2019 Drug Formulary. Effective March For federal employees and retirees on the Federal Employees Health Benefits Program

Transcription

1 Effective March Drug Formulary For federal employees and retirees on the Federal Employees Health Benefits Program All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. XB

2 Drug Formulary INTRODUCTION What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost. How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers. How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs. Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet. How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual s contracted benefit. Coverage for a specific drug is subject to each member s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage. Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions. Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at Nonformulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug. Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to

3 a higher cost share. The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 45 days prior to the effective date. What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs? Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a PA superscript next to the drug name. Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a ST superscript next to the drug name. Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with QL superscript next to the drug name. High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy. Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the webpage. Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are: Preferred blood glucose strips: o One Touch Verio

4 o One Touch Ultra o Prodigy prior authorization required o Contour Next prior authorization required o Freestyle prior authorization required Disposable insulin syringes and needles Lancing devices and lancets Preferred blood glucose meters are covered only when filled through mail order pharmacy. Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions. To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy. Address: Kaiser Permanente Mail Order Pharmacy PO Box Seattle, WA Phone: RXRX ( ) Fax: , or toll-free Specialty Drugs Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex conditions. Some specialty products are dispensed from a preferred specialty pharmacy vendor. Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at to find if you have OTC drug coverage. Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the webpage. Please consult your Benefit Booklet under Preventive Services or call Member Service if you have questions about your coverage for these drugs.

5 If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested nonpreferred contraceptive will be covered in full. How do I get additional information? Please contact Member Service at with any questions or concerns regarding the information contained in this document. The most current drug formulary is available at

6 Table of Contents ANTI-INFECTIVES PENICILLINS CEPHALOSPORIN FIRST GENERATION SECOND GENERATION THIRD GENERATION FOURTH GENERATION MACROLIDES TETRACYCLINES QUINOLONES AMINOGLYCOSIDES SULFONAMIDES ANTIMYCOBACTERIAL AGENTS ANTIFUNGALS ANTIVIRALS ANTIMALARIALS AMEBICIDES ANTHELMINTICS MISC. ANTI-INFECTIVES ANTINEOPLASTICS, ETC ALKYLATING AGENTS ANTIMETABOLITES HORMONAL AGENTS IMMUNOMODULATORS MITOTIC INHIBITORS ENZYME INHIBITORS TOPOISOMERASE I INHIBITOR ANTINEOPLASTICS MISC CHEMOTHERAPY RESCUE ANTINEOPLASTIC COMBO CARDIOVASCULAR DRUGS CARDIAC GLYCOSIDES ANTIANGINAL AGENTS BETA BLOCKERS CALCIUM CHANNEL BLOCKERS ANTIARRHYTHMICS ACE INHIBITORS

7 ANGIOTENSIN RCPTR BLOCKER DIRECT RENIN INHIBITORS ANTIHYPERTENSIVES MISC ANTIHYPERTENSIVE COMBO DIURETICS VASOPRESSORS ANTIHYPERLIPIDEMICS CARDIOVASCULAR - MISC DERMATOLOGICALS ACNE PRODUCTS ROSACEA AGENTS ANTIBIOTICS - TOPICAL ANTIFUNGALS - TOPICAL ANTIVIRALS - TOPICAL ANTIHISTAMINES-TOPICAL ANTI-INFLAMMATORY AGENTS ANTIPRURITICS ANTIPSORIATICS ANTISEBORRHEIC AGENTS CORTICOSTEROIDS - TOPICAL IMMUNOMODULATING AGENTS DERMATOLOGICALS - MISC ENDOCRINE AND METABOLIC CORTICOSTEROIDS ANDROGENS-ANABOLIC ESTROGENS CONTRACEPTIVES PROGESTINS ANTIDIABETIC AGENTS INSULIN AMYLIN ANALOGS INCRETIN MIMETIC AGENTS SULFONYLUREAS BIGUANIDES MEGLITINIDE ANALOGUES DIABETIC OTHER ALPHA-GLUCOSIDASE INHIBIT DPP-4 INHIBITORS INSULIN SENSITIZING AGENT

8 ANTIDIABETIC COMBINATIONS BISPHOSPHONATES CALCITONINS PARATHYROID HORMONE HORMONE RECEPTOR MDLTR LHRH/GNRH AGONIST GNRH/LHRH ANTAGONISTS GROWTH HORMONES GHRH SOMATOMEDINS SOMATOSTATIC AGENTS GH RECEPTOR ANTAGONISTS POSTERIOR PITUITARY CORTICOTROPIN PROLACTIN INHIBITORS VASOPRESSIN ANTAGONISTS PROGESTERONE ANTAGONISTS METABOLIC MODIFIERS THYROID AGENTS GASTROINTESTINAL LAXATIVES ANTIDIARRHEALS ULCER DRUGS ANTIEMETICS DIGESTIVE AIDS GASTROINTESTINAL - MISC GENITOURINARY URINARY ANTI-INFECTIVES URINARY ANTISPASMODICS VAGINAL PRODUCTS GENITOURINARY - MISC HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ANTICOAGULANTS HEMOSTATICS HEMATOLOGICAL - MISC MOUTH/THROAT/DENTAL AGENT NEUROLOGY, CNS, PSYCH

9 ANTIANXIETY AGENTS ANTIDEPRESSANTS ANTIPSYCHOTICS HYPNOTICS ADHD, NARCOLEPSY, ETC ANTICONVULSANTS ANTIPARKINSON AGENTS NEUROLOGY, PSYCH - MISC NEUROMUSCULAR AGENTS MUSCULOSKELETAL AGENTS ANTIMYASTHENIC AGENTS OPHTHALMOLOGY AND OTIC ANTI-INFECTIVES ARTIFICIAL TEAR/LUBRICANT BETA-BLOCKERS OPHTHALMIC STEROIDS PROSTAGLANDINS CYCLOPLEGIC MYDRIATICS DECONGESTANTS MIOTICS ADRENERGIC AGENTS IMMUNOMODULATORS LOCAL ANESTHETICS OPHTHALMICS - MISC OTIC AGENTS OXYTOCICS PAIN MANAGEMENT ANALGESICS - NONNARCOTIC ANALGESICS - OPIOID OPIOID ANTAGONIST ANTI-INFLAMMATORY MIGRAINE PRODUCTS GOUT AGENTS LOCAL ANESTHETICS-INJ RESPIRATORY, ALLERGY, ETC ANTIHISTAMINES NASAL AGENTS COUGH/COLD/ALLERGY

10 ANTIASTHMATIC/COPD AGENTS RESPIRATORY AGENTS - MISC TOXOIDS TOXOIDS IMMUNOGLOBULINS VACCINES VITAMINS VITAMINS MULTIVITAMINS MEDICAL DEVICES DIABETIC SUPPLIES MEDICAL DEVICES - MISC MISCELLANEOUS AGENTS

