2019 Comprehensive List of Covered Drugs

Transcription

1 Healthcare Marketplace Comprehensive Exchange Drug List: CY Comprehensive List of Covered Drugs PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Members must use network pharmacies to get their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change. What is the Network Health Comprehensive Drug List? A comprehensive drug list is a list of drugs that are covered by your plan. Network Health works with a team of health care providers to choose drugs that provide quality treatment. Network Health covers drugs on our comprehensive drug list, as long as: The drug is medically necessary. The prescription is filled at a Network Health network pharmacy. Other plan rules are followed. For more information on how to fill your prescriptions, please review your plan document or other plan materials. Are all drugs covered by my benefit plan included on this Comprehensive Drug List? Yes. This comprehensive drug list is a list of drugs specifically covered by your plan. If you have questions about a medication that is not on the comprehensive drug list, please call customer service at , 24 hours a day, seven days a week. TTY/TDD users, please call Can the Comprehensive Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed comprehensive drug list is up to date as of 2/1/2019. To get updated information about the drugs covered by Network Health, please visit or call customer service at , 24 hours a day, seven days a week. I

2 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 What else could result in changes to the covered drug list? We remove drugs from our drug list right away and will let members know when: The U.S. Food and Drug Administration (FDA) decides that a drug is unsafe. The drug maker removes the drug from the market. How do I use the Comprehensive Drug List? To find your drug on the comprehensive drug list follow the instructions below. You can look for your drug in the Index that starts on page 127. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index. Look in the Index and find your drug. Next to your drug, see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Network Health covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs, but provide the same quality of treatment. Are there any restrictions on my coverage? Some covered drugs may have more requirements or limits on coverage. These requirements and limits may include the following. Prior Authorization: Network Health needs you (or your prescriber) to get prior approval or authorization for certain drugs. This means that you need to get approval from Network Health before you fill your prescriptions. If you don t get approval, Network Health may not cover the drug. Quantity Limits: For certain drugs, Network Health limits the amount of the drug that it will cover. For example, Network Health provides 12 tablets per prescription for Sumatriptan tablets. Fill Limits: For certain drugs, Network Health limits the number of fills that it will cover for a drug. For example, Network Health allows 2 treatment cycles of Chantix in a plan year. Step Therapy: Network Health needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Network Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Network Health will then cover Drug B. You can find out if your drug has any special requirements or limits by looking on the comprehensive drug list that starts on page 1 after this preface. You can also get more information about the restrictions for specific covered drugs by visiting networkhealth.com/individual/benefits/individualdruglist.php. You can ask Network Health to make an exception to these restrictions or limits. See the section, What if my drug is not on the Comprehensive Drug List? on page III (3). II

3 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Does the Plan cover prescription drugs that are considered Preventive Services under the Affordable Care Act? The U.S. Department of Health and Human Services (HHS) has adopted Guidelines for Preventive Services under the Affordable Care Act (ACA). Under the ACA, some pharmacy benefit plans may provide a range of preventive services for $0 member cost share and are designated as tier 0 on this document. These items may include: Aspirin to Prevent Cardiovascular Disease Fluoride Supplementation in Children Folic Acid Supplementation for Members Expecting or Planning to be Pregnant Tobacco Use Counseling and Cessation Intervention Immunizations Women s Health Preventive Services (i.e., birth control, emergency contraception) Low Dosed Statin Medications to Prevent Cardiovascular Disease and Stroke (age restrictions apply) (designated at tier 1 in this document) A list of the preventive services covered under the plan is available on the member portal at login.networkhealth.com, or will be mailed to you upon request. You may request the list by calling the Network Health Customer Service number on your identification card. What if my drug is not on the Comprehensive Drug List? If your drug is not on this drug list, call customer service to confirm that your drug is not covered. If you learn that Network Health does not cover your drug, you have two choices: Ask customer service for a list of similar drugs that are covered by Network Health. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Network Health. Similar drugs that are preferred and covered by your plan s formulary may be easier to obtain and lower cost to you than non-preferred drugs. Ask Network Health to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Network Health limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more. Generally, Network Health will only approve your request for an exception if the preferred drugs included on the plan s drug list are not as effective in treating your condition or cause you to have adverse medical effects. How do I find out if my exception is granted? When you ask for a drug list utilization restriction exception, please send a statement from your prescriber that supports your request. We will make our decision within three business days of receipt of the information necessary to make a decision. III

4 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 You can ask for an expedited (fast) exception if you or your prescriber believes that your health could be seriously harmed by waiting up to three business days for a decision. If your expedited (fast) request is granted, we will give you a decision no later than 24 hours after we get your prescriber s supporting statement. For more information For more information about your Network Health prescription drug coverage, please view your policy. Network Health s Comprehensive Drug List The drug list gives coverage information for all drugs covered by Network Health. If you have trouble finding your drug on the list, turn to the Index that starts on page 127. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Network Health has any special requirements for coverage of your drug. Tier Name Tier Definition Tier 0 Tier 1 Preventive drugs Adherence Generics (limited only to categories of antidiabetics, statins and hypertensive drugs) Tier 2 Generic drugs Tier 3 Preferred brand drugs Tier 4 Non-preferred brand drugs Tier 5 Preferred Specialty Products Tier 6 Non-preferred Specialty Products IV

5 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Bronze Essential This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 $2.00 $4.00 Tier 2 $20.00 $55.00 Tier 3 $80.00 after deductible $ after deductible Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A Network Health Prestige Bronze 20 HDHP This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 20% after deductible 20% after deductible Tier 2 20% after deductible 20% after deductible Tier 3 20% after deductible 20% after deductible Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A V

6 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Bronze 0 This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 $2.00 $4.00 Tier 2 $20.00 $55.00 Tier 3 $70.00 after deductible $ after deductible Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A Network Health Prestige Bronze 50 HDHP This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 30% after deductible 30% after deductible Tier 2 30% after deductible 30% after deductible Tier 3 40% after deductible 40% after deductible Tier 4 50% after deductible 50% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A VI

