2016 List of Covered Drugs

Transcription

1 1 UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This is a list of drugs that members can get in UnitedHealthcare Connected for MyCare Ohio. UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or co-payments may change on January 1 of each year. You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date List of Covered Drugs online at Limitations, co-pays, and restrictions may apply. For more information, call UnitedHealthcare Connected for MyCare Ohio Member Services or read the UnitedHealthcare Connected for MyCare Ohio Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other formats, such as large print, braille or audio. Call , TTY 711. The call is free. You can get this information for free in other languages. Call , TTY 711. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al , TTY 711. Las llamadas son gratuitas. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit or O O Connecting Medicare Medicaid Medicare Approved Formulary File ID , Version 13 H2531_150629_153725_FINAL6 Approved Last updated June 1, 2016

2 2 2 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1 What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 9 are the drugs covered by UnitedHealthcare Connected for MyCare Ohio. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies..unitedhealthcare Connected for MyCare Ohio will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a UnitedHealthcare Connected for MyCare Ohio network pharmacy. UnitedHealthcare Connected for MyCare Ohio may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at , TTY Does the Drug List ever change? Yes. UnitedHealthcare Connected for MyCare Ohio may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected for MyCare Ohio before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

3 3 (For more information on these drug rules, see pages 3, 4 and 9.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date Drug List online at You can also call Member Services to check the current Drug List at , TTY What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will receive a letter letting you know about the change. Contact your doctor or other prescriber to make sure this cheaper drug will work for you. 4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options. 5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. If you don t get approval, UnitedHealthcare Connected for MyCare Ohio may not cover the drug. Quantity limits: Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

4 4 4 Step therapy: Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected for MyCare Ohio member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on pages has a column labeled. 7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

5 5 5 8 How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it after the List of Covered Drugs section. Find the name of your drug. The page number where you can find the drug will be next to it. To search by medical condition, find the section labeled List of drugs by medical condition on pages The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9 What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at , TTY 711 and ask about it. If you learn that UnitedHealthcare Connected for MyCare Ohio will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10 What if you are a new UnitedHealthcare Connected for MyCare Ohio member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected for MyCare Ohio. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

6 6 6 the drug requires prior approval by UnitedHealthcare Connected for MyCare Ohio, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 and may be up to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. 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. 11 Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected for MyCare Ohio to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UnitedHealthcare Connected for MyCare Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12 How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

7 How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. 14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Connected for MyCare Ohio covers both brand name drugs and generic drugs. 15 What are OTC drugs? OTC stands for over-the-counter. UnitedHealthcare Connected for MyCare Ohio covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC drugs are covered. 16 Does UnitedHealthcare Connected for MyCare Ohio cover OTC nondrug products? UnitedHealthcare Connected for MyCare Ohio covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC non-drug products are covered. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

8 What is your copay? You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to learn about the copay for each drug. UnitedHealthcare Connected for MyCare Ohio members living in nursing homes or other long-term care facilities will have no copays. Some members getting longterm care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs have the lowest copay. They are generic drugs. The copay will be from $1.20 to $2.95, depending on your level of Medicaid eligibility. Tier 2 drugs have a medium copay. They are brand name drugs. The copay will be from $3.60 to $7.40, depending on your level of Medicaid eligibility. Tier 3 drugs have a copay of $0. They are OTCs/Non-Part D drugs. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

9 91 For Track Refered Purpose List of Covered Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. The List of Covered Drugs that begins on the next page gives you information about the drugs covered by UnitedHealthcare Connected for MyCare Ohio. If you have trouble finding your drug in the list, turn to the Index that begins on page 123. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the column tells you if UnitedHealthcare Connected for MyCare Ohio has any rules for covering your drug. Utilization Management Restrictions PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. If you don t get approval, UnitedHealthcare Connected for MyCare Ohio may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. Other Special Requirements for Coverage 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. 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 an alternative drug is available to treat your condition. Note: If you are 65 or older, you may need to get a prior authorization (PA) or formulary exception from the health plan before the plan will cover 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. 9

10 1For 10 Track Refered Purpose 10 LA - Limited Access Drugs 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. For Track Refered Purpose Note: The asterisk (*) next to a drug means the drug is not a Part D drug. 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 these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at , TTY 711. You can also read the Member Handbook to learn how to appeal a decision. Analgesics Analgesics Acephen acephen (suppository)* Acetaminophen acetaminophen (suppository)* Fever Reducer Childrens fever reducer childrens (suppository)* Feverall Adults feverall adults (suppository)* Feverall Childrens feverall childrens (suppository)* Feverall Infants feverall infants (suppository)* Feverall Junior Strength feverall junior strength (suppository)* Nonsteroidal Anti-inflammatory Drugs Advil advil (200mg capsule, 200mg tablet)* Advil Junior Strength advil junior strength (100mg tablet, 100mg tablet chewable)* All Day Pain Relief all day pain relief (tablet)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

