5 Tier Commercial Formulary (List of Covered Drugs)

Transcription

1 Effective: August 1, 2015 Small Group Qualified Health Plans Individual Qualified Health Plans What is the Drug List? Also called a formulary by doctors and pharmacists, the Drug List is an extensive list of safe and effective, FDA-approved, brand name and generic prescription drugs used to treat the most common medical conditions. The Health First Pharmacy and Therapeutics Committee (P&T), a panel of physicians and pharmacists, developed our Drug List and updates it regularly. The list includes quality drugs available to you at reasonable cost. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included. The Pharmacy and Therapeutics Committee reviews and evaluates all available literature about a drug when updating the list. About Tiers Most covered prescription drugs will be categorized into one of five tiers. The cost of drugs varies widely, even though several different medications may be used to treat the same condition. What you pay for the prescription depends upon what tier the drug is listed in. Health First offers many benefit plans that can vary in coverage for each tier. Details about your specific benefit for each tier are included in the Health First Summary of Benefits. Prescriptions that exceed a 30 day 5 Tier Commercial Formulary (List of Covered Drugs) supply will default to a 90 day supply copay (this does not apply to coinsurances). For coinsurances, you will always pay a percentage of the total cost after the applicable deductible is met. Tier 1 Preferred Generic Drugs Tier 2 Non-Preferred Generic Drugs Tier 3 Preferred Brand Name Drugs and some generics Tier 4 Non-Preferred Brand Name Drugs and some generics (some plans may be limited to a 30-day supply) Tier 5 Specialty Drugs (Must obtain from Health First Family Pharmacy and some plans may be limited to a 30-day supply. For members living outside the state of Florida an exception will be considered to allow the member to obtain the medication at another pharmacy. Please contact our Customer Service Department to initiate this process.) No Cost Share 2015 ACA 5 Tier Formulary Version 1 Page 1

2 Generic drugs are prescription drugs that are identified by their chemical name. When the patent has expired on a brand name drug, the FDA permits new manufacturers to create an equivalent of the brand name drug and make it available to the public. Generally, more than one manufacturer will create generic versions, although often the same pharmaceutical firm that produces the brand name drug also makes the generic version. This prompts competitive pricing of the generic version and usually results in a less expensive drug. The Drug List is subject to change In order to continue to offer a safe and cost effective selection of prescription drugs, Health First periodically makes changes to the Drug List. These changes may include removing medications, adding restrictions, and/or covering a drug at a higher tier. Updated formularies are posted to the website as changes are made. The following list represents some of the most common scenarios in which changes to drug coverage will occur: Throughout the year, new medications are approved by the FDA. It is the policy of Health First that new drugs will be excluded for 6 months from the date of FDA approval, during which time the Health First Pharmacy and Therapeutics Committee can review the drug for safety and efficacy. The Drug List may change when a medication is withdrawn from the market due to safety reasons or if it becomes available overthe-counter (OTC). At the time that a medication on the Health First Drug List becomes available OTC, it may be excluded from coverage from that point forward. When a brand-name prescription drug loses its patent and the equivalent generic form is added to the Drug List, the brand-name drug may be moved to the highest non-specialty drug tier, which is generally Tier 4, or removed from the formulary. This formulary is current as of June 16, To get updated information about covered drugs, please visit our Web site at myhfhp.org or call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Health First requires you and/or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. In order for the plan to pay for these drugs, the physician ordering the prescription is required to submit all medical information to Health First documenting the medical necessity. These drugs are identified in the Drug List. Step Therapy: In some cases, Health First requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Please see the reference table on page 6 for a complete listing of the drugs which currently require step therapy. Quantity Limits: For certain drugs, Health First limits the amount of the drug that Health First will cover. For example, Health First provides 30 tablets per prescription for Jalyn. This may be in addition to a standard one month or three month supply. How can I make the most of my prescription drug benefit? Prescription drug costs continue to rise every year and can represent a significant part of your healthcare expenses. Health First can help you pay for your medications by sharing the cost with you and providing substantial discounts for medications you purchase. To help you manage your drug costs, here are some money-saving tips to consider: Use Tier 1 generic medications whenever possible. Generic drugs are the chemical equivalent of brand-name drugs, and are just as effective in most cases. If you take generic drugs you will generally pay less, so talk to your doctor about switching to a generic equivalent of any brand-name you are taking if it is appropriate. In addition, many of our prescription drug riders include a $2 copayment for Tier 1 generic drugs ensuring affordable access to many commonly prescribed medications. Please see the list of drugs below to determine which drugs are included in Tier 1. See if your prescription pills can be split in half. For some medications, pills may be available in different strengths but still have the same price. If you need one of these select medications, your doctor may be able to write your prescription so that you can get your pills at double strength, but half of the number of pills you d normally need, and you d only pay half of the regular price. Then you d split 2015 ACA 5 Tier Formulary Version 1 Page 2

3 them in half, so you d get the proper dose saving up to 50 percent of the cost! The drugs that may be eligible for the Pill-Splitting program are marked with the symbol (1/2) on the drug list, so review this information with your doctor if your drug qualifies. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that Health First 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. 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. You can ask Health First to make an exception and cover your drug. See below for information about how to request an exception. If Health First approves you or your physician s request for an exception to the Health First formulary the approved drug will be covered at the Tier 4 cost share. If the cost of the medication is greater than $500 per month it will be covered at the Tier 5 or Specialty Tier. Excluded drugs Health First does not provide coverage for all drugs. In addition to the drugs marked excluded in this drug list, newly FDA approved drugs are not covered unless the P & T Committee in its sole discretion approves these drugs for coverage. Health First will automatically exclude a particular drug if a generic version becomes available and an entire class of drugs if a particular drug within that class becomes available over the counter. The following are NOT covered by HFHP: Compounded drugs Cosmetics or any drugs used for cosmetic purposes (such as Retin-A, Rogaine, Topical Minoxidil, and Vaniqa) Diabetic supplies, blood glucose monitors and test strips other than those manufactured by Abbott under the product name Freestyle, Precision, and test strips Erectile dysfunction drugs (such as Viagra) Infertility drugs (such as Clomid) Injectables (except insulin, Imitrex, and those requiring prior authorization) Multivitamins and nutritional supplements (except prescription pre-natal vitamins) Nicotine products Nonprescriptive supplies or substances Oral and topical antifungals for onychomycosis (such as Lamisil, Sporanox, and Penlac) Over-the-counter (OTC) medications (such as Lotrimin, Zantac 75, Pepcid AC or their generic formulations), or any drug for which a similar over-the-counter version is available All new drugs approved by the FDA will be excluded from the preferred drug list/formulary unless HFHP s Pharmacy and Therapeutics Committee, in its sole discretion, decides to waive this exclusion for a particular drug. Support garments Syringes, needles, or other disposable supplies (except those used with insulin) 2015 ACA 5 Tier Formulary Version 1 Page 3

