InterCommunity Health Network Coordinated Care Organization, IHN-CCO

Transcription

1 InterCommunity Health Network Coordinated Care Organization, IHN-CCO 2017 Drug Formulary List of Covered Drugs IHNCCO #11597 Version 3 August 2017

2 Formulary Table of Contents LEGEND... 5 INTRODUCTION... 6 Mental Health Drugs... 7 The following drugs are financed separately by the State of Oregon... 7 (OMAP) and not subject to the IHN Formulary. This list contains... 7 the vast majority of products covered by the state, but may not be... 7 all-inclusive. Brand names listed are for reference only. To check... 7 for changes to the list, search for 7-11 Drug Carveout List at 7 PRIOR AUTHORIZATION... 9 QUANTITY LIMITATIONS (QL) *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Alternative Medicines* *Aminoglycosides* *Analgesics - Anti-Inflammatory* *Analgesics - Nonnarcotic* *Analgesics - Opioid* *Androgens-Anabolic* *Anorectal Agents* *Antacids* *Anthelmintics* *Antianginal Agents* *Antianxiety Agents* *Antiarrhythmics* *Antiasthmatic And Bronchodilator Agents* *Anticoagulants* *Anticonvulsants* *Antidiabetics* *Antidiarrheals* *Antidotes And Specific Antagonists* *Antidotes* *Antiemetics* *Antifungals* *Antihistamines* *Antihyperlipidemics*... 62

3 *Antihypertensives* *Anti-Infective Agents - Misc.* *Antimalarials* *Antimyasthenic Agents* *Antimyasthenic/Cholinergic Agents* *Antimycobacterial Agents* *Antineoplastics And Adjunctive Therapies* *Antiparkinson Agents* *Antipsychotics/Antimanic Agents* *Antivirals* *Assorted Classes* *Beta Blockers* *Biologicals Misc* *Calcium Channel Blockers* *Cardiotonics* *Cardiovascular Agents - Misc.* *Cephalosporins* *Contraceptives* *Corticosteroids* *Cough/Cold/Allergy* *Dermatologicals* *Diagnostic Products* *Digestive Aids* *Diuretics* *Endocrine And Metabolic Agents - Misc.* *Estrogens* *Fluoroquinolones* *Gastrointestinal Agents - Misc.* *Genitourinary Agents - Miscellaneous* *Gout Agents* *Hematological Agents - Misc.* *Hematopoietic Agents* *Hepatitis C Agent - Combinations*** *Hypnotics* *Laxatives* *Macrolides* *Medical Devices*

4 *Migraine Products* *Minerals & Electrolytes* *Mouth/Throat/Dental Agents* *Multivitamins* *Musculoskeletal Therapy Agents* *Nasal Agents - Systemic And Topical* *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** *Nutrients* *Ophthalmic Agents* *Otic Agents* *Oxytocics* *Pcsk9 Inhibitors*** *Penicillins* *Progestins* *Psychotherapeutic And Neurological Agents - Misc.* *Tetracyclines* *Thyroid Agents* *Ulcer Drugs* *Urinary Anti-Infectives* *Urinary Antispasmodics* *Vaccines* *Vaginal Products* *Vasopressors* *Vitamins*

5 LEGEND QL: Quantity limitations OTC: Over-the-counter PA: Prior authorization required. Call SPECIALTY: These drugs can be obtained at pharmacies that are considered Specialty. Call to get a list of participating pharmacies. MED: Morphine Equivalent Dose 5

6 INTRODUCTION InterCommunity Health Network (IHN) is pleased to provide the 2017 IHN Formulary as a reference and informational tool for physicians, pharmacists and patients. The IHN Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. Only the drugs listed on this closed formulary will be covered by IHN. 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 IHN members. If a physician deems an unlisted product to be medically necessary, the physician may request coverage through the medical exception process. Notice The IHN-CCO formulary is developed to reflect the State of Oregon Prioritized List of Health Services. The list uses ICD-10-CM diagnosis codes to rank health services. The prioritized health services list emphasizes prevention services and chronic diseases management. For more information about the prioritized health services list see This formulary is not intended to be a substitute for a medical provider s knowledge expertise, skill or judgement. IHN 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. IHN covers both brand name drugs and generic drugs. A generic drug has been approved by the FDA and has the same active ingredient as the brand name. Generally, when a generic version of a drug is available IHN 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. IHN 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 (PA): IHN requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from IHN before you fill your prescriptions. Quantity Limits (QL): For certain drugs, IHN limits the amount of the drug that is covered. Specialty Drug: These drugs can be obtained at pharmacies that are considered Specialty. Call to get a list of participating pharmacies. Morphine Equivalent Dose (MED): Morphine is considered the Gold Standard of opioids. MED allows prescribers, pharmacists, and patients to compare different opioid medications to each other. IHN may use the MED calculation to limit the amount of opioid medication that is covered. You can find out more about additional requirements or limits on covered medication by contacting our Customer Service Department or your physician. Preface The IHN Formulary is a listing of preferred drug products eligible for reimbursement by IHN. All medications are organized by therapeutic class and are listed with both the brand and generic name. For your convenience an index by both brand and generic names is located at the end of the IHN Formulary. 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. IHN will not cover prescription drugs when prescribed for experimental, investigational or non-fda approved indications. 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 IHN 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 IHN Formulary. Formulary decisions are communicated quarterly on the IHN internet site. Lost or Stolen Medications The IHN 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 never be filled early due to being lost or stolen. Please call the help desk at (541) or if you have any other questions regarding a member with this situation. 6

