2015 Comprehensive. Formulary. Service To Seniors (HMO) OC Preferred (HMO) It s Personal. (List of Covered Drugs)

Transcription

1 2015 Comprehensive Formulary Service To Seniors (HMO) OC Preferred (HMO) PLEASE READ: This document contains information about the drugs we cover in the Plans Service To Seniors (HMO) and OC Preferred (HMO). This formulary was updated on 08/08/2014. For more recent information or other questions, please contact Inter Valley Health Plan s Pharmacy Specialist at , 7:30 am to 8 pm, 7 days a week. TTY/TDD users should call (List of Covered Drugs) Formulary ID 15076, Version 11 It s Personal. H0545_FUY Accepted

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3 Table of Contents What is the Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) Formulary?...pg 2 Can the Formulary (drug list) change?...pg 2 How do I use the Formulary?...pg 3 What are generic drugs?...pg 3 Are there any restrictions on my coverage?...pg 3 What if my drug is not on the Formulary?...pg 4 How do I request an exception to the Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) Formulary?...pg 5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception?...pg 5 For more information...pg 6 Inter Valley Health Plan Service To Seniors (HMO) Copay Amounts...pg 7 Inter Valley Health Plan OC Preferred (HMO) Copay Amounts...pg 8 Formulary (List of covered drugs)...pg 11 Drugs Requiring Prior Authorization...pg 97 Drugs with Quantity...pg 101 Drugs Requiring Step Therapy...pg 110 Free First Fill Program...pg 112 Index of Drugs...pg 117 1

4 This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO). When it refers to plan or our plan, it means Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of August 8, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/ or copay ments/coinsurance may change on January 1, 2015, and from time to time during the year. What is the Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) Formulary? A formulary is a list of covered drugs selected by Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) in consultation with a team of healthcare providers, which represents the prescrip tion therapies believed to be a necessary part of a quality treatment program. The Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Inter Valley Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the begin ning of the year, we will not discon tinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which 2

5 you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August To get updated information about the drugs covered by Inter Valley Health Plan, please visit our web site at com/site/prescriptiondrugsearch.aspx or call our Pharmacy Specialist at , 7:30 am to 8 pm, 7 days a week. TTY/TDD users should call Inter Valley Health Plan provides updates to the Formulary in our quarterly newsletter, InterView, or on our website at PrescriptionDrugSearch.aspx. How do I use the Formulary? There are two ways to find your drug within the formulary: MEDICAL CONDITION The formulary begins on page 11. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 11. Then look under the category name for your drug. ALPHABETICAL LISTING If you are not sure what category to look under, you should look for your drug in the Index that begins on page 117. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. 3

6 Quantity : For certain drugs, Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) limits the amount of the drug that the Plan will cover. For example, Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) provides 30 tablets per 30 days prescription for Atorvastatin. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug 1 and Drug 2 both treat your medical condition, the Plan may not cover Drug 2 unless you try Drug 1 first. If Drug 1 does not work for you, the Plan will then cover Drug 2. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 11. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) formulary? on page 5 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact our Pharmacy Specialist and ask if your drug is covered. If you learn that Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) does not cover your drug, you have two options: You can ask our Pharmacy Specialist for a list of similar drugs that are covered by the Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the Plan. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. 4

7 How do I request an exception to the Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/ or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your 5

8 prescription until we have provided you with a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31- day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Exceptions are also available when you have experienced a change in the level of care you are receiving which requires you to transition from one facility or treatment center to another. Examples of situations in which you would be eligible for the one-time temporary fill exception when you are outside of the three month effective date with the Plan are as follows: If you are discharged from the hospital and provided a discharge list of medications based upon the Formulary of the hospital. If you end your skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and you need to revert back to the Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) formulary. If you give up hospice status to revert back to standard Medicare Part A and Part B benefits. If you are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. All of these situations would warrant a temporary one-time fill exception regardless of your effective date with the Plan. For more information For more detailed information about your Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 6

9 Inter Valley Health Plan Service To Seniors (HMO) Copay Amounts INITIAL COVERAGE LIMIT Drug Tier $2960, the total yearly drug costs in the initial coverage limit paid by both you and Inter Valley Health Plan Co-payment /Coinsurance (30 day Supply) Co-payment /Coinsurance (90 day Supply) Network Long- Term Care Cost-Sharing (31 day Supply) - Co-payment /Coinsurance (90-day supply) Out of Network Co-payment /Coinsurance (30-day supply)* TIER TIER TIER TIER TIER 5 1Preferred Generic Drugs 2Non-Preferred Generic Drugs 3Preferred Brand Drugs 4Non-Preferred Brand Drugs Specialty Drugs $5 Copay $15 Copay $5 Copay $10 Copay $5 Copay $15 Copay $45 Copay $15 Copay $30 Copay $15 Copay $39 Copay $117 Copay $39 Copay $78 Copay $39 Copay $79 Copay $237 Copay $79 Copay $158 Copay $79 Copay 33% Coinsurance N/A 33% Coinsurance N/A 33% Coinsurance TIER TIER TIER TIER COVERAGE GAP 1Preferred Generic Drugs 2Non-Preferred Generic Drugs 3Preferred Brand Drugs 4Non-Preferred Brand Drugs $5 Copay $15 Copay $5 Copay $10 Copay $5 Copay You pay 65% You pay 65% You pay 65% You pay 65% You pay 65% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45%% TIER 5 Specialty Drugs ** N/A ** N/A ** CATASTROPHIC COVERAGE After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of a $2.65 copay for generic (including brand drugs treated as generic) and $6.60 for all other drugs, or a 5% coinsurance. * You may have to pay more than your normal cost-sharing amount if you get your drugs at an out of-network pharmacy. ** You pay 65% for the total cost of the generic or 45% for the brand. 7

10 Inter Valley Health Plan OC Preferred (HMO) Copay Amounts INITIAL COVERAGE LIMIT Drug Tier $2960, the total yearly drug costs in the initial coverage limit paid by both you and Inter Valley Health Plan Co-payment /Coinsurance (30 day Supply) Co-payment /Coinsurance (90 day Supply) Network Long- Term Care Cost-Sharing (31 day Supply) - Co-payment /Coinsurance (90-day supply) Out of Network Co-payment /Coinsurance (30-day supply)* TIER TIER TIER TIER TIER 5 1Preferred Generic Drugs 2Non-Preferred Generic Drugs 3Preferred Brand Drugs 4Non-Preferred Brand Drugs Specialty Drugs $5 Copay $15 Copay $5 Copay $10 Copay $5 Copay $15 Copay $45 Copay $15 Copay $30 Copay $15 Copay $39 Copay $117 Copay $39 Copay $78 Copay $39 Copay $89 Copay $267 Copay $89 Copay $178 Copay $89 Copay 33% Coinsurance N/A 33% Coinsurance N/A 33% Coinsurance TIER TIER TIER TIER COVERAGE GAP 1Preferred Generic Drugs 2Non-Preferred Generic Drugs 3Preferred Brand Drugs 4Non-Preferred Brand Drugs $5 Copay $15 Copay $5 Copay $10 Copay $5 Copay You pay 65% You pay 65% You pay 65% You pay 65% You pay 65% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% You pay 45% TIER 5 Specialty Drugs ** N/A ** N/A ** CATASTROPHIC COVERAGE After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of a $2.65 copay for generic (including brand drugs treated as generic) and $6.60 for all other drugs, or a 5% coinsurance. * You may have to pay more than your normal cost-sharing amount if you get your drugs at an out of-network pharmacy. ** You pay 65% for the total cost of the generic or 45% for the brand. 8

