2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

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1 Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 207 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order by therapeutic class. To find a specific drug, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F). Some medications may be excluded as determined by benefit. MPC /0/208

2 207 PHP Individual and Family Metal Group Plans/ Employer Group Metal Plans Formulary lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Tier Notes Drug Name Tier Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** guanfacine hcl er QL (30 EA per 30 days) *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl 3 ST; QL (30 EA per 30 days) *AMPHETAMINE MIXTURES*** amphetamine-dextroamphet er oral capsule extended release 24 hour 0 mg, 5 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 25 mg, 30 mg amphetamine-dextroamphetamine *AMPHETAMINES*** dextroamphetamine sulfate er oral capsule extended release 24 hour 0 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (20 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) MPC /0/208

3 dextroamphetamine sulfate oral tablet methamphetamine hcl 3 VYVANSE ORAL CAPSULE 3 *ANALEPTICS*** caffeine citrate intravenous caffeine citrate oral solution 20 mg/ml *ANOREXIANTS NON-AMPHETAMINE*** phentermine hcl oral capsule 3 PA *STIMULANTS - MISC.*** PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA; PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days) PA; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) armodafinil oral tablet 200 mg, 250 mg PA; QL (30 EA per 30 days) armodafinil oral tablet 50 mg PA; QL (90 EA per 30 days) dexmethylphenidate hcl 3 dexmethylphenidate hcl er 3 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 0 mg methylphenidate hcl er (cd) oral capsule extended release 20 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (cd) oral capsule extended release 30 mg methylphenidate hcl er oral tablet extended release 0 mg, 20 mg, 27 mg, 54 mg PA; ST; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Max 8 Years) PA; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) MPC /0/208

4 methylphenidate hcl er oral tablet extended release 8 mg methylphenidate hcl er oral tablet extended release 24 hour 8 mg methylphenidate hcl er oral tablet extended release 24 hour 27 mg methylphenidate hcl er oral tablet extended release 24 hour 36 mg methylphenidate hcl er oral tablet extended release 24 hour 54 mg methylphenidate hcl er oral tablet extended release 36 mg methylphenidate hcl oral solution methylphenidate hcl oral tablet 0 mg, 5 mg methylphenidate hcl oral tablet 20 mg methylphenidate hcl oral tablet chewable 3 PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; PA required for age 9 years and older.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; PA required for age 9 years and older.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) Schedule II medications are limited to a 34 day maximum.; QL (450 ML per 30 days) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days) modafinil PA; QL (30 EA per 30 days) *AMINOGLYCOSIDES* *AMINOGLYCOSIDES*** neomycin sulfate oral paromomycin sulfate oral tobramycin inhalation 4 SP *ANALGESICS - ANTI-INFLAMMATORY* MPC /0/208

5 *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** XELJANZ 4 PA; SP; QL (60 EA per 30 days) XELJANZ XR 4 PA; QL (30 EA per 30 days) *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML, 40 MG/0.8ML *ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES*** 4 PA; SP HUMIRA 4 PA; SP HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS KIT HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; SP 4 PA; SP HUMIRA PEN 4 PA; SP HUMIRA PEN-CROHNS STARTER 4 PA; SP HUMIRA PEN-PSORIASIS STARTER 4 PA; SP *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** celecoxib oral 3 QL (60 EA per 30 days) *GOLD COMPOUNDS*** RIDAURA 2 *INTERLEUKIN-6 RECEPTOR INHIBITORS*** ACTEMRA INTRAVENOUS PA; SP ACTEMRA SUBCUTANEOUS 4 PA; SP; QL (3.6 ML per 30 days) *NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS*** diclofenac-misoprostol oral tablet delayed release 3 *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** diclofenac sodium er diclofenac sodium oral etodolac er etodolac oral FENOPROFEN CALCIUM ORAL TABLET 2 flurbiprofen oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er indomethacin oral MPC /0/208

6 ketoprofen oral ketorolac tromethamine oral QL (20 EA per 30 days) meclofenamate sodium oral capsule 00 mg 2 MECLOFENAMATE SODIUM ORAL CAPSULE 50 MG meloxicam oral tablet nabumetone oral naproxen dr naproxen oral tablet naproxen sodium oral tablet 275 mg, 550 mg oxaprozin piroxicam oral sulindac oral TOLMETIN SODIUM ORAL CAPSULE 2 TOLMETIN SODIUM ORAL TABLET 600 MG 2 *PYRIMIDINE SYNTHESIS INHIBITORS*** leflunomide oral *SELECTIVE COSTIMULATION MODULATORS*** ORENCIA CLICKJECT 4 PA; SP; QL (4 ML per 30 days) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** ENBREL SUBCUTANEOUS KIT 4 PA; SP ENBREL SUBCUTANEOUS SOLUTION 4 PA; SP ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 2 4 PA; SP; QL (4 ML per 28 days) 4 PA; SP ENBREL SURECLICK 4 PA; SP *ANALGESICS - NONNARCOTIC* *ANALGESICS-SEDATIVES*** butalbital-acetaminophen oral tablet mg QL (2 EA per day) butalbital-apap-caffeine oral tablet QL (6 EA per day) *SALICYLATES*** aspirin ec oral tablet delayed release 325 mg $0 Copay per PPACA guidelines aspirin ec oral tablet delayed release 8 mg AG (Min 45 Years and Max 79 Years) aspirin low dose oral tablet aspirin oral tablet aspirin oral tablet chewable (Min 45 Years and Max 79 Years) (Min 45 Years) (Min 45 Years) MPC /0/208

7 aspirin oral tablet delayed release 325 mg, 8 mg (Min 45 Years) aspirtab $0 Copay per PPACA guidelines BAYER ASPIRIN ORAL TABLET BAYER ASPIRIN ORAL TABLET DELAYED RELEASE (Min 45 Years) (Min 45 Years) BAYER ASPIRIN REGIMEN $0 Copay per PPACA guidelines childrens aspirin cvs aspirin oral tablet 325 mg cvs aspirin oral tablet delayed release 8 mg cvs childrens aspirin diflunisal oral ec-8 aspirin eq aspirin eq childrens aspirin eql aspirin eql childrens aspirin gnp aspirin oral tablet 325 mg gnp aspirin oral tablet delayed release hm aspirin mm aspirin NORWICH ASPIRIN ORAL TABLET 325 MG px aspirin px enteric aspirin qc aspirin qc childrens aspirin ra aspirin ra childrens aspirin (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) MPC /0/208

