Commercial Metal 5-Tier Formulary (List of Covered Drugs)

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1 Updated: September 15, 2017 Small Group Metal Plans Individual Metal Plans Commercial Metal 5-Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists, the Drug List is an extensive list of safe and effective, U.S. Food and Drug Administration (FDA)-approved, brand-name and generic prescription drugs used to treat the most common medical conditions. The Health First Pharmacy and Therapeutics Committee (P&T) a panel of physicians and pharmacists developed our Drug List and updates it regularly. The list includes quality drugs available to you at a reasonable cost. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included. The P&T Committee reviews and evaluates all available literature about a drug when updating the list. About Tiers Most covered prescription drugs will be categorized into one of five cost-sharing tiers. Drug costs vary widely, even though several different medications may be used to treat the same condition. What you pay for the prescription depends upon what tier the drug is listed in. Florida Hospital Care Advantage (FHCA) offers many benefit plans that can vary in coverage for each tier. Details about your specific benefit for each tier are included in the Florida Hospital Care Advantage Summary of Benefits. Prescriptions that exceed a 30-day supply will default to a 90-day supply copay (this does not apply to coinsurances). For coinsurances, you will always pay a percentage of the total cost after the applicable deductible is met. Tier 1 (T1) - Includes low-cost preferred generic drugs Tier 2 () - Includes higher-cost generic drugs Tier 3 () - Includes preferred brand-name drugs and some higher-cost generic drugs Tier 4 () - Includes higher-cost non-preferred brand-name drugs and generic drugs (some plans may be limited to a 30-day supply) Tier 5 (T5 SP) - Includes higher-cost biologics or prescription drugs that require close monitoring for safety and efficacy Preventive Care () - Includes some select preventive products, prescription medications and specific over-the-counter (OTC) medications available to you at no cost-sharing ($0) when applicable conditions are met 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 1

2 HIV/AIDS Drugs Safe Harbor (SH) Antiretroviral medications used to treat HIV/AIDS may have different copays than those on the Florida Hospital Care Advantage Summary of Benefits assigned to tiers indicated below. The listed copays will apply after applicable deductible amounts have been met. SH Tier 1 Copay (T1): No more than $40 per 30-day supply SH Tier 2 Copay (): No more than $55 per 30-day supply SH Tier 3 Copay (): No more than $70 per 30-day supply SH Tier 4 Copay (): No more than $150 per 30-day supply SH Tier 5 Copay (T5): No more than $200 per 30-day supply Generic drugs are prescription drugs that have the same active ingredients as brand-name drugs and are prescribed for the same reasons. When the patent expires on a brand-name drug, the FDA permits new manufacturers to produce an equivalent of the brand-name drug and make it available to the public. Generally, more than one manufacturer will produce generic versions, although often the same pharmaceutical firm that produces the brand-name drug also makes the generic version. This prompts competitive pricing of the generic version and usually results in a less expensive drug that is as safe and effective as the brand-name drug. What will my expenses be? Every plan is different, and your financial obligation will vary based on your specific plan. You are responsible for any cost sharing your plan requires. What is a deductible? A deductible is a set dollar amount that you must pay each calendar year before your health plan starts paying. If your plan includes an integrated pharmacy deductible, it will accumulate with your in-network medical deductible. Refer to your plan documents to see when your deductible starts over for your plan. What is the difference between a copayment and coinsurance? Copayments and coinsurance are types of member cost sharing, and they represent the portion of covered prescription expenses members must pay. A copayment is a flat dollar amount, while coinsurance is a percentage of the total allowable charges. What does out-of-pocket maximum mean? The out-of-pocket maximum protects you from catastrophic medical and prescription drug expenses by limiting how much you have to pay during the benefit year. Your cost sharing for covered prescription drugs (deductible, coinsurance and copayment) all accumulate with your in-network medical out-of-pocket maximum. Refer to your plan documents to see when your out-of-pocket maximum starts over for your plan and to verify the specific cost sharing you have for specific tiers. The Drug List is subject to change In order to continue to offer a safe and cost-effective selection of prescription drugs, Florida Hospital Care Advantage periodically makes changes to the Drug List. These changes may include removing medications, adding restrictions, and/or covering a drug at a higher tier. Updated formularies are posted to the website as changes are made. The following list represents some of the most common scenarios in which changes to drug coverage will occur: Throughout the year, new medications are approved by the FDA. It is the policy of Florida Hospital Care Advantage that new drugs will be excluded for six months from the date of FDA approval, during which time the Health First P&T Committee can review the drug for safety and efficacy. When a medication is withdrawn from the market due to safety reasons or if it becomes available over the counter. At the time that a medication on the Florida Hospital Care Advantage Drug List becomes available over the counter, it may be excluded from coverage from that point forward. When a brand-name prescription drug loses its patent and the equivalent generic form is added to the Drug List, the brand-name drug may be moved to Tier 4 or removed from the formulary _MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 2

