAC TROMETHAMINE KETOROLAC 300 MG/10 ML VIAL KETOROLAC TROMETHAMINE KETOROLAC 60 MG/2 ML CARPUJECT KETOROLAC TROMETHAMINE KETOROLAC 60 MG/2 ML SYRINGE KETOROLAC TROMETHAMINE KETOROLAC 60 MG/2 ML VIAL KETOROLAC TROMETHAMINE KINERET 100 MG/0.67 ML SYRINGE KINERET PA Prior Authorization required LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE LEFLUNOMIDE 20 MG TABLET LEFLUNOMIDE MELOXICAM 15 MG TABLET MELOXICAM MELOXICAM 7.5 MG TABLET MELOXICAM MELOXICAM 7.5 MG/5 ML SUSP MELOXICAM METHOTREXATE 2.5 MG TABLET METHOTREXATE NABUMETONE 500 MG TABLET NABUMETONE NABUMETONE 750 MG TABLET NABUMETONE NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN NAPROXEN 250 MG TABLET NAPROXEN NAPROXEN 375 MG TABLET NAPROXEN NAPROXEN 500 MG KIT NAPROXEN NAPROXEN 500 MG TABLET NAPROXEN NAPROXEN DR 375 MG TABLET NAPROXEN NAPROXEN DR 500 MG TABLET NAPROXEN NAPROXEN EC 375 MG TABLET NAPROXEN NAPROXEN EC 500 MG TABLET NAPROXEN NAPROXEN SOD CR 375 MG TABLET NAPROXEN SODIUM CR 18

19 2018 Trusted Health Plan Medicaid Formulary Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic NAPROXEN SOD CR 500 MG TABLET NAPROXEN SOD ER 375 MG TABLET NAPROXEN SOD ER 500 MG TABLET NAPROXEN SODIUM 275 MG TAB NAPROXEN SODIUM 550 MG TAB NAPROXEN SODIUM DS 550 MG TAB OXAPROZIN 600 MG CAPLET OXAPROZIN 600 MG TABLET SULINDAC 150 MG TABLET SULINDAC 200 MG TABLET NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN SODIUM ER NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM DS OXAPROZIN OXAPROZIN SULINDAC SULINDAC Analgesics - Narcotic ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-CODEINE 120 MG- 12 MG/5 ML SOLUTION ACETAMINOPHEN-CODEINE MG/5 ML ACETAMINOPHEN-CODEINE MG/10 ML ACETAMINOPHEN-CODEINE MG/12.5 ML ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ASCOMP WITH CODEINE CAPSULE ASCOMP WITH CODEINE QL BUTALB-ACETAMINOPH-CAFF- CODEIN BUTALB-ACETAMINOPH-CAFF- CODEIN FENTANYL 100 MCG/HR PATCH FENTANYL QL FENTANYL 12 MCG/HR PATCH FENTANYL QL FENTANYL 25 MCG/HR PATCH FENTANYL QL FENTANYL 50 MCG/HR PATCH FENTANYL QL FENTANYL 75 MCG/HR PATCH FENTANYL QL FIORINAL WITH CODEINE #3 CAP FIORINAL WITH CODEINE #3 QL FIORINAL-COD CAP FIORINAL WITH CODEINE #3 QL HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROMORPHONE 0.5 MG/0.5 ML HYDROMORPHONE 1 MG/ML CARPUJCT HYDROMORPHONE 1 MG/ML SOLUTION HYDROMORPHONE 1 MG/ML SYRINGE HYDROMORPHONE 110 MG/55 ML PCA SYRINGE (CMPD-RX) HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL QL QL QL QL QL QL QL 19

