2018 FORMULARY GUIDE (Employee groups)

Pharmacy Benefits Management Table of Contents Overview ...................................................................................................................................................... iii Important Phone Numbers ............................................................................................................................ iii Understanding Coverage and Cost‐Sharing ................................................................................................. iii Formulary ................................................................................................................................................ iii Understanding Our Symbols ........................................................................................................................ iv Prior Authorization .................................................................................................................................. iv Step Therapy ............................................................................................................................................ iv Quantity Limits ........................................................................................................................................ iv About Generic Drugs.................................................................................................................................... iv How to Fill Your Prescription Medications ................................................................................................... v Medication Supplies Not Covered by IU Health Plans ............................................................................ vi Formulary Listing ......................................................................................................................................... 1

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iuhealthplans.org

Pharmacy Benefits Management Overview This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more.

Important Phone Numbers Pharmacy Services ‐ 844.432.0704.

Understanding Coverage and Cost‐Sharing Formulary The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under your plan. The inclusion of specific medications on the IU Health Plans formulary is based on the medication's effectiveness, safety, and value. The formulary offers a wide selection of generic and brand name prescription drugs suggested by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who researches and evaluates medications. The formulary is periodically reviewed and updated throughout the year in order to ensure that our benefits package consistently and adequately meets your needs. When you need a prescription medication, you and your doctor can choose from five different levels of the formulary. These are Preferred Generics – Tier 1, Generics – Tier 2, Preferred Brands – Tier 3, Non‐ Preferred Brands – Tier 4 and Specialty – Tier 5. Each level has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. Preferred Generic Medications – Tier 1 have the lowest copayment/co‐insurance. Generic drugs offer the same level of safety and quality as their brand‐name equivalents. They have the same amount of active ingredients as brand‐name medications. You are required to use a generic version of the drug if one is available. Generic Medications – Tier 2 have low copayment/co‐insurance. Generic drugs offer the same level of safety and quality as their brand‐name equivalents. They have the same amount of active ingredients as brand‐name medications. You are required to use a generic version of the drug if one is available. Preferred‐Brand medications – Tier 3 have the middle level copayment/co‐insurance. These drugs are brand medications and “preferred” because of their value and effectiveness. Non‐Preferred Brand and Generic medications – Tier 4 have a higher copayment/co‐insurance level. These medications are brand and generic drugs that are more expensive and have similar effectiveness as tier 3 medications.

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Pharmacy Benefits Management Specialty and High cost medications – Tier 5 have the highest copayment/co‐insurance level. These also include Specialty medications which usually treat complex and rare conditions. These drugs can be high‐cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Non‐Formulary medications may be covered if the formulary medications do not work for you. If you require a Non‐Formulary medication, your doctor may request coverage for the Tier 4 or Tier 5 copayment by making a request for an exception.

Understanding Our Symbols Prior Authorization You will see the symbol “PA” next to certain drugs on our formulary tables. This is called prior authorization. Prior authorization helps ensure that you’re using the best drugs in the safest way. If you are currently taking or recently prescribed one of these drugs, please discuss possible alternatives or have your doctor request authorization by calling 844.432.0704. Drugs that require prior authorization are often:  Newer drugs for which the Health Plan wants to track usage.  Non‐formulary drugs which require the use of formulary drugs prior to coverage. These drugs are not used as a standard first option in treating a medical condition.  Drugs with potential side effects that the Health Plan wants to monitor for patient safety.  Drugs categorized as specialty medications.

Step Therapy You will see the symbol “ST” (Step Therapy) next to certain drugs on the formulary tables in this booklet. Step therapy ensures you are taking the most effective medication at the best cost. This means trying the least expensive medications usually generic medications or drugs that are considered as the standard first‐line treatment. How step therapy works Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or first‐line treatment drugs. The drug recommended will be approved by the Food and Drug Administration (FDA) as providing the same health benefit at a much lower cost. Step 2: If the generic drug in step 1 does not work for you, then you will have coverage for a brand‐name drug. For more information on step therapy call 844.432.0704.

Quantity Limits The symbol “QL” next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are getting the most cost‐effective dose for your medication, a quantity limit or dose duration may be placed on certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer’s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. iv

Pharmacy Benefits Management For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Prescriptions for specialty medications are limited to a 30‐day supply. For more information on quantity limits or dose durations call 844.432.0704.

About Generic Drugs Generic drugs have the same active ingredients as their brand‐name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand‐name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. Generic drugs have the same active ingredients as brand‐name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand‐name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand‐name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand‐name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand‐name drug.

How to Fill Your Prescription Medications Short‐term medications These are drugs you need immediately. This includes medications used to treat short term infections, or to relieve pain temporarily. You can fill these prescriptions at network pharmacies accepting Express Scripts prescriptions. Locate the nearest retail network pharmacy by calling 844.432.0704. To fill your prescription, present your member ID card and written prescription and pay your copayment/co‐ insurance as described above. Long‐term medications These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure, diabetes, etc. These medications can be mailed to your home for up to a 90‐day supply. Specialty medications Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can fill these prescriptions: 

Through CVS Specialty Pharmacy v

Pharmacy Benefits Management o CVS Specialty Pharmacy is a pharmacy that provides specialty medications. Please call 844.432.0704 to learn more about filling your specialty medication Filling Your Prescription When Traveling When you travel outside of your local area, thousands of pharmacies across the country will honor your IU Health Plans member ID card. To locate a participating pharmacy, contact your member services team at the phone number listed on the back of your member ID card or on 1 page of this booklet. To fill a prescription at a participating out‐of‐area pharmacy, present your IU Health Plans member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens:  Submit a Direct Reimbursement Claim form to IU Health Plans at: CVS Caremark - RxClaim P.O Box 52136 Phoenix, AZ 85072-2136  Or you may call your member services team for assistance  If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment. If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail‐order service so that you receive a 90‐day supply before you leave home.

Medication Supplies Not Covered by IU Health Plans No authorizations will be provided for medications that are reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged. Medications received at no charge to the member (workers’ compensation, medications purchased with a manufacturer’s coupon, etc.) will not be covered. Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription.

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List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Formulary Listing Effective 01/01/2018 Drug Name Drug Tier Requirements/Limit ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg 2 ST celecoxib cap 100 mg 2 ST; QL celecoxib cap 200 mg 2 ST; QL celecoxib cap 400 mg 2 ST; QL GOUT allopurinol tab 100 mg 1 allopurinol tab 300 mg 2 COLCRYS TAB 0.6MG 3 ULORIC TAB 40MG 3 ST; QL ULORIC TAB 80MG 3 ST LOCAL ANESTHETICS bupivacaine 0.75% in dextrose inj 2 8.25% MARCAINE INJ SPINAL 4 MISCELLANEOUS clonidine hcl inj (for epidural infusion) 2 100 mcg/ml clonidine hcl inj (for epidural infusion) 2 500 mcg/ml DURACLON INJ 4 PRIALT INJ 25MCG/ML 5 PRIALT INJ 100MCG 5 PRIALT INJ 500MCG 5 NON-OPIOID ANALGESICS butalbital-acetaminophen tab 50-325 2 mg butalbital-acetaminophen-caffeine cap 2 50-325-40 mg butalbital-acetaminophen-caffeine tab 2 50-325-40 mg butalbital-aspirin-caffeine cap 50-325- 2 40 mg NSAIDS choline & magnesium salicylates liq 500 2 mg/5ml diclofenac potassium tab 50 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er 24hr 100 mg diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab er 24hr 400 mg etodolac tab er 24hr 500 mg etodolac tab er 24hr 600 mg fenoprofen calcium tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg indomethacin cap er 75 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap er 24hr 200 mg ketorolac tromethamine tab 10 mg meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg mefenamic acid cap 250 mg meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg

Drug Tier Requirements/Limit 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 2 2 2 2 2 2 2 2 2 2 1 1 2 2 2 2 2 2 1 1 2

QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit naproxen tab ec 500 mg 2 oxaprozin tab 600 mg 2 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 PONSTEL CAP 250MG 4 salsalate tab 500 mg 2 salsalate tab 750 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sodium cap 400 mg 2 tolmetin sodium tab 200 mg 2 tolmetin sodium tab 600 mg 2 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 2 release 50-0.2 mg diclofenac w/ misoprostol tab delayed 2 release 75-0.2 mg NSAIDS, TOPICAL diclofenac sodium gel 1% 2 QL VOLTAREN GEL 1% 4 QL OPIOID ANALGESICS ABSTRAL SUB 100MCG 4 PA; QL ABSTRAL SUB 200MCG 4 PA; QL ABSTRAL SUB 300MCG 4 PA; QL ABSTRAL SUB 400MCG 4 PA; QL ABSTRAL SUB 600MCG 4 PA; QL ABSTRAL SUB 800MCG 4 PA; QL acetaminophen w/ codeine soln 120-12 2 mg/5ml acetaminophen w/ codeine tab 300-15 2 mg acetaminophen w/ codeine tab 300-30 2 mg acetaminophen w/ codeine tab 300-60 2 mg butalbital-acetaminophen-caff w/ cod 2 cap 50-325-40-30 mg butalbital-aspirin-caff w/ codeine cap 2 50-325-40-30 mg butorphanol tartrate nasal soln 10 2 QL mg/ml BUTRANS DIS 5MCG/HR 4 PA BUTRANS DIS 7.5/HR 4 PA BUTRANS DIS 10MCG/HR 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 4

Drug Name Drug Tier Requirements/Limit BUTRANS DIS 15MCG/HR 4 PA BUTRANS DIS 20MCG/HR 4 PA codeine sulfate tab 15 mg 2 codeine sulfate tab 30 mg 2 codeine sulfate tab 60 mg 2 fentanyl citrate lozenge on a handle 2 QL 200 mcg fentanyl citrate lozenge on a handle 2 QL 600 mcg fentanyl citrate lozenge on a handle 2 QL 800 mcg fentanyl citrate lozenge on a handle 2 QL 1200 mcg fentanyl citrate lozenge on a handle 2 QL 1600 mcg fentanyl td patch 72hr 12 mcg/hr 2 QL fentanyl td patch 72hr 25 mcg/hr 2 QL fentanyl td patch 72hr 50 mcg/hr 2 QL fentanyl td patch 72hr 75 mcg/hr 2 QL fentanyl td patch 72hr 100 mcg/hr 2 QL FENTORA TAB 100MCG 4 PA; QL FENTORA TAB 200MCG 4 PA; QL FENTORA TAB 400MCG 4 PA; QL FENTORA TAB 600MCG 4 PA; QL FENTORA TAB 800MCG 4 PA; QL hydrocodone-acetaminophen soln 7.5- 2 325 mg/15ml hydrocodone-acetaminophen soln 10- 2 325 mg/15ml hydrocodone-acetaminophen tab 2.5- 2 325 mg hydrocodone-acetaminophen tab 5-325 2 mg hydrocodone-acetaminophen tab 7.5- 2 325 mg hydrocodone-acetaminophen tab 102 325 mg hydrocodone-ibuprofen tab 5-200 mg 2 QL hydrocodone-ibuprofen tab 7.5-200 mg 2 QL hydrocodone-ibuprofen tab 10-200 mg 2 QL HYDROMORPHON SUP 3MG 2 hydromorphone hcl tab 2 mg 2 hydromorphone hcl tab 4 mg 2 hydromorphone hcl tab 8 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name LAZANDA SPR 100MCG LAZANDA SPR 300MCG LAZANDA SPR 400MCG meperidine hcl oral soln 50 mg/5ml methadone hcl soln 5 mg/5ml methadone hcl soln 10 mg/5ml methadone hcl tab 5 mg methadone hcl tab 10 mg methadone hcl tab for oral susp 40 mg MORPHINE SUL SUP 30MG morphine sulfate oral soln 10 mg/5ml morphine sulfate oral soln 20 mg/5ml morphine sulfate oral soln 100 mg/5ml (20 mg/ml) morphine sulfate suppos 5 mg morphine sulfate suppos 10 mg morphine sulfate suppos 20 mg morphine sulfate tab 15 mg morphine sulfate tab 30 mg morphine sulfate tab er 15 mg morphine sulfate tab er 30 mg morphine sulfate tab er 60 mg morphine sulfate tab er 100 mg morphine sulfate tab er 200 mg OPANA ER TAB 5MG OPANA ER TAB 7.5MG OPANA ER TAB 10MG OPANA ER TAB 15MG OPANA ER TAB 20MG OPANA ER TAB 30MG OPANA ER TAB 40MG oxycodone hcl cap 5 mg oxycodone hcl conc 100 mg/5ml (20 mg/ml) oxycodone hcl soln 5 mg/5ml oxycodone hcl tab 5 mg oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg oxycodone hcl tab 20 mg oxycodone hcl tab 30 mg oxycodone hcl tab er 12hr deter 10 mg oxycodone hcl tab er 12hr deter 15 mg oxycodone hcl tab er 12hr deter 20 mg

Drug Tier Requirements/Limit 4 PA; QL 4 PA; QL 4 PA; QL 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 4 4 4

QL QL QL QL QL QL QL QL QL QL QL QL QL QL

PA; QL PA; QL PA; QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit oxycodone hcl tab er 12hr deter 30 mg 4 PA; QL oxycodone hcl tab er 12hr deter 40 mg 4 PA; QL oxycodone hcl tab er 12hr deter 60 mg 4 PA; QL oxycodone hcl tab er 12hr deter 80 mg 4 PA; QL oxycodone w/ acetaminophen soln 5- 2 325 mg/5ml oxycodone w/ acetaminophen tab 2.5- 2 325 mg oxycodone w/ acetaminophen tab 7.5- 2 325 mg oxycodone w/ acetaminophen tab 10- 2 325 mg oxycodone-ibuprofen tab 5-400 mg 2 QL OXYCONTIN TAB 10MG CR 5 PA; QL OXYCONTIN TAB 15MG CR 5 PA; QL OXYCONTIN TAB 20MG CR 5 PA; QL OXYCONTIN TAB 30MG CR 5 PA; QL OXYCONTIN TAB 40MG CR 5 PA; QL OXYCONTIN TAB 60MG CR 5 PA; QL OXYCONTIN TAB 80MG CR 5 PA; QL oxymorphone hcl tab 5 mg 4 oxymorphone hcl tab 10 mg 4 oxymorphone hcl tab er 12hr 5 mg 4 QL oxymorphone hcl tab er 12hr 7.5 mg 4 QL oxymorphone hcl tab er 12hr 10 mg 4 QL oxymorphone hcl tab er 12hr 15 mg 4 QL oxymorphone hcl tab er 12hr 20 mg 4 QL oxymorphone hcl tab er 12hr 30 mg 4 QL oxymorphone hcl tab er 12hr 40 mg 4 QL SUBSYS SPR 100MCG 5 PA; QL SUBSYS SPR 200MCG 5 PA; QL SUBSYS SPR 400MCG 5 PA; QL SUBSYS SPR 600MCG 5 PA; QL SUBSYS SPR 800MCG 5 PA; QL SUBSYS SPR 1200MCG 5 PA; QL SUBSYS SPR 1600MCG 5 PA; QL tramadol hcl tab 50 mg 2 QL tramadol hcl tab er 24hr 100 mg 2 QL tramadol hcl tab er 24hr 200 mg 2 QL tramadol hcl tab er 24hr 300 mg 2 QL tramadol-acetaminophen tab 37.5-325 2 mg VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 7

Drug Name Drug Tier Requirements/Limit ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 1 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 1 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 mg/5ml 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 cefuroxime axetil tab 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN CEDAX CAP 400MG 4 CEDAX SUS 180/5ML 4 cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefpodoxime proxetil for susp 50 2 mg/5ml cefpodoxime proxetil for susp 100 2 mg/5ml cefpodoxime proxetil tab 100 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit cefpodoxime proxetil tab 200 mg 2 ceftibuten cap 400 mg 2 ceftibuten for susp 180 mg/5ml 2 SUPRAX CAP 400MG 4 SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 SUPRAX SUS 100/5ML 4 SUPRAX SUS 200/5ML 4 SUPRAX SUS 500/5ML 4 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab er 24hr 500 mg 2 DIFICID TAB 200MG 5 ST; QL E.E.S. GRAN SUS 200/5ML 4 ERYPED SUS 400/5ML 5 erythromycin ethylsuccinate tab 400 2 mg erythromycin stearate tab 250 mg 2 erythromycin tab 250 mg 2 erythromycin tab 500 mg 2 erythromycin tab delayed release 250 3 mg erythromycin tab delayed release 333 3 mg erythromycin tab delayed release 500 3 mg erythromycin w/ delayed release 2 particles cap 250 mg PCE TAB 333MG EC 3 PCE TAB 500MG EC 3 ZMAX SUS 2GM 4 QL ANTIBACTERIALS, FLUOROQUINOLONES AVELOX TAB 400MG 4 CIPRO (5%) SUS 250MG/5 4 CIPRO (10%) SUS 500MG/5 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit ciprofloxacin hcl tab 100 mg (base 2 equiv) ciprofloxacin hcl tab 250 mg (base 1 equiv) ciprofloxacin hcl tab 500 mg (base 1 equiv) ciprofloxacin hcl tab 750 mg (base 2 equiv) ciprofloxacin-ciprofloxacin hcl tab er 2 QL 24hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 2 QL 24hr 1000 mg(base eq) levofloxacin oral soln 25 mg/ml 2 moxifloxacin hcl tab 400 mg (base 2 equiv) ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 2 200-28.5 mg amoxicillin & k clavulanate chew tab 2 400-57 mg amoxicillin & k clavulanate for susp 2 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 2 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 2 400-57 mg/5ml amoxicillin & k clavulanate for susp 2 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 2 mg amoxicillin & k clavulanate tab 500-125 2 mg amoxicillin & k clavulanate tab 875-125 2 mg amoxicillin & k clavulanate tab er 12hr 2 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 2 mg amoxicillin (trihydrate) chew tab 250 2 mg amoxicillin (trihydrate) for susp 125 1 mg/5ml PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit amoxicillin (trihydrate) for susp 200 1 mg/5ml amoxicillin (trihydrate) for susp 250 1 mg/5ml amoxicillin (trihydrate) for susp 400 1 mg/5ml amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 2 ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 penicillin v potassium for soln 125 1 mg/5ml penicillin v potassium for soln 250 1 mg/5ml penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 2 ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 2 sulfamethoxazole-trimethoprim susp 2 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 1 400-80 mg sulfamethoxazole-trimethoprim tab 1 800-160 mg ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 2 50 mg doxycycline hyclate tab delayed release 2 75 mg doxycycline hyclate tab delayed release 2 100 mg doxycycline hyclate tab delayed release 2 150 mg doxycycline hyclate tab delayed release 2 200 mg doxycycline monohydrate cap 75 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25 2 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 100 mg 2 doxycycline monohydrate tab 150 mg 2 MINOCIN CAP 50MG 4 MINOCIN CAP 75MG 4 MINOCIN CAP 100MG 4 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 VIBRAMYCIN SYP 50MG/5ML 4 ANTIFUNGALS clotrimazole troche 10 mg 2 CRESEMBA CAP 186 MG 4 QL fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole tab 50 mg 2 QL fluconazole tab 100 mg 2 QL fluconazole tab 150 mg 1 QL fluconazole tab 200 mg 2 QL griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 itraconazole cap 100 mg 2 PA; QL NOXAFIL SUS 40MG/ML 5 PA NOXAFIL TAB 100MG 5 PA; QL nystatin oral powder 2 nystatin susp 100000 unit/ml 2 nystatin tab 500000 unit 2 ONMEL TAB 200MG 4 PA; QL SPORANOX SOL 10MG/ML 4 PA; QL terbinafine hcl tab 250 mg 2 QL voriconazole for susp 40 mg/ml 2 QL voriconazole tab 50 mg 2 QL voriconazole tab 200 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit ANTIMALARIALS COARTEM TAB 20-120MG 3 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 6002 300 mg abacavir sulfate-lamivudine-zidovudine 2 QL tab 300-150-300 mg ATRIPLA TAB 3 QL COMPLERA TAB 3 QL DESCOVY TAB 200/25 3 QL EPZICOM TAB 600-300 4 QL EVOTAZ TAB 300-150 4 QL GENVOYA TAB 3 QL lamivudine-zidovudine tab 150-300 mg 2 QL PREZCOBIX TAB 800-150 4 QL STRIBILD TAB 3 QL TRIUMEQ TAB 3 QL TRIZIVIR TAB 4 QL TRUVADA TAB 100-150 3 QL TRUVADA TAB 133-200 3 QL TRUVADA TAB 167-250 3 QL TRUVADA TAB 200-300 3 QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 3 PA; QL SELZENTRY TAB 150MG 3 PA; QL SELZENTRY TAB 300MG 3 PA; QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 5 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 3 QL ISENTRESS CHW 100MG 3 QL ISENTRESS HD TAB 600MG 3 QL ISENTRESS POW 100MG 3 QL ISENTRESS TAB 400MG 3 QL TIVICAY TAB 10MG 3 QL TIVICAY TAB 25MG 3 QL TIVICAY TAB 50MG 3 QL VITEKTA TAB 85MG 4 QL VITEKTA TAB 150MG 4 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

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Drug Name Drug Tier Requirements/Limit APTIVUS SOL 3 QL CRIXIVAN CAP 200MG 3 QL CRIXIVAN CAP 400MG 3 QL INVIRASE CAP 200MG 3 QL INVIRASE TAB 500MG 3 QL KALETRA SOL 3 PA; QL KALETRA TAB 100-25MG 3 QL KALETRA TAB 200-50MG 3 QL LEXIVA SUS 50MG/ML 3 QL LEXIVA TAB 700MG 3 QL lopinavir-ritonavir soln 400-100 2 QL mg/5ml (80-20 mg/ml) NORVIR CAP 100MG 3 QL NORVIR SOL 80MG/ML 3 QL NORVIR TAB 100MG 3 QL PREZISTA SUS 100MG/ML 3 QL PREZISTA TAB 75MG 3 QL PREZISTA TAB 150MG 3 QL PREZISTA TAB 600MG 3 QL PREZISTA TAB 800MG 3 QL REYATAZ CAP 150MG 3 QL REYATAZ CAP 200MG 3 QL REYATAZ CAP 300MG 3 QL REYATAZ POW 50MG 3 QL VIRACEPT TAB 250MG 3 QL VIRACEPT TAB 625MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NONNUCLEOSIDE EDURANT TAB 25MG 3 QL INTELENCE TAB 25MG 3 PA; QL INTELENCE TAB 100MG 3 PA; QL INTELENCE TAB 200MG 3 PA; QL nevirapine susp 50 mg/5ml 2 QL nevirapine tab 200 mg 2 QL nevirapine tab er 24hr 100 mg 2 QL nevirapine tab er 24hr 400 mg 2 QL RESCRIPTOR TAB 100 MG 3 QL RESCRIPTOR TAB 200MG 3 QL SUSTIVA CAP 50MG 3 QL SUSTIVA CAP 200MG 3 QL SUSTIVA TAB 600MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NUCLEOSIDE PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