3 This formulary is current as of January 1, To get updated information about covered drugs, please visit our website at myfhca.org or call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Florida Hospital Care Advantage requires you and/or your physician to get prior authorization for certain drugs. This means you will need to get approval from us before you fill your prescriptions. In order for the plan to pay for these drugs, the physician ordering the prescription is required to submit all medical information to Florida Hospital Care Advantage documenting the medical necessity. These drugs are identified in the Drug List. Step Therapy: In some cases, Florida Hospital Care Advantage 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. A complete list of drugs which require step therapy are listed in the Prior Authorization and Step Therapy Criteria document. Quantity Limits: For some covered drugs, there is a maximum amount that will be covered by Florida Hospital Care Advantage over a certain period of time. For example, Florida Hospital Care Advantage covers 30 tablets every 30 days or 90 tablets every 90 days for Tradjenta. How can I make the most of my prescription drug benefit? Prescription drug costs continue to rise every year and can represent a significant part of your healthcare expenses. Florida Hospital Care Advantage helps you pay for your medications by sharing the cost with you and providing substantial discounts for covered medications. To help you manage your drug costs, here are some money-saving tips to consider: Use generic medications whenever possible. Generic drugs are the chemical equivalent of brand-name drugs and are just as effective in most cases. If you take generic drugs, you will generally pay less. Talk to your doctor to see if switching to a generic equivalent of any brand-name drug you are taking is appropriate. Please see the list of drugs below to determine which generic drugs are included in lower cost sharing tiers. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that Florida Hospital Care Advantage does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Florida Hospital Care Advantage. When you receive the list, show it to your doctor and ask if switching to a covered medication is appropriate. You can ask your physician to send Florida Hospital Care Advantage information requesting we make an exception and cover your drug. If Florida Hospital Care Advantage approves the request for an exception to the formulary, the approved drug will be covered at the Tier 4 cost share unless the cost of the medication is greater than $500 per month, then it will be covered at the Tier 5 cost share. Excluded drugs Florida Hospital Care Advantage does not provide coverage for all drugs. In addition to the drugs marked excluded in this drug list, newly FDA-approved drugs are not covered unless the Health First P&T Committee in its sole discretion approves these drugs for coverage. Florida Hospital Care Advantage will automatically exclude a particular drug if a generic version becomes available and an entire class of drugs if a particular drug within that class becomes available over the counter _MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 3

4 The following are NOT covered by Florida Hospital Care Advantage: Compounded drugs Cosmetics or any drugs used for cosmetic purposes Diabetic supplies, blood glucose monitors and test strips other than those manufactured by Abbott under the product name Freestyle, Precision and test strips Erectile dysfunction drugs (such as Viagra) Infertility drugs (such as Clomid) Some injectables (except insulin and those requiring prior authorization) Most multivitamins and nutritional supplements (except prescription prenatal vitamins and products covered under the Preventive Care benefit) Nonprescription supplies or substances Most OTC medications (except products covered under the Preventive Care benefit) or any drug for which a similar over-the-counter version is available All new drugs approved by the FDA will be excluded from the preferred drug list/formulary unless the Health First P&T Committee, in its sole discretion, decides to waive this exclusion for a particular drug. Support garments Syringes, needles or other disposable supplies (except those used with insulin) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 4

