2018 SMALL GROUP DRUG FORMULARY For plans with effective start dates of January 1st through December 1st, 2018

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1 2018 SMALL GROUP DRUG FORMULARY For plans with effective start dates of January 1st through December 1st, 2018 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE PRESCRIPTION DRUGS WE COVER. Please refer to your Certificate of Coverage or other plan materials to determine if your drug is covered. This Drug Formulary does not guarantee coverage and is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs. For the most recent information or other questions, please contact Neighborhood Member Services at (TTY 711). This formulary is for members enrolled in Small Group health plans with plan start dates between January 1 st and December 31 st, This formulary will be effective until the small group plan renewal date occurring in 2019.

2 Neighborhood Health Plan 4T Exchange Formulary Effective: 1/1/2019 Last updated: 12/28/18 ALLERGENIC EXTRACTS/BIOLOGICALS MISC BIOLOGICALS MISC ADAGEN INJ 250/ML Tier 3 ALTERNATIVE MEDICINES ALTERNATIVE MEDICINE - M'S MELATONIN LIQ 1MG/4ML Tier 1 OTC melatonin sub 5mg Tier 1 OTC melatonin tab 1 mg Tier 1 OTC melatonin tab 3mg Tier 1 OTC melatonin tab 5 mg Tier 1 OTC melatonin tab 10mg cr Tier 1 OTC melatonin tab 300 mcg Tier 1 OTC ALTERNATIVE MEDICINE COMBINATIONS melatonin tr tab /vit-b6 Tier 1 OTC melatonin/ tab vit b-6 Tier 1 OTC ANALGESICS ANALGESIC COMBINATIONS EXCEDRIN TAB MIGRAINE Tier 1 OTC ANALGESICS OTHER acephen sup 325mg Tier 1 OTC acephen sup 650mg Tier 1 OTC acetamin jr tab 160mg rt Tier 1 OTC acetaminophen soln 160 mg/5ml Tier 1 OTC ed-apap liq 80mg/2.5 Tier 1 OTC FEVERALL INF SUP 80MG Tier 2 OTC mapap child tab 80mg rt Tier 1 OTC non-aspirin chw 80mg Tier 1 OTC pain/fever sup 120mg Tier 1 OTC tgt apap dro infants Tier 1 OTC TYLENOL 8 HR TAB 650MG Tier 1 OTC TYLENOL INFA SUS 160/5ML Tier 1 OTC TYLENOL SORE LIQ THROAT Tier 1 OTC TYLENOL TAB 325MG Tier 1 OTC TYLENOL TAB 500MG Tier 1 OTC COX-2 INHIBITORS celecoxib cap 50 mg Tier 1 QL (30 caps / 30 days) celecoxib cap 100 mg Tier 1 QL (30 caps / 30 days) celecoxib cap 200 mg Tier 1 QL (30 caps / 30 days) celecoxib cap 400 mg Tier 1 QL (30 caps / 30 days) 1

3 GOUT allopurinol tab 100 mg Tier 1 allopurinol tab 300 mg Tier 1 colchicine tab 0.6 mg Tier 1 ST colchicine w/ probenecid tab mg Tier 1 KRYSTEXXA INJ 8MG/ML Tier 4 PA probenecid tab 500 mg Tier 1 ULORIC TAB 40MG Tier 4 ST ULORIC TAB 80MG Tier 4 ST NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 50- Tier mg butalbital-acetaminophen-caffeine tab 50- Tier mg butalbital-aspirin-caffeine cap Tier 1 mg NSAIDS diclofenac potassium tab 50 mg Tier 1 ST diclofenac sodium tab delayed release 25 Tier 1 ST mg diclofenac sodium tab delayed release 50 Tier 1 mg diclofenac sodium tab delayed release 75 Tier 1 mg diclofenac sodium tab er 24hr 100 mg Tier 1 QL (30 tabs / 30 days) etodolac cap 200 mg Tier 1 etodolac cap 300 mg Tier 1 etodolac tab 400 mg Tier 1 etodolac tab 500 mg Tier 1 etodolac tab er 24hr 400 mg Tier 1 etodolac tab er 24hr 500 mg Tier 1 etodolac tab er 24hr 600 mg Tier 1 fenoprofen calcium tab 600 mg Tier 1 ST flurbiprofen tab 50 mg Tier 1 flurbiprofen tab 100 mg Tier 1 ibuprofen cap 200 mg Tier 1 OTC ibuprofen dro 50/1.25 Tier 1 OTC ibuprofen jr chw 100mg Tier 1 OTC ibuprofen susp 100 mg/5ml Tier 1 ibuprofen tab 200mg Tier 1 OTC ibuprofen tab 400 mg Tier 1 ibuprofen tab 600 mg Tier 1 ibuprofen tab 800 mg Tier 1 indomethacin cap 25 mg Tier 1 indomethacin cap 50 mg Tier 1 indomethacin cap er 75 mg Tier 1 2

4 ketorolac tromethamine inj 15 mg/ml Tier 1 PA, ST ketorolac tromethamine inj 30 mg/ml Tier 1 PA, ST ketorolac tromethamine tab 10 mg Tier 1 meclofenamate sodium cap 50 mg Tier 1 ST meclofenamate sodium cap 100 mg Tier 1 ST mefenamic acid cap 250 mg Tier 1 PA meloxicam susp 7.5 mg/5ml Tier 1 PA; AGE meloxicam tab 7.5 mg Tier 1 meloxicam tab 15 mg Tier 1 nabumetone tab 500 mg Tier 1 ST nabumetone tab 750 mg Tier 1 ST naproxen dr tab 375mg Tier 1 naproxen dr tab 500mg Tier 1 naproxen sod tab 220mg Tier 1 OTC naproxen sodium tab 275 mg Tier 1 naproxen sodium tab er 24hr 375 mg Tier 1 PA (base equiv) naproxen sodium tab er 24hr 500 mg Tier 1 PA, ST (base equiv) naproxen susp 125 mg/5ml Tier 1 AGE naproxen tab 250 mg Tier 1 naproxen tab 375 mg Tier 1 naproxen tab 500 mg Tier 1 oxaprozin tab 600 mg Tier 1 piroxicam cap 10 mg Tier 1 ST piroxicam cap 20 mg Tier 1 ST sm ibuprofen tab 100mg jr Tier 1 OTC sulindac tab 150 mg Tier 1 ST sulindac tab 200 mg Tier 1 ST tolmetin sodium cap 400 mg Tier 1 ST tolmetin sodium tab 200 mg Tier 1 ST tolmetin sodium tab 600 mg Tier 1 ST OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab 2- Tier 1 QL (90 tabs / 25 days) 0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 Tier 1 QL (90 tabs / 25 days) mg (base equiv) SUBOXONE MIS 2-0.5MG Tier 4 QL (90 units / 25 days), PA SUBOXONE MIS 4-1MG Tier 4 QL (90 units / 25 days), PA SUBOXONE MIS 8-2MG Tier 4 QL (90 units / 25 days), PA SUBOXONE MIS 12-3MG Tier 4 QL (60 units / 25 days), PA 3

5 OPIOID ANALGESICS acetaminophen w/ codeine soln mg/5ml Tier 1 QL (2700 ml / 25 days), PA acetaminophen w/ codeine tab mg Tier 1 QL (400 tabs / 25 days), PA; AGE acetaminophen w/ codeine tab mg Tier 1 QL (360 tabs / 25 days), PA; AGE acetaminophen w/ codeine tab mg Tier 1 QL (180 tabs / 25 days), PA; AGE butorphanol tartrate inj 1 mg/ml Tier 1 PA butorphanol tartrate inj 2 mg/ml Tier 1 PA butorphanol tartrate nasal soln 10 mg/ml Tier 1 QL (2 bottles / 25 days), PA codeine sulfate tab 15 mg Tier 1 QL (42 tabs / 25 days) codeine sulfate tab 30 mg Tier 1 QL (42 tabs / 25 days) codeine sulfate tab 60 mg Tier 1 QL (42 tabs / 25 days) duramorph inj 0.5mg/ml Tier 1 PA duramorph inj 1mg/ml Tier 1 PA endocet tab 5-325mg Tier 1 QL (360 tabs / 25 days) endocet tab Tier 1 QL (240 tabs / 25 days) endocet tab mg Tier 1 QL (180 tabs / 25 days), PA fentanyl citrate lozenge on a handle 400 mcg Tier 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 600 mcg Tier 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 800 mcg Tier 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 1200 mcg Tier 1 QL (120 lozenges / 25 days), PA fentanyl td patch 72hr 12 mcg/hr Tier 1 QL (10 patches / 25 days), PA fentanyl td patch 72hr 25 mcg/hr Tier 1 QL (10 patches / 25 days), PA fentanyl td patch 72hr 50 mcg/hr Tier 1 PA fentanyl td patch 72hr 75 mcg/hr Tier 1 PA fentanyl td patch 72hr 100 mcg/hr Tier 1 PA hydrocodone-acetaminophen soln Tier 1 QL (2700 ml / 25 days) mg/15ml hydrocodone-acetaminophen tab mg Tier 1 QL (240 tabs / 25 days) hydrocodone-acetaminophen tab Tier 1 QL (180 tabs / 25 days) mg hydrocodone-acetaminophen tab Tier 1 QL (180 tabs / 25 days) mg hydromorphone hcl liqd 1 mg/ml Tier 1 QL (600 ml / 25 days), PA 4

