Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare Georgia lanning for Healthy Babies - Family lanning lease read: This document tells about the drugs we cover in this plan. If you speak a different language or need something in Braille or audio, don t worry. We can provide translations and alternate formats at no cost to you. Just give us a call tollfree. Georgia Families and eachcare for Kids members call 1-866-231-1821. lanning for Healthy Babies members call 1-877-379-0020. All TTY users call 1-877- 247-6272. Si habla otro idioma o si necesita información en Braille o en audio, no se preocupe. odemos ofrecerle traducciones y formatos alternativos sin costo para usted. Simplemente llámenos sin costo. Los miembros de Georgia Families y eachcare for Kids llamen al 1-866-231-1821. Los miembros de lanning for Healthy Babies llamen al 1-877-379-0020. Todos los usuarios de TTY llamen al 1-877-247-6272. This list is updated each quarter. roviders, please visit our website for updates to the preferred drug list: https://www.wellcare.com/georgia/roviders/medicaid Members, please visit our website for updates to the preferred drug list: https://www.wellcare.com/georgia/members/medicaid-lans/4hb Last updated (1/01/2018) WellCare proudly serves Georgia Families, eachcare for Kids and lanning for Healthy Babies members. GA032872_CAD_LTR_ENG State Approved 04212016 72830 WellCare 2016 GA_01_16_v3 GA6CADLTR72830E_0116

Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** naproxen sodium oral tablet 220 mg *Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 mg QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML reeses pinworm medicine oral suspension 144 mg/ml *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg *Imidazoles*** ketoconazole oral tablet 200 mg *Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** metronidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 100 mg QL (450 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 1

Drug Name reference Details Coverage Details *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg *Antiprotozoal Agents*** atovaquone oral suspension 750 mg/5ml A *Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml clindamycin phosphate intravenous solution 150 mg/ml *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg *Antimalarials*** DARARIM ORAL TABLET 25 MG A hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg *Antivirals* *Herpes Agents - urine Analogues*** acyclovir oral capsule 200 mg QL (1200 ML per 31 days) QL (2400 ML per 31 days) acyclovir oral suspension 200 mg/5ml QL (3500 ML per 31 days) acyclovir oral tablet 400 mg, 800 mg valacyclovir hcl oral tablet 1 gm, 500 mg QL (62 EA per 31 days) *Influenza Agents*** rimantadine hcl oral tablet 100 mg *Neuraminidase Inhibitors*** oseltamivir phosphate capsule 30 mg oral 30 mg QL (40 EA per 365 days) oseltamivir phosphate capsule 45 mg oral 45 mg QL (20 EA per 365 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 2

Drug Name reference Details Coverage Details oseltamivir phosphate capsule 75 mg oral 75 mg QL (20 EA per 365 days) oseltamivir phosphate oral suspension reconstituted 6 mg/ml RELENZA DISKHALER INHALATION AEROSOL OWDER BREATH ACTIVATED 5 MG/BLISTER *Cephalosporins* *Cephalosporins - 1St Generation*** QL (360 ML per 365 days); AL (Max 18 Years) QL (40 EA per 365 days); AL (Min 7 Years) cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 10 gm cephalexin oral capsule 250 mg, 500 mg, 750 mg cephalexin oral suspension reconstituted 125 mg/5ml cephalexin oral suspension reconstituted 250 mg/5ml *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250 mg, 500 mg cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg *Contraceptives* *Biphasic Contraceptives - Oral*** QL (300 ML per 31 days) KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 3

