Memorial Hermann Advantage HMO Abridged Formulary. (Partial List of Covered Drugs)

Transcription

1 Memorial Hermann Advantage H 2019 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 19563, Version Number 4 This abridged formulary was updated on 08/24/2018. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Memorial Hermann Advantage H at or, for TTY users, 711, 8:00 a.m. to 8:00 p.m., CST, seven (7) days a week, October 1 March 31; and 8:00 a.m. to 8:00 p.m., CST, Monday through Friday, April 1 September 30, or visit healthplan.memorialhermann.org/medicare. 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 Memorial Hermann Advantage H. When it refers to plan or our plan, it means Memorial Hermann Advantage H. This document includes a partial list of the drugs (formulary) for our plan which is current as of 08/24/2018. For a complete, 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, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year. What is the Memorial Hermann Advantage H Abridged Formulary? A formulary is a list of covered drugs selected by Memorial Hermann Advantage H 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. Memorial Hermann Advantage H will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Memorial Hermann Advantage H network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by Memorial Hermann Advantage H. For a complete listing of all prescription drugs covered by Memorial Hermann Advantage H, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. H7115_PH_AbrFrmly_C IA 10/9/2018 1

2 Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Memorial Hermann Advantage H s Formulary? Drugs removed from the market. If the Food and Drug 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. 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 30 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 30-day supply of the drug. The enclosed formulary is current as of 08/24/2018. To get updated information about the drugs covered by Memorial Hermann Advantage H, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits or through direct member mailings. To review and/or print formulary changes during the year, please visit our website at healthplan.memorialhermann.org/medicare and refer to the Formulary Addendum on the Find a Drug page. If you would like to request a copy of the Formulary Addendum to be mailed to your home, please call Memorial Hermann Advantage H Customer Service at , 8:00 a.m. to 8:00 p.m., CST, seven (7) days a week, October 1 March 31; and 8:00 a.m. to 8:00 p.m., CST, Monday through Friday, April 1 September 30. TTY users should call 711. H7115_PH_AbrFrmly_C IA 10/9/2018 2

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. 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 number 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 73. 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? Memorial Hermann Advantage H 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: Prior Authorization: Memorial Hermann Advantage H requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Memorial Hermann Advantage H before you fill your prescriptions. If you don t get approval, Memorial Hermann Advantage H may not cover the drug. Quantity Limits: For certain drugs, Memorial Hermann Advantage H limits the amount of the drug that Memorial Hermann Advantage H will cover. For example, Memorial Hermann Advantage H provides 30 tablets per prescription for Digoxin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Memorial Hermann Advantage H requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For H7115_PH_AbrFrmly_C IA 10/9/2018 3

4 example, if Drug A and Drug B both treat your medical condition, Memorial Hermann Advantage H may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Memorial Hermann Advantage H will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains 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 Memorial Hermann Advantage H 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 Memorial Hermann Advantage H s 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. This document includes only a partial list of covered drugs, so Memorial Hermann Advantage H may cover your drug. For more information, 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 learn that Memorial Hermann Advantage H does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Memorial Hermann Advantage H. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Memorial Hermann Advantage H. You can ask Memorial Hermann Advantage H 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 Memorial Hermann Advantage H s Formulary? You can ask Memorial Hermann Advantage H 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 cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. H7115_PH_AbrFrmly_C IA 10/9/2018 4

5 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, Memorial Hermann Advantage H 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, Memorial Hermann Advantage H 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, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a 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. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. 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 and 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 93 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. As a current member of our plan, if you have a covered inpatient stay in the hospital or in a skilled nursing facility, the drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug benefit. When you are discharged home or to a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy may be covered under your Medicare Part D coverage. This transfer from one treatment setting to another is called a level-of-care change. Since your drug coverage is different depending on the setting where you obtain the drug, it is possible that a drug you were taking that was covered under your medical benefit might not be covered by Medicare Part D (for H7115_PH_AbrFrmly_C IA 10/9/2018 5

6 example, vitamins, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage). For more information For more detailed information about your Memorial Hermann Advantage H prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Memorial Hermann Advantage H, 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 Memorial Hermann Advantage H s Formulary The abridged formulary that begins on the next page provides coverage information about some of the drugs covered by Memorial Hermann Advantage H. If you have trouble finding your drug in the list, turn to the Index that begins on page 73. Remember: This is only a partial list of drugs covered by Memorial Hermann Advantage H. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine). The information in the Requirements/Limits column tells you if Memorial Hermann Advantage H has any special requirements for coverage of your drug. H7115_PH_AbrFrmly_C IA 10/9/2018 6

