Comprehensive PREFERRED DRUG LIST. Peach State Health Plan

Transcription

1 Comprehensive REFERRED DRUG LIST each State Health lan

2 each State Health lan: referred List (DL) This referred List is searchable. Here is how to search for a drug: 1. ress Control F to open the search tool 2. Type the drug name into the text box 3. ress enter harmacy rogram each State Health lan covers medicine for Medicaid and each Care for Kids members. The pharmacy team works with doctors and pharmacists to be sure medicine for a lot of illnesses are covered. each State Health lan pays for prescription drugs and some over-the-counter () medications. Your doctor must write a prescription for these drugs. The pharmacy program does not pay for all drugs. Some drugs need a prior authorization (A). Some drugs have limits on age, dose, and maximum quantities. You can call Member Services to talk to someone about the list of drugs each State Health lan covers. The Member Service phone number is (TTY/TTD ). You can also use the drug Lookup Tool in the secure member webpage to see if your drug is covered. You can get to the tool by using this link referred List (DL) The each State Health lan referred List (DL) is the list of covered drugs. The DL tells you the drugs you can get at local pharmacies. The list is updated every three months by the each State harmacy and Therapeutics (&T) Committee. The group is made of the each State Health lan Medical Director, harmacy Director, and several Georgia doctors, pharmacists, and specialists. harmacy Benefit Manager (BM) each State Health lan works with Envolve harmacy Solutions to pay for pharmacy claims. Some drugs on the DL need a prior authorization (A). Envolve harmacy Solutions reviews those requests. Envolve harmacy Solutions is our harmacy Benefit Manager (BM). Specialty s Some drugs are only paid for when you get them from each State Health lan s specialty pharmacy. AcariaHealth is the specialty pharmacy you should use. The each State Health lan harmacy Director and Medical Director review the A requests for these drugs. AcariaHealth provides you with the following services: Delivers drugs to the home or doctor s office Has pharmacists who can help 24 hours a day, seven days a week to answer your questions and help with drugs Helps you know your medicine better. This will help you understand your health condition better. These drugs are not usually available at local pharmacies. s that AcariaHealth provides are marked in the DL and on the Biopharmaceutical harmacy rogram list. Both of these lists are on the each State Health lan website at Intro reviewed: 09/11/18 II DL Intro 20187_MBR F&U_042617

3 each State Health lan: referred List (DL) Dispensing The pharmacy can give you up to 31 days supply of each new prescription or refill. 80% of the days supply or 25 days must have passed before the medicine can be refilled for DL drugs that are not controlled. Controlled medicines must have 90% of the supply used before the medicine can be refilled. Appropriate Use and Safety Edits Your safety is very important to each State Health lan. One of the ways we look out for your safety is through point-of sale (OS) edits when the medicine claim is sent by the pharmacy. These edits are based on the Food and Administration (FDA) approvals. One example would be only allowing one drug in the same therapy class each month. More information about the drugs that are part of the these edits can be found in the Appropriate Use and Safety Edits document on the each State Health lan website at rior Authorizations (A) Some drugs on the DL may require A. A request should be sent by the doctor or pharmacy to Envolve harmacy Solutions on the Medication rior Authorization Form. This form is on the each State Health lan website at The completed form and doctor notes to show your history should be faxed to Envolve harmacy Solutions at each State Health lan will cover the medicine if: 1. There is a medical reason you need that specific medication. 2. Other medications on the DL have not worked. All reviews are done by a licensed clinical pharmacist. They use the standards set by the each State Health lan &T Committee. If the request is approved, Envolve harmacy Solutions sends you doctor a fax. If it is not approved, each State Health lan and Envolve harmacy Solutions will send a letter to you and a fax to your doctor. The letter will have a list of other medicine. It will also tell you about the appeal process. Step Therapy Some drugs on the DL may require another drug to be used first. This is called Step Therapy. If you filled that required drug with each State Health lan already, the step therapy medicine will be covered. If you have not tried the DL medicine, your doctor will need to send in a A form with other medicine you have tried. If Envolve harmacy Solutions does not approve the A we will send you a letter and a fax to your doctor. The letter will tell you about the appeal process. Quantity each State Health lan may limit how much of a medicine you can get at one time. If the doctor feels you need a larger amount, a A may be sent to Envolve harmacy Solutions. If Envolve harmacy Solutions does not approve the A we will send you a letter and a fax to your doctor. The letter will tell you about the appeal process. Intro reviewed: 09/11/18 III DL Intro 20187_MBR F&U_042617

4 each State Health lan: referred List (DL) (5 peach state health plan. Age Some medicine on the each State Health lan DL may have age limits. These are based on the Food and Administration (FDA) approved labeling and for your safety. If the doctor feels you need the drug anyway, a A may be sent to Envolve harmacy Solutions. If Envolve harmacy Solutions does not approve the A we will send you a letter and a fax to your doctor. The letter will tell you about the appeal process. Medical Necessity Requests If you need a medicine that is not on the DL, your doctor can make a medical necessity (MN) A request for the drug. There are medicines on the DL to treat most conditions. For drugs not on the DL, each State Health lan requires: Doctor s notes to show you tried at least two DL drugs in the same class and used for the same diagnosis; or Doctor s notes to show you are allergic or cannot take at least two DL drugs in the same class; or Doctor s notes to show you cannot take any of the DL agents for your diagnosis. All reviews are done by a licensed clinical pharmacist. They use the standards set by the each State Health lan &T Committee. If the request is approved, Envolve harmacy Solutions sends you doctor a fax. If it is not approved, each State Health lan and Envolve harmacy Solutions will send a letter to you and a fax to your doctor. The letter will have a list of other medicine. It will also tell you about the appeal process. 72 Hour Emergency Supply olicy State and Federal law says a pharmacy can give you a 72 hour (3 day) supply of medicine if you are waiting on A review. harmacies will be paid for the 3 day supply even if the A is not approved. The pharmacy must call Envolve harmacy Solutions at for an override to send the 72 hour supply for payment. Exclusions Below you will find a list of things that are not part of the each State DL and are not covered by the 72 hour emergency supply policy: s that are considered experimental Efficacy Study and Implementation (DESI) drugs s prescribed for weight loss s prescribed for infertility s prescribed for erectile dysfunction s prescribed for cosmetic purposes or hair growth Cough and cold preparations Infusion therapy and supplies hysician administered drugs, that are not listed in the DL, Specialty Benefit, or the hysician Administered rior Authorization List Intro reviewed: 09/11/18 IV DL Intro 20187_MBR F&U_042617