8 salsalate oral sb aspirin sb childrens aspirin sm aspirin sm childrens aspirin (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) ST JOSEPH ADULT AG (Min 45 Years and Max 79 Years) ST JOSEPH ASPIRIN tgt aspirin tgt childrens aspirin th aspirin th enteric aspirin *ANALGESICS - OPIOID* *CODEINE COMBINATIONS*** acetaminophen-codeine #2 acetaminophen-codeine #3 acetaminophen-codeine #4 acetaminophen-codeine oral solution acetaminophen-codeine oral tablet mg butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine *HYDROCODONE COMBINATIONS*** hydrocodone-acetaminophen oral solution mg/5ml, 5-27 mg/0ml hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) QL (3 EA per day); AG (Min 2 Years) QL (3 EA per day); AG (Min 2 Years) QL (3 EA per day); AG (Min 2 Years) QL (66 ML per day); AG (Min 2 Years) QL (3 EA per day); AG (Min 2 Years) QL (6 EA per day); AG (Min 2 Years) QL (6 EA per day); AG (Min 2 Years) Schedule II medications are limited to a 34 day maximum. Schedule II medications are limited to a 34 day maximum.; QL (2.3 ML per day) Schedule II medications are limited to a 34 day maximum.; QL (2 EA per day) Schedule II medications are limited to a 34 day maximum.; QL (6 EA per day) MPC /0/208

9 hydrocodone-acetaminophen oral tablet mg *OPIOID AGONISTS*** codeine sulfate oral tablet 5 mg, 30 mg CODEINE SULFATE ORAL TABLET 60 MG 2 fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydromorphone hcl er oral tablet er 24 hour abusedeterrent 2 mg, 6 mg, 8 mg hydromorphone hcl oral tablet KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG levorphanol tartrate oral 3 MEPERIDINE HCL ORAL SOLUTION 2 METHADONE HCL ORAL SOLUTION 2 methadone hcl oral tablet morphine sulfate (concentrate) oral solution 20 mg/ml morphine sulfate er beads 3 morphine sulfate er oral capsule extended release 24 hour 0 mg morphine sulfate er oral capsule extended release 24 hour 00 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release morphine sulfate oral solution Schedule II medications are limited to a 34 day maximum.; QL (8 EA per day) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days); AG (Min 2 Years) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days); AG (Min 2 Years) Schedule II medications are limited to a 34 day maximum.; QL (0 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (2000 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (900 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (80 ML per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (000 ML per 30 days) MPC /0/208

10 morphine sulfate oral tablet Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) NUCYNTA ER 3 PA; QL (60 EA per 30 days) oxycodone hcl oral concentrate 00 mg/5ml oxycodone hcl oral tablet oxymorphone hcl er 3 oxymorphone hcl oral tablet 0 mg 3 oxymorphone hcl oral tablet 5 mg 3 tramadol hcl er (biphasic) oral tablet extended release 24 hour 00 mg tramadol hcl er (biphasic) oral tablet extended release 24 hour 200 mg tramadol hcl er oral tablet extended release 24 hour 00 mg tramadol hcl er oral tablet extended release 24 hour 200 mg tramadol hcl oral *OPIOID COMBINATIONS*** Schedule II medications are limited to a 34 day maximum.; QL (80 ML per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (360 EA per 30 days) ST; Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) QL (90 EA per 30 days); AG (Min 2 Years) QL (30 EA per 30 days); AG (Min 2 Years) QL (90 EA per 30 days); AG (Min 2 Years) QL (30 EA per 30 days); AG (Min 2 Years) QL (240 EA per 30 days); AG (Min 2 Years) endocet oral tablet mg QL (2 EA per day) oxycodone-acetaminophen oral capsule oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet mg ROXICET ORAL TABLET MG Schedule II medications are limited to a 34 day maximum.; QL (8 EA per day) Schedule II medications are limited to a 34 day maximum.; QL (2 EA per day) Schedule II medications are limited to a 34 day maximum.; QL (6 EA per day) Schedule II medications are limited to a 34 day maximum.; QL (8 EA per day) Schedule II medications are limited to a 34 day maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day maximum.; QL (2 EA per day) XARTEMIS XR 3 PA; QL (20 EA per 30 days) MPC /0/208

11 *OPIOID PARTIAL AGONISTS*** buprenorphine hcl sublingual tablet sublingual 2 mg 3 PA; QL (90 EA per 30 days) buprenorphine hcl sublingual tablet sublingual 8 mg 3 PA; QL (60 EA per 30 days) buprenorphine hcl-naloxone hcl QL (90 EA per 30 days) butorphanol tartrate nasal 3 QL (0 ML per 30 days) nalbuphine hcl injection solution 0 mg/ml SUBOXONE SUBLINGUAL FILM 2-3 MG 3 SUBOXONE SUBLINGUAL FILM MG, 4- MG, 8-2 MG *PENTAZOCINE COMBINATIONS*** 3 QL (60 EA per 30 days); AG (Min 6 Years) QL (90 EA per 30 days); AG (Min 6 Years) pentazocine-acetaminophen QL (6 EA per day) *TRAMADOL COMBINATIONS*** tramadol-acetaminophen *ANDROGENS-ANABOLIC* *ANABOLIC STEROIDS*** QL (300 EA per 30 days); AG (Min 2 Years) oxandrolone oral tablet 0 mg 3 PA; QL (60 EA per 30 days) oxandrolone oral tablet 2.5 mg 3 PA; QL (80 EA per 30 days) *ANDROGENS*** ANDRODERM TRANSDERMAL PATCH 24 HOUR 3 PA; QL (60 EA per 30 days) ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (.62%) ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (.62%) 2 PA; QL (300 GM per 30 days) 2 PA; QL (50 GM per 30 days) ANDROXY 3 PA; QL (20 EA per 30 days) danazol oral testosterone cypionate intramuscular solution 00 mg/ml, 200 mg/ml PA testosterone enanthate intramuscular solution PA testosterone transdermal gel 0 mg/act (2%) 3 PA; QL (20 GM per 30 days) *ANORECTAL AGENTS* *INTRARECTAL STEROIDS*** CORTIFOAM 3 hydrocortisone rectal enema *RECTAL ANESTHETIC/STEROIDS*** hydrocortisone ace-pramoxine rectal cream - % lidocaine-hydrocortisone ace rectal cream PROCTOFOAM HC 2 *RECTAL LOCAL ANESTHETICS*** pramoxine hcl rectal *RECTAL STEROIDS*** MPC /0/208

12 hydrocortisone rectal cream 2.5 % proctocare-hc procto-med hc PROCTOSOL HC proctozone-hc rectal *ANTHELMINTICS* *ANTHELMINTICS*** ALBENZA 3 BILTRICIDE 3 EMVERM 4 PA; QL (6 EA per 2 days) ivermectin oral 3 QL (2 EA per 20 days) *ANTIANGINAL AGENTS* *ANTIANGINALS-OTHER*** RANEXA 3 ST *NITRATES*** DILATRATE-SR 2 ISOSORBIDE DINITRATE ER 2 isosorbide dinitrate oral isosorbide dinitrate sublingual tablet sublingual 2.5 mg isosorbide mononitrate isosorbide mononitrate er MINITRAN TRANSDERMAL PATCH 24 HOUR 0.6 MG/HR NITRO-BID 2 nitroglycerin er nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg NITROGLYCERIN SUBLINGUAL TABLET SUBLINGUAL 0.6 MG nitroglycerin transdermal patch 24 hour *ANTIANXIETY AGENTS* *ANTIANXIETY AGENTS - MISC.*** buspirone hcl oral hydroxyzine hcl oral hydroxyzine pamoate oral meprobamate *BENZODIAZEPINES*** alprazolam oral tablet 0.25 mg, 0.5 mg, mg QL (90 EA per 30 days) alprazolam oral tablet 2 mg QL (35 EA per 30 days) chlordiazepoxide hcl QL (20 EA per 30 days) 2 MPC /0/208

