2017 Drug Formulary. Effective November For members covered through large employer groups with a 3-tier in-network pharmacy

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1 Effective November Drug Formulary For members covered through large employer groups with a 3-tier in-network pharmacy benefit or members with an out-of-network pharmacy benefit Access PPO Alliance Alliant Plus Core Elect PPO Omni PPO Options PPO 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 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

3 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. 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 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

4 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 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. 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. Excluded Prescription Products for Medications that have Over-The-Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium) and omeprazole/sodium bicarbonate (Zegerid).

5 Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the webpage. 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 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 ANGIOTENSIN RCPTR BLOCKER

7 DIRECT RENIN INHIBITORS ANTIHYPERTENSIVES MISC ANTIHYPERTENSIVE COMBO DIURETICS VASOPRESSORS ANTIHYPERLIPIDEMICS CARDIOVASCULAR - MISC DERMATOLOGICALS ACNE PRODUCTS ROSACEA AGENTS ANTIBIOTICS - TOPICAL ANTIFUNGALS - TOPICAL ANTIVIRALS - 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 ANTIDIABETIC COMBINATIONS

8 BISPHOSPHONATES CALCITONINS PARATHYROID HORMONE HORMONE RECEPTOR MDLTR LHRH/GNRH AGONIST 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 ANTIANXIETY AGENTS ANTIDEPRESSANTS

9 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 ANTIASTHMATIC/COPD AGENTS RESPIRATORY AGENTS - MISC

10 TOXOIDS VACCINES VITAMINS VITAMINS MULTIVITAMINS MEDICAL DEVICES DIABETIC SUPPLIES MEDICAL DEVICES - MISC MISCELLANEOUS AGENTS

11 PENICILLINS TIER 01 TIER 02 TIER 03 November 2017 ANTI-INFECTIVES GENERIC amox/k clav sus 200/5ML amox/k clav sus 250/5ML amox/k clav sus 400/5ML amox/k clav sus 600/5ML amox/k clav TAB amox/k clav TAB amox/k clav TAB amoxicillin sus 125/5ML amoxicillin sus 200/5ML amoxicillin sus 250/5ML amoxicillin sus 250MG/5m amoxicillin sus 400/5ML amoxicillin CAP 250MG amoxicillin CAP 500MG amoxicillin TAB 500MG amoxicillin TAB 875MG ampicillin inj 1gm ampicillin inj 250MG ampicillin inj 500MG ampicillin CAP 250MG ampicillin CAP 500MG dicloxacill CAP 250MG dicloxacill CAP 500MG penicilln vk sol 125/5ML penicilln vk sol 250/5ML penicilln vk TAB 250MG penicilln vk TAB 500MG Amox/K Clav Chw 200MG Amox/K Clav Chw 400MG Amoxicillin Chw 125MG Amoxicillin Chw 250MG Ampicillin CAP 500MG Ampicillin Inj 125MG Ampicillin Sus 125/5ML Ampicillin Sus 250/5ML Penicilln Vk Sol 125/5ML Penicilln Vk Sol 250/5ML PREFERRED Bicillin L-a Inj Bicillin L-a Inj Bicillin L-a Inj NON PREFERRED amox-pot cla TAB ER Amoxicillin TAB 775MG Augmentin Sus ES-600 Augmentin Sus 125/5ML Augmentin Sus 250/5ML Augmentin TAB 500MG Augmentin TAB 875MG Augmentin XR TAB 12HR Moxatag TAB 775MG CEPHALOSPORIN FIRST GENERATION TIER 01 GENERIC cefadroxil sus 250/5ML cefadroxil sus 500/5ML cefadroxil CAP 500MG cefadroxil TAB 1gm cefazolin inj 1gm cephalexin sus 125/5ML cephalexin sus 250/5ML cephalexin CAP 250MG cephalexin CAP 500MG TIER 03 NON PREFERRED cephalexin CAP 750MG Cephalexin TAB 250MG Cephalexin TAB 500MG Daxbia CAP 333MG Keflex CAP 250MG Keflex CAP 500MG Keflex CAP 750MG SECOND GENERATION TIER 01 GENERIC cefprozil sus 125/5ML cefprozil sus 250/5ML cefprozil TAB 250MG cefprozil TAB 500MG cefuroxime TAB 250MG cefuroxime TAB 500MG TIER 02 PREFERRED Ceftin Sus 125/5ML Ceftin Sus 250/5ML TIER 03 NON PREFERRED cefaclor CAP 250MG cefaclor CAP 500MG Cefaclor ER TAB 500MG Cefaclor Sus 125/5ML Cefaclor Sus 250/5ML Cefaclor Sus 375/5ML Ceftin TAB 250MG Ceftin TAB 500MG THIRD GENERATION TIER 01 GENERIC cefdinir sus 125/5ML cefdinir sus 250/5ML cefdinir CAP 300MG cefixime sus 100/5ML cefixime sus 200/5ML ceftazidime inj 1gm ceftriaxone inj 1gm ceftriaxone inj 2gm ceftriaxone inj 250MG ceftriaxone inj 500MG tazicef inj 1gm TIER 02 PREFERRED Suprax CAP 400MG Suprax Sus 500/5ML TIER 03 NON PREFERRED cefpodo prox sus 100/5ML cefpodo prox sus 50MG/5ML cefpodoxime TAB 100MG cefpodoxime TAB 200MG Cedax CAP 400MG Cedax Sus 180/5ML Cefditoren TAB 200MG Cefditoren TAB 400MG Ceftibuten CAP 400MG Ceftibuten Sus 180/5ML Fortaz Inj 1gm Spectracef TAB 400MG Suprax Chw 100MG Suprax Chw 200MG Suprax Sus 100/5ML Suprax Sus 200/5ML FOURTH GENERATION TIER 03 NON PREFERRED cefepime inj 1gm cefepime inj 2gm Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1

