2018 LIST OF COVERED DRUGS (FORMULARY)

Transcription

1 LIST OF COVERED DRUGS (FORMULARY) Prescription drug list information UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) Toll-Free , TTY a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week Formulary ID Number , Version 7 H2531_170614_100130_FINAL_01.02 Approved Last updated March 1, 2018

2 2 2 UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in UnitedHealthcare Connected for MyCare Ohio. v UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. v Benefits and/or copays may change on January 1 of each year. v You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date List of Covered Drugs online at v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected for MyCare Ohio Member Services or read the UnitedHealthcare Connected for MyCare Ohio Member Handbook. v Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. v If you speak Spanish, language assistance services, free of charge, are available to you. Call , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. v Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al , TTY 711, de lunes a viernes, de 8 a.m. a 8 p.m., hora local; correo de voz disponible las 24 horas del día, los 7 días de la semana. La llamada es gratuita. v You can get this document for free in other formats, such as large print, braille, or audio. Call , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. v You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

3 3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 3 1 What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by UnitedHealthcare Connected for MyCare Ohio. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. UnitedHealthcare Connected for MyCare Ohio will cover all medically necessary drugs on the Drug List if: Your doctor or other prescriber says you need them to get better or stay healthy, and You fill the prescription at a UnitedHealthcare Connected for MyCare Ohio network pharmacy. UnitedHealthcare Connected for MyCare Ohio may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at , TTY Does the Drug List ever change? Yes. UnitedHealthcare Connected for MyCare Ohio may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: A cheaper drug comes along that works as well as a drug on the Drug List now, or We learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected for MyCare Ohio before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see pages 4 and 9.) If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

4 4 4 We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date Drug List online at You can also call Member Services to check the current Drug List at , TTY What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will get a letter letting you know about the change. Contact your doctor or other prescriber to make sure this cheaper drug will work for you. 4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options. 5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. If you don t get approval, UnitedHealthcare Connected for MyCare Ohio may not cover the drug. Quantity limits: Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. Step therapy: Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

5 5 5 You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected for MyCare Ohio member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question 11 for more information about exceptions. 6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on pages has a column labeled. 7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8 How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

6 6 6 To search alphabetically, go to the Alphabetical Listing section. You can find it after the "List of Covered Drugs" section. Find the name of your drug. The page number where you can find the drug will be next to it. To search by medical condition, find the section labeled List of drugs by medical condition on pages The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9 What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at , TTY 711 and ask about it. If you learn that UnitedHealthcare Connected for MyCare Ohio will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10 What if you are a new UnitedHealthcare Connected for MyCare Ohio member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected for MyCare Ohio. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: You are taking a drug that is not on our Drug List, or Health plan rules do not let you get the amount ordered by your prescriber, or The drug requires prior approval by UnitedHealthcare Connected for MyCare Ohio, or You are taking a drug that is part of a step therapy restriction. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

7 7 7 If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as up to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and you are prescribed a drug that s not on the Drug List or if it s difficult for you to get your drugs, you are required to use the plan s exception process. You may ask for a one-time emergency supply of at least 31 days to give you time to talk to your doctor about other treatment options or to try to get an exception. 11 Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected for MyCare Ohio to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UnitedHealthcare Connected for MyCare Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12 How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 13 How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

8 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Connected for MyCare Ohio covers both brand name drugs and generic drugs. 15 What are OTC drugs? OTC stands for over-the-counter. UnitedHealthcare Connected for MyCare Ohio covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC drugs are covered. 16 Does UnitedHealthcare Connected for MyCare Ohio cover OTC nondrug products? UnitedHealthcare Connected for MyCare Ohio covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC non-drug products are covered. 17 What is your copay? You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to learn about the copay for each drug. UnitedHealthcare Connected for MyCare Ohio members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.25 to $3.35, depending on your income. Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.70 to $8.35, depending on your income. Tier 3 drugs have a $0 copay. They are OTCs/Non-Part D drugs. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 8 a.m. - 8 p.m. local time, Monday - Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

9 91 For Track Refered Purpose List of Covered Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. The List of Covered Drugs that begins on the next page gives you information about the drugs covered by UnitedHealthcare Connected for MyCare Ohio. If you have trouble finding your drug in the list, turn to the Index that begins on page 193. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the column tells you if UnitedHealthcare Connected for MyCare Ohio has any rules for covering your drug. Coverage Rules and Limits PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. If you don t get approval, UnitedHealthcare Connected for MyCare Ohio may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. LA - Limited access Drugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. 9