7 Mental Health Drugs The following drugs are financed separately by the State of Oregon (OMAP) and not subject to the IHN Formulary. This list contains the vast majority of products covered by the state, but may not be all-inclusive. Brand names listed are for reference only. To check for changes to the list, search for 7-11 Drug Carveout List at ABILIFY 10 MG TABLET (Aripiprazole) INVEGA SUSTENNA 39 MG PREF SYR (Paliperidone ALPRAZOLAM 0.25MG TABLET (Alprazolam) ANAFRANIL Palmitate) 25MG CAPSULE (Clomipramine Hcl) APLENZIN ER 174 MG LAMICTAL 25MG TABLET (Lamotrigine) TABLET (Bupropion Hbr) LEXAPRO 5 MG TABLET (Escitalopram Oxalate) APPBUTAMONE CONVENIENCE PACK (Bupropion Hcl/Diet LIBRAX CAPSULE (Chlordiazepoxide/Methscopolamn) Supp. No.16) LIBRITABS 5MG TABLET (Chlordiazepoxide) APPBUTAMONE-D CONVENIENCE PACK (Bupropion LIBRIUM 5MG CAPSULE (Chlordiazepoxide Hcl) Hcl/Diet Supp. No.15) LIMBITROL TABLET (Amitrip Hcl/Chlordiazepoxide) ASENDIN 100MG TABLET (Amoxapine) LITHIUM CITRATE 8 MEQ/5 ML SOL (Lithium Citrate) ATIVAN 1 MG TABLET (Lorazepam) LOXITANE 5MG CAPSULE (Loxapine Succinate) LOXITANE AVENTYL HCL 10 MG PULVULE (Nortriptyline Hcl) BUSPAR IM 50MG/ML VIAL (Loxapine Hcl) 5 MG TABLET (Buspirone Hcl) LUVOX 25MG TABLET (Fluvoxamine Maleate) CENTRUM ST.JOHN'S 300MG CAP (St. John's Wort) MAPROTILINE 25MG TABLET (Maprotiline Hcl) MARPLAN CITALOPRAM 10 MG/5 ML SOLUTION (Citalopram 10MG TABLET (Isocarboxazid) Hydrobromide) MOBAN 5 MG TABLET (Molindone Hcl) CLORAZEPATE 3.75MG TABLET (Clorazepate Dipotassium) NARDIL 15MG TABLET (Phenelzine Sulfate) CLOZARIL 25 MG TABLET (Clozapine) NAVANE 1MG CAPSULE (Thiothixene) CYMBALTA 20 MG CAPSULE (Duloxetine Hcl) NAVANE 5MG/ML ORAL CONC (Thiothixene Hcl) DEPACON 500 MG VIAL (Valproate Sodium) NEFAZODONE HCL 100 MG TABLET (Nefazodone Hcl) DEPAKOTE ER 250 MG TABLET (Divalproex Sodium) NUVIGIL 50 MG TABLET (Armodafinil) DESIPRAMINE 25MG TABLET (Desipramine Hcl) ORAP 1 MG TABLET (Pimozide) DIZAC 5MG/ML AMPUL (Diazepam/Soybean Oil) DOXEPIN PARNATE 10 MG TABLET (Tranylcypromine Sulfate) PAXIL 10MG/ML ORAL CONC (Doxepin Hcl) DROPERIDOL 2.5 CR 12.5 MG TABLET (Paroxetine Hcl) MG/ML AMPUL (Droperidol) PAXIPAM 20 MG TABLET (Halazepam) EFFEXOR 25 MG TABLET (Venlafaxine Hcl) PEXEVA 10 MG TABLET (Paroxetine Mesylate) ELAVIL 10MG TABLET (Amitriptyline Hcl) PRISTIQ 50 MG TABLET (Desvenlafaxine Succinate) EMSAM 6 MG/24 HOURS PATCH (Selegiline) PROLIXIN 2.5MG/ML VIAL (Fluphenazine Hcl) EQUANIL 400MG TABLET (Meprobamate) PROLIXIN DECANOATE 25 MG/ML (Fluphenazine EQUETRO 100 MG CAPSULE (Carbamazepine) ESKALITH Decanoate) PROLIXIN ENANTHATE 25MG/ML (Fluphenazine 300 MG CAPSULE (Lithium Carbonate) Enanthate) GABAZOLAMINE CONVENIENCE PACK (Alprazolam/Dietary PROVIGIL 100 MG TABLET (Modafinil) Suppl No.17) PROZAC WEEKLY 90 MG CAPSULE (Fluoxetine Hcl) GABOXETINE CONVENIENCE PACK (Fluoxetine REMERON 15 MG TABLET (Mirtazapine) Hcl/Diet.Supp No.17) RISPERDAL CONSTA 25 MG SYR (Risperidone GEODON 20 MG CAPSULE (Ziprasidone Hcl) Microspheres) GEODON 20 MG VIAL (Ziprasidone Mesylate) RISPERIDONE 1 MG/ML SOLUTION (Risperidone) HALDOL 0.5MG TABLET (Haloperidol) SAPHRIS 5 MG TABLET SUBLINGUAL (Asenapine) HALDOL 2MG/ML ORAL CONC (Haloperidol Lactate) SENTROXATINE CONVENIENCE PACK (Fluoxetine Hcl/Diet. HALDOL DECANOATE 50 AMPUL (Haloperidol Decanoate) Supp No.8) INTUNIV ER 1 MG TABLET (Guanfacine Hcl) SERAX 15MG CAPSULE (Oxazepam) INVEGA ER 6 MG TABLET (Paliperidone) 7

8 SERENTIL 10MG TABLET (Mesoridazine Besylate) SEROQUEL 100 MG TABLET (Quetiapine Fumarate) SPARINE 50MG TABLET (Promazine Hcl) STELAZINE 10MG/ML ORAL CONC (Trifluoperazine Hcl) STRATTERA 10 MG CAPSULE (Atomoxetine Hcl) SURMONTIL 25MG CAPSULE (Trimipramine Maleate) SYMBYAX 3-25 MG CAPSULE (Olanzapine/Fluoxetine Hcl) TRAZODONE 50MG TABLET (Trazodone Hcl) TRIAVIL 4-50 TABLET (Perphenazine/Amitriptyline Hcl) TRILAFON 5MG/ML AMPUL (Perphenazine) VALRELEASE 15MG CAPSULE (Diazepam) VESPRIN 20MG/ML VIAL (Triflupromazine Hcl) VITAJOULE POWDER (Glucose Polymers) TRAZODONE 50MG TABLET (Trazodone Hcl) TRIAVIL 4-50 TABLET (Perphenazine/Amitriptyline Hcl) TRILAFON 5MG/ML AMPUL (Perphenazine) VALRELEASE 15MG CAPSULE (Diazepam) TOFRANIL-PM 75MG CAPSULE (Imipramine Pamoate) TRANCOPAL 100MG CAPLET (Chlormezanone) TRAZAMINE CONVENIENCE PACK (Trazodone Hcl/Diet8) THIORIDAZINE 30MG/ML CONC (Thioridazine Hcl) THORAZINE 30MG/ML LIQ CONC (Chlorpromazine Hcl) TOFRANIL 10 MG TABLET (Imipramine Hcl) VIVACTIL 5MG TABLET (Protriptyline Hcl) WELLBUTRIN 75MG TABLET (Bupropion Hcl) ZOLOFT 50 MG TABLET (Sertraline Hcl) ZYPREXA 2.5 MG TABLET (Olanzapine) THIORIDAZINE 30MG/ML CONC (Thioridazine Hcl) THORAZINE 30MG/ML LIQ CONC (Chlorpromazine Hcl) TOFRANIL 10 MG TABLET (Imipramine Hcl) Generic Substitution The brand names listed in the formulary are for reference only. Only FDA approved AB rated generic drugs are considered to be therapeutically equivalent. 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. The process for requesting nonformulary medication(s) requires faxing a completed medical exception form to IHN-CCO. The IHN-CCO Clinical staff will review the form and make a decision. 8

