Partnership HMO SNP 2015 Formulary (List of Covered Drugs)

Transcription

1 Partnership HMO SNP 2015 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID: 15303, Version Number: 26 This formulary was updated on 10/1/2015. For more recent information or other questions, please contact us at or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit H _H _CWHPFC _FINAL Populated Template 9/23/2015 DHS Approved 8/27/2014

2 Note to existing members: 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 Care Wisconsin Health Plan, Inc. When it refers to plan or our plan, it means Partnership. This document includes a list of the drugs (formulary) for our plan which is current as of 10/1/2015. 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, premium and/or copayments/coinsurance may change on January 1, 2015, and from time to time during the year. Partnership is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid Program. Enrollment in Partnership depends on contract renewal. To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin Customer Service at (TTY/TDD Wisconsin Relay System 711).

3 What is the Partnership Formulary? A formulary is a list of covered drugs selected by Partnership in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Partnership will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Partnership 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 beginning of the year, we will not discontinue 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 you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, 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 Administration 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 10/1/2015. To get updated information about the drugs covered by Partnership, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, we will mail you updates to the formulary as needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or printing them from our Web site. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 i

4 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 number 2. 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 43. 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? Partnership 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: Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Partnership may not cover B unless you try A first. If A does not work for you, Partnership will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line 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. ii

5 You can ask Partnership 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 Partnership formulary? on page iii for information about how to request an exception. What are over-the-counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Plan. Partnership pays for certain OTC drugs. The 2015 Formulary Medicaid Supplement included with this formulary provides the list of OTC drugs covered by Partnership when they are ordered by a physician or nurse practitioner for a medical need and the product has a valid National Code (NDC) that is recognized by Wisconsin Medicaid s claims processing system. Partnership will provide these OTC drugs at no cost to you. The cost to Partnership of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap). 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 Customer Service and ask if your drug is covered. If you learn that Partnership does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Partnership. You can ask Partnership to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Partnership 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. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Partnership 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, Partnership will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii

6 You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary 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 days) 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 prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). 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 days) while you pursue a formulary exception. Current members with a change in where they receive care Partnership has a transition process that addresses unplanned transitions as members change treatment settings due to changes in the type of care they require. Changes in where you live or receive care may warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of program enrollment. Examples of situations include: You were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital. iv

7 You are in a skilled nursing facility and Medicare coverage (where payments include all pharmacy charges) comes to an end. In this circumstance your coverage will revert to our plan formulary. Beneficiaries who give up Hospice Status to revert back to standard Medicare or Medicaid benefits. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of medications that are highly individualized. Please note that our transition policy applies only to those drugs that are on our formulary and are supplied by a network pharmacy. For more information For more detailed information about your Partnership prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Partnership, 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 Partnership s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Partnership. If you have trouble finding your drug in the list, turn to the Index that begins on page 43. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., digoxin). The information in the Requirements/Limits column tells you if Partnership has any special requirements for coverage of your drug. v

8 Formulary: 15303, Version ID: 26 Date generated: September 22, 2015 List of Abbreviations B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. CB: This prescription drug has a capped benefit limit. ED: This prescription drug is not normally covered in a Medicare Prescription 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. FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it. GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service at , 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at , 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711. MO: Mail Order. This prescription drug is available through a mail-order service. PA: Prior Authorization. Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don t get approval, Partnership may not cover the drug. QL: Quantity Limit. For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Partnership may not cover drug B unless you try A first. If A does not work for you, Partnership will then cover B. Page 1 of 57

9 Tier Name Requirements/Limits Analgesics Nonsteroidal Anti-inflammatory s CELEBREX CAPS 100MG 1 ST (Non-Opioid Analgesics #2) celecoxib caps 1 ST (Non-Opioid Analgesics #2) etodolac er 1 PA (Beers-HEDIS Safety PA) etodolac caps, tabs 1 PA (Beers-HEDIS Safety PA) ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg 1 indomethacin caps 1 PA (Beers-HEDIS Safety PA) ketoprofen caps 1 PA (Beers-HEDIS Safety PA) nabumetone 1 PA (Beers-HEDIS Safety PA) naproxen dr 1 naproxen susp, tabs 1 oxycodone/ibuprofen 1 Opioid Analgesics, Long-acting fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr 1 QL (10 EA per 30 days) ST (Opioid Analgesics #3) methadone hcl conc, soln, tabs 1 methadose tabs 10mg 1 morphine sulfate er tbcr 1 morphine sulfate tabs 15mg, 30mg 1 oxycodone hcl er 1 ST (Opioid Analgesics #2) OXYCONTIN T12A 15MG, 30MG, 60MG 1 ST (Opioid Analgesics #2) tramadol hcl er tb24 1 ST (Tramadol #2) Opioid Analgesics, Short-acting acetaminophen/codeine #3 1 acetaminophen/codeine soln 1 acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg 1 CODEINE SULFATE TABS 1 duramorph 1 endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 1 fentanyl citrate oral transmucosal 1 ST (Opioid Analgesics #3) PA (Fentanyl Lozenges) hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg 1 hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1 Page 2 of 57 hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg, 500mg; 10mg, 500mg; 5mg, 500mg; 7.5mg, 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg, 750mg; 7.5mg hydrocodone/ibuprofen tabs 7.5mg; 200mg 1 hydromorphone hcl liqd, tabs 1 hydromorphone hcl inj 500mg/50ml 1 morphine sulfate inj 0.5mg/ml, 1mg/ml 1 morphine sulfate oral soln 10mg/5ml, 20mg/5ml, 20mg/ml 1 oxycodone hcl tabs 1 oxycodone/acetaminophen 1 roxicet soln 1 ROXICET TABS 325MG; 5MG 1 stagesic 1 tramadol hcl tabs 1 1