7 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Silver Essential This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 $2.00 $4.00 Tier 2 $20.00 $55.00 Tier 3 $80.00 $ Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A Network Health Prestige Silver 20 HDHP This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 20% after deductible 20% after deductible Tier 2 20% after deductible 20% after deductible Tier 3 20% after deductible 20% after deductible Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A VII

8 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Gold Essential This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 $2.00 $4.00 Tier 2 $15.00 $40.00 Tier 3 $60.00 $ Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A Network Health Prestige Gold 50 This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 $2.00 $4.00 Tier 2 $15.00 $40.00 Tier 3 $50.00 $ Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A VIII

9 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Gold 0 HDHP This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 N/A Tier 1 No charge after deductible No charge after deductible Tier 2 No charge after deductible No charge after deductible Tier 3 No charge after deductible No charge after deductible Tier 4 35% after deductible 35% after deductible Tier 5 35% after deductible N/A Tier 6 50% after deductible N/A Network Health Prestige Bronze Essential Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER Retail 30-Day Supply I/T/U Pharmacy 30-Day Supply 90-Day Supply I/T/U Pharmacy 90-Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 $2.00 $0.00 $4.00 N/A Tier 2 $20.00 $0.00 $55.00 N/A Tier 3 $80.00 after deductible $0.00 $ after deductible N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A IX

10 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Bronze 20 HDHP Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER Retail 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 20% after deductible $ % after deductible N/A Tier 2 20% after deductible $ % after deductible N/A Tier 3 20% after deductible $ % after deductible N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A Network Health Prestige Bronze 0 Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 $2.00 $0.00 $4.00 N/A Tier 2 $20.00 $0.00 $55.00 N/A Tier 3 $70.00 after deductible $0.00 $ after deductible N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A X

11 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Bronze 50 HDHP Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 30% after deductible $ % after deductible N/A Tier 2 30% after deductible $ % after deductible N/A Tier 3 40% after deductible $ % after deductible N/A Tier 4 50% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A Network Health Prestige Silver Essential Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 $2.00 $0.00 $4.00 N/A Tier 2 $20.00 $0.00 $55.00 N/A Tier 3 $80.00 $0.00 $ N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A XI

12 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Silver 20 HDHP Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 20% after deductible $ % after deductible N/A Tier 2 20% after deductible $ % after deductible N/A Tier 3 20% after deductible $ % after deductible N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A Network Health Prestige Gold Essential Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 $2.00 $0.00 $4.00 N/A Tier 2 $15.00 $0.00 $40.00 N/A Tier 3 $60.00 $0.00 $ N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A XII

13 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 Network Health Prestige Gold 50 Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 $2.00 $0.00 $4.00 N/A Tier 2 $15.00 $0.00 $40.00 N/A Tier 3 $50.00 $0.00 $ N/A Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A Network Health Prestige Gold 0 HDHP Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply I/T/U Pharmacy 30- Day Supply 90-Day Supply I/T/U Pharmacy 90- Day Supply Tier 0 $0.00 $0.00 N/A N/A Tier 1 Tier 2 Tier 3 No charge after deductible No charge after deductible No charge after deductible $0.00 $0.00 $0.00 No charge after deductible No charge after deductible No charge after deductible Tier 4 35% after deductible $ % after deductible N/A Tier 5 $0.00 N/A N/A N/A Tier 6 $0.00 N/A N/A N/A N/A N/A N/A XIII

14 Healthcare Marketplace Comprehensive Exchange Drug List: CY2019 The information listed in this document was current at the time of posting, however, changes occur frequently. The actual copay/coinsurance will be determined at the time the prescription is filled. For more information about your benefits contact Network Health Customer Service at For additional prescription drug information, log onto caremark.com or call Caremark at HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation, or Network Health Insurance Corporation and Network Health Plan. XIV

15 NHP-WI 6T STD Modified eff 02/01/2019 ANALGESICS COX-2 INHIBITORS celecoxib cap 50 mg Tier 2 celecoxib cap 100 mg Tier 2 celecoxib cap 200 mg Tier 2 celecoxib cap 400 mg Tier 2 GOUT allopurinol sodium for inj 500 mg Tier 2 allopurinol tab 100 mg Tier 2 allopurinol tab 300 mg Tier 2 colchicine tab 0.6 mg Tier 2 colchicine w/ probenecid tab mg Tier 2 probenecid tab 500 mg Tier 2 ULORIC TAB 40MG Tier 4 ST; ** ULORIC TAB 80MG Tier 4 ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 50- Tier 2 QL (48 caps / 25 days) mg butalbital-acetaminophen-caffeine cap 50- Tier 2 QL (48 caps / 25 days) mg butalbital-acetaminophen-caffeine tab 50- Tier 2 QL (48 tabs / 25 days) mg butalbital-aspirin-caffeine cap Tier 2 QL (48 caps / 25 days) mg tencon tab mg Tier 2 QL (48 tabs / 25 days) NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed Tier 2 release mg diclofenac w/ misoprostol tab delayed Tier 2 release mg NSAIDS diclofenac potassium tab 50 mg Tier 2 diclofenac sodium tab delayed release 25 Tier 2 mg diclofenac sodium tab delayed release 50 Tier 2 mg diclofenac sodium tab delayed release 75 Tier 2 mg diclofenac sodium tab er 24hr 100 mg Tier 2 etodolac cap 200 mg Tier 2 etodolac cap 300 mg Tier 2 etodolac tab 400 mg Tier 2 etodolac tab 500 mg Tier 2 1

