AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 0.667000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 0.750000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 1.500000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 2.000000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 2.500000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 3.000000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 3.750000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 6.000000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE MAX DAILY UNITS : 7.500000 240408 CARDIOTONIC AGENTS 000004 DIGOXIN PACE Medical Exception Required 282032 RESPIRATORY AND CNS STIMULANTS 000007 CAFFEINE/DEXTROSE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000008 CAFFEINE/MULTIVITAMIN PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000009 CAFFEINE/ETHYL ALCOHOL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000010 CAFFEINE/SODIUM BENZOATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000011 CAFFEINE CITRATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282032 RESPIRATORY AND CNS STIMULANTS 000012 CAFFEINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000013 THEOPHYLLINE/POTASSIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000014 THEOPHYLLINE/IODINATD GLYCEROL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000015 THEOPHYLLINE IN DEXTROSE 5 % PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000016 THEOPHYLL/ISOPROT/EPD/POT IOD PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000017 THEOPHYLLINE/EPHED/P.I./PHENOB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000018 THEOPHYLL/EPHEDRINE/PHENOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000019 THEOPHYLLINE/EPHED/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000020 THEOPHYLLINE/EPHED/HYDROXYZINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000022 THEOPHYLLINE/EPHEDRINE/PYRIL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000023 THEOPHYLLINE/EPHEDRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000024 THEOPHYLL/PSEUDOEPHED/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000025 THEOPHYLLINE ANHYDROUS PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000026 THEOPHYLLINE SOD GLY PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000027 AMINOPHYLLINE IN 0.9 % NACL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000028 AMINOPHYLLINE/POTASSIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000030 AMINOPHYLLINE/EPHED/POT IOD/PB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000032 AMINOPHYLLINE/EPHED/PHENOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000033 AMINOPHYLLINE/EPHED/AMOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000034 AMINOPHYLLINE/EPHED/PENTOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000035 AMINOPHYLLINE/EPHEDRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000036 AMINOPHYLLINE/PPA/CPM/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000037 AMINOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000038 DYPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000039 OXTRIPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents

1 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000042 GUAIFENESIN/THEOPHYLL/EPHED/PB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000043 GUAIFEN/THEOPHYLL/EPD/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000044 GUAIFEN/THEOPHYLLINE/EPHED/COD PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000045 GUAIFEN/THEOPHYLL/EPHED/PYRIL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000047 GUAIFENESIN/THEOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000048 GUAIFENESIN/THEOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000049 GUAIF/AMINOPHY/EPHED/PHENOBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000050 GUAIFENESIN/AMINOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000051 GUAIF/DYPHYLLIN/EPHED/PHENBARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000052 GUAIFEN/DYPHYLLINE/P‐EPHEDRINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000053 GUAIFENESIN/DYPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000054 GUAIFENESIN/OXTRIPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 000056 NOSCAPINE/THEOPHYLLINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121208 BETA‐ADRENERGIC AGONISTS 000060 ISOPROTERENOL/CALCIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000064 EPHEDRINE/POTASSIUM IODIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000065 EPHEDRINE/PHENOBARBITAL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000066 EPHEDRINE SULFATE/AMOBARBITAL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000067 EPHEDRINE SULFATE/SECOBARBITAL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 680400 ADRENALS 000070 BECLOMETHASONE DIPROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 000070 BECLOMETHASONE DIPROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 000070 BECLOMETHASONE DIPROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 680400 ADRENALS 000072 FLUNISOLIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 000072 FLUNISOLIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 000072 FLUNISOLIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 240404 ANTIARRHYTHMIC AGENTS 000073 QUINIDINE GLUCONATE PACE Medical Exception Required 280892 ANALGESICS AND ANTIPYRETICS, MISC. 000113 CLONIDINE HCL PACE Medical Exception Required 240816 CENTRAL ALPHA‐AGONISTS 000113 CLONIDINE HCL PACE Medical Exception Required 240816 CENTRAL ALPHA‐AGONISTS 000120 GUANFACINE HCL PACE Medical Exception Required 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 000120 GUANFACINE HCL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000127 CAPTOPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000128 CAPTOPRIL PACE MAX DAILY UNITS : 18.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000128 CAPTOPRIL PACE MAX DAILY UNITS : 36.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000128 CAPTOPRIL PACE MAX DAILY UNITS : 4.500000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000128 CAPTOPRIL PACE MAX DAILY UNITS : 9.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000128 CAPTOPRIL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000128 CAPTOPRIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000129 ENALAPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE MAX DAILY UNITS : 16.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE MAX DAILY UNITS : 40.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE MAX DAILY UNITS : 8.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000130 ENALAPRIL MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000131 LISINOPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 1.000000

2 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 1.400000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 16.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 40.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE MAX DAILY UNITS : 8.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 000132 LISINOPRIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 000142 PROPRANOLOL/HYDROCHLOROTHIAZID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 000155 DIHYDROERGOTAMINE MESYLATE PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 000155 DIHYDROERGOTAMINE MESYLATE PACE MAX DAILY UNITS : 0.500000 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 000155 DIHYDROERGOTAMINE MESYLATE PACE MAX DAILY UNITS : 3.000000 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 000155 DIHYDROERGOTAMINE MESYLATE PACE Medical Exception Required 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 000155 DIHYDROERGOTAMINE MESYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 241208 NITRATES AND NITRITES 000159 NITROGLYCERIN PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 000159 NITROGLYCERIN PACE Medical Exception Required 241208 NITRATES AND NITRITES 000160 AMYL NITRITE PACE Medical Exception Required 241208 NITRATES AND NITRITES 000166 ISOSORBIDE DINITRATE PACE Medical Exception Required 241292 VASODILATING AGENTS, MISCELLANEOUS 000175 ISOXSUPRINE HCL PACE Medical Exception Required 241292 VASODILATING AGENTS, MISCELLANEOUS 000177 ALPROSTADIL PACE AMOUNT : 8.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 241292 VASODILATING AGENTS, MISCELLANEOUS 000177 ALPROSTADIL PACE Used Exclusively in Males 241292 VASODILATING AGENTS, MISCELLANEOUS 000177 ALPROSTADIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 1.340000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 1.600000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 12.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 192.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 2.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 2.400000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 2.670000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 4.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 4.800000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE MAX DAILY UNITS : 6.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE Medical Exception Required 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000180 VERAPAMIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE MAX DAILY UNITS : 1.000000 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE MAX DAILY UNITS : 12.000000 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE MAX DAILY UNITS : 2.000000 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE MAX DAILY UNITS : 4.000000 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE MAX DAILY UNITS : 6.000000 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE Medical Exception Required 242808 DIHYDROPYRIDINES 000181 NIFEDIPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 1.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 1.285714 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 1.500000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 1.800000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 12.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 2.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 2.250000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 3.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 3.600000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 4.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 4.500000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 6.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE MAX DAILY UNITS : 72.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE Medical Exception Required 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 000182 DILTIAZEM HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242808 DIHYDROPYRIDINES 000183 NICARDIPINE HCL PACE MAX DAILY UNITS : 2.000000 242808 DIHYDROPYRIDINES 000183 NICARDIPINE HCL PACE MAX DAILY UNITS : 4.000000 242808 DIHYDROPYRIDINES 000183 NICARDIPINE HCL PACE MAX DAILY UNITS : 48.000000 242808 DIHYDROPYRIDINES 000183 NICARDIPINE HCL PACE MAX DAILY UNITS : 6.000000 242808 DIHYDROPYRIDINES 000183 NICARDIPINE HCL PACE Medical Exception Required 242808 DIHYDROPYRIDINES 000183 NICARDIPINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242808 DIHYDROPYRIDINES 000184 NIMODIPINE PACE Medical Exception Required 480800 ANTITUSSIVES 000206 CODEINE PHOSPHATE/GUAIFENESIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 000206 CODEINE PHOSPHATE/GUAIFENESIN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000206 CODEINE PHOSPHATE/GUAIFENESIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000209 GUAIFENESIN/HYDROCODONE PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 000209 GUAIFENESIN/HYDROCODONE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000209 GUAIFENESIN/HYDROCODONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000265 HYDROCODONE/PSEUDOEPHED/GUAIF PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30

3 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 480800 ANTITUSSIVES 000265 HYDROCODONE/PSEUDOEPHED/GUAIF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000265 HYDROCODONE/PSEUDOEPHED/GUAIF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 481600 EXPECTORANTS 000271 GUAIFENESIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000345 PROMETHAZINE HCL/CODEINE PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 000345 PROMETHAZINE HCL/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000345 PROMETHAZINE HCL/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000347 CHLORPHENIRAMINE/CODEINE PHOS PACE Medical Exception Required 480800 ANTITUSSIVES 000347 CHLORPHENIRAMINE/CODEINE PHOS PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 000347 CHLORPHENIRAMINE/CODEINE PHOS PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000347 CHLORPHENIRAMINE/CODEINE PHOS PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000348 CODEINE POLI/CHLORPHENIR POLIS PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 000348 CODEINE POLI/CHLORPHENIR POLIS PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000348 CODEINE POLI/CHLORPHENIR POLIS PACE MAX DAILY UNITS : 20.000000 480800 ANTITUSSIVES 000348 CODEINE POLI/CHLORPHENIR POLIS PACE Medical Exception Required 480800 ANTITUSSIVES 000348 CODEINE POLI/CHLORPHENIR POLIS PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000352 HYDROCODONE/CHLORPHEN P‐STIREX PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 000352 HYDROCODONE/CHLORPHEN P‐STIREX PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000352 HYDROCODONE/CHLORPHEN P‐STIREX PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000420 PROMETHAZINE/PHENYLEPH/CODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 000420 PROMETHAZINE/PHENYLEPH/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000420 PROMETHAZINE/PHENYLEPH/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40408 ETHYLENEDIAMINE DERIVATIVES 000438 PHENYLEPHRINE/PYRIL TAN/CPM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 000455 PHENYLPROPANOLAMINE HCL/ASA PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000484 PSEUDOEPHED/COD/CHLORPHENIR PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000484 PSEUDOEPHED/COD/CHLORPHENIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000486 PSEUDOEPHEDRINE HCL/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000487 HYDROCODONE/CPM/PSEUDOEPHED PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 000487 HYDROCODONE/CPM/PSEUDOEPHED PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000487 HYDROCODONE/CPM/PSEUDOEPHED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 000488 PSEUDOEPHED/HYDROCODONE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 000488 PSEUDOEPHED/HYDROCODONE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 000488 PSEUDOEPHED/HYDROCODONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40404 ETHANOLAMINE DERIVATIVES 000497 PSEUDOEPHED/DIPHENHYDRAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 400800 ALKALINIZING AGENTS 000523 SODIUM BICARBONATE PACE Used Exclusively in Females 560400 ANTACIDS AND ADSORBENTS 000523 SODIUM BICARBONATE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 000523 SODIUM BICARBONATE PACE Used Exclusively in Females 200404 IRON PREPARATIONS 000733 IRON DEXTRAN COMPLEX PACE Medical Exception Required 681200 CONTRACEPTIVES 000755 COPPER PACE Used Exclusively in Females 401200 REPLACEMENT PREPARATIONS 000755 COPPER PACE Used Exclusively in Females 682008 INSULINS 000768 INSULIN REGULAR, HUMAN PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 682020 SULFONYLUREAS 000800 CHLORPROPAMIDE PACE Medical Exception Required 402000 CALORIC AGENTS 000831 AA 3.5 %/ELECTROLYTE‐45 SOLN PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 000856 GLUTAMINE PACE Medical Exception Required 881600 VITAMIN D 000998 CALCIFEDIOL PACE Medical Exception Required 921200 ANTIDOTES 001063 LEUCOVORIN CALCIUM PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 001063 LEUCOVORIN CALCIUM PACE Medical Exception Required 880800 VITAMIN B COMPLEX 001063 LEUCOVORIN CALCIUM PACE Medical Exception Required 921200 ANTIDOTES 001108 SODIUM THIOSULFATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 560400 ANTACIDS AND ADSORBENTS 001163 CALCIUM CARBONATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 560400 ANTACIDS AND ADSORBENTS 001168 MAG HYDROX/ALUMINUM HYD/SIMETH PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562832 PROTECTANTS 001186 SUCRALFATE PACE MAX DAILY UNITS : 8.000000 562832 PROTECTANTS 001186 SUCRALFATE PACE MAX DAILY UNITS : 80.000000 562832 PROTECTANTS 001186 SUCRALFATE PACE Medical Exception Required 562828 PROSTAGLANDINS 001187 MISOPROSTOL PACE MAX DAILY UNITS : 4.000000 562828 PROSTAGLANDINS 001187 MISOPROSTOL PACE MAX DAILY UNITS : 8.000000 562828 PROSTAGLANDINS 001187 MISOPROSTOL PACE Medical Exception Required 561200 CATHARTICS AND LAXATIVES 001301 BISACODYL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 680800 ANDROGENS 001401 TESTOSTERONE ENANTHATE PACE Medical Exception Required 680800 ANDROGENS 001401 TESTOSTERONE ENANTHATE PACE Used Exclusively in Males 680800 ANDROGENS 001403 TESTOSTERONE PACE Medical Exception Required 680800 ANDROGENS 001403 TESTOSTERONE PACE Used Exclusively in Males 681604 ESTROGENS 001417 ESTRADIOL/PROGESTERONE PACE Medical Exception Required 681604 ESTROGENS 001417 ESTRADIOL/PROGESTERONE PACE Used Exclusively in Females 681604 ESTROGENS 001421 ESTRADIOL PACE Medical Exception Required 681604 ESTROGENS 001421 ESTRADIOL PACE Used Exclusively in Females 681604 ESTROGENS 001423 ESTROGENS, CONJUGATED/MEPROBAM PACE Used Exclusively in Females 681604 ESTROGENS 001424 ESTROGENS, CONJUGATED PACE Used Exclusively in Females 681604 ESTROGENS 001426 DIETHYLSTILBESTROL DIPHOSPHATE PACE Medical Exception Required 681604 ESTROGENS 001427 DIETHYLSTILBESTROL PACE Used Exclusively in Females

4 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 681604 ESTROGENS 001431 ESTROPIPATE PACE Used Exclusively in Females 681604 ESTROGENS 001432 QUINESTROL PACE Used Exclusively in Females 680800 ANDROGENS 001433 TESTOSTERONE AND ESTRADIOL CYP PACE Used Exclusively in Females 680800 ANDROGENS 001434 TESTOSTERONE ENAN/ESTRADIOL PACE Used Exclusively in Females 680800 ANDROGENS 001436 ME‐TESTOSTERONE/ESTROGEN,CON PACE Used Exclusively in Females 680800 ANDROGENS 001437 METHYLTESTOSTERONE/DIETHYLSTIL PACE Used Exclusively in Females 680800 ANDROGENS 001438 ESTROGEN,ESTER/ME‐TESTOSTERONE PACE Used Exclusively in Females 680800 ANDROGENS 001439 FLUOXYMEST/ETHINYL ESTRADIOL PACE Used Exclusively in Females 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 001440 PROGESTERONE PACE Used Exclusively in Females 683200 PROGESTINS 001440 PROGESTERONE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 001440 PROGESTERONE PACE Used Exclusively in Females 683200 PROGESTINS 001441 HYDROXYPROGESTERONE CAPROATE PACE Used Exclusively in Females 683200 PROGESTINS 001442 MEDROXYPROGESTERONE ACETATE PACE Used Exclusively in Females 683200 PROGESTINS 001443 NORETHINDRONE ACETATE PACE Used Exclusively in Females 760000 OXYTOCICS 001446 METHYLERGONOVINE MALEATE PACE Used Exclusively in Females 760000 OXYTOCICS 001447 OXYTOCIN PACE Used Exclusively in Females 760000 OXYTOCICS 001448 DINOPROST TROMETHAMINE PACE Used Exclusively in Females 760000 OXYTOCICS 001449 CARBOPROST TROMETHAMINE PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001451 ETHYNODIOL DIACETATE‐MESTRANOL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001452 NORETHINDRONE‐MESTRANOL PACE Medical Exception Required 681200 CONTRACEPTIVES 001452 NORETHINDRONE‐MESTRANOL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001453 NORETHINDRONE‐ETHINYL ESTRAD PACE Medical Exception Required 681200 CONTRACEPTIVES 001453 NORETHINDRONE‐ETHINYL ESTRAD PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001454 NORETHINDRONE‐E.ESTRADIOL‐IRON PACE Medical Exception Required 681200 CONTRACEPTIVES 001454 NORETHINDRONE‐E.ESTRADIOL‐IRON PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001455 NORETHINDRONE AC‐ETH ESTRADIOL PACE Medical Exception Required 681604 ESTROGENS 001455 NORETHINDRONE AC‐ETH ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 001455 NORETHINDRONE AC‐ETH ESTRADIOL PACE Used Exclusively in Females 681604 ESTROGENS 001455 NORETHINDRONE AC‐ETH ESTRADIOL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001456 ETHYNODIOL D‐ETHINYL ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 001456 ETHYNODIOL D‐ETHINYL ESTRADIOL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001457 NORGESTREL‐ETHINYL ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 001457 NORGESTREL‐ETHINYL ESTRADIOL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001458 NORGESTREL PACE Medical Exception Required 681200 CONTRACEPTIVES 001458 NORGESTREL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001459 NORETHINDRONE PACE Medical Exception Required 681200 CONTRACEPTIVES 001459 NORETHINDRONE PACE Used Exclusively in Females 681200 CONTRACEPTIVES 001460 LEVONORGESTREL‐ETHIN ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 001460 LEVONORGESTREL‐ETHIN ESTRADIOL PACE Used Exclusively in Females 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 001462 NONOXYNOL 9 PACE Used Exclusively in Females 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 001464 OCTOXYNOL 9 PACE Used Exclusively in Females 240404 ANTIARRHYTHMIC AGENTS 001478 LIDOCAINE HCL PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 001478 LIDOCAINE HCL PACE Medical Exception Required 940000 DEVICES 001478 LIDOCAINE HCL PACE Medical Exception Required 521600 LOCAL ANESTHETICS (EENT) 001478 LIDOCAINE HCL PACE Medical Exception Required 720000 LOCAL ANESTHETICS (PARENTERAL) 001478 LIDOCAINE HCL PACE Medical Exception Required 521600 LOCAL ANESTHETICS (EENT) 001519 COCAINE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 521600 LOCAL ANESTHETICS (EENT) 001519 COCAINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 001540 YOHIMBINE HCL/STRYCHNINE PACE Used Exclusively in Males 280492 GENERAL ANESTHETICS, MISCELLANEOUS 001555 KETAMINE HCL PACE Medical Exception Required 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001563 AMOBARBITAL SOD/SECOBARBITAL PACE MAX DAILY UNITS : 0.500000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001563 AMOBARBITAL SOD/SECOBARBITAL PACE MAX DAILY UNITS : 1.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001564 AMOBARBITAL SODIUM PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001564 AMOBARBITAL SODIUM PACE MAX DAILY UNITS : 0.400000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001564 AMOBARBITAL SODIUM PACE Medical Exception Required 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE MAX DAILY UNITS : 0.900000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE MAX DAILY UNITS : 1.800000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE MAX DAILY UNITS : 15.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE MAX DAILY UNITS : 3.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE MAX DAILY UNITS : 6.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001566 BUTABARBITAL SODIUM PACE Medical Exception Required 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE MAX DAILY UNITS : 0.500000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE MAX DAILY UNITS : 1.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE MAX DAILY UNITS : 1.200000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE MAX DAILY UNITS : 1.666667 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE MAX DAILY UNITS : 2.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE MAX DAILY UNITS : 3.333333 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001568 PENTOBARBITAL SODIUM PACE Medical Exception Required

5 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001570 SECOBARBITAL SODIUM PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001570 SECOBARBITAL SODIUM PACE MAX DAILY UNITS : 1.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001570 SECOBARBITAL SODIUM PACE MAX DAILY UNITS : 2.000000 282404 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 001570 SECOBARBITAL SODIUM PACE Medical Exception Required 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001578 CHLORAL HYDRATE PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001578 CHLORAL HYDRATE PACE MAX DAILY UNITS : 1.600000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001578 CHLORAL HYDRATE PACE MAX DAILY UNITS : 10.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001578 CHLORAL HYDRATE PACE MAX DAILY UNITS : 2.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001578 CHLORAL HYDRATE PACE MAX DAILY UNITS : 3.100000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001578 CHLORAL HYDRATE PACE Medical Exception Required 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001580 ETHCHLORVYNOL PACE MAX DAILY UNITS : 0.666667 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001580 ETHCHLORVYNOL PACE MAX DAILY UNITS : 1.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001580 ETHCHLORVYNOL PACE MAX DAILY UNITS : 2.500000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 001580 ETHCHLORVYNOL PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001592 TEMAZEPAM PACE MAX_CLAIM_QTY : 11.000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001592 TEMAZEPAM PACE MAX_CLAIM_QTY : 5.000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001592 TEMAZEPAM PACE MAX_CLAIM_QTY : 7.000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001592 TEMAZEPAM PACE AMOUNT : 15.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001592 TEMAZEPAM PACE AMOUNT : 240.000 TYPE : 'X' (Every X days) PERIOD DURATION : 183 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001592 TEMAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001593 FLURAZEPAM HCL PACE MAX DAILY UNITS : 1.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001593 FLURAZEPAM HCL PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001593 FLURAZEPAM HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001594 TRIAZOLAM PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001594 TRIAZOLAM PACE MAX_CLAIM_QTY : 11.000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001594 TRIAZOLAM PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 183 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001594 TRIAZOLAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001595 QUAZEPAM PACE INITIAL DOSE : 15.000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001595 QUAZEPAM PACE MAX DAILY UNITS : 1.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001595 QUAZEPAM PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001595 QUAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001610 CHLORDIAZEPOXIDE HCL PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001610 CHLORDIAZEPOXIDE HCL PACE MAX DAILY UNITS : 1.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001610 CHLORDIAZEPOXIDE HCL PACE MAX DAILY UNITS : 10.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001610 CHLORDIAZEPOXIDE HCL PACE MAX DAILY UNITS : 20.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001610 CHLORDIAZEPOXIDE HCL PACE MAX DAILY UNITS : 4.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001610 CHLORDIAZEPOXIDE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001611 CHLORDIAZEPOXIDE PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001611 CHLORDIAZEPOXIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 1.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 16.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 2.666667 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 4.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 5.333333 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE MAX DAILY UNITS : 8.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001612 CLORAZEPATE DIPOTASSIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 2.700000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 20.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 3.200000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 4.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 40.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 6.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE MAX DAILY UNITS : 8.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001615 DIAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001616 OXAZEPAM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001616 OXAZEPAM PACE MAX DAILY UNITS : 12.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001616 OXAZEPAM PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001616 OXAZEPAM PACE MAX DAILY UNITS : 4.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001616 OXAZEPAM PACE MAX DAILY UNITS : 6.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001616 OXAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE MAX DAILY UNITS : 1.500000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE MAX DAILY UNITS : 12.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE MAX DAILY UNITS : 2.000000

6 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE MAX DAILY UNITS : 3.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE MAX DAILY UNITS : 30.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE MAX DAILY UNITS : 6.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001617 ALPRAZOLAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001618 HALAZEPAM PACE MAX DAILY UNITS : 1.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001618 HALAZEPAM PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 001618 HALAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 1.400000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 100.000000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 2.700000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 20.000000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 6.700000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 001621 CHLORPROMAZINE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001626 FLUPHENAZINE HCL PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 001626 FLUPHENAZINE HCL PACE MAX DAILY UNITS : 10.000000 281608 ANTIPSYCHOTIC AGENTS 001626 FLUPHENAZINE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001626 FLUPHENAZINE HCL PACE MAX DAILY UNITS : 20.000000 281608 ANTIPSYCHOTIC AGENTS 001626 FLUPHENAZINE HCL PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 001626 FLUPHENAZINE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE INITIAL DOSE : 8.000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE MAX DAILY UNITS : 1.500000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE MAX DAILY UNITS : 12.000000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE MAX DAILY UNITS : 3.000000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE MAX DAILY UNITS : 4.800000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE MAX DAILY UNITS : 6.000000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE MAX DAILY UNITS : 7.500000 281608 ANTIPSYCHOTIC AGENTS 001627 PERPHENAZINE PACE Medical Exception Required 562208 ANTIHISTAMINES (GI DRUGS) 001628 PROCHLORPERAZINE EDISYLATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001628 PROCHLORPERAZINE EDISYLATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001630 TRIFLUOPERAZINE HCL PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 001630 TRIFLUOPERAZINE HCL PACE MAX DAILY UNITS : 10.000000 281608 ANTIPSYCHOTIC AGENTS 001630 TRIFLUOPERAZINE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001630 TRIFLUOPERAZINE HCL PACE MAX DAILY UNITS : 5.000000 281608 ANTIPSYCHOTIC AGENTS 001630 TRIFLUOPERAZINE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 1.400000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 10.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 13.400000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 20.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 40.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 6.400000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 001631 THIORIDAZINE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001635 MESORIDAZINE BESYLATE PACE MAX DAILY UNITS : 1.250000 281608 ANTIPSYCHOTIC AGENTS 001635 MESORIDAZINE BESYLATE PACE MAX DAILY UNITS : 12.500000 281608 ANTIPSYCHOTIC AGENTS 001635 MESORIDAZINE BESYLATE PACE MAX DAILY UNITS : 2.500000 281608 ANTIPSYCHOTIC AGENTS 001635 MESORIDAZINE BESYLATE PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001638 ISOCARBOXAZID PACE INITIAL DOSE : 30.000 281604 ANTIDEPRESSANTS 001638 ISOCARBOXAZID PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001638 ISOCARBOXAZID PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001638 ISOCARBOXAZID PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001639 PHENELZINE SULFATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001639 PHENELZINE SULFATE PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 001639 PHENELZINE SULFATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001640 TRANYLCYPROMINE SULFATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001640 TRANYLCYPROMINE SULFATE PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 001640 TRANYLCYPROMINE SULFATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001641 IMIPRAMINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001641 IMIPRAMINE HCL PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 001641 IMIPRAMINE HCL PACE MAX DAILY UNITS : 25.000000 281604 ANTIDEPRESSANTS 001641 IMIPRAMINE HCL PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001641 IMIPRAMINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001642 IMIPRAMINE PAMOATE PACE Medical Exception Required

7 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE MAX DAILY UNITS : 1.700000 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE MAX DAILY UNITS : 2.500000 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE MAX DAILY UNITS : 25.000000 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE MAX DAILY UNITS : 3.400000 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001643 AMITRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE MAX DAILY UNITS : 15.000000 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE MAX DAILY UNITS : 75.000000 281604 ANTIDEPRESSANTS 001644 NORTRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 1.700000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 2.500000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 25.000000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 3.400000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 001645 DESIPRAMINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001646 PROTRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001646 PROTRIPTYLINE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 001646 PROTRIPTYLINE HCL PACE MAX DAILY UNITS : 8.000000 281604 ANTIDEPRESSANTS 001646 PROTRIPTYLINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001648 AMOXAPINE PACE INITIAL DOSE : 75.000 281604 ANTIDEPRESSANTS 001648 AMOXAPINE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001648 AMOXAPINE PACE MAX DAILY UNITS : 12.000000 281604 ANTIDEPRESSANTS 001648 AMOXAPINE PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 001648 AMOXAPINE PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 001648 AMOXAPINE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001649 TRIMIPRAMINE MALEATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001649 TRIMIPRAMINE MALEATE PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 001649 TRIMIPRAMINE MALEATE PACE MAX DAILY UNITS : 2.500000 281604 ANTIDEPRESSANTS 001649 TRIMIPRAMINE MALEATE PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001649 TRIMIPRAMINE MALEATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 001650 DOXEPIN HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 001650 DOXEPIN HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 1.700000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 2.500000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 25.000000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 3.400000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 41.700000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE MAX DAILY UNITS : 83.400000 281604 ANTIDEPRESSANTS 001650 DOXEPIN HCL PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 001650 DOXEPIN HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001651 MAPROTILINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001651 MAPROTILINE HCL PACE MAX DAILY UNITS : 2.700000 281604 ANTIDEPRESSANTS 001651 MAPROTILINE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 001651 MAPROTILINE HCL PACE MAX DAILY UNITS : 8.000000 281604 ANTIDEPRESSANTS 001651 MAPROTILINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE MAX DAILY UNITS : 1.400000 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE MAX DAILY UNITS : 2.700000 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE MAX DAILY UNITS : 8.000000 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001652 TRAZODONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 1.500000