11 cephalexin sus 125/5ML cephalexin sus 250/5ML cephalexin CAP 250MG cephalexin CAP 500MG March 2019 TIER 03 NON-PREFERRED cephalexin CAP 750MG ANTI-INFECTIVES Cephalexin TAB 250MG PENICILLINS Cephalexin TAB 500MG TIER 01 GENERIC Daxbia CAP 333MG amox/k clav sus 200/5ML Keflex CAP 250MG amox/k clav sus 250/5ML Keflex CAP 500MG amox/k clav sus 400/5ML Keflex CAP 750MG amox/k clav sus 600/5ML SECOND GENERATION amox/k clav TAB TIER 01 GENERIC amox/k clav TAB cefprozil sus 125/5ML amox/k clav TAB cefprozil sus 250/5ML amoxicillin sus 125/5ML cefprozil TAB 250MG amoxicillin sus 200/5ML cefprozil TAB 500MG amoxicillin sus 250/5ML cefuroxime TAB 250MG amoxicillin sus 250MG/5m cefuroxime TAB 500MG amoxicillin sus 400/5ML TIER 02 PREFERRED amoxicillin CAP 250MG Ceftin Sus 125/5ML amoxicillin CAP 500MG Ceftin Sus 250/5ML amoxicillin TAB 500MG TIER 03 NON-PREFERRED amoxicillin TAB 875MG cefaclor CAP 250MG ampicillin inj 1gm cefaclor CAP 500MG ampicillin inj 250MG Cefaclor ER TAB 500MG ampicillin inj 500MG Cefaclor Sus 125/5ML ampicillin CAP 250MG Cefaclor Sus 250/5ML ampicillin CAP 500MG Cefaclor Sus 375/5ML dicloxacill CAP 250MG THIRD GENERATION dicloxacill CAP 500MG TIER 01 GENERIC penicilln vk sol 125/5ML cefdinir sus 125/5ML penicilln vk sol 250/5ML cefdinir sus 250/5ML penicilln vk TAB 250MG cefdinir CAP 300MG penicilln vk TAB 500MG cefixime sus 100/5ML Amox/K Clav Chw 200MG cefixime sus 200/5ML Amox/K Clav Chw 400MG ceftazidime inj 1gm Amoxicillin Chw 125MG ceftriaxone inj 1gm Amoxicillin Chw 250MG ceftriaxone inj 2gm Ampicillin CAP 500MG ceftriaxone inj 250MG Ampicillin Inj 125MG ceftriaxone inj 500MG Ampicillin Sus 125/5ML tazicef inj 1gm Ampicillin Sus 250/5ML TIER 02 PREFERRED Penicilln Vk Sol 125/5ML Suprax CAP 400MG Penicilln Vk Sol 250/5ML Suprax Sus 500/5ML TIER 02 PREFERRED TIER 03 NON-PREFERRED Bicillin L-a Inj cefpodo prox sus 100/5ML Bicillin L-a Inj cefpodo prox sus 50MG/5ML Bicillin L-a Inj cefpodoxime TAB 100MG TIER 03 NON-PREFERRED cefpodoxime TAB 200MG amox-pot cla TAB ER Cedax CAP 400MG Augmentin Sus ES-600 Cedax Sus 180/5ML Augmentin Sus 125/5ML Cefditoren TAB 200MG Augmentin Sus 250/5ML Cefditoren TAB 400MG Augmentin TAB 500MG Ceftibuten CAP 400MG Augmentin TAB 875MG Ceftibuten Sus 180/5ML Augmentin XR TAB 12HR Fortaz Inj 1gm Moxatag TAB 775MG Spectracef TAB 400MG Suprax Chw 100MG Suprax Chw 200MG CEPHALOSPORIN Suprax Sus 100/5ML FIRST GENERATION Suprax Sus 200/5ML TIER 01 GENERIC cefadroxil sus 250/5ML FOURTH GENERATION cefadroxil sus 500/5ML TIER 03 NON-PREFERRED cefepime inj 1gm cefadroxil CAP 500MG cefadroxil TAB 1gm Maxipime Inj 1gm cefazolin inj 1gm PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1

12 MACROLIDES TIER 01 GENERIC azithromycin sus 100/5ML azithromycin sus 200/5ML azithromycin TAB 250MG azithromycin TAB 500MG azithromycin TAB 600MG clarithromyc sus 125/5ML clarithromyc sus 250/5ML clarithromyc TAB 250MG clarithromyc TAB 500MG Azithromycin Pow 1gm PAK Clarithromyc Sus 125/5ML Clarithromyc Sus 250/5ML TIER 03 NON-PREFERRED clarithromyc TAB 500MG ER erythrom ETH sus 200/5ML erythromycin CAP 250MG EC erythromycin TAB 250MG bs erythromycin TAB 500MG bs Biaxin TAB 250MG E.e.s. Gran Sus 200/5ML E.e.s. 400 TAB 400MG Ery-TAB Tab 250MG EC Ery-TAB Tab 333MG EC Ery-TAB Tab 500MG EC Eryped Sus 200/5ML Eryped Sus 400/5ML Erythrocin TAB 250MG Erythrom ETH TAB 400MG Erythromycin Pow Ethylsuc PCE TAB 333MG EC PCE TAB 500MG EC Zithromax Pow 1gm PAK Zithromax Sus 100/5ML Zithromax Sus 200/5ML Zithromax TAB Tri-PAK Zithromax TAB Z-PAK Zithromax TAB 250MG Zithromax TAB 500MG Zithromax TAB 600MG Zmax Sus 2gm TIER 05 NON-PREFERRED BRAND SPECIALTY Dificid TAB 200MG QL,PA TETRACYCLINES TIER 01 GENERIC avidoxy TAB 100MG doxycyc mono CAP 100MG doxycyc mono CAP 150MG doxycyc mono CAP 50MG doxycyc mono CAP 75MG doxycyc mono TAB 100MG doxycyc mono TAB 150MG doxycyc mono TAB 50MG doxycyc mono TAB 75MG doxycycline TAB 100MG doxycycline TAB 50MG minocycline CAP 100MG minocycline CAP 50MG minocycline CAP 75MG mondoxyne nl CAP 100MG mondoxyne nl CAP 50MG mondoxyne nl CAP 75MG okebo CAP 100MG okebo CAP 75MG TIER 03 NON-PREFERRED coremino TAB 135MG PA coremino TAB 45MG PA TIER 05 coremino TAB 90MG PA demeclocycl TAB 150MG demeclocycl TAB 300MG doxycycl HYC CAP 100MG doxycycl HYC CAP 50MG doxycycl HYC TAB 100MG doxycycl HYC TAB 100MG DR doxycycl HYC TAB 150MG DR doxycycl HYC TAB 200MG DR doxycycl HYC TAB 50MG DR doxycycl HYC TAB 75MG DR doxycycline sus 25MG/5ML doxycycline TAB 150MG doxycycline TAB 75MG minocycline TAB 100MG minocycline TAB 105MG ER PA minocycline TAB 115MG ER PA minocycline TAB 135MG ER PA minocycline TAB 45MG ER PA minocycline TAB 50MG minocycline TAB 65MG ER PA minocycline TAB 75MG minocycline TAB 80MG ER PA minocycline TAB 90MG ER PA morgidox CAP 1X100MG morgidox CAP 1X50MG morgidox CAP 2X100MG soloxide TAB 150MG DR tetracycline CAP 250MG tetracycline CAP 500MG Acticlate TAB 150MG Acticlate TAB 75MG Adoxa PAK 1/ TAB 100MG Adoxa PAK 1/ TAB 150MG Adoxa PAK 2/ TAB 100MG Adoxa TAB 100MG Adoxa TAB 50MG Adoxa TAB 75MG Doryx Mpc TAB 120MG Doryx TAB 200MG Doryx TAB 50MG Doxycycl HYC TAB 50MG Minocin CAP 100MG Minocin CAP 50MG Minocin CAP 75MG Minocycline TAB 55MG ER PA Minolira TAB 105MG PA Minolira TAB 135MG PA Monodox CAP 100MG Monodox CAP 75MG Solodyn TAB 105MG PA Solodyn TAB 115MG PA Solodyn TAB 55MG PA Solodyn TAB 65MG PA Solodyn TAB 80MG PA Targadox TAB 50MG Tetracycline CAP 250MG Tetracycline CAP 500MG Vibramycin CAP 100MG Vibramycin Sus 25MG/5ML Vibramycin Syp 50MG/5ML Ximino CAP 135MG ER PA Ximino CAP 45MG ER PA Ximino CAP 90MG ER PA NON-PREFERRED BRAND SPECIALTY Nuzyra TAB 150MG QL,PA Seysara TAB 100MG QL,PA Seysara TAB 150MG QL,PA Seysara TAB 60MG QL,PA PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 2