6 hydromorphone hcl preservative free (pf) Tier 1 PA inj 10 mg/ml hydromorphone hcl tab 2 mg Tier 1 QL (180 tabs / 25 days), PA hydromorphone hcl tab 4 mg Tier 1 QL (150 tabs / 25 days), PA hydromorphone hcl tab 8 mg Tier 1 QL (60 tabs / 25 days), PA hydromorphone hcl tab er 24hr deter 8 mg Tier 1 QL (30 tabs / 25 days), PA hydromorphone hcl tab er 24hr deter 12 mg Tier 1 QL (30 tabs / 25 days), PA hydromorphone hcl tab er 24hr deter 16 mg Tier 1 QL (30 tabs / 25 days), PA hydromorphone hcl tab er 24hr deter 32 Tier 1 PA mg KADIAN CAP 10MG ER Tier 4 QL (60 caps / 25 days), PA KADIAN CAP 200MG ER Tier 4 QL (60 caps / 30 days), PA levorphanol tartrate tab 2 mg Tier 1 QL (240 tabs / 30 days), PA meperidine hcl oral soln 50 mg/5ml Tier 1 QL (3600 ml / 30 days), PA meperidine hcl tab 50 mg Tier 1 QL (240 tabs / 30 days), PA, ST meperidine hcl tab 100 mg Tier 1 QL (240 tabs / 30 days), PA, ST methadone hcl conc 10 mg/ml Tier 1 QL (60 ml / 25 days), PA methadone hcl inj 10 mg/ml Tier 1 QL (20 ml / 25 days), PA methadone hcl soln 5 mg/5ml Tier 1 QL (450 ml / 25 days), PA methadone hcl soln 10 mg/5ml Tier 1 QL (300 ml / 25 days), PA methadone hcl tab 5 mg Tier 1 QL (90 tabs / 25 days), PA methadone hcl tab 10 mg Tier 1 QL (60 tabs / 25 days), PA morphine sulfate cap er 24hr 20 mg Tier 1 QL (60 caps / 25 days), PA morphine sulfate cap er 24hr 30 mg Tier 1 QL (60 caps / 25 days), PA morphine sulfate cap er 24hr 50 mg Tier 1 QL (30 caps / 25 days), PA morphine sulfate cap er 24hr 60 mg Tier 1 QL (30 caps / 25 days), PA 5

7 morphine sulfate cap er 24hr 80 mg Tier 1 QL (30 caps / 25 days), PA morphine sulfate cap er 24hr 100 mg Tier 1 PA morphine sulfate tab 15 mg Tier 1 QL (180 tabs / 25 days), PA morphine sulfate tab 30 mg Tier 1 QL (90 tabs / 25 days), PA morphine sulfate tab er 15 mg Tier 1 QL (90 tabs / 25 days), PA morphine sulfate tab er 30 mg Tier 1 QL (90 tabs / 25 days), PA morphine sulfate tab er 60 mg Tier 1 PA morphine sulfate tab er 100 mg Tier 1 PA morphine sulfate tab er 200 mg Tier 1 PA nalbuphine hcl inj 10 mg/ml Tier 1 PA nalbuphine hcl inj 20 mg/ml Tier 1 PA NUCYNTA ER TAB 50MG Tier 4 QL (60 tabs / 25 days), PA NUCYNTA ER TAB 100MG Tier 4 QL (60 tabs / 25 days), PA NUCYNTA ER TAB 150MG Tier 4 PA NUCYNTA ER TAB 200MG Tier 4 PA NUCYNTA ER TAB 250MG Tier 4 PA NUCYNTA TAB 50MG Tier 4 QL (120 tabs / 25 days), PA NUCYNTA TAB 75MG Tier 4 QL (90 tabs / 25 days), PA NUCYNTA TAB 100MG Tier 4 QL (60 tabs / 25 days), PA oxycodone hcl conc 100 mg/5ml (20 mg/ml) Tier 1 QL (90 ml / 25 days), PA oxycodone hcl soln 5 mg/5ml Tier 1 QL (900 ml / 25 days), PA oxycodone hcl tab 5 mg Tier 1 QL (180 tabs / 25 days) oxycodone hcl tab 10 mg Tier 1 QL (180 tabs / 25 days), PA oxycodone hcl tab 15 mg Tier 1 QL (120 tabs / 25 days), PA oxycodone hcl tab 20 mg Tier 1 QL (90 tabs / 25 days), PA oxycodone hcl tab 30 mg Tier 1 QL (60 tabs / 25 days), PA oxycodone hcl tab er 12hr deter 15 mg Tier 1 QL (60 tabs / 25 days), PA oxycodone hcl tab er 12hr deter 30 mg Tier 1 QL (60 tabs / 25 days), PA oxycodone hcl tab er 12hr deter 60 mg Tier 1 PA 6

8 oxycodone w/ acetaminophen tab Tier 1 QL (360 tabs / 25 days) mg oxycodone w/ acetaminophen tab mg Tier 1 QL (360 tabs / 25 days) oxycodone w/ acetaminophen tab Tier 1 QL (240 tabs / 25 days) mg oxycodone w/ acetaminophen tab mg Tier 1 QL (180 tabs / 25 days), PA oxycodone-aspirin tab mg Tier 1 QL (360 tabs / 25 days) oxycodone-ibuprofen tab mg Tier 1 QL (28 tabs / 25 days), PA oxymorphone hcl tab 5 mg Tier 1 QL (180 tabs / 25 days), PA oxymorphone hcl tab 10 mg Tier 1 QL (90 tabs / 25 days), PA oxymorphone hcl tab er 12hr 5 mg Tier 1 QL (60 tabs / 25 days), PA oxymorphone hcl tab er 12hr 7.5 mg Tier 1 QL (60 tabs / 25 days), PA oxymorphone hcl tab er 12hr 10 mg Tier 1 QL (60 tabs / 25 days), PA oxymorphone hcl tab er 12hr 15 mg Tier 1 QL (60 tabs / 25 days), PA oxymorphone hcl tab er 12hr 20 mg Tier 1 PA oxymorphone hcl tab er 12hr 30 mg Tier 1 PA oxymorphone hcl tab er 12hr 40 mg Tier 1 PA tramadol hcl tab 50 mg Tier 1 QL (180 tabs / 25 days), PA; AGE tramadol hcl tab er 24hr 100 mg Tier 1 QL (30 tabs / 25 days), PA tramadol hcl tab er 24hr 200 mg Tier 1 PA tramadol hcl tab er 24hr 300 mg Tier 1 PA tramadol hcl tab er 24hr biphasic release Tier 1 PA 100 mg tramadol hcl tab er 24hr biphasic release Tier 1 PA 200 mg tramadol hcl tab er 24hr biphasic release Tier 1 PA 300 mg OPIOID COMBINATIONS ascomp/cod cap 30mg Tier 1 butalbital-acetaminophen-caff w/ cod cap Tier mg hydrocodone-ibuprofen tab mg Tier 1 tramadol-acetaminophen tab mg Tier 1 PA; AGE OPIOID PARTIAL AGONISTS buprenorphine td patch weekly 5 mcg/hr Tier 1 QL (4 patches / 28 days), PA 7

9 buprenorphine td patch weekly 7.5 mcg/hr Tier 1 PA buprenorphine td patch weekly 10 mcg/hr Tier 1 QL (4 patches / 28 days), PA buprenorphine td patch weekly 15 mcg/hr Tier 1 QL (4 patches / 28 days), PA buprenorphine td patch weekly 20 mcg/hr Tier 1 QL (4 patches / 28 days), PA pentazocine w/ naloxone tab mg Tier 1 PA OPIOID PARTIAL AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) Tier 1 QL (90 tabs / 25 days), PA buprenorphine hcl sl tab 8 mg (base equiv) Tier 1 QL (90 tabs / 25 days), PA SALICYLATES ALKA-SELTZER TAB 325MG Tier 1 OTC ALKA-SELTZER TAB 500MG Tier 1 OTC aspirin chw 81mg Tier 0 OTC aspirin tab 81mg ec Tier 0 OTC aspirin tab 325mg Tier 0 OTC aspirin tab 500mg Tier 1 OTC bayer asa tab 325mg Tier 0 OTC BAYER PLUS TAB 500MG Tier 1 OTC buffered asa tab 325mg Tier 1 OTC diflunisal tab 500 mg Tier 1 ST ECOTRIN M/S TAB 500MG EC Tier 1 OTC ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ TAB 5MG Tier 4 QL (60 tabs / 30 days), PA XELJANZ TAB 10MG Tier 4 QL (60 tabs / 30 days), PA XELJANZ XR TAB 11MG Tier 4 QL (30 tabs / 30 days), PA INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA) KINERET INJ Tier 4 PA, ST INTERLEUKIN-6 RECEPTOR INHIBITORS KEVZARA INJ 150/1.14 Tier 4 QL (2 syringes / 28 days), PA KEVZARA INJ 200/1.14 Tier 4 QL (2 syringes / 28 days), PA SELECTIVE COSTIMULATION MODULATORS ORENCIA CLCK INJ 125MG/ML Tier 4 PA ORENCIA INJ 50/0.4 Tier 4 PA ORENCIA INJ 87.5/0.7 Tier 4 PA ORENCIA INJ 125MG/ML Tier 4 PA ORENCIA INJ 250MG Tier 4 PA 8

