2018 Care1st Health Plan Arizona Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Transcription

1 2018 Care1st Health lan Arizona Medicaid Comprehensive referred Drug List (List of Covered Drugs) Care1st Health lan Arizona lease read: This document contains information about the we cover in this plan. lease note that the Care1st Health lan Arizona Medicaid referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (10/01/2018)

2 CARE1ST HEALTH LAN DRUG FORMULARY INFORMATION FOR CARE1ST HYSICIAN AND HARMACY ROVIDERS WHAT IS THE CARE1ST FORMULARY? Care1st Health lan (Care1st) offers a comprehensive list of covered medications chosen by the Care1st harmacy & Therapeutics (&T) Committee that is made up of community doctors and pharmacists. Care1st covers the listed on the formulary as long as: The drug is medically necessary andappropriate. The script is filled at a Care1st network pharmacy Other Care1st formulary management tools like step therapy, prior authorization, etc. are followed. Effective 10/01/2012, all AHCCCS plans adopted the AHCCCS referred Drug List (DL) as a core formulary. olicy 310 v in Chapter 300 of the AHCCCS AMM Manual outlines the intent of the MRDL: (olicy 310 v begins on page of Chapter 300) REFERRED DRUGS The AHCCCS Drug List and the AHCCCS Behavioral Health Drug List designate medications that are preferred for specific therapeutic classes. Contractors are required to maintain preferred drug lists, which includes every drug exactly as listed on the AHCCCS Drug List and/or the AHCCCS Behavioral Health Drug List, as applicable. When the AHCCCS Drug List and/or AHCCCS Behavioral Health Drug List specify a preferred drug(s) in a particular therapeutic class, Contractors are not permitted to add other preferred to their preferred drug lists in those therapeutic classes. All federally and state reimbursable that are not listed on Care1st Health Drug List is available through the prior authorization process. harmacy Department hone or Fax Visit our website at Effective 1/2018

3 NON COVERED MEDICATIONS lease note certain medications are excluded by AHCCCS and thus are not covered by Care1st. In order to reduce the risk of adverse effects to our members, These medications include but are not limited to the following: 1. Drugs and products used for the treatment of ED (Erectile Dysfunction) 2. Drugs used for Cosmetic urposes (e.g. Topical Minoxidil) 3. Experimental or Investigational Medications 4. Medications purchased outside of the UnitedStates 5. DESI (Drug Efficacy Study Implementation) not deemed effective by the FDA. 6. Medical Marijuana 7. Drugs covered under Medicare art D for AHCCCS members eligible for Medicare whether or not the member receives Medicare art D coverage 8. Drugs used for Infertility Treatment OVER THE COUNTER (OTC) DRUGS If an over the counter (OTC) product is listed on the formulary and a prescription is written and presented to the pharmacy, the product is covered by Care1st. Insulin and insulin syringes are available to Care1st members with a prescription (please see formulary for quantity limits). OTC medications that are not listed on the Drug List are not available for coverage by Care1st unless prior authorization is obtained first. DIABETIC TESTING SULIES Care1st only covers LifeScan a Johnson & Johnson Company diabetic testing supplies (One Touch glucose meters and test strips). If there is a medical reason why a different brand is required, providers may submit a prior authorization request to Care1st and this request may be approved with appropriate supporting documentation. harmacy Department hone or Fax Visit our website at Effective 1/2018

4 RESCRITION QUANTITIES rescriptions should be written for a therapeutic supply of medications. The amount to appropriately treat a medical condition up to a maximum of a 30 day supply. RIOR AUTHORIZATION (A) REQUIREMENTS FOR LONG ACTING OIOID MEDICATIONS A is required for all prescriptions for long acting opioid medications. The prescriber shall obtain A for all prescriptions for long acting opioid medications from Care1st, as applicable. 5 DAY SULY LIMIT OF RESCRITION OIOID MEDICATIONS CONTRACTOR REQUIREMENTS 1. Members under 18 years of age a. Except as otherwise specified in Section G(1)(b), Conditions and Care Exclusion from the 5 day Supply Limitation of this olicy, a prescriber shall limit the initial and refill prescriptions for any short acting opioid medication for a member under 18 years of age to no more than a 5 day supply. An initial prescription for a short acting opioid medication is one in which the member has not previously filled any prescription for a shortacting opioid medication within 60 days of the date of the pharmacy filling the current prescription as evidenced by the member s harmacy Benefit Management (BM) prescription profile. b. Conditions and Care Exclusion from the 5 day SupplyLimitation I. The initial and refill prescription 5 day supply limitation for short acting opioid medications does not apply to prescriptions for the following conditions and care instances: i. Active oncology diagnosis, ii. Hospice care, iii. End of life care (other thanhospice), iv. alliative care, v. Children on opioid wean at time of hospitaldischarge, vi. Skilled nursing facility care, vii. Traumatic injury, excluding post surgical procedures,and harmacy Department hone or Fax Visit our website at Effective 1/2018

