2017 Formulary Annual Notice of Change Medicare Advantage Plans (MAPD)

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1 Updated: October 1, Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2017 MAPD formulary. For a complete list, please refer to our website and review the 2017 MAPD Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions or need to obtain updated coverage determination and exception information, please contact Customer Service at or, for TTY users, , weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we are available seven days a week from 8 a.m. to 8 p.m. or you may visit myfhca.org. Please refer to your Evidence of Coverage for cost-sharing information. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and copayments/co-insurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. The Formulary and pharmacy network may change at any time. You will receive notice when necessary.

2 MEDICATIONS REMOVED FROM THE 2016 MAPD FORMULARY Medication Name ACTOPLUS MET XR 15 MG-1,000 MG, EXTENDED ACTOPLUS MET XR 30 MG-1,000 MG, EXTENDED AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED AMIODARONE 400 MG ANDROGEL 1 % (25 MG/2.5 GRAM) TRANSDERMAL GEL PACKET ANDROGEL 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKET APRISO GRAM CAPSULE,EXTENDED AVODART 0.5 MG CAPSULE BROMFENAC 0.09 % EYE DROPS Comment Formulary alternatives are available (e.g. pioglitazone and metformin) Formulary alternatives are available (e.g. pioglitazone and metformin) Amiodarone 200 mg is on formulary without a quantity limit Formulary alternatives are available (e.g. Lialda and Pentasa) Formulary alternatives available (e.g. diclofenac eye drops, ketorolac eye drops) CRESTOR 10 MG CRESTOR 20 MG CRESTOR 40 MG DEXILANT 30 MG CAPSULE, DELAYED DEXILANT 60 MG CAPSULE, DELAYED DOXYCYCLINE HYCLATE 50 MG EPITOL 200 MG EPOGEN 2,000 UNIT/ML INJECTION SOLUTION EPOGEN 3,000 UNIT/ML INJECTION SOLUTION EPOGEN 4,000 UNIT/ML INJECTION SOLUTION EPOGEN 20,000 UNIT/2 ML INJECTION SOLUTION EXELON PATCH 4.6 MG/24 HR TRANSDERMAL EXELON PATCH 9.5 MG/24 HR TRANSDERMAL EXELON PATCH 13.3 MG/24 HOUR TRANSDERMAL FAZACLO 12.5 MG DISINTEGRATING Formulary alternatives available (e.g. omeprazole, lansoprazole, pantoprazole) Formulary alternatives available (e.g. omeprazole, lansoprazole, pantoprazole) Formulary alternatives available (e.g. doxycycline hyclate 50 mg capsule) Formulary alternatives available (e.g. Procrit) Formulary alternatives available (e.g. Procrit) Formulary alternatives available (e.g. Procrit) Formulary alternatives available (e.g. Procrit)

3 MEDICATIONS REMOVED FROM THE 2016 MAPD FORMULARY Medication Name FAZACLO 25 MG DISINTEGRATING FAZACLO 100 MG DISINTEGRATING GLEEVEC 100 MG GLEEVEC 400 MG GLYSET 25 MG GLYSET 50 MG GLYSET 100 MG INNOPRAN XL 80 MG CAPSULE,EXTENDED INNOPRAN XL 120 MG CAPSULE,EXTENDED INVEGA 1.5 MG,EXTENDED INVEGA 3 MG,EXTENDED INVEGA 6 MG,EXTENDED INVEGA 9 MG,EXTENDED JALYN 0.5 MG-0.4 MG CAPSULE, EXTENDED LINCOCIN 300 MG/ML INJECTION SOLUTION MOVIPREP 100 G-7.5 G G-4.7 G ORAL POWDER PACKET MYFORTIC 180 MG, DELAYED MYFORTIC 360 MG, DELAYED NAMENDA 2 MG/ML ORAL SOLUTION NAMENDA 5 MG NAMENDA 10 MG NAMENDA TITRATION PAK 5 MG-10 MG S IN A DOSE PACK NUVIGIL 50 MG NUVIGIL 150 MG NUVIGIL 200 MG NUVIGIL 250 MG ORAP 1 MG ORAP 2 MG PATANOL 0.1 % EYE DROPS PROTONIX 40 MG INTRAVENOUS SOLUTION RAPAMUNE 0.5 MG RAPAMUNE 1 MG Comment Formulary alternatives available (e.g. propranolol ER capsule) Formulary alternatives available (e.g. propranolol ER capsule) Formulary alternatives available (e.g. Gavilyte, Suprep, Trilyte)

4 MEDICATIONS REMOVED FROM THE 2016 MAPD FORMULARY Medication Name RAPAMUNE 2 MG REMICADE 100 MG INTRAVENOUS SOLUTION RENAGEL 800 MG SULFASALAZINE 500 MG,DELAYED SURMONTIL 25 MG CAPSULE SURMONTIL 50 MG CAPSULE SURMONTIL 100 MG CAPSULE TARGRETIN 75 MG CAPSULE TIKOSYN 125 MCG CAPSULE TIKOSYN 250 MCG CAPSULE TIKOSYN 500 MCG CAPSULE TIZANIDINE 2 MG CAPSULE TIZANIDINE 4 MG CAPSULE TIZANIDINE 6 MG CAPSULE VOLTAREN 1 % TOPICAL GEL ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE ZYVOX 100 MG/5 ML ORAL SUSPENSION Comment Formulary alternatives available (e.g. Humira, Enbrel) Formulary alternatives available (e.g. calcium acetate, Renvela) Formulary alternatives available (e.g. sulfasalazine 500 mg tablet) Formulary alternatives available (e.g. tizanidine tablets) Formulary alternatives available (e.g. tizanidine tablets) Formulary alternatives available (e.g. tizanidine tablets) Formulary alternatives available (e.g. latanoprost, Lumigan, Travatan Z) MEDICATIONS ADDED TO THE 2017 MAPD FORMULARY Medication Name Benefit Tier AUBAGIO 14 MG Tier 5 AUBAGIO 7 MG Tier 5 BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION BUDESONIDE 1 MG/2 ML SUSPENSION FOR NEBULIZATION Tier 4 Tier 4 Tier 4 Quantity Limit (QL) QL 30 EA per 30 Days QL 30 EA per 30 Days Prior Authorization (PA) or Step Therapy (ST) Requirement PA Applies for New Starts Only PA Applies for New Starts Only Part B vs D PA Applies Part B vs D PA Applies Part B vs D PA Applies

5 MEDICATIONS ADDED TO THE 2017 MAPD FORMULARY Medication Name BUTRANS 10 MCG/HOUR TRANSDERMAL PATCH BUTRANS 15 MCG/HOUR TRANSDERMAL PATCH BUTRANS 20 MCG/HOUR TRANSDERMAL PATCH BUTRANS 5 MCG/HOUR TRANSDERMAL PATCH BUTRANS 7.5 MCG/HOUR TRANSDERMAL PATCH Benefit Tier Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 CAFERGOT 1 MG-100 MG Tier 4 Quantity Limit (QL) QL 4 EA per 28 days QL 4 EA per 28 days QL 4 EA per 28 days QL 4 EA per 28 days QL 4 EA per 28 days Prior Authorization (PA) or Step Therapy (ST) Requirement CAMILA 0.35 MG Tier 2 CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION CLINDAMYCIN 150 MG/ML INJECTION SOLUTION CLINDAMYCIN 150 MG/ML INJECTION SOLUTION (6 ML) Tier 4 Tier 2 Tier 2 CLOBETASOL 0.05 % LOTION Tier 4 CLOBETASOL 0.05 % SHAMPOO Tier 4 CYSTARAN 0.44 % EYE DROPS Tier 5 PA Applies DEXTROAMPHETAMINE- AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND DEXTROAMPHETAMINE- AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND DEXTROAMPHETAMINE- AMPHETAMINE ER 20 MG 24HR CAPSULE,EXTEND DEXTROAMPHETAMINE- AMPHETAMINE ER 25 MG 24HR CAPSULE,EXTEND Tier 4 Tier 4 Tier 4 Tier 4 QL 30 EA per 30 days QL 30 EA per 30 days QL 30 EA per 30 days QL 30 EA per 30 days