9 PRIOR AUTHORIZATION Drugs indicated with "PA" require Prior Authorization for coverage. Please call IHN (541) or or fax a completed PA form to for the following medications. This list is subject to change Humatrope SOLUTION RECONSTITUTED 5 MG INJECTION Humatrope SOLUTION RECONSTITUTED 6 MG INJECTION Humatrope SOLUTION RECONSTITUTED 12 MG INJECTION Humatrope SOLUTION RECONSTITUTED 24 MG INJECTION HumaLOG Mix 75/25 KwikPen Suspension Pen-injector (75-25) 100 UNIT/ML Subcutaneous HumaLOG Mix 50/50 KwikPen Suspension Pen-injector (50-50) 100 UNIT/ML Subcutaneous HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML Subcutaneous Emend CAPSULE 80 MG Oral Emend CAPSULE 125 MG Oral Emend CAPSULE 40 MG ORAL Zepatier TABLET MG ORAL Emend CAPSULE 80 & 125 MG ORAL Grastek TABLET SUBLINGUAL 2800 BAU SUBLINGUAL Rapamune SOLUTION 1 MG/ML ORAL 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 Stimate SOLUTION 1.5 MG/ML NASAL Mefloquine HCl TABLET 250 MG Oral ROPINIRole HCl TABLET 0.25 MG ORAL ROPINIRole HCl TABLET 0.5 MG ORAL ROPINIRole HCl TABLET 1 MG ORAL ROPINIRole HCl TABLET 2 MG ORAL ROPINIRole HCl TABLET 3 MG ORAL ROPINIRole HCl TABLET 4 MG ORAL ROPINIRole HCl TABLET 5 MG ORAL Mycophenolate Mofetil CAPSULE 250 MG ORAL Mycophenolate Mofetil TABLET 500 MG ORAL Montelukast Sodium TABLET 10 MG Oral Montelukast Sodium TABLET CHEWABLE 4 MG Oral Montelukast Sodium TABLET CHEWABLE 5 MG Oral Fluticasone Propionate SUSPENSION 50 MCG/ACT Nasal Loratadine TABLET 10 MG Oral Desenex CREAM 1 % EXTERNAL EQ Loratadine TABLET 10 MG Oral EQ Allergy Relief TABLET 10 MG Oral Sutent CAPSULE 12.5 MG ORAL Sutent CAPSULE 25 MG ORAL Sutent CAPSULE 37.5 MG ORAL Sutent CAPSULE 50 MG ORAL 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 Gengraf CAPSULE 25 MG ORAL Gengraf CAPSULE 100 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 Gengraf SOLUTION 100 MG/ML ORAL Humira Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous Exjade TABLET SOLUBLE 125 MG ORAL Exjade TABLET SOLUBLE 250 MG ORAL Exjade TABLET SOLUBLE 500 MG ORAL Gilenya CAPSULE 0.5 MG ORAL 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 Lantus SoloStar Solution Pen-injector 100 UNIT/ML Subcutaneous Ketoconazole CREAM 2 % EXTERNAL Ketoconazole TABLET 200 MG ORAL Voriconazole TABLET 50 MG Oral 9

10 Voriconazole TABLET 200 MG Oral Sildenafil Citrate TABLET 20 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 10 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 20 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 40 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 80 MG Oral CycloSPORINE Modified CAPSULE 25 MG Oral CycloSPORINE Modified CAPSULE 50 MG Oral CycloSPORINE Modified CAPSULE 100 MG Oral Celecoxib CAPSULE 100 MG ORAL Celecoxib CAPSULE 200 MG Oral Celecoxib CAPSULE 400 MG ORAL Celecoxib CAPSULE 50 MG ORAL Desmopressin Acetate TABLET 0.1 MG ORAL Desmopressin Acetate TABLET 0.2 MG Oral Topiramate CAPSULE SPRINKLE 15 MG ORAL Topiramate CAPSULE SPRINKLE 25 MG ORAL Allergy Relief TABLET 10 MG Oral Allergy/Congestion Relief Tablet Extended Release 12 Hour MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 15 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 30 MG Oral OxyCODONE HCl ER Tablet ER 12 Hour Abuse- Deterrent 60 MG Oral Flonase Allergy Relief SUSPENSION 50 MCG/ACT Nasal Chloroquine Phosphate TABLET 500 MG ORAL Clotrimazole CREAM 1 % External Tacrolimus OINTMENT 0.1 % EXTERNAL Tacrolimus OINTMENT 0.03 % EXTERNAL NovoLOG PenFill Solution Cartridge 100 UNIT/ML Subcutaneous NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML Subcutaneous CycloSPORINE Modified SOLUTION 100 MG/ML ORAL KP Clotrimazole CREAM 1 % EXTERNAL KP Loratadine TABLET 10 MG Oral KP Terbinafine Hydrochloride CREAM 1 % EXTERNAL Morphine Sulfate ER Tablet Extended Release 15 MG Oral Morphine Sulfate ER Tablet Extended Release 30 MG Oral Morphine Sulfate ER Tablet Extended Release 60 MG Oral Morphine Sulfate ER Tablet Extended Release 100 MG Oral Morphine Sulfate ER Tablet Extended Release 200 MG Oral Wal-itin D Tablet Extended Release 12 Hour MG Oral Athletes Foot CREAM 1 % EXTERNAL Memantine HCl TABLET 5 MG Oral Memantine HCl TABLET 10 MG Oral Pramipexole Dihydrochloride TABLET MG Oral Pramipexole Dihydrochloride TABLET 0.25 MG Oral Pramipexole Dihydrochloride TABLET 0.5 MG Oral Pramipexole Dihydrochloride TABLET 1 MG Oral Pramipexole Dihydrochloride TABLET 1.5 MG Oral Pramipexole Dihydrochloride TABLET 0.75 MG ORAL Tacrolimus CAPSULE 0.5 MG Oral Tacrolimus CAPSULE 1 MG ORAL Tacrolimus CAPSULE 5 MG Oral Fluorouracil CREAM 5 % EXTERNAL Donepezil HCl TABLET 5 MG Oral Donepezil HCl TABLET 10 MG Oral Voriconazole SUSPENSION RECONSTITUTED 40 MG/ML ORAL Dronabinol CAPSULE 2.5 MG ORAL Dronabinol CAPSULE 5 MG ORAL FentaNYL Patch 72 Hour 12 MCG/HR Transdermal FentaNYL Patch 72 Hour 25 MCG/HR Transdermal FentaNYL Patch 72 Hour 50 MCG/HR Transdermal FentaNYL Patch 72 Hour 75 MCG/HR Transdermal FentaNYL Patch 72 Hour 100 MCG/HR Transdermal Chloroquine Phosphate TABLET 250 MG ORAL Terbinafine HCl TABLET 250 MG Oral Clotrimazole Anti-Fungal CREAM 1 % External Memantine HCl SOLUTION 2 MG/ML ORAL Allergy TABLET 10 MG Oral Budesonide SUSPENSION 32 MCG/ACT Nasal Terbinafine HCl CREAM 1 % External Alavert TABLET 10 MG ORAL Dihydroergotamine Mesylate SOLUTION 1 MG/ML INJECTION Memantine HCl TABLET 5 (28)-10 (21) MG ORAL Mometasone Furoate SUSPENSION 50 MCG/ACT Nasal Loratadine-D 24HR Tablet Extended Release 24 Hour MG Oral Loratadine Childrens SOLUTION 5 MG/5ML ORAL Triamcinolone Acetonide Aerosol 55 MCG/ACT Nasal Topiramate TABLET 100 MG Oral Topiramate TABLET 25 MG Oral Topiramate TABLET 200 MG Oral Topiramate TABLET 50 MG Oral 10

