Health First Health Plans 2016 Formulary (List of Covered Drugs)

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1 Updated: November 1, 2016 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/1/2016. For more recent information or other questions, please contact Health First Health Plans Customer Service at or, for TTY users, , weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we are available seven days a week from 8 a.m. to 8 p.m. or visit myfhca.org. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Health First Health Plans. When it refers to plan or our plan, it means Florida Hospital Explorer Plan (HMO-POS) or Florida Hospital SunSaver Plan (HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of 11/1/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. The Formulary, pharmacy network, may change at any time. You will receive notice when necessary. Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 1

2 What is the Health First Health Plans Formulary? A formulary is a list of covered drugs selected by Health First Health Plans in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Health First Health Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Health First Health Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 11/1/2016. To get updated information about the drugs covered by Health First Health Plans, please contact us. Our contact information appears on the front and back cover pages. Printed formularies are updated via errata sheets in the event of midyear non-maintenance formulary changes. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 122. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Health First Health Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 2

3 Prior Authorization: Health First Health Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health First Health Plans before you fill your prescriptions. If you don t get approval, Health First Health Plans may not cover the drug. Quantity Limits: For certain drugs, Health First Health Plans limits the amount of the drug that Health First Health Plans will cover. For example, Health First Health Plans provides 31 tablets per prescription for TRADJENTA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Health First Health Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Health First Health Plans may not cover B unless you try A first. If A does not work for you, Health First Health Plans will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Health First Health Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Health First Health Plans formulary? on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Health First Health Plans does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Health First Health Plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Health First Health Plans. You can ask Health First Health Plans to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Health First Health Plans Formulary? You can ask Health First Health Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined costsharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health First Health Plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Health First Health Plans will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception, you should submit a Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 3

4 statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Additionally, we understand that if you have been enrolled in the plan for more than 90 days, there may be other situations in which you are prescribed non-formulary medications. These circumstances usually involve a change from one treatment setting to another, including but not limited to: Discharge from a hospital to home, Discharge from a skilled nursing facility to home, Ending a long-term care facility stay and returning to the community. As a current member, if you have been prescribed non-formulary medications as a result of changing from one treatment setting to another, you may be eligible to receive a one-time temporary 30-day supply of your non-formulary drugs. During this transition period you can talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so we will cover the drug(s) you take. You can contact our Customer Service to ask for a temporary supply if the above circumstances apply to you. Our Customer Service contact information is listed on the front and back cover pages. For more information For more detailed information about your Health First Health Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Health First Health Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 4

5 Your Cost Coverage Phase Initial Coverage Period You pay these amounts beginning January 1, 2016, or when you first enroll. When the total cost for your covered drugs reaches $3,310 (including what you pay and what we pay), the Coverage Gap stage begins. Florida Hospital SunSaver Plan Coverage Gap You pay these amounts after the total cost for your covered drugs reaches $3,310 (including what you pay and what we pay). When you have paid $4,850 out-ofpocket for covered drugs, the Catastrophic stage begins. Retail Mail Order Retail Mail Order 30-Day Supply 90-Day Supply 90-Day Supply 30-Day Supply 90-Day Supply 90 Day Supply 1* $2 $6 $0 $2 $6 $0 2 $5 $15 $0 3 $45 $135 $90 For some generics you pay 58% of the cost and for brand name drugs, you pay 45% of the price (50% paid by 4 $90 $270 $180 manufacturer and 5% paid by Health First Health Plans) 5 33% N/A N/A Florida Hospital Explorer Plan Retail Mail Order Retail Mail Order 30-Day Supply 90-Day Supply 90 Day Supply 30-Day Supply 90-Day Supply 90 Day Supply 1* $0 $0 $0 $0 $0 $0 2* $2 $6 $0 $2 $6 $0 Catastrophic After your yearly outof-pocket drug costs reach $4850, you pay a $2.95 copay for generic and a $7.40 copay for all other drugs, or 5% coinsurance (whichever is greater). 3 $45 $135 $90 For some generics you pay 58% of the cost and for brand 4 $90 $270 $180 name drugs, you pay 45% of the price (50% paid by 5 33% N/A N/A manufacturer and 5% paid by Health First Health Plans) * We provide additional coverage of this prescription drug in the coverage gap. Refer to our Evidence of Coverage for more information about this coverage. Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 5

6 Health First Health Plans Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Health First Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 122. The first column of the chart lists the drug name. name drugs are capitalized (e.g., DEXILANT) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if Health First Health Plans has any special requirements for coverage of your drug. Part B versus Part D (): This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Limited Availability (LA): This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or contact Health First Health Plans Customer Service at or, for TTY users, , weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we are available seven days a week from 8 a.m. to 8 p.m. or visit myfhca.org. Prior Authorization (): Health First Health Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health First Health Plans before you fill your prescriptions. If you do not get approval, Health First Health Plans may not cover the drug. Quantity Limit (QL): Quantity Limits may also be listed. (For example, 31/31 days would mean your coverage of this drug is limited to 31 pills every 31 days, or 1 pill per day.) Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount. Step Therapy (ST): In some cases, Health First Health Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if 1 and 2 both treat your medical condition, Health First Health Plans may not cover 2 unless you try 1 first. If 1 does not work for you, Health First Health Plans will then cover 2. Pill Splitting (1/2): You may be able to split these pills in half. Begin by asking your doctor if pill-splitting is right for you. If so, ask your doctor to write your prescription for half the number of pills and double the strength you normally need. For example, instead of 30 pills of 20 mg, you would get a prescription for 15 pills of 40 mg. Then you (or the pharmacy) can split them in half for the correct dose. This way, you only pay 50 percent of you copay. Call our Customer Service Department for details. Coverage Gap ( (S,E)): We provide additional coverage of this prescription drug in the coverage gap. Refer to our Evidence of Coverage for more information about this coverage. S Indicates coverage in the coverage gap for the Florida Hospital (FH) SunSaver Plan. E - Indicates coverage in the coverage gap for the Florida Hospital (FH) Explorer Plan. Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 6