12 Maxipime Inj 1gm 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 02 PREFERRED E.e.s. Gran Sus 200/5ML Eryped Sus 200/5ML TIER 03 NON PREFERRED clarithromyc TAB 500MG ER erythrom ETH sus 200/5ML erythromycin CAP 250MG EC Biaxin Sus 250/5ML Biaxin TAB 250MG Biaxin TAB 500MG Dificid TAB 200MG QL,PA E.e.s. 400 TAB 400MG Ery-TAB Tab 250MG EC Ery-TAB Tab 333MG EC Ery-TAB Tab 500MG EC Eryped Sus 400/5ML Erythrocin TAB 250MG Erythrom ETH TAB 400MG Erythromycin TAB 250MG Bs Erythromycin TAB 500MG Bs 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 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 minocycline CAP 100MG minocycline CAP 50MG minocycline CAP 75MG mondoxyne nl CAP 100MG mondoxyne nl CAP 50MG mondoxyne nl CAP 75MG TIER 03 NON PREFERRED 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 135MG ER PA minocycline TAB 45MG ER PA minocycline TAB 50MG minocycline TAB 75MG minocycline TAB 90MG ER PA morgidox CAP 1X100MG morgidox CAP 1X50MG morgidox CAP 2X100MG tetracycline CAP 250MG tetracycline CAP 500MG Acticlate TAB 150MG Acticlate TAB 75MG Adoxa CAP 150MG 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 Minocin CAP 100MG Minocin CAP 50MG Minocin CAP 75MG Minocycline TAB 45MG ER 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 Ximino CAP 45MG ER Ximino CAP 90MG ER QUINOLONES TIER 01 GENERIC ciprofloxacn sus 500MG/5 ciprofloxacn TAB 250MG ciprofloxacn TAB 500MG ciprofloxacn TAB 750MG levofloxacin sol 25MG/ML levofloxacin TAB 250MG levofloxacin TAB 500MG levofloxacin TAB 750MG moxifloxacin TAB 400MG Ciprofloxacn TAB 100MG Levofloxacin Sol 25MG/ML TIER 02 PREFERRED ciprofloxacn sus 250MG/5 Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 2

13 Cipro (5%) Sus 250MG/5 fluconazole TAB 200MG TIER 03 NON PREFERRED fluconazole TAB 50MG ciprofloxacn TAB 1000MG griseofulvin sus 125/5ML ciprofloxacn TAB 500MG ER griseofulvin TAB micr 500 ofloxacin TAB 400MG griseofulvin TAB ultr 125 Avelox Abc TAB 400MG griseofulvin TAB ultr 250 Avelox TAB 400MG itraconazole CAP 100MG PA Baxdela TAB 450MG QL,PA ketoconazole TAB 200MG Cipro (10%) Sus 500MG/5 nystatin TAB Cipro TAB 250MG terbinafine TAB 250MG Cipro TAB 500MG voriconazole sus 40MG/ML PA Cipro XR TAB 1000MG voriconazole TAB 200MG PA Cipro XR TAB 500MG voriconazole TAB 50MG PA Factive TAB 320MG Amphotericin Inj 50MG Levaquin TAB 250MG TIER 02 PREFERRED Levaquin TAB 500MG flucytosine CAP 250MG QL Levaquin TAB 750MG flucytosine CAP 500MG QL Ofloxacin TAB 300MG Cresemba CAP 186 MG QL,PA Sporanox Sol 10MG/ML PA AMINOGLYCOSIDES TIER 03 NON PREFERRED TIER 01 GENERIC bio-statin pow gentamicin inj 40MG/ML nystatin pow neomycin TAB 500MG Ancobon CAP 250MG QL tobramycin neb 300/5ML QL,PA Ancobon CAP 500MG QL TIER 03 NON PREFERRED Bio-statin CAP paromomycin CAP 250MG Bio-statin CAP Bethkis Neb 300/4ML QL,PA Diflucan Sus 10MG/ML Kitabis PAK Neb 300/5ML QL,PA Diflucan Sus 40MG/ML Streptomycin Inj 1gm Diflucan TAB 100MG Tobi Neb 300/5ML QL,PA Diflucan TAB 150MG Tobi Podhalr CAP 28MG QL,PA Diflucan TAB 200MG Tobramycin Neb 300/5ML QL,PA Diflucan TAB 50MG Grifulvin V TAB 500MG SULFONAMIDES Gris-peg TAB 125MG TIER 03 NON PREFERRED Gris-peg TAB 250MG Sulfadiazine TAB 500MG Lamisil Gra 125MG Lamisil Gra 187.5MG ANTIMYCOBACTERIAL AGENTS Lamisil TAB 250MG Noxafil Sus 40MG/ML TIER 01 GENERIC QL,PA ethambutol TAB 100MG Noxafil TAB 100MG PA ethambutol TAB 400MG Onmel TAB 200MG PA isoniazid TAB 100MG Sporanox CAP Pulsepak PA isoniazid TAB 300MG Sporanox CAP 100MG PA pyrazinamide TAB 500MG Vfend Sus 40MG/ML PA rifabutin CAP 150MG Vfend TAB 200MG PA rifampin CAP 150MG Vfend TAB 50MG PA TIER 02 rifampin CAP 300MG Isoniazid Syp 50MG/5ML ANTIVIRALS PREFERRED TIER 01 GENERIC Priftin TAB 150MG PA abaca/lamivu TAB QL TIER 03 Cycloserine CAP 250MG NON PREFERRED abacav/lamiv TAB /zidovud QL abacavir sol 20MG/ML Myambutol TAB 100MG abacavir TAB 300MG Myambutol TAB 400MG acyclovir sus 200/5ML Mycobutin CAP 150MG acyclovir CAP 200MG Paser Gra 4gm acyclovir TAB 400MG Rifadin CAP 150MG acyclovir TAB 800MG Rifadin CAP 300MG adefov dipiv TAB 10MG QL Rifamate CAP didanosine CAP 125MG Rifater TAB didanosine CAP 200MG Sirturo TAB 100MG QL,PA didanosine CAP 250MG Trecator TAB 250MG didanosine CAP 400MG entecavir TAB 0.5MG QL ANTIFUNGALS entecavir TAB 1MG QL fosamprenavi TAB 700MG TIER 01 GENERIC QL fluconazole sus 10MG/ML lamivud/zido TAB fluconazole sus 40MG/ML lamivudine sol 10MG/ML fluconazole TAB 100MG lamivudine TAB 100MG fluconazole TAB 150MG lamivudine TAB 150MG Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 3

