PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing

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1 Presbyterian Health Plan Presbyterian Insurance Company, Inc. PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing This list is in order by therapeutic class. To find a specific drug, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F). Some medications may be excluded as determined by benefit. MPC0564 Effective 6//08

2 lowercase italics = Generic drugs PHP Commercial Non-Metal Plans Formulary UPPERCASE BOLD = Brand name drugs Drug Name Tier Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** guanfacine hcl er oral tablet extended release 4 hour mg, mg, 3 mg, 4 mg *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule 0 mg, 00 mg, 8 mg, 5 mg, 40 mg, 60 mg, 80 mg *AMPHETAMINE MIXTURES*** amphetamine-dextroamphet er oral capsule extended release 4 hour 0 mg, 5 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 4 hour 0 mg, 5 mg, 30 mg amphetamine-dextroamphetamine oral tablet 0 mg amphetamine-dextroamphetamine oral tablet.5 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral tablet 0 mg, 5 mg amphetamine-dextroamphetamine oral tablet 30 mg *AMPHETAMINES*** dextroamphetamine sulfate er oral capsule extended release 4 hour 0 mg QL (30 EA per 30 days) 3 ST; PA required for 9 years and older.; QL (30 EA per 30 days) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for 9 years and older.; Schedule II medications are limited to a 34 day supply maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (0 EA per 30 days); AG (Min 6 Years and Max 8 Years) MPC0564 Effective 6//08

3 dextroamphetamine sulfate er oral capsule extended release 4 hour 5 mg dextroamphetamine sulfate er oral capsule extended release 4 hour 5 mg dextroamphetamine sulfate oral tablet 0 mg dextroamphetamine sulfate oral tablet 5 mg VYVANSE ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *ANALEPTICS*** caffeine citrate intravenous solution 60 mg/3ml caffeine citrate oral solution 0 mg/ml *ANOREXIANTS NON-AMPHETAMINE*** phentermine hcl oral capsule 5 mg, 30 mg, 37.5 mg 3 PA *STIMULANTS - MISC.*** 3 PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (0 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 8 Years) PA; Schedule II medications are limited to a 34 day supply maximum.; QL (30 EA per 30 days) armodafinil oral tablet 00 mg, 50 mg PA; QL (30 EA per 30 days) armodafinil oral tablet 50 mg PA; QL (90 EA per 30 days) dexmethylphenidate hcl er oral capsule extended release 4 hour 0 mg, 5 mg, 0 mg, 5 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 0 mg, 5 mg 3 dexmethylphenidate hcl oral tablet.5 mg 3 METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG 3 PA; PA required for age 9 years and older.; Schedule II medications are limited to a 34 day supply maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA; PA required for age 9 years and older.; Schedule II medications are limited to a 34 day supply maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA; PA required for age 9 years and older.; Schedule II medications are limited to a 34 day supply maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) MPC Effective 6//08

4 methylphenidate hcl er (cd) oral capsule extended release 0 mg, 0 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (cd) oral capsule extended release 30 mg methylphenidate hcl er oral tablet extended release 0 mg, 36 mg methylphenidate hcl er oral tablet extended release 8 mg, 7 mg methylphenidate hcl er oral tablet extended release 0 mg methylphenidate hcl er oral tablet extended release 4 hour 8 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 4 hour 7 mg methylphenidate hcl er oral tablet extended release 54 mg methylphenidate hcl oral tablet 0 mg, 5 mg methylphenidate hcl oral tablet 0 mg PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) PA required for age 9 years and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 8 Years) modafinil oral tablet 00 mg, 00 mg PA; QL (30 EA per 30 days) *AMINOGLYCOSIDES* *AMINOGLYCOSIDES*** neomycin sulfate oral tablet 500 mg MPC Effective 6//08

5 paromomycin sulfate oral capsule 50 mg tobramycin inhalation nebulization solution 300 mg/5ml *ANALGESICS - ANTI-INFLAMMATORY* *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** 4 SP XELJANZ ORAL TABLET 5 MG 4 PA; SP; QL (60 EA per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG *ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS KIT 40 MG/0.8ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; QL (30 EA per 30 days) 4 PA; SP 4 PA; SP HUMIRA PEN SUBCUTANEOUS KIT 40 MG/0.8ML 4 PA; SP HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 4 PA; SP 4 PA; SP 4 PA; SP 4 PA; SP 4 PA; SP HUMIRA SUBCUTANEOUS KIT 0 MG/0.4ML 4 PA HUMIRA SUBCUTANEOUS KIT 40 MG/0.8ML 4 PA; SP HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.ML, 0 MG/0.4ML, 40 MG/0.8ML *CYCLOOXYGENASE (COX-) INHIBITORS*** celecoxib oral capsule 00 mg, 00 mg, 400 mg, 50 mg *GOLD COMPOUNDS*** RIDAURA ORAL CAPSULE 3 MG *INTERLEUKIN-6 RECEPTOR INHIBITORS*** ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.9ML *NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS*** diclofenac-misoprostol oral tablet delayed release mg, mg 4 PA; SP QL (60 EA per 30 days) 4 PA; SP; QL (3.6 ML per 8 days) MPC Effective 6//08 3

6 *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** childrens ibuprofen oral suspension 40 mg/ml diclofenac sodium er oral tablet extended release 4 hour 00 mg diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg etodolac er oral tablet extended release 4 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 400 mg, 500 mg FENOPROFEN CALCIUM ORAL TABLET 600 MG flurbiprofen oral tablet 00 mg, 50 mg ibuprofen junior strength oral tablet chewable 00 mg ibuprofen lysine intravenous solution 0 mg/ml ibuprofen oral suspension 00 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 5 mg, 50 mg ketoprofen er oral capsule extended release 4 hour 00 mg ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet 0 mg QL (0 EA per 30 days) meclofenamate sodium oral capsule 00 mg MECLOFENAMATE SODIUM ORAL CAPSULE 50 MG meloxicam oral tablet 5 mg, 7.5 mg MOTRIN IB ORAL TABLET 00 MG nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 5 mg/5ml naproxen oral tablet 50 mg, 375 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 0 mg, 0 mg sulindac oral tablet 50 mg, 00 mg TOLMETIN SODIUM ORAL CAPSULE 400 MG TOLMETIN SODIUM ORAL TABLET 600 MG *PYRIMIDINE SYNTHESIS INHIBITORS*** MPC Effective 6//08 leflunomide oral tablet 0 mg, 0 mg

