2018 Comprehensive Preferred Drug List (List of Covered Drugs)

Transcription

1 2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the we cover in this plan. If you speak a different language or need something in Braille or audio, don t worry. We can provide translations and alternate formats at no cost to you. Just give us a call tollfree. Georgia Families and eachcare for Kids members call lanning for Healthy Babies members call All TTY users call Si habla otro idioma o si necesita información en Braille o en audio, no se preocupe. odemos ofrecerle traducciones y formatos alternativos sin costo para usted. Simplemente llámenos sin costo. Los miembros de Georgia Families y eachcare for Kids llamen al Los miembros de lanning for Healthy Babies llamen al Todos los usuarios de TTY llamen al This list is updated each quarter. roviders, please visit our website for updates to the preferred drug list: Members, please visit our website for updates to the preferred drug list: Last updated (10/01/2018) WellCare proudly serves Georgia Families, eachcare for Kids and lanning for Healthy Babies members. GA032872_CAD_LTR_ENG State Approved WellCare 2016 GA_01_16_v2 GA6CADLTR72830E_0116

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. Drug Name This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10, 100, 40, 60, 80 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic QL (31 EA per 31 days) atomoxetine hcl oral capsule 18 QL (62 EA per 31 days) atomoxetine hcl oral capsule 25 QL (93 EA per 31 days) *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er oral tablet extended release 10, 20 QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) 1

3 methylphenidate hcl er oral tablet extended release 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 54 methylphenidate hcl er oral tablet extended release 54 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 2 QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 melatonin oral tablet 5 *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** QL (93 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years and Max 6 Years) XELJANZ ORAL TABLET 5 MG A; QL (62 EA per 31 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.8ML HUMIRA EN-CD/UC/HS STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** A A; QL (31 EA per 31 days) celecoxib oral capsule 100, 50 QL (62 EA per 31 days) A A A

4 reference Details Coverage Details celecoxib oral capsule 200, 400 QL (31 EA per 31 days) *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 MEDI-ROFEN ORAL SUSENSION 40 MG/ML meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic Max quantity of 20, Max day supply of 5 per a calendar month; QL (20 EA per 31 days) naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 220 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 *yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION REFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML A 3

5 reference Details Coverage Details ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *Androgens-Anabolic* *Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens*** danazol oral capsule 100, 200, 50 *Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 (50 base) /ml *Antianginal Agents* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr A A =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 4

6 *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 *Benzodiazepines*** diazepam oral solution 1 /ml *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 reference Details Coverage Details MULTAQ ORAL TABLET 400 MG A ACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/DOSE ANORO ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/INH COMBIVENT RESIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT QL (60 EA per 30 days); AL (Min 4 Years and Max 5 Years) QL (60 EA per 31 days) QL (4 GM per 20 days) QL (13 GM per 30 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 5

7 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, mcg/act, mcg/act ipratropium-albuterol inhalation solution (3) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 6 QL (1 EA per 31 days); AL (Min 12 Years) QL (720 ML per 31 days) QL (10.2 GM per 30 days) A QL (720 ML per 31 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 /5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2, 4 STRIVERDI RESIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** QL (4 GM per 31 days) QL (36 GM per 31 days) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT QL (25.8 GM per 31 days) INCRUSE ELLITA INHALATION AEROSOL OWDER BREATH QL (1 EA per 31 days) ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) SIRIVA RESIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT QL (4 GM per 31 days)

8 *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 *Steroid Inhalants*** ARNUITY ELLITA INHALATION AEROSOL OWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml FLOVENT DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT reference Details Coverage Details AL (Min 1 Months and Max 2 Years) QL (30 EA per 31 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (10.6 GM per 30 days) QL (8.7 GM per 31 days) QL (10.6 GM per 31 Days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 7