10 tramadol hydrochloride/acetaminophen 1 Anesthetics Local Anesthetics lidocaine hcl jelly 1 lidocaine hcl external soln 1 lidocaine hcl inj 0.5%, 1% 1 lidocaine viscous 1 lidocaine/prilocaine crea 1 lidocaine oint 1 lidocaine ptch 1 QL (90 EA per 30 days) PA (Lidocaine Patch) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 1 disulfiram tabs 1 Opioid Dependence Treatments buprenorphine hcl/naloxone hcl 1 buprenorphine hcl inj 1 buprenorphine hcl subl 1 PA (Buprenorphine) naltrexone hcl tabs 1 Opioid Reversal Agents naloxone hcl inj 1 Smoking Cessation Agents buproban 1 CHANTIX CONTINUING MONTH PAK 1 PA (Varenicline (Chantix)) CHANTIX STARTING MONTH PAK 1 PA (Varenicline (Chantix)) CHANTIX TABS 0.5MG, 1MG 1 PA (Varenicline (Chantix)) NICOTROL INHALER 1 QL (336 EA per 21 days) PA (Nicotine (Nicotrol)) NICOTROL NS 1 QL (168 ML per 30 days) PA (Nicotine (Nicotrol NS)) Anti-inflammatory Agents Nonsteroidal Anti-inflammatory s diclofenac sodium gel 3% 1 PA (Diclofenac (Solaraze)) naproxen sodium tabs 275mg, 550mg 1 oxaprozin 1 PA (Beers-HEDIS Safety PA) Antibacterials Aminoglycosides gentak 1 gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%, 1 1mg/ml; 0.9% gentamicin sulfate crea, inj, external oint, ophthalmic oint, 1 ophthalmic soln isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9% 1 neomycin sulfate 1 neomycin/polymyxin b sulfates 1 paromomycin sulfate 1 streptomycin sulfate inj 1 tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml 1 Page 3 of 57

11 tobramycin sulfate ophthalmic soln 1 tobramycin sulfate inj 10mg/ml, 80mg/2ml 1 ZYLET 1 Antibacterials, Other ALCOHOL PREP PADS 1 baciim 1 bacitracin/polymyxin b 1 bacitracin oint 1 chloramphenicol sodium succinate 1 clindamycin hcl caps 1 clindamycin phosphate add-vantage 1 clindamycin phosphate crea 2% 1 colistimethate sodium 1 CUBICIN 1 linezolid tabs 1 methenamine hippurate 1 metronidazole in nacl 0.79% 1 metronidazole vaginal 1 metronidazole gel 0.75% 1 ST (Acne Agents #2) metronidazole tabs 1 MONUROL 1 mupirocin oint 1 neomycin/bacitracin/polymyxin 1 neomycin/polymyxin/bacitracin/hydrocortisone 1 neomycin/polymyxin/gramicidin 1 nitrofurantoin macrocrystals caps 50mg 1 QL (28 EA per 30 days) PA (Nitrofurantoin) nitrofurantoin monohydrate 1 QL (28 EA per 30 days) PA (Nitrofurantoin) polymyxin b sulfate/trimethoprim sulfate 1 polymyxin b sulfate inj 1 silver sulfadiazine crea 1 ssd 1 SYNERCID 1 trimethoprim tabs 1 TYGACIL 1 vancomycin hcl caps 1 vancomycin hcl inj 1000mg, 10gm, 500mg 1 vandazole 1 XIFAXAN TABS 550MG 1 ST (Hepatic Encephalopathy #2) ZYVOX 1 Beta-lactam, Cephalosporins cefaclor caps 1 cefadroxil 1 cefazolin sodium inj 10gm, 1gm; 5%, 1gm, 500mg 1 cefdinir 1 cefepime inj 1gm, 2gm 1 cefixime 1 cefpodoxime proxetil 1 Page 4 of 57

12 cefprozil 1 ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg 1 cefuroxime axetil tabs 1 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 1 CEFUROXIME/DEXTROSE 1 cephalexin caps 250mg, 500mg 1 cephalexin susr 1 SUPRAX CAPS, TABS 1 SUPRAX SUSR 100MG/5ML, 200MG/5ML 1 TEFLARO INJ 600MG 1 Beta-lactam, Other aztreonam inj 1gm 1 cefotetan 1 imipenem/cilastatin 1 INVANZ 1 meropenem inj 500mg 1 Beta-lactam, Penicillins amoxicillin 1 amoxicillin/clavulanate potassium 1 amoxicillin/clavulanate potassium er 1 ampicillin sodium inj 10gm, 1gm 1 ampicillin-sulbactam inj 10gm; 5gm, 2gm; 1gm 1 ampicillin caps 1 BICILLIN L-A 1 dicloxacillin sodium 1 nafcillin sodium inj 10gm, 1gm 1 NALLPEN/DEXTROSE INJ 0; 1GM/50ML 1 oxacillin sodium inj 10gm, 2gm 1 penicillin g potassium inj unit 1 penicillin v potassium 1 piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm, 1 4gm; 0.5gm ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 1 3GM/50ML; 0.375GM/50ML Macrolides azithromycin susr, tabs 1 azithromycin inj 500mg 1 clarithromycin er 1 clarithromycin susr, tabs 1 DIFICID 1 ST (Clostridum Difficlile Treatment #2) PA (fidaxomicin (Dificid)) e.e.s E.E.S. GRANULES 1 e.s.p. 1 ERY-TAB 1 ERYPED ERYPED erythrocin lactobionate inj 500mg 1 erythrocin stearate 1 Page 5 of 57

13 erythromycin base tabs 1 ERYTHROMYCIN ETHYLSUCCINATE TABS 1 erythromycin gel, oint, soln 1 KETEK 1 PA (Telithromycin (Ketek)) Quinolones AVELOX INJ 1 CIPRO HC 1 CIPRODEX 1 ciprofloxacin er 1 ciprofloxacin hcl soln, tabs 1 ciprofloxacin susr 1 ciprofloxacin inj 400mg/40ml 1 gatifloxacin 1 levofloxacin 1 levofloxacin in d5w inj 5%; 500mg/100ml 1 MOXEZA 1 ofloxacin ophthalmic soln, otic soln 1 VIGAMOX 1 Sulfonamides BLEPHAMIDE S.O.P. 1 sodium sulfacetamide soln 1 sulfacetamide sodium/prednisolone sodium phosphate 1 sulfadiazine tabs 1 sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 Tetracyclines demeclocycline hcl tabs 1 doxycycline hyclate caps, tabs 1 doxycycline monohydrate tabs 1 minocycline hcl caps 1 Anticonvulsants Anticonvulsants, Other APTIOM 1 FYCOMPA 1 levetiracetam 1 levetiracetam er 1 MAGNESIUM SULFATE IN D5W INJ 5%; 10MG/ML 1 phenobarbital elix, tabs 1 PA (Phenobarbital, new POTIGA 1 Calcium Channel Modifying Agents CELONTIN 1 ethosuximide 1 LYRICA SOLN 1 QL (1400 ML per 31 days) LYRICA CAPS 1 QL (93 EA per 31 days) zonisamide 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt 1 PA (Beers-HEDIS Safety PA, new Page 6 of 57

