National Drug List

Drug list — Four (4) Tier Drug Plan

Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company (Anthem) prescription drug benefits include medications on the Anthem National Drug List. Your coverage has limitations and exclusions. For example, provider administered drugs are not covered under your prescription benefit and drugs used for cosmetic purposes may not be covered. Always refer to your Certificate or Evidence of Coverage for details about what’s covered and what’s not. Then if you have additional questions, call Customer Service at the number on your member ID card.

39525CAMENABC Anthem Blue Cross Drug List

Your prescription drug benefit includes coverage for Q. How do we determine the tier of a drug? medications that you’ll find on the Anthem National Drug A. Medications on the Anthem National Drug List are List. You can often find more savings when your doctor grouped into tiers. Drugs on the lowest tier have the prescribes medicine that in our National Drug List. Here lowest cost share, which is what you pay. Drugs on the are some commonly asked questions and answers about highest tier cost you more. Several factors determine how the National Drug List works with your prescription what tier a drug is placed in, including: drug plan. }}Clinical considerations.

Q. What is a Drug List? }}Cost of the drug in comparison to other drugs used A. The Anthem National Drug List, also called a formulary, for the same type of treatment. has drugs on it that are approved by the U.S. Food and }}Availability of over-the-counter options. Drug Administration (FDA). This includes brand-name and generic drugs, reviewed and recommended for their Q. Is this list a complete listing of all covered drugs quality and for how well they work. The review is done by under the Anthem National Drug List? the National Pharmacy and Therapeutics (P&T) Process. A. Yes, this is a complete listing of all covered drugs. The P&T process involves an independent group of Preventive care drugs: We cover preventive care drugs with practicing doctors and pharmacists in charge of the zero cost share in compliance with the Affordable Care Act research and decisions surrounding our drug list. This (ACA). We cover contraceptives for members enrolled in a group meets regularly to review new and existing drugs. California plan according to state regulations. They choose the top drugs for our list — based on their safety, how they work and their value. Drugs on our list are reviewed from time to time. Sometimes this results in drugs being added or removed. So now and then, it’s a good idea to check the status of any drugs you may be taking. You can see the list by going to anthem.com/ca. Also, we will always try to notify you of any changes to the formulary that impact you. For more information about your drug plan, you can do the following: }}Go to anthem.com/ca

}}Call Customer Service at the number on your ID card

}}Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET

Tier definitions Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions. Tier 2 drugs have a medium cost share. These may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 2 drugs have a higher cost share than Tier 1. Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 3 drugs have a higher cost share than Tier 2. Tier 4 drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or drugs that are used to treat complex, chronic conditions and may need special handling. Anthem National Formulary Four-Tier

Table of Contents T a b l e o f C n t s ANALGESICS ...... 6 ANESTHETICS ...... 11 ANTIARTHRITICS ...... 14 ANTIASTHMATICS ...... 16 ANTIBIOTICS ...... 19 ANTICOAGULANTS ...... 30 ANTIDOTES ...... 31 ANTIFUNGALS ...... 31 ANTIHISTAMINE AND DECONGESTANT COMBINATION ...... 34 ANTIHISTAMINES ...... 34 ANTIHYPERGLYCEMICS ...... 34 ANTIINFECTIVES ...... 38 ANTIINFECTIVES/MISCELLANEOUS ...... 37 ANTINEOPLASTICS ...... 38 ANTI-OBESITY DRUGS ...... 44 ANTIPARKINSON DRUGS ...... 44 ANTIPLATELET DRUGS ...... 45 ANTIVIRALS ...... 46 AUTONOMIC DRUGS ...... 49 BIOLOGICALS ...... 51 BLOOD ...... 57 CARDIAC DRUGS ...... 61 CARDIOVASCULAR ...... 64 CNS DRUGS ...... 72 COLONY STIMULATING FACTORS ...... 76 CONTRACEPTIVES ...... 76 COUGH/COLD PREPARATIONS ...... 80 DIAGNOSTIC ...... 82 DIURETICS ...... 84 EENT PREPS ...... 85 ELECT/CALORIC/H2O ...... 89 GASTROINTESTINAL ...... 99 HERBALS ...... 105 HORMONES ...... 105 IMMUNOSUPPRESANT ...... 111 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ...... 112 MUSCLE RELAXANTS ...... 115 PRE-NATAL VITAMINS ...... 116 PSYCHOTHERAPEUTIC DRUGS ...... 119 SEDATIVE/HYPNOTICS ...... 126 SKIN PREPS ...... 126 SMOKING DETERRENTS ...... 137 THYROID PREPS ...... 137 UNCLASSIFIED DRUG PRODUCTS ...... 138 VITAMINS ...... 145

4 5 Drug Name Tier Notes BUPRENEX INJECTION 3 Anthem National Formulary SOLUTION Four-Tier buprenorphine hcl injection 1 solution buprenorphine hcl injection 1 syringe butalbital compound 1 w/codeine oral capsule butalbital-acetaminop-caf-co Drug Name Tier Notes 1 QL d oral capsule ANALGESICS butalbital-acetaminophen ABSTRAL SUBLINGUAL 1 3 PA; QL oral tablet TABLET butalbital-acetaminophen-caf acetaminophen-codeine oral 1 1 f oral capsule solution butalbital-acetaminophen-caf acetaminophen-codeine oral 1 1 f oral tablet tablet 300-15 mg butalbital-aspirin-caffeine acetaminophen-codeine oral 1 1 QL oral capsule tablet 300-30 mg, 300-60 mg butorphanol tartrate injection 1 ACTIQ BUCCAL solution LOZENGE ON A 3 PA; QL butorphanol tartrate nasal HANDLE 1 QL spray,non-aerosol ALFENTA INJECTION 3 SOLUTION BUTRANS TRANSDERMAL PATCH 3 QL alfentanil injection solution 1 WEEKLY ALLZITAL ORAL CAFERGOT ORAL 3 3 TABLET TABLET almotriptan malate oral tablet 1 QL CAMBIA ORAL 3 QL ALSUMA POWDER IN PACKET SUBCUTANEOUS PEN 3 ST; QL capacet oral capsule 1 INJECTOR CAPITAL WITH AMERGE ORAL 3 ST; QL CODEINE ORAL 3 QL TABLET SUSPENSION ascomp with codeine oral carisoprodol-asa-codeine oral 1 1 capsule tablet ASTRAMORPH-PF choline,magnesium salicylate 3 1 INJECTION SOLUTION oral liquid AXERT ORAL TABLET 3 ST; QL clonidine (pf) epidural 1 BELBUCA BUCCAL solution 3 PA; QL FILM codeine sulfate oral tablet 1 belladonna alkaloids-opium codeine-butalbital-asa-caff 1 1 rectal suppository oral capsule belladonna-opium rectal 1 CONZIP ORAL suppository CAPSULE,ER BIPHASE 3 QL BUPAP ORAL TABLET 3 24 HR 17-83

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 6 Drug Name Tier Notes Drug Name Tier Notes CONZIP ORAL duramorph (pf) injection 1 CAPSULE,ER BIPHASE 3 QL solution 24 HR 25-75 ELMIRON ORAL 3 D.H.E.45 INJECTION CAPSULE 3 PA SOLUTION EMBEDA ORAL DEMEROL (PF) CAPSULE,ORAL 3 PA; QL INJECTION SOLUTION ONLY,EXT.REL PELL 100 MG/2 ML, 25 MG/0.5 3 endocet oral tablet 1 QL ML, 50 MG/ML, 75 MG/1.5 ML endodan oral tablet 1 demerol (pf) injection ERGOMAR 1 3 solution 100 mg/ml SUBLINGUAL TABLET DEMEROL (PF) ESGIC ORAL CAPSULE 3 3 INJECTION SYRINGE ESGIC ORAL TABLET 3 DEMEROL INJECTION 3 EXALGO ER ORAL SOLUTION TABLET EXTENDED 3 ST; QL DEMEROL ORAL RELEASE 24 HR 3 TABLET fentanyl citrate (pf) injection 1 diclofenac potassium oral solution 1 tablet fentanyl citrate (pf) 1 diflunisal oral tablet 1 intravenous syringe dihydrocode-acetaminophen- fentanyl citrate buccal 1 QL 1 PA; QL caff oral capsule lozenge on a handle dihydrocodeine-aspirin-caff fentanyl transdermal patch 1 72 hour 100 mcg/hr, 12 oral capsule 1 QL mcg/hr, 25 mcg/hr, 50 dihydroergotamine injection 1 PA mcg/hr, 75 mcg/hr solution FENTANYL dihydroergotamine nasal 1 QL TRANSDERMAL PATCH spray,non-aerosol 72 HOUR 37.5 3 QL DILAUDID (PF) MCG/HOUR, 62.5 3 INJECTION SOLUTION MCG/HOUR, 87.5 DILAUDID ORAL MCG/HOUR 3 LIQUID FENTORA BUCCAL DILAUDID ORAL TABLET, 3 PA; QL 3 TABLET EFFERVESCENT DILAUDID-HP (PF) FIORICET ORAL 3 3 INJECTION SOLUTION CAPSULE diskets oral tablet,soluble 1 QL FIORICET WITH CODEINE ORAL 3 QL DOLOPHINE ORAL 3 QL CAPSULE TABLET FIORINAL ORAL DURACLON (PF) 3 3 CAPSULE EPIDURAL SOLUTION FIORINAL-CODEINE #3 3 DURAGESIC ORAL CAPSULE TRANSDERMAL PATCH 3 ST; QL 72 HOUR FROVA ORAL TABLET 3 ST; QL frovatriptan oral tablet 1 QL Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 7 Drug Name Tier Notes Drug Name Tier Notes HYCET ORAL IMITREX NASAL 3 QL 3 ST; QL SOLUTION SPRAY,NON-AEROSOL hydrocodone-acetaminophen IMITREX ORAL 3 ST; QL oral solution 10-325 mg/15 TABLET 1 QL ml(15 ml), 2.5-167 mg/5 ml, IMITREX STATDOSE 5-163 mg/7.5ml(7.5ml) KIT REFILL 3 ST; QL HYDROCODONE-ACET SUBCUTANEOUS AMINOPHEN ORAL CARTRIDGE 3 QL SOLUTION 7.5-325 MG/15 IMITREX STATDOSE ML PEN SUBCUTANEOUS 3 ST; QL hydrocodone-acetaminophen PEN INJECTOR oral tablet 10-300 mg, 1 QL IMITREX 10-325 mg, 5-300 mg, 5-325 SUBCUTANEOUS 3 ST; QL mg, 7.5-300 mg, 7.5-325 mg SOLUTION hydrocodone-acetaminophen INFUMORPH P/F 1 3 oral tablet 2.5-325 mg INJECTION SOLUTION hydrocodone-ibuprofen oral IONSYS TRANSDERMAL tablet 10-200 mg, 7.5-200 1 SYSTEM,TRANSDERMA 3 mg L PCA hydrocodone-ibuprofen oral isometh-dichloral-acetamino 1 QL 1 tablet 5-200 mg phn oral capsule hydromorphone (pf) injection isomethepten-caf-acetaminop 1 1 solution hen oral tablet hydromorphone injection 1 KADIAN ORAL solution CAPSULE,EXTEND.REL 3 ST; QL HYDROMORPHONE EASE PELLETS INJECTION SYRINGE 0.5 3 ketorolac injection cartridge 1 QL MG/0.5 ML ketorolac injection solution 1 QL hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 1 ketorolac injection syringe 1 QL mg/ml ketorolac intramuscular 1 QL hydromorphone oral liquid 1 solution ketorolac intramuscular hydromorphone oral tablet 1 1 QL syringe hydromorphone oral tablet 1 QL extended release 24 hr ketorolac oral tablet 1 QL hydromorphone rectal LAZANDA NASAL 1 3 PA; QL suppository SPRAY,NON-AEROSOL levorphanol tartrate oral HYSINGLA ER ORAL 1 TABLET,ORAL 3 PA; QL tablet ONLY,EXT.REL.24 HR lorcet (hydrocodone) oral 1 QL IBUDONE ORAL tablet 3 TABLET 10-200 MG lorcet hd oral tablet 1 QL IBUDONE ORAL 3 QL lorcet plus oral tablet 1 QL TABLET 5-200 MG lortab 10-325 oral tablet 1 QL ibuprofen-oxycodone oral 1 QL tablet lortab 5-325 oral tablet 1 QL lortab 7.5-325 oral tablet 1 QL Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 8 Drug Name Tier Notes Drug Name Tier Notes LORTAB ELIXIR ORAL MORPHINE 3 QL SOLUTION INTRAMUSCULAR PEN 3 margesic oral capsule 1 INJECTOR marten-tab oral tablet 1 morphine intravenous cartridge 10 mg/ml, 15 1 MAXALT ORAL TABLET 3 QL mg/ml, 2 mg/ml, 4 mg/ml MAXALT-MLT ORAL MORPHINE TABLET,DISINTEGRATI 3 QL INTRAVENOUS 3 NG CARTRIDGE 8 MG/ML mefenamic acid oral capsule 1 morphine intravenous pt 1 meperidine (pf) injection controlled analgesia syring 1 solution morphine intravenous meperidine injection solution 10 mg/ml, 100 mg/4 1 1 QL cartridge ml, 25 mg/ml, 250 mg/10 ml, 50 mg/ml meperidine oral solution 1 MORPHINE meperidine oral tablet 1 INTRAVENOUS 3 QL methadone injection solution 1 QL SOLUTION 4 MG/ML, 8 methadone intensol oral MG/ML 1 QL concentrate MORPHINE INTRAVENOUS methadone oral concentrate 1 QL 3 SYRINGE 10 MG/ML, 8 methadone oral solution 1 QL MG/ML methadone oral tablet 1 QL morphine intravenous 1 methadone oral tablet,soluble 1 QL syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er methadose oral concentrate 1 QL 1 QL multiphase 24 hr methadose oral tablet,soluble 1 QL morphine oral migergot rectal suppository 1 1 QL capsule,extend.release pellets MIGRANAL NASAL 3 QL morphine oral solution 10 SPRAY,NON-AEROSOL 1 mg/5 ml morphine (pf) in dextrose 5 1 morphine oral solution 20 % intravenous solution 1 QL mg/5 ml morphine (pf) injection 1 morphine oral tablet 1 QL solution morphine oral tablet morphine (pf) intravenous 1 QL extended release patient control.analgesia soln 1 morphine rectal suppository 150 mg/30 ml 1 10 mg, 30 mg, 5 mg morphine (pf) intravenous morphine rectal suppository patient control.analgesia soln 1 QL 1 QL 30 mg/30 ml 20 mg morphine concentrate oral MS CONTIN ORAL 1 QL solution TABLET EXTENDED 3 QL RELEASE morphine injection solution 1 nalbuphine injection solution 1 morphine injection syringe 1 naratriptan oral tablet 1 QL nodolor oral capsule 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 9 Drug Name Tier Notes Drug Name Tier Notes NORCO ORAL TABLET 3 QL RELPAX ORAL TABLET 2 QL NUCYNTA ER ORAL reprexain oral tablet 10-200 1 TABLET EXTENDED 3 ST; QL mg, 2.5-200 mg RELEASE 12 HR reprexain oral tablet 5-200 1 QL NUCYNTA ORAL mg 3 QL TABLET RIMSO-50 OFIRMEV INTRAVESICAL 3 INTRAVENOUS 3 SOLUTION SOLUTION rizatriptan oral tablet 1 QL OPANA ER ORAL rizatriptan oral 1 QL TABLET,ORAL 3 ST; QL tablet,disintegrating ONLY,EXT.REL.12 HR ROXICODONE ORAL OPANA INJECTION 3 3 TABLET SOLUTION SPRIX NASAL 3 OPANA ORAL TABLET 3 QL SPRAY,NON-AEROSOL OXAYDO ORAL SUBSYS SUBLINGUAL 3 3 PA; QL TABLET, ORAL ONLY SPRAY,NON-AEROSOL oxycodone oral capsule 1 sufenta intravenous solution 1 oxycodone oral concentrate 1 SUFENTANIL CITRATE oxycodone oral solution 1 INTRAVENOUS 3 oxycodone oral tablet 1 SOLUTION sumatriptan nasal OXYCODONE ORAL 1 QL TABLET,ORAL 3 QL spray,non-aerosol ONLY,EXT.REL.12 HR sumatriptan succinate oral 1 QL oxycodone-acetaminophen tablet 1 QL oral tablet sumatriptan succinate 1 QL oxycodone-aspirin oral tablet 1 QL subcutaneous cartridge sumatriptan succinate OXYCONTIN ORAL 1 QL TABLET,ORAL 2 QL subcutaneous pen injector ONLY,EXT.REL.12 HR sumatriptan succinate 1 QL oxymorphone oral tablet 1 QL subcutaneous solution oxymorphone oral tablet sumatriptan succinate 1 QL 1 QL extended release 12 hr subcutaneous syringe pentazocine-naloxone oral SUMAVEL DOSEPRO 1 SUBCUTANEOUS tablet 3 ST; QL NEEDLE-FREE PERCOCET ORAL 3 QL INJECTOR TABLET SYNALGOS-DC ORAL PONSTEL ORAL 3 3 CAPSULE CAPSULE TALWIN INJECTION PRIALT INTRATHECAL 3 4 PA SOLUTION SOLUTION tencon oral tablet 1 PRIMLEV ORAL 3 QL TABLET TRAMADOL ORAL CAPSULE,ER BIPHASE 3 QL PRODRIN ORAL 3 24 HR 17-83 TABLET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 10 Drug Name Tier Notes Drug Name Tier Notes TRAMADOL ORAL zebutal oral capsule 1 CAPSULE,ER BIPHASE 3 QL ZECUITY 24 HR 25-75 TRANSDERMAL PATCH, 3 ST; QL tramadol oral tablet 1 QL IONTOPHORETIC tramadol oral tablet extended ZEMBRACE 1 QL release 24 hr SYMTOUCH 3 ST; QL tramadol oral tablet, er SUBCUTANEOUS PEN 1 QL multiphase 24 hr INJECTOR tramadol-acetaminophen oral ZIPSOR ORAL CAPSULE 3 ST 1 QL tablet ZOHYDRO ER ORAL TREXIMET ORAL CAPSULE, ORAL ONLY, 3 PA; QL 3 ST; QL TABLET ER 12HR TREZIX ORAL CAPSULE 3 QL zolmitriptan oral tablet 1 QL TYLENOL-CODEINE #3 zolmitriptan oral 3 QL 1 QL ORAL TABLET tablet,disintegrating TYLENOL-CODEINE #4 ZOMIG NASAL 3 QL 3 ST; QL ORAL TABLET SPRAY,NON-AEROSOL ULTIVA INTRAVENOUS ZOMIG ORAL TABLET 3 ST; QL 3 RECON SOLN ZOMIG ZMT ORAL ULTRACET ORAL TABLET,DISINTEGRATI 3 ST; QL 3 QL TABLET NG ULTRAM ER ORAL ANESTHETICS TABLET EXTENDED 3 QL AMIDATE RELEASE 24 HR INTRAVENOUS 3 ULTRAM ORAL TABLET 3 QL SOLUTION VANATOL LQ ORAL AMIDATE 3 SOLUTION INTRAVENOUS 3 SYRINGE verdrocet oral tablet 1 ARTICADENT DENTAL vicodin es oral tablet 1 QL INJECTION 3 vicodin hp oral tablet 1 QL CARTRIDGE BREVITAL INJECTION vicodin oral tablet 1 QL 3 RECON SOLN VICOPROFEN ORAL 3 QL TABLET BUCALSEP MUCOUS MEMBRANE 3 XARTEMIS XR ORAL AEROSOL,SPRAY TAB,ORAL ONLY,IR - 3 ST; QL BUCALSEP MUCOUS ER, BIPHASE 3 MEMBRANE SOLUTION XODOL 10/300 ORAL 3 QL bupivacaine (pf) injection TABLET 1 solution XODOL 5/300 ORAL 3 QL bupivacaine injection TABLET 1 solution XODOL 7.5/300 ORAL 3 QL bupivacaine-dextrose-water( TABLET 1 pf) injection solution xylon 10 oral tablet 1 bupivacaine-epinephrine (pf) 1 zamicet oral solution 1 QL injection solution Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 11 Drug Name Tier Notes Drug Name Tier Notes BUPIVACAINE-EPINEPH ketamine injection solution 1 RINE BITART LDO PLUS TOPICAL 3 3 INJECTION GEL CARTRIDGE lidocaine (pf) in d7.5w bupivacaine-epinephrine 1 1 intrathecal solution injection solution lidocaine (pf) injection CARBOCAINE (PF) solution 10 mg/ml (1 %), 15 INJECTION SOLUTION 1 3 mg/ml (1.5 %), 40 mg/ml (4 10 MG/ML (1 %), 20 %), 5 mg/ml (0.5 %) MG/ML (2 %) LIDOCAINE (PF) carbocaine (pf) injection 1 INJECTION SOLUTION 3 solution 15 mg/ml (1.5 %) 20 MG/ML (2 %) CARBOCAINE lidocaine hcl injection 3 1 INJECTION SOLUTION solution CETACAINE TOPICAL lidocaine hcl laryngotracheal 3 1 AEROSOL,SPRAY solution CITANEST FORTE lidocaine hcl mucous 1 DENTAL INJECTION 3 membrane gel CARTRIDGE lidocaine hcl mucous 1 CITANEST PLAIN membrane jelly in applicator DENTAL INJECTION 3 lidocaine hcl mucous CARTRIDGE 1 membrane solution cocaine topical solution 1 lidocaine topical adhesive 1 compound 347 inhalation gas 1 patch,medicated DIPRIVAN lidocaine topical ointment 1 INTRAVENOUS 3 lidocaine viscous mucous EMULSION 1 membrane solution EMLA TOPICAL CREAM 3 lidocaine-epinephrine (pf) ethyl chloride topical 1 1 injection solution aerosol,spray LIDOCAINE-EPINEPHRI etomidate intravenous 1 NE BIT INJECTION 3 solution CARTRIDGE EXPAREL (PF) LOCAL lidocaine-epinephrine 1 INFILTRATION 3 injection solution SUSPENSION lidocaine-prilocaine topical 1 forane inhalation liquid 1 cream glydo mucous membrane lidocaine-prilocaine topical 1 1 jelly in applicator kit isoflurane inhalation liquid 1 LIDOCAINE-TETRACAI 3 IV INFUSION CPI KIT 3 NE TOPICAL CREAM KETALAR INJECTION LIDODERM TOPICAL 3 SOLUTION ADHESIVE 3 KETAMINE IN 0.9 % PATCH,MEDICATED SOD CHLORIDE LIVIXIL PAK TOPICAL 3 3 INTRAVENOUS KIT SYRINGE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 12 Drug Name Tier Notes Drug Name Tier Notes LP LITE PAK TOPICAL POLOCAINE INJECTION 3 3 KIT SOLUTION 2 % lta pre-attached polocaine-mpf injection 1 1 laryngotracheal solution solution MARCAINE (PF) PONTOCAINE TOPICAL 3 INJECTION SOLUTION SOLUTION 3 0.25 % (2.5 MG/ML), 0.5 propofol intravenous 1 % (5 MG/ML) emulsion marcaine (pf) injection 1 PROPOVEN (PF) solution 0.75 % (7.5 mg/ml) INTRAVENOUS 3 MARCAINE INJECTION EMULSION 3 SOLUTION PYRIDIUM ORAL 3 MARCAINE SPINAL (PF) TABLET 3 INJECTION SOLUTION relador pak plus topical kit 1 MARCAINE-EPINEPHRI relador pak topical kit 1 NE (PF) INJECTION 3 ropivacaine (pf) injection SOLUTION 1 solution MARCAINE-EPINEPHRI NE INJECTION 3 SENSORCAINE SOLUTION INJECTION SOLUTION 3 0.25 % (2.5 MG/ML) MEPIVACAINE (PF) sensorcaine injection solution INJECTION 3 1 CARTRIDGE 0.5 % (5 mg/ml) midazolam (pf) injection sensorcaine/epinephrine 1 1 cartridge injection solution midazolam (pf) injection SENSORCAINE-MPF 1 3 solution INJECTION SOLUTION midazolam (pf) injection SENSORCAINE-MPF 1 syringe 2 mg/2 ml (1 mg/ml) SPINAL INJECTION 3 SOLUTION MIDAZOLAM (PF) INJECTION SYRINGE 5 3 SENSORCAINE-MPF/EPI MG/ML NEPHRINE INJECTION 3 SOLUTION midazolam injection solution 1 sevoflurane inhalation liquid 1 NAROPIN (PF) 3 INJECTION SOLUTION sojourn inhalation liquid 1 NESACAINE INJECTION SPRAY AND STRETCH 3 SOLUTION TOPICAL 3 AEROSOL,SPRAY NESACAINE-MPF 3 SUPRANE INHALATION INJECTION SOLUTION 3 LIQUID PAIN EASE TOPICAL 3 AEROSOL,SPRAY SYNERA TOPICAL PATCH, MEDICATED 3 phenazopyridine oral tablet 1 SELF-HEATING PLIAGLIS TOPICAL 3 terrell inhalation liquid 1 CREAM tetracaine hcl (pf) injection polocaine injection solution 1 1 1 solution % (10 mg/ml) Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 13 Drug Name Tier Notes Drug Name Tier Notes ULTANE INHALATION COMFORT 3 3 QL LIQUID PAC-MELOXICAM KIT xylocaine dental-epinephrine COMFORT 1 3 injection cartridge PAC-NAPROXEN KIT XYLOCAINE CUPRIMINE ORAL 3 2 INJECTION SOLUTION CAPSULE XYLOCAINE-EPINEPHR DAYPRO ORAL TABLET 3 INE INJECTION 3 DEPEN TITRATABS 3 SOLUTION ORAL TABLET XYLOCAINE-MPF diclofenac sodium oral tablet 3 1 INJECTION SOLUTION extended release 24 hr XYLOCAINE-MPF/EPIN diclofenac sodium oral 1 EPHRINE INJECTION 3 tablet,delayed release (dr/ec) SOLUTION diclofenac-misoprostol oral ZINGO INTRADERMAL 1 ST 3 tablet,ir,delayed rel,biphasic PEN INJECTOR DISALCID ORAL 3 ANTIARTHRITICS TABLET allopurinol oral tablet 1 DUEXIS ORAL TABLET 3 ST; QL aloprim intravenous recon 1 DYLOJECT soln INTRAVENOUS 3 ANAPROX DS ORAL SOLUTION 3 TABLET EC-NAPROSYN ORAL ARAVA ORAL TABLET 3 TABLET,DELAYED 3 ARTHROTEC 50 ORAL RELEASE (DR/EC) TABLET,IR,DELAYED 3 ST ELITEK INTRAVENOUS 3 REL,BIPHASIC RECON SOLN ARTHROTEC 75 ORAL ENBREL TABLET,IR,DELAYED 3 ST SUBCUTANEOUS 4 PA; QL REL,BIPHASIC RECON SOLN CALDOLOR ENBREL INTRAVENOUS RECON 3 SUBCUTANEOUS 4 PA; QL SOLN SYRINGE CELEBREX ORAL ENBREL SURECLICK 3 ST; QL CAPSULE SUBCUTANEOUS PEN 4 PA; QL celecoxib oral capsule 1 ST; QL INJECTOR COLCHICINE ORAL etodolac oral capsule 1 3 PA; QL CAPSULE etodolac oral tablet 1 COLCHICINE ORAL etodolac oral tablet extended 3 PA; QL 1 TABLET release 24 hr colchicine-probenecid oral EUFLEXXA 1 tablet INTRA-ARTICULAR 4 PA COLCRYS ORAL SYRINGE 3 PA; QL TABLET FELDENE ORAL 3 COMFORT CAPSULE 3 PAC-IBUPROFEN KIT FENOPROFEN ORAL 3 ST CAPSULE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 14 Drug Name Tier Notes Drug Name Tier Notes fenoprofen oral tablet 1 KINERET flurbiprofen oral tablet 1 SUBCUTANEOUS 4 PA SYRINGE GEL-ONE INTRA-ARTICULAR 4 PA KRYSTEXXA SYRINGE INTRAVENOUS 4 PA SOLUTION GENVISC 850 INTRA-ARTICULAR 4 PA leflunomide oral tablet 1 SYRINGE meclofenamate oral capsule 1 HUMIRA PEDIATRIC meloxicam oral suspension 1 QL CROHN'S START 4 PA; QL meloxicam oral tablet 1 QL SUBCUTANEOUS MITIGARE ORAL SYRINGE KIT 3 PA; QL CAPSULE HUMIRA PEN CROHN'S-UC-HS START MOBIC ORAL 4 PA; QL 3 QL SUBCUTANEOUS PEN SUSPENSION INJECTOR KIT MOBIC ORAL TABLET 3 QL HUMIRA PEN MONOVISC PSORIASIS STARTER 4 PA; QL INTRA-ARTICULAR 4 PA SUBCUTANEOUS PEN SYRINGE INJECTOR KIT nabumetone oral tablet 1 HUMIRA PEN NALFON ORAL SUBCUTANEOUS PEN 4 PA; QL 3 ST INJECTOR KIT CAPSULE HUMIRA NAPRELAN CR ORAL SUBCUTANEOUS 4 PA; QL TABLET, ER 3 SYRINGE KIT MULTIPHASE 24 HR NAPROSYN ORAL HYALGAN 3 INTRA-ARTICULAR 4 PA TABLET SOLUTION naproxen oral suspension 1 HYALGAN naproxen oral tablet 1 INTRA-ARTICULAR 4 PA naproxen oral tablet,delayed 1 SYRINGE release (dr/ec) ibuprofen oral suspension 1 naproxen sodium oral tablet 1 ibuprofen oral tablet 1 naproxen sodium oral tablet, 1 INDOCIN ORAL er multiphase 24 hr 3 ST SUSPENSION ORENCIA (WITH INDOCIN RECTAL MALTOSE) 3 ST 4 PA SUPPOSITORY INTRAVENOUS RECON indomethacin oral capsule 1 SOLN indomethacin oral capsule, ORENCIA 1 extended release SUBCUTANEOUS 4 PA; QL SYRINGE ketoprofen oral capsule 1 ORTHOVISC ketoprofen oral capsule,ext 1 INTRA-ARTICULAR 4 PA rel. pellets 24 hr SYRINGE OTEZLA ORAL TABLET 4 PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 15 Drug Name Tier Notes Drug Name Tier Notes OTEZLA STARTER VIMOVO ORAL ORAL TABLETS,DOSE 4 PA; QL TABLET,IR,DELAYED 3 ST; QL PACK REL,BIPHASIC OTREXUP (PF) VIVLODEX ORAL 3 QL SUBCUTANEOUS 4 PA; QL CAPSULE AUTO-INJECTOR VOLTAREN-XR ORAL oxaprozin oral tablet 1 TABLET EXTENDED 3 piroxicam oral capsule 1 RELEASE 24 HR XELJANZ ORAL probenecid oral tablet 1 4 PA; QL TABLET RASUVO (PF) SUBCUTANEOUS 4 PA; QL XELJANZ XR ORAL AUTO-INJECTOR TABLET EXTENDED 4 RELEASE 24 HR RHEUMATREX ORAL 2 ZORVOLEX ORAL TABLETS,DOSE PACK 3 ST; QL CAPSULE RIDAURA ORAL 2 ZYLOPRIM ORAL CAPSULE 3 TABLET salsalate oral tablet 1 ANTIASTHMATICS SIMPONI ARIA ACCOLATE ORAL INTRAVENOUS 4 PA 3 SOLUTION TABLET SIMPONI acetylcysteine solution 1 SUBCUTANEOUS PEN 4 PA; QL ADVAIR DISKUS INJECTOR INHALATION BLISTER 2 QL SIMPONI WITH DEVICE SUBCUTANEOUS 4 PA; QL ADVAIR HFA SYRINGE INHALATION HFA 2 QL sulindac oral tablet 1 AEROSOL INHALER SUPARTZ FX AEROSPAN INTRA-ARTICULAR 4 PA INHALATION HFA 3 QL SYRINGE AEROSOL INHALER albuterol sulfate inhalation SYNVISC 1 INTRA-ARTICULAR 4 PA solution for nebulization SYRINGE albuterol sulfate oral syrup 1 SYNVISC-ONE albuterol sulfate oral tablet 1 INTRA-ARTICULAR 4 PA albuterol sulfate oral tablet 1 SYRINGE extended release 12 hr TIVORBEX ORAL 3 ST; QL ALVESCO INHALATION CAPSULE HFA AEROSOL 3 QL tolmetin oral capsule 1 INHALER tolmetin oral tablet 1 aminophylline intravenous 1 TREPADONE (WITH solution 250 mg/10 ml BROMELAIN) ORAL 3 AMINOPHYLLINE CAPSULE INTRAVENOUS 3 ULORIC ORAL TABLET 3 ST SOLUTION 500 MG/20 ML

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 16 Drug Name Tier Notes Drug Name Tier Notes ANORO ELLIPTA DALIRESP ORAL 3 QL INHALATION BLISTER 2 QL TABLET WITH DEVICE DULERA INHALATION ARCAPTA NEOHALER HFA AEROSOL 2 QL INHALATION CAPSULE, INHALER 3 QL W/INHALATION ELIXOPHYLLIN ORAL 2 DEVICE ELIXIR ARNUITY ELLIPTA FLOVENT DISKUS INHALATION BLISTER 2 QL INHALATION BLISTER 2 QL WITH DEVICE WITH DEVICE ASMANEX HFA FLOVENT HFA INHALATION HFA 2 QL INHALATION HFA 2 QL AEROSOL INHALER AEROSOL INHALER ASMANEX FORADIL AEROLIZER TWISTHALER INHALATION CAPSULE, 2 QL INHALATION AEROSOL W/INHALATION POWDR BREATH DEVICE ACTIVATED 110 MCG 2 QL GASTROCROM ORAL (30 DOSES), 220 MCG 3 (120 DOSES), 220 MCG CONCENTRATE (30 DOSES), 220 MCG (60 INCRUSE ELLIPTA DOSES) INHALATION BLISTER 3 QL ASMANEX WITH DEVICE TWISTHALER ipratropium bromide 1 QL INHALATION AEROSOL inhalation solution POWDR BREATH 2 ACTIVATED 110 MCG (7 ipratropium-albuterol DOSES), 220 MCG (14 inhalation solution for 1 DOSES) nebulization levalbuterol hcl inhalation ATROVENT HFA 1 INHALATION HFA 2 QL solution for nebulization AEROSOL INHALER metaproterenol oral syrup 1 BREO ELLIPTA metaproterenol oral tablet 1 INHALATION BLISTER 2 QL montelukast oral granules in 1 QL WITH DEVICE packet BROVANA INHALATION montelukast oral tablet 1 QL SOLUTION FOR 3 QL montelukast oral NEBULIZATION 1 QL tablet,chewable budesonide inhalation 1 QL suspension for nebulization NUCALA SUBCUTANEOUS 4 PA CINQAIR RECON SOLN INTRAVENOUS 3 SOLUTION PERFOROMIST INHALATION COMBIVENT RESPIMAT 2 QL 2 QL SOLUTION FOR INHALATION MIST NEBULIZATION cromolyn inhalation solution 1 PROAIR HFA for nebulization INHALATION HFA 2 QL cromolyn oral concentrate 1 AEROSOL INHALER

