2018 Year-to-date Formulary Additions and Deletions

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1 Health Choice Generations may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, and/or move a drug at a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. The tables below provide information about changes to our formulary that may impact you. You can also view the most recent formulary changes on our website at HealthChoiceGenerations.com. If you have any questions or concerns, please call us. We always want to help you. This information is available for free in other languages. Please call our customer service number at (TTY 711), 8 a.m. - 8 p.m., 7 days a week. Definitions: PA = Prior Authorization: Health Choice Generations requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, Health Choice Generations may not cover the drug. ST = Step Therapy: In some cases, Health Choice Generations requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Health Choice Generations may not cover drug B unless you try Drug A first. If Drug A does not work for you, Health Choice Generations will then cover Drug B. QL = Quantity Limit: For certain drugs, Health Choice Generations limits the amount of the drug that our plan will cover. Unless otherwise noted, the quantity listed is units (capsules, tablets) per 30 days. For example, Health Choice Generations provides 30 units per 30 day prescription for NAMENDA XR. This may be in addition to a standard one month or three month supply. BvD = Part B versus D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. *Alternative Drugs: Alternative drugs are drugs in the same therapeutic category/class or cost-sharing tier as the affected drug. Only your physician can determine if the alternate here is appropriate for you given the individualized nature of the drug therapy. Please consult your physician as to whether this is an appropriate drug for you.

2 Alternative Drug Tier Effective Date ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE Tier 1 & QL 60 N/A N/A TABS ABRAXANE SUSR Tier 1 & PA N/A N/A ACETAMINOPHEN/CODEINE TABS Tier 1 & QL 400 N/A N/A ACTEMRA SOLN Tier 1 & PA N/A N/A ADAGEN SOLN Tier 1 & PA N/A N/A ADCIRCA TABS Tier 1 & PA & QL 60 N/A N/A ADEMPAS TABS Tier 1 & PA & QL 90 N/A N/A ADVAIR DISKUS Tier 1 & QL 60 N/A N/A ADVAIR HFA Tier 1 & QL 24 N/A N/A AFINITOR DISPERZ Tier 1 & PA N/A N/A AFINITOR TABS Tier 1 & PA & QL 30 N/A N/A AKYNZEO CAPS Tier 1 & QL 2 & BvD N/A N/A ALBUTEROL SULFATE NEBU Tier 1 & QL & BvD N/A N/A ALDURAZYME SOLN Tier 1 & PA N/A N/A ALECENSA Tier 1 & PA & QL 240 N/A N/A ALENDRONATE SODIUM TABS 70MG Tier 1 & QL 4 N/A N/A ALLZITAL butalbital/acetaminophen tabs 325mg; 50mg Tier 1 & QL 360 ALMOTRIPTAN MALATE TABS Tier 1 & QL 12 N/A N/A

3 Alternative Drug Tier Effective Date ALOSETRON HYDROCHLORIDE TABS Tier 1 & PA N/A N/A ALPHAGAN P 0.15% ALPHAGAN P SOLN 0.1% Tier 1 ALPRAZOLAM INTENSOL Tier 1 & PA N/A N/A ALPRAZOLAM TABS Tier 1 & PA & QL N/A N/A ALPRAZOLAM XR Tier 1 & PA & QL N/A N/A ALUNBRIG TABS Tier 1 & PA & QL 180 N/A N/A AMITIZA CAPS Tier 1 & QL 60 N/A N/A AMLODIPINE/OLMESARTAN MEDOXOMIL amlodipine, olmesartan separately Tier 1 AMNESTEEM CAPS Tier 1 & PA N/A N/A AMOXAPINE TABS Tier 1 & PA N/A N/A AMPHETAMINE/DEXTROAMPHETAMINE CP24 Tier 1 & PA & QL 30 N/A N/A AMPHETAMINE/DEXTROAMPHETAMINE TABS Tier 1 & QL 90 N/A N/A AMPYRA Tier 1 & PA & QL 60 N/A N/A ANADROL-50 Tier 1 & PA N/A N/A ANDRODERM Tier 1 & PA N/A N/A APLENZIN TB24 Tier 1 & ST & QL 30 N/A N/A APOKYN Tier 1 & PA & QL 90 N/A N/A APREPITANT Tier 1 & QL & BvD N/A N/A ARCALYST Tier 1 & PA N/A N/A