14 clonazepam tabs 1 PA (Beers-HEDIS Safety PA, new DIAZEPAM GEL 10MG, 2.5MG, 20MG 1 PA (Beers-HEDIS Safety PA, new divalproex sodium 1 divalproex sodium dr 1 divalproex sodium er 1 gabapentin caps, soln, tabs 1 GABITRIL TABS 12MG, 16MG 1 ONFI TABS 1 PA (clobazam (Onfi), new starts only) ONFI SUSP 1 PA (Clobazam liquid (Onfi), new primidone tabs 1 SABRIL 1 tiagabine hydrochloride 1 valproate sodium inj 1 valproic acid caps, syrp 1 Glutamate Reducing Agents felbamate 1 lamotrigine er 1 lamotrigine chew, tabs 1 QUDEXY XR CS24 50MG 1 ST (Topiramate #2, new topiramate er 1 ST (Topiramate #2, new topiramate tabs 1 topiramate cpsp 1 PA (Topiramate (Topamax sprinkle), new TROKENDI XR 1 ST (Topiramate #2, new Sodium Channel Agents BANZEL 1 carbamazepine er 1 carbamazepine chew, susp, tabs 1 dilantin caps 30mg 1 epitol 1 fosphenytoin sodium inj 100mg pe/2ml 1 oxcarbazepine 1 OXTELLAR XR 1 ST (Oxcarbazepine #2, new starts only) PEGANONE 1 phenytoin sodium extended 1 phenytoin sodium inj 1 phenytoin chew, susp 1 VIMPAT 1 Antidementia Agents Cholinesterase Inhibitors donepezil hcl tbdp 1 donepezil hcl tabs 10mg, 5mg 1 EXELON SOLN 1 galantamine hydrobromide 1 Page 7 of 57

15 rivastigmine tartrate 1 N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl 1 NAMENDA 1 NAMENDA XR 1 NAMENDA XR TITRATION PACK 1 Antidepressants Antidepressants, Other BRINTELLIX 1 ST (Major Depressive Disorder #2, new PA (Vortioxetine (Brintellix), new budeprion sr 1 bupropion hcl sr 1 bupropion hcl xl 1 bupropion hcl tabs 1 maprotiline hcl 1 mirtazapine 1 PA (Beers-HEDIS Safety PA, new mirtazapine odt 1 PA (Beers-HEDIS Safety PA, new nefazodone hcl 1 trazodone hcl tabs 1 Monoamine Oxidase Inhibitors EMSAM 1 PA (Selegiline (Emsam), new starts only) MARPLAN 1 phenelzine sulfate tabs 1 tranylcypromine sulfate 1 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide 1 desvenlafaxine er 1 ST (Desvenlafaxine #2, new starts only) duloxetine hcl cpep 40mg 1 duloxetine hcl cpep 20mg, 30mg, 60mg 1 QL (62 EA per 31 days) FETZIMA 1 ST (Major Depressive Disorder #2, new FETZIMA TITRATION PACK 1 ST (Major Depressive Disorder #2, new fluoxetine dr 1 fluoxetine hcl caps, soln, tabs 1 fluvoxamine maleate 1 KHEDEZLA 1 ST (Desvenlafaxine #2, new starts only) paroxetine hcl 1 PA (Beer's List highly anticholinergic medications, new Page 8 of 57

16 paroxetine hcl er 1 PA (Beer's List highly anticholinergic medications, new PAXIL SUSP 1 PA (Paroxetine (Paxil), new starts only) sertraline hcl conc, tabs 1 venlafaxine hcl 1 venlafaxine hcl er 1 VIIBRYD 1 Tricyclics amitriptyline hcl tabs 1 PA (Beer's List highly anticholinergic medications, new amoxapine 1 PA (Beer's List highly anticholinergic medications, new clomipramine hcl caps 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new desipramine hcl tabs 1 PA (Beer's List highly anticholinergic medications, new doxepin hcl caps, conc 1 PA (Beer's List highly anticholinergic medications, new imipramine hcl tabs 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new imipramine pamoate 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new nortriptyline hcl soln 1 PA (Beer's List highly anticholinergic medications liquid, new nortriptyline hcl caps 1 PA (Beer's List highly anticholinergic medications, new protriptyline hcl 1 PA (Beer's List highly anticholinergic medications, new SURMONTIL 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new Page 9 of 57

17 trimipramine maleate caps 1 ST (Tricyclics #2, new PA (Beer's List highly anticholinergic medications, new Antiemetics Antiemetics, Other meclizine hcl tabs 1 PA (Beer's List highly anticholinergic medications) promethazine hcl inj 1 PA (Beers-HEDIS Safety PA) promethazine hcl supp 12.5mg, 25mg 1 PA (Beer's List highly anticholinergic medications) TRANSDERM-SCOP 1 PA (Beer's List highly anticholinergic medications) Emetogenic Therapy Adjuncts ANZEMET TABS 1 QL (9 EA per 30 days) ST (5-HT3 Antagonist Antiemetics #3) B/D ANZEMET INJ 1 ST (5-HT3 Antagonist Antiemetics #3) dronabinol 1 PA (Dronabinol (Marinol)) EMEND CAPS 0 1 QL (6 EA per 30 days) ST (5-HT3 Antagonist Antiemetics #3) B/D EMEND CAPS 125MG, 40MG, 80MG 1 QL (9 EA per 30 days) ST (5-HT3 Antagonist Antiemetics #3) B/D granisetron hcl tabs 1 ST (5-HT3 Antagonist Antiemetics #2) B/D granisetron hcl inj 0.1mg/ml, 1mg/ml 1 ST (5-HT3 Antagonist Antiemetics #2) granisol 1 ST (5-HT3 Antagonist Antiemetics #2) B/D ondansetron hcl oral soln 1 QL (950 ML per 31 days) ST (5- HT3 Antagonist Antiemetics #2) B/D ondansetron hcl inj 4mg/2ml 1 ondansetron hcl tabs 24mg 1 QL (31 EA per 31 days) ST (5-HT3 Antagonist Antiemetics #2) B/D ondansetron hcl tabs 4mg, 8mg 1 QL (62 EA per 31 days) B/D ondansetron odt 1 QL (62 EA per 31 days) B/D Antifungals Antifungals ABELCET 1 AMBISOME 1 amphotericin b 1 CANCIDAS 1 ciclopirox nail lacquer 1 ciclopirox olamine crea 1 ciclopirox sham, susp 1 clotrimazole crea, soln, troc 1 econazole nitrate crea 1 fluconazole in dextrose inj 56mg/ml; 400mg/200ml 1 Page 10 of 57