10 For Track Refered Purpose 1For 10 Track Refered Purpose 10 MED - Morphine equivalent dose Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is calculated based on the number of opioid drugs prescribed for you over a period of time. This cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for those individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at , TTY 711. You can also read the Member Handbook to learn how to appeal a decision. Analgesics Analgesics Hour Pain Relief 8 hour pain relief (tablet extended-release)* Acephen acephen (suppository)* Acetaminophen acetaminophen (120mg suppository, 650mg suppository, 160mg/5ml liquid, 160mg/5ml oral solution, 325mg tablet, 80mg tablet chewable)* Acetaminophen ER acetaminophen er (tablet extended-release)* Acetaminophen Extra Strength acetaminophen extra strength (tablet)* Arthritis Pain Relief arthritis pain relief (tablet extended-release)* Butalbital/Acetaminophen butalbital/acetaminophen (50mg-325mg tablet) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

11 2For 11 Track Refered Purpose Butalbital/Acetaminophen/Caffeine butalbital/acetaminophen/caffeine (325mg-50mg-40mg tablet, 50mg-325mg-40mg QL capsule) Butalbital/Aspirin/Caffeine butalbital/aspirin/caffeine (50mg-325mg-40mg capsule) QL Childrens Acetaminophen childrens acetaminophen (suspension)* Childrens Mapap Rapid Tabs childrens mapap rapid tabs (tablet dispersible)* Childrens Pain Reliever childrens pain reliever (tablet dispersible)* Childrens Silapap childrens silapap (liquid)* ED-APAP ed-apap (liquid)* Extra Strength Pain Relief extra strength pain relief (tablet)* FeverAll Adults feverall adults (suppository)* FeverAll Childrens feverall childrens (suppository)* FeverAll Infants feverall infants (suppository)* FeverAll Junior Strength feverall junior strength (suppository)* GNP 8 Hour Pain Reliever gnp 8 hour pain reliever (tablet extended-release)* GNP Arthritis Pain Relief gnp arthritis pain relief (tablet extended-release)* GNP Childrens Pain Relief gnp childrens pain relief (suspension)* GNP Infants Pain Relief gnp infants pain relief (suspension)* GNP Infants Pain/Fever gnp infants pain/fever (suspension)* GNP Pain & Fever Childrens gnp pain & fever childrens (suspension)* GNP Pain Relief gnp pain relief (tablet)* GNP Pain Relief Extra Strength gnp pain relief extra strength (tablet)* Goodsense Arthritis Pain goodsense arthritis pain (tablet extended-release)* Goodsense Pain & Fever Childrens goodsense pain & fever childrens (suspension)* Goodsense Pain & Fever Infants goodsense pain & fever infants (suspension)* Goodsense Pain Relief goodsense pain relief (tablet extended-release)* Goodsense Pain Relief Extra Strength goodsense pain relief extra strength (tablet)* HM Arthritis Pain Relief hm arthritis pain relief (tablet extended-release)* 11 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

12 3For 12 Track Refered Purpose 12 HM Pain & Fever Childrens hm pain & fever childrens (suspension)* HM Pain & Fever Infants hm pain & fever infants (suspension)* HM Pain Relief Extra Strength hm pain relief extra strength (tablet)* HM Pain Reliever hm pain reliever (tablet)* Junior Mapap junior mapap (tablet dispersible)* Mapap mapap (160mg/5ml liquid, 325mg tablet, 500mg tablet, 500mg capsule, 80mg tablet chewable)* Mapap Acetaminophen Extra Strength mapap acetaminophen extra strength (liquid)* Mapap Arthritis Pain mapap arthritis pain (tablet extended-release)* Mapap Childrens mapap childrens (160mg/5ml suspension, 80mg tablet dispersible)* Mapap Extra Strength mapap extra strength (tablet)* Non-Aspirin Childrens non-aspirin childrens (suspension)* Pain & Fever pain & fever (tablet)* Pain & Fever Childrens pain & fever childrens (160mg/5ml oral solution, 160mg/5ml suspension, 80mg tablet chewable)* Pain & Fever Extra Strength pain & fever extra strength (tablet)* Pain & Fever Infants pain & fever infants (suspension)* Pain Relief pain relief (tablet)* Pain Relief Childrens pain relief childrens (suspension)* Pain Relief Extra Strength pain relief extra strength (tablet)* Pain Reliever Extra Strength pain reliever extra strength (tablet)* Pharbetol pharbetol (tablet)* Pharbetol Extra Strength pharbetol extra strength (tablet)* QC Arthritis Pain Relief qc arthritis pain relief (tablet extended-release)* QC Non-Aspirin Childrens qc non-aspirin childrens (suspension)* QC Non-Aspirin Extra Strength qc non-aspirin extra strength (tablet)* QC Non-Aspirin Jr Strength qc non-aspirin jr strength (tablet dispersible)* Q-PAP q-pap (tablet)* Q-PAP Childrens q-pap childrens (suspension)* Q-PAP Extra Strength q-pap extra strength (tablet)* SB Non-Aspirin sb non-aspirin (tablet)* SB Non-Aspirin Extra Strength sb non-aspirin extra strength (tablet)* SB Pain Reliever Extra Strength sb pain reliever extra strength (tablet)* Sm 8 Hour Pain Relief sm 8 hour pain relief (tablet extended-release)* Sm Arthritis Pain Relief sm arthritis pain relief (tablet extended-release)* SM Pain & Fever Childrens sm pain & fever childrens (suspension)*