4 ARIPIPRAZOLE Tier 1 & QL N/A N/A ARIPIPRAZOLE ODT Tier 1 & QL N/A N/A ARMODAFINIL TABS Tier 1 & PA & QL N/A N/A ATOMOXETINE CAPS Tier 1 & QL N/A N/A ATRIPLA Tier 1 & QL 30 N/A N/A ATROPINE SULFATE 0.25MG/5ML diphenoxylate/atropine liqd 0.025mg/5ml Tier 1 & PA ATROVENT HFA Tier 1 & QL 25.8 N/A N/A AUBAGIO Tier 1 & PA & QL 30 N/A N/A AVANDIA pioglitzazone Tier 1 & QL AVONEX KIT Tier 1 & PA & QL 4 N/A N/A AVONEX PEN Tier 1 & PA & QL 4 N/A N/A AZATHIOPRINE TABS Tier 1 & BvD N/A N/A AZELASTINE HCL SOLN Tier 1 & QL 60 N/A N/A BARACLUDE SOLN Tier 1 & QL 600 N/A N/A BELEODAQ Tier 1 & PA N/A N/A BENLYSTA Tier 1 & PA N/A N/A BIVIGAM Tier 1 & PA N/A N/A BREO ELLIPTA Tier 1 & QL 60 N/A N/A BRISDELLE paroxetine Tier 1 & PA BUDESONIDE NASAL SPRAY Tier 1 & QL 17.2 N/A N/A

5 Alternative Drug Tier Effective Date BUDESONIDE SUSP Tier 1 & QL 120 & BvD N/A N/A BUPROPION HCL SR TB12 Tier 1 & QL 90 N/A N/A BUPROPION HCL XL TB24 Tier 1 & QL 30 N/A N/A BUTALBITAL/ACETAMINOPHEN TABS 300/50mg Tier 1 & PA N/A N/A BUTALBITAL/ACETAMINOPHEN TABS 325/50mg Tier 1 & PA & QL 360 N/A N/A BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPS 325/50/40mg Tier 1 & PA & QL 360 N/A N/A BUTISOL SODIUM 30MG no formulary alternative N/A BYDUREON Tier 1 & ST & QL 4 N/A N/A BYDUREON PEN Tier 1 & ST & QL 4 N/A N/A BYETTA Bydureon, Trulicity, Victoza Tier 1 & ST CALCITONIN-SALMON SOLN Tier 1 & QL 3.7 N/A N/A CAPRELSA TABS 100mg Tier 1 & PA & QL 60 N/A N/A CAPRELSA TABS 300mg Tier 1 & PA N/A N/A CARIMUNE NANOFILTERED SOLR Tier 1 & PA N/A N/A CAYSTON Tier 1 & PA N/A N/A CELECOXIB CAPS Tier 1 & QL 60 N/A N/A CEREZYME Tier 1 & PA N/A N/A CHANTIX Tier 1 & QL 504/365 days N/A N/A

6 CHLORPROPAMIDE glimepiride, glipizide, glyburide, tolazamide Alternative Drug Tier Tier 1 & QL, PA for glyburide Effective Date CIMZIA Tier 1 & PA N/A N/A CLARAVIS CAPS Tier 1 & PA N/A N/A CLONAZEPAM ODT Tier 1 & QL N/A N/A CLOZAPINE ODT Tier 1 & QL N/A N/A COMBIVENT RESPIMAT Tier 1 & QL 8 N/A N/A COMETRIQ Tier 1 & PA N/A N/A COMPLERA Tier 1 & QL 30 N/A N/A COPAXONE Tier 1 & PA & QL N/A N/A COTELLIC TABS Tier 1 & PA & QL 90 N/A N/A CUPRIMINE 250MG SYPRINE CAPS 250MG Tier 1 CYCLOPHOSPHAMIDE CAPS Tier 1 & BvD N/A N/A CYCLOSPORINE SOLN Tier 1 & BvD N/A N/A CYRAMZA SOLN Tier 1 & PA N/A N/A CYSTARAN SOLN Tier 1 & PA & 60/28 days N/A N/A DALIRESP TABS Tier 1 & PA N/A N/A DECITABINE SOLR Tier 1 & PA N/A N/A DEPO-PROVERA Tier 1 & QL 10/28 days N/A N/A DESCOVY TABS Tier 1 & QL 30 N/A N/A DESIPRAMINE HCL TABS Tier 1 & PA N/A N/A DESLORATADINE ODT 2.5MG, 5MG desloratadine tabs 5mg Tier 1