6 MEDICATIONS ADDED TO THE 2017 MAPD FORMULARY Medication Name DEXTROAMPHETAMINE- AMPHETAMINE ER 30 MG 24HR CAPSULE,EXTEND DEXTROAMPHETAMINE- AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND DIHYDROERGOTAMINE 0.5 MG/PUMP ACT. (4 MG/ML) NASAL SPRAY Benefit Tier Tier 4 Tier 4 Tier 3 EPLERENONE 25 MG Tier 4 Quantity Limit (QL) QL 30 EA per 30 days QL 30 EA per 30 days Prior Authorization (PA) or Step Therapy (ST) Requirement EPLERENONE 50 MG Tier 4 ERGOMAR 2 MG SUBLINGUAL Tier 3 ESTRACE 0.01% (0.1 MG/GRAM) Tier 4 VAGINAL CREAM FLUOCINOLONE 0.01 % TOPICAL BODY OIL Tier 3 GRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE GRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION (5 ML) HYDROMORPHONE 2 MG/ML INJECTION SYRINGE Tier 5 Tier 5 Tier 4 Tier 4 Part B vs D PA Applies Part B vs D PA Applies HYDROXYZINE HCL 10 MG Tier 3 PA Applies HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION Tier 3 PA Applies HYDROXYZINE HCL 25 MG Tier 3 PA Applies HYDROXYZINE HCL 50 MG Tier 3 PA Applies HYDROXYZINE PAMOATE 25 MG CAPSULE Tier 3 PA Applies

7 MEDICATIONS ADDED TO THE 2017 MAPD FORMULARY Medication Name HYDROXYZINE PAMOATE 50 MG CAPSULE HYDROXYZINE PAMOATE 100 MG CAPSULE LIALDA 1.2 GRAM,DELAYED Benefit Tier Tier 3 Tier 3 Tier 3 LINZESS 145 MCG CAPSULE Tier 3 Quantity Limit (QL) QL 120 EA per 30 days Prior Authorization (PA) or Step Therapy (ST) Requirement PA Applies PA Applies LINZESS 290 MCG CAPSULE Tier 3 MITOMYCIN 5 MG INTRAVENOUS SOLUTION MITOMYCIN 20 MG INTRAVENOUS SOLUTION MITOMYCIN 40 MG INTRAVENOUS SOLUTION MORPHINE 10 MG/5 ML ORAL SOLUTION MORPHINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION Tier 5 Tier 5 Tier 5 Tier 3 Tier 3 Tier 3 QL 2700 ML per 30 days QL 1350 ML per 30 days QL 600 ML per 30 days PA Applies for New Starts Only PA Applies for New Starts Only PA Applies for New Starts Only MOVANTIK 12.5 MG Tier 4 MOVANTIK 25 MG Tier 4 NALOXONE 0.4 MG/ML INJECTION SOLUTION NORETHINDRONE (CONTRACEPTIVE) 0.35 MG ORENITRAM MG,EXTENDED ORENITRAM 0.25 MG,EXTENDED Tier 2 Tier 2 Tier 4 Tier 4 PA Applies PA Applies

8 MEDICATIONS ADDED TO THE 2017 MAPD FORMULARY Medication Name ORENITRAM 1 MG,EXTENDED ORENITRAM 2.5 MG,EXTENDED Benefit Tier Tier 5 Tier 5 ORKAMBI 200 MG-125 MG Tier 5 Quantity Limit (QL) Prior Authorization (PA) or Step Therapy (ST) Requirement PA Applies PA Applies PA Applies PAZEO 0.7 % EYE DROPS Tier 3 PEGASYS 180 MCG/0.5 ML SUBCUTANEOUS SYRINGE Tier 5 QL 2 EA per 28 days PA Applies for New Starts Only PEGASYS 180 MCG/ML SUBCUTANEOUS SOLUTION Tier 5 QL 4 EA per 28 days PA Applies for New Starts Only PEGASYS PROCLICK 135 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR Tier 5 QL 2 EA per 28 days PA Applies for New Starts Only PEGASYS PROCLICK 180 MCG/0.5 ML SUBCUTANEOUS PEN INJECTOR Tier 5 QL 2 EA per 28 days PA Applies for New Starts Only PENTASA 250 MG CAPSULE,CONTROLLED Tier 3 QL 240 EA per 30 days PENTASA 500 MG CAPSULE,CONTROLLED Tier 3 QL 240 EA per 30 days PRIFTIN 150 MG Tier 4 QVAR 40 MCG/ACTUATION METERED AEROSOL ORAL INHALER QVAR 80 MCG/ACTUATION METERED AEROSOL ORAL INHALER RENVELA 0.8 GRAM ORAL POWDER PACKET RENVELA 2.4 GRAM ORAL POWDER PACKET SUPREP BOWEL PREP KIT 17.5 GRAM-3.13 GRAM-1.6 GRAM ORAL SOLUTION TOBI PODHALER 28 MG CAPSULE WITH INHALATION DEVICE Tier 3 Tier 3 Tier 5 Tier 5 Tier 4 Tier 5 ST Applied for New Starts Only PA Applies

9 MEDICATIONS ADDED TO THE 2017 MAPD FORMULARY Medication Name TRI-SPRINTEC (28) 0.18 MG(7)/0.215 MG(7)/0.25 MG(7)-35 MCG TYVASO 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION Benefit Tier Tier 2 Tier 5 UPTRAVI 1,000 MCG Tier 5 UPTRAVI 1,200 MCG Tier 5 UPTRAVI 1,400 MCG Tier 5 Quantity Limit (QL) QL 60 EA per 30 days QL 60 EA per 30 days QL 60 EA per 30 days Prior Authorization (PA) or Step Therapy (ST) Requirement Part B vs D PA Applies PA Applies PA Applies PA Applies UPTRAVI 1,600 MCG Tier 5 UPTRAVI 200 MCG (140)-800 MCG (60) S IN A DOSE PACK Tier 5 UPTRAVI 200 MCG Tier 5 UPTRAVI 400 MCG Tier 5 UPTRAVI 600 MCG Tier 5 UPTRAVI 800 MCG Tier 5 VENTAVIS 10 MCG/ML SOLUTION FOR NEBULIZATION VENTAVIS 20 MCG/ML SOLUTION FOR NEBULIZATION Tier 5 Tier 5 QL 60 EA per 30 days QL 200 EA per 28 days QL 60 EA per 30 days QL 60 EA per 30 days QL 60 EA per 30 days QL 60 EA per 30 days PA Applies PA Applies PA Applies PA Applies PA Applies PA Applies Part B vs D PA Applies Part B vs D PA Applies MEDICATIONS WITH TIERING CHANGES ACEBUTOLOL 200 MG CAPSULE ACEBUTOLOL 400 MG CAPSULE ACETAMINOPHEN 300 MG-CODEINE 15 MG ACETAMINOPHEN 300 MG-CODEINE 30 MG

10 ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION ACETAMINOPHEN 300 MG-CODEINE 60 MG ALBENZA 200 MG Tier 3 Tier 5 ALCLOMETASONE 0.05 % TOPICAL OINTMENT Tier 4 Tier 3 ALENDRONATE 5 MG ALENDRONATE 10 MG ALENDRONATE 35 MG ALENDRONATE 40 MG ALENDRONATE 70 MG ALFUZOSIN ER 10 MG,EXTENDED 24 HR AMANTADINE HCL 100 MG AMIKACIN 500 MG/2 ML INJECTION SOLUTION Tier 2 Tier 4 AMIODARONE 200 MG AMLODIPINE 2.5 MG Tier 1 Tier 6 ($0) AMLODIPINE 5 MG Tier 1 Tier 6 ($0) AMLODIPINE 10 MG Tier 1 Tier 6 ($0) AMLODIPINE 2.5 MG-BENAZEPRIL 10 MG CAPSULE AMLODIPINE 5 MG-BENAZEPRIL 10 MG CAPSULE AMLODIPINE 5 MG-BENAZEPRIL 20 MG CAPSULE AMLODIPINE 5 MG-BENAZEPRIL 40 MG CAPSULE AMLODIPINE 10 MG-BENAZEPRIL 20 MG CAPSULE AMLODIPINE 10 MG-BENAZEPRIL 40 MG CAPSULE AMLODIPINE 5 MG-VALSARTAN 160 MG Tier 4 Tier 2 AMLODIPINE 5 MG-VALSARTAN 320 MG Tier 4 Tier 2