13 clorazepate dipotassium oral tablet 5 mg QL (80 EA per 30 days) clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg QL (90 EA per 30 days) diazepam oral tablet QL (20 EA per 30 days) lorazepam injection QL (2.5 ML per day) lorazepam oral concentrate QL (50 ML per 30 days) lorazepam oral tablet QL (90 EA per 30 days) oxazepam QL (20 EA per 30 days) *ANTIARRHYTHMICS* *ANTIARRHYTHMICS TYPE I-A*** disopyramide phosphate oral quinidine gluconate er QUINIDINE SULFATE ORAL 2 *ANTIARRHYTHMICS TYPE I-B*** mexiletine hcl oral *ANTIARRHYTHMICS TYPE I-C*** flecainide acetate propafenone hcl *ANTIARRHYTHMICS TYPE III*** amiodarone hcl intravenous solution 50 mg/3ml amiodarone hcl oral tablet 200 mg, 400 mg MULTAQ 3 PA; QL (60 EA per 30 days) TIKOSYN 3 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *5-LIPOXYGENASE INHIBITORS*** zileuton er 4 PA; SP; QL (20 EA per 30 days) ZYFLO *ADRENERGIC COMBINATIONS*** ADVAIR DISKUS 3 ST; QL (60 EA per 30 days) ADVAIR HFA 3 ST; QL (2 GM per 30 days) ANORO ELLIPTA 3 ST COMBIVENT RESPIMAT 3 QL (4 GM per 30 days) DULERA 3 ST; QL (3 GM per 30 days) fluticasone-salmeterol 2 ST; QL ( EA per 30 days) ipratropium-albuterol STIOLTO RESPIMAT 2 ST SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT *ANTI-INFLAMMATORY AGENTS*** NF 2 ST; QL (7 GM per 30 days) 2 ST; QL (6.9 GM per 30 days) MPC /0/208

14 cromolyn sodium inhalation *BETA ADRENERGICS*** albuterol sulfate er albuterol sulfate inhalation albuterol sulfate oral isoproterenol hcl injection levalbuterol tartrate 3 ST; QL (30 GM per 30 days) METAPROTERENOL SULFATE ORAL 2 SEREVENT DISKUS 2 terbutaline sulfate injection terbutaline sulfate oral VENTOLIN HFA 2 *BRONCHODILATORS - ANTICHOLINERGICS*** ATROVENT HFA 2 ipratropium bromide inhalation SPIRIVA HANDIHALER 2 SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED *LEUKOTRIENE RECEPTOR ANTAGONISTS*** montelukast sodium oral tablet QL (30 EA per 30 days) montelukast sodium oral tablet chewable QL (30 EA per 30 days) zafirlukast *MIXED ADRENERGICS*** epinephrine hcl injection solution 3 *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** DALIRESP 2 PA; QL (30 EA per 30 days) *STEROID INHALANTS*** ALVESCO INHALATION AEROSOL SOLUTION 60 MCG/ACT ALVESCO INHALATION AEROSOL SOLUTION 80 MCG/ACT ASMANEX 20 METERED DOSES 2 ASMANEX 4 METERED DOSES 2 ASMANEX 30 METERED DOSES 2 ASMANEX 60 METERED DOSES 2 ASMANEX 7 METERED DOSES ST; QL (2.2 GM per 30 days) 3 ST; QL (6. GM per 30 days) MPC /0/208

15 ASMANEX HFA 2 QL (3 GM per 30 days) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml QL (20 ML per 30 days); AG (Max 2 Years) budesonide inhalation suspension mg/2ml 4 PA; QL (60 ML per 30 days) FLOVENT DISKUS 2 FLOVENT HFA 2 PULMICORT FLEXHALER 3 QVAR INHALATION AEROSOL SOLUTION 3 PA QVAR REDIHALER 3 PA *XANTHINES*** ELIXOPHYLLIN 3 THEOCHRON ORAL TABLET EXTENDED RELEASE 2 HOUR 200 MG theophylline er *ANTICOAGULANTS* *COUMARIN ANTICOAGULANTS*** warfarin sodium oral *DIRECT FACTOR XA INHIBITORS*** XARELTO ORAL TABLET 0 MG, 20 MG 2 QL (30 EA per 30 days) XARELTO ORAL TABLET 5 MG 2 XARELTO STARTER PACK 2 QL (5 EA per 90 days) *HEPARINS AND HEPARINOID-LIKE AGENTS*** heparin sodium (porcine) injection solution 0000 unit/ml, 5000 unit/ml heparin sodium lock flush intravenous solution 0 unit/ml heparin sodium lock flush intravenous solution 00 unit/ml *LOW MOLECULAR WEIGHT HEPARINS*** enoxaparin sodium injection Maximum 30 syringes per 90 days. enoxaparin sodium subcutaneous solution 00 mg/ml, 20 mg/0.8ml, 50 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 2500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.72ML, 2500 UNIT/0.2ML, UNIT/ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML *SYNTHETIC HEPARINOID-LIKE AGENTS*** fondaparinux sodium 4 PA *THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE*** Maximum 30 syringes per 90 days. 4 PA; QL (30 ML per 30 days) MPC /0/208

16 PRADAXA 3 PA; QL (60 EA per 30 days) *ANTICONVULSANTS* *ANTICONVULSANTS - BENZODIAZEPINES*** clonazepam oral QL (90 EA per 30 days) diazepam rectal 2 *ANTICONVULSANTS - MISC.*** carbamazepine er carbamazepine oral gabapentin oral capsule gabapentin oral solution 250 mg/5ml gabapentin oral tablet lamotrigine oral tablet lamotrigine oral tablet chewable levetiracetam oral ST; QL (5 EA per 30 days); AG (Max 7 Years) LYRICA ORAL CAPSULE 3 PA; QL (90 EA per 30 days) oxcarbazepine POTIGA 3 PA; QL (90 EA per 30 days) primidone oral topiramate oral VIMPAT ORAL SOLUTION 4 ST; QL (200 ML per 30 days) VIMPAT ORAL TABLET 4 ST; QL (60 EA per 30 days) zonisamide oral *CARBAMATES*** felbamate 3 *GABA MODULATORS*** GABITRIL ORAL TABLET 2 MG, 6 MG 3 tiagabine hcl 3 *HYDANTOINS*** DILANTIN INFATABS 3 DILANTIN ORAL CAPSULE 30 MG 3 fosphenytoin sodium phenytoin oral suspension 25 mg/5ml phenytoin sodium extended *SUCCINIMIDES*** ethosuximide oral *VALPROIC ACID*** MPC /0/208