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 17 Drug Name Tier Notes Drug Name Tier Notes PROAIR RESPICLICK THEO-24 ORAL INHALATION AEROSOL CAPSULE,EXTENDED 2 2 QL POWDR BREATH RELEASE 24HR ACTIVATED theochron oral tablet 1 PROVENTIL HFA extended release 12 hr INHALATION HFA 3 QL theophylline in dextrose 5 % AEROSOL INHALER intravenous parenteral 1 PULMICORT solution FLEXHALER theophylline oral elixir 1 INHALATION AEROSOL 2 QL POWDR BREATH theophylline oral solution 1 ACTIVATED theophylline oral tablet 1 PULMICORT extended release INHALATION theophylline oral tablet 3 QL 1 SUSPENSION FOR extended release 12 hr NEBULIZATION TUDORZA PRESSAIR QVAR INHALATION INHALATION AEROSOL 2 QL 3 QL AEROSOL POWDR BREATH SEEBRI NEOHALER ACTIVATED INHALATION CAPSULE, 3 QL UTIBRON NEOHALER W/INHALATION INHALATION CAPSULE, 3 QL DEVICE W/INHALATION SEREVENT DISKUS DEVICE INHALATION BLISTER 2 QL VENTOLIN HFA WITH DEVICE INHALATION HFA 2 QL SINGULAIR ORAL AEROSOL INHALER 3 QL GRANULES IN PACKET VOSPIRE ER ORAL SINGULAIR ORAL TABLET EXTENDED 3 3 QL TABLET RELEASE 12 HR SINGULAIR ORAL XOLAIR 3 QL TABLET,CHEWABLE SUBCUTANEOUS 4 PA RECON SOLN SPIRIVA RESPIMAT 2 QL INHALATION MIST XOPENEX CONCENTRATE SPIRIVA WITH INHALATION 3 QL HANDIHALER SOLUTION FOR INHALATION CAPSULE, 2 QL NEBULIZATION W/INHALATION DEVICE XOPENEX HFA INHALATION HFA 3 QL STIOLTO RESPIMAT 2 QL AEROSOL INHALER INHALATION MIST XOPENEX INHALATION STRIVERDI RESPIMAT 3 QL SOLUTION FOR 3 QL INHALATION MIST NEBULIZATION SYMBICORT zafirlukast oral tablet 1 INHALATION HFA 2 QL AEROSOL INHALER ZYFLO CR ORAL TABLET, ER 3 terbutaline oral tablet 1 MULTIPHASE 12 HR terbutaline subcutaneous 1 ZYFLO ORAL TABLET 3 solution Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 18 Drug Name Tier Notes Drug Name Tier Notes ANTIBIOTICS AUGMENTIN ORAL 3 ACTICLATE ORAL TABLET 3 ST TABLET AUGMENTIN XR ORAL ADOXA ORAL CAPSULE 3 ST TABLET EXTENDED 3 RELEASE 12 HR amikacin injection solution 1 AVAR LS TOPICAL 3 amoxicillin oral capsule 1 CLEANSER amoxicillin oral suspension AVAR LS TOPICAL 1 3 PA for reconstitution FOAM amoxicillin oral tablet 1 AVAR LS TOPICAL 3 AMOXICILLIN ORAL PADS, MEDICATED TABLET, ER 3 avar topical cleanser 1 PA MULTIPHASE 24 HR AVAR TOPICAL FOAM 3 PA amoxicillin oral 1 AVAR TOPICAL PADS, tablet,chewable 3 MEDICATED amoxicillin-pot clavulanate AVAR-E GREEN oral suspension for 1 3 reconstitution TOPICAL CREAM amoxicillin-pot clavulanate AVAR-E LS TOPICAL 1 3 PA oral tablet CREAM AVAR-E TOPICAL amoxicillin-pot clavulanate 3 oral tablet extended release 1 CREAM 12 hr AVELOX ABC PACK 3 QL amoxicillin-pot clavulanate ORAL TABLET 1 oral tablet,chewable AVELOX IN NACL (ISO-OSMOTIC) ampicillin oral capsule 1 3 INTRAVENOUS ampicillin oral suspension 1 PIGGYBACK for reconstitution AVELOX ORAL TABLET 3 QL ampicillin sodium injection 1 recon soln AVIDOXY DK KIT 3 ampicillin sodium avidoxy oral tablet 1 1 intravenous recon soln AVYCAZ ampicillin-sulbactam INTRAVENOUS RECON 3 1 injection recon soln SOLN ampicillin-sulbactam AZACTAM IN 1 DEXTROSE (ISO-OSM) intravenous recon soln 3 INTRAVENOUS AUGMENTIN ES-600 PIGGYBACK ORAL SUSPENSION FOR 3 AZACTAM INJECTION RECONSTITUTION 3 RECON SOLN AUGMENTIN ORAL SUSPENSION FOR AZASITE OPHTHALMIC 2 2 RECONSTITUTION DROPS 125-31.25 MG/5 ML azithromycin intravenous 1 AUGMENTIN ORAL recon soln SUSPENSION FOR azithromycin oral packet 1 QL 3 RECONSTITUTION 250-62.5 MG/5 ML Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 19 Drug Name Tier Notes Drug Name Tier Notes azithromycin oral suspension BICILLIN L-A 1 QL for reconstitution INTRAMUSCULAR 3 azithromycin oral tablet 1 QL SYRINGE aztreonam injection recon BLEPH-10 1 3 soln OPHTHALMIC DROPS azuphen mb oral capsule 1 BLEPHAMIDE OPHTHALMIC 3 baciim intramuscular recon 1 DROPS,SUSPENSION soln BLEPHAMIDE S.O.P. bacitracin intramuscular 1 OPHTHALMIC 3 recon soln OINTMENT bacitracin ophthalmic 1 bp 10-1 topical cleanser 1 ointment CAPASTAT INJECTION bacitracin-polymyxin b 3 1 RECON SOLN ophthalmic ointment CAYSTON INHALATION BACTRIM DS ORAL 3 SOLUTION FOR 4 TABLET NEBULIZATION BACTRIM ORAL 3 CEDAX ORAL CAPSULE 3 TABLET CEDAX ORAL BACTROBAN NASAL 2 SUSPENSION FOR 3 NASAL OINTMENT RECONSTITUTION BACTROBAN TOPICAL 3 cefaclor oral capsule 1 CREAM cefaclor oral suspension for BENZAMYCIN TOPICAL 1 3 reconstitution GEL cefaclor oral tablet extended BENZAMYCINPAK 1 3 ST release 12 hr TOPICAL GEL cefadroxil oral capsule 1 BENZODOX 30 KIT, cefadroxil oral suspension CLEANSER ER AND 3 1 TABLET for reconstitution BENZODOX 60 KIT, cefadroxil oral tablet 1 CLEANSER ER AND 3 cefazolin in dextrose (iso-os) TABLET intravenous piggyback 1 1 BESIVANCE gram/50 ml, 2 gram/50 ml OPHTHALMIC 3 CEFAZOLIN IN DROPS,SUSPENSION DEXTROSE (ISO-OS) BETHKIS INHALATION INTRAVENOUS 3 SOLUTION FOR 4 PIGGYBACK 2 NEBULIZATION GRAM/100 ML BIAXIN ORAL cefazolin injection recon soln 1 SUSPENSION FOR 3 cefazolin intravenous recon 1 RECONSTITUTION soln BIAXIN ORAL TABLET 3 cefdinir oral capsule 1 BICILLIN C-R cefdinir oral suspension for 1 INTRAMUSCULAR 3 reconstitution SYRINGE cefditoren pivoxil oral tablet 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 20 Drug Name Tier Notes Drug Name Tier Notes CEFEPIME IN ceftriaxone injection recon DEXTROSE 5 % soln 1 gram, 10 gram, 2 1 3 INTRAVENOUS gram, 250 mg, 500 mg PIGGYBACK CEFTRIAXONE cefepime in dextrose,iso-osm INJECTION RECON 3 1 intravenous piggyback SOLN 100 GRAM cefepime injection recon soln 1 ceftriaxone intravenous recon 1 cefixime oral suspension for soln 1 reconstitution cefuroxime axetil oral tablet 1 CEFOTAN INJECTION cefuroxime sodium injection 3 1 RECON SOLN recon soln cefotaxime injection recon cefuroxime sodium 1 1 soln intravenous recon soln CEFOTETAN IN CENTANY AT TOPICAL 3 DEXTROSE, ISO-OSM OINTMENT KIT 3 INTRAVENOUS CENTANY TOPICAL 3 PIGGYBACK OINTMENT cefotetan injection recon soln 1 cephalexin oral capsule 1 cefotetan intravenous recon cephalexin oral suspension 1 1 soln for reconstitution cefoxitin in dextrose, iso-osm 1 cephalexin oral tablet 1 intravenous piggyback CETRAXAL OTIC cefoxitin intravenous recon 3 1 DROPPERETTE soln chloramphenicol sod cefpodoxime oral suspension 1 succinate intravenous recon 1 for reconstitution soln cefpodoxime oral tablet 1 CILOXAN 3 cefprozil oral suspension for OPHTHALMIC DROPS 1 reconstitution CILOXAN cefprozil oral tablet 1 OPHTHALMIC 3 CEFTAZIDIME IN D5W OINTMENT INTRAVENOUS 3 CIPRO HC OTIC 3 PIGGYBACK DROPS,SUSPENSION ceftazidime injection recon CIPRO IN D5W 1 soln INTRAVENOUS 3 ceftibuten oral capsule 1 PIGGYBACK ceftibuten oral suspension for CIPRO ORAL 1 reconstitution SUSPENSION,MICROCA 3 QL PSULE RECON CEFTIN ORAL SUSPENSION FOR 3 CIPRO ORAL TABLET 3 QL RECONSTITUTION CIPRO XR ORAL CEFTIN ORAL TABLET 3 TABLET, ER 3 QL MULTIPHASE 24 HR ceftriaxone in dextrose,iso-os 1 CIPRODEX OTIC intravenous piggyback 2 DROPS,SUSPENSION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 21 Drug Name Tier Notes Drug Name Tier Notes ciprofloxacin (mixture) oral CLEOCIN T TOPICAL 1 QL 3 tablet, er multiphase 24 hr LOTION ciprofloxacin hcl ophthalmic CLEOCIN T TOPICAL 1 3 drops SOLUTION ciprofloxacin hcl oral tablet 1 QL CLEOCIN T TOPICAL 3 ciprofloxacin hcl otic SWAB 1 dropperette CLEOCIN VAGINAL 3 ciprofloxacin in 5 % dextrose CREAM 1 intravenous piggyback CLEOCIN VAGINAL 2 ciprofloxacin lactate SUPPOSITORY 1 intravenous solution CLIN SINGLE USE 3 ciprofloxacin oral INJECTION KIT suspension,microcapsule 1 QL CLINDACIN ETZ 3 ST recon TOPICAL KIT CLAFORAN IN clindacin etz topical swab 1 DEXTROSE(ISO-OSM) 3 clindacin p topical swab 1 INTRAVENOUS CLINDACIN PAC PIGGYBACK 3 ST TOPICAL KIT CLAFORAN INJECTION 3 CLINDAGEL TOPICAL RECON SOLN 3 ST GEL CLAFORAN INTRAVENOUS RECON 3 clindamycin hcl oral capsule 1 SOLN clindamycin in 5 % dextrose 1 clarithromycin oral intravenous piggyback 1 suspension for reconstitution clindamycin palmitate hcl 1 clarithromycin oral tablet 1 oral recon soln clarithromycin oral tablet clindamycin pediatric oral 1 1 extended release 24 hr recon soln cleansing wash topical clindamycin phosphate 1 1 cleanser injection solution clindamycin phosphate CLEOCIN IN 5 % 1 DEXTROSE intravenous solution 3 INTRAVENOUS clindamycin phosphate 1 PIGGYBACK topical foam CLEOCIN INJECTION clindamycin phosphate 3 1 SOLUTION topical gel CLEOCIN clindamycin phosphate 1 INTRAVENOUS 3 topical lotion SOLUTION clindamycin phosphate CLEOCIN ORAL 1 3 topical solution CAPSULE clindamycin phosphate CLEOCIN ORAL RECON 1 3 topical swab SOLN clindamycin phosphate CLEOCIN T TOPICAL 1 3 vaginal cream GEL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 22 Drug Name Tier Notes Drug Name Tier Notes CLINDESSE VAGINAL doxycycline monohydrate 1 CREAM,EXTENDED 3 oral capsule RELEASE DOXYCYCLINE colistin (colistimethate na) MONOHYDRATE ORAL 1 3 ST injection recon soln CAPSULE,IR - DELAY COLY-MYCIN M REL,BIPHASE PARENTERAL doxycycline monohydrate 3 INJECTION RECON oral suspension for 1 SOLN reconstitution COLY-MYCIN S OTIC doxycycline monohydrate 3 1 DROPS,SUSPENSION oral tablet CORTISPORIN TOPICAL e.e.s. 400 oral tablet 1 3 CREAM E.E.S. GRANULES ORAL CORTISPORIN TOPICAL SUSPENSION FOR 3 3 OINTMENT RECONSTITUTION CORTISPORIN-TC OTIC ery pads topical swab 1 3 DROPS,SUSPENSION erygel topical gel 1 CUBICIN ERYPED 200 ORAL INTRAVENOUS RECON 3 SUSPENSION FOR 3 SOLN RECONSTITUTION CYCLOSERINE ORAL 3 ERYPED 400 ORAL CAPSULE SUSPENSION FOR 3 DALVANCE RECONSTITUTION INTRAVENOUS 3 ery-tab oral tablet,delayed SOLUTION release (dr/ec) 250 mg, 333 1 DAPSONE ORAL mg 3 TABLET ERY-TAB ORAL demeclocycline oral tablet 1 TABLET,DELAYED 3 dicloxacillin oral capsule 1 RELEASE (DR/EC) 500 MG DIFICID ORAL TABLET 3 erythrocin (as stearate) oral 1 DORIBAX tablet INTRAVENOUS RECON 3 SOLN ERYTHROCIN INTRAVENOUS RECON 3 DORYX ORAL SOLN TABLET,DELAYED 3 ST erythromycin ethylsuccinate RELEASE (DR/EC) 1 oral tablet doxy-100 intravenous recon 1 erythromycin ophthalmic soln 1 ointment doxycycline hyclate 1 intravenous recon soln erythromycin oral capsule,delayed 1 doxycycline hyclate oral 1 release(dr/ec) capsule erythromycin oral tablet 1 doxycycline hyclate oral 1 erythromycin with ethanol tablet 1 topical gel doxycycline hyclate oral 1 ST tablet,delayed release (dr/ec) Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 23 Drug Name Tier Notes Drug Name Tier Notes erythromycin with ethanol gentamicin sulfate (pf) 1 topical solution intravenous solution 100 1 erythromycin with ethanol mg/10 ml 1 topical swab GENTAMICIN SULFATE erythromycin-benzoyl (PF) INTRAVENOUS 3 1 peroxide topical gel SOLUTION 60 MG/6 ML ethambutol oral tablet 1 gentamicin topical cream 1 EVOCLIN TOPICAL gentamicin topical ointment 1 3 FOAM HIPREX ORAL TABLET 3 FACTIVE ORAL hyolev mb oral tablet 1 3 QL TABLET hyophen oral tablet 1 FLAGYL ER ORAL ILOTYCIN TABLET EXTENDED 3 OPHTHALMIC 3 RELEASE OINTMENT FLAGYL ORAL imipenem-cilastatin 3 1 CAPSULE intravenous recon soln FLAGYL ORAL TABLET 3 INDIOMIN MB ORAL 3 FORTAZ IN DEXTROSE CAPSULE 5 % INTRAVENOUS 3 INVANZ INJECTION 3 PIGGYBACK RECON SOLN FORTAZ INJECTION INVANZ INTRAVENOUS 3 3 RECON SOLN RECON SOLN FORTAZ INTRAVENOUS 3 isoniazid injection solution 1 RECON SOLN isoniazid oral solution 1 FURADANTIN ORAL 3 SUSPENSION isoniazid oral tablet 1 gatifloxacin ophthalmic KEFLEX ORAL 1 3 drops CAPSULE gentak ophthalmic ointment 1 KETEK ORAL TABLET 3 gentamicin in nacl (iso-osm) KITABIS PAK INHALATION intravenous piggyback 100 4 mg/100 ml, 60 mg/50 ml, 70 1 SOLUTION FOR mg/50 ml, 80 mg/100 ml, 80 NEBULIZATION mg/50 ml, 90 mg/100 ml LEVAQUIN ORAL 3 QL GENTAMICIN IN NACL TABLET (ISO-OSM) levofloxacin in d5w 1 INTRAVENOUS 3 intravenous piggyback PIGGYBACK 100 MG/50 levofloxacin intravenous ML, 120 MG/100 ML 1 solution gentamicin injection solution 1 levofloxacin ophthalmic 1 gentamicin ophthalmic drops 1 drops gentamicin ophthalmic LEVOFLOXACIN ORAL 1 3 QL ointment SOLUTION gentamicin sulfate (ped) (pf) 1 levofloxacin oral tablet 1 QL injection solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 24 Drug Name Tier Notes Drug Name Tier Notes LINCOCIN INJECTION metro i.v. intravenous 3 1 SOLUTION piggyback lincomycin injection solution 1 METROGEL VAGINAL 3 linezolid intravenous VAGINAL GEL 1 parenteral solution metronidazole in nacl linezolid oral suspension for (iso-os) intravenous 1 1 PA; QL reconstitution piggyback linezolid oral tablet 1 PA; QL metronidazole oral capsule 1 linezolid-0.9% sodium metronidazole oral tablet 1 chloride intravenous 1 metronidazole vaginal gel 1 parenteral solution MINOCIN MACROBID ORAL INTRAVENOUS RECON 3 ST 3 CAPSULE SOLN MACRODANTIN ORAL MINOCIN ORAL 3 3 ST CAPSULE CAPSULE MAXIPIME INJECTION minocycline oral capsule 1 ST 3 RECON SOLN minocycline oral tablet 1 ST MAXIPIME minocycline oral tablet 1 ST INTRAVENOUS RECON 3 extended release 24 hr SOLN mondoxyne nl oral capsule 1 MAXITROL MONODOX ORAL OPHTHALMIC 3 3 ST DROPS,SUSPENSION CAPSULE MONUROL ORAL MAXITROL 3 OPHTHALMIC 3 PACKET OINTMENT MORGIDOX 1X100 KIT 3 MEFOXIN IN MORGIDOX 2X100 KIT 3 DEXTROSE (ISO-OSM) 3 INTRAVENOUS morgidox oral capsule 1 PIGGYBACK MOXATAG ORAL meropenem intravenous TABLET, ER 3 1 recon soln MULTIPHASE 24 HR MOXEZA OPHTHALMIC MEROPENEM-0.9% 2 SODIUM CHLORIDE DROPS, VISCOUS 3 INTRAVENOUS moxifloxacin oral tablet 1 QL PIGGYBACK MOXIFLOXACIN-SOD.A MERREM CE,SUL-WATER 3 INTRAVENOUS RECON 3 INTRAVENOUS SOLN PIGGYBACK methenamine hippurate oral mupirocin calcium topical 1 1 tablet cream methenamine mandelate oral mupirocin topical ointment 1 1 tablet MYAMBUTOL ORAL 3 methen-sod phos-meth TABLET 1 blue-hyos oral tablet MYCOBUTIN ORAL 3 CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 25 Drug Name Tier Notes Drug Name Tier Notes nafcillin in dextrose iso-osm OCUFLOX 1 3 intravenous piggyback OPHTHALMIC DROPS nafcillin injection recon soln 1 ofloxacin ophthalmic drops 1 nafcillin intravenous recon ofloxacin oral tablet 1 QL 1 soln ofloxacin otic drops 1 neomycin oral tablet 1 ORACEA ORAL neomycin-bacitracin-poly-hc CAPSULE,IR - DELAY 3 1 ophthalmic ointment REL,BIPHASE neomycin-bacitracin-polymy ORBACTIV 1 xin ophthalmic ointment INTRAVENOUS RECON 3 neomycin-polymyxin SOLN b-dexameth ophthalmic 1 OTIPRIO drops,suspension INTRATYMPANIC 3 neomycin-polymyxin SUSPENSION b-dexameth ophthalmic 1 oxacillin in ointment dextrose(iso-osm) 1 neomycin-polymyxin-gramic intravenous piggyback 1 idin ophthalmic drops oxacillin injection recon soln 1 neomycin-polymyxin-hc oxacillin intravenous recon 1 1 ophthalmic drops,suspension soln neomycin-polymyxin-hc otic PASER ORAL 1 drops,suspension GRANULES DR FOR 3 neomycin-polymyxin-hc otic SUSP IN PACKET 1 solution PCE ORAL TABLET, 3 neo-polycin hc ophthalmic PARTICLES/CRYSTALS 1 ointment PENICILLIN G POT IN neo-polycin ophthalmic DEXTROSE 1 3 ointment INTRAVENOUS PIGGYBACK NEOSPORIN (NEO-POLYM-GRAMICI penicillin g potassium 3 1 D) OPHTHALMIC injection recon soln DROPS penicillin g procaine 1 NEO-SYNALAR KIT intramuscular syringe 3 TOPICAL CREAM penicillin g sodium injection 1 NEO-SYNALAR recon soln 3 TOPICAL CREAM penicillin v potassium oral 1 nitrofurantoin macrocrystal recon soln 1 oral capsule penicillin v potassium oral 1 nitrofurantoin tablet monohyd/m-cryst oral 1 pfizerpen-g injection recon 1 capsule soln nitrofurantoin oral phosphasal oral tablet 1 1 suspension piperacillin-tazobactam 1 NUVESSA VAGINAL intravenous recon soln 3 GEL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 26 Drug Name Tier Notes Drug Name Tier Notes PLEXION CLEANSING rosula cleansing cloths 1 CLOTHS TOPICAL 3 topical pads, medicated PADS, MEDICATED ROSULA TOPICAL 3 PLEXION TOPICAL CLEANSER 3 CLEANSER SILVADENE TOPICAL 3 PLEXION TOPICAL CREAM 3 CREAM silver sulfadiazine topical 1 PLEXION TOPICAL cream 3 LOTION SIRTURO ORAL 3 polycin ophthalmic ointment 1 TABLET polymyxin b sulfate injection SIVEXTRO 1 recon soln INTRAVENOUS RECON 3 polymyxin b SOLN sulf-trimethoprim ophthalmic 1 SIVEXTRO ORAL 3 PA; QL drops TABLET POLYTRIM SOLODYN ORAL 3 OPHTHALMIC DROPS TABLET EXTENDED 3 ST PRED-G OPHTHALMIC RELEASE 24 HR 3 DROPS,SUSPENSION SPECTRACEF ORAL 3 PRED-G S.O.P. TABLET OPHTHALMIC 3 ss 10-2 topical cleanser 1 OINTMENT ssd topical cream 1 PRIFTIN ORAL TABLET 2 sss 10-5 topical cream 1 PRIMAXIN IV sss 10-5 topical foam 1 INTRAVENOUS RECON 3 SOLN STREPTOMYCIN INTRAMUSCULAR 3 PRIMSOL ORAL 3 QL RECON SOLN SOLUTION sulfacetamide sodium 1 pyrazinamide oral tablet 1 ophthalmic drops rifabutin oral capsule 1 sulfacetamide sodium 1 RIFADIN ophthalmic ointment INTRAVENOUS RECON 3 sulfacetamide sodium-sulfur SOLN topical cleanser 10-2 %, 1 RIFADIN ORAL 9.8-4.8 % 3 CAPSULE sulfacetamide sodium-sulfur RIFAMATE ORAL topical cleanser 10-5 % 1 PA 3 CAPSULE (w/w), 9-4 %, 9-4.5 % rifampin intravenous recon sulfacetamide sodium-sulfur 1 1 PA soln topical cream 10-2 % rifampin oral capsule 1 sulfacetamide sodium-sulfur RIFATER ORAL topical cream 10-5 % (w/w), 1 2 TABLET 9.8-4.8 % ROSANIL TOPICAL sulfacetamide sodium-sulfur 3 PA 1 CLEANSER topical foam sulfacetamide sodium-sulfur 1 topical lotion Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 27 Drug Name Tier Notes Drug Name Tier Notes sulfacetamide sodium-sulfur SUMAXIN TS TOPICAL 1 PA 3 PA topical pads, medicated SUSPENSION sulfacetamide sodium-sulfur SUPRAX ORAL 1 3 topical suspension 10-5 % CAPSULE sulfacetamide sodium-sulfur SUPRAX ORAL 1 PA topical suspension 8-4 % SUSPENSION FOR 3 sulfacetamide RECONSTITUTION sod-sulfur-urea topical 1 SUPRAX ORAL 3 cleanser TABLET,CHEWABLE sulfacetamide-prednisolone SYNERCID 1 ophthalmic drops INTRAVENOUS RECON 3 sulfacetamide-sulfur-cleansr2 SOLN 1 PA 3 topical kit TAZICEF INJECTION 3 sulfacleanse 8-4 topical RECON SOLN 1 PA suspension TAZICEF sulfact INTRAVENOUS RECON 3 na-sul-avobnz-otn-ocsa SOLN 1 topical combo pack,cleanser TEFLARO and cream INTRAVENOUS RECON 3 sulfadiazine oral tablet 1 SOLN sulfamethoxazole-trimethopri tetracycline oral capsule 1 1 m intravenous solution THALOMID ORAL 2 PA; QL sulfamethoxazole-trimethopri CAPSULE 1 m oral suspension thermazene topical cream 1 sulfamethoxazole-trimethopri TOBI INHALATION 1 m oral tablet SOLUTION FOR 4 SULFAMYLON NEBULIZATION 3 TOPICAL CREAM TOBI PODHALER 4 SULFAMYLON INHALATION CAPSULE 3 TOPICAL PACKET TOBI PODHALER INHALATION CAPSULE, sulfatrim oral suspension 1 4 W/INHALATION SUMADAN TOPICAL 3 PA DEVICE CLEANSER TOBRADEX SUMADAN TOPICAL 3 PA OPHTHALMIC 3 KIT DROPS,SUSPENSION SUMADAN XLT TOBRADEX TOPICAL COMBO 3 OPHTHALMIC 2 PACK,CLEANSER AND OINTMENT CREAM TOBRADEX ST SUMAXIN CP TOPICAL 3 PA OPHTHALMIC 3 KIT DROPS,SUSPENSION SUMAXIN TOPICAL 3 PA tobramycin in 0.225 % nacl CLEANSER inhalation solution for 4 SUMAXIN TOPICAL nebulization 3 PA PADS, MEDICATED tobramycin in 0.9 % nacl 1 intravenous piggyback Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 28 Drug Name Tier Notes Drug Name Tier Notes tobramycin ophthalmic drops 1 VANCOMYCIN IN tobramycin sulfate injection DEXTROSE ISO-OSM 1 3 recon soln INTRAVENOUS PIGGYBACK tobramycin sulfate injection 1 solution vancomycin intravenous recon soln 1,000 mg, 10 1 tobramycin-dexamethasone 1 gram, 5 gram, 500 mg ophthalmic drops,suspension VANCOMYCIN TOBREX OPHTHALMIC 3 INTRAVENOUS RECON 3 DROPS SOLN 750 MG TOBREX OPHTHALMIC 3 vancomycin oral capsule 1 OINTMENT vandazole vaginal gel 1 TRECATOR ORAL 3 TABLET VIBATIV INTRAVENOUS RECON 3 trimethoprim oral tablet 1 SOLN TYGACIL VIBRAMYCIN ORAL 3 INTRAVENOUS RECON 3 CAPSULE SOLN VIBRAMYCIN ORAL UNASYN INJECTION 3 SUSPENSION FOR 3 RECON SOLN RECONSTITUTION ur n-c oral tablet 1 VIBRAMYCIN ORAL 3 ST uramit mb oral capsule 1 SYRUP VIGAMOX URELLE ORAL TABLET 3 2 OPHTHALMIC DROPS uretron d-s oral tablet 1 XIFAXAN ORAL 3 PA; QL URIBEL ORAL CAPSULE 3 TABLET urimar-t oral tablet 1 zencia topical cleanser 1 PA urin ds oral tablet 1 ZERBAXA uro-blue oral tablet 1 INTRAVENOUS RECON 3 urogesic-blue oral tablet 1 SOLN uro-l oral tablet 1 ZINACEF IN STERILE WATER INTRAVENOUS 3 urolet mb oral tablet 1 PIGGYBACK uro-mp oral capsule 1 ZINACEF INJECTION 3 urophen mb oral tablet 1 RECON SOLN uryl oral tablet 1 ZINACEF INTRAVENOUS RECON 3 ustell oral capsule 1 SOLN UTA ORAL CAPSULE 3 ZITHROMAX utira-c oral tablet 1 INTRAVENOUS RECON 3 VANCOCIN ORAL SOLN 3 CAPSULE ZITHROMAX ORAL 3 QL VANCOMYCIN IN D5W PACKET INTRAVENOUS 3 ZITHROMAX ORAL PIGGYBACK SUSPENSION FOR 3 QL RECONSTITUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 29 Drug Name Tier Notes Drug Name Tier Notes ZITHROMAX ORAL ARGATROBAN 3 QL TABLET INTRAVENOUS 3 ZITHROMAX TRI-PAK SOLUTION 3 QL ORAL TABLET ARIXTRA ZITHROMAX Z-PAK SUBCUTANEOUS 4 3 QL ORAL TABLET SYRINGE ZMAX ORAL BIVALIRUDIN SUSPENSION,EXTENDE 3 QL INTRAVENOUS RECON 3 D REL RECON SOLN COUMADIN ORAL ZOSYN IN DEXTROSE 2 (ISO-OSM) TABLET 3 INTRAVENOUS ELIQUIS ORAL TABLET 2 QL PIGGYBACK enoxaparin subcutaneous 4 ZOSYN INTRAVENOUS solution 3 RECON SOLN enoxaparin subcutaneous 4 ZYLET OPHTHALMIC syringe 2 DROPS,SUSPENSION fondaparinux subcutaneous 4 ZYMAXID syringe 3 OPHTHALMIC DROPS FRAGMIN ZYVOX INTRAVENOUS SUBCUTANEOUS 4 PARENTERAL 3 SOLUTION SOLUTION FRAGMIN ZYVOX ORAL SUBCUTANEOUS 4 SUSPENSION FOR 3 PA; QL SYRINGE RECONSTITUTION hep flush-10 (pf) intravenous 1 ZYVOX ORAL TABLET 3 PA; QL solution ANTICOAGULANTS heparin (porcine) in 5 % dex ACD SOLUTION 3 intravenous parenteral 1 solution ACD-A SOLUTION 3 heparin (porcine) in nacl (pf) ANGIOMAX intravenous parenteral 1 INTRAVENOUS RECON 3 solution SOLN heparin (porcine) injection 1 ANTICOAG CITRATE cartridge PHOS DEXTROSE 3 heparin (porcine) injection SOLUTION 1 solution ARGATROBAN IN 0.9 % SOD CHLOR heparin flush intravenous kit 1 INTRAVENOUS 3 heparin PARENTERAL flush(porcine)-0.9nacl 1 SOLUTION intravenous kit ARGATROBAN IN 0.9 % heparin lock flush (porcine) 1 SOD CHLOR intravenous solution 3 INTRAVENOUS heparin lock flush (porcine) 1 SOLUTION intravenous syringe ARGATROBAN IN NACL heparin lock flush 1 (ISO-OS) INTRAVENOUS 3 intravenous solution SOLUTION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 30 Drug Name Tier Notes Drug Name Tier Notes heparin lock flush TRICITRASOL 1 intravenous syringe INJECTION 3 heparin lock intravenous CONCENTRATE 1 solution warfarin oral tablet 1 heparin XARELTO ORAL 2 QL lockflush(porcine)(pf) 1 TABLET intravenous syringe XARELTO ORAL 2 HEPARIN(PORCINE) IN TABLETS,DOSE PACK 0.45% NACL ANTIDOTES INTRAVENOUS 3 EVZIO INJECTION PARENTERAL 3 PA; QL SOLUTION 12,500 AUTO-INJECTOR UNIT/250 ML MOVANTIK ORAL 3 heparin(porcine) in 0.45% TABLET nacl intravenous parenteral 1 naloxone injection solution 1 solution 25,000 unit/250 ml, 25,000 unit/500 ml naloxone injection syringe 1 heparin, porcine (pf) naltrexone oral tablet 1 1 injection solution NARCAN NASAL 3 PA heparin, porcine (pf) SPRAY,NON-AEROSOL 1 injection syringe RELISTOR heparin, porcine (pf) SUBCUTANEOUS 3 1 intravenous solution SOLUTION heparin, porcine (pf) RELISTOR 1 intravenous syringe SUBCUTANEOUS 3 SYRINGE IPRIVASK SUBCUTANEOUS 4 REVIA ORAL TABLET 3 RECON SOLN ANTIFUNGALS jantoven oral tablet 1 ABELCET LOVENOX INTRAVENOUS 3 SUBCUTANEOUS 4 SUSPENSION SOLUTION AMBISOME INTRAVENOUS LOVENOX 3 SUBCUTANEOUS 4 SUSPENSION FOR SYRINGE RECONSTITUTION monoject prefill (pf) amphotericin b injection 1 1 intravenous syringe recon soln monoject prefill advanced ANCOBON ORAL 1 3 (pf) intravenous syringe CAPSULE PRADAXA ORAL CANCIDAS 2 QL CAPSULE INTRAVENOUS RECON 3 SOLN SAVAYSA ORAL 3 QL CICLODAN KIT TABLET 3 TOPICAL COMBO PACK SODIUM CITRATE 3 CICLODAN KIT SOLUTION 3 TOPICAL SOLUTION ciclodan topical cream 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 31 Drug Name Tier Notes Drug Name Tier Notes ciclodan topical solution 1 fluconazole in ciclopirox topical cream 1 dextrose(iso-o) intravenous 1 piggyback ciclopirox topical gel 1 FLUCONAZOLE IN ciclopirox topical shampoo 1 NACL (ISO-OSM) ciclopirox topical solution 1 INTRAVENOUS 3 PIGGYBACK 100 MG/50 ciclopirox topical suspension 1 ML ciclopirox-ure-camph-menth- 1 fluconazole in nacl (iso-osm) euc topical solution intravenous piggyback 200 1 clotrimazole mucous mg/100 ml, 400 mg/200 ml 1 membrane troche fluconazole oral suspension 1 clotrimazole topical cream 1 for reconstitution clotrimazole topical solution 1 fluconazole oral tablet 1 clotrimazole-betamethasone flucytosine oral capsule 1 1 topical cream griseofulvin microsize oral 1 clotrimazole-betamethasone suspension 1 topical lotion griseofulvin microsize oral 1 CNL 8 NAIL TOPICAL tablet 3 KIT griseofulvin ultramicrosize 1 CRESEMBA oral tablet INTRAVENOUS RECON 3 GRIS-PEG SOLN (ULTRAMICROSIZE) 3 CRESEMBA ORAL ORAL TABLET 3 PA CAPSULE GYNAZOLE-1 VAGINAL 3 DIFLUCAN ORAL CREAM SUSPENSION FOR 3 itraconazole oral capsule 1 PA RECONSTITUTION JUBLIA TOPICAL DIFLUCAN ORAL 3 SOLUTION WITH 3 TABLET APPLICATOR econazole topical cream 1 KERYDIN TOPICAL ECOZA TOPICAL FOAM 3 SOLUTION WITH 3 ERAXIS(WATER APPLICATOR DILUENT) ketoconazole oral tablet 1 3 INTRAVENOUS RECON ketoconazole topical cream 1 SOLN ketoconazole topical foam 1 ERTACZO TOPICAL 3 ketoconazole topical CREAM 1 shampoo EXELDERM TOPICAL 3 LAMISIL ORAL CREAM 3 GRANULES IN PACKET EXELDERM TOPICAL 3 SOLUTION LAMISIL ORAL TABLET 3 EXODERM TOPICAL LOPROX TOPICAL 3 3 LOTION SHAMPOO EXTINA TOPICAL LOTRISONE TOPICAL 3 3 FOAM CREAM

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 32 Drug Name Tier Notes Drug Name Tier Notes LUZU TOPICAL CREAM 3 ORAVIG BUCCAL MENTAX TOPICAL MUCO-ADHESIVE 3 3 CREAM BUCCAL TABLET miconazole-3 vaginal oxiconazole topical cream 1 1 suppository OXISTAT TOPICAL 3 MYCAMINE CREAM INTRAVENOUS RECON 3 OXISTAT TOPICAL 3 SOLN LOTION NAFTIFINE TOPICAL PEDIADERM AF 3 3 CREAM 1 % TOPICAL CREAM naftifine topical cream 2 % 1 PENLAC TOPICAL 3 NAFTIN TOPICAL SOLUTION 3 CREAM SPORANOX ORAL 3 PA NAFTIN TOPICAL GEL 3 CAPSULE SPORANOX ORAL NATACYN 3 PA OPHTHALMIC 3 SOLUTION DROPS,SUSPENSION SPORANOX PULSEPAK 3 PA NIZORAL TOPICAL ORAL CAPSULE 3 SHAMPOO TERAZOL 3 VAGINAL 3 NOXAFIL CREAM INTRAVENOUS 3 TERAZOL 7 VAGINAL 3 SOLUTION CREAM NOXAFIL ORAL terbinafine hcl oral tablet 1 3 SUSPENSION terconazole vaginal cream 1 NOXAFIL ORAL terconazole vaginal 1 TABLET,DELAYED 3 suppository RELEASE (DR/EC) TRIACETIN LIQUID 3 QL nyamyc topical powder 1 TRIPLE DYE TOPICAL 3 NYATA TOPICAL SWAB COMBO PACK,GEL AND 3 POWDER VFEND IV INTRAVENOUS 3 nystatin oral powder 1 SOLUTION nystatin oral suspension 1 VFEND ORAL nystatin oral tablet 1 SUSPENSION FOR 3 nystatin topical cream 1 RECONSTITUTION nystatin topical ointment 1 VFEND ORAL TABLET 3 voriconazole intravenous nystatin topical powder 1 1 solution nystatin-triamcinolone 1 voriconazole oral suspension topical cream 1 for reconstitution nystatin-triamcinolone 1 topical ointment voriconazole oral tablet 1 VUSION TOPICAL nystop topical powder 1 3 OINTMENT ONMEL ORAL TABLET 3 XOLEGEL TOPICAL 3 GEL Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 33 Drug Name Tier Notes Drug Name Tier Notes ANTIHISTAMINE AND diphenhydramine hcl oral 1 DECONGESTANT elixir COMBINATION ELESTAT 3 ST; QL ALLEGRA-D 24 HOUR OPHTHALMIC DROPS ORAL TABLET EMADINE 3 ST; QL 3 ST; QL EXTENDED RELEASE 24 OPHTHALMIC DROPS HR epinastine ophthalmic drops 1 QL centergy oral drops 1 hydroxyzine hcl 1 CLARINEX-D 12 HOUR intramuscular solution ORAL TABLET, ER 3 ST; QL HYDROXYZINE HCL MULTIPHASE 12 HR 3 ORAL SOLUTION promethazine vc oral syrup 1 hydroxyzine hcl oral tablet 1 promethazine-phenylephrine 1 hydroxyzine pamoate oral oral syrup 1 capsule SEMPREX-D ORAL 3 ST CAPSULE KARBINAL ER ORAL SUSPENSION,EXTENDE 3 ANTIHISTAMINES D REL 12 HR arbinoxa oral liquid 1 LASTACAFT 3 ST; QL arbinoxa oral tablet 1 OPHTHALMIC DROPS azelastine ophthalmic drops 1 QL levocetirizine oral solution 1 QL BEPREVE levocetirizine oral tablet 1 QL 3 ST; QL OPHTHALMIC DROPS olopatadine ophthalmic drops 1 ST; QL carbinoxamine maleate oral PATADAY 1 3 ST; QL liquid OPHTHALMIC DROPS carbinoxamine maleate oral PATANOL 1 3 ST; QL tablet OPHTHALMIC DROPS cetirizine oral solution 1 QL PAZEO OPHTHALMIC 3 ST; QL CLARINEX ORAL DROPS 3 ST; QL SYRUP PHENERGAN 3 CLARINEX ORAL INJECTION SOLUTION 3 ST; QL TABLET promethazine injection 1 clemastine oral tablet 1 solution CYPROHEPTADINE promethazine oral syrup 1 3 ORAL SYRUP promethazine oral tablet 1 cyproheptadine oral tablet 1 VISTARIL ORAL 3 desloratadine oral tablet 1 QL CAPSULE desloratadine oral XYZAL ORAL 1 QL 3 ST; QL tablet,disintegrating SOLUTION diphenhydramine hcl XYZAL ORAL TABLET 3 ST; QL 1 injection solution ANTIHYPERGLYCEMIC diphenhydramine hcl S 1 injection syringe acarbose oral tablet 1 diphenhydramine hcl oral ACTOPLUS MET ORAL 1 3 QL capsule TABLET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 34 Drug Name Tier Notes Drug Name Tier Notes ACTOPLUS MET XR glimepiride oral tablet 1 ORAL TABLET, ER 2 QL glipizide oral tablet 1 MULTIPHASE 24 HR glipizide oral tablet extended 1 ACTOS ORAL TABLET 3 QL release 24hr AFREZZA INHALATION glipizide-metformin oral CARTRIDGE, 1 3 PA; QL tablet W/INHALATION GLUCOPHAGE ORAL DEVICE 3 TABLET ALOGLIPTIN ORAL 3 ST; QL TABLET GLUCOPHAGE XR ORAL TABLET ALOGLIPTIN-METFOR 3 3 ST; QL EXTENDED RELEASE 24 MIN ORAL TABLET HR ALOGLIPTIN-PIOGLITA GLUCOTROL ORAL 3 ST; QL 3 ZONE ORAL TABLET TABLET AMARYL ORAL 3 GLUCOTROL XL ORAL TABLET TABLET EXTENDED 3 APIDRA SOLOSTAR RELEASE 24HR SUBCUTANEOUS 3 ST GLUCOVANCE ORAL 3 INSULIN PEN TABLET APIDRA GLUMETZA ORAL SUBCUTANEOUS 3 ST TABLET,ER 3 ST SOLUTION GAST.RETENTION 24 AVANDAMET ORAL HR 3 ST; QL TABLET glyburide micronized oral 1 AVANDIA ORAL tablet 3 ST; QL TABLET glyburide oral tablet 1 BYDUREON glyburide-metformin oral 1 SUBCUTANEOUS PEN 2 ST tablet INJECTOR GLYNASE ORAL 3 BYDUREON TABLET SUBCUTANEOUS 2 ST; QL SUSPENSION,EXTENDE GLYSET ORAL TABLET 2 D REL RECON GLYXAMBI ORAL 3 ST; QL BYETTA TABLET SUBCUTANEOUS PEN 2 ST; QL HUMALOG KWIKPEN INJECTOR SUBCUTANEOUS 2 chlorpropamide oral tablet 1 PA INSULIN PEN CYCLOSET ORAL HUMALOG MIX 50-50 3 KWIKPEN TABLET 2 SUBCUTANEOUS DUETACT ORAL 3 QL INSULIN PEN TABLET HUMALOG MIX 50-50 FARXIGA ORAL 3 ST; QL SUBCUTANEOUS 2 TABLET SUSPENSION FORTAMET ORAL TABLET EXTENDED 3 RELEASE 24HR

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 35 Drug Name Tier Notes Drug Name Tier Notes HUMALOG MIX 75-25 JARDIANCE ORAL 2 ST; QL KWIKPEN TABLET 2 SUBCUTANEOUS JENTADUETO ORAL 2 ST; QL INSULIN PEN TABLET HUMALOG MIX 75-25 KAZANO ORAL TABLET 3 ST; QL SUBCUTANEOUS 2 SUSPENSION KOMBIGLYZE XR ORAL TABLET, ER 3 ST; QL HUMALOG MULTIPHASE 24 HR SUBCUTANEOUS 2 KORLYM ORAL CARTRIDGE 4 PA TABLET HUMALOG SUBCUTANEOUS 2 LANTUS SOLOSTAR SOLUTION SUBCUTANEOUS 2 INSULIN PEN HUMULIN 70/30 KWIKPEN LANTUS 2 SUBCUTANEOUS SUBCUTANEOUS 2 INSULIN PEN SOLUTION HUMULIN 70/30 LEVEMIR FLEXTOUCH SUBCUTANEOUS 2 SUBCUTANEOUS 2 SUSPENSION INSULIN PEN HUMULIN N KWIKPEN LEVEMIR SUBCUTANEOUS 2 SUBCUTANEOUS 2 INSULIN PEN SOLUTION HUMULIN N metformin oral tablet 1 SUBCUTANEOUS 2 metformin oral tablet 1 SUSPENSION extended release 24 hr HUMULIN R INJECTION metformin oral tablet 2 1 SOLUTION extended release 24hr HUMULIN R U-500 metformin oral tablet,er (CONC) KWIKPEN 3 ST 2 gast.retention 24 hr SUBCUTANEOUS INSULIN PEN nateglinide oral tablet 1 HUMULIN R U-500 NESINA ORAL TABLET 3 ST; QL (CONCENTRATED) NOVOLIN 70/30 2 SUBCUTANEOUS SUBCUTANEOUS 2 SOLUTION SUSPENSION INVOKAMET ORAL NOVOLIN N 3 ST; QL TABLET SUBCUTANEOUS 2 INVOKANA ORAL SUSPENSION 3 ST; QL TABLET NOVOLIN R INJECTION 2 JANUMET ORAL SOLUTION 2 ST; QL TABLET NOVOLOG FLEXPEN JANUMET XR ORAL SUBCUTANEOUS 2 TABLET, ER 2 ST; QL INSULIN PEN MULTIPHASE 24 HR NOVOLOG MIX 70-30 JANUVIA ORAL FLEXPEN 2 ST; QL 2 TABLET SUBCUTANEOUS INSULIN PEN

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 36 Drug Name Tier Notes Drug Name Tier Notes NOVOLOG MIX 70-30 TOUJEO SOLOSTAR SUBCUTANEOUS 2 SUBCUTANEOUS 3 SOLUTION INSULIN PEN NOVOLOG PENFILL TRADJENTA ORAL 2 ST; DO SUBCUTANEOUS 2 TABLET CARTRIDGE TRESIBA FLEXTOUCH NOVOLOG U-100 SUBCUTANEOUS 3 ST SUBCUTANEOUS 2 INSULIN PEN SOLUTION TRESIBA FLEXTOUCH ONGLYZA ORAL U-200 SUBCUTANEOUS 3 ST 3 ST; DO TABLET 2.5 MG INSULIN PEN ONGLYZA ORAL TRULICITY 3 ST; QL TABLET 5 MG SUBCUTANEOUS PEN 3 ST; QL OSENI ORAL TABLET 3 ST; QL INJECTOR pioglitazone oral tablet 1 QL VICTOZA 2-PAK SUBCUTANEOUS PEN 2 ST; QL pioglitazone-glimepiride oral 1 QL INJECTOR tablet VICTOZA 3-PAK pioglitazone-metformin oral 1 QL SUBCUTANEOUS PEN 2 ST; QL tablet INJECTOR PRANDIN ORAL 3 XIGDUO XR ORAL TABLET TABLET, IR - ER, 3 ST; QL PRECOSE ORAL BIPHASIC 24HR 3 TABLET ANTIINFECTIVES/MISC repaglinide oral tablet 1 ELLANEOUS repaglinide-metformin oral ALBENZA ORAL 1 3 tablet TABLET RIOMET ORAL ALINIA ORAL 3 SOLUTION SUSPENSION FOR 3 RECONSTITUTION STARLIX ORAL TABLET 3 ALINIA ORAL TABLET 3 SYMLINPEN 120 SUBCUTANEOUS PEN 2 atovaquone oral suspension 1 INJECTOR atovaquone-proguanil oral 1 SYMLINPEN 60 tablet SUBCUTANEOUS PEN 2 BILTRICIDE ORAL 3 INJECTOR TABLET SYNJARDY ORAL chloroquine phosphate oral 2 ST; QL 1 TABLET tablet TANZEUM COARTEM ORAL 3 SUBCUTANEOUS PEN 3 ST; QL TABLET INJECTOR 30 MG/0.5 ML DARAPRIM ORAL 3 PA; QL TANZEUM TABLET SUBCUTANEOUS PEN 3 ST EMVERM ORAL INJECTOR 50 MG/0.5 ML 3 TABLET,CHEWABLE tolazamide oral tablet 1 fem ph vaginal gel 1 tolbutamide oral tablet 1 formadon topical solution 1 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 37 Drug Name Tier Notes Drug Name Tier Notes formadon topical solution ANTINEOPLASTICS 1 with applicator ABRAXANE formaldehyde topical INTRAVENOUS 1 3 solution with applicator SUSPENSION FOR GLUTARALDEHYDE RECONSTITUTION 2 SOLUTION ACTIMMUNE glycine irrigation solution 1 SUBCUTANEOUS 4 PA; QL SOLUTION glycine urologic irrigation 1 solution ADCETRIS INTRAVENOUS RECON 3 PA hydroxychloroquine oral 1 SOLN tablet adrucil intravenous solution 1 ivermectin oral tablet 1 AFINITOR DISPERZ MALARONE ORAL 3 ORAL TABLET FOR 3 PA TABLET SUSPENSION MALARONE PEDIATRIC AFINITOR ORAL 3 2 PA ORAL TABLET TABLET mefloquine oral tablet 1 ALECENSA ORAL 3 MEPRON ORAL CAPSULE 3 SUSPENSION ALFERON N INJECTION 4 NEBUPENT SOLUTION INHALATION RECON 2 ALIMTA INTRAVENOUS 3 PA SOLN RECON SOLN paromomycin oral capsule 1 ALKERAN PENTAM INJECTION INTRAVENOUS RECON 3 2 RECON SOLN SOLN PLAQUENIL ORAL ALKERAN ORAL 3 2 TABLET TABLET PRIMAQUINE ORAL anastrozole oral tablet 1 PA; QL 2 TABLET ARIMIDEX ORAL 3 PA; QL QUALAQUIN ORAL TABLET 3 PA; QL CAPSULE AROMASIN ORAL 3 PA; QL quinine sulfate oral capsule 1 PA; QL TABLET RELAGARD VAGINAL ARRANON 3 GEL INTRAVENOUS 3 SOLUTION STROMECTOL ORAL 3 TABLET ARZERRA INTRAVENOUS 3 PA TINDAMAX ORAL 3 SOLUTION TABLET AVASTIN tinidazole oral tablet 1 INTRAVENOUS 3 PA ANTIINFECTIVES SOLUTION ARESTIN DENTAL azacitidine injection recon 3 1 QL CARTRIDGE soln AVC VAGINAL 3 VAGINAL CREAM

