2018 Comprehensive Drug List (List of Covered Drugs)

Transcription

1 2018 Comprehensive Drug List (List of Covered Drugs) WellCare of Nebraska Children s Health Insurance lan (CHI) lease read: This document contains information about the drugs we cover in this plan. lease note that the Nebraska CHI Drug List is updated quarterly. NOTE: Nebraska CHI was formerly named Nebraska Family lanning. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (10/01/2018)

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. Drug Name This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er oral tablet extended release 10, 20 methylphenidate hcl er oral tablet extended release 18, 27, 36 methylphenidate hcl er oral tablet extended release 54 methylphenidate hcl oral tablet 10, 5 reference Details Coverage Details QL (62 EA per 31 days) QL (93 EA per 31 days) QL (62 EA per 31 days) QL (31 EA per 31 days) QL (31 EA per 31 days) QL (62 EA per 31 days) QL (93 EA per 31 days) QL (62 EA per 31 days) QL (31 EA per 31 days) methylphenidate hcl oral tablet 20 QL (93 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 1

3 reference Details Coverage Details methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - Ly*** lycopene oral capsule 10 *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 melatonin oral tablet 1, 3, 5 *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ ORAL TABLET 5 MG A; QL (62 EA per 31 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.8ML HUMIRA EN-CD/UC/HS STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.8ML HUMIRA EN-CD/UC/HS STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 2 A A; QL (31 EA per 31 days) A A A A A A QL (31 EA per 31 days)

4 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen junior strength oral tablet chewable 100 ibuprofen oral capsule 200 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 MEDI-ROFEN ORAL SUSENSION 40 MG/ML meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 reference Details Coverage Details Maximum of a 5 day supply per Rx per month; QL (20 EA per 31 days) naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral capsule 220 naproxen sodium oral tablet 220 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 *yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 3

5 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION REFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesic Combinations*** EXCEDRIN EXTRA STRENGTH ORAL TABLET MG sm tension headache oral tablet womens menstrual relief oral tablet *Analgesics Other*** ACEHEN RECTAL SUOSITORY 120 MG, 325 MG, 650 MG childrens mapap rapid tabs oral tablet dispersible 80 ed-apap oral liquid 160 /5ml FEVERALL INFANTS RECTAL SUOSITORY 80 MG infants pain relief oral suspension 80 /0.8ml JUNIOR MAA ORAL TABLET DISERSIBLE 160 MG MAA ACETAMINOHEN EXTRA STR ORAL LIQUID 500 MG/15ML mapap oral capsule 500 pain & fever childrens oral solution 160 /5ml pain & fever childrens oral tablet chewable 80 pain & fever oral tablet 325 pain relief 8 hour oral tablet extended release 650 pain relief childrens oral suspension 160 /5ml pain relief extra strength oral tablet 500 q-pap infants oral solution 80 /0.8ml reference Details Coverage Details A A A =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 4

6 *Salicylate Combinations*** effervescent pain relief oral tablet effervescent tri-buffered aspirin oral tablet 325 *Salicylates*** aspirin ec oral tablet delayed release 325 aspirin oral tablet 325 aspirin oral tablet chewable 81 aspirin oral tablet delayed release 81 aspirin rectal suppository 300, 600 diflunisal oral tablet 500 eq aspirin oral tablet delayed release 500 salsalate oral tablet 500, 750 sb backache extra strength oral tablet 500 *Analgesics - Opioid* *Codeine Combinations*** butalbital-apap-caff-cod oral capsule *Androgens-Anabolic* *Anabolic Steroids*** reference Details Coverage Details oxandrolone oral tablet 10, 2.5 A *Androgens*** danazol oral capsule 100, 200, 50 *Anorectal Agents* *Rectal Anesthetic Combinations*** hemorrhoidal rectal cream % *Rectal Combinations - Misc.*** goodsense hemorrhoidal rectal ointment % hemorrhoidal rectal ointment % hemorrhoidal rectal suppository 0.25 % sm hemorrhoidal rectal cream % *Rectal Local Anesthetics*** dibucaine rectal ointment 1 % lidocaine (anorectal) external cream 5 % ROCTOFOAM RECTAL FOAM 1 % QL (150 EA per 30 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 5

