Health First Health Plans 2015 Formulary (List of Covered Drugs)

Transcription

1 Updated: October 27, 2015 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/27/2015. For more recent information or other questions, please contact Health First Health Plans Customer Service at or, for TTY users, , weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we are available seven days a week from 8 a.m. to 8 p.m. If you call after hours, you can leave a message and we will return your call the next business day, or visit myfhca.org. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Health First Health Plans/Florida Hospital Care Advantage. When it refers to plan or our plan, it means Florida Hospital SunSaver Plan (HMO-POS) or Florida Hospital Explorer Plan (HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of 10/27/2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 1

2 What is the Health First Health Plans Formulary? A formulary is a list of covered drugs selected by Health First Health Plans in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Health First Health Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Health First Health Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/27/2015. To get updated information about the drugs covered by Health First Health Plans, please contact us. Our contact information appears on the front and back cover pages. Printed formularies are updated via errata sheets in the event of midyear non-maintenance formulary changes. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 115. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Health First Health Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 2

3 Prior Authorization: Health First Health Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health First Health Plans before you fill your prescriptions. If you don t get approval, Health First Health Plans may not cover the drug. Quantity Limits: For certain drugs, Health First Health Plans limits the amount of the drug that Health First Health Plans will cover. For example, Health First Health Plans provides 31 tablets per prescription for TRADJENTA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Health First Health Plans 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, Health First Health Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Health First Health Plans will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Health First Health Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Health First Health Plans formulary? on page 3 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Health First Health Plans does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Health First Health Plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Health First Health Plans. You can ask Health First Health Plans to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Health First Health Plans Formulary? You can ask Health First Health Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined costsharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health First Health Plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Health First Health Plans will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 3

4 supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Additionally, we understand that if you have been enrolled in the plan for more than 90 days, there may be other situations in which you are prescribed non-formulary medications. These circumstances usually involve a change from one treatment setting to another, including but not limited to: Discharge from a hospital to home, Discharge from a skilled nursing facility to home, Ending a long-term care facility stay and returning to the community. As a current member, if you have been prescribed non-formulary medications as a result of changing from one treatment setting to another, you may be eligible to receive a one-time temporary 30-day supply of your non-formulary drugs. During this transition period you can talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so we will cover the drug(s) you take. You can contact our Customer Service to ask for a temporary supply if the above circumstances apply to you. Our Customer Service contact information is listed on the front and back cover pages. For more information For more detailed information about your Health First Health Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Health First Health Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 4

5 Your Cost Coverage Phase Initial Coverage Period You pay these amounts beginning January 1, 2015, or when you first enroll. When the total cost for your covered drugs reaches $2,960 (including what you pay and what we pay), the Coverage Gap stage begins. Florida Hospital SunSaver Plan Coverage Gap You pay these amounts after the total cost for your covered drugs reaches $2,960 (including what you pay and what we pay). When you have paid $4,700 out-ofpocket for covered drugs, the Catastrophic stage begins. Retail Mail Order Retail Mail Order 30-Day Supply 90-Day Supply 90-Day Supply 30-Day Supply 90-Day Supply 90 Day Supply 1* $2 $6 $0 $2 $6 $0 2 $5 $15 $0 3 $45 $135 $90 For some generics you pay 65% of the cost and for brand name drugs, you pay 45% of the price (50% paid by 4 $90 $270 $180 manufacturer and 5% paid by Health First Health Plans) 5 33% N/A N/A Florida Hospital Explorer Plan Catastrophic After your yearly outof-pocket drug costs reach $4,700, you pay a $2.65 copay for generic and a $6.60 copay for all other drugs, or 5% coinsurance (whichever is greater). Retail Mail Order Retail Mail Order 30-Day Supply 90-Day Supply 90 Day Supply 30-Day Supply 90-Day Supply 90 Day Supply 1* $0 $0 $0 $0 $0 $0 2* $2 $6 $0 $2 $6 $0 3 $45 $135 $90 For some generics you pay 65% of the cost and for brand 4 $90 $270 $180 name drugs, you pay 45% of the price (50% paid by 5 33% N/A N/A manufacturer and 5% paid by Health First Health Plans) * We provide additional coverage of this prescription drug in the coverage gap. Refer to our Evidence of Coverage for more information about this coverage. Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 5

6 Health First Health Plans Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Health First Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 115. The first column of the chart lists the drug name. name drugs are capitalized (e.g., DEXILANT) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if Health First Health Plans has any special requirements for coverage of your drug. Part B versus Part D (): This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Limited Availability (LA): This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at , weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we re available seven days a week from 8 a.m. to 8 p.m. If you call after hours, you can leave a message and we will return your call the next business day. TTY users should call Prior Authorization (): Health First Health Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health First Health Plans before you fill your prescriptions. If you do not get approval, Health First Health Plans may not cover the drug. Quantity Limit (QL): Quantity Limits may also be listed. (For example, 31/31 days would mean your coverage of this drug is limited to 31 pills every 31 days, or 1 pill per day.) Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount. Step Therapy (ST): In some cases, Health First Health Plans 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 1 and Drug 2 both treat your medical condition, Health First Health Plans may not cover Drug 2 unless you try Drug 1 first. If Drug 1 does not work for you, Health First Health Plans will then cover Drug 2. Pill Splitting (1/2): You may be able to split these pills in half. Begin by asking your doctor if pill-splitting is right for you. If so, ask your doctor to write your prescription for half the number of pills and double the strength you normally need. For example, instead of 30 pills of 20 mg, you would get a prescription for 15 pills of 40 mg. Then you (or the pharmacy) can split them in half for the correct dose. This way, you only pay 50 percent of you copay. Call our Customer Service Department for details. Coverage Gap ( (S,E)): We provide additional coverage of this prescription drug in the coverage gap. Refer to our Evidence of Coverage for more information about this coverage. S Indicates coverage in the coverage gap for the Florida Hospital (FH) SunSaver Plan. E - Indicates coverage in the coverage gap for the Florida Hospital (FH) Explorer Plan. Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 6