13 QUINOLONES Myambutol TAB 400MG TIER 01 GENERIC Mycobutin CAP 150MG ciprofloxacn sus 250MG/5 Paser Gra 4gm ciprofloxacn sus 500MG/5 Rifadin CAP 150MG ciprofloxacn TAB 250MG Rifadin CAP 300MG ciprofloxacn TAB 500MG Rifamate CAP ciprofloxacn TAB 750MG Rifater TAB levofloxacin sol 25MG/ML Trecator TAB 250MG levofloxacin TAB 250MG TIER 05 NON-PREFERRED BRAND SPECIALTY levofloxacin TAB 500MG levofloxacin TAB 750MG Sirturo TAB 100MG QL,PA moxifloxacin TAB 400MG ANTIFUNGALS Ciprofloxacn TAB 100MG TIER 01 GENERIC TIER 02 PREFERRED fluconazole sus 10MG/ML Cipro (5%) Sus 250MG/5 fluconazole sus 40MG/ML TIER 03 NON-PREFERRED fluconazole TAB 100MG ofloxacin TAB 400MG fluconazole TAB 150MG Avelox Abc TAB 400MG fluconazole TAB 200MG Avelox TAB 400MG fluconazole TAB 50MG Cipro (10%) Sus 500MG/5 griseofulvin sus 125/5ML Cipro TAB 250MG griseofulvin TAB micr 500 Cipro TAB 500MG griseofulvin TAB ultr 125 Ciprofloxacn TAB 1000MG griseofulvin TAB ultr 250 Ciprofloxacn TAB 500MG ER itraconazole sol 10MG/ML PA Factive TAB 320MG itraconazole CAP 100MG PA Levaquin TAB 250MG ketoconazole TAB 200MG Levaquin TAB 500MG nystatin TAB Levaquin TAB 750MG terbinafine TAB 250MG Ofloxacin TAB 300MG voriconazole sus 40MG/ML PA TIER 05 NON-PREFERRED BRAND SPECIALTY voriconazole TAB 200MG PA Baxdela TAB 450MG QL,PA voriconazole TAB 50MG PA Amphotericin Inj 50MG AMINOGLYCOSIDES TIER 02 PREFERRED TIER 01 GENERIC Sporanox Sol 10MG/ML PA gentamicin inj 40MG/ML TIER 03 NON-PREFERRED neomycin TAB 500MG bio-statin pow TIER 03 NON-PREFERRED Bio-statin CAP paromomycin CAP 250MG Bio-statin CAP Arikayce Sus Diflucan Sus 10MG/ML Streptomycin Inj 1gm Diflucan Sus 40MG/ML TIER 04 SPECIALTY Diflucan TAB 100MG tobramycin neb 300/5ML QL,PA Diflucan TAB 150MG TIER 05 NON-PREFERRED BRAND SPECIALTY Diflucan TAB 200MG Bethkis Neb 300/4ML QL,PA Diflucan TAB 50MG Kitabis PAK Neb 300/5ML QL,PA Gris-peg TAB 125MG Tobi Neb 300/5ML QL,PA Gris-peg TAB 250MG Tobi Podhalr CAP 28MG QL,PA Lamisil TAB 250MG Tobramycin Neb 300/5ML QL,PA Onmel TAB 200MG PA Sporanox CAP Pulsepak PA SULFONAMIDES Sporanox CAP 100MG PA TIER 03 NON-PREFERRED Tolsura CAP 65MG PA Sulfadiazine TAB 500MG TIER 04 SPECIALTY flucytosine CAP 250MG QL ANTIMYCOBACTERIAL AGENTS flucytosine CAP 500MG QL TIER 01 GENERIC Cresemba CAP 186 MG QL,PA ethambutol TAB 100MG TIER 05 NON-PREFERRED BRAND SPECIALTY ethambutol TAB 400MG Ancobon CAP 250MG QL isoniazid TAB 100MG Ancobon CAP 500MG QL isoniazid TAB 300MG Noxafil Sus 40MG/ML QL,PA pyrazinamide TAB 500MG Noxafil TAB 100MG PA rifabutin CAP 150MG Vfend Sus 40MG/ML PA rifampin CAP 150MG Vfend TAB 200MG PA rifampin CAP 300MG Vfend TAB 50MG PA TIER 02 Isoniazid Syp 50MG/5ML PREFERRED ANTIVIRALS Priftin TAB 150MG TIER 01 GENERIC TIER 03 NON-PREFERRED abaca/lamivu TAB QL cycloserine CAP 250MG abacavir sol 20MG/ML Myambutol TAB 100MG abacavir TAB 300MG PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 3