16 etodolac tab er 24hr 400 mg Tier 2 etodolac tab er 24hr 500 mg Tier 2 etodolac tab er 24hr 600 mg Tier 2 fenoprofen calcium cap 400 mg Tier 2 fenoprofen calcium tab 600 mg Tier 2 flurbiprofen tab 50 mg Tier 2 flurbiprofen tab 100 mg Tier 2 ibuprofen susp 100 mg/5ml Tier 2 ibuprofen tab 400 mg Tier 2 ibuprofen tab 600 mg Tier 2 ibuprofen tab 800 mg Tier 2 indomethacin cap 25 mg Tier 2 indomethacin cap 50 mg Tier 2 ketoprofen cap er 24hr 200 mg Tier 2 ketorolac tromethamine im inj 60 mg/2ml Tier 2 (30 mg/ml) ketorolac tromethamine inj 15 mg/ml Tier 2 ketorolac tromethamine inj 30 mg/ml Tier 2 ketorolac tromethamine tab 10 mg Tier 2 QL (20 tabs / 25 days) meclofenamate sodium cap 50 mg Tier 2 meclofenamate sodium cap 100 mg Tier 2 mefenamic acid cap 250 mg Tier 2 meloxicam tab 7.5 mg Tier 2 meloxicam tab 15 mg Tier 2 nabumetone tab 500 mg Tier 2 nabumetone tab 750 mg Tier 2 naproxen dr tab 375mg Tier 2 naproxen dr tab 500mg Tier 2 naproxen tab 250 mg Tier 2 naproxen tab 375 mg Tier 2 naproxen tab 500 mg Tier 2 oxaprozin tab 600 mg Tier 2 piroxicam cap 10 mg Tier 2 piroxicam cap 20 mg Tier 2 sulindac tab 150 mg Tier 2 sulindac tab 200 mg Tier 2 tolmetin sodium cap 400 mg Tier 2 tolmetin sodium tab 200 mg Tier 2 tolmetin sodium tab 600 mg Tier 2 OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab mg (base equiv) Tier 0 QL (90 tabs / 25 days); $0 copay buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) Tier 0 QL (90 tabs / 25 days); $0 copay SUBOXONE MIS 2-0.5MG Tier 3 QL (90 units / 25 days) SUBOXONE MIS 4-1MG Tier 3 QL (90 units / 25 days) 2

17 SUBOXONE MIS 8-2MG Tier 3 QL (90 units / 25 days) SUBOXONE MIS 12-3MG Tier 3 QL (60 units / 25 days) ZUBSOLV SUB Tier 3 QL (90 units / 25 days) ZUBSOLV SUB Tier 3 QL (90 units / 25 days) ZUBSOLV SUB Tier 3 QL (90 units / 25 days) ZUBSOLV SUB Tier 3 QL (90 units / 25 days) ZUBSOLV SUB Tier 3 QL (60 units / 25 days) ZUBSOLV SUB Tier 3 QL (30 units / 25 days) OPIOID ANALGESICS acetaminophen w/ codeine soln mg/5ml Tier 2 acetaminophen w/ codeine tab mg Tier 2 acetaminophen w/ codeine tab mg Tier 2 acetaminophen w/ codeine tab mg Tier 2 QL (2700 ml / 25 days), ST; Subject to initial 7- day limit QL (400 tabs / 25 days), ST; Subject to initial 7- day limit QL (360 tabs / 25 days), ST; Subject to initial 7- day limit QL (180 tabs / 25 days), ST; Subject to initial 7- day limit QL (48 caps / 25 days) butalbital-acetaminophen-caff w/ cod cap Tier mg butorphanol tartrate inj 1 mg/ml Tier 2 butorphanol tartrate inj 2 mg/ml Tier 2 butorphanol tartrate nasal soln 10 mg/ml Tier 2 QL (2 bottles / 25 days) CAPITAL/COD SUS /5 Tier 4 QL (2700 ml / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 15 mg Tier 2 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 30 mg Tier 2 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 60 mg Tier 2 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit EMBEDA CAP MG Tier 3 QL (60 caps / 25 days), ST EMBEDA CAP MG Tier 3 QL (60 caps / 25 days), ST EMBEDA CAP 50-2MG Tier 3 QL (30 caps / 25 days), ST EMBEDA CAP MG Tier 3 QL (30 caps / 25 days), ST EMBEDA CAP MG Tier 3 QL (30 caps / 25 days), ST 3

18 EMBEDA CAP 100-4MG Tier 3, ST; High Strength Requires endocet tab Tier 2 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab 5-325mg Tier 2 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab Tier 2 QL (240 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit fentanyl citrate lozenge on a handle 200 mcg Tier 2 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 400 mcg Tier 2 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 600 mcg Tier 2 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 800 mcg Tier 2 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1200 mcg Tier 2 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1600 mcg Tier 2 QL (120 lozenges / 25 days), fentanyl td patch 72hr 12 mcg/hr Tier 2 QL (10 patches / 25 days), ST fentanyl td patch 72hr 25 mcg/hr Tier 2 QL (10 patches / 25 days), ST fentanyl td patch 72hr 50 mcg/hr Tier 2, ST; High Strength Requires fentanyl td patch 72hr 75 mcg/hr Tier 2, ST; High Strength Requires fentanyl td patch 72hr 100 mcg/hr Tier 2, ST; High Strength Requires hydrocodone-acetaminophen soln Tier 2 QL (2700 ml / 25 days), mg/15ml ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab mg Tier 2 QL (240 tabs / 25 days), ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg Tier 2 Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit QL (180 tabs / 25 days), ST; Subject to initial 7- day limit 4

19 HYDROMORPHON SUP 3MG Tier 4 QL (120 suppositories / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl inj 1 mg/ml Tier 2 hydromorphone hcl inj 2 mg/ml Tier 2 hydromorphone hcl inj 4 mg/ml Tier 2 hydromorphone hcl liqd 1 mg/ml Tier 2 QL (600 ml / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl preservative free (pf) Tier 2 inj 10 mg/ml hydromorphone hcl tab 2 mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 4 mg Tier 2 QL (150 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 8 mg Tier 2 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab er 24hr deter 8 mg Tier 2 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 12 mg Tier 2 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 16 mg Tier 2 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 32 mg Tier 2, ST; High Strength Requires HYSINGLA ER TAB 20 MG Tier 3 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 30 MG Tier 3 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 40 MG Tier 3 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 60 MG Tier 3 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 80 MG Tier 3 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 100 MG Tier 3, ST; High Strength Requires HYSINGLA ER TAB 120 MG Tier 3, ST; High Strength Requires lortab tab mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit 5

