Formulary (Drug List)

Formulary (Drug List) PacificSource Community Solutions This list was updated on /5/07 Please Read: This document contains information about the drugs we cover on this plan. For a complete, up-to-date list of covered drugs, visit our website: www.communitysolutions.pacificsource.com 07 Este manual está disponible en español a petición del interesado al (800) 4-45 para Central Oregon, o (855) 04-965 para Columbia Gorge. Si usted necesita servicios de intérprete, por favor llame al teléfono (800) 4-45 si vive en Central Oregon o al teléfono (855) 04-965 si vive en Columbia Gorge. You can get this in another language, large print, or another way that s best for you. Call toll-free (800) 4-45. TTY users call toll-free (800) 75-900. MEDM5v_DMAP Approved 080505

Prescription drugs are a very important part of your healthcare benefits. The following information will help you get the most out of your prescription drug benefit. Important Terms: What is a Formulary? A formulary is a drug list that includes generic, brand name, and specialty drugs that are covered by us. This list of drugs begins on page 4. The drug list has information on drug tiers and important notes that will help you see how or if your drug is covered. The formulary (drug list) is available online. To view the most current list visit our website: www.communitysolutions.pacificsource.com How do I use the Formulary? There are two ways to find a drug in the formulary:. Medical Condition The drugs are listed into categories that match the type of medical conditions treated by each drug. For example, drugs for anxiety are listed under the category "Antianxiety Agents".. Alphabetical Listing If you are not sure what category to look under, find your drug in the index that follows the formulary. The index provides an alphabetical listing of all the drugs included in the formulary and the page where they can be found in the formulary. What is a Tier? A tier shows how a drug is priced. Drugs on the formulary are grouped into tiers. Tier numbers go up as the price of the drug goes up. Tier (Generic) Generic drugs are approved by the Food and Drug Administration (FDA) as having the same active ingredient as brand name drugs. These drugs are generic and have the lowest prices and best value. Tier (Brand) These are brand name drugs and cost more than generic These drugs are only made by one drug company. You are required to try the generic drug instead of the brand drug if a generic drug is available. Tier (Specialty) These drugs are specialty drugs. Tier drugs are very expensive. Special restrictions apply to these drugs. What is a Co-pay? You do not have co-pays for your covered drugs. A co-pay is a set dollar amount that you would pay for each drug. What is an In-network Pharmacy? An in-network pharmacy is a pharmacy that has agreed to work with our members. They accept our payment in full for covered drugs. Are there any restrictions on my coverage? Yes. This next section includes any limitations or restrictions on your medication. This may include information on quantity limits, if the medication requires preapproval or step therapy, or if the medication has any other important restrictions (like an age restriction). We cover both brand name and generic drugs. If a generic drug is available, we will generally not cover a brand name drug. You must use an in-network pharmacy when filling your drugs. Most drugs are limited to a -day supply when filled at in-network retail pharmacies. Birth control can be filled for up to a 00-day supply at a participating pharmacy. You may get up to a 60-day supply of most drugs at Wellpartner, Inc., one of our in-network mail-order pharmacies. To get your drugs through mail-order, please contact one of our in-network mail-order pharmacies: Page of 45

Caremark Prescription Services (866) 6-4009 Toll-free 7 TTY www.caremark.com Wellpartner, Inc. (877) 95-5797 Toll-free (50) 76-466 TTY www.wellpartner.com Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Partial Fill: Some drugs have high cost and side effects that makes them harder to tolerate for long term use. These types of medications will be dispensed in a limited amount on the first fill only. This acts as a trial period to see if you are able to tolerate the drug. If the trial is a success, all other fills will be for the full amount. PA (Preapproval): If "PA" appears in the notes column, the drug requires preapproval. This means you will need to get approval from us to pay for your drug. Your doctor will need to submit chart notes to us. We will review the chart notes to see if we can approve the drug. If you do not get approval before you fill your prescription, we may not cover the drug. QL (Quantity Limits): If "QL" appears in the notes column, the drug may be covered by us but only up to a certain quantity or limit. If you need quantities higher than the limit shown, have your doctor contact us for approval. ST (Step Therapy): If "ST" appears in the notes column, you are required to try a lower-cost alternative drug ( Step drugs ) first before using the more expensive ( Step drugs ) drug. If it is medically necessary for you to use a Step drug first, your doctor will need to submit a request for approval. LA (Limited Access): If "LA" appears in the notes column, your drug has limited access. This means the drug is available only at certain pharmacies and is limited to a -day supply. Specialty Medications: Specialty drugs are listed as Tier on the formulary. Tier drugs are limited to a -day supply. They must be filled at CVS Caremark Specialty Pharmacy. CVS Caremark Specialty Pharmacy (800) 7-767 Toll-free, 7 TTY www.cvscaremarkspecialtyrx.com How do I get approval for my drug? Certain drugs will require additional approval (PA,ST, QL). This means that we will not pay for the drug without first receiving the important information we need from you or your doctor. If your drug requires "PA or QL" you can: Have your doctor submit medical chart notes to us for review. If your drug requires "ST" you can: Ask your doctor about prescribing a Step drug instead. You and your doctor can get more information about specific restrictions by visiting our website. We have posted our preapproval and step therapy policies on our website under "Utilization Management": www.communitysolutions.pacificsource.com/tools/drugsearch Which drugs are not covered by us? Sometimes we may have to add or remove drugs from the formulary or change coverage rules. We will work with your doctor to find a replacement drug if your drug is removed from the formulary. These drugs are not covered: Drugs not included in the formulary (non-formulary drugs). (see "How do I ask for an exception?" on page ). Drugs used to treat illnesses that are not covered by the Oregon Health Plan. Drugs that need preapproval but were not approved in advance by the plan. Drugs used for cosmetic (non-medical) reasons. Immunizations (shots) for travel outside of the country. Drugs that are paid for by Medicare (if you also have Medicare benefits). Drugs that need more research or testing. Page of 45