13 4For 13 Track Refered Purpose SM Pain & Fever Infants sm pain & fever infants (suspension)* SM Pain Reliever sm pain reliever (tablet)* SM Pain Reliever Extra Strength sm pain reliever extra strength (500mg capsule, 500mg tablet)* Tactinal tactinal (tablet)* Tactinal Extra Strength tactinal extra strength (tablet)* Tencon tencon (tablet) QL Zebutal zebutal (capsule) QL Nonsteroidal Anti-inflammatory Drugs All Day Pain Relief all day pain relief (otc only) (tablet)* All Day Relief all day relief (otc only) (tablet)* Aspir-81 aspir-81 (tablet delayed-release)* Aspirin aspirin (300mg suppository, 600mg suppository, 325mg tablet, 325mg tablet delayed-release, 81mg tablet delayed-release, 81mg tablet chewable)* Aspirin Adult Low Strength aspirin adult low strength (81mg tablet chewable, 81mg tablet delayed-release)* Aspirin EC aspirin ec (tablet delayed-release)* Aspirin EC Low Dose aspirin ec low dose (tablet delayed-release)* Aspirin Enteric Coated Adult Low Strength aspirin enteric coated adult low strength (tablet delayed-release)* Aspirin Low Dose aspirin low dose (81mg tablet chewable, 81mg tablet delayed-release)* Aspirin Low Strength aspirin low strength (tablet chewable)* Aspir-Low aspir-low (tablet delayed-release)* Childrens Aspirin childrens aspirin (tablet chewable)* Childrens Aspirin Low Strength childrens aspirin low strength (tablet chewable)* Childrens Ibuprofen childrens ibuprofen (otc only) (suspension)* Childs Ibuprofen childs ibuprofen (otc only) (suspension)* 13 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

14 5For 14 Track Refered Purpose 14 Diclofenac Potassium diclofenac potassium (tablet) Diclofenac Sodium diclofenac sodium (1% gel) PA Diclofenac Sodium DR diclofenac sodium dr (tablet delayed-release) Diclofenac Sodium ER diclofenac sodium er (tablet extended-release 24 hour) Diflunisal diflunisal (tablet) Ecpirin ecpirin (tablet delayed-release)* Enteric Coated Aspirin enteric coated aspirin (tablet delayed-release)* EQ Aspirin EC eq aspirin ec (tablet delayed-release)* Etodolac etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediaterelease) Flector FLECTOR (PATCH) $3.70-$8.35 (Tier 2) PA, QL Flurbiprofen flurbiprofen (tablet) GNP Adult Aspirin Low Strength gnp adult aspirin low strength (tablet chewable)* GNP All Day Pain Relief gnp all day pain relief (tablet)* GNP Aspirin gnp aspirin (325mg tablet, 325mg tablet delayedrelease)* GNP Aspirin Low Dose gnp aspirin low dose (tablet delayed-release)* GNP Childrens Ibuprofen gnp childrens ibuprofen (otc only) (suspension)* GNP Ibuprofen gnp ibuprofen (otc only) (tablet)* GNP Ibuprofen Infants gnp ibuprofen infants (suspension)* GNP Ibuprofen Junior Strength gnp ibuprofen junior strength (otc only) (tablet chewable)* GNP Naproxen Sodium gnp naproxen sodium (capsule)* Goodsense Aspirin goodsense aspirin (325mg tablet, 81mg tablet chewable)* Goodsense Ibuprofen goodsense ibuprofen (tablet)* Goodsense Ibuprofen Childrens goodsense ibuprofen childrens (suspension)* Goodsense Ibuprofen Infants goodsense ibuprofen infants (suspension)* Goodsense Ibuprofen Junior Strength goodsense ibuprofen junior strength (tablet chewable)* Goodsense Naproxen Sodium goodsense naproxen sodium (tablet)* HM Aspirin hm aspirin (325mg tablet, 81mg tablet chewable)* HM Aspirin EC hm aspirin ec (tablet delayed-release)* HM Aspirin EC Low Dose hm aspirin ec low dose (tablet delayed-release)* HM Ibuprofen hm ibuprofen (200mg capsule, 200mg tablet)*