7 ANALGESICS ANALGESICS Acetaminophen-Codeine #2 ORAL TABLET Acetaminophen-Codeine #3 ORAL TABLET Acetaminophen-Codeine #4 ORAL TABLET Acetaminophen-Codeine ORAL /5ML ; QL (248 EA per 31 ; QL (248 EA per 31 ; QL (248 EA per 31 Endocet ORAL TABLET , Endocet ORAL TABLET Hydrocodone- Acetaminophen ORAL /15ML Hydrocodone- Acetaminophen ORAL TABLET , 5-300, ; QL (248 EA per 31 ; QL (248 EA per 31 Days) ; QL (248 EA per 31 Days) Butalbital-Acetaminophen ORAL TABLET Butalbital-AP-Caff-Cod ORAL CAPSULE Butalbital-AP-Caffeine ORAL CAPSULE , Butalbital-AP-Caffeine ORAL TABLET Butalbital-Aspirin-Caffeine ORAL CAPSULE ; ; QL (186 EA per 31 ; QL (186 EA per 31 Days) ; ; QL (186 EA per 31 ; ; QL (186 EA per 31 ; QL (186 EA per 31 Hydrocodone- Acetaminophen ORAL TABLET , 5-325, Hydrocodone-Ibuprofen ORAL TABLET Oxycodone-Acetaminophen ORAL TABLET , , 5-325, Tencon ORAL TABLET ; QL (248 EA per 31 ; QL (155 EA per 31 ; QL (248 EA per 31 ; ; QL (186 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 7

8 Tramadol-Acetaminophen ORAL TABLET Zebutal ORAL CAPSULE NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ; QL (248 EA per 31 Days) ; ; QL (186 EA per 31 Etodolac ORAL TABLET 400, 500 Flurbiprofen ORAL TABLET 100, 50 Ibuprofen ORAL SUSPENSION 100 /5ML Celecoxib ORAL CAPSULE 100, 200, 400, 50 Diclofenac Potassium ORAL TABLET 50 Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Etodolac ER ORAL TABLET EXTENDED RELEASE 24 HR* 400, 500, 600 Ibuprofen ORAL TABLET 400, 600, 800 Indomethacin ORAL CAPSULE 25, 50 Ketoprofen ORAL CAPSULE 50, 75 Ketorolac Tromethamine INJECTION 15 /ML, 30 /ML Ketorolac Tromethamine INTRAMUSCULAR* 60 /2ML Meloxicam ORAL TABLET 15, 7.5 Nabumetone ORAL TABLET 500, 750 T1 (E,S) Etodolac ORAL CAPSULE 200, 300 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 8

9 Naproxen DR ORAL TABLET DELAYED RELEASE 375, 500 Naproxen ORAL SUSPENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 Naproxen Sodium ORAL TABLET 275, 550 Oxaprozin ORAL TABLET 600 Oxycodone-Ibuprofen ORAL TABLET Piroxicam ORAL CAPSULE 10, 20 QL (155 EA per 31 Days) FentaNYL TRANSDERMAL TCH 72 HR 100 M/HR, 12 M/HR, 25 M/HR, 50 M/HR, 75 M/HR Methadone HCl INJECTION 10 /ML Methadone HCl ORAL 10 /5ML, 5 /5ML Methadone HCl ORAL TABLET 10, 5 Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100, 15, 30, 60 QL (15 EA per 31 Days) ; QL (248 EA per 31 Days) ; QL (93 EA per 31 Sulindac ORAL TABLET 150, 200 OPIOID ANALGESICS, LONG-ACTING Duramorph INJECTION 0.5 /ML, 1 /ML Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 200 Morphine Sulfate ORAL TABLET 15, 30 ONA ER ORAL 10, 15, 20, 30, 40, 5, 7.5 ; QL (62 EA per 31 ; QL (248 EA per 31 QL (62 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 9

10 OxyMORphone HCl ER ORAL TABLET EXTENDED RELEASE 12 HR* 10, 15, 20, 30, 40, 5, 7.5 TraMADol HCl ER (Biphasic) ORAL TABLET EXTENDED RELEASE 24 HR* 300 TraMADol HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 100, 200 OPIOID ANALGESICS, SHORT-ACTING Codeine Sulfate ORAL TABLET 15, 30, 60 FentaNYL Citrate BUCCAL LOLLIPOP 1200 M, 1600 M, 200 M, 400 M, 600 M, 800 M HYDROmorphone HCl ORAL TABLET 2, 4, 8 HYDROmorphone HCl PF INJECTION 500 /50ML QL (62 EA per 31 QL (31 EA per 31 Days) QL (31 EA per 31 Days) ; QL (248 EA per 31 ; QL (248 EA per 31 Morphine Sulfate (PF) 10 /ML, 2 /ML, 4 /ML, 8 /ML Nalbuphine HCl INJECTION 10 /ML Nalbuphine HCl INJECTION 20 /ML OxyCODONE HCl ORAL TABLET 10 OxyCODONE HCl ORAL TABLET 15, 20, 30, 5 TraMADol HCl ORAL TABLET 50 ANESTHETICS LOCAL ANESTHETICS Lidocaine EXTERNAL OINTMENT 5 % Lidocaine EXTERNAL TCH 5 % QL (240 ML per 30 QL (120 ML per 30 ; QL (248 EA per 31 Days) ; QL (248 EA per 31 ; QL (248 EA per 31 Days) ; QL (93 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 10