7 *SELECTIVE COSTIMULATION MODULATORS*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 5 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML 4 PA; SP; QL (4 ML per 30 days) 4 PA; SP; QL (4 ML per 8 days) 4 PA; SP; QL (.6 ML per 8 days) 4 PA; SP; QL (.8 ML per 8 days) 4 PA; SP; QL (3.9 ML per 8 days) ENBREL SUBCUTANEOUS KIT 5 MG 4 PA; SP; QL (8 EA per 8 days) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/0.5ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *ANALGESICS-SEDATIVES*** butalbital-apap-caffeine oral tablet mg, mg 4 PA; SP; QL (4.08 ML per 8 days) 4 PA; SP; QL (7.84 ML per 8 days) 4 PA; SP; QL (7.84 ML per 8 days) QL (6 EA per day) butalbital-aspirin-caffeine oral tablet mg QL (6 EA per day) ZEBUTAL ORAL CAPSULE MG QL (6 EA per day) *SALICYLATES*** aspirin low dose oral tablet 8 mg aspirin oral tablet 35 mg, 8 mg $0 Copay per PPACA guidelines; AG (Min 45 Years) (Min 45 Years) aspirin oral tablet chewable 8 mg AG (Min 45 Years and Max 79 Years) aspirin oral tablet delayed release 35 mg, 8 mg BAYER ASPIRIN ORAL TABLET 35 MG BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 35 MG childrens aspirin oral tablet chewable 8 mg cvs aspirin oral tablet 35 mg cvs aspirin oral tablet delayed release 8 mg cvs childrens aspirin oral tablet chewable 8 mg (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) MPC Effective 6//08

8 diflunisal oral tablet 500 mg ec-8 aspirin oral tablet delayed release 8 mg eq aspirin oral tablet 35 mg eq aspirin oral tablet delayed release 35 mg, 500 mg eq childrens aspirin oral tablet chewable 8 mg eql aspirin oral tablet 35 mg eql childrens aspirin oral tablet chewable 8 mg gnp aspirin oral tablet 35 mg (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) gnp aspirin oral tablet delayed release 35 mg, 8 mg $0 copay per PPACA guidelines. hm aspirin oral tablet 35 mg $0 copay per PPACA guidelines. hm aspirin oral tablet chewable 8 mg $0 copay per PPACA guidelines. kp aspirin oral tablet delayed release 8 mg $0 copay per PPACA guidelines. mm aspirin oral tablet 35 mg $0 copay per PPACA guidelines. NORWICH ASPIRIN ORAL TABLET 35 MG $0 copay per PPACA guidelines. px aspirin oral tablet 35 mg $0 copay per PPACA guidelines. px aspirin oral tablet chewable 8 mg px enteric aspirin oral tablet delayed release 35 mg, 8 mg qc aspirin oral tablet 35 mg qc aspirin oral tablet delayed release 35 mg (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) qc childrens aspirin oral tablet chewable 8 mg AG (Min 45 Years) ra aspirin oral tablet 35 mg, 500 mg AG (Min 45 Years) ra childrens aspirin oral tablet chewable 8 mg AG (Min 45 Years) salsalate oral tablet 500 mg, 750 mg sb aspirin oral tablet 35 mg AG (Min 45 Years) sb aspirin oral tablet delayed release 8 mg AG (Min 45 Years) sb childrens aspirin oral tablet chewable 8 mg AG (Min 45 Years) sm aspirin oral tablet 35 mg sm childrens aspirin oral tablet chewable 8 mg ST JOSEPH ADULT LOW DOSE ORAL TABLET CHEWABLE 75 MG ST JOSEPH ASPIRIN ORAL TABLET CHEWABLE 8 MG ST JOSEPH ASPIRIN ORAL TABLET DELAYED RELEASE 8 MG (Min 45 Years) (Min 45 Years) AG (Min 45 Years and Max 79 Years) (Min 45 Years) (Min 45 Years) MPC Effective 6//08

9 tgt aspirin oral tablet 35 mg tgt aspirin oral tablet chewable 8 mg tgt aspirin oral tablet delayed release 8 mg tgt childrens aspirin oral tablet chewable 8 mg th aspirin oral tablet 35 mg th enteric aspirin oral tablet delayed release 35 mg *ANALGESICS - OPIOID* *CODEINE COMBINATIONS*** acetaminophen-codeine # oral tablet mg acetaminophen-codeine #3 oral tablet mg acetaminophen-codeine #4 oral tablet mg acetaminophen-codeine oral solution 0- mg/5ml butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg *HYDROCODONE COMBINATIONS*** hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral solution mg/5ml (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) (Min 45 Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (3 EA per day); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (3 EA per day); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (3 EA per day); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (66 ML per day); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (6 EA per day); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (6 EA per day); AG (Min Years) Schedule II medications are limited to a 34 day supply maximum.; QL (.3 ML per day) Schedule II medications are limited to a 34 day supply maximum.; QL (0 ML per day) MPC Effective 6//08

10 hydrocodone-acetaminophen oral tablet 0-35 mg, 5-35 mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg Schedule II medications are limited to a 34 day supply maximum.; QL ( EA per day) Schedule II medications are limited to a 34 day supply maximum.; QL (8 EA per day) Schedule II medications are limited to a 34 day supply maximum.; QL (6 EA per day) Schedule II medications are limited to a 34 day supply maximum.; QL (5 EA per day) HYDROGESIC ORAL CAPSULE MG QL (8 EA per day) *OPIOID AGONISTS*** codeine sulfate oral tablet 5 mg, 30 mg CODEINE SULFATE ORAL TABLET 60 MG fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydromorphone hcl oral tablet mg, 4 mg, 8 mg KADIAN ORAL CAPSULE EXTENDED RELEASE 4 HOUR 00 MG, 40 MG levorphanol tartrate oral tablet mg 3 MEPERIDINE HCL ORAL SOLUTION 50 MG/5ML meperidine hcl oral tablet 00 mg, 50 mg METHADONE HCL ORAL SOLUTION 0 MG/5ML, 5 MG/5ML methadone hcl oral tablet 0 mg, 5 mg morphine sulfate (concentrate) oral solution 0 mg/ml 3 PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days); AG (Min Years) Schedule II medications are limited to a 34 day supply maximum.; QL (0 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) ST; Schedule II medications are limited to a 34 day supply maximum.; QL (60 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (000 ML per 30 days) Schedule II medications are limited to a 34 day supply maximum. Schedule II medications are limited to a 34 day supply maximum. Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 ML per 30 days) MPC Effective 6//08

