South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

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1 2018 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the South Carolina Medicaid referred Drug List is updated quarterly. 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 (1/01/2018)

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. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *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 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10, 100, 40, 60, 80 QL (31 EA per 31 days) atomoxetine hcl oral capsule 18 QL (62 EA per 31 days) atomoxetine hcl oral capsule 25 QL (93 EA per 31 days) *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 QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) =referred, Dagger=N/A, 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= 1

3 Drug Name reference Details Coverage Details methylphenidate hcl er oral tablet extended release 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 54 methylphenidate hcl er oral tablet extended release 54 QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) 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 - Monoclonoal Antibodies*** HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.8ML HUMIRA EN-CROHNS 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 A A; QL (31 EA per 31 days) A A A QL (31 EA per 31 days) =referred, Dagger=N/A, 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= 2

4 Drug Name reference Details Coverage Details *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 100 /5ml 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 childrens oral suspension 100 /5ml ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 indomethacin oral capsule 25, 50 infants ibuprofen oral suspension 50 /1.25ml ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 QL (20 EA per 31 days) meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 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 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION REFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML A =referred, Dagger=N/A, 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= 3

5 Drug Name reference Details Coverage Details ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen extra strength oral liquid 500 /15ml acetaminophen oral solution 160 /5ml acetaminophen oral tablet 325 QL (279 EA per 31 days) acetaminophen oral tablet 500 QL (186 EA per 31 days) acetaminophen rectal suppository 650 apap oral tablet 325 QL (279 EA per 31 days) childrens non-aspirin oral suspension 160 /5ml infants silapap oral solution 100 /ml mapap oral liquid 160 /5ml pain & fever childrens oral suspension 160 /5ml *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet QL (186 EA per 31 days) butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-asa-caffeine oral capsule A A QL (186 EA per 31 days) QL (186 EA per 31 days) marten-tab oral tablet QL (186 EA per 31 days) *Salicylates*** aspirin ec oral tablet delayed release 325, 81 aspirin low dose oral tablet chewable 81 aspirin oral tablet 325 aspirin oral tablet delayed release 81 aspirin rectal suppository 600 diflunisal oral tablet 500 =referred, Dagger=N/A, 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= 4

6 Drug Name reference Details Coverage Details eq aspirin low dose oral tablet delayed release 81 salsalate oral tablet 500, 750 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet QL (248 EA per 31 days) acetaminophen-codeine #3 oral tablet QL (248 EA per 31 days) acetaminophen-codeine #4 oral tablet QL (248 EA per 31 days) acetaminophen-codeine oral solution /5ml ASCOM-CODEINE ORAL CASULE MG butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , 5-325, QL (186 EA per 31 days) QL (186 EA per 31 days) QL (186 EA per 31 days) QL (3720 ML per 31 days) QL (248 EA per 31 days) hydrocodone-ibuprofen oral tablet QL (155 EA per 31 days) *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QL (248 EA per 31 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid 1 /ml A; QL (10 EA per 30 days) hydromorphone hcl oral tablet 2, 4, 8 QL (248 EA per 31 days) hydromorphone hcl rectal suppository 3 methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 QL (248 EA per 31 days) morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate (pf) injection solution 0.5 /ml =referred, Dagger=N/A, 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= 5

7 Drug Name reference Details Coverage Details morphine sulfate (pf) intravenous solution 2 /ml, 4 /ml morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate injection solution 10 /ml, 15 /ml, 5 /ml, 8 /ml morphine sulfate intravenous solution 1 /ml, 25 /ml, 50 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml QL (248 EA per 31 days) morphine sulfate oral tablet 15, 30 QL (248 EA per 31 days) morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl er oral tablet er 12 hour abusedeterrent 10, 15, 20, 30, 40, 60, 80 ST; Must fail preferred Morphine ER tablets within the past 100 days; QL (62 EA per 31 days); AL (Min 11 Years) oxycodone hcl oral capsule 5 QL (248 EA per 31 days) oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 QL (248 EA per 31 days) tramadol hcl oral tablet 50 QL (248 EA per 31 days) *Opioid Combinations*** ENDOCET ORAL TABLET MG QL (248 EA per 31 days) oxycodone-acetaminophen oral tablet , 5-325, QL (248 EA per 31 days) oxycodone-aspirin oral tablet QL (186 EA per 31 days) *Opioid artial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 butorphanol tartrate nasal solution 10 /ml QL (2.5 ML per 31 days) pentazocine-naloxone hcl oral tablet ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG A QL (62 EA per 31 days); AL (Min 16 Years) QL (31 EA per 31 days); AL (Min 16 Years) =referred, Dagger=N/A, 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= 6