14 acyclovir sus 200/5ML Prezista Sus 100MG/ML acyclovir CAP 200MG Prezista TAB 150MG acyclovir TAB 400MG Prezista TAB 600MG acyclovir TAB 800MG Prezista TAB 75MG adefov dipiv TAB 10MG QL Prezista TAB 800MG atazanavir CAP 150MG QL Rebetol Sol 40MG/ML QL atazanavir CAP 200MG QL Relenza Mis Diskhale atazanavir CAP 300MG QL Rescriptor TAB 100 MG didanosine CAP 200MG Rescriptor TAB 200MG didanosine CAP 250MG Reyataz Pow 50MG didanosine CAP 400MG Tamiflu CAP 30MG efavirenz CAP 200MG Tamiflu CAP 45MG efavirenz CAP 50MG Tamiflu CAP 75MG efavirenz TAB 600MG Tamiflu Sus 6MG/ML entecavir TAB 0.5MG QL Tivicay TAB 10MG entecavir TAB 1MG QL Tivicay TAB 25MG lamivud/zido TAB Tivicay TAB 50MG lamivudine sol 10MG/ML Tybost TAB 150MG PA lamivudine TAB 100MG Videx Sol 2gm lamivudine TAB 150MG Videx Sol 4gm lamivudine TAB 300MG Viracept TAB 250MG lopin/riton sol 80-20/ML Viracept TAB 625MG moderiba TAB 200MG QL Viread Pow 40MG/Gm nevirapine TAB 100MG Viread TAB 150MG nevirapine TAB 200MG Viread TAB 200MG nevirapine TAB 400MG ER Viread TAB 250MG oseltamivir sus 6MG/ML TIER 03 NON-PREFERRED oseltamivir CAP 30MG famciclovir TAB 125MG oseltamivir CAP 45MG famciclovir TAB 250MG oseltamivir CAP 75MG famciclovir TAB 500MG ribasphere CAP 200MG QL nevirapine sus 50MG/5ML ribasphere TAB 200MG QL ribavirin inh 6gm ribavirin CAP 200MG QL Combivir TAB ribavirin TAB 200MG QL Copegus TAB 200MG QL rimantadine TAB 100MG Epivir HBV TAB 100MG ritonavir TAB 100MG Epivir Sol 10MG/ML stavudine CAP 15MG Epivir TAB 150MG stavudine CAP 20MG Epivir TAB 300MG stavudine CAP 30MG Flumadine TAB 100MG stavudine CAP 40MG Isentress Pow 100MG tenofovir TAB 300MG Kaletra Sol valacyclovir TAB 1gm Moderiba PAK 1200/Day QL valacyclovir TAB 500MG Moderiba PAK 800/Day zidovudine syp 50MG/5ML Moderiba TAB 1000/Day QL zidovudine CAP 100MG Moderiba TAB 600/Day QL zidovudine TAB 300MG Norvir TAB 100MG Symfi LO TAB Rebetol CAP 200MG QL Symfi TAB Retrovir CAP 100MG TIER 02 PREFERRED Retrovir Syp 50MG/5ML Crixivan CAP 200MG Ribapak PAK 1200/Day QL Crixivan CAP 400MG Ribapak PAK 800/Day Edurant TAB 25MG Ribapak TAB 1000/Day QL Emtriva CAP 200MG Ribapak TAB 600/Day QL Emtriva Sol 10MG/ML Ribasphere TAB 400MG Epivir HBV Sol 5MG/ML Ribasphere TAB 600MG QL Intelence TAB 100MG Sitavig TAB 50MG Intelence TAB 200MG Sustiva CAP 200MG Intelence TAB 25MG Sustiva CAP 50MG Invirase CAP 200MG Sustiva TAB 600MG Invirase TAB 500MG Valtrex TAB 1gm Isentress Chw 100MG Valtrex TAB 500MG Isentress Chw 25MG Videx EC CAP 125MG Isentress HD TAB 600MG Videx EC CAP 200MG Isentress TAB 400MG Videx EC CAP 250MG Kaletra TAB MG Videx EC CAP 400MG Kaletra TAB MG Viramune Sus 50MG/5ML Norvir CAP 100MG Viramune TAB 200MG Norvir Pow 100MG Viramune XR TAB 100MG Norvir Sol 80MG/ML Viramune XR TAB 400MG Prezcobix TAB QL Virazole Inh 6gm PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 4