14

Drug Name Drug Tier Requirements/Limit abacavir sulfate tab 300 mg (base 2 QL equiv) didanosine delayed release capsule 125 2 QL mg didanosine delayed release capsule 200 2 QL mg didanosine delayed release capsule 250 2 QL mg didanosine delayed release capsule 400 2 QL mg EMTRIVA CAP 200MG 3 QL EMTRIVA SOL 10MG/ML 3 QL EPIVIR SOL 10MG/ML 4 lamivudine oral soln 10 mg/ml 2 lamivudine tab 150 mg 2 lamivudine tab 300 mg 2 stavudine cap 15 mg 2 QL stavudine cap 20 mg 2 QL stavudine cap 30 mg 2 QL stavudine cap 40 mg 2 QL stavudine for oral soln 1 mg/ml 2 QL VIDEX SOL 2GM 3 QL VIDEX SOL 4GM 3 QL zidovudine cap 100 mg 2 QL zidovudine syrup 10 mg/ml 2 QL zidovudine tab 300 mg 2 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NUCLEOTIDE VIREAD POW 40MG/GM 3 VIREAD TAB 150MG 3 QL VIREAD TAB 200MG 3 QL VIREAD TAB 250MG 3 QL VIREAD TAB 300MG 3 QL ANTITUBERCULAR AGENTS cycloserine cap 250 mg 3 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 1 PASER GRA 4GM 3 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

15

Drug Name Drug Tier Requirements/Limit RIFAMATE CAP 4 rifampin cap 150 mg 2 rifampin cap 300 mg 2 RIFATER TAB 3 SIRTURO TAB 100MG 4 PA TRECATOR TAB 250MG 3 ANTIVIRALS, CMV AGENTS VALCYTE SOL 50MG/ML 5 QL VALCYTE TAB 450MG 5 valganciclovir hcl tab 450 mg (base 4 equivalent) ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B BARACLUDE SOL .05MG/ML 5 PA BARACLUDE TAB 0.5MG 5 PA BARACLUDE TAB 1MG 5 PA entecavir tab 0.5 mg 5 PA entecavir tab 1 mg 5 PA EPIVIR HBV SOL 5MG/ML 3 PA EPIVIR HBV TAB 100MG 4 PA lamivudine tab 100 mg (hbv) 2 PA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA TAB 400-100 5 PA; QL; Preferred for genotypes 2 and 3 HARVONI TAB 90-400MG 5 PA; QL; Preferred for genotypes 1, 4, 5 and 6 REBETOL SOL 40MG/ML 5 QL ribavirin cap 200 mg 5 QL ribavirin tab 200 mg 5 QL ribavirin tab 400 mg 5 QL ribavirin tab 600 mg 5 QL ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 1 acyclovir susp 200 mg/5ml 2 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 famciclovir tab 125 mg 2 QL famciclovir tab 250 mg 2 QL famciclovir tab 500 mg 2 QL valacyclovir hcl tab 1 gm 2 QL valacyclovir hcl tab 500 mg 2 QL ANTIVIRALS, INFLUENZA AGENTS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

16

Drug Name Drug Tier Requirements/Limit oseltamivir phosphate cap 30 mg (base 2 QL equiv) oseltamivir phosphate cap 45 mg (base 2 QL equiv) oseltamivir phosphate cap 75 mg (base 2 QL equiv) RELENZA MIS DISKHALE 4 QL rimantadine hydrochloride tab 100 mg 2 TAMIFLU CAP 30MG 4 QL TAMIFLU CAP 45MG 4 QL TAMIFLU CAP 75MG 4 QL TAMIFLU SUS 6MG/ML 4 QL MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 mg/5ml 2 BILTRICIDE TAB 600MG 3 CLEOCIN CAP 75MG 4 CLEOCIN CAP 150MG 4 CLEOCIN CAP 300MG 4 clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) dapsone tab 25 mg 3 dapsone tab 100 mg 3 ivermectin tab 3 mg 2 linezolid for susp 100 mg/5ml 4 QL linezolid tab 600 mg 2 QL MEPRON SUS 4 metronidazole cap 375 mg 2 metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 MYCOBUTIN CAP 150MG 4 NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 50 2 mg nitrofurantoin macrocrystalline cap 100 2 mg nitrofurantoin monohydrate 2 macrocrystalline cap 100 mg PRIMSOL SOL 50MG/5ML 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 17

Drug Name Drug Tier Requirements/Limit rifabutin cap 150 mg 2 SIVEXTRO INJ 200MG 5 SIVEXTRO TAB 200MG 5 QL STROMECTOL TAB 3MG 4 trimethoprim tab 100 mg 2 vancomycin hcl cap 125 mg 2 vancomycin hcl cap 250 mg 2 VANCOMYCIN INJ 500MG 4 VANCOMYCIN INJ 750MG 4 XIFAXAN TAB 200MG 4 QL XIFAXAN TAB 550MG 5 PA; QL ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN INJ 50MG 5 ALKERAN TAB 2MG 5 BENDEKA INJ 100/4ML 5 BICNU INJ 100MG 5 busulfan inj 6 mg/ml 5 BUSULFEX INJ 6MG/ML 5 carboplatin iv soln 50 mg/5ml 5 carboplatin iv soln 150 mg/15ml 5 carboplatin iv soln 450 mg/45ml 5 carboplatin iv soln 600 mg/60ml 5 cisplatin inj 50 mg/50ml (1 mg/ml) 5 cisplatin inj 100 mg/100ml (1 mg/ml) 5 cisplatin inj 200 mg/200ml (1 mg/ml) 5 CYCLOPHOSPH CAP 25MG 5 CYCLOPHOSPH CAP 50MG 5 cyclophosphamide for inj 1 gm 5 cyclophosphamide for inj 2 gm 5 cyclophosphamide for inj 500 mg 5 dacarbazine for inj 100 mg 5 dacarbazine for inj 200 mg 5 EMCYT CAP 140MG 5 PA GLEOSTINE CAP 5MG 5 PA GLEOSTINE CAP 10MG 5 PA GLEOSTINE CAP 40MG 5 PA GLEOSTINE CAP 100MG 5 PA HEXALEN CAP 50MG 5 IFEX INJ 1GM 5 ifosfamide for inj 1 gm 5 IFOSFAMIDE INJ 3GM 5 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

18

Drug Name Drug Tier Requirements/Limit ifosfamide iv inj 3 gm/60ml (50 mg/ml) 5 LEUKERAN TAB 2MG 3 melphalan hcl for inj 50 mg (base 5 equiv) MUSTARGEN INJ 10MG 5 MYLERAN TAB 2MG 3 oxaliplatin for iv inj 50 mg 5 oxaliplatin for iv inj 100 mg 5 oxaliplatin iv soln 50 mg/10ml 5 oxaliplatin iv soln 100 mg/20ml 5 TEMODAR CAP 5MG 5 PA TEMODAR CAP 20MG 5 PA TEMODAR CAP 100MG 5 PA TEMODAR CAP 140MG 5 PA TEMODAR CAP 180MG 5 PA TEMODAR CAP 250MG 5 PA TEMODAR INJ 100MG 5 PA temozolomide cap 5 mg 5 PA temozolomide cap 20 mg 5 PA temozolomide cap 100 mg 5 PA temozolomide cap 140 mg 5 PA temozolomide cap 180 mg 5 PA temozolomide cap 250 mg 5 PA TREANDA INJ 25MG 5 TREANDA INJ 100MG 5 VALCHLOR GEL 0.016% 5 PA ZANOSAR INJ 1GM 5 ANTIMETABOLITES ALIMTA INJ 100MG 5 ALIMTA INJ 500MG 5 azacitidine for inj 100 mg 5 capecitabine tab 150 mg 5 PA capecitabine tab 500 mg 5 PA cladribine iv soln 10 mg/10ml (1 2 mg/ml) clofarabine iv soln 1 mg/ml 5 CLOLAR INJ 1MG/ML 5 cytarabine inj 20 mg/ml 2 cytarabine inj pf 20 mg/ml 4 cytarabine inj pf 100 mg/ml 2 DACOGEN INJ 50MG 5 decitabine for inj 50 mg 2 DEPOCYT INJ 50MG/5ML 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

19

Drug Name Drug Tier Requirements/Limit floxuridine for inj 0.5 gm 5 fludarabine phosphate for inj 50 mg 5 fludarabine phosphate inj 25 mg/ml 5 fluorouracil inj 1 gm/20ml (50 mg/ml) 5 fluorouracil inj 2.5 gm/50ml (50 5 mg/ml) fluorouracil inj 5 gm/100ml (50 mg/ml) 5 fluorouracil inj 500 mg/10ml (50 5 mg/ml) gemcitabine hcl for inj 1 gm 2 gemcitabine hcl for inj 2 gm 2 gemcitabine hcl for inj 200 mg 2 gemcitabine hcl inj 1 gm/26.3ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 2 mg/ml) (base equiv) GEMZAR INJ 1GM 5 GEMZAR INJ 200MG 5 mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 mg/2ml 5 (25 mg/ml) methotrexate sodium inj 250 mg/10ml 5 (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml 2 (25 mg/ml) methotrexate sodium inj pf 100 2 mg/4ml (25 mg/ml) methotrexate sodium inj pf 200 2 mg/8ml (25 mg/ml) methotrexate sodium inj pf 250 2 mg/10ml (25 mg/ml) methotrexate sodium inj pf 1000 2 mg/40ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base 2 equiv) TABLOID TAB 40MG 5 PA VIDAZA INJ 100MG 5 XELODA TAB 150MG 5 PA XELODA TAB 500MG 5 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

20

Drug Name Drug Tier Requirements/Limit flutamide cap 125 mg 2 NILANDRON TAB 150MG 4 PA XTANDI CAP 40MG 5 PA; QL ZYTIGA TAB 250MG 5 PA; QL ZYTIGA TAB 500MG 5 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 5 PA FASLODEX INJ 250MG 5 HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg 2 exemestane tab 25 mg 2 letrozole tab 2.5 mg 2 HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS FIRMAGON INJ 80MG 5 PA; QL FIRMAGON INJ 120MG 5 PA; QL HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONERELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG 5 PA; QL ELIGARD INJ 22.5MG 5 PA; QL ELIGARD INJ 30MG 5 PA; QL ELIGARD INJ 45MG 5 PA; QL leuprolide acetate inj kit 5 mg/ml 5 PA; QL LUPRON DEPOT INJ 3.75MG 5 PA; QL LUPRON DEPOT INJ 7.5MG 5 PA; QL LUPRON DEPOT INJ 11.25MG 5 PA; QL LUPRON DEPOT INJ 22.5MG 5 PA; QL LUPRON DEPOT INJ 30MG 5 PA; QL LUPRON DEPOT INJ 45MG 5 PA; QL TRELSTAR INJ 3.75MG 5 PA; QL TRELSTAR INJ 11.25MG 5 PA; QL TRELSTAR MIX INJ 3.75MG 5 PA; QL TRELSTAR MIX INJ 11.25MG 5 PA; QL TRELSTAR MIX INJ 22.5MG 5 PA; QL VANTAS KIT 50MG 5 PA; QL ZOLADEX IMP 3.6MG 5 PA; QL ZOLADEX IMP 10.8MG 5 PA; QL HORMONAL ANTINEOPLASTICS, PROGESTINS DEPO-PROVERA INJ 400/ML 4 QL megestrol acetate susp 40 mg/ml 2 megestrol acetate tab 20 mg 2 megestrol acetate tab 40 mg 2 IMMUNOMODULATORS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

21

Drug Name POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG REVLIMID CAP 2.5MG REVLIMID CAP 5MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 20MG REVLIMID CAP 25MG THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG KINASE INHIBITORS AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AFINITOR TAB 10MG ALECENSA CAP 150MG ALUNBRIG TAB 30MG BOSULIF TAB 100MG BOSULIF TAB 500MG CABOMETYX TAB 20MG CABOMETYX TAB 40MG CABOMETYX TAB 60MG CAPRELSA TAB 100MG CAPRELSA TAB 300MG COMETRIQ KIT 60MG COMETRIQ KIT 100MG COMETRIQ KIT 140MG COTELLIC TAB 20MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG IBRANCE CAP 75MG IBRANCE CAP 100MG IBRANCE CAP 125MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG

Drug Tier Requirements/Limit 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA;

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL 22

Drug Name imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG INLYTA TAB 1MG INLYTA TAB 5MG IRESSA TAB 250MG JAKAFI TAB 5MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG KISQALI 200 PAK FEMARA KISQALI 400 PAK FEMARA KISQALI 600 PAK FEMARA KISQALI TAB 200DOSE KISQALI TAB 400DOSE KISQALI TAB 600DOSE LENVIMA CAP 8 MG LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG MEKINIST TAB 0.5MG MEKINIST TAB 2MG NEXAVAR TAB 200MG RYDAPT CAP 25MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG STIVARGA TAB 40MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TAB 40MG

Drug Tier Requirements/Limit 5 PA; QL 5

PA; QL

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA;

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL 23

Drug Name TAGRISSO TAB 80MG TARCEVA TAB 25MG TARCEVA TAB 100MG TARCEVA TAB 150MG TASIGNA CAP 150MG TASIGNA CAP 200MG TORISEL SOL 25MG/ML TYKERB TAB 250MG VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG ZELBORAF TAB 240MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG MISCELLANEOUS ABRAXANE INJ 100MG ADCETRIS INJ 50MG amifostine for inj 500 mg ARRANON INJ 5MG/ML AVASTIN INJ AVASTIN INJ 400/16ML bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit daunorubicin hcl inj 5 mg/ml (base equiv) dexrazoxane for inj 250 mg dexrazoxane for inj 500 mg DOCEFREZ INJ 20MG DOCEFREZ INJ 80MG docetaxel for inj conc 20 mg/ml docetaxel for inj conc 80 mg/4ml (20 mg/ml) DOCETAXEL INJ 20MG/ML DOCETAXEL INJ 80MG/4ML DOXIL INJ 2MG/ML doxorubicin hcl for inj 10 mg doxorubicin hcl for inj 50 mg doxorubicin hcl inj 2 mg/ml doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ELITEK INJ 1.5MG ELITEK INJ 7.5MG

Drug Tier Requirements/Limit 5 PA; QL 5 PA 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 QL 5 PA; QL 5 QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 PA; QL 5 5 2 5 5 5 5 5 5 2 2 5 5 2 2 5 5 5 5 5 5 2 5 5

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

24

Drug Name Drug Tier Requirements/Limit ELLENCE INJ 2MG/ML 5 epirubicin hcl iv soln 50 mg/25ml (2 2 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 5 mg/ml) ERBITUX INJ 100MG 5 ERBITUX INJ 200MG 5 ERIVEDGE CAP 150MG 5 PA; QL ETOPOPHOS INJ 100MG 5 etoposide cap 50 mg 4 PA etoposide inj 1 gm/50ml (20 mg/ml) 2 PA etoposide inj 100 mg/5ml (20 mg/ml) 2 PA etoposide inj 500 mg/25ml (20 mg/ml) 2 PA FARYDAK CAP 10MG 5 PA; QL FARYDAK CAP 15MG 5 PA; QL FARYDAK CAP 20MG 5 PA; QL HERCEPTIN INJ 150MG 5 HERCEPTIN INJ 440MG 5 hydroxyurea cap 500 mg 2 IDAMYCIN PFS INJ 5MG/5ML 5 IDAMYCIN PFS INJ 10/10ML 5 IDAMYCIN PFS INJ 20/20ML 5 idarubicin hcl iv inj 5 mg/5ml (1 5 mg/ml) idarubicin hcl iv inj 10 mg/10ml (1 2 mg/ml) idarubicin hcl iv inj 20 mg/20ml (1 5 mg/ml) IXEMPRA KIT INJ 15MG 5 IXEMPRA KIT INJ 45MG 5 JEVTANA INJ 60/1.5ML 5 KYPROLIS SOL 30MG 5 KYPROLIS SOL 60MG 5 leucovorin calcium for inj 500 mg 5 leucovorin calcium tab 5 mg 5 leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 5 leucovorin calcium tab 25 mg 5 LONSURF TAB 15-6.14 5 PA LONSURF TAB 20-8.19 5 PA LYNPARZA CAP 50MG 5 PA; QL LYSODREN TAB 500MG 5 PA MATULANE CAP 50MG 5 mesna inj 100 mg/ml 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 25

Drug Name Drug Tier Requirements/Limit MESNEX INJ 1GM 5 MESNEX TAB 400MG 5 mitomycin for iv soln 5 mg 5 mitomycin for iv soln 20 mg 5 mitomycin for iv soln 40 mg 5 mitoxantrone hcl inj conc 20 mg/10ml 5 (2 mg/ml) mitoxantrone hcl inj conc 25 5 mg/12.5ml (2 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml 5 (2 mg/ml) NAVELBINE INJ 10MG/ML 5 NAVELBINE INJ 50MG/5ML 5 NINLARO CAP 2.3MG 5 PA; QL NINLARO CAP 3MG 5 PA; QL NINLARO CAP 4MG 5 PA; QL NIPENT INJ 10MG 5 ODOMZO CAP 200MG 5 PA; QL paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2 paclitaxel iv conc 100 mg/16.7ml (6 2 mg/ml) paclitaxel iv conc 150 mg/25ml (6 2 mg/ml) paclitaxel iv conc 300 mg/50ml (6 2 mg/ml) PERJETA INJ 420/14ML 5 PHOTOFRIN INJ 75MG 5 PROLEUKIN INJ 22MU 5 RITUXAN INJ 100MG 5 PA RITUXAN INJ 500MG 5 PA RUBRACA TAB 200MG 5 PA; QL RUBRACA TAB 250MG 5 PA; QL RUBRACA TAB 300MG 5 PA; QL SYNRIBO INJ 3.5MG 5 PA TARGRETIN CAP 75MG 5 PA TARGRETIN GEL 1% 5 PA TAXOTERE INJ 20MG/ML 5 TAXOTERE INJ 80MG/4ML 5 TENIPOSIDE INJ 50MG/5ML 5 THERACYS INJ 5 TICE BCG INJ 5 tretinoin cap 10 mg 5 TRISENOX SOL 10MG/10M 5 UVADEX INJ 20MCG/ML 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

26

Drug Name Drug Tier Requirements/Limit VECTIBIX INJ 100MG 5 VECTIBIX INJ 400MG 5 VELCADE INJ 3.5MG 5 VENCLEXTA TAB 10MG 5 PA; QL VENCLEXTA TAB 50MG 5 PA; QL VENCLEXTA TAB 100MG 5 PA; QL VENCLEXTA TAB START PK 5 PA; QL vinblastine sulfate inj 1 mg/ml 2 vincristine sulfate iv soln 1 mg/ml 2 vinorelbine tartrate inj 10 mg/ml (base 2 equiv) vinorelbine tartrate inj 50 mg/5ml (10 2 mg/ml) (base equiv) YERVOY INJ 50MG 5 YERVOY INJ 200MG 5 ZALTRAP INJ 100/4ML 5 ZALTRAP INJ 200/8ML 5 ZEJULA CAP 100MG 5 PA; QL ZEVALIN KIT Y-90 5 ZINECARD INJ 250MG 5 ZINECARD INJ 500MG 5 ZOLINZA CAP 100MG 5 PA; QL TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 40MG/2ML 5 CAMPTOSAR INJ 100/5ML 5 CAMPTOSAR INJ 300/15ML 5 HYCAMTIN CAP 0.25MG 5 PA HYCAMTIN CAP 1MG 5 PA HYCAMTIN INJ 4MG 5 PA irinotecan hcl inj 40 mg/2ml (20 5 mg/ml) irinotecan hcl inj 100 mg/5ml (20 5 mg/ml) irinotecan hcl inj 500 mg/25ml (20 5 mg/ml) topotecan hcl for inj 4 mg 2 TOPOTECAN INJ 4MG/4ML 5 CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2 2.5-10 mg amlodipine besylate-benazepril hcl cap 2 5-10 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

27

Drug Name Drug Tier Requirements/Limit amlodipine besylate-benazepril hcl cap 2 5-20 mg amlodipine besylate-benazepril hcl cap 2 5-40 mg amlodipine besylate-benazepril hcl cap 2 10-20 mg amlodipine besylate-benazepril hcl cap 2 10-40 mg TARKA TAB 1-240 CR 4 TARKA TAB 2-180 CR 4 TARKA TAB 2-240 CR 4 TARKA TAB 4-240 CR 4 trandolapril-verapamil hcl tab er 1-240 2 mg trandolapril-verapamil hcl tab er 2-180 2 mg trandolapril-verapamil hcl tab er 2-240 2 mg trandolapril-verapamil hcl tab er 4-240 2 mg ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5- 2 6.25 mg benazepril & hydrochlorothiazide tab 2 10-12.5 mg benazepril & hydrochlorothiazide tab 2 20-12.5 mg benazepril & hydrochlorothiazide tab 2 20-25 mg captopril & hydrochlorothiazide tab 25- 2 15 mg captopril & hydrochlorothiazide tab 25- 2 25 mg captopril & hydrochlorothiazide tab 50- 2 15 mg captopril & hydrochlorothiazide tab 50- 2 25 mg enalapril maleate & hydrochlorothiazide 2 tab 5-12.5 mg enalapril maleate & hydrochlorothiazide 2 tab 10-25 mg fosinopril sodium & hydrochlorothiazide 2 tab 10-12.5 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

28

Drug Name Drug Tier Requirements/Limit fosinopril sodium & hydrochlorothiazide 2 tab 20-12.5 mg lisinopril & hydrochlorothiazide tab 10- 1 12.5 mg lisinopril & hydrochlorothiazide tab 20- 1 12.5 mg lisinopril & hydrochlorothiazide tab 20- 1 25 mg moexipril-hydrochlorothiazide tab 7.5- 2 12.5 mg moexipril-hydrochlorothiazide tab 15- 2 12.5 mg moexipril-hydrochlorothiazide tab 15- 2 25 mg quinapril-hydrochlorothiazide tab 10- 2 12.5 mg quinapril-hydrochlorothiazide tab 20- 2 12.5 mg quinapril-hydrochlorothiazide tab 20-25 2 mg ACE INHIBITORS benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 captopril tab 12.5 mg 2 captopril tab 25 mg 2 captopril tab 50 mg 2 captopril tab 100 mg 2 enalapril maleate tab 2.5 mg 2 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 20 mg 1 enalaprilat iv inj 1.25 mg/ml 2 fosinopril sodium tab 10 mg 2 fosinopril sodium tab 20 mg 2 fosinopril sodium tab 40 mg 2 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 moexipril hcl tab 7.5 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

29

Drug Name Drug Tier Requirements/Limit moexipril hcl tab 15 mg 2 perindopril erbumine tab 2 mg 2 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2 quinapril hcl tab 5 mg 2 quinapril hcl tab 10 mg 2 quinapril hcl tab 20 mg 2 quinapril hcl tab 40 mg 2 ramipril cap 1.25 mg 2 ramipril cap 2.5 mg 2 ramipril cap 5 mg 2 ramipril cap 10 mg 2 trandolapril tab 1 mg 2 trandolapril tab 2 mg 2 trandolapril tab 4 mg 2 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 2 mg/24hr clonidine hcl td patch weekly 0.2 2 mg/24hr clonidine hcl td patch weekly 0.3 2 mg/24hr guanfacine hcl tab 1 mg 1 guanfacine hcl tab 2 mg 1 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 4 PA DIBENZYLINE CAP 10MG 4 PA phenoxybenzamine hcl cap 10 mg 4 PA ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg 2 eplerenone tab 50 mg 2 spironolactone tab 25 mg 1 spironolactone tab 50 mg 2 spironolactone tab 100 mg 2 ALPHA BLOCKERS doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2 prazosin hcl cap 1 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