5 Preventive Care Medications: $0 Cost-share Medications and Products The Affordable Care Act (ACA), commonly known as healthcare reform, was signed into federal law in The ACA requires private insurers to cover certain preventive services without any patient cost-sharing (i.e., copayments, coinsurance and deductible) when they are delivered by a network provider. The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task Force [USPSTF], Advisory Committee on Immunization Practices [ACIP], and Health Resources and Services Administration [HRSA]) who have identified several medication categories that fall within the preventive health mandate. The following products, prescription medications and specific OTC medications (notated in Tier throughout this formulary) are available to our members at no ($0) cost-sharing when: Prescribed by a healthcare professional (all prescription and OTC medications will require a prescription) Age and/or gender appropriate This list will be reviewed periodically and is subject to change. Medicine/Product Category and Who is Covered Aspirin Men age 45-79; Women age Women < 55 years Fluoride Children age six months through five years Folic Acid Women only through age 50 years Iron Supplements Children age six months through 12 months Vitamin D Supplements Adults > 65 years of age Immunizations The age of coverage varies based on the vaccine product prescribed and recommendations by the U.S. Centers for Disease Control and Prevention (CDC) Contraceptive Methods Women only, through age 50 years Examples of the Medicine/Product Covered Aspirin 81 MG and 325 MG Aspirin 81 MG delayed-release and 325 MG delayed-release Fluoride chewable tablet 0.25 MG, 0.5 MG, and 1 MG; Fluoride drops 0.5 MG; Multivitamin with fluoride chewable 0.25 MG and 0.5 MG; Multivitamin with fluoride drops 0.25 MG and 0.5 MG; Fluoritab chewable tablet 0.25 MG and 0.5 MG Folic acid tablet 0.4 MG, 0.8 MG; and 1 MG Prenatal multivitamins with folic acid (0.4 MG and 0.8 MG) Iron (various strengths) drops, liquid, suspension, granules Multivitamin with iron drops, liquid, suspension Vitamin D 1,000 units or less per dose unit; Calcium with vitamin D (1,000 units or less per dose unit) Covered immunizations include those that are routine vaccines recommended by the Advisory Committee on Immunization Practices of the CDC and that meet the FDA-approved indications for age and/or gender limitations. Coverage also includes non-routine immunizations used to prevent other illnesses such as typhoid, yellow fever, and Japanese encephalitis. Covered products include one or more FDAapproved 16 contraceptive methods available through the prescription drug benefit, including: Generic OTC spermicide and legend diaphragms; Today contraceptive sponge; Female condom; FemCap ; 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 5

6 Medicine/Product Category and Who is Covered Contraceptive Methods (continued) Women only, through age 50 years Primary Prevention of Breast Cancer For women > 35 years of age who meet criteria Raloxifene is covered for only those who are postmenopausal If you are 35 years of age or older and have not had breast cancer, talk to your doctor about your risk. If appropriate, your doctor may offer to prescribe one of these risk-reducing medications. You or your doctor can then submit a Prior Authorization request to get the medication approved at $0 cost-share if coverage criteria are met. Tobacco Cessation Adults 18 and older Must receive counseling and have prescription from a healthcare provider Up to two, three-month treatment courses are covered at no cost each year (any additional treatment may be subject to a cost share) Medications Used to Prepare for Colonoscopy Adults > 50 and < 75 years of age Limit of two prescriptions per year Examples of the Medicine/Product Covered Generic oral, transdermal and intramuscular hormonal methods; NuvaRing ; Generic, OTC emergency contraceptives and Ella ; The intrauterine systems Mirena and Paragard ; The intradermal agent, Nexplanon Tamoxifen Raloxifene Zyban (generic); Chantix; Nicotine replacement products Generic products such as: Alophen Bisacodyl; Magnesium citrate; Milk of magnesia; Polyethylene glycol (PEG) 3350-electrolyte If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer or call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m _MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 6