17 divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule sprinkle divalproex sodium oral tablet delayed release valproic acid oral capsule valproic acid oral syrup *ANTIDEPRESSANTS* *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** mirtazapine oral tablet 5 mg, 30 mg, 45 mg QL (30 EA per 30 days) mirtazapine oral tablet dispersible *ANTIDEPRESSANTS - MISC.*** bupropion hcl er (sr) QL (60 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg bupropion hcl oral MAPROTILINE HCL 2 *MODIFIED CYCLICS*** nefazodone hcl oral tablet 00 mg, 50 mg, 200 mg, 250 mg trazodone hcl oral QL (90 EA per 30 days) QL (30 EA per 30 days) VIIBRYD ORAL TABLET 3 PA; QL (30 EA per 30 days) *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** EMSAM 4 PA; QL (30 EA per 30 days) phenelzine sulfate oral tranylcypromine sulfate *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** citalopram hydrobromide oral solution QL (600 ML per 30 days) citalopram hydrobromide oral tablet 0 mg, 20 mg QL (60 EA per 30 days) citalopram hydrobromide oral tablet 40 mg QL (30 EA per 30 days) escitalopram oxalate oral solution QL (600 ML per 30 days) escitalopram oxalate oral tablet 0 mg QL (45 EA per 30 days) escitalopram oxalate oral tablet 20 mg, 5 mg QL (30 EA per 30 days) fluoxetine hcl oral capsule fluoxetine hcl oral solution fluvoxamine maleate paroxetine hcl er oral tablet extended release 24 hour 2.5 mg 3 ST; QL (30 EA per 30 days) MPC /0/208

18 paroxetine hcl er oral tablet extended release 24 hour 25 mg, 37.5 mg ST paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg QL (30 EA per 30 days) paroxetine hcl oral tablet 40 mg QL (45 EA per 30 days) PAXIL ORAL SUSPENSION 2 QL (450 ML per 30 days) sertraline hcl oral concentrate sertraline hcl oral tablet 00 mg, 25 mg QL (60 EA per 30 days) sertraline hcl oral tablet 50 mg QL (45 EA per 30 days) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** desvenlafaxine succinate er 3 PA; QL (30 EA per 30 days) duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg duloxetine hcl oral capsule delayed release particles 60 mg venlafaxine hcl venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 37.5 mg venlafaxine hcl er oral capsule extended release 24 hour 75 mg *TRICYCLIC AGENTS*** amitriptyline hcl oral amoxapine 2 clomipramine hcl oral desipramine hcl oral doxepin hcl oral imipramine hcl oral nortriptyline hcl oral capsule *ANTIDIABETICS* *ALPHA-GLUCOSIDASE INHIBITORS*** acarbose *ANTIDIABETIC - AMYLIN ANALOGS*** SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR *BIGUANIDES*** metformin hcl er metformin hcl oral *DIABETIC OTHER*** GLUCAGON EMERGENCY 2 QL (60 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) 3 PA 3 PA MPC /0/208

19 *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** alogliptin benzoate 2 ST; QL (30 EA per 30 days) JANUVIA 2 ST; QL (30 EA per 30 days) ONGLYZA 3 PA; QL (30 EA per 30 days) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR- BIGUANIDE COMBINATIONS*** alogliptin-metformin hcl 2 ST; QL (60 EA per 30 days) JANUMET 2 ST; QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG *HUMAN INSULIN*** APIDRA 3 ST 2 ST; QL (30 EA per 30 days) 2 ST; QL (60 EA per 30 days) 3 PA; QL (60 EA per 30 days) 3 PA; QL (30 EA per 30 days) FIASP 2 QL (50 ML per 30 days) FIASP FLEXTOUCH 2 QL (45 ML per 30 days) HUMALOG 3 ST; QL (50 ML per 30 days) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML 3 ST; QL (45 ML per 30 days) HUMALOG MIX 50/50 3 ST; QL (50 ML per 30 days) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 ST; QL (45 ML per 30 days) HUMALOG MIX 75/25 3 ST; QL (50 ML per 30 days) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 ST; QL (45 ML per 30 days) HUMULIN 70/30 3 ST; QL (50 ML per 30 days) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 ST; QL (45 ML per 30 days) HUMULIN N 3 QL (50 ML per 30 days) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 ST; QL (45 ML per 30 days) HUMULIN R 3 ST; QL (50 ML per 30 days) HUMULIN R U-500 (CONCENTRATED) 4 ST; QL (20 ML per 30 days) LANTUS 2 QL (50 ML per 30 days) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (45 ML per 30 days) LEVEMIR 2 QL (50 ML per 30 days) LEVEMIR FLEXTOUCH 2 QL (45 ML per 30 days) NOVOLIN 70/30 2 QL (50 ML per 30 days) NOVOLIN 70/30 RELION 2 QL (50 ML per 30 days) MPC /0/208

20 NOVOLIN N 2 QL (50 ML per 30 days) NOVOLIN N RELION 2 QL (50 ML per 30 days) NOVOLIN R 2 QL (50 ML per 30 days) NOVOLIN R RELION 2 QL (50 ML per 30 days) NOVOLOG 2 QL (50 ML per 30 days) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (45 ML per 30 days) NOVOLOG MIX 70/30 2 QL (50 ML per 30 days) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE *INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS)*** 2 QL (45 ML per 30 days) 2 QL (45 ML per 30 days) BYDUREON BCISE 2 ST; QL (3.4 ML per 28 days) BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 ST; QL (4 EA per 28 days) BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER BYETTA 0 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 ST; QL (4 EA per 28 days) 3 ST; QL (2.4 ML per 30 days) 3 ST; QL (.2 ML per 30 days) TRULICITY 3 ST; QL (4 ML per 28 days) VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR *MEGLITINIDE ANALOGUES*** nateglinide repaglinide 3 *MEGLITINIDE-BIGUANIDE COMBINATIONS*** repaglinide-metformin hcl 3 ST *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** 2 ST; QL (9 ML per 30 days) FARXIGA 2 ST; QL (30 EA per 30 days) INVOKANA 3 ST; QL (30 EA per 30 days) *SULFONYLUREA-BIGUANIDE COMBINATIONS*** glipizide-metformin hcl glyburide-metformin *SULFONYLUREAS*** CHLORPROPAMIDE ORAL TABLET 00 MG 2 chlorpropamide oral tablet 250 mg 2 glimepiride MPC /0/208