11 morphine sulfate er beads oral capsule extended release 4 hour 0 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 4 hour 0 mg, 00 mg, 0 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 00 mg, 5 mg, 00 mg, 30 mg, 60 mg morphine sulfate oral solution 0 mg/5ml, 0 mg/5ml morphine sulfate oral tablet 5 mg, 30 mg oxycodone hcl oral concentrate 00 mg/5ml oxycodone hcl oral tablet 0 mg, 5 mg, 0 mg, 30 mg, 5 mg oxymorphone hcl er oral tablet extended release hour 0 mg, 5 mg, 0 mg, 30 mg, 40 mg, 5 mg, 7.5 mg tramadol hcl er oral tablet extended release 4 hour 00 mg tramadol hcl er oral tablet extended release 4 hour 00 mg, 300 mg tramadol hcl oral tablet 50 mg *OPIOID COMBINATIONS*** oxycodone-acetaminophen oral capsule mg oxycodone-acetaminophen oral tablet 0-35 mg,.5-35 mg, 5-35 mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg ST; Schedule II medications are limited to a 34 day supply maximum.; QL (30 EA per 30 days) ST; Schedule II medications are limited to a 34 day supply maximum.; QL (30 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (000 ML per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 ML per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) ST; Schedule II medications are limited to a 34 day supply maximum.; QL (60 EA per 30 days) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (90 EA per 30 days); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (30 EA per 30 days); AG (Min Years) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (40 EA per 30 days); AG (Min Years) Schedule II medications are limited to a 34 day supply maximum.; QL (8 EA per day) Schedule II medications are limited to a 34 day supply maximum.; QL ( EA per day) Schedule II medications are limited to a 34 day supply maximum.; QL (6 EA per day) Schedule II medications are limited to a 34 day supply maximum.; QL (8 EA per day) MPC0564 Effective 6//08

12 oxycodone-aspirin oral tablet mg ROXICET ORAL SOLUTION 5-35 MG/5ML ROXICET ORAL TABLET 5-35 MG *OPIOID PARTIAL AGONISTS*** Schedule II medications are limited to a 34 day supply maximum.; QL (80 EA per 30 days) Schedule II medications are limited to a 34 day supply maximum.; QL (60 ML per day) Schedule II medications are limited to a 34 day supply maximum.; QL ( EA per day) buprenorphine hcl sublingual tablet sublingual mg 3 PA; QL (90 EA per 30 days) buprenorphine hcl sublingual tablet sublingual 8 mg 3 PA; QL (60 EA per 30 days) buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5 mg, 8- mg butorphanol tartrate nasal solution 0 mg/ml 3 nalbuphine hcl injection solution 0 mg/ml, 0 mg/ml SUBOXONE SUBLINGUAL FILM -3 MG 3 SUBOXONE SUBLINGUAL FILM -0.5 MG, 4- MG, 8- MG *PENTAZOCINE COMBINATIONS*** QL (90 EA per 30 days) QL (60 EA per 30 days); AG (Min 6 Years) MPC0564 Effective 6//08 3 QL (90 EA per 30 days); AG (Min 6 Years) pentazocine-acetaminophen oral tablet mg QL (6 EA per day) *TRAMADOL COMBINATIONS*** tramadol-acetaminophen oral tablet mg *ANDROGENS-ANABOLIC* *ANDROGENS*** ANDRODERM TRANSDERMAL PATCH 4 HOUR MG/4HR ANDRODERM TRANSDERMAL PATCH 4 HOUR 4 MG/4HR ANDROGEL PUMP TRANSDERMAL GEL 0.5 MG/ACT (.6%) ANDROGEL TRANSDERMAL GEL 0.5 MG/.5GM (.6%) ANDROGEL TRANSDERMAL GEL 40.5 MG/.5GM (.6%) PA; Not covered for patients under years of age. Prior authorization required for patients to 8 years.; QL (300 EA per 30 days); AG (Min Years) 3 PA; QL (60 EA per 30 days) 3 PA; QL (30 EA per 30 days) PA; QL (50 GM per 30 days) PA; QL (37.5 GM per 30 days) PA; QL (50 GM per 30 days) ANDROXY ORAL TABLET 0 MG 3 PA; QL (0 EA per 30 days) danazol oral capsule 00 mg, 00 mg, 50 mg testosterone cypionate intramuscular solution 00 mg/ml, 00 mg/ml testosterone enanthate intramuscular solution 00 mg/ml PA PA testosterone transdermal gel 0 mg/act (%) 3 PA; QL (0 GM per 30 days)

13 *ANORECTAL AGENTS* *INTRARECTAL STEROIDS*** CORTIFOAM RECTAL FOAM 0 % 3 hydrocortisone rectal enema 00 mg/60ml *RECTAL ANESTHETIC/STEROIDS*** hydrocortisone ace-pramoxine rectal cream - % lidocaine-hydrocortisone ace rectal cream % PROCTOFOAM HC RECTAL FOAM - % *RECTAL STEROIDS*** PROCTOCREAM HC RECTAL CREAM.5 % PROCTOSOL HC RECTAL CREAM.5 % *ANTHELMINTICS* *ANTHELMINTICS*** ALBENZA ORAL TABLET 00 MG 3 BILTRICIDE ORAL TABLET 600 MG 3 ivermectin oral tablet 3 mg 3 QL ( EA per 0 days) *ANTIANGINAL AGENTS* *ANTIANGINALS-OTHER*** RANEXA ORAL TABLET EXTENDED RELEASE HOUR 000 MG, 500 MG *NITRATES*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG ISOSORBIDE DINITRATE ER ORAL TABLET EXTENDED RELEASE 40 MG isosorbide dinitrate oral tablet 0 mg, 0 mg, 30 mg, 5 mg isosorbide dinitrate sublingual tablet sublingual.5 mg isosorbide mononitrate er oral tablet extended release 4 hour 0 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 0 mg, 0 mg MINITRAN TRANSDERMAL PATCH 4 HOUR 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin er oral capsule extended release.5 mg, 9 mg nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg nitroglycerin sublingual tablet sublingual 0.6 mg nitroglycerin transdermal patch 4 hour 0. mg/hr, 0. mg/hr, 0.4 mg/hr *ANTIANXIETY AGENTS* 3 ST MPC Effective 6//08