30

Drug Name Drug Tier Requirements/Limit prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg 1 terazosin hcl cap 2 mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS telmisartan-amlodipine tab 40-5 mg 2 telmisartan-amlodipine tab 40-10 mg 2 telmisartan-amlodipine tab 80-5 mg 2 telmisartan-amlodipine tab 80-10 mg 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS candesartan cilexetil2 hydrochlorothiazide tab 16-12.5 mg candesartan cilexetil2 hydrochlorothiazide tab 32-12.5 mg candesartan cilexetil2 hydrochlorothiazide tab 32-25 mg irbesartan-hydrochlorothiazide tab 150- 2 12.5 mg irbesartan-hydrochlorothiazide tab 300- 2 12.5 mg losartan potassium & 2 hydrochlorothiazide tab 50-12.5 mg losartan potassium & 2 hydrochlorothiazide tab 100-12.5 mg losartan potassium & 2 hydrochlorothiazide tab 100-25 mg telmisartan-hydrochlorothiazide tab 40- 2 12.5 mg telmisartan-hydrochlorothiazide tab 80- 2 12.5 mg telmisartan-hydrochlorothiazide tab 80- 2 25 mg valsartan-hydrochlorothiazide tab 80- 2 12.5 mg valsartan-hydrochlorothiazide tab 160- 2 12.5 mg valsartan-hydrochlorothiazide tab 160- 2 25 mg valsartan-hydrochlorothiazide tab 320- 2 12.5 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

31

Drug Name Drug Tier Requirements/Limit valsartan-hydrochlorothiazide tab 320- 2 25 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg 2 candesartan cilexetil tab 8 mg 2 candesartan cilexetil tab 16 mg 2 candesartan cilexetil tab 32 mg 2 eprosartan mesylate tab 600 mg 2 irbesartan tab 75 mg 2 irbesartan tab 150 mg 2 irbesartan tab 300 mg 2 losartan potassium tab 25 mg 2 losartan potassium tab 50 mg 2 losartan potassium tab 100 mg 2 telmisartan tab 20 mg 2 telmisartan tab 40 mg 2 telmisartan tab 80 mg 2 valsartan tab 40 mg 2 valsartan tab 80 mg 2 valsartan tab 160 mg 2 valsartan tab 320 mg 2 ANTIARRHYTHMICS adenosine iv soln 6 mg/2ml 2 adenosine iv soln 12 mg/4ml 2 amiodarone hcl tab 100 mg 4 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 CORVERT INJ 1MG/10ML 4 disopyramide phosphate cap 100 mg 2 disopyramide phosphate cap 150 mg 2 flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 ibutilide fumarate inj 1 mg/10ml 2 lidocaine hcl iv inj 10 mg/ml 2 lidocaine hcl iv inj 20 mg/ml 2 lidocaine iv infusion in d5w inj 4 mg/ml 2 lidocaine iv infusion in d5w inj 8 mg/ml 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 MULTAQ TAB 400MG 3 NEXTERONE INJ 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

32

Drug Name Drug Tier Requirements/Limit NORPACE CAP 100MG CR 4 NORPACE CAP 150MG CR 4 PROCAINAMIDE INJ 500MG/ML 2 propafenone hcl cap er 12hr 225 mg 2 propafenone hcl cap er 12hr 325 mg 2 propafenone hcl cap er 12hr 425 mg 2 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 quinidine sulfate tab 200 mg 2 quinidine sulfate tab 300 mg 2 sotalol hcl (afib/afl) tab 80 mg 2 sotalol hcl (afib/afl) tab 120 mg 2 sotalol hcl (afib/afl) tab 160 mg 2 sotalol hcl tab 80 mg 1 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 TIKOSYN CAP 125MCG 3 TIKOSYN CAP 250MCG 3 TIKOSYN CAP 500MCG 3 XYLOCAINE INJ 2% 4 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 2 gm cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 COLESTID GRA 5GM 4 COLESTID POW 5GM 4 COLESTID TAB 1GM 4 colestipol hcl granule packets 5 gm 2 colestipol hcl granules 5 gm 2 colestipol hcl tab 1 gm 2 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 2 ZETIA TAB 10MG 3 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 mg 2 PA, ST (fenofibric acid equiv)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

33

Drug Name Drug Tier Requirements/Limit choline fenofibrate cap dr 135 mg 2 PA, ST (fenofibric acid equiv) fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2 fenofibrate micronized cap 134 mg 2 fenofibrate micronized cap 200 mg 2 fenofibrate tab 48 mg 2 fenofibrate tab 54 mg 2 fenofibrate tab 145 mg 2 fenofibrate tab 160 mg 2 fenofibric acid tab 35 mg 2 fenofibric acid tab 105 mg 2 gemfibrozil tab 600 mg 2 LOPID TAB 600MG 4 TRILIPIX CAP 45MG 4 PA, ST TRILIPIX CAP 135MG 4 PA, ST ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base 2 equivalent) atorvastatin calcium tab 20 mg (base 2 equivalent) atorvastatin calcium tab 40 mg (base 2 equivalent) atorvastatin calcium tab 80 mg (base 2 equivalent) CRESTOR TAB 5MG 4 PA CRESTOR TAB 10MG 4 PA CRESTOR TAB 20MG 4 PA CRESTOR TAB 40MG 4 PA ezetimibe-simvastatin tab 10-10 mg 4 QL ezetimibe-simvastatin tab 10-20 mg 4 QL ezetimibe-simvastatin tab 10-40 mg 4 QL ezetimibe-simvastatin tab 10-80 mg 4 QL fluvastatin sodium cap 20 mg 2 fluvastatin sodium cap 40 mg 2 lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 pravastatin sodium tab 10 mg 2 pravastatin sodium tab 20 mg 2 pravastatin sodium tab 40 mg 2 pravastatin sodium tab 80 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

34

Drug Name Drug Tier Requirements/Limit rosuvastatin calcium tab 5 mg 2 ST rosuvastatin calcium tab 10 mg 2 ST rosuvastatin calcium tab 20 mg 2 ST rosuvastatin calcium tab 40 mg 2 ST simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 VYTORIN TAB 10-10MG 4 ST; QL VYTORIN TAB 10-20MG 4 ST; QL VYTORIN TAB 10-40MG 4 ST; QL VYTORIN TAB 10-80MG 4 ST; QL ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS JUXTAPID CAP 5MG 5 PA; QL JUXTAPID CAP 10MG 5 PA; QL JUXTAPID CAP 20MG 5 PA; QL JUXTAPID CAP 30MG 5 PA; QL JUXTAPID CAP 40MG 5 PA; QL JUXTAPID CAP 60MG 5 PA; QL ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 5 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 mg 4 (antihyperlipidemic) niacin tab er 750 mg 4 (antihyperlipidemic) niacin tab er 1000 mg 4 (antihyperlipidemic) ANTILIPEMICS, OMEGA-3 FATTY ACIDS LOVAZA CAP 1GM 4 omega-3-acid ethyl esters cap 1 gm 4 VASCEPA CAP 1GM 3 ANTILIPEMICS, PCSK9 INHIBITORS REPATHA INJ 140MG/ML 5 PA; QL REPATHA PUSH INJ 420/3.5 5 PA; QL REPATHA SURE INJ 140MG/ML 5 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 2 atenolol & chlorthalidone tab 100-25 2 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

35

Drug Name Drug Tier Requirements/Limit bisoprolol & hydrochlorothiazide tab 1 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5- 1 6.25 mg bisoprolol & hydrochlorothiazide tab 1 10-6.25 mg metoprolol & hydrochlorothiazide tab 2 50-25 mg metoprolol & hydrochlorothiazide tab 2 100-25 mg metoprolol & hydrochlorothiazide tab 2 100-50 mg nadolol & bendroflumethiazide tab 40-5 2 mg nadolol & bendroflumethiazide tab 80-5 2 mg propranolol & hydrochlorothiazide tab 2 40-25 mg propranolol & hydrochlorothiazide tab 2 80-25 mg BETA-BLOCKERS acebutolol hcl cap 200 mg 2 acebutolol hcl cap 400 mg 2 atenolol tab 25 mg 1 atenolol tab 50 mg 1 atenolol tab 100 mg 1 betaxolol hcl tab 10 mg 2 betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 5 mg 2 bisoprolol fumarate tab 10 mg 2 BYSTOLIC TAB 2.5MG 4 PA, ST BYSTOLIC TAB 5MG 4 PA, ST BYSTOLIC TAB 10MG 4 PA, ST BYSTOLIC TAB 20MG 4 PA, ST carvedilol tab 3.125 mg 1 carvedilol tab 6.25 mg 1 carvedilol tab 12.5 mg 1 carvedilol tab 25 mg 1 INNOPRAN XL CAP 80MG 4 ST INNOPRAN XL CAP 120MG 4 ST labetalol hcl iv soln 5 mg/ml 2 labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2 labetalol hcl tab 300 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

36

Drug Name Drug Tier Requirements/Limit metoprolol succinate tab er 24hr 25 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 100 2 mg (tartrate equiv) metoprolol succinate tab er 24hr 200 2 mg (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml 2 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 5 mg 2 pindolol tab 10 mg 2 propranolol hcl cap er 24hr 60 mg 2 propranolol hcl cap er 24hr 80 mg 2 propranolol hcl cap er 24hr 120 mg 2 propranolol hcl cap er 24hr 160 mg 2 propranolol hcl inj 1 mg/ml 2 propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 2 propranolol hcl tab 40 mg 2 propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 2 timolol maleate tab 5 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 20 mg 2 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 CLEVIPREX EMU 0.5MG/ML 4 felodipine tab er 24hr 2.5 mg 2 felodipine tab er 24hr 5 mg 2 felodipine tab er 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 nicardipine hcl cap 20 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

37

Drug Name Drug Tier Requirements/Limit nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedipine cap 20 mg 2 nifedipine tab er 24hr 30 mg 2 nifedipine tab er 24hr 60 mg 2 nifedipine tab er 24hr 90 mg 2 nifedipine tab er 24hr osmotic release 2 90 mg nimodipine cap 30 mg 2 nisoldipine tab er 24hr 8.5 mg 2 nisoldipine tab er 24hr 17 mg 2 nisoldipine tab er 24hr 20 mg 2 nisoldipine tab er 24hr 25.5 mg 2 nisoldipine tab er 24hr 30 mg 2 nisoldipine tab er 24hr 34 mg 2 nisoldipine tab er 24hr 40 mg 2 NORVASC TAB 2.5MG 4 NORVASC TAB 5MG 4 NORVASC TAB 10MG 4 SULAR TAB 8.5MG 4 SULAR TAB 17MG 4 SULAR TAB 34MG 4 CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CARDIZEM LA TAB 120MG 4 diltiazem hcl cap er 12hr 60 mg 2 diltiazem hcl cap er 12hr 90 mg 2 diltiazem hcl cap er 12hr 120 mg 2 diltiazem hcl cap er 24hr 120 mg 2 diltiazem hcl cap er 24hr 180 mg 2 diltiazem hcl cap er 24hr 240 mg 2 diltiazem hcl coated beads cap er 24hr 2 120 mg diltiazem hcl coated beads cap er 24hr 2 180 mg diltiazem hcl coated beads cap er 24hr 2 240 mg diltiazem hcl coated beads cap er 24hr 2 300 mg diltiazem hcl coated beads cap er 24hr 2 360 mg diltiazem hcl coated beads tab er 24hr 2 180 mg diltiazem hcl coated beads tab er 24hr 2 240 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

38

Drug Name diltiazem hcl coated beads tab er 24hr 300 mg diltiazem hcl coated beads tab er 24hr 360 mg diltiazem hcl coated beads tab er 24hr 420 mg diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg diltiazem hcl tab 120 mg DILTIAZEM INJ 100MG verapamil hcl cap er 24hr 100 mg verapamil hcl cap er 24hr 120 mg verapamil hcl cap er 24hr 180 mg verapamil hcl cap er 24hr 200 mg verapamil hcl cap er 24hr 240 mg verapamil hcl cap er 24hr 300 mg verapamil hcl cap er 24hr 360 mg verapamil hcl iv soln 2.5 mg/ml verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab 120 mg verapamil hcl tab er 120 mg verapamil hcl tab er 180 mg verapamil hcl tab er 240 mg DIGITALIS GLYCOSIDES

Drug Tier Requirements/Limit 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

39

Drug Name Drug Tier Requirements/Limit digoxin inj 0.25 mg/ml 2 digoxin oral soln 0.05 mg/ml 2 digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 2 LANOXIN INJ 0.25MG/1 4 LANOXIN PED INJ 0.1MG/ML 4 LANOXIN TAB 0.25MG 4 LANOXIN TAB 0.125MG 4 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 ST TEKTURNA HCT TAB 150-25MG 3 ST TEKTURNA HCT TAB 300-12.5 3 ST TEKTURNA HCT TAB 300-25MG 3 ST TEKTURNA TAB 150MG 3 ST TEKTURNA TAB 300MG 3 ST DIURETICS acetazolamide cap er 12hr 500 mg 2 acetazolamide sodium for inj 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 ALDACTAZIDE TAB 50/50 4 amiloride & hydrochlorothiazide tab 5- 2 50 mg amiloride hcl tab 5 mg 2 bumetanide inj 0.25 mg/ml 2 bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2 chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 DIURIL SUS 250/5ML 3 DYRENIUM CAP 50MG 4 DYRENIUM CAP 100MG 4 furosemide inj 10 mg/ml 2 furosemide oral soln 8 mg/ml 2 furosemide oral soln 10 mg/ml 2 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 hydrochlorothiazide cap 12.5 mg 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

40

Drug Name hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg KEVEYIS TAB 50MG methazolamide tab 25 mg methazolamide tab 50 mg methyclothiazide tab 5 mg metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg spironolactone & hydrochlorothiazide tab 25-25 mg torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg torsemide tab 100 mg triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide cap 50-25 mg triamterene & hydrochlorothiazide tab 37.5-25 mg triamterene & hydrochlorothiazide tab 75-50 mg HEART FAILURE CORLANOR TAB 5MG CORLANOR TAB 7.5MG ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG MISCELLANEOUS alprostadil inj 500 mcg/ml atropine sulfate inj 0.4 mg/ml atropine sulfate inj 1 mg/ml atropine sulfate soln prefill syr 0.5 mg/5ml (0.1 mg/ml) atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml) clonidine & chlorthalidone tab 0.1-15 mg clonidine & chlorthalidone tab 0.2-15 mg

Drug Tier Requirements/Limit 1 1 1 2 2 5 PA; QL 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1

4 4 3 3 3

PA; PA; PA; PA; PA;

QL QL QL QL QL

2 2 2 2 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

41

Drug Name Drug Tier Requirements/Limit clonidine & chlorthalidone tab 0.3-15 2 mg ETHAMOLIN INJ 5% 4 hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2 hydralazine hcl tab 50 mg 1 hydralazine hcl tab 100 mg 1 methyldopa & hydrochlorothiazide tab 2 250-15 mg methyldopa & hydrochlorothiazide tab 2 250-25 mg methyldopa tab 250 mg 2 methyldopa tab 500 mg 2 methyldopate hcl inj 250 mg/5ml 2 midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2 midodrine hcl tab 10 mg 2 milrinone lactate in dextrose 5% iv soln 2 20 mg/100ml milrinone lactate in dextrose 5% iv soln 2 40 mg/200ml milrinone lactate iv soln 10 mg/10ml 2 (base equivalent) milrinone lactate iv soln 20 mg/20ml 2 (base equivalent) milrinone lactate iv soln 50 mg/50ml 2 (base equivalent) minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2 NATRECOR INJ 1.5MG 4 NEOPROFEN SOL 10MG/ML 4 NORTHERA CAP 200MG 5 PA; QL NORTHERA CAP 300MG 5 PA; QL papaverine hcl inj 30 mg/ml 2 PROSTIN VR INJ 500MCG 4 RANEXA TAB 500MG 3 RANEXA TAB 1000MG 3 NITRATES, INJECTABLE NITROGLYCER INJ 5MG/ML 2 NITRATES, ORAL ISORDIL TAB 40MG 4 isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab 10 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 42

Drug Name Drug Tier Requirements/Limit isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab er 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab er 24hr 30 2 mg isosorbide mononitrate tab er 24hr 60 2 mg isosorbide mononitrate tab er 24hr 120 2 mg nitroglycerin cap er 2.5 mg 2 nitroglycerin cap er 6.5 mg 2 nitroglycerin cap er 9 mg 2 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 2 mcg/spray nitroglycerin sl tab 0.3 mg 2 nitroglycerin sl tab 0.4 mg 2 nitroglycerin sl tab 0.6 mg 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) NITROLINGUAL SPR PUMPSPRA 4 NITROSTAT SUB 0.3MG 4 NITROSTAT SUB 0.4MG 4 NITROSTAT SUB 0.6MG 4 NITRATES, TRANSDERMAL NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.1MG/HR 4 NITRO-DUR DIS 0.2MG/HR 4 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.4MG/HR 4 NITRO-DUR DIS 0.6MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS TAB 5MG 5 PA; QL LETAIRIS TAB 10MG 5 PA; QL TRACLEER TAB 62.5MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

43

Drug Name Drug Tier Requirements/Limit TRACLEER TAB 125MG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITOR REVATIO TAB 20MG 5 PA; QL sildenafil citrate tab 20 mg 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI TAB 200/800 4 PA; QL UPTRAVI TAB 200MCG 5 PA; QL UPTRAVI TAB 400MCG 5 PA; QL UPTRAVI TAB 600MCG 5 PA; QL UPTRAVI TAB 800MCG 5 PA; QL UPTRAVI TAB 1000MCG 5 PA; QL UPTRAVI TAB 1200MCG 5 PA; QL UPTRAVI TAB 1400MCG 5 PA; QL UPTRAVI TAB 1600MCG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS epoprostenol sodium for inj 0.5 mg 5 PA FLOLAN INJ 0.5MG 5 PA FLOLAN INJ 1.5MG 5 PA ORENITRAM TAB 0.25MG 5 PA ORENITRAM TAB 0.125MG 5 PA ORENITRAM TAB 1MG 5 PA ORENITRAM TAB 2.5MG 5 PA ORENITRAM TAB 5MG 5 PA REMODULIN INJ 1MG/ML 5 PA REMODULIN INJ 2.5MG/ML 5 PA REMODULIN INJ 5MG/ML 5 PA REMODULIN INJ 10MG/ML 5 PA TYVASO START SOL 0.6MG/ML 5 PA VELETRI INJ 0.5MG 5 PA VENTAVIS SOL 10MCG/ML 5 PA VENTAVIS SOL 20MCG/ML 5 PA PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 5 PA; QL ADEMPAS TAB 1.5MG 5 PA; QL ADEMPAS TAB 1MG 5 PA; QL ADEMPAS TAB 2.5MG 5 PA; QL ADEMPAS TAB 2MG 5 PA; QL VASOPRESSORS dobutamine hcl inj 12.5 mg/ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

44

Drug Name dobutamine inj 1 mg/ml in d5w dobutamine inj 2 mg/ml in d5w dobutamine inj 4 mg/ml in d5w dopamine hcl inj 40 mg/ml dopamine hcl inj 80 mg/ml dopamine hcl inj 160 mg/ml ephedrine sulfate inj 50 mg/ml EPINEPHRINE INJ 1MG/ML phenylephrine hcl inj 10 mg/ml CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML alprazolam orally disintegrating tab 0.5 mg alprazolam orally disintegrating tab 0.25 mg alprazolam orally disintegrating tab 1 mg alprazolam orally disintegrating tab 2 mg alprazolam tab 0.5 mg alprazolam tab 0.25 mg alprazolam tab 1 mg alprazolam tab 2 mg alprazolam tab er 24hr 0.5 mg alprazolam tab er 24hr 1 mg alprazolam tab er 24hr 2 mg alprazolam tab er 24hr 3 mg chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.125 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg

Drug Tier Requirements/Limit 2 2 2 2 2 2 2 4 2

2 2

ST

2

ST

2

ST

2

ST

2 2 2 2 2 2 2 2 2 2 2 2

ST

2

ST

2

ST

2

ST

2

ST

2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

45

Drug Name clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg clorazepate dipotassium tab 15 mg diazepam conc 5 mg/ml diazepam inj 5 mg/ml DIAZEPAM INJ 10MG/2ML diazepam oral soln 1 mg/ml diazepam tab 2 mg diazepam tab 5 mg diazepam tab 10 mg lorazepam conc 2 mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg meprobamate tab 200 mg meprobamate tab 400 mg ANTICONVULSANTS APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BRIVIACT INJ 50MG/5ML BRIVIACT SOL 10MG/ML

Drug Tier Requirements/Limit 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 1 1 2 4 4 4 2 2 2 2 2

ST ST ST

4 4 4 4 4 4 4 4 4

PA; PA; PA; PA; PA PA PA PA; PA;

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

QL QL QL QL

QL QL 46

Drug Name Drug Tier Requirements/Limit BRIVIACT TAB 10MG 4 PA; QL BRIVIACT TAB 25MG 4 PA; QL BRIVIACT TAB 50MG 4 PA; QL BRIVIACT TAB 75MG 4 PA; QL BRIVIACT TAB 100MG 4 PA; QL carbamazepine cap er 12hr 100 mg 2 carbamazepine cap er 12hr 200 mg 2 carbamazepine cap er 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 1 carbamazepine tab er 12hr 100 mg 2 carbamazepine tab er 12hr 200 mg 2 carbamazepine tab er 12hr 400 mg 2 CARBATROL CAP 100MG 4 CARBATROL CAP 200MG 4 CARBATROL CAP 300MG 4 CELONTIN CAP 300MG 3 CEREBYX INJ 100/2ML 4 CEREBYX INJ 500/10ML 4 DEPAKOTE ER TAB 500MG 4 DIASTAT ACDL GEL 5-10MG 4 DIASTAT ACDL GEL 12.5-20 4 DIASTAT PED GEL 2.5M GEL 3 diazepam rectal gel delivery system 2.5 2 mg diazepam rectal gel delivery system 10 2 mg diazepam rectal gel delivery system 20 2 mg DILANTIN CAP 30MG 3 DILANTIN CAP 100MG 3 DILANTIN CHW 50MG 3 DILANTIN-125 SUS 125/5ML 3 divalproex sodium cap delayed release 2 sprinkle 125 mg divalproex sodium tab delayed release 2 125 mg divalproex sodium tab delayed release 2 250 mg divalproex sodium tab delayed release 2 500 mg divalproex sodium tab er 24 hr 250 mg 2 divalproex sodium tab er 24 hr 500 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