10 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl local preservative free (pf) inj Tier 1 1% XYLOCAINE INJ 1% Tier 3 PA ANORECTAL AGENTS INTRARECTAL STEROIDS UCERIS AER 2MG/ACT Tier 4 PA RECTAL COMBINATIONS hemorrhoidal cre Tier 1 OTC hemorrhoidal gel % Tier 1 OTC hemorrhoidal sup Tier 1 OTC RECTAL STEROIDS hydrocortisone acetate suppos 25 mg Tier 1 QL (12 supp / 1 day) ANTACIDS ANTACID COMBINATIONS antacid plus sus gas rel Tier 1 OTC maalox advan sus max st Tier 1 OTC ANTACIDS - ALUMINUM SALTS ALUM HYDROX SUS 320/5ML Tier 1 OTC ANTACIDS - BICARBONATE sodium bicarbonate tab 650 mg Tier 1 OTC ANTACIDS - CALCIUM SALTS cal antacid chw 1000mg Tier 1 OTC calc antacid chw 500mg Tier 1 OTC calc antacid chw 750mg Tier 1 OTC CALCIUM CARB TAB 648MG Tier 1 OTC calcium carbonate (antacid) susp 1250 Tier 1 OTC mg/5ml ANTACIDS - MAGNESIUM SALTS magnesium oxide tab 250 mg Tier 1 OTC ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 mg/ml) Tier 1 chloramphenicol sodium succinate for iv inj Tier 4 PA, ST 1 gm MONUROL PAK GRANULES Tier 4 PA, ST neomycin sulfate tab 500 mg Tier 1 paromomycin sulfate cap 250 mg Tier 1 streptomycin sulfate for inj 1 gm Tier 1 SULFADIAZINE TAB 500MG Tier 1 tobramycin nebu soln 300 mg/5ml Tier 3 PA tobramycin sulfate inj 10 mg/ml (base equivalent) Tier 1 9

11 tobramycin sulfate inj 80 mg/2ml (40 Tier 1 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG Tier 4 PA ALINIA SUS 100/5ML Tier 3 ALINIA TAB 500MG Tier 3 atovaquone susp 750 mg/5ml Tier 1 PA, ST AZACTAM INJ 2GM Tier 2 bacitracin intramuscular for soln Tier 1 unit BILTRICIDE TAB 600MG Tier 4 PA, ST clindamycin hcl cap 150 mg Tier 1 clindamycin hcl cap 300 mg Tier 1 colistimethate sod for inj 150 mg (colistin Tier 1 base activity) CUBICIN SOL 500MG Tier 4 PA, ST dapsone tab 25 mg Tier 1 dapsone tab 100 mg Tier 1 DORIBAX INJ 500MG Tier 4 PA imipenem-cilastatin intravenous for soln Tier 3 PA 250 mg imipenem-cilastatin intravenous for soln Tier 3 PA 500 mg INVANZ INJ 1GM Tier 3 PA ivermectin tab 3 mg Tier 1 LINCOCIN INJ 300MG/ML Tier 4 PA, ST lincomycin hcl inj 300 mg/ml Tier 1 PA linezolid for susp 100 mg/5ml Tier 1 PA linezolid iv soln 600 mg/300ml (2 mg/ml) Tier 1 PA linezolid tab 600 mg Tier 1 PA meropenem iv for soln 500 mg Tier 1 methenamine hippurate tab 1 gm Tier 1 metronidazole cap 375 mg Tier 1 PA, ST metronidazole in nacl 0.79% iv soln 500 Tier 1 mg/100ml metronidazole tab 250 mg Tier 1 metronidazole tab 500 mg Tier 1 NEBUPENT INH 300MG Tier 3 PA nitrofurantoin macrocrystalline cap 50 mg Tier 1 nitrofurantoin monohydrate Tier 1 macrocrystalline cap 100 mg PENTAM 300 INJ 300MG Tier 3 PA, ST PIN-X CHW 250MG Tier 2 OTC pin-x sus 50mg/ml Tier 1 OTC pinworm med sus 144mg/ml Tier 1 OTC polymyxin b sulfate for inj unit Tier 1 10

12 reeses med sus pinworm Tier 1 OTC SIVEXTRO INJ 200MG Tier 3 PA SIVEXTRO TAB 200MG Tier 3 PA sulfamethoxazole-trimethoprim iv soln Tier mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml Tier 1 sulfamethoxazole-trimethoprim tab Tier 1 mg sulfamethoxazole-trimethoprim tab 800- Tier mg trimethoprim tab 100 mg Tier 1 TYGACIL INJ 50MG Tier 3 PA vancomycin hcl cap 125 mg (base Tier 1 PA equivalent) vancomycin hcl cap 250 mg (base Tier 1 PA equivalent) vancomycin hcl for iv soln 1 gm (base Tier 1 equivalent) vancomycin hcl for iv soln 10 gm (base Tier 1 equivalent) vancomycin hcl for iv soln 500 mg (base Tier 1 equivalent) VIBATIV INJ 750MG Tier 3 PA XIFAXAN TAB 200MG Tier 4 PA XIFAXAN TAB 550MG Tier 4 PA ZYVOX SOL 2MG/ML Tier 1 PA ANTIFUNGALS ABELCET INJ 5MG/ML Tier 2 AMBISOME INJ 50MG Tier 2 amphotericin b for inj 50 mg Tier 1 CANCIDAS INJ 50MG Tier 3 PA CANCIDAS INJ 70MG Tier 3 PA ERAXIS INJ 100MG Tier 3 PA fluconazole for susp 10 mg/ml Tier 1 fluconazole for susp 40 mg/ml Tier 1 fluconazole tab 50 mg Tier 1 fluconazole tab 100 mg Tier 1 fluconazole tab 150 mg Tier 1 fluconazole tab 200 mg Tier 1 flucytosine cap 250 mg Tier 1 flucytosine cap 500 mg Tier 1 griseofulvin microsize susp 125 mg/5ml Tier 1 itraconazole cap 100 mg Tier 1 PA ketoconazole tab 200 mg Tier 1 MYCAMINE INJ 50MG Tier 3 PA, ST 11

13 MYCAMINE INJ 100MG Tier 3 PA, ST NOXAFIL SUS 40MG/ML Tier 4 PA, ST nystatin tab unit Tier 1 terbinafine hcl tab 250 mg Tier 1 voriconazole for inj 200 mg Tier 1 voriconazole tab 50 mg Tier 1 voriconazole tab 200 mg Tier 1 ANTIMALARIALS atovaquone-proguanil hcl tab mg Tier 1 PA, ST chloroquine phosphate tab 250 mg Tier 1 chloroquine phosphate tab 500 mg Tier 1 COARTEM TAB MG Tier 4 PA, ST DARAPRIM TAB 25MG Tier 3 mefloquine hcl tab 250 mg Tier 1 PRIMAQUINE TAB 26.3MG Tier 1 PA, ST quinine sulfate cap 324 mg Tier 1 PA, ST ANTIRETROVIRAL AGENTS abacavir sulfate tab 300 mg (base equiv) Tier 1 APTIVUS CAP 250MG Tier 2 APTIVUS SOL Tier 2 CRIXIVAN CAP 200MG Tier 2 CRIXIVAN CAP 400MG Tier 2 didanosine delayed release capsule 125 mg Tier 1 didanosine delayed release capsule 200 mg Tier 1 didanosine delayed release capsule 250 mg Tier 1 didanosine delayed release capsule 400 mg Tier 1 EDURANT TAB 25MG Tier 2 efavirenz cap 50 mg Tier 1 efavirenz cap 200 mg Tier 1 efavirenz tab 600 mg Tier 1 EMTRIVA CAP 200MG Tier 2 EMTRIVA SOL 10MG/ML Tier 2 FUZEON INJ 90MG Tier 3 INTELENCE TAB 25MG Tier 2 INTELENCE TAB 100MG Tier 2 INTELENCE TAB 200MG Tier 2 INVIRASE CAP 200MG Tier 2 INVIRASE TAB 500MG Tier 2 ISENTRESS CHW 25MG Tier 2 ISENTRESS CHW 100MG Tier 2 ISENTRESS TAB 400MG Tier 2 JULUCA TAB 50-25MG Tier 2 lamivudine oral soln 10 mg/ml Tier 1 lamivudine tab 150 mg Tier 1 lamivudine tab 300 mg Tier 1 12

14 LEXIVA SUS 50MG/ML Tier 2 LEXIVA TAB 700MG Tier 2 nevirapine susp 50 mg/5ml Tier 1 nevirapine tab 200 mg Tier 1 nevirapine tab er 24hr 100 mg Tier 1 nevirapine tab er 24hr 400 mg Tier 1 NORVIR CAP 100MG Tier 2 NORVIR SOL 80MG/ML Tier 2 NORVIR TAB 100MG Tier 2 PREZISTA SUS 100MG/ML Tier 2 PREZISTA TAB 75MG Tier 2 PREZISTA TAB 150MG Tier 2 PREZISTA TAB 600MG Tier 2 PREZISTA TAB 800MG Tier 2 RESCRIPTOR TAB 100 MG Tier 2 RESCRIPTOR TAB 200MG Tier 2 REYATAZ CAP 150MG Tier 2 REYATAZ CAP 200MG Tier 2 REYATAZ CAP 300MG Tier 2 SELZENTRY TAB 25MG Tier 2 SELZENTRY TAB 75MG Tier 2 SELZENTRY TAB 150MG Tier 2 SELZENTRY TAB 300MG Tier 2 stavudine cap 15 mg Tier 1 stavudine cap 20 mg Tier 1 stavudine cap 30 mg Tier 1 stavudine cap 40 mg Tier 1 stavudine for oral soln 1 mg/ml Tier 1 SUSTIVA CAP 50MG Tier 2 SUSTIVA CAP 200MG Tier 2 SUSTIVA TAB 600MG Tier 2 TYBOST TAB 150MG Tier 2 VIDEX SOL 2GM Tier 2 VIDEX SOL 4GM Tier 2 VIRACEPT TAB 250MG Tier 2 VIRACEPT TAB 625MG Tier 2 VIREAD POW 40MG/GM Tier 2 VIREAD TAB 150MG Tier 2 VIREAD TAB 200MG Tier 2 VIREAD TAB 250MG Tier 2 VIREAD TAB 300MG Tier 2 ZERIT CAP 15MG Tier 4 PA, ST ZERIT CAP 20MG Tier 4 PA, ST ZERIT CAP 30MG Tier 4 PA, ST ZERIT CAP 40MG Tier 4 PA, ST ZERIT SOL 1MG/ML Tier 4 PA, ST 13

