CoverKids. Preferred Formulary

Transcription

1 CoverKids SM Preferred Formulary

2 2017 CoverKids Formulary Table of Contents Abbreviations and Key to Drug Tiers...2 Drug Classes: Anti - Infectives... 5 Antineoplastic & Immunosuppressant Drugs...16 Autonomic & Cns Drugs, Neurology & Psych...20 Cardiovascular, Hypertension & Lipids...45 Dermatologicals/Topical Therapy...58 Diagnostics & Miscellaneous Agents...72 Ear, Nose & Throat Medications...74 Endocrine/Diabetes Gastroenterology Immunology, Vaccines & Biotechnology Musculoskeletal & Rheumatology Obstetrics & Gynecology Ophthalmology Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes Index of Drugs

3 Requirements/Limits Age-A = Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at to request a coverage review. LD= Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. PA= Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at to request a coverage review for a drug that requires prior authorization. QL= Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. SPRx = Specialty Medication. Includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. ST= Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at to request a coverage review. Please refer to the Step Therapy list included within this guidebook on page 3 for medications that require step therapy and the agents that are required to be taken first. lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs 2

4 Step Therapy Medication(s) Requiring Step Therapy Step Therapy Requirements Edarbi Edarbyclor Trial and failure of generic ARB Betaseron Trial and failure of Avonex, Copaxone, Extavia, or Rebif Non-preferred diabetic test strips (e.g., Accu- Chek, Freestyle) QL Trial and failure of preferred products made by Lifescan (OneTouch) or Ascencia (Contour or Breeze2) QL Rescula Xalatan Zioptan Apidra Apidra Solostar Humalog Trial and failure of latanoprost, Lumigan, or Travatan Z Trial and failure of Novolog Humulin Trial and failure of Novolin Proventil HFA QL Ventolin HFA QL Xopenex HFA QL Trial and failure of ProAir HFA QL or ProAir Respiclick QL Osphena Premarin Cream Vagifem Trial and failure of Estrace 0.01% cream 3

5 Drug Tiers = Generic Drugs = Preferred Brand Drugs = Non-Preferred Brand Drugs Pharmacy Appeals: To appeal a denial based on the prior authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN Fax: Please provide the following information with your written request: 1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information This list is subject to change. Please call Member Service at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up to date information. 4

6 Drug Name Drug Tier Requirements/Limits Anti - Infectives Antifungal Agents ANCOBON ORAL CAPSULE clotrimazole mucous membrane troche CRESEMBA ORAL CAPSULE DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION DIFLUCAN ORAL TABLET fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET itraconazole oral capsule ketoconazole oral tablet NOXAFIL ORAL SUSPENSION NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder nystatin oral suspension nystatin oral tablet ONMEL ORAL TABLET ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET SPORANOX ORAL SOLUTION SPORANOX PULSEPAK ORAL CAPSULE terbinafine hcl oral tablet VFEND ORAL SUSPENSION FOR RECONSTITUTION VFEND ORAL TABLET voriconazole oral suspension for reconstitution 5

7 Drug Name Drug Tier Requirements/Limits voriconazole oral tablet Antivirals abacavir oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir oral tablet amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA ORAL TABLET SPRx BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET COMBIVIR ORAL TABLET COMPLERA ORAL TABLET SPRx CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 6 DESCOVY ORAL TABLET SPRx didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet EPCLUSA ORAL TABLET PA; SPRx EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPIVIR ORAL SOLUTION EPIVIR ORAL TABLET EPZICOM ORAL TABLET EVOTAZ ORAL TABLET SPRx

8 Drug Name Drug Tier Requirements/Limits famciclovir oral tablet FAMVIR ORAL TABLET FLUMADINE ORAL TABLET FUZEON SUBCUTANEOUS RECON SOLN SPRx GENVOYA ORAL TABLET SPRx HARVONI ORAL TABLET PA; SPRx HEPSERA ORAL TABLET INTELENCE ORAL TABLET INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir oral solution nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET SPRx oseltamivir oral capsule 30 mg QL (20 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg QL (10 EA per 180 days) PREZCOBIX ORAL TABLET SPRx PREZISTA ORAL SUSPENSION 7

9 Drug Name PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR ORAL CAPSULE REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET rimantadine oral tablet SELZENTRY ORAL TABLET SOVALDI ORAL TABLET PA; SPRx stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET SPRx SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET 8 QL (20 EA per 180 days) TAMIFLU ORAL CAPSULE 30 MG QL (20 EA per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG QL (10 EA per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION Drug Tier TIVICAY ORAL TABLET SPRx TRIUMEQ ORAL TABLET SPRx TRIZIVIR ORAL TABLET TRUVADA ORAL TABLET TYBOST ORAL TABLET TYZEKA ORAL TABLET valacyclovir oral tablet VALCYTE ORAL RECON SOLN VALCYTE ORAL TABLET valganciclovir oral recon soln valganciclovir oral tablet VALTREX ORAL TABLET Requirements/Limits QL (180 ML per 180 days)

10 Drug Name VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIRAMUNE ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR VIRAZOLE INHALATION RECON SOLN VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ORAL TABLET SPRx ZERIT ORAL CAPSULE ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZOVIRAX ORAL TABLET Cephalosporins CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTION 9 cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml Drug Tier cefadroxil oral tablet Requirements/Limits