7 DESVENLAFAXINE ER TB24 Tier 1 & ST & QL N/A N/A DEXMETHYLPHENIDATE HCL ER CP24 Tier 1 & PA & QL 30 N/A N/A DEXMETHYLPHENIDATE HCL TABS Tier 1 & PA & QL 60 N/A N/A DEXTROAMPHETAMINE SULFATE TABS Tier 1 & PA & QL N/A N/A DICLOFENAC SODIUM GEL Tier 1 & QL 1000 N/A N/A DICLOFENAC SODIUM SOLN Tier 1 & PA N/A N/A DICYCLOMINE HCL SOLN Tier 1 & PA N/A N/A DIHYDROERGOTAMINE MESYLATE SOLN Tier 1 & QL 8 N/A N/A DIPHENOXYLATE/ATROPINE LIQD Tier 1 & PA N/A N/A DIPHENOXYLATE/ATROPINE TABS Tier 1 & PA N/A N/A DOXEPIN HCL CAPS Tier 1 & PA N/A N/A DOXEPIN HCL CONC Tier 1 & PA N/A N/A DULOXETINE HCL CAPS Tier 1 & QL N/A N/A ELAPRASE SOLN Tier 1 & PA N/A N/A ELIGARD Tier 1 & PA & QL N/A N/A ELIQUIS TABS Tier 1 & QL N/A N/A EMEND IV SOL 150MG ALOXI INJ 0.25MG/5ML, granisetron inj, ondansetron inj Tier 1 & QL (QL for ondansetron only) EMEND SUSR Tier 1 & BvD & QL 6 N/A N/A

8 Alternative Drug Tier Effective Date EMSAM PT24 Tier 1 & ST & QL 30 N/A N/A EMVERM Albenza, Biltricide, ivermectin Tier 1 ENBREL Tier 1 & PA N/A N/A ENTECAVIR TABS Tier 1 & QL 30 N/A N/A ERBITUX SOLN Tier 1 & PA N/A N/A ERIVEDGE CAPS Tier 1 & PA N/A N/A ESTAZOLAM TABS Tier 1 & PA & QL 30 N/A N/A EVOTAZ TABS Tier 1 & QL 30 N/A N/A EXJADE Tier 1 & PA N/A N/A FABRAZYME SOLR Tier 1 & PA N/A N/A FANAPT TABS Tier 1 & ST & QL 60 N/A N/A FANAPT TITRATION PACK Tier 1 & QL 8/180 N/A N/A FERRIPROX SOLN Tier1 & PA N/A N/A FERRIPROX TABS Tier 1 & PA N/A N/A FETZIMA CP24 Tier 1 & QL 30 N/A N/A FETZIMA TITRATION PACK Tier 1 & QL 56/365 days N/A N/A FIRMAGON SOLR Tier 1 & QL N/A N/A FLEBOGAMMA DIF SOLN Tier 1 & PA N/A N/A FLECTOR diclofenac 1% gel Tier 1 & QL 1000 gm FLOVENT DISKUS Tier 1 & QL N/A N/A FLOVENT HFA Tier 1 & QL N/A N/A