7 Florida Hospital Care Advantage Formulary The formulary provides coverage information about some of the drugs covered by Florida Hospital Care Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 107. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Notes column tells you if Florida Hospital Care Advantage has any special requirements for coverage of your drug. Specialty Drug (SP): Biologics or prescription drugs that require close monitoring and are limited to a 30-day supply. Prior Authorization (): Florida Hospital Care Advantage requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from Florida Hospital Care Advantage before you fill your prescriptions. If you don't get approval, the drug will not be covered. Quantity Limit (QL): Quantity Limits may also be listed. For example, 30 EA per 30 days would mean your coverage of this drug is limited to 30 pills every 30 days. Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount unless an exception is requested by your physician and approved by Florida Hospital Care Advantage. Step Therapy (ST): In some cases, Florida Hospital Care Advantage 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. A complete list of drugs which require step therapy are listed in the Prior Authorization and Step Therapy Criteria document. Safe Harbor (SH): Antiretroviral medications used to treat HIV/AIDS that may have different copays than those on the Florida Hospital Care Advantage Summary of Benefits assigned to tiers. No Cost-Share (): Select preventive products, prescription medications and specific OTC medications available to our members at no cost-sharing ($0) when applicable conditions are met _MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 7

8 ANALGESICS acetaminophen-caff-dihydrocod oral capsule mg acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg QL (2700 ML per 30 days) QL (240 EA per 30 days) acetaminophen-codeine oral tablet mg QL (180 EA per 30 days) almotriptan malate oral tablet 12.5 mg, 6.25 mg ST; QL (18 EA per 30 days) ascomp with codeine oral capsule mg aspirin oral tablet 325 mg aspirin oral tablet,delayed release (dr/ec) 325 mg BAYER ASPIRIN ORAL TABLET 325 MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG BUTALBITAL COMPOUND-CODEINE ORAL CAPSULE MG butalbital-acetaminop-caf-cod oral capsule mg, mg QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) butalbital-acetaminophen oral tablet mg QL (180 EA per 30 days) butalbital-acetaminophen-caff oral capsule mg, mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml BUTRANS TRANSDERMAL TCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (4 EA per 28 days) codeine sulfate oral tablet 15 mg, 30 mg, 60 mg QL (180 EA per 30 days) codeine-butalbital-asa-caff oral capsule mg diclofenac potassium oral tablet 50 mg diflunisal oral tablet 500 mg dihydroergotamine injection solution 1 mg/ml QL (180 EA per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 8

9 dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) ELMIRON ORAL CAPSULE 100 MG endocet oral tablet mg QL (180 EA per 30 days) endocet oral tablet mg, mg, mg ERGOMAR SUBLINGUAL TABLET 2 MG fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr QL (240 EA per 30 days) ; QL (120 EA per 30 days) QL (15 EA per 30 days) frovatriptan oral tablet 2.5 mg ST; QL (18 EA per 30 days) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (2700 ML per 30 days) QL (180 EA per 30 days) QL (240 EA per 30 days) QL (84 EA per 30 days) QL (50 EA per 30 days) hydromorphone oral tablet 2 mg, 4 mg, 8 mg QL (180 EA per 30 days) hydromorphone oral tablet extended release 24 hr 12 mg hydromorphone oral tablet extended release 24 hr 16 mg, 32 mg, 8 mg ; QL (30 EA per 30 days) ; QL (30 EA per 30 days) ibuprofen-oxycodone oral tablet mg QL (28 EA per 30 days) ketorolac oral tablet 10 mg levorphanol tartrate oral tablet 2 mg QL (180 EA per 30 days) LITE COAT ASPIRIN ORAL TABLET 325 MG mefenamic acid oral capsule 250 mg meperidine oral tablet 100 mg, 50 mg QL (180 EA per 30 days) methadone oral tablet 10 mg, 5 mg QL (240 EA per 30 days) MIGERGOT RECTAL SUPPOSITORY MG QL (20 EA per 28 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 9

