FORMULARY. Toll-Free , TTY a.m. to 8 p.m. local time, 7 days a week.

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1 205 Comprehensive FORMULARY (Complete list of covered drugs) UnitedHealthcare Dual Complete (PPO SNP) UnitedHealthcare Dual Complete RP (Regional PPO SNP) Please read: This document contains information about the drugs we cover in this plan. For more recent information or if you have other questions, please contact UnitedHealthcare Dual Complete Customer Service at: Toll-Free , TTY 7 8 a.m. to 8 p.m. local time, 7 days a week Medicare Approved Formulary File Submission ID Number , Version 20 Y0066_40622_65652_FINAL_M27.9 Approved Last updated October, 205

2 2 2 This document includes a complete list of the drugs (formulary) for our plan and is current as of October, 205. For an updated formulary (drug list), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. When this drug list (formulary) refers to we, us, or our, it means UnitedHealthcare. When it refers to plan or our plan, it means UnitedHealthcare Dual Complete. Note to existing members: Our list of covered drugs is called a Formulary. We call it the " List" for short. This complete drug list has changed since last year. Please review this document to make sure the plan still covers the drugs you take. You must generally use network pharmacies to use your prescription drug benefit.

3 3 The UnitedHealthcare Dual Complete COMPREHENSIVE FORMULARY (drug list) A formulary is a list of covered drugs selected by your plan 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. We call it the " List" for short. Your plan will generally cover the drugs listed in our formulary (drug list) as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a complete drug list of the drugs covered by your plan. For your drug to be covered by your plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our network pharmacies. To find out if your drug is covered:. See if your drug is included in this complete drug list. 2. Visit your plan website. You can use online tools to look up your drugs. The information is updated on a regular basis. The Web address appears on the front and back cover pages. 3. Call Customer Service. Our contact information appears on the front and back cover pages. 3

4 4 When the drug list may change We try to make as few changes to the drug list as possible during the plan year. If there are changes to the drug list, such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The drug list may change throughout the year when your plan: Adds a new drug as they become available, including new generic drugs. Removes a drug from the list because it has been found to be ineffective. Changes the requirements for a drug. Generally, if you are taking a drug on the 205 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 205 coverage year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from the drug list, will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the coverage year. We feel it is important for you to have access for the entire coverage year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy on a drug we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60- day supply of the drug. If the Food and Administration (FDA) declares a drug on our drug list to be unsafe or if the drug s manufacturer removes the drug from the market, your plan will immediately remove the drug from the drug list and notify members who take the drug. The enclosed drug list is current as of the date printed on the front and back cover pages. To get updated information about the drugs covered by your plan, please call Customer Service or visit our website using the information provided on the front and back cover pages of this drug list. 4

5 tiers and drug payment stages The amount you pay for a covered drug will depend on: Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you re in. The drug tier for your drug. Your plan has one tier named Covered s. All covered drugs are in this. The chart below shows your cost-sharing amount. For more information about drug coverage and cost-sharing amount, please review your Evidence of Coverage. 5 Cost-Share Covered 25% co-insurance If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to learn about your costs. You can also contact Customer Service. Our contact information appears on the front and back cover pages. 5

6 6 How to use the drug list There are two ways to find your prescription drugs in this complete drug list:. Medical condition: Turn to the Covered drugs by medical condition section, which begins on page 2, to look for drugs based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular s category and look under Cholesterol Control s. 2. Alphabetical list (index): If you are not sure what category to look under, turn to the Index of covered drugs section, which begins on page 88. Find the name of your drug. The page number where you can find the drug will be next to it. Important page numbers Covered drugs by medical condition Index of covered drugs Generic drugs Your plan covers both brand name drugs and generic drugs. Generic drugs are approved by the Food and Administration (FDA) as having the same active ingredients as brand name drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin). 6

7 Dummy Restrictions on your coverage Some of your plan s drugs may have additional requirements on coverage. If your drug has any requirements, there will be a code(s) in the column of the drug list. The codes and what they mean are shown below. 7 B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. LA - Limited access s are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. PA - Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don t get approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if another drug is available to treat your condition. Note: If you are 65 or older, you will need to get a prior authorization (PA) or formulary exception from the health plan before taking a high risk medication (HRM). If you are under 65, the prior authorization (PA) will not apply to you until the first time you get your prescription filled after turning 65. 7

8 8 You can find out if your drug has any additional requirements by looking it up in the Covered drugs by medical condition section that begins on page 2. You can also get more information about the on specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. You and your doctor may ask the plan for an exception to these or for a list of other, similar drugs that may treat your health condition. See the, How to request an exception to the UnitedHealthcare Dual Complete drug list section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement or limit, you may have to pay the full cost of the drug. If your drug is not on the drug list If your drug is not included in this complete formulary (list of covered drugs), you should contact Customer Service and ask if your drug is covered. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. If you learn that your plan does not cover your drug, you have two options:. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the appropriate drugs from the list. 2. Ask your plan to make an exception and cover your drug. See next page for information about how to request an exception. 8

9 How to request an exception to the UnitedHealthcare Dual Complete drug list At times you may need to ask for drug coverage that s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination). 9 You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask your plan to make. Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list. 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. Utilization exception: You can ask your plan to waive coverage on your drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a quantity limit, you can ask your plan to waive the limit and cover more. Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan s drug list or additional utilization would not be as effective in treating your condition and/or would cause adverse medical effects. Who can ask for a coverage decision You, your authorized representative or your doctor can ask for an initial coverage decision for a formulary exception or utilization restriction exception. When you are requesting a formulary exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. Receiving a coverage decision Generally, your plan will make a coverage decision within 72 hours after receiving your prescribing physician s statement. You can request an expedited, or fast, decision if you or your doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a decision within 24 hours after your plan receives your prescriber s or prescribing physician s supporting statement. 9