15 6For 15 Track Refered Purpose HM Ibuprofen Childrens hm ibuprofen childrens (suspension)* HM Ibuprofen IB hm ibuprofen ib (otc only) (tablet)* HM Ibuprofen Infants hm ibuprofen infants (otc only) (suspension)* HM Naproxen Sodium hm naproxen sodium (otc only) (capsule)* Ibu-200 ibu-200 (tablet)* Ibu-Drops ibu-drops (suspension)* Ibu-Drops Infants ibu-drops infants (suspension)* Ibuprofen ibuprofen (otc only) (100mg/5ml suspension, 200mg capsule, 200mg tablet)* Ibuprofen ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) Ibuprofen Childrens ibuprofen childrens (otc only) (suspension)* Ibuprofen Junior Strength ibuprofen junior strength (otc only) (tablet chewable)* Indomethacin indomethacin (25mg capsule, 50mg capsule) Infants Ibuprofen infants ibuprofen (otc only) (suspension)* Ketoprofen ketoprofen (capsule immediate-release) Ketorolac Tromethamine ketorolac tromethamine (15mg/ml injection, 30mg/ ml injection, 60mg/2ml injection) Meloxicameloxicam (tablet) 15 Naproxen naproxen (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediate-release, 500mg tablet immediate-release) Naproxen DR naproxen dr (tablet delayed-release) (generic ecnaprosyn) Naproxen Sodium naproxen sodium (otc only) (220mg capsule, 220mg tablet)* Provil provil (tablet)* QC Aspirin qc aspirin (tablet)* QC Chewable Aspirin Low Dose qc chewable aspirin low dose (tablet chewable)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

16 7For 16 Track Refered Purpose 16 QC Childrens Ibuprofen qc childrens ibuprofen (suspension)* QC Enteric Aspirin qc enteric aspirin (tablet delayed-release)* QC Ibuprofen qc ibuprofen (otc only) (tablet)* QC Ibuprofen IB qc ibuprofen ib (tablet)* QC Naproxen Sodium qc naproxen sodium (otc only) (tablet)* SB Aspirin sb aspirin (325mg tablet, 81mg tablet delayed- release)* SB Aspirin Adult Low Strength sb aspirin adult low strength (tablet delayedrelease)* SB Childrens Aspirin sb childrens aspirin (tablet chewable)* SB Childrens Ibuprofen sb childrens ibuprofen (otc only) (suspension)* SB Ibuprofen sb ibuprofen (tablet)* SB Infants Ibuprofen sb infants ibuprofen (suspension)* SB Low Dose Asa EC sb low dose asa ec (tablet delayed-release)* SB Naproxen Sodium sb naproxen sodium (tablet)* SM Aspirin sm aspirin (tablet)* SM Aspirin Adult Low Strength sm aspirin adult low strength (81mg tablet chewable, 81mg tablet delayed-release)* SM Aspirin Enteric Coated sm aspirin enteric coated (tablet delayed-release)* SM Childrens Aspirin sm childrens aspirin (tablet chewable)* SM Childrens Ibuprofen sm childrens ibuprofen (otc only) (suspension)* SM Ibuprofen sm ibuprofen (200mg capsule, 200mg tablet)* SM Ibuprofen IB sm ibuprofen ib (100mg tablet chewable, 200mg tablet)* SM Infants Ibuprofen sm infants ibuprofen (otc only) (suspension)* SM Naproxen Sodium sm naproxen sodium (tablet)* Sulindac sulindac (tablet) Opioid Analgesics, Long-acting Embeda EMBEDA (CAPSULE EXTENDED-RELEASE) $3.70-$8.35 (Tier 2) QL, MED Fentanyl fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch QL, MED 72 hour, 75mcg/hr patch 72 hour) Hydromorphone HCl ER hydromorphone hcl er (tablet extended-release 24 hour abuse-deterrent) QL, MED Hysingla ER HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR ABUSE-DETERRENT) $3.70-$8.35 (Tier 2) QL, MED Levorphanol Tartrate levorphanol tartrate (tablet) QL, MED