11 Lidocaine HCl (PF) INJECTION 0.5 % Lidocaine HCl EXTERNAL GEL 2 %, 2 % (10ML APPLICATOR), 2 % (5ML APPLICATOR) Lidocaine HCl EXTERNAL 4 % ; VIVITROL INTRAMUSCULAR* SUSPENSION RECONSTITUTED 380 OPIOID DEPENDENCE TREATMENTS Buprenorphine HCl INJECTION 0.3 /ML Lidocaine Viscous MOUTH/THROAT 2 % Lidocaine-Prilocaine EXTERNAL CREAM % Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2, 8 Naltrexone HCl ORAL TABLET 50 QL (93 EA per 31 ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ ANTI-CRAVING Acamprosate Calcium ORAL TABLET DELAYED RELEASE 333 Disulfiram ORAL TABLET 250, 500 Naltrexone HCl ORAL TABLET 50 SUBOXONE SUBLINGUAL FILM 12-3 SUBOXONE SUBLINGUAL FILM 2-0.5, 4-1, 8-2 OPIOID REVERSAL AGENTS Naloxone HCl INJECTION 0.4 /ML, 1 /ML QL (62 EA per 31 QL (93 EA per 31 SMOKING CESSATION AGENTS Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 11

12 BuPROPion HCl ER (Smoking Det) ORAL TABLET EXTENDED RELEASE 12 HR* 150 CHANTIX CONTINUING MONTH K ORAL TABLET 1 CHANTIX ORAL TABLET 0.5, 1 CHANTIX STARTING MONTH K ORAL TABLET 0.5 X 11 & 1 X 42 NICOTROL INHALATION INHALER 10 NICOTROL NS NASAL 10 /ML ANTIBACTERIALS AMINOGLYCOSIDES Amikacin Sulfate INJECTION 500 /2ML ; QL (62 EA per 31 QL (340 EA per 365 QL (340 EA per 365 QL (53 EA per 28 Gentamicin in Saline /ML-%, /ML- % Gentamicin in Saline /ML-%, /ML-% Gentamicin in Saline /ML-%, /ML-% Gentamicin Sulfate EXTERNAL CREAM 0.1 % Gentamicin Sulfate EXTERNAL OINTMENT 0.1 % Gentamicin Sulfate INJECTION 40 /ML Gentamicin Sulfate 10 /ML ; ; ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 12

13 Gentamicin Sulfate OPHTHALMIC OINTMENT 0.3 % Tobramycin Sulfate INJECTION 10 /ML, 80 /2ML Gentamicin Sulfate OPHTHALMIC 0.3 % Neomycin Sulfate ORAL TABLET 500 ANTIBACTERIALS Colistimethate Sodium INJECTION RECONSTITUTED 150 Neomycin-Polymyxin B GU IRRIGATION Paromomycin Sulfate ORAL CAPSULE 250 Streptomycin Sulfate INTRAMUSCULAR* RECONSTITUTED 1 GM TOBRADEX OPHTHALMIC OINTMENT % Tobramycin INHALATION NEBULIZATION 300 /5ML SYNERCID RECONSTITUTED ANTIBACTERIALS, OTHER Acetic Acid OTIC 2 % Bacitracin INTRAMUSCULAR* RECONSTITUTED UNIT Bacitracin OPHTHALMIC OINTMENT 500 UNIT/GM Tobramycin OPHTHALMIC 0.3 % BACTROBAN NASAL NASAL OINTMENT 2 % Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 13

14 Chloramphenicol Sod Succinate RECONSTITUTED 1 GM CLEOCIN VAGINAL SUPPOSITORY 100 Clindamycin HCl ORAL CAPSULE 150, 300 Clindamycin Phosphate VAGINAL CREAM 2 % CUBICIN RECONSTITUTED 500 Global Alcohol Prep Ease D 70 % Clindamycin Phosphate EXTERNAL GEL 1 % Clindamycin Phosphate EXTERNAL LOTION 1 % Clindamycin Phosphate EXTERNAL 1 % Clindamycin Phosphate EXTERNAL SWAB 1 % Clindamycin Phosphate in D5W 300 /50ML, 600 /50ML, 900 /50ML LINCOCIN INJECTION (Lincomycin HCl) 300 /ML Linezolid 600 /300ML Linezolid ORAL TABLET 600 Methenamine Hippurate ORAL TABLET 1 GM MetroNIDAZOLE EXTERNAL CREAM 0.75 % Clindamycin Phosphate INJECTION 600 /4ML MetroNIDAZOLE EXTERNAL GEL 0.75 % Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 14