14 lamivudine TAB 300MG Pegintron Kit 80mcg QL lopin/riton sol 80-20/ML Prezcobix TAB QL,PA moderiba TAB 200MG QL Prezista Sus 100MG/ML nevirapine TAB 200MG Prezista TAB 150MG nevirapine TAB 400MG ER Prezista TAB 600MG oseltamivir CAP 30MG Prezista TAB 75MG oseltamivir CAP 45MG Prezista TAB 800MG oseltamivir CAP 75MG Rebetol Sol 40MG/ML QL ribasphere CAP 200MG QL Relenza Mis Diskhale ribasphere TAB 200MG QL Rescriptor TAB 100 MG ribavirin CAP 200MG QL Rescriptor TAB 200MG ribavirin TAB 200MG QL Reyataz CAP 150MG QL rimantadine TAB 100MG Reyataz CAP 200MG QL stavudine sol 1MG/ML Reyataz CAP 300MG QL stavudine CAP 15MG Reyataz Pow 50MG QL stavudine CAP 20MG Selzentry Sol 20MG/ML QL stavudine CAP 30MG Selzentry TAB 150MG QL stavudine CAP 40MG Selzentry TAB 25MG valacyclovir TAB 1gm Selzentry TAB 300MG QL valacyclovir TAB 500MG Selzentry TAB 75MG valganciclov TAB 450MG QL Sovaldi TAB 400MG QL,PA zidovudine syp 50MG/5ML Stribild TAB QL,ST zidovudine CAP 100MG Sustiva CAP 200MG zidovudine TAB 300MG Sustiva CAP 50MG Nevirapine Sus 50MG/5ML Sustiva TAB 600MG TIER 02 PREFERRED Tamiflu Sus 6MG/ML Aptivus CAP 250MG QL Tivicay TAB 10MG Atripla TAB QL Tivicay TAB 25MG Baraclude Sol.05MG/ML QL Tivicay TAB 50MG Complera TAB QL,ST Triumeq TAB QL Crixivan CAP 200MG Truvada TAB QL Crixivan CAP 400MG Truvada TAB QL Descovy TAB 200/25 QL Truvada TAB QL Edurant TAB 25MG Truvada TAB QL Emtriva CAP 200MG Tybost TAB 150MG PA Emtriva Sol 10MG/ML Videx Sol 2gm Epclusa TAB QL,PA Videx Sol 4gm Epivir HBV Sol 5MG/ML Viracept TAB 250MG Genvoya TAB Viracept TAB 625MG Harvoni TAB MG QL,PA Viread Pow 40MG/Gm Intelence TAB 100MG Viread TAB 150MG Intelence TAB 200MG Viread TAB 200MG Intelence TAB 25MG Viread TAB 250MG Invirase CAP 200MG Viread TAB 300MG Invirase TAB 500MG Ziagen Sol 20MG/ML Isentress Chw 100MG TIER 03 NON PREFERRED Isentress Chw 25MG famciclovir TAB 125MG Isentress HD TAB 600MG famciclovir TAB 250MG Isentress TAB 400MG famciclovir TAB 500MG Kaletra TAB MG nevirapine TAB 100MG Kaletra TAB MG ribavirin inh 6gm Lexiva Sus 50MG/ML QL valganciclov sol 50MG/ML QL Lexiva TAB 700MG QL Aptivus Sol QL Norvir CAP 100MG Baraclude TAB 0.5MG QL Norvir Sol 80MG/ML Baraclude TAB 1MG QL Norvir TAB 100MG Combivir TAB Odefsey TAB QL Copegus TAB 200MG QL Peg-intron Kit 120 Rp QL Daklinza TAB 30MG PA Peg-intron Kit 120mcg QL Daklinza TAB 60MG PA Peg-intron Kit 150 Rp QL Daklinza TAB 90MG PA Peg-intron Kit 150mcg QL Epivir HBV TAB 100MG Peg-intron Kit 50mcg QL Epivir Sol 10MG/ML Peg-intron Kit 50mcg Rp QL Epivir TAB 150MG Peg-intron Kit 80mcg Rp QL Epivir TAB 300MG Pegasys Inj QL Epzicom TAB QL Pegasys Inj Proclick QL Evotaz TAB QL Pegasys Inj 180mcg/M QL Famvir TAB 125MG Pegintron Kit 120mcg QL Famvir TAB 250MG Pegintron Kit 150mcg QL Famvir TAB 500MG Pegintron Kit 50mcg QL Flumadine TAB 100MG Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 4