7 ANALGESICS OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 5 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr PA; ; QL (10 EA per 30 days) morphine sulfate er beads oral capsule extended release 24 hour 30 mg OPIOID ANALGESICS, SHORT-ACTING available only at certain pharmacies; =Mail Order. For more information call TTY Users acetaminophen-codeine oral tablet mg Tier 1 buprenorphine hcl sublingual tablet sublingual 2 mg butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg codeine sulfate oral tablet 15 mg Tier 1 PA; ; QL (240 EA per 30 days) ; QL (180 EA per 30 days) ; QL (180 EA per 30 days) FENTORA BUCCAL TABLET 400 MCG PA; ; QL (120 EA per 30 days) hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg hydromorphone hcl oral tablet 2 mg Tier 1 hydromorphone hcl pf injection solution 2 mg/ml meperidine hcl injection solution 25 mg/ml BvD; methadone hcl oral tablet 5 mg Tier 1 morphine sulfate oral tablet 15 mg Tier 1 oxycodone hcl oral capsule 5 mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet mg oxycodone-ibuprofen oral tablet mg 7

8 oxymorphone hcl oral tablet 5 mg pentazocine-naloxone hcl oral tablet mg tramadol hcl oral tablet 50 mg Tier 1 ; QL (240 EA per 30 days) tramadol-acetaminophen oral tablet mg ; QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine-prilocaine external cream % PA; ; QL (30 GM per 30 days) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium oral tablet delayed release 333 mg available only at certain pharmacies; =Mail Order. For more information call TTY Users disulfiram oral tablet 250 mg OPIOID ANTAGONISTS buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg ; QL (90 EA per 30 days) butorphanol tartrate nasal solution 10 mg/ml ; QL (10 ML per 30 days) naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID 4 MG/0.1ML ; QL (2 EA per 30 days) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG SKING CESSATION AGENTS bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg CHANTIX ORAL TABLET 0.5 MG 8

9 NICOTROL NS NASAL SOLUTION 10 MG/ML ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate injection solution 500 mg/2ml BvD; gentamicin in saline intravenous solution mg/ml-% available only at certain pharmacies; =Mail Order. For more information call TTY Users gentamicin sulfate injection solution 40 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted 1 gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin sulfate injection solution 10 mg/ml ANTIBACTERIALS, OTHER clindamycin hcl oral capsule 75 mg Tier 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml clindamycin phosphate injection solution 300 mg/2ml colistimethate sodium (cba) injection solution reconstituted 150 mg PA; ; QL (224 EA per 56 days) BvD; dapsone oral tablet 25 mg daptomycin intravenous solution reconstituted 500 mg PA; linezolid oral tablet 600 mg PA; ; QL (60 EA per 30 days) 9

10 methenamine hippurate oral tablet 1 gm Tier 1 metronidazole in nacl intravenous solution mg/100ml-% metronidazole oral capsule 375 mg BvD; NUROL ORAL PACKET 3 GM ; QL (2 EA per 30 days) nitrofurantoin macrocrystal oral capsule 25 mg nitrofurantoin monohyd macro oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5ml PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG tigecycline intravenous solution reconstituted 50 mg tinidazole oral tablet 250 mg trimethoprim oral tablet 100 mg Tier 1 vancomycin hcl in dextrose intravenous solution mg/150ml-% vancomycin hcl in nacl intravenous solution mg/100ml-% vancomycin hcl intravenous solution reconstituted 5000 mg, 750 mg BvD; BvD; BvD; BvD; BvD; XIFAXAN ORAL TABLET 200 MG PA; BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 250 mg cefadroxil oral capsule 500 mg cefazolin sodium injection solution reconstituted 500 mg cefdinir oral capsule 300 mg cefepime hcl injection solution reconstituted 1 gm available only at certain pharmacies; =Mail Order. For more information call TTY Users 10

11 cefotaxime sodium injection solution reconstituted 500 mg cefoxitin sodium intravenous solution reconstituted 1 gm cefpodoxime proxetil oral tablet 100 mg cefprozil oral tablet 250 mg ceftazidime injection solution reconstituted 1 gm ceftriaxone sodium injection solution reconstituted 250 mg cefuroxime axetil oral tablet 250 mg cefuroxime sodium injection solution reconstituted 750 mg BvD; BvD; cephalexin oral capsule 250 mg Tier 1 SUPRAX ORAL CAPSULE 400 MG TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM BETA-LACTAM, OTHER AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM aztreonam injection solution reconstituted 1 gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG doripenem intravenous solution reconstituted 500 mg imipenem-cilastatin intravenous solution reconstituted 250 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM PA; BvD; BvD; PA; LA BvD; BvD; available only at certain pharmacies; =Mail Order. For more information call TTY Users 11