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 38 Drug Name Tier Notes Drug Name Tier Notes BELEODAQ COTELLIC ORAL 3 PA; QL INTRAVENOUS RECON 3 PA TABLET SOLN cyclophosphamide 1 BENDEKA intravenous recon soln INTRAVENOUS 3 CYCLOPHOSPHAMIDE 3 SOLUTION ORAL CAPSULE bexarotene oral capsule 1 PA; QL CYRAMZA bicalutamide oral tablet 1 INTRAVENOUS 3 PA BICNU INTRAVENOUS SOLUTION 3 RECON SOLN cytarabine (pf) injection 1 bleomycin injection recon solution 1 soln cytarabine injection solution 1 BLINCYTO dacarbazine intravenous 3 PA 1 INTRAVENOUS KIT recon soln BOSULIF ORAL TABLET 2 PA; QL DACOGEN BUSULFEX INTRAVENOUS RECON 3 INTRAVENOUS 3 SOLN SOLUTION DARZALEX CAMPATH INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION daunorubicin intravenous 1 CAMPTOSAR recon soln INTRAVENOUS 3 daunorubicin intravenous 1 SOLUTION solution capecitabine oral tablet 1 PA; QL decitabine intravenous recon 1 CAPRELSA ORAL soln 2 PA; QL TABLET DEPOCYT (PF) CARAC TOPICAL INTRATHECAL 3 2 CREAM SUSPENSION carboplatin intravenous recon diclofenac sodium topical gel 1 PA; QL 1 soln DOCEFREZ carboplatin intravenous INTRAVENOUS RECON 3 1 solution SOLN CASODEX ORAL docetaxel intravenous 3 1 PA TABLET solution DOXIL INTRAVENOUS cisplatin intravenous solution 1 3 SUSPENSION cladribine intravenous 1 doxorubicin intravenous solution 1 recon soln CLOLAR doxorubicin intravenous INTRAVENOUS 3 1 SOLUTION solution COMETRIQ ORAL doxorubicin, peg-liposomal 3 PA; QL 1 CAPSULE intravenous suspension EFUDEX TOPICAL COSMEGEN 3 INTRAVENOUS RECON 3 CREAM SOLN Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 39 Drug Name Tier Notes Drug Name Tier Notes ELIGARD FLUOROPLEX TOPICAL 3 PA SUBCUTANEOUS 3 PA; QL CREAM SYRINGE fluorouracil intravenous 1 ELLENCE solution INTRAVENOUS 3 FLUOROURACIL 3 SOLUTION TOPICAL CREAM 0.5 % EMCYT ORAL CAPSULE 2 PA fluorouracil topical cream 5 1 EMPLICITI % INTRAVENOUS RECON 3 fluorouracil topical solution 1 SOLN flutamide oral capsule 1 epirubicin intravenous recon 1 soln FOLOTYN INTRAVENOUS 3 epirubicin intravenous 1 SOLUTION solution GAZYVA ERBITUX INTRAVENOUS 3 PA INTRAVENOUS 3 PA SOLUTION SOLUTION gemcitabine intravenous ERIVEDGE ORAL 1 2 PA; QL recon soln CAPSULE gemcitabine intravenous ERWINAZE INJECTION 1 3 PA solution RECON SOLN GEMZAR ETOPOPHOS INTRAVENOUS RECON 3 INTRAVENOUS RECON 3 SOLN SOLN GILOTRIF ORAL etoposide intravenous 3 PA; QL 1 TABLET solution GLEEVEC ORAL 3 PA; QL etoposide oral capsule 1 TABLET exemestane oral tablet 1 PA; QL GLEOSTINE ORAL 3 PA FARESTON ORAL CAPSULE 2 QL TABLET GLIADEL WAFER 3 FARYDAK ORAL IMPLANT WAFER 3 PA; QL CAPSULE HALAVEN FASLODEX INTRAVENOUS 3 PA INTRAMUSCULAR 3 SOLUTION SYRINGE HERCEPTIN FEMARA ORAL TABLET 3 PA; QL INTRAVENOUS RECON 3 PA FIRMAGON KIT W SOLN DILUENT SYRINGE HEXALEN ORAL 3 PA 2 SUBCUTANEOUS CAPSULE RECON SOLN HYCAMTIN floxuridine injection recon INTRAVENOUS RECON 3 PA 1 soln SOLN fludarabine intravenous HYCAMTIN ORAL 1 2 PA recon soln CAPSULE fludarabine intravenous HYDREA ORAL 1 3 solution CAPSULE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 40 Drug Name Tier Notes Drug Name Tier Notes hydroxyurea oral capsule 1 KEYTRUDA IBRANCE ORAL INTRAVENOUS RECON 3 PA 3 PA; QL CAPSULE SOLN ICLUSIG ORAL TABLET 2 PA; QL KEYTRUDA INTRAVENOUS 3 PA IDAMYCIN PFS SOLUTION INTRAVENOUS 3 SOLUTION KYPROLIS INTRAVENOUS RECON 3 PA idarubicin intravenous 1 SOLN solution LENVIMA ORAL IFEX INTRAVENOUS 3 PA; QL 3 CAPSULE RECON SOLN letrozole oral tablet 1 PA; QL ifosfamide intravenous recon 1 LEUKERAN ORAL soln 2 TABLET ifosfamide intravenous 1 solution leuprolide subcutaneous kit 1 PA ifosfamide-mesna LEVULAN TOPICAL 1 3 intravenous kit SOLUTION lipodox 50 intravenous imatinib oral tablet 1 PA; QL 1 suspension IMBRUVICA ORAL 3 PA; QL lipodox intravenous CAPSULE 1 suspension IMLYGIC INJECTION 3 LONSURF ORAL SUSPENSION 3 PA TABLET INLYTA ORAL TABLET 2 PA; QL LUPRON DEPOT (3 INTRON A INJECTION MONTH) 4 PA 3 PA RECON SOLN INTRAMUSCULAR INTRON A INJECTION SYRINGE KIT 4 PA SOLUTION LUPRON DEPOT (4 MONTH) IRESSA ORAL TABLET 2 PA; QL 3 PA INTRAMUSCULAR irinotecan intravenous 1 SYRINGE KIT solution LUPRON DEPOT (6 ISTODAX MONTH) 3 PA; QL INTRAVENOUS RECON 3 INTRAMUSCULAR SOLN SYRINGE KIT IXEMPRA LUPRON DEPOT INTRAVENOUS RECON 3 INTRAMUSCULAR 3 PA SOLN SYRINGE KIT JAKAFI ORAL TABLET 2 PA; QL LYNPARZA ORAL 3 PA; QL JEVTANA CAPSULE INTRAVENOUS 3 LYSODREN ORAL 2 QL SOLUTION TABLET KADCYLA MARQIBO 3 INTRAVENOUS RECON 3 PA INTRAVENOUS KIT SOLN MATULANE ORAL 2 CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 41 Drug Name Tier Notes Drug Name Tier Notes megestrol oral tablet 1 oxaliplatin intravenous 1 MEKINIST ORAL solution 3 PA; QL TABLET paclitaxel intravenous 1 melphalan hcl intravenous concentrate 1 recon soln PANRETIN TOPICAL 3 mercaptopurine oral tablet 1 GEL methotrexate sodium (pf) PERJETA 1 injection recon soln INTRAVENOUS 3 PA SOLUTION methotrexate sodium (pf) 1 injection solution PHOTOFRIN INTRAVENOUS RECON 3 methotrexate sodium 1 SOLN injection solution PICATO TOPICAL GEL 3 PA; QL methotrexate sodium oral 1 POMALYST ORAL tablet 3 PA; QL CAPSULE mitomycin intravenous recon 1 soln PORTRAZZA INTRAVENOUS 3 mitoxantrone intravenous 1 SOLUTION concentrate PROLEUKIN MUSTARGEN INTRAVENOUS RECON 3 INJECTION RECON 3 SOLN SOLN PROVENGE MYLERAN ORAL 2 INTRAVENOUS 4 PA TABLET SUSPENSION NAVELBINE PURIXAN ORAL 3 PA INTRAVENOUS 3 SUSPENSION SOLUTION REVLIMID ORAL NEXAVAR ORAL 2 PA; QL 2 PA; QL CAPSULE TABLET RITUXAN NILANDRON ORAL 2 QL INTRAVENOUS 3 PA TABLET CONCENTRATE NINLARO ORAL SOLARAZE TOPICAL 3 PA; QL 3 PA; QL CAPSULE GEL NIPENT INTRAVENOUS SOLTAMOX ORAL 3 2 RECON SOLN SOLUTION ODOMZO ORAL SPRYCEL ORAL 3 PA; QL 2 PA; QL CAPSULE TABLET ONCASPAR INJECTION STIVARGA ORAL 3 PA 2 PA; QL SOLUTION TABLET ONIVYDE SUTENT ORAL 2 PA; QL INTRAVENOUS 3 CAPSULE DISPERSION SYLATRON OPDIVO INTRAVENOUS 3 3 PA SUBCUTANEOUS KIT SOLUTION SYLVANT oxaliplatin intravenous recon 1 INTRAVENOUS RECON 4 PA soln SOLN

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 42 Drug Name Tier Notes Drug Name Tier Notes SYNRIBO TORISEL SUBCUTANEOUS 3 INTRAVENOUS RECON 2 RECON SOLN SOLN TABLOID ORAL TREANDA 2 TABLET INTRAVENOUS RECON 3 PA TAFINLAR ORAL SOLN 3 PA; QL CAPSULE TRELSTAR TAGRISSO ORAL INTRAMUSCULAR 3 PA; QL 3 PA; QL TABLET SYRINGE tretinoin (chemotherapy) oral tamoxifen oral tablet 1 1 capsule TARCEVA ORAL 2 PA; QL TREXALL ORAL TABLET 2 TABLET TARGRETIN ORAL 3 PA CAPSULE TRISENOX INTRAVENOUS 3 TARGRETIN TOPICAL 2 PA SOLUTION GEL TYKERB ORAL TABLET 2 PA; QL TASIGNA ORAL 2 PA; QL CAPSULE UNITUXIN INTRAVENOUS 3 TAXOTERE SOLUTION INTRAVENOUS 3 PA UVADEX INJECTION SOLUTION 3 SOLUTION TEMODAR VALCHLOR TOPICAL INTRAVENOUS RECON 2 PA 3 SOLN GEL TEMODAR ORAL VALSTAR 3 PA; QL CAPSULE INTRAVESICAL 2 SOLUTION temozolomide oral capsule 1 PA; QL VANTAS IMPLANT KIT 3 PA TENIPOSIDE INTRAVENOUS 3 VECTIBIX SOLUTION INTRAVENOUS 3 PA SOLUTION THERACYS INTRAVESICAL VELCADE INJECTION 3 3 PA SUSPENSION FOR RECON SOLN RECONSTITUTION VIDAZA INJECTION 3 thiotepa injection recon soln 1 RECON SOLN vinblastine intravenous TICE BCG 1 INTRAVESICAL solution 4 SUSPENSION FOR vincasar pfs intravenous 1 RECONSTITUTION solution TOLAK TOPICAL vincristine intravenous 3 1 CREAM solution toposar intravenous solution 1 vinorelbine intravenous 1 topotecan intravenous recon solution 1 soln VOTRIENT ORAL 2 PA; QL topotecan intravenous TABLET 1 solution Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 43 Drug Name Tier Notes Drug Name Tier Notes XALKORI ORAL phendimetrazine tartrate oral 2 PA; QL 1 PA CAPSULE capsule, extended release XELODA ORAL TABLET 3 PA phendimetrazine tartrate oral 1 PA XTANDI ORAL tablet 2 PA; QL CAPSULE phentermine oral capsule 1 PA YERVOY phentermine oral tablet 1 PA INTRAVENOUS 3 PA QSYMIA ORAL SOLUTION CAPSULE, ER 3 PA YONDELIS MULTIPHASE 24 HR INTRAVENOUS RECON 3 REGIMEX ORAL 3 PA SOLN TABLET ZALTRAP SAXENDA INTRAVENOUS 3 PA SUBCUTANEOUS PEN 3 PA SOLUTION INJECTOR ZANOSAR SUPRENZA ORAL INTRAVENOUS RECON 3 TABLET,DISINTEGRATI 3 PA SOLN NG ZELBORAF ORAL XENICAL ORAL 2 PA; QL 3 TABLET CAPSULE ZEVALIN (Y-90) 3 ANTIPARKINSON INTRAVENOUS KIT DRUGS ZOLADEX amantadine hcl oral capsule 1 SUBCUTANEOUS 3 PA; QL IMPLANT amantadine hcl oral solution 1 ZOLINZA ORAL amantadine hcl oral tablet 1 2 PA; QL CAPSULE APOKYN ZYDELIG ORAL SUBCUTANEOUS 4 PA 3 PA; QL TABLET CARTRIDGE ZYKADIA ORAL AZILECT ORAL 3 PA; QL 2 CAPSULE TABLET benztropine injection ZYTIGA ORAL TABLET 2 PA; QL 1 solution ANTI-OBESITY DRUGS benztropine oral tablet 1 ADIPEX-P ORAL 3 PA CAPSULE bromocriptine oral capsule 1 ADIPEX-P ORAL bromocriptine oral tablet 1 3 PA TABLET carbidopa oral tablet 1 BELVIQ ORAL TABLET 3 PA carbidopa-levodopa oral 1 benzphetamine oral tablet 1 PA tablet carbidopa-levodopa oral CONTRAVE ORAL 1 TABLET EXTENDED 3 PA tablet extended release RELEASE carbidopa-levodopa oral 1 diethylpropion oral tablet 1 PA tablet,disintegrating diethylpropion oral tablet carbidopa-levodopa-entacapo 1 PA 1 extended release ne oral tablet

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 44 Drug Name Tier Notes Drug Name Tier Notes COGENTIN INJECTION SINEMET ORAL 3 3 SOLUTION TABLET COMTAN ORAL STALEVO 100 ORAL 3 3 QL TABLET TABLET DUOPA J-TUBE STALEVO 125 ORAL 3 QL INTESTINAL PUMP 3 PA TABLET SUSPENSION STALEVO 150 ORAL 3 QL ELDEPRYL ORAL TABLET 3 CAPSULE STALEVO 200 ORAL 3 QL entacapone oral tablet 1 TABLET LODOSYN ORAL STALEVO 50 ORAL 3 3 QL TABLET TABLET MIRAPEX ER ORAL STALEVO 75 ORAL 3 QL TABLET EXTENDED 3 TABLET RELEASE 24 HR TASMAR ORAL TABLET 3 MIRAPEX ORAL 3 tolcapone oral tablet 1 TABLET trihexyphenidyl oral elixir 1 NEUPRO TRANSDERMAL PATCH 3 QL trihexyphenidyl oral tablet 1 24 HOUR ZELAPAR ORAL PARLODEL ORAL TABLET,DISINTEGRATI 3 3 CAPSULE NG PARLODEL ORAL ANTIPLATELET DRUGS 3 TABLET AGGRASTAT IN SODIUM CHLORIDE pramipexole oral tablet 1 3 INTRAVENOUS pramipexole oral tablet 1 SOLUTION extended release 24 hr AGGRENOX ORAL REQUIP ORAL TABLET 3 QL CAPSULE, ER 3 QL 0.25 MG MULTIPHASE 12 HR REQUIP ORAL TABLET AGRYLIN ORAL 3 0.5 MG, 1 MG, 2 MG, 3 3 CAPSULE MG, 4 MG, 5 MG anagrelide oral capsule 1 REQUIP XL ORAL aspirin-dipyridamole oral TABLET EXTENDED 3 1 QL RELEASE 24 HR capsule, er multiphase 12 hr BRILINTA ORAL ropinirole oral tablet 1 2 QL TABLET ropinirole oral tablet 1 extended release 24 hr cilostazol oral tablet 1 clopidogrel oral tablet 300 RYTARY ORAL 1 CAPSULE, EXTENDED 3 mg RELEASE clopidogrel oral tablet 75 mg 1 QL selegiline hcl oral capsule 1 dipyridamole oral tablet 1 selegiline hcl oral tablet 1 DURLAZA ORAL SINEMET CR ORAL CAPSULE,EXTENDED 3 QL TABLET EXTENDED 3 RELEASE 24HR RELEASE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 45 Drug Name Tier Notes Drug Name Tier Notes EFFIENT ORAL TABLET BARACLUDE ORAL 2 QL 4 10 MG SOLUTION EFFIENT ORAL TABLET BARACLUDE ORAL 2 DO 4 5 MG TABLET eptifibatide intravenous cidofovir intravenous 1 1 solution solution INTEGRILIN COMBIVIR ORAL 3 INTRAVENOUS 3 TABLET SOLUTION COMPLERA ORAL 2 KENGREAL TABLET INTRAVENOUS RECON 3 COPEGUS ORAL 4 SOLN TABLET PERSANTINE ORAL CRIXIVAN ORAL 3 2 TABLET CAPSULE PLAVIX ORAL TABLET 3 CYTOVENE 300 MG INTRAVENOUS RECON 4 PLAVIX ORAL TABLET SOLN 3 QL 75 MG DAKLINZA ORAL 4 PA; QL REOPRO TABLET INTRAVENOUS 3 DENAVIR TOPICAL 3 PA SOLUTION CREAM ticlopidine oral tablet 1 DESCOVY ORAL 3 ZONTIVITY ORAL TABLET 3 QL TABLET didanosine oral ANTIVIRALS capsule,delayed 1 abacavir oral tablet 1 release(dr/ec) abacavir-lamivudine-zidovud EDURANT ORAL 1 2 ine oral tablet TABLET EMTRIVA ORAL acyclovir oral capsule 1 2 CAPSULE acyclovir oral suspension 1 EMTRIVA ORAL 2 acyclovir oral tablet 1 SOLUTION acyclovir sodium intravenous 1 entecavir oral tablet 4 recon soln EPIVIR HBV ORAL acyclovir sodium intravenous 4 1 SOLUTION solution EPIVIR HBV ORAL 4 acyclovir topical ointment 1 TABLET adefovir oral tablet 4 EPIVIR ORAL 3 APTIVUS ORAL SOLUTION 2 CAPSULE EPIVIR ORAL TABLET 3 APTIVUS ORAL EPZICOM ORAL 2 2 SOLUTION TABLET ATRIPLA ORAL 2 EVOTAZ ORAL TABLET 3 TABLET famciclovir oral tablet 1 FAMVIR ORAL TABLET 3 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 46 Drug Name Tier Notes Drug Name Tier Notes FLUMADINE ORAL moderiba dose pack oral 3 4 TABLET tablets,dose pack foscarnet intravenous moderiba oral tablet 4 1 solution nevirapine oral suspension 1 FOSCAVIR nevirapine oral tablet 1 INTRAVENOUS 3 nevirapine oral tablet SOLUTION 1 extended release 24 hr FUZEON NORVIR ORAL SUBCUTANEOUS 2 2 RECON SOLN CAPSULE ganciclovir sodium NORVIR ORAL 4 2 intravenous recon soln SOLUTION GENVOYA ORAL NORVIR ORAL TABLET 2 2 TABLET ODEFSEY ORAL 3 HARVONI ORAL TABLET 4 PA; QL TABLET OLYSIO ORAL 4 PA; QL HEPSERA ORAL CAPSULE 4 TABLET PEGASYS PROCLICK INTELENCE ORAL SUBCUTANEOUS PEN 4 PA; QL 2 TABLET INJECTOR INVIRASE ORAL PEGASYS 2 CAPSULE SUBCUTANEOUS 4 PA; QL SOLUTION INVIRASE ORAL 2 TABLET PEGASYS SUBCUTANEOUS 4 PA; QL ISENTRESS ORAL 3 SYRINGE POWDER IN PACKET PEGINTRON REDIPEN ISENTRESS ORAL 2 SUBCUTANEOUS PEN 4 PA TABLET INJECTOR KIT ISENTRESS ORAL PEGINTRON 2 4 PA TABLET,CHEWABLE SUBCUTANEOUS KIT KALETRA ORAL PREZCOBIX ORAL 2 3 SOLUTION TABLET KALETRA ORAL PREZISTA ORAL 2 2 TABLET SUSPENSION lamivudine oral solution 1 PREZISTA ORAL 2 lamivudine oral tablet 100 TABLET 4 mg RAPIVAB lamivudine oral tablet 150 INTRAVENOUS 3 1 mg, 300 mg SOLUTION lamivudine-zidovudine oral REBETOL ORAL 1 4 tablet SOLUTION LEXIVA ORAL RELENZA DISKHALER 2 SUSPENSION INHALATION BLISTER 2 QL LEXIVA ORAL TABLET 2 WITH DEVICE RESCRIPTOR ORAL 2 TABLET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 47 Drug Name Tier Notes Drug Name Tier Notes RESCRIPTOR ORAL TECHNIVIE ORAL 2 4 PA; QL TABLET, DISPERSIBLE TABLET RETROVIR TIVICAY ORAL TABLET 3 INTRAVENOUS 2 trifluridine ophthalmic drops 1 SOLUTION TRIUMEQ ORAL RETROVIR ORAL 2 3 TABLET CAPSULE TRIZIVIR ORAL RETROVIR ORAL 3 3 TABLET SYRUP TRUVADA ORAL REYATAZ ORAL 2 2 TABLET CAPSULE TYZEKA ORAL TABLET 4 QL REYATAZ ORAL 2 POWDER IN PACKET valacyclovir oral tablet 1 VALCYTE ORAL RECON ribasphere oral capsule 4 3 SOLN ribasphere oral tablet 4 VALCYTE ORAL ribasphere ribapak oral 3 4 TABLET tablets,dose pack valganciclovir oral tablet 1 RIBATAB DOSE PACK VALTREX ORAL ORAL TABLETS,DOSE 4 3 PACK TABLET VEREGEN TOPICAL ribavirin oral capsule 4 3 OINTMENT ribavirin oral tablet 4 VIDEX 2 GRAM rimantadine oral tablet 1 PEDIATRIC ORAL 2 SELZENTRY ORAL RECON SOLN 2 TABLET VIDEX 4 GRAM SITAVIG BUCCAL PEDIATRIC ORAL 2 MUCO-ADHESIVE 3 PA RECON SOLN BUCCAL TABLET VIDEX EC ORAL SOVALDI ORAL CAPSULE,DELAYED 3 4 PA; QL TABLET RELEASE(DR/EC) stavudine oral capsule 1 VIEKIRA PAK ORAL 4 PA; QL stavudine oral recon soln 1 TABLETS,DOSE PACK STRIBILD ORAL VIRACEPT ORAL 2 2 TABLET TABLET SUSTIVA ORAL VIRAMUNE ORAL 2 3 CAPSULE SUSPENSION VIRAMUNE ORAL SUSTIVA ORAL TABLET 2 3 TABLET SYNAGIS INTRAMUSCULAR 4 PA VIRAMUNE XR ORAL SOLUTION TABLET EXTENDED 3 RELEASE 24 HR TAMIFLU ORAL 2 QL CAPSULE VIRAZOLE INHALATION RECON 3 TAMIFLU ORAL SOLN SUSPENSION FOR 2 QL RECONSTITUTION VIREAD ORAL POWDER 2 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 48 Drug Name Tier Notes Drug Name Tier Notes VIREAD ORAL TABLET 2 ADZENYS XR-ODT VIROPTIC ORAL 3 3 OPHTHALMIC DROPS TABLET,DISINTIG ER BIPHASE 24H VISTIDE INTRAVENOUS 3 SOLUTION anectine injection solution 1 VITEKTA ORAL ARICEPT ORAL 3 3 TABLET TABLET XERESE TOPICAL atracurium intravenous 3 PA 1 CREAM solution ZEPATIER ORAL bethanechol chloride oral 4 PA; QL 1 TABLET tablet ZERIT ORAL CAPSULE 3 BLOXIVERZ INTRAVENOUS 3 ZERIT ORAL RECON 3 SOLUTION SOLN BOTOX COSMETIC ZIAGEN ORAL 2 INJECTION RECON 4 PA SOLUTION SOLN ZIAGEN ORAL TABLET 3 BOTOX COSMETIC zidovudine oral capsule 1 INTRAMUSCULAR 4 PA RECON SOLN zidovudine oral syrup 1 BOTOX INJECTION 4 PA zidovudine oral tablet 1 RECON SOLN ZIRGAN OPHTHALMIC 3 cevimeline oral capsule 1 GEL cisatracurium intravenous ZOVIRAX ORAL 1 3 solution CAPSULE DESOXYN ORAL ZOVIRAX ORAL 3 3 TABLET SUSPENSION dexedrine oral tablet 1 PA ZOVIRAX ORAL 3 TABLET DEXEDRINE SPANSULE ORAL CAPSULE, 3 ST ZOVIRAX TOPICAL 3 PA; QL EXTENDED RELEASE CREAM dextroamphetamine oral ZOVIRAX TOPICAL 1 PA 3 capsule, extended release OINTMENT dextroamphetamine oral AUTONOMIC DRUGS 1 PA solution ADDERALL ORAL dextroamphetamine oral 3 1 PA TABLET tablet ADDERALL XR ORAL dextroamphetamine-ampheta CAPSULE,EXTENDED 1 PA mine oral capsule,extended 1 PA RELEASE 24HR release 24hr ADRENACLICK dextroamphetamine-ampheta 1 PA INJECTION 3 mine oral tablet AUTO-INJECTOR DIBENZYLINE ORAL 3 adrenalin injection solution 1 CAPSULE donepezil oral tablet 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 49 Drug Name Tier Notes Drug Name Tier Notes donepezil oral ISUPREL INJECTION 1 3 tablet,disintegrating SOLUTION dopamine in 5 % dextrose LEVOPHED 1 intravenous solution (BITARTRATE) 3 dopamine intravenous INTRAVENOUS 1 solution SOLUTION MESTINON ORAL DYANAVEL XR ORAL 2 SUSPEN, IR - ER, 3 ST SYRUP BIPHASIC 24HR MESTINON ORAL 3 DYSPORT TABLET INTRAMUSCULAR 4 PA MESTINON TIMESPAN RECON SOLN ORAL TABLET 3 enlon injection solution 1 EXTENDED RELEASE ENLON-PLUS methamphetamine oral tablet 1 INTRAVENOUS 3 midodrine oral tablet 1 SOLUTION MYOBLOC EPINEPHRINE HCL (PF) INTRAMUSCULAR 4 PA INTRAVENOUS 3 SOLUTION SOLUTION neostigmine methylsulfate 1 epinephrine injection injection solution 1 auto-injector neostigmine methylsulfate epinephrine injection intravenous solution 0.5 1 1 solution mg/ml epinephrine injection syringe 1 NEOSTIGMINE METHYLSULFATE EPIPEN 2-PAK 3 INJECTION 2 INTRAVENOUS AUTO-INJECTOR SOLUTION 1 MG/ML NIMBEX INTRAVENOUS EPIPEN JR 2-PAK 3 INJECTION 2 SOLUTION AUTO-INJECTOR norepinephrine bitartrate 1 EPISNAP INJECTION intravenous solution 3 KIT NORTHERA ORAL 3 EVEKEO ORAL TABLET 3 ST CAPSULE EVOXAC ORAL pancuronium intravenous 3 1 CAPSULE solution EXELON ORAL phenoxybenzamine oral 3 1 CAPSULE capsule phentolamine injection recon EXELON 1 TRANSDERMAL PATCH 3 ST soln 24 HOUR physostigmine salicylate 1 galantamine oral capsule,ext injection solution 1 rel. pellets 24 hr pilocarpine hcl oral tablet 1 galantamine oral solution 1 procentra oral solution 1 galantamine oral tablet 1 pyridostigmine bromide oral 1 guanidine oral tablet 1 tablet

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 50 Drug Name Tier Notes Drug Name Tier Notes pyridostigmine bromide oral AFLURIA 2015-2016 1 tablet extended release INTRAMUSCULAR 2 QL QUELICIN INJECTION SUSPENSION 3 SOLUTION ALL EXT-CAL PEPPER RAZADYNE ER ORAL TREE POLLEN 3 CAPSULE,EXT REL. 3 INJECTION SOLUTION PELLETS 24 HR ALL XT-WEED RAZADYNE ORAL POL-RUSSIAN THISTL 3 3 TABLET INJECTION SOLUTION regonol injection solution 1 ALL.XT,KBLUE-JUNE GRASS POLLEN 3 rivastigmine tartrate oral 1 INJECTION SOLUTION capsule ALLER rivastigmine transdermal EXT-ALTERNARIA 1 3 patch 24 hour ALTERNATA rocuronium intravenous INJECTION SOLUTION 1 solution ALLER EXT-AMERICAN SALAGEN ORAL COCKROACH 3 3 TABLET INJECTION SOLUTION URECHOLINE ORAL ALLER EXT-TREE 3 TABLET POLL,RED CEDAR 3 INJECTION SOLUTION vecuronium bromide 1 intravenous recon soln ALLER EXT-TREE POLLEN,AM ELM 3 XEOMIN INJECTION SOLUTION INTRAMUSCULAR 4 PA RECON SOLN ALLER EXT-TREE POLLEN,BAYBERRY 3 zenzedi oral tablet 10 mg, 5 1 ST INJECTION SOLUTION mg ALLER EXT-TREE ZENZEDI ORAL POLLEN,MESQUITE 3 TABLET 15 MG, 2.5 MG, 3 ST INJECTION SOLUTION 20 MG, 30 MG, 7.5 MG ALLER XT-SHAGBARK BIOLOGICALS HICKORY POLL 3 ACTHIB (PF) INJECTION SOLUTION INTRAMUSCULAR 3 ALLER XT-TREE RECON SOLN POL,E.COTTONWOOD 3 ADACEL(TDAP INJECTION SOLUTION ADOLESN/ADULT)(PF) 3 ALLER XT-TREE INTRAMUSCULAR POLLEN,BOX ELDER 3 SUSPENSION INJECTION SOLUTION ADACEL(TDAP ALLER XT-TREE ADOLESN/ADULT)(PF) 3 POLLEN,HACKBERRY 3 INTRAMUSCULAR INJECTION SOLUTION SYRINGE ALLER XT-TREE AFLURIA 2015-2016 (PF) POLLEN,RED BIRCH 3 INTRAMUSCULAR 2 QL INJECTION SOLUTION SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 51 Drug Name Tier Notes Drug Name Tier Notes ALLER XT-TREE ALLERG EXT-WEED POLLEN,WHITE ASH 3 POLLEN-MUGWORT 3 INJECTION SOLUTION INJECTION SOLUTION ALLER XT-TREE ALLERG EX-WEED POLLEN-WHITE OAK 3 POL-RGH PIGWEED 3 INJECTION SOLUTION INJECTION SOLUTION ALLER XT-WEED ALLERG XT,GRASS POLLEN-COCKLEBUR 3 POLLEN-TIMOTHY 3 PA INJECTION SOLUTION INJECTION SOLUTION ALLER XT-WEED ALLERG POLLEN-SAGEBRUSH 3 XT,GRASS-MEADOW 3 INJECTION SOLUTION FESCUE INJECTION ALLERG EX,GRASS SOLUTION POLLEN-BERMUDA 3 ALLERG XT-SHEEP INJECTION SOLUTION SOR,YELLW DOCK 3 ALLERG EX,GRASS INJECTION SOLUTION POLLEN-ORCHARD 3 ALLERG XT-WEED INJECTION SOLUTION POLL-DOG FENNEL 3 ALLERG EX-GRASS INJECTION SOLUTION POLLEN-JOHNSON 3 ALLERGEN INJECTION SOLUTION EX-FUSARIUM 3 ALLERG EXT,GRASS OXYSPORUM POLLEN-REDTOP 3 INJECTION SOLUTION INJECTION SOLUTION ALLERGEN EXT-ASPERGILLUS ALLERG 3 EXT-ACREMONIUM FUMIG INJECTION 3 STRICTUM INJECTION SOLUTION SOLUTION ALLERGEN EXT-ASPERGILLUS,MIX ALLERG EXT-BLACK 3 WALNUT POLLEN 3 ED INJECTION INJECTION SOLUTION SOLUTION ALLERG ALLERGEN EXT-GRASS,PERENNIAL EXT-AUREOBA.PULLUL 3 3 RYE INJECTION ANS INJECTION SOLUTION SOLUTION ALLERG ALLERGEN EXT-PENICILLIUM EXT-BOTRYTIS 3 3 NOTATUM INJECTION CINEREA INJECTION SOLUTION SOLUTION ALLERG EXT-TREE ALLERGEN EXT-C.CLADOSPORIOI POLLEN-ACACIA 3 3 INJECTION SOLUTION DES INJECTION SOLUTION ALLERG EXT-TREE POLLEN-ALDER 3 ALLERGEN EXT-C.SPHAEROSPERM INJECTION SOLUTION 3 UM INJECTION ALLERG EXT-TREE SOLUTION POLL-JUN, WEST 3 INJECTION SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 52 Drug Name Tier Notes Drug Name Tier Notes ALLERGEN ALLERGENIC EXT-CANDIDA EXT-MITE, D FARINAE 3 3 ALBICANS INJECTION INJECTION SOLUTION SOLUTION ALLERGENIC ALLERGEN EXT-MITE, D.PTERONY 3 EXT-CATTLE INJECTION SOLUTION 3 EPITHELIUM ALLERGENIC INJECTION SOLUTION EXT-MIXED RAGWEED 3 ALLERGEN INJECTION SOLUTION EXT-ENGLISH 3 ALLERGENIC PLANTAIN INJECTION EXT-MUCOR 3 QL SOLUTION PLUMBEUS INJECTION ALLERGEN SOLUTION EXT-GERMAN 3 ALLERGENIC COCKROACH EXT-PHOMA 3 INJECTION SOLUTION HERBARUM INJECTION ALLERGEN SOLUTION EXTRACT-D.SOROKINI 3 ALLERGENIC ANA INJECTION EXT-RHIZOPUS 3 SOLUTION ORYZAE INJECTION ALLERGEN EXTRACT-S. SOLUTION CEREVISIAE 3 ALLERGENIC INJECTION SOLUTION XT-EPICOCCUM 3 ALLERGEN EXT-T. NIGRUM INJECTION MENTAGROPHYTES 3 SOLUTION INJECTION SOLUTION ALLERGEN-WEED-LAM ALLERGEN EXT-TREE BSQUARTERS 3 POLLEN,PECAN 3 INJECTION SOLUTION INJECTION SOLUTION ALLERGN ALLERGEN EXT-MOUNT.CEDAR 3 XT-AM.SYCAMORE POLLEN INJECTION 3 POLLEN INJECTION SOLUTION SOLUTION ANASCORP ALLERGEN XT-GRASS INTRAVENOUS RECON 3 POLLEN-BAHIA 3 SOLN INJECTION SOLUTION ANTIVENIN ALLERGEN XT-QUEEN LATRODECTUS 3 PALM POLLEN 3 MACTANS INJECTION INJECTION SOLUTION RECON SOLN ALLERGEN ANTIVENIN MICRURUS XT-VIRGINIA LIVE OAK 3 FULVIUS INJECTION 3 INJECTION SOLUTION COMBO PACK ALLERGENIC APLISOL EX-HORSE INTRADERMAL 3 3 EPITHELIUM SOLUTION INJECTION SOLUTION ATGAM INTRAVENOUS 4 ALLERGENIC EXT-DOG SOLUTION EPITHELIUM 3 INJECTION SOLUTION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 53 Drug Name Tier Notes Drug Name Tier Notes BCG VACCINE, LIVE ENGERIX-B PEDIATRIC (PF) PERCUTANEOUS (PF) INTRAMUSCULAR 3 3 SUSPENSION FOR SYRINGE RECONSTITUTION EPIFIX AMNIOTIC BEXSERO (PF) MEMBRANE TOPICAL 3 INTRAMUSCULAR 3 SHEET SYRINGE EZ FLU 2015-16 BIOTHRAX (FLUVIRIN) (PF) 2 QL INTRAMUSCULAR 3 INTRAMUSCULAR SUSPENSION SYRINGE KIT BIVIGAM EZ FLU INTRAVENOUS 4 PA 2015-16(FLUCELVAX)(PF 2 QL SOLUTION ) INTRAMUSCULAR BOOSTRIX TDAP SYRINGE KIT INTRAMUSCULAR 3 FLEBOGAMMA DIF SUSPENSION INTRAVENOUS 4 PA BOOSTRIX TDAP SOLUTION INTRAMUSCULAR 3 FLUARIX QUAD SYRINGE 2015-2016 (PF) 2 QL candin intradermal allergen 1 INTRAMUSCULAR SYRINGE CARIMUNE NF NANOFILTERED FLUBLOK 2015-2016 (PF) 4 PA INTRAVENOUS RECON INTRAMUSCULAR 2 QL SOLN SOLUTION CAT HAIR STD FLUCELVAX 2015-2016 ALLERGENIC EXT 3 (PF) INTRAMUSCULAR 2 QL INJECTION SOLUTION SYRINGE CERVARIX VACCINE FLULAVAL QUAD 2015-2016 (PF) INTRAMUSCULAR 2 2 QL SYRINGE INTRAMUSCULAR SUSPENSION CROFAB INJECTION 3 RECON SOLN FLUMIST QUAD 2015-2016 NASAL NASAL 2 QL CYTOGAM SPRAY SYRINGE INTRAVENOUS 4 SOLUTION FLUVIRIN 2015-2016 (PF) INTRAMUSCULAR 2 QL DAPTACEL (DTAP SYRINGE PEDIATRIC) (PF) 3 INTRAMUSCULAR FLUVIRIN 2015-2016 SUSPENSION INTRAMUSCULAR 2 QL SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR 3 FLUZONE 2015-2016 SUSPENSION INTRAMUSCULAR 2 QL SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR 3 FLUZONE HIGH-DOSE 2015-16 (PF) SYRINGE 2 QL INTRAMUSCULAR ENGERIX-B PEDIATRIC SYRINGE (PF) INTRAMUSCULAR 3 SUSPENSION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 54 Drug Name Tier Notes Drug Name Tier Notes FLUZONE INTRADERM GRAFIX CORE TOPICAL 3 QUAD 2015-16 SHEET 2 QL INTRADERMAL GRAFIX PRIME 3 SYRINGE TOPICAL SHEET FLUZONE QUAD GRASTEK SUBLINGUAL 2015-2016 (PF) 3 PA; QL 2 QL TABLET INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR 3 FLUZONE QUAD SUSPENSION 2015-2016 (PF) 2 QL INTRAMUSCULAR HAVRIX (PF) SYRINGE INTRAMUSCULAR 3 SYRINGE FLUZONE QUAD 2015-2016 HEPAGAM B 2 QL 4 INTRAMUSCULAR INJECTION SOLUTION SUSPENSION HIZENTRA FLUZONE QUAD PEDI SUBCUTANEOUS 4 PA 2015-16 (PF) SOLUTION 2 QL INTRAMUSCULAR HYPERHEP B S/D SYRINGE INTRAMUSCULAR 4 GAMASTAN S/D SOLUTION INTRAMUSCULAR 4 PA HYPERHEP B S/D SOLUTION INTRAMUSCULAR 4 GAMMAGARD LIQUID SYRINGE 4 PA INJECTION SOLUTION HYPERHEP B S-D NEONATAL GAMMAGARD S-D (IGA 4 << 1 MCG/ML) INTRAMUSCULAR 4 PA INTRAVENOUS RECON SYRINGE SOLN HYPERRAB S/D (PF) GAMMAKED INTRAMUSCULAR 4 4 PA INJECTION SOLUTION SOLUTION GAMMAPLEX HYPERRHO S/D INTRAVENOUS 4 PA INTRAMUSCULAR 4 SOLUTION SYRINGE GAMUNEX-C HYPERTET S/D (PF) 4 PA INJECTION SOLUTION INTRAMUSCULAR 3 SYRINGE GARDASIL (PF) INTRAMUSCULAR 2 HYQVIA SUSPENSION SUBCUTANEOUS 4 PA SOLUTION GARDASIL (PF) INTRAMUSCULAR 2 IMOGAM RABIES-HT SYRINGE (PF) INTRAMUSCULAR 4 SOLUTION GARDASIL 9 (PF) INTRAMUSCULAR 2 IMOVAX RABIES VACCINE (PF) SUSPENSION 3 INTRAMUSCULAR GARDASIL 9 (PF) RECON SOLN INTRAMUSCULAR 2 SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 55 Drug Name Tier Notes Drug Name Tier Notes INFANRIX (DTAP) (PF) ORALAIR SUBLINGUAL 3 PA; QL INTRAMUSCULAR 3 TABLET SUSPENSION PEDIARIX (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR 3 INTRAMUSCULAR 3 SYRINGE SYRINGE PEDVAX HIB (PF) IPOL INJECTION INTRAMUSCULAR 3 3 SUSPENSION SOLUTION IXIARO (PF) PENTACEL (PF) 3 INTRAMUSCULAR 3 INTRAMUSCULAR KIT SYRINGE PNEUMOVAX 23 2 KINRIX (PF) INJECTION SOLUTION INTRAMUSCULAR 3 PNEUMOVAX 23 2 SUSPENSION INJECTION SYRINGE KINRIX (PF) PRE-PEN INTRAMUSCULAR 3 INTRADERMAL 3 SYRINGE SOLUTION MENACTRA (PF) PREVNAR 13 (PF) INTRAMUSCULAR 3 INTRAMUSCULAR 2 SOLUTION SYRINGE MENHIBRIX (PF) PRIVIGEN INTRAMUSCULAR 3 INTRAVENOUS 4 PA RECON SOLN SOLUTION MENOMUNE - PROQUAD (PF) A/C/Y/W-135 (PF) SUBCUTANEOUS 3 3 SUBCUTANEOUS SUSPENSION FOR RECON SOLN RECONSTITUTION MENOMUNE - QUADRACEL (PF) A/C/Y/W-135 3 INTRAMUSCULAR 3 SUBCUTANEOUS SUSPENSION RECON SOLN RABAVERT (PF) MENVEO INTRAMUSCULAR 3 A-C-Y-W-135-DIP (PF) 3 SUSPENSION FOR INTRAMUSCULAR KIT RECONSTITUTION MICRHOGAM RAGWITEK ULTRA-FILTERED PLUS 3 PA; QL 4 SUBLINGUAL TABLET INTRAMUSCULAR SYRINGE RECOMBIVAX HB (PF) INTRAMUSCULAR 3 M-M-R II (PF) SUSPENSION SUBCUTANEOUS 3 RECON SOLN RECOMBIVAX HB (PF) INTRAMUSCULAR 3 NABI-HB SYRINGE INTRAMUSCULAR 4 SOLUTION RHOGAM ULTRA-FILTERED PLUS 4 OCTAGAM INTRAMUSCULAR INTRAVENOUS 4 PA SYRINGE SOLUTION RHOPHYLAC 4 INJECTION SYRINGE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 56 Drug Name Tier Notes Drug Name Tier Notes ROTARIX ORAL VAQTA (PF) SUSPENSION FOR 3 INTRAMUSCULAR 3 RECONSTITUTION SUSPENSION ROTATEQ VACCINE VARIVAX (PF) 3 ORAL SUSPENSION SUBCUTANEOUS 3 SPHERUSOL SUSPENSION FOR INTRADERMAL 3 RECONSTITUTION SOLUTION VARIZIG STD GRASS INTRAMUSCULAR 3 POLLEN-SWEET RECON SOLN 3 VERNAL INJECTION VARIZIG SOLUTION INTRAMUSCULAR 3 TENIVAC (PF) SOLUTION INTRAMUSCULAR 3 VIVOTIF BERNA SUSPENSION VACCINE ORAL 2 TENIVAC (PF) CAPSULE,DELAYED INTRAMUSCULAR 3 RELEASE(DR/EC) SYRINGE VIVOTIF ORAL TETANUS,DIPHTHERIA CAPSULE,DELAYED 3 TOX PED(PF) RELEASE(DR/EC) 3 INTRAMUSCULAR WEED POLLEN-TRUE SUSPENSION MARSH ELDER 3 TETANUS-DIPHTHERIA INJECTION SOLUTION TOXOIDS-TD WINRHO SDF 3 4 INTRAMUSCULAR INJECTION SOLUTION SUSPENSION YF-VAX (PF) THYMOGLOBULIN SUBCUTANEOUS 3 INTRAVENOUS RECON 4 SUSPENSION FOR SOLN RECONSTITUTION TRUMENBA ZOSTAVAX (PF) INTRAMUSCULAR 3 SUBCUTANEOUS 2 SYRINGE SUSPENSION FOR TUBERSOL RECONSTITUTION INTRADERMAL 3 BLOOD SOLUTION ACTIVASE TWINRIX (PF) INTRAVENOUS RECON 3 INTRAMUSCULAR 3 SOLN SUSPENSION ADVATE INTRAVENOUS 4 PA TWINRIX (PF) RECON SOLN INTRAMUSCULAR 3 ADYNOVATE SYRINGE INTRAVENOUS 4 TYPHIM VI SOLUTION INTRAMUSCULAR 3 QL ALBUKED-25 SOLUTION INTRAVENOUS 3 TYPHIM VI PARENTERAL INTRAMUSCULAR 3 SOLUTION SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 57 Drug Name Tier Notes Drug Name Tier Notes ALBUKED-5 BEBULIN INTRAVENOUS INTRAVENOUS RECON 4 PA 3 PARENTERAL SOLN SOLUTION BENEFIX 4 PA albumin, human 25 % INTRAVENOUS KIT intravenous parenteral 1 buminate 25 % intravenous 1 solution parenteral solution ALBUMIN, HUMAN 5 % buminate 5 % intravenous INTRAVENOUS 1 2 parenteral solution PARENTERAL SOLUTION CATHFLO ACTIVASE INTRA-CATHETER 3 albuminar 25 % intravenous 1 RECON SOLN parenteral solution CEPROTIN (BLUE BAR) albuminar 5 % intravenous 1 INTRAVENOUS RECON 4 parenteral solution SOLN alburx (human) 25 % CEPROTIN (GREEN intravenous parenteral 1 BAR) INTRAVENOUS 4 solution RECON SOLN alburx (human) 5 % COAGADEX intravenous parenteral 1 INTRAVENOUS RECON 4 PA solution SOLN albutein 25 % intravenous CORIFACT 1 4 PA parenteral solution INTRAVENOUS KIT albutein 5 % intravenous 1 CYKLOKAPRON parenteral solution INTRAVENOUS 3 ALPHANATE SOLUTION INTRAVENOUS RECON 4 PA DEFITELIO SOLN INTRAVENOUS 3 ALPHANINE SD SOLUTION INTRAVENOUS RECON 4 PA DROXIA ORAL 2 SOLN CAPSULE ALPROLIX ELOCTATE INTRAVENOUS RECON 4 PA INTRAVENOUS RECON 4 PA SOLN SOLN AMICAR ORAL ENDO AVITENE 3 3 SOLUTION TOPICAL SHEET AMICAR ORAL TABLET 3 EVICEL TOPICAL 3 aminocaproic acid SOLUTION 1 intravenous solution FEIBA NF ASTRINGYN TOPICAL INTRAVENOUS RECON 4 PA 3 SOLUTION SOLN AVITENE FLOUR FLEXBUMIN 25 % 3 TOPICAL POWDER INTRAVENOUS 3 AVITENE TOPICAL PARENTERAL 3 POWDER IN PACKET SOLUTION AVITENE TOPICAL 3 SHEET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 58 Drug Name Tier Notes Drug Name Tier Notes FLEXBUMIN 5 % IDELVION INTRAVENOUS INTRAVENOUS RECON 4 3 PARENTERAL SOLN SOLUTION IXINITY INTRAVENOUS 4 PA GELFOAM RECON SOLN COMPRESSED SIZE 100 3 KCENTRA 3 TOPICAL SPONGE INTRAVENOUS KIT GELFOAM MUCOUS 3 KEDBUMIN MEMBRANE POWDER INTRAVENOUS 3 GELFOAM SPONGE PARENTERAL SIZE 100 TOPICAL 3 SOLUTION SPONGE KOATE-DVI GELFOAM SPONGE INTRAVENOUS RECON 4 PA SIZE 12-7MM TOPICAL 3 SOLN SPONGE KOGENATE FS GELFOAM SPONGE INTRAVENOUS RECON 4 PA SIZE 200 TOPICAL 3 SOLN SPONGE KOVALTRY GELFOAM SPONGE INTRAVENOUS RECON 4 SIZE 50 TOPICAL 3 SOLN SPONGE lmd 10 % in 0.9 % sodium GELFOAM TOPICAL chlor intravenous parenteral 1 3 SPONGE solution HELIXATE FS lmd 10 % in 5 % dextrose INTRAVENOUS RECON 4 PA intravenous parenteral 1 SOLN solution HEMOFIL M HIGH LYSTEDA ORAL 3 INTRAVENOUS RECON 4 PA TABLET SOLN MONOCLATE-P 4 PA HEMOFIL M LOW INTRAVENOUS KIT INTRAVENOUS RECON 4 PA MONONINE 4 PA SOLN INTRAVENOUS KIT HEMOFIL M MID MONSEL'S TOPICAL 3 INTRAVENOUS RECON 4 PA SOLUTION SOLN MONSEL'S TOPICAL HEMOFIL M SUPER SOLUTION WITH 3 HIGH INTRAVENOUS 4 PA APPLICATOR RECON SOLN NOVOEIGHT HESPAN 6 % IN NS INTRAVENOUS RECON 4 PA INTRAVENOUS 3 SOLN SOLUTION NOVOSEVEN RT hetastarch 6 % in 0.9 % nacl 1 INTRAVENOUS RECON 4 PA intravenous solution SOLN HEXTEND NUWIQ INTRAVENOUS 4 PA INTRAVENOUS 3 RECON SOLN SOLUTION OBIZUR INTRAVENOUS HUMATE-P 4 PA 4 PA RECON SOLN INTRAVENOUS KIT Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 59 Drug Name Tier Notes Drug Name Tier Notes OCTAPLAS (BLOOD SOLIRIS INTRAVENOUS 4 PA GROUP A) SOLUTION 3 INTRAVENOUS SYRINGE AVITENE 3 SOLUTION TOPICAL POWDER OCTAPLAS (BLOOD TACHOSIL TOPICAL GROUP AB) 3 ADHESIVE 3 INTRAVENOUS PATCH,MEDICATED SOLUTION THROMBATE III OCTAPLAS (BLOOD INTRAVENOUS RECON 3 GROUP B) 3 SOLN INTRAVENOUS SOLUTION THROMBI-GEL TOPICAL PADS, 3 OCTAPLAS (BLOOD MEDICATED GROUP O) 3 THROMBIN-JMI NASAL INTRAVENOUS 3 SOLUTION NASAL SPRAY SYRINGE OXYCEL COTTON-TYPE THROMBIN-JMI 3 3 PLEDGET PAD TOPICAL RECON SOLN pentoxifylline oral tablet THROMBIN-JMI 1 extended release TOPICAL SPRAY 3 SYRINGE plasbumin 25 % intravenous 1 parenteral solution THROMBIN-JMI TOPICAL 3 plasbumin 5 % intravenous 1 SPRAY,NON-AEROSOL parenteral solution THROMBI-PAD plasmanate intravenous 1 TOPICAL PADS, 3 parenteral solution MEDICATED PRAXBIND TISSEEL VHSD 3 INTRAVENOUS 3 TOPICAL KIT SOLUTION TISSEEL VHSD 3 PROFILNINE TOPICAL SYRINGE INTRAVENOUS RECON 4 PA TNKASE INTRAVENOUS SOLN 3 KIT protamine intravenous 1 tranexamic acid intravenous solution 1 QL solution RECOMBINATE INTRAVENOUS RECON 4 PA tranexamic acid oral tablet 1 QL SOLN TRETTEN RECOTHROM SPRAY INTRAVENOUS RECON 4 PA KIT TOPICAL RECON 3 SOLN SOLN ULTRAFOAM TOPICAL 3 RECOTHROM TOPICAL SPONGE 3 RECON SOLN VOLUVEN 6 % RIASTAP INTRAVENOUS 3 INTRAVENOUS RECON 3 PA SOLUTION SOLN WILATE INTRAVENOUS 4 PA RIXUBIS INTRAVENOUS KIT 4 PA RECON SOLN

