2017 Drug Formulary. List of Covered Drugs for 2017 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 2017 Drug Formulary Samaritan Everyday Choices & Samaritan Association Plans List of Covered Drugs for 2017 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This is your 2017 Samaritan Large Employer Groups Plan Formulary Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, Call (541) , (TTY ) to receive material in alternate format or language SCP LG #12231 Version 3, August 2017

2 How to contact Member Services If you have any questions or concerns or require additional assistance in selecting a pharmacy, please call or write to Samaritan Large Employer Groups Plan. We will be happy to help you. Call: (541) or Toll free: TTY: (This number requires special telephone equipment) 8 a.m. to 8 p.m. Visit: Samaritan Health Plans 2300 NW Walnut Blvd Corvallis, OR Monday Friday, 8:30 a.m. to 5 p.m. Write: Samaritan Large Employer Group Plans PO Box 1310 Corvallis, OR

3 Contents INTRODUCTION The Samaritan Health Plans Operations (SHPO) Pharmacy and Therapeutics (P & T) Committee Notice Lost or Stolen Medications Preface Product Selection Criteria Co-Pay Tiers Medication Exception PRIOR AUTHORIZATION (PA) QUANTITY LIMITATIONS (QL) STEP THERAPY (ST) *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** *Amphetamine Mixtures*** *Amphetamines*** *Stimulants - Misc.*** *Aminoglycosides* *Aminoglycosides*** *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies*** *Anti-Tnf-Alpha - Monoclonoal Antibodies*** *Cyclooxygenase 2 (Cox-2) Inhibitors*** *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** *Pyrimidine Synthesis Inhibitors*** *Soluble Tumor Necrosis Factor Receptor Agents*** *Analgesics - Nonnarcotic* *Analgesics-Sedatives*** *Salicylates*** *Analgesics - Opioid* *Codeine Combinations*** *Hydrocodone Combinations*** *Opioid Agonists*** *Opioid Combinations***

4 *Opioid Partial Agonists*** *Tramadol Combinations*** *Androgens-Anabolic* *Androgens*** *Anorectal Agents* *Intrarectal Steroids*** *Rectal Anesthetic/Steroids*** *Rectal Steroids*** *Anthelmintics* *Anthelmintics*** *Antianginal Agents* *Antianginals-Other*** *Nitrates*** *Antianxiety Agents* *Antianxiety Agents - Misc.*** *Benzodiazepines*** *Antiarrhythmics* *Antiarrhythmics Type I-A*** *Antiarrhythmics Type I-B*** *Antiarrhythmics Type I-C*** *Antiarrhythmics Type Iii*** *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** *Beta Adrenergics*** *Bronchodilators - Anticholinergics*** *Leukotriene Receptor Antagonists*** *Steroid Inhalants*** *Xanthines*** *Anticoagulants* *Coumarin Anticoagulants*** *Direct Factor Xa Inhibitors*** *Low Molecular Weight Heparins*** *Thrombin Inhibitors - Selective Direct & Reversible*** *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** *Anticonvulsants - Misc.***

5 *Gaba Modulators*** *Hydantoins*** *Succinimides*** *Valproic Acid*** *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** *Antidepressants - Misc.*** *Modified Cyclics*** *Monoamine Oxidase Inhibitors (Maois)*** *Selective Serotonin Reuptake Inhibitors (Ssris)*** *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** *Ssris-Nutritional Supplement Combinations*** *Tricyclic Agents*** *Antidiabetics* *Alpha-Glucosidase Inhibitors*** *Antidiabetic - Amylin Analogs*** *Biguanides*** *Diabetic Other*** *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** *Human Insulin*** *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** *Meglitinide Analogues*** *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** *Sulfonylurea-Biguanide Combinations*** *Sulfonylureas*** *Thiazolidinedione-Biguanide Combinations*** *Thiazolidinediones*** *Antidiarrheals* *Antiperistaltic Agents*** *Antidotes* *Antidotes - Chelating Agents*** *Opioid Antagonists*** *Antiemetics* *5-Ht3 Receptor Antagonists*** *Antiemetics - Anticholinergic***

6 *Antifungals* *Antifungals*** *Imidazoles*** *Triazoles*** *Antihistamines* *Antihistamines - Ethanolamines*** *Antihistamines - Non-Sedating*** *Antihistamines - Phenothiazines*** *Antihistamines - Piperidines*** *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** *Bile Acid Sequestrants*** *Fibric Acid Derivatives*** *Hmg Coa Reductase Inhibitors*** *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** *Intestinal Cholesterol Absorption Inhibitors*** *Nicotinic Acid Derivatives*** *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** *Ace Inhibitors & Thiazide/Thiazide-Like*** *Ace Inhibitors*** *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** *Angiotensin Ii Receptor Antagonists*** *Antiadrenergics - Centrally Acting*** *Antiadrenergics - Peripherally Acting*** *Beta Blocker & Diuretic Combinations*** *Vasodilators*** *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** *Anti-Infective Misc. - Combinations*** *Ketolides*** *Lincosamides*** *Oxazolidinones*** *Antimalarials* *Antimalarial Combinations*** *Antimalarials***