8 Drug Name reference Details Coverage Details *Androgens-Anabolic* *Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens*** danazol oral capsule 100, 200, 50 methitest oral tablet 10 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 12.5 /act (1%), 50 /5gm (1%) *Anorectal Agents* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml *Rectal Steroids*** ROCTOSOL HC RECTAL CREAM 2.5 % *Antacids* *Antacid & Simethicone*** antacid i oral suspension /5ml MAALOX MAX ORAL SUSENSION MG/5ML MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION MG/5ML MYLANTA ORAL SUSENSION MG/5ML *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium Salts*** antacid oral tablet chewable 500 calcium antacid extra strength oral tablet chewable 750 =referred, Dagger=N/A, 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= A A 7

9 Drug Name reference Details Coverage Details calcium antacid oral tablet chewable 500 calcium carbonate antacid oral suspension 1250 /5ml calcium carbonate antacid oral tablet 648 calcium carbonate antacid oral tablet chewable 750 *Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400, 420 *Anthelmintics* *Anthelmintics*** 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 /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 hydroxyzine hcl oral solution 10 /5ml QL (450 ML per 31 days) =referred, Dagger=N/A, 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= 8

10 Drug Name reference Details Coverage Details hydroxyzine hcl oral syrup 10 /5ml QL (450 ML per 31 days) hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 *Benzodiazepines*** alprazolam oral tablet 0.25, 0.5, 1, 2 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 AL (Min 9 Years) diazepam oral solution 1 /ml QL (1240 ML per 31 days) diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml, 4 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** lidocaine hcl (cardiac) intravenous solution 20 /ml 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 MULTAQ ORAL TABLET 400 MG A ACERONE ORAL TABLET 200 MG, 400 MG =referred, Dagger=N/A, 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= 9

11 Drug Name reference Details Coverage Details *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 *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 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 QL (720 ML per 31 days) QL (60 EA per 30 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 FORADIL AEROLIZER INHALATION CASULE 12 MCG levalbuterol tartrate inhalation aerosol 45 mcg/act QL (60 EA per 30 days) QL (30 GM per 31 days) =referred, Dagger=N/A, 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= 10

12 Drug Name reference Details Coverage Details 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*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED 62.5 MCG/INH QL (4 GM per 31 days) QL (36 GM per 31 days) QL (25.8 GM per 31 days) QL (1 EA per 31 days) 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 *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 QL (4 GM per 31 days) AL (Min 1 Months and Max 2 Years) QL (30 EA per 31 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) =referred, Dagger=N/A, 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= 11

13 Drug Name reference Details Coverage Details 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 FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** aminophylline intravenous solution 25 /ml 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 *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 QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (24 GM per 30 days) QL (10.6 GM per 30 days) QL (8.7 GM per 31 days) XARELTO ORAL TABLET 15 MG QL (62 EA per 31 days) XARELTO ORAL TABLET 20 MG ST; Must fail preferred Warfarin within the past 90 days; QL (31 EA per 31 days) =referred, Dagger=N/A, 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= 12

14 Drug Name reference Details Coverage Details XARELTO STARTER ACK ORAL TABLET THERAY ACK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium lock flush intravenous solution 100 unit/ml *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 *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml fondaparinux sodium subcutaneous solution 2.5 /0.5ml fondaparinux sodium subcutaneous solution 5 /0.4ml fondaparinux sodium subcutaneous solution 7.5 /0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** QL (51 EA per 30 days) QL (93 ML per 31 days) QL (28 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) QL (11.2 ML per 31 days) QL (16 ML per 31 days) QL (5.6 ML per 31 days) QL (8.4 ML per 31 days) clonazepam oral tablet 0.5, 1, 2 diazepam rectal gel 10, 2.5, 20 QL (3 EA per 31 days) *Anticonvulsants - Misc.*** 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, Dagger=N/A, 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= 13

15 Drug Name 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 peganone oral tablet 250 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 AL (Min 3 Years) =referred, Dagger=N/A, 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= 14

16 Drug Name reference Details Coverage Details ethosuximide oral solution 250 /5ml *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 (930 ML per 31 days); AL (Min 3 Years) 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, Dagger=N/A, 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= 15

17 Drug Name reference Details Coverage Details *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20 citalopram hydrobromide oral tablet 40 QL (31 EA per 31 days) 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 QL (62 EA per 31 days) QL (31 EA per 31 days) =referred, Dagger=N/A, 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= 16

18 Drug Name reference Details Coverage Details imipramine hcl oral tablet 10, 25, 50 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*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *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 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) =referred, Dagger=N/A, 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= 17

19 Drug Name reference Details Coverage Details BASAGLAR KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 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 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKEN SUBCUTANEOUS SOLUTION EN- INJECTOR 500 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML QL (60 ML per 31 days) QL (60 ML per 31 days) QL (30 ML per 30 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, Dagger=N/A, 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= 18