4 Health First Health Plans Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by Health First. If you have trouble finding your drug in the list, turn to the Index that begins on page 79. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Notes column tells you if Health First has any special requirements for coverage of your drug. Specialty Pharmacy (SP): Must obtain from Health First Family Pharmacy and some plans may be limited to a 30-day supply. For members living outside the state of Florida an exception will be considered to allow the member to obtain the medication at another pharmacy. Please contact our Customer Service Department to initiate this process. Prior Authorization (PA): Health First requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health First before you fill your prescriptions. If you don't get approval, Health First may not cover the drug. Quantity Limit (QL): Quantity Limits may also be listed. (For example, 30/30 days would mean your coverage of this drug is limited to 30 pills every 30 days.) Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount. Step Therapy (ST): In some cases, Health First 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 may not cover drug B unless you try Drug A first. If Drug A does not work for you, Health First will then cover Drug B. 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 d 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 save 50 percent of the cost. Call our Customer Service Department for details. For information about a specific drug not listed, please call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m ACA 5 Tier Formulary Version 1 Page 4

5 Preventive Care Medications: $0 Cost-share Medications and Products The Affordable Care Act (ACA), commonly known as health care reform, was signed into federal law in The ACA requires private insurers to cover certain preventive services without any patient cost-sharing (i.e., copayments, coinsurance and deductible) when they are delivered by a network provider. The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task Force [USPSTF], Advisory Committee on Immunization Practices [ACIP], and Health Resources and Services Administration [HRSA]) who have identified several medication categories that fall within the preventive health mandate. The following products, prescription medications and specific over-the-counter (OTC) medications (notated in Tier throughout this formulary) are available to our members at no ($0) cost-sharing when: Prescribed by a health care professional (all prescription and OTC medications will require a prescription) Age and/or gender appropriate U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements Aspirin (325 mg tablets, 81 mg chewable tablets) Vitamin D (50000 unit capsules) Iron (Ferrous Sulfate, 325 mg tablets) Folic Acid (1 mg tablets) Pediatric Multiple Vitamins w/ Fluoride (1 mg chewable tablets, 0.5 mg/ml solution) Pediatric Multiple Vitamins w/ Iron (15 mg chewable tablets, 10 mg/ml drops Sodium Fluoride (1 mg tablets, 1 mg chewable tablets) Tobacco Cessation Medications If you need help to quit smoking or using tobacco products, these preventive medications will be available at $0 cost-share. To qualify, you must be: 18 years of age or older, Receiving counseling and have a prescription from a health care provider, Up to two, 3-month treatment courses are covered at no cost each year. Any additional treatment may be subject to a cost-share. Covered treatment regimens include: Nicotine replacement therapy (nicotine patches, nicotine gum, nicotine lozenges, nicotine inhaler, nicotine nasal spray) Chantix Generic Zyban (bupropion) Breast Cancer Preventive Medications For women who are at increased risk for breast cancer but who have not had breast cancer, medications such as tamoxifen or raloxifene are available at $0 cost-share. If you are 35 years of age or older and have not had breast cancer, talk to your doctor about your risk. If appropriate, your doctor may offer to prescribe one of these risk-reducing medications. Your doctor can then submit a Prior Authorization request to get the medication approved at $0 cost-share if coverage criteria are met ACA 5 Tier Formulary Version 1 Page 5

6 Contraceptive Methods Oral contraceptives combined: NECON, NORTREL, WERA MG-MCG ALYACEN, CYCLAFEM, DASETTA, NECON, NORTREL 21, NORTREL 28, PRIMELLA 1-35 MG-MCG GILDESS, JUNEL, LARIN, MICROGESTIN, NORETHINDRONE-ETHINYL ESTRADIOL 1-20 MG-MCG GILDESS, JUNEL, LARIN, MICROGESTIN MG-MCG CRYSELLE, ELINEST, LOW-OGESTREL MG-MCG ESTARYLLA, MONO-LINYAH, MONONESSA, NORGESTIMATE-ETHINYL ESTRADIOL, PREVIFEM, SPRINTEC MG-MCG GILDESS FE, JUNEL FE, LARIN FE, MICROGESTIN FE, NORETHINDRONE-ETHINYL ESTRADIOL FE 1-20 MG-MCG GILDESS FE, JUNEL FE, LARIN FE, MICROGESTIN FE MG-MCG AZURETTE, DESOGESTREL-ETHINYL ESTRADIOL, KARIVA, PIMTREA, VIORELE MG (21/5) ALYACEN, CYCLAFEM, DASETTA, NECON, NORTREL, PRIMELLA 7/7/7 NORGESTIMATE-ETH ESTRADIOL, TRI-ESTARYLLA, TRI-LINYAH, TRINESSA, TRI-PREVIFEM, TRI-SPRINTEC Oral contraceptives extended/continuous use: INTROVALE, JOLESSA, LEVONORGESTREL-ETHYINYL ESTRADIOL, QUASENSE MG (91-DAY) Oral Contraceptives progestin only CAMILA, DEBLITANE, ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA, NORA-BE, NORETHINDRONE, NORLYROC, SHAROBEL 0.35 MG Injection: MEDROXYPROGESTERONE 150 MG INJ Patch: XULANE PATCH (generic OrthoEvra) Vaginal Ring: NUVARING (Vaginal Ring) Emergency Contraception-Progestin: LEVONORGESTREL 0.75 MG Emergency Contraception- Ulipristal Acetate: ELLA Implantable Rod: IMPLANON/NEXPLANON IUD Copper: PARAGUARD 2015 ACA 5 Tier Formulary Version 1 Page 6