10 morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) QL (600 ML per 30 days) morphine concentrate oral syringe 20 mg/ml QL (600 EA per 30 days) morphine oral solution 10 mg/5 ml QL (2700 ML per 30 days) morphine oral solution 20 mg/5 ml (4 mg/ml) QL (1350 ML per 30 days) morphine oral tablet 15 mg, 30 mg QL (180 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg QL (90 EA per 30 days) morphine oral tablet extended release 200 mg QL (60 EA per 30 days) naratriptan oral tablet 1 mg, 2.5 mg ST; QL (18 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG ONA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG ; QL (60 EA per 30 days) ; QL (180 EA per 30 days) QL (60 EA per 30 days) oxycodone oral solution 5 mg/5 ml QL (5400 ML per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg QL (180 EA per 30 days) oxycodone oral tablet 30 mg QL (120 EA per 30 days) oxycodone oral tablet 5 mg QL (240 EA per 30 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg ; QL (60 EA per 30 days) oxycodone-acetaminophen oral tablet mg QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg QL (240 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxymorphone oral tablet 10 mg, 5 mg QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg pentazocine-naloxone oral tablet mg QL (60 EA per 30 days) RELX ORAL TABLET 20 MG, 40 MG ST; QL (18 EA per 30 days) rizatriptan oral tablet 10 mg, 5 mg QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg QL (18 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml QL (18 EA per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 10

11 sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 ml QL (8 ML per 30 days) QL (8 ML per 30 days) tramadol oral tablet 50 mg QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr 100 mg, 200 mg, 300 mg tramadol oral tablet, er multiphase 24 hr 100 mg, 200 mg, 300 mg QL (30 EA per 30 days) QL (30 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (240 EA per 30 days) ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG QL (60 EA per 30 days) zolmitriptan oral tablet 2.5 mg, 5 mg ST; QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG ANESTHETICS lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) lidocaine hcl topical cream 3 % lidocaine hcl topical lotion 3 % ST; QL (18 EA per 30 days) ST; QL (12 EA per 30 days) lidocaine topical adhesive patch,medicated 5 % ; QL (90 EA per 30 days) lidocaine topical ointment 5 % ; QL (150 GM per 30 days) LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % lidocaine-prilocaine topical cream % lidocaine-prilocaine topical kit % phenazopyridine oral tablet 100 mg, 200 mg SYNERA TOPICAL TCH, MEDICATED SELF-HEATING MG ANTIALLERGY cromolyn oral concentrate 100 mg/5 ml ANTIARTHRITICS 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 11

12 allopurinol oral tablet 100 mg, 300 mg celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg DEPEN TITRATABS ORAL TABLET 250 MG diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 12 T1 QL (60 EA per 30 days) ; QL (8 EA per 28 days) ; QL (4 ML per 28 days) ; QL (8 ML per 28 days) ; QL (8 ML per 28 days) ; QL (3 EA per 180 days) ; QL (6 EA per 180 days) ; QL (4 EA per 180 days) ; QL (4 EA per 28 days) ; QL (2 EA per 28 days) ; QL (4 EA per 28 days)

13 ketoprofen oral capsule 50 mg, 75 mg leflunomide oral tablet 10 mg, 20 mg QL (30 EA per 30 days) meclofenamate oral capsule 100 mg, 50 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML sulindac oral tablet 150 mg, 200 mg tolmetin oral capsule 400 mg tolmetin oral tablet 200 mg, 600 mg T1 ULORIC ORAL TABLET 40 MG, 80 MG ST XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ANTIASTHMATICS acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 13

14 ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg aminophylline intravenous solution 250 mg/10 ml aminophylline oral tablet 100 mg, 200 mg ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION cromolyn inhalation solution for nebulization 20 mg/2 ml QL (60 EA per 30 days) QL (12 GM per 30 days) QL (13 GM per 30 days) QL (1 EA per 30 days) QL (26 GM per 30 days) QL (8 GM per 30 days) DALIRESP ORAL TABLET 500 MCG QL (30 EA per 30 days) DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION QL (13 GM per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 14