17 8For 17 Track Refered Purpose Methadone HCl methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution) QL, MED Methadone HCl METHADONE HCL (10MG/ML INJECTION) $3.70-$8.35 (Tier 2) Morphine Sulfate ER morphine sulfate er (100mg tablet extended-release, 15mg tablet extended-release, 200mg tablet extended-release, 30mg tablet extended-release, 60mg tablet extended-release) (generic ms contin) QL, MED Nucynta ER NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.70-$8.35 (Tier 2) QL, MED Tramadol HCl ER tramadol hcl er (100mg tablet extended-release 24 hour, 200mg tablet extended-release 24 hour, QL, MED 300mg tablet extended-release 24 hour) Xtampza ER XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12 HOUR ABUSE-DETERRENT) $3.70-$8.35 (Tier 2) QL, MED Opioid Analgesics, Short-acting Abstral ABSTRAL (TABLET SUBLINGUAL) $3.70-$8.35 (Tier 2) PA, QL Acetaminophen/Codeine acetaminophen/codeine (120mg-12mg/5ml oral solution, 300mg-15mg tablet, 300mg-30mg tablet, QL, MED 300mg-60mg tablet) Butorphanol Tartrate butorphanol tartrate (10mg/ml nasal solution) QL, MED Butorphanol Tartrate butorphanol tartrate (1mg/ml injection, 2mg/ml injection) Codeine Sulfate codeine sulfate (tablet) QL, MED Duramorph DURAMORPH (INJECTION) $3.70-$8.35 (Tier 2) Endocet endocet (tablet) QL, MED Fentanyl Citrate Oral Transmucosal fentanyl citrate oral transmucosal (lozenge on a handle) PA, QL Hydrocodone/Acetaminophen hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet, 7.5mg-325mg/15ml oral solution) QL, MED Hydrocodone/Ibuprofen hydrocodone/ibuprofen (7.5mg-200mg tablet) QL, MED 17 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

18 9For 18 Track Refered Purpose 18 Hydromorphone HCl hydromorphone hcl (10mg/ml injection, 50mg/5ml injection) Hydromorphone HCl hydromorphone hcl (1mg/ml liquid, 2mg tablet immediate-release, 4mg tablet immediate-release, QL, MED 8mg tablet immediate-release) Hydromorphone HCl HYDROMORPHONE HCL (2MG/ML INJECTION) $3.70-$8.35 (Tier 2) Lorcet lorcet (tablet) QL, MED Lorcet HD lorcet hd (tablet) QL, MED Lorcet Plus lorcet plus (tablet) QL, MED Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/ 5ml oral solution, 20mg/5ml oral solution) QL, MED Morphine Sulfate morphine sulfate (10mg/ml injection, 4mg/ml injection, 8mg/ml injection) Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE- RELEASE, 30MG TABLET IMMEDIATE-RELEASE) $3.70-$8.35 (Tier 2) QL, MED Morphine Sulfate MORPHINE SULFATE (2MG/ML INJECTION, 5MG/ML INJECTION) $3.70-$8.35 (Tier 2) Nalbuphine HCl nalbuphine hcl (injection) Oxycodone HCl oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediaterelease, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) QL, MED Oxycodone/Acetaminophen oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, QL, MED 7.5mg-325mg tablet) Oxycodone/Aspirin oxycodone/aspirin (tablet) QL, MED Oxycodone/Ibuprofen oxycodone/ibuprofen (tablet) QL, MED Tramadol HCl tramadol hcl (tablet immediate-release) QL, MED Tramadol HCl/Acetaminophen tramadol hcl/acetaminophen (tablet) QL, MED Trezix trezix (capsule) QL, MED Anesthetics Local Anesthetics Lidocaine lidocaine (otc only) (4% cream)* Lidocaine lidocaine (rx only) (5% ointment) Lidocaine lidocaine (rx only) (5% patch) PA, QL Lidocaine HCl lidocaine hcl (0.5% injection, 1% injection, 2% injection) B/D, PA

19 For Track Refered Purpose Lidocaine HCl lidocaine hcl (4% external solution) Lidocaine HCl lidocaine hcl (gel) Lidocaine Viscous lidocaine viscous (solution) Lidocaine/Prilocaine lidocaine/prilocaine (cream) Anti-Addiction/Substance Abuse Treatment Agents 19 Alcohol Deterrents/Anti-craving Acamprosate Calcium DR acamprosate calcium dr (tablet delayed-release) Disulfiram disulfiram (tablet) Naltrexone HCl naltrexone hcl (tablet) Vivitrol VIVITROL (INJECTION) $3.70-$8.35 (Tier 2) Opioid Dependence Treatments Buprenorphine HCl buprenorphine hcl (0.3mg/ml injection) Buprenorphine HCl buprenorphine hcl (2mg tablet sublingual, 8mg tablet sublingual) QL Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (tablet sublingual) QL Suboxone SUBOXONE (FILM) $3.70-$8.35 (Tier 2) QL Opioid Reversal Agents Naloxone HCl naloxone hcl (injection) Narcan NARCAN (LIQUID) $3.70-$8.35 (Tier 2) Smoking Cessation Agents Bupropion HCl SR bupropion hcl sr (150mg tablet extended-release 12 hour) Chantix CHANTIX (TABLET) $3.70-$8.35 (Tier 2) Chantix Continuing Month Pak CHANTIX CONTINUING MONTH PAK (TABLET) $3.70-$8.35 (Tier 2) Chantix Starting Month Pak CHANTIX STARTING MONTH PAK (TABLET) $3.70-$8.35 (Tier 2) GNP Nicotine Mini Lozenge gnp nicotine mini lozenge* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