7 Contraceptive Methods Continued IUD Progestin: MIRENA, SKYLA Diaphragm with Spermicide: OMNIFLEX DIAPHRAM Sponge with Spermicide: TODAY SPONGE Cervical Cap with Spermicide: FEMCAP, PRENTIF Female Condom: FC FEMALE CONDOM Spermicide alone: NONOXYNOL-9 GEL *** The FDA Birth Control Guide additionally lists sterilization surgery for men and male condoms, but the HRSA Guidelines exclude services relating to a man s reproductive capacity. If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer or call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m ACA 5 Tier Formulary Version 1 Page 7

8 Step Therapy Reference Table Step Therapy Reference Table Drug Name Drug that must be tried first Drug Name Drug that must be tried first AXERT CELEBREX/Celecoxib sumatriptan meloxicam RIZATRIPTAN; RIZATRIPTAN DISPERSIBLE sumatriptan ENABLEX Vesicare TREXIMET sumatriptan FROVA sumatriptan ULORIC allopurinol LYRICA MAXALT MLT METFORMIN ER OSM (GENERIC FORTAMET) ONGLYZA RELPAX gabapentin sumatriptan Metformin ER (generic Glucophage XR) Tradjenta sumatriptan VIIBRYD ZOLMITRIPTAN; ZOLMITRIPTAN ORAL DISPERSIBLE Trial of any two (2) of the following drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone, venlafaxine sumatriptan Covered Generic Drugs The following brand name drugs have generic alternatives that may be a cost savings to you Brand Name Drug Brand Tier Generic Alternative CRESTOR atorvastatin, simvastatin DEXILANT omeprazole, pantoprazole BENICAR losartan 2015 ACA 5 Tier Formulary Version 1 Page 8

9 Formulary Changes Drug Name Change Previous Tier New Tier Effective Date New Requirements/ Limits TAMIFLU Tiering Change T5 (SP) Change made 12/1/2014; Effective 1/1/2015 N/A HUMULIN R U-500 Addition - T5 (SP) Change made 12/3/2014; Effective 1/1/2015 QL Spiriva Respimat Addition - 2/13/2015 Striverdi Respimat Addition - 2/13/2015 Latuda 60mg and 120mg Prednisolone Sodium Phosphate 1% Ophthalmic Solution Addition - 2/20/2015 Tiering Change 3/2/2015 Grastek Addition - 3/2/2015 Ragwitek Addition - 3/2/2015 Zontivity Addition - 3/2/2015 Simbrinza Addition ACA 5 Tier Formulary Version 1 Page 9

10 Formulary Changes Drug Name Change Previous Tier New Tier Effective Date New Requirements/ Limits Duavee Addition - 3/2/2015 Glyxambi Addition - 3/2/2015 Harvoni Addition - T5 3/2/2015 PA Zyflor CR PA Added - - 3/5/2015 Viibryd Step Therapy Added - - 3/5/2015 Clorazepate PA Removed - - 3/5/2015 Tanzeum Tiering Change 3/18/2015 Pen Needles QL Change - - 3/19/2015 Increase QL to 200 needles per 31 days Linzess Addition - 3/20/2015 Brintellix Addition - 3/20/2015 Vyvanse 10 mg Addition - 4/27/ ACA 5 Tier Formulary Version 1 Page 10

11 Formulary Changes Drug Name Change Previous Tier New Tier Effective Date New Requirements/ Limits Sovaldi Addition - T5 (SP) 5/4/2015 PA Uloric Change 5/4/2015 Celecoxib Addition - 5/4/2015 Step therapy through meloxicam required Asmanex HFA Addition - 5/11/2015 QL 13 GM per 30 days Ella TABLET 30 MG ORAL Addition - 6/16/2015 NuvaRing RING MG/24HR VAGINAL Implanon/Nexplanon (share same GPI) Addition Addition - 6/16/2015-6/16/2015 Paragard Intrauterine Copper INTRAUTERINE DEVICE INTRAUTERINE Mirena INTRAUTERINE DEVICE 20 MCG/24HR INTRAUTERINE Skyla INTRAUTERINE DEVICE 13.5 MG INTRAUTERINE Omniflex Diaphragm DIAPHRAGM VAGINAL Addition Addition Addition Addition - 6/16/2015-6/16/2015-6/16/2015-6/16/ ACA 5 Tier Formulary Version 1 Page 11

12 Formulary Changes Drug Name Change Previous Tier New Tier Effective Date New Requirements/ Limits Prentif/FemCap Cavity-Rim Cerv Cap DEVICE 22 MM VAGINAL Prentif Cavity-Rim Cerv Cap DEVICE 25 MM VAGINAL Prentif Cavity-Rim Cerv Cap DEVICE 28 MM VAGINAL Prentif Cavity-Rim Cerv Cap DEVICE 31 MM VAGINAL FemCap DEVICE 30 MM VAGINAL Addition Addition Addition Addition Addition - 6/16/2015-6/16/2015-6/16/2015-6/16/2015-6/16/2015 FemCap DEVICE 26 MM VAGINAL Addition - 6/16/2015 Today Sponge 1000 MG VAGINAL Addition - 6/16/2015 FC2 Female Condom/FC Female Condom Addition - 6/16/2015 Nonoxynol-9 Gels Addition - 6/16/2015 testosterone cypionate inj 100mg/ml Addition - 6/16/2015 PA testosterone cypionate inj 200mg/ml Addition - 6/16/2015 PA testosterone enanthate inj 200mg/ml Addition - 6/16/2015 PA Vascepa Addition - 8/1/ ACA 5 Tier Formulary Version 1 Page 12