20 Drug Name reference Details Coverage Details NOVOLIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 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 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 , , 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) 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, Dagger=N/A, 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= 19

21 Drug Name reference Details Coverage Details *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 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 *Antidiarrheals* *Antidiarrheal Agents - Misc.*** acidophilus oral tablet acidophilus probiotic blend oral capsule acidophilus/bifidus oral wafer 100 acidophilus/l-sporogenes oral tablet FLORANEX ORAL ACKET FLORASTOR KIDS ORAL ACKET 250 MG stomach relief oral suspension 262 /15ml *Antidiarrheal Combinations*** CULTURELLE DIGESTIVE HEALTH ORAL CASULE 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, Dagger=N/A, 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= 20

22 Drug Name reference Details Coverage Details *Antiperistaltic Agents*** anti-diarrheal oral tablet 2 diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet LOERAMIDE A-D ORAL TABLET 2 MG loperamide hcl oral capsule 2 *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Antidotes* *Antidotes - Chelating Agents*** JADENU ORAL TABLET 180 MG, 360 MG, 90 MG JADENU SRINKLE ORAL ACKET 180 MG, 360 MG, 90 MG *Antidotes*** deferoxamine mesylate injection solution reconstituted 2 gm, 500 *Opioid Antagonists*** naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 *Antiemetics* *5-Ht3 Receptor Antagonists*** ondansetron hcl oral solution 4 /5ml ondansetron oral tablet dispersible 4, 8 *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5, 25 travel sickness oral tablet chewable 25 *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 A A QL (4 ML per 31 days) QL (450 ML per 31 days) =referred, Dagger=N/A, 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= 21

23 Drug Name reference Details Coverage Details 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*** WAL-FINATE ORAL TABLET 4 MG *Antihistamines - Ethanolamines*** aler-dryl oral tablet 50 allergy oral tablet 25 diphenhist oral liquid 12.5 /5ml diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral elixir 12.5 /5ml *Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL SUSENSION 30 MG/5ML cetirizine hcl childrens oral solution 1 /ml cetirizine hcl oral syrup 1 /ml, 5 /5ml cetirizine hcl oral tablet 10, 5 ST; Must fail preferred Loratadine within the past 180 days; QL (300 ML per 31 days) ST; Must fail preferred Loratadine within the past 180 days; QL (300 ML per 31 days) ST; Must fail preferred Loratadine within the past 180 days childrens loratadine oral syrup 5 /5ml QL (310 ML per 31 days) fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180, 60 =referred, Dagger=N/A, 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= 22

24 Drug Name reference Details Coverage Details levocetirizine dihydrochloride oral solution 2.5 /5ml levocetirizine dihydrochloride oral tablet 5 loratadine hives relief oral solution 5 /5ml QL (310 ML per 31 days) loratadine oral tablet 10 sm loratadine oral tablet dispersible 10 *Antihistamines - henothiazines*** promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 25 ROMETHEGAN RECTAL SUOSITORY 25 MG *Antihistamines - iperidines*** cyproheptadine hcl oral syrup 2 /5ml QL (300 ML per 31 days) cyproheptadine hcl oral tablet 4 *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 fluvastatin sodium er oral tablet extended release 24 hour 80 lovastatin oral tablet 10, 20, 40 =referred, Dagger=N/A, 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= 23

25 Drug Name reference Details Coverage Details 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 *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 =referred, Dagger=N/A, 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= 24

26 Drug Name reference Details Coverage Details 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 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 *Antiadrenergics - eripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 *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 QL (31 EA per 31 days) QL (31 EA per 31 days) ST; Must fail 2 of 3 preferred(losartan potassium, irbesartan, and valsartan tablets) within the past 100 days =referred, Dagger=N/A, 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= 25

27 Drug Name reference Details Coverage Details minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 750 vancomycin hcl oral capsule 125, 250 A *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 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 *Oxazolidinones*** linezolid oral tablet 600 A *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 QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Dagger=N/A, 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= 26

28 Drug Name reference Details Coverage Details 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 *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 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CASULE 50 MG A MYLERAN ORAL TABLET 2 MG A *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG, 500 MG A *Antiadrenals*** LYSODREN ORAL TABLET 500 MG A *Antiandrogens*** bicalutamide oral tablet 50 flutamide oral capsule 125 *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150, 500 A fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 /10ml gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/52.6ml, 200 /5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 200 =referred, Dagger=N/A, 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= 27 A A A