20 methadone con 10mg/ml Tier 2 QL (60 ml / 25 days), ST; (generic of Methadone Intensol, indicated for pain) methadone hcl conc 10 mg/ml Tier 2 QL (30 ml / 25 days); (indicated for opioid addiction) methadone hcl inj 10 mg/ml Tier 2 QL (20 ml / 25 days), ST methadone hcl soln 5 mg/5ml Tier 2 QL (450 ml / 25 days), ST methadone hcl soln 10 mg/5ml Tier 2 QL (300 ml / 25 days), ST methadone hcl tab 5 mg Tier 2 QL (90 tabs / 25 days), ST methadone hcl tab 10 mg Tier 2 QL (60 tabs / 25 days), ST methadone hcl tab for oral susp 40 mg Tier 2 QL (9 tabs / 25 days) methadose tab 40mg Tier 2 QL (9 tabs / 25 days) MORPHINE SUL INJ 2MG/ML Tier 4 MORPHINE SUL INJ 4MG/ML Tier 4 MORPHINE SUL INJ 5MG/ML Tier 4 MORPHINE SUL INJ 150/30ML Tier 4 MORPHINE SUL SUP 30MG Tier 3 QL (90 supp / 25 days), ST; Subject to initial 7- day limit morphine sulfate beads cap er 24hr 30 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 45 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 60 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 75 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 90 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 120 mg Tier 2, ST; High Strength Requires morphine sulfate cap er 24hr 10 mg Tier 2 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 20 mg Tier 2 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 30 mg Tier 2 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 50 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 60 mg Tier 2 QL (30 caps / 25 days), ST 6

21 morphine sulfate cap er 24hr 80 mg Tier 2 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 100 mg Tier 2, ST; High Strength Requires morphine sulfate inj 8 mg/ml Tier 2 morphine sulfate inj 10 mg/ml Tier 2 morphine sulfate inj pf 0.5 mg/ml Tier 2 morphine sulfate inj pf 1 mg/ml Tier 2 morphine sulfate iv soln 1 mg/ml Tier 2 morphine sulfate iv soln pf 4 mg/ml Tier 2 morphine sulfate iv soln pf 8 mg/ml Tier 2 morphine sulfate iv soln pf 10 mg/ml Tier 2 morphine sulfate iv soln pf 15 mg/ml Tier 2 morphine sulfate oral soln 10 mg/5ml Tier 2 QL (900 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate oral soln 20 mg/5ml Tier 2 QL (675 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate oral soln 100 mg/5ml (20 Tier 2 QL (135 ml / 25 days), mg/ml) ST; Subject to initial 7- day limit morphine sulfate suppos 5 mg Tier 2 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 10 mg Tier 2 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 20 mg Tier 2 QL (120 supp / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 15 mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate tab 30 mg Tier 2 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate tab er 15 mg Tier 2 QL (90 tabs / 25 days), ST morphine sulfate tab er 30 mg Tier 2 QL (90 tabs / 25 days), ST morphine sulfate tab er 60 mg Tier 2, ST; High Strength Requires morphine sulfate tab er 100 mg Tier 2, ST; High Strength Requires morphine sulfate tab er 200 mg Tier 2, ST; High Strength Requires nalbuphine hcl inj 10 mg/ml Tier 2 7

22 nalbuphine hcl inj 20 mg/ml Tier 2 NUCYNTA ER TAB 50MG Tier 3 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 100MG Tier 3 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 150MG Tier 3, ST; High Strength Requires NUCYNTA ER TAB 200MG Tier 3, ST; High Strength Requires NUCYNTA ER TAB 250MG Tier 3, ST; High Strength Requires NUCYNTA TAB 50MG Tier 3 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TAB 75MG Tier 3 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TAB 100MG Tier 3 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl cap 5 mg Tier 2 QL (180 caps / 25 days), ST; Subject to initial 7-day limit oxycodone hcl conc 100 mg/5ml (20 mg/ml) Tier 2 QL (90 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl soln 5 mg/5ml Tier 2 QL (900 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 5 mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 10 mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 15 mg Tier 2 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 20 mg Tier 2 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 30 mg Tier 2 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab er 12hr deter 10 mg Tier 2 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 15 mg Tier 2 QL (60 tabs / 25 days), ST 8

23 oxycodone hcl tab er 12hr deter 20 mg Tier 2 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 30 mg Tier 2 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 40 mg Tier 2, ST; High Strength Requires oxycodone hcl tab er 12hr deter 60 mg Tier 2, ST; High Strength Requires oxycodone hcl tab er 12hr deter 80 mg Tier 2, ST; High Strength Requires oxycodone w/ acetaminophen soln mg/5ml Tier 2 QL (1800 ml / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg Tier 2 Tier 2 Tier 2 Tier 2 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit QL (360 tabs / 25 days), ST; Subject to initial 7- day limit QL (240 tabs / 25 days), ST; Subject to initial 7- day limit QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-aspirin tab mg Tier 2 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-ibuprofen tab mg Tier 2 QL (28 tabs / 25 days), ST; Subject to initial 7- day limit OXYCONTIN TAB 10MG CR Tier 3 QL (60 tabs / 25 days), ST OXYCONTIN TAB 15MG CR Tier 3 QL (60 tabs / 25 days), ST OXYCONTIN TAB 20MG CR Tier 3 QL (60 tabs / 25 days), ST OXYCONTIN TAB 30MG CR Tier 3 QL (60 tabs / 25 days), ST OXYCONTIN TAB 40MG CR Tier 3, ST; High Strength Requires OXYCONTIN TAB 60MG CR Tier 3, ST; High Strength Requires OXYCONTIN TAB 80MG CR Tier 3, ST; High Strength Requires oxymorphone hcl tab 5 mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit 9