7 *Antacids* *Antacid & Simethicone*** ALMACONE ORAL TABLET CHEWABLE MG antacid plus anti-gas relief oral suspension /5ml, /5ml gnp antacid & anti-gas oral tablet chewable *Antacid Combinations*** GAVISCON EXTRA RELIEF FORMULA ORAL SUSENSION MG/10ML GAVISCON EXTRA STRENGTH ORAL TABLET CHEWABLE MG GAVISCON ORAL SUSENSION MG/15ML GAVISCON ORAL TABLET CHEWABLE MG gnp antacid oral tablet chewable mag-al oral liquid /5ml MI-ACID ORAL TABLET CHEWABLE MG sm foaming antacid oral tablet chewable *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium Salts*** calcium antacid extra strength oral tablet chewable 750 calcium antacid oral tablet chewable 500 calcium antacid ultra max st oral tablet chewable 1000 calcium carbonate antacid oral suspension 1250 /5ml calcium carbonate antacid oral tablet 648 TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE 1177 MG reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 6

8 *Antacids - Magnesium Salts*** magnesium oxide oral tablet 400, 420 *Anthelmintics* *Anthelmintics*** reference Details Coverage Details ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 (50 base) /ml *Antianginal Agents* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 *Benzodiazepines*** diazepam oral solution 1 /ml *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 7

9 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 reference Details Coverage Details MULTAQ ORAL TABLET 400 MG A ACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/DOSE ANORO ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/INH COMBIVENT RESIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, mcg/act, mcg/act ipratropium-albuterol inhalation solution (3) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml QL (60 EA per 30 days); AL (Min 4 Years and Max 5 Years) QL (60 EA per 31 days) QL (4 GM per 20 days) QL (13 GM per 30 days) QL (1 EA per 31 days); AL (Min 12 Years) QL (720 ML per 31 days) QL (10.2 GM per 30 days) A =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 8

10 *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml reference Details Coverage Details QL (720 ML per 31 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 /5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2, 4 STRIVERDI RESIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** QL (4 GM per 31 days) QL (36 GM per 31 days) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT QL (25.8 GM per 31 days) INCRUSE ELLITA INHALATION AEROSOL OWDER BREATH QL (1 EA per 31 days) ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) SIRIVA RESIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 *Mixed Adrenergics*** S2 (RACEINEHRINE) INHALATION NEBULIZATION SOLUTION 2.25 % QL (4 GM per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 9

11 *Steroid Inhalants*** ARNUITY ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml FLOVENT DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT *Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml reference Details Coverage Details QL (30 EA per 31 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (120 ML per 31 days) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (10.6 GM per 30 days) QL (8.7 GM per 31 days) QL (10.6 GM per 31 Days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 10

12 *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG reference Details Coverage Details XARELTO ORAL TABLET 15 MG QL (62 EA per 31 days) XARELTO ORAL TABLET 20 MG XARELTO STARTER ACK ORAL TABLET THERAY ACK 15 & 20 MG *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous solution 120 /0.8ml, 80 /0.8ml enoxaparin sodium subcutaneous solution 30 /0.3ml enoxaparin sodium subcutaneous solution 40 /0.4ml enoxaparin sodium subcutaneous solution 60 /0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 *Anticonvulsants - Misc.*** ST; Must fail preferred Warfarin within the past 90 days; QL (31 EA per 31 days) QL (51 EA per 30 days) QL (93 ML per 31 days) QL (31 ML per 31 days) QL (24.8 ML per 31 days) QL (9.3 ML per 31 days) QL (12.4 ML per 31 days) QL (18.6 ML per 31 days) carbamazepine oral suspension 100 /5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 QL (310 EA per 31 days) gabapentin oral capsule 300 QL (372 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 11

13 reference Details Coverage Details gabapentin oral capsule 400 QL (279 EA per 31 days) gabapentin oral solution 250 /5ml QL (2230 ML per 31 days) gabapentin oral tablet 600, 800 lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 QL (310 EA per 31 days) lamotrigine oral tablet chewable 25, 5 QL (310 EA per 31 days) levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml *Succinimides*** ethosuximide oral capsule 250 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 12

14 reference Details Coverage Details ethosuximide oral solution 250 /5ml QL (930 ML per 31 days) *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 divalproex sodium er oral tablet extended release 24 hour 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 QL (310 EA per 31 days) QL (279 EA per 31 days) QL (310 EA per 31 days) QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 13