5 each State Health lan: referred List (DL) (5 peach state health plan. Newly Approved roducts each State Health lan reviews new drugs before adding them to the DL. These medicines will need a A review until they are added to the DL. If it is not approved, each State Health lan and Envolve harmacy Solutions will send a letter to you and a fax to your doctor. The letter will have a list of other medicine. It will also tell you about the appeal process. Over-the-Counter Medications The each State Health lan DL covers some medicines. These s are covered when your doctor writes a prescription for one of them. Tobacco Cessation Medications Tobacco Cessation is when you quit smoking cigarettes. These are the medicines each State Health lan covers: generic nicotine replacement products (gum, lozenges, and patches) and bupropion SR (Zyban). You will need a prescription from your doctor for these medicines. Generic s Brand-name drugs will not be covered without A when a generic is available. Generic drugs have the same active ingredient and work the same as brand-name drugs. If you or your doctor feels a brand-name drug is needed, your doctor can ask for A. We will cover the brand-name drug if there is a medical reason you need the brand-name drug. If it is not approved, each State Health lan and Envolve harmacy Solutions will send a letter to you and a fax to your doctor. The letter will have a list of other medicine. It will also tell you about the appeal process. Efficacy Study and Implementation s Efficacy Study and Implementation (DESI) drugs are said to be less effective by the Food and Administration. DESI products are not covered by each State Health lan. Filling a rescription You can have medicine filled at a each State Health lan pharmacy. You can find a pharmacy by calling each State Health lan Member Services. You can also look for a pharmacy close to you using the rovider-lookup tool on the website. You will need to give the pharmacist your prescription and each State Health lan ID card. Ordering, rescribing and Referring (OR) rovider Requirements Georgia Medicaid and the Center for Medicaid and Medicare Services (CMS) want your doctor to be listed with Georgia Medicaid. each State Health lan and Envolve harmacy Solutions check pharmacy claims to be sure the doctor on your prescription is known with Georgia Families. If your prescription is written by a non-registered doctor, the prescription will be rejected. harmacies will also get a claims message if their store is not listed with Georgia Medicaid. Intro reviewed: 09/11/18 V DL Intro 20187_MBR F&U_042617

6 each State Health lan: referred List (DL) Copayments The table below shows co-pay amounts for the drugs. The co-pay is based on the actual cost of the medicine. Co-pays are not required for: children under the age of 21 who are covered under the Medicaid benefit eachcare for Kids members under age 6 pregnant women family planning supplies members in the hospital or a nursing home Alaskan Eskimo members, or American Indian members members with breast and cervical cancer rescription Member Copayment referred List (DL) Medicine $0.50 Non-DL Medicine Under $10.00 Between $10.01 and $25.00 Between $25.01 and $50.00 More than $50.01 $0.50 $1.00 $2.00 $3.00 Contact Information each State Health lan Member Services: Fax: each State Health lan Member Services TTY/TDD: Envolve harmacy Solutions rior Authorizations: Fax: Envolve harmacy Solutions CVS/Caremark harmacy Help Desk: AcariaHealth Shipping Questions: Intro reviewed: 09/11/18 VI DL Intro 20187_MBR F&U_042617

7 each State Health lan: referred List (DL) referred List ABBREVIATIONS REFERRED DRUG LIST TIER ABBREVIATIONS Definitions referred N Non-referred REQUIREMENT or LIMITS Requirement/ Requirement/Limit Description AL Age Limit: is limited to a specific age ACK rior Authorization: Review required before prescription can be filled Quantity Limit: There is a limit on the amount covered per prescription or within a set QL time frame. Rx/ roduct has both prescription and over the counter coverage Specialty : High-cost drugs used to treat complex conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a S specific pharmacy. Step Therapy: Requires trial and failure of one or more preferred products prior to ST coverage. CLINICAL EDIT DESCRITIONS Edit Name Edit Description Opioid Short-acting opioid medicines can only be filled for 7-days at a time. This limit is extended to 30-day fills when a member has a medical history of cancer, sickle cell, or palliative care in their records. ADHD First fill of ADHD medicines are limited to max 20 day supply for members age 6 to 12, after 30 days can be filled. Edit resets if no fills in 4 months. Insulin users are limited to 150 strips ; Non-insulin users are limited to 100 Test Strips strips per 90 days STANDARD ABBREVIATIONS Dose Form Dose Form Description Dose Form Dose Form Description AEB Aerosol owder Breath Activated EX External AERB Aerosol, breath activated GRAN Granules AERO Aerosol IJ Injection AJKT Auto-injector Kit IML Implant AUIJ Auto-injector INHA Inhaler CAS Capsule INJ Injectable CHEW Tablet Chewable IUD Intrauterine Device CONC Concentrate IV Intravenous C12 Capsule ER 12 HR LIQD Liquid C24 Capsule ER 24 HR LOTN Lotion CCR Capsule ER LOZG Lozenge CDR Capsule Delayed Release LO Lollipop CE Capsule Enteric Coated articles MISC Miscellaneous CS Capsule Sprinkle NA Nasal CREA Cream NEBU Nebulization solution CSDR Capsule Delayed Release Sprinkle OINT Ointment DEVI Device O Ophthalmic ELIX Elixir OHT Ophthalmic EMUL Emulsion OR Oral ENEM Enema ACK acket Intro reviewed: 09/11/18 VII DL Intro 20187_MBR F&U_042617

8 each State Health lan: referred List (DL) Dose Form EN NKT OT OWD RSY SKT STE T24 T72 TCH TTW TWK RE S.O.. SHAM SOAJ SOCT SOLN SOLR SON SOSY SRER STR SUBL Dose Form Description en-injector en-injector Kit otassium owder refilled Syringe refilled Syringe Kit aste atch 24 Hour atch 72 Hour atch atch Biweekly atch Weekly Rectal Sterile Ophthalmic reparation Shampoo Solution Auto-injector Solution Cartridge Solution Solution Reconstituted Solution en-injector Solution refilled Syringe Suspension Reconstituted ER Strip Tablet Sublingual Dose Form SUER SUN SU SUS SUSR SUSY SYR T12A TABS TB12 TB24 TBCR TBD TBEC TBEF TBK TBSO TEST TINC TROC VA VI WAFR XR Dose Form Description Suspension Extended Release Suspension en-injector Suppository Suspension Suspension Reconstituted Suspension refilled Syringe Syrup Tablet ER 12 Hour Abuse-Deterrent Tablets Tablet ER 12 Hour Tablet ER 24 Hour Tablet ER Tablet Dispersible Tablet Enteric Coated Tablet Effervescent Tablet Therapy ack Tablet Soluble Diagnostic Test Tincture Troche Vaginal Visual Indicator Wafer Extended Release Intro reviewed: 09/11/18 VIII DL Intro 20187_MBR F&U_042617

9 Name ADHD/ANTI-NARCOLESY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine- Dextroamphetamine) ADDERALL XR C24 (Use Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp , , , , , amphetaminedextroamphetamine tabs , , , , , , DEXEDRINE C24 (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 5, 10, 15 dextroamphetamine sulfate tabs 5, 10 N N N ADHD;QL(2 ea ; AL(At least 3 ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 3 ADHD;QL(2 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 3 Name VYVANSE CAS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG ST; Clinical Edit: ADHD;QL(1 ea Analeptics caffeine citrate soln or 20 QL(45 ml per /ml, 60 /3ml CAFFEINE CITRATED OWD QL(45 gm per Attention-Deficit/Hyperactivity Disorder (ADHD) ST; Clinical Edit: atomoxetine hcl caps ADHD;QL(1 ea ; AL(At least 6 clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 INTUNIV TB24 (Use Guanfacine HCl (ADHD)) KAVAY TB12 (Use Clonidine HCl (ADHD)) STRATTERA CAS (Use Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl) CONCERTA TBCR 36 MG (Use Methylphenidate HCl) dexmethylphenidate hcl tabs 5, 10, 2.5 FOCALIN TABS (Use Dexmethylphenidate HCl) N N N N N N ; AL(At least 6 ; AL(At least 6 ST; Clinical Edit: ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 6 -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 1