8 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 2.700000 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE MAX DAILY UNITS : 5.400000 281604 ANTIDEPRESSANTS 001653 BUPROPION HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 0.154000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 1.500000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 15.000000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 001655 FLUOXETINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 001656 AMITRIPTYLINE/CHLORDIAZEPOXIDE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001660 HALOPERIDOL DECANOATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001661 HALOPERIDOL LACTATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE INITIAL DOSE : 1.000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE MAX DAILY UNITS : 0.500000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE MAX DAILY UNITS : 10.000000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE MAX DAILY UNITS : 20.000000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE MAX DAILY UNITS : 5.000000 281608 ANTIPSYCHOTIC AGENTS 001662 HALOPERIDOL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001663 LOXAPINE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001663 LOXAPINE HCL PACE MAX DAILY UNITS : 3.000000 281608 ANTIPSYCHOTIC AGENTS 001663 LOXAPINE HCL PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 001664 LOXAPINE SUCCINATE PACE MAX DAILY UNITS : 10.000000 281608 ANTIPSYCHOTIC AGENTS 001664 LOXAPINE SUCCINATE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001664 LOXAPINE SUCCINATE PACE MAX DAILY UNITS : 20.000000 281608 ANTIPSYCHOTIC AGENTS 001664 LOXAPINE SUCCINATE PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 001664 LOXAPINE SUCCINATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001667 THIOTHIXENE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 001668 THIOTHIXENE PACE INITIAL DOSE : 4.000 281608 ANTIPSYCHOTIC AGENTS 001668 THIOTHIXENE PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 001668 THIOTHIXENE PACE MAX DAILY UNITS : 10.000000 281608 ANTIPSYCHOTIC AGENTS 001668 THIOTHIXENE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 001668 THIOTHIXENE PACE MAX DAILY UNITS : 20.000000 281608 ANTIPSYCHOTIC AGENTS 001668 THIOTHIXENE PACE MAX DAILY UNITS : 4.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE Medical Exception Required 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 1.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 1.500000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 12.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 2.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 24.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 3.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 30.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 4.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 5.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 6.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 60.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE MAX DAILY UNITS : 8.000000 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE Medical Exception Required 282032 RESPIRATORY AND CNS STIMULANTS 001682 METHYLPHENIDATE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001684 MEPERIDINE HCL/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001685 MEPERIDINE HCL/PROMETH HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001685 MEPERIDINE HCL/PROMETH HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001685 MEPERIDINE HCL/PROMETH HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001686 MEPERIDINE HCL/ATROPINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001686 MEPERIDINE HCL/ATROPINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001686 MEPERIDINE HCL/ATROPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001687 MEPERIDINE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001687 MEPERIDINE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001687 MEPERIDINE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001687 MEPERIDINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001688 ALPHAPRODINE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001689 PAREGORIC/KAOLIN/PECTIN PACE Medical Exception Required

9 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280808 OPIATE AGONISTS 001690 MORPHINE/OPIUM PACE Medical Exception Required 280808 OPIATE AGONISTS 001691 MORPHINE SULFATE/POTASSIUM/ALC PACE Medical Exception Required 280808 OPIATE AGONISTS 001693 MORPHINE SULFATE/ATROPINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001694 MORPHINE SULFATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001694 MORPHINE SULFATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001694 MORPHINE SULFATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001694 MORPHINE SULFATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001695 HYDROMORPHONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001695 HYDROMORPHONE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001695 HYDROMORPHONE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001695 HYDROMORPHONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001695 HYDROMORPHONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001696 OXYMORPHONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001696 OXYMORPHONE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001696 OXYMORPHONE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001696 OXYMORPHONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001696 OXYMORPHONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001697 CODEINE SULFATE/PAPAVERINE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001698 CODEINE/POTASSIUM CITRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE MAX DAILY UNITS : 12.121212 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE MAX DAILY UNITS : 12.300000 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001699 CODEINE/BUTALBITAL/ASA/CAFFEIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001700 CODEINE PHOS/ASPIRIN/CAFFEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001702 COD/ASA/SALICYLMD/ACETAMIN/CAF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001702 COD/ASA/SALICYLMD/ACETAMIN/CAF PACE Medical Exception Required 280808 OPIATE AGONISTS 001702 COD/ASA/SALICYLMD/ACETAMIN/CAF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001703 CODEINE PHOSPHATE/ASA/BUFFERS PACE Medical Exception Required 280808 OPIATE AGONISTS 001705 CODEINE/ASA/ACETAM/MG/AL HYDRX PACE Medical Exception Required 280808 OPIATE AGONISTS 001706 CODEINE/ASPIRIN/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001708 CODEINE/ASA/PHENACETIN/CAFFEIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001709 CODEINE/ASA/PHENACETIN/CAFFEIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001711 ASPIRIN/CODEINE PHOSPHATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001711 ASPIRIN/CODEINE PHOSPHATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001711 ASPIRIN/CODEINE PHOSPHATE PACE MAX DAILY UNITS : 12.300000 280808 OPIATE AGONISTS 001711 ASPIRIN/CODEINE PHOSPHATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001711 ASPIRIN/CODEINE PHOSPHATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001712 CODEINE/ASA/ACETAMINOPHEN/CAFF PACE Medical Exception Required 280808 OPIATE AGONISTS 001713 BUTALBIT/ACETAMIN/CAFF/CODEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001713 BUTALBIT/ACETAMIN/CAFF/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001713 BUTALBIT/ACETAMIN/CAFF/CODEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001713 BUTALBIT/ACETAMIN/CAFF/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001715 CODEINE/BUTALB/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE MAX DAILY UNITS : 12.000000 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE MAX DAILY UNITS : 13.333334 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE MAX DAILY UNITS : 166.666667 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE MAX DAILY UNITS : 8.000000 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE MAX DAILY UNITS : 90.000000 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001717 ACETAMINOPHEN WITH CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001720 CARISOPRODOL/ASPIRIN/CODEINE PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001720 CARISOPRODOL/ASPIRIN/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001720 CARISOPRODOL/ASPIRIN/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001721 CODEINE PHOSPHATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001721 CODEINE PHOSPHATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001721 CODEINE PHOSPHATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001721 CODEINE PHOSPHATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001722 CODEINE SULFATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001722 CODEINE SULFATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001722 CODEINE SULFATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001722 CODEINE SULFATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001724 HYDROCODONE/ASPIRIN/CAFFEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001727 HYDROCODONE BITARTRATE/ASPIRIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90

10 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280808 OPIATE AGONISTS 001727 HYDROCODONE BITARTRATE/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001727 HYDROCODONE BITARTRATE/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001727 HYDROCODONE BITARTRATE/ASPIRIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 10.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 119.760479 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 12.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 120.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 16.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 5.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 8.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE MAX DAILY UNITS : 90.000000 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001730 HYDROCODONE/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001731 HYDROCODONE BITARTRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001731 HYDROCODONE BITARTRATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001731 HYDROCODONE BITARTRATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001731 HYDROCODONE BITARTRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001731 HYDROCODONE BITARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001732 DIHYDROCODEINE/CAFFEIN/PROMETH PACE Medical Exception Required 280808 OPIATE AGONISTS 001733 DIHY‐COD/ASA/CAFFEINE/PROMETH PACE Medical Exception Required 280808 OPIATE AGONISTS 001734 ASPIRIN/CAFFEINE/DIHYDROCODEIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001734 ASPIRIN/CAFFEINE/DIHYDROCODEIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001735 DIHY‐COD/ASA/ACETAMINOPHN/CAFF PACE Medical Exception Required 280808 OPIATE AGONISTS 001737 DIHY‐COD/SALICYLAMIDE/ACETAMIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001738 DIHY‐COD/ACETAMIN/CAFF/PROMETH PACE Medical Exception Required 280808 OPIATE AGONISTS 001739 ACETAMINOPHEN/CAFF/DIHYDROCOD PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001739 ACETAMINOPHEN/CAFF/DIHYDROCOD PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001739 ACETAMINOPHEN/CAFF/DIHYDROCOD PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001740 OXYCODONE/ASPIRIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001740 OXYCODONE/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001740 OXYCODONE/ASPIRIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE AMOUNT : 120.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 10.000000 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 12.000000 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 4.000000 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 60.000000 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 8.000000 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001741 OXYCODONE HCL/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 10.700000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 16.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 18.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 2.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 21.400000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 32.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 320.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 4.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 42.666667 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 5.400000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 64.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE MAX DAILY UNITS : 8.000000 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001742 OXYCODONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001743 LEVORPHANOL TARTRATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001743 LEVORPHANOL TARTRATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001743 LEVORPHANOL TARTRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001743 LEVORPHANOL TARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280812 OPIATE PARTIAL AGONISTS 001744 NALBUPHINE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90

11 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280812 OPIATE PARTIAL AGONISTS 001744 NALBUPHINE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280812 OPIATE PARTIAL AGONISTS 001744 NALBUPHINE HCL PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001744 NALBUPHINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001745 METHADONE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001745 METHADONE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001745 METHADONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001745 METHADONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001746 FENTANYL CITRATE/DROPERIDOL PACE Medical Exception Required 280808 OPIATE AGONISTS 001747 FENTANYL CITRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001747 FENTANYL CITRATE PACE MAX_CLAIM_QTY : 6.000 280808 OPIATE AGONISTS 001747 FENTANYL CITRATE PACE AMOUNT : 48.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 280808 OPIATE AGONISTS 001747 FENTANYL CITRATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001747 FENTANYL CITRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001747 FENTANYL CITRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001749 SUFENTANIL CITRATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001749 SUFENTANIL CITRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001749 SUFENTANIL CITRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001750 ALFENTANIL HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001750 ALFENTANIL HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001750 ALFENTANIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001751 OPIUM/ASPIRIN/CAFFEINE/CAMPHOR PACE Medical Exception Required 280808 OPIATE AGONISTS 001752 OPIUM/ASPIRIN/CAFFEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001754 OPIUM/PHENYL SALICYLATE/BISMU PACE Medical Exception Required 560800 ANTIDIARRHEA AGENTS 001756 OPIUM/KAOLIN/PECTIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001756 OPIUM/KAOLIN/PECTIN PACE Medical Exception Required 560800 ANTIDIARRHEA AGENTS 001757 OPIUM/BISMUTH SUBCARBONATE/KAO PACE Medical Exception Required 280808 OPIATE AGONISTS 001758 OPIUM/BELLADONNA ALKALOIDS PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001758 OPIUM/BELLADONNA ALKALOIDS PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 001758 OPIUM/BELLADONNA ALKALOIDS PACE Medical Exception Required 280808 OPIATE AGONISTS 001758 OPIUM/BELLADONNA ALKALOIDS PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001759 OPIUM/AMMONIUM CHLORIDE PACE Medical Exception Required 280808 OPIATE AGONISTS 001761 OPIUM PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 0.700000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 0.900000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 1.000000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 1.300000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 12.000000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 2.000000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 3.000000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 4.000000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE MAX DAILY UNITS : 8.000000 280812 OPIATE PARTIAL AGONISTS 001762 BUPRENORPHINE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001763 PROPOXYPHENE/ASPIRIN/CAFFEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001763 PROPOXYPHENE/ASPIRIN/CAFFEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001763 PROPOXYPHENE/ASPIRIN/CAFFEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001763 PROPOXYPHENE/ASPIRIN/CAFFEINE PACE MAX DAILY UNITS : 12.187500 280808 OPIATE AGONISTS 001763 PROPOXYPHENE/ASPIRIN/CAFFEINE PACE Medical Exception Required 280808 OPIATE AGONISTS 001763 PROPOXYPHENE/ASPIRIN/CAFFEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001764 PROPOXYP HCL/ASA/PHENACET/CAFF PACE Medical Exception Required 280808 OPIATE AGONISTS 001765 PROPOXYPHENE HCL/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001766 PROPOXYPHENE NAPSYLATE/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 001767 PROPOXYPHENE HCL/ACETAMINOPHEN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001767 PROPOXYPHENE HCL/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001767 PROPOXYPHENE HCL/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001768 PROPOXYPHENE NAP/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001768 PROPOXYPHENE NAP/ACETAMINOPHEN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001768 PROPOXYPHENE NAP/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 001768 PROPOXYPHENE NAP/ACETAMINOPHEN PACE MAX DAILY UNITS : 12.000000 280808 OPIATE AGONISTS 001768 PROPOXYPHENE NAP/ACETAMINOPHEN PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001768 PROPOXYPHENE NAP/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001769 PROPOXYPHENE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001769 PROPOXYPHENE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001769 PROPOXYPHENE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001769 PROPOXYPHENE HCL PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001769 PROPOXYPHENE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 001769 PROPOXYPHENE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 001770 PROPOXYPHENE NAPSYLATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001770 PROPOXYPHENE NAPSYLATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 001770 PROPOXYPHENE NAPSYLATE PACE Medical Exception Required

12 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280808 OPIATE AGONISTS 001770 PROPOXYPHENE NAPSYLATE PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 001770 PROPOXYPHENE NAPSYLATE PACE Medical Exception Required 280808 OPIATE AGONISTS 001770 PROPOXYPHENE NAPSYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001776 MEFENAMIC ACID PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001776 MEFENAMIC ACID PACE MAX DAILY UNITS : 5.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001776 MEFENAMIC ACID PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001776 MEFENAMIC ACID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280812 OPIATE PARTIAL AGONISTS 001777 BUTORPHANOL TARTRATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280812 OPIATE PARTIAL AGONISTS 001777 BUTORPHANOL TARTRATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280812 OPIATE PARTIAL AGONISTS 001777 BUTORPHANOL TARTRATE PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001777 BUTORPHANOL TARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280812 OPIATE PARTIAL AGONISTS 001779 PENTAZOCINE HCL/ASPIRIN PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001780 PENTAZOCINE HCL/ACETAMINOPHEN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280812 OPIATE PARTIAL AGONISTS 001780 PENTAZOCINE HCL/ACETAMINOPHEN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280812 OPIATE PARTIAL AGONISTS 001780 PENTAZOCINE HCL/ACETAMINOPHEN PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001780 PENTAZOCINE HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 6.000000 280812 OPIATE PARTIAL AGONISTS 001780 PENTAZOCINE HCL/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280812 OPIATE PARTIAL AGONISTS 001781 PENTAZOCINE HCL/NALOXONE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280812 OPIATE PARTIAL AGONISTS 001781 PENTAZOCINE HCL/NALOXONE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280812 OPIATE PARTIAL AGONISTS 001781 PENTAZOCINE HCL/NALOXONE HCL PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001781 PENTAZOCINE HCL/NALOXONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280812 OPIATE PARTIAL AGONISTS 001782 PENTAZOCINE LACTATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280812 OPIATE PARTIAL AGONISTS 001782 PENTAZOCINE LACTATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280812 OPIATE PARTIAL AGONISTS 001782 PENTAZOCINE LACTATE PACE Medical Exception Required 280812 OPIATE PARTIAL AGONISTS 001782 PENTAZOCINE LACTATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001790 BUTALBITAL/ASPIRIN/CAFFEINE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001790 BUTALBITAL/ASPIRIN/CAFFEINE PACE MAX DAILY UNITS : 12.300000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001790 BUTALBITAL/ASPIRIN/CAFFEINE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001790 BUTALBITAL/ASPIRIN/CAFFEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001791 ORPHENADRINE/ASPIRIN/CAFFEINE PACE MAX DAILY UNITS : 4.000000 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001791 ORPHENADRINE/ASPIRIN/CAFFEINE PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001794 ASPIRIN/CAFFEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001795 ASPIRIN/SALICYLAMIDE/CAFFEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001801 ASPIRIN/SOD BICARB/CITRIC ACID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001805 ASA/ACETAMINOPHEN/CAFFEINE/CAL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001807 ASPIRIN/ACETAMINOPHEN/CAFFEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 12.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 16.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 18.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 37.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 45.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 5.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 7.500000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 74.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 75.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 9.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE MAX DAILY UNITS : 90.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001820 ASPIRIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280892 ANALGESICS AND ANTIPYRETICS, MISC. 001833 SALICYLAMIDE/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001840 CHOLINE SALICYL/MAG SALICYLATE PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001840 CHOLINE SALICYL/MAG SALICYLATE PACE MAX DAILY UNITS : 30.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001840 CHOLINE SALICYL/MAG SALICYLATE PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001840 CHOLINE SALICYL/MAG SALICYLATE PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001840 CHOLINE SALICYL/MAG SALICYLATE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001840 CHOLINE SALICYL/MAG SALICYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001843 MAG SALICYLATE/PHENYLTOLX PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001844 MAGNESIUM SALICYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001845 SALSALATE PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001845 SALSALATE PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001845 SALSALATE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001845 SALSALATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280892 ANALGESICS AND ANTIPYRETICS, MISC. 001846 SODIUM THIOSALICYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001847 DIFLUNISAL PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001847 DIFLUNISAL PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001847 DIFLUNISAL PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 001847 DIFLUNISAL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26

13 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280892 ANALGESICS AND ANTIPYRETICS, MISC. 001854 BUTALB/ACETAMINOPHEN/CAFFEINE PACE Medical Exception Required 280892 ANALGESICS AND ANTIPYRETICS, MISC. 001858 BUTALBITAL/ACETAMINOPHEN PACE Medical Exception Required 280892 ANALGESICS AND ANTIPYRETICS, MISC. 001866 ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280892 ANALGESICS AND ANTIPYRETICS, MISC. 001871 ISOMETHEPT/DICHLPHN/ACETAMINOP PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281000 OPIATE ANTAGONISTS 001874 NALOXONE HCL PACE Medical Exception Required 281000 OPIATE ANTAGONISTS 001874 NALOXONE HCL PACE AMOUNT : 0.800 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE PERCENT : 25.0 281000 OPIATE ANTAGONISTS 001874 NALOXONE HCL PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE PERCENT : 25.0 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE MAX DAILY UNITS : 16.000000 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE MAX DAILY UNITS : 2.000000 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE MAX DAILY UNITS : 32.000000 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE MAX DAILY UNITS : 4.000000 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE MAX DAILY UNITS : 8.000000 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE Medical Exception Required 281208 BENZODIAZEPINES (ANTICONVULSANTS) 001894 CLONAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 283616 DOPAMINE PRECURSORS 001897 LEVODOPA PACE Medical Exception Required 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001906 ORPHENADRINE CITRATE PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001906 ORPHENADRINE CITRATE PACE MAX DAILY UNITS : 2.000000 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001906 ORPHENADRINE CITRATE PACE MAX DAILY UNITS : 4.000000 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001906 ORPHENADRINE CITRATE PACE MAX DAILY UNITS : 6.666667 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 001906 ORPHENADRINE CITRATE PACE Medical Exception Required 480800 ANTITUSSIVES 001925 DEXTROMETHORPHAN HBR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001938 METHOCARBAMOL PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001938 METHOCARBAMOL PACE MAX DAILY UNITS : 45.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001938 METHOCARBAMOL PACE MAX DAILY UNITS : 6.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001938 METHOCARBAMOL PACE MAX DAILY UNITS : 9.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001938 METHOCARBAMOL PACE Medical Exception Required 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001941 CHLORZOXAZONE PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001941 CHLORZOXAZONE PACE MAX DAILY UNITS : 12.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001941 CHLORZOXAZONE PACE MAX DAILY UNITS : 4.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001941 CHLORZOXAZONE PACE MAX DAILY UNITS : 6.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001941 CHLORZOXAZONE PACE MAX DAILY UNITS : 8.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001941 CHLORZOXAZONE PACE Medical Exception Required 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001942 CARISOPRODOL/ASPIRIN PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001944 CARISOPRODOL PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001944 CARISOPRODOL PACE MAX DAILY UNITS : 4.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001944 CARISOPRODOL PACE MAX DAILY UNITS : 5.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001944 CARISOPRODOL PACE Medical Exception Required 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001945 METAXALONE PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001945 METAXALONE PACE MAX DAILY UNITS : 4.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001945 METAXALONE PACE MAX DAILY UNITS : 8.000000 122008 DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS 001947 DANTROLENE SODIUM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122008 DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS 001947 DANTROLENE SODIUM PACE MAX DAILY UNITS : 16.000000 122008 DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS 001947 DANTROLENE SODIUM PACE MAX DAILY UNITS : 20.000000 122008 DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS 001947 DANTROLENE SODIUM PACE MAX DAILY UNITS : 4.000000 122008 DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS 001947 DANTROLENE SODIUM PACE MAX DAILY UNITS : 8.000000 122008 DIRECT‐ACTING SKELETAL MUSCLE RELAXANTS 001947 DANTROLENE SODIUM PACE Medical Exception Required 122012 GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT 001949 BACLOFEN PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 001949 BACLOFEN PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122012 GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT 001949 BACLOFEN PACE MAX DAILY UNITS : 16.000000 122012 GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT 001949 BACLOFEN PACE MAX DAILY UNITS : 1600.000000 122012 GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT 001949 BACLOFEN PACE MAX DAILY UNITS : 4.000000 122012 GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT 001949 BACLOFEN PACE MAX DAILY UNITS : 8.000000 122012 GABA‐DERIVATIVE SKELETAL MUSCLE RELAXANT 001949 BACLOFEN PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 001949 BACLOFEN PACE Medical Exception Required 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 001950 CYCLOBENZAPRINE HCL PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE MAX DAILY UNITS : 1.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE MAX DAILY UNITS : 2.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE MAX DAILY UNITS : 3.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE MAX DAILY UNITS : 4.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE MAX DAILY UNITS : 6.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 001950 CYCLOBENZAPRINE HCL PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 001950 CYCLOBENZAPRINE HCL PACE Medical Exception Required 562292 ANTIEMETICS, MISCELLANEOUS 001955 DRONABINOL PACE Medical Exception Required 562292 ANTIEMETICS, MISCELLANEOUS 001955 DRONABINOL PACE MAX DAILY UNITS : 12.000000 562292 ANTIEMETICS, MISCELLANEOUS 001955 DRONABINOL PACE MAX DAILY UNITS : 24.000000 562292 ANTIEMETICS, MISCELLANEOUS 001955 DRONABINOL PACE MAX DAILY UNITS : 3.360000 562292 ANTIEMETICS, MISCELLANEOUS 001955 DRONABINOL PACE MAX DAILY UNITS : 6.000000 562208 ANTIHISTAMINES (GI DRUGS) 001970 DOXYLAMINE SUCCINATE/VIT B6 PACE Medical Exception Required

14 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 562208 ANTIHISTAMINES (GI DRUGS) 001975 MECLIZINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 120808 ANTIMUSCARINICS/ANTISPASMODICS 002028 GLYCOPYRROLATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 002050 EPINEPHRINE PACE Medical Exception Required 522400 MYDRIATICS 002050 EPINEPHRINE PACE Medical Exception Required 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 002050 EPINEPHRINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 522400 MYDRIATICS 002050 EPINEPHRINE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121208 BETA‐ADRENERGIC AGONISTS 002058 METAPROTERENOL SULFATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 282004 AMPHETAMINES 002064 AMPHETAMINE SULFATE PACE Medical Exception Required 282004 AMPHETAMINES 002064 AMPHETAMINE SULFATE PACE MAX DAILY UNITS : 12.000000 282004 AMPHETAMINES 002064 AMPHETAMINE SULFATE PACE MAX DAILY UNITS : 3.000000 282004 AMPHETAMINES 002064 AMPHETAMINE SULFATE PACE MAX DAILY UNITS : 4.000000 282004 AMPHETAMINES 002064 AMPHETAMINE SULFATE PACE MAX DAILY UNITS : 6.000000 282004 AMPHETAMINES 002064 AMPHETAMINE SULFATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE Medical Exception Required 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 12.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 2.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 24.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 3.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 4.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 6.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 60.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE MAX DAILY UNITS : 8.000000 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE Medical Exception Required 282004 AMPHETAMINES 002065 DEXTROAMPHETAMINE SULFATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282004 AMPHETAMINES 002067 METHAMPHETAMINE HCL PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 002067 METHAMPHETAMINE HCL PACE Medical Exception Required 282004 AMPHETAMINES 002067 METHAMPHETAMINE HCL PACE MAX DAILY UNITS : 1.000000 282004 AMPHETAMINES 002067 METHAMPHETAMINE HCL PACE MAX DAILY UNITS : 1.500000 282004 AMPHETAMINES 002067 METHAMPHETAMINE HCL PACE MAX DAILY UNITS : 3.000000 282004 AMPHETAMINES 002067 METHAMPHETAMINE HCL PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 002067 METHAMPHETAMINE HCL PACE Medical Exception Required 282004 AMPHETAMINES 002067 METHAMPHETAMINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 529200 EENT DRUGS, MISCELLANEOUS 002067 METHAMPHETAMINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282004 AMPHETAMINES 002070 BENZPHETAMINE HCL PACE Medical Exception Required 282004 AMPHETAMINES 002070 BENZPHETAMINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121208 BETA‐ADRENERGIC AGONISTS 002071 TERBUTALINE SULFATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121208 BETA‐ADRENERGIC AGONISTS 002072 RITODRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 121208 BETA‐ADRENERGIC AGONISTS 002072 RITODRINE HCL PACE Used Exclusively in Females 121208 BETA‐ADRENERGIC AGONISTS 002073 ALBUTEROL SULFATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE MAX DAILY UNITS : 12.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE MAX DAILY UNITS : 24.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE MAX DAILY UNITS : 480.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE MAX DAILY UNITS : 60.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002095 LABETALOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 002098 PHENOXYBENZAMINE HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 10.670000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 10.700000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 147.530000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 16.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 160.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 32.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 5.340000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 64.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 640.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 7.100000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE MAX DAILY UNITS : 80.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002101 PROPRANOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE MAX DAILY UNITS : 12.000000

15 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE MAX DAILY UNITS : 18.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE MAX DAILY UNITS : 4.500000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE MAX DAILY UNITS : 450.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE MAX DAILY UNITS : 6.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE MAX DAILY UNITS : 9.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002102 METOPROLOL TARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE MAX DAILY UNITS : 16.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE MAX DAILY UNITS : 2.666667 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002103 NADOLOL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002104 ATENOLOL PACE MAX DAILY UNITS : 100.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002104 ATENOLOL PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002104 ATENOLOL PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002104 ATENOLOL PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002104 ATENOLOL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002104 ATENOLOL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002105 TIMOLOL MALEATE PACE MAX DAILY UNITS : 12.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002105 TIMOLOL MALEATE PACE MAX DAILY UNITS : 3.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002105 TIMOLOL MALEATE PACE MAX DAILY UNITS : 6.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002105 TIMOLOL MALEATE PACE Medical Exception Required 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 002105 TIMOLOL MALEATE PACE MAX DAILY UNITS : 0.100000 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 002105 TIMOLOL MALEATE PACE MAX DAILY UNITS : 0.200000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002105 TIMOLOL MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 002105 TIMOLOL MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002106 PINDOLOL PACE MAX DAILY UNITS : 12.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002106 PINDOLOL PACE MAX DAILY UNITS : 6.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002106 PINDOLOL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002106 PINDOLOL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002107 ACEBUTOLOL HCL PACE MAX DAILY UNITS : 3.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002107 ACEBUTOLOL HCL PACE MAX DAILY UNITS : 6.000000 121608 BETA‐ADRENERGIC BLOCKING AGENTS(SYMPATH) 002107 ACEBUTOLOL HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002107 ACEBUTOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121608 BETA‐ADRENERGIC BLOCKING AGENTS(SYMPATH) 002107 ACEBUTOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002109 PENBUTOLOL SULFATE PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002109 PENBUTOLOL SULFATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002110 CARTEOLOL HCL PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002110 CARTEOLOL HCL PACE MAX DAILY UNITS : 4.000000 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 002110 CARTEOLOL HCL PACE MAX DAILY UNITS : 0.200000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 002110 CARTEOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 002110 CARTEOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282008 ANOREXIGENIC AGENTS 002111 PHENTERMINE HCL PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 002111 PHENTERMINE HCL PACE MAX DAILY UNITS : 1.000000 282008 ANOREXIGENIC AGENTS 002111 PHENTERMINE HCL PACE MAX DAILY UNITS : 2.000000 282008 ANOREXIGENIC AGENTS 002111 PHENTERMINE HCL PACE MAX DAILY UNITS : 3.000000 282008 ANOREXIGENIC AGENTS 002111 PHENTERMINE HCL PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 002111 PHENTERMINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282008 ANOREXIGENIC AGENTS 002113 DIETHYLPROPION HCL PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 002113 DIETHYLPROPION HCL PACE MAX DAILY UNITS : 1.400000 282008 ANOREXIGENIC AGENTS 002113 DIETHYLPROPION HCL PACE MAX DAILY UNITS : 4.000000 282008 ANOREXIGENIC AGENTS 002113 DIETHYLPROPION HCL PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 002113 DIETHYLPROPION HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282008 ANOREXIGENIC AGENTS 002115 PHENDIMETRAZINE TARTRATE PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 002115 PHENDIMETRAZINE TARTRATE PACE MAX DAILY UNITS : 1.000000 282008 ANOREXIGENIC AGENTS 002115 PHENDIMETRAZINE TARTRATE PACE MAX DAILY UNITS : 3.000000 282008 ANOREXIGENIC AGENTS 002115 PHENDIMETRAZINE TARTRATE PACE MAX DAILY UNITS : 6.000000 282008 ANOREXIGENIC AGENTS 002115 PHENDIMETRAZINE TARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 002116 FENFLURAMINE HCL PACE MAX DAILY UNITS : 6.000000 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 002117 MAZINDOL PACE MAX DAILY UNITS : 1.500000 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 002117 MAZINDOL PACE Medical Exception Required 563200 PROKINETIC AGENTS 002148 METOCLOPRAMIDE HCL PACE MAX DAILY UNITS : 12.000000 563200 PROKINETIC AGENTS 002148 METOCLOPRAMIDE HCL PACE MAX DAILY UNITS : 6.000000 563200 PROKINETIC AGENTS 002148 METOCLOPRAMIDE HCL PACE MAX DAILY UNITS : 60.000000 563200 PROKINETIC AGENTS 002148 METOCLOPRAMIDE HCL PACE MAX DAILY UNITS : 66.700000 563200 PROKINETIC AGENTS 002148 METOCLOPRAMIDE HCL PACE MAX DAILY UNITS : 80.000000 563200 PROKINETIC AGENTS 002148 METOCLOPRAMIDE HCL PACE Medical Exception Required 440000 ENZYMES 002159 COLLAGENASE CLOSTRIDIUM HIST. PACE Medical Exception Required