Drug Name reference Details Coverage Details *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 MG- alyacen 1/35 oral tablet 1-35 mg-mcg ARI ORAL TABLET 0.15-30 MG- AVIANE ORAL TABLET 0.1-20 MG- BALZIVA ORAL TABLET 0.4-35 MG- briellyn oral tablet 0.4-35 mg-mcg CRYSELLE-28 ORAL TABLET 0.3-30 MG- CYCLAFEM 1/35 ORAL TABLET 1-35 MG- DASETTA 1/35 ORAL TABLET 1-35 MG- ELINEST ORAL TABLET 0.3-30 MG- EMOQUETTE ORAL TABLET 0.15-30 MG- ESTARYLLA ORAL TABLET 0.25-35 MG- FALMINA ORAL TABLET 0.1-20 MG- GIANVI ORAL TABLET 3-0.02 MG GILDESS FE 1.5/30 ORAL TABLET 1.5-30 MG- GILDESS FE 1/20 ORAL TABLET 1-20 MG- JUNEL 1.5/30 ORAL TABLET 1.5-30 MG- JUNEL 1/20 ORAL TABLET 1-20 MG- JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG- JUNEL FE 1/20 ORAL TABLET 1-20 MG- KELNOR 1/35 ORAL TABLET 1-35 MG- LESSINA ORAL TABLET 0.1-20 MG- LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG- =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 4

Drug Name reference Details Coverage Details LORYNA ORAL TABLET 3-0.02 MG LOW-OGESTREL ORAL TABLET 0.3-30 MG- LUTERA ORAL TABLET 0.1-20 MG- marlissa oral tablet 0.15-30 mg-mcg MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG- MICROGESTIN 1/20 ORAL TABLET 1-20 MG- MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG- MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG- MONONESSA ORAL TABLET 0.25-35 MG- NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG- NECON 1/35 (28) ORAL TABLET 1-35 MG- norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG- NORTREL 1/35 (21) ORAL TABLET 1-35 MG- NORTREL 1/35 (28) ORAL TABLET 1-35 MG- OCELLA ORAL TABLET 3-0.03 MG ORSYTHIA ORAL TABLET 0.1-20 MG- HILITH ORAL TABLET 0.4-35 MG- ORTIA-28 ORAL TABLET 0.15-30 MG- REVIFEM ORAL TABLET 0.25-35 MG- RECLISEN ORAL TABLET 0.15-30 MG- SOLIA ORAL TABLET 0.15-30 MG- =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 5

Drug Name reference Details Coverage Details SRINTEC 28 ORAL TABLET 0.25-35 MG- SRONYX ORAL TABLET 0.1-20 MG- SYEDA ORAL TABLET 3-0.03 MG VESTURA ORAL TABLET 3-0.02 MG ZARAH ORAL TABLET 3-0.03 MG ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG- ZENCHENT ORAL TABLET 0.4-35 MG- ZOVIA 1/35E (28) ORAL TABLET 1-35 MG- *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR *Continuous Contraceptives - Oral*** AMETHYST ORAL TABLET 90-20 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg *Emergency Contraceptives*** QL (1 EA per 28 days) levonorgestrel oral tablet 0.75 mg QL (4 EA per 31 days) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG QL (1 EA per 31 days) OTION 2 ORAL TABLET 1.5 MG QL (1 EA per 31 days) LAN B ONE-STE ORAL TABLET 1.5 MG *Extended-Cycle Contraceptives - Oral*** QL (1 EA per 31 days) QUASENSE ORAL TABLET 0.15-0.03 MG QL (91 EA per 91 days) *rogestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml *rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG HEATHER ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG QL (1 ML per 93 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 6

Drug Name reference Details Coverage Details *Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/0.15-0.025 MG ENRESSE-28 ORAL TABLET MYZILRA ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG- NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG- TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/0.15-0.025 MG *Dermatologicals* *Antibiotic Mixtures Topical*** OLYSORIN EXTERNAL OINTMENT 500-10000 UNIT/GM *Antibiotics - Topical*** bacitracin zinc external ointment 500 unit/gm *Antifungals - Topical*** ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm nystatin external powder 100000 unit/gm terbinafine hcl external cream 1 % =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 7

