Wichita Public Schools USD259 Summary of Drug Coverage Covered Items Excluded Items

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1 Covered Items Accutane Acne topical products- generics only Aerochambers Anaphylactic Kits Antifungal topical products- generic only Aspirin oral -Rx and OTC Compounded medications of which at least one ingredient is a legend drug Contraceptives oral, intravaginal, transdermal, female OTC, implants, devices, injectables DESI Drugs Diabetic supplies Insulin pens/syringes/needles, test strips/tape/tabs, lancets Drugs for ADD/ADHD/Narcolepsy Drugs for Sexual Dysfunction Fluoride supplements- Rx oral only Folic acid -Rx and OTC Glucometers Growth hormones Immunizations/Vaccines/Toxoids (CDC Recommended Only) Injectables- self-administered and not listed under exclusions Insulin Iron supplements -Rx and OTC Legend drugs, except for drugs listed as exclusions Medical supplies needed to infuse covered medications Nasal steroids- Rx generics and OTC Non-sedating antihistamines Rx and OTC Ophthalmic antihistamines- generics PPI- Rx and OTC Smoking deterrents Rx and OTC State Restricted Drugs (i.e., DEA Schedule V) Topical tretinoins (ex. Avita, Retin-A)- generics only Vitamins Rx Prenatal, Rx pediatric and Vitamin D OTC Excluded Items Acne, oral antibiotics Acne, topical products brands Agents for weight loss Anabolic steroids Allergy serum/extracts Antifungal topical brands Anti-sera/immune globulins Anti-viral topical brands Anti-wrinkle agents (ex. Renova) Blood, blood factors, blood plasma or biological sera Cosmetic hair removal products (ex. Vaniqa) Dental products for periodontal disease Depigmenting agents (ex. Hydroxyquinone) Devices, appliances, or supplies, including support garments & non-medicinal substances Drugs indicated for cosmetic uses Fertility agents- all (oral and injectable) Hair growth stimulants Homeopathic/natural legend products Injectables- office administered Medical supplies Me Too Drug list Nasal steroids- Rx brands Non-legend drugs (OTC s), except as listed above

2 Nutritional supplements Ophthalmic antihistamines- brands Syringes/needles, other than insulin type Topical tretinoins (ex. Avita, Retin-A)- brands Vitamins, except Rx Prenatal, Rx pediatric and Vitamin D OTC Co-Payments Base, Premium Option 1, Premium Option 2 and Retiree Plans: Retail Mail Order Generic: $ 10 $ 20 Preferred Brand $ 30 $ 60 Non-Preferred Brand $ 55 $110 Specialty Medications 10% up to max $100 N/A Out-of-Area (PPO Plan): Retail Mail Order Generic: $ 10 $ 20 Preferred Brand $ 30 $ 60 Non-Preferred Brand $ 55 $110 Specialty Medications 10% up to max $100 N/A Base, Premium, Retiree and PPO Plans ONLY: Diabetic Preferred Insulin - $0 copay Diabetic Preferred supplies - $0 copay Generic blood pressure medications - $0 copay Generic cholesterol medications - $0 copay Dillon s Pharmacy Diabetic program (Base, Premium and PPO Plan Members): Once member is enrolled in the program, they will qualify for the following copays: Diabetic Preferred medications - $0 copay Generic oral diabetic medications - $0 copay MVP Plan: Prescriptions are covered at 100% once the $1,000 individual / $2,000 family annual deductible is met. If DAW2, patient-selected brand where generic available is chosen, the member pays the differential amount even if the $1,000 individual / $2,000 family annual deductible is met. PPACA Covered Medications and Copays for Both Plans: Preventive Medications - $0 copay Aspirin for patients 45 and older Folic acid for women up to the age of 55 Iron supplements up to the age of 1 Fluoride supplements up to the age of 6 Tobacco deterrents Vitamin D OTC for ages 65 and older Immunizations/Vaccines/Toxoids - $0 copay Hepatitis A vaccine Hepatitis B vaccine Influenza Vaccine Measles Vaccine Mumps Vaccine Polio Vaccine Human Papillomavirus Vaccine Rabies Vaccine