10 Name METADATE CD CCR (Use Methylphenidate HCl) methylphenidate hcl cpcr or 10, 20, 30, 40, 50, 60 methylphenidate hcl tabs or 10, 20 methylphenidate hcl tabs or 5 methylphenidate hcl tbcr or 10, 20, 36 methylphenidate hcl tbcr or 18, 27, 54 METHYLHENIDATE HYDROCHLORIDE ER TB24 18 MG, 27 MG, 54 MG METHYLHENIDATE HYDROCHLORIDE ER TB24 36 MG RITALIN TABS 10 MG, 20 MG (Use Methylphenidate HCl) RITALIN TABS 5 MG (Use Methylphenidate HCl) ALTERNATIVE MEDICINES Alternative Medicine - G's ginger (zingiber officinalis) caps 250 Alternative Medicine - M's melatonin tabs or 3, 5 N N N ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(3 ea ; AL(At least 3 ADHD;QL(6 ea ; AL(At least 3 ADHD;QL(2 ea ; AL(At least 6 ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(1 ea ; AL(At least 6 ADHD;QL(2 ea ; AL(At least 6 ADHD;QL(3 ea ; AL(At least 3 ADHD;QL(6 ea ; AL(At least 3 ;QL(4 ea ;QL(1 ea Name AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides neomycin sulfate tabs or TOBRAMYCIN SULFATE SOLN IJ 10 MG/ML, 40 MG/ML A tobramycin sulfate soln ij A 40 /ml, 80 /2ml, 1.2 gm/30ml tobramycin sulfate solr ij A 1.2 gm ANALGESICS - ANTI-INFLAMMATORY - s to Treat ain, Swelling, Muscle and Joint Conditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA EDIATRIC CROHNS DISEASE A; S STARTER ACK SKT HUMIRA EN NKT A; S HUMIRA EN-CD/UC/HS STARTER NKT HUMIRA EN-S/UV STARTER NKT HUMIRA SKT A; S A; S A; S Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) N ALEVE ARTHRITIS TABS N ;QL(2 ea (Use Naproxen Sodium) ALEVE TABS (Use Naproxen Sodium) N ;QL(2 ea ANAROX DS TABS (Use Naproxen Sodium) N CHILDRENS ADVIL SUS (Use Ibuprofen) N RX/ CHILDRENS MOTRIN N RX/ SUS (Use Ibuprofen) diclofenac potassium tabs diclofenac sodium tbec or 25, 50, 75 -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 2

11 Name etodolac caps 200, 300 etodolac tabs 400, 500 FELDENE CAS (Use iroxicam) FENOROFEN CALCIUM CAS OR 400 MG FENORTHO CAS 400 MG flurbiprofen tabs or 50, 100 ibuprofen chew or 100 ibuprofen lysine soln ibuprofen susp or 100 /5ml ibuprofen susp or 40 /ml, 50 /1.25ml ibuprofen tabs or 200 ibuprofen tabs or 400, 600, 800 INDOCIN SU INDOCIN SUS indomethacin caps or 25, 50 indomethacin sodium solr INFANTS ADVIL SUS (Use Ibuprofen) ketorolac tromethamine soln ij 15 /ml, 30 /ml ketorolac tromethamine tabs or 10 LODINE TABS (Use Etodolac) meloxicam tabs or 15, 7.5 MOBIC TABS (Use Meloxicam) N N N N RX/ QL(20 ea per 30 days ; AL(At least 17 Name MOTRIN INFANTS DROS SUS (Use Ibuprofen) nabumetone tabs or 500, 750 NALFON CAS 400 MG N NAROSYN SUS (Use Naproxen) N NAROSYN TABS (Use Naproxen) N naproxen sodium tabs or ;QL(2 ea 220 naproxen sodium tabs or 275, 550 naproxen susp or 125 /5ml naproxen tabs or 250, 375, 500 NEOROFEN SOLN (Use Ibuprofen Lysine) N piroxicam caps or 10, 20 sulindac tabs or 150, 200 yrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) N leflunomide tabs or 10, 20 Soluble Tumor Necrosis Factor Receptor Agents ENBREL SOLR A; S ENBREL SOSY A; S ENBREL SURECLICK A; S SOAJ ANALGESICS - NonNarcotic - s to Treat ain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen tabs QL(4 ea ; AL(At least 12 -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 3

12 Name butalbital-acetaminophencaffeine caps butalbital-acetaminophencaffeine tabs butalbital-aspirin-caffeine caps ESGIC TABS (Use Butalbital-Acetaminophen- Caffeine) FIORINAL CAS (Use Butalbital-Aspirin-Caffeine) TENCON TABS Analgesics Other acetaminophen chew or 80, 160 acetaminophen elix or 160 /5ml, 80 /2.5ml acetaminophen liqd or 160 /5ml acetaminophen soln or 160 /5ml, 650 /20.3ml, 325 /10.15ml acetaminophen supp re 120, 325, 650 acetaminophen susp or 160 /5ml, 80 /0.8ml, 80 /2.5ml acetaminophen tabs or 325, 500 NORTEM INFANTS SUS TYLENOL CHILDRENS CHEWABLES/AIN + FEVER CHEW (Use Acetaminophen) TYLENOL CHILDRENS SUS (Use Acetaminophen) N N N N QL(4 ea ; AL(At least 12 QL(4 ea ; AL(At least 12 QL(4 ea ; QL(4 ea ; AL(At least 12 QL(4 ea ; QL(4 ea ; AL(At least 12 ;QL(12 ea Name TYLENOL EXTRA STRENGTH TABS (Use Acetaminophen) TYLENOL INFANTS AIN+FEVER SUS (Use Acetaminophen) TYLENOL INFANTS SUS (Use Acetaminophen) TYLENOL TABS (Use Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) tabs aspirin chew or 81 ASIRIN SU RE 120 MG, 200 MG, 300 MG, 600 MG aspirin supp re 300, 600 aspirin tabs or 325 aspirin tbec or 81, 324, 325, 500 BUFFERIN TABS (Use Aspirin Buffered (Cal Carb- Mag Carb-Mag Oxide)) diflunisal tabs N N N N N ;QL(12 ea ;QL(12 ea DISALCID TABS (Use Salsalate) N ECOTRIN MAXIMUM STRENGTH TBEC (Use Aspirin) N ECOTRIN REGULAR STRENGTH TBEC (Use N Aspirin) salsalate tabs or 500, 750 ANALGESICS - OIOID - s to Treat ain, Muscle and Joint Conditions Opioid Agonists -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 4