14 *ANTIANXIETY AGENTS - MISC.*** buspirone hcl oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl oral syrup 0 mg/5ml hydroxyzine hcl oral tablet 0 mg, 5 mg, 50 mg hydroxyzine pamoate oral capsule 00 mg, 5 mg, 50 mg meprobamate oral tablet 00 mg, 400 mg *BENZODIAZEPINES*** alprazolam er oral tablet extended release 4 hour 0.5 mg, mg, mg alprazolam er oral tablet extended release 4 hour 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML MULTAQ ORAL TABLET 400 MG 3 PA; QL (60 EA per 30 days) MPC Effective 6//08 3 QL (30 EA per 30 days) 3 QL (60 EA per 30 days) alprazolam oral tablet 0.5 mg, 0.5 mg, mg QL (90 EA per 30 days) alprazolam oral tablet mg QL (35 EA per 30 days) chlordiazepoxide hcl oral capsule 0 mg, 5 mg, 5 mg QL (0 EA per 30 days) clorazepate dipotassium oral tablet 5 mg QL (80 EA per 30 days) clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg QL (90 EA per 30 days) diazepam oral tablet 0 mg, mg, 5 mg QL (0 EA per 30 days) lorazepam injection solution mg/ml, 4 mg/ml lorazepam oral concentrate mg/ml lorazepam oral tablet 0.5 mg, mg, mg QL (90 EA per 30 days) oxazepam oral capsule 0 mg, 5 mg, 30 mg QL (0 EA per 30 days) *ANTIARRHYTHMICS* *ANTIARRHYTHMICS TYPE I-A*** disopyramide phosphate oral capsule 00 mg, 50 mg quinidine gluconate er oral tablet extended release 34 mg quinidine sulfate er oral tablet extended release 300 mg QUINIDINE SULFATE ORAL TABLET 00 MG, 300 MG *ANTIARRHYTHMICS TYPE I-B*** mexiletine hcl oral capsule 50 mg, 00 mg, 50 mg *ANTIARRHYTHMICS TYPE I-C*** propafenone hcl oral tablet 50 mg, 5 mg, 300 mg *ANTIARRHYTHMICS TYPE III*** amiodarone hcl intravenous solution 50 mg/3ml amiodarone hcl oral tablet 00 mg, 400 mg dofetilide oral capsule 5 mcg, 50 mcg, 500 mcg 3 3

15 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *5-LIPOXYGENASE INHIBITORS*** zileuton er oral tablet extended release hour 600 mg *ADRENERGIC COMBINATIONS*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL 5- MCG/ACT, 30- MCG/ACT, 45- MCG/ACT ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 0-00 MCG/ACT DULERA INHALATION AEROSOL 00-5 MCG/ACT, 00-5 MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated 3-4 mcg/act, 3-4 mcg/act, 55-4 mcg/act ipratropium-albuterol inhalation solution (3) mg/3ml STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION.5-.5 MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *ANTI-INFLAMMATORY AGENTS*** cromolyn sodium inhalation nebulization solution 0 mg/ml *BETA ADRENERGICS*** albuterol sulfate er oral tablet extended release hour 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml,.5 mg/3ml albuterol sulfate oral syrup mg/5ml albuterol sulfate oral tablet mg, 4 mg isoproterenol hcl injection solution 0. mg/ml 4 PA; SP; QL (0 EA per 30 days) 3 ST; QL (60 EA per 30 days) 3 ST; QL ( GM per 30 days) 3 ST 3 QL (8 GM per 30 days) 3 ST; QL (3 GM per 30 days) ST; QL ( EA per 30 days) MPC Effective 6//08 ST ST; QL (6.9 GM per 30 days) levalbuterol tartrate hfa inhalation aerosol 45 mcg/act 3 ST; QL (30 GM per 30 days) MAXAIR AUTOHALER INHALATION AEROSOL BREATH ACTIVATED 00 MCG/INH METAPROTERENOL SULFATE ORAL SYRUP 0 MG/5ML METAPROTERENOL SULFATE ORAL TABLET 0 MG, 0 MG SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE 3

16 terbutaline sulfate injection solution mg/ml terbutaline sulfate oral tablet.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL SOLUTION 08 (90 BASE) MCG/ACT XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT *BRONCHODILATORS - ANTICHOLINERGICS*** ATROVENT HFA INHALATION AEROSOL SOLUTION 7 MCG/ACT ipratropium bromide inhalation solution 0.0 % SPIRIVA HANDIHALER INHALATION CAPSULE 8 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION.5 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT *LEUKOTRIENE RECEPTOR ANTAGONISTS*** 3 ST; QL (30 GM per 30 days) montelukast sodium oral tablet 0 mg QL (30 EA per 30 days) montelukast sodium oral tablet chewable 4 mg, 5 mg QL (30 EA per 30 days) zafirlukast oral tablet 0 mg, 0 mg *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** DALIRESP ORAL TABLET 500 MCG PA; QL (30 EA per 30 days) *STEROID INHALANTS*** ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX HFA INHALATION AEROSOL 00 MCG/ACT, 00 MCG/ACT budesonide inhalation suspension 0.5 mg/ml, 0.5 mg/ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 00 MCG/BLIST, 50 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 0 MCG/ACT, 0 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 80 MCG/ACT, 90 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT 3 QL (3 GM per 30 days) 3 3 PA QL (0 ML per 30 days); AG (Max Years) MPC Effective 6//08