11 Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) Formulary The formulary that begins on page 11 provides coverage information about some of the drugs covered by Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 117. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., simvastatin). The second column of the chart lists the alternate drug name (this is for reference only and if drug name is in this column is NOT a covered benefit). The third column of the chart lists the Tier number for each covered medication. Please refer to page 7 for Inter Valley Health Plan Service To Seniors (HMO) copay chart or page 8 for the Inter Valley Health Plan OC Preferred (HMO) copay chart. This copay chart will show you what the copayment is for each Tier. The fourth column of the chart will let you see if the listed medication is available to be filled for 90 days with one of our Pharmacies. Please refer to page 7 for Inter Valley Health Plan Service To Seniors (HMO) copay chart or page 8 for the Inter Valley Health Plan OC Preferred (HMO) copay chart for the 90 day copayment. The fifth column of the chart will let you see if the listed medication is available to be filled for 90 days at a local retail Pharmacy. Please refer to page 7 for Inter Valley Health Plan Service To Seniors (HMO) copay chart or page 8 for the Inter Valley Health Plan OC Preferred (HMO) copay chart for the 90 day copayment. The sixth column of the chart will show you if the listed medication has any special requirements or limits. The information in the column tells you if Inter Valley Health Plan Service To Seniors (HMO) or OC Preferred (HMO) has any special requirements for coverage of your drug. The seventh column of the chart will show you the route of the listed medication. 9

12 The following explains the abbreviations used in the Formulary: PA-Prior Authorization; QL Quantity ; ST-Step Therapy; -ection; TD-Transdermal; Rec-Rectal; -ical; NS-Nasal; Vag-Vaginal; Inh-Inhalation; OP-Ophthalmic; OT-Otic; MT-Mucus Membrane ical; SL-Sublingual; IR-Irrigation; BU-Buccal; TL-Translingual. Drugs marked with a * are the designated generic drugs offered in the Free First Fill Program. See page 112 for complete details. Drugs marked with ** indicates the prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Drugs marked with *** indicates the prescription has limited access. Please call Inter Valley Health Plan s Pharmacy Department at for more information. 10

13 ANALGESICS Analgesics, Other but-50 / apap-300 / caf-40 cap butalbital - acetaminophen - caffeine Tier 1 No No but-50 / apap-325 / caf-40 / codeine-30 cap FIORICET - CODEINE Tier 2 No No QL (180 per 30 but-50 / apap-325 / caf-40 cap butalbital - acetaminophen - caffeine Tier 1 No No QL (120 per 30 but-50 / apap-325 / caf-40 tab butalbital - acetaminophen - caffeine Tier 1 No No QL (120 per 30 but-50 / apap-325 tab butalbital - acetaminophen Tier 1 No No QL (180 per 30 but-50 / asa-325 / caff-40 cap butalbital - aspirin - caffeine Tier 1 No No QL (180 per 30 Nonsteroidal Anti-inflammatory Drugs diclofen pot tab 50mg CATAFLAM Tier 2 Yes Yes 7 diclofenac tab 100mg er VOLTAREN - XR Tier 2 Yes Yes 8 diclofenac tab 25mg dr VOLTAREN Tier 2 Yes Yes 9 diclofenac tab 50mg dr VOLTAREN Tier 2 Yes Yes 10 diclofenac tab 75mg dr VOLTAREN Tier 2 Yes Yes 11 diflunisal tab 500mg diflunisal Tier 2 Yes Yes 12 etodolac cap 200mg LODINE Tier 2 Yes Yes 13 etodolac cap 300mg LODINE Tier 2 Yes Yes 14 etodolac er tab 400mg LODINE XL Tier 2 Yes Yes 15 etodolac er tab 500mg LODINE XL Tier 2 Yes Yes 16 etodolac er tab 600mg LODINE XL Tier 2 Yes Yes 17 etodolac tab 400mg LODINE Tier 2 Yes Yes 18 etodolac tab 500mg LODINE Tier 2 Yes Yes 19 fenoprofen tab 600mg FENOPROFEN Tier 2 Yes Yes 20 flurbiprofen tab 100mg ANSAID Tier 2 Yes Yes 21 flurbiprofen tab 50mg ANSAID Tier 2 Yes Yes 22 ibuprofen sus 100/5ml MOTRIN Tier 1 Yes Yes 23 ibuprofen tab 400mg * MOTRIN Tier 1 Yes Yes 24 ibuprofen tab 600mg * MOTRIN Tier 1 Yes Yes 25 ibuprofen tab 800mg * MOTRIN Tier 1 Yes Yes 26 ketoprofen cap 200mg er ORUVAIL Tier 1 No No 27 ketoprofen cap 50mg KETOPROFEN Tier 1 Yes Yes 28 ketoprofen cap 75mg KETOPROFEN Tier 1 Yes Yes 29 meclofen sod cap 100mg meclofenamate Tier 2 Yes Yes 30 meclofen sod cap 50mg meclofenamate Tier 2 Yes Yes 31 meloxicam tab 15mg * MOBIC Tier 2 Yes Yes QL (30 per meloxicam tab 7.5mg * MOBIC Tier 2 Yes Yes QL (30 per nabumetone tab 500mg RELAFEN Tier 2 Yes Yes 34 nabumetone tab 750mg RELAFEN Tier 2 Yes Yes 35 11