18 fluconazole susr, tabs 1 flucytosine 1 griseofulvin microsize susp 1 itraconazole caps 1 ketoconazole crea, sham, tabs 1 miconazole 3 supp 1 MYCAMINE 1 NOXAFIL SUSP 1 NYSTATIN/TRIAMCINOLONE OINT 1 nystatin/triamcinolone crea 1 nystatin crea, oint, powd, susp, tabs 1 SPORANOX SOLN 1 terbinafine hcl tabs 1 terconazole 1 voriconazole inj, susr, tabs 1 zazole supp 1 Antigout Agents Antigout Agents allopurinol tabs 1 colchicine caps, tabs 1 COLCRYS 1 probenecid/colchicine 1 probenecid tabs 1 Antimigraine Agents Ergot Alkaloids CAFERGOT 1 PA (Beers-HEDIS Safety PA) ergomar 1 PA (Beers-HEDIS Safety PA) Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl 1 QL (9 EA per 30 days) rizatriptan benzoate 1 QL (18 EA per 30 days) rizatriptan benzoate odt 1 QL (18 EA per 30 days) sumatriptan succinate inj 1 QL (6 ML per 30 days) ST (Migraine Abortive Agents (5) #2) sumatriptan succinate tabs 1 QL (9 EA per 30 days) zolmitriptan odt 1 QL (6 EA per 30 days) ST (Migraine Abortive Agents (5) #2) zolmitriptan tabs 1 QL (9 EA per 30 days) ST (Migraine Abortive Agents (5) #2) ZOMIG NASAL SPRAY 1 QL (6 EA per 30 days) ST (Migraine Abortive Agents (5) #2) ZOMIG SOLN 2.5MG 1 QL (6 EA per 30 days) ST (Migraine Abortive Agents (5) #2) Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL 1 pyridostigmine bromide tabs 1 Antimycobacterials Antimycobacterials, Other DAPSONE TABS 1 Page 11 of 57

19 rifabutin 1 Antituberculars CAPASTAT SULFATE 1 ethambutol hcl tabs 1 ISONIAZID INJ 1 isoniazid tabs 1 PASER 1 PRIFTIN 1 pyrazinamide tabs 1 rifampin caps, inj 1 seromycin 1 SIRTURO 1 PA (Bedaquiline (Sirturo)) TRECATOR 1 Antineoplastics Alkylating Agents cyclophosphamide tabs 1 B/D HEXALEN 1 LEUKERAN 1 lomustine 1 MATULANE 1 TREANDA INJ 45MG/0.5ML 1 VALCHLOR 1 Antiandrogens bicalutamide 1 flutamide 1 NILANDRON 1 XTANDI 1 ZYTIGA 1 Antiangiogenic Agents CAPRELSA 1 REVLIMID 1 LA THALOMID 1 Antiestrogens/Modifiers EMCYT 1 FARESTON 1 SOLTAMOX 1 tamoxifen citrate tabs 1 Antimetabolites ADRUCIL INJ 500MG/10ML 1 ALIMTA INJ 500MG 1 hydroxyurea caps 1 mercaptopurine tabs 1 PURIXAN 1 TABLOID 1 Antineoplastics, Other amifostine 1 azacitidine 1 BELEODAQ 1 bleomycin sulfate inj 30unit 1 Page 12 of 57

20 cisplatin inj 100mg/100ml 1 PA (Beers-HEDIS Safety PA, new COMETRIQ 1 PA (Cabozantinib S-Malate (Cometriq), new daunorubicin hcl inj 5mg/ml 1 DAUNOXOME 1 decitabine 1 DOCEFREZ 1 DOCETAXEL INJ 80MG/4ML, 80MG/8ML 1 doxorubicin hcl inj 2mg/ml 1 ERIVEDGE 1 ERWINAZE 1 GILOTRIF 1 PA (Afatinib (Gilotrif), new starts only) HALAVEN 1 IBRANCE 1 JAKAFI 1 JEVTANA 1 leucovorin calcium tabs 1 leucovorin calcium inj 100mg, 350mg 1 LYNPARZA 1 MEKINIST 1 MENEST 1 mesna 1 MESNEX TABS 1 mitoxantrone hcl 1 ONCASPAR 1 oxaliplatin inj 100mg/20ml 1 POMALYST 1 PROLEUKIN 1 SYLATRON 1 SYNRIBO 1 PA (Omacetaxine Mepesuccinate (Synribo), new TAXOTERE INJ 80MG/4ML 1 TRISENOX 1 VELCADE 1 ZOLINZA 1 Antineoplastics FARYDAK 1 TAFINLAR 1 ZALTRAP INJ 100MG/4ML 1 ZYKADIA 1 Aromatase Inhibitors, 3rd Generation anastrozole tabs 1 exemestane 1 letrozole 1 Enzyme Inhibitors etoposide inj 500mg/25ml 1 topotecan hcl inj 4mg 1 Page 13 of 57