5 viii. Chronic conditions for which the provider has received A approval through Care1st. II. The initial prescription 5 day supply limitation for short acting opioid medications does not apply to prescriptions for post surgical procedures. However, initial prescriptions for short acting opioid medications for post surgical procedures are limited to a supply of no more than 14 days. 2. Members 18 years of age and older a. Except as otherwise specified in Section G(2)(b), Conditions and Care Exclusion from the 5 day Supply Limitation of this olicy, a prescriber shall limit the initial prescription for any short acting opioid medication for a member 18 years of age and older to no more than a 5 daysupply. An initial prescription for a short acting opioid medication is one in which the member has not previously filled any prescription for a short acting opioid medication within 60 days of the date of the pharmacy filling the current prescription as evidenced by the member s harmacy Benefit Management (BM) prescription profile. b. Conditions and Care Exclusion from the 5 day Initial SupplyLimitation I. The initial prescription 5 day supply limitation for short acting opioid medications does not apply to prescriptions for the following conditions and care instances: i. Active oncology diagnosis, ii. Hospice care, iii. End of life care (other thanhospice), iv. alliative care, v. Skilled nursing facility care, vi. Traumatic injury, excluding post surgical procedures,and vii. ost surgical procedures. Initial prescriptions for short acting opioid medications for post surgical procedures are limited to a supply of no more than 14 days. harmacy Department hone or Fax Visit our website at Effective 1/2018

6 FORMULARY TOOLS The formulary is under continuous review and revision. This handbook may not reflect the most current list of covered medications. To assist you with the selection of the proper agent to treat your patients needs, the formulary is posted on the Care1st Website and may also be printed for future reference. In addition, Care1st provides notice of formulary changes made by the Care1st &T Committee and the changes are posted on our website. HOW TO USE THE FORMULARY All are listed by their generic names and most common proprietary (branded) name. The brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any non generically available drug not found in this Formulary listing, or Formulary updates published by Care1st shall be considered a Non Formulary drug. All are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name is bolded. HOW TO CONTACT THE CARE1ST HARMACY DEARTMENT If you have any questions regarding the Care1st Formulary and/or the prior authorization process, please contact the Care1st harmacy Department and a pharmacy associate will assist you. roviders may submit rior Authorization requests via fax to roviders may call Care1st during normal business hours (8:00am 5:00pm Monday Friday) for assistance with pharmacy inquiries at CVS provides after hours support to assist with all inquiries. roviders may access this service by dialing the Care1st direct line Effective January 1, 2018, Care1st has a contracted with CVS Caremark to administer the prescription benefits. RXBIN: RXCN: MCAIDADV RXGR: RX8897 harmacy Department hone or Fax Visit our website at Effective 1/2018

7 VACCINES AND EMERGENCY MEDICATIONS ADMINISTERED BY HARMACISTS TO ERSONS AGE 19 YEARS AND OLDER Care1st covers vaccines and emergency medication without a prescription when administered by a pharmacist who is currently licensed and certified by the Arizona State Board of harmacy. Emergency Medication means emergency epinephrine and diphenhydramine. Vaccines are limited to pneumococcal and influenza vaccines. The pharmacy providing the vaccine must be an AHCCCS registered provider. Coverage is limited to Care1st s network pharmacies. EMERGENCY DRUG SULY In the event prior authorization is required for an antibiotic or a lifesustaining medication (other than excluded products), an emergency 5 day supply is covered, provided the following procedure is adhered to (even if a subsequent formal application for prior authorization is denied): The pharmacist must attempt to contact the physician to expedite a modification to the formulary alternative medication, if appropriate. The pharmacist must attempt to contact Care1st to initiate the prior authorization process and request emergency approval. On the following business day, the pharmacist contacts Care1st to report the provision of emergency medication supply. The emergency medicationsupply is limited to a 5 daysupply. The same process applies in the situation where the pharmacist is unable to verify member eligibility and has exhausted attempts to contact Care1st and the harmacy BenefitManager. The pharmacist must demonstrate that efforts to call Care1st either during normal business hours or accessing the after hours services were unsuccessful. harmacy Department hone or Fax Visit our website at Effective 1/2018