20 For Track Refered Purpose 20 GNP Nicotine Polacrilex gnp nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* GNP Nicotine Polacrilex Mini gnp nicotine polacrilex mini (lozenge)* GNP Nicotine Transdermal System gnp nicotine transdermal system (patch 24 hour)* Goodsense Nicotine Gum goodsense nicotine gum* HM Nicotine Polacrilex hm nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* HM Nicotine Transdermal System hm nicotine transdermal system (patch 24 hour)* HM Nicotine Transdermal System Step 3 hm nicotine transdermal system step 3 (patch 24 hour)* NicoDerm CQ nicoderm cq (patch 24 hour)* NICOrelief nicorelief (gum)* Nicorette nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* Nicorette Mini nicorette mini (lozenge)* Nicorette Starter Kit nicorette starter kit (gum)* Nicotine Polacrilex nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* Nicotine Transdermal System nicotine transdermal system (kit, 14mg/24hr patch 24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24 hour)* Nicotine Transdermal System Step 1 nicotine transdermal system step 1 (patch 24 hour)* Nicotine Transdermal System Step 2 nicotine transdermal system step 2 (patch 24 hour)* Nicotine Transdermal System Step 3 nicotine transdermal system step 3 (patch 24 hour)* Nicotrol Inhaler NICOTROL INHALER (INHALER) $3.70-$8.35 (Tier 2) SM Nicotine sm nicotine (2mg lozenge, 4mg gum)* SM Nicotine Polacrilex sm nicotine polacrilex (2mg gum, 4mg gum, 4mg lozenge)* SM Nicotine Transdermal System sm nicotine transdermal system (patch 24 hour)* Antibacterials Aminoglycosides Amikacin Sulfate amikacin sulfate (injection) Gentak gentak (ophthalmic ointment) Gentamicin Sulfate gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% ophthalmic solution, 10mg/ml injection, 40mg/ ml injection) Gentamicin Sulfate/0.9% Sodium Chloride gentamicin sulfate/0.9% sodium chloride (injection)

21 For Track Refered Purpose Isotonic Gentamicin isotonic gentamicin (injection) Neomycin Sulfate neomycin sulfate (tablet) Paromomycin Sulfate paromomycin sulfate (capsule) Streptomycin Sulfate streptomycin sulfate (injection) Tobramycin Sulfate tobramycin sulfate (0.3% ophthalmic solution, 10mg/ ml injection, 80mg/2ml injection) Tobrex TOBREX (0.3% OPHTHALMIC OINTMENT) $3.70-$8.35 (Tier 2) Antibacterials, Other BACiiM baciim (injection) Bacitracin bacitracin (otc only) (ointment)* Bacitracin bacitracin (rx only) (50000unit injection, 500unit/gm ophthalmic ointment) Bacitracin Zinc bacitracin zinc (ointment)* Bacitracin/Neomycin/Polymyxin bacitracin/neomycin/polymyxin (otc only) (ointment)* Bactroban Nasal BACTROBAN NASAL (OINTMENT) $3.70-$8.35 (Tier 2) PA Betadine betadine (external solution)* Betadine Skin Cleanser betadine skin cleanser (external solution)* Betadine Surgical Scrub betadine surgical scrub (external solution)* Betadine Swab Aid betadine swab aid (swab)* Betadine Swabsticks betadine swabsticks (swab)* Chloramphenicol Sodium Succinate chloramphenicol sodium succinate (injection) Clindamycin HCl clindamycin hcl (capsule immediate-release) Clindamycin Palmitate HCl clindamycin palmitate hcl (oral solution) Clindamycin Phosphate clindamycin phosphate (2% cream, 300mg/2ml injection, 600mg/4ml injection, 900mg/6ml injection) Clindamycin Phosphate D5W clindamycin phosphate in d5w (injection) Colistimethate Sodium colistimethate sodium (injection) Cubicin CUBICIN (INJECTION) $3.70-$8.35 (Tier 2) 21 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