3 Rubella Vaccine Varicella Vaccine Haemophilus Vaccine Meningococcal Vaccine Tetanus Toxoid Diphtheria Toxoid Pertussis Toxoid Pneumococcal Rotavirus Zostavex And combination products of these Vaccines or Toxoids Contraceptives Generic oral, injectable and patches at $0 copay Single source brands in classes that do not have a generic alternative (i.e. implants, IUD, devices, rings) at $0 copay Brands with generics available in route class (orals, injectables, patches) will be at regular copays intravaginal Effective 1/1/18: MVP Plan Only - Statins: $0 copay Lovastatin at $0 without PA for ages PAs can be requested for other low-to moderate dose statins to ensure criteria is met Copay may be waived on: Medical supplies needed to infuse covered medications- if dispensed at the same time as the medication Day Supply Allowed Retail 31 days Mail days Specialty 31 days Refill Edit An edit for 75% usage will be applied at retail and 75% usage at Mail Order before refills will be allowed. Effective 1/1/18: An edit for 90% usage will be applied at retail and Mail Order for narcotic & controlled medications. DAW Copay Differential - DAW 1 & 2: (DAW 1 added effective 1/1/18) If the patient/member or physician requests a brand name medication when a generic equivalent exists, the applicable BRAND copay plus the cost difference between the brand and generic will apply. DAW 1 & 2 differential amounts will not apply to Maximum out of Pocket (MOOP). Deductible MVP Plan Only $1,000 individual / $2,000 family Maximum Allowable Benefits N/A Drugs with Special Quantity Limits MaxorPlus standard Quantity Limits (QL) list applies for specific medications. List subject to change. Tobacco deterrents- Limited to 2-12 week cycles/year Depo Provera Contraceptive- 90 day supply allowed at retail for 3 retail copays Estring-- 90 day supply allowed at retail for 3 retail copays Seasonique/Seasonale- 91 day supply allowed at retail for 3 retail copays

4 Drugs Requiring Prior Authorization MaxorPlus standard Prior Authorization (PA) list applies for specific medications. List subject to change. Breast Cancer Preventative generic medications- if approved then $0 copay (PPACA) Abilify- brand Brand narcotic medications Brand topical antifungals Colcrys Combination inhalers Cuvposa Epaned Evzio Fulyzag Fycompa Giazo Gralise Horizant Jentadueto Kapvay Kazano Nymalize Performist Rescula Rilutek Savella Seroquel XR Striverdi Respimat Suboxone, Bunavil, Zubsolv Tekamlo Tekruna/Tekturna HCT Testosterone products Topical immunomodulator (i.e. Elidel, Protopic) Zioptan Zontivity Maximum Out of Pocket (MOOP): A separate prescription maximum out-of-pocket amount applies for prescription benefits per calendar year. DAW 1 & 2 differential amounts do not apply to MOOP. Base & PPO Plan: Premium Plan 1 & PPO: Premium Plan 2 & PPO: Retiree Plan: $1,000 individual $2,650 individual $1,150 individual $2,650 individual $2,000 family $5,300 family $2,300 family $5,300 family MVP Plan: $1,000 individual $2,000 family Formulary The MaxorPlus PREFERRED FORMULARY will be utilized to determine copay tiers for generic, preferred brand, and non-preferred brand medications. Network Prescriptions must be filled at a MaxorPlus SELECT NETWORK Pharmacy.

5 Specialty Medications Specialty medications are restricted to be filled at Maxor Specialty Pharmacy. Allow one retail fill for transition. Step Therapy Requirements Acne, topical medications: Step one: generics (i.e. tretinoin, clindamycin, benzoyl peroxide, adapalene) Step two: brands (i.e. Epiduo, Onexton, Veltin) ARB and combinations: Step one: generics (i.e. losartan, valsartan, irbesartan, valsartan/hctz, candesartan/hctz) Step two: brands (i.e. Benicar, Exforge, Azor) Biphosphonates: Step one: generics (i.e. alendronate, ibandronate) Step two: brands (i.e. Actonel, Atelvia, Boniva) Benign Prostatic Hyperplasia (BPH) medications: Step One: generics (i.e. dutasteride, finasteride, tamsulosin, doxazosin) Step Two: brands (i.e. Jalyn, Avodart, Rapaflo) Lamictal ODT or XR: Step one: lamotrigine Step two: Lamictal ODT or Lamictal XR OAB (Over active bladder): Step one: generics (i.e. tolterodine, trospium, oxybutynin) Step two: brands (i.e. Myrbetriq, Enablex, Santura XR) PPIs: Step one: generics (i.e. omeprazole, lansoprazole, raberprazole, esomeprazole) Step two: brands (i.e. Dexilant, Nexium, Prevacid) Sleep medications: Step one: generics (i.e. zolpidem, zaleplon, temazepam) Step two: brands (i.e. Belsoma, Edular, Intermezzo, Ambien CR) Statins: Step one: generics (i.e. simvastatin, atrovastatin, lovastatin) Step two: brands (i.e. Crestor, Altoprev, Lipitor) Topical Steroids: Step one: generics (i.e. clobetasol, triamcinolone, desonide, fluocinolone) Step two: brands (i.e. Taclonex, Vectical, Vanos) Triptans: Step one: generics (i.e. sumatriptan, zolmitriptan, rizatriptan) Step two: brands (i.e. Relpax, Frova, Maxalt, Zomig, Imitrex) Uloric/Colcrys: Step one: generics (i.e. allopurinol, colchicine) Step two: brands (i.e. Crestor, Altoprev, Lipitor)