13 Formulary Changes Drug Name Change Previous Tier New Tier Effective Date New Requirements/ Limits Breo Ellipta Addition - 8/1/2015 aripiprazole tablet Addition - 8/3/2015 PA fluoxetine 40mg capsule Addition - T1 8/10/2015 QL (62 EA per 31 amlodipine-benazepril capsule Addition - 8/10/2015 QL (31 EA per 31 acyclovir 5% ointment Addition - 8/10/2015 QL (60 GM per 31 metronidazole 1% external Addition - 8/10/2015 tacrolimus ointment Addition - 8/10/2015 PA amlodipine-valsartan Addition - 8/10/2015 amlodipine-valsartan-hctz Addition - 8/10/2015 tretinoin microsphere external Addition - 8/10/2015 butalbital-aspirin-caffeine-codeine capsule Addition - 8/10/2015 calcipotriene-betamethasone ointment Addition - 8/10/ ACA 5 Tier Formulary Version 1 Page 13

14 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES-AMPHETAMINE MIXTURES ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR amphetamine-dextroamphetamine oral tablet AMPHETAMINES-AMPHETAMINES dextroamphetamine sulfate er oral capsule extended release 24 hour dextroamphetamine sulfate oral tablet methamphetamine hcl oral tablet VYVANSE ORAL CAPSULE ANOREXIANTS NON-AMPHETAMINE-ANOREXIANTS NON- AMPHETAMINE phentermine hcl oral capsule 15 mg QL (180 EA Max Qty Per Fill Retail) phentermine hcl oral capsule 30 mg QL (90 EA Max Qty Per Fill Retail) phentermine hcl oral tablet QL (90 EA Max Qty Per Fill Retail) ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS-ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS INTUNIV ORAL TABLET EXTENDED RELEASE 24 HR QL (31 EA per 31 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS-ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR STRATTERA ORAL CAPSULE STIMULANTS - MISC.-STIMULANTS - MISC. DAYTRANA TRANSDERMAL PATCH dexmethylphenidate hcl oral tablet FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR METHYLIN ORAL METHYLIN ORAL TABLET CHEWABLE methylphenidate hcl er (la) oral capsule extended release 24 hour methylphenidate hcl er oral tablet extendedrelease methylphenidate hcl oral solution methylphenidate hcl oral tablet modafinil oral tablet ; QL (31 EA per 31 NUVIGIL ORAL TABLET ; QL (31 EA per 31 AMINOGLYCOSIDES AMINOGLYCOSIDES-AMINOGLYCOSIDES neomycin sulfate oral tablet paromomycin sulfate oral capsule streptomycin sulfate intramuscular solution reconstituted ANALGESICS - ANTI-INFLAMMATORY QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 14

15 ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES-ANTI-TNF- ALPHA - MONOCLONAL ANTIBODIES HUMIRA PEN SUBCUTANEOUS ; QL (1 EA per 31 HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS HUMIRA SUBCUTANEOUS 20 MG/0.4ML, 40 MG/0.8ML GOLD COMPOUNDS-GOLD COMPOUNDS RIDAURA ORAL CAPSULE ; QL (1 EA per 365 ; QL (1 EA per 365 ; QL (1 EA per 31 T5 (SP) INTERLEUKIN-1 BLOCKERS-INTERLEUKIN-1 BLOCKERS ARCALYST SUBCUTANEOUS RECONSTITUTED NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)- CYCLOOXYGENASE 2 (COX-2) INHIBITORS CELEBREX ORAL CAPSULE ST; QL (62 EA per 31 celecoxib oral capsule ST NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)- NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hr diclofenac sodium oral tablet delayed release T1 etodolac er oral tablet extended release 24 hr 500 mg, 600 mg etodolac oral capsule etodolac oral tablet fenoprofen calcium oral tablet flurbiprofen oral tablet ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule ketoprofen oral capsule ketorolac tromethamine oral tablet meclofenamate sodium oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet nabumetone oral tablet NAPROSYN ORAL TABLET 375 MG naproxen dr oral tablet delayed release 500 mg naproxen oral tablet naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule sulindac oral tablet T1 T1 T1 T1 T1 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 15

16 tolmetin sodium oral capsule tolmetin sodium oral tablet PYRIMIDINE SYNTHESIS INHIBITORS-PYRIMIDINE SYNTHESIS INHIBITORS leflunomide oral tablet QL (31 EA per 31 SELECTIVE COSTIMULATION MODULATORS-SELECTIVE COSTIMULATION MODULATORS ORENCIA INTRAVENOUS RECONSTITUTED SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS- SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL SUBCUTANEOUS ENBREL SUBCUTANEOUS KIT ; QL (8 EA per 31 ENBREL SURECLICK SUBCUTANEOUS ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS-ANALGESICS-SEDATIVES butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet mg FIORICET ORAL CAPSULE SALICYLATES-SALICYLATES aspirin low strength oral tablet chewable aspirin oral tablet 325 mg diflunisal oral tablet ANALGESICS - OPIOID OPIOID AGONISTS-OPIOID AGONISTS codeine sulfate oral tablet QL (248 EA per 31 EXALGO ORAL 12 MG, 16 MG, 8 MG fentanyl citrate buccal lollipop fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr ; QL (31 EA per 31 QL (15 EA per 31 hydromorphone hcl oral tablet QL (248 EA per 31 levorphanol tartrate oral tablet meperidine hcl oral tablet 50 mg methadone hcl oral tablet QL (248 EA per 31 morphine sulfate er oral tablet extendedrelease morphine sulfate oral solution morphine sulfate oral tablet QL (248 EA per 31 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR NUCYNTA ORAL TABLET PA OPANA ER ORAL T5 (SP) QL (61 EA per 31 Days) QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 16

17 oxycodone hcl oral solution oxycodone hcl oral tablet 10 mg, 20 mg, 5 mg oxycodone hcl oral tablet 15 mg, 30 mg QL (248 EA per 31 OXYCONTIN ORAL ; QL (62 EA per 31 oxymorphone hcl er oral tablet extended release 12 hr oxymorphone hcl oral tablet tramadol hcl er (biphasic) oral tablet extended release 24 hr 100 mg, 200 mg tramadol hcl er (biphasic) oral tablet extended release 24 hr 300 mg tramadol hcl er oral tablet extended release 24 hr 100 mg, 200 mg tramadol hcl er oral tablet extended release 24 hr 300 mg QL (62 EA per 31 Days) QL (31 EA per 31 Days) QL (31 EA per 31 Days) QL (31 EA per 31 Days) QL (31 EA per 31 Days) tramadol hcl oral tablet QL (372 EA per 31 OPIOID COMBINATIONS-CODEINE COMBINATIONS acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet QL (248 EA per 31 QL (248 EA per 31 QL (248 EA per 31 acetaminophen-codeine oral solution butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule OPIOID COMBINATIONS-DIHYDROCODEINE COMBINATIONS apap-caff-dihydrocodeine oral tablet OPIOID COMBINATIONS-HYDROCODONE COMBINATIONS hydrocodone-acetaminophen oral solution mg/15ml, mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg REPREXAIN ORAL TABLET MG OPIOID COMBINATIONS-OPIOID COMBINATIONS oxycodone-acetaminophen oral capsule QL (403 EA per 31 QL (248 EA per 31 QL (186 EA per 31 QL (155 EA per 31 QL (155 EA per 31 QL (155 EA per 31 QL (248 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 17