7 Generic Notes Drug Generic Notes ANALGESICS ANALGESICS Acetaminophen-Codeine #2 ORAL TABLET Acetaminophen-Codeine #3 ORAL TABLET ; QL (248 EA per 31 ; QL (248 EA per 31 Hydrocodone- Acetaminophen ORAL TABLET , 5-325, Hydrocodone-Ibuprofen ORAL TABLET ; QL (248 EA per 31 ; QL (155 EA per 31 Acetaminophen-Codeine #4 ORAL TABLET Acetaminophen-Codeine ORAL /5ML Butalbital-AP-Caff-Cod ORAL CAPSULE ; QL (248 EA per 31 QL (186 EA per 31 Oxycodone-Acetaminophen ORAL TABLET , , 5-325, Tramadol-Acetaminophen ORAL TABLET NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ; QL (248 EA per 31 ; QL (248 EA per 31 Endocet ORAL TABLET , Endocet ORAL TABLET Hydrocodone- Acetaminophen ORAL /15ML Hydrocodone- Acetaminophen ORAL TABLET , 5-300, ; QL (248 EA per 31 ; QL (248 EA per 31 ; QL (248 EA per 31 CELEBREX ORAL CAPSULE (Celecoxib) 100, 200, 400, 50 Diclofenac Potassium ORAL TABLET 50 Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 7

8 Generic Notes Drug Generic Notes Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Etodolac ORAL TABLET 400, 500 Nabumetone ORAL TABLET 500, 750 Naproxen DR ORAL TABLET DELAYED RELEASE 375, 500 Flurbiprofen ORAL TABLET 100, 50 Ibuprofen ORAL SUSPENSION 100 /5ML Naproxen ORAL SUSPENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 Ibuprofen ORAL TABLET 400, 600, 800 Naproxen Sodium ORAL TABLET 275, 550 Indomethacin ORAL CAPSULE 25, 50 Oxaprozin ORAL TABLET 600 Ketoprofen ORAL CAPSULE 50, 75 Oxycodone-Ibuprofen ORAL TABLET QL (155 EA per 31 Ketorolac Tromethamine INJECTION 15 /ML Ketorolac Tromethamine INJECTION 30 /ML ; ; QL (40 ML per 31 ; Piroxicam ORAL CAPSULE 10, 20 Sulindac ORAL TABLET 150, 200 OPIOID ANALGESICS, LONG-ACTING Meloxicam ORAL TABLET 15, 7.5 T1 (E,S) Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 8

9 Generic Notes Drug Generic Notes ACTIQ BUCCAL LOLLIPOP (FentaNYL Citrate) 1200 M, 1600 M, 400 M, 600 M, 800 M Duramorph INJECTION 0.5 /ML, 1 /ML Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100, 15, 30, 60 Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 200 ; QL (93 EA per 31 ; QL (62 EA per 31 FentaNYL Citrate BUCCAL LOLLIPOP 200 M FentaNYL TRANSDERMAL TCH 72 HR 100 M/HR, 12 M/HR, 25 M/HR, 50 M/HR, 75 M/HR Methadone HCl INJECTION 10 /ML Methadone HCl ORAL 10 /5ML, 5 /5ML ; QL (15 EA per 31 Morphine Sulfate ORAL TABLET 15, 30 ONA ER ORAL 10, 15, 20, 30, 40, 5, 7.5 TraMADol HCl ER (Biphasic) ORAL TABLET EXTENDED RELEASE 24 HR* 300 TraMADol HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 100, 200 ; QL (248 EA per 31 QL (62 EA per 31 QL (31 EA per 31 QL (31 EA per 31 Methadone HCl ORAL TABLET 10, 5 ; QL (248 EA per 31 OPIOID ANALGESICS, SHORT-ACTING Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 9

10 Generic Notes Drug Generic Notes ACTIQ BUCCAL LOLLIPOP (FentaNYL Citrate) 1200 M, 1600 M, 400 M, 600 M, 800 M Codeine Sulfate ORAL TABLET 15, 30, 60 FentaNYL TRANSDERMAL TCH 72 HR 100 M/HR, 12 M/HR, 25 M/HR, 50 M/HR, 75 M/HR HYDROmorphone HCl ORAL TABLET 2, 4, 8 OxyCODONE HCl ORAL TABLET 10 OxyCODONE HCl ORAL TABLET 15, 30, 5 TraMADol HCl ORAL TABLET 50 ANESTHETICS LOCAL ANESTHETICS ; QL (248 EA per 31 ; QL (15 EA per 31 ; QL (248 EA per 31 ; QL (248 EA per 31 ; QL (248 EA per 31 ; QL (248 EA per 31 Lidocaine EXTERNAL OINTMENT 5 % Lidocaine EXTERNAL TCH 5 % Lidocaine HCl (PF) INJECTION 0.5 %, 1 % Lidocaine HCl EXTERNAL 4 % Lidocaine Viscous MOUTH/THROAT 2 % Lidocaine-Prilocaine EXTERNAL CREAM % ; QL (93 EA per 31 ; ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ ANTI-CRAVING ANTABUSE ORAL TABLET (Disulfiram) 250, 500 CAMPRAL ORAL TABLET DELAYED RELEASE (Acamprosate Calcium) 333 QL (186 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 10