11 AMLODIPINE 10 MG-VALSARTAN 160 MG Tier 4 Tier 2 AMLODIPINE 10 MG-VALSARTAN 320 MG Tier 4 Tier 2 AMLODIPINE 5 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 12.5 MG Tier 4 Tier 3 AMLODIPINE 5 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 25 MG Tier 4 Tier 3 AMLODIPINE 10 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 12.5 MG Tier 4 Tier 3 AMLODIPINE 10 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 25 MG Tier 4 Tier 3 AMLODIPINE 10 MG-VALSARTAN 320 MG- HYDROCHLOROTHIAZIDE 25 MG Tier 4 Tier 3 AMOXAPINE 25 MG AMOXAPINE 50 MG AMOXAPINE 100 MG AMOXAPINE 150 MG AMOXICILLIN 250 MG CAPSULE AMOXICILLIN 500 MG CAPSULE AMOXICILLIN 125 MG CHEWABLE AMOXICILLIN 250 MG CHEWABLE AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION AMOXICILLIN 500 MG AMOXICILLIN 875 MG AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION AMOXICILLIN 200 MG-POTASSIUM CLAVULANATE 28.5 MG CHEWABLE AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG CHEWABLE AMOXICILLIN 200 MG-POTASSIUM CLAVULANATE 28.5 MG/5 ML ORAL

12 SUSPENSION AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG AMPICILLIN 250 MG CAPSULE AMPICILLIN 500 MG CAPSULE ANAGRELIDE 0.5 MG CAPSULE ANAGRELIDE 1 MG CAPSULE ATENOLOL 25 MG Tier 1 Tier 6 ($0) ATENOLOL 50 MG Tier 1 Tier 6 ($0) ATENOLOL 100 MG Tier 1 Tier 6 ($0) ATENOLOL 50 MG-CHLORTHALIDONE 25 MG ATENOLOL 100 MG-CHLORTHALIDONE 25 MG ATORVASTATIN 10 MG ATORVASTATIN 20 MG ATORVASTATIN 40 MG ATORVASTATIN 80 MG AZELASTINE 0.05 % EYE DROPS Tier 4 Tier 2 AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION AZITHROMYCIN 250 MG AZITHROMYCIN 250 MG (6 PACK)

13 AZITHROMYCIN 500 MG AZITHROMYCIN 600 MG BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT BENAZEPRIL 5 MG Tier 1 Tier 6 ($0) BENAZEPRIL 10 MG Tier 1 Tier 6 ($0) BENAZEPRIL 20 MG Tier 1 Tier 6 ($0) BENAZEPRIL 40 MG Tier 1 Tier 6 ($0) BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT Tier 4 Tier 2 Tier 4 Tier 2 BETAMETHASONE VALERATE 0.1 % LOTION BETAMETHASONE, AUGMENTED 0.05 % TOPICAL GEL BETAMETHASONE, AUGMENTED 0.05 % TOPICAL OINTMENT BETHANECHOL CHLORIDE 5 MG BETHANECHOL CHLORIDE 10 MG BETHANECHOL CHLORIDE 25 MG BETHANECHOL CHLORIDE 50 MG BICALUTAMIDE 50 MG BISOPROLOL FUMARATE 5 MG BISOPROLOL FUMARATE 10 MG BISOPROLOL 2.5 MG- HYDROCHLOROTHIAZIDE 6.25 MG BISOPROLOL 5 MG-HYDROCHLOROTHIAZIDE 6.25 MG BISOPROLOL 10 MG- HYDROCHLOROTHIAZIDE 6.25 MG BRIMONIDINE 0.2 % EYE DROPS BRIVIACT 10 MG/ML ORAL SOLUTION Tier 4 Tier 5 BRIVIACT 50 MG/5 ML INTRAVENOUS SOLUTION Tier 5 Tier 4

14 BROMOCRIPTINE 2.5 MG Tier 3 Tier 4 BROMOCRIPTINE 5 MG CAPSULE Tier 3 Tier 4 BUPRENORPHINE HCL 0.3 MG/ML INJECTION SYRINGE BUPRENORPHINE HCL 2 MG SUBLINGUAL BUPRENORPHINE HCL 8 MG SUBLINGUAL BUTALBITAL 50 MG-ACETAMINOPHEN 325 MG-CAFFEINE 40 MG-CODEINE 30 MG CAP BUTALBITAL-ACETAMINOPHEN 50 MG-325 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 2 Tier 3 Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 3 Tier 4 CANDESARTAN 4 MG Tier 4 Tier 3 CANDESARTAN 8 MG Tier 4 Tier 3 CANDESARTAN 16 MG Tier 4 Tier 3 CANDESARTAN 32 MG Tier 4 Tier 3 CANDESARTAN 16 MG- HYDROCHLOROTHIAZIDE 12.5 MG Tier 4 Tier 3 CANDESARTAN 32 MG- HYDROCHLOROTHIAZIDE 12.5 MG Tier 4 Tier 3 CANDESARTAN 32 MG- HYDROCHLOROTHIAZIDE 25 MG Tier 4 Tier 3 CAPTOPRIL 12.5 MG Tier 1 Tier 2 CAPTOPRIL 25 MG Tier 1 Tier 2 CAPTOPRIL 50 MG Tier 1 Tier 2 CAPTOPRIL 100 MG Tier 1 Tier 2 CARBAMAZEPINE 100 MG CHEWABLE CARBAMAZEPINE 200 MG CARBIDOPA 12.5 MG-LEVODOPA 50 MG- ENTACAPONE 200 MG Tier 3 Tier 4

15 CARBIDOPA MG-LEVODOPA 75 MG- ENTACAPONE 200 MG CARBIDOPA 25 MG-LEVODOPA 100 MG- ENTACAPONE 200 MG CARBIDOPA MG-LEVODOPA 125 MG- ENTACAPONE 200 MG CARBIDOPA 37.5 MG-LEVODOPA 150 MG- ENTACAPONE 200 MG CARBIDOPA 50 MG-LEVODOPA 200 MG- ENTACAPONE 200 MG Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4 CARTEOLOL 1 % EYE DROPS CARTIA XT 120 MG CAPSULE,EXTENDED CARTIA XT 180 MG CAPSULE,EXTENDED CARTIA XT 240 MG CAPSULE,EXTENDED CARTIA XT 300 MG CAPSULE,EXTENDED CARVEDILOL MG Tier 1 Tier 6 ($0) CARVEDILOL 6.25 MG Tier 1 Tier 6 ($0) CARVEDILOL 12.5 MG Tier 1 Tier 6 ($0) CARVEDILOL 25 MG Tier 1 Tier 6 ($0) CEFDINIR 300 MG CAPSULE CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION CEPHALEXIN 250 MG CAPSULE CEPHALEXIN 500 MG CAPSULE CIPROFLOXACIN 0.3 % EYE DROPS CIPROFLOXACIN 250 MG CIPROFLOXACIN 500 MG CIPROFLOXACIN 750 MG CITALOPRAM 10 MG CITALOPRAM 20 MG CITALOPRAM 40 MG

16 CLINDAMYCIN 150 MG CAPSULE CLINDAMYCIN 300 MG CAPSULE CLOBETASOL 0.05 % TOPICAL GEL Tier 2 Tier 4 CLONAZEPAM MG DISINTEGRATING CLONAZEPAM 0.25 MG DISINTEGRATING CLONAZEPAM 0.5 MG DISINTEGRATING CLONAZEPAM 1 MG DISINTEGRATING CLONAZEPAM 2 MG DISINTEGRATING Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 2 Tier 4 Tier 2 CLONIDINE HCL 0.1 MG CLONIDINE HCL 0.2 MG CLONIDINE HCL 0.3 MG CLOPIDOGREL 75 MG CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % LOTION Tier 4 Tier 3 CODEINE SULFATE 15 MG CODEINE SULFATE 30 MG CODEINE SULFATE 60 MG COLOCORT 100 MG/60 ML ENEMA Tier 3 Tier 4 CUPRIMINE 250 MG CAPSULE Tier 3 Tier 5 CYCLOPHOSPHAMIDE 25 MG CAPSULE CYCLOPHOSPHAMIDE 50 MG CAPSULE DANAZOL 50 MG CAPSULE Tier 3 Tier 4 DANAZOL 100 MG CAPSULE Tier 3 Tier 4 DANAZOL 200 MG CAPSULE Tier 3 Tier 4 DEPEN TITRATABS 250 MG Tier 3 Tier 5 DESIPRAMINE 10 MG Tier 3 Tier 4 DESIPRAMINE 25 MG Tier 3 Tier 4