10 0 What to do while you talk to your doctor about changing your drugs or requesting an exception New or continuing members As a new or continuing member in your plan, you may be taking drugs that are not on the drug list. Or you may be taking a drug that is on the drug list but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that your plan covers, or request a formulary exception so your plan will cover the drug you are currently taking. While you talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days you are a member of your plan. For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited, your plan may cover a temporary 30-day supply (unless you have a prescription written for fewer days) from a network pharmacy. After your first 30-day supply, your plan will not pay for these drugs, even if you have been a member of your plan less than 90 days. Long-term care facility residents If you re a resident of a long-term care facility, your plan may allow you to refill your prescription until we have provided you with a maximum of a 9- and may be up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is written for fewer days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a member of your plan. If you need a drug that s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of membership in the plan, your plan will cover a 3-day emergency supply of the drug (unless your prescription is written for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that s not on the drug list, or if it s difficult for you to get your drugs, you are required to use your plan s exception process. You may ask for a one-time emergency supply of up to 30 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. 0

11 s with dosages other than 30 days s packaged in an extended day supply Some drugs are packaged from the manufacturer to provide greater than a 30-day supply. When you fill these drugs, you may have to pay more than one co-pay for a single prescription. For more information, please contact Customer Service using the information on the front and back cover pages. Daily cost share for oral medications filled for less than a 30-day supply s in solid form taken orally (e.g., tablet or capsule) may be dispensed for a supply of less than 30 days. The daily cost share requirements do not apply to either of the following:. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions. For more information For more information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please call us toll-free at , TTY 7, 8 a.m. to 8 p.m. local time, 7 days a week. Or visit us online at If you have general questions about Medicare prescription drug coverage, visit or call Medicare at , TTY , 24 hours a day, 7 days a week.

12 track 2 Covered drugs by medical condition The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the Index of covered drugs, which begins on page 88. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the second column of the chart shows you which coverage level (tier) your drug is in. Your plan has one tier named Covered s. All covered drugs are in this. The or limit column shows you if your plan has any special coverage requirements for the drug. If quantity limits apply to a drug, the restriction amounts are shown in the chart on pages track Analgesics - s to Treat Pain, Inflammation, and Muscle and Joint Conditions Nonsteroidal Anti-Inflammatory s - Pain/Anti-Inflammatory s Celebrex QL Celecoxib (Capsule) QL Potassium Diclofenac Potassium Sodium DR Diclofenac Sodium DR Sodium ER Diclofenac Sodium ER Sodium/Misoprostol Diclofenac Sodium/ Misoprostol Diflunisal ( Etodolac (Immediate- Release) ER Etodolac ER Flurbiprofen ( Ibuprofen (Suspension, 400mg Tablet, 600mg Tablet, 800mg Ketoprofen (Immediate-Release Capsule) Tromethamine Ketorolac Tromethamine (5mg/ ml Injection, 30mg/ml Meloxicam ( Meloxicam (Suspension) Nabumetone ( Naproxen (Immediate- Release Tablet, Suspension) DR Naproxen DR PA, HRM Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 2

13 2tRACK 3 Sodium Naproxen Sodium (275mg Tablet, 550mg Oxaprozin Piroxicam (Capsule) Sulindac ( Opioid Analgesics, Long-acting - Opioid Pain Relievers Exalgo QL Fentanyl (00mcg/Hr Patch 72 Hour, 2mcg/Hr Patch 72 Hour, 25mcg/Hr Patch 72 Hour, 50mcg/Hr Patch 72 Hour, 75mcg/Hr Patch 72 Hour) ER Hydromorphone ER (2mg Tablet ER 24 Hour Abuse- Deterrent, 6mg Tablet ER 24 Hour Abuse- Deterrent, 8mg Tablet ER 24 Hour Abuse- Deterrent) ER Hydromorphone ER (32mg Tablet ER 24 Hour Abuse- Deterrent) QL QL QL Kadian (00mg Capsule Extended Release 24 Hour, 200mg Capsule Extended Release 24 Hour, 60mg Capsule Extended Release 24 Hour, 80mg Capsule Extended Release 24 Hour) Tartrate Levorphanol Tartrate ( Methadone (Oral Solution, Methadone ( Sulfate ER Tablet Morphine Sulfate ER Tablet (Generic MS Contin) QL QL QL QL Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 3

14 3tRACK 4 Sulfate ER 0mg Capsule Extended Release 24 Hour, 20mg Capsule Extended Release 24 Hour, 30mg Capsule Extended Release 24 Hour, 50mg Capsule Extended Release 24 Hour, 60mg Capsule Extended Release 24 Hour, 80mg Capsule Extended Release 24 Hour Morphine Sulfate ER 0mg Capsule Extended Release 24 Hour, 20mg Capsule Extended Release 24 Hour, 30mg Capsule Extended Release 24 Hour, 50mg Capsule Extended Release 24 Hour, 60mg Capsule Extended Release 24 Hour, 80mg Capsule Extended Release 24 Hour (Generic Kadian) Sulfate ER 00mg Capsule Extended Release 24 Hour Morphine Sulfate ER 00mg Capsule Extended Release 24 Hour (Generic Kadian) QL QL ER Nucynta ER QL ER Opana ER (Crush Resistant) QL ER 00mg, 200mg Tablet Extended Release 24 Hour Tramadol ER 00mg, 200mg Tablet Extended Release 24 QL Hour (Generic Ultram ER) ER 300mg Tablet Extended Release 24 Hour Tramadol ER 300mg Tablet Extended Release 24 QL Hour (Generic Ryzolt) Opioid Analgesics, Short-acting - Opioid Pain Relievers Abstral PA, QL Acetaminophen/Codeine Codeine QL Actiq PA, QL Tartrate Butorphanol Tartrate (Nasal Solution) QL Tartrate Butorphanol Tartrate ( Sulfate Codeine Sulfate ( Duramorph Endocet (325mg-0mg Tablet, 325mg-5mg Tablet, 325mg-7.5mg QL QL Endodan QL Citrate Oral Transmucosal Fentanyl Citrate Oral Transmucosal PA, QL Fentora PA, QL Hydrocodone/Acetaminophen Acetaminophen (325mg/5ml-7.5mg/ 5ml Oral Solution, 300mg-0mg Tablet, 300mg-5mg Tablet, 300mg-7.5mg Tablet, 325mg-0mg Tablet, 325mg-2.5mg Tablet, 325mg-5mg Tablet, 325mg-7.5mg Hydrocodone/Ibuprofen Ibuprofen (7.5mg-200mg Hydromorphone (Immediate-Release Hydromorphone (500mg/50ml Hydromorphone (Liquid) QL QL QL QL Lazanda PA, QL Lorcet QL HD Lorcet HD QL 4