12 meropenem intravenous solution reconstituted 500 mg BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250 mg Tier 1 amoxicillin-pot clavulanate oral tablet mg BvD; available only at certain pharmacies; =Mail Order. For more information call TTY Users ampicillin oral capsule 500 mg Tier 1 ampicillin sodium injection solution reconstituted 125 mg ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/ML BvD; dicloxacillin sodium oral capsule 250 mg nafcillin sodium injection solution reconstituted 1 gm oxacillin sodium injection solution reconstituted 1 gm, 2 gm penicillin g pot in dextrose intravenous solution unit/ml penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral tablet 250 mg Tier 1 piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm BvD; BvD; 12

13 ZOSYN INTRAVENOUS SOLUTION GM/50ML MACROLIDES azithromycin oral tablet 250 mg clarithromycin oral tablet 250 mg BvD; DIFICID ORAL TABLET 200 MG ST; ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG BvD; erythromycin base oral tablet 250 mg erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml QUINOLONES ciprofloxacin hcl oral tablet 100 mg ciprofloxacin in d5w intravenous solution 200 mg/100ml ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 500 mg levofloxacin in d5w intravenous solution 500 mg/100ml BvD; levofloxacin oral tablet 250 mg moxifloxacin hcl oral tablet 400 mg ofloxacin oral tablet 300 mg BvD; available only at certain pharmacies; =Mail Order. For more information call TTY Users 13

14 SULFONAMIDES sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral tablet mg SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML TETRACYCLINES Tier 1 doxycycline hyclate oral capsule 50 mg Tier 1 doxycycline monohydrate oral capsule 50 mg Tier 1 minocycline hcl oral capsule 50 mg Tier 1 tetracycline hcl oral capsule 250 mg ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT ORAL SOLUTION 10 MG/ML PA; BRIVIACT ORAL TABLET 100 MG PA; levetiracetam oral tablet 250 mg BARBITURATES phenobarbital oral tablet 15 mg Tier 1 primidone oral tablet 50 mg Tier 1 BENZODIAZEPINES clonazepam oral tablet 0.5 mg Tier 1 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG ONFI ORAL TABLET 10 MG PA; ; QL (60 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users 14

15 CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg LYRICA ORAL CAPSULE 25 MG ; QL (120 EA per 30 days) zonisamide oral capsule 25 mg GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium oral tablet delayed release 125 mg FYCOMPA ORAL TABLET 2 MG PA; available only at certain pharmacies; =Mail Order. For more information call TTY Users gabapentin oral capsule 100 mg Tier 1 SABRIL ORAL TABLET 500 MG PA; LA tiagabine hcl oral tablet 12 mg valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg Tier 1 VIGADRONE ORAL PACKET 500 MG PA; LA GLUTAMATE REDUCING AGENTS felbamate oral tablet 400 mg lamotrigine starter kit-blue oral kit 25 (35) mg SUBVENITE ORAL TABLET 25 MG topiramate oral tablet 25 mg SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG PA; ; QL (30 EA per 30 days) BANZEL ORAL TABLET 200 MG PA; ; QL (240 EA per 30 days) carbamazepine oral tablet 200 mg DILANTIN ORAL CAPSULE 30 MG 15

16 oxcarbazepine oral tablet 150 mg PEGANONE ORAL TABLET 250 MG phenytoin oral tablet chewable 50 mg Tier 1 VIMPAT ORAL TABLET 50 MG ; QL (60 EA per 30 days) ANTIDEMENTIA AGENTS CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 5 mg galantamine hydrobromide oral tablet 4 mg rivastigmine tartrate oral capsule 1.5 mg rivastigmine transdermal patch 24 hour 4.6 mg/24hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl oral tablet 5 mg NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7-10 MG ANTIDEPRESSANTS ; QL (30 EA per 30 days) PA; ANTIDEPRESSANTS, OTHER bupropion hcl oral tablet 75 mg Tier 1 maprotiline hcl oral tablet 25 mg mirtazapine oral tablet 7.5 mg Tier 1 nefazodone hcl oral tablet 50 mg trazodone hcl oral tablet 50 mg Tier 1 TRINTELLIX ORAL TABLET 5 MG ; QL (30 EA per 30 days) VIIBRYD ORAL TABLET 10 MG ; QL (30 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users 16

17 NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 6 MG/24HR MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 mg Tier 1 tranylcypromine sulfate oral tablet 10 mg SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hydrobromide oral tablet 10 mg Tier 1 desvenlafaxine er oral tablet extended release 24 hour 50 mg desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg duloxetine hcl oral capsule delayed release particles 20 mg PA; ; QL (30 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users escitalopram oxalate oral tablet 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG fluoxetine hcl oral capsule 10 mg Tier 1 fluvoxamine maleate oral tablet 25 mg olanzapine-fluoxetine hcl oral capsule 3-25 mg paroxetine hcl oral tablet 10 mg Tier 1 PEXEVA ORAL TABLET 10 MG ST; sertraline hcl oral tablet 25 mg Tier 1 venlafaxine hcl oral tablet 25 mg Tier 1 TRICYCLICS amitriptyline hcl oral tablet 10 mg Tier 1 amoxapine oral tablet 25 mg Tier 1 ; QL (30 EA per 30 days) 17