15 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg montelukast oral granules in packet 4 mg QL (60 EA per 30 days) QL (240 EA per 30 days) QL (12 GM per 30 days) QL (24 GM per 30 days) QL (10.6 GM per 30 days) montelukast oral tablet 10 mg QL (30 EA per 30 days) montelukast oral tablet,chewable 4 mg, 5 mg QL (30 EA per 30 days) PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION QL (60 EA per 30 days) QL (4 GM per 30 days) QL (30 EA per 30 days) QL (4 GM per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 15

16 SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 600 mg theophylline oral tablet extended release 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 16 ST; QL (10.2 GM per 30 days) QL (36 GM per 30 days) zafirlukast oral tablet 10 mg, 20 mg QL (60 EA per 30 days) ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR 600 MG ; QL (120 EA per 30 days) ZYFLO ORAL TABLET 600 MG ; QL (120 EA per 30 days) ANTIBIOTICS AK-POLY-BAC OPHTHALMIC OINTMENT ,000 UNIT/GRAM amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg amoxicillin oral tablet,chewable 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg T1 T1 T1 T1

17 amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml AVAR TOPICAL CLEANSER 10-5 % (W/W) AVAR-E GREEN TOPICAL CREAM 10-5 % (W/W) AVAR-E TOPICAL CREAM 10-5 % (W/W) AZASITE OPHTHALMIC DROPS 1 % azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % BENZAMYCINK TOPICAL GEL 3-5 % BESIVANCE OPHTHALMIC DROPS,SUSPENSION 0.6 % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CASTAT INJECTION RECON SOLN 1 GRAM CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML CEDAX ORAL CAPSULE 400 MG cefaclor oral capsule 250 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram, 100 gram, 300 g, 500 mg 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 17 T1

18 cefazolin injection recon soln 10 gram cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML ceftriaxone injection recon soln 1 gram, 10 gram, 100 gram, 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml chloramphenicol sod succinate intravenous recon soln 1 gram CILOXAN OPHTHALMIC OINTMENT 0.3 % CIPRO HC OTIC DROPS,SUSPENSION % CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg ciprofloxacin hcl ophthalmic drops 0.3 % ciprofloxacin hcl oral tablet 100 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg T1 T1 T _MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 18

19 ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg CLEOCIN VAGINAL SUPPOSITORY 100 MG CLINDACIN ETZ TOPICAL SWAB 1 % CLINDACIN P TOPICAL SWAB 1 % clindacin pac topical kit 1 % clindamycin hcl oral capsule 150 mg, 300 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % clindamycin phosphate vaginal cream 2 % COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML CORTISPORIN TOPICAL CREAM , MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % CORTISPORIN-TC OTIC DROPS,SUSPENSION MG/ML cycloserine oral capsule 250 mg dapsone oral tablet 100 mg, 25 mg demeclocycline oral tablet 150 mg, 300 mg dicloxacillin oral capsule 250 mg, 500 mg DIFICID ORAL TABLET 200 MG doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 19 T1

20 E.E.S. 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML E.E.S. 400 ORAL TABLET 400 MG E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML ERY DS TOPICAL SWAB 2 % ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin ophthalmic ointment 5 mg/gram (0.5 %) erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg erythromycin topical solution 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % erythromycin-benzoyl peroxide topical gel 3-5 % ethambutol oral tablet 100 mg, 400 mg FACTIVE ORAL TABLET 320 MG gatifloxacin ophthalmic drops 0.5 % GENTAK OPHTHALMIC OINTMENT 0.3 % (3 MG/GRAM) gentamicin ophthalmic drops 0.3 % gentamicin ophthalmic ointment 0.3 % (3 mg/gram) gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg KETEK ORAL TABLET 300 MG, 400 MG KETEK K ORAL TABLET 400 MG levofloxacin ophthalmic drops 0.5 % levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 20