11 Generic Notes Drug Generic Notes Naltrexone HCl ORAL TABLET 50 VIVITROL INTRAMUSCULAR* SUSPENSION RECONSTITUTED 380 OPIOID DEPENDENCE TREATMENTS Buprenorphine HCl INJECTION 0.3 /ML Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2, 8 Naltrexone HCl ORAL TABLET 50 SUBOXONE SUBLINGUAL FILM 12-3, 4-1 SUBOXONE SUBLINGUAL FILM 2-0.5, 8-2 OPIOID REVERSAL AGENTS Naloxone HCl INJECTION 1 /ML QL (93 EA per 31 QL (62 EA per 31 QL (62 EA per 31 SMOKING CESSATION AGENTS CHANTIX ORAL TABLET 0.5, 1 CHANTIX STARTING MONTH K ORAL TABLET 0.5 X 11 & 1 X 42 NICOTROL INHALATION INHALER 10 NICOTROL NS NASAL 10 /ML ANTIBACTERIALS AMINOGLYCOSIDES Amikacin Sulfate INJECTION 500 /2ML Gentamicin in Saline /ML-%, /ML- % Gentamicin in Saline /ML-%, /ML-% QL (340 EA per 365 QL (53 EA per 28 ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 11

12 Generic Notes Drug Generic Notes Gentamicin in Saline /ML-%, /ML-% Gentamicin Sulfate EXTERNAL CREAM 0.1 % Gentamicin Sulfate EXTERNAL OINTMENT 0.1 % Gentamicin Sulfate INJECTION 40 /ML Gentamicin Sulfate 10 /ML Gentamicin Sulfate OPHTHALMIC 0.3 % Neomycin Sulfate ORAL TABLET 500 Neomycin-Polymyxin B GU IRRIGATION Paromomycin Sulfate ORAL CAPSULE 250 ; ; Streptomycin Sulfate INTRAMUSCULAR* RECONSTITUTED 1 GM TOBI INHALATION NEBULIZATION (Tobramycin) 300 /5ML TOBRADEX OPHTHALMIC OINTMENT % Tobramycin OPHTHALMIC 0.3 % Tobramycin Sulfate in Saline /ML-% Tobramycin Sulfate INJECTION 10 /ML, 80 /2ML ANTIBACTERIALS Colistimethate Sodium INJECTION RECONSTITUTED 150 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 12

13 Generic Notes Drug Generic Notes SYNERCID RECONSTITUTED ANTIBACTERIALS, OTHER Acetic Acid OTIC 2 % ALTABAX EXTERNAL OINTMENT 1 % Bacitracin INTRAMUSCULAR* RECONSTITUTED UNIT Bacitracin OPHTHALMIC OINTMENT 500 UNIT/GM BACTROBAN NASAL NASAL OINTMENT 2 % Chloramphenicol Sod Succinate RECONSTITUTED 1 GM CLEOCIN IN D5W (Clindamycin Phosphate in D5W) 300 /50ML, 600 /50ML, 900 /50ML CLEOCIN VAGINAL CREAM 2 % CLEOCIN VAGINAL SUPPOSITORY 100 Clindamycin HCl ORAL CAPSULE 150, 300 Clindamycin Phosphate EXTERNAL 1 % Clindamycin Phosphate EXTERNAL LOTION 1 % Clindamycin Phosphate EXTERNAL 1 % Clindamycin Phosphate EXTERNAL SWAB 1 % Clindamycin Phosphate 600 /4ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 13

14 Generic Notes Drug Generic Notes Clindamycin Phosphate VAGINAL CREAM 2 % MetroNIDAZOLE VAGINAL 0.75 % CUBICIN RECONSTITUTED 500 Global Alcohol Prep Ease D 70 % LINCOCIN INJECTION 300 /ML Methenamine Hippurate ORAL TABLET 1 GM MetroNIDAZOLE EXTERNAL 0.75 % MetroNIDAZOLE EXTERNAL CREAM 0.75 % MONUROL ORAL CKET 3 GM Mupirocin EXTERNAL OINTMENT 2 % Nitrofurantoin Macrocrystal ORAL CAPSULE 100, 50 Nitrofurantoin Monohyd Macro ORAL CAPSULE 100 Polymyxin B Sulfate INJECTION RECONSTITUTED UNIT PRIMSOL ORAL 50 /5ML MetroNIDAZOLE EXTERNAL LOTION 0.75 % MetroNIDAZOLE in NaCl /100ML-% Trimethoprim ORAL TABLET 100 TYGACIL RECONSTITUTED 50 MetroNIDAZOLE ORAL TABLET 250, 500 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 14

15 Generic Notes Drug Generic Notes Vancomycin HCl RECONSTITUTED 10 GM, 500 Vancomycin HCl RECONSTITUTED 1000 Vancomycin HCl ORAL CAPSULE 125, 250 BETA-LACTAM, CEPHALOSPORINS Cefaclor ER ORAL TABLET EXTENDED RELEASE 12 HR* 500 Cefaclor ORAL CAPSULE 250, 500 Cefadroxil ORAL CAPSULE 500 Cefadroxil ORAL SUSPENSION RECONSTITUTED 250 /5ML, 500 /5ML XIFAXAN ORAL TABLET 200 ; QL (42 EA per 31 Cefadroxil ORAL TABLET 1 GM XIFAXAN ORAL TABLET 550 ZYVOX 2 /ML ZYVOX ORAL SUSPENSION RECONSTITUTED 100 /5ML ZYVOX ORAL TABLET (Linezolid) 600 ; QL (62 EA per 31 CeFAZolin Sodium INJECTION RECONSTITUTED 1 GM, 500 CeFAZolin Sodium INJECTION RECONSTITUTED 10 GM CeFAZolin Sodium 1-5 GM-% Cefdinir ORAL CAPSULE 300 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 15