47

Drug Name Drug Tier Requirements/Limit ethosuximide cap 250 mg 2 ethosuximide soln 250 mg/5ml 2 felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 fosphenytoin sodium inj 100 mg/2ml 2 (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml 2 (phenytoin equiv) FYCOMPA SUS 0.5MG/ML 4 QL FYCOMPA TAB 2MG 4 PA; QL FYCOMPA TAB 4MG 4 PA; QL FYCOMPA TAB 6MG 4 PA; QL FYCOMPA TAB 8MG 4 PA; QL FYCOMPA TAB 10MG 4 PA; QL FYCOMPA TAB 12MG 4 PA; QL gabapentin cap 100 mg 1 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin oral soln 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 KEPPRA INJ 500/5ML 4 KEPPRA SOL 100MG/ML 4 KEPPRA TAB 250MG 4 KEPPRA TAB 500MG 4 KEPPRA TAB 750MG 4 KEPPRA TAB 1000MG 4 KEPPRA XR TAB 500MG 4 QL KEPPRA XR TAB 750MG 4 QL lamotrigine tab 25 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 2 mg lamotrigine tab chewable dispersible 25 2 mg levetiracetam inj 500 mg/5ml (100 2 mg/ml) levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 48

Drug Name Drug Tier Requirements/Limit levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab er 24hr 500 mg 2 QL levetiracetam tab er 24hr 750 mg 2 QL ONFI SUS 2.5MG/ML 5 PA; QL ONFI TAB 10MG 5 PA; QL ONFI TAB 20MG 5 PA; QL oxcarbazepine susp 300 mg/5ml (60 2 mg/ml) oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 PHENOBARB INJ 65MG/ML 2 phenobarbital elixir 20 mg/5ml 2 phenobarbital sodium inj 130 mg/ml 2 phenobarbital tab 15 mg 2 phenobarbital tab 16.2 mg 2 phenobarbital tab 30 mg 2 phenobarbital tab 32.4 mg 2 phenobarbital tab 60 mg 2 phenobarbital tab 64.8 mg 2 phenobarbital tab 97.2 mg 2 phenobarbital tab 100 mg 2 PHENYTEK CAP 200MG 3 PHENYTEK CAP 300MG 3 phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 2 mg phenytoin sodium extended cap 200 2 mg phenytoin sodium extended cap 300 2 mg phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 POTIGA TAB 50MG 4 PA; QL POTIGA TAB 200MG 4 PA; QL POTIGA TAB 300MG 4 PA; QL POTIGA TAB 400MG 4 PA; QL primidone tab 50 mg 2 primidone tab 250 mg 2 SABRIL POW 500MG 5 PA; QL SABRIL TAB 500MG 5 PA; QL TEGRETOL SUS 100/5ML 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 49

Drug Name Drug Tier Requirements/Limit TEGRETOL-XR TAB 100MG 4 TEGRETOL-XR TAB 200MG 4 TEGRETOL-XR TAB 400MG 4 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 topiramate sprinkle cap 15 mg 2 QL topiramate sprinkle cap 25 mg 2 QL topiramate tab 25 mg 2 topiramate tab 50 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 valproate sodium inj 100 mg/ml 2 valproate sodium oral soln 250 mg/5ml 2 (base equiv) valproic acid cap 250 mg 2 VIMPAT INJ 200MG/20 4 PA VIMPAT SOL 10MG/ML 4 PA VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 zonisamide cap 100 mg 2 ANTIDEMENTIA donepezil hydrochloride orally 2 disintegrating tab 5 mg donepezil hydrochloride orally 2 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg 2 donepezil hydrochloride tab 10 mg 2 galantamine hydrobromide cap er 24hr 2 PA 8 mg galantamine hydrobromide cap er 24hr 2 PA 16 mg galantamine hydrobromide cap er 24hr 2 PA 24 mg galantamine hydrobromide oral soln 4 2 PA mg/ml galantamine hydrobromide tab 4 mg 2 PA galantamine hydrobromide tab 8 mg 2 PA galantamine hydrobromide tab 12 mg 2 PA memantine hcl oral solution 2 mg/ml 2 PA memantine hcl tab 5 mg 2 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 50

Drug Name Drug Tier Requirements/Limit memantine hcl tab 5 mg (28) & 10 mg 2 (21) titration pak memantine hcl tab 10 mg 2 PA rivastigmine tartrate cap 1.5 mg 2 PA rivastigmine tartrate cap 3 mg 2 PA rivastigmine tartrate cap 4.5 mg 2 PA rivastigmine tartrate cap 6 mg 2 PA rivastigmine td patch 24hr 4.6 mg/24hr 2 PA rivastigmine td patch 24hr 9.5 mg/24hr 2 PA rivastigmine td patch 24hr 13.3 2 PA mg/24hr ANTIDEPRESSANTS, MAOIS MARPLAN TAB 10MG 3 phenelzine sulfate tab 15 mg 2 tranylcypromine sulfate tab 10 mg 2 ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg 2 bupropion hcl tab 100 mg 2 bupropion hcl tab er 12hr 100 mg 2 bupropion hcl tab er 12hr 150 mg 2 bupropion hcl tab er 12hr 200 mg 2 bupropion hcl tab er 24hr 150 mg 2 bupropion hcl tab er 24hr 300 mg 2 chlordiazepoxide-amitriptyline tab 52 12.5 mg chlordiazepoxide-amitriptyline tab 10- 2 25 mg maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 mirtazapine orally disintegrating tab 15 2 mg mirtazapine orally disintegrating tab 30 2 mg mirtazapine orally disintegrating tab 45 2 mg mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 51

Drug Name ANTIDEPRESSANTS, SNRIS DESVENLAFAX TAB 50MG ER DESVENLAFAX TAB 100MG ER desvenlafaxine succinate tab er 24hr 25 mg (base equiv) desvenlafaxine succinate tab er 24hr 50 mg (base equiv) desvenlafaxine succinate tab er 24hr 100 mg (base equiv) desvenlafaxine tab er 24hr 50 mg desvenlafaxine tab er 24hr 100 mg duloxetine hcl enteric coated pellets cap 20 mg (base eq) duloxetine hcl enteric coated pellets cap 30 mg (base eq) duloxetine hcl enteric coated pellets cap 60 mg (base eq) FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP 120MG FETZIMA CAP TITRATIO KHEDEZLA TAB 50MG ER KHEDEZLA TAB 100MG ER PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRISTIQ TAB 100MG venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) venlafaxine hcl cap er 24hr 75 mg (base equivalent) venlafaxine hcl cap er 24hr 150 mg (base equivalent) venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) venlafaxine hcl tab er 24hr 75 mg (base equivalent) venlafaxine hcl tab er 24hr 150 mg (base equivalent)

Drug Tier Requirements/Limit 4 4 4

ST; QL ST; QL ST; QL

4

ST; QL

4

ST; QL

4 4 2

ST; QL ST; QL QL

2

QL

2

QL

4 4 4 4 4 4 4 4 4 4 2

PA; PA; PA; PA; PA; ST; ST; ST; ST; ST;

QL QL QL QL QL QL QL QL QL QL

2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

52

Drug Name venlafaxine hcl tab er 24hr 225 mg (base equivalent) ANTIDEPRESSANTS, SSRIS citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 5 mg (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) fluoxetine hcl (pmdd) cap 10 mg fluoxetine hcl (pmdd) cap 20 mg fluoxetine hcl (pmdd) tab 10 mg fluoxetine hcl (pmdd) tab 20 mg fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl cap delayed release 90 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg paroxetine hcl tab er 24hr 12.5 mg paroxetine hcl tab er 24hr 25 mg paroxetine hcl tab er 24hr 37.5 mg PAXIL SUS 10MG/5ML sertraline hcl oral conc 20 mg/ml sertraline hcl tab 25 mg sertraline hcl tab 50 mg sertraline hcl tab 100 mg TRINTELLIX TAB 5MG

Drug Tier Requirements/Limit 2

2 1

QL

1

QL

1

QL

2

QL

2

QL

2

QL

2

QL

1 1 1 1 1 1 1 2

QL

2 1 1 1 1 2 2 2 2 2 3 2 1 1 1 4

QL QL QL QL QL QL QL QL

PA; QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

53

Drug Name TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxapine tab 100 mg amoxapine tab 150 mg desipramine hcl tab 10 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imipramine pamoate cap 75 mg imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml protriptyline hcl tab 5 mg

Drug Tier Requirements/Limit 4 PA; QL 4 PA; QL 4 PA; QL 4 PA; QL 4 PA; QL 4 PA; QL 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

54

Drug Name Drug Tier Requirements/Limit protriptyline hcl tab 10 mg 2 SURMONTIL CAP 25MG 4 SURMONTIL CAP 50MG 4 SURMONTIL CAP 100MG 4 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg 2 amantadine hcl syrup 50 mg/5ml 2 amantadine hcl tab 100 mg 2 APOKYN INJ 10MG/ML 5 PA; QL AZILECT TAB 0.5MG 3 AZILECT TAB 1MG 3 benztropine mesylate inj 1 mg/ml 2 benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg 1 benztropine mesylate tab 2 mg 1 bromocriptine mesylate cap 5 mg (base 2 equivalent) bromocriptine mesylate tab 2.5 mg 2 (base equivalent) carbidopa & levodopa orally 2 disintegrating tab 10-100 mg carbidopa & levodopa orally 2 disintegrating tab 25-100 mg carbidopa & levodopa orally 2 disintegrating tab 25-250 mg carbidopa & levodopa tab 10-100 mg 2 carbidopa & levodopa tab 25-100 mg 2 carbidopa & levodopa tab 25-250 mg 2 carbidopa & levodopa tab er 25-100 mg2 carbidopa & levodopa tab er 50-200 mg2 carbidopa tab 25 mg 2 carbidopa-levodopa-entacapone tabs 2 12.5-50-200 mg carbidopa-levodopa-entacapone tabs 2 18.75-75-200 mg carbidopa-levodopa-entacapone tabs 2 25-100-200 mg carbidopa-levodopa-entacapone tabs 2 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 2 37.5-150-200 mg carbidopa-levodopa-entacapone tabs 2 50-200-200 mg DUOPA SUS 4.63-20 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

55

Drug Name entacapone tab 200 mg NEUPRO DIS 1MG/24HR NEUPRO DIS 2MG/24HR NEUPRO DIS 3MG/24HR NEUPRO DIS 4MG/24HR NEUPRO DIS 6MG/24HR NEUPRO DIS 8MG/24HR pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 0.125 mg pramipexole dihydrochloride tab 1 mg pramipexole dihydrochloride tab 1.5 mg pramipexole dihydrochloride tab er 24hr 0.75 mg pramipexole dihydrochloride tab er 24hr 0.375 mg pramipexole dihydrochloride tab er 24hr 1.5 mg pramipexole dihydrochloride tab er 24hr 2.25 mg pramipexole dihydrochloride tab er 24hr 3 mg pramipexole dihydrochloride tab er 24hr 3.75 mg pramipexole dihydrochloride tab er 24hr 4.5 mg rasagiline mesylate tab 0.5 mg (base equiv) rasagiline mesylate tab 1 mg (base equiv) ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 0.25 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg

Drug Tier Requirements/Limit 2 4 4 4 4 4 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

56

Drug Name ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) selegiline hcl cap 5 mg selegiline hcl tab 5 mg trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg ZELAPAR TAB 1.25MG ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 2 mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 20 mg aripiprazole tab 30 mg ARISTADA INJ 441MG/1. ARISTADA INJ 662MG/2 ARISTADA INJ 882MG/3 ARISTADA INJ 1064MG clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 25 mg clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg

Drug Tier Requirements/Limit 2 ST 2

ST

2

ST

2

ST

2

ST

2 2 2 1 2 4 4 4 4 4

PA; PA; PA; PA;

4

PA; QL

4 4 4 4 4 4 5 5 5 5 2

PA; PA; PA; PA; PA; PA; QL QL QL PA; PA;

2

PA; QL

2

PA; QL

2

PA; QL

2

PA; QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

QL QL QL QL

QL QL QL QL QL QL

QL QL

57

Drug Name Drug Tier Requirements/Limit clozapine tab 25 mg 2 clozapine tab 50 mg 2 clozapine tab 100 mg 2 clozapine tab 200 mg 2 FANAPT PAK 4 PA; QL FANAPT TAB 1MG 4 PA; QL FANAPT TAB 2MG 4 PA; QL FANAPT TAB 4MG 4 PA; QL FANAPT TAB 6MG 4 PA; QL FANAPT TAB 8MG 4 PA; QL FANAPT TAB 10MG 4 PA; QL FANAPT TAB 12MG 4 PA; QL GEODON INJ 20MG 4 INVEGA SUST INJ 39/0.25 5 PA; QL INVEGA SUST INJ 78/0.5ML 5 PA; QL INVEGA SUST INJ 117/0.75 5 PA; QL INVEGA SUST INJ 156MG/ML 5 PA; QL INVEGA SUST INJ 234/1.5 5 PA; QL INVEGA TRINZ INJ 273MG 5 PA; QL INVEGA TRINZ INJ 410MG 5 PA; QL INVEGA TRINZ INJ 546MG 5 PA; QL INVEGA TRINZ INJ 819MG 5 PA; QL LATUDA TAB 20MG 4 ST; QL LATUDA TAB 40MG 4 ST; QL LATUDA TAB 60MG 4 ST; QL LATUDA TAB 80MG 4 ST; QL LATUDA TAB 120MG 4 ST; QL loxapine succinate cap 5 mg 2 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 loxapine succinate cap 50 mg 2 NUPLAZID TAB 17MG 5 PA; QL olanzapine for im inj 10 mg 2 olanzapine orally disintegrating tab 5 2 QL mg olanzapine orally disintegrating tab 10 2 QL mg olanzapine orally disintegrating tab 15 2 QL mg olanzapine orally disintegrating tab 20 2 QL mg olanzapine tab 2.5 mg 2 QL olanzapine tab 5 mg 2 QL olanzapine tab 7.5 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 58

Drug Name olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 20 mg paliperidone tab er 24hr 1.5 mg paliperidone tab er 24hr 3 mg paliperidone tab er 24hr 6 mg paliperidone tab er 24hr 9 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone orally disintegrating tab mg risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab mg risperidone orally disintegrating tab mg risperidone orally disintegrating tab mg risperidone orally disintegrating tab mg risperidone soln 1 mg/ml risperidone tab 0.5 mg risperidone tab 0.25 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAPHRIS SUB 10MG SEROQUEL XR TAB 50MG SEROQUEL XR TAB 150MG SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG

Drug Tier Requirements/Limit 2 QL 2 QL 2 QL 4 PA; QL 4 PA; QL 4 PA; QL 4 PA; QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 4 QL 4 QL 5 QL 4 QL 0.5 2 QL 2

QL

1

2

QL

2

2

QL

3

2

QL

4

2

QL

2 2 2 2 2 2 2 4 4 4 4 4 4 4 4

QL QL QL QL QL QL QL ST; QL ST; QL ST; QL QL QL QL QL QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

59

Drug Name ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML CHLORPROMAZ INJ 50MG/2ML chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg fluphenazine decanoate inj 25 mg/ml fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg HALDOL DECAN INJ 50MG/ML HALDOL DECAN INJ 100MG/ML HALDOL INJ 5MG/ML haloperidol decanoate im soln 50 mg/ml haloperidol decanoate im soln 100 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg

Drug Tier Requirements/Limit 2 QL 2 QL 2 QL 2 QL 4 PA; QL 4 PA; QL 4 PA; QL 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 2 2 2 2 1 1 2 2 2 2 2 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

60

Drug Name Drug Tier Requirements/Limit perphenazine-amitriptyline tab 2-10 2 mg perphenazine-amitriptyline tab 2-25 2 mg perphenazine-amitriptyline tab 4-10 2 mg perphenazine-amitriptyline tab 4-25 2 mg perphenazine-amitriptyline tab 4-50 2 mg pimozide tab 1 mg 2 pimozide tab 2 mg 2 thioridazine hcl tab 10 mg 2 thioridazine hcl tab 25 mg 2 thioridazine hcl tab 50 mg 2 thioridazine hcl tab 100 mg 2 thiothixene cap 1 mg 2 thiothixene cap 2 mg 2 thiothixene cap 5 mg 2 thiothixene cap 10 mg 2 trifluoperazine hcl tab 1 mg (base 2 equivalent) trifluoperazine hcl tab 2 mg (base 2 equivalent) trifluoperazine hcl tab 5 mg (base 2 equivalent) trifluoperazine hcl tab 10 mg (base 2 equivalent) ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 5MG 4 QL ADDERALL TAB 7.5MG 4 QL ADDERALL TAB 10MG 4 QL ADDERALL TAB 12.5MG 4 QL ADDERALL TAB 15MG 4 QL ADDERALL TAB 20MG 4 QL ADDERALL TAB 30MG 4 QL amphetamine-dextroamphetamine cap 2 QL er 24hr 5 mg amphetamine-dextroamphetamine cap 2 QL er 24hr 10 mg amphetamine-dextroamphetamine cap 2 QL er 24hr 15 mg amphetamine-dextroamphetamine cap 2 QL er 24hr 20 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

61

Drug Name amphetamine-dextroamphetamine cap er 24hr 25 mg amphetamine-dextroamphetamine cap er 24hr 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg atomoxetine hcl cap 10 mg (base equiv) atomoxetine hcl cap 18 mg (base equiv) atomoxetine hcl cap 25 mg (base equiv) atomoxetine hcl cap 40 mg (base equiv) atomoxetine hcl cap 60 mg (base equiv) atomoxetine hcl cap 80 mg (base equiv) atomoxetine hcl cap 100 mg (base equiv) clonidine hcl tab er 12hr 0.1 mg DESOXYN TAB 5MG DEXEDRINE CAP 5MG CR DEXEDRINE CAP 10MG CR DEXEDRINE CAP 15MG CR dexmethylphenidate hcl cap er 24 hr 5 mg dexmethylphenidate hcl cap er 24 hr 10 mg dexmethylphenidate hcl cap er 24 hr 15 mg

Drug Tier Requirements/Limit 2 QL 2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2

QL

2 4 4 4 4 2

QL QL QL QL QL QL

2

QL

2

QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

62

Drug Name Drug Tier Requirements/Limit dexmethylphenidate hcl cap er 24 hr 2 QL 20 mg dexmethylphenidate hcl cap er 24 hr 2 QL 25 mg dexmethylphenidate hcl cap er 24 hr 2 QL 30 mg dexmethylphenidate hcl cap er 24 hr 2 QL 35 mg dexmethylphenidate hcl cap er 24 hr 2 QL 40 mg dexmethylphenidate hcl tab 2.5 mg 2 QL dexmethylphenidate hcl tab 5 mg 2 QL dexmethylphenidate hcl tab 10 mg 2 QL dextroamphetamine sulfate cap er 24hr 2 QL 5 mg dextroamphetamine sulfate cap er 24hr 2 QL 10 mg dextroamphetamine sulfate cap er 24hr 2 QL 15 mg dextroamphetamine sulfate tab 5 mg 2 QL dextroamphetamine sulfate tab 10 mg 2 QL FOCALIN XR CAP 25MG 4 QL FOCALIN XR CAP 35MG 4 QL guanfacine hcl tab er 24hr 1 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 2 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 3 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 4 mg (base 2 QL equiv) methamphetamine hcl tab 5 mg 2 QL methylphenidate hcl cap er 10 mg (cd) 2 QL methylphenidate hcl cap er 20 mg (cd) 2 QL methylphenidate hcl cap er 24hr 20 mg 2 QL (la) methylphenidate hcl cap er 24hr 30 mg 2 QL (la) methylphenidate hcl cap er 24hr 40 mg 2 QL (la) methylphenidate hcl cap er 30 mg (cd) 2 QL methylphenidate hcl cap er 40 mg (cd) 2 QL methylphenidate hcl cap er 50 mg (cd) 2 QL methylphenidate hcl cap er 60 mg (cd) 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

63

Drug Name methylphenidate hcl chew tab 2.5 mg methylphenidate hcl chew tab 5 mg methylphenidate hcl chew tab 10 mg methylphenidate hcl soln 5 mg/5ml methylphenidate hcl soln 10 mg/5ml methylphenidate hcl tab 5 mg methylphenidate hcl tab 10 mg methylphenidate hcl tab 20 mg methylphenidate hcl tab er 10 mg methylphenidate hcl tab er 24hr 18 mg methylphenidate hcl tab er 24hr 27 mg methylphenidate hcl tab er 24hr 36 mg methylphenidate hcl tab er 24hr 54 mg methylphenidate hcl tab er osmotic release (osm) 18 mg methylphenidate hcl tab er osmotic release (osm) 27 mg methylphenidate hcl tab er osmotic release (osm) 36 mg methylphenidate hcl tab er osmotic release (osm) 54 mg STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG STRATTERA CAP 100MG VYVANSE CAP 10MG VYVANSE CAP 20MG VYVANSE CAP 30MG VYVANSE CAP 40MG VYVANSE CAP 50MG VYVANSE CAP 60MG VYVANSE CAP 70MG FIBROMYALGIA LYRICA CAP 25MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG

Drug Tier Requirements/Limit 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2 QL 2

QL

2

QL

2

QL

4 4 4 4 4 4 4 4 4 4 4 4 4 4

QL QL QL QL QL QL QL PA; PA; PA; PA; PA; PA; PA;

QL QL QL QL QL QL QL

4 4 4 4 4 4 4

PA; PA; PA; PA; PA; PA; PA;

QL QL QL QL QL QL QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

64

Drug Name Drug Tier Requirements/Limit LYRICA CAP 300MG 4 PA; QL LYRICA SOL 20MG/ML 4 PA; QL SAVELLA MIS TITR PAK 4 PA; QL SAVELLA TAB 12.5MG 4 PA; QL SAVELLA TAB 25MG 4 PA; QL SAVELLA TAB 50MG 4 PA; QL SAVELLA TAB 100MG 4 PA; QL HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 mg 5 PA; QL tetrabenazine tab 25 mg 4 PA; QL XENAZINE TAB 12.5MG 5 PA; QL XENAZINE TAB 25MG 5 PA; QL HYPNOTICS, BENZODIAZEPINES estazolam tab 1 mg 2 estazolam tab 2 mg 2 flurazepam hcl cap 15 mg 2 flurazepam hcl cap 30 mg 2 midazolam hcl inj 2 mg/2ml (base 2 equivalent) midazolam hcl inj 5 mg/5ml (base 2 equivalent) midazolam hcl inj 5 mg/ml (base 2 equivalent) midazolam hcl inj 10 mg/2ml (base 2 equivalent) midazolam hcl inj 10 mg/10ml (base 2 equivalent) midazolam hcl inj 25 mg/5ml (base 2 equivalent) midazolam hcl inj 50 mg/10ml (base 2 equivalent) midazolam hcl syrup 2 mg/ml (base 2 equivalent) temazepam cap 7.5 mg 2 temazepam cap 15 mg 2 temazepam cap 22.5 mg 2 temazepam cap 30 mg 2 triazolam tab 0.25 mg 2 triazolam tab 0.125 mg 2 HYPNOTICS, NON-BENZODIAZEPINES AMYTAL SOD INJ 500MG 4 eszopiclone tab 1 mg 2 QL eszopiclone tab 2 mg 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