21 linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg meropenem intravenous recon soln 1 gram, 500 mg methenamine hippurate oral tablet 1 gram methenamine mandelate oral tablet 1 gram metronidazole oral tablet 250 mg, 500 mg metronidazole vaginal gel 0.75 % minocycline oral capsule 100 mg, 50 mg, 75 mg MONUROL ORAL CKET 3 GRAM MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % mupirocin topical ointment 2 % neomycin oral tablet 500 mg neomycin-bacitracin-poly-hc ophthalmic ointment ,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc otic drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution ,000-1 mg/ml-unit/ml-% nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml ofloxacin ophthalmic drops 0.3 % ofloxacin oral tablet 300 mg, 400 mg ofloxacin otic drops 0.3 % 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 21

22 SER ORAL GRANULES DR FOR SUSP IN CKET 4 GRAM penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg RIFAMATE ORAL CAPSULE MG rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG ROSANIL TOPICAL CLEANSER 10-5 % (W/W) ROSULA CLEANSING CLOTHS TOPICAL DS, MEDICATED 10-5 % silver sulfadiazine topical cream 1 % SIRTURO ORAL TABLET 100 MG SS 10-2 TOPICAL CLEANSER 10-2 % SSD TOPICAL CREAM 1 % SSS 10-5 TOPICAL CREAM 10-5 % (W/W) SSS 10-5 TOPICAL FOAM 10-5 % streptomycin intramuscular recon soln 1 gram sulfacetamide sodium ophthalmic drops 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium-sulfur topical cleanser 10-2 %, 10-5 % (w/w), %, % sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w), % sulfacetamide sodium-sulfur topical foam 10-5 % sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) sulfacetamide sodium-sulfur topical lotion 10-5 % (w/w), % sulfacetamide sodium-sulfur topical pads, medicated 10-4 % 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 22

23 sulfacetamide sodium-sulfur topical suspension 10-5 % sulfacetamide sod-sulfur-urea topical cleanser % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg SULFAMYLON TOPICAL CREAM 85 MG/G SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tetracycline oral capsule 250 mg, 500 mg THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG THERMAZENE TOPICAL CREAM 1 % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin ophthalmic drops 0.3 % tobramycin-dexamethasone ophthalmic drops,suspension % TRECATOR ORAL TABLET 250 MG trimethoprim oral tablet 100 mg vancomycin intravenous recon soln 1,000 mg, 500 mg 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 23 T1 vancomycin oral capsule 125 mg, 250 mg VIGAMOX OPHTHALMIC DROPS 0.5 % XIFAXAN ORAL TABLET 200 MG ; QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG ; QL (90 EA per 30 days)

24 ZYLET OPHTHALMIC DROPS,SUSPENSION % ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml QL (24 ML per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml QL (28 ML per 30 days) QL (22.4 ML per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml QL (8.4 ML per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml QL (11.2 ML per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml QL (16.8 ML per 30 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml ; QL (24 ML per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml ; QL (15 ML per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml ; QL (12 ML per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml ; QL (18 ML per 30 days) heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 20,000 unit/ml heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE CK 15 MG (42)- 20 MG (9) ANTIDOTES MOVANTIK ORAL TABLET 12.5 MG, 25 MG naloxone injection syringe 1 mg/ml T1 T _MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 24

25 naltrexone oral tablet 50 mg ANTIFUNGALS amphotericin b injection recon soln 50 mg CICLODAN TOPICAL SOLUTION 8 % ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % ciclopirox-vite-nail lacq remo topical kit 8-5 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % CRESEMBA INTRAVENOUS RECON SOLN 372 MG CRESEMBA ORAL CAPSULE 186 MG econazole topical cream 1 % ERTACZO TOPICAL CREAM 2 % EXELDERM TOPICAL CREAM 1 % EXELDERM TOPICAL SOLUTION 1 % fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5 ml GYNAZOLE-1 VAGINAL CREAM 2 % itraconazole oral capsule 100 mg ; QL (120 EA per 30 days) ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 25