14 naproxen dr tab 375mg NAPROSYN Tier 1 Yes Yes 36 naproxen dr tab 500mg NAPROSYN Tier 1 Yes Yes 37 naproxen sod tab 275mg ANAPROX Tier 1 Yes Yes 38 naproxen sod tab 550mg ANAPROX DS Tier 1 Yes Yes 39 naproxen sus 125/5ml NAPROSYN Tier 1 Yes Yes 40 naproxen tab 250mg NAPROXYN Tier 1 Yes Yes 41 naproxen tab 375mg NAPROSYN Tier 1 Yes Yes 42 naproxen tab 500mg NAPROSYN Tier 1 Yes Yes 43 oxaprozin tab 600mg DAYPRO Tier 2 Yes Yes 44 piroxicam cap 10mg FELDENE Tier 2 Yes Yes 45 piroxicam cap 20mg FELDENE Tier 2 Yes Yes 46 sulindac tab 150mg CLINORIL Tier 2 Yes Yes 47 sulindac tab 200mg CLINORIL Tier 2 Yes Yes 48 tolmetin sod cap 400mg TOLECTIN DS Tier 2 Yes Yes 49 tolmetin sod tab 600mg TOLECTIN Tier 1 Yes Yes Opioid Analgesics, Long-acting fentanyl dis 100mcg/hr DURAGESIC Tier 2 No No QL (30 per 30 TD fentanyl dis 12mcg/hr DURAGESIC Tier 2 No No QL (30 per 30 TD fentanyl dis 25mcg/hr DURAGESIC Tier 2 No No QL (30 per 30 TD fentanyl dis 50mcg/hr DURAGESIC Tier 2 No No QL (30 per 30 TD fentanyl dis 75mcg/hr DURAGESIC Tier 2 No No QL (30 per 30 TD levorphanol tab 2mg LEVO-DROMORAN Tier 2 No No QL (120 per 30 methadone inj 10mg/ml methadone Tier 3 No No PA, QL (120 per 30 morphine sul tab 100mg er MS CONTIN Tier 2 No No QL (120 per 30 morphine sul tab 15mg er MS CONTIN Tier 2 No No QL (120 per 30 morphine sul tab 200mg er MS CONTIN Tier 2 No No QL (120 per 30 morphine sul tab 30mg er MS CONTIN Tier 2 No No QL (120 per 30 morphine sul tab 60mg er MS CONTIN Tier 2 No No QL (120 per 30 OXYCONTIN TAB 10MG CR oxycodone er Tier 4 No No QL (90 per 30 OXYCONTIN TAB 15MG CR oxycodone er Tier 4 No No QL (90 per 30 OXYCONTIN TAB 20MG CR oxycodone er Tier 4 No No QL (90 per 30 OXYCONTIN TAB 30MG CR oxycodone er Tier 4 No No QL (90 per 30 OXYCONTIN TAB 40MG CR oxycodone er Tier 4 No No QL (90 per 30 OXYCONTIN TAB 60MG CR oxycodone er Tier 4 No No QL (90 per 30 OXYCONTIN TAB 80MG CR oxycodone er Tier 4 No No QL (90 per 30 12

15 Opioid Analgesics, Short-acting apap/codeine sol /5ml TYLENOL WITH CODEINE SOLN Tier 1 No No apap/codeine tab mg TYLENOL WITH CODEINE Tier 1 No No QL (400 per 30 apap/codeine tab mg TYLENOL WITH CODEINE Tier 1 No No QL (400 per 30 apap/codeine tab mg TYLENOL WITH CODEINE Tier 1 No No QL (400 per 30 butorphanol sol 10mg/ml butorphanol Tier 2 No No QL (10 per 30 NS DILAUDID INJ 1MG/ML hydromorphone Tier 3 No No DILAUDID INJ 2MG/ML hydromorphone Tier 3 No No DILAUDID INJ 4MG/ML hydromorphone Tier 3 No No DURAMORPH INJ 0.5MG/ML morphine Tier 3 No No DURAMORPH INJ 1MG/ML morphine Tier 3 No No endocet tab mg ENDOCET, PERCOCET Tier 2 No No QL (120 per 30 endocet tab 5-325mg ENDOCET, PERCOCET Tier 2 No No QL (120 per 30 endocet tab mg ENDOCET, PERCOCET Tier 2 No No QL (120 per 30 fentanyl ot loz 1200mcg ACTIQ Tier 2 No No PA, QL (120 per 30 BU fentanyl ot loz 1600mcg ACTIQ Tier 2 No No PA, QL (120 per 30 BU fentanyl ot loz 200mcg ACTIQ Tier 2 No No PA, QL (120 per 30 BU fentanyl ot loz 400mcg ACTIQ Tier 2 No No PA, QL (120 per 30 BU fentanyl ot loz 600mcg ACTIQ Tier 2 No No PA, QL (120 per 30 BU fentanyl ot loz 800mcg ACTIQ Tier 2 No No PA, QL (120 per 30 BU hydroco/apap tab mg NORCO Tier 2 No No QL (240 per 30 hydroco/apap tab 5-300mg XODOL Tier 2 No No QL (360 per 30 hydroco/apap tab 5-325mg NORCO Tier 2 No No QL (360 per 30 hydroco/apap tab mg XODOL Tier 2 No No QL (240 per 30 hydroco/apap tab mg NORCO Tier 2 No No QL (240 per 30 hydromorphon tab 2mg DILAUDID Tier 1 No No QL (120 per 30 hydromorphon tab 4mg DILAUDID Tier 1 No No QL (120 per 30 hydromorphon tab 8mg DILAUDID Tier 1 No No QL (120 per 30 morphine sul sol 10mg/5ml morphine soln Tier 2 No No morphine sul sol 20mg/5ml morphine soln Tier 2 No No morphine sul sol 20mg/ml morphine Tier 2 No No morphine sul tab 15mg morphine Tier 2 No No QL (120 per 30 morphine sul tab 30mg morphine Tier 2 No No QL (120 per 30 nalbuphine inj 10mg/ml NUBAIN Tier 2 No No PA, QL (120 per 30 13

16 nalbuphine inj 20mg/ml NUBAIN Tier 2 No No PA, QL (120 per 30 oxycod/apap tab mg ENDOCET, PERCOCET Tier 2 No No QL (120 per 30 oxycod/apap tab mg PERCOCET Tier 2 No No QL (120 per oxycod/apap tab 5-325mg ENDOCET, PERCOCET Tier 2 No No QL (120 per oxycod/apap tab mg ENDOCET, PERCOCET Tier 2 No No QL (120 per oxycodone cap 5mg ROXICODONE Tier 2 No No QL (120 per oxycodone con 100/5ml ROXICODONE Tier 2 No No 109 oxycodone tab 10mg ROXICODONE Tier 2 No No QL (120 per oxycodone tab 15mg ROXICODONE Tier 2 No No QL (120 per oxycodone tab 20mg ROXICODONE Tier 2 No No QL (120 per oxycodone tab 30mg ROXICODONE Tier 2 No No QL (120 per oxycodone tab 5mg ROXICODONE Tier 2 No No QL (120 per tramadl/apap tab mg ULTRCET Tier 2 No No QL (240 per tramadol hcl tab 50mg ULTRAM Tier 2 Yes Yes QL (240 per ANESTHETICS Local Anesthetics lido/prilocn cre % EMLA Tier 2 No No lidocaine gel 2% jelly lidocaine Tier 2 No No lidocaine gel 2% jelly XYLOCAINE Tier 2 No No lidocaine inj 0.5% XYLOCAINE Tier 1 No No PA lidocaine inj 1% XYLOCAINE Tier 1 No No PA lidocaine oin 5% XYLOCAINE Tier 2 No No lidocaine pad 5% LIDODERM Tier 2 No No PA, QL (90 per 30 lidocaine sol 2% visc XYLOCAINE Tier 2 No No MT lidocaine sol 4% XYLOCAINE Tier 2 No No ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving ACAMPRO CAL TAB 333MG acamprosate Tier 2 No No 126 disulfiram tab 250mg ANTABUSE Tier 2 No No 127 disulfiram tab 500mg ANTABUSE Tier 2 No No 128 Opioid Dependence Treatments buprenorphin inj 0.3mg/ml BUPRENEX Tier 2 No No PA 129 buprenorphin sub 2mg SUBUTEX Tier 2 No No QL (120 per SL buprenorphin sub 8mg SUBUTEX Tier 2 No No QL (120 per SL 14