15 ZIAGEN SOL 20MG/ML Tier 2 ZIAGEN TAB 300MG Tier 4 PA zidovudine cap 100 mg Tier 1 zidovudine syrup 10 mg/ml Tier 1 zidovudine tab 300 mg Tier 1 ANTIRETROVIRAL COMBINATION AGENTS ATRIPLA TAB Tier 2 BIKTARVY TAB Tier 2 COMPLERA TAB Tier 2 EPZICOM TAB Tier 2 EVOTAZ TAB Tier 2 GENVOYA TAB Tier 2 KALETRA SOL Tier 2 KALETRA TAB MG Tier 2 KALETRA TAB MG Tier 2 lamivudine-zidovudine tab mg Tier 1 ODEFSEY TAB Tier 2 PREZCOBIX TAB Tier 2 STRIBILD TAB Tier 2 TRIUMEQ TAB Tier 2 TRIZIVIR TAB Tier 2 TRUVADA TAB Tier 2 TRUVADA TAB Tier 2 TRUVADA TAB Tier 2 TRUVADA TAB Tier 2 ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM Tier 2 ethambutol hcl tab 100 mg Tier 1 ethambutol hcl tab 400 mg Tier 1 isoniazid inj 100 mg/ml Tier 1 isoniazid tab 100 mg Tier 1 isoniazid tab 300 mg Tier 1 MYCOBUTIN CAP 150MG Tier 2 PASER GRA 4GM Tier 2 pyrazinamide tab 500 mg Tier 1 PA, ST rifabutin cap 150 mg Tier 1 rifampin cap 150 mg Tier 1 rifampin cap 300 mg Tier 1 rifampin for inj 600 mg Tier 1 RIFATER TAB Tier 4 PA, ST TRECATOR TAB 250MG Tier 2 ANTIVIRALS acyclovir cap 200 mg Tier 1 acyclovir sodium for inj 500 mg Tier 1 acyclovir susp 200 mg/5ml Tier 1 14

16 acyclovir tab 400 mg Tier 1 acyclovir tab 800 mg Tier 1 adefovir dipivoxil tab 10 mg Tier 3 BARACLUDE SOL.05MG/ML Tier 2 BARACLUDE TAB 0.5MG Tier 2 PA BARACLUDE TAB 1MG Tier 2 PA cidofovir iv inj 75 mg/ml Tier 1 entecavir tab 0.5 mg Tier 3 entecavir tab 1 mg Tier 3 EPIVIR HBV SOL 5MG/ML Tier 2 famciclovir tab 125 mg Tier 1 famciclovir tab 250 mg Tier 1 famciclovir tab 500 mg Tier 1 lamivudine tab 100 mg (hbv) Tier 1 oseltamivir phosphate cap 30 mg (base Tier 1 equiv) oseltamivir phosphate cap 45 mg (base Tier 1 equiv) oseltamivir phosphate cap 75 mg (base Tier 1 equiv) oseltamivir phosphate for susp 6 mg/ml Tier 1 (base equiv) RELENZA MIS DISKHALE Tier 2 QL (3 inhalers / 180 days) rimantadine hydrochloride tab 100 mg Tier 1 valacyclovir hcl tab 1 gm Tier 1 valacyclovir hcl tab 500 mg Tier 1 valganciclovir hcl for soln 50 mg/ml (base Tier 3 AGE equiv) valganciclovir hcl tab 450 mg (base Tier 3 equivalent) CEPHALOSPORINS cefaclor cap 250 mg Tier 1 cefaclor cap 500 mg Tier 1 cefadroxil cap 500 mg Tier 1 cefadroxil for susp 250 mg/5ml Tier 1 cefadroxil for susp 500 mg/5ml Tier 1 cefadroxil tab 1 gm Tier 1 cefazolin sodium for inj 1 gm Tier 1 cefdinir cap 300 mg Tier 1 cefdinir for susp 125 mg/5ml Tier 1 cefdinir for susp 250 mg/5ml Tier 1 cefditoren pivoxil tab 200 mg (base Tier 4 PA, ST equivalent) cefditoren pivoxil tab 400 mg (base equivalent) Tier 4 PA, ST 15

17 cefepime hcl for inj 1 gm Tier 1 cefepime hcl for inj 2 gm Tier 1 cefixime for susp 100 mg/5ml Tier 1 PA cefixime for susp 200 mg/5ml Tier 1 PA cefotaxime sodium for inj 1 gm Tier 1 cefotaxime sodium for inj 2 gm Tier 1 cefotaxime sodium for inj 10 gm Tier 1 cefotaxime sodium for inj 500 mg Tier 1 CEFOTET/DEX INJ % Tier 4 PA, ST CEFOTET/DEX INJ % Tier 4 PA, ST cefoxitin sodium for inj 10 gm Tier 1 cefoxitin sodium for iv soln 1 gm Tier 1 cefpodoxime proxetil for susp 50 mg/5ml Tier 1 cefpodoxime proxetil for susp 100 mg/5ml Tier 1 cefpodoxime proxetil tab 100 mg Tier 1 cefpodoxime proxetil tab 200 mg Tier 1 cefprozil for susp 125 mg/5ml Tier 1 cefprozil for susp 250 mg/5ml Tier 1 cefprozil tab 250 mg Tier 1 cefprozil tab 500 mg Tier 1 ceftazidime for inj 1 gm Tier 1 ceftazidime for inj 2 gm Tier 1 ceftazidime for inj 6 gm Tier 1 CEFTIN SUS 250/5ML Tier 2 ceftriaxone sodium for inj 1 gm Tier 1 ceftriaxone sodium for inj 2 gm Tier 1 ceftriaxone sodium for inj 10 gm Tier 1 ceftriaxone sodium for inj 250 mg Tier 1 ceftriaxone sodium for inj 500 mg Tier 1 cefuroxime axetil tab 250 mg Tier 1 cefuroxime axetil tab 500 mg Tier 1 cephalexin cap 250 mg Tier 1 cephalexin cap 500 mg Tier 1 cephalexin for susp 125 mg/5ml Tier 1 cephalexin for susp 250 mg/5ml Tier 1 cephalexin tab 250 mg Tier 1 PA, ST cephalexin tab 500 mg Tier 1 PA, ST TEFLARO INJ 400MG Tier 3 PA, ST TEFLARO INJ 600MG Tier 3 PA, ST ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml Tier 1 azithromycin for susp 200 mg/5ml Tier 1 azithromycin iv for soln 500 mg Tier 1 azithromycin tab 250 mg Tier 1 azithromycin tab 500 mg Tier 1 16

18 azithromycin tab 600 mg Tier 1 clarithromycin for susp 125 mg/5ml Tier 1 clarithromycin for susp 250 mg/5ml Tier 1 clarithromycin tab 250 mg Tier 1 clarithromycin tab 500 mg Tier 1 clarithromycin tab er 24hr 500 mg Tier 1 PA, ST erythromycin ethylsuccinate tab 400 mg Tier 4 erythromycin tab 250 mg Tier 1 erythromycin tab 500 mg Tier 1 FLUOROQUINOLONES AVELOX INJ Tier 4 PA, ST ciprofloxacin hcl tab 100 mg (base equiv) Tier 1 ciprofloxacin hcl tab 250 mg (base equiv) Tier 1 ciprofloxacin hcl tab 500 mg (base equiv) Tier 1 ciprofloxacin hcl tab 750 mg (base equiv) Tier 1 ciprofloxacin iv soln 400 mg/40ml (1%) Tier 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr Tier 1 PA, ST 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr Tier 1 PA, ST 1000 mg(base eq) FACTIVE TAB 320MG Tier 4 PA, ST levofloxacin oral soln 25 mg/ml Tier 1 levofloxacin tab 250 mg Tier 1 levofloxacin tab 500 mg Tier 1 levofloxacin tab 750 mg Tier 1 PA, ST moxifloxacin hcl tab 400 mg (base equiv) Tier 1 ofloxacin tab 400 mg Tier 1 HEPATITIS C DAKLINZA TAB 30MG Tier 4 PA DAKLINZA TAB 60MG Tier 4 PA DAKLINZA TAB 90MG Tier 4 PA EPCLUSA TAB Tier 3 PA HARVONI TAB MG Tier 4 PA MAVYRET TAB MG Tier 3 PA OLYSIO CAP 150MG Tier 4 PA PEGASYS INJ 180MCG/M Tier 3 PA PEGASYS INJ PROCLICK Tier 3 PA ribasphere cap 200mg Tier 1 PA ribasphere tab 200mg Tier 1 ribasphere tab 400mg Tier 1 PA ribasphere tab 600mg Tier 1 PA ribavirin cap 200 mg Tier 1 PA ribavirin tab 200 mg Tier 1 SOVALDI TAB 400MG Tier 4 PA VOSEVI TAB Tier 3 PA 17