8 Who can request a rior Authorization? rescriber or the rescriber s staff on behalf of theprescriber The member or anyone acting on the member s behalf What documents are needed for rior Authorization Review? Completed rior Authorization Form Most recent chart notes ICD10 Diagnosis(es) List all therapeutic alternatives previously used with start/end dates and outcome rovide the start date and expected length oftherapy rovide all relevant lab values related to the patient's medical conditions lease provide patient's complete current medication list How long does it take to complete rior Authorization Review? Care1st s harmacy department makes every effort to make the decision as quickly as possible, turnaround time averages 24 hours. How are rior Authorizations reviewed? rior authorization requests submitted for review must be evaluated for clinical appropriateness based on: Care1st rior Authorization Guidelines when available Standards of practice and National Guidelines Food and Drug Administration (FDA) approved indications andlimits A non FDA approved medication for a specific diagnosis or condition or dosage is considered when all formulary plus FDA approved non formulary medications have been tried and failed with any of the following supportingdocumentation: a. ublished practice guidelines and treatment protocols b. Comparative data evaluating the efficacy, type and frequency of side effects and potential drug interactions among alternative products as well as the risks, benefits and potential member outcomes c. eer reviewed medical literature, including randomized clinical trials, outcomes, research data and pharmacoeconomic studies. harmacy Department hone or Fax Visit our website at Effective 1/2018

9 FORMULARY COMMENTS hysicians and pharmacists are encouraged to direct any suggestions, comments or requests for formulary additions to Care1st at the following address: Chief Medical Officer Care1st Health lan 2355 E Camelback Rd #300 hoenix, AZ harmacy Department hone or Fax Visit our website at Effective 1/2018

10 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. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg KAVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg STRATTERA ORAL CASULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG *Amphetamine Mixtures*** ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG ADDERALL XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg VYVANSE ORAL CASULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG reference Details Coverage Details QL (30 EA per 30 days); AL QL (120 EA per 30 days); AL QL (30 EA per 30 days) QL (30 EA per 30 days); AL QL (60 EA per 30 days); AL QL (30 EA per 30 days); AL QL (60 EA per 30 days); AL QL (60 EA per 30 days); AL QL (60 EA per 30 days); AL QL (30 EA per 30 days); AL QL (30 EA 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 1

11 *Stimulants - Misc.*** ATENSIO XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG DAYTRANA TRANSDERMAL ATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG FOCALIN XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er oral tablet extended release 18 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG QUILLIVANT XR ORAL SUSENSION RECONSTITUTED 25 MG/5ML RITALIN LA ORAL CASULE EXTENDED RELEASE 24 HOUR 10 MG reference Details Coverage Details QL (30 EA per 30 days); AL QL (30 EA per 30 days); AL QL (60 EA per 30 days); AL QL (60 EA per 30 days); AL QL (300 ML per 30 days); AL QL (30 EA per 30 days); AL QL (30 EA per 30 days); AL QL (60 EA per 30 days); AL QL (60 EA per 30 days); AL QL (60 EA per 30 days); AL (Min 6 Years and Max 999 Years) QL (90 EA per 30 days); AL QL (30 EA per 30 days); AL QL (150 ML per 30 days); AL QL (30 EA per 30 days); AL =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