9 FLUNISOLIDE SOLN Tier 1 & QL 50 N/A N/A FLURAZEPAM HCL estazolam, temazepam Tier 1 & QL 30 FLUTICASONE PROPIONATE/SALMETEROL Tier 1 & QL Advair Diskus, Advair HFA, (depends upon Dulera, Symbicort each inhaler) FOLOTYN SOLN Tier 1 & PA N/A N/A FONDAPARINUX SODIUM SOLN Tier 1 & QL N/A N/A FORFIVO XL Aplenzin; bupropion ER, SR, XL Tier 1 & QL for all & ST (for Aplenzin only) FORTEO SOLN Tier 1 & PA N/A N/A FOSAMAX PLUS D Tier 1 & ST N/A N/A FRAGMIN SOLN Tier 1 & QL N/A N/A FROVATRIPTAN SUCCINATE TABS Tier 1 & QL 12 N/A N/A FUSILEV IV SOL 50MG levoleucovorin inj 50mg Tier 1 FUZEON SOLR Tier 1 & QL 60 N/A N/A GENVOYA TABS Tier 1 & QL 30 N/A N/A GEODON SOLR Tier 1 & QL 60 N/A N/A GILENYA CAPS Tier 1 & QL 30 N/A N/A GILOTRIF TABS Tier 1 & QL 30 N/A N/A GLIPIZIDE ER TABS Tier 1 & QL N/A N/A GLIPIZIDE/METFORMIN HCL TABS Tier 1 & QL N/A N/A GLYBURIDE MICRONIZED TABS Tier 1 & QL N/A N/A GLYBURIDE TABS Tier 1 & QL N/A N/A HALAVEN SOLN Tier 1 & PA N/A N/A HEPARIN SODIUM/D5W 5% 100U/ML; 5% 50U/ML heparin sodium/d5w 5% 40U/ML Tier 1

10 HETLIOZ CAPS Tier 1 & QL 30 N/A N/A HUMIRA Tier 1 & PA N/A N/A HYDROCORTISONE OINT 1% hydrocortisone cream 1%, hydrocortisone oint 2.5% Tier 1 HYDROXYZINE HCL SOLN Tier 1 & PA N/A N/A HYDROXYZINE HCL SYRP Tier 1 & PA N/A N/A HYDROXYZINE PAMOATE CAPS Tier 1 & PA N/A N/A HYPERRAB S/D INJ Tier 1 & BvsD N/A N/A HYSINGLA ER buprenorphine patch, Butrans patch, Embeda, fentanyl patch, hydromophone ER, methadone, morphine ER tab/cap, oxymorphone ER tab, tramadol ER tab Tier 1 & QL (for buprenorphine and Butrans patches only) ILARIS SOLR Tier 1 & QL 2/28 days N/A N/A ILEVRO SUSP Tier 1 & QL 6 N/A N/A IMIPRAMINE HCL TABS Tier 1 & PA N/A N/A IMIPRAMINE PAMOATE CAPS Tier 1 & PA N/A N/A IMOVAX RABIES (H.D.C.V.) Tier 1 & BvD N/A N/A INCRELEX SOLN Tier 1 & PA N/A N/A INLYTA TABS Tier 1 & PA N/A N/A INTRON A Tier 1 & PA N/A N/A INVOKAMET TABS Tier 1 & QL 60 N/A N/A INVOKAMET XR TB24 Tier 1 & QL 60 N/A N/A INVOKANA TABS Tier 1 & QL N/A N/A

11 ISTODAX (OVERFILL) SOLR Tier 1 & PA N/A N/A ITRACONAZOLE CAPS Tier 1 & PA N/A N/A JAKAFI TABS Tier 1 & QL 60 N/A N/A JANUVIA TABS Tier 1 & ST N/A N/A JUXTAPID CAPS Tier 1 & QL 30 N/A N/A KADCYLA SOLR Tier 1 & PA N/A N/A KETOROLAC TROMETHAMINE TABS Tier 1 & QL 20 N/A N/A KISQALI TABS Tier 1 & QL 63/28days N/A N/A KISQALI/FEMARA PACK Tier 1 & QL 91/28days N/A N/A KORLYM TABS Tier 1 & QL 120 N/A N/A KUVAN Tier 1 & PA N/A N/A LAMICTAL XR LAMOTRIGINE STARTER KIT Tier 1 LATANOPROST SOLN Tier 1 & QL 2.5/25 days N/A N/A LATUDA TABS Tier 1 & QL N/A N/A LENVIMA Tier 1 & PA N/A N/A LEUKINE SOLR Tier 1 & PA N/A N/A LEVALBUTEROL NEBU Tier 1 & BvD & QL N/A N/A LEVOTHYROXINE IV SOL 100MG no formulary alternative N/A LIDOCAINE/PRILOCAINE CREA Tier 1 & QL 30 N/A N/A LINZESS CAPS Tier 1 & QL 30 N/A N/A LITHOSTAT acetic acid 0.25% soln 0.25% Tier 1

