The following is a list of medica ons or a formulary lis ng of medica ons covered for Medicaid recipients managed under the Hudson Health Plan Program. This list is not intended to be a complete and an all-inclusive list, but a representa ve list that is as comprehensive as possible. If there should ever be a ques on about medica on coverage as part of this program please contact Hudson Health Plan directly at 1-800-339-4557 or MaxorPlus, the pharmacy benefi t management company working with Hudson Health Plan to manage this prescrip on benefi t at 1-800-687-0707.

In addi on; Certain restric ons, quan ty limits, step therapy, and prior authoriza on requirements may apply. As brand name drugs become available generically, only the generic will be considered formulary.

M P D L 2014M P D L 2014

HHP-MDC JUNE 2014

Copay TierTier 1 (Generic): $1.00

Tier 2 (Preferred Brands) $1.00

Tier 3 (Non-Preferred Brands): $3.00

Anti-infective; Antifungal Agents: Rx Only Coverage Copay Tieramphotericin B Genericclotrimazole Genericfluconazole Genericgriseofulvin Genericitraconazole Genericketoconazole Genericnystatin Genericterbinafine HCl Genericvoriconazole GenericNOXAFIL Non-preferred BrandSPORANOX ORAL SOL Non-preferred Brand

Anti-infective; Antiviral HIV Specific: Rx Only Coverage Copay Tierabacavir Genericabacavir/lamivudine/zidovudine Genericdidanosine Genericlamivudine Genericlamivudine;zidovudine Genericnevirapine IR Genericstavudine Genericzidovudine GenericAGENERASE Preferred BrandAPTIVUS Preferred BrandATRIPLA Preferred BrandCOMPLERA Preferred BrandCRIXIVAN Preferred BrandEDURANT Preferred BrandEMTRIVA Preferred BrandEPZICOM Preferred BrandFUZEON Preferred BrandINTELENCE Preferred BrandINVIRASE Preferred Brand

2

Anti-infective; Antiviral HIV Specific (Cont): Rx Only Coverage Copay TierISENTRESS Preferred BrandKALETRA Preferred BrandLEXIVA Preferred BrandNORVIR Preferred BrandPREZISTA Preferred BrandRESCRIPTOR Preferred BrandREYATAZ Preferred BrandSELZENTRY Preferred BrandSTRIBILD Preferred BrandSUSTIVA Preferred BrandTIVICAY Preferred BrandTRUVADA Preferred BrandVIRACEPT Preferred BrandVIRAMUNE XR Preferred BrandVIREAD Preferred Brand

Anti-infective; Antiviral Hepatitis B: Rx Only Coverage Copay TierBARACLUDE Preferred BrandEPIVIR HBV Preferred BrandHEPSERA Preferred BrandTYZEKA Non-preferred Brand

Anti-infective; Antiviral Hepatitis C: Rx Only Coverage Copay Tierribavirin GenericPEGASYS Preferred BrandINCIVEK Preferred BrandVICTRELIS Preferred BrandCOPEGUS Non-preferred BrandINFERGEN Non-preferred BrandREBETOL Non-preferred BrandRIBAPAK Non-preferred BrandRIBASPHERE Non-preferred Brand

Anti-infective; Antiviral General: Rx Only Coverage Copay TierNotes:Notes:Synagis is subject to a prior authoriza on or clinical drug review toSynagis is subject to a prior authoriza on or clinical drug review toensure proper use of this medica on - if approved it is also limited to 5 ensure proper use of this medica on - if approved it is also limited to 5 doses or 5 months of treatment during the RSV season (Octoberdoses or 5 months of treatment during the RSV season (Octoberthrough March).through March).

acyclovir sodium Genericamantadine Genericfamciclovir Genericfoscarnet sodium Genericganciclovir Genericribavirin Genericvalacyclovir HCl GenericSYNAGIS Preferred BrandTAMIFLU Preferred BrandVALCYTE Preferred Brand

Anti-infective; Antibacterial Cephalosporin 1st Generation: Rx Only Coverage Copay Tiercefadroxil Genericcefazolin sodium Genericcephalexin Generic

3

Anti-infective; Antibacterial Cephalosporin 2nd Generation: Rx Only Coverage Copay Tiercefaclor Genericcefotetan Genericcefoxitin sodium Genericcefprozil Genericcefuroxime Generic

Anti-infective; Antibacterial Cephalosporin 3rd Generation: Rx Only Coverage Copay Tiercefdinir Genericcefotaxime sodium Genericcefpodoxime sodium Genericceftazidime Genericceftriaxone sodium Genericceftibuten GenericSUPRAX Non-preferred Brand

Anti-infective; Antibacterial Cephalosporin 4th Generation: Rx Only Coverage Copay Tiercefepime Generic

Anti-infective; Antibacterial Quinolone Antibiotic: Rx Only Coverage Copay Tierciprofloxacin Genericlevofloxacin Genericmoxifloxacin Genericofloxacin GenericNOROXIN Preferred Brand

Anti-infective; Antibacterial Macrolide Antibiotic: Rx Only Coverage Copay Tierazithromycin Genericclarithromycin Genericerythromycin base Genericerythromycin ethylsuccinate Genericerythromycin lactobionate Generic

Anti-infective; Antibacterial Penicillin Antibiotic: Rx Only Coverage Copay Tieramoxicillin Genericamoxicillin/clavulanate P Genericampicillin Genericampicillin-sulbactam Genericdicloxacillin sodium Genericnafcillin sodium Genericpenicillin G potassium Genericpenicillin G sodium Genericpiperacillin sodium GenericBICILLIN C-R Non-preferred BrandBICILLIN L-A Non-preferred Brand

Anti-infective; Antibacterial Sulfonamide Antibiotic: Rx Only Coverage Copay Tiersulfamethoxazole/trimethoprim Genericsulfadiazine Genericsulfasalazine Genericsulfazine Generic

4

Anti-infective; Antibacterial Tetracycline Antibiotic: Rx Only Coverage Copay TierNotes:Notes:all extended release formula ons for acne treatment are consideredall extended release formula ons for acne treatment are considerednon-formulary, the immediate release formula ons are covered.non-formulary, the immediate release formula ons are covered.

demeclocycline HCl Genericdoxycycline hyclate Genericdoxycycline monohydrate Genericminocycline HCL Generictetracycline HCl Genericvibramycin Generic

Anti-infective; Anti-Mycobacterium Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

ethambutol HCL Exemptisoniazid Exemptpyrazinamide Exemptrifabutin Exemptrifampin ExemptTRECATOR Exempt

Anti-infective; Miscellaneous Antibacterial Agents: Rx Only Coverage Copay Tiercolistimethate sodium Genericfuradantin Genericmacrodantin Genericnitrofurantoin monohydrate Genericvancomycin HCl GenericCAYSTON Preferred Brand

Anti-infective; Antimalarial Agents: Rx Only Coverage Copay Tieratovaquone/proguanil Genericchloroquine phosphate Generichydroxychloroquine sulfate Genericmefloquine HCl GenericDARAPRIM Preferred Brand

Anti-infective Antiparasitic Agent: Rx Only Coverage Copay Tieratovaquone Genericmebendazole Genericmetronidazole Genericparomomycin sulfate Generictinidazole GenericALBENZA Preferred BrandALINIA Preferred BrandNEBUPENT Preferred BrandYODOXIN Preferred Brand

Anti-infective; Lincosamide Antibiotic: Rx Only Coverage Copay Tierclindamycin HCl Genericclindamycin phosphate GenericLINCOCIN Non-preferred Brand

Anti-infective; Aminoglycoside Antibiotic: Rx Only Coverage Copay Tieramikacin sulfate Genericgentamicin sulfate Generickanamycin sulfate Genericneomycin sulfate Genericstreptomycin sulfate Generic

5

Anti-infective; Aminoglycoside Antibiotic (Cont): Rx Only Coverage Copay Tiertobramycin sulfate Generictobramycin nebulizer solution GenericNEO-FRADIN Non-preferred Brand

Anti-infective; Antiprotozoal Agents: Rx Only Coverage Copay TierMEPRON Preferred BrandNEBUPENT Preferred Brand

Anti-infective; Antibacterial Miscellaneous: Rx Only Coverage Copay Tiermethenamine hippurate Genericmethenamine mandelate Genericnitrofurantoin Genericphenazopyridine Generictrimethoprim GenericHIPREX Non-preferred BrandMONUROL Non-preferred BrandPRIMSOL Non-preferred Brand

Antineoplastic Agents: Rx Only Coverage Copay Tieranastrozole Genericazacitidine inj Genericbleomycin sulfate Genericcapecitabine Genericcyclophosphamide Genericcytarabine Genericdacarbazine Genericdaunorubicin HCl Genericdecitabine Genericdocetaxel Genericdoxorubicin HCl Genericetoposide Genericexemestane Genericfludarabine phosphate Genericfluorouracil Genericgemcitabine Generichydroxyurea Genericirinotecan Genericleucovorin calcium Genericleuprolide acetate GenericLetrozole Genericlomustine Genericmercaptopurine Genericmethotrexate Genericmitoxantrone HCl Genericoctreotide acetate Genericriluzole Generictamoxifen Generictemozolomide Genericteniposide Generic