Most drugs used to treat mental illnesses are paid for by the Oregon Health Authority (OHA). The pharmacy will bill OHA for these drugs. Please see your Member Handbook for a full list of benefit limits and exclusions. The Prioritized List of Health Services We contract with the Oregon Health Authority (OHA) and must follow their rules and guidelines. OHA covers a list of certain conditions and diseases. This list is called the Prioritized List of Health Services. For a drug to be covered, it must be used to treat a condition (illness) that is covered by the Oregon Health Plan. To view the current Prioritized List, please visit: www.oregon.gov/oha/herc/pages/prioritizedlist.aspx What if my drug is not on the Drug List? If your drug is not included on the list of covered drugs for your plan, you can: Visit our website or contact Customer Service for a list of similar drugs that are covered by us. You can talk to your doctor about prescribing a similar drug that is covered by us. You can ask us to make an exception and cover your drug. How do I ask for an exception? You can ask us to cover a drug even if it is not on the formulary. Your doctor will need to submit chart notes for us to review. Providers: For help submitting a request for an exception or preapproval, please contact our Pharmacy Services department: (54) 0-4999 (888) 47-778 Toll-free Getting Refills at the Same Time: It is important to take your drug(s) exactly as prescribed. This can be hard if you take many drugs that refill at different times. This may require many trips to the pharmacy. Our drug synchronization program may be able to coordinate your drug refills so your drugs will be ready at the same time. (Certain limitations apply.) We will work with your providers to review your options and develop you a synchronization plan. To synchronize your drug refills, please ask your doctor or pharmacist to contact our Pharmacy Services department: (54) 0-4999 (888) 47-778 Toll-free Contact Customer Service: For help or more information, please call Customer Service, Monday through Friday, 8:00 a.m. to 5:00 p.m. Central Oregon: (54) 8-590 or toll-free (800) 4-45 Columbia Gorge: (855) 04-965 TTY: (800) 75-900 The following will also be considered before we will cover a non-formulary drug: The condition that the drug is treating must be a covered condition according to OHA s Prioritized List. The reason why other drugs on the formulary (drug list) are not a good choice for you. How does my doctor submit a request for a drug? Your provider will need to submit a request for you online via the InTouch portal located on our website: www.communitysolutions.pacificsource.com/providers. Page of 45

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) amphetamine-dextroamphet er capsule extended release 4 hour 0 mg amphetamine-dextroamphet er capsule extended release 4 hour 5 mg amphetamine-dextroamphet er capsule extended release 4 hour 0 mg amphetamine-dextroamphet er capsule extended release 4 hour 5 mg amphetamine-dextroamphet er capsule extended release 4 hour 0 mg amphetamine-dextroamphet er capsule extended release 4 hour 5 mg amphetaminedextroamphetamine tablet 0 mg amphetaminedextroamphetamine tablet.5 mg QL 90/0 QL 60/0 QL 60/0 QL 60/0 QL 60/0 QL 90/0 QL 90/0 QL 90/0 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) - continued amphetaminedextroamphetamine tablet 5 mg amphetaminedextroamphetamine tablet 0 mg amphetaminedextroamphetamine tablet 0 mg amphetaminedextroamphetamine tablet 5 mg amphetaminedextroamphetamine tablet 7.5 mg caffeine citrate solution 0 mg/ml caffeine citrate solution 60 mg/ml dexmethylphenidate hcl er capsule extended release 4 hour 0 mg dexmethylphenidate hcl er capsule extended release 4 hour 5 mg QL 60/0 QL 60/0 QL 60/0 QL 0/0 QL 90/0 QL 0/0 QL 0/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 4 of 45

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) - continued dexmethylphenidate hcl er capsule extended release 4 hour 0 mg dexmethylphenidate hcl er capsule extended release 4 hour 5 mg dexmethylphenidate hcl er capsule extended release 4 hour 0 mg dexmethylphenidate hcl er capsule extended release 4 hour 5 mg dexmethylphenidate hcl er capsule extended release 4 hour 40 mg dexmethylphenidate hcl er capsule extended release 4 hour 5 mg dexmethylphenidate hcl tablet 0 mg dexmethylphenidate hcl tablet.5 mg dexmethylphenidate hcl tablet 5 mg QL 0/0 QL 0/0 QL 60/0 QL 0/0 QL 0/0 QL 0/0 QL 0/0 QL 60/0 QL 90/0 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) - continued dextroamphetamine sulfate er capsule extended release 4 hour 0 mg dextroamphetamine sulfate er capsule extended release 4 hour 5 mg dextroamphetamine sulfate er capsule extended release 4 hour 5 mg dextroamphetamine sulfate solution 5 mg/5ml dextroamphetamine sulfate tablet 0 mg dextroamphetamine sulfate tablet 5 mg methamphetamine hcl tablet 5 mg methylphenidate hcl er (cd) capsule extended release 0 mg methylphenidate hcl er (cd) capsule extended release 0 mg methylphenidate hcl er (cd) capsule extended release 0 mg QL 0/0 QL 0/0 QL 0/0 QL 800/0 QL 80/0 QL 90/0 QL 0/0 QL 60/0 QL 60/0 QL 60/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 5 of 45