Drug Name reference Details Coverage Details *Antivirals - Topical*** DENAVIR EXTERNAL CREAM 1 % ZOVIRAX EXTERNAL CREAM 5 % *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % *Imidazole-Related Antifungals - Topical*** baza antifungal external cream 2 % clotrimazole external cream 1 % clotrimazole external solution 1 % econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % *Rosacea Agents*** metronidazole external cream 0.75 % metronidazole external gel 1 % *Scabicides & ediculicides*** malathion external lotion 0.5 % ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days.; QL (5 GM per 28 days) ST; Must fail preferred oral acyclovir or valacyclovir within the past 100 days.; QL (5 GM per 28 days) QL (118 ML per 31 days); AL (Min 6 Years) spinosad external suspension 0.9 % AL (Min 6 Months) *Estrogens* *Estrogen & rogestin*** estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg *Fluoroquinolones* *Fluoroquinolones*** ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg levofloxacin oral tablet 250 mg, 500 mg, 750 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 8

Drug Name reference Details Coverage Details *Genitourinary Agents - Miscellaneous* *Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended release 24 hour 10 mg *Urinary Analgesics*** phenazopyridine hcl oral tablet 200 mg QL (12 EA per 31 days) *Hematopoietic Agents* *Cobalamins*** vitamin b-12 er oral tablet extended release 1000 mcg vitamin b-12 oral tablet 500 mcg vitamin b-12 sublingual tablet sublingual 1000 mcg *Folic Acid/Folates*** folic acid oral tablet 1 mg, 400 mcg, 800 mcg *Iron Combinations*** ferrex 150 forte oral capsule 150-25-1 mg-mcgmg *Iron*** ferretts oral tablet 325 (106 fe) mg ferrous sulfate oral liquid 220 (44 fe) mg/5ml OLY-IRON 150 ORAL CASULE 150 MG *Macrolides* *Azithromycin*** azithromycin hydrogencitrate intravenous solution reconstituted 2.5 gm azithromycin intravenous solution reconstituted 500 mg azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg QL (12 EA per 31 days) azithromycin oral tablet 500 mg, 600 mg *Clarithromycin*** clarithromycin er oral tablet extended release 24 hour 500 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 9

Drug Name reference Details Coverage Details clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg *Erythromycins*** E.E.S. GRANULES ORAL SUSENSION RECONSTITUTED 200 MG/5ML ERYED 200 ORAL SUSENSION RECONSTITUTED 200 MG/5ML ERYED 400 ORAL SUSENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 mg erythromycin ethylsuccinate oral tablet 400 mg *Minerals & Electrolytes* *Calcium Combinations*** calcium oral tablet chewable 500-100 mg-unit calcium+d3 oral tablet 600-800 mg-unit *Mouth/Throat/Dental Agents* *Anti-Infectives - Throat*** clotrimazole mouth/throat lozenge 10 mg clotrimazole mouth/throat troche 10 mg nystatin mouth/throat suspension 100000 unit/ml QL (300 ML per 31 days) *Multivitamins* *B-Complex Vitamins*** b complex oral capsule *B-Complex W/ C & Folic Acid*** DIALYVITE ORAL TABLET triphrocaps oral capsule 1 mg *B-Complex W/ Folic Acid*** b complex plus oral tablet *B-Complex W/Biotin & Folic Acid*** b-50 complex oral tablet extended release =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 10