18 oxycodone-acetaminophen oral tablet mg, mg, mg, mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet QL (248 EA per 31 QL (186 EA per 31 oxycodone-ibuprofen oral tablet QL (155 EA per 31 OPIOID COMBINATIONS-PENTAZOCINE COMBINATIONS pentazocine-acetaminophen oral tablet OPIOID COMBINATIONS-TRAMADOL COMBINATIONS tramadol-acetaminophen oral tablet OPIOID PARTIAL AGONISTS-OPIOID PARTIAL AGONISTS buprenorphine hcl sublingual tablet sublingual butorphanol tartrate injection solution 2 mg/ml BUTRANS TRANSDERMAL PATCH WEEKLY pentazocine-naloxone hcl oral tablet SUBOXONE SUBLINGUAL FILM ANDROGENS-ANABOLIC ANABOLIC STEROIDS-ANABOLIC STEROIDS ANADROL-50 ORAL TABLET oxandrolone oral tablet ANDROGENS-ANDROGENS ANDROGEL PUMP TRANSDERMAL MG/ACT (1.62%) ANDROGEL TRANSDERMAL MG/1.25GM (1.62%), 25 MG/2.5GM (1%) ANDROGEL TRANSDERMAL 50 MG/5GM (1%) ANDROXY ORAL TABLET danazol oral capsule PA; QL (300 GM per 31 PA TESTIM TRANSDERMAL PA testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution ANORECTAL AGENTS PA; QL (300 GM per 31 PA PA INTRARECTAL STEROIDS-INTRARECTAL STEROIDS hydrocortisone enema RECTAL COMBINATIONS-RECTAL ANESTHETIC/STEROIDS ANALPRAM ADVANCED COMBINATION KIT hydrocortisone ace-pramoxine cream lidocaine-hydrocortisone ace lidocaine-hydrocortisone ace cream lidocaine-hydrocortisone ace kit PROCORT CREAM QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 18

19 PROCTOFOAM HC FOAM RECTAL STEROIDS-RECTAL STEROIDS hydrocortisone acetate suppository PROCTO-PAK CREAM PROCTOSOL HC CREAM VASODILATING AGENTS-NITRATE VASODILATING AGENTS RECTIV OINTMENT ANTHELMINTICS ANTHELMINTICS-ANTHELMINTICS ALBENZA ORAL TABLET BILTRICIDE ORAL TABLET STROMECTOL ORAL TABLET ANTIANGINAL AGENTS ANTIANGINALS-OTHER-ANTIANGINALS-OTHER RANEXA ORAL TABLET EXTENDED RELEASE 12 HR NITRATES-NITRATES isosorbide dinitrate er oral tablet extendedrelease isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hr isosorbide mononitrate oral tablet MINITRAN TRANSDERMAL PATCH 24 HR NITRO-BID TRANSDERMAL OINTMENT nitroglycerin transdermal patch 24 hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC.-ANTIANXIETY AGENTS - MISC. buspirone hcl oral tablet hydroxyzine hcl intramuscular solution hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet BENZODIAZEPINES-BENZODIAZEPINES alprazolam er oral tablet extended release 24 hr alprazolam oral tablet chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet DIAZEPAM INTENSOL ORAL CONCENTRATE diazepam oral solution 1 mg/ml diazepam oral tablet lorazepam oral concentrate lorazepam oral tablet PA QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 19

20 ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A-ANTIARRHYTHMICS TYPE I-A disopyramide phosphate oral capsule NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 150 MG procainamide hcl injection solution quinidine gluconate er oral tablet extendedrelease quinidine sulfate er oral tablet extendedrelease quinidine sulfate oral tablet ANTIARRHYTHMICS TYPE I-C-ANTIARRHYTHMICS TYPE I-C flecainide acetate oral tablet propafenone hcl er oral capsule extended release 12 hour propafenone hcl oral tablet ANTIARRHYTHMICS TYPE III-ANTIARRHYTHMICS TYPE III amiodarone hcl oral tablet 200 mg, 400 mg MULTAQ ORAL TABLET ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES-ANTI-IGE MONOCLONAL ANTIBODIES XOLAIR SUBCUTANEOUS RECONSTITUTED ANTI-INFLAMMATORY AGENTS-ANTI-INFLAMMATORY AGENTS cromolyn sodium inhalation nebulization solution BRONCHODILATORS - ANTICHOLINERGICS- BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL, ipratropium bromide inhalation solution SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL, QL (26 GM per 31 QL (31 EA per 31 LEUKOTRIENE MODULATORS-5-LIPOXYGENASE INHIBITORS ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR ; QL (124 EA per 31 LEUKOTRIENE MODULATORS-LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium oral tablet QL (31 EA per 31 montelukast sodium oral tablet chewable QL (31 EA per 31 zafirlukast oral tablet QL (62 EA per 31 STEROID INHALANTS-STEROID INHALANTS ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED QL (1 EA per 31 Days) QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 20