15 MetroNIDAZOLE EXTERNAL LOTION 0.75 % MetroNIDAZOLE in NaCl /100ML-% Trimethoprim ORAL TABLET 100 TYGACIL RECONSTITUTED 50 MetroNIDAZOLE ORAL TABLET 250, 500 MetroNIDAZOLE VAGINAL GEL 0.75 % MONUROL ORAL CKET 3 GM Mupirocin EXTERNAL OINTMENT 2 % Nitrofurantoin Macrocrystal ORAL CAPSULE 100, 50 Nitrofurantoin Monohyd Macro ORAL CAPSULE 100 QL (90 EA per 365 QL (90 EA per 365 Vancomycin HCl RECONSTITUTED 10 GM, 500 Vancomycin HCl RECONSTITUTED 1000 Vancomycin HCl ORAL CAPSULE 125, 250 XIFAXAN ORAL TABLET 200 Nitrofurantoin ORAL CAPSULE 100 QL (90 EA per 365 XIFAXAN ORAL TABLET 550 ; QL (62 EA per 31 Polymyxin B Sulfate INJECTION RECONSTITUTED UNIT Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 15

16 ZYVOX ORAL SUSPENSION RECONSTITUTED (Linezolid) 100 /5ML BETA-LACTAM, CEPHALOSPORINS Cefaclor ER ORAL TABLET EXTENDED RELEASE 12 HR* 500 CeFAZolin Sodium 1-5 GM-% Cefdinir ORAL CAPSULE 300 Cefdinir ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Cefaclor ORAL CAPSULE 250, 500 Cefadroxil ORAL CAPSULE 500 Cefadroxil ORAL SUSPENSION RECONSTITUTED 250 /5ML, 500 /5ML Cefadroxil ORAL TABLET 1 GM CeFAZolin Sodium INJECTION RECONSTITUTED 1 GM, 500 CeFAZolin Sodium INJECTION RECONSTITUTED 10 GM Cefepime HCl INJECTION RECONSTITUTED 1 GM, 2 GM CefOXitin Sodium INJECTION RECONSTITUTED 10 GM CefOXitin Sodium RECONSTITUTED 1 GM, 2 GM CefOXitin Sodium-Dextrose RECONSTITUTED 1-4 GM-%, GM-% Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 16

17 Cefpodoxime Proxetil ORAL TABLET 100, 200 Cefprozil ORAL TABLET 250 CefTAZidime INJECTION RECONSTITUTED 2 GM, 6 GM Cephalexin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Cephalexin ORAL TABLET 250, 500 Fortaz RECONSTITUTED 1 GM CefTRIAXone Sodium INJECTION RECONSTITUTED 250, 500 CefTRIAXone Sodium RECONSTITUTED 1 GM, 10 GM, 2 GM Cefuroxime Axetil ORAL TABLET 250, 500 Cefuroxime Sodium INJECTION RECONSTITUTED 1.5 GM, 7.5 GM, 750 FORTAZ RECONSTITUTED 2 GM SUPRAX ORAL CAPSULE 400 SUPRAX ORAL SUSPENSION RECONSTITUTED 100 /5ML, 200 /5ML, 500 /5ML SUPRAX ORAL TABLET CHEWABLE 100, 200 Cephalexin ORAL CAPSULE 250, 500 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 17

18 TEFLARO RECONSTITUTED 400, 600 BETA-LACTAM, OTHER AZACTAM IN DEXTROSE 1 GM, 2 GM Aztreonam INJECTION RECONSTITUTED 1 GM Imipenem-Cilastatin RECONSTITUTED 250, 500 INVANZ INJECTION RECONSTITUTED 1 GM Meropenem RECONSTITUTED 500 Amoxicillin ORAL CAPSULE 250, 500 Amoxicillin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 200 /5ML, 250 /5ML, 400 /5ML Amoxicillin ORAL TABLET 500, 875 Amoxicillin ORAL TABLET CHEWABLE 125, 250 Amoxicillin-Pot Clavulanate ER ORAL TABLET EXTENDED RELEASE 12 HR* Amoxicillin-Pot Clavulanate ORAL SUSPENSION RECONSTITUTED /5ML, /5ML, /5ML BETA-LACTAM, PENICILLINS Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 18

19 Amoxicillin-Pot Clavulanate ORAL TABLET , , Amoxicillin-Pot Clavulanate ORAL TABLET CHEWABLE , Ampicillin ORAL CAPSULE 250, 500 Ampicillin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Ampicillin Sodium INJECTION RECONSTITUTED 1 GM Ampicillin Sodium INJECTION RECONSTITUTED 125 Ampicillin Sodium RECONSTITUTED 10 GM Ampicillin-Sulbactam Sodium INJECTION RECONSTITUTED 1.5 (1-0.5) GM Ampicillin-Sulbactam Sodium INJECTION RECONSTITUTED 3 (2-1) GM Ampicillin-Sulbactam Sodium RECONSTITUTED 15 (10-5) GM BACTOCILL IN DEXTROSE 1 GM/50ML, 2 GM/50ML BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR* SUSPENSION UNIT/2ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 19

20 BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML Piperacillin Sod- Tazobactam So RECONSTITUTED ( ) GM Dicloxacillin Sodium ORAL CAPSULE 250, 500 Nafcillin Sodium INJECTION RECONSTITUTED 1 GM ZOSYN GM/50ML, GM/50ML MACROLIDES Penicillin G Potassium INJECTION RECONSTITUTED UNIT Penicillin V Potassium ORAL RECONSTITUTED 125 /5ML, 250 /5ML AZASITE OPHTHALMIC 1 % Azithromycin RECONSTITUTED 500 Penicillin V Potassium ORAL TABLET 250, 500 Azithromycin ORAL SUSPENSION RECONSTITUTED 100 /5ML, 200 /5ML Azithromycin ORAL TABLET 250, 250 (6 CK), 500, 600 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 20