17 DESIPRAMINE 50 MG Tier 3 Tier 4 DESIPRAMINE 75 MG Tier 3 Tier 4 DESIPRAMINE 100 MG Tier 3 Tier 4 DESIPRAMINE 150 MG Tier 3 Tier 4 DEXTROAMPHETAMINE ER 5 MG CAPSULE,EXTENDED DEXTROAMPHETAMINE ER 10 MG CAPSULE,EXTENDED DEXTROAMPHETAMINE ER 15 MG CAPSULE,EXTENDED Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4 DICYCLOMINE 10 MG CAPSULE DICYCLOMINE 10 MG/5 ML ORAL SOLUTION DICYCLOMINE 20 MG DILT-XR 120 MG CAPSULE, EXTENDED DILT-XR 180 MG CAPSULE, EXTENDED DILT-XR 240 MG CAPSULE, EXTENDED DILTIAZEM 30 MG DILTIAZEM 60 MG DILTIAZEM 90 MG DILTIAZEM 120 MG DILTIAZEM CD 120 MG CAPSULE,EXTENDED 24 HR DILTIAZEM CD 240 MG CAPSULE,EXTENDED 24 HR DILTIAZEM CD 300 MG CAPSULE,EXTENDED 24 HR DILTIAZEM ER 180 MG CAPSULE,EXTENDED DILTIAZEM ER 360 MG CAPSULE,EXTENDED DILTIAZEM ER 420 MG CAPSULE,EXTENDED DORZOLAMIDE 2 % EYE DROPS DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS DOXYCYCLINE HYCLATE 50 MG CAPSULE

18 DOXYCYCLINE HYCLATE 100 MG CAPSULE Tier 4 Tier 3 DOXYCYCLINE HYCLATE 100 MG Tier 4 Tier 3 DULOXETINE 40 MG CAPSULE,DELAYED Tier 3 Tier 4 ECONAZOLE 1 % TOPICAL CREAM Tier 2 Tier 4 ENALAPRIL MALEATE 2.5 MG Tier 1 Tier 6 ($0) ENALAPRIL MALEATE 5 MG Tier 1 Tier 6 ($0) ENALAPRIL MALEATE 10 MG Tier 1 Tier 6 ($0) ENALAPRIL MALEATE 20 MG Tier 1 Tier 6 ($0) ENALAPRIL 5 MG-HYDROCHLOROTHIAZIDE 12.5 MG Tier 2 Tier 6 ($0) ENALAPRIL 10 MG-HYDROCHLOROTHIAZIDE 25 MG Tier 2 Tier 6 ($0) ENDOCET 5 MG-325 MG ENDOCET 7.5 MG-325 MG ENDOCET 10 MG-325 MG ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE Tier 5 Tier 4 ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE Tier 5 Tier 4 ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE Tier 5 Tier 4 ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT ETODOLAC ER 400 MG,EXTENDED 24 HR Tier 3 Tier 4 ETODOLAC ER 500 MG,EXTENDED 24 HR Tier 3 Tier 4 ETODOLAC ER 600 MG,EXTENDED 24 HR Tier 3 Tier 4 FELODIPINE ER 2.5 MG,EXTENDED 24 HR FELODIPINE ER 5 MG,EXTENDED 24 HR FELODIPINE ER 10 MG,EXTENDED 24 HR FENOFIBRATE MICRONIZED 43 MG CAPSULE FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE,DELAYED FENTANYL 12 MCG/HR TRANSDERMAL PATCH FENTANYL 25 MCG/HR TRANSDERMAL

19 PATCH FENTANYL 50 MCG/HR TRANSDERMAL PATCH FENTANYL 75 MCG/HR TRANSDERMAL PATCH FENTANYL 100 MCG/HR TRANSDERMAL PATCH FLUOCINOLONE 0.01 % TOPICAL CREAM Tier 4 Tier 3 FLUOCINOLONE % TOPICAL OINTMENT FLUOCINOLONE ACETONIDE OIL 0.01 % EAR DROPS FLUOCINONIDE 0.05 % TOPICAL GEL Tier 4 Tier 3 FLUOCINONIDE 0.05 % TOPICAL OINTMENT Tier 4 Tier 3 FLUOCINONIDE 0.05 % TOPICAL SOLUTION Tier 4 Tier 3 FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION Tier 4 Tier 3 FLUOROURACIL 2 % TOPICAL SOLUTION FLUOROURACIL 5 % TOPICAL CREAM FLUOROURACIL 5 % TOPICAL SOLUTION FLUOXETINE 10 MG CAPSULE FLUOXETINE 20 MG CAPSULE FLUOXETINE 40 MG CAPSULE FOSINOPRIL 10 MG FOSINOPRIL 20 MG FOSINOPRIL 40 MG FUROSEMIDE 10 MG/ML INJECTION SOLUTION Tier 3 Tier 1 FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION Tier 3 Tier 1 GALANTAMINE 4 MG/ML ORAL SOLUTION Tier 3 Tier 4 GENTAMICIN 0.3 % EYE DROPS GLIMEPIRIDE 1 MG Tier 1 Tier 6 ($0) GLIMEPIRIDE 2 MG Tier 1 Tier 6 ($0) GLIMEPIRIDE 4 MG Tier 1 Tier 6 ($0) GLIPIZIDE 5 MG Tier 1 Tier 6 ($0) GLIPIZIDE 10 MG Tier 1 Tier 6 ($0) GLIPIZIDE ER 2.5 MG, EXTENDED Tier 1 Tier 6 ($0)

20 24 HR GLIPIZIDE ER 5 MG, EXTENDED 24 HR Tier 1 Tier 6 ($0) GLIPIZIDE ER 10 MG, EXTENDED 24 HR Tier 1 Tier 6 ($0) GLYCOPYRROLATE 1 MG GLYCOPYRROLATE 2 MG GUANFACINE 1 MG GUANFACINE 2 MG HYDRALAZINE 10 MG HYDRALAZINE 25 MG HYDRALAZINE 50 MG HYDRALAZINE 100 MG HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE HYDROCHLOROTHIAZIDE 12.5 MG HYDROCHLOROTHIAZIDE 25 MG Tier 1 Tier 6 ($0) HYDROCHLOROTHIAZIDE 50 MG Tier 1 Tier 6 ($0) HYDROCODONE 10 MG-ACETAMINOPHEN 300 MG HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG HYDROCODONE 5 MG-ACETAMINOPHEN 300 MG HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG HYDROCODONE 7.5 MG-ACETAMINOPHEN 300 MG HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG HYDROCODONE 7.5 MG-IBUPROFEN 200 MG HYDROCORTISONE 100 MG/60 ML ENEMA Tier 2 Tier 4 HYDROMORPHONE 2 MG HYDROMORPHONE 4 MG HYDROMORPHONE 8 MG INDAPAMIDE 1.25 MG INDAPAMIDE 2.5 MG INVEGA SUSTENNA 78 MG/0.5 ML INTRAMUSCULAR SYRINGE Tier 4 Tier 5

21 IRBESARTAN 75 MG IRBESARTAN 150 MG IRBESARTAN 300 MG IRBESARTAN 150 MG- HYDROCHLOROTHIAZIDE 12.5 MG IRBESARTAN 300 MG- HYDROCHLOROTHIAZIDE 12.5 MG ITRACONAZOLE 100 MG CAPSULE Tier 3 Tier 4 IVERMECTIN 3 MG Tier 4 Tier 2 JANTOVEN 1 MG JANTOVEN 2 MG JANTOVEN 2.5 MG JANTOVEN 3 MG JANTOVEN 4 MG JANTOVEN 5 MG JANTOVEN 6 MG JANTOVEN 7.5 MG JANTOVEN 10 MG LAMIVUDINE 150 MG-ZIDOVUDINE 300 MG Tier 5 Tier 4 LANSOPRAZOLE 15 MG CAPSULE,DELAYED Tier 4 Tier 2 LANSOPRAZOLE 30 MG CAPSULE,DELAYED Tier 4 Tier 2 LATANOPROST % EYE DROPS LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION Tier 2 Tier 4 LEVOBUNOLOL 0.5 % EYE DROPS LEVOTHYROXINE 25 MCG LEVOTHYROXINE 50 MCG LEVOTHYROXINE 75 MCG LEVOTHYROXINE 88 MCG LEVOTHYROXINE 100 MCG LEVOTHYROXINE 112 MCG LEVOTHYROXINE 125 MCG LEVOTHYROXINE 137 MCG