15 4tRACK 5 Plus Lorcet Plus QL Lortab ( QL Sulfate Morphine Sulfate (Oral Solution) Sulfate Morphine Sulfate (Immediate-Release Sulfate Morphine Sulfate (0mg/ml Injection, 2mg/ml Injection, 4mg/ml Injection, 8mg/ml Nalbuphine ( Oxycodone (Capsule, Oxycodone (Concentrate) Oxycodone (Oral Solution) Oxycodone/Acetaminophen Acetaminophen (325mg-0mg Tablet, 325mg-2.5mg Tablet, 325mg-5mg Tablet, 325mg-7.5mg QL QL QL QL QL QL Oxycodone/Aspirin QL Oxycodone/Ibuprofen QL Oxymorphone (Immediate-Release) QL Subsys (00mcg Liquid, 200mcg Liquid, 400mcg Liquid, 600mcg Liquid, 800mcg Liquid) Tramadol (Immediate-Release /Acetaminophen Tramadol / Acetaminophen PA, QL QL QL Trezix QL Zamicet QL Anesthetics - s for Numbing Local Anesthetics Lidocaine (Ointment) Lidocaine (Patch) PA, QL 2% Viscous Solution Lidocaine 2% Viscous Solution Lidocaine (External Solution) Lidocaine (0.5% Injection, 2% Lidocaine (Gel) B/D, PA Lidocaine/Prilocaine (Cream) Anti-Addiction/Substance Abuse Treatment Agents - s for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 5

16 5tRACK 6 Calcium DR Acamprosate Calcium DR Disulfiram ( Naltrexone ( Vivitrol PA Opioid Dependence Treatments - Antidotes/Deterrents/Protectants Buprenorphine ( Buprenorphine (Tablet Sublingual) QL /Naloxone Buprenorphine / Naloxone PA, QL Naloxone (mg/ml Suboxone PA, QL Smoking Cessation Agents - Deterrents Buproban Chantix (0.5mg Tablet, mg Continuing Month Pak Chantix Continuing Month Pak Starting Month Pak Chantix Starting Month Pak Inhaler Nicotrol Inhaler Antibacterials - s to Treat Bacterial Infections Aminoglycosides - Antibiotics Sulfate Amikacin Sulfate (500mg/2ml Bethkis B/D, PA Gentak Sulfate Gentamicin Sulfate (Cream, Ointment, Ophthalmic Solution) Sulfate Gentamicin Sulfate ( Sulfate/NaCl Gentamicin Sulfate/ NaCl (0.9mg/ml-0.9% Injection,.4mg/ ml-0.9% Injection,.6mg/ml-0.9% Injection, mg/ml-0.9% Gentamicin Isotonic Gentamicin (0.8mg/ml-0.9% Injection,.2mg/ ml-0.9% Sulfate Neomycin Sulfate ( Sulfate Paromomycin Sulfate (Capsule) Sulfate Streptomycin Sulfate ( TOBI B/D, PA Podhaler TOBI Podhaler PA Tobradex (Ointment) Tobramycin (Nebulization Solution) Sulfate Tobramycin Sulfate (Ophthalmic Solution) Sulfate Tobramycin Sulfate (0mg/ml Injection, 80mg/2ml Sulfate/NaCl Tobramycin Sulfate/ NaCl Tobrex (Ointment) B/D, PA Antibacterials, Other - Antibiotics Altabax BACiiM Bacitracin (Ointment) Bacitracin ( Nasal Bactroban Nasal PA 6

17 6tRACK 7 Sodium Succinate Chloramphenicol Sodium Succinate Clindamycin (Capsule) Palmitate Clindamycin Palmitate Phosphate Clindamycin Phosphate (Cream, External Solution, Gel, Lotion, Swab) Phosphate Clindamycin Phosphate (50mg/ml Phosphate D5W Clindamycin Phosphate in D5W Sodium Colistimethate Sodium ( Cubicin Dalvance PA Doribax (500mg ER Flagyl ER Lincocin Linezolid ( PA Linezolid ( PA, QL Hippurate Methenamine Hippurate Metronidazole (Capsule, Metronidazole (Cream, Gel, Lotion) in NaCl 0.79% Metronidazole in NaCl 0.79% Vaginal Metronidazole Vaginal Mupirocin (Ointment) Mupirocin (Cream) B Sulfates Neomycin/Polymyxin B Sulfates Nitrofurantoin (Suspension) Macrocrystals Nitrofurantoin Macrocrystals Monohydrate Nitrofurantoin Monohydrate Noritate B Sulfate Polymyxin B Sulfate ( Primsol Sulfamylon (Cream) Synercid Tinidazole ( Trimethoprim ( Tygacil QL, HRM QL, HRM Vancocin PA Vancomycin (000mg Injection, 0gm Injection, 500mg Vancomycin (Capsule) PA Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 7