15 Viread TAB 300MG Reyataz CAP 200MG QL Xofluza TAB 20MG PA Reyataz CAP 300MG QL Xofluza TAB 40MG PA Sovaldi TAB 400MG QL,PA Zerit CAP 15MG Symtuza TAB QL,PA Zerit CAP 20MG Technivie TAB QL,PA Zerit CAP 30MG Trizivir TAB QL Zerit CAP 40MG Valcyte Sol 50MG/ML QL Zerit Sol 1MG/ML Valcyte TAB 450MG QL Ziagen Sol 20MG/ML Vemlidy TAB 25MG QL,PA Ziagen TAB 300MG Viekira PAK TAB QL,PA Zovirax CAP 200MG Viekira XR TAB QL,PA Zovirax Sus 200/5ML Zepatier TAB MG QL,PA Zovirax TAB 400MG TIER 04 Zovirax TAB 800MG ANTIMALARIALS SPECIALTY TIER 01 GENERIC abacav/lamiv TAB /zidovud QL chloroquine TAB 500MG fosamprenavi TAB 700MG QL hydroxychlor TAB 200MG valganciclov sol 50MG/ML QL Chloroquine TAB 250MG valganciclov TAB 450MG QL Primaquine TAB 26.3MG Aptivus CAP 250MG QL TIER 03 NON-PREFERRED Atripla TAB QL quinine sulf CAP 324MG Baraclude Sol.05MG/ML QL Coartem TAB MG Biktarvy TAB QL Krintafel TAB 150MG Cimduo TAB QL Plaquenil TAB 200MG Complera TAB QL,ST Qualaquin CAP 324MG Descovy TAB 200/25 QL TIER 04 SPECIALTY Epclusa TAB QL,PA Daraprim TAB 25MG QL Genvoya TAB Harvoni TAB MG QL,PA AMEBICIDES Juluca TAB 50-25MG QL TIER 03 NON-PREFERRED Ledip-sofosb TAB MG QL,PA Solosec Gra 2gm PA Lexiva Sus 50MG/ML QL Odefsey TAB QL ANTHELMINTICS Peg-intron Kit 120 Rp QL TIER 01 GENERIC Pegasys Inj QL albendazole TAB 200MG Pegasys Inj Proclick QL praziquantel TAB 600MG Pegasys Inj 180mcg/M QL TIER 02 PREFERRED Pegintron Kit 50mcg QL Albenza TAB 200MG Selzentry Sol 20MG/ML QL TIER 03 NON-PREFERRED Selzentry TAB 150MG QL ivermectin TAB 3MG Selzentry TAB 25MG Benznidazole TAB 100MG QL,PA Selzentry TAB 300MG QL Benznidazole TAB 12.5MG QL,PA Selzentry TAB 75MG Biltricide TAB 600MG Sofos/Velpat TAB QL,PA Emverm Chw 100MG Stribild TAB QL,ST Mebendazole Pow Triumeq TAB QL Stromectol TAB 3MG Truvada TAB QL Truvada TAB QL MISC. ANTI-INFECTIVES Truvada TAB QL TIER 01 GENERIC Truvada TAB QL clindamycin inj 300/2ML Vosevi TAB QL,PA clindamycin sol 75MG/5ML TIER 05 NON-PREFERRED BRAND SPECIALTY clindamycin CAP 150MG Aptivus Sol QL clindamycin CAP 300MG Baraclude TAB 0.5MG QL clindamycin CAP 75MG Baraclude TAB 1MG QL colistimeth inj 150MG Daklinza TAB 30MG PA dapsone TAB 100MG Daklinza TAB 60MG PA dapsone TAB 25MG Daklinza TAB 90MG PA linezolid sus 100/5ML QL Delstrigo TAB QL,PA linezolid TAB 600MG Epzicom TAB QL metronidazol TAB 250MG Evotaz TAB QL metronidazol TAB 500MG Fuzeon Inj 90MG QL smz-tmp sus /5 Hepsera TAB 10MG QL smz-tmp DS TAB Lexiva TAB 700MG QL smz-tmp TAB MG Mavyret TAB MG QL,PA smz/tmp DS TAB Olysio CAP 150MG QL,PA sulfatrim PD sus /5 Pifeltro TAB 100MG QL,PA trimethoprim TAB 100MG Prevymis TAB 240MG QL,PA vancomycin CAP 125MG QL Prevymis TAB 480MG QL,PA vancomycin CAP 250MG QL Reyataz CAP 150MG QL PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5

16 vancomycin 250/5ML Temodar CAP 100MG QL TIER 02 PREFERRED Temodar CAP 140MG QL Alinia Sus 100/5ML Temodar CAP 180MG QL Alinia TAB 500MG Temodar CAP 20MG QL Firvanq Sol 25MG/ML Temodar CAP 250MG QL Firvanq Sol 50MG/ML Temodar CAP 5MG QL Primsol Sol 50MG/5ML TIER 05 NON-PREFERRED BRAND SPECIALTY Trimpex Sol 50MG/5ML Valchlor Gel 0.016% QL,PA TIER 03 NON-PREFERRED lincomycin inj 300MG/ML ANTIMETABOLITES metronidazol CAP 375MG TIER 01 GENERIC tinidazole TAB 250MG capecitabine TAB 150MG QL,PA tinidazole TAB 500MG capecitabine TAB 500MG QL,PA Aemcolo TAB 194MG PA fluorouracil CRE 5% Bactrim DS TAB mercaptopur TAB 50MG Bactrim TAB MG methotrexate inj 1gm Cleocin CAP 150MG methotrexate inj 1gm/40ML Cleocin CAP 300MG methotrexate inj 25MG/ML Cleocin CAP 75MG methotrexate inj 250/10ML Cleocin Phos Inj 300/2ML methotrexate inj 50MG/2ML Cleocin PED Sol 75MG/5ML methotrexate TAB 2.5MG Coly-mycin M Inj 150MG Fluorouracil Sol 2% First-vanc Sol 25MG/ML Fluorouracil Sol 5% First-vanc Sol 50MG/ML Methotrexate Inj 25MG/ML Flagyl CAP 375MG TIER 02 PREFERRED Flagyl TAB 250MG Carac CRE 0.5% Flagyl TAB 500MG Fluoroplex CRE 1% Lincocin Inj 300MG/ML Fluorouracil CRE 0.5% Nebupent Inh 300MG Tabloid TAB 40MG Pentam 300 Inj 300MG TIER 03 NON-PREFERRED TIER 04 Tindamax TAB 500MG Efudex CRE 5% SPECIALTY Gemcitabine Inj 2gm/20ML atovaquone sus 750/5ML Gemcitabine Inj 200MG TIER 05 Sivextro TAB 200MG QL Purixan Sus 20MG/ML PA NON-PREFERRED BRAND SPECIALTY Tolak CRE 4% Cayston Inh 75MG QL,PA Trexall TAB 10MG Impavido CAP 50MG QL,PA Trexall TAB 15MG Mepron Sus Trexall TAB 5MG Vancocin HCL CAP 125MG QL Trexall TAB 7.5MG Vancocin HCL CAP 250MG QL Xatmep Sol 2.5MG/ML QL Xifaxan TAB 200MG QL,PA Xeloda TAB 150MG QL,PA Xifaxan TAB 550MG QL,PA Xeloda TAB 500MG QL,PA Zyvox Sus 100MG/5m QL Zyvox TAB 600MG HORMONAL AGENTS TIER 01 GENERIC ANTINEOPLASTICS, ETC. abiraterone TAB 250MG QL,PA ALKYLATING AGENTS anastrozole TAB 1MG TIER 01 GENERIC bicalutamide TAB 50MG cyclophosph CAP 25MG flutamide CAP 125MG cyclophosph CAP 50MG letrozole TAB 2.5MG melphalan TAB 2MG QL leuprolide inj 1MG/0.2 temozolomide CAP 100MG QL megestrol ac sus 40MG/ML temozolomide CAP 140MG QL megestrol ac sus 400MG/10 temozolomide CAP 180MG QL megestrol ac TAB 20MG temozolomide CAP 20MG QL megestrol ac TAB 40MG temozolomide CAP 250MG QL tamoxifen TAB 10MG temozolomide CAP 5MG QL tamoxifen TAB 20MG Cyclophosph CAP 25MG TIER 02 PREFERRED Cyclophosph CAP 50MG Lupron Depot Inj 11.25MG TIER 02 PREFERRED Lupron Depot Inj 22.5MG Gleostine CAP 10MG Lupron Depot Inj 3.75MG Gleostine CAP 100MG Lupron Depot Inj 30MG Gleostine CAP 40MG Lupron Depot Inj 45MG Gleostine CAP 5MG Lupron Depot Inj 7.5MG Leukeran TAB 2MG Xtandi CAP 40MG QL,PA Myleran TAB 2MG QL Zytiga TAB 250MG QL,PA TIER 03 NON-PREFERRED Zytiga TAB 500MG QL,PA Alkeran TAB 2MG QL TIER 03 NON-PREFERRED Hexalen CAP 50MG QL exemestane TAB 25MG PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 6