13 Name codeine sulfate tabs 15, 30, 60 CODEINE SULFATE TABS 15 MG, 30 MG, 60 MG (Use Codeine Sulfate) DEMEROL TABS OR 100 MG (Use Meperidine HCl) DILAUDID TABS OR 2 MG, 4 MG (Use Hydromorphone HCl) DILAUDID TABS OR 8 MG (Use Hydromorphone HCl) DOLOHINE TABS 10 MG (Use Methadone HCl) DOLOHINE TABS 5 MG (Use Methadone HCl) DURAGESIC T72 (Use Fentanyl) fentanyl pt72 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr HYDROMORHONE HCL SU RE 3 MG hydromorphone hcl tabs or 2, 4 hydromorphone hcl tabs or 8 MEERIDINE HCL SOLN OR 50 MG/5ML meperidine hcl tabs or 50, 100 methadone hcl tabs or 10 methadone hcl tabs or 5 N N N N N N N Opioids;QL(2 ea ; AL(At least 12 yrs old) Opioids;QL(2 ea ; AL(At least 12 yrs old) Opioids;QL(6 ea Opioids;QL(6 ea Opioids;QL(4 ea A; QL(10 ea A; QL(6 ea QL(0.34 ea QL(0.34 ea Opioids;QL(2 ea Opioids;QL(6 ea Opioids;QL(4 ea Opioids;QL(30 ml Opioids;QL(6 ea A; QL(10 ea A; QL(6 ea Name morphine sulfate soln or 10 /5ml, 20 /5ml morphine sulfate soln or 20 /ml, 100 /5ml MORHINE SULFATE SU RE 5 MG, 10 MG, 20 MG, 30 MG MORHINE SULFATE TABS OR 15 MG, 30 MG morphine sulfate tbcr or 15, 30, 60, 100, 200 MS CONTIN TBCR (Use Morphine Sulfate) oxycodone hcl caps or 5 oxycodone hcl conc or 100 /5ml OXYCODONE HCL ER T12A oxycodone hcl soln or 5 /5ml oxycodone hcl tabs or 30 oxycodone hcl tabs or 5, 10, 15, 20 OXYCONTIN T12A ROXICODONE TABS 30 MG (Use Oxycodone HCl) ROXICODONE TABS 5 MG, 15 MG (Use Oxycodone HCl) tramadol hcl tabs or 50 N N N Opioids;QL(21. 4 ml Opioids;QL(240 ml per Opioids;QL(18 ea per Opioids;QL(6 ea QL(3 ea QL(3 ea Opioids;QL(6 ea Opioids;QL(90 ml per A; QL(2 ea Opioids;QL(30 ml Opioids;QL(4 ea Opioids;QL(6 ea A; QL(2 ea Opioids;QL(4 ea Opioids;QL(6 ea Opioids;QL(4 ea ; AL(At least 18 yrs old) -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 5

14 Name ULTRAM TABS (Use Tramadol HCl) Opioid Combinations acetaminophen w/ codeine soln 120/5ml-12/5ml acetaminophen w/ codeine tabs , , butalbital-acetaminophencaffeine w/ codeine caps butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAS (Use Butalbital- Aspirin-Caffeine w/cod) hydrocodoneacetaminophen soln 2.5/5ml-108/5ml, 5/10ml-217/10ml, 7.5/15ml-325/15ml hydrocodoneacetaminophen tabs 5-325, , NORCO TABS (Use Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 5-325, , N N N Opioids;QL(4 ea ; AL(At least 18 yrs old) Opioids;QL(30 ml ; AL(At least 12 yrs old) Opioids;QL(6 ea ; AL(At least 12 yrs old) Opioids;QL(4 ea ; AL(At least 12 yrs old) Opioids;QL(4 ea ; AL(At least 12 yrs old) Opioids;QL(4 ea ; AL(At least 12 yrs old) Opioids;QL(18 0 ml Opioids;QL(6 ea Opioids;QL(6 ea Opioids;QL(6 ea Name oxycodone-aspirin tabs OXYCODONE/ACETAMIN OHEN SOLN ERCOCET TABS 5MG- 325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/ Acetaminophen) tramadol-acetaminophen tabs TYLENOL/CODEINE #3 TABS (Use Acetaminophen w/ Codeine) TYLENOL/CODEINE #4 TABS (Use Acetaminophen w/ Codeine) ULTRACET TABS (Use Tramadol-Acetaminophen) Opioid artial Agonists BELBUCA FILM BUNAVAIL FILM BURENEX SOLN (Use Buprenorphine HCl) buprenorphine hcl soln ij 0.3 /ml buprenorphine hcl subl sl 2, 8 buprenorphine hclnaloxone hcl dihydrate film 8-2 buprenorphine hclnaloxone hcl dihydrate subl 8-2, N N N N N Opioids;QL(6 ea Opioids;QL(30 ml Opioids;QL(6 ea Opioids;QL(4 ea ; AL(At least 18 yrs old) Opioids;QL(6 ea ; AL(At least 12 yrs old) Opioids;QL(6 ea ; AL(At least 12 yrs old) Opioids;QL(4 ea ; AL(At least 18 yrs old) A A A A A A;QL(2 ea A -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 6

15 Name SUBOXONE FILM 4MG- 1MG, 2MG-0.5MG SUBOXONE FILM 8MG- 2MG, 12MG-3MG ZUBSOLV SUBL A;QL(1 ea A;QL(2 ea A ANDROGENS-ANABOLIC - s to Regulate Hormones Androgens ANDRODERM T24 ANDROXY TABS DEO-TESTOSTERONE SOLN 200 MG/ML (Use Testosterone Cypionate) METHITEST TABS TESTOSTERONE CYIONATE SOLN IM 200 MG/ML testosterone cypionate soln im 200 /ml N QL(4 ml per 30 days QL(4 ml per 30 days QL(4 ml per 30 days ANORECTAL AGENTS - Rectal s to Treat ain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone N (Intrarectal)) hydrocortisone (intrarectal) enem Rectal Combinations ANALRAM-HC LOTN 1%-2.5% phenylephrine-shark liver oil-cocoa butter supp phenylephrine-shark liver oil-mineral oil-petrolatum oint Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) hydrocortisone (rectal) crea 2.5 % N QL(62 ml per 30 days ;QL(12 ea ;QL(31 gm Name ANTACIDS Antacid Combinations alum & mag hydroxsimethicone liqd 200/5ml-20/5ml- 200/5ml alum & mag hydroxsimethicone susp 200/5ml-20/5ml- 200/5ml, 200/5ml- 200/5ml-20/5ml- 20/5ml-200/5ml- 200/5ml Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUS OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs ;QL(744 ml ;QL(744 ml ;QL(100 ea Antacids - Calcium Salts calcium carbonate (antacid) chew 500 TUMS CHEW (Use Calcium Carbonate (Antacid)) N TUMS LASTING EFFECTS CHEW (Use Calcium N Carbonate (Antacid)) Antacids - Magnesium Salts magnesium oxide tabs 400 ANTHELMINTICS - s to Treat Worm Infections Anthelmintics EMVERM CHEW QL(1 ea per 14 days pyrantel pamoate susp or ;QL(60 ml REESES INWORM MEDICINE TABS per ;QL(3 ea per ANTI-INFECTIVE AGENTS - MISC. - s to Treat Bacterial Infections -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 7

16 Name Anti-infective Agents - Misc. FLAGYL TABS 250 MG, 500 MG (Use N Metronidazole) metronidazole tabs or 250, 500 trimethoprim tabs or Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- N Trimethoprim) BACTRIM TABS (Use Sulfamethoxazole- N Trimethoprim) sulfamethoxazoletrimethoprim susp or 40/5ml-200/5ml sulfamethoxazoletrimethoprim tabs or , Glycopeptides FIRVANQ SOLR QL(300 ml per VANCOCIN HCL CAS QL(4 ea 125 MG (Use Vancomycin N HCl) VANCOCIN HCL CAS QL(8 ea 250 MG (Use Vancomycin N HCl) vancomycin hcl caps or QL(4 ea 125 vancomycin hcl caps or QL(8 ea 250 vancomycin hcl solr iv 1 QL(14 ea per gm, 1000 vancomycin hcl solr iv 500 QL(14 ea per 30 days Leprostatics dapsone tabs or 25, 100 Lincosamides CLEOCIN CAS OR 150 MG, 300 MG (Use N Clindamycin HCl) Name CLEOCIN EDIATRIC GRANULES SOLR (Use Clindamycin almitate Hydrochloride) clindamycin hcl caps or 150, 300 clindamycin palmitate hydrochloride solr N QL(300 ml per QL(300 ml per Oxazolidinones SIVEXTRO TABS OR A; QL(6 ea per ANTIANGINAL AGENTS - s to Treat Chest ain Nitrates ISORDIL TITRADOSE TABS 5 MG (Use N Isosorbide Dinitrate) ISOSORBIDE DINITRATE ER TBCR isosorbide dinitrate tabs isosorbide mononitrate tabs 10, 20 isosorbide mononitrate tb24 30, 60, 120 NITRO-BID OINT NITRO-DUR T MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) nitroglycerin cpcr or 9, 2.5, 6.5 nitroglycerin pt24 td 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin subl sl 0.3, 0.4, 0.6 NITROSTAT SUBL (Use Nitroglycerin) N N QL(2 ea ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 15 QL(4 ea -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 8