12 *Alternative Medicines* *Alternative Medicine - Me's*** K Melatonin Oral Tablet 3 MG Melatonin Oral Tablet 1 MG, 10 MG, 5 MG Melatonin Oral Tablet Dispersible 3 MG Melatonin TR Oral Tablet Extended Release 1 MG *Alternative Medicine Combinations - Two Ingredients*** Melatin Oral Tablet 3-1 MG Melatonin Oral Tablet 3-10 MG RA Melatonin Oral Tablet 3-2 MG SM Melatonin Oral Tablet MG-MCG *Aminoglycosides* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML KITABIS AK NEBULIZATION SOLUTION 300 MG/5ML INHALATION 300 MG/5ML neomycin sulfate oral tablet 500 mg *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA EDIATRIC CROHNS START SUBCUTANEOUS REFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.4ML HUMIRA EN-CD/UC/HS STARTER SUBCUTANEOUS EN-INJECTOR KIT 80 MG/0.8ML HUMIRA EN-S/UV STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML reference Details Coverage Details A A A A 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 3

13 reference Details Coverage Details HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA EDIATRIC CROHNS START SUBCUTANEOUS REFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA EN SUBCUTANEOUS EN- INJECTOR KIT 40 MG/0.4ML HUMIRA EN-CD/UC/HS STARTER SUBCUTANEOUS EN-INJECTOR KIT 80 MG/0.8ML HUMIRA EN-S/UV STARTER SUBCUTANEOUS EN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS REFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** ADVIL JUNIOR STRENGTH ORAL TABLET 100 MG Diclofenac otassium Oral Tablet 50 MG diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg Etodolac ER Oral Tablet Extended Release 24 Hour 400 MG, 500 MG, 600 MG etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral capsule 400 mg fenoprofen calcium oral tablet 600 mg A A A A A 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

14 FENORTHO ORAL CASULE 200 MG flurbiprofen oral tablet 100 mg, 50 mg goodsense ibuprofen infants oral suspension 50 mg/1.25ml goodsense ibuprofen junior st oral tablet chewable 100 mg goodsense ibuprofen oral tablet 200 mg goodsense naproxen sodium oral tablet 220 mg ibuprofen oral capsule 200 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSENSION 25 MG/5ML INDOCIN RECTAL SUOSITORY 50 MG indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg Ketoprofen ER Oral Capsule Extended Release 24 Hour 200 MG ketoprofen oral capsule 50 mg, 75 mg reference Details Coverage Details ketorolac tromethamine oral tablet 10 mg QL (20 EA per 30 days) meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg Naproxen DR Oral Tablet Delayed Release 375 MG, 500 MG naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg *yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 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 5

15 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION REFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** ACEHEN RECTAL SUOSITORY 120 MG, 325 MG Acetaminophen Oral Solution 160 MG/5ML acetaminophen rectal suppository 650 mg apra oral elixir 160 mg/5ml Childrens Acetaminophen Oral Tablet Dispersible 80 MG childrens non-aspirin oral tablet chewable 80 mg ed-apap oral liquid 160 mg/5ml GoodSense ain Relief Extra St Oral Tablet 500 MG GoodSense ain Relief Oral Tablet Extended Release 650 MG MAA ACETAMINOHEN EXTRA STR ORAL LIQUID 500 MG/15ML mapap oral capsule 500 mg non-aspirin jr strength oral tablet chewable 160 mg ain & Fever Junior Oral Tablet Dispersible 160 MG pain relief childrens oral suspension 160 mg/5ml ain Reliever Oral Tablet 325 MG tgt acetaminophen infants oral suspension 80 mg/0.8ml reference Details Coverage Details A A 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 6

16 reference Details Coverage Details Triaminic Fever Reducer Oral Syrup 160 MG/5ML *Analgesics-Sedatives*** Butalbital-Acetaminophen Oral Tablet MG butalbital-apap-caffeine oral capsule mg butalbital-apap-caffeine oral tablet mg butalbital-aspirin-caffeine oral capsule mg butalbital-aspirin-caffeine oral tablet mg ESGIC ORAL CASULE MG *Salicylate Combinations*** Medi-Seltzer Oral Tablet Effervescent 325 MG *Salicylates*** Aspirin EC Oral Tablet Delayed Release 325 MG aspirin rectal suppository 300 mg, 600 mg Aspir-Low Oral Tablet Delayed Release 81 MG diflunisal oral tablet 500 mg goodsense aspirin oral tablet 325 mg goodsense aspirin oral tablet chewable 81 mg ra aspirin oral tablet 500 mg salsalate oral tablet 500 mg, 750 mg *Analgesics - Opioid* *Codeine Combinations*** QL (180 EA per 30 days) acetaminophen-codeine #2 oral tablet mg Limit 2 fills per 30 days. acetaminophen-codeine #3 oral tablet mg Limit 2 fills per 30 days. acetaminophen-codeine #4 oral tablet mg Limit 2 fills per 30 days. acetaminophen-codeine oral solution mg/5ml butalbital-apap-caff-cod oral capsule mg, mg Limit 2 fills per 30 days. Limit 2 fills 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 7