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) - continued methylphenidate hcl er (cd) capsule extended release 40 mg methylphenidate hcl er (cd) capsule extended release 50 mg methylphenidate hcl er (cd) capsule extended release 60 mg methylphenidate hcl er (la) capsule extended release 4 hour 0 mg methylphenidate hcl er (la) capsule extended release 4 hour 0 mg methylphenidate hcl er (la) capsule extended release 4 hour 40 mg methylphenidate hcl er (la) capsule extended release 4 hour 60 mg methylphenidate hcl er tablet extended release 0 mg methylphenidate hcl er tablet extended release 8 mg QL 0/0 QL 0/0 QL 0/0 QL 60/0 QL 60/0 QL 0/0 QL 0/0 QL 90/0 QL 60/0 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) - continued methylphenidate hcl er tablet extended release 0 mg methylphenidate hcl er tablet extended release 4 hour 8 mg methylphenidate hcl er tablet extended release 4 hour 7 mg methylphenidate hcl er tablet extended release 4 hour 6 mg methylphenidate hcl er tablet extended release 4 hour 54 mg methylphenidate hcl er tablet extended release 7 mg methylphenidate hcl er tablet extended release 6 mg methylphenidate hcl er tablet extended release 54 mg methylphenidate hcl solution 0 mg/5ml methylphenidate hcl solution 5 mg/5ml methylphenidate hcl tablet 0 mg QL 60/0 QL 60/0 QL 60/0 QL 60/0 QL 0/0 QL 60/0 QL 60/0 QL 0/0 QL 900/0 QL 800/0 QL 80/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 6 of 45

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (Medications to manage the symptoms of Attention Deficit Hyperactivity Disorder and excessive sleepiness) - continued methylphenidate hcl tablet 0 mg methylphenidate hcl tablet 5 mg methylphenidate hcl tablet chewable 0 mg methylphenidate hcl tablet chewable.5 mg methylphenidate hcl tablet chewable 5 mg VYVANSE CAPSULE 0 MG VYVANSE CAPSULE 0 MG VYVANSE CAPSULE 0 MG VYVANSE CAPSULE 40 MG VYVANSE CAPSULE 50 MG VYVANSE CAPSULE 60 MG VYVANSE CAPSULE 70 MG QL 90/0 QL 80/0 QL 80/0 QL 80/0 QL 80/0 QL 60/0, ST QL 0/0, ST QL 0/0, ST QL 0/0, ST QL 0/0, ST QL 0/0, ST QL 0/0, ST Amino Acids (Medications to treat sickle cell disease) ENDARI PACKET 5 GM AMINOGLYCOSIDES (Medications to treat certain types of bacterial infection) amikacin sulfate solution gm/4ml injection amikacin sulfate solution 500 mg/ml injection gentamicin sulfate solution 0 mg/ml injection neomycin sulfate tablet 500 mg paromomycin sulfate capsule 50 mg TOBI PODHALER CAPSULE 8 MG INHALATION TOBRAMYCIN NEBULIZATION SOLUTION 00 MG/5ML INHALATION tobramycin sulfate solution. gm/0ml injection tobramycin sulfate solution 0 mg/ml injection tobramycin sulfate solution gm/50ml injection tobramycin sulfate solution 80 mg/ml injection QL 6/, ST QL 68/ Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 7 of 45

AMINOGLYCOSIDES (Medications to treat certain types of bacterial infection) - continued tobramycin sulfate solution reconstituted. gm injection ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) ACTEMRA SOLUTION PREFILLED SYRINGE 6 MG/0.9ML ARCALYST SOLUTION RECONSTITUTED 0 MG PA, QL.60/8 celecoxib capsule 00 mg ST celecoxib capsule 00 mg ST celecoxib capsule 400 mg ST celecoxib capsule 50 mg ST diclofenac potassium tablet 50 mg diclofenac sodium er tablet extended release 4 hour 00 mg diclofenac sodium tablet delayed release 5 mg diclofenac sodium tablet delayed release 50 mg diclofenac sodium tablet delayed release 75 mg ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) - continued diclofenac-misoprostol tablet delayed release 50-0. mg diclofenac-misoprostol tablet delayed release 75-0. mg ENBREL SOLUTION PREFILLED SYRINGE 5 MG/0.5ML ENBREL SOLUTION PREFILLED SYRINGE 50 MG/ML ENBREL SOLUTION RECONSTITUTED 5 MG ENBREL SURECLICK SOLUTION AUTO-INJECTOR 50 MG/ML etodolac capsule 00 mg etodolac capsule 00 mg etodolac er tablet extended release 4 hour 400 mg etodolac er tablet extended release 4 hour 500 mg etodolac er tablet extended release 4 hour 600 mg etodolac tablet 400 mg etodolac tablet 500 mg PA, QL 8/8 PA, QL 4/8 PA, QL 8/8 PA, QL 4/8 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 8 of 45

ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) - continued flurbiprofen tablet 00 mg flurbiprofen tablet 50 mg HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PREFILLED SYRINGE KIT 0 MG/0.4ML HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML ibuprofen tablet 400 mg ibuprofen tablet 600 mg ibuprofen tablet 800 mg ILARIS (50MG DELIVERED) SOLUTION RECONSTITUTED 80 MG PA, QL /8 PA, QL /8 PA, QL /8 PA, QL /8 PA, QL /8 PA, QL /8 ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) - continued indomethacin capsule 5 mg indomethacin capsule 50 mg indomethacin er capsule extended release 75 mg ketoprofen capsule 50 mg ketoprofen capsule 75 mg ketorolac tromethamine solution 5 mg/ml injection ketorolac tromethamine solution 0 mg/ml injection ketorolac tromethamine solution 60 mg/ml injection ketorolac tromethamine solution 60 mg/ml intramuscular ketorolac tromethamine tablet 0 mg KINERET SOLUTION PREFILLED SYRINGE 00 MG/0.67ML QL 0/0 LA, PA, QL 8.76/8 leflunomide tablet 0 mg QL 0/0 leflunomide tablet 0 mg Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 9 of 45

ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) - continued mefenamic acid capsule 50 mg meloxicam tablet 5 mg meloxicam tablet 7.5 mg nabumetone tablet 500 mg nabumetone tablet 750 mg naproxen dr tablet delayed release 75 mg naproxen dr tablet delayed release 500 mg naproxen sodium tablet 75 mg naproxen sodium tablet 550 mg naproxen suspension 5 mg/5ml naproxen tablet 50 mg naproxen tablet 75 mg naproxen tablet 500 mg ORENCIA CLICKJECT SOLUTION AUTO-INJECTOR 5 MG/ML ST PA, QL 4/8 ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) - continued ORENCIA SOLUTION PREFILLED SYRINGE 5 MG/ML ORENCIA SOLUTION PREFILLED SYRINGE 50 MG/0.4ML ORENCIA SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML oxaprozin tablet 600 mg piroxicam capsule 0 mg piroxicam capsule 0 mg SIMPONI SOLUTION AUTO- INJECTOR 00 MG/ML SIMPONI SOLUTION AUTO- INJECTOR 50 MG/0.5ML SIMPONI SOLUTION PREFILLED SYRINGE 00 MG/ML SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML sulindac tablet 50 mg sulindac tablet 00 mg PA, QL 4/8 PA, QL 4/8 PA, QL 4/8 PA, QL /8 PA, QL /8 PA, QL 0.50/8 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 0 of 45

ANALGESICS - ANTI-INFLAMMATORY (Medications to treat pain and inflammation) - continued tolmetin sodium capsule 400 mg XELJANZ TABLET 5 MG XELJANZ XR TABLET EXTENDED RELEASE 4 HOUR MG PA, QL 56/8 PA, QL 0/0 ANALGESICS - NonNarcotic (Medications to treat pain that are not narcotics) butalbital-acetaminophen tablet 50-5 mg butalbital-apap-caffeine capsule 50-00-40 mg butalbital-apap-caffeine capsule 50-5-40 mg butalbital-apap-caffeine tablet 50-5-40 mg butalbital-asa-caffeine capsule 50-5-40 mg choline-mag trisalicylate liquid 500 mg/5ml diflunisal tablet 500 mg marten-tab tablet 50-5 mg salsalate tablet 500 mg QL 0/0 QL 0/0 QL 0/0 QL 0/0 QL 0/0 QL 0/0 ANALGESICS - NonNarcotic (Medications to treat pain that are not narcotics) - continued salsalate tablet 750 mg ANALGESICS - OPIOID (Medications to treat pain that are narcotics) acetaminophen-codeine # tablet 00-5 mg acetaminophen-codeine # tablet 00-0 mg acetaminophen-codeine #4 tablet 00-60 mg acetaminophen-codeine solution 0- mg/5ml alfentanil injectable 500 mcg/ml injection aspirin-caff-dihydrocodeine capsule 56.4-0-6 mg buprenorphine hcl solution 0. mg/ml injection buprenorphine hcl tablet sublingual mg sublingual buprenorphine hcl tablet sublingual 8 mg sublingual buprenorphine hcl-naloxone hcl tablet sublingual -0.5 mg sublingual QL 90/0 QL 90/0 QL 90/0 QL 5000/0 QL 0/0 PA QL 90/0 QL 90/0 QL 90/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page of 45

ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued buprenorphine hcl-naloxone hcl tablet sublingual 8- mg sublingual butorphanol tartrate solution 0 mg/ml nasal codeine sulfate tablet 5 mg codeine sulfate tablet 0 mg codeine sulfate tablet 60 mg endocet tablet 0-5 mg endocet tablet.5-5 mg endocet tablet 5-5 mg endocet tablet 7.5-5 mg fentanyl citrate lozenge on a handle 00 mcg buccal fentanyl citrate lozenge on a handle 600 mcg buccal fentanyl citrate lozenge on a handle 00 mcg buccal QL 90/0 QL 7.50/0 QL 60/0 QL 60/0 QL 60/0 QL 40/0 QL 60/0 QL 60/0 QL 0/0 PA, QL 0/0 PA, QL 0/0 PA, QL 50/0 ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued fentanyl citrate lozenge on a handle 400 mcg buccal fentanyl citrate lozenge on a handle 600 mcg buccal fentanyl citrate lozenge on a handle 800 mcg buccal fentanyl patch 7 hour 00 mcg/hr transdermal fentanyl patch 7 hour mcg/hr transdermal fentanyl patch 7 hour 5 mcg/hr transdermal fentanyl patch 7 hour 50 mcg/hr transdermal fentanyl patch 7 hour 75 mcg/hr transdermal hydrocodone-acetaminophen solution.5-08 mg/5ml hydrocodone-acetaminophen solution 5-7 mg/0ml hydrocodone-acetaminophen solution 7.5-5 mg/5ml hydrocodone-acetaminophen tablet 0-00 mg hydrocodone-acetaminophen tablet 0-5 mg PA, QL 60/0 PA, QL 60/0 PA, QL 0/0 QL 5/0 QL 5/0 QL 5/0 QL 5/0 QL 5/0 QL 5400/0 QL 5400/0 QL 5400/0 QL 60/0 QL 60/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page of 45

ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued hydrocodone-acetaminophen tablet.5-5 mg hydrocodone-acetaminophen tablet 5-00 mg hydrocodone-acetaminophen tablet 5-5 mg hydrocodone-acetaminophen tablet 7.5-00 mg hydrocodone-acetaminophen tablet 7.5-5 mg hydrocodone-ibuprofen tablet 0-00 mg hydrocodone-ibuprofen tablet 5-00 mg hydrocodone-ibuprofen tablet 7.5-00 mg hydromorphone hcl liquid mg/ml hydromorphone hcl tablet mg hydromorphone hcl tablet 4 mg hydromorphone hcl tablet 8 mg levorphanol tartrate tablet mg QL 60/0 QL 90/0 QL 60/0 QL 90/0 QL 60/0 QL 60/0 QL 60/0 QL 60/0 QL 900/0 QL 60/0 QL 40/0 QL 0/0 QL 0/0 ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued meperidine hcl solution 50 mg/ml injection meperidine hcl tablet 00 mg meperidine hcl tablet 50 mg methadone hcl concentrate 0 mg/ml methadone hcl solution 0 mg/5ml methadone hcl solution 5 mg/5ml methadone hcl tablet 0 mg methadone hcl tablet 5 mg methadone hcl tablet soluble 40 mg METHADOSE CONCENTRATE 0 MG/ML METHADOSE SUGAR-FREE CONCENTRATE 0 MG/ML morphine sulfate (concentrate) solution 00 mg/5ml QL 60/0 QL 60/0 QL 60/0 QL 0/0 QL 600/0 QL 00/0 QL 0/0 QL 40/0 QL 0/0 QL 0/0 QL 0/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page of 45

ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued morphine sulfate er capsule extended release 4 hour 0 mg morphine sulfate er capsule extended release 4 hour 00 mg morphine sulfate er capsule extended release 4 hour 0 mg morphine sulfate er capsule extended release 4 hour 0 mg morphine sulfate er capsule extended release 4 hour 50 mg morphine sulfate er capsule extended release 4 hour 60 mg morphine sulfate er capsule extended release 4 hour 80 mg morphine sulfate er tablet extended release 00 mg morphine sulfate er tablet extended release 5 mg morphine sulfate er tablet extended release 00 mg QL 0/0 QL 0/0 QL 0/0 QL 0/0 QL 60/0 QL 60/0 QL 0/0 QL 0/0 QL 0/0 QL 0/0 ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued morphine sulfate er tablet extended release 0 mg morphine sulfate er tablet extended release 60 mg morphine sulfate solution mg/ml intravenous morphine sulfate solution 0 mg/5ml morphine sulfate solution 0 mg/ml injection morphine sulfate solution 5 mg/ml injection morphine sulfate solution 0 mg/5ml MORPHINE SULFATE SOLUTION 5 MG/ML INJECTION morphine sulfate solution 8 mg/ml injection morphine sulfate tablet 5 mg morphine sulfate tablet 0 mg oxycodone hcl capsule 5 mg oxycodone hcl concentrate 00 mg/5ml QL 0/0 QL 60/0 QL 600/0 QL 60/0 QL 60/0 QL 40/0 QL 60/0 QL 70/0 QL 450/0 QL 40/0 QL 0/0 QL 60/0 QL 0/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 4 of 45

ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued oxycodone hcl er tablet er hour abuse-deterrent 0 mg oxycodone hcl er tablet er hour abuse-deterrent 5 mg oxycodone hcl er tablet er hour abuse-deterrent 0 mg oxycodone hcl er tablet er hour abuse-deterrent 0 mg oxycodone hcl er tablet er hour abuse-deterrent 40 mg oxycodone hcl er tablet er hour abuse-deterrent 60 mg oxycodone hcl solution 5 mg/5ml oxycodone hcl tablet 0 mg oxycodone hcl tablet 5 mg oxycodone hcl tablet 0 mg QL 40/0, ST QL 50/0, ST QL 0/0, ST QL 90/0, ST QL 60/0, ST QL 60/0, ST QL 400/0 QL 40/0 QL 50/0 QL 0/0 ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued oxycodone hcl tablet 0 mg oxycodone hcl tablet 5 mg oxycodone-acetaminophen tablet 0-5 mg oxycodone-acetaminophen tablet.5-5 mg oxycodone-acetaminophen tablet 5-5 mg oxycodone-acetaminophen tablet 7.5-5 mg oxycodone-aspirin tablet 4.855-5 mg oxycodone-ibuprofen tablet 5-400 mg oxymorphone hcl er tablet extended release hour 0 mg oxymorphone hcl er tablet extended release hour 5 mg oxymorphone hcl er tablet extended release hour 0 mg QL 90/0 QL 60/0 QL 40/0 QL 60/0 QL 60/0 QL 0/0 QL 60/0 QL 80/0 QL 0/0, ST QL 90/0, ST QL 60/0, ST Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 5 of 45

ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued oxymorphone hcl er tablet extended release hour 0 mg oxymorphone hcl er tablet extended release hour 5 mg oxymorphone hcl er tablet extended release hour 7.5 mg oxymorphone hcl tablet 0 mg oxymorphone hcl tablet 5 mg sufentanil citrate solution 00 mcg/ml intravenous sufentanil citrate solution 50 mcg/5ml intravenous sufentanil citrate solution 50 mcg/ml intravenous tramadol hcl er (biphasic) tablet extended release 4 hour 00 mg tramadol hcl er (biphasic) tablet extended release 4 hour 00 mg QL 60/0, ST QL 0/0, ST QL 0/0, ST QL 0/0 QL 40/0 QL 90/0 QL 0/0 ANALGESICS - OPIOID (Medications to treat pain that are narcotics) - continued tramadol hcl er (biphasic) tablet extended release 4 hour 00 mg tramadol hcl er capsule extended release 4 hour 50 mg tramadol hcl er tablet extended release 4 hour 00 mg tramadol hcl er tablet extended release 4 hour 00 mg tramadol hcl er tablet extended release 4 hour 00 mg tramadol hcl tablet 50 mg tramadol-acetaminophen tablet 7.5-5 mg QL 0/0 QL 60/0 QL 90/0 QL 0/0 QL 0/0 QL 40/0 QL 40/0 ANDROGENS-ANABOLIC (Medications to increase testosterone levels) danazol capsule 00 mg danazol capsule 00 mg danazol capsule 50 mg oxandrolone tablet 0 mg oxandrolone tablet.5 mg TESTOPEL PELLET 75 MG IMPLANT Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 6 of 45

ANDROGENS-ANABOLIC (Medications to increase testosterone levels) - continued testosterone cypionate solution 00 mg/ml intramuscular testosterone cypionate solution 00 mg/ml intramuscular testosterone enanthate solution 00 mg/ml intramuscular testosterone gel 50 mg/5gm (%) transdermal PA ANORECTAL AGENTS (Medications to treat pain and inflammation in the anus or rectum) CORTIFOAM FOAM 0 % RECTAL hydrocortisone enema 00 mg/60ml rectal RECTIV OINTMENT 0.4 % RECTAL UCERIS FOAM MG/ACT RECTAL ANTHELMINTICS (Medications to treat certain types of parasites) ALBENZA TABLET 00 MG BILTRICIDE TABLET 600 MG ANTHELMINTICS (Medications to treat certain types of parasites) - continued EMVERM TABLET CHEWABLE 00 MG ivermectin tablet mg QL /8 ANTIANGINAL AGENTS (Medications to treat chest pain ) isosorbide dinitrate er tablet extended release 40 mg isosorbide dinitrate tablet 0 mg isosorbide dinitrate tablet 0 mg isosorbide dinitrate tablet 0 mg isosorbide dinitrate tablet 5 mg isosorbide mononitrate er tablet extended release 4 hour 0 mg isosorbide mononitrate er tablet extended release 4 hour 0 mg isosorbide mononitrate er tablet extended release 4 hour 60 mg isosorbide mononitrate tablet 0 mg Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 7 of 45

ANTIANGINAL AGENTS (Medications to treat chest pain ) - continued isosorbide mononitrate tablet 0 mg minitran patch 4 hour 0. mg/hr transdermal minitran patch 4 hour 0. mg/hr transdermal minitran patch 4 hour 0.4 mg/hr transdermal minitran patch 4 hour 0.6 mg/hr transdermal nitroglycerin patch 4 hour 0. mg/hr transdermal nitroglycerin patch 4 hour 0. mg/hr transdermal nitroglycerin patch 4 hour 0.4 mg/hr transdermal nitroglycerin patch 4 hour 0.6 mg/hr transdermal nitroglycerin solution 0.4 mg/spray translingual nitroglycerin tablet sublingual 0. mg sublingual nitroglycerin tablet sublingual 0.4 mg sublingual nitroglycerin tablet sublingual 0.6 mg sublingual ANTIANGINAL AGENTS (Medications to treat chest pain ) - continued NITROMIST AEROSOL SOLUTION 400 MCG/SPRAY TRANSLINGUAL ANTIANXIETY AGENTS (Medications to treat anxiety disorders) hydroxyzine hcl syrup 0 mg/5ml hydroxyzine hcl tablet 0 mg hydroxyzine hcl tablet 5 mg hydroxyzine hcl tablet 50 mg hydroxyzine pamoate capsule 00 mg hydroxyzine pamoate capsule 5 mg hydroxyzine pamoate capsule 50 mg ANTIARRHYTHMICS (Medications to help control heart rate) amiodarone hcl tablet 00 mg amiodarone hcl tablet 00 mg amiodarone hcl tablet 400 mg Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 8 of 45

ANTIARRHYTHMICS (Medications to help control heart rate) - continued disopyramide phosphate capsule 00 mg disopyramide phosphate capsule 50 mg flecainide acetate tablet 00 mg flecainide acetate tablet 50 mg flecainide acetate tablet 50 mg mexiletine hcl capsule 50 mg mexiletine hcl capsule 00 mg mexiletine hcl capsule 50 mg NORPACE CR CAPSULE EXTENDED RELEASE HOUR 00 MG NORPACE CR CAPSULE EXTENDED RELEASE HOUR 50 MG pacerone tablet 00 mg pacerone tablet 00 mg pacerone tablet 400 mg ANTIARRHYTHMICS (Medications to help control heart rate) - continued PROCAINAMIDE HCL POWDER propafenone hcl er capsule extended release hour 5 mg propafenone hcl er capsule extended release hour 5 mg propafenone hcl er capsule extended release hour 45 mg propafenone hcl tablet 50 mg propafenone hcl tablet 5 mg propafenone hcl tablet 00 mg quinidine sulfate tablet 00 mg quinidine sulfate tablet 00 mg ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Medications to improve breathing in asthma and COPD) albuterol sulfate nebulization solution (.5 mg/ml) 0.08% inhalation Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 9 of 45

ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Medications to improve breathing in asthma and COPD) - continued albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation albuterol sulfate nebulization solution 0.6 mg/ml inhalation albuterol sulfate nebulization solution.5 mg/ml inhalation albuterol sulfate syrup mg/5ml ATROVENT HFA AEROSOL SOLUTION 7 MCG/ACT INHALATION BROVANA NEBULIZATION SOLUTION 5 MCG/ML INHALATION budesonide suspension 0.5 mg/ml inhalation budesonide suspension 0.5 mg/ml inhalation budesonide suspension mg/ml inhalation COMBIVENT RESPIMAT AEROSOL SOLUTION 0-00 MCG/ACT INHALATION QL 0/0 QL 80/0 QL 0/0 QL 60/0 QL 8/0 ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Medications to improve breathing in asthma and COPD) - continued cromolyn sodium nebulization solution 0 mg/ml inhalation DALIRESP TABLET 500 MCG DULERA AEROSOL 00-5 MCG/ACT INHALATION DULERA AEROSOL 00-5 MCG/ACT INHALATION ipratropium bromide solution 0.0 % inhalation ipratropium-albuterol solution 0.5-.5 () mg/ml inhalation levalbuterol hcl nebulization solution 0. mg/ml inhalation levalbuterol hcl nebulization solution 0.6 mg/ml inhalation levalbuterol hcl nebulization solution.5 mg/0.5ml inhalation levalbuterol hcl nebulization solution.5 mg/ml inhalation montelukast sodium packet 4 mg PA QL 65/0 PA Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 0 of 45

ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Medications to improve breathing in asthma and COPD) - continued montelukast sodium tablet 0 mg montelukast sodium tablet chewable 4 mg montelukast sodium tablet chewable 5 mg PERFOROMIST NEBULIZATION SOLUTION 0 MCG/ML INHALATION PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 80 MCG/ACT INHALATION PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT INHALATION QVAR AEROSOL SOLUTION 40 MCG/ACT INHALATION QVAR AEROSOL SOLUTION 80 MCG/ACT INHALATION SPIRIVA HANDIHALER CAPSULE 8 MCG INHALATION SPIRIVA RESPIMAT AEROSOL SOLUTION.5 MCG/ACT INHALATION PA PA PA QL 0/0 QL /0 QL 4/0 QL 0/0 QL 4/0 ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Medications to improve breathing in asthma and COPD) - continued STRIVERDI RESPIMAT AEROSOL SOLUTION.5 MCG/ACT INHALATION SYMBICORT AEROSOL 60-4.5 MCG/ACT INHALATION SYMBICORT AEROSOL 80-4.5 MCG/ACT INHALATION terbutaline sulfate tablet.5 mg terbutaline sulfate tablet 5 mg theophylline er tablet extended release hour 00 mg theophylline er tablet extended release hour 00 mg theophylline er tablet extended release hour 00 mg theophylline er tablet extended release hour 450 mg theophylline er tablet extended release 4 hour 400 mg theophylline er tablet extended release 4 hour 600 mg theophylline solution 80 mg/5ml Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page of 45

ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Medications to improve breathing in asthma and COPD) - continued TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION VENTOLIN HFA AEROSOL SOLUTION 08 (90 BASE) MCG/ACT INHALATION XOLAIR SOLUTION RECONSTITUTED 50 MG QL /0 QL 6/0 zafirlukast tablet 0 mg PA zafirlukast tablet 0 mg PA ANTICOAGULANTS (Medications that thin the blood) ELIQUIS TABLET.5 MG QL 60/0 ELIQUIS TABLET 5 MG enoxaparin sodium solution 00 mg/ml subcutaneous enoxaparin sodium solution 0 mg/0.8ml subcutaneous enoxaparin sodium solution 50 mg/ml subcutaneous enoxaparin sodium solution 0 mg/0.ml subcutaneous enoxaparin sodium solution 00 mg/ml injection QL 80/80 ANTICOAGULANTS (Medications that thin the blood) - continued enoxaparin sodium solution 40 mg/0.4ml subcutaneous enoxaparin sodium solution 60 mg/0.6ml subcutaneous enoxaparin sodium solution 80 mg/0.8ml subcutaneous fondaparinux sodium solution 0 mg/0.8ml subcutaneous fondaparinux sodium solution.5 mg/0.5ml subcutaneous fondaparinux sodium solution 5 mg/0.4ml subcutaneous fondaparinux sodium solution 7.5 mg/0.6ml subcutaneous FRAGMIN SOLUTION 0000 UNIT/ML FRAGMIN SOLUTION 500 UNIT/0.5ML FRAGMIN SOLUTION 5000 UNIT/0.6ML FRAGMIN SOLUTION 8000 UNT/0.7ML FRAGMIN SOLUTION 500 UNIT/0.ML FRAGMIN SOLUTION 5000 UNIT/0.ML Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page of 45

ANTICOAGULANTS (Medications that thin the blood) - continued heparin lock flush solution 0 unit/ml intravenous heparin lock flush solution 00 unit/ml intravenous heparin sodium flush kit 0-0.9 unit/ml-% intravenous heparin sodium flush kit 00-0.9 unit/ml-% intravenous heparin sodium lock flush solution 00 unit/ml intravenous IPRIVASK SOLUTION RECONSTITUTED 5 MG PRADAXA CAPSULE 50 MG PRADAXA CAPSULE 75 MG sash kit kit 00-0.9 unit/ml-% intravenous warfarin sodium tablet mg warfarin sodium tablet 0 mg warfarin sodium tablet mg ANTICOAGULANTS (Medications that thin the blood) - continued warfarin sodium tablet.5 mg warfarin sodium tablet mg warfarin sodium tablet 4 mg warfarin sodium tablet 5 mg warfarin sodium tablet 6 mg warfarin sodium tablet 7.5 mg XARELTO TABLET 0 MG QL 0/0 XARELTO TABLET 5 MG XARELTO TABLET 0 MG QL 0/0 ANTICONVULSANTS (Medications to to help control seizures) BANZEL SUSPENSION 40 MG/ML PA BANZEL TABLET 00 MG PA BANZEL TABLET 400 MG PA carbamazepine er capsule extended release hour 00 mg carbamazepine er capsule extended release hour 00 mg Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page of 45