21 Clarithromycin ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 Clarithromycin ORAL SUSPENSION RECONSTITUTED 125 /5ML, 250 /5ML Clarithromycin ORAL TABLET 250, 500 DIFICID ORAL TABLET 200 Ery EXTERNAL D 2 % QUINOLONES Ciprofloxacin HCl OPHTHALMIC 0.3 % Ciprofloxacin HCl ORAL TABLET 100 Ciprofloxacin HCl ORAL TABLET 250, 500, 750 Ciprofloxacin 400 /40ML ERYTHROCIN LACTOBIONATE RECONSTITUTED 500 Erythromycin Base ORAL TABLET 250, 500 Erythromycin EXTERNAL GEL 2 % Ciprofloxacin-Ciproflox HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 1000, 500 Gatifloxacin OPHTHALMIC 0.5 % Levofloxacin 25 /ML Erythromycin EXTERNAL 2 % Erythromycin OPHTHALMIC OINTMENT 5 /GM Levofloxacin OPHTHALMIC 0.5 % Levofloxacin ORAL 25 /ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 21

22 Levofloxacin ORAL TABLET 250, 500, 750 MOXEZA OPHTHALMIC 0.5 % Ofloxacin OPHTHALMIC 0.3 % Ofloxacin ORAL TABLET 400 Ofloxacin OTIC 0.3 % Sulfamethoxazole- Trimethoprim /5ML Sulfamethoxazole- Trimethoprim ORAL SUSPENSION /5ML Sulfamethoxazole- Trimethoprim ORAL TABLET , VIGAMOX OPHTHALMIC 0.5 % SULFONAMIDES Silver Sulfadiazine EXTERNAL CREAM 1 % SSD EXTERNAL CREAM 1 % Sulfacetamide Sodium OPHTHALMIC 10 % SulfADIAZINE ORAL TABLET 500 TETRACYCLINES Doxycycline Hyclate RECONSTITUTED 100 Doxycycline Hyclate ORAL CAPSULE 100 Doxycycline Hyclate ORAL CAPSULE 50 Doxycycline Hyclate ORAL TABLET 100 Doxycycline Hyclate ORAL TABLET Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 22

23 Doxycycline Hyclate ORAL TABLET 20 Doxycycline Monohydrate ORAL CAPSULE 100 Doxycycline Monohydrate ORAL TABLET 75 Minocycline HCl ORAL CAPSULE 100, 50, 75 Morgidox ORAL CAPSULE 50 LevETIRAcetam ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 LevETIRAcetam ER ORAL TABLET EXTENDED RELEASE 24 HR* 750 Levetiracetam in NaCl 1000 /100ML, 1500 /100ML, 500 /100ML ; QL (186 EA per 31 ; QL (124 EA per 31 ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT 50 /5ML BRIVIACT ORAL 10 /ML BRIVIACT ORAL TABLET 10 BRIVIACT ORAL TABLET 100, 25, 50, 75 Diazepam GEL 10, 2.5, 20 ; QL (1200 ML per 30 ; QL (1200 ML per 30 ; QL (240 EA per 30 ; QL (60 EA per 30 LevETIRAcetam 500 /5ML LevETIRAcetam ORAL 100 /ML LevETIRAcetam ORAL TABLET 1000, 250, 500, 750 POTIGA ORAL TABLET 200 POTIGA ORAL TABLET 300, 400 POTIGA ORAL TABLET 50 ; QL (93 EA per 31 ; QL (93 EA per 31 Days) ; QL (279 EA per 31 Days) Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 23

24 SPRITAM ORAL 1000, 250, 500, 750 CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 Ethosuximide ORAL CAPSULE 250 Ethosuximide ORAL 250 /5ML LYRICA ORAL CAPSULE 100, 150, 200, 25, 50, 75 LYRICA ORAL CAPSULE 225, 300 QL (93 EA per 31 QL (62 EA per 31 ClonazeM ORAL TABLET 2 ClonazeM ORAL TABLET DISPERSIBLE 0.125, 0.25, 0.5, 1, 2 Clorazepate Dipotassium ORAL TABLET 15 Clorazepate Dipotassium ORAL TABLET 3.75, 7.5 Diazepam Intensol ORAL CONCENTRATE 5 /ML Diazepam ORAL 1 /ML Diazepam ORAL TABLET 10 ; QL (310 EA per 31 Days) ; QL (186 EA per 31 Days) ; QL (93 EA per 31 Days) ; QL (124 EA per 31 Days) LYRICA ORAL 20 /ML QL (930 ML per 31 Diazepam ORAL TABLET 2, 5 ; QL (93 EA per 31 Days) Zonisamide ORAL CAPSULE 100, 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS ClonazeM ORAL TABLET 0.5, 1 ; QL (93 EA per 31 Days) Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250, 500 Divalproex Sodium ORAL 125 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 24