6

Antineoplastic Agents (Cont): Rx Only Coverage Copay Tiertretinoin Genericvinblastine sulfate Genericvincristine sulfate Genericvinorelbine tartrate GenericEMCYT Preferred BrandGILOTRIF Preferred BrandHYCAMTIN Preferred BrandIMBRUVICA Preferred BrandKADCYLA Preferred BrandLUPRON DEPOT Preferred BrandLYSODREN Preferred BrandMARQIBO Preferred BrandMATULANE Preferred BrandMENKINIST Preferred BrandTAFINLAR Preferred BrandTYKERB Preferred BrandZOLADEX Preferred BrandGAZYVA Non-preferred BrandIRESSA Non-preferred BrandTARGRETIN Non-preferred BrandTICE BCG Non-preferred BrandVALCHLOR GEL Non-preferred BrandXTANDI Non-preferred BrandZOLINZA Non-preferred Brand

Immunosuppressant Therapy Agents: Rx Only Coverage Copay Tierazathioprine Genericcyclosporine GenericHECORIA (tacrolimus) Genericmycophenolate Genericsirolimus Generictacrolimus GenericCELLCEPT Suspension Preferred BrandRAPAMUNE Preferred BrandSANDIMMUNE Preferred BrandGENGRAF Non-preferred BrandIMURAN Non-preferred BrandPROGRAF Non-preferred BrandZORTRESS Non-preferred Brand

Immune System Stimulant Agents: Rx Only Coverage Copay TierGAMMAGARD S/D Non-preferred BrandGAMMAGARD S/D IGA LESS TH Non-preferred BrandGAMUNEX Non-preferred BrandVIVAGLOBIN Non-preferred Brand

Alzheimer’s Medications: Rx Only Coverage Copay Tierdonepezil HCl Genericgalantamine hydrobromide Generic

7

Alzheimer’s Medications (Cont): Rx Only Coverage Copay Tierpyridostigmine bromide Genericrivastigmine tartrate GenericNAMENDA Preferred BrandXENAZINE Preferred BrandCOGNEX Non-preferred Brand

Antiparkinson’s Medications: Rx Only Coverage Copay Tieramantadine Genericbenztropine HCl Genericbromocriptine mesylate Genericcarbidopa Genericcarbidopa/levodopa Genericcarbidopa/levodopa/entacapone Genericentacapone Genericpramipexole dihydrochloride Genericropinirole HCl IR & XL Genericselegiline HCl Generictrihexyphenidyl HCl GenericAPOKYN Preferred BrandAZILECT Preferred BrandMIRAPEX ER Non-preferred BrandNEUPRO PATCH Non-preferred BrandZELAPAR Non-preferred Brand

Antispasmodic Skeletal Muscle Relaxant: Rx Only Coverage Copay Tierbaclofen Genericcarisoprodol Genericcarisoprodol/aspirin Genericchlozoxazone Genericcyclobenzaprine HCl Genericdantrolene sodium Genericdiazepam Genericlioresal intrathecal Genericmetaxalone Genericmethocarbamol Genericorphenadrine citrate Generictizanidine HCl Generictrospium IR & XR GenericGELNIQUE Preferred Brand

Osteoporosis Therapy Agents: Rx Only Coverage Copay Tieralendronate sodium Genericcalcitonin salmon, synthetic Genericestradiol/norethindrone acetate Genericibandronate Genericzoledronic acid GenericEVISTA Preferred BrandACTONEL Non-preferred Brand

8

Osteoporosis Therapy Agents (Cont): Rx Only Coverage Copay TierBINOSTO Non-preferred BrandMIACALCIN NASAL Non-preferred Brand

Rheumatologicals; Rheumatoid Arthritis/Psoriasis Agents: Rx Only Coverage Copay Tierleflunomide GenericENBREL Preferred BrandENBREL SURECLICK Preferred BrandHUMIRA Preferred BrandHUMIRA PEN Preferred BrandHUMIRA PEN-CROHNS DISEASE Preferred BrandHUMIRA PEN-PSORIASIS STAR Preferred BrandCIMZIA Non-preferred BrandKINERET Non-preferred BrandORENCIA Non-preferred BrandRIDAURA Non-preferred BrandSIMPONI Non-preferred BrandXELJANZ Non-preferred Brand

Anticoagulant; Coumadin Type: Rx Only Coverage Copay Tierwarfarin sodium GenericJantoven GenericELIQUIS Preferred BrandXARELTO Preferred BrandCOUMADIN Non-preferred Brand

Anticoagulant; Platelet Aggregation Inhibitors Rx Only Coverage Copay Tiercilostazol Genericclopidogrel Genericdipyridamole Genericticlopidine HCl GenericAGGRENOX Preferred BrandEFFIENT Preferred BrandBRILINTA Non-preferred Brand

Anticoagulant; Heparin and Related Agents: Rx Only Coverage Copay Tierargatroban Genericenoxaparin sodium Genericfondaparinux Genericheparin sodium GenericFRAGMIN Non-preferred BrandINNOHEP Non-preferred Brand

Antifibrolytic Agents: Rx Only Coverage Copay Tieraminocaproic acid Genericcyklokapron Generic

Hematinic/Leukocyte Stimulants: Rx Only Coverage Copay TierLEUKINE Preferred BrandNEUPOGEN Preferred BrandPROCRIT Preferred BrandPROLEUKIN Preferred Brand

9

Interferon Agents: Rx Only Coverage Copay TierINTRON-A Preferred BrandALFERON N Non-preferred Brand

Antiarrhythmic Agents Rx Only Coverage Copay Tieramiodarone HCl Genericdisopyramide phosphate Genericflecainide acetate Genericlidocaine HCl Genericmexiletine HCl Genericprocainamide HCl Genericpropafenone HCl Genericquinidine gluconate Genericquinidine sulfate GenericMULTAQ Preferred BrandTIKOSYN Preferred Brand

Cardiac Glycoside Agents: Rx Only Coverage Copay Tierdigoxin GenericLANOXICAPS Non-preferred BrandLANOXIN Non-preferred Brand

Lipotropic Agents; Triglyceride Reducers: Rx Only Coverage Copay Tiercholestyramine/cholestyramine light Genericfenofibrate Genericfenofibric acid Genericgemfibrozil GenericFENOGLIDE Preferred BrandWELCHOL Preferred BrandZETIA Preferred Brand

Lipotropic Agents; Cholesterol Reducers: Rx Only Coverage Copay TierNotes:Notes:Step therapy is in place for the sta n medica ons, requiring the use of Step therapy is in place for the sta n medica ons, requiring the use of generic sta ns and failure before a brand name agent will be allowed.generic sta ns and failure before a brand name agent will be allowed.

amlodipine/atorvastatin Genericatorvastatin Genericfluvastatin IR and ER Genericlovastatin Genericniacin Genericniacin ER Genericomega-3 OTC Agents Genericpravastatin Genericsimvastatin GenericALTOPREV Preferred BrandCRESTOR Preferred BrandSIMCOR Preferred BrandVYTORIN Preferred Brand

Antihypertensive; Sympatholytic Agents: Rx Only Coverage Copay Tierclonidine HCl oral Genericclonidine HCL patch Genericdoxazosin mesylate Genericguanabenz acetate Genericguanfacine Generic

10

Antihypertensive; Sympatholytic Agents (Cont): Rx Only Coverage Copay Tiermethyldopa Genericmethyldopa/HCTZ Genericprazosin HCl Genericreserpine Genericterazosin HCl GenericCARDURA XL Non-preferred BrandCATAPRES-TTS Non-preferred BrandCLORPRES Non-preferred BrandKAPVAY Non-preferred Brand

Antihypertensive: Vasodilator Agents: Rx Only Coverage Copay Tierhydralazine HCl Genericisosorbide dinitrate Genericisosorbide mononitrate Genericminoxidil Genericnitroglycerin GenericBIDIL Preferred BrandDILATRATE SR Preferred Brand

Antihypertensive; ACE Inhibitor and ACE Combinations: Rx Only Coverage Copay Tierbenazepril Genericbenazepril/HCTZ Genericbenazepril/amlodipine Genericcaptopril Genericcaptopril/HCTZ Genericenalapril maleate Genericenalapril maleate/HCTZ Genericfosinopril sodium Genericfosinopril sodium/HCTZ Genericlisinopril Genericlisinopril/HCTZ Genericmoexipril HCl Genericmoexipril HCl/HCTZ Genericperindopril erbumine Genericquinapril HCl Genericquinapril HCL/HCTZ Genericramipril Generictrandolapril Generic

Antihypertensive; Calcium Channel Blocker & Combinations: Rx Only Coverage Copay Tieramlodipine besylate Genericdiltiazem Genericfelodipine Genericisradipine Genericnifedipine Genericnisoldipine GenericDYNACIRC CR Non-preferred Brand