18 7tRACK 8 Vandazole Xifaxan PA Zyvox (Injection, Suspension Reconstituted) PA Zyvox ( PA, QL Beta-Lactam, Cephalosporins - Antibiotics Cefaclor (Capsule) ER Cefaclor ER Cefadroxil (Capsule) Cefadroxil (Suspension Reconstituted) Sodium Cefazolin Sodium (0gm Injection, gm Injection, gm-5% Injection, 500mg Cefdinir Cefepime (gm Injection, gm/ 50ml-5% Injection, 2gm Injection, 2gm/ 50ml-5% Cefixime Sodium Cefotaxime Sodium (gm Injection, 2gm Injection, 500mg Cefotetan Sodium Cefoxitin Sodium (0gm Injection, gm Injection, 2gm Sodium Cefoxitin Sodium (gm-4% Injection, 2gm-2.2% Proxetil Cefpodoxime Proxetil Cefprozil Ceftazidime (gm Injection, 2gm Injection, 6gm Ceftazidime/Dextrose Dextrose Sodium Ceftriaxone Sodium (0gm Injection, gm Injection, 250mg Injection, 2gm Injection, 500mg Axetil Cefuroxime Axetil Sodium Cefuroxime Sodium (.5gm Injection, 7.5gm Injection, 750mg Cephalexin (Capsule, Suspension Reconstituted) Fortaz (gm Injection, 2gm Injection, 6gm Suprax (Capsule, 500mg/5ml Suspension Reconstituted) Suprax (00mg/5ml Suspension Reconstituted, 200mg/ 5ml Suspension Reconstituted, Tablet Chewable) Tazicef (gm Injection, 2gm Injection, 6gm Zerbaxa PA Beta-Lactam, Other - Antibiotics 8

19 8tRACK 9 in Iso-Osmotic Dextrose Azactam in Iso- Osmotic Dextrose Aztreonam (gm Imipenem/Cilastatin Invanz Meropenem (500mg Beta-Lactam, Penicillins - Antibiotics Amoxicillin Clavulanate Amoxicillin/Potassium Clavulanate Clavulanate ER Amoxicillin/Potassium Clavulanate ER Ampicillin Sodium Ampicillin Sodium (0gm Injection, 25mg Injection, gm Ampicillin/Sulbactam in Dextrose Bactocill in Dextrose (gm/50ml in Dextrose Bactocill in Dextrose (2gm/50ml C-R Bicillin C-R L-A Bicillin L-A Sodium Dicloxacillin Sodium Sodium Nafcillin Sodium (gm Sodium Nafcillin Sodium (0gm Nallpen/Dextrose (gm/50ml Sodium Oxacillin Sodium (0gm Injection, 2gm G Potassium Penicillin G Potassium ( unit G Potassium in Iso-Osmotic Dextrose Penicillin G Potassium in Iso- Osmotic Dextrose (40000unit/ml Injection, 60000unit/ ml G Procaine Penicillin G Procaine G Sodium Penicillin G Sodium V Potassium Penicillin V Potassium Sodium/Tazobactam Sodium Piperacillin Sodium/ Tazobactam Sodium (3gm-0.375gm Injection, 4gm-0.5gm Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 9

20 9tRACK 20 Zosyn (3gm-0.375gm Injection, 5%-2gm/ 50ml-0.25gm/50ml Injection, 5%-3gm/ 50ml-0.375gm/50ml Macrolides - Antibiotics Azasite Azithromycin (Suspension Reconstituted, Azithromycin (500mg Clarithromycin (Suspension Reconstituted, ER Clarithromycin ER Dificid PA 400 E.E.S. 400 Granules E.E.S. Granules Pad 2% Ery Pad 2% Ery-Tab EryPed Lactobionate Erythrocin Lactobionate (500mg Stearate Erythrocin Stearate Erythromycin (External Solution, Gel, Ointment) Base Erythromycin Base Ethylsuccinate Erythromycin Ethylsuccinate ( Ilotycin Zmax Quinolones - Antibiotics Avelox ( Avelox ( ABC Pack Avelox ABC Pack Besivance Ciloxan (Ointment) Cipro (Suspension Reconstituted) Ciprofloxacin (400mg/ 40ml Injection, Suspension Reconstituted) ER Ciprofloxacin ER Ciprofloxacin (Ophthalmic Solution, I.V. in D5W Ciprofloxacin I.V. in D5W (200mg/ 00ml-5% Gatifloxacin Levofloxacin ( Levofloxacin (Ophthalmic Solution, Oral Solution) Levofloxacin ( D5W Levofloxacin in D5W (5%-500mg/00ml Moxeza Moxifloxacin ( Ofloxacin Vigamox Sulfonamides - Antibiotics Sulfadiazine Silver Sulfadiazine (Cream) SSD 20

21 0 track 2 Sodium Sulfacetamide Sodium (Ointment, Ophthalmic Solution) Sulfadiazine ( Sulfamethoxazole/Trimethoprim Trimethoprim (Suspension, Sulfamethoxazole/Trimethoprim Trimethoprim ( Sulfamethoxazole/Trimethoprim DS Trimethoprim DS Tetracyclines - Antibiotics Demeclocycline 00 Doxy 00 Doxycycline (Suspension Reconstituted) Doxycycline (Capsule) Hyclate Doxycycline Hyclate (Capsule) Hyclate Doxycycline Hyclate (Injection, Hyclate DR Doxycycline Hyclate DR Monohydrate Doxycycline Monohydrate Minocycline (Capsule) Minocycline ( ER Minocycline ER Tetracycline (Capsule) Vibramycin (Syrup) Anticonvulsants - s to Treat Seizures Anticonvulsants, Other - Seizure Control s Fycompa Levetiracetam (Oral Solution, Levetiracetam (000mg/ 00ml-750mg/00ml Injection, 500mg/ 00ml-540mg/00ml Injection, 500mg/ 00ml-820mg/00ml Levetiracetam (500mg/5ml ER Levetiracetam ER Potiga QL Calcium Channel Modifying Agents - Seizure Control s Celontin Ethosuximide (Capsule, Oral Solution) Zonisamide (Capsule) Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 2