16 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002159 COLLAGENASE CLOSTRIDIUM HIST. PACE Medical Exception Required 842404 BASIC LOTIONS AND LINIMENTS 002184 GLYCERIN PACE Used Exclusively in Females 842412 BASIC OINTMENTS AND PROTECTANTS 002184 GLYCERIN PACE Used Exclusively in Females 940000 DEVICES 002184 GLYCERIN PACE Used Exclusively in Females 842400 EMOLLIENTS, DEMULCENTS, AND PROTECTANTS 002184 GLYCERIN PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002184 GLYCERIN PACE Used Exclusively in Females 842404 BASIC LOTIONS AND LINIMENTS 002265 VITAMINS A AND D/ALOE VERA PACE Medical Exception Required 842412 BASIC OINTMENTS AND PROTECTANTS 002265 VITAMINS A AND D/ALOE VERA PACE Medical Exception Required 960000 PHARMACEUTICAL AIDS 002285 EMOLLIENT BASE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002285 EMOLLIENT BASE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 002468 TRETINOIN PACE Medical Exception Required 841600 CELL STIMULANTS AND PROLIFERANTS 002468 TRETINOIN PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002476 ISOTRETINOIN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 002637 TROLAMINE SALICYLATE PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 002793 LOVASTATIN PACE MAX DAILY UNITS : 1.333333 240608 HMG‐COA REDUCTASE INHIBITORS 002793 LOVASTATIN PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 002793 LOVASTATIN PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 002793 LOVASTATIN PACE MAX DAILY UNITS : 8.000000 240608 HMG‐COA REDUCTASE INHIBITORS 002793 LOVASTATIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 202816 HEMOSTATICS 002802 TRANEXAMIC ACID PACE Medical Exception Required 202816 HEMOSTATICS 002802 TRANEXAMIC ACID PACE Used Exclusively in Females 681612 ESTROGEN AGONIST‐ANTAGONISTS 002821 CLOMIPHENE CITRATE PACE Medical Exception Required 681808 GONADOTROPINS 002822 UROFOLLITROPIN PACE Used Exclusively in Females 682800 PITUITARY 002824 SOMATROPIN PACE Medical Exception Required 682904 SOMATOSTATIN AGONISTS 002826 OCTREOTIDE ACETATE PACE Medical Exception Required 682800 PITUITARY 002841 DESMOPRESSIN ACETATE PACE Medical Exception Required 680400 ADRENALS 002867 HYDROCORTISONE PACE Used Exclusively in Females 520808 CORTICOSTEROIDS (EENT) 002867 HYDROCORTISONE PACE Used Exclusively in Females 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 002867 HYDROCORTISONE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002867 HYDROCORTISONE PACE Used Exclusively in Females 848000 SUNSCREEN AGENTS 002867 HYDROCORTISONE PACE Used Exclusively in Females 680400 ADRENALS 002886 DEXAMETHASONE ACETATE PACE Medical Exception Required 680400 ADRENALS 002888 DEXAMETHASONE SODIUM PHOSPHATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 002888 DEXAMETHASONE SODIUM PHOSPHATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 002888 DEXAMETHASONE SODIUM PHOSPHATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 002888 DEXAMETHASONE SODIUM PHOSPHATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 680400 ADRENALS 002891 TRIAMCINOLONE ACETONIDE PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 002891 TRIAMCINOLONE ACETONIDE PACE Medical Exception Required 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 002891 TRIAMCINOLONE ACETONIDE PACE Medical Exception Required 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 002891 TRIAMCINOLONE ACETONIDE PACE Medical Exception Required 680400 ADRENALS 002891 TRIAMCINOLONE ACETONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 002891 TRIAMCINOLONE ACETONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 002891 TRIAMCINOLONE ACETONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 002891 TRIAMCINOLONE ACETONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002981 OCTOXYNOL 9/SOD BICARB/LACTIC PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002983 SOD CHLORIDE/OCTOXYNOL9/A.ALUM PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002984 OCTOXYNOL/SOD LACTATE/LA/CPYRD PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002985 SOD CHLORIDE/SOD LAURYL SULF PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002986 SOD BICARB/SODIUM PERBORATE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002987 EDETATE SODIUM/DOCUSATE/PELE PACE Used Exclusively in Females 760000 OXYTOCICS 002988 DINOPROSTONE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002989 OCTOXYNOL 9/CETYLPYRD CL PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002992 AMMONIUM ALUM/BORIC ACID PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002993 SAL ACID/LA/MERC SALTS/OXYQUIN PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002995 METHYL SALICYLATE/BORIC ACID PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002998 OCTOXYNOL9/SOD CIT/BA/CIT ACID PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 002999 ALCOHOL/PROP GLY/ISOBUTANE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003001 PROPYLENE GLYCOL ALGINATE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003002 POT SORBATE/SOD LAC/LA/CPYRD PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003003 POTASSIUM SORBATE/SOD BISULF PACE Used Exclusively in Females 960000 PHARMACEUTICAL AIDS 003004 POTASSIUM SORBATE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003004 POTASSIUM SORBATE PACE Used Exclusively in Females

17 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003005 SOD PROPIONATE/AMINO ACID/UREA PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003006 THYM/ALUM/EUCALYPT/ME‐SAL/MEN PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003007 ACETIC ACID/CETYLPYRD CL PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 003008 ACETIC ACID PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003008 ACETIC ACID PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 003009 METHYLBNZ/POLYETHYLENE GLYCOL PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003013 EDETATE SOD/DOCUSATE/AMINACRIN PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003014 TRAGACANTH MUC/BENZALK CHL PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003015 LA/METHYLBNZ/METHYLPARABEN PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003016 SOD PERBORATE/SOD LAURYL SULF PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003017 PHOSP AC,DIL/SOD LAURYL SULF PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003020 ACETIC AC/RICINOLEIC/OXYQUINOL PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 003022 GENTIAN VIOLET PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 003029 CANDICIDIN PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 003031 MICONAZOLE NITRATE PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 003032 BUTOCONAZOLE NITRATE PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 003033 TERCONAZOLE PACE Used Exclusively in Females 681604 ESTROGENS 003037 DIENESTROL/LACTOSE PACE Used Exclusively in Females 681604 ESTROGENS 003038 DIENESTROL PACE Used Exclusively in Females 960000 PHARMACEUTICAL AIDS 003038 DIENESTROL PACE Used Exclusively in Females 81220 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) 003040 SULFATHIAZ/SULFACT/S‐BENZ/UREA PACE Used Exclusively in Females 81220 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) 003041 SULFATHIAZ/SULFACET/SULFABENZ PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003047 SULFANILAMIDE/ALLANT/A‐CRINE PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003048 SULFANILAMIDE PACE Used Exclusively in Females 81220 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) 003048 SULFANILAMIDE PACE Used Exclusively in Females 840404 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) 003049 OXYTETRACYCLINE/POLYMYXIN B PACE Used Exclusively in Females 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 003304 BETAMETHASONE DIPROPIONATE PACE Medical Exception Required 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 003304 BETAMETHASONE DIPROPIONATE PACE AMOUNT : 28.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 TOLERANCE PERCENT : 25.0 680400 ADRENALS 003329 MOMETASONE FUROATE PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 003329 MOMETASONE FUROATE PACE Medical Exception Required 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 003329 MOMETASONE FUROATE PACE Medical Exception Required 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 003329 MOMETASONE FUROATE PACE Medical Exception Required 680400 ADRENALS 003329 MOMETASONE FUROATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 003329 MOMETASONE FUROATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 003329 MOMETASONE FUROATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 003329 MOMETASONE FUROATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 003346 MAFENIDE ACETATE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003718 INDOMETHACIN SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003719 INDOMETHACIN PACE MAX DAILY UNITS : 2.700000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003719 INDOMETHACIN PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003719 INDOMETHACIN PACE MAX DAILY UNITS : 40.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003719 INDOMETHACIN PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003719 INDOMETHACIN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003719 INDOMETHACIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 003723 IBUPROFEN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 10.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 16.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 160.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 32.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 5.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 64.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE MAX DAILY UNITS : 80.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE Medical Exception Required 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 003723 IBUPROFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003723 IBUPROFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003724 FENOPROFEN CALCIUM PACE MAX DAILY UNITS : 10.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003724 FENOPROFEN CALCIUM PACE MAX DAILY UNITS : 16.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003724 FENOPROFEN CALCIUM PACE MAX DAILY UNITS : 5.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003724 FENOPROFEN CALCIUM PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003724 FENOPROFEN CALCIUM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003724 FENOPROFEN CALCIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003725 TOLMETIN SODIUM PACE MAX DAILY UNITS : 10.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003725 TOLMETIN SODIUM PACE MAX DAILY UNITS : 3.333333 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003725 TOLMETIN SODIUM PACE MAX DAILY UNITS : 5.000000

18 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003725 TOLMETIN SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE MAX DAILY UNITS : 2.200000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE MAX DAILY UNITS : 3.300000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE MAX DAILY UNITS : 4.400000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE MAX DAILY UNITS : 7.500000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003726 NAPROXEN SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 003727 NAPROXEN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003727 NAPROXEN PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003727 NAPROXEN PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003727 NAPROXEN PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003727 NAPROXEN PACE MAX DAILY UNITS : 60.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003727 NAPROXEN PACE Medical Exception Required 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 003727 NAPROXEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003727 NAPROXEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003728 FLURBIPROFEN PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003728 FLURBIPROFEN PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003728 FLURBIPROFEN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003728 FLURBIPROFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003729 SULINDAC PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003729 SULINDAC PACE MAX DAILY UNITS : 2.700000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003729 SULINDAC PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003729 SULINDAC PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003730 MECLOFENAMATE SODIUM PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003730 MECLOFENAMATE SODIUM PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003730 MECLOFENAMATE SODIUM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003730 MECLOFENAMATE SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003732 PIROXICAM PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003732 PIROXICAM PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003732 PIROXICAM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003732 PIROXICAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 003733 DICLOFENAC SODIUM PACE Medical Exception Required 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 003733 DICLOFENAC SODIUM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003733 DICLOFENAC SODIUM PACE Medical Exception Required 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 1.200000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 16.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 2.250000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 4.500000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE MAX DAILY UNITS : 9.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003733 DICLOFENAC SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 003733 DICLOFENAC SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003733 DICLOFENAC SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 003736 KETOPROFEN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 1.500000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 12.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 24.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE Medical Exception Required 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 003736 KETOPROFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 003736 KETOPROFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 003892 MECHLORETHAMINE HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003893 CYCLOPHOSPHAMIDE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003895 MELPHALAN HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003898 THIOTEPA PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003901 CARMUSTINE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003902 CISPLATIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003903 IFOSFAMIDE/MESNA PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003904 CARBOPLATIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003906 METHOTREXATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003907 FLUOROURACIL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003908 MERCAPTOPURINE PACE Medical Exception Required

19 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 100000 ANTINEOPLASTIC AGENTS 003909 FLOXURIDINE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003910 CYTARABINE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003912 VINBLASTINE SULFATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003913 VINCRISTINE SULFATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003914 DACTINOMYCIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003915 PLICAMYCIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003916 DOXORUBICIN HCL PACE Medical Exception Required 524092 ANTIGLAUCOMA AGENTS, MISCELLANEOUS 003917 MITOMYCIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003917 MITOMYCIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003918 BLEOMYCIN SULFATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003919 DAUNORUBICIN HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003920 STREPTOZOCIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003922 TESTOLACTONE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 003924 ESTRAMUSTINE PHOSPHATE SODIUM PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 003927 DACARBAZINE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003929 ASPARAGINASE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003930 ETOPOSIDE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003932 MITOXANTRONE HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 003933 FLUTAMIDE PACE Used Exclusively in Males 925600 PROTECTIVE AGENTS 003934 MESNA PACE Medical Exception Required 520404 ANTIBACTERIALS (EENT) 004013 DOXYCYCLINE HYCLATE PACE MAX DAILY UNITS : 2.000000 520404 ANTIBACTERIALS (EENT) 004013 DOXYCYCLINE HYCLATE PACE Medical Exception Required 81224 TETRACYCLINE ANTIBIOTICS 004013 DOXYCYCLINE HYCLATE PACE MAX DAILY UNITS : 1.500000 81224 TETRACYCLINE ANTIBIOTICS 004013 DOXYCYCLINE HYCLATE PACE MAX DAILY UNITS : 2.000000 81224 TETRACYCLINE ANTIBIOTICS 004013 DOXYCYCLINE HYCLATE PACE MAX DAILY UNITS : 3.000000 81224 TETRACYCLINE ANTIBIOTICS 004013 DOXYCYCLINE HYCLATE PACE MAX DAILY UNITS : 4.000000 81224 TETRACYCLINE ANTIBIOTICS 004013 DOXYCYCLINE HYCLATE PACE MAX DAILY UNITS : 6.000000 81224 TETRACYCLINE ANTIBIOTICS 004013 DOXYCYCLINE HYCLATE PACE Medical Exception Required 81224 TETRACYCLINE ANTIBIOTICS 004015 MINOCYCLINE HCL PACE Medical Exception Required 81224 TETRACYCLINE ANTIBIOTICS 004015 MINOCYCLINE HCL PACE AMOUNT : 84.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180 81202 AMINOGLYCOSIDE ANTIBIOTICS 004032 GENTAMICIN SULFATE PACE Medical Exception Required 520404 ANTIBACTERIALS (EENT) 004032 GENTAMICIN SULFATE PACE Medical Exception Required 840404 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) 004032 GENTAMICIN SULFATE PACE Medical Exception Required 81228 ANTIBACTERIALS, MISCELLANEOUS 004042 VANCOMYCIN HCL PACE Medical Exception Required 840404 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) 004045 CLINDAMYCIN PHOSPHATE PACE Medical Exception Required 81228 ANTIBACTERIALS, MISCELLANEOUS 004045 CLINDAMYCIN PHOSPHATE PACE Medical Exception Required 840404 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) 004045 CLINDAMYCIN PHOSPHATE PACE Used Exclusively in Females 81228 ANTIBACTERIALS, MISCELLANEOUS 004045 CLINDAMYCIN PHOSPHATE PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 004062 SULFATHIAZOLE PACE Used Exclusively in Females 81220 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) 004062 SULFATHIAZOLE PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 004066 SULFISOXAZOLE PACE Used Exclusively in Females 81220 SULFONAMIDE ANTIBIOTICS (SYSTEMIC) 004066 SULFISOXAZOLE PACE Used Exclusively in Females 81492 ANTIFUNGALS, MISCELLANEOUS 004126 GRISEOFULVIN, MICROSIZE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 81492 ANTIFUNGALS, MISCELLANEOUS 004127 GRISEOFULVIN ULTRAMICROSIZE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 520416 ANTIFUNGALS (EENT) 004129 NYSTATIN PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 004129 NYSTATIN PACE Used Exclusively in Females 81428 POLYENE ANTIFUNGALS 004129 NYSTATIN PACE Used Exclusively in Females 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 004132 KETOCONAZOLE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 81408 AZOLE ANTIFUNGALS 004132 KETOCONAZOLE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 004137 CLOTRIMAZOLE PACE Used Exclusively in Females 83008 ANTIMALARIALS 004142 QUININE SULFATE PACE Medical Exception Required 840404 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) 004157 METRONIDAZOLE PACE Used Exclusively in Females 83092 ANTIPROTOZOALS, MISCELLANEOUS 004157 METRONIDAZOLE PACE Used Exclusively in Females 83092 ANTIPROTOZOALS, MISCELLANEOUS 004162 PENTAMIDINE ISETHIONATE PACE Medical Exception Required 80800 ANTHELMINTICS 004167 MEBENDAZOLE PACE Medical Exception Required 801200 VACCINES 004199 RABIES VACCINE,HUMAN DIPLOID PACE Medical Exception Required 800400 ANTITOXINS AND IMMUNE GLOBULINS 004202 IMMUNE GLOBULIN,GAMMA(IGG) PACE Medical Exception Required 800400 ANTITOXINS AND IMMUNE GLOBULINS 004210 VARICELLA‐ZOSTER IMMUNE GLOB PACE Medical Exception Required 801200 VACCINES 004219 BCG VACCINE, LIVE PACE Medical Exception Required 520492 EENT ANTI‐INFECTIVES, MISCELLANEOUS 004265 POVIDONE‐IODINE PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 004265 POVIDONE‐IODINE PACE Used Exclusively in Females 522800 MOUTHWASHES AND GARGLES 004265 POVIDONE‐IODINE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 004265 POVIDONE‐IODINE PACE Used Exclusively in Females 940000 DEVICES 004270 SODIUM HYPOCHLORITE PACE Used Exclusively in Females 380000 DISINFECTANTS (FOR NON‐DERMATOLOGIC USE) 004270 SODIUM HYPOCHLORITE PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 004270 SODIUM HYPOCHLORITE PACE Used Exclusively in Females 960000 PHARMACEUTICAL AIDS 004270 SODIUM HYPOCHLORITE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 004270 SODIUM HYPOCHLORITE PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 004300 OXYQUINOLINE PACE Used Exclusively in Females 940000 DEVICES 004410 MEDICAL SUPPLY, MISCELLANEOUS PACE Used Exclusively in Females

20 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 004428 INTRA‐UTERINE DEVICE (IUD) PACE Used Exclusively in Females 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 004480 DIPHENHYDRAMINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40404 ETHANOLAMINE DERIVATIVES 004480 DIPHENHYDRAMINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40404 ETHANOLAMINE DERIVATIVES 004482 DOXYLAMINE SUCCINATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40420 PROPYLAMINE DERIVATIVES 004503 BROMPHENIRAMINE MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40420 PROPYLAMINE DERIVATIVES 004505 CHLORPHENIRAMINE MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 004516 METHYSERGIDE MALEATE PACE MAX DAILY UNITS : 4.000000 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 004516 METHYSERGIDE MALEATE PACE Medical Exception Required 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 004516 METHYSERGIDE MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 004517 CIMETIDINE IN 0.9 % NACL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE MAX DAILY UNITS : 16.000000 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE MAX DAILY UNITS : 160.000000 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE MAX DAILY UNITS : 2.000000 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE MAX DAILY UNITS : 4.000000 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE MAX DAILY UNITS : 5.400000 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE MAX DAILY UNITS : 8.000000 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE Medical Exception Required 562812 HISTAMINE H2‐ANTAGONISTS 004518 CIMETIDINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 004519 RANITIDINE IN 0.45 % SODIUM CL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE MAX DAILY UNITS : 1.000000 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE MAX DAILY UNITS : 12.000000 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE MAX DAILY UNITS : 2.000000 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE MAX DAILY UNITS : 20.000000 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE MAX DAILY UNITS : 4.000000 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE Medical Exception Required 562812 HISTAMINE H2‐ANTAGONISTS 004520 RANITIDINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 004521 FAMOTIDINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 004522 NIZATIDINE PACE MAX DAILY UNITS : 1.000000 562812 HISTAMINE H2‐ANTAGONISTS 004522 NIZATIDINE PACE MAX DAILY UNITS : 2.000000 562812 HISTAMINE H2‐ANTAGONISTS 004522 NIZATIDINE PACE MAX DAILY UNITS : 20.000000 562812 HISTAMINE H2‐ANTAGONISTS 004522 NIZATIDINE PACE MAX DAILY UNITS : 4.000000 562812 HISTAMINE H2‐ANTAGONISTS 004522 NIZATIDINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 924400 IMMUNOSUPPRESSIVE AGENTS 004523 AZATHIOPRINE PACE Medical Exception Required 520892 EENT ANTI‐INFLAMMATORY AGENTS, MISC. 004524 CYCLOSPORINE PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 004524 CYCLOSPORINE PACE Medical Exception Required 81820 INTERFERON ANTIVIRALS 004528 INTERFERON ALFA‐2B,RECOMB. PACE Medical Exception Required 489200 RESPIRATORY TRACT AGENTS, MISCELLANEOUS 004529 ALPHA‐1‐PROTEINASE INHIBITOR PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 004553 EPOETIN ALFA PACE Medical Exception Required 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 004569 TIOCONAZOLE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 004570 IFOSFAMIDE PACE Medical Exception Required 280808 OPIATE AGONISTS 004576 OXYCODONE HCL/ASPIRIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 004576 OXYCODONE HCL/ASPIRIN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 004576 OXYCODONE HCL/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 004576 OXYCODONE HCL/ASPIRIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562836 PROTON‐PUMP INHIBITORS 004673 OMEPRAZOLE PACE MAX DAILY UNITS : 1.000000 562836 PROTON‐PUMP INHIBITORS 004673 OMEPRAZOLE PACE MAX DAILY UNITS : 2.000000 562836 PROTON‐PUMP INHIBITORS 004673 OMEPRAZOLE PACE MAX DAILY UNITS : 20.000000 562836 PROTON‐PUMP INHIBITORS 004673 OMEPRAZOLE PACE MAX DAILY UNITS : 4.000000 562836 PROTON‐PUMP INHIBITORS 004673 OMEPRAZOLE PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 004673 OMEPRAZOLE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 004707 OXYQUINOLINE/BORIC ACID PACE Used Exclusively in Females 281604 ANTIDEPRESSANTS 004744 CLOMIPRAMINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 004744 CLOMIPRAMINE HCL PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 004744 CLOMIPRAMINE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 004744 CLOMIPRAMINE HCL PACE MAX DAILY UNITS : 5.000000 281604 ANTIDEPRESSANTS 004744 CLOMIPRAMINE HCL PACE Medical Exception Required 682004 BIGUANIDES 004763 METFORMIN HCL PACE Medical Exception Required 682004 BIGUANIDES 004763 METFORMIN HCL PACE MAX DAILY UNITS : 2.550000 682004 BIGUANIDES 004763 METFORMIN HCL PACE MAX DAILY UNITS : 25.500000 682004 BIGUANIDES 004763 METFORMIN HCL PACE MAX DAILY UNITS : 3.000000 682004 BIGUANIDES 004763 METFORMIN HCL PACE MAX DAILY UNITS : 3.400000 682004 BIGUANIDES 004763 METFORMIN HCL PACE MAX DAILY UNITS : 5.100000 682004 BIGUANIDES 004763 METFORMIN HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE MAX DAILY UNITS : 1.333333 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE MAX DAILY UNITS : 2.500000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE MAX DAILY UNITS : 21.333333 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 004791 SOTALOL HCL PACE MAX DAILY UNITS : 64.000000

21 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 842404 BASIC LOTIONS AND LINIMENTS 004794 DIMETHICONE PACE Medical Exception Required 842412 BASIC OINTMENTS AND PROTECTANTS 004794 DIMETHICONE PACE Medical Exception Required 840412 SCABICIDES AND PEDICULICIDES 004794 DIMETHICONE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE INITIAL DOSE : 25.000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 0.500000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 0.700000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE MAX DAILY UNITS : 9.000000 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 004834 CLOZAPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 960000 PHARMACEUTICAL AIDS 004841 POLYCARBOPHIL PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 004841 POLYCARBOPHIL PACE Used Exclusively in Females 681200 CONTRACEPTIVES 004845 NORGESTIMATE‐ETHINYL ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 004845 NORGESTIMATE‐ETHINYL ESTRADIOL PACE Used Exclusively in Females 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE MAX DAILY UNITS : 1.500000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE MAX DAILY UNITS : 12.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE MAX DAILY UNITS : 3.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE MAX DAILY UNITS : 6.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 004846 LORAZEPAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 004867 ONABOTULINUMTOXINA PACE Medical Exception Required 81408 AZOLE ANTIFUNGALS 004868 FLUCONAZOLE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 004879 IBUPROFEN/PSEUDOEPHEDRINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 83008 ANTIMALARIALS 004882 MEFLOQUINE HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 005168 BETAXOLOL HCL PACE MAX DAILY UNITS : 1.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 005168 BETAXOLOL HCL PACE MAX DAILY UNITS : 2.000000 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 005168 BETAXOLOL HCL PACE MAX DAILY UNITS : 0.200000 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 005168 BETAXOLOL HCL PACE MAX DAILY UNITS : 0.400000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 005168 BETAXOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 524008 BETA‐ADRENERGIC BLOCKING AGENTS (EENT) 005168 BETAXOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 005175 KETOROLAC TROMETHAMINE PACE AMOUNT : 5.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 005175 KETOROLAC TROMETHAMINE PACE AMOUNT : 5.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 005175 KETOROLAC TROMETHAMINE PACE MAX DAILY UNITS : 0.800000 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 005175 KETOROLAC TROMETHAMINE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 005175 KETOROLAC TROMETHAMINE PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 005175 KETOROLAC TROMETHAMINE PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 005175 KETOROLAC TROMETHAMINE PACE Medical Exception Required 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 005175 KETOROLAC TROMETHAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 005175 KETOROLAC TROMETHAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 524020 MIOTICS 005198 PILOCARPINE HCL PACE Medical Exception Required 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 005198 PILOCARPINE HCL PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 005733 OCTOXYNOL 9/BENZETHONIUM CHLOR PACE Used Exclusively in Females 280808 OPIATE AGONISTS 005810 DEZOCINE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 006024 IDARUBICIN HCL PACE Medical Exception Required 242000 ALPHA‐ADRENERGIC BLOCKING AGENTS 006031 DOXAZOSIN MESYLATE PACE Used Exclusively in Males 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 006034 BEPRIDIL HCL PACE MAX DAILY UNITS : 1.333333 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 006034 BEPRIDIL HCL PACE MAX DAILY UNITS : 2.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 006034 BEPRIDIL HCL PACE Medical Exception Required 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 006034 BEPRIDIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 006036 ESTAZOLAM PACE INITIAL DOSE : 1.000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 006036 ESTAZOLAM PACE MAX DAILY UNITS : 1.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 006036 ESTAZOLAM PACE MAX DAILY UNITS : 2.000000 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 006036 ESTAZOLAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 006040 PULSATILLA PACE Used Exclusively in Females 562220 5‐HT3 RECEPTOR ANTAGONISTS 006055 ONDANSETRON HCL PACE Medical Exception Required 242808 DIHYDROPYRIDINES 006063 ISRADIPINE PACE MAX DAILY UNITS : 2.000000 242808 DIHYDROPYRIDINES 006063 ISRADIPINE PACE MAX DAILY UNITS : 4.000000 242808 DIHYDROPYRIDINES 006063 ISRADIPINE PACE MAX DAILY UNITS : 8.000000 242808 DIHYDROPYRIDINES 006063 ISRADIPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 922000 IMMUNOMODULATORY AGENTS 006068 INTERFERON GAMMA‐1B,RECOMB. PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 006070 FILGRASTIM PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 006074 SARGRAMOSTIM PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006080 RAMIPRIL PACE MAX DAILY UNITS : 16.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006080 RAMIPRIL PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006080 RAMIPRIL PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006080 RAMIPRIL PACE MAX DAILY UNITS : 8.000000