65

Drug Name Drug Tier eszopiclone tab 3 mg 2 HETLIOZ CAP 20MG 5 zaleplon cap 5 mg 2 zaleplon cap 10 mg 2 zolpidem tartrate tab 5 mg 2 zolpidem tartrate tab 10 mg 2 MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate nasal 2 spray 4 mg/ml MIGRAINE, MISCELLANEOUS isometheptene-dichloral2 acetaminophen cap 65-100-325 mg MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 2 almotriptan malate tab 12.5 mg 2 AXERT TAB 6.25MG 4 AXERT TAB 12.5MG 4 FROVA TAB 2.5MG 4 naratriptan hcl tab 1 mg (base equiv) 2 naratriptan hcl tab 2.5 mg (base equiv) 2 RELPAX TAB 20MG 4 RELPAX TAB 40MG 4 rizatriptan benzoate oral disintegrating 2 tab 5 mg (base eq) rizatriptan benzoate oral disintegrating 2 tab 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 equivalent) rizatriptan benzoate tab 10 mg (base 2 equivalent) sumatriptan nasal spray 5 mg/act 4 sumatriptan nasal spray 20 mg/act 4 sumatriptan succinate inj 6 mg/0.5ml 4 sumatriptan succinate solution auto4 injector 4 mg/0.5ml sumatriptan succinate solution auto4 injector 6 mg/0.5ml sumatriptan succinate solution 4 cartridge 4 mg/0.5ml sumatriptan succinate solution 4 cartridge 6 mg/0.5ml sumatriptan succinate solution prefilled 4 syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg 4

Requirements/Limit QL PA; QL QL QL QL QL

ST; ST; ST; ST; ST; QL QL ST; ST; QL

QL QL QL QL QL

QL QL

QL QL QL QL QL QL QL QL QL QL QL QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

66

Drug Name Drug Tier Requirements/Limit sumatriptan succinate tab 50 mg 4 QL sumatriptan succinate tab 100 mg 4 QL zolmitriptan orally disintegrating tab 2 QL 2.5 mg zolmitriptan orally disintegrating tab 5 2 QL mg zolmitriptan tab 2.5 mg 2 QL zolmitriptan tab 5 mg 2 QL ZOMIG SPR 2.5MG 4 QL ZOMIG SPR 5MG 4 QL MISCELLANEOUS BLOXIVERZ INJ 5MG/10ML 4 BLOXIVERZ INJ 10/10ML 4 BOTOX INJ 100UNIT 5 PA; QL BOTOX INJ 200UNIT 5 PA; QL caffeine & sodium benzoate inj 125-1252 mg/ml (500 mg/2ml) DYSPORT INJ 300UNIT 5 PA; QL DYSPORT INJ 500UNIT 5 PA; QL GUANIDINE TAB 125MG 2 neostigmine methylsulfate iv soln 5 4 mg/10 ml (0.5 mg/ml) neostigmine methylsulfate iv soln 10 4 mg/10 ml (1 mg/ml) REGONOL INJ 5MG/ML 4 riluzole tab 50 mg 5 PA; QL XEOMIN INJ 50 UNIT 5 PA; QL XEOMIN INJ 100UNIT 5 PA; QL XEOMIN INJ 200UNIT 5 PA; QL MOOD STABILIZERS lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg 2 lithium carbonate tab 300 mg 2 lithium carbonate tab er 300 mg 2 lithium carbonate tab er 450 mg 2 LITHIUM SOL 8MEQ/5ML 2 MULTIPLE SCLEROSIS AMPYRA TAB 10MG 5 PA; QL AUBAGIO TAB 7MG 5 PA; QL AUBAGIO TAB 14MG 5 PA; QL BETASERON INJ 0.3MG 5 ST; QL COPAXONE INJ 20MG/ML 5 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

67

Drug Name Drug Tier Requirements/Limit COPAXONE INJ 40MG/ML 5 QL GILENYA CAP 0.5MG 5 PA; QL LEMTRADA INJ 12/1.2ML 5 PA REBIF INJ 22/0.5 5 PA, ST; QL REBIF INJ 44/0.5 5 PA, ST; QL REBIF REBIDO INJ 22/0.5 5 PA, ST; QL REBIF REBIDO INJ 44/0.5 5 PA, ST; QL REBIF REBIDO INJ TITRATN 5 PA, ST; QL REBIF TITRTN INJ PACK 5 PA, ST; QL TECFIDERA CAP 120MG 5 PA; QL TECFIDERA CAP 240MG 5 PA; QL TECFIDERA MIS STARTER 5 PA; QL TYSABRI INJ 300/15ML 5 PA; QL ZINBRYTA INJ 150MG/ML 5 PA; QL MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg 2 baclofen tab 20 mg 2 carisoprodol tab 250 mg 2 QL carisoprodol tab 350 mg 2 QL carisoprodol w/ aspirin & codeine tab 2 200-325-16 mg carisoprodol w/ aspirin tab 200-325 mg 2 chlorzoxazone tab 500 mg 2 cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 10 mg 1 dantrolene sodium cap 25 mg 2 dantrolene sodium cap 50 mg 2 dantrolene sodium cap 100 mg 2 dantrolene sodium for iv soln 20 mg 2 GABLOFEN INJ 10000/20 4 GABLOFEN INJ 20000/20 4 GABLOFEN INJ 40000/20 4 LIORESAL INT INJ 0.05MG/1 4 LIORESAL INT INJ 10MG/5ML 4 LIORESAL INT INJ 10MG/20 4 LIORESAL INT INJ 40MG/20 4 metaxalone tab 800 mg 2 methocarbamol inj 1000 mg/10ml 2 methocarbamol tab 500 mg 2 methocarbamol tab 750 mg 2 orphenadrine citrate inj 30 mg/ml 2 orphenadrine citrate tab er 12hr 100 2 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

68

Drug Name Drug Tier Requirements/Limit tizanidine hcl tab 2 mg (base 2 equivalent) tizanidine hcl tab 4 mg (base 2 equivalent) MYASTHENIA GRAVIS ENLON INJ 150/15ML 4 MESTINON SYP 60MG/5ML 3 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab er 180 mg 5 NARCOLEPSY/CATAPLEXY armodafinil tab 50 mg 4 PA; QL armodafinil tab 150 mg 4 PA; QL armodafinil tab 200 mg 4 PA; QL armodafinil tab 250 mg 4 PA; QL modafinil tab 100 mg 4 PA; QL modafinil tab 200 mg 4 PA; QL NUVIGIL TAB 50MG 4 PA; QL NUVIGIL TAB 150MG 4 PA; QL NUVIGIL TAB 200MG 4 PA; QL NUVIGIL TAB 250MG 4 PA; QL PROVIGIL TAB 100MG 4 PA; QL PROVIGIL TAB 200MG 4 PA; QL XYREM SOL 500MG/ML 5 PA; QL NONDEPOLARIZING MUSCLE RELAXANTS ANECTINE INJ 20MG/ML 2 POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 4 PA; QL GRALISE TAB 300MG 4 PA; QL GRALISE TAB 600MG 4 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed 2 release 333 mg disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 VIVITROL INJ 380MG 5 PA PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST EVZIO INJ 4 PA; QL naloxone hcl inj 0.4 mg/ml 2 naloxone hcl inj 4 mg/10ml 2 naloxone hcl soln cartridge 0.4 mg/ml 2 naloxone hcl soln prefilled syringe 2 2 mg/2ml naltrexone hcl tab 50 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

69

Drug Name Drug Tier Requirements/Limit NARCAN SPR 3 QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS BUNAVAIL MIS 2.1-0.3 4 PA; QL BUNAVAIL MIS 4.2-0.7 4 PA; QL BUNAVAIL MIS 6.3-1MG 4 PA; QL buprenorphine hcl-naloxone hcl sl tab 4 PA; QL 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 4 PA; QL 8-2 mg (base equiv) SUBOXONE MIS 2-0.5MG 3 PA; QL SUBOXONE MIS 4-1MG 3 PA; QL SUBOXONE MIS 8-2MG 3 PA; QL SUBOXONE MIS 12-3MG 3 PA; QL ZUBSOLV SUB 0.7-0.18 3 PA; QL ZUBSOLV SUB 1.4-0.36 3 PA; QL ZUBSOLV SUB 2.9-0.71 3 PA; QL ZUBSOLV SUB 5.7-1.4 3 PA; QL ZUBSOLV SUB 8.6-2.1 3 PA; QL ZUBSOLV SUB 11.4-2.9 3 PA; QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base 2 PA; QL equiv) buprenorphine hcl sl tab 8 mg (base 2 PA; QL equiv) PROBUPHINE IMP KIT 74.2 5 PA; QL PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 5 PA; QL PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab 2 er 12hr 150 mg NICOTROL INH 3 NICOTROL NS SPR 10MG/ML 3 ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR 4 PA ANDRODERM DIS 4MG/24HR 4 PA ANDROGEL GEL 1%(25MG) 3 PA ANDROGEL GEL 1.62% 3 PA ANDROGEL GEL PUMP 1% 3 PA AVEED INJ 750/3ML 4 PA AXIRON SOL 30MG/ACT 4 PA FORTESTA GEL 10MG/ACT 4 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

70

Drug Name Drug Tier Requirements/Limit methyltestosterone cap 10 mg 5 PA STRIANT MIS 30MG 4 PA TESTIM GEL 1%(50MG) 4 PA TESTOPEL MIS PELLETS 4 PA testosterone cypionate im inj in oil 100 2 PA mg/ml testosterone cypionate im inj in oil 200 2 PA mg/ml testosterone enanthate im inj in oil 200 2 PA mg/ml testosterone td gel 10mg/act (2%) 4 PA testosterone td gel 12.5 mg/act (1%) 4 PA testosterone td gel 25 mg/2.5gm (1%) 4 PA testosterone td gel 50 mg/5gm (1%) 4 PA TESTRED CAP 10MG 4 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg 2 acarbose tab 50 mg 2 acarbose tab 100 mg 2 GLYSET TAB 25MG 4 GLYSET TAB 50MG 4 GLYSET TAB 100MG 4 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3 ST; QL SYMLNPEN 120 INJ 1000MCG 3 ST; QL ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 2 glipizide-metformin hcl tab 2.5-500 mg 2 glipizide-metformin hcl tab 5-500 mg 2 glyburide-metformin tab 1.25-250 mg 2 glyburide-metformin tab 2.5-500 mg 2 glyburide-metformin tab 5-500 mg 2 ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab er 24hr 500 mg 2 metformin hcl tab er 24hr 750 mg 2 RIOMET SOL 4 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG 3 JANUMET TAB 50-1000 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

71

Drug Name Drug Tier Requirements/Limit JANUMET XR TAB 50-500MG 3 JANUMET XR TAB 50-1000 3 JANUMET XR TAB 100-1000 3 JENTADUETO TAB 2.5-500 3 JENTADUETO TAB 2.5-850 3 JENTADUETO TAB 2.5-1000 3 JENTADUETO TAB XR 3 QL ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 TRADJENTA TAB 5MG 3 QL ANTIDIABETICS, INCRETIN MIMETIC AGENTS TANZEUM INJ 30MG 4 ST; QL TANZEUM INJ 50MG 4 ST; QL TRULICITY INJ 0.75/0.5 3 QL TRULICITY INJ 1.5/0.5 3 QL VICTOZA INJ 18MG/3ML 3 QL ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab 15- 2 500 mg pioglitazone hcl-metformin hcl tab 15- 2 850 mg ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone hcl-glimepiride tab 30-2 2 mg pioglitazone hcl-glimepiride tab 30-4 2 mg ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl tab 15 mg (base equiv) 2 pioglitazone hcl tab 30 mg (base equiv) 2 pioglitazone hcl tab 45 mg (base equiv) 2 ANTIDIABETICS, INSULINS HUMULIN R INJ U-500 3 QL LANTUS INJ 100/ML 3 LANTUS INJ SOLOSTAR 3 LEVEMIR INJ 3 LEVEMIR INJ FLEXTOUC 3 NOVOLIN INJ 70/30 3 NOVOLIN N INJ U-100 3 NOVOLIN R INJ U-100 3 NOVOLOG INJ 100/ML 3 QL NOVOLOG INJ FLEXPEN 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

72

Drug Name Drug Tier Requirements/Limit NOVOLOG INJ PENFILL 3 QL NOVOLOG MIX INJ 70/30 3 QL NOVOLOG MIX INJ FLEXPEN 3 QL TOUJEO SOLO INJ 300IU/ML 3 TRESIBA FLEX INJ 100UNIT 3 QL TRESIBA FLEX INJ 200UNIT 3 QL ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg 2 nateglinide tab 120 mg 2 repaglinide tab 0.5 mg 2 repaglinide tab 1 mg 2 repaglinide tab 2 mg 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 2 mg repaglinide-metformin hcl tab 2-500 2 mg ANTIDIABETICS, MISCELLANEOUS CYCLOSET TAB 0.8MG 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG 3 QL INVOKAMET TAB 50-1000 3 QL INVOKAMET TAB 150-500 3 QL INVOKAMET TAB 150-1000 3 QL SYNJARDY TAB 3 SYNJARDY TAB 5-500MG 3 SYNJARDY TAB 5-1000MG 3 SYNJARDY TAB 12.5-500 3 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TAB 100MG 3 QL INVOKANA TAB 300MG 3 QL JARDIANCE TAB 10MG 3 QL JARDIANCE TAB 25MG 3 QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG 3 QL GLYXAMBI TAB 25-5 MG 3 QL ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg 2 chlorpropamide tab 250 mg 2 glimepiride tab 1 mg 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

73

Drug Name glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide tab er 24hr 2.5 mg glipizide tab er 24hr 5 mg glipizide tab er 24hr 10 mg glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg tolbutamide tab 500 mg ANTIDIABETICS, SUPPLIES AUTOPEN MIS 1 UNIT AUTOPEN MIS 1-21UNIT AUTOPEN MIS 2 UNIT AUTOPEN MIS 2-32UNIT AUTOPEN MIS 2-42UNIT AUTOSHIELD MIS 29X3/16" BD PEN MINI MIS BD PEN NEEDL MIS 29GX1/2" BD PEN NEEDL MIS 31GX3/16 BD PEN NEEDL MIS 31GX5/16 BD PEN NEEDL MIS 32GX4MM CONTROL KIT MONITOR EASY TOUCH MIS 32GX5MM INSULIN PEN MIS 29GX12MM INSULIN SYRG MIS 0.3/28G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/31G INSULIN SYRG MIS 0.5/27G INSULIN SYRG MIS 0.5/28G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/31G INSULIN SYRG MIS 1ML

Drug Tier Requirements/Limit 1 1 1 1 2 2 2 2 1 1 1 1 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

74

Drug Name INSULIN SYRG MIS 1ML INSULIN SYRG MIS 1ML/25G INSULIN SYRG MIS 1ML/28G INSULIN SYRG MIS 1ML/29G INSULIN SYRG MIS 1ML/29G INSULIN SYRG MIS 1ML/30G INSULIN SYRG MIS 1ML/30G INSULIN SYRG MIS 1ML/31G INSULIN SYRG MIS 28GX1/2" INSUPEN SENS MIS 32GX6MM INSUPEN SENS MIS 32GX8MM LANCET CARRY MIS CASE LANCETS MIS LANCING DEVI MIS MULTI-LANCET KIT DEVICE NOVOFINE MIS 30GX8MM NOVOTWIST MIS 32GX5MM ONETOUCH KIT ULT MINI ONETOUCH KIT ULTRA 2 ONETOUCH KIT ULTRALNK ONETOUCH KIT VERIO ONETOUCH KIT VERIO FL ONETOUCH KIT VERIO IQ ONETOUCH TES ULTRA BL ONETOUCH TES VERIO PEN NEEDLES MIS 31GX6MM SURESTEP PRO TES HIGH CON SURESTEP PRO TES NORM CON 1ST TIER UNI MIS 29GX12MM ULTRAFLEX II MIS 31"/8MM ULTRAFLEX MIS 24"/10MM V-GO 20 KIT V-GO 30 KIT V-GO 40 KIT ANTIDOTES acetylcysteine inj 200 mg/ml CETYLEV TAB 2.5GM CETYLEV TAB 500MG DIGIFAB INJ 40MG flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) flumazenil iv soln 1 mg/10ml (0.1 mg/ml)

Drug Tier Requirements/Limit 3 3 3 3 3 3 3 3 3 3 3 3 QL 3 QL 3 3 3 3 3 3 3 3 3 3 3 QL 3 QL 3 3 4 3 4 4 4 PA 4 PA 4 PA 2 4 4 4 2

PA PA

2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

75

Drug Name Drug Tier fomepizole inj 1 gm/ml (for iv infusion) 2 PHYSOS SALIC INJ 1MG/ML 2 PROTOPAM CHL INJ 1GM 4 sodium thiosulfate inj 25% 2 CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 3 SENSIPAR TAB 60MG 3 SENSIPAR TAB 90MG 3 CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium oral soln 70 2 mg/75ml alendronate sodium tab 5 mg 2 alendronate sodium tab 10 mg 2 alendronate sodium tab 35 mg 2 alendronate sodium tab 40 mg 2 alendronate sodium tab 70 mg 1 BONIVA INJ 3MG/3ML 5 BONIVA TAB 150MG 4 etidronate disodium tab 400 mg 2 ibandronate sodium iv soln 3 mg/3ml 5 (base equivalent) ibandronate sodium tab 150 mg (base 2 equivalent) pamidronate disodium for inj 30 mg 2 pamidronate disodium for inj 90 mg 2 pamidronate disodium iv soln 3 mg/ml 2 pamidronate disodium iv soln 9 mg/ml 2 PAMIDRONATE INJ 6MG/ML 2 risedronate sodium tab 5 mg 2 risedronate sodium tab 30 mg 2 risedronate sodium tab 35 mg 2 risedronate sodium tab 150 mg 2 risedronate sodium tab delayed release 2 35 mg zoledronic acid inj conc for iv infusion 4 5 mg/5ml zoledronic acid iv soln 5 mg/100ml 5 ZOLEDRONIC INJ 4MG 5 ZOMETA INJ 4MG/100 5 CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 2 unit/act MIACALCIN INJ 200/ML 4

Requirements/Limit

QL

ST; QL QL ST; QL QL

ST; ST; ST; ST; ST;

QL QL QL QL QL

QL ST; QL QL ST; QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

76

Drug Name Drug Tier Requirements/Limit MIACALCIN SPR 200/ACT 4 CALCIUM REGULATORS, MISCELLANEOUS PROLIA SOL 60MG/ML 5 PA; QL XGEVA INJ 5 PA; QL CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 5 ST; QL NATPARA INJ 25MCG 5 PA; QL NATPARA INJ 50MCG 5 PA; QL NATPARA INJ 75MCG 5 PA; QL NATPARA INJ 100MCG 5 PA; QL CONTRACEPTIVES, BIPHASIC MIRCETTE TAB 28 DAY 4 CONTRACEPTIVES, EXTENDED CYCLE LOSEASONIQUE TAB 4 SEASONIQUE TAB 4 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA INJ 150MG/ML 4 QL CONTRACEPTIVES, MONOPHASIC BEYAZ TAB 4 LO LOESTRIN TAB 3 ENDOMETRIOSIS danazol cap 50 mg 2 PA danazol cap 100 mg 2 PA danazol cap 200 mg 2 PA LUPANETA KIT 3.75-5 5 PA; QL LUPANETA KIT 11.25-5 5 PA; QL SYNAREL SOL 2MG/ML 5 PA; QL ESTROGEN/PROGESTIN, ORAL ANGELIQ TAB 0.5-1MG 4 estradiol & norethindrone acetate tab 2 0.5-0.1 mg estradiol & norethindrone acetate tab 2 1-0.5 mg norethindrone acetate-ethinyl estradiol 2 tab 0.5 mg-2.5 mcg norethindrone acetate-ethinyl estradiol 2 tab 1 mg-5 mcg PREFEST TAB 4 PREMPHASE TAB 3 PREMPRO TAB 0.3-1.5 3 PREMPRO TAB 0.45-1.5 3 PREMPRO TAB 0.625-5 3 PREMPRO TAB .625-2.5 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

77

Drug Name Drug Tier Requirements/Limit ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO DIS WEEKLY 4 QL COMBIPATCH DIS .05/.14 4 QL COMBIPATCH DIS .05/.25 4 QL ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE TAB 0.45-20 3 ESTROGENS, INJECTABLE DEPO-ESTRADI INJ 5MG/ML 4 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 PREMARIN INJ 25MG 4 ESTROGENS, ORAL estradiol tab 0.5 mg 1 estradiol tab 1 mg 1 estradiol tab 2 mg 1 estropipate tab 0.75 mg 2 estropipate tab 1.5 mg 2 estropipate tab 3 mg 2 MENEST TAB 0.3MG 4 MENEST TAB 0.625MG 4 MENEST TAB 1.25MG 4 MENEST TAB 2.5MG 4 PREMARIN TAB 0.3MG 3 PREMARIN TAB 0.9MG 3 PREMARIN TAB 0.45MG 3 PREMARIN TAB 0.625MG 3 PREMARIN TAB 1.25MG 3 ESTROGENS, TRANSDERMAL ALORA DIS 0.1MG 4 QL ALORA DIS 0.05MG 4 QL ALORA DIS 0.025MG 4 QL ALORA DIS 0.075MG 4 QL DIVIGEL GEL 0.5MG 4 DIVIGEL GEL 0.25MG 4 DIVIGEL GEL 1MG/GM 4 estradiol td patch twice weekly 0.1 2 QL mg/24hr estradiol td patch twice weekly 0.05 2 QL mg/24hr estradiol td patch twice weekly 0.025 2 QL mg/24hr PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

78

Drug Name Drug Tier Requirements/Limit estradiol td patch twice weekly 0.075 2 QL mg/24hr estradiol td patch twice weekly 0.0375 2 QL mg/24hr estradiol td patch weekly 0.1 mg/24hr 2 QL estradiol td patch weekly 0.05 mg/24hr 2 QL estradiol td patch weekly 0.06 mg/24hr 2 QL estradiol td patch weekly 0.025 2 QL mg/24hr estradiol td patch weekly 0.075 2 QL mg/24hr estradiol td patch weekly 0.0375 2 QL mg/24hr (37.5 mcg/24hr) ESTROGEL GEL 4 QL EVAMIST SPR 1.53MG 4 MENOSTAR DIS 14MCG 4 QL MINIVELLE DIS 0.1MG 4 QL MINIVELLE DIS 0.05MG 4 QL MINIVELLE DIS 0.025MG 4 QL MINIVELLE DIS 0.075MG 4 QL MINIVELLE DIS 0.0375MG 4 QL ESTROGENS, VAGINAL ESTRACE VAG CRE 0.1MG/GM 4 ESTRING MIS 2MG 4 FEMRING MIS 0.1MG/24 4 FEMRING MIS 0.05/24H 4 PREMARIN VAG CRE 0.625MG 3 VAGIFEM TAB 10MCG 4 GLUCOCORTICOID COMBINATIONS CELESTONE INJ SOLUSPAN 4 GLUCOCORTICOIDS CORTEF TAB 5MG 4 CORTEF TAB 10MG 4 CORTEF TAB 20MG 4 cortisone acetate tab 25 mg 2 DEPO-MEDROL INJ 20MG/ML 4 DEPO-MEDROL INJ 40MG/ML 4 DEPO-MEDROL INJ 80MG/ML 4 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone sod phosphate 2 preservative free inj 10 mg/ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