16 Generic Notes Drug Generic Notes Cefdinir ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Cefepime HCl INJECTION RECONSTITUTED 1 GM, 2 GM Cefpodoxime Proxetil ORAL TABLET 100, 200 CefTRIAXone Sodium INJECTION RECONSTITUTED 250, 500 CefTRIAXone Sodium RECONSTITUTED 1 GM, 10 GM, 2 GM Cefuroxime Axetil ORAL TABLET 250, 500 Cephalexin ORAL CAPSULE 250, 500 Cephalexin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Cephalexin ORAL TABLET 250, 500 FORTAZ INJECTION RECONSTITUTED (CefTAZidime) 2 GM, 6 GM Fortaz RECONSTITUTED 1 GM FORTAZ RECONSTITUTED 2 GM Cefuroxime Sodium INJECTION RECONSTITUTED 1.5 GM, 7.5 GM, 750 SUPRAX ORAL CAPSULE 400 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 16

17 Generic Notes Drug Generic Notes SUPRAX ORAL SUSPENSION RECONSTITUTED 100 /5ML, 200 /5ML, 500 /5ML SUPRAX ORAL TABLET CHEWABLE 100, 200 TEFLARO RECONSTITUTED 400, 600 BETA-LACTAM, OTHER AZACTAM IN DEXTROSE 1 GM, 2 GM Aztreonam INJECTION RECONSTITUTED 1 GM INVANZ INJECTION RECONSTITUTED 1 GM Meropenem RECONSTITUTED 500 BETA-LACTAM, PENICILLINS Amoxicillin ORAL CAPSULE 250, 500 Amoxicillin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 200 /5ML, 250 /5ML, 400 /5ML Amoxicillin ORAL TABLET 500, 875 Imipenem-Cilastatin RECONSTITUTED 250, 500 Amoxicillin ORAL TABLET CHEWABLE 125, 250 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 17

18 Generic Notes Drug Generic Notes Amoxicillin-Pot Clavulanate ORAL SUSPENSION RECONSTITUTED /5ML, /5ML, /5ML Amoxicillin-Pot Clavulanate ORAL TABLET , , Amoxicillin-Pot Clavulanate ORAL TABLET CHEWABLE , Ampicillin ORAL CAPSULE 250, 500 Ampicillin Sodium INJECTION RECONSTITUTED 125 Ampicillin Sodium RECONSTITUTED 10 GM Ampicillin-Sulbactam Sodium INJECTION RECONSTITUTED 3 (2-1) GM Ampicillin-Sulbactam Sodium RECONSTITUTED 15 (10-5) GM Ampicillin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Ampicillin Sodium INJECTION RECONSTITUTED 1 GM BACTOCILL IN DEXTROSE 1 GM/50ML, 2 GM/50ML BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION UNIT/2ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 18

19 Generic Notes Drug Generic Notes BICILLIN C-R INTRAMUSCULAR* SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML Dicloxacillin Sodium ORAL CAPSULE 250, 500 Nafcillin Sodium INJECTION RECONSTITUTED 1 GM Timentin RECONSTITUTED 3.1 GM ZOSYN GM/50ML, GM/50ML ZOSYN RECONSTITUTED (Piperacillin Sod- Tazobactam So) GM MACROLIDES Penicillin G Potassium INJECTION RECONSTITUTED UNIT Penicillin V Potassium ORAL RECONSTITUTED 125 /5ML, 250 /5ML AZASITE OPHTHALMIC 1 % Azithromycin RECONSTITUTED 500 Penicillin V Potassium ORAL TABLET 250, 500 Azithromycin ORAL SUSPENSION RECONSTITUTED 100 /5ML, 200 /5ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 19

20 Generic Notes Drug Generic Notes Azithromycin ORAL TABLET 250, 500, 600 Erythromycin OPHTHALMIC OINTMENT 5 /GM Clarithromycin ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 Clarithromycin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Clarithromycin ORAL TABLET 250, 500 DIFICID ORAL TABLET 200 Ery EXTERNAL D 2 % ERYTHROCIN LACTOBIONATE RECONSTITUTED 500 Erythromycin Base ORAL TABLET 250, 500 QUINOLONES Ciprofloxacin HCl OPHTHALMIC 0.3 % Ciprofloxacin HCl ORAL TABLET 100, 250, 500, 750 Ciprofloxacin 400 /40ML Ciprofloxacin-Ciproflox HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 1000, 500 Levofloxacin 25 /ML Levofloxacin OPHTHALMIC 0.5 % Erythromycin EXTERNAL 2 % Levofloxacin ORAL 25 /ML Erythromycin EXTERNAL 2 % Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 20

21 Generic Notes Drug Generic Notes Levofloxacin ORAL TABLET 250, 500, 750 MOXEZA OPHTHALMIC 0.5 % Ofloxacin OPHTHALMIC 0.3 % Ofloxacin ORAL TABLET 300, 400 Ofloxacin OTIC 0.3 % VIGAMOX OPHTHALMIC 0.5 % ZYMAXID OPHTHALMIC (Gatifloxacin) 0.5 % SULFONAMIDES Silvadene EXTERNAL CREAM 1 % Silver Sulfadiazine EXTERNAL CREAM 1 % SSD EXTERNAL CREAM 1 % Sulfacetamide Sodium OPHTHALMIC 10 % SulfADIAZINE ORAL TABLET 500 Sulfamethoxazole- Trimethoprim /5ML Sulfamethoxazole- Trimethoprim ORAL SUSPENSION /5ML Sulfamethoxazole- Trimethoprim ORAL TABLET , TETRACYCLINES Doxycycline Hyclate ORAL TABLET 100, 20 Doxycycline Monohydrate ORAL CAPSULE 100, 50 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 21