24 oxymorphone hcl tab 10 mg Tier 2 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl tab er 12hr 5 mg Tier 2 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 7.5 mg Tier 2 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 10 mg Tier 2 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 15 mg Tier 2 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 20 mg Tier 2, ST; High Strength Requires oxymorphone hcl tab er 12hr 30 mg Tier 2, ST; High Strength Requires oxymorphone hcl tab er 12hr 40 mg Tier 2, ST; High Strength Requires tramadol hcl tab 50 mg Tier 2 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit tramadol hcl tab er 24hr 100 mg Tier 2 QL (30 tabs / 25 days), ST tramadol hcl tab er 24hr 200 mg Tier 2, ST; High Strength Requires tramadol hcl tab er 24hr 300 mg Tier 2, ST; High Strength Requires XARTEMIS XR TAB Tier 4 QL (120 tabs / 25 days) xylon tab mg Tier 2 QL (50 tabs / 25 days), ST; Subject to initial 7- day limit OPIOID RTIAL AGONISTS BELBUCA MIS 75MCG Tier 3 QL (60 films / 25 days), ST BELBUCA MIS 150MCG Tier 3 QL (60 films / 25 days), ST BELBUCA MIS 300MCG Tier 3 QL (60 films / 25 days), ST BELBUCA MIS 450MCG Tier 3 QL (60 films / 25 days), ST BELBUCA MIS 600MCG Tier 3, ST; High Strength Requires Prior Auth BELBUCA MIS 750MCG Tier 3, ST; High Strength Requires Prior Auth BELBUCA MIS 900MCG Tier 3, ST; High Strength Requires Prior Auth buprenorphine hcl inj 0.3 mg/ml (base equiv) Tier 2 10

25 buprenorphine hcl sl tab 2 mg (base equiv) Tier 0 QL (90 tabs / 25 days); $0 copay; Must obtain approval after the initial fill buprenorphine hcl sl tab 8 mg (base equiv) Tier 0 QL (90 tabs / 25 days); $0 copay; Must obtain approval after the initial fill SALICYLATES aspirin chw 81mg Tier 0 OTC, QL (100 tabs / 30 days); $0 copay-age and gender restrictions apply aspirin low tab 81mg ec Tier 0 OTC, QL (100 tabs / 30 days); $0 copay-age and gender restrictions apply diflunisal tab 500 mg Tier 2 ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% Tier 4 lidocaine hcl local inj 0.5% Tier 2 lidocaine hcl local inj 1% Tier 2 lidocaine hcl local inj 2% Tier 2 lidocaine hcl local preservative free (pf) inj Tier 2 0.5% lidocaine hcl local preservative free (pf) inj Tier 2 1% lidocaine hcl local preservative free (pf) inj Tier 2 1.5% lidocaine hcl local preservative free (pf) inj Tier 2 2% lidocaine hcl local preservative free (pf) inj Tier 2 4% ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 mg/ml) Tier 2 amikacin sulfate inj 500 mg/2ml (250 Tier 2 mg/ml) chloramphenicol sodium succinate for iv inj Tier 2 1 gm GENTAM/NACL INJ 0.9MG/ML Tier 4 GENTAM/NACL INJ 1.4MG/ML Tier 4 gentamicin in saline inj 0.8 mg/ml Tier 2 gentamicin in saline inj 1 mg/ml Tier 2 gentamicin in saline inj 1.2 mg/ml Tier 2 gentamicin in saline inj 1.6 mg/ml Tier 2 11

26 gentamicin in saline inj 2 mg/ml Tier 2 gentamicin sulfate inj 10 mg/ml Tier 2 gentamicin sulfate inj 40 mg/ml Tier 2 MONUROL K GRANULES Tier 4 neomycin sulfate tab 500 mg Tier 2 paromomycin sulfate cap 250 mg Tier 2 streptomycin sulfate for inj 1 gm Tier 2 SULFADIAZINE TAB 500MG Tier 4 tinidazole tab 250 mg Tier 2 tinidazole tab 500 mg Tier 2 tobramycin nebu soln 300 mg/5ml Tier 5 QL (280 ml / 28 days), tobramycin sulfate for inj 1.2 gm Tier 2 tobramycin sulfate inj 1.2 gm/30ml (40 Tier 2 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 Tier 2 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base Tier 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 Tier 2 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALINIA SUS 100/5ML Tier 3 ALINIA TAB 500MG Tier 3 atovaquone susp 750 mg/5ml Tier 2 AZACTAM/DEX INJ 1GM Tier 4 AZACTAM/DEX INJ 2GM Tier 4 aztreonam for inj 1 gm Tier 2 aztreonam for inj 2 gm Tier 2 CAYSTON INH 75MG Tier 5 QL (84 vials / 28 days), clindamycin hcl cap 75 mg Tier 2 clindamycin hcl cap 150 mg Tier 2 clindamycin hcl cap 300 mg Tier 2 clindamycin palmitate hcl for soln 75 Tier 2 mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml Tier 2 clindamycin phosphate inj 300 mg/2ml Tier 2 clindamycin phosphate inj 600 mg/4ml Tier 2 clindamycin phosphate inj 900 mg/6ml Tier 2 clindamycin phosphate iv soln 300 mg/2ml Tier 2 clindamycin phosphate iv soln 900 mg/6ml Tier 2 dapsone tab 25 mg Tier 2 dapsone tab 100 mg Tier 2 daptomycin for iv soln 500 mg Tier 2 DARAPRIM TAB 25MG Tier 4 12