11 2For 11 Track Refered Purpose 11 All Day Relief all day relief (tablet)* Aspir-81 aspir-81 (tablet delayed-release)* Aspirin aspirin (325mg tablet, 325mg tablet delayed-release, 81mg tablet delayed-release, 81mg tablet chewable)* Aspirin Adult Low Strength aspirin adult low strength (tablet chewable)* Aspirin Childrens aspirin childrens (tablet chewable)* Aspirin EC aspirin ec (tablet delayed-release)* Aspirin EC Low Dose aspirin ec low dose (tablet delayed-release)* Aspirin Enteric Coated Adult Low Strength aspirin enteric coated adult low strength (tablet delayedrelease)* Aspirin Low Dose aspirin low dose (81mg tablet chewable, 81mg tablet delayed-release)* Aspirin Low Strength aspirin low strength (tablet chewable)* Aspir-Low aspir-low (tablet delayed-release)* Childrens Advil childrens advil (suspension)* Childrens Aspirin childrens aspirin (tablet chewable)* Childrens Aspirin Low Strength childrens aspirin low strength (tablet chewable)* Childrens Ibuprofen childrens ibuprofen (otc only) (40mg/ml suspension)* Diclofenac Potassium diclofenac potassium (tablet immediate-release) Diclofenac Sodium diclofenac sodium (1% gel) PA Diclofenac Sodium DR diclofenac sodium dr (tablet delayed-release) Diclofenac Sodium ER diclofenac sodium er (tablet extended-release 24 hour) Diflunisal diflunisal (tablet) Ecpirin ecpirin (tablet delayed-release)* Enteric Coated Aspirin enteric coated aspirin (tablet delayed-release)* Etodolac etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediate-release) Flector FLECTOR (PATCH) $3.60-$7.40 (Tier 2) PA, QL Flurbiprofen flurbiprofen (tablet) GNP Adult Aspirin Low Strength gnp adult aspirin low strength (81mg tablet chewable, 81mg tablet delayed-release)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

12 3For 12 Track Refered Purpose 12 GNP All Day Pain Relief gnp all day pain relief (tablet)* GNP Aspirin gnp aspirin (tablet delayed-release)* GNP Aspirin Low Dose gnp aspirin low dose (tablet delayed-release)* GNP Ibuprofen gnp ibuprofen (otc only) (200mg tablet)* GNP Ibuprofen Junior Strength gnp ibuprofen junior strength (otc only) (100mg tablet chewable)* HM Aspirin hm aspirin (325mg tablet, 81mg tablet chewable)* HM Aspirin EC hm aspirin ec (tablet delayed-release)* HM Aspirin EC Low Dose hm aspirin ec low dose (tablet delayed-release)* HM Cold & Sinus Relief hm cold & sinus relief (tablet)* HM Ibuprofen hm ibuprofen (otc only) (200mg capsule, 200mg tablet)* HM Ibuprofen IB hm ibuprofen ib (otc only) (200mg tablet)* HM Ibuprofen Infants hm ibuprofen infants (otc only) (50mg/1.25ml suspension)* HM Naproxen Sodium hm naproxen sodium (otc only) (220mg tablet immediaterelease)* Ibu-Drops ibu-drops (otc only) (suspension)* Ibu-Drops Infants ibu-drops infants (otc only) (suspension)* Ibuprofen ibuprofen (otc only) (200mg capsule, 200mg tablet)* Ibuprofen Junior Strength ibuprofen junior strength (otc only) (100mg tablet chewable)* Ibuprofen ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) Infants Ibuprofen infants ibuprofen (otc only) (50mg/1.25ml suspension)* Ketoprofen ketoprofen (capsule immediate-release) Ketorolac Tromethamine ketorolac tromethamine (15mg/ml injection, 30mg/ml injection) Meloxicameloxicam (15mg tablet, 7.5mg tablet) Meloxicam MELOXICAM (7.5MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Miniprin Low Dose miniprin low dose (tablet delayed-release)* Naproxen naproxen (rx only) (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediate-release, 500mg tablet immediate-release) Naproxen DR naproxen dr (rx only) (375mg tablet delayed-release, 500mg tablet delayed-release) (generic ec-naprosyn) Naproxen Sodium naproxen sodium (otc only) (220mg capsule immediaterelease, 220mg tablet immediate-release)* Naproxen Sodium naproxen sodium (rx only) (275mg tablet immediate-release, 550mg tablet immediate-release) Provil provil (tablet)* QC Aspirin qc aspirin (325mg tablet, 325mg tablet delayed-release)*