7 *Antimyasthenic Agents* *Antimyasthenic Agents*** *Antimyasthenic/Cholinergic Agents*** *Antimycobacterial Agents* *Antimycobacterial Agents*** *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** *Antiadrenals*** *Antiandrogens*** *Antiestrogens*** *Antimetabolites*** *Antineoplastic - Autologous Cellular Immunotherapy*** *Antineoplastic - Histone Deacetylase Inhibitors*** *Antineoplastic - Monoclonal Antibodies*** *Antineoplastic - Mtor Kinase Inhibitors*** *Antineoplastic - Multikinase Inhibitors*** *Antineoplastic - Proteasome Inhibitors*** *Antineoplastic - Tyrosine Kinase Inhibitors*** *Antineoplastic Antibiotics*** *Antineoplastic -Antibody For Radiopharmaceutical Therapy*** *Antineoplastic Enzymes*** *Antineoplastics - Photoactivated Agents*** *Antineoplastics Misc.*** *Aromatase Inhibitors*** *Cardiac Protective Agents*** *Chemotherapy Adjuncts - Keratinocyte Growth Factors*** *Estrogens-Antineoplastic*** *Folic Acid Antagonists Rescue Agents*** *Imidazotetrazines*** *Lhrh Analogs*** *Mitotic Inhibitors*** *Nitrogen Mustards*** *Nitrosoureas*** *Progestins-Antineoplastic*** *Selective Retinoid X Receptor Agonists*** *Topoisomerase I Inhibitors***

8 *Urinary Tract Protective Agents*** *Antiparkinson Agents* *Antiparkinson Anticholinergics*** *Antiparkinson Dopaminergics*** *Antiparkinson Monoamine Oxidase Inhibitors*** *Levodopa Combinations*** *Nonergoline Dopamine Receptor Agonists*** *Peripheral Comt Inhibitors*** *Antipsychotics/Antimanic Agents* *Antimanic Agents*** *Antipsychotics - Misc.*** *Benzisoxazoles*** *Butyrophenones*** *Dibenzodiazepines*** *Dibenzothiazepines*** *Dibenzoxazepines*** *Dihydroindolones*** *Phenothiazines*** *Quinolinone Derivatives*** *Thienbenzodiazepines*** *Thioxanthenes*** *Antivirals* *Antiretroviral Combinations*** *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** *Antiretrovirals - Fusion Inhibitors*** *Antiretrovirals - Integrase Inhibitors*** *Antiretrovirals - Protease Inhibitors*** *Antiretrovirals - Rti-Non-Nucleoside Analogues*** *Antiretrovirals - Rti-Nucleoside Analogues-Purines*** *Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** *Antiretrovirals - Rti-Nucleotide Analogues*** *Cmv Agents*** *Hepatitis B Agents*** *Hepatitis C Agents*** *Herpes Agents - Purine Analogues***

9 *Herpes Agents - Thymidine Analogues*** *Influenza Agents*** *Neuraminidase Inhibitors*** *Rsv Agents - Nucleoside Analogues*** *Assorted Classes* *Cyclosporine Analogs*** *Immune Globulin Immunosuppressants*** *Inosine Monophosphate Dehydrogenase Inhibitors*** *Macrolide Immunosuppressants*** *Monoclonal Antibodies*** *Potassium Removing Resins*** *Purine Analogs*** *Beta Blockers* *Alpha-Beta Blockers*** *Beta Blockers Cardio-Selective*** *Beta Blockers Non-Selective*** *Biologicals Misc* *Allergenic Extracts*** *Calcium Channel Blockers* *Calcium Channel Blockers*** *Cardiotonics* *Cardiac Glycosides*** *Cardiovascular Agents - Misc.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** *Peripheral Vasodilators*** *Prostaglandin Vasodilators*** *Pulmonary Hypertension - Endothelin Receptor Antagonists*** *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** *Cephalosporins* *Cephalosporins - 1St Generation*** *Cephalosporins - 2Nd Generation*** *Cephalosporins - 3Rd Generation*** *Contraceptives* *Biphasic Contraceptives - Oral*** *Combination Contraceptives - Oral*** *Combination Contraceptives - Transdermal***

10 *Combination Contraceptives - Vaginal*** *Continuous Contraceptives - Oral*** *Emergency Contraceptives*** *Extended-Cycle Contraceptives - Oral*** *Progestin Contraceptives - Injectable*** *Progestin Contraceptives - Oral*** *Triphasic Contraceptives - Oral*** *Corticosteroids* *Glucocorticosteroids*** *Mineralocorticoids*** *Cough/Cold/Allergy* *Antitussive - Nonnarcotic*** *Antitussive - Opioid*** *Antitussive-Expectorant*** *Antitussive-Expectorants-Decongestant*** *Decongestant & Antihistamine*** *Decongestant W/ Expectorant*** *Misc. Respiratory Inhalants*** *Non-Narc Antitussive-Antihistamine*** *Non-Narc Antitussive-Decongestant-Antihistamine*** *Opioid Antitussive-Antihistamine*** *Opioid Antitussive-Decongestant*** *Opioid Antitussive-Decongestant-Antihistamine*** *Dermatologicals* *Acne Antibiotics*** *Acne Combinations*** *Acne Products*** *Antibiotics - Topical*** *Antifungals - Topical Combinations*** *Antifungals - Topical*** *Anti-Inflammatory Agents - Topical*** *Anti-Inflammatory Combinations - Topical*** *Antineoplastic Antimetabolites - Topical*** *Antipruritics - Topical*** *Antipsoriatics - Systemic*** *Antipsoriatics***

11 *Antiseborrheic Products*** *Antivirals - Topical*** *Burn Products*** *Corticosteroids - Topical*** *Imidazole-Related Antifungals - Topical*** *Immunomodulators Imidazoquinolinamines - Topical*** *Local Anesthetics - Topical*** *Macrolide Immunosuppressants - Topical*** *Rosacea Agents*** *Scabicides & Pediculicides*** *Topical Anesthetic Combinations*** *Wound Care - Growth Factor Agents*** *Diagnostic Products* *Diagnostic Tests*** *Digestive Aids* *Digestive Enzymes*** *Diuretics* *Carbonic Anhydrase Inhibitors*** *Diuretic Combinations*** *Loop Diuretics*** *Potassium Sparing Diuretics*** *Thiazides And Thiazide-Like Diuretics*** *Endocrine And Metabolic Agents - Misc.* *Bisphosphonates*** *Calcitonins*** *Carnitine Replenisher - Agents*** *Dopamine Receptor Agonists*** *Growth Hormones*** *Hyperparathyroid Treatment - Vitamin D Analogs*** *Lhrh/Gnrh Agonist Analog Pituitary Suppressants*** *Parathyroid Hormone And Derivatives*** *Selective Estrogen Receptor Modulators (Serms)*** *Vasopressin*** *Estrogens* *Estrogen & Androgen*** *Estrogen & Progestin***