27 doripenem for iv infusion 250 mg Tier 2 doripenem for iv infusion 500 mg Tier 2 EMVERM CHW 100MG Tier 4 QL (12 tabs / 365 days) ertapenem sodium for inj 1 gm (base Tier 2 equivalent) imipenem-cilastatin intravenous for soln Tier mg imipenem-cilastatin intravenous for soln Tier mg INVANZ INJ 1GM Tier 4 ivermectin tab 3 mg Tier 2 linezolid for susp 100 mg/5ml Tier 2 linezolid in sodium chloride iv soln 600 mg/300ml-0.9% Tier 2 linezolid iv soln 600 mg/300ml (2 mg/ml) Tier 2 linezolid tab 600 mg Tier 2 meropenem iv for soln 1 gm Tier 2 meropenem iv for soln 500 mg Tier 2 methenamine hippurate tab 1 gm Tier 2 metronidazole cap 375 mg Tier 2 metronidazole in nacl 0.79% iv soln 500 Tier 2 mg/100ml metronidazole tab 250 mg Tier 2 metronidazole tab 500 mg Tier 2 NEBUPENT INH 300MG Tier 4 nitrofurantoin macrocrystalline cap 25 mg Tier 2 ; High Risk Medications require for members age 70 and older nitrofurantoin macrocrystalline cap 50 mg Tier 2 ; High Risk Medications require for members age 70 and older nitrofurantoin macrocrystalline cap 100 mg Tier 2 ; High Risk Medications require for members age 70 and older nitrofurantoin monohydrate macrocrystalline cap 100 mg Tier 2 ; High Risk Medications require for members age 70 and older nitrofurantoin susp 25 mg/5ml Tier 2 ; High Risk Medications require for members age 70 and older PENTAM 300 INJ 300MG Tier 4 polymyxin b sulfate for inj unit Tier 2 13

28 praziquantel tab 600 mg Tier 2 QL (24 tabs / 365 days) PRIMSOL SOL 50MG/5ML Tier 3 SIVEXTRO INJ 200MG Tier 4 SIVEXTRO TAB 200MG Tier 4 sulfamethoxazole-trimethoprim iv soln Tier mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml Tier 2 sulfamethoxazole-trimethoprim tab Tier 2 mg sulfamethoxazole-trimethoprim tab 800- Tier mg trimethoprim tab 100 mg Tier 2 vancomycin hcl cap 125 mg (base Tier 2 QL (80 caps / 10 days) equivalent) vancomycin hcl cap 250 mg (base Tier 2 QL (80 caps / 10 days) equivalent) vancomycin hcl for iv soln 1 gm (base Tier 2 equivalent) vancomycin hcl for iv soln 5 gm (base Tier 2 equivalent) vancomycin hcl for iv soln 10 gm (base Tier 2 equivalent) vancomycin hcl for iv soln 500 mg (base Tier 2 equivalent) vancomycin hcl for iv soln 750 mg (base Tier 2 equivalent) XIFAXAN TAB 200MG Tier 3 XIFAXAN TAB 550MG Tier 3 ANTIFUNGALS amphotericin b for inj 50 mg Tier 2 BIO-STATIN CAP Tier 3 BIO-STATIN CAP Tier 3 bio-statin pow Tier 2 CRESEMBA CAP 186 MG Tier 4 fluconazole for susp 10 mg/ml Tier 2 fluconazole for susp 40 mg/ml Tier 2 fluconazole in dextrose inj 200 mg/100ml Tier 2 fluconazole in dextrose inj 400 mg/200ml Tier 2 fluconazole in nacl 0.9% inj 200 mg/100ml Tier 2 fluconazole in nacl 0.9% inj 400 mg/200ml Tier 2 fluconazole tab 50 mg Tier 2 fluconazole tab 100 mg Tier 2 fluconazole tab 150 mg Tier 2 fluconazole tab 200 mg Tier 2 FLUCONAZOLE/ INJ NACL 100 Tier 4 griseofulvin microsize susp 125 mg/5ml Tier 2 14

29 griseofulvin microsize tab 500 mg Tier 2 griseofulvin ultramicrosize tab 125 mg Tier 2 griseofulvin ultramicrosize tab 250 mg Tier 2 itraconazole cap 100 mg Tier 2 itraconazole oral soln 10 mg/ml Tier 2 NOXAFIL SUS 40MG/ML Tier 3 NOXAFIL TAB 100MG Tier 3 nystatin tab unit Tier 2 SPORANOX SOL 10MG/ML Tier 3 terbinafine hcl tab 250 mg Tier 2 voriconazole for susp 40 mg/ml Tier 4 voriconazole tab 50 mg Tier 4 voriconazole tab 200 mg Tier 4 ANTIMALARIALS atovaquone-proguanil hcl tab mg Tier 2 atovaquone-proguanil hcl tab mg Tier 2 chloroquine phosphate tab 250 mg Tier 2 chloroquine phosphate tab 500 mg Tier 2 COARTEM TAB MG Tier 4 mefloquine hcl tab 250 mg Tier 2 PRIMAQUINE TAB 26.3MG Tier 4 quinine sulfate cap 324 mg Tier 2 ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 mg/ml (base Tier 2 QL (900 ml / 30 days) equiv) abacavir sulfate tab 300 mg (base equiv) Tier 2 QL (60 tabs / 30 days) APTIVUS CAP 250MG Tier 3 QL (120 caps / 30 days) APTIVUS SOL Tier 3 QL (285 ml / 28 days) atazanavir sulfate cap 150 mg (base equiv) Tier 2 QL (30 caps / 30 days) atazanavir sulfate cap 200 mg (base equiv) Tier 2 QL (60 caps / 30 days) atazanavir sulfate cap 300 mg (base equiv) Tier 2 QL (30 caps / 30 days) CRIXIVAN CAP 200MG Tier 3 QL (450 caps / 30 days) CRIXIVAN CAP 400MG Tier 3 QL (180 caps / 30 days) didanosine delayed release capsule 200 mg Tier 2 QL (30 caps / 30 days) didanosine delayed release capsule 250 mg Tier 2 QL (30 caps / 30 days) didanosine delayed release capsule 400 mg Tier 2 QL (30 caps / 30 days) EDURANT TAB 25MG Tier 3 QL (60 tabs / 30 days) efavirenz cap 50 mg Tier 2 QL (90 caps / 30 days) efavirenz cap 200 mg Tier 2 QL (90 caps / 30 days) efavirenz tab 600 mg Tier 2 QL (30 tabs / 30 days) EMTRIVA CAP 200MG Tier 3 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML Tier 3 QL (680 ml / 28 days) fosamprenavir calcium tab 700 mg (base Tier 2 QL (120 tabs / 30 days) equiv) FUZEON INJ 90MG Tier 5 QL (60 vials / 30 days) 15