25 Divalproex Sodium ORAL TABLET DELAYED RELEASE 125, 250, 500 Gabapentin ORAL CAPSULE 100, 300 Gabapentin ORAL CAPSULE 400 Gabapentin ORAL 250 /5ML Gabapentin ORAL TABLET 600 Gabapentin ORAL TABLET 800 LamoTRIgine ORAL TABLET DISPERSIBLE 100, 200, 25, 50 ONFI ORAL SUSPENSION 2.5 /ML ONFI ORAL TABLET 10 ONFI ORAL TABLET 20 ; QL (372 EA per 31 ; QL (279 EA per 31 ; QL (2232 ML per 31 ; QL (186 EA per 31 ; QL (140 EA per 31 PHENobarbital ORAL ELIXIR 20 /5ML PHENobarbital ORAL TABLET 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 Primidone ORAL TABLET 250, 50 SABRIL ORAL CKET 500 SABRIL ORAL TABLET 500 TiaGABine HCl ORAL TABLET 2, 4 Valproate Sodium 500 /5ML Valproate Sodium ORAL SYRUP 250 /5ML Valproic Acid ORAL CAPSULE 250 GLUTAMATE REDUCING AGENTS Felbamate ORAL SUSPENSION 600 /5ML Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 25

26 Felbamate ORAL TABLET 400, 600 FYCOM ORAL SUSPENSION 0.5 /ML FYCOM ORAL TABLET 10, 12 FYCOM ORAL TABLET 2 FYCOM ORAL TABLET 4, 6, 8 LamoTRIgine ORAL TABLET 100, 150, 200, 25 LamoTRIgine ORAL TABLET CHEWABLE 25, 5 Topiramate ORAL CAPSULE SPRINKLE 15, 25 Topiramate ORAL TABLET 100, 200, 25, 50 SODIUM CHANNEL AGENTS ; QL (31 EA per 31 ; QL (62 EA per 31 Days) ; QL (31 EA per 31 Days) APTIOM ORAL TABLET 200, 400, 600, 800 BANZEL ORAL SUSPENSION 40 /ML BANZEL ORAL TABLET 200 BANZEL ORAL TABLET 400 CarBAMazepine ER ORAL TABLET EXTENDED RELEASE 12 HR* 100, 200, 400 CarBAMazepine ORAL SUSPENSION 100 /5ML CarBAMazepine ORAL TABLET CHEWABLE 100 CEREBYX INJECTION 500 PE/10ML Dilantin ORAL CAPSULE 30 ; QL (2480 ML per 31 Days) ; QL (93 EA per 31 Days) ; QL (248 EA per 31 Days) Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 26

27 EPITOL ORAL TABLET (CarBAMazepine) 200 Fosphenytoin Sodium INJECTION 100 PE/2ML VIMT 200 /20ML VIMT ORAL 10 /ML ; QL (1240 ML per 31 ; QL (1240 ML per 31 OXcarbazepine ORAL SUSPENSION 300 /5ML OXcarbazepine ORAL TABLET 150, 300, 600 Peganone ORAL TABLET 250 Phenytoin ORAL SUSPENSION 125 /5ML Phenytoin ORAL TABLET CHEWABLE 50 Phenytoin Sodium Extended ORAL CAPSULE 100, 200, 300 Phenytoin Sodium INJECTION 50 /ML Vimpat ORAL TABLET 100, 150, 50 VIMT ORAL TABLET 200 ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER Ergoloid Mesylates ORAL TABLET 1 CHOLINESTERASE INHIBITORS Donepezil HCl ORAL TABLET 10 Donepezil HCl ORAL TABLET 23 Donepezil HCl ORAL TABLET 5 Donepezil HCl ORAL TABLET DISPERSIBLE 10, 5 ; QL (62 EA per 31 ; QL (62 EA per 31 ; QL (62 EA per 31 Days) QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 27

28 EXELON TRANSDERMAL TCH 24 HR (Rivastigmine) 13.3 /24HR EXELON TRANSDERMAL TCH 24 HR (Rivastigmine) 4.6 /24HR, 9.5 /24HR Galantamine Hydrobromide ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16, 24, 8 Galantamine Hydrobromide ORAL 4 /ML QL (31 EA per 31 Days) QL (31 EA per 31 QL (31 EA per 31 QL (620 ML per 31 NAMENDA ORAL (Memantine HCl) 10 /5ML NAMENDA ORAL TABLET (Memantine HCl) 10, 5 NAMENDA TITRATION K ORAL TABLET (Memantine HCl) 5 (28)- 10 (21) NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14, 21, 28, 7 QL (320 ML per 31 QL (31 EA per 31 Days) Galantamine Hydrobromide ORAL TABLET 12, 4, 8 Rivastigmine Tartrate ORAL CAPSULE 1.5, 3, 4.5, 6 QL (62 EA per 31 QL (62 EA per 31 Days) N-METHYL-D-ASRTATE (NMDA) RECEPTOR ANTAGONIST NAMENDA XR TITRATION CK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10, QL (31 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 28

29 ANTIDEPRESSANTS ANTIDEPRESSANTS OLANZapine-FLUoxetine HCl ORAL CAPSULE 12-25, 12-50, 3-25, 6-25, 6-50 Perphenazine-Amitriptyline ORAL TABLET 2-10, 2-25, 4-10, 4-25, 4-50 ANTIDEPRESSANTS, OTHER ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300, 300 (1.5ML SYRINGE), 400 ARIPiprazole ORAL TABLET 10, 20, 30 ARIPiprazole ORAL TABLET 15, 2, 5 ARIPiprazole ORAL TABLET DISPERSIBLE 10, 15 ; 1/2; QL (31 EA per 31 QL (31 EA per 31 QL (62 EA per 31 BuPROPion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200 BuPROPion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150, 300 BuPROPion HCl ORAL TABLET 100, 75 Maprotiline HCl ORAL TABLET 25, 50, 75 Mirtazapine ORAL TABLET 15, 7.5 Mirtazapine ORAL TABLET 30, 45 Mirtazapine ORAL TABLET DISPERSIBLE 15, 30, 45 Nefazodone HCl ORAL TABLET 100, 150, 250, 50 Nefazodone HCl ORAL TABLET 200 ; QL (62 EA per 31 ; QL (31 EA per 31 Days) ; QL (93 EA per 31 ; QL (31 EA per 31 ; QL (31 EA per 31 ; QL (62 EA per 31 ; QL (93 EA per 31 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 29