12 *Estrogens*** *Fluoroquinolones* *Fluoroquinolones*** *Gastrointestinal Agents - Misc.* *Gallstone Solubilizing Agents*** *Gastrointestinal Antiallergy Agents*** *Gastrointestinal Chloride Channel Activators*** *Gastrointestinal Stimulants*** *Inflammatory Bowel Agents*** *Intestinal Acidifiers*** *Phosphate Binder Agents*** *Tumor Necrosis Factor Alpha Blockers*** *Genitourinary Agents - Miscellaneous* *5-Alpha Reductase Inhibitors*** *Alpha 1-Adrenoceptor Antagonists*** *Citrates*** *Interstitial Cystitis Agents*** *Urinary Analgesics*** *Gout Agents* *Gout Agent Combinations*** *Gout Agents*** *Uricosurics*** *Hematological Agents - Misc.* *Hematorheologic Agents*** *Phosphodiesterase Iii Inhibitors*** *Platelet Aggregation Inhibitor Combinations*** *Platelet Aggregation Inhibitors*** *Quinazoline Agents*** *Thienopyridine Derivatives*** *Hematopoietic Agents* *Cobalamins*** *Erythropoiesis-Stimulating Agents (Esas)*** *Erythropoietins*** *Folic Acid/Folate Combinations*** *Folic Acid/Folates*** *Granulocyte Colony-Stimulating Factors (G-Csf)***

13 *Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** *Hepatitis C Agent - Combinations*** *Hepatitis C Agent - Combinations*** *Hypnotics* *Barbiturate Hypnotics*** *Benzodiazepine Hypnotics*** *Non-Benzodiazepine - Gaba-Receptor Modulators*** *Selective Melatonin Receptor Agonists*** *Laxatives* *Bowel Evacuant Combinations*** *Laxatives - Miscellaneous*** *Saline Laxative Mixtures*** *Lysosomal Acid Lipase (Lal) Deficiency - Agents*** *Lysosomal Acid Lipase (Lal) Deficiency - Agents*** *Macrolides* *Azithromycin*** *Clarithromycin*** *Erythromycins*** *Medical Devices* *Glucose Monitoring Test Supplies*** *Needles & Syringes*** *Spacer/Aerosol-Holding Chambers & Supplies*** *Migraine Products* *Ergot Combinations*** *Migraine Combinations*** *Migraine Products*** *Selective Serotonin Agonists 5-Ht(1)*** *Minerals & Electrolytes* *Fluoride*** *Phosphate*** *Potassium Combinations*** *Potassium*** *Mouth/Throat/Dental Agents* *Anesthetics Topical Oral*** *Anti-Infectives - Throat*** *Antiseptics - Mouth/Throat***

14 *Fluoride Dental Products*** *Periodontal Anti-Infectives*** *Saliva Stimulants*** *Steroids - Mouth/Throat*** *Multivitamins* *Ped Multi Vitamins W/Fl & Fe*** *Ped Mv W/ Fluoride*** *Ped Vitamins Acd Fluoride & Iron*** *Ped Vitamins Acd W/ Fluoride*** *Prenatal Mv & Min W/Fe-Fa*** *Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** *Prenatal Mv & Min W/Fe-Fa-Dha*** *Prenatal Vitamins*** *Musculoskeletal Therapy Agents* *Central Muscle Relaxants*** *Direct Muscle Relaxants*** *Muscle Relaxant Combinations*** *Nasal Agents - Systemic And Topical* *Nasal Agents Misc. - Combinations*** *Nasal Anticholinergics*** *Nasal Antihistamines*** *Nasal Steroids*** *Systemic Decongestants*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** *Ophthalmic Agents* *Beta-Blockers - Ophthalmic Combinations*** *Beta-Blockers - Ophthalmic*** *Cycloplegic Mydriatics*** *Miotics - Direct Acting*** *Ophthalmic Antiallergic*** *Ophthalmic Antibiotics*** *Ophthalmic Anti-Infective Combinations*** *Ophthalmic Antivirals*** *Ophthalmic Carbonic Anhydrase Inhibitors*** *Ophthalmic Local Anesthetics***

15 *Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** *Ophthalmic Selective Alpha Adrenergic Agonists*** *Ophthalmic Steroid Combinations*** *Ophthalmic Steroids*** *Ophthalmic Sulfonamides*** *Prostaglandins - Ophthalmic*** *Otic Agents* *Otic Anti-Infectives*** *Otic Steroid-Anti-Infective Combinations*** *Otic Steroids*** *Passive Immunizing Agents* *Antiviral Monoclonal Antibodies*** *Pcsk9 Inhibitors*** *Pcsk9 Inhibitors*** *Penicillins* *Aminopenicillins*** *Natural Penicillins*** *Penicillin Combinations*** *Penicillinase-Resistant Penicillins*** *Potassium Removing Agents*** *Potassium Removing Agents*** *Progestins* *Progestins*** *Psychotherapeutic And Neurological Agents - Misc.* *Alcohol Deterrents*** *Cholinomimetics - Ache Inhibitors*** *Multiple Sclerosis Agents - Interferons*** *Multiple Sclerosis Agents - Nrf2 Pathway Activators*** *Multiple Sclerosis Agents*** *N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** *Psychotherapeutic And Neurological Agents - Misc.*** *Smoking Deterrents*** *Sphingosine 1-Phosphate (S1p) Receptor Modulators*** *Pulmonary Hypertension - Prostacyclin Receptor Agonist*** *Pulmonary Hypertension - Prostacyclin Receptor Agonist*** *Serotonin Modulators***