20 2018 Trusted Health Plan Medicaid Formulary Analgesics - Narcotic HYDROMORPHONE 2 MG TABLET HYDROMORPHONE 2 MG/ML CARPUJCT HYDROMORPHONE 2 MG/ML ISECURE HYDROMORPHONE 2 MG/ML VIAL HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE 4 MG TABLET HYDROMORPHONE 4 MG/ML CARPUJCT HYDROMORPHONE 5 MG/5 ML SOLN HYDROMORPHONE 8 MG TABLET HYDROMORPHONE HCL 110 MG/55 ML HYDROMORPHONE HCL 60 MG/30 ML HYDROMORPHONE HCL ER 12 MG TAB HYDROMORPHONE HCL ER 16 MG TAB HYDROMORPHONE HCL ER 32 MG TAB HYDROMORPHONE HCL ER 8 MG TAB HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE ER HYDROMORPHONE ER HYDROMORPHONE ER HYDROMORPHONE ER LORCET MG TABLET LORCET QL MEPERIDINE 100 MG/ML VIAL MORPHINE 10 MG/0.7 ML AUTO-INJ MORPHINE 10 MG/ML CARPUJECT MORPHINE 10 MG/ML SYRINGE MORPHINE 15 MG/ML VIAL MORPHINE 2 MG/ML CARPUJECT MORPHINE 2 MG/ML SYRINGE MORPHINE 20 MG/ML ORAL SYRINGE MORPHINE 30 MG/30 ML SYRINGE MORPHINE 4 MG/ML CARPUJECT MORPHINE 4 MG/ML SYRINGE MORPHINE 5 MG/ML SYRINGE MORPHINE 8 MG/ML CARPUJECT MORPHINE 8 MG/ML SYRINGE MORPHINE SULF 10 MG SUPPOS MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULF 100 MG/5 ML (20 MG/ ML) SOLUTION MORPHINE SULF 100 MG/5 ML SOLN MORPHINE SULF 20 MG SUPPOS MORPHINE SULF 20 MG/5 ML SOLN MEPERIDINE HCL MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE 20

21 2018 Trusted Health Plan Medicaid Formulary Analgesics - Narcotic MORPHINE SULF 30 MG SUPPOS MORPHINE SULF 5 MG SUPPOS MORPHINE SULF CR 100 MG TABLET MORPHINE SULF CR 60 MG TABLET MORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 15 MG TABLET MORPHINE SULF ER 200 MG TABLET MORPHINE SULF ER 30 MG TABLET MORPHINE SULF ER 60 MG TABLET MORPHINE SULFATE 10 MG/ML VIAL MORPHINE SULFATE 2 MG/ML VIAL MORPHINE SULFATE 25 MG/ML VIAL MORPHINE SULFATE 25 MG/ML VL MORPHINE SULFATE 5 MG/ML VIAL MORPHINE SULFATE 50 MG/ML VIAL MORPHINE SULFATE 8 MG/ML VIAL MORPHINE SULFATE ER 10 MG CAP MORPHINE SULFATE ER 100 MG CAP MORPHINE SULFATE ER 120 MG CAP MORPHINE SULFATE ER 20 MG CAP MORPHINE SULFATE ER 30 MG CAP MORPHINE SULFATE ER 45 MG CAP MORPHINE SULFATE ER 50 MG CAP MORPHINE SULFATE ER 60 MG CAP MORPHINE SULFATE ER 75 MG CAP MORPHINE SULFATE ER 80 MG CAP MORPHINE SULFATE ER 90 MG CAP MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE IR 30 MG TAB MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE CR MORPHINE SULFATE CR MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE MORPHINE SULFATE NORCO TABLET NORCO QL OXYCODONE HCL 10 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 100 MG/5 ML SOLN OXYCODONE HCL QL OXYCODONE HCL 15 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 20 MG TABLET OXYCODONE HCL OXYCODONE HCL 30 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL QL OXYCODONE HCL 5 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL QL OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE-ACETAMINOPHEN MG/5 ML SOLUTION OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN QL QL 21