Drug Name reference Details Coverage Details *Multivitamins*** multi-vitamins oral tablet *ed Mv W/ Fluoride*** multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg QUFLORA EDIATRIC ORAL SOLUTION 0.25 MG/ML QUFLORA EDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG *ed Vitamins Acd Fluoride & Iron*** tri-vit/fluoride/iron oral solution 0.25-10 mg/ml *ed Vitamins Acd W/ Fluoride*** tri-vitamin/fluoride oral solution 0.5 mg/ml vitamins acd-fluoride oral solution 0.25 mg/ml *ediatric Multiple Vitamins W/ C*** polyvitamin oral solution 35 mg/ml *ediatric Vitamins A & D W/ C*** tri-vitamin oral solution 1500-400-35 *renatal Mv & Min W/Fe-Fa*** CO-NATAL FA ORAL TABLET ELITE-OB ORAL TABLET 50-1.25 MG FOLIVANE-OB ORAL CASULE 130-92.4-1 MG MYNATAL ADVANCE ORAL TABLET mynatal-z oral tablet mynate 90 plus oral tablet extended release pnv prenatal plus multivit+dha oral 27-1 & 312 mg RENATABS RX ORAL TABLET 29-1 MG prenatal 19 oral tablet chewable prenatal low iron oral tablet 27-0.8 mg prenatal oral tablet 28-0.8 mg prenatal plus iron oral tablet 29-1 mg prenatal plus oral tablet 27-1 mg RENATAL-U ORAL CASULE 106.5-1 MG AL (Max 17 Years) AL (Max 17 Years) AL (Max 17 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 11

Drug Name reference Details Coverage Details TARON-C DHA ORAL CASULE 53.5-38-1 MG trinatal rx 1 oral tablet 60-1 mg TRINATE ORAL TABLET VINATE AZ EXTRA ORAL TABLET 29-1 MG VINATE II ORAL TABLET 29-1 MG VINATE M ORAL TABLET 27-1 MG *renatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** R NATAL 400 EC ORAL 29-1-200 & 400 MG (DR) *Vitamins W/ Lipotropics*** b-100 complex oral tablet b-100 cr oral tablet extended release *Ophthalmic Agents* *Ophthalmic Antibiotics*** ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % ofloxacin ophthalmic solution 0.3 % tobramycin ophthalmic solution 0.3 % *Ophthalmic Anti-Infective Combinations*** ak-poly-bac ophthalmic ointment 500-10000 unit/gm neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% *Ophthalmic Antivirals*** trifluridine ophthalmic solution 1 % *enicillins* *Aminopenicillins*** amoxicillin oral capsule 250 mg, 500 mg =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 12

Drug Name reference Details Coverage Details amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml *Natural enicillins*** BICILLIN L-A INTRAMUSCULAR SUSENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML penicillin g potassium injection solution reconstituted 5000000 unit penicillin g procaine intramuscular suspension 600000 unit/ml penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg FIZEREN-G INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT *enicillin Combinations*** amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg BICILLIN C-R 900/300 INTRAMUSCULAR SUSENSION 900000-300000 UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSENSION 1200000 UNIT/2ML *enicillinase-resistant enicillins*** dicloxacillin sodium oral capsule 250 mg, 500 mg oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm QL (300 ML per 31 days) QL (300 ML per 31 days) QL (300 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 13

Drug Name reference Details Coverage Details *rogestins* *rogestins*** medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 100 mg, 200 mg *Tetracyclines* *Tetracyclines*** doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg *Toxoids* *Toxoid Combinations*** ADACEL INTRAMUSCULAR SUSENSION 5-2-15.5 LF-/0.5 BOOSTRIX INTRAMUSCULAR SUSENSION 5-2.5-18.5 DATACEL INTRAMUSCULAR SUSENSION 10-15-5 DATACEL INTRAMUSCULAR SUSENSION 15-23-5 LF-/0.5 INFANRIX INTRAMUSCULAR SUSENSION 25-58-10 TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml *Urinary Anti-Infectives* *Urinary Anti-Infectives*** nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd macro oral capsule 100 mg AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 14