13 4For 13 Track Refered Purpose 13 QC Aspirin Low Dose qc aspirin low dose (tablet delayed-release)* QC Childrens Aspirin qc childrens aspirin (tablet chewable)* QC Ibuprofen qc ibuprofen (otc only) (200mg tablet)* QC Ibuprofen IB qc ibuprofen ib (otc only) (200mg tablet)* QC Naproxen Sodium qc naproxen sodium (otc only) (220mg tablet immediaterelease)* SB Aspirin sb aspirin (81mg tablet delayed-release)* SB Ibuprofen sb ibuprofen (otc only) (200mg tablet)* SB Naproxen Sodium sb naproxen sodium (otc only) (220mg tablet immediaterelease)* SM All Day Pain Relief sm all day pain relief (220mg tablet immediate-release)* SM Aspirin Adult Low Strength sm aspirin adult low strength (81mg tablet chewable, 81mg tablet delayed-release)* SM Aspirin Enteric Coated sm aspirin enteric coated (tablet delayed-release)* SM Childrens Aspirin sm childrens aspirin (tablet chewable)* SM Ibuprofen sm ibuprofen (otc only) (200mg tablet)* SM Ibuprofen IB sm ibuprofen ib (otc only) (200mg tablet)* SM Infants Ibuprofen sm infants ibuprofen (otc only) (50mg/1.25ml suspension)* SM Naproxen Sodium sm naproxen sodium (otc only) (220mg capsule immediaterelease, 220mg tablet immediate-release)* Sulindac sulindac (tablet) Voltaren VOLTAREN (GEL) $3.60-$7.40 (Tier 2) PA Opioid Analgesics, Long-acting Embeda EMBEDA (CAPSULE EXTENDED-RELEASE) $3.60-$7.40 (Tier 2) QL Fentanyl fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch 72 hour, 75mcg/hr patch 72 hour) Hydromorphone HCl ER hydromorphone hcl er (12mg tablet extended-release 24 hour abuse-deterrent, 16mg tablet extended-release 24 hour abuse-deterrent, 8mg tablet extended-release 24 hour abuse-deterrent) QL QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

14 5For 14 Track Refered Purpose 14 Hydromorphone HCl ER HYDROMORPHONE HCL ER (32MG TABLET EXTENDED-RELEASE 24 HOUR ABUSE- $3.60-$7.40 (Tier 2) QL DETERRENT) Levorphanol Tartrate levorphanol tartrate (tablet) QL Methadone HCl methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution) QL Methadone HCl METHADONE HCL (10MG/ML INJECTION) $3.60-$7.40 (Tier 2) Morphine Sulfate ER morphine sulfate er (tablet extended-release) (generic ms contin) QL Nucynta ER NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) QL Opioid Analgesics, Short-acting Abstral ABSTRAL (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2) PA, QL Acetaminophen/Codeine acetaminophen/codeine (120mg-12mg/5ml oral solution, 300mg-15mg tablet, 300mg-30mg tablet, 300mg-60mg tablet) QL Butorphanol Tartrate butorphanol tartrate (10mg/ml nasal solution) QL Butorphanol Tartrate butorphanol tartrate (1mg/ml injection, 2mg/ml injection) Codeine Sulfate codeine sulfate (tablet) QL Duramorph DURAMORPH (INJECTION) $3.60-$7.40 (Tier 2) Endocet endocet (tablet) QL Hydrocodone Bitartrate/Acetaminophen hydrocodone bitartrate/acetaminophen (7.5mg-325mg/ 15ml oral solution) QL Hydrocodone/Acetaminophen hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) QL Hydrocodone/Ibuprofen hydrocodone/ibuprofen (7.5mg-200mg tablet) QL Hydromorphone HCl hydromorphone hcl (1mg/ml liquid, 2mg tablet immediaterelease, 4mg tablet immediate-release, 8mg tablet QL immediate-release) Hydromorphone HCl hydromorphone hcl (500mg/50ml injection) Lorcet lorcet (tablet) QL Lorcet HD lorcet hd (tablet) QL Lorcet Plus lorcet plus (tablet) QL Lortab lortab (tablet) QL Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/5ml oral solution, 20mg/5ml oral solution) QL Morphine Sulfate MORPHINE SULFATE (10MG/ML INJECTION, 2MG/ML INJECTION, 4MG/ML INJECTION, 8MG/ML INJECTION) $3.60-$7.40 (Tier 2)

15 6For 15 Track Refered Purpose 15 Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE-RELEASE, 30MG TABLET $3.60-$7.40 (Tier 2) QL IMMEDIATE-RELEASE) Nalbuphine HCl nalbuphine hcl (injection) Oxycodone HCl oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediate-release, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) QL Oxycodone/Acetaminophen oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) QL Oxycodone/Aspirin oxycodone/aspirin (tablet) QL Oxycodone/Ibuprofen oxycodone/ibuprofen (tablet) QL Tramadol HCl tramadol hcl (tablet immediate-release) QL Tramadol HCl/Acetaminophen tramadol hcl/acetaminophen (tablet) QL Trezix trezix (320.5mg-30mg-16mg capsule) QL Anesthetics Local Anesthetics Lidocaine lidocaine (otc only) (cream)* Lidocaine HCl lidocaine hcl (rx only) (0.5% injection, 2% injection) B/D, PA Lidocaine HCl lidocaine hcl (rx only) (4% external solution) Lidocaine HCl lidocaine hcl (rx only) (2% gel) Lidocaine Viscous lidocaine viscous (rx only) (2% solution) Lidocaine lidocaine (rx only) (5% ointment) Lidocaine lidocaine (rx only) (5% patch) PA, QL Lidocaine/Prilocaine lidocaine/prilocaine (cream) Lidocream lidocream (cream)* QC AZO qc azo (tablet)* Anti-Addiction/Substance Abuse Treatment Agents You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