17 nilutamide TAB 150MG PA Imuran TAB 50MG toremifene TAB 60MG PA Myfortic TAB 180MG Arimidex TAB 1MG Myfortic TAB 360MG Aromasin TAB 25MG Neoral CAP 100MG Casodex TAB 50MG Neoral CAP 25MG Depo-provera Inj 400/ML Neoral Sol 100MG/ML Eligard Inj 22.5MG Pomalyst CAP 1MG QL,PA Eligard Inj 30MG Pomalyst CAP 2MG QL,PA Eligard Inj 45MG Pomalyst CAP 3MG QL,PA Eligard Inj 7.5MG Pomalyst CAP 4MG QL,PA Emcyt CAP 140MG QL Prograf CAP 0.5MG Erleada TAB 60MG QL,PA Prograf CAP 1MG Fareston TAB 60MG PA Prograf CAP 5MG Femara TAB 2.5MG Rapamune TAB 0.5MG Lysodren TAB 500MG PA Rapamune TAB 1MG Megestrol Pow Acetate Rapamune TAB 2MG Nilandron TAB 150MG PA Sandimmune CAP 100MG Soltamox Sol 10MG/5ML Sandimmune CAP 25MG Yonsa TAB 125MG QL,PA Sandimmune Sol 100MG/ML TIER 05 NON-PREFERRED BRAND SPECIALTY IMMUNOMODULATORS Zortress TAB 0.25MG QL TIER 01 GENERIC Zortress TAB 0.5MG QL azathioprine TAB 50MG Zortress TAB 0.75MG QL cyclosporine sol modified cyclosporine CAP 100MG Zortress TAB 1MG QL cyclosporine CAP 100MG MD MITOTIC INHIBITORS cyclosporine CAP 25MG TIER 01 GENERIC cyclosporine CAP 25MG mod Etoposide CAP 50MG QL gengraf sol 100MG/ML gengraf CAP 100MG ENZYME INHIBITORS gengraf CAP 25MG TIER 01 GENERIC gengraf CAP 50MG imatinib mes TAB 100MG QL,PA mycophenolat sus 200MG/ML imatinib mes TAB 400MG QL,PA mycophenolat CAP 250MG TIER 02 PREFERRED mycophenolat TAB 500MG Afinitor Dis TAB 2MG QL,PA mycophenolic TAB 180MG DR Afinitor Dis TAB 3MG QL,PA mycophenolic TAB 360MG DR Afinitor Dis TAB 5MG QL,PA sirolimus TAB 0.5MG Afinitor TAB 10MG QL,PA sirolimus TAB 1MG Afinitor TAB 2.5MG QL,PA sirolimus TAB 2MG Afinitor TAB 5MG QL,PA tacrolimus CAP 0.5MG Afinitor TAB 7.5MG QL,PA tacrolimus CAP 1MG Gilotrif TAB 20MG QL,PA tacrolimus CAP 5MG Gilotrif TAB 30MG QL,PA TIER 02 Cyclosporine CAP 50MG Mod Gilotrif TAB 40MG QL,PA PREFERRED Imbruvica CAP 140MG QL,PA sirolimus sol 1MG/ML Imbruvica CAP 70MG QL,PA Rapamune Sol 1MG/ML Imbruvica TAB 140MG QL,PA Revlimid CAP 10MG QL,PA Imbruvica TAB 280MG QL,PA Revlimid CAP 15MG QL,PA Imbruvica TAB 420MG QL,PA Revlimid CAP 2.5MG QL,PA Imbruvica TAB 560MG QL,PA Revlimid CAP 20MG QL,PA Iressa TAB 250MG QL,PA Revlimid CAP 25MG QL,PA Mekinist TAB 0.5MG QL,PA Revlimid CAP 5MG QL,PA Mekinist TAB 2MG QL,PA Thalomid CAP 100MG QL,PA Nexavar TAB 200MG PA Thalomid CAP 150MG QL,PA Rydapt CAP 25MG QL,PA Thalomid CAP 200MG QL,PA Sprycel TAB 100MG QL,PA TIER 03 Thalomid CAP 50MG QL,PA Sprycel TAB 140MG QL,PA NON-PREFERRED Sprycel TAB 20MG QL,PA Astagraf XL CAP 0.5MG Sprycel TAB 50MG QL,PA Astagraf XL CAP 1MG Sprycel TAB 70MG QL,PA Astagraf XL CAP 5MG Sprycel TAB 80MG QL,PA Azasan TAB 100MG Stivarga TAB 40MG PA Azasan TAB 75 MG Sutent CAP 12.5MG QL,PA Cellcept CAP 250MG Sutent CAP 25MG QL,PA Cellcept Sus 200MG/ML Sutent CAP 37.5MG QL,PA Cellcept TAB 500MG Sutent CAP 50MG QL,PA Envarsus XR TAB 0.75MG Tafinlar CAP 50MG QL,PA Envarsus XR TAB 1MG Tafinlar CAP 75MG QL,PA Envarsus XR TAB 4MG Tagrisso TAB 40MG QL,PA PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 7