Antihypertensive; Beta-Adrenergic Blocking and Combinations: Rx Only Coverage Copay Tieracebutolol HCl Generic

11

Antihypertensive; Beta-Adrenergic Blocking and Combos (Cont): Rx Only Coverage Copay Tieratenolol Genericatenolol/chlorthalidone Genericbetaxolol HCl Genericbisoprolol fumarate Genericbisoprolol fumarate/HCTZ Genericcarvedilol Genericlabetalol Genericmetoprolol succinate Genericmetoprolol tartrate Genericmetoprolol/HCTZ Genericnadolol Genericnadolol/bendroflumethiazide Genericpindolol Genericpropranolol Genericpropranolol/HCTZ Genericsotalol HCl Generictimolol maleate GenericBYSTOLIC Preferred BrandCOREG CR Preferred Brand

Antihypertensive; Angiotensin Receptor Binding (ARB): Rx Only Coverage Copay Tiercandesartan Genericcandesartan/HCTZ Genericirbesartan Genericirbesartan/HCTZ Genericlosartan potassium Genericlosartan potassium/HCTZ Generictelmisartan Generictelmisartan/amlodipine Generictelmisartan/HCTZ Genericvalsartan/HCTZ GenericDIOVAN Preferred Brand

Antihypertensive; Pulmonary Agents: Rx Only Coverage Copay Tierepoprostenol sodium GenericREMODULIN Preferred BrandTYVASO Preferred BrandVENTAVIS Preferred Brand

Antihypertensive; Diuretic Agents: Rx Only Coverage Copay Tieramiloride HCl Genericamiloride HCl/HCTZ Genericbumetanide Genericchlorothiazide Genericchlorthalidone Genericeplerenone Genericfurosemide Generichydrochlorothiazide (HCTZ) Genericindapamide Generic

12

Antihypertensive; Diuretic Agents (Cont): Rx Only Coverage Copay Tiermetolazone Genericspironolactone Genericspironolactone/HCTZ Generictorsemide Generictriamterene/HCTZ Generic

Antihypertensive; Other and Other Combinations: Rx Only Coverage Copay Tieramlodipine/benazepril Generictrandolapril/verapamil HCl GenericDEMSER Non-preferred BrandTARKA Non-preferred Brand

Cardiovascular; Miscellaneous Agents: Rx Only Coverage Copay Tierisoxsuprine GenericRANEXA Preferred Brand

Analgesic; NSAID and Combinations Rx and OTC Coverage Copay Tierdiclofenac IR and ER Genericdiclofenac; misoprostil Genericetodolac Genericflurbiprofen Genericibuprofen Genericindomethacin Genericketoprofen Genericketorolac Genericmeclofenamate sodium Genericmeloxicam Genericnabumetone Genericnaproxen sodium Genericoxaprozin Genericpiroxicam Genericsulindac Generictolmetin sodium GenericCELEBREX Preferred BrandVIMOVO Preferred BrandCATAFLAM Non-preferred BrandFLECTOR PATCH Non-preferred BrandSAVELLA Non-preferred Brand

Analgesic; Narcotic Agents: Rx Only Coverage Copay TierNotes:Notes:All fentanyl buccal (oral) agents are subject to a prior authoriza on or All fentanyl buccal (oral) agents are subject to a prior authoriza on or clinical drug review for appropriate use of these medica ons.clinical drug review for appropriate use of these medica ons.

There are strict quan ty limits in place for all extended release narco c There are strict quan ty limits in place for all extended release narco c medica ons as well as prior authoriza on requirements for all narco cs medica ons as well as prior authoriza on requirements for all narco cs to ensure propre use.to ensure propre use.

buprenorphine HCl Genericbuprenorphine/naloxone SL Genericbutorphanol tartrate Genericcodeine sulfate Genericfentanyl citrate Generichydromorphone HCl Genericlevorphanol tartrate Genericmeperidine Genericmethadone HCl Genericmorphine sulfate IR and ER Generic

13

Analgesic; Narcotic Agents (Cont): Rx Only Coverage Copay TierNotes:Notes:All fentanyl buccal (oral) agents are subject to a prior authoriza on or All fentanyl buccal (oral) agents are subject to a prior authoriza on or clinical drug review for appropriate use of these medica ons.clinical drug review for appropriate use of these medica ons.

There are strict quan ty limits in place for all extended release narco c There are strict quan ty limits in place for all extended release narco c medica ons as well as prior authoriza on requirements for all narco cs medica ons as well as prior authoriza on requirements for all narco cs to ensure propre use.to ensure propre use.

oxycodone HCl Genericoxymorphone Genericoxymorphone ER Generictramadol/tramadol ER GenericOPANA ER Preferred BrandOXYCONTIN Preferred BrandSUBOXONE FILM Preferred BrandACTIQ Non-preferred BrandAVINZA Non-preferred BrandEXALGO Non-preferred Brand

Analgesic; Narcotic Combination Agents: Rx Only Coverage Copay Tieracetaminophen/butalbital Genericacetaminophen/butalbital/caffeine Genericacetaminophen/tramadol Genericaspirin/butalbital/caffeine Genericcarisoprodol/aspirin/codeine Genericcodeine phosphate/acetaminophen Genericcodeine phosphate/aspirin Genericcodeine/APAP/butalbital/caffeine Generichydrocodone/acetaminophen Generichydrocodone/ibuprofen Genericoxycodone HCl/acetaminophen Genericoxycodone HCl/aspirin Genericoxycodone/ibuprofen GenericCAPITAL/CODEINE Non-preferred Brand

Analgesic; Non-Salicylate, Non-Narcotic Agents: Rx and OTC Coverage Copay Tieracetaminophen Genericclonidine Genericibuprofen Generic

Analgesic; Salicylate, Non-Narcotic Agents: Rx and OTC Coverage Copay Tieraspirin Genericaspirin buffered Genericaspirin enteric coated Genericbutalbital Genericbutalbital/aspirin Generic

Analgesic; Gout Therapy Agents: Rx Only Coverage Copay Tierallopurinol GenericULORIC Non-preferred Brand

Analgesic; Migraine Headache Pain: Rx Only Coverage Copay Tierdihydroergotamine mesylate Genericergotamine tartrate/caffeine Genericnaratriptan HCl Genericrizatriptan Genericsumatriptan succinate Genericzoledronic acid injection Generic

14

Analgesic; Migraine Headache Pain (Cont): Rx Only Coverage Copay Tierzolmitriptan GenericERGOMAR Preferred BrandRELPAX Preferred BrandTREXIMET Preferred Brand

Anticonvulsant; Epilepsy & Neuropathic Pain Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

There is a step therapy program in place for Lyrica, requiring the useThere is a step therapy program in place for Lyrica, requiring the useof generic gabapen n for all indica ons other than seizure control.of generic gabapen n for all indica ons other than seizure control.

benztropine HCl Exemptcarbamazepine Exemptclonazepam Exemptdiazepam rectal gel Exemptdivalproex sodium Exemptethosuximide Exemptfelbamate Exemptgabapentin Exemptklonopin Exemptlamotrigine Exemptlevetiracetam IR & ER Exemptoxcarbazepine Exemptphenobarbital Exemptphenytoin sodium Exemptprimidone Exempttiagabine HCl Exempttopiramate Exempttrihexyphenidyl HCl Exemptvalproic acid Exemptzonisamide ExemptBANZEL ExemptCELONTIN ExemptDIASTAT ACUDIAL ExemptEQUETRO ExemptFELBATOL ExemptGABITRIL ExemptLYRICA ExemptOXTELLAR XR ExemptPOTIGA ExemptTROKENDI ExemptVIMPAT Exempt

Multiple Sclerosis Agents: Rx Only Coverage Copay TierAVONEX Preferred BrandCOPAXONE Preferred BrandEXTAVIA Preferred BrandGILENYA Preferred BrandREBIF Preferred BrandREBIF TITRATION PACK Preferred BrandAUBAGIO Non-preferred BrandBETASERON Non-preferred Brand

15

Antidepressant; Tricyclic Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

amitriptyline Exemptamitriptyline/chlordiazepoxide Exemptamitriptyline/perphenazine Exemptamoxapine Exemptclomipramine HCl Exemptdesipramine HCl Exemptdoxepin HCl Exemptimipramine HCl Exemptimipramine pamoate Exemptnortriptyline HCl Exemptprotriptyline HCl Exempttrimipramine maleate Exempt

Antidepressant; Miscellaneous Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

budeprion Exemptbupropion HCL Exemptdesvenlafaxine Exemptduloxetine Exemptmirtazapine Exemptvenlafaxine HCl ExemptPRISTIQ Exempt

Antidepressant; MAO Inhibitor Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

phenelzine sulfate Exempttranylcypromine sulfate ExemptEMSAM ExemptMARPLAN Exempt

Antidepressant; Selective Serotonin Reuptake Inhibitor (SSRI): Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

citalopram hydrobromide Exemptescitalopram Exemptfluoxetine Exemptfluoxetine; olanzapine Exemptfluvoxamine maleate Exemptparoxetine HCl Exemptsertraline HCl ExemptPEXEVA ExemptSARAFEM Exempt