22 LEVOTHYROXINE 150 MCG LEVOTHYROXINE 175 MCG LEVOTHYROXINE 200 MCG LEVOTHYROXINE 300 MCG LISINOPRIL 2.5 MG Tier 1 Tier 6 ($0) LISINOPRIL 5 MG Tier 1 Tier 6 ($0) LISINOPRIL 10 MG Tier 1 Tier 6 ($0) LISINOPRIL 20 MG Tier 1 Tier 6 ($0) LISINOPRIL 30 MG Tier 1 Tier 6 ($0) LISINOPRIL 40 MG Tier 1 Tier 6 ($0) LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG Tier 2 Tier 6 ($0) LISINOPRIL 20 MG-HYDROCHLOROTHIAZIDE 12.5 MG Tier 2 Tier 6 ($0) LISINOPRIL 20 MG-HYDROCHLOROTHIAZIDE 25 MG Tier 2 Tier 6 ($0) LITHIUM CARBONATE 150 MG CAPSULE LITHIUM CARBONATE 300 MG CAPSULE LITHIUM CARBONATE 300 MG LITHIUM CARBONATE 600 MG CAPSULE LITHIUM CARBONATE ER 300 MG,EXTENDED LITHIUM CARBONATE ER 450 MG,EXTENDED LITHIUM CITRATE 8 MEQ/5 ML ORAL SOLUTION LOSARTAN 25 MG Tier 1 Tier 6 ($0) LOSARTAN 50 MG Tier 1 Tier 6 ($0) LOSARTAN 100 MG Tier 1 Tier 6 ($0) LOSARTAN 50 MG-HYDROCHLOROTHIAZIDE 12.5 MG Tier 2 Tier 6 ($0) LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG Tier 2 Tier 6 ($0) LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 25 MG Tier 2 Tier 6 ($0) LOVASTATIN 10 MG LOVASTATIN 20 MG LOVASTATIN 40 MG

23 LUMIGAN 0.01 % EYE DROPS Tier 4 Tier 3 MEMANTINE 2 MG/ML ORAL SOLUTION MEMANTINE 5 MG MEMANTINE 10 MG MEMANTINE 5 MG-10 MG S IN A DOSE PACK MEPROBAMATE 200 MG Tier 4 Tier 3 MEPROBAMATE 400 MG Tier 4 Tier 3 MESTINON 60 MG/5 ML SYRUP Tier 4 Tier 5 METFORMIN 500 MG Tier 1 Tier 6 ($0) METFORMIN 850 MG Tier 1 Tier 6 ($0) METFORMIN 1,000 MG Tier 1 Tier 6 ($0) METFORMIN ER 500 MG,EXTENDED 24 HR Tier 1 Tier 6 ($0) METFORMIN ER 750 MG,EXTENDED 24 HR Tier 1 Tier 6 ($0) METHADONE 5 MG METHADONE 10 MG METHAZOLAMIDE 25 MG Tier 3 Tier 4 METHAZOLAMIDE 50 MG Tier 3 Tier 4 METHIMAZOLE 5 MG METHIMAZOLE 10 MG METHYLDOPA 250 MG METHYLDOPA 500 MG METHYLPHENIDATE ER 20 MG,EXTENDED Tier 3 Tier 4 METOPROLOL TARTRATE 25 MG Tier 1 Tier 6 ($0) METOPROLOL TARTRATE 50 MG Tier 1 Tier 6 ($0) METOPROLOL TARTRATE 100 MG Tier 1 Tier 6 ($0) METRONIDAZOLE 0.75 % LOTION Tier 2 Tier 4 METRONIDAZOLE 0.75 % TOPICAL CREAM METRONIDAZOLE 0.75 % TOPICAL GEL METRONIDAZOLE 250 MG METRONIDAZOLE 500 MG MONTELUKAST 4 MG CHEWABLE

24 MONTELUKAST 5 MG CHEWABLE MONTELUKAST 10 MG MORPHINE 15 MG IMMEDIATE MORPHINE 30 MG IMMEDIATE MORPHINE ER 15 MG,EXTENDED MORPHINE ER 30 MG,EXTENDED MORPHINE ER 60 MG,EXTENDED MORPHINE ER 100 MG,EXTENDED MORPHINE ER 200 MG,EXTENDED MUPIROCIN 2 % TOPICAL OINTMENT NALTREXONE 50 MG NEFAZODONE 50 MG Tier 2 Tier 4 NEFAZODONE 100 MG Tier 2 Tier 4 NEFAZODONE 150 MG Tier 2 Tier 4 NEFAZODONE 200 MG Tier 2 Tier 4 NEFAZODONE 250 MG Tier 2 Tier 4 NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT- HYDROCORT 10 MG/ML EYE DROP,SUSP NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS NICARDIPINE 20 MG CAPSULE NICARDIPINE 30 MG CAPSULE NICOTROL NS 10 MG/ML NASAL SPRAY Tier 3 Tier 4 NORTRIPTYLINE 10 MG CAPSULE NORTRIPTYLINE 25 MG CAPSULE NORTRIPTYLINE 50 MG CAPSULE NORTRIPTYLINE 75 MG CAPSULE

25 NORTRIPTYLINE 10 MG/5 ML ORAL SOLUTION NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G- 0.1 % TOPICAL CREAM NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT Tier 2 Tier 4 Tier 2 Tier 4 OFLOXACIN 0.3 % EAR DROPS Tier 2 Tier 4 OLANZAPINE 2.5 MG OLANZAPINE 5 MG OLANZAPINE 7.5 MG OLANZAPINE 10 MG OLANZAPINE 15 MG OLANZAPINE 20 MG OXCARBAZEPINE 300 MG/5 ML ORAL SUSPENSION OXCARBAZEPINE 150 MG OXCARBAZEPINE 300 MG OXCARBAZEPINE 600 MG OXYBUTYNIN CHLORIDE ER 5 MG,EXTENDED 24 HR OXYBUTYNIN CHLORIDE ER 10 MG,EXTENDED 24 HR OXYBUTYNIN CHLORIDE ER 15 MG,EXTENDED 24 HR OXYCODONE 5 MG OXYCODONE 10 MG OXYCODONE 15 MG OXYCODONE 20 MG OXYCODONE 30 MG OXYCODONE-ACETAMINOPHEN 2.5 MG-325 MG OXYCODONE-ACETAMINOPHEN 5 MG-325 MG OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG OXYCODONE-ACETAMINOPHEN 10 MG-325 MG PAROXETINE 10 MG PAROXETINE 20 MG

26 PAROXETINE 30 MG PAROXETINE 40 MG PENICILLIN V POTASSIUM 125 MG/5 ML ORAL SOLUTION PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION PENICILLIN V POTASSIUM 250 MG PENICILLIN V POTASSIUM 500 MG PERPHENAZINE-AMITRIPTYLINE 2 MG-10 MG PERPHENAZINE-AMITRIPTYLINE 2 MG-25 MG PERPHENAZINE-AMITRIPTYLINE 4 MG-10 MG PERPHENAZINE-AMITRIPTYLINE 4 MG-25 MG PERPHENAZINE-AMITRIPTYLINE 4 MG-50 MG PHENELZINE 15 MG Tier 4 Tier 3 PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR PHENOBARBITAL 15 MG PHENOBARBITAL 16.2 MG PHENOBARBITAL 30 MG PHENOBARBITAL 32.4 MG PHENOBARBITAL 60 MG PHENOBARBITAL 64.8 MG PHENOBARBITAL 97.2 MG PHENOBARBITAL 100 MG PHENYTOIN 50 MG CHEWABLE Tier 4 Tier 2 PILOCARPINE 1 % EYE DROPS Tier 4 Tier 3 PILOCARPINE 2 % EYE DROPS Tier 4 Tier 3 PILOCARPINE 4 % EYE DROPS Tier 4 Tier 3 PILOCARPINE 5 MG PILOCARPINE 7.5 MG PIMOZIDE 1 MG Tier 3 Tier 4 PIMOZIDE 2 MG Tier 3 Tier 4 PIOGLITAZONE 15 MG