22 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006080 RAMIPRIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE MAX DAILY UNITS : 2.400000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006089 ETODOLAC PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 006104 OCTOXYNOL 9/SODIUM BENZOATE/LA PACE Used Exclusively in Females 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006106 FOSINOPRIL SODIUM PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006106 FOSINOPRIL SODIUM PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006106 FOSINOPRIL SODIUM PACE MAX DAILY UNITS : 8.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006106 FOSINOPRIL SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006113 BENAZEPRIL HCL PACE MAX DAILY UNITS : 16.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006113 BENAZEPRIL HCL PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006113 BENAZEPRIL HCL PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006113 BENAZEPRIL HCL PACE MAX DAILY UNITS : 8.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006113 BENAZEPRIL HCL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 006113 BENAZEPRIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242808 DIHYDROPYRIDINES 006205 FELODIPINE PACE MAX DAILY UNITS : 2.000000 242808 DIHYDROPYRIDINES 006205 FELODIPINE PACE MAX DAILY UNITS : 4.000000 242808 DIHYDROPYRIDINES 006205 FELODIPINE PACE MAX DAILY UNITS : 8.000000 242808 DIHYDROPYRIDINES 006205 FELODIPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 240608 HMG‐COA REDUCTASE INHIBITORS 006227 PRAVASTATIN SODIUM PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006227 PRAVASTATIN SODIUM PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006227 PRAVASTATIN SODIUM PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006227 PRAVASTATIN SODIUM PACE MAX DAILY UNITS : 8.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006227 PRAVASTATIN SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201218 PLATELET‐AGGREGATION INHIBITORS 006232 TICLOPIDINE HCL PACE MAX DAILY UNITS : 2.000000 922400 BONE RESORPTION INHIBITORS 006250 PAMIDRONATE DISODIUM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 006301 PENTOSTATIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 006308 FLUDARABINE PHOSPHATE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006311 NABUMETONE PACE MAX DAILY UNITS : 2.700000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006311 NABUMETONE PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006311 NABUMETONE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006311 NABUMETONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 10.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 16.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 5.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE MAX DAILY UNITS : 8.000000 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 006312 SIMVASTATIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 006323 METOPROLOL SUCCINATE PACE MAX DAILY UNITS : 16.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 006323 METOPROLOL SUCCINATE PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 006323 METOPROLOL SUCCINATE PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 006323 METOPROLOL SUCCINATE PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 006323 METOPROLOL SUCCINATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 006324 SERTRALINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 006324 SERTRALINE HCL PACE MAX DAILY UNITS : 10.000000 281604 ANTIDEPRESSANTS 006324 SERTRALINE HCL PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 006324 SERTRALINE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 006324 SERTRALINE HCL PACE MAX DAILY UNITS : 8.000000 281604 ANTIDEPRESSANTS 006324 SERTRALINE HCL PACE Medical Exception Required 480800 ANTITUSSIVES 006328 HYDROCODONE/CHLORPHENIRAMINE PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 006328 HYDROCODONE/CHLORPHENIRAMINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 006328 HYDROCODONE/CHLORPHENIRAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 006335 GUAIFEN/THEOP/P‐EPHED/BUTABARB PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 281604 ANTIDEPRESSANTS 006338 FLUVOXAMINE MALEATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 006338 FLUVOXAMINE MALEATE PACE MAX DAILY UNITS : 12.000000 281604 ANTIDEPRESSANTS 006338 FLUVOXAMINE MALEATE PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 006338 FLUVOXAMINE MALEATE PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 006338 FLUVOXAMINE MALEATE PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 006338 FLUVOXAMINE MALEATE PACE Medical Exception Required 241208 NITRATES AND NITRITES 006341 ISOSORBIDE MONONITRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 006342 MORPHINE SULFATE/D5W PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 006342 MORPHINE SULFATE/D5W PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60

23 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280808 OPIATE AGONISTS 006342 MORPHINE SULFATE/D5W PACE Medical Exception Required 280808 OPIATE AGONISTS 006342 MORPHINE SULFATE/D5W PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 529200 EENT DRUGS, MISCELLANEOUS 006396 HOMEOPATHIC DRUGS PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 006396 HOMEOPATHIC DRUGS PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 006396 HOMEOPATHIC DRUGS PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 006402 ALDESLEUKIN PACE Medical Exception Required 920800 5‐ALPHA‐REDUCTASE INHIBITORS 006421 FINASTERIDE PACE Used Exclusively in Males 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 006421 FINASTERIDE PACE Used Exclusively in Males 280808 OPIATE AGONISTS 006438 FENTANYL PACE Medical Exception Required 280808 OPIATE AGONISTS 006438 FENTANYL PACE INITIAL DOSE : 100.000 280808 OPIATE AGONISTS 006438 FENTANYL PACE AMOUNT : 10.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 280808 OPIATE AGONISTS 006438 FENTANYL PACE AMOUNT : 20.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 280808 OPIATE AGONISTS 006438 FENTANYL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 006438 FENTANYL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 006438 FENTANYL PACE Medical Exception Required 280808 OPIATE AGONISTS 006438 FENTANYL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121208 BETA‐ADRENERGIC AGONISTS 006439 RITODRINE HCL/D5W PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 242808 DIHYDROPYRIDINES 006494 AMLODIPINE BESYLATE PACE MAX DAILY UNITS : 1.000000 242808 DIHYDROPYRIDINES 006494 AMLODIPINE BESYLATE PACE MAX DAILY UNITS : 2.000000 242808 DIHYDROPYRIDINES 006494 AMLODIPINE BESYLATE PACE MAX DAILY UNITS : 4.000000 242808 DIHYDROPYRIDINES 006494 AMLODIPINE BESYLATE PACE Medical Exception Required 242808 DIHYDROPYRIDINES 006494 AMLODIPINE BESYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 81408 AZOLE ANTIFUNGALS 006503 ITRACONAZOLE PACE Medical Exception Required 81408 AZOLE ANTIFUNGALS 006503 ITRACONAZOLE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 281208 BENZODIAZEPINES (ANTICONVULSANTS) 006536 CLOBAZAM PACE Medical Exception Required 40800 SECOND GENERATION ANTIHISTAMINES 006544 CETIRIZINE HCL PACE MAX DAILY UNITS : 1.000000 40800 SECOND GENERATION ANTIHISTAMINES 006544 CETIRIZINE HCL PACE MAX DAILY UNITS : 10.000000 40800 SECOND GENERATION ANTIHISTAMINES 006544 CETIRIZINE HCL PACE MAX DAILY UNITS : 2.000000 40800 SECOND GENERATION ANTIHISTAMINES 006544 CETIRIZINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 680400 ADRENALS 006545 BUDESONIDE PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 006545 BUDESONIDE PACE Medical Exception Required 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE Medical Exception Required 680400 ADRENALS 006545 BUDESONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 006545 BUDESONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 680400 ADRENALS 006545 BUDESONIDE PACE MAX DAILY UNITS : 1.000000 680400 ADRENALS 006545 BUDESONIDE PACE MAX DAILY UNITS : 3.000000 680400 ADRENALS 006545 BUDESONIDE PACE MAX DAILY UNITS : 4.771000 680400 ADRENALS 006545 BUDESONIDE PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 0.280000 520808 CORTICOSTEROIDS (EENT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 0.573000 520808 CORTICOSTEROIDS (EENT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 0.667000 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 0.060000 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 0.067000 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 0.267000 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 2.000000 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 4.000000 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006545 BUDESONIDE PACE MAX DAILY UNITS : 8.000000 563200 PROKINETIC AGENTS 006550 CISAPRIDE MONOHYDRATE PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE AMOUNT : 1.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE PERCENT : 25.0 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 0.180000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 0.360000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 0.720000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 1.000000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 1.500000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 2.000000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 4.000000 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 006587 SUMATRIPTAN SUCCINATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40800 SECOND GENERATION ANTIHISTAMINES 006605 LORATADINE/PSEUDOEPHEDRINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 006607 FLUNISOLIDE/MENTHOL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006620 OXAPROZIN PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 006620 OXAPROZIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 680800 ANDROGENS 007304 TESTOSTERONE UNDECANOATE PACE Used Exclusively in Males

24 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 681604 ESTROGENS 007310 ESTRADIOL/NORETHINDRONE ACET PACE Medical Exception Required 681604 ESTROGENS 007310 ESTRADIOL/NORETHINDRONE ACET PACE Used Exclusively in Females 681200 CONTRACEPTIVES 007318 LEVONORGESTREL PACE Medical Exception Required 681200 CONTRACEPTIVES 007318 LEVONORGESTREL PACE Used Exclusively in Females 682092 ANTIDIABETIC AGENTS, MISCELLANEOUS 007325 MIFEPRISTONE PACE Used Exclusively in Females 760000 OXYTOCICS 007325 MIFEPRISTONE PACE Used Exclusively in Females 681200 CONTRACEPTIVES 007327 DESOGESTREL‐ETHINYL ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 007327 DESOGESTREL‐ETHINYL ESTRADIOL PACE Used Exclusively in Females 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE MAX DAILY UNITS : 1.400000 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE MAX DAILY UNITS : 2.400000 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE MAX DAILY UNITS : 20.000000 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 007344 PAROXETINE HCL PACE Medical Exception Required 285600 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR 007350 TETRABENAZINE PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 007378 LAMOTRIGINE PACE Medical Exception Required 121208 BETA‐ADRENERGIC AGONISTS 007393 SALMETEROL XINAFOATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242400 BETA‐ADRENERGIC BLOCKING AGENTS 007396 BISOPROLOL FUMARATE PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 007396 BISOPROLOL FUMARATE PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 007396 BISOPROLOL FUMARATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201204 ANTICOAGULANTS 007429 DALTEPARIN SODIUM,PORCINE PACE Medical Exception Required 81404 ALLYLAMINE ANTIFUNGALS 007590 TERBINAFINE HCL PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 007590 TERBINAFINE HCL PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 81404 ALLYLAMINE ANTIFUNGALS 007590 TERBINAFINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 007590 TERBINAFINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40800 SECOND GENERATION ANTIHISTAMINES 007605 LORATADINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562220 5‐HT3 RECEPTOR ANTAGONISTS 007611 GRANISETRON HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 007625 PACLITAXEL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 007631 QUINAPRIL HCL PACE MAX DAILY UNITS : 16.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 007631 QUINAPRIL HCL PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 007631 QUINAPRIL HCL PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 007631 QUINAPRIL HCL PACE MAX DAILY UNITS : 8.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 007631 QUINAPRIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 83092 ANTIPROTOZOALS, MISCELLANEOUS 007779 TINIDAZOLE PACE Medical Exception Required 280808 OPIATE AGONISTS 007796 DIHYDROCODEINE BITARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 007826 QUINAPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 007827 ACITRETIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 007840 CLADRIBINE PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 007840 CLADRIBINE PACE Medical Exception Required 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE Medical Exception Required 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE AMOUNT : 15.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE MAX DAILY UNITS : 0.100000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE MAX DAILY UNITS : 0.500000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE MAX DAILY UNITS : 1.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE MAX DAILY UNITS : 2.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 007842 ZOLPIDEM TARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 007845 MELPHALAN PACE Medical Exception Required 680400 ADRENALS 007873 FLUTICASONE PROPIONATE PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 007873 FLUTICASONE PROPIONATE PACE Medical Exception Required 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 007873 FLUTICASONE PROPIONATE PACE Medical Exception Required 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 007873 FLUTICASONE PROPIONATE PACE Medical Exception Required 680400 ADRENALS 007873 FLUTICASONE PROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 520808 CORTICOSTEROIDS (EENT) 007873 FLUTICASONE PROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 007873 FLUTICASONE PROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 840608 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) 007873 FLUTICASONE PROPIONATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 007876 NILUTAMIDE PACE Used Exclusively in Males 201204 ANTICOAGULANTS 007878 ENOXAPARIN SODIUM PACE Medical Exception Required 402000 CALORIC AGENTS 008001 AA 5.5 %/ELECTROLYTE‐TPN SOLN PACE Medical Exception Required 402000 CALORIC AGENTS 008003 AMINO ACIDS 8.5 %/ELECTROLYTES PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 008186 FELBAMATE PACE Medical Exception Required 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 1.500000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 1.800000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 2.000000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 2.400000

25 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 3.000000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 3.600000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 6.000000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE MAX DAILY UNITS : 7.200000 242808 DIHYDROPYRIDINES 008268 NISOLDIPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682002 ALPHA‐GLUCOSIDASE INHIBITORS 008283 ACARBOSE PACE MAX DAILY UNITS : 12.000000 682002 ALPHA‐GLUCOSIDASE INHIBITORS 008283 ACARBOSE PACE MAX DAILY UNITS : 3.000000 682002 ALPHA‐GLUCOSIDASE INHIBITORS 008283 ACARBOSE PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 008302 DICLOFENAC SODIUM/MISOPROSTOL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE MAX DAILY UNITS : 1.000000 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE MAX DAILY UNITS : 1.333333 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE MAX DAILY UNITS : 1.500000 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE MAX DAILY UNITS : 2.000000 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE MAX DAILY UNITS : 4.000000 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE MAX DAILY UNITS : 8.000000 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 008317 TRAMADOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 922000 IMMUNOMODULATORY AGENTS 008537 INTERFERON BETA‐1B PACE Medical Exception Required 801200 VACCINES 008575 RABIES VAC,ADS.,RHESUS MONKEY PACE Medical Exception Required 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 008645 TACRINE HCL PACE MAX DAILY UNITS : 16.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 008645 TACRINE HCL PACE MAX DAILY UNITS : 4.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 008645 TACRINE HCL PACE MAX DAILY UNITS : 5.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 008645 TACRINE HCL PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE INITIAL DOSE : 0.500 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 0.042000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 0.056000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 1.500000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 12.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 24.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 3.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 6.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 008721 RISPERIDONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 780000 RADIOACTIVE AGENTS 008779 STRONTIUM‐89 CHLORIDE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 008824 DICLOFENAC POTASSIUM PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 008824 DICLOFENAC POTASSIUM PACE MAX DAILY UNITS : 3.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 008824 DICLOFENAC POTASSIUM PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 008824 DICLOFENAC POTASSIUM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 008824 DICLOFENAC POTASSIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280892 ANALGESICS AND ANTIPYRETICS, MISC. 008831 GABAPENTIN PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 008831 GABAPENTIN PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 008831 GABAPENTIN PACE Medical Exception Required 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 1.500000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 2.250000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 4.500000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE MAX DAILY UNITS : 9.000000 281604 ANTIDEPRESSANTS 008847 VENLAFAXINE HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 008904 PEGASPARGASE PACE Medical Exception Required 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 008907 GUAIFENESIN/THEOPHYLLINE/EPHED PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 240608 HMG‐COA REDUCTASE INHIBITORS 008946 FLUVASTATIN SODIUM PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 008946 FLUVASTATIN SODIUM PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 008946 FLUVASTATIN SODIUM PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 008946 FLUVASTATIN SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 008947 GUAIFEN/THEOPHYLLINE/P‐EPHED PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 008962 BENAZEPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201204 ANTICOAGULANTS 008989 TINZAPARIN SODIUM,PORCINE PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 008991 TRANDOLAPRIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562836 PROTON‐PUMP INHIBITORS 008993 LANSOPRAZOLE PACE MAX DAILY UNITS : 1.000000

26 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 562836 PROTON‐PUMP INHIBITORS 008993 LANSOPRAZOLE PACE MAX DAILY UNITS : 2.000000 562836 PROTON‐PUMP INHIBITORS 008993 LANSOPRAZOLE PACE MAX DAILY UNITS : 30.000000 562836 PROTON‐PUMP INHIBITORS 008993 LANSOPRAZOLE PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 008993 LANSOPRAZOLE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 009004 ASPARAGINASE (ERWINIA CHRYSAN) PACE Medical Exception Required 480800 ANTITUSSIVES 009011 CODEINE PHOSPHATE/PYRILAMINE PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 009011 CODEINE PHOSPHATE/PYRILAMINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 009011 CODEINE PHOSPHATE/PYRILAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 120808 ANTIMUSCARINICS/ANTISPASMODICS 009040 IPRATROPIUM/ALBUTEROL SULFATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 009121 DIAPHRAGMS, ARC‐SPRING PACE Used Exclusively in Females 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 009122 DIAPHRAGMS, FLAT SPRING PACE Used Exclusively in Females 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 009123 DIAPHRAGMS, COIL SPRING PACE Used Exclusively in Females 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 009124 DIAPHRAGMS, WIDE SEAL PACE Used Exclusively in Females 280808 OPIATE AGONISTS 009523 LEVOMETHADYL ACETATE HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 009523 LEVOMETHADYL ACETATE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 009523 LEVOMETHADYL ACETATE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 009607 YOHIMBINE HCL/ZINC SULFATE PACE Used Exclusively in Males 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE MAX DAILY UNITS : 12.000000 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE MAX DAILY UNITS : 2.400000 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 009612 NEFAZODONE HCL PACE Medical Exception Required 681604 ESTROGENS 009649 ESTROGEN,CON/M‐PROGEST ACET PACE Used Exclusively in Females 240408 CARDIOTONIC AGENTS 009744 MILRINONE LACTATE/D5W PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681200 CONTRACEPTIVES 009752 ESTRAD CYP/M‐PROGEST ACET PACE Used Exclusively in Females 562812 HISTAMINE H2‐ANTAGONISTS 009793 CIMETIDINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 009829 LOSARTAN POTASSIUM PACE MAX DAILY UNITS : 1.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 009829 LOSARTAN POTASSIUM PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 009829 LOSARTAN POTASSIUM PACE MAX DAILY UNITS : 4.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 009829 LOSARTAN POTASSIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 009863 LOSARTAN/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 009934 MOEXIPRIL HCL PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 009934 MOEXIPRIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 010008 EDETATE DISOD/SOD BORATE/SLS PACE Used Exclusively in Females 924400 IMMUNOSUPPRESSIVE AGENTS 010012 MYCOPHENOLATE MOFETIL PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 010086 CYCLOSPORINE, MODIFIED PACE Medical Exception Required 81228 ANTIBACTERIALS, MISCELLANEOUS 010093 VANCOMYCIN/0.9 % SOD CHLORIDE PACE Medical Exception Required 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 010112 CERVICAL CAP PACE Used Exclusively in Females 922400 BONE RESORPTION INHIBITORS 010124 ALENDRONATE SODIUM PACE MAX DAILY UNITS : 0.143000 922400 BONE RESORPTION INHIBITORS 010124 ALENDRONATE SODIUM PACE MAX DAILY UNITS : 0.250000 922400 BONE RESORPTION INHIBITORS 010124 ALENDRONATE SODIUM PACE MAX DAILY UNITS : 0.290000 922400 BONE RESORPTION INHIBITORS 010124 ALENDRONATE SODIUM PACE MAX DAILY UNITS : 1.000000 922400 BONE RESORPTION INHIBITORS 010124 ALENDRONATE SODIUM PACE MAX DAILY UNITS : 10.700000 922400 BONE RESORPTION INHIBITORS 010124 ALENDRONATE SODIUM PACE MAX DAILY UNITS : 2.000000 100000 ANTINEOPLASTIC AGENTS 010143 BICALUTAMIDE PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 010222 DOXORUBICIN HCL PEG‐LIPOSOMAL PACE Medical Exception Required 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 010247 RILUZOLE PACE Medical Exception Required 681608 ANTIESTROGENS 010249 ANASTROZOLE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 010249 ANASTROZOLE PACE Medical Exception Required 681608 ANTIESTROGENS 010249 ANASTROZOLE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 010249 ANASTROZOLE PACE Used Exclusively in Females 861600 RESPIRATORY SMOOTH MUSCLE RELAXANTS 010254 AMINOPHYLLINE HYDRATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 010280 DOCETAXEL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 010321 CITALOPRAM HYDROBROMIDE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 010321 CITALOPRAM HYDROBROMIDE PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 010321 CITALOPRAM HYDROBROMIDE PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 010321 CITALOPRAM HYDROBROMIDE PACE MAX DAILY UNITS : 20.000000 281604 ANTIDEPRESSANTS 010321 CITALOPRAM HYDROBROMIDE PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 010321 CITALOPRAM HYDROBROMIDE PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 010705 LIDOCAINE PACE Medical Exception Required 720000 LOCAL ANESTHETICS (PARENTERAL) 010705 LIDOCAINE PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 010705 LIDOCAINE PACE AMOUNT : 3.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 720000 LOCAL ANESTHETICS (PARENTERAL) 010705 LIDOCAINE PACE AMOUNT : 3.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 121208 BETA‐ADRENERGIC AGONISTS 010747 FORMOTEROL FUMARATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 010778 IRINOTECAN HCL PACE Medical Exception Required 682904 SOMATOSTATIN AGONISTS 010781 LANREOTIDE ACETATE PACE Medical Exception Required

27 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 100000 ANTINEOPLASTIC AGENTS 010798 GEMCITABINE HCL PACE Medical Exception Required 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 010802 ALFUZOSIN HCL PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 010804 DAUNORUBICIN CITRATE LIPOSOMAL PACE Medical Exception Required 282080 WAKEFULNESS‐PROMOTING AGENTS 010865 MODAFINIL PACE Medical Exception Required 282080 WAKEFULNESS‐PROMOTING AGENTS 010865 MODAFINIL PACE MAX DAILY UNITS : 1.000000 282080 WAKEFULNESS‐PROMOTING AGENTS 010865 MODAFINIL PACE MAX DAILY UNITS : 2.000000 80800 ANTHELMINTICS 010933 IVERMECTIN PACE Medical Exception Required 840412 SCABICIDES AND PEDICULICIDES 010933 IVERMECTIN PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 010933 IVERMECTIN PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 011060 TOPIRAMATE PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 011060 TOPIRAMATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562836 PROTON‐PUMP INHIBITORS 011115 OMEPRAZOLE MAGNESIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 83092 ANTIPROTOZOALS, MISCELLANEOUS 011210 SECNIDAZOLE PACE Used Exclusively in Females 922000 IMMUNOMODULATORY AGENTS 011253 INTERFERON BETA‐1A PACE Medical Exception Required 280808 OPIATE AGONISTS 011265 MORPHINE SULFATE IN 0.9 % NACL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 011265 MORPHINE SULFATE IN 0.9 % NACL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 011265 MORPHINE SULFATE IN 0.9 % NACL PACE Medical Exception Required 280808 OPIATE AGONISTS 011265 MORPHINE SULFATE IN 0.9 % NACL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 011381 TOPOTECAN HCL PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 011465 THALIDOMIDE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE INITIAL DOSE : 15.000 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE MAX DAILY UNITS : 1.500000 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 011505 MIRTAZAPINE PACE Medical Exception Required 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 011582 TIZANIDINE HCL PACE AMOUNT : 21.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 011582 TIZANIDINE HCL PACE MAX DAILY UNITS : 18.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 011582 TIZANIDINE HCL PACE MAX DAILY UNITS : 6.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 011582 TIZANIDINE HCL PACE MAX DAILY UNITS : 9.000000 122004 CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 011582 TIZANIDINE HCL PACE Medical Exception Required 40800 SECOND GENERATION ANTIHISTAMINES 011595 FEXOFENADINE HCL PACE MAX DAILY UNITS : 1.000000 40800 SECOND GENERATION ANTIHISTAMINES 011595 FEXOFENADINE HCL PACE MAX DAILY UNITS : 2.000000 40800 SECOND GENERATION ANTIHISTAMINES 011595 FEXOFENADINE HCL PACE MAX DAILY UNITS : 20.000000 40800 SECOND GENERATION ANTIHISTAMINES 011595 FEXOFENADINE HCL PACE MAX DAILY UNITS : 4.000000 40800 SECOND GENERATION ANTIHISTAMINES 011595 FEXOFENADINE HCL PACE Medical Exception Required 40800 SECOND GENERATION ANTIHISTAMINES 011595 FEXOFENADINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681612 ESTROGEN AGONIST‐ANTAGONISTS 011632 TOREMIFENE CITRATE PACE Used Exclusively in Females 81228 ANTIBACTERIALS, MISCELLANEOUS 011697 RIFAMYCIN SODIUM PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 011735 OXCARBAZEPINE PACE Medical Exception Required 524004 ALPHA‐ADRENERGIC AGONISTS (EENT) 011786 BRIMONIDINE TARTRATE PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 011786 BRIMONIDINE TARTRATE PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 011788 ASA/MAG HYDROX/ALUMINUM HYDROX PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 011791 ASA/CALCIUM CARB/MAG/ALUMINUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 011792 ASPIRIN/CALCIUM CARBONATE/MAG PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE INITIAL DOSE : 2.500 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE MAX DAILY UNITS : 0.500000 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE MAX DAILY UNITS : 0.700000 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE MAX DAILY UNITS : 1.400000 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 011814 OLANZAPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 011931 REMIFENTANIL HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 011931 REMIFENTANIL HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 011931 REMIFENTANIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 012181 MELOXICAM PACE INITIAL DOSE : 20.000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 012181 MELOXICAM PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 012181 MELOXICAM PACE MAX DAILY UNITS : 10.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 012181 MELOXICAM PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 012181 MELOXICAM PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 012181 MELOXICAM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 680400 ADRENALS 012203 PRASTERONE (DHEA) PACE Medical Exception Required 680800 ANDROGENS 012203 PRASTERONE (DHEA) PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 012203 PRASTERONE (DHEA) PACE Medical Exception Required 680400 ADRENALS 012203 PRASTERONE (DHEA) PACE Used Exclusively in Females 680800 ANDROGENS 012203 PRASTERONE (DHEA) PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 012203 PRASTERONE (DHEA) PACE Used Exclusively in Females

28 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 012204 VALSARTAN PACE MAX DAILY UNITS : 1.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 012204 VALSARTAN PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 012204 VALSARTAN PACE MAX DAILY UNITS : 4.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 012204 VALSARTAN PACE MAX DAILY UNITS : 8.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 012204 VALSARTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 012259 DONEPEZIL HCL PACE MAX DAILY UNITS : 1.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 012259 DONEPEZIL HCL PACE MAX DAILY UNITS : 2.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 012259 DONEPEZIL HCL PACE MAX DAILY UNITS : 4.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 012259 DONEPEZIL HCL PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 012404 ATORVASTATIN CALCIUM PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 012404 ATORVASTATIN CALCIUM PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 012404 ATORVASTATIN CALCIUM PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 012404 ATORVASTATIN CALCIUM PACE MAX DAILY UNITS : 8.000000 240608 HMG‐COA REDUCTASE INHIBITORS 012404 ATORVASTATIN CALCIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 241292 VASODILATING AGENTS, MISCELLANEOUS 012474 ASPIRIN/DIPYRIDAMOLE PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 012660 ENALAPRIL MALEATE/FELODIPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682028 THIAZOLIDINEDIONES 012661 TROGLITAZONE PACE MAX DAILY UNITS : 1.500000 682028 THIAZOLIDINEDIONES 012661 TROGLITAZONE PACE MAX DAILY UNITS : 2.000000 682028 THIAZOLIDINEDIONES 012661 TROGLITAZONE PACE MAX DAILY UNITS : 3.000000 283228 SELECTIVE SEROTONIN AGONISTS 012779 SUMATRIPTAN PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 012779 SUMATRIPTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 012784 YOHIMBINE HCL PACE Used Exclusively in Males 202816 HEMOSTATICS 012793 FACTOR IX HUMAN RECOMBINANT PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 012810 GLATIRAMER ACETATE PACE Medical Exception Required 681808 GONADOTROPINS 012848 FOLLITROPIN BETA,RECOMB PACE Used Exclusively in Females 681604 ESTROGENS 012871 ESTRADIOL/LEVONORGESTREL PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 012879 CARMUSTINE IN POLIFEPROSAN 20 PACE Medical Exception Required 360000 DIAGNOSTIC AGENTS 012892 KIT IN‐111/CAPROMAB PENDETIDE PACE Used Exclusively in Males 201214 PLATELET‐REDUCING AGENTS 012902 ANAGRELIDE HCL PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 012958 ZOLMITRIPTAN PACE AMOUNT : 3.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 283228 SELECTIVE SEROTONIN AGONISTS 012958 ZOLMITRIPTAN PACE MAX DAILY UNITS : 2.000000 283228 SELECTIVE SEROTONIN AGONISTS 012958 ZOLMITRIPTAN PACE MAX DAILY UNITS : 4.000000 283228 SELECTIVE SEROTONIN AGONISTS 012958 ZOLMITRIPTAN PACE MAX DAILY UNITS : 8.000000 283228 SELECTIVE SEROTONIN AGONISTS 012958 ZOLMITRIPTAN PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 012958 ZOLMITRIPTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 240608 HMG‐COA REDUCTASE INHIBITORS 013041 CERIVASTATIN SODIUM PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 013041 CERIVASTATIN SODIUM PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 013041 CERIVASTATIN SODIUM PACE MAX DAILY UNITS : 2.666667 240608 HMG‐COA REDUCTASE INHIBITORS 013041 CERIVASTATIN SODIUM PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 013041 CERIVASTATIN SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 940000 DEVICES 013206 HYALURONATE SODIUM PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 013206 HYALURONATE SODIUM PACE Medical Exception Required 960000 PHARMACEUTICAL AIDS 013206 HYALURONATE SODIUM PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 013237 ENALAPRILAT DIHYDRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 283228 SELECTIVE SEROTONIN AGONISTS 013266 NARATRIPTAN HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 013432 MIBEFRADIL DI‐HCL PACE MAX DAILY UNITS : 1.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 013432 MIBEFRADIL DI‐HCL PACE MAX DAILY UNITS : 2.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 013432 MIBEFRADIL DI‐HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE Medical Exception Required 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 0.700000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 0.800000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 1.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 1.300000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 1.333000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 12.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 2.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 3.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 4.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 4.800000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 6.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE MAX DAILY UNITS : 8.000000 282004 AMPHETAMINES 013449 DEXTROAMPHETAMINE/AMPHETAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 013633 BROMFENAC SODIUM PACE MAX DAILY UNITS : 0.050000 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 013633 BROMFENAC SODIUM PACE MAX DAILY UNITS : 0.200000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 013633 BROMFENAC SODIUM PACE MAX DAILY UNITS : 6.000000 960000 PHARMACEUTICAL AIDS 013633 BROMFENAC SODIUM PACE Medical Exception Required 520820 EENT NONSTEROIDAL ANTI‐INFLAM. AGENTS 013633 BROMFENAC SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 013633 BROMFENAC SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 960000 PHARMACEUTICAL AIDS 013633 BROMFENAC SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 013778 MEMANTINE HCL PACE Medical Exception Required