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 60 Drug Name Tier Notes Drug Name Tier Notes XYNTHA CARDENE IV INTRAVENOUS 4 PA INTRAVENOUS 3 SOLUTION SOLUTION XYNTHA SOLOFUSE cardioplegic soln perfusion 1 INTRAVENOUS 4 PA solution SYRINGE CARDIZEM CD ORAL CARDIAC DRUGS CAPSULE,EXTENDED 3 DO ADALAT CC ORAL RELEASE 24HR 120 MG, TABLET EXTENDED 3 DO 180 MG RELEASE 30 MG CARDIZEM CD ORAL CAPSULE,EXTENDED ADALAT CC ORAL 3 QL TABLET EXTENDED 3 QL RELEASE 24HR 240 MG, RELEASE 60 MG, 90 MG 300 MG, 360 MG ADENOCARD CARDIZEM LA ORAL TABLET EXTENDED INTRAVENOUS 3 3 DO SYRINGE RELEASE 24 HR 120 MG, 180 MG adenosine intravenous 1 solution CARDIZEM LA ORAL TABLET EXTENDED adenosine intravenous 3 QL 1 RELEASE 24 HR 240 MG, syringe 300 MG, 360 MG, 420 MG afeditab cr oral tablet CARDIZEM ORAL 1 DO 3 QL extended release 30 mg TABLET afeditab cr oral tablet 1 QL cartia xt oral extended release 60 mg capsule,extended release 1 DO amiodarone intravenous 24hr 120 mg, 180 mg 1 solution cartia xt oral amiodarone intravenous capsule,extended release 1 QL 1 syringe 24hr 240 mg, 300 mg amiodarone oral tablet 1 CLEVIPREX INTRAVENOUS 3 amlodipine oral tablet 10 mg 1 QL EMULSION amlodipine oral tablet 2.5 CORDARONE ORAL 1 DO 2 mg, 5 mg TABLET CALAN ORAL TABLET 3 QL CORLANOR ORAL 2 PA; QL CALAN SR ORAL TABLET TABLET EXTENDED 3 QL CORVERT RELEASE INTRAVENOUS 3 CARDENE IV IN SOLUTION DEXTROSE 3 digitek oral tablet 1 INTRAVENOUS PIGGYBACK digox oral tablet 1 CARDENE IV IN digoxin injection solution 1 SODIUM CHLORIDE 3 digoxin injection syringe 1 INTRAVENOUS PIGGYBACK digoxin oral solution 1 digoxin oral tablet 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 61 Drug Name Tier Notes Drug Name Tier Notes DILATRATE-SR ORAL felodipine oral tablet 1 QL CAPSULE, EXTENDED 2 extended release 24 hr 10 mg RELEASE felodipine oral tablet diltiazem hcl intravenous extended release 24 hr 2.5 1 DO 1 recon soln mg, 5 mg diltiazem hcl intravenous flecainide oral tablet 1 1 solution ibutilide fumarate 1 diltiazem hcl oral capsule, intravenous solution extended release 120 mg, 1 DO ISOCHRON ORAL 180 mg TABLET EXTENDED 3 diltiazem hcl oral capsule, RELEASE extended release 240 mg, 1 QL ISORDIL ORAL TABLET 2 300 mg, 360 mg, 420 mg ISORDIL TITRADOSE 3 diltiazem hcl oral capsule,ext ORAL TABLET release degradable 120 mg, 1 DO isosorbide dinitrate oral 180 mg 1 tablet diltiazem hcl oral capsule,ext 1 QL isosorbide dinitrate oral release degradable 240 mg 1 tablet extended release diltiazem hcl oral isosorbide mononitrate oral capsule,extended release 12 1 QL 1 hr tablet isosorbide mononitrate oral diltiazem hcl oral 1 capsule,extended release 1 DO tablet extended release 24 hr 24hr 120 mg, 180 mg isradipine oral capsule 1 QL diltiazem hcl oral LANOXIN INJECTION capsule,extended release 3 1 QL SOLUTION 24hr 240 mg, 300 mg, 360 LANOXIN ORAL mg 2 TABLET diltiazem hcl oral tablet 1 QL LANOXIN PEDIATRIC 2 diltiazem hcl oral tablet INJECTION SOLUTION extended release 24 hr 180 1 DO lidocaine (pf) intravenous mg 1 solution diltiazem hcl oral tablet lidocaine (pf) intravenous extended release 24 hr 240 1 QL 1 mg, 300 mg, 360 mg, 420 mg syringe dilt-xr oral capsule,ext lidocaine in 5 % dextrose release degradable 120 mg, 1 DO (pf) intravenous parenteral 1 180 mg solution dilt-xr oral capsule,ext matzim la oral tablet 1 QL release degradable 240 mg extended release 24 hr 180 1 DO mg disopyramide phosphate oral 1 capsule matzim la oral tablet extended release 24 hr 240 1 QL dobutamine in d5w mg, 300 mg, 360 mg, 420 mg intravenous parenteral 1 solution mexiletine oral capsule 1 dobutamine intravenous milrinone in 5 % dextrose 1 1 solution intravenous piggyback

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 62 Drug Name Tier Notes Drug Name Tier Notes milrinone intravenous nitroglycerin in 5 % dextrose 1 1 solution intravenous solution MINITRAN nitroglycerin intravenous 1 TRANSDERMAL PATCH 3 solution 24 HOUR nitroglycerin oral capsule, 1 MULTAQ ORAL extended release 3 TABLET nitroglycerin transdermal 1 NEXTERONE patch 24 hour INTRAVENOUS 3 nitroglycerin translingual 1 SOLUTION aerosol,spray nicardipine intravenous nitroglycerin translingual 1 1 solution spray,non-aerosol nicardipine oral capsule 1 QL NITROLINGUAL nifedical xl oral tablet TRANSLINGUAL 3 1 DO extended release 24hr 30 mg SPRAY,NON-AEROSOL nifedical xl oral tablet NITROMIST 1 QL extended release 24hr 60 mg TRANSLINGUAL 3 nifedipine oral capsule 1 QL AEROSOL,SPRAY nifedipine oral tablet NITRONAL 1 DO extended release 24hr 30 mg INTRAVENOUS 3 SOLUTION nifedipine oral tablet NITROSTAT extended release 24hr 60 mg, 1 QL 2 90 mg SUBLINGUAL TABLET nifedipine oral tablet nitro-time oral capsule, 1 DO 1 extended release 30 mg extended release nifedipine oral tablet NORPACE CR ORAL extended release 60 mg, 90 1 QL CAPSULE, EXTENDED 2 mg RELEASE NORPACE ORAL nimodipine oral capsule 1 QL 3 CAPSULE nisoldipine oral tablet NORVASC ORAL extended release 24 hr 17 1 DO 3 QL mg, 20 mg, 8.5 mg TABLET 10 MG NORVASC ORAL nisoldipine oral tablet 3 DO extended release 24 hr 25.5 1 QL TABLET 2.5 MG, 5 MG mg, 30 mg, 34 mg, 40 mg NYMALIZE ORAL 3 nitro-bid transdermal SOLUTION 1 ointment pacerone oral tablet 1 NITRO-DUR PLEGISOL PERFUSION 3 TRANSDERMAL PATCH SOLUTION 24 HOUR 0.1 MG/HR, 0.2 3 procainamide injection 1 MG/HR, 0.4 MG/HR, 0.6 solution MG/HR PROCARDIA ORAL 3 QL NITRO-DUR CAPSULE TRANSDERMAL PATCH 2 24 HOUR 0.3 MG/HR, 0.8 PROCARDIA XL ORAL MG/HR TABLET EXTENDED 3 DO RELEASE 24HR 30 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 63 Drug Name Tier Notes Drug Name Tier Notes PROCARDIA XL ORAL verapamil oral capsule, 24 hr 1 DO TABLET EXTENDED er pellet ct 100 mg 3 QL RELEASE 24HR 60 MG, verapamil oral capsule, 24 hr 1 QL 90 MG er pellet ct 200 mg, 300 mg propafenone oral verapamil oral capsule,ext capsule,extended release 12 1 rel. pellets 24 hr 120 mg, 180 1 DO hr mg propafenone oral tablet 1 verapamil oral capsule,ext quinidine gluconate injection rel. pellets 24 hr 240 mg, 360 1 QL 1 solution mg quinidine gluconate oral verapamil oral tablet 1 QL 1 tablet extended release verapamil oral tablet 1 QL quinidine sulfate oral tablet 1 extended release RANEXA ORAL TABLET VERELAN ORAL EXTENDED RELEASE 12 2 CAPSULE,EXT REL. 3 DO HR PELLETS 24 HR 120 MG, RYTHMOL ORAL 180 MG 3 TABLET VERELAN ORAL CAPSULE,EXT REL. RYTHMOL SR ORAL 3 QL CAPSULE,EXTENDED 3 PELLETS 24 HR 240 MG, RELEASE 12 HR 360 MG SULAR ORAL TABLET VERELAN PM ORAL EXTENDED RELEASE 24 3 DO CAPSULE, 24 HR ER 3 DO HR 17 MG, 8.5 MG PELLET CT 100 MG SULAR ORAL TABLET VERELAN PM ORAL CAPSULE, 24 HR ER EXTENDED RELEASE 24 3 QL 3 QL HR 34 MG PELLET CT 200 MG, 300 MG taztia xt oral capsule, extended release 120 mg, 1 DO XYLOCAINE (CARDIAC) 180 mg (PF) INTRAVENOUS 3 SOLUTION taztia xt oral capsule, extended release 240 mg, 1 QL CARDIOVASCULAR 300 mg, 360 mg ACCUPRIL ORAL 3 TIAZAC ORAL TABLET CAPSULE, EXTENDED ACCURETIC ORAL 3 DO 3 RELEASE 120 MG, 180 TABLET MG acebutolol oral capsule 1 TIAZAC ORAL ACEON ORAL TABLET 3 CAPSULE, EXTENDED 3 QL ADCIRCA ORAL RELEASE 240 MG, 300 4 PA; QL MG, 360 MG, 420 MG TABLET TIKOSYN ORAL ADEMPAS ORAL 3 4 PA; QL CAPSULE TABLET verapamil intravenous ADVICOR ORAL 1 solution TABLET, ER MULTIPHASE 24 HR 2 QL verapamil intravenous 1 1,000-20 MG, 1,000-40 MG, syringe 750-20 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 64 Drug Name Tier Notes Drug Name Tier Notes ADVICOR ORAL atenolol oral tablet 1 TABLET, ER atenolol-chlorthalidone oral 2 DO 1 MULTIPHASE 24 HR tablet 500-20 MG atorvastatin oral tablet 10 1 DO alprostadil injection solution 1 mg, 20 mg, 40 mg ALTACE ORAL 3 atorvastatin oral tablet 80 mg 1 QL CAPSULE ATROPEN ALTOPREV ORAL INTRAMUSCULAR PEN 3 TABLET EXTENDED 3 ST; DO INJECTOR RELEASE 24 HR 20 MG, AVALIDE ORAL 40 MG 3 QL TABLET 150-12.5 MG ALTOPREV ORAL AVALIDE ORAL TABLET EXTENDED 3 ST; QL 3 RELEASE 24 HR 60 MG TABLET 300-12.5 MG AVAPRO ORAL TABLET amlodipine-atorvastatin oral 3 DO tablet 10-10 mg, 10-20 mg, 150 MG, 75 MG 1 QL 10-40 mg, 10-80 mg, 5-80 AVAPRO ORAL TABLET 3 QL mg 300 MG amlodipine-atorvastatin oral AZOR ORAL TABLET tablet 2.5-10 mg, 2.5-20 mg, 1 DO 10-20 MG, 10-40 MG, 5-40 2 QL 2.5-40 mg, 5-10 mg, 5-20 MG mg, 5-40 mg AZOR ORAL TABLET amlodipine-benazepril oral 2 DO 1 5-20 MG capsule benazepril oral tablet 1 amlodipine-valsartan oral benazepril-hydrochlorothiazi tablet 10-160 mg, 10-320 1 QL 1 mg, 5-320 mg de oral tablet amlodipine-valsartan oral BENICAR HCT ORAL 1 DO 2 DO tablet 5-160 mg TABLET 20-12.5 MG amlodipine-valsartan-hcthiaz BENICAR HCT ORAL id oral tablet 10-160-12.5 TABLET 40-12.5 MG, 2 QL 1 QL mg, 10-160-25 mg, 40-25 MG 10-320-25 mg, 5-160-25 mg BENICAR ORAL 2 DO amlodipine-valsartan-hcthiaz TABLET 20 MG 1 DO id oral tablet 5-160-12.5 mg BENICAR ORAL 2 QL ANTARA ORAL TABLET 40 MG, 5 MG 3 CAPSULE BETAPACE AF ORAL 3 ASCLERA TABLET INTRAVENOUS 3 BETAPACE ORAL 3 SOLUTION TABLET ATACAND HCT ORAL betaxolol oral tablet 1 TABLET 16-12.5 MG, 3 QL BIDIL ORAL TABLET 2 32-12.5 MG bisoprolol fumarate oral ATACAND HCT ORAL 1 3 tablet TABLET 32-25 MG bisoprolol-hydrochlorothiazi ATACAND ORAL 1 3 QL de oral tablet TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 65 Drug Name Tier Notes Drug Name Tier Notes BREVIBLOC IN NACL cholestyramine (with sugar) 1 (ISO-OSM) oral powder in packet INTRAVENOUS 3 cholestyramine light oral 1 PARENTERAL powder SOLUTION cholestyramine light oral 1 BREVIBLOC powder in packet INTRAVENOUS 3 SOLUTION clonidine hcl oral tablet 1 BYSTOLIC ORAL clonidine transdermal patch 3 1 TABLET weekly clorpres oral tablet 0.1-15 CADUET ORAL TABLET 1 10-10 MG, 10-20 MG, mg, 0.2-15 mg 3 QL 10-40 MG, 10-80 MG, 5-80 CLORPRES ORAL 3 MG TABLET 0.3-15 MG CADUET ORAL TABLET COLESTID FLAVORED 2.5-10 MG, 2.5-20 MG, 3 3 DO ORAL GRANULES 2.5-40 MG, 5-10 MG, 5-20 COLESTID FLAVORED MG, 5-40 MG 3 ORAL PACKET candesartan oral tablet 1 QL COLESTID ORAL 3 candesartan-hydrochlorothiaz GRANULES id oral tablet 16-12.5 mg, 1 QL COLESTID ORAL 32-12.5 mg 3 PACKET candesartan-hydrochlorothiaz 1 COLESTID ORAL id oral tablet 32-25 mg 3 TABLET captopril oral tablet 1 colestipol oral granules 1 captopril-hydrochlorothiazid 1 e oral tablet colestipol oral packet 1 CARDURA ORAL colestipol oral tablet 1 3 TABLET COREG CR ORAL CARDURA XL ORAL CAPSULE, ER 2 TABLET EXTENDED 3 MULTIPHASE 24 HR RELEASE 24HR COREG ORAL TABLET 3 carvedilol oral tablet 1 CORGARD ORAL 3 CATAPRES ORAL TABLET 3 TABLET CORLOPAM CATAPRES-TTS-1 INTRAVENOUS 3 TRANSDERMAL PATCH 3 SOLUTION WEEKLY CORZIDE ORAL 3 CATAPRES-TTS-2 TABLET TRANSDERMAL PATCH 3 COZAAR ORAL TABLET 3 QL WEEKLY CRESTOR ORAL CATAPRES-TTS-3 TABLET 10 MG, 20 MG, 5 2 DO TRANSDERMAL PATCH 3 MG WEEKLY CRESTOR ORAL 2 QL cholestyramine (with sugar) TABLET 40 MG 1 oral powder DEMSER ORAL 3 CAPSULE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 66 Drug Name Tier Notes Drug Name Tier Notes DIOVAN HCT ORAL fenofibrate nanocrystallized 1 TABLET 160-12.5 MG, 3 DO oral tablet 80-12.5 MG FENOFIBRATE ORAL 3 DIOVAN HCT ORAL CAPSULE TABLET 160-25 MG, 3 QL FENOFIBRATE ORAL 3 320-12.5 MG, 320-25 MG TABLET 120 MG, 40 MG DIOVAN ORAL TABLET 3 QL fenofibrate oral tablet 160 1 doxazosin oral tablet 1 mg, 54 mg DUTOPROL ORAL fenofibric acid (choline) oral TABLET EXTENDED 3 capsule,delayed 1 RELEASE 24 HR release(dr/ec) EDARBI ORAL TABLET 3 fenofibric acid oral tablet 1 EDARBYCLOR ORAL FENOGLIDE ORAL 3 QL 3 TABLET TABLET enalapril maleate oral tablet 1 FIBRICOR ORAL 3 enalaprilat intravenous TABLET 1 solution FLOLAN INTRAVENOUS 4 PA enalapril-hydrochlorothiazide RECON SOLN 1 oral tablet fluvastatin oral capsule 1 DO ENTRESTO ORAL fluvastatin oral tablet 2 PA; QL 1 TABLET extended release 24 hr EPANED ORAL RECON fosinopril oral tablet 1 3 SOLN fosinopril-hydrochlorothiazid 1 epoprostenol (glycine) e oral tablet 4 PA intravenous recon soln gemfibrozil oral tablet 1 eprosartan oral tablet 1 QL guanfacine oral tablet 1 ergoloid oral tablet 1 HEMANGEOL ORAL 3 esmolol intravenous solution 1 SOLUTION ETHAMOLIN hydralazine injection solution 1 INTRAVENOUS 3 hydralazine oral tablet 1 SOLUTION HYZAAR ORAL TABLET 3 QL EXFORGE HCT ORAL 100-12.5 MG, 100-25 MG TABLET 10-160-12.5 MG, 3 QL HYZAAR ORAL TABLET 10-160-25 MG, 10-320-25 3 DO MG, 5-160-25 MG 50-12.5 MG EXFORGE HCT ORAL INDERAL LA ORAL 3 DO TABLET 5-160-12.5 MG CAPSULE,EXTENDED 3 RELEASE 24 HR EXFORGE ORAL TABLET 10-160 MG, 3 QL INDERAL XL ORAL 10-320 MG, 5-320 MG CAPSULE,EXTENDED 3 RELEASE 24HR EXFORGE ORAL 3 DO indomethacin sodium TABLET 5-160 MG 1 intravenous recon soln fenofibrate micronized oral 1 capsule INNOPRAN XL ORAL CAPSULE,EXTENDED 3 RELEASE 24HR Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 67 Drug Name Tier Notes Drug Name Tier Notes irbesartan oral tablet 150 mg, LOFIBRA ORAL 1 DO 3 75 mg TABLET irbesartan oral tablet 300 mg 1 QL LOPID ORAL TABLET 3 irbesartan-hydrochlorothiazid LOPRESSOR HCT ORAL 1 QL 3 e oral tablet 150-12.5 mg TABLET irbesartan-hydrochlorothiazid LOPRESSOR 1 e oral tablet 300-12.5 mg INTRAVENOUS 3 isoxsuprine oral tablet 1 SOLUTION LOPRESSOR ORAL JUXTAPID ORAL 3 CAPSULE 10 MG, 20 MG, 3 PA TABLET 30 MG, 5 MG losartan oral tablet 1 QL JUXTAPID ORAL losartan-hydrochlorothiazide 3 PA; QL CAPSULE 40 MG, 60 MG oral tablet 100-12.5 mg, 1 QL KYNAMRO 100-25 mg SUBCUTANEOUS 3 PA; QL losartan-hydrochlorothiazide 1 DO SYRINGE oral tablet 50-12.5 mg labetalol intravenous solution 1 LOTENSIN HCT ORAL 3 labetalol intravenous syringe 1 TABLET LOTENSIN ORAL labetalol oral tablet 1 3 TABLET LESCOL ORAL 3 ST; DO LOTREL ORAL CAPSULE 3 CAPSULE LESCOL XL ORAL lovastatin oral tablet 10 mg, TABLET EXTENDED 3 ST 1 DO RELEASE 24 HR 20 mg LETAIRIS ORAL lovastatin oral tablet 40 mg 1 QL 4 PA; QL TABLET MAVIK ORAL TABLET 3 LEVATOL ORAL methyldopa oral tablet 1 3 TABLET methyldopa-hydrochlorothiaz 1 LIPITOR ORAL TABLET ide oral tablet 3 ST; DO 10 MG, 20 MG, 40 MG methyldopate intravenous 1 LIPITOR ORAL TABLET solution 3 ST; QL 80 MG metoprolol succinate oral 1 LIPOCHOL PLUS ORAL tablet extended release 24 hr 3 TABLET metoprolol LIPOFEN ORAL ta-hydrochlorothiaz oral 1 3 CAPSULE tablet lisinopril oral tablet 1 metoprolol tartrate 1 lisinopril-hydrochlorothiazid intravenous solution 1 e oral tablet metoprolol tartrate 1 LIVALO ORAL TABLET intravenous syringe 3 ST; DO 1 MG, 2 MG metoprolol tartrate oral tablet 1 LIVALO ORAL TABLET MICARDIS HCT ORAL 3 ST; QL 3 DO 4 MG TABLET 40-12.5 MG LOFIBRA ORAL 3 CAPSULE Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 68 Drug Name Tier Notes Drug Name Tier Notes MICARDIS HCT ORAL PHENYLEPHRINE IN TABLET 80-12.5 MG, 3 QL 0.9% NACL(PF) 3 80-25 MG INTRAVENOUS MICARDIS ORAL SYRINGE 3 DO TABLET 20 MG, 40 MG pindolol oral tablet 1 MICARDIS ORAL PRALUENT PEN 3 QL TABLET 80 MG SUBCUTANEOUS PEN 4 PA; QL MINIPRESS ORAL INJECTOR 3 CAPSULE PRALUENT SYRINGE minoxidil oral tablet 1 SUBCUTANEOUS 4 PA; QL SYRINGE moexipril oral tablet 1 PRAVACHOL ORAL moexipril-hydrochlorothiazid 3 DO 1 TABLET 20 MG e oral tablet PRAVACHOL ORAL 3 nadolol oral tablet 1 TABLET 40 MG nadolol-bendroflumethiazide PRAVACHOL ORAL 1 3 QL oral tablet TABLET 80 MG NATRECOR pravastatin oral tablet 10 mg, 1 DO INTRAVENOUS RECON 4 20 mg SOLN pravastatin oral tablet 40 mg 1 NEOPROFEN (IBUPROFEN LYSN)(PF) pravastatin oral tablet 80 mg 1 QL 3 INTRAVENOUS prazosin oral capsule 1 SOLUTION PRESTALIA ORAL 3 QL niacin oral tablet extended TABLET 14-10 MG 1 QL release 24 hr PRESTALIA ORAL NIACOR ORAL TABLET 3 TABLET 3.5-2.5 MG, 7-5 3 DO NIASPAN MG EXTENDED-RELEASE prevalite oral powder 1 ORAL TABLET 3 ST; QL prevalite oral powder in 1 EXTENDED RELEASE 24 packet HR PRINIVIL ORAL 3 QL NITROPRESS TABLET INTRAVENOUS 3 propranolol intravenous SOLUTION 1 solution OPSUMIT ORAL 4 PA; QL TABLET propranolol oral capsule,extended release 24 1 ORENITRAM ORAL hr TABLET EXTENDED 4 PA RELEASE propranolol oral solution 1 papaverine injection solution 1 QL propranolol oral tablet 1 perindopril erbumine oral propranolol-hydrochlorothiaz 1 1 tablet id oral tablet phenylephrine hcl injection PROSTIN VR 1 solution PEDIATRIC INJECTION 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 69 Drug Name Tier Notes Drug Name Tier Notes QUESTRAN LIGHT SOTRADECOL 3 ORAL POWDER INTRAVENOUS 3 QUESTRAN ORAL SOLUTION 3 POWDER SOTYLIZE ORAL 3 QUESTRAN ORAL SOLUTION 3 POWDER IN PACKET TARKA ORAL TABLET, quinapril oral tablet 1 IR - ER, BIPHASIC 24HR 3 DO 1-240 MG quinapril-hydrochlorothiazid 1 e oral tablet TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 3 QL ramipril oral capsule 1 2-180 MG, 2-240 MG, REMODULIN 4-240 MG 4 PA INJECTION SOLUTION TEKAMLO ORAL REPATHA SURECLICK TABLET 150-10 MG, 3 QL SUBCUTANEOUS PEN 4 PA; QL 300-10 MG, 300-5 MG INJECTOR TEKAMLO ORAL 3 DO REPATHA SYRINGE TABLET 150-5 MG SUBCUTANEOUS 4 PA; QL TEKTURNA HCT ORAL 3 DO SYRINGE TABLET 150-12.5 MG reserpine oral tablet 1 TEKTURNA HCT ORAL REVATIO TABLET 150-25 MG, 3 QL INTRAVENOUS 4 PA; QL 300-12.5 MG, 300-25 MG SOLUTION TEKTURNA ORAL 3 DO REVATIO ORAL TABLET 150 MG SUSPENSION FOR 4 PA; QL TEKTURNA ORAL 3 QL RECONSTITUTION TABLET 300 MG REVATIO ORAL telmisartan oral tablet 20 mg, 4 PA; QL 1 DO TABLET 40 mg SECTRAL ORAL 3 telmisartan oral tablet 80 mg 1 QL CAPSULE telmisartan-amlodipine oral sildenafil intravenous 4 PA; QL tablet 40-10 mg, 80-10 mg, 1 QL solution 80-5 mg sildenafil oral tablet 4 PA; QL telmisartan-amlodipine oral 1 DO SIMCOR ORAL TABLET, tablet 40-5 mg 3 QL ER MULTIPHASE 24 HR telmisartan-hydrochlorothiazi 1 DO simvastatin oral tablet 10 mg, d oral tablet 40-12.5 mg 1 DO 20 mg, 40 mg, 5 mg telmisartan-hydrochlorothiazi simvastatin oral tablet 80 mg 1 PA; QL d oral tablet 80-12.5 mg, 1 QL 80-25 mg sorine oral tablet 1 TENEX ORAL TABLET 3 sotalol af oral tablet 1 TENORETIC 100 ORAL 3 SOTALOL TABLET INTRAVENOUS 3 TENORETIC 50 ORAL SOLUTION 3 TABLET sotalol oral tablet 1 TENORMIN ORAL 3 TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 70 Drug Name Tier Notes Drug Name Tier Notes terazosin oral capsule 1 UPTRAVI ORAL 4 timolol maleate oral tablet 1 TABLETS,DOSE PACK TOPROL XL ORAL valsartan oral tablet 1 QL TABLET EXTENDED 3 valsartan-hydrochlorothiazid RELEASE 24 HR e oral tablet 160-12.5 mg, 1 DO TRACLEER ORAL 80-12.5 mg 4 PA; QL TABLET valsartan-hydrochlorothiazid trandolapril oral tablet 1 QL e oral tablet 160-25 mg, 1 QL 320-12.5 mg, 320-25 mg trandolapril-verapamil oral VARITHENA tablet, ir - er, biphasic 24hr 1 DO; QL 3 1-240 mg INTRAVENOUS FOAM VASERETIC ORAL trandolapril-verapamil oral 3 tablet, ir - er, biphasic 24hr TABLET 1 QL 2-180 mg, 2-240 mg, 4-240 VASOTEC ORAL 3 mg TABLET TRIBENZOR ORAL VAYAROL ORAL 2 3 TABLET CAPSULE TRICOR ORAL TABLET 3 VAZCULEP INJECTION 3 TRIGLIDE ORAL SOLUTION 3 TABLET VECAMYL ORAL 3 TRILIPIX ORAL TABLET CAPSULE,DELAYED 3 veletri intravenous recon soln 4 PA RELEASE(DR/EC) VENTAVIS TWYNSTA ORAL INHALATION 4 PA TABLET 40-10 MG, 80-10 3 QL SOLUTION FOR MG, 80-5 MG NEBULIZATION TWYNSTA ORAL VYTORIN 10-10 ORAL 3 DO 3 ST; QL TABLET 40-5 MG TABLET TYVASO INHALATION VYTORIN 10-20 ORAL 3 ST; QL SOLUTION FOR 4 PA; QL TABLET NEBULIZATION VYTORIN 10-40 ORAL 3 ST; QL TYVASO TABLET INSTITUTIONAL START VYTORIN 10-80 ORAL 3 ST; QL KIT INHALATION 4 PA; QL TABLET SOLUTION FOR WELCHOL ORAL NEBULIZATION 2 POWDER IN PACKET TYVASO REFILL KIT INHALATION WELCHOL ORAL 4 PA; QL 2 SOLUTION FOR TABLET NEBULIZATION ZEBETA ORAL TABLET 3 TYVASO STARTER KIT ZESTORETIC ORAL INHALATION 3 4 PA; QL TABLET SOLUTION FOR NEBULIZATION ZESTRIL ORAL TABLET 3 UPTRAVI ORAL ZETIA ORAL TABLET 3 ST; QL 4 TABLET ZIAC ORAL TABLET 3

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 71 Drug Name Tier Notes Drug Name Tier Notes ZOCOR ORAL TABLET carbamazepine oral 1 10 MG, 20 MG, 40 MG, 5 3 DO tablet,chewable MG CARBATROL ORAL ZOCOR ORAL TABLET CAPSULE, ER 2 3 PA; QL 80 MG MULTIPHASE 12 HR CNS DRUGS CELONTIN ORAL 3 ACTIVE-PAC KIT,GEL CAPSULE 3 AND CAPSULE CEREBYX INJECTION 3 AMPYRA ORAL TABLET SOLUTION EXTENDED RELEASE 12 4 PA; QL clonazepam oral tablet 1 HR clonazepam oral 1 APTIOM ORAL TABLET 3 tablet,disintegrating AUBAGIO ORAL COPAXONE 4 PA; QL TABLET SUBCUTANEOUS 4 PA AVONEX (WITH SYRINGE ALBUMIN) 4 PA DEHYDRATED INTRAMUSCULAR KIT ALCOHOL INJECTION 3 AVONEX SOLUTION INTRAMUSCULAR PEN 4 PA DEPACON INJECTOR KIT INTRAVENOUS 2 AVONEX SOLUTION INTRAMUSCULAR 4 PA DEPAKENE ORAL 2 SYRINGE CAPSULE AVONEX DEPAKENE ORAL 2 INTRAMUSCULAR 4 PA SOLUTION SYRINGE KIT DEPAKOTE ER ORAL BANZEL ORAL TABLET EXTENDED 2 3 SUSPENSION RELEASE 24 HR BANZEL ORAL TABLET 3 DEPAKOTE ORAL BETASERON TABLET,DELAYED 2 4 PA SUBCUTANEOUS KIT RELEASE (DR/EC) CAFCIT INTRAVENOUS DEPAKOTE SPRINKLES 3 SOLUTION ORAL CAPSULE, 2 SPRINKLE caffeine citrated intravenous 1 DIASTAT ACUDIAL solution 2 QL RECTAL KIT caffeine citrated oral solution 1 DIASTAT RECTAL KIT 2 QL caffeine-sodium benzoate 1 injection solution diazepam rectal kit 1 QL carbamazepine oral capsule, DILANTIN EXTENDED 1 2 er multiphase 12 hr ORAL CAPSULE carbamazepine oral DILANTIN INFATABS 1 suspension ORAL 2 TABLET,CHEWABLE carbamazepine oral tablet 1 DILANTIN ORAL carbamazepine oral tablet 2 1 CAPSULE extended release 12 hr

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 72 Drug Name Tier Notes Drug Name Tier Notes DILANTIN-125 ORAL GRALISE 30-DAY 2 SUSPENSION STARTER PACK ORAL 3 divalproex oral capsule, TABLET EXTENDED 1 sprinkle RELEASE 24 HR divalproex oral tablet GRALISE ORAL 1 extended release 24 hr TABLET EXTENDED 3 RELEASE 24 HR divalproex oral 1 tablet,delayed release (dr/ec) HORIZANT ORAL TABLET EXTENDED 3 DOPRAM RELEASE INTRAVENOUS 3 KEPPRA INTRAVENOUS SOLUTION 2 SOLUTION doxapram intravenous 1 KEPPRA ORAL solution 2 SOLUTION epitol oral tablet 1 KEPPRA ORAL TABLET 2 ethanol (ethyl alcohol) 1 injection solution KEPPRA XR ORAL TABLET EXTENDED 2 ethosuximide oral capsule 1 RELEASE 24 HR ethosuximide oral solution 1 KLONOPIN ORAL 3 EXTAVIA TABLET 4 ST SUBCUTANEOUS KIT LAMICTAL ODT ORAL EXTAVIA TABLET,DISINTEGRATI 2 SUBCUTANEOUS 4 ST NG RECON SOLN LAMICTAL ODT felbamate oral suspension 1 STARTER (BLUE) ORAL TABLET 2 felbamate oral tablet 1 DISINTEGRATING, FELBATOL ORAL DOSE PK 2 SUSPENSION LAMICTAL ODT FELBATOL ORAL STARTER (GREEN) 2 TABLET ORAL TABLET 2 fosphenytoin injection DISINTEGRATING, 1 solution DOSE PK FYCOMPA ORAL LAMICTAL ODT 3 TABLET STARTER (ORANGE) ORAL TABLET 2 gabapentin oral capsule 1 DISINTEGRATING, gabapentin oral solution 1 DOSE PK LAMICTAL ORAL gabapentin oral tablet 1 2 TABLET GABITRIL ORAL 2 TABLET LAMICTAL ORAL TABLET, CHEWABLE 2 GILENYA ORAL 4 PA; QL DISPERSIBLE CAPSULE LAMICTAL STARTER glatopa subcutaneous syringe 4 PA (BLUE) KIT ORAL 2 TABLETS,DOSE PACK

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 73 Drug Name Tier Notes Drug Name Tier Notes LAMICTAL STARTER LYRICA ORAL 3 PA; QL (GREEN) KIT ORAL 2 CAPSULE TABLETS,DOSE PACK LYRICA ORAL 3 PA; QL LAMICTAL STARTER SOLUTION (ORANGE) KIT ORAL 2 memantine oral solution 1 TABLETS,DOSE PACK memantine oral tablet 1 LAMICTAL XR ORAL MEMANTINE ORAL TABLET EXTENDED 3 3 RELEASE 24HR TABLETS,DOSE PACK MYSOLINE ORAL LAMICTAL XR 3 STARTER (BLUE) ORAL TABLET 3 TABLET EXTENDED NAMENDA ORAL 3 REL,DOSE PACK SOLUTION LAMICTAL XR NAMENDA ORAL 3 STARTER (GREEN) TABLET ORAL TABLET 3 EXTENDED REL,DOSE NAMENDA TITRATION PACK PAK ORAL 2 TABLETS,DOSE PACK LAMICTAL XR STARTER (ORANGE) NAMENDA XR ORAL ORAL TABLET 3 CAP,SPRINKLE,ER 24HR 2 EXTENDED REL,DOSE DOSE PACK PACK NAMENDA XR ORAL lamotrigine oral tablet 1 CAPSULE,SPRINKLE,ER 2 24HR lamotrigine oral tablet 1 disintegrating, dose pk NAMZARIC ORAL CAPSULE,SPRINKLE,ER 3 lamotrigine oral tablet 1 24HR extended release 24hr NEURONTIN ORAL lamotrigine oral tablet, 3 1 CAPSULE chewable dispersible NEURONTIN ORAL lamotrigine oral 3 1 SOLUTION tablet,disintegrating NEURONTIN ORAL lamotrigine oral tablets,dose 3 1 TABLET pack NUEDEXTA ORAL 3 LEMTRADA CAPSULE INTRAVENOUS 4 PA ONFI ORAL SOLUTION 3 SUSPENSION LEVETIRACETAM IN NACL (ISO-OS) ONFI ORAL TABLET 3 3 INTRAVENOUS oxcarbazepine oral 1 PIGGYBACK suspension levetiracetam intravenous oxcarbazepine oral tablet 1 1 solution OXTELLAR XR ORAL levetiracetam oral solution 1 TABLET EXTENDED 3 levetiracetam oral tablet 1 RELEASE 24 HR levetiracetam oral tablet PEGANONE ORAL 1 3 extended release 24 hr TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 74 Drug Name Tier Notes Drug Name Tier Notes PHENYTEK ORAL TEGRETOL ORAL 2 2 CAPSULE SUSPENSION phenytoin oral suspension 1 TEGRETOL ORAL 2 phenytoin oral TABLET 1 tablet,chewable TEGRETOL XR ORAL phenytoin sodium extended TABLET EXTENDED 2 1 oral capsule RELEASE 12 HR phenytoin sodium tetrabenazine oral tablet 1 PA 1 intravenous solution tiagabine oral tablet 1 phenytoin sodium TOPAMAX ORAL 1 2 intravenous syringe CAPSULE, SPRINKLE PLEGRIDY TOPAMAX ORAL 2 SUBCUTANEOUS PEN 4 PA TABLET INJECTOR topiramate oral capsule, 1 PLEGRIDY sprinkle SUBCUTANEOUS 4 PA TOPIRAMATE ORAL SYRINGE CAPSULE,SPRINKLE,ER 3 POTIGA ORAL TABLET 3 24HR primidone oral tablet 1 topiramate oral tablet 1 QUDEXY XR ORAL TRILEPTAL ORAL 2 CAPSULE,SPRINKLE,ER 3 SUSPENSION 24HR TRILEPTAL ORAL 3 REBIF (WITH ALBUMIN) TABLET SUBCUTANEOUS 4 ST TROKENDI XR ORAL SYRINGE CAPSULE,EXTENDED 3 REBIF REBIDOSE RELEASE 24HR SUBCUTANEOUS PEN 4 ST valproate sodium intravenous 1 INJECTOR solution REBIF TITRATION valproic acid (as sodium salt) 1 PACK SUBCUTANEOUS 4 ST oral solution SYRINGE valproic acid oral capsule 1 RILUTEK ORAL 4 VIMPAT INTRAVENOUS TABLET 3 SOLUTION riluzole oral tablet 4 VIMPAT ORAL SABRIL ORAL POWDER 3 3 SOLUTION IN PACKET VIMPAT ORAL TABLET 3 SABRIL ORAL TABLET 3 XENAZINE ORAL 3 PA SMARTRX GABAKIT TABLET KIT, CREAM AND 3 ZARONTIN ORAL CAPSULE 2 CAPSULE SPRITAM ORAL ZARONTIN ORAL TABLET FOR 3 2 SUSPENSION SOLUTION ZONEGRAN ORAL TECFIDERA ORAL 3 CAPSULE,DELAYED 4 PA; QL CAPSULE RELEASE(DR/EC) zonisamide oral capsule 1 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 75 Drug Name Tier Notes Drug Name Tier Notes COLONY STIMULATING amethia oral tablets,dose 1 PA FACTORS pack,3 month ARANESP (IN amethyst oral tablet 1 PA POLYSORBATE) 4 PA apri oral tablet 1 PA INJECTION SOLUTION aranelle (28) oral tablet 1 PA ARANESP (IN ashlyna oral tablets,dose POLYSORBATE) 4 PA 1 INJECTION SYRINGE pack,3 month EPOGEN INJECTION aubra oral tablet 1 PA 4 PA SOLUTION aviane oral tablet 1 PA GRANIX azurette (28) oral tablet 1 PA SUBCUTANEOUS 4 PA SYRINGE balziva (28) oral tablet 1 PA LEUKINE INJECTION bekyree (28) oral tablet 1 PA 4 PA RECON SOLN BEYAZ ORAL TABLET 3 PA MIRCERA INJECTION blisovi 24 fe oral tablet 1 PA 4 PA SYRINGE blisovi fe 1.5/30 (28) oral 1 MOZOBIL tablet SUBCUTANEOUS 4 PA blisovi fe 1/20 (28) oral 1 PA SOLUTION tablet NEULASTA BREVICON (28) ORAL 3 PA SUBCUTANEOUS 4 PA; QL TABLET SYRINGE briellyn oral tablet 1 PA NEULASTA SUBCUTANEOUS camila oral tablet 1 PA 4 PA; QL SYRINGE, W/ camrese lo oral tablets,dose 1 PA WEARABLE INJECTOR pack,3 month NEUPOGEN INJECTION camrese oral tablets,dose 4 PA 1 PA SOLUTION pack,3 month NEUPOGEN INJECTION CAYA CONTOURED 4 PA 2 SYRINGE VAGINAL DIAPHRAGM NPLATE caziant (28) oral tablet 1 SUBCUTANEOUS 4 PA chateal oral tablet 1 PA RECON SOLN cryselle (28) oral tablet 1 PA PROCRIT INJECTION 4 PA SOLUTION cyclafem 1/35 (28) oral tablet 1 PROMACTA ORAL cyclafem 7/7/7 (28) oral 4 PA 1 TABLET tablet ZARXIO INJECTION CYCLESSA (28) ORAL 4 PA 3 PA SYRINGE TABLET CONTRACEPTIVES cyred oral tablet 1 PA altavera (28) oral tablet 1 PA dasetta 1/35 (28) oral tablet 1 PA alyacen 1/35 (28) oral tablet 1 PA dasetta 7/7/7 (28) oral tablet 1 PA daysee oral tablets,dose alyacen 7/7/7 (28) oral tablet 1 PA 1 PA pack,3 month amethia lo oral tablets,dose 1 PA pack,3 month deblitane oral tablet 1 PA Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 76 Drug Name Tier Notes Drug Name Tier Notes delyla (28) oral tablet 1 PA heather oral tablet 1 PA DEPO-PROVERA introvale oral tablets,dose 1 PA INTRAMUSCULAR 3 PA pack,3 month SUSPENSION jencycla oral tablet 1 PA DEPO-PROVERA jolessa oral tablets,dose 1 PA INTRAMUSCULAR 3 PA pack,3 month SYRINGE jolivette oral tablet 1 PA DEPO-SUBQ PROVERA 104 SUBCUTANEOUS 3 PA juleber oral tablet 1 SYRINGE junel 1.5/30 (21) oral tablet 1 PA desog-e.estradiol/e.estradiol 1 PA junel 1/20 (21) oral tablet 1 PA oral tablet junel fe 1.5/30 (28) oral DESOGEN ORAL 1 PA 3 PA tablet TABLET junel fe 1/20 (28) oral tablet 1 PA desogestrel-ethinyl estradiol 1 PA oral tablet junel fe 24 oral tablet 1 PA drospirenone-ethinyl kaitlib fe oral tablet,chewable 1 1 PA estradiol oral tablet kariva (28) oral tablet 1 PA elinest oral tablet 1 PA kelnor 1/35 (28) oral tablet 1 PA ELLA ORAL TABLET 3 kimidess (28) oral tablet 1 emoquette oral tablet 1 kurvelo oral tablet 1 PA enpresse oral tablet 1 PA l norgest/e.estradiol-e.estrad enskyce oral tablet 1 PA oral tablets,dose pack,3 1 PA month errin oral tablet 1 PA larin 1.5/30 (21) oral tablet 1 PA estarylla oral tablet 1 PA larin 1/20 (21) oral tablet 1 PA ESTROSTEP FE-28 ORAL 3 PA TABLET larin 24 fe oral tablet 1 PA falmina (28) oral tablet 1 PA larin fe 1.5/30 (28) oral tablet 1 PA FEMCAP VAGINAL larin fe 1/20 (28) oral tablet 1 PA 2 DEVICE layolis fe oral 1 PA FEMCON FE ORAL tablet,chewable 3 PA TABLET,CHEWABLE leena 28 oral tablet 1 PA GENERESS FE ORAL lessina oral tablet 1 PA 3 PA TABLET,CHEWABLE levonest (28) oral tablet 1 PA gianvi (28) oral tablet 1 PA levonorgestrel-ethinyl estrad 1 PA gildagia oral tablet 1 oral tablet gildess 1.5/30 (21) oral tablet 1 PA levonorgestrel-ethinyl estrad gildess 1/20 (21) oral tablet 1 PA oral tablets,dose pack,3 1 PA month gildess 24 fe oral tablet 1 levonorg-eth estrad triphasic gildess fe 1.5/30 (28) oral 1 1 oral tablet tablet levora-28 oral tablet 1 PA gildess fe 1/20 (28) oral 1 tablet