11 Drug Name Drug Tier Requirements/Limits cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet cefixime oral suspension for reconstitution cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftibuten oral capsule ceftibuten oral suspension for reconstitution CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 10 CEFTIN ORAL TABLET 500 MG cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet SPECTRACEF ORAL TABLET 200 MG SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION SUPRAX ORAL TABLET,CHEWABLE Erythromycins & Other Macrolides azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML BIAXIN ORAL TABLET clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ORAL TABLET e.e.s. 400 oral tablet

12 Drug Name E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ORAL TABLET, PARTICLES/CRYSTALS ZITHROMAX ORAL PACKET ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION ZITHROMAX ORAL TABLET ZMAX ORAL SUSPENSION,EXTENDED REL RECON Miscellaneous Antiinfectives ALBENZA ORAL TABLET ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET atovaquone oral suspension atovaquone-proguanil oral tablet BILTRICIDE ORAL TABLET CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloroquine phosphate oral tablet CLEOCIN HCL ORAL CAPSULE CLEOCIN PEDIATRIC ORAL RECON SOLN Drug Tier Requirements/Limits PA; LD; SPRx 11

13 Drug Name Drug Tier Requirements/Limits clindamycin hcl oral capsule clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln COARTEM ORAL TABLET cycloserine oral capsule DARAPRIM ORAL TABLET PA; LD; SPRx ethambutol oral tablet FLAGYL ER ORAL TABLET EXTENDED RELEASE 12 FLAGYL ORAL CAPSULE FLAGYL ORAL TABLET hydroxychloroquine oral tablet isoniazid oral solution isoniazid oral tablet ivermectin oral tablet KETEK ORAL TABLET KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION LD; SPRx; QL (56 ML per 30 days) linezolid oral suspension for reconstitution QL (14 day supply per 30 days) linezolid oral tablet QL (14 day supply per 30 days) MALARONE ORAL TABLET MALARONE PEDIATRIC ORAL TABLET mefloquine oral tablet MEPRON ORAL SUSPENSION metronidazole oral capsule metronidazole oral tablet MYAMBUTOL ORAL TABLET 400 MG MYCOBUTIN ORAL CAPSULE NEBUPENT INHALATION RECON SOLN neomycin oral tablet paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PLAQUENIL ORAL TABLET

14 Drug Name PRIFTIN ORAL TABLET primaquine oral tablet pyrazinamide oral tablet QUALAQUIN ORAL CAPSULE quinine sulfate oral capsule rifabutin oral capsule RIFADIN ORAL CAPSULE RIFAMATE ORAL CAPSULE rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET LD; SPRx STROMECTOL ORAL TABLET TINDAMAX ORAL TABLET tinidazole oral tablet TOBI INHALATION SOLUTION FOR NEBULIZATION tobramycin in % nacl inhalation solution for nebulization 13 TRECATOR ORAL TABLET XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION SPRx; QL (56 ML per 30 days) SPRx; QL (56 ML per 30 days) QL (14 day supply per 30 days) ZYVOX ORAL TABLET QL (14 day supply per 30 days) Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr Drug Tier amoxicillin-pot clavulanate oral tablet,chewable Requirements/Limits

15 Drug Name Drug Tier Requirements/Limits ampicillin oral capsule ampicillin oral suspension for reconstitution AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML, MG/5 ML AUGMENTIN ORAL TABLET MG, MG AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet Quinolones AVELOX ABC PACK ORAL TABLET AVELOX ORAL TABLET CIPRO ORAL SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET 250 MG, 500 MG CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet ciprofloxacin oral suspension,microcapsule recon FACTIVE ORAL TABLET LEVAQUIN ORAL TABLET levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet ofloxacin oral tablet 300 mg, 400 mg Sulfa's & Related Agents BACTRIM DS ORAL TABLET BACTRIM ORAL TABLET 14

16 Drug Name Drug Tier Requirements/Limits sulfadiazine oral tablet sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfatrim oral suspension Tetracyclines ADOXA ORAL CAPSULE avidoxy oral tablet demeclocycline oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg 15 doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline oral capsule VIBRAMYCIN ORAL CAPSULE 100 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP Urinary Tract Agents FURADANTIN ORAL SUSPENSION HIPREX ORAL TABLET MACROBID ORAL CAPSULE MACRODANTIN ORAL CAPSULE methenamine hippurate oral tablet methenamine mandelate oral tablet MONUROL ORAL PACKET nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension

17 Drug Name PRIMSOL ORAL SOLUTION trimethoprim oral tablet Vancomycin VANCOCIN ORAL CAPSULE vancomycin oral capsule Antineoplastic & Immunosuppressant Drugs Adjunctive Agents 16 Drug Tier leucovorin calcium oral tablet MESNEX ORAL TABLET Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION Requirements/Limits PA; SPRx AFINITOR ORAL TABLET PA; SPRx ALECENSA ORAL CAPSULE PA; LD; SPRx ALKERAN ORAL TABLET anastrozole oral tablet ARIMIDEX ORAL TABLET AROMASIN ORAL TABLET ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR AZASAN ORAL TABLET azathioprine oral tablet SPRx bexarotene oral capsule SPRx bicalutamide oral tablet BOSULIF ORAL TABLET PA; LD; SPRx CABOMETYX ORAL TABLET PA; LD; SPRx capecitabine oral tablet SPRx CAPRELSA ORAL TABLET PA; LD; SPRx CASODEX ORAL TABLET CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION COMETRIQ ORAL CAPSULE LD; SPRx COTELLIC ORAL TABLET PA; LD; SPRx