19 ZEPATIER TAB MG Tier 4 PA PENICILLINS amoxicillin & k clavulanate chew tab 200- Tier mg amoxicillin & k clavulanate chew tab 400- Tier 1 57 mg amoxicillin & k clavulanate for susp 200- Tier mg/5ml amoxicillin & k clavulanate for susp mg/5ml Tier 1 amoxicillin & k clavulanate for susp Tier 1 mg/5ml amoxicillin & k clavulanate for susp mg/5ml Tier 1 PA, ST amoxicillin & k clavulanate tab mg Tier 1 amoxicillin & k clavulanate tab mg Tier 1 amoxicillin & k clavulanate tab mg Tier 1 amoxicillin & k clavulanate tab er 12hr Tier mg amoxicillin (trihydrate) cap 250 mg Tier 1 amoxicillin (trihydrate) cap 500 mg Tier 1 amoxicillin (trihydrate) chew tab 125 mg Tier 1 amoxicillin (trihydrate) chew tab 250 mg Tier 1 amoxicillin (trihydrate) for susp 125 Tier 1 mg/5ml amoxicillin (trihydrate) for susp 200 Tier 1 mg/5ml amoxicillin (trihydrate) for susp 250 Tier 1 mg/5ml amoxicillin (trihydrate) for susp 400 Tier 1 mg/5ml amoxicillin (trihydrate) tab 500 mg Tier 1 amoxicillin (trihydrate) tab 875 mg Tier 1 ampicillin & sulbactam sodium for inj 3 (2- Tier 1 1) gm ampicillin & sulbactam sodium for iv soln Tier 1 15 (10-5) gm ampicillin cap 250 mg Tier 1 ampicillin cap 500 mg Tier 1 ampicillin sodium for inj 1 gm Tier 1 ampicillin sodium for inj 125 mg Tier 1 ampicillin sodium for iv soln 10 gm Tier 1 BICILLIN C-R INJ 900/300 Tier 4 PA BICILLIN C-R INJ Tier 4 PA BICILLIN L-A INJ Tier 4 PA BICILLIN L-A INJ Tier 4 PA BICILLIN L-A INJ Tier 4 PA 18

20 dicloxacillin sodium cap 250 mg Tier 1 dicloxacillin sodium cap 500 mg Tier 1 nafcillin sodium for inj 1 gm Tier 1 oxacillin sodium for inj 1 gm (base Tier 1 PA, ST equivalent) oxacillin sodium for inj 2 gm (base Tier 1 PA, ST equivalent) oxacillin sodium for inj 10 gm (base Tier 1 PA, ST equivalent) PEN G PROC INJ Tier 1 PENICILL GK/ INJ DEX 1MU Tier 1 PENICILL GK/ INJ DEX 2MU Tier 1 PENICILL GK/ INJ DEX 3MU Tier 1 penicillin g potassium for inj unit Tier 1 penicillin g potassium for inj unit Tier 1 penicillin g sodium for inj unit Tier 1 penicillin v potassium for soln 125 mg/5ml Tier 1 penicillin v potassium for soln 250 mg/5ml Tier 1 penicillin v potassium tab 250 mg Tier 1 penicillin v potassium tab 500 mg Tier 1 piperacillin sod-tazobactam na for inj Tier 1 gm ( gm) piperacillin sod-tazobactam sod for inj 4.5 Tier 1 gm (4-0.5 gm) TETRACYCLINES demeclocycline hcl tab 150 mg Tier 1 demeclocycline hcl tab 300 mg Tier 1 doxycycline hyclate cap 100 mg Tier 1 doxycycline hyclate tab 20 mg Tier 1 doxycycline hyclate tab 100 mg Tier 1 doxycycline monohydrate cap 50 mg Tier 1 doxycycline monohydrate cap 100 mg Tier 1 doxycycline monohydrate for susp 25 Tier 1 mg/5ml doxycycline monohydrate tab 50 mg Tier 1 doxycycline monohydrate tab 75 mg Tier 1 PA, ST doxycycline monohydrate tab 100 mg Tier 1 doxycycline monohydrate tab 150 mg Tier 1 PA, ST minocycline hcl cap 50 mg Tier 1 minocycline hcl cap 75 mg Tier 1 minocycline hcl cap 100 mg Tier 1 minocycline hcl tab 50 mg Tier 1 minocycline hcl tab 75 mg Tier 1 minocycline hcl tab 100 mg Tier 1 tetracycline hcl cap 250 mg Tier 1 ST tetracycline hcl cap 500 mg Tier 1 ST 19

21 ANTICOAGULANTS HEPARINS AND HEPARINOID-LIKE AGENTS heparin sodium (porcine) 2 unit/ml in Tier 1 sodium chloride 0.9% heparin sodium (porcine) 40 unit/ml in Tier 1 d5w ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC. soothe tab 262mg Tier 1 OTC stomach relf chw 262mg Tier 1 OTC stomach relf sus 262/15ml Tier 1 OTC stomach relf sus 525/15ml Tier 1 OTC ANTIPERISTALTIC AGENTS anti-diarrhe liq 1mg/5ml Tier 1 OTC IMODIUM A-D CAP 2MG Tier 1 OTC IMODIUM A-D LIQ 1MG/7.5 Tier 1 OTC IMODIUM A-D TAB 2MG Tier 1 OTC ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS EXJADE TAB 125MG Tier 3 PA EXJADE TAB 250MG Tier 3 PA EXJADE TAB 500MG Tier 3 PA ANTIEMETICS SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS EMEND SUS 125MG Tier 2 QL (3 / fill) ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES CHLOR-TRIMET SYP 2MG/5ML Tier 1 OTC CHLOR-TRIMET TAB 4MG Tier 1 OTC CHLOR-TRIMET TAB 12MG CR Tier 1 OTC ANTIHISTAMINES - ETHANOLAMINES BENADRYL ALG TAB 25MG Tier 1 OTC BENADRYL ALL LIQ 12.5/5ML Tier 1 OTC diphenhydram cap 50mg Tier 1 OTC diphenhydramine hcl cap 25 mg Tier 1 OTC quenalin syp 12.5/5ml Tier 1 OTC TAVIST TAB 1.34MG Tier 1 OTC ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN INJ 50MG Tier 3 BICNU INJ 100MG Tier 3 BUSULFEX INJ 6MG/ML Tier 3 CYCLOPHOSPH CAP 25MG Tier 3 CYCLOPHOSPH CAP 50MG Tier 3 20

22 dacarbazine for inj 200 mg Tier 3 EMCYT CAP 140MG Tier 3 GLEOSTINE CAP 40MG Tier 3 GLEOSTINE CAP 100MG Tier 3 HEXALEN CAP 50MG Tier 3 IFEX INJ 1GM Tier 3 IFEX INJ 3GM Tier 3 ifosfamide for inj 1 gm Tier 3 PA LEUKERAN TAB 2MG Tier 3 MUSTARGEN INJ 10MG Tier 3 TREANDA INJ 100MG Tier 3 ZANOSAR INJ 1GM Tier 3 ANTHRACYCLINES DOXIL INJ 2MG/ML Tier 3 PA, ST doxorubicin hcl inj 2 mg/ml Tier 3 ELLENCE INJ 2MG/ML Tier 3 PA epirubicin hcl iv soln 50 mg/25ml (2 Tier 3 mg/ml) IDAMYCIN PFS INJ 5MG/5ML Tier 3 PA idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) Tier 3 PA ANTIBIOTICS bleomycin sulfate for inj 30 unit Tier 1 PA, ST COSMEGEN INJ 0.5MG Tier 3 PA, ST DAUNORUBICIN INJ 50MG Tier 3 mitomycin for iv soln 20 mg Tier 1 ANTIMETABOLITES ALIMTA INJ 500MG Tier 3 ARRANON INJ 5MG/ML Tier 3 capecitabine tab 150 mg Tier 3 capecitabine tab 500 mg Tier 3 cladribine iv soln 10 mg/10ml (1 mg/ml) Tier 3 CLOLAR INJ 1MG/ML Tier 2 cytarabine inj 20 mg/ml Tier 3 cytarabine inj pf 100 mg/ml Tier 3 DACOGEN INJ 50MG Tier 3 decitabine for inj 50 mg Tier 3 fludarabine phosphate for inj 50 mg Tier 3 fluorouracil iv soln 2.5 gm/50ml (50 Tier 1 mg/ml) gemcitabine hcl for inj 1 gm Tier 3 GEMZAR INJ 1GM Tier 3 PA mercaptopurine tab 50 mg Tier 1 methotrexate sodium for inj 1 gm Tier 1 methotrexate sodium inj pf 50 mg/2ml (25 Tier 1 mg/ml) 21