18 Tagrisso TAB 80MG QL,PA Ninlaro CAP 4MG QL,PA Tarceva TAB 100MG PA Rubraca TAB 200MG QL,PA Tarceva TAB 150MG PA Rubraca TAB 250MG QL,PA Tarceva TAB 25MG PA Rubraca TAB 300MG QL,PA Tykerb TAB 250MG QL,PA Talzenna CAP 0.25MG QL,PA Votrient TAB 200MG QL,PA Talzenna CAP 1MG QL,PA Zydelig TAB 100MG QL,PA Tasigna CAP 150MG QL,PA Zydelig TAB 150MG QL,PA Tasigna CAP 200MG QL,PA TIER 03 NON-PREFERRED Tasigna CAP 50MG QL,PA Alecensa CAP 150MG QL,PA Tibsovo TAB 250MG QL,PA Alunbrig PAK QL,PA Verzenio TAB 100MG QL,PA Alunbrig TAB 180MG QL,PA Verzenio TAB 150MG QL,PA Alunbrig TAB 30MG QL,PA Verzenio TAB 200MG QL,PA Alunbrig TAB 90MG QL,PA Verzenio TAB 50MG QL,PA Bosulif TAB 100MG QL,PA Vitrakvi CAP 100MG QL,PA Bosulif TAB 400MG QL,PA Vitrakvi CAP 25MG QL,PA Bosulif TAB 500MG QL,PA Vitrakvi Sol 20MG/ML QL,PA Braftovi CAP 50MG QL,PA Vizimpro TAB 15MG QL,PA Braftovi CAP 75MG QL,PA Vizimpro TAB 30MG QL,PA Cabometyx TAB 20MG PA Vizimpro TAB 45MG QL,PA Cabometyx TAB 40MG PA Xalkori CAP 200MG QL,PA Cabometyx TAB 60MG PA Xalkori CAP 250MG QL,PA Calquence CAP 100MG QL,PA Xospata TAB 40MG QL,PA Caprelsa TAB 100MG QL,PA Zejula CAP 100MG QL,PA Caprelsa TAB 300MG QL,PA Zelboraf TAB 240MG PA Cometriq Kit 100MG QL,PA Zolinza CAP 100MG QL,PA Cometriq Kit 140MG QL,PA Zykadia CAP 150MG QL,PA Cometriq Kit 60MG QL,PA Copiktra CAP 15MG QL,PA TOPOISOMERASE I INHIBITOR Copiktra CAP 25MG QL,PA TIER 03 NON-PREFERRED Cotellic TAB 20MG QL,PA Hycamtin CAP 0.25MG QL Farydak CAP 10MG QL,PA Hycamtin CAP 1MG QL Farydak CAP 15MG QL,PA Farydak CAP 20MG QL,PA ANTINEOPLASTICS MISC. Gleevec TAB 100MG QL,PA TIER 01 GENERIC Gleevec TAB 400MG QL,PA hydroxyurea CAP 500MG Ibrance CAP 100MG QL,PA tretinoin CAP 10MG QL Ibrance CAP 125MG QL,PA TIER 02 PREFERRED Ibrance CAP 75MG QL,PA Intron A Inj 10mu QL Iclusig TAB 15MG QL,PA Intron A Inj 18mu QL Iclusig TAB 45MG QL,PA Intron A Inj 25mu QL Idhifa TAB 100MG QL,PA Intron A Inj 50mu QL Idhifa TAB 50MG QL,PA Matulane CAP 50MG QL Inlyta TAB 1MG QL,PA Picato Gel 0.015% QL Inlyta TAB 5MG QL,PA Picato Gel 0.05% QL Jakafi TAB 10MG PA TIER 03 NON-PREFERRED Jakafi TAB 15MG PA bexarotene CAP 75MG QL,PA Jakafi TAB 20MG PA Alferon N Inj 5mu/ML Jakafi TAB 25MG PA Hydrea CAP 500MG Jakafi TAB 5MG PA Sylatron Kit 200mcg QL Kisqali TAB 200dose QL,PA Sylatron Kit 300mcg QL Kisqali TAB 400dose QL,PA Sylatron Kit 600mcg QL Kisqali TAB 600dose QL,PA Targretin CAP 75MG QL,PA Lenvima CAP 10 MG QL,PA TIER 05 NON-PREFERRED BRAND SPECIALTY Lenvima CAP 12MG QL,PA Actimmune Inj 2mu/0.5 QL Lenvima CAP 14 MG QL,PA Lenvima CAP 18 MG PA CHEMOTHERAPY RESCUE Lenvima CAP 20 MG QL,PA TIER 01 GENERIC Lenvima CAP 24 MG QL,PA leucovor CA TAB 25MG Lenvima CAP 4MG QL,PA leucovor CA TAB 5MG Lenvima CAP 8 MG PA mesna inj 1gm Lorbrena TAB 100MG QL,PA Leucovor CA TAB 10MG Lorbrena TAB 25MG QL,PA Leucovor CA TAB 15MG Lynparza CAP 50MG QL,PA TIER 02 PREFERRED Lynparza TAB 100MG QL,PA Mesnex TAB 400MG Lynparza TAB 150MG QL,PA TIER 03 NON-PREFERRED Mektovi TAB 15MG QL,PA Leucovorin Inj 100/10ML Nerlynx TAB 40MG QL,PA Ninlaro CAP 2.3MG QL,PA Ninlaro CAP 3MG QL,PA PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 8

19 ANTINEOPLASTIC COMBO TIER 03 NON-PREFERRED Kisqali 200 PAK Femara QL,PA Kisqali 400 PAK Femara QL,PA Kisqali 600 PAK Femara QL,PA Lonsurf TAB QL,PA Lonsurf TAB QL,PA CARDIOVASCULAR DRUGS CARDIAC GLYCOSIDES TIER 01 TIER 03 GENERIC digitek TAB 0.125MG digitek TAB 0.25MG digox TAB 0.125MG digox TAB 0.25MG digoxin inj 0.25MG/1 digoxin TAB 0.125MG digoxin TAB 0.25MG Digoxin Sol 50mcg/ML NON-PREFERRED Lanoxin Inj 0.25MG/1 Lanoxin PED Inj 0.1MG/ML Lanoxin TAB MG Lanoxin TAB 0.125MG Lanoxin TAB MG Lanoxin TAB 0.25MG ANTIANGINAL AGENTS TIER 01 GENERIC isosorb din TAB 10MG isosorb din TAB 20MG isosorb din TAB 30MG isosorb din TAB 5MG isosorb mono TAB 10MG isosorb mono TAB 120MG ER isosorb mono TAB 20MG isosorb mono TAB 30MG ER isosorb mono TAB 60MG ER minitran dis 0.1MG/HR minitran dis 0.2MG/HR minitran dis 0.4MG/HR minitran dis 0.6MG/HR nitro-time CAP 9MG CR nitroglycer dis 0.1MG/HR nitroglycer dis 0.2MG/HR nitroglycer dis 0.4MG/HR nitroglycer dis 0.6MG/HR nitroglycer CAP 9MG ER nitroglyceri sub 0.6MG nitroglycern sub 0.3MG nitroglycern sub 0.4MG TIER 02 PREFERRED Isordil TAB 40MG Nitro-bid Oin 2% Nitro-dur Dis 0.3MG/HR Nitro-dur Dis 0.8MG/HR TIER 03 NON-PREFERRED nitroglycrn spr 0.4MG Dilatrate SR CAP 40MG Gonitro Pow 400mcg Isordil TAB 5MG Isosorb Din TAB 40MG ER Nitro-dur Dis 0.1MG/HR Nitro-dur Dis 0.2MG/HR Nitro-dur Dis 0.4MG/HR Nitro-dur Dis 0.6MG/HR Nitroglycer Aer 400mcg Nitrolingual Spr Pumpspra Nitromist Aer 400mcg Nitrostat Sub 0.3MG Nitrostat Sub 0.4MG Nitrostat Sub 0.6MG Ranexa TAB 1000MG PA Ranexa TAB 500MG PA BETA BLOCKERS TIER 01 GENERIC acebutolol CAP 200MG acebutolol CAP 400MG atenolol TAB 100MG atenolol TAB 25MG atenolol TAB 50MG betaxolol TAB 10MG betaxolol TAB 20MG bisoprol fum TAB 10MG bisoprol fum TAB 5MG carvedilol TAB 12.5MG carvedilol TAB 25MG carvedilol TAB 3.125MG carvedilol TAB 6.25MG labetalol TAB 100MG labetalol TAB 200MG labetalol TAB 300MG metoprol suc TAB 100MG ER metoprol suc TAB 200MG ER metoprol suc TAB 25MG ER metoprol suc TAB 50MG ER metoprol TAR TAB 100MG metoprol TAR TAB 25MG metoprol TAR TAB 50MG metoprolol TAB 100MG ER metoprolol TAB 200MG ER metoprolol TAB 25MG ER metoprolol TAB 50MG ER nadolol TAB 20MG nadolol TAB 40MG nadolol TAB 80MG pindolol TAB 10MG pindolol TAB 5MG propranolol CAP 120MG ER propranolol CAP 160MG ER propranolol CAP 60MG ER propranolol CAP 80MG ER propranolol TAB 10MG propranolol TAB 20MG propranolol TAB 40MG propranolol TAB 60MG propranolol TAB 80MG sorine TAB 120MG sorine TAB 160MG sorine TAB 240MG sorine TAB 80MG sotalol AF TAB 120MG sotalol AF TAB 160MG sotalol AF TAB 80MG sotalol HCL TAB 120MG sotalol HCL TAB 160MG sotalol HCL TAB 240MG sotalol HCL TAB 80MG Metoprolol TAB 37.5MG Metoprolol TAB 75MG Propranolol Sol 20MG/5ML Propranolol Sol 40MG/5ML Timolol Mal TAB 10MG Timolol Mal TAB 20MG Timolol Mal TAB 5MG TIER 03 NON-PREFERRED carvedilol CAP 10MG ER PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 9