17 Name buspirone hcl tabs or 30, 7.5 buspirone hcl tabs or 5, 10 hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 HYDROXYZINE AMOATE CAS OR 100 MG hydroxyzine pamoate caps or 25, 50 meprobamate tabs VISTARIL CAS (Use Hydroxyzine amoate) Benzodiazepines alprazolam tabs or 0.25, 0.5, 1, 2 ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Use Lorazepam) chlordiazepoxide hcl caps clorazepate dipotassium tabs DIAZEAM SOLN OR 5 MG/5ML diazepam tabs or 2, 5, 10 lorazepam tabs or 0.5, 1, 2 oxazepam caps 10, 15, 30 OXAZEAM CAS 30 MG TRANXENE T TABS (Use Clorazepate Dipotassium) N N N QL(3 ea QL(6 ea QL(3 ea ; QL(3 ea ; QL(4 ea ; QL(3 ea ; AL (6 months to 12 years old) QL(4 ea ; QL(3 ea ; QL(4 ea ; QL(4 ea ; QL(3 ea ; Name VALIUM TABS (Use Diazepam) XANAX TABS (Use Alprazolam) N N QL(4 ea ; QL(3 ea ; ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORACE CAS (Use Disopyramide hosphate) NORACE CR C MG quinidine gluconate tbcr or 324 QUINIDINE SULFATE TABS OR 200 MG, 300 MG Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs propafenone hcl tabs 150, 225, 300 Antiarrhythmics Type III amiodarone hcl tabs or 200 dofetilide caps TIKOSYN CAS (Use N Dofetilide) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in QL(8 ml Bronchodilators - Anticholinergics ATROVENT HFA AERS INCRUSE ELLITA AEB -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs QL(25.8 gm per 9

18 Name ipratropium bromide soln in TUDORZA RESSAIR AEB Leukotriene Modulators montelukast sodium chew or 4, 5 montelukast sodium pack or 4 montelukast sodium tabs or 10 SINGULAIR CHEW (Use Montelukast Sodium) SINGULAIR ACK (Use Montelukast Sodium) SINGULAIR TABS (Use Montelukast Sodium) Steroid Inhalants AEROSAN AERS budesonide (inhalation) susp FLOVENT DISKUS AEB 100 MCG/BLIST, 250 MCG/BLIST FLOVENT DISKUS AEB 50 MCG/BLIST FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA AERO 44 MCG/ACT ULMICORT FLEXHALER AEB ULMICORT SUS (Use Budesonide (Inhalation)) QVAR AERS QVAR REDIHALER AERB Sympathomimetics N N N N QL(375 ml per 20 days QL(1 ea per 30 days QL(9 gm per 30 days QL(120 ml per ; AL(At least 1 yrs old - Up to 8 QL(2 ea QL(12 gm per QL(10.6 gm per QL(1 ea per fill QL(120 ml per ; AL(At least 1 yrs old - Up to 8 QL(17.4 gm per 2 rtl pack lmt per fill, Name ADVAIR DISKUS AEB ALBUTEROL SULFATE ER TB12 albuterol sulfate nebu in % albuterol sulfate nebu in 0.5 % albuterol sulfate nebu in 0.63 /3ml, 1.25 /3ml albuterol sulfate syrp or 2 /5ml albuterol sulfate tabs or 2, 4 albuterol sulfate tb12 or 4, 8 COMBIVENT RESIMAT AERS DULERA AERO ipratropium-albuterol soln METAROTERENOL SULFATE SYR OR 10 MG/5ML METAROTERENOL SULFATE TABS OR 10 MG, 20 MG ROAIR HFA AERS ROAIR RESICLICK AEB SEREVENT DISKUS AEB SYMBICORT AERO terbutaline sulfate tabs or 5, 2.5 VENTOLIN HFA AERS QL(60 ea per 30 days ; AL(At least 4 yrs old - Up to 11 QL(12.5 ml QL(375 ml per 30 days QL(4 gm per 30 days QL(13 gm per QL(12 ml QL(30 ml QL(8.5 gm per fill retail,17 gm AL(At least 4 yrs old - Up to 18 QL(60 ea per QL(11 gm per QL(8 gm per fill retail,16 gm per 30 days -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 10

19 Name VENTOLIN HFA AERS VOSIRE ER TB12 (Use Albuterol Sulfate) Xanthines ELIXOHYLLIN ELIX THEO-24 C24 theophylline soln 80 /15ml theophylline tb12 100, 200, 300, 450 theophylline tb24 400, 600 N ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) warfarin sodium tabs Direct Factor Xa Inhibitors BEVYXXA CAS ELIQUIS STARTER ACK TABS ELIQUIS TABS XARELTO TABS 10 MG XARELTO TABS 15 MG XARELTO TABS 20 MG Heparins And Heparinoid-Like Agents enoxaparin sodium soln ij 300 /3ml enoxaparin sodium soln sc 100 /ml, 150 /ml QL(18 gm per fill retail,36 gm QL(475 ml per QL(42 ea per 42 days QL(4 ea QL(4 ea QL(35 ea per 180 days QL(2 ea QL(42 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(14 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, Name enoxaparin sodium soln sc 30 /0.3ml enoxaparin sodium soln sc 40 /0.4ml enoxaparin sodium soln sc 60 /0.6ml enoxaparin sodium soln sc 80 /0.8ml, 120 /0.8ml heparin sodium (porcine) soln LOVENOX SOLN IJ 300 MG/3ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 100 MG/ML, 150 MG/ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 30 MG/0.3ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 40 MG/0.4ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 60 MG/0.6ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML (Use Enoxaparin Sodium) N N N N N N QL(5 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(6 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(9 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(12 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(42 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(14 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(5 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(6 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(9 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, QL(12 ml per 7 days 3 rtl MAX fill,180 rtl day(s) supply, ANTICONVULSANTS - s to Treat Seizures Anticonvulsants - Benzodiazepines clonazepam tabs or 0.5, 1, 2 QL(3 ea ; -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 11