15 Fuzeon Inj 90MG QL PREFERRED Hepsera TAB 10MG QL Daraprim TAB 25MG QL Isentress Pow 100MG TIER 03 NON PREFERRED Kaletra Sol quinine sulf CAP 324MG Mavyret TAB MG QL,PA Coartem TAB MG Moderiba PAK 1200/Day QL Plaquenil TAB 200MG Moderiba PAK 800/Day QL Qualaquin CAP 324MG Moderiba TAB 1000/Day QL Moderiba TAB 600/Day QL ANTHELMINTICS Olysio CAP 150MG QL,PA TIER 02 PREFERRED Rebetol CAP 200MG QL Albenza TAB 200MG Retrovir CAP 100MG Biltricide TAB 600MG Retrovir Syp 50MG/5ML TIER 03 NON PREFERRED Ribapak PAK 1200/Day QL ivermectin TAB 3MG Ribapak PAK 800/Day QL Emverm Chw 100MG Ribapak TAB 1000/Day QL Stromectol TAB 3MG Ribapak TAB 600/Day QL Ribasphere TAB 400MG QL MISC. ANTI-INFECTIVES Ribasphere TAB 600MG QL TIER 01 GENERIC Ribatab TAB 1000/Day QL atovaquone sus 750/5ML Ribatab TAB 1200/Day QL clindamycin inj 150MG/ML Ribatab TAB 800/Day QL clindamycin inj 300/2ML Sitavig TAB 50MG clindamycin inj 300MG Tamiflu CAP 30MG clindamycin sol 75MG/5ML Tamiflu CAP 45MG clindamycin CAP 150MG Tamiflu CAP 75MG clindamycin CAP 300MG Technivie TAB QL,PA clindamycin CAP 75MG Trizivir TAB QL colistimeth inj 150MG Tyzeka TAB 600MG QL dapsone TAB 100MG Valcyte Sol 50MG/ML QL dapsone TAB 25MG Valcyte TAB 450MG QL linezolid TAB 600MG Valtrex TAB 1gm metronidazol TAB 250MG Valtrex TAB 500MG metronidazol TAB 500MG Vemlidy TAB 25MG QL,PA smz-tmp sus /5 Victrelis CAP 200MG QL,PA smz-tmp DS TAB Videx EC CAP 125MG smz-tmp TAB MG Videx EC CAP 200MG smz/tmp DS TAB Videx EC CAP 250MG sulfatrim PD sus /5 Videx EC CAP 400MG trimethoprim TAB 100MG Viekira PAK TAB QL,PA vancomycin CAP 125MG Viekira XR TAB QL,PA vancomycin CAP 250MG Viramune Sus 50MG/5ML vancomycin 250/5ML Viramune TAB 200MG TIER 02 PREFERRED Viramune XR TAB 100MG linezolid sus 100/5ML QL Viramune XR TAB 400MG Alinia Sus 100/5ML Virazole Inh 6gm Alinia TAB 500MG Vitekta TAB 150MG QL,PA Invanz Inj 1gm Vitekta TAB 85MG QL,PA Primsol Sol 50MG/5ML Vosevi TAB QL,PA Sivextro TAB 200MG QL Zepatier TAB MG QL,PA Trimpex Sol 50MG/5ML Zerit CAP 15MG TIER 03 NON PREFERRED Zerit CAP 20MG lincomycin inj 300MG/ML Zerit CAP 30MG metronidazol CAP 375MG Zerit CAP 40MG tinidazole TAB 250MG Zerit Sol 1MG/ML tinidazole TAB 500MG Ziagen TAB 300MG Bactrim DS TAB Zovirax CAP 200MG Bactrim TAB MG Zovirax Sus 200/5ML Cayston Inh 75MG QL,PA Zovirax TAB 400MG Cleocin CAP 150MG Zovirax TAB 800MG Cleocin CAP 300MG Cleocin CAP 75MG ANTIMALARIALS Cleocin Phos Inj 300MG TIER 01 GENERIC Cleocin PED Sol 75MG/5ML chloroquine TAB 250MG Coly-mycin M Inj 150MG chloroquine TAB 500MG Flagyl CAP 375MG hydroxychlor TAB 200MG Flagyl TAB 250MG Chloroquine TAB 250MG Flagyl TAB 500MG Primaquine TAB 26.3MG Impavido CAP 50MG QL,PA TIER 02 Ketek TAB 300MG Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5