12 LIVALO TABS Tier 1 & ST N/A N/A LORAZEPAM INJ Tier 1 & PA N/A N/A LORAZEPAM INTENSOL Tier 1 & PA N/A N/A LORAZEPAM TABS Tier 1 & PA & QL N/A N/A LOTEMAX GEL Tier 1 & QL 20/365 days N/A N/A LOTEMAX OINT Tier 1 & QL 14/365 days N/A N/A LUMIZYME SOLR Tier 1 & PA N/A N/A LUPRON DEPOT (1-MONTH) Tier 1 & PA & QL 1/28 days N/A N/A LUPRON DEPOT (3-MONTH) Tier 1 & PA & QL 1/84 days N/A N/A LUPRON DEPOT (4-MONTH) Tier 1 & PA & QL 1/112 days N/A N/A LUPRON DEPOT (6-MONTH) Tier 1 & PA & QL 1/168 days N/A N/A LYRICA CAPS Tier 1 & QL N/A N/A MEKINIST TABS Tier 1 & PA N/A N/A MEPROBAMATE TAB alprazolam, chlordiazepoxide, diazepam, lorazepam, Tier 1 & QL oxazepam MESALAMINE DR 800MG mesalamine DR 1.2GM Tier 1 METHOCARBAMOL SOLN 1000MG/ML carisoprodol, chlorzoxazone 500mg, cyclobenzaprine, methocarbamol tab, orphenadrine ER Tier 1 & PA

13 Alternative Drug Tier Effective Date METHYLPHENIDATE HCL CD CAPS Tier 1 & PA & QL 30 N/A N/A METHYLPHENIDATE HCL CHEW Tier 1 & PA & QL N/A N/A METHYLPHENIDATE HCL ER CAPS Tier 1 & PA & QL 30 N/A N/A METHYLPHENIDATE HCL ER TABS Tier 1 & PA & QL N/A N/A METHYLPHENIDATE HCL TABS Tier 1 & PA & QL 90 N/A N/A METHYLPHENIDATE HYDROCHLORIDE SOLN Tier 1 & PA N/A N/A METHYLTESTOSTERONE CAPS Tier 1 & PA N/A N/A MIRCERA Aranesp Tier 1 & PA MIRVASO GEL Tier 1 & PA N/A N/A MITOXANTRONE HCL CONC Tier 1 & PA N/A N/A MODAFINIL TABS Tier 1 & PA & QL 30 N/A N/A MOMETASONE FUROATE SUSP Tier 1 & QL 34 N/A N/A MOZOBIL SOLN Tier 1 & PA & QL 38.4/365 days N/A N/A MYORISAN CAPS Tier 1 & PA N/A N/A MYTESI 125MG octreotide, Sandostatin, Signifor, somatuline Tier 1 & PA NAGLAZYME SOLN Tier 1 & PA N/A N/A NAMZARIC Tier 1 & QL 30 N/A N/A NATPARA Tier 1 & PA & QL 2/28 days N/A N/A

14 NEUPOGEN SOLN Tier 1 & ST N/A N/A NEUPRO PTCH Tier 1 & ST N/A N/A NEXAVAR TABS Tier 1 & PA N/A N/A NICOTROL INHALER Tier 1 & QL 2688/365 days N/A N/A NITROFURANTOIN MACROCRYSTALS CAPS Tier 1 & QL N/A N/A NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS CAPS Tier 1 & QL N/A N/A NORETHINDRONE ACETATE/ETHINYL ESTRADIOL TABS Tier 1 & PA N/A N/A NORGESTIMATE/ETHINYL ESTRADIOL 35MCG; 0.25MG estarylla tabs 35mcg, 0.25mg; femynor tabs 35mcg, 0.25mg; mono-linyah tabs 35mcg, 0.25mg; mononessa tabs 35mcg, 0.25mg; sprintec 28 tabs 35mcg, 0.25mg Tier 1 NORTRIPTYLINE HCL CAPS Tier 1 & PA N/A N/A NORTRIPTYLINE HCL SOLN Tier 1 & PA N/A N/A NUCALA SOLR Tier 1 & PA & QL 1/28 days N/A N/A NULOJIX SOLR Tier 1 & PA N/A N/A NUPLAZID TABS Tier 1 & PA & QL 60 N/A N/A ODEFSEY TABS Tier 1 & QL 30 N/A N/A