18 Drug Name CYCLOPHOSPHAMIDE ORAL CAPSULE Drug Tier Requirements/Limits cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule DROXIA ORAL CAPSULE EMCYT ORAL CAPSULE ERIVEDGE ORAL CAPSULE PA; LD; SPRx etoposide oral capsule exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE PA; LD; SPRx FEMARA ORAL TABLET flutamide oral capsule gengraf oral capsule gengraf oral solution GILOTRIF ORAL TABLET PA; LD; SPRx GLEEVEC ORAL TABLET SPRx GLEOSTINE ORAL CAPSULE HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE SPRx HYDREA ORAL CAPSULE hydroxyurea oral capsule IBRANCE ORAL CAPSULE PA; LD; SPRx ICLUSIG ORAL TABLET PA; LD; SPRx imatinib oral tablet SPRx IMBRUVICA ORAL CAPSULE PA; LD; SPRx IMURAN ORAL TABLET INLYTA ORAL TABLET PA; LD; SPRx IRESSA ORAL TABLET PA; LD; SPRx JAKAFI ORAL TABLET PA; LD; SPRx LENVIMA ORAL CAPSULE PA; LD; SPRx letrozole oral tablet LEUKERAN ORAL TABLET 17

19 Drug Name Drug Tier Requirements/Limits leuprolide subcutaneous kit PA; SPRx LONSURF ORAL TABLET PA; LD; SPRx LYNPARZA ORAL CAPSULE PA; LD; SPRx LYSODREN ORAL TABLET MATULANE ORAL CAPSULE SPRx MEGACE ES ORAL SUSPENSION MEGACE ORAL SUSPENSION megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 18 megestrol oral tablet MEKINIST ORAL TABLET PA; SPRx melphalan oral tablet mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection solution methotrexate sodium oral tablet mitoxantrone intravenous concentrate SPRx mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) MYLERAN ORAL TABLET NEORAL ORAL CAPSULE NEORAL ORAL SOLUTION NEXAVAR ORAL TABLET PA; LD; SPRx nilandron oral tablet nilutamide oral tablet NINLARO ORAL CAPSULE PA; LD; SPRx octreotide acetate injection solution SPRx

20 Drug Name Drug Tier Requirements/Limits octreotide acetate injection syringe SPRx ODOMZO ORAL CAPSULE PA; SPRx PROGRAF ORAL CAPSULE PURIXAN ORAL SUSPENSION SPRx RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET RHEUMATREX ORAL TABLETS,DOSE PACK SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION SPRx SIGNIFOR SUBCUTANEOUS SOLUTION PA; LD; SPRx sirolimus oral tablet SOLTAMOX ORAL SOLUTION SPRYCEL ORAL TABLET SPRx STIVARGA ORAL TABLET PA; LD; SPRx SUTENT ORAL CAPSULE PA; LD; SPRx TABLOID ORAL TABLET tacrolimus oral capsule TAFINLAR ORAL CAPSULE PA; LD; SPRx TAGRISSO ORAL TABLET PA; LD; SPRx tamoxifen oral tablet TARCEVA ORAL TABLET PA; LD; SPRx TARGRETIN ORAL CAPSULE SPRx TARGRETIN TOPICAL GEL PA; SPRx TASIGNA ORAL CAPSULE SPRx TEMODAR ORAL CAPSULE PA; SPRx temozolomide oral capsule PA; SPRx THALOMID ORAL CAPSULE PA; LD; SPRx tretinoin (chemotherapy) oral capsule TREXALL ORAL TABLET TYKERB ORAL TABLET PA; LD; SPRx VENCLEXTA ORAL TABLET PA; LD; SPRx 19

21 Drug Name Drug Tier Requirements/Limits VENCLEXTA STARTING PACK ORAL PA; LD; SPRx TABLETS,DOSE PACK VOTRIENT ORAL TABLET PA; LD; SPRx XALKORI ORAL CAPSULE PA; LD; SPRx XELODA ORAL TABLET SPRx XTANDI ORAL CAPSULE PA; LD; SPRx ZEJULA ORAL CAPSULE PA; LD; SPRx ZELBORAF ORAL TABLET PA; LD; SPRx ZOLINZA ORAL CAPSULE SPRx ZORTRESS ORAL TABLET ZYDELIG ORAL TABLET PA; SPRx ZYKADIA ORAL CAPSULE PA; SPRx ZYTIGA ORAL TABLET 250 MG SPRx Autonomic & Cns Drugs, Neurology & Psych Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM QL (90 EA per 30 days) buprenorphine-naloxone sublingual tablet QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET QL (90 EA per 30 days) Anticonvulsants APTIOM ORAL TABLET BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet clonazepam oral tablet,disintegrating 20