17 REVIA TAB 50MG naltrexone Tier 3 No No 132 SUBOXONE MIS 12-3MG buprenorphine - naloxone Tier 4 No No QL (60 per SL SUBOXONE MIS 2-0.5MG buprenorphine - naloxone Tier 4 No No QL (90 per SL SUBOXONE MIS 4-1MG buprenorphine - naloxone Tier 4 No No QL (45 per SL SUBOXONE MIS 8-2MG buprenorphine - naloxone Tier 4 No No QL (90 per SL Opioid Reversal Agents naloxone inj 1mg/ml NARCAN Tier 2 No No naltrexone tab 50mg naltrexone Tier 2 No No Smoking Cessation Agents buproban tab 150mg bupropion Tier 2 No No QL (90 per 30 bupropion tab 100mg WELLBUTRIN Tier 2 Yes Yes QL (120 per 30 bupropion tab 100mg sr WELLBUTRIN SR, BUDEPRION SR Tier 2 Yes Yes QL (60 per 30 bupropion tab 150mg sr WELLBUTRIN SR, BUDEPRION SR Tier 2 Yes Yes QL (90 per 30 bupropion tab 200mg sr WELLBUTRIN SR, BUDEPRION SR Tier 2 Yes Yes QL (30 per 30 bupropion tab 75mg WELLBUTRIN Tier 2 Yes Yes QL (180 per 30 bupropn hcl tab 150mg xl WELLBUTRIN XL Tier 2 Yes Yes QL (30 per 30 bupropn hcl tab 300mg xl WELLBUTRIN XL Tier 2 Yes Yes QL (45 per 30 CHANTIX PAK 0.5& 1MG varenicline Tier 3 No No QL (60 per 30 CHANTIX TAB 0.5MG varenicline Tier 3 No No QL (60 per 30 CHANTIX TAB 1MG varenicline Tier 3 No No QL (60 per 30 NICOTROL NS SPR 10MG/ML nicotine Tier 4 No No QL (40 per 30 NS ANTIBACTERIALS Aminoglycosides amikacin inj 500/2ml amikacin Tier 2 No No PA gentak oin 0.3% GENTAK Tier 2 No No OP gentam/nacl inj 100mg GENTAMICIN Tier 2 No No PA gentam/nacl inj 60mg GENTAMICIN Tier 2 No No gentam/nacl inj 80mg/100ml GENTAMICIN Tier 2 No No PA gentam/nacl inj 80mg/50ml GENTAMICIN Tier 2 No No gentamicin cre 0.1% gentamicin Tier 1 No No gentamicin inj 10mg/ml GENTAMICIN Tier 2 No No PA gentamicin inj 40mg/ml GENTAMICIN Tier 2 No No PA gentamicin oin 0.1% gentamicin Tier 1 No No gentamicin sol 0.3% GENTAK Tier 2 No No OP neomycin tab 500mg NEOMYCIN Tier 2 No No 15

18 paromomycin cap 250mg PARAMOMYCIN Tier 1 No No 163 streptomycin inj 1gm streptomycin Tier 4 No No 164 TOBRADEX OIN % tobramycin - dexamethasone Tier 4 No Yes 165 OP tobramycin inj 80mg/2ml tobramycin Tier 2 No No PA 166 tobramycin sol 0.3% TOBREX Tier 1 No No 167 OP Antibacterials, Other acetic acid sol 2% ACETIC ACID Tier 2 No No OT baciim inj 50000unt BACITRACIN Tier 2 No No PA bacitracin oin bacitracin Tier 2 No No OP BACTROBAN OIN NASAL 2% mupirocin Tier 4 No No NS chloramphen inj 1gm chloramphenicol Tier 4 No No PA clindamycin aer 1% CLEOCIN-T Tier 2 No No clindamycin cap 150mg CLEOCIN Tier 2 No No clindamycin cap 300mg CLEOCIN Tier 2 No No clindamycin cre 2% CLEOCIN Tier 2 No No Vag clindamycin gel 1% CLEOCIN-T Tier 2 No No clindamycin inj 150mg/ml CLEOCIN Tier 2 No No PA clindamycin inj 300mg CLEOCIN Tier 2 No No clindamycin inj 600mg CLEOCIN Tier 2 No No clindamycin lot 1% CLEOCIN-T Tier 2 No No clindamycin pad 1% CLEOCIN-T Tier 2 No No clindamycin sol 1% CLEOCIN-T Tier 2 No No colistimeth inj 150mg colistimethate Tier 2 No No PA CUBICIN SOL 500MG daptomycin Tier 4 No No PA methenam hip tab 1gm HIPREX Tier 2 No No metron/nacl inj 500mg FLAGYL Tier 2 No No PA metronidazol cre 0.75% metronidazole Tier 2 No No metronidazol gel 0.75% METROGEL-VAG, VANDAZOLE Tier 2 No No Vag metronidazol gel 0.75% metronidazole Tier 2 No No metronidazol gel 1% FLAGYL Tier 2 No No metronidazol lot 0.75% metronidazole Tier 2 No No metronidazol tab 250mg FLAGYL Tier 1 No No metronidazol tab 500mg FLAGYL Tier 1 No No mupirocin oin 2% BACTROBAN Tier 2 No No neo/poly gu sol 40/ml NEOSPORIN GU Tier 1 No No IR nitrofur mac cap 50mg MACRODANTIN Tier 2 No No nitrofurantn cap 100mg MACROBID Tier 2 No No SULFAMYLON CRE 85MG/GM mafenide Tier 4 No No SULFAMYLON PAK 5% mafenide Tier 4 No No 16