Drug Name reference Details Coverage Details *Vaccines* *Viral Vaccines*** ENGERIX-B INJECTION SUSENSION 10 /0.5ML, 20 /ML ENGERIX-B INTRAMUSCULAR INJECTABLE 10 /0.5ML, 20 /ML RECOMBIVAX HB INJECTION SUSENSION 10 /ML, 40 /ML, 5 /0.5ML *Vaginal roducts* *Imidazole-Related Antifungals*** 3 day vaginal vaginal cream 2 % clotrimazole 3 vaginal cream 2 % clotrimazole vaginal cream 1 % miconazole 3 combo pack app vaginal kit 200 & 2 mg-% (9gm) miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) miconazole 3 vaginal suppository 200 mg miconazole nitrate vaginal cream 2 % miconazole nitrate vaginal suppository 100 mg MONISTAT 3 VAGINAL CREAM 4 % terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg *Vaginal Anti-Infectives*** clindamycin phosphate vaginal cream 2 % metronidazole vaginal gel 0.75 % *Vitamins* *Vitamin C*** ascorbic acid oral tablet 500 mg natural c/rose hips oral tablet 500 mg vitamin c-rose hips oral tablet 500 mg AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) AL (Min 19 Years and Max 20 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 15

=referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 16

Index 3 day vaginal... 15 acyclovir... 2 ADACEL...14 ak-poly-bac... 12 ALBENZA... 1 alfuzosin hcl er... 9 ALTAVERA...4 alyacen 1/35...4 AMETHYST... 6 amoxicillin...12, 13 amoxicillin-pot clavulanate...13 ampicillin... 13 ARI...4 ascorbic acid... 15 atovaquone...2 atovaquone-proguanil hcl...2 AVIANE...4 azithromycin... 9 azithromycin hydrogencitrate... 9 b complex...10 b complex plus...10 b-100 complex...12 b-100 cr...12 b-50 complex...10 bacitracin zinc...7 BALZIVA...4 baza antifungal... 8 BICILLIN C-R... 13 BICILLIN C-R 900/300... 13 BICILLIN L-A... 13 BILTRICIDE... 1 BOOSTRIX... 14 briellyn... 4 calcium... 10 calcium+d3... 10 CAMILA... 6 CAZIANT... 7 cefaclor...3 cefadroxil...3 cefazolin sodium...3 cefdinir... 3 cefpodoxime proxetil...3 cefprozil...3 ceftriaxone sodium... 3 cefuroxime axetil... 3 cephalexin...3 ciclopirox...7 ciclopirox olamine...7 ciprofloxacin hcl...8, 12 clarithromycin...10 clarithromycin er...9 clindamycin hcl... 2 clindamycin palmitate hcl... 2 clindamycin phosphate...2, 15 clotrimazole...8, 10, 15 clotrimazole 3...15 CO-NATAL FA...11 CRYSELLE-28...4 CYCLAFEM 1/35...4 DATACEL... 14 DARARIM... 2 DASETTA 1/35... 4 DENAVIR...8 DIALYVITE...10 dicloxacillin sodium...13 doxycycline hyclate... 14 doxycycline monohydrate... 14 E.E.S. GRANULES...10 econazole nitrate... 8 ELINEST...4 ELITE-OB... 11 EMOQUETTE... 4 ENGERIX-B... 15 ENRESSE-28...7 ERRIN... 6 ERYED 200...10 ERYED 400...10 ERY-TAB... 10 ERYTHROCIN STEARATE 10 erythromycin...12 erythromycin base... 10 erythromycin ethylsuccinate... 10 ESTARYLLA...4 estradiol-norethindrone acet... 8 FALMINA... 4 ferretts...9 ferrex 150 forte... 9 ferrous sulfate... 9 fluconazole...1 folic acid... 9 FOLIVANE-OB... 11 gentamicin sulfate... 12 GIANVI...4 GILDESS FE 1.5/30... 4 GILDESS FE 1/20... 4 griseofulvin microsize... 1 griseofulvin ultramicrosize...1 HEATHER...6 hydroxychloroquine sulfate...2 INFANRIX... 14 ivermectin... 1 JOLIVETTE... 6 JUNEL 1.5/30... 4 JUNEL 1/20...4 JUNEL FE 1.5/30... 4 JUNEL FE 1/20... 4 KARIVA... 3 KELNOR 1/35...4 ketoconazole... 1, 8 LESSINA...4 levofloxacin...8 levonorgestrel...6 levonorgestrel-ethinyl estrad...6 LEVORA 0.15/30 (28)...4 LORYNA... 5 LOW-OGESTREL... 5 LUTERA...5 malathion...8 marlissa... 5 medroxyprogesterone acetate6, 14 mefloquine hcl... 2 metronidazole... 1, 8, 15 miconazole 3... 15 miconazole 3 combo pack... 15 miconazole 3 combo pack app...15 miconazole nitrate... 15 MICROGESTIN 1.5/30...5 MICROGESTIN 1/20...5 MICROGESTIN FE 1.5/30... 5 MICROGESTIN FE 1/20...5 MONISTAT 3...15 MONONESSA... 5 multivitamin/fluoride... 11 multi-vitamins... 11 MYNATAL ADVANCE...11 mynatal-z...11 mynate 90 plus... 11 MYZILRA...7 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 17