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 77 Drug Name Tier Notes Drug Name Tier Notes LILETTA MODICON (28) ORAL 3 INTRAUTERINE TABLET 3 INTRAUTERINE mono-linyah oral tablet 1 PA DEVICE mononessa (28) oral tablet 1 PA LO LOESTRIN FE ORAL 2 PA TABLET my way oral tablet 1 QL LOESTRIN 1.5/30 (21) myzilra oral tablet 1 3 PA ORAL TABLET NATAZIA ORAL 3 PA LOESTRIN 1/20 (21) TABLET 3 PA ORAL TABLET necon 0.5/35 (28) oral tablet 1 PA LOESTRIN FE 1.5/30 3 PA necon 1/35 (28) oral tablet 1 PA (28-DAY) ORAL TABLET necon 1/50 (28) oral tablet 1 PA LOESTRIN FE 1/20 3 PA (28-DAY) ORAL TABLET necon 10/11 (28) oral tablet 1 PA lomedia 24 fe oral tablet 1 necon 7/7/7 (28) oral tablet 1 PA NEXPLANON loryna (28) oral tablet 1 PA 4 SUBDERMAL IMPLANT LOSEASONIQUE ORAL next choice one dose oral TABLETS,DOSE PACK,3 3 PA 1 QL MONTH tablet low-ogestrel (28) oral tablet 1 PA nikki (28) oral tablet 1 lutera (28) oral tablet 1 PA nora-be oral tablet 1 PA noreth-ethinyl estradiol-iron lyza oral tablet 1 1 PA oral tablet,chewable marlissa oral tablet 1 PA norethindrone medroxyprogesterone 1 PA 1 PA (contraceptive) oral tablet intramuscular suspension norethindrone ac-eth medroxyprogesterone 1 PA 1 PA estradiol oral tablet intramuscular syringe norethindrone-e.estradiol-iro microgestin 1.5/30 (21) oral 1 PA 1 PA n oral tablet tablet norgestimate-ethinyl microgestin 1/20 (21) oral 1 PA estradiol oral tablet 1 tablet 0.18/0.215/0.25 mg-25 mcg MICROGESTIN 24 FE 3 norgestimate-ethinyl ORAL TABLET estradiol oral tablet 1 PA microgestin fe 1.5/30 (28) 0.18/0.215/0.25 mg-35 mcg 1 PA oral tablet (28), 0.25-35 mg-mcg microgestin fe 1/20 (28) oral NORINYL 1+35 (28) 1 PA 3 PA tablet ORAL TABLET MINASTRIN 24 FE ORAL NORINYL 1+50 (28) 2 PA 3 PA TABLET,CHEWABLE ORAL TABLET MIRCETTE (28) ORAL norlyroc oral tablet 1 PA 3 PA TABLET NOR-QD ORAL TABLET 3 PA MIRENA nortrel 0.5/35 (28) oral tablet 1 PA INTRAUTERINE 3 INTRAUTERINE nortrel 1/35 (21) oral tablet 1 PA DEVICE nortrel 1/35 (28) oral tablet 1 PA

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 78 Drug Name Tier Notes Drug Name Tier Notes nortrel 7/7/7 (28) oral tablet 1 PA SEASONIQUE ORAL NUVARING VAGINAL TABLETS,DOSE PACK,3 3 PA 2 PA RING MONTH setlakin oral tablets,dose ocella oral tablet 1 PA 1 PA pack,3 month ogestrel (28) oral tablet 1 PA sharobel oral tablet 1 PA orsythia oral tablet 1 SKYLA INTRAUTERINE ORTHO MICRONOR 3 INTRAUTERINE 3 ORAL TABLET DEVICE ORTHO TRI-CYCLEN 3 PA sprintec (28) oral tablet 1 PA (28) ORAL TABLET sronyx oral tablet 1 PA ORTHO TRI-CYCLEN 3 PA LO (28) ORAL TABLET syeda oral tablet 1 PA ORTHO-CYCLEN (28) tarina fe 1/20 (28) oral tablet 1 PA 3 PA ORAL TABLET tilia fe oral tablet 1 PA ORTHO-NOVUM 1/35 (28) tri-estarylla oral tablet 1 PA 3 ORAL TABLET tri-legest fe oral tablet 1 PA ORTHO-NOVUM 7/7/7 3 tri-linyah oral tablet 1 PA (28) ORAL TABLET tri-lo-estarylla oral tablet 1 OVCON-35 (28) ORAL 3 PA TABLET tri-lo-marzia oral tablet 1 PARAGARD T 380A tri-lo-sprintec oral tablet 1 INTRAUTERINE 3 QL trinessa (28) oral tablet 1 PA INTRAUTERINE DEVICE trinessa lo oral tablet 1 TRI-NORINYL (28) ORAL philith oral tablet 1 PA 3 PA TABLET pimtrea (28) oral tablet 1 PA tri-previfem (28) oral tablet 1 pirmella oral tablet 1 0.5/0.75/1 mg- 35 mcg tri-sprintec (28) oral tablet 1 PA pirmella oral tablet 1-35 trivora (28) oral tablet 1 PA 1 PA mg-mcg velivet triphasic regimen (28) 1 PA PLAN B ONE-STEP oral tablet 3 QL ORAL TABLET vestura (28) oral tablet 1 PA portia oral tablet 1 PA vienva oral tablet 1 previfem oral tablet 1 viorele (28) oral tablet 1 PA QUARTETTE ORAL vyfemla (28) oral tablet 1 TABLETS,DOSE PACK,3 3 PA wera (28) oral tablet 1 PA MONTH WIDE-SEAL quasense oral tablets,dose 1 PA DIAPHRAGM 60 2 pack,3 month VAGINAL DIAPHRAGM reclipsen (28) oral tablet 1 PA WIDE-SEAL SAFYRAL ORAL DIAPHRAGM 65 2 3 TABLET VAGINAL DIAPHRAGM

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 79 Drug Name Tier Notes Drug Name Tier Notes WIDE-SEAL ephedrine sulfate injection 1 DIAPHRAGM 70 2 solution VAGINAL DIAPHRAGM EPHEDRINE WIDE-SEAL SULFATE-0.9%NACL(PF 3 DIAPHRAGM 75 2 ) INTRAVENOUS VAGINAL DIAPHRAGM SYRINGE WIDE-SEAL FLOWTUSS ORAL 3 DIAPHRAGM 80 2 SOLUTION VAGINAL DIAPHRAGM guaiatussin ac oral liquid 1 WIDE-SEAL guaifenesin ac oral liquid 1 DIAPHRAGM 85 2 VAGINAL DIAPHRAGM guaifenesin dac oral syrup 1 HISTEX-AC ORAL WIDE-SEAL 3 DIAPHRAGM 90 2 SYRUP VAGINAL DIAPHRAGM HYCOFENIX ORAL 3 WIDE-SEAL SOLUTION DIAPHRAGM 95 2 hydrocodone-chlorphenirami VAGINAL DIAPHRAGM ne oral suspension,extended 1 wymzya fe oral rel 12 hr 1 tablet,chewable hydrocodone-cpm-pseudoeph 1 xulane transdermal patch ed oral solution 1 QL weekly hydrocodone-homatropine 1 YASMIN (28) ORAL oral syrup 5-1.5 mg/5 ml 3 PA TABLET HYDROCODONE-HOMA YAZ (28) ORAL TABLET 3 PA TROPINE ORAL SYRUP 3 5-1.5 MG/5 ML (5 ML) zarah oral tablet 1 hydrocodone-homatropine 1 zenchent (28) oral tablet 1 PA oral tablet zenchent fe oral 1 PA hydromet oral syrup 1 tablet,chewable iophen c-nr oral liquid 1 zovia 1/35e (28) oral tablet 1 PA lortuss ex oral syrup 1 zovia 1/50e (28) oral tablet 1 PA MAR-COF BP ORAL 3 COUGH/COLD LIQUID PREPARATIONS MAR-COF CG ORAL 3 benzonatate oral capsule 1 LIQUID BROMFED DM ORAL 3 m-clear wc oral liquid 1 SYRUP M-END MAX D ORAL brompheniramine-pseudoeph 3 1 LIQUID -dm oral syrup M-END PE ORAL 3 CAPCOF ORAL LIQUID 3 LIQUID centergy dm oral drops 1 NINJACOF-XG ORAL 3 cheratussin ac oral liquid 1 LIQUID cheratussin dac oral syrup 1 OBREDON ORAL 3 CODEINE-GUAIFENESI SOLUTION 3 N ORAL LIQUID phenylhistine dh oral liquid 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 80 Drug Name Tier Notes Drug Name Tier Notes POLY-TUSSIN AC ORAL ZODRYL AC 30 ORAL 2 3 LIQUID SUSPENSION PRO-CLEAR AC ORAL ZODRYL AC 35 ORAL 2 3 LIQUID SUSPENSION PRO-CLEAR CAPS ZODRYL AC 40 ORAL 2 2 ORAL CAPSULE SUSPENSION promethazine vc-codeine oral ZODRYL AC 50 ORAL 1 3 syrup SUSPENSION promethazine-codeine oral ZODRYL AC 60 ORAL 1 3 syrup SUSPENSION promethazine-dm oral syrup 1 ZODRYL AC 80 ORAL 3 promethazine-phenyleph-cod SUSPENSION 1 eine oral syrup ZODRYL DAC 25 ORAL 3 PRO-RED AC (W/ SUSPENSION DEXCHLORPHENIR) 3 ZODRYL DAC 30 ORAL 3 ORAL LIQUID SUSPENSION relcof c oral liquid 1 ZODRYL DAC 35 ORAL 3 RESPA-AR ORAL SUSPENSION TABLET EXTENDED 3 ZODRYL DAC 40 ORAL 3 RELEASE 12 HR SUSPENSION REZIRA ORAL ZODRYL DAC 50 ORAL 3 3 SOLUTION SUSPENSION rydex oral liquid 1 ZODRYL DAC 60 ORAL 3 TESSALON PERLES SUSPENSION 3 ORAL CAPSULE ZODRYL DAC 80 ORAL 3 tusnel c oral syrup 1 SUSPENSION TUSNEL PEDIATRIC ZODRYL DEC 25 ORAL 3 3 ORAL LIQUID SUSPENSION ZODRYL DEC 30 ORAL TUSSICAPS ORAL 2 CAPSULE,EXTENDED 2 SUSPENSION RELEASE 12 HR ZODRYL DEC 35 ORAL 3 tussigon oral tablet 1 SUSPENSION ZODRYL DEC 40 ORAL TUSSIONEX 3 PENNKINETIC ER ORAL SUSPENSION 3 SUSPENSION,EXTENDE ZODRYL DEC 50 ORAL 3 D REL 12 HR SUSPENSION TUZISTRA XR ORAL ZODRYL DEC 60 ORAL 3 SUSPENSION,EXTENDE 3 SUSPENSION D REL 12 HR ZODRYL DEC 80 ORAL 3 virtussin ac oral liquid 1 SUSPENSION virtussin dac oral syrup 1 ZONATUSS ORAL 3 VITUZ ORAL SOLUTION 3 CAPSULE ZODRYL AC 25 ORAL Z-TUSS AC ORAL 3 2 SUSPENSION LIQUID

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 81 Drug Name Tier Notes Drug Name Tier Notes ZUTRIPRO ORAL CLEVER CHOICE 3 SOLUTION MICRO TEST STRIP 3 ST; QL DIAGNOSTIC STRIP ACCU-CHEK AVIVA CLEVER CHOICE PRO 2 QL 3 ST; QL PLUS TEST STRP STRIP STRIP ACCU-CHEK AVIVA CLEVER CHOICE TEST 2 QL 3 ST; QL STRIP STRIPS STRIP ACCU-CHEK COMPACT CLEVER CHOICE 2 QL 3 ST; QL PLUS TEST STRIP VOICE+ TEST STRIP ACCU-CHEK COMPACT CONTOUR NEXT STRIPS 2 QL 3 ST; QL TEST STRIP STRIP CONTOUR TEST STRIPS ACCU-CHEK 3 ST; QL SMARTVIEW TEST 2 QL STRIP STRIP STRIP CONTROL G3 STRIP 3 ST; QL ACCUTREND GLUCOSE CONTROL TEST STRIP 3 ST; QL 3 QL STRIP COOL GLUCOSE TEST 3 ST; QL ACURA TEST STRIPS STRIP STRIP 3 ST; QL STRIP DIATRUE PLUS TEST 3 ST; QL ADVANCED GLUC STRIP STRIP METER TEST STRIP 3 ST; QL EASY GLUCO G2 STRIP 3 ST; QL STRIP EASY PLUS II TEST ADVOCATE REDI-CODE 3 ST; QL 3 ST; QL STRIP STRIP EASY STEP STRIP 3 ST; QL ADVOCATE 3 ST; QL EASY TALK GLUCOSE REDI-CODE+ STRIP 3 ST; QL TEST STRIP ADVOCATE TEST 3 ST; QL STRIPS STRIP EASY TOUCH STRIP 3 ST; QL AGAMATRIX AMP TEST EASY TRAK GLUCOSE 3 ST; QL 3 ST; QL STRIPS STRIP TEST STRIP EASYGLUCO PLUS ASSURE 4 STRIPS STRIP 3 ST; QL 3 ST; QL STRIP ASSURE PLATINUM 3 ST; QL EASYGLUCO TEST STRIP 3 ST; QL STRIP ASSURE PRISM MULTI 3 ST; QL STRIP STRIP EASYMAX 15 STRIP 3 ST; QL BG-STAR STRIP 3 ST; QL EASYMAX STRIP 3 ST; QL BIONIME RIGHTEST ELEMENT COMPACT 3 ST; QL 3 ST; QL TEST STRIPS STRIP TEST STRIPS STRIP BLOOD GLUCOSE TEST ELEMENT TEST STRIPS 3 ST; QL 3 ST; QL STRIP STRIP BREEZE 2 TEST STRIPS EMBRACE BLOOD 3 ST; QL STRIP GLUCOSE SYSTEM 3 ST; QL STRIP CARESENS N TEST 3 ST; QL EMBRACE EVO TEST STRIPS STRIP 3 ST; QL STRIPS STRIP

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 82 Drug Name Tier Notes Drug Name Tier Notes EMBRACE PRO TEST FREESTYLE LITE 3 ST; QL 3 ST; QL STRIPS STRIP STRIPS STRIP EVENCARE G2 STRIP 3 ST; QL FREESTYLE PRECISION 3 ST; QL EVENCARE G3 TEST NEO STRIPS STRIP 3 ST; QL STRIP FREESTYLE TEST 3 ST; QL EVENCARE MINI STRIP GLUCOSE TEST STR 3 ST; QL G-4 TEST STRIP 3 ST; QL STRIP GE100 BLOOD EVENCARE TEST STRIP 3 ST; QL GLUCOSE TEST STRIP 3 ST; QL EVOLUTION TEST STRIP 3 ST; QL STRIPS STRIP GENSTRIP TEST STRIP 3 ST; QL EZ SMART PLUS TEST STRIP 3 ST; QL STRIP GLUCO NAVII TEST 3 ST; QL EZ SMART TEST STRIP 3 ST; QL STRIP STRIP FIFTY50 TEST STRIP GLUCOCARD 01 3 ST; QL 3 ST; QL STRIP SENSOR PLUS STRIP GLUCOCARD FORA D10 STRIP 3 ST; QL 3 ST; QL EXPRESSION STRIP FORA D15G STRIP 3 ST; QL GLUCOCARD SHINE 3 ST; QL FORA D20 STRIP 3 ST; QL TEST STRIPS STRIP FORA D40-G31 TEST GLUCOCARD VITAL 3 ST; QL 3 ST; QL STRIPS STRIP SENSOR STRIP FORA G20 STRIP 3 ST; QL GLUCOCARD VITAL 3 ST; QL FORA G30A STRIP 3 ST; QL TEST STRIPS STRIP FORA GD50 TEST GLUCOCOM GLUCOSE 3 ST; QL 3 ST; QL STRIPS STRIP STRIP FORA TEST STRIP GM100 STRIP 3 ST; QL 3 ST; QL STRIP GMATE TEST STRIPS 3 ST; QL FORA TN'G VOICE TEST STRIP 3 ST; QL STRIPS STRIP HEALTHPRO TEST 3 ST; QL FORA V10 STRIP 3 ST; QL STRIPS STRIP FORA V12 GLUCOSE INFINITY TEST STRIPS 3 ST; QL 3 ST; QL STRIP STRIP FORA V20 STRIP 3 ST; QL LIBERTY TEST STRIP 3 ST; QL FORA V30A STRIP 3 ST; QL MAXIMA STRIP 3 ST; QL MICRO BLOOD FORACARE GD20 STRIP 3 ST; QL 3 ST; QL GLUCOSE STRIP FORACARE GD40 STRIP 3 ST; QL MICRODOT BLOOD FORTISCARE GLUCOSE 3 ST; QL GLUCOSE SYSTEM 3 ST; QL TEST STRIPS STRIP STRIP FREESTYLE INSULINX MYGLUCOHEALTH 3 ST; QL 3 ST; QL STRIP STRIP FREESTYLE INSULINX NEUTEK 2TEK TEST 3 ST; QL 3 ST; QL TEST STRIPS STRIP STRIPS STRIP

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 83 Drug Name Tier Notes Drug Name Tier Notes NOVA MAX GLUCOSE SMARTEST TEST STRIP 3 ST; QL 3 ST; QL TEST STRIP SOLUS V2 TEST STRIPS 3 ST; QL ON CALL EXPRESS STRIP 3 ST; QL TEST STRIP STRIP SURE-TEST EASYPLUS 3 ST; QL ON CALL PLUS TEST MINI STRIP 3 ST; QL STRIP STRIP TELCARE TEST STRIPS 3 ST; QL ON CALL VIVID TEST STRIP 3 ST; QL STRIP STRIP TEST N'GO TEST STRIP 3 ST; QL ONETOUCH ULTRA 2 QL TRUE METRIX TEST STRIP GLUCOSE TEST STRIP 3 ST; QL ONETOUCH VERIO STRIP 2 QL STRIP TRUETEST TEST STRIPS 3 ST; QL OPTIUM EZ STRIP 3 ST; QL STRIP OPTIUM TEST STRIP 3 ST; QL TRUETRACK SMART 3 ST; QL OPTUMRX STRIP 3 ST; QL SYSTEM STRIP PHARMACIST CHOICE TRUETRACK TEST 3 ST; QL 3 ST; QL STRIP STRIP PRECISION PCX PLUS ULTIMA TEST STRIPS 3 ST; QL 3 ST; QL TEST STRIP STRIP PRECISION PCX TEST ULTRATRAK STRIP 3 ST; QL 3 ST; QL STRIP ULTRATRAK 3 ST; QL PRECISION POINT OF ULTIMATE STRIP 3 ST; QL CARE TEST STRIP UNISTRIP1 TEST STRIP 3 ST; QL PRECISION Q-I-D TEST STRIP 3 ST; QL STRIP WAVESENSE JAZZ 3 ST; QL PRECISION XTRA TEST STRIP 3 ST; QL STRIP WAVESENSE PRESTO 3 ST; QL PREMIUM V10 STRIP 3 ST; QL STRIP PRODIGY NO CODING DIURETICS 3 ST; QL STRIP acetazolamide oral capsule, 1 QUINTET AC STRIP 3 ST; QL extended release REFUAH PLUS STRIP 3 ST; QL acetazolamide oral tablet 1 acetazolamide sodium RELION 1 CONFIRM-MICRO 3 ST; QL injection recon soln STRIP ALDACTAZIDE ORAL 3 RELION PRIME TEST TABLET 3 ST; QL STRIPS STRIP ALDACTONE ORAL 3 RELION ULTIMA STRIP 3 ST; QL TABLET REVEAL TEST STRIP amiloride oral tablet 1 3 ST; QL STRIP amiloride-hydrochlorothiazid 1 RIGHTEST GS550 TEST e oral tablet 3 ST; QL STRIPS STRIP AMMONIUM CHLORIDE SMART SENSE TEST INTRAVENOUS 3 3 ST; QL STRIPS STRIP SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 84 Drug Name Tier Notes Drug Name Tier Notes bumetanide injection solution 1 MAXZIDE ORAL 3 bumetanide oral tablet 1 TABLET MAXZIDE-25MG ORAL chlorothiazide oral tablet 1 3 TABLET chlorothiazide sodium 1 intravenous recon soln methazolamide oral tablet 1 chlorthalidone oral tablet 1 methyclothiazide oral tablet 1 DEMADEX ORAL metolazone oral tablet 1 3 TABLET MICROZIDE ORAL 3 DIAMOX SEQUELS CAPSULE ORAL CAPSULE, 3 NEPTAZANE ORAL 3 EXTENDED RELEASE TABLET DIURIL IV OSMITROL 10 % INTRAVENOUS RECON 3 INTRAVENOUS 3 SOLN PARENTERAL DIURIL ORAL SOLUTION 3 SUSPENSION osmitrol 15 % intravenous 1 DYAZIDE ORAL parenteral solution 3 CAPSULE osmitrol 20 % intravenous 1 DYRENIUM ORAL parenteral solution 3 CAPSULE OSMITROL 5 % EDECRIN ORAL INTRAVENOUS 3 3 TABLET PARENTERAL SOLUTION eplerenone oral tablet 1 RESECTISOL ethacrynate sodium 3 1 URETHRAL SOLUTION intravenous recon soln SAMSCA ORAL TABLET 3 furosemide injection solution 1 SODIUM EDECRIN furosemide injection syringe 1 INTRAVENOUS RECON 3 furosemide oral solution 1 SOLN furosemide oral tablet 1 spironolactone oral tablet 1 hydrochlorothiazide oral spironolacton-hydrochlorothi 1 1 capsule az oral tablet hydrochlorothiazide oral torsemide oral tablet 1 1 tablet triamterene-hydrochlorothiaz 1 indapamide oral tablet 1 id oral capsule triamterene-hydrochlorothiaz INSPRA ORAL TABLET 3 1 id oral tablet LASIX ORAL TABLET 3 VAPRISOL mannitol 10 % intravenous 1 INTRAVENOUS 3 parenteral solution SOLUTION mannitol 20 % intravenous 1 EENT PREPS parenteral solution acetasol hc otic drops 1 mannitol 25 % intravenous 1 solution acetic acid otic solution 1 mannitol 5 % intravenous acetic acid-aluminum acetate 1 1 parenteral solution otic drops Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 85 Drug Name Tier Notes Drug Name Tier Notes acuicyn topical azelastine nasal 1 1 QL spray,non-aerosol spray,non-aerosol ACULAR LS AZOPT OPHTHALMIC 3 2 OPHTHALMIC DROPS DROPS,SUSPENSION ACULAR OPHTHALMIC balanced salt intraocular 3 1 DROPS solution ACUVAIL (PF) BECONASE AQ NASAL 3 ST; QL OPHTHALMIC 3 SPRAY,NON-AEROSOL DROPPERETTE BETADINE ADRENALIN NASAL OPHTHALMIC PREP 3 3 SOLUTION OPHTHALMIC AKTEN (PF) SOLUTION 3 OPHTHALMIC GEL BETAGAN 3 ALCAINE OPHTHALMIC DROPS 3 OPHTHALMIC DROPS betaxolol ophthalmic drops 1 ALOCRIL BETIMOL 3 ST; QL 3 OPHTHALMIC DROPS OPHTHALMIC DROPS ALOMIDE BETOPTIC S 3 ST; QL OPHTHALMIC DROPS OPHTHALMIC 2 ALPHAGAN P DROPS,SUSPENSION OPHTHALMIC DROPS 2 bimatoprost ophthalmic 1 0.1 % drops ALPHAGAN P brimonidine ophthalmic 1 OPHTHALMIC DROPS 3 drops 0.15 % bromfenac ophthalmic drops 1 ALREX OPHTHALMIC 3 bss intraocular solution 1 DROPS,SUSPENSION BSS PLUS altacaine ophthalmic drops 1 INTRAOCULAR 3 altafluor ophthalmic drops 1 SOLUTION AMVISC INTRAOCULAR budesonide nasal 4 1 QL SYRINGE spray,non-aerosol AMVISC PLUS carteolol ophthalmic drops 1 INTRAOCULAR 4 CELLUGEL SYRINGE INTRAOCULAR 3 apraclonidine ophthalmic SYRINGE 1 drops COMBIGAN 2 ASTEPRO NASAL OPHTHALMIC DROPS 2 QL SPRAY,NON-AEROSOL CORTANE-B TOPICAL 3 atropine ophthalmic drops 1 LOTION atropine ophthalmic ointment 1 COSOPT (PF) ATROVENT NASAL OPHTHALMIC 3 3 QL SPRAY,NON-AEROSOL DROPPERETTE AVENOVA TOPICAL COSOPT OPHTHALMIC 3 3 SPRAY,NON-AEROSOL DROPS azelastine nasal aerosol,spray 1 QL cromolyn ophthalmic drops 1 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 86 Drug Name Tier Notes Drug Name Tier Notes CYCLOGYL flurox ophthalmic drops 1 3 OPHTHALMIC DROPS FML FORTE CYCLOMYDRIL OPHTHALMIC 3 3 OPHTHALMIC DROPS DROPS,SUSPENSION cyclopentolate ophthalmic FML LIQUIFILM 1 drops OPHTHALMIC 3 CYSTARAN DROPS,SUSPENSION 3 OPHTHALMIC DROPS FML S.O.P. DERMOTIC OIL OTIC OPHTHALMIC 3 3 DROPS OINTMENT dexamethasone sodium GELFILM 1 3 phosphate ophthalmic drops OPHTHALMIC FILM diclofenac sodium homatropaire ophthalmic 1 1 ophthalmic drops drops homatropine hbr ophthalmic DISCOVISC 1 INTRAOCULAR 3 drops SYRINGE hydrocortisone-acetic acid 1 dorzolamide ophthalmic otic drops 1 drops ILEVRO OPHTHALMIC 2 dorzolamide-timolol DROPS,SUSPENSION 1 ophthalmic drops ILUVIEN DUOVISC VISCO INTRAVITREAL 4 PA ELASTIC IMPLANT 3 INTRAOCULAR IOPIDINE SYRINGE OPHTHALMIC 3 DUREZOL DROPPERETTE 2 QL OPHTHALMIC DROPS IOPIDINE 3 DYMISTA NASAL OPHTHALMIC DROPS 3 QL SPRAY,NON-AEROSOL ipratropium bromide nasal 1 QL EYLEA INTRAVITREAL spray,non-aerosol 4 PA SOLUTION ISOPTO ATROPINE 3 FLAREX OPHTHALMIC OPHTHALMIC DROPS 3 DROPS,SUSPENSION ISOPTO CARPINE 3 flucaine ophthalmic drops 1 OPHTHALMIC DROPS flunisolide nasal ISTALOL OPHTHALMIC 1 ST; QL 3 spray,non-aerosol DROPS, ONCE DAILY fluocinolone acetonide oil JETREA (PF) 1 otic drops INTRAVITREAL 3 PA SOLUTION fluorescein-benoxinate 1 ophthalmic drops ketorolac ophthalmic drops 1 fluorescein-proparacaine LACRISERT 1 3 ophthalmic drops OPHTHALMIC INSERT fluorometholone ophthalmic latanoprost ophthalmic drops 1 1 drops,suspension levobunolol ophthalmic 1 flurbiprofen sodium drops 1 ophthalmic drops Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 87 Drug Name Tier Notes Drug Name Tier Notes LOTEMAX OMIDRIA OPHTHALMIC 3 INTRAOCULAR 3 DROPS,GEL CONCENTRATE LOTEMAX OMNARIS NASAL 3 ST; QL OPHTHALMIC 2 SPRAY,NON-AEROSOL DROPS,SUSPENSION OMNIPRED LOTEMAX OPHTHALMIC 3 OPHTHALMIC 2 DROPS,SUSPENSION OINTMENT OZURDEX LUCENTIS INTRAVITREAL 3 PA INTRAVITREAL 4 PA IMPLANT SOLUTION PAREMYD 3 QL LUMIGAN OPHTHALMIC DROPS 2 OPHTHALMIC DROPS PATANASE NASAL 3 QL MACUGEN SPRAY,NON-AEROSOL INTRAVITREAL 4 PA phenylephrine hcl 1 SYRINGE ophthalmic drops MAXIDEX PHOSPHOLINE IODIDE 3 OPHTHALMIC 3 OPHTHALMIC DROPS DROPS,SUSPENSION pilocarpine hcl ophthalmic 1 MEMBRANEBLUE drops INTRAOCULAR 3 SYRINGE PRED FORTE OPHTHALMIC 3 metipranolol ophthalmic 1 DROPS,SUSPENSION drops PRED MILD MIOCHOL-E 3 OPHTHALMIC 3 INTRAOCULAR KIT DROPS,SUSPENSION miostat intraocular solution 1 prednisolone acetate 1 MITOSOL ophthalmic drops,suspension 3 OPHTHALMIC KIT prednisolone sodium 1 mometasone nasal phosphate ophthalmic drops 1 ST; QL spray,non-aerosol PROLENSA 3 MYDRIACYL OPHTHALMIC DROPS 3 OPHTHALMIC DROPS proparacaine ophthalmic 1 naphazoline ophthalmic drops 1 drops PROVISC NASONEX NASAL INTRAOCULAR 4 3 ST; QL SPRAY,NON-AEROSOL SYRINGE NEVANAC QNASL NASAL HFA 3 ST; QL OPHTHALMIC 3 AEROSOL INHALER DROPS,SUSPENSION RESCULA 3 ocucoat intraocular syringe 1 OPHTHALMIC DROPS OCUFEN OPHTHALMIC RESTASIS 3 DROPS OPHTHALMIC 2 olopatadine nasal DROPPERETTE 1 QL spray,non-aerosol