15 OFEV CAPS Tier 1 & PA N/A N/A OLANZAPINE/FLUOXETINE CAPS Tier 1 & QL N/A N/A OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLO ROTHIAZIDE olmesartan/hydrochlorothiazi de and amlodipine separately Tier 1 ONDANSETRON HCL ODT Tier 1 & BvD N/A N/A ONDANSETRON HCL SOLN Tier 1 & BvD & QL 450 N/A N/A ONDANSETRON HCL TABS Tier 1 & BvD N/A N/A OPANA ER (CRUSH RESISTANT) buprenorphine patch, Butrans patch, Embeda, fentanyl patch, hydromophone ER, methadone, morphine ER tab/cap, oxymorphone ER tab, tramadol ER tab Tier 1 & QL (for buprenorphine and Butrans patches only) OPSUMIT TABS Tier 1 & PA & QL 30 N/A N/A ORAVIG clotrimazole lozg 10mg Tier 1 ORENCIA Tier 1 & PA N/A N/A ORENCIA CLICKJET Tier 1 & PA & QL 4/28 days N/A N/A ORKAMBI TABS Tier 1 & PA & QL 112/28 days N/A N/A OSELTAMIVIR PHOSPHATE CAPS Tier 1 & QL N/A N/A OXTELLAR XR oxcarbazepine tab Tier 1

16 OXYCONTIN buprenorphine patch, Butrans patch, Embeda, fentanyl patch, hydromophone ER, methadone, morphine ER tab/cap, oxymorphone ER tab, tramadol ER tab Alternative Drug Tier Tier 1 & QL (for buprenorphine and Butrans patches only) Effective Date PACERONE 100MG, 400MG amiodarone 100mg, 400mg Tier 1 PALIPERIDONE ER TB24 Tier 1 & QL N/A N/A PAROXETINE HCL ER TB24 Tier 1 & PA N/A N/A PAROXETINE HCL TAB Tier 1 & PA PATADAY olopatadine hydrochloride soln 0.2% Tier 1 PAXIL SUSP Tier 1 & PA N/A N/A PEGASYS Tier 1 & PA N/A N/A PEGINTRON Tier 1 & PA N/A N/A PEG-PREP Gavilyte-C, Gavilyte-G, Gavilyte-H, Gavilyte-N/flavor pack, Moviprep, PEG-3350, Suprep, Trilyte Tier 1 PERJETA SOLN Tier 1 & PA N/A N/A PERPHENAZINE/AMITRIPTYLINE TABS Tier 1 & PA N/A N/A PEXEVA TABS Tier 1 & PA & QL N/A N/A PIOGLITAZONE HCL/METFORMIN HCL TABS Tier 1 & QL 90 N/A N/A PIOGLITAZONE HCL-GLIMEPIRIDE TABS Tier 1 & QL 45 N/A N/A

17 PRADAXA CAPS Tier 1 & QL 60 N/A N/A PREDNISOLONE SODIUM PHOSPHATE ODT prednisolone soln 15mg/5ml Tier 1 PREPOPIK Gavilyte-C, Gavilyte-G, Gavilyte-H, Gavilyte-N/flavor pack, Moviprep, PEG-3350, Suprep, Trilyte Tier 1 PREZCOBIX TABS Tier 1 & QL 30 N/A N/A PRIVIGEN SOLN Tier 1 & PA N/A N/A PROCRIT SOLN Tier 1 & PA N/A N/A PROLASTIN-C SOLR Tier 1 & PA N/A N/A PROLIA SOLN Tier 1 & QL 2/365 days N/A N/A PROMACTA TABS Tier 1 & PA N/A N/A PROPANTHELINE BROMIDE TABS Tier 1 & PA N/A N/A PULMICORT FLEXHALER Aerospan, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent HFA, QVAR Tier 1 & QL PULMOZYME SOLN Tier 1 & PA N/A N/A QUETIAPINE FUMARATE ER TB24 Tier 1 & QL N/A N/A RAVICTI LIQD Tier 1 & PA N/A N/A RELENZA DISKHALER Tier 1 & QL 240/365 days N/A N/A RELISTOR SOLN Tier 1 & PA & QL N/A N/A RELISTOR TABS Tier 1 & PA & QL 90 N/A N/A