11 TGT Allergy/Congestion Relief Tablet Extended Release 12 Hour MG Oral TGT Allergy/Congestion Relief Tablet Extended Release 24 Hour MG Oral TGT Allergy Relief TABLET 10 MG Oral TGT Athletes Foot CREAM 1 % EXTERNAL TGT Loratadine Childrens SYRUP 5 MG/5ML ORAL TGT Clotrimazole CREAM 1 % EXTERNAL RA Loratadine TABLET 10 MG Oral RA Foot Care Antifungal CREAM 1 % EXTERNAL RA Loratadine SYRUP 5 MG/5ML ORAL RA Jock Itch CREAM 1 % EXTERNAL RA Athletes Foot CREAM 1 % EXTERNAL RA Lorata-D Tablet Extended Release 24 Hour MG Oral RA Clotrimazole CREAM 1 % EXTERNAL RA Allergy/Congestion Relief Tablet Extended Release 12 Hour MG Oral RA Loratadine Childrens SYRUP 5 MG/5ML ORAL Clotrimazole AF CREAM 1 % EXTERNAL Jock Itch Relief CREAM 1 % EXTERNAL Jock Itch CREAM 1 % EXTERNAL Nasal Allergy 24 Hour Aerosol 55 MCG/ACT Nasal SB Loratadine Allergy Relief TABLET 10 MG Oral SB Clotrimazole Foot CREAM 1 % EXTERNAL SB Loratadine TABLET 10 MG Oral SB Allergy Relief/Nasal Decong Tablet Extended Release 24 Hour MG Oral SB Loratadine SYRUP 5 MG/5ML ORAL GNP Athletes Foot CREAM 1 % EXTERNAL GNP Loratadine TABLET 10 MG Oral GNP Terbinafine Hydrochloride CREAM 1 % EXTERNAL GNP Loratadine SYRUP 5 MG/5ML ORAL Gabitril TABLET 16 MG ORAL Loratadine Childrens SYRUP 5 MG/5ML ORAL Truvada TABLET MG ORAL Vyvanse CAPSULE 30 MG ORAL Vyvanse CAPSULE 50 MG ORAL Vyvanse CAPSULE 20 MG ORAL Allergy Relief-D Tablet Extended Release 12 Hour MG Oral Shopko Allergy Relief-D (Lora) Tablet Extended Release 12 Hour MG Oral Allergy Relief D-24 Tablet Extended Release 24 Hour MG Oral Athletes Foot AF CREAM 1 % EXTERNAL EQ Allergy & Congestion Relief Tablet Extended Release 12 Hour MG Oral EQL Allergy/Congestion Relief Tablet Extended Release 24 Hour MG Oral EQL Athletes Foot CREAM 1 % EXTERNAL EQL Antifungal CREAM 1 % EXTERNAL EQL Athletes Foot(Terbinafine) CREAM 1 % EXTERNAL EQL Allergy Relief TABLET 10 MG Oral Nasacort Allergy 24HR Aerosol 55 MCG/ACT Nasal Nasacort Allergy 24HR Children Aerosol 55 MCG/ACT Nasal Meijer Allergy Relief-D Tablet Extended Release 12 Hour MG Oral Meijer Allergy Relief TABLET 10 MG Oral Meijer Allergy/Congestion Tablet Extended Release 24 Hour MG Oral Allergy Relief/Nasal Decongest Tablet Extended Release 24 Hour MG Oral PX Athletic Foot CREAM 1 % EXTERNAL PX Allergy Relief Loratadine TABLET 10 MG Oral Allergy Relief D Tablet Extended Release 24 Hour MG Oral PX Allergy Relief D (Loratid) Tablet Extended Release 12 Hour MG Oral PX Allergy Relief D Tablet Extended Release 24 Hour MG Oral Antifungal Foot CREAM 1 % EXTERNAL Fluorouracil SOLUTION 5 % EXTERNAL Fluorouracil SOLUTION 2 % EXTERNAL Loratadine-D 12HR Tablet Extended Release 12 Hour MG Oral GNP Loratadine-D 12HR Tablet Extended Release 12 Hour MG Oral GNP Loratadine Childrens SYRUP 5 MG/5ML ORAL GNP Allergy & Congestion Tablet Extended Release 24 Hour MG Oral GNP Loratadine-D 24 Hour Tablet Extended Release 24 Hour MG Oral Loradamed TABLET 10 MG Oral EQ Jock Itch CREAM 1 % EXTERNAL EQ Allergy Relief D 24 Hour Tablet Extended Release 24 Hour MG Oral EQ Antifungal CREAM 1 % EXTERNAL EQ Athletes Foot (Terbinafine) CREAM 1 % EXTERNAL SM Loratadine TABLET 10 MG Oral SM Loratadine D Tablet Extended Release 12 Hour MG Oral SM Antifungal Clotrimazole CREAM 1 % EXTERNAL SM Childrens Loratadine SYRUP 5 MG/5ML ORAL SM Lorata-dine D Tablet Extended Release 24 Hour MG Oral SM Loratadine SYRUP 5 MG/5ML ORAL SM Athletes Foot CREAM 1 % EXTERNAL 11