19 SYNERCID INJ 500MG dalfopristin - quinupristin Tier 5 No No PA 201 trimethoprim tab 100mg PROLOPRIM Tier 2 No No 202 TYGACIL INJ 50MG tigecycline Tier 4 No No PA 203 VANCOCIN HCL CAP 125MG vancomycin Tier 5 No No PA 204 VANCOCIN HCL CAP 250MG vancomycin Tier 5 No No PA 205 vancomycin inj 1000mg VANCOMYCIN Tier 2 No No PA 206 vancomycin inj 500mg VANCOCIN Tier 2 No No PA 207 vandazole gel 0.75% METROGEL-VAG, VANDAZOLE Tier 2 No No 208 Vag ZYVOX SOL 2MG/ML linezolid Tier 5 No No PA 209 ZYVOX SUS 100MG/5ML linezolid Tier 5 No No PA 210 ZYVOX TAB 600MG linezolid Tier 5 No No PA, QL (28 per Beta-lactam, Cephalosporins cefaclor cap 250mg CECLOR Tier 1 No No cefaclor cap 500mg CECLOR Tier 1 No No cefaclor er tab 500mg CECLOR Tier 1 No No cefadroxil cap 500mg DURICEF Tier 1 No No cefadroxil sus 250/5ml DURICEF Tier 1 No No cefadroxil sus 500/5ml DURICEF Tier 1 No No cefadroxil tab 1gm DURICEF Tier 1 No No cefazolin inj 1gm ANCEF Tier 2 No No PA cefazolin inj 500mg ANCEF Tier 2 No No PA cefdinir cap 300mg OMNICEF Tier 2 No No cefdinir sus 125/5ml OMNICEF Tier 2 No No cefdinir sus 250/5ml OMNICEF Tier 2 No No cefepime inj 1gm MAXIPIME Tier 2 No No PA cefepime inj 2gm MAXIPIME Tier 2 No No PA cefoxitin inj 1gm MEFOXIN Tier 2 No No PA cefoxitin inj 2gm MEFOXIN Tier 2 No No PA cefpodo prox sus 100/5ml VANTIN Tier 2 No No cefpodo prox sus 50mg/5ml VANTIN Tier 2 No No cefpodoxime tab 100mg VANTIN Tier 2 No No cefpodoxime tab 200mg VANTIN Tier 2 No No cefprozil sus 125/5ml CEFZIL Tier 2 No No cefprozil sus 250/5ml CEFZIL Tier 2 No No cefprozil tab 250mg CEFZIL Tier 2 No No cefprozil tab 500mg CEFZIL Tier 2 No No ceftriaxone inj 1gm ROCEPHIN Tier 2 No No PA ceftriaxone inj 250mg ROCEPHIN Tier 2 No No PA 17

20 ceftriaxone inj 2gm ROCEPHIN Tier 2 No No PA 238 ceftriaxone inj 500mg ROCEPHIN Tier 2 No No PA 239 cefuroxime inj 1.5gm ZINACEF Tier 2 No No PA 240 cefuroxime inj 7.5gm ZINACEF Tier 2 No No PA 241 cefuroxime inj 750mg ZINACEF Tier 2 No No PA 242 cefuroxime tab 250mg CEFTIN Tier 2 No No 243 cefuroxime tab 500mg CEFTIN Tier 2 No No 244 cephalexin cap 250mg KEFLEX Tier 1 No No 245 cephalexin cap 500mg KEFLEX Tier 1 No No 246 cephalexin sus 125/5ml KEFLEX Tier 1 No No 247 cephalexin sus 250/5ml KEFLEX Tier 1 No No 248 cephalexin tab 250mg KEFLEX Tier 1 No No 249 cephalexin tab 500mg KEFLEX Tier 1 No No 250 SUPRAX CAP 400MG cefixime Tier 4 No No 251 SUPRAX TAB 400MG cefixime Tier 4 No No 252 TEFLARO INJ 400MG ceftaroline Tier 4 No No PA 253 TEFLARO INJ 600MG ceftaroline Tier 4 No No PA 254 Beta-lactam, Other aztreonam inj 1gm AZACTAM Tier 4 No No PA imipenem/cil inj 500mg imipenem-cilastatin Tier 2 No No PA INVANZ INJ 1GM ertapenem Tier 4 No No MERREM INJ 500MG meropenem Tier 3 No No PA Beta-lactam, Penicillins amox-pot cla tab er AUGMENTIN Tier 2 No No amox/k clav chw 200mg AUGMENTIN Tier 2 No No amox/k clav chw 400mg AUGMENTIN Tier 2 No No amox/k clav sus 200/5ml AUGMENTIN Tier 2 No No amox/k clav sus 250/5ml AUGMENTIN Tier 2 No No amox/k clav sus 400/5ml AUGMENTIN Tier 2 No No amox/k clav sus 600/5ml AUGMENTIN Tier 2 No No amox/k clav tab 250mg AUGMENTIN Tier 2 No No amox/k clav tab 500mg AUGMENTIN Tier 2 No No amox/k clav tab 875mg AUGMENTIN Tier 2 No No amoxicillin cap 250mg AMOXIL Tier 1 No No amoxicillin cap 500mg AMOXIL Tier 1 No No amoxicillin chw 125mg AMOXIL Tier 1 No No amoxicillin chw 250mg AMOXIL Tier 1 No No 18

21 amoxicillin sus 125/5ml AMOXIL Tier 1 No No amoxicillin sus 200/5ml AMOXIL Tier 1 No No amoxicillin sus 250/5ml AMOXIL Tier 1 No No amoxicillin sus 400/5ml AMOXIL Tier 1 No No amoxicillin tab 500mg AMOXIL Tier 1 No No amoxicillin tab 875mg AMOXIL Tier 1 No No amp-sulbacta inj 15gm UNASYN Tier 2 No No PA amp-sulbacta inj 3gm UNASYN Tier 2 No No PA ampicillin cap 250mg ampicillin Tier 1 No No ampicillin cap 500mg ampicillin Tier 1 No No AMPICILLIN INJ 125MG ampicillin Tier 2 No No PA ampicillin inj 1gm ampicillin Tier 2 No No PA ampicillin sus 125/5ml ampicillin Tier 1 No No ampicillin sus 250/5ml ampicillin Tier 1 No No BICILLIN C-R INJ penicillin g benzathine - penicillin g Tier 3 No No procaine BICILLIN C-R INJ 900/300 penicillin g benzathine - penicillin g Tier 3 No No procaine BICILLIN L-A INJ penicillin g benzathine Tier 3 No No BICILLIN L-A INJ penicillin g benzathine Tier 3 No No BICILLIN L-A INJ penicillin g benzathine Tier 3 No No dicloxacill cap 250mg DYCIL, DYNAPEN Tier 1 No No dicloxacill cap 500mg DYCIL, DYNAPEN Tier 1 No No nafcillin inj 1gm NAFCILLIN Tier 2 No No PA NALLPEN/DEX INJ 1GM/50ML nafcillin Tier 2 No No PA pen g proc inj PEN G PROCAINE Tier 2 No No PA PEN G SOD INJ pen g sod Tier 3 No No PA penicilln vk sol 125/5ml VEETIDS Tier 1 No No penicilln vk sol 250/5ml VEETIDS Tier 1 No No penicilln vk tab 250mg VEETIDS Tier 1 No No penicilln vk tab 500mg VEETIDS Tier 1 No No PFIZERPEN-G INJ 5MU penicillin g potassium Tier 3 No No PA piper/tazoba inj gm ZOSYN Tier 2 No No PA piper/tazoba inj 4-0.5gm ZOSYN Tier 2 No No PA Cystic Fibrosis Agents tobramycin neb 300/5ml TOBI Tier 2 No No PA Inh 19