18 chlordiazepoxide-amitriptyline oral tablet mg clomipramine hcl oral capsule 25 mg desipramine hcl oral tablet 10 mg Tier 1 doxepin hcl oral capsule 10 mg Tier 1 imipramine hcl oral tablet 10 mg Tier 1 imipramine pamoate oral capsule 75 mg nortriptyline hcl oral capsule 10 mg Tier 1 protriptyline hcl oral tablet 5 mg trimipramine maleate oral capsule 25 mg ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 12.5 mg Tier 1 scopolamine transdermal patch 72 hour 1 mg/3days trimethobenzamide hcl oral capsule 300 mg EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 40 mg BvD; ; QL (8 EA per 30 days) dronabinol oral capsule 2.5 mg PA; ; QL (60 EA per 30 days) granisetron hcl oral tablet 1 mg BvD; ; QL (60 EA per 30 days) ondansetron hcl oral tablet 4 mg BvD; ; QL (120 EA per 30 days) ondansetron oral tablet dispersible 4 mg BvD; ; QL (120 EA per 30 days) VARUBI ORAL TABLET 90 MG PA; ; QL (8 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users 18

19 ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg caspofungin acetate intravenous solution reconstituted 50 mg clotrimazole mouth/throat lozenge 10 mg ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG fluconazole in sodium chloride intravenous solution mg/100ml-% Tier 1 fluconazole oral tablet 50 mg flucytosine oral capsule 250 mg griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg BvD; BvD; BvD; PA; PA; BvD; itraconazole oral capsule 100 mg PA; ketoconazole oral tablet 200 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin mouth/throat suspension unit/ml nystatin oral tablet unit Tier 1 PA; PA; ORAVIG BUCCAL TABLET 50 MG available only at certain pharmacies; =Mail Order. For more information call TTY Users 19

20 terbinafine hcl oral tablet 250 mg Tier 1 ; QL (84 EA per 168 days) voriconazole oral tablet 50 mg ; QL (120 EA per 30 days) ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100 mg Tier 1 colchicine oral capsule 0.6 mg colchicine-probenecid oral tablet mg Tier 1 probenecid oral tablet 500 mg Tier 1 ULORIC ORAL TABLET 40 MG ST; ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS BUPAP ORAL TABLET MG ; QL (180 EA per 30 days) butalbital-apap-caffeine oral tablet mg ; QL (180 EA per 30 days) celecoxib oral capsule 50 mg ; QL (60 EA per 30 days) diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet delayed release 25 mg diclofenac sodium transdermal solution 1.5 % PA; ; QL (450 ML per 30 days) diclofenac-misoprostol oral tablet delayed release mg available only at certain pharmacies; =Mail Order. For more information call TTY Users diflunisal oral tablet 500 mg etodolac oral capsule 200 mg Tier 1 flurbiprofen oral tablet 50 mg Tier 1 IBU ORAL TABLET 600 MG Tier 1 indomethacin oral capsule 25 mg Tier 1 20

21 ketorolac tromethamine oral tablet 10 mg meclofenamate sodium oral capsule 50 mg meloxicam oral tablet 7.5 mg Tier 1 nabumetone oral tablet 500 mg Tier 1 naproxen oral tablet 250 mg Tier 1 naproxen sodium oral tablet 275 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg sulindac oral tablet 150 mg Tier 1 tolmetin sodium oral capsule 400 mg ANTIMIGRAINE AGENTS SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS dihydroergotamine mesylate nasal solution 4 mg/ml ST; ; QL (24 ML per 28 days) eletriptan hydrobromide oral tablet 20 mg ; QL (12 EA per 30 days) ergotamine-caffeine oral tablet mg ; QL (40 EA per 28 days) naratriptan hcl oral tablet 1 mg ; QL (12 EA per 30 days) rizatriptan benzoate oral tablet 5 mg ; QL (12 EA per 30 days) sumatriptan succinate oral tablet 25 mg ; QL (12 EA per 30 days) zolmitriptan oral tablet 2.5 mg ; QL (12 EA per 30 days) ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 125 mg pyridostigmine bromide oral tablet 60 mg Tier 1 available only at certain pharmacies; =Mail Order. For more information call TTY Users 21