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 88 Drug Name Tier Notes Drug Name Tier Notes RETISERT travoprost (benzalkonium) 1 INTRAVITREAL 3 ophthalmic drops IMPLANT TRIESENCE (PF) RHINOCORT AQUA INTRAOCULAR 3 NASAL 3 ST; QL SUSPENSION SPRAY,NON-AEROSOL tropicamide ophthalmic 1 SIMBRINZA drops OPHTHALMIC 2 TRUSOPT 3 DROPS,SUSPENSION OPHTHALMIC DROPS tetcaine ophthalmic drops 1 TYZINE NASAL DROPS 3 tetracaine hcl (pf) ophthalmic 0.05 % 1 drops TYZINE NASAL DROPS 3 QL tetracaine hcl ophthalmic 0.1 % 1 drops TYZINE NASAL 3 TETRAVISC FORTE SPRAY,NON-AEROSOL OPHTHALMIC VERAMYST NASAL 3 3 ST; QL DROPPERETTE,HYPER SPRAY,SUSPENSION VISCOUS VEXOL OPHTHALMIC 3 TETRAVISC FORTE DROPS,SUSPENSION OPHTHALMIC 3 DROPS,HYPERVISCOUS VISCOAT INTRAOCULAR 3 TETRAVISC SYRINGE OPHTHALMIC 3 DROPPERETTE,VISCOU VISIONBLUE S INTRAOCULAR 3 SYRINGE TETRAVISC XALATAN OPHTHALMIC DROPS, 3 3 VISCOUS OPHTHALMIC DROPS ZETONNA NASAL HFA TICANASE NASAL 3 ST; QL KIT,SPRAY AEROSOL INHALER 3 ST; QL SUSPENSION AND ZIOPTAN (PF) SPRAY OPHTHALMIC 3 timolol maleate ophthalmic DROPPERETTE 1 drops ELECT/CALORIC/H2O timolol maleate ophthalmic ACTIVE FE ORAL 1 3 gel forming solution TABLET TIMOPTIC OCUDOSE ADDAMEL N (PF) OPHTHALMIC 3 INTRAVENOUS 3 DROPPERETTE SOLUTION TIMOPTIC 3 amino acids 15 % OPHTHALMIC DROPS intravenous parenteral 1 TIMOPTIC-XE solution OPHTHALMIC GEL 3 AMINOSYN 10 % FORMING SOLUTION INTRAVENOUS 2 TRAVATAN Z PARENTERAL 2 OPHTHALMIC DROPS SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 89 Drug Name Tier Notes Drug Name Tier Notes AMINOSYN 3.5 % AMINOSYN-HBC 7% INTRAVENOUS INTRAVENOUS 2 3 PARENTERAL PARENTERAL SOLUTION SOLUTION AMINOSYN 7 % AMINOSYN-PF 10 % INTRAVENOUS INTRAVENOUS 2 3 PARENTERAL PARENTERAL SOLUTION SOLUTION AMINOSYN 7 % WITH AMINOSYN-PF 7 % ELECTROLYTES (SULFITE-FREE) INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION AMINOSYN 8.5 % AMINOSYN-RF 5.2 % INTRAVENOUS INTRAVENOUS 2 3 PARENTERAL PARENTERAL SOLUTION SOLUTION AMINOSYN 8.5 AURYXIA ORAL 3 %-ELECTROLYTES TABLET INTRAVENOUS 2 bd posiflush normal saline 1 PARENTERAL injection syringe SOLUTION bd posiflush saline blunt 1 AMINOSYN II 10 % cann injection syringe INTRAVENOUS 3 bd pre-filled normal saline PARENTERAL 1 SOLUTION injection syringe bd pre-filled saline blunt can AMINOSYN II 15 % 1 INTRAVENOUS injection syringe 3 PARENTERAL BIFERA RX ORAL 3 SOLUTION TABLET AMINOSYN II 7 % calcium acetate oral capsule 1 INTRAVENOUS 3 PARENTERAL calcium acetate oral tablet 1 SOLUTION calcium chloride intravenous 1 AMINOSYN II 8.5 % solution INTRAVENOUS calcium chloride intravenous 3 1 PARENTERAL syringe SOLUTION calcium gluconate 1 AMINOSYN II 8.5 intravenous solution %-ELECTROLYTES calcium-folic acid-vitamin d 1 INTRAVENOUS 3 oral wafer PARENTERAL SOLUTION centratex oral capsule 1 chromium chloride AMINOSYN M 3.5 % 1 INTRAVENOUS intravenous solution 3 PARENTERAL CLINIMIX 5%/D15W SOLUTION SULFITE FREE INTRAVENOUS 3 PARENTERAL SOLUTION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 90 Drug Name Tier Notes Drug Name Tier Notes CLINIMIX 5%/D25W CLINIMIX E 4.25%/D25W SULFITE-FREE SUL FREE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION CLINIMIX 2.75%/D5W CLINIMIX E 4.25%/D5W SULFIT FREE SULF FREE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION CLINIMIX 4.25%/D10W CLINIMIX E 5%/D15W SULF FREE SULFIT FREE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION CLINIMIX 4.25%/D5W CLINIMIX E 5%/D20W SULFIT FREE SULFIT FREE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION CLINIMIX 4.25%-D20W CLINIMIX E 5%/D25W SULF-FREE SULFIT FREE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION CLINIMIX 4.25%-D25W CLINISOL SF 15 % SULF-FREE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION CLINPRO 5000 DENTAL 3 CLINIMIX PASTE 5%-D20W(SULFITE-FRE copper chloride intravenous 1 E) INTRAVENOUS 3 solution PARENTERAL SOLUTION corvita 150 oral tablet 1 CORVITE 150 ORAL CLINIMIX E 2.75%/D10W 3 SUL FREE TABLET INTRAVENOUS 3 CORVITE FE ORAL 3 PARENTERAL TABLET SOLUTION cysteine (l-cysteine) 1 CLINIMIX E 2.75%/D5W intravenous solution SULF FREE INTRAVENOUS 3 cytra k crystals oral packet 1 PARENTERAL cytra-2 oral solution 1 SOLUTION cytra-3 oral solution 1 CLINIMIX E 4.25%/D10W cytra-k oral solution 1 SUL FREE INTRAVENOUS 3 d10 %-0.45 % sodium PARENTERAL chloride intravenous 1 SOLUTION parenteral solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 91 Drug Name Tier Notes Drug Name Tier Notes d2.5 %-0.45 % sodium dextrose 5 % in water (d5w) 1 chloride intravenous 1 intravenous piggyback parenteral solution dextrose 5 %-lactated ringers d5 % and 0.9 % sodium intravenous parenteral 1 chloride intravenous 1 solution parenteral solution dextrose 5%-0.2 % sod d5 %-0.45 % sodium chloride intravenous 1 chloride intravenous 1 parenteral solution parenteral solution dextrose 5%-0.3 % delflex with 2.5 % dextrose sod.chloride intravenous 1 1 intraperitoneal solution parenteral solution delflex-lc/1.5% dextrose dextrose 50 % in water 1 intraperitoneal solution (d50w) intravenous 1 delflex-lc/2.5% dextrose parenteral solution 1 intraperitoneal solution dextrose 50 % in water 1 delflex-lc/4.25% dextrose (d50w) intravenous syringe 1 intraperitoneal solution dextrose 70 % in water DELFLEX-SM WITH (d70w) intravenous 1 1.5% DEXTROSE parenteral solution 2 INTRAPERITONEAL DIANEAL LOW SOLUTION CALCIUM/1.5% DEX 3 denta 5000 plus dental cream 1 INTRAPERITONEAL SOLUTION dentagel dental gel 1 DIANEAL LOW dextrose 10 % and 0.2 % CALCIUM/4.25% DEX 3 nacl intravenous parenteral 1 INTRAPERITONEAL solution SOLUTION dextrose 10 % in water DIANEAL PD-2 WITH 2.5 (d10w) intravenous 1 % DEX 3 parenteral solution INTRAPERITONEAL dextrose 20 % in water SOLUTION (d20w) intravenous 1 DIANEAL PD-2 WITH parenteral solution 4.25 % DEX 3 dextrose 25 % in water INTRAPERITONEAL 1 (d25w) intravenous syringe SOLUTION dextrose 30 % in water DIANEAL PD-2/1.5% DEXTROSE (d30w) intravenous 1 3 parenteral solution INTRAPERITONEAL SOLUTION dextrose 40 % in water (d40w) intravenous 1 DIANEAL WITH 1.5% DEXTROSE parenteral solution 3 INTRAPERITONEAL dextrose 5 % in ringers SOLUTION intravenous parenteral 1 solution DIANEAL WITH 2.5 % DEXTROSE 3 dextrose 5 % in water (d5w) INTRAPERITONEAL intravenous parenteral 1 SOLUTION solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 92 Drug Name Tier Notes Drug Name Tier Notes DIANEAL WITH 4.25 % FLUORABON ORAL 3 DEXTROSE DROPS 3 INTRAPERITONEAL fluor-a-day (with xylitol) oral 1 SOLUTION tablet,chewable EFFER-K ORAL FLUOR-A-DAY ORAL TABLET, 3 3 DROPS EFFERVESCENT 10 fluoridex daily defense MEQ, 20 MEQ 1 dental gel effer-k oral tablet, 1 effervescent 25 meq FLUORIDEX SENSITIVITY RELIEF 3 electrolyte-48 in d5w DENTAL GEL intravenous parenteral 1 FLUORITAB ORAL solution 3 DROPS eliphos oral tablet 1 fluoritab oral tablet,chewable 1 EXTRANEAL 7.5 % FLURA-DROPS ORAL INTRAPERITONEAL 3 3 SOLUTION DROPS fe c plus oral tablet 1 focalgin dss oral tablet 1 FOLGARD OS ORAL FERAHEME 3 INTRAVENOUS 3 TABLET SOLUTION folivane-f oral capsule 1 FERIVA 21-7 TABLET 3 folivane-plus oral capsule 1 ORAL TABLET FOSRENOL ORAL 3 ST FERIVA FA POWDER IN PACKET (SUMALATE) ORAL 3 FOSRENOL ORAL CAPSULE 3 ST TABLET,CHEWABLE FERIVA ORAL FOSTEUM ORAL CAPSULE,EXT RELEASE 3 3 MULTIPHASE CAPSULE ferocon oral capsule 1 FREAMINE HBC 6.9 % INTRAVENOUS 3 FERRALET 90 PARENTERAL DUAL-IRON DELIVERY 3 SOLUTION ORAL TABLET freamine iii 10 % intravenous 1 ferraplus 90 oral tablet 1 parenteral solution ferrex 150 forte oral capsule 1 FUSION PLUS ORAL 3 ferrex 150 forte plus oral CAPSULE 1 capsule FUSION SPRINKLES ferrex 28 oral tablet 1 ORAL POWDER IN 3 PACKET FERRLECIT INTRAVENOUS 3 GLUCAGEN HYPOKIT SOLUTION INJECTION RECON 2 SOLN ferrocite plus oral tablet 1 GLUCAGON ferrogels forte oral capsule 1 EMERGENCY KIT 2 FLORIVA (HUMAN) INJECTION (FLUORIDE-VITAMIN 3 KIT D3) ORAL DROPS Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 93 Drug Name Tier Notes Drug Name Tier Notes GLYCOPHOS IONOSOL-B IN D5W INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION PARENTERAL hematinic plus vit/minerals SOLUTION 1 oral tablet IONOSOL-MB IN D5W hematinic/folic acid oral INTRAVENOUS 1 3 tablet PARENTERAL SOLUTION hematogen fa oral capsule 1 IROSPAN 24/6 ORAL 3 hematogen forte oral capsule 1 TABLET hematogen oral capsule 1 ISOLYTE S PH 7.4 HEMATRON ORAL INTRAVENOUS 3 3 LIQUID PARENTERAL SOLUTION HEMATRON-AF ORAL TABLET EXTENDED 3 ISOLYTE-P IN 5 % RELEASE 24 HR DEXTROSE INTRAVENOUS 3 HEMAX ORAL TABLET PARENTERAL EXTENDED RELEASE 24 3 SOLUTION HR ISOLYTE-S hemetab oral tablet 1 INTRAVENOUS 3 HEMOCYTE-F ORAL PARENTERAL 3 TABLET SOLUTION HEMOCYTE-PLUS KABIVEN 3 ORAL CAPSULE INTRAVENOUS 3 HEPATAMINE 8% EMULSION INTRAVENOUS KAYEXALATE ORAL 3 3 PARENTERAL POWDER SOLUTION k-effervescent oral tablet, 1 HYDROCHLORIC ACID effervescent 3 (BULK) LIQUID kionex oral powder 1 HYPERLYTE CR kionex oral suspension 1 INTRAVENOUS 3 klor-con 10 oral tablet SOLUTION 1 extended release ICAR-C PLUS ORAL 3 klor-con 8 oral tablet TABLET 1 extended release iferex 150 forte oral capsule 1 klor-con m10 oral tablet,er 1 infed injection solution 1 particles/crystals INJECTAFER klor-con m15 oral tablet,er 1 INTRAVENOUS 3 particles/crystals SOLUTION klor-con m20 oral tablet,er INTEGRA F ORAL 1 3 particles/crystals CAPSULE klor-con oral packet 1 INTEGRA PLUS ORAL 3 klor-con sprinkle oral CAPSULE 1 capsule, extended release IODOPEN KLOR-CON/25 ORAL INTRAVENOUS 3 3 SOLUTION PACKET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 94 Drug Name Tier Notes Drug Name Tier Notes klor-con/ef oral tablet, MAXFE 1 effervescent (FOLATE-DOCUSATE) 3 K-PHOS NO 2 ORAL ORAL TABLET 3 TABLET monoject 0.9% sodium 1 K-PHOS ORIGINAL chloride injection syringe ORAL 2 monoject prefill advanced ns 1 TABLET,SOLUBLE injection syringe k-phos-neutral oral tablet 1 monoject prefill saline flush 1 k-sol oral liquid 1 injection syringe K-TAB ORAL TABLET multigen folic oral tablet 1 EXTENDED RELEASE 10 3 multigen oral tablet 1 MEQ, 20 MEQ multigen plus oral tablet 1 k-tab oral tablet extended 1 MULTITRACE-4 release 8 meq CONCENTRATE 3 lactated ringers intravenous INTRAVENOUS 1 parenteral solution SOLUTION ludent fluoride oral MULTITRACE-4 1 tablet,chewable INTRAVENOUS 3 lugols oral solution 1 SOLUTION LYSIPLEX PLUS ORAL MULTITRACE-4 3 NEONATAL TABLET 3 INTRAVENOUS MAGNEBIND 400 ORAL 3 SOLUTION TABLET multitrace-4 pediatric magnesium chloride injection 1 1 intravenous solution solution MULTITRACE-5 MAGNESIUM SULFATE CONCENTRATE 3 IN D5W INTRAVENOUS 3 INTRAVENOUS PIGGYBACK SOLUTION magnesium sulfate in water MULTITRACE-5 intravenous parenteral 1 INTRAVENOUS 3 solution SOLUTION magnesium sulfate in water myferon 150 forte oral 1 1 intravenous piggyback capsule magnesium sulfate injection 1 NEPHRAMINE 5.4 % solution INTRAVENOUS 3 magnesium sulfate injection PARENTERAL 1 syringe SOLUTION manganese chloride NEPHRON FA ORAL 1 3 intravenous solution TABLET manganese sulfate NEUT INTRAVENOUS 1 3 intravenous solution SOLUTION normal saline flush injection marlexate oral powder 1 1 syringe MAXARON FORTE 3 ORAL TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 95 Drug Name Tier Notes Drug Name Tier Notes NORMOSOL-M IN 5 % PLASMA-LYTE-56 IN 5 DEXTROSE % DEXTROSE INTRAVENOUS 3 INTRAVENOUS 3 PARENTERAL PARENTERAL SOLUTION SOLUTION NORMOSOL-R IN 5 % poly-iron 150 forte oral 1 DEXTROSE capsule INTRAVENOUS 3 pot,sodium citrate-citric acid 1 PARENTERAL oral solution SOLUTION potassium acetate 1 NORMOSOL-R intravenous solution INTRAVENOUS 3 PARENTERAL potassium bicarb and SOLUTION chloride oral tablet, 1 effervescent NORMOSOL-R PH 7.4 INTRAVENOUS potassium bicarb-citric acid 3 1 PARENTERAL oral tablet, effervescent SOLUTION potassium chlorid-d5-0.45%nacl NUFERA ORAL TABLET 3 1 intravenous parenteral NUTRESTORE ORAL 3 solution POWDER IN PACKET potassium chloride in nutrilyte intravenous solution 1 0.9%nacl intravenous 1 ORACIT ORAL parenteral solution 3 SOLUTION potassium chloride in 5 % PEDITRACE dex intravenous parenteral 1 INTRAVENOUS 3 solution SOLUTION potassium chloride in lr-d5 PERIKABIVEN intravenous parenteral 1 INTRAVENOUS 3 solution EMULSION potassium chloride 1 perio med dental solution 1 intravenous piggyback PHOSLO ORAL potassium chloride 3 ST 1 CAPSULE intravenous solution PHOSLYRA ORAL potassium chloride oral 3 ST 1 SOLUTION capsule, extended release phospha 250 neutral oral potassium chloride oral 1 1 tablet liquid PLASMA-LYTE 148 potassium chloride oral 1 INTRAVENOUS packet 3 PARENTERAL potassium chloride oral tablet 1 SOLUTION extended release PLASMA-LYTE A potassium chloride oral INTRAVENOUS 1 3 tablet,er particles/crystals PARENTERAL SOLUTION potassium chloride-0.45 % nacl intravenous parenteral 1 solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 96 Drug Name Tier Notes Drug Name Tier Notes potassium PRISMASOL BGK chloride-d5-0.2%nacl HEMODIALYSIS 3 1 intravenous parenteral SOLUTION solution PRISMASOL BK potassium HEMODIALYSIS 3 chloride-d5-0.3%nacl SOLUTION 1 intravenous parenteral PROCALAMINE 3% solution INTRAVENOUS 3 potassium PARENTERAL chloride-d5-0.9%nacl SOLUTION 1 intravenous parenteral PROFERRIN-FORTE 3 solution ORAL TABLET potassium citrate oral tablet PROGLYCEM ORAL 1 3 extended release SUSPENSION potassium citrate-citric acid 1 PROSOL 20 % oral packet INTRAVENOUS 3 potassium citrate-citric acid PARENTERAL 1 oral solution SOLUTION potassium phosphate purevit dualfe plus oral 1 m-/d-basic intravenous 1 capsule solution RENAGEL ORAL 3 ST premasol 10 % intravenous TABLET 1 parenteral solution RENVELA ORAL 2 PREMASOL 6 % POWDER IN PACKET INTRAVENOUS RENVELA ORAL 3 2 PARENTERAL TABLET SOLUTION ringers intravenous 1 PREVIDENT 5000 parenteral solution BOOSTER PLUS 3 DENTAL PASTE SACCHARIN POWDER 3 PREVIDENT 5000 DRY selenium intravenous 3 1 MOUTH DENTAL GEL solution PREVIDENT 5000 se-tan plus oral capsule 1 ENAMEL PROTECT 3 sf 5000 plus dental cream 1 DENTAL PASTE sf dental gel 1 PREVIDENT 5000 PLUS 3 SHOHL'S MODIFIED DENTAL CREAM 3 ORAL SOLUTION PREVIDENT 5000 sodium acetate intravenous SENSITIVE DENTAL 3 1 PASTE solution PREVIDENT DENTAL sodium bicarbonate 3 1 GEL intravenous solution PREVIDENT DENTAL sodium bicarbonate 3 1 SOLUTION intravenous syringe PRISMASOL B22GK sodium chloride 0.45 % HEMODIALYSIS 3 intravenous parenteral 1 SOLUTION solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 97 Drug Name Tier Notes Drug Name Tier Notes sodium chloride 0.45 % SODIUM POLYSTYRENE 1 intravenous piggyback SULFONATE RECTAL 3 sodium chloride 0.9 % ENEMA 50 GRAM/200 1 injection solution ML sodium chloride 0.9 % SORBITOL POWDER 3 1 injection syringe sps oral suspension 1 SODIUM CHLORIDE 0.9 sps rectal enema 1 % INJECTION SYRINGE, 3 SSKI ORAL SOLUTION 3 WITH SWAB CAP strong iodine oral solution 1 sodium chloride 0.9 % intravenous parenteral 1 SWABFLUSH solution INJECTION SYRINGE, 3 WITH SWAB CAP sodium chloride 0.9 % 1 syrex sodium chloride 0.9% intravenous piggyback 1 injection syringe sodium chloride 3 % TANDEM PLUS ORAL intravenous parenteral 1 3 solution CAPSULE sodium chloride 5 % taron forte oral capsule 1 intravenous parenteral 1 THAM INTRAVENOUS 3 solution SOLUTION sodium chloride intravenous 1 tl g-fol os oral tablet 1 parenteral solution tl icon oral capsule 1 sodium citrate-citric acid oral 1 tl-hem 150 oral tablet solution 1 extended release 24 hr sodium ferric gluconat-sucrose intravenous 1 TPN ELECTROLYTES II solution INTRAVENOUS 3 SOLUTION sodium fluoride dental 1 solution TPN ELECTROLYTES INTRAVENOUS 3 sodium fluoride oral drops 1 SOLUTION sodium fluoride oral 1 TRACE ELEMENTS tablet,chewable 4/PEDIATRIC 3 sodium lactate intravenous INTRAVENOUS 1 solution SOLUTION sodium phosphate travasol 10 % intravenous 1 1 intravenous solution parenteral solution sodium polystyrene (sorb tricitrates oral solution 1 1 free) oral suspension tricon oral capsule 1 sodium polystyrene sulfonate 1 TRIFERIC oral powder HEMODIALYSIS 3 sodium polystyrene sulfonate SOLUTION 1 oral suspension trigels-f forte oral capsule 1 sodium polystyrene sulfonate 1 TROPHAMINE 10 % rectal enema 30 gram/120 ml INTRAVENOUS 3 PARENTERAL SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 98 Drug Name Tier Notes Drug Name Tier Notes TROPHAMINE 6% XURIDEN ORAL 3 INTRAVENOUS GRANULES IN PACKET 3 PARENTERAL zinc chloride intravenous 1 SOLUTION solution ULTRABAG/DIANEAL zinc sulfate intravenous PD-2/1.5% DEX 1 3 solution INTRAPERITONEAL SOLUTION zinc sulfate oral capsule 1 ULTRABAG/DIANEAL GASTROINTESTINAL PD-2/2.5% DEX 3 ACIPHEX ORAL INTRAPERITONEAL TABLET,DELAYED 3 ST; QL SOLUTION RELEASE (DR/EC) ULTRABAG/DIANEAL ACIPHEX SPRINKLE PD-2/4.25%DEX ORAL CAPSULE, 3 3 ST; QL INTRAPERITONEAL DELAYED REL SOLUTION SPRINKLE ULTRABAG/DIANEAL/2. ACTIGALL ORAL 5% DEXTROSE 3 3 CAPSULE INTRAPERITONEAL AKYNZEO ORAL SOLUTION 3 QL CAPSULE UROCIT-K 10 ORAL TABLET EXTENDED 3 alosetron oral tablet 1 RELEASE ALOXI INTRAVENOUS 3 PA UROCIT-K 15 ORAL SOLUTION TABLET EXTENDED 3 AMITIZA ORAL 2 RELEASE CAPSULE UROCIT-K 5 ORAL AMMONUL TABLET EXTENDED 3 INTRAVENOUS 3 RELEASE SOLUTION UROQID-ACID NO.2 amoxicil-clarithromy-lansopr 3 1 ORAL TABLET az oral combo pack VELPHORO ORAL ANA-LEX KIT RECTAL 3 ST 3 TABLET,CHEWABLE KIT VELTASSA ORAL ANALPRAM ADVANCED 3 3 POWDER IN PACKET KIT VENOFER ANALPRAM E RECTAL INTRAVENOUS 3 KIT,CREAM AND 3 SOLUTION TOWELETTE virt-phos 250 neutral oral ANALPRAM-HC 1 3 tablet RECTAL CREAM virtrate-2 oral solution 1 ANALPRAM-HC virtrate-3 oral solution 1 SINGLES RECTAL 3 CREAM virtrate-k oral solution 1 anaspaz oral VITAFOL ORAL 1 3 tablet,disintegrating TABLET ANTIVERT ORAL 3 vp-gstn oral capsule 1 TABLET anucort-hc rectal suppository 1 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 99 Drug Name Tier Notes Drug Name Tier Notes ANUSOL-HC RECTAL CHENODAL ORAL 3 3 CREAM TABLET ANUSOL-HC RECTAL chlordiazepoxide-clidinium 3 1 SUPPOSITORY oral capsule ANZEMET CHOLBAM ORAL 3 PA; QL INTRAVENOUS CAPSULE 3 SOLUTION 100 MG/5 ML, cimetidine hcl oral solution 1 12.5 MG/0.625 ML cimetidine oral tablet 1 ANZEMET INTRAVENOUS 3 QL CIMZIA POWDER FOR SOLUTION 20 MG/ML RECONST 4 PA; QL SUBCUTANEOUS KIT ANZEMET ORAL 3 QL TABLET CIMZIA STARTER KIT SUBCUTANEOUS 4 PA; QL APRISO ORAL SYRINGE KIT CAPSULE,EXTENDED 3 ST RELEASE 24HR CIMZIA SUBCUTANEOUS 4 PA; QL ASACOL HD ORAL SYRINGE KIT TABLET,DELAYED 2 COLAZAL ORAL RELEASE (DR/EC) 3 CAPSULE atropine injection solution 1 COLYTE WITH FLAVOR atropine injection syringe 1 PACKS ORAL RECON 3 AZULFIDINE EN-TABS SOLN ORAL COMPAZINE ORAL 3 3 TABLET,DELAYED TABLET RELEASE (DR/EC) COMPAZINE RECTAL AZULFIDINE ORAL 3 3 SUPPOSITORY TABLET compro rectal suppository 1 balsalazide oral capsule 1 constulose oral solution 1 BENTYL INTRAMUSCULAR 3 CREON ORAL SOLUTION CAPSULE,DELAYED 2 RELEASE(DR/EC) BENTYL ORAL 3 CUVPOSA ORAL CAPSULE 3 SOLUTION BENTYL ORAL TABLET 3 CYTOTEC ORAL BUPHENYL ORAL 3 3 TABLET POWDER DELZICOL ORAL BUPHENYL ORAL 3 PA CAPSULE,DELAYED 2 TABLET RELEASE(DR/EC) CANASA RECTAL 2 DEXILANT ORAL SUPPOSITORY CAPSULE,BIPHASE 3 ST; QL carafate oral suspension 1 DELAYED RELEAS CARAFATE ORAL DICLEGIS ORAL 3 TABLET TABLET,DELAYED 3 PA; QL CESAMET ORAL RELEASE (DR/EC) 3 CAPSULE dicyclomine intramuscular 1 solution Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 100 Drug Name Tier Notes Drug Name Tier Notes dicyclomine oral capsule 1 GATTEX ONE-VIAL 3 PA dicyclomine oral solution 1 SUBCUTANEOUS KIT dicyclomine oral tablet 1 gavilyte-c oral recon soln 1 dimenhydrinate injection gavilyte-g oral recon soln 1 1 solution gavilyte-h and bisacodyl oral 1 DIPENTUM ORAL kit 3 ST CAPSULE gavilyte-n oral recon soln 1 diphenoxylate-atropine oral generlac oral solution 1 1 liquid GIAZO ORAL TABLET 3 diphenoxylate-atropine oral glycopyrrolate injection 1 1 tablet solution DONNATAL ORAL 3 glycopyrrolate oral tablet 1 ELIXIR GOLYTELY ORAL DONNATAL ORAL 3 3 POWDER IN PACKET TABLET GOLYTELY ORAL 3 dronabinol oral capsule 1 RECON SOLN ed-spaz oral granisetron (pf) intravenous 1 1 tablet,disintegrating solution EMEND INTRAVENOUS granisetron hcl intravenous 3 PA 1 RECON SOLN solution EMEND ORAL CAPSULE 3 QL granisetron hcl oral tablet 1 QL EMEND ORAL hemmorex-hc rectal 3 QL 1 CAPSULE,DOSE PACK suppository ENTEREG ORAL hydrocortisone acetate rectal 3 1 CAPSULE suppository ENTYVIO hydrocortisone rectal cream 1 INTRAVENOUS RECON 4 PA; QL hydrocortisone-pramoxine SOLN 1 rectal cream enulose oral solution 1 hyoscyamine sulfate oral 1 esomeprazole magnesium drops oral capsule,delayed 3 ST; QL hyoscyamine sulfate oral release(dr/ec) 1 elixir esomeprazole sodium 1 hyoscyamine sulfate oral intravenous recon soln 1 tablet famotidine (pf) intravenous 1 hyoscyamine sulfate oral solution 1 tablet extended release 12 hr famotidine (pf)-nacl (iso-os) 1 hyoscyamine sulfate oral intravenous piggyback 1 tablet,disintegrating famotidine intravenous 1 hyoscyamine sulfate solution 1 sublingual tablet famotidine oral suspension 1 hyosyne oral drops 1 famotidine oral tablet 1 hyosyne oral elixir 1 GATTEX 30-VIAL 3 PA intralipid intravenous SUBCUTANEOUS KIT 1 emulsion 20 % Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 101 Drug Name Tier Notes Drug Name Tier Notes INTRALIPID lidocaine-hydrocortisone-alo 1 INTRAVENOUS 3 e rectal kit 3-2.5 % (7 gram) EMULSION 30 % LINZESS ORAL 2 ipecac oral syrup 1 CAPSULE KEPIVANCE LIPOSYN II INTRAVENOUS RECON 4 INTRAVENOUS 3 SOLN EMULSION KINEVAC INJECTION liposyn iii intravenous 3 1 RECON SOLN emulsion KRISTALOSE ORAL LITHOSTAT ORAL 3 3 PACKET TABLET lactulose oral solution 1 LOMOTIL ORAL 3 lansoprazole oral TABLET capsule,delayed 3 QL loperamide oral capsule 1 release(dr/ec) LOTRONEX ORAL 3 LEVBID ORAL TABLET TABLET EXTENDED RELEASE 12 3 LOVAZA ORAL 3 ST; QL HR CAPSULE LEVSIN INJECTION MARINOL ORAL 2 3 SOLUTION CAPSULE LEVSIN ORAL TABLET 3 meclizine oral tablet 1 LEVSIN/SL 3 mesalamine rectal enema 1 SUBLINGUAL TABLET mesalamine with cleansing 1 LIALDA ORAL wipe rectal enema kit TABLET,DELAYED 2 RELEASE (DR/EC) methscopolamine oral tablet 1 metoclopramide hcl injection LIBRAX (WITH 1 CLIDINIUM) ORAL 3 solution CAPSULE metoclopramide hcl injection 1 LIDOCAINE syringe HCL-HYDROCORTISON metoclopramide hcl oral 3 1 AC RECTAL CREAM 3 solution %-1 % (7 GRAM) metoclopramide hcl oral lidocaine hcl-hydrocortison 1 1 tablet ac rectal cream 3-0.5 % metoclopramide hcl oral 1 LIDOCAINE tablet,disintegrating HCL-HYDROCORTISON 3 AC RECTAL GEL METOZOLV ODT ORAL TABLET,DISINTEGRATI 3 lidocaine hcl-hydrocortison 1 NG ac rectal kit misoprostol oral tablet 1 lidocaine-hydrocortisone-alo 1 MOTOFEN ORAL e rectal gel 3 TABLET LIDOCAINE-HYDROCO MOVIPREP ORAL RTISONE-ALOE 3 3 RECTAL KIT 2-2 % POWDER IN PACKET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 102 Drug Name Tier Notes Drug Name Tier Notes NEXIUM IV oscimin sl sublingual tablet 1 INTRAVENOUS RECON 3 oscimin sr oral tablet 1 SOLN extended release 12 hr NEXIUM ORAL OSMOPREP ORAL 3 CAPSULE,DELAYED 3 ST; QL TABLET RELEASE(DR/EC) PANCREAZE ORAL NEXIUM PACKET ORAL CAPSULE,DELAYED 3 GRANULES DR FOR 2 QL RELEASE(DR/EC) SUSP IN PACKET pantoprazole intravenous 1 QL nizatidine oral capsule 1 recon soln nizatidine oral solution 1 pantoprazole oral 1 QL NULEV ORAL tablet,delayed release (dr/ec) TABLET,DISINTEGRATI 3 paregoric oral liquid 1 QL NG peg 3350-electrolytes oral 1 NULYTELY WITH recon soln FLAVOR PACKS ORAL 3 peg-3350 with flavor packs RECON SOLN 1 oral recon soln NUTRILIPID peg-electrolyte soln oral INTRAVENOUS 3 1 EMULSION recon soln NUTRIPORT BALLOON peg-prep oral kit 1 2 KIT PENTASA ORAL OMECLAMOX-PAK CAPSULE, EXTENDED 2 3 ORAL COMBO PACK RELEASE omega-3 acid ethyl esters PEPCID ORAL 1 ST; QL 3 oral capsule SUSPENSION omeprazole oral PEPCID ORAL TABLET 3 capsule,delayed 1 QL PERTZYE ORAL release(dr/ec) CAPSULE,DELAYED 3 omeprazole-sodium RELEASE(DR/EC) 1 QL bicarbonate oral capsule phenadoz rectal suppository 1 ondansetron hcl (pf) injection 1 phenergan rectal suppository 1 solution phenobarb-hyoscy-atropine-s ondansetron hcl (pf) injection 1 1 cop oral tablet syringe phenohytro oral tablet 1 ondansetron hcl intravenous 1 polyethylene glycol 3350 solution 1 oral powder ondansetron hcl oral solution 1 QL polyethylene glycol 3350 1 ondansetron hcl oral tablet 1 QL oral powder in packet ondansetron oral 1 QL pramcort rectal cream 1 tablet,disintegrating PREPOPIK ORAL 3 opium tincture oral tincture 1 POWDER IN PACKET oscimin oral tablet 1 PREVACID ORAL oscimin oral CAPSULE,DELAYED 3 ST; QL 1 tablet,disintegrating RELEASE(DR/EC)

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 103 Drug Name Tier Notes Drug Name Tier Notes PREVACID SOLUTAB ranitidine hcl oral capsule 1 ORAL 3 ST; QL ranitidine hcl oral syrup 1 TABLET,DISINTEGRAT, DELAY REL ranitidine hcl oral tablet 1 PREVPAC ORAL RAVICTI ORAL LIQUID 3 PA; QL 3 COMBO PACK RECTIV RECTAL 3 PRILOSEC ORAL OINTMENT SUSP,DELAYED 3 QL REGLAN ORAL TABLET 3 RELEASE FOR RECON REMICADE prochlorperazine edisylate 1 INTRAVENOUS RECON 4 PA injection solution SOLN prochlorperazine maleate RESTORA RX ORAL 1 3 oral tablet CAPSULE prochlorperazine rectal 1 RESTORA SPRINKLES suppository ORAL POWDER IN 3 PROCORT RECTAL PACKET 3 CREAM ROBINUL FORTE ORAL 3 PROCTOCORT RECTAL TABLET 3 CREAM ROBINUL INJECTION 3 QL PROCTOCORT RECTAL SOLUTION 3 SUPPOSITORY ROBINUL ORAL 3 QL PROCTOFOAM HC TABLET 3 RECTAL FOAM ROWASA RECTAL 3 procto-pak rectal cream 1 ENEMA KIT proctosol hc rectal cream 1 SANCUSO TRANSDERMAL PATCH 3 QL proctozone-hc rectal cream 1 WEEKLY promethazine rectal SCOPOLAMINE HBR 1 3 suppository INJECTION SOLUTION promethegan rectal SENSURA CLICK 1 3 suppository OSTOMY POUCH propantheline oral tablet 1 SENSURA OSTOMY 3 PROTONIX BASE PLATE INTRAVENOUS RECON 3 ST SFROWASA RECTAL 3 SOLN ENEMA PROTONIX ORAL sodium phenylbutyrate oral 1 GRANULES DR FOR 3 ST; QL powder SUSP IN PACKET SUCRAID ORAL 4 PROTONIX ORAL SOLUTION TABLET,DELAYED 3 ST; QL RELEASE (DR/EC) sucralfate oral tablet 1 PYLERA ORAL sulfasalazine oral tablet 1 3 CAPSULE sulfasalazine oral 1 rabeprazole oral tablet,delayed release (dr/ec) 1 ST; QL tablet,delayed release (dr/ec) sulfazine oral tablet 1 ranitidine hcl injection 1 solution Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 104 Drug Name Tier Notes Drug Name Tier Notes SUPREP BOWEL PREP ZENPEP ORAL 3 KIT ORAL RECON SOLN CAPSULE,DELAYED 2 SYMAX DUOTAB ORAL RELEASE(DR/EC) TABLET,EXT RELEASE 3 ZOFRAN (AS MULTIPHASE HYDROCHLORIDE) 3 symax fastabs oral INTRAVENOUS 1 tablet,disintegrating SOLUTION symax-sl sublingual tablet 1 ZOFRAN (AS HYDROCHLORIDE) 3 QL symax-sr oral tablet extended 1 ORAL SOLUTION release 12 hr ZOFRAN (AS TIGAN HYDROCHLORIDE) 3 QL INTRAMUSCULAR 3 ORAL TABLET SOLUTION ZOFRAN ODT ORAL TIGAN ORAL CAPSULE 3 TABLET,DISINTEGRATI 3 QL TRANSDERM-SCOP NG TRANSDERMAL PATCH 2 ZUPLENZ ORAL FILM 3 QL 3 DAY ZYPRAM RECTAL trilyte with flavor packets 1 KIT,CREAM AND 3 oral recon soln TOWELETTE trimethobenzamide oral 1 HERBALS capsule TEARS AGAIN URSO 250 ORAL 3 HYDRATE ORAL 3 TABLET CAPSULE URSO FORTE ORAL VP-PRECIP ORAL 3 3 TABLET CAPSULE ursodiol oral capsule 1 HORMONES ursodiol oral tablet 1 ACTHAR H.P. 4 PA VARUBI ORAL TABLET 3 QL INJECTION GEL VASCAZEN ORAL ACTHREL 3 CAPSULE INTRAVENOUS RECON 3 SOLN VASCEPA ORAL 3 ST; QL ACTIVE INJECTION KIT CAPSULE 3 D INJECTION KIT VIBERZI ORAL TABLET 3 PA; QL ACTIVELLA ORAL VIOKACE ORAL 3 3 TABLET TABLET a-hydrocort injection recon VSL#3 DS ORAL 1 3 soln POWDER IN PACKET ALORA TRANSDERMAL ZANTAC INJECTION 3 3 PATCH SEMIWEEKLY SOLUTION ANADROL-50 ORAL 3 ZANTAC ORAL TABLET 3 TABLET ZEGERID ORAL 3 ST; QL ANDRODERM CAPSULE TRANSDERMAL PATCH 3 PA; QL ZEGERID ORAL 24 HOUR 3 ST; QL PACKET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 105 Drug Name Tier Notes Drug Name Tier Notes ANDROGEL budesonide oral TRANSDERMAL GEL IN capsule,delayed,extend.releas 1 METERED-DOSE PUMP 3 PA; QL e 1.25 GRAM/ ACTUATION cabergoline oral tablet 1 (1 %) calcitonin (salmon) nasal 1 QL ANDROGEL spray,non-aerosol TRANSDERMAL GEL IN METERED-DOSE PUMP 2 PA; QL CELESTONE SOLUSPAN 20.25 MG/1.25 GRAM INJECTION 3 (1.62 %) SUSPENSION ANDROGEL CERVIDIL VAGINAL TRANSDERMAL GEL IN INSERT, EXTENDED 3 PACKET 1 % (25 3 PA; QL RELEASE MG/2.5GRAM), 1 % (50 CETROTIDE 4 PA MG/5 GRAM) SUBCUTANEOUS KIT ANDROGEL chorionic gonadotropin, TRANSDERMAL GEL IN human intramuscular recon 4 PA PACKET 1.62 % (20.25 2 PA; QL soln MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) CLIMARA PRO TRANSDERMAL PATCH 2 ANDROID ORAL 3 WEEKLY CAPSULE CLIMARA androxy oral tablet 1 TRANSDERMAL PATCH 3 ANGELIQ ORAL WEEKLY 3 TABLET clomiphene citrate oral tablet 1 PA ARISTOSPAN colocort rectal enema 1 INTRA-ARTICULAR 3 INJECTION COMBIPATCH SUSPENSION TRANSDERMAL PATCH 2 SEMIWEEKLY ARISTOSPAN INTRALESIONAL CORTEF ORAL TABLET 3 3 INJECTION CORTENEMA RECTAL 3 SUSPENSION ENEMA AVEED CORTIFOAM RECTAL 3 INTRAMUSCULAR 3 FOAM SOLUTION cortisone oral tablet 1 AXIRON CORTROSYN TRANSDERMAL 3 PA; QL INJECTION RECON 3 SOLUTION IN SOLN METERED PUMP W/APP cosyntropin injection recon AYGESTIN ORAL 1 3 soln TABLET COSYNTROPIN BETA-1 INJECTION KIT 3 INTRAVENOUS 3 betamethasone acet,sod phos SOLUTION 1 injection suspension covaryx h.s. oral tablet 1 BRAVELLE INJECTION 4 ST covaryx oral tablet 1 RECON SOLN CRINONE VAGINAL 4 PA GEL Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 106 Drug Name Tier Notes Drug Name Tier Notes danazol oral capsule 1 DEXPAK 6 DAY ORAL 3 DDAVP INJECTION TABLETS,DOSE PACK 3 SOLUTION DIVIGEL DDAVP NASAL TRANSDERMAL GEL IN 2 3 AEROSOL,SPRAY PACKET DDAVP NASAL DOUBLEDEX 3 3 SOLUTION INJECTION KIT DDAVP ORAL TABLET 3 DUAVEE ORAL TABLET 3 DELESTROGEN eemt hs oral tablet 1 3 INTRAMUSCULAR OIL eemt oral tablet 1 deltasone oral tablet 1 EGRIFTA DEPO-ESTRADIOL SUBCUTANEOUS 4 PA; QL 3 INTRAMUSCULAR OIL RECON SOLN 1 MG DEPO-MEDROL EGRIFTA INJECTION 3 SUBCUTANEOUS 4 PA SUSPENSION RECON SOLN 2 MG DEPO-PROVERA ELESTRIN INTRAMUSCULAR 3 PA TRANSDERMAL GEL IN 3 SOLUTION METERED-DOSE PUMP DEPO-TESTOSTERONE ENDOMETRIN 3 3 INTRAMUSCULAR OIL VAGINAL INSERT desmopressin injection ENJUVIA ORAL TABLET 3 1 solution ENTOCORT EC ORAL desmopressin nasal CAPSULE,DELAYED,EX 3 1 aerosol,spray TEND.RELEASE ESTRACE ORAL desmopressin nasal solution 1 3 TABLET desmopressin nasal 1 ESTRACE VAGINAL spray,non-aerosol 3 CREAM desmopressin oral tablet 1 estradiol oral tablet 1 dexamethasone intensol oral 1 estradiol transdermal patch drops 1 semiweekly dexamethasone oral elixir 1 estradiol transdermal patch 1 dexamethasone oral solution 1 weekly dexamethasone oral tablet 1 estradiol valerate 1 dexamethasone sodium phos intramuscular oil 1 (pf) injection solution estradiol-norethindrone acet 1 dexamethasone sodium oral tablet 1 phosphate injection solution ESTRING VAGINAL 2 dexamethasone sodium RING 1 phosphate injection syringe ESTROGEL DEXPAK 10 DAY ORAL TRANSDERMAL GEL IN 3 3 TABLETS,DOSE PACK METERED-DOSE PUMP DEXPAK 13 DAY ORAL estrogens-methyltestosterone 3 1 TABLETS,DOSE PACK oral tablet

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 107 Drug Name Tier Notes Drug Name Tier Notes estropipate oral tablet 1 HUMATROPE EVAMIST INJECTION RECON 4 PA TRANSDERMAL 2 SOLN SPRAY,NON-AEROSOL hydrocortisone oral tablet 1 FEMHRT LOW DOSE hydrocortisone rectal enema 1 3 ORAL TABLET INCRELEX FEMRING VAGINAL SUBCUTANEOUS 4 PA 3 RING SOLUTION fludrocortisone oral tablet 1 jevantique lo oral tablet 1 FOLLISTIM AQ jinteli oral tablet 1 4 PA INJECTION SOLUTION KENALOG INJECTION 3 FOLLISTIM AQ SUSPENSION SUBCUTANEOUS 4 PA lopreeza oral tablet 1 CARTRIDGE LUPANETA PACK (1 FORTESTA MONTH) KIT. SYRINGE 4 PA TRANSDERMAL GEL IN 3 PA; QL AND TABLET METERED-DOSE PUMP LUPANETA PACK (3 fortical nasal 1 QL MONTH) KIT. SYRINGE 4 PA spray,non-aerosol AND TABLET fyavolv oral tablet 1 LUPRON DEPOT (3 GANIRELIX MONTH) 4 PA SUBCUTANEOUS 4 PA INTRAMUSCULAR SYRINGE SYRINGE KIT GENOTROPIN LUPRON DEPOT MINIQUICK INTRAMUSCULAR 4 PA; QL 4 PA SUBCUTANEOUS SYRINGE KIT SYRINGE LUPRON DEPOT-PED (3 GENOTROPIN MONTH) 4 PA SUBCUTANEOUS 4 PA INTRAMUSCULAR CARTRIDGE SYRINGE KIT GONAL-F RFF LUPRON DEPOT-PED REDI-JECT INTRAMUSCULAR KIT 4 PA 4 ST SUBCUTANEOUS PEN 11.25 MG, 15 MG INJECTOR LUPRON DEPOT-PED GONAL-F RFF INTRAMUSCULAR KIT 4 PA; QL SUBCUTANEOUS 4 ST 7.5 MG (PED) RECON SOLN MAKENA GONAL-F INTRAMUSCULAR OIL 4 PA SUBCUTANEOUS 4 ST 250 MG/ML RECON SOLN MAKENA HEMABATE INTRAMUSCULAR OIL 4 INTRAMUSCULAR 3 250 MG/ML (1 ML) SOLUTION MEDROL (PAK) ORAL 3 HUMATROPE TABLETS,DOSE PACK INJECTION 4 PA MEDROL ORAL CARTRIDGE TABLET 16 MG, 32 MG, 4 3 MG, 8 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 108 Drug Name Tier Notes Drug Name Tier Notes MEDROL ORAL MYALEPT 2 TABLET 2 MG SUBCUTANEOUS 4 medroxyprogesterone oral RECON SOLN 1 tablet NATESTO NASAL GEL MENEST ORAL TABLET 2 IN METERED-DOSE 3 PA; QL PUMP MENOPUR SUBCUTANEOUS 4 PA NATPARA RECON SOLN SUBCUTANEOUS 3 PA; QL CARTRIDGE MENOSTAR TRANSDERMAL PATCH 3 NORDITROPIN FLEXPRO WEEKLY 4 PA SUBCUTANEOUS PEN methergine oral tablet 1 INJECTOR METHITEST ORAL norethindrone acetate oral 3 1 TABLET tablet METHYLERGONOVINE norethindrone ac-eth 3 1 INJECTION SOLUTION estradiol oral tablet methylergonovine oral tablet 1 novarel intramuscular recon 4 PA methylprednisolone acetate soln 1 injection suspension NUTROPIN AQ NUSPIN methylprednisolone oral SUBCUTANEOUS PEN 4 PA 1 tablet INJECTOR methylprednisolone oral NUTROPIN AQ 1 tablets,dose pack SUBCUTANEOUS 4 PA CARTRIDGE methylprednisolone sodium 1 octreotide acetate injection succ injection recon soln 4 PA solution methylprednisolone sodium 1 octreotide acetate injection succ intravenous recon soln 4 PA syringe methyltestosterone oral 1 capsule OMNITROPE SUBCUTANEOUS 4 PA MIACALCIN INJECTION 4 CARTRIDGE SOLUTION OMNITROPE MIACALCIN NASAL 3 QL SUBCUTANEOUS 4 PA SPRAY,NON-AEROSOL RECON SOLN millipred dp oral tablets,dose 1 ORAPRED ODT ORAL pack TABLET,DISINTEGRATI 3 PA MILLIPRED ORAL NG 3 SOLUTION OVIDREL millipred oral tablet 1 SUBCUTANEOUS 4 PA mimvey lo oral tablet 1 SYRINGE OXANDRIN ORAL mimvey oral tablet 1 3 PA TABLET MINIVELLE TRANSDERMAL PATCH 3 oxandrolone oral tablet 1 PA SEMIWEEKLY oxytocin injection solution 1 PEDIAPRED ORAL 3 SOLUTION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 109 Drug Name Tier Notes Drug Name Tier Notes PITOCIN INJECTION PROVERA ORAL 3 3 SOLUTION TABLET prednisolone oral solution 1 RAYOS ORAL prednisolone sodium TABLET,DELAYED 3 1 phosphate oral solution RELEASE (DR/EC) prednisolone sodium SAIZEN CLICK.EASY phosphate oral 1 SUBCUTANEOUS 4 PA tablet,disintegrating CARTRIDGE prednisone intensol oral SAIZEN 1 concentrate SUBCUTANEOUS 4 PA RECON SOLN prednisone oral solution 1 SANDOSTATIN 4 PA prednisone oral tablet 1 INJECTION SOLUTION prednisone oral tablets,dose 1 SANDOSTATIN LAR pack DEPOT 4 PA PREFEST ORAL INTRAMUSCULAR KIT 3 TABLET SANDOSTATIN LAR PREGNYL DEPOT INTRAMUSCULAR 4 PA INTRAMUSCULAR 4 PA RECON SOLN SUSPENSION,EXTENDE D REL RECON PREMARIN INJECTION 2 RECON SOLN serophene oral tablet 1 PA PREMARIN ORAL SEROSTIM 2 TABLET SUBCUTANEOUS 4 PA RECON SOLN PREMARIN VAGINAL 2 CREAM SIGNIFOR LAR INTRAMUSCULAR PREMPHASE ORAL 4 2 SUSPENSION FOR TABLET RECONSTITUTION PREMPRO ORAL 2 SIGNIFOR TABLET SUBCUTANEOUS 4 PA PREPIDIL VAGINAL SOLUTION 3 GEL SOLU-CORTEF (PF) PRO-C-DURE 5 INJECTION RECON 3 3 INJECTION KIT SOLN PRO-C-DURE 6 SOLU-CORTEF 3 INJECTION KIT INJECTION RECON 3 progesterone in oil SOLN 1 intramuscular oil SOLU-MEDROL (PF) progesterone intramuscular INJECTION RECON 3 1 oil SOLN progesterone micronized oral SOLU-MEDROL (PF) 1 capsule INTRAVENOUS RECON 3 SOLN PROMETRIUM ORAL 3 CAPSULE SOLU-MEDROL INTRAVENOUS RECON 3 PROSTIN E2 VAGINAL 3 SOLN SUPPOSITORY

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 110 Drug Name Tier Notes Drug Name Tier Notes SOMATULINE DEPOT VASOSTRICT SUBCUTANEOUS 4 INTRAVENOUS 3 SYRINGE SOLUTION STIMATE NASAL veripred 20 oral solution 1 3 SPRAY,NON-AEROSOL VIVELLE-DOT STRIANT BUCCAL TRANSDERMAL PATCH 3 MUCOADHESIVE 3 PA; QL SEMIWEEKLY SYSTEM ER 12 HR VOGELXO 3 PA; QL SUPPRELIN LA TRANSDERMAL GEL 4 PA IMPLANT KIT VOGELXO SYNAREL NASAL TRANSDERMAL GEL IN 3 PA; QL 4 PA SPRAY,NON-AEROSOL METERED-DOSE PUMP TESTIM VOGELXO 3 PA; QL TRANSDERMAL GEL TRANSDERMAL GEL IN 3 PA; QL TESTONE CIK PACKET 3 INTRAMUSCULAR KIT ZOMACTON TESTOPEL IMPLANT SUBCUTANEOUS 4 PA 3 PA PELLET RECON SOLN testosterone cypionate ZORBTIVE 1 intramuscular oil SUBCUTANEOUS 4 PA RECON SOLN testosterone enanthate 1 intramuscular oil IMMUNOSUPPRESANT TESTOSTERONE ACTEMRA 3 PA; QL TRANSDERMAL GEL INTRAVENOUS 4 PA SOLUTION TESTOSTERONE TRANSDERMAL GEL IN 3 PA; QL ACTEMRA METERED-DOSE PUMP SUBCUTANEOUS 4 PA SYRINGE testosterone transdermal gel in packet 1 % (25 1 PA; QL ASTAGRAF XL ORAL mg/2.5gram) CAPSULE,EXTENDED 3 PA RELEASE 24HR TESTOSTERONE TRANSDERMAL GEL IN AZASAN ORAL TABLET 2 PA 3 PA; QL PACKET 1 % (50 MG/5 azathioprine oral tablet 1 PA GRAM) CELLCEPT TESTRED ORAL INTRAVENOUS 3 3 PA CAPSULE INTRAVENOUS RECON triamcinolone acetonide SOLN 1 injection suspension CELLCEPT ORAL 2 PA UCERIS ORAL CAPSULE TABLET,DELAYED AND 3 CELLCEPT ORAL EXT.RELEASE SUSPENSION FOR 2 PA VAGIFEM VAGINAL RECONSTITUTION 2 TABLET CELLCEPT ORAL 2 PA vasopressin injection solution 1 TABLET cyclosporine intravenous 1 PA solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 111 Drug Name Tier Notes Drug Name Tier Notes cyclosporine modified oral SANDIMMUNE ORAL 1 PA 2 PA capsule CAPSULE cyclosporine modified oral SANDIMMUNE ORAL 1 PA 2 PA solution SOLUTION cyclosporine oral capsule 1 PA SIMULECT ELIDEL TOPICAL INTRAVENOUS RECON 3 PA 2 ST CREAM SOLN ENVARSUS XR ORAL sirolimus oral tablet 1 PA TABLET EXTENDED 3 PA STELARA RELEASE 24 HR SUBCUTANEOUS 4 PA; QL gengraf oral capsule 1 PA SYRINGE gengraf oral solution 1 PA tacrolimus oral capsule 1 PA IMURAN ORAL TABLET 3 PA tacrolimus topical ointment 1 ST mycophenolate mofetil oral ZORTRESS ORAL 1 PA 2 PA capsule TABLET mycophenolate mofetil oral MISCELLANEOUS 1 PA suspension for reconstitution MEDICAL SUPPLIES, DEVICES, NON-DRUG mycophenolate mofetil oral 1 PA 1ST TIER UNILET tablet 2 COMFORTOUCH mycophenolate sodium oral 1 PA tablet,delayed release (dr/ec) ACCU-CHEK FASTCLIX 2 ACCU-CHEK FASTCLIX MYFORTIC ORAL 2 TABLET,DELAYED 3 PA KIT RELEASE (DR/EC) ACCU-CHEK 2 NEORAL ORAL MULTICLIX LANCET 2 PA CAPSULE ACCU-CHEK NEORAL ORAL MULTICLIX LANCET 2 2 PA SOLUTION KIT ACCU-CHEK NULOJIX 2 INTRAVENOUS RECON 3 PA SAFE-T-PRO SOLN ACCU-CHEK 2 PROGRAF SAFE-T-PRO PLUS INTRAVENOUS 2 PA ACCU-CHEK SOFT DEV 2 SOLUTION LANCETS KIT PROGRAF ORAL ACCU-CHEK SOFTCLIX 2 PA 2 CAPSULE LANCETS PROTOPIC TOPICAL acti-lance lancets 17 gauge, 3 ST 1 OINTMENT 28 gauge RAPAMUNE ORAL ACTI-LANCE LANCETS 2 PA 2 SOLUTION 23 GAUGE RAPAMUNE ORAL ADVANCED LANCING 2 PA 2 TABLET DEVICE KIT SANDIMMUNE ADVANCED TRAVEL 2 INTRAVENOUS 3 PA LANCETS SOLUTION ADVOCATE LANCET 2