23 TABLOID TAB 40MG Tier 2 TREXALL TAB 5MG Tier 4 ST TREXALL TAB 7.5MG Tier 4 ST TREXALL TAB 10MG Tier 4 ST TREXALL TAB 15MG Tier 4 ST VIDAZA INJ 100MG Tier 3 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG Tier 3 DOCEFREZ INJ 20MG Tier 3 PA DOCEFREZ INJ 80MG Tier 3 PA DOCETAXEL INJ 80MG/4ML Tier 3 DOCETAXEL INJ 80MG/8ML Tier 3 ETOPOPHOS INJ 100MG Tier 3 HALAVEN INJ 1MG/2ML Tier 3 PA IXEMPRA KIT INJ 45MG Tier 3 paclitaxel iv conc 30 mg/5ml (6 mg/ml) Tier 1 TAXOTERE INJ 80MG/4ML Tier 3 PA ANTIMITOTIC, VINCA ALKALOIDS vincasar pfs inj 1mg/ml Tier 3 vincristine sulfate iv soln 1 mg/ml Tier 3 PA vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) Tier 1 ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INJ Tier 3 ZALTRAP INJ 100/4ML Tier 3 PA ANTINEOPLASTIC - ANTIBODIES ARZERRA CON 100/5ML Tier 3 HERCEPTIN INJ 440MG Tier 3 OPDIVO INJ 40MG/4ML Tier 4 PA PERJETA INJ 420/14ML Tier 3 RITUXAN INJ 100MG Tier 3 VECTIBIX INJ 100MG Tier 3 YERVOY INJ 50MG Tier 3 ANTINEOPLASTIC ENZYME INHIBITORS VELCADE INJ 3.5MG Tier 3 BIOLOGIC RESPONSE MODIFIERS BELEODAQ INJ 500MG Tier 3 PA ERBITUX INJ 100MG Tier 3 ERIVEDGE CAP 150MG Tier 3 FARYDAK CAP 10MG Tier 3 PA FARYDAK CAP 15MG Tier 3 PA FARYDAK CAP 20MG Tier 3 PA IBRANCE CAP 75MG Tier 4 QL (21 caps / 28 days), PA 22

24 IBRANCE CAP 100MG Tier 4 QL (21 caps / 28 days), PA IBRANCE CAP 125MG Tier 4 QL (21 caps / 28 days), PA LYNPARZA CAP 50MG Tier 3 PA, ST ZOLINZA CAP 100MG Tier 3 HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg Tier 1 bicalutamide tab 50 mg Tier 1 ELIGARD INJ 7.5MG Tier 3 PA, ST ELIGARD INJ 30MG Tier 3 PA, ST ELIGARD INJ 45MG Tier 3 PA, ST exemestane tab 25 mg Tier 1 FARESTON TAB 60MG Tier 3 PA FASLODEX INJ 250/5ML Tier 3 FIRMAGON INJ 80MG Tier 3 PA FIRMAGON INJ 120MG Tier 3 PA flutamide cap 125 mg Tier 1 letrozole tab 2.5 mg Tier 1 leuprolide acetate inj kit 5 mg/ml Tier 3 PA, ST LUPR DEP-PED INJ 3M 30MG Tier 3 PA LUPR DEP-PED INJ 7.5MG Tier 3 PA LUPR DEP-PED INJ 11.25MG Tier 3 PA LUPR DEP-PED INJ 15MG Tier 3 PA LUPRON DEPOT INJ 3.75MG Tier 3 PA LUPRON DEPOT INJ 7.5MG Tier 3 PA LUPRON DEPOT INJ 11.25MG Tier 3 PA LUPRON DEPOT INJ 22.5MG Tier 3 PA LUPRON DEPOT INJ 30MG Tier 3 PA LUPRON DEPOT INJ 45MG Tier 3 PA LYSODREN TAB 500MG Tier 3 megestrol acetate susp 40 mg/ml Tier 1 megestrol acetate susp 625 mg/5ml Tier 1 PA megestrol acetate tab 20 mg Tier 1 megestrol acetate tab 40 mg Tier 1 PA NILANDRON TAB 150MG Tier 3 tamoxifen citrate tab 10 mg (base Tier 0 equivalent) tamoxifen citrate tab 20 mg (base Tier 0 equivalent) TRELSTAR MIX INJ 3.75MG Tier 3 PA, ST TRELSTAR MIX INJ 11.25MG Tier 3 PA, ST XTANDI CAP 40MG Tier 4 PA ZOLADEX IMP 3.6MG Tier 3 PA ZOLADEX IMP 10.8MG Tier 3 PA ZYTIGA TAB 250MG Tier 3 23

25 KINASE INHIBITORS AFINITOR TAB 2.5MG Tier 3 AFINITOR TAB 5MG Tier 3 AFINITOR TAB 7.5MG Tier 3 AFINITOR TAB 10MG Tier 3 BOSULIF TAB 100MG Tier 3 BOSULIF TAB 500MG Tier 3 CAPRELSA TAB 100MG Tier 3 PA, ST CAPRELSA TAB 300MG Tier 3 PA, ST COMETRIQ KIT 60MG Tier 3 COMETRIQ KIT 100MG Tier 3 COMETRIQ KIT 140MG Tier 3 GILOTRIF TAB 20MG Tier 3 PA GILOTRIF TAB 30MG Tier 3 PA GILOTRIF TAB 40MG Tier 3 PA GLEEVEC TAB 100MG Tier 3 GLEEVEC TAB 400MG Tier 3 ICLUSIG TAB 15MG Tier 3 ICLUSIG TAB 45MG Tier 3 imatinib mesylate tab 100 mg (base Tier 4 PA equivalent) imatinib mesylate tab 400 mg (base Tier 4 PA equivalent) IMBRUVICA CAP 140MG Tier 3 PA INLYTA TAB 1MG Tier 3 PA INLYTA TAB 5MG Tier 3 PA JAKAFI TAB 5MG Tier 3 JAKAFI TAB 10MG Tier 3 JAKAFI TAB 15MG Tier 3 JAKAFI TAB 20MG Tier 3 JAKAFI TAB 25MG Tier 3 LENVIMA CAP 10 MG Tier 3 PA LENVIMA CAP 14 MG Tier 3 PA LENVIMA CAP 20 MG Tier 3 PA LENVIMA CAP 24 MG Tier 3 PA NEXAVAR TAB 200MG Tier 3 SPRYCEL TAB 20MG Tier 3 SPRYCEL TAB 50MG Tier 3 SPRYCEL TAB 70MG Tier 3 SPRYCEL TAB 80MG Tier 3 SPRYCEL TAB 100MG Tier 3 SPRYCEL TAB 140MG Tier 3 STIVARGA TAB 40MG Tier 3 SUTENT CAP 12.5MG Tier 3 SUTENT CAP 25MG Tier 3 SUTENT CAP 50MG Tier 3 24

26 TARCEVA TAB 25MG Tier 3 TARCEVA TAB 100MG Tier 3 TARCEVA TAB 150MG Tier 3 TORISEL SOL 25MG/ML Tier 3 PA TYKERB TAB 250MG Tier 3 VOTRIENT TAB 200MG Tier 3 XALKORI CAP 200MG Tier 3 XALKORI CAP 250MG Tier 3 ZELBORAF TAB 240MG Tier 3 MISCELLANEOUS bexarotene cap 75 mg Tier 3 PA, ST DROXIA CAP 200MG Tier 4 PA, ST DROXIA CAP 300MG Tier 4 PA, ST DROXIA CAP 400MG Tier 4 PA, ST hydroxyurea cap 500 mg Tier 1 MATULANE CAP 50MG Tier 2 mitoxantrone hcl inj conc 25 mg/12.5ml (2 Tier 1 mg/ml) PROLEUKIN INJ 22MU Tier 3 SYLATRON KIT 200MCG Tier 3 PA SYLATRON KIT 300MCG Tier 3 PA SYLATRON KIT 600MCG Tier 3 PA SYNRIBO INJ 3.5MG Tier 3 tretinoin cap 10 mg Tier 1 UVADEX INJ 20MCG/ML Tier 4 PA PLATINUM-BASED AGENTS carboplatin iv soln 600 mg/60ml Tier 3 cisplatin inj 50 mg/50ml (1 mg/ml) Tier 3 oxaliplatin iv soln 100 mg/20ml Tier 3 PROTECTIVE AGENTS amifostine for inj 500 mg Tier 1 leucovorin calcium for inj 100 mg Tier 1 leucovorin calcium tab 5 mg Tier 1 leucovorin calcium tab 10 mg Tier 1 leucovorin calcium tab 15 mg Tier 1 leucovorin calcium tab 25 mg Tier 1 mesna inj 100 mg/ml Tier 1 PA, ST MESNEX TAB 400MG Tier 2 TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 100/5ML Tier 3 PA etoposide inj 100 mg/5ml (20 mg/ml) Tier 3 HYCAMTIN INJ 4MG Tier 4 PA irinotecan hcl inj 100 mg/5ml (20 mg/ml) Tier 3 toposar inj 100/5ml Tier 3 PA topotecan hcl for inj 4 mg (base equiv) Tier 3 25

27 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC COMBINATIONS KISQALI 200 PAK FEMARA Tier 2 PA KISQALI 400 PAK FEMARA Tier 2 PA KISQALI 600 PAK FEMARA Tier 2 PA ANTINEOPLASTIC ENZYME INHIBITORS NERLYNX TAB 40MG Tier 4 QL (180 tabs / 30 days), PA VERZENIO TAB 50MG Tier 4 QL (56 tabs / 28 days), PA VERZENIO TAB 100MG Tier 4 QL (56 tabs / 28 days), PA VERZENIO TAB 150MG Tier 4 QL (56 tabs / 28 days), PA VERZENIO TAB 200MG Tier 4 QL (56 tabs / 28 days), PA ANTINEOPLASTIC ENZYMES ERWINAZE INJ 10000UNT Tier 3 PA CHEMOTHERAPY ADJUNCTS ELITEK INJ 1.5MG Tier 3 KEPIVANCE INJ 6.25MG Tier 3 PA, ST CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS FUSILEV INJ 50MG Tier 4 PA levoleucovorin calcium for iv inj 50 mg Tier 1 (base equiv) VORAXAZE INJ 1000UNIT Tier 3 PA ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS chlorhexidine gluconate liquid 4% Tier 1 OTC HIBICLENS LIQ 4% Tier 1 OTC IODINE ANTISEPTICS NUPREP 5% SOL POV-IODI Tier 1 OTC POVIDONE-IOD SOL 0.75% Tier 1 OTC POVIDONE-IOD SOL 1% Tier 1 OTC povidone-iod sol 7.5% Tier 1 OTC povidone-iodine oint 10% Tier 1 OTC povidone-iodine soln 10% Tier 1 OTC ANTIVIRALS CMV AGENTS foscarnet sodium inj 24 mg/ml Tier 3 PA, ST FOSCAVIR INJ 24MG/ML Tier 3 PA, ST ganciclovir sodium for inj 500 mg Tier 3 HEPATITIS AGENTS RIBAPAK TAB 1000/DAY Tier 4 PA VIEKIRA PAK TAB Tier 4 PA 26