16 Ketek TAB 400MG TIER 02 PREFERRED Lincocin Inj 300MG/ML Carac CRE 0.5% Mepron Sus Fluoroplex CRE 1% Nebupent Inh 300MG Tabloid TAB 40MG Pentam 300 Inj 300MG TIER 03 NON PREFERRED Tindamax TAB 250MG Efudex CRE 5% Tindamax TAB 500MG Purixan Sus 20MG/ML PA Vancocin HCL CAP 125MG Tolak CRE 4% Vancocin HCL CAP 250MG Trexall TAB 10MG Vancomycn 25 Sol 25MG/ML Trexall TAB 15MG Vancomycn 50 Sol 50MG/ML Trexall TAB 5MG Xifaxan TAB 200MG QL,PA Trexall TAB 7.5MG Xifaxan TAB 550MG QL,PA Xatmep Sol 2.5MG/ML QL Zyvox Sus 100MG/5m QL Xeloda TAB 150MG QL,PA Zyvox TAB 600MG Xeloda TAB 500MG QL,PA ANTINEOPLASTICS, ETC. ALKYLATING AGENTS TIER 01 TIER 02 TIER 03 GENERIC melphalan TAB 2MG QL temozolomide CAP 100MG QL temozolomide CAP 140MG QL temozolomide CAP 180MG QL temozolomide CAP 20MG QL temozolomide CAP 250MG QL temozolomide CAP 5MG QL Cyclophosph CAP 25MG Cyclophosph CAP 50MG Lomustine CAP 10MG Lomustine CAP 100MG Lomustine CAP 40MG PREFERRED Gleostine CAP 10MG Gleostine CAP 100MG Gleostine CAP 40MG Gleostine CAP 5MG Leukeran TAB 2MG Myleran TAB 2MG QL NON PREFERRED Alkeran TAB 2MG QL Hexalen CAP 50MG QL Temodar CAP 100MG QL Temodar CAP 140MG QL Temodar CAP 180MG QL Temodar CAP 20MG QL Temodar CAP 250MG QL Temodar CAP 5MG QL Valchlor Gel 0.016% QL,PA ANTIMETABOLITES TIER 01 GENERIC capecitabine TAB 150MG QL,PA capecitabine TAB 500MG QL,PA fluorouracil dro 2% fluorouracil dro 5% fluorouracil CRE 5% mercaptopur TAB 50MG methotrexate inj 1gm methotrexate inj 1gm/40ML methotrexate inj 100/4ML methotrexate inj 200/8ML methotrexate inj 25MG/ML methotrexate inj 250/10ML methotrexate inj 50MG/2ML methotrexate TAB 2.5MG Fluorouracil CRE 0.5% Fluorouracil Sol 2% Fluorouracil Sol 5% Methotrexate Inj 25MG/ML HORMONAL AGENTS TIER 01 GENERIC anastrozole TAB 1MG bicalutamide TAB 50MG flutamide CAP 125MG letrozole TAB 2.5MG leuprolide inj 1MG/0.2 megestrol ac sus 40MG/ML megestrol ac sus 400MG/10 megestrol ac TAB 20MG megestrol ac TAB 40MG tamoxifen TAB 10MG tamoxifen TAB 20MG TIER 02 PREFERRED Lupron Depot Inj 11.25MG Lupron Depot Inj 22.5MG Lupron Depot Inj 3.75MG Lupron Depot Inj 30MG Lupron Depot Inj 45MG Lupron Depot Inj 7.5MG Xtandi CAP 40MG QL,PA Zytiga TAB 250MG QL,PA Zytiga TAB 500MG QL,PA TIER 03 NON PREFERRED exemestane TAB 25MG nilutamide TAB 150MG PA Arimidex TAB 1MG Aromasin TAB 25MG Casodex TAB 50MG Depo-provera Inj 400/ML QL Eligard Inj 22.5MG Eligard Inj 30MG Eligard Inj 45MG Eligard Inj 7.5MG Emcyt CAP 140MG QL Fareston TAB 60MG PA Femara TAB 2.5MG Lysodren TAB 500MG PA Megace Oral Sus 40MG/ML Nilandron TAB 150MG PA Soltamox Sol 10MG/5ML IMMUNOMODULATORS TIER 01 GENERIC azathioprine TAB 50MG cyclosporine sol modified cyclosporine CAP 100MG cyclosporine CAP 100MG MD cyclosporine CAP 25MG cyclosporine CAP 25MG mod gengraf sol 100MG/ML gengraf CAP 100MG gengraf CAP 25MG Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 6