26 MENTAX TOPICAL CREAM 1 % naftifine topical cream 1 %, 2 % NAFTIN TOPICAL GEL 1 %, 2 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7 ML NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nystatin oral powder 150 million unit, 2 billion unit, 50 million unit, 500 million unit nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM oxiconazole topical cream 1 % terbinafine hcl oral tablet 250 mg QL (30 EA per 30 days) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg VUSION TOPICAL OINTMENT % ANTIHISTAMINE AND DECONGESTANT COMBINATION fexofenadine-pseudoephedrine oral tablet extended release 12 hr mg PROMETHAZINE VC ORAL SYRUP MG/5 ML 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 26

27 promethazine-phenylephrine oral syrup mg/5 ml ANTIHISTAMINES azelastine ophthalmic drops 0.05 % BEPREVE OPHTHALMIC DROPS 1.5 % carbinoxamine maleate oral tablet 4 mg clemastine oral tablet 2.68 mg cyproheptadine oral tablet 4 mg desloratadine oral tablet 5 mg QL (30 EA per 30 days) dexchlorpheniramine maleate oral syrup 2 mg/5 ml diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml EMADINE OPHTHALMIC DROPS 0.05 % epinastine ophthalmic drops 0.05 % fexofenadine oral suspension 30 mg/5 ml hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml, 10 mg/5 ml (5 ml) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg LASTACAFT OPHTHALMIC DROPS 0.25 % QL (6 ML per 30 days) levocetirizine oral solution 2.5 mg/5 ml levocetirizine oral tablet 5 mg QL (30 EA per 30 days) olopatadine ophthalmic drops 0.1 % QL (10 ML per 30 days) TADAY OPHTHALMIC DROPS 0.2 % QL (10 ML per 30 days) ZEO OPHTHALMIC DROPS 0.7 % promethazine injection solution 25 mg/ml, 50 mg/ml promethazine injection syringe 25 mg/ml promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg ANTIHYPERGLYCEMICS acarbose oral tablet 100 mg, 25 mg, 50 mg QL (90 EA per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 27

28 APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML chlorpropamide oral tablet 100 mg, 250 mg ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) QL (4 EA per 28 days) QL (4 EA per 28 days) QL (2.4 ML per 28 days) QL (1.2 ML per 30 days) CYCLOSET ORAL TABLET 0.8 MG ; QL (180 EA per 30 days) FARXIGA ORAL TABLET 10 MG, 5 MG ST glimepiride oral tablet 1 mg T1 QL (240 EA per 30 days) glimepiride oral tablet 2 mg T1 QL (120 EA per 30 days) glimepiride oral tablet 4 mg T1 QL (60 EA per 30 days) glipizide oral tablet 10 mg T1 QL (120 EA per 30 days) glipizide oral tablet 5 mg T1 QL (240 EA per 30 days) glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg T1 QL (60 EA per 30 days) glipizide-metformin oral tablet mg QL (240 EA per 30 days) glipizide-metformin oral tablet mg, mg QL (120 EA per 30 days) glyburide micronized oral tablet 1.5 mg, 3 mg QL (120 EA per 30 days) glyburide micronized oral tablet 6 mg QL (60 EA per 30 days) glyburide oral tablet 1.25 mg QL (480 EA per 30 days) glyburide oral tablet 2.5 mg QL (240 EA per 30 days) glyburide oral tablet 5 mg QL (60 EA per 30 days) glyburide-metformin oral tablet mg QL (240 EA per 30 days) glyburide-metformin oral tablet mg, mg GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML QL (120 EA per 30 days) ST; QL (60 ML per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 28

29 HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML INVOKANA ORAL TABLET 100 MG, 300 MG ST ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) QL (20 ML per 30 days) JARDIANCE ORAL TABLET 10 MG, 25 MG QL (30 EA per 30 days) JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML QL (60 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) ST; QL (60 ML per 30 days) ST; QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) metformin oral tablet 1,000 mg T1 QL (60 EA per 30 days) metformin oral tablet 500 mg T1 QL (150 EA per 30 days) metformin oral tablet 850 mg T1 QL (90 EA per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg T1 T1 QL (120 EA per 30 days) QL (60 EA per 30 days) 36194_MPINFO334FH (09/2017) 2018 Commercial Metal 5-Tier Formulary, Version 2 Page 29

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