9 *Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG reference Details Coverage Details XARELTO ORAL TABLET 15 MG QL (62 EA per 31 days) XARELTO ORAL TABLET 20 MG XARELTO STARTER ACK ORAL TABLET THERAY ACK 15 & 20 MG *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous solution 120 /0.8ml, 80 /0.8ml enoxaparin sodium subcutaneous solution 30 /0.3ml enoxaparin sodium subcutaneous solution 40 /0.4ml enoxaparin sodium subcutaneous solution 60 /0.6ml ST; Must fail preferred Warfarin within the past 90 days; QL (31 EA per 31 days) QL (51 EA per 30 days) QL (93 ML per 31 days) QL (31 ML per 31 days) QL (24.8 ML per 31 days) QL (9.3 ML per 31 days) QL (12.4 ML per 31 days) QL (18.6 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 8

10 *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 *Anticonvulsants - Misc.*** reference Details Coverage Details carbamazepine oral suspension 100 /5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 QL (310 EA per 31 days) gabapentin oral capsule 300 QL (372 EA per 31 days) gabapentin oral capsule 400 QL (279 EA per 31 days) gabapentin oral solution 250 /5ml QL (2230 ML per 31 days) gabapentin oral tablet 600 QL (186 EA per 31 days) gabapentin oral tablet 800 QL (124 EA per 31 days) lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 QL (310 EA per 31 days) lamotrigine oral tablet chewable 25, 5 QL (310 EA per 31 days) levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 9

11 *Hydantoins*** reference Details Coverage Details DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml *Succinimides*** ethosuximide oral capsule 250 AL (Min 3 Years) ethosuximide oral solution 250 /5ml *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 divalproex sodium er oral tablet extended release 24 hour 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 10 QL (930 ML per 31 days); AL (Min 3 Years) QL (310 EA per 31 days) QL (279 EA per 31 days) QL (310 EA per 31 days) QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200

12 reference Details Coverage Details bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 60 duloxetine hcl oral capsule delayed release particles 30, 40 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 QL (62 EA per 31 days) QL (31 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 11

13 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 reference Details Coverage Details nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 12 QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days

14 *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** alogliptin-metformin hcl oral tablet , JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Human Insulin*** ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION EN- INJECTOR 100 UNIT/ML ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS SOLUTION EN-INJECTOR 100 UNIT/ML BASAGLAR KWIKEN SOLUTION EN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS SOLUTION EN-INJECTOR 200 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSENSION (75-25) 100 UNIT/ML HUMULIN 70/30 KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML reference Details Coverage Details ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 13

15 HUMULIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS SUSENSION EN- INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKEN SUBCUTANEOUS SOLUTION EN- INJECTOR 500 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG MIX 70/30 FLEXEN SUBCUTANEOUS SUSENSION EN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSENSION (70-30) 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS EN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSENSION RECONSTITUTED ER 2 MG VICTOZA SUBCUTANEOUS SOLUTION EN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 reference Details Coverage Details QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) A; QL (4 ML per 28 days) A; QL (4 EA per 28 days) A; QL (4 EA per 28 days) A; QL (9 ML per 30 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 14

16 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** STEGLATRO ORAL TABLET 15 MG, 5 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET MG pioglitazone hcl-metformin hcl oral tablet , *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheal/robiotic Agents* *Antidiarrheal/robiotic Agents - Misc.*** pink bismuth oral suspension 262 /15ml reference Details Coverage Details ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days ST; Must fail preferred metformin, metformin er, or riomet within the past 100 days =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 15

17 *Antidiarrheals* *Antidiarrheal Agents - Misc.*** pink bismuth oral suspension 262 /15ml *Antidotes* *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml, 4 /10ml naloxone hcl injection solution prefilled syringe 2 /2ml NARCAN NASAL LIQUID 4 MG/0.1ML *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm *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 reference Details Coverage Details QL (450 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 16

18 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 48, 54 fenofibric acid oral capsule delayed release 135 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors*** reference Details Coverage Details ezetimibe oral tablet 10 A *Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, lisinopril-hydrochlorothiazide oral tablet , , =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 17