22 track 22 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control s AcuDial Diastat AcuDial Pediatric Diastat Pediatric Diazepam (Gel) Sodium Divalproex Sodium Sodium DR Divalproex Sodium DR Sodium ER Divalproex Sodium ER Gabapentin (Capsule, Gabapentin (Oral Solution) Gabitril (2mg Tablet, 6mg Tablet, 2mg Gabitril (4mg Onfi (Suspension) QL Onfi (0mg QL Onfi (20mg QL Phenobarbital (Elixir, Primidone ( PA, HRM Sabril PA, QL, LA Tiagabine (2mg QL Tiagabine (4mg Sodium Valproate Sodium (00mg/ml Acid Valproic Acid (Capsule, Syrup) Glutamate Reducing Agents - Seizure Control s Felbamate ( Felbamate (Suspension) Felbatol ODT Lamictal ODT (Tablet Dispersible) Starter Kit Lamictal Starter Kit (Blue Kit, Orange Kit) Starter Kit Lamictal Starter Kit (Green Kit) Lamotrigine (Immediate-Release Lamotrigine (Tablet Chewable) QL ODT Lamotrigine ODT QL Topiramate (Immediate-Release Capsule Sprinkle, Immediate-Release XR Trokendi XR (00mg Capsule Extended Release 24 Hour, 25mg Capsule Extended Release QL 24 Hour, 50mg Capsule Extended Release 24 Hour) XR Trokendi XR (200mg Capsule Extended QL Release 24 Hour) Sodium Channel Agents - Seizure Control s Aptiom QL Banzel (200mg Banzel (Suspension, 400mg 22

23 2 track 23 Carbamazepine (Suspension, Tablet, Tablet Chewable) ER Carbamazepine ER Dilantin Infatabs Dilantin Infatabs Dilantin-25 Epitol Equetro Sodium Fosphenytoin Sodium (00mg pe/2ml Oxcarbazepine ( Oxcarbazepine (Suspension) Peganone Phenytek Phenytoin (Suspension, Tablet Chewable) Sodium Phenytoin Sodium ( Sodium Extended Phenytoin Sodium Extended (Capsule) Tegretol (Suspension, Tegretol-XR Vimpat ( PA Vimpat (Oral Solution, QL Antidementia Agents - s to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia s Donepezil ( Donepezil (Tablet Dispersible) Exelon (Patch 24 Hour) Hydrobromide Galantamine Hydrobromide Tartrate Rivastigmine Tartrate QL, ST N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia s Memantine PA Titration Pak Memantine Titration Pak Namenda (Oral Solution) PA PA Namenda ( PA Titration Pak Namenda Titration Pak PA XR Namenda XR PA XR Titration Pack Namenda XR Titration Pack PA Antidepressants - s to Treat Depression Antidepressants, Other - Antidepressants Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 23

24 3 track 24 Bupropion ( SR Bupropion SR XL Bupropion XL XL Forfivo XL Mirtazapine ODT Mirtazapine ODT Monoamine Oxidase Inhibitors - Antidepressants Emsam Marplan Sulfate Phenelzine Sulfate ( Sulfate Tranylcypromine Sulfate SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor) - Antidepressants Brintellix QL Hydrobromide Citalopram Hydrobromide ( Hydrobromide Citalopram Hydrobromide (Oral Solution) Oxalate Escitalopram Oxalate ( Oxalate Escitalopram Oxalate (Oral Solution) Fetzima QL, ST Titration Pack Fetzima Titration Pack DR Fluoxetine DR (Capsule Delayed Release) Fluoxetine (Capsule, Oral Solution, 0mg Tablet, 20mg ST Maleate Fluvoxamine Maleate (Immediate-Release Maprotiline Nefazodone Paroxetine ER Paroxetine ER Paxil (Suspension) Pristiq QL Sertraline ( Sertraline (Concentrate) Trazodone ( Venlafaxine (Immediate-Release ER Venlafaxine ER (Capsule Extended Release 24 Hour) Viibryd QL Tricyclics - Antidepressants Amitriptyline ( PA, HRM Amoxapine Clomipramine (Capsule) Desipramine ( Doxepin (Capsule, Concentrate) PA, HRM PA, HRM Imipramine ( PA, HRM Pamoate Imipramine Pamoate PA, HRM Nortriptyline (Capsule, Oral Solution) Pamelor Protriptyline 24

25 4 track 25 Surmontil Antiemetics - s to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting s Compro Meclizine ( Metoclopramide ( Metoclopramide (Oral Solution) Metoclopramide ( Perphenazine ( Prochlorperazine (Suppository) Edisylate Prochlorperazine Edisylate ( Maleate Prochlorperazine Maleate ( Transderm-Scop Emetogenic Therapy Adjuncts - Nausea and Vomiting s Aloxi Anzemet ( B/D, PA Cesamet PA Dronabinol (2.5mg Capsule, 5mg Capsule) Dronabinol (0mg Capsule) PA PA Emend (Capsule) PA Granisetron (0.mg/ml Injection, mg/ml Granisetron ( Ondansetron ( Ondansetron (4mg/2ml Ondansetron (Oral Solution) B/D, PA B/D, PA B/D, PA ODT Ondansetron ODT B/D, PA Sancuso Antifungals - s to Treat Fungal Infections Antifungals - Fungal Infection s Abelcet B/D, PA AmBisome B/D, PA B Amphotericin B ( Ancobon Cancidas Ciclopirox Nail Lacquer Ciclopirox Nail Lacquer Olamine Ciclopirox Olamine (Cream) Clotrimazole (% Cream, External Solution, Troche) B/D, PA Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 25