17 QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT *XANTHINES*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/5ML theophylline er oral tablet extended release hour 00 mg, 00 mg, 300 mg, 450 mg theophylline er oral tablet extended release 4 hour 400 mg, 600 mg *ANTICOAGULANTS* *COUMARIN ANTICOAGULANTS*** warfarin sodium oral tablet mg, 0 mg, mg,.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *DIRECT FACTOR XA INHIBITORS*** 3 PA XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG QL (30 EA per 30 days) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 5 & 0 MG *HEPARINS AND HEPARINOID-LIKE AGENTS*** heparin sodium (porcine) injection solution 0000 unit/ml, 5000 unit/ml sash kit intravenous kit unit/ml-% *LOW MOLECULAR WEIGHT HEPARINS*** enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous solution 00 mg/ml, 0 mg/0.8ml, 50 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/ML, 5000 UNIT/0.ML, 7500 UNIT/0.3ML, UNIT/3.8ML *SYNTHETIC HEPARINOID-LIKE AGENTS*** fondaparinux sodium subcutaneous solution 0 mg/0.8ml,.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml *ANTICONVULSANTS* *ANTICONVULSANTS - BENZODIAZEPINES*** QL (5 EA per 90 days) Maximum 30 syringes per 90 days. Prior authorization required for amounts exceeding plan quantity limits. Maximum 30 syringes per 90 days. Prior authorization required for amounts exceeding plan quantity limits. 4 PA; QL (30 ML per 30 days) 4 PA clonazepam oral tablet 0.5 mg, mg, mg QL (90 EA per 30 days) clonazepam oral tablet dispersible 0.5 mg, 0.5 mg, 0.5 mg, mg, mg QL (90 EA per 30 days) MPC Effective 6//08

18 diazepam rectal gel 0 mg,.5 mg, 0 mg *ANTICONVULSANTS - MISC.*** carbamazepine er oral capsule extended release hour 00 mg, 00 mg, 300 mg carbamazepine er oral tablet extended release hour 00 mg, 00 mg, 400 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 00 mg carbamazepine oral tablet chewable 00 mg gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 50 mg/5ml gabapentin oral tablet 600 mg, 800 mg lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet chewable 5 mg, 5 mg levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 50 mg, 500 mg, 750 mg LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 50 MG, 75 MG ST; QL (5 EA per 30 days); AG (Max 7 Years) MPC Effective 6//08 3 PA; QL (90 EA per 30 days) LYRICA ORAL CAPSULE 5 MG, 300 MG 3 PA; QL (60 EA per 30 days) oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg POTIGA ORAL TABLET 00 MG, 300 MG, 400 MG, 50 MG primidone oral tablet 50 mg, 50 mg topiramate oral capsule sprinkle 5 mg, 5 mg topiramate oral tablet 00 mg, 00 mg, 5 mg, 50 mg 3 PA; QL (90 EA per 30 days) VIMPAT ORAL SOLUTION 0 MG/ML 4 ST; QL (00 ML per 30 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG zonisamide oral capsule 00 mg, 5 mg, 50 mg *CARBAMATES*** felbamate oral suspension 600 mg/5ml 3 felbamate oral tablet 400 mg, 600 mg 3 *GABA MODULATORS*** tiagabine hcl oral tablet mg, 6 mg, mg, 4 mg 3 *HYDANTOINS*** DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG 3 4 ST; QL (60 EA per 30 days)

19 phenytoin oral suspension 5 mg/5ml phenytoin sodium extended oral capsule 00 mg, 00 mg, 300 mg *SUCCINIMIDES*** ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml *VALPROIC ACID*** divalproex sodium er oral tablet extended release 4 hour 50 mg, 500 mg divalproex sodium oral capsule sprinkle 5 mg divalproex sodium oral tablet delayed release 5 mg, 50 mg, 500 mg valproic acid oral capsule 50 mg valproic acid oral syrup 50 mg/5ml *ANTIDEPRESSANTS* *ALPHA- RECEPTOR ANTAGONISTS (TETRACYCLICS)*** mirtazapine oral tablet 5 mg, 30 mg, 45 mg QL (30 EA per 30 days) mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg *ANTIDEPRESSANTS - MISC.*** bupropion hcl er (sr) oral tablet extended release hour 00 mg, 50 mg, 00 mg bupropion hcl er (xl) oral tablet extended release 4 hour 50 mg bupropion hcl er (xl) oral tablet extended release 4 hour 300 mg bupropion hcl oral tablet 00 mg, 75 mg MAPROTILINE HCL ORAL TABLET 5 MG, 50 MG, 75 MG *MODIFIED CYCLICS*** trazodone hcl oral tablet 00 mg, 50 mg, 300 mg, 50 mg MPC Effective 6//08 QL (60 EA per 30 days) QL (90 EA per 30 days) QL (30 EA per 30 days) VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG 3 PA; QL (30 EA per 30 days) *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** EMSAM TRANSDERMAL PATCH 4 HOUR MG/4HR, 6 MG/4HR, 9 MG/4HR phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** 4 PA; QL (30 EA per 30 days) citalopram hydrobromide oral solution 0 mg/5ml QL (600 ML per 30 days) citalopram hydrobromide oral tablet 0 mg, 0 mg QL (60 EA per 30 days)

20 citalopram hydrobromide oral tablet 40 mg QL (30 EA per 30 days) escitalopram oxalate oral solution 5 mg/5ml QL (600 ML per 30 days) escitalopram oxalate oral tablet 0 mg QL (45 EA per 30 days) escitalopram oxalate oral tablet 0 mg, 5 mg QL (30 EA per 30 days) fluoxetine hcl oral capsule 0 mg, 0 mg, 40 mg fluoxetine hcl oral solution 0 mg/5ml fluvoxamine maleate oral tablet 00 mg, 5 mg, 50 mg paroxetine hcl er oral tablet extended release 4 hour.5 mg, 5 mg, 37.5 mg ST paroxetine hcl oral tablet 0 mg, 0 mg, 30 mg QL (30 EA per 30 days) paroxetine hcl oral tablet 40 mg QL (45 EA per 30 days) PAXIL ORAL SUSPENSION 0 MG/5ML 3 PA; QL (900 ML per 30 days) sertraline hcl oral concentrate 0 mg/ml sertraline hcl oral tablet 00 mg, 5 mg QL (60 EA per 30 days) sertraline hcl oral tablet 50 mg QL (45 EA per 30 days) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** duloxetine hcl oral capsule delayed release particles 0 mg, 30 mg, 60 mg venlafaxine hcl er oral capsule extended release 4 hour 50 mg, 37.5 mg venlafaxine hcl er oral capsule extended release 4 hour 75 mg venlafaxine hcl oral tablet 00 mg, 5 mg, 37.5 mg, 50 mg, 75 mg *TRICYCLIC AGENTS*** amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 5 mg, 50 mg clomipramine hcl oral capsule 5 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg doxepin hcl oral concentrate 0 mg/ml imipramine hcl oral tablet 0 mg, 5 mg, 50 mg nortriptyline hcl oral capsule 0 mg, 5 mg, 50 mg, 75 mg *ANTIDIABETICS* *ALPHA-GLUCOSIDASE INHIBITORS*** acarbose oral tablet 00 mg, 5 mg, 50 mg *ANTIDIABETIC - AMYLIN ANALOGS*** SYMLINPEN 0 SUBCUTANEOUS SOLUTION PEN-INJECTOR 700 MCG/.7ML QL (60 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) MPC Effective 6//08 3 PA