19 *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 *Angiotensin II Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet , , valsartan-hydrochlorothiazide oral tablet , , , , *Angiotensin II Receptor Antagonists*** irbesartan oral tablet 150, 300, 75 losartan potassium oral tablet 100, 25, 50 olmesartan medoxomil oral tablet 20 olmesartan medoxomil oral tablet 40, 5 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 reference Details Coverage Details QL (31 EA per 31 days) QL (31 EA per 31 days) ST; Must fail 2 of 3 preferred(losartan potassium, irbesartan, and valsartan tablets) within the past 100 days ST; Must fail 2 of 3 preferred(losartan potassium, irbesartan, and valsartan tablets) within the past 100 days =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 18

20 reference Details Coverage Details methyldopa oral tablet 250, 500 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , *Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml A *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous solution 150 /ml *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 19

21 *Antimalarials*** reference Details Coverage Details DARARIM ORAL TABLET 25 MG A hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic Agents* *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG, 500 MG A *Antimetabolites*** methotrexate sodium injection solution 250 /10ml *Lhrh Analogs*** TRELSTAR INTRAMUSCULAR SUSENSION RECONSTITUTED MG, 3.75 MG *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 A =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 20

22 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 156 MG/ML reference Details Coverage Details QL (62 EA per 31 days) A; QL (0.75 ML per 28 days) A; QL (1 ML per 28 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 21

23 INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 39 MG/0.25ML INVEGA SUSTENNA INTRAMUSCULAR SUSENSION 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 273 MG/0.875ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 410 MG/1.315ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 546 MG/1.75ML INVEGA TRINZA INTRAMUSCULAR SUSENSION 819 MG/2.625ML RISERDAL CONSTA INTRAMUSCULAR SUSENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 22 A; QL (1.5 ML per 28 days) A; QL (0.25 ML per 28 days) A; QL (0.5 ML per 28 days) A; QL (0.88 ML per 91 days) A; QL (1.31 ML per 91 days) A; QL (1.75 ML per 91 days) A; QL (2.63 ML per 91 days) A; QL (2 EA per 28 days) QL (62 EA per 31 days); AL (Min 5 Years) QL (496 ML per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years)

24 *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 23 ST; Must fail preferred quetiapine, olanzapine, risperidone, or risperidone ODT within the past 100 days.; AL (Min 10 Years) AL (Min 10 Years) AL (Min 18 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years) AL (Min 12 Years) AL (Min 2 Years) prochlorperazine rectal suppository 25 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR REFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED 300 MG, 400 MG AL (Min 2 Years) AL (Min 6 Years) A; QL (1 EA per 28 days) A; QL (1 EA per 28 days)

25 reference Details Coverage Details ABILIFY MAINTENA INTRAMUSCULAR SUSENSION RECONSTITUTED ER 300 MG, 400 MG aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15, 2, 20, 30, 5 ARISTADA INTRAMUSCULAR REFILLED SYRINGE 1064 MG/3.9ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 441 MG/1.6ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 662 MG/2.4ML ARISTADA INTRAMUSCULAR REFILLED SYRINGE 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antivirals* *Antiretroviral Combinations*** REZCOBIX ORAL TABLET MG *Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A EIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 100 *Herpes Agents - urine Analogues*** acyclovir oral capsule 200 =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 24 A; QL (1 EA per 28 days) A; QL (3.9 ML per 56 days) A; QL (1.6 ML per 28 days) A; QL (2.4 ML per 28 days) A; QL (3.2 ML per 28 days) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 12 Years) acyclovir oral suspension 200 /5ml QL (3500 ML per 31 days) acyclovir oral tablet 400, 800 valacyclovir hcl oral tablet 1 gm, 500 QL (62 EA per 31 days) *Influenza Agents*** rimantadine hcl oral tablet 100 *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 QL (40 EA per 365 days) oseltamivir phosphate oral capsule 45, 75 QL (20 EA per 365 days)