16 7For 16 Track Refered Purpose 16 Alcohol Deterrents/Anti-craving Acamprosate Calcium DR acamprosate calcium dr (tablet delayed-release) Disulfiram disulfiram (tablet) Naltrexone HCl naltrexone hcl (tablet) Vivitrol VIVITROL (INJECTION) $3.60-$7.40 (Tier 2) PA Opioid Dependence Treatments Buprenorphine HCl buprenorphine hcl (0.3mg/ml injection) Buprenorphine HCl buprenorphine hcl (2mg tablet sublingual, 8mg tablet sublingual) QL Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (tablet sublingual) PA, QL Naloxone HCl naloxone hcl (injection) Narcan NARCAN (LIQUID) $3.60-$7.40 (Tier 2) Suboxone SUBOXONE (FILM) $3.60-$7.40 (Tier 2) PA, QL Smoking Cessation Agents Buproban buproban (tablet extended-release 12 hour) Chantix CHANTIX (TABLET) $3.60-$7.40 (Tier 2) Chantix Continuing Month Pak CHANTIX CONTINUING MONTH PAK (TABLET) $3.60-$7.40 (Tier 2) Chantix Starting Month Pak CHANTIX STARTING MONTH PAK (TABLET) $3.60-$7.40 (Tier 2) GNP Nicotine Mini Lozenge gnp nicotine mini lozenge* GNP Nicotine Polacrilex gnp nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* GNP Nicotine Polacrilex Mini gnp nicotine polacrilex mini (lozenge)* HM Nicotine Polacrilex hm nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* HM Nicotine Transdermal System hm nicotine transdermal system (patch 24 hour)* HM Nicotine Transdermal System Step 3 hm nicotine transdermal system step 3 (patch 24 hour)* NicoDerm CQ nicoderm cq (patch 24 hour)* NICOrelief nicorelief (gum)* Nicorette nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* Nicorette Mini nicorette mini (lozenge)* Nicorette Starter Kit nicorette starter kit (gum)* Nicotine nicotine (patch 24 hour)* Nicotine Polacrilex nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* Nicotine Transdermal System nicotine transdermal system (patch 24 hour)* Nicotrol Inhaler NICOTROL INHALER $3.60-$7.40 (Tier 2)

17 8For 17 Track Refered Purpose 17 SM Nicotine sm nicotine (14mg/24hr patch 24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24 hour, 2mg lozenge, 4mg gum)* SM Nicotine Polacrilex sm nicotine polacrilex (2mg gum, 4mg gum, 4mg lozenge)* Antibacterials Aminoglycosides Amikacin Sulfate amikacin sulfate (injection) Bethkis BETHKIS (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Gentak gentak (ophthalmic ointment) Gentamicin Sulfate gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% ophthalmic ointment, 0.3% ophthalmic solution, 10mg/ml injection, 40mg/ml injection) Gentamicin Sulfate/0.9% Sodium Chloride gentamicin sulfate/0.9% sodium chloride (injection) Isotonic Gentamicin isotonic gentamicin (injection) Neomycin Sulfate neomycin sulfate (tablet) Paromomycin Sulfate paromomycin sulfate (capsule) Streptomycin Sulfate streptomycin sulfate (injection) TOBI (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Podhaler TOBI PODHALER (CAPSULE) $3.60-$7.40 (Tier 2) PA Tobradex TOBRADEX (OPHTHALMIC OINTMENT) $3.60-$7.40 (Tier 2) Tobramycin tobramycin (nebulized solution) B/D, PA Tobramycin Sulfate tobramycin sulfate (0.3% ophthalmic solution, 10mg/ml injection, 80mg/2ml injection) Tobrex TOBREX (0.3% OPHTHALMIC OINTMENT) $3.60-$7.40 (Tier 2) Antibacterials, Other BACiiM baciim (injection) Bacitracin bacitracin (otc only) (500unit/gm ointment)* Bacitracin Zinc bacitracin zinc (otc only) (ointment)* Bacitracin bacitracin (rx only) (50000unit injection, 500unit/gm ophthalmic ointment) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