20 Name DIASTAT ACUDIAL GEL DIASTAT EDIATRIC GEL diazepam (anticonvulsant) gel DIAZEAM GEL RE 20 MG, 2.5 MG DIAZEAM RECTAL GEL GEL KLONOIN TABS (Use Clonazepam) Anticonvulsants - Misc. carbamazepine chew or 100 carbamazepine susp or 100 /5ml carbamazepine tabs or 200 carbamazepine tb12 or 100, 200, 400 gabapentin caps or 100, 300, 400 gabapentin soln or 250 /5ml, 300 /6ml gabapentin tabs or 600 gabapentin tabs or 800 KERA SOLN OR 100 MG/ML (Use Levetiracetam) KERA TABS OR 1000 MG (Use Levetiracetam) KERA TABS OR 250 MG, 750 MG (Use Levetiracetam) KERA TABS OR 500 MG (Use Levetiracetam) N N N N N QL(1 ea per fill ; AL(At least 2 QL(1 ea per fill ; AL(At least 2 QL(1 ea per fill ; AL(At least 2 QL(1 ea per fill ; AL(At least 2 QL(1 ea per fill ; AL(At least 2 QL(3 ea ; QL(9 ea QL(6 ea QL(4 ea QL(16 ml QL(4 ea QL(6 ea Name KERA XR TB24 (Use Levetiracetam) LAMICTAL CHEWABLE DISERSIBLE CHEW (Use Lamotrigine) LAMICTAL TABS (Use Lamotrigine) LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine) lamotrigine chew or 5, 25 lamotrigine tabs or 25, 100, 150, 200 lamotrigine tb24 or 25, 50, 100, 200, 250, 300 levetiracetam soln or 100 /ml, 500 /5ml levetiracetam tabs or 1000 levetiracetam tabs or 250, 750 levetiracetam tabs or 500 levetiracetam tb24 or 500, 750 MYSOLINE TABS (Use rimidone) NEURONTIN CAS 100 MG, 300 MG, 400 MG (Use Gabapentin) NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NEURONTIN TABS 600 MG (Use Gabapentin) NEURONTIN TABS 800 MG (Use Gabapentin) oxcarbazepine susp oxcarbazepine tabs primidone tabs or 50, 250 N N N N N N N N N ST; Use levetiracetam IR ST; Use lamotrigine IR ST; Use lamotrigine IR QL(16 ml QL(4 ea QL(6 ea ST; Use levetiracetam IR QL(9 ea QL(6 ea QL(4 ea -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 12

21 Name TEGRETOL SUS (Use Carbamazepine) TEGRETOL TABS (Use Carbamazepine) TEGRETOL-XR TB12 (Use Carbamazepine) TOAMAX SRINKLE CS 15 MG (Use Topiramate) TOAMAX SRINKLE CS 25 MG (Use Topiramate) TOAMAX TABS 100 MG (Use Topiramate) TOAMAX TABS 200 MG (Use Topiramate) TOAMAX TABS 25 MG, 50 MG (Use Topiramate) topiramate cpsp or 15 N N N N N N N N QL(6 ea QL(8 ea QL(4 ea QL(3 ea QL(6 ea QL(6 ea Name GABITRIL TABS (Use Tiagabine HCl) tiagabine hcl tabs Hydantoins DILANTIN CAS 100 MG (Use henytoin Sodium Extended) DILANTIN CAS 30 MG DILANTIN INFATABS CHEW (Use henytoin) DILANTIN-125 SUS (Use henytoin) phenytoin chew or 50 phenytoin sodium extended caps 100 phenytoin sodium soln ij N topiramate cpsp or 25 topiramate tabs or 100 topiramate tabs or 200 topiramate tabs or 25, 50 TRILETAL SUS (Use Oxcarbazepine) TRILETAL TABS (Use Oxcarbazepine) ZONEGRAN CAS (Use Zonisamide) zonisamide caps or 25, 50, 100 Carbamates felbamate susp felbamate tabs FELBATOL SUS (Use Felbamate) FELBATOL TABS (Use Felbamate) GABA Modulators N N N N N QL(8 ea QL(4 ea QL(3 ea QL(6 ea phenytoin susp or 125 /5ml Succinimides ethosuximide caps or 250 ethosuximide soln or 250 /5ml ZARONTIN CAS (Use Ethosuximide) ZARONTIN SOLN (Use Ethosuximide) Valproic Acid DEAKENE CAS (Use Valproic Acid) DEAKENE SOLN (Use Valproate Sodium) DEAKOTE ER TB MG (Use Divalproex Sodium) DEAKOTE ER TB MG (Use Divalproex Sodium) DEAKOTE SRINKLES CSDR (Use Divalproex Sodium) N N N N N QL(3 ea QL(7 ea QL(8 ea -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 13

22 Name DEAKOTE TBEC 125 MG (Use Divalproex Sodium) DEAKOTE TBEC 250 MG (Use Divalproex Sodium) DEAKOTE TBEC 500 MG (Use Divalproex Sodium) divalproex sodium csdr or 125 divalproex sodium tb24 or 250 divalproex sodium tb24 or 500 divalproex sodium tbec or 125 divalproex sodium tbec or 250 divalproex sodium tbec or 500 valproate sodium soln or 250 /5ml valproic acid caps N N N QL(2 ea QL(3 ea QL(7 ea QL(8 ea QL(3 ea QL(7 ea QL(2 ea QL(3 ea QL(7 ea ANTIDERESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs or 15 QL(3 ea mirtazapine tabs or 30 QL(1.5 ea mirtazapine tabs or 45, 7.5 mirtazapine tbdp or 15 mirtazapine tbdp or 30 mirtazapine tbdp or 45 REMERON SOLTAB TBD 15 MG (Use Mirtazapine) REMERON SOLTAB TBD 30 MG (Use Mirtazapine) REMERON SOLTAB TBD 45 MG (Use Mirtazapine) REMERON TABS 15 MG (Use Mirtazapine) N N N N QL(3 ea QL(1.5 ea QL(3 ea QL(1.5 ea QL(3 ea Name REMERON TABS 30 MG (Use Mirtazapine) REMERON TABS 45 MG (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 75, 100 bupropion hcl tb12 or 100 bupropion hcl tb12 or 150 bupropion hcl tb12 or 200 bupropion hcl tb24 or 150 bupropion hcl tb24 or 300 MAROTILINE HCL TABS N N QL(1.5 ea QL(3 ea QL(4 ea QL(3 ea QL(2 ea QL(3 ea WELLBUTRIN SR TB MG (Use Bupropion HCl) N QL(4 ea WELLBUTRIN SR TB12 QL(3 ea 150 MG (Use Bupropion N HCl) WELLBUTRIN SR TB12 QL(2 ea 200 MG (Use Bupropion N HCl) WELLBUTRIN XL TB24 QL(3 ea 150 MG (Use Bupropion N HCl) WELLBUTRIN XL TB MG (Use Bupropion N HCl) Monoamine Oxidase Inhibitors (MAOIs) NARDIL TABS (Use henelzine Sulfate) N ARNATE TABS (Use Tranylcypromine Sulfate) N phenelzine sulfate tabs or tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 14