22 Macrolides AZASITE SOL 1% azithromycin Tier 4 No No OP azithromycin inj 500mg ZITHROMAX Tier 2 No No PA azithromycin sus 100/5ml ZITHROMAX Tier 2 No No QL (30 per 5 azithromycin sus 200/5ml ZITHROMAX Tier 2 No No QL (90 per 5 azithromycin tab 250mg ZITHROMAX Tier 2 No No QL (6 per 5 azithromycin tab 500mg ZITHROMAX Tier 2 No No QL (6 per 5 azithromycin tab 600mg ZITHROMAX Tier 2 No No QL (6 per 5 clarithromyc sus 125/5ml BIAXIN Tier 2 No No clarithromyc sus 250/5ml BIAXIN Tier 2 No No clarithromyc tab 250mg BIAXIN Tier 2 No No QL (28 per 14 clarithromyc tab 500mg BIAXIN Tier 2 No No QL (28 per 14 clarithromyc tab 500mg er BIAXIN XL Tier 1 No No QL (28 per 14 ery pad 2% ERY Tier 2 No No ery-tab tab 250mg ec erythromycin Tier 1 No No ery-tab tab 333mg ec erythromycin Tier 1 No No ery-tab tab 500mg ec erythromycin Tier 1 No No erythrocin inj 500mg erythromycin Tier 2 No No PA erythrocin tab 250mg ERYTHROCIN Tier 1 No No erythromycin gel 2% ERYGEL Tier 2 No No erythromycin oin ROMYCIN Tier 2 No No OP erythromycin sol 2% ERYGEL Tier 2 No No erythromycin tab 250mg bs ERY-TAB, E.E.S. Tier 1 No No erythromycin tab 500mg bs ERY-TAB, E.E.S. Tier 1 No No Quinolones AVELOX ABC TAB 400MG moxifloxacin Tier 4 No No QL (14 per 14 AVELOX TAB 400MG moxifloxacin Tier 4 No No QL (14 per 14 BESIVANCE SUS 0.6% besifloxacin Tier 4 No No OP ciprofloxacn inj 200mg CIPRO Tier 2 No No ciprofloxacn inj 400mg CIPRO Tier 2 No No PA ciprofloxacn sol 0.3% CILOXAN Tier 2 No No OP ciprofloxacn tab 1000mg CIPRO XR Tier 1 No No ciprofloxacn tab 100mg CIPRO Tier 1 No No ciprofloxacn tab 250mg CIPRO Tier 1 No No ciprofloxacn tab 500mg CIPRO Tier 1 No No ciprofloxacn tab 500mg er CIPRO XR Tier 1 No No ciprofloxacn tab 750mg CIPRO Tier 1 No No 20

23 gatifloxacin sol 0.5% ZYMAXID Tier 2 No No 341 OP levoflox/d5w inj 500/100ml LEVAQUIN Tier 2 No No PA 342 levofloxacin inj 25mg/ml LEVAQUIN Tier 2 No No PA 343 levofloxacin sol 0.5% QUIXIN Tier 2 No No 344 OP levofloxacin sol 25mg/ml LEVAQUIN Tier 2 No No 345 levofloxacin tab 250mg LEVAQUIN Tier 1 No No QL (14 per levofloxacin tab 500mg LEVAQUIN Tier 1 No No QL (14 per levofloxacin tab 750mg LEVAQUIN Tier 1 No No QL (14 per ofloxacin dro 0.3% FLOXIN OTIC Tier 2 No No 349 OT ofloxacin dro 0.3% OCUFLOX Tier 2 No No 350 OP ofloxacin tab 200mg FLOXIN Tier 2 No No 351 ofloxacin tab 300mg FLOXIN Tier 2 No No 352 ofloxacin tab 400mg FLOXIN Tier 2 No No 353 VIGAMOX DRO 0.5% moxifloxacin Tier 4 No No 354 OP Sulfonamides silver sulfa cre 1% SILVADENE - SSD Tier 1 No No smz-tmp inj /5ml BACTRIM, SEPTRA Tier 2 No No PA smz-tmp sus /5ml BACTRIM, SEPTRA Tier 1 No No smz-tmp tab mg BACTRIM, SEPTRA Tier 1 No No smz/tmp ds tab mg BACTRAM DS, SEPTRA DS Tier 1 No No sod sulfacet sol 10% BLEPH-10 Tier 1 No No OP ssd cre 1% SILVADENE - SSD Tier 1 No No sulfacet sod oin 10% BLEPH-10 Tier 1 No No OP sulfacetamid sus 10% KLARON Tier 2 No No sulfadiazine tab 500mg sulfadiazine Tier 2 No No Tetracyclines demeclocycl tab 150mg DECLOMYCIN Tier 2 No No demeclocycl tab 300mg DECLOMYCIN Tier 2 No No doxycyc mono tab 150mg VIBRATAB Tier 1 No No doxycyc mono tab 50mg VIBRATAB Tier 1 No No doxycyc mono tab 75mg VIBRATAB Tier 1 No No doxycycl hyc cap 100mg vibramycin Tier 1 No No doxycycl hyc cap 50mg vibramycin Tier 1 No No doxycycl hyc tab 100mg vibramycin Tier 1 No No doxycycl hyc tab 100mg dr VIBRATAB Tier 1 No No doxycycl hyc tab 75mg dr VIBRATAB Tier 1 No No minocycline cap 100mg MINOCIN Tier 2 No No 21