17 gengraf CAP 50MG PREFERRED mycophenolat sus 200MG/ML Afinitor Dis TAB 2MG QL,PA mycophenolat CAP 250MG Afinitor Dis TAB 3MG QL,PA mycophenolat TAB 500MG Afinitor Dis TAB 5MG QL,PA mycophenolic TAB 180MG DR Afinitor TAB 10MG QL,PA mycophenolic TAB 360MG DR Afinitor TAB 2.5MG QL,PA sirolimus TAB 0.5MG Afinitor TAB 5MG QL,PA sirolimus TAB 1MG Afinitor TAB 7.5MG QL,PA sirolimus TAB 2MG Gilotrif TAB 20MG QL,PA tacrolimus CAP 0.5MG Gilotrif TAB 30MG QL,PA tacrolimus CAP 1MG Gilotrif TAB 40MG QL,PA tacrolimus CAP 5MG Imbruvica CAP 140MG QL,PA Cyclosporine CAP 50MG Mod Iressa TAB 250MG QL,PA TIER 02 PREFERRED Mekinist TAB 0.5MG QL,PA Rapamune Sol 1MG/ML Mekinist TAB 2MG QL,PA Revlimid CAP 10MG QL,PA Nexavar TAB 200MG PA Revlimid CAP 15MG QL,PA Sprycel TAB 100MG QL,PA Revlimid CAP 2.5MG QL,PA Sprycel TAB 140MG QL,PA Revlimid CAP 20MG QL,PA Sprycel TAB 20MG QL,PA Revlimid CAP 25MG QL,PA Sprycel TAB 50MG QL,PA Revlimid CAP 5MG QL,PA Sprycel TAB 70MG QL,PA Thalomid CAP 100MG QL,PA Sprycel TAB 80MG QL,PA Thalomid CAP 150MG QL,PA Stivarga TAB 40MG PA Thalomid CAP 200MG QL,PA Sutent CAP 12.5MG QL,PA Thalomid CAP 50MG QL,PA Sutent CAP 25MG QL,PA TIER 03 NON PREFERRED Sutent CAP 37.5MG QL,PA Astagraf XL CAP 0.5MG Sutent CAP 50MG QL,PA Astagraf XL CAP 1MG Tafinlar CAP 50MG QL,PA Astagraf XL CAP 5MG Tafinlar CAP 75MG QL,PA Azasan TAB 100MG Tarceva TAB 100MG PA Azasan TAB 75 MG Tarceva TAB 150MG PA Cellcept CAP 250MG Tarceva TAB 25MG PA Cellcept Sus 200MG/ML Tykerb TAB 250MG QL,PA Cellcept TAB 500MG Votrient TAB 200MG QL,PA Envarsus XR TAB 0.75MG Zydelig TAB 100MG QL,PA Envarsus XR TAB 1MG Zydelig TAB 150MG QL,PA Envarsus XR TAB 4MG TIER 03 NON PREFERRED Imuran TAB 50MG Alecensa CAP 150MG QL,PA Myfortic TAB 180MG Alunbrig TAB 30MG QL,PA Myfortic TAB 360MG Bosulif TAB 100MG QL,PA Neoral CAP 100MG Bosulif TAB 500MG QL,PA Neoral CAP 25MG Cabometyx TAB 20MG PA Neoral Sol 100MG/ML Cabometyx TAB 40MG PA Pomalyst CAP 1MG QL,PA Cabometyx TAB 60MG PA Pomalyst CAP 2MG QL,PA Caprelsa TAB 100MG QL,PA Pomalyst CAP 3MG QL,PA Caprelsa TAB 300MG QL,PA Pomalyst CAP 4MG QL,PA Cometriq Kit 100MG QL,PA Prograf CAP 0.5MG Cometriq Kit 140MG QL,PA Prograf CAP 1MG Cometriq Kit 60MG QL,PA Prograf CAP 5MG Cotellic TAB 20MG QL,PA Rapamune TAB 0.5MG Farydak CAP 10MG QL,PA Rapamune TAB 1MG Farydak CAP 15MG QL,PA Rapamune TAB 2MG Farydak CAP 20MG QL,PA Sandimmune CAP 100MG Gleevec TAB 100MG QL,PA Sandimmune CAP 25MG Gleevec TAB 400MG QL,PA Sandimmune Sol 100MG/ML Ibrance CAP 100MG QL,PA Zortress TAB 0.25MG QL Ibrance CAP 125MG QL,PA Zortress TAB 0.5MG QL Ibrance CAP 75MG QL,PA Zortress TAB 0.75MG QL Iclusig TAB 15MG QL,PA Iclusig TAB 45MG QL,PA MITOTIC INHIBITORS Idhifa TAB 100MG QL,PA TIER 01 GENERIC Idhifa TAB 50MG QL,PA Etoposide CAP 50MG QL Inlyta TAB 1MG QL,PA ENZYME INHIBITORS TIER 01 GENERIC imatinib mes TAB 100MG QL,PA imatinib mes TAB 400MG QL,PA TIER 02 Effective November 1, 2017 Inlyta TAB 5MG QL,PA Jakafi TAB 10MG PA Jakafi TAB 15MG PA Jakafi TAB 20MG PA Jakafi TAB 25MG PA Jakafi TAB 5MG PA Kisqali TAB 200dose QL,PA PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 7

18 Kisqali TAB 400dose QL,PA NON PREFERRED Kisqali TAB 600dose QL,PA Kisqali 200 PAK Femara QL,PA Lenvima CAP 10 MG QL,PA Kisqali 400 PAK Femara QL,PA Lenvima CAP 14 MG QL,PA Kisqali 600 PAK Femara QL,PA Lenvima CAP 18 MG PA Lonsurf TAB QL,PA Lenvima CAP 20 MG QL,PA Lonsurf TAB QL,PA Lenvima CAP 24 MG QL,PA Lenvima CAP 8 MG PA CARDIOVASCULAR DRUGS Lynparza CAP 50MG QL,PA CARDIAC GLYCOSIDES Lynparza TAB 100MG QL,PA TIER 01 GENERIC Lynparza TAB 150MG QL,PA digitek TAB 0.125MG Nerlynx TAB 40MG QL,PA digitek TAB 0.25MG Ninlaro CAP 2.3MG QL,PA digox TAB 0.125MG Ninlaro CAP 3MG QL,PA digox TAB 0.25MG Ninlaro CAP 4MG QL,PA digoxin inj 0.25MG/1 Rubraca TAB 200MG QL,PA digoxin TAB 0.125MG Rubraca TAB 250MG QL,PA digoxin TAB 0.25MG Rubraca TAB 300MG QL,PA Digoxin Sol 50mcg/ML Rydapt CAP 25MG QL,PA TIER 03 NON PREFERRED Tagrisso TAB 40MG QL,PA Lanoxin Inj 0.25MG/1 Tagrisso TAB 80MG QL,PA Lanoxin PED Inj 0.1MG/ML Tasigna CAP 150MG QL,PA Lanoxin TAB MG Tasigna CAP 200MG QL,PA Lanoxin TAB 0.125MG Xalkori CAP 200MG QL,PA Lanoxin TAB MG Xalkori CAP 250MG QL,PA Lanoxin TAB 0.25MG Zejula CAP 100MG QL,PA Zelboraf TAB 240MG PA ANTIANGINAL AGENTS Zolinza CAP 100MG QL,PA TIER 01 GENERIC Zykadia CAP 150MG QL,PA isosorb din TAB 10MG isosorb din TAB 20MG TOPOISOMERASE I INHIBITOR isosorb din TAB 30MG TIER 03 NON PREFERRED isosorb din TAB 5MG Hycamtin CAP 0.25MG QL isosorb mono TAB 10MG Hycamtin CAP 1MG QL isosorb mono TAB 120MG ER isosorb mono TAB 20MG ANTINEOPLASTICS MISC. isosorb mono TAB 30MG ER TIER 01 GENERIC isosorb mono TAB 60MG ER hydroxyurea CAP 500MG minitran dis 0.1MG/HR tretinoin CAP 10MG QL minitran dis 0.2MG/HR TIER 02 PREFERRED minitran dis 0.4MG/HR Intron A Inj 10mu QL minitran dis 0.6MG/HR Intron A Inj 18mu QL nitro-time CAP 9MG CR Intron A Inj 25mu QL nitroglycer dis 0.1MG/HR Intron A Inj 50mu QL nitroglycer dis 0.2MG/HR Matulane CAP 50MG QL nitroglycer dis 0.4MG/HR Picato Gel 0.015% QL nitroglycer dis 0.6MG/HR Picato Gel 0.05% QL nitroglycer CAP 9MG ER TIER 03 NON PREFERRED nitroglyceri sub 0.6MG bexarotene CAP 75MG QL,PA nitroglycern sub 0.3MG Actimmune Inj 2mu/0.5 QL nitroglycern sub 0.4MG Alferon N Inj 5mu/ML TIER 02 PREFERRED Hydrea CAP 500MG Isordil TAB 40MG Sylatron Kit 200mcg QL Nitro-bid Oin 2% Sylatron Kit 300mcg QL Nitro-dur Dis 0.3MG/HR Sylatron Kit 600mcg QL Nitro-dur Dis 0.8MG/HR Targretin CAP 75MG QL,PA TIER 03 NON PREFERRED nitroglycrn spr 0.4MG CHEMOTHERAPY RESCUE Dilatrate SR CAP 40MG TIER 01 GENERIC Gonitro Pow 400mcg leucovor CA TAB 25MG Isordil TAB 5MG leucovor CA TAB 5MG Isosorb Din TAB 40MG ER mesna inj 1gm Nitro-dur Dis 0.1MG/HR Leucovor CA TAB 10MG Nitro-dur Dis 0.2MG/HR TIER 02 Leucovor CA TAB 15MG Nitro-dur Dis 0.4MG/HR PREFERRED Nitro-dur Dis 0.6MG/HR Mesnex TAB 400MG Nitroglycer Aer 400mcg Nitrolingual Spr Pumpspra ANTINEOPLASTIC COMBO Nitromist Aer 400mcg TIER 03 Nitrostat Sub 0.3MG Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 8