21 glipizide er glipizide oral glyburide micronized glyburide oral TOLAZAMIDE 2 TOLBUTAMIDE 2 *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** pioglitazone hcl-glimepiride ST *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** AVANDAMET ORAL TABLET MG 3 ST AVANDAMET ORAL TABLET MG, MG, MG pioglitazone hcl-metformin hcl ST *THIAZOLIDINEDIONES*** AVANDIA 3 ST pioglitazone hcl ST; QL (30 EA per 30 days) *ANTIDIARRHEALS* *ANTIPERISTALTIC AGENTS*** DIPHENOXYLATE-ATROPINE ORAL LIQUID 2 diphenoxylate-atropine oral tablet *ANTIDOTES* *OPIOID ANTAGONISTS*** naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution mg/ml naltrexone hcl oral NARCAN 2 *ANTIEMETICS* *5-HT3 RECEPTOR ANTAGONISTS*** 3 Naloxone injectable used with nasal atomizer is covered.; QL (2 ML per 30 days) Naloxone injectable used with nasal atomizer is covered.; QL (4 ML per 30 days) ANZEMET ORAL 3 PA; QL (4 EA per 30 days) granisetron hcl oral ST; QL (20 EA per 30 days) ondansetron QL (90 EA per 30 days) ondansetron hcl injection solution 4 mg/2ml ondansetron hcl oral solution AG (Max 4 Years) ondansetron hcl oral tablet 4 mg, 8 mg QL (90 EA per 30 days) *ANTIEMETICS - ANTICHOLINERGIC*** MPC /0/208

22 meclizine hcl oral tablet 25 mg scopolamine 3 trimethobenzamide hcl oral *SUBSTANCE P/NEUROKININ (NK) RECEPTOR ANTAGONISTS*** aprepitant oral capsule 25 mg, 40 mg 3 aprepitant oral capsule 80 & 25 mg, 80 mg 3 PA; Quantity is limited to 40mg and 25mg= per fill, 80/25 Pack=3( package)per fill, 80 mg=3 per fill; QL ( EA per 30 days) PA; Quantity is limited to 40mg and 25mg= per fill, 80/25 Pack=3( package)per fill, 80 mg=3 per fill; QL (3 EA per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED 4 PA; QL (6 EA per 28 days) *ANTIFUNGALS* *ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** caspofungin acetate *ANTIFUNGALS*** BIO-STATIN ORAL CAPSULE UNIT 2 griseofulvin microsize oral suspension griseofulvin ultramicrosize oral tablet 25 mg 3 GRIS-PEG ORAL TABLET 250 MG 3 nystatin oral tablet terbinafine hcl oral QL (90 EA per 365 days) *IMIDAZOLES*** ketoconazole oral *TRIAZOLES*** fluconazole oral itraconazole oral 4 ST; QL (68 EA per 365 days) voriconazole oral suspension reconstituted 4 PA voriconazole oral tablet 4 PA; QL (60 EA per 30 days) *ANTIHISTAMINES* *ANTIHISTAMINES - ETHANOLAMINES*** carbinoxamine maleate oral tablet 4 mg 3 diphenhydramine hcl oral elixir *ANTIHISTAMINES - NON-SEDATING*** desloratadine oral tablet 3 levocetirizine dihydrochloride oral 3 *ANTIHISTAMINES - PHENOTHIAZINES*** promethazine hcl injection MPC /0/208

23 promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal promethegan rectal suppository 25 mg PROMETHEGAN RECTAL SUPPOSITORY 50 MG *ANTIHISTAMINES - PIPERIDINES*** cyproheptadine hcl oral *ANTIHYPERLIPIDEMICS* *ANTIHYPERLIPIDEMICS - MISC.*** omega-3-acid ethyl esters 3 QL (20 EA per 30 days) *BILE ACID SEQUESTRANTS*** cholestyramine light cholestyramine oral colestipol hcl oral tablet 3 prevalite oral packet PREVALITE ORAL POWDER WELCHOL 2 *FIBRIC ACID DERIVATIVES*** fenofibrate micronized oral capsule 34 mg, 200 mg, 67 mg fenofibrate oral tablet 45 mg, 60 mg, 48 mg, 54 mg gemfibrozil oral *HMG COA REDUCTASE INHIBITORS*** atorvastatin calcium oral QL (30 EA per 30 days) fluvastatin sodium 3 LIVALO 3 ST lovastatin $0 Copay per PPACA guidelines. pravastatin sodium rosuvastatin calcium simvastatin oral $0 Copay per PPACA guidelines. *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** ezetimibe-simvastatin 3 *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** ezetimibe *NICOTINIC ACID DERIVATIVES*** niacin er (antihyperlipidemic) *ANTIHYPERTENSIVES* MPC /0/208

24 *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** amlodipine besy-benazepril hcl *ACE INHIBITORS & THIAZIDE/THIAZIDE- LIKE*** benazepril-hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE 2 enalapril-hydrochlorothiazide fosinopril sodium-hctz lisinopril-hydrochlorothiazide moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide *ACE INHIBITORS*** benazepril hcl oral captopril oral enalapril maleate oral fosinopril sodium lisinopril oral moexipril hcl perindopril erbumine 3 quinapril hcl ramipril trandolapril *AGENTS FOR PHEOCHROMOCYTOMA*** phenoxybenzamine hcl oral 3 *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE*** candesartan cilexetil-hctz 3 irbesartan-hydrochlorothiazide losartan potassium-hctz olmesartan medoxomil-hctz 3 valsartan-hydrochlorothiazide *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** candesartan cilexetil 3 eprosartan mesylate 3 ST irbesartan losartan potassium MPC /0/208

25 olmesartan medoxomil oral 3 telmisartan 3 ST; QL (30 EA per 30 days) valsartan 3 *ANTIADRENERGICS - CENTRALLY ACTING*** clonidine hcl oral clonidine hcl transdermal guanfacine hcl oral methyldopa oral *ANTIADRENERGICS - PERIPHERALLY ACTING*** doxazosin mesylate prazosin hcl oral terazosin hcl oral *BETA BLOCKER & DIURETIC COMBINATIONS*** atenolol-chlorthalidone bisoprolol-hydrochlorothiazide metoprolol-hydrochlorothiazide PROPRANOLOL-HCTZ 2 *DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB*** TEKTURNA HCT 3 PA; QL (30 EA per 30 days) *DIRECT RENIN INHIBITORS*** TEKTURNA 3 PA; QL (30 EA per 30 days) *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** eplerenone 3 *VASODILATORS*** hydralazine hcl injection hydralazine hcl oral minoxidil oral *ANTI-INFECTIVE AGENTS - MISC.* *ANTI-INFECTIVE AGENTS - MISC.*** baciim 3 CAYSTON 4 PA; SP; QL (84 ML per 56 days) metronidazole oral tablet nebupent SP PENTAM 4 SP MPC /0/208