22 ANTIMYCOBACTERIALS ANTITUBERCULARS ethambutol hcl oral tablet 100 mg Tier 1 isoniazid oral tablet 100 mg Tier 1 PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin oral capsule 150 mg RIFATER ORAL TABLET MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 25 mg BvD; HEXALEN ORAL CAPSULE 50 MG PA; LEUKERAN ORAL TABLET 2 MG ANTIANGIOGENIC AGENTS REVLIMID ORAL CAPSULE 2.5 MG PA; THALOMID ORAL CAPSULE 50 MG PA; ANTIMETABOLITES mercaptopurine oral tablet 50 mg TABLOID ORAL TABLET 40 MG available only at certain pharmacies; =Mail Order. For more information call TTY Users 22

23 ANTINEOPLASTICS ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML PA; LA AFINITOR ORAL TABLET 2.5 MG PA; ; QL (30 EA per 30 days) ALECENSA ORAL CAPSULE 150 MG PA; ALUNBRIG ORAL TABLET 30 MG PA; LA; QL (180 EA per 30 days) bexarotene oral capsule 75 mg PA; bicalutamide oral tablet 50 mg ; QL (30 EA per 30 days) BOSULIF ORAL TABLET 100 MG PA; ; QL (120 EA per 30 days) CABOMETYX ORAL TABLET 20 MG PA; LA CALQUENCE ORAL CAPSULE 100 MG PA; LA; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 100 MG PA; LA; QL (60 EA per 30 days) COTELLIC ORAL TABLET 20 MG PA; LA DROXIA ORAL CAPSULE 200 MG ELIGARD SUBCUTANEOUS KIT 45 MG PA; EMCYT ORAL CAPSULE 140 MG ERIVEDGE ORAL CAPSULE 150 MG PA; ERLEADA ORAL TABLET 60 MG PA; LA FARYDAK ORAL CAPSULE 10 MG PA; FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG fluorouracil external solution 2 % flutamide oral capsule 125 mg PA; GILOTRIF ORAL TABLET 20 MG PA; LA hydroxyurea oral capsule 500 mg Tier 1 IBRANCE ORAL CAPSULE 75 MG PA; ICLUSIG ORAL TABLET 15 MG PA; LA; QL (60 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users 23

24 IDHIFA ORAL TABLET 50 MG PA; LA; QL (60 EA per 30 days) imatinib mesylate oral tablet 100 mg PA; ; QL (180 EA per 30 days) IMBRUVICA ORAL CAPSULE 70 MG PA; LA INLYTA ORAL TABLET 1 MG PA; ; QL (180 EA per 30 days) INTRON A INJECTION SOLUTION UNIT/ML PA; IRESSA ORAL TABLET 250 MG PA; LA JAKAFI ORAL TABLET 5 MG PA; LA; QL (60 EA per 30 days) KISQALI 200 DOSE ORAL TABLET 200 MG PA; KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG leucovorin calcium oral tablet 5 mg Tier 1 PA; PA; LONSURF ORAL TABLET MG PA; LA LUPRON DEPOT (1-NTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-NTH) INTRAMUSCULAR KIT MG LUPRON DEPOT (4-NTH) INTRAMUSCULAR KIT 30 MG PA; PA; PA; LYNPARZA ORAL CAPSULE 50 MG PA; LA LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG PA; LA megestrol acetate oral tablet 20 mg Tier 1 MEKINIST ORAL TABLET 0.5 MG PA; LA NERLYNX ORAL TABLET 40 MG PA; LA; QL (180 EA per 30 days) NEXAVAR ORAL TABLET 200 MG PA; LA; QL (120 EA per 30 days) nilutamide oral tablet 150 mg ; QL (60 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users 24

25 NINLARO ORAL CAPSULE 2.3 MG PA; ODOMZO ORAL CAPSULE 200 MG PA; LA POMALYST ORAL CAPSULE 1 MG PA; LA RUBRACA ORAL TABLET 250 MG PA; LA RYDAPT ORAL CAPSULE 25 MG PA; ; QL (240 EA per 30 days) SPRYCEL ORAL TABLET 20 MG PA; ; QL (90 EA per 30 days) STIVARGA ORAL TABLET 40 MG PA; LA SUTENT ORAL CAPSULE 12.5 MG PA; SYLATRON SUBCUTANEOUS KIT 200 MCG PA; SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG PA; TAFINLAR ORAL CAPSULE 50 MG PA; LA TAGRISSO ORAL TABLET 40 MG PA; LA tamoxifen citrate oral tablet 10 mg Tier 1 TARCEVA ORAL TABLET 25 MG PA; ; QL (90 EA per 30 days) TASIGNA ORAL CAPSULE 50 MG PA; TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3.75 MG tretinoin oral capsule 10 mg PA; TYKERB ORAL TABLET 250 MG PA; ; QL (150 EA per 30 days) VALCHLOR EXTERNAL GEL % PA; ; QL (60 GM per 30 days) VENCLEXTA ORAL TABLET 10 MG PA; LA VERZENIO ORAL TABLET 50 MG PA; LA VOTRIENT ORAL TABLET 200 MG PA; ; QL (120 EA per 30 days) XALKORI ORAL CAPSULE 200 MG PA; ; QL (60 EA per 30 days) XTANDI ORAL CAPSULE 40 MG PA; ST; LA; QL (120 EA per 30 days) YONSA ORAL TABLET 125 MG PA; ; QL (120 EA per 30 days) ZEJULA ORAL CAPSULE 100 MG PA; LA; QL (90 EA per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users 25