22 Generic Notes Drug Generic Notes Doxycycline Monohydrate ORAL TABLET 50, 75 Minocycline HCl ORAL CAPSULE 100, 50, 75 ANTICONVULSANTS LevETIRAcetam ORAL TABLET 1000 LevETIRAcetam ORAL TABLET 250, 500, 750 POTIGA ORAL TABLET 200 ; QL (93 EA per 31 ; QL (62 EA per 31 ; QL (93 EA per 31 ANTICONVULSANTS, OTHER Diazepam 10, 2.5, 20 LevETIRAcetam ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 ; QL (186 EA per 31 POTIGA ORAL TABLET 300, 400 POTIGA ORAL TABLET 50 CALCIUM CHANNEL MODIFYING AGENTS ; QL (93 EA per 31 ; QL (279 EA per 31 LevETIRAcetam ER ORAL TABLET EXTENDED RELEASE 24 HR* 750 LEVETIRACETAM IN NACL 1000 /100ML, 1500 /100ML, 500 /100ML LevETIRAcetam 500 /5ML LevETIRAcetam ORAL 100 /ML ; QL (124 EA per 31 CELONTIN ORAL CAPSULE 300 Ethosuximide ORAL CAPSULE 250 Ethosuximide ORAL 250 /5ML LYRICA ORAL CAPSULE 100, 150, 200, 25, 50, 75 LYRICA ORAL CAPSULE 225, 300 QL (93 EA per 31 QL (62 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 22

23 Generic Notes Drug Generic Notes LYRICA ORAL 20 /ML QL (930 ML per 31 Diazepam ORAL TABLET 10 ; QL (124 EA per 31 Zonisamide ORAL CAPSULE 100, 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS ClonazeM ORAL TABLET 0.5, 1 ClonazeM ORAL TABLET 2 ClonazeM ORAL TABLET DISPERSIBLE 0.125, 0.25, 0.5, 1, 2 Clorazepate Dipotassium ORAL TABLET 15 Clorazepate Dipotassium ORAL TABLET 3.75, 7.5 Diazepam Intensol ORAL CONCENTRATE 5 /ML Diazepam ORAL 1 /ML ; QL (93 EA per 31 ; QL (310 EA per 31 ; QL (186 EA per 31 ; QL (93 EA per 31 Diazepam ORAL TABLET 2, 5 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250, 500 Divalproex Sodium ORAL CAPSULE SPRINKLE 125 Divalproex Sodium ORAL TABLET DELAYED RELEASE 125, 250, 500 Gabapentin ORAL CAPSULE 100, 300 Gabapentin ORAL CAPSULE 400 Gabapentin ORAL 250 /5ML Gabapentin ORAL TABLET 600 Gabapentin ORAL TABLET 800 ; QL (93 EA per 31 ; QL (372 EA per 31 ; QL (279 EA per 31 ; QL (2232 ML per 31 ; QL (186 EA per 31 ; QL (140 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 23

24 Generic Notes Drug Generic Notes LamoTRIgine ORAL TABLET DISPERSIBLE 100, 200, 25, 50 ONFI ORAL SUSPENSION 2.5 /ML ONFI ORAL TABLET 10 ONFI ORAL TABLET 20 PHENobarbital ORAL ELIXIR 20 /5ML PHENobarbital ORAL TABLET 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 Valproate Sodium 500 /5ML Valproic Acid ORAL CAPSULE 250 Valproic Acid ORAL SYRUP 250 /5ML GLUTAMATE REDUCING AGENTS Felbamate ORAL SUSPENSION 600 /5ML Felbamate ORAL TABLET 400, 600 FYCOM ORAL TABLET 10, 12 FYCOM ORAL TABLET 2 ; QL (31 EA per 31 ; QL (62 EA per 31 Primidone ORAL TABLET 250, 50 SABRIL ORAL CKET 500 SABRIL ORAL TABLET 500 TiaGABine HCl ORAL TABLET 2, 4 FYCOM ORAL TABLET 4, 6, 8 LAMICTAL ODT ORAL TABLET DISPERSIBLE 100, 200, 25, 50 ; QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 24

25 Generic Notes Drug Generic Notes LamoTRIgine ORAL TABLET 100, 150, 200, 25 CarBAMazepine ORAL SUSPENSION 100 /5ML LamoTRIgine ORAL TABLET CHEWABLE 25, 5 CarBAMazepine ORAL TABLET CHEWABLE 100 Topiramate ORAL CAPSULE SPRINKLE 15, 25 CEREBYX INJECTION 500 PE/10ML Topiramate ORAL TABLET 100, 200, 25, 50 Dilantin Infatabs ORAL TABLET CHEWABLE 50 SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200, 400, 600, 800 BANZEL ORAL SUSPENSION 40 /ML BANZEL ORAL TABLET 200 BANZEL ORAL TABLET 400 CarBAMazepine ER ORAL TABLET EXTENDED RELEASE 12 HR* 200, 400 ; QL (2480 ML per 31 ; QL (93 EA per 31 ; QL (248 EA per 31 Dilantin ORAL CAPSULE 30 EPITOL ORAL TABLET (CarBAMazepine) 200 Fosphenytoin Sodium INJECTION 100 PE/2ML OXcarbazepine ORAL SUSPENSION 300 /5ML OXcarbazepine ORAL TABLET 150, 300, 600 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 25