27 PIOGLITAZONE 30 MG PIOGLITAZONE 45 MG POLYMYXIN B SULFATE 10,000 UNIT- TRIMETHOPRIM 1 MG/ML EYE DROPS POTASSIUM CHLORIDE 20 MEQ/100 ML INTRAVENOUS PIGGYBACK PRAMIPEXOLE MG PRAMIPEXOLE 0.25 MG PRAMIPEXOLE 0.5 MG PRAMIPEXOLE 1 MG PRAMIPEXOLE 1.5 MG PRAVASTATIN 10 MG Tier 1 Tier 6 ($0) PRAVASTATIN 20 MG Tier 1 Tier 6 ($0) PRAVASTATIN 40 MG Tier 1 Tier 6 ($0) PRAVASTATIN 80 MG Tier 1 Tier 6 ($0) PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY Tier 2 Tier 4 PROCRIT 3,000 UNIT/ML INJECTION SOLUTION Tier 3 Tier 4 PROCRIT 4,000 UNIT/ML INJECTION SOLUTION Tier 3 Tier 4 PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED PROPRANOLOL ER 120 MG CAPSULE,24 HR,EXTENDED PROPRANOLOL ER 160 MG CAPSULE,24 HR,EXTENDED PYRIDOSTIGMINE BROMIDE 60 MG QUINAPRIL 5 MG QUINAPRIL 10 MG QUINAPRIL 20 MG QUINAPRIL 40 MG QUINIDINE GLUCONATE ER 324 MG,EXTENDED Tier 2 Tier 4 QUININE 324 MG CAPSULE Tier 2 Tier 4 RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 5 MG CAPSULE

28 RAMIPRIL 10 MG CAPSULE RANITIDINE 150 MG RANITIDINE 300 MG RELISTOR 12 MG/0.6 ML SUBCUTANEOUS SOLUTION Tier 4 Tier 5 RENVELA 800 MG Tier 4 Tier 5 REPAGLINIDE 0.5 MG Tier 4 Tier 2 REPAGLINIDE 1 MG Tier 4 Tier 2 REPAGLINIDE 2 MG Tier 4 Tier 2 SANTYL 250 UNIT/GRAM TOPICAL OINTMENT Tier 3 Tier 4 SELEGILINE 5 MG CAPSULE SERTRALINE 25 MG SERTRALINE 50 MG SERTRALINE 100 MG SIMVASTATIN 5 MG Tier 1 Tier 6 ($0) SIMVASTATIN 10 MG Tier 1 Tier 6 ($0) SIMVASTATIN 20 MG Tier 1 Tier 6 ($0) SIMVASTATIN 40 MG Tier 1 Tier 6 ($0) SIMVASTATIN 80 MG Tier 1 Tier 6 ($0) SPIRONOLACTONE 25 MG SPIRONOLACTONE 50 MG SPIRONOLACTONE 100 MG SULFAMETHOXAZOLE 400 MG- TRIMETHOPRIM 80 MG SULFAMETHOXAZOLE 800 MG- TRIMETHOPRIM 160 MG SYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER Tier 4 Tier 3 SYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER Tier 4 Tier 3 SYMLINPEN 120 2,700 MCG/2.7 ML SUBCUTANEOUS PEN INJECTOR Tier 4 Tier 5 SYMLINPEN 60 1,500 MCG/1.5 ML SUBCUTANEOUS PEN INJECTOR Tier 4 Tier 5 TANZEUM 30 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR Tier 3 Tier 4 TANZEUM 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR Tier 3 Tier 4 TAZTIA XT 120 MG CAPSULE,EXTENDED

29 TAZTIA XT 180 MG CAPSULE,EXTENDED TAZTIA XT 240 MG CAPSULE,EXTENDED TAZTIA XT 300 MG CAPSULE,EXTENDED TAZTIA XT 360 MG CAPSULE,EXTENDED TEFLARO 400 MG INTRAVENOUS SOLUTION Tier 4 Tier 5 TEFLARO 600 MG INTRAVENOUS SOLUTION Tier 4 Tier 5 TELMISARTAN 20 MG Tier 4 Tier 2 TELMISARTAN 40 MG Tier 4 Tier 2 TELMISARTAN 80 MG Tier 4 Tier 2 TERAZOSIN 1 MG CAPSULE TERAZOSIN 2 MG CAPSULE TERAZOSIN 5 MG CAPSULE TERAZOSIN 10 MG CAPSULE TIMOLOL MALEATE 0.25 % EYE DROPS TIMOLOL MALEATE 0.5 % EYE DROPS TOBRAMYCIN 0.3 % EYE DROPS TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION TORSEMIDE 5 MG TORSEMIDE 10 MG TORSEMIDE 20 MG TORSEMIDE 100 MG TRAMADOL 37.5 MG-ACETAMINOPHEN 325 MG TRAMADOL 50 MG TRANDOLAPRIL 1 MG TRANDOLAPRIL 2 MG TRANDOLAPRIL 4 MG TRAZODONE 50 MG TRAZODONE 100 MG TRAZODONE 150 MG TRETINOIN 0.01 % TOPICAL GEL TRETINOIN % TOPICAL CREAM

30 TRETINOIN % TOPICAL GEL TRETINOIN 0.05 % TOPICAL CREAM TRETINOIN 0.1 % TOPICAL CREAM TRIAMCINOLONE ACETONIDE 0.1 % LOTION Tier 4 Tier 2 TRIAMTERENE 37.5 MG- HYDROCHLOROTHIAZIDE 25 MG CAPSULE TRIAMTERENE 75 MG- HYDROCHLOROTHIAZIDE 50 MG TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR TRIHEXYPHENIDYL 2 MG TRIHEXYPHENIDYL 5 MG TRIMETHOPRIM 100 MG TYGACIL 50 MG INTRAVENOUS SOLUTION Tier 4 Tier 5 VALSARTAN 40 MG VALSARTAN 80 MG VALSARTAN 160 MG VALSARTAN 320 MG VALSARTAN 80 MG-HYDROCHLOROTHIAZIDE 12.5 MG VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 12.5 MG VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 25 MG VALSARTAN 320 MG- HYDROCHLOROTHIAZIDE 12.5 MG VALSARTAN 320 MG- HYDROCHLOROTHIAZIDE 25 MG VANCOMYCIN 500 MG INTRAVENOUS SOLUTION VERAPAMIL 40 MG VERAPAMIL 80 MG VERAPAMIL 120 MG VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED VERAPAMIL ER 180 MG 24 HR CAPSULE,EXTENDED VERAPAMIL ER 240 MG 24 HR CAPSULE,EXTENDED VERAPAMIL ER 360 MG 24 HR CAPSULE,EXTENDED VERAPAMIL ER (PM) 100 MG CAPSULE 24HR

31 PELLET CT,EXT. VERAPAMIL ER (PM) 200 MG CAPSULE 24HR PELLET CT,EXT. VERAPAMIL ER (PM) 300 MG CAPSULE 24HR PELLET CT,EXT. VERAPAMIL ER (SR) 120 MG,EXTENDED VERAPAMIL ER (SR) 180 MG,EXTENDED VERAPAMIL ER (SR) 240 MG,EXTENDED VERSACLOZ 50 MG/ML ORAL SUSPENSION Tier 4 Tier 5 VIRACEPT 625 MG Tier 4 Tier 5 VORICONAZOLE 50 MG Tier 4 Tier 5 VORICONAZOLE 200 MG Tier 4 Tier 5 WARFARIN 1 MG WARFARIN 2 MG WARFARIN 2.5 MG WARFARIN 3 MG WARFARIN 4 MG WARFARIN 5 MG WARFARIN 6 MG WARFARIN 7.5 MG WARFARIN 10 MG ZAFIRLUKAST 10 MG ZAFIRLUKAST 20 MG ZELBORAF 240 MG Tier 5 Tier 3 ZIPRASIDONE 20 MG CAPSULE Tier 4 Tier 2 ZIPRASIDONE 40 MG CAPSULE Tier 4 Tier 2 ZIPRASIDONE 60 MG CAPSULE Tier 4 Tier 2 ZIPRASIDONE 80 MG CAPSULE Tier 4 Tier 2 ZORTRESS 0.25 MG Tier 4 Tier 5 ZOVIRAX 5 % TOPICAL CREAM Tier 4 Tier 5 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)