29 Drug Name reference Details Coverage Details mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml, 100 /4ml, 200 /8ml, 25 /ml, 250 /10ml, 50 /2ml methotrexate sodium injection solution 250 /10ml, 50 /2ml methotrexate sodium injection solution reconstituted 1 gm TABLOID ORAL TABLET 40 MG A *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG A *Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 MG A *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 MG A *Antineoplastic - Monoclonal Antibodies*** HERCETIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 440 MG ODIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 MG/4ML *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic - Multikinase Inhibitors*** A A A STIVARGA ORAL TABLET 40 MG A SUTENT ORAL CASULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100 MG, 500 MG A CARELSA ORAL TABLET 100 MG, 300 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ICLUSIG ORAL TABLET 15 MG, 45 MG A imatinib mesylate oral tablet 100, 400 A A A A; QL (31 EA per 31 days) =referred, Dagger=N/A, 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= 28

30 Drug Name reference Details Coverage Details SRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CASULE 150 MG, 200 MG TYKERB ORAL TABLET 250 MG A XALKORI ORAL CASULE 200 MG, 250 MG ZYKADIA ORAL CASULE 150 MG A; QL (155 EA per 31 days) *Antineoplastic Enzymes*** ONCASAR INJECTION SOLUTION 750 UNIT/ML *Antineoplastics Misc.*** hydroxyurea oral capsule 500 *Aromatase Inhibitors*** anastrozole oral tablet 1 exemestane oral tablet 25 A; QL (31 EA per 31 days) letrozole oral tablet 2.5 *Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 MG A *Folic Acid Antagonists Rescue Agents*** leucovorin calcium injection solution reconstituted 100, 200, 350, 50 leucovorin calcium oral tablet 10, 15, 25, 5 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Lhrh Analogs*** TRELSTAR INTRAMUSCULAR SUSENSION RECONSTITUTED MG, 3.75 MG A A A A A A A A =referred, Dagger=N/A, 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= 29

31 Drug Name reference Details Coverage Details TRELSTAR MIXJECT INTRAMUSCULAR SUSENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG *Mitotic Inhibitors*** etoposide oral capsule 50 A *Nitrogen Mustards*** cyclophosphamide oral capsule 25, 50 A LEUKERAN ORAL TABLET 2 MG A melphalan oral tablet 2 A *Nitrosoureas*** lomustine oral capsule 10, 100, 40 A *rogestins-antineoplastic*** megestrol acetate oral suspension 40 /ml QL (600 ML per 31 days) megestrol acetate oral tablet 20, 40 *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML *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 A A =referred, Dagger=N/A, 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= 30

32 Drug Name reference Details Coverage Details *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 *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 INVEGA TRINZA INTRAMUSCULAR SUSENSION 273 MG/0.875ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 410 MG/1.315ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 546 MG/1.75ML 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) A; QL (0.88 ML per 91 days) A; QL (1.31 ML per 91 days) A; QL (1.75 ML per 91 days) =referred, Dagger=N/A, 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= 31

33 Drug Name reference Details Coverage Details INVEGA TRINZA INTRAMUSCULAR SUSENSION 819 MG/2.625ML RISERDAL CONSTA INTRAMUSCULAR SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml A; QL (2.63 ML per 91 days) A; QL (2 EA per 28 days) QL (62 EA per 31 days); AL (Min 5 Years) QL (496 ML per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 *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 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years) ST; Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.; AL (Min 10 Years) AL (Min 10 Years) AL (Min 18 Years) =referred, Dagger=N/A, 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= 32

34 Drug Name reference Details Coverage Details *henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years) AL (Min 12 Years) AL (Min 2 Years) prochlorperazine rectal suppository 25 AL (Min 2 Years) 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 AL (Min 2 Years) AL (Min 6 Years) 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) =referred, Dagger=N/A, 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= 33

35 Drug Name reference Details Coverage Details 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 *Antiretrovirals Adjuvants*** *Antiretrovirals Adjuvants*** A; QL (3.2 ML per 42 days) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 12 Years) tybost oral tablet 150 QL (31 EA per 31 days) *Antiseptics & Disinfectants* *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 4 % QL (480 ML per 31 days) *Antivirals* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet ATRILA ORAL TABLET MG COMLERA ORAL TABLET MG QL (31 EA per 31 days) QL (62 EA per 31 days) DESCOVY ORAL TABLET MG QL (31 EA per 31 days) GENVOYA ORAL TABLET MG KALETRA ORAL TABLET MG, MG lamivudine-zidovudine oral tablet lopinavir-ritonavir oral solution /5ml QL (31 EA per 31 days) ODEFSEY ORAL TABLET MG QL (31 EA per 31 days) REZCOBIX ORAL TABLET MG STRIBILD ORAL TABLET MG QL (31 EA per 31 days) TRIUMEQ ORAL TABLET MG QL (31 EA per 31 days) TRUVADA ORAL TABLET MG, MG, MG, MG QL (31 EA per 31 days) =referred, Dagger=N/A, 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= 34

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