18 9For 18 Track Refered Purpose 18 Bacitracin/Neomycin/Polymyxin bacitracin/neomycin/polymyxin (otc only) (ointment)* Bactroban Nasal BACTROBAN NASAL (OINTMENT) $3.60-$7.40 (Tier 2) PA Betadine Surgical Scrub betadine surgical scrub (external solution)* Chloramphenicol Sodium Succinate chloramphenicol sodium succinate (injection) Clindamycin HCl clindamycin hcl (capsule immediate-release) Clindamycin Palmitate HCl clindamycin palmitate hcl (oral solution) Clindamycin Phosphate clindamycin phosphate (2% cream, 600mg/4ml injection) Clindamycin Phosphate D5W clindamycin phosphate in d5w (injection) Colistimethate Sodium colistimethate sodium (injection) Cubicin CUBICIN (INJECTION) $3.60-$7.40 (Tier 2) Dalvance DALVANCE (INJECTION) $3.60-$7.40 (Tier 2) PA Double Antibiotic double antibiotic (ointment)* GNP Bacitracin Zinc gnp bacitracin zinc (otc only) (ointment)* GNP Povidone-Iodine gnp povidone-iodine (external solution)* GNP Triple Antibiotic gnp triple antibiotic (ointment)* GNP Triple Antibiotic Plus gnp triple antibiotic plus (ointment)* HM Bacitracin hm bacitracin (otc only) (ointment)* HM Double Antibiotic hm double antibiotic (ointment)* HM Povidone-Iodine hm povidone-iodine (external solution)* HM Triple Antibiotic hm triple antibiotic (ointment)* Lincocin LINCOCIN (INJECTION) $3.60-$7.40 (Tier 2) Lincomycin HCl lincomycin hcl (injection) Linezolid linezolid (100mg/5ml suspension, 600mg/300ml injection) PA Linezolid LINEZOLID (600MG TABLET) $3.60-$7.40 (Tier 2) PA, QL Methenamine Hippurate methenamine hippurate (tablet) Metronidazole metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75% lotion, 250mg tablet immediate-release, 500mg tablet immediate-release, 375mg capsule immediate-release) Metronidazole in NaCl 0.79% metronidazole in nacl 0.79% (injection) Metronidazole Vaginal metronidazole vaginal (gel) Mupirocin mupirocin (2% ointment) Neomycin/Polymyxin B Sulfates neomycin/polymyxin b sulfates (rx only) (irrigation solution) Nitrofurantoin nitrofurantoin (suspension) Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg capsule) (generic macrodantin) Nitrofurantoin Monohydrate 100mg Capsule nitrofurantoin monohydrate 100mg capsule (generic macrobid) Operand Scrub operand scrub (external solution)* Polymyxin B Sulfate polymyxin b sulfate (injection)

19 For Track Refered Purpose 19 Povidone-Iodine povidone-iodine (10% external solution, 10% ointment)* Primsol PRIMSOL (ORAL SOLUTION) $3.60-$7.40 (Tier 2) QC Bacitracin qc bacitracin (otc only) (ointment)* SM Double Antibiotic sm double antibiotic (ointment)* SM Triple Antibiotic sm triple antibiotic (ointment)* Synercid SYNERCID (INJECTION) $3.60-$7.40 (Tier 2) Tinidazole tinidazole (tablet) Trimethoprim trimethoprim (tablet) Triple Antibiotic triple antibiotic (ointment)* Tygacil TYGACIL (INJECTION) $3.60-$7.40 (Tier 2) Vancocin HCl VANCOCIN HCL (CAPSULE) $3.60-$7.40 (Tier 2) PA Vancomycin HCl vancomycin hcl (1000mg injection, 10gm injection, 500mg injection) Vancomycin HCl vancomycin hcl (125mg capsule, 250mg capsule) PA Vandazole VANDAZOLE (GEL) $3.60-$7.40 (Tier 2) Xifaxan XIFAXAN (TABLET) $3.60-$7.40 (Tier 2) PA Zyvox ZYVOX (100MG/5ML SUSPENSION, 600MG/ 300ML INJECTION) $3.60-$7.40 (Tier 2) PA Beta-lactam, Cephalosporins Cefaclor cefaclor (250mg capsule immediate-release, 500mg capsule immediate-release) Cefadroxil cefadroxil (250mg/5ml suspension, 500mg/5ml suspension, 500mg capsule) Cefazolin Sodium cefazolin sodium (10gm injection, 1gm injection, 500mg injection, 1gm/50ml injection) Cefdinir cefdinir (125mg/5ml suspension, 250mg/5ml suspension, 300mg capsule) Cefepime cefepime (1gm injection, 2gm injection) Cefepime CEFEPIME (1GM/50ML INJECTION, 2GM/50ML $3.60-$7.40 (Tier 2) INJECTION) Cefixime cefixime (suspension) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