12 SM Allergy Relief Loratadine TABLET 10 MG Oral Zafirlukast TABLET 10 MG ORAL Zafirlukast TABLET 20 MG ORAL Zetia TABLET 10 MG ORAL Tarceva TABLET 25 MG ORAL Tarceva TABLET 100 MG ORAL Tarceva TABLET 150 MG ORAL CVS Itch Relief CREAM 1 % EXTERNAL CVS Athletes Foot CREAM 1 % EXTERNAL CVS Jock Itch CREAM 1 % EXTERNAL CVS Allergy Relief-D12 Tablet Extended Release 12 Hour MG Oral CVS Allergy Relief TABLET 10 MG Oral CVS Clotrimazole CREAM 1 % EXTERNAL CVS Loratadine TABLET 10 MG Oral CVS Loratadine-D 24 Hour Tablet Extended Release 24 Hour MG Oral CVS Ringworm CREAM 1 % EXTERNAL Sporanox SOLUTION 10 MG/ML ORAL Childrens Loratadine SYRUP 5 MG/5ML ORAL Suprep Bowel Prep Kit SOLUTION GM/180ML Oral Clotrimazole GRx CREAM 1 % EXTERNAL Loratadine SOLUTION 5 MG/5ML ORAL Loratadine Hives Relief SOLUTION 5 MG/5ML ORAL Childrens Loratadine SOLUTION 5 MG/5ML ORAL Sirolimus TABLET 1 MG ORAL Sirolimus TABLET 2 MG ORAL Sensipar TABLET 30 MG ORAL Sensipar TABLET 60 MG ORAL Sensipar TABLET 90 MG ORAL Epogen SOLUTION 2000 UNIT/ML INJECTION Epogen SOLUTION UNIT/ML INJECTION Epogen SOLUTION 4000 UNIT/ML INJECTION Epogen SOLUTION 3000 UNIT/ML INJECTION Epogen SOLUTION UNIT/ML INJECTION Neupogen SOLUTION 300 MCG/ML INJECTION Enbrel Solution Prefilled Syringe 50 MG/ML Subcutaneous Enbrel SureClick Solution Auto-injector 50 MG/ML Subcutaneous Enbrel Solution Prefilled Syringe 25 MG/0.5ML Subcutaneous Vyvanse CAPSULE 10 MG ORAL Vyvanse CAPSULE 40 MG ORAL Vyvanse CAPSULE 60 MG ORAL Vyvanse CAPSULE 70 MG ORAL 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 Sirolimus TABLET 0.5 MG ORAL CycloSPORINE CAPSULE 25 MG ORAL CycloSPORINE CAPSULE 100 MG ORAL Letairis TABLET 5 MG ORAL Letairis TABLET 10 MG ORAL Epclusa TABLET MG ORAL HM Allergy Relief/Nasal Decong Tablet Extended Release 24 Hour MG Oral HM Loratadine Childrens SYRUP 5 MG/5ML ORAL HM Allergy Relief TABLET 10 MG Oral HM Allergy & Congestion Tablet Extended Release 12 Hour MG Oral HM Loratadine TABLET 10 MG Oral Gabitril TABLET 12 MG ORAL QC Loratadine Allergy Relief TABLET 10 MG Oral QC Loratadine-D Tablet Extended Release 24 Hour MG Oral QC Athletes Foot CREAM 1 % EXTERNAL QC Clotrimazole CREAM 1 % EXTERNAL KLS AllerClear D-12HR Tablet Extended Release 12 Hour MG Oral Tecfidera CAPSULE DELAYED RELEASE 120 MG ORAL Tecfidera CAPSULE DELAYED RELEASE 240 MG ORAL Tracleer TABLET 62.5 MG ORAL Tracleer TABLET 125 MG ORAL Fluorouracil CREAM 0.5 % EXTERNAL Kineret Solution Prefilled Syringe 100 MG/0.67ML Subcutaneous Anti-Fungal CREAM 1 % EXTERNAL Pro-Ex Antifungal CREAM 1 % EXTERNAL Mycophenolate Mofetil SUSPENSION RECONSTITUTED 200 MG/ML ORAL Loratadine SYRUP 5 MG/5ML ORAL EQ Athletes Foot CREAM 1 % EXTERNAL EQ Childrens Loratadine SYRUP 5 MG/5ML ORAL 12

13 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 Accu-Chek Aviva Plus STRIP IN VITRO Accu-Chek Compact Plus STRIP IN VITRO Accu-Chek SmartView STRIP IN VITRO Accutrend Glucose STRIP IN VITRO Acetaminophen-Codeine #2 TABLET MG Oral Acetaminophen-Codeine #3 TABLET MG Oral Acetaminophen-Codeine #4 TABLET MG ORAL Acetaminophen-Codeine TABLET MG ORAL Acetaminophen-Codeine TABLET MG Oral Acetaminophen-Codeine TABLET MG ORAL Acura Blood Glucose Test STRIP In Vitro Acyclovir OINTMENT 5 % EXTERNAL 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 Advance Intuition Test STRIP IN VITRO Advance Micro-Draw Test STRIP IN VITRO Advocate Redi-Code STRIP IN VITRO Advocate Redi-Code+ Test STRIP IN VITRO Advocate Test STRIP IN VITRO AgaMatrix AMP Test STRIP IN VITRO AgaMatrix Jazz Test STRIP IN VITRO AgaMatrix KeyNote Test STRIP IN VITRO AgaMatrix Presto Test STRIP IN VITRO 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 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 Assure 3 Test STRIP IN VITRO Assure 4 Test STRIP IN VITRO Assure II STRIP IN VITRO Assure Platinum STRIP IN VITRO Assure Prism multi Test STRIP IN VITRO Assure Pro Test STRIP IN VITRO Atrovent HFA Aerosol Solution 17 MCG/ACT Inhalation Bayer Contour Next Test STRIP IN VITRO Bayer Contour Test STRIP IN VITRO Bioscanner Glucose Test STRIP IN VITRO Blood Glucose Test STRIP IN VITRO 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 Quantity Limit QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(5 GM per 30 days) QL(60 doses per 30 days) QL(60 doses per 30 days) QL(60 doses per 30 days) QL(12 GM per 30 days) QL(12 GM per 30 days) QL(12 GM 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(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 INH per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(120 VIAL per 30 days) 13