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 112 Drug Name Tier Notes Drug Name Tier Notes ALTERNATE SITE FINGERSTIX LANCETS 2 2 LANCET FIRST CHOICE 2 ASSURE HAEMOLANCE LANCETS THIN 2 PLUS FORA V10-V12-D10-D20 3 ASSURE LANCE 2 COMBO PACK ASSURE LANCE PLUS 2 FORACARE LANCETS 2 AUTOLET IMPRESSION FREESTYLE LANCETS 2 2 LANC DEV KIT FREESTYLE UNISTIK 2 2 BD MICROTAINER 2 GLUCOCOM LANCETS 2 LANCET GLUCOLET 2 BD ULTRA FINE 2 AUTOMATIC LANCING 2 LANCETS KIT BD ULTRA-FINE II 2 GMATE LANCETS 2 LANCETS HEALTHY ACCENTS BULLSEYE MINI 2 2 UNILET LANCET SAFETY LANCETS HYPOLANCE AST CAREONE THIN 2 2 LANCING KIT LANCET INCONTROL SUPER CAREONE ULTRA THIN 2 2 THIN LANCETS LANCET INCONTROL ULTRA CLEVER CHEK 2 2 THIN LANCETS LANCETS INJECT EASE LANCETS 2 COAGUCHEK LANCETS 2 INVACARE LANCETS 2 COLOR LANCETS 2 KINNEY BRAND 2 COMFORT LANCETS 2 LANCETS DROPLET LANCETS 2 LANCETS 2 EASY COMFORT 2 LANCETS, SUPER THIN 2 LANCETS LANCETS,THIN 2 EASY TOUCH LANCETS 2 LANCETS,ULTRA THIN 2 EASY TOUCH SAFETY 2 LANCING DEVICE LANCETS 2 WITH LANCETS KIT EASY TOUCH TWIST 2 LANZO LANCING LANCETS 3 DEVICE KIT EASY TWIST AND CAP 2 LANCETS LITE TOUCH LANCETS 2 MEDISENSE THIN EMBRACE LANCETS 2 2 LANCETS e-z ject lancets 1 MEDLANCE PLUS E-Z JECT THIN 2 2 LANCETS LANCETS MICRO THIN LANCETS 2 EZ SMART LANCETS 2 MICROLET 2 LANCING FIFTY50 SAFETY SEAL 2 2 DEVICE KIT LANCETS MICROLET LANCET 2 FINE 30 UNIVERSAL 2 LANCETS MONOLET LANCETS 2 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 113 Drug Name Tier Notes Drug Name Tier Notes MONOLET THIN SOLUS V2 LANCING 2 2 LANCETS DEVICE KIT MULTI-LANCET STERILANCE TL 2 2 DEVICE 2 KIT SUPER THIN LANCETS 2 MYGLUCOHEALTH SURE COMFORT 2 2 LANCETS LANCETS NOVA SAFETY SUREFLEX DEVICE 2 2 LANCETS WITH LANCETS KIT NOVA SUREFLEX 2 SURE-LANCE 2 LANCETS SURE-LANCE ULTRA 2 ON CALL LANCET 2 THIN ON CALL PLUS LANCET 2 SURE-TOUCH LANCET 2 ONETOUCH DELICA 2 TECHLITE LANCETS 2 LANC DEVICE KIT TELCARE LANCETS 2 ONETOUCH DELICA 2 LANCETS THIN LANCETS 2 ONETOUCH SURESOFT TOPCARE UNIVERSAL1 2 2 LANCING DEV LANCET ONETOUCH TRUEPLUS LANCETS 2 2 ULTRASOFT LANCETS ULTI-LANCE KIT 2 ON-THE-GO LANCETS 2 ULTILET BASIC 2 PRESSURE ACTIVATED LANCETS 2 LANCETS ULTILET CLASSIC 2 PRODIGY LANCETS 2 LANCETS PRODIGY TWIST TOP ULTILET LANCETS 2 2 LANCET ULTILET SAFETY 2 RELIAMED LANCET 2 LANCETS RELIAMED SAFETY ULTRA THIN II 2 2 SEAL LANCETS LANCETS RELION THIN LANCETS 2 ULTRA THIN LANCETS 2 RELION ULTRA THIN ULTRA THIN PLUS 2 2 PLUS LANCETS LANCETS RIGHTEST GL300 ULTRA TLC LANCETS 2 2 LANCETS ULTRALANCE 2 SAFETY LANCETS 2 LANCETS ULTRA-THIN II SAFETY SEAL LANCETS 2 2 LANCETS SAFETY-LET LANCETS 2 UNILET SINGLE-LET 2 COMFORTOUCH 2 SMART SENSE LANCET 2 LANCETS UNILET EXCELITE II 2 SMARTEST LANCET 2 LANCET SOFT TOUCH LANCETS 2 UNILET EXCELITE 2 SOLUS V2 LANCETS 2 LANCET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 114 Drug Name Tier Notes Drug Name Tier Notes UNILET GP LANCET 2 DANTRIUM UNILET LANCET 2 INTRAVENOUS RECON 3 SOLN UNILET LANCETS 2 DANTRIUM ORAL UNILET SUPER THIN 3 2 CAPSULE LANCETS dantrolene oral capsule 1 UNISTIK 2 DEVICE KIT 2 FEXMID ORAL TABLET 3 UNISTIK 2 NORMAL 2 LANCET,DEVICE KIT GABLOFEN INTRATHECAL 4 UNISTIK 3 COMFORT 2 SOLUTION DEVICE KIT GABLOFEN UNISTIK 3 COMFORT 2 INTRATHECAL 4 LANCET SYRINGE UNISTIK 3 EXTRA 2 LIORESAL LANCET INTRATHECAL 3 UNISTIK 3 GENTLE 2 SOLUTION LORZONE ORAL UNISTIK 3 KIT 2 3 TABLET UNISTIK 3 LANCETS 2 metaxall oral tablet 1 UNISTIK 3 NEONATAL 2 DEVICE KIT metaxalone oral tablet 1 UNISTIK 3 NEONATAL methocarbamol injection 2 1 KIT solution UNISTIK 3 NORMAL methocarbamol oral tablet 1 2 LANCET orphenadrine citrate injection 1 UNISTIK CZT LANCET 2 solution orphenadrine citrate oral UNISTIK SAFETY 2 1 tablet extended release UNISTIK TOUCH 2 PARAFON FORTE DSC LANCETS 3 QL ORAL TABLET UNIVERSAL 1 LANCETS 2 revonto intravenous recon MUSCLE RELAXANTS 1 soln AMRIX ORAL ROBAXIN INJECTION 3 QL CAPSULE,EXTENDED 3 SOLUTION RELEASE 24HR ROBAXIN ORAL 3 QL baclofen oral tablet 1 TABLET carisoprodol oral tablet 1 ROBAXIN-750 ORAL 3 QL carisoprodol-aspirin oral TABLET 1 tablet RYANODEX chlorzoxazone oral tablet 1 INTRAVENOUS 3 COMFORT SUSPENSION FOR PAC-CYCLOBENZAPRIN 3 RECONSTITUTION E KIT SKELAXIN ORAL 3 COMFORT TABLET 3 PAC-TIZANIDINE KIT SOMA ORAL TABLET 3 cyclobenzaprine oral tablet 1 tizanidine oral capsule 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 115 Drug Name Tier Notes Drug Name Tier Notes tizanidine oral tablet 1 dothelle dha oral capsule 1 ZANAFLEX ORAL DUET DHA BALANCED 3 3 CAPSULE ORAL COMBO PACK ZANAFLEX ORAL DUET DHA WITH 3 TABLET OMEGA-3 ORAL 3 PRE-NATAL VITAMINS COMBO PACK ACTIVE OB ORAL elite-ob 400 oral capsule 1 3 CAPSULE elite-ob oral capsule 1 ATABEX EC ORAL ENBRACE HR ORAL TABLET,DELAYED 2 CAPSULE,IR - DELAY 3 RELEASE (DR/EC) REL,BIPHASE BAL-CARE DHA EXTRA-VIRT PLUS DHA 2 ESSENTIAL ORAL ORAL CAPSULE 3 COMBO PACK,TABLET focalgin 90 dha oral combo 1 AND CAP,DR pack bal-care dha oral combo 1 focalgin ca oral combo pack 1 pack,tablet and cap,dr folbecal oral tablet, er CADEAU DHA ORAL 1 3 multiphase 24 hr CAPSULE FOLET DHA ORAL 3 calcium pnv oral capsule 1 COMBO PACK CITRANATAL FOLET ONE ORAL 3 (DUAL-IRON) ORAL 3 CAPSULE TABLET folivane-ob oral capsule 1 CITRANATAL 90 DHA hemenatal ob + dha oral (ALGAL OIL) ORAL 3 1 COMBO PACK combo pack CITRANATAL ASSURE hemenatal ob oral tablet 1 3 ORAL COMBO PACK inatal advance oral tablet 1 CITRANATAL B-CALM inatal ultra oral tablet 1 (FE GLUC) ORAL 3 levomefolate dha oral TABLETS, SEQUENTIAL 1 capsule CITRANATAL DHA (ALGAL OIL) ORAL 3 macnatal cn dha oral capsule 1 COMBO PACK MARNATAL-F ORAL 3 CITRANATAL CAPSULE HARMONY (IRON FUM) 3 MAXINATE ORAL 3 ORAL CAPSULE TABLET c-nate dha oral capsule 1 M-VIT ORAL TABLET 3 complete natal dha oral mynatal advance oral tablet 1 1 combo pack mynatal oral capsule 1 completenate oral 1 mynatal oral tablet 1 tablet,chewable mynatal plus oral tablet 1 CONCEPT DHA ORAL 3 CAPSULE mynatal-z oral tablet 1 CONCEPT OB ORAL mynate 90 plus oral tablet 3 1 CAPSULE extended release Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 116 Drug Name Tier Notes Drug Name Tier Notes NATACHEW (FE PAIRE OB PLUS DHA 3 BIS-GLYCINATE) ORAL 3 ORAL COMBO PACK TABLET,CHEWABLE pnv 29-1 oral tablet 1 NATALVIT ORAL 3 pnv ob+dha oral combo pack 1 TABLET pnv-dha + docusate oral NATELLE ONE ORAL 1 3 capsule CAPSULE pnv-dha oral capsule 1 NEEVODHA (WITH pnv-ferrous fumarate-docu-fa ALGAL OIL) ORAL 3 1 CAPSULE oral tablet NESTABS ABC ORAL pnv-omega oral capsule 1 3 COMBO PACK pnv-select oral tablet 1 NESTABS DHA ORAL 3 pnv-vp-u oral capsule 1 COMBO PACK pr natal 400 ec oral combo NESTABS ORAL 1 3 pack,tablet and cap,dr TABLET pr natal 400 oral combo pack 1 newgen oral tablet 1 pr natal 430 ec oral combo NEXA PLUS ORAL 1 3 pack,tablet and cap,dr CAPSULE pr natal 430 oral combo pack 1 NIVA-PLUS ORAL 3 PREFERA-OB ONE TABLET 3 ORAL CAPSULE OB COMPLETE GOLD 3 PREFERA-OB ORAL ORAL CAPSULE 3 TABLET OB COMPLETE ONE 3 PREFERA-OB PLUS DHA ORAL CAPSULE 3 ORAL COMBO PACK OB COMPLETE ORAL 3 prena1 chew oral TABLET 1 tablet,chew,ir - dr,biphase OB COMPLETE PETITE 3 prena1 pearl oral capsule,ir - ORAL CAPSULE 1 delay rel,biphase OB COMPLETE PREMIER ORAL 3 prenaissance next oral tablet 1 TABLET prenaissance oral capsule 1 OB COMPLETE WITH prenaissance plus oral 3 1 DHA ORAL CAPSULE capsule obstetrix dha oral combo PRENATA ORAL 1 3 pack,tablet and cap,dr TABLET,CHEWABLE OBSTETRIX EC ORAL prenatabs fa oral tablet 1 TABLET,DELAYED 3 prenatabs rx oral tablet 1 RELEASE (DR/EC) PRENATAL 19 (WITH OBTREX DHA ORAL DOCUSATE) ORAL 3 COMBO PACK,TABLET 3 TABLET AND CAP,DR PRENATAL 19 ORAL O-CAL FA ORAL 3 3 TABLET,CHEWABLE TABLET prenatal low iron oral tablet 1 O-CAL PRENATAL 3 ORAL TABLET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 117 Drug Name Tier Notes Drug Name Tier Notes prenatal plus (calcium carb) PROVIDA OB ORAL 1 3 oral tablet CAPSULE prenatal plus oral tablet 1 PUREFE OB PLUS ORAL 3 prenatal vitamin plus low CAPSULE 1 iron oral tablet PUREFE PLUS ORAL 3 prenatal-u oral capsule 1 CAPSULE PRENATE AM ORAL relnate dha oral capsule 1 3 TABLET R-NATAL OB ORAL 3 QL PRENATE CHEWABLE CAPSULE ORAL 3 rulavite dha oral capsule 1 TABLET,CHEWABLE SELECT-OB (FOLIC PRENATE DHA (FERR ACID) ORAL 3 ASP GLYCIN) ORAL 3 TABLET,CHEWABLE CAPSULE SELECT-OB + DHA 3 PRENATE DHA ORAL ORAL COMBO PACK 3 CAPSULE SELECT-OB ORAL 3 PRENATE ELITE (IRON TABLET,CHEWABLE ASP GLYC) ORAL 3 se-natal 19 (with docusate) 1 TABLET oral tablet PRENATE ELITE ORAL se-natal 19 oral 3 1 TABLET tablet,chewable PRENATE ENHANCE 3 se-tan dha oral capsule 1 ORAL CAPSULE taron-c dha oral capsule 1 PRENATE ESSENTIAL 3 taron-prex prenatal-dha oral ORAL CAPSULE 1 capsule PRENATE THRIVITE RX ORAL ESSENTIAL(IRON-ASP-G 3 3 L) ORAL CAPSULE TABLET PRENATE MINI (FERR thrivite-19 oral tablet 1 ASP GLYCIN) ORAL 3 tl-select oral capsule 1 CAPSULE triadvance oral tablet 1 QL PRENATE MINI ORAL 3 TRICARE ORAL CAPSULE 3 TABLET PRENATE PIXIE ORAL 3 CAPSULE TRICARE PRENATAL DHA ONE ORAL 3 PRENATE RESTORE 3 CAPSULE ORAL CAPSULE trinatal gt oral tablet 1 PRENATE STAR ORAL 3 TABLET trinatal rx 1 oral tablet 1 preplus oral tablet 1 trinate oral tablet 1 PREQUE 10 ORAL TRISTART DHA ORAL 3 3 TABLET CAPSULE pretab oral tablet 1 tri-tabs dha oral combo pack 1 PROVIDA DHA ORAL triveen-duo dha oral combo 3 1 CAPSULE pack triveen-one oral capsule 1 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 118 Drug Name Tier Notes Drug Name Tier Notes triveen-prx rnf oral capsule 1 VITAFOL ULTRA ORAL 3 trust natal dha oral combo CAPSULE 1 pack vitafol-ob oral tablet 1 ultimatecare one nf oral VITAFOL-OB+DHA 1 3 capsule ORAL COMBO PACK ultimatecare one oral capsule 1 VITAFOL-ONE ORAL 3 vemavite-prx-2 oral capsule 1 CAPSULE vena-bal dha oral combo VITAMED MD ONE RX 1 3 pack,tablet and cap,dr ORAL CAPSULE VITAMED MD PLUS RX vinacal oral tablet 1 3 ORAL COMBO PACK vinate care oral 1 tablet,chewable VITAMEDMD REDICHEW RX ORAL 3 vinate dha oral capsule 1 TABLET,CHEW,IR - VINATE DHA RF ORAL DR,BIPHASE 3 CAPSULE VITAPEARL ORAL vinate gt oral tablet 1 CAPSULE,IR - DELAY 3 REL,BIPHASE vinate ii oral tablet 1 VITATRUE ORAL 3 vinate m oral tablet 1 COMBO PACK vinate one oral tablet 1 VIVA DHA ORAL 3 vinate pn care oral tablet 1 CAPSULE vinate ultra oral tablet 1 vol-nate oral tablet 1 virt nate oral tablet 1 vol-plus oral tablet 1 virt-advance oral tablet 1 vol-tab rx oral tablet 1 virt-c dha oral capsule 1 vp-ch plus oral capsule 1 virt-care one oral capsule 1 vp-ch-pnv oral capsule 1 virt-nate dha oral capsule 1 vp-ggr-b6 oral tablet 1 virt-nate oral tablet 1 vp-heme ob + dha oral 1 virt-pn dha oral capsule 1 combo pack virt-pn oral tablet 1 vp-heme ob oral tablet 1 virt-pn plus oral capsule 1 vp-heme one oral capsule 1 VIRTPREX ORAL VP-PNV-DHA ORAL 3 3 CAPSULE CAPSULE virt-select oral capsule 1 zatean-ch oral capsule 1 virt-vite gt oral tablet 1 zatean-pn dha oral capsule 1 VITAFOL FE+ (WITH zatean-pn plus oral capsule 1 DOCUSATE) ORAL 3 zingiber oral tablet 1 CAPSULE PSYCHOTHERAPEUTIC VITAFOL GUMMIES DRUGS ORAL 3 ABILIFY MAINTENA TABLET,CHEWABLE INTRAMUSCULAR 3 VITAFOL NANO ORAL SUSPENSION,EXTENDE 3 TABLET D REL RECON Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 119 Drug Name Tier Notes Drug Name Tier Notes ABILIFY MAINTENA BRISDELLE ORAL 3 INTRAMUSCULAR CAPSULE 3 SUSPENSION,EXTENDE bupropion hcl oral tablet 100 1 QL D REL SYRING mg ABILIFY ORAL TABLET 3 bupropion hcl oral tablet 75 1 DO ADASUVE INHALATION mg AEROSOL POWDR 3 bupropion hcl oral tablet 1 DO BREATH ACTIVATED extended release 100 mg ADDYI ORAL TABLET 3 PA; QL bupropion hcl oral tablet 1 QL alprazolam intensol oral extended release 150 mg 1 concentrate bupropion hcl oral tablet 1 alprazolam oral tablet 1 extended release 200 mg alprazolam oral tablet bupropion hcl oral tablet 1 extended release 24 hr extended release 24 hr 150 1 DO alprazolam oral mg 1 tablet,disintegrating bupropion hcl oral tablet amitriptyline oral tablet 1 extended release 24 hr 300 1 QL mg amitriptyline-chlordiazepoxi 1 de oral tablet buspirone oral tablet 1 CELEXA ORAL TABLET amoxapine oral tablet 1 3 ST; DO 10 MG, 20 MG ANAFRANIL ORAL 3 CELEXA ORAL TABLET CAPSULE 3 ST; QL 40 MG APLENZIN ORAL chlordiazepoxide hcl oral TABLET EXTENDED 3 DO 1 RELEASE 24 HR 174 MG capsule chlorpromazine injection APLENZIN ORAL 1 TABLET EXTENDED solution 3 QL RELEASE 24 HR 348 MG, chlorpromazine oral tablet 1 PA 522 MG citalopram oral solution 1 QL APTENSIO XR ORAL citalopram oral tablet 10 mg, CAP,ER 1 DO 3 ST 20 mg SPRINKLE,BIPHASIC 40-60 citalopram oral tablet 40 mg 1 QL aripiprazole oral solution 1 PA clomipramine oral capsule 1 clonidine hcl oral tablet aripiprazole oral tablet 1 PA 1 extended release 12 hr aripiprazole oral 1 PA clorazepate dipotassium oral tablet,disintegrating 1 tablet ARISTADA INTRAMUSCULAR clozapine oral tablet 1 PA 3 SUSPENSION,EXTENDE clozapine oral D REL SYRING tablet,disintegrating 100 mg, 1 PA ATIVAN ORAL TABLET 3 12.5 mg, 25 mg BRINTELLIX ORAL CLOZAPINE ORAL 3 ST; DO TABLET 10 MG, 5 MG TABLET,DISINTEGRATI 3 PA NG 150 MG, 200 MG BRINTELLIX ORAL 3 ST; QL TABLET 20 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 120 Drug Name Tier Notes Drug Name Tier Notes CLOZARIL ORAL doxepin oral capsule 1 2 PA TABLET doxepin oral concentrate 1 CONCERTA ORAL droperidol injection solution 1 TABLET EXTENDED 3 ST RELEASE 24HR duloxetine oral capsule,delayed 1 QL CYMBALTA ORAL release(dr/ec) 20 mg, 40 mg, CAPSULE,DELAYED 3 QL 60 mg RELEASE(DR/EC) 20 MG, 60 MG duloxetine oral capsule,delayed 1 DO CYMBALTA ORAL release(dr/ec) 30 mg CAPSULE,DELAYED 3 DO RELEASE(DR/EC) 30 MG EFFEXOR XR ORAL CAPSULE,EXTENDED 3 QL DAYTRANA RELEASE 24HR 150 MG TRANSDERMAL PATCH 3 ST; QL 24 HOUR EFFEXOR XR ORAL CAPSULE,EXTENDED 3 DO desipramine oral tablet 1 RELEASE 24HR 37.5 MG, DESVENLAFAXINE 75 MG FUMARATE ORAL 3 EMSAM TABLET EXTENDED TRANSDERMAL PATCH 3 RELEASE 24HR 24 HOUR DESVENLAFAXINE EQUETRO ORAL ORAL TABLET 3 QL CAPSULE, ER 3 EXTENDED RELEASE 24 MULTIPHASE 12 HR HR 100 MG escitalopram oxalate oral 1 QL DESVENLAFAXINE solution ORAL TABLET 3 DO escitalopram oxalate oral EXTENDED RELEASE 24 1 DO HR 50 MG tablet 10 mg, 5 mg escitalopram oxalate oral DESVENLAFAXINE 1 QL ORAL TABLET tablet 20 mg 3 QL EXTENDED RELEASE FANAPT ORAL TABLET 3 PA 24HR 100 MG FANAPT ORAL 3 PA DESVENLAFAXINE TABLETS,DOSE PACK ORAL TABLET 3 DO EXTENDED RELEASE FAZACLO ORAL 24HR 50 MG TABLET,DISINTEGRATI 2 PA NG dexmethylphenidate oral 1 PA capsule,er biphasic 50-50 FETZIMA ORAL CAPSULE,EXT REL 3 QL dexmethylphenidate oral 1 PA 24HR DOSE PACK tablet FETZIMA ORAL diazepam injection solution 1 CAPSULE,EXTENDED 3 QL diazepam injection syringe 1 RELEASE 24 HR diazepam intensol oral fluoxetine oral capsule 10 1 1 DO concentrate mg, 20 mg diazepam oral concentrate 1 fluoxetine oral capsule 40 mg 1 QL diazepam oral solution 1 diazepam oral tablet 1 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 121 Drug Name Tier Notes Drug Name Tier Notes fluoxetine oral haloperidol lactate injection 1 PA capsule,delayed 1 QL solution release(dr/ec) haloperidol lactate oral 1 PA fluoxetine oral solution 1 QL concentrate fluoxetine oral tablet 10 mg 1 DO haloperidol oral tablet 1 PA fluoxetine oral tablet 20 mg 1 imipramine hcl oral tablet 1 FLUOXETINE ORAL imipramine pamoate oral 3 QL 1 TABLET 60 MG capsule fluphenazine decanoate INTUNIV ER ORAL 1 PA injection solution TABLET EXTENDED 3 fluphenazine hcl injection RELEASE 24 HR 1 PA solution INVEGA ORAL TABLET fluphenazine hcl oral EXTENDED RELEASE 3 PA 1 PA concentrate 24HR fluphenazine hcl oral elixir 1 PA INVEGA SUSTENNA INTRAMUSCULAR 3 PA fluphenazine hcl oral tablet 1 PA SYRINGE fluvoxamine oral INVEGA TRINZA capsule,extended release 1 QL INTRAMUSCULAR 3 PA 24hr SYRINGE fluvoxamine oral tablet 100 1 QL IRENKA ORAL mg CAPSULE,DELAYED 3 QL fluvoxamine oral tablet 25 RELEASE(DR/EC) 1 DO mg, 50 mg KAPVAY ORAL TABLET FOCALIN ORAL EXTENDED RELEASE 12 3 3 ST TABLET HR FOCALIN XR ORAL KHEDEZLA ORAL CAPSULE,ER BIPHASIC 3 ST TABLET EXTENDED 3 QL 50-50 RELEASE 24HR 100 MG FORFIVO XL ORAL KHEDEZLA ORAL TABLET EXTENDED 3 QL TABLET EXTENDED 3 DO RELEASE 24 HR RELEASE 24HR 50 MG GEODON LATUDA ORAL TABLET 3 PA INTRAMUSCULAR 2 PA LEXAPRO ORAL 3 ST; QL RECON SOLN SOLUTION GEODON ORAL LEXAPRO ORAL 3 PA 3 ST; DO CAPSULE TABLET 10 MG, 5 MG guanfacine oral tablet LEXAPRO ORAL 1 3 ST; QL extended release 24 hr TABLET 20 MG HALDOL DECANOATE lithium carbonate oral 1 INTRAMUSCULAR 3 PA capsule SOLUTION lithium carbonate oral tablet 1 HALDOL INJECTION 3 PA lithium carbonate oral tablet SOLUTION 1 extended release haloperidol decanoate 1 PA intramuscular solution lithium citrate oral solution 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 122 Drug Name Tier Notes Drug Name Tier Notes LITHOBID ORAL NORPRAMIN ORAL 3 TABLET EXTENDED 2 TABLET RELEASE nortriptyline oral capsule 1 lorazepam intensol oral 1 nortriptyline oral solution 1 concentrate NUVIGIL ORAL TABLET 3 PA; QL lorazepam oral concentrate 1 150 MG, 250 MG, 50 MG lorazepam oral tablet 1 NUVIGIL ORAL TABLET 3 PA loxapine succinate oral 200 MG 1 PA capsule olanzapine intramuscular 1 PA maprotiline oral tablet 1 recon soln MARPLAN ORAL olanzapine oral tablet 10 mg, 3 1 TABLET 15 mg, 2.5 mg, 5 mg, 7.5 mg meprobamate oral tablet 1 olanzapine oral tablet 20 mg 1 PA METADATE CD ORAL olanzapine oral CAPSULE, ER BIPHASIC 3 tablet,disintegrating 10 mg, 1 30-70 20 mg metadate er oral tablet olanzapine oral 1 extended release tablet,disintegrating 15 mg, 5 1 PA METHYLIN ORAL mg 3 ST SOLUTION olanzapine-fluoxetine oral 1 PA METHYLIN ORAL capsule 3 ST TABLET,CHEWABLE OLEPTRO ER ORAL methylphenidate oral TABLET EXTENDED 3 1 PA capsule, er biphasic 30-70 RELEASE 24 HR methylphenidate oral ORAP ORAL TABLET 3 PA 1 PA capsule,er biphasic 50-50 oxazepam oral capsule 1 methylphenidate oral paliperidone oral tablet 1 PA 1 PA solution extended release 24hr methylphenidate oral tablet 1 PA PAMELOR ORAL 3 methylphenidate oral tablet CAPSULE 1 PA extended release PARNATE ORAL 3 methylphenidate oral tablet TABLET 1 PA extended release 24hr paroxetine hcl oral tablet 10 1 DO methylphenidate oral mg, 20 mg 1 PA tablet,chewable paroxetine hcl oral tablet 30 1 QL mirtazapine oral tablet 1 mg, 40 mg mirtazapine oral paroxetine hcl oral tablet 1 tablet,disintegrating extended release 24 hr 12.5 1 DO mg modafinil oral tablet 100 mg 1 PA; DO paroxetine hcl oral tablet modafinil oral tablet 200 mg 1 PA; QL extended release 24 hr 25 1 QL molindone oral tablet 1 PA mg, 37.5 mg NARDIL ORAL TABLET 3 PAXIL CR ORAL TABLET EXTENDED 3 ST; DO nefazodone oral tablet 1 RELEASE 24 HR 12.5 MG

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 123 Drug Name Tier Notes Drug Name Tier Notes PAXIL CR ORAL QUILLIVANT XR ORAL TABLET EXTENDED SUSPENSION,EXT REL 3 ST 3 ST; QL RELEASE 24 HR 25 MG, 24HR,RECON 37.5 MG REMERON ORAL 3 QL PAXIL ORAL TABLET 15 MG 3 ST; QL SUSPENSION REMERON ORAL 3 PAXIL ORAL TABLET 10 TABLET 30 MG, 45 MG 3 ST; DO MG, 20 MG REMERON SOLTAB PAXIL ORAL TABLET 30 ORAL 3 ST; QL 3 QL MG, 40 MG TABLET,DISINTEGRATI perphenazine oral tablet 1 NG 15 MG perphenazine-amitriptyline REMERON SOLTAB 1 ORAL oral tablet 3 TABLET,DISINTEGRATI PEXEVA ORAL TABLET 3 ST; DO NG 30 MG, 45 MG 10 MG, 20 MG REXULTI ORAL PEXEVA ORAL TABLET 3 PA 3 ST; QL TABLET 30 MG, 40 MG RISPERDAL CONSTA phenelzine oral tablet 1 INTRAMUSCULAR 2 PA pimozide oral tablet 1 PA SYRINGE PRISTIQ ORAL TABLET RISPERDAL M-TAB ORAL EXTENDED RELEASE 24 2 QL 3 PA HR 100 MG TABLET,DISINTEGRATI NG PRISTIQ ORAL TABLET RISPERDAL ORAL EXTENDED RELEASE 24 2 DO 3 PA HR 25 MG, 50 MG SOLUTION RISPERDAL ORAL protriptyline oral tablet 1 3 PA TABLET PROVIGIL ORAL 3 PA; DO TABLET 100 MG risperidone oral solution 1 PA PROVIGIL ORAL risperidone oral tablet 1 PA 3 PA; QL TABLET 200 MG risperidone oral 1 PA PROZAC ORAL tablet,disintegrating 3 ST; DO CAPSULE 10 MG, 20 MG RITALIN LA ORAL PROZAC ORAL CAPSULE,ER BIPHASIC 3 ST 3 ST; QL CAPSULE 40 MG 50-50 10 MG, 60 MG PROZAC WEEKLY RITALIN LA ORAL ORAL CAPSULE,ER BIPHASIC 3 ST; QL 3 CAPSULE,DELAYED 50-50 20 MG, 30 MG, 40 RELEASE(DR/EC) MG quetiapine oral tablet 100 RITALIN ORAL TABLET 3 1 mg, 200 mg, 25 mg, 300 mg SAPHRIS (BLACK quetiapine oral tablet 400 CHERRY) SUBLINGUAL 3 PA 1 PA mg, 50 mg TABLET SARAFEM ORAL QUILLICHEW ER ORAL 3 DO TABLET,CHEW,IR-ER.BI 3 ST TABLET 10 MG PHASIC24HR SARAFEM ORAL 3 TABLET 20 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 124 Drug Name Tier Notes Drug Name Tier Notes SEROQUEL ORAL VIIBRYD ORAL TABLET 3 PA 3 ST; QL TABLET 40 MG SEROQUEL XR ORAL VIIBRYD ORAL 3 ST; QL TABLET EXTENDED 2 PA TABLETS,DOSE PACK RELEASE 24 HR VRAYLAR ORAL 3 PA sertraline oral concentrate 1 QL CAPSULE sertraline oral tablet 100 mg 1 QL VRAYLAR ORAL 3 PA sertraline oral tablet 25 mg, CAPSULE,DOSE PACK 1 DO 50 mg VYVANSE ORAL 2 PA STRATTERA ORAL CAPSULE 2 CAPSULE WELLBUTRIN ORAL 3 QL SURMONTIL ORAL TABLET 3 CAPSULE WELLBUTRIN SR ORAL SYMBYAX ORAL TABLET EXTENDED 3 DO 3 PA CAPSULE RELEASE 100 MG thioridazine oral tablet 1 WELLBUTRIN SR ORAL TABLET EXTENDED 3 thiothixene oral capsule 1 RELEASE 150 MG, 200 TOFRANIL ORAL MG 3 TABLET WELLBUTRIN XL ORAL TRANXENE T-TAB TABLET EXTENDED 3 DO 3 ORAL TABLET RELEASE 24 HR 150 MG tranylcypromine oral tablet 1 WELLBUTRIN XL ORAL TABLET EXTENDED 3 QL trazodone oral tablet 1 RELEASE 24 HR 300 MG trifluoperazine oral tablet 1 XANAX ORAL TABLET 3 trimipramine oral capsule 1 XANAX XR ORAL VALIUM ORAL TABLET 3 TABLET EXTENDED 3 venlafaxine oral RELEASE 24 HR capsule,extended release 1 QL ziprasidone hcl oral capsule 1 PA 24hr 150 mg ZOLOFT ORAL 3 ST; QL venlafaxine oral CONCENTRATE capsule,extended release 1 DO ZOLOFT ORAL TABLET 3 ST; QL 24hr 37.5 mg, 75 mg 100 MG venlafaxine oral tablet 1 QL ZOLOFT ORAL TABLET 3 ST; DO VENLAFAXINE ORAL 25 MG, 50 MG TABLET EXTENDED 3 QL ZYPREXA RELEASE 24HR 150 MG, INTRAMUSCULAR 3 PA 225 MG RECON SOLN VENLAFAXINE ORAL ZYPREXA ORAL TABLET EXTENDED 3 DO TABLET 10 MG, 2.5 MG, 3 RELEASE 24HR 37.5 MG, 20 MG, 7.5 MG 75 MG ZYPREXA ORAL VERSACLOZ ORAL 3 PA 3 PA TABLET 15 MG, 5 MG SUSPENSION VIIBRYD ORAL TABLET 3 ST; DO 10 MG, 20 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 125 Drug Name Tier Notes Drug Name Tier Notes ZYPREXA RELPREVV phenobarbital sodium 1 INTRAMUSCULAR injection solution 3 PA SUSPENSION FOR PRECEDEX IN 0.9 % RECONSTITUTION SODIUM CHLOR 3 ZYPREXA ZYDIS ORAL INTRAVENOUS TABLET,DISINTEGRATI 3 SOLUTION NG PRECEDEX SEDATIVE/HYPNOTICS INTRAVENOUS 3 AMBIEN CR ORAL SOLUTION TABLET,EXT RELEASE 3 ST; QL RESTORIL ORAL 3 MULTIPHASE CAPSULE AMBIEN ORAL TABLET 3 ST; QL ROZEREM ORAL 3 ST; QL AMYTAL INJECTION TABLET 3 RECON SOLN seconal sodium oral capsule 1 ATIVAN INJECTION SILENOR ORAL 3 3 ST; QL SOLUTION TABLET BELSOMRA ORAL SONATA ORAL 3 ST; QL 3 ST; QL TABLET CAPSULE BUTISOL ORAL TABLET 3 temazepam oral capsule 1 dexmedetomidine triazolam oral tablet 1 1 intravenous solution XYREM ORAL 3 PA; QL EDLUAR SUBLINGUAL SOLUTION 3 ST; QL TABLET zaleplon oral capsule 1 ST; QL estazolam oral tablet 1 zolpidem oral tablet 1 QL eszopiclone oral tablet 1 mg, zolpidem oral tablet,ext 1 QL 1 ST; QL 2 mg release multiphase eszopiclone oral tablet 3 mg 1 PA; QL zolpidem sublingual tablet 1 ST; QL flurazepam oral capsule 1 ZOLPIMIST ORAL 3 ST; QL HALCION ORAL SPRAY,NON-AEROSOL 3 TABLET SKIN PREPS HETLIOZ ORAL 4 PA; QL 8-MOP ORAL CAPSULE 2 CAPSULE ABSORICA ORAL INTERMEZZO 3 PA; QL 3 ST; QL CAPSULE SUBLINGUAL TABLET ACANYA TOPICAL GEL 2 lorazepam injection solution 1 acetic acid irrigation solution 1 lorazepam injection syringe 1 acitretin oral capsule 1 LUNESTA ORAL 3 ST; QL ACLARO TOPICAL TABLET 3 EMULSION midazolam oral syrup 1 ACZONE TOPICAL GEL 3 NEMBUTAL SODIUM 3 INJECTION SOLUTION adapalene topical cream 1 PA phenobarbital oral elixir 1 adapalene topical gel 1 PA adapalene topical gel with phenobarbital oral tablet 1 1 pump

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 126 Drug Name Tier Notes Drug Name Tier Notes ADAPALENE TOPICAL AMPHADASE 3 PA 3 LOTION INJECTION SOLUTION ADVANCED ALLERGY ANALPRAM-HC 3 COLLECT KIT TOPICAL 3 ST TOPICAL LOTION KIT apexicon e topical cream 3 ST ala-cort topical cream 1 AQUA GLYCOLIC HC 3 ST ALA-QUIN TOPICAL TOPICAL COMBO PACK 3 CREAM ARTISS TOPICAL 3 ALA-SCALP TOPICAL SYRINGE 3 ST LOTION ATOPICLAIR TOPICAL 3 alclometasone topical cream 1 CREAM alclometasone topical ATRALIN TOPICAL GEL 3 PA 1 ointment ATRAPRO CP TOPICAL ALCORTIN A TOPICAL COMBO PACK,CREAM 3 3 GEL AND GEL ALCORTIN A TOPICAL ATRAPRO DERMAL 3 GEL IN PACKET SPRAY TOPICAL 3 ALDARA TOPICAL SPRAY,NON-AEROSOL 3 PA; QL CREAM IN PACKET ATRAPRO HYDROGEL 3 ALEVICYN TOPICAL GEL ANTIPRURITIC SG 3 AVAGE TOPICAL 3 PA TOPICAL SPRAY GEL CREAM ALEVICYN avita topical cream 1 PA ANTIPRURITIC 3 AVITA TOPICAL GEL 3 PA TOPICAL GEL avo cream topical emulsion 1 ALEVICYN DERMAL AZELEX TOPICAL TOPICAL 3 3 PA SPRAY,NON-AEROSOL CREAM ALOQUIN TOPICAL BEAU RX TOPICAL GEL 3 3 GEL BENSAL HP TOPICAL 3 alphaquin hp topical cream 1 OINTMENT ALTABAX TOPICAL BENZACLIN PUMP 2 3 ST OINTMENT TOPICAL GEL aluminum acetate topical BENZACLIN TOPICAL 1 3 ST solution GEL ALUVEA TOPICAL BENZEFOAM TOPICAL 3 3 PA CREAM FOAM BENZEFOAM ULTRA amcinonide topical cream 3 ST 3 PA TOPICAL FOAM amcinonide topical lotion 3 ST BENZEPRO amcinonide topical ointment 3 ST (MICROSPHERES) 3 PA ammonium lactate topical TOPICAL CLEANSER 1 cream benzepro topical towelette 1 PA ammonium lactate topical benzoyl peroxide topical 1 1 PA lotion cleanser 6 %, 7 %

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 127 Drug Name Tier Notes Drug Name Tier Notes benzoyl peroxide topical calcitrene topical ointment 1 1 cleanser 9 % calcitriol topical ointment 1 benzoyl peroxide topical CAPEX TOPICAL 1 PA 3 ST foam SHAMPOO betamethasone dipropionate celacyn topical gel with 3 ST 1 topical cream pump betamethasone dipropionate 3 ST cem-urea topical gel 1 topical lotion CERAMAX TOPICAL betamethasone dipropionate 3 3 ST CREAM topical ointment claravis oral capsule 2 PA; QL betamethasone valerate 3 ST clindamycin-benzoyl topical cream 1 peroxide topical gel betamethasone valerate 3 ST topical foam clobetasol scalp solution 1 betamethasone valerate clobetasol topical cream 1 3 ST topical lotion clobetasol topical foam 1 betamethasone valerate 3 ST clobetasol topical gel 1 topical ointment clobetasol topical lotion 1 betamethasone, augmented 1 topical cream clobetasol topical ointment 1 betamethasone, augmented clobetasol topical shampoo 1 1 ST topical gel clobetasol topical 1 betamethasone, augmented spray,non-aerosol 1 ST topical lotion clobetasol-emollient topical 1 betamethasone, augmented cream 1 topical ointment clobetasol-emollient topical 1 BIAFINE EMULSION foam 3 TOPICAL EMULSION CLOBEX TOPICAL 3 ST BIONECT TOPICAL LOTION 3 CREAM CLOBEX TOPICAL 3 ST BIONECT TOPICAL SHAMPOO 3 FOAM CLOBEX TOPICAL 3 ST BIONECT TOPICAL GEL 3 SPRAY,NON-AEROSOL blanche topical cream 1 CLOCORTOLONE PIVALATE TOPICAL 3 ST bp-50% urea topical 1 CREAM emulsion CLODAN KIT TOPICAL bpo topical gel 1 PA KIT,SHAMPOO AND 3 ST bpo topical towelette 1 PA CLEANSER calcipotriene scalp solution 1 clodan topical shampoo 1 CLODERM TOPICAL calcipotriene topical cream 1 3 ST CREAM calcipotriene topical 1 COAL TAR TOPICAL ointment 3 SOLUTION calcipotriene-betamethasone 1 CONDYLOX TOPICAL topical ointment 3 GEL Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 128 Drug Name Tier Notes Drug Name Tier Notes CONDYLOX TOPICAL DERMASORB XM 3 SOLUTION COMPLETE KIT 3 CORDRAN TAPE LARGE TOPICAL CREAM 3 ST ROLL TOPICAL TAPE DERMATOP TOPICAL 3 ST CORDRAN TAPE SMALL CREAM 3 ST ROLL TOPICAL TAPE DERMATOP TOPICAL 3 ST CORDRAN TOPICAL OINTMENT 3 ST CREAM DERMAWERX SDS 3 ST CORDRAN TOPICAL TOPICAL KIT 3 ST LOTION dermazene topical cream 1 CORDRAN TOPICAL DESONATE TOPICAL 3 ST 3 ST OINTMENT GEL cormax scalp solution 1 desonide topical cream 3 ST COSENTYX (2 desonide topical lotion 3 ST SYRINGES) 4 PA; QL desonide topical ointment 3 ST SUBCUTANEOUS DESOWEN TOPICAL SYRINGE 3 ST CREAM COSENTYX PEN (2 DESOWEN TOPICAL PENS) SUBCUTANEOUS 4 PA; QL 3 ST PEN INJECTOR LOTION desoximetasone topical COSENTYX PEN 3 ST SUBCUTANEOUS PEN 4 PA; QL cream INJECTOR desoximetasone topical gel 3 ST COSENTYX desoximetasone topical 3 ST SUBCUTANEOUS 4 PA; QL ointment SYRINGE diclofenac sodium topical CUTIVATE TOPICAL 1 3 ST drops CREAM diclofenac sodium topical gel 1 CUTIVATE TOPICAL 3 ST LOTION DICLOTRAL TOPICAL COMBO DERMA-SMOOTHE/FS 3 3 ST PACK,SOLUTION AND BODY OIL TOPICAL OIL CREAM DERMA-SMOOTHE/FS DIFFERIN TOPICAL 3 ST 3 PA SCALP OIL SCALP OIL CREAM DERMASORB AF DIFFERIN TOPICAL 3 PA COMPLETE KIT 3 GEL TOPICAL CREAM DIFFERIN TOPICAL 3 PA DERMASORB HC GEL WITH PUMP COMPLETE KIT DIFFERIN TOPICAL TOPICAL COMBO 3 ST 3 PA PACK,CLEANSER AND LOTION LOTION diflorasone topical cream 3 ST DERMASORB TA diflorasone topical ointment 3 ST COMPLETE KIT 3 ST DIPROLENE AF 3 ST TOPICAL CREAM TOPICAL CREAM