16 *Serotonin Modulators*** *Tetracyclines* *Tetracyclines*** *Thyroid Agents* *Antithyroid Agents*** *Thyroid Hormones*** *Ulcer Drugs* *Anticholinergic Combinations*** *Antispasmodics*** *Belladonna Alkaloids*** *H-2 Antagonists*** *Misc. Anti-Ulcer*** *Proton Pump Inhibitors*** *Quaternary Anticholinergics*** *Ulcer Anti-Infective W/ Proton Pump Inhibitors*** *Ulcer Drugs - Prostaglandins*** *Urinary Anti-Infectives* *Urinary Anti-Infectives*** *Urinary Antispasmodics* *Urinary Antispasmodic - Antimuscarinic (Anticholinergic)*** *Urinary Antispasmodic - Antimuscarinics (Antichol)***(New) *Urinary Antispasmodics - Cholinergic Agonists*** *Urinary Antispasmodics - Cholinergic Agonists*** (New) *Urinary Antispasmodics - Direct Muscle Relaxants*** *Urinary Antispasmodics - Direct Muscle Relaxants*** (New) *Vaccines* *Viral Vaccines*** *Vaginal Products* *Imidazole-Related Antifungals*** *Vaginal Anti-Infectives*** *Vaginal Estrogens*** *Vasopressors* *Anaphylaxis Therapy Agents*** *Vasopressors*** *Vitamins* *Vitamin B-3***

17 *Vitamin D*** *Vitamin K*** Index

18 LEGEND PA: ST: QL: PRIOR AUTHORIZATION IS REQUIRED STEP THERAPY QUANTITY LIMIT INTRODUCTION Samaritan Health Plan Operations is pleased to provide the 2017 Samaritan Choice Plan (SCP) Formulary as a reference and informational tool for physicians, pharmacists and patients. The SCP Formulary is designed to assist practitioners in selecting clinically appropriate and costeffective products for their patients. The Samaritan Health Plans Operations (SHPO) Pharmacy and Therapeutics (P & T) Committee The SHPO P&T Committee has reviewed all the medications listed on the formulary. Medications found to be clinically appropriate and cost effective have been selected as an option for SCP members. If a physician deems an unlisted product to be medically necessary, the physician may request coverage through the medical exception process. Notice This formulary is not intended to be a substitute for a medical provider s knowledge expertise, skill or judgment. SCP assumes no responsibility for the actions or omissions of any medical provider based upon the information herein. The medical provider should always consult the drug manufacturer s product insert for detailed information. The medications listed on this formulary are subject to change pursuant to the formulary management activities of SHPO and the Plan s Provisions. The presence of a medication on this formulary does not guarantee that you as a plan member will be prescribed that drug by your primary care physician or contracting provider for a particular medical condition. These medications may be subject to Prior Authorization. As new generics become available the corresponding brand name drug may no longer be considered a preferred agent. Branded Generics and Generics: All prescription medications enter the market place as brand name medications and when patents expire, other firms get FDA approval to market generic alternatives to the brand. There are two types of alternatives which are as follows: Generic- A generic alternative to a patented medication. An example of a generic is Levothyroxine. These medications are found on Tier 2 of the formulary. Branded Generic- A generic alternatives that a pharmaceuticals firm has branded. Branded Generics may cost more than the truly generic version. An example of Branded Generic is Synthroid, which is the original brand medication of generic Levothyroxine. These medications are found on Tier 2 and Tier 3 of the formulary book. SCP covers both brand name drugs and generic drugs. Generic drugs are approved by the FDA as having the same active ingredient as the brand name drug. Generally, when a generic version of a drug is available SCP will require that the generic be used by members unless it is medically necessary for a member to use the brand version of a drug. SCP uses a formulary, that lists the covered prescription medications. Some covered medications may have additional requirements or limits on coverage. These requirements may include: Prior Authorization: SCP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SCP before you fill your prescriptions. Quantity Limits: For certain drugs, SCP limits the amount of the drug that is covered. Managed drug limit means quantity limit. Step Therapy: In some cases, SCP 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, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. You can find out more about additional requirements or limits on covered medication by contacting our Customer Service Department or you physician. listings, please contact us at (541) or

19 Lost or Stolen Medications The SCP policy for lost or stolen medications is that they are not covered unless the medication is emergent and a police report has been filed. Narcotic medications will not be filled early due to being lost or stolen. Please call Customer Service at (541) or (800) if you have any other questions regarding a member with this situation. Preface The SCP Formulary is a listing of preferred drug products eligible for reimbursement by SCP. All medications are listed organized by therapeutic class and appropriate Tier. Brand names are listed to assist in product recognition. Unless noted, all applicable dosage forms and strengths are generally covered. Extended release formulations (e.g., ext-rel, SR) are not considered formulary drugs unless specified. SCP will not cover prescription drugs when prescribed for experimental or investigational uses. Product Selection Criteria The SHPO P&T Committee is composed of physicians, pharmacists and health professionals. The primary goal of the Committee is to maintain and evaluate the SCP formulary based upon an objective analysis of the safety, efficacy, indications, adverse events, compliance, contraindications and cost-effectiveness of each drug. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently included in the SCP Formulary. Co-Pay Tiers The level of prescription drug coverage is determined through a five-tier system. The tiers are as follows: Tier 1: Therapeutic/Preventative Tier specific therapeutic and preventative medications. Tier 2: Preferred Generic Tier Generic drugs provide the same high quality medicine and therapeutic benefits found in brand-name medications without the brand-name price. Tier 3: Preferred Tier Preferred Brand Name drugs provide high quality, effective and affordable prescription benefits to SCP members. Tier 4: Non-Preferred Tier Tier 5: Specialty Tier - Specialty medications as defined by the SHPO P&T Committee (generally very high cost, unique therapies). Medication Exception Exceptions are made in two rare circumstances: 1. There is a documented reaction to a component of the generic not present in the branded product. Usually this is a dye, filler, or preservative. 2. There is objective evidence of therapeutic failure after adjustment of dosage and/or timing of doses, and assurance of patient compliance. An example would be failure obtain/maintain therapeutic drug levels after dosage adjustments. If a medication is not on the formulary but is medically necessary you may request a formulary exception by faxing a completed medication exception form to SCP at