79

Drug Name Drug Tier Requirements/Limit dexamethasone sodium phosphate inj 4 2 mg/ml dexamethasone sodium phosphate inj 2 10 mg/ml dexamethasone sodium phosphate inj 2 20 mg/5ml dexamethasone sodium phosphate inj 2 100 mg/10ml dexamethasone sodium phosphate inj 2 120 mg/30ml dexamethasone soln 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK PAK 6 DAY 3 DEXPAK PAK 10 DAY 3 DEXPAK PAK 13 DAY 3 fludrocortisone acetate tab 0.1 mg 2 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 KENALOG-10 INJ 10MG/ML 4 KENALOG-40 INJ 40MG/ML 4 METHYLPRD PF INJ 40MG/ML 4 METHYLPRD PF INJ 80MG/ML 4 methylprednisolone acetate inj susp 40 2 mg/ml methylprednisolone acetate inj susp 80 2 mg/ml methylprednisolone sod succ for inj 40 2 mg (base equiv) methylprednisolone sod succ for inj 125 2 mg (base equiv) methylprednisolone sod succ for inj 2 1000 mg (base equiv) methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

80

Drug Name Drug Tier Requirements/Limit methylprednisolone tab therapy pack 4 2 mg (21) MILLIPRED DP PAK 5MG 2 prednisolone sod phosph oral soln 6.7 2 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 2 10 mg/5ml (base equiv) prednisolone sod phosphate oral soln 2 15 mg/5ml (base equiv) prednisolone sod phosphate oral soln 2 20 mg/5ml (base equiv) prednisolone sodium phosphate oral 2 soln 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 2 solution equivalent) prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 prednisone tab 50 mg 2 SOLU-CORTEF INJ 100MG 4 SOLU-CORTEF INJ 250MG 4 SOLU-CORTEF INJ 500MG 4 SOLU-CORTEF INJ 1000MG 4 SOLU-MEDROL INJ 1GM 4 SOLU-MEDROL INJ 2GM 4 SOLU-MEDROL INJ 40MG 4 SOLU-MEDROL INJ 125MG 4 SOLU-MEDROL INJ 500MG 4 GLUCOSE ELEVATING AGENT GLUCAGEN INJ 1MG 3 QL GLUCAGEN INJ HYPOKIT 3 QL GLUCAGON KIT 1MG 3 QL PROGLYCEM SUS 50MG/ML 3 HUMAN GROWTH HORMONES HUMATROPE INJ 5MG 5 PA HUMATROPE INJ 6MG 5 PA HUMATROPE INJ 12MG 5 PA HUMATROPE INJ 24MG 5 PA SEROSTIM INJ 4MG 5 PA SEROSTIM INJ 5MG 5 PA SEROSTIM INJ 6MG 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 81

Drug Name Drug Tier Requirements/Limit HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 2 calcitriol cap 0.25 mcg 2 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 doxercalciferol cap 0.5 mcg 2 doxercalciferol cap 1 mcg 2 doxercalciferol cap 2.5 mcg 2 doxercalciferol inj 4 mcg/2ml (2 2 mcg/ml) HECTOROL CAP 0.5MCG 4 HECTOROL CAP 1MCG 4 HECTOROL CAP 2.5MCG 4 HECTOROL INJ 2MCG/ML 3 HECTOROL INJ 4MCG/2ML 4 paricalcitol cap 1 mcg 2 paricalcitol cap 2 mcg 2 paricalcitol cap 4 mcg 2 paricalcitol iv soln 2 mcg/ml 4 paricalcitol iv soln 5 mcg/ml 4 ROCALTROL CAP 0.5MCG 4 ROCALTROL CAP 0.25MCG 4 ROCALTROL SOL 1MCG/ML 4 ZEMPLAR CAP 1MCG 4 ZEMPLAR CAP 2MCG 4 ZEMPLAR INJ 2MCG/ML 4 ZEMPLAR INJ 5MCG/ML 4 INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 5 PA LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 5 PA CEREZYME INJ 400UNIT 5 PA ELAPRASE INJ 6MG/3ML 5 PA ELELYSO INJ 200UNIT 5 PA FABRAZYME INJ 5MG 5 PA FABRAZYME INJ 35MG 5 PA NAGLAZYME INJ 1MG/ML 5 PA VIMIZIM INJ 5MG/5ML 5 PA VPRIV INJ 400UNIT 5 PA ZAVESCA CAP 100MG 5 PA MISCELLANEOUS ADAGEN INJ 250/ML 5 PA AMMONUL INJ 10% 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

82

Drug Name cabergoline tab 0.5 mg CARBAGLU TAB 200MG CERVIDIL VAG MIS 10MG INS CYSTADANE POW H.P. ACTHAR INJ 80UNIT HEMABATE INJ 250MCG KANUMA INJ 20/10ML KORLYM TAB 300MG levocarnitine inj 200 mg/ml levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg LUPR DEP-PED INJ 3M 30MG LUPR DEP-PED INJ 7.5MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG methylergonovine maleate inj 0.2 mg/ml MYALEPT INJ 11.3MG octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN CAP 10MG ORFADIN SUS 4MG/ML oxytocin inj 10 unit/ml PITOCIN INJ 10UNT/ML PREPIDIL GEL 0.5MG/3G PROSTIN E2 SUP 20MG RAVICTI LIQ 1.1GM/ML SANDOSTATIN INJ 50MCG/ML SANDOSTATIN INJ 100MCG SANDOSTATIN INJ 200MCG SANDOSTATIN INJ 500MCG SANDOSTATIN INJ 1000MCG SANDOSTATIN KIT LAR 10MG

Drug Tier Requirements/Limit 2 5 PA 3 5 PA 5 PA; QL 4 5 5 PA; QL 2 2 2 5 5 5 5 4 5 5

PA; PA; PA; PA;

QL QL QL QL

PA; QL

5 5 5 5 5 5 5 5 2 4 3 3 5 5 5 5 5 5 5

PA PA PA PA

PA; QL

PA; QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

83

Drug Name Drug Tier Requirements/Limit SANDOSTATIN KIT LAR 20MG 5 PA; QL SANDOSTATIN KIT LAR 30MG 5 PA; QL SIGNIFOR INJ 0.3MG/ML 5 PA; QL SIGNIFOR INJ 0.6MG/ML 5 PA; QL SIGNIFOR INJ 0.9MG/ML 5 PA; QL SIGNIFOR LAR INJ 20MG 5 PA; QL SIGNIFOR LAR INJ 40MG 5 PA; QL SIGNIFOR LAR INJ 60MG 5 PA; QL SOMATULINE INJ 60/0.2ML 5 PA; QL SOMATULINE INJ 90/0.3ML 5 PA; QL SOMATULINE INJ 120/.5ML 5 PA; QL SOMAVERT INJ 10MG 5 PA; QL SOMAVERT INJ 15MG 5 PA; QL SOMAVERT INJ 20MG 5 PA; QL SOMAVERT INJ 25MG 5 PA; QL SOMAVERT INJ 30MG 5 PA; QL STRENSIQ INJ 18/0.45 5 PA STRENSIQ INJ 28/0.7ML 5 PA STRENSIQ INJ 40MG/ML 5 PA STRENSIQ INJ 80/0.8ML 5 PA SUPPRELIN LA KIT 50MG 5 PA; QL SYPRINE CAP 250MG 5 PA THYROGEN INJ 1.1MG 5 PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG 5 PA KUVAN POW 500MG 5 PA KUVAN TAB 100MG 5 PA PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG 3 calcium acetate (phosphate binder) cap 2 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 2 667 mg RENAGEL TAB 400MG 5 RENAGEL TAB 800MG 5 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML 5 PA PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 1 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

84

Drug Name Drug Tier Requirements/Limit medroxyprogesterone acetate tab 5 mg 1 medroxyprogesterone acetate tab 10 1 mg norethindrone acetate tab 5 mg 2 progesterone micronized cap 100 mg 2 progesterone micronized cap 200 mg 2 PROGESTINS, VAGINAL CRINONE GEL 4% VAG 3 ENDOMETRIN SUP 100MG 4 THYROID AGENTS, ANTITHYROID AGENTS iodine solution strong 5% (lugol's) 2 methimazole tab 5 mg 2 methimazole tab 10 mg 2 propylthiouracil tab 50 mg 2 SSKI SOL 1GM/ML 2 THYROID SUPPLEMENTS CYTOMEL TAB 5MCG 4 CYTOMEL TAB 25MCG 4 CYTOMEL TAB 50MCG 4 LEVOTHYROXIN INJ 200MCG 2 levothyroxine sodium for iv inj 100 mcg 2 levothyroxine sodium for iv inj 500 mcg 2 levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 300 mcg 2 liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 50 mcg 2 NATURE THROI TAB 162.5MG 2 NATURE-THROI TAB 16.25MG 4 NATURE-THROI TAB 32.5MG 2 NATURE-THROI TAB 48.75MG 4 NATURE-THROI TAB 81.25MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

85

Drug Name Drug Tier Requirements/Limit NATURE-THROI TAB 97.5MG 2 NATURE-THROI TAB 113.75MG 4 NATURE-THROI TAB 130MG 2 NATURE-THROI TAB 146.25MG 4 NATURE-THROI TAB 195MG 2 NATURE-THROI TAB 260MG 2 NATURE-THROI TAB 325MG 2 SYNTHROID TAB 25MCG 4 SYNTHROID TAB 50MCG 4 SYNTHROID TAB 75MCG 4 SYNTHROID TAB 88MCG 4 SYNTHROID TAB 100MCG 4 SYNTHROID TAB 112MCG 4 SYNTHROID TAB 125MCG 4 SYNTHROID TAB 137MCG 4 SYNTHROID TAB 150MCG 4 SYNTHROID TAB 175MCG 4 SYNTHROID TAB 200MCG 4 SYNTHROID TAB 300MCG 4 THYROLAR-1 TAB 60MG 3 THYROLAR-1/2 TAB 30MG 3 THYROLAR-1/4 TAB 15MG 3 THYROLAR-2 TAB 120MG 3 THYROLAR-3 TAB 180MG 3 TIROSINT CAP 13MCG 4 TIROSINT CAP 25MCG 4 TIROSINT CAP 50MCG 4 TIROSINT CAP 75MCG 4 TIROSINT CAP 88MCG 4 TIROSINT CAP 100MCG 4 TIROSINT CAP 112MCG 4 TIROSINT CAP 125MCG 4 TIROSINT CAP 137MCG 4 TIROSINT CAP 150MCG 4 TRIOSTAT INJ 10MCG/ML 4 WESTHROID TAB 32.5MG 2 WESTHROID TAB 97.5MG 2 WESTHROID TAB 130MG 2 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 5 PA; QL SAMSCA TAB 30MG 5 PA; QL VASOPRESSINS desmopressin acetate inj 4 mcg/ml 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

86

Drug Name Drug Tier Requirements/Limit desmopressin acetate nasal soln 0.01% 5 (refrigerated) desmopressin acetate nasal spray soln 5 0.01% desmopressin acetate nasal spray soln 5 0.01% (refrigerated) desmopressin acetate tab 0.1 mg 2 desmopressin acetate tab 0.2 mg 2 STIMATE SOL 1.5MG/ML 5 GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine liq 2.5-0.025 2 mg/5ml diphenoxylate w/ atropine tab 2.52 0.025 mg loperamide hcl cap 2 mg 2 ANTIEMETICS AKYNZEO CAP 300-0.5 4 QL ALOXI INJ 0.25MG/5 4 ST aprepitant capsule 40 mg 3 QL aprepitant capsule 80 mg 3 QL aprepitant capsule 125 mg 3 QL aprepitant capsule therapy pack 80 & 3 QL 125 mg CESAMET CAP 1MG 3 DIMENHYDRIN INJ 50MG/ML 2 dronabinol cap 2.5 mg 2 dronabinol cap 5 mg 2 dronabinol cap 10 mg 2 droperidol inj 2.5 mg/ml 2 EMEND CAP 40MG 3 QL EMEND CAP 80MG 3 QL EMEND CAP 125MG 3 QL EMEND SOL 150MG 4 QL EMEND TRIPAC PAK 80 & 125 3 QL granisetron hcl inj 0.1 mg/ml 2 ST; QL granisetron hcl inj 1 mg/ml 2 ST; QL granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 ST; QL granisetron hcl tab 1 mg 2 ST; QL meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 metoclopramide hcl inj 5 mg/ml 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

87

Drug Name metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg metoclopramide hcl tab 10 mg ondansetron hcl inj 4 mg/2ml (2 mg/ml) ondansetron hcl inj 40 mg/20ml (2 mg/ml) ondansetron hcl oral soln 4 mg/5ml ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron hcl tab 24 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg prochlorperazine edisylate inj 5 mg/ml prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine suppos 25 mg promethazine hcl inj 25 mg/ml promethazine hcl inj 50 mg/ml promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg SANCUSO DIS 3.1MG TIGAN INJ 100MG/ML TRANSDERM-SC DIS 1.5MG trimethobenzamide hcl cap 300 mg ANTISPASMODICS BELLA/OPIUM SUP 16.2-30 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg CUVPOSA SOL 1MG/5ML dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg GLYCOPYRROLA INJ 1MG/5ML

Drug Tier Requirements/Limit 1 1 1 2 2 2 2 2 2 2

QL QL QL QL

2

QL

2 1 1 2 2 2 2 2 2 1 2 1 2 4 4 4 2

ST; QL

2 2 4 1 2 1 2

PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

88

Drug Name Drug Tier Requirements/Limit glycopyrrolate inj 0.2 mg/ml 2 glycopyrrolate inj 0.4 mg/2ml (0.2 2 mg/ml) glycopyrrolate inj 1 mg/5ml (0.2 2 mg/ml) glycopyrrolate inj 4 mg/20ml (0.2 2 mg/ml) glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2 hyoscyamine sulfate elixir 0.125 2 mg/5ml hyoscyamine sulfate soln 0.125 mg/ml 2 hyoscyamine sulfate tab 0.125 mg 2 hyoscyamine sulfate tab disint 0.125 2 mg hyoscyamine sulfate tab er 12hr 0.375 2 mg hyoscyamine sulfate tab sl 0.125 mg 2 LEVSIN INJ 0.5MG/ML 4 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 propantheline bromide tab 15 mg 2 SYMAX DUOTAB TAB 4 CHOLELITHOLYTICS ursodiol cap 300 mg 2 ursodiol tab 250 mg 2 ursodiol tab 500 mg 2 INFLAMMATORY BOWEL DISEASE, INJECTABLE AGENTS ENTYVIO INJ 300MG 5 PA; QL INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM 3 ASACOL HD TAB 800MG 3 balsalazide disodium cap 750 mg 2 budesonide delayed release particles 2 cap 3 mg DELZICOL CAP 400MG 3 DIPENTUM CAP 250MG 4 ST GIAZO TAB 1.1GM 4 LIALDA TAB 1.2GM 4 ST PENTASA CAP 250MG CR 4 PENTASA CAP 500MG CR 4 sulfasalazine tab 500 mg 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

89

Drug Name Drug Tier Requirements/Limit sulfasalazine tab delayed release 500 2 mg UCERIS TAB 9MG 5 PA INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 5 CORTIFOAM AER 90MG 4 hydrocortisone enema 100 mg/60ml 2 mesalamine enema 4 gm 2 UCERIS AER 2MG/ACT 5 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 4 QL AMITIZA CAP 24MCG 4 QL LINZESS CAP 72MCG 3 QL LINZESS CAP 145MCG 3 QL LINZESS CAP 290MCG 3 QL IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 4 PA; QL alosetron hcl tab 1 mg (base equiv) 4 PA; QL LOTRONEX TAB 0.5MG 4 PA; QL LOTRONEX TAB 1MG 4 PA; QL VIBERZI TAB 75MG 5 PA; QL VIBERZI TAB 100MG 5 PA; QL LAXATIVES/STOOL SOFTENERS GOLYTELY SOL 3 lactulose solution 10 gm/15ml 2 NULYTELY SOL FLAV PKS 3 OSMOPREP TAB 1.5GM 4 peg 3350-kcl-na bicarb-nacl-na sulfate 2 for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate 2 for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 2 420 gm polyethylene glycol 3350 oral powder 2 polyethylene glycol 3350 oral powder 2 MISCELLANEOUS BUPHENYL POW 4 PA BUPHENYL TAB 500MG 4 PA CARAFATE SUS 1GM/10ML 3 cromolyn sodium oral conc 100 mg/5ml 2 GASTROCROM CON 100/5ML 3 GATTEX KIT 5MG 5 PA; QL KEPIVANCE INJ 6.25MG 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

90

Drug Name lactulose (encephalopathy) solution 10 gm/15ml OCALIVA TAB 5MG OCALIVA TAB 10MG RECTIV OIN 0.4% sodium phenylbutyrate oral powder 3 gm/teaspoonful SUCRAID SOL 8500/ML sucralfate tab 1 gm OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG PANCREATIC ENZYMES CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 36000UNT PANCREAZE CAP 4200UNIT PANCREAZE CAP 10500UNT PANCREAZE CAP 16800UNT PANCREAZE CAP 21000UNT PERTZYE CAP VIOKACE TAB VIOKACE TAB 20880 ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 40000UNT PROSTAGLANDINS misoprostol tab 100 mcg misoprostol tab 200 mcg SALIVA STIMULANTS cevimeline hcl cap 30 mg pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg STEROIDS, RECTAL EPIFOAM AER 1% hydrocortisone acetate suppos 25 mg hydrocortisone acetate suppos 30 mg

Drug Tier Requirements/Limit 2 5 5 4 4

PA PA PA PA

5 2

PA

3 3

QL QL

3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4

ST ST ST ST ST ST ST ST ST ST ST ST ST ST

2 2 2 2 2 4 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

91

Drug Name hydrocortisone acetate w/ pramoxine rectal cream 1-1% hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% hydrocortisone rectal cream 1% hydrocortisone rectal cream 2.5% lidocaine-hydrocortisone acetate rectal cream 3-0.5% lidocaine-hydrocortisone acetate rectal cream kit 2-2% lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal cream kit 3-1% lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% PROCTOFOAM AER HC 1% ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack OMECLAMOX- MIS PAK GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg CARDURA XL TAB 4MG CARDURA XL TAB 8MG dutasteride cap 0.5 mg dutasteride-tamsulosin hcl cap 0.5-0.4 mg finasteride tab 5 mg RAPAFLO CAP 4MG RAPAFLO CAP 8MG tamsulosin hcl cap 0.4 mg UROXATRAL TAB 10MG GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% glycine irrigation soln 1.5% neomycin-polymyxin b gu irrigation soln NEOSPORIN GU SOL 40/ML IR RESECTISOL SOL 5% sodium chloride irrigation soln 0.9% MISCELLANEOUS

Drug Tier Requirements/Limit 2 2 2 2 2 2 2 2 2 4 2 4

2 4 4 2 2 2 4 4 2 4

QL QL

ST ST

2 2 2 4 3 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

92

Drug Name acetic acid-oxyquinoline vaginal gel 0.9-0.025% bethanechol chloride tab 5 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 50 mg CYSTAGON CAP 50MG CYSTAGON CAP 150MG ELMIRON CAP 100MG FEM PH GEL mannitol iv soln 5% mannitol iv soln 25% methenamine hippurate tab 1 gm methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg ORACIT SOL phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg pot & sod citrates w/ cit ac soln 550500-334 mg/5ml potassium citrate & citric acid powder pack 3300-1002 mg potassium citrate & citric acid soln 1100-334 mg/5ml potassium citrate tab er 5 meq (540 mg) potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) PROCYSBI CAP 25MG PROCYSBI CAP 75MG RIMSO-50 SOL 50% SHOHLS SOL MODIFIED sodium citrate & citric acid soln 500334 mg/5ml THIOLA TAB 100MG PERITONEAL DIALYSIS SOLUTION DELFLEX-LC/ SOL 2.5% DEX URINARY ANTISPASMODICS MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg

Drug Tier Requirements/Limit 4 2 2 2 2 5 5 3 2 2 2 2 2

PA PA

3 2 2 2 2 2 2 2 2 5 5 3 3 2

PA; QL PA; QL

5 4 3 3 2 2

QL QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

93

Drug Name oxybutynin chloride tab er 24hr 5 mg oxybutynin chloride tab er 24hr 10 mg oxybutynin chloride tab er 24hr 15 mg tolterodine tartrate cap er 24hr 2 mg tolterodine tartrate cap er 24hr 4 mg tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg trospium chloride cap er 24hr 60 mg trospium chloride tab 20 mg VESICARE TAB 5MG VESICARE TAB 10MG VAGINAL ANTI-INFECTIVES CLEOCIN SUP 100MG clindamycin phosphate vaginal cream 2% GYNAZOLE-1 CRE 2% METROGEL-VAG GEL 0.75% metronidazole vaginal gel 0.75% terconazole vaginal suppos 80 mg HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ANGIOMAX INJ 250MG ARGATROBAN INJ 50MG/50M argatroban inj 250 mg/2.5ml (concentrate for iv infusion) ARGATROBAN INJ 250/250 bivalirudin for iv soln 250 mg enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 300 mg/3ml fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml fondaparinux sodium subcutaneous inj 10 mg/0.8ml

Drug Tier Requirements/Limit 2 2 2 2 2 2 2 2 2 3 3 3 2 4 3 2 2

4 4 4 4 2 2 2 2 2 2 2 2 2 5

QL

5

QL

5

QL

5

QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

94

Drug Name FRAGMIN INJ 2500/0.2 FRAGMIN INJ 5000/0.2 FRAGMIN INJ 7500/0.3 FRAGMIN INJ 10000/ML FRAGMIN INJ 12500UNT FRAGMIN INJ 15000UNT FRAGMIN INJ 18000UNT FRAGMIN INJ 95000UNT heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) inj 10000 unit/ml heparin sodium (porcine) inj 20000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml ANTICOAGULANTS, ORAL ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG warfarin sodium tab 1 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg warfarin sodium tab 10 mg XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG ANTIHEMOPHILIC AGENTS OBIZUR INJ 500 UNIT HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG ARANESP INJ 25MCG ARANESP INJ 40MCG ARANESP INJ 60MCG ARANESP INJ 100MCG ARANESP INJ 150MCG

Drug Tier Requirements/Limit 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL 2 2 2 2 2