15 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 60 duloxetine hcl oral capsule delayed release particles 30, 40 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 reference Details Coverage Details QL (62 EA per 31 days) QL (31 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 14

16 reference Details Coverage Details nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other - Combinations*** ra glucose oral tablet chewable 4-6 gm- *Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm INSTA-GLUCOSE ORAL GEL 77.4 % *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 15 QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days QL (60 ML per 31 days) QL (60 ML per 31 days)

17 BASAGLAR KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 KWIKEN SUBCUTANEOUS SOLUTION EN- INJECTOR 500 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML reference Details Coverage Details QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 16

18 NOVOLOG FLEXEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLOG ENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS EN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSENSION RECONSTITUTED ER 2 MG VICTOZA SUBCUTANEOUS SOLUTION EN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 reference Details Coverage Details QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) A; QL (4 ML per 28 days) A; QL (4 EA per 28 days) A; QL (4 EA per 28 days) A; QL (9 ML per 30 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 17

19 reference Details Coverage Details glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET MG pioglitazone hcl-metformin hcl oral tablet , *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheal/robiotic Agents* *Antidiarrheal/robiotic Agents - Misc.*** gnp pink bismuth oral tablet 262 peptic relief oral tablet chewable 262 pink bismuth oral suspension 262 /15ml stomach relief max st oral suspension 525 /15ml *Antidiarrheal/robiotic Combinations*** acidophilus/pectin oral capsule *Antidiarrheals* *Antidiarrheal Agents - Misc.*** gnp pink bismuth oral tablet 262 peptic relief oral tablet chewable 262 pink bismuth oral suspension 262 /15ml stomach relief max st oral suspension 525 /15ml ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days. ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 18

20 *Antidiarrheal Combinations*** acidophilus/pectin oral capsule *Antiperistaltic Agents*** anti-diarrheal oral tablet 2 loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml sm anti-diarrheal oral capsule 2 *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** actidose/sorbitol oral liquid 25 gm/120ml actidose-aqua oral liquid 25 gm/120ml EZ CHAR ORAL SUSENSION RECONSTITUTED *Antidotes* *Antidotes*** actidose/sorbitol oral liquid 25 gm/120ml actidose-aqua oral liquid 25 gm/120ml EZ CHAR ORAL SUSENSION RECONSTITUTED sm ipecac syrup oral syrup *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml, 4 /10ml naloxone hcl injection solution prefilled syringe 2 /2ml NARCAN NASAL LIQUID 4 MG/0.1ML *Antiemetics* *Antiemetic Combinations*** anti-nausea oral solution *Antiemetics - Anticholinergic*** dimenhydrinate oral tablet 50 gnp motion sickness relief oral tablet 25 meclizine hcl oral tablet 12.5 travel sickness oral tablet chewable 25 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 19

21 *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines*** ALA-HIST IR ORAL TABLET 2 MG chlorpheniramine maleate er oral tablet extended release 12 ed chlorped jr oral syrup 2 /5ml ED CHLORED ORAL LIQUID 2 MG/ML ed-chlortan oral tablet 4 J-TAN D ORAL LIQUID 1 MG/ML VANAHIST D ORAL LIQUID MG/ML *Antihistamines - Ethanolamines*** allergy relief childrens oral liquid 12.5 /5ml allergy relief oral capsule 25 allergy relief oral tablet 25 diphenhydramine hcl oral capsule 50 gnp dayhist allergy oral tablet 1.34 silphen cough oral syrup 12.5 /5ml *Antihistamines - Non-Sedating*** all day allergy childrens oral solution 5 /5ml aller-ease oral tablet 60 reference Details Coverage Details QL (450 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 20

22 reference Details Coverage Details allergy oral tablet dispersible 10 cetirizine hcl oral tablet 5 cetirizine hcl oral tablet chewable 10, 5 eq allergy relief oral tablet 10 fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180 goodsense all day allergy oral tablet 10 loratadine childrens oral solution 5 /5ml *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 54 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 A *Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 21

23 *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, lisinopril-hydrochlorothiazide oral tablet , , *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 *Angiotensin II Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet , , valsartan-hydrochlorothiazide oral tablet , , , , *Angiotensin II Receptor Antagonists*** irbesartan oral tablet 150, 300, 75 reference Details Coverage Details QL (31 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 22