26 Generic Notes Drug Generic Notes Peganone ORAL TABLET 250 PHENYTEK ORAL CAPSULE 200, 300 Phenytoin ORAL SUSPENSION 125 /5ML Phenytoin ORAL TABLET CHEWABLE 50 Phenytoin Sodium Extended ORAL CAPSULE 100, 200, 300 Phenytoin Sodium INJECTION 50 /ML VIMT 200 /20ML VIMT ORAL 10 /ML Vimpat ORAL TABLET 100, 150, 50 VIMT ORAL TABLET 200 ; QL (1240 ML per 31 ; QL (1240 ML per 31 ; QL (62 EA per 31 ; QL (62 EA per 31 ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER Ergoloid Mesylates ORAL TABLET 1 CHOLINESTERASE INHIBITORS ARICEPT ORAL TABLET (Donepezil HCl) 23 Donepezil HCl ORAL TABLET 10 Donepezil HCl ORAL TABLET 5 Donepezil HCl ORAL TABLET DISPERSIBLE 10, 5 EXELON TRANSDERMAL TCH 24 HR 13.3 /24HR EXELON TRANSDERMAL TCH 24 HR 4.6 /24HR, 9.5 /24HR QL (31 EA per 31 ; QL (62 EA per 31 QL (31 EA per 31 QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 26

27 Generic Notes Drug Generic Notes Galantamine Hydrobromide ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16, 24, 8 Galantamine Hydrobromide ORAL 4 /ML Galantamine Hydrobromide ORAL TABLET 12, 4, 8 Rivastigmine Tartrate ORAL CAPSULE 1.5, 3, 4.5, 6 QL (31 EA per 31 QL (620 ML per 31 QL (62 EA per 31 QL (62 EA per 31 N-METHYL-D-ASRTATE (NMDA) RECEPTOR ANTAGONIST NAMENDA ORAL 10 /5ML NAMENDA ORAL TABLET (Memantine HCl) 10, 5 QL (320 ML per 31 NAMENDA TITRATION K ORAL TABLET (Memantine HCl) 5 (28)- 10 (21) NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14, 21, 28, 7 NAMENDA XR TITRATION CK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 ANTIDEPRESSANTS ANTIDEPRESSANTS OLANZapine-FLUoxetine HCl ORAL CAPSULE 12-25, 12-50, 3-25, 6-25, 6-50 QL (31 EA per 31 Perphenazine-Amitriptyline ORAL TABLET 2-10, 2-25, 4-10, 4-25, 4-50 ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 27

28 Generic Notes Drug Generic Notes ANTIDEPRESSANTS, OTHER ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300, 400 ABILIFY ORAL TABLET (ARIPiprazole) 10, 20, 30 ABILIFY ORAL TABLET (ARIPiprazole) 15, 2, 5 Buproban ORAL TABLET EXTENDED RELEASE 12 HR* 150 BuPROPion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200 BuPROPion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150, 300 1/2; QL (31 EA per 31 QL (31 EA per 31 QL (62 EA per 31 ; QL (62 EA per 31 ; QL (31 EA per 31 Maprotiline HCl ORAL TABLET 25, 50, 75 Mirtazapine ORAL TABLET 15, 7.5 Mirtazapine ORAL TABLET 30, 45 Mirtazapine ORAL TABLET DISPERSIBLE 15, 30, 45 Nefazodone HCl ORAL TABLET 100, 150, 250, 50 Nefazodone HCl ORAL TABLET 200 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150, 200, 300, 400, 50 TraZODone HCl ORAL TABLET 100, 150, 50 TraZODone HCl ORAL TABLET 300 ; QL (93 EA per 31 ; QL (31 EA per 31 ; QL (31 EA per 31 ; QL (62 EA per 31 ; QL (93 EA per 31 BuPROPion HCl ORAL TABLET 100, 75 VIIBRYD ORAL KIT 10 & 20 & 40 ST; QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 28

29 Generic Notes Drug Generic Notes MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL TCH 24 HR 12 /24HR, 6 /24HR, 9 /24HR MARPLAN ORAL TABLET 10 NARDIL ORAL TABLET (Phenelzine Sulfate) 15 Tranylcypromine Sulfate ORAL TABLET 10 SSRIS/ SNRIS BRINTELLIX ORAL TABLET 10, 20, 5 Citalopram Hydrobromide ORAL 10 /5ML Citalopram Hydrobromide ORAL TABLET 10, 40 Citalopram Hydrobromide ORAL TABLET 20 ; QL (31 EA per 31 ST ; QL (31 EA per 31 T1 (E,S); QL (620 ML per 31 ; QL (31 EA per 31 ; QL (62 EA per 31 DULoxetine HCl ORAL CAPSULE DELAYED RELEASE RTICLES 20, 60 DULoxetine HCl ORAL CAPSULE DELAYED RELEASE RTICLES 30 Escitalopram Oxalate ORAL 5 /5ML Escitalopram Oxalate ORAL TABLET 10, 20 Escitalopram Oxalate ORAL TABLET 5 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120, 20, 40, 80 FETZIMA TITRATION ORAL 20 & 40 FLUoxetine HCl ORAL CAPSULE 10, 20 FLUoxetine HCl ORAL CAPSULE 40 QL (62 EA per 31 QL (93 EA per 31 ; QL (620 ML per 31 1/2; ; QL (31 EA per 31 ; QL (31 EA per 31 ST; QL (31 EA per 31 ST; QL (31 EA per 31 ; QL (93 EA per 31 ; QL (62 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 29