24 minocycline cap 50mg MINOCIN Tier 2 No No 376 minocycline cap 75mg MINOCIN Tier 2 No No 377 minocycline tab 100mg DYNACIN Tier 2 No No 378 minocycline tab 135mg er SOLODYN Tier 2 No No 379 minocycline tab 45mg er SOLODYN Tier 2 No No 380 minocycline tab 50mg DYNACIN Tier 2 No No 381 minocycline tab 75mg DYNACIN Tier 2 No No 382 minocycline tab 90mg er SOLODYN Tier 2 No No 383 ANTICONVULSANTS Anticonvulsants, Other levetiraceta sol 100mg/ml KEPPRA Tier 2 Yes Yes levetiraceta tab 1000mg KEPPRA Tier 2 Yes Yes levetiraceta tab 250mg KEPPRA Tier 2 Yes Yes levetiraceta tab 500mg KEPPRA Tier 2 Yes Yes levetiraceta tab 500mg er KEPPRA XR Tier 2 No No levetiraceta tab 750mg KEPPRA Tier 2 Yes Yes levetiraceta tab 750mg er KEPPRA XR Tier 2 No No levetiracetm inj 500/5ml KEPPRA Tier 2 No No POTIGA TAB 200MG ezogabine Tier 4 No Yes QL (180 per 30 POTIGA TAB 300MG ezogabine Tier 4 No Yes QL (120 per 30 POTIGA TAB 400MG ezogabine Tier 4 No Yes QL (90 per 30 POTIGA TAB 50MG ezogabine Tier 4 No Yes QL (720 per 30 Calcium Channel Modifying Agents CELONTIN CAP 300MG methsuximide Tier 4 No No 396 ethosuximide cap 250mg ZARONTIN Tier 1 Yes Yes 397 ethosuximide sol 250/5ml ZARONTIN Tier 1 Yes Yes 398 LYRICA CAP 100MG pregabalin Tier 3 No No 399 LYRICA CAP 150MG pregabalin Tier 3 No No 400 LYRICA CAP 200MG pregabalin Tier 3 No No 401 LYRICA CAP 225MG pregabalin Tier 3 No No 402 LYRICA CAP 25MG pregabalin Tier 3 No No 403 LYRICA CAP 300MG pregabalin Tier 3 No No 404 LYRICA CAP 50MG pregabalin Tier 3 No No 405 LYRICA CAP 75MG pregabalin Tier 3 No No 406 LYRICA SOL 20MG/ML pregabalin Tier 3 No No 407 zonisamide cap 100mg ZONEGRAN Tier 2 Yes Yes 408 zonisamide cap 25mg ZONEGRAN Tier 2 Yes Yes

25 zonisamide cap 50mg ZONEGRAN Tier 2 Yes Yes Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazep odt tab 0.125mg KLONOPIN ODT Tier 2 No No PA clonazep odt tab 0.25mg KLONOPIN ODT Tier 2 No No PA clonazep odt tab 0.5mg KLONOPIN ODT Tier 2 No No PA clonazep odt tab 1mg KLONOPIN ODT Tier 2 No No PA clonazep odt tab 2mg KLONOPIN ODT Tier 2 No No PA clonazepam tab 0.5mg KLONOPIN Tier 2 No No PA clonazepam tab 1mg KLONOPIN Tier 2 No No PA clonazepam tab 2mg KLONOPIN Tier 2 No No PA cloraz dipot tab 15mg TRANXENE Tier 2 No No PA, QL (90 per 30 cloraz dipot tab 3.75mg TRANXENE Tier 2 No No PA, QL (90 per 30 cloraz dipot tab 7.5mg TRANXENE Tier 2 No No PA, QL (90 per 30 DIASTAT ACDL GEL MG diazepam gel Tier 3 No No PA Rec DIASTAT ACDL GEL 5-10MG diazepam gel Tier 3 No No PA, QL (30 per 30 Rec DIASTAT PED GEL 2.5MG diazepam gel Tier 3 No No PA, QL (30 per 30 Rec diazepam con 5mg/ml VALIUM Tier 2 No No PA, QL (240 per 30 diazepam sol 1mg/ml VALIUM Tier 2 No No PA, QL (1200 per 30 diazepam tab 10mg VALIUM Tier 2 No No PA, QL (180 per 30 diazepam tab 2mg VALIUM Tier 2 No No PA, QL (90 per 30 diazepam tab 5mg VALIUM Tier 2 No No PA, QL (240 per 30 divalproex cap 125mg DEPAKOTE Tier 2 Yes Yes divalproex tab 125mg dr DEPAKOTE Tier 2 Yes Yes divalproex tab 250mg dr DEPAKOTE Tier 2 Yes Yes divalproex tab 250mg er DEPAKOTE Tier 2 Yes Yes divalproex tab 500mg dr DEPAKOTE Tier 2 Yes Yes divalproex tab 500mg er DEPAKOTE Tier 2 Yes Yes FYCOMPA TAB 10MG perampanel Tier 4 No No QL (30 per 30 FYCOMPA TAB 12MG perampanel Tier 4 No No QL (30 per 30 FYCOMPA TAB 2MG perampanel Tier 4 No No QL (120 per 30 FYCOMPA TAB 4MG perampanel Tier 4 No No QL (90 per 30 23

26 FYCOMPA TAB 6MG perampanel Tier 4 No No QL (60 per FYCOMPA TAB 8MG perampanel Tier 4 No No QL (30 per 30 gabapentin cap 100mg NEURONTIN Tier 1 Yes Yes QL (360 per 30 gabapentin cap 300mg NEURONTIN Tier 1 Yes Yes QL (360 per 30 gabapentin cap 400mg NEURONTIN Tier 1 Yes Yes QL (270 per 30 gabapentin sol 250/5ml NEURONTIN Tier 1 Yes Yes gabapentin tab 600mg NEURONTIN Tier 1 Yes Yes QL (180 per 30 gabapentin tab 800mg NEURONTIN Tier 1 Yes Yes QL (120 per 30 GABITRIL TAB 12MG tiagabine Tier 4 No No GABITRIL TAB 16MG tiagabine Tier 4 No No lorazepam tab 0.5mg ATIVAN Tier 2 No No QL (60 per 30 lorazepam tab 1mg ATIVAN Tier 2 No No QL (60 per 30 lorazepam tab 2mg ATIVAN Tier 2 No No QL (60 per 30 ONFI SUS 2.5MG/ML clobazam Tier 4 No No ONFI TAB 10MG clobazam Tier 4 No No QL (60 per 30 ONFI TAB 20MG clobazam Tier 4 No No QL (60 per 30 phenobarb elx 20mg/5ml phenobarbital Tier 2 No No PA, QL (1500 per 30 phenobarb tab 100mg phenobarbital Tier 2 No No PA, QL (90 per 30 phenobarb tab 15mg phenobarbital Tier 2 No No PA, QL (120 per 30 phenobarb tab 16.2mg phenobarbital Tier 2 No No PA, QL (360 per 30 phenobarb tab 30mg phenobarbital Tier 2 No No PA, QL (195 per 30 phenobarb tab 32.4mg phenobarbital Tier 2 No No PA, QL (180 per 30 phenobarb tab 60mg phenobarbital Tier 2 No No PA, QL (60 per 30 PHENOBARB TAB 64.8MG phenobarbital Tier 2 No No PA, QL (90 per 30 PHENOBARB TAB 97.2MG phenobarbital Tier 2 No No PA, QL (60 per 30 primidone tab 250mg MYSOLINE Tier 1 Yes Yes primidone tab 50mg MYSOLINE Tier 1 Yes Yes SABRIL POW 500MG *** vigabatrin Tier 5 No No PA, QL (180 per 30 SABRIL TAB 500MG *** vigabatrin Tier 5 No No PA, QL (180 per 30 tiagabine tab 2mg GABITRIL Tier 2 No No tiagabine tab 4mg GABITRIL Tier 2 No No valproate inj 100mg/ml DEPAKENE Tier 2 No No valproic acd cap 250mg DEPAKENE Tier 2 Yes Yes 24