29 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 013778 MEMANTINE HCL PACE MAX DAILY UNITS : 1.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 013778 MEMANTINE HCL PACE MAX DAILY UNITS : 10.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 013778 MEMANTINE HCL PACE MAX DAILY UNITS : 2.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 013778 MEMANTINE HCL PACE MAX DAILY UNITS : 4.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 013778 MEMANTINE HCL PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 013795 CARVEDILOL PACE MAX DAILY UNITS : 16.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 013795 CARVEDILOL PACE MAX DAILY UNITS : 32.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 013795 CARVEDILOL PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 013795 CARVEDILOL PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 013795 CARVEDILOL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 013819 PERPHENAZINE/AMITRIPTYLINE HCL PACE Medical Exception Required 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE Medical Exception Required 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE MAX DAILY UNITS : 10.000000 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE MAX DAILY UNITS : 100.000000 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE MAX DAILY UNITS : 12.000000 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE MAX DAILY UNITS : 16.000000 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE MAX DAILY UNITS : 25.000000 283616 DOPAMINE PRECURSORS 013894 CARBIDOPA/LEVODOPA PACE MAX DAILY UNITS : 8.000000 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 013907 DALFAMPRIDINE PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 013911 PERINDOPRIL ERBUMINE PACE MAX DAILY UNITS : 2.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 013911 PERINDOPRIL ERBUMINE PACE MAX DAILY UNITS : 4.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 013911 PERINDOPRIL ERBUMINE PACE MAX DAILY UNITS : 8.000000 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 013911 PERINDOPRIL ERBUMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 1.400000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 1.700000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 16.000000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 2.700000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 014015 QUETIAPINE FUMARATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 014293 MOEXIPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE AMOUNT : 10.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE Medical Exception Required 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE MAX DAILY UNITS : 15.000000 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE MAX DAILY UNITS : 3.750000 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE MAX DAILY UNITS : 5.000000 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE MAX DAILY UNITS : 7.500000 280808 OPIATE AGONISTS 014296 HYDROCODONE/IBUPROFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 402000 CALORIC AGENTS 014945 AMINO AC 4.25%/LYTES/DEX 5 % PACE Medical Exception Required 402000 CALORIC AGENTS 014946 AMINO ACIDS 4.25%/LYTES/DEX10% PACE Medical Exception Required 402000 CALORIC AGENTS 014947 AMINO ACID 4.25%/LYTE/DEXT 25% PACE Medical Exception Required 402000 CALORIC AGENTS 014950 AA 2.75 %/ELECTROLYTE‐TPN/D5W PACE Medical Exception Required 402000 CALORIC AGENTS 014951 AMINO AC 2.75 %/LYTES/DEXT 10% PACE Medical Exception Required 282408 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 015344 DIAZEPAM (IN SOYBEAN OIL) PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 015345 AA/MV‐MN/DIETARY,PROT SUPPLEMN PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 015576 IRBESARTAN PACE MAX DAILY UNITS : 1.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 015576 IRBESARTAN PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 015576 IRBESARTAN PACE MAX DAILY UNITS : 4.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 015576 IRBESARTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 015681 GLYCERIN/MIN OIL/POLYCARBOPHIL PACE Used Exclusively in Females 281292 ANTICONVULSANTS, MISCELLANEOUS 015773 TIAGABINE HCL PACE Medical Exception Required 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 015906 EPINEPHRINE BITARTRATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 522400 MYDRIATICS 015906 EPINEPHRINE BITARTRATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 016196 LIDOCAINE/PRILOCAINE PACE Medical Exception Required 340000 DENTAL AGENTS 016196 LIDOCAINE/PRILOCAINE PACE Medical Exception Required 83092 ANTIPROTOZOALS, MISCELLANEOUS 016200 MILTEFOSINE PACE Medical Exception Required 480800 ANTITUSSIVES 016248 HYDROCODONE/CPM/PSEUDOEPHED/GG PACE Medical Exception Required 280808 OPIATE AGONISTS 016248 HYDROCODONE/CPM/PSEUDOEPHED/GG PACE Medical Exception Required 283632 MONOAMINE OXIDASE B INHIBITORS 016483 SELEGILINE HCL PACE Medical Exception Required 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 016520 GALANTAMINE HBR PACE MAX DAILY UNITS : 1.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 016520 GALANTAMINE HBR PACE MAX DAILY UNITS : 1.500000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 016520 GALANTAMINE HBR PACE MAX DAILY UNITS : 2.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 016520 GALANTAMINE HBR PACE MAX DAILY UNITS : 3.000000

30 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 016520 GALANTAMINE HBR PACE MAX DAILY UNITS : 6.000000 562220 5‐HT3 RECEPTOR ANTAGONISTS 016576 DOLASETRON MESYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 016687 OXALIPLATIN PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 016740 NEBIVOLOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 016785 BENDAMUSTINE HCL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 016845 ENALAPRIL MAL/DILTIAZEM MAL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40800 SECOND GENERATION ANTIHISTAMINES 016846 FEXOFENADINE/PSEUDOEPHEDRINE PACE MAX DAILY UNITS : 1.000000 40800 SECOND GENERATION ANTIHISTAMINES 016846 FEXOFENADINE/PSEUDOEPHEDRINE PACE MAX DAILY UNITS : 2.000000 40800 SECOND GENERATION ANTIHISTAMINES 016846 FEXOFENADINE/PSEUDOEPHEDRINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 016848 RITUXIMAB PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016913 CANDESARTAN CILEXETIL PACE MAX DAILY UNITS : 1.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016913 CANDESARTAN CILEXETIL PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016913 CANDESARTAN CILEXETIL PACE MAX DAILY UNITS : 4.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016913 CANDESARTAN CILEXETIL PACE MAX DAILY UNITS : 8.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016913 CANDESARTAN CILEXETIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201600 HEMATOPOIETIC AGENTS 016916 OPRELVEKIN PACE Medical Exception Required 681612 ESTROGEN AGONIST‐ANTAGONISTS 016917 RALOXIFENE HCL PACE Used Exclusively in Females 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016920 EPROSARTAN MESYLATE PACE MAX DAILY UNITS : 1.333333 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016920 EPROSARTAN MESYLATE PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 016920 EPROSARTAN MESYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 922000 IMMUNOMODULATORY AGENTS 016921 DACLIZUMAB PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 016921 DACLIZUMAB PACE Medical Exception Required 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 016924 SIBUTRAMINE HCL M‐HYDRATE PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 016924 SIBUTRAMINE HCL M‐HYDRATE PACE MAX DAILY UNITS : 2.000000 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 016924 SIBUTRAMINE HCL M‐HYDRATE PACE MAX DAILY UNITS : 3.000000 282092 ANOREXIGENIC AGENTS AND STIMULANTS, MISC 016924 SIBUTRAMINE HCL M‐HYDRATE PACE MAX DAILY UNITS : 6.000000 81202 AMINOGLYCOSIDE ANTIBIOTICS 016926 TOBRAMYCIN IN 0.225% SOD CHLOR PACE Medical Exception Required 81218 QUINOLONE ANTIBIOTICS 016936 TROVAFLOXACIN MESYLATE PACE Medical Exception Required 81218 QUINOLONE ANTIBIOTICS 016937 ALATROFLOXACIN MESYLATE PACE Medical Exception Required 841600 CELL STIMULANTS AND PROLIFERANTS 017028 BECAPLERMIN PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 017084 VALSARTAN/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201218 PLATELET‐AGGREGATION INHIBITORS 017433 CILOSTAZOL PACE MAX DAILY UNITS : 2.000000 201218 PLATELET‐AGGREGATION INHIBITORS 017433 CILOSTAZOL PACE MAX DAILY UNITS : 4.000000 201218 PLATELET‐AGGREGATION INHIBITORS 017539 CLOPIDOGREL BISULFATE PACE MAX DAILY UNITS : 1.000000 201218 PLATELET‐AGGREGATION INHIBITORS 017539 CLOPIDOGREL BISULFATE PACE Medical Exception Required 81202 AMINOGLYCOSIDE ANTIBIOTICS 017765 TOBRAMYCIN PACE Medical Exception Required 520404 ANTIBACTERIALS (EENT) 017765 TOBRAMYCIN PACE Medical Exception Required 682016 MEGLITINIDES 017915 REPAGLINIDE PACE Medical Exception Required 682016 MEGLITINIDES 017915 REPAGLINIDE PACE MAX DAILY UNITS : 16.000000 682016 MEGLITINIDES 017915 REPAGLINIDE PACE MAX DAILY UNITS : 32.000000 682016 MEGLITINIDES 017915 REPAGLINIDE PACE MAX DAILY UNITS : 8.000000 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 017931 DILTIAZEM MALATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 202816 HEMOSTATICS 017973 FACTOR XIII PACE Medical Exception Required 402000 CALORIC AGENTS 018083 AA 3.5 %/ELECTROLYTE‐TPN SOLN PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE AMOUNT : 8.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE MAX DAILY UNITS : 0.500000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE MAX DAILY UNITS : 1.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE MAX DAILY UNITS : 2.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE MAX DAILY UNITS : 3.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE MAX DAILY UNITS : 37.500000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE MAX DAILY UNITS : 6.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 018084 SILDENAFIL CITRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 018311 GUARANA PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 018385 CAPECITABINE PACE Medical Exception Required 681200 CONTRACEPTIVES 018520 DESOG‐E.ESTRADIOL/E.ESTRADIOL PACE Medical Exception Required 681200 CONTRACEPTIVES 018520 DESOG‐E.ESTRADIOL/E.ESTRADIOL PACE Used Exclusively in Females 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 018527 RIVASTIGMINE TARTRATE PACE MAX DAILY UNITS : 2.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 018527 RIVASTIGMINE TARTRATE PACE MAX DAILY UNITS : 2.700000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 018527 RIVASTIGMINE TARTRATE PACE MAX DAILY UNITS : 4.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 018527 RIVASTIGMINE TARTRATE PACE MAX DAILY UNITS : 6.000000 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 018527 RIVASTIGMINE TARTRATE PACE MAX DAILY UNITS : 8.000000 283228 SELECTIVE SEROTONIN AGONISTS 018535 RIZATRIPTAN BENZOATE PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 283228 SELECTIVE SEROTONIN AGONISTS 018535 RIZATRIPTAN BENZOATE PACE MAX DAILY UNITS : 3.000000 283228 SELECTIVE SEROTONIN AGONISTS 018535 RIZATRIPTAN BENZOATE PACE MAX DAILY UNITS : 6.000000 283228 SELECTIVE SEROTONIN AGONISTS 018535 RIZATRIPTAN BENZOATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 640000 HEAVY METAL ANTAGONISTS 018544 DEFERIPRONE PACE Medical Exception Required

31 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 563600 ANTI‐INFLAMMATORY AGENTS (GI DRUGS) 018569 BALSALAZIDE DISODIUM PACE Used Exclusively in Males 682002 ALPHA‐GLUCOSIDASE INHIBITORS 018595 MIGLITOL PACE Medical Exception Required 682002 ALPHA‐GLUCOSIDASE INHIBITORS 018595 MIGLITOL PACE MAX DAILY UNITS : 12.000000 682002 ALPHA‐GLUCOSIDASE INHIBITORS 018595 MIGLITOL PACE MAX DAILY UNITS : 3.000000 682002 ALPHA‐GLUCOSIDASE INHIBITORS 018595 MIGLITOL PACE MAX DAILY UNITS : 6.000000 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 018602 AUTOLOGOUS CULT. CHONDROCYTES PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 018603 MYCOPHENOLATE MOFETIL HCL PACE Medical Exception Required 243204 ANGIOTENSIN‐CONVERTING ENZYME INHIBITORS 018610 FOSINOPRIL/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681200 CONTRACEPTIVES 018682 L‐NORGEST‐ETH ESTR/PRG TST KIT PACE Medical Exception Required 681200 CONTRACEPTIVES 018682 L‐NORGEST‐ETH ESTR/PRG TST KIT PACE Used Exclusively in Females 940000 DEVICES 018683 GLYCERIN/PROPYLENE GLYCOL/WATR PACE Used Exclusively in Females 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 018747 INFLIXIMAB PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 018751 ORLISTAT PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 018751 ORLISTAT PACE MAX DAILY UNITS : 3.000000 569200 GI DRUGS, MISCELLANEOUS 018751 ORLISTAT PACE MAX DAILY UNITS : 6.000000 569200 GI DRUGS, MISCELLANEOUS 018751 ORLISTAT PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 018801 TRASTUZUMAB PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 018830 ETANERCEPT PACE Medical Exception Required 81604 ANTITUBERCULOSIS AGENTS 018831 RIFAPENTINE PACE Medical Exception Required 401819 PHOSPHATE‐REMOVING AGENTS 018832 SEVELAMER HCL PACE Medical Exception Required 401819 PHOSPHATE‐REMOVING AGENTS 018832 SEVELAMER HCL PACE MAX DAILY UNITS : 16.000000 401819 PHOSPHATE‐REMOVING AGENTS 018832 SEVELAMER HCL PACE MAX DAILY UNITS : 17.866004 401819 PHOSPHATE‐REMOVING AGENTS 018832 SEVELAMER HCL PACE MAX DAILY UNITS : 32.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 018839 TELMISARTAN PACE MAX DAILY UNITS : 1.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 018839 TELMISARTAN PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 018839 TELMISARTAN PACE MAX DAILY UNITS : 4.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 018839 TELMISARTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562836 PROTON‐PUMP INHIBITORS 018847 RABEPRAZOLE SODIUM PACE MAX DAILY UNITS : 1.000000 562836 PROTON‐PUMP INHIBITORS 018847 RABEPRAZOLE SODIUM PACE MAX DAILY UNITS : 4.000000 562836 PROTON‐PUMP INHIBITORS 018847 RABEPRAZOLE SODIUM PACE MAX DAILY UNITS : 8.000000 562836 PROTON‐PUMP INHIBITORS 018847 RABEPRAZOLE SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 366000 THYROID FUNCTION 018855 THYROTROPIN ALFA PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 018963 IRBESARTAN/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 018979 CELECOXIB PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 018979 CELECOXIB PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 018979 CELECOXIB PACE MAX DAILY UNITS : 4.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 018979 CELECOXIB PACE MAX DAILY UNITS : 8.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 018979 CELECOXIB PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 018979 CELECOXIB PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682904 SOMATOSTATIN AGONISTS 019000 OCTREOTIDE ACETATE,MI‐SPHERES PACE Medical Exception Required 562220 5‐HT3 RECEPTOR ANTAGONISTS 019058 ONDANSETRON PACE Medical Exception Required 40404 ETHANOLAMINE DERIVATIVES 019892 PHENYLEPHRINE/DIPHENHYDRAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 019963 FLUTICASONE PROPION/SALMETEROL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 019963 FLUTICASONE PROPION/SALMETEROL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE INITIAL DOSE : 20.000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE MAX DAILY UNITS : 0.500000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE MAX DAILY UNITS : 10.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE MAX DAILY UNITS : 5.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020208 ROFECOXIB PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682028 THIAZOLIDINEDIONES 020214 ROSIGLITAZONE MALEATE PACE Medical Exception Required 682028 THIAZOLIDINEDIONES 020214 ROSIGLITAZONE MALEATE PACE Medical Exception Required 682028 THIAZOLIDINEDIONES 020214 ROSIGLITAZONE MALEATE PACE MAX DAILY UNITS : 1.000000 682028 THIAZOLIDINEDIONES 020214 ROSIGLITAZONE MALEATE PACE MAX DAILY UNITS : 2.000000 682028 THIAZOLIDINEDIONES 020214 ROSIGLITAZONE MALEATE PACE MAX DAILY UNITS : 4.000000 681804 ANTIGONADTROPINS 020305 CETRORELIX ACETATE PACE Used Exclusively in Females 682028 THIAZOLIDINEDIONES 020324 PIOGLITAZONE HCL PACE Medical Exception Required 682028 THIAZOLIDINEDIONES 020324 PIOGLITAZONE HCL PACE MAX DAILY UNITS : 1.000000 682028 THIAZOLIDINEDIONES 020324 PIOGLITAZONE HCL PACE MAX DAILY UNITS : 1.500000 682028 THIAZOLIDINEDIONES 020324 PIOGLITAZONE HCL PACE MAX DAILY UNITS : 3.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 020347 ZALEPLON PACE AMOUNT : 15.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 020347 ZALEPLON PACE MAX DAILY UNITS : 1.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 020347 ZALEPLON PACE MAX DAILY UNITS : 2.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 020347 ZALEPLON PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 020355 TEMOZOLOMIDE PACE Medical Exception Required 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 020397 ACETIC ACID/OXYQUINOLINE PACE Used Exclusively in Females 81228 ANTIBACTERIALS, MISCELLANEOUS 020401 RIFAXIMIN PACE Medical Exception Required 81228 ANTIBACTERIALS, MISCELLANEOUS 020401 RIFAXIMIN PACE AMOUNT : 3.000 TYPE : 'X' (Every X days) PERIOD DURATION : 180

32 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 020420 DICLOFENAC EPOLAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 924400 IMMUNOSUPPRESSIVE AGENTS 020519 SIROLIMUS PACE Medical Exception Required 683200 PROGESTINS 020653 PROGESTERONE, MICRONIZED PACE Used Exclusively in Females 681200 CONTRACEPTIVES 020735 ETONOGESTREL PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 020743 GUARANA/CHROME/WILLOW/MA‐HUANG PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 681604 ESTROGENS 020778 ESTRADIOL/NORGESTIMATE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 020803 EXEMESTANE PACE Medical Exception Required 563600 ANTI‐INFLAMMATORY AGENTS (GI DRUGS) 020953 ALOSETRON HCL PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 020974 TACROLIMUS PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 020974 TACROLIMUS PACE Medical Exception Required 681808 GONADOTROPINS 021094 GONADORELIN ACETATE PACE Used Exclusively in Females 681808 GONADOTROPINS 021102 LEUPROLIDE ACETATE PACE Medical Exception Required 681808 GONADOTROPINS 021102 LEUPROLIDE ACETATE PACE Used Exclusively in Females 681808 GONADOTROPINS 021102 LEUPROLIDE ACETATE PACE Used Exclusively in Males 681808 GONADOTROPINS 021104 HISTRELIN ACETATE PACE Medical Exception Required 681808 GONADOTROPINS 021104 HISTRELIN ACETATE PACE Used Exclusively in Males 681808 GONADOTROPINS 021114 GOSERELIN ACETATE PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 021119 SIBERIAN GINSENG ROOT EXTRACT PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 021150 VERTEPORFIN PACE Medical Exception Required 81228 ANTIBACTERIALS, MISCELLANEOUS 021157 LINEZOLID PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 021218 GEMTUZUMAB OZOGAMICIN PACE Medical Exception Required 681808 GONADOTROPINS 021219 FOLLITROPIN BETA/GANIRELIX PACE Used Exclusively in Females 284000 FIBROMYALGIA AGENTS 021229 MILNACIPRAN HCL PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 021280 CANDESARTAN/HYDROCHLOROTHIAZID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 801200 VACCINES 021300 HEPATITIS B VIRUS VACCINE,RECB PACE Medical Exception Required 202816 HEMOSTATICS 021313 FACTOR IX PACE Medical Exception Required 562812 HISTAMINE H2‐ANTAGONISTS 021332 FAMOTIDINE/CA CARB/MAG HYDROX PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 81820 INTERFERON ANTIVIRALS 021367 PEGINTERFERON ALFA‐2B PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 021607 ESOMEPRAZOLE MAGNESIUM PACE MAX DAILY UNITS : 1.000000 562836 PROTON‐PUMP INHIBITORS 021607 ESOMEPRAZOLE MAGNESIUM PACE MAX DAILY UNITS : 16.000000 562836 PROTON‐PUMP INHIBITORS 021607 ESOMEPRAZOLE MAGNESIUM PACE MAX DAILY UNITS : 2.000000 562836 PROTON‐PUMP INHIBITORS 021607 ESOMEPRAZOLE MAGNESIUM PACE MAX DAILY UNITS : 32.000000 562836 PROTON‐PUMP INHIBITORS 021607 ESOMEPRAZOLE MAGNESIUM PACE MAX DAILY UNITS : 4.000000 562836 PROTON‐PUMP INHIBITORS 021607 ESOMEPRAZOLE MAGNESIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 021725 MEPERIDINE HCL IN 0.9 % NACL PACE Medical Exception Required 280808 OPIATE AGONISTS 021725 MEPERIDINE HCL IN 0.9 % NACL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 83092 ANTIPROTOZOALS, MISCELLANEOUS 021759 BENZNIDAZOLE PACE Medical Exception Required 922400 BONE RESORPTION INHIBITORS 021845 ZOLEDRONIC ACID PACE Medical Exception Required 682016 MEGLITINIDES 021859 NATEGLINIDE PACE Medical Exception Required 682016 MEGLITINIDES 021859 NATEGLINIDE PACE MAX DAILY UNITS : 3.000000 682016 MEGLITINIDES 021859 NATEGLINIDE PACE MAX DAILY UNITS : 6.000000 681808 GONADOTROPINS 021868 CHORIOGONADOTROPIN ALFA PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 021869 RIMABOTULINUMTOXINB PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 021873 TELMISARTAN/HYDROCHLOROTHIAZID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 283228 SELECTIVE SEROTONIN AGONISTS 021894 ALMOTRIPTAN MALATE PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 283228 SELECTIVE SEROTONIN AGONISTS 021894 ALMOTRIPTAN MALATE PACE MAX DAILY UNITS : 2.000000 283228 SELECTIVE SEROTONIN AGONISTS 021894 ALMOTRIPTAN MALATE PACE MAX DAILY UNITS : 4.000000 283228 SELECTIVE SEROTONIN AGONISTS 021894 ALMOTRIPTAN MALATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40800 SECOND GENERATION ANTIHISTAMINES 021934 DESLORATADINE PACE MAX DAILY UNITS : 1.000000 40800 SECOND GENERATION ANTIHISTAMINES 021934 DESLORATADINE PACE MAX DAILY UNITS : 10.000000 40800 SECOND GENERATION ANTIHISTAMINES 021934 DESLORATADINE PACE MAX DAILY UNITS : 2.000000 40800 SECOND GENERATION ANTIHISTAMINES 021934 DESLORATADINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 021974 ZIPRASIDONE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 021974 ZIPRASIDONE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 021974 ZIPRASIDONE HCL PACE MAX DAILY UNITS : 2.700000 281608 ANTIPSYCHOTIC AGENTS 021974 ZIPRASIDONE HCL PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 021974 ZIPRASIDONE HCL PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 021974 ZIPRASIDONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 021993 BUDESONIDE/FORMOTEROL FUMARATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 021993 BUDESONIDE/FORMOTEROL FUMARATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681808 GONADOTROPINS 021994 LEUPROLIDE ACETATE/LIDOCAINE PACE Medical Exception Required 681808 GONADOTROPINS 021994 LEUPROLIDE ACETATE/LIDOCAINE PACE Used Exclusively in Males 562836 PROTON‐PUMP INHIBITORS 022008 PANTOPRAZOLE SODIUM PACE MAX DAILY UNITS : 2.000000 562836 PROTON‐PUMP INHIBITORS 022008 PANTOPRAZOLE SODIUM PACE MAX DAILY UNITS : 4.000000 562836 PROTON‐PUMP INHIBITORS 022008 PANTOPRAZOLE SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682008 INSULINS 022025 INSULIN GLARGINE,HUM.REC.ANLOG PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681200 CONTRACEPTIVES 022026 ETHINYL ESTRADIOL/DROSPIRENONE PACE Medical Exception Required 681200 CONTRACEPTIVES 022026 ETHINYL ESTRADIOL/DROSPIRENONE PACE Used Exclusively in Females

33 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 022038 LIDOCAINE/TRANSPARENT DRESSING PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 022096 IMATINIB MESYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 022112 ALEMTUZUMAB PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 022112 ALEMTUZUMAB PACE Medical Exception Required 280808 OPIATE AGONISTS 022708 HYDROMORPHONE HCL IN 0.9% NACL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 022708 HYDROMORPHONE HCL IN 0.9% NACL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 022708 HYDROMORPHONE HCL IN 0.9% NACL PACE Medical Exception Required 280808 OPIATE AGONISTS 022708 HYDROMORPHONE HCL IN 0.9% NACL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 022723 FENTANYL/BUPIVACAINE/0.9% NACL PACE Medical Exception Required 280808 OPIATE AGONISTS 022724 FENTANYL CITRATE‐0.9 % NACL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 022724 FENTANYL CITRATE‐0.9 % NACL/PF PACE AMOUNT : 48.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 280808 OPIATE AGONISTS 022724 FENTANYL CITRATE‐0.9 % NACL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 022724 FENTANYL CITRATE‐0.9 % NACL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 022724 FENTANYL CITRATE‐0.9 % NACL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 022725 HYDROMORPHONE/BUPIVAC/0.9%NACL PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 022851 CALCIPOTRIENE/BETAMETHASONE PACE AMOUNT : 28.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 40800 SECOND GENERATION ANTIHISTAMINES 022864 CETIRIZINE HCL/PSEUDOEPHEDRINE PACE MAX DAILY UNITS : 2.000000 40800 SECOND GENERATION ANTIHISTAMINES 022864 CETIRIZINE HCL/PSEUDOEPHEDRINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 022880 TRAMADOL HCL/ACETAMINOPHEN PACE AMOUNT : 5.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 280808 OPIATE AGONISTS 022880 TRAMADOL HCL/ACETAMINOPHEN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 022880 TRAMADOL HCL/ACETAMINOPHEN PACE Medical Exception Required 280808 OPIATE AGONISTS 022880 TRAMADOL HCL/ACETAMINOPHEN PACE MAX DAILY UNITS : 10.666667 280808 OPIATE AGONISTS 022880 TRAMADOL HCL/ACETAMINOPHEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201600 HEMATOPOIETIC AGENTS 022889 DARBEPOETIN ALFA IN ALBUMN SOL PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 022890 DARBEPOETIN ALFA IN POLYSORBAT PACE Medical Exception Required 681808 GONADOTROPINS 022933 LUTROPIN ALFA PACE Used Exclusively in Females 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 022953 ANAKINRA PACE Medical Exception Required 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE Medical Exception Required 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 1.000000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 1.100000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 1.600000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 2.000000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 2.700000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 4.000000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE MAX DAILY UNITS : 8.000000 282032 RESPIRATORY AND CNS STIMULANTS 022987 DEXMETHYLPHENIDATE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 283228 SELECTIVE SEROTONIN AGONISTS 022988 FROVATRIPTAN SUCCINATE PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 283228 SELECTIVE SEROTONIN AGONISTS 022988 FROVATRIPTAN SUCCINATE PACE MAX DAILY UNITS : 3.000000 283228 SELECTIVE SEROTONIN AGONISTS 022988 FROVATRIPTAN SUCCINATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 022990 BOSENTAN PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 022990 BOSENTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 940000 DEVICES 023041 SYRING‐NEEDL,DISP,INSUL,0.3 ML PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 283228 SELECTIVE SEROTONIN AGONISTS 023093 ELETRIPTAN HYDROBROMIDE PACE AMOUNT : 3.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 283228 SELECTIVE SEROTONIN AGONISTS 023093 ELETRIPTAN HYDROBROMIDE PACE MAX DAILY UNITS : 1.000000 283228 SELECTIVE SEROTONIN AGONISTS 023093 ELETRIPTAN HYDROBROMIDE PACE MAX DAILY UNITS : 2.000000 681808 GONADOTROPINS 023164 TRIPTORELIN PAMOATE PACE Medical Exception Required 681808 GONADOTROPINS 023164 TRIPTORELIN PAMOATE PACE Used Exclusively in Males 563200 PROKINETIC AGENTS 023178 TEGASEROD HYDROGEN MALEATE PACE MAX DAILY UNITS : 2.000000 563200 PROKINETIC AGENTS 023178 TEGASEROD HYDROGEN MALEATE PACE MAX DAILY UNITS : 6.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 023222 VALDECOXIB PACE MAX DAILY UNITS : 0.500000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 023222 VALDECOXIB PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 023222 VALDECOXIB PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681200 CONTRACEPTIVES 023235 NORELGESTROMIN/ETHIN.ESTRADIOL PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 023253 NITISINONE PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 023255 PEGFILGRASTIM PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 023353 INTERFERON BETA‐1A/ALBUMIN PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 023379 ZIPRASIDONE MESYLATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 023379 ZIPRASIDONE MESYLATE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 023379 ZIPRASIDONE MESYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280812 OPIATE PARTIAL AGONISTS 023438 BUPRENORPHINE PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 023490 OLMESARTAN MEDOXOMIL PACE MAX DAILY UNITS : 1.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 023490 OLMESARTAN MEDOXOMIL PACE MAX DAILY UNITS : 2.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 023490 OLMESARTAN MEDOXOMIL PACE MAX DAILY UNITS : 8.000000 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 023490 OLMESARTAN MEDOXOMIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 023523 FULVESTRANT PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 023523 FULVESTRANT PACE Used Exclusively in Females 81408 AZOLE ANTIFUNGALS 023720 VORICONAZOLE PACE Medical Exception Required 681200 CONTRACEPTIVES 023721 ETONOGESTREL/ETHINYL ESTRADIOL PACE Used Exclusively in Females 281604 ANTIDEPRESSANTS 024022 ESCITALOPRAM OXALATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 024022 ESCITALOPRAM OXALATE PACE MAX DAILY UNITS : 1.000000