17 reference Details Coverage Details butalbital-asa-caff-codeine oral capsule mg *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg Limit 2 fills per 30 days. Limit 2 fills per 30 days. Limit 2 fills per 30 days. Limit 2 fills per 30 days. LORCET HD ORAL TABLET MG Limit 2 fills per 30 days. LORTAB ORAL ELIXIR MG/15ML Limit 2 fills per 30 days. VERDROCET ORAL TABLET MG Limit 2 fills per 30 days. ZAMICET ORAL SOLUTION MG/15ML *Opioid Agonists*** Codeine Sulfate Oral Tablet 15 MG, 30 MG, 60 MG EMBEDA ORAL CASULE EXTENDED RELEASE MG, MG, MG, 50-2 MG, MG, MG fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr Limit 2 fills per 30 days. Limit 2 fills per 30 days.; QL (240 EA per 30 days) hydromorphone hcl oral liquid 1 mg/ml Limit 2 fills per 30 days. hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg Limit 2 fills per 30 days. hydromorphone hcl rectal suppository 3 mg Limit 2 fills per 30 days. Meperidine HCl Oral Solution 50 MG/5ML Limit 2 fills per 30 days. meperidine hcl oral tablet 100 mg, 50 mg Limit 2 fills per 30 days. morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml A A Limit 2 fills per 30 days. A Limit 2 fills per 30 days. morphine sulfate oral tablet 15 mg, 30 mg Limit 2 fills per 30 days. morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg Limit 2 fills per 30 days. oxycodone hcl oral capsule 5 mg Limit 2 fills 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 8

18 reference Details Coverage Details oxycodone hcl oral concentrate 100 mg/5ml Limit 2 fills per 30 days. oxycodone hcl oral solution 5 mg/5ml Limit 2 fills per 30 days. oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg Limit 2 fills per 30 days. tramadol hcl oral tablet 50 mg Limit 2 fills per 30 days. XTAMZA ER ORAL CASULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG *Opioid Combinations*** oxycodone-acetaminophen oral solution mg/5ml oxycodone-acetaminophen oral tablet mg, mg, mg, mg A A Limit 2 fills per 30 days. Limit 2 fills per 30 days. Oxycodone-Aspirin Oral Tablet MG Limit 2 fills per 30 days. oxycodone-ibuprofen oral tablet mg Limit 2 fills per 30 days. *Opioid artial Agonists*** BUTRANS ATCH WEEKLY 10 MCG/HR TRANSDERMAL 10 MCG/HR BUTRANS ATCH WEEKLY 15 MCG/HR TRANSDERMAL 15 MCG/HR BUTRANS ATCH WEEKLY 20 MCG/HR TRANSDERMAL 20 MCG/HR BUTRANS ATCH WEEKLY 5 MCG/HR TRANSDERMAL 5 MCG/HR BUTRANS ATCH WEEKLY 7.5 MCG/HR TRANSDERMAL 7.5 MCG/HR entazocine-naloxone HCl Oral Tablet MG SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG *Androgens-Anabolic* *Androgens*** ANDRODERM TRANSDERMAL ATCH 24 HOUR 2 MG/24HR, 4 MG/24HR A A A A A Limit 2 fills per 30 days. 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 9