Antipsychotic; Phenothiazine Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

chlorpromazine HCl Exemptfluphenazine deconate Exemptfluphenazine HCl Exemptperphenazine Exemptthioridazine HCl Exempttrifluoperazine HCl Exempt

Antipsychotic; Miscellaneous Antipsychotic Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

clozapine Exempthaloperidol Exemptlithium carbonate Exempt

16

Antipsychotic; Miscellaneous Antipsychotic Agents (Cont): Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

lithium citrate Exemptloxapine Exemptolanzapine Exemptolanzapine; fluoxetine Exemptquetiapine IR Exemptrisperidone Exemptthiothixene Exemptziprasidone ExemptABILIFY ExemptEQUETRO ExemptFANAPT ExemptINVEGA ExemptLATUDA ExemptORAP ExemptSEROQUEL XR ExemptSYMBYAX ExemptVIIBRYD ExemptMOBAN Non-preferred Brand

Psychotherapeutic; Hypnotic Agents: Rx and OTC Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

All brand name agents in this class are considered non-formularyAll brand name agents in this class are considered non-formularyand generic medica ons are covered in this class.and generic medica ons are covered in this class.

chloral hydrate Exemptdiphenhydramine HCl Exemptestazolam Exemptflurazepam Exempthydroxyzine HCl Exempthydroxyzine pamoate Exemptlorazepam Exempttemazepam Exempttriazolam Exemptzaleplon Exemptzolpidem tartrate ExemptGNP NIGHTTIME SLEEP AID Exempt

Psychotherapeutic; Miscellaneous Agents: Rx Only Coverage Copay TierNotes:Notes:Xyrem is subject to a prior authoriza on or clinical drug review to help Xyrem is subject to a prior authoriza on or clinical drug review to help ensure appropriate u liza on.ensure appropriate u liza on.

amphetamine/dextroamphetamine Genericdexmethylphenidate HCl IR & ER Genericdextroamphetamine sulfate Genericlithium carbonate Genericlithium citrate Genericmethamphetamine HCl Genericmethylphenidate HCl Genericmodafinil GenericDAYTRANA Preferred BrandINTUNIV Preferred BrandSTRATTERA Preferred BrandVYVANSE Preferred BrandXYREM Preferred Brand

17

Antianxiety; Anxiolytic Agents: Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

alprazolam Exemptbuspirone HCl Exemptchlordiazepoxide HCl Exemptclorazepate dipotassium Exemptdiazepam Exemptdiazepam rectal gel Exemptlorazepam Exemptoxazepam Exempt

Dermatologicals; Corticosteroid Topical Agents Rx and OTC Coverage Copay Tieralclometasone dipropionate Genericamcinonide Genericbetamethasone dipropionate Genericbetamethasone dipropionate/propylene glycol Genericbetamethasone valerate Genericclobetasol propionate Genericclobetasol propionate/emollient Genericdesonide Genericdesoximetasone Genericdesoximetasone Genericdiflorasone diacetate Genericfluocinonide Genericfluocinonide/emollient Genericfluocinolone acetonide Genericfluticasone propionate Generichalobetasol propionate Generichydrocortisone Genericmometasone furoate Generictriamcinolone acetonide GenericCORDRAN TAPE Non-preferred Brand

Dermatologicals; Topical Anesthetic Agents: Rx Only Coverage Copay TierNotes:Notes:Lidoderm/lidocaine pad is subject to a prior authoriza on or clinicalLidoderm/lidocaine pad is subject to a prior authoriza on or clinicaldrug review to help ensure appropriate u liza on.drug review to help ensure appropriate u liza on.

hydrocortisone acetate/lidocaine HCl Genericlidocaine HCL Genericlidocaine Pad 5% Generic

Dermatologicals; Acne Therapy Agents: Rx Only Coverage Copay TierNotes:Notes:All brand name topical tre noin and clindamycin agents are considered All brand name topical tre noin and clindamycin agents are considered as non-formulary, generic topical agents are covered in these categories.as non-formulary, generic topical agents are covered in these categories.

benzoyl peroxide Genericclindamycin phosphate Genericerythromycin base/benzoyl peroxide Genericerythromycin base/ethyl alcohol Genericisotretinoin Genericmetronidazole cream Genericsulfacetamide sodium Genericsulfacetamide sodium/sulfur Generictretinoin topical GenericFINACEA Preferred BrandMETROGEL 1% Preferred BrandTAZORAC Preferred Brand

18

Dermatologicals; Acne Therapy Agents (Cont): Rx Only Coverage Copay TierNotes:Notes:All brand name topical tre noin and clindamycin agents are considered All brand name topical tre noin and clindamycin agents are considered as non-formulary, generic topical agents are covered in these categories.as non-formulary, generic topical agents are covered in these categories.

AMNESTEEM (ORAL) Non-preferred BrandCLARAVIS (ORAL) Non-preferred BrandSOTRET (ORAL) Non-preferred BrandZODERM Non-preferred Brand

Dermatologicals; Topical Antibacterial Agents: Rx Only Coverage Copay Tiergentamicin sulfate Genericmupirocin ointment Genericsulfacetamide sodium GenericALTABAX Preferred BrandBACTROBAN NASAL Preferred Brand

Dermatologicals; Topical Antifungal Agents: Rx and OTC Coverage Copay Tierciclopirox Genericclotrimazole/betamethasone Genericeconazole nitrate Genericketoconazole Genericnystatin Genericnystatin/triamcinolone GenericCARRINGTON ANTIFUNGAL GenericCLOTRIMAZOLE ANTI-FUNGAL GenericCLOTRIMAZOLE/BETAMETHASON GenericGNP ATHLETES FOOT GenericGNP TERBINAFINE HYDROCHLO GenericLAMISIL AF DEFENSE GenericLAMISIL AT GenericSM ANTIFUNGAL CLOTRIMAZOL GenericSM ANTIFUNGAL TOLNAFTATE GenericSM ATHLETES FOOT GenericEXELDERM Preferred BrandMENTAX Preferred BrandERTACZO Non-preferred BrandOXISTAT Non-preferred BrandXOLEGEL Non-preferred Brand

Dermatologicals; Topical Antiviral Agents: Rx and OTC Coverage Copay TierABREVA Genericacyclovir GenericDENAVIR Non-preferred Brand

Dermatologicals; Topical Burn Therapy Agents: Rx Only Coverage Copay Tiersilver sulfadiazine Generic

Dermatologicals; Topical Enzyme (Wound Healing) Agents: Rx Only Coverage Copay TierNotes:Notes:Regranex is subject to a prior authoriza on or clinical drug review toRegranex is subject to a prior authoriza on or clinical drug review tohelp ensure appropriate u liza on.help ensure appropriate u liza on.

trypsin/balsam peru/castor oil GenericREGRANEX Non-preferred BrandSANTYL Non-preferred Brand

Dermatologicals; Antipsoriatic Agents: Rx Only Coverage Copay TierAcitretin Genericcalcipotriene Generichydrocortisone acetate/pramoxine HCl Generic

19

Dermatologicals; Antipsoriatic Agents (Cont): Rx Only Coverage Copay Tierselenium sulfide Genericsulfacetamide sodium GenericTAZORAC Non-preferred Brand

Dermatologicals; Topical Scabicide Agents: Rx and OTC Coverage Copay Tierlindane Genericmalathion Genericpermethrin GenericGNP LICE TREATMENT GenericLICE KILLING GenericLICE KILLING SHAMPOO MAXI GenericLICE TREATMENT CREME RINS GenericPERMETHRIN GenericSM LICE TREATMENT GenericEURAX Preferred BrandULESFIA Preferred Brand

Dermatologicals; Miscellaneous Agents: Rx Only Coverage Copay Tieraluminum chloride Genericammonium lactate Genericdibezyline/padimate O/hydroquinone Genericdiclofenac gel Genericfluorouracil solution Generichydroquinone Genericimiquimod Genericpodofilox Genericurea GenericCARAC Preferred BrandEFUDEX Preferred BrandPANRETIN Preferred Brand

Gastroenterology; Antivertigo/Antiemetic Agents: Rx and OTC Coverage Copay Tierdimenhydrinate Genericgranisetron HCL Genericmeclizine HCl Genericondansetron HCl Genericprochlorperazine Genericpromethazine HCl Generictrimethobenzamide HCl GenericANZEMET Preferred BrandSANCUSO Preferred BrandTRANSDERM-SCOP Preferred Brand

Gastroenterology; Antacid Agents: OTC Coverage Copay TierACID GONE GenericANTACID ANTI-GAS MAXIMUM GenericANTACID ANTI-GAS REGULAR GenericANTACID/ANTI-GAS GenericCALCIUM ANTACID EXTRA STR GenericCHEWABLE ANTACID Generic