14 Budesonide SUSPENSION 0.5 MG/2ML Inhalation Budesonide SUSPENSION 1 MG/2ML INHALATION Butalbital-APAP-Caffeine CAPSULE MG Oral Butalbital-APAP-Caffeine CAPSULE MG Oral Butalbital-APAP-Caffeine TABLET MG Oral Butalbital-Aspirin-Caffeine CAPSULE MG ORAL CareOne Blood Glucose Test STRIP IN VITRO CareSens N Glucose Test STRIP IN VITRO Clever Chek Auto-Code Test STRIP IN VITRO Clever Chek Auto-Code Voice STRIP IN VITRO Clever Chek Test STRIP IN VITRO Clever Choice Auto-Code Test STRIP IN VITRO Clever Choice Micro Test STRIP IN VITRO Combivent Respimat Aerosol Solution MCG/ACT Inhalation Control AST STRIP In Vitro Control Test STRIP In Vitro CVS Advanced Glucose Test STRIP IN VITRO CVS Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL CVS Omeprazole Tablet Delayed Release 20 MG Oral DiaTrue Plus Test STRIP IN VITRO Diclofenac Sodium GEL 1 % Transdermal Dulera Aerosol MCG/ACT Inhalation Dulera Aerosol MCG/ACT Inhalation Duo-Care Test STRIP IN VITRO Easy Plus II Glucose Test STRIP IN VITRO Easy Step Test STRIP IN VITRO Easy Talk Blood Glucose Test STRIP IN VITRO Easy Touch HealthPro Test STRIP IN VITRO Easy Touch Test STRIP IN VITRO Easy Trak Blood Glucose Test STRIP IN VITRO EasyGluco Plus STRIP IN VITRO EasyGluco STRIP IN VITRO EasyMax 15 Test STRIP In Vitro EASYMax Test STRIP IN VITRO EasyPlus Blood Glucose Test STRIP IN VITRO EasyPRO Blood Glucose Test STRIP IN VITRO EasyPRO Plus STRIP IN VITRO Element Compact Test STRIP IN VITRO Element Test STRIP IN VITRO Embrace Blood Glucose Test STRIP IN VITRO Embrace Evo Blood Glucose Test STRIP IN VITRO Embrace Pro Glucose Test STRIP IN VITRO Endocet TABLET MG ORAL Endocet TABLET MG ORAL Endocet TABLET MG ORAL Endocet TABLET MG ORAL EQ Blood Glucose Test STRIP IN VITRO EQ Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL EQ Omeprazole TABLET DELAYED RELEASE 20 MG ORAL EQL Omeprazole TABLET DELAYED RELEASE 20 MG ORAL EvenCare + Blood Glucose Test STRIP IN VITRO EvenCare Blood Glucose Test STRIP IN VITRO EvenCare G2 Test STRIP IN VITRO EvenCare G3 Test STRIP IN VITRO EvenCare Mini Glucose Test STRIP IN VITRO Evolution Autocode STRIP IN VITRO ExacTech R-S-G Test STRIP IN VITRO ExacTech Test STRIP IN VITRO Ez Smart Blood Glucose Test STRIP IN VITRO Ez Smart Plus Glucose Test STRIP IN VITRO FentaNYL Patch 72 Hour 100 MCG/HR Transdermal QL(60 VIAL per 30 days) QL(30 VIAL per 30 days) QL(20 EA per 30 days) QL(20 EA per 30 days) QL(20 EA per 30 days) QL(20 EA per 30 days) QL(4 GM per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(100 GM per 30 days) QL(13 GM per 30 days) QL(13 GM per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(10 EA per 30 days) 14

15 FentaNYL Patch 72 Hour 12 MCG/HR Transdermal FentaNYL Patch 72 Hour 25 MCG/HR Transdermal FentaNYL Patch 72 Hour 50 MCG/HR Transdermal FentaNYL Patch 72 Hour 75 MCG/HR Transdermal Fifty50 Glucose Test 2.0 STRIP IN VITRO Flovent Diskus Aerosol Powder Breath Activated 100 MCG/BLIST Inhalation Flovent Diskus Aerosol Powder Breath Activated 250 MCG/BLIST Inhalation Flovent Diskus Aerosol Powder Breath Activated 50 MCG/BLIST Inhalation Flovent HFA Aerosol 110 MCG/ACT Inhalation Flovent HFA Aerosol 220 MCG/ACT Inhalation Flovent HFA Aerosol 44 MCG/ACT Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT Inhalation FORA D10 Blood Glucose Test STRIP IN VITRO FORA D15g Blood Glucose Test STRIP IN VITRO FORA D20 Blood Glucose Test STRIP IN VITRO FORA G20 Blood Glucose Test STRIP IN VITRO FORA G30a Blood Glucose Test STRIP IN VITRO Fora GD20 Test STRIP IN VITRO FORA GD50 Blood Glucose Test STRIP IN VITRO FORA V10 Blood Glucose Test STRIP IN VITRO FORA V12 Blood Glucose Test STRIP IN VITRO FORA V20 Blood Glucose Test STRIP IN VITRO FORA V30a Blood Glucose Test STRIP IN VITRO ForaCare GD40 Test STRIP IN VITRO ForaCare premium V10 Test STRIP IN VITRO ForaCare Test N Go Test STRIP IN VITRO FortisCare Test STRIP IN VITRO FreeStyle InsuLinx Test STRIP IN VITRO FreeStyle Lite Test STRIP IN VITRO FreeStyle Test STRIP IN VITRO GE100 Blood Glucose Test STRIP IN VITRO GenStrip 50 STRIP IN VITRO GHT Test STRIP IN VITRO Glucocard 01 Sensor Plus STRIP IN VITRO Glucocard Expression Test STRIP IN VITRO Glucocard Shine Test STRIP IN VITRO Glucocard Vital Test STRIP IN VITRO Glucocard X-Sensor STRIP IN VITRO GlucoCom Test STRIP IN VITRO GlucoNavii Blood Glucose Test STRIP IN VITRO Gmate Blood Glucose Test STRIP IN VITRO GNP Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL GNP Omeprazole TABLET DELAYED RELEASE 20 MG ORAL HM Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL HM Omeprazole TABLET DELAYED RELEASE 20 MG ORAL Hydrocodone-Acetaminophen TABLET MG Oral Hydrocodone-Acetaminophen TABLET MG Oral Hydrocodone-Acetaminophen TABLET MG Oral HYDROmorphone HCl TABLET 2 MG Oral HYDROmorphone HCl TABLET 4 MG Oral HYDROmorphone HCl TABLET 8 MG Oral Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH Inhalation Infinity Blood Glucose Test STRIP IN VITRO Ipratropium-Albuterol SOLUTION (3) MG/3ML Inhalation KLS Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL KLS Omeprazole TABLET DELAYED RELEASE 20 MG ORAL Kroger Blood Glucose Test STRIP IN VITRO Kroger Premium Glucose Test STRIP IN VITRO Kroger Test STRIP IN VITRO QL(10 EA per 30 days) QL(10 EA per 30 days) QL(10 EA per 30 days) QL(10 EA per 30 days) QL(60 doses per 30 days) QL(60 doses per 30 days) QL(60 doses per 30 days) QL(24 GM per 30 days) QL(24 GM per 30 days) QL(22 GM per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(1 EA per 30 days) QL(180 VIAL per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) 15