21 ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL budesonide inhalation suspension FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL PULMICORT INHALATION SUSPENSION 1 MG/2ML QL (1 EA per 31 Days) QL (1 EA per 31 Days) QL (1 EA per 31 Days) QL (1 EA per 31 Days) QL (13 GM per 30 QL (124 EA per 31 QL (24 GM per 31 SYMPATHOMIMETICS-ADRENERGIC COMBINATIONS ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL QL (62 EA per 31 QL (12 GM per 31 BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED COMBIVENT RESPIMAT INHALATION AEROSOL, DULERA INHALATION AEROSOL QL (13 GM per 31 ipratropium-albuterol inhalation solution SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT SYMPATHOMIMETICS-BETA ADRENERGICS albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup albuterol sulfate oral tablet ARCAPTA NEOHALER INHALATION CAPSULE BROVANA INHALATION NEBULIZATION levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml MAXAIR AUTOHALER INHALATION AEROSOL, BREATH ACTIVATED metaproterenol sulfate oral syrup ST; QL (10.2 GM per 31 ST; QL (13.8 GM per 31 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 21

22 metaproterenol sulfate oral tablet PERFOROMIST INHALATION NEBULIZATION PROVENTIL HFA INHALATION AEROSOL, SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED STRIVERDI RESPIMAT INHALATION AEROSOL, terbutaline sulfate oral tablet QL (13.4 GM per 31 Days) QL (62 EA per 31 SYMPATHOMIMETICS-MIXED ADRENERGICS epinephrine hcl injection solution 1 mg/ml XANTHINES-XANTHINES aminophylline intravenous solution theophylline er oral tablet extended release 12 hr theophylline er oral tablet extended release 24 hr ANTICOAGULANTS COUMARIN ANTICOAGULANTS-COUMARIN ANTICOAGULANTS JANTOVEN ORAL TABLET warfarin sodium oral tablet DIRECT FACTOR XA INHIBITORS-DIRECT FACTOR XA INHIBITORS XARELTO ORAL TABLET 10 MG PA; QL (31 EA per 31 XARELTO ORAL TABLET 15 MG, 20 MG HEPARINS AND HEPARINOID-LIKE AGENTS-HEPARINS AND HEPARINOID-LIKE AGENTS heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml HEPARINS AND HEPARINOID-LIKE AGENTS-LOW MOLECULAR WEIGHT HEPARINS enoxaparin sodium injection solution T5 (SP) QL (24 ML per 90 Days) enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous solution 30 mg/0.3ml enoxaparin sodium subcutaneous solution 40 mg/0.4ml enoxaparin sodium subcutaneous solution 60 mg/0.6ml PA T5 (SP) QL (28 ML per 90 Days) T5 (SP) QL (22.4 ML per 90 Days) T5 (SP) QL (8.4 ML per 90 Days) T5 (SP) QL (11.2 ML per 90 Days) T5 (SP) QL (16.8 ML per 90 Days) HEPARINS AND HEPARINOID-LIKE AGENTS-SYNTHETIC HEPARINOID-LIKE AGENTS fondaparinux sodium subcutaneous solution THROMBIN INHIBITORS-THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 22

23 PRADAXA ORAL CAPSULE ANTICONVULSANTS ANTICONVULSANTS - BENZODIAZEPINES-ANTICONVULSANTS - BENZODIAZEPINES clonazepam oral tablet diazepam ONFI ORAL SUSPENSION ANTICONVULSANTS - MISC.-ANTICONVULSANTS - MISC. BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hr carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet chewable gabapentin oral capsule 100 mg, 300 mg QL (372 EA per 31 gabapentin oral capsule 400 mg QL (279 EA per 31 gabapentin oral solution QL (2232 ML per 31 gabapentin oral tablet 600 mg QL (186 EA per 31 gabapentin oral tablet 800 mg QL (140 EA per 31 LAMICTAL ODT ORAL KIT LAMICTAL ODT ORAL TABLET DISPERSIBLE lamotrigine oral tablet lamotrigine oral tablet chewable levetiracetam er oral tablet extended release 24 hr 500 mg levetiracetam er oral tablet extended release 24 hr 750 mg levetiracetam oral solution QL (93 EA per 31 Days) QL (186 EA per 31 QL (124 EA per 31 levetiracetam oral tablet 1000 mg QL (93 EA per 31 levetiracetam oral tablet 250 mg, 750 mg QL (62 EA per 31 levetiracetam oral tablet 500 mg QL (186 EA per 31 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG, 300 MG oxcarbazepine oral suspension oxcarbazepine oral tablet POTIGA ORAL TABLET primidone oral tablet topiramate oral capsule sprinkle topiramate oral tablet ST; QL (93 EA per 31 ST; QL (62 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 23

24 VIMPAT ORAL ; QL (1240 ML per 31 VIMPAT ORAL TABLET ; QL (62 EA per 31 zonisamide oral capsule CARBAMATES-CARBAMATES felbamate oral suspension felbamate oral tablet T5 (SP) T5 (SP) GABA MODULATORS-GABA MODULATORS GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG T5 (SP) GABITRIL ORAL TABLET 4 MG T5 (SP) QL (124 EA per 31 SABRIL ORAL TABLET HYDANTOINS-HYDANTOINS PEGANONE ORAL TABLET phenytoin oral suspension 125 mg/5ml phenytoin sodium extended oral capsule SUCCINIMIDES-SUCCINIMIDES CELONTIN ORAL CAPSULE ethosuximide oral capsule ethosuximide oral solution VALPROIC ACID-VALPROIC ACID divalproex sodium er oral tablet extended release 24 hr divalproex sodium oral capsule sprinkle divalproex sodium oral tablet delayed release valproic acid oral capsule valproic acid oral syrup ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)-ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine oral tablet 15 mg, 7.5 mg QL (93 EA per 31 mirtazapine oral tablet 30 mg, 45 mg QL (31 EA per 31 mirtazapine oral tablet dispersible QL (31 EA per 31 ANTIDEPRESSANTS - MISC.-ANTIDEPRESSANTS - MISC. bupropion hcl er (sr) oral tablet extended release 12 hr bupropion hcl er (xl) oral tablet extended release 24 hr bupropion hcl oral tablet maprotiline hcl oral tablet QL (62 EA per 31 QL (31 EA per 31 MONOAMINE OXIDASE INHIBITORS (MAOIS)-MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM TRANSDERMAL PATCH 24 HR MARPLAN ORAL TABLET phenelzine sulfate oral tablet QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 24