30 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150, 200, 300, 400, 50 TraZODone HCl ORAL TABLET 100, 150, 50 TraZODone HCl ORAL TABLET 300 MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL TCH 24 HR 12 /24HR, 6 /24HR, 9 /24HR MARPLAN ORAL TABLET 10 Phenelzine Sulfate ORAL TABLET 15 Tranylcypromine Sulfate ORAL TABLET 10 SSRIS/ SNRIS Citalopram Hydrobromide ORAL 10 /5ML ; QL (31 EA per 31 ST ; QL (620 ML per 31 Days) Citalopram Hydrobromide ORAL TABLET 10, 40 Citalopram Hydrobromide ORAL TABLET 20 DULoxetine HCl ORAL CAPSULE DELAYED RELEASE RTICLES 20, 60 DULoxetine HCl ORAL CAPSULE DELAYED RELEASE RTICLES 30 DULoxetine HCl ORAL CAPSULE DELAYED RELEASE RTICLES 40 Escitalopram Oxalate ORAL 5 /5ML Escitalopram Oxalate ORAL TABLET 10, 20 Escitalopram Oxalate ORAL TABLET 5 ; QL (31 EA per 31 Days) ; QL (62 EA per 31 Days) QL (62 EA per 31 Days) QL (93 EA per 31 Days) QL (62 EA per 31 ; QL (620 ML per 31 Days) 1/2; ; QL (31 EA per 31 Days) ; QL (31 EA per 31 Days) Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 30

31 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120, 20, 40, 80 FETZIMA TITRATION ORAL 20 & 40 ST; QL (31 EA per 31 Days) ST; QL (31 EA per 31 Roxetine HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 12.5 Roxetine HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 25, 37.5 QL (31 EA per 31 Days) QL (62 EA per 31 Days) FLUoxetine HCl ORAL CAPSULE 10, 20 FLUoxetine HCl ORAL CAPSULE 40 FLUoxetine HCl ORAL CAPSULE DELAYED RELEASE 90 FLUoxetine HCl ORAL 20 /5ML FLUoxetine HCl ORAL TABLET 10 FLUoxetine HCl ORAL TABLET 20 ; QL (93 EA per 31 ; QL (62 EA per 31 ; QL (620 ML per 31 Days) QL (93 EA per 31 QL (124 EA per 31 Roxetine HCl ORAL TABLET 10, 20, 30, 40 XIL ORAL SUSPENSION 10 /5ML PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100, 50 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 ; QL (93 EA per 31 Days) QL (930 ML per 31 Days) ST; QL (31 EA per 31 Days) ST; QL (31 EA per 31 FluvoxaMINE Maleate ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100, 150 FluvoxaMINE Maleate ORAL TABLET 100, 25, 50 QL (62 EA per 31 Days) Sertraline HCl ORAL CONCENTRATE 20 /ML Sertraline HCl ORAL TABLET 100, 25, 50 ; QL (310 ML per 31 Days) ; QL (62 EA per 31 Days) Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 31

32 TRINTELLIX ORAL TABLET 10, 20, 5 ; QL (30 EA per 30 Amoxapine ORAL TABLET 100, 150, 25, 50 Venlafaxine HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 Venlafaxine HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 37.5, 75 Venlafaxine HCl ORAL TABLET 100, 25, 37.5, 50, 75 ; QL (62 EA per 31 Days) ; QL (93 EA per 31 ; QL (93 EA per 31 Days) 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 ; VIIBRYD ORAL TABLET 10 VIIBRYD ORAL TABLET 20, 40 VIIBRYD STARTER CK ORAL KIT 10 & 20 TRICYCLICS Amitriptyline HCl ORAL TABLET 10, 100, 150, 25, 50, 75 ST; QL (31 EA per 31 Days) ST; QL (31 EA per 31 ST; QL (30 EA per 30 ; Doxepin HCl ORAL CONCENTRATE 10 /ML Imipramine HCl ORAL TABLET 10, 25, 50 Nortriptyline HCl ORAL CAPSULE 10, 25, 50, 75 Nortriptyline HCl ORAL 10 /5ML Protriptyline HCl ORAL TABLET 10, 5 ; ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 32

33 Surmontil ORAL CAPSULE 100, 25, 50 Trimipramine Maleate ORAL CAPSULE 100, 25, 50 ANTIEMETICS ANTIEMETICS, OTHER ChlorproMAZINE HCl INJECTION 50 /2ML Perphenazine ORAL TABLET 16, 2, 4, 8 PHENADOZ SUPPOSITORY (Promethazine HCl) 12.5 PHENERGAN SUPPOSITORY (Promethazine HCl) 12.5, 25, 50 ChlorproMAZINE HCl ORAL TABLET 10, 100, 200, 25, 50 DiphenhydrAMINE HCl INJECTION 50 /ML Meclizine HCl ORAL TABLET 12.5, 25 Metoclopramide HCl INJECTION 5 /ML Metoclopramide HCl ORAL 5 /5ML Metoclopramide HCl ORAL TABLET 10, 5 ; Prochlorperazine Edisylate INJECTION 5 /ML Prochlorperazine Maleate ORAL TABLET 10, 5 Prochlorperazine SUPPOSITORY 25 Promethazine HCl INJECTION 25 /ML, 50 /ML Promethazine HCl ORAL SYRUP 6.25 /5ML Promethazine HCl ORAL TABLET 12.5, 25, 50 ; ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 33