32 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION ADEFOVIR 10 MG ADDED QL 4500 ML PER 30 DAYS QL REMOVED AFINITOR 2.5 MG AFINITOR 5 MG AFINITOR 7.5 MG AFINITOR 10 MG ALECENSA 150 MG CAPSULE ALENDRONATE 5 MG ALENDRONATE 10 MG ALENDRONATE 40 MG AMLODIPINE 5 MG-BENAZEPRIL 40 MG CAPSULE AMLODIPINE 10 MG-BENAZEPRIL 40 MG CAPSULE AMLODIPINE 5 MG-VALSARTAN 160 MG AMLODIPINE 5 MG-VALSARTAN 320 MG AMLODIPINE 10 MG-VALSARTAN 160 MG AMLODIPINE 10 MG-VALSARTAN 320 MG AMLODIPINE 5 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 12.5 MG AMLODIPINE 5 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 25 MG AMLODIPINE 10 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 12.5 MG AMLODIPINE 10 MG-VALSARTAN 160 MG- HYDROCHLOROTHIAZIDE 25 MG AMLODIPINE 10 MG-VALSARTAN 320 MG- HYDROCHLOROTHIAZIDE 25 MG AMOXICILLIN-CLARITHROMYCIN-LANSOPRAZOLE 500 MG-500 MG-30 MG COMBO PACK AVONEX (WITH ALBUMIN) 30 MCG INTRAMUSCULAR KIT AVONEX 30 MCG/0.5 ML INTRAMUSCULAR PEN KIT AVONEX 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT AZELASTINE 0.15 % (205.5 MCG) NASAL SPRAY QL REMOVED QL REMOVED QL REMOVED QL 60 EA PER 30 DAYS ADDED QL 240 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 30 EA PER 30 DAYS QL 112 EA PER 30 DAYS QL 4 EA PER 28 DAYS QL 4 EA PER 28 DAYS QL 1 EA PER 28 DAYS QL 60 ML PER 30 DAYS

33 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) AZELASTINE 137 MCG (0.1 %) NASAL SPRAY AEROSOL AZOPT 1 % EYE DROPS,SUSPENSION QL 60 ML PER 30 DAYS REMOVED QL BETASERON 0.3 MG SUBCUTANEOUS KIT BOSULIF 100 MG BOSULIF 500 MG BUPROPION HCL SR 150 MG,SUSTAINED- BUPROPION HCL XL 150 MG 24 HR, EXTENDED BYDUREON 2 MG SUBCUTANEOUS EXTENDED SUSPENSION BYDUREON 2 MG/0.65 ML SUBCUTANEOUS PEN INJECTOR BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH CODEINE SULFATE 15 MG CODEINE SULFATE 30 MG CODEINE SULFATE 60 MG COMBIVENT RESPIMAT 20 MCG-100 MCG/ACTUATION SOLUTION FOR INHALATION CYCLOSET 0.8 MG DESLORATADINE 5 MG DEXMETHYLPHENIDATE 2.5 MG DEXMETHYLPHENIDATE 5 MG DEXMETHYLPHENIDATE 10 MG DEXTROAMPHETAMINE 5 MG DEXTROAMPHETAMINE 10 MG ADDED QL 14 EA PER 28 DAYS ADDED QL 120 EA PER 30 DAYS CHANGED QL 90 EA PER 30 DAYS CHANGED QL 90 EA PER 30 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS CHANGED QL 2.4 ML PER 30 DAYS CHANGED QL 1.2 ML PER 30 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS CHANGED QL 180 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS ADDED QL 8 GM PER 30 DAYS ADDED QL 180 EA PER 30 DAYS ADDED QL 180 EA PER 30 DAYS ADDED QL 180 EA PER 30 DAYS

34 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) DEXTROAMPHETAMINE ER 5 MG CAPSULE,EXTENDED DEXTROAMPHETAMINE ER 10 MG CAPSULE,EXTENDED DEXTROAMPHETAMINE ER 15 MG CAPSULE,EXTENDED DEXTROAMPHETAMINE-AMPHETAMINE 5 MG DEXTROAMPHETAMINE-AMPHETAMINE 7.5 MG DEXTROAMPHETAMINE-AMPHETAMINE 10 MG DEXTROAMPHETAMINE-AMPHETAMINE 12.5 MG ADDED QL 90 EA PER 30 DAYS ADDED QL 180 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS ADDED QL 90 EA per 30 days ADDED QL 90 EA per 30 days ADDED QL 90 EA per 30 days ADDED QL 90 EA per 30 days DEXTROAMPHETAMINE-AMPHETAMINE 15 MG DEXTROAMPHETAMINE-AMPHETAMINE 20 MG DEXTROAMPHETAMINE-AMPHETAMINE 30 MG DOXAZOSIN 1 MG DOXAZOSIN 2 MG DOXAZOSIN 4 MG DOXAZOSIN 8 MG DRONABINOL 2.5 MG CAPSULE DRONABINOL 5 MG CAPSULE DRONABINOL 10 MG CAPSULE DULERA 100 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER DULERA 200 MCG-5 MCG/ACTUATION HFA AEROSOL INHALER ENBREL 25 MG/0.5 ML (0.51 ML) SUBCUTANEOUS SYRINGE ENDOCET 10 MG-325 MG ENOXAPARIN 40MG/0.4ML EPIPEN 2-PAK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR ADDED QL 90 EA per 30 days ADDED QL 90 EA per 30 days ADDED QL 60 EA per 30 days QL REMOVED QL REMOVED QL REMOVED ADDED QL 13 GM PER 30 DAYS ADDED QL 13 GM PER 30 DAYS ADDED QL 4 ML PER 28 DAYS CHANGED QL TO 180 EA PER 30 DAYS CHANGED QL 11.2 ML PER 30 DAYS ADDED QL 4 EA PER 30 DAYS

35 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) EPIPEN JR 2-PAK 0.15 MG/0.3 ML INJECTION,AUTO- INJECTOR ESBRIET 267 MG CAPSULE ESTRADIOL MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH ESTRADIOL MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH ESTRADIOL MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH ESTRADIOL MG/24 HR WEEKLY TRANSDERMAL PATCH ESTRADIOL MG/24 HR WEEKLY TRANSDERMAL PATCH ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH ESTRADIOL 0.06 MG/24 HR WEEKLY TRANSDERMAL PATCH ESTRADIOL MG/24 HR WEEKLY TRANSDERMAL PATCH ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH FANAPT 1 MG ADDED QL 4 EA PER 30 DAYS ADDED QL 270 EA PER 30 DAYS ADDED QL 8 EA PER 28 DAYS ADDED QL 8 EA PER 28 DAYS ADDED QL 8 EA PER 28 DAYS ADDED QL 8 EA PER 28 DAYS ADDED QL 8 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS FANAPT 2 MG FANAPT 4 MG FANAPT 6 MG FANAPT 8 MG FANAPT 10 MG FANAPT 12 MG FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) S IN A DOSE PACK FARYDAK 10 MG CAPSULE FARYDAK 15 MG CAPSULE FARYDAK 20 MG CAPSULE FENTANYL 400 MCG LOZENGE ON A HANDLE ADDED QL 8 EA PER 28 DAYS ADDED QL 6 EA PER 21 DAYS ADDED QL 6 EA PER 21 DAYS ADDED QL 6 EA PER 21 DAYS ADDED QL 120 EA PER 30 DAYS