20 For Track Refered Purpose 20 Cefotaxime Sodium cefotaxime sodium (injection) Cefotetan cefotetan (injection) Cefoxitin Sodium cefoxitin sodium (10gm injection, 1gm injection, 2gm injection) Cefoxitin Sodium CEFOXITIN SODIUM (1GM-4% INJECTION, 2GM-2.2% INJECTION) $3.60-$7.40 (Tier 2) Cefpodoxime Proxetil cefpodoxime proxetil (100mg tablet, 200mg tablet, 100mg/ 5ml suspension, 50mg/5ml suspension) Cefprozil cefprozil (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) Ceftazidime ceftazidime (injection) Ceftazidime/Dextrose CEFTAZIDIME/DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2) Ceftriaxone Sodium ceftriaxone sodium (10gm injection, 1gm injection, 2gm injection, 250mg injection, 500mg injection) Cefuroxime Axetil cefuroxime axetil (tablet) Cefuroxime Sodium cefuroxime sodium (injection) Cephalexin cephalexin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule, 750mg capsule) Fortaz FORTAZ (1GM INJECTION, 2GM INJECTION, 2GM INJECTION, 6GM INJECTION) $3.60-$7.40 (Tier 2) Suprax suprax (100mg tablet chewable, 200mg tablet chewable, 100mg/5ml suspension, 200mg/5ml suspension) Suprax SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Tazicef tazicef (injection) Zerbaxa ZERBAXA (INJECTION) $3.60-$7.40 (Tier 2) PA Beta-lactam, Other Azactam in Iso-Osmotic Dextrose AZACTAM IN ISO-OSMOTIC DEXTROSE $3.60-$7.40 (Tier 2) (INJECTION) Aztreonam aztreonam (injection) Doribax DORIBAX (500MG INJECTION) $3.60-$7.40 (Tier 2) Imipenem/Cilastatin imipenem/cilastatin (injection) Invanz INVANZ (INJECTION) $3.60-$7.40 (Tier 2) Meropenem meropenem (injection) Beta-lactam, Penicillins Amoxicillin amoxicillin (capsule, oral suspension, tablet, tablet chewable)

21 For Track Refered Purpose 21 Amoxicillin/Clavulanate Potassium amoxicillin/clavulanate potassium (oral suspension, tablet chewable, tablet immediate-release) (generic augmentin) Amoxicillin/Clavulanate Potassium ER amoxicillin/clavulanate potassium er (tablet extendedrelease 12 hour) Ampicillin ampicillin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule) Ampicillin Sodium ampicillin sodium (10gm injection, 125mg injection, 1gm injection) Ampicillin-Sulbactam ampicillin-sulbactam (10gm-5gm injection, 1gm-0.5gm injection, 2gm-1gm injection) Bactocill in Dextrose BACTOCILL IN DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2) Bicillin C-R BICILLIN C-R (INJECTION) $3.60-$7.40 (Tier 2) Bicillin L-A BICILLIN L-A (INJECTION) $3.60-$7.40 (Tier 2) Dicloxacillin Sodium dicloxacillin sodium (capsule) Nafcillin Sodium nafcillin sodium (injection) Nallpen/Dextrose NALLPEN/DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2) Oxacillin Sodium oxacillin sodium (injection) Penicillin G Potassium penicillin g potassium (injection) Penicillin G Procaine penicillin g procaine (injection) Penicillin G Sodium penicillin g sodium (injection) Penicillin V Potassium penicillin v potassium (125mg/5ml oral solution, 250mg/ 5ml oral solution, 250mg tablet, 500mg tablet) Piperacillin Sodium/Tazobactam Sodium piperacillin sodium/tazobactam sodium (injection) Macrolides Azithromycin azithromycin (100mg/5ml oral suspension, 200mg/5ml oral suspension, 250mg tablet, 500mg tablet, 600mg tablet, 500mg injection) Clarithromycin clarithromycin (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) Clarithromycin ER clarithromycin er (tablet extended-release 24 hour) Dificid DIFICID (TABLET) $3.60-$7.40 (Tier 2) PA E.E.S. 400 e.e.s. 400 (tablet) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