20 carvedilol CAP 20MG ER diltiazem CAP 240MG ER carvedilol CAP 40MG ER diltiazem CAP 300MG CD carvedilol CAP 80MG ER diltiazem CAP 300MG ER Betapace AF TAB 120MG diltiazem CAP 360MG CD Betapace AF TAB 160MG diltiazem CAP 360MG ER Betapace AF TAB 80MG diltiazem CAP 60MG ER Betapace TAB 120MG diltiazem CAP 90MG ER Betapace TAB 160MG diltiazem ER CAP 360MG Betapace TAB 80MG diltiazem TAB 120MG Bystolic TAB 10MG diltiazem TAB 30MG Bystolic TAB 2.5MG diltiazem TAB 60MG Bystolic TAB 20MG diltiazem TAB 90MG Bystolic TAB 5MG felodipine TAB 10MG ER Coreg CR CAP 10MG felodipine TAB 2.5MG ER Coreg CR CAP 20MG felodipine TAB 5MG ER Coreg CR CAP 40MG isradipine CAP 2.5MG Coreg CR CAP 80MG isradipine CAP 5MG Coreg TAB 12.5MG nicardipine CAP 20MG Coreg TAB 25MG nicardipine CAP 30MG Coreg TAB 3.125MG nifedipine CAP 10MG Coreg TAB 6.25MG nifedipine CAP 20MG Corgard TAB 20MG nifedipine TAB 30MG ER Corgard TAB 40MG nifedipine TAB 60MG ER Corgard TAB 80MG nifedipine TAB 90MG ER First - Meto Sol 10MG/ML nimodipine CAP 30MG Hemangeol Sol 4.28/ML PA verapamil CAP 120MG ER Inderal LA CAP 120MG verapamil CAP 120MG SR Inderal LA CAP 160MG verapamil CAP 180MG ER Inderal LA CAP 60MG verapamil CAP 180MG SR Inderal LA CAP 80MG verapamil CAP 240MG ER Inderal XL CAP 120MG verapamil CAP 240MG SR Inderal XL CAP 80MG verapamil TAB 120MG Innopran XL CAP 120MG verapamil TAB 120MG ER Innopran XL CAP 80MG verapamil TAB 180MG ER Kapspargo CAP 100MG verapamil TAB 240MG ER Kapspargo CAP 200MG verapamil TAB 40MG Kapspargo CAP 25MG verapamil TAB 80MG Kapspargo CAP 50MG Verapamil CAP 360MG SR Lopressor TAB 100MG TIER 03 NON-PREFERRED Lopressor TAB 50MG diltiazem CAP 120MG/24 Sotylize Sol 5MG/ML diltiazem CAP 180MG/24 Tenormin TAB 100MG diltiazem CAP 240MG/24 Tenormin TAB 25MG diltiazem CAP 300MG/24 Tenormin TAB 50MG diltiazem CAP 360MG/24 Toprol XL TAB 100MG diltiazem CAP 420MG/24 Toprol XL TAB 200MG diltiazem ER TAB 180MG Toprol XL TAB 25MG diltiazem ER TAB 240MG Toprol XL TAB 50MG diltiazem ER TAB 300MG Zebeta TAB 10MG diltiazem ER TAB 360MG diltiazem ER TAB 420MG CALCIUM CHANNEL BLOCKERS matzim LA TAB 180MG/24 TIER 01 GENERIC matzim LA TAB 240MG/24 afeditab TAB 30MG CR matzim LA TAB 300MG/24 afeditab TAB 60MG CR matzim LA TAB 360MG/24 amlodipine TAB 10MG matzim LA TAB 420MG/24 amlodipine TAB 2.5MG nisoldipine TAB 17MG ER amlodipine TAB 5MG nisoldipine TAB 34MG ER cartia XT CAP 120/24HR nisoldipine TAB 8.5MG ER cartia XT CAP 180/24HR taztia XT CAP 120MG/24 cartia XT CAP 240/24HR taztia XT CAP 180MG/24 cartia XT CAP 300/24HR taztia XT CAP 240MG/24 dilt-xr CAP 120MG taztia XT CAP 300MG/24 dilt-xr CAP 180MG taztia XT CAP 360MG/24 dilt-xr CAP 240MG verapamil CAP 100MG ER diltiazem CAP 120MG CD verapamil CAP 200MG ER diltiazem CAP 120MG ER verapamil CAP 300MG ER diltiazem CAP 180MG CD Adalat CC TAB 30MG ER diltiazem CAP 180MG ER Adalat CC TAB 60MG ER diltiazem CAP 240MG CD Adalat CC TAB 90MG ER Calan SR TAB 120MG PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 10