20

Gastroenterology; Antacid Agents (Cont): OTC Coverage Copay TierGAVISCON EXTRA STRENGTH R GenericMAALOX ADVANCED GenericMAALOX ADVANCED MAXIMUM S GenericMAALOX CHILDRENS GenericMAALOX MAX GenericMAALOX REGULAR STRENGTH GenericSODIUM BICARBONATE GenericTUMS GenericTUMS CALCIUM FOR LIFE BON GenericTUMS E-X 750 GenericTUMS KIDS GenericTUMS SMOOTHIES GenericTUMS ULTRA 1000 Generic

Gastroenterology; Histamine 2 Reducing Agents: Rx and OTC Coverage Copay Tiercimetidine HCl Genericfamotidine Genericnizatidine Genericranitidine HCl Generic

Gastroenterology; Proton Pump Reducing Agents: Rx and OTC Coverage Copay TierNotes:Notes:Eff ec ve 5-15-2013 all brand name agents in this class of medica onsEff ec ve 5-15-2013 all brand name agents in this class of medica onsare non-formulary, unless medical necessity can be demonstrated.are non-formulary, unless medical necessity can be demonstrated.

esomeprazole injection Genericlansoprazole Genericlansoprazole/amoxicillin/clarithromycin Genericomeprazole Genericomeprazole/sodium bicarbonate Genericpantoprazole GenericPREVACID 24HR GenericPRILOSEC OTC Genericrabeprazole Generic

Gastroenterology; Other Ulcer Therapy: Rx Only Coverage Copay Tiermisoprostol Genericsucralfate GenericCARAFATE Preferred BrandPYLERA Preferred Brand

Gastroenterology; Antidiarrheal Agents: Rx and OTC Coverage Copay Tierdiphenoxylate/atropine sulfate Genericloperamide HCl GenericBISMATROL GenericKAOPECTATE GenericPINK BISMUTH Generic

Gastroenterology; Laxative/Cathartic Agents: Rx and OTC Coverage Copay Tierdocusate sodium GenericBISACODYL EC GenericCITRUCEL GenericEX-LAX ULTRA Generic

21

Gastroenterology; Laxative/Cathartic Agents (Cont): Rx and OTC Coverage Copay TierFIBER TABS GenericFIBERCON GenericGENFIBER Genericlactulose GenericMILK OF MAGNESIA GenericPEGYLAX POWDER GenericSENNA CONCENTRATE GenericSTOOL SOFTENER GenericAMITIZA Preferred BrandHALFLYTELY BOWEL PREP Preferred Brand

Gastroenterology; Antispasmodic Agents: Rx Only Coverage Copay Tierdicyclomine HCl Genericglycopyrrolate Generichyoscyamine Genericmethscopolamine Generic

Gastroenterology; Bile Salts: Rx Only Coverage Copay Tierursodiol GenericACTIGALL Non-preferred BrandCHENODAL Non-preferred BrandURSO FORTE Non-preferred Brand

Gastroenterology; Digestive Enzymes: Rx Only Coverage Copay Tieramylase/lipase/protease GenericCREON Preferred BrandPANCREAZE DR Preferred BrandPERTZYE Preferred BrandULTRASE Preferred BrandVIOKACE Preferred BrandZENPEP Preferred Brand

Gastroenterology; Irritable Bowel Syndrome & Miscellaneous: Rx Only Coverage Copay Tierbalsalazide disodium Genericbudesonide Genericmesalamine Genericsulfasalazine GenericAPRISO Preferred BrandASACOL HD Preferred BrandCANASA Preferred BrandLOTRONEX Preferred BrandPENTASA Preferred BrandRELISTOR Preferred Brand

Gastroenterology; Electrolyte Agents: Rx and OTC Coverage Copay TierMAGNEBIND 300 GenericFOSRENOL Preferred BrandRENVELA Preferred BrandRENAGEL Non-preferred Brand

22

Obstetrics; Contraceptives, Oral, Injectable, Vaginal & Topical : Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

All brand name oral contracep ves are considerd non-formularyAll brand name oral contracep ves are considerd non-formularyrequiring the use and failure of generics before a brand name agentrequiring the use and failure of generics before a brand name agentwill be considered for use.will be considered for use.

APRI ExemptARANELLE ExemptAUBRA ExemptAVIANE ExemptAZURETTE ExemptBALZIVA ExemptBREVICON-28 ExemptCAMILA ExemptCAMRESE ExemptCAZIANT ExemptCESIA ExemptCRYSELLE-28 ExemptCYCLESSA ExemptDESOGEN Exemptdrospirenone/ethinyl estradiol ExemptENPRESSE-28 ExemptENSKYCE ExemptERRIN ExemptFALMINA ExemptGIANVI ExemptGILDESS FE 1.5/30 ExemptGILDESS FE 1/20 ExemptJENCYLA ExemptJOLESSA ExemptJOLIVETTE ExemptJUNEL 1.5/30 ExemptJUNEL 1/20 ExemptJUNEL FE 1.5/30 ExemptJUNEL FE 1/20 ExemptKARIVA ExemptKELNOR 1/35 ExemptLARIN 1/20 ExemptLARIN FE ExemptLESSINA-28 ExemptLEVLEN CONTRACT PACK Exemptlevonorgestrel ExemptLEVORA 0.15/30-28 ExemptLUTERA ExemptLYZA ExemptMARLISSA ExemptMIRCETTE ExemptMONONESSA ExemptMY WAY ExemptMYZILRA ExemptNATAZIA ExemptNORGESTREL/ETHINYL ESTRAD Exempt

23

Obstetrics; Contraceptives, Oral, Inj, Vaginal & Topical (Cont): Rx Only Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

All brand name oral contracep ves are considerd non-formularyAll brand name oral contracep ves are considerd non-formularyrequiring the use and failure of generics before a brand name agentrequiring the use and failure of generics before a brand name agentwill be considered for use.will be considered for use.

NOR-QD ExemptOCELLA ExemptPIRMELLA 7/7/7 & 1/35 ExemptPORTIA-28 ExemptPREVIFEM ExemptPIMTREA ExemptQUASENSE ExemptRECLIPSEN ExemptSPRINTEC 28 ExemptTILIA FE ExemptTRI-LEGEST FE ExemptTRI-LINYAH ExemptTRI-LO-SPRINTEC ExemptVIORELE ExemptVYFEMLA ExemptWERA ExemptZENCHENT FE Chew ExemptZOVIA 1/35E ExemptZOVIA 1/50E ExemptPLAN B ExemptPLAN B ONE-STEP ExemptMEDROXYPROGESTERONE ACETA ExemptNUVARING ExemptORTHO EVRA ExemptORTHO TRI-CYCLEN LO Exempt

Obstetrics; Estrogen & Progesterone Agents: Rx Only Coverage Copay Tierestradiol Genericestropipate Genericmedroxyprogesterone acetate Genericnorethindrone Genericprogesterone GenericCENESTIN Preferred BrandCLIMARA Preferred BrandCLIMARA PRO Preferred BrandDIVIGEL Preferred BrandENJUVIA Preferred BrandESTRACE VAGINAL CREAM Preferred BrandEVAMIST Preferred BrandPREMARIN Preferred BrandPREMARIN VAGINAL Preferred Brand

Obstetrics; Estrogen Combination Agents: Rx Only Coverage Copay Tier estrogens, esterofi ed/methyltestosterone Generic

estradiol/norethindrone GenericCOMBIPATCH Preferred BrandPREMPHASE Preferred BrandPREMPRO Preferred Brand

24

Obstetrics; Vaginal Antibiotic/Antifungal Agents: Rx and OTC Coverage Copay Tierclindamycin phosphate vaginal Genericclotrimazole vaginal GenericGNP MICONAZOLE 7 Genericmetronidazole vaginal Genericmiconazole vaginal GenericMICONAZOLE 1 GenericMICONAZOLE 3 GenericMICONAZOLE 7 Genericnystatin vaginal GenericAVC Preferred BrandVAGIFEM Preferred Brand

Obstetrics; Specialized OB/GYN Agents: Rx Only Coverage Copay Tierleuprolide acetate GenericLUPRON DEPOT Preferred BrandLUPRON DEPOT-PED Preferred BrandSYNAREL Preferred Brand

Ophthalmology; Beta-blocker Agents: Rx Only Coverage Copay Tierbetaxolol HCl Genericcarteolol HCl Genericlevobunolol HCl Genericmetipranolol Generictimolol maleate GenericBETOPTIC-S Preferred Brand

Ophthalmology; Cholinesterase Inhibitor Agents: Rx Only Coverage Copay Tierphospholine iodide Generic

Ophthalmology; Direct Acting Miotic Agents: Rx Only Coverage Copay Tierpilocarpine HCL GenericPILOPINE HS Non-preferred Brand

Ophthalmology; Other Glaucoma Agents: Rx Only Coverage Copay Tierdorzolamide HCL Genericdorzolamide HCL/timolol maleate Generictravaprost GenericAZOPT Preferred BrandISOPTO CARBACHOL Preferred BrandLUMIGAN Preferred BrandTRAVATAN Z Preferred BrandSIMBRINZA Non-preferred Brand