26 5 track 26 Nitrate Econazole Nitrate (Cream) Eraxis (00mg Exelderm Fluconazole (Suspension Reconstituted, in Dextrose Fluconazole in Dextrose (56mg/ ml-400mg/200ml Flucytosine (Capsule) Microsize Griseofulvin Microsize Ultramicrosize Griseofulvin Ultramicrosize Gynazole- Itraconazole (Capsule) PA Ketoconazole (Cream, Shampoo, Ketoconazole (Foam) Lamisil (Packet) Mentax 3 Miconazole 3 (Suppository) Mycamine Naftifine Naftin Natacyn Noxafil (Suspension) Noxafil (Tablet Delayed Release) Nyamyc PA Nystatin (Cream, Ointment, 00000unit/ gm Powder, Suspension, Nystatin/Triamcinolone Nystop ONMEL PA Oxistat Sporanox (Oral Solution) Terbinafine ( Terconazole Vfend (Suspension, Voriconazole (Injection, Suspension Reconstituted, Zazole (0.4% Cream) Zazole (0.8% Cream) PA Antigout Agents - s to Treat Gout Antigout Agents - Gout s Allopurinol ( 0.6mg Tablet Colchicine 0.6mg Tablet (Generic Colcrys) Colcrys Probenecid ( Probenecid/Colchicine Uloric ST Antimigraine Agents - s to Treat Migraines Ergot Alkaloids - Migraine s Mesylate Dihydroergotamine Mesylate ( Migergot 26

27 6 track 27 Serotonin (5-HT) b/d Receptor Agonists - Migraine s Naratriptan Benzoate Rizatriptan Benzoate Benzoate ODT Rizatriptan Benzoate ODT Sumatriptan (Nasal Solution) Succinate Sumatriptan Succinate ( Succinate Sumatriptan Succinate (6mg/0.5ml Succinate Refill Sumatriptan Succinate Refill (4mg/0.5ml Succinate Refill Sumatriptan Succinate Refill (6mg/0.5ml DosePro Sumavel DosePro Antimyasthenic Agents - s to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis s Guanidine Mestinon (Syrup) Timespan Mestinon Timespan Bromide Pyridostigmine Bromide ( Bromide Pyridostigmine Bromide (Tablet Extended Release) Antimycobacterials - s to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives Dapsone ( Mycobutin Rifabutin Antituberculars - Tuberculosis s Sulfate Capastat Sulfate Ethambutol ( Isoniazid (Syrup, Isoniazid ( Paser Priftin Pyrazinamide ( Rifampin (Capsule) Rifampin ( Rifater Sirturo Trecator Antineoplastics - s to Treat Cancer Alkylating Agents - Chemotherapy Agents BiCNU Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 27

28 7 track 28 Busulfex Cyclophosphamide (Capsule) Dacarbazine (200mg B/D, PA Hexalen PA Ifosfamide (gm Leukeran Lomustine Matulane Melphalan Mustargen Treanda (00mg Injection, 45mg/ 0.5ml PA Valchlor PA Zanosar Antiandrogens - Hormone Suppressants Bicalutamide Flutamide Nilandron Xtandi PA Zytiga PA Antiangiogenic Agents - Chemotherapy Agents Pomalyst PA Revlimid PA, LA Thalomid PA Antiestrogens/Modifiers - Chemotherapy Agents Emcyt PA Fareston Faslodex Soltamox Citrate Tamoxifen Citrate ( Antimetabolites - Chemotherapy Agents Adrucil (500mg/0ml B/D, PA Alimta (500mg PA Cladribine B/D, PA Clolar Aqueous Cytarabine Aqueous B/D, PA Droxia Elitek (.5mg Fluorouracil (2.5gm/ 50ml Folotyn (40mg/2ml Gemcitabine (gm Gemzar (gm Hydroxyurea (Capsule) Mercaptopurine ( Nipent B/D, PA PA Purixan PA Tabloid PA Antineoplastics, Other - Chemotherapy Agents Abraxane PA Amifostine Arranon Azacitidine PA Beleodaq PA Sulfate Bleomycin Sulfate (30unit B/D, PA 28

29 8 track 29 Carboplatin (50mg/ 5ml Cisplatin (00mg/ 00ml Cosmegen Dacogen Daunorubicin DaunoXome Decitabine Dexrazoxane (250mg Docefrez (20mg Docetaxel (80mg/4ml Docetaxel (80mg/ 8ml Doxil Doxorubicin (2mg/ ml Ellence (200mg/ 00ml Eloxatin (00mg/ 20ml Epirubicin (50mg/ 25ml Erwinaze PA B/D, PA Farydak PA Phosphate Fludarabine Phosphate (50mg Fusilev Halaven PA Ibrance PA, QL PFS Idamycin PFS (20mg/20ml Idarubicin (0mg/ 0ml Irinotecan (00mg/5ml Istodax PA Kit Ixempra Kit (45mg Jevtana PA Calcium Leucovorin Calcium ( Calcium Leucovorin Calcium (00mg Injection, 350mg Calcium Levoleucovorin Calcium Lynparza PA, QL Mesna Mesnex ( Mitomycin (20mg Mitoxantrone Oncaspar Oxaliplatin (00mg/ 20ml Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 29

30 9 track 30 Paclitaxel (300mg/ 50ml Proleukin PA Synribo PA Taxotere (80mg/4ml Trisenox PA Velcade PA Vidaza PA Sulfate Vinblastine Sulfate ( B/D, PA PFS Vincasar PFS B/D, PA Sulfate Vincristine Sulfate ( Tartrate Vinorelbine Tartrate (50mg/5ml Zaltrap (00mg/4ml Zinecard (250mg B/D, PA PA PA Zolinza PA Zydelig PA, QL Zykadia PA, QL Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents Anastrozole ( Exemestane Letrozole ( Enzyme Inhibitors - Chemotherapy Agents Etopophos Etoposide (500mg/ 25ml Hycamtin Toposar (gm/50ml Topotecan (4mg Molecular Target Inhibitors - Chemotherapy Agents Afinitor PA Disperz Afinitor Disperz PA Bosulif PA Caprelsa PA, LA Cometriq PA Erivedge PA Gilotrif PA Gleevec PA Iclusig PA Imbruvica PA Inlyta PA Jakafi PA, LA Lenvima PA Mekinist PA Nexavar PA Sprycel PA Stivarga PA Sutent PA Tafinlar PA Tarceva PA Tasigna PA Tykerb PA Votrient PA Xalkori PA, LA Zelboraf PA Monoclonal Antibodies - Chemotherapy Agents Arzerra PA Avastin PA Cyramza PA 30