27 valproic acd syp 250/5ml DEPAKENE Tier 2 Yes Yes 473 Glutamate Reducing Agents felbamate sus 600/5ml FELBATOL Tier 2 No No felbamate tab 400mg FELBATOL Tier 2 No No felbamate tab 600mg FELBATOL Tier 2 No No LAMICTAL ODT TAB 100MG lamotrigine disintegrating Tier 3 Yes Yes LAMICTAL ODT TAB 200MG lamotrigine disintegrating Tier 3 Yes Yes LAMICTAL ODT TAB 25MG lamotrigine disintegrating Tier 3 Yes Yes LAMICTAL ODT TAB 50MG lamotrigine disintegrating Tier 3 Yes Yes lamotrigine chw 25mg LAMICTAL CHEWABLE Tier 1 Yes Yes lamotrigine chw 5mg LAMICTAL CHEWABLE Tier 1 Yes Yes lamotrigine tab 100mg LAMICTAL Tier 1 Yes Yes lamotrigine tab 150mg LAMICTAL Tier 1 Yes Yes lamotrigine tab 200mg LAMICTAL Tier 1 Yes Yes lamotrigine tab 25mg LAMICTAL Tier 1 Yes Yes QUDEXY XR CAP 100/24HR topiramate Tier 4 No No QUDEXY XR CAP 150/24HR topiramate Tier 4 No No QUDEXY XR CAP 200/24HR topiramate Tier 4 No No QUDEXY XR CAP 25/24HR topiramate Tier 4 No No QUDEXY XR CAP 50/24HR topiramate Tier 4 No No topiramate cap 15mg TOPAMAX Tier 2 Yes Yes topiramate cap 25mg TOPAMAX Tier 2 Yes Yes topiramate tab 100mg TOPAMAX Tier 2 Yes Yes topiramate tab 200mg TOPAMAX Tier 2 Yes Yes topiramate tab 25mg TOPAMAX Tier 2 Yes Yes topiramate tab 50mg TOPAMAX Tier 2 Yes Yes TROKENDI XR CAP 100MG topiramate Tier 4 No No TROKENDI XR CAP 200MG topiramate Tier 4 No No TROKENDI XR CAP 25MG topiramate Tier 4 No No TROKENDI XR CAP 50MG topiramate Tier 4 No No Sodium Channel Agents APTIOM TAB 200MG eslicarbazepine Tier 4 No No APTIOM TAB 400MG eslicarbazepine Tier 4 No No APTIOM TAB 600MG eslicarbazepine Tier 4 No No APTIOM TAB 800MG eslicarbazepine Tier 4 No No BANZEL SUS 40MG/ML rufinamide Tier 4 No No QL (2400 per 30 BANZEL TAB 200MG rufinamide Tier 4 No No QL (240 per 30 25

28 BANZEL TAB 400MG rufinamide Tier 4 No No QL (240 per carbamazepin cap 100mg er TEGRETOL XR Tier 1 Yes Yes 509 carbamazepin cap 200mg er TEGRETOL XR Tier 1 Yes Yes 510 carbamazepin cap 300mg er TEGRETOL XR Tier 1 Yes Yes 511 carbamazepin chw 100mg TEGRETOL Tier 1 Yes Yes 512 carbamazepin sus 100/5ml TEGRETOL Tier 1 Yes Yes 513 carbamazepin tab 200mg TEGRETOL Tier 1 Yes Yes 514 carbamazepin tab 200mg er TEGRETOL XR Tier 1 Yes Yes 515 carbamazepin tab 400mg er TEGRETOL XR Tier 1 Yes Yes 516 DILANTIN CAP 100MG phenytoin Tier 3 Yes Yes 517 DILANTIN CAP 30MG phenytoin Tier 3 Yes Yes 518 DILANTIN CHW 50MG phenytoin Tier 3 Yes Yes 519 DILANTIN-125 SUS 125/5ML phenytoin Tier 3 Yes Yes 520 epitol tab 200mg TEGRETOL Tier 1 Yes Yes 521 EQUETRO CAP 100MG carbamazepine sr Tier 4 No Yes 522 EQUETRO CAP 200MG carbamazepine sr Tier 4 No Yes 523 EQUETRO CAP 300MG carbamazepine sr Tier 4 No Yes 524 oxcarbazepin sus 300mg/5ml TRILEPTAL Tier 2 No No 525 oxcarbazepin tab 150mg TRILEPTAL Tier 2 Yes Yes 526 oxcarbazepin tab 300mg TRILEPTAL Tier 2 Yes Yes 527 oxcarbazepin tab 600mg TRILEPTAL Tier 2 Yes Yes 528 OXTELLAR XR TAB 150MG oxcarbazepine Tier 4 No No QL (480 per OXTELLAR XR TAB 300MG oxcarbazepine Tier 4 No No QL (240 per OXTELLAR XR TAB 600MG oxcarbazepine Tier 4 No No QL (120 per PEGANONE TAB 250MG ethotoin Tier 4 No No 532 phenytoin chw 50mg dilantin chewable Tier 1 Yes Yes 533 phenytoin ex cap 100mg DILANTIN Tier 1 Yes Yes 534 phenytoin ex cap 200mg DILANTIN Tier 1 Yes Yes 535 phenytoin ex cap 300mg DILANTIN Tier 1 Yes Yes 536 phenytoin sus 125/5ml DILANTIN Tier 1 Yes Yes 537 TEGRETOL-XR TAB 100MG carbamazepine er Tier 3 No No 538 VIMPAT INJ 200MG/20ML lacosamide Tier 4 No No QL (1200 per VIMPAT SOL 10MG/ML lacosamide Tier 4 No No QL (1200 per VIMPAT TAB 100MG lacosamide Tier 4 No No QL (60 per VIMPAT TAB 150MG lacosamide Tier 4 No No QL (60 per VIMPAT TAB 200MG lacosamide Tier 4 No No QL (60 per VIMPAT TAB 50MG lacosamide Tier 4 No No QL (60 per ANTIDEMENTIA AGENTS Antidementia Agents, Other ERGOLOID MES TAB 1MG ORAL ERGOLOID MESYLATES Tier 3 No No 26