Ophthalmology; Cycloplegic Mydriatic Agents: Rx Only Coverage Copay Tieratropine sulfate Genericcyclopentolate HCl Generichomatropine hydrobromide Genericprocainamide Generic

Ophthalmology; Non-steroidal anti-inflammatory Agents: Rx Only Coverage Copay Tierdiclofenac sodium Genericflurbiprofen sodium Genericketorolac tromethamine Generic

25

Ophthalmology; Non-steroidal anti-inflammatory Agents (Cont): Rx Only Coverage Copay TierFML LIQUIFILM Non-preferred BrandNEVANAC Non-preferred BrandPROLENSA Non-preferred Brand

Ophthalmology; Vasoconstrictor Agents: Rx Only Coverage Copay Tiernaphazoline HCl Genericphenylephrine HCl GenericAK-CON Non-preferred BrandMYDFRIN Non-preferred Brand

Ophthalmology; Antibiotic Agents: Rx Only Coverage Copay Tierbacitracin Genericbacitracin/neomycin/polymyxin Genericbacitracin/polymyxin B Genericciprofloxacin HCl Genericerythromycin Genericgatifloxacin Genericgentamicin sulfate Genericofloxacin Genericpolymyxin B sulfate/trimethoprim Genericsulfacetamide sodium Generictobramycin sulfate GenericBESIVANCE Preferred BrandCILOXAN Preferred BrandNATACYN Preferred BrandTOBREX OINTMENT Preferred BrandVIGAMOX Preferred Brand

Ophthalmology; Sulfonamide Antibacterial Agents: Rx Only Coverage Copay Tiersulfacetamide sodium GenericBLEPH-10 Non-preferred BrandBLEPHAMIDE Non-preferred BrandBLEPHAMIDE S.O.P. Non-preferred Brand

Ophthalmology; Steroid Agents: Rx Only Coverage Copay Tierdexamethasone sodium phosphate Genericfluorometholone Genericprednisolone acetate Genericprednisolone sodium phosphate GenericALREX Preferred BrandFML S.O.P. Preferred BrandLOTEMAX Preferred BrandOZURDEX Preferred BrandPRED MILD Preferred BrandRETISERT Preferred Brand

Ophthalmology; Steroid Antibiotic Combination Agents: Rx Only Coverage Copay Tierneomycin/bacitracin/polymyxin/hydrocor sone Genericneomycin/polymyxin/hydrocortisone Genericneomycin/polymyxin/dexamethasone Generic

26

Ophthalmology; Steroid Antibiotic Combination Agents (Cont): Rx Only Coverage Copay Tiersulfacetamide/prednisolone sodium Generictobramycin sulfate/dexamethasone GenericTOBRADEX OINTMENT Preferred BrandZYLET Preferred Brand

Ophthalmology; Sympathomimetic Agents: Rx Only Coverage Copay Tierapraclonidine HCl GenericBrimonidine tartrate Genericdipivefrin HCl GenericALPHAGAN P Preferred Brand

Ophthalmology; Antiviral Agents: Rx Only Coverage Copay Tiertrifluridine GenericVIROPTIC Non-preferred Brand

Ophthalmology; Miscellaneous Agents: Rx Only Coverage Copay TierNotes:Notes:There is a step therapy program in place for the an histamine agentsThere is a step therapy program in place for the an histamine agentsrequiring the use of generics fi rst. For Restasis the pa ent must have requiring the use of generics fi rst. For Restasis the pa ent must have used and failed ar fi cial tears and gels.used and failed ar fi cial tears and gels.

azelastine HCl Genericcromolyn sodium Genericepinastine Genericketotifen GenericLUCENTIS Preferred BrandPATADAY Preferred BrandPATANOL Preferred BrandRESTASIS Preferred Brand

Ophthalmology; Artificial Tears/Hydrating Agents: Rx Only Coverage Copay TierAKWA TEARS GenericARTIFICIAL TEARS GenericDRY EYES GenericHYPOTEARS GenericISOPTO TEARS GenericLIQUITEARS GenericOPTIVE SENSITIVE GenericREFRESH DRY EYE THERAPY GenericTEARS NATURALE GenericTEARS RENEWED GenericLACRISERT Preferred Brand

Otic Preparations; Steroid, Antibiotic & Miscellaneous: Rx Only Coverage Copay Tieracetic acid solution Genericacetic acid/aluminum acetate Genericacetic acid/hydrocortisone Genericantipyrine/benzocaine/glycerin Genericbenzocaine Genericofloxacin Generichydrocortisone/pramoxine/chloroxylenol Genericneomycin/polymyxin/hydrocortisone GenericMURO 128 GenericSODIUM CHLORIDE GenericCIPRODEX Preferred Brand

27

Endocrine; Antithyroid Agents: Rx Only Coverage Copay Tiermethimazole Genericpropylthiouracil GenericTAPAZOLE Non-preferred Brand

Endocrine; Thyroid Hormone Agents: Rx Only Coverage Copay Tierlevothyroxine sodium Genericliothyronine sodium Genericthyroid GenericLEVOXYL GenericARMOUR THYROID Non-preferred BrandTHYROLAR Non-preferred BrandTIROSINT Non-preferred Brand

Endocrine; Adrenal Hormone Agents: Rx Only Coverage Copay Tiercortisone acetate Genericdexamethasone Genericfludrocortisone acetate Generichydrocortisone Genericmethylprednisolone Genericprednisolone sodium phosphate Genericprednisone GenericCELESTONE Non-preferred BrandCORTEF Non-preferred BrandDEPO-MEDROL Non-preferred BrandKENALOG-10 Non-preferred BrandKENALOG-40 Non-preferred BrandPEDIAPRED Non-preferred Brand

Endocrine; Androgens General: Rx Only Coverage Copay Tiermegestrol acetate GenericMEGACE ES Non-preferred Brand

Endocrine; Antiandrogen Agents: Rx Only Coverage Copay Tierbicalutamide Genericflutamide GenericCASODEX Non-preferred BrandEULEXIN Non-preferred BrandNILANDRON Non-preferred Brand

Endocrine; Androgen Hormone Agents: Rx Only Coverage Copay Tierdanazol Generictestosterone cypionate Generictestosterone propionate GenericANDRODERM Preferred BrandANDROGEL Preferred BrandAXIRON Preferred BrandFORTESTA Non-preferred BrandTESTIM Non-preferred Brand

Endocrine; Ovulatory Stimulant Agents: Rx Only Coverage Copay Tierclomiphene citrate Generic

28

Endocrine; Miscellaneous Agents: Rx Only Coverage Copay Tiercabergoline Genericcalcitonin salmon, synthetic Genericcalcitriol Genericdesmopressin acetate Genericdesmopressin acetate/sodium phosphate Genericdoxercalciferol Genericoctreotide acetate Genericparicalcitol GenericCEREZYME Preferred BrandKUVAN Preferred BrandSAMSCA Preferred BrandSANDOSTATIN LAR DEPOT Preferred BrandSENSIPAR Preferred BrandSTIMATE Preferred BrandSYNREL Preferred BrandVPRIV Preferred Brand

Endocrine; Gonadotropin & Related Agents: Rx Only Coverage Copay Tierchorionic gonadotropin Generic

Endocrine; Growth Hormone Replacement Agents: Rx Only Coverage Copay TierNotes:Notes:All growth hormone products are subject to a prior authoriza on orAll growth hormone products are subject to a prior authoriza on orclinical drug review, especially if the pa ent is age 21 or older to help clinical drug review, especially if the pa ent is age 21 or older to help ensure proper use of these medica ons.ensure proper use of these medica ons.

Seros m is subject to a prior authoriza on or clinical drug reviewSeros m is subject to a prior authoriza on or clinical drug reviewregardless of the pa ent’s age.regardless of the pa ent’s age.