22 Drug Name DEPAKENE ORAL CAPSULE DEPAKENE ORAL SOLUTION DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT diazepam rectal kit DILANTIN EXTENDED ORAL CAPSULE DILANTIN INFATABS ORAL TABLET,CHEWABLE 21 DILANTIN ORAL CAPSULE DILANTIN-125 ORAL SUSPENSION divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR Drug Tier ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet FELBATOL ORAL SUSPENSION FELBATOL ORAL TABLET FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg, 300 mg gabapentin oral capsule 400 mg QL (350 EA per 30 days) gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg QL (350 EA per 30 days) GABITRIL ORAL TABLET Requirements/Limits

23 Drug Name KEPPRA ORAL SOLUTION Drug Tier Requirements/Limits KEPPRA ORAL TABLET KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR KLONOPIN ORAL TABLET LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 25 MG, 50 MG LAMICTAL ODT ORAL QL (350 EA per 30 days) TABLET,DISINTEGRATING 200 MG LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ORAL TABLET 100 MG, 150 MG, 25 MG LAMICTAL ORAL TABLET 200 MG QL (350 EA per 30 days) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 25 MG, 250 MG, 300 MG, 50 MG LAMICTAL XR ORAL TABLET EXTENDED QL (350 EA per 30 days) RELEASE 24HR 200 MG LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 22

24 Drug Name LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 23 lamotrigine oral tablet 100 mg, 150 mg, 25 mg lamotrigine oral tablet 200 mg QL (350 EA per 30 days) lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr 100 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet extended release 24hr 200 mg lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating 100 mg, 25 mg, 50 mg QL (350 EA per 30 days) lamotrigine oral tablet,disintegrating 200 mg QL (350 EA per 30 days) levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION MYSOLINE ORAL TABLET NEURONTIN ORAL CAPSULE 100 MG, 300 MG NEURONTIN ORAL CAPSULE 400 MG QL (350 EA per 30 days) NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET 600 MG NEURONTIN ORAL TABLET 800 MG QL (350 EA per 30 days) ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR Drug Tier PEGANONE ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet Requirements/Limits

25 Drug Name PHENYTEK ORAL CAPSULE phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule POTIGA ORAL TABLET primidone oral tablet QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 50 MG QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 200 MG, 25 MG 24 roweepra oral tablet SABRIL ORAL POWDER IN PACKET LD; SPRx SABRIL ORAL TABLET LD; SPRx SPRITAM ORAL TABLET FOR SUSPENSION TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR tiagabine oral tablet TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG TOPAMAX ORAL CAPSULE, SPRINKLE 25 MG TOPAMAX ORAL TABLET 100 MG, 50 MG QL (350 EA per 30 days) QL (350 EA per 30 days) TOPAMAX ORAL TABLET 200 MG, 25 MG QL (350 EA per 30 days) topiramate oral capsule, sprinkle 15 mg topiramate oral capsule, sprinkle 25 mg QL (350 EA per 30 days) TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 50 MG TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 200 MG, 25 MG Drug Tier topiramate oral tablet 100 mg, 200 mg, 50 mg Requirements/Limits QL (350 EA per 30 days)

26 Drug Name Drug Tier Requirements/Limits topiramate oral tablet 25 mg QL (350 EA per 30 days) TRILEPTAL ORAL SUSPENSION TRILEPTAL ORAL TABLET TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG, 25 MG valproic acid (as sodium salt) oral solution 250 mg/5 ml 25 valproic acid oral capsule VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZARONTIN ORAL CAPSULE ZARONTIN ORAL SOLUTION ZONEGRAN ORAL CAPSULE 100 MG, 25 MG zonisamide oral capsule Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE SPRx AZILECT ORAL TABLET benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet COMTAN ORAL TABLET DUOPA J-TUBE INTESTINAL PUMP SUSPENSION ELDEPRYL ORAL CAPSULE entacapone oral tablet QL (350 EA per 30 days) PA; LD; SPRx

27 Drug Name LODOSYN ORAL TABLET MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR MIRAPEX ORAL TABLET NEUPRO TRANSDERMAL PATCH 24 HOUR PARLODEL ORAL CAPSULE PARLODEL ORAL TABLET pramipexole oral tablet pramipexole oral tablet extended release 24 hr rasagiline oral tablet REQUIP ORAL TABLET REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR 26 ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet SINEMET CR ORAL TABLET EXTENDED RELEASE SINEMET ORAL TABLET STALEVO 100 ORAL TABLET STALEVO 125 ORAL TABLET STALEVO 150 ORAL TABLET STALEVO 200 ORAL TABLET STALEVO 50 ORAL TABLET STALEVO 75 ORAL TABLET TASMAR ORAL TABLET 100 MG tolcapone oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet ZELAPAR ORAL TABLET,DISINTEGRATING Migraine & Cluster Headache Therapy Drug Tier Requirements/Limits almotriptan malate oral tablet QL (18 EA per 30 days)