21 ZYDELIG 1 Molecular Target Inhibitors AFINITOR 1 AFINITOR DISPERZ 1 BOSULIF 1 GLEEVEC 1 ICLUSIG 1 IMBRUVICA 1 INLYTA 1 LENVIMA 10MG DAILY DOSE 1 LENVIMA 14MG DAILY DOSE 1 LENVIMA 20MG DAILY DOSE 1 LENVIMA 24MG DAILY DOSE 1 NEXAVAR 1 SPRYCEL 1 STIVARGA 1 SUTENT 1 TARCEVA 1 TASIGNA 1 TYKERB 1 VOTRIENT 1 XALKORI 1 PA (crizotinib (Xalkori), new starts only) ZELBORAF 1 PA (Vemurafenib (Zelboraf), new Monoclonal Antibodies ARZERRA INJ 100MG/5ML 1 AVASTIN INJ 100MG/4ML 1 CYRAMZA 1 KADCYLA INJ 100MG 1 KEYTRUDA 1 OPDIVO INJ 40MG/4ML 1 PERJETA 1 RITUXAN 1 YERVOY INJ 50MG/10ML 1 Retinoids bexarotene 1 PANRETIN 1 TARGRETIN 1 tretinoin caps 10mg 1 Antiparasitics Anthelmintics ALBENZA 1 BILTRICIDE 1 ivermectin tabs 1 Antiprotozoals ALINIA 1 atovaquone 1 atovaquone/proguanil hcl 1 Page 14 of 57

22 chloroquine phosphate tabs 1 COARTEM 1 DARAPRIM 1 hydroxychloroquine sulfate tabs 1 mefloquine hcl 1 NEBUPENT 1 PA (Pentamidine) PENTAM PA (Pentamidine) primaquine phosphate tabs 1 quinine sulfate 1 Pediculicides/Scabicides EURAX LOTN 1 LINDANE SHAM 1 lindane lotn 1 permethrin crea 1 Antiparkinson Agents Anticholinergics benztropine mesylate tabs 1 PA (Beer's List highly anticholinergic medications) trihexyphenidyl hcl 1 PA (Beer's List highly anticholinergic medications) Antiparkinson Agents, Other entacapone 1 TASMAR 1 tolcapone 1 Dopamine Agonists APOKYN 1 ST (Apomorphine #2) bromocriptine mesylate caps, tabs 1 NEUPRO 1 ST (Rotigotine #2) pramipexole dihydrochloride 1 ropinirole hcl 1 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 1 carbidopa/levodopa er 1 carbidopa/levodopa/entacapone 1 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 1 ST (Monoamine Oxidase B (MOA- B) Inhibitors #2, new selegiline hcl caps, tabs 1 Antipsychotics 1st Generation/Typical chlorpromazine hcl inj, tabs 1 PA (Beer's List highly anticholinergic medications, new compro 1 PA (Beer's List highly anticholinergic medications, new fluphenazine decanoate inj 1 PA (Beer's List highly anticholinergic medications, new Page 15 of 57

23 fluphenazine hcl conc, elix, inj, tabs 1 PA (Beer's List highly anticholinergic medications, new haloperidol decanoate 1 haloperidol lactate 1 haloperidol conc, tabs 1 loxapine succinate caps 1 PA (Beer's List highly anticholinergic medications, new ORAP 1 PA (Beer's List highly anticholinergic medications, new perphenazine tabs 1 PA (Beer's List highly anticholinergic medications, new prochlorperazine 1 PA (Beer's List highly anticholinergic medications) prochlorperazine edisylate inj 1 PA (Beer's List highly anticholinergic medications, new prochlorperazine maleate tabs 1 PA (Beer's List highly anticholinergic medications, new thioridazine hcl tabs 1 PA (Beer's List highly anticholinergic medications, new thiothixene caps 1 PA (Beer's List highly anticholinergic medications, new trifluoperazine hcl tabs 1 PA (Beer's List highly anticholinergic medications, new 2nd Generation/Atypical ABILIFY DISCMELT 1 PA (Aripiprazole (Abilify), new ABILIFY MAINTENA 1 ABILIFY INJ, TABS 1 ABILIFY ORAL SOLN 1 PA (Aripiprazole (Abilify), new aripiprazole tabs 1 FANAPT 1 ST (Anti-psychotic #3, new starts only) FANAPT TITRATION PACK 1 ST (Anti-psychotic #3, new starts only) GEODON INJ 1 INVEGA 1 ST (Paliperidone #3, new INVEGA SUSTENNA 1 ST (Paliperidone #3, new LATUDA 1 ST (Anti-psychotic #3, new starts only) Page 16 of 57

24 olanzapine 1 ST (Olanzapine #2, new PA (Beer's List highly anticholinergic medications, new olanzapine odt 1 ST (Olanzapine #2, new PA (Olanzapine (Zyprexa Zydis), new quetiapine fumarate 1 RISPERDAL CONSTA 1 risperidone 1 risperidone odt 1 SAPHRIS 1 SEROQUEL XR 1 ziprasidone hcl 1 ST (Anti-psychotic #2; Paliperidone #2, new ZYPREXA RELPREVV INJ 210MG 1 PA (Olanzapine IM (Zyprexa Relprevv), new Treatment-Resistant clozapine 1 clozapine odt 1 PA (Clozapine, new FAZACLO TBDP 150MG, 200MG 1 PA (Clozapine, new VERSACLOZ 1 PA (Clozapine, new Antispasticity Agents Antispasticity Agents baclofen tabs 1 dantrolene sodium caps 1 tizanidine hcl tabs 1 PA (Beer's List highly anticholinergic medications) Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir 1 ganciclovir inj 1 valganciclovir 1 ZIRGAN 1 Anti-hepatitis B (HBV) Agents adefovir dipivoxil 1 BARACLUDE SOLN 1 entecavir 1 INTRON A W/DILUENT INJ 10MU 1 INTRON A INJ 18MU, 50MU, UNIT/ML 1 TYZEKA 1 Anti-hepatitis C (HCV) Agents HARVONI 1 QL (28 EA per 28 days) PA (ledipasvir-sofosbuvir (Harvoni)) INCIVEK 1 PA (Telaprevir (Incivek)) MODERIBA 1200 DOSE PACK 1 MODERIBA 800 DOSE PACK 1 moderiba tabs 1 OLYSIO 1 PA (Simeprevir (Olysio)) Page 17 of 57