26 reference Details Coverage Details oseltamivir phosphate oral suspension reconstituted 6 /ml RELENZA DISKHALER INHALATION AEROSOL OWDER BREATH ACTIVATED 5 MG/BLISTER *Assorted Classes* *Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 25 GENGRAF ORAL CASULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 *Macrolide Immunosuppressants*** tacrolimus oral capsule 0.5, 1, 5 *urine Analogs*** azathioprine oral tablet 50 *Beta Blockers* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl intravenous solution 5 /ml labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective*** acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 QL (360 ML per 365 days); AL (Max 18 Years) QL (40 EA per 365 days); AL (Min 7 Years) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 25

27 metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, 50 metoprolol tartrate intravenous solution 1 /ml metoprolol tartrate intravenous solution cartridge 5 /5ml metoprolol tartrate oral tablet 100, 25, 37.5, 50, 75 *Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 240 reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 26

28 reference Details Coverage Details diltiazem hcl intravenous solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hour 10, 2.5, 5 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG nifedipine er oral tablet extended release 24 hour 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 60, 90 nifedipine oral capsule 10 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* *Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg *Cardiovascular Agents - Misc.* *eripheral Vasodilators*** no flush niacin oral tablet 500 *ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG A QL (31 EA per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 27

29 *ulmonary Hypertension - hosphodiesterase Inhibitors*** reference Details Coverage Details ADCIRCA ORAL TABLET 20 MG A sildenafil citrate oral tablet 20 A *Cephalosporins* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 10 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml cephalexin oral suspension reconstituted 250 /5ml *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 *Contraceptives* *Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET /0.01 MG (21/5) QL (300 ML per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 28

30 *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET MG- MCG ARI ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG briellyn oral tablet mcg CRYSELLE-28 ORAL TABLET MG- MCG EMOQUETTE ORAL TABLET MG- MCG ESTARYLLA ORAL TABLET MG- MCG GIANVI ORAL TABLET MG JUNEL 1.5/30 ORAL TABLET MG- MCG JUNEL 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG- MCG KELNOR 1/35 ORAL TABLET 1-35 MG- MCG LESSINA ORAL TABLET MG-MCG LEVORA 0.15/30 (28) ORAL TABLET MG-MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG-MCG LUTERA ORAL TABLET MG-MCG MICROGESTIN 1.5/30 ORAL TABLET MG-MCG MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 29

31 MONONESSA ORAL TABLET MG- MCG NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG- MCG norethin-eth estradiol-fe oral tablet chewable mcg NORTREL 0.5/35 (28) ORAL TABLET MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG OCELLA ORAL TABLET MG ORTIA-28 ORAL TABLET MG- MCG REVIFEM ORAL TABLET MG- MCG RECLISEN ORAL TABLET MG- MCG SOLIA ORAL TABLET MG-MCG SRINTEC 28 ORAL TABLET MG- MCG SRONYX ORAL TABLET MG-MCG SYEDA ORAL TABLET MG VESTURA ORAL TABLET MG ZARAH ORAL TABLET MG ZENCHENT FE ORAL TABLET CHEWABLE MG-MCG ZOVIA 1/35E (28) ORAL TABLET 1-35 MG- MCG *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING MG/24HR *Continuous Contraceptives - Oral*** AMETHYST ORAL TABLET MCG reference Details Coverage Details QL (1 EA per 28 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 30

32 levonorgestrel-ethinyl estrad oral tablet mcg *Emergency Contraceptives*** reference Details Coverage Details levonorgestrel oral tablet 0.75 QL (4 EA per 31 days) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG QL (1 EA per 31 days) OTION 2 ORAL TABLET 1.5 MG QL (1 EA per 31 days) LAN B ONE-STE ORAL TABLET 1.5 MG QL (1 EA per 31 days) *Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET MG QL (91 EA per 91 days) *rogestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular suspension 150 /ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 /ml *rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG *Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/ MG ENRESSE-28 ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG QL (1 ML per 93 days) QL (1 ML per 93 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 31