GENOTROPIN Preferred BrandGENOTROPIN MINIQUICK Preferred BrandHUMATROPE Preferred BrandHUMATROPE COMBO PACK Preferred BrandNORDITROPIN CARTRIDGE Preferred BrandNORDITROPIN FLEXPRO Preferred BrandNORDITROPIN NORDIFLEX PEN Preferred BrandNUTROPIN Non-preferred BrandOMNITROPE Non-preferred BrandSAIZEN Non-preferred BrandTEV-TROPIN Non-preferred Brand

Endocrine; Diabetes - Insulin Therapy: Rx and OTC Coverage Copay TierHUMALOG Preferred BrandHUMALOG KWIKPEN Preferred BrandHUMALOG MIX 50/50 Preferred BrandHUMALOG MIX 50/50 KWIKPEN Preferred BrandHUMALOG MIX 50/50 PEN Preferred BrandHUMALOG MIX 75/25 Preferred BrandHUMALOG MIX 75/25 KWIKPEN Preferred BrandHUMALOG MIX 75/25 PEN Preferred BrandHUMALOG PEN Preferred BrandHUMULIN 70/30 Preferred BrandHUMULIN 70/30 PEN Preferred BrandHUMULIN N Preferred BrandHUMULIN N U-100 PEN Preferred BrandHUMULIN R Preferred Brand

29

Endocrine; Diabetes - Insulin Therapy (Cont): Rx and OTC Coverage Copay TierHUMULIN R U-500 (CONCENTR Preferred BrandLANTUS Preferred BrandLANTUS FOR OPTICLIK Preferred BrandLANTUS SOLOSTAR Preferred BrandLEVEMIR Preferred BrandLEVEMIR FLEXPEN Preferred BrandAPIDRA Non-preferred BrandAPIDRA SOLOSTAR Non-preferred BrandNOVOLOG Non-preferred BrandNOVOLOG FLEXPEN Non-preferred BrandNOVOLOG MIX 70/30 Non-preferred BrandNOVOLOG MIX 70/30 PREFILL Non-preferred BrandNOVOLOG PENFILL Non-preferred Brand

Endocrine; Non-Insulin Diabetes Agents: Rx Only Coverage Copay TierNotes:Notes:All oral brand name agents in this class are subject to a step therapyAll oral brand name agents in this class are subject to a step therapyprogram requiring the use of generic medica ons rather than brand program requiring the use of generic medica ons rather than brand name agents when ever possible.name agents when ever possible.

acarbose Genericacetohexamide Genericchlorpropamide Genericglimepiride Genericglipizide/glipizide ER Genericglipizide/metformin HCl Genericglyburide Genericglyburide/metformin HCl Genericmetformin HCl Genericnateglinide Genericpioglitazone Genericpioglitazone;metformin Genericpioglitazone;glimepiride Genericrepaglinide Generictolazamide Generictolbutamide GenericBYDUREON Preferred BrandBYETTA Preferred BrandJANUMET/JANUMET XR Preferred BrandJANUVIA Preferred BrandKOMBIGLYZE Preferred BrandONGLYZA Preferred BrandTRADJENTA Preferred BrandAVANDAMET Non-preferred BrandAVANDARYL Non-preferred BrandAVANDIA Non-preferred BrandINVOKANA Non-preferred BrandJENTADUETO Non-preferred BrandJUVISYNC Non-preferred BrandKAZANO Non-preferred BrandNESINA Non-preferred Brand

30

Endocrine; Non-Insulin Diabetes Agents (Cont): Rx Only Coverage Copay TierNotes:Notes:All oral brand agents in this class subject to step therapy requiring use of All oral brand agents in this class subject to step therapy requiring use of generic medica ons rather than brand name agents when possible.generic medica ons rather than brand name agents when possible.

OSENI Non-preferred BrandSYMLINPEN Non-preferred BrandVICTOZA Non-preferred Brand

Endocrine; Glucose Elevating Agents: Rx Only Coverage Copay TierGLUCOSE GenericGLUTOSE 15 GenericGLUTOSE 45 GenericINSTA-GLUCOSE GenericSM GLUCOSE GenericGLUCAGON EMERGENCY KIT Preferred BrandGLUCAGEN Non-preferred BrandGLUCAGEN HYPOKIT Non-preferred BrandPROGLYCEM Non-preferred Brand

Endocrine, Diabetes Testing; Insulin Syringes, etc.: Rx and OTC Coverage Copay Tierinsulin Syringes - various Genericlancets - various GenericONETOUCH METERS (ALL) Preferred BrandONETOUCH TEST STRIPS (ALL) Preferred BrandNIPRO METERS (ALL) Preferred BrandNIPRO TEST STRIPS (ALL) Preferred BrandACCU-CHEK METERS (ALL) Non-preferred BrandACCU-CHEK TEST STRIPS (ALL) Non-preferred Brand

Respiratory; Antihistamine First Generation: Rx and OTC Coverage Copay Tiercarbinoxamine maleate Genericchlorpheniramine maleate Genericclemastine fumarate Genericcyproheptadine HCl Genericdiphenhydramine HCl Generichydroxyzine HCl Generichydroxyzine pamoate Generic

Respiratory; Antihistamine Second Generation: Rx and OTC Coverage Copay Tiercetirizine HCl Genericdesloratadine Genericfexofenadine Genericlevocetirizine Genericloratadine GenericALLEGRA Generic

Respiratory; Antihistamine & Decongestant First Generation: Rx and OTC Coverage Copay TierAPRODINE GenericBROMALINE GenericBROTAPP GenericCOMTREX FLU THERAPY MAXIM GenericDIMETAPP COLD & ALLERGY Generic

Respiratory; Antihistamine & Decongestant Second Generation: Rx and OTC Coverage Copay Tiercetirizine/Pseudoephedrine Genericfexofenadine/pseudoephedrine Generic

31

Respiratory; Antihistamine & Decongestant Second Gen (Cont): Rx and OTC Coverage Copay Tierloratadine-D 24 hr GenericALLERGY RELIEF D-24 Generic

Antihistamine Nasal Formulations: Rx Only Coverage Copay Tierazelastine HCl GenericASTEPRO Preferred BrandPATANASE Non-preferred Brand

Respiratory; Adrenergic Agents (Anaphylaxis): Rx Only Coverage Copay Tierepinephrine inj 0.15mg & 0.3mg GenericEPIPEN Preferred BrandEPIPEN JR. Preferred Brand

Respiratory; Corticosteroid Agents (Oral): Rx Only Coverage Copay Tiercortisone acetate Genericdexamethasone Generichydrocortisone Genericmethylprednisolone Genericprednisolone Genericprednisone Generic

Respiratory; Antitusive Combination Agents: Rx and OTC Coverage Copay Tierbenzonatate Genericdextromethorphan/PSE/brompheniramine Genericguaifenesin/codeine phosphate Genericguaifenesin/dextromethorphan Generichydrocodone/homatropine Genericphenylephrine/brompheniramine GenericALLFEN GenericQ-TUSSIN GenericROBITUSSIN CHEST CONGESTION GenericROBITUSSIN PEDIATRIC GenericSM TUSSIN GenericTUSSICAPS Preferred Brand

Respiratory; Xanthine Agents: Rx Only Coverage Copay Tieraminophylline Genericcaffeine citrate Generictheophylline GenericELIXOPHYLLIN Non-preferred BrandLUFYLLIN Non-preferred BrandTHEO-24 Non-preferred BrandUNIPHYL Non-preferred Brand

Respiratory; Beta Agonists Oral: Rx Only Coverage Copay Tieralbuterol sulfate Genericmetaproterenol sulfate Genericterbutaline sulfate GenericVOSPIRE ER Non-preferred Brand

Respiratory; Beta Agonist Inhaler: Rx Only Coverage Copay Tieralbuterol inhalation solution Genericisoetharine HCL inhalation solution Generic

32

Respiratory; Beta Agonist Inhaler (Cont): Rx Only Coverage Copay Tierlevalbuterol HCL inhalation solution Genericmetaproterenol sulfate inhaler GenericFORADIL AEROLIZER Preferred BrandPROAIR HFA Preferred BrandSEREVENT DISKUS Preferred BrandVENTOLIN HFA Preferred BrandXOPENEX HFA Non-preferred Brand

Respiratory; Inhaled Corticosteroid Agents: Rx Only Coverage Copay Tierbudesonide GenericASMANEX METERED INHALER Preferred BrandPULMICORT FLEXHALER Preferred BrandQVAR Preferred BrandFLOVENT HFA Non-preferred BrandFLOVENT DISKUS/ROTADISK Non-preferred Brand

Respiratory; Intranasal Steroid Agents: Rx Only Coverage Copay TierNotes:Notes:There is a step therapy program in place for the nasal steroids requiring There is a step therapy program in place for the nasal steroids requiring the use and failure of generics before a brand name agent is allowed.the use and failure of generics before a brand name agent is allowed.

flunisolide Genericfluticasone GenericNasacort OTC Generictriamcinolone acetonide GenericNASONEX Preferred BrandRHINOCORT AQUA Non-preferred BrandVERAMYST Non-preferred Brand

Respiratory; Miscellaneous Nasal Agents: Rx and OTC Coverage Copay TierBABY AYR SALINE GenericDEEP SEA NASAL SPRAY GenericGNP NASAL DECONGESTANT Genericipratropium bromide GenericNASAL SPRAY GenericMUCINEX NASAL SPRAY MOIST GenericNEO-SYNEPHRINE 12 HOUR EX GenericPSEUDOEPHEDRINE HCL GenericPULMOSAL GenericSM NASAL SPRAY 12 HOUR GenericBACTROBAN NASAL Preferred Brand

Respiratory; Miscellaneous Pulmonary Agents: Rx Only Coverage Copay TierNotes:Notes:All agents prescribed for pulmonary hypertension are subject to a prior All agents prescribed for pulmonary hypertension are subject to a prior authoriza on or clinical drug review to help ensure appropriate use of authoriza on or clinical drug review to help ensure appropriate use of these medica ons.these medica ons.