25 PEG-INTRON REDIPEN 1 PEG-INTRON INJ 50MCG/0.5ML 1 PEGASYS 1 PEGASYS PROCLICK 1 PEGINTRON INJ 120MCG/0.5ML, 150MCG/0.5ML, 1 80MCG/0.5ML RIBASPHERE RIBAPAK TABS 0 1 ribasphere ribapak tabs 400mg, 600mg 1 ribasphere tabs 1 SOVALDI 1 QL (28 EA per 28 days) PA (Sofosbuvir (Sovaldi)) VICTRELIS 1 PA (boceprivir (Victrelis)) Anti-HIV Agents, Integrase Inhibitors (INSTI) ISENTRESS 1 TIVICAY 1 VITEKTA 1 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA 1 EDURANT 1 INTELENCE 1 nevirapine 1 nevirapine er 1 RESCRIPTOR 1 STRIBILD 1 SUSTIVA 1 VIRAMUNE XR TB24 100MG 1 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir 1 abacavir sulfate/lamivudine/zidovudine 1 didanosine 1 EMTRIVA 1 EPIVIR HBV SOLN 1 EPIVIR SOLN 1 EPZICOM 1 lamivudine 1 lamivudine/zidovudine 1 RETROVIR IV INFUSION 1 stavudine 1 TRIUMEQ 1 TRUVADA 1 VIDEX PEDIATRIC SOLR 2GM 1 VIREAD 1 ZIAGEN SOLN 1 zidovudine 1 Anti-HIV Agents, Other FUZEON 1 SELZENTRY 1 Page 18 of 57

26 Anti-HIV Agents, Protease Inhibitors APTIVUS 1 CRIXIVAN 1 EVOTAZ 1 INVIRASE 1 KALETRA 1 LEXIVA 1 NORVIR 1 PREZCOBIX 1 PREZISTA SUSP 1 PREZISTA TABS 150MG, 600MG, 75MG, 800MG 1 REYATAZ PACK 1 REYATAZ CAPS 150MG, 200MG, 300MG 1 VIRACEPT 1 Anti-influenza Agents amantadine hcl caps, tabs 1 RELENZA DISKHALER 1 rimantadine hcl 1 TAMIFLU 1 Antiherpetic Agents acyclovir sodium inj 50mg/ml 1 acyclovir caps, susp, tabs 1 famciclovir tabs 1 trifluridine soln 1 valacyclovir hcl 1 Antivirals ATRIPLA 1 Anxiolytics Anxiolytics, Other buspirone hcl tabs 1 Benzodiazepines alprazolam 1 PA (Beers-HEDIS Safety PA) clorazepate dipotassium 1 PA (Beers-HEDIS Safety PA, new diazepam intensol 1 PA (Beers-HEDIS Safety PA, new diazepam soln 1mg/ml 1 PA (Beers-HEDIS Safety PA, new diazepam tabs 10mg, 2mg, 5mg 1 PA (Beers-HEDIS Safety PA, new estazolam 1 PA (Beers-HEDIS Safety PA) lorazepam intensol 1 PA (Beers-HEDIS Safety PA) lorazepam tabs 1 PA (Beers-HEDIS Safety PA, new oxazepam 1 PA (Beers-HEDIS Safety PA) temazepam 1 PA (Beers-HEDIS Safety PA) triazolam 1 PA (Beers-HEDIS Safety PA) Bipolar Agents Mood Stabilizers Page 19 of 57

27 lithium 1 lithium carbonate er 1 lithium carbonate caps, tabs 1 Blood Glucose Regulators Antidiabetic Agents acarbose 1 ST (Misc Diabetes Agents #2) AVANDAMET 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) AVANDARYL 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) AVANDIA 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) BYETTA INJ 10MCG/0.04ML 1 ST (Incretin mimetics #2) CYCLOSET 1 ST (Misc Diabetes Agents #2) glimepiride 1 glipizide er 1 glipizide/metformin hcl 1 glipizide tabs 1 GLYSET 1 ST (Misc Diabetes Agents #2) JANUMET 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) JANUVIA 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) JENTADUETO 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) metformin hcl er tb24 500mg, 750mg 1 metformin hcl tabs 1 nateglinide 1 pioglitazone hcl 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) pioglitazone hcl/metformin hcl 1 ST (Incretin mimetics #2; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) PRANDIMET 1 ST (Meglitinide #2) repaglinide 1 ST (Meglitinide #2) SYMLINPEN ST (Incretin mimetics #2) SYMLINPEN 60 1 ST (Incretin mimetics #2) TRADJENTA 1 ST (Dipeptidyl Peptidase-4 (DPP-4) Inhibitors #2) Glycemic Agents clinimix 4.25%/dextrose 20% 1 B/D CLINIMIX 5%/DEXTROSE 15% 1 B/D CLINIMIX 5%/DEXTROSE 20% 1 B/D CLINIMIX E 2.75%/DEXTROSE 10% 1 CLINIMIX E 2.75%/DEXTROSE 5% 1 CLINIMIX E 4.25%/DEXTROSE 25% 1 CLINIMIX E 4.25%/DEXTROSE 5% 1 CLINIMIX E 5%/DEXTROSE 15% 1 CLINIMIX E 5%/DEXTROSE 25% 1 DEXTROSE 10%/NACL 0.45% 1 Page 20 of 57

28 Name Tier dextrose 10% flex container 1 dextrose 10%/nacl 0.2% 1 dextrose 2.5%/sodium chloride 0.45% 1 dextrose 5% 1 dextrose 5%/nacl 0.2% 1 DEXTROSE 5%/NACL 0.225% 1 dextrose 5%/nacl 0.33% 1 dextrose 5%/nacl 0.45% 1 dextrose 5%/nacl 0.9% 1 GLUCAGEN HYPOKIT 1 GLUCAGON EMERGENCY KIT 1 IONOSOL-B/DEXTROSE 5% 1 IONOSOL-MB/DEXTROSE 5% 1 KCL 0.075%/D5W/NACL 0.45% 1 KCL 0.15%/D5W/LR 1 KCL 0.15%/D5W/NACL 0.2% 1 KCL 0.15%/D5W/NACL 0.225% 1 KCL 0.15%/D5W/NACL 0.9% 1 KCL 0.3%/D5W/NACL 0.45% 1 KCL 0.3%/D5W/NACL 0.9% 1 normosol-r in d5w 1 POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% 1 POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% 1 POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 1 PROGLYCEM 1 Insulins APIDRA 1 APIDRA SOLOSTAR 1 HUMALOG 1 HUMALOG KWIKPEN 1 HUMALOG MIX 50/50 1 HUMALOG MIX 50/50 KWIKPEN 1 HUMALOG MIX 75/25 1 HUMALOG MIX 75/25 KWIKPEN 1 HUMULIN 70/30 1 HUMULIN 70/30 KWIKPEN 1 HUMULIN N 1 HUMULIN N KWIKPEN 1 HUMULIN R 1 HUMULIN R U-500 (CONCENTRATED) 1 LANTUS 1 LANTUS SOLOSTAR 1 LEVEMIR 1 LEVEMIR FLEXTOUCH 1 NOVOLIN 70/30 1 NOVOLIN N 1 NOVOLIN R 1 NOVOLOG 1 NOVOLOG FLEXPEN 1 Requirements/Limits Page 21 of 57