19 reference Details Coverage Details ANDROGEL UM TRANSDERMAL GEL MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) ANDROXY ORAL TABLET 10 MG danazol oral capsule 100 mg, 200 mg, 50 mg testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) testosterone transdermal solution 30 mg/act A VOGELXO UM TRANSDERMAL GEL 12.5 MG/ACT (1%) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) *Anorectal Agents* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA 100 MG/60ML CORTIFOAM RECTAL FOAM 10 % *Rectal Steroids*** hydrocortisone rectal cream 1 % ROCTO-AK RECTAL CREAM 1 % roctosol HC Rectal Cream 2.5 % *Antacids* *Antacid & Simethicone*** Antacid lus Anti-Gas Relief Oral Suspension MG/5ML Mi-Acid Maximum Strength Oral Suspension MG/5ML *Antacids - Aluminum Salts*** Aluminum Hydroxide Gel Oral Suspension 320 MG/5ML A A A A A 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 10

20 *Antacids - Bicarbonate*** Sodium Bicarbonate Oral Tablet 325 MG, 650 MG *Antacids - Calcium Salts*** Calcium Antacid Extra Strength Oral Tablet Chewable 750 MG Calcium Antacid Oral Tablet Chewable 500 MG Calcium Carbonate Antacid Oral Tablet 648 MG *Antacids - Magnesium Salts*** Magnesium Oxide Oral Tablet 250 MG *Anthelmintics* *Anthelmintics*** reference Details Coverage Details ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 mg A inworm Medicine Oral Suspension 144 (50 Base) MG/ML *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *Nitrates*** DILATRATE-SR ORAL CASULE EXTENDED RELEASE 40 MG ISORDIL TITRADOSE ORAL TABLET 40 MG isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg NITRO-BID TRANSDERMAL OINTMENT 2 % 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 11

21 reference Details Coverage Details NITRO-DUR TRANSDERMAL ATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) buspirone hcl oral tablet 30 mg Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) hydroxyzine hcl oral syrup 10 mg/5ml QL (300 ML per 30 days) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg QL (240 EA per 30 days) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg ALRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg alprazolam oral tablet 2 mg alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg alprazolam oral tablet dispersible 2 mg QL (120 EA per 30 days) Limit 1 fill per 30 days.; QL (30 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 ML per 15 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 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 12

22 reference Details Coverage Details chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg DIAZEAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 1 mg/ml diazepam oral tablet 10 mg, 2 mg, 5 mg LORAZEAM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam oral tablet 0.5 mg, 1 mg lorazepam oral tablet 2 mg oxazepam oral capsule 10 mg, 15 mg, 30 mg *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg NORACE CR ORAL CASULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 ML per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; AL Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 ML per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 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 13

23 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg reference Details Coverage Details MULTAQ ORAL TABLET 400 MG A ACERONE ORAL TABLET 200 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE BEVESI AEROSHERE INHALATION AEROSOL MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ipratropium-albuterol inhalation solution (3) mg/3ml STIOLTO RESIMAT INHALATION AEROSOL SOLUTION MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT A ST; Must fail preferred Beclomethasone, Budesonide, Fluticasone,or Mometasone within the past 180 days. A ST; Must fail preferred Beclomethasone, Budesonide, Fluticasone,or Mometasone within the past 180 days. A ST; Must fail preferred Beclomethasone, Budesonide, Fluticasone,or Mometasone within the past 180 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

24 *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml Albuterol Sulfate Oral Tablet 2 MG, 4 MG levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml metaproterenol sulfate oral tablet 10 mg, 20 mg ROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL OWDER BREATH ACTIVATED 50 MCG/DOSE Terbutaline Sulfate Oral Tablet 2.5 MG, 5 MG *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.02 % SIRIVA HANDIHALER INHALATION CASULE 18 MCG *Leukotriene Receptor Antagonists*** reference Details Coverage Details AL (Min 1 Months and Max 4 Years) montelukast sodium oral packet 4 mg AL (Min 1 Months and Max 4 Years) montelukast sodium oral tablet 10 mg QL (30 EA per 30 days) montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER BREATH ACTIVATED 110 MCG/INH A QL (30 EA 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 15