3 3 1 1 1 1 1 1 1 1 1 3 3 3 3

QL QL

QL QL QL QL

4 5 5 5 5 5 5

PA PA PA PA PA PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

95

Drug Name Drug Tier ARANESP INJ 200MCG 5 ARANESP INJ 300MCG 5 ARANESP INJ 500MCG 5 EPOGEN INJ 2000/ML 5 EPOGEN INJ 3000/ML 5 EPOGEN INJ 4000/ML 5 EPOGEN INJ 10000/ML 5 EPOGEN INJ 20000/ML 5 GRANIX INJ 300/0.5 5 GRANIX INJ 480/0.8 5 LEUKINE INJ 250MCG 5 NEULASTA INJ 6MG/0.6M 5 NEUPOGEN INJ 300/0.5 5 NEUPOGEN INJ 300MCG 5 NEUPOGEN INJ 480/0.8 5 NEUPOGEN INJ 480MCG 5 PROCRIT INJ 40000/ML 5 ZARXIO INJ 300/0.5 5 ZARXIO INJ 480/0.8 5 HEMOSTATICS, SYSTEMIC aminocaproic acid inj 250 mg/ml 2 tranexamic acid iv soln 1000 mg/10ml 2 (100 mg/ml) tranexamic acid tab 650 mg 2 HEMOSTATICS, TOPICAL ASTRINGYN SOL 259MG/GM 3 AVITENE PAD 35X35MM 4 AVITENE POW FLOUR 4 AVITENE SYRG MIS 1GM 4 ENDO AVITENE MIS 5MM DIA 4 ENDO AVITENE MIS 10MM DIA 4 GELFOAM MIS DENTAL 4 4 GELFOAM MIS SPON COM 4 GELFOAM POW 4 MONSELS FERR SOL SUBSULF 4 THROMBIN-JMI KIT 20000UNT 4 HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 5 CINRYZE SOL 500 UNIT 5 FIRAZYR INJ 30MG/3ML 5 KALBITOR INJ 10MG/ML 5 RUCONEST INJ 2100UNIT 5 IDIOPATHIC THROMBOCYTOPENIC PURPURA

Requirements/Limit PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA

PA; QL

PA; QL PA; QL PA; QL PA PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

96

Drug Name Drug Tier Requirements/Limit NPLATE INJ 250MCG 5 PA NPLATE INJ 500MCG 5 PA PROMACTA TAB 12.5MG 5 PA; QL PROMACTA TAB 25MG 5 PA; QL PROMACTA TAB 50MG 5 PA; QL PROMACTA TAB 75MG 5 PA; QL MISCELLANEOUS ACD FORMULA SOL A 4 ACTIVASE INJ 50MG 4 ACTIVASE INJ 100MG 4 ANTICOAG CIT SOL DEX SOL 4 ANTICOAG CPD SOL 3 CATHFLO ACTI INJ VASE 4 CEPROTIN INJ 1000UNIT 4 CHEMET CAP 100MG 4 PA cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 deferoxamine mesylate for inj 2 gm 2 deferoxamine mesylate for inj 500 mg 2 DESFERAL INJ 2GM 5 DESFERAL INJ 500MG 5 EXJADE TAB 125MG 5 PA EXJADE TAB 250MG 5 PA EXJADE TAB 500MG 5 PA FERRIPROX SOL 100MG/ML 4 PA FERRIPROX TAB 500MG 5 PA JADENU TAB 90MG 5 PA JADENU TAB 180MG 5 PA JADENU TAB 360MG 5 PA NOCLOT-50 SOL ACD-A 4 pentoxifylline tab er 400 mg 2 protamine sulfate inj 10 mg/ml 2 THROMBAT III INJ 500UNIT 4 TRICITRASOL CON 4 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 5 PA PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG 4 aspirin-dipyridamole cap er 12hr 252 200 mg BRILINTA TAB 60MG 3 QL BRILINTA TAB 90MG 3 QL

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

97

Drug Name clopidogrel bisulfate tab 75 mg (base equiv) clopidogrel bisulfate tab 300 mg (base equiv) dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg EFFIENT TAB 5MG EFFIENT TAB 10MG REOPRO INJ 2MG/ML ZONTIVITY TAB 2.08MG PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg STEM CELL MOBILIZERS MOZOBIL INJ IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS ACTEMRA INJ 80MG/4ML ACTEMRA INJ 162/0.9 ACTEMRA INJ 200/10ML ACTEMRA INJ 400/20ML CIMZIA KIT CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ML COSENTYX INJ 150MG/ML COSENTYX PEN INJ 300DOSE ENBREL INJ 25/0.5ML ENBREL INJ 25MG ENBREL INJ 50MG/ML ENBREL SRCLK INJ 50MG/ML HUMIRA INJ 10MG/0.2 HUMIRA KIT 20MG/0.4 HUMIRA KIT 40MG/0.8 HUMIRA PEN INJ 40MG/0.8 KINERET INJ ORENCIA INJ 50/0.4 ORENCIA INJ 87.5/0.7 ORENCIA INJ 125MG/ML ORENCIA INJ 250MG REMICADE INJ 100MG SIMPONI ARIA SOL 50MG/4ML SIMPONI INJ 50/0.5ML

Drug Tier Requirements/Limit 1 2 2 2 2 3 3 4 4

QL QL PA; QL

2 2 5

PA; QL

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA; PA PA PA; PA;

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

QL QL 98

Drug Name Drug Tier Requirements/Limit SIMPONI INJ 100MG/ML 5 PA; QL STELARA INJ 5MG/ML 5 PA; QL STELARA INJ 45MG/0.5 5 PA; QL STELARA INJ 90MG/ML 5 PA; QL TALTZ INJ 80MG/ML 5 PA; QL XELJANZ TAB 5MG 5 PA; QL XELJANZ XR TAB 11MG 5 PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) DEPEN TITRA TAB 250MG 5 PA hydroxychloroquine sulfate tab 200 mg 2 leflunomide tab 10 mg 2 leflunomide tab 20 mg 2 OTREXUP INJ 7.5/0.4 5 PA; QL OTREXUP INJ 10MG 5 PA; QL OTREXUP INJ 12.5/0.4 5 QL OTREXUP INJ 15MG 5 PA; QL OTREXUP INJ 17.5/0.4 5 QL OTREXUP INJ 20MG 5 PA; QL OTREXUP INJ 22.5/0.4 5 QL OTREXUP INJ 25MG 5 PA; QL RASUVO INJ 7.5MG 5 PA; QL RASUVO INJ 10MG 5 PA; QL RASUVO INJ 12.5MG 5 PA; QL RASUVO INJ 15MG 5 PA; QL RASUVO INJ 17.5MG 5 PA; QL RASUVO INJ 20MG 5 PA; QL RASUVO INJ 22.5MG 5 PA; QL RASUVO INJ 25MG 5 PA; QL RASUVO INJ 27.5MG 5 PA; QL RASUVO INJ 30MG 5 PA; QL IMMUNE GLOBULINS ATGAM INJ 250MG 5 CARIMUNE NF INJ 6GM 5 PA CARIMUNE NF INJ 12GM 5 PA FLEBOGAMMA INJ 20/400ML 5 PA FLEBOGAMMA INJ DIF 5% 5 PA GAMASTAN S/D INJ 5 PA GAMMAGARD INJ 1GM/10ML 5 PA GAMMAGARD INJ 2.5GM/25 5 PA GAMMAGARD INJ 5GM/50ML 5 PA GAMMAGARD INJ 10GM/100 5 PA GAMMAGARD INJ 20GM/200 5 PA GAMMAGARD INJ 30GM/300 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

99

Drug Name Drug Tier Requirements/Limit GAMMAGARD SD INJ 5GM HU 5 PA GAMMAGARD SD INJ 10GM HU 5 PA GAMUNEX-C INJ 40/400ML 5 PA HIZENTRA INJ 1GM/5ML 5 PA HIZENTRA INJ 2GM/10ML 5 PA HIZENTRA INJ 4GM/20ML 5 PA HIZENTRA INJ 10/50ML 5 PA HYQVIA INJ 2.5-200 5 PA HYQVIA INJ 5-400 5 PA HYQVIA INJ 10-800 5 PA HYQVIA INJ 20-1600 5 PA HYQVIA INJ 30-2400 5 PA OCTAGAM INJ 1GM 5 PA OCTAGAM INJ 2.5GM 5 PA OCTAGAM INJ 2GM/20ML 5 PA OCTAGAM INJ 5GM 5 PA OCTAGAM INJ 10GM 5 PA OCTAGAM INJ 25GM 5 PA PRIVIGEN INJ 5 GRAMS 5 PA PRIVIGEN INJ 10GRAMS 5 PA PRIVIGEN INJ 20GRAMS 5 PA PRIVIGEN INJ 40GRAMS 5 PA THYMOGLOBULN INJ 25MG 5 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 5 PA ALFERON N INJ 5MU/ML 5 PA INTRON A INJ 10MU 5 PA INTRON A INJ 18MU 5 PA INTRON A INJ 25MU 5 PA INTRON A INJ 50MU 5 PA PEG-INTRON KIT 50MCG 5 PA; QL PEG-INTRON KIT 80MCG 5 PA; QL PEG-INTRON KIT 120MCG 5 PA; QL PEG-INTRON KIT 150MCG 5 PA; QL PEGASYS INJ 180MCG/M 5 PA; QL PEGASYS INJ PROCLICK 5 PA; QL SYLATRON KIT 200MCG 5 PA SYLATRON KIT 300MCG 5 PA SYLATRON KIT 600MCG 5 PA IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG 5 PA; QL ILARIS (150) INJ 180MG 5 PA; QL ILARIS INJ 150MG/ML 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

100

Drug Name Drug Tier Requirements/Limit OTEZLA TAB 10/20/30 5 PA; QL OTEZLA TAB 30MG 5 PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES azathioprine tab 50 mg 2 CELLCEPT CAP 250MG 4 CELLCEPT IV INJ 500MG 5 CELLCEPT SUS 200MG/ML 4 CELLCEPT TAB 500MG 4 mycophenolate mofetil cap 250 mg 2 mycophenolate mofetil for oral susp 2 200 mg/ml mycophenolate mofetil tab 500 mg 2 mycophenolate sodium tab dr 180 mg 2 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg 2 (mycophenolic acid equiv) IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine cap 25 mg 2 cyclosporine cap 100 mg 2 cyclosporine iv soln 50 mg/ml 2 cyclosporine modified cap 50 mg 2 cyclosporine modified oral soln 100 2 mg/ml NEORAL CAP 25MG 4 NEORAL CAP 100MG 4 NEORAL SOL 100MG/ML 4 PROGRAF CAP 0.5MG 4 PROGRAF CAP 1MG 4 PROGRAF CAP 5MG 4 PROGRAF INJ 5MG/ML 5 SANDIMMUNE CAP 25MG 4 SANDIMMUNE CAP 100MG 4 SANDIMMUNE INJ 50MG/ML 5 SANDIMMUNE SOL 100MG/ML 3 tacrolimus cap 0.5 mg 2 tacrolimus cap 1 mg 2 tacrolimus cap 5 mg 2 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 5 PA BENLYSTA INJ 400MG 5 PA NULOJIX INJ 250MG 5 PA SIMULECT INJ 10MG 5 SIMULECT INJ 20MG 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

101

Drug Name Drug Tier Requirements/Limit IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 3 PA RAPAMUNE TAB 0.5MG 4 PA RAPAMUNE TAB 1MG 5 PA RAPAMUNE TAB 2MG 4 PA sirolimus tab 0.5 mg 2 PA sirolimus tab 1 mg 2 PA sirolimus tab 2 mg 2 PA ZORTRESS TAB 0.5MG 4 PA ZORTRESS TAB 0.25MG 4 PA ZORTRESS TAB 0.75MG 4 PA MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 5 PA; QL SYNAGIS INJ 100MG/ML 5 PA; QL VACCINES BCG VACCINE INJ 5 NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS CARDIOTEK-RX TAB 4 folic acid-pyridoxine-cyanocobalamin 2 tab 2.5-25-2 mg FOLTANX TAB 2 METAFOLBIC TAB PLUS 2 PHENYLADE POW GMP 4 PURALOR CI TAB 4 ELECTROLYTES, MISCELLANEOUS K-PHOS TAB 4 K-PHOS TAB NEUTRAL 2 K-PHOS TAB NO 2 4 pot phos monobasic w/sod phos di & 2 monobas tab 155-852-130mg ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 3 EFFER-K TAB 20MEQ 3 KLOR-CON M15 TAB 15MEQ ER 2 KLOR-CON-25 POW 25MEQ 4 pot bicarbonate & chloride effer tab 25 2 meq potassium bicarbonate effer tab 25 2 meq potassium chloride cap er 8 meq 2 potassium chloride cap er 10 meq 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

102

Drug Name Drug Tier Requirements/Limit potassium chloride microencapsulated 2 crys er tab 10 meq potassium chloride microencapsulated 2 crys er tab 20 meq potassium chloride oral soln 10% (20 2 meq/15ml) potassium chloride oral soln 20% (40 2 meq/15ml) potassium chloride powder packet 20 2 meq potassium chloride tab er 8 meq (600 2 mg) potassium chloride tab er 10 meq 2 potassium chloride tab er 20 meq 2 (1500 mg) ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 2 15 gm/60ml sodium polystyrene sulfonate powder 2 sodium polystyrene sulfonate powder 4 VELTASSA POW 8.4GM 5 PA; QL VELTASSA POW 16.8GM 5 PA; QL VELTASSA POW 25.2GM 5 PA; QL VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS ANIMI-3 CAP 4 ANIMI-3 CAP VIT D 4 BP VIT 3 CAP 4 FOLGARD RX TAB 4 folic acid tab 1 mg 1 folic acid-vitamin b6-vitamin b12 tab 2 2.2-25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2 2.2-25-1 mg folic acid-vitamin b6-vitamin b12 tab 2 2.5-25-1 mg FOLTRATE TAB 3 VITAMINS AND MINERALS, MISCELLANEOUS ACTIVE FE TAB 75-1.25 4 AQUASOL A INJ 50000/ML 4 b-complex w/ c & folic acid cap 1 mg 2 b-complex w/ c & folic acid tab 1 mg 2 BIFERARX TAB 4 CALCIUM-FA WAF PLUS D 2 CORVITE 150 TAB 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

103

Drug Name Drug Tier Requirements/Limit CORVITE FE TAB 4 ergocalciferol cap 50000 unit 2 ESCAVITE CHW 4 ESCAVITE D CHW 4 fe asp gly-fe polysacch-succ ac-c2 threon ac-b12-fa cap fe asparto gly-fe fum-b12-fa-c-succinic 2 ac tab ther pack fe fumarate w/ b12-vit c-fa-ifc cap 110-2 0.015-75-0.5-240 mg FERAHEME INJ 510/17ML 4 FERIVA CAP 75-1MG 4 FERRALET 90 TAB 4 FERRAPLUS 90 TAB 2 ferrex 150 cap 150mg 2 FERRLECIT INJ 12.5MG/M 4 FLORIVA CHW 0.5MG 4 FLORIVA CHW 0.25MG 4 FLORIVA CHW 1MG 4 FLORIVA DRO 0.25MG 4 FLUOR-A-DAY CHW 0.5MG F 2 FLUOR-A-DAY CHW 0.25MG F 2 FLUOR-A-DAY CHW 1MG F 2 FOCALGIN DSS TAB 90-1MG 2 FUSION PAK SPRINKLE 4 FUSION PLUS CAP 4 GALZIN CAP 25MG 3 PA GALZIN CAP 50MG 3 PA HEMATOGEN FA CAP 2 HEMATRON-AF TAB 4 HEMETAB TAB 2 hydroxocobalamin inj 1000 mcg/ml 2 INFED INJ 50MG/ML 2 INTEGRA F CAP 4 INTEGRA PLUS CAP 4 iron combination cap 2 iron polysacch complex-vit b12-fa cap 2 150-0.025-1 mg iron polysacch complex-vit b12-fa cap 2 150-0.025-1 mg iron-folic acid-vit c-vit b6-vit b12-zinc 2 tab 150-1.25 mg IROSPAN 24/6 MIS 4 MAGNEBIND TAB 400 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

104

Drug Name MEPHYTON TAB 5MG NEPHPLEX RX TAB NEPHRON FA TAB NEURIN-SL SUB NICADAN TAB pediatric multiple vitamin w/ minerals & c drops 45 mg/ml pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml pediatric multiple vitamins w/ fluoride chew tab 0.5 mg pediatric multiple vitamins w/ fluoride chew tab 0.25 mg pediatric multiple vitamins w/ fluoride chew tab 1 mg pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 mg/ml pediatric vitamins acd w/ fluoride soln 0.25 mg/ml POLY-VI-FLOR CHW 0.5MG POLY-VI-FLOR CHW 0.25MG POLY-VI-FLOR CHW 1MG POLY-VI-FLOR SUS 0.25/ML POLY-VI-FLOR SUS /IRON PROFERRIN- TAB FORTE PUREFE CAP PLUS pyridoxine hcl inj 100 mg/ml QUFLORA PED CHW 0.5MG QUFLORA PED CHW 0.25MG QUFLORA PED CHW 1MG sod ferric gluc cmplx in sucrose iv soln 12.5 mg/ml (fe eq) sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride tab 1 mg f (from 2.2 mg naf)

Drug Tier Requirements/Limit 4 2 4 4 4 4 4 2 2 2 2 4 4 2 2 2 4 4 4 4 4 4 4 2 4 4 4 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

105

Drug Name Drug Tier Requirements/Limit TANDEM PLUS CAP 4 TARON FORTE CAP 2 TEXAVITE LQ LIQ 4 thiamine hcl inj 100 mg/ml 2 TRI-VI-FLOR SUS 0.5MG/ML 4 TRI-VI-FLOR SUS 0.25/ML 4 VENOFER INJ 20MG/ML 4 VITAMINS AND MINERALS, PRENATAL VITAMINS ACTIVE OB CAP 4 ATABEX EC TAB 29-1MG 4 C-NATE DHA CAP 28-1-200 2 CALCIUM PNV CAP 2 CITRANATAL CAP HARMONY 4 CITRANATAL MIS 90 DHA 4 CITRANATAL MIS B-CALM 4 CITRANATAL PAK ASSURE 4 CITRANATAL PAK DHA 4 CITRANATAL TAB RX 4 COMPLETE NAT PAK DHA 2 COMPLETENATE CHW 2 CONCEPT DHA CAP 4 CONCEPT OB CAP 4 DOTHELLE DHA CAP 2 DUET DHA 400 MIS 25-1-400 4 DUET DHA MIS BALANCED 4 ENBRACE HR CAP 4 EXTRA-VIRT CAP PLUS DHA 2 FOCALGIN 90 MIS DHA 2 FOCALGIN CA MIS 2 FOLET DHA PAK 4 FOLET ONE CAP 38-1-225 4 FOLIVANE-OB CAP 2 HEMENATAL OB TAB 28-6-1MG 2 LEVOMEFOLATE CAP DHA 2 M-VIT TAB 27-1MG 3 MARNATAL-F CAP 4 MYNATAL CAP 2 MYNATAL TAB 2 MYNATAL TAB ADVANCE 2 MYNATAL-Z TAB 2 MYNATE 90 TAB PLUS 2 NATACHEW CHW 4 NATELLE ONE CAP 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

106

Drug Name Drug Tier Requirements/Limit NEEVO DHA CAP 27-1.13 4 NESTABS ABC MIS 4 NESTABS DHA PAK 4 NEWGEN TAB 32-1MG 2 NIVA-PLUS TAB 4 O-CAL FA TAB 3 O-CAL TAB PRENATAL 3 OB COMPLETE CAP ONE 4 OB COMPLETE CAP PETITE 4 OB COMPLETE TAB 3 OB COMPLETE TAB PREMIER 4 OBSTETRIX EC TAB 3 OBSTETRIX PAK DHA 4 PNV OB+DHA PAK 2 PNV PRENATAL TAB PLUS 2 PNV PRENATAL TAB PLUS 2 PNV TABS TAB 29-1MG 2 PNV-DHA CAP DOCUSATE 2 PR NATAL 400 PAK 2 PR NATAL 430 PAK 2 PR NATAL 430 PAK EC 2 PREFERAOB MIS +DHA 4 PRENAISSANCE CAP PLUS 2 PRENAISSANCE TAB NEXT 2 PRENAT PLUS TAB 27-1MG 2 prenat w/o a w/fefum-methfol-fa-dha 2 cap 27-0.6-0.4-300 mg PRENATA CHW 29-1MG 4 PRENATAL TAB 27-1MG 2 PRENATAL TAB PLUS 2 PRENATAL VIT TAB LOW IRON 2 prenatal vit w/ dss-fe fumarate-fa tab 2 29-1 mg prenatal vit w/ dss-iron carbonyl-fa tab 2 90-1 mg prenatal vit w/ fe fum-methylfolate-fa 2 tab 27-0.6-0.4 mg prenatal vit w/ fe fumarate-fa chew tab 2 29-1 mg prenatal vit w/ fe fumarate-fa tab 27-1 2 mg prenatal vit w/ fe fumarate-fa tab 28-1 2 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

107

Drug Name Drug Tier Requirements/Limit prenatal vit w/ fe fumarate-fa tab 29-1 2 mg PRENATAL+FE TAB 29-1MG 2 PRENATAL-U CAP 106.5-1 2 PRENATE AM TAB 1MG 4 PRENATE CAP ENHANCE 4 PRENATE CAP ESSENTIA 4 PRENATE CAP PIXIE 4 PRENATE CAP RESTORE 4 PRENATE CHW 0.6-0.4 4 PRENATE DHA CAP 4 PRENATE MINI CAP 4 PRENATE STAR TAB 20-1MG 4 PRENATE TAB ELITE 4 PREPLUS TAB 27-1MG 2 PRETAB TAB 29-1MG 2 PROVIDA DHA CAP 4 PROVIDA OB CAP 4 PUREFE OB CAP PLUS 4 REDICHEW RX CHW 4 RELNATE DHA CAP 2 SE-NATAL 19 TAB 2 SELECT-OB CHW 4 SELECT-OB+ PAK DHA 4 TARON-C DHA CAP 2 TARON-PREX CAP 2 TL-SELECT CAP 2 TRI-TABS DHA MIS 2 TRICARE PRE CAP 27-1-500 4 TRICARE TAB PRENATAL 4 TRISTART DHA CAP 4 TRIVEEN-PRX CAP RNF 2 VEMAVITE- CAP PRX 2 2 VENA-BAL MIS DHA 2 VINATE II TAB 2 VINATE M TAB 2 VINATE ONE TAB 2 VIRT NATE TAB 2 VIRT NATE TAB 28-1MG 2 VIRT-ADVANCE TAB 90-1MG 2 VIRT-C DHA CAP 2 VIRT-CARE CAP ONE 2 VIRT-NATE CAP DHA 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

108

Drug Name Drug Tier Requirements/Limit VIRT-PN PLUS CAP 2 VIRT-PN TAB 2 VIRT-VITE GT TAB 90-1MG 2 VITAFOL CAP ULTRA 4 VITAFOL FE+ CAP 4 VITAFOL-NANO TAB 4 VITAFOL-OB PAK +DHA 4 VITAFOL-ONE CAP 4 VITAMEDMD CAP ONE RX 4 VITAPEARL CAP 4 VITATRUE MIS 4 VIVA DHA CAP 4 VOL-PLUS TAB 2 VOL-TAB RX TAB 4 VP-CH PLUS CAP 2 VP-CH-PNV CAP 2 VP-HEME OB TAB 2 VP-HEME ONE CAP 2 VP-HEME-OB TAB 28-6-1MG 2 VP-PNV-DHA CAP 4 ZATEAN-CH CAP 2 ZATEAN-PN CAP DHA 2 ZATEAN-PN CAP PLUS 2 RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJ 1MG/ML 4 ADRENALIN INJ 30/30ML 4 epinephrine hcl inj 1 mg/ml 2 epinephrine hcl soln prefilled syringe 2 0.1 mg/ml epinephrine solution auto-injector 0.3 2 mg/0.3ml (1:1000) epinephrine solution auto-injector 0.15 2 mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG 4 EPIPEN-JR INJ 2-PAK 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER 62.5-25 3 STIOLTO AER 2.5-2.5 3 UTIBRON CAP NEOHALER 4 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT ACTING COMBIVENT AER 20-100 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