29 NOVOLOG MIX 70/30 1 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 1 NOVOLOG PENFILL 1 Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin sodium 1 fondaparinux sodium 1 ST (injectable anticoagulants #2) FRAGMIN INJ 7500UNIT/0.3ML, 95000UNIT/3.8ML 1 ST (Anticoagulation #2) FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML, 1 ST (injectable anticoagulants #2) 15000UNIT/0.6ML, 18000UNT/0.72ML, 25000UNIT/ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML heparin sodium/d5w 1 heparin sodium/nacl 0.9% 1 HEPARIN SODIUM INJ 2000UNIT/ML, 2500UNIT/ML 1 heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, unit/ml PRADAXA 1 ST (Anticoagulation #2) PA (Beers- HEDIS Safety PA) warfarin sodium tabs 1 XARELTO 1 ST (Anticoagulation #2) XARELTO STARTER PACK 1 ST (Anticoagulation #2) Blood Formation Modifiers anagrelide hydrochloride 1 ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 1 PA (Darbepoetin alfa (Aranesp)) 100MCG/ML, 10MCG/0.4ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML EPOGEN 1 PA (Epoetin (Epogen/Procrit)) LEUKINE INJ 250MCG 1 PA (Sargramostim (Leukine)) NEUMEGA 1 PA (Oprelvekin (Neumega)) NEUPOGEN 1 PA (Filgrastim (Neupogen)) PROCRIT 1 PA (Epoetin (Epogen/Procrit)) PROMACTA 1 PA (Eltrombopag olamine (Promacta)) Coagulants tranexamic acid inj, tabs 1 Platelet Modifying Agents AGGRENOX 1 aspirin/dipyridamole 1 BRILINTA 1 cilostazol 1 clopidogrel 1 ticlopidine hcl 1 PA (Beers-HEDIS Safety PA) Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl tabs 1 PA (Beers-HEDIS Safety PA) Page 22 of 57

30 clonidine hcl ptwk 1 PA (clonidine transdermal (Catapres- TTS)) methyldopa tabs 1 PA (Beers-HEDIS Safety PA) methyldopate hcl 1 PA (Beers-HEDIS Safety PA) midodrine hcl 1 Alpha-adrenergic Blocking Agents CARDURA XL 1 PA (Beers-HEDIS Safety PA) prazosin hcl 1 PA (Beers-HEDIS Safety PA) Angiotensin II Receptor Antagonists candesartan cilexetil 1 losartan potassium 1 losartan potassium/hydrochlorothiazide 1 valsartan 1 ST (Angiotensin Receptor Antagonists #2) valsartan/hydrochlorothiazide 1 ST (Angiotensin Receptor Antagonists #2) Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide 1 benazepril hcl tabs 1 captopril/hydrochlorothiazide 1 captopril tabs 1 enalapril maleate/hydrochlorothiazide 1 enalapril maleate tabs 1 lisinopril 1 lisinopril/hydrochlorothiazide 1 quinapril hcl 1 quinapril/hydrochlorothiazide 1 ramipril 1 Antiarrhythmics amiodarone hcl inj 50mg/ml 1 PA (Beers-HEDIS Safety PA) amiodarone hcl tabs 200mg, 400mg 1 PA (Beers-HEDIS Safety PA) disopyramide phosphate caps 1 PA (Beers-HEDIS Safety PA) flecainide acetate 1 mexiletine hcl 1 MULTAQ 1 ST (Dronedarone (Multaq) #2) propafenone hcl 1 propafenone hcl er 1 quinidine gluconate cr 1 quinidine sulfate 1 sotalol hcl (af) tabs 120mg 1 PA (Beers-HEDIS Safety PA) sotalol hcl tabs 160mg, 240mg, 80mg 1 PA (Beers-HEDIS Safety PA) TIKOSYN 1 Beta-adrenergic Blocking Agents acebutolol hcl caps 1 atenolol tabs 1 bisoprolol fumarate 1 bisoprolol fumarate/hydrochlorothiazide 1 carvedilol 1 Page 23 of 57

31 COREG CR 1 ST (Beta Blockers - Extended Release #2) labetalol hcl inj, tabs 1 metoprolol succinate er 1 metoprolol tartrate inj, tabs 1 metoprolol/hydrochlorothiazide 1 nadolol/bendroflumethiazide 1 PINDOLOL 1 propranolol hcl er 1 propranolol hcl inj, tabs 1 propranolol/hydrochlorothiazide 1 Calcium Channel Blocking Agents afeditab cr 1 amlodipine besylate tabs 1 cartia xt 1 dilt-cd cp24 300mg 1 dilt-xr 1 diltiazem cd cp24 240mg 1 diltiazem hcl er cp24 120mg, 180mg, 300mg, 360mg, 420mg 1 diltiazem hcl er cp12 1 diltiazem hcl tabs 1 diltzac 1 matzim la 1 nifedical xl 1 nifedipine er 1 nifedipine caps 1 PA (Beers-HEDIS Safety PA) nimodipine caps 1 taztia xt 1 verapamil hcl er 1 verapamil hcl sr cp24 360mg 1 verapamil hcl inj, tabs 1 Cardiovascular Agents, Other DEMSER 1 digoxin inj 1 PA (Beers-HEDIS Safety PA) digoxin tabs 125mcg 1 digoxin tabs 250mcg 1 PA (Beers-HEDIS Safety PA) pentoxifylline er 1 RANEXA 1 PA (Ranolazine (Ranexa)) TEKTURNA 1 ST (Angiotensin Receptor Antagonists #3) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide sodium 1 acetazolamide tabs 1 Diuretics, Loop bumetanide inj, tabs 1 furosemide inj, tabs 1 furosemide oral soln 10mg/ml 1 torsemide tabs 1 Diuretics, Potassium-sparing Page 24 of 57