22 2018 Trusted Health Plan Medicaid Formulary Analgesics - Narcotic OXYCODONE-ASPIRIN MG TABLET OXYCODONE HCL-ASPIRIN TRAMADOL ER 100 MG TABLET TRAMADOL HCL ER QL Limited to 30 Tablets per 25 days TRAMADOL HCL 50 MG TABLET TRAMADOL HCL QL TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER QL Limited to 30 Tablets per 25 days TRAMADOL HCL ER 200 MG TABLET TRAMADOL HCL ER QL Limited to 30 Tablets per 25 days TRAMADOL HCL ER 300 MG TABLET TRAMADOL HCL ER QL Limited to 30 Tablets per 25 days TRAMADOL-ACETAMINOPHEN MG TAB TRAMADOL HCL- ACETAMINOPHEN ULTRAM 50 MG TABLET ULTRAM QL VICODIN MG TABLET VICODIN QL XODOL TABLET XODOL QL 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 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 NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN 0.3 MG TABLET SL NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN 0.6 MG TABLET SL NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN 400 MCG SPRAY NITROGLYCERIN 5 MG/ML VIAL NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN ER 6.5 MG CAP NITROGLYCERIN ER 9 MG CAPSULE NITROGLYCERIN LINGUAL 0.4 MG ISOSORBIDE DINITRATE ER ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER NITROGLYCERIN PATCH NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN QL 22

23 2018 Trusted Health Plan Medicaid Formulary Anorectal - Glucocorticoids ANUCORT-HC 25 MG SUPPOSITORY ANUSOL-HC 25 MG SUPPOSITORY HEMMOREX-HC 25 MG SUPPOSITORY HYDROCORTISONE 1% CREAM HYDROCORTISONE AC 25 MG SUPP HYDROCORTISONE AC 30 MG SUPP ANUCORT-HC ANUSOL-HC HEMMOREX-HC HYDROCORTISONE HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE Anorectal Combinations LIDOCAINE-HC 3-1% CREAM KIT LIDOCAINE-HYDROCORTISONE Anterior Pituitary Hormones and Hormone Antagonists DANAZOL 100 MG CAPSULE DANAZOL 200 MG CAPSULE LUPRON DEPOT MG (LUPANETA) DANAZOL DANAZOL LUPRON DEPOT (LUPANETA) PA Prior Authorization Required LUPRON DEPOT MG 3MO KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA Prior Authorization Required LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA Prior Authorization Required LUPRON DEPOT-PED MG 3MO KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED MG KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED PA Prior Authorization required LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA Prior Authorization required OCTREOTIDE 1,000 MCG/5 ML VIAL OCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE 5,000 MCG/5 ML VIAL OCTREOTIDE ACET 100 MCG/ML AMP OCTREOTIDE ACET 200 MCG/ML VL OCTREOTIDE ACET 50 MCG/ML AMP OCTREOTIDE ACET 500 MCG/ML AMP SANDOSTATIN 0.05 MG/ML AMPUL SANDOSTATIN 0.1 MG/ML AMPUL SANDOSTATIN 0.2 MG/ML VIAL SANDOSTATIN 0.5 MG/ML AMPUL SANDOSTATIN 1 MG/ML VIAL OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE SANDOSTATIN SANDOSTATIN SANDOSTATIN SANDOSTATIN SANDOSTATIN Anti-Infective - Immunologic Adjuvants ACTIMMUNE 100 MCG/0.5 ML VIAL ACTIMMUNE PA,SP Prior Authorization required Antianxiety Agents ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM ALPRAZOLAM 23