25 tranylcypromine sulfate oral tablet SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)- SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral solution citalopram hydrobromide oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg, 20 mg escitalopram oxalate oral tablet 5 mg fluoxetine hcl oral capsule 10 mg, 20 mg 1/2 T1 QL (93 EA per 31 fluoxetine hcl oral capsule 40 mg T1 QL (62 EA per 31 fluoxetine hcl oral solution fluvoxamine maleate oral tablet paroxetine hcl er oral tablet extended release 24 hr paroxetine hcl oral tablet PAXIL ORAL SUSPENSION PEXEVA ORAL TABLET sertraline hcl oral concentrate sertraline hcl oral tablet QL (62 EA per 31 SEROTONIN MODULATORS-SEROTONIN MODULATORS BRINTELLIX ORAL TABLET T1 nefazodone hcl oral tablet 100 mg, 150 mg, 250 mg, 50 mg QL (62 EA per 31 nefazodone hcl oral tablet 200 mg QL (93 EA per 31 trazodone hcl oral tablet 100 mg, 150 mg, 50 mg trazodone hcl oral tablet 300 mg VIIBRYD ORAL KIT T5 (SP) ST; QL (31 EA per 31 VIIBRYD ORAL TABLET T5 (SP) ST; QL (31 EA per 31 SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)-SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release particles 30 mg PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg T1 QL (62 EA per 31 Days) QL (93 EA per 31 Days) QL (31 EA per 31 QL (31 EA per 31 QL (93 EA per 31 venlafaxine hcl oral tablet QL (93 EA per 31 TRICYCLIC AGENTS-TRICYCLIC AGENTS QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 25

26 amitriptyline hcl oral tablet amoxapine oral tablet clomipramine hcl oral capsule desipramine hcl oral tablet doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet nortriptyline hcl oral capsule protriptyline hcl oral tablet SURMONTIL ORAL CAPSULE TOFRANIL-PM ORAL CAPSULE VIVACTIL ORAL TABLET ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS-ALPHA-GLUCOSIDASE INHIBITORS acarbose oral tablet QL (93 EA per 31 GLYSET ORAL TABLET ANTIDIABETIC - AMYLIN ANALOGS-ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 120 SUBCUTANEOUS SYMLINPEN 60 SUBCUTANEOUS ANTIDIABETIC COMBINATIONS-DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS JENTADUETO ORAL TABLET ANTIDIABETIC COMBINATIONS-SGL INHIBITOR - DPP-4 INHIBITOR COMBINATIONS GLYXAMBI ORAL TABLET ANTIDIABETIC COMBINATIONS-SULFONYLUREA-BIGUANIDE COMBINATIONS glipizide-metformin hcl oral tablet mg glipizide-metformin hcl oral tablet mg, mg glyburide-metformin oral tablet mg glyburide-metformin oral tablet mg, mg QL (248 EA per 31 QL (124 EA per 31 QL (248 EA per 31 QL (124 EA per 31 ANTIDIABETIC COMBINATIONS-SULFONYLUREA- THIAZOLIDINEDIONE COMBINATIONS pioglitazone hcl-glimepiride oral tablet BIGUANIDES-BIGUANIDES metformin hcl er (osm) oral tablet extended release 24 hr 1000 mg metformin hcl er (osm) oral tablet extended release 24 hr 500 mg metformin hcl er oral tablet extended release 24 hr 500 mg metformin hcl er oral tablet extended release 24 hr 750 mg QL (31 EA per 31 ST; QL (62 EA per 31 ST; QL (155 EA per 31 QL (124 EA per 31 QL (62 EA per 31 metformin hcl oral tablet 1000 mg T1 QL (62 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 26

27 metformin hcl oral tablet 500 mg T1 QL (155 EA per 31 metformin hcl oral tablet 850 mg T1 QL (93 EA per 31 DIABETIC OTHER-DIABETIC OTHER GLUCAGEN HYPOKIT INJECTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS-DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS ONGLYZA ORAL TABLET ST TRADJENTA ORAL TABLET DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC-DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES CYCLOSET ORAL TABLET INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)- INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) BYDUREON SUBCUTANEOUS BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED BYETTA 10 MCG PEN SUBCUTANEOUS BYETTA 5 MCG PEN SUBCUTANEOUS TANZEUM SUBCUTANEOUS VICTOZA SUBCUTANEOUS QL (4.8 ML per 31 QL (4.8 ML per 31 INSULIN SENSITIZING AGENTS-THIAZOLIDINEDIONES AVANDIA ORAL TABLET pioglitazone hcl oral tablet INSULIN-HUMAN INSULIN HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS LEVEMIR FLEXPEN SUBCUTANEOUS LEVEMIR FLEXTOUCH SUBCUTANEOUS LEVEMIR SUBCUTANEOUS NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION NOVOLIN R INJECTION NOVOLOG FLEXPEN SUBCUTANEOUS NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS NOVOLOG SUBCUTANEOUS T5 (SP) QL (20 ML per 28 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL (60 ML per 31 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 27

28 MEGLITINIDE ANALOGUES-MEGLITINIDE ANALOGUES nateglinide oral tablet QL (93 EA per 31 repaglinide oral tablet QL (93 EA per 31 Days) SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGL) INHIBITORS- SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGL) INHIBITORS INVOKANA ORAL TABLET PA SULFONYLUREAS-SULFONYLUREAS chlorpropamide oral tablet glimepiride oral tablet 1 mg QL (248 EA per 31 glimepiride oral tablet 2 mg QL (124 EA per 31 glimepiride oral tablet 4 mg QL (62 EA per 31 glipizide er oral tablet extended release 24 hr 10 mg glipizide er oral tablet extended release 24 hr 2.5 mg glipizide er oral tablet extended release 24 hr 5 mg QL (62 EA per 31 QL (248 EA per 31 QL (124 EA per 31 glipizide oral tablet 10 mg T1 QL (124 EA per 31 glipizide oral tablet 5 mg T1 QL (248 EA per 31 GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR glyburide micronized oral tablet 1.5 mg, 3 mg glyburide micronized oral tablet 6 mg QL (124 EA per 31 QL (62 EA per 31 glyburide oral tablet 1.25 mg QL (496 EA per 31 glyburide oral tablet 2.5 mg QL (248 EA per 31 glyburide oral tablet 5 mg QL (124 EA per 31 tolazamide oral tablet tolbutamide oral tablet ANTIDIARRHEALS ANTIPERISTALTIC AGENTS-ANTIPERISTALTIC AGENTS diphenatol oral tablet diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet loperamide hcl oral capsule MOTOFEN ORAL TABLET ANTIDOTES ANTIDOTES - CHELATING AGENTS-ANTIDOTES - CHELATING AGENTS CHEMET ORAL CAPSULE EXJADE ORAL TABLET SOLUBLE FERRIPROX ORAL TABLET OPIOID ANTAGONISTS-OPIOID ANTAGONISTS QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 28