30 Generic Notes Drug Generic Notes FLUoxetine HCl ORAL CAPSULE DELAYED RELEASE 90 XIL ORAL SUSPENSION 10 /5ML QL (930 ML per 31 FLUoxetine HCl ORAL 20 /5ML FLUoxetine HCl ORAL TABLET 10 FLUoxetine HCl ORAL TABLET 20 FluvoxaMINE Maleate ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100, 150 FluvoxaMINE Maleate ORAL TABLET 100, 25, 50 Roxetine HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 12.5 Roxetine HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 25, 37.5 Roxetine HCl ORAL TABLET 10, 20, 30, 40 ; QL (620 ML per 31 QL (93 EA per 31 QL (124 EA per 31 QL (62 EA per 31 QL (31 EA per 31 QL (62 EA per 31 ; QL (93 EA per 31 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100, 50 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 Sertraline HCl ORAL CONCENTRATE 20 /ML Sertraline HCl ORAL TABLET 100, 25, 50 Venlafaxine HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 Venlafaxine HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 37.5, 75 Venlafaxine HCl ORAL TABLET 100, 25, 37.5, 50, 75 ST; QL (31 EA per 31 ST; QL (31 EA per 31 ; QL (310 ML per 31 ; QL (62 EA per 31 ; QL (62 EA per 31 ; QL (93 EA per 31 QL (93 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 30

31 Generic Notes Drug Generic Notes VIIBRYD ORAL TABLET 10 VIIBRYD ORAL TABLET 20, 40 TRICYCLICS Amitriptyline HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Amoxapine ORAL TABLET 100, 150, 25, 50 ClomiPRAMINE HCl ORAL CAPSULE 25, 50, 75 Desipramine HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CAPSULE 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CONCENTRATE 10 /ML ST; QL (31 EA per 31 ST; QL (31 EA per 31 ; ; ; Imipramine HCl ORAL TABLET 10, 25, 50 Nortriptyline HCl ORAL CAPSULE 10, 25, 50, 75 Nortriptyline HCl ORAL 10 /5ML Protriptyline HCl ORAL TABLET 10, 5 Surmontil ORAL CAPSULE 100, 25, 50 ANTIEMETICS ANTIEMETICS, OTHER ChlorproMAZINE HCl INJECTION 25 /ML ChlorproMAZINE HCl ORAL TABLET 10, 100, 200, 25, 50 DiphenhydrAMINE HCl INJECTION 50 /ML ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 31

32 Generic Notes Drug Generic Notes Meclizine HCl ORAL TABLET 12.5, 25 Dronabinol ORAL CAPSULE 2.5, 5 ; QL (62 EA per 31 Metoclopramide HCl INJECTION 5 /ML Metoclopramide HCl ORAL 5 /5ML Metoclopramide HCl ORAL TABLET 10, 5 Perphenazine ORAL TABLET 16, 2, 4, 8 Prochlorperazine Edisylate INJECTION 5 /ML ; EMEND ORAL CAPSULE 125, 40, 80 & 125, 80 Granisetron HCl 0.1 /ML, 1 /ML Granisetron HCl ORAL TABLET 1 Ondansetron HCl INJECTION 4 /2ML Ondansetron HCl ORAL 4 /5ML ; QL (62 EA per 31 ; ; Prochlorperazine Maleate ORAL TABLET 10, 5 Prochlorperazine SUPPOSITORY 25 Ondansetron HCl ORAL TABLET 4, 8 Ondansetron ORAL TABLET DISPERSIBLE 4, 8 EMETOGENIC THERAPY ADJUNCTS ANTIFUNGALS Dronabinol ORAL CAPSULE 10 ; QL (62 EA per 31 ANTIFUNGALS Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 32

33 Generic Notes Drug Generic Notes ABELCET SUSPENSION 5 /ML AMBISOME SUSPENSION RECONSTITUTED 50 Amphotericin B INJECTION RECONSTITUTED 50 CANCIDAS RECONSTITUTED 50, 70 Ciclopirox EXTERNAL SHAMPOO 1 % Ciclopirox EXTERNAL 8 % Ciclopirox Olamine EXTERNAL CREAM 0.77 % Ciclopirox Olamine EXTERNAL SUSPENSION 0.77 % Clotrimazole EXTERNAL CREAM 1 % Clotrimazole EXTERNAL 1 % Clotrimazole MOUTH/THROAT TROCHE 10 Econazole Nitrate EXTERNAL CREAM 1 % Fluconazole in Dextrose 400 /200ML Fluconazole ORAL SUSPENSION RECONSTITUTED 10 /ML, 40 /ML Fluconazole ORAL TABLET 100, 150, 200, 50 Flucytosine ORAL CAPSULE 250, 500 Griseofulvin Microsize ORAL SUSPENSION 125 /5ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 33

34 Generic Notes Drug Generic Notes Itraconazole ORAL CAPSULE 100 Ketoconazole EXTERNAL CREAM 2 % Ketoconazole EXTERNAL SHAMPOO 2 % Ketoconazole ORAL TABLET 200 MYCAMINE RECONSTITUTED 100 MYCAMINE RECONSTITUTED 50 NAFTIN EXTERNAL 1 % ; QL (124 EA per 31 NOXAFIL ORAL SUSPENSION 40 /ML Nystatin EXTERNAL CREAM UNIT/GM Nystatin EXTERNAL OINTMENT UNIT/GM Nystatin EXTERNAL POWDER UNIT/GM Nystatin MOUTH/THROAT SUSPENSION UNIT/ML Nystatin ORAL TABLET UNIT Nystop EXTERNAL POWDER UNIT/GM NAFTIN EXTERNAL CREAM (Naftifine HCl) 1 % NATACYN OPHTHALMIC SUSPENSION 5 % Terbinafine HCl ORAL TABLET 250 Terconazole VAGINAL CREAM 0.4 %, 0.8 % ; QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 34