28 Drug Name ALSUMA SUBCUTANEOUS PEN INJECTOR QL (8 ML per 30 days) AMERGE ORAL TABLET QL (18 EA per 30 days) CAFERGOT ORAL TABLET D.H.E.45 INJECTION SOLUTION dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL (8 ML per 30 days) ERGOMAR SUBLINGUAL TABLET frovatriptan oral tablet QL (18 EA per 30 days) IMITREX NASAL SPRAY,NON-AEROSOL QL (12 EA per 30 days) IMITREX ORAL TABLET QL (18 EA per 30 days) IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML 27 QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) IMITREX SUBCUTANEOUS SOLUTION QL (8 ML per 30 days) isometh-dichloral-acetaminophn oral capsule isomethepten-caf-acetaminophen oral tablet mg migergot rectal suppository MIGRANAL NASAL SPRAY,NON AEROSOL Drug Tier QL (8 ML per 30 days) naratriptan oral tablet QL (18 EA per 30 days) nodolor oral capsule Requirements/Limits RELPAX ORAL TABLET QL (18 EA per 30 days) rizatriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol QL (12 EA per 30 days) sumatriptan succinate oral tablet QL (18 EA per 30 days)

29 Drug Name Drug Tier Requirements/Limits sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution QL (8 ML per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) zolmitriptan oral tablet QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating QL (18 EA per 30 days) Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR ARICEPT ORAL TABLET donepezil oral tablet donepezil oral tablet,disintegrating EXELON ORAL CAPSULE galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet HORIZANT ORAL TABLET EXTENDED RELEASE PA; SPRx KEVEYIS ORAL TABLET PA; LD; SPRx memantine oral solution memantine oral tablet memantine oral tablets,dose pack NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 28

30 Drug Name NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR NUEDEXTA ORAL CAPSULE RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR RAZADYNE ORAL TABLET rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hour tetrabenazine oral tablet PA; SPRx XENAZINE ORAL TABLET SPRx Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet QL (350 EA per 30 days) carisoprodol oral tablet carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet cyclobenzaprine oral tablet 10 mg QL (350 EA per 30 days) cyclobenzaprine oral tablet 5 mg, 7.5 mg DANTRIUM ORAL CAPSULE 25 MG, 50 MG dantrolene oral capsule FEXMID ORAL TABLET meprobamate oral tablet MESTINON ORAL SYRUP MESTINON ORAL TABLET MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 29 Drug Tier metaxalone oral tablet 800 mg Requirements/Limits

31 Drug Name Drug Tier Requirements/Limits methocarbamol oral tablet orphenadrine citrate oral tablet extended release PARAFON FORTE DSC ORAL TABLET pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release 30 ROBAXIN ORAL TABLET ROBAXIN-750 ORAL TABLET SKELAXIN ORAL TABLET SOMA ORAL TABLET tizanidine oral capsule 2 mg, 6 mg tizanidine oral capsule 4 mg QL (350 EA per 30 days) tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg QL (350 EA per 30 days) ZANAFLEX ORAL CAPSULE ZANAFLEX ORAL TABLET Narcotic Analgesics ABSTRAL SUBLINGUAL TABLET QL (9 EA per 30 days) acetaminophen-caff-dihydrocod oral capsule QL (120 EA per 30 days) acetaminophen-caff-dihydrocod oral tablet mg acetaminophen-codeine oral solution mg/5 ml QL (4500 ML per 30 days) acetaminophen-codeine oral tablet QL (180 EA per 30 days) ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 1,600 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 200 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 400 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 600 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 800 MCG QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) QL (116 EA per 30 days) QL (77 EA per 30 days) QL (58 EA per 30 days)

32 Drug Name Drug Tier Requirements/Limits ascomp with codeine oral capsule QL (120 EA per 30 days) aspirin-caffeine-dihydrocodein oral capsule QL (240 EA per 30 days) BUPAP ORAL TABLET MG QL (120 EA per 30 days) butalbital compound w/codeine oral capsule QL (120 EA per 30 days) butalbital-acetaminop-caf-cod oral capsule QL (120 EA per 30 days) butalbital-acetaminophen oral tablet QL (120 EA per 30 days) butalbital-acetaminophen-caff oral capsule QL (120 EA per 30 days) butalbital-acetaminophen-caff oral tablet mg QL (120 EA per 30 days) butalbital-aspirin-caffeine oral capsule QL (120 EA per 30 days) butorphanol tartrate nasal spray,non-aerosol QL (5 ML per 28 days) BUTRANS TRANSDERMAL PATCH WEEKLY PA; QL (4 EA per 28 days) capacet oral capsule QL (120 EA per 30 days) CAPITAL WITH CODEINE ORAL SUSPENSION codeine sulfate oral tablet QL (180 EA per 30 days) codeine-butalbital-asa-caff oral capsule QL (120 EA per 30 days) DEMEROL ORAL TABLET QL (120 EA per 30 days) DILAUDID ORAL LIQUID QL (30 ML per 30 days) DILAUDID ORAL TABLET QL (120 EA per 30 days) diskets oral tablet,soluble PA; QL (50 EA per 30 days) DOLOPHINE ORAL TABLET PA; QL (120 EA per 30 days) DURAGESIC TRANSDERMAL PATCH 72 HOUR endocet oral tablet mg, mg, mg, mg PA; QL (10 EA per 30 days) QL (120 EA per 30 days) ESGIC ORAL CAPSULE QL (120 EA per 30 days) ESGIC ORAL TABLET QL (120 EA per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) 31