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 129 Drug Name Tier Notes Drug Name Tier Notes DIPROLENE TOPICAL FINACEA TOPICAL GEL 2 PA 3 ST LOTION FLECTOR DIPROLENE TOPICAL TRANSDERMAL PATCH 3 ST 3 ST OINTMENT 12 HOUR DOVONEX TOPICAL fluocinolone and shower cap 3 3 ST CREAM scalp oil doxepin topical cream 1 fluocinolone topical cream 3 ST drithocreme hp topical cream 1 fluocinolone topical oil 3 ST DRYSOL DAB-O-MATIC fluocinolone topical ointment 3 ST 3 TOPICAL SOLUTION fluocinolone topical solution 3 ST DRYSOL TOPICAL 3 fluocinonide topical cream 1 SOLUTION fluocinonide topical gel 1 ST DUAC TOPICAL GEL 3 fluocinonide topical ointment 1 eletone topical cream 1 fluocinonide topical solution 1 ELIMITE TOPICAL 3 CREAM fluocinonide-e topical cream 1 ELOCON TOPICAL fluticasone topical cream 3 ST 3 ST CREAM fluticasone topical lotion 3 ST ELOCON TOPICAL 3 ST fluticasone topical ointment 3 ST OINTMENT forma-ray solution 1 ELOCON TOPICAL 3 ST GENADUR (WITH SOLUTION 3 LEXINAL) KIT emulsion sb topical emulsion 1 GENADUR TOPICAL ENSTILAR TOPICAL 3 3 LIQUID FOAM GORDONS UREA 3 EPICERAM TOPICAL TOPICAL OINTMENT EMULSION, EXTENDED 3 RELEASE GUAIACOL LIQUID 3 halobetasol propionate EPIDUO FORTE 1 TOPICAL GEL WITH 3 PA topical cream PUMP halobetasol propionate 1 EPIDUO TOPICAL GEL 3 PA topical ointment EPIDUO TOPICAL GEL HALOG TOPICAL 3 PA 3 ST WITH PUMP CREAM EPIFOAM TOPICAL HALOG TOPICAL 3 3 ST FOAM OINTMENT EURAX TOPICAL hpr plus hydrogel topical 3 1 CREAM kit,cream and gel EURAX TOPICAL hpr plus topical cream 1 3 LOTION hpr plus topical foam 1 FABIOR TOPICAL HPR PLUS-MB 3 PA FOAM HYDROGEL TOPICAL 3 FINACEA TOPICAL COMBO PACK,GEL AND 2 PA FOAM FOAM hpr topical foam 1 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 130 Drug Name Tier Notes Drug Name Tier Notes HYDRO 35 TOPICAL IODOFLEX TOPICAL 3 3 FOAM PADS, MEDICATED HYDRO 40 TOPICAL iodoquinol-hc topical cream 1 3 FOAM IODOSORB TOPICAL 3 hydrocortisone butyrate GEL 3 ST topical cream KENALOG TOPICAL 3 ST hydrocortisone butyrate AEROSOL 3 ST topical ointment KERAFOAM TOPICAL 3 hydrocortisone butyrate FOAM 3 ST topical solution KERALAC TOPICAL 3 hydrocortisone CREAM 3 ST butyr-emollient topical cream KERALYT RX TOPICAL 3 hydrocortisone topical cream 1 GEL hydrocortisone topical lotion 1 KERALYT SCALP hydrocortisone topical COMPLETE TOPICAL 1 3 ointment KIT,SHAMPOO AND GEL hydrocortisone valerate 3 ST KLARON TOPICAL topical cream 3 SUSPENSION hydrocortisone valerate 3 ST topical ointment klofensaid ii topical drops 1 hydrocortisone-iodoquinol-al lactated ringers irrigation 1 1 oe topical cream in packet solution hydrocortisone-min oil-wht lactic acid e topical cream 1 1 pet topical ointment lactic acid topical lotion 1 hydrocortisone-pramoxine LATISSE BASE OF THE 1 topical cream EYELASHES DROPS 3 hydroquinone microspheres WITH APPLICATOR topical cream,extended 1 latrix topical suspension 1 release lidocaine hcl-hydrocortison 1 hydroquinone topical cream 1 ac topical cream HYGEL TOPICAL GEL 3 lindane topical shampoo 1 HYLATOPIC PLUS LOCOID LIPOCREAM 3 3 ST TOPICAL CREAM TOPICAL CREAM HYLATOPIC PLUS LOCOID TOPICAL 3 3 ST TOPICAL FOAM CREAM HYLATOPIC TOPICAL LOCOID TOPICAL 3 3 ST FOAM LOTION imiquimod topical cream in LOCOID TOPICAL 1 PA; QL 3 ST packet OINTMENT INOVA 4-1 TOPICAL LOCOID TOPICAL 3 3 ST COMBO PACK SOLUTION INOVA 8-2 TOPICAL LOUTREX TOPICAL 3 3 COMBO PACK CREAM INOVA TOPICAL lugols topical solution 1 3 COMBO PACK Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 131 Drug Name Tier Notes Drug Name Tier Notes luxamend topical emulsion 1 NEOSALUS TOPICAL 3 LUXIQ TOPICAL FOAM 3 ST CREAM LYCELLE TOPICAL NEOSALUS TOPICAL 3 3 GEL FOAM NEOSALUS TOPICAL malathion topical lotion 1 3 LOTION mb hydrogel (cyclomethicone) topical 1 NEOSPORIN GU kit,cream and gel IRRIGANT IRRIGATION 3 SOLUTION mb hydrogel topical 1 kit,cream and gel NEUAC KIT TOPICAL COMBO PACK,CREAM 3 ST melpaque hp topical cream 1 AND GEL melquin 3 topical solution 1 neuac topical gel 1 methoxsalen rapid oral 1 nivatopic plus topical cream 1 capsule NORITATE TOPICAL methyl salicylate topical 3 PA 1 CREAM liquid NOVACORT TOPICAL METROCREAM 3 3 GEL TOPICAL CREAM NUOX TOPICAL GEL 3 METROGEL TOPICAL 3 NUVAIL TOPICAL NAIL GEL 3 FILM SOLUTION METROGEL TOPICAL 3 GEL WITH PUMP OLUX TOPICAL FOAM 3 ST METROLOTION OLUX-E TOPICAL 3 3 ST TOPICAL LOTION FOAM ONEXTON TOPICAL metronidazole topical cream 1 2 GEL metronidazole topical gel 1 OVACE PLUS SHAMPOO metronidazole topical gel 3 1 TOPICAL SHAMPOO with pump OVACE PLUS TOPICAL metronidazole topical lotion 1 CLEANSER,EXTENDED 3 MICROCYN HYDROGEL RELEASE 3 TOPICAL GEL OVACE PLUS TOPICAL 3 MICROCYN TOPICAL CREAM 3 SPRAY,NON-AEROSOL OVACE PLUS TOPICAL 3 MIRVASO TOPICAL FOAM 3 GEL OVACE PLUS TOPICAL 3 mometasone topical cream 1 LOTION mometasone topical ointment 1 OVACE PLUS WASH TOPICAL 3 mometasone topical solution 1 CLEANSER,GEL myorisan oral capsule 2 PA; QL EXTENDED RELEASE NATROBA TOPICAL OVACE TOPICAL 3 3 SUSPENSION CLEANSER neomycin-polymyxin b gu OVIDE TOPICAL 1 3 irrigation solution LOTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 132 Drug Name Tier Notes Drug Name Tier Notes OXSORALEN TOPICAL PRAMOSONE TOPICAL 3 3 LOTION CREAM 2.5-1 % OXSORALEN ULTRA PRAMOSONE TOPICAL 3 2 ORAL CAPSULE LOTION PACNEX HP TOPICAL PRAMOSONE TOPICAL 3 PA 2 PADS, MEDICATED OINTMENT PACNEX LP TOPICAL prednicarbate topical cream 3 ST 3 PA PADS, MEDICATED prednicarbate topical 3 ST PACNEX MX TOPICAL ointment 3 PA CLEANSER PRESERA TOPICAL 3 PACNEX TOPICAL FOAM 3 PA CLEANSER PROMISEB COMPLETE PANDEL TOPICAL TOPICAL 3 ST 3 CREAM KIT,CLEANSER AND PEDIADERM HC CREAM TOPICAL KIT,LOTION PROMISEB TOPICAL 3 ST 3 AND CREAM CREAM,EMOLLIENT pruclair topical cream 1 PEDIADERM TA 3 ST prudoxin topical cream 1 TOPICAL CREAM prumyx topical cream 1 PEDIAPALM TOPICAL 3 SPRAY,NON-AEROSOL prutect topical emulsion 1 PSORCON TOPICAL PENNSAID TOPICAL 3 ST SOLUTION IN 3 ST CREAM METERED-DOSE PUMP PYROGALLIC ACID 3 permethrin topical cream 1 TOPICAL OINTMENT PHENOL LIQUID 3 QUTENZA TOPICAL KIT 2 PHYSIOLYTE RADIAPLEXRX 3 3 IRRIGATION SOLUTION TOPICAL GEL PHYSIOSOL rea lo 39 topical cream 1 IRRIGATION 3 rea lo 40 topical cream 1 IRRIGATION SOLUTION rea lo 40 topical lotion 1 PODOCON TOPICAL 3 LIQUID recedo topical gel 1 podofilox topical solution 1 refissa topical cream 1 PA REGRANEX TOPICAL POTASSIUM 3 HYDROXIDE TOPICAL 3 GEL SOLUTION remeven topical cream 1 PR BENZOYL RENOVA TOPICAL 3 PA PEROXIDE TOPICAL 3 PA CREAM CLEANSER RETIN-A MICRO PUMP pr cream topical cream 1 TOPICAL GEL WITH 3 PA PRAMOSONE E PUMP 3 TOPICAL CREAM RETIN-A MICRO 3 PA PRAMOSONE TOPICAL TOPICAL GEL 2 CREAM 1-1 % Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 133 Drug Name Tier Notes Drug Name Tier Notes RETIN-A TOPICAL SANADERMRX 3 PA 3 ST CREAM TOPICAL KIT RETIN-A TOPICAL GEL 3 PA SANTYL TOPICAL 3 ringers irrigation solution 1 OINTMENT SCALACORT DK rosadan topical cream 1 3 ST TOPICAL COMBO PACK rosadan topical gel 1 scalacort topical lotion 1 ROSADAN TOPICAL KIT, CLEANSER AND 3 seb-prev topical cleanser 1 GEL selenium sulfide topical 1 ROSADAN TOPICAL lotion KIT,CLEANSER AND 3 selenium sulfide topical 1 CREAM shampoo salacyn topical cream 1 SELRX TOPICAL 3 salacyn topical lotion 1 SHAMPOO SALEX TOPICAL SERNIVO TOPICAL 3 3 COMBO PACK SPRAY WITH PUMP SILAZONE-II TOPICAL SALEX TOPICAL 3 KIT,CLEANSER AND 3 KIT CREAM ER silver nitrate applicators 1 SALEX TOPICAL topical stick 3 SHAMPOO silver nitrate topical ointment 1 salicylic acid er-ceramides silver nitrate topical solution 1 1 topical combo pack SILVRSTAT TOPICAL 3 salicylic acid er-ceramides GEL topical kit,cleanser and 1 SKLICE TOPICAL 3 cream er LOTION salicylic acid topical cream 1 sodium chloride irrigation 1 salicylic acid topical solution 1 cream,extended release sonafine topical emulsion 1 salicylic acid topical film SOOLANTRA TOPICAL 1 3 forming liquid w/appl CREAM salicylic acid topical foam 1 SORBITOL IRRIGATION 3 salicylic acid topical gel 1 SOLUTION salicylic acid topical liquid 1 SORBITOL-MANNITOL 3 salicylic acid topical lotion 1 URETHRAL SOLUTION salicylic acid topical SORIATANE ORAL 1 3 lotion,extended release CAPSULE salicylic acid topical SORILUX TOPICAL 1 3 shampoo FOAM SALKERA TOPICAL spinosad topical suspension 1 3 FOAM sulfacetamide sodium (acne) 1 SALVAX DUO PLUS topical suspension 3 TOPICAL FOAM sulfacetamide sodium topical 1 salvax topical foam 1 cleanser Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 134 Drug Name Tier Notes Drug Name Tier Notes SULFACETAMIDE TALTZ SYRINGE (3 SODIUM TOPICAL 3 PACK) SUBCUTANEOUS 3 CLEANSER, GEL SYRINGE sulfacetamide sodium topical TALTZ SYRINGE 1 cleanser,gel extended release SUBCUTANEOUS 3 sulfacetamide sodium topical SYRINGE 1 shampoo TAZORAC TOPICAL 2 SURE RESULT DSS CREAM PREMIUM PACK TAZORAC TOPICAL 2 TOPICAL COMBO 3 GEL PACK,SOLUTION AND TEMOVATE E TOPICAL 3 ST CREAM CREAM SURE RESULT TAC PAK TEMOVATE TOPICAL 3 ST 3 ST TOPICAL KIT CREAM SYNALAR CREAM KIT TEMOVATE TOPICAL 3 ST 3 ST TOPICAL CREAM OINTMENT SYNALAR OINTMENT TERSI FOAM TOPICAL KIT TOPICAL COMBO 3 3 ST FOAM PACK,OINTMENT AND TETRIX TOPICAL CREAM 3 CREAM SYNALAR TOPICAL 3 ST TEXACORT TOPICAL CREAM 3 ST SOLUTION SYNALAR TOPICAL 3 ST TOPICORT TOPICAL OINTMENT 3 ST CREAM SYNALAR TOPICAL 3 ST TOPICORT TOPICAL SOLUTION 3 ST GEL SYNALAR TS TOPICAL 3 ST TOPICORT TOPICAL KIT 3 ST OINTMENT TACLONEX TOPICAL 3 TOPICORT TOPICAL OINTMENT 3 ST SPRAY,NON-AEROSOL TACLONEX TOPICAL 3 tretinoin (emollient) topical SUSPENSION 1 PA cream TALTZ AUTOINJECTOR (2 PACK) tretinoin microspheres 3 1 PA SUBCUTANEOUS topical gel AUTO-INJECTOR tretinoin microspheres 1 PA TALTZ AUTOINJECTOR topical gel with pump (3 PACK) 3 tretinoin topical cream 1 PA SUBCUTANEOUS AUTO-INJECTOR tretinoin topical gel 1 PA TRETIN-X CREAM KIT TALTZ AUTOINJECTOR 3 PA SUBCUTANEOUS 3 TOPICAL COMBO PACK AUTO-INJECTOR TRETIN-X TOPICAL 3 PA TALTZ SYRINGE (2 CREAM PACK) SUBCUTANEOUS 3 triamcinolone acetonide 1 ST; QL SYRINGE topical aerosol

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 135 Drug Name Tier Notes Drug Name Tier Notes triamcinolone acetonide umecta topical foam 1 1 QL topical cream 0.025 %, 0.5 % UMECTA TOPICAL 3 triamcinolone acetonide NAIL FILM SUSPENSION 1 ST topical cream 0.1 % URAMAXIN GT 3 triamcinolone acetonide TOPICAL GEL 1 QL topical lotion 0.025 % URAMAXIN GT triamcinolone acetonide TOPICAL KIT,CREAM 3 1 topical lotion 0.1 % AND GEL triamcinolone acetonide URAMAXIN TOPICAL 1 QL 3 topical ointment CREAM trianex topical ointment 1 URAMAXIN TOPICAL 3 tri-chlor topical solution 1 FOAM URAMAXIN TOPICAL TRICHLOROACETIC 3 ACID TOPICAL RECON 3 GEL SOLN URAMAXIN TOPICAL 3 triderm topical cream 1 LOTION TRI-LUMA TOPICAL urea nail stick topical 3 1 CREAM solution TROPAZONE LOTION urea topical cream 1 3 TOPICAL LOTION urea topical foam 1 ULESFIA TOPICAL urea topical gel 1 3 LOTION UREA TOPICAL LOTION 3 ULTRASAL-ER 40 % TOPICAL 3 urea topical lotion 45 % 1 FILM-FORMING SOLN urea topical nail film ER W/ APPL 1 suspension ULTRAVATE TOPICAL 3 ST urea-hyaluronate sodium CREAM 1 topical kit ULTRAVATE TOPICAL 3 ST OINTMENT ure-k topical cream 1 ULTRAVATE X UREVAZ TOPICAL 3 ST 3 TOPICAL COMBO PACK CREAM UTOPIC TOPICAL ULTRAVATE X 3 TOPICAL COMBO CREAM 3 ST PACK,OINTMENT AND VANIQA TOPICAL 3 CREAM CREAM UMECTA NAIL FILM VANOS TOPICAL PEN TOPICAL NAIL 3 ST 3 CREAM FILM SUSP, PEN VANOXIDE-HC APPLICATOR 3 TOPICAL SUSPENSION UMECTA PD TOPICAL 3 EMULSION, ADHESIVE VASELINE WHITE PETROLEUM TOPICAL 3 UMECTA PD TOPICAL 3 OINTMENT IN PACKET SUSPENSION,ADHESIVE VASHE WOUND UMECTA TOPICAL 3 THERAPY IRRIGATION 3 EMULSION IRRIGATION SOLUTION Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 136 Drug Name Tier Notes Drug Name Tier Notes VECTICAL TOPICAL CHANTIX ORAL 3 3 QL OINTMENT TABLET VELTIN TOPICAL GEL 3 ST CHANTIX STARTING VERDESO TOPICAL MONTH BOX ORAL 3 QL 3 ST FOAM TABLETS,DOSE PACK VIRASAL TOPICAL NICOTROL FILM FORMING LIQUID 3 INHALATION 3 W/APPL CARTRIDGE VITRASE INJECTION NICOTROL NS NASAL 3 3 SOLUTION SPRAY,NON-AEROSOL VOLTAREN TOPICAL ZYBAN ORAL TABLET 3 3 QL GEL EXTENDED RELEASE VYTONE TOPICAL THYROID PREPS 3 CREAM IN PACKET ARMOUR THYROID 2 water for irrigation, sterile ORAL TABLET 1 irrigation solution CYTOMEL ORAL 3 WHYTEDERM TDPAK TABLET 3 ST TOPICAL KIT LEVOTHYROXINE WHYTEDERM INTRAVENOUS RECON 3 TRILASIL PAK 3 ST SOLN 100 MCG TOPICAL KIT levothyroxine intravenous 1 XCLAIR TOPICAL recon soln 200 mcg, 500 mcg 3 CREAM levothyroxine oral tablet 1 ZANABIN TOPICAL GEL 3 levoxyl oral tablet 1 zenatane oral capsule 2 PA; QL liothyronine intravenous 1 ZIANA TOPICAL GEL 3 ST solution ZITHRANOL TOPICAL liothyronine oral tablet 1 3 SHAMPOO methimazole oral tablet 1 ZITHRANOL-RR nature-throid oral tablet 1 TOPICAL CREAM, 3 np thyroid oral tablet 1 RAPID RELEASE propylthiouracil oral tablet 1 ZONALON TOPICAL 3 SYNTHROID ORAL CREAM 2 TABLET ZYCLARA TOPICAL TAPAZOLE ORAL CREAM IN 3 PA; QL 3 METERED-DOSE PUMP TABLET ZYCLARA TOPICAL THYROGEN 3 PA; QL CREAM IN PACKET INTRAMUSCULAR 3 RECON SOLN SMOKING THYROLAR-1 ORAL DETERRENTS 3 TABLET buproban oral tablet 1 QL THYROLAR-1/2 ORAL extended release 3 TABLET CHANTIX CONTINUING THYROLAR-1/4 ORAL MONTH BOX ORAL 3 QL 3 TABLET TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 137 Drug Name Tier Notes Drug Name Tier Notes THYROLAR-2 ORAL AQUORAL MUCOUS 3 TABLET MEMBRANE 3 THYROLAR-3 ORAL AEROSOL,SPRAY 3 TABLET ARALAST NP TIROSINT ORAL INTRAVENOUS RECON 4 PA 3 CAPSULE SOLN TRIOSTAT ARCALYST INTRAVENOUS 3 SUBCUTANEOUS 4 PA; QL SOLUTION RECON SOLN unithroid oral tablet 1 ATELVIA ORAL TABLET,DELAYED 3 QL westhroid oral tablet 1 RELEASE (DR/EC) WP THYROID ORAL AVODART ORAL 3 3 PA TABLET CAPSULE UNCLASSIFIED DRUG bacteriostatic PRODUCTS water(parabens) injection 1 acamprosate oral solution 1 tablet,delayed release (dr/ec) BAL IN OIL ACETADOTE INTRAMUSCULAR 3 INTRAVENOUS 3 SOLUTION SOLUTION BENLYSTA acetylcysteine intravenous INTRAVENOUS RECON 4 PA 1 solution SOLN ACTONEL ORAL BERINERT 3 QL 4 PA TABLET INTRAVENOUS KIT ADAGEN BINOSTO ORAL INTRAMUSCULAR 4 TABLET, 3 QL SOLUTION EFFERVESCENT BONIVA INTRAVENOUS ALDURAZYME 4 ST INTRAVENOUS 4 PA SYRINGE SOLUTION BONIVA ORAL TABLET 3 ST; QL alendronate oral solution 1 BRIDION alendronate oral tablet 1 QL INTRAVENOUS 3 SOLUTION alfuzosin oral tablet extended 1 BUNAVAIL BUCCAL release 24 hr 3 PA; QL FILM amifostine crystalline 1 buprenorphine hcl sublingual intravenous recon soln 1 PA; QL tablet ANTABUSE ORAL 3 buprenorphine-naloxone TABLET 1 PA; QL sublingual tablet APLIGRAF TOPICAL 3 DISK BUTYLATED HYDROXYTOLUENE 3 APPTRIM ORAL 3 POWDER CAPSULE CA-DTPA APPTRIM-D ORAL 3 INTRAVENOUS 3 CAPSULE SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 138 Drug Name Tier Notes Drug Name Tier Notes CALCIUM DISODIUM CIALIS ORAL TABLET 3 PA; QL VERSENATE 3 2.5 MG, 5 MG INJECTION SOLUTION CINRYZE calcium folinate (leucovorin) INTRAVENOUS RECON 4 PA; QL 1 injection solution SOLN CAPHOSOL MUCOUS CO-BALAMIN ORAL 3 3 MEMBRANE SOLUTION CAPSULE CARBAGLU ORAL CONCEPTION KIT 3 4 TABLET, DISPERSIBLE CO-VERATROL ORAL 3 CARDIOVID PLUS ORAL CAPSULE 3 CAPSULE cryoserv solution 1 CARNITOR CUROSURF (SUGAR-FREE) ORAL 3 INTRATRACHEAL 3 SOLUTION SUSPENSION CARNITOR CYANOKIT INTRAVENOUS 3 INTRAVENOUS RECON 3 SOLUTION SOLN CARNITOR ORAL CYSTADANE ORAL 3 3 SOLUTION POWDER CARNITOR ORAL CYSTAGON ORAL 3 4 TABLET CAPSULE CARTICEL IMPLANT darifenacin oral tablet 3 1 SUSPENSION extended release 24 hr CAVERJECT IMPULSE DEBACTEROL MUCOUS 3 INTRACAVERNOSAL 3 PA MEMBRANE SOLUTION KIT DEBACTEROL MUCOUS 3 CAVERJECT MEMBRANE SWAB INTRACAVERNOSAL 3 PA deferoxamine injection recon RECON SOLN 4 soln CELACYN POST PROCEDURE TOPICAL DERMAGRAFT 3 3 COMBO PACK,GEL AND TOPICAL SHEET SPRAY DERMANIC ORAL CELLULOSE (BULK) TABLET,IR,DELAYED 3 3 POWDER REL,BIPHASIC CERDELGA ORAL DERMAWERX 4 PA CAPSULE SURGICAL PLUS PAK 3 TOPICAL KIT CEREZYME DESFERAL INJECTION INTRAVENOUS RECON 4 PA 4 SOLN RECON SOLN CHEMET ORAL DETROL LA ORAL 3 CAPSULE CAPSULE,EXTENDED 3 ST RELEASE 24HR chlorhexidine gluconate mucous membrane 1 DETROL ORAL TABLET 3 ST mouthwash dexrazoxane hcl intravenous 1 CIALIS ORAL TABLET recon soln 2 PA 10 MG, 20 MG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 139 Drug Name Tier Notes Drug Name Tier Notes DIGIFAB ESBRIET ORAL 4 PA; QL INTRAVENOUS RECON 3 CAPSULE SOLN ethyl acetate liquid 1 DILUENT FOR etidronate disodium oral EPOPROSTENOL/FLOL 1 3 tablet A INTRAVENOUS EUCALYPTUS FLAVOR SOLUTION 3 OIL disulfiram oral tablet 1 EVISTA ORAL TABLET 3 DITROPAN XL ORAL EXJADE ORAL TABLET, TABLET EXTENDED 3 ST 4 RELEASE 24HR DISPERSIBLE doxercalciferol intravenous FABRAZYME 1 solution INTRAVENOUS RECON 4 SOLN doxercalciferol oral capsule 1 FERRIPROX ORAL doxycycline hyclate oral 4 1 SOLUTION tablet FERRIPROX ORAL 4 DUODOTE TABLET INTRAMUSCULAR PEN 3 INJECTOR finasteride oral tablet 1 mg 1 dutasteride oral capsule 1 PA finasteride oral tablet 5 mg 1 PA dutasteride-tamsulosin oral FIRAZYR 1 PA capsule, er multiphase 24 hr SUBCUTANEOUS 4 PA SYRINGE EDEX INTRACAVERNOSAL 3 PA flavoxate oral tablet 1 KIT FLOMAX ORAL ELAPRASE CAPSULE,EXTENDED 3 INTRAVENOUS 4 PA RELEASE 24HR SOLUTION flumazenil intravenous 1 ELELYSO solution INTRAVENOUS RECON 4 PA fomepizole intravenous 1 SOLN solution ELLIOTTS B (PF) FORTEO INTRATHECAL 3 SUBCUTANEOUS PEN 4 PA; QL SOLUTION INJECTOR ENABLEX ORAL FOSAMAX ORAL 3 QL TABLET EXTENDED 3 ST TABLET RELEASE 24 HR FOSAMAX PLUS D ENDOFORM ORAL TABLET 70-2,800 2 QL FENESTRATED 3 MG-UNIT TOPICAL SHEET FOSAMAX PLUS D ENDOFORM TOPICAL 3 ORAL TABLET 70-5,600 2 SHEET MG-UNIT ENTERAGAM ORAL FOSTEUM PLUS ORAL 3 3 POWDER IN PACKET CAPSULE EPISIL MUCOUS FUSILEV MEMBRANE GEL 3 INTRAVENOUS RECON 3 FORMING SOLUTION SOLN Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 140 Drug Name Tier Notes Drug Name Tier Notes GABADONE ORAL KALBITOR 3 CAPSULE SUBCUTANEOUS 4 PA GALZIN ORAL SOLUTION 3 CAPSULE KALYDECO ORAL 4 PA; QL GELCLAIR MUCOUS GRANULES IN PACKET MEMBRANE GEL IN 3 KALYDECO ORAL 4 PA; QL PACKET TABLET GELFILM IMPLANT KANUMA 3 FILM INTRAVENOUS 3 GELNIQUE SOLUTION TRANSDERMAL GEL IN 3 ST KEVEYIS ORAL 4 PA; QL PACKET TABLET GELX MUCOUS KUVAN ORAL POWDER 3 4 PA MEMBRANE GEL IN PACKET GLASSIA KUVAN ORAL 4 PA INTRAVENOUS 4 PA TABLET,SOLUBLE SOLUTION leucovorin calcium injection 1 HECTOROL recon soln INTRAVENOUS 3 leucovorin calcium oral 1 SOLUTION tablet HECTOROL ORAL LEVITRA ORAL 3 3 PA CAPSULE TABLET HYLENEX INJECTION levocarnitine (with sugar) 3 1 SOLUTION oral solution HYPER-SAL levocarnitine intravenous INHALATION 1 3 solution SOLUTION FOR NEBULIZATION levocarnitine oral tablet 1 HYPERTENSA ORAL levoleucovorin calcium 3 1 CAPSULE intravenous solution ibandronate intravenous LIMBREL ORAL 1 ST 3 solution CAPSULE ibandronate intravenous LIMBREL250 ORAL 4 ST 3 syringe CAPSULE LIMBREL500 ORAL ibandronate oral tablet 1 ST; QL 3 CAPSULE ILARIS (PF) LISTER-V ORAL SUBCUTANEOUS 4 PA 3 RECON SOLN CAPSULE INFASURF LUMIZYME INTRATRACHEAL 3 INTRAVENOUS RECON 4 PA SUSPENSION SOLN MEGACE ES ORAL JADENU ORAL TABLET 4 3 SUSPENSION JALYN ORAL CAPSULE, 3 PA MEGACE ORAL ER MULTIPHASE 24 HR 3 SUSPENSION megestrol oral suspension 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 141 Drug Name Tier Notes Drug Name Tier Notes mesna intravenous solution 1 NITHIODOTE MESNEX INTRAVENOUS 3 INTRAVENOUS 3 SOLUTION SOLUTION NUMOISYN MUCOUS 3 MESNEX ORAL TABLET 2 MEMBRANE LIQUID NUMOISYN MUCOUS METASTRON 3 INTRAVENOUS 3 MEMBRANE LOZENGE SOLUTION OFEV ORAL CAPSULE 4 PA; QL METHAZEL ORAL ORAFATE MUCOUS 3 3 CAPSULE MEMBRANE PASTE methylene blue (antidote) oralone dental paste 1 1 intravenous solution ORAMAGICRX MIFEPREX ORAL MUCOUS MEMBRANE 3 3 TABLET MOUTHWASH MUCOTROL ORAL ORFADIN ORAL 3 QL 4 WAFER CAPSULE MUGARD MUCOUS ORKAMBI ORAL 3 QL 4 PA; QL MEMBRANE SOLUTION TABLET MURI-LUBE OIL 2 OSPHENA ORAL 3 PA; QL MUSE URETHRAL TABLET 3 PA SUPPOSITORY oxybutynin chloride oral 1 MYOZYME syrup INTRAVENOUS RECON 4 PA oxybutynin chloride oral 1 SOLN tablet MYRBETRIQ ORAL oxybutynin chloride oral 1 TABLET EXTENDED 3 tablet extended release 24hr RELEASE 24 HR OXYTROL NAGLAZYME TRANSDERMAL PATCH 3 ST INTRAVENOUS 4 PA SEMIWEEKLY SOLUTION pamidronate intravenous 4 NEBUSAL INHALATION recon soln SOLUTION FOR 2 pamidronate intravenous 4 NEBULIZATION solution NEUTRASAL MUCOUS PANHEMATIN MEMBRANE POWDER 3 INTRAVENOUS RECON 3 IN PACKET SOLN NEXAVIR INJECTION 3 PARICALCITOL SOLUTION HEMODIALYSIS PORT 3 niacin-aze INJECTION SOLUTION 1 ac-turmer-fa-b6-zn oral tablet paricalcitol oral capsule 1 NICADAN ORAL paroex oral rinse mucous 3 1 TABLET membrane mouthwash NICAZEL FORTE ORAL PERCURA ORAL 3 3 TABLET CAPSULE NICAZEL ORAL 3 TABLET Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 142 Drug Name Tier Notes Drug Name Tier Notes PERIDEX MUCOUS RECLAST MEMBRANE 3 INTRAVENOUS 4 MOUTHWASH SOLUTION periogard mucous membrane RHEUMATE ORAL 1 3 mouthwash CAPSULE PH 12 DILUENT FOR risedronate oral tablet 1 QL FLOLAN INTRAVENOUS 3 risedronate oral 1 QL SOLUTION tablet,delayed release (dr/ec) PRALIDOXIME RUCONEST INTRAMUSCULAR PEN 3 INTRAVENOUS RECON 4 PA; QL INJECTOR SOLN PROCYSBI ORAL SALIVAMAX MUCOUS CAPSULE, DELAYED 4 ST MEMBRANE POWDER 3 REL SPRINKLE IN PACKET PROLASTIN-C SAVELLA ORAL 2 QL INTRAVENOUS RECON 4 PA TABLET SOLN SAVELLA ORAL 2 QL PROLIA TABLETS,DOSE PACK SUBCUTANEOUS 3 PA; QL SYRINGE SCLEROSOL INTRAPLEURAL PROPECIA ORAL 3 3 INTRAPLEURAL TABLET AEROSOL POWDER PROSCAR ORAL SENSIPAR ORAL 3 PA 4 TABLET TABLET PROTHELIAL MUCOUS SENTRA AM ORAL 3 3 MEMBRANE PASTE CAPSULE PROTOPAM CHLORIDE SENTRA PM ORAL 3 INJECTION RECON 3 CAPSULE SOLN sodium bisulfite granules 1 pulmosal inhalation solution 1 sodium chlor 0.9% for nebulization 1 bacteriostat injection solution PULMOZYME sodium chloride inhalation INHALATION 4 1 SOLUTION solution for nebulization Q-CARE RX Q2 KIT 3 SODIUM NITRITE INTRAVENOUS 3 Q-CARE RX Q4 KIT 3 SOLUTION RADIAGEL TOPICAL 3 sodium succinate powder 1 GEL sodium thiosulfate 1 RADIGEL ACEMANNAN intravenous solution HYDROGEL TOPICAL 3 GEL SOMAVERT SUBCUTANEOUS 4 RADIOGARDASE ORAL 3 RECON SOLN CAPSULE sorbitol solution 1 raloxifene oral tablet 1 STAXYN ORAL RAPAFLO ORAL 3 TABLET,DISINTEGRATI 3 PA CAPSULE NG Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 143 Drug Name Tier Notes Drug Name Tier Notes STENDRA ORAL trospium oral 3 PA TABLET capsule,extended release 1 STERILE TALC 24hr INTRAPLEURAL trospium oral tablet 1 3 SUSPENSION FOR TYBOST ORAL TABLET 3 RECONSTITUTION TYSABRI sterile water for injection 1 INTRAVENOUS 4 PA injection solution SOLUTION STRENSIQ UROXATRAL ORAL SUBCUTANEOUS 4 PA TABLET EXTENDED 3 SOLUTION RELEASE 24 HR SUBOXONE VAYACOG ORAL 2 PA; QL 3 SUBLINGUAL FILM CAPSULE SULFZIX ORAL VAYARIN ORAL 3 3 POWDER CAPSULE SURFAXIN VENELEX TOPICAL 3 INTRATRACHEAL 3 OINTMENT SUSPENSION VENELEX TOPICAL 3 SURVANTA OINTMENT IN PACKET INTRATRACHEAL 3 VESICARE ORAL SUSPENSION 3 TABLET SYPRINE ORAL 3 CAPSULE VIAGRA ORAL TABLET 2 PA tamsulosin oral VIASPAN (BELZER UW) capsule,extended release 1 COLD SS PERFUSION 3 24hr IRRIGATION SOLUTION THERAMINE ORAL VIMIZIM 3 CAPSULE INTRAVENOUS 4 SOLUTION THERAMINE PLUS VISTOGARD ORAL ORAL POWDER IN 3 3 PACKET GRANULES IN PACKET THIOLA ORAL TABLET 3 PA; QL VISUDYNE INTRAVENOUS RECON 4 TL-ICARE ORAL 3 SOLN CAPSULE VIVITROL tolterodine oral INTRAMUSCULAR 4 PA capsule,extended release 1 SUSPENSION,EXTENDE 24hr D REL RECON tolterodine oral tablet 1 VORAXAZE TOVIAZ ORAL TABLET INTRAVENOUS RECON 3 EXTENDED RELEASE 24 3 SOLN HR VPRIV INTRAVENOUS 4 PA TOZAL ORAL CAPSULE 3 RECON SOLN triamcinolone acetonide vp-zel oral tablet 1 1 QL dental paste water for inject, bacteriostat 1 injection solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 144 Drug Name Tier Notes Drug Name Tier Notes water for injection, sterile ZOMETA 1 injection solution INTRAVENOUS 3 PA water for injection, sterile SOLUTION 4 MG/5 ML intravenous parenteral 1 ZUBSOLV SUBLINGUAL 3 PA; QL solution TABLET WHYTEDERM ZYTAZE ORAL 3 SURGIPAK TOPICAL 3 CAPSULE KIT VITAMINS XGEVA advanced am-pm oral combo 1 SUBCUTANEOUS 3 PA; QL pack SOLUTION ANIMI-3 WITH VITAMIN XIAFLEX INJECTION 3 4 PA D ORAL CAPSULE RECON SOLN AQUASOL A XOFIGO INTRAVENOUS 3 PA INTRAMUSCULAR 3 SOLUTION SOLUTION ZAVESCA ORAL ascorbic acid injection 4 PA 1 CAPSULE solution ZEMAIRA b complex 100 injection 1 INTRAVENOUS RECON 4 PA solution SOLN B-12 COMPLIANCE 3 ZEMPLAR INJECTION KIT INTRAVENOUS 2 SOLUTION b-12 kit injection kit 1 ZEMPLAR ORAL BACMIN ORAL TABLET 3 3 CAPSULE calcitriol intravenous 1 ZINECARD (AS HCL) solution INTRAVENOUS RECON 3 calcitriol oral capsule 1 SOLN calcitriol oral solution 1 ZN-DTPA INTRAVENOUS 3 CARDIOTEK-RX SOLUTION (BIOPERINE) ORAL 3 TABLET zoledronic acid intravenous 1 PA recon soln CEREFOLIN NAC (ALGAL OIL) ORAL 3 zoledronic acid intravenous 1 PA TABLET solution CEREFOLIN ORAL 3 ZOLEDRONIC TABLET ACID-MANNITOL-WATE 4 R INTRAVENOUS chewable PIGGYBACK multivit-a,b,d,e,k,zn oral 1 tablet,chewable zoledronic acid-mannitol-water 4 ciferex oral capsule 1 intravenous solution COMPLETE ZOMETA FORMULATION D3000 3 INTRAVENOUS 3 ORAL CAPSULE SOLUTION 4 MG/100 ML COMPLETE FORMULATION 3 PEDIATRIC ORAL DROPS Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 145 Drug Name Tier Notes Drug Name Tier Notes corvita oral tablet 1 folbee plus oral tablet 1 CORVITE FREE ORAL folbic oral tablet 1 3 TABLET folbic rf oral tablet 1 CORVITE ORAL FOLGARD RX ORAL 3 3 TABLET TABLET cyanocobalamin (vitamin 1 folic acid injection solution 1 b-12) injection solution folic acid oral tablet 1 DEPLIN (ALGAL OIL) 3 folic acid-vit b6-vit b12 oral ORAL CAPSULE 1 tablet DIALYVITE 3000 ORAL 3 TABLET folplex 2.2 oral tablet 1 DIALYVITE 5000 ORAL foltanx oral tablet 1 3 TABLET foltanx rf oral capsule 1 DIALYVITE 800 WITH FOLTRATE ORAL 3 3 IRON ORAL TABLET TABLET dialyvite oral tablet 1 FOLTX ORAL TABLET 3 DIALYVITE SUPREME D FORTAVIT ORAL 3 3 ORAL TABLET CAPSULE DRISDOL ORAL hydroxocobalamin 3 1 CAPSULE intramuscular solution DURACHOL ORAL 3 INFUVITE ADULT CAPSULE INTRAVENOUS 3 ELDERCAPS ORAL SOLUTION 3 CAPSULE INFUVITE PEDIATRIC ELIGEN B12 ORAL INTRAVENOUS 3 3 TABLET SOLUTION levomefolate calcium oral ENLYTE (FERROUS 1 GLYCINE) ORAL tablet 3 CAPSULE,IR - DELAY levomefolate-algal oil oral 1 REL,BIPHASE capsule ergocalciferol (vitamin d2) levomefol-b6-meb12-algal 1 1 oral capsule oil oral capsule ESCAVITE D ORAL lmefol ca-acetyl-meb12-algal 1 TABLET,CHEW,IR - 3 oral tablet DR,BIPHASE l-methyl-b6-b12 oral tablet 1 ESCAVITE LQ ORAL 3 l-methylfolate ca p-5-p DROPS 1 me-cbl oral capsule ESCAVITE ORAL 3 l-methylfolate forte oral TABLET,CHEWABLE 1 capsule fabb oral tablet 1 l-methylfolate oral tablet 1 FLORIVA ORAL 3 TABLET,CHEWABLE l-methyl-mc nac oral tablet 1 FLORIVA PLUS ORAL l-methyl-mc oral tablet 1 3 DROPS lmthf-pyridoxine-cyanocobal 1 amn oral tablet folbee oral tablet 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 146 Drug Name Tier Notes Drug Name Tier Notes m.v.i. adult intravenous NEPHROCAPS QT ORAL 1 solution TABLET,DISINTEGRATI 3 M.V.I. PEDIATRIC NG INTRAVENOUS RECON 3 nephro-vite rx oral tablet 1 SOLN NEURIN-SL 3 M.V.I.-12 (WITHOUT SUBLINGUAL TABLET VITAMIN K) 3 NICOMIDE INTRAVENOUS (SELENIUM-CHROMIU 3 SOLUTION M) ORAL TABLET MACUVEX ORAL NICOMIDE ORAL 3 3 CAPSULE TABLET MACUZIN ORAL NIVA-FOL ORAL 3 3 CAPSULE TABLET MEPHYTON ORAL NOXIFOL-D3 ORAL 2 3 TABLET TABLET metafolbic oral tablet 1 NUTRICAP ORAL 3 metafolbic plus oral tablet 1 TABLET metafolbic plus rf oral tablet 1 OCUVEL ORAL 3 METANX (ALGAL OIL) CAPSULE 3 ORAL CAPSULE ortho d oral capsule 1 METHAVER ORAL PED 3 CAPSULE MULTIVITAMINS-A,B,D, 3 multi-vit with fluoride-iron E,K,ZN ORAL DROPS 1 oral drops PHYSICIANS EZ USE 3 multi-vitamin with fluoride B-12 INJECTION KIT 1 oral drops PHYTONADIONE multivitamin with fluoride (VITAMIN K1) 3 1 oral tablet,chewable INJECTION SYRINGE multi-vitamin with fluoride PODIAPN ORAL 1 3 oral tablet,chewable CAPSULE multivitamins with fluoride POLY-VI-FLOR FS ORAL 1 3 oral tablet,chewable FILM mvc-fluoride oral POLY-VI-FLOR ORAL 1 tablet,chewable DROPS,SUSPENSION 3 BIPHASIC MYKIDZ IRON POLY-VI-FLOR ORAL FLUORIDE ORAL 2 3 SUSPENSION TABLET,CHEWABLE mynephrocaps oral capsule 1 POLY-VI-FLOR WITH IRON ORAL NASCOBAL NASAL 3 3 DROPS,SUSPENSION SPRAY,NON-AEROSOL BIPHASIC nephplex rx oral tablet 1 POLY-VI-FLOR WITH NEPHROCAPS ORAL IRON ORAL 3 3 CAPSULE TABLET,CHEWABLE POTABA ORAL 3 CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 147 Drug Name Tier Notes Drug Name Tier Notes PROTECT IRON ORAL tri-vit with fluoride and iron 3 1 TABLET oral drops PURALOR CI ORAL tri-vitamin with fluoride oral 1 TABLET,CHEW,IR - 3 drops DR,BIPHASE UDAMIN SP ORAL 3 pyridoxine (vitamin b6) TABLET 1 injection solution VASCULERA ORAL 3 QUFLORA PEDIATRIC TABLET 3 DROPS ORAL DROPS v-c forte oral capsule 1 QUFLORA PEDIATRIC vic-forte oral capsule 1 ORAL 3 VIRT-CAPS ORAL TABLET,CHEWABLE 3 CAPSULE renal caps oral capsule 1 virt-gard oral tablet 1 rena-vite rx oral tablet 1 virt-vite forte oral tablet 1 reno caps oral capsule 1 virt-vite oral tablet 1 REQ49+ ORAL TABLET 3 QL VIRT-VITE PLUS ORAL REVESTA ORAL 3 3 TABLET CAPSULE vit 3 oral capsule 1 ROCALTROL ORAL 3 VITAL-D RX ORAL CAPSULE 3 TABLET ROCALTROL ORAL 3 SOLUTION vitamin d2 oral capsule 1 SOFTGELS vitamin k injection solution 1 MULTIVIT-A,B,D,E,K,ZN 3 vitamin k1 injection solution 1 ORAL CAPSULE vitamins a,c,d and fluoride STROVITE FORTE 1 3 oral drops ORAL TABLET VITA-RESPA ORAL STROVITE ONE ORAL 3 3 TABLET TABLET vol-care rx oral tablet 1 SUPERVITE (EC) ORAL TABLET,DELAYED 3 vp-vite rx oral tablet 1 RELEASE (DR/EC) zavara oral capsule 1 SUPERVITE ORAL 3 LIQUID TEXAVITE LQ ORAL 3 DROPS thiamine hcl (vitamin b1) 1 injection solution tl gard rx oral tablet 1 triphrocaps oral capsule 1 triple vitamin with fluoride 1 oral drops TRI-VI-FLOR ORAL DROPS,SUSPENSION 3 BIPHASIC

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 148 Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit Effective 4/1/16 149 KEY PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month. ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.

Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Customer Service at the telephone number listed on your identification card. For more information, please visit anthem.com/ca }}If you have additional questions about your prescription benefits please call the Customer Service number on your ID card

}}Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET

}}For the most current version of this prescription drug list, please visit anthem.com/ca

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 02/16