34 PROMETHEGAN SUPPOSITORY (Promethazine HCl) 25, 50 TRANSDERM-SCOP (1.5 ) TRANSDERMAL TCH 72 HR 1 /3DAYS EMETOGENIC THERAPY ADJUNCTS Dronabinol ORAL CAPSULE 10 Dronabinol ORAL CAPSULE 2.5, 5 EMEND ORAL CAPSULE 125, 40, 80 & 125, 80 Granisetron HCl 0.1 /ML, 1 /ML Granisetron HCl ORAL TABLET 1 Ondansetron HCl INJECTION 4 /2ML QL (10 EA per 30 ; QL (62 EA per 31 ; QL (62 EA per 31 ; Ondansetron HCl ORAL 4 /5ML Ondansetron HCl ORAL TABLET 24, 4, 8 Ondansetron ORAL TABLET DISPERSIBLE 4, 8 ANTIFUNGALS ANTIFUNGALS ABELCET SUSPENSION 5 /ML AMBISOME SUSPENSION RECONSTITUTED 50 Amphotericin B INJECTION RECONSTITUTED 50 CANCIDAS RECONSTITUTED 50, 70 ; ; Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 34

35 Ciclopirox EXTERNAL SHAMPOO 1 % Ciclopirox EXTERNAL 8 % Ciclopirox Olamine EXTERNAL CREAM 0.77 % Ciclopirox Olamine EXTERNAL SUSPENSION 0.77 % Clotrimazole EXTERNAL CREAM 1 % Clotrimazole EXTERNAL 1 % Clotrimazole MOUTH/THROAT TROCHE 10 Fluconazole ORAL TABLET 100, 150, 200, 50 Flucytosine ORAL CAPSULE 250, 500 Griseofulvin Microsize ORAL SUSPENSION 125 /5ML Itraconazole ORAL CAPSULE 100 Ketoconazole EXTERNAL CREAM 2 % Ketoconazole EXTERNAL SHAMPOO 2 % Ketoconazole ORAL TABLET 200 ; QL (124 EA per 31 Days) Econazole Nitrate EXTERNAL CREAM 1 % Fluconazole in Dextrose 400 /200ML Fluconazole ORAL SUSPENSION RECONSTITUTED 10 /ML, 40 /ML MYCAMINE RECONSTITUTED 100 MYCAMINE RECONSTITUTED 50 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 35

36 Naftifine HCl EXTERNAL CREAM 1 % Terbinafine HCl ORAL TABLET 250 ; QL (31 EA per 31 NAFTIN EXTERNAL GEL 1 % Terconazole VAGINAL CREAM 0.4 %, 0.8 % NATACYN OPHTHALMIC SUSPENSION 5 % NOXAFIL ORAL SUSPENSION 40 /ML Nystatin EXTERNAL CREAM UNIT/GM Nystatin EXTERNAL OINTMENT UNIT/GM Nystatin EXTERNAL POWDER UNIT/GM Nystatin MOUTH/THROAT SUSPENSION UNIT/ML Nystatin ORAL TABLET UNIT Nystop EXTERNAL POWDER UNIT/GM Voriconazole RECONSTITUTED 200 Voriconazole ORAL SUSPENSION RECONSTITUTED 40 /ML Voriconazole ORAL TABLET 200, 50 ANTIGOUT AGENTS ANTIGOUT AGENTS Allopurinol ORAL TABLET 100, 300 COLCHICINE ORAL CAPSULE 0.6 COLCHICINE ORAL TABLET 0.6 Colchicine-Probenecid ORAL TABLET Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 36

37 COLCRYS ORAL TABLET 0.6 Probenecid ORAL TABLET 500 ULORIC ORAL TABLET 40, 80 ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS Betamethasone Dipropionate Aug EXTERNAL CREAM 0.05 % Betamethasone Dipropionate Aug EXTERNAL GEL 0.05 % QL (124 EA per 31 ST Betamethasone Dipropionate EXTERNAL OINTMENT 0.05 % Betamethasone Valerate EXTERNAL CREAM 0.1 % Betamethasone Valerate EXTERNAL LOTION 0.1 % Betamethasone Valerate EXTERNAL OINTMENT 0.1 % Cortisone Acetate ORAL TABLET 25 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Diclofenac Potassium ORAL TABLET 50 Betamethasone Dipropionate Aug EXTERNAL LOTION 0.05 % Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 Betamethasone Dipropionate Aug EXTERNAL OINTMENT 0.05 % Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Betamethasone Dipropionate EXTERNAL CREAM 0.05 % Etodolac ORAL TABLET 400, 500 Prior Authorization required ST Step Therapy ½ Qualifies for pill splitting QL Quantity Limit applies LA Limited Access Part B vs Part D administrative authorization Y0089_EL4822FH Accepted Formulary ID 16172, Version 22 Page 37

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