19 Nitrostat Sub 0.4MG Betapace AF TAB 80MG Nitrostat Sub 0.6MG Betapace TAB 120MG Ranexa TAB 1000MG PA Betapace TAB 160MG Ranexa TAB 500MG PA Betapace TAB 80MG Bystolic TAB 10MG BETA BLOCKERS Bystolic TAB 2.5MG TIER 01 GENERIC Bystolic TAB 20MG acebutolol CAP 200MG Bystolic TAB 5MG acebutolol CAP 400MG Coreg CR CAP 10MG atenolol TAB 100MG Coreg CR CAP 20MG atenolol TAB 25MG Coreg CR CAP 40MG atenolol TAB 50MG Coreg CR CAP 80MG betaxolol TAB 10MG Coreg TAB 12.5MG betaxolol TAB 20MG Coreg TAB 25MG bisoprol fum TAB 10MG Coreg TAB 3.125MG bisoprol fum TAB 5MG Coreg TAB 6.25MG carvedilol TAB 12.5MG Corgard TAB 20MG carvedilol TAB 25MG Corgard TAB 40MG carvedilol TAB 3.125MG Corgard TAB 80MG carvedilol TAB 6.25MG Hemangeol Sol 4.28/ML PA labetalol TAB 100MG Inderal LA CAP 120MG labetalol TAB 200MG Inderal LA CAP 160MG labetalol TAB 300MG Inderal LA CAP 60MG metoprol suc TAB 100MG ER Inderal LA CAP 80MG metoprol suc TAB 200MG ER Inderal XL CAP 120MG metoprol suc TAB 25MG ER Inderal XL CAP 80MG metoprol suc TAB 50MG ER Innopran XL CAP 120MG metoprol TAR TAB 100MG Innopran XL CAP 80MG metoprol TAR TAB 25MG Lopressor TAB 100MG metoprol TAR TAB 50MG Lopressor TAB 50MG metoprolol TAB 100MG ER Sectral CAP 200MG metoprolol TAB 200MG ER Sectral CAP 400MG metoprolol TAB 25MG ER Sotylize Sol 5MG/ML metoprolol TAB 50MG ER Tenormin TAB 100MG nadolol TAB 20MG Tenormin TAB 25MG nadolol TAB 40MG Tenormin TAB 50MG nadolol TAB 80MG Toprol XL TAB 100MG pindolol TAB 10MG Toprol XL TAB 200MG pindolol TAB 5MG Toprol XL TAB 25MG propranolol CAP 120MG ER Toprol XL TAB 50MG propranolol CAP 160MG ER Zebeta TAB 10MG propranolol CAP 60MG ER propranolol CAP 80MG ER Zebeta TAB 5MG propranolol TAB 10MG CALCIUM CHANNEL BLOCKERS propranolol TAB 20MG TIER 01 GENERIC propranolol TAB 40MG afeditab TAB 30MG CR propranolol TAB 60MG afeditab TAB 60MG CR propranolol TAB 80MG amlodipine TAB 10MG sorine TAB 120MG amlodipine TAB 2.5MG sorine TAB 160MG amlodipine TAB 5MG sorine TAB 240MG cartia XT CAP 120/24HR sorine TAB 80MG cartia XT CAP 180/24HR sotalol AF TAB 120MG cartia XT CAP 240/24HR sotalol AF TAB 160MG cartia XT CAP 300/24HR sotalol AF TAB 80MG dilt-xr CAP 120MG sotalol HCL TAB 120MG dilt-xr CAP 180MG sotalol HCL TAB 160MG dilt-xr CAP 240MG sotalol HCL TAB 240MG diltiazem CAP 120MG CD sotalol HCL TAB 80MG diltiazem CAP 120MG ER Metoprolol TAB 37.5MG diltiazem CAP 180MG CD Metoprolol TAB 75MG diltiazem CAP 180MG ER Propranolol Sol 20MG/5ML diltiazem CAP 240MG CD Propranolol Sol 40MG/5ML diltiazem CAP 240MG ER Timolol Mal TAB 10MG diltiazem CAP 300MG CD Timolol Mal TAB 20MG diltiazem CAP 300MG ER Timolol Mal TAB 5MG diltiazem CAP 360MG CD TIER 03 NON PREFERRED diltiazem CAP 360MG ER Betapace AF TAB 120MG diltiazem CAP 60MG ER Betapace AF TAB 160MG diltiazem CAP 90MG ER Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 9