26 trimethoprim oral vancomycin hcl intravenous solution reconstituted 000 mg, 500 mg, 5000 mg vancomycin hcl oral 4 PA XIFAXAN ORAL TABLET 200 MG 4 PA; QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG 4 PA; QL (60 EA per 30 days) *ANTI-INFECTIVE MISC. - COMBINATIONS*** erythromycin-sulfisoxazole sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet *ANTIPROTOZOAL AGENTS*** atovaquone oral *LEPROSTATICS*** dapsone oral 2 *LINCOSAMIDES*** clindamycin hcl oral capsule 50 mg, 300 mg clindamycin palmitate hcl *OXAZOLIDINONES*** linezolid oral 4 PA *ANTIMALARIALS* *ANTIMALARIAL COMBINATIONS*** atovaquone-proguanil hcl oral tablet mg 3 *ANTIMALARIALS*** chloroquine phosphate oral hydroxychloroquine sulfate oral primaquine phosphate oral 2 *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC AGENTS*** MESTINON ORAL SYRUP 3 pyridostigmine bromide oral *ANTIMYASTHENIC/CHOLINERGIC AGENTS*** MESTINON ORAL SYRUP 3 pyridostigmine bromide oral *ANTIMYASTHENIC/CHOLINERGIC AGENTS* MESTINON ORAL SYRUP 3 pyridostigmine bromide oral MPC /0/208

27 *ANTIMYCOBACTERIAL AGENTS* *ANTI TB COMBINATIONS*** RIFAMATE 4 *ANTIMYCOBACTERIAL AGENTS*** ethambutol hcl oral ISONIAZID ORAL SYRUP 2 isoniazid oral tablet PASER PRIFTIN 3 pyrazinamide oral rifabutin 4 rifampin oral TRECATOR 3 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ALKYLATING AGENTS*** busulfan HEXALEN 4 PA; SP MYLERAN 4 PA; SP *ANDROGEN BIOSYNTHESIS INHIBITORS*** ZYTIGA ORAL TABLET 250 MG 4 PA; QL (20 EA per 30 days) ZYTIGA ORAL TABLET 500 MG 4 PA; QL (60 EA per 30 days) *ANTIADRENALS*** LYSODREN 4 *ANTIANDROGENS*** bicalutamide flutamide XTANDI 4 PA; SP; QL (20 EA per 30 days) *ANTIESTROGENS*** FARESTON 4 PA; SP; QL (30 EA per 30 days) tamoxifen citrate oral PA *ANTIMETABOLITES*** capecitabine 4 PA; SP mercaptopurine oral methotrexate oral methotrexate sodium (pf) injection solution gm/40ml, 00 mg/4ml, 25 mg/ml, 250 mg/0ml, 50 mg/2ml methotrexate sodium injection solution 25 mg/ml ME MPC /0/208

28 methotrexate sodium injection solution reconstituted TABLOID 4 PA; SP TREXALL 2 *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** TAFINLAR 4 PA; SP; QL (20 EA per 30 days) ZELBORAF 4 PA; SP; QL (240 EA per 30 days) *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** ERIVEDGE 4 PA; SP; QL (30 EA per 30 days) ODOMZO 4 PA; QL (30 EA per 30 days) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** FARYDAK 4 PA; QL (6 EA per 2 days) ZOLINZA 4 PA; SP; QL (20 EA per 30 days) *ANTINEOPLASTIC - IMMUNOMODULATORS*** POMALYST 4 PA; SP; QL (2 EA per 28 days) *ANTINEOPLASTIC - MEK INHIBITORS*** MEKINIST ORAL TABLET 0.5 MG 4 PA; SP; QL (90 EA per 30 days) MEKINIST ORAL TABLET 2 MG 4 PA; SP; QL (30 EA per 30 days) *ANTINEOPLASTIC - MONOCLONAL ANTIBODIES*** ARZERRA BAVENCIO PA *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** AFINITOR 4 PA; SP AFINITOR DISPERZ 4 PA; SP *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** NEXAVAR 4 PA; SP; QL (20 EA per 30 days) RYDAPT 4 ME PA; QL for AML = 20/30 QL for ASM, SM-AHN,and MCL= 240/30.; QL (20 EA per 30 days) STIVARGA 4 PA; SP; QL (20 EA per 30 days) SUTENT 4 PA; SP *ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS*** ALECENSA 4 PA; QL (240 EA per 30 days) ALUNBRIG 4 PA; QL (80 EA per 30 days) BOSULIF ORAL TABLET 00 MG, 500 MG 4 PA; SP; QL (20 EA per 30 days) CALQUENCE 4 PA; QL (60 EA per 30 days) MPC /0/208

29 CAPRELSA ORAL TABLET 00 MG 4 PA; SP; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 300 MG 4 PA; SP; QL (30 EA per 30 days) COMETRIQ (00 MG DAILY DOSE) 4 PA COMETRIQ (40 MG DAILY DOSE) 4 PA COMETRIQ (60 MG DAILY DOSE) 4 PA GILOTRIF 4 PA; QL (30 EA per 30 days) ICLUSIG ORAL TABLET 5 MG 4 PA; QL (60 EA per 30 days) ICLUSIG ORAL TABLET 45 MG 4 PA; QL (30 EA per 30 days) imatinib mesylate 4 PA; SP IMBRUVICA 4 PA; The quantity is limited to 90 capsules per 30 days for CLL and WM and 20 capsules per 30 days for MCL and MZL.; QL (20 EA per 30 days) INLYTA 4 PA; SP; QL (20 EA per 30 days) IRESSA 4 PA; SP; QL (30 EA per 30 days) LENVIMA 0 MG DAILY DOSE 4 PA; QL (30 EA per 30 days) LENVIMA 4 MG DAILY DOSE 4 PA; QL (60 EA per 30 days) LENVIMA 20 MG DAILY DOSE 4 PA; QL (60 EA per 30 days) LENVIMA 24 MG DAILY DOSE 4 PA; QL (90 EA per 30 days) SPRYCEL 4 PA; SP; QL (30 EA per 30 days) TARCEVA 4 PA; SP; QL (60 EA per 30 days) TASIGNA 4 PA; SP; QL (20 EA per 30 days) TYKERB 4 PA; SP; QL (80 EA per 30 days) VOTRIENT 4 PA; SP; QL (20 EA per 30 days) XALKORI 4 PA; SP; QL (60 EA per 30 days) ZYKADIA 4 PA; SP; QL (50 EA per 30 days) *ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES*** ADCETRIS PA BESPONSA PA *ANTINEOPLASTIC COMBINATIONS*** KISQALI FEMARA 200 DOSE TABLET THERAPY PACK 200 & 2.5 MG ORAL KISQALI FEMARA 400 DOSE TABLET THERAPY PACK 200 & 2.5 MG ORAL KISQALI FEMARA 600 DOSE TABLET THERAPY PACK 200 & 2.5 MG ORAL 4 PA; QL (49 EA per 28 days) 4 PA; QL (70 EA per 28 days) 4 PA; QL (9 EA per 28 days) LONSURF ORAL TABLET MG 4 PA; QL (40 EA per 28 days) LONSURF ORAL TABLET MG 4 PA; SP; QL (40 EA per 28 days) VYXEOS *ANTINEOPLASTICS MISC.*** PA; Up to 2 cycles of induction (5 doses total) and 2 cycles of consolidation (4 doses total) will be authorized.; QL (2 cycles per Induction) MPC /0/208