26 ZELBORAF ORAL TABLET 240 MG PA; ; QL (240 EA per 30 days) ZOLINZA ORAL CAPSULE 100 MG PA; ; QL (120 EA per 30 days) ZYDELIG ORAL TABLET 100 MG PA; LA; QL (90 EA per 30 days) ZYKADIA ORAL CAPSULE 150 MG PA; ZYTIGA ORAL TABLET 500 MG PA; ; QL (120 EA per 30 days) AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 mg exemestane oral tablet 25 mg ; QL (60 EA per 30 days) letrozole oral tablet 2.5 mg TREATMENT ADJUNCTS MESNEX ORAL TABLET 400 MG ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG benznidazole oral tablet 12.5 mg Tier 1 EMVERM ORAL TABLET CHEWABLE 100 MG available only at certain pharmacies; =Mail Order. For more information call TTY Users ivermectin oral tablet 3 mg ANTIPROTOZOALS ALINIA ORAL TABLET 500 MG PA; ; QL (6 EA per 30 days) atovaquone oral suspension 750 mg/5ml atovaquone-proguanil hcl oral tablet mg chloroquine phosphate oral tablet 250 mg Tier 1 COARTEM ORAL TABLET MG 26

27 hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg quinine sulfate oral capsule 324 mg PA; ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate oral tablet 0.5 mg Tier 1 trihexyphenidyl hcl oral tablet 2 mg Tier 1 ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 mg entacapone oral tablet 200 mg DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML bromocriptine mesylate oral capsule 5 mg NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR pramipexole dihydrochloride oral tablet mg ropinirole hcl oral tablet 0.25 mg PA; LA; QL (60 ML per 30 days) ST; DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa-entacapone oral tablet mg RYTARY ORAL CAPSULE EXTENDED RELEASE MG ST; available only at certain pharmacies; =Mail Order. For more information call TTY Users 27

28 NOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline mesylate oral tablet 0.5 mg ; QL (30 EA per 30 days) selegiline hcl oral capsule 5 mg ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl oral tablet 10 mg COMPRO RECTAL SUPPOSITORY 25 MG fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl oral tablet 1 mg Tier 1 haloperidol decanoate intramuscular solution 50 mg/ml Tier 1 haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg Tier 1 loxapine succinate oral capsule 5 mg Tier 1 perphenazine oral tablet 2 mg perphenazine-amitriptyline oral tablet 2-10 mg pimozide oral tablet 1 mg prochlorperazine maleate oral tablet 5 mg Tier 1 thioridazine hcl oral tablet 10 mg Tier 1 thiothixene oral capsule 1 mg Tier 1 trifluoperazine hcl oral tablet 1 mg Tier 1 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 400 MG ST; available only at certain pharmacies; =Mail Order. For more information call TTY Users 28

29 FANAPT ORAL TABLET 1 MG ST; ; QL (60 EA per 30 days) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML ST; LATUDA ORAL TABLET 20 MG ST; ; QL (30 EA per 30 days) NUPLAZID ORAL CAPSULE 34 MG ST; LA NUPLAZID ORAL TABLET 17 MG ST; LA olanzapine oral tablet 2.5 mg ; QL (30 EA per 30 days) paliperidone er oral tablet extended release 24 hour 1.5 mg quetiapine fumarate oral tablet 25 mg ST; ; QL (60 EA per 30 days) REXULTI ORAL TABLET 0.25 MG ST; ; QL (30 EA per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG risperidone oral tablet 0.25 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG ST; ST; ; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE 1.5 MG ST; ; QL (120 EA per 30 days) ziprasidone hcl oral capsule 20 mg ; QL (60 EA per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG TREATMENT-RESISTANT clozapine oral tablet 25 mg ST; VERSACLOZ ORAL SUSPENSION 50 MG/ML ST; ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PREVYMIS ORAL TABLET 240 MG PA; ; QL (100 EA per 100 days) valganciclovir hcl oral tablet 450 mg available only at certain pharmacies; =Mail Order. For more information call TTY Users 29