34 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 281604 ANTIDEPRESSANTS 024022 ESCITALOPRAM OXALATE PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 024022 ESCITALOPRAM OXALATE PACE MAX DAILY UNITS : 20.000000 281604 ANTIDEPRESSANTS 024022 ESCITALOPRAM OXALATE PACE MAX DAILY UNITS : 4.000000 120808 ANTIMUSCARINICS/ANTISPASMODICS 024024 TIOTROPIUM BROMIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 024243 OMACETAXINE MEPESUCCINATE PACE Medical Exception Required 561200 CATHARTICS AND LAXATIVES 024291 SOD PICOSULF/MAG OX/CITRIC AC PACE AMOUNT : 1.000 TYPE : 'X' (Every X days) PERIOD DURATION : 365 682028 THIAZOLIDINEDIONES 024353 ROSIGLITAZONE/METFORMIN HCL PACE Medical Exception Required 682020 SULFONYLUREAS 024429 GLIPIZIDE/METFORMIN HCL PACE MAX DAILY UNITS : 4.000000 682020 SULFONYLUREAS 024429 GLIPIZIDE/METFORMIN HCL PACE MAX DAILY UNITS : 8.000000 100000 ANTINEOPLASTIC AGENTS 024430 KIT Y‐90/IBRITUMOMAB/H.ALBUMIN PACE Medical Exception Required 240605 CHOLESTEROL ABSORPTION INHIBITORS 024459 EZETIMIBE PACE MAX DAILY UNITS : 1.000000 920800 5‐ALPHA‐REDUCTASE INHIBITORS 024485 DUTASTERIDE PACE Used Exclusively in Males 280808 OPIATE AGONISTS 024522 FENTANYL/ROPIVACAINE/NS/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 024522 FENTANYL/ROPIVACAINE/NS/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 024522 FENTANYL/ROPIVACAINE/NS/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 0.044000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 0.059000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 0.500000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 0.750000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 1.500000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 15.000000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 3.000000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 6.000000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE MAX DAILY UNITS : 7.500000 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 024551 ARIPIPRAZOLE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682408 PARATHYROID AGENTS 024700 TERIPARATIDE PACE Medical Exception Required 682408 PARATHYROID AGENTS 024700 TERIPARATIDE PACE AMOUNT : 730.000 TYPE : 'L' (Lifetime) 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE Medical Exception Required 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 1.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 1.250000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 1.700000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 10.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 2.500000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 4.000000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE MAX DAILY UNITS : 5.500000 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 024703 ATOMOXETINE HCL PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 024744 EPROSARTAN/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 024800 ADALIMUMAB PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 024800 ADALIMUMAB PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE AMOUNT : 8.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE MAX DAILY UNITS : 1.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE MAX DAILY UNITS : 2.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE MAX DAILY UNITS : 30.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE Used Exclusively in Males 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 024859 TADALAFIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 440000 ENZYMES 024861 AGALSIDASE BETA PACE Medical Exception Required 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 025002 RACEPINEPHRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 025002 RACEPINEPHRINE HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 240608 HMG‐COA REDUCTASE INHIBITORS 025009 ROSUVASTATIN CALCIUM PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025009 ROSUVASTATIN CALCIUM PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025009 ROSUVASTATIN CALCIUM PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025009 ROSUVASTATIN CALCIUM PACE MAX DAILY UNITS : 8.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025009 ROSUVASTATIN CALCIUM PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 025009 ROSUVASTATIN CALCIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 960000 PHARMACEUTICAL AIDS 025035 VARDENAFIL HCL PACE AMOUNT : 8.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE AMOUNT : 8.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 960000 PHARMACEUTICAL AIDS 025035 VARDENAFIL HCL PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE Medical Exception Required

35 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 960000 PHARMACEUTICAL AIDS 025035 VARDENAFIL HCL PACE Medical Exception Required 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE MAX DAILY UNITS : 1.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE MAX DAILY UNITS : 2.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE MAX DAILY UNITS : 4.000000 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE MAX DAILY UNITS : 8.000000 960000 PHARMACEUTICAL AIDS 025035 VARDENAFIL HCL PACE Used Exclusively in Males 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE Used Exclusively in Males 960000 PHARMACEUTICAL AIDS 025035 VARDENAFIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 025035 VARDENAFIL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 861204 ANTIMUSCARINICS 025056 OXYBUTYNIN PACE AMOUNT : 8.000 TYPE : 'X' (Every X days) PERIOD DURATION : 28 TOLERANCE DAYS : 3 562232 NEUROKININ‐1 RECEPTOR ANTAGONISTS 025058 APREPITANT PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 025098 MIGLUSTAT PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 025178 GEFITINIB PACE Medical Exception Required 681604 ESTROGENS 025182 ESTRADIOL ACETATE PACE Used Exclusively in Females 924400 IMMUNOSUPPRESSIVE AGENTS 025201 MYCOPHENOLATE SODIUM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 025202 BORTEZOMIB PACE Medical Exception Required 280808 OPIATE AGONISTS 025246 FENTANYL/BUPIVACAINE/NS/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 025246 FENTANYL/BUPIVACAINE/NS/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 025246 FENTANYL/BUPIVACAINE/NS/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 025277 MORPHINE SULFATE/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 025277 MORPHINE SULFATE/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 025277 MORPHINE SULFATE/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 025277 MORPHINE SULFATE/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 025386 FENTANYL CITRATE/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 025386 FENTANYL CITRATE/PF PACE AMOUNT : 48.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE DAYS : 3 280808 OPIATE AGONISTS 025386 FENTANYL CITRATE/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 025386 FENTANYL CITRATE/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 025386 FENTANYL CITRATE/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 489200 RESPIRATORY TRACT AGENTS, MISCELLANEOUS 025399 OMALIZUMAB PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 025401 ASPIRIN(CALC&MG)/PRAVASTATIN PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 025446 OLMESARTAN/HYDROCHLOROTHIAZIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 025509 RISPERIDONE MICROSPHERES PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 025509 RISPERIDONE MICROSPHERES PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 025509 RISPERIDONE MICROSPHERES PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562220 5‐HT3 RECEPTOR ANTAGONISTS 025512 PALONOSETRON HCL PACE Medical Exception Required 800400 ANTITOXINS AND IMMUNE GLOBULINS 025631 IMMUNE GLOB,GAM CAPRYLATE(IGG) PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 025742 LANSOPRAZOLE/NAPROXEN PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 025742 LANSOPRAZOLE/NAPROXEN PACE MAX DAILY UNITS : 2.666667 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 025742 LANSOPRAZOLE/NAPROXEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 025796 PAROXETINE MESYLATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 025796 PAROXETINE MESYLATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 025796 PAROXETINE MESYLATE PACE Used Exclusively in Females 281604 ANTIDEPRESSANTS 025800 OLANZAPINE/FLUOXETINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 025800 OLANZAPINE/FLUOXETINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 025800 OLANZAPINE/FLUOXETINE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 842800 KERATOLYTIC AGENTS 025845 BENZOYL PEROXIDE/UREA PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 025905 PEMETREXED DISODIUM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 025947 CETUXIMAB PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 025951 AMLODIPINE/ATORVASTATIN PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025951 AMLODIPINE/ATORVASTATIN PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025951 AMLODIPINE/ATORVASTATIN PACE MAX DAILY UNITS : 4.000000 240608 HMG‐COA REDUCTASE INHIBITORS 025951 AMLODIPINE/ATORVASTATIN PACE MAX DAILY UNITS : 8.000000 100000 ANTINEOPLASTIC AGENTS 025963 BEVACIZUMAB PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 025963 BEVACIZUMAB PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 025968 ESOMEPRAZOLE SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 026287 ILOPROST TROMETHAMINE PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 026287 ILOPROST TROMETHAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201292 ANTITHROMBOTIC AGENTS, MISCELLANEOUS 026300 DEFIBROTIDE SODIUM PACE Medical Exception Required 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 026314 HYDROCORTISONE/ALOE/IODOQUINOL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 026361 AZACITIDINE PACE Medical Exception Required 682008 INSULINS 026407 INSULIN DETEMIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280892 ANALGESICS AND ANTIPYRETICS, MISC. 026470 PREGABALIN PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 026470 PREGABALIN PACE Medical Exception Required 281604 ANTIDEPRESSANTS 026521 DULOXETINE HCL PACE Medical Exception Required 281604 ANTIDEPRESSANTS 026521 DULOXETINE HCL PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 026521 DULOXETINE HCL PACE MAX DAILY UNITS : 3.000000 281604 ANTIDEPRESSANTS 026521 DULOXETINE HCL PACE MAX DAILY UNITS : 4.000000 281604 ANTIDEPRESSANTS 026521 DULOXETINE HCL PACE MAX DAILY UNITS : 6.000000 281604 ANTIDEPRESSANTS 026521 DULOXETINE HCL PACE Medical Exception Required 940000 DEVICES 026552 HYLAN G‐F 20 PACE Medical Exception Required

36 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 100000 ANTINEOPLASTIC AGENTS 026745 ERLOTINIB HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 026757 IBUPROFEN/OXYCODONE HCL PACE AMOUNT : 7.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 280808 OPIATE AGONISTS 026757 IBUPROFEN/OXYCODONE HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 026757 IBUPROFEN/OXYCODONE HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 026757 IBUPROFEN/OXYCODONE HCL PACE MAX DAILY UNITS : 4.000000 280808 OPIATE AGONISTS 026757 IBUPROFEN/OXYCODONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 026768 MORPHINE SULFATE LIPOSOMAL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 026768 MORPHINE SULFATE LIPOSOMAL/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 026768 MORPHINE SULFATE LIPOSOMAL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 026768 MORPHINE SULFATE LIPOSOMAL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 026791 ESZOPICLONE PACE INITIAL DOSE : 1.000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 026791 ESZOPICLONE PACE MAX DAILY UNITS : 0.700000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 026791 ESZOPICLONE PACE MAX DAILY UNITS : 1.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 026791 ESZOPICLONE PACE MAX DAILY UNITS : 2.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 026791 ESZOPICLONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 841600 CELL STIMULANTS AND PROLIFERANTS 026792 PALIFERMIN PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 026805 PEGAPTANIB SODIUM PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 026805 PEGAPTANIB SODIUM PACE AMOUNT : 0.900 TYPE : 'X' (Every X days) PERIOD DURATION : 42 TOLERANCE DAYS : 3 242892 CALCIUM‐CHANNEL BLOCKING AGENTS, MISC. 026810 DILTIAZEM HCL/D5W PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 760000 OXYTOCICS 026811 OXYTOCIN IN 5 % DEXTROSE PACE Medical Exception Required 760000 OXYTOCICS 026811 OXYTOCIN IN 5 % DEXTROSE PACE Used Exclusively in Females 760000 OXYTOCICS 026812 OXYTOCIN/0.9 % SODIUM CHLORIDE PACE Medical Exception Required 760000 OXYTOCICS 026812 OXYTOCIN/0.9 % SODIUM CHLORIDE PACE Used Exclusively in Females 760000 OXYTOCICS 026813 OXYTOCIN IN DEXTROSE 5 % IN LR PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 026816 CLOFARABINE PACE Medical Exception Required 280892 ANALGESICS AND ANTIPYRETICS, MISC. 026826 ZICONOTIDE ACETATE PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 032691 CICLESONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 032691 CICLESONIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 682003 AMYLINOMIMETICS 032805 PRAMLINTIDE ACETATE PACE Medical Exception Required 682006 INCRETIN MIMETICS 032893 EXENATIDE PACE Medical Exception Required 283632 MONOAMINE OXIDASE B INHIBITORS 032911 RASAGILINE MESYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 032975 EVEROLIMUS PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 032975 EVEROLIMUS PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 033008 LIDOCAINE/TETRACAINE PACE Medical Exception Required 801200 VACCINES 033092 BCG LIVE PACE Medical Exception Required 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 033126 RAMELTEON PACE MAX DAILY UNITS : 1.000000 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 033126 RAMELTEON PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 033208 CONTRACEPT BARRIER DEV, VENTED PACE Used Exclusively in Females 280808 OPIATE AGONISTS 033243 MEPERIDINE HCL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 033243 MEPERIDINE HCL/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 033243 MEPERIDINE HCL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 033243 MEPERIDINE HCL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 033248 MEPERIDINE HCL IN 0.9% NACL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 033283 MORPHINE SULFATE/D5W/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 033283 MORPHINE SULFATE/D5W/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 033283 MORPHINE SULFATE/D5W/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 033283 MORPHINE SULFATE/D5W/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 940000 DEVICES 033296 INCONT DEVICE,MUSCLE TONER,ELT PACE Used Exclusively in Females 640000 HEAVY METAL ANTAGONISTS 033337 DEFERASIROX PACE Medical Exception Required 682028 THIAZOLIDINEDIONES 033371 ROSIGLITAZONE/GLIMEPIRIDE PACE Medical Exception Required 682028 THIAZOLIDINEDIONES 033371 ROSIGLITAZONE/GLIMEPIRIDE PACE Medical Exception Required 760000 OXYTOCICS 033377 OXYTOCIN/RINGER'S LACTATE PACE Medical Exception Required 760000 OXYTOCICS 033377 OXYTOCIN/RINGER'S LACTATE PACE Used Exclusively in Females 240492 CARDIAC DRUGS, MISCELLANEOUS 033396 IVABRADINE HCL PACE Medical Exception Required 240492 CARDIAC DRUGS, MISCELLANEOUS 033396 IVABRADINE HCL PACE MAX DAILY UNITS : 15.000000 240492 CARDIAC DRUGS, MISCELLANEOUS 033396 IVABRADINE HCL PACE MAX DAILY UNITS : 2.000000 240492 CARDIAC DRUGS, MISCELLANEOUS 033396 IVABRADINE HCL PACE MAX DAILY UNITS : 3.000000 100000 ANTINEOPLASTIC AGENTS 033400 SORAFENIB TOSYLATE PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 033411 ABATACEPT/MALTOSE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 033412 LENALIDOMIDE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 033445 SUNITINIB MALATE PACE Medical Exception Required 81408 AZOLE ANTIFUNGALS 033461 POSACONAZOLE PACE Medical Exception Required 283632 MONOAMINE OXIDASE B INHIBITORS 033510 SELEGILINE PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 033512 OMEPRAZOLE/SODIUM BICARBONATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 033537 SOD PROPION/INOSITOL/AA14/UREA PACE Used Exclusively in Females 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 033548 VAGINAL DEODORANT COMB NO.1 PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 033549 VAGINAL ANTISEPTICS COMBO NO.1 PACE Used Exclusively in Females 282032 RESPIRATORY AND CNS STIMULANTS 033556 METHYLPHENIDATE PACE Medical Exception Required

37 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 282032 RESPIRATORY AND CNS STIMULANTS 033556 METHYLPHENIDATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562220 5‐HT3 RECEPTOR ANTAGONISTS 033598 ONDANSETRON HCL/PF PACE Medical Exception Required 940000 DEVICES 033656 RING PESSARY PACE Used Exclusively in Females 129200 AUTONOMIC DRUGS, MISCELLANEOUS 033766 VARENICLINE TARTRATE PACE AMOUNT : 84.000 TYPE : 'X' (Every X days) PERIOD DURATION : 360 280808 OPIATE AGONISTS 033774 FENTANYL HCL PACE Medical Exception Required 681200 CONTRACEPTIVES 033792 L‐NORGEST/E.ESTRADIOL‐E.ESTRAD PACE Medical Exception Required 681200 CONTRACEPTIVES 033792 L‐NORGEST/E.ESTRADIOL‐E.ESTRAD PACE Used Exclusively in Females 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 033810 IBUPROFEN LYSINE/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 033855 DASATINIB PACE Medical Exception Required 681200 CONTRACEPTIVES 033988 NORETH‐ETHINYL ESTRADIOL/IRON PACE Medical Exception Required 681200 CONTRACEPTIVES 033988 NORETH‐ETHINYL ESTRADIOL/IRON PACE Used Exclusively in Females 682028 THIAZOLIDINEDIONES 033991 PIOGLITAZONE HCL/GLIMEPIRIDE PACE Medical Exception Required 682028 THIAZOLIDINEDIONES 033991 PIOGLITAZONE HCL/GLIMEPIRIDE PACE MAX DAILY UNITS : 1.000000 682408 PARATHYROID AGENTS 034000 PARATHYROID HORMONE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 034070 VORINOSTAT PACE Medical Exception Required 121208 BETA‐ADRENERGIC AGONISTS 034087 ARFORMOTEROL TARTRATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 034126 SITAGLIPTIN PHOSPHATE PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 034126 SITAGLIPTIN PHOSPHATE PACE MAX DAILY UNITS : 1.000000 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 034126 SITAGLIPTIN PHOSPHATE PACE MAX DAILY UNITS : 2.000000 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 034126 SITAGLIPTIN PHOSPHATE PACE MAX DAILY UNITS : 4.000000 81832 NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS 034163 TELBIVUDINE PACE Medical Exception Required 562220 5‐HT3 RECEPTOR ANTAGONISTS 034189 ONDANSETRON HCL/D5W/PF PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 034245 CARVEDILOL PHOSPHATE PACE MAX DAILY UNITS : 1.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 034245 CARVEDILOL PHOSPHATE PACE MAX DAILY UNITS : 2.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 034245 CARVEDILOL PHOSPHATE PACE MAX DAILY UNITS : 4.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 034245 CARVEDILOL PHOSPHATE PACE MAX DAILY UNITS : 8.000000 242400 BETA‐ADRENERGIC BLOCKING AGENTS 034245 CARVEDILOL PHOSPHATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 034343 PALIPERIDONE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 034343 PALIPERIDONE PACE MAX DAILY UNITS : 1.333333 281608 ANTIPSYCHOTIC AGENTS 034343 PALIPERIDONE PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 034343 PALIPERIDONE PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 034343 PALIPERIDONE PACE MAX DAILY UNITS : 8.000000 281608 ANTIPSYCHOTIC AGENTS 034343 PALIPERIDONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 81408 AZOLE ANTIFUNGALS 034344 FLUCONAZOLE IN NACL,ISO‐OSM PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 81408 AZOLE ANTIFUNGALS 034345 FLUCONAZOLE IN DEXTROSE,ISO‐OS PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 562220 5‐HT3 RECEPTOR ANTAGONISTS 034348 ONDANSETRON IN 0.9 % NACL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 034369 HYDROCODONE/ACETAM/DIET.SUP.11 PACE Medical Exception Required 242808 DIHYDROPYRIDINES 034433 AMLODIPINE BESYLATE/VALSARTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE Medical Exception Required 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 1.000000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 1.200000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 1.400000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 1.700000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 2.000000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 2.300000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 3.000000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 3.500000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE MAX DAILY UNITS : 7.000000 282004 AMPHETAMINES 034486 LISDEXAMFETAMINE DIMESYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682004 BIGUANIDES 034492 METFORMIN/CAFF/AA7/HRB125/CHOL PACE Medical Exception Required 243240 RENIN INHIBITORS 034493 ALISKIREN HEMIFUMARATE PACE Cannnot co‐administer Insulin and/or Anti‐Diabetic medications 682004 BIGUANIDES 034495 METFORMIN/AA 7/HERB125/CHOLINE PACE Medical Exception Required 280808 OPIATE AGONISTS 034524 TRAMADOL/DIETARY SUPP. NO. 11 PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 034541 LAPATINIB DITOSYLATE PACE Medical Exception Required 280808 OPIATE AGONISTS 034574 ASPIRIN/CAFFEIN/DIHYDROCODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 034574 ASPIRIN/CAFFEIN/DIHYDROCODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 034574 ASPIRIN/CAFFEIN/DIHYDROCODEINE PACE MAX DAILY UNITS : 11.300000 280808 OPIATE AGONISTS 034574 ASPIRIN/CAFFEIN/DIHYDROCODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 923200 COMPLEMENT INHIBITORS 034618 ECULIZUMAB PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 034634 IBUPROFEN/DIPHENHYDRAMINE CIT PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 801200 VACCINES 034649 HEPATITIS B VIRUS VACCINE/PF PACE Medical Exception Required 922400 BONE RESORPTION INHIBITORS 034717 ZOLEDRONIC ACID/MANNITOL‐WATER PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 034756 FLUTICASONE FUROATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 034756 FLUTICASONE FUROATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 562220 5‐HT3 RECEPTOR ANTAGONISTS 034765 GRANISETRON HCL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 034805 HYDROMORPHONE HCL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 034805 HYDROMORPHONE HCL/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60

38 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280808 OPIATE AGONISTS 034805 HYDROMORPHONE HCL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 034805 HYDROMORPHONE HCL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 034849 AMBRISENTAN PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 034849 AMBRISENTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282080 WAKEFULNESS‐PROMOTING AGENTS 034868 ARMODAFINIL PACE Medical Exception Required 282080 WAKEFULNESS‐PROMOTING AGENTS 034868 ARMODAFINIL PACE MAX DAILY UNITS : 1.000000 282080 WAKEFULNESS‐PROMOTING AGENTS 034868 ARMODAFINIL PACE MAX DAILY UNITS : 1.250000 282080 WAKEFULNESS‐PROMOTING AGENTS 034868 ARMODAFINIL PACE MAX DAILY UNITS : 1.700000 282080 WAKEFULNESS‐PROMOTING AGENTS 034868 ARMODAFINIL PACE MAX DAILY UNITS : 5.000000 100000 ANTINEOPLASTIC AGENTS 034870 TEMSIROLIMUS PACE Medical Exception Required 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 034884 RIVASTIGMINE PACE INITIAL DOSE : 4.600 120400 PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 034884 RIVASTIGMINE PACE MAX DAILY UNITS : 1.000000 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 034939 ACITRETIN/EMOLLIENT COMB NO.26 PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 035005 METHOXY PEG‐EPOETIN BETA PACE Medical Exception Required 242808 DIHYDROPYRIDINES 035042 AMLODIPINE BES/OLMESARTAN MED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 801200 VACCINES 035081 HUMAN PAPILOMVIRUS VAC,QVAL/PF PACE Medical Exception Required 562812 HISTAMINE H2‐ANTAGONISTS 035085 FAMOTIDINE/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562812 HISTAMINE H2‐ANTAGONISTS 035107 FAMOTIDINE IN NACL,ISO‐OSM/PF PACE MAX DAILY UNITS : 100.000000 562812 HISTAMINE H2‐ANTAGONISTS 035107 FAMOTIDINE IN NACL,ISO‐OSM/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 035149 NILOTINIB HCL PACE Medical Exception Required 480800 ANTITUSSIVES 035174 PSEUDOEPHED/CODEINE/GUAIFEN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035174 PSEUDOEPHED/CODEINE/GUAIFEN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035174 PSEUDOEPHED/CODEINE/GUAIFEN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035177 P/EPHED/CODEINE/ACETAMINOPH/GG PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035177 P/EPHED/CODEINE/ACETAMINOPH/GG PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035177 P/EPHED/CODEINE/ACETAMINOPH/GG PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840620 NONSTEROIDAL ANTI‐INFLAMMAT.AGENTS(SKIN) 035182 KETOPROFEN, MICRONIZED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 035182 KETOPROFEN, MICRONIZED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035195 CHLOR‐MAL/CODEINE/ACETAMINOPHN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035195 CHLOR‐MAL/CODEINE/ACETAMINOPHN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035195 CHLOR‐MAL/CODEINE/ACETAMINOPHN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035208 PE‐CODEINE‐ACETAMINOPHEN‐GUAIF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035208 PE‐CODEINE‐ACETAMINOPHEN‐GUAIF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035208 PE‐CODEINE‐ACETAMINOPHEN‐GUAIF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 401819 PHOSPHATE‐REMOVING AGENTS 035262 SEVELAMER CARBONATE PACE Medical Exception Required 401819 PHOSPHATE‐REMOVING AGENTS 035262 SEVELAMER CARBONATE PACE MAX DAILY UNITS : 3.000000 401819 PHOSPHATE‐REMOVING AGENTS 035262 SEVELAMER CARBONATE PACE MAX DAILY UNITS : 9.000000 940000 DEVICES 035326 AMNIOTIC FLUID DETECTION TEST PACE Used Exclusively in Females 243240 RENIN INHIBITORS 035338 ALISKIREN/HYDROCHLOROTHIAZIDE PACE Cannnot co‐administer Insulin and/or Anti‐Diabetic medications 562232 NEUROKININ‐1 RECEPTOR ANTAGONISTS 035346 FOSAPREPITANT DIMEGLUMINE PACE Medical Exception Required 480800 ANTITUSSIVES 035350 PHENYLEPHRINE HCL/DIHYDROCO BT PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035350 PHENYLEPHRINE HCL/DIHYDROCO BT PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035350 PHENYLEPHRINE HCL/DIHYDROCO BT PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035354 BROMPHENIRAM/PE/DIHYDROCODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035354 BROMPHENIRAM/PE/DIHYDROCODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035354 BROMPHENIRAM/PE/DIHYDROCODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035361 BROMPHENIRAMINE/P‐EPH/CODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035361 BROMPHENIRAMINE/P‐EPH/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035361 BROMPHENIRAMINE/P‐EPH/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 035420 DESVENLAFAXINE SUCCINATE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 035420 DESVENLAFAXINE SUCCINATE PACE MAX DAILY UNITS : 0.500000 281604 ANTIDEPRESSANTS 035420 DESVENLAFAXINE SUCCINATE PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 035420 DESVENLAFAXINE SUCCINATE PACE MAX DAILY UNITS : 16.000000 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 035438 RILONACEPT PACE Medical Exception Required 801200 VACCINES 035486 MENING VAC A,C,Y,W‐135 DIP/PF PACE Medical Exception Required 801200 VACCINES 035489 RABIES VACC, HUMAN DIPLOID/PF PACE Medical Exception Required 283228 SELECTIVE SEROTONIN AGONISTS 035534 SUMATRIPTAN SUCC/NAPROXEN SOD PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 035554 CERTOLIZUMAB PEGOL PACE Medical Exception Required 480800 ANTITUSSIVES 035571 BROMPHENRM/PSEUDOEPH/DIHYDROCD PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035571 BROMPHENRM/PSEUDOEPH/DIHYDROCD PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035571 BROMPHENRM/PSEUDOEPH/DIHYDROCD PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035573 DIHYDROCODEINE/GUAIFENESIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035573 DIHYDROCODEINE/GUAIFENESIN PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035573 DIHYDROCODEINE/GUAIFENESIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 801200 VACCINES 035580 RABIES VACCINE (PCEC)/PF PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 035611 METHYLNALTREXONE BROMIDE PACE Medical Exception Required 480800 ANTITUSSIVES 035645 DEXCHLORPHEN/PHENYLEPH/CODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035645 DEXCHLORPHEN/PHENYLEPH/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035645 DEXCHLORPHEN/PHENYLEPH/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26