22 For Track Refered Purpose 22 Granules E.E.S. GRANULES (SUSPENSION) $3.60-$7.40 (Tier 2) EryPed 200 ERYPED 200 (SUSPENSION) $3.60-$7.40 (Tier 2) EryPed 400 ERYPED 400 (SUSPENSION) $3.60-$7.40 (Tier 2) Ery-Tab ery-tab (tablet delayed-release) Erythrocin Lactobionate erythrocin lactobionate (injection) Erythromycin erythromycin (250mg capsule delayed-release, 5mg/gm ophthalmic ointment) Erythromycin Base erythromycin base (tablet) Erythromycin Ethylsuccinate erythromycin ethylsuccinate (tablet) Ilotycin ilotycin (ophthalmic ointment) Zmax ZMAX (SUSPENSION) $3.60-$7.40 (Tier 2) Quinolones Avelox AVELOX (400MG/250ML-0.8% INJECTION) $3.60-$7.40 (Tier 2) Ciprofloxacin ciprofloxacin (250mg/5ml suspension, 500mg/5ml suspension, 400mg/40ml injection) Ciprofloxacin ER ciprofloxacin er (tablet extended-release 24 hour) Ciprofloxacin HCl ciprofloxacin hcl (0.3% ophthalmic solution, 100mg tablet immediate-release, 250mg tablet immediate-release, 500mg tablet immediate-release, 750mg tablet immediaterelease) Ciprofloxacin I.V. in D5W ciprofloxacin i.v. in d5w (injection) Levofloxacin levofloxacin (0.5% ophthalmic solution, 250mg tablet, 500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/ml oral solution) Levofloxacin D5W levofloxacin in d5w (injection) Moxeza MOXEZA (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Moxifloxacin HCl moxifloxacin hcl (400mg tablet) Moxifloxacin HCl MOXIFLOXACIN HCL (400MG/250ML $3.60-$7.40 (Tier 2) INJECTION) Ofloxacin ofloxacin (0.3% ophthalmic solution, 0.3% otic solution, 400mg tablet) Sulfonamides Silver Sulfadiazine silver sulfadiazine (cream) Sodium Sulfacetamide sodium sulfacetamide (10% ophthalmic solution) SSD (CREAM) $3.60-$7.40 (Tier 2) Sulfacetamide Sodium sulfacetamide sodium (ophthalmic ointment) Sulfadiazine sulfadiazine (tablet)

23 For Track Refered Purpose 23 Sulfamethoxazole/Trimethoprim sulfamethoxazole/trimethoprim (200mg-40mg/5ml suspension, 400mg-80mg tablet, 400mg-80mg/5ml injection) Sulfamethoxazole/Trimethoprim DS sulfamethoxazole/trimethoprim ds (tablet) Tetracyclines Demeclocycline HCl demeclocycline hcl (tablet) Doxy 100 doxy 100 (injection) Doxycycline doxycycline (150mg capsule immediate-release, 75mg capsule immediate-release, 25mg/5ml suspension) Doxycycline Hyclate doxycycline hyclate (100mg capsule immediate-release, 50mg capsule immediate-release, 100mg injection, 100mg tablet immediate-release, 20mg tablet immediate-release) Doxycycline Monohydrate doxycycline monohydrate (100mg capsule, 50mg capsule, 100mg tablet, 150mg tablet, 50mg tablet, 75mg tablet) Minocycline HCl minocycline hcl (100mg capsule immediate-release, 50mg capsule immediate-release, 75mg capsule immediaterelease) Tetracycline HCl TETRACYCLINE HCL (CAPSULE) $3.60-$7.40 (Tier 2) Vibramycin VIBRAMYCIN (50MG/5ML SYRUP) $3.60-$7.40 (Tier 2) Anticonvulsants Anticonvulsants, Other Fycompa FYCOMPA (TABLET) $3.60-$7.40 (Tier 2) Levetiracetam levetiracetam (1000mg tablet immediate-release, 250mg tablet immediate-release, 500mg tablet immediate-release, 750mg tablet immediate-release, 100mg/ml oral solution, 500mg/5ml injection) Levetiracetam LEVETIRACETAM (1000MG/100ML INJECTION, 1500MG/100ML INJECTION, 500MG/100ML $3.60-$7.40 (Tier 2) INJECTION) Levetiracetam ER levetiracetam er (tablet extended-release 24 hour) Potiga POTIGA (TABLET) $3.60-$7.40 (Tier 2) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

24 For Track Refered Purpose 24 Calcium Channel Modifying Agents Celontin CELONTIN (CAPSULE) $3.60-$7.40 (Tier 2) Ethosuximide ethosuximide (250mg capsule, 250mg/5ml oral solution) Zonisamide zonisamide (capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents Diastat AcuDial DIASTAT ACUDIAL (GEL) $3.60-$7.40 (Tier 2) Diastat Pediatric DIASTAT PEDIATRIC (GEL) $3.60-$7.40 (Tier 2) Diazepam DIAZEPAM (10MG GEL, 2.5MG GEL, 20MG GEL) $3.60-$7.40 (Tier 2) Divalproex Sodium divalproex sodium (capsule sprinkle delayed-release) Divalproex Sodium DR divalproex sodium dr (tablet delayed-release) Divalproex Sodium ER divalproex sodium er (tablet extended-release 24 hour) Gabapentin gabapentin (100mg capsule, 300mg capsule, 400mg capsule, 250mg/5ml oral solution, 600mg tablet, 800mg tablet) Gabitril GABITRIL (12MG TABLET, 16MG TABLET) $3.60-$7.40 (Tier 2) QL Onfi ONFI (10MG TABLET, 20MG TABLET) $3.60-$7.40 (Tier 2) QL Onfi ONFI (2.5MG/ML SUSPENSION) $3.60-$7.40 (Tier 2) Phenobarbital phenobarbital (100mg tablet, 15mg tablet, 16.2mg tablet, 30mg tablet, 32.4mg tablet, 60mg tablet, 64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir) Primidone primidone (tablet) Sabril SABRIL (500MG PACKET, 500MG TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA Tiagabine HCl tiagabine hcl (tablet) Valproate Sodium valproate sodium (100mg/ml injection) Valproic Acid valproic acid (250mg capsule, 250mg/5ml syrup) Glutamate Reducing Agents Felbamate felbamate (400mg tablet, 600mg tablet, 600mg/5ml suspension) Felbatol FELBATOL (600MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Lamotrigine lamotrigine (100mg tablet immediate-release, 150mg tablet immediate-release, 200mg tablet immediate-release, 25mg tablet immediate-release, 25mg tablet chewable, 5mg tablet chewable) Topiramate topiramate (100mg tablet immediate-release, 200mg tablet immediate-release, 25mg tablet immediate-release, 50mg tablet immediate-release, 15mg capsule sprinkle immediaterelease, 25mg capsule sprinkle immediate-release) Sodium Channel Agents