33 Drug Name Drug Tier Requirements/Limits fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 32 QL (116 EA per 30 days) QL (77 EA per 30 days) QL (58 EA per 30 days) PA; QL (10 EA per 30 days) QL (9 EA per 30 days) FIORICET ORAL CAPSULE QL (120 EA per 30 days) FIORICET WITH CODEINE ORAL CAPSULE MG QL (120 EA per 30 days) FIORINAL ORAL CAPSULE QL (120 EA per 30 days) FIORINAL-CODEINE #3 ORAL CAPSULE QL (120 EA per 30 days) HYCET ORAL SOLUTION QL (5550 ML per 30 days) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (5550 ML per 30 days) QL (120 EA per 30 days) QL (120 EA per 30 days) hydromorphone oral liquid QL (30 ML per 30 days) hydromorphone oral tablet QL (120 EA per 30 days) hydromorphone rectal suppository QL (60 EA per 30 days) IBUDONE ORAL TABLET QL (120 EA per 30 days) ibuprofen-oxycodone oral tablet QL (28 EA per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG PA; QL (60 EA per 30 days) levorphanol tartrate oral tablet QL (120 EA per 30 days) lorcet (hydrocodone) oral tablet QL (120 EA per 30 days) lorcet hd oral tablet QL (120 EA per 30 days) lorcet plus oral tablet mg QL (120 EA per 30 days) lortab oral tablet QL (120 EA per 30 days)

34 Drug Name Drug Tier Requirements/Limits lortab oral tablet QL (120 EA per 30 days) lortab oral tablet QL (120 EA per 30 days) LORTAB ELIXIR ORAL SOLUTION MG/15 ML 33 QL (480 ML per 30 days) margesic oral capsule QL (120 EA per 30 days) marten-tab oral tablet QL (120 EA per 30 days) meperidine oral solution QL (480 ML per 30 days) meperidine oral tablet QL (120 EA per 30 days) methadone oral concentrate PA; QL (120 ML per 30 days) methadone oral solution 10 mg/5 ml PA; QL (480 ML per 30 days) methadone oral solution 5 mg/5 ml PA; QL (960 ML per 30 days) methadone oral tablet PA; QL (120 EA per 30 days) methadone oral tablet,soluble PA; QL (50 EA per 30 days) methadose oral concentrate PA; QL (120 ML per 30 days) methadose oral tablet,soluble PA; QL (50 EA per 30 days) morphine concentrate oral solution QL (300 ML per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg PA; QL (50 EA per 30 days) PA; QL (60 EA per 30 days) morphine oral capsule,extend.release pellets PA; QL (60 EA per 30 days) morphine oral solution QL (900 ML per 30 days) morphine oral tablet QL (120 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg PA; QL (60 EA per 30 days) morphine oral tablet extended release 200 mg PA; QL (30 EA per 30 days) morphine rectal suppository QL (120 EA per 30 days) MS CONTIN ORAL TABLET EXTENDED RELEASE PA; QL (60 EA per 30 days) NORCO ORAL TABLET QL (120 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR PA; QL (60 EA per 30 days) NUCYNTA ORAL TABLET QL (120 EA per 30 days) OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR PA; QL (60 EA per 30 days)

35 Drug Name OPANA ORAL TABLET QL (120 EA per 30 days) oxycodone oral capsule QL (120 EA per 30 days) oxycodone oral concentrate QL (120 ML per 30 days) oxycodone oral solution QL (480 ML per 30 days) oxycodone oral tablet QL (120 EA per 30 days) oxycodone-acetaminophen oral solution QL (480 ML per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg 34 QL (120 EA per 30 days) oxycodone-aspirin oral tablet QL (120 EA per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG PA; QL (60 EA per 30 days) PA; QL (50 EA per 30 days) oxymorphone oral tablet QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr PA; QL (60 EA per 30 days) pentazocine-naloxone oral tablet QL (120 EA per 30 days) PERCOCET ORAL TABLET MG, MG, MG, MG QL (120 EA per 30 days) PRIMLEV ORAL TABLET QL (120 EA per 30 days) reprexain oral tablet QL (120 EA per 30 days) ROXICODONE ORAL TABLET QL (120 EA per 30 days) SYNALGOS-DC ORAL CAPSULE QL (240 EA per 30 days) tencon oral tablet QL (120 EA per 30 days) tramadol oral tablet QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr PA; QL (30 EA per 30 days) tramadol oral tablet, er multiphase 24 hr PA; QL (30 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) TREZIX ORAL CAPSULE MG QL (120 EA per 30 days) TYLENOL-CODEINE #3 ORAL TABLET QL (180 EA per 30 days) TYLENOL-CODEINE #4 ORAL TABLET QL (180 EA per 30 days) ULTRACET ORAL TABLET QL (240 EA per 30 days) ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG Drug Tier Requirements/Limits PA; QL (30 EA per 30 days) ULTRAM ORAL TABLET QL (240 EA per 30 days)