25 reference Details Coverage Details FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT ULMICORT FLEXHALER INHALATION AEROSOL OWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT ULMICORT INHALATION SUSENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** Elixophyllin Oral Elixir 80 MG/15ML Theophylline ER Oral Tablet Extended Release 12 Hour 100 MG, 200 MG, 300 MG, 450 MG Theophylline ER Oral Tablet Extended Release 24 Hour 400 MG, 600 MG *Anticoagulants* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG QL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER ACK ORAL TABLET THERAY ACK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-%, unit/ml-%, unit/ml-% heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml heparin sod (porcine) in d5w intravenous solution 100 unit/ml A QL (60 EA per 30 days) QL (51 EA 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 16

26 reference Details Coverage Details heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml heparin sodium flush intravenous kit unit/ml-% sash kit intravenous kit unit/ml-% *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml *Thrombin Inhibitors - Selective Direct & Reversible*** RADAXA ORAL CASULE 110 MG, 150 MG, 75 MG *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 EA per 30 days) Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) Limit 1 fill per 30 days.; QL (120 EA per 30 days); AL (Min 6 Years) clonazepam oral tablet dispersible 2 mg Limit 1 fill per 30 days.; QL (60 EA per 30 days); AL (Min 6 Years) DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG QL (2 EA per 30 days) DIASTAT EDIATRIC RECTAL GEL 2.5 MG QL (2 EA per 30 days) ONFI ORAL SUSENSION 2.5 MG/ML A ONFI ORAL TABLET 10 MG, 20 MG 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 17

27 *Anticonvulsants - Misc.*** reference Details Coverage Details BANZEL ORAL SUSENSION 40 MG/ML A BANZEL ORAL TABLET 200 MG, 400 MG A carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg lamotrigine starter kit-blue oral kit 25 (35) mg levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg LYRICA ORAL CASULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML A oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg primidone oral tablet 250 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg 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 18

28 reference Details Coverage Details topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg VIMAT ORAL SOLUTION 10 MG/ML A VIMAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg *Carbamates*** felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG A tiagabine hcl oral tablet 2 mg, 4 mg A *Hydantoins*** DILANTIN ORAL CASULE 30 MG phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg *Succinimides*** ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg A QL (30 EA per 30 days); AL QL (30 EA per 30 days); AL =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

29 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg reference Details Coverage Details QL (60 EA per 30 days); AL QL (30 EA per 30 days); AL bupropion hcl oral tablet 100 mg, 75 mg QL (120 EA per 30 days); AL maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg AL *Modified Cyclics*** nefazodone hcl oral tablet 100 mg, 250 mg, 50 mg nefazodone hcl oral tablet 150 mg nefazodone hcl oral tablet 200 mg trazodone hcl oral tablet 100 mg trazodone hcl oral tablet 150 mg trazodone hcl oral tablet 300 mg trazodone hcl oral tablet 50 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG *Monoamine Oxidase Inhibitors (Maois)*** QL (60 EA per 30 days); AL QL (120 EA per 30 days); AL QL (90 EA per 30 days); AL QL (120 EA per 30 days); AL QL (60 EA per 30 days); AL QL (30 EA per 30 days); AL QL (90 EA per 30 days); AL EMSAM TRANSDERMAL ATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 A MG/24HR MARLAN ORAL TABLET 10 MG AL phenelzine sulfate oral tablet 15 mg AL tranylcypromine sulfate oral tablet 10 mg AL *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg A QL (600 ML per 30 days); AL QL (60 EA per 30 days); AL =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

30 reference Details Coverage Details citalopram hydrobromide oral tablet 20 mg, 40 mg escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 10 mg, 20 mg escitalopram oxalate oral tablet 5 mg fluoxetine hcl oral capsule 10 mg, 40 mg QL (30 EA per 30 days); AL QL (600 ML per 30 days); AL QL (30 EA per 30 days); AL QL (60 EA per 30 days); AL QL (60 EA per 30 days); AL fluoxetine hcl oral capsule 20 mg QL (120 EA per 30 days); AL fluoxetine hcl oral capsule delayed release 90 mg A fluoxetine hcl oral solution 20 mg/5ml fluvoxamine maleate er oral capsule extended release 24 hour 100 mg fluvoxamine maleate er oral capsule extended release 24 hour 150 mg fluvoxamine maleate oral tablet 100 mg fluvoxamine maleate oral tablet 25 mg fluvoxamine maleate oral tablet 50 mg paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg paroxetine hcl oral tablet 40 mg AXIL ORAL SUSENSION 10 MG/5ML EXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 100 mg QL (600 ML per 30 days); AL QL (90 EA per 30 days); AL QL (60 EA per 30 days); AL QL (90 EA per 30 days); AL QL (60 EA per 30 days); AL QL (180 EA per 30 days); AL QL (90 EA per 30 days); AL QL (30 EA per 30 days); AL QL (45 EA per 30 days); AL QL (900 ML per 30 days); AL A QL (300 ML per 30 days); AL QL (60 EA per 30 days); AL =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