33 reference Details Coverage Details TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/ MG *Corticosteroids* *Glucocorticosteroids*** hydrocortisone oral tablet 10, 20, 5 methylprednisolone oral tablet 4 prednisolone sodium phosphate oral solution 25 /5ml prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 prednisone oral tablet therapy pack 10 (21), 10 (48), 5 (21), 5 (48) *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Cough/Cold/Allergy* *Iodine Expectorants*** SSKI ORAL SOLUTION 1 GM/ML *Dermatologicals* *Acne roducts*** cvs creamy acne face wash external liquid 4 % *Antibiotics - Topical*** bacitracin zinc external ointment 500 unit/gm *Antifungals - Topical*** ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm terbinafine hcl external cream 1 % *Anti-Inflammatory Agents - Topical*** diclofenac sodium transdermal gel 1 % QL (200 GM per 31 days) =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 32

34 *Antivirals - Topical*** acyclovir external ointment 5 % DENAVIR EXTERNAL CREAM 1 % ZOVIRAX EXTERNAL CREAM 5 % *Corticosteroids - Topical*** hydrocortisone external cream 0.5 % *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % urea external cream 40 % *Imidazole-Related Antifungals - Topical*** baza antifungal external cream 2 % clotrimazole external cream 1 % clotrimazole external solution 1 % econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % *Misc. Topical*** HYERCARE EXTERNAL SOLUTION 20 % *Rosacea Agents*** metronidazole external cream 0.75 % metronidazole external gel 1 % *Scabicides & ediculicides*** reference Details Coverage Details =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 33 ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days; QL (5 GM per 28 days) ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days; QL (5 GM per 28 days) malathion external lotion 0.5 % QL (118 ML per 31 days); AL (Min 6 Years) spinosad external suspension 0.9 % AL (Min 6 Months) *Diagnostic roducts* *Diagnostic Drugs*** dipyridamole intravenous solution 5 /ml

35 *Diagnostic Tests*** reference Details Coverage Details CLINISTIX IN VITRO STRI QL (100 EA per 31 days) DIASTIX IN VITRO STRI QL (100 EA per 31 days) KETOSTIX IN VITRO STRI QL (100 EA per 31 days) ONETOUCH ULTRA BLUE STRI IN VITRO ONETOUCH VERIO STRI IN VITRO RECISION XTRA KETONE IN VITRO STRI *Digestive Aids* *Digestive Enzymes*** CREON ORAL CASULE DELAYED RELEASE ARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT VIOKACE ORAL TABLET UNIT, UNIT ZENE ORAL CASULE DELAYED RELEASE ARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, 5000 UNIT, UNIT *Diuretics* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour 500 acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 *Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old QL: 200/31 days for members 21 years old and younger; QL: 100/31 days for members over 21 years old =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 34

36 reference Details Coverage Details spironolactone-hctz oral tablet triamterene-hctz oral capsule triamterene-hctz oral tablet , *Loop Diuretics*** bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 1, 2 furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 torsemide oral tablet 10, 100, 20, 5 *otassium Sparing Diuretics*** amiloride hcl oral tablet 5 spironolactone oral tablet 100, 25, 50 *Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 DIURIL ORAL SUSENSION 250 MG/5ML hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 12.5, 25, 50 indapamide oral tablet 1.25, 2.5 metolazone oral tablet 10, 2.5, 5 *Endocrine And Metabolic Agents - Misc.* *Bisphosphonates*** alendronate sodium oral tablet 10, 35, 40, 5, 70 ibandronate sodium oral tablet 150 QL (1 EA per 28 days) *Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 A *Gaa Deficiency Treatment - Agents*** LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG *Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg =referred, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name / lowercase italics= Generic 35 A