36 Drug Name Drug Tier Requirements/Limits verdrocet oral tablet QL (120 EA per 30 days) vicodin es oral tablet QL (120 EA per 30 days) vicodin hp oral tablet QL (120 EA per 30 days) vicodin oral tablet QL (120 EA per 30 days) XODOL 10/300 ORAL TABLET QL (120 EA per 30 days) XODOL 5/300 ORAL TABLET QL (120 EA per 30 days) XODOL 7.5/300 ORAL TABLET QL (120 EA per 30 days) xylon 10 oral tablet QL (150 EA per 30 days) zamicet oral solution QL (480 ML per 30 days) zebutal oral capsule mg QL (120 EA per 30 days) Non-Narcotic Analgesics ANAPROX DS ORAL TABLET ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC 35 CELEBREX ORAL CAPSULE celecoxib oral capsule choline,magnesium salicylate oral liquid DAYPRO ORAL TABLET diclofenac potassium oral tablet QL (350 EA per 30 days) diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg diclofenac sodium oral tablet,delayed release (dr/ec) 75 mg QL (350 EA per 30 days) QL (350 EA per 30 days) diclofenac sodium topical gel 1 % QL (100 GM per 30 days) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic diflunisal oral tablet DISALCID ORAL TABLET dologesic (w-phenyltoloxamine) oral capsule EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC)

37 Drug Name Drug Tier Requirements/Limits etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr FELDENE ORAL CAPSULE fenoprofen oral tablet flurbiprofen oral tablet 100 mg QL (350 EA per 30 days) flurbiprofen oral tablet 50 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION INDOCIN RECTAL SUPPOSITORY indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule QL (350 EA per 30 days) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 36 ketorolac oral tablet LODINE ORAL TABLET meclofenamate oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet 15 mg QL (350 EA per 30 days) meloxicam oral tablet 7.5 mg MOBIC ORAL SUSPENSION MOBIC ORAL TABLET nabumetone oral tablet NALFON ORAL CAPSULE 400 MG NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR NAPROSYN ORAL SUSPENSION NAPROSYN ORAL TABLET 500 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec)

38 Drug Name Drug Tier Requirements/Limits naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule PONSTEL ORAL CAPSULE REVIA ORAL TABLET salsalate oral tablet SPRIX NASAL SPRAY,NON-AEROSOL LD sulindac oral tablet tolmetin oral capsule tolmetin oral tablet VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR zflex oral tablet Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution QL (2 units per 1 claim) naloxone injection syringe QL (2 units per 1 claim) naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING ABILIFY ORAL TABLET Age-A ADDERALL ORAL TABLET alprazolam intensol oral concentrate alprazolam oral tablet alprazolam oral tablet extended release 24 hr alprazolam oral tablet,disintegrating AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE AMBIEN ORAL TABLET amitriptyline oral tablet QL (2 EA per 30 days) SPRx; Age-A SPRx; Age-A 37

39 Drug Name Drug Tier Requirements/Limits amitriptyline-chlordiazepoxide oral tablet amoxapine oral tablet ANAFRANIL ORAL CAPSULE aripiprazole oral solution Age-A aripiprazole oral tablet Age-A aripiprazole oral tablet,disintegrating Age-A ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML 38 armodafinil oral tablet PA ATIVAN ORAL TABLET bupropion hcl oral tablet bupropion hcl oral tablet extended release 12 hr 100 mg, 200 mg bupropion hcl oral tablet extended release 24 hr buspirone oral tablet BUTISOL ORAL TABLET 30 MG CELEXA ORAL TABLET chlordiazepoxide hcl oral capsule chlorpromazine oral tablet citalopram oral solution citalopram oral tablet clomipramine oral capsule clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium oral tablet clozapine oral tablet Age-A clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 mg, 200 mg SPRx; Age-A Age-A Age-A CLOZARIL ORAL TABLET Age-A CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) DAYTRANA TRANSDERMAL PATCH 24 HOUR

40 Drug Name Drug Tier Requirements/Limits desipramine oral tablet desvenlafaxine succinate oral tablet extended release 24 hr 39 dexedrine oral tablet DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 15 MG dexmethylphenidate oral capsule,er biphasic dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral solution dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet diazepam intensol oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet DORAL ORAL TABLET doxepin oral capsule doxepin oral concentrate duloxetine oral capsule,delayed release(dr/ec) EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet estazolam oral tablet eszopiclone oral tablet FANAPT ORAL TABLET Age-A FANAPT ORAL TABLETS,DOSE PACK Age-A FAZACLO ORAL TABLET,DISINTEGRATING fluoxetine oral capsule Age-A

41 Drug Name Drug Tier Requirements/Limits fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg fluoxetine oral tablet 60 mg fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet flurazepam oral capsule fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet GEODON ORAL CAPSULE Age-A guanfacine oral tablet extended release 24 hr guanidine oral tablet HALCION ORAL TABLET 0.25 MG haloperidol lactate oral concentrate haloperidol oral tablet imipramine hcl oral tablet imipramine pamoate oral capsule INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR INVEGA ORAL TABLET EXTENDED RELEASE 24HR INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR 40 Age-A LATUDA ORAL TABLET Age-A LEXAPRO ORAL SOLUTION LEXAPRO ORAL TABLET lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml SPRx; Age-A SPRx; Age-A