20 diltiazem TAB 120MG Cardizem CD CAP 240MG/24 diltiazem TAB 30MG Cardizem CD CAP 300MG/24 diltiazem TAB 60MG Cardizem CD CAP 360MG/24 diltiazem TAB 90MG Cardizem LA TAB 120MG felodipine TAB 10MG ER Cardizem LA TAB 180MG felodipine TAB 2.5MG ER Cardizem LA TAB 240MG felodipine TAB 5MG ER Cardizem LA TAB 300MG/24 isradipine CAP 2.5MG Cardizem LA TAB 360MG isradipine CAP 5MG Cardizem LA TAB 420MG/24 nicardipine CAP 20MG Cardizem TAB 120MG nicardipine CAP 30MG Cardizem TAB 30MG nifedical XL TAB 30MG Cardizem TAB 60MG nifedical XL TAB 60MG Nisoldipine TAB 20MG ER nifedipine CAP 10MG Nisoldipine TAB 25.5MG nifedipine CAP 20MG Nisoldipine TAB 30MG ER nifedipine TAB 30MG ER Nisoldipine TAB 40MG ER nifedipine TAB 60MG ER Norvasc TAB 10MG nifedipine TAB 90MG ER Norvasc TAB 2.5MG nimodipine CAP 30MG Norvasc TAB 5MG verapamil CAP 120MG ER Nymalize Sol 30/10ML QL verapamil CAP 120MG SR Nymalize Sol 60/20ML QL verapamil CAP 180MG ER Procardia CAP 10MG verapamil CAP 180MG SR Procardia XL TAB 30MG CR verapamil CAP 240MG ER Procardia XL TAB 60MG CR verapamil CAP 240MG SR Procardia XL TAB 90MG CR verapamil CAP 360MG SR Sular TAB 17MG verapamil TAB 120MG Sular TAB 34MG verapamil TAB 120MG ER Sular TAB 8.5MG verapamil TAB 180MG ER Tiazac CAP 120MG/24 verapamil TAB 240MG ER Tiazac CAP 180MG/24 verapamil TAB 40MG Tiazac CAP 240MG/24 verapamil TAB 80MG Tiazac CAP 300MG/24 TIER 03 NON PREFERRED Tiazac CAP 360MG/24 diltiazem CAP 120MG/24 Tiazac CAP 420MG/24 diltiazem CAP 180MG/24 Verelan CAP 120MG SR diltiazem CAP 240MG/24 Verelan CAP 180MG SR diltiazem CAP 300MG/24 Verelan CAP 240MG SR diltiazem CAP 360MG/24 Verelan CAP 360MG SR diltiazem CAP 420MG/24 Verelan PM CAP 100MG ER diltiazem ER TAB 180MG Verelan PM CAP 200MG ER diltiazem ER TAB 240MG Verelan PM CAP 300MG ER diltiazem ER TAB 300MG diltiazem ER TAB 360MG ANTIARRHYTHMICS diltiazem ER TAB 420MG TIER 01 GENERIC matzim LA TAB 180MG/24 amiodarone TAB 200MG matzim LA TAB 240MG/24 disopyramide CAP 100MG matzim LA TAB 300MG/24 disopyramide CAP 150MG matzim LA TAB 360MG/24 flecainide TAB 100MG matzim LA TAB 420MG/24 flecainide TAB 150MG nisoldipine TAB 17MG ER flecainide TAB 50MG nisoldipine TAB 34MG ER mexiletine CAP 150MG nisoldipine TAB 8.5MG ER mexiletine CAP 200MG taztia XT CAP 120MG/24 mexiletine CAP 250MG taztia XT CAP 180MG/24 pacerone TAB 200MG taztia XT CAP 240MG/24 propafenone TAB 150MG taztia XT CAP 300MG/24 propafenone TAB 225MG taztia XT CAP 360MG/24 propafenone TAB 300MG verapamil CAP 100MG ER quinidine gl TAB 324MG CR verapamil CAP 200MG ER quinidine gl TAB 324MG ER verapamil CAP 300MG ER quinidine SU TAB 300MG Adalat CC TAB 30MG ER Procainamide Inj 100MG/ML Adalat CC TAB 60MG ER Procainamide Inj 500MG/ML Adalat CC TAB 90MG ER Quinidine Gl Inj 80MG/ML Calan SR TAB 120MG Quinidine SU TAB 200MG Calan SR TAB 180MG Quinidine SU TAB 300MG Calan SR TAB 240MG Quinidine SU TAB 300MG ER Calan TAB 120MG TIER 02 PREFERRED Calan TAB 80MG Norpace CAP 100MG CR Cardizem CD CAP 120MG/24 Norpace CAP 150MG CR Cardizem CD CAP 180MG/24 Effective November 1, 2017 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 10

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