23 Name CELEXA TABS 10 MG (Use Citalopram Hydrobromide) CELEXA TABS 20 MG (Use Citalopram Hydrobromide) CELEXA TABS 40 MG (Use Citalopram Hydrobromide) citalopram hydrobromide soln 10 /5ml citalopram hydrobromide tabs 10 citalopram hydrobromide tabs 20 citalopram hydrobromide tabs 40 escitalopram oxalate tabs 10 escitalopram oxalate tabs 20 escitalopram oxalate tabs 5 fluoxetine hcl caps or 10, 20 fluoxetine hcl caps or 40 fluoxetine hcl soln or 20 /5ml fluoxetine hcl tabs or 10 fluoxetine hcl tabs or 20 fluvoxamine maleate tabs 100 fluvoxamine maleate tabs 25, 50 LEXARO TABS 10 MG (Use Escitalopram Oxalate) N N N N QL(4 ea QL(2 ea QL(4 ea QL(2 ea QL(2 ea ; AL(At least 12 ; AL(At least 12 QL(4 ea ; AL(At least 12 QL(4 ea QL(2 ea ; AL(At least 7 QL(600 ml per 30 days ; AL(Up to 6 yrs old ) ; AL(At least 7 QL(4 ea QL(3 ea QL(2 ea QL(2 ea ; AL(At least 12 Name LEXARO TABS 20 MG (Use Escitalopram Oxalate) LEXARO TABS 5 MG (Use Escitalopram Oxalate) paroxetine hcl tabs 10 paroxetine hcl tabs 20 paroxetine hcl tabs 30, 40 paroxetine hcl tb24 25, 12.5, 37.5 AXIL CR TB24 (Use aroxetine HCl) AXIL SUS 10 MG/5ML AXIL TABS 10 MG (Use aroxetine HCl) AXIL TABS 20 MG (Use aroxetine HCl) AXIL TABS 30 MG, 40 MG (Use aroxetine HCl) ROZAC CAS 10 MG, 20 MG (Use Fluoxetine HCl) ROZAC CAS 40 MG (Use Fluoxetine HCl) sertraline hcl conc or 20 /ml sertraline hcl tabs or 100 sertraline hcl tabs or 25, 50 ZOLOFT CONC 20 MG/ML (Use Sertraline HCl) ZOLOFT TABS 100 MG (Use Sertraline HCl) ZOLOFT TABS 25 MG, 50 MG (Use Sertraline HCl) Serotonin Modulators NEFAZODONE HCL TABS 100 MG, 150 MG nefazodone hcl tabs 50, 250 N N N N N N N N N N N ; AL(At least 12 QL(4 ea ; AL(At least 12 QL(6 ea QL(3 ea QL(2 ea A; QL(40 ml QL(6 ea QL(3 ea QL(2 ea QL(4 ea QL(2 ea ; AL(At least 7 QL(6 ml QL(2 ea QL(4 ea QL(6 ml QL(2 ea QL(4 ea -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 15

24 Name NEFAZODONE HYDROCHLORIDE TABS trazodone hcl tabs or 300 trazodone hcl tabs or 50, 100, 150 TRINTELLIX TABS VIIBRYD TABS QL(2 ea A; QL(1 ea ; AL(At least 18 yrs old) A; QL(1 ea Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CE (Use Duloxetine HCl) desvenlafaxine succinate tb desvenlafaxine succinate tb24 25, 50 duloxetine hcl cpep or 20, 30, 60 EFFEXOR XR C MG (Use Venlafaxine HCl) EFFEXOR XR C MG (Use Venlafaxine HCl) EFFEXOR XR C24 75 MG (Use Venlafaxine HCl) RISTIQ TB MG (Use Desvenlafaxine Succinate) RISTIQ TB24 25 MG, 50 MG (Use Desvenlafaxine Succinate) venlafaxine hcl cp venlafaxine hcl cp venlafaxine hcl cp24 75 venlafaxine hcl tabs 25, 50, 75, 100, 37.5 venlafaxine hcl tb N N N N N N ; AL(At least 7 ST; QL(4 ea ST; QL(1 ea ; AL(At least 7 QL(2 ea QL(4 ea QL(5 ea ST; QL(4 ea ST; QL(1 ea QL(2 ea QL(4 ea QL(5 ea QL(2 ea Name venlafaxine hcl tb24 75, 225, 37.5 Tricyclic Agents amitriptyline hcl tabs or 10, 25, 50, 75, 100, 150 AMOXAINE TABS ANAFRANIL CAS 75 MG (Use Clomipramine HCl) N clomipramine hcl caps or 75 desipramine hcl tabs or 10, 50, 75, 100, 150 desipramine hcl tabs or 25 QL(2 ea doxepin hcl caps or 10, 25, 50, 75, 100, 150 doxepin hcl conc or 10 /ml ELAVIL TABS (Use Amitriptyline HCl) N imipramine hcl tabs or 10, 25, 50 NORRAMIN TABS 10 MG (Use Desipramine HCl) N NORRAMIN TABS 25 MG (Use Desipramine HCl) N QL(2 ea nortriptyline hcl caps or 10, 25, 50, 75 nortriptyline hcl soln or 10 QL(20 ml /5ml NORTRITYLINE HCL SOLN OR 10 MG/5ML QL(20 ml AMELOR CAS (Use Nortriptyline HCl) N TOFRANIL TABS (Use Imipramine HCl) N ANTIDIABETICS - s to Regulate Blood Sugar Antidiabetic - Amylin Analogs -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 16

25 Name SYMLINEN 120 SON SYMLINEN 60 SON Antidiabetic Combinations ACTOLUS MET TABS (Use ioglitazone HCl- Metformin HCl) alogliptin-metformin hcl tabs alogliptin-pioglitazone tabs glipizide-metformin hcl tabs GLUCOVANCE TABS (Use Glyburide-Metformin) glyburide-metformin tabs JENTADUETO TABS pioglitazone hcl-metformin hcl tabs SEGLUROMET TABS Biguanides GLUCOHAGE TABS 500 MG (Use Metformin HCl) GLUCOHAGE TABS 850 MG, 1000 MG (Use Metformin HCl) GLUCOHAGE XR TB MG (Use Metformin HCl) GLUCOHAGE XR TB MG (Use Metformin HCl) metformin hcl tabs or 500 metformin hcl tabs or 850, 1000 metformin hcl tb24 or 500 metformin hcl tb24 or 750 N N N N N N A; QL(11 ml A; QL(6 ml QL(2 ea QL(2 ea A; QL(2 ea QL(2 ea ST; QL(2 ea QL(4 ea QL(4 ea QL(3 ea QL(4 ea QL(4 ea QL(3 ea Name Diabetic Other BD GLUCOSE CHEW CVS GLUCOSE CHEW 4 GM DEX4 QUICK DISSOLVE GLUCOSE CHEW ;QL(50 ea ;QL(50 ea ;QL(50 ea GLUCAGEN HYOKIT SOLR GLUCAGON EMERGENCY KIT KIT QL(1 ea per fill GLUCOSE CHEW 4 GM ;QL(50 ea GN GLUCOSE CHEW 4 ;QL(50 ea GM GN QUICK DISSOLVE ;QL(50 ea GLUCOSE CHEW LEADER QUICK DISSOLVE GLUCOSE CHEW ;QL(50 ea SM GLUCOSE CHEW 4 ;QL(50 ea GM WALGREENS GLUCOSE ;QL(50 ea CHEW 4 GM Dipeptidyl eptidase-4 (D-4) Inhibitors alogliptin benzoate tabs TRADJENTA TABS A; QL(1 ea ; AL(At least 18 yrs old) Incretin Mimetic Agents (GL-1 Receptor A; QL(3.4 ml BYDUREON BCISE AUIJ per 28 days -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 17