42 Drug Name LITHOBID ORAL TABLET EXTENDED RELEASE 41 lorazepam intensol oral concentrate lorazepam oral concentrate lorazepam oral tablet loxapine succinate oral capsule LUNESTA ORAL TABLET maprotiline oral tablet MARPLAN ORAL TABLET metadate er oral tablet extended release methamphetamine oral tablet METHYLIN ORAL SOLUTION METHYLIN ORAL TABLET,CHEWABLE methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet extended release 24hr methylphenidate hcl oral tablet,chewable midazolam oral syrup 2 mg/ml mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil oral tablet PA molindone oral tablet NARDIL ORAL TABLET nefazodone oral tablet NORPRAMIN ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG Drug Tier nortriptyline oral capsule nortriptyline oral solution NUPLAZID ORAL TABLET PA; SPRx Requirements/Limits

43 Drug Name NUVIGIL ORAL TABLET PA olanzapine oral tablet Age-A olanzapine oral tablet,disintegrating Age-A olanzapine-fluoxetine oral capsule Age-A ORAP ORAL TABLET oxazepam oral capsule paliperidone oral tablet extended release 24hr Age-A PAMELOR ORAL CAPSULE PARNATE ORAL TABLET paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 42 PAXIL ORAL SUSPENSION PAXIL ORAL TABLET perphenazine oral tablet perphenazine-amitriptyline oral tablet PEXEVA ORAL TABLET phenelzine oral tablet pimozide oral tablet PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR procentra oral solution protriptyline oral tablet PROZAC ORAL CAPSULE PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC) quazepam oral tablet quetiapine oral tablet Age-A quetiapine oral tablet extended release 24 hr Age-A QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON REMERON ORAL TABLET REMERON SOLTAB ORAL TABLET,DISINTEGRATING Drug Tier Requirements/Limits

44 Drug Name RESTORIL ORAL CAPSULE RISPERDAL CONSTA INTRAMUSCULAR SPRx; Age-A SYRINGE RISPERDAL M-TAB ORAL Age-A TABLET,DISINTEGRATING RISPERDAL ORAL SOLUTION Age-A RISPERDAL ORAL TABLET Age-A risperidone oral solution Age-A risperidone oral tablet Age-A risperidone oral tablet,disintegrating Age-A RITALIN ORAL TABLET ROZEREM ORAL TABLET SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG 43 SARAFEM ORAL TABLET 10 MG, 20 MG seconal sodium oral capsule Age-A SEROQUEL ORAL TABLET Age-A SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline oral concentrate sertraline oral tablet SONATA ORAL CAPSULE STRATTERA ORAL CAPSULE SURMONTIL ORAL CAPSULE Age-A SYMBYAX ORAL CAPSULE Age-A temazepam oral capsule thioridazine oral tablet thiothixene oral capsule TOFRANIL ORAL TABLET TRANXENE T-TAB ORAL TABLET 3.75 MG, 7.5 MG Drug Tier tranylcypromine oral tablet trazodone oral tablet triazolam oral tablet trifluoperazine oral tablet Requirements/Limits

45 Drug Name Drug Tier Requirements/Limits trimipramine oral capsule TRINTELLIX ORAL TABLET VALIUM ORAL TABLET venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 44 VYVANSE ORAL CAPSULE VYVANSE ORAL TABLET,CHEWABLE WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR XANAX ORAL TABLET XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR XYREM ORAL SOLUTION PA zaleplon oral capsule zenzedi oral tablet 10 mg, 5 mg ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule Age-A ZOLOFT ORAL CONCENTRATE ZOLOFT ORAL TABLET zolpidem oral tablet zolpidem oral tablet,ext release multiphase ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING Age-A SPRx; Age-A Age-A

46 Drug Name Drug Tier Requirements/Limits Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents amiodarone oral tablet BETAPACE AF ORAL TABLET BETAPACE ORAL TABLET CORDARONE ORAL TABLET disopyramide phosphate oral capsule dofetilide oral capsule flecainide oral tablet mexiletine oral capsule MULTAQ ORAL TABLET NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 45 NORPACE ORAL CAPSULE pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral tablet extended release quinidine sulfate oral tablet RYTHMOL ORAL TABLET 225 MG RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR sorine oral tablet sotalol af oral tablet sotalol oral tablet SOTYLIZE ORAL SOLUTION TIKOSYN ORAL CAPSULE Antihypertensive Therapy ACCUPRIL ORAL TABLET ACCURETIC ORAL TABLET acebutolol oral capsule ACEON ORAL TABLET 4 MG, 8 MG ADALAT CC ORAL TABLET EXTENDED RELEASE

47 Drug Name Drug Tier Requirements/Limits afeditab cr oral tablet extended release ALDACTAZIDE ORAL TABLET ALDACTONE ORAL TABLET ALTACE ORAL CAPSULE amiloride oral tablet amiloride-hydrochlorothiazide oral tablet amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-olmesartan oral tablet amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet ATACAND HCT ORAL TABLET ATACAND ORAL TABLET atenolol oral tablet atenolol-chlorthalidone oral tablet AVALIDE ORAL TABLET AVAPRO ORAL TABLET AZOR ORAL TABLET benazepril oral tablet benazepril-hydrochlorothiazide oral tablet BENICAR HCT ORAL TABLET BENICAR ORAL TABLET betaxolol oral tablet BIDIL ORAL TABLET bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet bumetanide oral tablet BYSTOLIC ORAL TABLET CALAN ORAL TABLET CALAN SR ORAL TABLET EXTENDED RELEASE candesartan oral tablet candesartan-hydrochlorothiazid oral tablet 46