39 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 200404 IRON PREPARATIONS 035687 FERRIC CARBOXYMALTOSE PACE Medical Exception Required 242808 DIHYDROPYRIDINES 035778 NICARDIPINE IN DEXTROSE,ISO‐OS PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 242808 DIHYDROPYRIDINES 035779 NICARDIPINE IN NACL, ISO‐OSM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 035784 PYRIL MA/PE/CODEINE PHOS PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 035784 PYRIL MA/PE/CODEINE PHOS PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 035784 PYRIL MA/PE/CODEINE PHOS PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 569200 GI DRUGS, MISCELLANEOUS 035795 ALVIMOPAN PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 035798 ROMIPLOSTIM PACE Medical Exception Required 562220 5‐HT3 RECEPTOR ANTAGONISTS 035877 GRANISETRON PACE AMOUNT : 4.000 TYPE : 'X' (Every X days) PERIOD DURATION : 28 TOLERANCE DAYS : 3 562220 5‐HT3 RECEPTOR ANTAGONISTS 035877 GRANISETRON PACE AMOUNT : 180.000 TYPE : 'X' (Every X days) PERIOD DURATION : 365 940000 DEVICES 035888 DIAPHRAGM FITTING SET,ARCSPRNG PACE Used Exclusively in Females 923200 COMPLEMENT INHIBITORS 035962 ICATIBANT ACETATE PACE Medical Exception Required 280808 OPIATE AGONISTS 035968 OXYCODONE HCL,TEREPHTH/ASPIRIN PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 035968 OXYCODONE HCL,TEREPHTH/ASPIRIN PACE Medical Exception Required 280808 OPIATE AGONISTS 035968 OXYCODONE HCL,TEREPHTH/ASPIRIN PACE MAX DAILY UNITS : 12.000000 280808 OPIATE AGONISTS 035968 OXYCODONE HCL,TEREPHTH/ASPIRIN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201600 HEMATOPOIETIC AGENTS 035989 ELTROMBOPAG OLAMINE PACE Medical Exception Required 921200 ANTIDOTES 035991 SUGAMMADEX SODIUM PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 036015 ADAPALENE/BENZOYL PEROXIDE PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 036021 PLERIXAFOR PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 036085 DEXLANSOPRAZOLE PACE MAX DAILY UNITS : 1.000000 562836 PROTON‐PUMP INHIBITORS 036085 DEXLANSOPRAZOLE PACE MAX DAILY UNITS : 2.000000 562836 PROTON‐PUMP INHIBITORS 036085 DEXLANSOPRAZOLE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 036097 MORPHINE SULFATE/0.9% NACL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 036097 MORPHINE SULFATE/0.9% NACL/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 036097 MORPHINE SULFATE/0.9% NACL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 036097 MORPHINE SULFATE/0.9% NACL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 036107 HYDROMORPHONE HCL/0.9% NACL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 036107 HYDROMORPHONE HCL/0.9% NACL/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 036107 HYDROMORPHONE HCL/0.9% NACL/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 036107 HYDROMORPHONE HCL/0.9% NACL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 036119 SILODOSIN PACE Used Exclusively in Males 681804 ANTIGONADTROPINS 036138 DEGARELIX ACETATE PACE Used Exclusively in Males 281604 ANTIDEPRESSANTS 036156 BUPROPION HBR PACE Medical Exception Required 281604 ANTIDEPRESSANTS 036156 BUPROPION HBR PACE Medical Exception Required 281604 ANTIDEPRESSANTS 036156 BUPROPION HBR PACE MAX DAILY UNITS : 0.700000 281604 ANTIDEPRESSANTS 036156 BUPROPION HBR PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 036156 BUPROPION HBR PACE MAX DAILY UNITS : 2.000000 201218 PLATELET‐AGGREGATION INHIBITORS 036159 PRASUGREL HCL PACE Medical Exception Required 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 036181 EPHEDRINE SULFATE/GUAIFENESIN PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 036187 USTEKINUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 036214 CYTARABINE/PF PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 036278 GOLIMUMAB PACE Medical Exception Required 242808 DIHYDROPYRIDINES 036305 AMLODIPINE/VALSARTAN/HCTHIAZID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681200 CONTRACEPTIVES 036325 ESTRADIOL VALERATE/DIENOGEST PACE Medical Exception Required 681200 CONTRACEPTIVES 036325 ESTRADIOL VALERATE/DIENOGEST PACE Used Exclusively in Females 402828 VASOPRESSIN ANTAGONISTS 036348 TOLVAPTAN PACE Medical Exception Required 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE Medical Exception Required 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE MAX DAILY UNITS : 12.000000 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE MAX DAILY UNITS : 2.400000 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE MAX DAILY UNITS : 3.000000 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE MAX DAILY UNITS : 4.000000 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE MAX DAILY UNITS : 6.000000 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE MAX DAILY UNITS : 8.000000 280808 OPIATE AGONISTS 036411 TAPENTADOL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682006 INCRETIN MIMETICS 036436 LIRAGLUTIDE PACE Medical Exception Required 682006 INCRETIN MIMETICS 036436 LIRAGLUTIDE PACE Medical Exception Required 682006 INCRETIN MIMETICS 036436 LIRAGLUTIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 036440 MICONAZOLE/CLEANSER 17 ON WIPE PACE Used Exclusively in Females 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 036466 TOCILIZUMAB PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 036470 VAGINAL MOISTURIZER COMBO NO.2 PACE Used Exclusively in Females 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 036471 SAXAGLIPTIN HCL PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 036471 SAXAGLIPTIN HCL PACE MAX DAILY UNITS : 1.000000 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 036471 SAXAGLIPTIN HCL PACE MAX DAILY UNITS : 2.000000 280808 OPIATE AGONISTS 036476 HYDROMORPHONE/BUPIV/0.9NACL/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 036476 HYDROMORPHONE/BUPIV/0.9NACL/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 036476 HYDROMORPHONE/BUPIV/0.9NACL/PF PACE Medical Exception Required

40 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 280808 OPIATE AGONISTS 036476 HYDROMORPHONE/BUPIV/0.9NACL/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 036479 PALIPERIDONE PALMITATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 036479 PALIPERIDONE PALMITATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 036479 PALIPERIDONE PALMITATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 036576 ASENAPINE MALEATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 036576 ASENAPINE MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 036577 MORPHINE SULFATE/NALTREXONE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 036577 MORPHINE SULFATE/NALTREXONE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 036577 MORPHINE SULFATE/NALTREXONE PACE Medical Exception Required 280808 OPIATE AGONISTS 036577 MORPHINE SULFATE/NALTREXONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 036581 TOSITUMOMAB IODINE‐131/MALTOSE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 036582 TOSITUMOMAB (WITH MALTOSE) PACE Medical Exception Required 681200 CONTRACEPTIVES 036597 ULIPRISTAL ACETATE PACE Medical Exception Required 681200 CONTRACEPTIVES 036597 ULIPRISTAL ACETATE PACE Used Exclusively in Females 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 036622 OCTOXYNOL 9/CITRIC ACID PACE Used Exclusively in Females 243240 RENIN INHIBITORS 036626 ALISKIREN/VALSARTAN PACE Cannnot co‐administer Insulin and/or Anti‐Diabetic medications 81404 ALLYLAMINE ANTIFUNGALS 036628 TERBINAFINE/HYDROXYPY.CHITOSAN PACE AMOUNT : 60.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 100000 ANTINEOPLASTIC AGENTS 036644 PRALATREXATE PACE Medical Exception Required 40408 ETHYLENEDIAMINE DERIVATIVES 036649 PYRIL MAL/PSEUDOEPHED/CODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 40408 ETHYLENEDIAMINE DERIVATIVES 036649 PYRIL MAL/PSEUDOEPHED/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 40408 ETHYLENEDIAMINE DERIVATIVES 036649 PYRIL MAL/PSEUDOEPHED/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 036655 OXYQUINOLINE/SOD.LAURYL SULFAT PACE Used Exclusively in Females 480800 ANTITUSSIVES 036680 PHENYLEPH/DIHYDROCODEINE/GUAIF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 036680 PHENYLEPH/DIHYDROCODEINE/GUAIF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 036680 PHENYLEPH/DIHYDROCODEINE/GUAIF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 036687 INCOBOTULINUMTOXINA PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 036697 TELMISARTAN/AMLODIPINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 036709 PAZOPANIB HCL PACE Medical Exception Required 480800 ANTITUSSIVES 036713 CHLORPHEN/PSEUDOEPHED/CODEINE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 036713 CHLORPHEN/PSEUDOEPHED/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 036713 CHLORPHEN/PSEUDOEPHED/CODEINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 036716 OLANZAPINE PAMOATE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 036716 OLANZAPINE PAMOATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 760000 OXYTOCICS 036724 OXYTOCIN IN D5W‐0.9% SODIUM CL PACE Used Exclusively in Females 760000 OXYTOCICS 036725 OXYTOCIN/D5W‐0.45 % SODIUM CHL PACE Used Exclusively in Females 760000 OXYTOCICS 036726 OXYTOCIN IN D5W‐0.2% SODIUM CL PACE Used Exclusively in Females 281608 ANTIPSYCHOTIC AGENTS 036778 ILOPERIDONE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 036778 ILOPERIDONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 40408 ETHYLENEDIAMINE DERIVATIVES 036779 PYRILAM/PHENYLE/DIHYDROCODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 036866 TRAMADOL/GLUCOSAMINE PACE Medical Exception Required 563200 PROKINETIC AGENTS 036920 PRUCALOPRIDE SUCCINATE PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 036930 AMIFAMPRIDINE PHOSPHATE PACE Medical Exception Required 240608 HMG‐COA REDUCTASE INHIBITORS 036983 PITAVASTATIN CALCIUM PACE MAX DAILY UNITS : 1.000000 240608 HMG‐COA REDUCTASE INHIBITORS 036983 PITAVASTATIN CALCIUM PACE MAX DAILY UNITS : 2.000000 240608 HMG‐COA REDUCTASE INHIBITORS 036983 PITAVASTATIN CALCIUM PACE MAX DAILY UNITS : 4.000000 920800 5‐ALPHA‐REDUCTASE INHIBITORS 036984 DUTASTERIDE/TAMSULOSIN HCL PACE Used Exclusively in Males 121208 BETA‐ADRENERGIC AGONISTS 037011 INDACATEROL MALEATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 922400 BONE RESORPTION INHIBITORS 037012 DENOSUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037047 CABAZITAXEL PACE Used Exclusively in Males 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 037050 MOMETASONE/FORMOTEROL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 037050 MOMETASONE/FORMOTEROL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 037089 OLMESARTAN/AMLODIPIN/HCTHIAZID PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 840406 ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) 037093 ACYCLOVIR/HYDROCORTISONE PACE Medical Exception Required 801200 VACCINES 037122 BCG VACCINE, LIVE/PF PACE Medical Exception Required 483200 PHOSPHODIESTERASE TYPE 4 INHIBITORS 037123 ROFLUMILAST PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 243240 RENIN INHIBITORS 037135 ALISKIREN/AMLODIPINE BESYLATE PACE Cannnot co‐administer Insulin and/or Anti‐Diabetic medications 561200 CATHARTICS AND LAXATIVES 037152 SODIUM, POTASSIUM,MAG SULFATES PACE AMOUNT : 1.000 TYPE : 'X' (Every X days) PERIOD DURATION : 365 40416 PIPERAZINE DERIVATIVES 037177 CHLORCYCLI/PSEUDOEPHED/CODEINE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 922000 IMMUNOMODULATORY AGENTS 037180 FINGOLIMOD HCL PACE Medical Exception Required 480800 ANTITUSSIVES 037187 CHLORCYCLIZINE HCL/CODEINE PH PACE AMOUNT : 14.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 480800 ANTITUSSIVES 037187 CHLORCYCLIZINE HCL/CODEINE PH PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 037187 CHLORCYCLIZINE HCL/CODEINE PH PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681200 CONTRACEPTIVES 037200 DROSPIR/ETH ESTRA/LEVOMEFOL CA PACE Medical Exception Required 681200 CONTRACEPTIVES 037200 DROSPIR/ETH ESTRA/LEVOMEFOL CA PACE Used Exclusively in Females 840492 LOCAL ANTI‐INFECTIVES, MISCELLANEOUS 037221 HYDROCORTISONE/IODOQUIN/ALOE 2 PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037256 ERIBULIN MESYLATE PACE Medical Exception Required

41 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 801200 VACCINES 037261 ZOSTER VACCINE LIVE/PF PACE AMOUNT : 1.000 TYPE : 'L' (Lifetime) 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 037265 MICONAZOLE NITRATE/ZINC OX/PET PACE Medical Exception Required 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 037278 DEXTROMETHORPHAN HBR/QUINIDINE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 037321 LURASIDONE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 037321 LURASIDONE HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 243240 RENIN INHIBITORS 037333 ALISKIREN/AMLODIPIN/HCTHIAZIDE PACE Cannnot co‐administer Insulin and/or Anti‐Diabetic medications 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 037444 AZILSARTAN MEDOXOMIL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 924400 IMMUNOSUPPRESSIVE AGENTS 037462 BELIMUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037503 IPILIMUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037531 VANDETANIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037571 ABIRATERONE ACETATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037571 ABIRATERONE ACETATE PACE Used Exclusively in Males 281292 ANTICONVULSANTS, MISCELLANEOUS 037574 GABAPENTIN ENACARBIL PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 037576 LINAGLIPTIN PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 037585 ASPIRIN/DIPHENHYDRAMINE CITRAT PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 037597 VILAZODONE HCL PACE Medical Exception Required 81840 HCV ANTIVIRALS 037609 BOCEPREVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 037609 BOCEPREVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 81840 HCV ANTIVIRALS 037629 TELAPREVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 037629 TELAPREVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 037649 METHADONE HCL IN 0.9 % NACL PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 037649 METHADONE HCL IN 0.9 % NACL PACE Medical Exception Required 81212 MACROLIDE ANTIBIOTICS 037674 FIDAXOMICIN PACE Medical Exception Required 81212 MACROLIDE ANTIBIOTICS 037674 FIDAXOMICIN PACE AMOUNT : 10.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 037725 REMIFENTANIL IN 0.9 % NACL/PF PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 037760 EPOPROSTENOL SODIUM (GLYCINE) PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 037762 EPOPROSTENOL SODIUM (ARGININE) PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 037762 EPOPROSTENOL SODIUM (ARGININE) PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280808 OPIATE AGONISTS 037768 FENTANYL CITRAT/DEXTROSE 5%/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 037812 HYDROMORPHONE HCL IN D5W/PF PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 037825 ABATACEPT PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037837 VEMURAFENIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037879 BRENTUXIMAB VEDOTIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 037916 CRIZOTINIB PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 038054 SITAGLIPTIN/SIMVASTATIN PACE Medical Exception Required 280808 OPIATE AGONISTS 038056 SUFENTANIL/BUPIVACAINE/NS/PF PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 038202 RUXOLITINIB PHOSPHATE PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 038209 AFLIBERCEPT PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 038251 RESVERA/CHROM/GR.TEA/EGCG/DIG3 PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 038370 AZILSARTAN MED/CHLORTHALIDONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 921200 ANTIDOTES 038387 GLUCARPIDASE PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 038388 FEMININE HYGIENE CLEANSER NO.1 PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 038446 AXITINIB PACE Medical Exception Required 682006 INCRETIN MIMETICS 038451 EXENATIDE MICROSPHERES PACE Medical Exception Required 682006 INCRETIN MIMETICS 038451 EXENATIDE MICROSPHERES PACE Medical Exception Required 481412 CYSTIC FIBROSIS (CFTR) POTENTIATORS 038461 IVACAFTOR PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 038464 LINAGLIPTIN/METFORMIN HCL PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 038464 LINAGLIPTIN/METFORMIN HCL PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 038464 LINAGLIPTIN/METFORMIN HCL PACE AMOUNT : 2.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 201600 HEMATOPOIETIC AGENTS 038746 PEGINESATIDE PACE Medical Exception Required 280808 OPIATE AGONISTS 038867 SUFENTANIL CITRATE/PF PACE Medical Exception Required 440000 ENZYMES 038937 TALIGLUCERASE ALFA PACE Medical Exception Required 560800 ANTIDIARRHEA AGENTS 038961 OPIUM TINCTURE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 560800 ANTIDIARRHEA AGENTS 038961 OPIUM TINCTURE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 560800 ANTIDIARRHEA AGENTS 038961 OPIUM TINCTURE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 569200 GI DRUGS, MISCELLANEOUS 039124 CHOLIC ACID PACE Medical Exception Required 681604 ESTROGENS 039160 DROSPIRENONE/ESTRADIOL PACE Used Exclusively in Females 242808 DIHYDROPYRIDINES 039280 NICARDIPINE IN 5 % DEXTROSE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 480800 ANTITUSSIVES 039314 HYDROCODONE BIT/HOMATROP ME‐BR PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 480800 ANTITUSSIVES 039314 HYDROCODONE BIT/HOMATROP ME‐BR PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 480800 ANTITUSSIVES 039314 HYDROCODONE BIT/HOMATROP ME‐BR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 039338 CARFILZOMIB PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 039347 PHENTERMINE/TOPIRAMATE PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 039347 PHENTERMINE/TOPIRAMATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 120808 ANTIMUSCARINICS/ANTISPASMODICS 039528 ACLIDINIUM BROMIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 039580 ENZALUTAMIDE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 039580 ENZALUTAMIDE PACE Used Exclusively in Males 569200 GI DRUGS, MISCELLANEOUS 039583 LINACLOTIDE PACE Medical Exception Required

42 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 100000 ANTINEOPLASTIC AGENTS 039590 BOSUTINIB PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 039624 TERIFLUNOMIDE PACE Medical Exception Required 281292 ANTICONVULSANTS, MISCELLANEOUS 039628 PERAMPANEL PACE INITIAL DOSE : 2.000 280808 OPIATE AGONISTS 039644 MORPHINE IN ISO SOD CHLORID/PF PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 039644 MORPHINE IN ISO SOD CHLORID/PF PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 039644 MORPHINE IN ISO SOD CHLORID/PF PACE Medical Exception Required 280808 OPIATE AGONISTS 039644 MORPHINE IN ISO SOD CHLORID/PF PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 039665 REGORAFENIB PACE Medical Exception Required 940000 DEVICES 039720 OVULATION, PREGNANCY TEST KIT PACE Used Exclusively in Females 529200 EENT DRUGS, MISCELLANEOUS 039734 OCRIPLASMIN/PF PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 039768 TOFACITINIB CITRATE PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 039768 TOFACITINIB CITRATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 039815 CABOZANTINIB S‐MALATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 039815 CABOZANTINIB S‐MALATE PACE MAX DAILY UNITS : 1.000000 100000 ANTINEOPLASTIC AGENTS 039815 CABOZANTINIB S‐MALATE PACE MAX DAILY UNITS : 1.290000 100000 ANTINEOPLASTIC AGENTS 039815 CABOZANTINIB S‐MALATE PACE MAX DAILY UNITS : 1.800000 100000 ANTINEOPLASTIC AGENTS 039815 CABOZANTINIB S‐MALATE PACE MAX DAILY UNITS : 3.000000 100000 ANTINEOPLASTIC AGENTS 039859 PONATINIB HCL PACE Medical Exception Required 682904 SOMATOSTATIN AGONISTS 039866 PASIREOTIDE DIASPARTATE PACE Medical Exception Required 240692 ANTILIPEMIC AGENTS, MISCELLANEOUS 039883 LOMITAPIDE MESYLATE PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 039890 TEDUGLUTIDE PACE Medical Exception Required 81604 ANTITUBERCULOSIS AGENTS 039895 BEDAQUILINE FUMARATE PACE Medical Exception Required 560800 ANTIDIARRHEA AGENTS 039897 CROFELEMER PACE Medical Exception Required 681808 GONADOTROPINS 039945 LEUPROLIDE/NORETHINDRONE ACET PACE Used Exclusively in Females 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 039967 ALOGLIPTIN BENZ/PIOGLITAZONE PACE Medical Exception Required 682005 DIPEPTIDYL PEPTIDASE‐4(DPP‐4) INHIBITORS 039968 ALOGLIPTIN BENZOATE PACE Medical Exception Required 401000 AMMONIA DETOXICANTS 039990 GLYCEROL PHENYLBUTYRATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 039996 POMALIDOMIDE PACE Medical Exception Required 240692 ANTILIPEMIC AGENTS, MISCELLANEOUS 040041 MIPOMERSEN SODIUM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 040046 ADO‐TRASTUZUMAB EMTANSINE PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 040092 VAGINAL MOISTURIZER COMBO NO.4 PACE Used Exclusively in Females 681612 ESTROGEN AGONIST‐ANTAGONISTS 040096 OSPEMIFENE PACE Used Exclusively in Females 940000 DEVICES 040098 HYALURONATE SOD, CROSS‐LINKED PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 040137 DAPAGLIFLOZIN PROPANEDIOL PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 040168 DIMETHYL FUMARATE PACE Medical Exception Required 960000 PHARMACEUTICAL AIDS 040168 DIMETHYL FUMARATE PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 040171 CANAGLIFLOZIN PACE Medical Exception Required 480200 ANTIFIBROTIC AGENTS 040237 PIRFENIDONE PACE Medical Exception Required 480200 ANTIFIBROTIC AGENTS 040237 PIRFENIDONE PACE MAX DAILY UNITS : 3.000000 480200 ANTIFIBROTIC AGENTS 040237 PIRFENIDONE PACE MAX DAILY UNITS : 9.000000 480200 ANTIFIBROTIC AGENTS 040237 PIRFENIDONE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 040319 FLUTICASONE/VILANTEROL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 040319 FLUTICASONE/VILANTEROL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 780000 RADIOACTIVE AGENTS 040334 RADIUM‐223 DICHLORIDE PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 040360 DABRAFENIB MESYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 040361 TRAMETINIB DIMETHYL SULFOXIDE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 040362 ZIV‐AFLIBERCEPT PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 040373 LORCASERIN HCL PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 040373 LORCASERIN HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201600 HEMATOPOIETIC AGENTS 040426 TBO‐FILGRASTIM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 040478 AFATINIB DIMALEATE PACE Medical Exception Required 562836 PROTON‐PUMP INHIBITORS 040532 ESOMEPRAZOLE STRONTIUM PACE AMOUNT : 180.000 TYPE : 'X' (Every X days) PERIOD DURATION : 210 562836 PROTON‐PUMP INHIBITORS 040532 ESOMEPRAZOLE STRONTIUM PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 562836 PROTON‐PUMP INHIBITORS 040532 ESOMEPRAZOLE STRONTIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281604 ANTIDEPRESSANTS 040637 VORTIOXETINE HYDROBROMIDE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 040637 VORTIOXETINE HYDROBROMIDE PACE Medical Exception Required 281604 ANTIDEPRESSANTS 040637 VORTIOXETINE HYDROBROMIDE PACE MAX DAILY UNITS : 1.000000 281604 ANTIDEPRESSANTS 040637 VORTIOXETINE HYDROBROMIDE PACE MAX DAILY UNITS : 2.000000 281604 ANTIDEPRESSANTS 040637 VORTIOXETINE HYDROBROMIDE PACE MAX DAILY UNITS : 4.000000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 040644 RIOCIGUAT PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 040644 RIOCIGUAT PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 040677 MACITENTAN PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 040677 MACITENTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 040683 METHOTREXATE/PF PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 040700 DICLOFENAC SUBMICRONIZED PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 040700 DICLOFENAC SUBMICRONIZED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 040703 OBINUTUZUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 040745 IBRUTINIB PACE Medical Exception Required 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 040763 LULICONAZOLE PACE Medical Exception Required

43 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 81840 HCV ANTIVIRALS 040771 SIMEPREVIR SODIUM PACE Medical Exception Required 81840 HCV ANTIVIRALS 040771 SIMEPREVIR SODIUM PACE AMOUNT : 168.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 040771 SIMEPREVIR SODIUM PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 040771 SIMEPREVIR SODIUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682006 INCRETIN MIMETICS 040782 LIXISENATIDE PACE Medical Exception Required 682006 INCRETIN MIMETICS 040782 LIXISENATIDE PACE Medical Exception Required 81840 HCV ANTIVIRALS 040795 SOFOSBUVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 040795 SOFOSBUVIR PACE AMOUNT : 336.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 040795 SOFOSBUVIR PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 040795 SOFOSBUVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 040795 SOFOSBUVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 241212 PHOSPHODIESTERASE TYPE 5 INHIBITORS 040798 AVANAFIL PACE Used Exclusively in Males 520404 ANTIBACTERIALS (EENT) 040806 CIPROFLOXACIN HCL/FLUOCINOLONE PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 040827 TREPROSTINIL DIOLAMINE PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 040827 TREPROSTINIL DIOLAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 682008 INSULINS 040844 INSULIN DEGLUDEC PACE Medical Exception Required 682008 INSULINS 040844 INSULIN DEGLUDEC PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 120808 ANTIMUSCARINICS/ANTISPASMODICS 040852 UMECLIDINIUM BRM/VILANTEROL TR PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 120808 ANTIMUSCARINICS/ANTISPASMODICS 040852 UMECLIDINIUM BRM/VILANTEROL TR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 681604 ESTROGENS 040855 ESTROGENS,CONJ/BAZEDOXIFENE PACE Used Exclusively in Females 282492 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC 040927 TASIMELTEON PACE Medical Exception Required 440000 ENZYMES 040929 ELOSULFASE ALFA PACE Medical Exception Required 121212 ALPHA‐ AND BETA‐ADRENERGIC AGONISTS 040936 DROXIDOPA PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 040967 APREMILAST PACE Medical Exception Required 121208 BETA‐ADRENERGIC AGONISTS 040969 OLODATEROL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 202816 HEMOSTATICS 041044 FACTOR IX REC, FC FUSION PROTN PACE Medical Exception Required 684000 LEPTINS 041078 METRELEPTIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041101 SILTUXIMAB PACE Medical Exception Required 121208 BETA‐ADRENERGIC AGONISTS 041107 INDACATEROL/GLYCOPYRROLATE PACE Medical Exception Required 121208 BETA‐ADRENERGIC AGONISTS 041107 INDACATEROL/GLYCOPYRROLATE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 041109 RAMUCIRUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041111 CERITINIB PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 041115 UMECLIDINIUM BROMIDE PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 569200 GI DRUGS, MISCELLANEOUS 041146 VEDOLIZUMAB PACE Medical Exception Required 682006 INCRETIN MIMETICS 041163 ALBIGLUTIDE PACE Medical Exception Required 682006 INCRETIN MIMETICS 041163 ALBIGLUTIDE PACE INITIAL DOSE : 4.300 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 041184 EFINACONAZOLE PACE Medical Exception Required 202816 HEMOSTATICS 041187 ANTIHEMOPH.FVIII REC,FC FUSION PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041188 DAPAGLIFLOZIN/METFORMIN HCL PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041188 DAPAGLIFLOZIN/METFORMIN HCL PACE MAX DAILY UNITS : 1.000000 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041188 DAPAGLIFLOZIN/METFORMIN HCL PACE MAX DAILY UNITS : 2.000000 81228 ANTIBACTERIALS, MISCELLANEOUS 041209 TEDIZOLID PHOSPHATE PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041217 EMPAGLIFLOZIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041264 BELINOSTAT PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041287 CANAGLIFLOZIN/METFORMIN HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041297 IDELALISIB PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 041331 PEGINTERFERON BETA‐1A PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 041346 ELIGLUSTAT TARTRATE PACE Medical Exception Required 840408 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE) 041353 TAVABOROLE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041369 PEMBROLIZUMAB PACE Medical Exception Required 81840 HCV ANTIVIRALS 041377 DACLATASVIR DIHYDROCHLORIDE PACE Medical Exception Required 81840 HCV ANTIVIRALS 041377 DACLATASVIR DIHYDROCHLORIDE PACE AMOUNT : 84.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 041377 DACLATASVIR DIHYDROCHLORIDE PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 041377 DACLATASVIR DIHYDROCHLORIDE PACE MAX DAILY UNITS : 3.000000 81840 HCV ANTIVIRALS 041377 DACLATASVIR DIHYDROCHLORIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282008 ANOREXIGENIC AGENTS 041389 NALTREXONE HCL/BUPROPION HCL PACE Medical Exception Required 282008 ANOREXIGENIC AGENTS 041389 NALTREXONE HCL/BUPROPION HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 800400 ANTITOXINS AND IMMUNE GLOBULINS 041391 IGG/HYALURONIDASE,RECOMBINANT PACE Medical Exception Required 682006 INCRETIN MIMETICS 041421 DULAGLUTIDE PACE Medical Exception Required 682006 INCRETIN MIMETICS 041421 DULAGLUTIDE PACE AMOUNT : 0.072 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 81840 HCV ANTIVIRALS 041457 LEDIPASVIR/SOFOSBUVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 041457 LEDIPASVIR/SOFOSBUVIR PACE AMOUNT : 168.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 041457 LEDIPASVIR/SOFOSBUVIR PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 041457 LEDIPASVIR/SOFOSBUVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 041457 LEDIPASVIR/SOFOSBUVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 562232 NEUROKININ‐1 RECEPTOR ANTAGONISTS 041467 NETUPITANT/PALONOSETRON HCL PACE Medical Exception Required 940000 DEVICES 041475 NA MG FL/NA PHO/NACL/HA/NA HYP PACE Medical Exception Required