21 SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR 500 MCG/.5ML *BIGUANIDES*** metformin hcl er oral tablet extended release 4 hour 500 mg, 750 mg metformin hcl oral tablet 000 mg, 500 mg, 850 mg *DIABETIC OTHER*** GLUCAGON EMERGENCY INJECTION KIT MG *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** alogliptin benzoate oral tablet.5 mg, 5 mg, 6.5 mg 3 PA MPC0564 Effective 6//08 ST; QL (30 EA per 30 days) JANUVIA ORAL TABLET 00 MG, 5 MG, 50 MG ST; QL (30 EA per 30 days) ONGLYZA ORAL TABLET.5 MG, 5 MG 3 PA; QL (30 EA per 30 days) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR- BIGUANIDE COMBINATIONS*** alogliptin-metformin hcl oral tablet mg, mg ST; QL (60 EA per 30 days) JANUMET ORAL TABLET MG, MG ST; QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG JANUMET XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 4 HOUR MG, MG *DPP-4 INHIBITOR-THIAZOLIDINEDIONE COMBINATIONS*** alogliptin-pioglitazone oral tablet.5-5 mg,.5-30 mg,.5-45 mg, 5-5 mg, 5-30 mg, 5-45 mg *HUMAN INSULIN*** FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML ST; QL (30 EA per 30 days) ST; QL (60 EA per 30 days) 3 PA; QL (60 EA per 60 days) 3 PA; QL (30 EA per 30 days) ST; QL (30 EA per 30 days) QL (45 ML per 30 days) FIASP SUBCUTANEOUS SOLUTION 00 UNIT/ML QL (50 ML per 30 days) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 00 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 00 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML 3 ST; QL (45 ML per 30 days) 3 ST; QL (50 ML per 30 days) 3 ST; QL (45 ML per 30 days) 3 ST; QL (50 ML per 30 days) HUMULIN R INJECTION SOLUTION 00 UNIT/ML 3 ST; QL (50 ML per 30 days) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML 4 ST; QL (0 ML per 30 days)

22 LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML QL (45 ML per 30 days) QL (50 ML per 30 days) QL (45 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) QL (50 ML per 30 days) NOVOLIN R INJECTION SOLUTION 00 UNIT/ML QL (50 ML per 30 days) NOVOLIN R RELION INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 00 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 00 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 00 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML *INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS)*** BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR MG/0.85ML BYDUREON SUBCUTANEOUS PEN-INJECTOR MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER MG BYETTA 0 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 0 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.0ML TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML,.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 8 MG/3ML *MEGLITINIDE ANALOGUES*** nateglinide oral tablet 0 mg, 60 mg repaglinide oral tablet 0.5 mg, mg, mg 3 QL (50 ML per 30 days) QL (45 ML per 30 days) QL (45 ML per 30 days) QL (50 ML per 30 days) QL (45 ML per 30 days) QL (50 ML per 30 days) ST; QL (3.4 ML per 8 days) ST; QL (4 EA per 8 days) ST; QL (4 EA per 8 days) 3 ST; QL (.4 ML per 30 days) 3 ST; QL (. ML per 30 days) 3 ST; QL ( ML per 8 days) ST; QL (9 ML per 30 days) MPC0564 Effective 6//08

23 *MEGLITINIDE-BIGUANIDE COMBINATIONS*** repaglinide-metformin hcl oral tablet -500 mg, -500 mg *SODIUM-GLUCOSE CO-TRANSPORTER (SGLT) INHIBITORS*** 3 ST FARXIGA ORAL TABLET 0 MG, 5 MG ST; QL (30 EA per 30 days) *SULFONYLUREA-BIGUANIDE COMBINATIONS*** glipizide-metformin hcl oral tablet.5-50 mg, mg, mg glyburide-metformin oral tablet.5-50 mg, mg, mg *SULFONYLUREAS*** CHLORPROPAMIDE ORAL TABLET 00 MG, 50 MG glimepiride oral tablet mg, mg, 4 mg glipizide er oral tablet extended release 4 hour 0 mg,.5 mg, 5 mg glipizide oral tablet 0 mg, 5 mg glyburide micronized oral tablet.5 mg, 3 mg, 6 mg glyburide oral tablet.5 mg,.5 mg, 5 mg TOLAZAMIDE ORAL TABLET 50 MG, 500 MG TOLBUTAMIDE ORAL TABLET 500 MG *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** pioglitazone hcl-glimepiride oral tablet 30- mg, 30-4 mg *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** AVANDAMET ORAL TABLET -000 MG, -500 MG, MG, MG pioglitazone hcl-metformin hcl oral tablet mg, mg *THIAZOLIDINEDIONES*** MPC Effective 6//08 ST ST ST AVANDIA ORAL TABLET MG, 4 MG, 8 MG 3 ST pioglitazone hcl oral tablet 5 mg, 30 mg, 45 mg ST; QL (30 EA per 30 days) *ANTIDIARRHEALS* *ANTIPERISTALTIC AGENTS*** diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg *ANTIDOTES* *OPIOID ANTAGONISTS***