18 RELPAX REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS almotriptan, frovastiptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan Alternative Drug Tier Tier 1 & QL Effective Date Tier 1 & QL 150 N/A N/A REPATHA Tier 1 & PA & QL 3/28 days N/A N/A REVLIMID CAPS Tier 1 & PA N/A N/A REXULTI TABS Tier 1 & QL 30 N/A N/A RIOMET SOLN Tier 1 & QL 765/30 days N/A N/A RISEDRONATE SODIUM DR TABS Tier 1 & QL 4/28 days N/A N/A RISEDRONATE SODIUM TABS Tier 1 & QL N/A N/A RISPERIDONE ODT Tier 1 & QL 60 N/A N/A RITUXAN SOLN Tier 1 & PA N/A N/A RUBRACA TABS Tier 1 & PA & QL 120 N/A N/A SABRIL Tier 1 & PA N/A N/A SAMSCA TABS Tier 1 & QL N/A N/A SANCUSO PTCH Tier 1 & QL 2 N/A N/A SANDIMMUNE CAP 25MG, 100MG cyclosporine, Gengraf Tier 1 & BvD SAPHRIS SUBL Tier 1 & QL 60 N/A N/A SAVELLA TABS Tier 1 & QL 60 N/A N/A SAVELLA TITRATION PACK Tier 1 & QL 110/365 days N/A N/A

19 SEREVENT DISKUS Tier 1 & QL 60 N/A N/A SIGNIFOR SOLN Tier 1 & PA & QL 60 N/A N/A SILDENAFIL SOLN Tier 1 & PA N/A N/A SIMPONI Tier 1 & PA N/A N/A SOMATULINE DEPOT SOLN Tier 1 & PA N/A N/A SPIRIVA RESPIMAT Tier 1 & QL 4 N/A N/A SPRYCEL TABS Tier 1 & PA N/A N/A STELARA Tier 1 & PA N/A N/A STIOLTO RESPIMAT Tier 1 & QL 4 N/A N/A STRATTERA atomoxetine Tier 1 & QL STRIBILD TABS Tier 1 & QL 30 N/A N/A SUBOXONE FILM Tier 1 & QL N/A N/A SULFACETAMIDE SODIUM SUSP 10% sulfacetamide sodium/prednisolone sodium phosphate soln 0.23%; 10% Tier 1 SUMATRIPTAN SUCCINATE SOLN Tier 1 & QL 12 N/A N/A SUTENT CAPS Tier 1 & PA N/A N/A SYLATRON Tier 1 & PA N/A N/A SYMLINPEN Tier 1 & PA N/A N/A SYNRIBO SOLR Tier 1 & PA N/A N/A TAFINLAR CAPS Tier 1 & PA N/A N/A TAGRISSO TABS Tier 1 & PA & QL 30 N/A N/A

20 Alternative Drug Tier Effective Date TAMIFLU SUSP Tier 1 & QL 720/365 days N/A N/A TARCEVA TABS Tier 1 & PA & QL N/A N/A TARGRETIN GEL Tier 1 & PA N/A N/A TASIGNA CAPS Tier 1 & PA N/A N/A TECENTRIQ SOLN Tier 1 & PA N/A N/A TECFIDERA CAPS Tier 1 & PA & QL 60 N/A N/A TECFIDERA STARTER PACK Tier 1 & PA & QL 120/365 days N/A N/A TEMAZEPAM CAPS Tier 1 & PA & QL 30 N/A N/A TENCON TABS Tier 1 & PA & QL 360 N/A N/A TERBINAFINE HCL TABS Tier 1 & QL 84/180 days N/A N/A TESTOSTERONE CYPIONATE SOLN Tier 1 & PA N/A N/A TESTOSTERONE ENANTHATE SOLN Tier 1 & PA N/A N/A THIORIDAZINE HCL TABS Tier 1 & PA N/A N/A TOBI PODHALER Tier 1 & QL 224/56 days N/A N/A TOBRADEX SUSP 0.1%, 0.3% TOLAK CREAM 4% tobramycin/dexamethasone susp 0.1%; 0.3% fluorouracil soln 2%, fluorouracil crea 5%, fluorouracil soln 5% TOLAZAMIDE TABS Tier 1 & QL N/A N/A Tier 1 Tier 1