24 reference Details Coverage Details losartan potassium oral tablet 100, 25, 50 olmesartan medoxomil oral tablet 20, 40, 5 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , *Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml A *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 23 QL (31 EA per 31 days) ST; Must fail 2 of 3 preferred(losartan potassium, irbesartan, and valsartan tablets) within the past 100 days QL (1200 ML per 31 days)

25 reference Details Coverage Details clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous solution 150 /ml *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet *Antimalarials*** DARARIM ORAL TABLET 25 MG A hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic Agents* *Antimyasthenic Agents*** MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 *Antimyasthenic/Cholinergic Agents* MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 24 QL (2400 ML per 31 days)

26 reference Details Coverage Details rifampin intravenous solution reconstituted 600 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG, 500 MG A *Lhrh Analogs*** TRELSTAR INTRAMUSCULAR SUSENSION RECONSTITUTED MG, 3.75 MG *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 A =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 25

27 *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 39 MG/0.25ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 78 MG/0.5ML reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 26 QL (62 EA per 31 days) A; QL (0.75 ML per 28 days) A; QL (1 ML per 28 days) A; QL (1.5 ML per 28 days) A; QL (0.25 ML per 28 days) A; QL (0.5 ML per 28 days) INVEGA TRINZA INTRAMUSCULAR SUSENSION 273 MG/0.875ML A; QL (0.88 ML per 91 days) INVEGA TRINZA INTRAMUSCULAR SUSENSION 410 MG/1.315ML A; QL (1.31 ML per 91 days) INVEGA TRINZA INTRAMUSCULAR SUSENSION 546 MG/1.75ML A; QL (1.75 ML per 91 days) INVEGA TRINZA INTRAMUSCULAR SUSENSION 819 MG/2.625ML A; QL (2.63 ML per 91 days) RISERDAL CONSTA INTRAMUSCULAR SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 A; QL (2 EA per 28 days) MG, 50 MG RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, QL (62 EA per 31 days) 4 MG risperidone oral solution 1 /ml QL (496 ML per 31 days) risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 QL (62 EA per 31 days)

28 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 reference Details Coverage Details QL (62 EA per 31 days) clozapine oral tablet dispersible 12.5 QL (31 EA per 31 days) *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml ST; Must fail preferred quetiapine, olanzapine, risperidone, or risperidone ODT within the past 100 days. fluphenazine hcl oral concentrate 5 /ml QL (248 ML per 31 days) fluphenazine hcl oral elixir 2.5 /5ml QL (2480 ML per 31 days) fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 27

29 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR REFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED ER 300 MG, 400 MG aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 ARISTADA INTRAMUSCULAR REFILLED SYRINGE 1064 MG/3.9ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 441 MG/1.6ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 662 MG/2.4ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antiseptics & Disinfectants* *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 2 % REMEDY ANTIMICROBIAL CLEANSER EXTERNAL LIQUID 0.12 % *Iodine Antiseptics*** BETADINE SKIN CLEANSER EXTERNAL SOLUTION 7.5 % reference Details Coverage Details A; QL (1 EA per 28 days) A; QL (1 EA per 28 days) A; QL (1 EA per 28 days) A; QL (3.9 ML per 56 days) A; QL (1.6 ML per 28 days) A; QL (2.4 ML per 28 days) A; QL (3.2 ML per 28 days) QL (31 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 28

30 reference Details Coverage Details BETADINE SWAB AID EXTERNAL SWAB 10 % povidone-iodine external ointment 10 % povidone-iodine external solution 10 % *Antivirals* *Antiretroviral Combinations*** REZCOBIX ORAL TABLET MG *Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A EIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 100 *Herpes Agents - urine Analogues*** acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml QL (3500 ML per 31 days) acyclovir oral tablet 400, 800 valacyclovir hcl oral tablet 1 gm, 500 QL (62 EA per 31 days) *Influenza Agents*** rimantadine hcl oral tablet 100 *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 QL (40 EA per 365 days) oseltamivir phosphate oral capsule 45, 75 QL (20 EA per 365 days) oseltamivir phosphate oral suspension reconstituted 6 /ml RELENZA DISKHALER INHALATION AEROSOL OWDER BREATH ACTIVATED 5 MG/BLISTER *Assorted Classes* *Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 25 GENGRAF ORAL CASULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 29 QL (360 ML per 365 days); AL (Max 18 Years) QL (40 EA per 365 days)