24 naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution mg/ml naltrexone hcl oral tablet 50 mg Naloxone injectable used with nasal atomizer is covered.; QL ( ML per 30 days) Naloxone injectable used with nasal atomizer is covered.; QL (4 ML per 30 days) NARCAN NASAL LIQUID 4 MG/0.ML QL ( EA Max Qty Per Fill Retail) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG *ANTIEMETICS* *5-HT3 RECEPTOR ANTAGONISTS*** 4 PA; SP; QL ( EA per 30 days) ANZEMET ORAL TABLET 00 MG, 50 MG 3 PA; QL (4 EA per 30 days) granisetron hcl oral tablet mg ST; QL (0 EA per 30 days) ondansetron hcl oral solution 4 mg/5ml AG (Max 4 Years) ondansetron hcl oral tablet 4 mg, 8 mg QL (90 EA per 30 days) ondansetron oral tablet dispersible 4 mg, 8 mg QL (90 EA per 30 days) *ANTIEMETICS - ANTICHOLINERGIC*** scopolamine transdermal patch 7 hour mg/3days 3 trimethobenzamide hcl oral capsule 300 mg *SUBSTANCE P/NEUROKININ (NK) RECEPTOR ANTAGONISTS*** aprepitant oral capsule 5 mg, 40 mg 3 PA; QL ( EA per 30 days) aprepitant oral capsule 80 & 5 mg, 80 mg 3 PA; QL (3 EA per 30 days) CINVANTI INTRAVENOUS EMULSION 30 MG/8ML EMEND ORAL SUSPENSION RECONSTITUTED 5 MG *ANTIFUNGALS* *ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg *ANTIFUNGALS*** BIO-STATIN ORAL CAPSULE UNIT griseofulvin microsize oral suspension 5 mg/5ml GRIS-PEG ORAL TABLET 5 MG, 50 MG 3 nystatin oral tablet unit PA 4 PA; QL (6 EA per 8 days) terbinafine hcl oral tablet 50 mg QL (90 EA per 365 days) *IMIDAZOLES*** ketoconazole oral tablet 00 mg *TRIAZOLES*** MPC Effective 6//08

25 fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 00 mg, 50 mg itraconazole oral capsule 00 mg 4 ST; QL (68 EA per 365 days) VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 PA; QL (60 ML per 30 days) voriconazole oral tablet 00 mg, 50 mg 4 PA; QL (60 EA per 30 days) *ANTIHISTAMINES* *ANTIHISTAMINES - PHENOTHIAZINES*** PHENADOZ RECTAL SUPPOSITORY 5 MG promethazine hcl injection solution 5 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.5 mg/5ml promethazine hcl oral tablet.5 mg, 5 mg, 50 mg promethazine hcl rectal suppository.5 mg PROMETHEGAN RECTAL SUPPOSITORY 50 MG *ANTIHISTAMINES - PIPERIDINES*** cyproheptadine hcl oral syrup mg/5ml cyproheptadine hcl oral tablet 4 mg *ANTIHYPERLIPIDEMICS* *ANTIHYPERLIPIDEMICS - MISC.*** omega-3-acid ethyl esters oral capsule gm 3 QL (0 EA per 30 days) VASCEPA ORAL CAPSULE GM 3 QL (0 EA per 30 days) *BILE ACID SEQUESTRANTS*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose PREVALITE ORAL PACKET 4 GM PREVALITE ORAL POWDER 4 GM/DOSE WELCHOL ORAL PACKET 3.75 GM WELCHOL ORAL TABLET 65 MG *FIBRIC ACID DERIVATIVES*** fenofibrate micronized oral capsule 34 mg, 00 mg, 67 mg fenofibrate oral tablet 45 mg, 60 mg, 48 mg, 54 mg gemfibrozil oral tablet 600 mg *HMG COA REDUCTASE INHIBITOR COMBINATIONS*** MPC Effective 6//08

26 ADVICOR ORAL TABLET EXTENDED RELEASE 4 HOUR MG, MG, MG, MG SIMCOR ORAL TABLET EXTENDED RELEASE 4 HOUR MG, MG, MG *HMG COA REDUCTASE INHIBITORS*** atorvastatin calcium oral tablet 0 mg, 0 mg, 40 mg, 80 mg fluvastatin sodium oral capsule 0 mg, 40 mg 3 lovastatin oral tablet 0 mg, 0 mg, 40 mg pravastatin sodium oral tablet 0 mg, 0 mg, 40 mg, 80 mg rosuvastatin calcium oral tablet 0 mg, 0 mg, 40 mg, 5 mg simvastatin oral tablet 0 mg, 0 mg, 40 mg, 5 mg, 80 mg *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** ezetimibe-simvastatin oral tablet 0-0 mg, 0-0 mg, 0-40 mg, 0-80 mg *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** 3 ST 3 ST QL (30 EA per 30 days) MPC Effective 6//08 ezetimibe oral tablet 0 mg *NICOTINIC ACID DERIVATIVES*** niacin er (antihyperlipidemic) oral tablet extended release 000 mg, 500 mg, 750 mg *ANTIHYPERTENSIVES* *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** amlodipine besy-benazepril hcl oral capsule 0-0 mg, 0-40 mg,.5-0 mg, 5-0 mg, 5-0 mg, 5-40 mg *ACE INHIBITORS & THIAZIDE/THIAZIDE- LIKE*** benazepril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg, mg CAPTOPRIL-HYDROCHLOROTHIAZIDE ORAL TABLET 5-5 MG, 5-5 MG, 50-5 MG, 50-5 MG enalapril-hydrochlorothiazide oral tablet 0-5 mg, 5-.5 mg fosinopril sodium-hctz oral tablet 0-.5 mg, 0-.5 mg lisinopril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg moexipril-hydrochlorothiazide oral tablet 5-.5 mg, 5-5 mg, mg quinapril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg 3

27 *ACE INHIBITORS*** benazepril hcl oral tablet 0 mg, 0 mg, 40 mg, 5 mg captopril oral tablet 00 mg,.5 mg, 5 mg, 50 mg enalapril maleate oral tablet 0 mg,.5 mg, 0 mg, 5 mg fosinopril sodium oral tablet 0 mg, 0 mg, 40 mg lisinopril oral tablet 0 mg,.5 mg, 0 mg, 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 5 mg, 7.5 mg perindopril erbumine oral tablet mg, 4 mg, 8 mg 3 quinapril hcl oral tablet 0 mg, 0 mg, 40 mg, 5 mg ramipril oral capsule.5 mg, 0 mg,.5 mg, 5 mg trandolapril oral tablet mg, mg, 4 mg *AGENTS FOR PHEOCHROMOCYTOMA*** phenoxybenzamine hcl oral capsule 0 mg 3 *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE*** candesartan cilexetil-hctz oral tablet 6-.5 mg, 3-.5 mg, 3-5 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan potassium-hctz oral tablet mg, 00-5 mg, mg olmesartan medoxomil-hctz oral tablet 0-.5 mg, mg, 40-5 mg valsartan-hydrochlorothiazide oral tablet mg, 60-5 mg, mg, 30-5 mg, mg *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** candesartan cilexetil oral tablet 6 mg, 3 mg, 4 mg, 8 mg irbesartan oral tablet 50 mg, 300 mg, 75 mg losartan potassium oral tablet 00 mg, 5 mg, 50 mg olmesartan medoxomil oral tablet 0 mg, 40 mg, 5 mg 3 valsartan oral tablet 60 mg, 30 mg, 40 mg, 80 mg 3 *ANTIADRENERGICS - CENTRALLY ACTING*** clonidine hcl oral tablet 0. mg, 0. mg, 0.3 mg clonidine hcl transdermal patch weekly 0. mg/4hr, 0. mg/4hr, 0.3 mg/4hr guanfacine hcl oral tablet mg, mg methyldopa oral tablet 50 mg, 500 mg MPC Effective 6//08