29 naltrexone hcl oral tablet ANTIEMETICS 5-H RECEPTOR ANTAGONISTS-5-H RECEPTOR ANTAGONISTS ANZEMET ORAL TABLET 50 MG granisetron hcl oral tablet GRANISOL ORAL ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg QL (31 EA per 31 ondansetron hcl oral tablet 4 mg, 8 mg ondansetron oral tablet dispersible QL (62 EA per 31 ANTIEMETICS - ANTICHOLINERGIC-ANTIEMETICS - ANTICHOLINERGIC meclizine hcl oral tablet TIGAN INTRAMUSCULAR trimethobenzamide hcl oral capsule PA ANTIEMETICS - MISCELLANEOUS-ANTIEMETICS - MISCELLANEOUS CESAMET ORAL CAPSULE dronabinol oral capsule ; QL (62 EA per 31 SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS- SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS EMEND ORAL CAPSULE PA; QL (62 EA per 31 ANTIFUNGALS ANTIFUNGALS-ANTIFUNGALS flucytosine oral capsule griseofulvin microsize oral suspension nystatin oral tablet T5 (SP) terbinafine hcl oral tablet QL (31 EA per 31 IMIDAZOLE-RELATED ANTIFUNGALS-IMIDAZOLES ketoconazole oral tablet IMIDAZOLE-RELATED ANTIFUNGALS-TRIAZOLES fluconazole oral tablet itraconazole oral capsule PA NOXAFIL ORAL SUSPENSION voriconazole oral tablet ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES-ANTIHISTAMINES - ETHANOLAMINES carbinoxamine maleate oral tablet clemastine fumarate oral syrup clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl injection solution QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 29

30 ANTIHISTAMINES - NON-SEDATING-ANTIHISTAMINES - NON- SEDATING levocetirizine dihydrochloride oral solution levocetirizine dihydrochloride oral tablet ANTIHISTAMINES - PHENOTHIAZINES-ANTIHISTAMINES - PHENOTHIAZINES promethazine hcl injection solution 25 mg/ml promethazine hcl oral syrup promethazine hcl oral tablet 12.5 mg, 25 mg promethazine hcl oral tablet 50 mg promethazine hcl suppository 12.5 mg, 25 mg PROMETHEGAN SUPPOSITORY ANTIHISTAMINES - PIPERIDINES-ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl oral tablet ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS-INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB LIPTRUZET ORAL TABLET QL (93 EA per 31 Days) VYTORIN ORAL TABLET ANTIHYPERLIPIDEMICS - MISC.-ANTIHYPERLIPIDEMICS - MISC. LOVAZA ORAL CAPSULE T1 VASCEPA ORAL CAPSULE BILE ACID SEQUESTRANTS-BILE ACID SEQUESTRANTS cholestyramine light oral packet cholestyramine light oral powder cholestyramine oral packet cholestyramine oral powder colestipol hcl oral granules colestipol hcl oral tablet PREVALITE ORAL PACKET PREVALITE ORAL POWDER WELCHOL ORAL TABLET FIBRIC ACID DERIVATIVES-FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate oral tablet 145 mg, 48 mg fenofibrate oral tablet 160 mg, 54 mg fenofibric acid oral capsule delayed release gemfibrozil oral tablet HMG COA REDUCTASE INHIBITORS-HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg atorvastatin calcium oral tablet 20 mg, 40 mg, 80 mg T1 T1 QL (31 EA per 31 1/2; QL (31 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 30

31 CRESTOR ORAL TABLET 40 MG 1/2; QL (31 EA per 31 fluvastatin sodium oral capsule LIVALO ORAL TABLET 4 MG lovastatin oral tablet pravastatin sodium oral tablet QL (31 EA per 31 simvastatin oral tablet T1 QL (31 EA per 31 INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS- INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA ORAL TABLET NICOTINIC ACID DERIVATIVES-NICOTINIC ACID DERIVATIVES NIACOR ORAL TABLET NIASPAN ORAL TABLET EXTENDEDRELEASE ANTIHYPERTENSIVES ACE INHIBITORS-ACE INHIBITORS benazepril hcl oral tablet captopril oral tablet enalapril maleate oral tablet fosinopril sodium oral tablet lisinopril oral tablet moexipril hcl oral tablet perindopril erbumine oral tablet quinapril hcl oral tablet T1 T1 T1 T1 T1 ramipril oral capsule trandolapril oral tablet AGENTS FOR PHEOCHROMOCYTOMA-AGENTS FOR PHEOCHROMOCYTOMA DIBENZYLINE ORAL CAPSULE ANGIOTENSIN II RECEPTOR ANTAGONISTS-ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR ORAL TABLET 1/2 candesartan cilexetil oral tablet QL (31 EA per 31 Days) EDARBI ORAL TABLET T5 (SP) QL (31 EA per 31 eprosartan mesylate oral tablet irbesartan oral tablet 150 mg, 75 mg irbesartan oral tablet 300 mg 1/2 losartan potassium oral tablet 100 mg, 50 mg losartan potassium oral tablet 25 mg telmisartan oral tablet 1/2 valsartan oral tablet 1/2 ANTIADRENERGIC ANTIHYPERTENSIVES-ANTIADRENERGICS - CENTRALLY ACTING clonidine hcl oral tablet clonidine hcl transdermal patch weekly guanfacine hcl oral tablet methyldopa oral tablet QL Quantity Limit applies SP Specialty Pharmacy No Cost Share ($0) 2015 ACA 5 Tier Formulary Version 1 Page 31