28 CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-Tier 1 10 mg amlodipine besylate-benazepril hcl cap 5- Tier 1 10 mg amlodipine besylate-benazepril hcl cap 5- Tier 1 20 mg amlodipine besylate-benazepril hcl cap 5- Tier 1 40 mg amlodipine besylate-benazepril hcl cap 10- Tier 1 20 mg amlodipine besylate-benazepril hcl cap 10- Tier 1 40 mg benazepril & hydrochlorothiazide tab 5- Tier mg benazepril & hydrochlorothiazide tab 10- Tier mg benazepril & hydrochlorothiazide tab 20- Tier mg benazepril & hydrochlorothiazide tab Tier 1 mg enalapril maleate & hydrochlorothiazide tab Tier mg enalapril maleate & hydrochlorothiazide tab Tier mg fosinopril sodium & hydrochlorothiazide tab Tier mg fosinopril sodium & hydrochlorothiazide tab Tier mg lisinopril & hydrochlorothiazide tab Tier 1 mg lisinopril & hydrochlorothiazide tab Tier 1 mg lisinopril & hydrochlorothiazide tab Tier 1 mg moexipril-hydrochlorothiazide tab Tier 1 mg quinapril-hydrochlorothiazide tab Tier 1 mg quinapril-hydrochlorothiazide tab Tier 1 mg quinapril-hydrochlorothiazide tab mg Tier 1 trandolapril-verapamil hcl tab er mg Tier 1 trandolapril-verapamil hcl tab er mg Tier 1 trandolapril-verapamil hcl tab er mg Tier 1 trandolapril-verapamil hcl tab er mg Tier 1 PA, ST PA, ST PA PA PA PA 27

29 ACE INHIBITORS benazepril hcl tab 5 mg Tier 1 benazepril hcl tab 10 mg Tier 1 benazepril hcl tab 20 mg Tier 1 benazepril hcl tab 40 mg Tier 1 enalapril maleate tab 2.5 mg Tier 1 enalapril maleate tab 5 mg Tier 1 enalapril maleate tab 10 mg Tier 1 enalapril maleate tab 20 mg Tier 1 fosinopril sodium tab 10 mg Tier 1 fosinopril sodium tab 20 mg Tier 1 fosinopril sodium tab 40 mg Tier 1 lisinopril tab 2.5 mg Tier 1 lisinopril tab 5 mg Tier 1 lisinopril tab 10 mg Tier 1 lisinopril tab 20 mg Tier 1 lisinopril tab 30 mg Tier 1 lisinopril tab 40 mg Tier 1 moexipril hcl tab 7.5 mg Tier 1 moexipril hcl tab 15 mg Tier 1 perindopril erbumine tab 2 mg Tier 1 perindopril erbumine tab 4 mg Tier 1 perindopril erbumine tab 8 mg Tier 1 quinapril hcl tab 5 mg Tier 1 quinapril hcl tab 10 mg Tier 1 quinapril hcl tab 20 mg Tier 1 quinapril hcl tab 40 mg Tier 1 ramipril cap 1.25 mg Tier 1 ramipril cap 2.5 mg Tier 1 ramipril cap 5 mg Tier 1 ramipril cap 10 mg Tier 1 trandolapril tab 1 mg Tier 1 trandolapril tab 2 mg Tier 1 trandolapril tab 4 mg Tier 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg Tier 1 ST eplerenone tab 50 mg Tier 1 ST ALPHA BLOCKERS doxazosin mesylate tab 1 mg Tier 1 doxazosin mesylate tab 2 mg Tier 1 doxazosin mesylate tab 4 mg Tier 1 doxazosin mesylate tab 8 mg Tier 1 prazosin hcl cap 1 mg Tier 1 prazosin hcl cap 2 mg Tier 1 prazosin hcl cap 5 mg Tier 1 28

30 terazosin hcl cap 1 mg (base equivalent) Tier 1 terazosin hcl cap 2 mg (base equivalent) Tier 1 terazosin hcl cap 5 mg (base equivalent) Tier 1 terazosin hcl cap 10 mg (base equivalent) Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab Tier 1 mg amlodipine besylate-valsartan tab Tier 1 mg amlodipine besylate-valsartan tab Tier 1 mg amlodipine besylate-valsartan tab Tier 1 mg amlodipine-valsartan-hydrochlorothiazide Tier 1 PA, ST tab mg amlodipine-valsartan-hydrochlorothiazide Tier 1 PA, ST tab mg amlodipine-valsartan-hydrochlorothiazide Tier 1 PA, ST tab mg amlodipine-valsartan-hydrochlorothiazide Tier 1 PA, ST tab mg amlodipine-valsartan-hydrochlorothiazide Tier 1 PA, ST tab mg AZOR TAB 5-20MG Tier 4 PA, ST AZOR TAB 5-40MG Tier 4 PA, ST AZOR TAB 10-20MG Tier 4 PA, ST AZOR TAB 10-40MG Tier 4 PA, ST BENICAR HCT TAB Tier 4 ST BENICAR HCT TAB Tier 4 ST BENICAR HCT TAB 40-25MG Tier 4 ST candesartan cilexetil-hydrochlorothiazide Tier 1 PA, ST tab mg candesartan cilexetil-hydrochlorothiazide Tier 1 PA, ST tab mg candesartan cilexetil-hydrochlorothiazide Tier 1 PA, ST tab mg irbesartan-hydrochlorothiazide tab 150- Tier mg irbesartan-hydrochlorothiazide tab 300- Tier mg losartan potassium & hydrochlorothiazide Tier 1 tab mg losartan potassium & hydrochlorothiazide Tier 1 tab mg losartan potassium & hydrochlorothiazide tab mg Tier 1 29

31 olmesartan medoxomil-hydrochlorothiazide Tier 1 tab mg olmesartan medoxomil-hydrochlorothiazide Tier 1 tab mg olmesartan medoxomil-hydrochlorothiazide Tier 1 tab mg olmesartan-amlodipine-hydrochlorothiazide Tier 1 tab mg olmesartan-amlodipine-hydrochlorothiazide Tier 1 tab mg olmesartan-amlodipine-hydrochlorothiazide Tier 1 tab mg telmisartan-amlodipine tab 40-5 mg Tier 1 telmisartan-amlodipine tab mg Tier 1 telmisartan-amlodipine tab 80-5 mg Tier 1 telmisartan-amlodipine tab mg Tier 1 telmisartan-hydrochlorothiazide tab 40- Tier 1 PA, ST 12.5 mg telmisartan-hydrochlorothiazide tab mg Tier 1 PA, ST telmisartan-hydrochlorothiazide tab Tier 1 mg valsartan-hydrochlorothiazide tab Tier 1 mg valsartan-hydrochlorothiazide tab Tier 1 mg valsartan-hydrochlorothiazide tab Tier 1 mg valsartan-hydrochlorothiazide tab Tier 1 mg valsartan-hydrochlorothiazide tab Tier 1 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR TAB 5MG Tier 4 ST BENICAR TAB 20MG Tier 4 ST BENICAR TAB 40MG Tier 4 ST candesartan cilexetil tab 4 mg Tier 1 PA, ST candesartan cilexetil tab 8 mg Tier 1 PA, ST candesartan cilexetil tab 16 mg Tier 1 PA, ST candesartan cilexetil tab 32 mg Tier 1 PA, ST EDARBI TAB 40MG Tier 4 PA, ST EDARBI TAB 80MG Tier 4 PA, ST eprosartan mesylate tab 600 mg Tier 1 ST irbesartan tab 75 mg Tier 1 irbesartan tab 150 mg Tier 1 irbesartan tab 300 mg Tier 1 losartan potassium tab 25 mg Tier 1 30