22 For Track Refered Purpose 22 Dalvance DALVANCE (INJECTION) $3.70-$8.35 (Tier 2) PA Daptomycin daptomycin (injection) Double Antibiotic double antibiotic (ointment)* GNP Bacitracin Zinc gnp bacitracin zinc (ointment)* GNP Povidone-Iodine gnp povidone-iodine (external solution)* GNP Triple Antibiotic gnp triple antibiotic (ointment)* GNP Triple Antibiotic Plus gnp triple antibiotic plus (ointment)* HM Bacitracin hm bacitracin (ointment)* HM Double Antibiotic hm double antibiotic (ointment)* HM Povidone-Iodine hm povidone-iodine (external solution)* HM Triple Antibiotic hm triple antibiotic (ointment)* HM Triple Antibiotic Plus Maximum Strength hm triple antibiotic plus maximum strength (ointment)* Lincomycin HCl lincomycin hcl (injection) Linezolid linezolid (100mg/5ml suspension, 600mg/300ml injection) PA Linezolid linezolid (600mg tablet) PA, QL Methenamine Hippurate methenamine hippurate (tablet) Metronidazole metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75% lotion, 250mg tablet immediate-release, 500mg tablet immediate-release) Metronidazole in NaCl 0.79% metronidazole in nacl 0.79% (injection) Metronidazole Vaginal metronidazole vaginal (gel) Mupirocin mupirocin (2% ointment) Neomycin/Polymyxin B Sulfates neomycin/polymyxin b sulfates (irrigation solution) Nitrofurantoin nitrofurantoin (suspension) Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg capsule) (generic macrodantin) Nitrofurantoin Monohydrate nitrofurantoin monohydrate (100mg capsule) (generic macrobid) Polymyxin B Sulfate polymyxin b sulfate (injection) Povidone-Iodine povidone-iodine (10% external solution, 10% ointment)* QC Povidone Iodine qc povidone iodine (external solution)* SB Povidone-Iodine sb povidone-iodine (solution)* Sm Antibiotic sm antibiotic (ointment)* Sm Antibiotic Plus Pain Relief Maximum Strength sm antibiotic plus pain relief maximum strength (cream)*

23 For Track Refered Purpose SM Double Antibiotic sm double antibiotic (ointment)* Sm Povidone-Iodine sm povidone-iodine (external solution)* SM Triple Antibiotic sm triple antibiotic (ointment)* SM Triple Antibiotic Plus Maximum Strength sm triple antibiotic plus maximum strength (ointment)* Synercid SYNERCID (INJECTION) $3.70-$8.35 (Tier 2) Tigecycline TIGECYCLINE (INJECTION) $3.70-$8.35 (Tier 2) Tinidazole tinidazole (tablet) Trimethoprim trimethoprim (tablet) Triple Antibiotic triple antibiotic (ointment)* Triple Antibiotic Plus triple antibiotic plus (ointment)* Tygacil TYGACIL (INJECTION) $3.70-$8.35 (Tier 2) Vancomycin HCl vancomycin hcl (1000mg injection, 10gm injection, 500mg injection, 125mg capsule, 250mg capsule) Vandazole VANDAZOLE (GEL) $3.70-$8.35 (Tier 2) Beta-lactam, Cephalosporins Cefaclor cefaclor (250mg capsule immediate-release, 500mg capsule immediate-release) Cefadroxil cefadroxil (250mg/5ml suspension, 500mg/5ml suspension, 500mg capsule) Cefazolin Sodium cefazolin sodium (injection) Cefdinir cefdinir (125mg/5ml suspension, 250mg/5ml suspension, 300mg capsule) Cefepime cefepime (injection) Cefixime cefixime (suspension) Cefotaxime Sodium cefotaxime sodium (injection) Cefotetan cefotetan (injection) Cefoxitin Sodium cefoxitin sodium (10gm injection, 1gm injection, 2gm injection) 23 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

24 For Track Refered Purpose 24 Cefpodoxime Proxetil cefpodoxime proxetil (100mg tablet, 200mg tablet, 100mg/5ml suspension, 50mg/5ml suspension) Cefprozil cefprozil (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) Ceftazidime ceftazidime (injection) Ceftriaxone Sodium ceftriaxone sodium (10gm injection, 1gm injection, 250mg injection, 2gm injection, 500mg injection) Cefuroxime Axetil cefuroxime axetil (tablet) Cefuroxime Sodium cefuroxime sodium (injection) Cephalexin cephalexin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule, 750mg capsule) Suprax suprax (100mg tablet chewable, 200mg tablet chewable) Suprax SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.70-$8.35 (Tier 2) Tazicef tazicef (injection) Zerbaxa ZERBAXA (INJECTION) $3.70-$8.35 (Tier 2) PA Beta-lactam, Other Azactam AZACTAM (INJECTION) $3.70-$8.35 (Tier 2) Aztreonam aztreonam (injection) Imipenem/Cilastatin imipenem/cilastatin (injection) Invanz INVANZ (INJECTION) $3.70-$8.35 (Tier 2) Meropenem meropenem (injection) Beta-lactam, Penicillins Amoxicillin amoxicillin (125mg tablet chewable, 250mg tablet chewable, 125mg/5ml suspension, 200mg/5ml suspension, 250mg/5ml suspension, 400mg/5ml suspension, 250mg capsule, 500mg capsule, 500mg tablet, 875mg tablet) Amoxicillin/Clavulanate Potassium amoxicillin/clavulanate potassium (200mg-28.5mg tablet chewable, 400mg-57mg tablet chewable, 200mg/5ml-28.5mg/5ml suspension, 250mg/ 5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml suspension, 600mg/5ml-42.9mg/5ml suspension, 250mg-125mg tablet immediate-release, 500mg-125mg tablet immediate-release, 875mg-125mg tablet immediate-release) (generic augmentin)