30 ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 10 mg PA; ; QL (30 EA per 30 days) entecavir oral tablet 0.5 mg PA; ; QL (30 EA per 30 days) lamivudine oral tablet 100 mg RIBASPHERE ORAL CAPSULE 200 MG VEMLIDY ORAL TABLET 25 MG PA; ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING MAVYRET ORAL TABLET MG PA; VOSEVI ORAL TABLET MG PA; ANTI-HEPATITIS C (HCV) AGENTS, OTHER PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML PA; ANTIHERPETIC AGENTS acyclovir oral capsule 200 mg Tier 1 acyclovir sodium intravenous solution 50 mg/ml BvD; famciclovir oral tablet 125 mg valacyclovir hcl oral tablet 500 mg ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EDURANT ORAL TABLET 25 MG efavirenz oral capsule 50 mg GENVOYA ORAL TABLET MG available only at certain pharmacies; =Mail Order. For more information call TTY Users INTELENCE ORAL TABLET 25 MG 30

31 nevirapine oral tablet 200 mg ODEFSEY ORAL TABLET MG RESCRIPTOR ORAL TABLET 100 MG SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral tablet 300 mg abacavir sulfate-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg BIKTARVY ORAL TABLET MG DESCOVY ORAL TABLET MG EMTRIVA ORAL CAPSULE 200 MG EVOTAZ ORAL TABLET MG JULUCA ORAL TABLET MG lamivudine oral tablet 150 mg lamivudine-zidovudine oral tablet mg PREZCOBIX ORAL TABLET MG stavudine oral capsule 15 mg STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG VIDEX ORAL SOLUTION RECONSTITUTED 4 GM VIREAD ORAL TABLET 150 MG available only at certain pharmacies; =Mail Order. For more information call TTY Users 31

32 zidovudine oral capsule 100 mg ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG ISENTRESS HD ORAL TABLET 600 MG SELZENTRY ORAL TABLET 25 MG TIVICAY ORAL TABLET 10 MG TYBOST ORAL TABLET 150 MG ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG atazanavir sulfate oral capsule 150 mg CRIXIVAN ORAL CAPSULE 200 MG fosamprenavir calcium oral tablet 700 mg INVIRASE ORAL CAPSULE 200 MG KALETRA ORAL TABLET MG NORVIR ORAL PACKET 100 MG PREZISTA ORAL TABLET 75 MG ritonavir oral tablet 100 mg VIRACEPT ORAL TABLET 250 MG ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 mg available only at certain pharmacies; =Mail Order. For more information call TTY Users 32

33 ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 5 mg Tier 1 hydroxyzine hcl oral tablet 10 mg Tier 1 hydroxyzine pamoate oral capsule 25 mg Tier 1 meprobamate oral tablet 200 mg BENZODIAZEPINES alprazolam oral tablet 0.25 mg Tier 1 chlordiazepoxide hcl oral capsule 5 mg Tier 1 clorazepate dipotassium oral tablet 3.75 mg diazepam oral tablet 2 mg Tier 1 lorazepam oral tablet 0.5 mg Tier 1 oxazepam oral capsule 10 mg BIPOLAR AGENTS OD STABILIZERS GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG lithium carbonate oral capsule 150 mg Tier 1 lithium oral solution 8 meq/5ml Tier 1 BLOOD GLUCOSE REGULATORS ST; ; QL (60 EA per 30 days) ANTIDIABETIC AGENTS acarbose oral tablet 25 mg available only at certain pharmacies; =Mail Order. For more information call TTY Users 33

34 AVANDIA ORAL TABLET 2 MG CYCLOSET ORAL TABLET 0.8 MG glimepiride oral tablet 1 mg Tier 1 glipizide oral tablet 5 mg Tier 1 glipizide-metformin hcl oral tablet mg Tier 1 glyburide micronized oral tablet 1.5 mg glyburide oral tablet 1.25 mg glyburide-metformin oral tablet mg INVOKAMET ORAL TABLET MG ST; INVOKANA ORAL TABLET 100 MG ST; JANUMET ORAL TABLET MG ; QL (60 EA per 30 days) JANUVIA ORAL TABLET 25 MG ; QL (30 EA per 30 days) JARDIANCE ORAL TABLET 10 MG ST; metformin hcl oral tablet 500 mg Tier 1 miglitol oral tablet 25 mg nateglinide oral tablet 60 mg OZEMPIC SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.25 OR 0.5 MG/DOSE pioglitazone hcl oral tablet 15 mg Tier 1 pioglitazone hcl-glimepiride oral tablet 30-2 mg pioglitazone hcl-metformin hcl oral tablet mg ; QL (6 ML per 30 days) available only at certain pharmacies; =Mail Order. For more information call TTY Users repaglinide oral tablet 0.5 mg repaglinide-metformin hcl oral tablet mg SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR UNT-MCG/ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SYNJARDY ORAL TABLET MG ST; ST; ; QL (18 ML per 30 days) PA; ; QL (10.8 ML per 28 days) 34