16 Lansoprazole CAPSULE DELAYED RELEASE 15 MG Oral Lansoprazole CAPSULE DELAYED RELEASE 30 MG Oral Liberty Next Generation Test STRIP IN VITRO Liberty Test STRIP IN VITRO Margesic CAPSULE MG ORAL Maxima Blood Glucose Test STRIP In Vitro Meijer Blood Glucose Test STRIP IN VITRO Meijer Premium Glucose Test STRIP IN VITRO Methadone HCl TABLET 10 MG Oral Methadone HCl TABLET 5 MG Oral Methadone HCl TABLET SOLUBLE 40 MG ORAL Methadose TABLET SOLUBLE 40 MG ORAL Methylphenidate HCl ER Tablet Extended Release 18 MG Oral Methylphenidate HCl ER Tablet Extended Release 27 MG Oral Methylphenidate HCl ER Tablet Extended Release 36 MG Oral Methylphenidate HCl ER Tablet Extended Release 54 MG Oral Microdot Test STRIP IN VITRO Morphine Sulfate ER Tablet Extended Release 100 MG Oral Morphine Sulfate ER Tablet Extended Release 15 MG Oral Morphine Sulfate ER Tablet Extended Release 200 MG Oral Morphine Sulfate ER Tablet Extended Release 30 MG Oral Morphine Sulfate ER Tablet Extended Release 60 MG Oral Morphine Sulfate TABLET 15 MG ORAL Morphine Sulfate TABLET 30 MG ORAL MyGlucoHealth Test STRIP IN VITRO Narcan Liquid 4 MG/0.1ML Nasal Neutek 2Tek Test STRIP IN VITRO NexGen Test STRIP IN VITRO Nova Max Glucose Test STRIP IN VITRO Omeprazole CAPSULE DELAYED RELEASE 20 MG Oral Omeprazole CAPSULE DELAYED RELEASE 40 MG Oral Omeprazole TABLET DELAYED RELEASE 20 MG ORAL On Call Express Blood Glucose STRIP IN VITRO On Call Plus Blood Glucose STRIP IN VITRO On Call Vivid Blood Glucose STRIP IN VITRO Ondansetron HCl SOLUTION 4 MG/5ML Oral Ondansetron HCl TABLET 24 MG 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 OneTouch Ultra Blue STRIP IN VITRO OneTouch Verio STRIP IN VITRO Optium Test STRIP IN VITRO OptiumEZ Test STRIP IN VITRO OptumRx Blood Glucose Test STRIP IN VITRO 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 QL(60 EA per 30 days) QL(60 EA per 30 days) QL(20 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 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(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(1 EA per 365 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(30 EA 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(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) QL(180 EA per 30 days) 16

17 Oxycodone-Acetaminophen TABLET MG Oral Oxycodone-Acetaminophen TABLET MG Oral Pantoprazole Sodium Tablet Delayed Release 20 MG Oral Pantoprazole Sodium Tablet Delayed Release 40 MG Oral Pharmacist Choice Autocode STRIP IN VITRO Pharmacist Choice No Coding STRIP IN VITRO PocketChem EZ Test STRIP IN VITRO Precision PCX Plus Test STRIP IN VITRO Precision PCx STRIP IN VITRO Precision Point of Care Test STRIP IN VITRO Precision QID Test STRIP IN VITRO Precision Sof-Tact Test STRIP IN VITRO Precision Xtra Blood Glucose STRIP IN VITRO ProAir HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation Prodigy No Coding Blood Gluc STRIP IN VITRO Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation PTS Panels Glucose Test STRIP IN VITRO PX Omeprazole TABLET DELAYED RELEASE 20 MG ORAL QuickTek Test STRIP IN VITRO Quintet AC Blood Glucose Test STRIP IN VITRO Quintet Blood Glucose Test STRIP IN VITRO Qvar Aerosol Solution 40 MCG/ACT Inhalation Qvar Aerosol Solution 80 MCG/ACT Inhalation RA Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL RA Omeprazole TABLET DELAYED RELEASE 20 MG ORAL RA TRUEtest Test STRIP IN VITRO RefuAH Plus Blood Glucose Test STRIP IN VITRO ReliOn Confirm/micro Test STRIP IN VITRO ReliOn Prime Test STRIP IN VITRO ReliOn Ultima Test STRIP IN VITRO Reveal Blood Glucose Test STRIP IN VITRO Rexall Blood Glucose Test STRIP IN VITRO Rightest GS100 Blood Glucose STRIP IN VITRO Rightest GS300 Blood Glucose STRIP IN VITRO Rightest GS550 Blood Glucose STRIP IN VITRO 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 SB Omeprazole TABLET DELAYED RELEASE 20 MG ORAL Serevent Diskus Aerosol Powder Breath Activated 50 MCG/DOSE Inhalation SM Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL SM Omeprazole TABLET DELAYED RELEASE 20 MG ORAL Smart Sense Premium Test STRIP IN VITRO Smart Sense Value Test STRIP IN VITRO Smartest Blood Glucose Test STRIP IN VITRO Solus V2 Test STRIP IN VITRO 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 SOLUTION 20 MG/ACT NASAL SUMAtriptan SOLUTION 5 MG/ACT NASAL SUMAtriptan Succinate SOLUTION 6 MG/0.5ML Subcutaneous SUMAtriptan Succinate TABLET 100 MG Oral SUMAtriptan Succinate TABLET 25 MG Oral SUMAtriptan Succinate TABLET 50 MG Oral Supreme Test STRIP IN VITRO Sure Edge Test STRIP IN VITRO Sure-Test EasyPlus Mini Test STRIP IN VITRO QL(180 EA per 30 days) QL(180 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(2 INH per 30 days) QL(2 INH per 30 days) QL(60 EA per 30 days) QL(15 GM per 30 days) QL(15 GM per 30 days) QL(60 EA per 30 days) QL(60 EA 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(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(30 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(6 ML per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) 17