25 For Track Refered Purpose Amoxicillin/Clavulanate Potassium ER amoxicillin/clavulanate potassium er (tablet extended-release 12 hour) Ampicillin ampicillin (capsule) Ampicillin Sodium ampicillin sodium (10gm injection, 125mg injection, 1gm injection) Ampicillin-Sulbactam ampicillin-sulbactam (injection) Bactocill in Dextrose BACTOCILL IN DEXTROSE (INJECTION) $3.70-$8.35 (Tier 2) Bicillin C-R BICILLIN C-R (INJECTION) $3.70-$8.35 (Tier 2) Bicillin L-A BICILLIN L-A (INJECTION) $3.70-$8.35 (Tier 2) Dicloxacillin Sodium dicloxacillin sodium (capsule) Nafcillin Sodium nafcillin sodium (injection) Oxacillin Sodium oxacillin sodium (injection) Penicillin G Potassium penicillin g potassium (injection) Penicillin G Procaine penicillin g procaine (injection) Penicillin G Sodium penicillin g sodium (injection) Penicillin V Potassium penicillin v potassium (125mg/5ml oral solution, 250mg/5ml oral solution, 250mg tablet, 500mg tablet) Piperacillin/Tazobactam piperacillin/tazobactam (injection) Macrolides Azithromycin azithromycin (100mg/5ml suspension, 200mg/5ml suspension, 250mg tablet, 500mg tablet, 500mg injection, 600mg tablet) Clarithromycin clarithromycin (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) Clarithromycin ER clarithromycin er (tablet extended-release 24 hour) Dificid DIFICID (TABLET) $3.70-$8.35 (Tier 2) Granules E.E.S. GRANULES (SUSPENSION) $3.70-$8.35 (Tier 2) Ery-Tab ery-tab (tablet delayed-release) 25 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

26 For Track Refered Purpose 26 EryPed 200 ERYPED 200 (SUSPENSION) $3.70-$8.35 (Tier 2) EryPed 400 ERYPED 400 (SUSPENSION) $3.70-$8.35 (Tier 2) Erythrocin Lactobionate erythrocin lactobionate (injection) Erythromycin erythromycin (250mg capsule delayed-release, 5mg/ gm ophthalmic ointment) Erythromycin Base erythromycin base (tablet) Erythromycin Ethylsuccinate erythromycin ethylsuccinate (200mg/5ml suspension, 400mg tablet) Zmax ZMAX (SUSPENSION) $3.70-$8.35 (Tier 2) Quinolones Avelox AVELOX (400MG/250ML-0.8% INJECTION) $3.70-$8.35 (Tier 2) Ciprofloxacin ciprofloxacin (250mg/5ml suspension, 500mg/5ml suspension, 400mg/40ml injection) Ciprofloxacin ER ciprofloxacin er (tablet extended-release 24 hour) Ciprofloxacin HCl ciprofloxacin hcl (0.3% ophthalmic solution, 100mg tablet immediate-release, 250mg tablet immediaterelease, 500mg tablet immediate-release, 750mg tablet immediate-release) Ciprofloxacin I.V. in D5W ciprofloxacin i.v. in d5w (injection) Levofloxacin levofloxacin (0.5% ophthalmic solution, 250mg tablet, 500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/ml oral solution) Levofloxacin D5W levofloxacin in d5w (injection) Moxeza MOXEZA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2) Moxifloxacin HCl moxifloxacin hcl (0.5% ophthalmic solution, 400mg tablet) Moxifloxacin HCl MOXIFLOXACIN HCL (400MG/250ML INJECTION) Ofloxacin ofloxacin (0.3% ophthalmic solution, 0.3% otic solution, 300mg tablet, 400mg tablet) Vigamox VIGAMOX (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2) Sulfonamides Silver Sulfadiazine SILVER SULFADIAZINE (CREAM) $3.70-$8.35 (Tier 2) Sodium Sulfacetamide sodium sulfacetamide (ophthalmic solution) SSD (CREAM) $3.70-$8.35 (Tier 2) Sulfacetamide Sodium sulfacetamide sodium (ophthalmic ointment) Sulfadiazine sulfadiazine (tablet)