35 Generic Notes Drug Generic Notes Voriconazole RECONSTITUTED 200 Voriconazole ORAL TABLET 200, 50 ANTIGOUT AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS CELEBREX ORAL CAPSULE (Celecoxib) 100, 200, 400, 50 Diclofenac Potassium ORAL TABLET 50 ANTIGOUT AGENTS Allopurinol ORAL TABLET 100, 300 Colchicine-Probenecid ORAL TABLET COLCRYS ORAL TABLET 0.6 Probenecid ORAL TABLET 500 ULORIC ORAL TABLET 40, 80 ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS PrednisoLONE Acetate OPHTHALMIC SUSPENSION 1 % QL (124 EA per 31 ST Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Etodolac ORAL TABLET 400, 500 Flurbiprofen ORAL TABLET 100, 50 Ibuprofen ORAL SUSPENSION 100 /5ML Ibuprofen ORAL TABLET 400, 600, 800 Indomethacin ORAL CAPSULE 25, 50 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 35

36 Generic Notes Drug Generic Notes Ketoprofen ORAL CAPSULE 50, 75 Oxycodone-Ibuprofen ORAL TABLET QL (155 EA per 31 Ketorolac Tromethamine INJECTION 15 /ML Ketorolac Tromethamine INJECTION 30 /ML Meloxicam ORAL TABLET 15, 7.5 Nabumetone ORAL TABLET 500, 750 T1 ; ; QL (40 ML per 31 ; (E,S) Piroxicam ORAL CAPSULE 10, 20 Sulindac ORAL TABLET 150, 200 ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS TREXIMET ORAL TABLET ERGOT ALKALOIDS QL (12 EA per 31 Naproxen DR ORAL TABLET DELAYED RELEASE 375, 500 Naproxen ORAL SUSPENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 Naproxen Sodium ORAL TABLET 275, 550 Dihydroergotamine Mesylate INJECTION 1 /ML MIGERGOT SUPPOSITORY PROPHYLACTIC Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250, 500 QL (20 EA per 28 Oxaprozin ORAL TABLET 600 Divalproex Sodium ORAL CAPSULE SPRINKLE 125 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 36

37 Generic Notes Drug Generic Notes Divalproex Sodium ORAL TABLET DELAYED RELEASE 125, 250, 500 Timolol Maleate ORAL TABLET 10, 20, 5 Topiramate ORAL CAPSULE SPRINKLE 15, 25 Topiramate ORAL TABLET 100, 200, 25, 50 Valproic Acid ORAL CAPSULE 250 Valproic Acid ORAL SYRUP 250 /5ML SUMAtriptan Succinate ORAL TABLET 100, 25, 50 SUMAtriptan Succinate SUBCUTANEOUS* 6 /0.5ML SUMAtriptan Succinate SUBCUTANEOUS* 6 /0.5ML ZOMIG ORAL TABLET (ZOLMitriptan) 2.5, 5 ZOMIG ZMT ORAL TABLET DISPERSIBLE (ZOLMitriptan) 2.5, 5 ANTIMYASTHENIC AGENTS ; QL (12 EA per 31 QL (8 ML per 31 QL (8 ML per 31 ST; QL (12 EA per 30 ST; QL (12 EA per 31 SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS RASYMTHOMIMETICS Naratriptan HCl ORAL TABLET 1, 2.5 ST; QL (12 EA per 31 Guanidine HCl ORAL TABLET 125 Rizatriptan Benzoate ORAL TABLET 10, 5 Rizatriptan Benzoate ORAL TABLET DISPERSIBLE 10, 5 ST; QL (12 EA per 31 ST; QL (12 EA per 31 MESTINON ORAL SYRUP 60 /5ML MESTINON ORAL TABLET 60 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 37

38 Generic Notes Drug Generic Notes MESTINON ORAL TABLET EXTENDEDRELEASE* (Pyridostigmine Bromide ER) 180 Pyridostigmine Bromide ORAL TABLET 60 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER Isoniazid ORAL TABLET 100, 300 SER ORAL CKET 4 GM Pyrazinamide ORAL TABLET 500 Rifampin RECONSTITUTED 600 Dapsone ORAL TABLET 100, 25 Rifampin ORAL CAPSULE 150, 300 MYCOBUTIN ORAL CAPSULE (Rifabutin) 150 ANTITUBERCULARS CASTAT SULFATE INJECTION RECONSTITUTED 1 GM Ethambutol HCl ORAL TABLET 100, 400 Isoniazid ORAL SYRUP 50 /5ML RIFATER ORAL TABLET TRECATOR ORAL TABLET 250 ANTINEOPLASTICS ALKYLATING AGENTS CYCLOPHOSPHAMID E ORAL CAPSULE 25, 50 Cyclophosphamide ORAL TABLET 25, 50 HEXALEN ORAL CAPSULE 50 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 38

39 Generic Notes Drug Generic Notes LEUKERAN ORAL TABLET 2 Lomustine ORAL CAPSULE 10, 100, 40 MATULANE ORAL CAPSULE 50 REVLIMID ORAL CAPSULE 10, 15, 25, 5 THALOMID ORAL CAPSULE 100, 150, 200, 50 ANTIESTROGENS/MODIFIERS ; LA THIOTE INJECTION RECONSTITUTED 15 ANTIANDROGENS Bicalutamide ORAL TABLET 50 Flutamide ORAL CAPSULE 125 NILANDRON ORAL TABLET 150 XTANDI ORAL CAPSULE 40 ZYTIGA ORAL TABLET 250 ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE 1, 2, 3, 4 ; QL (124 EA per 31 EMCYT ORAL CAPSULE 140 FARESTON ORAL TABLET 60 SOLTAMOX ORAL 10 /5ML Tamoxifen Citrate ORAL TABLET 10, 20 ANTIMETABOLITES DROXIA ORAL CAPSULE 200, 300, 400 Hydroxyurea ORAL CAPSULE 500 PURIXAN ORAL SUSPENSION 2000 /100ML TABLOID ORAL TABLET 40 QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting Y0089_EL4170FH Accepted Formulary ID 15183, Version 24 Page 39