18 SureChek Blood Glucose Test STRIP IN VITRO SW Omeprazole TABLET DELAYED RELEASE 20 MG ORAL Symbicort Aerosol MCG/ACT Inhalation Symbicort Aerosol MCG/ACT Inhalation Telcare Blood Glucose Test STRIP IN VITRO TGT Blood Glucose Test STRIP IN VITRO TGT Omeprazole TABLET DELAYED RELEASE 20 MG ORAL TraMADol HCl TABLET 50 MG Oral True Metrix Blood Glucose Test STRIP IN VITRO TRUEtest Test STRIP IN VITRO TrueTrack Test STRIP IN VITRO Ultima Test STRIP IN VITRO UltraTRAK PRO Test STRIP IN VITRO UltraTRAK Ultimate Test STRIP IN VITRO Unistrip1 Generic STRIP IN VITRO Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation Victory AGM-4000 Test STRIP IN VITRO Vocal Point Blood Glucose Test STRIP IN VITRO WaveSense Presto STRIP IN VITRO ZOLMitriptan TABLET 2.5 MG Oral ZOLMitriptan TABLET 5 MG Oral ZOLMitriptan TABLET DISPERSIBLE 2.5 MG ORAL QL(60 EA per 30 days) QL(6 GM per 30 days) QL(6.9 GM per 30 days) QL(60 EA per 30 days) QL(180 EA per 30 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) STEP THERAPY (ST) The following products have step therapy limitations. This list is subject to change. Product Acyclovir OINTMENT 5 % EXTERNAL Farxiga TABLET 10 MG ORAL Farxiga TABLET 5 MG ORAL Invokana TABLET 100 MG ORAL Invokana TABLET 300 MG ORAL Janumet TABLET MG ORAL Janumet TABLET MG Oral Janumet XR Tablet Extended Release 24 Hour MG Oral Janumet XR Tablet Extended Release 24 Hour MG Oral Janumet XR Tablet Extended Release 24 Hour MG Oral Januvia TABLET 100 MG ORAL Januvia TABLET 25 MG ORAL Januvia TABLET 50 MG ORAL Algorithm must try/fail oral acyclovir Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo 18

19 Jardiance TABLET 10 MG ORAL Jardiance TABLET 25 MG ORAL Kombiglyze XR Tablet Extended Release 24 Hour MG Oral Kombiglyze XR Tablet Extended Release 24 Hour MG Oral Kombiglyze XR Tablet Extended Release 24 Hour MG Oral Onglyza TABLET 2.5 MG ORAL Onglyza TABLET 5 MG ORAL Tanzeum Pen-injector 30 MG Subcutaneous Tanzeum Pen-injector 50 MG Subcutaneous Tradjenta TABLET 5 MG ORAL Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT Inhalation Fluticasone-Salmeterol Aerosol Powder Breath Activated MCG/ACT Inhalation Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo Must try/fail a sulfonylurea AND metformin or metformin/sulfonylurea combo must try/fail 2 of the preferred inhaler brands (Advair, Breo Ellipta, Symbicort) must try/fail 2 of the preferred inhaler brands (Advair, Breo Ellipta, Symbicort) must try/fail 2 of the preferred inhaler brands (Advair, Breo Ellipta, Symbicort) 19

20 lowercase = Generic drugs UPPERCASE BOLD = Brand name drugs Status ALT = Alt BE = Benefit Exclusion NC = Not Covered NF = Non Formulary SCO = State Carveout = Tier 1 Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *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 ZENZEDI ORAL TABLET 5 MG *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 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, 20 mg methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg Notes PA = Prior Authorization Required PA = PA for New Starts QL = Quantity Limit ST = Step Therapy Required STNS = Step Therapy Required For New Starts PA QL (30 EA per 30 days) 20

21 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 methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG *Alternative Medicines* *Alternative Medicine - Cr's*** cranberry extract oral capsule 200 mg sm cranberry oral tablet 500 mg *Alternative Medicine - Me's*** cvs melatonin extra strength oral tablet 5 mg cvs melatonin oral capsule 10 mg, 5 mg cvs melatonin oral tablet 3 mg, 5 mg cvs melatonin oral tablet chewable 5 mg cvs melatonin oral tablet dispersible 10 mg cvs melatonin sublingual tablet sublingual 10 mg cvs quality sleep oral capsule 10 mg cvs sleep aid oral tablet 5 mg gnp melatonin maximum strength oral tablet 5 mg gnp melatonin oral tablet 3 mg kp melatonin oral tablet 3 mg melatonin er oral tablet extended release 5 mg melatonin extra strength oral liquid 5 mg/15ml melatonin maximum strength oral tablet 5 mg melatonin oral capsule 1 mg, 10 mg, 2.5 mg, 3 mg, 5 mg melatonin oral tablet 1 mg, 10 mg, 200 mcg, 3 mg, 300 mcg, 5 mg melatonin oral tablet dispersible 10 mg melatonin sublingual tablet sublingual 10 mg, 3 mg pa melatonin oral tablet 5 mg ra melatonin oral tablet 10 mg, 3 mg, 5 mg sm melatonin oral tablet 3 mg 21