21 TRACLEER Adcirca, Adempas, Letairis, Opsumit, orenitram, sildenafil, Uptravi Alternative Drug Tier Tier 1 & PA & QL Effective Date TRAMADOL HCL ER CP24 tramadol ER tab 24 Tier 1 TRESIBA FLEXTOUCH Lantus vial, Lantus Solostar, Levemir vial, Levemir Flextouch, Toujeo Tier 1 TRETINOIN GEL Tier 1 & PA N/A N/A TRIAZOLAM TAB estazolam, temazepam Tier 1 & QL 30 TRIMIPRAMINE MALEATE CAPS Tier 1 & PA N/A N/A TRINTELLIX TABS Tier 1 & QL 30 N/A N/A TRIUMEQ TABS Tier 1 & QL 30 N/A N/A TROKENDI XR CP24 topiramate ER cap 24 Tier 1 TRUVADA TABS Tier 1 & QL 30 N/A N/A TYGACIL SOLR 50MG tigecycline inj 50mg Tier 1 TYSABRI CONC Tier 1 & PA N/A N/A ULORIC TABS Tier 1 & ST N/A N/A UPTRAVI TABS Tier 1 & PA & QL 60 N/A N/A URSODIOL CAP 300MG ursodiol tabs 250mg, 500mg Tier 1 VALCHLOR GEL Tier 1 & PA N/A N/A VALPROATE SODIUM SOLN 500MG/5ML valproic acid soln 250mg/5ml Tier 1 VELCADE SOLR Tier 1 & PA N/A N/A VENTAVIS SOLN Tier 1 & PA & QL 270 N/A N/A

22 VENTOLIN HFA Proair HFA, Proair Respiclick Tier 1 VERSACLOZ SUSP Tier 1 & QL 540 N/A N/A VICTOZA Tier 1 & ST & QL 9 N/A N/A VIIBRYD STARTER PACK Tier 1 & QL 60/365 days N/A N/A VIIBRYD TABS Tier 1 & QL 30 N/A N/A VRAYLAR CAPS Tier 1 & ST & QL 30 N/A N/A XARELTO STARTER PACK Tier 1 & QL 102/365 days N/A N/A XELJANZ TABS Tier 1 & PA N/A N/A XGEVA SOLN Tier 1 & PA N/A N/A XOLAIR SOLR Tier 1 & PA N/A N/A XTANDI CAPS Tier 1 & PA N/A N/A XYREM SOLN Tier 1 & PA & QL 540 N/A N/A YERVOY SOLN Tier 1 & PA N/A N/A ZALTRAP SOLN Tier 1 & PA N/A N/A ZARXIO Tier 1 & PA N/A N/A ZAVESCA CAPS Tier 1 & PA N/A N/A ZEBUTAL CAPS Tier 1 & PA & QL 360 N/A N/A ZEJULA CAPS Tier 1 & PA & 90 N/A N/A ZETIA 10MG ezetimibe 10mg Tier 1 ZILEUTON ER TB12 Tier 1 & ST N/A N/A

23 ZIPRASIDONE HCL CAPS Tier 1 & QL 60 N/A N/A ZOLINZA CAPS Tier 1 & PA N/A N/A ZOLPIDEM TARTRATE TABS Tier 1 & PA & QL 30 N/A N/A ZOMETA SOLN 4MG/100ML zoledronic acid inj 4mg, zoledronic acid inj 5mg/100ml Tier 1 ZORTRESS TABS Tier 1 & PA N/A N/A ZYDELIG TABS Tier 1 & PA N/A N/A ZYFLO TABS Tier 1 & ST N/A N/A ZYKADIA CAPS Tier 1 & PA N/A N/A ZYTIGA TABS Tier 1 & PA N/A N/A