109

Drug Name Drug Tier Requirements/Limit ipratropium-albuterol nebu soln 0.52 2.5(3) mg/3ml ANTICHOLINERGICS ATROVENT HFA AER 17MCG 4 ipratropium bromide inhal soln 0.02% 2 SEEBRI NEOHA CAP 15.6MCG 4 SPIRIVA AER 1.25MCG 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR RESPIMAT 3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine & phenylephrine syrup 2 6.25-5 mg/5ml ANTIHISTAMINES, LOW-SEDATING levocetirizine dihydrochloride soln 2.5 2 PA mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 2 ANTIHISTAMINES, SEDATING carbinoxamine maleate soln 4 mg/5ml 2 carbinoxamine maleate tab 4 mg 2 clemastine fumarate tab 2.68 mg 2 cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 2 diphenhydramine hcl cap 50 mg 5 diphenhydramine hcl elixir 12.5 5 mg/5ml diphenhydramine hcl inj 50 mg/ml 5 hydroxyzine hcl im soln 25 mg/ml 2 hydroxyzine hcl im soln 50 mg/ml 2 hydroxyzine hcl syrup 10 mg/5ml 2 hydroxyzine hcl tab 10 mg 2 hydroxyzine hcl tab 25 mg 2 hydroxyzine hcl tab 50 mg 2 hydroxyzine pamoate cap 25 mg 2 hydroxyzine pamoate cap 50 mg 2 hydroxyzine pamoate cap 100 mg 2 ANTITUSSIVE COMBINATIONS, NON-OPIOID promethazine-dm syrup 6.25-15 1 mg/5ml pseudoephed-bromphen-dm syrup 30- 4 2-10 mg/5ml ANTITUSSIVE COMBINATIONS, OPIOID CAPCOF SYP 5-2-10MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

110

Drug Name Drug Tier Requirements/Limit guaifenesin-codeine soln 100-6.3 2 mg/5ml guaifenesin-codeine soln 100-10 2 mg/5ml hydrocod polst-chlorphen polst er susp 2 10-8 mg/5ml hydrocodone w/ homatropine syrup 5- 2 1.5 mg/5ml M-END PE LIQ 4 PHENHIST DH LIQ 30-2-10 2 promethazine w/ codeine syrup 6.25- 2 10 mg/5ml TUSSICAPS CAP 5-4MG 4 TUSSICAPS CAP 10-8MG 4 TUSSIONEX SUS 10-8/5ML 3 Z-TUSS AC LIQ 2-9/5ML 4 ANTITUSSIVES benzonatate cap 100 mg 1 benzonatate cap 200 mg 2 BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active Inhalation ARCAPTA CAP 75MCG 4 ST SEREVENT DIS AER 50MCG 3 STRIVERDI AER 2.5MCG 4 BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive Inhalation BROVANA NEB 15MCG 4 PERFOROMIST NEB 20MCG 4 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 2 mg/ml) albuterol sulfate soln nebu 0.63 2 mg/3ml (base equiv) albuterol sulfate soln nebu 0.083% (2.51 mg/3ml) albuterol sulfate soln nebu 1.25 2 mg/3ml (base equiv) levalbuterol hcl soln nebu 0.31 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml 2 (base equiv) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

111

Drug Name levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg PROVENTIL AER HFA VENTOLIN HFA AER XOPENEX HFA AER BETA AGONISTS, INJECTABLE ISUPREL INJ 0.2MG/ML terbutaline sulfate inj 1 mg/ml BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab er 12hr 4 mg albuterol sulfate tab er 12hr 8 mg terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg CYSTIC FIBROSIS BETHKIS NEB 300/4ML CAYSTON INH 75MG KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG ORKAMBI TAB 200-125 PULMOZYME SOL 1MG/ML TOBI PODHALR CAP 28MG tobramycin nebu soln 300 mg/5ml LEUKOTRIENE MODIFIERS montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) zafirlukast tab 10 mg zafirlukast tab 20 mg MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml

Drug Tier Requirements/Limit 2 2 2 2 4 3 4

PA; QL QL PA, ST; QL

4 2 1 1 2 2 2 2 2 5 5 5 5 5 5 5 5 5

QL QL PA; PA; PA; PA; PA; QL QL

2

QL

2

QL

2

QL

2

QL

QL QL QL QL QL

2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

112

Drug Name Drug Tier Requirements/Limit MEDICAL SUPPLIES AEROCHAMBER MIS PLUS 4 MISCELLANEOUS acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 ARALAST NP INJ 400MG 5 PA ARALAST NP INJ 500MG 5 PA ARALAST NP INJ 800MG 5 PA CINQAIR INJ 5 PA GLASSIA INJ 5 PA HYPER-SAL NEB 7% 4 HYPERSAL NEB 3.5% 4 ipratropium bromide nasal soln 0.03% 2 (21 mcg/spray) ipratropium bromide nasal soln 0.06% 2 (42 mcg/spray) NEBUSAL NEB 6% 4 NUCALA INJ 100MG 5 PA; QL PROLASTIN-C INJ 1000MG 5 PA sodium chloride soln nebu 0.9% 2 sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% 2 sodium chloride soln nebu 10% 2 XOLAIR SOL 150MG 5 PA; QL ZEMAIRA INJ 1000MG 5 PA NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 2 mcg/spray) azelastine hcl nasal spray 0.15% 2 (205.5 mcg/spray) olopatadine hcl nasal soln 0.6% 2 PATANASE SPR 0.6% 4 PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 4 PA PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 5 PA ESBRIET TAB 267MG 5 PA ESBRIET TAB 801MG 5 PA OFEV CAP 100MG 5 PA OFEV CAP 150MG 5 PA STEROID INHALANTS ARNUITY ELPT INH 100MCG 3 ARNUITY ELPT INH 200MCG 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

113

Drug Name Drug Tier Requirements/Limit ASMANEX 30 AER 110MCG 3 ASMANEX 120 AER 220MCG 3 ASMANEX HFA AER 100 MCG 3 ASMANEX HFA AER 200 MCG 3 budesonide inhalation susp 0.5 mg/2ml 2 budesonide inhalation susp 0.25 2 mg/2ml budesonide inhalation susp 1 mg/2ml 2 FLOVENT DISK AER 50MCG 3 FLOVENT DISK AER 100MCG 3 FLOVENT DISK AER 250MCG 3 FLOVENT HFA AER 44MCG 3 FLOVENT HFA AER 110MCG 3 FLOVENT HFA AER 220MCG 3 PULMICORT INH 90MCG 3 PULMICORT INH 180MCG 3 QVAR AER 40MCG 3 QVAR AER 80MCG 3 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 BREO ELLIPTA INH 100-25 3 BREO ELLIPTA INH 200-25 3 SYMBICORT AER 80-4.5 3 SYMBICORT AER 160-4.5 3 TOPICAL DECONGESTANTS ADRENALIN SOL 1:1000 3 TYZINE PED DRO 0.05% 3 XANTHINES ELIXOPHYLLIN ELX 80/15ML 4 THEO-24 CAP 100MG CR 4 THEO-24 CAP 200MG CR 4 THEO-24 CAP 300MG CR 4 THEO-24 CAP 400MG ER 4 theophylline soln 80 mg/15ml 2 theophylline tab er 12hr 100 mg 2 theophylline tab er 12hr 200 mg 2 theophylline tab er 12hr 300 mg 2 theophylline tab er 12hr 450 mg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

114

Drug Name Drug Tier Requirements/Limit theophylline tab er 24hr 400 mg 2 theophylline tab er 24hr 600 mg 2 TOPICAL DERMATOLOGY, ACNE: ORAL isotretinoin cap 10 mg 2 isotretinoin cap 20 mg 2 isotretinoin cap 30 mg 2 isotretinoin cap 40 mg 2 DERMATOLOGY, ACNE: TOPICAL ACZONE GEL 5% 4 PA ACZONE GEL 7.5% 4 PA adapalene cream 0.1% 2 adapalene gel 0.1% 2 adapalene gel 0.3% 2 AZELEX CRE 20% 4 PA benzoyl peroxide-erythromycin gel 5- 2 3% clindamycin phosphate foam 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 creamy face liq wash 4% 2 erythromycin gel 2% 2 erythromycin pads 2% 2 erythromycin soln 2% 2 oscion clnsr lot 6% 2 sulfacetamide sodium w/ sulfur 2 emulsion 10-1% sulfacetamide sodium w/ sulfur wash 9- 2 4.5% tazarotene cream 0.1% 2 TAZORAC CRE 0.1% 4 PA TAZORAC CRE 0.05% 4 PA TAZORAC GEL 0.1% 4 PA TAZORAC GEL 0.05% 4 PA tretinoin cream 0.1% 2 tretinoin cream 0.05% 2 tretinoin cream 0.025% 2 tretinoin gel 0.01% 2 tretinoin gel 0.025% 2 DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

115

Drug Name Drug Tier Requirements/Limit fluorouracil soln 2% 4 fluorouracil soln 5% 5 LEVULAN KERA SOL 20% 3 DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 4 BACTROBAN OIN NASAL 2% 4 gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 mupirocin oint 2% 2 silver sulfadiazine cream 1% 2 DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox olamine susp 0.77% (base 2 equiv) ciclopirox solution 8% 2 clotrimazole cream 1% 2 clotrimazole w/ betamethasone lotion 2 1-0.05% econazole nitrate cream 1% 2 EXELDERM CRE 1% 4 EXELDERM SOL 1% 4 EXODERM LOT 25-1% 4 ketoconazole cream 2% 2 ketoconazole shampoo 2% 2 nystatin cream 100000 unit/gm 2 nystatin oint 100000 unit/gm 2 nystatin topical powder 100000 2 unit/gm nystatin-triamcinolone cream 100000- 2 0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 2 unit/gm-% oxiconazole nitrate cream 1% 2 PENLAC SOL 8% 4 DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 4 acitretin cap 17.5 mg 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

116

Drug Name Drug Tier Requirements/Limit methoxsalen rapid cap 10 mg 5 PA OXSORALEN-UL CAP 10MG 5 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 2 calcipotriene oint 0.005% 2 calcipotriene soln 0.005% (50 mcg/ml) 2 calcitriol oint 3 mcg/gm 2 DRITHO-CREME CRE HP 1% 3 ZITHRANOL-RR CRE 1.2% 4 DERMATOLOGY, ANTISEBORRHEICS selenium sulfide-pyrithione zinc in urea 2 shampoo 2.25% DERMATOLOGY, ANTISEPTICS/DISINFECTANTS formaldehyde solution 20% 4 PHENOL LIQ 89% 2 DERMATOLOGY, ATOPIC DERMATITIS ELIDEL CRE 1% 4 PA tacrolimus oint 0.1% 2 PA; QL tacrolimus oint 0.03% 2 PA; QL DERMATOLOGY, CORTICOSTEROID COMBINATIONS pramoxine-hc cream 1-2.5% 2 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream 0.1% 2 amcinonide lotion 0.1% 2 AMCINONIDE OIN 0.1% 2 betamethasone dipropionate 2 augmented cream 0.05% betamethasone dipropionate 2 augmented lotion 0.05% betamethasone dipropionate cream 2 0.05% betamethasone dipropionate lotion 2 0.05% desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone oint 0.25% 2 diflorasone diacetate cream 0.05% 2 fluocinonide cream 0.05% 2 fluocinonide emulsified base cream 2 0.05% fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

117

Drug Name Drug Tier Requirements/Limit triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide oint 0.5% 2 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone dipropionate cream 2 0.05% alclometasone dipropionate oint 0.05% 2 desonide cream 0.05% 2 desonide lotion 0.05% 2 desonide oint 0.05% 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide oil 0.01% (body 2 oil) fluocinolone acetonide oil 0.01% (scalp 2 oil) fluocinolone acetonide soln 0.01% 2 hydrocortisone cream 2.5% 2 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream 0.1% 2 (base equivalent) betamethasone valerate lotion 0.1% 2 (base equivalent) betamethasone valerate oint 0.1% 2 (base equivalent) desoximetasone cream 0.05% 2 desoximetasone oint 0.05% 2 fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate oint 0.005% 2 hydrocortisone butyrate cream 0.1% 2 hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% 2 (lotion) prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 118

Drug Name Drug Tier Requirements/Limit triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 1 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate 2 augmented gel 0.05% betamethasone dipropionate 2 augmented oint 0.05% clobetasol propionate cream 0.05% 2 clobetasol propionate emollient base 2 cream 0.05% clobetasol propionate gel 0.05% 2 clobetasol propionate oint 0.05% 2 clobetasol propionate soln 0.05% 2 diflorasone diacetate oint 0.05% 2 halobetasol propionate cream 0.05% 2 halobetasol propionate oint 0.05% 2 DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 2 12% lactic acid (ammonium lactate) lotion 2 10% UREA NAIL MIS 50% 2 DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 4 PA; QL LIDODERM DIS 5% 4 PA; QL DERMATOLOGY, LOCAL ANESTHETICS ANACAINE OIN 3 CETACAINE AER 4 cocaine hcl soln 4% 2 LIDO-K LOT 3% 2 lidocaine hcl cream 3% 2 lidocaine hcl gel 2% 2 lidocaine hcl soln 4% 2 lidocaine oint 5% 2 lidocaine-prilocaine cream 2.5-2.5% 2 lidocaine-prilocaine cream kit 2.5-2.5% 2 QUTENZA KIT 8% 1-PCH 5 PA; QL DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 4 ARZOL SILVER MIS NITR APP 3 BUCALSEP SOL 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

119

Drug Name Drug Tier Requirements/Limit BUCALSEP SPR 3 CONDYLOX GEL 0.5% 4 DENAVIR CRE 1% 4 DRYSOL SOL 20% 4 GEBAUERS SPR AER /STRETCH 4 GORDOFILM SOL 3 imiquimod cream 5% 2 PANRETIN GEL 0.1% 5 PA PODOCON SOL 25% 3 podofilox soln 0.5% 2 PR CREAM KIT 2 salicylic acid cream 6% 2 salicylic acid film forming liquid 27.5% 2 salicylic acid lotion 6% 2 salicylic acid shampoo 6% 2 SALICYLIC ACID SOLN 26% 2 salisol fort sol 26% 2 SANTYL OIN 250/GM 3 SILVER NITRA OIN 10% 2 SILVER NITRA SOL 0.5% 2 SILVER NITRA SOL 10% 2 SILVER NITRA SOL 25% 2 SILVER NITRA SOL 50% 2 SULFAMYLON CRE 85MG/GM 3 TRI-CHLOR LIQ 80% 3 DERMATOLOGY, ROSACEA FINACEA GEL 15% 4 metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole lotion 0.75% 2 MIRVASO GEL 0.33% 4 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX CRE 10% 3 EURAX LOT 10% 3 lindane shampoo 1% 3 malathion lotion 0.5% 2 permethrin cream 5% 2 ULESFIA LOT 5% 4 DERMATOLOGY, WOUND CARE PRODUCTS AVO CREAM EMU 2 BIAFINE EMU 4 PRUTECT EMU 2 REGENECARE GEL 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

120

Drug Name Drug Tier Requirements/Limit SILVRSTAT GEL DRESSING 4 SONAFINE EMU 4 IRRIGATION SOLUTIONS irrigation solution, physiological 4 lactated ringer's for irrigation 2 ringer's solution for irrigation 2 water for irrigation, sterile irrigation 2 soln MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS AQUORAL SPR 4 BIOTENE DRY SPR MOIST 3 BIOTENE SPR MOUTH 3 CAPHOSOL SOL 3 chlorhexidine gluconate soln 0.12% 1 DEBACTEROL SOL 30-50% 3 fluorid sens pst 1.1-5% 4 GELCLAIR GEL 4 lidocaine hcl laryngotracheal soln 4% 2 lidocaine hcl viscous soln 2% 1 MOI-STIR SOL 3 MOUTHKOTE SOL 3 NUMOISYN LOZ 4 PREVDNT 5000 PST 1.1% 4 PREVDNT 5000 PST 1.1-5% 4 PREVIDENT CRE 5000 PLS 4 PREVIDENT GEL 1.1% 4 PREVIDENT GEL 1.1% BER 4 PREVIDENT GEL 1.1% CHR 4 PREVIDENT GEL 1.1% MIN 4 PREVIDENT PST 5000 BST 4 sodium fluoride cream 1.1% 2 sodium fluoride gel 1.1% (0.5% f) 2 sodium fluoride paste 1.1% 4 sodium fluoride rinse 0.2% 2 sodium fluoride rinse 0.2% 2 triamcinolone acetonide dental paste 2 0.1% MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS ORAMAGICRX SUS 4 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS bacitracin-polymyxin-neomycin-hc 2 ophth oint 1% PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

121

Drug Name Drug Tier Requirements/Limit BLEPHAMIDE OIN S.O.P. 3 BLEPHAMIDE SUS OP 3 neomycin-polymyxin-dexamethasone 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 PRED-G S.O.P OIN OP 3 PRED-G SUS OP 3 sulfacetamide sodium-prednisolone 2 ophth soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 4 TOBRADEX ST SUS 0.3-0.05 4 tobramycin-dexamethasone ophth susp 2 0.3-0.1% ZYLET SUS 0.5-0.3% 4 OPHTHALMIC, ANTI-INFECTIVES AZASITE SOL 1% 4 bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 2 BESIVANCE SUS 0.6% 4 BETADINE SOL 5% OP 3 CILOXAN OIN 0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% 2 erythromycin ophth oint 5 mg/gm 1 gatifloxacin ophth soln 0.5% 2 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 levofloxacin ophth soln 0.5% 2 MOXEZA SOL 0.5% 3 neomycin-bacitrac zn-polymyx 2 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-2 10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 polymyxin b-trimethoprim ophth soln 2 10000 unit/ml-0.1% sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 4 TOBREX SOL 0.3% OP 3 VIGAMOX DRO 0.5% 3 ZYMAXID SOL 0.5% 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 122

Drug Name Drug Tier Requirements/Limit OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACUVAIL SOL 0.45% 4 QL bromfenac sodium ophth soln 0.09% 2 (base equiv) (once-daily) diclofenac sodium ophth soln 0.1% 1 flurbiprofen sodium ophth soln 0.03% 2 ketorolac tromethamine ophth soln 2 QL 0.4% ketorolac tromethamine ophth soln 2 QL 0.5% NEVANAC SUS 0.1% 4 PROLENSA SOL 0.07% 4 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX SUS 0.2% 4 dexamethasone sodium phosphate 2 ophth soln 0.1% DUREZOL EMU 0.05% 3 FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 FML FORTE SUS 0.25% OP 4 FML LIQUIFLM SUS 0.1% OP 4 FML OIN 0.1% OP 3 ILUVIEN IMP 0.19MG 5 PA; QL LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 OMNIPRED SUS 1% OP 4 PRED MILD SUS 0.12% OP 4 prednisolone acetate ophth susp 1% 2 TRIESENCE INJ 40MG/ML 4 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 BEPREVE DRO 1.5% 4 cromolyn sodium ophth soln 4% 2 EMADINE SOL 0.05% OP 4 epinastine hcl ophth soln 0.05% 2 olopatadine hcl ophth soln 0.1% (base 2 equivalent) PATADAY SOL 0.2% 3 PAZEO DRO 0.7% 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

123

Drug Name Drug Tier Requirements/Limit OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 3 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 2 ZIRGAN GEL 0.15% 3 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 carteolol hcl ophth soln 1% 2 ISTALOL SOL 0.5% OP 4 levobunolol hcl ophth soln 0.5% 2 metipranolol ophth soln 0.3% 2 timolol maleate ophth gel forming soln 2 0.5% timolol maleate ophth gel forming soln 2 0.25% timolol maleate ophth soln 0.5% 2 timolol maleate ophth soln 0.25% 2 TIMOPTIC OCU SOL 0.5% OP 4 TIMOPTIC OCU SOL 0.25% OP 4 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl ophth soln 0.5% 2 BETOPTIC-S SUS 0.25% OP 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS COSOPT PF SOL 4 dorzolamide hcl-timolol maleate ophth 2 soln 22.3-6.8 mg/ml OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA SUS 1-0.2% 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT SUS 1% OP 3 dorzolamide hcl ophth soln 2% 2 OPHTHALMIC, DIAGNOSTIC PRODUCTS fluorescein sodium ophth strips 1 mg 4 fluorescein w/ benoxinate ophth soln 2 0.25-0.4% OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% 3 QL OPHTHALMIC, MISCELLANEOUS AMVISC INJ 12MG/ML 4 AMVISC PLUS INJ 16MG/ML 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 124

Drug Name Drug Tier Requirements/Limit CYSTARAN SOL 0.44% 5 PA; QL EYLEA INJ 2/0.05ML 5 PA JETREA INJ 2.5MG/ML 5 PA; QL LACRISERT MIS 5MG OP 4 LUCENTIS SOL 0.3MG 5 PA LUCENTIS SOL 0.5MG 5 PA MACUGEN INJ 5 MEMBRANEBLUE SOL 0.15% 4 ophthalmic irrigation solution 2 intraocular phenylephrine hcl ophth soln 2.5% 2 phenylephrine hcl ophth soln 10% 2 PROVISC INJ 1% 4 tetracaine hcl ophth soln 0.5% 2 tetracaine hcl ophth soln 0.5% 4 VISUDYNE INJ 15MG 5 OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP 2 atropine sulfate ophth soln 1% 2 CYCLOMYDRIL SOL OP 3 cyclopentolate hcl ophth soln 0.5% 2 cyclopentolate hcl ophth soln 1% 2 cyclopentolate hcl ophth soln 2% 2 homatropine hbr ophth soln 5% 2 tropicamide ophth soln 0.5% 2 tropicamide ophth soln 1% 2 OPHTHALMIC, PARASYMPATHOMIMETICS MIOSTAT INJ 0.01% OP 4 pilocarpine hcl ophth soln 1% 2 pilocarpine hcl ophth soln 4% 2 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 2 ST latanoprost ophth soln 0.005% 2 LUMIGAN SOL 0.01% 3 TRAVATAN Z DRO 0.004% 4 ST ZIOPTAN DRO 0.0015% 4 ST OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 3 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 3 brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 2 PHOSPHOLINE SOL 0.125%OP 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

125

Drug Name Drug Tier Requirements/Limit OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 3 hydrocortisone w/ acetic acid otic soln 2 1-2% neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp 3.5 2 mg/ml-10000 unit/ml-1% OTIC, ANTI-INFECTIVES acetic acid 2% in aluminum acetate otic2 soln acetic acid otic soln 2% 2 CETRAXAL SOL 0.2% 4 ciprofloxacin hcl otic soln 0.2% (base 2 equivalent) ofloxacin otic soln 0.3% 2 OTIC, MISCELLANEOUS DERMOTIC OIL 0.01% 4 fluocinolone acetonide (otic) oil 0.01% 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy

126

Index Generate the Index