20 PRIOR AUTHORIZATION (PA) Drugs indicated with "PA" require Prior Authorization for coverage, this includes some generic versions. Please call Customer Service at (541) or or fax completed PA form to to request prior authorization (PA) for the following medications. This list is subject to change. Humatrope SOLUTION RECONSTITUTED 5 MG INJECTION HumaLOG KwikPen Solution Pen-injector 200 UNIT/ML Subcutaneous Humatrope SOLUTION RECONSTITUTED 6 MG INJECTION Humatrope SOLUTION RECONSTITUTED 12 MG INJECTION Humatrope SOLUTION RECONSTITUTED 24 MG INJECTION HumaLOG Mix 75/25 KwikPen Suspension Peninjector (75-25) 100 UNIT/ML Subcutaneous HumaLOG Mix 50/50 KwikPen Suspension Peninjector (50-50) 100 UNIT/ML Subcutaneous HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML Subcutaneous HumuLIN 70/30 KwikPen Suspension Pen-injector (70-30) 100 UNIT/ML Subcutaneous HumuLIN N KwikPen Suspension Pen-injector 100 UNIT/ML Subcutaneous Zepatier TABLET MG ORAL Grastek TABLET SUBLINGUAL 2800 BAU SUBLINGUAL Genotropin SOLUTION RECONSTITUTED 5 MG Subcutaneous Genotropin SOLUTION RECONSTITUTED 12 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 0.2 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 0.4 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 0.6 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 0.8 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 1 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 1.2 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 1.4 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED Genotropin MiniQuick SOLUTION RECONSTITUTED 1.8 MG Subcutaneous Genotropin MiniQuick SOLUTION RECONSTITUTED 2 MG Subcutaneous Leukine SOLUTION RECONSTITUTED 250 MCG Intravenous Praluent Solution Pen-injector 75 MG/ML Subcutaneous Praluent Solution Pen-injector 150 MG/ML Subcutaneous Praluent Solution Prefilled Syringe 75 MG/ML Subcutaneous Praluent Solution Prefilled Syringe 150 MG/ML Subcutaneous Linezolid SUSPENSION RECONSTITUTED 100 MG/5ML ORAL Revatio SUSPENSION RECONSTITUTED 10 MG/ML ORAL Revatio SOLUTION 10 MG/12.5ML Intravenous Lyrica CAPSULE 25 MG ORAL Lyrica CAPSULE 50 MG ORAL Lyrica CAPSULE 75 MG ORAL Lyrica CAPSULE 100 MG ORAL Lyrica CAPSULE 150 MG ORAL Lyrica CAPSULE 200 MG ORAL Lyrica CAPSULE 300 MG ORAL Lyrica CAPSULE 225 MG Oral Humira Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous Humira Pediatric Crohns Start Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous Humira Pen Pen-injector Kit 40 MG/0.8ML Subcutaneous Humira Pen-Crohns Starter Pen-injector Kit 40 MG/0.8ML Subcutaneous Humira Pen-Psoriasis Starter Pen-injector Kit 40 MG/0.8ML Subcutaneous Humira Prefilled Syringe Kit 10 MG/0.2ML Subcutaneous Humira Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous Gilenya CAPSULE 0.5 MG ORAL 1.6 MG Subcutaneous 20