30 INTELENCE TAB 25MG Tier 3 QL (120 tabs / 30 days) INTELENCE TAB 100MG Tier 3 QL (120 tabs / 30 days) INTELENCE TAB 200MG Tier 3 QL (60 tabs / 30 days) INVIRASE CAP 200MG Tier 3 QL (300 caps / 30 days) INVIRASE TAB 500MG Tier 3 QL (120 tabs / 30 days) ISENTRESS CHW 25MG Tier 3 QL (180 tabs / 30 days) ISENTRESS CHW 100MG Tier 3 QL (180 tabs / 30 days) ISENTRESS HD TAB 600MG Tier 3 QL (60 tabs / 30 days) ISENTRESS POW 100MG Tier 3 QL (60 packets / 30 days) ISENTRESS TAB 400MG Tier 3 QL (120 tabs / 30 days) lamivudine oral soln 10 mg/ml Tier 2 QL (900 ml / 30 days) lamivudine tab 150 mg Tier 2 QL (60 tabs / 30 days) lamivudine tab 300 mg Tier 2 QL (30 tabs / 30 days) LEXIVA SUS 50MG/ML Tier 3 QL (1575 ml / 28 days) nevirapine susp 50 mg/5ml Tier 2 QL (1200 ml / 30 days) nevirapine tab 200 mg Tier 2 QL (60 tabs / 30 days) nevirapine tab er 24hr 100 mg Tier 2 QL (90 tabs / 30 days) nevirapine tab er 24hr 400 mg Tier 2 QL (30 tabs / 30 days) NORVIR CAP 100MG Tier 3 QL (360 caps / 30 days) NORVIR POW 100MG Tier 3 QL (360 packets / 30 days) NORVIR SOL 80MG/ML Tier 3 QL (480 ml / 30 days) PREZISTA SUS 100MG/ML Tier 3 QL (400 ml / 30 days) PREZISTA TAB 75MG Tier 3 QL (300 tabs / 30 days) PREZISTA TAB 150MG Tier 3 QL (180 tabs / 30 days) PREZISTA TAB 600MG Tier 3 QL (60 tabs / 30 days) PREZISTA TAB 800MG Tier 3 QL (30 tabs / 30 days) RESCRIPTOR TAB 100 MG Tier 4 QL (900 tabs / 30 days) RESCRIPTOR TAB 200MG Tier 4 QL (450 tabs / 30 days) RETROVIR INJ 10MG/ML Tier 3 REYATAZ POW 50MG Tier 3 QL (180 packets / 30 days) ritonavir tab 100 mg Tier 2 QL (360 tabs / 30 days) SELZENTRY SOL 20MG/ML Tier 3 QL (1840 ml / 30 days) SELZENTRY TAB 25MG Tier 3 QL (240 tabs / 30 days) SELZENTRY TAB 75MG Tier 3 QL (60 tabs / 30 days) SELZENTRY TAB 150MG Tier 3 QL (60 tabs / 30 days) SELZENTRY TAB 300MG Tier 3 QL (120 tabs / 30 days) stavudine cap 15 mg Tier 2 QL (60 caps / 30 days) stavudine cap 20 mg Tier 2 QL (60 caps / 30 days) stavudine cap 30 mg Tier 2 QL (60 caps / 30 days) stavudine cap 40 mg Tier 2 QL (60 caps / 30 days) tenofovir disoproxil fumarate tab 300 mg Tier 2 QL (30 tabs / 30 days) TIVICAY TAB 10MG Tier 3 QL (60 tabs / 30 days) TIVICAY TAB 25MG Tier 3 QL (60 tabs / 30 days) 16

31 TIVICAY TAB 50MG Tier 3 QL (60 tabs / 30 days) TROGARZO INJ 150MG/ML Tier 5 TYBOST TAB 150MG Tier 3 QL (30 tabs / 30 days) VIDEX EC CAP 125MG Tier 3 QL (30 caps / 30 days) VIDEX SOL 2GM Tier 3 QL (1200 ml / 30 days) VIDEX SOL 4GM Tier 3 QL (1200 ml / 30 days) VIRACEPT TAB 250MG Tier 3 QL (300 tabs / 30 days) VIRACEPT TAB 625MG Tier 3 QL (120 tabs / 30 days) VIRAMUNE SUS 50MG/5ML Tier 3 QL (1200 ml / 30 days) VIREAD POW 40MG/GM Tier 3 QL (240 gm / 30 days) VIREAD TAB 150MG Tier 3 QL (30 tabs / 30 days) VIREAD TAB 200MG Tier 3 QL (30 tabs / 30 days) VIREAD TAB 250MG Tier 3 QL (30 tabs / 30 days) ZERIT SOL 1MG/ML Tier 3 QL (2400 ml / 30 days) zidovudine cap 100 mg Tier 2 QL (180 caps / 30 days) zidovudine syrup 10 mg/ml Tier 2 QL (1800 ml / 30 days) zidovudine tab 300 mg Tier 2 QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab mg Tier 2 QL (30 tabs / 30 days) abacavir sulfate-lamivudine-zidovudine tab Tier 2 QL (60 tabs / 30 days) mg BIKTARVY TAB Tier 3 QL (30 tabs / 30 days) CIMDUO TAB Tier 3 QL (30 tabs / 30 days) COMPLERA TAB Tier 3 QL (30 tabs / 30 days) DESCOVY TAB 200/25 Tier 3 QL (30 tabs / 30 days) EVOTAZ TAB Tier 3 QL (30 tabs / 30 days) GENVOYA TAB Tier 3 QL (30 tabs / 30 days) KALETRA TAB MG Tier 3 QL (240 tabs / 30 days) KALETRA TAB MG Tier 3 QL (120 tabs / 30 days) lamivudine-zidovudine tab mg Tier 2 QL (60 tabs / 30 days) lopinavir-ritonavir soln mg/5ml Tier 2 QL (390 ml / 30 days) (80-20 mg/ml) ODEFSEY TAB Tier 3 QL (30 tabs / 30 days) PREZCOBIX TAB Tier 3 QL (30 tabs / 30 days) STRIBILD TAB Tier 3 QL (30 tabs / 30 days) SYMFI LO TAB Tier 3 QL (30 tabs / 30 days) SYMFI TAB Tier 3 QL (30 tabs / 30 days) TRIUMEQ TAB Tier 3 QL (30 tabs / 30 days) TRUVADA TAB Tier 3 QL (30 tabs / 30 days) TRUVADA TAB Tier 3 QL (30 tabs / 30 days) TRUVADA TAB Tier 3 QL (30 tabs / 30 days) TRUVADA TAB Tier 3 QL (30 tabs / 30 days), ST; **; (coverage for pre and post-exposure prophylaxis only) 17