ANTICONVULSANTS (Medications to to help control seizures) - continued carbamazepine er capsule extended release hour 00 mg carbamazepine er tablet extended release hour 00 mg carbamazepine er tablet extended release hour 00 mg carbamazepine er tablet extended release hour 400 mg carbamazepine suspension 00 mg/5ml carbamazepine tablet 00 mg carbamazepine tablet chewable 00 mg CELONTIN CAPSULE 00 MG clonazepam tablet 0.5 mg QL 90/0 clonazepam tablet mg clonazepam tablet mg QL 0/0 QL 00/0 ANTICONVULSANTS (Medications to to help control seizures) - continued clonazepam tablet dispersible 0.5 mg clonazepam tablet dispersible 0.5 mg clonazepam tablet dispersible 0.5 mg clonazepam tablet dispersible mg clonazepam tablet dispersible mg QL 60/0 QL 60/0 QL 60/0 QL 0/0 QL 00/0 diazepam gel 0 mg rectal QL 5/0 diazepam gel.5 mg rectal QL 5/0 diazepam gel 0 mg rectal QL 5/0 DILANTIN CAPSULE 0 MG ethosuximide capsule 50 mg ethosuximide solution 50 mg/5ml felbamate suspension 600 mg/5ml felbamate tablet 400 mg felbamate tablet 600 mg FYCOMPA SUSPENSION 0.5 MG/ML QL 680/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 4 of 45

ANTICONVULSANTS (Medications to to help control seizures) - continued FYCOMPA TABLET 0 MG QL 0/0 FYCOMPA TABLET MG QL 0/0 FYCOMPA TABLET MG QL 0/0 FYCOMPA TABLET 4 MG QL 0/0 FYCOMPA TABLET 6 MG QL 0/0 FYCOMPA TABLET 8 MG QL 0/0 gabapentin capsule 00 mg gabapentin capsule 00 mg gabapentin capsule 400 mg gabapentin solution 50 mg/5ml gabapentin tablet 600 mg gabapentin tablet 800 mg GABITRIL TABLET MG GABITRIL TABLET 6 MG levetiracetam er tablet extended release 4 hour 500 mg levetiracetam er tablet extended release 4 hour 750 mg ANTICONVULSANTS (Medications to to help control seizures) - continued levetiracetam solution 00 mg/ml levetiracetam tablet 000 mg levetiracetam tablet 50 mg levetiracetam tablet 500 mg levetiracetam tablet 750 mg LYRICA CAPSULE 00 MG LYRICA CAPSULE 50 MG LYRICA CAPSULE 00 MG LYRICA CAPSULE 5 MG LYRICA CAPSULE 5 MG LYRICA CAPSULE 00 MG LYRICA CAPSULE 50 MG LYRICA CAPSULE 75 MG PA, QL 90/0 PA, QL 90/0 PA, QL 90/0 PA, QL 60/0 PA, QL 90/0 PA, QL 60/0 PA, QL 90/0 PA, QL 90/0 Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 5 of 45

ANTICONVULSANTS (Medications to to help control seizures) - continued ONFI SUSPENSION.5 MG/ML PA ONFI TABLET 0 MG PA ONFI TABLET 0 MG PA oxcarbazepine suspension 00 mg/5ml oxcarbazepine tablet 50 mg oxcarbazepine tablet 00 mg oxcarbazepine tablet 600 mg phenytoin infatabs tablet chewable 50 mg phenytoin sodium extended capsule 00 mg phenytoin sodium extended capsule 00 mg phenytoin sodium extended capsule 00 mg phenytoin suspension 5 mg/5ml phenytoin tablet chewable 50 mg primidone tablet 50 mg ANTICONVULSANTS (Medications to to help control seizures) - continued primidone tablet 50 mg SABRIL TABLET 500 MG tiagabine hcl tablet mg QL 60/0 tiagabine hcl tablet 4 mg topiramate capsule sprinkle 5 mg topiramate capsule sprinkle 5 mg topiramate tablet 00 mg topiramate tablet 00 mg topiramate tablet 5 mg topiramate tablet 50 mg VIGABATRIN PACKET 500 MG zonisamide capsule 00 mg zonisamide capsule 5 mg zonisamide capsule 50 mg QL 40/0 ANTIDIABETICS (Medications to help control blood sugar levels in patients with diabetes) acarbose tablet 00 mg acarbose tablet 5 mg acarbose tablet 50 mg Medications with a Pre-approval (PA), Step Therapy (ST), or Quantity Limit (QL) in the NOTES field may have certain limits, see page for details. Members: call our Customer Service department for all questions about benefits. Central Oregon members call toll-free (800) 4-45. Columbia Gorge members call toll-free (855) 04-965. TTY users call (800) 75-900. Providers: call our Pharmacy Services Helpdesk at (54) 0-4999 or (888) 47-778 to request a Pre-approval or Coverage Exception. Page 6 of 45