31 20 track 3 Herceptin PA Keytruda PA Opdivo (40mg/4ml PA Perjeta PA Rituxan PA Sylvant (00mg PA Retinoids - Chemotherapy Agents Bexarotene PA Panretin PA Targretin (Capsule) PA Tretinoin (Capsule) Antiparasitics - s to Treat Parasitic Infections Anthelmintics - Worm Infection s Albenza Biltricide Ivermectin ( Stromectol Antiprotozoals - Protozoal Infection s Alinia Atovaquone (Suspension) Atovaquone/Proguanil Phosphate Chloroquine Phosphate ( Coartem DARAPRIM Sulfate Hydroxychloroquine Sulfate ( Mefloquine Mepron Nebupent B/D, PA 300 Pentam 300 Phosphate Primaquine Phosphate ( Sulfate Quinine Sulfate (Capsule) PA Pediculicides/Scabicides - Scabies and Lice s Eurax Lindane (Lotion, Shampoo) Malathion Permethrin Antiparkinson Agents - s to Treat Parkinson's Disease Anticholinergics - Parkinson's Disease s Mesylate Benztropine Mesylate ( PA, HRM Mesylate Benztropine Mesylate ( Trihexyphenidyl PA, HRM Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 3

32 2 track 32 Antiparkinson Agents, Other - Parkinson's Disease s Amantadine (Capsule, Syrup, Entacapone Tasmar Tolcapone Dopamine Agonists - Parkinson's Disease s Apokyn PA Mesylate Bromocriptine Mesylate (Capsule, Dihydrochloride Pramipexole Dihydrochloride (Immediate-Release Ropinirole (Immediate-Release) Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease s Carbidopa ( Carbidopa/Levodopa ER Carbidopa/Levodopa ER ODT Carbidopa/Levodopa ODT Carbidopa/Levodopa/Entacapone Levodopa/ Entacapone Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease s Azilect Selegiline (Capsule, Zelapar Antipsychotics - s to Treat Mood Disorders st Generation/Typical - Mood Disorder s Chlorpromazine ( Chlorpromazine ( Decanoate Fluphenazine Decanoate ( Fluphenazine ( Fluphenazine (Concentrate, Elixir) Fluphenazine ( Haloperidol (Concentrate, Decanoate Haloperidol Decanoate ( Lactate Haloperidol Lactate ( Succinate Loxapine Succinate QL Orap Thioridazine ( Thiothixene PA, HRM Trifluoperazine ( 2nd Generation/Atypical - Mood Disorder s Abilify QL Maintena Abilify Maintena Aripiprazole (0mg Tablet, 5mg Tablet, 2mg Tablet, 5mg QL 32

33 22 track 33 Aripiprazole (20mg Tablet, 30mg ODT Clozapine ODT (00mg Tablet Dispersible, 2.5mg Tablet Dispersible, 50mg Tablet Dispersible, 25mg Tablet Dispersible) ODT Clozapine ODT (200mg Tablet Dispersible) Fanapt (mg Tablet, 2mg Tablet, 4mg Fanapt (0mg Tablet, 2mg Tablet, 6mg Tablet, 8mg Titration Pack Fanapt Titration Pack Fazaclo (2.5mg Tablet Dispersible, 25mg Tablet Dispersible) Fazaclo (00mg Tablet Dispersible, 50mg Tablet Dispersible, 200mg Tablet Dispersible) Geodon ( QL QL QL QL, ST QL, ST ST QL QL Invega QL Sustenna Invega Sustenna (39mg/0.25ml Sustenna Invega Sustenna (7mg/0.75ml Injection, 56mg/ml Injection, 234mg/.5ml Injection, 78mg/0.5ml Latuda QL Olanzapine ( QL Olanzapine ( ODT Olanzapine ODT QL Fumarate Quetiapine Fumarate QL Rexulti PA, QL Consta Risperdal Consta (2.5mg Injection, 25mg Consta Risperdal Consta (37.5mg Injection, 50mg Risperidone ( Risperidone (Oral Solution) ODT Risperidone ODT Saphris QL XR Seroquel XR QL Versacloz Ziprasidone QL Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 33

34 23 track 34 Relprevv Zyprexa Relprevv (20mg Treatment-Resistant - Mood Disorder s Clozapine Antivirals - s to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral s Cidofovir Ganciclovir ( B/D, PA Valcyte Valganciclovir Vistide Zirgan Anti-hepatitis B (HBV) Agents - Hepatitis B s Dipivoxil Adefovir Dipivoxil Baraclude Entecavir HBV Epivir HBV (Oral Solution) Hepsera Lamivudine (00mg Tyzeka Anti-hepatitis C (HCV) Agents - Hepatitis C s Copegus PA Harvoni PA, QL A Intron A (8mu Injection, 50mu Injection, unit/ml PA A W/Diluent Intron A W/Diluent (0mu Moderiba (200mg 200 Dose Pack Moderiba 200 Dose Pack 800 Dose Pack Moderiba 800 Dose Pack PA Olysio PA, QL Pegasys PA ProClick Pegasys ProClick PA PegIntron ( PA Redipen PegIntron Redipen PA Rebetol PA Ribasphere (Capsule, 200mg Ribasphere (400mg Ribasphere (600mg Ribapak Ribasphere Ribapak Ribavirin (Capsule, Sovaldi PA, QL Sylatron PA Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV s Evotaz QL Isentress (25mg Tablet Chewable) QL Isentress (Packet) QL Isentress (Tablet, 00mg Tablet Chewable) QL Prezcobix QL 34