32 ANTITUBERCULAR AGENTS cycloserine cap 250 mg Tier 2 ethambutol hcl tab 100 mg Tier 2 ethambutol hcl tab 400 mg Tier 2 isoniazid inj 100 mg/ml Tier 2 isoniazid syrup 50 mg/5ml Tier 2 isoniazid tab 100 mg Tier 2 isoniazid tab 300 mg Tier 2 SER GRA 4GM Tier 4 PRIFTIN TAB 150MG Tier 3 pyrazinamide tab 500 mg Tier 2 rifabutin cap 150 mg Tier 2 RIFAMATE CAP Tier 3 rifampin cap 150 mg Tier 2 rifampin cap 300 mg Tier 2 rifampin for inj 600 mg Tier 2 RIFATER TAB Tier 3 SIRTURO TAB 100MG Tier 4 TRECATOR TAB 250MG Tier 3 ANTIVIRALS acyclovir cap 200 mg Tier 2 acyclovir sodium for inj 500 mg Tier 2 acyclovir sodium iv soln 50 mg/ml Tier 2 acyclovir susp 200 mg/5ml Tier 2 acyclovir tab 400 mg Tier 2 acyclovir tab 800 mg Tier 2 adefovir dipivoxil tab 10 mg Tier 5 BARACLUDE SOL.05MG/ML Tier 4 cidofovir iv inj 75 mg/ml Tier 2 entecavir tab 0.5 mg Tier 5 entecavir tab 1 mg Tier 5 EPIVIR HBV SOL 5MG/ML Tier 3 famciclovir tab 125 mg Tier 2 famciclovir tab 250 mg Tier 2 famciclovir tab 500 mg Tier 2 lamivudine tab 100 mg (hbv) Tier 2 oseltamivir phosphate cap 30 mg (base Tier 2 QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 mg (base Tier 2 QL (20 caps / 90 days) equiv) oseltamivir phosphate cap 75 mg (base Tier 2 QL (20 caps / 90 days) equiv) oseltamivir phosphate for susp 6 mg/ml Tier 2 QL (300 ml / 90 days) (base equiv) RELENZA MIS DISKHALE Tier 3 QL (2 inhalers / 90 days) 18

33 ribavirin for inhal soln 6 gm Tier 2 rimantadine hydrochloride tab 100 mg Tier 2 valacyclovir hcl tab 1 gm Tier 2 valacyclovir hcl tab 500 mg Tier 2 valganciclovir hcl for soln 50 mg/ml (base Tier 2 equiv) valganciclovir hcl tab 450 mg (base Tier 2 equivalent) VEMLIDY TAB 25MG Tier 4 CEPHALOSPORINS cefaclor cap 250 mg Tier 2 cefaclor cap 500 mg Tier 2 CEFACLOR ER TAB 500MG Tier 3 cefaclor for susp 125 mg/5ml Tier 2 cefaclor for susp 250 mg/5ml Tier 2 cefaclor for susp 375 mg/5ml Tier 2 cefadroxil cap 500 mg Tier 2 cefadroxil for susp 250 mg/5ml Tier 2 cefadroxil for susp 500 mg/5ml Tier 2 cefadroxil tab 1 gm Tier 2 cefazolin sodium for inj 1 gm Tier 2 cefazolin sodium for inj 10 gm Tier 2 cefazolin sodium for inj 20 gm Tier 2 cefazolin sodium for inj 500 mg Tier 2 cefazolin sodium for iv soln 1 gm Tier 2 cefdinir cap 300 mg Tier 2 cefdinir for susp 125 mg/5ml Tier 2 cefdinir for susp 250 mg/5ml Tier 2 cefditoren pivoxil tab 200 mg (base Tier 2 equivalent) cefditoren pivoxil tab 400 mg (base Tier 2 equivalent) cefepime hcl for inj 1 gm Tier 2 cefepime hcl for inj 2 gm Tier 2 cefixime for susp 100 mg/5ml Tier 2 cefixime for susp 200 mg/5ml Tier 2 cefotaxime sodium for inj 1 gm Tier 2 cefotaxime sodium for inj 2 gm Tier 2 cefotaxime sodium for inj 10 gm Tier 2 cefotaxime sodium for inj 500 mg Tier 2 cefotetan disodium for inj 1 gm Tier 2 cefotetan disodium for inj 2 gm Tier 2 cefotetan disodium for inj 10 gm Tier 2 cefoxitin sodium for inj 10 gm Tier 2 cefoxitin sodium for iv soln 1 gm Tier 2 cefoxitin sodium for iv soln 2 gm Tier 2 19