26 Name BYDUREON EN EN BYDUREON SRER BYETTA SON 10 MCG/0.04ML BYETTA SON 5 MCG/0.02ML VICTOZA SON Insulin Sensitizing Agents ACTOS TABS (Use ioglitazone HCl) pioglitazone hcl tabs Insulin ADMELOG SOLN ADMELOG SOLOSTAR SON BASAGLAR KWIKEN SON HUMALOG MIX 50/50 KWIKEN SUN HUMALOG MIX 50/50 SUS HUMALOG MIX 75/25 KWIKEN SUN HUMALOG MIX 75/25 SUS HUMULIN 70/30 KWIKEN SUN HUMULIN 70/30 SUS N A; QL(4 ea per 28 days ; AL(At least 18 yrs old) A; QL(4 ea per 28 days ; AL(At least 18 yrs old) A; QL(2.4 ml ; AL(At least 18 yrs old) A; QL(1.2 ml ; AL(At least 18 yrs old) A; QL(1.8 ml QL(40 ml per 30 days QL(1 ml QL(1 ml QL(1 ml QL(40 ml per 30 days QL(1 ml QL(40 ml per 30 days ;QL(1 ml ;QL(40 ml Name HUMULIN N KWIKEN SUN HUMULIN N SUS HUMULIN R SOLN NOVOLIN 70/30 FLEXEN RELION SUN NOVOLIN 70/30 FLEXEN SUN NOVOLIN 70/30 RELION SUS NOVOLIN 70/30 SUS NOVOLIN N RELION SUS NOVOLIN N SUS NOVOLIN R RELION SOLN NOVOLIN R SOLN NOVOLOG MIX 70/30 REFILLED FLEXEN SUN NOVOLOG MIX 70/30 SUS Meglitinide Analogues nateglinide tabs ;QL(1 ml ;QL(40 ml ;QL(40 ml ;QL(1 ml ;QL(1 ml ;QL(40 ml ;QL(40 ml ;QL(40 ml ;QL(40 ml ;QL(40 ml ;QL(40 ml QL(1 ml QL(40 ml per 30 days QL(3 ea STARLIX TABS (Use Nateglinide) N QL(3 ea Sodium-Glucose Co-Transporter 2 (SGLT2) JARDIANCE TABS A; QL(1 ea STEGLATRO TABS ST; QL(1 ea Sulfonylureas -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 18

27 Name AMARYL TABS 1 MG, 2 MG (Use Glimepiride) AMARYL TABS 4 MG (Use Glimepiride) glimepiride tabs 1, 2 glimepiride tabs 4 glipizide tabs or 5, 10 glipizide tb24 or 5, 10, 2.5 GLUCOTROL TABS (Use Glipizide) GLUCOTROL XL TB24 (Use Glipizide) glyburide micronized tabs N N N N QL(4 ea QL(2 ea QL(4 ea QL(2 ea glyburide tabs or 5, 2.5, 1.25 GLYNASE TABS (Use Glyburide Micronized) N ANTIDIARRHEAL/ROBIOTIC AGENTS - s to Treat Diarrhea Antidiarrheal/robiotic Agents - Misc. bismuth subsalicylate chew or 262 bismuth subsalicylate susp or 525 /15ml ETO-BISMOL CHEW 262 MG (Use Bismuth Subsalicylate) N ETO-BISMOL INSTACOOL CHEW (Use N Bismuth Subsalicylate) ETO-BISMOL MAX STRENGTH SUS (Use N Bismuth Subsalicylate) ETO-BISMOL TO-GO CHEW (Use Bismuth N Subsalicylate) Antiperistaltic Agents diphenoxylate w/ atropine tabs DIHENOXYLATE/ATRO INE LIQD Name IMODIUM A-D CAS 2 MG (Use Loperamide HCl) IMODIUM A-D TABS 2 MG (Use Loperamide HCl) LOMOTIL TABS (Use Diphenoxylate w/ Atropine) loperamide hcl caps or 2 loperamide hcl liqd or 1 /5ml loperamide hcl tabs or 2 N N N ;QL(8 ea ; RX/ ;QL(8 ea ;QL(8 ea ; RX/ ;QL(40 ml ;QL(8 ea ANTIDOTES AND SECIFIC ANTAGONISTS Antidotes - Chelating Agents CHEMET CAS JADENU TABS Antidotes and Specific Antagonists SM IECAC SYRU SYR VISTOGARD ACK Opioid Antagonists NALOXONE HCL SOCT IJ 0.4 MG/ML naloxone hcl soln ij 0.4 /ml, 4 /10ml NALOXONE HCL SOSY IJ 2 MG/2ML naltrexone hcl tabs or A; S QL(2 ml per 90 days QL(2 ml per 90 days QL(4 ml per 90 days NARCAN LIQD QL(4 ea per 90 days ANTIEMETICS - s to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists ondansetron hcl soln or 4 QL(50 ml per /5ml 30 days ondansetron hcl tabs or 24 QL(1 ea per 14 ondansetron hcl tabs or 4, 8 -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs days QL(2 ea 19

28 Name ondansetron tbdp ZOFRAN ODT TBD (Use N Ondansetron) ZOFRAN SOLN 4 MG/5ML N (Use Ondansetron HCl) ZOFRAN TABS 4 MG, 8 MG (Use Ondansetron N HCl) Antiemetics - Anticholinergic dimenhydrinate tabs or 50 DRAMAMINE CHEW DRAMAMINE TABS (Use Dimenhydrinate) meclizine hcl chew or 25 meclizine hcl tabs or 25, 12.5 N QL(2 ea QL(2 ea QL(50 ml per 30 days QL(2 ea ;QL(24 ea per ;QL(24 ea per ;QL(24 ea per RX/ ANTIFUNGALS - s to Treat Fungal Infections Antifungals GRIS-EG TABS (Use Griseofulvin Ultramicrosize) griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs LAMISIL TABS (Use Terbinafine HCl) nystatin tabs or terbinafine hcl tabs or N N Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML (Use N Fluconazole) DIFLUCAN TABS 100 MG, N 200 MG (Use Fluconazole) DIFLUCAN TABS 150 MG N (Use Fluconazole) QL(90 ea per 120 days QL(6 ea QL(90 ea per 120 days QL(70 ml per QL(2 ea per fill Name DIFLUCAN TABS 50 MG (Use Fluconazole) fluconazole susr or 10 /ml, 40 /ml fluconazole tabs or 100, 200 fluconazole tabs or 150 fluconazole tabs or 50 itraconazole caps or 100 SORANOX CAS 100 MG (Use Itraconazole) SORANOX ULSEAK CAS (Use Itraconazole) N N N QL(3 ea per 14 days QL(70 ml per QL(2 ea per fill QL(3 ea per 14 days A; QL(1 ea A; QL(1 ea A; QL(1 ea ANTIHISTAMINES - s to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON SYR 2 MG/5ML (Use N Chlorpheniramine Maleate) CHLOR-TRIMETON TABS 4 MG (Use N Chlorpheniramine Maleate) chlorpheniramine maleate syrp or 2 /5ml chlorpheniramine maleate tabs or 4 Antihistamines - Ethanolamines ALER-DRYL TABS BENADRYL ALLERGY CAS (Use Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl) BENADRYL ALLERGY TABS (Use Diphenhydramine HCl) clemastine fumarate tabs or 1.34 diphenhydramine hcl caps or 25 N N N ;QL(120 ea per ;QL(120 ea per QL(4 ea QL(4 ea ;QL(240 ml per ;QL(4 ea ;QL(2 ea QL(4 ea -referred drug, N-Non-preferred, AL-Age Limit, A-rior Authorization QL-Quantity limit, S-Specialty drug, ST-Step Therapy, RX/ - both Rx and NDCs 20