naproxen sodium... 1 natural c/rose hips... 15 NECON 0.5/35 (28)...5 NECON 1/35 (28)... 5 NECON 7/7/7... 7 neomycin-bacitracin znpolymyx...12 neomycin-polymyxingramicidin...12 NEXT CHOICE ONE DOSE...6 nitrofurantoin macrocrystal...14 nitrofurantoin monohyd macro. 14 NORA-BE... 6 norethindrone acetate... 14 norethin-eth estradiol-fe... 5 NORTREL 0.5/35 (28)...5 NORTREL 1/35 (21)...5 NORTREL 1/35 (28)...5 NORTREL 7/7/7...7 NUVARING... 6 nystatin... 1, 7, 10 OCELLA... 5 ofloxacin...12 OTION 2... 6 ORSYTHIA...5 oseltamivir phosphate... 2, 3 oxacillin sodium... 13 penicillin g potassium... 13 penicillin g procaine...13 penicillin v potassium...13 FIZEREN-G... 13 phenazopyridine hcl...9 HILITH... 5 IN-X... 1 LAN B ONE-STE... 6 pnv prenatal plus multivit+dha..11 OLY-IRON 150...9 polymyxin b-trimethoprim... 12 OLYSORIN... 7 polyvitamin... 11 ORTIA-28... 5 R NATAL 400 EC... 12 RENATABS RX... 11 prenatal...11 prenatal 19...11 prenatal low iron... 11 prenatal plus...11 prenatal plus iron... 11 RENATAL-U...11 REVIFEM...5 primaquine phosphate...2 progesterone micronized... 14 QUASENSE... 6 QUFLORA EDIATRIC...11 RECLISEN... 5 RECOMBIVAX HB... 15 reeses pinworm medicine... 1 RELENZA DISKHALER... 3 REMEVEN... 8 rimantadine hcl... 2 SOLIA... 5 spinosad... 8 SRINTEC 28... 6 SRONYX...6 sulfamethoxazole-trimethoprim.. 2 SYEDA...6 TARON-C DHA... 12 TENIVAC...14 terbinafine hcl... 1, 7 terconazole...15 tetanus-diphtheria toxoids td... 14 tobramycin...12 TRI-ESTARYLLA...7 trifluridine...12 trimethoprim...1 trinatal rx 1...12 TRINATE...12 TRINESSA (28)...7 triphrocaps...10 TRI-REVIFEM...7 TRI-SRINTEC...7 tri-vit/fluoride/iron...11 tri-vitamin...11 tri-vitamin/fluoride... 11 TRIVORA (28)... 7 valacyclovir hcl... 2 VELIVET... 7 VESTURA...6 VINATE AZ EXTRA...12 VINATE II...12 VINATE M...12 vitamin b-12... 9 vitamin b-12 er... 9 vitamin c-rose hips...15 vitamins acd-fluoride... 11 ZARAH... 6 ZENCHENT... 6 ZENCHENT FE...6 ZOVIA 1/35E (28)...6 ZOVIRAX... 8 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC roducts Require Rx, UERCASE= Brand name drugs/ lowercase italics= 18