44 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 480200 ANTIFIBROTIC AGENTS 041489 NINTEDANIB ESYLATE PACE Medical Exception Required 480200 ANTIFIBROTIC AGENTS 041489 NINTEDANIB ESYLATE PACE MAX DAILY UNITS : 2.000000 480200 ANTIFIBROTIC AGENTS 041489 NINTEDANIB ESYLATE PACE MAX DAILY UNITS : 3.000000 480200 ANTIFIBROTIC AGENTS 041489 NINTEDANIB ESYLATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 202816 HEMOSTATICS 041515 ANTIHEMOPHILIC FVIII,REC PORC PACE Medical Exception Required 81808 ANTIRETROVIRALS 041531 DARUNAVIR/COBICISTAT PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 100000 ANTINEOPLASTIC AGENTS 041612 BLINATUMOMAB PACE Medical Exception Required 81206 CEPHALOSPORIN ANTIBIOTICS 041641 CEFTOLOZANE/TAZOBACTAM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041642 OLAPARIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041642 OLAPARIB PACE Used Exclusively in Females 81840 HCV ANTIVIRALS 041644 OMBITA/PARITAP/RITON/DASABUVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 041644 OMBITA/PARITAP/RITON/DASABUVIR PACE AMOUNT : 168.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 041644 OMBITA/PARITAP/RITON/DASABUVIR PACE MAX DAILY UNITS : 3.000000 81840 HCV ANTIVIRALS 041644 OMBITA/PARITAP/RITON/DASABUVIR PACE MAX DAILY UNITS : 4.000000 81840 HCV ANTIVIRALS 041644 OMBITA/PARITAP/RITON/DASABUVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 041654 NIVOLUMAB PACE Medical Exception Required 201204 ANTICOAGULANTS 041672 EDOXABAN TOSYLATE PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 041686 NALOXEGOL OXALATE PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 041692 ACLIDINIUM BROM/FORMOTEROL FUM PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 041715 SECUKINUMAB PACE Medical Exception Required 81808 ANTIRETROVIRALS 041722 ATAZANAVIR SULFATE/COBICISTAT PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041724 EMPAGLIFLOZIN/LINAGLIPTIN PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 041724 EMPAGLIFLOZIN/LINAGLIPTIN PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 100000 ANTINEOPLASTIC AGENTS 041725 PALBOCICLIB PACE Medical Exception Required 81840 HCV ANTIVIRALS 041734 OMBITASVIR/PARITAPREV/RITONAV PACE Medical Exception Required 81840 HCV ANTIVIRALS 041734 OMBITASVIR/PARITAPREV/RITONAV PACE AMOUNT : 84.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 041734 OMBITASVIR/PARITAPREV/RITONAV PACE MAX DAILY UNITS : 2.000000 81840 HCV ANTIVIRALS 041734 OMBITASVIR/PARITAPREV/RITONAV PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 041756 LENVATINIB MESYLATE PACE Medical Exception Required 800400 ANTITOXINS AND IMMUNE GLOBULINS 041763 IMMUN GLOB G/SORB/GLY/IGA 0‐50 PACE Medical Exception Required 81206 CEPHALOSPORIN ANTIBIOTICS 041790 CEFTAZIDIME/AVIBACTAM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041794 PANOBINOSTAT LACTATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 041794 PANOBINOSTAT LACTATE PACE AMOUNT : 336.000 TYPE : 'X' (Every X days) PERIOD DURATION : 365 800400 ANTITOXINS AND IMMUNE GLOBULINS 041795 IMMUN GLOB G/GLY/GLUC/IGA 0‐50 PACE Medical Exception Required 800400 ANTITOXINS AND IMMUNE GLOBULINS 041796 IMMUN GLOB G(IGG)/GLY/IGA OV50 PACE Medical Exception Required 800400 ANTITOXINS AND IMMUNE GLOBULINS 041798 IMMUN GLOB G(IGG)/PRO/IGA 0‐50 PACE Medical Exception Required 81408 AZOLE ANTIFUNGALS 041817 ISAVUCONAZONIUM SULFATE PACE Medical Exception Required 682008 INSULINS 041880 INSULIN DEGLUDEC/LIRAGLUTIDE PACE Medical Exception Required 682008 INSULINS 041880 INSULIN DEGLUDEC/LIRAGLUTIDE PACE Medical Exception Required 682008 INSULINS 041880 INSULIN DEGLUDEC/LIRAGLUTIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 041986 INDOMETHACIN, SUBMICRONIZED PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 041986 INDOMETHACIN, SUBMICRONIZED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 202816 HEMOSTATICS 042040 FACTOR IX HUMAN RECOMB,THR 148 PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 042048 TIOTROPIUM BR/OLODATEROL HCL PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 042048 TIOTROPIUM BR/OLODATEROL HCL PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 120808 ANTIMUSCARINICS/ANTISPASMODICS 042048 TIOTROPIUM BR/OLODATEROL HCL PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 320000 CONTRACEPTIVES (E.G. FOAMS, DEVICES) 042112 DIAPHRAGMS, CONTOURED PACE Used Exclusively in Females 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 042183 EMPAGLIFLOZIN/METFORMIN HCL PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 042183 EMPAGLIFLOZIN/METFORMIN HCL PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 042183 EMPAGLIFLOZIN/METFORMIN HCL PACE AMOUNT : 2.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 042256 SACUBITRIL/VALSARTAN PACE Medical Exception Required 243208 ANGIOTENSIN II RECEPTOR ANTAGONISTS 042256 SACUBITRIL/VALSARTAN PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 042283 BREXPIPRAZOLE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 042283 BREXPIPRAZOLE PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 042283 BREXPIPRAZOLE PACE INITIAL DOSE : 0.500 240624 PCSK9 INHIBITORS 042347 ALIROCUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 042369 SONIDEGIB PHOSPHATE PACE Medical Exception Required 240624 PCSK9 INHIBITORS 042378 EVOLOCUMAB PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 042445 ELUXADOLINE PACE Medical Exception Required 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 042447 FLIBANSERIN PACE Used Exclusively in Females 562232 NEUROKININ‐1 RECEPTOR ANTAGONISTS 042468 ROLAPITANT HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 042544 TRIFLURIDINE/TIPIRACIL HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 042552 CARIPRAZINE HCL PACE MAX DAILY UNITS : 1.000000 281608 ANTIPSYCHOTIC AGENTS 042552 CARIPRAZINE HCL PACE MAX DAILY UNITS : 1.400000 281608 ANTIPSYCHOTIC AGENTS 042552 CARIPRAZINE HCL PACE MAX DAILY UNITS : 2.000000 281608 ANTIPSYCHOTIC AGENTS 042552 CARIPRAZINE HCL PACE MAX DAILY UNITS : 4.000000 281608 ANTIPSYCHOTIC AGENTS 042552 CARIPRAZINE HCL PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 042595 ARIPIPRAZOLE LAUROXIL PACE Medical Exception Required

45 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 281608 ANTIPSYCHOTIC AGENTS 042595 ARIPIPRAZOLE LAUROXIL PACE AMOUNT : 1.000 TYPE : 'X' (Every X days) PERIOD DURATION : 30 TOLERANCE PERCENT : 25.0 283632 MONOAMINE OXIDASE B INHIBITORS 042752 SAFINAMIDE MESYLATE PACE Medical Exception Required 481020 INTERLEUKIN ANTAGONISTS 042775 MEPOLIZUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 042796 COBIMETINIB FUMARATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 042803 OSIMERTINIB MESYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 042826 IXAZOMIB CITRATE PACE Medical Exception Required 202816 HEMOSTATICS 042832 ANTIHEMO.FVIII,FULL LENGTH PEG PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 042839 MELOXICAM, SUBMICRONIZED PACE Medical Exception Required 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 042839 MELOXICAM, SUBMICRONIZED PACE MAX DAILY UNITS : 1.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 042839 MELOXICAM, SUBMICRONIZED PACE MAX DAILY UNITS : 2.000000 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 042839 MELOXICAM, SUBMICRONIZED PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 042895 ALECTINIB HCL PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 16.000000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 2.000000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 2.300000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 2.700000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 3.200000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 4.000000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 5.400000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE MAX DAILY UNITS : 8.000000 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE Medical Exception Required 484800 VASODILATING AGENTS (RESPIRATORY TRACT) 042922 SELEXIPAG PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 404000 URICOSURIC AGENTS 042929 LESINURAD PACE Medical Exception Required 404000 URICOSURIC AGENTS 042929 LESINURAD PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 043030 ELBASVIR/GRAZOPREVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 043030 ELBASVIR/GRAZOPREVIR PACE AMOUNT : 112.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 043030 ELBASVIR/GRAZOPREVIR PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 043030 ELBASVIR/GRAZOPREVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 202816 HEMOSTATICS 043140 FACTOR IX RECOM,ALBUMIN FUSION PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 043193 IXEKIZUMAB PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 043249 INFLIXIMAB‐DYYB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 043284 VENETOCLAX PACE Medical Exception Required 280808 OPIATE AGONISTS 043322 HYDROMORPHONE/ROPIV/SOD CHL/PF PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 043352 GLYCOPYRROLATE/FORMOTEROL FUM PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 043352 GLYCOPYRROLATE/FORMOTEROL FUM PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 120808 ANTIMUSCARINICS/ANTISPASMODICS 043352 GLYCOPYRROLATE/FORMOTEROL FUM PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 281608 ANTIPSYCHOTIC AGENTS 043373 PIMAVANSERIN TARTRATE PACE Medical Exception Required 280808 OPIATE AGONISTS 043376 OXYCODONE MYRISTATE PACE AMOUNT : 30.000 TYPE : 'X' (Every X days) PERIOD DURATION : 90 280808 OPIATE AGONISTS 043376 OXYCODONE MYRISTATE PACE AMOUNT : 2.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 280808 OPIATE AGONISTS 043376 OXYCODONE MYRISTATE PACE Medical Exception Required 280808 OPIATE AGONISTS 043376 OXYCODONE MYRISTATE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 043408 ATEZOLIZUMAB PACE Medical Exception Required 840800 ANTIPRURITICS AND LOCAL ANESTHETICS 043419 LIDOCAINE/DIMETHICONE PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 043438 OBETICHOLIC ACID PACE Medical Exception Required 241292 VASODILATING AGENTS, MISCELLANEOUS 043457 PAPAVERINE HCL/ALPROSTAD/WATER PACE Used Exclusively in Males 121604 ALPHA‐ADRENERGIC BLOCKING AGENT(SYMPATH) 043459 PHENTOLAMINE/ALPROSTADIL/WATER PACE Used Exclusively in Males 366800 ROENTGENOGRAPHY AND OTHER IMAGING AGENTS 043467 FLUCICLOVINE F 18 PACE Used Exclusively in Males 202816 HEMOSTATICS 043468 ANTIHEM.FVIII,SIN‐CHN,B‐DM TRU PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 043496 NEBIVOLOL HCL/VALSARTAN PACE Medical Exception Required 242400 BETA‐ADRENERGIC BLOCKING AGENTS 043496 NEBIVOLOL HCL/VALSARTAN PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 241292 VASODILATING AGENTS, MISCELLANEOUS 043499 PAPAVERINE/PHENTOLAMINE/WATER PACE Used Exclusively in Males 241292 VASODILATING AGENTS, MISCELLANEOUS 043500 PAPAV/PHENTOLAM/ALPROST/WATER PACE Used Exclusively in Males 81840 HCV ANTIVIRALS 043561 SOFOSBUVIR/VELPATASVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 043561 SOFOSBUVIR/VELPATASVIR PACE AMOUNT : 84.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 043561 SOFOSBUVIR/VELPATASVIR PACE MAX DAILY UNITS : 1.000000 81840 HCV ANTIVIRALS 043561 SOFOSBUVIR/VELPATASVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 282004 AMPHETAMINES 043652 AMPHETAMINE PACE Medical Exception Required 282004 AMPHETAMINES 043652 AMPHETAMINE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 800400 ANTITOXINS AND IMMUNE GLOBULINS 043712 IMMUNE GLOBUL G/GLY/IGA AVG 46 PACE Medical Exception Required 280808 OPIATE AGONISTS 043767 OXYCODONE HCL/NALTREXONE HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 043793 MELPHALAN HCL/BETADEX SBES PACE Medical Exception Required 81832 NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS 043907 TENOFOVIR ALAFENAMIDE PACE Medical Exception Required 81832 NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS 043907 TENOFOVIR ALAFENAMIDE PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 682008 INSULINS 043944 INSULIN GLARGINE/LIXISENATIDE PACE Medical Exception Required 682008 INSULINS 043944 INSULIN GLARGINE/LIXISENATIDE PACE Medical Exception Required 682008 INSULINS 043944 INSULIN GLARGINE/LIXISENATIDE PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 683200 PROGESTINS 043985 HYDROXYPROGESTERONE CAPROAT/PF PACE Used Exclusively in Females 840692 ANTI‐INFLAMMATORY AGENTS, MISC (SKIN) 043999 CRISABOROLE PACE Medical Exception Required

46 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 100000 ANTINEOPLASTIC AGENTS 044002 RUCAPARIB CAMSYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044002 RUCAPARIB CAMSYLATE PACE Used Exclusively in Females 922400 BONE RESORPTION INHIBITORS 044040 ZOLEDRONIC AC/MANNITOL/0.9NACL PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 044054 PLECANATIDE PACE MAX DAILY UNITS : 1.000000 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 044102 BRODALUMAB PACE Medical Exception Required 560800 ANTIDIARRHEA AGENTS 044132 TELOTRISTAT ETIPRATE PACE Medical Exception Required 560800 ANTIDIARRHEA AGENTS 044132 TELOTRISTAT ETIPRATE PACE AMOUNT : 3.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 100000 ANTINEOPLASTIC AGENTS 044151 RIBOCICLIB SUCCINATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044151 RIBOCICLIB SUCCINATE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 044170 AVELUMAB PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 044176 NALDEMEDINE TOSYLATE PACE Medical Exception Required 569200 GI DRUGS, MISCELLANEOUS 044176 NALDEMEDINE TOSYLATE PACE MAX DAILY UNITS : 1.000000 100000 ANTINEOPLASTIC AGENTS 044177 NIRAPARIB TOSYLATE PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 044178 OCRELIZUMAB PACE Medical Exception Required 481020 INTERLEUKIN ANTAGONISTS 044180 DUPILUMAB PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 044180 DUPILUMAB PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 044183 SARILUMAB PACE Medical Exception Required 285600 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR 044192 DEUTETRABENAZINE PACE Medical Exception Required 285600 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR 044202 VALBENAZINE TOSYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044226 BRIGATINIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044227 MIDOSTAURIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044230 DURVALUMAB PACE Medical Exception Required 682408 PARATHYROID AGENTS 044231 ABALOPARATIDE PACE Medical Exception Required 682408 PARATHYROID AGENTS 044231 ABALOPARATIDE PACE AMOUNT : 730.000 TYPE : 'L' (Lifetime) 682408 PARATHYROID AGENTS 044231 ABALOPARATIDE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 044246 RIBOCICLIB SUCCINATE/LETROZOLE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044246 RIBOCICLIB SUCCINATE/LETROZOLE PACE Used Exclusively in Females 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 044252 EDARAVONE PACE Medical Exception Required 440000 ENZYMES 044258 CERLIPONASE ALFA PACE Medical Exception Required 682004 BIGUANIDES 044266 METFORMIN/BLOOD SUGAR DIAGNOST PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 044296 BARICITINIB PACE Medical Exception Required 202816 HEMOSTATICS 044322 FACTOR IX HUMAN REC,PEGYLATED PACE Medical Exception Required 81218 QUINOLONE ANTIBIOTICS 044372 DELAFLOXACIN MEGLUMINE PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 044418 GUSELKUMAB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044421 NERATINIB MALEATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044421 NERATINIB MALEATE PACE AMOUNT : 365.000 TYPE : 'L' (Lifetime) 100000 ANTINEOPLASTIC AGENTS 044421 NERATINIB MALEATE PACE Used Exclusively in Females 81840 HCV ANTIVIRALS 044428 SOFOSBUVIR/VELPATAS/VOXILAPREV PACE Medical Exception Required 81840 HCV ANTIVIRALS 044428 SOFOSBUVIR/VELPATAS/VOXILAPREV PACE AMOUNT : 84.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 044428 SOFOSBUVIR/VELPATAS/VOXILAPREV PACE MAX DAILY UNITS : 1.000000 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 044432 INFLIXIMAB‐ABDA PACE Medical Exception Required 929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS 044433 MIGALASTAT HCL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044438 INOTUZUMAB OZOGAMICIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044450 ENASIDENIB MESYLATE PACE Medical Exception Required 81840 HCV ANTIVIRALS 044453 GLECAPREVIR/PIBRENTASVIR PACE Medical Exception Required 81840 HCV ANTIVIRALS 044453 GLECAPREVIR/PIBRENTASVIR PACE AMOUNT : 112.000 TYPE : 'L' (Lifetime) 81840 HCV ANTIVIRALS 044453 GLECAPREVIR/PIBRENTASVIR PACE MAX DAILY UNITS : 3.000000 81840 HCV ANTIVIRALS 044453 GLECAPREVIR/PIBRENTASVIR PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 201204 ANTICOAGULANTS 044458 BETRIXABAN MALEATE PACE AMOUNT : 42.000 TYPE : 'X' (Every X days) PERIOD DURATION : 60 100000 ANTINEOPLASTIC AGENTS 044461 DAUNORUBICIN/CYTARABINE LIPOS PACE Medical Exception Required 404000 URICOSURIC AGENTS 044474 LESINURAD/ALLOPURINOL PACE AMOUNT : 1.000 TYPE : 'D' (Daily) PERIOD DURATION : 1 TOLERANCE PERCENT : 25.0 81207 MISC. BETA‐LACTAM ANTIBIOTICS 044482 MEROPENEM/VABORBACTAM PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044483 TISAGENLECLEUCEL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044503 COPANLISIB DI‐HCL PACE Medical Exception Required 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 044508 FLUTICASONE/UMECLIDIN/VILANTER PACE Medical Exception Required 481008 CORTICOSTEROIDS (RESPIRATORY TRACT) 044508 FLUTICASONE/UMECLIDIN/VILANTER PACE HISTORY PERIOD : 45 SWITCHBACK PERIOD : 26 100000 ANTINEOPLASTIC AGENTS 044537 ABEMACICLIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044577 AXICABTAGENE CILOLEUCEL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044607 ACALABRUTINIB PACE Medical Exception Required 81892 ANTIVIRALS, MISCELLANEOUS 044622 LETERMOVIR PACE Medical Exception Required 481020 INTERLEUKIN ANTAGONISTS 044635 BENRALIZUMAB PACE Medical Exception Required 801200 VACCINES 044645 HEPATITIS B VACCINE/CPG1018/PF PACE Medical Exception Required 440000 ENZYMES 044653 VESTRONIDASE ALFA‐VJBK PACE Medical Exception Required 682006 INCRETIN MIMETICS 044675 SEMAGLUTIDE PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 044687 GLYCOPYRROL/NEBULIZER/ACCESSOR PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 120808 ANTIMUSCARINICS/ANTISPASMODICS 044691 GLYCOPYRROLATE/NEB.ACCESSORIES PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 044709 ERTUGLIFLOZIN PIDOLATE PACE Medical Exception Required 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 044716 ERTUGLIFLOZIN/METFORMIN PACE Medical Exception Required

47 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 044716 ERTUGLIFLOZIN/METFORMIN PACE Medical Exception Required 261200 GENE THERAPY 044720 VORETIGENE NEPARVOVEC‐RZYL PACE Medical Exception Required 684400 RENIN‐ANGIOTENSIN‐ALDOSTERONE SYST(RAAS) 044721 ANGIOTENSIN II ACETATE, HUMAN PACE Medical Exception Required 681200 CONTRACEPTIVES 044733 LEVONORGEST/ETH.ESTRADIOL/IRON PACE Medical Exception Required 681200 CONTRACEPTIVES 044733 LEVONORGEST/ETH.ESTRADIOL/IRON PACE Used Exclusively in Females 280804 NONSTEROIDAL ANTI‐INFLAMMATORY AGENTS 044767 DICLOFENAC SODIUM/MENTHOL PACE Medical Exception Required 481404 CYSTIC FIBROSIS (CFTR) CORRECTORS 044771 TEZACAFTOR/IVACAFTOR PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044773 APALUTAMIDE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044773 APALUTAMIDE PACE Used Exclusively in Males 81808 ANTIRETROVIRALS 044791 IBALIZUMAB‐UIYK PACE Medical Exception Required 280808 OPIATE AGONISTS 044795 BENZHYDROCODONE/ACETAMINOPHEN PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 044823 TILDRAKIZUMAB‐ASMN PACE Medical Exception Required 81228 ANTIBACTERIALS, MISCELLANEOUS 044848 LINEZOLID IN DEXTROSE 5% PACE Medical Exception Required 409200 ELECTROLYTIC,CALORIC,WATER BALANCE MISC, 044867 BUROSUMAB‐TWZA PACE Medical Exception Required 562232 NEUROKININ‐1 RECEPTOR ANTAGONISTS 044890 FOSNETUPITANT/PALONOSETRON PACE Medical Exception Required 202892 ANTIHEMORRHAGIC AGENTS, MISCELLANEOUS 044899 FACTOR XA,INACTIVATED‐ZHZO PACE Medical Exception Required 520808 CORTICOSTEROIDS (EENT) 044921 DEXAMETHASONE/PF PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 044931 EPOETIN ALFA‐EPBX PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 044942 AVATROMBOPAG MALEATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044946 ABIRATERONE ACET,SUBMICRONIZED PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 044946 ABIRATERONE ACET,SUBMICRONIZED PACE Used Exclusively in Males 281292 ANTICONVULSANTS, MISCELLANEOUS 045006 CANNABIDIOL (CBD) EXTRACT PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 045010 PEGFILGRASTIM‐JMDB PACE Medical Exception Required 241292 VASODILATING AGENTS, MISCELLANEOUS 045035 ALPROSTADIL IN SODIUM CHLORIDE PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 045039 ENCORAFENIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045040 BINIMETINIB PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 045050 ARIPIPRAZOLE LAUROXIL,SUBMICR. PACE Medical Exception Required 281608 ANTIPSYCHOTIC AGENTS 045050 ARIPIPRAZOLE LAUROXIL,SUBMICR. PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 045086 GLYCOPYRRONIUM TOSYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045088 GEMCITABINE HCL IN 0.9 % NACL PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045096 IVOSIDENIB PACE Medical Exception Required 681804 ANTIGONADTROPINS 045108 ELAGOLIX SODIUM PACE Used Exclusively in Females 83008 ANTIMALARIALS 045121 TAFENOQUINE SUCCINATE PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 045127 LUSUTROMBOPAG PACE Medical Exception Required 201600 HEMATOPOIETIC AGENTS 045154 FILGRASTIM‐AAFI PACE Medical Exception Required 681200 CONTRACEPTIVES 045161 SEGESTERONE AC/ETHIN ESTRADIOL PACE Used Exclusively in Females 923200 COMPLEMENT INHIBITORS 045177 LANADELUMAB‐FLYO PACE Medical Exception Required 280808 OPIATE AGONISTS 045206 HYDROMORPHONE HCL IN WATER/PF PACE Medical Exception Required 283212 CALCITONIN GENE‐RELATED PEPTIDE ANTAG. 045236 FREMANEZUMAB‐VFRM PACE Medical Exception Required 529200 EENT DRUGS, MISCELLANEOUS 045258 CENEGERMIN‐BKBJ PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045269 DUVELISIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045283 DACOMITINIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045284 CEMIPLIMAB‐RWLC PACE Medical Exception Required 81224 TETRACYCLINE ANTIBIOTICS 045315 OMADACYCLINE TOSYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045363 MOXETUMOMAB PASUDOTOX‐TDFK PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045368 TALAZOPARIB TOSYLATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045448 LORLATINIB PACE Medical Exception Required 849200 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 045452 GLYCERIN/POLYCARBOPHL/CARBOMER PACE Used Exclusively in Females 921200 ANTIDOTES 045458 LEVOLEUCOVORIN PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 045477 REVEFENACIN PACE Medical Exception Required 120808 ANTIMUSCARINICS/ANTISPASMODICS 045477 REVEFENACIN PACE Cannnot co‐administer inhaled Insulin and Asthma/COPD/Smoking Cessation agents 100000 ANTINEOPLASTIC AGENTS 045494 LAROTRECTINIB SULFATE PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045502 GLASDEGIB MALEATE PACE Medical Exception Required 924400 IMMUNOSUPPRESSIVE AGENTS 045503 EMAPALUMAB‐LZSG PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045506 GILTERITINIB FUMARATE PACE Medical Exception Required 923200 COMPLEMENT INHIBITORS 045548 RAVULIZUMAB‐CWVZ PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045555 TAGRAXOFUSP‐ERZS PACE Medical Exception Required 201292 ANTITHROMBOTIC AGENTS, MISCELLANEOUS 045591 CAPLACIZUMAB‐YHDP PACE Medical Exception Required 282080 WAKEFULNESS‐PROMOTING AGENTS 045666 SOLRIAMFETOL HCL PACE Medical Exception Required 922000 IMMUNOMODULATORY AGENTS 045670 SIPONIMOD PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045687 ERDAFITINIB PACE Medical Exception Required 281604 ANTIDEPRESSANTS 045692 BREXANOLONE PACE Used Exclusively in Females 682018 SODIUM‐GLUC COTRANSPORT 2 (SGLT2) INHIB 045747 DAPAGLIFLOZ/SAXAGLIP/METFORMIN PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045761 ALPELISIB PACE Medical Exception Required 681200 CONTRACEPTIVES 045765 DROSPIRENONE PACE Medical Exception Required 681200 CONTRACEPTIVES 045765 DROSPIRENONE PACE Used Exclusively in Females 289200 CENTRAL NERVOUS SYSTEM AGENTS, MISC. 045878 BREMELANOTIDE ACETATE PACE Used Exclusively in Females 100000 ANTINEOPLASTIC AGENTS 045909 DAROLUTAMIDE PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 045912 PEXIDARTINIB HYDROCHLORIDE PACE Medical Exception Required

48 AHFS Therapeutic AHFS Therapeutic Class Description HICL HICL Description Program Edit Criteria 1 Edit Criteria 2 Edit Criteria 3 Edit Criteria 4 Edit Criteria 5 Class 241292 VASODILATING AGENTS, MISCELLANEOUS 045929 PAPAVER/PHENTOLAMINE/ALPROSTAD PACE Used Exclusively in Males 100000 ANTINEOPLASTIC AGENTS 045952 ENTRECTINIB PACE Medical Exception Required 100000 ANTINEOPLASTIC AGENTS 045953 FEDRATINIB DIHYDROCHLORIDE PACE Medical Exception Required 923600 DISEASE‐MODIFYING ANTIRHEUMATIC AGENTS 045955 UPADACITINIB PACE Medical Exception Required

49