32 losartan potassium tab 50 mg Tier 1 losartan potassium tab 100 mg Tier 1 olmesartan medoxomil tab 5 mg Tier 1 olmesartan medoxomil tab 20 mg Tier 1 olmesartan medoxomil tab 40 mg Tier 1 telmisartan tab 20 mg Tier 1 PA, ST telmisartan tab 40 mg Tier 1 PA, ST telmisartan tab 80 mg Tier 1 PA, ST valsartan tab 40 mg Tier 1 valsartan tab 80 mg Tier 1 valsartan tab 160 mg Tier 1 valsartan tab 320 mg Tier 1 ANTIARRHYTHMICS amiodarone hcl tab 200 mg Tier 1 amiodarone hcl tab 400 mg Tier 1 disopyramide phosphate cap 100 mg Tier 1 disopyramide phosphate cap 150 mg Tier 1 flecainide acetate tab 50 mg Tier 1 flecainide acetate tab 100 mg Tier 1 flecainide acetate tab 150 mg Tier 1 lidocaine hcl iv inj 20 mg/ml Tier 1 mexiletine hcl cap 150 mg Tier 1 mexiletine hcl cap 200 mg Tier 1 mexiletine hcl cap 250 mg Tier 1 MULTAQ TAB 400MG Tier 3 PA NORPACE CAP 100MG CR Tier 4 PA, ST NORPACE CAP 150MG CR Tier 4 PA, ST pacerone tab 100mg Tier 1 procainamide hcl inj 100 mg/ml Tier 3 PA, ST procainamide hcl inj 500 mg/ml Tier 3 PA, ST propafenone hcl tab 150 mg Tier 1 propafenone hcl tab 225 mg Tier 1 propafenone hcl tab 300 mg Tier 1 quinidine gluconate tab er 324 mg Tier 1 PA, ST quinidine sulfate tab 200 mg Tier 1 PA, ST quinidine sulfate tab 300 mg Tier 1 PA, ST sorine tab 80mg Tier 1 sorine tab 120mg Tier 1 sorine tab 160mg Tier 1 sorine tab 240mg Tier 1 sotalol hcl (afib/afl) tab 120 mg Tier 1 sotalol hcl tab 80 mg Tier 1 sotalol hcl tab 160 mg Tier 1 sotalol hcl tab 240 mg Tier 1 31

33 ANTIHYPERTENSIVE COMBINATIONS methyldopa & hydrochlorothiazide tab 250-Tier 1 15 mg methyldopa & hydrochlorothiazide tab 250-Tier 1 25 mg TEKTURNA HCT TAB Tier 4 ST TEKTURNA HCT TAB MG Tier 4 ST TEKTURNA HCT TAB Tier 4 ST TEKTURNA HCT TAB MG Tier 4 ST ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder packets 4 gm Tier 1 colesevelam hcl tab 625 mg Tier 1 colestipol hcl granules 5 gm Tier 1 colestipol hcl tab 1 gm Tier 1 prevalite pow 4gm Tier 1 WELCHOL PAK 3.75GM Tier 4 PA ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ezetimibe tab 10 mg Tier 1 ANTILIPEMICS, FIBRATES fenofibrate micronized cap 67 mg Tier 1 fenofibrate micronized cap 134 mg Tier 1 fenofibrate micronized cap 200 mg Tier 1 fenofibrate tab 54 mg Tier 1 fenofibrate tab 145 mg Tier 1 fenofibrate tab 160 mg Tier 1 gemfibrozil tab 600 mg Tier 1 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS VYTORIN TAB 10-10MG Tier 4 PA, ST VYTORIN TAB 10-20MG Tier 4 PA, ST VYTORIN TAB 10-40MG Tier 4 PA, ST VYTORIN TAB 10-80MG Tier 4 PA, ST ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base Tier 0 equivalent) atorvastatin calcium tab 20 mg (base Tier 0 equivalent) atorvastatin calcium tab 40 mg (base Tier 1 equivalent) atorvastatin calcium tab 80 mg (base Tier 1 equivalent) LIVALO TAB 1MG Tier 4 ST LIVALO TAB 2MG Tier 4 ST LIVALO TAB 4MG Tier 4 ST lovastatin tab 10 mg Tier 0 32

34 lovastatin tab 20 mg Tier 0 lovastatin tab 40 mg Tier 0 pravastatin sodium tab 10 mg Tier 0 pravastatin sodium tab 20 mg Tier 0 pravastatin sodium tab 40 mg Tier 0 pravastatin sodium tab 80 mg Tier 0 rosuvastatin calcium tab 5 mg Tier 0 rosuvastatin calcium tab 10 mg Tier 0 rosuvastatin calcium tab 20 mg Tier 1 rosuvastatin calcium tab 40 mg Tier 1 simvastatin tab 5 mg Tier 0 simvastatin tab 10 mg Tier 0 simvastatin tab 20 mg Tier 0 simvastatin tab 40 mg Tier 0 simvastatin tab 80 mg Tier 1 PA ANTILIPEMICS, MISCELLANEOUS NIASPAN TAB 500MG ER Tier 4 PA, ST NIASPAN TAB 750MG ER Tier 4 PA, ST NIASPAN TAB 1000 ER Tier 4 PA ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm Tier 4 PA, ST ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML Tier 4 PA REPATHA INJ 140MG/ML Tier 3 PA REPATHA PUSH INJ 420/3.5 Tier 3 PA REPATHA SURE INJ 140MG/ML Tier 3 PA BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab mg Tier 1 atenolol & chlorthalidone tab mg Tier 1 bisoprolol & hydrochlorothiazide tab 2.5- Tier mg bisoprolol & hydrochlorothiazide tab Tier 1 mg bisoprolol & hydrochlorothiazide tab 10- Tier mg metoprolol & hydrochlorothiazide tab 50- Tier 1 25 mg metoprolol & hydrochlorothiazide tab 100- Tier 1 25 mg metoprolol & hydrochlorothiazide tab 100- Tier 1 50 mg nadolol & bendroflumethiazide tab 40-5 mg Tier 1 nadolol & bendroflumethiazide tab 80-5 mg Tier 1 propranolol & hydrochlorothiazide tab 40- Tier 1 25 mg 33

35 propranolol & hydrochlorothiazide tab 80- Tier 1 25 mg BETA-BLOCKERS acebutolol hcl cap 200 mg Tier 1 acebutolol hcl cap 400 mg Tier 1 atenolol tab 25 mg Tier 1 atenolol tab 50 mg Tier 1 atenolol tab 100 mg Tier 1 betaxolol hcl tab 10 mg Tier 1 PA, ST betaxolol hcl tab 20 mg Tier 1 PA, ST bisoprolol fumarate tab 5 mg Tier 1 bisoprolol fumarate tab 10 mg Tier 1 BYSTOLIC TAB 2.5MG Tier 4 PA, ST BYSTOLIC TAB 5MG Tier 4 PA, ST BYSTOLIC TAB 10MG Tier 4 PA, ST BYSTOLIC TAB 20MG Tier 4 PA, ST carvedilol tab mg Tier 1 carvedilol tab 6.25 mg Tier 1 carvedilol tab 12.5 mg Tier 1 carvedilol tab 25 mg Tier 1 COREG CR CAP 10MG Tier 4 PA, ST COREG CR CAP 20MG Tier 4 PA, ST COREG CR CAP 40MG Tier 4 PA, ST COREG CR CAP 80MG Tier 4 PA, ST labetalol hcl tab 100 mg Tier 1 labetalol hcl tab 200 mg Tier 1 labetalol hcl tab 300 mg Tier 1 LEVATOL TAB 20MG Tier 4 PA, ST metoprolol succinate tab er 24hr 25 mg Tier 1 (tartrate equiv) metoprolol succinate tab er 24hr 50 mg Tier 1 (tartrate equiv) metoprolol succinate tab er 24hr 100 mg Tier 1 (tartrate equiv) metoprolol succinate tab er 24hr 200 mg Tier 1 (tartrate equiv) metoprolol tartrate tab 25 mg Tier 1 metoprolol tartrate tab 50 mg Tier 1 metoprolol tartrate tab 100 mg Tier 1 nadolol tab 20 mg Tier 1 nadolol tab 40 mg Tier 1 nadolol tab 80 mg Tier 1 pindolol tab 5 mg Tier 1 pindolol tab 10 mg Tier 1 propranolol hcl cap er 24hr 60 mg Tier 1 propranolol hcl cap er 24hr 80 mg Tier 1 34

36 propranolol hcl cap er 24hr 120 mg Tier 1 propranolol hcl cap er 24hr 160 mg Tier 1 propranolol hcl oral soln 20 mg/5ml Tier 1 propranolol hcl oral soln 40 mg/5ml Tier 1 propranolol hcl tab 10 mg Tier 1 propranolol hcl tab 20 mg Tier 1 propranolol hcl tab 40 mg Tier 1 propranolol hcl tab 60 mg Tier 1 propranolol hcl tab 80 mg Tier 1 timolol maleate tab 5 mg Tier 1 timolol maleate tab 10 mg Tier 1 timolol maleate tab 20 mg Tier 1 CALCIUM CHANNEL BLOCKERS afeditab tab 30mg cr Tier 1 afeditab tab 60mg cr Tier 1 amlodipine besylate tab 2.5 mg (base Tier 1 equivalent) amlodipine besylate tab 5 mg (base Tier 1 equivalent) amlodipine besylate tab 10 mg (base Tier 1 equivalent) cartia xt cap 120/24hr Tier 1 cartia xt cap 180/24hr Tier 1 cartia xt cap 240/24hr Tier 1 cartia xt cap 300/24hr Tier 1 dilt-xr cap 180mg Tier 1 dilt-xr cap 240mg Tier 1 diltiazem hcl cap er 24hr 180 mg Tier 1 diltiazem hcl coated beads cap er 24hr 120 Tier 1 mg diltiazem hcl coated beads cap er 24hr 240 Tier 1 mg diltiazem hcl coated beads cap er 24hr 300 Tier 1 mg diltiazem hcl extended release beads cap Tier 1 er 24hr 120 mg diltiazem hcl extended release beads cap Tier 1 er 24hr 180 mg diltiazem hcl extended release beads cap Tier 1 er 24hr 300 mg diltiazem hcl extended release beads cap Tier 1 er 24hr 360 mg diltiazem hcl extended release beads cap Tier 1 er 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) Tier 1 diltiazem hcl tab 30 mg Tier 1 diltiazem hcl tab 60 mg Tier 1 35