Examples = Adcirca, Le ris & Reva o Examples = Adcirca, Le ris & Reva o

acetylcysteine Genericcromolyn sodium inhalation Genericipratropium/albuterol sulfate Genericipratropium bromide inhalation solution Genericmontelukast Genericsildenafil (pulmonary hypertension) GenericADCIRCA Preferred BrandATROVENT HFA Preferred BrandCOMBIVENT Preferred BrandDULERA Preferred BrandLETAIRIS Preferred Brand

33

Respiratory; Miscellaneous Pulmonary Agents (Cont): Rx Only Coverage Copay TierNotes:Notes:All agents prescribed for pulmonary hypertension are subject to a prior All agents prescribed for pulmonary hypertension are subject to a prior authoriza on or clinical drug review to help ensure appropriate use of authoriza on or clinical drug review to help ensure appropriate use of these medica ons.these medica ons.

Examples = Adcirca, Le ris & Reva oExamples = Adcirca, Le ris & Reva o

PULMOZYME Preferred BrandSPIRIVA HANDIHALER Preferred BrandSYMBICORT Preferred BrandTRACLEER Preferred BrandTYVASO Preferred BrandVENTAVIS Preferred BrandADVAIR DISKUS Non-preferred BrandADVAIR HFA Non-preferred BrandANORO ELLIPTA Non-preferred BrandXOLAIR Non-preferred BrandZYFLO Non-preferred BrandZYFLO CR Non-preferred Brand

Urological; Cholenergic Stimulant Agents: Rx Only Coverage Copay Tierbethanechol chloride Generic

Urological; Anticholinergic & Antispasmodic Agents: Rx Only Coverage Copay Tierdicyclomine HCl Genericflavoxate HCL Generichyoscyamine sulfate Genericoxybutinin chloride Generictolterodine IR & ER Generictrospium chloride IR & XR GenericMYRBETRIQ Preferred Brand

Urological; Urinary Tract Anesthetic Agents: Rx Only Coverage Copay Tierphenazopyridine HCl GenericELMIRON Preferred Brand

Urological; Benign Prostatic Hyperplasia (BPH) Agents: Rx Only Coverage Copay Tieralfuzosin Genericdoxazosin mesylate Genericfinasteride Genericterazosin HCl Generictamsulosin HCl GenericAVODART Preferred BrandJALYN Non-preferred Brand

Urological; Urinary Tract PH Modifier Agents: Rx Only Coverage Copay Tiercitric acid/sodium citrate Genericpotassium citrate Genericpotassium phosphate GenericK-PHOS NEUTRAL Non-preferred BrandRENACIDIN Non-preferred BrandUROCIT-K 10 Non-preferred BrandUROCIT-K 15 Non-preferred Brand

Vitamin & Hematinic Agents - Prenatal: Rx and OTC Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

folic acid ExemptCYTRANATAL Exemptprenatal vitamin (multiple) Exempt

34

Vitamin & Hematinic Agents - Prenatal (Cont): Rx and OTC Coverage Copay TierNotes:Notes:This therapeu c category is exempt from copayments.This therapeu c category is exempt from copayments.

NEEVO ExemptNEEVO DHA ExemptNIFEREX GOLD ExemptNIFEREX-150 FORTE ExemptNIFEREX-PN FORTE ExemptPRENATE DHA ExemptPRENATE ELITE ExemptPRIMACARE ExemptPRIMACARE ONE ExemptREPLIVA 21/7 ExemptCONCEPT DHA ExemptCONCEPT OB ExemptMISSION PRENATAL ExemptMISSION PRENATAL HP ExemptMISSION PRENATAL/FOLIC AC ExemptPNV-DHA ExemptPNV-DHA PLUS ExemptPNV-IRON ExemptPNV-OMEGA ExemptPNV-SELECT ExemptSTUART PRENATAL Exempt

Vitamin & Hematinic Agents - General: Rx and OTC Coverage Copay TierNotes:Notes:Vitamins shall be covered as either prescrip on only or asVitamins shall be covered as either prescrip on only or asover-the-counter vitamin prepara ons with a valid prescrip on.over-the-counter vitamin prepara ons with a valid prescrip on.

Vitamins shall be provided as appropriate for the pa ent’s age - Vitamins shall be provided as appropriate for the pa ent’s age - Infant, Pediatric, Adult, Geriatric, etc.Infant, Pediatric, Adult, Geriatric, etc.

cyanocobalamin (Vitamin B-12) Genericergocalciferol (Vitamin D) Genericfluoride Iron/multiple vitamin Genericvitamin A Genericvitamin B1 Genericvitamin B6 Genericvitamin C Genericvitamin D Genericvitamin K1 Genericmultiple vitamin formulation Genericmultiple vitamin with minerals GenericB-COMPLEX WITH B-12 GenericBIOTIN GenericCENTRUM GenericCENTRUM SILVER ULTRA MENS GenericCENTURY SENIOR GenericCEROVITE ADVANCED FORMULA GenericCOMPETE GenericCOMPLETE GenericDAILY VITE GenericDAILY-VITE/IRON GenericFOLGARD GenericFOLTX GenericGERI-VITE Generic

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Vitamin & Hematinic Agents - General (Cont): Rx and OTC Coverage Copay TierGLUTOFAC GenericGOLDEN AGE VITAMIN/MINERA GenericHAIRVITE GenericHEXAVITAMIN GenericICAPS MV GenericIROMIN-G GenericMEPHYTON GenericMERIBIN GenericMULTI-DELYN GenericMULTI-DELYN/IRON GenericMULTILEX GenericMULTILEX-T&M GenericMULTIVITAMINS GenericNEPHRO-VITE GenericOCUVITE GenericONCE DAILY GenericONCE DAILY/IRON GenericONCOVITE GenericONE DAILY GenericONE DAILY MENS GenericONE DAILY W/IRON GenericPYRIDOXINE HCL GenericRENA-VITE GenericTHERAPEUTIC GenericTHERAPEUTIC-M GenericTHERA-PLUS GenericVI-STRESS GenericVITABEE W/C GenericVITAMIN A GenericVITAMIN B COMPLEX GenericVITAMIN LIQUID GenericVITAMINS & MINERALS Generic

Vitamin & Hematinic; Iron Replacement Agents: Rx & OTC Coverage Copay Tierferrous fumarate Genericferrous gluconate Genericferrous sulfate GenericFERATAB GenericFERATE GenericFERGON GenericFER-IN-SOL GenericPOLY-IRON 150 GenericPOLYSACCHARIDE IRON COMPL GenericSLOW FE GenericSLOW RELEASE IRON GenericDEXFERRUM Non-preferred BrandFERRLECIT Non-preferred Brand

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Vitamin & Hematinic; Iron Replacement Agents (Cont): Rx & OTC Coverage Copay TierINFED Non-preferred BrandVENOFER Non-preferred Brand

Electrolyte Replacement; Potassium Agents: Rx Only Coverage Copay Tierpotassium bicarbonate/citric acid Genericpotassium chloride Genericpotassium Cl/potassium bicarb/citric GenericEFFER-K Non-preferred BrandKLOR-CON Non-preferred Brand

Electrolyte Replacement; Other Agents: Rx and OTC Coverage Copay Tiercalcium Genericcalcium carbonate Genericcalcium citrate Genericcalcium lactate Genericcalcium/vitamin D Genericpotassium phosphate Genericsodium phosphate GenericCALTRATE 600+D GenericCALTRATE 600+D PLUS GenericFOSFREE GenericOYSTER SHELL CALCIUM GenericOYSTER SHELL CALCIUM/D GenericOYSTER SHELL CALCIUM/VITA Generic

Smoking Cessation Agents: Rx and OTC Coverage Copay Tierbupropion HCl SR Genericnicotine gum Genericnicotine lozenge Genericnicotine patch GenericNICODERM CQ GenericNICORETTE GenericNICORETTE STARTER KIT GenericNICOTROL INHALER GenericNICOTROL NS GenericCHANTIX Preferred Brand

Miscellaneous Therapeutic Agents: Rx Only Coverage Copay TierAcampro Cal Genericriluzole GenericADAGEN Preferred BrandANTABUSE Preferred BrandCHEMET Preferred BrandEXJADE Preferred BrandKALYDECO Preferred BrandORFADIN Preferred BrandPROLASTIN Preferred BrandXIFAXAN 200mg Preferred BrandAGRYLIN Non-preferred BrandAMPYRA Non-preferred Brand

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Certain restric ons, quan ty limits, step therapy, and prior authoriza on Certain restric ons, quan ty limits, step therapy, and prior authoriza on requirements may apply. As brand name drugs become available generically, requirements may apply. As brand name drugs become available generically, only the generic will be considered formulary.only the generic will be considered formulary.

Miscellaneous Therapeutic Agents (Cont): Rx Only Coverage Copay TierANAGRELIDE HYDROCHLORIDE Non-preferred BrandDEFEROXAMINE MESYLATE Non-preferred BrandDESFERAL Non-preferred BrandGALZIN Non-preferred BrandJUXTAPID Non-preferred BrandSIGNIFOR Non-preferred BrandSYPRINE Non-preferred BrandZAVESCA Non-preferred Brand