25 For Track Refered Purpose 25 Aptiom APTIOM (TABLET) $3.60-$7.40 (Tier 2) QL Banzel BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION) Carbamazepine carbamazepine (100mg tablet chewable, 100mg/5ml suspension, 200mg tablet immediate-release) Carbamazepine ER carbamazepine er (capsule extended-release 12 hour, tablet extended-release 12 hour) $3.60-$7.40 (Tier 2) Dilantin dilantin (capsule) Dilantin INFATABS dilantin infatabs (tablet chewable) Epitol epitol (tablet) Fosphenytoin Sodium fosphenytoin sodium (injection) Oxcarbazepine oxcarbazepine (150mg tablet, 300mg tablet, 600mg tablet, 300mg/5ml suspension) Peganone PEGANONE (TABLET) $3.60-$7.40 (Tier 2) Phenytek phenytek (capsule) Phenytoin phenytoin (125mg/5ml suspension, 50mg tablet chewable) Phenytoin Sodium phenytoin sodium (injection) Phenytoin Sodium Extended phenytoin sodium extended (capsule) Tegretol-XR TEGRETOL-XR (100MG TABLET EXTENDED- RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) Vimpat VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML $3.60-$7.40 (Tier 2) QL ORAL SOLUTION) Vimpat VIMPAT (200MG/20ML INJECTION) $3.60-$7.40 (Tier 2) PA Antidementia Agents Cholinesterase Inhibitors Donepezil HCl donepezil hcl (10mg tablet dispersible, 5mg tablet dispersible, 10mg tablet immediate-release, 5mg tablet immediate-release) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

26 For Track Refered Purpose 26 Exelon EXELON (13.3MG/24HR PATCH 24 HOUR, 4.6MG/24HR PATCH 24 HOUR, 9.5MG/24HR $3.60-$7.40 (Tier 2) QL, ST PATCH 24 HOUR) Rivastigmine Tartrate rivastigmine tartrate (capsule immediate-release) QL Rivastigmine Transdermal System rivastigmine transdermal system (patch 24 hour) QL, ST N-methyl-D-aspartate (NMDA) Receptor Antagonist Memantine HCl memantine hcl (10mg tablet, 5mg tablet, 2mg/ml oral solution) PA, QL Memantine HCl Titration Pak MEMANTINE HCL TITRATION PAK (TABLET) $3.60-$7.40 (Tier 2) PA Namenda NAMENDA (10MG/5ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) PA, QL Namenda XR NAMENDA XR (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Namenda XR Titration Pack NAMENDA XR TITRATION PACK (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Antidepressants Antidepressants, Other Bupropion HCl bupropion hcl (tablet immediate-release) Bupropion HCl SR bupropion hcl sr (tablet extended-release 12 hour) Bupropion HCl XL bupropion hcl xl (tablet extended-release 24 hour) Mirtazapine mirtazapine (tablet immediate-release) Mirtazapine ODT mirtazapine odt (tablet dispersible) Monoamine Oxidase Inhibitors Emsam EMSAM (PATCH 24 HOUR) $3.60-$7.40 (Tier 2) QL Marplan MARPLAN (TABLET) $3.60-$7.40 (Tier 2) Phenelzine Sulfate phenelzine sulfate (tablet) Tranylcypromine Sulfate tranylcypromine sulfate (tablet) SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Brintellix BRINTELLIX (TABLET) $3.60-$7.40 (Tier 2) QL Citalopram HBr citalopram hbr (10mg tablet, 20mg tablet, 40mg tablet, 10mg/5ml oral solution) Escitalopram Oxalate escitalopram oxalate (10mg tablet, 20mg tablet, 5mg tablet, 5mg/5ml oral solution) Fetzima FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL, ST