31 reference Details Coverage Details sertraline hcl oral tablet 25 mg sertraline hcl oral tablet 50 mg *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg duloxetine hcl oral capsule delayed release particles 60 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 venlafaxine hcl oral tablet 100 mg, 37.5 mg, 50 mg venlafaxine hcl oral tablet 25 mg venlafaxine hcl oral tablet 75 mg *Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg QL (90 EA per 30 days); AL QL (120 EA per 30 days); AL QL (120 EA per 30 days); AL QL (120 EA per 30 days); AL QL (60 EA per 30 days); AL QL (30 EA per 30 days); AL QL (90 EA per 30 days); AL QL (90 EA per 30 days); AL QL (120 EA per 30 days); AL QL (150 EA per 30 days); AL AL AL AL AL QL (90 EA per 30 days); AL doxepin hcl oral concentrate 10 mg/ml QL (180 ML per 30 days); AL imipramine hcl oral tablet 10 mg, 25 mg, 50 mg AL imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg AL =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

32 reference Details Coverage Details nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg AL nortriptyline hcl oral solution 10 mg/5ml AL protriptyline hcl oral tablet 10 mg, 5 mg AL trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg *Antidiabetic - Amylin Analogs*** SYMLINEN 120 SUBCUTANEOUS SOLUTION EN-INJECTOR 2700 MCG/2.7ML SYMLINEN 60 SUBCUTANEOUS SOLUTION EN-INJECTOR 1500 MCG/1.5ML *Biguanides*** metformin hcl er (mod) oral tablet extended release 24 hour 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg RIOMET ORAL SOLUTION 500 MG/5ML *Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG A ONGLYZA ORAL TABLET 2.5 MG, 5 MG A TRADJENTA ORAL TABLET 5 MG A AL A A A A QL (1 EA per 30 days) QL (1 EA 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 23

33 *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JENTADUETO ORAL TABLET MG, MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Human Insulin*** HUMALOG KWIKEN SOLUTION EN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 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 HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 SUSENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML HUMULIN N SUSENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML HUMULIN R SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML reference Details Coverage Details A A A 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 24

34 reference Details Coverage Details HUMULIN R U-500 KWIKEN SUBCUTANEOUS SOLUTION EN- INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SOLUTION EN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION EN- INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXEN SOLUTION EN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 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 NOVOLOG ENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS EN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSENSION RECONSTITUTED ER 2 MG BYETTA 10 MCG EN SUBCUTANEOUS SOLUTION EN-INJECTOR 10 MCG/0.04ML BYETTA 5 MCG EN SUBCUTANEOUS SOLUTION EN-INJECTOR 5 MCG/0.02ML VICTOZA SUBCUTANEOUS SOLUTION EN-INJECTOR 18 MG/3ML A A A A 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 25

35 *Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg repaglinide oral tablet 0.5 mg, 1 mg, 2 mg *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet mg, mg, mg glyburide-metformin oral tablet mg, mg, mg *Sulfonylureas*** ChlorproAMIDE Oral Tablet 100 MG, 250 MG glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg TOLAZamide Oral Tablet 250 MG, 500 MG TOLBUTamide Oral Tablet 500 MG *Thiazolidinedione-Biguanide Combinations*** ACTOLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG pioglitazone hcl-metformin hcl oral tablet mg, mg *Thiazolidinediones*** Avandia Oral Tablet 2 MG, 4 MG pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg *Antidiarrheal/robiotic Agents* *Antidiarrheal/robiotic Agents - Misc.*** Stomach Relief Oral Suspension 262 MG/15ML reference Details Coverage Details 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 26