31 *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 *Macrolide Immunosuppressants*** tacrolimus oral capsule 0.5, 1, 5 *urine Analogs*** azathioprine oral tablet 50 *Beta Blockers* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl intravenous solution 5 /ml labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective*** acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, 50 metoprolol tartrate intravenous solution 1 /ml metoprolol tartrate intravenous solution cartridge 5 /5ml metoprolol tartrate oral tablet 100, 25, 37.5, 50, 75 *Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 30

32 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 240 diltiazem hcl intravenous solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hour 10, 2.5, 5 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG nifedipine er oral tablet extended release 24 hour 60, 90 reference Details Coverage Details QL (31 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 31

33 reference Details Coverage Details nifedipine er osmotic release oral tablet extended release 24 hour 30, 60, 90 nifedipine oral capsule 10 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* *Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg *Cardiovascular Agents - Misc.* *eripheral Vasodilators*** niacin flush free oral capsule 500 no flush niacin oral tablet 500 *ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG A *ulmonary Hypertension - hosphodiesterase Inhibitors*** ADCIRCA ORAL TABLET 20 MG A sildenafil citrate oral tablet 20 A *Cephalosporins* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 10 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml cephalexin oral suspension reconstituted 250 /5ml =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 32 QL (300 ML per 31 days)

34 *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 *Chemicals* *Fixed Oils*** hm castor oil oil *Liquids*** camphor spirit spirit glycerin liquid *Solvents*** sm isopropyl alcohol solution 50 % *Corticosteroids* *Glucocorticosteroids*** hydrocortisone oral tablet 10, 20, 5 methylprednisolone oral tablet 4 prednisolone sodium phosphate oral solution 25 /5ml prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 prednisone oral tablet therapy pack 10 (21), 10 (48), 5 (21), 5 (48) *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 33

35 *Cough/Cold/Allergy* *Antihistamine-Analgesics*** ACETA-GESIC ORAL TABLET MG *Antitussive-Expectorant*** guaifenesin-codeine oral solution /5ml mucus relief cough childrens oral liquid /5ml tussin dm oral liquid /5ml tussin dm oral syrup /5ml *Antitussive-Expectorants-Decongestant*** cheratussin dac oral solution /5ml gnp tussin cf cough & cold oral syrup /5ml LORTUSS EX ORAL LIQUID MG/5ML TUSNEL C ORAL SYRU MG/5ML tussin cf cough & cold oral liquid /5ml *Aromatic Inhalants*** gnp chest rub external ointment % sm medicated chest rub external ointment % *Decongestant & Antihistamine*** childrens cold & allergy oral elixir /5ml ED A-HIST ORAL TABLET 4-10 MG loratadine-d 24hr oral tablet extended release 24 hour rynex pse oral liquid 1-15 /5ml SUDOGEST SINUS/ALLERGY ORAL TABLET 4-60 MG TRIAMINIC COLD & ALLERGY ORAL SYRU MG/5ML *Expectorants*** mucus relief childrens oral liquid 100 /5ml organ-i nr oral tablet 200 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 34

36 reference Details Coverage Details tussin mucus+chest congestion oral syrup 100 /5ml *Iodine Expectorants*** SSKI ORAL SOLUTION 1 GM/ML *Non-Narc Antitussive-Decongestant- Antihistamine*** cold/cough childrens oral elixir /5ml Q-TA DM ORAL ELIXIR MG/5ML rynex dm oral liquid /5ml *Dermatologicals* *Acne Combinations*** benzoyl peroxide-erythromycin external gel 5-3 % *Acne roducts*** acne medication 10 external gel 10 % acne medication 10 external lotion 10 % acne medication 5 external gel 5 % acne medication 5 external lotion 5 % BENZERO EXTERNAL FOAM 5.3 % BENZERO SHORT CONTACT EXTERNAL FOAM 9.8 % benzoyl peroxide cleanser external lotion 3 %, 6 %, 9 % benzoyl peroxide external gel 2.5 % benzoyl peroxide wash external liquid 5 % cvs creamy acne face wash external liquid 4 % ANOXYL WASH EXTERNAL LIQUID 10 % *Analgesics - Topical*** MINERAL ICE EXTERNAL GEL 2 % *Antibiotic Mixtures Topical*** double antibiotic external ointment unit/gm sm antibiotic plus pain relief external cream triple antibiotic external ointment triple antibiotic plus external ointment 1 % =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= Generic drugs 35