21 Cosentyx Sensoready Pen Solution Auto-injector 150 MG/ML Subcutaneous Cosentyx Solution Prefilled Syringe 150 MG/ML Subcutaneous Entresto TABLET MG ORAL Entresto TABLET MG ORAL Entresto TABLET MG ORAL Intron A SOLUTION RECONSTITUTED UNIT INJECTION Intron A SOLUTION RECONSTITUTED UNIT INJECTION Intron A SOLUTION RECONSTITUTED UNIT INJECTION Intron A SOLUTION UNIT/ML INJECTION Intron A SOLUTION UNIT/ML INJECTION Lantus SoloStar Solution Pen-injector 100 UNIT/ML Subcutaneous Apidra SoloStar Solution Pen-injector 100 UNIT/ML Subcutaneous Sildenafil Citrate TABLET 20 MG Oral Linezolid TABLET 600 MG ORAL ARIPiprazole TABLET 5 MG Oral ARIPiprazole TABLET 10 MG Oral ARIPiprazole TABLET 15 MG Oral ARIPiprazole TABLET 20 MG Oral ARIPiprazole TABLET 30 MG Oral ARIPiprazole TABLET 2 MG Oral Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 50 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 60 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 100 MG ORAL NovoLOG PenFill Solution Cartridge 100 UNIT/ML Subcutaneous NovoLOG Mix 70/30 FlexPen Suspension Pen-injector (70-30) 100 UNIT/ML Subcutaneous NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML Subcutaneous Sildenafil Citrate SOLUTION 10 MG/12.5ML Levemir FlexTouch Solution Pen-injector 100 UNIT/ML Subcutaneous Norditropin FlexPro SOLUTION 5 MG/1.5ML Subcutaneous Norditropin FlexPro SOLUTION 10 MG/1.5ML Subcutaneous Norditropin FlexPro SOLUTION 15 MG/1.5ML Subcutaneous Virazole SOLUTION RECONSTITUTED 6 GM Inhalation SymlinPen 60 Solution Pen-injector 1500 MCG/1.5ML Subcutaneous SymlinPen 120 Solution Pen-injector 2700 MCG/2.7ML Subcutaneous Terbinafine HCl TABLET 250 MG Oral Omnitrope SOLUTION 5 MG/1.5ML Subcutaneous Omnitrope SOLUTION 10 MG/1.5ML Subcutaneous Omnitrope SOLUTION RECONSTITUTED 5.8 MG Subcutaneous Truvada TABLET MG ORAL Ranexa Tablet Extended Release 12 Hour 500 MG Oral Serostim SOLUTION RECONSTITUTED 4 MG Subcutaneous Serostim SOLUTION RECONSTITUTED 5 MG Subcutaneous Serostim SOLUTION RECONSTITUTED 6 MG Subcutaneous Saizen SOLUTION RECONSTITUTED 5 MG INJECTION Saizen Click.Easy SOLUTION RECONSTITUTED 8.8 MG INJECTION Saizen SOLUTION RECONSTITUTED 8.8 MG INJECTION Zorbtive SOLUTION RECONSTITUTED 8.8 MG Subcutaneous Zetia TABLET 10 MG ORAL Nutropin AQ Pen SOLUTION 10 MG/2ML Subcutaneous Nutropin AQ NuSpin 10 SOLUTION 10 MG/2ML Subcutaneous Nutropin AQ NuSpin 5 SOLUTION 5 MG/2ML Subcutaneous Nutropin AQ NuSpin 20 SOLUTION 20 MG/2ML Subcutaneous Intravenous 21

22 Epogen SOLUTION 2000 UNIT/ML INJECTION Epogen SOLUTION UNIT/ML INJECTION Epogen SOLUTION 4000 UNIT/ML INJECTION Neupogen Solution Prefilled Syringe 480 MCG/0.8ML Injection Epogen SOLUTION 3000 UNIT/ML INJECTION Epogen SOLUTION UNIT/ML INJECTION Neupogen SOLUTION 300 MCG/ML INJECTION Neupogen SOLUTION 480 MCG/1.6ML INJECTION Neupogen Solution Prefilled Syringe 300 MCG/0.5ML Injection Remicade SOLUTION RECONSTITUTED 100 MG Intravenous Procrit SOLUTION 2000 UNIT/ML INJECTION Procrit SOLUTION 3000 UNIT/ML INJECTION Procrit SOLUTION 4000 UNIT/ML INJECTION Procrit SOLUTION UNIT/ML INJECTION Procrit SOLUTION UNIT/ML INJECTION Procrit SOLUTION UNIT/ML INJECTION Synagis SOLUTION 100 MG/ML Intramuscular Synagis SOLUTION 50 MG/0.5ML Intramuscular Ranexa Tablet Extended Release 12 Hour 1000 MG Oral Epclusa TABLET MG ORAL Nuplazid TABLET 17 MG ORAL Tecfidera CAPSULE DELAYED RELEASE 120 MG ORAL Tecfidera CAPSULE DELAYED RELEASE 240 MG ORAL Ranexa Tablet Extended Release 12 Hour 1000 MG Oral Epclusa TABLET MG ORAL Nuplazid TABLET 17 MG ORAL 22

23 QUANTITY LIMITATIONS (QL) Drugs with QL will have the limitations noted in the column to the right of the drug name. Once the QL has been exceeded a PA will be required. Managed drug limitations are subject to change. Product Advair Diskus Aerosol Powder Breath Activated MCG/DOSE Inhalation Advair Diskus Aerosol Powder Breath Activated MCG/DOSE Inhalation Advair Diskus Aerosol Powder Breath Activated MCG/DOSE Inhalation Advair HFA Aerosol MCG/ACT Inhalation Advair HFA Aerosol MCG/ACT Inhalation Advair HFA Aerosol MCG/ACT Inhalation Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION Albuterol Sulfate NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION Albuterol Sulfate NEBULIZATION SOLUTION 0.63 MG/3ML INHALATION Albuterol Sulfate NEBULIZATION SOLUTION 1.25 MG/3ML INHALATION Alendronate Sodium TABLET 10 MG Oral Alendronate Sodium TABLET 35 MG Oral Alendronate Sodium TABLET 40 MG Oral Alendronate Sodium TABLET 5 MG Oral Alendronate Sodium TABLET 70 MG Oral Almotriptan Malate TABLET 12.5 MG ORAL Almotriptan Malate TABLET 6.25 MG ORAL Anoro Ellipta Aerosol Powder Breath Activated MCG/INH Inhalation Asmanex 120 Metered Doses Aerosol Powder Breath Activated 220 MCG/INH Inhalation Asmanex 14 Metered Doses Aerosol Powder Breath Activated 220 MCG/INH Inhalation Asmanex 30 Metered Doses Aerosol Powder Breath Activated 110 MCG/INH Inhalation Asmanex 30 Metered Doses Aerosol Powder Breath Activated 220 MCG/INH Inhalation Asmanex 60 Metered Doses Aerosol Powder Breath Activated 220 MCG/INH Inhalation Asmanex 7 Metered Doses Aerosol Powder Breath Activated 110 MCG/INH Inhalation Asmanex HFA Aerosol 100 MCG/ACT Inhalation Asmanex HFA Aerosol 200 MCG/ACT Inhalation Atrovent HFA Aerosol Solution 17 MCG/ACT Inhalation Breo Ellipta Aerosol Powder Breath Activated MCG/INH Inhalation Breo Ellipta Aerosol Powder Breath Activated MCG/INH Inhalation Budesonide SUSPENSION 0.25 MG/2ML INHALATION Budesonide SUSPENSION 0.5 MG/2ML Inhalation Quantity Limit QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(180 VIAL per 30 days) QL(180 VIAL per 30 days) QL(180 VIAL per 30 days) QL(180 VIAL per 30 days) QL(30 EA per 30 days) QL(8 EA per 28 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(4 EA per 28 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(1 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 INH per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(120 VIAL per 30 days) QL(60 VIAL per 30 days) 23