36 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) FENTANYL 600 MCG LOZENGE ON A HANDLE ADDED QL 120 EA PER 30 DAYS FENTANYL 800 MCG LOZENGE ON A HANDLE FENTANYL 1,200 MCG LOZENGE ON A HANDLE FENTANYL 1,600 MCG LOZENGE ON A HANDLE FENTANYL 200 MCG LOZENGE ON A HANDLE FLUNISOLIDE 25 MCG (0.025 %) NASAL SPRAY FLUOXETINE 10 MG FLUOXETINE 90 MG CAPSULE,DELAYED FLUVOXAMINE 25 MG FLUVOXAMINE 50 MG FLUVOXAMINE 100 MG GABAPENTIN 100 MG CAPSULE GABAPENTIN 300 MG CAPSULE GABAPENTIN 800 MG GILOTRIF 20 MG GILOTRIF 30 MG GILOTRIF 40 MG HETLIOZ 20 MG CAPSULE HUMIRA 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KIT HUMIRA PEDIATRIC CROHN'S STARTER 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KIT HUMIRA PEDIATRIC CROHN'S STARTER 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KIT (6 PACK) HUMIRA PEN 40 MG/0.8 ML SUBCUTANEOUS HUMIRA PEN CROHN'S-ULC COLITIS-HIDR SUP STARTER 40 MG/0.8 ML SUB-Q KIT HYDROCODONE 10 MG-ACETAMINOPHEN 300 MG HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG ADDED QL 120 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS ADDED QL 50 ML PER 30 DAYS CHANGED QL 240 EA PER 30 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 90 EA PER 30 DAYS ADDED QL 90 EA PER 30 DAYS ADDED QL 90 EA PER 30 DAYS CHANGED QL 270 EA PER 30 DAYS CHANGED QL 270 EA PER 30 DAYS CHANGED QL 120 EA PER 30 DAYS CHANGED QL 4 EA PER 28 DAYS CHANGED QL 3 EA PER 180 DAYS CHANGED QL 6 EA PER 180 DAYS CHANGED QL 4 EA PER 28 DAYS CHANGED QL 6 EA PER 180 DAYS CHANGED QL 84 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS CHANGED QL 84 EA PER 30 DAYS

37 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION HYDROCODONE 7.5 MG-IBUPROFEN 200 MG HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION HYDROMORPHONE 2 MG ADDED QL 2700 ML PER 30 DAYS CHANGED QL 50 EA PER 30 DAYS ADDED QL 120 ML PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS HYDROMORPHONE 4 MG HYDROMORPHONE 8 MG IBRANCE 75 MG CAPSULE IBRANCE 100 MG CAPSULE IBRANCE 125 MG CAPSULE IBUPROFEN-OXYCODONE 400 MG-5 MG ICLUSIG 15 MG ICLUSIG 45 MG INLYTA 1 MG INLYTA 5 MG IPRATROPIUM BROMIDE 0.03 % NASAL SPRAY IPRATROPIUM BROMIDE 0.06 % NASAL SPRAY IRESSA 250 MG JAKAFI 25 MG JARDIANCE 10 MG JARDIANCE 25 MG KALYDECO 50 MG ORAL GRANULES IN PACKET KALYDECO 75 MG ORAL GRANULES IN PACKET KALYDECO 150 MG LATUDA 20 MG LATUDA 40 MG LATUDA 60 MG CHANGED QL 180 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS ADDED QL 21 EA PER 28 DAYS ADDED QL 21 EA PER 28 DAYS ADDED QL 21 PEA ER 28 DAYS CHANGED QL 28 EA PER 30 DAYS ADDED QL 180 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS ADDED QL 30 ML PER 30 DAYS ADDED QL 30 ML PER 30 DAYS ADDED QL 56 EA PER 28 DAYS ADDED QL 56 EA PER 28 DAYS

38 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) LATUDA 80 MG LATUDA 120 MG LEFLUNOMIDE 10 MG LEFLUNOMIDE 20 MG LENVIMA 10 MG/DAY (10 MG X 1/DAY) CAPSULE LENVIMA 20 MG/DAY (10 MG X 2) CAPSULE LEVOCETIRIZINE 5 MG LORAZEPAM 0.5 MG LORAZEPAM 1 MG LORAZEPAM 2 MG LOVASTATIN 10 MG LOVASTATIN 20 MG LOVASTATIN 40 MG MEKINIST 0.5 MG MEKINIST 2 MG MEMANTINE 2 MG/ML ORAL SOLUTION METHADONE 10 MG/5 ML ORAL SOLUTION METHADONE 10 MG/ML INJECTION SOLUTION METHADONE 5 MG/5 ML ORAL SOLUTION REMOVED QL REMOVED QL CHANGED QL 180 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS CHANGED QL 150 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS CHANGED QL 300 ML PER 30 DAYS ADDED QL 1800 ML PER 30 DAYS ADDED QL 360 ML PER 30 DAYS ADDED QL 3600 ML PER 30 DAYS METHYLPHENIDATE 5 MG ADDED 90 EA PER 30 METHYLPHENIDATE 10 MG ADDED 90 EA PER 30 METHYLPHENIDATE 20 MG ADDED 90 EA PER 30 METHYLPHENIDATE ER 20 MG,EXTENDED MORPHINE SULFATE 15 MG ADDED 90 EA PER 30 CHANGED QL 180 EA PER 30 DAYS MORPHINE SULFATE 30 MG NARATRIPTAN 1 MG NARATRIPTAN 2.5 MG CHANGED QL 180 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS

39 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) NEULASTA 6 MG/0.6 ML SUBCUTANEOUS SYRINGE QL REMOVED NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE NEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION NINLARO 2.3 MG CAPSULE NINLARO 3 MG CAPSULE NINLARO 4 MG CAPSULE NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE OFEV 100 MG CAPSULE OFEV 150 MG CAPSULE OXYCODONE 10 MG OXYCODONE 15 MG OXYCODONE 20 MG OXYCODONE 30 MG OXYCODONE-ACETAMINOPHEN 10 MG-325 MG RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE RIZATRIPTAN 5 MG DISINTEGRATING RIZATRIPTAN 10 MG DISINTEGRATING RIZATRIPTAN 5 MG RIZATRIPTAN 10 MG ROZEREM 8 MG SILDENAFIL 20 MG STIVARGA 40 MG TANZEUM 30 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TANZEUM 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TERAZOSIN 1 MG CAPSULE QL REMOVED QL REMOVED QL REMOVED ADDED QL 3 EA PER 28 DAYS ADDED QL 3 EA PER 28 DAYS ADDED QL 3 P EA ER 28 DAYS QL REMOVED CHANGED QL 180 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS CHANGED QL 180 EA PER 30 DAYS CHANGED QL 120 EA PER 30 DAYS CHANGED QL TO 180 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS ADDED QL 90 EA PER 30 DAYS ADDED QL 84 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS ADDED QL 4 EA PER 28 DAYS

40 MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL) TERAZOSIN 2 MG CAPSULE TERAZOSIN 5 MG CAPSULE TERAZOSIN 10 MG CAPSULE XIFAXAN 550 MG XTANDI 40 MG CAPSULE ZOLMITRIPTAN 2.5 MG DISINTEGRATING ZOLMITRIPTAN 5 MG DISINTEGRATING ZOLMITRIPTAN 2.5 MG ZOLMITRIPTAN 5 MG CHANGED QL 90 EA PER 30 DAYS ADDED QL 120 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS CHANGED QL 18 EA PER 30 DAYS MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES Medication Name Change Description ADCIRCA AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION DELESTROGEN 10 MG/ML INTRAMUSCULAR OIL ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL FANAPT S FETZIMA CAPSULES GENTAMICIN 100 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK LATUDA S LIDOCAINE 5 % TOPICAL OINTMENT PRISTIQ 100 MG,EXTENDED PRISTIQ 50 MG,EXTENDED RISPERDAL CONSTA SYRINGE CHANGED TO PA FOR NEW STARTS ONLY REMOVED B VS D PA REMOVED PA REMOVED PA REMOVED PA CHANGED FROM ST TO PA FOR NEW STARTS ONLY CHANGED FROM ST TO PA FOR NEW STARTS ONLY REMOVED B VS D PA REMOVED B VS D PA CHANGED FROM ST TO PA FOR NEW STARTS ONLY PA ADDED REMOVED ST REMOVED ST CHANGED FROM ST TO PA FOR NEW STARTS ONLY

41 MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES Medication Name Change Description SAPHRIS S VIIBRYD S VRAYLAR CAPSULES CHANGED FROM ST TO PA FOR NEW STARTS ONLY CHANGED FROM ST TO PA FOR NEW STARTS ONLY CHANGED FROM ST TO PA FOR NEW STARTS ONLY

42 Nondiscrimination Notice Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, accessible electronic formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact Sherri Wynn. If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sherri Wynn, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, , (TTY), Fax: , Sherri Wynn@health-first.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance Sherri Wynn, ADA/Section 504 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_EL6075FH Accepted

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