30 hydroxyurea oral INTRON A INJECTION SOLUTION 4 SP INTRON-A SUBCUTANEOUS KIT UNIT/0.2ML 4 SP MATULANE 4 PA; SP SYLATRON SUBCUTANEOUS KIT 4 X 200 MCG, 4 X 300 MCG, 600 MCG *AROMATASE INHIBITORS*** anastrozole oral exemestane 3 letrozole oral *ESTROGENS-ANTINEOPLASTIC*** 4 PA; SP EMCYT 4 PA; SP *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** leucovorin calcium injection solution reconstituted 350 mg LEUCOVORIN CALCIUM ORAL TABLET 0 MG, 5 MG leucovorin calcium oral tablet 25 mg, 5 mg *IMIDAZOTETRAZINES*** 3 PA temozolomide 4 PA; SP *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** JAKAFI 4 PA; SP; QL (60 EA per 30 days) *LHRH ANALOGS*** leuprolide acetate injection LUPRON DEPOT (-MONTH) LUPRON DEPOT (4-MONTH) *MITOTIC INHIBITORS*** 2 etoposide oral 3 SP *NITROGEN MUSTARDS*** cyclophosphamide oral capsule 3 LEUKERAN 4 PA; SP melphalan *NITROSOUREAS*** lomustine 3 PA *PROGESTINS-ANTINEOPLASTIC*** depo-provera intramuscular suspension 400 mg/ml SP; PA required if billed with Dx codes F64. - F64.9. PA required if billed with Dx codes F64. - F64.9. PA required if billed with Dx codes F64. - F64.9. $0 Copay per PPACA guidelines; AG MPC /0/208

31 megestrol acetate oral suspension 40 mg/ml, 400 mg/0ml megestrol acetate oral tablet *SELECTIVE RETINOID X RECEPTOR AGONISTS*** bexarotene 4 PA; SP *TOPOISOMERASE I INHIBITORS*** HYCAMTIN ORAL 4 PA; SP *URINARY TRACT PROTECTIVE AGENTS*** MESNEX ORAL 2 *ANTI-OBESITY AGENT COMBINATIONS** *ANTI-OBESITY AGENT COMBINATIONS** CONTRAVE 3 PA; QL (20 EA per 30 days) *ANTIPARKINSON AGENTS* *ANTIPARKINSON ANTICHOLINERGICS*** benztropine mesylate injection benztropine mesylate oral trihexyphenidyl hcl *ANTIPARKINSON DOPAMINERGICS*** amantadine hcl oral bromocriptine mesylate oral *ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS*** rasagiline mesylate oral 3 ST selegiline hcl oral *CENTRAL/PERIPHERAL COMT INHIBITORS*** tolcapone 3 *LEVODOPA COMBINATIONS*** carbidopa-levodopa carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa-entacapone 3 *NONERGOLINE DOPAMINE RECEPTOR AGONISTS*** APOKYN SUBCUTANEOUS SOLUTION 4 PA; SP pramipexole dihydrochloride ropinirole hcl MPC /0/208

32 *PERIPHERAL COMT INHIBITORS*** entacapone *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIMANIC AGENTS*** LITHIUM 2 lithium carbonate er lithium carbonate oral *ANTIPSYCHOTICS - MISC.*** LATUDA 4 PA; QL (30 EA per 30 days) ziprasidone hcl QL (60 EA per 30 days) *BENZISOXAZOLES*** FANAPT 4 ST; QL (60 EA per 30 days) FANAPT TITRATION PACK 4 ST; QL ( EA Max Qty Per Fill Retail) INVEGA 4 PA; QL (30 EA per 30 days) INVEGA SUSTENNA 4 SP INVEGA TRINZA 4 PA; SP paliperidone er 4 PA; QL (30 EA per 30 days) RISPERDAL CONSTA 4 SP risperidone oral solution risperidone oral tablet risperidone oral tablet dispersible 0.5 mg, mg, 2 mg, 3 mg, 4 mg *BUTYROPHENONES*** haloperidol decanoate intramuscular haloperidol lactate haloperidol oral *DIBENZODIAZEPINES*** clozapine oral tablet *DIBENZO-OXEPINO PYRROLES*** 3 PA SAPHRIS 4 PA; QL (60 EA per 30 days) *DIBENZOTHIAZEPINES*** quetiapine fumarate oral tablet 00 mg, 200 mg, 300 mg, 400 mg quetiapine fumarate oral tablet 25 mg, 50 mg *DIBENZOXAZEPINES*** loxapine succinate oral *PHENOTHIAZINES*** chlorpromazine hcl oral COMPRO QL (90 EA per 30 days) QL (90 EA per 30 days); AG (Max 2 Years) MPC /0/208

33 fluphenazine decanoate injection FLUPHENAZINE HCL ORAL CONCENTRATE 2 FLUPHENAZINE HCL ORAL ELIXIR 2 fluphenazine hcl oral tablet perphenazine oral prochlorperazine prochlorperazine edisylate injection prochlorperazine maleate oral thioridazine hcl oral trifluoperazine hcl oral *QUINOLINONE DERIVATIVES*** aripiprazole oral solution 4 PA aripiprazole oral tablet 4 PA; QL (30 EA per 30 days) aripiprazole oral tablet dispersible 4 PA ARISTADA 4 SP REXULTI 4 PA; QL (30 EA per 30 days) *THIENBENZODIAZEPINES*** olanzapine oral *THIOXANTHENES*** thiothixene oral *ANTIRETROVIRALS ADJUVANTS*** *ANTIRETROVIRALS ADJUVANTS*** Prior Authorization required for patients under 6 years of age; QL (30 EA per 30 days); AG (Min 6 Years) TYBOST 2 QL (30 EA per 30 days) *ANTISEPTICS & DISINFECTANTS* *CHLORINE ANTISEPTICS*** chlorhexidine gluconate solution 20 % *ANTIVIRALS* *ANTIRETROVIRAL COMBINATIONS*** abacavir sulfate-lamivudine QL (30 EA per 30 days) abacavir-lamivudine-zidovudine QL (60 EA per 30 days) ATRIPLA 2 QL (30 EA per 30 days) COMPLERA 4 DESCOVY 4 QL (30 EA per 30 days) EVOTAZ 4 QL (30 EA per 30 days) GENVOYA 4 QL (30 EA per 30 days) JULUCA 4 QL (30 EA per 30 days) KALETRA ORAL TABLET 2 QL (20 EA per 30 days) lamivudine-zidovudine QL (60 EA per 30 days) MPC /0/208