35 24 track 35 Stribild QL Tivicay QL Vitekta QL Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV s Atripla QL Complera QL Edurant QL Intelence (25mg Intelence (00mg Tablet, 200mg QL QL Nevirapine QL ER Nevirapine ER QL Rescriptor QL Sustiva (50mg Capsule) Sustiva (200mg Capsule, Viramune (Suspension) XR Viramune XR (00mg Tablet Extended Release 24 Hour) QL QL QL QL XR Viramune XR (400mg Tablet Extended Release QL 24 Hour) Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV s Abacavir QL Sulfate/Lamivudine/Zidovudine Abacavir Sulfate/ Lamivudine/Zidovudine QL Combivir QL Didanosine QL Emtriva QL Epivir (Oral Solution) QL Epzicom QL Lamivudine (Oral Solution, 50mg Tablet, 300mg QL Lamivudine/Zidovudine QL IV Infusion Retrovir IV Infusion Stavudine QL Trizivir QL Truvada QL Tybost QL Pediatric Videx Pediatric (2gm Oral Solution) QL Viread QL Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 35

36 25 track 36 Ziagen (Oral Solution) QL Zidovudine QL Anti-HIV Agents, Other - HIV s Fuzeon QL Selzentry QL Triumeq QL Anti-HIV Agents, Protease Inhibitors - HIV s Aptivus QL Crixivan QL Invirase QL Kaletra (00mg-25mg Kaletra (Oral Solution, 200mg-50mg QL QL Lexiva (Suspension) QL Lexiva ( QL Norvir QL Prezista (75mg Prezista (Suspension, 50mg Tablet, 600mg Tablet, 800mg QL QL Reyataz QL Viracept QL Anti-Influenza Agents - Flu s Diskhaler Relenza Diskhaler QL Rimantadine Tamiflu QL Antiherpetic Agents - Herpes s Acyclovir ( Acyclovir (Capsule, Suspension) Acyclovir (Ointment) QL Sodium Acyclovir Sodium (50mg/ml B/D, PA Denavir QL Famciclovir ( Trifluridine (Ophthalmic Solution) Valacyclovir ( Zovirax (Cream) QL Zovirax (Ointment) QL Antivirals - s to Treat Viral Infections Virazole Anxiolytics - s to Treat Anxiety Anxiolytics, Other - Anxiety s Buspirone ( Hydroxyzine ( PA, HRM Hydroxyzine (Oral Solution) PA, HRM Pamoate Hydroxyzine Pamoate (Capsule) PA, HRM Benzodiazepines - Anxiety s Alprazolam (Immediate- Release QL Chlordiazepoxide QL Clonazepam ( QL ODT Clonazepam ODT QL Dipotassium Clorazepate Dipotassium Diazepam (mg/ml Oral Solution) QL Diazepam ( QL 36

37 26 track 37 Intensol Diazepam Intensol (5mg/ml Concentrate) QL Lorazepam ( QL Intensol Lorazepam Intensol (Oral Solution) QL Bipolar Agents - s to Treat Mood Disorders Mood Stabilizers - Mood Disorder s Lithium Carbonate Lithium Carbonate (Capsule, Carbonate ER Lithium Carbonate ER Blood Glucose Regulators - s to Regulate Blood Sugar Antidiabetic Agents - Diabetic s Acarbose QL Avandamet PA, QL Avandia PA, QL Bydureon QL Byetta QL Cycloset PA, QL Glimepiride QL Glipizide (Immediate- Release QL ER Glipizide ER QL Glipizide/Metformin QL Glyset QL Invokamet QL Invokana QL Janumet QL XR Janumet XR QL Januvia QL Jardiance QL Jentadueto QL Kazano QL XR Kombiglyze XR QL Metformin ( QL ER 500mg, 750mg Tablet Extended Release 24 Hour Metformin ER 500mg, 750mg Tablet Extended Release 24 Hour (Generic Glucophage XR) ER 000mg Tablet Extended Release 24 Hour Metformin ER 000mg Tablet Extended Release 24 Hour (Generic Fortamet) QL QL Nateglinide QL Nesina QL Onglyza QL Oseni QL Pioglitazone QL /Glimepiride Pioglitazone / Glimepiride /Metformin Pioglitazone / Metformin QL QL PrandiMet QL Bold type = Brand name drug Plain type = Generic drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization QL = Quantity limits see pages ST = Step therapy HRM = High risk medication You can find information on what the symbols and abbreviations in this table mean by going to page number 7. 37

38 27 track 38 Repaglinide QL Riomet QL 20 SymlinPen 20 PA 60 SymlinPen 60 PA Tradjenta QL Trulicity QL Victoza QL Glycemic Agents - Diabetic s HypoKit Glucagen HypoKit Emergency Kit Glucagon Emergency Kit Proglycem Insulins - Diabetic s Apidra SoloStar Apidra SoloStar Humalog (Vial) KwikPen Humalog KwikPen Mix Humalog Mix (Vial) Mix KwikPen Humalog Mix KwikPen Humulin (Vial) 70/30 Kwikpen Humulin 70/30 Kwikpen N Kwikpen Humulin N Kwikpen Lantus SoloStar Lantus SoloStar Levemir (Vial) FlexTouch Levemir FlexTouch Novolin (Vial) Novolog (Vial) FlexPen Novolog FlexPen Mix Novolog Mix Mix FlexPen Novolog Mix FlexPen PenFill Novolog PenFill SoloStar Toujeo SoloStar Blood Products/Modifiers/Volume Expanders - s to Treat Blood Disorders Anticoagulants - Blood Thinners Arixtra Coumadin Eliquis PA, QL Sodium Enoxaparin Sodium (300mg/3ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Sodium Enoxaparin Sodium (00mg/ml Injection, 20mg/0.8ml Injection, 50mg/ml Sodium Fondaparinux Sodium (2.5mg/0.5ml Sodium Fondaparinux Sodium (0mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Fragmin (2500unit/ 0.2ml Injection, 5000unit/0.2ml Fragmin (0000unit/ ml Injection, 2500unit/0.5ml Injection, 5000unit/ 0.6ml Injection, 8000unit/0.72ml Injection, 7500unit/ 0.3ml Injection, 95000unit/3.8ml QL QL 38