24 Budesonide SUSPENSION 1 MG/2ML INHALATION QL(30 VIAL per 30 days) Combivent Respimat Aerosol Solution MCG/ACT Inhalation QL(4 GM per 30 days) Daytrana PATCH 10 MG/9HR TRANSDERMAL QL(30 EA per 30 days) Daytrana PATCH 15 MG/9HR TRANSDERMAL QL(30 EA per 30 days) Daytrana PATCH 20 MG/9HR TRANSDERMAL QL(30 EA per 30 days) Daytrana PATCH 30 MG/9HR TRANSDERMAL QL(30 EA per 30 days) Dihydroergotamine Mesylate SOLUTION 4 MG/ML NASAL QL(12 ML per 30 days) Dulera Aerosol MCG/ACT Inhalation QL(1 EA per 30 days) Dulera Aerosol MCG/ACT Inhalation QL(1 EA per 30 days) Endocet TABLET MG ORAL QL(360 EA per 30 days) Endocet TABLET MG ORAL QL(360 EA per 30 days) Endocet TABLET MG ORAL QL(360 EA per 30 days) Endocet TABLET MG ORAL QL(360 EA per 30 days) Enoxaparin Sodium SOLUTION 100 MG/ML Subcutaneous QL(14 ML per 7 days) Enoxaparin Sodium SOLUTION 120 MG/0.8ML Subcutaneous QL(14 ML per 7 days) Enoxaparin Sodium SOLUTION 150 MG/ML Subcutaneous QL(14 ML per 7 days) Enoxaparin Sodium SOLUTION 30 MG/0.3ML Subcutaneous QL(4.2 ML per 7 days) Enoxaparin Sodium SOLUTION 300 MG/3ML INJECTION QL(14 ML per 7 days) Enoxaparin Sodium SOLUTION 40 MG/0.4ML Subcutaneous QL(5.6 ML per 7 days) Enoxaparin Sodium SOLUTION 60 MG/0.6ML Subcutaneous QL(8.4 ML per 7 days) Enoxaparin Sodium SOLUTION 80 MG/0.8ML Subcutaneous QL(11.2 ML per 7 days) FentaNYL Patch 72 Hour 100 MCG/HR Transdermal QL(10 EA per 30 days) FentaNYL Patch 72 Hour 12 MCG/HR Transdermal QL(10 EA per 30 days) FentaNYL Patch 72 Hour 25 MCG/HR Transdermal QL(10 EA per 30 days) FentaNYL Patch 72 Hour 50 MCG/HR Transdermal QL(10 EA per 30 days) FentaNYL Patch 72 Hour 75 MCG/HR Transdermal QL(10 EA per 30 days) Flovent HFA Aerosol 110 MCG/ACT Inhalation QL(2 EA per 30 days) Flovent HFA Aerosol 220 MCG/ACT Inhalation QL(2 EA per 30 days) Flovent HFA Aerosol 44 MCG/ACT Inhalation QL(2 EA per 30 days) Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT QL(1 EA per 30 days) Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT QL(1 EA per 30 days) Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT QL(1 EA per 30 days) Inhalation Frovatriptan Succinate TABLET 2.5 MG ORAL QL(12 EA per 30 days) GaviLyte-G SOLUTION RECONSTITUTED 236 GM ORAL QL(236 ML per 30 days) GaviLyte-N with Flavor Pack SOLUTION RECONSTITUTED 420 GM ORAL QL(420 ML per 30 days) Ibandronate Sodium TABLET 150 MG ORAL QL(1 EA per 30 days) Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH Inhalation QL(1 EA per 30 days) Ipratropium-Albuterol SOLUTION (3) MG/3ML Inhalation QL(180 VIAL per 30 days) Lansoprazole CAPSULE DELAYED RELEASE 30 MG Oral QL(60 EA per 30 days) Modafinil TABLET 100 MG Oral QL(30 EA per 30 days) Modafinil TABLET 200 MG Oral QL(30 EA per 30 days) 24