32 amiloride hcl tabs 1 amiloride/hydrochlorothiazide 1 spironolactone/hydrochlorothiazide 1 spironolactone tabs 25mg 1 spironolactone tabs 100mg, 50mg 1 PA (Beers-HEDIS Safety PA) triamterene/hydrochlorothiazide 1 Diuretics, Thiazide candesartan cilexetil/hydrochlorothiazide 1 chlorthalidone tabs 25mg, 50mg 1 hydrochlorothiazide caps, tabs 1 indapamide tabs 1 metolazone 1 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized 1 ST (Fibric Acid Dyslipidemics #2) fenofibrate caps 1 ST (Fibric Acid Dyslipidemics #2) fenofibrate tabs 145mg, 160mg, 48mg, 54mg 1 ST (Fibric Acid Dyslipidemics #2) fenofibric acid dr 1 FIBRICOR 1 ST (Fibric Acid Dyslipidemics #2) gemfibrozil tabs 1 Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium 1 LIPTRUZET 1 lovastatin 1 pravastatin sodium 1 simvastatin 1 Dyslipidemics, Other cholestyramine light pack 1 cholestyramine powd 1 colestipol hcl 1 JUXTAPID 1 PA (Lomitapide (Juxtapid)) niacin er 1 ST (Niacin #2) niacor 1 omega-3-acid ethyl esters 1 VYTORIN 1 ST (HMGCoA Inhibitors / Cholesterol Absorption Inhibitors #2) WELCHOL TABS 1 ZETIA 1 ST (HMGCoA Inhibitors / Cholesterol Absorption Inhibitors #2) Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate er 1 isosorbide dinitrate tabs 1 isosorbide dinitrate subl 2.5mg 1 isosorbide mononitrate 1 isosorbide mononitrate er 1 nitroglycerin transdermal pt24 0.1mg/hr 1 nitroglycerin inj 1 nitroglycerin pt24 0.2mg/hr, 0.4mg/hr, 0.6mg/hr 1 Page 25 of 57

33 NITROSTAT 1 Vasodilators, Direct-acting Arterial hydralazine hcl inj, tabs 1 minoxidil tabs 1 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine cp24 1 QL (62 EA per 31 days) ST (Alpha- Adrenergic Agonists #2) PA (Beers- HEDIS Safety PA) amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 1 QL (62 EA per 31 days) PA (Beers- 7.5mg HEDIS Safety PA) amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 1 QL (93 EA per 31 days) PA (Beers- HEDIS Safety PA) 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg dextroamphetamine sulfate er 1 PA (Beers-HEDIS Safety PA) dextroamphetamine sulfate tabs 1 PA (Beers-HEDIS Safety PA) Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines dexmethylphenidate hcl 1 PA (Beers-HEDIS Safety PA) guanfacine er 1 QL (31 EA per 31 days) PA (Guanfacine (Intuniv)) metadate er 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl cd cpcr 10mg, 50mg, 60mg 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl er cp24 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl er tbcr 18mg, 20mg, 27mg, 36mg, 54mg 1 PA (Beers-HEDIS Safety PA) methylphenidate hcl tabs 1 PA (Beers-HEDIS Safety PA) methylphenidate hydrochloride 1 PA (Beers-HEDIS Safety PA) STRATTERA 1 ST (Norepinephrine Reuptake Inhibitors #2) Central Nervous System, Other HORIZANT 1 PA (gabapentin encarbil XR (Horizant)) NUEDEXTA 1 PA (Dextromethorphan Hydrobromide/Quinidine Sulfate (Nuedexta)) riluzole 1 PA (Riluzole (Rilutek)) XENAZINE 1 PA (Tetrabenazine (Xenazine)) Multiple Sclerosis Agents AVONEX 1 BETASERON 1 COPAXONE INJ 20MG/ML 1 GILENYA 1 PA (fingolimod (Gilenya)) GLATOPA 1 REBIF 1 REBIF REBIDOSE 1 REBIF REBIDOSE TITRATION PACK 1 REBIF TITRATION PACK 1 Page 26 of 57

34 TYSABRI 1 PA (Natalizumab (Tysabri)) Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate oral rinse 1 periogard 1 pilocarpine hcl tabs 7.5mg 1 pilocarpine hydrochloride 1 triamcinolone in orabase 1 Dermatological Agents Dermatological Agents 8-MOP 1 acitretin 1 ST (Psoriasis Agents #3) PA (Acitretin) adapalene gel 0.1% 1 ST (Acne Agents #3) ammonium lactate crea, lotn 1 amnesteem 1 PA (Isotretinoin) calcipotriene oint, soln 1 claravis caps 10mg, 20mg, 40mg 1 PA (Isotretinoin) clindamycin phosphate lotn 1% 1 clindamycin phosphate soln 1% 1 CURITY GAUZE PADS 2"X2" 1 diclofenac sodium transdermal soln 1.5% 1 erythromycin/benzoyl peroxide 1 ST (Acne Agents #2) fluorouracil crea 1 fluorouracil soln 2% 1 imiquimod crea 1 PA (Imiquimod (Aldara), new starts only) methoxsalen caps 1 myorisan 1 PA (Isotretinoin) OXSORALEN 1 podofilox soln 1 PROTOPIC 1 REGRANEX 1 QL (15 GM per 30 days) PA (Becaplermin (Regranex)) SANTYL 1 QL (30 GM per 30 days) PA (Collagenase (Santyl)) selenium sulfide lotn 1 sulfacetamide sodium 1 tacrolimus oint 0.03%, 0.1% 1 TAZORAC GEL 1 QL (100 GM per 30 days) ST (Acne Agents #3; Psoriasis Agents #2) TAZORAC CREA 1 QL (60 GM per 30 days) ST (Acne Agents #3; Psoriasis Agents #2) tretinoin crea 0.025%, 0.05%, 0.1% 1 ST (Acne Agents #2) tretinoin gel 0.01%, 0.025% 1 ST (Acne Agents #2) UVADEX 1 VOLTAREN 1 ST (Topical diclofenac #2) ZENATANE CAPS 30MG 1 PA (Isotretinoin) zenatane caps 10mg, 20mg, 40mg 1 PA (Isotretinoin) Page 27 of 57