35 SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG tolazamide oral tablet 250 mg tolbutamide oral tablet 500 mg Tier 1 TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 18 MG/3ML XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR UNIT-MG/ML GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG ST; ; QL (2 ML per 30 days) ; QL (9 ML per 30 days) ST; ; QL (15 ML per 30 days) PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML available only at certain pharmacies; =Mail Order. For more information call TTY Users 35

36 TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML BLOOD PRODUCTS/DIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG enoxaparin sodium subcutaneous solution 30 mg/0.3ml fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML heparin sodium (porcine) injection solution 1000 unit/ml available only at certain pharmacies; =Mail Order. For more information call TTY Users JANTOVEN ORAL TABLET 1 MG Tier 1 PRADAXA ORAL CAPSULE 75 MG ST; XARELTO ORAL TABLET 10 MG BLOOD FORMATION DIFIERS EPOGEN INJECTION SOLUTION 2000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG NEUPOGEN INJECTION SOLUTION 300 MCG/ML PA; ST; PA; PA; PROMACTA ORAL TABLET 12.5 MG PA; ; QL (30 EA per 30 days) TAVALISSE ORAL TABLET 100 MG PA; ; QL (60 EA per 30 days) tranexamic acid oral tablet 650 mg 36

37 ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML PLATELET DIFYING AGENTS anagrelide hcl oral capsule 0.5 mg aspirin-dipyridamole er oral capsule extended release 12 hour mg PA; BRILINTA ORAL TABLET 60 MG cilostazol oral tablet 50 mg clopidogrel bisulfate oral tablet 75 mg dipyridamole oral tablet 25 mg prasugrel hcl oral tablet 5 mg CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0.1 mg Tier 1 guanfacine hcl oral tablet 1 mg Tier 1 methyldopa oral tablet 250 mg Tier 1 midodrine hcl oral tablet 2.5 mg ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate oral tablet 1 mg Tier 1 ergoloid mesylates oral tablet 1 mg prazosin hcl oral capsule 1 mg Tier 1 terazosin hcl oral capsule 1 mg Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 4 mg available only at certain pharmacies; =Mail Order. For more information call TTY Users 37

38 eprosartan mesylate oral tablet 600 mg irbesartan oral tablet 75 mg Tier 1 losartan potassium oral tablet 25 mg Tier 1 olmesartan medoxomil oral tablet 5 mg TEKTURNA ORAL TABLET 150 MG telmisartan oral tablet 20 mg valsartan oral tablet 40 mg Tier 1 ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl oral tablet 5 mg Tier 1 captopril oral tablet 12.5 mg enalapril maleate oral tablet 2.5 mg Tier 1 fosinopril sodium oral tablet 10 mg Tier 1 lisinopril oral tablet 2.5 mg Tier 1 moexipril hcl oral tablet 7.5 mg Tier 1 perindopril erbumine oral tablet 2 mg Tier 1 quinapril hcl oral tablet 5 mg Tier 1 ramipril oral capsule 1.25 mg Tier 1 trandolapril oral tablet 1 mg Tier 1 ANTIARRHYTHMICS amiodarone hcl oral tablet 100 mg disopyramide phosphate oral capsule 100 mg dofetilide oral capsule 125 mcg flecainide acetate oral tablet 50 mg mexiletine hcl oral capsule 150 mg MULTAQ ORAL TABLET 400 MG propafenone hcl oral tablet 150 mg available only at certain pharmacies; =Mail Order. For more information call TTY Users 38

39 quinidine sulfate oral tablet 200 mg Tier 1 ANTIHYPERTENSIVE COMBINATIONS amiloride-hydrochlorothiazide oral tablet 5-50 mg Tier 1 amlodipine besy-benazepril hcl oral capsule mg amlodipine besylate-valsartan oral tablet mg Tier 1 amlodipine-olmesartan oral tablet 5-20 mg amlodipine-valsartan-hctz oral tablet mg atenolol-chlorthalidone oral tablet mg Tier 1 benazepril-hydrochlorothiazide oral tablet mg bisoprolol-hydrochlorothiazide oral tablet mg Tier 1 Tier 1 candesartan cilexetil-hctz oral tablet mg captopril-hydrochlorothiazide oral tablet mg enalapril-hydrochlorothiazide oral tablet mg Tier 1 ENTRESTO ORAL TABLET MG ; QL (60 EA per 30 days) fosinopril sodium-hctz oral tablet mg Tier 1 irbesartan-hydrochlorothiazide oral tablet mg lisinopril-hydrochlorothiazide oral tablet mg Tier 1 losartan potassium-hctz oral tablet mg Tier 1 methyldopa-hydrochlorothiazide oral tablet mg Tier 1 available only at certain pharmacies; =Mail Order. For more information call TTY Users 39