24 2018 Trusted Health Plan Medicaid Formulary Antianxiety Agents ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG TABLET BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL 7.5 MG TABLET CHLORDIAZEPOXIDE 10 MG CAPSULE CHLORDIAZEPOXIDE 25 MG CAPSULE CHLORDIAZEPOXIDE 5 MG CAPSULE CLONAZEPAM MG DIS TAB CLONAZEPAM MG ODT CLONAZEPAM 0.25 MG ODT CLONAZEPAM 0.5 MG DIS TABLET CLONAZEPAM 0.5 MG ODT CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1 MG DIS TABLET CLONAZEPAM 1 MG ODT CLONAZEPAM 1 MG TABLET CLONAZEPAM 2 MG ODT CLONAZEPAM 2 MG TABLET DIAZEPAM 10 MG TABLET DIAZEPAM 10 MG/2 ML CARPUJECT DIAZEPAM 10 MG/2 ML SYRINGE DIAZEPAM 10 MG/2 ML SYRINGE (CMPD-RX) DIAZEPAM 2 MG TABLET DIAZEPAM 5 MG TABLET DIAZEPAM 5 MG/5 ML ORAL SOLN DIAZEPAM 5 MG/5 ML SOLUTION DIAZEPAM 5 MG/ML ORAL CONC DIAZEPAM 5 MG/ML VIAL DIAZEPAM 50 MG/10 ML VIAL HYDROXYZINE 10 MG/5 ML SOLN HYDROXYZINE 10 MG/5 ML SYRUP HYDROXYZINE 100 MG/2 ML VIAL HYDROXYZINE 25 MG/ML VIAL HYDROXYZINE 50 MG/ML VIAL HYDROXYZINE 500 MG/10 ML VIAL HYDROXYZINE HCL 10 MG TABLET HYDROXYZINE HCL 25 MG TABLET HYDROXYZINE HCL 50 MG TABLET ALPRAZOLAM ALPRAZOLAM BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM HYDROXYZINE HCL SYRUP HYDROXYZINE HCL SYRUP HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL 24

25 2018 Trusted Health Plan Medicaid Formulary Antianxiety Agents LORAZEPAM 0.5 MG TABLET LORAZEPAM LORAZEPAM 1 MG TABLET LORAZEPAM LORAZEPAM 2 MG TABLET LORAZEPAM OXAZEPAM 10 MG CAPSULE OXAZEPAM OXAZEPAM 15 MG CAPSULE OXAZEPAM OXAZEPAM 30 MG CAPSULE OXAZEPAM Antiarrhythmics AMIODARONE HCL 200 MG TABLET AMIODARONE HCL AMIODARONE HCL 400 MG TABLET AMIODARONE HCL BETAPACE 120 MG TABLET BETAPACE BETAPACE 160 MG TABLET BETAPACE BETAPACE 240 MG TABLET BETAPACE BETAPACE 80 MG TABLET BETAPACE BETAPACE AF 120 MG TABLET BETAPACE AF BETAPACE AF 160 MG TABLET BETAPACE AF BETAPACE AF 80 MG TABLET BETAPACE AF DILTIAZEM 125 MG/25 ML VIAL DILTIAZEM HCL DILTIAZEM 25 MG/5 ML VIAL DILTIAZEM HCL DILTIAZEM 50 MG/10 ML VIAL DILTIAZEM HCL DILTIAZEM HCL 100 MG VIAL DILTIAZEM HCL DISOPYRAMIDE 100 MG CAPSULE DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE 150 MG CAPSULE DISOPYRAMIDE PHOSPHATE FLECAINIDE ACETATE 100 MG TAB FLECAINIDE ACETATE FLECAINIDE ACETATE 150 MG TAB FLECAINIDE ACETATE FLECAINIDE ACETATE 50 MG TAB FLECAINIDE ACETATE LIDOCAINE HCL 1% ABBOJECT LIDOCAINE HCL LIDOCAINE HCL 1% SYRINGE LIDOCAINE HCL LIDOCAINE HCL 2% ABBOJECT LIDOCAINE HCL LIDOCAINE HCL 2% LUER-JET LIDOCAINE HCL LIDOCAINE HCL 2% SYRINGE LIDOCAINE HCL LIDOCAINE HCL 2% VIAL LIDOCAINE HCL PHENYTOIN 100 MG/2 ML VIAL PHENYTOIN SODIUM PHENYTOIN 250 MG/5 ML VIAL PHENYTOIN SODIUM PHENYTOIN 50 MG/ML VIAL PHENYTOIN SODIUM PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 225 MG TAB PROPAFENONE HCL PROPAFENONE HCL 300 MG TAB PROPAFENONE HCL PROPAFENONE HCL ER 225 MG CAP PROPAFENONE HCL ER PROPAFENONE HCL ER 325 MG CAP PROPAFENONE HCL ER PROPAFENONE HCL ER 425 MG CAP PROPAFENONE HCL ER SORINE 120 MG TABLET SORINE SORINE 160 MG TABLET SORINE 25