25 MoviPrep SOLUTION RECONSTITUTED 100 GM ORAL Naratriptan HCl TABLET 1 MG ORAL Naratriptan HCl TABLET 2.5 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 10 MG Oral Omeprazole CAPSULE DELAYED RELEASE 20 MG Oral Omeprazole CAPSULE DELAYED RELEASE 40 MG Oral Ondansetron HCl SOLUTION 4 MG/5ML Oral Ondansetron HCl TABLET 4 MG Oral Ondansetron HCl TABLET 8 MG Oral Ondansetron TABLET DISPERSIBLE 4 MG Oral Ondansetron TABLET DISPERSIBLE 8 MG Oral OxyCODONE HCl CAPSULE 5 MG ORAL OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 10 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 15 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 20 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 30 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 40 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 60 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse-Deterrent 80 MG Oral OxyCODONE HCl TABLET 10 MG Oral OxyCODONE HCl TABLET 15 MG Oral OxyCODONE HCl TABLET 20 MG Oral OxyCODONE HCl TABLET 30 MG Oral OxyCODONE HCl TABLET 5 MG ORAL Oxycodone-Acetaminophen TABLET MG Oral Oxycodone-Acetaminophen TABLET MG Oral Oxycodone-Acetaminophen TABLET MG Oral Oxycodone-Acetaminophen TABLET MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 10 MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 15 MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 20 MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 30 MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 40 MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 60 MG Oral OxyCONTIN Tablet ER 12 Hour Abuse-Deterrent 80 MG Oral Pantoprazole Sodium Tablet Delayed Release 20 MG Oral Pantoprazole Sodium Tablet Delayed Release 40 MG Oral PEG 3350-KCl-Na Bicarb-NaCl SOLUTION RECONSTITUTED 420 GM ORAL PEG-3350/Electrolytes SOLUTION RECONSTITUTED 236 GM ORAL Prevacid SoluTab TABLET DISPERSIBLE 15 MG ORAL Prevacid SoluTab TABLET DISPERSIBLE 30 MG ORAL Primlev TABLET MG Oral Primlev TABLET MG Oral QL(100 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(600 ML per 30 days) QL(180 EA per 30 days) QL(90 EA per 30 days) QL(180 EA per 30 days) QL(90 EA per 30 days) QL(360 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(420 ML per 30 days) QL(236 ML per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) 25

26 Primlev TABLET MG Oral ProAir HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation Pulmicort Flexhaler Aerosol Powder Breath Activated 180 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 Relpax TABLET 20 MG ORAL Relpax TABLET 40 MG ORAL Risedronate Sodium TABLET 150 MG ORAL Risedronate Sodium TABLET 35 MG Oral Rizatriptan Benzoate TABLET 10 MG Oral Rizatriptan Benzoate TABLET 5 MG Oral Rizatriptan Benzoate TABLET DISPERSIBLE 10 MG Oral Rizatriptan Benzoate TABLET DISPERSIBLE 5 MG Oral Serevent Diskus Aerosol Powder Breath Activated 50 MCG/DOSE Inhalation Spiriva HandiHaler CAPSULE 18 MCG INHALATION Suboxone FILM 12-3 MG SUBLINGUAL Suboxone FILM MG SUBLINGUAL Suboxone FILM 4-1 MG SUBLINGUAL Suboxone FILM 8-2 MG SUBLINGUAL SUMAtriptan Succinate TABLET 100 MG Oral SUMAtriptan Succinate TABLET 25 MG Oral SUMAtriptan Succinate TABLET 50 MG Oral Symbicort Aerosol MCG/ACT Inhalation Symbicort Aerosol MCG/ACT Inhalation Terbinafine HCl TABLET 250 MG Oral Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation Xarelto TABLET 10 MG ORAL Xarelto TABLET 15 MG ORAL Xarelto TABLET 20 MG ORAL Xopenex HFA Aerosol 45 MCG/ACT Inhalation ZOLMitriptan TABLET 2.5 MG Oral ZOLMitriptan TABLET 5 MG Oral ZOLMitriptan TABLET DISPERSIBLE 2.5 MG ORAL ZOLMitriptan TABLET DISPERSIBLE 5 MG ORAL Zolpidem Tartrate ER Tablet Extended Release 12.5 MG Oral Zolpidem Tartrate ER Tablet Extended Release 6.25 MG Oral Zolpidem Tartrate TABLET 10 MG Oral Zolpidem Tartrate TABLET 5 MG Oral Zostavax SOLUTION RECONSTITUTED UNT/0.65ML Subcutaneous QL(360 EA per 30 days) QL(2 INH per 30 days) QL(2 INH per 30 days) QL(1 INH per 30 days) QL(1 INH per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(1 EA per 30 days) QL(4 EA per 28 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(10.2 GM per 30 days) QL(10.2 GM per 30 days) QL(90 EA per 365 days) QL(2 INH per 30 days) QL(34 EA per 34 days) QL(34 EA per 34 days) QL(34 EA per 34 days) QL(2 INH per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(1 EA per 365 days) 26

27 STEP THERAPY (ST) The following products have step therapy limitations. This list is subject to change. ST Group Dexilant Farxiga Invokana Janumet Janumet XR Januvia Jardiance Kombiglyze XR Onglyza Tanzeum Pen-injector Tradjenta Trulicity Pen-injector Fluticasone-Salmeterol aerosol powder Topical testosterone Algorithm must try/fail 2 formulary generic PPIs Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo Must try/fail metformin AND a sulfonylurea or metformin/sulfonylurea combo must try/fail 2 of the preferred inhalers (Advair, Breo Ellipta, Symbicort) must try/fail injectable testosterone Trintellix must try/fail 2 generic SSRIs and/or SNRIs Viibryd must try/fail 2 generic SSRIs and/or SNRIs Vraylar must try/fail 2 generic second generation antipsychotics 27

28 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Status NC = Not Covered NF = Non-Formulary = Tier 1 = Tier 2 = Tier 3 T4 = Tier 4 = Tier 5 Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Stimulants - Misc.*** DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg T4 T4 Notes PA = Prior Authorization Required PANS = PA for New Starts QL = Quantity Limit ST = Step Therapy Required STNS = Step Therapy Required For New Starts QL (30 EA per 30 days) 28

29 Drug Status Notes dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg modafinil oral tablet 100 mg, 200 mg QL (30 EA per 30 days) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 29 T4 PA PA PA PA

30 Drug Status Notes HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg 30 PA PA PA PA PA PA

31 Drug Status Notes ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketoprofen er oral capsule extended release 24 hour 200 mg ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml ketorolac tromethamine oral tablet 10 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium er oral tablet extended release 24 hour 500 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg VIVLODEX ORAL CAPSULE 10 MG, 5 MG *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* 31 T4