34 lopinavir-ritonavir QL (300 ML per 30 days) ODEFSEY 4 QL (30 EA per 30 days) PREZCOBIX 4 QL (30 EA per 30 days) STRIBILD 4 QL (30 EA per 30 days) TRIUMEQ 4 QL (30 EA per 30 days) TRUVADA 2 QL (30 EA per 30 days) *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** SELZENTRY ORAL TABLET 50 MG, 300 MG 2 QL (20 EA per 30 days) *ANTIRETROVIRALS - FUSION INHIBITORS*** FUZEON SUBCUTANEOUS KIT 4 QL (60 EA per 30 days) FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** isentress hd 2 QL (60 EA per 30 days) ISENTRESS ORAL PACKET 2 QL (60 EA per 30 days) ISENTRESS ORAL TABLET 2 QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 2 QL (20 EA per 30 days) TIVICAY ORAL TABLET 0 MG 3 QL (30 EA per 30 days) TIVICAY ORAL TABLET 25 MG, 50 MG 4 QL (30 EA per 30 days) VITEKTA 4 QL (30 EA per 30 days) *ANTIRETROVIRALS - PROTEASE INHIBITORS*** APTIVUS ORAL CAPSULE 2 QL (20 EA per 30 days) APTIVUS ORAL SOLUTION 2 atazanavir sulfate QL (60 EA per 30 days) CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL (80 EA per 30 days) fosamprenavir calcium QL (20 EA per 30 days) INVIRASE 2 QL (20 EA per 30 days) LEXIVA ORAL SUSPENSION 2 NORVIR ORAL CAPSULE 2 QL (360 EA per 30 days) NORVIR ORAL SOLUTION 2 QL (450 ML per 30 days) NORVIR ORAL TABLET 2 QL (360 EA per 30 days) PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG 2 QL (60 EA per 30 days) PREZISTA ORAL TABLET 800 MG 2 QL (30 EA per 30 days) REYATAZ ORAL PACKET 2 4 QL (50 EA per 30 days); AG (Max 8 Years) VIRACEPT ORAL TABLET 2 QL (20 EA per 30 days) *ANTIRETROVIRALS - RTI-NON- NUCLEOSIDE ANALOGUES*** EDURANT 4 MPC /0/208

35 efavirenz QL (30 EA per 30 days) INTELENCE 2 QL (60 EA per 30 days) nevirapine er oral tablet extended release 24 hour 400 mg QL (30 EA per 30 days) nevirapine oral suspension QL (200 ML per 30 days) nevirapine oral tablet QL (30 EA per 30 days) RESCRIPTOR 2 QL (80 EA per 30 days) SUSTIVA ORAL TABLET 2 QL (30 EA per 30 days) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES*** abacavir sulfate oral solution QL (900 ML per 30 days) abacavir sulfate oral tablet QL (60 EA per 30 days) didanosine QL (30 EA per 30 days) VIDEX 2 QL (200 ML per 30 days) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES*** EMTRIVA ORAL CAPSULE 2 QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 2 lamivudine oral solution QL (900 ML per 30 days) lamivudine oral tablet 50 mg lamivudine oral tablet 300 mg QL (30 EA per 30 days) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES*** stavudine oral capsule QL (60 EA per 30 days) stavudine oral solution reconstituted QL (2400 ML per 30 days) zidovudine oral capsule QL (60 EA per 30 days) zidovudine oral syrup QL (800 ML per 30 days) zidovudine oral tablet QL (60 EA per 30 days) *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** tenofovir disoproxil fumarate 4 QL (30 EA per 30 days) VIREAD ORAL POWDER 4 VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG 4 *CMV AGENTS*** foscarnet sodium intravenous solution 24 mg/ml 3 valganciclovir hcl oral solution reconstituted 4 PA; QL (900 ML per 30 days) valganciclovir hcl oral tablet 4 PA; QL (60 EA per 30 days) *HEPATITIS B AGENTS*** entecavir 4 EPIVIR HBV ORAL SOLUTION 2 QL (900 ML per 30 days) lamivudine oral tablet 00 mg QL (30 EA per 30 days) VEMLIDY 4 QL (30 EA per 30 days) MPC /0/208

36 *HEPATITIS C AGENTS*** PEGASYS SUBCUTANEOUS KIT 4 PA; SP PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML 4 PA; SP ribavirin oral capsule 4 PA; SP ribavirin oral tablet 200 mg 4 PA; SP *HERPES AGENTS - PURINE ANALOGUES*** acyclovir oral valacyclovir hcl oral *HERPES AGENTS - THYMIDINE ANALOGUES*** famciclovir oral *INFLUENZA AGENTS*** rimantadine hcl *NEURAMINIDASE INHIBITORS*** oseltamivir phosphate oral capsule 30 mg 3 QL (20 EA per 80 days) oseltamivir phosphate oral capsule 45 mg, 75 mg 3 QL (0 EA per 80 days) oseltamivir phosphate oral suspension reconstituted 3 QL (80 ML per 80 days) RELENZA DISKHALER 3 QL (20 EA per 26 days) *ASSORTED CLASSES* *ANTILEPROTICS*** THALOMID 4 PA *B-LYMPHOCYTE STIMULATOR (BLYS)- SPECIFIC INHIBITORS*** BENLYSTA SUBCUTANEOUS 4 PA; SP; QL (4 ML per 28 days) *CHELATING AGENTS*** CUPRIMINE ORAL CAPSULE 250 MG 2 DEPEN TITRATABS 2 *CYCLOSPORINE ANALOGS*** cyclosporine modified cyclosporine oral capsule GENGRAF ORAL SOLUTION 2 SANDIMMUNE ORAL SOLUTION 2 *IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES*** REVLIMID ORAL CAPSULE 0 MG, 5 MG, 25 MG, 5 MG 4 PA; SP REVLIMID ORAL CAPSULE 2.5 MG, 20 MG 4 PA *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** MPC /0/208

37 mycophenolate mofetil *MACROLIDE IMMUNOSUPPRESSANTS*** HECORIA RAPAMUNE ORAL SOLUTION 3 sirolimus oral 3 tacrolimus oral ZORTRESS 4 PA *POTASSIUM REMOVING RESINS*** KIONEX sodium polystyrene sulfonate oral powder *PURINE ANALOGS*** azathioprine oral *BETA BLOCKERS* *ALPHA-BETA BLOCKERS*** carvedilol labetalol hcl intravenous solution labetalol hcl oral *BETA BLOCKERS CARDIO- SELECTIVE*** acebutolol hcl oral atenolol oral betaxolol hcl oral bisoprolol fumarate BYSTOLIC 3 metoprolol succinate er metoprolol tartrate oral tablet 00 mg, 25 mg, 50 mg *BETA BLOCKERS NON-SELECTIVE*** LEVATOL 3 nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol propranolol hcl er PROPRANOLOL HCL ORAL SOLUTION 2 propranolol hcl oral tablet sotalol hcl (af) sotalol hcl oral TIMOLOL MALEATE ORAL 2 *CALCIUM CHANNEL BLOCKERS* MPC /0/208

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