28 *ANTIADRENERGICS - PERIPHERALLY ACTING*** doxazosin mesylate oral tablet mg, mg, 4 mg, 8 mg prazosin hcl oral capsule mg, mg, 5 mg terazosin hcl oral capsule mg, 0 mg, mg, 5 mg *BETA BLOCKER & DIURETIC COMBINATIONS*** atenolol-chlorthalidone oral tablet 00-5 mg, 50-5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg metoprolol-hydrochlorothiazide oral tablet 00-5 mg, mg, 50-5 mg PROPRANOLOL-HCTZ ORAL TABLET 40-5 MG, 80-5 MG *VASODILATORS*** hydralazine hcl injection solution 0 mg/ml hydralazine hcl oral tablet 0 mg, 00 mg, 5 mg, 50 mg minoxidil oral tablet 0 mg,.5 mg *ANTI-INFECTIVE AGENTS - MISC.* *ANTI-INFECTIVE AGENTS - MISC.*** metronidazole oral tablet 50 mg, 500 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG trimethoprim oral tablet 00 mg vancomycin hcl intravenous solution reconstituted 500 mg MPC Effective 6//08 3 SP; QL ( Vial per 8 days) 4 SP vancomycin hcl oral capsule 5 mg 3 ST; QL (40 EA per 30 days) vancomycin hcl oral capsule 50 mg 3 PA; QL (80 EA per 30 days) XIFAXAN ORAL TABLET 00 MG 4 PA; QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG 4 PA; QL (60 EA per 30 days) *ANTI-INFECTIVE MISC. - COMBINATIONS*** erythromycin-sulfisoxazole oral suspension reconstituted mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg *ANTIPROTOZOAL AGENTS*** atovaquone oral suspension 750 mg/5ml

29 *LEPROSTATICS*** dapsone oral tablet 00 mg, 5 mg *LINCOSAMIDES*** clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml *OXAZOLIDINONES*** linezolid oral suspension reconstituted 00 mg/5ml 4 PA linezolid oral tablet 600 mg 4 PA *ANTIMALARIALS* *ANTIMALARIALS*** chloroquine phosphate oral tablet 50 mg, 500 mg hydroxychloroquine sulfate oral tablet 00 mg primaquine phosphate oral tablet 6.3 mg *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC AGENTS*** MESTINON ORAL SYRUP 60 MG/5ML 3 pyridostigmine bromide oral tablet 60 mg *ANTIMYCOBACTERIAL AGENTS* *ANTIMYCOBACTERIAL AGENTS*** ethambutol hcl oral tablet 00 mg, 400 mg ISONIAZID ORAL SYRUP 50 MG/5ML isoniazid oral tablet 00 mg, 300 mg PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 50 MG 3 pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg 3 rifampin oral capsule 50 mg, 300 mg TRECATOR ORAL TABLET 50 MG 3 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ALKYLATING AGENTS*** HEXALEN ORAL CAPSULE 50 MG 4 PA; SP MYLERAN ORAL TABLET MG 4 PA; SP *ANDROGEN BIOSYNTHESIS INHIBITORS*** ZYTIGA ORAL TABLET 50 MG 4 PA; QL (0 EA per 30 days) ZYTIGA ORAL TABLET 500 MG 4 PA; QL (60 EA per 30 days) *ANTIADRENALS*** MPC Effective 6//08

30 LYSODREN ORAL TABLET 500 MG 4 *ANTIANDROGENS*** bicalutamide oral tablet 50 mg ERLEADA ORAL TABLET 60 MG 4 PA; QL (0 EA per 30 days) flutamide oral capsule 5 mg XTANDI ORAL CAPSULE 40 MG 4 PA; SP; QL (0 EA per 30 days) *ANTIESTROGENS*** FARESTON ORAL TABLET 60 MG 4 PA; SP; QL (30 EA per 30 days) tamoxifen citrate oral tablet 0 mg, 0 mg PA *ANTIMETABOLITES*** capecitabine oral tablet 50 mg, 500 mg 4 PA; SP mercaptopurine oral tablet 50 mg methotrexate oral tablet.5 mg methotrexate sodium (pf) injection solution 50 mg/ml methotrexate sodium injection solution 5 mg/ml methotrexate sodium injection solution reconstituted gm TABLOID ORAL TABLET 40 MG 4 PA; SP TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** TAFINLAR ORAL CAPSULE 50 MG, 75 MG 4 PA; SP; QL (0 EA per 30 days) ZELBORAF ORAL TABLET 40 MG 4 PA; SP; QL (40 EA per 30 days) *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** ERIVEDGE ORAL CAPSULE 50 MG 4 PA; SP; QL (30 EA per 30 days) ODOMZO ORAL CAPSULE 00 MG 4 PA; QL (30 EA per 30 days) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG 4 PA; QL (6 EA per days) ZOLINZA ORAL CAPSULE 00 MG 4 PA; SP; QL (0 EA per 30 days) *ANTINEOPLASTIC - IMMUNOMODULATORS*** POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG *ANTINEOPLASTIC - MEK INHIBITORS*** 4 PA; SP; QL ( EA per 8 days) MEKINIST ORAL TABLET 0.5 MG 4 PA; SP; QL (90 EA per 30 days) MEKINIST ORAL TABLET MG 4 PA; SP; QL (30 EA per 30 days) *ANTINEOPLASTIC - MONOCLONAL ANTIBODIES*** MPC Effective 6//08

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